2017 Formulary Annual Notice of Change - … Formulary Annual Notice of Change ... determination and...
Transcript of 2017 Formulary Annual Notice of Change - … Formulary Annual Notice of Change ... determination and...
Updated: October 10, 2016
2017 Formulary Annual Notice of Change
Commercial 5 Tier - Qualified Health Plans (QHP)
This is a listing of the changes that have occurred to the 2017 Commercial Qualified Health Plans 5 Tier formulary. For a complete list, please refer to our website and review the 2017 QHP Comprehensive Formulary (Drug List). Click here to view the comprehensive formulary. Please carefully review these changes. If you have any questions or need to obtain updated coverage determination and exception information, please call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m. or visit myFHCA.org. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and copayments/co-insurance may change on January 1 of each year. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. The Formulary and pharmacy network may change at any time. You will receive notice when necessary.
Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
36194_MPINFO165FH (11/2016)
MEDICATIONS REMOVED FROM THE 2016 QHP FORMULARY
Medication Name Medication Name
Abilify Discmelt 10mg tablet,disintegrating donepezil 10mg tablet,disintegrating
Aggrenox 25-200mg capsule, ER multiphase 12 hr donepezil 5mg tablet,disintegrating
amiodarone 400mg tablet Edarbi 40mg tablet
AndroGel 1 %(25 mg/2.5gram) gel in packet Edarbi 80mg tablet
AndroGel 1 %(50 mg/5 gram) gel in packet EEMT HS 0.625-1.25mg tablet
AndroGel 1.25 gram/actuation (1 %) gel in metered-dose pump
Enablex 15mg tablet extended release 24 hr
Atralin 0.05% gel Enablex 7.5mg tablet extended release 24 hr
Avodart 0.5mg capsule eprosartan 600mg tablet
Axert 12.5mg tablet FazaClo 100mg tablet,disintegrating
Axert 6.25mg tablet FazaClo 12.5mg tablet,disintegrating
betamethasone valerate 0.12% foam FazaClo 150mg tablet,disintegrating
Carac 0.5% cream FazaClo 200mg tablet,disintegrating
Cardizem LA 120mg tablet extended release 24 hr FazaClo 25mg tablet,disintegrating
cefaclor 500mg tablet extended release 12 hr Fluoroplex 1% cream
Celebrex 100mg capsule fluorouracil 0.5% cream
Celebrex 200mg capsule Frova 2.5mg tablet
Celebrex 400mg capsule Gleevec 100mg tablet
Celebrex 50mg capsule Gleevec 400mg tablet
ClindaMax 1% gel Glyset 100mg tablet
clindamycin HCl 75mg capsule Glyset 25mg tablet
clindamycin phosphate 1% foam Glyset 50mg tablet
clobetasol 0.05% foam Gralise 30-Day Starter Pack 300 mg (9)-600 mg (69) tablet extended release 24 hr
clobetasol-emollient 0.05% foam Ibudone 5-200mg tablet
Cloderm 0.1% cream Jalyn 0.5-0.4mg capsule, ER multiphase 24 hr
Colcrys 0.6mg tablet Januvia 100mg tablet
Cormax 0.05% solution Januvia 25mg tablet
Crestor 10mg tablet Januvia 50mg tablet
Crestor 20mg tablet Lamictal ODT 100mg tablet,disintegrating
Crestor 40mg tablet Lamictal ODT 200mg tablet,disintegrating
Crestor 5mg tablet Lamictal ODT 25mg tablet,disintegrating
cyclobenzaprine 7.5mg tablet Lamictal ODT 50mg tablet,disintegrating
Dibenzyline 10mg capsule Lamictal ODT Starter (Blue) 25 mg (21)-50 mg (7) tablet disintegrating, dose pk
diltiazem HCl 360mg capsule,extended release 24hr Lamictal ODT Starter (Green) 50 mg (42)-100 mg (14) tablet disintegrating, dose pk
MEDICATIONS REMOVED FROM THE 2016 QHP FORMULARY
Medication Name Medication Name Lamictal ODT Starter (Orange) 25 mg(14)-50 mg(14)-100 mg (7) tablet disintegrating, dose pk
Niaspan Extended-Release 500mg tablet extended release 24 hr
Liptruzet 10-10mg tablet Niaspan Extended-Release 750mg tablet extended release 24 hr
Liptruzet 10-20mg tablet Nuvigil 150mg tablet
Liptruzet 10-40mg tablet Nuvigil 200mg tablet
Liptruzet 10-80mg tablet Nuvigil 250mg tablet
Lodosyn 25mg tablet Nuvigil 50mg tablet
Lotronex 0.5mg tablet Onglyza 2.5mg tablet
Lotronex 1mg tablet Onglyza 5mg tablet
Luxiq 0.12% foam Orap 1mg tablet
Mestinon Timespan 180mg tablet extended release Orap 2mg tablet
metformin 1,000mg tablet extended release 24hr Orapred ODT 10mg tablet,disintegrating
metformin 500mg tablet extended release 24hr Orapred ODT 15mg tablet,disintegrating
methylphenidate 10mg tablet,chewable Orapred ODT 30mg tablet,disintegrating
methylphenidate 2.5mg tablet,chewable Ovace Plus Shampoo 10% shampoo
methylphenidate 5mg tablet,chewable Ovace Plus Wash 10% cleanser,gel extended release
Migranol Oxistat 1% cream
Minivelle 0.025mg/24 hr patch semiweekly OxyContin 10mg tablet extended release 12 hr
Minivelle 0.0375mg/24 hr patch semiweekly OxyContin 10mg tablet,oral only,ext.rel.12 hr
Minivelle 0.05mg/24 hr patch semiweekly OxyContin 15mg tablet extended release 12 hr
Minivelle 0.075mg/24 hr patch semiweekly OxyContin 15mg tablet,oral only,ext.rel.12 hr
Minivelle 0.1mg/24 hr patch semiweekly OxyContin 160mg tablet extended release 12 hr
minocycline 100mg tablet OxyContin 20mg tablet extended release 12 hr
minocycline 50mg tablet OxyContin 20mg tablet,oral only,ext.rel.12 hr
minocycline 75mg tablet OxyContin 30mg tablet extended release 12 hr
Naftin 2% cream OxyContin 30mg tablet,oral only,ext.rel.12 hr
Namenda 10mg tablet OxyContin 40mg tablet extended release 12 hr
Namenda 2mg/mL solution OxyContin 40mg tablet,oral only,ext.rel.12 hr
Namenda 5mg tablet OxyContin 60mg tablet extended release 12 hr
Namenda Titration Pak 5-10mg tablets,dose pack OxyContin 60mg tablet,oral only,ext.rel.12 hr
naproxen sodium 275mg tablet OxyContin 80mg tablet extended release 12 hr
naproxen sodium 550mg tablet OxyContin 80mg tablet,oral only,ext.rel.12 hr
Nasonex 50mcg/actuation spray,non-aerosol Patanol 0.1% drops
Niaspan Extended-Release 1,000mg tablet extended release 24 hr
Proventil HFA 90mcg/actuation HFA aerosol inhaler
MEDICATIONS REMOVED FROM THE 2016 QHP FORMULARY
Medication Name Medication Name
ranitidine HCl 150mg capsule Tasmar 100mg tablet
ranitidine HCl 300mg capsule temazepam 22.5mg capsule
Rapamune 0.5mg tablet temazepam 7.5mg capsule
Rapamune 1mg tablet Testim 50mg/5 gram (1 %) gel
Rapamune 2mg tablet Tikosyn 125mcg capsule
Rea Lo 39 39% cream Tikosyn 250mcg capsule
Rea Lo 40 40% cream Tikosyn 500mcg capsule
Reclast 5mg/100 mL solution timolol maleate 0.25% gel forming solution
Remicade 100mg recon soln timolol maleate 0.5% gel forming solution
Rosadan 0.75% cream tizanidine 2mg capsule
Rosadan 0.75% gel tizanidine 4mg capsule
Soriatane 10mg capsule tizanidine 6mg capsule
Soriatane 17.5mg capsule Treximet 85-500mg tablet
Soriatane 25mg capsule Valcyte 450mg tablet
Stromectol 3mg tablet Vandazole 0.75% gel
Suprax 100mg/5 mL suspension for reconstitution Vectical 3mcg/gram ointment
Suprax 200mg/5 mL suspension for reconstitution Voltaren 1% gel
Sure-Touch Lancet misc Xenazine 12.5mg tablet
Surmontil 100mg capsule Xenazine 25mg tablet
Surmontil 25mg capsule Zovirax 5% cream
Surmontil 50mg capsule Zymaxid 0.5% drops
Taclonex 0.005-0.064% ointment Zyvox 100mg/5 mL suspension for reconstitution
Targretin 75mg capsule Zyvox 600mg tablet
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
acetaminophen-codeine 120 mg-12 mg/5 mL (5 mL) solution
Tier 3 QL(2700 ML per 30
days) None
acetaminophen-codeine 240 mg-24 mg/10 mL (10 mL) solution
Tier 3 QL(2700 ML per 30
days) None
acetaminophen-codeine 300 mg-30 mg/12.5 mL solution
Tier 3 QL(2700 ML per 30
days) None
acetic acid-aluminum acetate 2% drops Tier 2 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Addyi 100mg tablet Tier 5 None PA
Adempas 0.5mg tablet Tier 5 None PA
Adempas 1.5mg tablet Tier 5 None PA
Adempas 1mg tablet Tier 5 None PA
Adempas 2.5mg tablet Tier 5 None PA
Adempas 2mg tablet Tier 5 None PA
Adrucil 500mg/10 mL solution Tier 3 None None
Afeditab CR 30mg tablet extended release Tier 2 None None
Afeditab CR 60mg tablet extended release Tier 2 None None
AK-Poly-Bac 500-10,000unit/gram ointment Tier 2 None None
albuterol sulfate 5mg/mL solution for nebulization
Tier 2 None None
aluminum chloride 20% solution Tier 2 None None
aminophylline 100mg tablet Tier 2 None None
aminophylline 200mg tablet Tier 2 None None
Ampyra 10mg tablet extended release 12 hr Tier 5 None PA
Amturnide 150-5-12.5mg tablet Tier 3 None None
Amturnide 300-10-12.5mg tablet Tier 3 None None
Amturnide 300-10-25mg tablet Tier 3 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Amturnide 300-5-12.5mg tablet Tier 3 None None
Amturnide 300-5-25mg tablet Tier 3 None None
antipyrine-benzocaine 5.4-1.4% drops Tier 2 None None
Aptiom 200mg tablet Tier 4 None PA
Aptiom 400mg tablet Tier 4 None PA
Aptiom 600mg tablet Tier 4 None PA
Aptiom 800mg tablet Tier 4 None PA
Aranesp (in albumin) 100mcg/0.5 mL syringe Tier 5 None PA
Aranesp (in albumin) 100mcg/mL solution Tier 5 None PA
Aranesp (in albumin) 150mcg/0.3 mL syringe Tier 5 None PA
Aranesp (in albumin) 150mcg/0.75 mL solution
Tier 5 None PA
Aranesp (in albumin) 200mcg/0.4 mL syringe Tier 5 None PA
Aranesp (in albumin) 200mcg/mL solution Tier 5 None PA
Aranesp (in albumin) 25mcg/0.42 mL syringe Tier 5 None PA
Aranesp (in albumin) 25mcg/mL solution Tier 5 None PA
Aranesp (in albumin) 300mcg/0.6 mL syringe Tier 5 None PA
Aranesp (in albumin) 300mcg/mL solution Tier 5 None PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Aranesp (in albumin) 40mcg/0.4 mL syringe Tier 5 None PA
Aranesp (in albumin) 40mcg/mL solution Tier 5 None PA
Aranesp (in albumin) 500mcg/mL syringe Tier 5 None PA
Aranesp (in albumin) 60mcg/0.3 mL syringe Tier 5 None PA
Aranesp (in albumin) 60mcg/mL solution Tier 5 None PA
Aranesp (in polysorbate) 100mcg/0.5 mL syringe
Tier 5 None PA
Aranesp (in polysorbate) 100mcg/mL solution Tier 5 None PA
Aranesp (in polysorbate) 10mcg/0.4 mL syringe
Tier 5 None PA
Aranesp (in polysorbate) 150mcg/0.3 mL syringe
Tier 5 None PA
Aranesp (in polysorbate) 150mcg/0.75 mL solution
Tier 5 None PA
Aranesp (in polysorbate) 200mcg/0.4 mL syringe
Tier 5 None PA
Aranesp (in polysorbate) 200mcg/mL solution Tier 5 None PA
Aranesp (in polysorbate) 25mcg/0.42 mL syringe
Tier 5 None PA
Aranesp (in polysorbate) 25mcg/mL solution Tier 5 None PA
Aranesp (in polysorbate) 300mcg/0.6 mL syringe
Tier 5 None PA
Aranesp (in polysorbate) 300mcg/mL solution Tier 5 None PA
Aranesp (in polysorbate) 40mcg/0.4 mL syringe
Tier 5 None PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Aranesp (in polysorbate) 40mcg/mL solution Tier 5 None PA
Aranesp (in polysorbate) 500mcg/mL syringe Tier 5 None PA
Aranesp (in polysorbate) 60mcg/0.3 mL syringe
Tier 5 None PA
Aranesp (in polysorbate) 60mcg/mL solution Tier 5 None PA
Aranesp SureClick (polysorbat) 100mcg/0.5 mL pen injector
Tier 5 None PA
Aranesp SureClick (polysorbat) 150mcg/0.3 mL pen injector
Tier 5 None PA
Aranesp SureClick (polysorbat) 200mcg/0.4 mL pen injector
Tier 5 None PA
Aranesp SureClick (polysorbat) 25mcg/0.42 mL pen injector
Tier 5 None PA
Aranesp SureClick (polysorbat) 300mcg/0.6 mL pen injector
Tier 5 None PA
Aranesp SureClick (polysorbat) 40mcg/0.4 mL pen injector
Tier 5 None PA
Aranesp SureClick (polysorbat) 500mcg/mL pen injector
Tier 5 None PA
Aranesp SureClick (polysorbat) 60mcg/0.3 mL pen injector
Tier 5 None PA
aripiprazole 10mg tablet,disintegrating Tier 5 QL(60 EA per 30
days) None
aripiprazole 15mg tablet,disintegrating Tier 5 QL(60 EA per 30
days) None
armodafinil 150mg tablet Tier 4 QL (30 EA per 30
days) PA
armodafinil 200mg tablet Tier 4 QL (30 EA per 30
days) PA
armodafinil 250mg tablet Tier 4 QL (30 EA per 30
days) PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
armodafinil 50mg tablet Tier 4 QL (30 EA per 30
days) PA
atropine in 0.9 % sod chloride 0.25 mg/5 mL(0.05 mg/mL) syringe
Tier 4 None None
atropine sulfate (PF) 1% drops Tier 2 None None
Aubagio 14mg tablet Tier 5 None PA
Aubagio 7mg tablet Tier 5 QL(30 EA per 30
days) PA
Avandia 8mg tablet Tier 4 None None
BD Lancet Device misc Tier 3 None None
bimatoprost 0.03% drops Tier 4 QL(5 ML per 31
days) 0 None
Butalbital Compound-Codeine 30-50-325-40mg capsule
Tier 4 QL(180 EA per 30
days) None
butalbital-acetaminop-caf-cod 50-325-40-30mg capsule
Tier 4 QL(180 EA per 30
days) None
calcitriol 3mcg/gram ointment Tier 5 None PA
carbamazepine 100mg tablet extended release 12 hr
Tier 3 None None
carbamazepine 100mg/5 mL (5 mL) suspension
Tier 3 None None
carbamazepine 200mg/10 mL suspension Tier 3 None None
Cayston 75mg/mL solution for nebulization Tier 5 None PA
Cedax 400mg capsule Tier 4 None None
cefazolin 10gram recon soln Tier 3 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
cefazolin 1gram recon soln Tier 2 None None
cefazolin 500mg recon soln Tier 2 None None
cefazolin in dextrose (iso-os) 1gram/50 mL piggyback
Tier 3 None None
cefditoren pivoxil 200mg tablet Tier 2 None None
cefditoren pivoxil 400mg tablet Tier 2 None None
cefpodoxime 100mg/5 mL suspension for reconstitution
Tier 3 None None
cefpodoxime 50mg/5 mL suspension for reconstitution
Tier 3 None None
ceftriaxone 100gram recon soln Tier 2 None None
cefuroxime sodium 1.5gram recon soln Tier 2 None None
cefuroxime sodium 7.5gram recon soln Tier 2 None None
cefuroxime sodium 750mg recon soln Tier 2 None None
cevimeline 30mg capsule Tier 2 None None
Chantix Starting Month Pak 0.5 mg (11)-1 mg (42) tablets,dose pack
Tie 6 QL(106 EA per 365
days) None
Cialis 2.5mg tablet Tier 4 None PA
Cialis 5mg tablet Tier 4 None PA
ciclopirox-ure-camph-menth-euc 8% solution Tier 3 None None
ciclopirox-vitE-nail lacq remo 8-5% kit Tier 3 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Cinryze 500unit (5 mL) recon soln Tier 5 None PA
Clindacin Pac 1% kit Tier 2 None None
clotrimazole 10mg troche Tier 2 None None
clozapine 100mg tablet,disintegrating Tier 4 None PA
clozapine 12.5mg tablet,disintegrating Tier 4 None PA
