PLEASE READ: THIS DOCUMENT CON sure that itstill contains thedrugsyou take. This formulary haschanged sincelast yea Note to existing members: Michigan Complete Health(Medicare-Medicaid Plan) LIST OFCOVERED DRUGS (FORMULARY) H9487_18_LOD Version Number: HPMS ApprovedFormulary FileSubmissionID:18491 Updated For moreinformation, visitmmp.michigancompletehealth.com. messag On weekends andonstate orfederal holidays, you may beasked to leave a atServices 1-844-239-7387(TT If you have questions, pleasecallMichigan Complete Health(MMP)Member WE COVER INTHISPLAN. e. Yourcall willbereturned businessda withinthenext 1/2018. 2018 _Approved_09062017 Y: 711),from 8a.m.to 8p.m.,seven days aweek. TAINS INFORM r. Pleasereview thisdocument to make ATION ABOUTTHEDRUGS y. Thecall isfree. 15 Notice of Non-Discrimination. Michigan Complete Health Medicare-Medicaid Plan (MMP) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Michigan Complete Health (MMP) does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Michigan Complete Health (MMP): • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Michigan Complete Health (MMP)’s Member Services at 1-844-239-7387 (TTY: 711) from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. If you believe that Michigan Complete Health (MMP) has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Michigan Complete Health (MMP)’s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368– 1019, (TDD: 1-800–537–7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Language Services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-844-239-7387 (TTY: 711). ATENCIÓN: si habla espa ol, tiene a su disposici n servicios gratuitos de asistencia ling ística. Llame al 1-844-239-7387 (TTY: 711). ﺔ:ظﺣوﻠﻣ اذإ تﻛﻧ ثدﺣﺗﺗ ﺔﻐﻠﻟا ،ﺔﺑﯾرﻌﻟا ﺈنﻓ تﺎﻣدﺧ ةدﺎﻋﺳﻣﻟا ﺔوﯾﻐﻠﻟا رﻓاﺗﺗو كﻟ ن.ﺎﺟﻣﻟﺎﺑ لﺻاﺗ مﻗرﺑ 7387-239-844-1 ( مﻗر وﺻﻟافﺎﺗھ مﻛﻟﺑام : 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請 電 1-844-239-7387（TTY：711)。 ܿ ܿ ܿ ܵ ܵ ܿ ܵ ܵ ܵ ܿ ܿ ܿ ܿ ܵ ܵ ܘܙ ܼ ܗܪܐ: ܸܐ ܢ ܼܐ ܬܘܚ ܢ ܹܟܐ ܼܗ ܸܡܙ ܝܡ ܼ ܘܬ ܢ ܸܠܫܢܐ ܐ ܘܬ ܪ ܵܝܐ، ܡ ܼܨܝ ܘܬ ܢ ܼܕܩ ܝܒܠ ܼ ܘܬ ܢ ܵ ܿ ܵ ܿ ܵ ܵ ܵ ܿ ܿ 1-844-239-7387 (TTY: 711) ܢܝܢܐ ܵ ܡܸ ܠܥܼܿ ܢ ܩܘܪ .ܬ ܼ ܐܝ ܢܓܵ ܡܼ ܐܢܫܠܒܸ ܐ ܪܬ ܝܼܿ ܗܕܼ ܐܬܹ ܡܠܼ ܚܸ CHÚ Ý: Nếu bạn n i Tiếng Việt, c các dịch vụ hỗ trợ ng n ngữ miễn phí dành cho bạn. Gọi số 1-844-239- 7387 (TTY: 711). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-844-239-7387 (TTY: 711). 주의: 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-239-7387 (TTY: 711) 번으로 전화해 주십시오. ল�뷍 ক쇁নঃ যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল� আেছ। েফান ক쇁ন ১-844-239-7387 (TTY: 711)। UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1- 844-239-7387 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verf gung. Rufnummer: 1-844-239-7387 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-844-239-7387 (TTY: 711). 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1 -844-239-7387（TTY: 711）まで 、お電話にてご連絡ください。 ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-844-239-7387 (TTY: 711). OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-844-239-7387 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-844-239-7387 (TTY: 711).
H9487_18_LOD_Approved_09062017
This is a list of drugs that members can get in Michigan Complete Health (MMP).
Michigan Complete Health Medicare-Medicaid Plan (MMP) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.
Benefits may change on January 1 of each year. You can always check Michigan Complete Health (MMP)’s up-to-date List of Covered Drugs online at mmp.michigancompletehealth.com.
Limitations, restrictions, and patient pay amounts may apply. This means that you may have to pay for some services and that you need to follow certain rules to have Michigan Complete Health (MMP) pay for your services. For more information, call Michigan Complete Health (MMP) Member Services or read the Michigan Complete Health (MMP) Member Handbook.
Si habla espa ol, tiene a su disposici n servicios gratuitos de asistencia ling ística. Llame al 1-844-239-7387 (TTY: 711) de 8 a. m. a 8 p. m., los siete días de la semana. Los usuarios de TTY deben llamar al 711. Los fines de semana y los días feriados estatales o nacionales, es posible que se le pida que deje un mensaje. Le devolveremos la llamada durante el pr ximo día hábil. La llamada es gratuita.
You can also get this document for free in other formats, such as large print, braille, or audio. Call 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.
If you would like us to send you member materials on an ongoing basis in other formats, such as Braille or large print, or in a language other than English, please call Member Services at the number at the bottom of the page. Tell Member Services that you would like to place a standing request to get your materials in another format or language.
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. i Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.
1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Michigan Complete Health (MMP). These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”
Michigan Complete Health (MMP) will cover all medically necessary drugs on the Drug List if:
your doctor or other prescriber says you need them to get better or stay healthy, and
you fill the prescription at a Michigan Complete Health (MMP) network pharmacy.
Michigan Complete Health (MMP) may have additional steps to access certain drugs (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website at mmp.michigancompletehealth.com or call Member Services toll-free at 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.
2. Does the Drug List ever change?
Yes. Michigan Complete Health (MMP) may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:
a cheaper drug comes along that works as well as a drug on the Drug List now, or
we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
Decide to require or not require prior approval for a drug. (Prior approval is permission from Michigan Complete Health (MMP) before you can get a drug.)
Add or change the amount of a drug you can get (called “quantity limits”).
Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. ii (For more information on these drug rules, see page iii.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.
You can always check Michigan Complete Health (MMP)’s up to date Drug List online at mmp.michigancompletehealth.com. You can also call Member Services to check the current Drug List at 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.
3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will mail you a notice if you are taking a drug and we change our rules for covering it. You will receive the notice by mail at least 60 days before we change the drug rules or remove the drug from our Drug List. We will also put these types of changes on our website at mmp.michigancompletehealth.com.
4. What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you.
5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:
Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Michigan Complete Health (MMP) before you fill your
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. iii prescription. If you don’t get approval, Michigan Complete Health (MMP) may not cover the drug.
Quantity limits: Sometimes Michigan Complete Health (MMP) limits the amount of a drug you can get.
Step therapy: Sometimes Michigan Complete Health (MMP) requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your prescriber thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1- Index 1. You can also get more information by visiting our web site at mmp.michigancompletehealth.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.
You can also ask for an “exception” from these limits. Please see question 11 for more information on exceptions.
If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Michigan Complete Health (MMP) member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question 11 for more information about exceptions.
6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?
The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”
7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. iv 8. How can you find a drug on the Drug List?
There are two ways to find a drug:
You can search alphabetically (if you know how to spell the drug), or
You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it in the Index that begins on page Index 1.
To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where you will find drugs that treat heart conditions.
9. What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week, and ask about it. If you learn that Michigan Complete Health (MMP) will not cover the drug, you can do one of these things:
Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.
10. What if you are a new Michigan Complete Health (MMP) member and can’t find your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Michigan Complete Health (MMP). This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.
We will cover a 30-day supply of your drug if:
you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. v the drug requires prior approval by Michigan Complete Health (MMP), or
you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.
Level of Care Changes
If your level of care changes, we will cover a transition supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility.
If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 30-day supply.
If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 31-day supply.
11. Can you ask for an exception to cover your drug?
Yes. You can ask Michigan Complete Health (MMP) to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
For example, Michigan Complete Health (MMP) may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.
Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.
12. How long does it take to get an exception?
First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. vi supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.
13. How can you ask for an exception?
To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).
Michigan Complete Health (MMP) covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. Michigan Complete Health (MMP) covers some OTC drugs when they are written as prescriptions by your provider.
You can read the Michigan Complete Health (MMP) Drug List to see what OTC drugs are covered.
16. Does Michigan Complete Health (MMP) cover OTC non-drug products?
Michigan Complete Health (MMP) covers some OTC non-drug products when they are written as prescriptions by your provider.
You can read the Michigan Complete Health (MMP) Drug List to see what OTC non-drug products are covered.
17. What is your copay?
As a Michigan Complete Health (MMP) member, you have no copays for prescription and OTC drugs as long as you follow Michigan Complete Health (MMP)’s rules.
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. vii 18. What are drug tiers?
Tiers are groups of drugs.
Tier 1 drugs are generic drugs.
Tier 2 drugs are brand drugs.
Tier 3 drugs are Non-Medicare prescription or over-the-counter drugs.
All tiers do not have a copay.
List of Covered Drugs
The list of covered drugs that begins on page 1 gives you information about the drugs covered by Michigan Complete Health (MMP). If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., ELIQUIS TABS) and generic drugs are listed in lower-case italics (e.g., warfarin sodium tabs).
The information in the necessary actions, restrictions, or limits on use column tells you if - Michigan Complete Health (MMP) has any rules for covering your drug. Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:
Abbreviati What this means How it works on
AL Age Limit This drug may need prior authorization if your age does not meet drug maker, FDA or clinical guidelines.
B/D Medicare Part B This drug may need prior authorization to decide if it vs. Part D should be covered under Medicare Part B or Part D. This is a Medicare rule. Your doctor or other prescriber may need to give more facts to help us make this decision.
LA Limited Access This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message.. Your call will be returned within the next business day.
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. viii Abbreviati What this means How it works on
MO Mail Order This drug is available for up to a 90-day supply at a mail order pharmacy in addition to certain other network pharmacies. Consider getting a 90-day supply of your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).
NF Not Covered This drug is not covered on the Drug List. You can ask for an exception for the drug to be covered.
NT Not Part D This drug is not a “Part D drug.” You will not be required to pay a copay for these drugs.
PA Prior Authorization This drug requires prior authorization. This means that you or your doctor must get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug.
QL Quantity Limit This drug has a limit on the amount that our plan will cover.
RX/OTC Prescription and This drug is made in both prescription form and OTC Over-the-Counter form. (OTC)
SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that we will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of ibuprofen is 3200 mg. Therefore, we will only cover four tablets per day for ibuprofen 800 mg. ST Step Therapy This drug requires step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.
Note: The NT next to a drug means the drug is not a “Part D drug.” These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. ix is not covered or is no longer covered by Medicare or Michigan Medicaid. If you or your prescriber disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1-844-239-7387 (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. You can also read Chapter 9 in the Member Handbook to learn how to appeal a decision.
List of Drugs by Medical Condition
The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where you will find drugs that treat heart conditions.
If you have questions, please call Michigan Complete Health (MMP) at 1-844-239-7387 (TTY: ? 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. x What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ADHD/ANTI-NARCOLEPSY/ANTI- $0 MO OBESITY/ANOREXIANTS - Drugs to Treat clonidine hcl (adhd) tb12 (Tier ADHD, Sleep and Eating Disorders 1) $0 AL(Up to 64 yrs Amphetamines guanfacine hcl (adhd) tb24 (Tier old); MO $0 MO 1) amphetamine- (Tier dextroamphetamine cp24 1) Stimulants - Misc. $0 MO $0 MO amphetamine- (Tier CONCERTA TBCR (Tier dextroamphetamine tabs 1) 2) $0 MO $0 MO dextroamphetamine sulfate dexmethylphenidate hcl (Tier (Tier cp24 10 mg, 15 mg, 20 mg cp24 5 mg, 10 mg, 15 mg 1) 1) $0 MO $0 MO dextroamphetamine sulfate dexmethylphenidate hcl (Tier (Tier tabs 5 mg, 10 mg, 2.5 mg tabs 5 mg, 10 mg 1) 1) $0 PA; MO methylphenidate hcl cp24 $0 MO methamphetamine hcl tabs (Tier or 20 mg, 30 mg, 40 mg, 60 (Tier 1) mg 1) methylphenidate hcl cpcr or $0 QL(1 ea daily); Attention-Deficit/Hyperactivity Disorder (ADHD) 10 mg, 40 mg, 50 mg, 60 (Tier MO $0 SL(10 ea daily); atomoxetine hcl caps 10 mg 1) (Tier MO mg $0 1) methylphenidate hcl cpcr or QL(2 ea daily); (Tier MO $0 SL(1 ea daily); 20 mg atomoxetine hcl caps 100 1) (Tier MO mg 1) $0 MO methylphenidate hcl cpcr or (Tier $0 SL(5.55 ea 30 mg atomoxetine hcl caps 18 1) (Tier daily); MO mg $0 1) methylphenidate hcl tabs or QL(3 ea daily); (Tier MO $0 SL(4 ea daily); 5 mg, 10 mg, 20 mg atomoxetine hcl caps 25 1) (Tier MO mg $0 1) methylphenidate hcl tb24 or Non-Osmotic (Tier Release $0 SL(2.5 ea 27 mg, 36 mg atomoxetine hcl caps 40 1) (Tier daily); MO mg 1) methylphenidate hcl tbcr or $0 MO 18 mg, 27 mg, 36 mg, 54 (Tier $0 SL(1.66 ea atomoxetine hcl caps 60 mg 1) (Tier daily); MO mg $0 1) methylphenidate hcl tbcr or QL(3 ea daily); (Tier MO $0 SL(1.25 ea 20 mg atomoxetine hcl caps 80 1) (Tier daily); MO mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 1 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 PA; MO $0 modafinil tabs 100 mg (Tier TOBI PODHALER CAPS (Tier 1) 2) $0 PA; QL(1 ea $0 B/D modafinil tabs 200 mg (Tier daily); MO tobramycin nebu in (Tier 1) 1) $0 MO tobramycin sulfate soln ij $0 MO RITALIN LA CP24 60 MG (Tier 40 mg/ml, 80 mg/2ml, 1.2 (Tier 2) gm/30ml 1) $0 ALLERGENIC EXTRACTS/BIOLOGICALS MISC tobramycin sulfate solr ij (Tier 1.2 gm Biologicals Misc 1) $0 LA; MO ANALGESICS - ANTI-INFLAMMATORY - Drugs ADAGEN SOLN (Tier to Treat Pain, Swelling, Muscle and Joint 2) Conditions AMINOGLYCOSIDES - Drugs to Treat Bacterial Anti-TNF-alpha - Monoclonal Antibodies Infections HUMIRA PEDIATRIC $0 PA Aminoglycosides CROHNS DISEASE (Tier STARTER PACK PSKT 2) $0 MO amikacin sulfate soln ij 1 (Tier $0 PA gm/4ml, 500 mg/2ml 1) HUMIRA PEN PNKT (Tier 2) $0 B/D $0 BETHKIS NEBU (Tier HUMIRA PEN-CD/UC/HS PA 2) (Tier STARTER PNKT 2) $0 gentamicin in saline soln $0 (Tier HUMIRA PEN-PS/UV PA 0.9%-1mg/ml 1) (Tier STARTER PNKT 2) $0 MO gentamicin sulfate soln ij (Tier $0 PA 40 mg/ml 1) HUMIRA PSKT (Tier 2) $0 B/D KITABIS PAK NEBU (Tier $0 PA 2) SIMPONI ARIA SOLN (Tier 2) $0 MO neomycin sulfate tabs or (Tier $0 PA 1) SIMPONI SOAJ (Tier 2) $0 MO paromomycin sulfate caps (Tier $0 PA 1) SIMPONI SOSY (Tier 2) Antirheumatic - Enzyme Inhibitors
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 2 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 PA $0 PA XELJANZ TABS (Tier ACTEMRA SOSY (Tier 2) 2) Antirheumatic Antimetabolites $0 PA KEVZARA SOAJ (Tier OTREXUP SOAJ 10 PA 2) MG/0.4ML, 15 MG/0.4ML, $0 20 MG/0.4ML, 25 $0 PA (Tier KEVZARA SOSY (Tier MG/0.4ML, 12.5 2) MG/0.4ML, 17.5 2) MG/0.4ML, 22.5 MG/0.4ML Nonsteroidal Anti-inflammatory Agents (NSAIDs) RASUVO SOAJ 10 PA $0 MO MG/0.2ML, 15 MG/0.3ML, celecoxib caps (Tier 20 MG/0.4ML, 25 $0 1) MG/0.5ML, 30 MG/0.6ML, (Tier $0 RX/OTC; MO; 7.5 MG/0.15ML, 12.5 CHILDRENS ADVIL SUSP 2) (Tier NT MG/0.25ML, 17.5 (Ibuprofen) 3) MG/0.35ML, 22.5 $0 RX/OTC; MO; MG/0.45ML CHILDRENS MOTRIN (Tier NT Gold Compounds SUSP (Ibuprofen) 3) $0 MO $0 MO RIDAURA CAPS (Tier diclofenac potassium tabs (Tier 2) 1) Interleukin-1 Blockers $0 MO diclofenac sodium tb24 or (Tier $0 LA 100 mg ARCALYST SOLR (Tier 1) 2) $0 MO diclofenac sodium tbec or (Tier Interleukin-1 Receptor Antagonist (IL-1Ra) 25 mg, 50 mg, 75 mg 1) $0 PA; MO $0 KINERET SOSY (Tier diclofenac w/ misoprostol MO 2) (Tier tbec 1) Interleukin-1beta Blockers $0 MO $0 PA; LA etodolac caps (Tier ILARIS SOLN (Tier 1) 2) $0 MO $0 PA; LA etodolac tabs (Tier ILARIS SOLR (Tier 1) 2) $0 MO Interleukin-6 Receptor Inhibitors etodolac tb24 (Tier 1) $0 PA ACTEMRA SOLN (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 3 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 flurbiprofen tabs or 50 mg, MO ketorolac tromethamine $0 AL(Up to 64 yrs (Tier soln im 30 mg/ml, 60 (Tier old); MO 100 mg 1) mg/2ml 1) $0 MO; NT $0 MO ibuprofen caps or 200 mg (Tier mefenamic acid caps or (Tier 3) 1) $0 MO; NT $0 MO ibuprofen chew or 100 mg (Tier meloxicam tabs or 15 mg, (Tier 3) 7.5 mg 1) $0 Over-the- $0 MO ibuprofen susp or 100 (Tier counter;RX/OT mg/5ml nabumetone tabs (Tier 3) C; MO; NT 1) $0 RX/OTC; MO $0 NT ibuprofen susp or 100 (Tier naproxen sodium caps or (Tier mg/5ml 1) 220 mg 3) $0 NT $0 MO; NT ibuprofen susp or 40 (Tier naproxen sodium tabs or (Tier mg/ml, 50 mg/1.25ml 3) 220 mg 3) $0 $0 MO; NT naproxen sodium tabs or MO ibuprofen tabs or 200 mg (Tier (Tier 3) 275 mg, 550 mg 1) $0 $0 SL(8 ea daily); naproxen tabs or 250 mg, MO ibuprofen tabs or 400 mg (Tier MO (Tier 1) 375 mg, 500 mg 1) $0 $0 SL(5.33 ea naproxen tbec or 375 mg, MO ibuprofen tabs or 600 mg (Tier daily); MO (Tier 1) 500 mg 1) $0 SL(4 ea daily); $0 MO ibuprofen tabs or 800 mg (Tier MO oxaprozin tabs (Tier 1) 1) $0 $0 indomethacin caps or 25 AL(Up to 64 yrs piroxicam caps or 10 mg, MO (Tier old); MO (Tier mg, 50 mg 1) 20 mg 1) $0 AL(Up to 64 yrs $0 MO indomethacin cpcr or 75 sulindac tabs or 150 mg, (Tier old); MO (Tier mg 1) 200 mg 1) $0 $0 MO ketoprofen caps 50 mg, 75 (Tier tolmetin sodium caps 400 (Tier mg 1) mg 1) $0 AL(Up to 64 yrs $0 ketorolac tromethamine tolmetin sodium tabs 200 (Tier old); MO (Tier soln ij 15 mg/ml, 30 mg/ml 1) mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 4 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Phosphodiesterase 4 (PDE4) Inhibitors EXCEDRIN TENSION $0 NT $0 HEADACHE TABS (Tier PA Acetaminophen-Caffeine) 3) OTEZLA TABS (Tier ( 2) $0 NT $0 HISTAFLEX TABS (Tier PA 3) OTEZLA TBPK (Tier 2) Analgesics Other Pyrimidine Synthesis Inhibitors $0 MO; NT acetaminophen caps or (Tier $0 MO 500 mg leflunomide tabs or 10 mg, (Tier 3) 20 mg 1) $0 MO; NT acetaminophen chew or 80 (Tier Selective Costimulation Modulators mg 3) $0 PA $0 MO; NT ORENCIA CLICKJECT (Tier acetaminophen liqd or 160 SOAJ (Tier 2) mg/5ml 3) $0 PA $0 NT ORENCIA SOLR (Tier acetaminophen liqd or 500 (Tier 2) mg/15ml, 1000 mg/30ml 3) $0 PA acetaminophen soln or 160 $0 MO; NT ORENCIA SOSY (Tier mg/5ml, 650 mg/20.3ml, (Tier 2) 325 mg/10.15ml 3) Soluble Tumor Necrosis Factor Receptor Agents $0 MO; NT acetaminophen supp re (Tier $0 PA 120 mg, 325 mg, 650 mg ENBREL MINI SOCT (Tier 3) 2) $0 MO; NT acetaminophen susp or (Tier $0 PA 160 mg/5ml, 80 mg/2.5ml ENBREL SOLR (Tier 3) 2) $0 MO; NT acetaminophen tabs or 325 (Tier $0 PA mg, 500 mg ENBREL SOSY (Tier 3) 2) $0 MO; NT acetaminophen tbcr or 650 (Tier $0 PA mg ENBREL SURECLICK (Tier 3) SOAJ 2) $0 MO; NT acetaminophen tbdp or 160 (Tier ANALGESICS - NonNarcotic - Drugs to Treat mg Pain, Muscle and Joint Conditions 3) $0 NT Analgesic Combinations acetaminophen tbdp or 80 (Tier $0 NT mg 3) acetaminophen-caffeine (Tier tabs 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 5 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 QL(0.94 ea FEVERALL INFANTS NT (Tier fentanyl pt72 25 mcg/hr (Tier daily); MO SUPP 3) 1) Salicylates $0 Limit 15 $0 fentanyl pt72 50 mcg/hr, 75 patches per aspirin buffered (cal carb- MO; NT (Tier (Tier mcg/hr 1) month;QL(0.5 mag carb-mag oxide) tabs 3) ea daily); MO $0 $0 MO; NT hydromorphone hcl liqd or QL(50 ml (Tier daily); MO aspirin chew or 81 mg (Tier 1 mg/ml 3) 1) $0 NT hydromorphone hcl soln ij $0 aspirin supp re 300 mg, (Tier 10 mg/ml, 50 mg/5ml, 500 (Tier 600 mg 