Partnership HMO SNP 2016 Formulary (List of … HMO SNP 2016 Formulary (List of Covered Drugs)...
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Transcript of Partnership HMO SNP 2016 Formulary (List of … HMO SNP 2016 Formulary (List of Covered Drugs)...
Partnership HMO SNP
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
Formulary ID: 16373, Version Number: 39
This formulary was updated on 10/17/2016. For more recent information or other questions, please contact us at 1-800-963-0035 or, for TTY users, Wisconsin Relay System 711, 24-hours a day/7 days a week
(office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit 3 www.carewisc.org. 3 T U U 3 3 T
H5209-002_CWHPFC 9-2-16_FINAL Populated Template 10/17/2016 DHS Approved 8/14/2015
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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.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Care Wisconsin Health Plan, Inc. When it refers to “plan” or “our plan,” it means Partnership.
This document includes a list of the drugs (formulary) for our plan which is current as of 9/27/2016. 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, premium and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.
Partnership is a Coordinated Care plan with a Medicare Advantage contract and a contract with the Wisconsin Medicaid Program. Enrollment in Partnership depends on contract renewal.
The formulary, pharmacy and/or provider network may change at any time. You will receive notice when necessary.
To receive this formulary in an alternate format or language, contact your Team or call Care Wisconsin Customer Service at 1-800-963-0035 (TTY/TDD Wisconsin Relay System 711).
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What is the Partnership Formulary?
A formulary is a list of covered drugs selected by Partnership 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. Partnership will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Partnership 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 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 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, 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 9/27/2016. To get updated information about the drugs covered by Partnership, please contact us. Our contact information appears on the front and back cover pages.
In the event of mid-year non-maintenance formulary changes, we will mail you updates to the formulary as needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or printing them from our Web site.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 9. 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
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category name in the list that begins on page number 9. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 93. 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?
Partnership 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: Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don’t get approval, Partnership may not cover the drug.
Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply.
Step Therapy: In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Partnership may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Partnership will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization 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 Partnership 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 Partnership formulary?” on page 6 for information about how to request an exception.
What are over-the-counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Partnership pays for certain OTC drugs. Care Wisconsin covers the OTC formulations of the following drugs as part of its Part D Step Therapy program:
omeprazole lansoprazole esomeprazole loratadine fexofenadine cetirizine nasal triamcinolone nasal fluticasone.
In addition, the 2016 Formulary Medicaid Supplement included with this formulary provides the list of OTC drugs covered by Partnership when they are ordered by a physician or nurse practitioner for a medical need. The drug must also have a valid National Drug Code (NDC) that is recognized by Wisconsin Medicaid. Partnership will provide these OTC drugs at no cost to you.
The cost to Partnership of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap).
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 Service and ask if your drug is covered.
If you learn that Partnership does not cover your drug, you have two options:
You can ask Customer Service for a list of similar drugs that are covered by Partnership. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Partnership.
You can ask Partnership to make an exception and cover your drug. See below for information about how to request an exception.
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How do I request an exception to the Partnership Formulary?
You can ask us 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. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Partnership 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, Partnership will only approve your request for an exception if the alternative drugs included on the plan’s formulary 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 or utilization restriction exception. When you request a formulary 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.
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 a 93-day transition supply, consistent with the 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
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emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
Current members with a change in where they receive care
Partnership has a transition process that addresses unplanned transitions as members change treatment settings due to changes in the type of care they require. Changes in where you live or receive care may warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of program enrollment. Examples of situations include:
You were discharged from the hospital and were provided a discharge list of medications based upon the formulary of the hospital.
You are in a skilled nursing facility and Medicare coverage (where payments include all pharmacy charges) comes to an end. In this circumstance your coverage will revert to our plan formulary.
Beneficiaries who give up Hospice Status to revert back to standard Medicare or Medicaid benefits. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of
medications that are highly individualized.
Please note that our transition policy applies only to those drugs that are on our formulary and are supplied by a network pharmacy.
For more information
For more detailed information about your Partnership prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Partnership, 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 1-877-486-2048. Or, visit http://www.medicare.gov.
Partnership’s Formulary
The formulary that begins on the next page provides coverage information about the drugs covered by Partnership. If you have trouble finding your drug in the list, turn to the Index that begins on page 93.
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The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., digoxin).
The information in the Requirements/Limits column tells you if Partnership has any special requirements for coverage of your drug.
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Formulary: 16373, Version ID: 39
Date generated: 10/17/2016
List of Abbreviations
B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
CB: This prescription drug has a capped benefit limit.
ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
FF: Free First Fill. This prescription drug will be provided at zero cost-sharing the first time you fill it.
GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-963-0035, 24-hours a day/7 days a week (office hours: Monday- Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-800-963-0035, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711.
MO: Mail Order Drug. This prescription drug is available through a mail-order service.
PA: Prior Authorization. Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don’t get approval, Partnership may not cover the drug.
QL: Quantity Limit. For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply.
ST: Step Therapy. In some cases, Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Partnership may not cover drug B unless you try Drug A first. If Drug A does not work for you, Partnership will then cover Drug B.
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10
LEGEND
TIER NAME
1 Covered
SYMBOL NAME DESCRIPTION
There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame. QL Quantity Limit
You (or your physician) are required to get prior authorization
before you fill your prescription for this drug. Without prior
approval, we may not cover this drug.
PA Prior Authorization
In some cases, you may be required to first try certain drugs to
treat your medical condition before we will cover another drug
for that condition.
ST
LA
Step Therapy
Limited Access This prescription drug is limited to certain pharmacies.
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DRUG NAME TIER REQUIREMENTS/LIMITS
Analgesics
Nonsteroidal Anti-inflammatory Drugs
celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule)
1 ST
etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er 24h)
1
1
PA
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet)
ibuprofen/oxycodone hcl 400mg-5mg tablet
ketoprofen (50 mg capsule, 75 mg capsule)
nabumetone (500 mg tablet, 750 mg tablet)
1
1
1
1
PA
PA
naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet)
sulindac (150 mg tablet, 200 mg tablet) 1 PA
Opioid Analgesics, Long-acting
fentanyl (12 mcg/hr, 25 mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100 mcg/hr)
1
1
1
ST, QL (10 PER 30 DAYS)
methadone hcl (5 mg/5 ml solution, 5 mg tablet, 10 mg/5 ml solution, 10 mg tablet)
morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tablet er, 100 mg tablet er, 200 mg tablet er)
oxycodone hcl (10 mg tab er, 15 mg tab er, 20 mg tab er, 30 mg tab er, 40 mg tab er, 60 mg tab er, 80 mg tab er)
1
1
ST
ST tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr)
Opioid Analgesics, Short-acting
acetaminophen with codeine phosphate (120- 12mg/5 solution, 300mg/12.5 solution, 300mg- 30mg tablet, 300mg-60mg tablet, 300mg-15mg tablet)
1
1 codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
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DRUG NAME TIER REQUIREMENTS/LIMITS
DURAMORPH (5 MG/10 ML, 10 MG/10 ML) 1
ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10-325 MG TABLET)
1
1
1
fentanyl citrate (200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg)
PA, ST
hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-325mg tablet, hydrocodone/acetaminophen 7.5-325 mg tablet, hydrocodone/acetaminophen 10mg- 325mg tablet)
hydrocodone/ibuprofen (hydrocodone/ibuprofen 5mg-200mg tablet, hydrocodone/ibuprofen 7.5- 200 mg tablet, hydrocodone/ibuprofen 10mg- 200mg tablet)
1
hydromorphone hcl (1 mg/ml liquid, 2 mg/ml syringe, 2 mg tablet, 4 mg tablet, 8 mg tablet)
1
1
1
hydromorphone hcl/pf (hcl/pf 10 mg/ml ampul, hcl/pf 10 mg/ml vial)
morphine sulfate (10 mg/5 ml solution, 15 mg tablet, 20 mg/5 ml solution, 30 mg tablet, 100 mg/5ml solution)
oxycodone hcl (5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)
1
1 oxycodone hcl/acetaminophen (hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)
oxycodone hcl/acetaminophen 5-325/5 ml solution
1 QL (1860 ML PER 30 DAYS)
tramadol hcl 50 mg tablet 1
1 tramadol hcl/acetaminophen 37.5-325mg tablet
Anesthetics
Local Anesthetics
lidocaine 5 % adh. patch 1
1
PA, QL (93 PER 31 DAYS)
lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 4 % solution, 5 mg/ml vial, 20 mg/ml vial, 40 mg/ml solution)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
13
DRUG NAME TIER REQUIREMENTS/LIMITS
lidocaine hcl/pf (hcl/pf 5 mg/ml vial, hcl/pf 20 mg/ml ampul luer, hcl/pf 20 mg/ml ampul, hcl/pf 20 mg/ml vial, hcl/pf 100 mg/5ml syringe)
1
lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5 kit)
1
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium 333 mg tablet dr 1
disulfiram (250 mg tablet, 500 mg tablet) 1
Opioid Dependence Treatments
buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe)
1
buprenorphine hcl (2 mg tab, 8 mg tab) 1
1
PA
buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg tab, /naloxone 8 mg-2 mg tab)
naltrexone hcl 50 mg tablet 1
1 Opioid Reversal Agents
naloxone hcl 1 mg/ml syringe
Smoking Cessation Agents
bupropion hcl 150 mg tablet er 1
1 CHANTIX (0.5 MG TABLET, 1 MG TABLET, STARTING MONTH BOX)
PA
NICOTROL CARTRIDGE INHALER
NICOTROL NS 10 MG/ML SPRAY
1
1
PA, ST, QL (336 PER 21 DAYS)
PA, QL (168 ML PER 30 DAYS)
Anti-inflammatory Agents
Glucocorticoids
dexamethasone sod phosphate (4 mg/ml vial, 4 mg/ml syringe)
1
1 methylprednisolone sod succ 40 mg vial
Nonsteroidal Anti-inflammatory Drugs
diclofenac sodium 3 % gel (gram) 1 PA
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
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DRUG NAME TIER REQUIREMENTS/LIMITS
naproxen sodium (275 mg tablet, 550 mg tablet)
oxaprozin 600 mg tablet
1
1 PA
Antibacterials
Aminoglycosides
GENTAK 0.3 % EYE OINTMENT 1
1 gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops, 40 mg/ml vial)
gentamicin sulfate in sodium chloride, iso- osmotic (gentamic60 mg/50ml, gentamic80 mg/50ml, gentamic80mg/100ml,
1
gentamic100mg/0.1l, gentamic120mg/0.1l)
gentamicin sulfate/pf (sulfate/pf 20 mg/2 ml vial, sulfate/pf 60 mg/6 ml vial port, sulfate/pf 80 mg/8 ml vial port, sulfate/pf 100mg/10ml vial port)
1
neomycin sulfate 500 mg tablet 1
1 neomycin sulfate/polymyxin b sulfate (su/polymyx 40-200k/ml ampul, su/polymyx 40- 200k/ml vial)
paromomycin sulfate 250 mg capsule
streptomycin sulfate 1 g vial
tobramycin 0.3 % drops
1
1
1
1 tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial)
ZYLET EYE DROPS 1
Antibacterials, Other
BACIIM 50,000 UNITS VIAL 1
1
1
bacitracin 500 unit/g oint. (g)
bacitracin/polymyxin b sulfate 500-10k/g oint. (g)
chloramphenicol sod succ 1 g vial 1
1 clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule)
clindamycin phosphate (2 % cream/appl, 150 mg/ml vial, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
15
DRUG NAME TIER REQUIREMENTS/LIMITS
colistin (colistimethate na) 150 mg vial
CUBICIN 500 MG VIAL
1
1
1
1
linezolid (600mg/300 iv soln, 600 mg tablet)
linezolid-0.9% sodium chloride 600mg/300 iv soln
methenamine hippurate 1 g tablet 1
1 metronidazole (0.75 % gel w/appl, 250 mg tablet, 500 mg tablet)
metronidazole 0.75 % gel (gram) 1
1
ST
metronidazole/sodium chloride 500mg/0.1l piggyback
MONUROL 3 GM SACHET 1
1
1
1
mupirocin 2 % oint. (g)
neomycin su/baci zn/poly/hc 3.5-10k-1 oint. (g)
neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g)
neomycin/polymyxn b/gramicidin 1.75mg-10k drops
1
nitrofurantoin macrocrystal 50 mg capsule
nitrofurantoin monohyd/m-cryst 100 mg capsule
polymyxin b sulf/trimethoprim 10000-1/ml drops
polymyxin b sulfate 500k unit vial
silver sulfadiazine 1 % cream (g)
SSD 1% CREAM
1
1
1
1
1
1
1
1
1
1
PA
PA
SYNERCID 500 MG VIAL
trimethoprim 100 mg tablet
TYGACIL 50 MG VIAL
vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial, 125 mg capsule, 250 mg capsule, 500 mg vial, 500 mg vial port, 750 mg vial port, 750 mg vial)
VANDAZOLE VAGINAL 0.75% GEL 1
1
1
XIFAXAN (200 MG TABLET, 550 MG TABLET)
ZYVOX 100 MG/5 ML SUSPENSION
ST
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
16
DRUG NAME TIER REQUIREMENTS/LIMITS
Beta-lactam, Cephalosporins
cefaclor (250 mg capsule, 500 mg capsule) 1
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon)
1
cefazolin sodium (1 g vial, 1 g vial port, 10 g vial, 20 g vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial)
1
cefazolin sodium/dextrose, iso-osmotic (sodium/dextrose,iso 1 g/50 ml froz.piggy, sodium/dextrose,iso 1 g/50 ml piggyback)
1
1 cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule)
cefepime hcl (1 vial, 2 vial) 1
1
1
1
cefixime (100 mg/5ml, 200 mg/5ml)
cefoxitin sodium (1 vial, 2 vial, 10 vial)
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet)
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet)
1
1 ceftriaxone sodium (1 g vial, 1 g vial port, 2 g vial port, 2 g vial, 10 g vial, 100 g bulkbaginj, 250 mg vial, 500 mg vial)
cefuroxime axetil (250 mg tablet, 500 mg tablet) 1
1 cefuroxime sodium (1.5 g vial, 7.5g vial, 7.5 g vial, 75 g bulkbaginj, 750 mg vial)
cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule)
1
SUPRAX 400 MG CAPSULE 1
1 TEFLARO (400 MG VIAL, 600 MG VIAL)
Beta-lactam, Other
aztreonam (1 vial, 2 vial) 1
1
1
cefotetan disodium (1 vial, 2 vial, 10 vial)
imipenem/cilastatin sodium (imipenem/cilastatin 250 mg vial, imipenem/cilastatin 500 mg vial)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
17
DRUG NAME TIER REQUIREMENTS/LIMITS
INVANZ 1 GM VIAL 1
meropenem (1 g vial, 500 mg vial) 1
1 Beta-lactam, Penicillins
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet)
amoxicillin/potassium clavulanate 1 (amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 200-28.5/5 susp recon, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 250-125 mg tablet, amoxicillin/potassium 400-57mg tab chew, amoxicillin/potassium 400-57mg/5 susp recon, amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susp recon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h) ampicillin sodium (1 g vial, 1 g vial port, 2 g vial, 10 g vial, 250 mg vial, 500 mg vial)
1
