sign in sign up
<<
Home , Apraclonidine, Octreotide

Drug Status Changes As communicated in the November 1, 2020 Provider Update and effective for fill dates on or after January 1, 2021, the following drugs will be moving tiers: Drug Name 2020 Tier 2021 Tier Abacavir Sulfate Solution T3 T4 Abacavir Sulfate Tablet 300 MG T2 T4 Abacavir Sulfate-Lamivudine T3 T4 Tablet Acamprosate Calcium Tablet T2 T4 Delayed Release 333 MG ACETASOL HC SOLUTION T2 T3 Capsule ER T2 T4 12HR Acetazolamide Tablet T2 T3 Acyclovir Capsule T1 T2 Acyclovir Sodium IV Solution T2 T4 50 MG/ML Adapalene Cream T2 T4 AFIRMELLE TABLET T2 T4 Albuterol Sulfate Syrup T1 T4 Alendronate Sodium Oral T2 T4 Solution ALTAVERA TABLET T2 T4 ALYACEN TABLET T2 T4 Amantadine Capsule T2 T3 Amantadine Tablet T2 T3 Amethia Tablet T2 T4 AMETHYST TABLET 90-20MCG T2 T4 Amikacin Sulfate Injection T2 T4 Amiloride & T1 T2 Hydrochlorothiazide Tablet 5- 50 MG Tablet T2 T4 Ammonium Lactate Lotion 12% T2 T3 Tablet T2 T3 Amoxicillin & K Clavulanate T2 T4 Tablet ER 12HR 1000-62.5 MG For IV Solution T2 T4 Ampicillin & Sulbactam Sodium T2 T4 For Injection Ampicillin & Sulbactam Sodium T2 T4 For IV Solution Ampicillin Capsule 500 MG T1 T2 Ampicillin Sodium For Injection T2 T4 Ampicillin Sodium For IV T2 T4 Solution Anagrelide Capsule T2 T3 Apraclonidine Ophthalmic T2 T3 Solution Apri T2 T4 Aranelle T2 T4

10/2020 1 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Ashlyna Tablet T2 T4 Assure ID Safety T2 T3 Syringe Sulfate Ophthalmic T2 T3 Solution Aubra EQ Tablet T2 T4 Aubra Tablet T2 T4 AUROVELA 24 TABLET T2 T4 AUROVELA FE TABLET T2 T4 AUROVELA TABLET T2 T4 Aviane T2 T4 Avita Cream T2 T3 Avita Gel T2 T3 AYUNA TABLET T2 T4 Azelastine Nasal Spray T2 T3 Azelastine Ophthalmic Solution T2 T3 Azithromycin IV For Solution T2 T4 Aztreonam For Injection 1 GM T2 T4 AZURETTE T2 T4 Bacitracin-Polymyxin- T2 T3 -HC Ophthalmic Oint 1% Baclofen Tablet T1 T2 Disodium Capsule T2 T4 750 MG Balziva T2 T4 Banzel Suspension T3 T4 Banzel Tablet T3 T4 BEKYREE TABLET T2 T4 Benztropine Tablet T1 T2 Tablet T2 T3 & T1 T2 Hydrochlorothiazide Tablet BLISOVI 24 T2 T4 BLISOVI FE T2 T4 Briellyn Tablet T2 T4 Tartrate T2 T4 Ophthalmic Solution Mesylate Capsule T2 T3 5 MG Bromocriptine Mesylate Tablet T2 T3 2.5 MG Delayed Release T3 T4 Particles Capsule 3 MG Budesonide Inhalation T2 T4 Suspension Budesonide Tablet ER 24HR 9 T3 T5 MG Bumetanide Injection T2 T4 T2 T4 Sublingual Film Bupropion Tablet ER 24HR T2 T3 Tablet T1 T2 Nasal Solution T2 T3

