2020 Drug Coverage allcare cco
3Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
Table of Contents
ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132nd Gen Antihistamine & Decongestant Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antihistamine - 1st Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antihistamine - 2nd Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Nasal Anti-Inflammatory Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Nasal Mast Cell Stabilizers Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ANTIEMESIS/ANTIVERTIGO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Antiemetic/Antivertigo Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ANTIRETROVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ASTHMA AND COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-16Anticholinergic, Orally Inhaled Short Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Anticholinergics, Orally Inhaled Long Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Beta-Adrenergic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Beta-Adrenergic Agents, Inhaled, Short Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Beta-Adrenergic Agents, Inhaled, Ultra-Long Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Beta-Adrenergic Agents, Orally Inhaled, Long Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Beta-Adrenergic and Anticholinergic Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Beta-Adrenergic and Glucocorticoid Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Beta-Adrenergic-Anticholinergic-Glucocort, Inhaled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Glucocorticoids, Orally Inhaled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Interleukin-4(IL-4) Receptor Alpha Antagonist, Mab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Interleukin-5(IL-5) Receptor Alpha Antagonist, Mab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Leukotriene Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Mast Cell Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Mast Cell Stabilizers, Orally Inhaled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Monoclonal Antibodies to Immunoglobulin E(IGE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Monoclonal Antibody - Interleukin - 5 Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Xanthines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
AUTONOMIC NERVOUS SYSTEM DISORDERS . . . . . . . . . . . . . . . . . . . 16-17Alzheimer’s Therapy, NMDA Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cholinesterase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
BEHAVIORAL HEALTH – OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Adrenergics, Aromatic, Non-Catecholamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Anti-Alcoholic Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
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Barbiturates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Narcotic Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Sedative-Hypnotics, Non-Barbiturate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
TX for Attention Deficit-Hyperact (ADHD)/Narcolepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CARDIOVASCULAR DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-22Ace Inhibitor/Calcium Channel Blocker Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Ace Inhibitor/Thiazide & Thiazide-Like Diuretic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Alpha/Beta-Adrenergic Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Alpha-Adrenergic Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Angiotensin Recept-Neprilysin Inhibitor Combo (ARNI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Angiotensin Receptor Antag ./Thiazide Diuretic Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Angiotensin Receptor Antgnst & Calc . Channel Blocker . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Antiarrhythmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Antihyperlipidemic - HMG COA Reductase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Antihyperlipidemic - PCSK9 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Antihypertensives, Ace Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Antihypertensives, Angiotensin Receptor Antagonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Antihypertensives, Sympatholytic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Antihypertensives, Vasodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Beta-Adrenergic Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Beta-Adrenergic Blocking Agents/Thiazide & Related . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Bile Salt Sequestrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Calcium Channel Blocking Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Digitalis Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Lipotropics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Loop Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Potassium Sparing Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Potassium Sparing Diuretics in Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Pulm . Anti-HTN, Sel . C-GMP Phosphodiesterase T5 Inhib . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Thiazide and Related Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Vasodilators, Coronary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
CONTRACEPTION/OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-24Contraceptives, Intravaginal, Systemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Contraceptives, Implantable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Contraceptives, Injectable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Contraceptives, Intravaginal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Contraceptives, Oral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
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Contraceptives, Transdermal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Diaphragms/Cervical Cap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Oxytocics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
COUGH AND COLD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-261st Gen Antihistamine & Decongestant Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1st Gen Antihistamine-Decongestant - Analgesic Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Analgesic, Non-Sal . - 1st Generation Antihistamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Antitussives, Non-Narcotic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Decongest-Analgesic, Non-Salicylate Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Decongestant-Expectorant Combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Expectorants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Narcotic Antituss-1st Gen . Antihistamine-Decongest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Narcotic Antituss-Decongestant-Expectorant Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Narcotic Antitussive-1st Generation Antihistamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Narcotic Antitussive-Expectorant Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Non-Narc Antitus-1st Gen Antihist-Decon-Analges CB . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Non-Narc Antituss-Decongestant-Analgesic-Expect CB . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Non-Narc Antitussive-1st Gen Antihistamine Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Non-Narc Antituss-Decongestant-Expectorant CMB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Non-Narcotic Antitussive and Expectorant Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Nose Preparations, Vasoconstrictors (RX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Nose Preparations, Vasoconstrictors (OTC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Sympathomimetic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
DERMATOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-31Acne Agents, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antipruritics, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antipsoriatics Agents, Systemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antipsoriatics Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Antiseborrheic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Emollients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Iodine Antiseptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Irritants/Counter-Irritants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Keratolytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Oxidizing Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Protectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Rosacea Agents, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Topical Agents, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
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Topical Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Topical Antibiotics/Antiinflammatory, Steroidal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Topical Antifungal/Antiinflammatory, Steroid Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Topical Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Topical Anti-Inflammatory Steroidal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Topical Anti-Inflammatory, NSAIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Topical Antineoplastic & Premalignant Lesion Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Topical Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Topical Immunosuppressive Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Topical Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Topical Preparations, Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Topical Preparations, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Topical Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
DIABETES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-33Antihypergly, (DPP-4) Inhibitor & Biguanide Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antihypergly, DPP-4, Enzyme Inhib & Thiazolidinedione . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antihypergly, Incretin Mimetic (GLP-1 Recep . Agonist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antihyperglycemic-Sod/Gluc Contransport2 (SGLT2) Inhib . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antihyperglycemic, Alpha-Glucosidase Inhib (N-S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antihyperglycemic, DPP-4 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Antihyperglycemic, Insulin-Release Stimulant Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Antihyperglycemic, Insulin-Response Enhancer (N-S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Antihyperglycemic, Insulin & GLP-1 Receptor Agonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Antihyperglycemic, Insulin-Rel Stim . & Biguanide Comb . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Antihyperglycemic-SGL T2 Inhibitor & Biguanide Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Diabetic Ulcer Preparations, Topical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Hyperglycemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Insulins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
EAR DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Ear Preparations, Misc . Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Ear Preparations, Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Ear Preparations, Ear Wax Removers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Otic Preparations, Anti-Inflammatory-Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
ELECTROLYTE REGULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34-35Electrolyte Depleters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Potassium Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
Sodium/Saline Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
ENDOCRINE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35-36Antidiuretic and Vasopressor Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Antineoplastic LHRH (GNRH) Agonist, Pituitary Suppr . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Antithyroid Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Bone Formation Agents - Sclerostin Inhibitors, Mono . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Bone Resorption Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Growth Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
LHRH (GNRH) Antagonist, Pituitary Suppressant Agents . . . . . . . . . . . . . . . . . . . . . . . . . 36
LHRH (GNRH) Agnst Pit . Sup-Central Precocious Puberty . . . . . . . . . . . . . . . . . . . . . . . . 36
Menopausal Sympt Supp-Sel Estrogen Recep Modulator . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Parathyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Pituitary Suppressive Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Thyroid Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
EYE DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-39Artificial Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Carbonic Anhydrase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Eye Antibiotic-Corticoid Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Eye Anti-Infectives (Rx Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Eye Inflammatory Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Eye Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Eye Preparations, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Eye Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Miotics/Other Intraoc . Pressure Reducers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Mydriatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Ophthalmic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Ophthalmic Mass Cell Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Ophthalmic Preparations, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
GOUT AND RELATED DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Colchicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Hyperuricemia TX - Purine Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Uricosuric Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
HEMATOLOGICAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39-40Anticoagulants, Coumarin Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Antifibrinolytic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Direct Factor XA Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
AllCare Health AllCareHealth.com/Medicaid8
Heparin and Related Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Platelet Aggregation Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Sickle Cell Anemia Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Vitamin K Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
HORMONAL DEFICIENCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40-41Androgen/Estrogen Preps for Female Sexual Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 40
Androgenic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Estrogen & Selective Estrogen Recept Mod (Serm) Comb . . . . . . . . . . . . . . . . . . . . . . . . . 40
Estrogenic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Progestational Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
IMMUNIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