clozapine 150mg tablet,disintegrating Tier 4 None PA
clozapine 200mg tablet,disintegrating Tier 4 None PA
clozapine 25mg tablet,disintegrating Tier 4 None PA
codeine-butalbital-ASA-caff 30-50-325-40mg capsule
Tier 4 QL(180 EA per 30
days) None
Cometriq 100 mg/day(80mg x1-20 mg x1) capsule
Tier 5 None PA
Cometriq 140 mg/day(80mg x1-20 mg x3) capsule
Tier 5 None PA
Cometriq 60 mg/day(20 mg x 3/day) capsule Tier 5 None PA
Copaxone 20mg/mL syringe Tier 5 None PA
Cordran Tape Large Roll 4mcg/cm2 tape Tier 4 None None
Cresemba 186mg capsule Tier 5 None PA
Cresemba 372mg recon soln Tier 5 None PA
cyclosporine 250mg/5 mL solution Tier 3 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Cystaran 0.44% drops Tier 4 None PA
Daklinza 30mg tablet Tier 5 None PA
Daklinza 60mg tablet Tier 5 None PA
Daliresp 500mcg tablet Tier 4 QL(30 EA per 30
days) None
darifenacin 15mg tablet extended release 24 hr
Tier 4 None None
darifenacin 7.5mg tablet extended release 24 hr
Tier 4 None None
Decara 50,000unit capsule Tier 3 None None
Descovy 200-25mg tablet Tier 3 None None
desloratadine 5mg tablet Tier 2 QL(30 EA per 30
days) None
desmopressin 10 mcg/spray(0.1 mL) aerosol,spray
Tier 3 None None
desoximetasone 0.05% ointment Tier 3 None None
dexamethasone sodium phosphate 4mg/mL solution
Tier 2 None None
dexamethasone sodium phosphate 4mg/mL syringe
Tier 3 None None
dexchlorpheniramine maleate 2mg/5 mL syrup Tier 4 None None
dextroamphetamine-amphetamine 10mg capsule,extended release 24hr
Tier 2 QL(30 EA per 30
days) None
dextroamphetamine-amphetamine 10mg tablet
Tier 2 QL(90 EA per 30
days) None
dextroamphetamine-amphetamine 15mg capsule,extended release 24hr
Tier 2 QL(30 EA per 30
days) None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
dextroamphetamine-amphetamine 20mg capsule,extended release 24hr
Tier 2 QL(30 EA per 30
days) None
dextroamphetamine-amphetamine 20mg tablet
Tier 2 QL(90 EA per 30
days) None
dextroamphetamine-amphetamine 25mg capsule,extended release 24hr
Tier 2 QL(30 EA per 30
days) None
dextroamphetamine-amphetamine 30mg capsule,extended release 24hr
Tier 2 QL(30 EA per 30
days) None
dextroamphetamine-amphetamine 30mg tablet
Tier 2 QL(60 EA per 30
days) None
dextroamphetamine-amphetamine 5mg capsule,extended release 24hr
Tier 2 QL(30 EA per 30
days) None
dextroamphetamine-amphetamine 5mg tablet Tier 2 QL(90 EA per 30
days) None
diclofenac sodium 1% gel Tier 3 None None
dicyclomine 10mg/5 mL syrup Tier 2 None None
digoxin 0.25 mg/5 mL(5 mL) solution Tier 3 None None
dihydrocode-acetaminophen-caff 16-320.5-30mg capsule
Tier 4 None None
dihydroergotamine 0.5 mg/pumpact. (4 mg/mL) spray,non-aerosol
Tier 4 None None
DILT-CD 120mg capsule,extended release 24hr
Tier 2 None None
DILT-CD 180mg capsule,extended release 24hr
Tier 2 None None
DILT-CD 240mg capsule,extended release 24hr
Tier 2 None None
diphenhydramine HCl 50mg/mL solution Tier 2 None None
diphenoxylate-atropine 2.5-0.025mg tablet Tier 2 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
dipivefrin 0.1% drops Tier 4 None None
dofetilide 125mcg capsule Tier 4 None None
dofetilide 250mcg capsule Tier 4 None None
dofetilide 500mcg capsule Tier 4 None None
Donnatal 16.2-0.1037-0.0194 mg/5 mL elixir Tier 4 None None
E.E.S. 200 200mg/5 mL suspension for reconstitution
Tier 4 None None
Eliquis 2.5mg tablet Tier 4 None None
Eliquis 5mg tablet Tier 4 None None
Epiduo 0.1-2.5% gel Tier 4 None None
EpiPen 0.3mg/0.3 mL auto-injector Tier 3 QL(4 EA per 30
days) None
EpiPen Jr 0.15mg/0.3 mL auto-injector Tier 3 QL(4 EA per 30
days) None
erythromycin 2% solution Tier 2 None None
erythromycin 250mg capsule,delayed release(DR/EC)
Tier 4 None None
Evotaz 300-150mg tablet Tier 3 None None
Farydak 10mg capsule Tier 5 QL(6 EA per 21
days) PA
Farydak 15mg capsule Tier 5 QL(6 EA per 21
days) PA
Farydak 20mg capsule Tier 5 QL(6 EA per 21
days) PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Fetzima 120mg capsule,extended release 24 hr
Tier 4 QL(30 EA per 30
days) PA
Fetzima 20 mg (2)-40 mg (26) capsule,Ext Rel 24hr dose pack
Tier 4 QL(30 EA per 30
days) PA
Fetzima 20mg capsule,extended release 24 hr Tier 4 QL(30 EA per 30
days) PA
Fetzima 40mg capsule,extended release 24 hr Tier 4 QL(30 EA per 30
days) PA
Fetzima 80mg capsule,extended release 24 hr Tier 4 QL(30 EA per 30
days) PA
fexofenadine 30mg/5 mL suspension Tier 2 None None
fexofenadine-pseudoephedrine 60-120mg tablet extended release 12 hr
Tier 3 None None
Finacea Plus 15% kit Tier 4 None None
fluocinolone 0.025% cream Tier 3 None None
fluocinolone 0.025% ointment Tier 3 None None
fluorouracil 50mg/mL solution Tier 3 None None
fluoxetine 10mg capsule Tier 2 None None
fluoxetine 10mg tablet Tier 3 QL(240 EA per 30
days) None
fluoxetine 20mg capsule Tier 2 QL(90 EA per 30
days) None
fluoxetine 20mg tablet Tier 3 QL(120 EA per 30
days) None
frovatriptan 2.5mg tablet Tier 4 QL(18 EA per 30
days) ST Applies
furosemide 40mg/4 mL solution Tier 1 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Fycompa 0.5mg/mL suspension Tier 4 None PA
Fycompa 10mg tablet Tier 4 QL(30 EA per 30
days) PA
Fycompa 12mg tablet Tier 4 QL(30 EA per 30
days) PA
Fycompa 2 mg (7)-4 mg (7) tablets,dose pack Tier 4 None PA
Fycompa 2mg tablet Tier 4 QL(60 EA per 30
days) PA
Fycompa 4mg tablet Tier 4 QL(30 EA per 30
days) PA
Fycompa 6mg tablet Tier 4 QL(30 EA per 30
days) PA
Fycompa 8mg tablet Tier 4 QL(30 EA per 30
days) PA
gabapentin 250mg/5 mL (5 mL) solution Tier 2 QL(2160 ML per 30
days) None
gabapentin 300mg/6 mL (6 mL) solution Tier 2 QL(2160 ML per 30
days) None
Gammagard Liquid 10% solution Tier 5 None PA
Gammagard S-D (IgA < 1 mcg/mL) 10gram recon soln
Tier 5 None PA
Gammagard S-D (IgA < 1 mcg/mL) 5gram recon soln
Tier 5 None PA
Gengraf 100mg capsule Tier 3 None None
Gengraf 25mg capsule Tier 3 None None
Gengraf 50mg capsule Tier 3 None None
Genvoya 150-150-200-10mg tablet Tier 3 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Gilotrif 20mg tablet Tier 5 QL(30 EA per 30
days) PA
Gilotrif 30mg tablet Tier 5 QL(30 EA per 30
days) PA
Gilotrif 40mg tablet Tier 5 QL(30 EA per 30
days) PA
GlucaGen 1mg recon soln Tier 3 None None
heparin (porcine) 20,000unit/mL syringe Tier 2 None None
hydrocodone-acetaminophen 2.5-325mg tablet
Tier 3 QL(240 EA per 30
days) None
hydrocodone-acetaminophen 5-300mg tablet Tier 3 QL(240 EA per 30
days) None
hydrocodone-ibuprofen 10-200mg tablet Tier 3 QL(50 EA per 30
days) None
hydrocortisone 1% cream Tier 2 None None
hydrocortisone 1% packet Tier 2 None None
hydrocortisone 2.5% cream Tier 2 None None
hydrocortisone-aloe vera 1% cream Tier 2 None None
hydrocortisone-aloe vera 1% ointment Tier 2 None None
hydrocortisone-min oil-wht pet 1% ointment Tier 2 None None
hydrocortisone-oatmeal-aloe-E 1% cream Tier 2 None None
hydroxyzine HCl 10mg/5 mL (5 mL) solution Tier 2 None None
HyQvia 10 gram/100 mL (10 %) solution Tier 5 None PA
HyQvia 2.5 gram/25 mL (10 %) solution Tier 5 None PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
HyQvia 20 gram/200 mL (10 %) solution Tier 5 None PA
HyQvia 30 gram/300 mL (10 %) solution Tier 5 None PA
HyQvia 5 gram/50 mL (10 %) solution Tier 5 None PA
Ibrance 100mg capsule Tier 5 QL(21 EA per 28
days) PA
Ibrance 125mg capsule Tier 5 QL(21 EA per 28
days) PA
Ibrance 75mg capsule Tier 5 QL(21 EA per 28
days) PA
Iclusig 15mg tablet Tier 5 QL(60 EA per 30
days) PA
Iclusig 45mg tablet Tier 5 QL(30 EA per 30
days) PA
imatinib 100mg tablet Tier 5 QL(180 EA per 30
days) PA
imatinib 400mg tablet Tier 5 QL(60 EA per 30
days) PA
Imbruvica 140mg capsule Tier 5 QL(120 EA per 30
days) PA
Incruse Ellipta 62.5mcg/actuation blister with device
Tier 3 None None
Kalydeco 150mg tablet Tier 5 QL(60 EA per 30
days) PA
Kalydeco 50mg granules in packet Tier 5 QL(56 EA per 28
days) PA
Kalydeco 75mg granules in packet Tier 5 QL(56 EA per 28
days) PA
Kapidex 30mg capsule,biphase delayed releas
Tier 3 None None
Ketek Pak 400mg tablet Tier 5 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Klor-Con Sprinkle 10mEq capsule, extended release
Tier 2 None None
Klor-Con Sprinkle 8mEq capsule, extended release
Tier 2 None None
Lacrisert 5mg insert Tier 5 None PA
lactulose 10 gram/15 mL(15 mL) solution Tier 2 None None
lamotrigine 25 mg (21)-50 mg (7) tablet disintegrating, dose pk
Tier 3 None None
lamotrigine 25 mg (42)-100 mg (7) tablets,dose pack
Tier 3 None None
lamotrigine 25 mg (84)-100 mg (14) tablets,dose pack
Tier 3 None None
lamotrigine 25 mg(14)-50 mg(14)-100 mg (7) tablet disintegrating, dose pk
Tier 3 None None
lamotrigine 25mg (35) tablets,dose pack Tier 3 None None
lamotrigine 50 mg (42)-100 mg (14) tablet disintegrating, dose pk
Tier 3 None None
lancets misc Tier 3 QL(200 EA per 30
days) None
Lenvima 10 mg/day (10mg x 1/day) capsule Tier 5 QL(30 EA per 30
days) PA
Lenvima 14 mg/day(10 mgx 1-4 mg x 1) capsule
Tier 5 QL(30 EA per 30
days) PA
Lenvima 18 mg/day (10mg x 1-4 mg x2) capsule
Tier 5 QL(30 EA per 30
days) PA
Lenvima 20 mg/day(10 mg x 2) capsule Tier 5 QL(30 EA per 30
days) PA
Lenvima 24 mg/day(10 mgx 2-4 mg x 1) capsule
Tier 5 QL(30 EA per 30
days) PA
Lenvima 8 mg/day(4 mg x 2) capsule Tier 5 QL(30 EA per 30
days) PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
leuprolide 1mg/0.2 mL solution Tier 5 None PA
levetiracetam 500mg/5 mL (5 mL) solution Tier 2 None None
Levoxyl 100mcg tablet Tier 2 None None
Levoxyl 112mcg tablet Tier 2 None None
Levoxyl 125mcg tablet Tier 2 None None
Levoxyl 137mcg tablet Tier 2 None None
Levoxyl 150mcg tablet Tier 2 None None
Levoxyl 175mcg tablet Tier 2 None None
Levoxyl 200mcg tablet Tier 2 None None
Levoxyl 25mcg tablet Tier 2 None None
Levoxyl 50mcg tablet Tier 2 None None
Levoxyl 75mcg tablet Tier 2 None None
Levoxyl 88mcg tablet Tier 2 None None
lidocaine HCl 2% solution Tier 2 None None
Lipofen 150mg capsule Tier 3 None None
Lipofen 50mg capsule Tier 3 None None
lithium citrate 8mEq/5 mL (5 mL) solution Tier 2 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
lomustine 100mg capsule Tier 4 None None
lomustine 10mg capsule Tier 4 None None
lomustine 40mg capsule Tier 4 None None
Lotemax 0.5% drops,gel Tier 4 None None
Lupaneta Pack (1 month) 3.75 mg-5 mg (30) kit. syringe and tablet
Tier 5 None PA
Lupaneta Pack (3 month) 11.25 mg-5 mg (90) kit. syringe and tablet
Tier 5 None PA
Lynparza 50mg capsule Tier 5 QL(480 EA per 30
days) PA
Mekinist 0.5mg tablet Tier 5 QL(120 EA per 30
days) PA
Mekinist 2mg tablet Tier 5 QL(30 EA per 30
days) PA
methenamine mandelate 1gram tablet Tier 3 None None
metronidazole 1% gel with pump Tier 4 None None
mexiletine 150mg capsule Tier 2 None None
mexiletine 200mg capsule Tier 2 None None
mexiletine 250mg capsule Tier 2 None None
miglitol 100mg tablet Tier 4 QL(90 EA per 30
days) None
miglitol 25mg tablet Tier 4 QL(90 EA per 30
days) None
miglitol 50mg tablet Tier 4 QL(90 EA per 30
days) None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
misoprostol 100mcg tablet Tier 2 None None
Moderiba 200mg tablet Tier 4 None PA
mometasone 50mcg/actuation spray,non-aerosol
Tier 4 None None
morphine concentrate 20mg/mL syringe Tier 3 QL(600 EA per 30
days) None
Movantik 12.5mg tablet Tier 4 None PA
Movantik 25mg tablet Tier 4 None PA
mycophenolate mofetil 200mg/mL suspension for reconstitution
Tier 4 None None
Myrbetriq 25mg tablet extended release 24 hr Tier 3 None None
Myrbetriq 50mg tablet extended release 24 hr Tier 3 None None
naftifine 2% cream Tier 4 None None
naloxone 1mg/mL syringe Tier 2 None None
Namenda XR 14mg capsule,sprinkle,ER 24hr Tier 3 QL(30 EA per 30
days) None
Namenda XR 21mg capsule,sprinkle,ER 24hr Tier 3 QL(30 EA per 30
days) None
Namenda XR 28mg capsule,sprinkle,ER 24hr Tier 3 QL(30 EA per 30
days) None
Namenda XR 7-14-21-28mg cap,sprinkle,ER 24hr dose pack
Tier 3 None None
Namenda XR 7mg capsule,sprinkle,ER 24hr Tier 3 QL(30 EA per 30
days) None
Natpara 100mcg/dose cartridge Tier 5 None PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Natpara 25mcg/dose cartridge Tier 5 None PA
Natpara 50mcg/dose cartridge Tier 5 None PA
Natpara 75mcg/dose cartridge Tier 5 None PA
Neulasta 6mg/0.6 mL syringe, w/ wearable injector
Tier 5 None PA
Neupogen 300mcg/0.5 mL syringe Tier 5 None PA
Neupogen 480mcg/0.8 mL syringe Tier 5 None PA
niacin 500mg tablet Tier 2 None None
Northera 100mg capsule Tier 5 None PA
Northera 200mg capsule Tier 5 None PA
Northera 300mg capsule Tier 5 None PA
Norvir Soft Gelatin 100mg capsule Tier 3 None None
Noxafil 100mg tablet,delayed release (DR/EC) Tier 5 None PA
Noxafil 300mg/16.7 mL solution Tier 5 None PA
Nuedexta 20-10mg capsule Tier 5 QL QL(60 EA per
30 days) PA
nystatin 150 millionunit powder Tier 2 None None
nystatin 2 billionunit powder Tier 2 None None
nystatin 50 millionunit powder Tier 2 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
nystatin 500 millionunit powder Tier 2 None None
Odefsey 200-25-25mg tablet Tier 3 None None
Odomzo 200mg capsule Tier 5 QL(30 EA per 30
days) PA
omega 3-dha-epa-fish oil 1,000 mg (120mg-180 mg) capsule
Tier 4 None None
omeprazole magnesium 20mg capsule,delayed release(DR/EC)
Tier 2 None None
Onfi 10mg tablet Tier 5 None PA
Onfi 2.5mg/mL suspension Tier 5 None PA
Onfi 20mg tablet Tier 5 None PA
Opsumit 10mg tablet Tier 5 None PA
Orencia ClickJect 125mg/mL auto-injector Tier 5 None PA
Orenitram 0.125mg tablet extended release Tier 5 None PA
Orenitram 0.25mg tablet extended release Tier 5 None PA
Orenitram 1mg tablet extended release Tier 5 None PA
Orenitram 2.5mg tablet extended release Tier 5 None PA
Osphena 60mg tablet Tier 4 None PA
oxiconazole 1% cream Tier 4 None None
oxycodone 10mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30
days) PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
