2018 Tufts Medicare Preferred HMO Individual Formulary · Tufts Medicare Preferred HMO will...

PLEASE READ: This document contains information about the drugs we cover in this plan

This formulary was updated on July 1, 2018 For more recent information or

other questions, please contact us at 1-800-701-9000 or, for TTY users, 711,

Monday - Friday 8:00 a.m. - 8:00 p.m. (from Oct. 1 - Feb. 14 representatives are

available 7 days a week, 8:00 a.m. - 8:00 p.m.). After hours and on holidays,

please leave a message and a representative will return your call on the next

business day. Or visit tuftsmedicarepreferred.org.

Note to existing members: This formulary has changed since last year. Please

review this document to make sure that it still contains the drugs you take.

18381 Version 14

H2256_2018_2 Accepted

Tufts Medicare Preferred HMO2018 Formulary (List of Covered Drugs)

TuFTS MEDiCARE PREFERRED HMO PLANS | 2018

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TufTs Medicare Preferred HMO_

2018 formulary (List of covered drugs)

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Tufts Health Plan Medicare Preferred. When it refers to “plan” or “our plan,” it means Tufts Medicare Preferred HMO.

This document includes a list of the drugs (formulary) for our plan which is current as of September, 2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

What is the Tufts Medicare Preferred HMO formulary?A formulary is a list of covered drugs selected by Tufts Medicare Preferred HMO in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Tufts Medicare Preferred HMO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Tufts Medicare Preferred HMO network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

can the formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of September, 2017. To get updated information about the drugs covered by Tufts Medicare Preferred HMO, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year non-maintenance formulary change, you will be notified via an errata sheet.

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How do i use the formulary? There are two ways to find your drug within the formulary:Medical conditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 69. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Tufts Medicare Preferred HMO covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: Tufts Medicare Preferred HMO requires you or your physician to get prior authorization

for certain drugs. This means that you will need to get approval from Tufts Medicare Preferred HMO beforeyou fill your prescriptions. If you don’t get approval, Tufts Medicare Preferred HMO may not cover the drug.

• Quantity Limits: For certain drugs, Tufts Medicare Preferred HMO limits the amount of the drug thatTufts Medicare Preferred HMO will cover. For example, Tufts Medicare Preferred HMO provides 30 tabletsper prescription for ROZEREM. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Tufts Medicare Preferred HMO requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. For example, if Drug A andDrug B both treat your medical condition, Tufts Medicare Preferred HMO may not cover Drug B unless youtry Drug A first. If Drug A does not work for you, Tufts Medicare Preferred HMO will then cover Drug B.

• Non-extended day supply drug: For certain drugs, Tufts Medicare Preferred HMO limits quantities up to a30-day supply per fill.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explains our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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You can ask Tufts Medicare Preferred HMO to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Tufts Medicare Preferred HMO formulary?” below for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Relations and ask if your drug is covered.

If you learn that Tufts Medicare Preferred HMO does not cover your drug, you have two options:

• You can ask Customer Relations for a list of similar drugs that are covered by Tufts Medicare Preferred HMO.When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby Tufts Medicare Preferred HMO.

• You can ask Tufts Medicare Preferred HMO to make an exception and cover your drug. See below forinformation about how to request an exception.

How do i request an exception to the Tufts Medicare Preferred HMO formulary?You can ask Tufts Medicare Preferred HMO to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be coveredat a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lowercost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier.If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, TuftsMedicare Preferred HMO limits the amount of the drug that we will cover. If your drug has a quantity limit,you can ask us to waive the limit and cover a greater amount.

Generally, Tufts Medicare Preferred HMO will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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What do i do before i can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

As a current member, if you are admitted to or discharged from a long term facility and experience an unplanned drug change, you can request that we approve a one-time, temporary fill of the non-covered medication to allow you time to discuss a transition plan with your physician. Your physician can also request an exception to coverage for the non-covered drug based on review for medical necessity following the standard exception process outlined previously. The temporary “first fill” will generally be up to a 31-day supply, but may be extended to allow you and your physician time to manage the complexities of multiple medications or when special circumstances warrant. You can request a temporary prescription fill by calling the Tufts Medicare Preferred HMO Customer Relations department.

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for more informationFor more detailed information about your Tufts Medicare Preferred HMO prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Tufts Medicare Preferred HMO, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 711.Or, visit http://www.medicare.gov.

Tufts Medicare Preferred HMO formularyThe formulary that begins on page 3 provides coverage information about the drugs covered by Tufts Medicare Preferred HMO. If you have trouble finding your drug in the list, turn to the Index that begins on page 69.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PROAIR HFA) and generic drugs are listed in lower-case italics (e.g., omeprazole).

The information in the Requirements/Limits column tells you if Tufts Medicare Preferred HMO has any special requirements for coverage of your drug.

B vs d: Medicare Part B or dThese drugs require prior authorization to determine appropriate coverage under Medicare Part B or Part D. Some Part B drugs may require a 20% co-insurance for Tufts Medicare Preferred HMO Saver Rx members.

QL: Quantity Limit applies.Because of potential safety and utilization concerns, Tufts Medicare Preferred HMO has placed dispensing limitations on a small number of prescription drugs. This means that the pharmacy will only dispense a certain quantity of a drug within a given time period. These quantities are based on recognized standards of care, such as U.S. Food and Drug Administration recommendations for use. If your doctor believes you need a quantity greater than the program limitation, your doctor can submit a request for coverage under the Medical Review Process. The Medical Review Process allows you or your doctor to ask Tufts Medicare Preferred HMO to make an exception to our coverage rules. See the section, “How do I request an exception to the Tufts Medicare Preferred HMO formulary?” on page III for information about how to request an exception.

Hi: Home infusion drug.This prescription drug may be covered under our medical benefit. For more information, call Customer Relations at 1-800-701-9000, Monday-Friday 8:00 a.m. – 8:00 p.m. (From Oct. 1 –Feb. 14 representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m.). After hours and on holidays, please leave a message and a representative will return your call on the next business day. TTY users should call 711.

La: Limited access drug.This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Relations at 1-800-701-9000, Monday-Friday 8:00 a.m. – 8:00 p.m. (From Oct. 1 –Feb. 14 representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m.). After hours and on holidays, please leave a message and a representative will return your call the on next business day. TTY users should call 711.

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Pa: Prior authorization required.The Prior Authorization process encourages rational prescribing of drug products with significant safety and/or financial concerns. A provider can submit a request for coverage based on a member’s medical need for a particular drug. If approved, the member pays the designated tier co-payment. An appeal process exists for denied requests.

sTPa: step Therapy Prior authorization applies.Step Therapy is an automated form of Prior Authorization, which uses claims history for approval of a drug at the point of sale. Step Therapy Programs help encourage the clinically proven use of first-line therapies and are designed to ensure the utilization of the most therapeutically appropriate and cost-effective agents first, before other treatments may be covered.

Members who are currently on drugs that meet the initial Step Therapy criteria will automatically be able to fill their prescriptions for a stepped medication. If the member does not meet the initial Step Therapy criteria, the prescription will deny at the point of sale with a message indicating that Prior Authorization (PA) is required. Physicians may submit Prior Authorization requests to Tufts Medicare Preferred HMO for members who do not meet the Step Therapy criteria at the point of sale under the Medical Review process. The Medical Review Process allows you or your doctor to ask Tufts Medicare Preferred HMO to make an exception to our coverage rules. See the section, “How do I request an exception to the Tufts Medicare Preferred HMO formulary?” on page III for information about how to request an exception.

Transplant:This drug is covered under Part B when used for a Medicare covered organ transplant. Some Part B drugs may require a 20% co-insurance for Tufts Medicare Preferred HMO Saver Rx members.

coverage Gap:For Tufts Medicare Preferred HMO Prime Rx Plus members, we provide additional coverage for Tier 1 and Tier 2 drugs in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage.

Part B drug:No co-payment is required and the cost of the medication does not apply to your Part D benefit. Some Part B drugs may require a 20% co-insurance for Tufts Medicare Preferred HMO Saver Rx members.

Neds: Non-extended day supply drugIn an effort to contain drug costs, certain high-cost drugs will be limited up to a 30-day supply per fill.

sP: available through a designated special Pharmacy provider You have the option to obtain this drug through a designated Specialty Pharmacy provider. These pharmacies specialize in supplying a select number of medications directly to our members. They also provide free delivery to your home, educational support 24/7 by phone, support of nurses and pharmacists, and will work closely with your doctor. Medications include, but are not limited to, drugs used in the treatment of multiple sclerosis, hepatitis C, rheumatoid arthritis, and cancers treated with oral medications. SP-CVS specialty: 1-800-237-2767

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HMO saver rxBarnstable, Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester counties

HMO Basic rxBarnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester counties

HMO Value rxBarnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester counties

deductible $400 (for your Tier 3, Tier 4 and

Tier 5 drugs)

$350 (for your Tier 3, Tier 4 and

Tier 5 drugs)

$300 (for your Tier 3, Tier 4 and

Tier 5 drugs)

copays retail 30-day supply

Mail order 90-day supply

retail 30-day supply




Tier 1 $6 $12 $4 $8 $4 $8Tier 2 $12 $24 $8 $16 $8 $16Tier 3 $47 $94 $47 $94 $47 $94Tier 4 $100 $300 $100 $300 $100 $300Tier 5 25% N/A 26% N/A 27% N/Acoverage Gap stageAfter your total prescription drug costs reach $3,750, and until your payments reach $5,000, you pay:

• 44% of costs for Part D generic drugs• 35% of costs for Part D brand drugs

catastrophic coverage stageAfter the coverage gap, when your payments for the year are greater than $5,000, you pay the greater of:

5% per prescription, or $3.35 per prescription for Part D generic drugs, $8.35 per prescription for Part D brand drugs.

Your Prescription drug costs

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HMO Prime rxBarnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester counties

HMO Prime rx PlusBarnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, and Suffolk counties

deductible $0 $0

copays retail 30-day supply




Tier 1 $4 $8 $2 $4Tier 2 $8 $16 $4 $8Tier 3 $47 $94 $30 $60Tier 4 $100 $300 $80 $240Tier 5 33% N/A 33% N/Acoverage Gap stageAfter your total prescription drug costs reach $3,750, and until your payments reach $5,000, you pay:

• 44% of costs for Part D generic drugs• 35% of costs for Part D brand drugs

• Tier 1 copayments for preferred generic drugs on tier 1

• Tier 2 copayments for generic drugs on tier 2• 44% of costs for All other Part D generic drugs• 35% of costs for Part D brand drugs

catastrophic coverage stageAfter the coverage gap, when your payments for the year are greater than $5,000, you pay the greater of:

5% per prescription, or $3.35 per prescription for Part D generic drugs, $8.35 per prescription for Part D brand drugs.

Your Prescription drug costs

Tufts Medicare Preferred HMO

2018 Formulary (List of Covered Drugs)

Table of Contents

ANTI-INFECTIVES AND INFECTIOUS DISEASE...............................................................................................3BLOOD MODIFYING AGENTS............................................................................................................................. 9CANCER DRUGS................................................................................................................................................... 11CARDIOVASCULAR AGENTS............................................................................................................................ 17DIABETES MELLITUS..........................................................................................................................................22EAR, NOSE AND THROAT...................................................................................................................................25EYE.......................................................................................................................................................................... 25GASTROINTESTINAL DRUGS............................................................................................................................28HOME INFUSION THERAPY...............................................................................................................................31HORMONES........................................................................................................................................................... 35IMMUNOLOGIC AGENTS....................................................................................................................................37MISCELLANEOUS DRUGS..................................................................................................................................39NEUROLOGICAL DRUGS....................................................................................................................................45PAIN AND INFLAMMATORY DISEASES..........................................................................................................49PSYCHIATRIC........................................................................................................................................................53RESPIRATORY DRUGS........................................................................................................................................58SKIN.........................................................................................................................................................................61WOMEN'S HEALTH.............................................................................................................................................. 65

1

Tufts Medicare Preferred HMO

2018 Formulary (List of Covered Drugs)

Drug Name Drug Tier Requirements/Limits

ANTI-INFECTIVES AND INFECTIOUS DISEASEANTIFUNGALS, SYSTEMIC AND ORAL TOPICALclotrimazole Tier-2

CRESEMBA Tier-5 NEDS

fluconazole Tier-2

flucytosine Tier-5 NEDS

griseofulvin microsize Tier-2

griseofulvin ultramicrosize Tier-2

itraconazole Tier-2 PA

ketoconazole Tier-3

NOXAFIL Tier-5 NEDS

nystatin Tier-2

terbinafine hcl Tier-1 QL (42 EA per 42 days)

voriconazole oral suspension reconstituted Tier-5 NEDS

voriconazole oral tablet 200 mg Tier-5 QL (28 EA per 14 days); NEDS

voriconazole oral tablet 50 mg Tier-5 QL (56 EA per 14 days); NEDS

ANTI-INFECTIVES, MISCELLANEOUS

ALBENZA Tier-5 NEDS

ALINIA Tier-4

BILTRICIDE Tier-3

ivermectin Tier-2

linezolid Tier-5 NEDS

methenamine hippurate Tier-2

metronidazole Tier-2

MONUROL Tier-4

neomycin sulfate Tier-2

nitrofurantoin macrocrystal Tier-2 PA; QL (90 EA per 365 days)

nitrofurantoin monohyd macro Tier-2 PA; QL (90 EA per 365 days)

SIVEXTRO Tier-5 NEDS

STROMECTOL Tier-3

trimethoprim Tier-2

vancomycin hcl Tier-3 NEDS

You can find information on what the symbols and abbreviations on this table mean by going to page V.3

Drug Name Drug Tier Requirements/LimitsXIFAXAN ORAL TABLET 200 MG Tier-5 NEDS

XIFAXAN ORAL TABLET 550 MG Tier-5 PA; NEDS

ANTIMALARIALS AND ANTIPROTOZOALSatovaquone Tier-5 NEDS

atovaquone-proguanil hcl Tier-2

chloroquine phosphate Tier-2

COARTEM Tier-3 QL (24 EA per 3 days)

dapsone tablets Tier-2

DARAPRIM Tier-3

hydroxychloroquine sulfate Tier-2

mefloquine hcl Tier-2

NEBUPENT Tier-4 B vs D

paromomycin sulfate Tier-2

PENTAM Tier-3 B vs D

primaquine phosphate Tier-2

quinine sulfate Tier-2

tinidazole Tier-2

ANTIVIRALSabacavir sulfate oral solution Tier-3

abacavir sulfate oral tablet Tier-2

abacavir sulfate-lamivudine Tier-5 NEDS

abacavir-lamivudine-zidovudine Tier-5 NEDS

acyclovir oral capsule Tier-1

acyclovir oral suspension Tier-3

acyclovir oral tablet Tier-2

adefovir dipivoxil Tier-5 NEDS

amantadine hcl Tier-2

APTIVUS Tier-5 NEDS

atazanavir sulfate Tier-5 NEDS

ATRIPLA Tier-5 NEDS

BIKTARVY Tier-5 NEDS

COMPLERA Tier-5 NEDS

CRIXIVAN Tier-3

DESCOVY Tier-5 NEDS

didanosine Tier-2

EDURANT Tier-5 NEDS


Drug Name Drug Tier Requirements/Limitsefavirenz oral capsule Tier-3

efavirenz oral tablet Tier-5 NEDS

EMTRIVA Tier-3

entecavir Tier-5 NEDS

EPCLUSA Tier-5 PA; SP-CVS specialty; NEDS

EPIVIR Tier-3

EVOTAZ Tier-5 NEDS

famciclovir Tier-2

fosamprenavir calcium Tier-5 NEDS

FUZEON Tier-5 SP-CVS specialty; NEDS

GENVOYA Tier-5 NEDS

HARVONI Tier-5 PA; SP-CVS specialty; NEDS

INTELENCE ORAL TABLET 100 MG, 25 MG Tier-3

INTELENCE ORAL TABLET 200 MG Tier-5 NEDS

INTRON A INJECTION SOLUTION 10000000 UNIT/ML

Tier-3

INTRON A INJECTION SOLUTION 6000000 UNIT/ML

Tier-3 SP-CVS specialty

INTRON A INJECTION SOLUTION RECONSTITUTED

Tier-3 SP-CVS specialty

INVIRASE Tier-5 NEDS

ISENTRESS HD Tier-5 QL (60 EA per 30 days); NEDS

ISENTRESS ORAL PACKET Tier-3

ISENTRESS ORAL TABLET Tier-5 QL (120 EA per 30 days); NEDS

ISENTRESS ORAL TABLET CHEWABLE 100 MG

Tier-5 QL (180 EA per 30 days); NEDS

ISENTRESS ORAL TABLET CHEWABLE 25 MG

Tier-3 QL (720 EA per 30 days)

JULUCA Tier-5 NEDS

KALETRA ORAL SOLUTION Tier-5 NEDS

KALETRA ORAL TABLET 100-25 MG Tier-3

KALETRA ORAL TABLET 200-50 MG Tier-5 NEDS

lamivudine Tier-2

lamivudine-zidovudine Tier-2

LEXIVA ORAL SUSPENSION Tier-3

LEXIVA ORAL TABLET Tier-5 NEDS

lopinavir-ritonavir Tier-3

MAVYRET Tier-5 PA; SP-CVS specialty; NEDS

nevirapine Tier-2


Drug Name Drug Tier Requirements/Limitsnevirapine er Tier-2

NORVIR Tier-3

ODEFSEY Tier-5 NEDS

oseltamivir phosphate oral capsule 30 mg Tier-1 QL (56 EA per 180 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg Tier-1 QL (28 EA per 180 days)

oseltamivir phosphate oral suspension reconstituted

Tier-1 QL (750 ML per 30 days)

PEGASYS Tier-5SP-CVS specialty; QL (4 ML per 28 days); NEDS

PEGASYS PROCLICK Tier-5SP-CVS specialty; QL (4 ML per 28 days); NEDS

PREVYMIS Tier-5 PA; NEDS

PREZCOBIX Tier-5 NEDS

PREZISTA Tier-5 NEDS

REBETOL Tier-3 SP-CVS specialty

RELENZA DISKHALER Tier-3 QL (60 EA per 180 days)

RESCRIPTOR Tier-3

REYATAZ Tier-5 NEDS

ribasphere Tier-2 SP-CVS specialty

RIBASPHERE RIBAPAK Tier-5 SP-CVS specialty; NEDS

ribavirin Tier-2 SP-CVS specialty

rimantadine hcl Tier-2

ritonavir Tier-3

SELZENTRY ORAL SOLUTION Tier-4 QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET 150 MG Tier-5 QL (60 EA per 30 days); NEDS

SELZENTRY ORAL TABLET 25 MG Tier-4 QL (120 EA per 30 days)

SELZENTRY ORAL TABLET 300 MG Tier-5 QL (120 EA per 30 days); NEDS

SELZENTRY ORAL TABLET 75 MG Tier-4 QL (60 EA per 30 days)

SOVALDI Tier-5 PA; SP-CVS specialty; NEDS

stavudine Tier-2

STRIBILD Tier-5 NEDS

SUSTIVA ORAL CAPSULE 200 MG Tier-5 NEDS

SUSTIVA ORAL CAPSULE 50 MG Tier-3

SUSTIVA ORAL TABLET Tier-5 NEDS

SYMFI LO Tier-5 NEDS

TAMIFLU ORAL SOLUTION Tier-3 QL (360 ML per 180 days)

tenofovir disoproxil fumarate Tier-5 NEDS

TIVICAY ORAL TABLET 10 MG Tier-4


Drug Name Drug Tier Requirements/LimitsTIVICAY ORAL TABLET 25 MG, 50 MG Tier-5 NEDS

TRIUMEQ Tier-5 NEDS

TRUVADA Tier-5 NEDS

TYBOST Tier-3

valacyclovir hcl Tier-3

valganciclovir hcl Tier-5 NEDS

VEMLIDY Tier-5 NEDS

VIDEX Tier-3

VIDEX EC Tier-3

VIRACEPT ORAL TABLET 250 MG Tier-3

VIRACEPT ORAL TABLET 625 MG Tier-5 NEDS

VIRAMUNE SUSPENSION Tier-3

VIREAD Tier-5 NEDS

VOSEVI Tier-5 PA; SP-CVS specialty; NEDS

ZEPATIER Tier-5 PA; SP-CVS specialty; NEDS

ZERIT Tier-3

ZIAGEN Tier-3

zidovudine Tier-2

BETA-LACTAM ANTIBIOTICS

amoxicillin Tier-1

amoxicillin-pot clavulanate Tier-2

amoxicillin-pot clavulanate er Tier-2

ampicillin Tier-2

BICILLIN C-R Tier-3

BICILLIN C-R 900/300 Tier-3

BICILLIN L-A Tier-3

cefaclor Tier-2

cefaclor er Tier-2

cefadroxil Tier-2

cefdinir Tier-2

cefixime Tier-2

cefpodoxime proxetil Tier-2

cefprozil Tier-2

cefuroxime axetil Tier-2

cephalexin oral capsule Tier-1

cephalexin oral suspension reconstituted Tier-2

cephalexin oral tablet Tier-2


Drug Name Drug Tier Requirements/Limitsdicloxacillin sodium Tier-3

penicillin v potassium Tier-1

SUPRAX Tier-4

MACROLIDES AND CLINDAMYCINazithromycin oral packet Tier-2

azithromycin oral suspension reconstituted Tier-2

azithromycin oral tablet Tier-1

clarithromycin Tier-2

clarithromycin er Tier-2

clindamycin capsules Tier-1

clindamycin oral solution Tier-3

DIFICID Tier-5 PA; NEDS

e.e.s. 400 Tier-2

E.E.S. GRANULES Tier-4

eryped 200 Tier-2

eryped 400 Tier-2

ERY-TAB Tier-4

erythrocin stearate Tier-3

erythromycin base oral capsule delayed release particles

Tier-2

erythromycin base oral tablet Tier-3

erythromycin ethylsuccinate oral suspension reconstituted

Tier-3

erythromycin ethylsuccinate oral tablet Tier-2

PCE Tier-4

MYCOBACTERIAL INFECTIONSethambutol hcl Tier-2

isoniazid oral syrup Tier-2

isoniazid oral tablet Tier-1

PASER Tier-4

PRIFTIN Tier-3

pyrazinamide Tier-2

rifabutin Tier-2

RIFAMATE Tier-4

rifampin Tier-2

RIFATER Tier-4

SIRTURO Tier-5 PA; NEDS

TRECATOR Tier-4


Drug Name Drug Tier Requirements/LimitsQUINOLONESBAXDELA Tier-5 NEDS

ciprofloxacin Tier-2

ciprofloxacin hcl Tier-1

ciprofloxacin-ciproflox hcl er Tier-2

levofloxacin oral solution Tier-3

levofloxacin oral tablet Tier-1

moxifloxacin hcl Tier-3

ofloxacin Tier-2

SULFONAMIDES

sulfadiazine Tier-2

sulfamethoxazole-trimethoprim oral suspension Tier-2

sulfamethoxazole-trimethoprim oral tablet Tier-1

TETRACYCLINESdemeclocycline hcl Tier-2

doxycycline hyclate oral capsule 100 mg Tier-3

doxycycline hyclate oral capsule 50 mg Tier-1

doxycycline hyclate oral tablet 100 mg, 150 mg, 75 mg

Tier-3

doxycycline hyclate oral tablet 20 mg Tier-1

doxycycline hyclate oral tablet delayed release100 mg

Tier-3

doxycycline hyclate oral tablet delayed release150 mg, 200 mg, 50 mg, 75 mg

Tier-1

doxycycline monohydrate oral capsule Tier-1

doxycycline monohydrate oral suspension reconstituted

Tier-2

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg

Tier-1

doxycycline monohydrate oral tablet 150 mg Tier-3

minocycline hcl Tier-3

minocycline hcl er Tier-3

tetracycline hcl Tier-3

VIBRAMYCIN Tier-4

BLOOD MODIFYING AGENTSANTIPLATELET THERAPYanagrelide hcl Tier-2

aspirin-dipyridamole er Tier-3


Drug Name Drug Tier Requirements/LimitsBRILINTA Tier-4

cilostazol Tier-2

clopidogrel bisulfate Tier-1

dipyridamole Tier-2 PA

EFFIENT Tier-4

prasugrel hcl Tier-3

ZONTIVITY Tier-4

BLOOD CELL STIMULATORSLEUKINE Tier-5 SP-CVS specialty; NEDS

MOZOBIL Tier-5 NEDS

NEULASTA Tier-5SP-CVS specialty; QL (1 ML per 14 days); NEDS

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Tier-3SP-CVS specialty; QL (10 ML per 14 days)

PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML

Tier-5SP-CVS specialty; QL (10 ML per 14 days); NEDS

PROMACTA Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

ZARXIO Tier-5SP-CVS specialty; QL (10 ML per 14 days); NEDS

BLOOD THINNERSCOUMADIN Tier-4

ELIQUIS Tier-3

ELIQUIS STARTER PACK Tier-3

enoxaparin sodium Tier-3

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Tier-5 NEDS

fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml

Tier-2

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

Tier-5 NEDS

FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML

Tier-3

jantoven Tier-1

PRADAXA Tier-4

warfarin sodium Tier-1

XARELTO Tier-3


Drug Name Drug Tier Requirements/LimitsXARELTO STARTER PACK Tier-3

BLOOD, MISCELLANEOUSpentoxifylline er Tier-2

STIMATE Tier-4

tranexamic acid Tier-2

CANCER DRUGSINJECTABLE AGENTSABRAXANE Tier-5 NEDS

ALIMTA Tier-5 NEDS

ALIQOPA Tier-5 PA; NEDS

ALKERAN Tier-5 NEDS

ARRANON Tier-5 NEDS

AVASTIN Tier-5 NEDS

azacitidine Tier-5 NEDS

BAVENCIO Tier-5 NEDS

BELEODAQ Tier-5 NEDS

BICNU Tier-5 NEDS

bleomycin sulfate Tier-2 PA

bortezomib Tier-5 NEDS

busulfan Tier-2

CAMPTOSAR Tier-3

carboplatin Tier-2

cisplatin Tier-2

cladribine Tier-2 PA

clofarabine Tier-2

CLOLAR Tier-5 NEDS

COSMEGEN Tier-5 NEDS

CYRAMZA Tier-3 PA

cytarabine Tier-2 PA

cytarabine (pf) Tier-2 PA

dacarbazine Tier-2

DACOGEN Tier-5 NEDS

dactinomycin Tier-5 NEDS

DARZALEX Tier-5 NEDS

daunorubicin hcl Tier-2

decitabine Tier-5 NEDS

dexrazoxane Tier-2


Drug Name Drug Tier Requirements/Limitsdocetaxel Tier-5 NEDS

doxorubicin hcl Tier-2

doxorubicin hcl liposomal Tier-2

ELITEK Tier-5 NEDS

ELLENCE Tier-5 NEDS

EMPLICITI Tier-5 NEDS

epirubicin hcl Tier-2

ERBITUX Tier-5 NEDS

ERWINAZE Tier-5 NEDS

ETOPOPHOS Tier-5 NEDS

etoposide Tier-2

FASLODEX Tier-5 NEDS

fludarabine phosphate Tier-2

fluorouracil Tier-2 PA

ganciclovir sodium Tier-2 PA

gemcitabine hcl Tier-5 NEDS

HALAVEN Tier-5 NEDS

HERCEPTIN Tier-5 NEDS

idarubicin hcl Tier-2

ifosfamide Tier-2

IMFINZI Tier-5 NEDS

irinotecan hcl Tier-2

ISTODAX (OVERFILL) Tier-5 NEDS

JEVTANA Tier-5 NEDS

KADCYLA Tier-5 PA; NEDS

KEYTRUDA Tier-5 NEDS

LARTRUVO Tier-5 NEDS

melphalan hcl Tier-2

mitomycin Tier-2

mitoxantrone hcl Tier-2

MUSTARGEN Tier-5 NEDS

MYLOTARG Tier-5 NEDS

OPDIVO Tier-5 NEDS

oxaliplatin Tier-2

paclitaxel Tier-2

PERJETA Tier-5 PA; NEDS

PROLEUKIN Tier-5 NEDS


Drug Name Drug Tier Requirements/LimitsRITUXAN Tier-5 PA; NEDS

SYLATRON Tier-5SP-CVS specialty; QL (4 EA per 28 days); NEDS

SYNRIBO Tier-5 NEDS

TECENTRIQ Tier-5 NEDS

thiotepa Tier-5 NEDS

topotecan hcl Tier-5 NEDS

TORISEL Tier-5 NEDS

TREANDA Tier-5 NEDS

TRISENOX Tier-4

VECTIBIX Tier-5 NEDS

VELCADE Tier-5 NEDS

vinblastine sulfate Tier-2 PA

vincasar pfs Tier-2 PA

vincristine sulfate Tier-2 PA

vinorelbine tartrate Tier-2

VYXEOS Tier-5 NEDS

YERVOY Tier-5 NEDS

YONDELIS Tier-5 NEDS

ZALTRAP Tier-5 NEDS

ZANOSAR Tier-5 NEDS

ORAL AGENTS

AFINITOR Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

AFINITOR DISPERZ Tier-5PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

ALECENSA Tier-5 PA; SP-CVS specialty; NEDS

ALKERAN Tier-3 Part B

ALUNBRIG Tier-5 PA; SP-CVS specialty; NEDS

anastrozole Tier-1

bexarotene Tier-2 SP-CVS specialty

bicalutamide Tier-2

BOSULIF ORAL TABLET 100 MG Tier-5PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

BOSULIF ORAL TABLET 400 MG, 500 MG Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

CABOMETYX Tier-5 PA; SP-CVS specialty; NEDS

CALQUENCE Tier-5 PA; NEDS


Drug Name Drug Tier Requirements/Limitscapecitabine Tier-2 Part B; SP-CVS specialty

CAPRELSA ORAL TABLET 100 MG Tier-5PA; QL (60 EA per 30 days); NEDS

CAPRELSA ORAL TABLET 300 MG Tier-5PA; QL (30 EA per 30 days); NEDS

COMETRIQ (100 MG DAILY DOSE) Tier-5 PA; NEDS



COTELLIC Tier-5 PA; SP-CVS specialty; NEDS

CYCLOPHOSPHAMIDE Tier-3 B vs D; SP-CVS specialty

DROXIA Tier-3

EMCYT Tier-3 SP-CVS specialty

ERIVEDGE Tier-5 PA; SP-CVS specialty; NEDS

ERLEADA Tier-5 PA; NEDS

etoposide Tier-2 Part B; SP-CVS specialty

exemestane Tier-2

FARESTON Tier-3

FARYDAK Tier-5 PA; SP-CVS specialty; NEDS

flutamide Tier-2

GILOTRIF Tier-5 PA; NEDS

GLEOSTINE Tier-4 SP-CVS specialty

HEXALEN Tier-5 NEDS

HYCAMTIN Tier-3 Part B; SP-CVS specialty

hydroxyurea Tier-2

IBRANCE Tier-5 PA; SP-CVS specialty; NEDS

ICLUSIG Tier-5 PA; NEDS

IDHIFA Tier-5PA; QL (30 EA per 30 days); NEDS

imatinib mesylate Tier-5 SP-CVS specialty; NEDS

IMBRUVICA Tier-5 PA; NEDS

INLYTA Tier-5 PA; SP-CVS specialty; NEDS

IRESSA Tier-5 PA; NEDS

JAKAFI Tier-5 PA; SP-CVS specialty; NEDS

KISQALI 200 DOSE Tier-5 PA; SP-CVS specialty; NEDS



KISQALI FEMARA 200 DOSE Tier-5 PA; SP-CVS specialty; NEDS

KISQALI FEMARA 400 DOSE Tier-5 PA; SP-CVS specialty; NEDS


Drug Name Drug Tier Requirements/LimitsKISQALI FEMARA 600 DOSE Tier-5 PA; SP-CVS specialty; NEDS

KYPROLIS Tier-5 NEDS

LENVIMA 10 MG DAILY DOSE Tier-5 PA; NEDS






letrozole Tier-1

LEUKERAN Tier-3

LONSURF Tier-5 PA; SP-CVS specialty; NEDS

LYNPARZA Tier-5 PA; NEDS

LYSODREN Tier-3

MATULANE Tier-5 NEDS

megestrol acetate Tier-1 PA

MEKINIST Tier-5 PA; SP-CVS specialty; NEDS

melphalan Tier-2 Part B

mercaptopurine Tier-2

MYLERAN Tier-3 Part B

NERLYNX Tier-5 PA; NEDS

NEXAVAR Tier-5PA; SP-CVS specialty; QL (220 EA per 30 days); NEDS

nilutamide Tier-5 NEDS

NINLARO Tier-5 PA; SP-CVS specialty; NEDS

ODOMZO Tier-5 PA; SP-CVS specialty; NEDS

POMALYST Tier-5 PA; SP-CVS specialty; NEDS

PURIXAN Tier-5 NEDS

REVLIMID Tier-5 PA; SP-CVS specialty; NEDS

RUBRACA Tier-5PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

RYDAPT Tier-5 PA; SP-CVS specialty; NEDS

SOLTAMOX Tier-3

SPRYCEL ORAL TABLET 100 MG, 140 MG Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG

Tier-5PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

STIVARGA Tier-5PA; SP-CVS specialty; QL (90 EA per 30 days); NEDS

SUTENT Tier-5 PA; SP-CVS specialty; NEDS


Drug Name Drug Tier Requirements/LimitsTABLOID Tier-3 SP-CVS specialty

TAFINLAR Tier-5 PA; SP-CVS specialty; NEDS

TAGRISSO Tier-5 PA; NEDS

tamoxifen citrate Tier-2

TARCEVA ORAL TABLET 100 MG Tier-5SP-CVS specialty; QL (90 EA per 30 days); NEDS

TARCEVA ORAL TABLET 150 MG, 25 MG Tier-5SP-CVS specialty; QL (30 EA per 30 days); NEDS

TARGRETIN Tier-5 SP-CVS specialty; NEDS

TASIGNA Tier-5 PA; SP-CVS specialty; NEDS

temozolomide Tier-3 Part B; SP-CVS specialty

THALOMID Tier-5 SP-CVS specialty; NEDS

tretinoin Tier-2 SP-CVS specialty

TYKERB Tier-5PA; SP-CVS specialty; QL (180 EA per 30 days); NEDS

VENCLEXTA ORAL TABLET 10 MG, 50 MG Tier-4 PA

VENCLEXTA ORAL TABLET 100 MG Tier-5 PA; NEDS

VENCLEXTA STARTING PACK Tier-5 PA; NEDS

VERZENIO Tier-5 PA; NEDS

VOTRIENT Tier-5PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

XALKORI Tier-5 PA; SP-CVS specialty; NEDS

XTANDI Tier-5PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

ZEJULA Tier-5 PA; NEDS

ZELBORAF Tier-5 PA; SP-CVS specialty; NEDS

ZOLINZA Tier-5 PA; SP-CVS specialty; NEDS

ZURAMPIC Tier-4 PA

ZYDELIG Tier-5 PA; NEDS

ZYKADIA Tier-5 PA; SP-CVS specialty; NEDS

ZYTIGA ORAL TABLET 250 MG Tier-5PA; SP-CVS specialty; QL (120 EA per 30 days); NEDS

ZYTIGA ORAL TABLET 500 MG Tier-5 PA; SP-CVS specialty; NEDS

PROTECTIVE AGENTSFUSILEV Tier-5 NEDS

leucovorin calcium Tier-2

levoleucovorin calcium Tier-5 NEDS

mesna Tier-2

MESNEX Tier-5 NEDS



XURIDEN Tier-5PA; QL (120 EA per 30 days); NEDS

ZINECARD Tier-3

CARDIOVASCULAR AGENTSACE INHIBITORSbenazepril hcl Tier-1

captopril Tier-1

enalapril maleate Tier-2

fosinopril sodium Tier-1

lisinopril Tier-1

moexipril hcl Tier-1

perindopril erbumine Tier-1

quinapril hcl Tier-1

ramipril Tier-1

trandolapril Tier-1

ALPHA1 BLOCKERSCARDURA XL Tier-4

doxazosin mesylate Tier-1

prazosin hcl Tier-1

terazosin hcl Tier-1

ANGINA

CORLANOR Tier-4 PA

isosorbide dinitrate Tier-1

isosorbide dinitrate er Tier-1

isosorbide mononitrate Tier-2

isosorbide mononitrate er Tier-2

NITRO-BID Tier-4

nitroglycerin intravenous Tier-2

nitroglycerin sublingual Tier-2

nitroglycerin transdermal Tier-2

nitroglycerin translingual Tier-3

NITROSTAT Tier-3

RANEXA Tier-3

ANGIOTENSIN II RECEPTOR BLOCKERScandesartan cilexetil Tier-1

eprosartan mesylate Tier-1


Drug Name Drug Tier Requirements/Limitsirbesartan Tier-1

losartan potassium Tier-1

olmesartan medoxomil Tier-3

telmisartan Tier-3

valsartan Tier-2

ANTI-ARRHYTHMICS AND CARDIAC GLYCOSIDESamiodarone hcl Tier-2

digitek oral tablet 125 mcg Tier-1

digitek oral tablet 250 mcg Tier-1 PA

digox oral tablet 125 mcg Tier-1

digox oral tablet 250 mcg Tier-1 PA

digoxin injection Tier-1

digoxin oral solution Tier-1 PA

digoxin oral tablet 125 mcg Tier-1

digoxin oral tablet 250 mcg Tier-1 PA

disopyramide phosphate Tier-2 PA

dofetilide Tier-3

flecainide acetate Tier-2

LANOXIN ORAL TABLET 125 MCG, 62.5 MCG

Tier-4

LANOXIN TABLET 187.5 MCG, 250 MCG Tier-4 PA

mexiletine hcl Tier-2

MULTAQ Tier-4

NORPACE CR Tier-4 PA

propafenone hcl Tier-2

propafenone hcl er Tier-3

quinidine gluconate er Tier-2

quinidine sulfate Tier-2

sorine Tier-2

sotalol hcl Tier-1

sotalol hcl (af) Tier-1

SOTYLIZE Tier-4

ANTIHYPERTENSIVE FIXED-DOSE COMBINATION PRODUCTSamlodipine besy-benazepril hcl Tier-1

amlodipine besylate-valsartan Tier-3

amlodipine-atorvastatin Tier-3


Drug Name Drug Tier Requirements/Limitsamlodipine-olmesartan Tier-3

amlodipine-valsartan-hctz Tier-3

atenolol-chlorthalidone Tier-1

benazepril-hydrochlorothiazide Tier-1

bisoprolol-hydrochlorothiazide Tier-1

candesartan cilexetil-hctz Tier-1

captopril-hydrochlorothiazide Tier-1

DUTOPROL Tier-4

enalapril-hydrochlorothiazide Tier-1

ENTRESTO Tier-4 PA

fosinopril sodium-hctz Tier-1

irbesartan-hydrochlorothiazide Tier-2

lisinopril-hydrochlorothiazide Tier-1

losartan potassium-hctz Tier-1

metoprolol-hydrochlorothiazide Tier-2

moexipril-hydrochlorothiazide Tier-1

nadolol-bendroflumethiazide Tier-2

olmesartan medoxomil-hctz Tier-3

olmesartan-amlodipine-hctz Tier-3

propranolol-hctz Tier-2

quinapril-hydrochlorothiazide Tier-2

TEKTURNA HCT Tier-3

telmisartan-amlodipine Tier-1

telmisartan-hctz Tier-3

trandolapril-verapamil hcl er Tier-2

valsartan-hydrochlorothiazide Tier-2

BETA AND ALPHA BLOCKERScarvedilol Tier-1

carvedilol phosphate er Tier-3

COREG CR Tier-4

labetalol hcl Tier-2

BETA BLOCKERSacebutolol hcl Tier-2

atenolol Tier-1

betaxolol hcl Tier-2

bisoprolol fumarate Tier-2

metoprolol succinate er Tier-2


Drug Name Drug Tier Requirements/Limitsmetoprolol tartrate Tier-1

nadolol Tier-3

pindolol Tier-2

propranolol hcl er Tier-2

propranolol hcl oral solution Tier-2

propranolol hcl oral tablet Tier-1

timolol maleate Tier-2

CALCIUM CHANNEL BLOCKERSafeditab cr Tier-2

amlodipine besylate Tier-1

cartia xt Tier-2

diltiazem hcl Tier-1

diltiazem hcl er Tier-2

diltiazem hcl er beads Tier-2

diltiazem hcl er coated beads Tier-2

dilt-xr Tier-2

felodipine er Tier-2

isradipine Tier-2

matzim la Tier-2

nicardipine hcl Tier-2

nifedipine Tier-2 PA

nifedipine er Tier-2

nifedipine er osmotic release Tier-2

nimodipine Tier-2

nisoldipine er Tier-2

NYMALIZE Tier-5 NEDS

taztia xt Tier-2

verapamil hcl Tier-1

verapamil hcl er Tier-1

CENTRALLY ACTING AGENTS

clonidine hcl oral Tier-1

clonidine hcl transdermal Tier-2

midodrine hcl Tier-2

NORTHERA Tier-5 PA; NEDS

DIRECT RENIN INHIBITORSTEKTURNA Tier-3


Drug Name Drug Tier Requirements/LimitsDIURETICSamiloride hcl Tier-2

amiloride-hydrochlorothiazide Tier-1

bumetanide Tier-1

CAROSPIR Tier-4

chlorothiazide Tier-2

chlorthalidone Tier-1

EDECRIN Tier-3

eplerenone Tier-2

ethacrynic acid Tier-3

furosemide oral solution Tier-2

furosemide oral tablet Tier-1

hydrochlorothiazide Tier-1

indapamide Tier-1

methyclothiazide Tier-2

metolazone Tier-2

spironolactone Tier-1

spironolactone-hctz Tier-2

torsemide Tier-2

triamterene-hctz Tier-1

LIPID LOWERING AGENTSatorvastatin calcium Tier-1

cholestyramine light Tier-2

colestipol hcl Tier-2

ezetimibe Tier-3

ezetimibe-simvastatin Tier-3

fenofibrate Tier-2

fenofibrate micronized Tier-3

fenofibric acid Tier-3

FLOLIPID Tier-3

fluvastatin sodium Tier-3

fluvastatin sodium er Tier-3

gemfibrozil Tier-1

JUXTAPID Tier-5 PA; NEDS

KYNAMRO Tier-5 PA; SP-CVS specialty; NEDS

lovastatin Tier-1

niacin er Tier-3


Drug Name Drug Tier Requirements/Limitsniacor Tier-2

omega-3-acid ethyl esters Tier-3

pravastatin sodium Tier-2

PREVALITE Tier-4

REPATHA Tier-5 PA; SP-CVS specialty; NEDS

REPATHA PUSHTRONEX SYSTEM Tier-5 PA; SP-CVS specialty; NEDS

REPATHA SURECLICK Tier-5 PA; SP-CVS specialty; NEDS

rosuvastatin calcium Tier-3

simvastatin Tier-1

VASCEPA Tier-3

WELCHOL Tier-4

POTASSIUM REPLACEMENTklor-con Tier-1

klor-con 10 Tier-1

klor-con m10 Tier-1

KLOR-CON M15 Tier-4

klor-con m20 Tier-1

klor-con sprinkle Tier-1

K-TAB Tier-4

potassium chloride Tier-1

potassium chloride crys er Tier-1

potassium chloride er Tier-1

VASODILATORSBIDIL Tier-3

hydralazine hcl Tier-1

minoxidil Tier-2

DIABETES MELLITUSDIABETIC SUPPLIESassure insulin safety syringe Tier-2

comfort assist insulin syringe Tier-2

cvs gauze sterile Tier-2

exel comfort point pen needle Tier-2

gauze pads Tier-2

global alcohol prep ease Tier-2

insulin syringe Tier-2

INSULIN SYRINGE Tier-3

lancets Tier-2 Part B


Drug Name Drug Tier Requirements/LimitsONETOUCH ULTRA BLUE Tier-3 Part B

preferred plus insulin syringe Tier-2

RELI-ON INSULIN SYRINGE Tier-3

GLUCOSE ELEVATINGGLUCAGEN HYPOKIT Tier-3

GLUCAGON EMERGENCY Tier-3

PROGLYCEM Tier-4

INSULINSHUMALOG Tier-3

HUMALOG JUNIOR KWIKPEN Tier-3

HUMALOG KWIKPEN Tier-3

HUMALOG MIX 50/50 Tier-3

HUMALOG MIX 50/50 KWIKPEN Tier-3

HUMALOG MIX 75/25 Tier-3

HUMALOG MIX 75/25 KWIKPEN Tier-3

HUMULIN 70/30 Tier-3

HUMULIN 70/30 KWIKPEN Tier-3

HUMULIN N Tier-3

HUMULIN N KWIKPEN Tier-3

HUMULIN R Tier-3

HUMULIN R U-500 (CONCENTRATED) Tier-3

HUMULIN R U-500 KWIKPEN Tier-3

LANTUS Tier-3

LANTUS SOLOSTAR Tier-3

TOUJEO MAX SOLOSTAR Tier-3

TOUJEO SOLOSTAR Tier-3

NON-INSULIN INJECTABLESBYDUREON Tier-3

BYDUREON BCISE Tier-3

BYETTA 10 MCG PEN Tier-4

BYETTA 5 MCG PEN Tier-4

OZEMPIC Tier-3

SYMLINPEN 120 Tier-3

SYMLINPEN 60 Tier-3

TRULICITY Tier-3

VICTOZA Tier-3


Drug Name Drug Tier Requirements/LimitsORAL AGENTSacarbose Tier-1

ACTOPLUS MET XR Tier-4

chlorpropamide Tier-1 PA

glimepiride Tier-1

glipizide Tier-1

glipizide er Tier-1

glipizide-metformin hcl Tier-1

glyburide Tier-2 PA

glyburide micronized Tier-1 PA

glyburide-metformin Tier-1 PA

INVOKAMET Tier-3

INVOKAMET XR Tier-3

INVOKANA Tier-3

JANUMET Tier-3

JANUMET XR Tier-3

JANUVIA Tier-3

JARDIANCE Tier-3

JENTADUETO Tier-3

JENTADUETO XR Tier-3

metformin hcl Tier-1

metformin hcl er Tier-1

metformin hcl er 1,000 mg Tier-1

miglitol Tier-3

nateglinide Tier-1

pioglitazone hcl Tier-1

pioglitazone hcl-glimepiride Tier-2

pioglitazone hcl-metformin hcl Tier-3

repaglinide Tier-1

repaglinide-metformin hcl Tier-3

RIOMET Tier-3

SYNJARDY Tier-3

tolazamide Tier-1

tolbutamide Tier-1

TRADJENTA Tier-3



EAR, NOSE AND THROATEARacetic acid Tier-2

CIPRO HC Tier-3

CIPRODEX Tier-3

fluocinolone acetonide Tier-2

hydrocortisone-acetic acid Tier-2

ofloxacin Tier-3

MOUTH AND THROAT

cevimeline hcl Tier-2

chlorhexidine gluconate Tier-1

periogard Tier-1

pilocarpine hcl Tier-2

triamcinolone acetonide Tier-2

NOSEazelastine hcl Tier-2 QL (120 ML per 90 days)

