Post on 03-Feb-2018
Drug Formulary
www.keystonefirstpa.com
100KF-162188
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
1
lowercase italics= Generic drugs
UPPERCASE= Brand name
drugs
Tier Alt= Alt
Benefit Exclusion= Benefit
Exclusion
Non-formulary= Non-formulary
Not covered= Not covered
T1= Formulary
T2= Non-Preferred Brand,
Generic Available
T3= Non-Formulary
T4= Specialty
Notes AL= Age limit applies
PA= PA Applies
QL= Quantity Limit
ST= ST applies
Drug Tier Notes
Antihistamine Drugs
Ethanolamine Derivatives
clemastine T1
DIPHENHIST T1
diphenhydramine hcl injection T1 QL (20 ML per 25 days)
diphenhydramine hcl oral T1
SLEEP AID (DOXYLAMINE) T1
First Gen. Antihist. Derivatives, Misc.
cyproheptadine T1
First Generation Antihistamines
ALLER-CHLOR T1
chlorpheniramine maleate T1
clemastine T1
cyproheptadine T1
DIPHENHIST T1
diphenhydramine hcl injection T1 QL (20 ML per 25 days)
diphenhydramine hcl oral T1
SLEEP AID (DOXYLAMINE) T1
Phenothiazine Derivatives
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
2
Drug Tier Notes
PHENERGAN T2
promethazine injection solution T1 QL (20 ML per 25 days)
promethazine injection syringe T1
promethazine oral T1
promethazine rectal T1
PROMETHAZINE VC T1
PROMETHAZINE VC-CODEINE T1
Piperazine Derivatives
ANTIVERT T2
hydroxyzine hcl T1
hydroxyzine pamoate T1
meclizine T1
VISTARIL T2
Propylamine Derivatives
ALLER-CHLOR T1
chlorpheniramine maleate T1
M-END DMX T1
Second Generation Antihistamines
ALAVERT T2
ALAVERT D-12 ALLERGY-SINUS T2
ALLEGRA ALLERGY T2 ST
cetirizine T1
cetirizine-pseudoephedrine T1
CHILDREN'S CLARITIN T2
CLARINEX T3 PA
CLARITIN T2
CLARITIN REDITABS T2
CLARITIN-D 12 HOUR T2
CLARITIN-D 24 HOUR T2
desloratadine T3 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
3
Drug Tier Notes
fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)
fexofenadine oral tablet T1 ST
levocetirizine oral solution T3 PA
levocetirizine oral tablet T1 ST
loratadine T1
loratadine-pseudoephedrine T1
XYZAL ORAL SOLUTION T3 PA
XYZAL ORAL TABLET T2 ST
ZYRTEC T2
ZYRTEC-D T2
Anti-Infective Agents
Adamantanes
amantadine hcl T1
Allylamines
LAMISIL T2 QL (90 DS per 365 DYs)
terbinafine hcl T1 QL (90 DS per 365 DYs)
Amebicides
FLAGYL T2
metronidazole T1
paromomycin T1 PA; QL (10 DS per 30 DYs)
YODOXIN T1
Aminoglycosides
BETHKIS T4 PA
paromomycin T1 PA; QL (10 DS per 30 DYs)
TOBI T4 PA
TOBI PODHALER T4 PA
Aminopenicillins
amoxicillin T1
amoxicillin-pot clavulanate T1
ampicillin T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
4
Drug Tier Notes
AUGMENTIN T2
Anthelmintics
ALBENZA T1
BILTRICIDE T1
ivermectin T1
STROMECTOL T2
Antifungals, Miscellaneous
griseofulvin microsize T1
griseofulvin ultramicrosize T1
GRIS-PEG (ULTRAMICROSIZE) ORAL
TABLET 125 MG
T1
GRIS-PEG (ULTRAMICROSIZE) ORAL
TABLET 250 MG
T2
SSKI T1
Antimalarials
ARALEN T2
chloroquine phosphate T1
DARAPRIM T4 PA
hydroxychloroquine T1
mefloquine T1
PLAQUENIL T2
primaquine T1
quinidine sulfate T1
Antimycobacterials, Miscellaneous
dapsone T1
Antiprotozoals, Miscellaneous
dapsone T1
FLAGYL T2
MEPRON T1 PA
metronidazole T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
5
Drug Tier Notes
NEBUPENT T4 PA
Antituberculosis Agents
AVELOX T2 QL (10 QY per 30 DYs)
AVELOX ABC PACK T2 QL (1 FL per 30 DYs)
BIAXIN T2 QL (1 FL per 30 DYs)
BIAXIN XL T2 QL (1 FL per 30 DYs)
CIPRO ORAL SUSPENSION,MICROCAPSULE
RECON
T2
CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)
ciprofloxacin T1
ciprofloxacin hcl oral tablet 250 mg T1 QL (68 EA per 34 DYs)
ciprofloxacin hcl oral tablet 500 mg T1 QL (68 QY per 34 DYs)
ciprofloxacin hcl oral tablet 750 mg T1 QL (28 QY per 30 DYs)
clarithromycin T1 QL (1 FL per 30 DYs)
ethambutol T1
isoniazid T1
LEVAQUIN ORAL SOLUTION T2 QL (1 FL per 30 DYs)
LEVAQUIN ORAL TABLET T2 QL (14 QY per 30 DYs)
levofloxacin oral solution T1 QL (1 FL per 30 DYs)
levofloxacin oral tablet T1 QL (14 QY per 30 DYs)
moxifloxacin T1 QL (10 QY per 30 DYs)
pyrazinamide T1
rifabutin T1
RIFADIN INTRAVENOUS T4 PA
RIFADIN ORAL T2
rifampin T1
Azoles
DIFLUCAN ORAL SUSPENSION FOR
RECONSTITUTION
T2
DIFLUCAN ORAL TABLET 100 MG, 200 MG,
50 MG
T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
6
Drug Tier Notes
DIFLUCAN ORAL TABLET 150 MG T2 QL (2 QY per 30 DYs)
fluconazole oral suspension for reconstitution T1
fluconazole oral tablet 100 mg, 200 mg, 50 mg T1
fluconazole oral tablet 150 mg T1 QL (2 QY per 30 DYs)
ketoconazole T1
Carbapenems
INVANZ T4 PA
Chloramphenicol
chloramphenicol sod succinate T1
Cyclic Lipopeptides
CUBICIN T4 PA
Erythromycins
ERY-TAB T1
ERYTHROCIN (AS STEARATE) T1
erythromycin T2
erythromycin ethylsuccinate T1
erythromycin-sulfisoxazole T1
Fifth Generation Cephalosporins
TEFLARO T4 PA
First Generation Cephalosporins
cefadroxil T1
cephalexin T1
KEFLEX T2
Glycopeptides
DALVANCE T4 PA
vancomycin T1 PA
Glycylcyclines
TYGACIL T4 PA
Hcv Polymerase Inhibitors
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
7
Drug Tier Notes
EPCLUSA T4 PA
HARVONI T4 PA
SOVALDI T4 PA
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
Hcv Protease Inhibitors
OLYSIO T4 PA
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
ZEPATIER T4 PA
Hcv Replication Complex Inhibitors
EPCLUSA T4 PA
HARVONI T4 PA
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
ZEPATIER T4 PA
Hiv Entry And Fusion Inhibitors
FUZEON T4 PA
SELZENTRY ORAL TABLET 150 MG T1 QL (2 EA per 1 day)
SELZENTRY ORAL TABLET 25 MG, 300 MG,
75 MG
T1
Hiv Integrase Inhibitors
GENVOYA T1
ISENTRESS T1
STRIBILD T1
TIVICAY T1
TRIUMEQ T1
Hiv Nonnucleoside Rev.Transcrip. Inhib.
EDURANT T1
INTELENCE ORAL TABLET 100 MG T1 QL (2 EA per 1 day)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
8
Drug Tier Notes
INTELENCE ORAL TABLET 200 MG T1
nevirapine oral suspension T1
nevirapine oral tablet T1
nevirapine oral tablet extended release 24 hr 100
mg
T1 QL (4 EA per 1 day)
nevirapine oral tablet extended release 24 hr 400
mg
T1
ODEFSEY T1
RESCRIPTOR T1
SUSTIVA ORAL CAPSULE 200 MG T1
SUSTIVA ORAL CAPSULE 50 MG T1 QL (3 EA per 1 day)
SUSTIVA ORAL TABLET T1
Hiv Nucleoside, Nucleotide Rt Inhibitors
abacavir T1
abacavir-lamivudine-zidovudine T1
COMBIVIR T2
DESCOVY T1
didanosine T1
EMTRIVA T1
EPIVIR T2
EPIVIR HBV ORAL SOLUTION T1
EPIVIR HBV ORAL TABLET T2
EPZICOM T1
GENVOYA T1
lamivudine T1
lamivudine-zidovudine T1
ODEFSEY T1
RETROVIR T2
stavudine oral capsule 15 mg, 20 mg T1 QL (2 EA per 1 day)
stavudine oral capsule 30 mg, 40 mg T1
stavudine oral recon soln T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
9
Drug Tier Notes
STRIBILD T1
TRIZIVIR T2
TRUVADA T1
VIDEX 2 GRAM PEDIATRIC T1
VIDEX EC T2
VIREAD T1
ZERIT T2
ZIAGEN T1
zidovudine T1
Hiv Protease Inhibitors
APTIVUS T1
CRIXIVAN T1
INVIRASE T1
KALETRA T1
LEXIVA T1
NORVIR T1
PREZCOBIX T1
PREZISTA ORAL SUSPENSION T1
PREZISTA ORAL TABLET 150 MG T1 QL (6 EA per 1 day)
PREZISTA ORAL TABLET 600 MG, 800 MG T1
PREZISTA ORAL TABLET 75 MG T1 QL (4 EA per 1 day)
REYATAZ T1
VIEKIRA PAK T4 PA
VIEKIRA XR T4 PA
VIRACEPT T1
Interferons
ALFERON N T4 PA
INTRON A T4 PA
PEGASYS T4 PA
PEGASYS PROCLICK T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
10
Drug Tier Notes
PEGINTRON T4 PA
PEGINTRON REDIPEN T4 PA
SYLATRON T4 PA
Lincomycins
CLEOCIN HCL T2
CLEOCIN PEDIATRIC T2
clindamycin hcl T1
clindamycin palmitate hcl T1
Macrolides
ERY-TAB T1
ERYTHROCIN (AS STEARATE) T1
erythromycin T2
erythromycin ethylsuccinate T1
Monobactams
CAYSTON T4 PA
Monoclonal Antibodies
SYNAGIS T4 PA
Natural Penicillins
penicillin v potassium T1
Neuraminidase Inhibitors
RELENZA DISKHALER T1 QL (1 FL per 180 DYs)
TAMIFLU T1 QL (1 FL per 180 DYs)
Nucleosides And Nucleotides
acyclovir T1
adefovir T4 PA
BARACLUDE T4 PA
cidofovir T4 PA
COPEGUS T4 PA
CYTOVENE T4 PA
entecavir T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
11
Drug Tier Notes
HEPSERA T3 PA
MODERIBA DOSE PACK T4 PA
REBETOL T4 PA
RIBASPHERE T4 PA
RIBASPHERE RIBAPAK T4 PA
RIBATAB DOSE PACK T4 PA
valacyclovir oral tablet 1 gram T1
valacyclovir oral tablet 500 mg T1 QL (3 EA per 1 day)
VALCYTE T4 PA
valganciclovir T4 PA
VALTREX T2
VIRAZOLE T4 PA
ZOVIRAX T2
Other Macrolides
azithromycin oral packet T1 QL (1 FL per 30 DYs)
azithromycin oral suspension for reconstitution T1 QL (1 FL per 30 DYs)
azithromycin oral tablet 250 mg T1 QL (6 QY per 30 DYs)
azithromycin oral tablet 500 mg T1 QL (1 FL per 30 DYs)
azithromycin oral tablet 600 mg T1 QL (8 QY per 24 DYs)
BIAXIN T2 QL (1 FL per 30 DYs)
BIAXIN XL T2 QL (1 FL per 30 DYs)
clarithromycin T1 QL (1 FL per 30 DYs)
ZITHROMAX T2 QL (1 FL per 30 DYs)
ZITHROMAX TRI-PAK T2 QL (1 FL per 30 DYs)
ZMAX T1 QL (1 QY per 30 DYs)
Oxazolidinones
linezolid T3 PA
SIVEXTRO T4 PA
ZYVOX T3 PA
Penicillinase-Resistant Penicillins
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
12
Drug Tier Notes
dicloxacillin T1
Polyenes
nystatin T1
Polymyxins
colistin (colistimethate na) T4 PA
Quinolones
AVELOX T2 QL (10 QY per 30 DYs)
CIPRO ORAL SUSPENSION,MICROCAPSULE
RECON
T2
CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)
ciprofloxacin T1
ciprofloxacin hcl oral tablet 250 mg T1 QL (68 EA per 34 DYs)
ciprofloxacin hcl oral tablet 500 mg T1 QL (68 QY per 34 DYs)
ciprofloxacin hcl oral tablet 750 mg T1 QL (28 QY per 30 DYs)
LEVAQUIN T2 QL (14 QY per 30 DYs)
levofloxacin oral solution T1 QL (1 FL per 30 DYs)
levofloxacin oral tablet T1 QL (14 QY per 30 DYs)
moxifloxacin T1 QL (10 QY per 30 DYs)
Rifamycins
rifabutin T1
RIFADIN INTRAVENOUS T4 PA
RIFADIN ORAL T2
rifampin T1
Second Generation Cephalosporins
cefaclor T1
cefprozil T1
CEFTIN ORAL SUSPENSION FOR
RECONSTITUTION
T1 QL (100 QY per 1 day)
CEFTIN ORAL TABLET T2
cefuroxime axetil oral suspension for
reconstitution
T1 QL (100 QY per 1 day)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
13
Drug Tier Notes
cefuroxime axetil oral tablet 250 mg T1 QL (2 EA per 1 day)
cefuroxime axetil oral tablet 500 mg T1
Sulfonamides (Systemic)
AZULFIDINE T2
AZULFIDINE EN-TABS T2
BACTRIM T2
BACTRIM DS T2
erythromycin-sulfisoxazole T1
sulfadiazine T1
sulfamethoxazole-trimethoprim T1
sulfasalazine T1
Tetracyclines
doxycycline monohydrate T1
minocycline T1
tetracycline T1
Third Generation Cephalosporins
cefdinir T1
cefpodoxime T1
ceftriaxone T1
Urinary Anti-Infectives
MACROBID T2
MACRODANTIN T2
nitrofurantoin T1
nitrofurantoin macrocrystal T1
nitrofurantoin monohyd/m-cryst T1
trimethoprim T1
Antineoplastic Agents
Antineoplastic Agents
ABRAXANE T4 PA
ADCETRIS T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
14
Drug Tier Notes
ADRUCIL T4 PA
AFINITOR T4 PA
AFINITOR DISPERZ T4 PA
ALFERON N T4 PA
ALIMTA T4 PA
ALKERAN T4 PA
anastrozole T1
ARIMIDEX T2
AROMASIN T4 PA
ARZERRA T4 PA
AVASTIN T4 PA
azacitidine T4 PA
BELEODAQ T4 PA
bicalutamide T1
BICNU T4 PA
bleomycin T4 PA
BOSULIF T4 PA
BUSULFEX T4 PA
CAMPTOSAR T4 PA
CAPRELSA T4 PA
carboplatin T4 PA
CASODEX T2
CEENU T1
cisplatin T4 PA
COMETRIQ T4 PA
COSMEGEN T4 PA
cyclophosphamide intravenous T4 PA
cyclophosphamide oral T1
CYRAMZA T4 PA
cytarabine T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
15
Drug Tier Notes
cytarabine (pf) T4 PA
dacarbazine T4 PA
daunorubicin T4 PA
decitabine T4 PA
DOCEFREZ T4 PA
docetaxel T4 PA
doxorubicin T4 PA
doxorubicin, peg-liposomal T4 PA
DROXIA T1
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
ELLENCE T4 PA
ELOXATIN T4 PA
EMCYT T1
epirubicin T4 PA
ERBITUX T4 PA
ERIVEDGE T4 PA
ERWINAZE T4 PA
ETOPOPHOS T4 PA
etoposide T4 PA
FARESTON T1 ST
FASLODEX T4 PA
FEMARA T2 QL (1 QY per 1 DY)
FIRMAGON T4 PA
floxuridine T4 PA
fludarabine T4 PA
fluorouracil T4 PA
flutamide T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
16
Drug Tier Notes
FOLOTYN T4 PA
GAZYVA T4 PA
gemcitabine T4 PA
GEMZAR T4 PA
GILOTRIF T4 PA
GLEEVEC T4 PA
GLEOSTINE T4 PA
HALAVEN T4 PA
HERCEPTIN T4 PA
HEXALEN T4 PA
HYCAMTIN T4 PA
HYDREA T2
hydroxyurea T1
ICLUSIG T4 PA
IDAMYCIN PFS T4 PA
IFEX T4 PA
ifosfamide T4 PA
ifosfamide-mesna T4 PA
imatinib T4 PA
IMBRUVICA T4 PA
INLYTA T4 PA