3) mg/50ml 1) $0 $0 NT hydromorphone hcl soln ij 2 Preservative ASPIRIN SUPP RE 300 (Tier Free (Tier mg/ml MG, 600 MG 3) 1) $0 MO; NT $0 MO hydromorphone hcl soln ij 2 (Tier aspirin tabs or 325 mg (Tier mg/ml 3) 1) $0 $0 MO; NT hydromorphone hcl tabs or QL(25 ea aspirin tbec or 81 mg, 324 (Tier daily); MO (Tier 2 mg mg, 325 mg 3) 1) $0 $0 MO hydromorphone hcl tabs or QL(12.5 ea (Tier daily); MO diflunisal tabs (Tier 4 mg 1) 1) $0 hydromorphone hcl tabs or QL(6.25 ea ANALGESICS - OPIOID - Drugs to Treat Pain, (Tier daily); MO Muscle and Joint Conditions 8 mg 1) Opioid Agonists HYDROMORPHONE $0 Preservative $0 HYDROCHLORIDE SOLN (Tier Free fentanyl citrate lpop bu 200 PA; QL(8 ea (Tier daily); MO 2 MG/ML 2) mcg 1) $0 PA; QL(1 ea LAZANDA SOLN 100 (Tier fentanyl citrate lpop bu 400 $0 PA; QL(4 ea MCG/ACT daily); MO mcg, 600 mcg, 800 mcg, (Tier daily); MO 2) 1200 mcg, 1600 mcg 1) $0 PA; QL(0.5 ea LAZANDA SOLN 300 (Tier $0 QL(0.5 ea MCG/ACT daily); MO fentanyl pt72 100 mcg/hr (Tier daily); MO 2) 1) $0 LAZANDA SOLN 400 PA; QL(0.27 ea (Tier daily); MO $0 Limit 43 MCG/ACT patches per 2) fentanyl pt72 12 mcg/hr (Tier 1) month;QL(1.44 ea daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 6 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 meperidine hcl soln ij 25 AL(Up to 64 yrs morphine sulfate soln ij 0.5 (Tier old) (Tier mg/ml 1) mg/ml 1) $0 $0 meperidine hcl soln ij 50 AL(Up to 64 yrs morphine sulfate soln ij 1 MO (Tier old); MO (Tier mg/ml, 100 mg/ml 1) mg/ml 1) $0 QL(6.67 ml $0 QL(100 ml methadone hcl conc or 10 morphine sulfate soln or 10 (Tier daily); MO (Tier daily); MO mg/ml 1) mg/5ml 1) $0 QL(33.34 ml $0 QL(50 ml methadone hcl soln or 10 morphine sulfate soln or 20 (Tier daily); MO (Tier daily); MO mg/5ml 1) mg/5ml 1) $0 QL(66.67 ml $0 QL(10 ml methadone hcl soln or 5 morphine sulfate soln or 20 (Tier daily); MO (Tier daily); MO mg/5ml 1) mg/ml, 100 mg/5ml 1) $0 QL(6.67 ea $0 methadone hcl tabs or 10 MORPHINE SULFATE QL(13.34 ea (Tier daily); MO (Tier daily); MO mg 1) TABS OR 15 MG 2) $0 QL(13.34 ea $0 methadone hcl tabs or 5 MORPHINE SULFATE QL(6.67 ea (Tier daily); MO (Tier daily); MO mg 1) TABS OR 30 MG 2) $0 $0 morphine sulfate cp24 or QL(20 ea morphine sulfate tbcr or QL(2 ea daily); (Tier daily); MO (Tier MO 10 mg 1) 100 mg, 200 mg 1) $0 QL(2 ea daily); $0 QL(13.34 ea morphine sulfate cp24 or morphine sulfate tbcr or 15 (Tier MO (Tier daily); MO 100 mg 1) mg 1) $0 QL(10 ea $0 QL(6.67 ea morphine sulfate cp24 or morphine sulfate tbcr or 30 (Tier daily); MO (Tier daily); MO 20 mg 1) mg 1) $0 QL(6.67 ea $0 QL(3.34 ea morphine sulfate cp24 or morphine sulfate tbcr or 60 (Tier daily); MO (Tier daily); MO 30 mg 1) mg 1) $0 QL(4 ea daily); $0 QL(26.67 ea morphine sulfate cp24 or oxycodone hcl caps or 5 (Tier MO (Tier daily); MO 50 mg 1) mg 1) $0 $0 morphine sulfate cp24 or QL(3.34 ea oxycodone hcl conc or 100 QL(6.67 ml (Tier daily); MO (Tier daily); MO 60 mg 1) mg/5ml 1) $0 QL(2.5 ea $0 QL(13.3 ea morphine sulfate cp24 or oxycodone hcl tabs or 10 (Tier daily); MO (Tier daily); MO 80 mg 1) mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 7 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 QL(8.9 ea $0 SL(1.5 ea oxycodone hcl tabs or 15 tramadol hcl tb24 or 200 (Tier daily); MO (Tier daily); MO mg 1) mg 1) $0 QL(6.65 ea $0 SL(1 ea daily); oxycodone hcl tabs or 20 tramadol hcl tb24 or 300 (Tier daily); MO (Tier MO mg 1) mg 1) $0 QL(4.44 ea $0 oxycodone hcl tabs or 30 ZOHYDRO ER C12A 10 PA; QL(16.8 ea (Tier daily); MO (Tier daily); MO mg 1) MG 2) $0 QL(26.67 ea $0 ZOHYDRO ER C12A 15 PA; QL(11.2 ea oxycodone hcl tabs or 5 mg (Tier daily); MO (Tier daily); MO 1) MG 2) $0 QL(6.67 ea $0 oxymorphone hcl tabs 10 ZOHYDRO ER C12A 20 PA; QL(8.4 ea (Tier daily); MO (Tier daily); MO mg 1) MG 2) $0 QL(13.34 ea $0 oxymorphone hcl tabs 5 ZOHYDRO ER C12A 30 PA; QL(5.6 ea (Tier daily); MO (Tier daily); MO mg 1) MG 2) $0 QL(4.44 ea $0 oxymorphone hcl tb12 15 ZOHYDRO ER C12A 40 PA; QL(4.2 ea (Tier daily); MO (Tier daily); MO mg 1) MG 2) $0 QL(8.89 ea $0 oxymorphone hcl tb12 7.5 ZOHYDRO ER C12A 50 PA; QL(3.37 ea (Tier daily); MO (Tier daily); MO mg 1) MG 2) $0 PA; QL(16 ea Opioid Combinations SUBSYS LIQD 100 MCG (Tier daily); MO $0 2) acetaminophen w/ codeine SL(150 ml (Tier daily); MO $0 PA; QL(2 ea soln 120mg/5ml-12mg/5ml 1) SUBSYS LIQD 1200 MCG (Tier daily) $0 2) acetaminophen w/ codeine SL(13.3 ea (Tier daily); MO $0 PA; QL(8 ea tabs 300mg-15mg 1) SUBSYS LIQD 200 MCG (Tier daily); MO $0 2) acetaminophen w/ codeine SL(12 ea daily); (Tier MO SUBSYS LIQD 400 MCG, $0 PA; QL(4 ea tabs 300mg-30mg 1) (Tier 600 MCG, 800 MCG, 1600 daily); MO $0 SL(6 ea daily); MCG 2) acetaminophen w/ codeine (Tier MO $0 SL(8 ea daily); tabs 300mg-60mg 1) tramadol hcl tabs or 50 mg (Tier MO $0 AL(Up to 64 yrs 1) butalbital-aspirin-caffeine (Tier old); SL(6 ea $0 SL(3 ea daily); w/cod caps tramadol hcl tb24 or 100 1) daily); MO (Tier MO mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 8 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) hydrocodone- Limit 5535mls $0 Limit 210mls $0 per butorphanol tartrate soln na (Tier per month;QL(7 acetaminophen soln 10 mg/ml 2.5mg/5ml-108mg/5ml, (Tier month;SL(184. 1) ml daily); MO 5mg/10ml-217mg/10ml, 1) 5 ml daily); MO $0 MO 7.5mg/15ml-325mg/15ml nalbuphine hcl soln ij 10 (Tier mg/ml, 20 mg/ml 1) hydrocodone- $0 SL(13.3 ea acetaminophen tabs 5mg- daily); MO (Tier ANDROGENS-ANABOLIC - Drugs to Regulate 300mg, 10mg-300mg, 1) 7.5mg-300mg Hormones Anabolic Steroids hydrocodone- $0 SL(12.3 ea acetaminophen tabs 5mg- (Tier daily); MO $0 MO 325mg, 10mg-325mg, 1) ANADROL-50 TABS (Tier 7.5mg-325mg 2) $0 MO $0 MO hydrocodone-ibuprofen (Tier oxandrolone tabs or 10 mg, (Tier tabs 1) 2.5 mg 1) $0 oxycodone w/ SL(12.3 ea Androgens (Tier daily); MO $0 acetaminophen tabs 1) MO ANDRODERM PT24 (Tier $0 MO 2) oxycodone-aspirin tabs (Tier 1) ANDROGEL GEL 40.5 $0 MO MG/2.5GM, 20.25 (Tier $0 tramadol-acetaminophen SL(8 ea daily); MG/1.25GM (Testosterone) 2) (Tier MO tabs 1) $0 MO ANDROGEL PUMP GEL (Tier (Testosterone) Opioid Partial Agonists 2) $0 MO $0 LA buprenorphine hcl soln ij (Tier 0.3 mg/ml AVEED SOLN (Tier 1) 2) $0 PA; QL(16 ea $0 MO buprenorphine hcl subl sl 2 (Tier danazol caps or 50 mg, mg daily); MO (Tier 1) 100 mg, 200 mg 1) $0 PA; QL(4 ea $0 MO buprenorphine hcl subl sl 8 (Tier mg daily); MO fluoxymesterone tabs (Tier 1) 1) buprenorphine hcl- $0 PA; MO $0 MO naloxone hcl dihydrate subl (Tier methyltestosterone caps or (Tier 8mg-2mg, 2mg-0.5mg 1) 1) $0 $0 butorphanol tartrate soln ij MO MO (Tier testosterone cypionate soln (Tier 2 mg/ml 1) 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 9 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 testosterone enanthate MO alum & mag hydrox- $0 NT (Tier simethicone chew 200mg- (Tier soln im 1) 25mg-200mg 3) testosterone gel 1 %, 1.62 $0 MO alum & mag hydrox- MO; NT %, 50 mg/5gm, 25 (Tier simethicone liqd $0 mg/2.5gm, 40.5 mg/2.5gm, 1) 200mg/5ml-20mg/5ml- (Tier 20.25 mg/1.25gm 200mg/5ml, 400mg/5ml- 3) TESTOSTERONE GEL 1 $0 MO 40mg/5ml-400mg/5ml %, 50 MG/5GM, 25 (Tier alum & mag hydrox- MO; NT MG/2.5GM 2) simethicone susp $0 MO 200mg/5ml-20mg/5ml- TESTOSTERONE PUMP (Tier 200mg/5ml, 400mg/5ml- GEL 2) 40mg/5ml-400mg/5ml, $0 200mg/5ml-200mg/5ml- (Tier $0 MO 20mg/5ml-20mg/5ml- 3) VOGELXO GEL (Tier 200mg/5ml-200mg/5ml, 2) 400mg/5ml-400mg/5ml- $0 MO 40mg/5ml-40mg/5ml- VOGELXO PUMP GEL (Tier 400mg/5ml-400mg/5ml 2) aluminum hydroxide-mag $0 MO; NT ANORECTAL AGENTS - Rectal Drugs to Treat carb susp 95mg/15ml- (Tier Pain, Swelling and Itching 358mg/15ml, 254mg/5ml- 3) 237.5mg/5ml Intrarectal Steroids GAVISCON EXTRA MO; NT $0 MO hydrocortisone (intrarectal) STRENGTH RELIEF $0 (Tier (Tier enem 1) FORMULA SUSP (Aluminum Hydroxide-Mag 3) $0 MO Carb) UCERIS FOAM RE 2 (Tier MG/ACT 2) GAVISCON EXTRA MO; NT STRENGTH SUSP $0 Rectal Steroids 254MG/5ML-237.5MG/5ML (Tier $0 MO (Aluminum Hydroxide-Mag 3) hydrocortisone (rectal) crea (Tier Carb) 1) GAVISCON SUSP MO; NT Vasodilating Agents 95MG/15ML-358MG/15ML, $0 95MG/15ML-95MG/15ML- $0 MO (Tier 358MG/15ML- 3) RECTIV OINT (Tier 358MG/15ML (Aluminum 2) Hydroxide-Mag Carb) ANTACIDS $0 NT MAG-AL LIQD (Tier Antacid Combinations 3) Antacids - Aluminum Salts
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 10 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT TUMS KIDS CHEW $0 MO; NT ALUMINUM HYDROXIDE (Tier SUSP OR (Calcium Carbonate (Tier 3) (Antacid)) 3) Antacids - Bicarbonate TUMS LASTING EFFECTS $0 MO; NT $0 MO; NT CHEW (Calcium Carbonate (Tier sodium bicarbonate (Tier (Antacid)) 3) (antacid) tabs 3) TUMS SMOOTHIES $0 MO; NT CHEW (Calcium Carbonate (Tier Antacids - Calcium Salts (Antacid)) 3) $0 NT TUMS ULTRA 1000 CHEW $0 MO; NT ANTACID CHEW (Tier (Calcium Carbonate (Tier 3) (Antacid)) 3) $0 NT ANTACID SOFT CHEWS (Tier Antacids - Magnesium Salts CHEW 3) $0 MO; NT magnesium oxide tabs 400 (Tier calcium carbonate $0 MO; NT mg, 420 mg (antacid) chew 500 mg, (Tier 3) 750 mg, 1000 mg 3) ANTHELMINTICS - Drugs to Treat Worm calcium carbonate $0 MO; NT Infections (antacid) susp 1250 (Tier Anthelmintics mg/5ml 3) $0 MO $0 MO; NT calcium carbonate albendazole tabs or (Tier (Tier 1) (antacid) tabs 648 mg 3) $0 MO $0 ALBENZA TABS CALCIUM CARBONATE MO; NT (Tier (Tier (Albendazole) 2) TABS OR 648 MG 3) $0 MO $0 TUMS CHEW (Calcium MO; NT ivermectin tabs or (Tier (Tier 1) Carbonate (Antacid)) 3) TUMS CHEWY BITES $0 MO; NT ANTI-INFECTIVE AGENTS - MISC. - Drugs to CHEW (Calcium Carbonate (Tier Treat Bacterial Infections (Antacid)) 3) Anti-infective Agents - Misc. $0 NT $0 MO TUMS CHEWY DELIGHTS (Tier CHEW colistimethate sodium solr ij (Tier 3) 1) TUMS E-X 750 CHEW $0 MO; NT $0 MO (Calcium Carbonate (Tier IMPAVIDO CAPS (Tier (Antacid)) 3) 2) TUMS EXTRA STRENGTH $0 MO; NT $0 SL(10.6 ea metronidazole caps or 375 750 CHEW (Calcium (Tier (Tier daily); MO Carbonate (Antacid)) 3) mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 11 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 MO metronidazole in nacl soln (Tier atovaquone susp (Tier 1) 1) $0 SL(16 ea daily); metronidazole tabs or 250 Carbapenems (Tier MO mg 1) $0 MO ertapenem sodium solr (Tier $0 SL(8 ea daily); metronidazole tabs or 500 1) (Tier MO mg 1) $0 MO imipenem-cilastatin solr (Tier $0 B/D; MO 1) NEBUPENT SOLR (Tier $0 MO 2) INVANZ SOLR IJ (Tier $0 MO (Ertapenem Sodium) 2) PENTAM 300 SOLR (Tier $0 2) MO meropenem solr 1 gm (Tier $0 MO 1) tinidazole tabs or 250 mg, (Tier 500 mg 1) $0 meropenem solr 500 mg (Tier $0 MO 1) trimethoprim tabs or (Tier 1) $0 VABOMERE SOLR (Tier $0 MO 2) XIFAXAN TABS 200 MG (Tier 2) Chloramphenicols $0 QL(3 ea daily); $0 chloramphenicol sodium (Tier XIFAXAN TABS 550 MG (Tier MO succinate solr 2) 1) Anti-infective Misc. - Combinations Cyclic Lipopeptides $0 MO $0 sulfamethoxazole- (Tier daptomycin solr 500 mg (Tier trimethoprim soln 1) 1) $0 MO Glycopeptides sulfamethoxazole- (Tier trimethoprim susp $0 1) ORBACTIV SOLR (Tier $0 MO 2) sulfamethoxazole- (Tier trimethoprim tabs $0 PA; MO 1) vancomycin hcl caps or (Tier 125 mg, 250 mg Antiprotozoal Agents 1) $0 MO ALINIA TABS 500 MG (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 12 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 VANCOMYCIN HCL IN clindamycin phosphate soln MO $0 (Tier DEXTROSE SOLN 5%- ij 600 mg/4ml, 900 mg/6ml 1GM/200ML, 5%- (Tier 1) 500MG/100ML, 5%- 2) $0 750MG/150ML clindamycin phosphate soln (Tier iv 600 mg/4ml $0 1) vancomycin hcl solr iv 1 (Tier gm, 5 gm, 10 gm $0 MO 1) lincomycin hcl soln ij (Tier $0 MO 1) vancomycin hcl solr iv 500 (Tier mg 1) Monobactams $0 MO Glycylcyclines aztreonam solr (Tier $0 1) TIGECYCLINE SOLR (Tier $0 PA; LA 2) CAYSTON SOLR (Tier $0 2) tigecycline solr (Tier 1) Oxazolidinones $0 $0 linezolid soln iv 600 TYGACIL SOLR (Tier (Tier mg/300ml 1) (Tigecycline) 2) $0 Leprostatics LINEZOLID SOLN IV (Tier 600MG/300ML-0.9% $0 MO 2) dapsone tabs or 25 mg, (Tier 100 mg $0 MO 1) linezolid susr or 100 (Tier mg/5ml Lincosamides 1) CLEOCIN PHOSPHATE $0 $0 MO SOLN IV 600 MG/4ML (Tier linezolid tabs or 600 mg (Tier (Clindamycin Phosphate) 2) 1) $0 MO $0 clindamycin hcl caps or 75 (Tier SIVEXTRO SOLR IV (Tier mg, 150 mg, 300 mg 1) 2) $0 MO $0 MO clindamycin palmitate (Tier SIVEXTRO TABS OR (Tier hydrochloride solr 1) 2) $0 $0 clindamycin phosphate in ZYVOX SOLN IV 200 (Tier (Tier MG/100ML d5w soln 1) 2) clindamycin phosphate $0 Polymyxins soln ij 150 mg/ml, 9000 (Tier mg/60ml 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 13 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 polymyxin b sulfate solr ij (Tier ANTIANXIETY AGENTS - Drugs to Treat Anxiety 1) Antianxiety Agents - Misc. Streptogramins buspirone hcl tabs or 5 mg, $0 MO $0 10 mg, 15 mg, 30 mg, 7.5 (Tier SYNERCID SOLR (Tier mg 1) 2) $0 hydroxyzine hcl soln im 50 AL(Up to 64 yrs (Tier old); MO ANTIANGINAL AGENTS - Drugs to Treat Chest mg/ml Pain 1) $0 hydroxyzine hcl syrp or 10 AL(Up to 64 yrs Antianginals-Other (Tier old); MO $0 PA; MO mg/5ml 1) RANEXA TB12 (Tier $0 hydroxyzine hcl tabs or 10 AL(Up to 64 yrs 2) (Tier old); MO mg, 25 mg, 50 mg Nitrates 1) $0 $0 MO hydroxyzine pamoate caps AL(Up to 64 yrs (Tier old); MO isosorbide dinitrate tabs (Tier or 25 mg, 50 mg 1) 1) $0 MO Benzodiazepines isosorbide dinitrate tbcr (Tier $0 MO 1) alprazolam tabs or 0.25 (Tier $0 MO mg, 0.5 mg, 1 mg, 2 mg 1) isosorbide mononitrate (Tier tabs 10 mg, 20 mg $0 MO 1) alprazolam tb24 or 0.5 mg, (Tier $0 MO 1 mg, 2 mg, 3 mg 1) isosorbide mononitrate (Tier tb24 30 mg, 60 mg, 120 mg $0 MO 1) alprazolam tbdp or 0.25 (Tier $0 MO mg, 0.5 mg, 1 mg, 2 mg 1) NITROGLYCERIN (Tier LINGUAL AERS $0 MO 2) clorazepate dipotassium (Tier nitroglycerin pt24 td 0.1 $0 MO tabs 1) mg/hr, 0.2 mg/hr, 0.4 (Tier $0 MO mg/hr, 0.6 mg/hr 1) diazepam conc or 5 mg/ml (Tier $0 MO 1) nitroglycerin soln tl 0.4 (Tier mg/spray $0 MO 1) diazepam soln or 5 mg/5ml (Tier $0 MO 1) nitroglycerin subl sl 0.3 mg, (Tier 0.4 mg, 0.6 mg $0 MO 1) diazepam tabs or 2 mg, 5 (Tier $0 MO mg, 10 mg 1) NITROSTAT SUBL (Tier (Nitroglycerin) 2) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 14 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO lorazepam conc or 2 mg/ml (Tier propafenone hcl tabs (Tier 1) 1) $0 MO Antiarrhythmics Type III lorazepam soln ij 2 mg/ml, (Tier 4 mg/ml, 20 mg/10ml $0 MO 1) amiodarone hcl tabs or 100 (Tier $0 MO mg, 200 mg, 400 mg 1) lorazepam tabs or 0.5 mg, (Tier 1 mg, 2 mg 1) $0 dofetilide caps (Tier $0 MO 1) oxazepam caps 10 mg, 15 (Tier mg, 30 mg 1) $0 MO MULTAQ TABS (Tier ANTIARRHYTHMICS - Drugs to treat abnormal 2) heart rhythms ANTIASTHMATIC AND BRONCHODILATOR Antiarrhythmics Type I-A AGENTS - Drugs to Treat Lung Conditions $0 AL(Up to 64 yrs disopyramide phosphate Anti-Inflammatory Agents (Tier old); MO caps 1) $0 B/D; MO cromolyn sodium nebu in (Tier $0 MO 1) quinidine gluconate tbcr or (Tier 324 mg 1) Antiasthmatic - Monoclonal Antibodies $0 MO $0 PA; LA quinidine sulfate tabs (Tier CINQAIR SOLN (Tier 1) 2) $0 PA Antiarrhythmics Type I-B FASENRA SOSY (Tier $0 MO 2) mexiletine hcl caps (Tier 1) $0 PA; LA NUCALA SOLR (Tier Antiarrhythmics Type I-C 2) $0 SL(4 ea daily); $0 flecainide acetate tabs 100 PA; LA (Tier MO XOLAIR SOLR (Tier mg 1) 2) $0 SL(2.66 ea Bronchodilators - Anticholinergics flecainide acetate tabs 150 (Tier mg daily); MO 1) $0 Limit 2 inhalers per $0 SL(8 ea daily); ATROVENT HFA AERS (Tier flecainide acetate tabs 50 2) month;QL(0.86 (Tier MO gm daily); MO mg 1) $0 B/D; MO $0 MO ipratropium bromide soln in (Tier propafenone hcl cp12 (Tier 1) 1) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 15 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 SL(20 ea daily); SPIRIVA HANDIHALER QL(1 ea daily); FLOVENT DISKUS AEPB (Tier MO (Tier MO CAPS 2) 100 MCG/BLIST 2) Limit 1 inhaler $0 SL(8 ea daily); FLOVENT DISKUS AEPB (Tier $0 per month (60 250 MCG/BLIST MO SPIRIVA RESPIMAT (Tier actuations);SL( 2) AERS 2) 0.14 gm daily); $0 SL(40 ea daily); MO FLOVENT DISKUS AEPB (Tier 50 MCG/BLIST MO Limit 2 inhalers 2) $0 per month (30 Limit 2 inhalers TUDORZA PRESSAIR (Tier $0 AEPB actuations);QL( FLOVENT HFA AERO 110 per 2) 0.07 ea daily); (Tier MCG/ACT, 220 MCG/ACT 2) month;QL(0.8 MO gm daily); MO Limit 1 inhaler $0 Limit 1 inhaler $0 per month (60 FLOVENT HFA AERO 44 per TUDORZA PRESSAIR (Tier actuations);QL( (Tier AEPB MCG/ACT 2) month;QL(0.36 2) 0.04 ea daily); gm daily); MO MO $0 Limit 3 inhalers Leukotriene Modulators per QVAR AERS (Tier $0 MO 2) month;QL(0.87 montelukast sodium chew (Tier gm daily); MO 4 mg, 5 mg 1) Sympathomimetics $0 MO $0 MO montelukast sodium tabs (Tier 10 mg ADVAIR DISKUS AEPB (Tier 1) 2) $0 MO $0 QL(4 gm daily); zafirlukast tabs (Tier ADVAIR HFA AERO (Tier MO 1) 2) Selective Phosphodiesterase 4 (PDE4) Inhibitors albuterol sulfate nebu in $0 B/D; MO $0 QL(1 ea daily); 0.63 mg/3ml, 0.083 %, 0.5 (Tier DALIRESP TABS (Tier MO %, 1.25 mg/3ml 1) 2) $0 albuterol sulfate syrp or 2 MO Steroid Inhalants (Tier mg/5ml 1) $0 Limit 2 inhalers per month (120 $0 MO AEROSPAN AERS (Tier albuterol sulfate tabs or 2 (Tier 2) actuations);SL( mg, 4 mg 0.6 gm daily) 1) $0 MO budesonide (inhalation) $0 B/D; MO albuterol sulfate tb12 or 4 susp 0.25 mg/2ml, 0.5 (Tier (Tier mg, 8 mg 1) mg/2ml 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 16 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 QL(2 ea daily); $0 Limit 1 inhaler ANORO ELLIPTA AEPB (Tier MO STRIVERDI RESPIMAT per 2) (Tier AERS 2) month;SL(0.14 Limit 2 inhalers gm daily); MO BREO ELLIPTA AEPB $0 per month $0 MO 25MCG/INH-100MCG/INH, (Tier (Institutional terbutaline sulfate tabs or 5 (Tier mg, 2.5 mg 25MCG/INH-200MCG/INH 2) Pack);SL(2 ea 1) daily); MO $0 MO BREO ELLIPTA AEPB $0 Limit 1 inhaler TRELEGY ELLIPTA AEPB (Tier 25MCG/INH-100MCG/INH, (Tier per month;SL(2 2) 25MCG/INH-200MCG/INH 2) ea daily); MO $0 UTIBRON NEOHALER MO Limit 1 inhaler (Tier $0 CAPS 2) COMBIVENT RESPIMAT (Tier per AERS month;SL(0.2 2) Xanthines gm daily); MO $0 $0 QL(4 gm daily); aminophylline soln (Tier DULERA AERO (Tier MO 1) 2) $0 MO $0 B/D; MO theophylline tb12 100 mg, (Tier ipratropium-albuterol soln (Tier 200 mg, 300 mg, 450 mg 1) 1) $0 MO levalbuterol hcl nebu in B/D; MO theophylline tb24 400 mg, (Tier $0 600 mg 0.31 mg/3ml, 0.63 mg/3ml, (Tier 1) 1.25 mg/3ml, 1.25 1) mg/0.5ml ANTICOAGULANTS - Blood Thinners $0 MO PROAIR HFA AERS (Tier Coumarin Anticoagulants 2) $0 MO $0 MO warfarin sodium tabs (Tier PROAIR RESPICLICK (Tier 1) AEPB 2) Direct Factor Xa Inhibitors $0 MO $0 QL(1 ea daily) PROVENTIL HFA AERS (Tier BEVYXXA CAPS (Tier 2) 2) $0 QL(2 ea daily); $0 MO SEREVENT DISKUS (Tier ELIQUIS STARTER PACK AEPB MO (Tier 2) TABS 2) $0 Limit 1 inhaler $0 MO STIOLTO RESPIMAT (Tier per ELIQUIS TABS (Tier AERS 2) month;SL(0.14 2) gm daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 17 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 SL(40 ea daily); XARELTO STARTER MO (Tier clonazepam tabs or 0.5 mg (Tier MO PACK TBPK 2) 1) $0 $0 SL(20 ea daily); XARELTO TABS 10 MG, MO (Tier clonazepam tabs or 1 mg (Tier MO 15 MG, 20 MG 2) 1) Heparins And Heparinoid-Like Agents $0 SL(10 ea daily); clonazepam tabs or 2 mg (Tier MO $0 MO 1) enoxaparin sodium soln (Tier 1) clonazepam tbdp or 0.125 $0 MO $0 mg, 0.25 mg, 0.5 mg, 1 mg, (Tier MO 2 mg 1) fondaparinux sodium soln (Tier 1) $0 MO $0 DIASTAT ACUDIAL GEL (Tier MO 2) FRAGMIN SOLN (Tier 2) $0 MO DIASTAT PEDIATRIC GEL (Tier $0 MO heparin sodium (porcine) (Tier 2) soln 1) $0 MO diazepam (anticonvulsant) (Tier Thrombin Inhibitors gel 2) $0 $0 MO argatroban soln 250 (Tier DIAZEPAM GEL RE 20 mg/2.5ml (Tier 1) MG, 2.5 MG 2) $0 $0 MO IPRIVASK SOLR (Tier DIAZEPAM RECTAL GEL (Tier 2) GEL 2) $0 MO $0 MO PRADAXA CAPS (Tier ONFI SUSP (Tier 2) 2) ANTICONVULSANTS - Drugs to Treat Seizures $0 MO ONFI TABS (Tier AMPA Glutamate Receptor Antagonists 2) $0 MO Anticonvulsants - Misc. FYCOMPA SUSP (Tier $0 MO 2) APTIOM TABS (Tier $0 MO 2) FYCOMPA TABS (Tier $0 MO 2) BANZEL SUSP (Tier Anticonvulsants - Benzodiazepines 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 18 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 MO gabapentin soln or 250 MO BANZEL TABS (Tier (Tier 2) mg/5ml, 300 mg/6ml 1) $0 SL(20 ml daily) $0 MO BRIVIACT SOLN IV 50 (Tier gabapentin tabs or 600 mg, (Tier MG/5ML 2) 800 mg 1) $0 $0 MO BRIVIACT SOLN OR 10 PA; SL(20 ml (Tier daily); MO LAMICTAL XR KIT (Tier MG/ML 2) 2) $0 $0 MO BRIVIACT TABS OR 10 PA; SL(20 ea lamotrigine chew 5 mg, 25 (Tier daily); MO (Tier MG 2) mg 1) $0 $0 MO BRIVIACT TABS OR 100 PA; SL(2 ea lamotrigine tabs 25 mg, (Tier daily); MO (Tier MG 2) 100 mg, 150 mg, 200 mg 1) $0 $0 BRIVIACT TABS OR 25 PA; SL(8 ea lamotrigine tb24 25 mg, 50 MO (Tier mg, 100 mg, 200 mg, 250 (Tier MG daily); MO 2) mg, 300 mg 1) $0 PA; SL(4 ea $0 BRIVIACT TABS OR 50 (Tier levetiracetam in sodium MG daily); MO (Tier 2) chloride soln 1) $0 PA; SL(2.67 ea $0 MO BRIVIACT TABS OR 75 (Tier levetiracetam soln iv 500 MG daily); MO (Tier 2) mg/5ml 1) $0 MO $0 MO carbamazepine chew or (Tier levetiracetam soln or 100 100 mg (Tier 1) mg/ml, 500 mg/5ml 1) $0 MO levetiracetam tabs or 250 $0 MO carbamazepine cp12 or (Tier 100 mg, 200 mg, 300 mg mg, 500 mg, 750 mg, 1000 (Tier 1) mg 1) $0 MO $0 MO carbamazepine susp or (Tier levetiracetam tb24 or 500 100 mg/5ml (Tier 1) mg, 750 mg 1) $0 MO $0 QL(2 ea daily); carbamazepine tabs or 200 (Tier LYRICA CAPS 150 MG, mg (Tier MO 1) 200 MG, 225 MG 2) $0 MO $0 QL(3 ea daily); carbamazepine tb12 or 100 (Tier LYRICA CAPS 25 MG, 50 mg, 200 mg, 400 mg (Tier MO 1) MG, 75 MG, 100 MG 2) $0 MO $0 SL(2 ea daily); gabapentin caps or 100 (Tier mg, 300 mg, 400 mg LYRICA CAPS 300 MG (Tier MO 1) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 19 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 SL(30 ml daily); VIMPAT SOLN OR 10 MO LYRICA SOLN 20 MG/ML (Tier MO (Tier 2) MG/ML 2) $0 $0 MO VIMPAT TABS OR 50 MG, MO oxcarbazepine susp (Tier (Tier 1) 100 MG, 150 MG, 200 MG 2) $0 MO $0 MO oxcarbazepine tabs (Tier zonisamide caps (Tier 1) 1) $0 SL(6 ea daily); Carbamates POTIGA TABS 200 MG (Tier MO $0 2) MO felbamate susp (Tier $0 SL(3 ea daily); 1) POTIGA TABS 400 MG (Tier MO $0 2) MO felbamate tabs (Tier $0 SL(24 ea daily); 1) POTIGA TABS 50 MG (Tier MO 2) GABA Modulators $0 MO $0 MO primidone tabs or 50 mg, GABITRIL TABS 12 MG, (Tier (Tier 