BACTROBAN NASAL Tier-4

cyproheptadine hcl Tier-2 PA

desloratadine Tier-2

flunisolide Tier-3 QL (150 ML per 90 days)

fluticasone propionate Tier-1 QL (48 GM per 90 days)

hydroxyzine hcl Tier-2 PA

hydroxyzine pamoate Tier-2 PA

ipratropium bromide nasal solution 0.03 % Tier-2 QL (180 ML per 90 days)

ipratropium bromide nasal solution 0.06 % Tier-2 QL (90 ML per 90 days)

levocetirizine dihydrochloride Tier-2

mometasone furoate Tier-3 QL (102 GM per 90 days)

olopatadine hcl Tier-2 QL (91.5 GM per 90 days)


EYEALLERGYALOCRIL Tier-4

ALOMIDE Tier-4

azelastine hcl Tier-2

cromolyn sodium Tier-2

EMADINE Tier-4

epinastine hcl Tier-2


Drug Name Drug Tier Requirements/LimitsLASTACAFT Tier-4

olopatadine hcl Tier-3

ANTI-INFECTIVESAZASITE Tier-4

bacitracin Tier-2

bacitracin-polymyxin b Tier-2

bacitra-neomycin-polymyxin-hc Tier-2

BESIVANCE Tier-3

BLEPHAMIDE Tier-4

BLEPHAMIDE S.O.P. Tier-4

ciprofloxacin hcl Tier-2

COLY-MYCIN S Tier-4

erythromycin Tier-2

gatifloxacin Tier-2

gentak Tier-2

gentamicin sulfate Tier-3

levofloxacin Tier-2

MOXEZA Tier-4

moxifloxacin hcl Tier-3

neomycin-bacitracin zn-polymyx Tier-2

neomycin-polymyxin-hc Tier-2

ofloxacin Tier-2

polymyxin b-trimethoprim Tier-2

sulfacetamide sodium Tier-2

sulfacetamide-prednisolone Tier-2

TOBRADEX Tier-4

TOBRADEX ST Tier-4

tobramycin Tier-2

tobramycin-dexamethasone Tier-2

VIGAMOX Tier-3

ANTI-INFLAMMATORIESALREX Tier-3

dexamethasone sodium phosphate Tier-2

diclofenac sodium Tier-2

DUREZOL Tier-3

FLAREX Tier-4

fluorometholone Tier-2


Drug Name Drug Tier Requirements/Limitsflurbiprofen sodium Tier-1

FML Tier-3

FML FORTE Tier-4

ILEVRO Tier-4

ketorolac tromethamine Tier-2

LOTEMAX Tier-3

MAXIDEX Tier-4

neomycin-polymyxin-dexameth Tier-2

neomycin-polymyxin-gramicidin Tier-2

neomycin-polymyxin-hc Tier-2

NEVANAC Tier-4

PRED MILD Tier-3

PRED-G Tier-3

PRED-G S.O.P. Tier-3

prednisolone acetate Tier-3

prednisolone sodium phosphate Tier-2

PROLENSA Tier-4

ZYLET Tier-4

ANTIVIRALS

trifluridine Tier-2

ZIRGAN Tier-4

GLAUCOMAacetazolamide Tier-2

acetazolamide er Tier-2

ALPHAGAN P 0.1% Tier-3

apraclonidine hcl Tier-2

AZOPT Tier-3

betaxolol hcl Tier-2

BETIMOL Tier-3

BETOPTIC-S Tier-3

bimatoprost Tier-2

brimonidine tartrate Tier-2

carteolol hcl Tier-1

COMBIGAN Tier-3

dorzolamide hcl Tier-2

dorzolamide hcl-timolol mal Tier-2

IOPIDINE Tier-4


Drug Name Drug Tier Requirements/Limitslatanoprost Tier-2

levobunolol hcl Tier-2

LUMIGAN Tier-3

methazolamide Tier-2

metipranolol Tier-2

PHOSPHOLINE IODIDE Tier-3

pilocarpine hcl Tier-2

SIMBRINZA Tier-4

timolol maleate ophthalmic gel forming solution Tier-3

timolol maleate ophthalmic solution 0.25 %, 0.5 %

Tier-1

timolol maleate ophthalmic solution 0.5 % (daily) Tier-3

TRAVATAN Z Tier-3

VYZULTA Tier-4 PA

OPHTHALMIC DRUGS, MISCELLANEOUSatropine sulfate Tier-2

CYSTARAN Tier-3

NATACYN Tier-4

proparacaine hcl Tier-2

RESTASIS Tier-3

GASTROINTESTINAL DRUGSEMESISALOXI Tier-5 NEDS

ANZEMET Tier-3 B vs D

aprepitant Tier-3 B vs D

CESAMET Tier-3 B vs D

CINVANTI Tier-3

compro Tier-2

dronabinol Tier-3 B vs D

EMEND Tier-3 B vs D

granisetron hcl Tier-2 B vs D

meclizine hcl Tier-2

metoclopramide hcl Tier-2

ondansetron Tier-2 B vs D

ondansetron hcl Tier-2 B vs D

PALONOSETRON HCL Tier-4


Drug Name Drug Tier Requirements/Limitsprochlorperazine Tier-2

prochlorperazine maleate Tier-2

promethazine hcl Tier-2 PA

SANCUSO Tier-4

scopolamine Tier-3

TRANSDERM-SCOP PATCH Tier-4

VARUBI Tier-4 B vs D

ENZYMESCARBAGLU Tier-5 PA; NEDS

CREON Tier-3

CYSTAGON Tier-4

ZENPEP Tier-4

GASTROINTESTINAL DRUGS, MISCELLANEOUSalosetron hcl Tier-5 NEDS

CHOLBAM Tier-5 PA; NEDS

constulose Tier-2

cromolyn sodium Tier-2

dicyclomine hcl Tier-1

enulose Tier-2

GATTEX Tier-5 PA; SP-CVS specialty; NEDS

generlac Tier-2

glycopyrrolate Tier-2

KRISTALOSE Tier-3

lactulose Tier-2

levocarnitine Tier-2

loperamide hcl Tier-3

megestrol acetate Tier-2 PA

MOVANTIK Tier-3

MOVIPREP Tier-4

MYTESI Tier-3 PA

OCALIVA Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

OSMOPREP Tier-4

peg 3350-kcl-na bicarb-nacl Tier-2

peg-3350/electrolytes Tier-2

polyethylene glycol 3350 Tier-2

propantheline bromide Tier-2


Drug Name Drug Tier Requirements/LimitsRELISTOR Tier-5 NEDS

SUPREP BOWEL PREP KIT Tier-4

trilyte Tier-2

UCERIS Tier-4

ursodiol Tier-2

XERMELO Tier-5 PA; NEDS

GASTROINTESTINAL DRUGS, PEPTIC ULCER TREATMENT, REFLUX (GERD)amoxicill-clarithro-lansopraz Tier-3

CARAFATE SUSPENSION Tier-4

cimetidine Tier-3

cimetidine solution Tier-2

esomeprazole magnesium Tier-3

esomeprazole strontium Tier-3

famotidine oral suspension reconstituted Tier-2

famotidine oral tablet Tier-1

lansoprazole Tier-3

methscopolamine bromide Tier-2

misoprostol Tier-2

nizatidine Tier-2

omeprazole Tier-1

omeprazole-sodium bicarbonate Tier-4

pantoprazole sodium Tier-2

PYLERA Tier-3

rabeprazole sodium Tier-3

ranitidine hcl Tier-2

sucralfate Tier-2

INFLAMMATORY BOWEL DISEASEAMITIZA Tier-3

APRISO Tier-3

balsalazide disodium Tier-2

budesonide Tier-2

CANASA Tier-3

colocort Tier-2

DELZICOL Tier-4

hydrocortisone Tier-2

LINZESS Tier-3


Drug Name Drug Tier Requirements/Limitsmesalamine oral Tier-3

mesalamine rectal Tier-2

ROWASA Tier-4

sulfasalazine Tier-2

UCERIS Tier-5 NEDS

HOME INFUSION THERAPYACUTE CARE DRUGSABELCET Tier-5 PA; NEDS

acetazolamide sodium Tier-2

acyclovir sodium Tier-2 PA

AMBISOME Tier-5 PA; NEDS

amikacin sulfate Tier-2 HI; Part B

aminophylline Tier-2

amphotericin b Tier-2 PA

ampicillin sodium Tier-2 HI; Part B

ampicillin-sulbactam sodium Tier-2 HI; Part B

ARGATROBAN Tier-4

atropine sulfate Tier-2

AVELOX Tier-3 HI; Part B

AVYCAZ Tier-3 HI; Part B

azithromycin Tier-2 HI; Part B

aztreonam Tier-2 HI; Part B

bactocill in dextrose Tier-2 HI; Part B

benztropine mesylate Tier-2

bumetanide Tier-2

butorphanol tartrate Tier-2

calcitriol Tier-2

CANCIDAS Tier-5 NEDS

CAPASTAT SULFATE Tier-3

CARDENE IV Tier-4

caspofungin acetate Tier-5 NEDS

cefazolin sodium Tier-2 HI; Part B

cefepime hcl Tier-2 HI; Part B

cefotaxime sodium Tier-2 HI; Part B

cefotetan disodium Tier-2 HI; Part B

cefoxitin sodium Tier-2 HI; Part B

ceftazidime Tier-2 HI; Part B


Drug Name Drug Tier Requirements/Limitsceftriaxone sodium Tier-2 HI; Part B

cefuroxime sodium Tier-2 HI; Part B

chloramphenicol sod succinate Tier-2 HI; Part B

cidofovir Tier-5 NEDS

ciprofloxacin Tier-2 HI; Part B

ciprofloxacin in d5w Tier-2 HI; Part B

clindamycin phosphate Tier-2 HI; Part B

clindamycin phosphate in d5w Tier-2 HI; Part B

colistimethate sodium Tier-2 HI; Part B

colistimethate sodium (cba) Tier-2 HI; Part B

CRESEMBA Tier-5 NEDS

cyclosporine Tier-2 B vs D

DALVANCE Tier-3 HI; Part B

daptomycin Tier-2 HI; Part B

dexamethasone sodium phosphate Tier-2

diltiazem hcl Tier-2

diphenhydramine hcl Tier-2

doripenem Tier-2 HI; Part B

DOXY 100 Tier-4 HI; Part B

EMEND Tier-3

ERAXIS Tier-3

ERYTHROCIN LACTOBIONATE Tier-3 HI; Part B

esomeprazole sodium Tier-2

fluconazole in sodium chloride Tier-2

furosemide Tier-2

gentamicin in saline Tier-2 HI; Part B

gentamicin sulfate Tier-2 HI; Part B

granisetron hcl Tier-2

heparin sodium (porcine) Tier-2

hydroxyzine hcl Tier-2

imipenem-cilastatin Tier-2 HI; Part B

INVANZ Tier-3 HI; Part B

isoniazid Tier-2

labetalol hcl Tier-2

levetiracetam in nacl Tier-2

levofloxacin Tier-2 HI; Part B

levofloxacin in d5w Tier-2 HI; Part B


Drug Name Drug Tier Requirements/Limitslevothyroxine sodium Tier-2

lidocaine hcl Tier-2

lidocaine hcl (pf) Tier-2

LINCOCIN Tier-3 HI; Part B

lincomycin hcl Tier-2 HI; Part B

linezolid Tier-2 HI; Part B

meropenem Tier-2 HI; Part B

methotrexate sodium Tier-2 B vs D

methotrexate sodium (pf) Tier-2 B vs D

metoclopramide hcl Tier-2

metoprolol tartrate Tier-2

metronidazole in nacl Tier-2 HI; Part B

moxifloxacin hcl Tier-2 HI; Part B

MYCAMINE Tier-3

nafcillin sodium Tier-2 HI; Part B

ondansetron hcl Tier-2

ORBACTIV Tier-3 HI; Part B

oxacillin sodium Tier-2 HI; Part B

penicillin g pot in dextrose Tier-2 HI; Part B

penicillin g potassium Tier-2 HI; Part B

penicillin g sodium Tier-2 HI; Part B

piperacillin sod-tazobactam so Tier-2 HI; Part B

polymyxin b sulfate Tier-2 HI; Part B

prochlorperazine edisylate Tier-2

PROGRAF INJECTION Tier-3 B vs D

promethazine hcl Tier-2

RETROVIR Tier-3

rifampin Tier-2 HI; Part B

SIVEXTRO Tier-3 HI; Part B

streptomycin sulfate Tier-2 HI; Part B

sulfamethoxazole-trimethoprim Tier-2 HI; Part B

SYNERCID Tier-5 HI; Part B; NEDS

TEFLARO Tier-3 HI; Part B

tigecycline Tier-2 HI; Part B

tobramycin sulfate Tier-2 HI; Part B

TYGACIL Tier-3 HI; Part B

VABOMERE Tier-5 HI; Part B; NEDS


Drug Name Drug Tier Requirements/Limitsvalproate sodium Tier-2

vancomycin hcl Tier-2 HI; Part B

voriconazole Tier-2

ZERBAXA Tier-5 HI; Part B; NEDS

ELECTROLYTESdextrose Tier-2

dextrose in lactated ringers Tier-2

dextrose-nacl Tier-2

IONOSOL-MB IN D5W Tier-3

ISOLYTE-P IN D5W Tier-3

ISOLYTE-S Tier-3

kcl in dextrose-nacl Tier-2

kcl-lactated ringers-d5w Tier-2

lactated ringers Tier-2

magnesium sulfate Tier-2

NORMOSOL-M IN D5W Tier-3

NORMOSOL-R IN D5W Tier-3

NORMOSOL-R PH 7.4 Tier-3

PLASMA-LYTE 148 Tier-3

PLASMA-LYTE A Tier-3

potassium chloride Tier-2

potassium chloride in dextrose Tier-2

potassium chloride in nacl Tier-2

ringers Tier-2

sodium chloride Tier-2

sodium lactate Tier-2

IV NUTRITIONAMINOSYN II Tier-3 B vs D

AMINOSYN II/ELECTROLYTES Tier-3 B vs D

AMINOSYN/ELECTROLYTES Tier-3 B vs D

AMINOSYN-HBC Tier-3 B vs D

AMINOSYN-PF Tier-3 B vs D

AMINOSYN-RF Tier-3 B vs D

CLINIMIX E/DEXTROSE (2.75/10) Tier-3 B vs D





Drug Name Drug Tier Requirements/LimitsCLINIMIX E/DEXTROSE (4.25/5) Tier-3 B vs D

CLINIMIX E/DEXTROSE (5/15) Tier-3 B vs D



CLINIMIX/DEXTROSE (2.75/5) Tier-3 B vs D





CLINIMIX/DEXTROSE (5/15) Tier-3 B vs D



CLINISOL SF Tier-3 B vs D

FREAMINE HBC Tier-3 B vs D

HEPATAMINE Tier-3 B vs D

INTRALIPID Tier-3 B vs D

NEPHRAMINE Tier-3 B vs D

NUTRILIPID Tier-3 B vs D

PLENAMINE Tier-3 B vs D

PREMASOL Tier-3 B vs D

PROCALAMINE Tier-3 B vs D

PROSOL Tier-3 B vs D

tpn electrolytes Tier-2 B vs D

TRAVASOL Tier-3 B vs D

TROPHAMINE Tier-3 B vs D

HORMONESADRENAL CORTICOSTEROIDScortisone acetate Tier-2

DEPO-MEDROL Tier-3

dexamethasone intensol Tier-2

dexamethasone oral elixir Tier-2

dexamethasone oral tablet Tier-1

dexpak 13 day Tier-2

fludrocortisone acetate Tier-2

HP ACTHAR Tier-5 PA; NEDS


MEDROL Tier-4


Drug Name Drug Tier Requirements/Limitsmethylprednisolone Tier-2 Transplant

methylprednisolone acetate Tier-2 Transplant

methylprednisolone sodium succ Tier-2 Transplant

MILLIPRED Tier-4 Transplant

ORAPRED ODT Tier-4 Transplant

prednisolone Tier-2 Transplant

prednisolone sodium phosphate Tier-2 Transplant

PREDNISONE INTENSOL Tier-4 Transplant

prednisone oral solution Tier-2 Transplant

prednisone oral tablet Tier-1 Transplant

prednisone oral tablet therapy pack Tier-2 Transplant

SOLU-CORTEF Tier-4

SOLU-MEDROL Tier-4

VERIPRED 20 Tier-4 Transplant

ANDROGENSANADROL-50 Tier-4

AVEED Tier-4

danazol Tier-2

DEPO-TESTOSTERONE Tier-4

METHITEST Tier-4

methyltestosterone Tier-5 NEDS

oxandrolone Tier-2

testosterone cypionate Tier-2

testosterone enanthate Tier-2

testosterone transdermal gel Tier-3

testosterone transdermal solution Tier-2

GONADOTROPIN RELEASING AGONISTSELIGARD Tier-3

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG

Tier-5 NEDS

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

Tier-3

leuprolide acetate Tier-2

LUPRON DEPOT (1-MONTH) Tier-5 NEDS





Drug Name Drug Tier Requirements/LimitsLUPRON DEPOT-PED (1-MONTH) Tier-5 NEDS

LUPRON DEPOT-PED (3-MONTH) Tier-5 NEDS

SYNAREL Tier-5 NEDS

TRELSTAR MIXJECT Tier-5 NEDS

THYROID REPLACEMENT AND ANTITHYROID AGENTSlevo-t Tier-1

levothyroxine sodium Tier-1

levoxyl Tier-2

liothyronine sodium Tier-2

methimazole Tier-1

propylthiouracil Tier-2

SYNTHROID Tier-4

THYROLAR-1 Tier-4

THYROLAR-1/2 Tier-4

THYROLAR-1/4 Tier-4

THYROLAR-2 Tier-4

THYROLAR-3 Tier-4

TIROSINT Tier-4

TRIOSTAT Tier-3

unithroid Tier-1

IMMUNOLOGIC AGENTSIMMUNE STIMULANTSACTHIB Tier-3 Part B

ACTIMMUNE Tier-5 NEDS

ADACEL Tier-3

ADAGEN Tier-5 NEDS

bcg vaccine Tier-2

BEXSERO Tier-3

BIVIGAM Tier-5 PA; HI; Part B; NEDS

BOOSTRIX Tier-3

CARIMUNE NF Tier-5 PA; HI; Part B; NEDS

DAPTACEL Tier-3

diphtheria-tetanus toxoids dt Tier-2

ENGERIX-B Tier-3 B vs D

FLEBOGAMMA DIF Tier-5 PA; HI; Part B; NEDS

GAMASTAN S/D Tier-3 PA; HI; Part B


Drug Name Drug Tier Requirements/LimitsGAMMAGARD Tier-5 PA; HI; Part B; NEDS

GAMMAGARD S/D LESS IGA Tier-5 PA; HI; Part B; NEDS

GAMMAKED Tier-5 PA; HI; Part B; NEDS

GAMMAPLEX Tier-5 PA; HI; Part B; NEDS

GAMUNEX-C Tier-5 PA; HI; Part B; NEDS

GARDASIL 9 Tier-3

HAVRIX Tier-3

HIBERIX Tier-3

HYPERRAB S/D Tier-3

IMOGAM RABIES-HT Tier-3

IMOVAX RABIES Tier-3

INFANRIX Tier-3

IPOL Tier-3

IXIARO Tier-3

KINRIX Tier-3

MENACTRA Tier-3

MENVEO Tier-3

M-M-R II Tier-3

OCTAGAM Tier-3 PA; HI; Part B

PEDIARIX Tier-3

PEDVAX HIB Tier-3

PNEUMOVAX 23 Tier-3 Part B

PREVNAR 13 Tier-3 Part B

PRIVIGEN Tier-5 PA; HI; Part B; NEDS

PROQUAD Tier-3

QUADRACEL Tier-3

RABAVERT Tier-3

RECOMBIVAX HB Tier-3 B vs D

ROTARIX Tier-3

ROTATEQ Tier-3

SHINGRIX Tier-3

TENIVAC Tier-3

tetanus-diphtheria toxoids td Tier-2

TRUMENBA Tier-3

TWINRIX Tier-3

TYPHIM VI Tier-3

VAQTA Tier-3


Drug Name Drug Tier Requirements/LimitsVARIVAX Tier-3

VARIZIG Tier-3

YF-VAX Tier-3

ZINPLAVA Tier-5 PA; NEDS

ZOSTAVAX Tier-3

IMMUNOSUPPRESSIVESASTAGRAF XL Tier-4 B vs D

ATGAM Tier-3 B vs D

BENLYSTA Tier-5 PA; NEDS

CELLCEPT Tier-5 B vs D; NEDS

cyclosporine Tier-2 B vs D

cyclosporine modified Tier-2 B vs D

ENVARSUS XR Tier-4 B vs D; SP-CVS specialty

gengraf Tier-2 B vs D

mycophenolate mofetil Tier-2 B vs D

mycophenolate mofetil hcl Tier-2 B vs D

mycophenolate sodium Tier-2 B vs D

NULOJIX Tier-5 B vs D; NEDS

RAPAMUNE ORAL SOLUTION Tier-3 B vs D

SIMULECT Tier-5 B vs D; NEDS

sirolimus Tier-2 B vs D

tacrolimus Tier-2 B vs D

THYMOGLOBULIN Tier-3 B vs D

ZORTRESS Tier-5B vs D; QL (60 EA per 30 days); NEDS

MISCELLANEOUS DRUGSACROMEGALYoctreotide acetate Tier-2

SANDOSTATIN LAR DEPOT Tier-5 NEDS

SIGNIFOR LAR Tier-5 PA; QL (2 EA per 28 days); NEDS

SOMATULINE DEPOT Tier-5 NEDS

SOMAVERT Tier-5 PA; SP-CVS specialty; NEDS

AMYOTROPHIC LATERAL SCLEROSISRADICAVA Tier-5 PA; NEDS

riluzole Tier-3


Drug Name Drug Tier Requirements/LimitsANAPHYLAXIS EMERGENCYepinephrine Tier-2 QL (2 EA per 1 day)