1 ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 vial, sodium/sulbactam 3 vial, sodium/sulbactam 15 vial)
ampicillin trihydrate (250 mg capsule, 500 mg capsule)
1
1
1
1
BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS, 2,400,000 UNITS)
dicloxacillin sodium (250 mg capsule, 500 mg capsule)
nafcillin in dextrose, iso-osmotic (1 g/50 ml, 2 g/100 ml)
nafcillin sodium (1 vial, 2 vial, 10 vial) 1
1
1
1
oxacillin sodium (1 vial, 2 vial port, 2 vial, 10 vial)
penicillin g potassium (5mm vial, 20mm vial)
penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
18
DRUG NAME TIER REQUIREMENTS/LIMITS
piperacillin sodium/tazobactam sodium (sodium/tazobactam 2.25 vial port, sodium/tazobactam 2.25 vial,
1
sodium/tazobactam 3.375 vial, sodium/tazobactam 3.375 vial port, sodium/tazobactam 4.5 vial, sodium/tazobactam 4.5 vial port, sodium/tazobactam 40.5 vial)
ZOSYN (2.25 GM/50 ML BAG, 3.375 GM/50 ML, 4.5 GM/100 ML BAG)
1
Macrolides
azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg vial port, 500 mg tablet, 500 mg vial, 600 mg tablet)
1
1 clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet)
DIFICID 200 MG TABLET
E.E.S. 200 MG/5 ML GRANULES
E.E.S. 400 FILMTAB
1
1
1
1
PA, ST
ERY-TAB (EC 250 MG TABLET, 333 MG TABLET EC, EC 333 MG TABLET, EC 500 MG TABLET)
ERYPED 200 MG/5 ML SUSPENSION
ERYPED 400 MG/5 ML SUSPENSION
ERYTHROCIN 250 MG FILMTAB
1
1
1
1 ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL)
erythromycin base (5 mg/g oint. (g), 250 mg tablet, 500 mg tablet)
1
1 erythromycin base/ethyl alcohol (base/ethanol 2 % solution, base/ethanol 2 % gel (gram))
erythromycin ethylsuccinate 400 mg tablet 1
1 KETEK (300 MG TABLET, 400 MG TABLET) PA
Quinolones
AVELOX IV 400 MG/250 ML 1
1
1
CIPRO HC OTIC SUSPENSION
CIPRODEX OTIC SUSPENSION
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
19
DRUG NAME TIER REQUIREMENTS/LIMITS
ciprofloxacin (250 mg/5ml, 500 mg/5ml) 1
ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet)
1
1
1
ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml vial)
ciprofloxacin/ciprofloxacin hcl (ciprofloxacin/ciprofloxa 500 mg, ciprofloxacin/ciprofloxa 1000 mg)
gatifloxacin 0.5 % drops 1
1 levofloxacin (0.5 % drops, 25 mg/ml vial, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 500mg/20ml solution, 750 mg tablet)
levofloxacin/dextrose 5 % in water (levofloxacin/d5w 750mg/.15l, levofloxacin/d5w 250mg/50ml, levofloxacin/d5w 500mg/0.1l)
1
MOXEZA 0.5% EYE DROPS
ofloxacin 0.3 % drops
1
1
1 VIGAMOX 0.5% EYE DROPS
Sulfonamides
sulfacetamide sodium 10 % drops 1
1 sulfacetamide/prednisolone sp 10 %-0.23% drops
sulfadiazine 500 mg tablet 1
1 sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 80-16mg/ml vial, sulfamethoxazole/trimethoprim 200- 40mg/5 oral susp, sulfamethoxazole/trimethoprim 400mg-80mg tablet, sulfamethoxazole/trimethoprim 800- 160/20 oral susp, sulfamethoxazole/trimethoprim 800-160 mg tablet)
Tetracyclines
demeclocycline hcl (150 mg tablet, 300 mg tablet)
1
DOXY 100 VIAL 1
1 doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
20
DRUG NAME TIER REQUIREMENTS/LIMITS
doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet)
1
minocycline hcl (50 mg capsule, 75 mg capsule, 100 mg capsule)
1
Anticonvulsants
Anticonvulsants, Other
APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET)
1
1 BRIVIACT (10 MG/ML ORAL SOLN, 10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 50 MG/5 ML VIAL, 75 MG TABLET, 100 MG TABLET)
FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)
1
1 levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg/5ml solution, 500 mg tab er 24h, 500 mg tablet, 500 mg/5ml vial, 750 mg tablet, 750 mg tab er 24h, 1000 mg tablet)
phenobarbital (15 mg tablet, 30 mg tablet, 60 mg tablet, 64.8 mg tablet)
1
1
1
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY phenobarbital (16.2 mg tablet, 20 mg/5 ml elixir, 32.4 mg tablet, 97.2mg tablet, 100 mg tablet)
POTIGA (50 MG TABLET, 200 MG TABLET, 300 MG TABLET, 400 MG TABLET)
ROWEEPRA 500 MG TABLET 1
1 SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET)
PA - FOR NEW STARTS ONLY
Calcium Channel Modifying Agents
CELONTIN 300 MG KAPSEAL 1
1 ethosuximide (250 mg/5ml solution, 250 mg capsule)
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)
1 QL (93 PER 31 DAYS)
zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
21
DRUG NAME TIER REQUIREMENTS/LIMITS
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tab rapdis, 2 mg tab rapdis)
1
1
PA - FOR NEW STARTS ONLY
clonazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY diazepam (2.5 mg, 5-7.5-10mg, 12.5-15-20) 1
1 divalproex sodium (125 mg tablet dr, 125 mg cap sprink, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tablet dr)
gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg/6ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet)
1
GABITRIL (12 MG TABLET, 16 MG TABLET) 1
1 ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET)
PA - FOR NEW STARTS ONLY
primidone (50 mg tablet, 250 mg tablet) 1
1 SABRIL (500 MG TABLET, 500 MG POWDER PACKET)
tiagabine hcl (2 mg tablet, 4 mg tablet) 1
1 valproic acid (as sodium salt) (valproate sodium) (salt) 250 mg/5ml solution, salt) 500 mg/5ml vial, salt) 500mg/10ml solution)
valproic acid 250 mg capsule 1
Glutamate Reducing Agents
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp)
1
1 lamotrigine (25 mg tablet, 25 mg tab er 24, 25 mg tb chw dsp, 50 mg tab er 24, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24)
QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE)
1 ST
topiramate (15 mg cap, 25 mg cap) 1
1
PA - FOR NEW STARTS ONLY
ST topiramate (25 mg cap 24, 50 mg cap 24, 100 mg cap 24, 150 mg cap 24, 200 mg cap 24)
topiramate (25 mg tablet, 100 mg tablet, 200 mg tablet)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
22
DRUG NAME TIER REQUIREMENTS/LIMITS
TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 200 MG CAPSULE)
1 ST
Sodium Channel Agents
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET)
1
1 carbamazepine (100 mg tab er 12h, 100 mg cpmp 12hr, 100 mg/5ml oral susp, 100 mg tab chew, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h)
DILANTIN (30 MG KAPSEAL, 30 MG CAPSULE)
EPITOL 200 MG TABLET
1
1
1 fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial)
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet)
1
1 OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET)
ST
PEGANONE 250 MG TABLET 1
1 phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp)
phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul)
1
1
1
phenytoin sodium extended (100 mg capsule, 200 mg capsule, 300 mg capsule)
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET)
Antidementia Agents
Cholinesterase Inhibitors
donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis)
1
1 galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)
rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
23
DRUG NAME TIER REQUIREMENTS/LIMITS
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl (2 mg/ml solution, 5 mg-10 mg tab ds pk, 5 mg tablet, 10 mg tablet)
1
1 NAMENDA (2 MG/ML SOLUTION, 5-10 MG TITRATION PK, 5 MG TABLET, 10 MG TABLET)
Antidepressants
Antidepressants, Other
bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg tablet, 150 mg tab er 24h, 150 mg tablet er, 200 mg tablet er, 300 mg tab er 24h)
1
maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg tablet)
1
1 mirtazapine (15 mg tablet, 15 mg tab rapdis, 30 mg tablet, 45 mg tablet, 45 mg tab rapdis)
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY mirtazapine (7.5 mg tablet, 30 mg tab rapdis) 1
1 nefazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet)
trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 300 mg tablet)
1
TRINTELLIX (10 MG TABLET, 20 MG TABLET)
TRINTELLIX 5 MG TABLET
1
1
PA - FOR NEW STARTS ONLY, ST
PA - FOR NEW STARTS ONLY, ST
Monoamine Oxidase Inhibitors
EMSAM (6 MG/24, 9 MG/24, 12 MG/24) 1
1
1
1
PA - FOR NEW STARTS ONLY
MARPLAN 10 MG TABLET
phenelzine sulfate 15 mg tablet
tranylcypromine sulfate 10 mg tablet
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet)
1
1
1
desvenlafaxine (50 mg tab er 24h, 50 mg tab er 24, 100 mg tab er 24h, 100 mg tab er 24)
ST
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 40 mg capsule dr, 60 mg capsule dr)
QL (62 PER 31 DAYS)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
24
DRUG NAME TIER REQUIREMENTS/LIMITS
escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mg tablet)
1 ST
FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE)
1
1
ST
fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr)
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
1 paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 37.5 mg tab er 24h, 40 mg tablet)
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY paroxetine hcl (12.5 mg tab er, 25 mg tab er) 1
1 sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet)
venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg tab er 24, 75 mg cap er 24h, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h, 150 mg tab er 24)
1
VIIBRYD (10-20 MG STARTER PACK, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET)
1
1 Tricyclics
amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)
PA - FOR NEW STARTS ONLY
amoxapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 150 mg tablet)
1
1
1
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY, ST
PA, PA - FOR NEW STARTS ONLY
clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule)
desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)
doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)
1 PA - FOR NEW STARTS ONLY
imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet)
1
1
PA, PA - FOR NEW STARTS ONLY, ST
PA, PA - FOR NEW STARTS ONLY nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
25
DRUG NAME TIER REQUIREMENTS/LIMITS
nortriptyline hcl 10 mg/5 ml solution 1 PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY, ST
protriptyline hcl (5 mg tablet, 10 mg tablet) 1
1 SURMONTIL (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE)
trimipramine maleate (25 mg capsule, 50 mg capsule, 100 mg capsule)
1 PA - FOR NEW STARTS ONLY, ST
Antiemetics
Antiemetics, Other
meclizine hcl (12.5 mg tablet, 25 mg tablet) 1
1
PA
PA promethazine hcl (12.5 mg supp.rect, 12.5 mg tablet, 25 mg/ml vial, 25 mg tablet, 25 mg/ml ampul, 25 mg supp.rect, 25 mg/ml syringe, 50 mg/ml ampul, 50 mg/ml vial)
PROMETHEGAN 25 MG SUPPOSITORY
TRANSDERM-SCOP 1.5 MG/3 DAY
1
1
PA
PA
Emetogenic Therapy Adjuncts
ANZEMET (50 MG TABLET, 100 MG TABLET) 1 PA - TO CONFIRM PART D COVERAGE, ST, QL (9 PER 30 DAYS)
ANZEMET 20 MG/ML VIAL
dronabinol 10 mg capsule
dronabinol 2.5 mg capsule
dronabinol 5 mg capsule
1
1
1
1
1
ST
PA, QL (62 PER 31 DAYS)
PA, QL (248 PER 31 DAYS)
PA, QL (124 PER 31 DAYS)
EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MG CAPSULE)
PA - TO CONFIRM PART D COVERAGE, ST, QL (9 PER 30 DAYS)
EMEND TRIPACK 1 PA - TO CONFIRM PART D COVERAGE, ST, QL (6 PER 30 DAYS)
granisetron hcl (1 mg/ml(1) vial, 1 mg/ml vial)
granisetron hcl 1 mg tablet
1
1
ST
PA - TO CONFIRM PART D COVERAGE, ST
granisetron hcl/pf (hcl/pf 1 mg/ml(1) vial, hcl/pf 100 mcg/ml vial)
1
1
1
ST
ondansetron (4 mg tab rapdis, 8 mg tab rapdis) PA - TO CONFIRM PART D COVERAGE, QL (62 PER 31 DAYS)
ondansetron hcl (4 mg tablet, 8 mg tablet) PA - TO CONFIRM PART D COVERAGE, QL (62 PER 31 DAYS)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
26
DRUG NAME TIER REQUIREMENTS/LIMITS
ondansetron hcl 24 mg tablet 1 PA - TO CONFIRM PART D COVERAGE, ST, QL (31 PER 31 DAYS)
ondansetron hcl 4 mg/5 ml solution 1
1
PA - TO CONFIRM PART D COVERAGE, ST, QL (950 ML PER 31 DAYS)
ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 mg/2 ml vial)
ST
Antifungals
ABELCET 100 MG/20 ML VIAL
AMBISOME 50 MG VIAL
1
1
1
1
1
1
amphotericin b 50 mg vial
CANCIDAS (50 MG VIAL, 70 MG VIAL)
ciclopirox (1 % shampoo, 8 % solution)
ciclopirox olamine (0.77 % cream (g), 0.77 % suspension)
clotrimazole (1 % cream (g), 1 % solution, 10 mg troche)
1
econazole nitrate 1 % cream (g) 1
1 fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)
fluconazole in dextrose, iso-osmotic (200mg/0.1l, 400mg/0.2l)
1
flucytosine (250 mg capsule, 500 mg capsule) 1
1 griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet)
itraconazole 100 mg capsule 1
1 ketoconazole (2 % cream (g), 2 % shampoo, 200 mg tablet)
miconazole nitrate 200 mg supp.vag
MYCAMINE (50 MG VIAL, 100 MG VIAL)
NOXAFIL 40 MG/ML SUSPENSION
1
1
1
1
1
NYAMYC 100,000 UNITS/GM POWDER
nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g))
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
27
DRUG NAME TIER REQUIREMENTS/LIMITS
nystatin/triamcinolone acetonide (nystatin/triamcin 100000-0.1 cream (g), nystatin/triamcin 100000-0.1 oint. (g))
1
NYSTOP 100,000 UNITS/GM POWDER
SPORANOX 10 MG/ML SOLUTION
terbinafine hcl 250 mg tablet
1
1
1
1 terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag)
voriconazole (50 mg tablet, 200 mg tablet, 200 mg vial, 200 mg/5ml susp recon)
1
Antigout Agents
allopurinol (100 mg tablet, 300 mg tablet)
colchicine (0.6 mg capsule, 0.6 mg tablet)
colchicine/probenecid 0.5-500mg tablet
COLCRYS 0.6 MG TABLET
1
1
1
1
1
1
MITIGARE 0.6 MG CAPSULE
probenecid 500 mg tablet
Antimigraine Agents
Ergot Alkaloids
CAFERGOT TABLET 1
1 dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial)
ST
ERGOMAR 2 MG TABLET SL 1
Prophylactic
divalproex sodium 500 mg tab er 24h 1
1 topiramate 50 mg tablet
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1
1
QL (9 PER 30 DAYS)
QL (18 PER 30 DAYS) rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis, 10 mg tablet, 10 mg tab rapdis)
sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet)
1 QL (9 PER 30 DAYS)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
28
DRUG NAME TIER REQUIREMENTS/LIMITS
sumatriptan succinate (4 mg/0.5ml pen injctr, 4 mg/0.5ml cartridge, 6 mg/0.5ml cartridge, 6 mg/0.5ml vial)
1 ST, QL (6 ML PER 30 DAYS)
zolmitriptan (2.5 mg tab rapdis, 5 mg tab rapdis)
zolmitriptan (2.5 mg tablet, 5 mg tablet)
ZOMIG (2.5 MG, 5 MG)
1
1
1
ST, QL (6 PER 30 DAYS)
ST, QL (9 PER 30 DAYS)
ST, QL (6 PER 30 DAYS)
Antimyasthenic Agents
Parasympathomimetics
guanidine hcl 125 mg tablet 1
1 pyridostigmine bromide 60 mg tablet
Antimycobacterials
Antimycobacterials, Other
dapsone (25 mg tablet, 100 mg tablet) 1
1 rifabutin 150 mg capsule
Antituberculars
CAPASTAT SULFATE 1 GM VIAL 1
1
1
ethambutol hcl (100 mg tablet, 400 mg tablet)
isoniazid (100 mg/ml vial, 100 mg tablet, 300 mg tablet)
PASER GRANULES 4 GM PACKET 1
1
1
pyrazinamide 500 mg tablet
rifampin (150 mg capsule, 300 mg capsule, 600 mg vial)
SIRTURO 100 MG TABLET
TRECATOR 250 MG TABLET
1
1
PA
Antineoplastics
Alkylating Agents
cyclophosphamide (25 mg capsule, 50 mg capsule)
1
1
PA - TO CONFIRM PART D COVERAGE
GLEOSTINE 5 MG CAPSULE
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
29
DRUG NAME TIER REQUIREMENTS/LIMITS
HEXALEN 50 MG CAPSULE
LEUKERAN 2 MG TABLET
MATULANE 50 MG CAPSULE
thiotepa 15 mg vial
1
1
1
1
1 VALCHLOR 0.016% GEL
Antiandrogens
bicalutamide 50 mg tablet 1
1
1
1
1
1
flutamide 125 mg capsule
NILANDRON 150 MG TABLET
nilutamide 150 mg tablet
XTANDI 40 MG CAPSULE
ZYTIGA 250 MG TABLET
Antiangiogenic Agents
CAPRELSA (100 MG TABLET, 300 MG TABLET) 1
1 REVLIMID (2.5 MG CAPSULE, 5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE)
LA
THALOMID (50 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE)
1
Antiestrogens/Modifiers
EMCYT 140 MG CAPSULE 1
1
1
1
FARESTON 60 MG TABLET
SOLTAMOX 10 MG/5 ML SOLN
tamoxifen citrate (10 mg tablet, 20 mg tablet)
Antimetabolites
ADRUCIL (5 GRAM/100 ML VIAL, 500 MG/10 ML VIAL, 2,500 MG/50 ML VIAL)
1
ALIMTA (100 MG VIAL, 500 MG VIAL) 1
1 DROXIA (200 MG CAPSULE, 300 MG CAPSULE, 400 MG CAPSULE)
hydroxyurea 500 mg capsule 1
1 LONSURF (15 MG-6.14 MG TABLET, 20 MG-8.19 MG TABLET)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
30
DRUG NAME TIER REQUIREMENTS/LIMITS
mercaptopurine 50 mg tablet
PURIXAN 20 MG/ML ORAL SUSP
TABLOID 40 MG TABLET
1
1
1
1 FARYDAK (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE)
VENCLEXTA (10 MG TABLET, 50 MG TABLET, 100 MG TABLET)
1 PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY VENCLEXTA STARTING PACK 1
1 ZALTRAP (100 MG/4 ML VIAL, 200 MG/8 ML VIAL)
ZYKADIA 150 MG CAPSULE 1
Antineoplastics, Other
ALECENSA 150 MG CAPSULE 1
1
1
1
1
1
amifostine crystalline 500 mg vial
azacitidine 100 mg vial
BELEODAQ 500 MG VIAL
bleomycin sulfate (15 vial, 30 vial)
CABOMETYX (20 MG TABLET, 40 MG TABLET, 60 MG TABLET)
cisplatin 1 mg/ml vial 1
1
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK)
COTELLIC 20 MG TABLET 1
1
LA
CYRAMZA (100 MG/10 ML VIAL, 500 MG/50 ML VIAL)
daunorubicin hcl (5 mg/ml vial, 20 mg vial)
decitabine 50 mg vial
1
1
1
1
DOCEFREZ 20 MG VIAL
docetaxel (20 mg/2 ml vial, 20mg/ml(1) vial, 80 mg/8 ml vial, 80 mg/4 ml vial, 140 mg/7ml vial, 160 mg/8ml vial, 160mg/16ml vial, 200mg/20ml vial)
doxorubicin hcl (2 mg/ml vial, 10 mg vial, 10 mg/5 ml vial, 20 mg/10ml vial, 50 mg vial, 50 mg/25ml vial)
1
1 doxorubicin hcl peg-liposomal 2 mg/ml vial
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
31
DRUG NAME TIER REQUIREMENTS/LIMITS
ERIVEDGE 150 MG CAPSULE
ERWINAZE 10,000 UNITS VIAL
1
1
1 GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG TABLET)
PA - FOR NEW STARTS ONLY
HALAVEN 1 MG/2 ML VIAL 1
1 IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125 MG CAPSULE)
IRESSA 250 MG TABLET 1
1 JAKAFI (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 25 MG TABLET)
JEVTANA 60 MG/1.5 ML KIT 1
1 leucovorin calcium (5 mg tablet, 10 mg/ml vial, 10 mg tablet, 15 mg tablet, 25 mg tablet, 50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500mg/50ml vial, 500 mg vial)
levoleucovorin calcium 10 mg/ml vial
LYNPARZA 50 MG CAPSULE
1
1
1
1