10/2020 2 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Tablet T2 T3 Calcitonin Nasal Solution T2 T3 Calcitriol Ointment T2 T4 Calcium Acetate Capsule 667 T2 T3 MG Calcium Acetate Tablet 667 MG T2 T3 CALPHRON TABLET 667MG T2 T3 Camila T2 T3 CAMRESE T2 T4 Carbamazepine Capsule ER T2 T3 12HR Carbamazepine Chewable T2 T3 Tablet 100 MG Carbamazepine Tablet 200 MG T1 T3 Carbamazepine Tablet ER 12HR T2 T3 Carbidopa Tablet 25 MG T2 T4 Carbidopa-Levodopa- T2 T4 Entacapsuleone Tablets Ophthalmic Solution T1 T2 CAZIANT T2 T4 Cefadroxil Capsule 500 MG T1 T2 Cefazolin Sodium For Injection T2 T4 Cefdinir Capsule 300 MG T2 T3 Cefdinir Suspension T2 T3 Cefepime For Injection T2 T4 Cefixime For Suspension T2 T4 Cefotetan For Injection T2 T4 Cefoxitin For Injection T2 T4 Cefoxitin For IV Solution T2 T4 Cefpodoxime For Suspension T2 T4 Cefpodoxime Tablet T2 T4 Cefprozil For Suspension T2 T3 Cefprozil Tablet T2 T3 Ceftazidime For Injection T2 T4 Ceftriaxone For Injection T2 T4 Cefuroxime For IV Solution T2 T4 Cephalexin Capsule T1 T2 CESIA PAK T2 T4 CHATEAL EQ T2 T4 CHATEAL TABLET T2 T4 Chlorhexidine Solution T1 T2 Chlorthalidone Tablet T1 T2 Ciclopirox Cream T2 T3 Ciclopirox Gel T2 T3 Ciclopirox Suspension T2 T3 Ciprofloxacin in D5W T2 T4 Ciprofloxacin Ophthalmic T1 T2 Solution Ciprofloxacin Tablet T1 T3 Citalopram Oral Solution T1 T3 Clarithromycin For Suspension T2 T4 Clarithromycin Tablet T2 T3

10/2020 3 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Clarithromycin Tablet ER 24HR T2 T3 500 MG CLINDACIN T2 T3 CLINDACIN-P PAD T2 T3 Clindamycin Capsule T1 T2 Clindamycin Phosphate Gel T2 T3 Clindamycin Phosphate in D5W T2 T4 IV Solution Clindamycin Phosphate T2 T4 Injection Clindamycin Phosphate Lotion T2 T3 Clindamycin Phosphate T2 T3 Solution Clindamycin Phosphate Swab T2 T3 Clindamycin Phosphate Vaginal T2 T3 Cream Capsule T2 T4 Clonazepam ODT T3 T4 Clonazepam Tablet T1 T2 Tablet ER 12HR T2 T4 Clonidine Patch T2 T4 Clopidogrel Tablet T1 T2 Clotrimazole T3 T4 Lotion ODT T2 T4 Clozapine Tablet T2 T3 Colchicine Capsule T2 T3 Colchicine Tablet T2 T3 Colestipol Granule Packets T2 T4 Colestipol Tablet T2 T3 Colistimethate for Injection T2 T5 Comfort Assist Insulin Syringe T2 T3 Cromolyn Sodium Solution T2 T3 CYCLAFEM TABLET T2 T4 Tablet T3 T4 Cyclophosphamide Capsule T3 T4 Cyclosporine Capsule T2 T3 Cyclosporine Modified Capsule T2 T3 Cyclosporine Oral Solution T2 T3 Syrup T2 T4 Cyproheptadine Tablet T2 T4 CYRED EQ TABLET T2 T4 CYRED TABLET T2 T4 Dantrolene Capsule T2 T4 Daptomycin For IV Solution T2 T5 DASETTA TABLET T2 T4 DAYSEE TABLET T2 T4 Deblitane Tablet T2 T3 DECADRON TABLET T1 T2 DELYLA T2 T4 Tablet T2 T3 Desmopressin Nasal Spray T2 T4 Solution