IMMUNOSUPPRESSION/MODULATION . . . . . . . . . . . . . . . . . . . . . . . . . . 41Immunomodulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Immunosuppressives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
INFECTIOUS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41-462nd Gen . Anaerobic Antiprotozoal-Antibacterial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Absorbable Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Aminoglycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Anaerobic Antiprotozoal-Antibacterial Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Anthelmintics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antifungal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antifungal Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antileprotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antimalarial Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Anti-Mycobacterium Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Antiretroviral-Nucleoside, Nucleotide, Protease Inh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Antitubercular Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Antivirals, General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Cephalosporins - 1st Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Cephalosporins - 2nd Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Cephalosporins - 3rd Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Chemotherapeutics, Antibacterial, Misc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Hep C - NS5A, NS3/4A, Nucleotide NS5B Inhib . Combo . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Hep C Virus - NS5A & NS5B Polymerase Inhib . Combo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Hepatitis B Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Hepatitis C Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Hepatitis C Virus - NS5A and NS3/4A Inhibitor Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
9Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
Lincosamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Nitrofuran Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Rifamycins and Related Derivative Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Tetracyclines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Vancomycin and Derivatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
INFLAMMATORY DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46-48Anti-Inflammatory Tumor Necrosis Factor Inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Anti-Inflammatory, Pyrimidine Synthesis Inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Anti-Inflammatory, Phosphodiesterase-4 (PDE4) Inhib . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Interleukin-6 (IL-6) Receptor Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Janus Kinase (JAK) Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Mineralocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
NSAIDS, Cyclooxygenase 2 Inhibitor - Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
NSAIDS, Cyclooxygenase Inhibitor - Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
LOCAL ANESTHESIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
LOWER GASTROINTESTINAL DISORDERS . . . . . . . . . . . . . . . . . . . . . .49-50Ammonia Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Antidiarrheals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Bile Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Chronic Inflam . Colon DX, 5-A-Salicylat, Rectal TX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Drug TX-Chronic Inflam . Colon DX, 5-Aminosalicylat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Laxatives and Cathartics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Laxatives, Local, Rectal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Rectal/Lower Bowel Prep ., Glucocort . (Non-Hemorr) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
MISCELLANEOUS AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50Anaphylaxis Therapy Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Parasympathetic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
NEUROLOGICAL DISEASE – MISCELLANEOUS . . . . . . . . . . . . . . . . . . . .50Agents to Treat Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
ONCOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
AllCare Health AllCareHealth.com/Medicaid10
ORAL/PHARYNGEAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Dental Aids and Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Nose Preparations, Miscellaneous (RX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Periodontal Collagenase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
OTHER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51-52Antioxidant Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Appetite Stim . for Anorexia, Cachexia, Wasting Synd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Dietary Supplement, Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
General Inhalation Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Insecticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Metabolic Deficiency Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Protein Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Thickening Agents, Oral, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
PAIN MANAGEMENT – ANALGESICS . . . . . . . . . . . . . . . . . . . . . . . . . 52-55Analgesic, Salicylate, Barbiturate, & Xanthine CMB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Analgesic, Non-Salicylate, Barbiturate, & Xanthine CMB . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Analgesic/Antipyretics, Salicylates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Analgesic/Antipyretics, Non-Salicylates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
Analgesics, Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Antimigraine Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Narc . & Non-Sal . Analgesic, Barbiturate & Xanthine CMB . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Narcotic Analgesic & Non-Salicylate Analgesic Comb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Narcotic and Salicylate Analgesic Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Narcotic Withdrawal Therapy Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
PARKINSONS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Antiparkinsonism Drugs, Anticholinergic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Antiparkinsonism Drugs, Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Decarboxylase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
SEIZURE DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Anticonvulsant - Benzodiazepine Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
SKELETAL MUSCLE DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Agents to TX Periodic Paralysis - Carbon Anhyd Inh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Skeletal Muscle Relaxants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
11Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
Please note any medication over $650 per fill, will require a PAAllCare CCO is a Generic Mandatory plan – generic drugs must be used when availableCertain drugs must be obtained through MedImpact Direct Specialty Pharmacy (MIDS)If you have questions concerning the AllCare CCO Drug Coverage Plan, please call (541) 471-4106
SMOKING CESSATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Smoking Deterrent Agents (Ganglionic Stim, Others) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Smoking Deterrent - Nicotinic Recept . Partial Agonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Smoking Deterrents, Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
UPPER GASTROINTESTINAL DISORDERS . . . . . . . . . . . . . . . . . . . . . 57-59Antacids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Anticholinergics/Antispasmodics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Antiflatulents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Anti-Ulcer Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Emetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Histamine H2-Receptor Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Intestinal Motility Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Pancreatic Enzymes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Proton-Pump Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
URINARY TRACT – FUNCTIONAL DISORDERS . . . . . . . . . . . . . . . . . . . . 59Benign Prostatic Hypertrophy/Micturition Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Overactive Bladder Agents, BETA-3 Adrenergic Recep . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Urinary PH Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Urinary Tract Anesthetic/Analgesic Agnt (AZO-DYE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Urinary Tract Antispasmodic/Antiincontinence Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
VAGINAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60Vaginal Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Vaginal Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Vaginal Estrogen Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
VITAMIN AND/OR MINERAL DEFICIENCY . . . . . . . . . . . . . . . . . . . . . 60-61Cariostatic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Replacement Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Vitamin B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Vitamin E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
AllCare Health AllCareHealth.com/Medicaid12
Drug Table
13Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentALLERGY
2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSTIER 1
LORATADINE/PSEUDOEPHEDRINE (TAB ER 12H) 5 MG‐120MG PAANTIHISTAMINES - 1ST GENERATION
TIER 1CHLORPHENIRAMINE (SYRUP) 2 MG/5 MLCHLORPHENIRAMINE (TAB ER) 12 MGCHLORPHENIRAMINE (TAB) 4 MGDIPHENHYDRAMINE (ELIXIR) 12.5MG/5MLDIPHENHYDRAMINE (LIQUID) 12.5MG/5MLDIPHENHYDRAMINE (SYRUP) 12.5MG/5MLDIPHENHYDRAMINE (TAB RAPDIS) 12.5 MGHYDROXYZINE (SOLUTION) 10 MG/5 ML DL: 90 IN 180 DAYSHYDROXYZINE (TAB) 10 MG, 25 MG, 50 MG DL: 90 IN 180 DAYSHYDROXYZINE PAM (CAP) 100 MG QL: 4 IN 1 DAYSHYDROXYZINE PAM (CAP) 25 MG, 50 MG QL: 6 IN 1 DAYSPROMETHAZINE (SYRUP) 6.25MG/5MLPROMETHAZINE (TAB) 12.5 MG, 25 MG, 50 MG
TIER 3CLEMASTINE FUM (TAB) 1.34 MG, 2.68 MG STCYPROHEPTADINE (SYRUP) 2 MG/5 MLCYPROHEPTADINE (TAB) 4 MG
ANTIHISTAMINES - 2ND GENERATIONTIER 1
CETIRIZINE (SOLUTION) 1 MG/ML, 5 MG/5 ML QL: 150 IN 30 DAYSCETIRIZINE (TAB) 10 MG, 5 MG QL: 1 IN 1 DAYSLORATADINE (SOLUTION) 5 MG/5 ML QL: 150 IN 30 DAYSLORATADINE (TAB RAPDIS) 10 MGLORATADINE (TAB) 10 MG QL: 1 IN 1 DAYS
NASAL ANTI-INFLAMMATORY STEROIDSTIER 1
FLUTICASONE PROP (SPRAY SUSP) 50 MCG QL: 16 IN 30 DAYS|3 IN 273 DAYS
TIER 3BUDESONIDE (SPRAY/PUMP) 32MCG STFLUNISOLIDE (SPRAY) 25 MCG STTRIAMCINOLONE ACET (SPRAY) 55 MCG ST
NASAL MAST CELL STABILIZERS AGENTSTIER 1
CROMOLYN SOD (SPRAY/PUMP) 5.2 MGANTIEMESIS/ANTIVERTIGO
ANTIEMETIC/ANTIVERTIGO AGENTSTIER 1
DIMENHYDRINATE (TAB) 50 MG
AllCare Health AllCareHealth.com/Medicaid14
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentMECLIZINE (TAB CHEW) 25 MGMECLIZINE (TAB) 12.5 MG, 25 MGONDANSETRON (TAB RAPDIS) 4 MG, 8 MG QL: 180 IN 135 DAYSONDANSETRON (TAB) 4 MG, 8 MG QL: 180 IN 135 DAYSPROCHLORPERAZINE (SUPP.RECT) 25 MGPROCHLORPERAZINE (TAB) 10 MG, 5 MGPROMETHAZINE (SUPP.RECT) 25 MG, 50 MG, 12.5 MG
TIER 2DIMENHYDRINATE [DRAMAMINE] (TAB CHEW) 50 MG
TIER 3DOXYLAMINE SUCC/VIT B6 (TAB DR) 10 MG‐10MG PAONDANSETRON (SOLUTION) 4 MG/5 ML AL: ≤ 4 YEARSSCOPOLAMINE (PATCH TD 3) 1 MG/3 DAY
ANTIRETROVIRALSMay be subject to prior authorization and/or other utilization management restrictions
ALL ANTIRETROVIRAL AGENTS PAASTHMA AND COPD
ANTICHOLINERGIC, ORALLY INHALED SHORT ACTINGTIER 1
IPRATROPIUM BROMIDE (SOLUTION) 0.2 MG/ML AL: ≥ 18 YEARSTIER 2
IPRATROPIUM BROMIDE [ATROVENT HFA] 17MCG AL: ≥ 18 YEARSANTICHOLINERGICS, ORALLY INHALED LONG ACTING
TIER 2ACLIDINIUM BROMIDE [TUDORZA PRESSAIR] 400 MCG QL: 1 IN 23 DAYSUMECLIDINIUM BROMIDE [INCRUSE ELLIPTA] 62.5 MCG QL: 1 IN 23 DAYS
TIER 3TIOTROPIUM BROMIDE [SPIRIVA RESPIMAT] (MIST INHAL) 1.25 MCG, 2.5 MCG QL: 4 IN 30 DAYS
BETA-ADRENERGIC AGENTSTIER 1
ALBUTEROL SULF (SYRUP) 2 MG/5 MLALBUTEROL SULF (TAB ER 12H) 4 MG, 8 MGALBUTEROL SULF (TAB) 2 MG, 4 MG
TIER 3TERBUTALINE SULF (TAB) 5 MG, 2.5 MG ST
BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGTIER 1
ALBUTEROL SULF 90 MCG QL: 2 IN 30 DAYSALBUTEROL SULF (SOLUTION) 5 MG/MLALBUTEROL SULF (VIAL‐NEB) MULTIPLE STRENGTHSLEVALBUTEROL TARTRATE 45 MCG QL: 2 IN 23 DAYS
TIER 2ALBUTEROL SULF [PROAIR RESPICLICK] 90 MCG QL: 2 IN 30 DAYS
BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING
15Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentTIER 2
OLODATEROL [STRIVERDI RESPIMAT] (MIST INHAL) 2.5 MCG QL: 4 IN 30 DAYS, AL: ≥ 18 YEARS
BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGTIER 3
SALMETEROL XINAFOATE [SEREVENT DISKUS] 50 MCG QL: 2 IN 1 DAYS|60 IN 23 DAYS, AL: ≥ 18 YEARS, ST
BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONSTIER 1
IPRATROPIUM/ALBUTEROL SULF (AMPUL‐NEB) 0.5‐3MG/3 AL: ≥ 18 YEARSTIER 2
IPRATROPIUM/ALBUTEROL SULF [COMBIVENT RESPIMAT] (MIST INHAL) 20‐100 MCG
QL: 4 IN 23 DAYS, AL: ≥ 18 YEARS
TIOTROPIUM BR/OLODATEROL [STIOLTO RESPIMAT] (MIST INHAL) 2.5‐2.5MCG QL: 4 IN 30 DAYS
UMECLIDINIUM BRM/VILANTEROL TR [ANORO ELLIPTA] 62.5‐25MCG QL: 1 IN 23 DAYSBETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS
TIER 1FLUTICASONE PROPION/SALMETEROL 100‐50 MCG, 250‐50 MCG, 500‐50 MCG QL: 2 IN 1 DAYS, ST
FLUTICASONE PROPION/SALMETEROL 55‐14 MCG, 113‐14 MCG, 232‐14 MCG
TIER 2BUDESONIDE/FORMOTEROL FUM [SYMBICORT] 80‐4.5 MCG, 160‐4.5MCG QL: 10.2 IN 23 DAYS, ST
TIER 3FLUTICASONE PROPION/SALMETEROL [ADVAIR HFA] 45‐21 MCG, 115‐21MCG, 230‐21MCG
QL: 12 IN 23 DAYS, ST
FLUTICASONE/VILANTEROL [BREO ELLIPTA] 100‐25MCG, 200‐25 MCG STMOMETASONE/FORMOTEROL [DULERA] 100‐5 MCG, 200‐5 MCG QL: 13 IN 23 DAYS, AL: ≥ 12
YEARS, STBETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALED
TIER 2FLUTICASONE/UMECLIDIN/VILANTER [TRELEGY ELLIPTA] 100‐62.5 ST
GLUCOCORTICOIDS, ORALLY INHALEDTIER 1
BUDESONIDE (AMPUL‐NEB) 0.25MG/2ML, 0.5 MG/2ML, 1 MG/2 ML AL: ≤ 5 YEARSTIER 2
BECLOMETHASONE DIP [QVAR REDIHALER] 40 MCG, 80 MCG QL: 1 IN 23 DAYSBUDESONIDE [PULMICORT FLEXHALER] 90 MCG, 180 MCG QL: 1 IN 23 DAYSFLUTICASONE FUROATE [ARNUITY ELLIPTA] 100 MCG, 200 MCGFLUTICASONE PROP [ARMONAIR RESPICLICK] 55 MCG, 232 MCGFLUTICASONE PROP [FLOVENT DISKUS] 100 MCG, 250 MCG, 50 MCG QL: 60 IN 23 DAYSFLUTICASONE PROP [FLOVENT HFA] 110 MCG, 44 MCG QL: 12 IN 23 DAYS
TIER 3FLUTICASONE PROP [FLOVENT HFA] 220 MCG QL: 12 IN 23 DAYS, ST
AllCare Health AllCareHealth.com/Medicaid16
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentINTERLEUKIN-4(IL-4) RECEPTOR ALPHA ANTAGONIST, MAB
TIER 2DUPILUMAB [DUPIXENT] (SYRINGE) 300 MG/2ML PA, FL: FILLS≤1 IN 365 DAYS, MS
INTERLEUKIN-5(IL-5) RECEPTOR ALPHA ANTAGONIST, MABTIER 2
BENRALIZUMAB [FASENRA] (SYRINGE) 30 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS
LEUKOTRIENE RECEPTOR ANTAGONISTSTIER 1
MONTELUKAST SOD (TAB CHEW) 4 MG QL: 30 IN 30 DAYS, AL: < 6 YEARS
MONTELUKAST SOD (TAB CHEW) 5 MG QL: 30 IN 30 DAYSMONTELUKAST SOD (TAB) 10 MG QL: 30 IN 30 DAYS
TIER 3MONTELUKAST SOD (GRAN PACK) 4 MG PA, QL: 30 IN 30 DAYS
MAST CELL STABILIZERSTIER 1
CROMOLYN SOD (ORAL CONC) 20 MG/MLMAST CELL STABILIZERS, ORALLY INHALED
TIER 1CROMOLYN SOD (AMPUL‐NEB) 20 MG/2 ML
MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE)TIER 2