MEKINIST (0.5 MG TABLET, 2 MG TABLET)
MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET)
mesna 100 mg/ml vial 1
1
1
1
MESNEX 400 MG TABLET
mitoxantrone hcl 2 mg/ml vial
NINLARO (2.3 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE)
ODOMZO 200 MG CAPSULE 1
1
LA
ONCASPAR (750 UNIT/ML VIAL, 3,750 UNIT/5 ML VIAL)
oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial, 100mg/20ml vial)
1
paclitaxel 6 mg/ml vial 1
1 POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE)
PROLEUKIN 22 MILLION UNIT VIAL 1
1
1
SYLATRON (200 MCG, 300 MCG, 600 MCG)
SYLATRON 4-PACK (200 MCG, 300 MCG)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
32
DRUG NAME TIER REQUIREMENTS/LIMITS
SYNRIBO 3.5 MG/ML VIAL 1 PA - FOR NEW STARTS ONLY
LA TAGRISSO (40 MG TABLET, 80 MG TABLET)
TAXOTERE (20 MG/ML VIAL, 80 MG/4 ML VIAL)
TRISENOX 10 MG/10 ML AMPULE
VELCADE 3.5 MG VIAL
1
1
1
1
1 ZOLINZA 100 MG CAPSULE
Aromatase Inhibitors, 3rd Generation
anastrozole 1 mg tablet 1
1
1
exemestane 25 mg tablet
letrozole 2.5 mg tablet
Enzyme Inhibitors
etoposide 20 mg/ml vial 1
1
1
topotecan hcl (4 mg/4 ml vial, 4 mg vial)
ZYDELIG (100 MG TABLET, 150 MG TABLET)
Molecular Target Inhibitors
AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET)
1
1 AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5 MG TABLET)
BOSULIF (100 MG TABLET, 500 MG TABLET)
GLEEVEC (100 MG TABLET, 400 MG TABLET)
ICLUSIG (15 MG TABLET, 45 MG TABLET)
1
1
1
1 imatinib mesylate (100 mg tablet, 400 mg tablet)
IMBRUVICA 140 MG CAPSULE 1
1
1
INLYTA (1 MG TABLET, 5 MG TABLET)
LENVIMA (8 MG, 10 MG, 14 MG, 18 MG, 20 MG, 24 MG)
NEXAVAR 200 MG TABLET 1
1 SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MG TABLET, 100 MG TABLET, 140 MG TABLET)
STIVARGA 40 MG TABLET 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
33
DRUG NAME TIER REQUIREMENTS/LIMITS
SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MG CAPSULE)
1
TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 1
1 TARCEVA (25 MG TABLET, 100 MG TABLET, 150 MG TABLET)
TASIGNA (150 MG CAPSULE, 200 MG CAPSULE)
TYKERB 250 MG TABLET
1
1
1
1
1
VOTRIENT 200 MG TABLET
XALKORI (200 MG CAPSULE, 250 MG CAPSULE)
ZELBORAF 240 MG TABLET
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
Monoclonal Antibodies
ARZERRA 1,000 MG/50 ML VIAL 1
1 AVASTIN (100 MG/4 ML VIAL, 400 MG/16 ML VIAL)
DARZALEX (100 MG/5 ML VIAL, 400 MG/20 ML VIAL)
1 LA
EMPLICITI (300 MG VIAL, 400 MG VIAL)
HERCEPTIN 440 MG VIAL
1
1
1
1
1
KADCYLA (100 MG VIAL, 160 MG VIAL)
KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL)
OPDIVO (40 MG/4 ML VIAL, 100 MG/10 ML VIAL)
PERJETA 420 MG/14 ML VIAL
RITUXAN 10 MG/ML VIAL
1
1
1
1
TECENTRIQ 1,200 MG/20 ML VIAL
YERVOY (50 MG/10 ML VIAL, 200 MG/40 ML VIAL)
Retinoids
bexarotene 75 mg capsule 1
1
1
PANRETIN 0.1% GEL
TARGRETIN (1% GEL, 75 MG SOFTGEL, 75 MG CAPSULE)
tretinoin 10 mg capsule 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
34
DRUG NAME
Antiparasitics
TIER REQUIREMENTS/LIMITS
Anthelmintics
ALBENZA 200 MG TABLET 1
BILTRICIDE 600 MG TABLET 1
1 ivermectin 3 mg tablet
Antiprotozoals
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET)
1
atovaquone 750 mg/5ml oral susp 1
1 atovaquone/proguanil hcl (atovaquone/proguanil 62.5-25 mg tablet, atovaquone/proguanil 250-100 mg tablet)
chloroquine phosphate (250 mg tablet, 500 mg tablet)
1
COARTEM TABLETS 1
1
1
1
1
1
1
1
1
DARAPRIM 25 MG TABLET
hydroxychloroquine sulfate 200 mg tablet
mefloquine hcl 250 mg tablet
NEBUPENT 300 MG INHAL POWDER
PENTAM 300 VIAL
PA
PA
primaquine phosphate 26.3 mg tablet
quinine sulfate 324 mg capsule
tinidazole (250 mg tablet, 500 mg tablet)
Pediculicides/Scabicides
EURAX 10% LOTION 1
1
1
lindane 1 % shampoo
permethrin 5 % cream (g)
Antiparkinson Agents
Anticholinergics
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1 PA
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
35
DRUG NAME TIER REQUIREMENTS/LIMITS
trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet)
1 PA
Antiparkinson Agents, Other
entacapone 200 mg tablet 1
1 tolcapone 100 mg tablet
Dopamine Agonists
APOKYN 30 MG/3 ML CARTRIDGE 1
1
ST
ST
bromocriptine mesylate (2.5 mg tablet, 5 mg capsule)
NEUPRO (1 MG/24 HR, 2 MG/24 HR, 3 MG/24 HR, 4 MG/24 HR, 6 MG/24 HR, 8 MG/24 HR)
1
1 pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet)
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet)
1
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa (carbidopa/levodopa 10mg- 100mg tablet, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 25mg-100mg tablet er, carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa 50mg-200mg tablet er)
1
carbidopa/levodopa/entacapone 1 (carbidopa/levodopa/entacapone 12.5-50 mg tablet, carbidopa/levodopa/entacapone 18.75- 75mg tablet, carbidopa/levodopa/entacapone 25-100-200 tablet, carbidopa/levodopa/entacapone 31.25-125 tablet, carbidopa/levodopa/entacapone 37.5- 150mg tablet, carbidopa/levodopa/entacapone 50-200-200 tablet)
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT (0.5 MG TABLET, 1 MG TABLET) 1
1
ST
selegiline hcl (5 mg tablet, 5 mg capsule)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
36
DRUG NAME TIER REQUIREMENTS/LIMITS
Antipsychotics
1st Generation/Typical
chlorpromazine hcl (10 mg tablet, 25 mg/ml ampul)
1 PA - FOR NEW STARTS ONLY
chlorpromazine hcl (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)
1 PA, PA - FOR NEW STARTS ONLY
COMPRO 25 MG SUPPOSITORY 1
1
1
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
fluphenazine decanoate 25 mg/ml vial
fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 2.5 mg/ml vial, 5 mg tablet, 5 mg/ml oral conc)
fluphenazine hcl 10 mg tablet 1
1
PA, PA - FOR NEW STARTS ONLY
haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet)
haloperidol decanoate (50 mg/ml vial, 50 mg/ml ampul, 100 mg/ml ampul, 100 mg/ml vial)
1
1
1
1
haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial, 5 mg/ml ampul)
loxapine succinate (5 mg capsule, 10 mg capsule, 25 mg capsule, 50 mg capsule)
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY molindone hcl (5 mg tablet, 10 mg tablet, 25 mg tablet)
ORAP 1 MG TABLET
ORAP 2 MG TABLET
1
1
1
PA - FOR NEW STARTS ONLY
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet)
perphenazine 16 mg tablet 1
1
1
1
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
PA
pimozide (1 mg tablet, 2 mg tablet)
prochlorperazine 25 mg supp.rect
prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vial)
PA - FOR NEW STARTS ONLY
prochlorperazine maleate (5 mg tablet, 10 mg tablet)
1
1
1
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)
thiothixene (1 mg capsule, 2 mg capsule, 5 mg capsule, 10 mg capsule)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
37
DRUG NAME TIER REQUIREMENTS/LIMITS
trifluoperazine hcl (1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet)
1 PA - FOR NEW STARTS ONLY
2nd Generation/Atypical
ABILIFY MAINTENA (ER 300 MG, ER 400 MG) 1
1
PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY aripiprazole (10 mg tab rapdis, 15 mg tab rapdis)
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)
1
1
1
ARISTADA (ER 441 MG/1.6 ML, ER 662 MG/2.4 ML, ER 882 MG/3.2 ML)
ST
ST FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET, TITRATION PACK)
GEODON 20 MG/ML VIAL 1
1
ST
ST INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 6 MG TABLET, ER 9 MG TABLET)
INVEGA SUSTENNA (39 MG/0.25 ML, 78 MG/0.5 ML, 117 MG/0.75 ML, 156 MG/ML SYRG, 234 MG/1.5 ML)
1
1
ST
ST
ST
INVEGA TRINZA (273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML)
LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET, 120 MG TABLET)
1
1
1
1
NUPLAZID 17 MG TABLET PA - FOR NEW STARTS ONLY, QL (62 PER 31 DAYS)
olanzapine (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 10 mg vial, 15 mg tablet, 20 mg tablet)
PA, PA - FOR NEW STARTS ONLY
olanzapine (5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 15 mg tab rapdis, 20 mg tab rapdis)
PA - FOR NEW STARTS ONLY
paliperidone (1.5 mg tab er 24, 3 mg tab er 24, 6 mg tab er 24, 9 mg tab er 24)
1
1
ST
ST
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet)
REXULTI (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)
1
1 RISPERDAL CONSTA (12.5 MG, 37.5 MG, 50 MG)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
38
DRUG NAME TIER REQUIREMENTS/LIMITS
risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)
1
SAPHRIS (2.5 MG TAB SL BLK CHRY, 5 MG TAB SL BLK CHERRY, 5 MG TABLET SUBLINGUAL, 10 MG TAB SUBLINGUAL, 10 MG TAB SL BLK CHERY)
1
1 SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 300 MG TABLET, 400 MG TABLET)
VRAYLAR (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE)
1
1
1
PA - FOR NEW STARTS ONLY, QL (31 PER 31 DAYS)
ziprasidone hcl (20 mg capsule, 40 mg capsule, 60 mg capsule, 80 mg capsule)
ST
ZYPREXA RELPREVV (210 MG VIAL, 210 MG VL KIT, 300 MG VL KIT, 300 MG VIAL, 405 MG VL KIT, 405 MG VIAL)
PA - FOR NEW STARTS ONLY
Treatment-Resistant
clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 100 mg tab rapdis, 150 mg tab rapdis, 200 mg tab rapdis)
1 PA - FOR NEW STARTS ONLY
clozapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)
1
1
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY FAZACLO (12.5 MG TABLET, 12.5 MG ODT, 25 MG TABLET, 25 MG ODT, 100 MG ODT, 100 MG TABLET)
VERSACLOZ 50 MG/ML SUSPENSION 1 PA - FOR NEW STARTS ONLY
Antispasticity Agents
baclofen (10 mg tablet, 20 mg tablet) 1
1 dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule)
tizanidine hcl (2 mg tablet, 4 mg tablet) 1 PA
Antivirals
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ATRIPLA TABLET 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
39
DRUG NAME TIER REQUIREMENTS/LIMITS
TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET)
1
VITEKTA (85 MG TABLET, 150 MG TABLET) 1
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA TABLET 1
1
1
EDURANT 25 MG TABLET
INTELENCE (25 MG TABLET, 100 MG TABLET, 200 MG TABLET)
nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h)
1
ODEFSEY TABLET 1
1
1
1
RESCRIPTOR (100 MG TABLET, 200 MG TABLET)
STRIBILD TABLET
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET)
VIRAMUNE XR 100 MG TABLET 1
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir sulfate 300 mg tablet 1
abacavir/lamivudine/zidovudine 150-300mg tablet
1
DESCOVY 200-25 MG TABLET 1
1 didanosine (125 mg capsule dr, 200 mg capsule dr, 250 mg capsule dr, 400 mg capsule dr)
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)
1
EPIVIR HBV 25 MG/5 ML SOLN
EPZICOM TABLET
1
1
1
1
GENVOYA TABLET
lamivudine (10 mg/ml solution, 100 mg tablet, 150 mg tablet, 300 mg tablet)
lamivudine/zidovudine 150-300mg tablet 1
1
1
RETROVIR 200 MG/20 ML VIAL
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule)
TRIUMEQ TABLET 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
40
DRUG NAME TIER REQUIREMENTS/LIMITS
TRUVADA (100 MG-150 MG TABLET, 133 MG- 200 MG TABLET, 167 MG-250 MG TABLET, 200 MG-300 MG TABLET)
1
VIDEX (2 GM SOLN, 4 GM SOLN) 1
1 VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER)
ZIAGEN 20 MG/ML SOLUTION 1
1 zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet)
Anti-HIV Agents, Other
FUZEON (90 MG VIAL, CONVENIENCE KIT) 1
1
1
SELZENTRY (150 MG TABLET, 300 MG TABLET)
TYBOST 150 MG TABLET
Anti-HIV Agents, Protease Inhibitors
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)
1
CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE)
EVOTAZ 300 MG-150 MG TABLET
1
1
1
1
INVIRASE (200 MG CAPSULE, 500 MG TABLET)
KALETRA (100-25 MG TABLET, 200-50 MG TABLET, 400-100/5 ML ORAL SOLU)
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)
1
1 NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG SOFTGEL CAP)
PREZCOBIX 800 MG-150 MG TABLET 1
1 PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 600 MG TABLET, 800 MG TABLET)
REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)
1
VIRACEPT (250 MG TABLET, 625 MG TABLET)
ZEPATIER 50-100 MG TABLET
1
1 PA, QL (28 PER 28 DAYS)
Anti-cytomegalovirus (CMV) Agents
cidofovir 75 mg/ml vial 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
41
DRUG NAME TIER REQUIREMENTS/LIMITS
ganciclovir sodium 500 mg vial
valganciclovir hcl 450 mg tablet
ZIRGAN 0.15% OPHTHALMIC GEL
1
1
1
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil 10 mg tablet 1
1
1
1
BARACLUDE 0.05 MG/ML SOLUTION
entecavir (0.5 mg tablet, 1 mg tablet)
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)
TYZEKA 600 MG TABLET 1
1 Anti-hepatitis C (HCV) Agents
DAKLINZA (30 MG TABLET, 60 MG TABLET, 90
MG TABLET) PA
HARVONI 90-400 MG TABLET
MODERIBA 200 MG TABLET
OLYSIO 150 MG CAPSULE
1
1
1
1
PA, QL (28 PER 28 DAYS)
PA
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)
PEGASYS PROCLICK (135 MCG/0.5, 180 MCG/0.5)
1
1
1
PEGINTRON (50 MCG, 80 MCG, 120 MCG, 150 MCG)
PEGINTRON REDIPEN (50 MCG, 50 MCG 4PK, 80 MCG, 80 MCG 4PK, 120 MCG 4PK, 120 MCG, 150 MCG, 150 MCG 4PK)
RIBASPHERE 200 MG TABLET
SOVALDI 400 MG TABLET
VIEKIRA PAK
1
1
1
PA, QL (28 PER 28 DAYS)
PA
Anti-influenza Agents
amantadine hcl (100 mg tablet, 100 mg capsule) 1
1
1
1
RELENZA 5 MG DISKHALER
rimantadine hcl 100 mg tablet
TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
42
DRUG NAME TIER REQUIREMENTS/LIMITS
Antiherpetic Agents
acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet)
1
acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 mg vial)
1
1 famciclovir (125 mg tablet, 250 mg tablet, 500 mg tablet)
trifluridine 1 % drops 1
1 valacyclovir hcl (500 mg tablet, 1000 mg tablet)
Anxiolytics
Anxiolytics, Other
buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet)
1
1 doxepin hcl 10 mg/ml oral conc PA - FOR NEW STARTS ONLY
Benzodiazepines
alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
1
1
1
1
PA
clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet, 15 mg tablet)
PA - FOR NEW STARTS ONLY
PA, PA - FOR NEW STARTS ONLY
PA - FOR NEW STARTS ONLY
PA, PA - FOR NEW STARTS ONLY
diazepam (2 mg tablet, 5 mg tablet, 10 mg tablet)
diazepam (5 mg/5 ml solution, 5 mg/ml oral conc)
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
LORAZEPAM INTENSOL 2 MG/ML 1
1
PA
PA oxazepam (10 mg capsule, 15 mg capsule, 30 mg capsule)
temazepam (7.5 mg capsule, 15 mg capsule, 22.5 mg capsule, 30 mg capsule)
1
1
PA
PA triazolam (0.125 mg tablet, 0.25 mg tablet)
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor
PAXIL 10 MG/5 ML SUSPENSION 1 PA - FOR NEW STARTS ONLY
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
43
DRUG NAME TIER REQUIREMENTS/LIMITS
venlafaxine hcl 225 mg tab er 24 1
Bipolar Agents
Bipolar Agents, Other
ABILIFY MAINTENA (ER 300 MG, ER 400 MG) 1
1
PA - FOR NEW STARTS ONLY
RISPERDAL CONSTA 25 MG SYR
Mood Stabilizers
lamotrigine 5 mg tb chw dsp 1
1 lithium carbonate (150 mg capsule, 300 mg tablet er, 300 mg tablet, 300 mg capsule, 450 mg tablet er, 600 mg capsule)
lithium citrate 8 meq/5 ml solution
Blood Glucose Regulators
Antidiabetic Agents
1
acarbose (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
AVANDIA (2 MG TABLET, 4 MG TABLET)
BYETTA (5 MCG, 10 MCG)
1
1
1
1
1
ST
ST
CYCLOSET 0.8 MG TABLET
FARXIGA (5 MG TABLET, 10 MG TABLET) ST
glimepiride (1 mg tablet, 2 mg tablet, 4 mg tablet)
glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 10 mg tablet)
1
1 glipizide/metformin hcl (glipizide/metformin 2.5- 250 mg tablet, glipizide/metformin 2.5-500 mg tablet, glipizide/metformin 5 mg-500mg tablet)
GLYSET (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)
1
1 INVOKAMET (50-1,000 MG TABLET, 50-500 MG TABLET, 150-500 MG TABLET, 150-1,000 MG TABLET)
ST
INVOKANA (100 MG TABLET, 300 MG TABLET) 1
1
ST
ST JANUMET (50-1,000 MG TABLET, 50-500 MG TABLET)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
44
DRUG NAME TIER REQUIREMENTS/LIMITS
JANUVIA (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)
1 ST
metformin hcl (500 mg tabergr24h, 500 mg tab er 24, 500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet)
1
1 miglitol (25 mg tablet, 50 mg tablet, 100 mg tablet)
nateglinide (60 mg tablet, 120 mg tablet) 1
1 pioglitazone hcl (15 mg tablet, 30 mg tablet, 45 mg tablet)
ST
ST pioglitazone hcl/metformin hcl (/metformin 15mg-500mg tablet, /metformin 15mg-850mg tablet)
1
repaglinide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
1
ST
ST repaglinide/metformin hcl (repaglinide/metformin 1mg-500mg tablet, repaglinide/metformin 2 mg-500mg tablet)
SYMLINPEN 120 PEN INJECTOR
SYMLINPEN 60 PEN INJECTOR
VICTOZA 2-PAK 18 MG/3 ML PEN
VICTOZA 3-PAK 18 MG/3 ML PEN
1
1
1
1
ST
ST
ST
ST
Glycemic Agents
CLINIMIX (4.25%-20%, 5%-20%, 5%-15%) 1
1
PA - TO CONFIRM PART D COVERAGE
CLINIMIX E (2.75%-5%, 2.75%-10%, 4.25%-25%, 4.25%-5%, 5%-15%, 5%-25%)
dextrose 10 % and 0.2 % nacl 10 %-0.2 % dehp fr bg
1
dextrose 10 % and 0.45 % nacl 10%-0.45% iv soln 1
1 dextrose 10 % in water (10 % 10 % iv soln, 10 % 10 % dehp fr bg)
dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln
1
dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln
dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln
1
1
1 dextrose 5 % in water (5 % 5 % iv soln, 5 % pgy vl prt, 5 % 5 % vial, 5 % pggybk prt)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
45
DRUG NAME TIER REQUIREMENTS/LIMITS
dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln
dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln
1
1
1 GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG VIAL, 1 MG HYPOKIT 2-PACK)
GLUCAGON 1 MG EMERGENCY KIT
IONOSOL B-D5W IV SOLUTION
1
1
1
1
1
IONOSOL MB-D5W IV SOLUTION
NORMOSOL-R-DEXTROSE 5% IV SOLN
potassium chloride in dextrose 5 % and 0.9 % sodium chloride (chloride/d5-0.9%nacl 40 meq/l soln, chloride/d5-0.9%nacl 20 meq/l soln)
potassium chloride in dextrose 5 %-0.45 % sodium chloride (chloride/d5-0.45nacl 10 meq/l soln, chloride/d5-0.45nacl 20 meq/l soln, chloride/d5-0.45nacl 40 meq/l soln, chloride/d5- 0.45nacl 30 meq/l soln)