10/2020 4 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Desmopressin Tablet T2 T3 Desvenlafaxine Tablet ER 24HR T2 T3 Dexamethasone Tablet T1 T2 Dextroamphetamine Capsule T2 T3 ER 24HR Dextrose 10% w/ Sodium T2 T4 Chloride Dextrose 2.5% w/ Sodium T2 T4 Chloride Dextrose 5% w/ Sodium T2 T4 Chloride Dextrose Injection T2 T4 Diazepam Rectal Gel T2 T4 Diclofenac Gel T3 T4 Diclofenac Epolamine Patch T3 T4 Dicyclomine Oral Solution T1 T2 Dicyclomine Tablet T1 T2 Dicyclomine Capsule 10 MG T1 T2 Didanosine Delayed Release T2 T3 Capsule Digitek T1 T2 Digoxin T1 T2 Digoxin Oral Solution T1 T3 Diltiazem Tablet T1 T2 Disulfiram Tablet T2 T3 Dotti TD Patch T2 T3 Tablet T1 T2 Concentrate T2 T3 Doxercalciferol Capsule T3 T4 Doxycycline Hyclate Capsule 50 T1 T3 MG Doxycycline Hyclate Tablet T2 T3 Doxycycline Monohydrate T1 T3 Capsule Doxycycline Monohydrate T2 T4 Suspension Doxycycline Monohydrate T1 T3 Tablet Dronabinol Capsule T3 T4 DROSPIRENONE/ETHINYL T2 T4 TABLET Drospirenone-Ethinyl Estradiol T2 T4 Tablet Dutasteride Capsule T2 T3 Econazole Nitrate Cream T3 T4 Emoquette Tablet T2 T4 ENDOCET TABLET T2 T3 Enoxaparin T3 T4 ENPRESSE-28 T2 T4 ENSKYCE TABLET T2 T4 Entacapone Tablet T2 T4 Entecavir Tablet T3 T4 Epinephrine Injection T2 T3

10/2020 5 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Epinephrine Solution Auto- T2 T3 injector Epitol Tablet T1 T3 Eplerenone Tablet T2 T3 Errin Tablet T2 T3 Ertapenem For Injection T2 T4 Ery Pads T2 T3 Erythromycin For Suspension T3 T4 Erythromycin Gel T2 T4 Erythromycin Tablet T2 T4 Erythromycin Tablet T3 T4 Erythromycin Tablet Delayed T2 T4 Release Erythromycin w/ Delayed T2 T4 Release Particles Capsule 250 MG Estradiol Intramuscular T2 T4 Estradiol Tablet T1 T3 Estradiol TD Patch T2 T3 Estradiol Vaginal Cream T3 T4 Estradiol Vaginal Tablet T3 T4 Ethosuximide Capsule T2 T3 Ethosuximide Solution T2 T3 Etodolac Tablet T2 T3 Exemestane Tablet T2 T4 Falmina T2 T4 Famotidine Tablet T1 T2 Felbamate Suspension T2 T5 Felbamate Tablet T2 T4 TD Patch T2 T4 Flac T2 T4 Fluconazole Injection T2 T4 Fluocinolone OTIC T2 T4 Fluorometholone Ophthalmic T2 T3 Suspension Fluorouracil Cream T2 T4 Fluoxetine Capsule T1 T2 Fluoxetine Capsule Delayed T1 T4 Release 90 MG Elixir T2 T4 Fluphenazine Injection T2 T4 Fluphenazine Injection T2 T4 Fluphenazine Oral Concentrate T2 T3 Flurbiprofen Ophthalmic T1 T2 Solution Flutamide Capsule T2 T3 Fluticasone Nasal Suspension T1 T2 Fluticasone- T2 T3 Fluvoxamine Tablet T2 T3 Fondaparinux Injection T2 T4 Furosemide Injection T2 T4 Furosemide Oral Solution T1 T2 Galantamine Capsule ER 24HR T2 T4