OMALIZUMAB [XOLAIR] (SYRINGE) 75MG/0.5ML, 150 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS
OMALIZUMAB [XOLAIR] (VIAL) 150 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
MONOCLONAL ANTIBODY - INTERLEUKIN-5 ANTAGONISTSTIER 2
MEPOLIZUMAB [NUCALA] (VIAL) 100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
XANTHINESTIER 1
THEOPHYLLINE ANHYDROUS (ELIXIR) 80 MG/15MLTHEOPHYLLINE ANHYDROUS (SOLUTION) 80 MG/15MLTHEOPHYLLINE ANHYDROUS (TAB ER 12H) 100 MG, 200 MG, 300 MG, 450 MG
THEOPHYLLINE ANHYDROUS (TAB ER 24H) 400 MG, 600 MGTIER 2
THEOPHYLLINE ANHYDROUS [THEO‐24] (CAP ER 24H) 400 MG, 200 MG, 300 MG
AUTONOMIC NERVOUS SYSTEM DISORDERSALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS
TIER 1
17Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentMEMANTINE (SOLUTION) 2 MG/ML PAMEMANTINE (TAB) 5 MG, 10 MG
CHOLINESTERASE INHIBITORSTIER 1
DONEPEZIL (TAB RAPDIS) 5 MG, 10 MGDONEPEZIL (TAB) 23 MG, 10 MG, 5 MGGALANTAMINE HBR (CAP24H PEL) 8 MG, 16 MG, 24 MG PAGALANTAMINE HBR (SOLUTION) 4 MG/ML PAGALANTAMINE HBR (TAB) 12 MG, 4 MG, 8 MGRIVASTIGMINE (PATCH TD24) 4.6MG/24HR, 9.5MG/24HR PARIVASTIGMINE TARTRATE (CAP) 1.5 MG, 3 MG, 4.5 MG, 6 MG PA
BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINE
TIER 1DEXTROAMPHETAMINE SULF (CAP ER) 10 MG, 15 MG, 5 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS
DEXTROAMPHETAMINE SULF (TAB) 10 MG, 5 MGDEXTROAMPHETAMINE/AMPHETAMINE (CAP ER 24H) 10 MG, 20 MG, 30 MG, 5 MG, 15 MG, 25 MG
QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS
DEXTROAMPHETAMINE/AMPHETAMINE (TAB) MULTIPLE STRENGTHSTIER 3
LISDEXAMFETAMINE [VYVANSE] (CAP) MULTIPLE STRENGTHS PA, QL: 1 IN 1 DAYS, AL: ≥ 6 YEARS
LISDEXAMFETAMINE [VYVANSE] (TAB CHEW) 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG
PA, QL: 1 IN 1 DAYS, AL: ≥ 6 YEARS
ANTI-ALCOHOLIC PREPARATIONSTIER 1
ACAMPROSATE CALC (TAB DR) 333 MGBARBITURATES
TIER 1PHENOBARBITAL (ELIXIR) 20 MG/5 MLPHENOBARBITAL (TAB) MULTIPLE STRENGTHS
NARCOTIC ANTAGONISTSTIER 1
NALTREXONE (TAB) 50 MGTIER 2
NALOXONE [NARCAN] (SPRAY) 4 MGSEDATIVE-HYPNOTICS,NON-BARBITURATE
TIER 1DIPHENHYDRAMINE (CAP) 50 MG, 25 MGDIPHENHYDRAMINE (TAB) 25 MGDOXYLAMINE SUCC (TAB) 25 MG
TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYTIER 1
AllCare Health AllCareHealth.com/Medicaid18
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentMETHYLPHENIDATE (30‐70) 20 MG, 10 MG, 30 MG, 40 MG, 50 MG, 60 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS
METHYLPHENIDATE (50‐50) 20 MG, 30 MG, 40 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS
METHYLPHENIDATE (SOLUTION) 5 MG/5 ML, 10 MG/5 ML QL: 20 IN 1 DAYSMETHYLPHENIDATE (TAB ER 24) 54 MG, 18 MG, 36 MG, 27 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS
METHYLPHENIDATE (TAB ER) 20 MG, 10 MG QL: 2 IN 1 DAYS, AL: ≤ 19 YEARS
METHYLPHENIDATE (TAB) 10 MG, 5 MG, 20 MGTIER 3
DEXMETHYLPHENIDATE (50‐50) 5 MG, 10 MG, 20 MG, 30 MG, 40 MG, 15 MG QL: 1 IN 1 DAYS|2 IN 1 DAYS, AL: ≤ 19 YEARS|≥ 6 YEARS, ST
DEXMETHYLPHENIDATE (TAB) 2.5 MG, 5 MG, 10 MG QL: 3 IN 1 DAYS, AL: ≥ 6 YEARS, ST
METHYLPHENIDATE [DAYTRANA] (PATCH TD24) 10MG/9HR, 15MG/9HR, 20 MG/9 HR, 30MG/9HR
PA, QL: 1 IN 1 DAYS, AL: ≤ 17 YEARS|≥ 6 YEARS
CARDIOVASCULAR DISEASEACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION
TIER 1AMLODIPINE BESYLATE/BENAZEPRIL (CAP) MULTIPLE STRENGTHS
ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETICTIER 1
BENAZEPRIL/HCTZ (TAB) 5‐6.25MG, 10‐12.5MG, 20‐12.5 MG, 20 MG‐25MGENALAPRIL/HCTZ (TAB) 10 MG‐25MG, 5MG‐12.5MGLISINOPRIL/HCTZ (TAB) 20‐12.5 MG, 20 MG‐25MG, 10‐12.5MG
ALPHA/BETA-ADRENERGIC BLOCKING AGENTSTIER 1
CARVEDILOL (TAB) 25 MG, 12.5 MG, 3.125 MG, 6.25 MGTIER 3
CARVEDILOL PHOSPHATE (CPMP 24HR) 10 MG, 20 MG, 40 MG, 80 MG PALABETALOL (TAB) 300 MG, 200 MG, 100 MG
ALPHA-ADRENERGIC BLOCKING AGENTSTIER 1
DOXAZOSIN MESYLATE (TAB) 1 MG, 2 MG, 4 MG, 8 MGPRAZOSIN (CAP) 1 MG, 2 MG, 5 MGTERAZOSIN (CAP) 1 MG, 2 MG, 5 MG, 10 MG
ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)TIER 3
SACUBITRIL/VALSARTAN [ENTRESTO] (TAB) 24 MG‐26MG, 49 MG‐51MG, 97MG‐103MG
PA
ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMBTIER 1
IRBESARTAN/HCTZ (TAB) 150‐12.5MG, 300‐12.5MG
19Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentLOSARTAN/HCTZ (TAB) 50‐12.5 MG, 100MG‐25MG, 100‐12.5MGVALSARTAN/HCTZ (TAB) MULTIPLE STRENGTHS
ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKRTIER 1
AMLODIPINE BESYLATE/VALSARTAN (TAB) MULTIPLE STRENGTHSANTIARRHYTHMICS
TIER 1AMIODARONE (TAB) 200 MG, 400 MGDISOPYRAMIDE PHOSPHATE (CAP) 100 MG, 150 MGFLECAINIDE ACET (TAB) 100 MG, 50 MG, 150 MGMEXILETINE (CAP) 150 MG, 200 MG, 250 MGPROPAFENONE (TAB) 150 MG, 300 MG, 225 MGQUINIDINE GLUCONATE (TAB ER) 324 MGQUINIDINE SULF (TAB) 200 MG, 300 MG
TIER 2DISOPYRAMIDE PHOSPHATE [NORPACE CR] (CAP ER) 100 MG, 150 MG
TIER 3DOFETILIDE (CAP) 125 MCG, 250 MCG, 500 MCG
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORSTIER 1
ATORVASTATIN CALC (TAB) 10 MG, 20 MG, 40 MG, 80 MGLOVASTATIN (TAB) 20 MG, 40 MG, 10 MGPRAVASTATIN SOD (TAB) 80 MG, 10 MG, 20 MG, 40 MGROSUVASTATIN CALC (TAB) 10 MG, 20 MG, 40 MG, 5 MGSIMVASTATIN (TAB) 5 MG, 10 MG, 20 MG, 40 MG, 80 MG
TIER 3FLUVASTATIN SOD (CAP) 20 MG, 40 MGFLUVASTATIN SOD (TAB ER 24H) 80 MGLOVASTATIN [ALTOPREV] (TAB ER 24H) 40 MG, 60 MG
ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORSTIER 2
ALIROCUMAB [PRALUENT PEN] (PEN INJCTR) 75 MG/ML, 150 MG/ML PA, MSEVOLOCUMAB [REPATHA PUSHTRONEX] (WEAR INJCT) 420 MG/3.5 PA, MSEVOLOCUMAB [REPATHA SURECLICK] (PEN INJCTR) 140 MG/ML PA, MSEVOLOCUMAB [REPATHA SYRINGE] (SYRINGE) 140 MG/ML PA, MS
ANTIHYPERTENSIVES, ACE INHIBITORSTIER 1
BENAZEPRIL (TAB) 5 MG, 10 MG, 20 MG, 40 MGENALAPRIL (TAB) 5 MG, 10 MG, 20 MG, 2.5 MGFOSINOPRIL SOD (TAB) 40 MG, 10 MG, 20 MGLISINOPRIL (TAB) 5 MG, 10 MG, 20 MG, 40 MG, 2.5 MG, 30 MGQUINAPRIL (TAB) 10 MG, 20 MG, 5 MG, 40 MGRAMIPRIL (CAP) 1.25 MG, 2.5 MG, 5 MG, 10 MGTRANDOLAPRIL (TAB) 1 MG, 2 MG, 4 MG
TIER 3
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentCAPTOPRIL (TAB) 100 MG, 25 MG, 50 MG, 12.5 MGMOEXIPRIL (TAB) 7.5 MG, 15 MG
ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTTIER 1
IRBESARTAN (TAB) 150 MG, 300 MG, 75 MGLOSARTAN POT (TAB) 25 MG, 50 MG, 100 MGVALSARTAN (TAB) 320 MG, 160 MG, 80 MG, 40 MG
TIER 3OLMESARTAN (TAB) 5 MG, 20 MG, 40 MG STTELMISARTAN (TAB) 40 MG, 80 MG, 20 MG ST
ANTIHYPERTENSIVES, SYMPATHOLYTICTIER 1
CLONIDINE (TAB) 0.1 MG, 0.2 MG, 0.3 MG AL: ≥ 6 YEARSGUANFACINE (TAB) 1 MG, 2 MG QL: 3 IN 1 DAYS, AL: ≥ 6 YEARS
METHYLDOPA (TAB) 250 MG, 500 MGANTIHYPERTENSIVES, VASODILATORS
TIER 1HYDRALAZINE (TAB) 10 MG, 100 MG, 25 MG, 50 MGMINOXIDIL (TAB) 10 MG, 2.5 MG
BETA-ADRENERGIC BLOCKING AGENTSTIER 1
ACEBUTOLOL (CAP) 200 MG, 400 MGATENOLOL (TAB) 100 MG, 50 MG, 25 MGMETOPROLOL SUCC (TAB ER 24H) 25 MG, 50 MG, 100 MG, 200 MGMETOPROLOL TARTRATE (TAB) 100 MG, 50 MGPROPRANOLOL (SOLUTION) 20 MG/5 ML, 40MG/5MLPROPRANOLOL (TAB) 10 MG, 20 MG, 40 MG, 60 MG, 80 MGSOTALOL (TAB) 160 MG, 80 MG, 240 MG, 120 MG
TIER 3BETAXOLOL (TAB) 10 MG, 20 MGBISOPROLOL FUM (TAB) 10 MG, 5 MGNADOLOL (TAB) 40 MG, 80 MG, 20 MGPROPRANOLOL (CAP SA 24H) 80 MG, 120 MG, 160 MG, 60 MGTIMOLOL (TAB) 10 MG, 20 MG, 5 MG
BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATEDTIER 1
ATENOLOL/CHLORTHALIDONE (TAB) 50 MG‐25MG, 100MG‐25MGBILE SALT SEQUESTRANTS
TIER 1CHOLESTYRAMINE (WITH SUGAR) (POWD PACK) 4 G DL: 60 DAYSCHOLESTYRAMINE (WITH SUGAR) (POWDER) 4 G DL: 60 DAYSCHOLESTYRAMINE/ASPARTAME (POWD PACK) 4 G DL: 60 DAYSCHOLESTYRAMINE/ASPARTAME (POWDER) 4 G DL: 60 DAYS
TIER 3
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentCOLESEVELAM (POWD PACK) 3.75 G STCOLESEVELAM (TAB) 625 MG STCOLESTIPOL (PACKET) 5 G STCOLESTIPOL (TAB) 1 G ST
CALCIUM CHANNEL BLOCKING AGENTSTIER 1
AMLODIPINE BESYLATE (TAB) 2.5 MG, 10 MG, 5 MGDILTIAZEM (CAP ER 24H) 180 MG, 240 MG, 300 MG, 120 MG, 360 MGDILTIAZEM (CAP ER DEG) 180 MG, 240 MG, 120 MGDILTIAZEM (CAP SA 24H) MULTIPLE STRENGTHSDILTIAZEM (TAB) 30 MG, 60 MG, 90 MG, 120 MGFELODIPINE (TAB ER 24H) 2.5 MG, 5 MG, 10 MGNIFEDIPINE (CAP) 10 MG, 20 MGNIFEDIPINE (TAB ER 24) 30 MG, 60 MG, 90 MGNIFEDIPINE (TAB ER) 90 MG, 60 MG, 30 MGVERAPAMIL (CAP24H PCT) 100 MG, 200 MG, 300 MGVERAPAMIL (TAB ER) 240 MG, 180 MG, 120 MGVERAPAMIL (TAB) 120 MG, 80 MG, 40 MG
TIER 3DILTIAZEM (CAP ER 12H) 90 MG, 120 MG, 60 MGVERAPAMIL (CAP24H PEL) 180 MG, 240 MG, 120 MG, 360 MG
DIGITALIS GLYCOSIDESTIER 1
DIGOXIN (TAB) 125 MCG, 250 MCGTIER 2
DIGOXIN (SOLUTION) 50 MCG/MLLIPOTROPICS
TIER 1EZETIMIBE (TAB) 10 MGFENOFIBRATE (TAB) 160 MG, 54 MGFENOFIBRATE NANOCRYSTALLIZED (TAB) 48 MG, 145MGGEMFIBROZIL (TAB) 600 MGNIACIN (TAB ER 24H) 500 MG, 750 MG, 1000 MG PANIACIN (TAB) 500 MGOMEGA‐3 ACID ETHYL ESTERS (CAP) 1 G PAOMEGA‐3S/DHA/EPA/FISH OIL (CAP DR) 120‐180‐60 QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL (CAP) 600‐1200MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [CENTRUM PRONUTRIENTS OMEGA‐3] (CAP) 332.5 MG
QL: 1 PER DAY
OMEGA‐3S/DHA/EPA/FISH OIL [FISH OIL] (CAP DR) 300‐1000MG, 720‐1200MG QL: 1 PER DAY
OMEGA‐3S/DHA/EPA/FISH OIL [FISH OIL] (CAP) 360‐1200MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OCEAN BLUE OMEGA‐3] (CAP) 350 MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA ESSENTIALS BASIC] (LIQUID) 1400MG/5ML
QL: 1 PER DAY
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA POWER] (CAP) 1050 MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA‐3 FISH OIL] (CAP DR) 1000‐1400 QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [VASCAZEN] (CAP) 900‐110 MG QL: 1 PER DAY
TIER 3FENOFIBRATE,MICRONIZED (CAP) 134 MG, 200 MG ST
LOOP DIURETICSTIER 1
FUROSEMIDE (SOLUTION) 10 MG/ML, 40MG/5MLFUROSEMIDE (TAB) 20 MG, 40 MG, 80 MGTORSEMIDE (TAB) 5 MG, 10 MG, 20 MG, 100 MG
TIER 3BUMETANIDE (TAB) 0.5 MG, 1 MG, 2 MG
POTASSIUM SPARING DIURETICSTIER 1
AMILORIDE (TAB) 5 MGSPIRONOLACTONE (TAB) 100 MG, 25 MG, 50 MG
POTASSIUM SPARING DIURETICS IN COMBINATIONTIER 1
AMILORIDE/HCTZ (TAB) 5 MG‐50 MGSPIRONOLACT/HCTZ (TAB) 25 MG‐25MGTRIAMTERENE/HCTZ (CAP) 37.5‐25 MGTRIAMTERENE/HCTZ (TAB) 75 MG‐50MG, 37.5‐25 MG
TIER 2SPIRONOLACT/HCTZ [ALDACTAZIDE] (TAB) 50 MG‐50MG
PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIBTIER 1
SILDENAFIL CIT (TAB) 20 MG QL: 3 IN 1 DAYS, AL: > 10 YEARS
THIAZIDE AND RELATED DIURETICSTIER 1
HCTZ (CAP) 12.5 MGHCTZ (TAB) 25 MG, 50 MG, 12.5 MGINDAPAMIDE (TAB) 2.5 MG, 1.25 MG
TIER 3CHLORTHALIDONE (TAB) 25 MG, 50 MGMETOLAZONE (TAB) 10 MG, 2.5 MG, 5 MG
VASODILATORS,CORONARYTIER 1
ISOSORBIDE DINIT (TAB ER) 40 MGISOSORBIDE DINIT (TAB) 10 MG, 20 MG, 30 MG, 5 MGISOSORBIDE MONONIT (TAB ER 24H) 60 MG, 120 MG, 30 MGISOSORBIDE MONONIT (TAB) 20 MGNITROGLYCERIN (PATCH TD24) 0.4MG/HR, 0.1MG/HR, 0.2MG/HR, 0.6MG/HR
NITROGLYCERIN (TAB SUBL) 0.3 MG, 0.4 MG, 0.6 MG
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentTIER 2
ISOSORBIDE DINIT [DILATRATE‐SR] (CAP ER) 40 MGISOSORBIDE DINIT [ISORDIL] (TAB) 40 MGNITROGLYCERIN [NITRO‐BID] (OINT. ) 2 %NITROGLYCERIN [NITRO‐DUR] (PATCH TD24) 0.3 MG/HR, 0.8MG/HR
TIER 3NITROGLYCERIN [NITROMIST] (SPRAY) 400MCG/SPR
CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC
TIER 2ETONOGESTREL/ETHINYL ESTRADIOL [NUVARING] (VAG RING) .12‐.015MG DL: 100 DAYS
CONTRACEPTIVES,IMPLANTABLETIER 2
ETONOGESTREL [NEXPLANON] (IMPLANT) 68 MG DL: 100 DAYSCONTRACEPTIVES,INJECTABLE
TIER 1MEDROXYPROGESTERONE ACET (SYRINGE) 150 MG/ML DL: 100 DAYSMEDROXYPROGESTERONE ACET (VIAL) 150 MG/ML DL: 100 DAYS
CONTRACEPTIVES,INTRAVAGINALTIER 1
NONOXYNOL 9 (FOAM/APPL) 12.5 % DL: 100 DAYSNONOXYNOL 9 (GEL/PF APP) 4 % DL: 100 DAYS
TIER 2NONOXYNOL 9 [GYNOL II] (JELLY/APPL) 3 % DL: 100 DAYSNONOXYNOL 9 [TODAY CONTRACEPTIVE SPONGE] (CON.SPONGE) 1000 MG DL: 100 DAYS
NONOXYNOL 9 [VCF] (FILM) 28 % DL: 100 DAYSCONTRACEPTIVES,ORAL
TIER 1DESOG‐E.ESTRADIOL/E.ESTRADIOL (TAB) 21‐5 (28) DL: 100 DAYSDESOGESTREL‐ETHINYL ESTRADIOL (TAB) 7 DAYS X 3, 0.15‐0.03 DL: 100 DAYSETHINYL ESTRADIOL/DROSPIRENONE (TAB) 0.03MG‐3MG, 0.02‐3(28) DL: 100 DAYSETHYNODIOL D‐ETHINYL ESTRADIOL (TAB) 1 MG‐35MCG, 1 MG‐50MCG DL: 100 DAYSLEVONORGESTREL (TAB) 1.5 MG DL: 100 DAYSLEVONORGESTREL‐ETHIN ESTRADIOL (TAB) 0.15‐0.03, 6‐5‐10, 0.1‐0.02MG, 90‐20 MCG
DL: 100 DAYS
LEVONORGESTREL‐ETHIN ESTRADIOL (TBDSPK 3MO) 0.15‐0.03 DL: 100 DAYSL‐NORGEST/E.ESTRADIOL‐E.ESTRAD (TBDSPK 3MO) 100‐20(84), 150‐30(84) DL: 100 DAYS
NORETH‐ETHINYL ESTRADIOL/IRON (TAB CHEW) 0.8‐25(24), 0.4‐35(21) DL: 100 DAYSNORETHINDRONE (TAB) 0.35 MG DL: 100 DAYSNORETHINDRONE AC‐ETH ESTRADIOL (TAB) 1.5‐0.03MG, 1MG‐20MCG DL: 100 DAYSNORETHINDRONE‐E.ESTRADIOL‐IRON (TAB) 1MG‐20(24), 1.5‐30(21), 1MG‐20(21), 5‐7‐9‐7
DL: 100 DAYS
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentNORETHINDRONE‐ETHINYL ESTRAD (TAB) MULTIPLE STRENGTHS DL: 100 DAYSNORGESTIMATE‐ETHINYL ESTRADIOL (TAB) 0.25‐0.035, 7DAYSX3 28, 7DAYSX3 LO DL: 100 DAYS
NORGESTREL‐ETHINYL ESTRADIOL (TAB) 0.3‐0.03MG, 0.5 MG‐50 DL: 100 DAYSCONTRACEPTIVES,TRANSDERMAL
TIER 1NORELGESTROMIN/ETHIN.ESTRADIOL (PATCH TDWK) 150‐35/24H DL: 100 DAYS
DIAPHRAGMS/CERVICAL CAPTIER 1
DIAPHRAGMS, CONTOURED [CAYA CONTOURED] (DIAPHRAGM) 65 MM‐80MM DL: 100 DAYS
DIAPHRAGMS, WIDE SEAL [WIDE SEAL DIAPHRAGM] (DIAPHRAGM) MULTIPLE STRENGTHS
DL: 100 DAYS
OXYTOCICSTIER 1
METHYLERGONOVINE (TAB) 0.2 MGCOUGH AND COLD
1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSTIER 1
CHLORPHENIRAMINE/PSEUDOEPHED (LIQUID) 2‐30MG/5MLCHLORPHENIRAMINE/PSEUDOEPHED (TAB) 4 MG‐60 MGPHENYLEPHRINE HCL/PROMETH (SYRUP) 5‐6.25MG/5TRIPROLIDINE/PSEUDOEPHEDRINE (SYRUP) 1.25‐30/5TRIPROLIDINE/PSEUDOEPHEDRINE (TAB) 2.5MG‐60MG
1ST GEN ANTIHISTAMINE-DECONGESTANT-ANALGESIC COMBTIER 1
PSEUDOEPHED/ACETAMINOPHEN/CPM (TAB) 30‐500‐2MGTIER 2
P‐EPHED HCL/ACETAMINOPHN/DPHA [BENADRYL] (TAB) 30MG‐500MGANALGESIC, NON-SAL.- 1ST GENERATION ANTIHISTAMINE
TIER 1ACETAMINOPHEN/DIPHENHYDRAMINE (TAB) 500MG‐25MG
ANTITUSSIVES,NON-NARCOTICTIER 1
BENZONATATE (CAP) 100 MG, 200 MG QL: 30 IN 365 DAYSDEXTROMETHORPHAN HBR (LIQUID) 15 MG/5 MLDEXTROMETHORPHAN HBR (SYRUP) 5 MG/5 ML, 15 MG/5 ML, 7.5 MG/5ML
TIER 2DEXTROMETHORPHAN HBR [SCOT‐TUSSIN DM COUGH CHASER] (LOZENGE) 2.5 MGDEXTROMETHORPHAN HBR [SCOT‐TUSSIN] (LIQUID) 10 MG/5 ML
DECONGEST-ANALGESIC,NON-SALICYLATE COMB.TIER 2
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
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MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentPSEUDOEPHEDRINE/ACETAMINOPHEN [NEXAFED SINUS PRESSURE‐PAIN] (TAB) 30MG‐325MG
DECONGESTANT-EXPECTORANT COMBINATIONSTIER 1
GUAIFENESIN/PSEUDOEPHEDRNE (TAB ER 12H) 600MG‐60MG, 1200‐120MG
GUAIFENESIN/PSEUDOEPHEDRNE (TAB) 400MG‐60MGTIER 2
GUAIFENESIN/PSEUDOEPHEDRNE [TUSNEL PEDIATRIC] (DROPS) 50‐7.5MG/1
DECONGESTANTS, ORALTIER 2
PSEUDOEPHEDRINE [SUDAFED 24‐HOUR] (TAB ER 24H) 240 MGEXPECTORANTS
TIER 1GUAIFENESIN (LIQUID) 200 MG/5ML, 100 MG/5MLGUAIFENESIN (TAB ER 12H) 600 MGGUAIFENESIN (TAB) 400 MG, 200 MG
NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTTIER 1
PROMETHAZINE/PHENYLEPH/CODEINE (SYRUP) 6.25‐5‐10 AL: ≥ 12 YEARSNARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB
TIER 1PSEUDOEPHED/CODEINE/GUAIFEN (SYRUP) 30‐10‐100 AL: ≥ 12 YEARS
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINETIER 1
PROMETHAZINE HCL/CODEINE (SYRUP) 6.25‐10/5 AL: ≥ 12 YEARSNARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION
TIER 1CODEINE PHOSPHATE/GUAIFENESIN (LIQUID) 10‐100MG/5, 20‐200/10 AL: ≥ 12 YEARS
NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CBTIER 1
DM/P‐EPHED/ACETAMINOPH/DOXYLAM (CAP) 15‐30‐325DM/P‐EPHED/ACETAMINOPH/DOXYLAM (LIQUID) 30‐12.5/30DM/PSEUDOEPHED/ACETAMINOPH/CPM (PACKET) 30‐60‐1000
NON-NARC ANTITUSS-DECONGESTANT-ANALGESIC-EXPECT CBTIER 1
PSEUDOEPH/DM/GUAIFEN/ACETAMIN (CAP) 30‐10‐250NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.