16 MG (Tiagabine HCl) 250 mg 1) 2) $0 PA; SL(3 ea $0 LA SPRITAM TB3D 1000 MG (Tier daily); MO SABRIL PACK (Vigabatrin) (Tier 2) 2) $0 PA; SL(12 ea $0 LA SPRITAM TB3D 250 MG (Tier daily); MO SABRIL TABS (Tier 2) 2) $0 PA; SL(6 ea $0 MO SPRITAM TB3D 500 MG (Tier daily); MO tiagabine hcl tabs (Tier 2) 1) $0 PA; SL(4 ea $0 LA SPRITAM TB3D 750 MG (Tier daily); MO vigabatrin pack (Tier 2) 1) $0 MO Hydantoins topiramate cpsp or 15 mg, (Tier 25 mg $0 1) fosphenytoin sodium soln (Tier 100 mg pe/2ml $0 MO 1) topiramate tabs or 25 mg, (Tier 50 mg, 100 mg, 200 mg $0 MO 1) fosphenytoin sodium soln (Tier 500 mg pe/10ml $0 1) VIMPAT SOLN IV 200 (Tier MG/20ML 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 20 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO PEGANONE TABS (Tier valproic acid caps (Tier 2) 1) $0 MO ANTIDEPRESSANTS - Drugs to Treat phenytoin chew or 50 mg (Tier Depression 1) phenytoin sodium extended $0 MO Alpha-2 Receptor Antagonists (Tetracyclics) caps 30 mg, 100 mg, 200 (Tier $0 MO mg, 300 mg 1) mirtazapine tabs (Tier 1) $0 phenytoin sodium soln ij (Tier $0 MO 1) mirtazapine tbdp (Tier 1) $0 phenytoin susp or 125 MO (Tier Antidepressants - Misc. mg/5ml 1) $0 SL(4.5 ea bupropion hcl tabs or 100 Succinimides (Tier daily); MO mg 1) $0 MO $0 SL(6 ea daily); CELONTIN CAPS (Tier bupropion hcl tabs or 75 2) (Tier MO mg 1) $0 MO ethosuximide caps or 250 $0 SL(4 ea daily); (Tier bupropion hcl tb12 or 100 mg 1) (Tier MO mg 1) $0 MO ethosuximide soln or 250 $0 SL(2.66 ea (Tier bupropion hcl tb12 or 150 mg/5ml 1) (Tier daily); MO mg 1) Valproic Acid $0 SL(2 ea daily); bupropion hcl tb12 or 200 $0 MO (Tier MO divalproex sodium csdr (Tier mg 1) 1) $0 SL(3 ea daily); bupropion hcl tb24 or 150 $0 MO (Tier MO divalproex sodium tb24 (Tier mg 1) 1) $0 SL(1.5 ea bupropion hcl tb24 or 300 $0 MO (Tier daily); MO divalproex sodium tbec (Tier mg 1) 1) BUPROPION $0 ST; MO $0 valproate sodium soln iv HYDROCHLORIDE ER (Tier (Tier TB24 2) 100 mg/ml, 500 mg/5ml 1) $0 ST; MO $0 valproate sodium soln or MO FORFIVO XL TB24 (Tier (Tier 2) 250 mg/5ml 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 21 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 MO fluoxetine hcl soln or 20 MO maprotiline hcl tabs (Tier (Tier 1) mg/5ml 1) $0 MO Monoamine Oxidase Inhibitors (MAOIs) fluoxetine hcl tabs or 10 $0 (Tier MO mg, 20 mg 1) EMSAM PT24 (Tier 2) $0 MO fluvoxamine maleate cp24 (Tier $0 MO 1) MARPLAN TABS (Tier 2) $0 MO fluvoxamine maleate tabs (Tier $0 MO 1) phenelzine sulfate tabs or (Tier 1) $0 MO paroxetine hcl tabs (Tier $0 MO tranylcypromine sulfate (Tier 1) tabs 1) $0 MO paroxetine hcl tb24 (Tier Selective Serotonin Reuptake Inhibitors (SSRIs) 1) $0 citalopram hydrobromide SL(20 ml daily); $0 MO (Tier MO soln 10 mg/5ml PAXIL SUSP 10 MG/5ML (Tier 1) 2) $0 citalopram hydrobromide SL(4 ea daily); $0 MO (Tier MO sertraline hcl conc or 20 tabs 10 mg (Tier 1) mg/ml 1) $0 citalopram hydrobromide SL(2 ea daily); $0 MO (Tier MO sertraline hcl tabs or 25 tabs 20 mg (Tier 1) mg, 50 mg, 100 mg 1) $0 citalopram hydrobromide SL(1 ea daily); (Tier MO Serotonin Modulators tabs 40 mg 1) nefazodone hcl tabs 50 mg, $0 MO $0 100 mg, 150 mg, 200 mg, (Tier MO 250 mg 1) escitalopram oxalate soln (Tier 1) trazodone hcl tabs or 50 $0 MO $0 MO mg, 100 mg, 150 mg, 300 (Tier escitalopram oxalate tabs (Tier mg 1) 1) $0 ST; QL(2 ea $0 MO TRINTELLIX TABS 10 MG (Tier daily); MO fluoxetine hcl caps or 10 (Tier 2) mg, 20 mg, 40 mg 1) $0 ST; QL(1 ea $0 MO TRINTELLIX TABS 20 MG (Tier daily); MO fluoxetine hcl cpdr or 90 (Tier 2) mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 22 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 SL(3.75 ea ST; QL(4 ea venlafaxine hcl tabs 100 TRINTELLIX TABS 5 MG (Tier daily); MO (Tier daily); MO 2) mg 1) $0 $0 SL(15 ea daily); VIIBRYD STARTER PACK ST; MO (Tier venlafaxine hcl tabs 25 mg (Tier MO KIT 2) 1) $0 $0 SL(10 ea daily); ST; MO venlafaxine hcl tabs 37.5 VIIBRYD TABS (Tier (Tier MO 2) mg 1) Serotonin-Norepinephrine Reuptake Inhibitors $0 SL(7.5 ea venlafaxine hcl tabs 50 mg (Tier daily); MO $0 ST; MO 1) DESVENLAFAXINE ER (Tier TB24 50 MG, 100 MG 2) $0 SL(5 ea daily); venlafaxine hcl tabs 75 mg (Tier MO $0 MO desvenlafaxine succinate (Tier 1) tb24 $0 1) venlafaxine hcl tb24 150 SL(1.5 ea (Tier daily); MO $0 MO mg duloxetine hcl cpep 20 mg, (Tier 1) 30 mg, 60 mg $0 ST; SL(1 ea 1) venlafaxine hcl tb24 225 (Tier daily); MO $0 ST; QL(2 ea mg 1) FETZIMA CP24 20 MG (Tier daily); MO $0 2) venlafaxine hcl tb24 37.5 SL(6 ea daily); (Tier MO $0 mg FETZIMA CP24 40 MG, 80 ST; QL(1 ea 1) (Tier daily); MO MG, 120 MG 2) $0 SL(3 ea daily); venlafaxine hcl tb24 75 mg (Tier MO $0 ST; MO 1) FETZIMA TITRATION (Tier PACK C4PK 2) Tricyclic Agents $0 ST; MO $0 AL(Up to 64 yrs KHEDEZLA TB24 (Tier amitriptyline hcl tabs (Tier old); MO 2) 1) $0 SL(1.5 ea $0 MO venlafaxine hcl cp24 150 (Tier daily); MO amoxapine tabs (Tier mg 1) 1) $0 SL(6 ea daily); $0 AL(Up to 64 yrs venlafaxine hcl cp24 37.5 clomipramine hcl caps or (Tier MO (Tier old); MO mg 1) 25 mg, 50 mg, 75 mg 1) $0 SL(3 ea daily); desipramine hcl tabs or 10 $0 MO venlafaxine hcl cp24 75 mg (Tier MO mg, 25 mg, 50 mg, 75 mg, (Tier 1) 100 mg, 150 mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 23 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 doxepin hcl caps or 10 mg, AL(Up to 64 yrs $0 PA; Limit 12mls 25 mg, 50 mg, 75 mg, 100 (Tier old); MO per 1) SYMLINPEN 60 SOPN (Tier mg, 150 mg 2) month;QL(0.4 $0 ml daily); MO doxepin hcl conc or 10 AL(Up to 64 yrs (Tier old); MO Antidiabetic Combinations mg/ml 1) $0 PA; SL(2 ea $0 alogliptin-metformin hcl imipramine hcl tabs or 10 AL(Up to 64 yrs (Tier daily); MO (Tier old); MO tabs mg, 25 mg, 50 mg 2) 1) $0 alogliptin-pioglitazone tabs PA; SL(2 ea $0 AL(Up to 64 yrs (Tier daily); MO imipramine pamoate caps (Tier old); MO 12.5mg-15mg 2) 1) $0 PA; SL(1.5 ea $0 alogliptin-pioglitazone tabs nortriptyline hcl caps or 10 MO (Tier daily); MO (Tier 12.5mg-30mg 2) mg, 25 mg, 50 mg, 75 mg 1) alogliptin-pioglitazone tabs $0 PA; SL(1 ea $0 nortriptyline hcl soln or 10 MO 25mg-15mg, 25mg-30mg, (Tier daily); MO (Tier 25mg-45mg, 12.5mg-45mg 2) mg/5ml 1) $0 glipizide-metformin hcl tabs SL(8 ea daily); $0 MO (Tier MO protriptyline hcl tabs (Tier 2.5mg-250mg 1) 1) $0 SL(4 ea daily); $0 AL(Up to 64 yrs glipizide-metformin hcl tabs SURMONTIL CAPS (Tier MO (Tier old); MO 5mg-500mg, 2.5mg-500mg 1) (Trimipramine Maleate) 2) $0 AL(Up to 64 yrs $0 AL(Up to 64 yrs glyburide-metformin tabs (Tier old); SL(8 ea trimipramine maleate caps 1.25mg-250mg (Tier old); MO 1) daily); MO or 25 mg, 50 mg, 100 mg 1) $0 AL(Up to 64 yrs ANTIDIABETICS - Drugs to Regulate Blood glyburide-metformin tabs (Tier old); SL(4 ea 5mg-500mg, 2.5mg-500mg Sugar 1) daily); MO Alpha-Glucosidase Inhibitors INVOKAMET TABS $0 SL(2 ea daily); $0 QL(3 ea daily); 150MG-500MG, 50MG- (Tier MO acarbose tabs (Tier MO 1000MG, 150MG-1000MG 2) 1) $0 SL(4 ea daily); INVOKAMET TABS 50MG- (Tier $0 QL(3 ea daily); 500MG MO miglitol tabs (Tier MO 2) 1) INVOKAMET XR TB24 $0 SL(2 ea daily); 150MG-500MG, 50MG- (Tier MO Antidiabetic - Amylin Analogs 1000MG, 150MG-1000MG 2) $0 PA; Limit 12mls $0 SL(4 ea daily); per INVOKAMET XR TB24 (Tier SYMLINPEN 120 SOPN (Tier 50MG-500MG MO 2) month;QL(0.4 2) ml daily); MO
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 24 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 SL(2 ea daily); pioglitazone hcl-metformin SL(3 ea daily); JANUMET TABS (Tier MO (Tier MO 2) hcl tabs 1) $0 $0 JANUMET XR TB24 SL(1 ea daily); REPAGLINIDE/METFORM SL(5 ea daily); (Tier IN HYDROCHLORIDE (Tier MO 100MG-1000MG MO 2) TABS 2) JANUMET XR TB24 $0 SL(2 ea daily); $0 SL(2 ea daily); 50MG-500MG, 50MG- (Tier MO SYNJARDY TABS 5MG- (Tier 1000MG, 12.5MG-1000MG MO 1000MG 2) 2) $0 $0 SL(2 ea daily); SYNJARDY TABS 5MG- SL(4 ea daily); JENTADUETO TABS (Tier MO (Tier MO 2) 500MG, 12.5MG-500MG 2) $0 $0 SL(1 ea daily); JENTADUETO XR TB24 SL(2 ea daily); SYNJARDY XR TB24 (Tier MO (Tier MO 2.5MG-1000MG 2) 25MG-1000MG 2) $0 $0 JENTADUETO XR TB24 SL(1 ea daily); SYNJARDY XR TB24 SL(2 ea daily); (Tier 5MG-1000MG, 10MG- (Tier MO 5MG-1000MG MO 2) 1000MG, 12.5MG-1000MG 2) $0 PA; SL(2 ea Biguanides KAZANO TABS (Tier daily); MO $0 SL(2.55 ea 2) metformin hcl tabs or 1000 (Tier daily); MO $0 mg KOMBIGLYZE XR TB24 PA; SL(2 ea 1) (Tier daily); MO 2.5MG-1000MG $0 SL(5.1 ea 2) metformin hcl tabs or 500 (Tier daily); MO KOMBIGLYZE XR TB24 $0 PA; SL(1 ea mg 1) 5MG-500MG, 5MG- (Tier daily); MO $0 SL(3 ea daily); 1000MG 2) metformin hcl tabs or 850 (Tier MO $0 PA; SL(2 ea mg 1) OSENI TABS 12.5MG- (Tier 15MG daily); MO $0 Osmotic;SL(2.5 2) metformin hcl tb24 or 1000 (Tier ea daily); MO $0 mg OSENI TABS 12.5MG- PA; SL(1.5 ea 1) (Tier daily); MO $0 30MG 2) metformin hcl tb24 or 500 Osmotic;SL(5 (Tier ea daily); MO mg OSENI TABS 25MG- $0 PA; SL(1 ea 1) 15MG, 25MG-30MG, (Tier daily); MO $0 SL(4 ea daily); 25MG-45MG, 12.5MG- metformin hcl tb24 or 500 2) (Tier MO 45MG mg 1) $0 pioglitazone hcl-glimepiride SL(1.5 ea $0 SL(2.66 ea (Tier daily); MO metformin hcl tb24 or 750 tabs (Tier daily); MO 1) mg 1) Diabetic Other
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 25 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 GLUCAGEN HYPOKIT MO PA; QL(2 ea (Tier ONGLYZA TABS 2.5 MG (Tier daily); MO SOLR 2) 2) $0 $0 GLUCAGON MO PA; QL(1 ea (Tier ONGLYZA TABS 5 MG (Tier daily); MO EMERGENCY KIT KIT 2) 2) $0 PA; SL(4 ea $0 QL(1 ea daily); KORLYM TABS (Tier daily); LA; MO TRADJENTA TABS (Tier MO 2) 2) $0 MO Dopamine Receptor Agonists - Antidiabetic PROGLYCEM SUSP (Tier 2) $0 QL(6 ea daily); CYCLOSET TABS (Tier MO Dipeptidyl Peptidase-4 (DPP-4) Inhibitors 2) $0 alogliptin benzoate tabs PA; QL(2 ea Incretin Mimetic Agents (GLP-1 Receptor (Tier daily); MO 12.5 mg 2) $0 ST; MO BYDUREON BCISE AUIJ (Tier $0 PA; QL(1 ea alogliptin benzoate tabs 25 2) (Tier daily); MO mg 2) $0 ST; MO BYDUREON PEN PEN (Tier $0 alogliptin benzoate tabs PA; QL(4 ea 2) (Tier daily); MO 6.25 mg 2) $0 ST; MO BYDUREON SRER (Tier $0 QL(1 ea daily); 2) JANUVIA TABS 100 MG (Tier MO 2) $0 ST; MO BYETTA SOPN (Tier $0 QL(4 ea daily); 2) JANUVIA TABS 25 MG (Tier MO 2) $0 ST; Limit 9mls per $0 QL(2 ea daily); VICTOZA SOPN (Tier 2) month;QL(0.3 JANUVIA TABS 50 MG (Tier MO ml daily); MO 2) $0 PA; QL(2 ea Insulin Sensitizing Agents NESINA TABS 12.5 MG (Tier daily); MO $0 SL(4 ea daily); 2) AVANDIA TABS 2 MG (Tier MO 2) $0 PA; QL(1 ea NESINA TABS 25 MG (Tier daily); MO $0 SL(2 ea daily); 2) AVANDIA TABS 4 MG (Tier MO 2) $0 PA; QL(4 ea NESINA TABS 6.25 MG (Tier daily); MO $0 SL(3 ea daily); 2) pioglitazone hcl tabs 15 mg (Tier MO 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 26 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 SL(1.5 ea $0 Limit 45mls per pioglitazone hcl tabs 30 mg (Tier daily); MO HUMULIN N SUSP (Tier month;QL(1.5 1) 2) ml daily); MO $0 SL(1 ea daily); $0 Limit 45mls per pioglitazone hcl tabs 45 mg (Tier MO HUMULIN R SOLN (Tier month;QL(1.5 1) 2) ml daily); MO Insulin $0 Limit 45mls per HUMULIN R U-500 (Tier month;QL(1.5 $0 Limit 45mls per (CONCENTRATED) SOLN HUMALOG JUNIOR (Tier 2) ml daily); MO KWIKPEN SOPN month;QL(1.5 2) ml daily); MO $0 Limit 45mls per HUMULIN R U-500 (Tier month;QL(1.5 $0 Limit 45mls per KWIKPEN SOPN HUMALOG KWIKPEN (Tier 2) ml daily); MO SOPN month;QL(1.5 2) ml daily); MO $0 Limit 45mls per $0 Limit 45mls per LANTUS SOLN (Tier month;QL(1.5 HUMALOG MIX 50/50 (Tier 2) ml daily); MO KWIKPEN SUPN month;QL(1.5 2) ml daily); MO $0 Limit 45mls per LANTUS SOLOSTAR (Tier month;QL(1.5 $0 Limit 45mls per SOPN HUMALOG MIX 50/50 (Tier 2) ml daily); MO SUSP month;QL(1.5 2) ml daily); MO $0 Limit 45mls per LEVEMIR FLEXTOUCH (Tier month;QL(1.5 $0 Limit 45mls per SOPN HUMALOG MIX 75/25 (Tier 2) ml daily); MO KWIKPEN SUPN month;QL(1.5 2) ml daily); MO $0 Limit 45mls per $0 Limit 45mls per LEVEMIR SOLN (Tier month;QL(1.5 HUMALOG MIX 75/25 (Tier 2) ml daily); MO SUSP month;QL(1.5 2) ml daily); MO $0 Limit 15mls per TOUJEO MAX SOLOSTAR (Tier month;QL(0.5 $0 Limit 45mls per SOPN HUMALOG SOCT (Tier month;QL(1.5 2) ml daily); MO 2) ml daily); MO $0 Limit 15mls per TOUJEO SOLOSTAR (Tier month;QL(0.5 $0 Limit 45mls per SOPN HUMALOG SOLN (Tier month;QL(1.5 2) ml daily); MO 2) ml daily); MO $0 Limit 45mls per TRESIBA FLEXTOUCH (Tier month;QL(1.5 $0 Limit 45mls per SOPN 100 UNIT/ML HUMULIN 70/30 KWIKPEN (Tier 2) ml daily); MO SUPN month;QL(1.5 2) ml daily); MO $0 Limit 27mls per TRESIBA FLEXTOUCH (Tier month;QL(0.9 $0 Limit 45mls per SOPN 200 UNIT/ML HUMULIN 70/30 SUSP (Tier month;QL(1.5 2) ml daily); MO 2) ml daily); MO Meglitinide Analogues $0 Limit 45mls per $0 QL(3 ea daily); HUMULIN N KWIKPEN (Tier month;QL(1.5 SUPN nateglinide tabs (Tier MO 2) ml daily); MO 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 27 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 SL(32 ea daily); $0 AL(Up to 64 yrs repaglinide tabs 0.5 mg (Tier glyburide micronized tabs (Tier old); SL(8 ea MO 1.5 mg 1) 1) daily); MO $0 SL(16 ea daily); $0 AL(Up to 64 yrs repaglinide tabs 1 mg (Tier MO glyburide micronized tabs 3 (Tier old); SL(4 ea mg 1) 1) daily); MO $0 SL(8 ea daily); $0 AL(Up to 64 yrs repaglinide tabs 2 mg (Tier MO glyburide micronized tabs 6 (Tier old); SL(2 ea mg 1) 1) daily); MO Sodium-Glucose Co-Transporter 2 (SGLT2) $0 AL(Up to 64 yrs $0 MO glyburide tabs or 1.25 mg (Tier old); SL(16 ea INVOKANA TABS (Tier 1) daily); MO 2) $0 AL(Up to 64 yrs $0 MO glyburide tabs or 2.5 mg (Tier old); SL(8 ea JARDIANCE TABS (Tier 1) daily); MO 2) $0 AL(Up to 64 yrs glyburide tabs or 5 mg (Tier old); SL(4 ea Sulfonylureas 1) daily); MO $0 SL(8 ea daily); $0 SL(4 ea daily); glimepiride tabs 1 mg (Tier MO tolazamide tabs 250 mg (Tier MO 1) 1) $0 SL(4 ea daily); $0 SL(2 ea daily); glimepiride tabs 2 mg (Tier MO tolazamide tabs 500 mg (Tier MO 1) 1) $0 SL(2 ea daily); $0 SL(6 ea daily); glimepiride tabs 4 mg (Tier MO tolbutamide tabs (Tier MO 1) 1) $0 SL(4 ea daily); glipizide tabs or 10 mg (Tier MO ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs 1) to Treat Diarrhea $0 SL(8 ea daily); Antidiarrheal/Probiotic Agents - Misc. glipizide tabs or 5 mg (Tier MO $0 MO; NT 1) bismuth subsalicylate chew (Tier or 262 mg $0 SL(2 ea daily); 3) glipizide tb24 or 10 mg (Tier MO bismuth subsalicylate susp $0 MO; NT 1) or 262 mg/15ml, 525 (Tier $0 SL(8 ea daily); mg/30ml, 527 mg/30ml 3) glipizide tb24 or 2.5 mg (Tier MO $0 NT 1) bismuth subsalicylate susp (Tier or 525 mg/15ml $0 SL(4 ea daily); 3) glipizide tb24 or 5 mg (Tier MO $0 NT 1) bismuth subsalicylate tabs (Tier or 262 mg 3) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 28 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Antiperistaltic Agents Opioid Antagonists $0 MO $0 diphenoxylate w/ atropine (Tier naloxone hcl sosy ij 2 (Tier tabs 1) mg/2ml 1) $0 RX/OTC; MO; $0 MO IMODIUM A-D CAPS 2 MG (Tier NT naltrexone hcl tabs or (Tier (Loperamide HCl) 3) 1) $0 Over-the- ANTIEMETICS - Drugs to Treat Nausea and loperamide hcl caps or 2 (Tier counter;RX/OT mg Vomiting 3) C; MO; NT 5-HT3 Receptor Antagonists $0 RX/OTC; MO loperamide hcl caps or 2 $0 B/D; MO (Tier granisetron hcl tabs or 1 mg 1) (Tier mg 1) $0 MO; NT loperamide hcl liqd or 1 $0 (Tier ondansetron hcl soln ij 4 MO mg/5ml, 1 mg/7.5ml 3) (Tier mg/2ml, 40 mg/20ml 1) $0 MO; NT loperamide hcl susp or 1 $0 B/D; MO (Tier ondansetron hcl soln or 4 mg/7.5ml 3) (Tier mg/5ml 1) $0 MO; NT loperamide hcl tabs or 2 $0 B/D (Tier ondansetron hcl tabs or 24 mg 3) (Tier mg 1) ANTIDOTES AND SPECIFIC ANTAGONISTS $0 B/D; MO ondansetron hcl tabs or 4 (Tier Antidotes - Chelating Agents mg, 8 mg 1) $0 LA $0 B/D; MO EXJADE TBSO (Tier ondansetron tbdp (Tier 2) 1) $0 PA; LA; MO FERRIPROX TABS 500 (Tier Antiemetics - Anticholinergic MG 2) $0 RX/OTC; MO meclizine hcl tabs or 25 (Tier $0 mg, 12.5 mg JADENU SPRINKLE PACK (Tier 1) 2) $0 MO $0 scopolamine pt72 (Tier JADENU TABS (Tier 1) 2) $0 MO TIGAN SOLN IM 100 (Tier Antidotes and Specific Antagonists MG/ML 2) $0 MO $0 MO VISTOGARD PACK (Tier TRANSDERM-SCOP PT72 (Tier 2) 2) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 29 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO TRANSDERM-SCOP PT72 (Tier caspofungin acetate solr 70 (Tier (Scopolamine) 2) mg 1) Antiemetics - Miscellaneous $0 $0 ERAXIS SOLR 100 MG (Tier B/D; MO 2) CESAMET CAPS (Tier 2) $0 $0 MYCAMINE SOLR 100 MG (Tier B/D; MO 2) dronabinol caps (Tier 1) $0 MO MYCAMINE SOLR 50 MG (Tier $0 B/D; MO 2) SYNDROS SOLN (Tier 2) Antifungals Substance P/Neurokinin 1 (NK1) Receptor $0 PA $0 ABELCET SUSP (Tier PA; MO 2) aprepitant caps 40 mg (Tier 1) $0 PA AMBISOME SUSR (Tier $0 B/D; MO aprepitant caps 80 mg, 125 (Tier 2) mg 1) $0 PA; MO amphotericin b solr ij 50 mg (Tier $0 B/D 1) VARUBI TABS OR 90 MG (Tier 2) $0 MO flucytosine caps 500 mg (Tier ANTIFUNGALS - Drugs to Treat Fungal Infections 1) $0 MO Antifungal - Glucan Synthesis Inhibitors griseofulvin microsize susp (Tier $0 1) CANCIDAS SOLR 50 MG (Tier (Caspofungin Acetate) $0 MO 2) griseofulvin microsize tabs (Tier $0 MO 1) CANCIDAS SOLR 70 MG (Tier (Caspofungin Acetate) $0 MO 2) griseofulvin ultramicrosize (Tier $0 tabs 1) CASPOFUNGIN ACETATE (Tier SOLR 50 MG $0 MO 2) nystatin tabs (Tier $0 1) caspofungin acetate solr 50 (Tier mg $0 MO 1) terbinafine hcl tabs or (Tier $0 MO 1) CASPOFUNGIN ACETATE (Tier SOLR 70 MG 2) Imidazole-Related Antifungals
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 30 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO CRESEMBA CAPS OR (Tier voriconazole tabs or 50 mg, (Tier 186 MG 2) 200 mg 1) $0 CRESEMBA SOLR IV 372 (Tier ANTIHISTAMINES - Drugs to Treat Allergies MG 2) Antihistamines - Alkylamines fluconazole in dextrose $0 $0 MO; NT soln 200mg/100ml- (Tier ALA-HIST IR TABS (Tier 56mg/ml, 400mg/200ml- 1) 3) 56mg/ml $0 NT fluconazole in nacl soln $0 chlorpheniramine maleate (Tier 200mg/100ml-0.9%, (Tier syrp or 2 mg/5ml 3) 400mg/200ml-0.9% 1) $0 MO; NT $0 MO chlorpheniramine maleate fluconazole susr or 10 (Tier (Tier tabs or 4 mg 3) mg/ml, 40 mg/ml 1) $0 MO; NT $0 chlorpheniramine maleate fluconazole tabs or 50 mg, MO (Tier (Tier tbcr or 12 mg 3) 100 mg, 150 mg, 200 mg 1) $0 NT $0 MO itraconazole caps or 100 ED CHLORPED LIQD (Tier (Tier 3) mg 1) $0 NT $0 MO HISTEX PD LIQD (Tier ketoconazole tabs or (Tier 3) 1) $0 NT $0 HISTEX SYRP 2.5 NOXAFIL SOLN IV 300 (Tier (Tier MG/5ML 3) MG/16.7ML 2) $0 NT $0 NOXAFIL SUSP OR 40 MO PEDIAVENT CHEW (Tier (Tier 3) MG/ML 2) $0 NT $0 NOXAFIL TBEC OR 100 MO PEDIAVENT SYRP (Tier (Tier 3) MG 2) $0 NT $0 triprolidine hcl liqd or 0.313 (Tier voriconazole solr iv 200 mg (Tier mg/ml 3) 1) $0 MO; NT $0 MO triprolidine hcl liqd or 0.625 voriconazole susr or 40 (Tier (Tier mg/ml 3) mg/ml 1) $0 NT VANACLEAR PD LIQD (Tier (Triprolidine HCl) 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 31 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 NT VANAHIST PD LIQD (Tier VANAMINE PD LIQD (Tier (Triprolidine HCl) 3) (Diphenhydramine HCl) 3) Antihistamines - Ethanolamines Antihistamines - Non-Sedating $0 AL(Up to 64 yrs $0 MO; NT carbinoxamine maleate cetirizine hcl chew 5 mg, 10 (Tier old); MO (Tier soln 4 mg/5ml 1) mg 3) $0 AL(Up to 64 yrs $0 RX/OTC; MO carbinoxamine maleate cetirizine hcl soln 1 mg/ml, (Tier old); MO (Tier tabs 4 mg 1) 5 mg/5ml 1) $0 clemastine fumarate tabs MO; NT $0 Over-the- (Tier cetirizine hcl soln 1 mg/ml, (Tier counter;RX/OT or 1.34 mg 5 mg/5ml 3) 3) C; MO; NT $0 AL(Up to 64 yrs clemastine fumarate tabs $0 Over-the- (Tier old); MO cetirizine hcl syrp 1 mg/ml, (Tier counter;RX/OT or 2.68 mg 5 mg/5ml 1) 3) C; MO; NT $0 MO; NT $0 MO; NT diphenhydramine hcl caps (Tier cetirizine hcl tabs 5 mg, 10 or 25 mg (Tier 3) mg 3) $0 diphenhydramine hcl caps RX/OTC; MO; $0 MO (Tier NT or 50 mg desloratadine tabs (Tier 3) 1) $0 diphenhydramine hcl elix or AL(Up to 64 yrs $0 MO (Tier old); RX/OTC 12.5 mg/5ml desloratadine tbdp (Tier 1) 1) diphenhydramine hcl liqd or $0 MO; NT $0 MO; NT 25 mg/10ml, 50 mg/20ml, (Tier fexofenadine hcl susp (Tier 12.5 mg/5ml 3) 3) $0 NT $0 MO; NT diphenhydramine hcl liqd or (Tier 6.25 mg/ml fexofenadine hcl tabs (Tier 3) 3) $0 MO levocetirizine $0 RX/OTC; MO diphenhydramine hcl soln ij (Tier 50 mg/ml dihydrochloride soln 2.5 (Tier 1) mg/5ml 1) $0 MO; NT $0 RX/OTC; MO diphenhydramine hcl tabs (Tier levocetirizine or 25 mg (Tier 3) dihydrochloride tabs 5 mg 1) $0 NT $0 MO; NT SILPHEN COUGH SYRP (Tier loratadine soln or 5 mg/5ml (Tier 3) 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 32 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT Antihyperlipidemics - Misc. loratadine syrp or 5 mg/5ml (Tier 3) $0 PA; LA KYNAMRO SOSY (Tier $0 MO; NT 2) loratadine tabs or 10 mg (Tier $0 MO 3) omega-3-acid ethyl esters (Tier $0 MO; NT caps 1) loratadine tbdp or 10 mg (Tier 3) $0 ST; MO VASCEPA CAPS (Tier ZYRTEC CHILDRENS $0 RX/OTC; MO; 2) ALLERGY SOLN (Tier NT (Cetirizine HCl) 3) Bile Acid Sequestrants $0 MO Antihistamines - Phenothiazines cholestyramine light pack (Tier $0 promethazine hcl soln ij 25 AL(Up to 64 yrs 1) (Tier old); MO mg/ml, 50 mg/ml $0 MO 1) cholestyramine light powd (Tier $0 promethazine hcl soln or AL(Up to 64 yrs 1) (Tier old); MO 6.25 mg/5ml $0 MO 1) cholestyramine pack or 4 (Tier $0 gm promethazine hcl supp re AL(Up to 64 yrs 1) (Tier old); MO 25 mg, 12.5 mg $0 MO 1) cholestyramine powd or 4 (Tier $0 gm/dose promethazine hcl syrp or AL(Up to 64 yrs 1) (Tier old); MO 6.25 mg/5ml $0 MO 1) colesevelam hcl pack (Tier $0 promethazine hcl tabs or AL(Up to 64 yrs 1) (Tier old); MO $0 MO 25 mg, 50 mg, 12.5 mg 1) colesevelam hcl tabs (Tier Antihistamines - Piperazines 1) $0 NT $0 MO AHIST TABS (Tier colestipol hcl gran (Tier 3) 1) Antihistamines - Piperidines $0 MO colestipol hcl pack (Tier $0 cyproheptadine hcl syrp or AL(Up to 64 yrs 1) (Tier old); MO 2 mg/5ml 1) $0 MO colestipol hcl tabs (Tier $0 cyproheptadine hcl tabs or AL(Up to 64 yrs 1) (Tier old); MO 4 mg 1) $0 MO WELCHOL PACK (Tier ANTIHYPERLIPIDEMICS - Drugs to Treat High (Colesevelam HCl) 2) Cholesterol You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 33 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO WELCHOL TABS (Tier fluvastatin sodium tb24 80 (Tier (Colesevelam HCl) 2) mg 1) $0 QL(1 ea daily); Fibric Acid Derivatives lovastatin tabs 10 mg, 20 (Tier MO $0 