oxycodone 15mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30
days) PA
oxycodone 20mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30
days) PA
oxycodone 30mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30
days) PA
oxycodone 40mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30
days) PA
oxycodone 60mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30
days) PA
oxycodone 80mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30
days) PA
paliperidone 1.5mg tablet extended release 24hr
Tier 5 QL(30 EA per 30
days) PA
paliperidone 3mg tablet extended release 24hr
Tier 5 QL(30 EA per 30
days) PA
paliperidone 6mg tablet extended release 24hr
Tier 5 QL(60 EA per 30
days) PA
paliperidone 9mg tablet extended release 24hr
Tier 5 QL(30 EA per 30
days) PA
Pazeo 0.7% drops Tier 3 None None
PegIntron 120mcg/0.5 mL kit Tier 5 None PA
PegIntron 150mcg/0.5 mL kit Tier 5 None PA
PegIntron 50mcg/0.5 mL kit Tier 5 None PA
PegIntron 80mcg/0.5 mL kit Tier 5 None PA
Pentasa 250mg capsule, extended release Tier 3 QL(240 EA per 30
days) None
Pentasa 500mg capsule, extended release Tier 3 QL(240 EA per 30
days) None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Phenergan 12.5mg suppository Tier 3 None None
Phenergan 25mg suppository Tier 3 None None
Phenergan 50mg suppository Tier 3 None None
phenobarb-hyoscy-atropine-scop 16.2-0.1037-0.0194 mg tablet
Tier 4 None None
phenoxybenzamine 10mg capsule Tier 3 None None
phenytoin 100mg/4 mL suspension Tier 2 None None
phenytoin 100mg/4 mL syringe Tier 2 None None
pilocarpine HCl 1% drops Tier 3 None None
pilocarpine HCl 2% drops Tier 3 None None
pilocarpine HCl 4% drops Tier 3 None None
pioglitazone-metformin 15-500mg tablet Tier 3 QL(90 EA per 30
days) None
pioglitazone-metformin 15-850mg tablet Tier 3 QL(90 EA per 30
days) None
Pomalyst 1mg capsule Tier 5 None PA
Pomalyst 2mg capsule Tier 5 None PA
Pomalyst 3mg capsule Tier 5 None PA
Pomalyst 4mg capsule Tier 5 None PA
prednisolone 15mg/5 mL solution Tier 2 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
prednisolone sodium phosphate 15mg/5 mL (5 mL) solution
Tier 2 None None
Prepopik 10 mg-3.5gram-12 gram powder in packet
Tier 4 None None
Prezcobix 800-150mg-mg tablet Tier 3 None None
Prezista 300mg tablet Tier 3 None None
prochlorperazine Edisylate 5mg/mL solution Tier 2 None None
Prolensa 0.07% drops Tier 3 None None
promethazine 25mg/mL syringe Tier 3 None None
rabeprazole 20mg tablet,delayed release (DR/EC)
Tier 4 QL(30 EA per 30
days) None
Renvela 0.8gram powder in packet Tier 5 None None
Renvela 2.4gram powder in packet Tier 5 None None
Retrovir 300mg tablet Tier 4 None None
Reyataz 100mg capsule Tier 3 None None
Ribasphere 200mg capsule Tier 4 None PA
Ribasphere 200mg tablet Tier 4 None PA
Rifamate 300-150mg capsule Tier 4 None None
ringers solution Tier 2 None None
risperidone 0.5mg tablet,disintegrating Tier 3 QL(120 EA per 30
days) None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
risperidone 1mg tablet,disintegrating Tier 3 QL(120 EA per 30
days) None
risperidone 1mg/mL syringe Tier 2 None None
risperidone 2mg tablet,disintegrating Tier 3 QL(120 EA per 30
days) None
risperidone 3mg tablet,disintegrating Tier 3 QL(120 EA per 30
days) None
risperidone 4mg tablet,disintegrating Tier 3 QL(120 EA per 30
days) None
rosuvastatin 10mg tablet Tier 4 QL(30 EA per 30
days) None
rosuvastatin 20mg tablet Tier 4 QL(30 EA per 30
days) None
rosuvastatin 40mg tablet Tier 4 QL(30 EA per 30
days) None
rosuvastatin 5mg tablet Tier 4 QL(30 EA per 30
days) None
Sandostatin LAR Depot 10mg kit Tier 5 None PA
Sandostatin LAR Depot 20mg kit Tier 5 None PA
Sandostatin LAR Depot 30mg kit Tier 5 None PA
Saphris 10mg tablet Tier 4 None PA
Saphris 5mg tablet Tier 4 None None
selenium sulfide 2.5% shampoo Tier 2 None None
Signifor 0.3mg/mL (1 mL) solution Tier 5 None PA
Signifor 0.6mg/mL (1 mL) solution Tier 5 None PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Signifor 0.9mg/mL (1 mL) solution Tier 5 None PA
Signifor LAR 20mg suspension for reconstitution
Tier 5 None PA
Signifor LAR 40mg suspension for reconstitution
Tier 5 None PA
Signifor LAR 60mg suspension for reconstitution
Tier 5 None PA
Silenor 3mg tablet Tier 4 None None
sodium chloride 0.9 % 0.9% solution Tier 2 None None
sodium fluoride 1 mg fluoride(2.2 mg) tablet Tie 6 None None
sodium polystyrene (sorb free) 15gram/60 mL suspension
Tier 3 None None
Sorine 120mg tablet Tier 2 None None
Sorine 160mg tablet Tier 2 None None
Sorine 240mg tablet Tier 2 None None
Sorine 80mg tablet Tier 2 None None
Stiolto Respimat 2.5-2.5mcg/actuation mist Tier 3 QL(4 GM per 30
days) None
Stivarga 40mg tablet Tier 5 QL(84 EA per 28
days) PA
sulfacetamide sodium 10% cleanser,gel extended release
Tier 4 None None
sulfacetamide sodium-urea 10-10% lotion Tier 2 None None
sulfasalazine 500mg tablet,delayed release (DR/EC)
Tier 2 None None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Suprax 100mg tablet,chewable Tier 4 None None
Suprax 200mg tablet,chewable Tier 4 None None
Suprax 400mg capsule Tier 4 None None
Synjardy 12.5-1,000mg tablet Tier 3 None None
Synjardy 12.5-500mg tablet Tier 3 None None
Synjardy 5-1,000mg tablet Tier 3 None None
Synjardy 5-500mg tablet Tier 3 None None
Tafinlar 50mg capsule Tier 5 None PA
Tafinlar 75mg capsule Tier 5 None PA
tetrabenazine 25mg tablet Tier 5 None PA
Tis-U-Sol solution Tier 3 None None
Tivicay 10mg tablet Tier 3 None None
Tivicay 25mg tablet Tier 3 None None
tobramycin in 0.225 % NaCl 300mg/5 mL solution for nebulization
Tier 5 None PA
Transderm-Scop 1.5 mg (1 mgover 3 days) patch 3 day
Tier 4 None None
travoprost (benzalkonium) 0.004% drops Tier 3 QL(5 ML per 31
days) None
tretinoin (emollient) 0.05% cream Tier 3 None None
triamcinolone acetonide 55mcg aerosol,spray Tier 2 None None
Trintellix 10mg tablet Tier 3 QL(30 EA per 30
days) None
Trintellix 20mg tablet Tier 3 QL(30 EA per 30
days) None
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Trintellix 5mg tablet Tier 3 QL(30 EA per 30
days) None
Triumeq 600-50-300mg tablet Tier 3 None None
Truvada 100-150mg tablet Tier 3 None None
Truvada 133-200mg tablet Tier 3 None None
Truvada 167-250mg tablet Tier 3 None None
Tudorza Pressair 400mcg/actuation aerosol powdr breath activated
Tier 4 None None
Tybost 150mg tablet Tier 3 QL(30 EA per 30
days) None
valproic acid (as sodium salt) 250mg/5 mL (5 mL) solution
Tier 2 None None
valproic acid (as sodium salt) 250mg/5 mL syringe
Tier 2 None None
valproic acid (as sodium salt) 500 mg/10 mL(10 mL) solution
Tier 2 None None
vancomycin 1,000mg recon soln Tier 2 None None
vancomycin 500mg recon soln Tier 2 None None
Varubi 90mg tablet Tier 5 None PA
Victoza 3-Pak 0.6 mg/0.1 mL(18 mg/3 mL) pen injector
Tier 4 None PA
Viibryd 10 mg (7)-20 mg(7)-40 mg (16) tablets,dose pack
Tier 4 QL(30 EA per 30
days) ST
Vimpat 50 mg (14)-100 mg (14) tablets,dose pack
Tier 5 None PA
Visicol 1.5gram tablet Tier 2 None None
Vitekta 150mg tablet Tier 3 QL(30 EA per 30
days) None
Vitekta 85mg tablet Tier 3 QL(30 EA per 30
days) None
voriconazole 200 mg/5 mL(40 mg/mL) suspension for reconstitution
Tier 5 None PA
MEDICATIONS ADDED TO THE 2017 QHP FORMULARY
Medication Name Benefit
Tier Quantity Limit
(QL)
Prior Authorization (PA) or Step Therapy (ST)
Requirement
Vraylar 1.5 mg (1)-3 mg (6) capsule,dose pack
Tier 5 None PA
Vraylar 1.5mg capsule Tier 5 None PA
Vraylar 3mg capsule Tier 5 None PA
Vraylar 4.5mg capsule Tier 5 None PA
Vraylar 6mg capsule Tier 5 None PA
WelChol 3.75gram powder in packet Tier 4 None None
Xarelto 15 mg (42)-20 mg (9) tablets,dose pack
Tier 4 None None
Xeljanz 5mg tablet Tier 5 None PA
Xeljanz XR 11mg tablet extended release 24 hr
Tier 5 None PA
Xgeva 120 mg/1.7 mL(70 mg/mL) solution Tier 5 None PA
zoledronic acid-mannitol-water 5mg/100 mL piggyback
Tier 5 None PA
Zydelig 100mg tablet Tier 5 QL(60 EA per 30
days) PA
Zydelig 150mg tablet Tier 5 QL(60 EA per 30
days) PA
Zyflo 600mg tablet Tier 5 QL(120 EA per 30
days) PA
Zykadia 150mg capsule Tier 5 QL(150 EA per 30
days) PA
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
acamprosate 333mg tablet,delayed release (DR/EC) Tier 2 Tier 4
acetaminophen-codeine 120-12mg/5 mL solution Tier 2 Tier 3
acetaminophen-codeine 300-15mg tablet Tier 2 Tier 3
acetaminophen-codeine 300-30mg tablet Tier 2 Tier 3
acetaminophen-codeine 300-60mg tablet Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
Acetasol HC 1-2% drops Tier 2 Tier 3
acetazolamide 125mg tablet Tier 2 Tier 3
acetazolamide 250mg tablet Tier 2 Tier 3
acyclovir 200mg/5 mL suspension Tier 2 Tier 3
adapalene 0.1% cream Tier 2 Tier 3
adapalene 0.1% gel Tier 2 Tier 3
Adderall XR 10mg capsule,extended release 24hr Tier 3 Tier 4
Adderall XR 15mg capsule,extended release 24hr Tier 3 Tier 4
Adderall XR 20mg capsule,extended release 24hr Tier 3 Tier 4
Adderall XR 25mg capsule,extended release 24hr Tier 3 Tier 4
Adderall XR 30mg capsule,extended release 24hr Tier 3 Tier 4
Adderall XR 5mg capsule,extended release 24hr Tier 3 Tier 4
Albenza 200mg tablet Tier 3 Tier 5
albuterol sulfate 2mg tablet Tier 2 Tier 4
albuterol sulfate 4mg tablet Tier 2 Tier 4
alendronate 35mg tablet Tier 2 Tier 1
alendronate 70mg tablet Tier 2 Tier 1
alfuzosin 10mg tablet extended release 24 hr Tier 3 Tier 2
Alphagan P 0.1% drops Tier 3 Tier 4
alprazolam 0.5mg tablet extended release 24 hr Tier 2 Tier 3
alprazolam 1mg tablet extended release 24 hr Tier 2 Tier 3
alprazolam 2mg tablet extended release 24 hr Tier 2 Tier 3
alprazolam 3mg tablet extended release 24 hr Tier 2 Tier 3
Altabax 1% ointment Tier 3 Tier 4
amantadine HCl 100mg capsule Tier 2 Tier 3
amantadine HCl 100mg tablet Tier 2 Tier 3
amcinonide 0.1% cream Tier 2 Tier 4
amlodipine 10mg tablet Tier 2 Tier 1
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
amlodipine 2.5mg tablet Tier 2 Tier 1
amlodipine 5mg tablet Tier 2 Tier 1
amlodipine-benazepril 10-20mg capsule Tier 4 Tier 2
amlodipine-benazepril 10-40mg capsule Tier 4 Tier 2
amlodipine-benazepril 2.5-10mg capsule Tier 4 Tier 2
amlodipine-benazepril 5-10mg capsule Tier 4 Tier 2
amlodipine-benazepril 5-20mg capsule Tier 4 Tier 2
amlodipine-benazepril 5-40mg capsule Tier 4 Tier 2
amlodipine-valsartan 10-160mg tablet Tier 3 Tier 2
amlodipine-valsartan 10-320mg tablet Tier 3 Tier 2
amlodipine-valsartan 5-160mg tablet Tier 3 Tier 2
amlodipine-valsartan 5-320mg tablet Tier 3 Tier 2
amoxapine 100mg tablet Tier 3 Tier 2
amoxapine 150mg tablet Tier 3 Tier 2
amoxapine 25mg tablet Tier 3 Tier 2
amoxapine 50mg tablet Tier 3 Tier 2
amoxicillin 125mg tablet,chewable Tier 1 Tier 2
amoxicillin-pot clavulanate 1,000-62.5mg tablet extended release 12 hr
Tier 2 Tier 3
amoxicillin-pot clavulanate 250-125mg tablet Tier 2 Tier 3
amoxicillin-pot clavulanate 250-62.5mg/5 mL suspension for reconstitution
Tier 2 Tier 3
anagrelide 0.5mg capsule Tier 2 Tier 3
anagrelide 1mg capsule Tier 2 Tier 3
Anucort-HC 25mg suppository Tier 2 Tier 3
Ascomp with Codeine 30-50-325-40mg capsule Tier 2 Tier 3
aspirin-dipyridamole 25-200mg capsule, ER multiphase 12 hr
Tier 3 Tier 4
atenolol-chlorthalidone 100-25mg tablet Tier 1 Tier 2
atenolol-chlorthalidone 50-25mg tablet Tier 1 Tier 2
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
atovaquone 750mg/5 mL suspension Tier 4 Tier 5
atovaquone-proguanil 250-100mg tablet Tier 2 Tier 4
atovaquone-proguanil 62.5-25mg tablet Tier 2 Tier 4
Avar 10-5% (w/w) cleanser Tier 2 Tier 4
Avar-E 10-5% (w/w) cream Tier 2 Tier 4
Avar-E Green 10-5% (w/w) cream Tier 2 Tier 4
azelastine 0.15 %(205.5 mcg) spray,non-aerosol Tier 2 Tier 3
azelastine 137 mcg(0.1 %) aerosol,spray Tier 2 Tier 3
azithromycin 250mg tablet Tier 2 Tier 1
azithromycin 500mg tablet Tier 2 Tier 1
azithromycin 600mg tablet Tier 2 Tier 1
bacitracin 500unit/gram ointment Tier 2 Tier 3
Bactroban Nasal 2% ointment Tier 3 Tier 4
balsalazide 750mg capsule Tier 2 Tier 3
betamethasone dipropionate 0.05% cream Tier 2 Tier 3
betamethasone dipropionate 0.05% ointment Tier 2 Tier 3
betamethasone valerate 0.1% lotion Tier 2 Tier 3
betamethasone, augmented 0.05% lotion Tier 2 Tier 3
bethanechol chloride 10mg tablet Tier 2 Tier 3
bethanechol chloride 25mg tablet Tier 2 Tier 3
bethanechol chloride 50mg tablet Tier 2 Tier 3
bethanechol chloride 5mg tablet Tier 2 Tier 3
Betoptic S 0.25% drops,suspension Tier 3 Tier 4
Beyaz 3-0.02-0.451mg (24) tablet Tier 3 Tier 4
brimonidine 0.15% drops Tier 2 Tier 3
brimonidine 0.2% drops Tier 2 Tier 1
Bromfed DM 2-30-10mg/5 mL syrup Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
bromocriptine 2.5mg tablet Tier 2 Tier 4
bromocriptine 5mg capsule Tier 2 Tier 4
brompheniramine-pseudoeph-DM 2-30-10mg/5 mL syrup
Tier 2 Tier 3
Brovana 15mcg/2 mL solution for nebulization Tier 5 Tier 4
budesonide 0.25mg/2 mL suspension for nebulization Tier 2 Tier 4
budesonide 0.5mg/2 mL suspension for nebulization Tier 2 Tier 4
budesonide 1mg/2 mL suspension for nebulization Tier 2 Tier 4
buprenorphine HCl 2mg tablet Tier 2 Tier 3
buprenorphine HCl 8mg tablet Tier 2 Tier 3
Butalbital Compound W/Codeine 30-50-325-40mg capsule
Tier 2 Tier 4
butalbital-acetaminop-caf-cod 50-300-40-30mg capsule
Tier 2 Tier 4
butalbital-acetaminophen 50-325mg tablet Tier 2 Tier 4
butalbital-acetaminophen-caff 50-300-40mg capsule Tier 2 Tier 4
butalbital-acetaminophen-caff 50-325-40mg capsule Tier 2 Tier 4
butalbital-acetaminophen-caff 50-325-40mg tablet Tier 2 Tier 4
butalbital-aspirin-caffeine 50-325-40mg capsule Tier 2 Tier 4
butorphanol tartrate 1mg/mL solution Tier 2 Tier 3
butorphanol tartrate 2mg/mL solution Tier 2 Tier 3
cabergoline 0.5mg tablet Tier 2 Tier 3
calcipotriene 0.005% cream Tier 2 Tier 4
calcipotriene 0.005% ointment Tier 2 Tier 4
calcipotriene 0.005% solution Tier 2 Tier 4