1
potassium chloride in lr-d5 20 meq/l iv soln
potassium chloride/d5-0.2%nacl 20 meq/l iv soln
potassium chloride/d5-0.3%nacl 20 meq/l iv soln
PROGLYCEM 50 MG/ML ORAL SUSP
1
1
1
1
Insulins
APIDRA 100 UNITS/ML VIAL 1
1
1
APIDRA SOLOSTAR 100 UNITS/ML
HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL)
HUMALOG 100 UNITS/ML KWIKPEN
HUMALOG 200 UNITS/ML KWIKPEN
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 50-50 VIAL
1
1
1
1
1
1
1
1
1
HUMALOG MIX 75-25 KWIKPEN
HUMALOG MIX 75-25 VIAL
HUMULIN R 500 UNITS/ML VIAL
LANTUS 100 UNITS/ML VIAL
LANTUS SOLOSTAR 100 UNITS/ML
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
46
DRUG NAME TIER REQUIREMENTS/LIMITS
LEVEMIR 100 UNITS/ML VIAL 1
LEVEMIR FLEXPEN 100 UNITS/ML
LEVEMIR FLEXTOUCH 100 UNITS/ML
1
1
1 NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL)
NOVOLOG 100 UNITS/ML FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN SYRN
NOVOLOG MIX 70-30 VIAL
1
1
1
1 TOUJEO SOLOSTAR 300 UNITS/ML
Blood Products/Modifiers/Volume Expanders
Anticoagulants
enoxaparin sodium (100 mg/ml, 150 mg/ml) 1
1
1
1
1
1
1
PA, QL (34 ML PER 17 DAYS)
PA, QL (27.2 ML PER 17 DAYS)
PA, QL (102 ML PER 17 DAYS)
PA, QL (10.2 ML PER 17 DAYS)
PA, QL (17.6 ML PER 17 DAYS)
PA, QL (20.4 ML PER 17 DAYS)
ST
enoxaparin sodium (80mg/0.8ml, 120mg/.8ml)
enoxaparin sodium 300mg/3ml vial
enoxaparin sodium 30mg/0.3ml syringe
enoxaparin sodium 40mg/0.4ml syringe
enoxaparin sodium 60mg/0.6ml syringe
fondaparinux sodium (2.5 mg/0.5, 5mg/0.4ml, 7.5mg/0.6, 10mg/0.8ml)
FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL)
1 PA, ST
heparin sodium,porcine (1000/ml vial, 5000/ml vial, 5000/ml(1) cartridge, 10000/ml vial, 20000/ml vial)
1
1 heparin sodium,porcine/dextrose 5 % in water (sodium,porcine/d5w 25000/250 soln, sodium,porcine/d5w 20k/500ml soln, sodium,porcine/d5w 12500/250 soln, sodium,porcine/d5w 25000/500 soln)
PRADAXA (75 MG CAPSULE, 110 MG CAPSULE, 150 MG CAPSULE)
1
1
PA, ST
warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 10 mg tablet)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
47
DRUG NAME TIER REQUIREMENTS/LIMITS
XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, STARTER PACK)
1 ST
Blood Formation Modifiers
anagrelide hcl (0.5 mg capsule, 1 mg capsule) 1
1 ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/ML VIAL, 25 MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)
PA
EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL)
1 PA
LEUKINE 250 MCG VIAL 1
1
PA
PA NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML SYR, 480 MCG/1.6 ML VIAL, 480 MCG/0.8 ML SYR)
PROCRIT (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL)
1
1
PA
PA PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET)
Coagulants
BRILINTA (60 MG TABLET, 90 MG TABLET) 1
1 tranexamic acid (650 mg tablet, 1000 mg/10 vial, 1000 mg/10 ampul)
Platelet Modifying Agents
AGGRENOX 25 MG-200 MG CAPSULE 1
1
1
1
aspirin/dipyridamole 25mg-200mg cpmp 12hr
cilostazol (50 mg tablet, 100 mg tablet)
clopidogrel bisulfate (75 mg tablet, 300 mg tablet)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
48
DRUG NAME TIER REQUIREMENTS/LIMITS
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine (0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr)
1 PA
PA clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet)
1
methyldopa (250 mg tablet, 500 mg tablet)
methyldopate hcl 250 mg/5ml vial
1
1
1
PA
PA
midodrine hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
Alpha-adrenergic Blocking Agents
CARDURA XL (4 MG TABLET, 8 MG TABLET) 1
1
PA
PA prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule)
Angiotensin II Receptor Antagonists
candesartan cilexetil (4 mg tablet, 8 mg tablet, 16 mg tablet, 32 mg tablet)
1
1
1
1
ENTRESTO (24 MG-26 MG TABLET, 49 MG-51 MG TABLET, 97 MG-103 MG TABLET)
ST
irbesartan (75 mg tablet, 150 mg tablet, 300 mg tablet)
irbesartan/hydrochlorothiazide (irbesartan/hydrochlorothiazide 150-12.5mg tablet, irbesartan/hydrochlorothiazide 300- 12.5mg tablet)
losartan potassium (25 mg tablet, 50 mg tablet, 100 mg tablet)
1
1 losartan potassium/hydrochlorothiazide (losartan/hydrochlorothiazide 50-12.5 mg tablet, losartan/hydrochlorothiazide 100-12.5mg tablet, losartan/hydrochlorothiazide 100mg-25mg tablet)
telmisartan (20 mg tablet, 40 mg tablet, 80 mg tablet)
1 ST
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
49
DRUG NAME TIER REQUIREMENTS/LIMITS
telmisartan/hydrochlorothiazide 1 ST (telmisartan/hydrochlorothiazid 40-12.5 mg tablet, telmisartan/hydrochlorothiazid 80- 12.5mg tablet, telmisartan/hydrochlorothiazid 80 mg-25mg tablet)
valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet, 320 mg tablet)
1
1
ST
ST valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 80-12.5mg tablet, valsartan/hydrochlorothiazide 160- 12.5mg tablet, valsartan/hydrochlorothiazide 160-25mg tablet, valsartan/hydrochlorothiazide 320mg-25mg tablet, valsartan/hydrochlorothiazide 320-12.5mg tablet)
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet)
1
1 benazepril hcl/hydrochlorothiazide (benazepril/hydrochlorothiazide 5-6.25mg tablet, benazepril/hydrochlorothiazide 10- 12.5mg tablet, benazepril/hydrochlorothiazide 20-12.5 mg tablet, benazepril/hydrochlorothiazide 20 mg-25mg tablet)
captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)
1
1 captopril/hydrochlorothiazide (captopril/hydrochlorothiazide 25 mg-25mg tablet, captopril/hydrochlorothiazide 25 mg- 15mg tablet, captopril/hydrochlorothiazide 50 mg-15mg tablet, captopril/hydrochlorothiazide 50 mg-25mg tablet)
enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet)
1
1 enalapril maleate/hydrochlorothiazide (enalapril/hydrochlorothiazide 5mg-12.5mg tablet, enalapril/hydrochlorothiazide 10 mg- 25mg tablet)
lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
50
DRUG NAME TIER REQUIREMENTS/LIMITS
lisinopril/hydrochlorothiazide 1 (lisinopril/hydrochlorothiazide 10-12.5mg tablet, lisinopril/hydrochlorothiazide 20-12.5 mg tablet, lisinopril/hydrochlorothiazide 20 mg-25mg tablet)
quinapril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet)
1
1 quinapril hcl/hydrochlorothiazide (quinapril/hydrochlorothiazide 10-12.5mg tablet, quinapril/hydrochlorothiazide 20 mg- 25mg tablet, quinapril/hydrochlorothiazide 20- 12.5 mg tablet)
ramipril (1.25 mg capsule, 2.5 mg capsule, 5 mg capsule, 10 mg capsule)
1
Antiarrhythmics
amiodarone hcl (50 mg/ml vial, 50 mg/ml ampul, 200 mg tablet, 400 mg tablet)
1
1
1
1
1
PA
PA disopyramide phosphate (100 mg capsule, 150 mg capsule)
dofetilide (125 mcg capsule, 250 mcg capsule, 500 mcg capsule)
flecainide acetate (50 mg tablet, 100 mg tablet, 150 mg tablet)
mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule)
MULTAQ 400 MG TABLET 1
1
ST
propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225 mg tablet, 300 mg tablet, 325 mg cap er 12h, 425 mg cap er 12h)
quinidine gluconate 324 mg tablet er 1
1
1
quinidine sulfate (200 mg tablet, 300 mg tablet)
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet)
PA
TIKOSYN (125 MCG CAPSULE, 250 MCG CAPSULE, 500 MCG CAPSULE)
1
Beta-adrenergic Blocking Agents
acebutolol hcl (200 mg capsule, 400 mg capsule) 1
1 atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
51
DRUG NAME TIER REQUIREMENTS/LIMITS
bisoprolol fumarate (5 mg tablet, 10 mg tablet) 1
bisoprolol fumarate/hydrochlorothiazide (fumarate/hctz 2.5-6.25mg tablet, fumarate/hctz 5-6.25mg tablet, fumarate/hctz 10-6.25mg tablet)
1
carvedilol (3.125 mg tablet, 6.25 mg tablet, 12.5 mg tablet, 25 mg tablet)
1
1
1
1
1
COREG CR (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE, 80 MG CAPSULE)
ST
labetalol hcl (5 mg/ml vial, 100 mg tablet, 200 mg tablet, 300 mg tablet)
metoprolol succinate (25 mg tab er, 50 mg tab er, 100 mg tab er, 200 mg tab er)
metoprolol tartrate (5 mg/5 ml syringe, 5 mg/5 ml ampul, 5 mg/5 ml vial, 25 mg tablet, 50 mg tablet, 100 mg tablet)
metoprolol tartrate/hydrochlorothiazide (metoprolol/hydrochlorothiazide 50 mg-25mg tablet, metoprolol/hydrochlorothiazide 100mg- 50mg tablet, metoprolol/hydrochlorothiazide 100mg-25mg tablet)
1
1 nadolol/bendroflumethiazide (nadolol/bendroflumethiazide 40 mg tablet, nadolol/bendroflumethiazide 80 mg tablet)
pindolol (5 mg tablet, 10 mg tablet) 1
1 propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 mg tablet, 40 mg tablet, 60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h)
propranolol hcl/hydrochlorothiazide (propranolol/hydrochlorothiazid 40 tablet, propranolol/hydrochlorothiazid 80 tablet)
1
Calcium Channel Blocking Agents
AFEDITAB CR (30 MG TABLET, 60 MG TABLET) 1
1 amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
CARTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE)
1
1 DILT-CD (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
52
DRUG NAME TIER REQUIREMENTS/LIMITS
DILT-XR (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE)
1
diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg capsule er, 180 mg cap er deg, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 420 mg capsule er)
1
MATZIM LA (180 MG TABLET, 240 MG TABLET, 300 MG TABLET, 360 MG TABLET, 420 MG TABLET)
1
NIFEDICAL XL (30 MG TABLET, 60 MG TABLET) 1
1 nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er)
nimodipine 30 mg capsule 1
1 TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE)
verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml vial, 40 mg tablet, 80 mg tablet, 100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet, 120 mg tablet er, 180 mg tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel)
1
Cardiovascular Agents, Other
DEMSER 250 MG CAPSULE 1
1
1
DIGOX 125 MCG TABLET
digoxin (250 mcg/ml ampul, 250 mcg/ml syringe)
PA
digoxin 125 mcg tablet 1
1
QL (62 PER 31 DAYS)
NORTHERA (100 MG CAPSULE, 200 MG CAPSULE)
PA, QL (42 PER 14 DAYS)
NORTHERA 300 MG CAPSULE 1
1
1
PA, QL (84 PER 14 DAYS)
PA
pentoxifylline 400 mg tablet er
RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
53
DRUG NAME TIER REQUIREMENTS/LIMITS
TEKTURNA (150 MG TABLET, 300 MG TABLET) 1 ST
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide (125 mg tablet, 250 mg tablet) 1
1
1
acetazolamide sodium 500 mg vial
methazolamide 50 mg tablet
Diuretics, Loop
bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
1
1
furosemide (10 mg/ml solution, 10 mg/ml vial, 20 mg tablet, 40 mg tablet, 80 mg tablet)
torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg tablet)
Diuretics, Potassium-sparing
amiloride hcl 5 mg tablet 1
1 amiloride/hydrochlorothiazide 5 mg-50 mg tablet
spironolact/hydrochlorothiazid 25 mg-25mg tablet
1
spironolactone (50 mg tablet, 100 mg tablet)
spironolactone 25 mg tablet
1
1
1
PA
triamterene/hydrochlorothiazide (triamterene/hydrochlorothiazid 37.5-25 mg capsule, triamterene/hydrochlorothiazid 37.5-25 mg tablet, triamterene/hydrochlorothiazid 50 mg-25mg capsule, triamterene/hydrochlorothiazid 75 mg-50mg tablet)
Diuretics, Thiazide
candesartan cilexetil/hydrochlorothiazide (candesartan/hydrochlorothiazid 16-12.5mg tablet, candesartan/hydrochlorothiazid 32- 12.5mg tablet, candesartan/hydrochlorothiazid 32mg-25mg tablet)
1
chlorthalidone (25 mg tablet, 50 mg tablet) 1
1 hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet)
indapamide (1.25 mg tablet, 2.5 mg tablet) 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
54
DRUG NAME TIER REQUIREMENTS/LIMITS
metolazone (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
1
Dyslipidemics, Fibric Acid Derivatives
fenofibrate (40 mg tablet, 50 mg capsule, 54 mg tablet, 120 mg tablet, 150 mg capsule, 160 mg tablet)
1 ST
fenofibrate nanocrystallized (48 mg tablet, 145mg tablet)
1
1
ST
ST fenofibrate,micronized (43 mg capsule, 67 mg capsule, 130 mg capsule, 134mg capsule, 200 mg capsule)
fenofibric acid (35 mg tablet, 105 mg tablet) 1
1
ST
fenofibric acid (choline) ((choline) 45 mg capsule dr, (choline) 135 mg capsule dr)
fenoprofen calcium 400 mg capsule
FIBRICOR (35 MG TABLET, 105 MG TABLET)
gemfibrozil 600 mg tablet
1
1
1
ST
ST
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium (10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet)
1
1
1
1
lovastatin (10 mg tablet, 20 mg tablet, 40 mg tablet)
pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet)
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet)
Dyslipidemics, Other
cholestyramine (with sugar) (suar) 4 powder, suar) 4 powd pack)
1
1 cholestyramine/aspartame (cholestyramine/aspartame 4 powd pack, cholestyramine/aspartame 4 powder)
colestipol hcl (1 tablet, 5 packet, 5 ranules) 1
1 JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE)
PA
PA KYNAMRO 200 MG/ML SYRINGE 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
55
DRUG NAME TIER REQUIREMENTS/LIMITS
niacin (500 mg tab er, 750 mg tab er, 1000 mg tab er)
1
omega-3 acid ethyl esters 1 g capsule
PREVALITE (PACKET, POWDER)
1
1
1
1
1
1
REPATHA 140 MG/ML SURECLICK
REPATHA 140 MG/ML SYRINGE
REPATHA 420 MG/3.5ML PUSHTRONX
PA, ST
PA, ST
PA, ST
VYTORIN (10-80 MG TABLET, 10-10 MG TABLET, 10-40 MG TABLET, 10-20 MG TABLET)
WELCHOL 625 MG TABLET
ZETIA 10 MG TABLET
1
1
ST
Vasodilators, Direct-acting Arterial
hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg tablet, 50 mg tablet, 100 mg tablet)
1
1 minoxidil (2.5 mg tablet, 10 mg tablet)
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet er)
1
1 isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 24h)
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 50 mg/10ml vial)
1
1 NITROSTAT (0.3 MG TABLET, 0.4 MG TABLET, 0.6 MG TABLET)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
56
DRUG NAME TIER REQUIREMENTS/LIMITS
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
dextroamphetamine sulf- 1 ST, QL (62 PER 31 DAYS) saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg cap er, dextroamphetamine/amphetamine 10 mg cap er, dextroamphetamine/amphetamine 15 mg cap er, dextroamphetamine/amphetamine 20 mg cap er, dextroamphetamine/amphetamine 25 mg cap er, dextroamphetamine/amphetamine 30 mg cap er)
dextroamphetamine sulf- 1 QL (93 PER 31 DAYS) saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 12.5 mg tablet, dextroamphetamine/amphetamine 15 mg tablet, dextroamphetamine/amphetamine 20 mg tablet)
dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er)
1
1 dextroamphetamine/amphetamine 30 mg tablet QL (62 PER 31 DAYS)
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)
1
1
1
guanfacine hcl (1 mg tab er, 2 mg tab er, 3 mg tab er, 4 mg tab er)
PA, QL (31 PER 31 DAYS)
METADATE ER 20 MG TABLET
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
57
DRUG NAME TIER REQUIREMENTS/LIMITS
methylphenidate hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 ml solution, 10 mg cpbp 30-70, 18 mg tab er 24, 20 mg cpbp 30- 70, 20 mg tablet, 20 mg cpbp 50-50, 20 mg tablet er, 27 mg tab er 24, 30 mg cpbp 50-50, 30 mg cpbp 30-70, 36 mg tab er 24, 40 mg cpbp 50- 50, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70)
1
STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE, 100 MG CAPSULE)
1 ST
Central Nervous System, Other
HETLIOZ 20 MG CAPSULE 1
1
PA
PA HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET)
NUEDEXTA 20-10 MG CAPSULE 1
1
1
1
PA
PA
PA
PA
riluzole 50 mg tablet
tetrabenazine (12.5 mg tablet, 25 mg tablet)
XENAZINE (12.5 MG TABLET, 25 MG TABLET)
Fibromyalgia Agents
LYRICA 20 MG/ML ORAL SOLUTION 1
1
QL (1400 ML PER 31 DAYS)
QL (62 PER 31 DAYS) SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET)
Multiple Sclerosis Agents
AMPYRA ER 10 MG TABLET 1
1
1
PA
PA AUBAGIO (7 MG TABLET, 14 MG TABLET)
AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT, PREFILLED SYR 30 MCG)
AVONEX PEN (30 MCG/0.5 ML, 30 MCG/0.5 ML KIT)
1
BETASERON (0.3 MG VIAL, 0.3 MG KIT)
COPAXONE 40 MG/ML SYRINGE
GILENYA 0.5 MG CAPSULE
1
1
1
1
1
GLATOPA 20 MG/ML SYRINGE
REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE, TITRATION PACK)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
58
DRUG NAME TIER REQUIREMENTS/LIMITS
TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE)
1
TYSABRI 300 MG/15 ML VIAL 1 PA
Dental and Oral Agents
chlorhexidine gluconate 0.12 % mouthwash
PERIOGARD 0.12% ORAL RINSE
1
1
1
1
pilocarpine hcl (5 mg tablet, 7.5 mg tablet)
triamcinolone acetonide 0.1 % paste (g)
Dermatological Agents
8-MOP 10 MG CAPSULE 1
1 acitretin (10 mg capsule, 17.5 mg capsule, 25 mg capsule)
PA, ST
ST adapalene 0.1 % gel (gram) 1
1
1
1
ammonium lactate (12 % lotion, 12 % cream (g))
calcipotriene (0.005 % oint. (g), 0.005 % solution)
CLARAVIS (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE)
PA
clindamycin phosphate (1 % lotion, 1 % solution)
COSENTYX 150 MG/ML PEN INJECT
COSENTYX 150 MG/ML SYRINGE
1
1
1
1
1
1
1
ST
ST
ST
ST
ST
ST
COSENTYX 300 MG DOSE-2 PENS
COSENTYX 300 MG DOSE-2 SYRINGE
diclofenac sodium 1 % gel (gram)
erythromycin/benzoyl peroxide 3 %-5 % gel (gram)
fluocinolone acetonide 0.01 % oil 1
1 fluorouracil (0.5 % cream (g), 2 % solution, 5 % cream (g))
imiquimod 5 % cream pack 1
1
PA - FOR NEW STARTS ONLY
PA MYORISAN (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE)
podofilox 0.5 % solution 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
59
DRUG NAME TIER REQUIREMENTS/LIMITS
REGRANEX 0.01% GEL 1 PA, QL (15 GM PER 30 DAYS)
PA, QL (30 GM PER 30 DAYS) SANTYL OINTMENT 1
1
1
1
1
1
1
1
selenium sulfide 2.5 % lotion
sulfacetamide sodium 10 % suspension
tacrolimus (0.03 % (g), 0.1 % (g))
TAZORAC (0.05% GEL, 0.1% GEL)
TAZORAC (0.05%, 0.1%)
ST, QL (100 GM PER 30 DAYS)
ST, QL (60 GM PER 30 DAYS)
TOLAK 4% CREAM
tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025 % cream (g), 0.05 % cream (g), 0.1 % cream (g))
ST
UVADEX 20 MCG/ML VIAL 1
1 ZENATANE (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE)
PA
Enzyme Replacement/Modifiers