10/2020 6 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Galantamine Oral Solution T2 T4 Galantamine Tablet T2 T4 Gatifloxacin Ophthalmic T2 T3 Solution Gemfibrozil Tablet T1 T2 Gengraf Capsule T2 T3 Gengraf Oral Solution T2 T3 Gentamicin Injection T2 T4 GIANVI T2 T4 Glyburide Micronized Tablet T1 T3 Glyburide Tablet T2 T3 Glyburide-Metformin Tablet T2 T3 Granisetron Tablet T2 T4 Griseofulvin Microsize T2 T4 Suspension Griseofulvin Microsize Tablet T2 T4 Griseofulvin Ultramicrosize T2 T4 Tablet Tablet T2 T3 HAILEY T2 T4 Injection T2 T4 Haloperidol Intramuscular T2 T4 Solution Haloperidol Oral Concentrate T1 T2 Haloperidol Tablet T1 T2 HEATHER T2 T3 Heparin T2 T3 Hydralazine Tablet T1 T2 -Acetaminophen T2 T3 Solution Hydrocodone-Acetaminophen T2 T3 Tablet Hydrocodone-Ibuprofen Tablet T2 T3 Hydrocortisone Acetic Acid Otic T2 T3 Solution Hydrocortisone Enema T2 T4 Hydrocortisone Tablet T2 T3 Liquid T2 T4 Hydromorphone Tablet ER T3 T4 24HR Tablet T2 T3 Hydroxyzine Pamoate Capsule T2 T3 Hydroxyzine SYRUP T2 T3 IBU TABLET T1 T2 Ibuprofen Tablet T1 T2 Imipenem-Cilastatin T2 T4 Intravenous For Solution Tablet T2 T4 INCASSIA T2 T3 Indapamide Tablet T1 T2 Indomethacin Capsule T1 T2 Insulin Pen Needle T2 T3 Insulin Syringes T2 T3

10/2020 7 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Introvale T2 T4 ISIBLOOM T2 T4 Isoniazid Syrup T2 T4 Isoniazid Tablet T1 T2 Isosorbide Dinitrate Tablet T1 T2 Ivermectin Tablet T2 T3 JAIMIESS T2 T4 JASMIEL T2 T4 JENCYCLA T2 T3 Jinteli T2 T4 JOLESSA T2 T4 JULEBER T2 T4 Junel T2 T4 Junel FE T2 T4 KAITLIB FE CHEWABLE T2 T4 KALLIGA T2 T4 Kariva T2 T4 KCl in Dextrose NaCl Injection T2 T4 KCl-Lactated Ringers-D5W T2 T4 Kelnor 1/35 T2 T4 Ketoprofen Capsule T2 T3 Ketorolac Ophthalmic Solution T2 T3 Kionex Oral Suspension T2 T3 KLOR-CON SPRINKLE CAPSULE T1 T2 KURVELO T2 T4 Lamivudine Oral Solution T2 T3 Lamivudine Tablet T2 T3 Lamivudine-Zidovudine Tablet T2 T4 Lamotrigine Tablet T1 T2 Lamotrigine Tablet Chewable T2 T3 Larin T2 T4 LARISSIA T2 T4 LAYOLIS FE T2 T4 LEENA T2 T4 Lessina T2 T4 Letrozole Tablet T1 T2 Leucovorin Tablet T2 T3 Leuprolide Injection T2 T4 Levalbuterol Solution T2 T4 Levetiracetam Tablet ER 24HR T2 T3 Levocarnitine Oral Solution T2 T3 Levocarnitine Tablet T2 T3 Levofloxacin IV Solution T2 T4 Levofloxacin Ophthalmic T2 T3 Solution Levonest T2 T4 Levonorgestrel & Ethinyl T2 T4 Estradiol Levora T2 T4 Levo-T T1 T3 Levoxyl T2 T3 Lidocaine Ointment T3 T4