BOTULINUM TOXINSBOTOX Tier-3 PA

DYSPORT Tier-3 PA

XEOMIN Tier-3 PA

CASTLEMAN DISEASESYLVANT Tier-5 PA; NEDS

CASTLEMAN'S DISEASE

SYLVANT Tier-5 PA; NEDS

CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMESARCALYST Tier-5 PA; SP-CVS specialty; NEDS

ILARIS Tier-5 PA; NEDS

CUSHING'S SYNDROME

KORLYM Tier-5PA; QL (120 EA per 30 days); NEDS

SIGNIFOR Tier-5PA; QL (60 ML per 30 days); NEDS

CYSTIC FIBROSISBETHKIS Tier-5 B vs D; NEDS

CAYSTON Tier-5 NEDS

KALYDECO Tier-5PA; QL (60 EA per 30 days); NEDS

ORKAMBI Tier-5PA; QL (120 EA per 30 days); NEDS

PULMOZYME Tier-5 B vs D; NEDS

TOBI PODHALER Tier-5 NEDS

tobramycin Tier-5 B vs D; NEDS

CYSTINURIACYSTADANE Tier-5 NEDS

DETOXIFICATION AGENTSCHEMET Tier-4

EXJADE Tier-5 NEDS

FERRIPROX Tier-5 NEDS

JADENU Tier-5 NEDS

JADENU SPRINKLE Tier-5 NEDS


Drug Name Drug Tier Requirements/LimitsDUCHENNE MUSCULAR DYSTROPHY

EMFLAZA ORAL SUSPENSION Tier-5PA; QL (26 ML per 30 days); NEDS

EMFLAZA ORAL TABLET Tier-5PA; QL (30 EA per 30 days); NEDS

EXONDYS 51 Tier-5 PA; NEDS

FABRY DISEASEFABRAZYME Tier-5 PA; NEDS

GAUCHER'S DISEASECERDELGA Tier-5 PA; NEDS

CEREZYME Tier-5 PA; NEDS

ELELYSO Tier-5 PA; NEDS

VPRIV Tier-5 PA; NEDS

ZAVESCA Tier-5 PA; NEDS

GROWTH HORMONE DEFICIENCYEGRIFTA Tier-5 PA; SP-CVS specialty; NEDS

GENOTROPIN Tier-3 PA; SP-CVS specialty

GENOTROPIN MINIQUICK Tier-3 PA; SP-CVS specialty

HUMATROPE Tier-5 PA; SP-CVS specialty; NEDS

INCRELEX Tier-5 PA; SP-CVS specialty; NEDS

NORDITROPIN FLEXPRO Tier-5 PA; SP-CVS specialty; NEDS

NUTROPIN AQ NUSPIN 10 Tier-5 PA; SP-CVS specialty; NEDS



OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML

Tier-5 PA; SP-CVS specialty; NEDS

OMNITROPE SUBCUTANEOUS SOLUTION 5 MG/1.5ML

Tier-3 PA; SP-CVS specialty

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED


SAIZEN Tier-5 PA; SP-CVS specialty; NEDS

SAIZEN CLICK.EASY Tier-5 PA; SP-CVS specialty; NEDS

SEROSTIM Tier-5 PA; SP-CVS specialty; NEDS

ZOMACTON Tier-3 PA; SP-CVS specialty

ZORBTIVE Tier-5 PA; SP-CVS specialty; NEDS

HEREDITARY ANGIOEDEMABERINERT Tier-5 NEDS

CINRYZE Tier-5 PA; NEDS



FIRAZYR Tier-5PA; SP-CVS specialty; QL (18 ML per 30 days); NEDS

HAEGARDA Tier-5 PA; NEDS

RUCONEST Tier-5 NEDS

HEREDITARY TYROSINEMIA TYPE 1ORFADIN ORAL CAPSULE Tier-5 PA; SP-CVS specialty; NEDS

ORFADIN ORAL SUSPENSION Tier-5 PA; NEDS

HUNTINGTON'S CHOREAAUSTEDO Tier-5 PA; SP-CVS specialty; NEDS

tetrabenazine Tier-5 PA; SP-CVS specialty; NEDS

HYPERCALCEMIA

SENSIPAR Tier-5 NEDS

HYPERPARATHYROIDISMcalcitriol Tier-2

doxercalciferol Tier-2

paricalcitol Tier-2

HYPOPARATHYROIDISM

NATPARA Tier-5PA; SP-CVS specialty; QL (2 EA per 28 days); NEDS

HYPOPHOSPHATASIASTRENSIQ Tier-5 PA; NEDS

LYSOSOMAL ACID LIPASE DEFICIENCY

KANUMA Tier-5 PA; NEDS

MUCOPOLYSACCHARIDOSISALDURAZYME Tier-5 NEDS

ELAPRASE Tier-5 NEDS

LUMIZYME Tier-5 NEDS

NAGLAZYME Tier-5 NEDS

MULTIPLE SCLEROSIS

AMPYRA Tier-5PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

AUBAGIO Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

AVONEX Tier-5SP-CVS specialty; QL (4 EA per 28 days); NEDS

AVONEX PEN Tier-5SP-CVS specialty; QL (4 EA per 28 days); NEDS



AVONEX PREFILLED Tier-5SP-CVS specialty; QL (4 EA per 28 days); NEDS

BETASERON Tier-5SP-CVS specialty; QL (15 EA per 30 days); NEDS

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML


COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML


EXTAVIA Tier-5SP-CVS specialty; QL (15 EA per 30 days); NEDS

GILENYA Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

PLEGRIDY Tier-5SP-CVS specialty; QL (1 ML per 28 days); NEDS

PLEGRIDY STARTER PACK Tier-5 SP-CVS specialty; NEDS

REBIF Tier-5SP-CVS specialty; QL (12 ML per 28 days); NEDS

REBIF REBIDOSE Tier-5SP-CVS specialty; QL (12 ML per 28 days); NEDS

REBIF REBIDOSE TITRATION PACK Tier-5 SP-CVS specialty; NEDS

REBIF TITRATION PACK Tier-5 SP-CVS specialty; NEDS

TECFIDERA ORAL STARTER PACK Tier-5 PA; SP-CVS specialty; NEDS

TECFIDERA ORAL CAPSULE DELAYED RELEASE


TYSABRI Tier-5 PA; NEDS

MYASTHENIA GRAVISguanidine hcl Tier-2

MESTINON SYRUP Tier-4

pyridostigmine bromide Tier-2

pyridostigmine bromide er Tier-2

OPIOID ANTAGONISTSbuprenorphine hcl Tier-3 QL (90 EA per 30 days)

buprenorphine hcl-naloxone hcl Tier-3 QL (90 EA per 30 days)

EVZIO Tier-5 PA; NEDS

naloxone hcl Tier-2

NARCAN Tier-4 QL (4 EA per 30 days)

SUBOXONE FILM Tier-4 QL (90 EA per 30 days)

PAGET'S DISEASEetidronate disodium Tier-2


Drug Name Drug Tier Requirements/LimitsPHENYLKETONURIAKUVAN Tier-5 PA; SP-CVS specialty; NEDS

PHEOCHROMOCYTOMADEMSER Tier-5 NEDS

DIBENZYLINE Tier-4

phenoxybenzamine hcl Tier-3

PHOSPHATE BINDERSAURYXIA Tier-5 NEDS

calcium acetate (phos binder) Tier-2

RENVELA Tier-3

sevelamer carbonate oral packets Tier-3

POTASSIUM BINDERkionex Tier-2

sodium polystyrene sulfonate Tier-2

sps Tier-2

VELTASSA Tier-4

PRIMARY PERIODIC PARALYSISKEVEYIS Tier-5 PA; NEDS

RESPIRATORY SYNCYTIAL VIRUS

SYNAGIS Tier-5 SP-CVS specialty; NEDS

SMOKING CESSATIONbupropion hcl er (smoking det) Tier-2

CHANTIX Tier-4 QL (60 EA per 30 days)

CHANTIX CONTINUING MONTH PAK Tier-4 QL (56 EA per 28 days)

CHANTIX STARTING MONTH PAK Tier-4 QL (53 EA per 28 days)

NICOTROL Tier-3

NICOTROL NS Tier-4

SUCRASE DEFICIENCYSUCRAID Tier-5 NEDS

SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA

alfuzosin hcl er Tier-2

CIALIS Tier-4 PA; QL (30 EA per 30 days)

dutasteride Tier-3

dutasteride-tamsulosin hcl Tier-3

finasteride Tier-1

tamsulosin hcl Tier-2


Drug Name Drug Tier Requirements/LimitsTARDIVE DYSKINESIAINGREZZA Tier-5 PA; NEDS

UREA CYCLE DISORDERSBUPHENYL Tier-5 NEDS

RAVICTI Tier-5 PA; NEDS

sodium phenylbutyrate Tier-5 NEDS

UROLOGIC DISORDERSbethanechol chloride Tier-2

darifenacin hydrobromide er Tier-3

desmopressin ace rhinal tube Tier-2

desmopressin ace spray refrig Tier-2

desmopressin acetate Tier-2

ELMIRON Tier-4

flavoxate hcl Tier-2

MYRBETRIQ Tier-4

oxybutynin chloride er Tier-2

oxybutynin chloride oral syrup Tier-2

oxybutynin chloride oral tablet Tier-1

potassium citrate er Tier-2

SAMSCA Tier-5 NEDS

tolterodine tartrate Tier-3

tolterodine tartrate er Tier-3

TOVIAZ Tier-3

trospium chloride Tier-3

trospium chloride er Tier-3

UROCIT-K 10 Tier-4

UROCIT-K 15 Tier-4

UROCIT-K 5 Tier-4

VESICARE Tier-4

WILSON'S DISEASE

CUPRIMINE Tier-5 NEDS

DEPEN TITRATABS Tier-3

SYPRINE Tier-5 NEDS

trientine hcl Tier-5 NEDS

NEUROLOGICAL DRUGSALZHEIMER'S DISEASEdonepezil hcl oral tablet Tier-1


Drug Name Drug Tier Requirements/Limitsdonepezil hcl oral tablet dispersible Tier-2

ergoloid mesylates Tier-2

galantamine hydrobromide Tier-2

galantamine hydrobromide er Tier-2

memantine hcl er Tier-3

memantine hcl oral solution Tier-3

memantine hcl oral tablet Tier-2

NAMENDA XR Tier-3

NAMENDA XR TITRATION PACK Tier-3

rivastigmine Tier-2

rivastigmine tartrate Tier-2

MIGRAINE THERAPYalmotriptan malate Tier-2

dihydroergotamine mesylate injection Tier-2 PA

dihydroergotamine mesylate nasal Tier-2

eletriptan hydrobromide Tier-3

frovatriptan succinate Tier-3

MIGERGOT Tier-3

MIGRANAL Tier-4

naratriptan hcl Tier-2

rizatriptan benzoate Tier-2

sumatriptan nasal solution 20 mg/act Tier-3

sumatriptan nasal solution 5 mg/act Tier-2

sumatriptan succinate oral Tier-2

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml

Tier-2

sumatriptan succinate refill subcutaneous solution cartridge 6 mg/0.5ml

Tier-3

sumatriptan succinate subcutaneous solution Tier-3

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml

Tier-2

sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml

Tier-3

sumatriptan-naproxen sodium Tier-3

zolmitriptan Tier-2

PARKINSON'S DISEASEAPOKYN Tier-5 NEDS

AZILECT Tier-3


Drug Name Drug Tier Requirements/Limitsbenztropine mesylate Tier-1 PA

bromocriptine mesylate Tier-2

cabergoline Tier-2

carbidopa Tier-2

carbidopa-levodopa Tier-2

carbidopa-levodopa er Tier-2

carbidopa-levodopa-entacapone Tier-2

CYCLOSET Tier-3

DUOPA Tier-4

entacapone Tier-2

NEUPRO Tier-4 QL (30 EA per 30 days)

pramipexole dihydrochloride Tier-2

pramipexole dihydrochloride er Tier-2

rasagiline mesylate Tier-3

ropinirole hcl Tier-2

ropinirole hcl er Tier-2

RYTARY Tier-4

selegiline hcl Tier-2

tolcapone Tier-5 NEDS

trihexyphenidyl hcl Tier-1 PA

PSEUDOBULBAR AFFECTNUEDEXTA Tier-3 PA

SEIZURESAPTIOM Tier-4 PA

BANZEL Tier-3

BRIVIACT Tier-5 PA; NEDS

carbamazepine er Tier-2

carbamazepine oral suspension Tier-2

carbamazepine oral tablet Tier-1

carbamazepine oral tablet chewable Tier-2

CELONTIN Tier-4

clonazepam oral tablet Tier-1

clonazepam oral tablet dispersible Tier-2

DIASTAT ACUDIAL Tier-3

DIASTAT PEDIATRIC Tier-3

diazepam Tier-2

diazepam intensol Tier-2


Drug Name Drug Tier Requirements/LimitsDILANTIN Tier-3

DILANTIN INFATABS Tier-3

divalproex sodium Tier-2

divalproex sodium er Tier-2

epitol Tier-1

ethosuximide Tier-2

felbamate Tier-2

fosphenytoin sodium Tier-2

FYCOMPA Tier-4 PA

gabapentin oral capsule Tier-1

gabapentin oral solution Tier-2

gabapentin oral tablet Tier-1

GABITRIL Tier-3

HORIZANT Tier-4 QL (60 EA per 30 days)

lamotrigine er Tier-3

lamotrigine oral tablet Tier-1

lamotrigine oral tablet chewable Tier-2

lamotrigine oral tablet dispersible Tier-2

lamotrigine starter kit-blue Tier-2

lamotrigine starter kit-green Tier-2

lamotrigine starter kit-orange Tier-2

levetiracetam Tier-2

levetiracetam er Tier-2

LYRICA Tier-4 STPA

LYRICA CR Tier-4 STPA

ONFI ORAL SUSPENSION Tier-4

ONFI ORAL TABLET Tier-4 QL (60 EA per 30 days)

oxcarbazepine Tier-2

OXTELLAR XR Tier-4

PEGANONE Tier-4

phenobarbital Tier-2 PA

phenytoin Tier-2

phenytoin sodium Tier-2

phenytoin sodium extended Tier-2

primidone Tier-2

QUDEXY XR Tier-4

roweepra Tier-2


Drug Name Drug Tier Requirements/Limitsroweepra xr Tier-2

SABRIL Tier-5 NEDS

SAVELLA Tier-3 STPA; QL (180 EA per 90 days)

SAVELLA TITRATION PACK Tier-3 STPA

SPRITAM Tier-4

TEGRETOL-XR Tier-3

tiagabine hcl Tier-2

topiramate Tier-2

topiramate er Tier-2

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG

Tier-4

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG

Tier-5 NEDS

valproate sodium Tier-2

valproic acid Tier-2

vigabatrin Tier-5 NEDS

VIMPAT INTRAVENOUS Tier-4

VIMPAT ORAL SOLUTION Tier-4 PA

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

Tier-5PA; QL (60 EA per 30 days); NEDS

VIMPAT ORAL TABLET 50 MG Tier-4 PA; QL (60 EA per 30 days)

zonisamide Tier-2

SPASTICITY

baclofen Tier-1

cyclobenzaprine hcl Tier-3 PA

dantrolene sodium Tier-2

tizanidine hcl oral capsule Tier-3

tizanidine hcl oral tablet Tier-2

PAIN AND INFLAMMATORY DISEASESARTHRITISACTEMRA Tier-5 PA; SP-CVS specialty; NEDS

AZASAN Tier-4 B vs D

azathioprine Tier-2 B vs D

azathioprine sodium Tier-2 B vs D

CIMZIA Tier-5PA; SP-CVS specialty; QL (2 EA per 28 days); NEDS



CIMZIA PREFILLED Tier-5PA; SP-CVS specialty; QL (2 EA per 30 days); NEDS

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML

Tier-5PA; SP-CVS specialty; QL (8.16 ML per 28 days); NEDS

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED


ENBREL SURECLICK Tier-5PA; SP-CVS specialty; QL (7.84 ML per 28 days); NEDS

HUMIRA Tier-5PA; SP-CVS specialty; QL (6 EA per 28 days); NEDS

HUMIRA PEDIATRIC CROHNS START Tier-5 PA; SP-CVS specialty; NEDS

HUMIRA PEN Tier-5PA; SP-CVS specialty; QL (6 EA per 28 days); NEDS

HUMIRA PEN-CROHNS STARTER Tier-5 PA; SP-CVS specialty; NEDS

HUMIRA PEN-PSORIASIS STARTER Tier-5 PA; SP-CVS specialty; NEDS

INFLECTRA Tier-5 PA; NEDS

KEVZARA Tier-5PA; QL (2.28 ML per 28 days); NEDS

KINERET Tier-5PA; QL (20.1 ML per 28 days); NEDS

leflunomide Tier-2

methotrexate Tier-2 B vs D

ORENCIA CLICKJECT Tier-5PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS

ORENCIA INTRAVENOUS Tier-5 PA; SP-CVS specialty; NEDS

ORENCIA SUBCUTANEOUS Tier-5PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS

RASUVO Tier-4

REMICADE Tier-5 PA; NEDS

RENFLEXIS Tier-5 PA; NEDS

RIDAURA Tier-5 NEDS

SIMPONI ARIA Tier-5 PA; SP-CVS specialty; NEDS

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML

Tier-5PA; SP-CVS specialty; QL (1 ML per 28 days); NEDS

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/0.5ML


SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML

Tier-5PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS


Drug Name Drug Tier Requirements/LimitsSIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.5ML


TREXALL Tier-4 B vs D

XATMEP Tier-5 B vs D; NEDS

XELJANZ Tier-5PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

XELJANZ XR Tier-5PA; SP-CVS specialty; QL (30 EA per 30 days); NEDS

GOUTallopurinol Tier-1

colchicine Tier-2

colchicine-probenecid Tier-2

probenecid Tier-2

ULORIC Tier-3 STPA

PAIN, NSAID ANALGESICScelecoxib Tier-3 PA

diclofenac potassium Tier-3

diclofenac sodium Tier-2

diclofenac sodium er Tier-2

diclofenac-misoprostol Tier-2

diflunisal Tier-3

etodolac Tier-2

etodolac er Tier-2

fenoprofen calcium Tier-2

flurbiprofen Tier-2

ibuprofen oral suspension Tier-2

ibuprofen oral tablet Tier-1

INDOCIN ORAL SUSPENSION Tier-4

indomethacin Tier-1 PA

indomethacin er Tier-3 PA

ketoprofen Tier-2

ketoprofen er Tier-2

meclofenamate sodium Tier-2

mefenamic acid Tier-2

meloxicam Tier-1

nabumetone Tier-2

naproxen dr Tier-2

naproxen oral suspension Tier-2


Drug Name Drug Tier Requirements/Limitsnaproxen oral tablet Tier-1

naproxen sodium Tier-1

naproxen sodium er Tier-1

oxaprozin Tier-2

piroxicam Tier-3

profeno Tier-2

sulindac Tier-2

tolmetin sodium Tier-2

PAIN, OPIOID AND OTHER ANALGESICS

ABSTRAL Tier-5PA; QL (120 EA per 30 days); NEDS

acetaminophen-codeine #3 Tier-2 QL (240 EA per 30 days)

acetaminophen-codeine oral solution Tier-2 QL (3600 ML per 30 days)

acetaminophen-codeine oral tablet Tier-2 QL (240 EA per 30 days)

ACTIQ Tier-5PA; QL (120 EA per 30 days); NEDS

BELBUCA Tier-4 QL (60 EA per 30 days)

buprenorphine Tier-3 QL (4 EA per 28 days)

butorphanol tartrate Tier-2 QL (7.5 ML per 30 days)

BUTRANS Tier-4 QL (4 EA per 28 days)

codeine sulfate Tier-3 QL (180 EA per 30 days)