ADAGEN 250 UNITS/ML VIAL
ALDURAZYME 2.9 MG/5 ML VIAL
CEREZYME 400 UNITS VIAL
1
1
1
1 CREON (DR 3,000 CAPSULE, DR 6,000 CAPSULE, DR 12,000 CAPSULE, DR 24,000 CAPSULE, DR 36,000 CAPSULE)
CYSTADANE POWDER 1
1
1
1
1
1
CYSTAGON (50 MG CAPSULE, 150 MG CAPSULE)
ELAPRASE 6 MG/3 ML VIAL
ELELYSO 200 UNITS VIAL
FABRAZYME (5 MG VIAL, 35 MG VIAL)
KUVAN (100 MG TABLET, 100 MG POWDER PACKET, 500 MG POWDER PACKET)
PA
LUMIZYME 50 MG VIAL 1
1
1
NAGLAZYME 5 MG/5 ML VIAL
PANCREAZE (DR 4,200 CAP, DR 10,500 CAP, DR 16,800 CAP, DR 21,000 CAP)
sodium phenylbutyrate 0.94 g/g powder 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
60
DRUG NAME TIER REQUIREMENTS/LIMITS
STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80 MG/0.8 ML VIAL)
1 PA
SUCRAID 8,500 UNITS/ML SOLN
VPRIV 400 UNITS VIAL
1
1
1
1
ZAVESCA 100 MG CAPSULE
ZENPEP (DR 3,000 CAPSULE, DR 5,000 CAPSULE, DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE)
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
dicyclomine hcl (10 mg capsule, 20 mg tablet) 1
1
PA
PA
glycopyrrolate (0.2 mg/ml vial, 1 mg/5 ml syringe, 1 mg tablet, 2 mg tablet)
Gastrointestinal Agents, Other
cromolyn sodium 20 mg/ml oral conc 1
1 diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025mg tablet, hcl/atropine 2.5-.025/5 liquid)
GATTEX (5 MG ONE-VIAL, 5 MG 30-VIAL) 1
1
1
loperamide hcl 2 mg capsule
metoclopramide hcl (5 mg tablet, 5 mg/ml vial, 10 mg tablet)
PA
ST MOVANTIK (12.5 MG TABLET, 25 MG TABLET) 1
1 RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL)
ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)
1
Histamine2 (H2) Receptor Antagonists
famotidine (20 mg tablet, 40mg/5ml oral susp, 40 mg tablet)
1
1
1
famotidine in nacl,iso-osm/pf 20 mg/50ml piggyback
famotidine/pf 20 mg/2 ml vial
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
61
DRUG NAME TIER REQUIREMENTS/LIMITS
ranitidine hcl (15 mg/ml syrup, 25 mg/ml vial, 50 mg/2 ml vial, 150 mg capsule, 150 mg tablet, 300 mg tablet, 300 mg capsule)
1
Irritable Bowel Syndrome Agents
alosetron hcl (0.5 mg tablet, 1 mg tablet) 1
1
PA
AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES)
Laxatives
CONSTULOSE 10 GM/15 ML SOLN 1
1
1
1
1
1
1
1
ENULOSE 10 GM/15 ML SOLUTION
GAVILYTE-C SOLUTION
GAVILYTE-G SOLUTION
GAVILYTE-N SOLUTION
GENERLAC 10 GM/15 ML SOLUTION
lactulose (10 g/15 ml, 20 g/30 ml)
peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl (3350/na sulf,bicarb,cl/kcl 236-22.74g soln, 3350/na sulf,bicarb,cl/kcl 240-22.72g soln)
polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder)
1
1 TRILYTE WITH FLAVOR PACKETS
Protectants
CARAFATE 1 GM/10 ML SUSP 1
1
1
misoprostol (100 mcg tablet, 200 mcg tablet)
sucralfate 1 g tablet
Proton Pump Inhibitors
esomeprazole sodium (20 mg vial, 40 mg vial) 1
1
ST
ST lansoprazole (15 mg capsule dr, 30 mg capsule dr)
omeprazole (10 mg capsule dr, 20 mg capsule dr)
1
omeprazole 40 mg capsule dr 1
1
ST
ST pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
62
DRUG NAME TIER REQUIREMENTS/LIMITS
PROTONIX IV 40 MG VIAL 1
Genitourinary Agents
Antispasmodics, Urinary
darifenacin hydrobromide (7.5 mg tab er, 15 mg tab er)
1
1
1
PA, ST
PA
MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET)
oxybutynin chloride (5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 15 mg tab er 24)
OXYTROL 3.9 MG/24HR PATCH 1
1
PA, ST
PA, ST tolterodine tartrate (1 mg tablet, 2 mg tablet, 2 mg cap er 24h, 4 mg cap er 24h)
TOVIAZ (ER 4 MG TABLET, ER 8 MG TABLET) 1
1
ST
trospium chloride (20 mg tablet, 60 mg cap er 24h)
PA, ST
VESICARE (5 MG TABLET, 10 MG TABLET) 1 PA, ST
PA
Benign Prostatic Hypertrophy Agents
AVODART 0.5 MG SOFTGEL 1
1 doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet)
dutasteride 0.5 mg capsule
finasteride 5 mg tablet
1
1
1
1
tamsulosin hcl 0.4 mg cap er 24h
terazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule, 10 mg capsule)
PA
Genitourinary Agents, Other
bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet)
1
ELMIRON 100 MG CAPSULE
THIOLA 100 MG TABLET
1
1
Phosphate Binders
FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 750 MG POWDER PACKET, 1,000 MG POWDER PACK, 1,000 MG TABLET CHEW)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
63
DRUG NAME TIER REQUIREMENTS/LIMITS
RENAGEL (400 MG TABLET, 800 MG TABLET) 1
RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET, 800 MG TABLET)
1
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
A-HYDROCORT 100 MG VIAL 1
1
1
betamethasone dipropionate 0.05 % lotion
betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 % cream (g), betamethasone/propylene 0.05 % oint. (g))
betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g))
1
1 clobetasol propionate (0.05 % shampoo, 0.05 % cream (g), 0.05 % oint. (g), 0.05 % gel (gram))
clobetasol propionate/emoll 0.05 % cream (g) 1
1
1
CLODAN 0.05% SHAMPOO
clotrimazole/betamethasone dip 1 %-0.05 % cream (g)
DEPO-MEDROL 20 MG/ML VIAL 1
1
1
desonide 0.05 % lotion
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)
fludrocortisone acetate 0.1 mg tablet 1
1 fluocinolone acetonide (0.01 % cream (g), 0.025 % oint. (g), 0.025 % cream (g))
fluocinolone acetonide oil 0.01 % drops 1
1 fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g))
fluocinonide/emollient base 0.05 % cream (g) 1
1 fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g))
hydrocortisone (1 % oint. (g), 1 % cream (g), 2.5 % cream (g), 2.5 % oint. (g), 2.5 % cream/appl, 5 mg tablet, 10 mg tablet, 20 mg tablet)
1
1 hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
64
DRUG NAME TIER REQUIREMENTS/LIMITS
hydrocortisone valerate 0.2 % cream (g) 1
methylprednisolone (4 mg tablet, 4 mg tab ds pk, 8 mg tablet, 16 mg tablet, 32 mg tablet)
1
1
1
1
methylprednisolone acetate (40 mg/ml vial, 80 mg/ml vial)
methylprednisolone sodium succinate (125 mg vial, 1000 mg vial)
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution)
prednisolone 15 mg/5 ml solution 1
1 prednisolone sod phosphate (5 mg/5 ml, 15 mg/5 ml, 25 mg/5 ml)
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg tab ds pk, 10 mg tablet, 10 mg tab ds pk, 20 mg tablet)
1
PROCTOSOL-HC 2.5% CREAM
PROCTOZONE-HC 2.5% CREAM
1
1
1 SOLU-CORTEF (250 MG VIAL, 500 MG VIAL, 1,000 MG VIAL)
triamcinolone acetonide (0.025 % cream (g), 0.025 % oint. (g), 0.025 % lotion, 0.1 % oint. (g), 0.1 % cream (g), 0.5 % oint. (g), 0.5 % cream (g))
1
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 4 mcg/ml vial, 4 mcg/ml ampul, 10/spray spray/pump)
1
GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG CARTRIDGE)
1 PA
PA HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, 24 MG CARTRIDGE)
1
INCRELEX 40 MG/4 ML VIAL 1
1 NORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15 MG/1.5, 30 MG/3 ML)
PA
PA NORDITROPIN NORDIFLEX 30 MG/3 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
65
DRUG NAME TIER REQUIREMENTS/LIMITS
NUTROPIN AQ (20 MG/2ML CART, CARTRIDGE)
NUTROPIN AQ NUSPIN (5, 10, 20)
1 PA
PA
PA
1
1 OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG)
PREGNYL 10,000 UNITS VIAL 1
1
PA
PA SAIZEN (5 MG VIAL, 8.8 MG VIAL, 8.8 MG CLICK.EASY CARTG)
SEROSTIM (4 MG VIAL, 5 MG VIAL, 6 MG VIAL)
ZORBTIVE 8.8 MG VIAL
1
1
PA
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
KORLYM 300 MG TABLET 1 PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50 TABLET 1
oxandrolone (2.5 mg tablet, 10 mg tablet) 1
Androgens
ANDRODERM (2 MG/24HR, 4 MG/24HR) 1
1
1
PA
PA ANDROGEL 1%(5G) GEL PACKET
danazol (50 mg capsule, 100 mg capsule, 200 mg capsule)
TESTIM 1% (50MG) GEL 1
1
PA
PA testosterone (1.25 g(1%) gel md pmp, 50 mg (1%) gel (gram), 50 mg (1%) gel packet)
testosterone cypionate (100 mg/ml vial, 200 mg/ml vial)
1 PA
testosterone enanthate 200 mg/ml vial 1
1
PA
PA VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 MG/5 GEL PACKT)
Estrogens
AMETHIA 0.15-0.03-0.01 MG TAB
AMETHYST 90-20 MCG TABLET
APRI 28 DAY TABLET
1
1
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
66
DRUG NAME TIER REQUIREMENTS/LIMITS
ARANELLE 28 TABLET 1
AUBRA-28 TABLET 1
1
1
1
1
1
1
1
1
1
1
1
AVIANE-28 TABLET
BALZIVA 28 TABLET
BRIELLYN TABLET
CRYSELLE-28 TABLET
CYCLAFEM (1-35-28 TABLET, 7-7-7-28 TABLET)
DELYLA-28 TABLET
desog-e.estradiol/e.estradiol 21-5 tablet
EMOQUETTE 28 DAY TABLET
ENPRESSE-28 TABLET
ESTRACE 0.01% CREAM
estradiol (.025mg/24h, .0375mg/24, 0.05mg/24h, 0.06mg/24h, .075mg/24h, 0.1mg/24hr)
PA
estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
1
estradiol/norethindrone acet 0.5-0.1mg tablet 1
1 ethinyl estradiol/drospirenone 0.03mg-3mg tablet
FALMINA-28 TABLET 1
1
1
1
1
1
1
GIANVI 3 MG-0.02 MG TABLET
GILDAGIA 0.4 MG-0.035 MG TAB
GILDESS 1.5 MG-30 MCG TABLET
INTROVALE 0.15-0.03 MG TABLET
JINTELI 1 MG-5 MCG TABLET
JUNEL (1 MG-20 MCG TABLET, 1.5 MG-30 MCG TABLET)
JUNEL FE (1 MG-20 MCG TABLET, 1.5 MG-30 MCG TABLET)
1
KARIVA 28 DAY TABLET 1
1
1
1
KELNOR 1-35 28 TABLET
LARIN (1.5 MG-30 MCG TABLET, 21 1-20 TABLET)
LARIN FE (1-20 TABLET, 1.5-30 TABLET)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
67
DRUG NAME TIER REQUIREMENTS/LIMITS
LEENA 28 TABLET 1
LESSINA-28 TABLET
LEVONEST-28 TABLET
1
1
1 levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 0.15-0.03 tbdspk 3mo, 0.15-0.03 tablet, 90- 20mcg tablet)
LEVORA-28 TABLET 1
1
1
1
1
1
1
1
LORYNA 3 MG-0.02 MG TABLET
LUTERA-28 TABLET
MARLISSA-28 TABLET
MICROGESTIN (21 1.5-30 TAB, 21 1-20 TABLET)
MICROGESTIN FE (1-20 TABLET, 1.5-30 TAB)
MONONESSA 28 TABLET
NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 7-7- 7-28 TABLET)
NIKKI 3 MG-0.02 MG TABLET 1
1
1
norethindrone ac-eth estradiol 1mg-5mcg tablet
NORTREL (0.5-35 TABLET, 1-35 TABLET, 7-7-7-28 TABLET)
OCELLA 3 MG-0.03 MG TABLET
ORSYTHIA-28 TABLET
1
1
1
1
1
1
PIMTREA 28 DAY TABLET
PIRMELLA 1-35-28 TABLET
PORTIA-28 TABLET
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET)
PA
PREMARIN VAGINAL CREAM-APPL
PREMPHASE 0.625-5 MG TABLET
1
1
1
PA
PA PREMPRO (0.3 MG-1.5 MG TABLET, 0.45-1.5 MG TABLET, 0.625-5 MG TABLET, 0.625-2.5 MG TABLET)
PREVIFEM TABLET 1
1
1
QUASENSE 0.15-0.03 MG TABLET
RECLIPSEN 28 DAY TABLET
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
68
DRUG NAME TIER REQUIREMENTS/LIMITS
SPRINTEC 28 DAY TABLET
SRONYX 0.10-0.02 MG TABLET
TARINA FE 1-20 TABLET
TRI-LEGEST FE-28 DAY TABLET
TRI-PREVIFEM TABLET
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
TRI-SPRINTEC TABLET
TRINESSA TABLET
TRIVORA-28 TABLET
VELIVET 28 DAY TABLET
VESTURA 3 MG-0.02 MG TABLET
VYFEMLA 28 TABLET
WYMZYA FE CHEWABLE TABLET
ZENCHENT 0.4 MG-35 MCG TABLET
ZOVIA 1-35E TABLET
ZOVIA 1-50E TABLET
Progestins
CAMILA 0.35 MG TABLET 1
1
1
1
1
1
1
1
DEPO-PROVERA 400 MG/ML VIAL
DEPO-SUBQ PROVERA 104 SYRINGE
ERRIN 0.35 MG TABLET
hydroxyprogesterone caproate 250 mg/ml vial
JOLIVETTE TABLET
PA
LYZA 0.35 MG TABLET
medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 150 mg/ml vial, 150 mg/ml syringe)
MEGACE ES 625 MG/5 ML SUSP 1
1
PA
megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp)
PA - FOR NEW STARTS ONLY
megestrol acetate 625mg/5ml oral susp
NORA-BE TABLET
1
1
1
PA
norethindrone 0.35 mg tablet
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
69
DRUG NAME TIER REQUIREMENTS/LIMITS
norethindrone acetate 5 mg tablet 1
progesterone,micronized (100 mg capsule, 200 mg capsule)
1
Selective Estrogen Receptor Modifying Agents
raloxifene hcl 60 mg tablet 1
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet)
1
liothyronine sodium (5 mcg tablet, 10 mcg/ml vial, 25 mcg tablet, 50 mcg tablet)
1
Hormonal Agents, Suppressant (Adrenal)
LYSODREN 500 MG TABLET 1
1
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR (30 MG TABLET, 60 MG TABLET, 90 MG TABLET)
Hormonal Agents, Suppressant (Pituitary)
cabergoline 0.5 mg tablet 1
1 ELIGARD (7.5 MG B, 7.5 MG KIT, 22.5 MG B, 22.5 MG KIT, 30 MG B, 30 MG KIT, 45 MG B, 45 MG KIT)
FIRMAGON (2 X 120 MG VIALS, 2 X 120 MG KIT, 80 MG VIAL, 80 MG KIT)
1
1
1
leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial)
LUPRON DEPOT (DEPOT 3.75 MG, DEPOT-4 MONTH, DEPOT 7.5 MG, DEPOT 11.25 MG 3MO, DEPOT 22.5 MG 3MO, DEPOT 45 MG 6MO)
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MG KIT, 15 MG KIT, 30 MG 3MO KIT)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
70
DRUG NAME TIER REQUIREMENTS/LIMITS
octreotide acetate (50 mcg/ml vial, 50 mcg/ml ampul, 100 mcg/ml ampul, 100 mcg/ml vial, 200 mcg/ml vial, 500 mcg/ml ampul, 500 mcg/ml vial, 1000mcg/ml vial)
1
SANDOSTATIN LAR (10 MG, 20 MG, 30 MG) 1
1 SANDOSTATIN LAR DEPOT (10 MG VL, 10 MG KT, 20 MG VL, 20 MG KT, 30 MG KT, 30 MG VL)
SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML) 1
1 SIGNIFOR LAR (20 MG VIAL, 20 MG KIT, 40 MG KIT, 40 MG VIAL, 60 MG VIAL, 60 MG KIT)
SOMATULINE DEPOT (90 MG/0.3 ML, 120 MG/0.5 ML)
1
1 SOMAVERT (10 MG VIAL, 15 MG VIAL, 20 MG VIAL, 25 MG VIAL, 30 MG VIAL)
SYNAREL 2 MG/ML NASAL SPRAY 1
1
PA
TRELSTAR (3.75 MG SYRINGE, 3.75 MG VIAL, 11.25 MG SYRINGE, 11.25 MG VIAL, 22.5 MG VIAL, 22.5 MG SYRINGE)
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole (5 mg tablet, 10 mg tablet) 1
1 propylthiouracil 50 mg tablet
Immunological Agents
Angioedema (HAE) Agents
CINRYZE 500 UNIT VIAL 1
1
PA
PA FIRAZYR 30 MG/3 ML SYRINGE
Immune Suppressants
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE)
1 PA - TO CONFIRM PART D COVERAGE
AZASAN (75 MG TABLET, 100 MG TABLET)
azathioprine 50 mg tablet
1
1
1
1
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
azathioprine sodium 100 mg vial
BENLYSTA (120 MG VIAL, 400 MG VIAL) PA
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
71
DRUG NAME TIER REQUIREMENTS/LIMITS
CELLCEPT 500 MG VIAL 1 PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE cyclosporine (25 mg capsule, 100 mg capsule, 250 mg/5ml vial, 250 mg/5ml ampul)
1
1
1
1
1
cyclosporine, modified (25 mg capsule, 100 mg/ml solution, 100 mg capsule)
PA - TO CONFIRM PART D COVERAGE
ENBREL (25 MG KIT, 50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR)
ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET)
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG/ML SOLUTION, 100 MG CAPSULE)
HUMIRA (20 MG/0.4 ML, 40 MG/0.8 ML)
HUMIRA 40 MG/0.8 ML PEN
1
1
1
1
1
HUMIRA PEN CROHN-UC-HS STARTER
KINERET 100 MG/0.67 ML SYRINGE
methotrexate sodium (2.5 mg tablet, 25 mg/ml vial)
methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial)
1
1
1
mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet)
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
mycophenolate sodium (180 mg tablet dr, 360 mg tablet dr)
NULOJIX 250 MG VIAL 1
1
1
1
1
1
1
ORENCIA (125 MG/ML SYRINGE, 250 MG VIAL)
ORENCIA CLICKJECT 125 MG/ML
PROGRAF 5 MG/ML AMPULE
RAPAMUNE 1 MG/ML ORAL SOLN
REMICADE 100 MG VIAL
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule)
1
TORISEL 25 MG KIT 1
1 TREXALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 15 MG TABLET)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
72
DRUG NAME TIER REQUIREMENTS/LIMITS
ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MG TABLET)
1 PA - TO CONFIRM PART D COVERAGE
Immunizing Agents, Passive
ATGAM 50 MG/ML AMPUL 1
1 CARIMUNE NF NANOFILTERED (3 GM VIAL, 6 GM VIAL, 12 GM VIAL)
PA - TO CONFIRM PART D COVERAGE
GAMMAGARD LIQUID 10% VIAL 1
1
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE GAMMAGARD S-D (2.5 GM VL W/ST, 5 G (IGA<1) SOLN, 5 GM VL W/SET, 10 G (IGA<1) SOL, 10 GM VL W/ST)
GAMUNEX-C (1 GRAM/10 ML VIAL, 2.5 GRAM/25 ML VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML VIAL, 40 GRAM/400 ML VIAL)
1 PA - TO CONFIRM PART D COVERAGE
HYPERRAB S-D 150 UNITS/ML VIAL
THYMOGLOBULIN 25 MG VIAL
1
1
Immunomodulators
ACTIMMUNE 100 MCG/0.5 ML VIAL 1
1
1
1
1
1
ARCALYST 220 MG INJECTION
ILARIS 180 MG VIAL PA
leflunomide (10 mg tablet, 20 mg tablet)
SIMULECT (10 MG VIAL, 20 MG VIAL)
SYNAGIS (50 MG/0.5 ML VIAL, 100 MG/1 ML VIAL)
XELJANZ 5 MG TABLET 1
1
PA
PA XELJANZ XR 11 MG TABLET
Vaccines
ACTHIB (VIAL, WITH DILUENT) 1
1
1
1
1
1
1
ADACEL TDAP VIAL
bcg vaccine, live/pf 50 mg vial
BEXSERO PREFILLED SYRINGE
BOOSTRIX TDAP (SYRINGE, VIAL)
CERVARIX VACCINE SYRINGE
DAPTACEL DTAP VACCINE
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
73
DRUG NAME TIER REQUIREMENTS/LIMITS
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL)
1 PA - TO CONFIRM PART D COVERAGE
ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN)
1 PA - TO CONFIRM PART D COVERAGE
GARDASIL (SYRINGE, VIAL) 1
1
1
GARDASIL 9 (9 VIAL, 9 SYRINGE)
HAVRIX (720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML SYRINGE, 1,440 UNITS/ML VIAL)
HIBERIX (VIAL, WITH DILUENT) 1
1 IMOVAX RABIES VACCINE (VACCINE VIAL, VACCINE+DILUENT)
INFANRIX DTAP VIAL 1
1
1
1
1
1
1
1
1
1
1
1
1
1
IPOL VIAL
IXIARO 6 MCG/0.5 ML SYRINGE
M-M-R II VACCINE (VIAL, WITH DILUENT)
MENACTRA VIAL
MENHIBRIX VACCINE VIAL
MENOMUNE-A-C-Y-W-135 (VIAL, W-DILUENT)
MENVEO A-C-Y-W-135-DIP VIAL KT
PEDVAXHIB VACCINE VIAL
PENTACEL ACTHIB COMPONENT VIAL
PROQUAD VIAL
QUADRACEL DTAP-IPV VIAL
RABAVERT RABIES VACCINE VIAL
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10 MCG/ML VIAL, 10 MCG/ML SYR, 40 MCG/ML VIAL)
PA - TO CONFIRM PART D COVERAGE
ROTARIX VACCINE SUSPENSION
ROTATEQ VACCINE
1
1
1
1
1
1
1
TENIVAC SYRINGE
tetanus, diphtheria tox,adult 2-2 lf/0.5 vial
tetanus,diphtheria toxd ped/pf 5-25/0.5ml vial
TRUMENBA 120 MCG/0.5 ML VACCIN
TWINRIX VACCINE VIAL
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
74
DRUG NAME TIER REQUIREMENTS/LIMITS
TYPHIM VI 25 MCG/0.5 ML VIAL
VAQTA (25 UNITS/0.5 ML, 50 UNITS/ML)
VARIVAX VACCINE (VIAL, WITH DILUENT)
VARIZIG 125 UNIT/1.2 ML VIAL
YF-VAX (1 VIAL, 5 VIAL)
1
1
1
1
1
1 ZOSTAVAX VIAL
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO ER 0.375 GRAM CAPSULE 1
1
1
1
1
1
1
1
ASACOL HD DR 800 MG TABLET
balsalazide disodium 750 mg capsule
CANASA 1,000 MG SUPPOSITORY
DELZICOL DR 400 MG CAPSULE
DIPENTUM 250 MG CAPSULE
ST
ST LIALDA DR 1.2 GM TABLET
PENTASA (250 MG CAPSULE, 500 MG CAPSULE)