10/2020 8 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Lidocaine Patch T3 T4 LILLOW T2 T4 Lindane Shampoo T2 T4 Linezolid IV Solution T2 T4 Lithium Carbonate Capsule T1 T2 Lithium Carbonate Tablet 300 T1 T2 MG Lithium Carbonate Tablet ER T1 T2 Lithium Oral Solution T1 T3 LORCET TABLET T2 T3 LORYNA T2 T4 LO-ZUMANDIMI T2 T4 LUTERA T2 T4 LYZA T2 T3 Magnesium Injection T2 T4 Malathion Lotion T2 T4 Marlissa T2 T4 Medroxyprogesterone T1 T4 Suspension Medroxyprogesterone Tablet T1 T2 Megestrol Suspension T2 T3 Megestrol Suspension T2 T4 Megestrol Tablet T1 T3 Memantine Titration Pak T2 T3 Mercapsuletopurine Tablet T2 T3 Meropenem IV For Solution T2 T4 Mesalamine Enema T2 T4 Mesalamine Suppository T3 T5 Metaproterenol Syrup T2 T4 Solution T2 T3 Methadone Tablet T2 T3 Methamphetamine Tablet T2 T3 Methenamine Tablet T2 T4 Methimazole T1 T2 Metoclopramide Solution T1 T2 Metolazone T2 T3 Metronidazole Cream T2 T4 Metronidazole Gel T2 T4 Metronidazole in NaCl IV T2 T4 Solution Mexiletine Capsule T2 T3 Vaginal Suppository T2 T3 Microgestin T2 T4 Tablet T2 T3 Misoprostol Tablet T2 T3 Mometasone Nasal Suspension T3 T4 Oral Solution T2 T3 Morphine Sulfate Tablet T2 T3 Morphine Sulfate Tablet ER T3 T4 Moxifloxacin in Sodium T2 T4 Chloride Injection Moxifloxacin Ophthalmic T3 T4 Solution

10/2020 9 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Mupirocin Cream T2 T3 Mycophenolate Capsule T2 T3 Mycophenolate Tablet T2 T3 Tablet T3 T4 Nafcillin For Injection T2 T4 Nafcillin For IV Solution T2 T4 Tablet T2 T3 Naproxen Suspension T2 T4 Naproxen Tablet T1 T2 Naproxen Tablet T1 T2 Necon T2 T4 Tablet T2 T4 Neomycin-Bacitracin T2 T3 Ophthalmic Ointment Neomycin-Polymy-Gramicidin T2 T3 Ophthalmic Solution Neomycin-Polymyxin-HC T2 T4 Ophthalmic Suspension Neomycin-Polymyxin-HC Otic T2 T3 Solution Neomycin-Polymyxin-HC Otic T2 T3 Suspension Nevirapine Suspension T2 T4 Nevirapine Tablet T2 T3 Nevirapine Tablet ER 24HR T2 T4 Niacin Tablet ER T3 T4 Nikki T2 T4 Nimodipine Capsule T2 T4 Nitrofurantoin Capsule T2 T3 Nitrofurantoin Monohydrate T2 T3 Capsule NORA-BE T2 T3 NORCO TABLET T2 T3 Norethindrone & Ethinyl T2 T4 Estradiol-Fe Chewable NORETHINDRONE T2 T4 ACETATE/ETHINYL ESTRADIOL TABLET Norethindrone Tablet T1 T2 NORETHINDRONE TABLET T2 T3 NORGESTIMATE/ETHINYL T2 T4 ESTRADIOL NORLYDA T2 T3 NORLYROC T2 T3 Nortrel T2 T4 T1 T2 Nortriptyline Solution T1 T2 OCELLA T2 T4 Octreotide Acetate Injection T2 T4 100 MCG/ML (0.1 MG/ML) Octreotide Acetate Injection T2 T5 1000 MCG/ML (1 MG/ML) Octreotide Acetate Injection T2 T4 200 MCG/ML (0.2 MG/ML)