INTRON A T4 PA
irinotecan T4 PA
ISTODAX T4 PA
IXEMPRA T4 PA
JAKAFI T4 PA
JEVTANA T4 PA
KADCYLA T4 PA
KEYTRUDA T4 PA
KYPROLIS T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
17
Drug Tier Notes
letrozole T1 QL (1 QY per 1 DY)
LEUKERAN T4 PA
leuprolide T4 PA
lomustine T4 PA
LUPANETA PACK (1 MONTH) T4 PA
LUPANETA PACK (3 MONTH) T4 PA
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT (6 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
LYSODREN T4 PA
MARQIBO T4 PA
MATULANE T4
MEGACE T2
MEGACE ES T2 QL (150 QY per 30 DYs)
megestrol oral suspension 400 mg/10 ml (40
mg/ml)
T1
megestrol oral suspension 625 mg/5 ml T1 QL (150 ML per 30 DYs)
megestrol oral tablet T1
MEKINIST T4 PA
mercaptopurine T1
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
mitomycin T4 PA
mitoxantrone T4 PA
MUSTARGEN T4 PA
MYLERAN T1
NEXAVAR T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
18
Drug Tier Notes
nilutamide T4 PA
NIPENT T4 PA
ONCASPAR T4 PA
OTREXUP (PF) T4 PA
oxaliplatin T4 PA
PERJETA T4 PA
PHOTOFRIN T4 PA
POMALYST T4 PA
PROLEUKIN T4 PA
REVLIMID T4 PA
RHEUMATREX T2
RITUXAN T4 PA
RITUXAN HYCELA T4 PA
SPRYCEL T4 PA
STIVARGA T4 PA
SUTENT T4 PA
SYLATRON T4 PA
SYLVANT T4 PA
SYNRIBO T4 PA
TABLOID T4 PA
TAFINLAR T4 PA
tamoxifen T1
TARCEVA T4 PA
TARGRETIN T4 PA
TASIGNA T4 PA
TAXOTERE T4 PA
TEMODAR T4 PA
teniposide T4 PA
THERACYS T4 PA
TICE BCG T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
19
Drug Tier Notes
TOPOSAR T4 PA
topotecan T4 PA
TREANDA T4 PA
TRELSTAR T4 PA
TRELSTAR DEPOT T4 PA
TRELSTAR LA T4 PA
tretinoin (chemotherapy) T4 PA
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
TRISENOX T4 PA
TYKERB T4 PA
VALSTAR T4 PA
VANTAS T4 PA
VECTIBIX T4 PA
VELCADE T4 PA
vinblastine T4 PA
VINCASAR PFS T4 PA
vinorelbine T4 PA
VOTRIENT T4 PA
XALKORI T4 PA
XELODA T4 PA
XTANDI T4 PA
YERVOY T4 PA
ZALTRAP T4 PA
ZELBORAF T4 PA
ZEVALIN (Y-90) T4 PA
ZOLADEX T4 PA
ZOLINZA T4 PA
ZYDELIG T4 PA
ZYKADIA T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
20
Drug Tier Notes
ZYTIGA T4 PA
Antitoxins,Immune Glob,Toxoids,Vaccines
Antitoxins And Immune Globulins
CARIMUNE NF NANOFILTERED T4 PA
CYTOGAM T4 PA
FLEBOGAMMA DIF T4 PA
GAMASTAN S/D T4 PA
GAMMAGARD LIQUID T4 PA
GAMMAGARD S/D T4 PA
GAMUNEX-C T4 PA
HEPAGAM B T4 PA
HIZENTRA T4 PA
HYPERHEP B S/D T4 PA
HYPERHEP B S-D NEONATAL T4 PA
HYPERRAB S/D (PF) T4 PA
HYPERTET S/D (PF) T4 PA
HYQVIA T4 PA
NABI-HB T4 PA
OCTAGAM T4 PA
RHOGAM ULTRA-FILTERED PLUS T4 PA
RHOPHYLAC T4 PA
VARIZIG T4 PA
WINRHO SDF T4 PA
Toxoids
ADACEL(TDAP ADOLESN/ADULT)(PF) T1 AL
BOOSTRIX TDAP T1 AL
Vaccines
AFLURIA 2016-2017 T1 QL (0.5 ML per 180 days); AL
AFLURIA 2016-2017 (PF) T1 QL (0.5 ML per 180 days); AL
AFLURIA 2017-2018 T1 QL (0.5 ML per 180 days); AL
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
21
Drug Tier Notes
AFLURIA 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL
AFLURIA QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL
AFLURIA QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL
ENGERIX-B (PF) T1 AL
FLUARIX QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL
FLUCELVAX QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL
FLUCELVAX QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL
FLULAVAL QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL
FLULAVAL QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL
FLUVIRIN 2017-2018 T1 QL (0.5 ML per 180 days); AL
FLUVIRIN 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL
FLUZONE HIGH-DOSE 2017-18 (PF) T1 QL (0.5 ML per 180 days); AL
FLUZONE INTRADERM QUAD 2017-18 T1 QL (0.1 ML per 180 days); AL
FLUZONE QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL
FLUZONE QUAD 2017-2018 (PF)
INTRAMUSCULAR SUSPENSION
T1 QL (0.5 ML per 180 days); AL
FLUZONE QUAD 2017-2018 (PF)
INTRAMUSCULAR SYRINGE
T1 QL (0.5 ML per 180 days)
HAVRIX (PF) T1 AL
PNEUMOVAX 23 INJECTION SOLUTION T1 AL
PNEUMOVAX 23 INJECTION SYRINGE T1
PREVNAR 13 (PF) T1 AL
RECOMBIVAX HB (PF) T1 AL
THERACYS T4 PA
TICE BCG T4 PA
TWINRIX (PF) T1 AL
VAQTA (PF) T1 AL
ZOSTAVAX (PF) T1 QL (1 QY per 365 DYs)
Autonomic Drugs
Alpha- And Beta-Adrenergic Agonists
ALAVERT D-12 ALLERGY-SINUS T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
22
Drug Tier Notes
BROMFED DM T1
cetirizine-pseudoephedrine T1
CHERATUSSIN DAC T1
CLARITIN-D 12 HOUR T2
CLARITIN-D 24 HOUR T2
epinephrine T1 QL (2 EA per 30 DYs)
loratadine-pseudoephedrine T1
M-END DMX T1
MUCINEX D T1
pseudoephedrine hcl T1
ZYRTEC-D T2
Alpha-Adrenergic Agonists
CATAPRES T2
CATAPRES-TTS-1 T2
CATAPRES-TTS-2 T2
CATAPRES-TTS-3 T2
clonidine T1
clonidine hcl T1
CLORPRES T1
ED BRON GP T1
methyldopa T1
methyldopa-hydrochlorothiazide T1
phenylephrine-chlophedianol-gg T1
PROMETHAZINE VC T1
PROMETHAZINE VC-CODEINE T1
ROBAFEN CF (PHENYLEPHRINE) T1
Antimuscarinics/Antispasmodics
ANORO ELLIPTA T1
ATROVENT HFA T1
BENTYL T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
23
Drug Tier Notes
COMBIVENT RESPIMAT T1
dicyclomine T1
diphenoxylate-atropine T1
glycopyrrolate T1
hydrocodone-homatropine T1
hyoscyamine sulfate T1
ipratropium bromide T1
LEVBID T2
LOMOTIL T2
propantheline T1
ROBINUL T2
ROBINUL FORTE T2
SPIRIVA RESPIMAT T1 AL
TUSSIGON T1
Antiparkinsonian Agents
benztropine T1
trihexyphenidyl T1
Autonomic Drugs, Miscellaneous
CHANTIX T1 QL (360 QY per 365 DYs); AL
CHANTIX CONTINUING MONTH BOX T1 QL (360 EA per 365 DYs)
CHANTIX CONTINUING MONTH PAK T1 QL (360 EA per 365 DYs)
CHANTIX STARTING MONTH BOX T1 QL (360 QY per 365 DYs); AL
NICODERM CQ T2
NICORETTE T2
nicotine T1
nicotine (polacrilex) buccal gum T1
nicotine (polacrilex) buccal lozenge T1 QL (20 EA per 1 day)
nicotine (polacrilex) buccal mini lozenge T1 QL (20 EA per 1 day)
Centrally Acting Skeletal Muscle Relaxnt
carisoprodol T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
24
Drug Tier Notes
chlorzoxazone T1
cyclobenzaprine T1
methocarbamol T1
ROBAXIN T2
ROBAXIN-750 T2
SOMA T2
tizanidine T1
ZANAFLEX T2
Gaba-Derivative Skeletal Muscle Relaxant
baclofen T1
GABLOFEN T4 PA
LIORESAL T4 PA
Non-Sel. Beta-Adrenergic Blocking Agents
BETAPACE T2
BETAPACE AF T2
carvedilol T1
COREG T2
CORGARD T2
CORZIDE T2
INDERAL LA T2
labetalol T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
timolol maleate T1
TRANDATE T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
25
Drug Tier Notes
Non-Sel.Alpha-1-Adrenergic Blocking Agts
CARDURA T2
doxazosin T1
MINIPRESS T2
prazosin T1
terazosin T1
Non-Sel.Alpha-Adrenergic Blocking Agents
CAFERGOT T2
D.H.E.45 T2
DIBENZYLINE T2
dihydroergotamine injection T1 QL (12 ML per 30 days)
dihydroergotamine nasal T1 QL (1 QY per 30 DYs)
ERGOMAR T1 QL (20 EA per 30 days)
MIGRANAL T2 QL (1 QY per 30 DYs)
phenoxybenzamine T1 PA
Parasympathomimetic (Cholinergic Agents)
ARICEPT T2 AL
ARICEPT ODT T2 AL
bethanechol chloride T1
donepezil oral tablet 10 mg T1 AL
donepezil oral tablet 5 mg T1 QL (1 EA per 1 DY); AL
donepezil oral tablet,disintegrating T1 AL
EXELON ORAL T2 AL
EXELON TRANSDERMAL PATCH 24 HOUR
4.6 MG/24 HR
T1 QL (1 EA per 1 day); AL
EXELON TRANSDERMAL PATCH 24 HOUR
9.5 MG/24 HR
T1 AL
MESTINON ORAL SYRUP T1
MESTINON ORAL TABLET T2
MESTINON TIMESPAN T2
PROSTIGMIN T1 AL
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
26
Drug Tier Notes
pyridostigmine bromide T1 AL
rivastigmine T1 AL
rivastigmine tartrate oral capsule 1.5 mg, 3 mg T1 QL (2 EA per 1 day); AL
rivastigmine tartrate oral capsule 4.5 mg, 6 mg T1 AL
URECHOLINE T2
Selective Alpha-1-Adrenergic Block.Agent
alfuzosin T1
carvedilol T1
COREG T2
labetalol T1
tamsulosin T1
TRANDATE T2
Selective Beta-2-Adrenergic Agonists
albuterol sulfate T1
ANORO ELLIPTA T1
BREO ELLIPTA T1
COMBIVENT RESPIMAT T1
DULERA T1 QL (13 QY per 30 DYs); AL
SEREVENT DISKUS T1
terbutaline T1
VENTOLIN HFA T1 QL (1 QY per 30 DYs)
XOPENEX HFA T1 ST
Selective Beta-Adrenergic Blocking Agent
atenolol T1
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
27
Drug Tier Notes
metoprolol tartrate T1
TENORMIN T2
TOPROL XL T2
ZEBETA T2
ZIAC T2
Skeletal Muscle Relaxants, Miscellaneous
BOTOX T4 PA
BOTOX COSMETIC T4 PA
DYSPORT T4 PA
MYOBLOC T4 PA
XEOMIN T4 PA
Blood Formation, Coagulation, Thrombosis
Coumarin Derivatives
COUMADIN T2
warfarin T1
Direct Factor Xa Inhibitors
ARIXTRA T4 PA
ELIQUIS T1
XARELTO T1
Direct Thrombin Inhibitors
PRADAXA ORAL CAPSULE 110 MG, 150 MG T1
PRADAXA ORAL CAPSULE 75 MG T1 QL (2 EA per 1 day)
Hematopoietic Agents
ARANESP (IN ALBUMIN) T4 PA
ARANESP (IN POLYSORBATE) T4 PA
EPOGEN T4 PA
GRANIX T4 PA
LEUKINE T4 PA
MOZOBIL T4 PA
NEULASTA T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
28
Drug Tier Notes
NEUMEGA T4 PA
NEUPOGEN T4 PA
NPLATE T4 PA
PROCRIT T4 PA
PROMACTA T4 PA
ZARXIO T4 PA
Hemorrheologic Agents
pentoxifylline T1
Hemostatics
ADVATE T4 PA
ALPHANATE T4 PA
ALPHANINE SD T4 PA
ALPROLIX T4 PA
AMICAR T1
BEBULIN T4 PA
BENEFIX T4 PA
CORIFACT T4 PA
DDAVP NASAL T2 PA
DDAVP ORAL T2 PA; AL
desmopressin nasal T1 PA
desmopressin oral T1 PA; AL
ELOCTATE T4 PA
FEIBA NF T4 PA
HEMOFIL M HIGH T4 PA
HEMOFIL M LOW T4 PA
HEMOFIL M MID T4 PA
HEMOFIL M SUPER HIGH T4 PA
HUMATE-P T4 PA
KOATE-DVI T4 PA
KOGENATE FS T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
29
Drug Tier Notes
MONOCLATE-P T4 PA
NOVOSEVEN RT T4 PA
PROFILNINE T4 PA
RECOMBINATE T4 PA
RIASTAP T4 PA
RIXUBIS T4 PA
STIMATE T1 PA
WILATE T4 PA
XYNTHA T4 PA
XYNTHA SOLOFUSE T4 PA
Heparins
enoxaparin T4 PA
FRAGMIN T4 PA
heparin (porcine) T1
LOVENOX T4 PA
Iron Preparations
CADEAU DHA T1
CENTRUM COMPLETE T2 AL
CERTAVITE-ANTIOXID (IRON GLUC) T2
DAILY PRENATAL T1
DAILY VITES/IRON T1 AL
FERAHEME T4 PA
FERRETTS T1
FERRLECIT T4 PA
ferrous fumarate T1
ferrous gluconate T1
ferrous sulfate T1
INFED T4 PA
INJECTAFER T4 PA
iron oral tablet T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
30
Drug Tier Notes
IRON ORAL TABLET EXTENDED RELEASE T1
MULTIGEN T1
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
MULTI-VIT WITH FLUORIDE-IRON T1 AL
MULTIVITAMIN WITH MINERALS T1
OBSTETRIX DHA T1
OBTREX DHA T1
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
POLY-VITAMIN WITH IRON T1 AL
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENATA T1
PRENATAL + DHA T1
PRENATAL 19 T1
PRENATAL MULTI-DHA T1
PRENATAL MULTI-DHA (ALGAL OIL) T1
PRENATAL VITAMIN T1
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
PRORENAL QD T1
TRINATAL GT T1
TRIVEEN-DUO DHA T1
TRI-VI-SOL WITH IRON T1 AL
TRI-VIT WITH FLUORIDE AND IRON T1 AL
VENOFER T4 PA
WOMEN'S PRENATAL + DHA T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
31
Drug Tier Notes
Platelet-Aggregation Inhibitors
aspirin T1
aspirin-caffeine-dihydrocodein T3
aspirin-dipyridamole T1
butalbital-aspirin-caffeine T1
cilostazol T1
clopidogrel T1
dipyridamole T1
EFFIENT ORAL TABLET 10 MG T1
EFFIENT ORAL TABLET 5 MG T1 QL (1 EA per 1 day)
PERSANTINE T2
PLAVIX T2
PLETAL T2
SYNALGOS-DC T3
ticlopidine T1
Thrombolytic Agents
ACTIVASE T4 PA
aspirin T1
aspirin-caffeine-dihydrocodein T3
butalbital-aspirin-caffeine T1
CATHFLO ACTIVASE T4 PA
SYNALGOS-DC T3
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
CARDURA T2
carvedilol T1
COREG T2
doxazosin T1
labetalol T1
MINIPRESS T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
32
Drug Tier Notes
prazosin T1
terazosin T1
TRANDATE T2
Alpha-Adrenergic Blocking Agt.(Hypoten)
CARDURA T2
doxazosin T1
labetalol T1
MINIPRESS T2
prazosin T1
terazosin T1
TRANDATE T2
Angiotensin Ii Receptor Antagon.(Hypotn)
AVALIDE T2 ST
AVAPRO T2 ST
COZAAR T2
HYZAAR T2
irbesartan T1 ST
irbesartan-hydrochlorothiazide T1 ST
losartan T1
losartan-hydrochlorothiazide T1
valsartan T1 ST
valsartan-hydrochlorothiazide T1 ST
Angiotensin Ii Receptor Antagonists
AVALIDE T2 ST
AVAPRO T2 ST
COZAAR T2
HYZAAR T2
irbesartan T1 ST
irbesartan-hydrochlorothiazide T1 ST
losartan T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
33
Drug Tier Notes
losartan-hydrochlorothiazide T1
valsartan T1 ST
valsartan-hydrochlorothiazide T1 ST
Angiotensin-Convert.Enzyme Inhib(Hypotn)
ACCUPRIL T2
ACCURETIC T2
ACEON T2
benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)
benazepril oral tablet 40 mg T1
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
captopril T1
captopril-hydrochlorothiazide T1
enalapril maleate T1
enalapril-hydrochlorothiazide T1
fosinopril T1
lisinopril T1
lisinopril-hydrochlorothiazide T1
LOTENSIN T2
LOTENSIN HCT T2
MAVIK T2
moexipril T1
moexipril-hydrochlorothiazide T1
perindopril erbumine T1
PRINIVIL T2
quinapril T1
quinapril-hydrochlorothiazide T1
trandolapril T1
UNIRETIC T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
34
Drug Tier Notes
UNIVASC T2
VASERETIC T2
VASOTEC T2
ZESTORETIC T2
ZESTRIL T2
Angiotensin-Converting Enzyme Inhibitors
ACCUPRIL T2
ACCURETIC T2
ACEON T2
benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)
benazepril oral tablet 40 mg T1
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
captopril T1
captopril-hydrochlorothiazide T1
enalapril maleate T1
enalapril-hydrochlorothiazide T1
fosinopril T1
lisinopril T1
lisinopril-hydrochlorothiazide T1
LOTENSIN T2
LOTENSIN HCT T2
MAVIK T2
moexipril T1
moexipril-hydrochlorothiazide T1
perindopril erbumine T1
PRINIVIL T2
quinapril T1
quinapril-hydrochlorothiazide T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
35
Drug Tier Notes
trandolapril T1
UNIRETIC T2
UNIVASC T2
VASERETIC T2
VASOTEC T2
ZESTORETIC T2
ZESTRIL T2
Antiarrhythmics, Miscellaneous
digoxin T1
LANOXIN T2
Antilipemic Agents, Miscellaneous
JUXTAPID T4 PA
KYNAMRO T4 PA
niacin oral capsule, extended release T1
niacin oral tablet T1
niacin oral tablet extended release 1,000 mg, 500
mg, 750 mg
T1 ST
niacin oral tablet extended release 24 hr T1 ST
niacin oral tablet extended release 250 mg T1
NIACOR T1
Beta-Adrenergic Blocking Agents
atenolol T1
BETAPACE T2
BETAPACE AF T2
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
carvedilol T1
COREG T2
CORGARD T2
CORZIDE T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
36
Drug Tier Notes
INDERAL LA T2
labetalol T1
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
metoprolol tartrate T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
TENORMIN T2
timolol maleate T1
TOPROL XL T2
TRANDATE T2
ZEBETA T2
ZIAC T2
Beta-Adrenergic Blocking Agt.(Hypoten)
atenolol T1
BETAPACE T2
BETAPACE AF T2
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
CORGARD T2
CORZIDE T2
INDERAL LA T2
labetalol T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
37
Drug Tier Notes
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
metoprolol tartrate T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
TENORMIN T2
timolol maleate T1
TOPROL XL T2
TRANDATE T2
ZEBETA T2
ZIAC T2
Bile Acid Sequestrants
cholestyramine (with sugar) T1
CHOLESTYRAMINE LIGHT T1
COLESTID T2
colestipol T1
PREVALITE T1
QUESTRAN T2
QUESTRAN LIGHT T2
WELCHOL T1
Calcium-Channel Block.Agt,Misc(Hypoten)
CALAN T2
CALAN SR T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
38
Drug Tier Notes
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 180 MG, 240 MG
T1
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 300 MG, 360 MG
T2
TIAZAC T2
verapamil T1
VERELAN T2
Calcium-Channel Blocking Agents
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
AMTURNIDE T2 ST
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 30 MG
T1
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 60 MG
T2
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
39
Drug Tier Notes
nifedipine oral tablet extended release 90 mg T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
PROCARDIA T2
PROCARDIA XL T2
SULAR T2
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 180 MG, 240 MG
T1
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 300 MG, 360 MG
T2
TEKAMLO T2 ST
TIAZAC T2
verapamil T1
VERELAN T2
Calcium-Channel Blocking Agents, Misc.
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 180 MG, 240 MG
T1
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 300 MG, 360 MG
T2
TIAZAC T2
verapamil T1
VERELAN T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
40
Drug Tier Notes
Carbonic Anhydrase Inhibitors(Hypoten)
acetazolamide T1
DIAMOX SEQUELS T2 PA
Cardiotonic Agents
digoxin T1
LANOXIN T2
milrinone T4 PA
Central Alpha-Agonists
CATAPRES T2
CATAPRES-TTS-1 T2
CATAPRES-TTS-2 T2
CATAPRES-TTS-3 T2
clonidine T1
clonidine hcl T1
CLORPRES T1
guanfacine oral tablet T1
guanfacine oral tablet extended release 24 hr T1 AL
methyldopa T1
methyldopa-hydrochlorothiazide T1
TENEX T2
Cholesterol Absorption Inhibitors
ezetimibe T1
Class Ia Antiarrhythmics
disopyramide phosphate T1
NORPACE T2
NORPACE CR T2
quinidine gluconate T1
quinidine sulfate T1
Class Ib Antiarrhythmics
DILANTIN T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
41
Drug Tier Notes
DILANTIN EXTENDED T2
DILANTIN INFATABS T2
DILANTIN-125 T2
mexiletine T1
phenytoin T1
phenytoin sodium extended T1
Class Ic Antiarrhythmics
flecainide T1
propafenone T1
RYTHMOL T2
Class Ii Antiarrhythmics
atenolol T1
BETAPACE T2
BETAPACE AF T2
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
carvedilol T1
COREG T2
CORGARD T2
CORZIDE T2
INDERAL LA T2
labetalol T1
LOPRESSOR T2
LOPRESSOR HCT T2
metoprolol succinate T1
metoprolol ta-hydrochlorothiaz T1
metoprolol tartrate T1
nadolol T1
nadolol-bendroflumethiazide T1
pindolol T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
42
Drug Tier Notes
propranolol T1
propranolol-hydrochlorothiazid T1
sotalol T1
SOTALOL AF T1
TENORMIN T2
timolol maleate T1
TOPROL XL T2
TRANDATE T2
ZEBETA T2
ZIAC T2
Class Iii Antiarrhythmics
amiodarone T1
BETAPACE T2
BETAPACE AF T2
CORDARONE T2
MULTAQ T3 PA
sotalol T1
SOTALOL AF T1
Class Iv Antiarrhythmics
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
ISOPTIN SR T2
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 180 MG, 240 MG
T1
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 300 MG, 360 MG
T2
TIAZAC T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
43
Drug Tier Notes
verapamil T1
VERELAN T2
Dihydropyridines
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
AMTURNIDE T2 ST
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 30 MG
T1
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 60 MG
T2
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
nifedipine oral tablet extended release 90 mg T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
PROCARDIA T2
PROCARDIA XL T2
SULAR T2
TEKAMLO T2 ST
Dihydropyridines (Hypotensive Agents)
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 30 MG
T1
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 60 MG
T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
44
Drug Tier Notes
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
nifedipine oral tablet extended release 90 mg T1
nisoldipine oral tablet extended release 24 hr 17
mg, 8.5 mg
T1 QL (1 EA per 1 day)
nisoldipine oral tablet extended release 24 hr 20
mg, 30 mg, 34 mg, 40 mg
T1
NORVASC T2
PROCARDIA T2
PROCARDIA XL T2
SULAR T2
TEKAMLO T2 ST
Direct Vasodilators
hydralazine T1
minoxidil T1
Diuretics, Miscellaneous (Hypotensive)
THEO-24 T1
theophylline T1
Fibric Acid Derivatives
fenofibrate T1
fenofibrate micronized T1
fenofibrate nanocrystallized T1
gemfibrozil T1
LOFIBRA T2
LOPID T2
TRICOR T2
Hmg-Coa Reductase Inhibitors
atorvastatin oral tablet 10 mg T1 QL (1 EA per 1 DY)
atorvastatin oral tablet 20 mg, 40 mg, 80 mg T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
45
Drug Tier Notes
fluvastatin T1 ST
LESCOL T2 ST
LESCOL XL T1 ST
LIPITOR T2
lovastatin oral tablet 10 mg, 20 mg T1 QL (3 EA per 1 day)
lovastatin oral tablet 40 mg T1
MEVACOR T2
PRAVACHOL T2 ST
pravastatin oral tablet 10 mg, 20 mg T1 ST; QL (1 EA per 1 day)
pravastatin oral tablet 40 mg T1 ST; QL (2 EA per 1 day)
pravastatin oral tablet 80 mg T1 ST
rosuvastatin T1
simvastatin T1
ZOCOR T2
Hypotensive Agents, Miscellaneous
BETAPACE T2
BETAPACE AF T2
CARDURA T2
carvedilol T1
COREG T2
DIBENZYLINE T2
doxazosin T1
INDERAL LA T2
phenoxybenzamine T1 PA
pindolol T1
propranolol T1
sotalol T1
SOTALOL AF T1
terazosin T1
timolol maleate T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
46
Drug Tier Notes
Loop Diuretics (Hypotensive Agents)
bumetanide T1
DEMADEX T2
furosemide T1
LASIX T2
torsemide T1
Mineralocorticoid (Aldosterone) Antagnts
ALDACTAZIDE T2
ALDACTONE T2
spironolactone T1
spironolacton-hydrochlorothiaz T1
Mineralocorticoid(Aldoster.)Antag(Hypot)
ALDACTAZIDE T2
ALDACTONE T2
spironolactone T1
spironolacton-hydrochlorothiaz T1
Nitrates And Nitrites
ISORDIL T2
isosorbide dinitrate T1
isosorbide mononitrate T1
NITRO-BID T2
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6
MG/HR
T2
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.3 MG/HR, 0.8 MG/HR
T1
nitroglycerin T1
NITROSTAT T1
NITRO-TIME T2
Peripheral Adrenergic Inhibitors
reserpine T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
47
Drug Tier Notes
Phosphodiesterase Type 5 Inhibitors
ADCIRCA T4 PA
cilostazol T1
PLETAL T2
REVATIO T4 PA
sildenafil T1 PA
Potassium-Sparing Diuretics (Hypoten)
ALDACTAZIDE T2
ALDACTONE T2
amiloride T1
amiloride-hydrochlorothiazide T1
DYAZIDE T2
DYRENIUM T1
MAXZIDE T2
MAXZIDE-25MG T2
spironolactone T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
Renin Inhibitors
AMTURNIDE T2 ST
TEKAMLO T2 ST
Thiazide Diuretics(Hypotensive Agents)
ACCURETIC T2
ALDACTAZIDE T2
amiloride-hydrochlorothiazide T1
AMTURNIDE T2 ST
AVALIDE T2 ST
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
48
Drug Tier Notes
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
bisoprolol-hydrochlorothiazide T1
captopril-hydrochlorothiazide T1
chlorothiazide T1
CORZIDE T2
DIURIL T1
DYAZIDE T2
enalapril-hydrochlorothiazide T1
hydrochlorothiazide T1
HYZAAR T2
irbesartan-hydrochlorothiazide T1 ST
lisinopril-hydrochlorothiazide T1
LOPRESSOR HCT T2
losartan-hydrochlorothiazide T1
LOTENSIN HCT T2
MAXZIDE T2
MAXZIDE-25MG T2
methyclothiazide T1
methyldopa-hydrochlorothiazide T1
metoprolol ta-hydrochlorothiaz T1
moexipril-hydrochlorothiazide T1
nadolol-bendroflumethiazide T1
propranolol-hydrochlorothiazid T1
quinapril-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
UNIRETIC T2
valsartan-hydrochlorothiazide T1 ST
VASERETIC T2
ZESTORETIC T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
49
Drug Tier Notes
ZIAC T2
Thiazide-Like Diuretics(Hypotensive Agt)
chlorthalidone T1
CLORPRES T1
indapamide T1
metolazone T1
ZAROXOLYN T2
Vasodilating Agents, Miscellaneous
ADALAT CC T2
amlodipine oral tablet 10 mg T1
amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)
AMTURNIDE T2 ST
aspirin-dipyridamole T1
CALAN T2
CALAN SR T2
CARDIZEM T2
CARDIZEM CD T2
diltiazem hcl T1
DILT-XR T2
dipyridamole T1
epoprostenol (glycine) T4 PA
FLOLAN T4 PA
ISOPTIN SR T2
LETAIRIS T4 PA
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 30 MG
T1
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 60 MG
T2
nifedipine oral capsule T1
nifedipine oral tablet extended release 24hr T1
nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
50
Drug Tier Notes
nifedipine oral tablet extended release 90 mg T1
NORVASC T2
OPSUMIT T4 PA
ORENITRAM T4 PA
PERSANTINE T2
PROCARDIA T2
PROCARDIA XL T2
REMODULIN T4 PA
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 180 MG, 240 MG
T1
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 300 MG, 360 MG
T2
TEKAMLO T2 ST
TIAZAC T2
TRACLEER T4 PA
TYVASO T4 PA
TYVASO REFILL KIT T4 PA
TYVASO STARTER KIT T4 PA
UPTRAVI T4 PA
VELETRI T4 PA
VENTAVIS T4 PA
verapamil T1
VERELAN T2
Cellular Therapy
Cellular Therapy
PROVENGE T4 PA
Central Nervous System Agents
Adamantanes (Cns)
amantadine hcl T1
Amphetamines
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
51
Drug Tier Notes
ADDERALL T2
ADDERALL XR T2
DEXEDRINE SPANSULE T2
dextroamphetamine T1 PA; AL
dextroamphetamine-amphetamine T1 PA; AL
VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30
MG, 40 MG, 50 MG, 60 MG, 70 MG
T1 PA; AL
VYVANSE ORAL TABLET,CHEWABLE T1
Analgesics And Antipyretics, Misc.