TIER 1PROMETHAZINE/DEXTROMETHORPHAN (SYRUP) 6.25‐15/5
NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMBTIER 1
GUAIFENESIN/DM/PSEUDOEPHEDRINE (LIQUID) 50‐5‐15/5GUAIFENESIN/DM/PSEUDOEPHEDRINE (SYRUP) 100‐10‐30
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentGUAIFENESIN/DM/PSEUDOEPHEDRINE (TAB) 200‐10‐30
TIER 2GUAIFENESIN/DM/PSEUDOEPHEDRINE [TUSNEL DM PEDIATRIC] (DROPS) 2.5‐7.5/ML
NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB.TIER 1
GUAIFENESIN/DEXTROMETHORPHAN (LIQUID) 100‐10MG/5, 200‐30MG/5GUAIFENESIN/DEXTROMETHORPHAN (SYRUP) 100‐10MG/5
NOSE PREPARATIONS, VASOCONSTRICTORS (RX)TIER 2
EPINEPHRINE [ADRENALIN CHLORIDE] (SOLUTION) 1 MG/MLNOSE PREPARATIONS, VASOCONSTRICTORS(OTC)
TIER 1OXYMETAZOLINE (MIST) 0.05 %OXYMETAZOLINE (SPRAY) 0.05 %OXYMETAZOLINE (SPRAY/PUMP) 0.05 %
SYMPATHOMIMETIC AGENTSTIER 1
PSEUDOEPHEDRINE (DROPS) 9.4MG/MLPSEUDOEPHEDRINE (LIQUID) 15 MG/5 MLPSEUDOEPHEDRINE (TAB ER) 120 MGPSEUDOEPHEDRINE (TAB) 30 MG, 60 MG
DERMATOLOGYACNE AGENTS,TOPICAL
TIER 1SULFACETAMIDE SOD (SUSPENSION) 10 % PA
ANTIPRURITICS,TOPICALTIER 1
DIPHENHYDRAMINE (CREAM ) 2 %DIPHENHYDRAMINE (GEL (ML)) 2 %DIPHENHYDRAMINE (SPRAY) 2 %DIPHENHYDRAMINE HCL/ZINC ACET (CREAM ) 2 %‐0.1 %
ANTIPSORIATIC AGENTS,SYSTEMICTIER 1
METHOXSALEN (CAP LQ RAP) 10 MGTIER 3
RISANKIZUMAB‐RZAA [SKYRIZI (2 SYRINGES) KIT] (SYRINGEKIT) 150MG/1.66 PA, MS
RISANKIZUMAB‐RZAA [SKYRIZI] (SYRINGE) 75 MG/0.83 PA, MSSECUKINUMAB [COSENTYX (2 SYRINGES)] (SYRINGE) 150 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS
SECUKINUMAB [COSENTYX PEN (2 PENS)] (PEN INJCTR) 150 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS
TILDRAKIZUMAB‐ASMN [ILUMYA] (SYRINGE) 100 MG/ML PA, MSANTIPSORIATICS AGENTS
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentTIER 2
ANTHRALIN [DRITHOCREME HP] (CREAM ) 1 %TIER 3
CALCIPOTRIENE (CREAM ) 0.005 % PA, QL: 60 IN 30 DAYSCALCIPOTRIENE (OINT. ) 0.005 % PA, QL: 60 IN 30 DAYSCALCIPOTRIENE (SOLUTION) 0.005 % PA, QL: 60 IN 30 DAYS
ANTISEBORRHEIC AGENTSTIER 1
SELENIUM SULFIDE (LOTION) 2.5 % PASELENIUM SULFIDE (SHAMPOO) 1 %SULFACETAMIDE SOD (CLEANSER) 10 % PA
TIER 2SULFACETAMIDE SOD [OVACE PLUS] (SHAMPOO) 10 % PA
EMOLLIENTSTIER 1
GLYCERIN (LIQUID) IODINE ANTISEPTICS
TIER 1POVIDONE‐IODINE (GEL (ML)) 10 %POVIDONE‐IODINE (LIQUID PKT) 10 %POVIDONE‐IODINE (MED. SWAB) 10 %POVIDONE‐IODINE (OINT. ) 10 %POVIDONE‐IODINE (SOLUTION) 7.5 %, 10 %POVIDONE‐IODINE (SPRAY) 10 %
TIER 2POVIDONE‐IODINE [BETADINE] (SOLUTION) 5 %POVIDONE‐IODINE [SUMMER'S EVE DOUCHE] (SOLUTION) 0.3 %
IRRITANTS/COUNTER-IRRITANTSTIER 1
CAPSAICIN (ADH. PATCH) 0.025 %CAPSAICIN (CREAM ) 0.025 %, 0.033 %, 0.075 %, 0.1 %MENTHOL (GEL (GRAM)) MENTHOL (POWDER) 1 %MENTHOL/ALOE VERA/VITAMIN E (GEL (GRAM)) 7 %
TIER 2MENTHOL [STOPAIN] (SPRAY) 6 %MENTHOL/ALOE VERA EXTRACT [ICY HOT] (GEL (GRAM)) 16 %METHYL SALICYLATE/MENTHOL [SALONPAS] (ADH. PATCH) 10 %‐3 % PA
KERATOLYTICSTIER 1
PODOFILOX (SOLUTION) 0.5 %OXIDIZING AGENTS
TIER 1CARBAMIDE PEROXIDE (SOLUTION) 10 %
PROTECTIVES
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
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Therapeutic Indication / Drug Name CommentTIER 1
ALUMINUM HYDROXIDE (OINT. ) , 1.2 %CORN STARCH (POWDER) 83.7 %VIT A/VITAMIN D3/E/ALOE V/ZINC (OINT. ) ZINC OXIDE (OINT. ) 16 %, 20 %, 12.8%, ZINC OXIDE (PASTE ) 25 %
ROSACEA AGENTS, TOPICALTIER 1
METRONIDAZOLE (CREAM ) 0.75 % PAMETRONIDAZOLE (GEL (GRAM)) 0.75 % PAMETRONIDAZOLE (LOTION) 0.75 % PA
TIER 2METRONIDAZOLE [NORITATE] (CREAM ) 1 % PA
TOPICAL AGENTS,MISCELLANEOUSTIER 1
UREA (CREAM ) 20 % QL: 85 IN 30 DAYSTOPICAL ANTIBIOTICS
TIER 1BACITRACIN (OINT. ) 500 UNIT/GBACITRACIN (PACKET) 500 UNIT/GBACITRACIN ZINC (OINT. ) 500 UNIT/GBACITRACIN ZINC (PACKET) 500 UNIT/GBACITRACIN ZINC/POLYMYXIN B (OINT. ) 500‐10K/GBACITRACIN/POLYMYXIN B SULF (PACKET) GENTAMICIN SULF (OINT. ) 0.1 %, 0.3 %MUPIROCIN (OINT. ) 2 % QL: 112 IN 30 DAYSNEOMYCIN/BACITRACIN/POLYMYXINB (OINT PACK) 3.5‐400‐5KNEOMYCIN/BACITRACIN/POLYMYXINB (OINT. ) 3.5‐400‐5KNEOMYCN/BACITRC/POLYMYX/PRAMOX (OINT. ) 3.5‐10K‐10
TIER 3GENTAMICIN SULF (CREAM ) 0.1 %MUPIROCIN CALC (CREAM ) 2 % ST
TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDALTIER 2
NEOMYC/BACIT/POLYMYX/HYDROCORT [CORTISPORIN] (OINT. ) 1 %NEOMYCIN/POLYMYXIN B/HYDROCORT [CORTISPORIN] (CREAM ) 0.5 %
TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENTTIER 1
CLOTRIMAZOLE/BETAMETHASONE DIP (CREAM ) 1 %‐0.05 %TOPICAL ANTIFUNGALS
TIER 1CICLOPIROX (SOLUTION) 8 %CLOTRIMAZOLE (CREAM ) 1 %CLOTRIMAZOLE (SOLUTION) 1 %MICONAZOLE NIT (AERO POWD) 2 %
29Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentMICONAZOLE NIT (CREAM ) 2 %MICONAZOLE NIT (CREAM(ML)) 2 %MICONAZOLE NIT (OINT. ) 2 %MICONAZOLE NIT (POWDER) 2 %MICONAZOLE NIT (TINCTURE) 2 %NYSTATIN (CREAM ) 100000/GNYSTATIN (OINT. ) 100000/GNYSTATIN (POWDER) 100000/G QL: 120 IN 30 DAYSTERBINAFINE (CREAM ) 1 %TOLNAFTATE (AERO POWD) 1 %TOLNAFTATE (CREAM ) 1 %TOLNAFTATE (POWDER) 1 %TOLNAFTATE (SOLUTION) 1 %
TIER 2MICONAZOLE NIT [LOTRIMIN AF] (SPRAY) 2 %TERBINAFINE [LAMISIL] (SPRAY) 1 % PA
TIER 3KETOCONAZOLE (CREAM ) 2 % FL: 3 IN 365 DAYS, STKETOCONAZOLE (SHAMPOO) 2 % STKETOCONAZOLE [NIZORAL A‐D] (SHAMPOO) 1 % STNYSTATIN/TRIAMCIN (CREAM ) 100000‐0.1 STNYSTATIN/TRIAMCIN (OINT. ) 100000‐0.1 ST
TOPICAL ANTI-INFLAMMATORY STEROIDALTIER 1
BETAMETHASONE DIP (CREAM ) 0.05 % PABETAMETHASONE DIP (GEL (GRAM)) 0.05 % PABETAMETHASONE DIP (LOTION) 0.05 % PABETAMETHASONE DIP (OINT. ) 0.05 % PABETAMETHASONE VALERATE (CREAM ) 0.1 % PABETAMETHASONE VALERATE (LOTION) 0.1 % PABETAMETHASONE VALERATE (OINT. ) 0.1 % PABETAMETHASONE/PROPYLENE GLYC (CREAM ) 0.05 % PABETAMETHASONE/PROPYLENE GLYC (LOTION) 0.05 % PABETAMETHASONE/PROPYLENE GLYC (OINT. ) 0.05 % PACLOBETASOL PROP (CREAM ) 0.05 % PACLOBETASOL PROP (OINT. ) 0.05 % PACLOBETASOL PROP (SOLUTION) 0.05 % PACLOBETASOL PROP/EMOLL (CREAM ) 0.05 % PAFLUOCINOLONE ACET (OIL) 0.01 % PAFLUOCINONIDE (CREAM ) 0.05 % PAFLUOCINONIDE (GEL (GRAM)) 0.05 % PAFLUOCINONIDE (OINT. ) 0.05 % PAFLUOCINONIDE (SOLUTION) 0.05 % PAFLUOCINONIDE/EMOLLIENT BASE (CREAM ) 0.05 % PAFLUTICASONE PROP (CREAM ) 0.05 % PA
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Therapeutic Indication / Drug Name CommentFLUTICASONE PROP (OINT. ) 0.005 % PAHYDROCORTISONE (CREAM ) 0.5 %, 1 %, 2.5 %HYDROCORTISONE (CREAM PACK) 1 %HYDROCORTISONE (CRM/PE APP) 1 %HYDROCORTISONE (GEL (GRAM)) 1 %HYDROCORTISONE (LOTION) 2 %, 0.5 %, 1 %, 2.5 %HYDROCORTISONE (OINT. ) 1 %, 0.5 %, 2.5 %HYDROCORTISONE (SOLUTION) 1 %HYDROCORTISONE (SPRAY) 1 %HYDROCORTISONE ACET (CREAM ) 1 %, 0.5 %HYDROCORTISONE ACET (OINT. ) 1 %HYDROCORTISONE BUTYRATE (SOLUTION) 0.1 % PAHYDROCORTISONE/ALOE VERA (CREAM ) 1 %MOMETASONE FUROATE (CREAM ) 0.1 % PAMOMETASONE FUROATE (OINT. ) 0.1 % PAMOMETASONE FUROATE (SOLUTION) 0.1 % PATRIAMCINOLONE ACET (CREAM ) 0.025 %, 0.1 %, 0.5 % QL: 454 IN 365 DAYSTRIAMCINOLONE ACET (LOTION) 0.025 %, 0.1 % QL: 240 IN 365 DAYSTRIAMCINOLONE ACET (OINT. ) 0.025 %, 0.1 %, 0.5 % QL: 454 IN 365 DAYS
TOPICAL ANTI-INFLAMMATORY, NSAIDSTIER 1
DICLOFENAC SOD (GEL (GRAM)) 1 % QL: 100 IN 23 DAYSTOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS
TIER 3FLUOROURACIL (CREAM ) 0.5 %, 5 % PAFLUOROURACIL (SOLUTION) 2 %, 5 % PAFLUOROURACIL [FLUOROPLEX] (CREAM ) 1 % PA
TOPICAL ANTIPARASITICSTIER 1
PERMETHRIN (CREAM ) 5 %PERMETHRIN (LIQUID) 1 %PIPERONYL BUTOX/PYRETHR/PERMET (KIT) 4‐.33‐.5%PIPERONYL BUTOXIDE/PYRETHRINS (SHAMPOO) 4%‐0.33%
TIER 3MALATHION (LOTION) 0.5 % ST
TOPICAL IMMUNOSUPPRESSIVE AGENTSTIER 1
TACROLIMUS (OINT. ) 0.03 %, 0.1 % PATOPICAL LOCAL ANESTHETICS
TIER 1LIDOCAINE (ADH. PATCH) 5 % PALIDOCAINE (OINT. ) 5 % QL: 60 IN 30 DAYSLIDOCAINE/PRILOCAINE (CREAM ) 2.5 %‐2.5% QL: 60 IN 30 DAYS
TIER 2
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Therapeutic Indication / Drug Name CommentTETRACAINE/BENZOCAINE/BUTAMBEN [CETACAINE ANESTHETIC] (LIQUID) 2%‐14%‐2%
TOPICAL PREPARATIONS,ANTIBACTERIALSTIER 1
CHLORHEXIDINE GLUCONATE (LIQUID) 4 %, 2 %TOPICAL PREPARATIONS,MISCELLANEOUS
TIER 1CALCIUM ACET/ALUMINUM SULF (POWD PACK) 51 %‐49 %, 839‐1191MG, 952‐1347MG
PA
SOD CHLORIDE (SPRAY) 0.9 %, 0.65 %TIER 2
SOD CHLORIDE [NORMLGEL] (GEL (GRAM)) 0.9 %TOPICAL SULFONAMIDES
TIER 1SILVER SULFADIAZINE (CREAM ) 1 %
DIABETESANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.
TIER 1ALOGLIPTIN BENZ/METFORMIN (TAB) 12.5‐500MG, 12.5‐1000 QL: 2 IN 1 DAYS
TIER 2LINAGLIPTIN/METFORMIN [JENTADUETO XR] (TAB BP 24H) 2.5‐1000MG, 5MG‐1000MG
PA
LINAGLIPTIN/METFORMIN [JENTADUETO] (TAB) 2.5‐500 MG, 2.5‐850 MG, 2.5‐1000MG
PA
ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONETIER 1
ALOGLIPTIN BENZ/PIOGLITAZONE (TAB) MULTIPLE STRENGTHS QL: 1 IN 1 DAYSANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)
TIER 2EXENATIDE MICROSPHERES [BYDUREON BCISE] (AUTO INJCT) 2MG/0.85ML PA
EXENATIDE MICROSPHERES [BYDUREON PEN] (PEN INJCTR) 2MG/0.65ML PALIXISENATIDE [ADLYXIN] (PEN INJCTR) 20 MCG/0.2, 10‐20 (1) PA
TIER 3DULAGLUTIDE [TRULICITY] (PEN INJCTR) 0.75MG/0.5, 1.5 MG/0.5 PAEXENATIDE [BYETTA] (PEN INJCTR) 5MCG/0.02, 10MCG/0.04 PALIRAGLUTIDE [VICTOZA 2‐PAK] (PEN INJCTR) 0.6 MG/0.1 PA
ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBTIER 2
ERTUGLIFLOZIN PIDOLATE [STEGLATRO] (TAB) 5 MG, 15 MG QL: 1 IN 1 DAYS, STTIER 3
EMPAGLIFLOZIN [JARDIANCE] (TAB) 10 MG, 25 MG PAANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)
TIER 1ACARBOSE (TAB) 100 MG, 50 MG, 25 MG
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Therapeutic Indication / Drug Name CommentMIGLITOL (TAB) 25 MG, 50 MG, 100 MG
ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSTIER 1
ALOGLIPTIN BENZOATE (TAB) 25 MG, 12.5 MG, 6.25 MG QL: 1 IN 1 DAYSTIER 2
LINAGLIPTIN [TRADJENTA] (TAB) 5 MG PA, QL: 1 IN 1 DAYSANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE
TIER 1GLIMEPIRIDE (TAB) 1 MG, 2 MG, 4 MGGLIPIZIDE (TAB ER 24) 10 MG, 5 MG, 2.5 MGGLIPIZIDE (TAB) 5 MG, 10 MGGLYBURIDE (TAB) 1.25 MG, 2.5 MG, 5 MGGLYBURIDE,MICRONIZED (TAB) 1.5 MG, 3 MG, 6 MG
TIER 3NATEGLINIDE (TAB) 60 MG, 120 MG QL: 3 IN 1 DAYS
ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)TIER 1
PIOGLITAZONE (TAB) 15 MG, 30 MG, 45 MGTIER 2
ROSIGLITAZONE [AVANDIA] (TAB) 2 MG, 4 MGANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)
TIER 1METFORMIN (TAB ER 24H) 750 MG, 500 MGMETFORMIN (TAB) 500 MG, 850 MG, 1000 MG
TIER 3METFORMIN (TAB ER 24) 1000 MG, 500 MG
ANTIHYPERGLYCEMIC,INSULIN & GLP-1 RECEPTOR AGONISTTIER 2
INSULIN DEGLUDEC/LIRAGLUTIDE [XULTOPHY 100‐3.6] (INSULN PEN) 100‐3.6/ML PA
TIER 3INSULIN GLARGINE/LIXISENATIDE [SOLIQUA 100‐33] (INSULN PEN) 100‐33/ML PA
ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMBTIER 1
GLIPIZIDE/METFORMIN (TAB) 2.5‐250 MG, 2.5‐500 MG, 5 MG‐500MGGLYBURIDE/METFORMIN (TAB) 1.25‐250MG, 5 MG‐500MG, 2.5‐500 MG
ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMBTIER 2
ERTUGLIFLOZIN/METFORMIN [SEGLUROMET] (TAB) MULTIPLE STRENGTHS QL: 2 IN 1 DAYS, ST
TIER 3EMPAGLIFLOZIN/METFORMIN [SYNJARDY XR] (TAB BP 24H) MULTIPLE STRENGTHS
PA
EMPAGLIFLOZIN/METFORMIN [SYNJARDY] (TAB) MULTIPLE STRENGTHS PA
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Therapeutic Indication / Drug Name CommentDIABETIC ULCER PREPARATIONS,TOPICAL
TIER 2BECAPLERMIN [REGRANEX] (GEL (GRAM)) 0.01 % PA
HYPERGLYCEMICSTIER 1
DEXTROSE (GEL (GRAM)) 40 %DEXTROSE (GEL PACKET) 15 G/33 GDEXTROSE (LIQUID) 15G/59ML, 15 G/60 MLDEXTROSE (TAB CHEW) 1 GDEXTROSE (TAB CHEW) 4 G FL: FILLS≤2 IN 30 DAYS
TIER 2DEXTROSE/DEXTRIN/MALTOSE [INSTA‐GLUCOSE] (GEL (GRAM)) 24 G/31GGLUCAGON [GVOKE HYPOPEN] (AUTO INJCT) 0.5 MG/0.1, 1 MG/0.2ML QL: 6 PER YEARGLUCAGON [GVOKE SYRINGE] (SYRINGE) 0.5 MG/0.1, 1 MG/0.2ML QL: 6 PER YEARGLUCAGON,HUMAN RECOMBINANT [GLUCAGEN] (VIAL) 1 MG, 1 MG/ML QL: 6 PER YEAR
4 GLUCAGON,HUMAN RECOMBINANT [GLUCAGON] (VIAL) 1 MG, 1 MG/ML QL: 6 PER YEARGLUCAGON [BAQSIMI] (SPRAY) 3 MG QL: 6 PER YEAR
INSULINSTIER 1
INSULIN LISPRO [HUMALOG] (INSULN PEN) 100/MLINSULIN LISPRO [HUMALOG] (VIAL) 100/ML
TIER 2INSULIN GLARGINE [BASAGLAR KWIKPEN] (INSULN PEN) 100/ML (3)INSULIN LISPRO [ADMELOG SOLOSTAR] (INSULN PEN) 100/MLINSULIN LISPRO [ADMELOG] (VIAL) 100/MLINSULIN LISPRO PROTAMIN/LISPRO [HUMALOG MIX 75‐25 KWIKPEN] (INSULN PEN) 75‐25/MLINSULIN LISPRO PROTAMIN/LISPRO [HUMALOG MIX 75‐25] (VIAL) 75‐25/ML
INSULIN NPH HUM/REG INSULIN HM [NOVOLIN 70‐30 FLEXPEN] (INSULN PEN) 70‐30/MLINSULIN NPH HUM/REG INSULIN HM [NOVOLIN 70‐30] (VIAL) 70‐30/MLINSULIN NPH HUMAN ISOPHANE [NOVOLIN N] (VIAL) 100/MLINSULIN REGULAR, HUMAN [HUMULIN R U‐500 KWIKPEN] (INSULN PEN) 500/ML (3)INSULIN REGULAR, HUMAN [NOVOLIN R] (VIAL) 100/ML
TIER 3INSULIN ASPART PROT/INSULN ASP [NOVOLOG MIX 70‐30 FLEXPEN] (INSULN PEN) 70‐30/ML
ST
INSULIN ASPART PROT/INSULN ASP [NOVOLOG MIX 70‐30] (VIAL) 70‐30/ML ST
INSULIN DEGLUDEC [TRESIBA FLEXTOUCH U‐100] (INSULN PEN) 100/ML (3) PA
INSULIN DEGLUDEC [TRESIBA FLEXTOUCH U‐200] (INSULN PEN) 200/ML (3) PA
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Therapeutic Indication / Drug Name CommentINSULIN DETEMIR [LEVEMIR FLEXTOUCH] (INSULN PEN) 100/ML (3) STINSULIN DETEMIR [LEVEMIR] (VIAL) 100/ML STINSULIN GLARGINE [LANTUS] (VIAL) 100/ML STINSULIN GLARGINE [TOUJEO MAX SOLOSTAR] (INSULN PEN) 300/ML (3) PAINSULIN GLARGINE [TOUJEO SOLOSTAR] (INSULN PEN) 300/ML PAINSULIN GLULISINE [APIDRA] (VIAL) 100/ML DL: 63 DAYS, STINSULIN LISPRO [HUMALOG JUNIOR KWIKPEN] (INS PEN HF) 100/ML PAINSULIN LISPRO [HUMALOG KWIKPEN U‐200] (INSULN PEN) 200/ML (3) PAINSULIN NPH HUM/REG INSULIN HM [HUMULIN 70/30 KWIKPEN] (INSULN PEN) 70‐30/ML
ST
INSULIN NPH HUM/REG INSULIN HM [HUMULIN 70‐30] (VIAL) 70‐30/ML STINSULIN NPH HUMAN ISOPHANE [HUMULIN N] (VIAL) 100/ML STINSULIN REGULAR, HUMAN [HUMULIN R] (VIAL) 100/ML STINSULIN DEGLUDEC [TRESIBA] (VIAL) 100/ML PAINSULIN LISPRO PROTAMIN/LISPRO [HUMALOG MIX 50‐50 KWIKPEN] (INSULN PEN) 50‐50/MLINSULIN NPH HUMAN ISOPHANE [HUMULIN N KWIKPEN] (INSULN PEN) 100/ML (3)
EAR DISORDERSEAR PREPARATIONS, MISC. ANTI-INFECTIVES
TIER 1ACETIC ACID (SOLUTION) 2 %, HYDROCORTISONE/ACETIC ACID (DROPS) 1 %‐2 %
EAR PREPARATIONS,ANTIBIOTICSTIER 1
CIPROFLOXACIN (DROPERETTE) 0.2 %NEOMYCIN/POLYMYXIN B/HYDROCORT (SOLUTION) 3.5‐10K‐1
TIER 3NEOMYC/COLIST/HYDROCORT/THONZN [COLY‐MYCIN S] (DROPS SUSP)
EAR PREPARATIONS,EAR WAX REMOVERSTIER 1
CARBAMIDE PEROXIDE (DROPS) 6.5 %OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS
TIER 2CIPROFLOXACIN HCL/DEXAMETH [CIPRODEX] (DROPS SUSP) 0.3 %‐0.1%
TIER 3CIPROFLOXACIN/HYDROCORTISONE [CIPRO HC] (DROPS SUSP) 0.2 %‐1 %
ELECTROLYTE REGULATIONELECTROLYTE DEPLETERS
TIER 1CALCIUM ACET (CAP) 667 MGCALCIUM ACET (TAB) 667 MGSEVELAMER CARBONATE (POWD PACK) 0.8 G, 2.4 G PASEVELAMER CARBONATE (TAB) 800 MG
TIER 3
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Therapeutic Indication / Drug Name CommentSEVELAMER HCL (TAB) 400 MG, 800 MG PA
POTASSIUM REPLACEMENTTIER 1
POTASSIUM &MAGNESIUM ASPARTATE (CAP) 250‐250 MGPOTASSIUM (TAB) 99 MGPOTASSIUM BICARBONATE/CIT AC (TAB EFF) 25 MEQPOTASSIUM CHLORIDE (CAP ER) 8 MEQ, 10 MEQPOTASSIUM CHLORIDE (TAB ER PRT) 10 MEQ, 20 MEQPOTASSIUM CHLORIDE (TAB ER) 10 MEQ, 8 MEQ, 20 MEQPOTASSIUM GLUC (TAB) 2.5 MEQ, 595(99)MG, 500(83)MG, 550(90)MG
TIER 3POTASSIUM CHLORIDE (LIQUID) 40MEQ/15ML, 20MEQ/15MLPOTASSIUM CHLORIDE (PACKET) 20 MEQ
SODIUM/SALINE PREPARATIONSTIER 1
0.9 % SOD CHLORIDE (SOLUTION) 0.9 %ENDOCRINE DISORDERS
ANTIDIURETIC AND VASOPRESSOR HORMONESTIER 1
DESMOPRESSIN ACET (TAB) 0.1 MG, 0.2 MG PATIER 2
DESMOPRESSIN ACET [STIMATE] (SPRAY/PUMP) 150/SPRAY PAANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.