10/2020 10 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Octreotide Acetate Injection 50 T2 T4 MCG/ML (0.05 MG/ML) Octreotide Acetate Injection T2 T5 500 MCG/ML (0.5 MG/ML) Ofloxacin Tablet T2 T3 IM Injection T2 T4 Olanzapine-Fluoxetine Capsule T2 T3 Omega-3-acid Ethyl Esters T3 T4 Capsule Omeprazole Capsule Delayed T1 T2 Release Ondansetron Oral Solution T2 T4 ORALONE DENTAL PASTE T2 T3 Orsythia T2 T4 Oseltamivir Capsule T1 T3 Oseltamivir For Suspension T1 T3 Oxacillin Injection T2 T4 Oxcarbazepine Suspension T2 T4 Oxcarbazepine Tablet T2 T3 Oxybutynin Syrup T1 T2 Oxybutynin Tablet T1 T2 Concentrate T2 T4 Oxycodone Solution T2 T3 Oxycodone w/ Acetaminophen T2 T3 Tablet Oxycodone-Aspirin Tablet T2 T3 Oxycodone-Ibuprofen Tablet T2 T3 Paricalcitol Capsule T2 T4 PAROEX SOL T1 T2 Capsule T2 T4 Paroxetine Tablet T1 T2 Penicillin G For Injection T2 T5 Penicillin V Potassium For T1 T2 Solution Penicillin V Potassium Tablet T1 T2 PERIOGARD SOL T1 T2 PFIZERPEN INJECTION T2 T4 Phenelzine Tablet T2 T3 PHILITH T2 T4 Ophthalmic Solution T2 T3 Pilocarpine Tablet T2 T4 PIMTREA TABLET T2 T4 PiperacillinTazobactam For T2 T4 Injection PIRMELLA TABLET T2 T4 Podofilox Solution T2 T3 Sulfate For T2 T4 Injection Portia T2 T4 Potassium Chloride Capsule ER T1 T2 Potassium Chloride in Dextrose T2 T4 Injection Potassium Chloride Injection T2 T4

10/2020 11 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Potassium Chloride T1 T2 Microencapsulesulated Crystal ER Tablet Potassium Chloride Oral T1 T3 Solution Potassium Chloride Powder T1 T3 Packet 20 mEq Potassium Chloride Tablet ER 8 T1 T2 mEq (600 MG) Potassium Citrate Tablet ER T2 T3 Pramipexole Tablet T1 T2 Capsule T1 T2 Suppository T2 T4 Prochlorperazine Tablet T1 T2 Syrup T2 T3 Promethazine Tablet T2 T3 Tablet T1 T2 Pyridostigmine Oral Solution T3 T5 Pyridostigmine Tablet T2 T3 Tablet ER T2 T4 Quinine Sulfate Capsule T2 T4 Raloxifene Tablet T2 T3 RECLIPSEN TABLET T2 T4 Ribavirin Tablet T2 T3 Rifampin For Injection T2 T4 Rimantadine Tablet T2 T4 ODT T2 T4 Risperidone Solution 1 MG/ML T2 T4 Risperidone Tablet T1 T2 Rivastigmine Capsule T2 T3 Rivastigmine TD Patch 24HR T2 T4 Rizatriptan ODT T2 T3 Rizatriptan Tablet T2 T3 ROSADAN CREAM T2 T4 ROSADAN GEL T2 T4 Roweepra XR T2 T3 Sancuso TD Patch T4 T5 Selegiline Capsule T2 T3 Selegiline Tablet T2 T3 Sertraline Oral Concentrate T2 T4 SETLAKIN TABLET T2 T4 Sevelamer Carbonate Packet T3 T5 Sevelamer Tablet T3 T4 Sharobel T2 T3 Silver Sulfadiazine Cream T2 T3 SIMLIYA T2 T4 SIMPESSE TABLET T2 T4 Sirolimus Oral Solution T3 T5 Sirolimus Tablet T2 T4 Sodium Chloride Irrigation T2 T3 Solution Sodium Chloride IV Solution T2 T4 Sodium Polystyrene Powder T2 T3