Glucocorticoids
budesonide 3 mg capdr - er 1
1 cortisone acetate 25 mg tablet
Sulfonamides
sulfasalazine (500 mg tablet, 500 mg tablet dr) 1
Metabolic Bone Disease Agents
alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg tablet)
1
1
1
1
calcitonin,salmon,synthetic 200/spray spray/pump
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution, 1 mcg/ml ampul)
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule, 4mcg/2ml ampul, 4mcg/2ml vial)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
75
DRUG NAME TIER REQUIREMENTS/LIMITS
etidronate disodium (200 mg tablet, 400 mg tablet)
1
FORTEO 600 MCG/2.4 ML PEN INJ
FORTICAL 200 UNITS NASAL SPRAY
1
1
1
ST
ST ibandronate sodium (3 mg/3 ml vial, 150 mg tablet)
ibandronate sodium 3 mg/3 ml syringe 1
1 MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL)
PROLIA 60 MG/ML SYRINGE 1
1
1
1
ST
XGEVA 120 MG/1.7 ML VIAL
zoledronic acid (4 mg/5 ml vial, 4 mg vial) PA
ST zoledronic acid in mannitol and water for injection (acid/mannitol-water 5 mg/100ml infus. btl, acid/mannitol-water 5 mg/100ml piggyback)
Miscellaneous Therapeutic Agents
FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET)
1 ST
fomepizole 1 g/ml vial 1
1
1
1
1
INTRALIPID 20% IV FAT EMUL PA - TO CONFIRM PART D COVERAGE
PA NATPARA (25 MCG, 50 MCG, 75 MCG, 100 MCG)
NUTRILIPID 20% IV FAT EMULSION PA - TO CONFIRM PART D COVERAGE
pen needle, diabetic (, 30gx 5/16", , 31 gx3/16", , 31 gx5/16")
PHYSIOLYTE IRRIGATION SOLN
PHYSIOSOL IRRIGATION SOLN
1
1
1
1
1
1
ringers solution irrig soln
ringers solution,lactated irrig soln
sodium chloride irrig solution 0.9 % irrig soln
syring-needl,disp,insul,0.3 ml 30gx 5/16" disp syrin
syringe with needle, insulin, safety, 0.3 ml (ge,needle,insuln,sf,0.3ml 30gx 5/16" disp, ge,needle,insuln,sf,0.3ml 29 g x1/2" disp)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
76
DRUG NAME TIER REQUIREMENTS/LIMITS
syringe with needle, insulin, safety, 0.5 ml (29 g x1/2" disp, 30gx 5/16" disp)
1
syringe with needle, insulin, safety, 1 ml (29 g x1/2" disp, 30gx 5/16" disp)
1
1 syringe with needle,disposable,insulin 1 ml (ge disp, ge 28gx1/2" disp, ge 29 g x1/2" disp, ge 30gx 5/16" disp, ge 30gx1/2" disp)
syringe with needle,insulin,0.5 ml (ml 28 gauge disp, ml 29 g x1/2" disp, ml 30gx 5/16" disp, ml 30gx1/2" disp)
1
1 water for irrigation,sterile irrig soln
Ophthalmic Agents
Ophthalmic Agents, Other
atropine sulfate 1 % drops 1
1
1
LACRISERT 5 MG EYE INSERT
RESTASIS 0.05% EYE EMULSION QL (60 PER 30 DAYS)
Ophthalmic Anti-allergy Agents
azelastine hcl 0.05 % drops 1
1
1
1
1
1
cromolyn sodium 4 % drops
epinastine hcl 0.05 % drops
olopatadine hcl 0.1 % drops
PATADAY 0.2% EYE DROPS
PATANOL 0.1% EYE DROPS
QL (10 ML PER 30 DAYS)
QL (10 ML PER 30 DAYS)
Ophthalmic Anti-inflammatories
ALREX 0.2% EYE DROPS 1
1
1
1
1
1
1
dexamethasone sod phosphate 0.1 % drops
diclofenac sodium 0.1 % drops
DUREZOL 0.05% EYE DROPS
fluorometholone 0.1 % drops susp
flurbiprofen sodium 0.03 % drops
ketorolac tromethamine (0.4 % drops, 0.5 % drops)
QL (10 ML PER 30 DAYS)
LOTEMAX (EYE DROPS, OPHTHALMIC GEL) 1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
77
DRUG NAME TIER REQUIREMENTS/LIMITS
neomycin/polymyxin b sulfate/dexamethasone (neo/polymyx sulf/dexameth 0.1 % drops susp, neo/polymyx sulf/dexameth 3.5-10k-.1 oint. (g))
1
prednisolone acetate 1 % drops susp
prednisolone sod phosphate 1 % drops
TOBRADEX EYE OINTMENT
1
1
1
1 tobramycin/dexamethasone 0.3 %-0.1% drops susp
VEXOL 1% EYE DROPS 1
Ophthalmic Antiglaucoma Agents
acetazolamide 500 mg capsule er 1
1
1
1
1
1
1
1
1
1
1
1
ALPHAGAN P 0.1% DROPS
apraclonidine hcl 0.5 % drops
AZOPT 1% EYE DROPS QL (10 ML PER 30 DAYS)
QL (10 ML PER 30 DAYS)
brimonidine tartrate (0.15 % drops, 0.2 % drops)
dorzolamide hcl 2 % drops
dorzolamide hcl/timolol maleat 22.3-6.8/1 drops
levobunolol hcl 0.5 % drops
methazolamide 25 mg tablet
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops)
SIMBRINZA 1%-0.2% EYE DROPS
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel, 0.5 % drops)
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost 0.005 % drops 1
1
1
QL (5 ML PER 30 DAYS)
QL (5 ML PER 30 DAYS)
QL (5 ML PER 30 DAYS)
LUMIGAN 0.01% EYE DROPS
travoprost (benzalkonium) 0.004 % drops
Otic Agents
acetic acid 2 % solution 1
1 neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxin sulf/hc 3.5-10k-1 solution, neomycin/polymyxin sulf/hc 3.5-10k-1 drops susp)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
78
DRUG NAME TIER REQUIREMENTS/LIMITS
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS (100-50, 250-50, 500-50) 1 QL (60 PER 30 DAYS)
ADVAIR HFA (45-21 MCG, 115-21 MCG, 230-21 MCG)
1 QL (12 GM PER 30 DAYS)
ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #60, TWISTHALER 220 MCG #30, TWISTHALR 220 MCG #120)
1
ASMANEX HFA (100 MCG, 200 MCG)
BREO ELLIPTA 100-25 MCG INH
1
1
1 budesonide (0.25mg/2ml, 0.5 mg/2ml, 1 mg/2 ml)
PA - TO CONFIRM PART D COVERAGE
budesonide 32mcg spray/pump 1
1
1
1
1
1
1
1
1
1
1
FLOVENT HFA (110 MCG, 220 MCG)
FLOVENT HFA 44 MCG INHALER
flunisolide 25 mcg spray
QL (24 GM PER 30 DAYS)
QL (21.2 GM PER 30 DAYS)
fluticasone propionate 50 mcg spray susp
mometasone furoate 50 mcg spray/pump
PULMICORT 1 MG/2 ML RESPULE
PULMICORT FLEXHALER (90 MCG, 180 MCG)
QVAR 40 MCG ORAL INHALER
ST
PA - TO CONFIRM PART D COVERAGE
QL (8.7 GM PER 30 DAYS)
QL (17.4 GM PER 30 DAYS) QVAR 80 MCG ORAL INHALER
SYMBICORT (80-4.5 MCG, 160-4.5 MCG)
Antihistamines
azelastine hcl (137 mcg spray/pump, 205.5mcg spray/pump)
1 ST
diphenhydramine hcl 50 mg/ml vial
levocetirizine dihydrochloride 5 mg tablet
olopatadine hcl 0.6 % spray/pump
1
1
1
PA
ST
Antileukotrienes
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mg tablet)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
79
DRUG NAME TIER REQUIREMENTS/LIMITS
zafirlukast (10 mg tablet, 20 mg tablet)
ZYFLO 600 MG FILMTAB
1
1
1
ST
ST ZYFLO CR 600 MG TABLET
Bronchodilators, Anticholinergic
ATROVENT HFA INHALER 1
1
1
1
1
COMBIVENT RESPIMAT INHAL SPRAY
ipratropium bromide (21 mcg, 42 mcg)
ipratropium bromide 0.2 mg/ml solution PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE ipratropium/albuterol sulfate 0.5-3mg/3 ampul- neb
SPIRIVA 18 MCG CP-HANDIHALER
SPIRIVA RESPIMAT 1.25 MCG INH
SPIRIVA RESPIMAT 2.5 MCG INH
TUDORZA PRESSAIR 400 MCG INH
1
1
1
1
ST
ST
ST
Bronchodilators, Sympathomimetic
ADRENACLICK (0.15 MG AUTO-INJCT, 0.3 MG AUTO-INJECT)
1
1
QL (2 PER 60 DAYS)
albuterol sulfate (0.63mg/3ml vial-neb, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 5 mg/ml solution)
PA - TO CONFIRM PART D COVERAGE
epinephrine 0.3mg/0.3 auto injct
EPIPEN 0.3 MG AUTO-INJECTOR
EPIPEN 2-PAK 0.3 MG AUTO-INJCT
EPIPEN JR 0.15 MG AUTO-INJCT
EPIPEN JR 2-PAK 0.15 MG INJCTR
1
1
1
1
1
1
QL (2 PER 60 DAYS)
QL (2 PER 60 DAYS)
QL (2 PER 60 DAYS)
QL (2 PER 60 DAYS)
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet)
PROAIR HFA 90 MCG INHALER
SEREVENT DISKUS 50 MCG
1
1
1
ST
QL (60 PER 30 DAYS)
terbutaline sulfate (1 mg/ml vial, 2.5 mg tablet, 5 mg tablet)
VENTOLIN HFA (90 MCG INHALER, RELION 90 MCG INH)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
80
DRUG NAME TIER REQUIREMENTS/LIMITS
Cystic Fibrosis Agents
CAYSTON 75 MG INHAL SOLUTION 1
KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET)
1 PA, QL (62 PER 31 DAYS)
ORKAMBI 200 MG-125 MG TABLET
PULMOZYME 1 MG/ML AMPUL
1
1
1
PA
PA, ST
PA tobramycin in 0.225% nacl 300 mg/5ml ampul- neb
Mast Cell Stabilizers
cromolyn sodium 20 mg/2 ml ampul-neb 1
1
PA - TO CONFIRM PART D COVERAGE
Phosphodiesterase Inhibitors, Airways Disease
aminophylline (250mg/10ml vial, 250mg/10ml ampul, 500mg/20ml vial, 500mg/20ml ampul)
DALIRESP 500 MCG TABLET 1
1
PA
THEO-24 (ER 100 MG CAPSULE, ER 200 MG CAPSULE, ER 300 MG CAPSULE, ER 400 MG CAPSULE)
theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h)
1
Pulmonary Antihypertensives
ADCIRCA 20 MG TABLET 1
1
PA
ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG TABLET, 2 MG TABLET, 2.5 MG TABLET)
ST, QL (93 PER 31 DAYS)
LETAIRIS (5 MG TABLET, 10 MG TABLET)
OPSUMIT 10 MG TABLET
1
1
1
ST
ST, QL (31 PER 31 DAYS)
REMODULIN (1 MG/ML VIAL, 2.5 MG/ML VIAL, 5 MG/ML VIAL, 10 MG/ML VIAL)
PA - TO CONFIRM PART D COVERAGE, ST
sildenafil citrate 20 mg tablet 1
1
PA
TRACLEER (62.5 MG TABLET, 125 MG TABLET) ST, LA
Respiratory Tract Agents, Other
acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1
1
1
PA - TO CONFIRM PART D COVERAGE
PA
ARALAST NP (500 MG VIAL, 1,000 MG VIAL)
ESBRIET 267 MG CAPSULE
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
81
DRUG NAME TIER REQUIREMENTS/LIMITS
GLASSIA 1 GM/50 ML VIAL 1
OFEV (100 MG CAPSULE, 150 MG CAPSULE)
PROLASTIN C 1,000 MG VIAL
TYZINE PEDIATRIC 0.05% DROP
XOLAIR 150 MG VIAL
1
1
1
1
1
PA
ZEMAIRA 1,000 MG VIAL
Skeletal Muscle Relaxants
cyclobenzaprine hcl 10 mg tablet 1
1
PA
PA methocarbamol (500 mg tablet, 750 mg tablet)
Sleep Disorder Agents
GABA Receptor Modulators
zaleplon (5 mg capsule, 10 mg capsule) 1
1
PA
PA zolpidem tartrate (5 mg tablet, 10 mg tablet)
Sleep Disorders, Other
modafinil (100 mg tablet, 200 mg tablet) 1
1
1
PA
LA
ROZEREM 8 MG TABLET
XYREM 500 MG/ML ORAL SOLUTION
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
ammonium chloride 5 meq/ml vial 1
1
1
1
1
CARBAGLU 200 MG DISPER TABLET
CUPRIMINE 250 MG CAPSULE
DEPEN 250 MG TITRATAB
PA
EXJADE (125 MG TABLET, 250 MG TABLET, 500 MG TABLET)
JADENU (90 MG TABLET, 180 MG TABLET, 360 MG TABLET)
1
sodium lactate 5 meq/ml vial 1
1 sodium polystyrene sulfonate (15 g/60 ml oral susp, 30 g/120ml enema, 50 g/200ml enema, powder)
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
82
DRUG NAME TIER REQUIREMENTS/LIMITS
SYPRINE 250 MG CAPSULE 1
Electrolyte/Mineral Replacement
0.9 % sodium chloride (0.9 % 0.9 % iv soln, 0.9 % 0.9 % syringe, 0.9 % pggybk prt, 0.9 % 0.9 % vial, 0.9 % pgy vl prt)
1
AMINOSYN II (7%, 8.5%, 10%)
AMINOSYN II 8.5%-ELECTROLYTES
AMINOSYN M 3.5% IV SOLUTION
1
1
1
1
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE AMINOSYN WITH ELECTROLYTES (7%- ELECTROLYTE, 8.5%-ELECTROLYTES)
AMINOSYN-HBC 7% IV SOLUTION
AMINOSYN-PF (7%, 10%)
1
1
1
1
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
calcium acetate 667 mg capsule
CLINIMIX (2.75%-5%, 4.25%-5%, 4.25%-25%, 4.25%-10%, 5%-25%)
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE CLINIMIX E 4.25%-10% SOLUTION
CLINIMIX E 5%-20% SOLUTION
CLINISOL 15% SOLUTION
1
1
1
1
1
PA - TO CONFIRM PART D COVERAGE
dextrose 5%-lactated ringers 5 % iv soln
FLUOR-A-DAY (0.25 MG TAB, 0.5 MG TAB, 1 MG TABLET)
FLUORITAB (0.5 MG TABLET, 1 MG TABLET)
FREAMINE HBC 6.9% IV SOLN
HEPATAMINE 8% IV SOLUTION
ISOLYTE P-DEXTROSE 5% SOLN
ISOLYTE S IV SOLUTION-EXCEL
KLOR-CON 10 MEQ TABLET
KLOR-CON 8 MEQ TABLET
1
1
1
1
1
1
1
1
1
1
1
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
KLOR-CON M10 TABLET
KLOR-CON M15 TABLET
KLOR-CON M20 TABLET
LUDENT FLUORIDE (0.25 MG TB CHW, 0.5 MG TB CHEW, 1 MG TAB CHEW)
magnesium sulfate (4 meq/ml syringe, 4 meq/ml vial)
1
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
83
DRUG NAME TIER REQUIREMENTS/LIMITS
NEPHRAMINE 5.4% IV SOLUTION
NORMOSOL-M AND DEXTROSE 5%
NORMOSOL-R PH 7.4 IV SOLUTION
PLASMA-LYTE 148 IV SOLUTION
PLASMA-LYTE 56-DEXTROSE 5%
PLASMA-LYTE A PH 7.4 SOLN.
1 PA - TO CONFIRM PART D COVERAGE
1
1
1
1
1
1 potassium chloride (2 meq/ml vial, 2 meq/ml iv soln, 8 meq capsule er, 8 meq tablet er, 10 meq tablet er, 10 meq tab er prt, 10 meq capsule er, 20 meq tablet er, 20 meq tab er prt)
potassium chloride (20meq/15ml, 40meq/15ml)
potassium chloride in 0.9%nacl 20 meq/l iv soln
1
1
1
PA
potassium chloride in 5 % dextrose in water (20 meq/l soln, 40 meq/l soln)
potassium chloride-0.45% nacl 20 meq/l iv soln 1
1 potassium citrate (5 tablet er, 10 tablet er, 15 tablet er)
PREMASOL (6%, 10%) 1
1
1
1
1
1
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
PROCALAMINE IV SOLUTION
PROSOL 20% INJECTION
ringers solution iv soln
ringers solution,lactated iv soln
sodium chloride 0.45 % (0.45 % pggybk prt, 0.45 % 0.45 % iv soln)
sodium chloride 2.5 meq/ml vial
sodium chloride 3 % 3 % iv soln
sodium chloride 5 % 5 % iv soln
1
1
1
1 sodium fluoride (0.25(0.55) tab chew, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew, 1mg(2.2mg) tablet)
TPN ELECTROLYTES VIAL 1
1
1
TRAVASOL 10% SOLN VIAFLEX
TROPHAMINE 10% IV SOLUTION
PA - TO CONFIRM PART D COVERAGE
PA - TO CONFIRM PART D COVERAGE
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
84
DRUG NAME TIER REQUIREMENTS/LIMITS
Vitamins
ACTIVE OB SOFTGEL 1
ATABEX EC CAPLET 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
BAL-CARE DHA COMBO PACK
BAL-CARE DHA ESSENTIAL PACK
BP FOLINATAL PLUS B TABLET
C-NATE DHA SOFTGEL
CADEAU DHA SOFTGEL
CALCIUM-PNV 28-1-250 MG SFTGL
CITRANATAL 90 DHA COMBO PACK
CITRANATAL ASSURE COMBO PACK
CITRANATAL B-CALM COMBO PACK
CITRANATAL DHA PACK
CITRANATAL HARMONY CAPSULE
CITRANATAL RX TABLET
COMPLETE NATAL DHA
COMPLETENATE TABLET CHEW
CONCEPT DHA CAPSULE
CONCEPT OB CAPSULE
DOTHELLE DHA SOFTGEL
DUET DHA 400 COMBO PACK
DUET DHA 430 MG COMBO PACK
DUET DHA BALANCED (25 MG IRON)
DUET DHA EC (400 EC, 430 EC)
ELITE OB DHA SOFTGEL
ELITE-OB 400 CAPSULE
ENBRACE HR SOFTGEL
EXTRA-VIRT PLUS DHA SOFTGEL
FOCALGIN 90 DHA COMBO PACK
FOCALGIN CA COMBO PACK
FOCALGIN-B TABLET
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
85
DRUG NAME TIER REQUIREMENTS/LIMITS
FOLBECAL TABLET 1
FOLET DHA COMBO PACK
FOLET ONE SOFTGEL
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
FOLIVANE-OB CAPSULE
FOLIVANE-PRX DHA NF CAPSULE
GESTICARE DHA COMBO PACK
HEMENATAL OB + DHA COMBO PACK
HEMENATAL OB TABLET
INATAL ADVANCE TABLET
INATAL ULTRA TABLET
INFANATE BALANCE SOFTGEL
INFANATE PLUS SOFTGEL
KOSHER PRENATAL PLUS IRON TAB
M-VIT CAPLET
MACNATAL CN DHA SOFTGEL
MARNATAL-F CAPSULE
MAXINATE TABLET
MYNATAL (CAPSULE, ULTRACAPLET)
MYNATAL ADVANCE TABLET
MYNATAL PLUS CAPTAB
MYNATAL-Z CAPTAB
MYNATE 90 PLUS CAPLET SA
NATACHEW TABLET
NATALVIRT 90 DHA COMBO PACK
NATALVIRT CA COMBO PACK
NATALVIT TABLET
NATELLE ONE CAPSULE
NEEVODHA CAPSULE
NESTABS ABC PRENATAL COMBO PK
NESTABS DHA COMBO PACK
NESTABS TABLET
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
86
DRUG NAME TIER REQUIREMENTS/LIMITS
NEWGEN TABLET 1
NEXA PLUS SOFTGEL 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
NIACOR 500 MG TABLET
NIVA-PLUS TABLET
O-CAL FA TABLET
O-CAL PRENATAL TABLET
OB COMPLETE CAPLET
OB COMPLETE GOLD SOFTGEL
OB COMPLETE ONE SOFTGEL
OB COMPLETE PETITE SOFTGEL
OB COMPLETE PREMIER TABLET
OB COMPLETE WITH DHA SOFTGEL
OBSTETRIX DHA COMBO PAK
OBSTETRIX EC CAPLET
OBSTETRIX ONE SOFTGEL
OBTREX DHA PRENATAL VITAMIN
OBTREX PRENATAL CAPLET
PAIRE OB PLUS DHA COMBO PACK
PNV 29-1 TABLET
pnv no.115/iron fumarate/fa 29 mg-1 mg tab chew
PNV OB+DHA COMBO PACK 1
1
1
pnv w-o ca no5/iron fum/fa 106.5-1mg capsule
pnv with ca#74/iron/folic acid 27 mg-1 mg tablet
pnv with ca,no.72/iron,carb/fa 29 mg-1 mg tablet
1
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet 1
1 pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule
PNV-DHA + DOCUSATE SOFTGEL
PNV-DHA SOFTGEL
1
1
1 PNV-OMEGA SOFTGEL
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
87
DRUG NAME TIER REQUIREMENTS/LIMITS
PNV-SELECT TABLET 1
PNV-TOTAL SOFTGEL 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PNV-VP-U CAPSULE
pnv115/iron fumarate/fa/dss 29-1-25 mg tablet
PR NATAL 400 COMBO PACK
PR NATAL 400 EC COMBO PACK
PR NATAL 430 COMBO PACK
PR NATAL 430 EC COMBO PACK
PREFERA OB TABLET
PREFERA-OB ONE SOFTGEL
PREFERA-OB PLUS DHA COMBO PACK
PREFOL-DHA CAPSULE
PRENA1 CHEW TABLET
PRENA1 PEARL SOFTGEL
PRENA1 TRUE COMBO PACK
PRENAISSANCE 90 DHA COMBO PACK
PRENAISSANCE BALANCE SOFTGEL
PRENAISSANCE CAPSULE
PRENAISSANCE DHA COMBO PACK
PRENAISSANCE NEXT TABLET
PRENAISSANCE NEXT-B TABLET
PRENAISSANCE PLUS SOFTGEL
PRENAISSANCE PROMISE COMBO PCK
PRENAPLUS TABLET
PRENATA CHEWABLE TABLET
PRENATABS FA TABLET
PRENATABS RX TABLET
prenatal vit #60/iron fum/fa 27 mg-1 mg tablet
prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet
PRENATE AM TABLET
PRENATE CHEWABLE TABLET
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88
DRUG NAME TIER REQUIREMENTS/LIMITS
PRENATE DHA SOFTGEL
PRENATE ELITE TABLET
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PRENATE ENHANCE SOFTGEL
PRENATE ESSENTIAL SOFTGEL
PRENATE MINI SOFTGEL
PRENATE PIXIE SOFTGEL
PRENATE RESTORE SOFTGEL
PRENATE STAR TABLET
PREPLUS CA-FE 27 MG-FA 1 MG TB
PREQUE 10 TABLET
PRETAB 29 MG-1 MG TABLET
PROVIDA DHA CAPSULE
PROVIDA OB CAPSULE
PUREFE OB PLUS CAPSULE
PUREFE PLUS CAPSULE
R-NATAL OB SOFTGEL
RELNATE DHA PRENATAL SOFTGEL
RULAVITE DHA SOFTGEL
SE-NATAL 19 (19 CHEWABLE TABLET, 19 TABLET)
SE-TAN DHA CAPSULE
SELECT-OB + DHA PACK
SELECT-OB CHEWABLE CAPLET
TARON-BC TABLET
TARON-C DHA CAPSULE
TARON-PREX PRENATAL DHA CAP
THRIVITE 19 TABLET
THRIVITE RX TABLET
TL FOLATE TABLET
TL-CARE DHA SOFTGEL
TL-SELECT CAPSULE
TRI-TABS DHA COMBO PACK
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89
DRUG NAME TIER REQUIREMENTS/LIMITS
TRIADVANCE TABLET 1
TRICARE PRENATAL DHA ONE SFTGL
TRICARE PRENATAL TABLET
TRICARE PRENATAL WITH DHA PACK
TRINATAL GT TABLET
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
TRINATAL RX 1 TABLET
TRINATE TABLET
TRISTART DHA SOFTGEL
TRIVEEN-DUO DHA COMBO PACK
TRIVEEN-ONE CAPSULE
TRIVEEN-PRX RNF CAPSULE
TRUST NATAL DHA
ULTIMATECARE ONE CAPSULE
ULTIMATECARE ONE NF CAPSULE
VEMAVITE-PRX 2 CAPSULE
VENA-BAL DHA COMBO PACK
VENATAL-FA TABLET
VINACAL PRENATAL TABLET
VINATE CARE CHEWABLE TABLET
VINATE DHA GELCAP
VINATE DHA RF GELCAP
VINATE GT TABLET
VINATE II TABLET
VINATE ONE TABLET
VINATE PN CARE TABLET
VINATE ULTRA TABLET
VINATE-M TABLET
VIRT NATE TABLET
VIRT-ADVANCE TABLET
VIRT-BAL DHA COMBO PACK
VIRT-BAL DHA PLUS COMBO PACK
You can find information on what the symbols and abbreviations on this table mean by going to page 11.