SL(4.33 ea mg 1) ANTARA CAPS 30 MG (Tier daily); MO 2) $0 QL(2 ea daily); lovastatin tabs 40 mg (Tier MO $0 SL(1.44 ea 1) ANTARA CAPS 90 MG (Tier daily); MO 2) $0 QL(1 ea daily); pravastatin sodium tabs (Tier MO $0 MO 1) choline fenofibrate cpdr (Tier 1) $0 QL(1 ea daily); $0 rosuvastatin calcium tabs (Tier MO fenofibrate micronized caps SL(1 ea daily); 1) (Tier MO 130 mg $0 1) simvastatin tabs or 5 mg, QL(1 ea daily); $0 (Tier MO fenofibrate micronized caps SL(3.02 ea 10 mg, 20 mg, 40 mg 1) (Tier daily); MO 43 mg 1) $0 SL(1 ea daily); simvastatin tabs or 80 mg (Tier MO $0 MO fenofibrate micronized caps (Tier 1) 67 mg, 134 mg, 200 mg 1) Intestinal Cholesterol Absorption Inhibitors $0 $0 fenofibrate tabs 48 mg, 54 MO QL(1 ea daily); (Tier ezetimibe tabs (Tier MO mg, 145 mg, 160 mg 1) 1) $0 MO Microsomal Triglyceride Transfer Protein (MTP) gemfibrozil tabs or (Tier $0 1) PA; SL(6 ea JUXTAPID CAPS 10 MG (Tier daily); LA; MO $0 MO 2) TRIGLIDE TABS (Tier $0 2) PA; SL(3 ea JUXTAPID CAPS 20 MG (Tier daily); LA; MO HMG CoA Reductase Inhibitors 2) $0 MO $0 PA; SL(2 ea atorvastatin calcium tabs (Tier JUXTAPID CAPS 30 MG (Tier daily); LA; MO 1) 2) $0 QL(3 ea daily); $0 fluvastatin sodium caps 20 PA; SL(1.5 ea (Tier MO JUXTAPID CAPS 40 MG (Tier daily); LA; MO mg 1) 2) $0 QL(2 ea daily); $0 fluvastatin sodium caps 40 PA; SL(12 ea (Tier MO JUXTAPID CAPS 5 MG (Tier daily); LA; MO mg 1) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 34 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 PA; SL(1 ea captopril tabs or 25 mg, 50 MO JUXTAPID CAPS 60 MG (Tier daily); LA; MO (Tier 2) mg, 100 mg, 12.5 mg 1) $0 Nicotinic Acid Derivatives enalapril maleate tabs or SL(4 ea daily); (Tier MO $0 MO 10 mg niacin (antihyperlipidemic) (Tier 1) tbcr $0 1) enalapril maleate tabs or SL(16 ea daily); (Tier MO Proprotein Convertase Subtilisin/Kexin Type 9 2.5 mg 1) PA; Limit 2mls $0 $0 enalapril maleate tabs or SL(2 ea daily); PRALUENT SOPN 150 per 28 (Tier MO (Tier 20 mg MG/ML 2) days;SL(0.08 1) ml daily) $0 enalapril maleate tabs or 5 SL(8 ea daily); PA; Limit 4mls (Tier MO $0 mg PRALUENT SOPN 75 (Tier per 28 1) MG/ML 2) days;SL(0.15 $0 ml daily) MO fosinopril sodium tabs (Tier $0 PA; Limit 2mls 1) PRALUENT SOSY 150 (Tier per 28 lisinopril tabs or 5 mg, 10 $0 MO MG/ML 2) days;SL(0.08 mg, 20 mg, 30 mg, 40 mg, (Tier ml daily) 2.5 mg 1) $0 PA; Limit 4mls $0 MO PRALUENT SOSY 75 (Tier per 28 moexipril hcl tabs (Tier MG/ML 2) days;SL(0.15 1) ml daily) $0 SL(8 ea daily); $0 perindopril erbumine tabs 2 REPATHA PUSHTRONEX PA (Tier MO (Tier mg 1) SYSTEM SOCT 2) $0 SL(4 ea daily); perindopril erbumine tabs 4 $0 PA (Tier MO REPATHA SOSY (Tier mg 1) 2) $0 SL(2 ea daily); $0 perindopril erbumine tabs 8 REPATHA SURECLICK PA (Tier MO (Tier mg 1) SOAJ 2) $0 MO ANTIHYPERTENSIVES - Drugs to Treat High quinapril hcl tabs (Tier Blood Pressure 1) ACE Inhibitors $0 MO $0 MO ramipril caps (Tier benazepril hcl tabs or 5 (Tier 1) mg, 10 mg, 20 mg, 40 mg 1) $0 MO trandolapril tabs (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 35 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Agents for Pheochromocytoma $0 MO prazosin hcl caps (Tier $0 MO 1) DEMSER CAPS (Tier 2) $0 MO terazosin hcl caps (Tier $0 MO phenoxybenzamine hcl (Tier 1) caps or 1) Antihypertensive Combinations Angiotensin II Receptor Antagonists $0 MO amlodipine besylate- (Tier $0 MO benazepril hcl caps 1) candesartan cilexetil tabs (Tier 1) $0 MO atenolol & chlorthalidone (Tier $0 MO tabs 1) DIOVAN TABS (Valsartan) (Tier 2) $0 MO benazepril & (Tier $0 MO hydrochlorothiazide tabs 1) eprosartan mesylate tabs (Tier 1) $0 MO bisoprolol & (Tier $0 MO hydrochlorothiazide tabs 1) irbesartan tabs (Tier 1) $0 MO candesartan cilexetil- (Tier $0 MO hydrochlorothiazide tabs 1) losartan potassium tabs (Tier 1) $0 MO captopril & (Tier $0 MO hydrochlorothiazide tabs 1) valsartan tabs (Tier 1) $0 MO CORZIDE TABS 80MG- (Tier Antiadrenergic Antihypertensives 5MG 2) $0 MO DIOVAN HCT TABS $0 MO clonidine hcl tabs or 0.1 (Tier mg, 0.2 mg, 0.3 mg (Valsartan- (Tier 1) Hydrochlorothiazide) 2) $0 MO $0 MO clonidine ptwk (Tier enalapril maleate & (Tier 1) hydrochlorothiazide tabs 1) $0 MO $0 MO doxazosin mesylate tabs (Tier fosinopril sodium & (Tier 1) hydrochlorothiazide tabs 1) $0 AL(Up to 64 yrs $0 MO guanfacine hcl tabs (Tier old); MO irbesartan- (Tier 1) hydrochlorothiazide tabs 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 36 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 lisinopril & MO ANTIMALARIALS - Drugs to Treat Malaria (Tier (Parasitic Infections) hydrochlorothiazide tabs 1) $0 MO Antimalarial Combinations losartan potassium & $0 (Tier atovaquone-proguanil hcl MO hydrochlorothiazide tabs 1) (Tier tabs 250mg-100mg 1) metoprolol & $0 MO hydrochlorothiazide tabs $0 MO (Tier COARTEM TABS (Tier 50mg-25mg, 100mg-25mg, 1) 100mg-50mg 2) $0 MO Antimalarials moexipril- (Tier hydrochlorothiazide tabs $0 MO 1) chloroquine phosphate tabs (Tier or 250 mg, 500 mg $0 MO 1) nadolol & (Tier bendroflumethiazide tabs $0 1) DARAPRIM TABS (Tier $0 MO 2) quinapril- (Tier hydrochlorothiazide tabs $0 MO 1) hydroxychloroquine sulfate (Tier tabs or $0 MO 1) TEKTURNA HCT TABS (Tier $0 MO 2) mefloquine hcl tabs (Tier $0 MO 1) valsartan- (Tier hydrochlorothiazide tabs $0 MO 1) primaquine phosphate tabs (Tier Direct Renin Inhibitors 1) $0 MO $0 MO PRIMAQUINE (Tier TEKTURNA TABS (Tier PHOSPHATE TABS 2) 2) $0 Selective Aldosterone Receptor Antagonists PA; MO quinine sulfate caps or (Tier $0 MO 1) eplerenone tabs (Tier 1) ANTIMYASTHENIC/CHOLINERGIC AGENTS Vasodilators Antimyasthenic/Cholinergic Agents $0 MO $0 hydralazine hcl tabs or 10 (Tier mg, 25 mg, 50 mg, 100 mg GUANIDINE HCL TABS (Tier 1) 2) $0 MO $0 MO minoxidil tabs or 10 mg, 2.5 (Tier pyridostigmine bromide mg (Tier 1) tabs or 60 mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 37 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 pyridostigmine bromide MO LA (Tier SIRTURO TABS (Tier tbcr or 180 mg 1) 2) ANTIMYCOBACTERIAL AGENTS - Drugs to $0 MO Treat Tuberculosis (Bacterial Infections) TRECATOR TABS (Tier 2) Anti TB Combinations $0 ANTINEOPLASTICS AND ADJUNCTIVE MO THERAPIES - Drugs to Treat Cancer isoniazid & rifampin caps (Tier 1) Alkylating Agents $0 $0 MO ALKERAN TABS OR 2 MG B/D; MO RIFATER TABS (Tier (Tier 2) (Melphalan) 2) Antimycobacterial Agents $0 $0 BENDEKA SOLN (Tier MO 2) aminosalicylic acid pack or (Tier 1) $0 BICNU SOLR (Carmustine) (Tier $0 2) CAPASTAT SULFATE (Tier SOLR 2) $0 busulfan soln (Tier $0 MO ethambutol hcl tabs or 100 (Tier 1) mg, 400 mg 1) $0 carboplatin soln (Tier $0 MO isoniazid tabs or 100 mg, (Tier 1) 300 mg 1) $0 carmustine solr (Tier $0 MO 1) PRIFTIN TABS (Tier 2) cisplatin soln 50 mg/50ml, $0 $0 100 mg/100ml, 200 (Tier MO mg/200ml 1) pyrazinamide tabs or (Tier $0 1) cyclophosphamide caps or B/D; MO $0 MO (Tier 25 mg, 50 mg 1) rifabutin caps (Tier 1) CYCLOPHOSPHAMIDE $0 B/D; MO $0 MO CAPS OR 25 MG, 50 MG (Tier rifampin caps or 150 mg, (Tier (Cyclophosphamide) 2) 300 mg 1) $0 $0 EVOMELA SOLR (Tier rifampin solr iv 600 mg (Tier 2) 1) $0 GLEOSTINE CAPS 10 MG (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 38 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 GLEOSTINE CAPS 40 MG, MO (Tier TREANDA SOLR (Tier 100 MG 2) 2) $0 MO $0 LA HEXALEN CAPS (Tier YONDELIS SOLR (Tier 2) 2) $0 $0 MO IFEX SOLR 3 GM (Tier ZANOSAR SOLR (Tier 2) 2) $0 Antimetabolites ifosfamide soln 1 gm/20ml, (Tier 3 gm/60ml 1) $0 ALIMTA SOLR (Tier $0 2) ifosfamide solr 1 gm (Tier 1) $0 ARRANON SOLN (Tier $0 2) IFOSFAMIDE SOLR 3 GM (Tier $0 2) azacitidine susr (Tier $0 MO 1) LEUKERAN TABS (Tier $0 2) PA cladribine soln (Tier $0 1) melphalan hcl solr (Tier 1) $0 clofarabine soln (Tier $0 B/D; MO 1) melphalan tabs (Tier 1) $0 PA cytarabine soln (Tier $0 1) MUSTARGEN SOLR (Tier $0 2) decitabine solr (Tier $0 1) oxaliplatin soln (Tier $0 1) fludarabine phosphate solr (Tier $0 50 mg 1) oxaliplatin solr (Tier 1) fluorouracil soln iv 1 $0 PA gm/20ml, 5 gm/100ml, 2.5 (Tier $0 gm/50ml, 500 mg/10ml 1) TEMODAR SOLR (Tier 2) $0 FOLOTYN SOLN (Tier $0 2) thiotepa solr ij (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 39 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 gemcitabine hcl soln (Tier ARZERRA CONC (Tier 1) 2) $0 $0 LA gemcitabine hcl solr (Tier BAVENCIO SOLN (Tier 1) 2) GEMCITABINE $0 $0 MO HYDROCHLORIDE SOLN (Tier BESPONSA SOLR (Tier 2 GM/20ML, 200 MG/2ML 2) 2) $0 MO $0 mercaptopurine tabs or (Tier BLINCYTO SOLR (Tier 1) 2) methotrexate sodium soln ij $0 $0 1 gm/40ml, 50 mg/2ml, 250 (Tier CAMPATH SOLN (Tier mg/10ml 1) 2) $0 $0 LA methotrexate sodium solr ij (Tier DARZALEX SOLN (Tier 1 gm 1) 2) methotrexate sodium tabs $0 MO $0 or 5 mg, 10 mg, 15 mg, 2.5 (Tier EMPLICITI SOLR (Tier mg, 7.5 mg 1) 2) $0 PA $0 PURIXAN SUSP (Tier ERBITUX SOLN (Tier 2) 2) $0 MO $0 LA TABLOID TABS (Tier GAZYVA SOLN (Tier 2) 2) $0 PA; MO $0 XATMEP SOLN (Tier HERCEPTIN SOLR (Tier 2) 2) Antineoplastic - Angiogenesis Inhibitors $0 LA IMFINZI SOLN (Tier $0 2) AVASTIN SOLN (Tier 2) $0 PA KADCYLA SOLR (Tier $0 LA 2) CYRAMZA SOLN (Tier 2) $0 KEYTRUDA SOLN (Tier $0 PA 2) ZALTRAP SOLN (Tier 2) $0 LA; MO LARTRUVO SOLN (Tier Antineoplastic - Antibodies 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 40 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO Antineoplastic - Hormonal and Related Agents MYLOTARG SOLR (Tier $0 2) MO anastrozole tabs or (Tier $0 1) OPDIVO SOLN (Tier $0 2) MO bicalutamide tabs (Tier $0 1) PERJETA SOLN (Tier 2) $0 MO DEPO-PROVERA SUSP (Tier $0 2) PORTRAZZA SOLN (Tier 2) $0 ELIGARD KIT (Tier $0 2) POTELIGEO SOLN (Tier 2) $0 MO EMCYT CAPS (Tier $0 2) RITUXAN SOLN (Tier 2) $0 PA ERLEADA TABS (Tier $0 PA 2) TECENTRIQ SOLN (Tier $0 2) MO exemestane tabs (Tier $0 1) VECTIBIX SOLN (Tier $0 2) MO FARESTON TABS (Tier $0 PA 2) YERVOY SOLN (Tier 2) $0 FASLODEX SOLN (Tier Antineoplastic - BCL-2 Inhibitors 2) $0 $0 VENCLEXTA STARTING PA; LA; MO (Tier FIRMAGON SOLR (Tier PACK TBPK 2) 2) $0 PA; LA; MO $0 MO VENCLEXTA TABS (Tier flutamide caps (Tier 2) 1) Antineoplastic - Hedgehog Pathway Inhibitors HYDROXYPROGESTERO $0 $0 NE CAPROATE SOLN IM (Tier LA 1.25 GM/5ML 2) ERIVEDGE CAPS (Tier 2) $0 MO $0 letrozole tabs (Tier PA; LA 1) ODOMZO CAPS (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 41 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 PA; LA leuprolide acetate kit ij (Tier XTANDI CAPS (Tier 1) 2) $0 $0 LUPRON DEPOT (1- PA (Tier YONSA TABS (Tier MONTH) KIT 2) 2) $0 $0 LUPRON DEPOT (3- (Tier ZOLADEX IMPL (Tier MONTH) KIT 2) 2) $0 $0 LUPRON DEPOT (4- PA (Tier ZYTIGA TABS (Tier MONTH) KIT 2) 2) $0 LUPRON DEPOT (6- Antineoplastic - Immunomodulators (Tier $0 MONTH) KIT 2) LA POMALYST CAPS (Tier $0 MO 2) LYSODREN TABS (Tier 2) Antineoplastic Antibiotics $0 $0 PA megestrol acetate susp or AL(Up to 64 yrs (Tier old); MO bleomycin sulfate solr (Tier 40 mg/ml, 400 mg/10ml 1) 1) $0 $0 megestrol acetate tabs or AL(Up to 64 yrs (Tier old); MO COSMEGEN SOLR (Tier 20 mg, 40 mg 1) 2) $0 MO $0 nilutamide tabs (Tier dactinomycin solr (Tier 1) 1) $0 MO $0 SOLTAMOX SOLN (Tier daunorubicin hcl soln (Tier 2) 1) $0 MO $0 tamoxifen citrate tabs or 10 DAUNORUBICIN (Tier (Tier HYDROCHLORIDE SOLN mg, 20 mg 1) 2) $0 $0 TRELSTAR MIXJECT doxorubicin hcl liposomal (Tier (Tier inj SUSR 2) 1) $0 $0 doxorubicin hcl soln 2 (Tier TRELSTAR SUSR (Tier mg/ml 2) 1) $0 $0 doxorubicin hcl solr 10 mg, (Tier VANTAS KIT (Tier 50 mg 2) 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 42 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 PA; LA epirubicin hcl soln (Tier ALECENSA CAPS (Tier 1) 2) $0 $0 MO idarubicin hcl soln (Tier ALIQOPA SOLR (Tier 1) 2) $0 $0 mitomycin solr iv 5 mg, 20 PA; LA (Tier ALUNBRIG TABS (Tier mg, 40 mg 1) 2) $0 $0 PA; LA mitoxantrone hcl conc (Tier ALUNBRIG TBPK (Tier 1) 2) $0 $0 PA VALSTAR SOLN (Tier BELEODAQ SOLR (Tier 2) 2) Antineoplastic Combinations $0 BORTEZOMIB SOLR (Tier $0 PA KISQALI FEMARA 200 (Tier 2) DOSE TBPK 2) $0 PA BOSULIF TABS (Tier $0 PA 2) KISQALI FEMARA 400 (Tier DOSE TBPK 2) $0 PA; MO BRAFTOVI CAPS (Tier $0 PA 2) KISQALI FEMARA 600 (Tier DOSE TBPK 2) $0 PA CABOMETYX TABS (Tier $0 PA 2) LONSURF TABS (Tier 2) $0 PA; LA; MO CALQUENCE CAPS (Tier $0 2) RITUXAN HYCELA SOLN (Tier 2) $0 PA; LA; MO $0 CAPRELSA TABS (Tier MO 2) VYXEOS SUSR (Tier 2) $0 PA; LA; MO COMETRIQ KIT (Tier Antineoplastic Enzyme Inhibitors 2) $0 PA $0 PA; LA AFINITOR DISPERZ TBSO (Tier COTELLIC TABS (Tier 2) 2) $0 PA $0 PA; LA AFINITOR TABS (Tier FARYDAK CAPS (Tier 2) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 43 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 PA; LA; MO $0 GILOTRIF TABS (Tier KYPROLIS SOLR (Tier 2) 2) $0 PA $0 PA; MO GLEEVEC TABS 400 MG (Tier LENVIMA 10 MG DAILY (Tier (Imatinib Mesylate) 2) DOSE CPPK 2) $0 $0 LA LENVIMA 12MG DAILY PA IBRANCE CAPS (Tier (Tier 2) DOSE CPPK 2) $0 $0 PA; LA; MO LENVIMA 14 MG DAILY PA; MO ICLUSIG TABS (Tier (Tier 2) DOSE CPPK 2) $0 $0 PA LENVIMA 18 MG DAILY PA; MO IDHIFA TABS (Tier (Tier 2) DOSE CPPK 2) $0 $0 PA LENVIMA 20 MG DAILY PA; MO imatinib mesylate tabs (Tier (Tier 1) DOSE CPPK 2) $0 PA; LA; MO $0 PA; MO IMBRUVICA CAPS 140 (Tier LENVIMA 24 MG DAILY (Tier MG 2) DOSE CPPK 2) $0 $0 PA; LA LENVIMA 4 MG DAILY PA IMBRUVICA CAPS 70 MG (Tier (Tier 2) DOSE CPPK 2) $0 $0 IMBRUVICA TABS 140 PA; LA LENVIMA 8 MG DAILY PA; MO MG, 280 MG, 420 MG, 560 (Tier (Tier DOSE CPPK MG 2) 2) $0 PA; LA $0 PA; LA; MO INLYTA TABS (Tier LYNPARZA CAPS (Tier 2) 2) $0 LA; MO $0 PA; LA; MO IRESSA TABS (Tier LYNPARZA TABS (Tier 2) 2) $0 $0 ) PA ISTODAX (OVERFILL (Tier MEKINIST TABS (Tier SOLR 2) 2) $0 PA; LA $0 PA JAKAFI TABS (Tier MEKTOVI TABS (Tier 2) 2) $0 PA $0 PA; LA KISQALI TABS (Tier NERLYNX TABS (Tier 2) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 44 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 LA $0 NEXAVAR TABS (Tier TYKERB TABS (Tier 2) 2) $0 PA $0 NINLARO CAPS (Tier VELCADE SOLR (Tier 2) 2) $0 $0 PA ROMIDEPSIN SOLR (Tier VERZENIO TABS (Tier 2) 2) $0 PA; LA $0 PA RUBRACA TABS (Tier VOTRIENT TABS (Tier 2) 2) $0 PA $0 PA RYDAPT CAPS (Tier XALKORI CAPS (Tier 2) 2) $0 PA $0 PA; LA; MO SPRYCEL TABS (Tier ZEJULA CAPS (Tier 2) 2) $0 PA; LA $0 PA; LA STIVARGA TABS (Tier ZELBORAF TABS (Tier 2) 2) $0 $0 SUTENT CAPS (Tier ZOLINZA CAPS (Tier 2) 2) $0 $0 PA; LA TAFINLAR CAPS (Tier ZYDELIG TABS (Tier 2) 2) $0 PA; LA $0 PA; LA TAGRISSO TABS (Tier ZYKADIA CAPS (Tier 2) 2) $0 PA Antineoplastic Enzymes TARCEVA TABS (Tier $0 2) MO ERWINAZE SOLR (Tier $0 PA 2) TASIGNA CAPS (Tier $0 2) ONCASPAR SOLN (Tier $0 2) temsirolimus soln (Tier 1) Antineoplastics Misc. $0 $0 LA TORISEL SOLN (Tier ACTIMMUNE SOLN (Tier (Temsirolimus) 2) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 45 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 ARSENIC TRIOXIDE (Tier UVADEX SOLN (Tier SOLN IV 2) 2) $0 Chemotherapy Adjuncts bexarotene caps (Tier 1) $0 ELITEK SOLR (Tier $0 2) dacarbazine solr (Tier 1) $0 KEPIVANCE SOLR (Tier $0 MO 2) hydroxyurea caps or (Tier 1) Chemotherapy Rescue/Antidote Agents $0 $0 MO INTRON A SOLN (Tier amifostine solr (Tier 2) 1) $0 $0 INTRON A SOLR (Tier dexrazoxane solr (Tier 2) 1) $0 LA $0 MO MATULANE CAPS (Tier ETHYOL SOLR (Tier 2) 2) $0 leucovorin calcium solr ij 50 $0 NIPENT SOLR (Tier mg, 100 mg, 200 mg, 350 (Tier 2) mg, 500 mg 1) $0 $0 MO leucovorin calcium tabs or (Tier PROLEUKIN SOLR (Tier 5 mg, 10 mg, 15 mg, 25 mg 2) 1) $0 $0 SYLATRON KIT (Tier levoleucovorin calcium soln (Tier 2) 1) $0 MO $0 SYNRIBO SOLR (Tier levoleucovorin calcium solr (Tier 2) 1) $0 LEVOLEUCOVORIN SOLN $0 TICE BCG SUSR (Tier 250 MG/25ML (Tier 2) (Levoleucovorin Calcium) 2) $0 MO $0 tretinoin (chemotherapy) LEVOLEUCOVORIN SOLR (Tier (Tier 175 MG caps 1) 2) $0 $0 TRISENOX SOLN (Tier mesna soln (Tier 2) 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 46 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 MESNEX TABS OR 400 MO MO (Tier MARQIBO SUSP (Tier MG 2) 2) $0 $0 TOTECT SOLR (Tier paclitaxel conc (Tier 2) 1) Mitotic Inhibitors $0 PA; MO vinblastine sulfate soln (Tier $0 MO 1) ABRAXANE SUSR (Tier 2) $0 PA; MO vincristine sulfate soln (Tier $0 1) DOCETAXEL CONC 20 (Tier MG/ML, 80 MG/4ML 2) $0 vinorelbine tartrate soln 10 (Tier $0 mg/ml docetaxel conc 20 mg/ml, (Tier 1) 80 mg/4ml 1) $0 MO vinorelbine tartrate soln 50 (Tier $0 mg/5ml docetaxel soln 20 mg/2ml, (Tier 1) 80 mg/8ml, 160 mg/16ml 1) Topoisomerase I Inhibitors $0 DOCETAXEL SOLN 20 $0 CAMPTOSAR SOLN 300 (Tier (Tier MG/2ML, 80 MG/8ML, 160 MG/15ML MG/16ML 2) 2) DOCETAXEL SOLN 20 $0 $0 MG/2ML, 80 MG/8ML, 160 (Tier irinotecan hcl soln (Tier MG/16ML (Docetaxel) 2) 1) $0 $0 MO ETOPOPHOS SOLR (Tier ONIVYDE INJ (Tier 2) 2) etoposide soln iv 1 $0 $0 topotecan hcl soln 4 (Tier gm/50ml, 100 mg/5ml, 500 (Tier mg/4ml mg/25ml 1) 1) $0 $0 TOPOTECAN HCL SOLN (Tier HALAVEN SOLN (Tier 4 MG/4ML 2) 2) $0 $0 TOPOTECAN HCL SOLN (Tier IXEMPRA KIT SOLR (Tier 4 MG/4ML (Topotecan HCl) 2) 2) $0 $0 JEVTANA SOLN (Tier topotecan hcl solr 4 mg (Tier 2) 1) ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 47 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Antiparkinson Adjuvants $0 MO bromocriptine mesylate (Tier $0 MO tabs or 2.5 mg 1) carbidopa tabs or (Tier 1) $0 MO carbidopa-levodopa tabs (Tier Antiparkinson Anticholinergics 1) $0 MO $0 MO benztropine mesylate soln (Tier ij 1 mg/ml carbidopa-levodopa tbcr (Tier 1) 1) $0 benztropine mesylate tabs AL(Up to 64 yrs $0 MO (Tier old); MO or 0.5 mg, 1 mg, 2 mg carbidopa-levodopa tbdp (Tier 1) 1) $0 AL(Up to 64 yrs $0 B/D; MO trihexyphenidyl hcl elix (Tier old); MO DUOPA SUSP (Tier 1) 2) $0 AL(Up to 64 yrs $0 MO trihexyphenidyl hcl tabs (Tier old); MO NEUPRO PT24 (Tier 1) 2) Antiparkinson COMT Inhibitors pramipexole $0 MO $0 SL(8 ea daily); dihydrochloride tabs 0.125 (Tier entacapone tabs (Tier MO mg, 0.25 mg, 0.75 mg, 0.5 1) 1) mg, 1 mg, 1.5 mg $0 MO $0 MO ropinirole hydrochloride (Tier tolcapone tabs (Tier tabs 1) 1) Antiparkinson Dopaminergics $0 MO ropinirole hydrochloride (Tier $0 MO tb24 1) amantadine hcl caps or (Tier 100 mg 1) $0 MO RYTARY CPCR (Tier $0 MO 2) amantadine hcl syrp or 50 (Tier mg/5ml 1) Antiparkinson Monoamine Oxidase Inhibitors $0 MO $0 MO amantadine hcl tabs or 100 (Tier rasagiline mesylate tabs (Tier mg 1) 1) $0 LA $0 MO APOKYN SOCT (Tier selegiline hcl caps or (Tier 2) 1) $0 MO $0 MO bromocriptine mesylate (Tier selegiline hcl tabs or (Tier caps or 5 mg 1) 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 48 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ANTIPSYCHOTICS/ANTIMANIC AGENTS - $0 PA; LA Drugs to Treat Mood Disorders NUPLAZID TABS (Tier 2) Antimanic Agents $0 PA; SL(4 ea $0 lithium carbonate caps or MO VRAYLAR CAPS 1.5 MG (Tier daily); MO (Tier 2) 150 mg, 300 mg, 600 mg 1) $0 PA; SL(2 ea $0 MO lithium carbonate tabs or VRAYLAR CAPS 3 MG (Tier daily); MO (Tier 2) 300 mg 1) $0 PA; SL(1.4 ea $0 MO lithium carbonate tbcr or VRAYLAR CAPS 4.5 MG (Tier daily); MO (Tier 2) 300 mg, 450 mg 1) $0 PA; SL(1 ea $0 MO VRAYLAR CAPS 6 MG (Tier daily); MO LITHIUM SOLN (Tier 2) 2) $0 PA; MO Antipsychotics - Misc. VRAYLAR CPPK (Tier $0 MO 2) EQUETRO CP12 (Tier $0 MO 2) ziprasidone hcl caps (Tier $0 MO 1) GEODON SOLR IM 20 MG (Tier Benzisoxazoles 2) $0 MO $0 PA; SL(1.33 ea FANAPT TABS (Tier LATUDA TABS 120 MG (Tier daily); MO 2) 2) $0 MO $0 PA; SL(8 ea INVEGA SUSTENNA (Tier LATUDA TABS 20 MG (Tier daily); MO SUSP 2) 2) $0 $0 PA; SL(4 ea INVEGA TRINZA SUSP (Tier LATUDA TABS 40 MG (Tier daily); MO 2) 2) $0 SL(8 ea daily); $0 PA; SL(2.67 ea paliperidone tb24 1.5 mg (Tier MO LATUDA TABS 60 MG (Tier daily); MO 1) 2) $0 SL(4 ea daily); $0 PA; SL(2 ea paliperidone tb24 3 mg (Tier MO LATUDA TABS 80 MG (Tier daily); MO 1) 2) $0 SL(2 ea daily); $0 PA; LA paliperidone tb24 6 mg (Tier MO NUPLAZID CAPS (Tier 1) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 49 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 SL(1.33 ea $0 paliperidone tb24 9 mg (Tier daily); MO CLOZAPINE ODT TBDP (Tier 1) 2) $0 $0 Limit 8 vials per RISPERDAL CONSTA 28 clozapine tabs (Tier (Tier 1) SUSR 12.5 MG 2) days;SL(0.29 ea daily); MO $0 Limit 4 vials per clozapine tbdp (Tier $0 1) RISPERDAL CONSTA (Tier 28 SUSR 25 MG 2) days;SL(0.15 $0 ea daily); MO FAZACLO TBDP 12.5 MG (Tier (Clozapine) $0 Limit 4 vials per 2) RISPERDAL CONSTA (Tier 42 days;SL(0.1 SUSR 37.5 MG $0 2) ea daily); MO FAZACLO TBDP 150 MG, (Tier 200 MG 2) $0 Limit 2 vials per RISPERDAL CONSTA (Tier 28 $0 MO SUSR 50 MG 2) days;SL(0.08 loxapine succinate caps (Tier ea daily); MO 1) $0 MO $0 MO risperidone soln 1 mg/ml (Tier olanzapine solr (Tier 1) 1) risperidone tabs 0.25 mg, $0 MO $0 MO 0.5 mg, 1 mg, 2 mg, 3 mg, (Tier olanzapine tabs (Tier 4 mg 1) 1) risperidone tbdp 0.25 mg, $0 MO $0 MO 0.5 mg, 1 mg, 2 mg, 3 mg, (Tier olanzapine tbdp (Tier 4 mg 1) 1) Butyrophenones quetiapine fumarate tabs $0 MO $0 MO 25 mg, 50 mg, 100 mg, 200 (Tier haloperidol decanoate soln (Tier mg, 300 mg, 400 mg 1) im 50 mg/ml, 100 mg/ml 1) $0 SL(2 ea daily); $0 MO SAPHRIS SUBL 10 MG (Tier MO haloperidol lactate conc (Tier 2) 1) $0 SL(8 ea daily); $0 MO SAPHRIS SUBL 2.5 MG (Tier MO haloperidol lactate soln (Tier 2) 1) $0 SL(4 ea daily); $0 MO SAPHRIS SUBL 5 MG (Tier MO haloperidol tabs (Tier 2) 1) $0 PA; SL(18 ml VERSACLOZ SUSP (Tier daily) Dibenzapines 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 50 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 ZYPREXA RELPREVV MO (Tier trifluoperazine hcl tabs (Tier SUSR 210 MG 2) 1) Phenothiazines Quinolinone Derivatives $0 $0 chlorpromazine hcl soln ij MO MO (Tier ABILIFY MAINTENA PRSY (Tier 25 mg/ml 1) 2) $0 $0 chlorpromazine hcl soln ij MO (Tier ABILIFY MAINTENA SRER (Tier 50 mg/2ml 1) 2) chlorpromazine hcl tabs or $0 MO $0 SL(30 ml daily); 10 mg, 25 mg, 50 mg, 100 (Tier aripiprazole soln 1 mg/ml (Tier MO mg, 200 mg 1) 1) $0 $0 SL(3 ea daily); fluphenazine decanoate MO (Tier aripiprazole tabs 10 mg (Tier MO soln ij 1) 1) $0 $0 SL(2 ea daily); fluphenazine hcl conc or 5 MO (Tier aripiprazole tabs 15 mg (Tier MO mg/ml 1) 1) $0 $0 SL(15 ea daily); fluphenazine hcl soln ij 2.5 MO (Tier aripiprazole tabs 2 mg (Tier MO mg/ml 1) 1) $0 $0 SL(1.5 ea fluphenazine hcl tabs or 1 MO (Tier aripiprazole tabs 20 mg (Tier daily); MO mg, 5 mg, 10 mg, 2.5 mg 1) 1) $0 $0 SL(1 ea daily); perphenazine tabs or 2 