acetaminophen T1
acetaminophen-caff-dihydrocod T3
acetaminophen-codeine T1
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1
butalbital-acetaminophen T1
butalbital-acetaminophen-caff T1
CAPITAL WITH CODEINE T3
ED-APAP T1
ENDOCET ORAL TABLET 10-325 MG, 2.5-325
MG, 7.5-325 MG
T3
ENDOCET ORAL TABLET 5-325 MG T1
ESGIC T2
FIORICET WITH CODEINE T3
gabapentin T1
HORIZANT T4 PA
HYCET T3
hydrocodone-acetaminophen oral solution T1
hydrocodone-acetaminophen oral tablet 10-300
mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg
T3
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
52
Drug Tier Notes
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,
7.5-750 mg
T1
hydrocodone-acetaminophen oral tablet 10-650
mg
T2
LORTAB T2
LORTAB ELIXIR ORAL SOLUTION 10-300
MG/15 ML
T1
LORTAB ELIXIR ORAL SOLUTION 7.5-500
MG/15 ML
T2
MARTEN-TAB T2
NEURONTIN T2
oxycodone-acetaminophen oral capsule T1
oxycodone-acetaminophen oral solution T3
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 7.5-325 mg
T3
oxycodone-acetaminophen oral tablet 5-325 mg T1
PAIN RELIEF T2
PERCOCET ORAL TABLET 10-325 MG, 2.5-
325 MG, 7.5-325 MG
T3
PERCOCET ORAL TABLET 5-325 MG T2
PRIALT T4 PA
PRIMLEV T3
Q-PAP T1
tramadol-acetaminophen T3
TREZIX T3
TYLENOL-CODEINE #4 T2
ULTRACET T3
VERDROCET T3
VICODIN T3
VICODIN ES T3
VICODIN HP T3
XODOL 10/300 T3
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
53
Drug Tier Notes
XODOL 5/300 T3
XODOL 7.5/300 T3
ZAMICET T1
Anticholinergic Agents (Cns)
benztropine T1
trihexyphenidyl T1
Anticonvulsants, Miscellaneous
BANZEL T3 PA
carbamazepine T1
DEPAKENE T2
DEPAKOTE T2
DEPAKOTE ER T2
DEPAKOTE SPRINKLES T2
divalproex oral capsule, delayed rel sprinkle T1
divalproex oral tablet extended release 24 hr 250
mg
T1 QL (3 EA per 1 day)
divalproex oral tablet extended release 24 hr 500
mg
T1
divalproex oral tablet,delayed release (dr/ec) T1
gabapentin T1
HORIZANT T4 PA
KEPPRA T2
LAMICTAL T2
LAMICTAL STARTER (BLUE) KIT T1
LAMICTAL STARTER (GREEN) KIT T1
LAMICTAL STARTER (ORANGE) KIT T1
lamotrigine oral tablet 100 mg T1 QL (5 EA per 1 day)
lamotrigine oral tablet 150 mg, 200 mg T1
lamotrigine oral tablet 25 mg T1 QL (3 EA per 1 day)
lamotrigine oral tablet, chewable dispersible 25
mg
T1 QL (3 EA per 1 day)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
54
Drug Tier Notes
lamotrigine oral tablet, chewable dispersible 5 mg T1 QL (2 EA per 1 day)
levetiracetam T1
NEURONTIN T2
oxcarbazepine T1
SABRIL T4 PA
TEGRETOL T2
TEGRETOL XR T2
TOPAMAX T2
topiramate oral capsule, sprinkle T1
topiramate oral tablet 100 mg, 200 mg, 25 mg T1
topiramate oral tablet 50 mg T1 QL (6 EA per 1 day)
TRILEPTAL T2
valproic acid T1
valproic acid (as sodium salt) T1
Antidepressants, Miscellaneous
bupropion hcl T1
mirtazapine oral tablet T1 QL (1 EA per 1 day)
mirtazapine oral tablet,disintegrating T1
REMERON T2
REMERON SOLTAB T2
WELLBUTRIN T2
WELLBUTRIN SR T2
WELLBUTRIN XL T2
ZYBAN T2
Antimanic Agents
DEPAKENE T2
DEPAKOTE T2
DEPAKOTE ER T2
DEPAKOTE SPRINKLES T2
divalproex oral capsule, delayed rel sprinkle T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
55
Drug Tier Notes
divalproex oral tablet extended release 24 hr 250
mg
T1 QL (3 EA per 1 day)
divalproex oral tablet extended release 24 hr 500
mg
T1
divalproex oral tablet,delayed release (dr/ec) T1
lithium carbonate T1
lithium citrate T1
LITHOBID T2
valproic acid T1
valproic acid (as sodium salt) T1
Antimigraine Agents, Miscellaneous
ASCOMP WITH CODEINE T3
aspirin T1
aspirin-caffeine-dihydrocodein T3
BUTALBITAL COMPOUND W/CODEINE T1
BUTALBITAL COMPOUND-CODEINE T3
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1
butalbital-acetaminophen-caff T1
butalbital-aspirin-caffeine T1
CAFERGOT T2
codeine-butalbital-asa-caff T3
D.H.E.45 T2
DEPAKENE T2
DEPAKOTE T2
DEPAKOTE ER T2
DEPAKOTE SPRINKLES T2
dihydroergotamine injection T1 QL (12 ML per 30 days)
dihydroergotamine nasal T1 QL (1 QY per 30 DYs)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
56
Drug Tier Notes
divalproex oral capsule, delayed rel sprinkle T1
divalproex oral tablet extended release 24 hr 250
mg
T1 QL (3 EA per 1 day)
divalproex oral tablet extended release 24 hr 500
mg
T1
divalproex oral tablet,delayed release (dr/ec) T1
ERGOMAR T1 QL (20 EA per 30 days)
ESGIC T2
FIORICET WITH CODEINE T3
FIORINAL-CODEINE #3 T2
INDERAL LA T2
MIGRANAL T2 QL (1 QY per 30 DYs)
propranolol T1
SYNALGOS-DC T3
timolol maleate T1
tramadol-acetaminophen T3
ULTRACET T3
valproic acid T1
valproic acid (as sodium salt) T1
Antipsychotics, Miscellaneous
loxapine succinate T1 AL
pimozide T1 AL
Anxiolytics,Sedatives,And Hypnotics,Misc
AMBIEN T2
AMBIEN CR T3 PA
buspirone T1
droperidol T1
EDLUAR T3 PA
eszopiclone T1 ST
HETLIOZ T4 PA
hydroxyzine hcl T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
57
Drug Tier Notes
hydroxyzine pamoate T1
LUNESTA T3 PA
meprobamate T1
PHENERGAN T2
promethazine injection solution T1 QL (20 ML per 25 days)
promethazine injection syringe T1
promethazine oral T1
promethazine rectal T1
SLEEP AID (DOXYLAMINE) T1
SONATA T2
VISTARIL T2
zaleplon oral capsule 10 mg T1 QL (14 EA per 25 days)
zaleplon oral capsule 5 mg T1 QL (1 EA per 1 day)
zolpidem T1
Atypical Antipsychotics
ABILIFY T2 AL
ABILIFY MAINTENA T4 PA
aripiprazole oral solution T1 AL
aripiprazole oral tablet 10 mg, 15 mg T1 QL (1 EA per 1 DY); AL
aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg T1 AL
aripiprazole oral tablet,disintegrating 10 mg T1 QL (2 EA per 1 day); AL
aripiprazole oral tablet,disintegrating 15 mg T1 AL
ARISTADA T4 PA
clozapine oral tablet 100 mg, 200 mg, 50 mg T1 AL
clozapine oral tablet 25 mg T1 QL (3 EA per 1 day); AL
CLOZARIL T2 AL
GEODON T2 AL
INVEGA SUSTENNA T4 PA
INVEGA TRINZA T4 PA
LATUDA T1 AL
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
58
Drug Tier Notes
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg,
7.5 mg
T1 QL (1 EA per 1 day); AL
olanzapine oral tablet 20 mg T1 AL
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50
mg
T1 QL (3 EA per 1 day); AL
quetiapine oral tablet 300 mg, 400 mg T1 AL
quetiapine oral tablet extended release 24 hr T1 AL
RISPERDAL T2 AL
RISPERDAL CONSTA T4 PA
risperidone oral solution T1 AL
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg
T1 QL (2 EA per 1 day); AL
risperidone oral tablet 3 mg, 4 mg T1 AL
SAPHRIS T1 AL
SAPHRIS (BLACK CHERRY) T1 QL (2 EA per 1 day); AL
SEROQUEL T2 AL
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg T1 QL (2 EA per 1 day); AL
ziprasidone hcl oral capsule 80 mg T1 AL
ZYPREXA INTRAMUSCULAR T4 PA
ZYPREXA ORAL T2 AL
ZYPREXA RELPREVV T4 PA
Barbiturates (Anticonvulsants)
MYSOLINE T2
phenobarbital T1
primidone T1
Barbiturates (Anxiolytic, Sedative/Hyp)
ASCOMP WITH CODEINE T3
BUTALBITAL COMPOUND W/CODEINE T1
BUTALBITAL COMPOUND-CODEINE T3
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
59
Drug Tier Notes
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1
butalbital-acetaminophen T1
butalbital-acetaminophen-caff T1
butalbital-aspirin-caffeine T1
codeine-butalbital-asa-caff T3
ESGIC T2
FIORICET WITH CODEINE T3
FIORINAL-CODEINE #3 T2
MARTEN-TAB T2
phenobarbital T1
Benzodiazepines (Anticonvulsants)
ATIVAN T2
clonazepam T1
clorazepate dipotassium T1
DIASTAT T1 QL (2 QY per 30 DYs)
DIASTAT ACUDIAL T1 QL (2 QY per 30 DYs)
diazepam T1
KLONOPIN T2
lorazepam T1
TRANXENE T-TAB T2
Benzodiazepines (Anxiolytic,Sedativ/Hyp)
alprazolam T1 QL (4 EA per 1 day)
amitriptyline-chlordiazepoxide T1
ATIVAN T2
chlordiazepoxide hcl T1
clonazepam T1
clorazepate dipotassium T1
DIASTAT T1 QL (2 QY per 30 DYs)
DIASTAT ACUDIAL T1 QL (2 QY per 30 DYs)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
60
Drug Tier Notes
diazepam T1
estazolam T1
HALCION T2
KLONOPIN T2
lorazepam T1
oxazepam T1
RESTORIL T2
temazepam T1
TRANXENE T-TAB T2
triazolam T1
XANAX T2
Butyrophenones
haloperidol T1 AL
haloperidol decanoate T1
haloperidol lactate injection T1
haloperidol lactate oral T1 AL
Central Nervous System Agents, Misc.
atomoxetine T1 AL
guanfacine oral tablet T1
guanfacine oral tablet extended release 24 hr T1 AL
memantine T1 AL
NAMENDA T2 AL
NAMENDA TITRATION PAK T2 AL
riluzole T4 PA
TENEX T2
XENAZINE T4 PA
XYREM T4 PA
Cyclooxygenase-2 (Cox-2) Inhibitors
celecoxib oral capsule 100 mg, 200 mg, 50 mg T1 QL (2 EA per 1 day)
celecoxib oral capsule 400 mg T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
61
Drug Tier Notes
Dopamine Precursors
carbidopa-levodopa T1
SINEMET T2
SINEMET CR T2
Ergot-Deriv. Dopamine Receptor Agonists
bromocriptine T1
cabergoline T1 PA
PARLODEL T2
Fibromyalgia Agents
CYMBALTA T2
duloxetine oral capsule,delayed release(dr/ec) 20
mg
T1 QL (3 EA per 1 day)
duloxetine oral capsule,delayed release(dr/ec) 30
mg
T1 QL (2 EA per 1 day)
duloxetine oral capsule,delayed release(dr/ec) 60
mg
T1 QL (1 EA per 1 day)
SAVELLA ORAL TABLET 100 MG T1
SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50
MG
T1 QL (2 EA per 1 day)
SAVELLA ORAL TABLETS,DOSE PACK T1
Hydantoins
DILANTIN T2
DILANTIN EXTENDED T2
DILANTIN INFATABS T2
DILANTIN-125 T2
phenytoin T1
phenytoin sodium extended T1
Monoamine Oxidase B Inhibitors
ELDEPRYL T2
selegiline hcl T1
Monoamine Oxidase Inhibitors
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
62
Drug Tier Notes
ELDEPRYL T2
NARDIL T2
PARNATE T2
phenelzine T1
selegiline hcl T1
tranylcypromine T1
Nonergot-Deriv.Dopamine Receptor Agonist
APOKYN T4 PA
MIRAPEX T2
pramipexole T1
REQUIP T2
ropinirole T1
Opiate Agonists
ABSTRAL T3
acetaminophen-caff-dihydrocod T3
acetaminophen-codeine T1
ACTIQ T3
ASCOMP WITH CODEINE T3
aspirin-caffeine-dihydrocodein T3
belladonna alkaloids-opium T3
BELLADONNA-OPIUM T3
BUTALBITAL COMPOUND W/CODEINE T1
BUTALBITAL COMPOUND-CODEINE T3
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1
CAPITAL WITH CODEINE T3
codeine sulfate T3
codeine-butalbital-asa-caff T3
DEMEROL T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
63
Drug Tier Notes
DILAUDID T2
DOLOPHINE T2
DURAGESIC T2 QL (10 QY per 30 DYs)
ENDOCET ORAL TABLET 10-325 MG, 2.5-325
MG, 7.5-325 MG
T3
ENDOCET ORAL TABLET 5-325 MG T1
ENDODAN T2
fentanyl T1 QL (10 QY per 30 DYs)
fentanyl citrate T3
FENTORA T3
FIORICET WITH CODEINE T3
FIORINAL-CODEINE #3 T2
HYCET T3
hydrocodone-acetaminophen oral solution T1
hydrocodone-acetaminophen oral tablet 10-300
mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg
T3
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,
7.5-750 mg
T1
hydrocodone-acetaminophen oral tablet 10-650
mg
T2
hydrocodone-ibuprofen T3
hydromorphone T1
IBUDONE T3
ibuprofen-oxycodone T3
KADIAN ORAL CAPSULE,EXTEND.RELEASE
PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 50
MG, 60 MG, 80 MG
T2
KADIAN ORAL CAPSULE,EXTEND.RELEASE
PELLETS 200 MG
T1
LAZANDA T3
levorphanol tartrate T3
LORTAB T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
64
Drug Tier Notes
LORTAB ELIXIR ORAL SOLUTION 10-300
MG/15 ML
T1
LORTAB ELIXIR ORAL SOLUTION 7.5-500
MG/15 ML
T2
meperidine T1
methadone T1
morphine concentrate T1
morphine intramuscular T3
morphine oral capsule, er multiphase 24 hr T3 PA
morphine oral capsule,extend.release pellets 10
mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg
T1
morphine oral capsule,extend.release pellets 80
mg
T1 QL (2 EA per 1 day)
morphine oral solution T1
morphine oral tablet T1
morphine oral tablet extended release T1
morphine rectal T1
MS CONTIN T2
NUCYNTA T3
OPANA T3
OXAYDO T3
oxycodone oral capsule T1 QL (12 EA per 1 day)
oxycodone oral concentrate T2
oxycodone oral solution T3
oxycodone oral tablet 10 mg T1 QL (9 EA per 1 day)
oxycodone oral tablet 15 mg T1 QL (7 EA per 1 day)
oxycodone oral tablet 20 mg, 30 mg T1
oxycodone oral tablet 5 mg T1 QL (12 EA per 1 day)
oxycodone-acetaminophen oral capsule T1
oxycodone-acetaminophen oral solution T3
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 7.5-325 mg
T3
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
65
Drug Tier Notes
oxycodone-acetaminophen oral tablet 5-325 mg T1
oxycodone-aspirin T1
oxymorphone T3
PERCOCET ORAL TABLET 10-325 MG, 2.5-
325 MG, 7.5-325 MG
T3
PERCOCET ORAL TABLET 5-325 MG T2
PRIMLEV T3
PROMETHAZINE VC-CODEINE T1
REPREXAIN T3
ROXICODONE ORAL TABLET 15 MG, 30 MG T2
ROXICODONE ORAL TABLET 5 MG T3
SUBSYS T3
SYNALGOS-DC T3
tramadol T1
tramadol-acetaminophen T3
TREZIX T3
TYLENOL-CODEINE #4 T2
ULTRACET T3
ULTRAM T2
VERDROCET T3
VICODIN T3
VICODIN ES T3
VICODIN HP T3
VICOPROFEN T3
XODOL 10/300 T3
XODOL 5/300 T3
XODOL 7.5/300 T3
XYLON 10 T3
ZAMICET T1
Opiate Antagonists
naloxone T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
66
Drug Tier Notes
naltrexone T1
NARCAN T1
REVIA T2
VIVITROL T1 QL (1 EA per 30 days)
Opiate Partial Agonists
buprenorphine hcl T3 PA
buprenorphine-naloxone T1 PA
butorphanol tartrate T1 PA
nalbuphine T1
ZUBSOLV T3 PA
Other Nonsteroidal Anti-Inflam. Agents
ANAPROX T2
ANAPROX DS T2
CATAFLAM T2
CHILDREN'S IBUPROFEN T2
DAYPRO T2
diclofenac potassium T1
diclofenac sodium oral T1
diclofenac sodium topical T1 ST
EC-NAPROSYN T2
FELDENE T2
fenoprofen T1
hydrocodone-ibuprofen T3
IBUDONE T3
ibuprofen T1
ibuprofen-oxycodone T3
INDOCIN T1
indomethacin T1
INFANT'S IBUPROFEN T2
ketoprofen T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