90
DRUG NAME TIER REQUIREMENTS/LIMITS
VIRT-C DHA SOFTGEL 1
VIRT-CARE ONE CAPSULE
VIRT-NATE DHA SOFTGEL
VIRT-NATE TABLET
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
VIRT-PN DHA SOFTGEL
VIRT-PN PLUS SOFTGEL
VIRT-PN TABLET
VIRT-SELECT CAPSULE
VIRT-VITE GT TABLET
VIRTPREX CAPSULE
VITAFOL FE+ DOCUSATE COMBO PCK
VITAFOL GUMMIES
VITAFOL NANO TABLET
VITAFOL ULTRA SOFTGEL
VITAFOL-OB CAPLET
VITAFOL-OB+DHA COMBO PACK
VITAFOL-ONE CAPSULE
VITAMEDMD ONE RX SOFTGEL
VITAMEDMD PLUS RX COMBO PACK
VITAMEDMD REDICHEW RX TAB CHEW
VITAPEARL SOFTGEL
VITATRUE COMBO PACK
VIVA DHA PRENATAL SOFTGEL
VOL-NATE TABLET
VOL-PLUS TABLET
VOL-TAB RX TABLET
VP CH ULTRA SOFTGEL
VP-CH PLUS SOFTGEL
VP-CH-PNV PRENATAL SOFTGEL
VP-ERA OB PLUS TABLET
VP-GGR-B6 TABLET
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91
DRUG NAME TIER REQUIREMENTS/LIMITS
VP-HEME OB + DHA COMBO PACK
VP-HEME OB TABLET
1
1
1
1
1
1
1
1
1
VP-HEME ONE SOFTGEL
VP-PNV-DHA (CAPSULE, SOFTGEL)
ZATEAN-CH CAPSULE
ZATEAN-PN DHA CAPSULE
ZATEAN-PN PLUS SOFTGEL
ZATEAN-PN TABLET
ZINGIBER TABLET
Uncategorized
Unclassified
EZ FLU 16-17 (FLUZON QUAD PED) 1
1
1
1
1
EZ FLU 2016-17 (AFLURIA) KIT
EZ FLU 2016-17 (FLUVIRIN) KIT
FLUARIX QUAD 2016-2017 SYRINGE
FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017 VIAL)
FLUMIST QUAD NASAL 2016-17 VAC
FLUZONE INTRADERM QUAD 2016-17
1
1
1 FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL)
FLUZONE QUAD PEDI 2016-17 SYR 1
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92
Index of Drugs
0 ALBENZA
albuterol sulfate
ALDURAZYME
ALECENSA
alendronate sodium
ALIMTA
ALINIA
allopurinol
alosetron hcl
ALPHAGAN P
alprazolam
ALREX
amantadine hcl
AMBISOME
AMETHIA
AMETHYST
amifostine crystalline
amiloride hcl
amiloride hcl/hydrochlorothiazide
aminophylline
AMINOSYN II
35
80
60
31
75
30
35
28
62
78
43
77
42
27
66
66
31
54
54
81
83
83
83
83
83
83
51
62
25
52
82
59
25
18
18
27
18
18
18
58
66
0.9 % sodium chloride 83
59 8 8-MOP
A A-HYDROCORT
abacavir sulfate
abacavir sulfate/lamivudine/zidovudine
ABELCET
ABILIFY MAINTENA
acamprosate calcium
acarbose
acebutolol hcl
acetaminophen with codeine phosphate
acetazolamide
acetazolamide sodium
acetic acid
acetylcysteine
acitretin
ACTHIB
ACTIMMUNE
ACTIVE OB
acyclovir
acyclovir sodium
ADACEL TDAP
ADAGEN
adapalene
ADCIRCA
adefovir dipivoxil
ADEMPAS
ADRENACLICK
ADRUCIL
ADVAIR DISKUS
ADVAIR HFA
AFEDITAB CR
AFINITOR
64
40
40
27
38,44
14
44
51
12
54,78
54
78
81
59
73
73
85
43
43
73
60
59
81
42
81
80
30
79
79
52
33
33
48
AMINOSYN II WITH ELECTROLYTES
AMINOSYN M
AMINOSYN WITH ELECTROLYTES
AMINOSYN-HBC
AMINOSYN-PF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlodipine besylate
ammonium chloride
ammonium lactate
amoxapine
amoxicillin
amoxicillin/potassium clavulanate
amphotericin b
ampicillin sodium
ampicillin sodium/sulbactam sodium
ampicillin trihydrate
AMPYRA AFINITOR DISPERZ
AGGRENOX ANADROL-50
93
anagrelide hcl
anastrozole
ANDRODERM
ANDROGEL
ANZEMET
APIDRA
APIDRA SOLOSTAR
APOKYN
apraclonidine hcl
APRI
APRISO
APTIOM
APTIVUS
ARALAST NP
ARANELLE
ARANESP
ARCALYST
aripiprazole
ARISTADA
ARZERRA
ASACOL HD
ASMANEX
ASMANEX HFA
aspirin/dipyridamole
ASTAGRAF XL
ATABEX EC
atenolol
48
33
66
66
26
46
46
36
78
66
75
21
41
81
67
48
73
38
38
34
75
79
79
48
71
85
51
73
55
35
35
39
77
80
58
67
44
34
19
67
63
AVONEX 58
58
31
71
71
71
77,79
36
19
78
AVONEX PEN
azacitidine
AZASAN
azathioprine
azathioprine sodium
azelastine hcl
AZILECT
azithromycin
AZOPT
aztreonam 17
B BACIIM
bacitracin
bacitracin/polymyxin b sulfate
baclofen
BAL-CARE DHA
BAL-CARE DHA ESSENTIAL
balsalazide disodium
BALZIVA
BANZEL
BARACLUDE
bcg vaccine, live/pf
BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
BENLYSTA
benztropine mesylate
betamethasone dipropionate
betamethasone dipropionate/propylene glycol 64
betamethasone valerate
BETASERON
bethanechol chloride
bexarotene
BEXSERO
15
15
15
39
85
85
75
67
23
42
73
31
50
50
71
35
64
ATGAM
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
atropine sulfate
ATROVENT HFA
AUBAGIO
AUBRA
AVANDIA
AVASTIN
AVELOX IV
AVIANE
64
58
63
34
73
30
18
35
52
52
bicalutamide
BICILLIN L-A
BILTRICIDE
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide AVODART
94
bleomycin sulfate
BOOSTRIX TDAP
BOSULIF
BREO ELLIPTA
BRIELLYN
BRILINTA
brimonidine tartrate
BRIVIACT
bromocriptine mesylate
budesonide
bumetanide
buprenorphine hcl
buprenorphine hcl/naloxone hcl
bupropion hcl
buspirone hcl
BYETTA
31
73
33
79
67
48
78
21
36
75,79
54
14
14
14,24
43
carbidopa/levodopa/entacapone
CARDURA XL
CARIMUNE NF NANOFILTERED
CARTIA XT
carvedilol
CAYSTON
cefaclor
cefadroxil
cefazolin sodium
cefazolin sodium/dextrose, iso-osmotic
cefdinir
36
49
73
52
52
81
17
17
17
17
17
17
17
17
17
17
17
17
17
17
12
72
21
17
60
73
14
15
59
35
37
54
55
55
27
27
41
48
71
19
19
cefepime hcl
cefixime
cefotetan disodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
celecoxib
CELLCEPT
CELONTIN
cephalexin
CEREZYME
44
C C-NATE DHA
cabergoline
CABOMETYX
CADEAU DHA
CAFERGOT
calcipotriene
calcitonin,salmon,synthetic
calcitriol
calcium acetate
CALCIUM PNV
CAMILA
CANASA
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
captopril
captopril/hydrochlorothiazide
CARAFATE
85
70
31
85
28
59
75
75
83
85
69
75
27
49
54
29
30
50
50
62
82
23
36
CERVARIX
CHANTIX
chloramphenicol sod succ
chlorhexidine gluconate
chloroquine phosphate
chlorpromazine hcl
chlorthalidone
cholestyramine (with sugar)
cholestyramine/aspartame
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
CINRYZE
CIPRO HC
CARBAGLU
carbamazepine
carbidopa/levodopa CIPRODEX
95
ciprofloxacin 20
20
20
20
31
24
85
85
85
85
85
85
59
COMPLETE NATAL DHA
COMPLETENATE
COMPRO
CONCEPT DHA
CONCEPT OB
CONSTULOSE
COPAXONE
85
85
37
85
85
62
58
52
75
59
59
59
59
ciprofloxacin hcl
ciprofloxacin lactate
ciprofloxacin/ciprofloxacin hcl
cisplatin
citalopram hydrobromide
CITRANATAL 90 DHA
CITRANATAL ASSURE
CITRANATAL B-CALM
CITRANATAL DHA
CITRANATAL HARMONY
CITRANATAL RX
COREG CR
cortisone acetate
COSENTYX (2 SYRINGES)
COSENTYX PEN
COSENTYX PEN (2 PENS)
COSENTYX SYRINGE
COTELLIC
CLARAVIS
clarithromycin 19 31
clindamycin hcl 15 CREON 60
clindamycin phosphate
CLINIMIX
CLINIMIX E
15,59
45,83
45,83
83
CRIXIVAN
cromolyn sodium
CRYSELLE
41
61,77,81
67
CLINISOL CUBICIN 16
clobetasol propionate
clobetasol propionate/emollient base
CLODAN
clomipramine hcl
clonazepam
64
64
64
25
CUPRIMINE
CYCLAFEM
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
82
67
82
29
22 44
clonidine 49 cyclosporine 72
clonidine hcl 49
48
43
27
cyclosporine, modified
CYRAMZA
CYSTADANE
72
31
60
60
clopidogrel bisulfate
clorazepate dipotassium
clotrimazole CYSTAGON
clotrimazole/betamethasone dipropionate
clozapine
COARTEM
64
39
35
D DAKLINZA 42
81
66
39
29
73
35
63
34
31
codeine sulfate
colchicine
colchicine/probenecid
COLCRYS
colestipol hcl
colistin (as colistimethate sodium)
COMBIVENT RESPIMAT
COMETRIQ
12
28
28
28
55
16
80
31
DALIRESP
danazol
dantrolene sodium
dapsone
DAPTACEL DTAP
DARAPRIM
darifenacin hydrobromide
DARZALEX
daunorubicin hcl COMPLERA 40
96
decitabine
DELYLA
DELZICOL
demeclocycline hcl
DEMSER
31
67
75
20
53
82
64
69
69
40
25
65
DILT-CD
DILT-XR
diltiazem hcl
DIPENTUM
diphenhydramine hcl
diphenoxylate hcl/atropine sulfate
disopyramide phosphate
disulfiram
divalproex sodium
DOCEFREZ
52
53
53
75
79
61
51
14
22,28
31
DEPEN
DEPO-MEDROL
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
DESCOVY
desipramine hcl
desmopressin acetate
docetaxel
dofetilide
31
51
desogestrel-ethinyl estradiol/ethinyl estradiol 67 donepezil hcl 23
desonide
desvenlafaxine
dexamethasone
dexamethasone sod phosphate
dexmethylphenidate hcl
64
24
64
14,77
57
dorzolamide hcl
dorzolamide hcl/timolol maleate
DOTHELLE DHA
doxazosin mesylate
doxepin hcl
doxercalciferol
doxorubicin hcl
doxorubicin hcl pegylated liposomal
DOXY 100
doxycycline hyclate
doxycycline monohydrate
dronabinol
DROXIA
DUET DHA
78
78
85
63
25,43
75
31
31
20
20
21
26
30
85
85
85
85
dextroamphetamine sulf-
saccharate/amphetamine sulf-aspartate
dextroamphetamine sulfate
dextrose 10 % and 0.2 % sodium chloride
dextrose 10 % and 0.45 % sodium chloride
dextrose 10 % in water
dextrose 2.5 % and 0.45 % sodium chloride
dextrose 5 % and 0.2 % sodium chloride
dextrose 5 % and 0.3 % sodium chloride
dextrose 5 % and 0.45 % sodium chloride
dextrose 5 % and 0.9 % sodium chloride
dextrose 5 % in lactated ringers
dextrose 5 % in water
57
57
45
45
45
45
46
45
46 DUET DHA 400
DUET DHA BALANCED
DUET DHA EC
45
83
45 duloxetine hcl 24
diazepam 22,43 DURAMORPH 13
diclofenac sodium
dicloxacillin sodium
dicyclomine hcl
didanosine
DIFICID
DIGOX
digoxin
dihydroergotamine mesylate
DILANTIN
14,59,77
18
61
40
19
53
53
28
23
DUREZOL
dutasteride
77
63
E E.E.S. 200
E.E.S. 400
econazole nitrate
EDURANT
ELAPRASE
19
19
27
40
60
97
ELELYSO
ELIGARD
ELITE OB DHA
ELITE-OB 400
ELMIRON
EMCYT
EMEND
EMOQUETTE
EMPLICITI
EMSAM
60
70
85
85
63
30
26
67
34
24
40
50
50
85
72
13
74
74
47
67
36
42
49
62
72
77
80
80
80
80
80
23
40
48
40
28
32
69
32
19
19
ERYPED 400 19
19
19
19
59
19
19
81
25
62
67
67
67
29
67
21
76
12
33
35
41
33
82
85
92
92
92
ERYTHROCIN LACTOBIONATE
ERYTHROCIN STEARATE
erythromycin base
erythromycin base/benzoyl peroxide
erythromycin base/ethyl alcohol
erythromycin ethylsuccinate
ESBRIET
escitalopram oxalate
esomeprazole sodium
ESTRACE
estradiol
estradiol/norethindrone acetate
ethambutol hcl
ethinyl estradiol/drospirenone
ethosuximide
etidronate disodium
etodolac
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBRACE HR
ENBREL
ENDOCET
ENGERIX-B ADULT
ENGERIX-B PEDIATRIC-ADOLESCENT
enoxaparin sodium
ENPRESSE
entacapone
entecavir
etoposide
EURAX
EVOTAZ
exemestane
ENTRESTO
ENULOSE
EXJADE
EXTRA-VIRT PLUS DHA
EZ FLU 16-17 (FLUZON QUAD PED)
EZ FLU 2016-2017 (AFLURIA)
EZ FLU 2016-2017 (FLUVIRIN)
ENVARSUS XR
epinastine hcl
epinephrine
EPIPEN
EPIPEN 2-PAK
EPIPEN JR
EPIPEN JR 2-PAK
EPITOL
EPIVIR HBV
EPOGEN
EPZICOM
ERGOMAR
ERIVEDGE
ERRIN
ERWINAZE
ERY-TAB
ERYPED 200
F FABRAZYME
FALMINA
famciclovir
famotidine
famotidine in sodium chloride, iso-osmotic/pf 61
famotidine/pf
FANAPT
FARESTON
FARXIGA
FARYDAK
FAZACLO
felbamate
60
67
43
61
61
38
30
44
31
39
22
98
fenofibrate 55
55
55
55
55
55
12
13
76
25
55
63
71
70
51
79
92
27
27
27
64
92
92
79
59,64
64
64
64
83
83
77
59
25
37
37
77
30
64,79
25
92
92
FLUZONE QUAD PEDI 2016-2017
FOCALGIN 90 DHA
FOCALGIN CA
FOCALGIN-B
FOLBECAL
FOLET DHA
92
85
85
85
86
86
86
85
86
86
76
47
76
76
23
63
47
83
54
41
21
fenofibrate nanocrystallized
fenofibrate,micronized
fenofibric acid
fenofibric acid (choline)
fenoprofen calcium
fentanyl
fentanyl citrate
FERRIPROX
FETZIMA
FIBRICOR
finasteride
FIRAZYR
FIRMAGON
flecainide acetate
FLOVENT HFA
FLUARIX QUAD 2016-2017
fluconazole
fluconazole in dextrose, iso-osmotic
flucytosine
fludrocortisone acetate
FLULAVAL QUAD 2016-2017
FLUMIST QUAD 2016-2017
flunisolide
fluocinolone acetonide
fluocinolone acetonide oil
fluocinonide
fluocinonide/emollient base
FLUOR-A-DAY
FLUORITAB
fluorometholone
fluorouracil
fluoxetine hcl
fluphenazine decanoate
fluphenazine hcl
flurbiprofen sodium
flutamide
fluticasone propionate
fluvoxamine maleate
FLUZONE INTRADERM QUAD 2016-17
FLUZONE QUAD 2016-2017
FOLET ONE
FOLINATAL PLUS B
FOLIVANE-OB
FOLIVANE-PRX DHA NF
fomepizole
fondaparinux sodium
FORTEO
FORTICAL
fosphenytoin sodium
FOSRENOL
FRAGMIN
FREAMINE HBC
furosemide
FUZEON
FYCOMPA
G gabapentin 22
22
23
73
73
73
42
74
74
20
61
62
62
62
55
62
72
65
GABITRIL
galantamine hbr
GAMMAGARD LIQUID
GAMMAGARD S-D
GAMUNEX-C
ganciclovir sodium
GARDASIL
GARDASIL 9
gatifloxacin
GATTEX
GAVILYTE-C
GAVILYTE-G
GAVILYTE-N
gemfibrozil
GENERLAC
GENGRAF
GENOTROPIN
99
GENTAK 15
15
HEPATAMINE
HERCEPTIN
HETLIOZ
HEXALEN
HIBERIX
HORIZANT
HUMALOG
HUMALOG KWIKPEN U-100
HUMALOG KWIKPEN U-200
HUMALOG MIX 50-50
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 75-25
HUMALOG MIX 75-25 KWIKPEN
HUMATROPE
83
34
58
30
74
58
46
46
46
46
46
46
46
65
72
72
72
46
56
54
13
13
64
64
65
13
13
35
69
30
73
gentamicin sulfate
gentamicin sulfate in sodium chloride, iso-
osmotic
gentamicin sulfate/pf
GENVOYA
GEODON
GESTICARE DHA
GIANVI
GILDAGIA
GILDESS
GILENYA
GILOTRIF
GLASSIA
GLATOPA
GLEEVEC
GLEOSTINE
glimepiride
glipizide
glipizide/metformin hcl
GLUCAGEN
GLUCAGON EMERGENCY KIT
glycopyrrolate
GLYSET
granisetron hcl
granisetron hcl/pf
griseofulvin, microsize
guanfacine hcl
guanidine hcl
15
15
40
38
86
67
67
67
58
32
82
58
33
29
44
44
44
46
46
61
44
26
26
27
57
29
HUMIRA
HUMIRA PEN
HUMIRA PEN CROHN-UC-HS STARTER
HUMULIN R U-500
hydralazine hcl
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone/ibuprofen
hydrocortisone
hydrocortisone butyrate
hydrocortisone valerate
hydromorphone hcl
hydromorphone hcl/pf
hydroxychloroquine sulfate
hydroxyprogesterone caproate
hydroxyurea
H HALAVEN
HYPERRAB S-D
32
37
37
37
42
74
86
86
47
haloperidol I ibandronate sodium
IBRANCE
ibuprofen
ibuprofen/oxycodone hcl
ICLUSIG
ILARIS
imatinib mesylate
IMBRUVICA
haloperidol decanoate
haloperidol lactate
HARVONI
76
32
12
12
33
73
33
33
HAVRIX
HEMENATAL OB
HEMENATAL OB + DHA
heparin sodium,porcine
heparin sodium,porcine/dextrose 5 % in water 47
100
imipenem/cilastatin sodium
imipramine hcl
imiquimod
IMOVAX RABIES VACCINE
INATAL ADVANCE
INATAL ULTRA
INCRELEX
17
25
59
74
86
86
65
54
86
86
74
33
40
76
42
67
18
38
38
38
41
44
44
46
46
74
80
80
49
49
32
39
83
83
29
56
56
27
35
74
J JADENU 82
32
44
45
32
67
69
67
67
55
JAKAFI
JANUMET
JANUVIA
JEVTANA
JINTELI
JOLIVETTE
JUNEL
indapamide
INFANATE BALANCE
INFANATE PLUS
INFANRIX DTAP
INLYTA
INTELENCE
INTRALIPID
INTRON A
INTROVALE
INVANZ
INVEGA
INVEGA SUSTENNA
INVEGA TRINZA
INVIRASE
INVOKAMET
INVOKANA
IONOSOL B WITH DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IPOL
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
IRESSA
ISENTRESS
JUNEL FE
JUXTAPID
K KADCYLA
KALETRA
KALYDECO
KARIVA
KELNOR 1-35
KETEK
ketoconazole
ketoprofen
ketorolac tromethamine
KEYTRUDA
34
41
81
67
67
19
27
12
77
34
72
83
83
83
83
83
66
86
60
55
KINERET
KLOR-CON 10
KLOR-CON 8
KLOR-CON M10
KLOR-CON M15
KLOR-CON M20
KORLYM
KOSHER PRENATAL PLUS IRON
KUVAN
KYNAMRO
ISOLYTE P WITH DEXTROSE
ISOLYTE S
isoniazid
isosorbide dinitrate
isosorbide mononitrate
itraconazole
L labetalol hcl
LACRISERT
lactulose
lamivudine
lamivudine/zidovudine
52
77
62
40
40
ivermectin
IXIARO
101
lamotrigine
lansoprazole
LANTUS
LANTUS SOLOSTAR
LARIN
LARIN FE
latanoprost
LATUDA
LEENA
leflunomide
LENVIMA
LESSINA
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
LEVEMIR
LEVEMIR FLEXPEN
LEVEMIR FLEXTOUCH
levetiracetam
levobunolol hcl
levocetirizine dihydrochloride
levofloxacin
levofloxacin/dextrose 5 % in water
levoleucovorin calcium
LEVONEST
levonorgestrel-ethinyl estradiol
LEVORA-28
levothyroxine sodium
LEXIVA
LIALDA
lidocaine
lidocaine hcl
lidocaine hcl/pf
lidocaine/prilocaine
lindane
linezolid
linezolid in 0.9 % sodium chloride
liothyronine sodium
22,44
62
46
46
67
67
78
38
68
73
33
68
81
33
32
30
48
70
47
47
47
21
78
79
20
20
32
68
68
68
70
41
75
13
13
14
14
35
16
16
70
lisinopril 50
51
44
44
30
61
43
43
68
49
49
77
55
37
83
78
60
70
70
68
32
21,58
70
69
lisinopril/hydrochlorothiazide
lithium carbonate
lithium citrate
LONSURF
loperamide hcl
lorazepam
LORAZEPAM INTENSOL
LORYNA
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
lovastatin
loxapine succinate
LUDENT FLUORIDE
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
LUTERA
LYNPARZA
LYRICA
LYSODREN
LYZA
M M-M-R II VACCINE 74
86
86
83
24
68
86
24
30
53
86
26
69
35
69
M-VIT
MACNATAL CN DHA
magnesium sulfate
maprotiline hcl
MARLISSA
MARNATAL-F
MARPLAN
MATULANE
MATZIM LA
MAXINATE
meclizine hcl
medroxyprogesterone acetate
mefloquine hcl
MEGACE ES
102
megestrol acetate
MEKINIST
memantine hcl
MENACTRA
MENEST
69
32
24
74
32
74
74
74
31
18
32
32
57
80
45
12
54,78
16
71
82
72
72
49
49
58
65
65
14,65
61
55
52
52
52
16
16
51
76
27
68
68
49
miglitol
minocycline hcl
minoxidil
mirtazapine
misoprostol
MITIGARE
mitoxantrone hcl
modafinil
45
21
56
24
62
28
32
82
42
37
65,79
68
79
16
12,13
61
20
51
16
27
72
72
86
86