calcitonin (salmon) 200unit/actuation spray,non-aerosol
Tier 4 Tier 3
Canasa 1,000mg suppository Tier 4 Tier 5
captopril 100mg tablet Tier 1 Tier 2
captopril 12.5mg tablet Tier 1 Tier 2
captopril 25mg tablet Tier 1 Tier 2
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
captopril 50mg tablet Tier 1 Tier 2
captopril-hydrochlorothiazide 25-15mg tablet Tier 1 Tier 2
captopril-hydrochlorothiazide 25-25mg tablet Tier 1 Tier 2
captopril-hydrochlorothiazide 50-15mg tablet Tier 1 Tier 2
captopril-hydrochlorothiazide 50-25mg tablet Tier 1 Tier 2
Carafate 100mg/mL suspension Tier 3 Tier 4
carbamazepine 100mg capsule, ER multiphase 12 hr Tier 2 Tier 3
carbamazepine 100mg/5 mL suspension Tier 2 Tier 3
carbamazepine 200mg capsule, ER multiphase 12 hr Tier 2 Tier 3
carbamazepine 200mg tablet extended release 12 hr Tier 2 Tier 3
carbamazepine 300mg capsule, ER multiphase 12 hr Tier 2 Tier 3
carbamazepine 400mg tablet extended release 12 hr Tier 2 Tier 3
carbidopa 25mg tablet Tier 3 Tier 4
carvedilol 12.5mg tablet Tier 2 Tier 1
carvedilol 25mg tablet Tier 2 Tier 1
carvedilol 3.125mg tablet Tier 2 Tier 1
carvedilol 6.25mg tablet Tier 2 Tier 1
cefaclor 250mg capsule Tier 2 Tier 3
cefaclor 500mg capsule Tier 2 Tier 3
cefadroxil 1gram tablet Tier 2 Tier 3
cefadroxil 250mg/5 mL suspension for reconstitution Tier 2 Tier 3
cefadroxil 500mg/5 mL suspension for reconstitution Tier 2 Tier 3
cefdinir 125mg/5 mL suspension for reconstitution Tier 2 Tier 3
cefdinir 250mg/5 mL suspension for reconstitution Tier 2 Tier 3
cefpodoxime 100mg tablet Tier 2 Tier 3
cefpodoxime 200mg tablet Tier 2 Tier 3
cefprozil 125mg/5 mL suspension for reconstitution Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
cefprozil 250mg/5 mL suspension for reconstitution Tier 2 Tier 3
cefuroxime axetil 250mg tablet Tier 2 Tier 3
cefuroxime axetil 500mg tablet Tier 2 Tier 3
cephalexin 125mg/5 mL suspension for reconstitution Tier 1 Tier 2
cephalexin 250mg/5 mL suspension for reconstitution Tier 1 Tier 2
chlordiazepoxide-clidinium 5-2.5mg capsule Tier 2 Tier 3
chlorpromazine 100mg tablet Tier 2 Tier 3
chlorpromazine 10mg tablet Tier 2 Tier 3
chlorpromazine 200mg tablet Tier 2 Tier 3
chlorpromazine 25mg tablet Tier 2 Tier 3
chlorpromazine 50mg tablet Tier 2 Tier 3
cholestyramine (with sugar) 4gram powder Tier 2 Tier 3
cholestyramine (with sugar) 4gram powder in packet Tier 2 Tier 3
Cholestyramine Light 4gram powder Tier 1 Tier 3
Cholestyramine Light 4gram powder in packet Tier 1 Tier 3
ciclopirox 0.77% cream Tier 2 Tier 3
ciclopirox 0.77% gel Tier 2 Tier 3
ciclopirox 0.77% suspension Tier 2 Tier 3
ciclopirox 1% shampoo Tier 2 Tier 3
Cipro HC 0.2-1% drops,suspension Tier 3 Tier 4
ciprofloxacin (mixture) 1,000mg tablet, ER multiphase 24 hr
Tier 2 Tier 3
ciprofloxacin (mixture) 500mg tablet, ER multiphase 24 hr
Tier 2 Tier 3
ciprofloxacin HCl 0.3% drops Tier 2 Tier 1
ciprofloxacin HCl 100mg tablet Tier 2 Tier 4
ciprofloxacin HCl 250mg tablet Tier 2 Tier 1
ciprofloxacin HCl 500mg tablet Tier 2 Tier 1
ciprofloxacin HCl 750mg tablet Tier 2 Tier 1
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
citalopram 10mg tablet Tier 2 Tier 1
citalopram 20mg tablet Tier 2 Tier 1
citalopram 40mg tablet Tier 2 Tier 1
Claravis 10mg capsule Tier 5 Tier 4
Claravis 20mg capsule Tier 5 Tier 4
Claravis 30mg capsule Tier 5 Tier 4
Claravis 40mg capsule Tier 5 Tier 4
clemastine 2.68mg tablet Tier 2 Tier 3
Cleocin 100mg suppository Tier 3 Tier 4
clindamycin HCl 150mg capsule Tier 2 Tier 1
clindamycin HCl 300mg capsule Tier 2 Tier 1
clindamycin palmitate HCl 75mg/5 mL recon soln Tier 2 Tier 3
clindamycin phosphate 1% gel Tier 2 Tier 3
clindamycin phosphate 1% lotion Tier 2 Tier 3
clindamycin phosphate 1% solution Tier 2 Tier 3
clindamycin phosphate 2% cream Tier 2 Tier 3
clindamycin-benzoyl peroxide 1.2 %(1 % base)-5 % gel
Tier 2 Tier 4
clindamycin-benzoyl peroxide 1-5% gel Tier 2 Tier 4
clobetasol 0.05% cream Tier 2 Tier 4
clobetasol 0.05% gel Tier 2 Tier 4
clobetasol 0.05% lotion Tier 2 Tier 4
clobetasol 0.05% ointment Tier 2 Tier 4
clobetasol 0.05% shampoo Tier 2 Tier 4
clobetasol 0.05% solution Tier 2 Tier 3
clobetasol-emollient 0.05% cream Tier 2 Tier 4
clocortolone pivalate 0.1% cream Tier 2 Tier 4
Clodan 0.05% shampoo Tier 2 Tier 4
clomipramine 25mg capsule Tier 2 Tier 4
clomipramine 50mg capsule Tier 2 Tier 4
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
clomipramine 75mg capsule Tier 2 Tier 4
clonidine 0.1mg/24 hr patch weekly Tier 2 Tier 3
clonidine 0.2mg/24 hr patch weekly Tier 2 Tier 3
clonidine 0.3mg/24 hr patch weekly Tier 2 Tier 3
clonidine HCl 0.1mg tablet Tier 2 Tier 1
clonidine HCl 0.2mg tablet Tier 2 Tier 1
clonidine HCl 0.3mg tablet Tier 2 Tier 1
clotrimazole-betamethasone 1-0.05% lotion Tier 2 Tier 3
codeine sulfate 15mg tablet Tier 2 Tier 3
codeine sulfate 30mg tablet Tier 2 Tier 3
codeine sulfate 60mg tablet Tier 2 Tier 3
colestipol 1gram tablet Tier 2 Tier 3
colestipol 5gram granules Tier 2 Tier 3
Compro 25mg suppository Tier 2 Tier 4
cyclosporine 100mg capsule Tier 2 Tier 3
cyclosporine 25mg capsule Tier 2 Tier 3
cyclosporine modified 100mg capsule Tier 2 Tier 3
cyclosporine modified 100mg/mL solution Tier 2 Tier 3
cyclosporine modified 25mg capsule Tier 2 Tier 3
cyclosporine modified 50mg capsule Tier 2 Tier 3
Cystaran 0.44% drops Tier 4 Tier 5
danazol 100mg capsule Tier 2 Tier 4
danazol 200mg capsule Tier 2 Tier 4
danazol 50mg capsule Tier 2 Tier 4
dantrolene 100mg capsule Tier 2 Tier 3
dantrolene 25mg capsule Tier 2 Tier 3
dantrolene 50mg capsule Tier 2 Tier 3
Denavir 1% cream Tier 3 Tier 4
Depen Titratabs 250mg tablet Tier 4 Tier 5
Dermazene 1-1% cream Tier 2 Tier 3
desmopressin 0.1mg tablet Tier 2 Tier 3
desmopressin 0.2mg tablet Tier 2 Tier 3
desmopressin 10 mcg/spray(0.1 mL) spray,non-aerosol
Tier 2 Tier 3
desonide 0.05% cream Tier 2 Tier 4
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
desonide 0.05% lotion Tier 2 Tier 4
desonide 0.05% ointment Tier 2 Tier 4
desoximetasone 0.05% cream Tier 2 Tier 3
desoximetasone 0.05% gel Tier 2 Tier 3
desoximetasone 0.25% cream Tier 2 Tier 3
desoximetasone 0.25% ointment Tier 2 Tier 3
dexmethylphenidate 10mg tablet Tier 2 Tier 3
dexmethylphenidate 2.5mg tablet Tier 2 Tier 3
dexmethylphenidate 5mg tablet Tier 2 Tier 3
dextroamphetamine 10mg capsule, extended release Tier 2 Tier 4
dextroamphetamine 10mg tablet Tier 2 Tier 3
dextroamphetamine 15mg capsule, extended release Tier 2 Tier 4
dextroamphetamine 5mg capsule, extended release Tier 2 Tier 4
dextroamphetamine 5mg tablet Tier 2 Tier 3
diazepam 5 mg/5 mL(1 mg/mL) solution Tier 2 Tier 4
diclofenac potassium 50mg tablet Tier 1 Tier 2
dicyclomine 10mg capsule Tier 2 Tier 1
dicyclomine 20mg tablet Tier 2 Tier 1
Dipentum 250mg capsule Tier 4 Tier 5
doxycycline hyclate 100mg capsule Tier 2 Tier 3
doxycycline hyclate 100mg tablet Tier 2 Tier 3
doxycycline hyclate 50mg capsule Tier 2 Tier 3
doxycycline monohydrate 100mg tablet Tier 2 Tier 3
doxycycline monohydrate 50mg tablet Tier 2 Tier 3
doxycycline monohydrate 75mg tablet Tier 2 Tier 3
dronabinol 2.5mg capsule Tier 5 Tier 4
dronabinol 5mg capsule Tier 5 Tier 4
Droxia 200mg capsule Tier 3 Tier 4
Droxia 300mg capsule Tier 3 Tier 4
Droxia 400mg capsule Tier 3 Tier 4
Durezol 0.05% drops Tier 3 Tier 4
econazole 1% cream Tier 2 Tier 4
Elidel 1% cream Tier 3 Tier 4
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
Elmiron 100mg capsule Tier 3 Tier 4
enalapril-hydrochlorothiazide 10-25mg tablet Tier 2 Tier 1
enalapril-hydrochlorothiazide 5-12.5mg tablet Tier 2 Tier 1
Endocet 10-325mg tablet Tier 2 Tier 3
Endocet 2.5-325mg tablet Tier 2 Tier 3
Endocet 5-325mg tablet Tier 2 Tier 3
Endocet 7.5-325mg tablet Tier 2 Tier 3
enoxaparin 100mg/mL syringe Tier 5 Tier 4
enoxaparin 120mg/0.8 mL syringe Tier 5 Tier 4
enoxaparin 150mg/mL syringe Tier 5 Tier 4
enoxaparin 300mg/3 mL solution Tier 5 Tier 4
enoxaparin 30mg/0.3 mL syringe Tier 5 Tier 4
enoxaparin 40mg/0.4 mL syringe Tier 5 Tier 4
enoxaparin 60mg/0.6 mL syringe Tier 5 Tier 4
enoxaparin 80mg/0.8 mL syringe Tier 5 Tier 4
entacapone 200mg tablet Tier 3 Tier 4
eplerenone 25mg tablet Tier 2 Tier 3
eplerenone 50mg tablet Tier 2 Tier 3
ergoloid 1mg tablet Tier 2 Tier 3
Ery Pads 2% swab Tier 2 Tier 3
erythromycin 250mg tablet Tier 2 Tier 4
erythromycin 500mg tablet Tier 2 Tier 4
erythromycin ethylsuccinate 400mg tablet Tier 2 Tier 4
erythromycin-benzoyl peroxide 3-5% gel Tier 2 Tier 4
escitalopram oxalate 5mg/5 mL solution Tier 2 Tier 3
estradiol 0.025mg/24 hr patch semiweekly Tier 3 Tier 4
estradiol 0.025mg/24 hr patch weekly Tier 2 Tier 3
estradiol 0.0375mg/24 hr patch semiweekly Tier 3 Tier 4
estradiol 0.0375mg/24 hr patch weekly Tier 2 Tier 3
estradiol 0.05mg/24 hr patch semiweekly Tier 3 Tier 4
estradiol 0.05mg/24 hr patch weekly Tier 2 Tier 3
estradiol 0.06mg/24 hr patch weekly Tier 2 Tier 3
estradiol 0.075mg/24 hr patch semiweekly Tier 2 Tier 4
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
estradiol 0.075mg/24 hr patch weekly Tier 2 Tier 3
estradiol 0.1mg/24 hr patch semiweekly Tier 3 Tier 4
estradiol 0.1mg/24 hr patch weekly Tier 2 Tier 3
estrogens-methyltestosterone 0.625-1.25mg tablet Tier 2 Tier 3
estrogens-methyltestosterone 1.25-2.5mg tablet Tier 2 Tier 3
eszopiclone 1mg tablet Tier 3 Tier 2
eszopiclone 2mg tablet Tier 3 Tier 2
eszopiclone 3mg tablet Tier 3 Tier 2
ethambutol 100mg tablet Tier 2 Tier 3
ethambutol 400mg tablet Tier 2 Tier 3
ethosuximide 250mg capsule Tier 2 Tier 3
ethosuximide 250mg/5 mL solution Tier 2 Tier 3
etodolac 200mg capsule Tier 2 Tier 3
etodolac 300mg capsule Tier 2 Tier 3
etodolac 400mg tablet Tier 2 Tier 3
etodolac 400mg tablet extended release 24 hr Tier 2 Tier 4
etodolac 500mg tablet Tier 2 Tier 3
etodolac 500mg tablet extended release 24 hr Tier 2 Tier 4
etodolac 600mg tablet extended release 24 hr Tier 2 Tier 4
exemestane 25mg tablet Tier 2 Tier 4
famciclovir 125mg tablet Tier 4 Tier 3
famciclovir 250mg tablet Tier 4 Tier 3
famciclovir 500mg tablet Tier 4 Tier 3
famotidine 40 mg/5 mL(8 mg/mL) suspension Tier 2 Tier 4
fenofibrate nanocrystallized 145mg tablet Tier 3 Tier 2
fenofibrate nanocrystallized 48mg tablet Tier 3 Tier 2
fenofibric acid (choline) 45mg capsule,delayed release(DR/EC)
Tier 3 Tier 2
fentanyl 100mcg/hr patch 72 hour Tier 2 Tier 3
fentanyl 12mcg/hr patch 72 hour Tier 2 Tier 3
fentanyl 25mcg/hr patch 72 hour Tier 2 Tier 3
fentanyl 50mcg/hr patch 72 hour Tier 2 Tier 3
fentanyl 75mcg/hr patch 72 hour Tier 2 Tier 3
flunisolide 25mcg (0.025 %) spray,non-aerosol Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
fluocinolone 0.01% cream Tier 2 Tier 3
fluocinolone 0.01% oil Tier 2 Tier 3
fluocinolone 0.01% solution Tier 2 Tier 3
fluocinolone acetonide oil 0.01% drops Tier 2 Tier 3
fluocinolone and shower cap 0.01% oil Tier 2 Tier 3
fluocinonide 0.05% cream Tier 2 Tier 3
fluocinonide 0.05% gel Tier 2 Tier 3
fluocinonide 0.05% ointment Tier 2 Tier 3
fluocinonide 0.05% solution Tier 2 Tier 3
Fluocinonide-E 0.05% cream Tier 2 Tier 3
fluorouracil 2% solution Tier 2 Tier 3
fluorouracil 5% cream Tier 2 Tier 3
fluorouracil 5% solution Tier 2 Tier 3
flutamide 125mg capsule Tier 2 Tier 3
fluvastatin 20mg capsule Tier 2 Tier 3
fluvastatin 40mg capsule Tier 2 Tier 3
Focalin XR 25mg capsule,ER biphasic 50-50 Tier 3 Tier 4
Focalin XR 35mg capsule,ER biphasic 50-50 Tier 3 Tier 4
furosemide 10mg/mL solution Tier 1 Tier 2
galantamine 12mg tablet Tier 2 Tier 3
galantamine 16mg capsule,ext rel. pellets 24 hr Tier 2 Tier 3
galantamine 24mg capsule,ext rel. pellets 24 hr Tier 2 Tier 3
galantamine 4mg tablet Tier 2 Tier 3
galantamine 4mg/mL solution Tier 2 Tier 4
galantamine 8mg capsule,ext rel. pellets 24 hr Tier 2 Tier 3
galantamine 8mg tablet Tier 2 Tier 3
Gavilyte-C 240-22.72-6.72-5.84 gram recon soln Tier 2 Tier 6 ($0)
GaviLyte-G 236-22.74-6.74-5.86 gram recon soln Tier 2 Tier 6 ($0)
GaviLyte-N 420gram recon soln Tier 2 Tier 6 ($0)
Gengraf 100mg/mL solution Tier 2 Tier 3
glimepiride 1mg tablet Tier 2 Tier 1
glimepiride 2mg tablet Tier 2 Tier 1
glimepiride 4mg tablet Tier 2 Tier 1
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
glipizide 10mg tablet extended release 24hr Tier 2 Tier 1
glipizide 2.5mg tablet extended release 24hr Tier 2 Tier 1
glipizide 5mg tablet extended release 24hr Tier 2 Tier 1
granisetron HCl 1mg tablet Tier 2 Tier 3
halobetasol propionate 0.05% cream Tier 2 Tier 4
halobetasol propionate 0.05% ointment Tier 2 Tier 4
hydrocodone-acetaminophen 10-300mg tablet Tier 2 Tier 3
hydrocodone-acetaminophen 10-325mg tablet Tier 2 Tier 3
hydrocodone-acetaminophen 5-325mg tablet Tier 2 Tier 3
hydrocodone-acetaminophen 7.5-300mg tablet Tier 2 Tier 3
hydrocodone-acetaminophen 7.5-325mg tablet Tier 2 Tier 3
hydrocodone-acetaminophen 7.5-325mg/15 mL solution
Tier 2 Tier 4
hydrocodone-ibuprofen 5-200mg tablet Tier 2 Tier 3
hydrocodone-ibuprofen 7.5-200mg tablet Tier 2 Tier 3
hydrocortisone 1% lotion Tier 2 Tier 1
hydrocortisone 100mg/60 mL enema Tier 2 Tier 4
hydrocortisone 2.5% lotion Tier 2 Tier 3
hydrocortisone acetate 25mg suppository Tier 2 Tier 3
hydrocortisone acetate 30mg suppository Tier 2 Tier 3
hydrocortisone butyrate 0.1% ointment Tier 2 Tier 4
hydrocortisone butyrate 0.1% solution Tier 2 Tier 4
hydrocortisone butyr-emollient 0.1% cream Tier 3 Tier 4
hydrocortisone valerate 0.2% cream Tier 2 Tier 4
hydrocortisone-acetic acid 1-2% drops Tier 2 Tier 3
hydrocortisone-pramoxine 1-1% cream Tier 2 Tier 3
hydrocortisone-pramoxine 2.5-1% cream Tier 2 Tier 3
hydromorphone 16mg tablet extended release 24 hr Tier 5 Tier 4
hydromorphone 2mg tablet Tier 2 Tier 3
hydromorphone 32mg tablet extended release 24 hr Tier 5 Tier 4
hydromorphone 4mg tablet Tier 2 Tier 3
hydromorphone 8mg tablet Tier 2 Tier 3