TIER 1LEUPROLIDE ACET (KIT) 1 MG/0.2ML PA, FL: FILLS≤1 IN 365 DAYS, MS
LEUPROLIDE ACET (VIAL) 1 MG/0.2ML PA, FL: FILLS≤1 IN 365 DAYS, MS
TIER 2GOSERELIN ACET [ZOLADEX] (IMPLANT) 10.8 MG, 3.6 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
LEUPROLIDE ACET [ELIGARD] (SYRINGE) 7.5 MG, 22.5 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
LEUPROLIDE ACET [LUPRON DEPOT] (SYRINGEKIT) 22.5 MG FL: FILLS≤1 IN 365 DAYS, ST, MS
TRIPTORELIN PAM [TRELSTAR] (VIAL) 11.25 MG, 3.75 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
ANTITHYROID PREPARATIONSTIER 1
METHIMAZOLE (TAB) 10 MG, 5 MGPROPYLTHIOURACIL (TAB) 50 MG
BONE FORMATION AGENTS - SCLEROSTIN INHIBITOR, MONOTIER 3
ROMOSOZUMAB‐AQQG [EVENITY (2 SYRINGES)] (SYRINGE) 210MG/2.34 PA, MSROMOSOZUMAB‐AQQG [EVENITY] (SYRINGE) 105MG/1.17 PA, MS
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Therapeutic Indication / Drug Name CommentBONE RESORPTION INHIBITORS
TIER 1ALENDRONATE SOD (SOLUTION) 70 MG/75MLALENDRONATE SOD (TAB) 35 MG, 10 MG, 40 MG, 5 MG, 70 MGIBANDRONATE SOD (TAB) 150 MGRALOXIFENE (TAB) 60 MG
GROWTH HORMONESTIER 2
SOMATROPIN [GENOTROPIN] (CARTRIDGE) 12 MG/ML, 5 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS
SOMATROPIN [GENOTROPIN] (SYRINGE) MULTIPLE STRENGTHS PA, FL: FILLS≤1 IN 365 DAYS, MS
SOMATROPIN [OMNITROPE] (VIAL) 5.8 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSTIER 2
LEUPROLIDE ACET [LUPRON DEPOT] (SYRINGEKIT) 11.25 MG, 30 MG, 7.5 MG PA, FL: FILLS≤1 IN 365 DAYS, ST, MS
LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTSTIER 2
ELAGOLIX SOD [ORILISSA] (TAB) 150 MG, 200 MG PALHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY
TIER 2LEUPROLIDE ACET [LUPRON DEPOT‐PED] (KIT) 11.25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
LEUPROLIDE ACET [LUPRON DEPOT‐PED] (KIT) 7.5 MG, 15 MG FL: FILLS≤1 IN 365 DAYS, MSLEUPROLIDE ACET [LUPRON DEPOT‐PED] (SYRINGEKIT) 11.25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATORTIER 2
OSPEMIFENE [OSPHENA] (TAB) 60 MG PAPARATHYROID HORMONES
TIER 2PARATHYROID HORMONE [NATPARA] (CARTRIDGE) 25MCG/DOSE, 50MCG/DOSE, 75MCG/DOSE, 100 MCG
PA, FL: FILLS≤1 IN 365 DAYS, MS
PITUITARY SUPPRESSIVE AGENTSTIER 1
CABERGOLINE (TAB) 0.5 MG PATHYROID HORMONES
TIER 2LEVOTHYROXINE SOD [SYNTHROID] (TAB) MULTIPLE STRENGTHS
TIER 3LIOTHYRONINE SOD (TAB) 25 MCG, 5 MCG, 50 MCG ST
EYE DISORDERSARTIFICIAL TEARS
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Therapeutic Indication / Drug Name CommentTIER 1
DEXTRAN 70/HYPROMELLOSE (DROPERETTE) DEXTRAN 70/HYPROMELLOSE (DROPS) 0.1%‐0.3%, GLYCERIN/PROPYLENE GLYCOL (DROPS) 0.3%‐1%POLYVINYL ALCOHOL (DROPS) 1.4 %POLYVINYL ALCOHOL/POVIDONE (DROPS) 0.5%‐0.6%
TIER 2DEXTRAN 70/HYPROMELLOSE/PF [GENTEAL TEARS] (DROPERETTE) 0.1%‐0.3%
CARBONIC ANHYDRASE INHIBITORSTIER 1
ACETAZOLAMIDE (CAP ER) 500 MGACETAZOLAMIDE (TAB) 125 MG, 250 MGMETHAZOLAMIDE (TAB) 50 MG, 25 MG
EYE ANTIBIOTIC-CORTICOID COMBINATIONSTIER 1
NEOMYCIN/BACIT/P‐MYX/HYDROCORT (OINT. ) 3.5‐10K‐1NEOMYCIN/POLYMYXIN B/DEXAMETHA (DROPS SUSP) 0.1 %NEOMYCIN/POLYMYXIN B/DEXAMETHA (OINT. ) 3.5‐10K‐.1NEOMYCIN/POLYMYXIN B/HYDROCORT (DROPS SUSP) 3.5‐10K‐10TOBRAMYCIN/DEXAMETHASONE (DROPS SUSP) 0.3 %‐0.1%
TIER 2TOBRAMYCIN/DEXAMETHASONE [TOBRADEX] (OINT. ) 0.3 %‐0.1%
EYE ANTIINFLAMMATORY AGENTSTIER 1
DEXAMETHASONE SOD PHOSPHATE (DROPS) 0.1 %DICLOFENAC SOD (DROPS) 0.1 %FLUOROMETHOLONE (DROPS SUSP) 0.1 %KETOROLAC TROMETHAMINE (DROPS) 0.4 %, 0.5 %PREDNISOLONE ACET (DROPS SUSP) 1 %
TIER 2DEXAMETHASONE [MAXIDEX] (DROPS SUSP) 0.1 %FLUOROMETHOLONE [FML FORTE] (DROPS SUSP) 0.25 %FLUOROMETHOLONE [FML S.O.P.] (OINT. ) 0.1 %PREDNISOLONE ACET [PRED MILD] (DROPS SUSP) 0.12 %
EYE ANTIVIRALSTIER 1
TRIFLURIDINE (DROPS) 1 %EYE PREPARATIONS, MISCELLANEOUS (OTC)
TIER 1LANOLIN/MINERAL OIL/PETROLATUM (OINT. ) MINERAL OIL/PETROLATUM,WHITE (OINT. ) 15 %‐83 %
TIER 2MINERAL OIL/PETROLATUM,WHITE [REFRESH LACRI‐LUBE] (OINT. ) 42.5‐56.8%
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Therapeutic Indication / Drug Name CommentMINERAL OIL/PETROLATUM,WHITE [REFRESH P.M.] (OINT. ) 42.5‐57.3%
EYE SULFONAMIDESTIER 1
SULFACETAMIDE SOD (DROPS) 10 %SULFACETAMIDE SOD (OINT. ) 10 %SULFACETAMIDE/PREDNISOLONE SP (DROPS) 10 %‐0.23%
TIER 2SULFACETAMIDE/PREDNISOLONE [BLEPHAMIDE S.O.P.] (OINT) 10 %‐0.2 %
SULFACETAMIDE/PREDNISOLONE [BLEPHAMIDE] (DROPS SUSP) 10 %‐0.2 %
MIOTICS/OTHER INTRAOC. PRESSURE REDUCERSTIER 1
APRACLONIDINE (DROPS) 0.5 %BETAXOLOL (DROPS) 0.5 %BIMATOPROST (DROPS) 0.03 %BRIMONIDINE TARTRATE (DROPS) 0.15 %, 0.2 %CARTEOLOL (DROPS) 1 %DORZOLAMIDE (DROPS) 2 %LATANOPROST (DROPS) 0.005 %LEVOBUNOLOL (DROPS) 0.5 %METIPRANOLOL (DROPS) 0.3 %PILOCARPINE (DROPS) 1 %, 2 %, 4 %TIMOLOL (DROPS) 0.25 %, 0.5 %TIMOLOL (SOL‐GEL) 0.25 %, 0.5 %
TIER 2APRACLONIDINE [IOPIDINE] (DROPERETTE) 1 %DORZOLAMIDE HCL/TIMOLOL MALEAT [COSOPT] (DROPS) 22.3‐6.8/1ECHOTHIOPHATE IODIDE [PHOSPHOLINE IODIDE] (DROPS) 0.125 %TIMOLOL/PF [TIMOPTIC OCUDOSE] (DROPERETTE) 0.25 %, 0.5 %TRAVOPROST [TRAVATAN Z] (DROPS) 0.004 %
TIER 3BETAXOLOL [BETOPTIC S] (DROPS SUSP) 0.25 %BRINZOLAMIDE [AZOPT] (DROPS SUSP) 1 %
MYDRIATICSTIER 1
ATROPINE SULF (DROPS) 1 %ATROPINE SULF (OINT. ) 1 %CYCLOPENTOLATE (DROPS) 0.5 %, 1 %, 2 %HOMATROPINE HBR (DROPS) 5 %TROPICAMIDE (DROPS) 0.5 %, 1 %
TIER 2CYCLOPENTOLATE/PHENYLEPHRINE [CYCLOMYDRIL] (DROPS) 0.2 %‐1 %HYDROXYAMPHETAMINE/TROPICAMIDE [PAREMYD] (DROPS) 1 %‐0.25 %
OPHTHALMIC ANTIBIOTICS
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Therapeutic Indication / Drug Name CommentTIER 1
BACITRACIN/POLYMYXIN B SULF (OINT. ) 500‐10K/GCIPROFLOXACIN (DROPS) 0.3 %ERYTHROMYCIN BASE (OINT. ) 5 MG/GRAMLEVOFLOXACIN (DROPS) 0.5 %MOXIFLOXACIN (DROPS) 0.5 %NEOMYCIN SULF/BACITRACIN/POLY (OINT. ) 3.5MG‐400NEOMYCIN/POLYMYXN B/GRAMICIDIN (DROPS) 1.75MG‐10KOFLOXACIN (DROPS) 0.3 %POLYMYXIN B SULF/TRIMETHOPRIM (DROPS) 10000‐1/MLTOBRAMYCIN (DROPS) 0.3 %
TIER 2MOXIFLOXACIN [MOXEZA] (DROPS VISC) 0.5 %TOBRAMYCIN [TOBREX] (OINT. ) 0.3 %
TIER 3CIPROFLOXACIN [CILOXAN] (OINT. ) 0.3 %GENTAMICIN SULF (DROPS) 0.3 %
OPHTHALMIC MAST CELL STABILIZERSTIER 1
CROMOLYN SOD (DROPS) 4 %TIER 3
NEDOCROMIL SOD [ALOCRIL] (DROPS) 2 %OPHTHALMIC PREPARATIONS, MISCELLANEOUS
TIER 1SOD CHLORIDE (DROPS) 2 %, 5 %, 0.65 %SOD CHLORIDE (OINT. ) 5 %
GOUT AND RELATED DISEASESCOLCHICINE
TIER 1COLCHICINE (TAB) 0.6 MG
HYPERURICEMIA TX - PURINE INHIBITORSTIER 1
ALLOPURINOL (TAB) 100 MG, 300 MGURICOSURIC AGENTS
TIER 1PROBENECID (TAB) 500 MGPROBENECID/COLCHICINE (TAB) 500‐0.5 MG
HEMATOLOGICAL DISORDERSANTICOAGULANTS,COUMARIN TYPE
TIER 1WARFARIN SOD (TAB) MULTIPLE STRENGTHS
ANTIFIBRINOLYTIC AGENTSTIER 1
TRANEXAMIC ACID (TAB) 650 MGDIRECT FACTOR XA INHIBITORS
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Therapeutic Indication / Drug Name CommentTIER 2
APIXABAN [ELIQUIS] (TAB) 2.5 MG QL: 2 IN 1 DAYSAPIXABAN [ELIQUIS] (TAB) 5 MG QL: 74 IN 23 DAYSRIVAROXABAN [XARELTO] (TAB DS PK) 15 MG‐20MG FL: FILLS≤1 IN 180 DAYS
TIER 3RIVAROXABAN [XARELTO] (TAB) 10 MG, 15 MG, 20 MG
HEPARIN AND RELATED PREPARATIONSTIER 1
ENOXAPARIN SOD (SYRINGE) MULTIPLE STRENGTHSENOXAPARIN SOD (VIAL) 300MG/3MLHEPARIN SOD,PORCINE (SYRINGE) MULTIPLE STRENGTHSHEPARIN SOD,PORCINE (VIAL) 100/ML, 10 UNIT/MLHEPARIN SOD,PORCINE/PF (SYRINGE) MULTIPLE STRENGTHSHEPARIN SOD,PORCINE/PF (VIAL) 100/ML (1), 10 UNIT/ML
TIER 3FONDAPARINUX SOD (SYRINGE) 2.5 MG/0.5, 5MG/0.4ML, 7.5MG/0.6, 10MG/0.8ML
PLATELET AGGREGATION INHIBITORSTIER 1
ASPIRIN (TAB CHEW) 81 MGASPIRIN (TAB DR) 81 MG, 325 MG, 500 MG, 650 MGASPIRIN/DIPYRIDAMOLE (CPMP 12HR) 25MG‐200MGCILOSTAZOL (TAB) 100 MG, 50 MGCLOPIDOGREL BISULF (TAB) 75 MGPRASUGREL (TAB) 5 MG, 10 MG
SICKLE CELL ANEMIA AGENTSTIER 2
HYDROXYUREA [DROXIA] (CAP) 200 MG, 300 MG, 400 MGVITAMIN K PREPARATIONS
TIER 1PHYTONADIONE (VIT K1) (TAB) 5 MG, 100 MCG
HORMONAL DEFICIENCYANDROGEN/ESTROGEN PREPS FOR FEMALE SEXUAL DYSFUNC
TIER 2PRASTERONE (DHEA) [INTRAROSA] (INSERT) 6.5 MG PA
ANDROGENIC AGENTSTIER 1
TESTOSTERONE CYPIONATE (VIAL) 100 MG/ML, 200 MG/ML AL: <45 YOTIER 3
TESTOSTERONE (GEL (GRAM)) 50 MG (1%) PATESTOSTERONE (GEL MD PMP) 12.5/1.25G, 10 MG (2%) PATESTOSTERONE (GEL PACKET) 25MG(1%), 50 MG (1%) PATESTOSTERONE (SOL MD PMP) 30MG/1.5ML PA
ESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMBTIER 2
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Therapeutic Indication / Drug Name CommentESTROGENS,CONJ/BAZEDOXIFENE [DUAVEE] (TAB) 0.45‐20 MG PA
ESTROGENIC AGENTSTIER 1
ESTRADIOL (PATCH TDSW) MULTIPLE STRENGTHSESTRADIOL (PATCH TDWK) MULTIPLE STRENGTHSESTRADIOL (TAB) 1 MG, 2 MG, 0.5 MG, 10 MCGESTRADIOL/NORETHINDRONE ACET (TAB) 1 MG‐0.5MG, 0.5‐0.1 MG
TIER 2ESTRADIOL/NORETHINDRONE ACET [COMBIPATCH] (PATCH TDSW) .05‐.14/24, .05‐.25/24
TIER 3ESTROGEN,CON/M‐PROGEST ACET [PREMPRO] (TAB) 0.45‐1.5MG, 0.3‐1.5MG, 0.625‐5 MG, 0.625‐2.5
ST
ESTROGENS, CONJUGATED [PREMARIN] (TAB) 0.625 MG, 0.3 MG, 0.9 MG, 1.25 MG, 0.45MG
ST
PROGESTATIONAL AGENTSTIER 1
MEDROXYPROGESTERONE ACET (TAB) 10 MG, 2.5 MG, 5 MGNORETHINDRONE ACET (TAB) 5 MGPROGESTERONE, MICRONIZED (CAP) 100 MG, 200 MG
TIER 2MEDROXYPROGESTERONE ACET [DEPO‐PROVERA] (VIAL) 400 MG/ML ST
IMMUNIZATIONMay be subject to clinical guidelines and age restrictions
MULTIPLE AGENTS Check with your physician or pharmacist.