10/2020 12 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Tablet T1 T2 Spironolactone Tablet T1 T2 SPS Oral Suspension T2 T3 SRONYX TABLET T2 T4 SSD Cream T2 T3 Stavudine Capsule T2 T3 For Injection T2 T5 SUBVENITE TABLET T1 T2 Sulfadiazine Tablet T2 T4 Sulfamethoxazole- T1 T2 Trimethoprim Tablet Sumatriptan Injection 6 T3 T4 MG/0.5ML Sumatriptan Nasal Spray 20 T3 T4 MG/ACT Sumatriptan Nasal Spray 5 T2 T4 MG/ACT Sumatriptan Solution Auto- T2 T4 injector 4 MG/0.5ML Sumatriptan Solution Auto- T3 T4 injector 6 MG/0.5ML Sumatriptan Solution Cartridge T2 T4 4 MG/0.5ML Sumatriptan Solution Cartridge T3 T4 6 MG/0.5ML Sumatriptan Solution Prefilled T3 T4 Syringe 6 MG/0.5ML SYEDA T2 T4 Tacrolimus Capsule T2 T3 Tarina FE T2 T4 TAZICEF INJECTION T2 T4 Tenofovir Tablet T3 T4 Capsule T1 T2 Terbinafine Tablet T1 T2 Terconazole Vaginal Cream T2 T3 Terconazole Vaginal T2 T3 Suppository Testosterone Enanthate T2 T3 in Oil Testosterone TD Gel T3 T4 Tablet T1 T3 Thiothixene Capsule T1 T3 Tiadylt ER 24HR T2 T3 Tigecycline For IV Solution T2 T5 Ophthalmic Solution T1 T2 Timolol Tablet T2 T3 Tinidazole Tablet T2 T4 Tobramycin Injection T2 T4 Tobramycin-Dexamethasone T2 T3 Ophthalmic Suspension Topiramate Tablet T1 T2 TPN Electrolytes Concentrate T2 T4 TPN Electrolytes Solution T2 T4 Tablet T1 T2

10/2020 13 Drug Status Changes

Drug Name 2020 Tier 2021 Tier Tramadol Tablet ER 24HR T2 T3 Tranexamic Acid Tablet T2 T3 Tranylcypromine Tablet T2 T4 Tablet T1 T2 Tretinoin Cream T2 T4 TRI FEMYNOR T2 T4 Triamcinolone Acetonide Dental T2 T3 Paste Triamterene T1 T2 Hydrochlorothiazide Capsule Triamterene T1 T2 Hydrochlorothiazide Tablet TRI-ESTARYLL T2 T4 Tablet T2 T3 Trifluoperazine Tablet T2 T3 Trifluridine Ophthalmic Solution T2 T3 Trihexyphenidyl Tablet T1 T2 Trihexyphenidyl Oral Solution T1 T2 TRI-LINYAH T2 T4 TRI-MILI T2 T4 Capsule T2 T4 Tri-Previfem T2 T4 TRI-SPRINTEC T2 T4 Trivora T2 T4 TRI-VYLIBRA T2 T4 TULANA T2 T3 Unithroid T1 T3 Ursodiol Capsule T2 T3 Capsule T3 T4 Vancomycin For IV Solution T2 T4 Velivet T2 T4 Venlafaxine Tablet T2 T3 Venlafaxine Tablet ER 24HR T2 T3 Verapamil Tablet T1 T2 Verapamil Tablet ER T1 T2 VIENVA T2 T4 VIORELE T2 T4 VOLNEA T2 T4 Vyfemla T2 T4 WERA T2 T4 Zaleplon T2 T3 ZARAH T2 T4 Zidovudine T2 T3 Zidovudine Syrup T2 T3 Zidovudine Tablet T2 T3 Zovia T2 T4 ZUMANDIMINE T2 T4

10/2020 14 Drug Status Changes