mg, MO (Tier aripiprazole tabs 30 mg (Tier MO 4 mg, 8 mg, 16 mg 1) 1) $0 $0 SL(6 ea daily); prochlorperazine edisylate MO (Tier aripiprazole tabs 5 mg (Tier MO soln ij 1) 1) $0 $0 SL(3 ea daily); prochlorperazine maleate MO (Tier aripiprazole tbdp 10 mg (Tier MO tabs or 5 mg, 10 mg 1) 1) $0 MO $0 SL(2 ea daily); prochlorperazine supp (Tier aripiprazole tbdp 15 mg (Tier MO 1) 1) $0 MO $0 thioridazine hcl tabs or 10 (Tier ARISTADA INITIO PRSY (Tier mg, 25 mg, 50 mg, 100 mg 1) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 51 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 MO ARISTADA PRSY (Tier abacavir sulfate soln (Tier 2) 1) $0 PA; SL(16 ea $0 MO REXULTI TABS 0.25 MG (Tier daily); MO abacavir sulfate tabs (Tier 2) 1) $0 $0 MO PA; SL(8 ea abacavir sulfate-lamivudine REXULTI TABS 0.5 MG (Tier daily); MO (Tier 2) tabs 1) $0 $0 PA; SL(4 ea abacavir sulfate- MO REXULTI TABS 1 MG (Tier daily); MO (Tier 2) lamivudine-zidovudine tabs 1) $0 PA; SL(2 ea $0 MO REXULTI TABS 2 MG (Tier daily); MO APTIVUS CAPS 250 MG (Tier 2) 2) $0 $0 PA; SL(1.33 ea APTIVUS SOLN 100 REXULTI TABS 3 MG (Tier daily); MO (Tier 2) MG/ML 2) $0 PA; SL(1 ea $0 MO REXULTI TABS 4 MG (Tier daily); MO atazanavir sulfate caps (Tier 2) 1) Thioxanthenes $0 MO $0 ATRIPLA TABS (Tier MO 2) thiothixene caps (Tier 1) $0 MO BIKTARVY TABS (Tier ANTISEPTICS & DISINFECTANTS 2) $0 MO Iodine Antiseptics CIMDUO TABS (Tier $0 MO; NT 2) BETADINE SOLN 10 % (Tier (Povidone-Iodine) $0 MO 3) COMPLERA TABS (Tier $0 NT 2) povidone-iodine oint ex 10 (Tier % $0 MO 3) CRIXIVAN CAPS (Tier $0 MO; NT 2) povidone-iodine soln ex 10 (Tier % $0 3) DELSTRIGO TABS (Tier ANTIVIRALS - Drugs to Treat Viral Infections 2) $0 MO Antiretrovirals DESCOVY TABS (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 52 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 ISENTRESS CHEW 100 SL(6 ea daily); didanosine cpdr (Tier (Tier MO 1) MG 2) $0 MO $0 SL(24 ea daily); EDURANT TABS (Tier ISENTRESS CHEW 25 MG (Tier MO 2) 2) $0 MO $0 MO efavirenz caps (Tier ISENTRESS HD TABS (Tier 1) 2) $0 MO $0 ISENTRESS PACK 100 SL(2 ea daily); efavirenz tabs (Tier (Tier MO 1) MG 2) $0 $0 MO ISENTRESS TABS 400 MO EMTRIVA CAPS (Tier (Tier 2) MG 2) $0 MO $0 EMTRIVA SOLN (Tier JULUCA TABS (Tier 2) 2) $0 $0 MO KALETRA TABS 100MG- MO EVOTAZ TABS (Tier (Tier 2) 25MG, 200MG-50MG 2) $0 MO $0 MO fosamprenavir calcium tabs (Tier lamivudine soln (Tier 1) 1) $0 $0 MO FUZEON SOLR (Tier lamivudine tabs (Tier 2) 1) $0 MO $0 MO GENVOYA TABS (Tier lamivudine-zidovudine tabs (Tier 2) 1) $0 $0 INTELENCE TABS 100 MO MO (Tier LEXIVA SUSP 50 MG/ML (Tier MG, 200 MG 2) 2) $0 $0 MO LEXIVA TABS 700 MG INTELENCE TABS 25 MG (Tier (Tier 2) (Fosamprenavir Calcium) 2) $0 MO $0 MO INVIRASE CAPS (Tier lopinavir-ritonavir soln (Tier 2) 1) $0 MO $0 MO INVIRASE TABS (Tier nevirapine susp (Tier 2) 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 53 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO nevirapine tabs (Tier REYATAZ PACK 50 MG (Tier 1) 2) $0 MO $0 MO nevirapine tb24 (Tier ritonavir tabs (Tier 1) 1) $0 $0 SELZENTRY SOLN 20 NORVIR CAPS 100 MG (Tier (Tier 2) MG/ML 2) $0 $0 MO SELZENTRY TABS 150 MO NORVIR PACK 100 MG (Tier (Tier 2) MG, 300 MG 2) $0 $0 MO SELZENTRY TABS 25 NORVIR SOLN 80 MG/ML (Tier (Tier 2) MG, 75 MG 2) $0 $0 NORVIR TABS 100 MG MO MO (Tier stavudine caps (Tier (Ritonavir) 2) 1) $0 MO $0 MO ODEFSEY TABS (Tier STRIBILD TABS (Tier 2) 2) $0 $0 MO SUSTIVA CAPS PIFELTRO TABS (Tier (Tier 2) (Efavirenz) 2) $0 MO $0 MO PREZCOBIX TABS (Tier SUSTIVA TABS (Efavirenz) (Tier 2) 2) $0 MO $0 MO PREZISTA SUSP (Tier SYMFI LO TABS (Tier 2) 2) $0 MO $0 MO PREZISTA TABS (Tier SYMFI TABS (Tier 2) 2) $0 MO $0 MO RESCRIPTOR TABS (Tier SYMTUZA TABS (Tier 2) 2) $0 $0 MO RETROVIR IV INFUSION (Tier tenofovir disoproxil (Tier SOLN 2) fumarate tabs 1) REYATAZ CAPS 150 MG, $0 MO $0 MO 200 MG, 300 MG (Tier TIVICAY TABS (Tier (Atazanavir Sulfate) 2) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 54 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO TRIUMEQ TABS (Tier zidovudine syrp (Tier 2) 1) $0 $0 MO TROGARZO SOLN (Tier zidovudine tabs (Tier 2) 1) $0 MO CMV Agents TRUVADA TABS (Tier $0 2) cidofovir soln (Tier $0 MO 1) TYBOST TABS (Tier $0 2) PA; MO ganciclovir sodium solr (Tier $0 MO 1) VIDEX EC CPDR 125 MG (Tier $0 PA 2) PREVYMIS SOLN IV 240 (Tier $0 MO MG/12ML, 480 MG/24ML 2) VIDEXPEDIATRIC SOLR (Tier $0 PA; MO 2) PREVYMIS TABS OR 240 (Tier $0 MO MG, 480 MG 2) VIRACEPT TABS (Tier $0 MO 2) valganciclovir hcl tabs 450 (Tier $0 MO mg 1) VIRAMUNE SUSP 50 (Tier MG/5ML (Nevirapine) 2) Hepatitis Agents $0 MO $0 MO VIREAD POWD 40 MG/GM (Tier adefovir dipivoxil tabs (Tier 2) 1) $0 MO $0 MO VIREAD TABS 150 MG, BARACLUDE SOLN 0.05 (Tier (Tier MG/ML 200 MG, 250 MG 2) 2) VIREAD TABS 300 MG $0 MO $0 PA (Tenofovir Disoproxil (Tier DAKLINZA TABS (Tier Fumarate) 2) 2) $0 MO $0 MO ZERIT SOLR 1 MG/ML (Tier entecavir tabs (Tier 2) 1) $0 MO $0 PA ZIAGEN SOLN 20 MG/ML (Tier EPCLUSA TABS (Tier (Abacavir Sulfate) 2) 2) $0 MO $0 MO EPIVIR HBV SOLN 5 (Tier zidovudine caps (Tier MG/ML 1) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 55 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 PA $0 MO HARVONI TABS (Tier acyclovir caps or 200 mg (Tier 2) 1) $0 $0 MO acyclovir sodium soln 50 PA lamivudine (hbv) tabs (Tier (Tier 1) mg/ml 1) $0 $0 PA acyclovir susp or 200 MO MAVYRET TABS (Tier (Tier 2) mg/5ml 1) $0 $0 MO PEG-INTRON REDIPEN (Tier acyclovir tabs or 400 mg, (Tier KIT 2) 800 mg 1) $0 $0 PEGASYS PROCLICK MO (Tier famciclovir tabs (Tier SOLN 2) 1) $0 $0 valacyclovir hcl tabs or 1 MO PEGASYS SOLN (Tier (Tier 2) gm, 500 mg, 1000 mg 1) $0 Influenza Agents PEGINTRON KIT (Tier $0 2) oseltamivir phosphate caps QL(4 ea daily); (Tier MO $0 or 30 mg 1) ribavirin (hepatitis c) caps (Tier $0 MO 1) oseltamivir phosphate caps (Tier $0 or 45 mg, 75 mg 1) ribavirin (hepatitis c) tabs (Tier $0 MO 1) oseltamivir phosphate susr (Tier $0 PA or 6 mg/ml 1) SOVALDI TABS (Tier 2) $0 MO RELENZA DISKHALER (Tier $0 ST; MO AEPB 2) VEMLIDY TABS (Tier $0 MO 2) rimantadine hydrochloride (Tier $0 PA tabs 1) VOSEVI TABS (Tier $0 MO 2) TAMIFLU SUSR 6 MG/ML (Tier $0 PA (Oseltamivir Phosphate) 2) ZEPATIER TABS (Tier 2) Respiratory Syncytial Virus (RSV) Agents $0 Herpes Agents ribavirin solr in (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 56 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 BETA BLOCKERS - Drugs to Treat High Blood metoprolol tartrate tabs or MO Pressure (Tier 25 mg, 50 mg, 100 mg 1) Alpha-Beta Blockers METOPROLOL $0 MO $0 MO TARTRATE TABS OR 75 (Tier carvedilol phosphate cp24 (Tier MG, 37.5 MG 2) 1) Beta Blockers Non-Selective $0 SL(8 ea daily); $0 carvedilol tabs 12.5 mg (Tier MO nadolol tabs or 20 mg, 40 MO 1) (Tier mg, 80 mg 1) $0 SL(4 ea daily); carvedilol tabs 25 mg (Tier MO $0 MO 1) pindolol tabs (Tier 1) $0 SL(32 ea daily); carvedilol tabs 3.125 mg (Tier MO propranolol hcl cp24 or 60 $0 MO 1) mg, 80 mg, 120 mg, 160 (Tier mg 1) $0 SL(16 ea daily); carvedilol tabs 6.25 mg (Tier MO propranolol hcl tabs or 10 $0 MO 1) mg, 20 mg, 40 mg, 60 mg, (Tier 80 mg 1) $0 MO COREG CR CP24 (Tier $0 MO (Carvedilol Phosphate) 2) sotalol hcl (afib/afl) tabs (Tier 1) $0 MO labetalol hcl tabs or 100 (Tier $0 tabs;MO mg, 200 mg, 300 mg 1) sotalol hcl tabs (Tier 1) Beta Blockers Cardio-Selective $0 MO $0 acebutolol hcl caps or 200 MO SOTYLIZE SOLN (Tier (Tier 2) mg, 400 mg 1) $0 MO CALCIUM CHANNEL BLOCKERS - Drugs to atenolol tabs or 25 mg, 50 (Tier Treat High Blood Pressure mg, 100 mg 1) Calcium Channel Blockers $0 MO $0 amlodipine besylate tabs or SL(1 ea daily); betaxolol hcl tabs (Tier (Tier MO 1) 10 mg 1) $0 MO $0 amlodipine besylate tabs or SL(4 ea daily); bisoprolol fumarate tabs (Tier (Tier MO 1) 2.5 mg 1) $0 MO $0 amlodipine besylate tabs or SL(2 ea daily); metoprolol succinate tb24 (Tier (Tier MO 1) 5 mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 57 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO diltiazem hcl coated beads (Tier verapamil hcl tabs or 40 (Tier cp24 1) mg, 80 mg, 120 mg 1) $0 MO $0 MO diltiazem hcl coated beads (Tier verapamil hcl tbcr or 120 (Tier tb24 1) mg, 180 mg, 240 mg 1) $0 $0 diltiazem hcl cp12 or 60 MO MO (Tier VERELAN CP24 360 MG (Tier mg, 90 mg, 120 mg 1) 2) $0 diltiazem hcl cp24 or 120 MO CARDIOTONICS - Drugs to Treat Heart Failure (Tier and Abnormal Heart Rhythm mg, 180 mg, 240 mg 1) $0 MO Cardiac Glycosides diltiazem hcl extended $0 (Tier DIGOXIN SOLN OR 0.05 MO release beads cp24 1) (Tier MG/ML 2) $0 MO diltiazem hcl tabs or 30 mg, (Tier digoxin tabs or 0.125 mg, $0 MO 60 mg, 90 mg, 120 mg 1) 0.25 mg, 125 mcg, 250 (Tier mcg 1) $0 MO $0 felodipine tb24 (Tier LANOXIN TABS OR 62.5 MO 1) (Tier MCG, 187.5 MCG 2) $0 MO nicardipine hcl caps or 20 (Tier mg, 30 mg CARDIOVASCULAR AGENTS - MISC. - Drugs to 1) Treat Heart and Circulation Conditions $0 MO Cardiovascular Agents Misc. - Combinations nifedipine tb24 or 30 mg, (Tier 60 mg, 90 mg 1) $0 MO amlodipine besylate- (Tier $0 MO atorvastatin calcium tabs 1) nimodipine caps or 30mg, (Tier 30 mg 1) $0 PA; MO ENTRESTO TABS (Tier $0 MO 2) nisoldipine tb24 (Tier 1) Prostaglandin Vasodilators $0 $0 B/D; LA NYMALIZE SOLN (Tier REMODULIN SOLN (Tier 2) 2) $0 B/D; LA verapamil hcl cp24 or 100 $0 MO mg, 120 mg, 180 mg, 200 TYVASO REFILL SOLN (Tier (Tier 2) mg, 240 mg, 300 mg, 360 1) mg $0 B/D; LA TYVASO SOLN (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 58 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 B/D; LA $0 PA; SL(15 ea TYVASO STARTER SOLN (Tier ADEMPAS TABS 0.5 MG (Tier daily) 2) 2) $0 B/D; LA $0 PA; SL(7.5 ea VENTAVIS SOLN (Tier ADEMPAS TABS 1 MG (Tier daily) 2) 2) Pulmonary Hypertension - Endothelin Receptor $0 PA; SL(5 ea $0 ADEMPAS TABS 1.5 MG (Tier daily) LA 2) LETAIRIS TABS (Tier 2) $0 PA; SL(3.75 ea $0 ADEMPAS TABS 2 MG (Tier daily) PA 2) OPSUMIT TABS (Tier 2) $0 PA; SL(3 ea ADEMPAS TABS 2.5 MG (Tier daily) $0 LA TRACLEER TABS 125 (Tier 2) MG, 62.5 MG 2) Sinus Node Inhibitors $0 $0 SL(3 ea daily); TRACLEER TBSO 32 MG (Tier CORLANOR TABS 5 MG (Tier MO 2) 2) Pulmonary Hypertension - Phosphodiesterase $0 SL(2 ea daily); CORLANOR TABS 7.5 MG (Tier MO $0 PA ADCIRCA TABS (Tadalafil (Tier 2) (Pulmonary Hypertension)) 2) CEPHALOSPORINS - Drugs to Treat Bacterial $0 Infections sildenafil citrate (pulmonary PA (Tier Cephalosporins - 1st Generation hypertension) soln 1) $0 MO $0 sildenafil citrate (pulmonary PA cefadroxil caps 500 mg (Tier (Tier 1) hypertension) tabs 1) $0 MO $0 tadalafil (pulmonary PA cefadroxil susr 500 mg/5ml (Tier (Tier 1) hypertension) tabs 1) $0 MO Pulmonary Hypertension - Prostacyclin Receptor cefadroxil tabs 1 gm (Tier $0 PA; LA 1) UPTRAVI TABS (Tier $0 MO 2) cefazolin sodium solr ij 1 (Tier gm, 10 gm, 500 mg $0 PA; LA 1) UPTRAVI TBPK (Tier $0 MO 2) cephalexin caps 250 mg, (Tier 500 mg, 750 mg 1) Pulmonary Hypertension - Sol Guanylate Cyclase
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 59 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO cephalexin susr 125 (Tier cefpodoxime proxetil tabs (Tier mg/5ml, 250 mg/5ml 1) 100 mg, 200 mg 1) Cephalosporins - 2nd Generation $0 MO ceftazidime solr ij 1 gm, 2 (Tier $0 MO gm cefaclor caps 250 mg, 500 (Tier 1) mg 1) $0 $0 ceftazidime solr ij 6 gm (Tier cefoxitin sodium solr ij 10 (Tier 1) gm $0 1) ceftriaxone sodium solr ij 1 SL(4 ea daily); (Tier MO $0 gm cefoxitin sodium solr iv 1 (Tier 1) gm, 2 gm $0 SL(2 ea daily); 1) ceftriaxone sodium solr ij 2 (Tier MO $0 MO gm 1) cefprozil susr 250 mg/5ml (Tier $0 1) ceftriaxone sodium solr ij SL(16 ea daily); (Tier MO $0 MO 250 mg cefprozil tabs 250 mg, 500 (Tier 1) mg $0 1) ceftriaxone sodium solr ij SL(8 ea daily); (Tier MO $0 MO 500 mg 1) cefuroxime axetil tabs (Tier 1) $0 SL(4 ea daily) ceftriaxone sodium solr iv 1 (Tier $0 gm cefuroxime sodium solr iv (Tier 1) 1.5 gm 1) $0 MO ceftriaxone sodium solr iv (Tier Cephalosporins - 3rd Generation 10 gm 1) $0 MO $0 MO cefdinir caps (Tier SUPRAX CAPS 400 MG (Tier 1) 2) $0 MO cefdinir susr (Tier Cephalosporins - 4th Generation 1) $0 MO cefepime hcl solr (Tier $0 MO 1) cefixime chew (Tier $0 1) CEFEPIME SOLN 2 $0 (Tier MO GM/100ML 2) cefixime susr (Tier 1) Cephalosporins - 5th Generation $0 $0 cefpodoxime proxetil susr MO (Tier TEFLARO SOLR 600 MG (Tier 100 mg/5ml 1) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 60 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 CONTRACEPTIVES - Drugs to Prevent norgestimate-ethinyl MO Pregnancy (Tier estradiol tabs 1) Combination Contraceptives - Oral $0 MO $0 norgestrel & ethinyl desogestrel & ethinyl MO (Tier (Tier estradiol tabs 1) estradiol tabs 1) Combination Contraceptives - Transdermal $0 MO desogestrel-ethinyl $0 (Tier norelgestromin-ethinyl MO estradiol (biphasic) tabs 1) (Tier estradiol ptwk 1) $0 drospirenone-ethinyl MO (Tier Combination Contraceptives - Vaginal estradiol tabs 1) $0 MO $0 MO NUVARING RING (Tier ethynodiol diacet & eth (Tier 2) estrad tabs 1mg-35mcg 1) Emergency Contraceptives $0 MO $0 levonorgestrel & eth (Tier estradiol tabs ELLA TABS (Tier 1) 2) $0 MO $0 NT levonorgestrel-eth estradiol (Tier levonorgestrel (emergency (triphasic) tabs (Tier 1) oc) tabs 3) $0 biphasic;MO PLAN B ONE-STEP TABS $0 NT levonorgestrel-ethinyl (Tier estradiol (91-day) tabs (Levonorgestrel (Tier 1) (Emergency OC)) 3) norethin acet & estrad-fe $0 MO tabs 75mg-20mcg-1mg, (Tier Progestin Contraceptives - Injectable 75mg-30mcg-1.5mg 1) medroxyprogesterone $0 MO $0 MO acetate (contraceptive) (Tier norethindrone & eth (Tier susp 1) estradiol tabs 1) medroxyprogesterone $0 MO norethindrone & ethinyl $0 MO acetate (contraceptive) (Tier estradiol-fe chew 0.4mg- (Tier susy 1) 35mcg 1) Progestin Contraceptives - Oral $0 MO $0 MO norethindrone acet & eth (Tier norethindrone estra tabs (Tier 1) (contraceptive) tabs 1) $0 MO norethindrone-eth estradiol CORTICOSTEROIDS - Steroid Hormone Drugs to (Tier Treat Systemic Swelling Conditions (triphasic) tabs 1) $0 MO Glucocorticosteroids norgestimate-ethinyl (Tier estradiol (triphasic) tabs 1) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 61 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO betamethasone sod (Tier hydrocortisone tabs or 5 (Tier phosphate & acetate susp 1) mg, 10 mg, 20 mg 1) $0 MO $0 MO budesonide cpep or 3 mg (Tier KENALOG-10 SUSP (Tier 1) 2) $0 $0 MO KENALOG-40 SUSP MO cortisone acetate tabs or (Tier (Tier 1) (Triamcinolone Acetonide) 2) $0 $0 DEPO-MEDROL SUSP 20 MO MO (Tier MEDROL TABS 2 MG (Tier MG/ML 2) 2) $0 MO $0 MO dexamethasone elix or 0.5 (Tier methylprednisolone acetate (Tier mg/5ml 1) susp ij 40 mg/ml, 80 mg/ml 1) $0 Preservative $0 MO dexamethasone sodium methylprednisolone sod (Tier Free;MO (Tier phosphate soln ij 10 mg/ml 1) succ solr 1) $0 $0 MO dexamethasone sodium (Tier methylprednisolone tabs or (Tier phosphate soln ij 10 mg/ml 1) 4 mg, 8 mg, 16 mg, 32 mg 1) $0 dexamethasone sodium $0 MO methylprednisolone tbpk or MO phosphate soln ij 4 mg/ml, (Tier (Tier 4 mg 1) 20 mg/5ml, 100 mg/10ml, 1) 120 mg/30ml prednisolone sodium $0 MO $0 phosphate soln or 5 (Tier dexamethasone soln or 0.5 MO (Tier mg/5ml, 15 mg/5ml 1) mg/5ml 1) prednisolone sodium $0 MO dexamethasone tabs or $0 MO phosphate tbdp or 10 mg, (Tier 0.75 mg, 0.5 mg, 1 mg, 2 (Tier 15 mg, 30 mg 1) mg, 4 mg, 6 mg, 1.5 mg 1) $0 prednisolone soln or 15 MO $0 MO (Tier dexamethasone tbpk or 1.5 (Tier mg/5ml 1) mg 1) $0 MO $0 prednisolone syrp or 15 (Tier PA; LA; MO mg/5ml EMFLAZA SUSP (Tier 1) 2) $0 MO $0 PA; LA; MO prednisolone tabs or 5 mg (Tier EMFLAZA TABS (Tier 1) 2) $0 MO prednisone conc or 5 (Tier mg/ml 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 62 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 B/D; MO prednisone soln or 5 (Tier acetylcysteine soln in 10 %, (Tier mg/5ml 1) 20 % 1) prednisone tabs or 1 mg, 5 $0 MO DERMATOLOGICALS - Drugs to Treat Skin mg, 10 mg, 20 mg, 50 mg, (Tier Conditions 2.5 mg 1) Acne Products $0 Dose Pack;MO prednisone tbpk or 5 mg (Tier $0 1) ABSORICA CAPS (Tier 2) $0 MO prednisone tbpk or 5 mg, $0 (Tier ACNE MEDICATION 10 NT 10 mg 1) (Tier LOTN 3) $0 MO SOLU-CORTEF SOLR 100 (Tier $0 MO MG, 250 MG, 500 MG 2) adapalene crea 0.1 % (Tier 1) $0 SOLU-CORTEF SOLR (Tier $0 RX/OTC; MO 1000 MG 2) adapalene gel 0.1 % (Tier 1) $0 MO SOLU-MEDROL SOLR $0 (Tier benzoyl peroxide gel ex 10 RX/OTC; MO; 500 MG 2) (Tier NT % 3) $0 MO $0 TAPERDEX 6-DAY TBPK (Tier BENZOYL PEROXIDE MO; NT 2) (Tier GEL EX 2.5 % 3) $0 MO triamcinolone acetonide $0 (Tier benzoyl peroxide gel ex 5 MO; NT susp ij 40 mg/ml 1) (Tier % 3) Mineralocorticoids $0 RX/OTC; MO; $0 MO benzoyl peroxide liqd ex 5 fludrocortisone acetate (Tier NT (Tier % 3) tabs or 1) $0 benzoyl peroxide- MO COUGH/COLD/ALLERGY - Drugs to Treat (Tier erythromycin gel Cough, Cold and Allergy Symptoms 1) Cough/Cold/Allergy Combinations $0 MO CLINDAGEL GEL (Tier $0 MO 2) promethazine & (Tier phenylephrine soln 1) $0 MO clindamycin phosphate (Tier $0 MO (topical) foam 1) promethazine & (Tier phenylephrine syrp 1) $0 MO clindamycin phosphate (Tier Mucolytics (topical) gel 1) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 63 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 clindamycin phosphate MO MO (Tier CENTANY OINT (Tier (topical) lotn 1) 2) $0 MO $0 MO clindamycin phosphate (Tier gentamicin sulfate (topical) (Tier (topical) soln 1) crea 1) $0 MO $0 MO clindamycin phosphate (Tier gentamicin sulfate (topical) (Tier (topical) swab 1) oint 1) $0 clindamycin phosphate- $0 MO mupirocin calcium (topical) MO benzoyl peroxide (Tier (Tier crea (refrigerate) gel 1) 1) $0 MO $0 MO clindamycin phosphate- (Tier mupirocin oint ex (Tier benzoyl peroxide gel 1) 1) $0 MO $0 MO; NT erythromycin (acne aid) neomycin-bacitracin- (Tier (Tier polymyxin oint soln 1) 3) $0 Antifungals - Topical isotretinoin caps or 10 mg, (Tier 20 mg, 30 mg, 40 mg $0 MO; NT 1) AZOLEN TINCTURE (Tier $0 MO SOLN 3) sulfacetamide sodium (Tier (acne) lotn $0 MO 1) ciclopirox gel 0.77 % (Tier $0 tretinoin crea ex 0.025 %, MO 1) (Tier $0 MO 0.05 %, 0.1 % 1) ciclopirox olamine crea ex (Tier $0 MO 1) tretinoin gel ex 0.025 %, (Tier 0.01 % $0 MO 1) ciclopirox olamine susp ex (Tier $0 MO 1) tretinoin microsphere gel (Tier $0 MO 1) ciclopirox sham 1 % (Tier Anti-inflammatory Agents - Topical 1) $0 MO $0 MO diclofenac sodium (topical) (Tier ciclopirox soln 8 % (Tier gel 1 % 1) 1) $0 PA; MO $0 RX/OTC; MO FLECTOR PTCH (Tier clotrimazole (topical) crea (Tier 2) 1) Antibiotics - Topical
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 64 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 Over-the- miconazole nitrate (topical) MO; NT clotrimazole (topical) crea (Tier counter;RX/OT (Tier crea 3) C; MO; NT 3) $0 RX/OTC; MO $0 MO clotrimazole (topical) soln (Tier naftifine hcl crea 2 % (Tier 1) 1) $0 MO $0 MO clotrimazole w/ (Tier NAFTIN GEL 2 % (Tier betamethasone crea 1) 2) $0 MO $0 MO clotrimazole w/ (Tier nystatin (topical) crea (Tier betamethasone lotn 1) 1) $0 MO $0 MO econazole nitrate crea (Tier nystatin (topical) oint (Tier 1) 1) $0 MO; NT $0 MO FUNGOID TINCTURE (Tier nystatin (topical) powd (Tier SOLN 3) 1) $0 MO $0 MO ketoconazole (topical) crea (Tier nystatin-triamcinolone crea (Tier 1) 1) $0 MO $0 MO ketoconazole (topical) foam (Tier nystatin-triamcinolone oint (Tier 1) 1) $0 MO $0 MO; NT ketoconazole (topical) (Tier terbinafine hcl (topical) crea (Tier sham 1) 3) $0 MO; NT $0 MO; NT LAMISIL AT CREA (Tier tolnaftate crea ex (Tier (Terbinafine HCl (Topical)) 3) 3) LAMISIL AT JOCK ITCH $0 MO; NT $0 MO; NT CREA (Terbinafine HCl (Tier tolnaftate powd ex (Tier (Topical)) 3) 3) $0 RX/OTC; MO; Antineoplastic or Premalignant Lesion Agents - LOTRIMIN AF CREA 1 % (Tier (Clotrimazole (Topical)) NT $0 MO 3) CARAC CREA (Tier LOTRIMIN AF FOR HER $0 RX/OTC; MO; 2) CREA (Clotrimazole (Tier NT $0 MO (Topical)) 3) diclofenac sodium (actinic (Tier LOTRIMIN AF JOCK ITCH $0 RX/OTC; MO; keratoses) gel 1) CREA (Clotrimazole (Tier NT (Topical)) 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 65 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO fluorouracil (topical) crea (Tier methoxsalen rapid caps (Tier 1) 1) $0 MO $0 PA fluorouracil (topical) soln (Tier SILIQ SOSY (Tier 1) 2) $0 MO $0 PA FLUOROURACIL CREA (Tier STELARA SOSY SC 90 (Tier EX 0.5 % 2) MG/ML, 45 MG/0.5ML 2) $0 MO $0 PA PANRETIN GEL (Tier TALTZ SOAJ (Tier 2) 2) $0 MO $0 PA PICATO GEL (Tier TALTZ SOSY (Tier 2) 2) $0 $0 MO TARGRETIN GEL EX 1 % (Tier tazarotene crea (Tier 2) 1) $0 PA; MO $0 MO VALCHLOR GEL (Tier TAZORAC CREA 0.05 % (Tier 2) 2) $0 Antipsoriatics TAZORAC GEL 0.05 %, MO $0 (Tier MO 0.1 % 2) acitretin caps (Tier 1) $0 PA $0 TREMFYA SOSY (Tier MO 2) calcipotriene crea (Tier 1) Antiseborrheic Products $0 $0 MO selenium sulfide lotn ex 2.5 MO calcipotriene oint (Tier (Tier 1) % 1) $0 MO Antivirals - Topical calcipotriene soln (Tier 1) $0 MO acyclovir topical oint (Tier $0 PA; LA 1) COSENTYX (Tier SENSOREADY PEN SOAJ 2) $0 MO DENAVIR CREA (Tier $0 PA; LA 2) COSENTYX SOSY (Tier 2) $0 MO ZOVIRAX CREA EX 5 % (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 66 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Burn Products betamethasone $0 MO $0 dipropionate augmented (Tier MO oint 1) mafenide acetate pack ex (Tier 1) $0 MO betamethasone valerate (Tier $0 MO crea ex 0.1 % silver sulfadiazine crea ex (Tier 1) 1) $0 MO betamethasone valerate (Tier $0 MO foam ex 0.12 % SULFAMYLON CREA 85 (Tier 1) MG/GM 2) $0 MO betamethasone valerate (Tier $0 MO lotn ex 0.1 % SULFAMYLON PACK 5 % (Tier 1) (Mafenide Acetate) 2) $0 MO betamethasone valerate (Tier Corticosteroids - Topical oint ex 0.1 % 1) $0 MO $0 MO alclometasone dipropionate (Tier clobetasol propionate crea crea (Tier 1) ex 1) $0 MO $0 MO alclometasone dipropionate (Tier clobetasol propionate oint (Tier 1) emollient base crea 1) $0 MO $0 MO amcinonide crea (Tier clobetasol propionate (Tier 1) emulsion foam 1) $0 MO $0 MO betamethasone (Tier clobetasol propionate foam dipropionate (topical) crea (Tier 1) ex 1) $0 MO $0 MO betamethasone (Tier clobetasol propionate gel dipropionate (topical) lotn (Tier 1) ex 1) $0 MO $0 MO betamethasone (Tier clobetasol propionate lotn dipropionate (topical) oint (Tier 1) ex 1) betamethasone $0 MO $0 MO dipropionate augmented (Tier clobetasol propionate oint (Tier