EMBEDA Tier-4 QL (60 EA per 30 days)

endocet Tier-3 QL (240 EA per 30 days)

fentanyl Tier-2 QL (10 EA per 30 days)

fentanyl citrate Tier-5PA; QL (120 EA per 30 days); NEDS

FENTORA Tier-5PA; QL (120 EA per 30 days); NEDS

hydrocodone-acetaminophen oral solution Tier-2 QL (3600 ML per 30 days)

hydrocodone-acetaminophen oral tablet Tier-2 QL (240 EA per 30 days)

hydrocodone-ibuprofen Tier-2 QL (240 EA per 30 days)

hydromorphone hcl er Tier-3 QL (30 EA per 30 days)

hydromorphone hcl oral liquid Tier-2 QL (1350 ML per 30 days)

hydromorphone hcl oral tablet 2 mg, 4 mg Tier-2 QL (240 EA per 30 days)

hydromorphone hcl oral tablet 8 mg Tier-2 QL (120 EA per 30 days)

HYSINGLA ER Tier-4 QL (60 EA per 30 days)

LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT



Drug Name Drug Tier Requirements/LimitsLAZANDA NASAL SOLUTION 400 MCG/ACT


levorphanol tartrate Tier-2 QL (240 EA per 30 days)

methadone hcl oral solution 10 mg/5ml Tier-2 QL (600 ML per 30 days)

methadone hcl oral solution 5 mg/5ml Tier-2 QL (1200 ML per 30 days)

methadone hcl oral tablet Tier-2 QL (120 EA per 30 days)

morphine sulfate (concentrate) Tier-2 QL (180 ML per 30 days)

morphine sulfate er Tier-3 QL (60 EA per 30 days)

morphine sulfate er beads Tier-3 QL (60 EA per 30 days)

morphine sulfate oral solution Tier-2 QL (900 ML per 30 days)

morphine sulfate oral tablet Tier-2 QL (180 EA per 30 days)

oxycodone hcl er Tier-3 QL (60 EA per 30 days)

oxycodone hcl oral capsule Tier-2 QL (240 EA per 30 days)

oxycodone hcl oral concentrate Tier-2 QL (120 ML per 30 days)

oxycodone hcl oral solution Tier-2 QL (2400 ML per 30 days)

oxycodone hcl oral tablet 10 mg, 15 mg Tier-2 QL (180 EA per 30 days)

oxycodone hcl oral tablet 20 mg, 30 mg Tier-2 QL (120 EA per 30 days)

oxycodone hcl oral tablet 5 mg Tier-2 QL (240 EA per 30 days)

oxycodone-acetaminophen Tier-2 QL (240 EA per 30 days)

oxycodone-aspirin Tier-2 QL (240 EA per 30 days)

oxycodone-ibuprofen Tier-2 QL (120 EA per 30 days)

OXYCONTIN Tier-3 QL (60 EA per 30 days)

oxymorphone hcl Tier-2 QL (180 EA per 30 days)

oxymorphone hcl er Tier-2 QL (60 EA per 30 days)

SUBSYS Tier-5PA; QL (120 EA per 30 days); NEDS

tramadol hcl Tier-1 QL (240 EA per 30 days)

tramadol hcl er Tier-2 QL (30 EA per 30 days)

tramadol hcl er (biphasic) Tier-2 QL (30 EA per 30 days)

tramadol-acetaminophen Tier-2 QL (240 EA per 30 days)

PSYCHIATRICALCOHOL DETERRENTS

acamprosate calcium Tier-2

disulfiram Tier-2

naltrexone hcl Tier-2

VIVITROL Tier-5 NEDS

ANXIETYalprazolam er Tier-2


Drug Name Drug Tier Requirements/Limitsalprazolam intensol Tier-2

alprazolam oral tablet Tier-1

alprazolam oral tablet dispersible Tier-2

buspirone hcl Tier-1

chlordiazepoxide-amitriptyline Tier-2

clorazepate dipotassium Tier-2

lorazepam oral concentrate Tier-2

lorazepam oral tablet Tier-1

oxazepam Tier-3

ATTENTION DEFICIT DISORDER

ADDERALL XR Tier-4 STPA

amphetamine-dextroamphet er Tier-2

amphetamine-dextroamphetamine Tier-2

atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg, 60 mg


atomoxetine hcl oral capsule 100 mg, 80 mg Tier-3 QL (30 EA per 30 days)

clonidine hcl er Tier-2

DESOXYN Tier-4 PA

DEXEDRINE Tier-4

dexmethylphenidate hcl Tier-2

dexmethylphenidate hcl er Tier-2

dextroamphetamine sulfate Tier-2

dextroamphetamine sulfate er Tier-2

FOCALIN XR Tier-3 STPA

guanfacine hcl er Tier-2 PA; QL (90 EA per 90 days)

KAPVAY Tier-4

METADATE ER Tier-4

methamphetamine hcl Tier-2 PA

METHYLIN Tier-3

methylphenidate hcl Tier-2

methylphenidate hcl er Tier-2

methylphenidate hcl er (cd) Tier-2

methylphenidate hcl er (la) Tier-2

QUILLIVANT XR Tier-4 STPA

VYVANSE Tier-4 STPA

BIPOLAR DISORDEREQUETRO Tier-4


Drug Name Drug Tier Requirements/Limitslithium Tier-1

lithium carbonate Tier-1

lithium carbonate er Tier-1

olanzapine-fluoxetine hcl Tier-2 STPA

RISPERDAL CONSTA Tier-3

risperidone oral solution Tier-2

risperidone oral tablet Tier-1

risperidone oral tablet dispersible Tier-2

DEPRESSION

amitriptyline hcl Tier-2 PA

amoxapine Tier-2

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG

Tier-4 STPA

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 522 MG

Tier-5 STPA; NEDS

bupropion hcl Tier-2

bupropion hcl er (sr) Tier-2

bupropion hcl er (xl) Tier-2

citalopram hydrobromide Tier-1

clomipramine hcl Tier-2 PA

desipramine hcl Tier-2

desvenlafaxine er Tier-2

desvenlafaxine succinate er Tier-2

doxepin hcl oral capsule Tier-3 PA

doxepin hcl oral concentrate Tier-2 PA

duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg


duloxetine hcl oral capsule delayed release particles 30 mg, 40 mg


EMSAM Tier-5 STPA; NEDS

escitalopram oxalate oral solution Tier-2

escitalopram oxalate oral tablet Tier-1

FETZIMA Tier-4 STPA

FETZIMA TITRATION Tier-4 STPA

fluoxetine hcl oral capsule Tier-1

fluoxetine hcl oral capsule delayed release Tier-1

fluoxetine hcl oral solution Tier-2

fluoxetine hcl oral tablet 10 mg, 20 mg Tier-3


Drug Name Drug Tier Requirements/Limitsfluoxetine hcl oral tablet 60 mg Tier-2

fluvoxamine maleate Tier-2

fluvoxamine maleate er Tier-2

imipramine hcl Tier-2 PA

imipramine pamoate Tier-2 PA

maprotiline hcl Tier-2

MARPLAN Tier-4

mirtazapine Tier-2

nefazodone hcl Tier-2

nortriptyline hcl Tier-1

paroxetine hcl Tier-1

paroxetine hcl er Tier-1

paroxetine mesylate Tier-1

PAXIL ORAL SUSPENSION Tier-4

PEXEVA Tier-4 STPA

phenelzine sulfate Tier-2

protriptyline hcl Tier-2

sertraline hcl oral concentrate Tier-2

sertraline hcl oral tablet Tier-1

SURMONTIL Tier-3 PA

tranylcypromine sulfate Tier-2

trazodone hcl Tier-1

trimipramine maleate Tier-2 PA

TRINTELLIX Tier-4 STPA

venlafaxine hcl Tier-2

venlafaxine hcl er Tier-2

VIIBRYD Tier-4 STPA

VIIBRYD STARTER PACK Tier-4 STPA

INSOMNIA

estazolam Tier-2

eszopiclone Tier-3 PA; QL (90 EA per 365 days)

flurazepam hcl Tier-2

HETLIOZ Tier-5 PA; NEDS

ROZEREM Tier-4 QL (30 EA per 30 days)

SILENOR Tier-4 QL (30 EA per 30 days)

temazepam Tier-2

triazolam Tier-2


Drug Name Drug Tier Requirements/Limitszaleplon Tier-2 PA; QL (90 EA per 365 days)

zolpidem tartrate er Tier-2 PA; QL (90 EA per 365 days)

zolpidem tartrate oral Tier-2 PA; QL (90 EA per 365 days)

zolpidem tartrate sublingual Tier-3 PA; QL (90 EA per 365 days)

NARCOLEPSYarmodafinil Tier-3 PA

modafinil Tier-3 PA

XYREM Tier-5 NEDS

PSYCHOSES

ABILIFY MAINTENA Tier-5 NEDS

aripiprazole Tier-3 STPA

ARISTADA Tier-5 NEDS

chlorpromazine hcl Tier-2

clozapine Tier-2

FANAPT Tier-4 STPA

FANAPT TITRATION PACK Tier-4 STPA

FAZACLO Tier-3

fluphenazine decanoate Tier-2

fluphenazine hcl Tier-2

GEODON INTRAMUSCULAR INJECTION Tier-4

haloperidol Tier-1

haloperidol decanoate Tier-2

haloperidol lactate Tier-2

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 78 MG/0.5ML

Tier-5 NEDS

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML

Tier-3

INVEGA TRINZA Tier-3

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

Tier-5STPA; QL (30 EA per 30 days); NEDS

LATUDA ORAL TABLET 80 MG Tier-5STPA; QL (60 EA per 30 days); NEDS

loxapine succinate Tier-2

NUPLAZID Tier-5PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

olanzapine intramuscular Tier-2

olanzapine oral Tier-2 STPA

ORAP Tier-3


Drug Name Drug Tier Requirements/Limitspaliperidone er Tier-3

perphenazine Tier-2

perphenazine-amitriptyline Tier-2

pimozide Tier-2

quetiapine fumarate er Tier-3 STPA

quetiapine fumarate oral tablet 100 mg, 200 mg, 300 mg, 400 mg

Tier-2 STPA

quetiapine fumarate oral tablet 25 mg, 50 mg Tier-2 STPA; QL (60 EA per 30 days)

REXULTI ORAL TABLET 0.25 MG Tier-4

REXULTI ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

Tier-5 NEDS

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG

Tier-5 STPA; NEDS

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG, 5 MG

Tier-4 STPA

thioridazine hcl Tier-1 PA

thiothixene Tier-1

trifluoperazine hcl Tier-2

VERSACLOZ Tier-5 NEDS

VRAYLAR ORAL CAPSULE Tier-5 NEDS

VRAYLAR ORAL CAPSULE THERAPY PACK

Tier-4

ziprasidone hcl Tier-2 STPA

ZYPREXA Tier-3

ZYPREXA RELPREVV Tier-3

RESPIRATORY DRUGSASTHMAADVAIR DISKUS Tier-3 QL (180 EA per 90 days)

ADVAIR HFA Tier-3 QL (72 GM per 90 days)

albuterol sulfate er Tier-3

albuterol sulfate inhalation nebulization solution(2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml

Tier-2 B vs D; QL (1080 ML per 90 days)

albuterol sulfate inhalation nebulization solution(5 mg/ml) 0.5%

Tier-2 B vs D; QL (180 EA per 90 days)

albuterol sulfate oral syrup Tier-1

albuterol sulfate oral tablet Tier-3

ALVESCO INHALATION AEROSOL SOLUTION 160 MCG/ACT

Tier-4 QL (36.6 GM per 90 days)


Drug Name Drug Tier Requirements/LimitsALVESCO INHALATION AEROSOL SOLUTION 80 MCG/ACT

Tier-4 QL (18.3 GM per 90 days)

ANORO ELLIPTA Tier-3 QL (180 EA per 90 days)

ARCAPTA NEOHALER Tier-4 QL (90 EA per 90 days)

ARNUITY ELLIPTA Tier-3 QL (90 EA per 90 days)

ASMANEX 120 METERED DOSES Tier-3 QL (360 EA per 90 days)



ASMANEX HFA Tier-3 QL (39 GM per 90 days)

ATROVENT HFA Tier-3 QL (77.4 GM per 90 days)

BREO ELLIPTA Tier-3 QL (180 EA per 90 days)

BROVANA Tier-4 B vs D; QL (360 ML per 90 days)

budesonide Tier-2 B vs D; QL (720 ML per 90 days)

COMBIVENT RESPIMAT Tier-3 QL (24 GM per 90 days)

cromolyn sodium Tier-2 B vs D; QL (720 ML per 90 days)

FASENRA Tier-5 PA; NEDS

FLOVENT DISKUS Tier-3 QL (360 EA per 90 days)

FLOVENT HFA Tier-3 QL (72 GM per 90 days)

fluticasone-salmeterol Tier-2 QL (3 EA per 90 days)

INCRUSE ELLIPTA Tier-3 QL (90 EA per 90 days)

ipratropium bromide Tier-2 B vs D; QL (900 ML per 90 days)

ipratropium-albuterol Tier-2 B vs D; QL (1620 ML per 90 days)

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml




levalbuterol hcl inhalation nebulization solution1.25 mg/0.5ml

Tier-2 B vs D; QL (270 EA per 90 days)



levalbuterol tartrate Tier-3 QL (90 GM per 90 days)

metaproterenol sulfate Tier-2

montelukast sodium oral packet Tier-2

montelukast sodium oral tablet Tier-1

montelukast sodium oral tablet chewable Tier-2

PERFOROMIST Tier-3 B vs D; QL (360 ML per 90 days)

PROAIR HFA Tier-3 QL (51 GM per 90 days)

PROAIR RESPICLICK Tier-3 QL (6 EA per 90 days)

PROVENTIL HFA Tier-4 QL (40.2 GM per 90 days)


Drug Name Drug Tier Requirements/LimitsPULMICORT FLEXHALER Tier-4 QL (6 EA per 90 days)

QVAR Tier-3 QL (52.2 GM per 90 days)

QVAR REDIHALER Tier-3 QL (63.6 GM per 90 days)

SEREVENT DISKUS Tier-3 QL (180 EA per 90 days)

SPIRIVA HANDIHALER Tier-3 QL (90 EA per 90 days)

SPIRIVA RESPIMAT Tier-3 QL (12 GM per 90 days)

STRIVERDI RESPIMAT Tier-4 QL (180 GM per 90 days)

SYMBICORT Tier-3 QL (30.6 GM per 90 days)

terbutaline sulfate Tier-2

theophylline Tier-2

theophylline er Tier-2

VENTOLIN HFA Tier-4 QL (108 GM per 90 days)

zafirlukast Tier-2

zileuton er Tier-3

IDIOPATHIC PULMONARY FIBROSIS

ESBRIET ORAL CAPSULE Tier-5PA; SP-CVS specialty; QL (270 EA per 30 days); NEDS

ESBRIET ORAL TABLET Tier-5PA; SP-CVS specialty; QL (90 EA per 30 days); NEDS

OFEV Tier-5PA; QL (60 EA per 30 days); NEDS

PULMONARY HYPERTENSION

ADCIRCA Tier-5 PA; SP-CVS specialty; NEDS

ADEMPAS Tier-5 PA; SP-CVS specialty; NEDS

LETAIRIS Tier-5 PA; SP-CVS specialty; NEDS

OPSUMIT Tier-5 PA; SP-CVS specialty; NEDS

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG


ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

Tier-5 PA; SP-CVS specialty; NEDS

REMODULIN Tier-5 PA; NEDS

REVATIO ORAL SOLUTION Tier-5 PA; SP-CVS specialty; NEDS

sildenafil citrate intravenous Tier-5 PA; NEDS

sildenafil citrate oral Tier-3 PA; SP-CVS specialty

TRACLEER Tier-5 PA; SP-CVS specialty; NEDS

UPTRAVI ORAL TABLET Tier-5PA; SP-CVS specialty; QL (60 EA per 30 days); NEDS

UPTRAVI ORAL TABLET THERAPY PACK Tier-5 PA; SP-CVS specialty; NEDS

VENTAVIS Tier-5 PA; NEDS


Drug Name Drug Tier Requirements/LimitsRESPIRATORY DRUGS, MISCELLANEOUSacetylcysteine Tier-2 B vs D

ARALAST NP Tier-5 NEDS

DALIRESP Tier-4

GLASSIA Tier-5 NEDS

NUCALA Tier-5 PA; NEDS

ORALAIR Tier-4 PA

PROLASTIN-C Tier-5 NEDS

XOLAIR Tier-5 PA; NEDS

ZEMAIRA Tier-3

SKINACNE ROSACEAFINACEA Tier-3


NORITATE Tier-5 NEDS

SOOLANTRA Tier-4

ACNE VULGARISABSORICA Tier-4

adapalene Tier-2 PA

adapalene-benzoyl peroxide Tier-3 PA

amnesteem Tier-2

ATRALIN Tier-4 PA

avita Tier-2 PA

AZELEX Tier-4

benzoyl peroxide-erythromycin Tier-2

claravis Tier-2

CLINDAGEL Tier-4

clindamycin phos-benzoyl perox Tier-2

clindamycin phosphate Tier-2

ery Tier-2

erythromycin Tier-2

EVOCLIN Tier-4

FABIOR Tier-4 PA

isotretinoin Tier-2

RETIN-A Tier-4 PA

RETIN-A MICRO Tier-4 PA


Drug Name Drug Tier Requirements/LimitsRETIN-A MICRO PUMP Tier-4 PA

tretinoin Tier-2 PA

tretinoin microsphere Tier-2 PA

BACTERIAL INFECTIONS, TOPICALCORTISPORIN Tier-4

gentamicin sulfate Tier-3

mupirocin Tier-2

mupirocin calcium Tier-2

silver sulfadiazine Tier-2

ssd Tier-2

CORTICOSTEROIDS, TOPICALALA SCALP Tier-4

ala-cort Tier-1

alclometasone dipropionate Tier-2

amcinonide Tier-2

apexicon e Tier-2

betamethasone dipropionate Tier-2

betamethasone dipropionate aug Tier-2

betamethasone valerate Tier-2

CAPEX Tier-4

clobetasol propionate Tier-3

clobetasol propionate e Tier-3

clodan Tier-3

CLODERM Tier-4

CORDRAN Tier-4

desonide Tier-3

desoximetasone Tier-2

diflorasone diacetate Tier-3

fluocinolone acetonide Tier-1

fluocinolone acetonide scalp Tier-1

fluocinonide emulsified base Tier-3

fluocinonide external cream Tier-3 QL (120 GM per 30 days)

fluocinonide external gel Tier-3

fluocinonide external ointment Tier-3

fluocinonide external solution Tier-3

flurandrenolide external cream Tier-3

flurandrenolide external lotion Tier-3


Drug Name Drug Tier Requirements/Limitsflurandrenolide external ointment Tier-3 QL (120 GM per 30 days)

fluticasone propionate Tier-2

halobetasol propionate Tier-2

HALOG Tier-4


hydrocortisone ace-pramoxine Tier-2

hydrocortisone butyrate Tier-1

hydrocortisone valerate Tier-3

KENALOG Tier-4

mometasone furoate Tier-2

nolix Tier-3

PANDEL Tier-4

prednicarbate Tier-2


TRIANEX Tier-4

triderm Tier-2

FUNGAL INFECTIONS, TOPICALciclopirox external gel Tier-2

ciclopirox external shampoo Tier-2

ciclopirox external solution Tier-3

ciclopirox olamine Tier-2

clotrimazole external cream Tier-3

clotrimazole external solution Tier-2

clotrimazole-betamethasone Tier-3

econazole nitrate Tier-3

ERTACZO Tier-4

EXELDERM Tier-4

ketoconazole Tier-3

MENTAX Tier-4

naftifine hcl external cream 1 % Tier-2

naftifine hcl external cream 2 % Tier-3

NAFTIN GEL Tier-3

nyamyc Tier-2

nystatin Tier-2

nystatin-triamcinolone Tier-3

nystop Tier-2

oxiconazole nitrate Tier-3


Drug Name Drug Tier Requirements/LimitsOXISTAT Tier-3

PSORIASIS AND SEBORRHEAacitretin Tier-5 NEDS

calcipotriene Tier-3 QL (120 GM per 30 days)

calcipotriene-betameth diprop Tier-3

calcitriol Tier-2

COSENTYX 300 DOSE Tier-5PA; SP-CVS specialty; QL (2 ML per 28 days); NEDS

COSENTYX SENSOREADY 300 DOSE Tier-5PA; SP-CVS specialty; QL (2 ML per 28 days); NEDS

methoxsalen rapid Tier-5 NEDS

OTEZLA Tier-5 PA; SP-CVS specialty; NEDS

SILIQ Tier-5PA; QL (2 ML per 28 days); NEDS

STELARA Tier-5 PA; SP-CVS specialty; NEDS

TALTZ Tier-5PA; SP-CVS specialty; QL (4 ML per 28 days); NEDS

tazarotene Tier-3 PA

TAZORAC Tier-4 PA

TREMFYA Tier-5PA; QL (1 ML per 28 days); NEDS

SCABIES AND PEDICULOSISEURAX Tier-3

lindane Tier-2

malathion Tier-2

permethrin Tier-3

SKLICE Tier-4

TOPICAL, MISCELLANEOUSammonium lactate Tier-3

ANUSOL-HC Tier-4

diclofenac sodium transdermal gel Tier-3 QL (200 GM per 30 days)

diclofenac sodium transdermal solution Tier-2

doxepin hcl Tier-2 QL (90 GM per 30 days)

DUPIXENT Tier-5 PA; NEDS

ELIDEL Tier-4 STPA

EUCRISA Tier-4 PA

fluorouracil Tier-2

lidocaine external ointment Tier-3 QL (100 GM per 30 days)