hydromorphone 8mg tablet extended release 24 hr Tier 5 Tier 4
hydroxychloroquine 200mg tablet Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
ibuprofen-oxycodone 400-5mg tablet Tier 2 Tier 3
imiquimod 5% cream in packet Tier 5 Tier 4
Invega Sustenna 117mg/0.75 mL syringe Tier 4 Tier 5
Invega Sustenna 156mg/mL syringe Tier 4 Tier 5
Invega Sustenna 234mg/1.5 mL syringe Tier 4 Tier 5
Invega Sustenna 39mg/0.25 mL syringe Tier 4 Tier 5
Invega Sustenna 78mg/0.5 mL syringe Tier 4 Tier 5
irbesartan 150mg tablet Tier 2 Tier 1
irbesartan 300mg tablet Tier 2 Tier 1
irbesartan 75mg tablet Tier 2 Tier 1
irbesartan-hydrochlorothiazide 150-12.5mg tablet Tier 2 Tier 1
irbesartan-hydrochlorothiazide 300-12.5mg tablet Tier 2 Tier 1
isosorbide dinitrate 10mg tablet Tier 2 Tier 3
isosorbide dinitrate 20mg tablet Tier 2 Tier 3
isosorbide dinitrate 30mg tablet Tier 2 Tier 3
isosorbide dinitrate 40mg tablet extended release Tier 2 Tier 3
isosorbide dinitrate 5mg tablet Tier 2 Tier 3
itraconazole 100mg capsule Tier 3 Tier 4
ivermectin 3mg tablet Tier 3 Tier 2
Jantoven 10mg tablet Tier 2 Tier 1
Jantoven 1mg tablet Tier 2 Tier 1
Jantoven 2.5mg tablet Tier 2 Tier 1
Jantoven 2mg tablet Tier 2 Tier 1
Jantoven 3mg tablet Tier 2 Tier 1
Jantoven 4mg tablet Tier 2 Tier 1
Jantoven 5mg tablet Tier 2 Tier 1
Jantoven 6mg tablet Tier 2 Tier 1
Jantoven 7.5mg tablet Tier 2 Tier 1
lansoprazole 15mg capsule,delayed release(DR/EC) Tier 3 Tier 2
lansoprazole 30mg capsule,delayed release(DR/EC) Tier 3 Tier 2
latanoprost 0.005% drops Tier 2 Tier 1
leflunomide 10mg tablet Tier 2 Tier 3
leflunomide 20mg tablet Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
letrozole 2.5mg tablet Tier 4 Tier 2
Leukeran 2mg tablet Tier 3 Tier 4
levocarnitine (with sugar) 100mg/mL solution Tier 2 Tier 3
levocarnitine 330mg tablet Tier 2 Tier 3
levocetirizine 2.5mg/5 mL solution Tier 2 Tier 4
levofloxacin 250mg/10 mL solution Tier 2 Tier 4
lidocaine 5% ointment Tier 2 Tier 4
lidocaine HCl-hydrocortison ac 3-0.5% kit Tier 2 Tier 4
lidocaine HCl-hydrocortison ac 3-1% (7 gram) kit Tier 2 Tier 4
lidocaine-hydrocortisone-aloe 2-2% kit Tier 2 Tier 4
lidocaine-hydrocortisone-aloe 3-2.5% (7 gram) kit Tier 2 Tier 4
lindane 1% lotion Tier 2 Tier 3
lindane 1% shampoo Tier 2 Tier 3
lithium carbonate 150mg capsule Tier 2 Tier 1
lithium carbonate 300mg capsule Tier 2 Tier 1
lithium carbonate 600mg capsule Tier 2 Tier 1
Livalo 1mg tablet Tier 5 Tier 4
Livalo 2mg tablet Tier 5 Tier 4
Livalo 4mg tablet Tier 5 Tier 4
Lopreeza 0.5-0.1mg tablet Tier 2 Tier 3
Lopreeza 1-0.5mg tablet Tier 2 Tier 3
losartan 100mg tablet Tier 2 Tier 1
losartan 25mg tablet Tier 2 Tier 1
losartan 50mg tablet Tier 2 Tier 1
losartan-hydrochlorothiazide 100-12.5mg tablet Tier 2 Tier 1
losartan-hydrochlorothiazide 100-25mg tablet Tier 2 Tier 1
losartan-hydrochlorothiazide 50-12.5mg tablet Tier 2 Tier 1
Lotemax 0.5% drops,suspension Tier 3 Tier 4
Lumigan 0.01% drops Tier 4 Tier 3
malathion 0.5% lotion Tier 2 Tier 3
mefenamic acid 250mg capsule Tier 2 Tier 4
memantine 10mg tablet Tier 4 Tier 2
memantine 5-10mg tablets,dose pack Tier 4 Tier 2
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
memantine 5mg tablet Tier 4 Tier 2
meperidine 100mg tablet Tier 2 Tier 3
meperidine 50mg tablet Tier 2 Tier 3
meprobamate 200mg tablet Tier 2 Tier 3
meprobamate 400mg tablet Tier 2 Tier 3
mercaptopurine 50mg tablet Tier 2 Tier 3
mesalamine 4gram/60 mL enema Tier 2 Tier 4
mesalamine with cleansing wipe 4gram/60 mL enema kit
Tier 2 Tier 4
metaxalone 800mg tablet Tier 2 Tier 4
metformin 500mg tablet extended release 24 hr Tier 2 Tier 1
metformin 750mg tablet extended release 24 hr Tier 2 Tier 1
methadone 10mg tablet Tier 2 Tier 3
methadone 5mg tablet Tier 2 Tier 3
methazolamide 25mg tablet Tier 2 Tier 4
methazolamide 50mg tablet Tier 2 Tier 4
methimazole 10mg tablet Tier 2 Tier 1
methimazole 5mg tablet Tier 2 Tier 1
methylergonovine 0.2mg tablet Tier 2 Tier 3
methylphenidate 20mg tablet extended release Tier 3 Tier 4
metronidazole 0.75% cream Tier 2 Tier 3
metronidazole 0.75% gel Tier 2 Tier 3
metronidazole 0.75% lotion Tier 2 Tier 4
metronidazole 1% gel Tier 3 Tier 4
midodrine 10mg tablet Tier 2 Tier 3
midodrine 2.5mg tablet Tier 2 Tier 3
midodrine 5mg tablet Tier 2 Tier 3
Mimvey 1-0.5mg tablet Tier 2 Tier 3
Mimvey Lo 0.5-0.1mg tablet Tier 2 Tier 3
modafinil 100mg tablet Tier 5 Tier 4
modafinil 200mg tablet Tier 5 Tier 4
moexipril 15mg tablet Tier 2 Tier 3
moexipril 7.5mg tablet Tier 2 Tier 3
moexipril-hydrochlorothiazide 15-12.5mg tablet Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
moexipril-hydrochlorothiazide 15-25mg tablet Tier 2 Tier 3
moexipril-hydrochlorothiazide 7.5-12.5mg tablet Tier 2 Tier 3
morphine 10mg/5 mL solution Tier 2 Tier 3
morphine 15mg tablet Tier 2 Tier 3
morphine 20 mg/5 mL(4 mg/mL) solution Tier 2 Tier 3
morphine 30mg tablet Tier 2 Tier 3
morphine concentrate 100 mg/5 mL(20 mg/mL) solution
Tier 2 Tier 3
mycophenolate mofetil 250mg capsule Tier 2 Tier 3
mycophenolate mofetil 500mg tablet Tier 2 Tier 3
mycophenolate sodium 180mg tablet,delayed release (DR/EC)
Tier 5 Tier 4
mycophenolate sodium 360mg tablet,delayed release (DR/EC)
Tier 5 Tier 4
Myorisan 10mg capsule Tier 5 Tier 4
Myorisan 20mg capsule Tier 5 Tier 4
Myorisan 30mg capsule Tier 5 Tier 4
Myorisan 40mg capsule Tier 5 Tier 4
naphazoline 0.1% drops Tier 1 Tier 2
naproxen 500mg tablet,delayed release (DR/EC) Tier 1 Tier 2
nateglinide 120mg tablet Tier 2 Tier 3
nateglinide 60mg tablet Tier 2 Tier 3
Nature-Throid 113.75mg tablet Tier 3 Tier 2
Nature-Throid 130mg tablet Tier 3 Tier 2
Nature-Throid 146.25mg tablet Tier 3 Tier 2
Nature-Throid 16.25mg tablet Tier 3 Tier 2
Nature-Throid 162.5mg tablet Tier 3 Tier 2
Nature-Throid 195mg tablet Tier 3 Tier 2
Nature-Throid 260mg tablet Tier 3 Tier 2
Nature-Throid 32.5mg tablet Tier 3 Tier 2
Nature-Throid 325mg tablet Tier 3 Tier 2
Nature-Throid 48.75mg tablet Tier 3 Tier 2
Nature-Throid 65mg tablet Tier 3 Tier 2
Nature-Throid 81.25mg tablet Tier 3 Tier 2
Nature-Throid 97.5mg tablet Tier 3 Tier 2
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
nicardipine 20mg capsule Tier 2 Tier 3
nicardipine 30mg capsule Tier 2 Tier 3
Nilandron 150mg tablet Tier 3 Tier 5
nisoldipine 17mg tablet extended release 24 hr Tier 2 Tier 3
nisoldipine 20mg tablet extended release 24 hr Tier 2 Tier 3
nisoldipine 25.5mg tablet extended release 24 hr Tier 2 Tier 3
nisoldipine 30mg tablet extended release 24 hr Tier 2 Tier 3
nisoldipine 34mg tablet extended release 24 hr Tier 2 Tier 3
nisoldipine 40mg tablet extended release 24 hr Tier 2 Tier 3
nisoldipine 8.5mg tablet extended release 24 hr Tier 2 Tier 3
nortriptyline 10mg capsule Tier 2 Tier 1
nortriptyline 25mg capsule Tier 2 Tier 1
nortriptyline 50mg capsule Tier 2 Tier 1
nortriptyline 75mg capsule Tier 2 Tier 1
Nucynta ER 100mg tablet extended release 12 hr Tier 5 Tier 4
Nucynta ER 150mg tablet extended release 12 hr Tier 5 Tier 4
Nucynta ER 200mg tablet extended release 12 hr Tier 5 Tier 4
Nucynta ER 250mg tablet extended release 12 hr Tier 5 Tier 4
Nucynta ER 50mg tablet extended release 12 hr Tier 5 Tier 4
nystatin 100,000unit/gram ointment Tier 4 Tier 2
nystatin-triamcinolone 100,000-0.1unit/g-% cream Tier 2 Tier 4
nystatin-triamcinolone 100,000-0.1unit/gram-% ointment
Tier 1 Tier 4
ofloxacin 0.3% drops Tier 2 Tier 4
olanzapine 10mg tablet,disintegrating Tier 2 Tier 3
olanzapine 15mg tablet,disintegrating Tier 2 Tier 3
olanzapine 20mg tablet,disintegrating Tier 2 Tier 3
olanzapine 5mg tablet,disintegrating Tier 2 Tier 3
olanzapine-fluoxetine 12-25mg capsule Tier 2 Tier 4
olanzapine-fluoxetine 12-50mg capsule Tier 2 Tier 4
olanzapine-fluoxetine 3-25mg capsule Tier 2 Tier 4
olanzapine-fluoxetine 6-25mg capsule Tier 2 Tier 4
olanzapine-fluoxetine 6-50mg capsule Tier 2 Tier 4
olopatadine 0.6% spray,non-aerosol Tier 3 Tier 4
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
ondansetron 4mg tablet,disintegrating Tier 2 Tier 3
ondansetron 8mg tablet,disintegrating Tier 2 Tier 3
Opana ER 10mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4
Opana ER 15mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4
Opana ER 20mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4
Opana ER 30mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4
Opana ER 40mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4
Opana ER 5mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4
Opana ER 7.5mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4
OsmoPrep 1.5gram tablet Tier 3 Tier 4
oxandrolone 10mg tablet Tier 2 Tier 5
oxandrolone 2.5mg tablet Tier 2 Tier 5
oxaprozin 600mg tablet Tier 2 Tier 3
oxybutynin chloride 5mg tablet Tier 1 Tier 2
oxybutynin chloride 5mg tablet extended release 24hr Tier 3 Tier 2
oxycodone 10mg tablet Tier 2 Tier 3
oxycodone 15mg tablet Tier 2 Tier 3
oxycodone 20mg tablet Tier 2 Tier 3
oxycodone 30mg tablet Tier 2 Tier 3
oxycodone 5mg tablet Tier 2 Tier 3
oxycodone-acetaminophen 10-325mg tablet Tier 2 Tier 3
oxycodone-acetaminophen 2.5-325mg tablet Tier 2 Tier 3
oxycodone-acetaminophen 5-325mg tablet Tier 2 Tier 3
oxycodone-acetaminophen 7.5-325mg tablet Tier 2 Tier 3
oxycodone-aspirin 4.8355-325mg tablet Tier 2 Tier 3
oxymorphone 10mg tablet Tier 3 Tier 4
oxymorphone 5mg tablet Tier 3 Tier 4
paromomycin 250mg capsule Tier 2 Tier 3
paroxetine HCl 12.5mg tablet extended release 24 hr Tier 2 Tier 3
paroxetine HCl 25mg tablet extended release 24 hr Tier 2 Tier 3
paroxetine HCl 37.5mg tablet extended release 24 hr Tier 2 Tier 3
peg 3350-electrolytes 236-22.74-6.74-5.86 gram recon soln
Tier 2 Tier 6 ($0)
peg 3350-electrolytes 240-22.72-6.72-5.84 gram recon soln
Tier 2 Tier 6 ($0)
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
peg-electrolyte soln 420gram recon soln Tier 2 Tier 6 ($0)
pentazocine-naloxone 50-0.5mg tablet Tier 2 Tier 3
permethrin 5% cream Tier 2 Tier 4
Phenadoz 12.5mg suppository Tier 2 Tier 3
Phenadoz 25mg suppository Tier 2 Tier 3
phenelzine 15mg tablet Tier 2 Tier 3
Physiolyte 140-5-3-98mEq/L solution Tier 2 Tier 4
pilocarpine HCl 5mg tablet Tier 2 Tier 3
pilocarpine HCl 7.5mg tablet Tier 2 Tier 3
piroxicam 10mg capsule Tier 2 Tier 3
piroxicam 20mg capsule Tier 2 Tier 3
podofilox 0.5% solution Tier 2 Tier 3
polyethylene glycol 3350 17gram powder in packet Tier 2 Tier 6 ($0)
polyethylene glycol 3350 17gram/dose powder Tier 2 Tier 6 ($0)
potassium citrate 10mEq (1,080 mg) tablet extended release
Tier 2 Tier 3
potassium citrate 15mEq tablet extended release Tier 2 Tier 3
potassium citrate 5mEq (540 mg) tablet extended release
Tier 2 Tier 3
prednisolone sodium phosphate 10mg tablet,disintegrating
Tier 3 Tier 4
prednisolone sodium phosphate 15mg tablet,disintegrating
Tier 3 Tier 4
prednisolone sodium phosphate 30mg tablet,disintegrating
Tier 3 Tier 4
Prevalite 4gram powder Tier 1 Tier 3
Prevalite 4gram powder in packet Tier 1 Tier 3
prochlorperazine 25mg suppository Tier 2 Tier 4
prochlorperazine Edisylate 10 mg/2 mL(5 mg/mL) solution
Tier 2 Tier 4
Proctofoam HC 1-1% foam Tier 3 Tier 4
Proglycem 50mg/mL suspension Tier 3 Tier 4
promethazine 12.5mg suppository Tier 2 Tier 3
promethazine 12.5mg tablet Tier 1 Tier 2
promethazine 25mg suppository Tier 2 Tier 3
promethazine 25mg tablet Tier 1 Tier 2
promethazine 25mg/mL solution Tier 2 Tier 3
promethazine 50mg suppository Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
promethazine 50mg tablet Tier 1 Tier 2
promethazine 50mg/mL solution Tier 2 Tier 3
promethazine 6.25mg/5 mL syrup Tier 2 Tier 3
Promethazine VC 6.25-5mg/5 mL syrup Tier 2 Tier 3
Promethazine VC-Codeine 6.25-5-10mg/5 mL syrup Tier 2 Tier 3
promethazine-codeine 6.25-10mg/5 mL syrup Tier 2 Tier 3
promethazine-phenyleph-codeine 6.25-5-10mg/5 mL syrup
Tier 2 Tier 3
promethazine-phenylephrine 6.25-5mg/5 mL syrup Tier 2 Tier 3
Promethegan 12.5mg suppository Tier 2 Tier 3
Promethegan 25mg suppository Tier 2 Tier 3
Promethegan 50mg suppository Tier 2 Tier 3
propylthiouracil 50mg tablet Tier 2 Tier 3
protriptyline 10mg tablet Tier 2 Tier 3
protriptyline 5mg tablet Tier 2 Tier 3
pyridostigmine bromide 60mg tablet Tier 2 Tier 3
quinapril 10mg tablet Tier 2 Tier 1
quinapril 20mg tablet Tier 2 Tier 1
quinapril 40mg tablet Tier 2 Tier 1
quinapril 5mg tablet Tier 2 Tier 1
quinidine gluconate 324mg tablet extended release Tier 2 Tier 4
ramipril 1.25mg capsule Tier 2 Tier 1
ramipril 10mg capsule Tier 2 Tier 1
ramipril 2.5mg capsule Tier 2 Tier 1
ramipril 5mg capsule Tier 2 Tier 1
Rapamune 1mg/mL solution Tier 3 Tier 5
Renvela 800mg tablet Tier 4 Tier 5
repaglinide 0.5mg tablet Tier 3 Tier 2
repaglinide 1mg tablet Tier 3 Tier 2
repaglinide 2mg tablet Tier 3 Tier 2
ribavirin 200mg capsule Tier 5 Tier 4
ribavirin 200mg tablet Tier 5 Tier 4
risperidone 0.25mg tablet,disintegrating Tier 2 Tier 3
rivastigmine tartrate 1.5mg capsule Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
rivastigmine tartrate 3mg capsule Tier 2 Tier 3
rivastigmine tartrate 4.5mg capsule Tier 2 Tier 3
rivastigmine tartrate 6mg capsule Tier 2 Tier 3
ropinirole 12mg tablet extended release 24 hr Tier 2 Tier 4
ropinirole 2mg tablet extended release 24 hr Tier 2 Tier 4
ropinirole 4mg tablet extended release 24 hr Tier 2 Tier 4
ropinirole 6mg tablet extended release 24 hr Tier 2 Tier 4
ropinirole 8mg tablet extended release 24 hr Tier 2 Tier 4
Rosanil 10-5% (w/w) cleanser Tier 2 Tier 4
Savella 100mg tablet Tier 3 Tier 4
Savella 12.5 mg (5)-25mg(8)-50 mg(42) tablets,dose pack
Tier 3 Tier 4
Savella 12.5mg tablet Tier 3 Tier 4
Savella 25mg tablet Tier 3 Tier 4
Savella 50mg tablet Tier 3 Tier 4
sildenafil 20mg tablet Tier 5 Tier 4
sirolimus 0.5mg tablet Tier 3 Tier 4
sirolimus 1mg tablet Tier 3 Tier 4
sirolimus 2mg tablet Tier 3 Tier 4
Sirturo 100mg tablet Tier 4 Tier 5
SS 10-2 10-2% cleanser Tier 3 Tier 4