67
Drug Tier Notes
meclofenamate T1
meloxicam oral tablet 15 mg T1
meloxicam oral tablet 7.5 mg T1 QL (1 EA per 1 DY)
MOBIC T2
NAPROSYN T2
naproxen T1
naproxen sodium T1
oxaprozin T1
piroxicam T1
REPREXAIN T3
VICOPROFEN T3
XYLON 10 T3
Phenothiazines
chlorpromazine T1 AL
fluphenazine decanoate T1
fluphenazine hcl injection T1
fluphenazine hcl oral T1 AL
perphenazine T1 AL
perphenazine-amitriptyline T1 AL
prochlorperazine T1
prochlorperazine edisylate T1 QL (20 ML per 30 days)
prochlorperazine maleate T1 AL
thioridazine T1 AL
trifluoperazine T1 AL
Respiratory And Cns Stimulants
acetaminophen-caff-dihydrocod T3
ASCOMP WITH CODEINE T3
aspirin-caffeine-dihydrocodein T3
BUTALBITAL COMPOUND W/CODEINE T1
BUTALBITAL COMPOUND-CODEINE T3
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
68
Drug Tier Notes
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg
T3
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
T1
butalbital-acetaminophen-caff T1
butalbital-aspirin-caffeine T1
CAFCIT T2
caffeine citrate T1
codeine-butalbital-asa-caff T3
CONCERTA T2 PA; AL
dexmethylphenidate oral capsule,er biphasic 50-
50 10 mg, 15 mg, 5 mg
T1 PA; QL (1 EA per 1 day); AL
dexmethylphenidate oral capsule,er biphasic 50-
50 20 mg
T1 PA; QL (2 EA per 1 day); AL
dexmethylphenidate oral capsule,er biphasic 50-
50 30 mg, 40 mg
T1 PA; AL
dexmethylphenidate oral tablet 10 mg T1 PA; AL
dexmethylphenidate oral tablet 2.5 mg, 5 mg T1 QL (4 EA per 1 day); AL
ESGIC T2
FIORICET WITH CODEINE T3
FIORINAL-CODEINE #3 T2
FOCALIN XR ORAL CAPSULE,ER BIPHASIC
50-50 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5
MG
T2 PA; AL
FOCALIN XR ORAL CAPSULE,ER BIPHASIC
50-50 25 MG, 35 MG
T1 PA; AL
methylphenidate hcl oral solution T1 AL
methylphenidate hcl oral tablet T1 PA; AL
methylphenidate hcl oral tablet extended release T1 PA; AL
methylphenidate hcl oral tablet extended release
24hr 18 mg, 27 mg, 54 mg
T1 PA; QL (1 EA per 1 day); AL
methylphenidate hcl oral tablet extended release
24hr 36 mg
T1 PA; QL (2 EA per 1 day); AL
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
69
Drug Tier Notes
methylphenidate hcl oral tablet,chewable T1 AL
RITALIN T2 PA; AL
RITALIN SR T2 PA; AL
SYNALGOS-DC T3
TREZIX T3
Salicylates
ASCOMP WITH CODEINE T3
aspirin T1
aspirin-caffeine-dihydrocodein T3
aspirin-dipyridamole T1
BUTALBITAL COMPOUND W/CODEINE T1
BUTALBITAL COMPOUND-CODEINE T3
butalbital-aspirin-caffeine T1
choline,magnesium salicylate T1
codeine-butalbital-asa-caff T3
ENDODAN T2
FIORINAL-CODEINE #3 T2
oxycodone-aspirin T1
salsalate T1
SYNALGOS-DC T3
Sel.Serotonin,Norepi Reuptake Inhibitor
CYMBALTA T2
duloxetine oral capsule,delayed release(dr/ec) 20
mg
T1 QL (3 EA per 1 day)
duloxetine oral capsule,delayed release(dr/ec) 30
mg
T1 QL (2 EA per 1 day)
duloxetine oral capsule,delayed release(dr/ec) 60
mg
T1 QL (1 EA per 1 day)
EFFEXOR XR T2
SAVELLA ORAL TABLET 100 MG T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
70
Drug Tier Notes
SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50
MG
T1 QL (2 EA per 1 day)
SAVELLA ORAL TABLETS,DOSE PACK T1
venlafaxine oral capsule,extended release 24hr
150 mg
T1
venlafaxine oral capsule,extended release 24hr
37.5 mg, 75 mg
T1 QL (1 EA per 1 day)
venlafaxine oral tablet 100 mg T1
venlafaxine oral tablet 25 mg, 37.5 mg, 50 mg, 75
mg
T1 QL (3 EA per 1 day)
venlafaxine oral tablet extended release 24hr 150
mg, 225 mg
T1
venlafaxine oral tablet extended release 24hr 37.5
mg, 75 mg
T1 QL (1 EA per 1 day)
Selective Serotonin Agonists
AMERGE T3 PA; QL (12 QY per 30 DYs)
eletriptan hbr T3 PA; QL (12 EA per 30 days)
FROVA T3 PA; QL (12 QY per 30 DYs)
IMITREX ORAL T2 QL (12 QY per 30 DYs)
IMITREX STATDOSE KIT REFILL T2 QL (2 QY per 30 DYs)
IMITREX STATDOSE PEN T2 QL (2 QY per 30 DYs)
IMITREX SUBCUTANEOUS T2 QL (4 QY per 30 DYs)
MAXALT T2 QL (12 QY per 30 DYs)
MAXALT-MLT T2 QL (12 QY per 30 DYs)
rizatriptan T1 QL (12 QY per 30 DYs)
sumatriptan T1 QL (6 QY per 30 DYs)
sumatriptan succinate oral T1 QL (12 QY per 30 DYs)
sumatriptan succinate subcutaneous cartridge T1 QL (2 QY per 30 DYs)
sumatriptan succinate subcutaneous pen injector T1 QL (2 QY per 30 DYs)
sumatriptan succinate subcutaneous solution T1 QL (4 QY per 30 DYs)
ZOMIG T3 PA; QL (1 QY per 30 DYs)
Selective-Serotonin Reuptake Inhibitors
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
71
Drug Tier Notes
CELEXA T2
citalopram T1
escitalopram oxalate T1
fluoxetine T1
fluvoxamine T1
LEXAPRO T2
paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg T1
paroxetine hcl oral tablet 20 mg T1 QL (1 EA per 1 day)
PAXIL T2
PROZAC T2
sertraline oral concentrate T1
sertraline oral tablet 100 mg T1
sertraline oral tablet 25 mg, 50 mg T1 QL (1 EA per 1 day)
ZOLOFT T2
Serotonin Modulators
nefazodone T1
trazodone T1
Succinimides
ethosuximide T1
ZARONTIN T2
Thioxanthenes
thiothixene T1 AL
Tricyclics, Other Norepi-Ru Inhibitors
amitriptyline T1
amitriptyline-chlordiazepoxide T1
amoxapine T1
ANAFRANIL T2
clomipramine T1
desipramine T1
doxepin T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
72
Drug Tier Notes
imipramine hcl T1
maprotiline T1
NORPRAMIN T2
nortriptyline T1
PAMELOR T2
perphenazine-amitriptyline T1
TOFRANIL T2
Devices
Devices
1ST TIER UNIFINE PENTIPS T1 QL (100 EA per 20 days)
1ST TIER UNIFINE PENTIPS PLUS T1 QL (100 EA per 20 days)
ACCU-CHEK AVIVA CONTROL SOLN T1
ACCU-CHEK AVIVA PLUS METER T1
ACCU-CHEK FASTCLIX T1
ACCU-CHEK GUIDE GLUCOSE METER T1
ACCU-CHEK GUIDE L1-L2 CTRL SOL T1
ACCU-CHEK MULTICLIX LANCET T1
ACCU-CHEK NANO T1
ACCU-CHEK SMARTVIEW CONTRL SOL T1
ACCU-CHEK SOFT DEV LANCETS T1
ACCU-CHEK SOFTCLIX LANCET DEV T1
ACCU-CHEK SOFTCLIX LANCETS T1
EUFLEXXA T4 PA
GEL-ONE T4 PA
HYALGAN T4 PA
MEDI-JECTOR NEEDLE-FREE SYR A T1 QL (1 EA per 365 days)
MEDI-JECTOR NEEDLE-FREE SYR B T1 QL (1 EA per 365 days)
MEDI-JECTOR NEEDLE-FREE SYR C T1 QL (1 EA per 365 days)
MONOVISC T4 PA
NEEDLE FREE SYRINGE KIT A T1 QL (100 EA per 20 days)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
73
Drug Tier Notes
NEEDLE FREE SYRINGE KIT B T1 QL (100 EA per 20 days)
NEUROPEN T1 QL (1 EA per 365 days)
NEUROTIPS T1 QL (1 EA per 365 days)
ORTHOVISC T4 PA
PEN NEEDLE T1 QL (100 EA per 20 days)
pen needle, diabetic T1 QL (100 EA per 20 days)
PENTIPS T1 QL (100 EA per 20 days)
SOFT TOUCH LANCETS T1
SOLESTA T4 PA
SYNVISC T4 PA
SYNVISC-ONE T4 PA
UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2",
30 GAUGE X 5/16", 31 GAUGE X 1/4", 31
GAUGE X 5/16"
T1 QL (100 EA per 20 days)
UNIFINE PENTIPS NEEDLE 29 GAUGE X
5/16"
T1 QL (1 EA per 365 days)
UNIFINE PENTIPS PLUS T1 QL (100 EA per 20 days)
Diagnostic Agents
Adrenocortical Insufficiency
ACTHREL T4 PA
Diabetes Mellitus
ACCU-CHEK AVIVA PLUS TEST STRP T1
ACCU-CHEK GUIDE T1
ACCU-CHEK SMARTVIEW TEST STRIP T1
Pituitary Function
ACTHREL T4 PA
Protein
ALBUSTIX REAGENT T1
Thyroid Function
THYROGEN T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
74
Drug Tier Notes
Electrolytic, Caloric, And Water Balance
Alkalinizing Agents
potassium citrate T1
sodium citrate-citric acid T1
UROCIT-K 10 T2
UROCIT-K 5 T2
Ammonia Detoxicants
CARBAGLU T4 PA
lactulose T1
Caloric Agents
glucose T1
Carbonic Anhydrase Inhibitors
acetazolamide T1
DIAMOX SEQUELS T2 PA
Diuretics, Miscellaneous
THEO-24 T1
theophylline T1
Loop Diuretics
bumetanide T1
DEMADEX T2
furosemide T1
LASIX T2
torsemide T1
Phosphate-Removing Agents
calcium acetate T1
FOSRENOL T1
PHOSLO T2
sevelamer carbonate T1
Potassium-Removing Agents
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
75
Drug Tier Notes
SPS (WITH SORBITOL) T1
Potassium-Sparing Diuretics
ALDACTAZIDE T2
ALDACTONE T2
amiloride T1
amiloride-hydrochlorothiazide T1
DYAZIDE T2
DYRENIUM T1
MAXZIDE T2
MAXZIDE-25MG T2
spironolactone T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
Replacement Preparations
ANTACID EXTRA-STRENGTH T1
CALCITRATE T2
CALCIUM 600 T1
CALCIUM 600 + D(3) T2
CALCIUM ANTACID T1
calcium carbonate T1
calcium carbonate-vitamin d2 T1
calcium carbonate-vitamin d3 T1
calcium citrate T1
calcium citrate-vitamin d3 T1
CITRACAL + D3 (CALCIUM PHOS) T1
CITRUS CALCIUM T2
DAILY PRENATAL T1
KLOR-CON T1
KLOR-CON M10 T2
KLOR-CON M20 T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
76
Drug Tier Notes
LIQUID CALCIUM WITH VITAMIN D T1
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
OYSTER SHELL CALCIUM 500 T2
OYSTER SHELL CALCIUM-VIT D2 T1
OYSTER SHELL CALCIUM-VIT D3 ORAL
TABLET 250-125 MG-UNIT
T1
OYSTER SHELL CALCIUM-VIT D3 ORAL
TABLET 500 MG(1,250MG) -400 UNIT
T2
PEDIATRIC ELECTROLYTE T1
potassium chloride T1
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENATAL VITAMIN T1
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
TRIVEEN-DUO DHA T1
TUMS T2
TUMS ULTRA T2
Thiazide Diuretics
ACCURETIC T2
ALDACTAZIDE T2
amiloride-hydrochlorothiazide T1
AMTURNIDE T2 ST
AVALIDE T2 ST
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg
T1 QL (2 EA per 1 day)
benazepril-hydrochlorothiazide oral tablet 20-25
mg
T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
77
Drug Tier Notes
bisoprolol-hydrochlorothiazide T1
captopril-hydrochlorothiazide T1
chlorothiazide T1
CORZIDE T2
DIURIL T1
DYAZIDE T2
enalapril-hydrochlorothiazide T1
hydrochlorothiazide T1
HYZAAR T2
irbesartan-hydrochlorothiazide T1 ST
lisinopril-hydrochlorothiazide T1
LOPRESSOR HCT T2
losartan-hydrochlorothiazide T1
LOTENSIN HCT T2
MAXZIDE T2
MAXZIDE-25MG T2
methyclothiazide T1
methyldopa-hydrochlorothiazide T1
metoprolol ta-hydrochlorothiaz T1
moexipril-hydrochlorothiazide T1
nadolol-bendroflumethiazide T1
propranolol-hydrochlorothiazid T1
quinapril-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
UNIRETIC T2
valsartan-hydrochlorothiazide T1 ST
VASERETIC T2
ZESTORETIC T2
ZIAC T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
78
Drug Tier Notes
Thiazide-Like Diuretics
chlorthalidone T1
CLORPRES T1
indapamide T1
metolazone T1
ZAROXOLYN T2
Uricosuric Agents
probenecid T1
probenecid-colchicine T1
Vasopressin Antagonists
SAMSCA T4 PA
Enzymes
Enzymes
ACTIVASE T4 PA
ADAGEN T4 PA
ALDURAZYME T4 PA
CATHFLO ACTIVASE T4 PA
CEREZYME T4 PA
ELAPRASE T4 PA
ELELYSO T4 PA
ELITEK T4 PA
FABRAZYME T4 PA
MYOZYME T4 PA
NAGLAZYME T4 PA
PULMOZYME T4 PA
SUCRAID T4 PA
VIMIZIM T4 PA
VORAXAZE T4 PA
VPRIV T4 PA
XIAFLEX T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
79
Drug Tier Notes
Eye, Ear, Nose And Throat (Eent) Preps.
Alpha-Adrenergic Agonists (Eent)
ALPHAGAN P T2
brimonidine T1
Antiallergic Agents
ALAWAY T2 QL (1 QY per 30 DYs)
ASTELIN T2
ASTEPRO T2
azelastine T1
cromolyn T1
ketotifen fumarate T1 QL (1 QY per 30 DYs)
PATADAY T1 ST; QL (1 QY per 30 DYs)
ZADITOR T2 QL (1 QY per 30 DYs)
Antibacterials (Eent)
bacitracin-polymyxin b T1
BLEPH-10 T2
CILOXAN T2
CIPRODEX T3 PA; ST
ciprofloxacin hcl T1 QL (10 ML per 25 days)
CORTISPORIN T2
erythromycin T1 QL (3.5 GM per 25 days)
GENTAK T1 QL (4 GM per 30 days)
gentamicin T1
MAXITROL T2
MOXEZA T1
moxifloxacin T1 QL (3 ML per 30 days)
neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)
neomycin-bacitracin-polymyxin T1 QL (4 GM per 30 days)
neomycin-polymyxin b-dexameth ophthalmic
drops,suspension
T1 QL (5 ML per 30 days)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
80
Drug Tier Notes
neomycin-polymyxin b-dexameth ophthalmic
ointment
T1 QL (4 GM per 30 days)
neomycin-polymyxin-gramicidin T1 QL (10 ML per 25 days)
neomycin-polymyxin-hc T1
NEOSPORIN (NEO-POLYM-GRAMICID) T2
OCUFLOX T2
ofloxacin ophthalmic T1 QL (10 ML per 25 days)
ofloxacin otic T1
polymyxin b sulf-trimethoprim T1 QL (10 ML per 30 days)
POLYTRIM T2
sulfacetamide sodium T1
sulfacetamide-prednisolone T1
TOBRADEX T2
tobramycin T1 QL (5 ML per 25 days)
tobramycin-dexamethasone T1
TOBREX OPHTHALMIC DROPS T2
TOBREX OPHTHALMIC OINTMENT T1 QL (4 GM per 30 days)
Antivirals (Eent)
trifluridine T1 QL (8 ML per 25 days)
VIROPTIC T2
Beta-Adrenergic Blocking Agents (Eent)
BETAGAN T2
carteolol T1
COSOPT T2
dorzolamide-timolol T1
levobunolol T1
timolol maleate T1
TIMOPTIC T2
TIMOPTIC OCUDOSE (PF) T1
TIMOPTIC-XE T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
81
Drug Tier Notes
Carbonic Anhydrase Inhibitors (Eent)
acetazolamide T1
COSOPT T2
DIAMOX SEQUELS T2 PA
dorzolamide T1
dorzolamide-timolol T1
TRUSOPT T2
Corticosteroids (Eent)
ACETASOL HC T2
CIPRODEX T3 PA; ST
dexamethasone sodium phosphate T1
fluorometholone T1
fluticasone T1
FML FORTE T1
FML LIQUIFILM T2
FML S.O.P. T1
hydrocortisone-acetic acid T1
MAXIDEX T1
MAXITROL T2
neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)
neomycin-polymyxin b-dexameth ophthalmic
drops,suspension
T1 QL (5 ML per 30 days)
neomycin-polymyxin b-dexameth ophthalmic
ointment
T1 QL (4 GM per 30 days)
neomycin-polymyxin-hc T1
OMNARIS T3 PA
OZURDEX T4 PA
PRED FORTE T2
PRED MILD T1
prednisolone acetate T1
prednisolone sodium phosphate T1 QL (10 ML per 30 days)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
82
Drug Tier Notes
RETISERT T4 PA
TOBRADEX T2
tobramycin-dexamethasone T1
triamcinolone acetonide T1 ST
Eent Anti-Infectives, Miscellaneous
ACETASOL HC T2
acetic acid T1
acetic acid-aluminum acetate T1
chlorhexidine gluconate T1
hydrocortisone-acetic acid T1
PERIOGARD T2
Eent Anti-Inflammatory Agents, Misc.