Drug Name Drug Tier Requirements/Limitslidocaine external patch Tier-3 PA; QL (90 EA per 30 days)

lidocaine hcl external gel Tier-2 QL (100 ML per 30 days)

lidocaine hcl external solution Tier-2

lidocaine viscous Tier-2

lidocaine-prilocaine Tier-3

neomycin-polymyxin b Tier-2

PANRETIN Tier-5 NEDS

procto-med hc Tier-2

procto-pak Tier-2

proctosol hc Tier-2

proctozone-hc Tier-2

prudoxin Tier-2

REGRANEX Tier-3

SANTYL Tier-3

selenium sulfide Tier-2

sodium chloride Tier-2

sterile water for irrigation Tier-2

sulfacetamide sodium (acne) Tier-2

SULFAMYLON Tier-4

tacrolimus Tier-3

TARGRETIN Tier-5 SP-CVS specialty; NEDS

VALCHLOR Tier-5 NEDS

VIRAL INFECTIONS, TOPICALCONDYLOX Tier-4

DENAVIR Tier-5 NEDS

imiquimod Tier-2

podofilox Tier-2

ZOVIRAX Tier-3

WOMEN'S HEALTHCONTRACEPTIVES

amethia Tier-2

apri Tier-2

aranelle Tier-2

ashlyna Tier-2

aubra Tier-2

aviane Tier-2

balziva Tier-2


Drug Name Drug Tier Requirements/LimitsBEYAZ Tier-4

briellyn Tier-2

camila Tier-2

deblitane Tier-2

delyla Tier-2

desogestrel-ethinyl estradiol Tier-2

drospirenone-ethinyl estradiol Tier-2

emoquette Tier-2

errin Tier-2

estradiol-norethindrone acet Tier-2

falmina Tier-2

GENERESS FE Tier-4

introvale Tier-2

jinteli Tier-2

junel 1.5/30 Tier-2

junel 1/20 Tier-2

junel fe 1.5/30 Tier-2

junel fe 1/20 Tier-2

junel fe 24 Tier-2

kariva Tier-2

kelnor 1/35 Tier-2

larin 1.5/30 Tier-2

larin 1/20 Tier-2

larin fe 1.5/30 Tier-2

larin fe 1/20 Tier-2

lessina Tier-2

levonest Tier-2

levonorgest-eth estrad 91-day Tier-2

levonorgestrel-ethinyl estradiol Tier-2

levora 0.15/30 (28) Tier-2

LO LOESTRIN FE Tier-4

marlissa Tier-2

microgestin 1.5/30 Tier-2

microgestin 1/20 Tier-2

microgestin fe 1.5/30 Tier-2

microgestin fe 1/20 Tier-2

necon 0.5/35 (28) Tier-2


Drug Name Drug Tier Requirements/Limitsnecon 7/7/7 Tier-2

nikki Tier-2

norethin ace-eth estrad-fe Tier-2

norethindrone-eth estradiol Tier-2

norethin-eth estradiol-fe Tier-2

norlyroc Tier-2

nortrel 0.5/35 (28) Tier-2

nortrel 1/35 (21) Tier-2

nortrel 1/35 (28) Tier-2

nortrel 7/7/7 Tier-2

NUVARING Tier-3

orsythia Tier-2

ORTHO TRI-CYCLEN (28) Tier-4

portia-28 Tier-2

quasense Tier-2

SAFYRAL Tier-4

sharobel Tier-2

tarina fe 1/20 Tier-2

trinessa (28) Tier-2

tri-previfem Tier-2

tri-sprintec Tier-2

trivora (28) Tier-2

velivet Tier-2

vyfemla Tier-2

ZENCHENT Tier-4

zovia 1/35e (28) Tier-2

zovia 1/50e (28) Tier-2

MENOPAUSAL SYMPTOMS/OSTEOPOROSISalendronate sodium oral solution Tier-2

alendronate sodium oral tablet Tier-1

ALORA Tier-4 PA

ANGELIQ Tier-4

calcitonin (salmon) Tier-2

COMBIPATCH Tier-4 PA

CRINONE Tier-3 PA

DELESTROGEN Tier-4


Drug Name Drug Tier Requirements/LimitsDEPO-ESTRADIOL Tier-3

DEPO-PROVERA Tier-3

DEPO-SUBQ PROVERA 104 Tier-3

DIVIGEL Tier-4

DUAVEE Tier-4 PA

ELESTRIN Tier-4

ESTRACE Tier-3

estradiol oral Tier-1 PA

estradiol transdermal Tier-2 PA

estradiol vaginal Tier-3

estradiol valerate Tier-2

ESTRING Tier-3

estropipate Tier-2 PA

EVAMIST Tier-4

FEMHRT LOW DOSE Tier-4 PA

FEMRING Tier-3

FORTEO Tier-5 PA; SP-CVS specialty; NEDS

fyavolv Tier-2 PA

ibandronate sodium intravenous Tier-2

ibandronate sodium oral Tier-3

medroxyprogesterone acetate Tier-1

MENEST Tier-4 PA

MENOSTAR Tier-4 PA

MIACALCIN Tier-3

norethindrone acetate Tier-2

pamidronate disodium Tier-2

PREMARIN INJECTION Tier-4

PREMARIN ORAL Tier-4 PA

PREMARIN VAGINAL Tier-4

PREMPHASE Tier-4 PA

PREMPRO Tier-4 PA

progesterone micronized Tier-2

PROLIA Tier-3 PA

raloxifene hcl Tier-2

RECLAST Tier-3

risedronate sodium Tier-3

TYMLOS Tier-5 PA; NEDS


Drug Name Drug Tier Requirements/LimitsXGEVA Tier-5 PA; NEDS

yuvafem Tier-3

zoledronic acid Tier-2

PRENATAL VITAMINSprenatal Tier-2

PRETERM BIRTHhydroxyprogesterone caproate Tier-3 PA; SP-CVS specialty

MAKENA Tier-5 SP-CVS specialty; NEDS

VAGINAL INFECTIONS

AVC VAGINAL Tier-4

CLEOCIN Tier-4

clindamycin phosphate Tier-2

GYNAZOLE-1 Tier-4


miconazole 3 Tier-2

terconazole Tier-2

vandazole Tier-3

WOMEN'S HEALTH, MISCELLANEOUSINTRAROSA Tier-4

OSPHENA Tier-4


Indexabacavir sulfate ............................ 4abacavir sulfate-lamivudine ......... 4abacavir-lamivudine-zidovudine .. 4ABELCET.................................. 31ABILIFY MAINTENA.............. 57ABRAXANE.............................. 11ABSORICA................................ 61ABSTRAL.................................. 52acamprosate calcium .................. 53acarbose ......................................24acebutolol hcl ..............................19acetaminophen-codeine .............. 52acetaminophen-codeine #3 ......... 52acetazolamide ............................. 27acetazolamide er .........................27acetazolamide sodium .................31acetic acid ...................................25acetylcysteine .............................. 61acitretin .......................................64ACTEMRA.................................49ACTHIB..................................... 37ACTIMMUNE............................37ACTIQ........................................ 52ACTOPLUS MET XR................24acyclovir ........................................4acyclovir sodium .........................31ADACEL.................................... 37ADAGEN....................................37adapalene ....................................61adapalene-benzoyl peroxide ....... 61ADCIRCA.................................. 60ADDERALL XR........................ 54adefovir dipivoxil .......................... 4ADEMPAS................................. 60ADVAIR DISKUS..................... 58ADVAIR HFA............................58afeditab cr ...................................20AFINITOR..................................13AFINITOR DISPERZ................ 13ALA SCALP...............................62ala-cort ....................................... 62ALBENZA....................................3albuterol sulfate .......................... 58albuterol sulfate er ......................58alclometasone dipropionate ........62ALDURAZYME........................ 42ALECENSA............................... 13alendronate sodium .................... 67alfuzosin hcl er ............................44ALIMTA.....................................11ALINIA.........................................3

ALIQOPA...................................11ALKERAN........................... 11, 13allopurinol .................................. 51almotriptan malate ......................46ALOCRIL................................... 25ALOMIDE..................................25ALORA.......................................67alosetron hcl ............................... 29ALOXI........................................28ALPHAGAN P 0.1%..................27alprazolam .................................. 54alprazolam er ..............................53alprazolam intensol .................... 54ALREX....................................... 26ALUNBRIG................................13ALVESCO............................58, 59amantadine hcl ..............................4AMBISOME...............................31amcinonide ..................................62amethia ....................................... 65amikacin sulfate .......................... 31amiloride hcl ...............................21amiloride-hydrochlorothiazide ... 21aminophylline ............................. 31AMINOSYN II........................... 34AMINOSYN II/ELECTROLYTES.................. 34AMINOSYN/ELECTROLYTES.................................................. 34AMINOSYN-HBC..................... 34AMINOSYN-PF......................... 34AMINOSYN-RF.........................34amiodarone hcl ........................... 18AMITIZA....................................30amitriptyline hcl ..........................55amlodipine besy-benazepril hcl .. 18amlodipine besylate .................... 20amlodipine besylate-valsartan ....18amlodipine-atorvastatin ..............18amlodipine-olmesartan ............... 19amlodipine-valsartan-hctz .......... 19ammonium lactate .......................64amnesteem ...................................61amoxapine ...................................55amoxicill-clarithro-lansopraz .....30amoxicillin .................................... 7amoxicillin-pot clavulanate .......... 7amoxicillin-pot clavulanate er ......7amphetamine-dextroamphet er ... 54amphetamine-dextroamphetamine .....................54

amphotericin b ............................ 31ampicillin ...................................... 7ampicillin sodium ........................31ampicillin-sulbactam sodium ......31AMPYRA................................... 42ANADROL-50............................36anagrelide hcl ............................... 9anastrozole ..................................13ANGELIQ...................................67ANORO ELLIPTA.....................59ANUSOL-HC............................. 64ANZEMET................................. 28apexicon e ................................... 62APLENZIN.................................55APOKYN....................................46apraclonidine hcl ........................ 27aprepitant ....................................28apri ..............................................65APRISO...................................... 30APTIOM..................................... 47APTIVUS..................................... 4ARALAST NP............................61aranelle ....................................... 65ARCALYST............................... 40ARCAPTA NEOHALER........... 59ARGATROBAN.........................31aripiprazole .................................57ARISTADA................................ 57armodafinil ................................. 57ARNUITY ELLIPTA................. 59ARRANON.................................11ashlyna ........................................65ASMANEX 120 METERED DOSES........................................59ASMANEX 30 METERED DOSES........................................59ASMANEX 60 METERED DOSES........................................59ASMANEX HFA........................59aspirin-dipyridamole er ................ 9assure insulin safety syringe .......22ASTAGRAF XL.........................39atazanavir sulfate ..........................4atenolol ....................................... 19atenolol-chlorthalidone .............. 19ATGAM......................................39atomoxetine hcl ...........................54atorvastatin calcium ................... 21atovaquone ....................................4atovaquone-proguanil hcl .............4ATRALIN...................................61

71

ATRIPLA..................................... 4atropine sulfate ..................... 28, 31ATROVENT HFA......................59AUBAGIO..................................42aubra ...........................................65AURYXIA..................................44AUSTEDO..................................42AVASTIN...................................11AVC VAGINAL.........................69AVEED.......................................36AVELOX....................................31aviane ..........................................65avita ............................................ 61AVONEX....................................42AVONEX PEN...........................42AVONEX PREFILLED............. 43AVYCAZ....................................31azacitidine ...................................11AZASAN.................................... 49AZASITE....................................26azathioprine ................................ 49azathioprine sodium ....................49azelastine hcl .............................. 25AZELEX.....................................61AZILECT....................................46azithromycin ........................... 8, 31AZOPT....................................... 27aztreonam ................................... 31bacitracin ....................................26bacitracin-polymyxin b ............... 26bacitra-neomycin-polymyxin-hc . 26baclofen .......................................49bactocill in dextrose ....................31BACTROBAN NASAL............. 25balsalazide disodium .................. 30balziva .........................................65BANZEL.....................................47BAVENCIO................................11BAXDELA................................... 9bcg vaccine ................................. 37BELBUCA..................................52BELEODAQ...............................11benazepril hcl ..............................17benazepril-hydrochlorothiazide ..19BENLYSTA............................... 39benzoyl peroxide-erythromycin ...61benztropine mesylate .............31, 47BERINERT.................................41BESIVANCE..............................26betamethasone dipropionate .......62betamethasone dipropionate aug .............................................. 62

betamethasone valerate .............. 62BETASERON.............................43betaxolol hcl ..........................19, 27bethanechol chloride ...................45BETHKIS................................... 40BETIMOL...................................27BETOPTIC-S..............................27bexarotene ...................................13BEXSERO.................................. 37BEYAZ....................................... 66bicalutamide ............................... 13BICILLIN C-R..............................7BICILLIN C-R 900/300............... 7BICILLIN L-A..............................7BICNU........................................11BIDIL..........................................22BIKTARVY..................................4BILTRICIDE................................ 3bimatoprost ................................. 27bisoprolol fumarate .................... 19bisoprolol-hydrochlorothiazide .. 19BIVIGAM...................................37bleomycin sulfate ........................ 11BLEPHAMIDE...........................26BLEPHAMIDE S.O.P................ 26BOOSTRIX................................ 37bortezomib .................................. 11BOSULIF....................................13BOTOX.......................................40BREO ELLIPTA........................ 59briellyn ........................................66BRILINTA..................................10brimonidine tartrate ....................27BRIVIACT................................. 47bromocriptine mesylate ...............47BROVANA.................................59budesonide ............................ 30, 59bumetanide ............................21, 31BUPHENYL............................... 45buprenorphine .............................52buprenorphine hcl .......................43buprenorphine hcl-naloxone hcl .43bupropion hcl ..............................55bupropion hcl er (smoking det) ...44bupropion hcl er (sr) ...................55bupropion hcl er (xl) ...................55buspirone hcl .............................. 54busulfan .......................................11butorphanol tartrate ............. 31, 52BUTRANS..................................52BYDUREON.............................. 23BYDUREON BCISE..................23

BYETTA 10 MCG PEN.............23BYETTA 5 MCG PEN...............23cabergoline ................................. 47CABOMETYX........................... 13calcipotriene ............................... 64calcipotriene-betameth diprop ....64calcitonin (salmon) ..................... 67calcitriol ..........................31, 42, 64calcium acetate (phos binder) .....44CALQUENCE............................ 13camila ......................................... 66CAMPTOSAR............................11CANASA....................................30CANCIDAS................................31candesartan cilexetil ...................17candesartan cilexetil-hctz ........... 19CAPASTAT SULFATE............. 31capecitabine ................................14CAPEX....................................... 62CAPRELSA................................14captopril ......................................17captopril-hydrochlorothiazide ....19CARAFATE SUSPENSION...... 30CARBAGLU.............................. 29carbamazepine ............................47carbamazepine er ........................47carbidopa ....................................47carbidopa-levodopa ....................47carbidopa-levodopa er ................47carbidopa-levodopa-entacapone 47carboplatin ..................................11CARDENE IV............................ 31CARDURA XL.......................... 17CARIMUNE NF.........................37CAROSPIR.................................21carteolol hcl ................................ 27cartia xt .......................................20carvedilol .................................... 19carvedilol phosphate er .............. 19caspofungin acetate .................... 31CAYSTON................................. 40cefaclor ......................................... 7cefaclor er .....................................7cefadroxil ...................................... 7cefazolin sodium ......................... 31cefdinir ..........................................7cefepime hcl ................................ 31cefixime ......................................... 7cefotaxime sodium .......................31cefotetan disodium ...................... 31cefoxitin sodium .......................... 31cefpodoxime proxetil .....................7

72

cefprozil ........................................ 7ceftazidime .................................. 31ceftriaxone sodium ......................32cefuroxime axetil ...........................7cefuroxime sodium ...................... 32celecoxib ..................................... 51CELLCEPT.................................39CELONTIN................................ 47cephalexin ..................................... 7CERDELGA............................... 41CEREZYME...............................41CESAMET..................................28cevimeline hcl ............................. 25CHANTIX.................................. 44CHANTIX CONTINUING MONTH PAK.............................44CHANTIX STARTING MONTH PAK.............................44CHEMET....................................40chloramphenicol sod succinate ...32chlordiazepoxide-amitriptyline ...54chlorhexidine gluconate ..............25chloroquine phosphate ..................4chlorothiazide ............................. 21chlorpromazine hcl ..................... 57chlorpropamide ...........................24chlorthalidone .............................21CHOLBAM................................ 29cholestyramine light ....................21CIALIS....................................... 44ciclopirox .................................... 63ciclopirox olamine ...................... 63cidofovir ......................................32cilostazol ..................................... 10cimetidine ....................................30cimetidine solution ......................30CIMZIA...................................... 49CIMZIA PREFILLED................ 50CINRYZE................................... 41CINVANTI................................. 28CIPRO HC.................................. 25CIPRODEX................................ 25ciprofloxacin ........................... 9, 32ciprofloxacin hcl ..................... 9, 26ciprofloxacin in d5w ................... 32ciprofloxacin-ciproflox hcl er ....... 9cisplatin .......................................11citalopram hydrobromide ........... 55cladribine ....................................11claravis ....................................... 61clarithromycin ...............................8clarithromycin er .......................... 8

CLEOCIN................................... 69CLINDAGEL..............................61clindamycin capsules .................... 8clindamycin oral solution ............. 8clindamycin phos-benzoyl perox .61clindamycin phosphate ... 32, 61, 69clindamycin phosphate in d5w ....32CLINIMIX E/DEXTROSE (2.75/10)......................................34CLINIMIX E/DEXTROSE (2.75/5)........................................34CLINIMIX E/DEXTROSE (4.25/10)......................................34CLINIMIX E/DEXTROSE (4.25/25)......................................34CLINIMIX E/DEXTROSE (4.25/5)........................................35CLINIMIX E/DEXTROSE (5/15)...........................................35CLINIMIX E/DEXTROSE (5/20)...........................................35CLINIMIX E/DEXTROSE (5/25)...........................................35CLINIMIX/DEXTROSE (2.75/5)........................................35CLINIMIX/DEXTROSE (4.25/10)......................................35CLINIMIX/DEXTROSE (4.25/20)......................................35CLINIMIX/DEXTROSE (4.25/25)......................................35CLINIMIX/DEXTROSE (4.25/5)........................................35CLINIMIX/DEXTROSE (5/15). 35CLINIMIX/DEXTROSE (5/20). 35CLINIMIX/DEXTROSE (5/25). 35CLINISOL SF.............................35clobetasol propionate ................. 62clobetasol propionate e ...............62clodan ......................................... 62CLODERM.................................62clofarabine ..................................11CLOLAR.................................... 11clomipramine hcl ........................ 55clonazepam ................................. 47clonidine hcl ................................20clonidine hcl er ........................... 54clopidogrel bisulfate ................... 10clorazepate dipotassium ............. 54clotrimazole ............................ 3, 63clotrimazole-betamethasone ....... 63clozapine ..................................... 57

COARTEM...................................4codeine sulfate ............................ 52colchicine ....................................51colchicine-probenecid .................51colestipol hcl ...............................21colistimethate sodium ................. 32colistimethate sodium (cba) ........32colocort ....................................... 30COLY-MYCIN S........................26COMBIGAN...............................27COMBIPATCH.......................... 67COMBIVENT RESPIMAT........59COMETRIQ (100 MG DAILY DOSE).........................................14COMETRIQ (140 MG DAILY DOSE).........................................14COMETRIQ (60 MG DAILY DOSE).........................................14comfort assist insulin syringe ..... 22COMPLERA.................................4compro ........................................ 28CONDYLOX..............................65constulose ................................... 29COPAXONE...............................43CORDRAN.................................62COREG CR................................ 19CORLANOR.............................. 17cortisone acetate .........................35CORTISPORIN.......................... 62COSENTYX 300 DOSE.............64COSENTYX SENSOREADY 300 DOSE...................................64COSMEGEN.............................. 11COTELLIC................................. 14COUMADIN.............................. 10CREON.......................................29CRESEMBA...........................3, 32CRINONE...................................67CRIXIVAN...................................4cromolyn sodium .............25, 29, 59CUPRIMINE.............................. 45cvs gauze sterile ..........................22cyclobenzaprine hcl .................... 49CYCLOPHOSPHAMIDE.......... 14CYCLOSET................................47cyclosporine ..........................32, 39cyclosporine modified .................39cyproheptadine hcl ......................25CYRAMZA................................ 11CYSTADANE............................ 40CYSTAGON...............................29CYSTARAN...............................28

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cytarabine ................................... 11cytarabine (pf) .............................11dacarbazine .................................11DACOGEN.................................11dactinomycin ...............................11DALIRESP................................. 61DALVANCE.............................. 32danazol ........................................36dantrolene sodium ...................... 49dapsone tablets ............................. 4DAPTACEL............................... 37daptomycin ..................................32DARAPRIM................................. 4darifenacin hydrobromide er ......45DARZALEX...............................11daunorubicin hcl .........................11deblitane ..................................... 66decitabine ....................................11DELESTROGEN........................67delyla ...........................................66DELZICOL.................................30demeclocycline hcl ........................9DEMSER.................................... 44DENAVIR.................................. 65DEPEN TITRATABS................ 45DEPO-ESTRADIOL.................. 68DEPO-MEDROL........................35DEPO-PROVERA......................68DEPO-SUBQ PROVERA 104... 68DEPO-TESTOSTERONE.......... 36DESCOVY................................... 4desipramine hcl ...........................55desloratadine .............................. 25desmopressin ace rhinal tube ..... 45desmopressin ace spray refrig .... 45desmopressin acetate .................. 45desogestrel-ethinyl estradiol .......66desonide ...................................... 62desoximetasone ........................... 62DESOXYN................................. 54desvenlafaxine er ........................ 55desvenlafaxine succinate er ........ 55dexamethasone ............................35dexamethasone intensol .............. 35dexamethasone sodium phosphate ..............................26, 32DEXEDRINE..............................54dexmethylphenidate hcl ...............54dexmethylphenidate hcl er .......... 54dexpak 13 day ............................. 35dexrazoxane ................................ 11dextroamphetamine sulfate .........54

dextroamphetamine sulfate er .....54dextrose .......................................34dextrose in lactated ringers ........ 34dextrose-nacl ...............................34DIASTAT ACUDIAL................ 47DIASTAT PEDIATRIC............. 47diazepam ..................................... 47diazepam intensol ....................... 47DIBENZYLINE..........................44diclofenac potassium .................. 51diclofenac sodium ........... 26, 51, 64diclofenac sodium er ...................51diclofenac-misoprostol ............... 51dicloxacillin sodium ......................8dicyclomine hcl ........................... 29didanosine .....................................4DIFICID........................................8diflorasone diacetate .................. 62diflunisal ..................................... 51digitek ......................................... 18digox ........................................... 18digoxin ........................................ 18dihydroergotamine mesylate .......46DILANTIN................................. 48DILANTIN INFATABS.............48diltiazem hcl ..........................20, 32diltiazem hcl er ........................... 20diltiazem hcl er beads ................. 20diltiazem hcl er coated beads ......20dilt-xr .......................................... 20diphenhydramine hcl ...................32diphtheria-tetanus toxoids dt ...... 37dipyridamole ............................... 10disopyramide phosphate ............. 18disulfiram ....................................53divalproex sodium .......................48divalproex sodium er .................. 48DIVIGEL.................................... 68docetaxel ..................................... 12dofetilide ..................................... 18donepezil hcl ......................... 45, 46doripenem ................................... 32dorzolamide hcl .......................... 27dorzolamide hcl-timolol mal .......27doxazosin mesylate ..................... 17doxepin hcl ............................55, 64doxercalciferol ............................42doxorubicin hcl ........................... 12doxorubicin hcl liposomal .......... 12DOXY 100..................................32doxycycline hyclate ....................... 9doxycycline monohydrate ............. 9

dronabinol ...................................28drospirenone-ethinyl estradiol ....66DROXIA.....................................14DUAVEE....................................68duloxetine hcl ..............................55DUOPA.......................................47DUPIXENT................................ 64DUREZOL..................................26dutasteride .................................. 44dutasteride-tamsulosin hcl ..........44DUTOPROL............................... 19DYSPORT.................................. 40e.e.s. 400 ....................................... 8E.E.S. GRANULES......................8econazole nitrate .........................63EDECRIN................................... 21EDURANT................................... 4efavirenz ........................................5EFFIENT.................................... 10EGRIFTA................................... 41ELAPRASE................................ 42ELELYSO...................................41ELESTRIN................................. 68eletriptan hydrobromide ............. 46ELIDEL...................................... 64ELIGARD...................................36ELIQUIS.....................................10ELIQUIS STARTER PACK...... 10ELITEK...................................... 12ELLENCE...................................12ELMIRON.................................. 45EMADINE..................................25EMBEDA................................... 52EMCYT...................................... 14EMEND................................ 28, 32EMFLAZA................................. 41emoquette ....................................66EMPLICITI.................................12EMSAM......................................55EMTRIVA.................................... 5enalapril maleate ........................ 17enalapril-hydrochlorothiazide ....19ENBREL.....................................50ENBREL SURECLICK..............50endocet ........................................52ENGERIX-B...............................37enoxaparin sodium ......................10entacapone ..................................47entecavir ........................................5ENTRESTO................................19enulose ........................................ 29ENVARSUS XR.........................39