SSS 10-5 10-5% (w/w) cream Tier 2 Tier 4
SSS 10-5 10-5% foam Tier 2 Tier 4
sulfacetamide sodium 10% cleanser Tier 2 Tier 4
sulfacetamide sodium-sulfur 10-2% cleanser Tier 3 Tier 4
sulfacetamide sodium-sulfur 10-2% cream Tier 3 Tier 4
sulfacetamide sodium-sulfur 10-5% (w/v) lotion Tier 2 Tier 4
sulfacetamide sodium-sulfur 10-5% (w/w) cleanser Tier 2 Tier 4
sulfacetamide sodium-sulfur 10-5% (w/w) cream Tier 2 Tier 4
sulfacetamide sodium-sulfur 10-5% foam Tier 2 Tier 4
sulfacetamide sodium-sulfur 10-5% suspension Tier 2 Tier 4
sulfacetamide sodium-sulfur 9.8-4.8% cleanser Tier 2 Tier 4
sulfacetamide sodium-sulfur 9.8-4.8% cream Tier 2 Tier 4
sulfacetamide sodium-sulfur 9-4.5% cleanser Tier 2 Tier 4
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
sulfacetamide sod-sulfur-urea 10-5-10% cleanser Tier 2 Tier 4
sulfamethoxazole-trimethoprim 200-40mg/5 mL suspension
Tier 1 Tier 2
sulfamethoxazole-trimethoprim 400-80mg/5 mL solution
Tier 1 Tier 3
SymlinPen 120 2,700mcg/2.7 mL pen injector Tier 3 Tier 5
SymlinPen 60 1,500mcg/1.5 mL pen injector Tier 3 Tier 5
Syprine 250mg capsule Tier 4 Tier 5
telmisartan 20mg tablet Tier 4 Tier 2
telmisartan 40mg tablet Tier 4 Tier 2
telmisartan 80mg tablet Tier 4 Tier 2
terconazole 0.4% cream Tier 2 Tier 4
terconazole 0.8% cream Tier 2 Tier 4
terconazole 80mg suppository Tier 2 Tier 4
testosterone cypionate 100mg/mL oil Tier 2 Tier 3
testosterone cypionate 200mg/mL oil Tier 2 Tier 3
testosterone enanthate 200mg/mL oil Tier 2 Tier 3
tetracycline 250mg capsule Tier 2 Tier 4
tetracycline 500mg capsule Tier 2 Tier 4
tinidazole 500mg tablet Tier 3 Tier 2
tobramycin-dexamethasone 0.3-0.1% drops,suspension
Tier 2 Tier 3
tolterodine 1mg tablet Tier 2 Tier 3
tolterodine 2mg tablet Tier 2 Tier 3
topiramate 15mg capsule, sprinkle Tier 2 Tier 3
topiramate 25mg capsule, sprinkle Tier 2 Tier 3
Toviaz 4mg tablet extended release 24 hr Tier 3 Tier 4
Toviaz 8mg tablet extended release 24 hr Tier 3 Tier 4
tramadol 100mg tablet extended release 24 hr Tier 3 Tier 4
tramadol 100mg tablet, ER multiphase 24 hr Tier 3 Tier 4
tramadol 200mg tablet extended release 24 hr Tier 3 Tier 4
tramadol 200mg tablet, ER multiphase 24 hr Tier 3 Tier 4
tramadol 50mg tablet Tier 2 Tier 3
tramadol-acetaminophen 37.5-325mg tablet Tier 2 Tier 3
trazodone 100mg tablet Tier 1 Tier 2
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
trazodone 150mg tablet Tier 1 Tier 2
trazodone 300mg tablet Tier 1 Tier 4
trazodone 50mg tablet Tier 1 Tier 2
tretinoin 0.01% gel Tier 2 Tier 3
tretinoin 0.025% cream Tier 2 Tier 3
tretinoin 0.025% gel Tier 2 Tier 3
tretinoin 0.05% cream Tier 2 Tier 3
tretinoin 0.05% gel Tier 2 Tier 3
tretinoin 0.1% cream Tier 2 Tier 3
triamcinolone acetonide 0.1% paste Tier 2 Tier 3
trifluridine 1% drops Tier 2 Tier 3
TriLyte With Flavor Packets 420gram recon soln Tier 2 Tier 6 ($0)
ursodiol 250mg tablet Tier 2 Tier 4
ursodiol 300mg capsule Tier 2 Tier 4
ursodiol 500mg tablet Tier 2 Tier 4
Veltin 1.2-0.025% gel Tier 4 Tier 5
Victoza 2-Pak 0.6 mg/0.1 mL(18 mg/3 mL) pen injector
Tier 5 Tier 4
Viibryd 10 mg (7)-20 mg (23) tablets,dose pack Tier 5 Tier 4
Viibryd 10mg tablet Tier 5 Tier 4
Viibryd 20mg tablet Tier 5 Tier 4
Viibryd 40mg tablet Tier 5 Tier 4
warfarin 10mg tablet Tier 2 Tier 1
warfarin 1mg tablet Tier 2 Tier 1
warfarin 2.5mg tablet Tier 2 Tier 1
warfarin 2mg tablet Tier 2 Tier 1
warfarin 3mg tablet Tier 2 Tier 1
warfarin 4mg tablet Tier 2 Tier 1
warfarin 5mg tablet Tier 2 Tier 1
warfarin 6mg tablet Tier 2 Tier 1
warfarin 7.5mg tablet Tier 2 Tier 1
Yasmin (28) 3-0.03mg tablet Tier 2 Tier 4
YAZ (28) 3-0.02mg tablet Tier 2 Tier 4
zafirlukast 10mg tablet Tier 2 Tier 3
MEDICATIONS WITH TIERING CHANGES
Medication Name 2016 Tier 2017 Tier
zafirlukast 20mg tablet Tier 2 Tier 3
Zenatane 10mg capsule Tier 5 Tier 4
Zenatane 20mg capsule Tier 5 Tier 4
Zenatane 30mg capsule Tier 5 Tier 4
Zenatane 40mg capsule Tier 5 Tier 4
Ziana 1.2-0.025% gel Tier 4 Tier 5
Zioptan (PF) 0.0015% dropperette Tier 3 Tier 4
zolmitriptan 2.5mg tablet Tier 3 Tier 4
zolmitriptan 2.5mg tablet,disintegrating Tier 3 Tier 4
zolmitriptan 5mg tablet Tier 3 Tier 4
zolmitriptan 5mg tablet,disintegrating Tier 3 Tier 4
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
acetaminophen-codeine 120-12mg/5 mL solution QL(2700 ML per 30 days)
acetaminophen-codeine 300-60mg tablet QL(180 EA per 30 days)
Adderall XR 10mg capsule,extended release 24hr QL(30 EA per 30 days)
Adderall XR 15mg capsule,extended release 24hr QL(30 EA per 30 days)
Adderall XR 20mg capsule,extended release 24hr QL(30 EA per 30 days)
Adderall XR 25mg capsule,extended release 24hr QL(30 EA per 30 days)
Adderall XR 30mg capsule,extended release 24hr QL(30 EA per 30 days)
Adderall XR 5mg capsule,extended release 24hr QL(30 EA per 30 days)
Afinitor 10mg tablet QL(60 EA per 30 days)
alfuzosin 10mg tablet extended release 24 hr QL(30 EA per 30 days)
almotriptan malate 12.5mg tablet QL(18 EA per 30 days)
almotriptan malate 6.25mg tablet QL(18 EA per 30 days)
alprazolam 0.25mg tablet QL(120 EA per 30 days)
alprazolam 0.5mg tablet QL(120 EA per 30 days)
alprazolam 0.5mg tablet extended release 24 hr QL(90 EA per 30 days)
alprazolam 1mg tablet QL(240 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
alprazolam 1mg tablet extended release 24 hr QL(60 EA per 30 days)
alprazolam 2mg tablet QL(150 EA per 30 days)
alprazolam 2mg tablet extended release 24 hr QL(60 EA per 30 days)
alprazolam 3mg tablet extended release 24 hr QL(60 EA per 30 days)
amlodipine-valsartan 10-160mg tablet QL(30 EA per 30 days)
amlodipine-valsartan 10-320mg tablet QL(30 EA per 30 days)
amlodipine-valsartan 5-160mg tablet QL(30 EA per 30 days)
amlodipine-valsartan 5-320mg tablet QL(30 EA per 30 days)
amlodipine-valsartan-hcthiazid 10-160-12.5mg tablet QL(30 EA per 30 days)
amlodipine-valsartan-hcthiazid 10-160-25mg tablet QL(30 EA per 30 days)
amlodipine-valsartan-hcthiazid 10-320-25mg tablet QL(30 EA per 30 days)
amlodipine-valsartan-hcthiazid 5-160-12.5mg tablet QL(30 EA per 30 days)
amlodipine-valsartan-hcthiazid 5-160-25mg tablet QL(30 EA per 30 days)
Analpram Advanced 2.5 %-1 %/630 mg/1 %-1 % kit QL(4 EA per 30 days)
anastrozole 1mg tablet QL(30 EA per 30 days)
AndroGel 1.62 % (20.25mg/1.25 gram) gel in packet QL Removed
AndroGel 1.62 % (40.5mg/2.5 gram) gel in packet QL Removed
AndroGel 20.25 mg/1.25gram (1.62 %) gel in metered-dose pump
QL Removed
Asmanex HFA 100mcg/actuation HFA aerosol inhaler QL(13 GM per 30 days)
Asmanex HFA 200mcg/actuation HFA aerosol inhaler QL(13 GM per 30 days)
Aubagio 14mg tablet QL(30 EA per 30 days)
Avonex (with albumin) 30mcg kit QL(4 EA per 28 days)
Avonex 30mcg/0.5 mL pen injector kit QL(4 EA per 28 days)
Avonex 30mcg/0.5 mL syringe kit QL(1 EA per 28 days)
azelastine 0.15 %(205.5 mcg) spray,non-aerosol QL(60 ML per 30 days)
azelastine 137 mcg(0.1 %) aerosol,spray QL(60 ML per 30 days)
Banzel 200mg tablet QL(90 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
Banzel 400mg tablet QL(240 EA per 30 days)
Banzel 40mg/mL suspension QL(2400 ML per 30 days)
Betaseron 0.3mg kit QL(14 EA per 28 days)
Brintellix 10mg tablet QL(30 EA per 30 days)
Brintellix 20mg tablet QL(30 EA per 30 days)
Brintellix 5mg tablet QL(30 EA per 30 days)
brompheniramine-pseudoeph-DM 2-30-10mg/5 mL syrup QL(1200 ML per 30 days)
buprenorphine HCl 2mg tablet QL(90 EA per 30 days)
buprenorphine HCl 8mg tablet QL(90 EA per 30 days)
bupropion HCl 150mg tablet extended release QL(90 EA per 30 days)
bupropion HCl 150mg tablet extended release 24 hr QL(90 EA per 30 days)
Butalbital Compound W/Codeine 30-50-325-40mg capsule QL(180 EA per 30 days)
butalbital-acetaminop-caf-cod 50-300-40-30mg capsule QL(180 EA per 30 days)
butalbital-acetaminophen 50-325mg tablet QL(180 EA per 30 days)
butalbital-acetaminophen-caff 50-300-40mg capsule QL(180 EA per 30 days)
butalbital-acetaminophen-caff 50-325-40mg capsule QL(180 EA per 30 days)
butalbital-acetaminophen-caff 50-325-40mg tablet QL(180 EA per 30 days)
butalbital-aspirin-caffeine 50-325-40mg capsule QL(180 EA per 30 days)
Butrans 10mcg/hour patch weekly QL(4 EA per 28 days)
Butrans 15mcg/hour patch weekly QL(4 EA per 28 days)
Butrans 20mcg/hour patch weekly QL(4 EA per 28 days)
Butrans 5mcg/hour patch weekly QL(4 EA per 28 days)
Butrans 7.5mcg/hour patch weekly QL(4 EA per 28 days)
Bydureon 2mg suspension,extended rel recon QL(4 EA per 28 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
Bydureon 2mg/0.65 mL pen injector QL(4 EA per 28 days)
Byetta 10 mcg/dose(250mcg/mL) 2.4 mL pen injector QL(2.4 ML per 28 days)
Byetta 5 mcg/dose (250mcg/mL) 1.2 mL pen injector QL(1.2 ML per 30 days)
cabergoline 0.5mg tablet QL(16 EA per 28 days)
calcitonin (salmon) 200unit/actuation spray,non-aerosol QL(3.7 ML per 30 days)
Caprelsa 100mg tablet QL(60 EA per 30 days)
Caprelsa 300mg tablet QL(30 EA per 30 days)
carisoprodol 350mg tablet QL(30 EA per 30 days)
chlorzoxazone 500mg tablet QL(120 EA per 30 days)
citalopram 10mg tablet QL(30 EA per 30 days)
citalopram 10mg/5 mL solution QL(600 ML per 30 days)
citalopram 20mg tablet QL(60 EA per 30 days)
citalopram 40mg tablet QL(30 EA per 30 days)
clonazepam 0.5mg tablet QL(90 EA per 30 days)
clonazepam 1mg tablet QL(90 EA per 30 days)
clonazepam 2mg tablet QL(300 EA per 30 days)
clonidine 0.1mg/24 hr patch weekly QL(4 EA per 28 days)
clonidine 0.2mg/24 hr patch weekly QL(4 EA per 28 days)
clonidine 0.3mg/24 hr patch weekly QL(4 EA per 28 days)
clorazepate dipotassium 15mg tablet QL(180 EA per 30 days)
clorazepate dipotassium 3.75mg tablet QL(90 EA per 30 days)
clorazepate dipotassium 7.5mg tablet QL(90 EA per 30 days)
codeine sulfate 15mg tablet QL(180 EA per 30 days)
codeine sulfate 30mg tablet QL(180 EA per 30 days)
codeine sulfate 60mg tablet QL(180 EA per 30 days)
Combivent Respimat 20-100mcg/actuation mist QL(8 GM per 30 days)
cyclobenzaprine 10mg tablet QL(90 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
cyclobenzaprine 5mg tablet QL(90 EA per 30 days)
Cycloset 0.8mg tablet QL(180 EA per 30 days)
Daytrana 10mg/9 hr patch 24 hour QL(30 EA per 30 days)
Daytrana 15mg/9 hr patch 24 hour QL(30 EA per 30 days)
Daytrana 20mg/9 hr patch 24 hour QL(30 EA per 30 days)
Daytrana 30mg/9 hr patch 24 hour QL(30 EA per 30 days)
dexmethylphenidate 10mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
dexmethylphenidate 10mg tablet QL(60 EA per 30 days)
dexmethylphenidate 15mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
dexmethylphenidate 2.5mg tablet QL(60 EA per 30 days)
dexmethylphenidate 20mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
dexmethylphenidate 30mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
dexmethylphenidate 40mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
dexmethylphenidate 5mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
dexmethylphenidate 5mg tablet QL(60 EA per 30 days)
dextroamphetamine 10mg capsule, extended release QL(180 EA per 30 days)
dextroamphetamine 10mg tablet QL(180 EA per 30 days)
dextroamphetamine 15mg capsule, extended release QL(120 EA per 30 days)
dextroamphetamine 5mg capsule, extended release QL(90 EA per 30 days)
dextroamphetamine 5mg tablet QL(180 EA per 30 days)
dextroamphetamine-amphetamine 12.5mg tablet QL(90 EA per 30 days)
dextroamphetamine-amphetamine 15mg tablet QL(90 EA per 30 days)
dextroamphetamine-amphetamine 7.5mg tablet QL(90 EA per 30 days)
diazepam 10mg tablet QL(120 EA per 30 days)
diazepam 2mg tablet QL(90 EA per 30 days)
diazepam 5mg tablet QL(90 EA per 30 days)
doxazosin 1mg tablet QL(30 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
doxazosin 2mg tablet QL(30 EA per 30 days)
doxazosin 4mg tablet QL(30 EA per 30 days)
doxazosin 8mg tablet QL(60 EA per 30 days)
dronabinol 10mg capsule QL Removed
dronabinol 2.5mg capsule QL Removed
dronabinol 5mg capsule QL Removed
Emsam 12mg/24 hr patch 24 hour QL(30 EA per 30 days)
Emsam 6mg/24 hr patch 24 hour QL(30 EA per 30 days)
Emsam 9mg/24 hr patch 24 hour QL(30 EA per 30 days)
Enbrel 25mg/0.5mL (0.51) syringe QL(4 ML per 28 days)
Enbrel 50mg/mL (0.98 mL) syringe QL(8 ML per 28 days)
Enbrel SureClick 50mg/mL (0.98 mL) pen injector QL(8 ML per 28 days)
Endocet 10-325mg tablet QL(180 EA per 30 days)
enoxaparin 100mg/mL syringe QL(28 ML per 30 days)
enoxaparin 120mg/0.8 mL syringe QL(22.4 ML per 30 days)
enoxaparin 150mg/mL syringe QL(28 ML per 30 days)
enoxaparin 300mg/3 mL solution QL(24 ML per 30 days)
enoxaparin 30mg/0.3 mL syringe QL(8.4 ML per 30 days)
enoxaparin 40mg/0.4 mL syringe QL(11.2 ML per 30 days)
enoxaparin 60mg/0.6 mL syringe QL(16.8 ML per 30 days)
enoxaparin 80mg/0.8 mL syringe QL(22.4 ML per 30 days)
entacapone 200mg tablet QL(240 EA per 30 days)
entecavir 0.5mg tablet QL(30 EA per 30 days)
entecavir 1mg tablet QL(30 EA per 30 days)
Entresto 24-26mg tablet QL(60 EA per 30 days)
Entresto 49-51mg tablet QL(60 EA per 30 days)
Entresto 97-103mg tablet QL(60 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
EpiPen 2-Pak 0.3mg/0.3 mL auto-injector QL(4 EA per 30 days)
EpiPen Jr 2-Pak 0.15mg/0.3 mL auto-injector QL(4 EA per 30 days)
Erivedge 150mg capsule QL(30 EA per 30 days)
escitalopram oxalate 10mg tablet QL(30 EA per 30 days)
escitalopram oxalate 20mg tablet QL(30 EA per 30 days)
escitalopram oxalate 5mg tablet QL(30 EA per 30 days)
escitalopram oxalate 5mg/5 mL solution QL(600 ML per 30 days)
estradiol 0.025mg/24 hr patch semiweekly QL(8 EA per 28 days)
estradiol 0.025mg/24 hr patch weekly QL(4 EA per 28 days)
estradiol 0.0375mg/24 hr patch semiweekly QL(8 EA per 28 days)
estradiol 0.0375mg/24 hr patch weekly QL(4 EA per 28 days)
estradiol 0.05mg/24 hr patch semiweekly QL(8 EA per 28 days)
estradiol 0.05mg/24 hr patch weekly QL(4 EA per 28 days)