IMMUNOSUPPRESSION/MODULATIONIMMUNOMODULATORS
TIER 1IMIQUIMOD (CREAM PACK) 5 % PA
IMMUNOSUPPRESSIVESTIER 1
AZATHIOPRINE (TAB) 50 MGCYCLOSPORINE (CAP) 100 MG, 25 MGCYCLOSPORINE, MODIFIED (CAP) 50 MG, 25 MG, 100 MGCYCLOSPORINE, MODIFIED (SOLUTION) 100 MG/MLMYCOPHENOLATE MOFETIL (CAP) 250 MGMYCOPHENOLATE MOFETIL (SUSP RECON) 200 MG/MLMYCOPHENOLATE MOFETIL (TAB) 500 MGTACROLIMUS (CAP) 1 MG, 5 MG, 0.5 MG
TIER 2CYCLOSPORINE [SANDIMMUNE] (SOLUTION) 100 MG/ML
INFECTIOUS DISEASE2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL
TIER 1
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Therapeutic Indication / Drug Name CommentTINIDAZOLE (TAB) 250 MG, 500 MG QL: 12 IN 60 DAYS
ABSORBABLE SULFONAMIDESTIER 1
SULFAMETHOXAZOLE/TRIMETHOPRIM (ORAL SUSP) 200‐40MG/5SULFAMETHOXAZOLE/TRIMETHOPRIM (TAB) 400MG‐80MG, 800‐160 MG
AMINOGLYCOSIDESTIER 1
NEOMYCIN SULF (TAB) 500 MG QL: 6 IN 1 DAYS, DL: 1 DAYS, FL: FILLS≤1 IN 30 DAYS
TOBRAMYCIN IN 0.225% SOD CHLOR (AMPUL‐NEB) 300 MG/5ML PA, FL: FILLS≤1 IN 365 DAYS, MS
ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTSTIER 1
METRONIDAZOLE (TAB) 250 MG, 500 MGANTHELMINTICS
TIER 1IVERMECTIN (TAB) 3 MGPRAZIQUANTEL (TAB) 600 MG PAPYRANTEL PAM (ORAL SUSP) 50 MG/ML
TIER 3ALBENDAZOLE (TAB) 200 MG PA
ANTIFUNGAL AGENTSTIER 1
CLOTRIMAZOLE (TROCHE) 10 MGFLUCONAZOLE (SUSP RECON) 40 MG/ML, 10 MG/ML DL: 21 IN 180 DAYSFLUCONAZOLE (TAB) 100 MG, 200 MG, 50 MG, 150 MG QL: 21 IN 180 DAYSITRACONAZOLE (SOLUTION) 10 MG/ML PAKETOCONAZOLE (TAB) 200 MG STTERBINAFINE (TAB) 250 MG QL: 1 PER DAY, FL: 84 DAYS PER
YEARTIER 3
ITRACONAZOLE (CAP) 100 MG PAVORICONAZOLE (SUSP RECON) 200 MG/5ML PAVORICONAZOLE (TAB) 50 MG, 200 MG PA
ANTIFUNGAL ANTIBIOTICSTIER 1
NYSTATIN (ORAL SUSP) 100000/MLNYSTATIN (TAB) 500K UNIT
TIER 3GRISEOFULVIN ULTRAMICROSIZE (TAB) 125 MG, 250 MG PAGRISEOFULVIN, MICROSIZE (ORAL SUSP) 125 MG/5ML PAGRISEOFULVIN, MICROSIZE (TAB) 500 MG PA
ANTILEPROTICSTIER 1
DAPSONE (TAB) 100 MG, 25 MG
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Therapeutic Indication / Drug Name CommentANTIMALARIAL DRUGS
TIER 1HYDROXYCHLOROQUINE SULF (TAB) 200 MG
ANTI-MYCOBACTERIUM AGENTSTIER 1
ETHAMBUTOL (TAB) 100 MG, 400 MGISONIAZID (SOLUTION) 50 MG/5 MLISONIAZID (TAB) 100 MG, 300 MG
ANTIRETROVIRAL-NUCLEOSIDE,NUCLEOTIDE,PROTEASE INH.TIER 2
DARUNAVIR/COB/EMTRI/TENOF ALAF [SYMTUZA] (TAB) 800‐150 MG PAANTITUBERCULAR ANTIBIOTICS
TIER 1RIFAMPIN (CAP) 150 MG, 300 MG
ANTIVIRALS, GENERALTIER 1
ACYCLOVIR (CAP) 200 MGACYCLOVIR (ORAL SUSP) 200 MG/5ML QL: 30 IN 180 DAYS ≤ 5, DL: 30 IN
180 DAYSACYCLOVIR (TAB) 800 MG, 400 MGOSELTAMIVIR PHOSPHATE (CAP) 75 MG, 30 MG, 45 MGOSELTAMIVIR PHOSPHATE (SUSP RECON) 6 MG/ML QL: 3 IN 180 DAYSRIBAVIRIN (VIAL‐NEB) 6 G PA
TIER 2ZANAMIVIR [RELENZA] 5 MG
TIER 3BALOXAVIR MARBOXIL [XOFLUZA] (TAB) 20 MG, 40 MG PAVALACYCLOVIR (TAB) 1000 MG QL: 21 IN 60 DAYS|3 IN 1 DAYS
VALACYCLOVIR (TAB) 500 MG QL: 1 IN 1 DAYSCEPHALOSPORINS - 1ST GENERATION
TIER 1CEFADROXIL (CAP) 500 MGCEFADROXIL (SUSP RECON) 250 MG/5ML, 500 MG/5MLCEFADROXIL (TAB) 1 GCEPHALEXIN (CAP) 250 MG, 500 MGCEPHALEXIN (SUSP RECON) 125 MG/5ML, 250 MG/5MLCEPHALEXIN (TAB) 500 MG, 250 MG
CEPHALOSPORINS - 2ND GENERATIONTIER 1
CEFACLOR (CAP) 250 MG, 500 MGCEFACLOR (SUSP RECON) 125 MG/5ML, 250 MG/5ML, 375 MG/5MLCEFACLOR (TAB ER 12H) 500 MGCEFPROZIL (SUSP RECON) 125 MG/5ML, 250 MG/5MLCEFPROZIL (TAB) 250 MG, 500 MG
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Therapeutic Indication / Drug Name CommentCEFUROXIME AXETIL (TAB) 250 MG, 500 MG
CEPHALOSPORINS - 3RD GENERATIONTIER 1
CEFDINIR (CAP) 300 MGCEFDINIR (SUSP RECON) 250 MG/5ML, 125 MG/5MLCEFIXIME (SUSP RECON) 100 MG/5MLCEFPODOXIME PROXETIL (SUSP RECON) 50 MG/5 ML, 100 MG/5MLCEFPODOXIME PROXETIL (TAB) 100 MG, 200 MG
CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.TIER 1
TRIMETHOPRIM (TAB) 100 MGTIER 2
TRIMETHOPRIM [TRIMPEX] (SOLUTION) 50 MG/5 MLHEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBO
TIER 2SOFOSBUVIR/VELPATAS/VOXILAPREV [VOSEVI] (TAB) 400‐100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.TIER 1
SOFOSBUVIR/VELPATASVIR (TAB) 400‐100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
HEPATITIS B TREATMENT AGENTSTIER 1
ADEFOVIR DIPIVOXIL (TAB) 10 MG FL: FILLS≤1 IN 365 DAYS, MSENTECAVIR (TAB) 0.5 MG, 1 MG FL: FILLS≤1 IN 365 DAYS, MS
TIER 2ENTECAVIR [BARACLUDE] (SOLUTION) 0.05 MG/ML FL: FILLS≤1 IN 365 DAYS, MSLAMIVUDINE [EPIVIR HBV] (SOLUTION) 25 MG/5 ML AL: < 12 YEARS
HEPATITIS C TREATMENT AGENTSTIER 1
RIBAVIRIN (CAP) 200 MG PARIBAVIRIN (TAB) 200 MG, 600 MG PA
TIER 2PEGINTERFERON ALFA‐2A [PEGASYS PROCLICK] (PEN INJCTR) 180MCG/0.5 PA, FL: FILLS≤1 IN 365 DAYS, MS
PEGINTERFERON ALFA‐2A [PEGASYS] (SYRINGE) 180MCG/0.5 PA, FL: FILLS≤1 IN 365 DAYS, MS
PEGINTERFERON ALFA‐2A [PEGASYS] (VIAL) 180MCG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS
PEGINTERFERON ALFA‐2B [PEGINTRON] (KIT) 50 MCG/0.5 PA, FL: FILLS≤1 IN 365 DAYS, MS
HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBTIER 2
ELBASVIR/GRAZOPREVIR [ZEPATIER] (TAB) 50MG‐100MG PA, FL: FILLS≤1 IN 365 DAYS, MS
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Therapeutic Indication / Drug Name CommentGLECAPREVIR/PIBRENTASVIR [MAVYRET] (TAB) 100MG‐40MG PA, FL: FILLS≤1 IN 365 DAYS, MS
LINCOSAMIDESTIER 1
CLINDAMYCIN (CAP) 150 MG, 75 MG, 300 MGCLINDAMYCIN PALMITATE (SOLN RECON) 75 MG/5 ML
MACROLIDESTIER 1
AZITHROMYCIN (PACKET) 1 GAZITHROMYCIN (SUSP RECON) 100 MG/5ML, 200 MG/5MLAZITHROMYCIN (TAB) 250 MG, 600 MG, 500 MGCLARITHROMYCIN (SUSP RECON) 125 MG/5ML, 250 MG/5ML PACLARITHROMYCIN (TAB ER 24H) 500 MG DL: 14 IN 180 DAYSCLARITHROMYCIN (TAB) 250 MG PACLARITHROMYCIN (TAB) 500 MG DL: 14 IN 180 DAYS
TIER 3ERYTHROMYCIN BASE (CAP DR) 250 MGERYTHROMYCIN BASE (TAB DR) 250 MG, 500 MGERYTHROMYCIN BASE (TAB) 250 MG, 500 MGERYTHROMYCIN BASE [ERY‐TAB] (TAB DR) 333 MGERYTHROMYCIN ETHYLSUCC (SUSP RECON) 200 MG/5ML, 400 MG/5ML FL: FILLS=1 IN 23 DAYSERYTHROMYCIN ETHYLSUCC (TAB) 400 MGERYTHROMYCIN STEARATE (TAB) 250 MG
NITROFURAN DERIVATIVESTIER 1
NITROFURANTOIN MACROCRYSTAL (CAP) 100 MG, 25 MG, 50 MGNITROFURANTOIN MONOHYD/M‐CRYST (CAP) 100 MG
TIER 3NITROFURANTOIN (ORAL SUSP) 25 MG/5 ML
PENICILLINSTIER 1
AMOXICILLIN (CAP) 250 MG, 500 MGAMOXICILLIN (SUSP RECON) MULTIPLE STRENGTHSAMOXICILLIN (TAB CHEW) 125 MG, 250 MGAMOXICILLIN (TAB) 875 MG, 500 MGAMOXICILLIN/POTASSIUM CLAV (SUSP RECON) MULTIPLE STRENGTHSAMOXICILLIN/POTASSIUM CLAV (TAB CHEW) 400‐57MG, 200‐28.5MGAMOXICILLIN/POTASSIUM CLAV (TAB ER 12H) 1000‐62.5AMOXICILLIN/POTASSIUM CLAV (TAB) 250‐125 MG, 500‐125 MG, 875‐125 MG
AMPICILLIN TRIHYDRATE (CAP) 250 MG, 500 MGDICLOXACILLIN SOD (CAP) 250 MG, 500 MGPENICILLIN V POT (SOLN RECON) 125 MG/5ML, 250 MG/5MLPENICILLIN V POT (TAB) 250 MG, 500 MG
TIER 2
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Therapeutic Indication / Drug Name CommentAMOXICILLIN/POTASSIUM CLAV [AUGMENTIN] (SUSP RECON) 125‐31.25/
PENICILLIN G BENZATHINE [BICILLIN L‐A] (SYRINGE) 600000/ML, 1.2MM/2 ML, 2.4MM/4ML
QL: 4 IN 28 DAYS
QUINOLONESTIER 1
CIPROFLOXACIN (TAB) 250 MG, 500 MG, 750 MG, 100 MGLEVOFLOXACIN (TAB) 250 MG, 500 MG, 750 MG
TIER 2CIPROFLOXACIN [CIPRO] (SUS MC REC) 250 MG/5ML, 500 MG/5ML
TIER 3OFLOXACIN (TAB) 300 MG, 400 MG
RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICSTIER 2
RIFAXIMIN [XIFAXAN] (TAB) 550 MG, 200 MG PATETRACYCLINES
TIER 1DOXYCYCLINE HYCLATE (CAP) 100 MG, 50 MG QL: 60 IN 30 DAYSDOXYCYCLINE MONOHYDRATE (CAP) 100 MG, 50 MG QL: 60 IN 30 DAYSDOXYCYCLINE MONOHYDRATE (SUSP RECON) 25 MG/5 MLDOXYCYCLINE MONOHYDRATE (TAB) 100 MG, 50 MG
TIER 2DOXYCYCLINE CALC [VIBRAMYCIN] (SYRUP) 50 MG/5 ML
TIER 3TETRACYCLINE (CAP) 250 MG, 500 MG QL: 4 IN 1 DAYS
VANCOMYCIN AND DERIVATIVESTIER 1
VANCOMYCIN (CAP) 125 MG QL: 4 IN 1 DAYS|40 IN 23 DAYS
VANCOMYCIN (CAP) 250 MG PAVANCOMYCIN (SOLN RECON) 50 MG/ML PA
TIER 2VANCOMYCIN [FIRVANQ] (SOLN RECON) 25 MG/ML PA
INFLAMMATORY DISEASEANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR
TIER 2INFLIXIMAB‐DYYB [INFLECTRA] (VIAL) 100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
TIER 3ADALIMUMAB [HUMIRA PEN] (PEN IJ KIT) 40MG/0.8ML PA, FL: FILLS≤1 IN 365 DAYS, MS
ADALIMUMAB [HUMIRA] (SYRINGEKIT) 40MG/0.8ML, 10MG/0.2ML, 20MG/0.4ML
PA, FL: FILLS≤1 IN 365 DAYS, MS
ETANERCEPT [ENBREL SURECLICK] (PEN INJCTR) 50MG/ML(1) PA, FL: FILLS≤1 IN 365 DAYS, MS
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Therapeutic Indication / Drug Name CommentETANERCEPT [ENBREL] (SYRINGE) 50MG/ML(1), 25MG/0.5ML PA, FL: FILLS≤1 IN 365 DAYS, MS
ETANERCEPT [ENBREL] (VIAL) 25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
INFLIXIMAB [REMICADE] (VIAL) 100 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITORTIER 1
LEFLUNOMIDE (TAB) 10 MG, 20 MGANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.