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EPCLUSA.....................................5epinastine hcl .............................. 25epinephrine ................................. 40epirubicin hcl .............................. 12epitol ........................................... 48EPIVIR......................................... 5eplerenone ...................................21eprosartan mesylate ....................17EQUETRO..................................54ERAXIS......................................32ERBITUX................................... 12ergoloid mesylates ...................... 46ERIVEDGE................................ 14ERLEADA..................................14errin ............................................ 66ERTACZO..................................63ERWINAZE................................12ery ............................................... 61eryped 200 .....................................8eryped 400 .....................................8ERY-TAB..................................... 8ERYTHROCIN LACTOBIONATE......................32erythrocin stearate ........................8erythromycin ......................... 26, 61erythromycin base .........................8erythromycin ethylsuccinate ......... 8ESBRIET.................................... 60escitalopram oxalate ...................55esomeprazole magnesium ........... 30esomeprazole sodium ..................32esomeprazole strontium .............. 30estazolam .................................... 56ESTRACE...................................68estradiol ...................................... 68estradiol valerate ........................ 68estradiol-norethindrone acet ...... 66ESTRING................................... 68estropipate .................................. 68eszopiclone ..................................56ethacrynic acid ............................21ethambutol hcl .............................. 8ethosuximide ............................... 48etidronate disodium .................... 43etodolac .......................................51etodolac er .................................. 51ETOPOPHOS............................. 12etoposide ............................... 12, 14EUCRISA................................... 64EURAX.......................................64EVAMIST...................................68EVOCLIN...................................61

EVOTAZ...................................... 5EVZIO........................................ 43exel comfort point pen needle ..... 22EXELDERM...............................63exemestane .................................. 14EXJADE..................................... 40EXONDYS 51............................ 41EXTAVIA...................................43ezetimibe ..................................... 21ezetimibe-simvastatin ..................21FABIOR......................................61FABRAZYME............................41falmina ........................................ 66famciclovir .................................... 5famotidine ................................... 30FANAPT.....................................57FANAPT TITRATION PACK...57FARESTON................................14FARYDAK................................. 14FASENRA.................................. 59FASLODEX............................... 12FAZACLO..................................57felbamate .....................................48felodipine er ................................ 20FEMHRT LOW DOSE...............68FEMRING.................................. 68fenofibrate ...................................21fenofibrate micronized ................ 21fenofibric acid .............................21fenoprofen calcium ..................... 51fentanyl ....................................... 52fentanyl citrate ............................ 52FENTORA..................................52FERRIPROX.............................. 40FETZIMA................................... 55FETZIMA TITRATION.............55FINACEA................................... 61finasteride ................................... 44FIRAZYR................................... 42FIRMAGON............................... 36FLAREX.....................................26flavoxate hcl ................................45FLEBOGAMMA DIF................ 37flecainide acetate ........................ 18FLOLIPID...................................21FLOVENT DISKUS...................59FLOVENT HFA......................... 59fluconazole ....................................3fluconazole in sodium chloride ...32flucytosine ..................................... 3fludarabine phosphate ................ 12fludrocortisone acetate ............... 35

flunisolide ................................... 25fluocinolone acetonide ..........25, 62fluocinolone acetonide scalp ...... 62fluocinonide ................................ 62fluocinonide emulsified base .......62fluorometholone ..........................26fluorouracil ........................... 12, 64fluoxetine hcl .........................55, 56fluphenazine decanoate ...............57fluphenazine hcl .......................... 57flurandrenolide ..................... 62, 63flurazepam hcl ............................ 56flurbiprofen ................................. 51flurbiprofen sodium .................... 27flutamide ..................................... 14fluticasone propionate .......... 25, 63fluticasone-salmeterol .................59fluvastatin sodium .......................21fluvastatin sodium er ...................21fluvoxamine maleate ................... 56fluvoxamine maleate er ...............56FML............................................ 27FML FORTE.............................. 27FOCALIN XR............................ 54fondaparinux sodium .................. 10FORTEO.....................................68fosamprenavir calcium ................. 5fosinopril sodium ........................ 17fosinopril sodium-hctz ................ 19fosphenytoin sodium ................... 48FRAGMIN..................................10FREAMINE HBC.......................35frovatriptan succinate .................46furosemide .............................21, 32FUSILEV....................................16FUZEON.......................................5fyavolv .........................................68FYCOMPA................................. 48gabapentin .................................. 48GABITRIL..................................48galantamine hydrobromide .........46galantamine hydrobromide er .... 46GAMASTAN S/D...................... 37GAMMAGARD......................... 38GAMMAGARD S/D LESS IGA............................................. 38GAMMAKED............................ 38GAMMAPLEX...........................38GAMUNEX-C............................38ganciclovir sodium ......................12GARDASIL 9............................. 38gatifloxacin ................................. 26

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GATTEX.................................... 29gauze pads .................................. 22gemcitabine hcl ...........................12gemfibrozil .................................. 21GENERESS FE.......................... 66generlac ...................................... 29gengraf ........................................39GENOTROPIN...........................41GENOTROPIN MINIQUICK.... 41gentak ..........................................26gentamicin in saline ....................32gentamicin sulfate ...........26, 32, 62GENVOYA...................................5GEODON INTRAMUSCULAR INJECTION................................57GILENYA...................................43GILOTRIF.................................. 14GLASSIA................................... 61GLEOSTINE.............................. 14glimepiride ..................................24glipizide .......................................24glipizide er .................................. 24glipizide-metformin hcl ...............24global alcohol prep ease .............22GLUCAGEN HYPOKIT............23GLUCAGON EMERGENCY.... 23glyburide ..................................... 24glyburide micronized .................. 24glyburide-metformin ................... 24glycopyrrolate .............................29gnp ultra com insulin syringe ..... 22GNP ULTRA COM INSULIN SYRINGE................................... 22granisetron hcl ......................28, 32griseofulvin microsize ...................3griseofulvin ultramicrosize ........... 3guanfacine hcl er ........................ 54guanidine hcl .............................. 43GYNAZOLE-1........................... 69HAEGARDA..............................42HALAVEN................................. 12halobetasol propionate ............... 63HALOG...................................... 63haloperidol ..................................57haloperidol decanoate ................ 57haloperidol lactate ......................57HARVONI....................................5HAVRIX.....................................38heparin sodium (porcine) ............32HEPATAMINE.......................... 35HERCEPTIN.............................. 12

HETLIOZ....................................56HEXALEN..................................14HIBERIX.................................... 38HORIZANT................................48HP ACTHAR..............................35HUMALOG................................23HUMALOG JUNIOR KWIKPEN..................................23HUMALOG KWIKPEN.............23HUMALOG MIX 50/50............. 23HUMALOG MIX 50/50 KWIKPEN..................................23HUMALOG MIX 75/25............. 23HUMALOG MIX 75/25 KWIKPEN..................................23HUMATROPE........................... 41HUMIRA.................................... 50HUMIRA PEDIATRIC CROHNS START...................... 50HUMIRA PEN............................50HUMIRA PEN-CROHNS STARTER...................................50HUMIRA PEN-PSORIASIS STARTER...................................50HUMULIN 70/30....................... 23HUMULIN 70/30 KWIKPEN....23HUMULIN N..............................23HUMULIN N KWIKPEN.......... 23HUMULIN R..............................23HUMULIN R U-500 (CONCENTRATED)..................23HUMULIN R U-500 KWIKPEN..................................23HYCAMTIN...............................14hydralazine hcl ............................22hydrochlorothiazide ....................21hydrocodone-acetaminophen ......52hydrocodone-ibuprofen ...............52hydrocortisone ................ 30, 35, 63hydrocortisone ace-pramoxine ... 63hydrocortisone butyrate ..............63hydrocortisone valerate .............. 63hydrocortisone-acetic acid ......... 25hydromorphone hcl .....................52hydromorphone hcl er .................52hydroxychloroquine sulfate ...........4hydroxyprogesterone caproate ... 69hydroxyurea ................................ 14hydroxyzine hcl ..................... 25, 32hydroxyzine pamoate .................. 25HYPERRAB S/D........................38HYSINGLA ER..........................52

ibandronate sodium .................... 68IBRANCE...................................14ibuprofen .....................................51ICLUSIG.....................................14idarubicin hcl ..............................12IDHIFA.......................................14ifosfamide ....................................12ILARIS....................................... 40ILEVRO......................................27imatinib mesylate ........................ 14IMBRUVICA............................. 14IMFINZI..................................... 12imipenem-cilastatin .....................32imipramine hcl ............................ 56imipramine pamoate ................... 56imiquimod ................................... 65IMOGAM RABIES-HT............. 38IMOVAX RABIES.....................38INCRELEX.................................41INCRUSE ELLIPTA.................. 59indapamide ................................. 21INDOCIN ORAL SUSPENSION............................ 51indomethacin ...............................51indomethacin er .......................... 51INFANRIX................................. 38INFLECTRA.............................. 50INGREZZA................................ 45INLYTA......................................14INTELENCE................................ 5INTRALIPID..............................35INTRAROSA............................. 69INTRON A................................... 5introvale ......................................66INVANZ..................................... 32INVEGA SUSTENNA............... 57INVEGA TRINZA..................... 57INVIRASE....................................5INVOKAMET............................ 24INVOKAMET XR......................24INVOKANA...............................24IONOSOL-MB IN D5W............ 34IOPIDINE................................... 27IPOL........................................... 38ipratropium bromide .............25, 59ipratropium-albuterol ................. 59irbesartan ....................................18irbesartan-hydrochlorothiazide ..19IRESSA.......................................14irinotecan hcl .............................. 12ISENTRESS................................. 5ISENTRESS HD...........................5

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ISOLYTE-P IN D5W................. 34ISOLYTE-S................................ 34isoniazid ..................................8, 32isosorbide dinitrate .....................17isosorbide dinitrate er .................17isosorbide mononitrate ............... 17isosorbide mononitrate er ...........17isotretinoin ..................................61isradipine .................................... 20ISTODAX (OVERFILL)............12itraconazole .................................. 3ivermectin ......................................3IXIARO...................................... 38JADENU.....................................40JADENU SPRINKLE.................40JAKAFI.......................................14jantoven .......................................10JANUMET..................................24JANUMET XR........................... 24JANUVIA................................... 24JARDIANCE.............................. 24JENTADUETO...........................24JENTADUETO XR.................... 24JEVTANA.................................. 12jinteli ........................................... 66JULUCA....................................... 5junel 1.5/30 ................................. 66junel 1/20 .................................... 66junel fe 1.5/30 ............................. 66junel fe 1/20 ................................ 66junel fe 24 ................................... 66JUXTAPID................................. 21KADCYLA.................................12KALETRA....................................5KALYDECO.............................. 40KANUMA.................................. 42KAPVAY....................................54kariva .......................................... 66kcl in dextrose-nacl .....................34kcl-lactated ringers-d5w .............34kelnor 1/35 .................................. 66KENALOG................................. 63ketoconazole ............................3, 63ketoprofen ................................... 51ketoprofen er ...............................51ketorolac tromethamine .............. 27KEVEYIS................................... 44KEVZARA................................. 50KEYTRUDA.............................. 12KINERET................................... 50KINRIX...................................... 38kionex ..........................................44

KISQALI 200 DOSE..................14KISQALI 400 DOSE..................14KISQALI 600 DOSE..................14KISQALI FEMARA 200 DOSE 14KISQALI FEMARA 400 DOSE 14KISQALI FEMARA 600 DOSE 15klor-con .......................................22klor-con 10 ..................................22klor-con m10 ...............................22KLOR-CON M15....................... 22klor-con m20 ...............................22klor-con sprinkle .........................22KORLYM................................... 40KRISTALOSE............................29K-TAB........................................ 22KUVAN......................................44KYNAMRO................................21KYPROLIS.................................15labetalol hcl .......................... 19, 32lactated ringers ...........................34lactulose ......................................29lamivudine .....................................5lamivudine-zidovudine ..................5lamotrigine ..................................48lamotrigine er ............................. 48lamotrigine starter kit-blue .........48lamotrigine starter kit-green .......48lamotrigine starter kit-orange .... 48lancets ......................................... 22LANOXIN.................................. 18lansoprazole ................................30LANTUS.....................................23LANTUS SOLOSTAR...............23larin 1.5/30 ................................. 66larin 1/20 .................................... 66larin fe 1.5/30 ..............................66larin fe 1/20 .................................66LARTRUVO...............................12LASTACAFT............................. 26latanoprost ..................................28LATUDA....................................57LAZANDA........................... 52, 53leflunomide ................................. 50LENVIMA 10 MG DAILY DOSE..........................................15LENVIMA 14 MG DAILY DOSE..........................................15LENVIMA 18 MG DAILY DOSE..........................................15LENVIMA 20 MG DAILY DOSE..........................................15

LENVIMA 24 MG DAILY DOSE..........................................15LENVIMA 8 MG DAILY DOSE..........................................15lessina ......................................... 66LETAIRIS...................................60letrozole ...................................... 15leucovorin calcium ......................16LEUKERAN...............................15LEUKINE................................... 10leuprolide acetate ....................... 36levalbuterol hcl ........................... 59levalbuterol tartrate ....................59levetiracetam ...............................48levetiracetam er .......................... 48levetiracetam in nacl ...................32levobunolol hcl ............................28levocarnitine ............................... 29levocetirizine dihydrochloride .... 25levofloxacin .......................9, 26, 32levofloxacin in d5w ..................... 32levoleucovorin calcium ...............16levonest ....................................... 66levonorgest-eth estrad 91-day .... 66levonorgestrel-ethinyl estradiol ..66levora 0.15/30 (28) ..................... 66levorphanol tartrate ....................53levo-t ........................................... 37levothyroxine sodium ............ 33, 37levoxyl ......................................... 37LEXIVA........................................5lidocaine ............................... 64, 65lidocaine hcl ..........................33, 65lidocaine hcl (pf) .........................33lidocaine viscous .........................65lidocaine-prilocaine ....................65LINCOCIN................................. 33lincomycin hcl .............................33lindane ........................................ 64linezolid ...................................3, 33LINZESS.................................... 30liothyronine sodium .................... 37lisinopril ......................................17lisinopril-hydrochlorothiazide ....19lithium ......................................... 55lithium carbonate ........................55lithium carbonate er ................... 55LO LOESTRIN FE..................... 66LONSURF.................................. 15loperamide hcl ............................ 29lopinavir-ritonavir ........................ 5lorazepam ................................... 54

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losartan potassium ......................18losartan potassium-hctz .............. 19LOTEMAX.................................27lovastatin .....................................21loxapine succinate .......................57LUMIGAN..................................28LUMIZYME...............................42LUPRON DEPOT (1-MONTH).36LUPRON DEPOT (3-MONTH).36LUPRON DEPOT (4-MONTH).36LUPRON DEPOT (6-MONTH).36LUPRON DEPOT-PED (1-MONTH).................................... 37LUPRON DEPOT-PED (3-MONTH).................................... 37LYNPARZA............................... 15LYRICA..................................... 48LYRICA CR............................... 48LYSODREN............................... 15magnesium sulfate ...................... 34MAKENA...................................69malathion .................................... 64maprotiline hcl ............................56marlissa .......................................66MARPLAN.................................56MATULANE..............................15matzim la .....................................20MAVYRET...................................5MAXIDEX..................................27meclizine hcl ............................... 28meclofenamate sodium ................51MEDROL................................... 35medroxyprogesterone acetate ..... 68mefenamic acid ........................... 51mefloquine hcl ...............................4megestrol acetate .................. 15, 29MEKINIST................................. 15meloxicam ................................... 51melphalan ................................... 15melphalan hcl ..............................12memantine hcl .............................46memantine hcl er .........................46MENACTRA..............................38MENEST.................................... 68MENOSTAR.............................. 68MENTAX................................... 63MENVEO................................... 38mercaptopurine ...........................15meropenem ..................................33mesalamine ................................. 31mesna .......................................... 16MESNEX....................................16

MESTINON SYRUP..................43METADATE ER........................ 54metaproterenol sulfate ................ 59metformin hcl .............................. 24metformin hcl er ..........................24metformin hcl er 1,000 mg ..........24methadone hcl .............................53methamphetamine hcl ................. 54methazolamide ............................ 28methenamine hippurate .................3methimazole ................................ 37METHITEST.............................. 36methotrexate ................................50methotrexate sodium ...................33methotrexate sodium (pf) ............ 33methoxsalen rapid .......................64methscopolamine bromide .......... 30methyclothiazide ......................... 21METHYLIN................................54methylphenidate hcl .................... 54methylphenidate hcl er ................54methylphenidate hcl er (cd) ........ 54methylphenidate hcl er (la) ......... 54methylprednisolone .....................36methylprednisolone acetate ........ 36methylprednisolone sodium succ 36methyltestosterone ...................... 36metipranolol ................................28metoclopramide hcl ...............28, 33metolazone .................................. 21metoprolol succinate er .............. 19metoprolol tartrate ................20, 33metoprolol-hydrochlorothiazide . 19metronidazole ................... 3, 61, 69metronidazole in nacl ................. 33mexiletine hcl .............................. 18MIACALCIN..............................68miconazole 3 ............................... 69microgestin 1.5/30 ...................... 66microgestin 1/20 ......................... 66microgestin fe 1.5/30 .................. 66microgestin fe 1/20 ..................... 66midodrine hcl .............................. 20MIGERGOT............................... 46miglitol ........................................24MIGRANAL...............................46MILLIPRED............................... 36minocycline hcl ............................. 9minocycline hcl er .........................9minoxidil ..................................... 22mirtazapine ................................. 56misoprostol ................................. 30

mitomycin ....................................12mitoxantrone hcl ......................... 12M-M-R II.................................... 38modafinil ..................................... 57moexipril hcl ............................... 17moexipril-hydrochlorothiazide ... 19mometasone furoate ..............25, 63montelukast sodium .................... 59MONUROL.................................. 3morphine sulfate ......................... 53morphine sulfate (concentrate) ...53morphine sulfate er ..................... 53morphine sulfate er beads ...........53MOVANTIK...............................29MOVIPREP................................ 29MOXEZA................................... 26moxifloxacin hcl ................9, 26, 33MOZOBIL.................................. 10MULTAQ................................... 18mupirocin ....................................62mupirocin calcium ...................... 62MUSTARGEN........................... 12MYCAMINE.............................. 33mycophenolate mofetil ................ 39mycophenolate mofetil hcl .......... 39mycophenolate sodium ................39MYLERAN.................................15MYLOTARG..............................12MYRBETRIQ.............................45MYTESI..................................... 29nabumetone .................................51nadolol ........................................ 20nadolol-bendroflumethiazide ......19nafcillin sodium .......................... 33naftifine hcl ................................. 63NAFTIN GEL.............................63NAGLAZYME........................... 42naloxone hcl ................................43naltrexone hcl ............................. 53NAMENDA XR......................... 46NAMENDA XR TITRATION PACK..........................................46naproxen ............................... 51, 52naproxen dr .................................51naproxen sodium .........................52naproxen sodium er .................... 52naratriptan hcl ............................ 46NARCAN................................... 43NATACYN.................................28nateglinide .................................. 24NATPARA................................. 42NEBUPENT................................. 4