RESTASIS T1 PA
Eent Drugs, Miscellaneous
apraclonidine T1
ARTIFICIAL TEARS (POLYVIN ALC) T2
ATROVENT T2
CYSTARAN T4 PA
EYLEA T4 PA
IOPIDINE OPHTHALMIC DROPPERETTE T1
IOPIDINE OPHTHALMIC DROPS T2
ipratropium bromide T1
JETREA (PF) T4 PA
LUCENTIS T4 PA
MACUGEN T4 PA
polyvinyl alcohol T1
TEARS NATURALE FREE (PF) T1
TEARS NATURALE II T1
VISUDYNE T4 PA
Eent Nonsteroidal Anti-Inflam. Agents
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
83
Drug Tier Notes
ACULAR T2
ACULAR LS T2
flurbiprofen sodium T1 QL (2.5 ML per 30 days)
ketorolac ophthalmic drops 0.4 % T1 QL (5 ML per 30 days)
ketorolac ophthalmic drops 0.5 % T1 QL (20 ML per 25 days)
OCUFEN T2
Local Anesthetics (Eent)
lidocaine hcl T1
LIDOCAINE VISCOUS T1
XYLOCAINE T2
Miotics
ISOPTO CARBACHOL T2
PHOSPHOLINE IODIDE T1
pilocarpine hcl T1
PILOPINE HS T1
Mydriatics
atropine T1
cyclopentolate T1
Prostaglandin Analogs
latanoprost T1 QL (6 ML per 30 days)
travoprost (benzalkonium) T1 ST; QL (5 ML per 30 days)
XALATAN T2
Vasoconstrictors
ADRENALIN T1
MYDFRIN T2
naphazoline T1
NEO-SYNEPHRINE (PHENYLEPHRINE) T2
phenylephrine hcl T1
Gastrointestinal Drugs
5-Ht3 Receptor Antagonists
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
84
Drug Tier Notes
ALOXI T4 PA
granisetron hcl T1 ST
ondansetron T1
ondansetron hcl T1
ZOFRAN (AS HYDROCHLORIDE) T2
ZOFRAN ODT T2
Antacids And Adsorbents
aluminum hydroxide gel T1
ANTACID EXTRA-STRENGTH T1
ANTACID PLUS ANTI-GAS T1
bismuth subsalicylate T1
CALCIUM ANTACID T1
magnesium oxide T1
PEPTO-BISMOL T2
PINK BISMUTH T1
sodium bicarbonate T1
TUMS T2
TUMS ULTRA T2
URO-MAG T1
Antidiarrhea Agents
bismuth subsalicylate T1
diphenoxylate-atropine T1
LOMOTIL T2
loperamide T1
PEPTO-BISMOL T2
PINK BISMUTH T1
Antiemetics, Miscellaneous
DICLEGIS T1 PA
scopolamine base T3 PA
Antiflatulents
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
85
Drug Tier Notes
ANTACID PLUS ANTI-GAS T1
Antihistamines (Gi Drugs)
ANTIVERT T2
DICLEGIS T1 PA
meclizine T1
prochlorperazine T1
prochlorperazine edisylate T1 QL (20 ML per 30 days)
prochlorperazine maleate T1
TIGAN T2
trimethobenzamide T1
Anti-Inflammatory Agents (Gi Drugs)
AZULFIDINE T2
AZULFIDINE EN-TABS T2
balsalazide T1
CANASA T1
COLAZAL T2
DELZICOL T1
mesalamine T1
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 250 MG
T1 QL (6 EA per 1 day)
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 500 MG
T1
sulfasalazine T1
Cathartics And Laxatives
AMITIZA ORAL CAPSULE 24 MCG T1
AMITIZA ORAL CAPSULE 8 MCG T1 QL (2 EA per 1 day)
bisacodyl T1
COL-RITE T1
COLYTE WITH FLAVOR PACKS T2
docusate calcium T1
docusate sodium T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
86
Drug Tier Notes
FLEET LAXATIVE T1
GAVILYTE-G T1
GOLYTELY T2
MILK OF MAGNESIA T1
MINERAL OIL HEAVY T1
MIRALAX T2
NATURAL FIBER LAXATIVE (SUGAR) T1
NATURAL FIBER LAXATIVE THERAPY T1
NULYTELY WITH FLAVOR PACKS T2
peg 3350-electrolytes T1
peg-electrolyte soln T1
polyethylene glycol 3350 T1
SENNA T1
SENNA-S T2
sennosides-docusate sodium T1
SILACE T2
TRILYTE WITH FLAVOR PACKETS T2
Cholelitholytic Agents
ACTIGALL T2
URSO 250 T2
URSO FORTE T2
ursodiol T1
Digestants
CREON T1
ZENPEP T1
Gi Drugs, Miscellaneous
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
ENTYVIO T4 PA
GATTEX 30-VIAL T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
87
Drug Tier Notes
HUMIRA T4 PA
HUMIRA PEN T4 PA
LINZESS ORAL CAPSULE 145 MCG, 290 MCG T1 AL
LINZESS ORAL CAPSULE 72 MCG T1
REMICADE T4 PA
Histamine H2-Antagonists
cimetidine T1
cimetidine hcl T1
famotidine T1
nizatidine oral capsule 150 mg T1 QL (2 EA per 1 day)
nizatidine oral capsule 300 mg T1
PEPCID T2
ranitidine hcl T1
ZANTAC T2
Neurokinin-1 Receptor Antagonists
EMEND INTRAVENOUS T4 PA
EMEND ORAL CAPSULE 125 MG, 80 MG T1
EMEND ORAL CAPSULE 40 MG T1 QL (1 QY per 30 DYs)
EMEND ORAL CAPSULE,DOSE PACK T1
Prokinetic Agents
metoclopramide hcl T1
REGLAN T2
Prostaglandins
CYTOTEC T2
misoprostol T1
Protectants
CARAFATE T2
sucralfate T1
Proton-Pump Inhibitors
ACIPHEX T3 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
88
Drug Tier Notes
esomeprazole magnesium T3 PA
lansoprazole T1 ST; QL (1 EA per 1 day)
NEXIUM 24HR T1 ST; QL (1 EA per 1 day)
NEXIUM PACKET T3 PA
omeprazole T1 QL (1 EA per 1 day)
omeprazole-sodium bicarbonate T1 ST
pantoprazole T1 QL (1 EA per 1 day)
PREVACID 24HR T1 ST; QL (1 EA per 1 day)
PRILOSEC T1 QL (1 EA per 1 day); AL
PRILOSEC OTC T3 PA
PROTONIX ORAL GRANULES DR FOR SUSP
IN PACKET
T3 PA
PROTONIX ORAL TABLET,DELAYED
RELEASE (DR/EC)
T2
rabeprazole T3 PA
ZEGERID T3 PA
ZEGERID OTC T2 ST
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET T1
CUPRIMINE T4 PA
deferoxamine T4 PA
DEPEN TITRATABS T4 PA
EXJADE T4 PA
FERRIPROX T4 PA
GALZIN T4 PA
JADENU T4 PA
JADENU SPRINKLE T4 PA
SYPRINE T4 PA
Hormones And Synthetic Substitutes
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
89
Drug Tier Notes
Adrenals
ARNUITY ELLIPTA T1
ASMANEX HFA T1
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (30 DOSES), 220 MCG (120 DOSES), 220
MCG (30 DOSES), 220 MCG (60 DOSES)
T1 QL (1 QY per 30 DYs)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (7 DOSES)
T1 QL (1 QY per 7 DYs)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 220
MCG (14 DOSES)
T1 QL (1 QY per 14 DYs)
BREO ELLIPTA T1
budesonide inhalation suspension for nebulization
0.25 mg/2 ml
T1 QL (60 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
0.5 mg/2 ml
T1 QL (120 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
1 mg/2 ml
T1 QL (60 ML per 30 DYs); AL
CORTEF T2
cortisone T1
dexamethasone T1
DEXAMETHASONE INTENSOL T1
dexamethasone sodium phos (pf) T1
dexamethasone sodium phosphate T1
DULERA T1 QL (13 QY per 30 DYs); AL
EMFLAZA T4 PA
ENTOCORT EC T3 PA
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION
T1 QL (120 QY per 30 DYs)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION
T1 QL (240 QY per 30 DYs)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
90
Drug Tier Notes
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 50 MCG/ACTUATION
T1 QL (60 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION
T1 QL (12 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 220 MCG/ACTUATION
T1 QL (24 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 44 MCG/ACTUATION
T1 QL (10.6 QY per 30 DYs)
fludrocortisone T1
hydrocortisone T1
MEDROL T2
MEDROL (PAK) T2
methylprednisolone T1
ORAPRED T2
prednisolone T1
prednisolone sodium phosphate T1
prednisone T1
PREDNISONE INTENSOL T1
PRELONE T2
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.25 MG/2 ML, 1 MG/2
ML
T2 QL (60 QY per 30 DYs); AL
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.5 MG/2 ML
T2 QL (120 QY per 30 DYs); AL
QVAR INHALATION AEROSOL 40
MCG/ACTUATION
T1 QL (8.7 QY per 30 DYs)
QVAR INHALATION AEROSOL 80
MCG/ACTUATION
T1 QL (17.4 QY per 30 DYs)
Androgens
AVEED T4 PA
danazol T1 PA
fluoxymesterone T1 PA
TESTIM T3 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
91
Drug Tier Notes
TESTOPEL T4 PA
testosterone T1 PA
testosterone cypionate T1 PA
testosterone enanthate T1 PA; QL (1 QY per 30 DYs)
Antidiabetic Agents, Miscellaneous
WELCHOL T1
Antithyroid Agents
methimazole T1
propylthiouracil T1
SSKI T1
TAPAZOLE T2
Biguanides
glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
GLUCOPHAGE T2
GLUCOPHAGE XR T2
GLUCOVANCE T2
glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)
glyburide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
JANUMET T1 ST
JANUMET XR T1 ST
metformin oral tablet T1
metformin oral tablet extended release 24 hr 500
mg
T1
metformin oral tablet extended release 24 hr 750
mg
T1 QL (2 EA per 1 day)
Contraceptives
APRI T2
ARANELLE (28) T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
92
Drug Tier Notes
AVIANE T2
BALZIVA (28) T1
CAMILA T2
CAMRESE T1
CRYSELLE (28) T1
CYCLESSA (28) T2
desog-e.estradiol/e.estradiol T1
DESOGEN T2
desogestrel-ethinyl estradiol T2
drospirenone-ethinyl estradiol T1
ELLA T1
ENPRESSE T1
ERRIN T2
ESTROSTEP FE-28 T2
FEMCON FE T2
INTROVALE T2
JOLESSA T2
JOLIVETTE T2
JUNEL 1.5/30 (21) T1
JUNEL 1/20 (21) T2
JUNEL FE 1.5/30 (28) T2
JUNEL FE 1/20 (28) T2
KARIVA (28) T2
KELNOR 1/35 (28) T1
KURVELO T2
LEENA 28 T1
LESSINA T2
levonorgestrel-ethinyl estrad T1
LEVORA-28 T2
LOESTRIN 1.5/30 (21) T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
93
Drug Tier Notes
LOESTRIN 1/20 (21) T2
LOESTRIN 24 FE T1
LOESTRIN FE 1.5/30 (28-DAY) T1
LOESTRIN FE 1/20 (28-DAY) T2
LOW-OGESTREL (28) T1
LUTERA (28) T2
MICROGESTIN 1.5/30 (21) T1
MICROGESTIN 1/20 (21) T2
MICROGESTIN FE 1.5/30 (28) T1
MICROGESTIN FE 1/20 (28) T2
MIRCETTE (28) T2
MODICON (28) T2
MONONESSA (28) T2
NECON 1/35 (28) T1
NECON 1/50 (28) T1
NECON 7/7/7 (28) T1
NEXT CHOICE ONE DOSE T1
NORA-BE T2
norethindrone (contraceptive) T1
norethindrone ac-eth estradiol T1
norethindrone-e.estradiol-iron T1
norgestimate-ethinyl estradiol T1
NORINYL 1/35 (28) T2
NORTREL 0.5/35 (28) T1
NORTREL 1/35 (21) T1
NORTREL 1/35 (28) T1
NORTREL 7/7/7 (28) T1
NUVARING T1 QL (1 EA per 28 DYs)
OCELLA T2
OGESTREL (28) T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
94
Drug Tier Notes
ORTHO TRI-CYCLEN (28) T2
ORTHO TRI-CYCLEN LO (28) T2
ORTHO-NOVUM 1/35 (28) T2
OVCON-35 (28) T2
PLAN B T2
PLAN B ONE-STEP T1
PORTIA T2
QUASENSE T2
RECLIPSEN (28) T1
SEASONIQUE T2
SPRINTEC (28) T2
SRONYX T2
TILIA FE T1
TRINESSA (28) T1
TRI-NORINYL (28) T2
TRI-SPRINTEC (28) T2
TRIVORA (28) T1
VELIVET TRIPHASIC REGIMEN (28) T1
XULANE T1 QL (3 EA per 28 days)
YASMIN (28) T2
ZENCHENT FE T1
ZOVIA 1/35E (28) T1
ZOVIA 1/50E (28) T1
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors
JANUMET T1 ST
JANUMET XR T1 ST
JANUVIA T1 ST
Estrogen Agonist-Antagonists
raloxifene T1
Estrogens
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
95
Drug Tier Notes
CLIMARA T2
ESTRACE ORAL T2
ESTRACE VAGINAL T1
estradiol T1
estropipate T1
FEMHRT LOW DOSE T2
JINTELI T2
MENEST T1
norethindrone ac-eth estradiol T1
PREMARIN T1
PREMPHASE T1
PREMPRO T1
Glycogenolytic Agents
GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)
GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)
Gonadotropins
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
leuprolide T4 PA
LUPANETA PACK (1 MONTH) T4 PA
LUPANETA PACK (3 MONTH) T4 PA
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT (6 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
VANTAS T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
96
Drug Tier Notes
ZOLADEX T4 PA
Incretin Mimetics
TRULICITY T1 ST
VICTOZA 2-PAK T1 ST
VICTOZA 3-PAK T1 ST
Insulins
APIDRA T1 QL (3 QY per 30 DYs)
APIDRA SOLOSTAR T1 QL (2 QY per 30 DYs)
BASAGLAR KWIKPEN T1 QL (30 ML per 30 DYs)
HUMALOG KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 50-50 T1 QL (3 QY per 30 DYs)
HUMALOG MIX 50-50 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG MIX 75-25 T1 QL (3 QY per 30 DYs)
HUMALOG MIX 75-25 KWIKPEN T1 QL (2 QY per 30 DYs)
HUMALOG SUBCUTANEOUS CARTRIDGE T1 QL (2 QY per 30 DYs)
HUMALOG SUBCUTANEOUS SOLUTION T1 QL (3 QY per 30 DYs)
HUMULIN 70/30 T1 QL (3 QY per 30 DYs)
HUMULIN N T1 QL (3 QY per 30 DYs)
HUMULIN R U-100 T1 QL (3 QY per 30 DYs)
HUMULIN R U-500 (CONCENTRATED) T1
Parathyroid
calcitonin (salmon) T1
FORTEO T4 PA
MIACALCIN INJECTION T4 PA
MIACALCIN NASAL T2
TYMLOS T4 PA
Pituitary
DDAVP NASAL T2 PA
DDAVP ORAL T2 PA; AL
desmopressin nasal T1 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
97
Drug Tier Notes
desmopressin oral T1 PA; AL
GENOTROPIN T4 PA
GENOTROPIN MINIQUICK T4 PA
HUMATROPE T4 PA
NORDITROPIN FLEXPRO T4 PA
NORDITROPIN NORDIFLEX T4 PA
NUTROPIN AQ T4 PA
NUTROPIN AQ NUSPIN T4 PA
OMNITROPE T4 PA
SAIZEN T4 PA
SAIZEN CLICK.EASY T4 PA
SEROSTIM T4 PA
STIMATE T1 PA
Progestins