TIER 2APREMILAST [OTEZLA] (TAB DS PK) 10‐20‐30MG PA, FL: FILLS≤1 IN 365 DAYS, MS
APREMILAST [OTEZLA] (TAB) 30 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
GLUCOCORTICOIDSTIER 1
BUDESONIDE (CAPDR ‐ ER) 3 MG PADEXAMETHASONE (ELIXIR) 0.5 MG/5MLDEXAMETHASONE (SOLUTION) 0.5 MG/5MLDEXAMETHASONE (TAB DS PK) 1.5MG (51)DEXAMETHASONE (TAB) MULTIPLE STRENGTHSHYDROCORTISONE (TAB) 10 MG, 20 MG, 5 MGMETHYLPREDNISOLONE (TAB DS PK) 4 MGMETHYLPREDNISOLONE (TAB) 16 MG, 32 MG, 4 MG, 8 MGPREDNISOLONE (SOLUTION) 15 MG/5 MLPREDNISOLONE SOD PHOSPHATE (SOLUTION) 15 MG/5 ML, 5 MG/5 MLPREDNISONE (SOLUTION) 5 MG/5 MLPREDNISONE (TAB DS PK) 5 MG, 10 MGPREDNISONE (TAB) 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG, 50 MG
TIER 2DEXAMETHASONE [DEXAMETHASONE INTENSOL] (DROPS) 1 MG/MLHYDROCORTISONE SOD SUCC [SOLU‐CORTEF] (VIAL) 100 MGHYDROCORTISONE SOD SUCC/PF [SOLU‐CORTEF] (VIAL) 100 MG/2ML, 250 MG/2ML, 500 MG/4MLMETHYLPREDNISOLONE [MEDROL] (TAB) 2 MGPREDNISOLONE [MILLIPRED DP] (TAB DS PK) 5 MG (21), 5 MG (48)PREDNISOLONE [MILLIPRED] (TAB) 5 MGPREDNISONE [PREDNISONE INTENSOL] (ORAL CONC) 5 MG/ML
TIER 3METHYLPREDNISOLONE SOD SUCC/PF [SOLU‐MEDROL] (VIAL) 40 MG/ML, 125 MG/2ML
INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORSTIER 2
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Therapeutic Indication / Drug Name CommentTOCILIZUMAB [ACTEMRA] (SYRINGE) 162 MG/0.9 PA, FL: FILLS≤1 IN 365 DAYS, MS
JANUS KINASE (JAK) INHIBITORSTIER 2
TOFACITINIB CIT [XELJANZ XR] (TAB ER 24H) 11 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
TOFACITINIB CIT [XELJANZ] (TAB) 5 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
MINERALOCORTICOIDSTIER 1
FLUDROCORTISONE ACET (TAB) 0.1 MGNSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPE
TIER 1CELECOXIB (CAP) 100 MG, 200 MG QL: 30 IN 30 DAYS
NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPETIER 1
DICLOFENAC SOD (TAB DR) 25 MG, 50 MG, 75 MGDICLOFENAC SOD (TAB ER 24H) 100 MGIBUPROFEN (CAP) 200 MGIBUPROFEN (DROPS SUSP) 50 MG/1.25IBUPROFEN (ORAL SUSP) 100 MG/5MLIBUPROFEN (TAB CHEW) 100 MGIBUPROFEN (TAB) 400 MG, 600 MG, 200 MG, 800 MG, 100 MGKETOPROFEN (CAP) 50 MG, 75 MG, 25 MGMELOXICAM (TAB) 7.5 MG, 15 MGNABUMETONE (TAB) 500 MG, 750 MGNAPROXEN (ORAL SUSP) 125 MG/5MLNAPROXEN (TAB DR) 375 MG, 500 MGNAPROXEN (TAB) 250 MG, 375 MG, 500 MGNAPROXEN SOD (TBMP 24HR) 500 MG, 375 MGPIROXICAM (CAP) 10 MG, 20 MGSULINDAC (TAB) 150 MG, 200 MG
TIER 2INDOMETHACIN [INDOCIN] (SUPP.RECT) 50 MG
TIER 3ETODOLAC (CAP) 200 MG, 300 MGETODOLAC (TAB ER 24H) 600 MG, 400 MG, 500 MG PAETODOLAC (TAB) 400 MG, 500 MG PAFLURBIPROFEN (TAB) 50 MG, 100 MGINDOMETHACIN (CAP ER) 75 MGINDOMETHACIN (CAP) 25 MG, 50 MGINDOMETHACIN [INDOCIN] (ORAL SUSP) 25 MG/5 MLNAPROXEN SOD (TAB) 275 MG, 550 MG, 220 MG
LOCAL ANESTHESIALOCAL ANESTHETICS
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Therapeutic Indication / Drug Name CommentTIER 1
LIDOCAINE (JELLY(ML)) 2 % QL: 30 IN 30 DAYSLIDOCAINE (SOLUTION) 2 %, 40 MG/ML DL: 10 IN 365 DAYS
LOWER GASTROINTESTINAL DISORDERSAMMONIA INHIBITORS
TIER 1LACTULOSE (SOLUTION) 10 G/15 ML QL: 2838 IN 30 DAYS, DL: 90 IN
360 DAYSANTIDIARRHEALS
TIER 1BISMUTH SUBSALICYLATE (ORAL SUSP) 262MG/15ML, 525MG/15MLBISMUTH SUBSALICYLATE (TAB CHEW) 262 MGBISMUTH SUBSALICYLATE (TAB) 262 MGDIPHENOXYLATE HCL/ATROPINE (LIQUID) 2.5‐.025/5DIPHENOXYLATE HCL/ATROPINE (TAB) 2.5‐.025MGLOPERAMIDE (CAP) 2 MG QL: 8 IN 1 DAYSLOPERAMIDE (TAB) 2 MG QL: 8 IN 1 DAYS
BILE SALTSTIER 1
URSODIOL (CAP) 300 MG QL: 2 IN 1 DAYSURSODIOL (TAB) 250 MG
CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TXTIER 1
MESALAMINE (ENEMA) 4 G/60 ML QL: 1800 IN 23 DAYSTIER 3
MESALAMINE (SUPP.RECT) 1000 MG PADRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT
TIER 1BALSALAZIDE DISOD (CAP) 750 MGSULFASALAZINE (TAB DR) 500 MGSULFASALAZINE (TAB) 500 MG
TIER 3MESALAMINE (TAB DR) 800 MG, 1.2 G PAMESALAMINE [APRISO] (CAP ER 24H) 0.375G PA
LAXATIVES AND CATHARTICSTIER 1
BISAC/NACL/NAHCO3/KCL/PEG 3350 (KIT) 5 MG‐210 GBISACODYL (TAB DR) 5 MGBISACODYL (TAB) 5 MGDOCUSATE SOD (CAP) 100 MG, 250 MG, 50 MGDOCUSATE SOD (LIQUID) 50 MG/5 MLDOCUSATE SOD (SYRUP) 60 MG/15ML, 50 MG/15MLDOCUSATE SOD (TAB) 100 MGMAGNESIUM HYDROXIDE (ORAL SUSP) 400 MG/5MLPOLYETHYLENE GLYCOL 3350 (POWD PACK) 17G
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Therapeutic Indication / Drug Name CommentPOLYETHYLENE GLYCOL 3350 (POWDER) 17G/DOSEPSYLLIUM HUSK (CAP) 0.52GSENNOSIDES (TAB) 8.6 MGSOD CHLORIDE/NAHCO3/KCL/PEG (SOLN RECON) 420G
TIER 2PEG3350/SOD SUL/NACL/KCL/ASB/C [MOVIPREP] (POWD PACK) 7.5‐2.691G
PEG3350/SOD SULF,BICARB,CL/KCL [GOLYTELY] (POWD PACK) 227.1‐21.5SOD, POT,MAG SULFS [SUPREP] (SOLN RECON) 17.5‐3.13G
TIER 3PEG3350/SOD SULF,BICARB,CL/KCL (SOLN RECON) 236‐22.74G, 240‐22.72G
LAXATIVES, LOCAL/RECTALTIER 1
DOCUSATE SOD (ENEMA) 283 MG, 283 MG/5MLGLYCERIN (SUPP.RECT) ADULT, PEDIATRIC
TIER 2BISACODYL (ENEMA) 10MG/30MLGLYCERIN [PEDIA‐LAX] (SOL/PF APP) 2.8G/2.7ML
RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)TIER 1
HYDROCORTISONE (ENEMA) 100MG/60MLTIER 2
HYDROCORTISONE ACET [CORTIFOAM] (FOAM/APPL) 10 %MISCELLANEOUS AGENTS
ANAPHYLAXIS THERAPY AGENTSTIER 1
EPINEPHRINE (AUTO INJCT) 0.15MG/0.3, 0.3MG/0.3, 0.15/0.15 QL: 4 IN 365 DAYSPARASYMPATHETIC AGENTS
TIER 1BETHANECHOL CHLORIDE (TAB) 10 MG, 25 MG, 5 MG, 50 MG
TIER 3CEVIMELINE (CAP) 30 MGPILOCARPINE (TAB) 5 MG
NEUROLOGICAL DISEASE - MISCELLANEOUSAGENTS TO TREAT MULTIPLE SCLEROSIS
TIER 1GLATIRAMER ACET (SYRINGE) 20 MG/ML PA, FL: FILLS≤1 IN 365 DAYS, MS
TIER 2DIMETHYL FUM [TECFIDERA] (CAP DR) 120‐240 MG, 120 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
FINGOLIMOD [GILENYA] (CAP) 0.5 MG, 0.25 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
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Therapeutic Indication / Drug Name CommentINTERFERON BETA‐1A [AVONEX PEN] (PEN IJ KIT) 30MCG/.5ML PA, FL: FILLS≤1 IN 365 DAYS, MS
INTERFERON BETA‐1A [AVONEX] (SYRINGEKIT) 30MCG/.5ML PA, FL: FILLS≤1 IN 365 DAYS, MS
INTERFERON BETA‐1A/ALBUMIN [AVONEX] (KIT) 30 MCG PA, FL: FILLS≤1 IN 365 DAYS, MS
INTERFERON BETA‐1B [EXTAVIA] (KIT) 0.3 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
INTERFERON BETA‐1B [EXTAVIA] (VIAL) 0.3 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
ONCOLOGYMay be subject to prior authorization and/or other utilization management restrictions
ALL ONCOLOGY AGENTS PA, MSORAL/PHARYNGEAL DISORDERS
DENTAL AIDS AND PREPARATIONSTIER 1
CHLORHEXIDINE GLUCONATE (MOUTHWASH) 0.12 %TRIAMCINOLONE ACET (PASTE ) 0.1 %
NOSE PREPARATIONS, MISCELLANEOUS (RX)TIER 1
IPRATROPIUM BROMIDE (SPRAY) 42 MCG, 21 MCG AL: ≥ 18 YEARSPERIODONTAL COLLAGENASE INHIBITORS
TIER 1DOXYCYCLINE HYCLATE (TAB) 20 MG, 100 MG
OTHER DRUGSANTIOXIDANT AGENTS
TIER 1ALPHA LIPOIC ACID (CAP) 600 MG QL: 1 IN 1 DAYS
APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.TIER 1
MEGESTROL ACET (ORAL SUSP) 400MG/10MLCONDOMS
TIER 1CONDOMS, FEMALE [FC2 FEMALE CONDOM] (EACH) QL: 12 PER FILL, DL: 100 DAYS
CONDOMS, LATEX, LUBRICATED [CONDOMS] (EACH) QL: 12 PER FILL, DL: 100 DAYS
CONDOMS, LATEX, NON‐LUBRICATED [TRUSTEX‐RIA] (EACH) QL: 12 PER FILL, DL: 100 DAYS
CONDOMS, NON‐LATEX, LUBRICATED [DUREX AVANTI BARE REAL FEEL] (EACH) QL: 12 PER FILL, DL: 100 DAYS
DIAGNOSTIC PREPARATIONS,MISC.TIER 2
GLUCAGON (VIAL) 1 MG QL: 6 PER YEARDIETARY SUPPLEMENT, MISCELLANEOUS
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Therapeutic Indication / Drug Name CommentTIER 1
ACETYLCYSTEINE (CAP) 600 MG PAOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA‐3 FISH OIL] (CAP) 300‐1000MG QL: 1 PER DAYOMEGA‐3S/DHA/EPA/FISH OIL [OMEGA‐3] (TAB CHEW) 71MG‐425MG QL: 1 PER DAY
GENERAL INHALATION AGENTSTIER 1
SOD CHLORIDE FOR INHALATION (VIAL‐NEB) 0.9 %, 10 %, 3 %INSECTICIDES
TIER 1PERMETHRIN (SPRAY) 0.5 %
METABOLIC DEFICIENCY AGENTSTIER 1
LEVOCARNITINE (WITH SUGAR) (SOLUTION) 100 MG/ML PATIER 2
LEVOCARNITINE [CARNITOR SF] (SOLUTION) 100 MG/ML PAPROTEIN REPLACEMENT
TIER 1LEVOCARNITINE (TAB) 500 MG, 330 MG PA
THICKENING AGENTS, ORALTIER 1
CORN STARCH [RESOURCE THICKENUP] (POWDER) MALTODEXTRIN/XANTHAN GUM [THICKEN UP CLEAR] (POWDER) STARCH [THICK NOW] (POWDER) STARCH [THICK‐IT] (POWD PACK)
PAIN MANAGEMENT - ANALGESICSANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB
TIER 1BUTALBITAL/ASPIRIN/CAFFEINE (CAP) 50‐325‐40 QL: 30 IN 23 DAYSBUTALBITAL/ASPIRIN/CAFFEINE (TAB) 50‐325‐40 QL: 30 IN 23 DAYS
ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMBTIER 1
BUTALB/ACETAMINOPHEN/CAFFEINE (CAP) 50‐325‐40 QL: 30 IN 23 DAYSBUTALB/ACETAMINOPHEN/CAFFEINE (TAB) 50‐325‐40 QL: 30 IN 23 DAYS
ANALGESIC/ANTIPYRETICS, SALICYLATESTIER 1
ASPIRIN (SUPP.RECT) 600 MG, 300 MGASPIRIN (TAB) 325 MG, 500 MGASPIRIN/ACETAMINOPHEN/CAFFEINE (TAB) 250‐250‐65ASPIRIN/CALCIUM CARBONATE/MAG (TAB) 325 MG
ANALGESIC/ANTIPYRETICS,NON-SALICYLATETIER 1
ACETAMINOPHEN (CAP) 325 MG, 500 MGACETAMINOPHEN (DROPS SUSP) 80MG/0.8MLACETAMINOPHEN (DROPS) 100 MG/MLACETAMINOPHEN (ELIXIR) 160 MG/5ML
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Therapeutic Indication / Drug Name CommentACETAMINOPHEN (LIQUID) 160 MG/5ML, 500MG/15MLACETAMINOPHEN (ORAL SUSP) 160 MG/5MLACETAMINOPHEN (SOLUTION) 160 MG/5ML, 325/10.15, 650MG/20.3ACETAMINOPHEN (SUPP.RECT) 120 MG, 325 MG, 650 MGACETAMINOPHEN (TAB CHEW) 160 MG, 80 MGACETAMINOPHEN (TAB ER) 650 MGACETAMINOPHEN (TAB) 500 MG, 325 MG
TIER 2ACETAMINOPHEN [FEVERALL] (SUPP.RECT) 80 MG
ANALGESICS,NARCOTICSAll narcotic agents are limited to ≤90 morphine milligram equivalents (MME) per day
TIER 1HYDROMORPHONE (TAB) 2 MG PA, QL: 11.2 IN 1 DAYS, DL: 7
DAYS, FL: FILLS≤1 IN 60 DAYSHYDROMORPHONE (TAB) 4 MG PA, QL: 5.6 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYSHYDROMORPHONE (TAB) 8 MG PA, QL: 2.8 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYSMORPHINE SULF (SOLUTION) 10 MG/5 ML PA, QL: 45 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYSMORPHINE SULF (SOLUTION) 100 MG/5ML PA, QL: 4 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYSMORPHINE SULF (SOLUTION) 20 MG/5 ML PAMORPHINE SULF (TAB ER) 30 MG, 15 MG PA, QL: 3 IN 1 DAYSMORPHINE SULF (TAB ER) 60 MG PA, QL: 1 IN 1 DAYSOXYCODONE (TAB) 5 MG QL: 12 IN 1 DAYS, DL: 7 DAYS, FL:
FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 10 MG QL: 6 IN 1 DAYS, DL: 7 DAYS, FL:
FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 15 MG PA, QL: 4 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 20 MG PA, QL: 3 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYSOXYCODONE (TAB) 30 MG PA, QL: 2 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYSTRAMADOL (TAB) 50 MG QL: 8 IN 1 DAYS, DL: 7 DAYS, FL:
FILLS≤1 IN 60 DAYSTIER 2
MORPHINE SULF [MORPHINE SULFATE] (TAB) 15 MG PA, QL: 6 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
MORPHINE SULF [MORPHINE SULFATE] (TAB) 30 MG PA, QL: 3 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
TIER 3FENTANYL (PATCH TD72) MULTIPLE STRENGTHS PA
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Therapeutic Indication / Drug Name CommentMETHADONE (ORAL CONC) 10 MG/ML PA, QL: 10 IN 1 DAYSMETHADONE (SOLUTION) 10 MG/5 ML PA, QL: 10 IN 1 DAYS, DL: 7 DAYS,
FL: FILLS≤1 IN 60 DAYS
METHADONE (SOLUTION) 5 MG/5 ML PA, QL: 20 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
METHADONE (TAB) 10 MG PA, QL: 2.8 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
METHADONE (TAB) 5 MG PA, QL: 10 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
MORPHINE SULF (CAP ER PEL) 50 MG, 20 MG, 60 MG PAMORPHINE SULF (CPMP 24HR) 120 MG, 90 MG, 60 MG, 30 MG PAMORPHINE SULF (SUPP.RECT) 10 MG, 20 MG, 5 MG, 30 MG PA, QL: 1 IN 1 DAYSMORPHINE SULF (TAB ER) 200 MG, 100 MG PA, QL: 60 IN 27 DAYS, FL: FILLS≤1
IN 180 DAYSANTIMIGRAINE PREPARATIONS
TIER 1NARATRIPTAN (TAB) 2.5 MG, 1 MG QL: 9 IN 23 DAYSRIZATRIPTAN BENZOATE (TAB RAPDIS) 5 MG, 10 MG QL: 9 IN 23 DAYSRIZATRIPTAN BENZOATE (TAB) 5 MG, 10 MG QL: 9 IN 23 DAYSSUMATRIPTAN SUCC (TAB) 50 MG, 100 MG, 25 MG QL: 9 IN 23 DAYSZOLMITRIPTAN (TAB RAPDIS) 5 MG, 2.5 MG QL: 9 IN 23 DAYSZOLMITRIPTAN (TAB) 2.5 MG, 5 MG QL: 9 IN 23 DAYS