crea 1) ex 1) betamethasone $0 MO $0 MO dipropionate augmented (Tier clobetasol propionate sham (Tier gel 1) ex 1) betamethasone $0 MO $0 MO dipropionate augmented (Tier clobetasol propionate soln (Tier lotn 1) ex 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 67 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO desonide crea ex (Tier fluocinonide oint ex 0.05 % (Tier 1) 1) $0 MO $0 MO desonide lotn ex (Tier fluocinonide soln ex 0.05 % (Tier 1) 1) $0 $0 MO fluticasone propionate crea MO desonide oint ex (Tier (Tier 1) ex 0.05 % 1) $0 MO $0 MO desoximetasone crea ex (Tier fluticasone propionate lotn (Tier 0.25 % 1) ex 0.05 % 1) $0 MO $0 MO desoximetasone gel ex (Tier fluticasone propionate oint (Tier 0.05 % 1) ex 0.005 % 1) $0 MO $0 MO desoximetasone oint ex (Tier halobetasol propionate (Tier 0.25 % 1) crea 1) $0 MO $0 MO diflorasone diacetate oint (Tier halobetasol propionate oint (Tier 1) 1) $0 MO $0 MO; NT fluocinolone acetonide crea (Tier hydrocortisone (topical) (Tier ex 0.025 %, 0.01 % 1) crea 0.5 % 3) $0 MO $0 RX/OTC; MO fluocinolone acetonide oil (Tier hydrocortisone (topical) (Tier ex 0.01 % 1) crea 1 % 1) $0 fluocinolone acetonide oint MO $0 Over-the- (Tier hydrocortisone (topical) (Tier counter;RX/OT ex 0.025 % crea 1%, 1 % 1) 3) C; MO; NT $0 MO $0 MO fluocinolone acetonide soln (Tier hydrocortisone (topical) ex 0.01 % (Tier 1) crea 2.5 % 1) $0 MO $0 MO; NT fluocinonide crea ex 0.05 (Tier hydrocortisone (topical) lotn % (Tier 1) 1 % 3) $0 MO $0 MO fluocinonide emulsified (Tier hydrocortisone (topical) lotn base crea (Tier 1) 2.5 % 1) $0 MO $0 MO; NT fluocinonide gel ex 0.05 % (Tier hydrocortisone (topical) oint (Tier 1) 0.5 % 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 68 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 Over-the- MONISTAT SOOTHING $0 RX/OTC; MO; hydrocortisone (topical) (Tier counter;RX/OT (Tier NT oint 1 % CARE ITCH RELIEF CREA 3) C; MO; NT (Hydrocortisone (Topical)) 3) $0 $0 hydrocortisone (topical) RX/OTC; MO MO (Tier prednicarbate crea (Tier oint 1 % 1) 1) $0 MO $0 MO hydrocortisone (topical) (Tier triamcinolone acetonide (Tier oint 2.5 % 1) (topical) aers 0.147 mg/gm 1) $0 hydrocortisone (topical) NT triamcinolone acetonide $0 MO (Tier (topical) crea 0.025 %, 0.1 (Tier soln 1 % 3) %, 0.5 % 1) $0 MO triamcinolone acetonide $0 MO hydrocortisone butyrate (Tier crea (topical) lotn 0.025 %, 0.1 (Tier 1) % 1) $0 MO triamcinolone acetonide $0 MO hydrocortisone butyrate (Tier hydrophilic lipo base crea (topical) oint 0.025 %, 0.1 (Tier 1) % 1) $0 MO Emollients hydrocortisone butyrate (Tier oint 1) LAC-HYDRIN TWELVE $0 RX/OTC; MO; LOTN (Lactic Acid (Tier NT $0 MO (Ammonium Lactate)) 3) hydrocortisone butyrate (Tier soln 1) $0 Over-the- lactic acid (ammonium (Tier counter;RX/OT lactate) crea 12 % $0 MO 3) C; MO; NT hydrocortisone valerate (Tier crea 1) $0 RX/OTC; MO lactic acid (ammonium (Tier $0 MO lactate) crea 12 % 1) hydrocortisone valerate (Tier oint 1) $0 Over-the- lactic acid (ammonium (Tier counter;RX/OT lactate) lotn 12 % $0 NT 3) C; MO; NT hydrocortisone-aloe vera (Tier crea 3) $0 RX/OTC; MO lactic acid (ammonium (Tier $0 MO lactate) lotn 12 % 1) mometasone furoate crea (Tier ex 1) Enzymes - Topical $0 MO $0 MO mometasone furoate oint (Tier SANTYL OINT (Tier ex 1) 2) $0 MO Immunomodulating Agents - Topical mometasone furoate soln (Tier ex 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 69 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO imiquimod crea ex (Tier lidocaine-prilocaine crea (Tier 1) 1) $0 MO Rosacea Agents IMIQUIMOD PUMP CREA (Tier $0 2) MO FINACEA GEL (Tier $0 MO 2) ZYCLARA CREA (Tier $0 MO 2) metronidazole (topical) (Tier $0 crea ZYCLARA PUMP CREA MO 1) (Tier $0 2.5 %, 3.75 % 2) MO metronidazole (topical) gel (Tier Immunosuppressive Agents - Topical 1) $0 PA; MO $0 MO ELIDEL CREA (Tier metronidazole (topical) lotn (Tier 2) 1) $0 PA; MO $0 PA; MO tacrolimus (topical) oint (Tier MIRVASO GEL (Tier 1) 2) Keratolytic/Antimitotic Agents Scabicides & Pediculicides $0 MO $0 MO podofilox soln ex (Tier malathion lotn (Tier 1) 1) Local Anesthetics - Topical $0 MO permethrin crea ex 5 % (Tier $0 MO; NT 1) lidocaine crea ex 4 % (Tier 3) $0 MO; NT permethrin liqd ex 1 % (Tier $0 RX/OTC; MO 3) lidocaine hcl gel ex 2 % (Tier 1) $0 NT permethrin lotn ex 1 % (Tier $0 MO 3) lidocaine hcl soln ex 4 % (Tier 1) pyrethrins-piperonyl $0 MO; NT $0 butoxide sham 0.3%- (Tier MO 0.33%-4%, 0.33%-4% 3) lidocaine oint ex 5 % (Tier 1) Wound Care Products $0 PA; MO $0 MO lidocaine ptch ex 5 % (Tier REGRANEX GEL (Tier 1) 2) DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 70 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Digestive Enzymes $0 MO bumetanide tabs or 0.5 mg, (Tier $0 MO 1 mg, 2 mg 1) CREON CPEP (Tier 2) $0 MO furosemide soln ij 10 mg/ml (Tier $0 MO 1) PANCREAZE CPEP (Tier 2) $0 MO furosemide soln or 10 (Tier $0 LA mg/ml 1) SUCRAID SOLN (Tier 2) $0 MO furosemide tabs or 20 mg, (Tier DIURETICS - Drugs to Treat Heart, Circulation 40 mg, 80 mg 1) Conditions and Blood Pressure $0 MO Carbonic Anhydrase Inhibitors torsemide tabs (Tier $0 MO 1) acetazolamide cp12 or 500 (Tier Potassium Sparing Diuretics mg 1) $0 MO $0 MO acetazolamide tabs or 250 amiloride hcl tabs or (Tier (Tier 1) mg 1) $0 MO $0 MO spironolactone tabs or 25 methazolamide tabs or 25 (Tier (Tier mg, 50 mg, 100 mg 1) mg, 50 mg 1) Thiazides and Thiazide-Like Diuretics Diuretic Combinations $0 MO $0 MO amiloride & chlorothiazide tabs 500 mg (Tier (Tier 1) hydrochlorothiazide tabs 1) $0 MO $0 spironolactone & MO chlorthalidone tabs 25 mg (Tier (Tier 1) hydrochlorothiazide tabs 1) $0 MO triamterene & $0 MO hydrochlorothiazide caps or (Tier hydrochlorothiazide caps (Tier 12.5 mg 1) 37.5mg-25mg 1) $0 MO triamterene & $0 hydrochlorothiazide tabs or (Tier hydrochlorothiazide caps (Tier 25 mg, 50 mg, 12.5 mg 1) 50mg-25mg 1) $0 MO triamterene & $0 MO indapamide tabs (Tier hydrochlorothiazide tabs (Tier 1) 75mg-50mg, 37.5mg-25mg 1) $0 MO Loop Diuretics metolazone tabs (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 71 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ENDOCRINE AND METABOLIC AGENTS - $0 zoledronic acid conc 4 (Tier MISC. - Drugs to Treat Bone Disease and mg/5ml Regulate Hormones 1) $0 QL(0.28 ml zoledronic acid soln 5 Bone Density Regulators (Tier daily) $0 QL(0.15 ea mg/100ml alendronate sodium tabs 1) (Tier daily); MO 35 mg, 70 mg 1) Corticotropin $0 MO $0 PA; LA alendronate sodium tabs 5 (Tier H.P. ACTHAR GEL (Tier mg, 10 mg 1) 2) $0 MO Fertility Regulators calcitonin (salmon) soln (Tier $0 PA 1) chorionic gonadotropin solr (Tier im 1) $0 PA; Limit 2.4mls per 28 FORTEO SOLN (Tier $0 PA 2) days;QL(0.09 NOVAREL SOLR (Tier ml daily) 2) $0 QL(0.04 ml ibandronate sodium soln iv Growth Hormone Receptor Antagonists (Tier daily); MO 3 mg/3ml 1) $0 PA; LA SOMAVERT SOLR (Tier $0 Limit 1 tab per 2) ibandronate sodium tabs or 28 days (3 per (Tier Growth Hormones 150 mg 1) 84);QL(0.036 ea daily); MO $0 PA GENOTROPIN MINIQUICK (Tier $0 MO SOLR 0.4 MG MIACALCIN SOLN IJ 200 (Tier 2) UNIT/ML 2) $0 PA GENOTROPIN SOLR 5 (Tier $0 PA; LA MG NATPARA CART (Tier 2) 2) $0 PA HUMATROPE COMBO (Tier $0 PA; QL(0.01 ml PACK SOLR PROLIA SOLN (Tier daily) 2) 2) $0 PA HUMATROPE SOLR 6 (Tier $0 PA MG, 12 MG, 24 MG TYMLOS SOPN (Tier 2) 2) NORDITROPIN FLEXPRO $0 PA SOLN 5 MG/1.5ML, 10 (Tier $0 Limit 6.8mls per 28 MG/1.5ML 2) XGEVA SOLN (Tier 2) days;QL(0.243 $0 PA ml daily) NUTROPIN AQ NUSPIN (Tier 20 SOLN 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 72 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 PA $0 LA OMNITROPE SOLN 5 (Tier FABRAZYME SOLR 35 (Tier MG/1.5ML, 10 MG/1.5ML 2) MG 2) $0 $0 SEROSTIM SOLR 4 MG, 6 PA LA (Tier KANUMA SOLN (Tier MG 2) 2) $0 PA $0 PA; LA ZOMACTON SOLR 5 MG (Tier KUVAN PACK (Tier 2) 2) Hormone Receptor Modulators $0 PA; LA $0 KUVAN TBSO (Tier QL(1 ea daily); 2) raloxifene hcl tabs (Tier MO 1) $0 RX/OTC; MO levocarnitine (metabolic (Tier Insulin-Like Growth Factors (Somatomedins) modifiers) tabs 330 mg 1) $0 LA $0 LA INCRELEX SOLN (Tier LUMIZYME SOLR (Tier 2) 2) LHRH/GnRH Agonist Analog Pituitary $0 LA; MO $0 MYALEPT SOLR (Tier LUPRON DEPOT-PED (1- (Tier 2) MONTH) KIT 2) $0 LA $0 NAGLAZYME SOLN (Tier LUPRON DEPOT-PED (3- (Tier 2) MONTH) KIT 2) $0 LA; MO ORFADIN CAPS 2 MG, 5 (Tier $0 MO MG, 10 MG, 20 MG SYNAREL SOLN (Tier 2) 2) $0 MO paricalcitol caps or 1 mcg, (Tier $0 MO 2 mcg, 4 mcg TRIPTODUR SRER (Tier 1) 2) $0 LA RAVICTI LIQD (Tier Metabolic Modifiers 2) $0 MO calcitriol caps or 0.25 mcg, (Tier $0 PA; MO 0.5 mcg 1) RAYALDEE CPCR (Tier 2) $0 MO calcitriol soln or 1 mcg/ml (Tier $0 1) SENSIPAR TABS (Tier 2) $0 LA; MO CARBAGLU TABS (Tier $0 PA; LA; MO 2) STRENSIQ SOLN (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 73 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 LA Limit 3 vials per VIMIZIM SOLN (Tier $0 28 2) SIGNIFOR LAR SRER 20 (Tier days;SL(0.11 MG $0 SL(4 ea daily); 2) ea daily); LA; XURIDEN PACK (Tier MO MO 2) Limit 2 vials per $0 28 Posterior Pituitary Hormones SIGNIFOR LAR SRER 30 (Tier MG days;SL(0.07 $0 MO 2) ea daily); LA; DDAVP SOLN NA 0.01 % (Tier MO 2) Limit 3 vials per $0 MO $0 56 desmopressin acetate soln (Tier SIGNIFOR LAR SRER 40 ij 4 mcg/ml (Tier days;SL(0.054 1) MG 2) ea daily); LA; $0 MO MO desmopressin acetate (Tier spray refrigerated soln Limit 1 vial per 1) $0 28 $0 MO SIGNIFOR LAR SRER 60 (Tier days;SL(0.036 desmopressin acetate (Tier MG spray soln 2) ea daily); LA; 1) MO $0 MO $0 LA; MO desmopressin acetate tabs (Tier or 0.1 mg, 0.2 mg SIGNIFOR SOLN (Tier 1) 2) Prolactin Inhibitors $0 SOMATULINE DEPOT (Tier $0 MO SOLN cabergoline tabs (Tier 2) 1) Vasopressin Receptor Antagonists Somatostatic Agents $0 PA; LA octreotide acetate soln 50 $0 JYNARQUE TBPK (Tier mcg/ml, 100 mcg/ml, 200 (Tier 2) mcg/ml 1) $0 $0 SAMSCA TABS (Tier SANDOSTATIN LAR (Tier 2) DEPOT KIT 20 MG, 30 MG 2) ESTROGENS - Hormone Replacement/Modifying Limit 6 vials per Drugs $0 28 Estrogen Combinations SIGNIFOR LAR SRER 10 (Tier days;SL(0.21 MG $0 AL(Up to 64 yrs 2) ea daily); LA; estradiol & norethindrone MO (Tier old); MO acetate tabs 1) norethindrone acetate- $0 AL(Up to 64 yrs ethinyl estradiol tabs (Tier old); MO 2.5mcg-0.5mg 1) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 74 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 AL(Up to 64 yrs ciprofloxacin hcl tabs or $0 MO PREMPHASE TABS (Tier old); MO 100 mg, 250 mg, 500 mg, (Tier 2) 750 mg 1) $0 AL(Up to 64 yrs $0 ciprofloxacin in d5w soln PREMPRO TABS (Tier old); MO (Tier 2) 200mg/100ml-5% 1) Estrogens $0 MO ciprofloxacin in d5w soln (Tier $0 MO 400mg/200ml-5% DELESTROGEN OIL 10 (Tier 1) MG/ML $0 2) ciprofloxacin soln iv 400 $0 (Tier AL(Up to 64 yrs mg/40ml 1) DIVIGEL GEL (Tier old); MO $0 2) ciprofloxacin-ciprofloxacin MO estradiol ptwk td 0.025 AL(Up to 64 yrs (Tier hcl tb24 1) mg/24hr, 0.075 mg/24hr, $0 old); MO 0.05 mg/24hr, 0.06 (Tier $0 mg/24hr, 0.1 mg/24hr, 37.5 1) levofloxacin in d5w soln (Tier mcg/24hr 1) $0 AL(Up to 64 yrs $0 estradiol tabs or 0.5 mg, 1 levofloxacin soln iv 25 (Tier (Tier old); MO mg/ml mg, 2 mg 1) 1) $0 MO $0 MO estradiol valerate oil im 20 levofloxacin soln or 25 (Tier (Tier mg/ml mg/ml, 40 mg/ml 1) 1) $0 $0 AL(Up to 64 yrs levofloxacin tabs or 250 QL(1 ea daily); estropipate tabs 0.75 mg, (Tier MO (Tier old); MO mg, 500 mg, 750 mg 1.5 mg 1) 1) PREMARIN TABS OR $0 AL(Up to 64 yrs GASTROINTESTINAL AGENTS - MISC. - 0.625 MG, 0.45 MG, 0.3 (Tier old); MO Miscellaneous Gastrointestinal Drugs MG, 0.9 MG, 1.25 MG 2) Farnesoid X Receptor (FXR) Agonists FLUOROQUINOLONES - Drugs to Treat Bacterial $0 PA; SL(1 ea Infections OCALIVA TABS 10 MG (Tier daily) Fluoroquinolones 2) $0 PA $0 PA; SL(2 ea BAXDELA SOLR IV 300 (Tier OCALIVA TABS 5 MG (Tier daily) MG 2) 2) $0 ST Gallstone Solubilizing Agents BAXDELA TABS OR 450 (Tier MG $0 LA 2) chenodiol tabs (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 75 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO ursodiol caps or 300 mg (Tier DELZICOL CPDR (Tier 1) 2) $0 $0 ursodiol tabs or 250 mg, MO MO (Tier DIPENTUM CAPS (Tier 500 mg 1) 2) Gastrointestinal Antiallergy Agents $0 PA ENTYVIO SOLR (Tier $0 MO cromolyn sodium (Tier 2) (mastocytosis) conc 1) $0 PA INFLECTRA SOLR (Tier Gastrointestinal Stimulants 2) $0 MO $0 MO metoclopramide hcl soln ij (Tier 5 mg/ml mesalamine enem re 4 gm (Tier 1) 1) $0 MO $0 MO metoclopramide hcl soln or (Tier mesalamine tbec or 800 5 mg/5ml, 10 mg/10ml (Tier 1) mg 1) $0 MO $0 MO metoclopramide hcl tabs or (Tier 5 mg, 10 mg mesalamine w/ cleanser kit (Tier 1) 1) Inflammatory Bowel Agents $0 PA $0 MO REMICADE SOLR (Tier APRISO CP24 (Tier 2) 2) $0 PA STELARA SOLN IV 130 (Tier $0 MO MG/26ML ASACOL HD TBEC (Tier 2) 2) $0 MO $0 MO sulfasalazine tabs or (Tier ASACOL HD TBEC (Tier 1) (Mesalamine) 2) $0 MO $0 MO sulfasalazine tbec or (Tier balsalazide disodium caps (Tier 1) 1) Intestinal Acidifiers $0 PA $0 MO CIMZIA KIT (Tier lactulose (encephalopathy) (Tier 2) soln 1) $0 PA CIMZIA STARTER KIT KIT (Tier Irritable Bowel Syndrome (IBS) Agents 2) $0 PA; MO alosetron hcl tabs (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 76 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO GENITOURINARY AGENTS - MISCELLANEOUS LINZESS CAPS (Tier - Miscellaneous Drugs to Treat Reproductive 2) Organs and Urinary System $0 PA; MO VIBERZI TABS (Tier Alkalinizers 2) potassium citrate $0 MO (alkalinizer) tbcr 540 mg, (Tier Peripheral Opioid Receptor Antagonists 1080 mg 1) $0 MO MOVANTIK TABS (Tier Cystinosis Agents 2) $0 (Tier $0 MO CYSTAGON CAPS RELISTOR SOLN SC 8 (Tier 2) MG/0.4ML, 12 MG/0.6ML 2) Genitourinary Irrigants Phosphate Binder Agents $0 MO (Tier $0 MO acetic acid soln calcium acetate (phosphate (Tier 1) binder) caps $0 1) neomycin/polymyxin b gu MO FOSRENOL CHEW 500 $0 MO (Tier soln 1) MG, 750 MG, 1000 MG (Tier $0 (Lanthanum Carbonate) 2) sodium chloride (gu MO $0 (Tier MO irrigant) soln 1) lanthanum carbonate chew (Tier 1) Prostatic Hypertrophy Agents $0 MO $0 MO RENVELA TABS 800 MG (Tier ) alfuzosin hcl tb24 (Tier (Sevelamer Carbonate 2) 1) $0 $0 sevelamer carbonate pack MO MO (Tier dutasteride caps (Tier 2.4 gm 1) 1) $0 MO $0 MO sevelamer carbonate tabs (Tier dutasteride-tamsulosin hcl (Tier 800 mg 1) caps 1) Short Bowel Syndrome (SBS) Agents $0 MO $0 finasteride tabs or (Tier PA; LA 1) GATTEX KIT (Tier 2) $0 MO tamsulosin hcl caps (Tier Tryptophan Hydroxylase Inhibitors 1) $0 PA; LA; MO XERMELO TABS (Tier GOUT AGENTS - Drugs to Treat Gout 2) Gout Agent Combinations
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 77 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 colchicine w/ probenecid MO PA (Tier TAVALISSE TABS (Tier tabs 1) 2) Gout Agents Hematorheologic Agents $0 SL(8 ea daily); $0 MO allopurinol tabs or 100 mg (Tier MO pentoxifylline tbcr or (Tier 1) 1) $0 SL(2.66 ea Plasma Kallikrein Inhibitors allopurinol tabs or 300 mg (Tier daily); MO $0 1) KALBITOR SOLN (Tier $0 MO 2) colchicine tabs or (Tier 2) Platelet Aggregation Inhibitors $0 MO $0 MO COLCRYS TABS (Tier anagrelide hcl caps (Tier 2) 1) $0 MO Uricosurics aspirin-dipyridamole cp12 (Tier $0 MO 1) probenecid tabs (Tier 1) $0 MO BRILINTA TABS (Tier HEMATOLOGICAL AGENTS - MISC. - Drugs to 2) Treat Blood Disorders $0 MO Bradykinin B2 Receptor Antagonists cilostazol tabs (Tier 1) $0 PA $0 FIRAZYR SOLN (Tier clopidogrel bisulfate tabs 2) (Tier 300 mg 1) Complement Inhibitors $0 MO $0 LA clopidogrel bisulfate tabs (Tier BERINERT KIT (Tier 75 mg 1) 2) $0 dipyridamole tabs or 25 AL(Up to 64 yrs $0 PA; LA (Tier old); MO CINRYZE SOLR (Tier mg, 50 mg, 75 mg 1) 2) $0 MO $0 PA EFFIENT TABS (Prasugrel (Tier HAEGARDA SOLR (Tier HCl) 2) 2) $0 MO $0 prasugrel hcl tabs (Tier RUCONEST SOLR (Tier 1) 2) Hemataologic - Tyrosine Kinase Inhibitors
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 78 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 PA ZONTIVITY TABS (Tier GRANIX SOSY (Tier 2) 2) HEMATOPOIETIC AGENTS - Drugs to Treat $0 PA Blood Disorders LEUKINE SOLR (Tier 2) Agents for Gaucher Disease $0 PA $0 PA NEULASTA ONPRO KIT (Tier CERDELGA CAPS (Tier PSKT 2) 2) $0 PA $0 PA; LA NEULASTA SOSY (Tier CEREZYME SOLR (Tier 2) 2) $0 PA $0 NEUPOGEN SOLN (Tier ELELYSO SOLR (Tier 2) 2) $0 PA $0 LA; MO NEUPOGEN SOSY (Tier miglustat caps (Tier 2) 1) PROCRIT SOLN 2000 PA $0 UNIT/ML, 3000 UNIT/ML, $0 VPRIV SOLR (Tier 4000 UNIT/ML, 10000 (Tier 2) UNIT/ML, 20000 UNIT/ML, 2) $0 LA; MO 40000 UNIT/ML ZAVESCA CAPS (Tier (Miglustat) $0 PA; SL(12 ea 2) PROMACTA TABS 12.5 (Tier MG daily); LA Agents for Sickle Cell Anemia 2) $0 MO $0 PA; SL(6 ea DROXIA CAPS (Tier PROMACTA TABS 25 MG (Tier daily); LA 2) 2) $0 PA; MO $0 PA; SL(3 ea ENDARI PACK (Tier PROMACTA TABS 50 MG (Tier daily); LA 2) 2) $0 Hematopoietic Growth Factors PA; SL(2 ea PROMACTA TABS 75 MG (Tier daily); LA $0 PA 2) ARANESP ALBUMIN (Tier FREE SOLN 2) $0 PA ZARXIO SOSY (Tier $0 PA 2) ARANESP ALBUMIN (Tier FREE SOSY 2) Iron $0 PA $0 MO; NT carbonyl iron susp 15 (Tier EPOGEN SOLN (Tier mg/1.25ml 2) 3) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 79 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 phenobarbital tabs or 15 AL(Up to 64 yrs FERROUS GLUCONATE MO; NT $0 (Tier mg, 30 mg, 60 mg, 100 mg, old); MO TABS OR 324 MG 3) (Tier 16.2 mg, 32.4 mg, 64.8 mg, 1) $0 MO; NT 97.2 mg ferrous sulfate tabs or 65 (Tier Hypnotics - Tricyclic Agents mg, 325 mg 3) $0 QL(2 ea daily); $0 FERROUS SULFATE MO; NT SILENOR TABS 3 MG (Tier MO (Tier 2) TBEC OR 324 MG 3) $0 QL(1 ea daily); Stem Cell Mobilizers SILENOR TABS 6 MG (Tier MO $0 PA 2) MOZOBIL SOLN (Tier Non-Barbiturate Hypnotics 2) $0 MO HEMOSTATICS - Drugs to Stop Bleeding/Treat temazepam caps (Tier Blood Disorders 1) Hemostatics - Systemic $0 MO TRIAZOLAM TABS 0.125 (Tier $0 MO MG 2) AMICAR SOLN 0.25 (Tier GM/ML 2) $0 MO triazolam tabs 0.25 mg (Tier $0 MO 1) AMICAR TABS 500 MG (Tier 2) $0 AL(Up to 64 yrs zaleplon caps (Tier old); MO $0 1) tranexamic acid soln iv (Tier 1000 mg/10ml 1) $0 AL(Up to 64 yrs zolpidem tartrate tabs or 10 (Tier old); SL(1 ea $0 MO mg 1) tranexamic acid tabs or (Tier daily); MO 650 mg 1) $0 AL(Up to 64 yrs zolpidem tartrate tabs or 5 (Tier old); SL(2 ea mg HYPNOTICS/SEDATIVES/SLEEP DISORDER 1) daily); MO AGENTS $0 AL(Up to 64 yrs zolpidem tartrate tbcr or Barbiturate Hypnotics (Tier old); SL(1 ea 12.5 mg $0 AL(Up to 64 yrs 1) daily); MO BUTISOL SODIUM TABS (Tier old); MO $0 AL(Up to 64 yrs 2) zolpidem tartrate tbcr or (Tier old); SL(2 ea 6.25 mg $0 1) daily); MO phenobarbital elix or 20 AL(Up to 64 yrs (Tier old); MO Orexin Receptor Antagonists mg/5ml 1) $0 PA; SL(2 ea $0 phenobarbital soln or 20 AL(Up to 64 yrs BELSOMRA TABS 10 MG (Tier daily); MO (Tier old); MO 2) mg/5ml 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 80 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 PA; SL(1.33 ea lactulose soln 10 gm/15ml, MO BELSOMRA TABS 15 MG (Tier daily); MO (Tier 2) 20 gm/30ml 1) $0 $0 RX/OTC; MO; PA; SL(1 ea MIRALAX PACK BELSOMRA TABS 20 MG (Tier daily); MO (Tier NT 2) (Polyethylene Glycol 3350) 3) $0 $0 RX/OTC; MO; PA; SL(4 ea MIRALAX POWD BELSOMRA TABS 5 MG (Tier daily); MO (Tier NT 2) (Polyethylene Glycol 3350) 3) Selective Melatonin Receptor Agonists $0 RX/OTC; MO polyethylene glycol 3350 (Tier $0 PA; MO pack or 1) HETLIOZ CAPS (Tier $0 Over-the- 2) polyethylene glycol 3350 $0 (Tier counter;RX/OT MO pack or 3) C; MO; NT ROZEREM TABS (Tier 2) $0 RX/OTC; MO polyethylene glycol 3350 (Tier powd or LAXATIVES - Bowel Treatment Drugs 1) $0 Over-the- Bulk Laxatives polyethylene glycol 3350 (Tier counter;RX/OT powd or $0 MO; NT 3) C; MO; NT psyllium powd 28.3 %, 58.6 (Tier %, 48.57 % 3) Saline Laxatives $0 NT $0 MO; NT FLEET ENEMA ENEM (Tier psyllium powd 30.9 % (Tier (Sodium Phosphates) 3) 3) FLEET ENEMA SIX PACK $0 MO; NT Laxative Combinations ENEM (Sodium (Tier bisacodyl-peg 3350-pot $0 Phosphates) 3) chloride-sod bicarb-sod (Tier $0 MO; NT chloride kit 1) FLEET PEDIATRIC ENEM (Tier peg 3350-kcl-sod bicarb- $0 MO (Sodium Phosphates) 3) sod chloride-sod sulfate (Tier sodium phosphates enem MO; NT solr 1) re 16gm/133ml-6gm/133ml, $0 peg 3350-potassium $0 MO 19gm/118ml-7gm/118ml, chloride-sod bicarbonate- (Tier (Tier 9.5gm/59ml-3.5gm/59ml, 3) sod chloride solr 1) 19gm/118ml-19gm/118ml- $0 7gm/118ml-7gm/118ml SUPREP BOWEL PREP MO (Tier Stimulant Laxatives KIT SOLN 2) $0 MO; NT Laxatives - Miscellaneous bisacodyl supp re 10 mg (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 81 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 QL(1.2 ea azithromycin tabs or 250 bisacodyl tbec or 5 mg (Tier (Tier daily); MO 3) mg 1) $0 QL(1 ea daily); Surfactant Laxatives azithromycin tabs or 500 (Tier MO $0 MO; NT mg 1) COLACE CAPS (Docusate (Tier Sodium) $0 QL(0.29 ea 3) azithromycin tabs or 600 (Tier daily); MO $0 MO; NT mg 1) COLACE CLEAR CAPS (Tier (Docusate Sodium) 3) Clarithromycin $0 $0 MO; NT clarithromycin susr or 250 MO docusate calcium caps (Tier (Tier 3) mg/5ml 1) $0 MO; NT $0 MO docusate sodium caps or (Tier clarithromycin tabs or 250 (Tier 50 mg, 100 mg, 250 mg 3) mg, 500 mg 1) $0 MO; NT $0 MO docusate sodium liqd or 50 (Tier clarithromycin tb24 or 500 (Tier mg/5ml, 150 mg/15ml 3) mg 1) $0 docusate sodium syrp or MO; NT Erythromycins (Tier $0 60 mg/15ml 3) erythromycin base tabs 250 SL(16 ea daily); (Tier MO mg LOCAL ANESTHETICS-Parenteral - Drugs for 1) Numbing $0 SL(8 ea daily); erythromycin base tabs 500 Local Anesthetics - Amides (Tier MO mg 1) $0 lidocaine hcl (local anesth.) (Tier erythromycin $0 SL(10 ea daily); soln 1 %, 2 % 1) ethylsuccinate tabs or 400 (Tier MO mg 1) MACROLIDES - Drugs to Treat Bacterial $0 SL(8 ea daily) Infections erythromycin lactobionate (Tier solr Azithromycin 1) $0 MO $0 SL(16 ea daily); azithromycin solr iv 500 mg (Tier erythromycin stearate tabs (Tier MO 1) 1) $0 azithromycin susr or 100 QL(3 ml daily); Fidaxomicin (Tier MO mg/5ml $0 MO 1) DIFICID TABS (Tier $0 azithromycin susr or 200 QL(4.5 ml 2) (Tier daily); MO mg/5ml 1) MEDICAL DEVICES AND SUPPLIES