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necon 0.5/35 (28) ........................ 66necon 7/7/7 ..................................67nefazodone hcl ............................ 56neomycin sulfate ........................... 3neomycin-bacitracin zn-polymyx ....................................... 26neomycin-polymyxin b ................ 65neomycin-polymyxin-dexameth ...27neomycin-polymyxin-gramicidin 27neomycin-polymyxin-hc ........ 26, 27NEPHRAMINE.......................... 35NERLYNX................................. 15NEULASTA............................... 10NEUPRO.................................... 47NEVANAC.................................27nevirapine ..................................... 5nevirapine er .................................6NEXAVAR.................................15niacin er ...................................... 21niacor ..........................................22nicardipine hcl ............................ 20NICOTROL................................ 44NICOTROL NS.......................... 44nifedipine .................................... 20nifedipine er ................................ 20nifedipine er osmotic release ...... 20nikki .............................................67nilutamide ................................... 15nimodipine .................................. 20NINLARO.................................. 15nisoldipine er .............................. 20NITRO-BID................................17nitrofurantoin macrocrystal ..........3nitrofurantoin monohyd macro .....3nitroglycerin ............................... 17NITROSTAT.............................. 17nizatidine .....................................30nolix ............................................ 63NORDITROPIN FLEXPRO...... 41norethin ace-eth estrad-fe ...........67norethindrone acetate .................68norethindrone-eth estradiol ........ 67norethin-eth estradiol-fe ............. 67NORITATE................................ 61norlyroc .......................................67NORMOSOL-M IN D5W.......... 34NORMOSOL-R IN D5W........... 34NORMOSOL-R PH 7.4..............34NORPACE CR........................... 18NORTHERA...............................20nortrel 0.5/35 (28) ...................... 67nortrel 1/35 (21) ......................... 67

nortrel 1/35 (28) ......................... 67nortrel 7/7/7 ................................ 67nortriptyline hcl .......................... 56NORVIR....................................... 6NOXAFIL.....................................3NUCALA....................................61NUEDEXTA...............................47NULOJIX....................................39NUPLAZID................................ 57NUTRILIPID..............................35NUTROPIN AQ NUSPIN 10.....41NUTROPIN AQ NUSPIN 20.....41NUTROPIN AQ NUSPIN 5.......41NUVARING............................... 67nyamyc ........................................ 63NYMALIZE................................20nystatin ....................................3, 63nystatin-triamcinolone ................63nystop ..........................................63OCALIVA.................................. 29OCTAGAM................................ 38octreotide acetate ........................39ODEFSEY.................................... 6ODOMZO...................................15OFEV..........................................60ofloxacin ........................... 9, 25, 26olanzapine ...................................57olanzapine-fluoxetine hcl ............55olmesartan medoxomil ................18olmesartan medoxomil-hctz ........ 19olmesartan-amlodipine-hctz ....... 19olopatadine hcl ..................... 25, 26omega-3-acid ethyl esters ........... 22omeprazole ..................................30omeprazole-sodium bicarbonate .30OMNITROPE............................. 41ondansetron ................................ 28ondansetron hcl .................... 28, 33ONETOUCH ULTRA BLUE.....23ONFI........................................... 48OPDIVO..................................... 12OPSUMIT...................................60ORALAIR...................................61ORAP..........................................57ORAPRED ODT........................ 36ORBACTIV................................33ORENCIA...................................50ORENCIA CLICKJECT............ 50ORENITRAM.............................60ORFADIN...................................42ORKAMBI................................. 40orsythia ....................................... 67

ORTHO TRI-CYCLEN (28)...... 67oseltamivir phosphate ...................6OSMOPREP............................... 29OSPHENA..................................69OTEZLA.....................................64oxacillin sodium ..........................33oxaliplatin ................................... 12oxandrolone ................................ 36oxaprozin .................................... 52oxazepam .................................... 54oxcarbazepine ............................. 48oxiconazole nitrate ......................63OXISTAT................................... 64OXTELLAR XR.........................48oxybutynin chloride .....................45oxybutynin chloride er ................ 45oxycodone hcl ............................. 53oxycodone hcl er ......................... 53oxycodone-acetaminophen ..........53oxycodone-aspirin .......................53oxycodone-ibuprofen .................. 53OXYCONTIN.............................53oxymorphone hcl .........................53oxymorphone hcl er .................... 53OZEMPIC...................................23paclitaxel .....................................12paliperidone er ............................58PALONOSETRON HCL............28pamidronate disodium ................ 68PANDEL.....................................63PANRETIN.................................65pantoprazole sodium ...................30paricalcitol ..................................42paromomycin sulfate .....................4paroxetine hcl ............................. 56paroxetine hcl er ......................... 56paroxetine mesylate .................... 56PASER..........................................8PAXIL ORAL SUSPENSION... 56PCE............................................... 8PEDIARIX..................................38PEDVAX HIB............................ 38peg 3350-kcl-na bicarb-nacl .......29peg-3350/electrolytes ..................29PEGANONE...............................48PEGASYS.....................................6PEGASYS PROCLICK................6penicillin g pot in dextrose ......... 33penicillin g potassium ................. 33penicillin g sodium ......................33penicillin v potassium ................... 8PENTAM......................................4

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pentoxifylline er .......................... 11PERFOROMIST.........................59perindopril erbumine .................. 17periogard .................................... 25PERJETA....................................12permethrin ...................................64perphenazine ...............................58perphenazine-amitriptyline .........58PEXEVA.....................................56phenelzine sulfate ........................56phenobarbital ..............................48phenoxybenzamine hcl ................ 44phenytoin .....................................48phenytoin sodium ........................ 48phenytoin sodium extended .........48PHOSPHOLINE IODIDE.......... 28pilocarpine hcl ...................... 25, 28pimozide ......................................58pindolol ....................................... 20pioglitazone hcl ...........................24pioglitazone hcl-glimepiride .......24pioglitazone hcl-metformin hcl ... 24piperacillin sod-tazobactam so ...33piroxicam .................................... 52PLASMA-LYTE 148..................34PLASMA-LYTE A.....................34PLEGRIDY.................................43PLEGRIDY STARTER PACK.. 43PLENAMINE............................. 35PNEUMOVAX 23......................38podofilox ..................................... 65polyethylene glycol 3350 ............ 29polymyxin b sulfate ..................... 33polymyxin b-trimethoprim ...........26POMALYST...............................15portia-28 ..................................... 67potassium chloride ................22, 34potassium chloride crys er ..........22potassium chloride er ................. 22potassium chloride in dextrose ... 34potassium chloride in nacl ..........34potassium citrate er .................... 45PRADAXA................................. 10pramipexole dihydrochloride ......47pramipexole dihydrochloride er . 47prasugrel hcl ...............................10pravastatin sodium ......................22prazosin hcl .................................17PRED MILD...............................27PRED-G......................................27PRED-G S.O.P............................27prednicarbate ..............................63

prednisolone ............................... 36prednisolone acetate ...................27prednisolone sodium phosphate...............................................27, 36prednisone ...................................36PREDNISONE INTENSOL.......36preferred plus insulin syringe .....23PREMARIN................................68PREMASOL............................... 35PREMPHASE.............................68PREMPRO..................................68prenatal .......................................69PREVALITE...............................22PREVNAR 13.............................38PREVYMIS.................................. 6PREZCOBIX................................ 6PREZISTA....................................6PRIFTIN....................................... 8primaquine phosphate .................. 4primidone ....................................48PRIVIGEN..................................38PROAIR HFA.............................59PROAIR RESPICLICK..............59probenecid .................................. 51PROCALAMINE....................... 35prochlorperazine .........................29prochlorperazine edisylate ......... 33prochlorperazine maleate ...........29PROCRIT................................... 10procto-med hc ............................. 65procto-pak ...................................65proctosol hc ................................ 65proctozone-hc ..............................65profeno ........................................52progesterone micronized .............68PROGLYCEM............................23PROGRAF INJECTION............ 33PROLASTIN-C.......................... 61PROLENSA................................27PROLEUKIN..............................12PROLIA......................................68PROMACTA.............................. 10promethazine hcl ...................29, 33propafenone hcl .......................... 18propafenone hcl er ......................18propantheline bromide ................29proparacaine hcl .........................28propranolol hcl ........................... 20propranolol hcl er .......................20propranolol-hctz ......................... 19propylthiouracil .......................... 37PROQUAD................................. 38

PROSOL..................................... 35protriptyline hcl .......................... 56PROVENTIL HFA..................... 59prudoxin ......................................65PULMICORT FLEXHALER.....60PULMOZYME........................... 40PURIXAN...................................15PYLERA.....................................30pyrazinamide .................................8pyridostigmine bromide .............. 43pyridostigmine bromide er ..........43QUADRACEL............................38quasense ......................................67QUDEXY XR.............................48quetiapine fumarate .................... 58quetiapine fumarate er ................58QUILLIVANT XR..................... 54quinapril hcl ................................17quinapril-hydrochlorothiazide ....19quinidine gluconate er ................ 18quinidine sulfate ..........................18quinine sulfate ...............................4QVAR......................................... 60QVAR REDIHALER................. 60RABAVERT...............................38rabeprazole sodium .................... 30RADICAVA............................... 39raloxifene hcl .............................. 68ramipril ....................................... 17RANEXA....................................17ranitidine hcl ...............................30RAPAMUNE ORAL SOLUTION................................ 39rasagiline mesylate ..................... 47RASUVO....................................50RAVICTI.................................... 45REBETOL.................................... 6REBIF......................................... 43REBIF REBIDOSE.................... 43REBIF REBIDOSE TITRATION PACK................... 43REBIF TITRATION PACK....... 43RECLAST...................................68RECOMBIVAX HB...................38REGRANEX...............................65RELENZA DISKHALER.............6RELI-ON INSULIN SYRINGE. 23RELISTOR................................. 30REMICADE............................... 50REMODULIN............................ 60RENFLEXIS...............................50RENVELA..................................44

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repaglinide ..................................24repaglinide-metformin hcl .......... 24REPATHA..................................22REPATHA PUSHTRONEX SYSTEM.....................................22REPATHA SURECLICK...........22RESCRIPTOR.............................. 6RESTASIS..................................28RETIN-A.................................... 61RETIN-A MICRO...................... 61RETIN-A MICRO PUMP.......... 62RETROVIR................................ 33REVATIO ORAL SOLUTION..60REVLIMID.................................15REXULTI................................... 58REYATAZ....................................6ribasphere ..................................... 6RIBASPHERE RIBAPAK........... 6ribavirin ........................................ 6RIDAURA.................................. 50rifabutin ........................................ 8RIFAMATE..................................8rifampin ...................................8, 33RIFATER......................................8riluzole ........................................ 39rimantadine hcl .............................6ringers .........................................34RIOMET..................................... 24risedronate sodium ..................... 68RISPERDAL CONSTA..............55risperidone ..................................55ritonavir ........................................ 6RITUXAN.................................. 13rivastigmine ................................ 46rivastigmine tartrate ................... 46rizatriptan benzoate .................... 46ropinirole hcl .............................. 47ropinirole hcl er ..........................47rosuvastatin calcium ...................22ROTARIX...................................38ROTATEQ..................................38ROWASA................................... 31roweepra ..................................... 48roweepra xr .................................49ROZEREM................................. 56RUBRACA................................. 15RUCONEST............................... 42RYDAPT.................................... 15RYTARY....................................47SABRIL...................................... 49SAFYRAL.................................. 67SAIZEN...................................... 41

SAIZEN CLICK.EASY..............41SAMSCA....................................45SANCUSO..................................29SANDOSTATIN LAR DEPOT..39SANTYL.....................................65SAPHRIS....................................58SAVELLA.................................. 49SAVELLA TITRATION PACK 49scopolamine ................................ 29selegiline hcl ............................... 47selenium sulfide .......................... 65SELZENTRY............................... 6SENSIPAR................................. 42SEREVENT DISKUS................ 60SEROSTIM.................................41sertraline hcl ...............................56sevelamer carbonate oral packets ........................................ 44sharobel ...................................... 67SHINGRIX................................. 38SIGNIFOR..................................40SIGNIFOR LAR.........................39sildenafil citrate .......................... 60SILENOR................................... 56SILIQ.......................................... 64silver sulfadiazine ....................... 62SIMBRINZA.............................. 28SIMPONI..............................50, 51SIMPONI ARIA......................... 50SIMULECT................................ 39simvastatin .................................. 22sirolimus ..................................... 39SIRTURO..................................... 8SIVEXTRO.............................3, 33SKLICE...................................... 64sodium chloride .................... 34, 65sodium lactate .............................34sodium phenylbutyrate ................45sodium polystyrene sulfonate ......44SOLTAMOX.............................. 15SOLU-CORTEF......................... 36SOLU-MEDROL........................36SOMATULINE DEPOT.............39SOMAVERT.............................. 39SOOLANTRA............................ 61sorine .......................................... 18sotalol hcl ....................................18sotalol hcl (af) .............................18SOTYLIZE................................. 18SOVALDI.....................................6SPIRIVA HANDIHALER..........60SPIRIVA RESPIMAT................ 60

spironolactone ............................ 21spironolactone-hctz .....................21SPRITAM................................... 49SPRYCEL...................................15sps ............................................... 44ssd ............................................... 62stavudine ....................................... 6STELARA.................................. 64sterile water for irrigation .......... 65STIMATE................................... 11STIVARGA................................ 15STRENSIQ................................. 42streptomycin sulfate .................... 33STRIBILD.................................... 6STRIVERDI RESPIMAT...........60STROMECTOL............................3SUBOXONE FILM.................... 43SUBSYS..................................... 53SUCRAID...................................44sucralfate .................................... 30sulfacetamide sodium ..................26sulfacetamide sodium (acne) ...... 65sulfacetamide-prednisolone ........26sulfadiazine ................................... 9sulfamethoxazole-trimethoprim.................................................9, 33SULFAMYLON......................... 65sulfasalazine ............................... 31sulindac .......................................52sumatriptan ................................. 46sumatriptan succinate .................46sumatriptan succinate refill ........ 46sumatriptan-naproxen sodium .... 46SUPRAX.......................................8SUPREP BOWEL PREP KIT.... 30SURMONTIL............................. 56SUSTIVA..................................... 6SUTENT..................................... 15SYLATRON............................... 13SYLVANT..................................40SYMBICORT............................. 60SYMFI LO....................................6SYMLINPEN 120...................... 23SYMLINPEN 60........................ 23SYNAGIS................................... 44SYNAREL..................................37SYNERCID................................ 33SYNJARDY............................... 24SYNRIBO...................................13SYNTHROID............................. 37SYPRINE....................................45TABLOID...................................16

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tacrolimus ............................. 39, 65TAFINLAR.................................16TAGRISSO.................................16TALTZ........................................64TAMIFLU ORAL SOLUTION....6tamoxifen citrate ......................... 16tamsulosin hcl ............................. 44TARCEVA................................. 16TARGRETIN........................16, 65tarina fe 1/20 ...............................67TASIGNA...................................16tazarotene ................................... 64TAZORAC................................. 64taztia xt ........................................20TECENTRIQ.............................. 13TECFIDERA.............................. 43TEFLARO.................................. 33TEGRETOL-XR.........................49TEKTURNA...............................20TEKTURNA HCT......................19telmisartan .................................. 18telmisartan-amlodipine ...............19telmisartan-hctz .......................... 19temazepam .................................. 56temozolomide .............................. 16TENIVAC...................................38tenofovir disoproxil fumarate ....... 6terazosin hcl ................................17terbinafine hcl ...............................3terbutaline sulfate ....................... 60terconazole ..................................69testosterone ................................. 36testosterone cypionate .................36testosterone enanthate ................ 36tetanus-diphtheria toxoids td ...... 38tetrabenazine ...............................42tetracycline hcl ..............................9THALOMID............................... 16theophylline .................................60theophylline er ............................ 60thioridazine hcl ........................... 58thiotepa ....................................... 13thiothixene ...................................58THYMOGLOBULIN................. 39THYROLAR-1........................... 37THYROLAR-1/2........................ 37THYROLAR-1/4........................ 37THYROLAR-2........................... 37THYROLAR-3........................... 37tiagabine hcl ............................... 49tigecycline ................................... 33timolol maleate ..................... 20, 28

tinidazole .......................................4TIROSINT.................................. 37TIVICAY..................................6, 7tizanidine hcl ...............................49TOBI PODHALER.....................40TOBRADEX...............................26TOBRADEX ST.........................26tobramycin ............................ 26, 40tobramycin sulfate ...................... 33tobramycin-dexamethasone ........ 26tolazamide ...................................24tolbutamide ................................. 24tolcapone .....................................47tolmetin sodium ...........................52tolterodine tartrate ......................45tolterodine tartrate er ................. 45topiramate ...................................49topiramate er .............................. 49topotecan hcl ...............................13TORISEL....................................13torsemide .....................................21TOUJEO MAX SOLOSTAR..... 23TOUJEO SOLOSTAR................23TOVIAZ......................................45tpn electrolytes ............................35TRACLEER................................60TRADJENTA............................. 24tramadol hcl ................................53tramadol hcl er ........................... 53tramadol hcl er (biphasic) .......... 53tramadol-acetaminophen ............53trandolapril .................................17trandolapril-verapamil hcl er ..... 19tranexamic acid ...........................11TRANSDERM-SCOP PATCH.. 29tranylcypromine sulfate .............. 56TRAVASOL............................... 35TRAVATAN Z...........................28trazodone hcl .............................. 56TREANDA................................. 13TRECATOR................................. 8TRELSTAR MIXJECT.............. 37TREMFYA................................. 64tretinoin .................................16, 62tretinoin microsphere ..................62TREXALL.................................. 51triamcinolone acetonide ....... 25, 63triamterene-hctz ..........................21TRIANEX...................................63triazolam ..................................... 56triderm ........................................ 63trientine hcl .................................45

trifluoperazine hcl .......................58trifluridine ...................................27trihexyphenidyl hcl ......................47trilyte ...........................................30trimethoprim ................................. 3trimipramine maleate ..................56trinessa (28) ................................ 67TRINTELLIX............................. 56TRIOSTAT................................. 37tri-previfem ................................. 67TRISENOX.................................13tri-sprintec .................................. 67TRIUMEQ.................................... 7trivora (28) ..................................67TROKENDI XR......................... 49TROPHAMINE.......................... 35trospium chloride ........................45trospium chloride er ................... 45TRULICITY............................... 23TRUMENBA..............................38TRUVADA...................................7TWINRIX................................... 38TYBOST.......................................7TYGACIL...................................33TYKERB.................................... 16TYMLOS....................................68TYPHIM VI................................38TYSABRI................................... 43UCERIS................................ 30, 31ULORIC..................................... 51unithroid ..................................... 37UPTRAVI................................... 60UROCIT-K 10............................ 45UROCIT-K 15............................ 45UROCIT-K 5.............................. 45ursodiol ....................................... 30VABOMERE..............................33valacyclovir hcl .............................7VALCHLOR...............................65valganciclovir hcl ......................... 7valproate sodium .................. 34, 49valproic acid ............................... 49valsartan ..................................... 18valsartan-hydrochlorothiazide ... 19vancomycin hcl ....................... 3, 34vandazole .................................... 69VAQTA...................................... 38VARIVAX..................................39VARIZIG....................................39VARUBI..................................... 29VASCEPA.................................. 22VECTIBIX..................................13

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VELCADE..................................13velivet ..........................................67VELTASSA................................44VEMLIDY....................................7VENCLEXTA............................ 16VENCLEXTA STARTING PACK..........................................16venlafaxine hcl ............................ 56venlafaxine hcl er ........................56VENTAVIS................................ 60VENTOLIN HFA....................... 60verapamil hcl .............................. 20verapamil hcl er ..........................20VERIPRED 20............................36VERSACLOZ.............................58VERZENIO................................ 16VESICARE.................................45VIBRAMYCIN.............................9VICTOZA...................................23VIDEX..........................................7VIDEX EC....................................7vigabatrin ....................................49VIGAMOX................................. 26VIIBRYD....................................56VIIBRYD STARTER PACK..... 56VIMPAT..................................... 49vinblastine sulfate ....................... 13vincasar pfs .................................13vincristine sulfate ........................13vinorelbine tartrate .....................13VIRACEPT...................................7VIRAMUNE SUSPENSION........7VIREAD....................................... 7VIVITROL..................................53voriconazole ............................3, 34VOSEVI........................................7VOTRIENT................................ 16VPRIV........................................ 41VRAYLAR................................. 58vyfemla ........................................67VYVANSE................................. 54VYXEOS.................................... 13VYZULTA..................................28warfarin sodium ..........................10WELCHOL.................................22XALKORI.................................. 16XARELTO..................................10XARELTO STARTER PACK... 11XATMEP....................................51XELJANZ...................................51XELJANZ XR............................ 51XEOMIN.................................... 40

XERMELO................................. 30XGEVA...................................... 69XIFAXAN.................................... 4XOLAIR..................................... 61XTANDI..................................... 16XURIDEN.................................. 17XYREM......................................57YERVOY....................................13YF-VAX..................................... 39YONDELIS................................ 13yuvafem ....................................... 69zafirlukast ................................... 60zaleplon .......................................57ZALTRAP.................................. 13ZANOSAR................................. 13ZARXIO..................................... 10ZAVESCA..................................41ZEJULA......................................16ZELBORAF................................16ZEMAIRA.................................. 61ZENCHENT............................... 67ZENPEP......................................29ZEPATIER................................... 7ZERBAXA................................. 34ZERIT........................................... 7ZIAGEN........................................7zidovudine ..................................... 7zileuton er ................................... 60ZINECARD................................ 17ZINPLAVA................................ 39ziprasidone hcl ............................58ZIRGAN..................................... 27zoledronic acid ............................69ZOLINZA................................... 16zolmitriptan .................................46zolpidem tartrate .........................57zolpidem tartrate er .................... 57ZOMACTON..............................41zonisamide .................................. 49ZONTIVITY...............................10ZORBTIVE.................................41ZORTRESS................................ 39ZOSTAVAX...............................39zovia 1/35e (28) .......................... 67zovia 1/50e (28) .......................... 67ZOVIRAX.................................. 65ZURAMPIC................................16ZYDELIG................................... 16ZYKADIA.................................. 16ZYLET........................................27ZYPREXA..................................58ZYPREXA RELPREVV............ 58

ZYTIGA......................................16

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Tufts Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Tufts Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

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• Provides free aids and services to people with disabilities to communicate effectively with us, such as:— Written information in other formats (large print, audio, accessible electronic formats, other formats)

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If you need these services, contact Tufts Health Plan at 1-800-701-9000 (TTY: 711).

If you believe that Tufts Health Plan 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:

Tufts Health Plan, attention:

Civil Rights Coordinator, Legal Dept.705 Mount Auburn St. Watertown, MA 02472Phone: 1-888-880-8699 ext. 48000, (TTY number—711 or 1-800-439-2370. Español: 866-930-9252) Fax: 617-972-9048Email: [email protected].

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Tufts Health Plan Civil Rights Coordinator is available to help you.

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u.s. department of Health and Human services200 Independence Avenue, SWRoom 509F, HHH Building Washington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

thpmp.org | 1-800-701-9000

This formulary was updated on July 1, 2018. For more recent information or other questions,

please contact us at 1-800-701-9000 or, for TTY users, 711, Monday - Friday 8:00 a.m. - 8:00 p.m.

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