estradiol 0.06mg/24 hr patch weekly QL(4 EA per 28 days)
estradiol 0.075mg/24 hr patch semiweekly QL(8 EA per 28 days)
estradiol 0.075mg/24 hr patch weekly QL(4 EA per 28 days)
estradiol 0.1mg/24 hr patch semiweekly QL(8 EA per 28 days)
estradiol 0.1mg/24 hr patch weekly QL(4 EA per 28 days)
eszopiclone 1mg tablet QL(30 EA per 30 days)
eszopiclone 2mg tablet QL(30 EA per 30 days)
eszopiclone 3mg tablet QL(30 EA per 30 days)
Fanapt 10mg tablet QL(60 EA per 30 days)
Fanapt 12mg tablet QL(60 EA per 30 days)
Fanapt 1mg tablet QL(60 EA per 30 days)
Fanapt 1mg(2)-2mg(2)-4mg(2)-6mg(2) tablets,dose pack QL(8 EA per 28 days)
Fanapt 2mg tablet QL(60 EA per 30 days)
Fanapt 4mg tablet QL(60 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
Fanapt 6mg tablet QL(60 EA per 30 days)
Fanapt 8mg tablet QL(60 EA per 30 days)
Fareston 60mg tablet QL(30 EA per 30 days)
fentanyl citrate 1,200mcg lozenge on a handle QL(120 EA per 30 days)
fentanyl citrate 1,600mcg lozenge on a handle QL(120 EA per 30 days)
fentanyl citrate 200mcg lozenge on a handle QL(120 EA per 30 days)
fentanyl citrate 400mcg lozenge on a handle QL(120 EA per 30 days)
fentanyl citrate 600mcg lozenge on a handle QL(120 EA per 30 days)
fentanyl citrate 800mcg lozenge on a handle QL(120 EA per 30 days)
Flovent Diskus 100mcg/actuation blister with device QL(60 EA per 30 days)
Flovent Diskus 250mcg/actuation blister with device QL(240 EA per 30 days)
Flovent Diskus 50mcg/actuation blister with device QL(60 EA per 30 days)
Flovent HFA 110mcg/actuation HFA aerosol inhaler QL(12 GM per 30 days)
Flovent HFA 44mcg/actuation HFA aerosol inhaler QL(10.6 GM per 30 days)
fluoxetine 10mg capsule QL(90 EA per 30 days)
fluoxetine 20 mg/5 mL(4 mg/mL) solution QL(600 ML per 30 days)
fluvoxamine 100mg tablet QL(90 EA per 30 days)
fluvoxamine 25mg tablet QL(90 EA per 30 days)
fluvoxamine 50mg tablet QL(90 EA per 30 days)
Focalin XR 25mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
Focalin XR 35mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
fondaparinux 10mg/0.8 mL syringe QL(24 ML per 30 days)
fondaparinux 2.5mg/0.5 mL syringe QL(15 ML per 30 days)
fondaparinux 5mg/0.4 mL syringe QL(12 ML per 30 days)
fondaparinux 7.5mg/0.6 mL syringe QL(18 ML per 30 days)
Forteo 20 mcg/dose -600 mcg/2.4 mL pen injector QL(2.4 ML per 28 days)
FreeStyle Lancets 28gauge misc QL(200 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
gabapentin 100mg capsule QL(270 EA per 30 days)
gabapentin 300mg capsule QL(270 EA per 30 days)
gabapentin 800mg tablet QL(120 EA per 30 days)
glipizide 10mg tablet extended release 24hr QL(60 EA per 30 days)
glipizide 2.5mg tablet extended release 24hr QL(60 EA per 30 days)
glipizide 5mg tablet extended release 24hr QL(60 EA per 30 days)
GlucaGen 1mg recon soln QL(4 EA per 30 days)
GlucaGen Diagnostic Kit 1mg/mL recon soln QL(4 EA per 30 days)
glyburide 5mg tablet QL(60 EA per 30 days)
guanfacine 1mg tablet extended release 24 hr QL(30 EA per 30 days)
guanfacine 2mg tablet extended release 24 hr QL(30 EA per 30 days)
guanfacine 3mg tablet extended release 24 hr QL(30 EA per 30 days)
guanfacine 4mg tablet extended release 24 hr QL(30 EA per 30 days)
Horizant 300mg tablet extended release QL(60 EA per 30 days)
Horizant 600mg tablet extended release QL(60 EA per 30 days)
Humira 10mg/0.2 mL syringe kit QL(2 EA per 28 days)
Humira 20mg/0.4 mL syringe kit QL(2 EA per 28 days)
Humira 40mg/0.8 mL syringe kit QL(4 EA per 28 days)
Humira Pen 40mg/0.8 mL pen injector kit QL(4 EA per 28 days)
hydrocodone-acetaminophen 10-300mg tablet QL(180 EA per 30 days)
hydrocodone-acetaminophen 10-325mg tablet QL(180 EA per 30 days)
hydrocodone-acetaminophen 5-325mg tablet QL(240 EA per 30 days)
hydrocodone-acetaminophen 7.5-300mg tablet QL(240 EA per 30 days)
hydrocodone-acetaminophen 7.5-325mg tablet QL(84 EA per 30 days)
hydrocodone-acetaminophen 7.5-325mg/15 mL solution QL(2700 ML per 30 days)
hydrocodone-ibuprofen 5-200mg tablet QL(50 EA per 30 days)
hydrocodone-ibuprofen 7.5-200mg tablet QL(50 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
hydromorphone 2mg tablet QL(180 EA per 30 days)
hydromorphone 4mg tablet QL(180 EA per 30 days)
hydromorphone 8mg tablet QL(180 EA per 30 days)
ibandronate 150mg tablet QL(1 EA per 28 days)
ibuprofen-oxycodone 400-5mg tablet QL(28 EA per 30 days)
imiquimod 5% cream in packet QL(20 EA per 28 days)
ipratropium bromide 0.03% spray,non-aerosol QL(30 ML per 30 days)
ipratropium bromide 0.06% spray,non-aerosol QL(30 ML per 30 days)
itraconazole 100mg capsule QL(120 EA per 30 days)
Jakafi 25mg tablet QL(60 EA per 30 days)
Jardiance 10mg tablet QL(30 EA per 30 days)
Jardiance 25mg tablet QL(30 EA per 30 days)
Jentadueto 2.5-1,000mg tablet QL(60 EA per 30 days)
Jentadueto 2.5-500mg tablet QL(60 EA per 30 days)
Jentadueto 2.5-850mg tablet QL(60 EA per 30 days)
lansoprazole 15mg capsule,delayed release(DR/EC) QL(30 EA per 30 days)
lansoprazole 30mg capsule,delayed release(DR/EC) QL(30 EA per 30 days)
Latuda 120mg tablet QL(30 EA per 30 days)
Latuda 20mg tablet QL(30 EA per 30 days)
Latuda 40mg tablet QL(30 EA per 30 days)
Latuda 60mg tablet QL(30 EA per 30 days)
Latuda 80mg tablet QL(60 EA per 30 days)
levetiracetam 1,000mg tablet QL Removed
levetiracetam 250mg tablet QL Removed
levetiracetam 500mg tablet QL Removed
levetiracetam 750mg tablet QL Removed
levocetirizine 5mg tablet QL(30 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
levorphanol tartrate 2mg tablet QL(180 EA per 30 days)
Lialda 1.2gram tablet,delayed release (DR/EC) QL(120 EA per 30 days)
lidocaine 5% ointment QL(150 GM per 30 days)
lidocaine HCl-hydrocortison ac 3-0.5% kit QL(4 EA per 30 days)
lidocaine HCl-hydrocortison ac 3-1% (7 gram) kit QL(4 EA per 30 days)
lidocaine-hydrocortisone-aloe 2-2% kit QL(4 EA per 30 days)
lidocaine-hydrocortisone-aloe 3-2.5% (7 gram) kit QL(4 EA per 30 days)
lorazepam 0.5mg tablet QL(180 EA per 30 days)
lorazepam 1mg tablet QL(180 EA per 30 days)
lorazepam 2mg tablet QL(150 EA per 30 days)
losartan 100mg tablet QL(30 EA per 30 days)
losartan 25mg tablet QL(60 EA per 30 days)
losartan 50mg tablet QL(60 EA per 30 days)
losartan-hydrochlorothiazide 100-12.5mg tablet QL(30 EA per 30 days)
losartan-hydrochlorothiazide 100-25mg tablet QL(30 EA per 30 days)
losartan-hydrochlorothiazide 50-12.5mg tablet QL(60 EA per 30 days)
lovastatin 10mg tablet QL(30 EA per 30 days)
lovastatin 20mg tablet QL(60 EA per 30 days)
lovastatin 40mg tablet QL(60 EA per 30 days)
Lupron Depot (3 Month) 11.25mg syringe kit QL(1 EA per 84 days)
Lupron Depot (3 Month) 22.5mg syringe kit QL(1 EA per 84 days)
Lupron Depot (4 Month) 30mg syringe kit QL(1 EA per 112 days)
Lupron Depot (6 Month) 45mg syringe kit QL(1 EA per 168 days)
Lupron Depot 3.75mg syringe kit QL(1 EA per 28 days)
Lupron Depot 7.5mg syringe kit QL(1 EA per 28 days)
Lupron Depot-Ped (3 Month) 11.25mg syringe kit QL(1 EA per 84 days)
Lupron Depot-Ped (3 Month) 30mg syringe kit QL(1 EA per 84 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
Lupron Depot-Ped 11.25mg kit QL(1 EA per 28 days)
Lupron Depot-Ped 15mg kit QL(1 EA per 28 days)
Lupron Depot-Ped 7.5mg (Ped) kit QL(1 EA per 28 days)
memantine 2mg/mL solution QL(300 ML per 30 days)
meperidine 100mg tablet QL(180 EA per 30 days)
meperidine 50mg tablet QL(180 EA per 30 days)
metaxalone 800mg tablet QL(120 EA per 30 days)
methamphetamine 5mg tablet QL(90 EA per 30 days)
methylphenidate 10mg tablet QL(90 EA per 30 days)
methylphenidate 10mg tablet extended release QL(180 EA per 30 days)
methylphenidate 18mg tablet extended release 24hr QL(30 EA per 30 days)
methylphenidate 20mg capsule,ER biphasic 50-50 QL(60 EA per 30 days)
methylphenidate 20mg tablet QL(90 EA per 30 days)
methylphenidate 20mg tablet extended release QL(90 EA per 30 days)
methylphenidate 27mg tablet extended release 24hr QL(30 EA per 30 days)
methylphenidate 30mg capsule,ER biphasic 50-50 QL(60 EA per 30 days)
methylphenidate 36mg tablet extended release 24hr QL(30 EA per 30 days)
methylphenidate 40mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)
methylphenidate 54mg tablet extended release 24hr QL(30 EA per 30 days)
methylphenidate 5mg tablet QL(90 EA per 30 days)
Migergot 2-100mg suppository QL(20 EA per 28 days)
morphine 100mg tablet extended release QL(90 EA per 30 days)
morphine 10mg/5 mL solution QL(2700 ML per 30 days)
morphine 15mg tablet QL(180 EA per 30 days)
morphine 15mg tablet extended release QL(90 EA per 30 days)
morphine 20 mg/5 mL(4 mg/mL) solution QL(1350 ML per 30 days)
morphine 200mg tablet extended release QL(60 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
morphine 30mg tablet QL(180 EA per 30 days)
morphine 30mg tablet extended release QL(90 EA per 30 days)
morphine 60mg tablet extended release QL(90 EA per 30 days)
morphine concentrate 100 mg/5 mL(20 mg/mL) solution QL(600 ML per 30 days)
naratriptan 1mg tablet QL(18 EA per 30 days)
naratriptan 2.5mg tablet QL(18 EA per 30 days)
Nexavar 200mg tablet QL(120 EA per 30 days)
Nucynta 100mg tablet QL(180 EA per 30 days)
Nucynta 50mg tablet QL(180 EA per 30 days)
Nucynta 75mg tablet QL(180 EA per 30 days)
Nucynta ER 100mg tablet extended release 12 hr QL(60 EA per 30 days)
Nucynta ER 150mg tablet extended release 12 hr QL(60 EA per 30 days)
Nucynta ER 200mg tablet extended release 12 hr QL(60 EA per 30 days)
Nucynta ER 250mg tablet extended release 12 hr QL(60 EA per 30 days)
Nucynta ER 50mg tablet extended release 12 hr QL(60 EA per 30 days)
olanzapine 10mg tablet QL(30 EA per 30 days)
olanzapine 10mg tablet,disintegrating QL(30 EA per 30 days)
olanzapine 15mg tablet QL(30 EA per 30 days)
olanzapine 15mg tablet,disintegrating QL(30 EA per 30 days)
olanzapine 2.5mg tablet QL(30 EA per 30 days)
olanzapine 20mg tablet QL(30 EA per 30 days)
olanzapine 20mg tablet,disintegrating QL(30 EA per 30 days)
olanzapine 5mg tablet QL(30 EA per 30 days)
olanzapine 5mg tablet,disintegrating QL(30 EA per 30 days)
olanzapine 7.5mg tablet QL(30 EA per 30 days)
olopatadine 0.1% drops QL(10 ML per 30 days)
orphenadrine citrate 100mg tablet extended release QL(60 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
oxandrolone 10mg tablet QL(120 EA per 30 days)
oxandrolone 2.5mg tablet QL(60 EA per 30 days)
oxybutynin chloride 10mg tablet extended release 24hr QL(30 EA per 30 days)
oxybutynin chloride 15mg tablet extended release 24hr QL(60 EA per 30 days)
oxybutynin chloride 5mg tablet QL(120 EA per 30 days)
oxybutynin chloride 5mg tablet extended release 24hr QL(30 EA per 30 days)
oxycodone 10mg tablet QL(180 EA per 30 days)
oxycodone 15mg tablet QL(180 EA per 30 days)
oxycodone 20mg tablet QL(180 EA per 30 days)
oxycodone 30mg tablet QL(120 EA per 30 days)
oxycodone 5mg/5 mL solution QL(5400 ML per 30 days)
oxycodone-aspirin 4.8355-325mg tablet QL(360 EA per 30 days)
oxymorphone 10mg tablet QL(120 EA per 30 days)
oxymorphone 5mg tablet QL(120 EA per 30 days)
pantoprazole 20mg tablet,delayed release (DR/EC) QL(60 EA per 30 days)
pantoprazole 40mg tablet,delayed release (DR/EC) QL(60 EA per 30 days)
paroxetine HCl 10mg tablet QL(90 EA per 30 days)
paroxetine HCl 12.5mg tablet extended release 24 hr QL(30 EA per 30 days)
paroxetine HCl 20mg tablet QL(90 EA per 30 days)
paroxetine HCl 25mg tablet extended release 24 hr QL(60 EA per 30 days)
paroxetine HCl 30mg tablet QL(90 EA per 30 days)
paroxetine HCl 37.5mg tablet extended release 24 hr QL(60 EA per 30 days)
paroxetine HCl 40mg tablet QL(90 EA per 30 days)
Paxil 10mg/5 mL suspension QL(900 ML per 30 days)
Pegasys 180mcg/0.5 mL syringe QL(2 ML per 28 days)
Pegasys 180mcg/mL solution QL(4 ML per 28 days)
Pegasys ProClick 135mcg/0.5 mL pen injector QL(2 ML per 28 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
Pegasys ProClick 180mcg/0.5 mL pen injector QL(2 ML per 28 days)
pioglitazone 15mg tablet QL(30 EA per 30 days)
pioglitazone 30mg tablet QL(30 EA per 30 days)
pioglitazone 45mg tablet QL(30 EA per 30 days)
Potiga 200mg tablet QL(90 EA per 30 days)
Potiga 300mg tablet QL(90 EA per 30 days)
Potiga 400mg tablet QL(90 EA per 30 days)
Potiga 50mg tablet QL(270 EA per 30 days)
Praluent Pen 150mg/mL pen injector QL(2 ML per 28 days)
Praluent Pen 75mg/mL pen injector QL(2 ML per 28 days)
Praluent Syringe 150mg/mL syringe QL(2 ML per 28 days)
Praluent Syringe 75mg/mL syringe QL(2 ML per 28 days)
primaquine 26.3mg tablet QL(30 EA per 30 days)
Procrit 10,000unit/mL solution QL(14 ML per 30 days)
Procrit 2,000unit/mL solution QL(14 ML per 30 days)
Procrit 20,000unit/mL solution QL(14 ML per 30 days)
Procrit 3,000unit/mL solution QL(14 ML per 30 days)
Procrit 4,000unit/mL solution QL(14 ML per 30 days)
Procrit 40,000unit/mL solution QL(14 ML per 30 days)
Prolia 60mg/mL syringe QL(1 ML per 180 days)
Promacta 12.5mg tablet QL(60 EA per 30 days)
Promacta 25mg tablet QL(60 EA per 30 days)
Promacta 50mg tablet QL(60 EA per 30 days)
Promacta 75mg tablet QL(60 EA per 30 days)
quetiapine 100mg tablet QL(90 EA per 30 days)
quetiapine 200mg tablet QL(90 EA per 30 days)
quetiapine 25mg tablet QL(90 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
quetiapine 300mg tablet QL(90 EA per 30 days)
quetiapine 400mg tablet QL(90 EA per 30 days)
quetiapine 50mg tablet QL(90 EA per 30 days)
Relenza Diskhaler 5mg/actuation blister with device QL(60 EA per 180 days)
Relpax 20mg tablet QL(18 EA per 30 days)
Relpax 40mg tablet QL(18 EA per 30 days)
Repatha SureClick 140mg/mL pen injector QL(3 ML per 28 days)
Repatha Syringe 140mg/mL syringe QL(3 ML per 28 days)
Restasis 0.05% dropperette QL(60 EA per 30 days)
risedronate 150mg tablet QL(1 EA per 30 days)
risedronate 30mg tablet QL(30 EA per 30 days)
risedronate 35mg tablet QL(4 EA per 28 days)
risedronate 5mg tablet QL(30 EA per 30 days)