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 82 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Bandages-Dressings-Tape $0 ergotamine tartrate subl sl (Tier $0 RX/OTC; MO 1) gauze pads 2"x2" (Tier 1) $0 MO MIGRANAL SOLN (Tier Misc. Devices 2) $0 RX/OTC; MO ALCOHOL PADS (Tier Serotonin Agonists 2) $0 MO almotriptan malate tabs (Tier Parenteral Therapy Supplies 1) $0 RX/OTC; MO $0 QL(0.3 ea INSULIN SYRINGES AND (Tier PEN NEEDLES naratriptan hcl tabs (Tier daily); MO 2) 1) MIGRAINE PRODUCTS - Drugs to Treat Migraine $0 QL(0.4 ea Headaches rizatriptan benzoate tabs (Tier daily); MO 1) Migraine Combinations $0 QL(0.4 ea $0 MO ergotamine w/ caffeine rizatriptan benzoate tbdp (Tier daily); MO (Tier 1) supp re 2mg-100mg 1) $0 $0 Limit 4mls per sumatriptan-naproxen MO sumatriptan succinate soaj (Tier month;QL(0.14 (Tier sc 4 mg/0.5ml, 6 mg/0.5ml sodium tabs 1) 1) ml daily); MO $0 $0 MO Limit 4mls per TREXIMET TABS 10MG- sumatriptan succinate soct (Tier month;QL(0.14 (Tier sc 4 mg/0.5ml, 6 mg/0.5ml 60MG 2) 1) ml daily); MO TREXIMET TABS 85MG- $0 MO $0 Limit 4mls per sumatriptan succinate soln (Tier month;QL(0.14 500MG (Sumatriptan- (Tier sc 6 mg/0.5ml Naproxen Sodium) 2) 1) ml daily); MO $0 sumatriptan succinate tabs QL(0.3 ea Migraine Products - Monoclonal Antibodies (Tier daily); MO $0 PA; MO or 25 mg, 50 mg, 100 mg 1) AIMOVIG SOAJ (Tier $0 SL(4 ea daily); 2) zolmitriptan tabs 2.5 mg (Tier MO Migraine Products 1) $0 MO $0 SL(2 ea daily); dihydroergotamine (Tier zolmitriptan tabs 5 mg (Tier MO mesylate soln ij 1 mg/ml 1) 1) $0 MO $0 SL(4 ea daily); dihydroergotamine (Tier zolmitriptan tbdp 2.5 mg (Tier MO mesylate soln na 4 mg/ml 2) 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 83 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 SL(2 ea daily); magnesium oxide (mg MO; NT zolmitriptan tbdp 5 mg (Tier MO (Tier 1) supplement) tabs 241.3 mg 3) $0 MINERALS & ELECTROLYTES MAGNESIUM SULFATE (Tier SOLN IJ 50 % Calcium 2) $0 NT $0 calcium carbonate tabs or magnesium sulfate soln ij (Tier (Tier 50 % 500 mg, 1250 mg 3) 1) calcium carbonate- $0 MO; NT magnesium sulfate soln iv $0 cholecalciferol tabs 500mg- (Tier 2 gm/50ml, 4 gm/50ml, 4 (Tier 200unit 3) gm/100ml, 20 gm/500ml, 1) 40 gm/1000ml calcium carbonate-vitamin $0 MO; NT d tabs 200unit-500mg, MAGNESIUM SULFATE (Tier SOLN IV 2 GM/50ML, 4 500mg-200unit, 500mg- 3) $0 500mg-200unit-200unit GM/50ML, 4 GM/100ML, (Tier 20 GM/500ML, 40 2) $0 MO; NT GM/1000ML (Magnesium oyster shell tabs (Tier Sulfate) 3) $0 MO; NT Electrolyte Mixtures NU-MAG TBEC (Tier $0 3) dextrose in lactated ringers (Tier soln $0 MO; NT 1) SLOW-MAG TBEC (Tier dextrose w/ sodium $0 3) chloride soln 0.45%-2.5%, (Tier Phosphate 0.45%-5% 1) sodium phosphates $0 $0 dextrose w/ sodium MO (sodium phosphate dibasic (Tier (Tier & monobasic) soln 1) chloride soln 0.9%-5% 1) $0 Potassium lactated ringer's soln (Tier $0 MO K-TAB TBCR 8 MEQ, 20 (Tier 1) MEQ parenteral electrolytes soln B/D 2) 20meq/20ml-5meq/20ml- $0 $0 MO potassium chloride cpcr or (Tier 35meq/20ml-35meq/20ml- (Tier 8 meq, 10 meq 4.5meq/20ml- 1) 1) 29.5meq/20ml $0 MO POTASSIUM CHLORIDE (Tier potassium chloride in $0 ER TBCR dextrose & sodium chloride (Tier 2) soln 0.45%-20meq/l-5% 1) potassium chloride $0 MO Magnesium microencapsulated crystals (Tier er tbcr 1) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 84 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO Immunosuppressive Agents potassium chloride soln iv (Tier 2 meq/ml 1) $0 B/D; MO ASTAGRAF XL CP24 (Tier $0 MO 2) POTASSIUM CHLORIDE (Tier SOLN IV 2 MEQ/ML 2) $0 B/D AZATHIOPRINE SOLR IJ (Tier $0 MO 100 MG 2) potassium chloride soln or (Tier 10 %, 20 % $0 B/D; MO 1) azathioprine tabs or 50 mg, (Tier $0 MO 75 mg, 100 mg 1) potassium chloride tbcr or (Tier 8 meq, 10 meq $0 B/D; MO 1) cyclosporine caps or 25 (Tier mg, 100 mg Sodium 1) $0 sodium chloride soln iv cyclosporine modified (for $0 B/D; MO (Tier microemulsion) caps 25 (Tier 0.45 % 1) mg, 50 mg, 100 mg 1) $0 MO $0 B/D sodium chloride soln iv 0.9 (Tier cyclosporine soln iv 50 % (Tier 1) mg/ml 1) $0 B/D; MO MISCELLANEOUS THERAPEUTIC CLASSES ENVARSUS XR TB24 (Tier Chelating Agents 2) $0 MO $0 B/D; MO mycophenolate mofetil (Tier CUPRIMINE CAPS (Tier caps 2) 1) $0 MO $0 B/D mycophenolate mofetil hcl (Tier DEPEN TITRATABS TABS (Tier solr 2) 1) $0 MO $0 B/D; MO SYPRINE CAPS (Trientine (Tier mycophenolate mofetil susr (Tier HCl) 2) 1) $0 MO $0 B/D; MO trientine hcl caps (Tier mycophenolate mofetil tabs (Tier 1) 1) $0 B/D; MO Immunomodulators mycophenolate sodium (Tier $0 PA; LA tbec 1) REVLIMID CAPS (Tier $0 B/D 2) NULOJIX SOLR (Tier $0 2) THALOMID CAPS (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 85 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 ST; SL(1 ea PROGRAF SOLN IV 5 B/D (Tier VELTASSA PACK 25.2 GM (Tier daily); LA; MO MG/ML 2) 2) $0 $0 ST; SL(3 ea RAPAMUNE SOLN 1 B/D; MO (Tier VELTASSA PACK 8.4 GM (Tier daily); LA; MO MG/ML 2) 2) $0 B/D; MO Systemic Lupus Erythematosus Agents SANDIMMUNE SOLN OR (Tier 100 MG/ML $0 PA 2) BENLYSTA SOAJ SC 200 (Tier $0 B/D MG/ML 2) SIMULECT SOLR (Tier $0 PA 2) BENLYSTA SOLR IV 120 (Tier $0 B/D; MO MG 2) sirolimus tabs (Tier 1) $0 PA BENLYSTA SOSY SC 200 (Tier $0 B/D; MO MG/ML 2) tacrolimus caps or 0.5 mg, (Tier 1 mg, 5 mg 1) MOUTH/THROAT/DENTAL AGENTS $0 B/D THYMOGLOBULIN SOLR (Tier Anesthetics Topical Oral 2) $0 MO lidocaine hcl (mouth-throat) (Tier $0 B/D; MO soln ZORTRESS TABS (Tier 1) 2) Anti-infectives - Throat Irrigation Solutions $0 MO $0 clotrimazole lozg mt (Tier irrigation solutions, (Tier 1) physiological soln 1) $0 MO $0 MO clotrimazole troc mt (Tier water for irrigation, sterile (Tier 1) soln 1) $0 MO nystatin (mouth-throat) (Tier Potassium Removing Agents susp 1) $0 MO sodium polystyrene (Tier Antiseptics - Mouth/Throat sulfonate powd or 1) $0 MO chlorhexidine gluconate (Tier sodium polystyrene $0 MO (mouth-throat) soln sulfonate susp or 15 (Tier 1) gm/60ml 1) Steroids - Mouth/Throat $0 ST; SL(1.5 ea $0 MO VELTASSA PACK 16.8 GM (Tier daily); LA; MO triamcinolone acetonide (Tier 2) (mouth) pste 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 86 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Throat Products - Misc. b complex w/ c tabs 10mg- MO; NT $0 10mg-15mg-50mg-5mg- MO 300mg, 15mg-10mg-50mg- cevimeline hcl caps (Tier 1) 10mg-5mg-300mg, 50mg- 10mg-10mg-15mg-5mg- $0 MO 300mg, 10.2mg-10mg- pilocarpine hcl (oral) tabs (Tier 15mg-50mg-5mg-300mg, 1) 15mg-10.2mg-10mg-50mg- 5mg-300mg, 15mg-50mg- MULTIVITAMINS 10.2mg-10mg-5mg-300mg, B-Complex w/ C 50mg-10.2mg-10mg-15mg- 5mg-300mg, 50mg-15mg- 10mg-10.2mg-5mg-300mg, 15mg-20mg-50mg-10mg- 10mcg-5mg-300mg, 100mg-10mg-20mg- 10mcg-15mg-5mg-500mg, $0 15mg-150mg-10mg-50mg- (Tier 10.2mg-5mg-300mg, 3) 15mg-10mg-50mg-10.2mg- 6mcg-400mcg-5mg-300mg, 25mg-5.5mg-20mg- 100mcg-5mg-25mg- 400mcg-1000mcg-60mg, 100mg-100mg-25mg- 20mg-6mg-15mcg-100mg- 5mcg-2mg-150mg, 100mg- 100mg-5.5mg-20mg- 15mcg-25mg-400mcg- 5mcg-2mg-150mg, 100mg- 20mg-5.5mg-15mcg-2mg- 25mg-150mg-400mcg- 5mcg-150mg, 10.2mg- 10.2mg-10mg-10mg-50mg- 50mg-15mg-15mg-5mg- 5mg-300mg-300mg Multivitamins $0 MO; NT ESTROFACTORS TABS (Tier 3) $0 MO; NT MULTI VITAMIN TABS (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 87 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 SL(8 ea daily); MULTI VITAMIN/D-3 TABS (Tier baclofen tabs or 10 mg (Tier MO 3) 1) $0 MO; NT $0 SL(4 ea daily); multiple vitamin tabs (Tier baclofen tabs or 20 mg (Tier MO 3) 1) $0 $0 MO; NT BACLOFEN TABS OR 5 SL(16 ea daily) NEOMULTIVITE TABS (Tier (Tier 3) MG 2) $0 $0 AL(Up to 64 yrs MO; NT carisoprodol tabs or 350 OMNICAP TABS (Tier (Tier old); MO 3) mg 1) $0 MO; NT $0 AL(Up to 64 yrs QUINTABS TABS (Tier chlorzoxazone tabs 500 mg (Tier old); MO 3) 1) $0 $0 MO; NT cyclobenzaprine hcl tabs or AL(Up to 64 yrs THERA TABS (Tier (Tier old); MO 3) 5 mg, 10 mg 1) Prenatal Vitamins $0 AL(Up to 64 yrs metaxalone tabs (Tier old); MO $0 MO 1) NESTABS TABS (Tier $0 AL(Up to 64 yrs 2) methocarbamol tabs or 500 (Tier old); MO $0 MO mg, 750 mg 1) PRENATE AM TABS (Tier 2) $0 SL(18 ea daily); tizanidine hcl caps or 2 mg (Tier MO $0 MO 1) PRENATE CHEW (Tier 2) $0 SL(9 ea daily); tizanidine hcl caps or 4 mg (Tier MO VIRT-PN DHA CAPS MO 1) 600MCG-330MG-300MG- $0 45MG-140MG-27MG- $0 SL(6 ea daily); (Tier tizanidine hcl caps or 6 mg (Tier MO 12MCG-200UNIT- 2) 400MCG-10UNIT-25MG- 1) 85MG $0 SL(18 ea daily); $0 MO tizanidine hcl tabs or 2 mg (Tier MO ZATEAN-PN DHA CAPS (Tier 1) 2) $0 SL(9 ea daily); tizanidine hcl tabs or 4 mg (Tier MO MUSCULOSKELETAL THERAPY AGENTS - 1) Drugs to Treat Spasms Direct Muscle Relaxants Central Muscle Relaxants
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 88 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 dantrolene sodium caps or MO $0 Over-the- (Tier fluticasone propionate (Tier counter;RX/OT 25 mg, 50 mg, 100 mg (nasal) susp 1) 3) C; MO; NT $0 NASAL AGENTS - SYSTEMIC AND TOPICAL - fluticasone propionate RX/OTC; MO Drugs to treat the Nose or Sinus (Tier (nasal) susp 1) Nasal Antiallergy $0 RX/OTC; MO; $0 NASACORT ALLERGY azelastine hcl soln 0.1 %, MO (Tier NT (Tier 24HR AERO 3) 137 mcg/spray 1) NASACORT ALLERGY $0 RX/OTC; MO; $0 MO; NT 24HR AERO NT cromolyn sodium (nasal) (Tier (Tier aers (Triamcinolone Acetonide 3) 3) (Nasal)) $0 MO NASACORT ALLERGY $0 RX/OTC; MO; olopatadine hcl (nasal) soln (Tier 24HR CHILDRENS AERO NT 1) (Tier (Triamcinolone Acetonide 3) Nasal Anticholinergics (Nasal)) $0 MO $0 Over-the- ipratropium bromide (nasal) triamcinolone acetonide (Tier counter;RX/OT (Tier (nasal) aero soln 1) 3) C; MO; NT Nasal Steroids $0 RX/OTC; MO triamcinolone acetonide (Tier $0 Over-the- (nasal) aero 1) budesonide (nasal) susp (Tier counter;RX/OT 3) C; MO; NT NEUROMUSCULAR AGENTS - Drugs to $0 RX/OTC; MO Relax/Paralyze Muscles budesonide (nasal) susp (Tier ALS Agents 1) $0 PA; MO FLONASE ALLERGY $0 RX/OTC; MO; RADICAVA SOLN (Tier RELIEF CHILDRENS (Tier NT 2) SUSP (Fluticasone 3) $0 MO Propionate (Nasal)) riluzole tabs (Tier FLONASE ALLERGY $0 RX/OTC; MO; 1) RELIEF SUSP (Fluticasone (Tier NT Propionate (Nasal)) 3) Muscular Dystrophy Agents $0 RX/OTC; MO; $0 PA; LA; MO FLONASE SENSIMIST EXONDYS 51 SOLN (Tier (Tier NT SUSP 3) 2) $0 MO Neuromuscular Blocking Agent - Neurotoxins flunisolide (nasal) soln (Tier $0 PA; MO 1) BOTOX SOLR (Tier 2)
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2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 89 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 PA; MO GENTEAL MILD TO $0 NT XEOMIN SOLR (Tier MODERATE SOLN (Tier 2) (Hypromellose (Ophth)) 3) $0 MO; NT NUTRIENTS GENTEAL SEVERE GEL (Tier Carbohydrates 3) $0 B/D GENTEAL TEARS $0 MO; NT dextrose soln iv 10 % (Tier MODERATE PF SOLN (Tier 1) (Dextran 70-Hypromellose) 3) $0 B/D; MO GENTEAL TEARS $0 MO; NT dextrose soln iv 5 % (Tier MODERATEPF SOLN (Tier 1) (Dextran 70-Hypromellose) 3) GONAK SOLN $0 NT Lipids (Hypromellose (Tier $0 B/D (Gonioscopic)) 3) fat emulsion emul (Tier $0 NT 1) hypromellose (gonioscopic) (Tier soln Proteins 3) $0 B/D $0 NT amino acid electrolyte (Tier hypromellose (ophth) soln (Tier infusion soln 1) 3) $0 B/D $0 MO; NT amino acid infusion 15% (Tier ISOPTO TEARS SOLN (Tier 1) 3) $0 MO; NT OPHTHALMIC AGENTS - Drugs to Treat the Eye polyvinyl alcohol soln op (Tier Artificial Tears and Lubricants 3) $0 MO; NT polyvinyl alcohol-povidone $0 NT artificial tear ointment oint (Tier (ophth) soln 0.6%-0.5%, (Tier 3) 6mg/ml-5mg/ml 3) $0 MO; NT $0 MO; NT REFRESH LIQUIGEL (Tier artificial tear solution soln (Tier SOLN 3) 3) $0 MO; NT REFRESH PLUS SOLN $0 MO; NT carboxymethylcellulose (Tier (Carboxymethylcellulose (Tier sodium (ophth) gel 1 % 3) Sodium (Ophth)) 3) $0 MO; NT REFRESH TEARS SOLN $0 MO; NT carboxymethylcellulose (Tier (Carboxymethylcellulose (Tier sodium (ophth) soln 0.5 % 3) Sodium (Ophth)) 3) $0 MO; NT SYSTANE OVERNIGHT $0 MO; NT dextran 70-hypromellose (Tier THERAPY LUBRICANT (Tier soln 3) EYE GEL 3)
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2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 90 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 white petrolatum-mineral oil MO; NT MO (Tier apraclonidine hcl soln (Tier oint 3) 1) Beta-blockers - Ophthalmic $0 MO brimonidine tartrate soln (Tier $0 MO 1) betaxolol hcl (ophth) soln (Tier 1) Ophthalmic Anti-infectives $0 MO $0 MO carteolol hcl (ophth) soln (Tier AZASITE SOLN (Tier 1) 2) dorzolamide hcl-timolol $0 MO $0 MO maleate soln 2%-0.5%, (Tier bacitracin (ophthalmic) oint (Tier 22.3mg/ml-6.8mg/ml 1) 1) $0 MO $0 MO bacitracin-polymyxin b (Tier levobunolol hcl soln (Tier (ophth) oint 1) 1) $0 MO $0 MO timolol maleate (ophth) ciprofloxacin hcl (ophth) (Tier (Tier soln solg 0.25 %, 0.5 % 1) 1) $0 MO $0 MO timolol maleate (ophth) (Tier erythromycin (ophth) oint (Tier soln 0.25 %, 0.5 % 1) 1) TIMOLOL MALEATE $0 MO $0 MO OPHTHALMIC GEL (Tier gatifloxacin (ophth) soln (Tier FORMING SOLG 2) 1) Cycloplegic Mydriatics $0 MO gentamicin sulfate (ophth) (Tier $0 MO oint 1) cyclopentolate hcl soln op (Tier 1 % 1) $0 MO gentamicin sulfate (ophth) (Tier Miotics soln 1) $0 $0 MO PHOSPHOLINE IODIDE (Tier SOLR levofloxacin (ophth) soln (Tier 2) 1) $0 MO $0 MO pilocarpine hcl soln op 1 %, (Tier moxifloxacin hcl (ophth) 2 %, 4 % (Tier 1) soln 1) Ophthalmic Adrenergic Agents $0 MO $0 MO NATACYN SUSP (Tier ALPHAGAN P SOLN 0.1 % (Tier 2) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 91 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO $0 MO neomycin-bacitracin zn- (Tier bacitracin-poly-neomycin- (Tier polymyxin oint 1) hc oint 1) $0 MO $0 MO neomycin-polymyxin- (Tier dexamethasone sodium (Tier gramicidin soln 1) phosphate (ophth) soln 1) $0 MO $0 MO ofloxacin (ophth) soln (Tier DUREZOL EMUL (Tier 1) 2) $0 MO $0 MO polymyxin b-trimethoprim (Tier fluorometholone (ophth) (Tier soln 1) susp 1) $0 MO $0 sulfacetamide sodium MO (Tier LOTEMAX OINT (Tier (ophth) soln 1) 2) $0 $0 MO neomycin-polymy- MO tobramycin (ophth) soln (Tier (Tier 1) dexameth oint 1) $0 $0 MO neomycin-polymy- MO trifluridine soln op (Tier (Tier 1) dexameth susp 1) $0 MO $0 MO VIGAMOX SOLN (Tier prednisolone acetate (Tier (Moxifloxacin HCl (Ophth)) 2) (ophth) susp 1) $0 $0 MO sulfacetamide sod- MO ZIRGAN GEL (Tier (Tier 2) prednisolone soln 1) Ophthalmic Immunomodulators $0 MO tobramycin- (Tier $0 MO dexamethasone susp 1) RESTASIS EMUL (Tier 2) Ophthalmics - Misc. $0 $0 RESTASIS MULTIDOSE MO MO (Tier azelastine hcl (ophth) soln (Tier EMUL 2) 1) Ophthalmic Local Anesthetics $0 MO $0 AZOPT SUSP (Tier MO 2) proparacaine hcl soln op (Tier $0 1) bromfenac sodium (ophth) Once daily (Tier dosing;MO Ophthalmic Steroids soln 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 92 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 cromolyn sodium (ophth) MO MO (Tier latanoprost soln (Tier soln 1) 1) Limit 60mls per $0 MO $0 28 LUMIGAN SOLN (Tier CYSTARAN SOLN (Tier days;QL(2.15 2) 2) ml daily); LA; $0 MO MO TRAVATAN Z SOLN (Tier $0 MO 2) diclofenac sodium (ophth) (Tier soln 1) OTIC AGENTS - Drugs to Treat the Ear $0 MO Otic Agents - Miscellaneous dorzolamide hcl soln (Tier 1) $0 MO acetic acid (otic) soln (Tier $0 MO 1) epinastine hcl (ophth) soln (Tier 1) Otic Anti-infectives $0 MO $0 MO flurbiprofen sodium soln (Tier ofloxacin (otic) soln (Tier 1) 1) $0 MO Otic Combinations ILEVRO SUSP (Tier $0 MO 2) CIPRODEX SUSP (Tier $0 MO 2) ketorolac tromethamine (Tier (ophth) soln $0 MO 1) neomycin-polymyxin-hc (Tier $0 MO; NT (otic) soln 1) ketotifen fumarate (ophth) (Tier soln $0 MO 3) neomycin-polymyxin-hc (Tier $0 MO (otic) susp 1) NEVANAC SUSP (Tier 2) Otic Steroids $0 MO $0 MO fluocinolone acetonide (Tier olopatadine hcl soln 0.2 % (Tier (otic) oil 1) 1) $0 MO; NT $0 MO ZADITOR SOLN (Ketotifen hydrocortisone w/acetic (Tier (Tier acid soln Fumarate (Ophth)) 3) 1) Prostaglandins - Ophthalmic OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding $0 MO bimatoprost soln (Tier Oxytocics 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 93 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 methylergonovine maleate MO (Tier HYPERRAB S/D SOLN (Tier tabs or 0.2 mg 1) 2) PASSIVE IMMUNIZING AND TREATMENT $0 IMOGAM RABIES-HT (Tier AGENTS - Antibody Drugs to Treat Low Immune SOLN 300 UNIT/2ML System 2) $0 Immune Serums KEDRAB SOLN (Tier $0 B/D 2) BIVIGAM SOLN (Tier 2) OCTAGAM SOLN 2 $0 B/D GM/20ML, 5 GM/50ML, 10 (Tier $0 B/D GM/100ML, 20 GM/200ML 2) CUVITRU SOLN (Tier 2) $0 B/D PRIVIGEN SOLN (Tier $0 B/D 2) FLEBOGAMMA DIF SOLN (Tier 10 % 2) $0 VARIZIG SOLN (Tier $0 FLEBOGAMMA DIF SOLN B/D; 5 GM/50 2) (Tier ML 10 % 2) Monoclonal Antibodies $0 B/D $0 SYNAGIS SOLN 50 (Tier GAMASTAN INJ (Tier MG/0.5ML 2) 2) $0 B/D $0 PA GAMASTAN S/D INJ (Tier ZINPLAVA SOLN (Tier 2) 2) $0 B/D Passive Immunizing Agents - Combinations GAMMAGARD LIQUID (Tier SOLN $0 B/D 2) HYQVIA KIT (Tier $0 B/D 2) GAMMAKED SOLN (Tier 2) PENICILLINS - Drugs to Treat Bacterial Infections GAMMAPLEX SOLN 5 $0 B/D Aminopenicillins GM/50ML, 10GM/100ML, (Tier 20 GM/200ML 2) $0 MO amoxicillin caps 250 mg, (Tier $0 B/D 500 mg 1) GAMUNEX-C SOLN (Tier 2) amoxicillin susr 125 $0 MO mg/5ml, 200 mg/5ml, 250 (Tier $0 B/D mg/5ml, 400 mg/5ml 1) HIZENTRA SOLN (Tier 2) $0 MO amoxicillin tabs 500 mg, (Tier 875 mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 94 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 ampicillin & sulbactam ampicillin caps 250 mg (Tier (Tier 1) sodium solr ij 5gm-10gm 1) $0 $0 MO ampicillin & sulbactam ampicillin caps 500 mg (Tier (Tier 1) sodium solr iv 5gm-10gm 1) $0 ampicillin sodium solr ij 1 MO BICILLIN C-R SUSP $0 MO (Tier 300000UNIT/ML- (Tier gm, 2 gm 1) 300000UNIT/ML 2) $0 BICILLIN C-R SUSP $0 ampicillin sodium solr iv 10 (Tier gm 900000UNIT/2ML- (Tier 1) 300000UNIT/2ML 2) Natural Penicillins $0 piperacillin sodium- (Tier $0 MO tazobactam sodium solr BICILLIN L-A SUSP (Tier 1) 2) Penicillinase-Resistant Penicillins $0 MO $0 MO penicillin g potassium solr (Tier dicloxacillin sodium caps (Tier 1) 1) $0 MO $0 penicillin v potassium solr (Tier NAFCILLIN SODIUM 250 mg/5ml (Tier 1) SOLR IJ 10 GM 2) $0 MO $0 MO penicillin v potassium tabs (Tier 250 mg, 500 mg nafcillin sodium solr ij 2 gm (Tier 1) 1) Penicillin Combinations $0 nafcillin sodium solr iv 10 (Tier $0 MO gm amoxicillin & pot (Tier 1) clavulanate chew 1) $0 $0 MO oxacillin sodium solr 10 gm (Tier amoxicillin & pot (Tier 1) clavulanate susr 1) $0 MO $0 MO oxacillin sodium solr 2 gm (Tier amoxicillin & pot (Tier 1) clavulanate tabs 1) PROGESTINS - Hormone Replacement/Modifying $0 Drugs amoxicillin & pot MO (Tier Progestins clavulanate tb12 1) medroxyprogesterone $0 MO $0 ampicillin & sulbactam MO acetate tabs or 5 mg, 10 (Tier (Tier mg, 2.5 mg 1) sodium solr ij 1gm-2gm 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 95 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 megestrol acetate AL(Up to 64 yrs $0 AL(At least 60 (Tier old); MO memantine hcl cp24 14 mg (Tier yrs old); SL(2 (appetite) susp 1) 1) ea daily); MO $0 MO norethindrone acetate tabs $0 AL(At least 60 (Tier yrs old); or 1) memantine hcl cp24 21 mg (Tier 1) SL(1.33 ea $0 MO daily); MO progesterone micronized (Tier caps $0 AL(At least 60 1) memantine hcl cp24 28 mg (Tier yrs old); SL(1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL 1) ea daily); MO AGENTS - MISC. - Drugs to Treat Mental and $0 AL(At least 60 Emotional Conditions memantine hcl cp24 7 mg (Tier yrs old); SL(4 1) ea daily); MO Agents for Chemical Dependency $0 AL(At least 60 memantine hcl soln 2 $0 MO (Tier yrs old); MO acamprosate calcium tbec (Tier mg/ml 1) 1) $0 MO $0 memantine hcl tabs 5 mg, disulfiram tabs or 250 mg, MO (Tier (Tier 10 mg 1) 500 mg 1) $0 AL(At least 60 Anti-Cataplectic Agents NAMENDA XR CP24 14 (Tier MG (Memantine HCl) yrs old); SL(2 $0 LA; MO 2) ea daily); MO XYREM SOLN (Tier AL(At least 60 2) $0 NAMENDA XR CP24 21 (Tier yrs old); Antidementia Agents MG (Memantine HCl) 2) SL(1.33 ea daily); MO $0 MO donepezil hydrochloride (Tier $0 AL(At least 60 tabs NAMENDA XR CP24 28 (Tier yrs old); SL(1 1) MG (Memantine HCl) 2) ea daily); MO $0 MO donepezil hydrochloride (Tier $0 AL(At least 60 tbdp NAMENDA XR CP24 7 MG (Tier yrs old); SL(4 1) (Memantine HCl) 2) ea daily); MO $0 MO galantamine hydrobromide $0 (Tier NAMENDA XR TITRATION AL(At least 60 cp24 1) (Tier yrs old); MO PACK CP24 2) $0 MO galantamine hydrobromide (Tier $0 MO soln 1) rivastigmine pt24 (Tier 1) $0 MO galantamine hydrobromide (Tier $0 MO tabs 1) rivastigmine tartrate caps (Tier 1) Combination Psychotherapeutics