AYGESTIN T2
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
T1
DEPO-PROVERA INTRAMUSCULAR
SUSPENSION
T2
FEMHRT LOW DOSE T2
JINTELI T2
LUPANETA PACK (1 MONTH) T4 PA
LUPANETA PACK (3 MONTH) T4 PA
MAKENA T4 PA
medroxyprogesterone intramuscular T1 QL (1 ML per 30 days)
medroxyprogesterone oral T1
norethindrone acetate T1
norethindrone ac-eth estradiol T1
PROVERA T2
Somatostatin Agonists
octreotide acetate T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
98
Drug Tier Notes
SANDOSTATIN T4 PA
SANDOSTATIN LAR DEPOT T4 PA
SIGNIFOR T4 PA
SOMATULINE DEPOT T4 PA
Somatotropin Agonists
EGRIFTA T4 PA
INCRELEX T4 PA
Somatotropin Antagonists
SOMAVERT T4 PA
Sulfonylureas
AMARYL T2
DIABETA T2
glimepiride oral tablet 1 mg, 2 mg T1 QL (3 EA per 1 day)
glimepiride oral tablet 4 mg T1
glipizide oral tablet 10 mg T1
glipizide oral tablet 5 mg T1 QL (5 EA per 1 day)
glipizide oral tablet extended release 24hr 10 mg T1
glipizide oral tablet extended release 24hr 2.5 mg,
5 mg
T1 QL (3 EA per 1 day)
glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
GLUCOTROL T2
GLUCOTROL XL T2
GLUCOVANCE T2
glyburide micronized oral tablet 1.5 mg, 3 mg T1 QL (3 EA per 1 day)
glyburide micronized oral tablet 6 mg T1
glyburide oral tablet 1.25 mg, 2.5 mg T1 QL (3 EA per 1 day)
glyburide oral tablet 5 mg T1
glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
99
Drug Tier Notes
glyburide-metformin oral tablet 2.5-500 mg, 5-500
mg
T1
GLYNASE T2
Thyroid Agents
ARMOUR THYROID T1
CYTOMEL T2
levothyroxine T1
liothyronine T1
NATURE-THROID T1
SYNTHROID T2
THYROLAR-1 T1
THYROLAR-1/2 T1
THYROLAR-1/4 T1
THYROLAR-2 T1
THYROLAR-3 T1
UNITHROID T2
Miscellaneous Therapeutic Agents
5-Alpha-Reductase Inhibitors
dutasteride T1
finasteride T1
PROSCAR T2
Alcohol Deterrents
ANTABUSE T2
disulfiram T1
naltrexone T1
REVIA T2
VIVITROL T1 QL (1 EA per 30 days)
Antidotes
CHEMET T1
deferoxamine T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
100
Drug Tier Notes
FOSRENOL T1
FUSILEV T4 PA
GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)
GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)
leucovorin calcium T4 PA
MEPHYTON T1
naloxone T1
NARCAN T1
sevelamer carbonate T1
SPS (WITH SORBITOL) T1
SSKI T1
VORAXAZE T4 PA
Antigout Agents
allopurinol oral tablet 100 mg T1
allopurinol oral tablet 300 mg T1 QL (2 EA per 1 day)
ANAPROX T2
ANAPROX DS T2
EC-NAPROSYN T2
INDOCIN T1
indomethacin T1
KRYSTEXXA T4 PA
NAPROSYN T2
naproxen T1
naproxen sodium T1
probenecid T1
probenecid-colchicine T1
ZYLOPRIM T2
Bone Resorption Inhibitors
alendronate T1
BONIVA T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
101
Drug Tier Notes
calcitonin (salmon) T1
DIDRONEL T2
etidronate disodium T1
FOSAMAX T2
MIACALCIN INJECTION T4 PA
MIACALCIN NASAL T2
pamidronate T4 PA
PROLIA T4 PA
raloxifene T1
RECLAST T4 PA
XGEVA T4 PA
zoledronic acid T4 PA
zoledronic ac-mannitol-0.9nacl T4 PA
ZOMETA T4 PA
Cariostatic Agents
CLINPRO 5000 T1 AL
fluoride (sodium) T1 AL
FLUORITAB T1 AL
MULTI-VIT WITH FLUORIDE-IRON T1 AL
MULTI-VITAMIN WITH FLUORIDE T1 AL
MULTIVITAMINS WITH FLUORIDE T1 AL
PHOS-FLUR T1 AL
PREVIDENT T2 AL
PREVIDENT 5000 PLUS T2 AL
SF T1 AL
SF 5000 PLUS T1 AL
TRI-VIT WITH FLUORIDE AND IRON T1 AL
TRI-VITAMIN WITH FLUORIDE T1 AL
Complement Inhibitors
BERINERT T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
102
Drug Tier Notes
CINRYZE T4 PA
FIRAZYR T4 PA
KALBITOR T4 PA
RUCONEST T4 PA
SOLIRIS T4 PA
Disease-Modifying Antirheumatic Agents
ACTEMRA T4 PA
ARAVA T2
azathioprine T1
AZULFIDINE T2
AZULFIDINE EN-TABS T2
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
CUPRIMINE T4 PA
cyclosporine T1
cyclosporine modified T1
DEPEN TITRATABS T4 PA
ENBREL T4 PA
ENBREL SURECLICK T4 PA
GENGRAF T2
HUMIRA T4 PA
HUMIRA PEN T4 PA
hydroxychloroquine T1
IMURAN T2
KINERET T4 PA
leflunomide T1
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
NEORAL T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
103
Drug Tier Notes
ORENCIA T4 PA
ORENCIA (WITH MALTOSE) T4 PA
ORENCIA CLICKJECT T4 PA
OTEZLA T4 PA
OTEZLA STARTER T4 PA
OTREXUP (PF) T4 PA
PLAQUENIL T2
REMICADE T4 PA
RHEUMATREX T2
SANDIMMUNE T2
SIMPONI T4 PA
SIMPONI ARIA T4 PA
STELARA T4 PA
sulfasalazine T1
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
XELJANZ T4 PA
XELJANZ XR T4 PA
Gonadotropin-Releasing Hormone Antagnts
FIRMAGON T4 PA
Immunomodulatory Agents
ACTEMRA T4 PA
ACTIMMUNE T4 PA
ARAVA T2
AUBAGIO T4 PA
AVONEX T4 PA
AVONEX (WITH ALBUMIN) T4 PA
azathioprine T1
AZULFIDINE T2
AZULFIDINE EN-TABS T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
104
Drug Tier Notes
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
COPAXONE T4 PA
cyclosporine T1
cyclosporine modified T1
ENBREL T4 PA
ENBREL SURECLICK T4 PA
ENTYVIO T4 PA
EXTAVIA T4 PA
GENGRAF T2
GILENYA T4 PA
GLATOPA T4 PA
HUMIRA T4 PA
HUMIRA PEN T4 PA
hydroxychloroquine T1
IMURAN T2
INTRON A T4 PA
KINERET T4 PA
leflunomide T1
LEMTRADA T4 PA
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
NEORAL T2
ORENCIA T4 PA
ORENCIA (WITH MALTOSE) T4 PA
ORENCIA CLICKJECT T4 PA
OTREXUP (PF) T4 PA
PLAQUENIL T2
PLEGRIDY T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
105
Drug Tier Notes
POMALYST T4 PA
PROLEUKIN T4 PA
REBIF (WITH ALBUMIN) T4 PA
REBIF REBIDOSE T4 PA
REBIF TITRATION PACK T4 PA
REVLIMID T4 PA
RHEUMATREX T2
SANDIMMUNE T2
SIMPONI T4 PA
SIMPONI ARIA T4 PA
STELARA T4 PA
sulfasalazine T1
TECFIDERA T4 PA
THALOMID T4 PA
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
TYSABRI T4 PA
XELJANZ T4 PA
XELJANZ XR T4 PA
Immunosuppressive Agents
ASTAGRAF XL T4 PA
ATGAM T4 PA
azathioprine T1
BENLYSTA T4 PA
CELLCEPT T2
CELLCEPT INTRAVENOUS T4 PA
cyclophosphamide intravenous T4 PA
cyclophosphamide oral T1
cyclosporine T1
cyclosporine modified T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
106
Drug Tier Notes
ELIDEL T1 PA
GENGRAF T2
IMURAN T2
mercaptopurine T1
methotrexate sodium (pf) T4 PA
methotrexate sodium injection T4 PA
methotrexate sodium oral T1
mycophenolate mofetil T1
NEORAL T2
NULOJIX T4 PA
OTREXUP (PF) T4 PA
PROGRAF INTRAVENOUS T4 PA
PROGRAF ORAL T2
RAPAMUNE T4 PA
RHEUMATREX T2
SANDIMMUNE T2
SIMULECT T4 PA
tacrolimus T1
THYMOGLOBULIN T4 PA
TREXALL ORAL TABLET 10 MG, 5 MG T4 PA
TREXALL ORAL TABLET 7.5 MG T1
ZORTRESS T4 PA
Other Miscellaneous Therapeutic Agents
acetylcysteine T1
AMPYRA T4 PA
ARCALYST T4 PA
BOTOX T4 PA
BOTOX COSMETIC T4 PA
CARNITOR T2
CARNITOR (SUGAR-FREE) T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
107
Drug Tier Notes
CERDELGA T4 PA
CYSTADANE T4 PA
DEMSER T4 PA
DYSPORT T4 PA
ILARIS (PF) T4 PA
KUVAN T4 PA
levocarnitine T1
MYOBLOC T4 PA
octreotide acetate T4 PA
ORFADIN T4 PA
PANHEMATIN T4 PA
PREZCOBIX T1
PROCYSBI T4 PA
REMICADE T4 PA
SANDOSTATIN T4 PA
SANDOSTATIN LAR DEPOT T4 PA
THIOLA T4 PA
XEOMIN T4 PA
ZAVESCA T4 PA
Protective Agents
amifostine crystalline T4 PA
MESNEX T4 PA
Oxytocics
Oxytocics
METHERGINE T1 QL (28 EA per 7 days)
Pharmaceutical Aids
Pharmaceutical Aids
DILUENT FOR EPOPROSTENOL/FLOLA T4 PA
Radioactive Agents
Radioactive Agents
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
108
Drug Tier Notes
XOFIGO T4 PA
Respiratory Tract Agents
Alpha And Beta Adrenergic Agonist(Respr)
ALAVERT D-12 ALLERGY-SINUS T2
BROMFED DM T1
cetirizine-pseudoephedrine T1
CHERATUSSIN DAC T1
CLARITIN-D 12 HOUR T2
CLARITIN-D 24 HOUR T2
epinephrine T1 QL (2 EA per 30 DYs)
loratadine-pseudoephedrine T1
M-END DMX T1
MUCINEX D T1
pseudoephedrine hcl T1
ZYRTEC-D T2
Anticholinergic Agents (Respir.Tract)
ANORO ELLIPTA T1
ATROVENT HFA T1
COMBIVENT RESPIMAT T1
diphenoxylate-atropine T1
ipratropium bromide T1
LOMOTIL T2
SPIRIVA RESPIMAT T1 AL
Antifibrotic Agents
ESBRIET T4 PA
OFEV T4 PA
Antitussives
aspirin-caffeine-dihydrocodein T3
benzonatate T1
BROMFED DM T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
109
Drug Tier Notes
CHERATUSSIN AC T2
CHERATUSSIN DAC T1
codeine sulfate T3
codeine-guaifenesin T1 AL
hydrocodone-homatropine T1
M-END DMX T1
phenylephrine-chlophedianol-gg T1
PROMETHAZINE VC-CODEINE T1
promethazine-codeine T1
promethazine-dm T1
ROBAFEN CF (PHENYLEPHRINE) T1
ROBAFEN DM T1
SYNALGOS-DC T3
TESSALON PERLES T2
TUSSIGON T1
Cystic Fibrosis (Cftr) Potentiators
KALYDECO T4 PA
Expectorants
CHERATUSSIN AC T2
CHERATUSSIN DAC T1
codeine-guaifenesin T1 AL
ED BRON GP T1
guaifenesin T1
MUCINEX T2
MUCINEX D T1
phenylephrine-chlophedianol-gg T1
ROBAFEN CF (PHENYLEPHRINE) T1
ROBAFEN DM T1
SSKI T1
First Generation Antihist.(Respir Tract)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
110
Drug Tier Notes
ALLER-CHLOR T1
BROMFED DM T1
chlorpheniramine maleate T1
clemastine T1
cyproheptadine T1
DICLEGIS T1 PA
DIPHENHIST T1
diphenhydramine hcl injection T1 QL (20 ML per 25 days)
diphenhydramine hcl oral T1
M-END DMX T1
PHENERGAN T2
promethazine injection solution T1 QL (20 ML per 25 days)
promethazine injection syringe T1
promethazine oral T1
PROMETHAZINE VC T1
PROMETHAZINE VC-CODEINE T1
promethazine-codeine T1
promethazine-dm T1
SLEEP AID (DOXYLAMINE) T1
Leukotriene Modifiers
montelukast oral granules in packet T1 QL (1 EA per 1 day); AL
montelukast oral tablet T1 QL (1 EA per 1 day)
montelukast oral tablet,chewable T1 QL (1 EA per 1 day)
SINGULAIR ORAL GRANULES IN PACKET T2 AL
SINGULAIR ORAL TABLET T2
SINGULAIR ORAL TABLET,CHEWABLE T2
Mast-Cell Stabilizers
cromolyn T1
Mucolytic Agents
acetylcysteine T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
111
Drug Tier Notes
PULMOZYME T4 PA
Nasal Preparations (Steroids)
fluticasone T1
OMNARIS T3 PA
triamcinolone acetonide T1 ST
Orally Inhaled Preparations (Steroids)
ARNUITY ELLIPTA T1
ASMANEX HFA T1
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (30 DOSES), 220 MCG (120 DOSES), 220
MCG (30 DOSES), 220 MCG (60 DOSES)
T1 QL (1 QY per 30 DYs)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (7 DOSES)
T1 QL (1 QY per 7 DYs)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 220
MCG (14 DOSES)
T1 QL (1 QY per 14 DYs)
BREO ELLIPTA T1
budesonide inhalation suspension for nebulization
0.25 mg/2 ml
T1 QL (60 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
0.5 mg/2 ml
T1 QL (120 QY per 30 DYs); AL
budesonide inhalation suspension for nebulization
1 mg/2 ml
T1 QL (60 ML per 30 DYs); AL
DULERA T1 QL (13 QY per 30 DYs); AL
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION
T1 QL (120 QY per 30 DYs)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION
T1 QL (240 QY per 30 DYs)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 50 MCG/ACTUATION
T1 QL (60 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION
T1 QL (12 QY per 30 DYs)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
112
Drug Tier Notes
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 220 MCG/ACTUATION
T1 QL (24 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 44 MCG/ACTUATION
T1 QL (10.6 QY per 30 DYs)
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.25 MG/2 ML, 1 MG/2
ML
T2 QL (60 QY per 30 DYs); AL
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.5 MG/2 ML
T2 QL (120 QY per 30 DYs); AL
QVAR INHALATION AEROSOL 40
MCG/ACTUATION
T1 QL (8.7 QY per 30 DYs)
QVAR INHALATION AEROSOL 80
MCG/ACTUATION
T1 QL (17.4 QY per 30 DYs)
Phosphodiesterase Type 4 Inhibitors
DALIRESP T1 ST
Respiratory Tract Agents, Miscellaneous
ARALAST NP T4 PA
GLASSIA T4 PA
XOLAIR T4 PA
ZEMAIRA T4 PA
Second Generation Antihist(Respir Tract)
ALAVERT T2
ALAVERT D-12 ALLERGY-SINUS T2
ALLEGRA ALLERGY T2 ST
cetirizine T1
cetirizine-pseudoephedrine T1
CHILDREN'S CLARITIN T2
CLARINEX T3 PA
CLARITIN T2
CLARITIN REDITABS T2
CLARITIN-D 12 HOUR T2
CLARITIN-D 24 HOUR T2
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
113
Drug Tier Notes
desloratadine T3 PA
fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)
fexofenadine oral tablet T1 ST
levocetirizine oral solution T3 PA
levocetirizine oral tablet T1 ST
loratadine T1
loratadine-pseudoephedrine T1
XYZAL ORAL SOLUTION T3 PA
XYZAL ORAL TABLET T2 ST
ZYRTEC T2
ZYRTEC-D T2
Select.Beta-2-Adrenergic Agonist(Respir)
albuterol sulfate T1
ANORO ELLIPTA T1
BREO ELLIPTA T1
COMBIVENT RESPIMAT T1
DULERA T1 QL (13 QY per 30 DYs); AL
SEREVENT DISKUS T1
terbutaline T1
VENTOLIN HFA T1 QL (1 QY per 30 DYs)
XOPENEX HFA T1 ST
Vasodilating Agents (Respiratory Tract)
ADCIRCA T4 PA
epoprostenol (glycine) T4 PA
FLOLAN T4 PA
LETAIRIS T4 PA
OPSUMIT T4 PA
ORENITRAM T4 PA
REMODULIN T4 PA
REVATIO T4 PA
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
114
Drug Tier Notes
sildenafil T1 PA
TRACLEER T4 PA
TYVASO T4 PA
TYVASO REFILL KIT T4 PA
TYVASO STARTER KIT T4 PA
UPTRAVI T4 PA
VELETRI T4 PA
VENTAVIS T4 PA
Xanthine Derivatives
THEO-24 T1
theophylline T1
Skin And Mucous Membrane Agents
Antibacterials (Skin, Mucous Membrane)
bacitracin-polymyxin b T1
BACTROBAN T2
BENZAMYCIN T2
CLEOCIN T T2
clindamycin phosphate T1
ERY PADS T1
erythromycin with ethanol T1
erythromycin-benzoyl peroxide T1
gentamicin T1
METROGEL T2
METROGEL VAGINAL T2
metronidazole T1
mupirocin T1
POLYSPORIN T2
Anti-Inflammatory Agents (Skin, Mucous)
amcinonide T1 QL (15 GM per 30 days)
betamethasone dipropionate T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
115
Drug Tier Notes
betamethasone valerate T1
betamethasone, augmented T1
clobetasol T1
clobetasol-emollient T1
clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)
desonide T1
desoximetasone T1
diflorasone topical cream T1 QL (15 GM per 25 days)
diflorasone topical ointment T1 QL (15 GM per 30 days)
DIPROLENE T2
DIPROLENE AF T2
ELOCON TOPICAL CREAM T2 QL (45 QY per 30 DYs)
ELOCON TOPICAL OINTMENT T2 QL (45 QY per 30 DYs)
ELOCON TOPICAL SOLUTION T2
fluocinolone T1
fluocinonide T1
FLUOCINONIDE-E T1
hydrocortisone T1
hydrocortisone acetate T1
hydrocortisone valerate T1
hydrocortisone-min oil-wht pet T1
LOTRISONE T2 QL (15 QY per 34 DYs)
mometasone topical cream T1 QL (45 QY per 30 DYs)
mometasone topical ointment T1 QL (45 QY per 30 DYs)
mometasone topical solution T1
PROCTOFOAM HC T1
TEMOVATE T2
TEMOVATE E T2
TOPICORT T2
triamcinolone acetonide T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
116
Drug Tier Notes
WESTCORT T2
Antipruritics And Local Anesthetics
dibucaine T1
lidocaine T3 PA
lidocaine hcl T1
lidocaine-prilocaine T1 QL (30 QY per 30 DYs)
LIDODERM T3 PA
NUPERCAINAL T1
phenazopyridine T1
PROCTOFOAM HC T1
PYRIDIUM T2
Antivirals (Skin And Mucous Membrane)
ZOVIRAX T3 PA
Astringents
DRYSOL DAB-O-MATIC T2
Azoles (Skin And Mucous Membrane)
clotrimazole T1
clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)
ketoconazole topical cream T1
ketoconazole topical shampoo T1 ST
LOTRIMIN AF T2
LOTRISONE T2 QL (15 QY per 34 DYs)
miconazole nitrate T1
MICONAZOLE-3 T1
NIZORAL T2 ST
NIZORAL A-D T1
Basic Lotions And Liniments
AMLACTIN T2
ammonium lactate T1
Basic Ointments And Protectants
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
117
Drug Tier Notes
ammonium lactate T1
LAC-HYDRIN T2
Benzylamines (Skin And Mucous Membrane)
LOTRIMIN ULTRA T1
MENTAX T2
Cell Stimulants And Proliferants
KEPIVANCE T4 PA
tretinoin T1 AL
tretinoin microspheres T1 AL
Keratolytic Agents
benzoyl peroxide T1
DESQUAM-X T1
NEUTROGENA ON THE SPOT T1
NEUTROGENA T-GEL CONDITNER(SA) T1
sulfacetamide sodium-sulfur T1
urea T1
Keratoplastic Agents
DRITHOCREME HP T1
Local Anti-Infectives, Miscellaneous
KLARON T2
selenium sulfide T1
SILVADENE T2
silver sulfadiazine T1
sulfacetamide sodium (acne) T1
sulfacetamide sodium-sulfur T1
Pigmenting Agents
8-MOP T4 PA
OXSORALEN ULTRA T4 PA
Polyenes (Skin And Mucous Membrane)
nystatin T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
118
Drug Tier Notes
nystatin-triamcinolone T1
Scabicides And Pediculicides
CUTTER BACKWOODS T1 QL (170 GM per 6 days)
CUTTER SKINSATIONS T1 QL (177 ML per 6 days)
LICE BEDDING SPRAY T1 QL (142 GM per 5 days)
LICE KILLING T1 QL (120 QY per 30 DYs)
OFF ACTIVE T1 QL (170 GM per 6 days)
OFF DEEP WOODS T1 QL (170 GM per 6 days)
OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)
OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)
permethrin topical cream T1 QL (60 QY per 1 PD)
permethrin topical liquid T1 QL (118 QY per 30 DYs)
REPEL SPORTSMEN T1 QL (184 GM per 6 days)
REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)
RID COMPLETE LICE ELIM KIT T1 QL (141.8 GM per 5 days)
spinosad T1
STOP LICE T1 QL (142 GM per 5 days)
Skin And Mucous Membrane Agents, Misc.
ABSORICA T3 PA
ALDARA T2 QL (24 QY per 30 DYs)
ARTHRITIS PAIN RELIEF(CAPSAIC) T1
capsaicin T1
CAPZASIN-HP T1
CLARAVIS T1 PA; QL (1 EA per 1 day)
CONDYLOX T2
COSENTYX T4 PA
COSENTYX (2 SYRINGES) T4 PA
COSENTYX PEN T4 PA
COSENTYX PEN (2 PENS) T4 PA
CUTTER BACKWOODS T1 QL (170 GM per 6 days)
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
119
Drug Tier Notes
CUTTER SKINSATIONS T1 QL (177 ML per 6 days)
diclofenac sodium T1 ST
ELIDEL T1 PA
HIGH POTENCY CAPSAICIN T1
imiquimod T1 QL (24 QY per 30 DYs)
INSECT REPELLENT (PICARIDIN) T1 QL (118 GM per 4 days)
MYORISAN T1 PA; QL (1 EA per 1 day)
NATRAPEL T1 QL (177 ML per 6 days)
OFF ACTIVE T1 QL (170 GM per 6 days)
OFF DEEP WOODS T1 QL (170 GM per 6 days)
OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)
OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)
podofilox T1
PROTOPIC TOPICAL OINTMENT 0.03 % T2 PA
PROTOPIC TOPICAL OINTMENT 0.1 % T1 PA
REPEL SPORTSMEN T1 QL (184 GM per 6 days)
REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)
SANTYL T1
STELARA T4 PA
tacrolimus T1 PA
TALTZ AUTOINJECTOR T4 PA
TALTZ SYRINGE T4 PA
TARGRETIN T4 PA
TRIXAICIN HP T1
ZENATANE T1 PA; QL (1 EA per 1 day)
ZOSTRIX-HP FOOT T1
ZOSTRIX-HP TOPICAL CREAM 0.075 % T2
ZOSTRIX-HP TOPICAL CREAM 0.1 % T1
Thiocarbamates(Skin And Mucous Membrane)
tolnaftate T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
120
Drug Tier Notes
Smooth Muscle Relaxants
Antimuscarinics
DETROL T2
DETROL LA ORAL CAPSULE,EXTENDED
RELEASE 24HR 2 MG
T2
DETROL LA ORAL CAPSULE,EXTENDED
RELEASE 24HR 4 MG
T1
flavoxate T1
oxybutynin chloride T1
tolterodine oral capsule,extended release 24hr 2
mg
T1 QL (1 EA per 1 day)
tolterodine oral capsule,extended release 24hr 4
mg
T1
tolterodine oral tablet 1 mg T1 QL (2 EA per 1 day)
tolterodine oral tablet 2 mg T1
trospium T1
Respiratory Smooth Muscle Relaxants
THEO-24 T1
theophylline T1
Vitamins
Multivitamin Preparations
CADEAU DHA T1
CENTRUM COMPLETE T2 AL
CERTAVITE-ANTIOXID (IRON GLUC) T2
CHILDREN'S CHEWABLE VITAMIN T1 AL
CHILD'S VITAMIN WITH IRON T1 AL
CHILDS/IRON T1 AL
COMPLETE NATAL DHA T1
COMPLETENATE T2
DAILY PRENATAL T1
DAILY VITES/IRON T1 AL
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
121
Drug Tier Notes
GERAVIM T1 AL
MULTI-VIT WITH FLUORIDE-IRON T1 AL
multivitamin T1 AL
MULTI-VITAMIN WITH FLUORIDE T1 AL
MULTIVITAMIN WITH MINERALS T1
MULTIVITAMINS WITH FLUORIDE T1 AL
MY-VITALIFE T1 AL
OBSTETRIX DHA T1
OBTREX DHA T1
ONE DAILY PLUS MINERALS T1 AL
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
PEDIAVIT T1 AL
POLY-VI-SOL T2 AL
POLY-VI-SOL WITH IRON T2 AL
POLY-VITAMIN T1 AL
POLY-VITAMIN WITH IRON T1 AL
POLYVITAMIN/IRON T1 AL
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENA1 CHEW (QUATREFOLIC) T1
PRENATA T1
PRENATAL + DHA T1
PRENATAL 19 T1
PRENATAL GUMMY T1
PRENATAL MULTI-DHA T1
PRENATAL MULTI-DHA (ALGAL OIL) T1
PRENATAL VITAMIN T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
122
Drug Tier Notes
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
PRORENAL QD T1
TAB-A-VITE-MINERALS T1 AL
THERATRUM COMPLETE 50 PLUS T1 AL
TRINATAL GT T1
TRIVEEN-DUO DHA T1
TRI-VI-SOL WITH IRON T1 AL
TRI-VIT WITH FLUORIDE AND IRON T1 AL
TRI-VITAMIN T1 AL
TRI-VITAMIN WITH FLUORIDE T1 AL
TRUST NATAL DHA T1
VITRUM SENIOR T1 AL
WOMEN'S PRENATAL + DHA T1
Vitamin A
beta carotene T1 AL
TRI-VI-SOL WITH IRON T1 AL
TRI-VITAMIN T1 AL
TRI-VITAMIN WITH FLUORIDE T1 AL
vitamin a T1 AL
Vitamin B Complex
B COMPLEX-VITAMIN B12 T1 AL
b complex-vitamin c-folic acid T1 AL
B-COMPLEX WITH VITAMIN C T1 AL
biotin T1 AL
CADEAU DHA T1
CENTRUM COMPLETE T2 AL
cyanocobalamin (vitamin b-12) injection T1
cyanocobalamin (vitamin b-12) oral tablet T2 AL
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
123
Drug Tier Notes
cyanocobalamin (vitamin b-12) oral tablet
extended release
T1 AL
cyanocobalamin (vitamin b-12) sublingual T1 AL
DAILY PRENATAL T1
DICLEGIS T1 PA
folic acid T1
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
niacinamide T1
NICOMIDE T1
OBSTETRIX DHA T1
OBTREX DHA T1
ONE DAILY PRENATAL T1
ONE-A-DAY WOMENS FORMULA T1
pantothenic acid (vit b5) T1 AL
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PRENA1 CHEW (QUATREFOLIC) T1
PRENATA T1
PRENATAL + DHA T1
PRENATAL 19 T1
PRENATAL GUMMY T1
PRENATAL MULTI-DHA T1
PRENATAL MULTI-DHA (ALGAL OIL) T1
PRENATAL VITAMIN T1
PRENATAL VITAMIN PLUS LOW IRON T1
prenatal vit-iron fum-folic ac T1
PRORENAL QD T1
PYRI 500 T1 AL
pyridoxine (vitamin b6) T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
124
Drug Tier Notes
riboflavin (vitamin b2) T1 AL
STRESS B-COMPLEX T1
thiamine hcl (vitamin b1) oral tablet 100 mg T1 AL
thiamine hcl (vitamin b1) oral tablet 250 mg T1
TRINATAL GT T1
TRIVEEN-DUO DHA T1
vit b complex-folic acid T1 AL
VITAMIN B-1 ORAL TABLET 100 MG T2 AL
VITAMIN B-1 ORAL TABLET 250 MG T2
VITAMIN B-1 ORAL TABLET 50 MG T1 AL
VITAMIN B-12 ORAL T1 AL
VITAMIN B-12 SUBLINGUAL T2 AL
VITAMIN B-2 ORAL TABLET 100 MG, 25 MG T1 AL
VITAMIN B-2 ORAL TABLET 50 MG T2 AL
VITAMIN B-6 ORAL TABLET 100 MG, 25 MG T1
VITAMIN B-6 ORAL TABLET 250 MG T1 AL
VITAMIN B-6 ORAL TABLET 50 MG T2
VITAMIN B-6 ORAL TABLET EXTENDED
RELEASE
T1 AL
VITAMINS B COMPLEX T1 AL
WOMEN'S PRENATAL + DHA T1
Vitamin C
ascorbic acid (vitamin c) oral tablet T1 AL
ascorbic acid (vitamin c) oral tablet extended
release 1,500 mg
T1
ascorbic acid (vitamin c) oral tablet extended
release 500 mg
T1 AL
b complex-vitamin c-folic acid T1 AL
B-COMPLEX WITH VITAMIN C T1 AL
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
125
Drug Tier Notes
STRESS B-COMPLEX T1
TRI-VI-SOL WITH IRON T1 AL
TRI-VITAMIN T1 AL
TRI-VITAMIN WITH FLUORIDE T1 AL
VITAMIN C ORAL SYRUP T1 AL
VITAMIN C ORAL TABLET 1,000 MG, 500
MG
T1 AL
VITAMIN C ORAL TABLET 250 MG T2 AL
VITAMIN C ORAL TABLET EXTENDED
RELEASE
T2 AL
VITAMIN C ORAL TABLET,CHEWABLE T1 AL
Vitamin D
calcitriol T1
CALCIUM 600 + D(3) T2
calcium carbonate-vitamin d2 T1
calcium carbonate-vitamin d3 T1
calcium citrate-vitamin d3 T1
cholecalciferol (vitamin d3) T1
CITRACAL + D3 (CALCIUM PHOS) T1
CITRUS CALCIUM T2
DRISDOL T2
ergocalciferol (vitamin d2) T1
JUST D T2
LIQUID CALCIUM WITH VITAMIN D T1
ONE-A-DAY WOMEN'S PRENATAL 1 T1
OYSTER SHELL CALCIUM-VIT D2 T1
OYSTER SHELL CALCIUM-VIT D3 T1
PRORENAL QD T1
ROCALTROL T2
TRI-VI-SOL WITH IRON T1 AL
TRI-VITAMIN T1 AL
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
126
Drug Tier Notes
TRI-VITAMIN WITH FLUORIDE T1 AL
VITAMIN D3 ORAL CAPSULE 1,000 UNIT,
2,000 UNIT
T2
VITAMIN D3 ORAL CAPSULE 400 UNIT T1
VITAMIN D3 ORAL TABLET 1,000 UNIT,
2,000 UNIT
T2
VITAMIN D3 ORAL TABLET 400 UNIT T1
VITAMIN D3 ORAL TABLET,CHEWABLE T2
Vitamin E
vitamin e T1 AL
vitamin e (dl, acetate) T1 AL
vitamin e mixed T1 AL
Vitamin K Activity
MEPHYTON T1
KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the
list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity
Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-
6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.
127
Index
INDEX \e " " \c "3" \h "A" \z "1033"