Risperdal Consta 12.5mg/2 mL syringe QL(4 EA per 28 days)
Risperdal Consta 25mg/2 mL syringe QL(4 EA per 28 days)
Risperdal Consta 37.5mg/2 mL syringe QL(4 EA per 28 days)
Risperdal Consta 50mg/2 mL syringe QL(4 EA per 28 days)
risperidone 0.25mg tablet QL(120 EA per 30 days)
risperidone 0.25mg tablet,disintegrating QL(120 EA per 30 days)
risperidone 0.5mg tablet QL(120 EA per 30 days)
risperidone 1mg tablet QL(120 EA per 30 days)
risperidone 2mg tablet QL(120 EA per 30 days)
risperidone 3mg tablet QL(120 EA per 30 days)
risperidone 4mg tablet QL(120 EA per 30 days)
rizatriptan 10mg tablet QL(18 EA per 30 days)
rizatriptan 10mg tablet,disintegrating QL(18 EA per 30 days)
rizatriptan 5mg tablet QL(18 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
rizatriptan 5mg tablet,disintegrating QL(18 EA per 30 days)
Rozerem 8mg tablet QL(30 EA per 30 days)
Savella 100mg tablet QL(60 EA per 30 days)
Savella 12.5 mg (5)-25mg(8)-50 mg(42) tablets,dose pack QL(55 EA per 30 days)
Savella 12.5mg tablet QL(60 EA per 30 days)
Savella 25mg tablet QL(60 EA per 30 days)
Savella 50mg tablet QL(60 EA per 30 days)
Sensipar 30mg tablet QL(60 EA per 30 days)
Sensipar 60mg tablet QL(60 EA per 30 days)
Sensipar 90mg tablet QL(120 EA per 30 days)
sertraline 20mg/mL concentrate QL(300 ML per 30 days)
Spiriva Respimat 1.25mcg/actuation mist QL(4 GM per 30 days)
Spiriva Respimat 2.5mcg/actuation mist QL(4 GM per 30 days)
Sprycel 100mg tablet QL(30 EA per 30 days)
Sprycel 140mg tablet QL(30 EA per 30 days)
Sprycel 20mg tablet QL(30 EA per 30 days)
Sprycel 50mg tablet QL(30 EA per 30 days)
Sprycel 70mg tablet QL(30 EA per 30 days)
Sprycel 80mg tablet QL(30 EA per 30 days)
Strattera 100mg capsule QL(30 EA per 30 days)
Strattera 10mg capsule QL(60 EA per 30 days)
Strattera 18mg capsule QL(60 EA per 30 days)
Strattera 25mg capsule QL(60 EA per 30 days)
Strattera 40mg capsule QL(60 EA per 30 days)
Strattera 60mg capsule QL(30 EA per 30 days)
Strattera 80mg capsule QL(30 EA per 30 days)
Suboxone 12-3mg film QL(60 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
Suboxone 2-0.5mg film QL(90 EA per 30 days)
Suboxone 4-1mg film QL(90 EA per 30 days)
Suboxone 8-2mg film QL(90 EA per 30 days)
Sutent 12.5mg capsule QL(30 EA per 30 days)
Sutent 25mg capsule QL(30 EA per 30 days)
Sutent 37.5mg capsule QL(30 EA per 30 days)
Sutent 50mg capsule QL(30 EA per 30 days)
Symbicort 80-4.5mcg/actuation HFA aerosol inhaler QL(10.2 GM per 30 days)
Tanzeum 30mg/0.5 mL pen injector QL(4 EA per 28 days)
Tanzeum 50mg/0.5 mL pen injector QL(4 EA per 28 days)
Tarceva 100mg tablet QL(30 EA per 30 days)
Tarceva 150mg tablet QL(30 EA per 30 days)
Tarceva 25mg tablet QL(30 EA per 30 days)
Tasigna 150mg capsule QL(120 EA per 30 days)
Tasigna 200mg capsule QL(120 EA per 30 days)
temazepam 15mg capsule QL(30 EA per 30 days)
temazepam 30mg capsule QL(30 EA per 30 days)
terazosin 10mg capsule QL(60 EA per 30 days)
terazosin 1mg capsule QL(30 EA per 30 days)
terazosin 2mg capsule QL(30 EA per 30 days)
terazosin 5mg capsule QL(30 EA per 30 days)
testosterone 1 %(25 mg/2.5gram) gel in packet QL Removed
testosterone 1 %(50 mg/5 gram) gel in packet QL Removed
testosterone 1.25 gram/actuation (1 %) gel in metered-dose pump
QL Removed
tiagabine 4mg tablet QL Removed
Tradjenta 5mg tablet QL(30 EA per 30 days)
tramadol 50mg tablet QL(240 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
tramadol-acetaminophen 37.5-325mg tablet QL(240 EA per 30 days)
Transderm-Scop 1.5 mg (1 mgover 3 days) patch 3 day QL(10 EA per 30 days)
Tresiba FlexTouch U-200 200 unit/mL(3 mL) insulin pen QL(36 ML per 30 days)
Tykerb 250mg tablet QL(180 EA per 30 days)
venlafaxine 150mg capsule,extended release 24hr QL(60 EA per 30 days)
Votrient 200mg tablet QL(120 EA per 30 days)
Vytorin 10-10 10-10mg tablet QL(30 EA per 30 days)
Vytorin 10-20 10-20mg tablet QL(30 EA per 30 days)
Vytorin 10-40 10-40mg tablet QL(30 EA per 30 days)
Vytorin 10-80 10-80mg tablet QL(30 EA per 30 days)
Vyvanse 10mg capsule QL(30 EA per 30 days)
Vyvanse 20mg capsule QL(30 EA per 30 days)
Vyvanse 30mg capsule QL(30 EA per 30 days)
Vyvanse 40mg capsule QL(30 EA per 30 days)
Vyvanse 50mg capsule QL(30 EA per 30 days)
Vyvanse 60mg capsule QL(30 EA per 30 days)
Vyvanse 70mg capsule QL(30 EA per 30 days)
Xalkori 200mg capsule QL(60 EA per 30 days)
Xalkori 250mg capsule QL(60 EA per 30 days)
Xarelto 10mg tablet QL Removed
Xifaxan 550mg tablet QL(90 EA per 30 days)
Xtandi 40mg capsule QL(120 EA per 30 days)
Zetia 10mg tablet QL(30 EA per 30 days)
Zolinza 100mg capsule QL(120 EA per 30 days)
zolmitriptan 2.5mg tablet QL(18 EA per 30 days)
zolmitriptan 2.5mg tablet,disintegrating QL(18 EA per 30 days)
zolmitriptan 5mg tablet QL(18 EA per 30 days)
MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES
DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)
zolmitriptan 5mg tablet,disintegrating QL(18 EA per 30 days)
Zytiga 250mg tablet QL(120 EA per 30 days)
MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES
Medication Name Change Description
aripiprazole 10mg tablet PA Removed
aripiprazole 15mg tablet PA Removed
aripiprazole 20mg tablet PA Removed
aripiprazole 2mg tablet PA Removed
aripiprazole 30mg tablet PA Removed
aripiprazole 5mg tablet PA Removed
celecoxib 100mg capsule ST Removed
celecoxib 200mg capsule ST Removed
celecoxib 400mg capsule ST Removed
celecoxib 50mg capsule ST Removed
Cycloset 0.8mg tablet PA Added
eszopiclone 1mg tablet PA Removed
eszopiclone 2mg tablet PA Removed
eszopiclone 3mg tablet PA Removed
Horizant 300mg tablet extended release PA Added
Horizant 600mg tablet extended release PA Added
lidocaine 5% adhesive patch,medicated PA Added
lidocaine 5% ointment PA Added
Lyrica 100mg capsule ST Removed
Lyrica 150mg capsule ST Removed
Lyrica 200mg capsule ST Removed
Lyrica 225mg capsule ST Removed
Lyrica 25mg capsule ST Removed
MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES
Medication Name Change Description
Lyrica 300mg capsule ST Removed
Lyrica 50mg capsule ST Removed
Lyrica 75mg capsule ST Removed
meropenem 500mg recon soln PA Added
naratriptan 1mg tablet ST Added
naratriptan 2.5mg tablet ST Added
oxandrolone 10mg tablet PA Added
oxandrolone 2.5mg tablet PA Added
Saphris 5mg tablet PA Added
testosterone 50mg/5 gram (1 %) gel PA Added
Xarelto 10mg tablet PA Removed
Xarelto 15mg tablet PA Removed
Xarelto 20mg tablet PA Removed
36194_MPINFO165FH (11/2016)
Nondiscrimination Notice
Florida Hospital Care Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage:
Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
Qualified sign language interpreters
Written information in other formats (large print, accessible electronic formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, please contact Sherri Wynn. If you believe that Florida Hospital Care Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Sherri Wynn, ADA/Section 504 Coordinator, 6450 US Highway 1, Rockledge, FL 32955, 321-434-4521, 1-800-955-8771 (TTY), Fax: 321-434-4362, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance Sherri Wynn, ADA/Section 504 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. 36194_MPINFO110FH (10/2016_r1)
English:
This Notice has Important Information. This notice has important information about your application or
coverage through Florida Hospital Care Advantage. Look for key dates in this notice. You may need to take
action by certain deadlines to keep your health coverage or help with costs. You have the right to get this
information and help in your language at no cost. Call 844-522-5279.
Spanish:
Este Aviso contiene información importante. Este aviso contiene información importante acerca de la solicitud
o cobertura que usted tiene con Florida Hospital Care Advantage. Preste atención a las fechas clave que
contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su
cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma
sin costo alguno. Llame al 844-522-5279.
Haitian Creole:
Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a gen enfòmasyon enpòtan konsènan aplikasyon w lan
oswa konsènan kouvèti asirans lan atravè Florida Hospital Care Advantage. Chèche dat ki enpòtan nan avi sila
a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka
ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen
pou peye pou sa. Rele nan 844-522-5279.
Vietnamese:
Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn đăng ký hoặc hợp
đồng bảo hiểm qua chương trình Florida Hospital Care Advantage của Quý vị. Xin xem các ngày quan trọng
trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức
khỏe hoặc được trợ trúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn
ngữ của mình miễn phí. Xin gọi số 844-522-5279.
Portuguese:
Este aviso contém informações importantes. Este aviso contém informações importantes a respeito da sua
solicitação ou cobertura por meio dos Florida Hospital Care Advantage. Consulte datas importantes neste aviso.
Talvez seja necessário que você tome providências dentro de determinados prazos para manter a sua cobertura
de plano de saúde ou ajuda com custos. Você tem o direito de obter estas informações e ajuda no seu idioma e
sem custos. Ligue para 844-522-5279.
Chinese:
本通知包含重要的資訊。本通知包含關於您透過 Florida Hospital Care Advantage
提交的申請或保險的重要資訊。請留意本通知內的重要日期。您可能需要在截止日期之前採取行動,以
保留您的健康保險或費用補貼。您有權以您的母語免費取得本資訊及幫助。請撥電話 844-522-5279。
French:
Cet avis a d'importantes informations. Cet avis a d'importantes informations sur votre demande ou la couverture
par l'intermédiaire Florida Hospital Care Advantage. Rechercher les dates clés dans le présent avis. Vous devrez
peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les
coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez 844-
522-5279.
Tagalog:
Ang Paunawa na ito ay naglalaman ng Mahalagang Impormasyon. Ang paunawa na ito ay naglalaman ng
mahalagang impormasyon tungkol sa iyong aplikasyon o pagkakasaklaw sa Florida Hospital Care Advantage.
Tingnan ang mga mahalagang petsa dito sa paunawa. Maaring mangailangan kang magsagawa ng hakbang sa
ilang mga itinakdang panahon upang mapanatili ang iyong pagkakasaklaw sa kalusugan o makatulong sa mga
gastusin. May karapatan kang makuha ang impormasyon at tulong na ito sa iyong wika nang libre. Tumawag sa
844-522-5279.
Russian:
Настоящее уведомление содержит важную информацию. Это уведомление содержит важную
информацию о вашем заявлении или страховом покрытии через Florida Hospital Care Advantage.
Посмотрите на ключевые даты в настоящем уведомлении. Вам, возможно, потребуется принять меры к
определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы
имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по
телефону 844-522-5279.
Arabic:
Florida Hospital Careيحوي هذا اإلشعار معلومات هامة. يحوي هذا االشعار معلومات مهمة بخصوص طلبك للحصول على التغطية من خالل Advantageلتغطية الصحية . ابحث عن التواريخ الهامة في هذا االشعار. قد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة في دفع ا
.5279-522-844أو للمساعدة في دفع التكاليف. لك الحق في الحصول على معلومات والمساعدة بلغتك من دون أي تكلفة. اتصل بالرقم
Italian:
Questo avviso contiene informazioni importanti. Questo avviso contiene informazioni importanti sulla sua
domanda o copertura attraverso Florida Hospital Care Advantage. Cerchi le date chiave in questo avviso.
Potrebbe essere necessario un suo intervento entro una scadenza determinata per consentirle di mantenere la sua
copertura o sovvenzione. Ha il diritto di ottenere queste informazioni e assistenza nella sua lingua
gratuitamente. Chiami il numero 844-522-5279.
German:
Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält wichtige
Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Florida Hospital Care
Advantage. Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten
Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Anspruch auf Hilfe mit den Kosten zu
behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an
unter 844-522-5279.
Korean:
본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고 Florida
Hospital Care Advantage를 통한 보장에 관한 정보를 포함하고 있습니다. 본 통지서에서 핵심이
되는 날짜들을 확인하십시오. 귀하는 건강 보장을 계속 유지하거나 비용을 절감하기 위해서 일정한
마감일까지 조치를 취해야 할 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용
부담없이 얻을 수 있는 권리가 있습니다. 844-522-5279로 전화하십시오.
Polish:
Niniejsze ogłoszenie zawiera ważne informacje. Niniejsze ogłoszenie zawiera ważne informacje dotyczące
Państwa wniosku lub zakresu świadczeń realizowanych poprzez Florida Hospital Care Advantage. Może
zaistnieć potrzeba podjęcia przez Państwa pewnych działań w określonym terminie w celu zachowania
ubezpieczenia zdrowotnego lub otrzymania pomocy związanej z kosztami. Macie Państwo prawo do
bezpłatnego uzyskania informacji i pomocy w języku ojczystym. Prosimy zadzwonić pod numer 844-522-5279.
Gujarati:
આ સચૂનામાાં અગત્યની માહિતી છે. આ સચૂનામાાં દ્વારા તમારી અરજી અથવા કવરેજ વવશેની અગત્યની માહિતી છે. આ સચૂનામાાંની ખાસ તારીખો જુઓ. તમારા આરોગ્ય કવરેજને જાળવી રાખવા અથવા ખચચ અંગે મદદ મેળવવા માટે
ચોક્કસ સમયમયાચદા સધુીમાાં તમારે કાયચવાિી કરવાની જરૂર પડી શકે છે. તમને આ માહિતી અને મદદ તમારી ભાષામાાં વવના મલૂ્યે
મેળવવાનો અવધકાર છે. 844-522-5279 પર કૉલ કરો.
Thai:
ประกาศนีม้ีข้อมลูส าคญั ประกาศนีม้ีข้อมลูที่ส าคญัเก่ียวกบัการสมคัรหรือขอบเขตการประกนัสขุภาพของคณุผา่น Florida Hospital Care
Advantage โปรดดกู าหนดการส าคญัในประกาศนี ้คณุอาจจะต้องด าเนินการภายในเวลาที่ก าหนดเพื่อจะรักษาการประกนัสขุภาพของคณุหรือการชว่ยเหลอืที่มคีา่ใช้จ่าย คณุมีสทิธิที่จะได้รับข้อมลูและความชว่ยเหลอืนีใ้นภาษาของคณุโดยไมม่ีคา่ใช้จา่ย โทร 844-522-5279.
Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage.
Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability,
age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including
enrollment and benefit determinations.
36194_MPINFO112FH (10/2016)