86
86
86
MENHIBRIX
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
mercaptopurine
meropenem
mesna
MESNEX
METADATE ER
metaproterenol sulfate
metformin hcl
methadone hcl
MODERIBA
molindone hcl
mometasone furoate
MONONESSA
montelukast sodium
MONUROL
morphine sulfate
MOVANTIK
MOXEZA methazolamide
methenamine hippurate
methimazole
MULTAQ
mupirocin
MYCAMINE methocarbamol
methotrexate sodium
methotrexate sodium/pf
methyldopa
methyldopate hcl
methylphenidate hcl
methylprednisolone
methylprednisolone acetate
methylprednisolone sodium succinate
metoclopramide hcl
metolazone
metoprolol succinate
metoprolol tartrate
metoprolol tartrate/hydrochlorothiazide
metronidazole
metronidazole in sodium chloride
mexiletine hcl
mycophenolate mofetil
mycophenolate sodium
MYNATAL
MYNATAL ADVANCE
MYNATAL PLUS
MYNATAL-Z
MYNATE 90 PLUS
MYORISAN
MYRBETRIQ
59
63
N nabumetone
nadolol/bendroflumethiazide
nafcillin in dextrose, iso-osmotic
nafcillin sodium
NAGLAZYME
naloxone hcl
naltrexone hcl
NAMENDA
naproxen
naproxen sodium
12
52
18
18
60
14
14
24
12
15
MIACALCIN
miconazole nitrate
MICROGESTIN
MICROGESTIN FE
midodrine hcl
103
naratriptan hcl
NATACHEW
NATALVIRT 90 DHA
NATALVIRT CA
NATALVIT
nateglinide
NATELLE ONE
NATPARA
NEBUPENT
NECON
NEEVODHA
nefazodone hcl
neomycin sulfate
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
neomycin sulfate/bacitracin/polymyxin b
neomycin sulfate/polymyxin b sulfate
neomycin sulfate/polymyxin b sulfate/gramicidin
d
neomycin sulfate/polymyxin b
sulfate/hydrocortisone
neomycin/polymyxin b sulfate/dexamethasone 78
NEPHRAMINE
NESTABS
NESTABS ABC
NESTABS DHA
NEUPOGEN
NEUPRO
nevirapine
NEWGEN
NEXA PLUS
NEXAVAR
niacin
28
86
86
86
86
45
86
76
35
68
86
24
15
nimodipine
NINLARO
nitrofurantoin macrocrystal
nitrofurantoin monohydrate/macrocrystals
nitroglycerin
NITROSTAT
NIVA-PLUS
NORA-BE
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
norethindrone
norethindrone acetate
norethindrone acetate-ethinyl estradiol
NORMOSOL-M AND DEXTROSE
NORMOSOL-R AND DEXTROSE
NORMOSOL-R PH 7.4
NORTHERA
NORTREL
nortriptyline hcl
NORVIR
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
NOXAFIL
NUEDEXTA
NULOJIX
NUPLAZID
NUTRILIPID
NUTROPIN AQ
NUTROPIN AQ NUSPIN
NYAMYC
53
32
16
16
56
56
87
69
65
65
69
70
68
84
46
84
53
68
25,26
41
47
47
47
47
27
58
72
38
76
66
66
27
27
28
28
16
16
15
16
78
84
86
86
86
48
36
40
87
87
33
56
87
14
14
53
53
68
30
30
nystatin
nystatin/triamcinolone acetonide
NYSTOP
NIACOR
NICOTROL
NICOTROL NS
NIFEDICAL XL
nifedipine
NIKKI
O O-CAL FA
O-CAL PRENATAL
OB COMPLETE
OB COMPLETE GOLD
87
87
87
87
NILANDRON
nilutamide
104
OB COMPLETE ONE
OB COMPLETE PETITE
OB COMPLETE PREMIER
OB COMPLETE WITH DHA
OBSTETRIX DHA
OBSTETRIX EC
OBSTETRIX ONE
OBTREX
OBTREX DHA
OCELLA
octreotide acetate
ODEFSEY
87
87
87
87
87
87
87
87
87
68
71
40
32
82
20
38
77,79
42
56
62
66
32
26
26,27
27
22
34
81
37
72
72
81
68
18
32
66
15
43
23
23
63
oxycodone hcl
oxycodone hcl/acetaminophen
OXYTROL
12,13
13
63
P paclitaxel
PAIRE OB PLUS DHA
paliperidone
PANCREAZE
32
87
38
60
34
62
15
25
29
77
77
43
74
PANRETIN
pantoprazole sodium
paromomycin sulfate
paroxetine hcl
PASER
PATADAY
PATANOL
PAXIL
PEDVAXHIB
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEGINTRON REDIPEN
pen needle, diabetic
penicillin g potassium
penicillin v potassium
PENTACEL ACTHIB COMPONENT
PENTAM 300
PENTASA
pentoxifylline
PERIOGARD
PERJETA
ODOMZO
OFEV
ofloxacin
olanzapine
olopatadine hcl
OLYSIO
omega-3 acid ethyl esters
omeprazole
OMNITROPE
ONCASPAR
ondansetron
ondansetron hcl
ondansetron hcl/pf
ONFI
OPDIVO
OPSUMIT
ORAP
ORENCIA
ORENCIA CLICKJECT
ORKAMBI
ORSYTHIA
oxacillin sodium
oxaliplatin
oxandrolone
oxaprozin
62
23
42
42
42
42
76
18
18
74
35
75
53
59
34
35
37
24
21
23
23
23
permethrin
perphenazine
phenelzine sulfate
phenobarbital
phenytoin
phenytoin sodium
phenytoin sodium extended
oxazepam
oxcarbazepine
OXTELLAR XR
oxybutynin chloride
105
PHYSIOLYTE
PHYSIOSOL
pilocarpine hcl
pimozide
PIMTREA
pindolol
pioglitazone hcl
pioglitazone hcl/metformin hcl
piperacillin sodium/tazobactam sodium
PIRMELLA
PLASMA-LYTE 148
PLASMA-LYTE 56 IN DEXTROSE
PLASMA-LYTE A PH 7.4
PNV 29-1
PNV OB+DHA
PNV-DHA
PNV-DHA + DOCUSATE
PNV-OMEGA
PNV-SELECT
PNV-TOTAL
PNV-VP-U
podofilox
polyethylene glycol 3350
polymyxin b sulfate
polymyxin b sulfate/trimethoprim
POMALYST
PORTIA
potassium chloride
potassium chloride in 0.45 % sodium chloride
potassium chloride in 0.9 % sodium chloride
potassium chloride in 5 % dextrose in water
potassium chloride in dextrose 5 % and 0.9 %
sodium chloride
potassium chloride in dextrose 5 %-0.2 % sodium
chloride
potassium chloride in dextrose 5 %-0.45 % sodium
chloride
76
76
59,78
37
68
52
45
45
19
68
84
84
84
87
87
87
87
87
88
88
88
59
62
16
16
32
68
84
potassium citrate
POTIGA
PR NATAL 400
PR NATAL 400 EC
PR NATAL 430
PR NATAL 430 EC
PRADAXA
pramipexole di-hcl
pravastatin sodium
prazosin hcl
84
21
88
88
88
88
47
36
55
49
65
78
65,78
65
88
88
88
88
66
68
84
68
68
88
88
88
88
88
88
88
88
88
88
88
88
88
88
88
prednisolone
prednisolone acetate
prednisolone sod phosphate
prednisone
PREFERA OB
PREFERA-OB ONE
PREFERA-OB PLUS DHA
PREFOL-DHA
PREGNYL
PREMARIN
PREMASOL
PREMPHASE
PREMPRO
PRENA1 CHEW
PRENA1 PEARL
PRENA1 TRUE
PRENAISSANCE
PRENAISSANCE 90 DHA
PRENAISSANCE BALANCE
PRENAISSANCE DHA
PRENAISSANCE NEXT
PRENAISSANCE NEXT-B
PRENAISSANCE PLUS
PRENAISSANCE PROMISE
PRENAPLUS
PRENATA
PRENATABS FA
PRENATABS RX
prenatal vitamin comb no.79/iron
fumarat/fa/lmefolate ca/dha
84
84
84
46
46
46
46
46
potassium chloride in dextrose 5% and 0.3 %
sodium chloride
potassium chloride in lactated ringers and 5 %
dextrose
87
106
prenatal vitamin no.15/iron,carbonyl/folic
acid/docusate sod
prenatal vitamins comb no.115/iron
fumarate/folic acid
prenatal vitamins comb no.115/iron
fumarate/folic acid/dss
prenatal vitamins combo no.60/ferrous
fumarate/folic acid
PROCRIT 48
65
65
70
46
72
82
32
76
48
26
26
51
52
52
71
74
84
63
26
89
89
79
79
81
89
89
31
29
29
88
87
88
88
87
PROCTOSOL-HC
PROCTOZONE-HC
progesterone,micronized
PROGLYCEM
PROGRAF
PROLASTIN C
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
PROMETHEGAN
propafenone hcl
propranolol hcl
propranolol hcl/hydrochlorothiazide
propylthiouracil
PROQUAD
PROSOL
PROTONIX IV
protriptyline hcl
PROVIDA DHA
PROVIDA OB
prenatal vits with calcium #72/ferrous
fumarate/folic acid
prenatal vits with calcium #72/iron,carbonyl/folic
acid 87
prenatal vits with calcium #74/ferrous
fumarate/folic acid
prenatal vits without calc no5/ferrous
fumarate/folic acid
PRENATE AM
PRENATE CHEWABLE
PRENATE DHA
PRENATE ELITE
PRENATE ENHANCE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PIXIE
PRENATE RESTORE
PRENATE STAR
PREPLUS
PREQUE 10
PRETAB
PREVALITE
PREVIFEM
PREZCOBIX
PREZISTA
primaquine phosphate
primidone
PROAIR HFA
probenecid
87
87
88
88
89
89
89
89
89
89
89
89
89
89
89
56
68
41
41
35
22
80
28
84
37
37
37
PULMICORT
PULMICORT FLEXHALER
PULMOZYME
PUREFE OB PLUS
PUREFE PLUS
PURIXAN
pyrazinamide
pyridostigmine bromide
Q QUADRACEL DTAP-IPV
QUASENSE
QUDEXY XR
quetiapine fumarate
quinapril hcl
quinapril hcl/hydrochlorothiazide
quinidine gluconate
quinidine sulfate
quinine sulfate
74
68
22
38
51
51
51
51
35
PROCALAMINE
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
107
QVAR 79 RITUXAN 34
23
28
36
74
74
21
82
89
rivastigmine tartrate
rizatriptan benzoate
ropinirole hcl
ROTARIX
ROTATEQ
ROWEEPRA
R R-NATAL OB
RABAVERT
raloxifene hcl
ramipril
89
74
70
51
53
62
72
58
68
RANEXA ROZEREM
RULAVITE DHA ranitidine hcl
RAPAMUNE
REBIF S SABRIL RECLIPSEN 22
66
71
71
60
39
58
89
89
89
89
36
60
41
70
80
39
66
25
71
71
81
16
78
73
55
72
29
84
84
RECOMBIVAX HB
REGRANEX
RELENZA
RELISTOR
RELNATE DHA
REMICADE
REMODULIN
RENAGEL
RENVELA
74
60
42
61
89
72
81
64
64
45
45
56
56
56
40
77
40
30
38
41
42
29
29
58
SAIZEN
SANDOSTATIN LAR
SANDOSTATIN LAR DEPOT
SANTYL
SAPHRIS
SAVELLA
SE-NATAL 19
SE-TAN DHA
SELECT-OB
SELECT-OB + DHA
selegiline hcl
selenium sulfide
SELZENTRY
repaglinide
repaglinide/metformin hcl
REPATHA PUSHTRONEX
REPATHA SURECLICK
REPATHA SYRINGE
RESCRIPTOR
RESTASIS
RETROVIR
REVLIMID
REXULTI
REYATAZ
SENSIPAR
SEREVENT DISKUS
SEROQUEL XR
SEROSTIM
sertraline hcl
SIGNIFOR
SIGNIFOR LAR
sildenafil citrate
silver sulfadiazine
SIMBRINZA
SIMULECT
simvastatin
sirolimus
SIRTURO
RIBASPHERE
rifabutin
rifampin
riluzole
rimantadine hcl
ringers solution
ringers solution,lactated
RISPERDAL CONSTA
risperidone
42
76,84
76,84
38,44
39
sodium chloride
sodium chloride 0.45 %
108
sodium chloride 3 %
sodium chloride 5 %
sodium chloride irrigating solution
sodium fluoride
sodium lactate
sodium phenylbutyrate
sodium polystyrene sulfonate
SOLTAMOX
SOLU-CORTEF
SOMATULINE DEPOT
SOMAVERT
sotalol hcl
SOVALDI
84
84
76
84
82
60
82
30
65
71
71
51
42
80
80
54
54
28
69
21
33
69
16
40
33
58
61
15
40
61
62
20,60
SUSTIVA
SUTENT
SYLATRON
SYLATRON 4-PACK
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
SYPRINE
syringe with needle, insulin, safety, 0.3 ml
syringe with needle, insulin, safety, 0.5 ml
syringe with needle, insulin, safety, 1 ml
syringe with needle,disposable,insulin 1 ml
syringe with needle,insulin,0.3 ml
syringe with needle,insulin,0.5 ml
40
34
32
32
79
45
45
73
71
16
33
83
76
77
77
77
76
77
SPIRIVA
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
SPRINTEC
SPRITAM
SPRYCEL
SRONYX
SSD
stavudine
STIVARGA
STRATTERA
STRENSIQ
streptomycin sulfate
STRIBILD
SUCRAID
sucralfate
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate
T TABLOID
tacrolimus
TAFINLAR
TAGRISSO
31
60,72
34
33
42
30
63
34
34
69
89
89
89
34
33
60
53
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
TARINA FE
TARON-BC
TARON-C DHA
TARON-PREX PRENATAL
TASIGNA
TAXOTERE
TAZORAC
TAZTIA XT
TECENTRIQ
TECFIDERA
TEFLARO
20
20
20
75
12
sulfadiazine
sulfamethoxazole/trimethoprim
sulfasalazine
sulindac
sumatriptan succinate
SUPRAX
34
59
17
28,29
17
SURMONTIL 26 TEKTURNA 54
109
telmisartan
telmisartan/hydrochlorothiazide
temazepam
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
TESTIM
testosterone
testosterone cypionate
testosterone enanthate
tetanus and diphtheria toxoids, adult
tetanus,diphtheria toxoid ped/pf
tetrabenazine
THALOMID
THEO-24
theophylline anhydrous
THIOLA
thioridazine hcl
thiotepa
thiothixene
THRIVITE 19
THRIVITE RX
THYMOGLOBULIN
tiagabine hcl
TIKOSYN
timolol maleate
tinidazole
TIVICAY
tizanidine hcl
TL FOLATE
TL-CARE DHA
TL-SELECT
TOBRADEX
tobramycin
tobramycin in 0.225 % sodium chloride
tobramycin sulfate
tobramycin/dexamethasone
TOLAK
49
50
43
74
63
28
80
28
66
66
66
66
74
74
58
30
81
81
63
37
30
37
89
89
73
22
51
78
35
40
39
89
89
89
78
15
81
15
78
60
36
tolterodine tartrate
topiramate
topotecan hcl
TORISEL
torsemide
TOUJEO SOLOSTAR
TOVIAZ
TPN ELECTROLYTES
TRACLEER
63
22,28
33
72
54
47
63
84
81
12,13
13
48
26
24
84
78
24
29
71
34,60
72
69
69
69
89
90
59,65
54
43
90
90
90
38
43
36
62
tramadol hcl
tramadol hcl/acetaminophen
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVASOL
travoprost (benzalkonium)
trazodone hcl
TRECATOR
TRELSTAR
tretinoin
TREXALL
TRI-LEGEST FE
TRI-PREVIFEM
TRI-SPRINTEC
TRI-TABS DHA
TRIADVANCE
triamcinolone acetonide
triamterene/hydrochlorothiazide
triazolam
TRICARE
TRICARE PRENATAL DHA ONE
TRICARE PRENATAL WITH DHA
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
TRILYTE WITH FLAVOR PACKETS
trimethoprim
trimipramine maleate
TRINATAL GT
TRINATAL RX 1
TRINATE
16
26
90
90
tolcapone 90
110
TRINESSA
TRINTELLIX
TRISENOX
TRISTART DHA
TRIUMEQ
TRIVEEN-DUO DHA
TRIVEEN-ONE
TRIVEEN-PRX RNF
TRIVORA-28
TROKENDI XR
TROPHAMINE
trospium chloride
TRUMENBA
TRUST NATAL DHA
TRUVADA
TUDORZA PRESSAIR
TWINRIX
TYBOST
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYZEKA
TYZINE
69
24
33
90
40
90
90
90
69
23
84
63
74
90
41
80
74
41
16
34
75
59
42
82
VANDAZOLE
VAQTA
VARIVAX VACCINE
VARIZIG
VELCADE
VELIVET
VEMAVITE-PRX 2
VENA-BAL DHA
VENATAL-FA
VENCLEXTA
VENCLEXTA STARTING PACK
venlafaxine hcl
VENTOLIN HFA
verapamil hcl
VERSACLOZ
VESICARE
16
75
75
75
33
69
90
90
90
31
31
25,44
80
53
39
63
69
78
45
45
41
42
20
25
23
90
90
90
90
90
90
90
90
90
90
41
40
41
90
90
90
VESTURA
VEXOL
VICTOZA 2-PAK
VICTOZA 3-PAK
VIDEX
VIEKIRA PAK
VIGAMOX
VIIBRYD
VIMPAT
VINACAL
VINATE CARE
VINATE DHA
VINATE DHA RF
VINATE GT
U ULTIMATECARE ONE
ULTIMATECARE ONE NF
ursodiol
90
90
61
60 UVADEX
VINATE II
V valacyclovir hcl
VALCHLOR
valganciclovir hcl
valproic acid
valproic acid (as sodium salt) (valproate
sodium)
valsartan
valsartan/hydrochlorothiazide
vancomycin hcl
VINATE ONE
VINATE PN CARE
VINATE ULTRA
VINATE-M
VIRACEPT
VIRAMUNE XR
VIREAD
VIRT NATE
VIRT-ADVANCE
VIRT-BAL DHA
43
30
42
22
22
50
50
16
111
VIRT-BAL DHA PLUS
VIRT-C DHA
VIRT-CARE ONE
VIRT-NATE
VIRT-NATE DHA
VIRT-PN
90
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
91
40
91
66
91
91
91
28
34
91
91
91
91
91
92
92
92
92
61
VRAYLAR
VYFEMLA
VYTORIN
39
69
56
W warfarin sodium
water for irrigation,sterile
WELCHOL
47
77
56
69
VIRT-PN DHA
VIRT-PN PLUS
VIRT-SELECT
VIRT-VITE GT
VIRTPREX
VITAFOL FE+
VITAFOL GUMMIES
VITAFOL NANO
VITAFOL ULTRA
VITAFOL-OB
VITAFOL-OB+DHA
VITAFOL-ONE
VITAMEDMD ONE RX
VITAMEDMD PLUS RX
VITAMEDMD REDICHEW RX
VITAPEARL
VITATRUE
VITEKTA
VIVA DHA
VOGELXO
VOL-NATE
VOL-PLUS
VOL-TAB RX
voriconazole
VOTRIENT
WYMZYA FE
X XALKORI
XARELTO
XELJANZ
XELJANZ XR
XENAZINE
XGEVA
XIFAXAN
XOLAIR
XTANDI
XYREM
34
48
73
73
58
76
16
82
30
82
Y YERVOY 34
75 YF-VAX
Z zafirlukast
zaleplon
ZALTRAP
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
ZAVESCA
ZELBORAF
ZEMAIRA
ZENATANE
ZENCHENT
ZENPEP
80
82
31
92
92
92
92
61
34
82
60
69
61
41
VP CH ULTRA
VP-CH PLUS
VP-CH-PNV
VP-ERA OB PLUS
VP-GGR-B6
VP-HEME OB
VP-HEME OB + DHA
VP-HEME ONE
VP-PNV-DHA
VPRIV ZEPATIER
112
ZETIA
ZIAGEN
zidovudine
ZINGIBER
ziprasidone hcl
ZIRGAN
zoledronic acid
zoledronic acid in mannitol and water for
injection
56
41
41
92
39
42
76
76
33
29
82
29
21
66
73
75
19
69
69
33
80
80
31
15
39
30
16
ZOLINZA
zolmitriptan
zolpidem tartrate
ZOMIG
zonisamide
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
ZOVIA 1-35E
ZOVIA 1-50E
ZYDELIG
ZYFLO
ZYFLO CR
ZYKADIA
ZYLET
ZYPREXA RELPREVV
ZYTIGA
ZYVOX
113
List of drugs by medical condition Analgesics 12
13
14
14
15
21
23
24
26
27
28
28
29
29
29
35
35
37
39
39
43
44
44
47
49
57
59
59
60
61
63
64
65
66
66
70
70
Anesthetics
Anti-Addiction/Substance Abuse Treatment Agents
Anti-inflammatory Agents
Antibacterials
Anticonvulsants
Antidementia Agents
Antidepressants
Antiemetics
Antifungals
Antigout Agents
Antimigraine Agents
Antimyasthenic Agents
Antimycobacterials
Antineoplastics
Antiparasitics
Antiparkinson Agents
Antipsychotics
Antispasticity Agents
Antivirals
Anxiolytics
Bipolar Agents
Blood Glucose Regulators
Blood Products/Modifiers/Volume Expanders
Cardiovascular Agents
Central Nervous System Agents
Dental and Oral Agents
Dermatological Agents
Enzyme Replacement/Modifiers
Gastrointestinal Agents
Genitourinary Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Suppressant (Adrenal)
114
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Thyroid)
Immunological Agents
70
70
71
71
75
75
76
77
78
79
82
82
82
92
Inflammatory Bowel Disease Agents
Metabolic Bone Disease Agents
Miscellaneous Therapeutic Agents
Ophthalmic Agents
Otic Agents
Respiratory Tract/Pulmonary Agents
Skeletal Muscle Relaxants
Sleep Disorder Agents
Therapeutic Nutrients/Minerals/Electrolytes
Uncategorized
115
We have made no changes to this formulary since 09/27/2016. For more recent information or
other questions, please contact CARE WISCONSIN at 1-800-963-0035, or, for TTY users, 711,
8 a.m. - 8 p.m. The call is free. Or visit http://www.carewisc.org/.
This formulary was updated on 9/27/2016. For more recent information or other questions, please contact us at 1-800-963-0035 or, for TTY users, Wisconsin Relay System 711, 24-hours a day/7 days a
week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit www.carewisc.org.
Care Wisconsin Health Plan P.O. Box 14017
Madison, Wisconsin 53708-0017 1-800-963-0035
TTY/TDD Wisconsin Relay System 711 www.carewisc.org