TIER 2ERENUMAB‐AOOE [AIMOVIG AUTOINJECTOR] (AUTO INJCT) 70 MG/ML PA
TIER 3ERGOTAMINE TARTRATE/CAFFEINE (TAB) 1 MG‐100MG QL: 30 IN 23 DAYSERGOTAMINE TARTRATE/CAFFEINE [MIGERGOT] (SUPP.RECT) 2‐100MG QL: 30 IN 23 DAYSSUMATRIPTAN (SPRAY) 5 MG, 20 MG PA
NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMBTIER 1
BUTALBIT/ACETAMIN/CAFF/CODEINE (CAP) 50‐325‐30 QL: 6 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS
NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMBAll narcotic agents are limited to ≤90 morphine milligram equivalents (MME) per day
TIER 1ACETAMINOPHEN WITH CODEINE (SOLUTION) 120‐12MG/5 QL: 240 IN 1 DAYS, DL: 7 DAYS, FL:
FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS
ACETAMINOPHEN WITH CODEINE (TAB) 300MG‐15MG, 300MG‐30MG QL: 20 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS
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Therapeutic Indication / Drug Name CommentACETAMINOPHEN WITH CODEINE (TAB) 300MG‐60MG QL: 10 IN 1 DAYS, DL: 7 DAYS, FL:
FILLS≤1 IN 60 DAYS, AL: ≥ 12 YEARS
HYDROCODONE/ACETAMINOPHEN (SOLUTION) 7.5‐325/15 QL: 180 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
HYDROCODONE/ACETAMINOPHEN (TAB) 10MG‐300MG, 10MG‐325MG QL: 9 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
HYDROCODONE/ACETAMINOPHEN (TAB) MULTIPLE STRENGTHS QL: 12 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
OXYCODONE HCL/ACETAMINOPHEN (TAB) 10MG‐325MG QL: 6 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
OXYCODONE HCL/ACETAMINOPHEN (TAB) 5 MG‐325MG, 2.5‐325 MG QL: 12 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
OXYCODONE HCL/ACETAMINOPHEN (TAB) 7.5‐325 MG QL: 8 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
NARCOTIC AND SALICYLATE ANALGESIC COMBINATIONTIER 1
OXYCODONE HCL/ASPIRIN (TAB) 4.8355‐325 QL: 8 IN 1 DAYS, DL: 7 DAYS, FL: FILLS≤1 IN 60 DAYS
NARCOTIC WITHDRAWAL THERAPY AGENTSTIER 1
BUPRENORPHINE (TAB SUBL) 2 MG, 8 MG QL: 3 IN 1 DAYS, DL: 30 IN 180 DAYS
BUPRENORPHINE HCL/NALOXONE (FILM) 2 MG‐0.5MG, 8 MG‐2 MG QL: 3 IN 1 DAYS, DL: 30 IN 180 DAYS
BUPRENORPHINE HCL/NALOXONE (TAB SUBL) 2 MG‐0.5MG, 8 MG‐2 MG QL: 3 IN 1 DAYS, DL: 30 IN 180 DAYS
PARKINSONS DISEASEANTIPARKINSONISM DRUGS,ANTICHOLINERGIC
TIER 1BENZTROPINE MESYLATE (TAB) 0.5 MG, 1 MG, 2 MGTRIHEXYPHENIDYL (ELIXIR) 2 MG/5 MLTRIHEXYPHENIDYL (TAB) 2 MG, 5 MG
ANTIPARKINSONISM DRUGS,OTHERTIER 1
CARBIDOPA/LEVODOPA (TAB ER) 50MG‐200MG, 25MG‐100MGCARBIDOPA/LEVODOPA (TAB) 10MG‐100MG, 25MG‐100MG, 25MG‐250MG
ENTACAPONE (TAB) 200 MGPRAMIPEXOLE DI‐(TAB) MULTIPLE STRENGTHS PAROPINIROLE (TAB) MULTIPLE STRENGTHS PA
TIER 3AMANTADINE (CAP) 100 MG
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Therapeutic Indication / Drug Name CommentAMANTADINE (SOLUTION) 50 MG/5 MLAMANTADINE (TAB) 100 MGCARBIDOPA/LEVODOPA [RYTARY] (CAP ER) 23.75‐95MG, 36.25‐145, 48.75‐195, 61.25‐245
ST
SELEGILINE (CAP) 5 MGSELEGILINE (TAB) 5 MGTOLCAPONE (TAB) 100 MG
DECARBOXYLASE INHIBITORSTIER 1
CARBIDOPA (TAB) 25 MGSEIZURE DISORDER
ANTICONVULSANT - BENZODIAZEPINE TYPETIER 1
CLONAZEPAM (TAB RAPDIS) 0.125 MG, 0.25 MG, 0.5 MG, 1 MG, 2 MGCLONAZEPAM (TAB) 0.5 MG, 1 MG, 2 MGDIAZEPAM (KIT) 5‐7.5‐10MG, 12.5‐15‐20, 2.5 MG QL: 4 IN 365 DAYS
ANTICONVULSANTSTIER 1
CARBAMAZEPINE (CPMP 12HR) 200 MG, 100 MG, 300 MGCARBAMAZEPINE (ORAL SUSP) 100 MG/5MLCARBAMAZEPINE (TAB CHEW) 100 MGCARBAMAZEPINE (TAB ER 12H) 100 MG, 200 MG, 400 MGCARBAMAZEPINE (TAB) 200 MGETHOSUXIMIDE (CAP) 250 MGETHOSUXIMIDE (SOLUTION) 250 MG/5MLFELBAMATE (ORAL SUSP) 600 MG/5MLFELBAMATE (TAB) 400 MG, 600 MGGABAPENTIN (CAP) 100 MG, 300 MG QL: 12 IN 1 DAYSGABAPENTIN (CAP) 400 MG QL: 9 IN 1 DAYSGABAPENTIN (TAB) 600 MG QL: 6 IN 1 DAYSGABAPENTIN (TAB) 800 MG QL: 4.5 IN 1 DAYSLEVETIRACETAM (SOLUTION) 500 MG/5ML, 100 MG/MLLEVETIRACETAM (TAB ER 24H) 500 MG, 750 MGLEVETIRACETAM (TAB) 750 MG, 250 MG, 500 MG, 1000 MGOXCARBAZEPINE (ORAL SUSP) 300 MG/5MLOXCARBAZEPINE (TAB) 300 MG, 600 MG, 150 MGPHENYTOIN (ORAL SUSP) 100 MG/4MLPHENYTOIN (TAB CHEW) 50 MGPRIMIDONE (TAB) 250 MG, 50 MGTIAGABINE (TAB) 4 MG, 12 MG, 16 MG, 2 MG STTOPIRAMATE (CAP SPRINK) 15 MG, 25 MG QL: 4 IN 1 DAYSTOPIRAMATE (TAB) 50 MG, 100 MG, 200 MG, 25 MGZONISAMIDE (CAP) 25 MG, 50 MG, 100 MG
TIER 2BRIVARACETAM [BRIVIACT] (TAB) 10 MG, 25 MG, 50 MG, 75 MG, 100 MG ST
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Therapeutic Indication / Drug Name CommentLACOSAMIDE [VIMPAT] (SOLUTION) 10 MG/ML STLACOSAMIDE [VIMPAT] (TAB) 50 MG, 100 MG, 150 MG, 200 MG STMETHSUXIMIDE [CELONTIN] (CAP) 300 MG STPHENYTOIN [DILANTIN‐125] (ORAL SUSP) 125 MG/5MLPHENYTOIN SOD EXTENDED [DILANTIN] (CAP) 100 MG, 30 MGPHENYTOIN SOD EXTENDED [PHENYTEK] (CAP) 300 MG, 200 MG
TIER 3PREGABALIN (CAP) 200 MG, 300 MG, 225 MG PAPREGABALIN (CAP) 25 MG, 50 MG, 75 MG, 100 MG, 150 MG QL: 3 PER DAY
SKELETAL MUSCLE DISORDERAGENTS TO TX PERIODIC PARALYSIS - CARBON ANHYD INH
TIER 2DICHLORPHENAMIDE [KEVEYIS] (TAB) 50 MG PA, FL: FILLS≤1 IN 365 DAYS, MS
SKELETAL MUSCLE RELAXANTSTIER 1
BACLOFEN (TAB) 10 MG QL: 240 IN 30 DAYSBACLOFEN (TAB) 20 MG QL: 120 IN 30 DAYSCYCLOBENZAPRINE (TAB) 5 MG, 10 MGMETHOCARBAMOL (TAB) 500 MG, 750 MG
TIER 3TIZANIDINE (TAB) 2 MG, 4 MG QL: 3 IN 1 DAYS, ST
SMOKING CESSATIONSMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)
TIER 1NICOTINE (PATCH TD24) 7MG/24HR, 14MG/24HR, 21 MG/24HR QL: 180 YEAR|30 IN 23 DAYSNICOTINE POLACRILEX (GUM) 2 MG, 4 MG QL: 24 IN 1 DAYS|4400 YEARNICOTINE POLACRILEX (LOZENGE) 4 MG, 2 MG QL: 24 IN 1 DAYS|3600 YEARNICOTINE POLACRILEX (LOZNG MINI) 4 MG, 2 MG QL: 24 IN 1 DAYS|3600 YEAR
TIER 2NICOTINE [NICOTINE PATCH] (PATCH DYSQ) 21‐14‐7MG QL: 180 YEAR|30 IN 23 DAYS
TIER 3NICOTINE [NICOTROL NS] (SPRAY) 10 MG/ML PANICOTINE [NICOTROL] (CARTRIDGE) 10 MG PA
SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTTIER 2
VARENICLINE TARTRATE [CHANTIX] (TAB DS PK) 0.5 (11)‐1 QL: 56 IN 21 DAYS, DL: 180 IN 365 DAYS
VARENICLINE TARTRATE [CHANTIX] (TAB) 0.5 MG, 1 MG QL: 60 IN 30 DAYS, DL: 180 IN 365 DAYS
SMOKING DETERRENTS, OTHERTIER 1
BUPROPION (TAB ER 12H) 150 MGUPPER GASTROINTESTINAL DISORDERS
ANTACIDS
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Therapeutic Indication / Drug Name CommentTIER 1
ALUMINUM HYDROXIDE (ORAL SUSP) 320 MG/5ML, 600 MG/5MLCALCIUM CARBONATE (ORAL SUSP) 400 MG/5MLCALCIUM CARBONATE (TAB CHEW) MULTIPLE STRENGTHSMAG CARB/ALUMINUM HYDROX/ALGIN (ORAL SUSP) 131‐31.7/5, 358‐95/15
MAG HYDROX/ALUMINUM HYD/SIMETH (ORAL SUSP) 200‐200‐20, 400‐400‐40
MAG/ALUMINUM/SOD BICARB/ALGINC (TAB CHEW) 20 MG‐80MGMAGNESIUM CARB/ALUMINUM HYDROX (TAB CHEW) 105‐160MG
TIER 2MAG CARB/ALUMINUM HYDROX/ALGIN [GAVISCON] (ORAL SUSP) 237.5‐254
ANTICHOLINERGICS/ANTISPASMODICSTIER 1
DICYCLOMINE (CAP) 10 MGDICYCLOMINE (TAB) 20 MG
TIER 3DICYCLOMINE (SOLUTION) 10 MG/5 ML
ANTIFLATULENTSTIER 1
SIMETHICONE (CAP) 125 MG, 180 MG, 166MGSIMETHICONE (DROPS SUSP) 40MG/0.6MLSIMETHICONE (TAB CHEW) 80 MG, 125 MGSIMETHICONE (TAB) 125 MG
ANTI-ULCER PREPARATIONSTIER 1
MISOPROSTOL (TAB) 200 MCG, 100 MCGSUCRALFATE (TAB) 1 G
EMETICSTIER 1
IPECAC (SYRUP) HISTAMINE H2-RECEPTOR INHIBITORS
TIER 1FAMOTIDINE (ORAL SUSP) 40MG/5MLFAMOTIDINE (TAB) 20 MG, 40 MG, 10 MGFAMOTIDINE/CA CARB/MAG HYDROX (TAB CHEW) 10‐800‐165RANITIDINE (CAP) 150 MG, 300 MGRANITIDINE (SYRUP) 15 MG/MLRANITIDINE (TAB) 150 MG, 300 MG, 75 MG
TIER 3CIMETIDINE (SOLUTION) 300 MG/5MLCIMETIDINE (TAB) 200 MG, 300 MG, 400 MG, 800 MG
INTESTINAL MOTILITY STIMULANTSTIER 1
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentMETOCLOPRAMIDE (SOLUTION) 10 MG/10ML, 5 MG/5 ML DL: 90 IN 180 DAYSMETOCLOPRAMIDE (TAB) 10 MG QL: 6 IN 1 DAYS, DL: 90 IN 180
DAYSMETOCLOPRAMIDE (TAB) 5 MG QL: 12 IN 1 DAYS, DL: 90 IN 180
DAYSPANCREATIC ENZYMES
TIER 2LIPASE/PROTEASE/AMYLASE [CREON] (CAP DR) 6K‐19K‐30K, 12K‐38K‐60, 24‐76‐120KLIPASE/PROTEASE/AMYLASE [ZENPEP] (CAP DR) MULTIPLE STRENGTHS
PROTON-PUMP INHIBITORSTIER 1
LANSOPRAZOLE (CAP DR) 15 MG, 30 MGOMEPRAZOLE (CAP DR) 20 MG, 40 MG, 10 MGPANTOPRAZOLE SOD (TAB DR) 40 MG, 20 MG
TIER 3ESOMEPRAZOLE MAG (CAP DR) 20 MG, 40 MG QL: 1 IN 1 DAYS|60 IN 180 DAYS,
STLANSOPRAZOLE (TAB RAP DR) 15 MG, 30 MG STRABEPRAZOLE SOD (TAB DR) 20 MG QL: 30 IN 30 DAYS, ST
4OMEPRAZOLE (TAB RAP DR) 20 MG QL: 1 IN 1 DAYS, FL: 60 DAYS PER
YEARURINARY TRACT - FUNCTIONAL DISORDERS
BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTSTIER 1
FINASTERIDE (TAB) 5 MGTAMSULOSIN (CAP) 0.4 MG
TIER 3ALFUZOSIN (TAB ER 24H) 10 MG ST
OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEPTIER 2
MIRABEGRON [MYRBETRIQ] (TAB ER 24H) 25 MG, 50 MG PAURINARY PH MODIFIERS
TIER 1POTASSIUM CIT (TAB ER) 5 MEQ, 10 MEQ, 15 MEQPOTASSIUM CIT/CITRIC ACID (SOLUTION) 1100‐334/5
URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)TIER 1
PHENAZOPYRIDINE (TAB) 100 MG, 200 MG, 97.5 MGURINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.
4SOLIFENACIN SUCC (TAB) 5 MG, 10 MG QL: 1 PER DAY
URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTTIER 1
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LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentOXYBUTYNIN CHLORIDE (SYRUP) 5 MG/5 MLOXYBUTYNIN CHLORIDE (TAB ER 24) 5 MG, 10 MG, 15 MGOXYBUTYNIN CHLORIDE (TAB) 5 MG
TIER 3TOLTERODINE TARTRATE (CAP ER 24H) 4 MG, 2 MG QL: 1 IN 1 DAYS, STTOLTERODINE TARTRATE (TAB) 1 MG, 2 MG QL: 2 IN 1 DAYS, ST
VAGINAL DISORDERSVAGINAL ANTIBIOTICS
TIER 1CLINDAMYCIN PHOSPHATE (CREAM/APPL) 2 %
TIER 2METRONIDAZOLE [VANDAZOLE] (GEL W/APPL) 0.75 %
TIER 3CLINDAMYCIN PHOSPHATE [CLEOCIN] (SUPP.VAG) 100 MG
VAGINAL ANTIFUNGALSTIER 1
CLOTRIMAZOLE (CREAM/APPL) 1 %, 2 %MICONAZOLE NIT (CMB PF CRM) 200 MG‐2 %MICONAZOLE NIT (CREAM/APPL) 2 %, 4 %MICONAZOLE NIT (KIT) 200 MG‐2 %, 1200MG‐2%MICONAZOLE NIT (SUPP.VAG) 100 MG, 200 MGMICONAZOLE/CLEANSER 17 ON WIPE (KIT) 200 MG‐2 %
TIER 2MICONAZOLE NIT [MONISTAT 3] (CRM/PF APP) 4 %
TIER 3TERCONAZOLE (CREAM/APPL) 0.4 %, 0.8 % STTERCONAZOLE (SUPP.VAG) 80 MG ST
VAGINAL ESTROGEN PREPARATIONSTIER 2
ESTRADIOL [ESTRING] (VAG RING) 7.5MCG/24H QL: 1 IN 90 DAYS, DL: 90 DAYS
TIER 3ESTRADIOL (CREAM/APPL) 0.01 % QL: 42.5 IN 30 DAYSESTROGENS, CONJUGATED [PREMARIN] (CREAM/APPL) 0.625 MG/G PA
VITAMIN AND/OR MINERAL DEFICIENCY - refer to website for compCARIOSTATIC AGENTS
TIER 1FLUORIDE (SODIUM) (CREAM (G)) 0.011 FLUORIDE (SODIUM) (GEL (G)) 0.011 FLUORIDE (SODIUM) (TAB CHEW) MULTIPLE STRENGTHS FLUORIDE (SODIUM) [FLUORABON] (DROPS) MULTIPLE STRENGTHS
REPLACEMENT PREPARATIONSTIER 1
CALCIUM CARBONATE (TABLET) MULTIPLE STRENGTHS CALCIUM CARBONATE/VITAMIN D3 (TABLET) MULTIPLE STRENGTHS
61Member Services (541) 471-4106 Toll free (888) 460-0185 TTY 711 Language Access (888) 260-4297
LegendAllCare CCO is a Generic-Mandatory plan – generic drugs must be used when available
PA Prior Authorization required FL Fill Limit ST Step Therapy QL Quantity Limit
MS Must fill through specialty pharmacy program DL Day Supply Limit AL Age Limit
Therapeutic Indication / Drug Name CommentFERROUS GLUCONATE (TABLET) MULTIPLE STRENGTHS FERROUS SULFATE (TABLET) MULTIPLE STRENGTHS MAGNESIUM OXIDE (TABLET) MULTIPLE STRENGTHS MULTIVITAMIN WITH MINERALS PEDIATRIC VITAMINS PRENATAL VITAMINS
VITAMIN ATIER 1
BETA‐CAROTENE (CAPSULE) MULTIPLE STRENGTHS VITAMIN A (CAPSULE) MULTIPLE STRENGTHS
VITAMIN BTIER 1
CYANOCOBALAMIN (VITAMIN B‐12) (TABLET) MULTIPLE STRENGTHS PYRIDOXINE (VITAMIN B‐6) (TABLET) MULTIPLE STRENGTHS RIBOFLAVIN(VITAMIN B‐2) (TABLET) MULTIPLE STRENGTHS THIAMINE(VITAMIN B‐1) (TABLET) MULTIPLE STRENGTHS
VITAMIN CTIER 1
ASCORBIC ACID (VITAMIN C) MULTIPLE STRENGTHS VITAMIN D
TIER 1CHOLECALCIFEROL (VITAMIN D3) MULTIPLE STRENGTHS ERGOCALCIFEROL (VITAMIN D2) MULTIPLE STRENGTHS
VITAMIN ETIER 1
VITAMIN E MIXED (CAPSULE) 400 UNIT, 1000 UNIT VITAMIN E MULTIPLE STRENGTHS
Updated on November 27, 2019Effective on January 1, 2020
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