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 96 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 AL(Up to 64 yrs $0 PA chlordiazepoxide- COPAXONE SOSY (Tier old); MO (Tier amitriptyline tabs 1) (Glatiramer Acetate) 2) $0 $0 olanzapine-fluoxetine hcl MO PA (Tier dalfampridine tb12 (Tier caps 1) 1) $0 $0 perphenazine-amitriptyline AL(Up to 64 yrs PA (Tier old); MO EXTAVIA KIT (Tier tabs 1) 2) Movement Disorder Drug Therapy $0 PA $0 GILENYA CAPS 0.5 MG (Tier SL(4 ea daily); 2) AUSTEDO TABS 12 MG (Tier LA 2) $0 PA glatiramer acetate sosy (Tier $0 SL(8 ea daily); 1) AUSTEDO TABS 6 MG (Tier LA 2) $0 PA; LA LEMTRADA SOLN (Tier $0 SL(5.33 ea 2) AUSTEDO TABS 9 MG (Tier daily); LA 2) $0 PA $0 OCREVUS SOLN (Tier PA 2) tetrabenazine tabs (Tier 1) $0 PA PLEGRIDY SOPN (Tier Multiple Sclerosis Agents 2) $0 PA $0 PA AMPYRA TB12 (Tier (Dalfampridine) PLEGRIDY SOSY (Tier 2) 2) $0 PA $0 PA AUBAGIO TABS (Tier PLEGRIDY STARTER (Tier 2) PACK SOPN 2) $0 PA $0 PA AVONEX KIT (Tier PLEGRIDY STARTER (Tier 2) PACK SOSY 2) $0 PA $0 PA AVONEX PEN AJKT (Tier REBIF REBIDOSE SOAJ (Tier 2) 2) $0 PA $0 PA AVONEX PSKT (Tier REBIF REBIDOSE (Tier 2) TITRATIONPACK SOAJ 2) $0 PA $0 PA BETASERON KIT (Tier REBIF SOSY (Tier 2) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 97 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 PA $0 MO; NT REBIF TITRATION PACK (Tier NICORETTE GUM (Tier SOSY 2) (Nicotine Polacrilex) 3) $0 $0 MO; NT PA NICORETTE LOZG TECFIDERA CPDR (Tier (Tier 2) (Nicotine Polacrilex) 3) $0 PA $0 MO; NT TECFIDERA STARTER (Tier NICORETTE MINI LOZG (Tier PACK MISC 2) (Nicotine Polacrilex) 3) $0 PA NICORETTE STARTER $0 MO; NT TYSABRI CONC (Tier KIT GUM (Nicotine (Tier 2) Polacrilex) 3) $0 Pseudobulbar Affect (PBA) Agents nicotine polacrilex gum mt MO; NT $0 (Tier PA; MO 2 mg, 4 mg 3) NUEDEXTA CAPS (Tier 2) $0 MO; NT nicotine polacrilex lozg mt 2 (Tier Psychotherapeutic and Neurological Agents - mg, 4 mg 3) $0 AL(Up to 64 yrs $0 MO; NT ergoloid mesylates tabs or (Tier old); MO nicotine pt24 (Tier 1) 3) $0 MO NICOTINE $0 NT pimozide tabs (Tier TRANSDERMAL SYSTEM (Tier 1) KIT 3) Smoking Deterrents $0 NICOTROL INHALER SL(17 ea daily); $0 (Tier MO bupropion hcl (smoking SL(2 ea daily); INHA (Tier MO 2) deterrent) tb12 1) $0 MO $0 MO NICOTROL NS SOLN (Tier CHANTIX CONTINUING (Tier 2) MONTHPAK TABS 2) Vasomotor Symptom Agents $0 MO BRISDELLE CAPS $0 MO CHANTIX STARTING (Tier MONTH PAK TABS (Paroxetine Mesylate (Tier 2) (Vasomotor)) 2) $0 MO $0 MO CHANTIX TABS (Tier paroxetine mesylate (Tier 2) (vasomotor) caps 1) $0 MO; NT NICODERM CQ PT24 (Tier RESPIRATORY AGENTS - MISC. - Drugs to (Nicotine) 3) Treat Lung Conditions Alpha-Proteinase Inhibitor (Human)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 98 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 ARALAST NP SOLR 1000 LA; MO TETRACYCLINES - Drugs to Treat Bacterial (Tier Infections MG 2) $0 LA; MO Tetracyclines PROLASTIN-C SOLR 1000 (Tier $0 MO MG 2) demeclocycline hcl tabs (Tier 1) $0 LA; MO ZEMAIRA SOLR (Tier doxycycline (monohydrate) $0 MO 2) caps 50 mg, 75 mg, 100 (Tier mg 1) Cystic Fibrosis Agents $0 MO $0 PA; MO doxycycline (monohydrate) (Tier KALYDECO PACK (Tier susr 25 mg/5ml 1) 2) doxycycline (monohydrate) $0 MO $0 PA; MO tabs 50 mg, 75 mg, 100 (Tier KALYDECO TABS (Tier mg, 150 mg 1) 2) $0 MO $0 doxycycline hyclate caps or ORKAMBI TABS 100MG- PA; LA; MO (Tier (Tier 50 mg, 100 mg 1) 125MG, 200MG-125MG 2) $0 MO $0 B/D doxycycline hyclate solr iv (Tier PULMOZYME SOLN (Tier 100 mg 1) 2) $0 MO $0 PA; LA doxycycline hyclate tabs or (Tier SYMDEKO TBPK (Tier 20 mg, 100 mg 1) 2) $0 MO Pulmonary Fibrosis Agents doxycycline hyclate tbec or (Tier 150 mg $0 PA; LA 1) ESBRIET CAPS (Tier $0 MO 2) minocycline hcl caps or 50 (Tier mg, 75 mg, 100 mg $0 PA; LA 1) ESBRIET TABS (Tier $0 MO 2) minocycline hcl tabs or 50 (Tier mg, 100 mg $0 PA; LA 1) OFEV CAPS (Tier $0 MO 2) tetracycline hcl caps or 250 (Tier mg, 500 mg SULFONAMIDES - Drugs to Treat Bacterial 1) Infections THYROID AGENTS - Drugs to Regulate Thyroid Sulfonamides Hormones $0 MO Antithyroid Agents sulfadiazine tabs or (Tier 1) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 99 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 methimazole tabs or 5 mg, MO (Tier PENTACEL SUSR (Tier 10 mg 1) 2) $0 MO $0 propylthiouracil tabs or (Tier QUADRACEL SUSP (Tier 1) 2) Thyroid Hormones $0 B/D TENIVAC INJ (Tier levothyroxine sodium tabs MO 2) or 25 mcg, 50 mcg, 75 $0 mcg, 88 mcg, 100 mcg, TETANUS/DIPHTHERIA $0 B/D (Tier TOXOIDS-ADSORBED (Tier 112 mcg, 125 mcg, 137 1) mcg, 150 mcg, 175 mcg, SUSP 2) 200 mcg, 300 mcg ULCER DRUGS - Drugs to Treat Bowel, Intestine $0 MO and Stomach Conditions liothyronine sodium tabs or (Tier 5 mcg, 25 mcg, 50 mcg 1) Antispasmodics $0 MO dicyclomine hcl caps or 10 TOXOIDS (Tier mg 1) Toxoid Combinations $0 MO $0 dicyclomine hcl tabs or 20 (Tier ADACEL SUSP (Tier mg 1) 2) $0 MO $0 glycopyrrolate soln ij 0.2 (Tier BOOSTRIX SUSP (Tier mg/ml 1) 2) $0 SL(8 ea daily); $0 glycopyrrolate tabs or 1 mg (Tier MO DAPTACEL SUSP (Tier 1) 2) $0 SL(4 ea daily); DIPHTHERIA/TETANUS $0 B/D glycopyrrolate tabs or 2 mg (Tier MO TOXOIDS ADSORBED (Tier 1) PEDIATRIC SUSP 2) $0 MO $0 methscopolamine bromide (Tier INFANRIX SUSP (Tier tabs or 5 mg, 2.5 mg 1) 2) H-2 Antagonists $0 KINRIX SUSP (Tier $0 RX/OTC; MO 2) cimetidine tabs or 200 mg (Tier 1) $0 PEDIARIX SUSP (Tier $0 Over-the- 2) cimetidine tabs or 200 mg (Tier counter;RX/OT 3) C; MO; NT
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 100 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 $0 cimetidine tabs or 300 mg, MO MO; NT (Tier ranitidine hcl tabs or 75 mg (Tier 400 mg, 800 mg 1) 3) famotidine soln iv 20 $0 $0 RX/OTC; MO; TAGAMET HB TABS (Tier mg/2ml, 40 mg/4ml, 200 (Tier (Cimetidine) NT mg/20ml 1) 3) $0 ZANTAC 150 MAXIMUM $0 RX/OTC; MO; famotidine susr or 40 MO (Tier STRENGTH TABS (Tier NT mg/5ml 1) (Ranitidine HCl) 3) $0 MO; NT $0 ZANTAC 75 TABS MO; NT famotidine tabs or 10 mg (Tier (Tier 3) (Ranitidine HCl) 3) $0 Over-the- Misc. Anti-Ulcer famotidine tabs or 20 mg (Tier counter;RX/OT $0 3) C; MO; NT MO sucralfate tabs or (Tier $0 RX/OTC; MO 1) famotidine tabs or 20 mg (Tier 1) Proton Pump Inhibitors $0 MO $0 MO; NT famotidine tabs or 40 mg (Tier CVS OMEPRAZOLE TBEC (Tier 1) 3) $0 MO $0 ST; MO nizatidine caps 150 mg, (Tier DEXILANT CPDR (Tier 300 mg 1) 2) PEPCID AC MAXIMUM $0 RX/OTC; MO; $0 MO; NT STRENGTH TABS (Tier NT EQ OMEPRAZOLE TBEC (Tier (Famotidine) 3) 3) $0 MO $0 MO; NT ranitidine hcl caps or 150 (Tier EQL OMEPRAZOLE TBEC (Tier mg, 300 mg 1) 3) ranitidine hcl syrp or 15 $0 MO $0 RX/OTC; MO esomeprazole magnesium (Tier mg/ml, 75 mg/5ml, 150 (Tier cpdr 20 mg mg/10ml 1) 1) $0 $0 Over-the- esomeprazole magnesium MO ranitidine hcl tabs or 150 (Tier counter;RX/OT (Tier mg cpdr 40 mg 3) C; MO; NT 1) $0 RX/OTC; MO $0 ranitidine hcl tabs or 150 esomeprazole sodium solr (Tier (Tier 40 mg mg 1) 1) $0 MO $0 MO; NT ranitidine hcl tabs or 300 GNP OMEPRAZOLE (Tier (Tier TBEC mg 1) 3)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 101 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 MO; NT HM OMEPRAZOLE TBEC (Tier PX OMEPRAZOLE TBEC (Tier 3) 3) $0 MO; NT $0 MO; NT KLS OMEPRAZOLE TBEC (Tier RA OMEPRAZOLE TBEC (Tier 3) 3) $0 Over-the- $0 MO; NT lansoprazole cpdr or 15 mg (Tier counter;RX/OT SB OMEPRAZOLE TBEC (Tier 3) C; MO; NT 3) $0 RX/OTC; MO $0 MO; NT lansoprazole cpdr or 15 mg (Tier SM OMEPRAZOLE TBEC (Tier 1) 3) $0 MO $0 MO; NT lansoprazole cpdr or 30 mg (Tier SW OMEPRAZOLE TBEC (Tier 1) 3) NEXIUM PACK 5 MG, 10 $0 ST; MO $0 MO; NT MG, 20 MG, 40 MG, 2.5 (Tier TGT OMEPRAZOLE TBEC (Tier MG 2) 3) $0 MO Ulcer Drugs - Prostaglandins omeprazole cpdr or 10 mg, (Tier 40 mg $0 MO 1) misoprostol tabs or 100 (Tier $0 RX/OTC; MO mcg, 200 mcg 1) omeprazole cpdr or 20 mg (Tier 1) Ulcer Therapy Combinations $0 NT $0 MO omeprazole magnesium amoxicillin-clarithromycin (Tier (Tier w/ lansoprazole misc cpdr 3) 1) $0 MO; NT famotidine-calcium $0 NT OMEPRAZOLE TBEC OR (Tier carbonate-magnesium (Tier 20 MG 3) hydroxide chew 3) $0 $0 MO pantoprazole sodium solr iv (Tier OMECLAMOX-PAK MISC (Tier 40 mg 1) 2) $0 MO omeprazole-sodium $0 RX/OTC; MO pantoprazole sodium tbec (Tier bicarbonate caps 20mg- (Tier or 20 mg, 40 mg 1) 1100mg 1) $0 RX/OTC; MO; omeprazole-sodium $0 MO PREVACID 24HR CPDR (Tier NT bicarbonate caps 40mg- (Tier (Lansoprazole) 3) 1100mg 1) $0 MO; NT omeprazole-sodium $0 ST; 20MG- PRILOSEC OTC TBEC (Tier bicarbonate pack 20mg- (Tier 1680 MG;MO 3) 1680mg 1)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 102 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) URINARY ANTI-INFECTIVES - Drugs to Treat Urinary Antispasmodics - Cholinergic Agonists Bladder/Kidney Infections $0 MO Urinary Anti-infectives bethanechol chloride tabs (Tier 1) $0 methenamine hippurate MO (Tier Urinary Antispasmodics - Direct Muscle Relaxants tabs 1) $0 MO $0 flavoxate hcl tabs (Tier nitrofurantoin macrocrystal AL(Up to 64 yrs (Tier old); MO 1) caps or 50 mg, 100 mg 1) $0 MO VACCINES nitrofurantoin monohyd (Tier Bacterial Vaccines macro caps 1) $0 URINARY ANTISPASMODICS - Drugs to Treat ACTHIB SOLR (Tier Miscellaneous Bladder Spasms 2) Urinary Antispasmodic - Antimuscarinics $0 $0 MO BCG VACCINE INJ (Tier oxybutynin chloride syrp (Tier 2) 1) $0 $0 MO BEXSERO SUSY (Tier oxybutynin chloride tabs (Tier 2) 1) $0 $0 MO HIBERIX SOLR (Tier oxybutynin chloride tb24 (Tier 2) 1) $0 $0 MO MENACTRA INJ (Tier tolterodine tartrate cp24 (Tier 2) 1) $0 MENOMUNE-A/C/Y/W-135 (Tier $0 MO INJ tolterodine tartrate tabs (Tier 2) 1) $0 $0 MO MENVEO SOLR (Tier trospium chloride cp24 (Tier 2) 1) $0 $0 MO PEDVAX HIB SUSP (Tier trospium chloride tabs (Tier 2) 1) $0 TRUMENBA SUSY (Tier Urinary Antispasmodics - Beta-3 Adrenergic 2) $0 MO $0 MYRBETRIQ TB24 (Tier TYPHIM VI SOLN (Tier 2) 2)
You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 103 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Viral Vaccines $0 ROTATEQ SOLN (Tier $0 B/D 2) ENGERIX-B SUSP IJ 20 (Tier MCG/ML, 10 MCG/0.5ML 2) $0 SHINGRIX SUSR (Tier $0 2) GARDASIL 9 SUSP (Tier 2) $0 STAMARIL SUSR (Tier $0 2) GARDASIL 9 SUSY (Tier 2) $0 $0 TWINRIX SUSP (Tier 2) GARDASIL SUSP (Tier 2) $0 VAQTA SUSP (Tier $0 2) HAVRIX SUSP (Tier 2) $0 VARIVAX INJ (Tier $0 B/D IMOVAX RABIES (Tier 2) (H.D.C.V.) INJ 2) $0 YF-VAX INJ (Tier $0 2) IPOL INACTIVATED IPV (Tier INJ 2) $0 ZOSTAVAX SUSR (Tier $0 2) IXIARO SUSP (Tier 2) VAGINAL PRODUCTS - Drugs to Treat Vaginal $0 Infections and Low Hormones M-M-R II INJ (Tier Vaginal Anti-infectives 2) $0 MO $0 clindamycin phosphate (Tier PROQUAD SUSR (Tier vaginal crea 1) 2) $0 MO; NT $0 B/D clotrimazole vaginal crea 1 (Tier RABAVERT SUSR (Tier % 3) 2) $0 NT $0 B/D clotrimazole vaginal crea 2 (Tier RECOMBIVAX HB SUSP (Tier % 3) 2) $0 MO $0 metronidazole vaginal gel (Tier ROTARIX SUSR (Tier 1) 2) $0 MO; NT miconazole nitrate vaginal (Tier crea 2 % 3) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 104 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 miconazole nitrate vaginal NORTHERA CAPS 200 PA; SL(9 ea (Tier (Tier daily) crea 4 % 3) MG 2) $0 NT $0 miconazole nitrate vaginal NORTHERA CAPS 300 PA; SL(6 ea (Tier (Tier daily) kit 3) MG 2) $0 MO; NT Vasopressors miconazole nitrate vaginal (Tier supp 100 mg 3) $0 dobutamine hcl soln (Tier $0 MO 1) terconazole vaginal crea (Tier 1) $0 MO midodrine hcl tabs (Tier $0 MO 1) terconazole vaginal supp (Tier 1) VITAMINS $0 NT tioconazole vaginal oint (Tier Oil Soluble Vitamins 3) $0 MO; NT cholecalciferol caps or (Tier Vaginal Estrogens 10000 unit, 50000 unit 3) $0 MO $0 MO; NT estradiol vaginal crea 0.1 (Tier mg/gm DECARA CAPS (Tier 1) 3) $0 MO $0 MO; NT PREMARIN CREA VA (Tier ergocalciferol soln or 8000 0.625 MG/GM (Tier 2) unit/ml 3) VASOPRESSORS - Drugs to Treat Heart and Water Soluble Vitamins Circulation Conditions $0 MO; NT Anaphylaxis Therapy Agents niacin cpcr or 500 mg (Tier $0 MO 3) epinephrine (anaphylaxis) (Tier soaj 2) $0 MO EPIPEN 2-PAK SOAJ (Tier 2) $0 MO EPIPEN-JR 2-PAK SOAJ (Tier 2) Neurogenic Orthostatic Hypotension (NOH) - $0 NORTHERA CAPS 100 PA; SL(18 ea (Tier daily) MG 2) You can find information on what the symbols and abbreviations in this table mean by going to page viii.
2018 Michigan Complete Health (MMP) Drug List Updated 11/01/2018 105 Index abacavir sulfate 52 alendronate sodium 72 ampicillin 95 abacavir sulfate-lamivudine 52 alfuzosin hcl 77 ampicillin & sulbactam abacavir sulfate-lamivudine- ALIMTA 39 sodium 95 ampicillin sodium 95 zidovudine 52 ALINIA 12 ABELCET 30 AMPYRA 97 ALIQOPA 43 ABILIFY MAINTENA 51 ANADROL-50 9 ALKERAN 38 ABRAXANE 47 anagrelide hcl 78 allopurinol 78 ABSORICA 63 anastrozole 41 almotriptan malate 83 acamprosate calcium 96 ANDRODERM 9 alogliptin benzoate 26 acarbose 24 ANDROGEL 9 alogliptin-metformin hcl 24 acebutolol hcl 57 ANDROGEL PUMP 9 alogliptin-pioglitazone 24 acetaminophen 5 ANORO ELLIPTA 17 alosetron hcl 76 acetaminophen w/ codeine 8 ANTACID 11 ALPHAGAN P 91 acetaminophen-caffeine 5 ANTACID SOFT CHEWS 11 alprazolam 14 acetazolamide 71 alum & mag hydrox- ANTARA 34 acetic acid 77 simethicone 10 APOKYN 48 acetic acid (otic) 93 ALUMINUM HYDROXIDE 11 apraclonidine hcl 91 acetylcysteine 63 aluminum hydroxide-mag aprepitant 30 acitretin 66 carb 10 APRISO 76 ALUNBRIG 43 ACNE MEDICATION 10 63 APTIOM 18 amantadine hcl 48 ACTEMRA 3 APTIVUS 52 AMBISOME 30 ACTHIB 103 ARALAST NP 99 amcinonide 67 ACTIMMUNE 45 ARANESP ALBUMIN FREE 79 AMICAR 80 acyclovir 56 ARCALYST 3 amifostine 46 acyclovir sodium 56 argatroban 18 amikacin sulfate 2 acyclovir topical 66 aripiprazole 51 amiloride & ADACEL 100 hydrochlorothiazide 71 ARISTADA 52 ADAGEN 2 amiloride hcl 71 ARISTADA INITIO 51 adapalene 63 amino acid electrolyte ARRANON 39 ADCIRCA 59 infusion 90 ARSENIC TRIOXIDE 46 adefovir dipivoxil 55 amino acid infusion 15% 90 artificial tear ointment 90 ADEMPAS 59 aminophylline 17 artificial tear solution 90 ADVAIR DISKUS 16 aminosalicylic acid 38 ARZERRA 40 ADVAIR HFA 16 amiodarone hcl 15 ASACOL HD 76 AEROSPAN 16 amitriptyline hcl 23 aspirin 6 AFINITOR 43 amlodipine besylate 57 ASPIRIN 6 amlodipine besylate- AFINITOR DISPERZ 43 atorvastatin calcium 58 aspirin 6 AHIST 33 amlodipine besylate-benazepril aspirin buffered (cal carb-mag AIMOVIG 83 hcl 36 carb-mag oxide) 6 aspirin-dipyridamole 78 ALA-HIST IR 31 amoxapine 23 ASTAGRAF XL 85 albendazole 11 amoxicillin 94 atazanavir sulfate 52 ALBENZA 11 amoxicillin & pot clavulanate 95 atenolol 57 albuterol sulfate 16 amoxicillin-clarithromycin w/ atenolol & chlorthalidone 36 alclometasone dipropionate 67 lansoprazole 102 atomoxetine hcl 1 ALCOHOL PADS 83 amphetamine- dextroamphetamine 1 atorvastatin calcium 34 ALECENSA 43 amphotericin b 30 atovaquone 12
Index 1 atovaquone-proguanil hcl 37 BESPONSA 40 budesonide (nasal) 89 ATRIPLA 52 BETADINE 52 bumetanide 71 ATROVENT HFA 15 betamethasone dipropionate buprenorphine hcl 9 AUBAGIO 97 (topical) 67 buprenorphine hcl-naloxone hcl betamethasone dipropionate AUSTEDO 97 dihydrate 9 augmented 67 bupropion hcl 21 AVANDIA 26 betamethasone sod phosphate & acetate 62 bupropion hcl (smoking AVASTIN 40 deterrent) 98 AVEED 9 betamethasone valerate 67 BUPROPION AVONEX 97 BETASERON 97 HYDROCHLORIDE ER 21 AVONEX PEN 97 betaxolol hcl 57 buspirone hcl 14 azacitidine 39 betaxolol hcl (ophth) 91 busulfan 38 butalbital-aspirin-caffeine AZASITE 91 bethanechol chloride 103 BETHKIS 2 w/cod 8 AZATHIOPRINE 85 BUTISOL SODIUM 80 BEVYXXA 17 azathioprine 85 butorphanol tartrate 9 bexarotene 46 azelastine hcl 89 BYDUREON 26 BEXSERO 103 azelastine hcl (ophth) 92 BYDUREON BCISE 26 bicalutamide 41 azithromycin 82 BYDUREON PEN 26 BICILLIN C-R 95 AZOLEN TINCTURE 64 BYETTA 26 BICILLIN L-A 95 AZOPT 92 cabergoline 74 BICNU 38 aztreonam 13 CABOMETYX 43 BIKTARVY 52 b complex w/ c 87 calcipotriene 66 bimatoprost 93 bacitracin (ophthalmic) 91 calcitonin (salmon) 72 bacitracin-poly-neomycin-hc 92 bisacodyl 81,82 bisacodyl-peg 3350-pot calcitriol 73 bacitracin-polymyxin b calcium acetate (phosphate (ophth) 91 chloride-sod bicarb-sod chloride 81 binder) 77 baclofen 88 bismuth subsalicylate 28 CALCIUM CARBONATE 11 BACLOFEN 88 bisoprolol & calcium carbonate 84 balsalazide disodium 76 hydrochlorothiazide 36 calcium carbonate (antacid) 11 BANZEL 18 bisoprolol fumarate 57 calcium carbonate- BARACLUDE 55 BIVIGAM 94 cholecalciferol 84 BAVENCIO 40 bleomycin sulfate 42 calcium carbonate-vitamin d 84 BAXDELA 75 BLINCYTO 40 CALQUENCE 43 BCG VACCINE 103 BOOSTRIX 100 CAMPATH 40 BELEODAQ 43 BORTEZOMIB 43 CAMPTOSAR 47 BELSOMRA 80,81 BOSULIF 43 CANCIDAS 30 benazepril & BOTOX 89 candesartan cilexetil 36 hydrochlorothiazide 36 BRAFTOVI 43 candesartan cilexetil- benazepril hcl 35 hydrochlorothiazide 36 BREO ELLIPTA 17 BENDEKA 38 CAPASTAT SULFATE 38 BRILINTA 78 BENLYSTA 86 CAPRELSA 43 brimonidine tartrate 91 benzoyl peroxide 63 captopril 35 BRISDELLE 98 BENZOYL PEROXIDE 63 captopril & BRIVIACT 19 hydrochlorothiazide 36 benzoyl peroxide 63 bromfenac sodium (ophth) 92 CARAC 65 benzoyl peroxide- erythromycin 63 bromocriptine mesylate 48 CARBAGLU 73 benztropine mesylate 48 budesonide 62 carbamazepine 19 BERINERT 78 budesonide (inhalation) 16 carbidopa 48 carbidopa-levodopa 48
Index 2 carbinoxamine maleate 32 chlordiazepoxide-amitriptyline clindamycin phosphate-benzoyl carbonyl iron 79 97 peroxide 64 chlorhexidine gluconate clindamycin phosphate-benzoyl carboplatin 38 (mouth-throat) 86 peroxide (refrigerate) 64 carboxymethylcellulose sodium chloroquine phosphate 37 clobetasol propionate 67 (ophth) 90 chlorothiazide 71 clobetasol propionate emollient carisoprodol 88 chlorpheniramine maleate 31 base 67 carmustine 38 clobetasol propionate chlorpromazine hcl 51 carteolol hcl (ophth) 91 emulsion 67 chlorthalidone 71 carvedilol 57 clofarabine 39 chlorzoxazone 88 carvedilol phosphate 57 clomipramine hcl 23 cholecalciferol 105 CASPOFUNGIN ACETATE 30 clonazepam 18 cholestyramine 33 caspofungin acetate 30 clonidine 36 cholestyramine light 33 CASPOFUNGIN ACETATE 30 clonidine hcl 36 choline fenofibrate 34 caspofungin acetate 30 clonidine hcl (adhd) 1 chorionic gonadotropin 72 CAYSTON 13 clopidogrel bisulfate 78 ciclopirox 64 cefaclor 60 clorazepate dipotassium 14 ciclopirox olamine 64 cefadroxil 59 clotrimazole 86 cidofovir 55 cefazolin sodium 59 clotrimazole (topical) 64 cilostazol 78 cefdinir 60 clotrimazole vaginal 104 CIMDUO 52 clotrimazole w/ CEFEPIME 60 cimetidine 100,101 betamethasone 65 cefepime hcl 60 CIMZIA 76 clozapine 50 cefixime 60 CIMZIA STARTER KIT 76 CLOZAPINE ODT 50 cefoxitin sodium 60 CINQAIR 15 COARTEM 37 cefpodoxime proxetil 60 CINRYZE 78 COLACE 82 cefprozil 60 CIPRODEX 93 COLACE CLEAR 82 ceftazidime 60 ciprofloxacin 75 colchicine 78 ceftriaxone sodium 60 ciprofloxacin hcl 75 colchicine w/ probenecid 78 cefuroxime axetil 60 ciprofloxacin hcl (ophth) 91 COLCRYS 78 cefuroxime sodium 60 ciprofloxacin in d5w 75 colesevelam hcl 33 celecoxib 3 ciprofloxacin-ciprofloxacin colestipol hcl 33 CELONTIN 21 hcl 75 colistimethate sodium 11 CENTANY 64 cisplatin 38 COMBIVENT RESPIMAT 17 cephalexin 59,60 citalopram hydrobromide 22 COMETRIQ 43 CERDELGA 79 cladribine 39 COMPLERA 52 CEREZYME 79 clarithromycin 82 CONCERTA 1 CESAMET 30 clemastine fumarate 32 COPAXONE 97 cetirizine hcl 32 CLEOCIN PHOSPHATE 13 COREG CR 57 cevimeline hcl 87 CLINDAGEL 63 CORLANOR 59 CHANTIX 98 clindamycin hcl 13 cortisone acetate 62 CHANTIX CONTINUING clindamycin palmitate CORZIDE 36 MONTHPAK 98 hydrochloride 13 COSENTYX 66 CHANTIX STARTING MONTH clindamycin phosphate 13 PAK 98 COSENTYX SENSOREADY clindamycin phosphate PEN 66 chenodiol 75 (topical) 63 CHILDRENS ADVIL 3 clindamycin phosphate in COSMEGEN 42 CHILDRENS MOTRIN 3 d5w 13 COTELLIC 43 chloramphenicol sodium clindamycin phosphate CREON 71 succinate 12 vaginal 104 CRESEMBA 31
Index 3 CRIXIVAN 52 DEPO-MEDROL 62 diflunisal 6 cromolyn sodium 15 DEPO-PROVERA 41 DIGOXIN 58 cromolyn sodium DESCOVY 52 digoxin 58 (mastocytosis) 76 desipramine hcl 23 dihydroergotamine mesylate 83 cromolyn sodium (nasal) 89 desloratadine 32 diltiazem hcl 58 cromolyn sodium (ophth) 93 desmopressin acetate 74 diltiazem hcl coated beads 58 CUPRIMINE 85 desmopressin acetate diltiazem hcl extended release CUVITRU 94 spray 74 beads 58 CVS OMEPRAZOLE 101 desmopressin acetate spray DIOVAN 36 cyclobenzaprine hcl 88 refrigerated 74 DIOVAN HCT 36 desogestrel & ethinyl cyclopentolate hcl 91 estradiol 61 DIPENTUM 76 cyclophosphamide 38 desogestrel-ethinyl estradiol diphenhydramine hcl 32 CYCLOPHOSPHAMIDE 38 (biphasic) 61 diphenoxylate w/ atropine 29 CYCLOSET 26 desonide 68 DIPHTHERIA/TETANUS cyclosporine 85 desoximetasone 68 TOXOIDS ADSORBED 100 cyclosporine modified (for DESVENLAFAXINE ER 23 PEDIATRIC microemulsion) 85 desvenlafaxine succinate 23 dipyridamole 78 cyproheptadine hcl 33 dexamethasone 62 disopyramide phosphate 15 CYRAMZA 40 dexamethasone sodium disulfiram 96 CYSTAGON 77 phosphate 62 divalproex sodium 21 dexamethasone sodium DIVIGEL 75 CYSTARAN 93 phosphate (ophth) 92 dobutamine hcl 105 cytarabine 39 DEXILANT 101 DOCETAXEL 47 dacarbazine 46 dexmethylphenidate hcl 1 docetaxel 47 dactinomycin 42 dexrazoxane 46 DOCETAXEL 47 DAKLINZA 55 dextran 70-hypromellose 90 docusate calcium 82 dalfampridine 97 dextroamphetamine sulfate 1 docusate sodium 82 DALIRESP 16 dextrose 90 dofetilide 15 danazol 9 dextrose in lactated ringers84 dantrolene sodium 89 dextrose w/ sodium donepezil hydrochloride 96 dapsone 13 chloride 84 dorzolamide hcl 93 DAPTACEL 100 DIASTAT ACUDIAL 18 dorzolamide hcl-timolol DIASTAT PEDIATRIC 18 maleate 91 daptomycin 12 doxazosin mesylate 36 diazepam 14 DARAPRIM 37 doxepin hcl 24 DIAZEPAM 18 DARZALEX 40 doxorubicin hcl 42 diazepam (anticonvulsant) 18 daunorubicin hcl 42 doxorubicin hcl liposomal 42 DAUNORUBICIN DIAZEPAM RECTAL GEL 18 doxycycline (monohydrate) 99 HYDROCHLORIDE 42 diclofenac potassium 3 doxycycline hyclate 99 DDAVP 74 diclofenac sodium 3 DECARA 105 diclofenac sodium (actinic dronabinol 30 decitabine 39 keratoses) 65 drospirenone-ethinyl diclofenac sodium (ophth) 93 estradiol 61 DELESTROGEN 75 DROXIA 79 diclofenac sodium (topical) 64 DELSTRIGO 52 DULERA 17 diclofenac w/ misoprostol 3 DELZICOL 76 duloxetine hcl 23 dicloxacillin sodium 95 demeclocycline hcl 99 DUOPA 48 dicyclomine hcl 100 DEMSER 36 DUREZOL 92 didanosine 53 DENAVIR 66 dutasteride 77 DIFICID 82 DEPEN TITRATABS 85 dutasteride-tamsulosin hcl 77 diflorasone diacetate 68
Index 4 econazole nitrate 65 ergocalciferol 105 FANAPT 49 ED CHLORPED 31 ergoloid mesylates 98 FARESTON 41 EDURANT 53 ergotamine tartrate 83 FARYDAK 43 efavirenz 53 ergotamine w/ caffeine 83 FASENRA 15 EFFIENT 78 ERIVEDGE 41 FASLODEX 41 ELELYSO 79 ERLEADA 41 fat emulsion 90 ELIDEL 70 ertapenem sodium 12 FAZACLO 50 ELIGARD 41 ERWINAZE 45 felbamate 20 ELIQUIS 17 erythromycin (acne aid) 64 felodipine 58 ELIQUIS STARTER PACK 17 erythromycin (ophth) 91 fenofibrate 34 ELITEK 46 erythromycin base 82 fenofibrate micronized 34 ELLA 61 erythromycin fentanyl 6 EMCYT 41 ethylsuccinate 82 fentanyl citrate 6 erythromycin lactobionate 82 EMFLAZA 62 FERRIPROX 29 erythromycin stearate 82 EMPLICITI 40 FERROUS GLUCONATE 80 ESBRIET 99 EMSAM 22 ferrous sulfate 80 escitalopram oxalate 22 EMTRIVA 53 FERROUS SULFATE 80 esomeprazole enalapril maleate 35 magnesium 101 FETZIMA 23 enalapril maleate & esomeprazole sodium 101 FETZIMA TITRATION PACK23 hydrochlorothiazide 36 estradiol 75 FEVERALL INFANTS 6 ENBREL 5 estradiol & norethindrone fexofenadine hcl 32 ENBREL MINI 5 acetate 74 FINACEA 70 ENBREL SURECLICK 5 estradiol vaginal 105 finasteride 77 ENDARI 79 estradiol valerate 75 FIRAZYR 78 ENGERIX-B 104 ESTROFACTORS 87 FIRMAGON 41 enoxaparin sodium 18 estropipate 75 flavoxate hcl 103 entacapone 48 ethambutol hcl 38 FLEBOGAMMA DIF 94 entecavir 55 ethosuximide 21 flecainide acetate 15 ENTRESTO 58 ethynodiol diacet & eth FLECTOR 64 ENTYVIO 76 estrad 61 FLEET ENEMA 81 ENVARSUS XR 85 ETHYOL 46 FLEET ENEMA SIX PACK 81 EPCLUSA 55 etodolac 3 FLEET PEDIATRIC 81 epinastine hcl (ophth) 93 ETOPOPHOS 47 etoposide 47 FLONASE ALLERGY epinephrine (anaphylaxis) 105 RELIEF 89 EPIPEN 2-PAK 105 EVOMELA 38 FLONASE ALLERGY RELIEF EPIPEN-JR 2-PAK 105 EVOTAZ 53 CHILDRENS 89 EXCEDRIN TENSION FLONASE SENSIMIST 89 epirubicin hcl 43 HEADACHE 5 FLOVENT DISKUS 16 EPIVIR HBV 55 exemestane 41 FLOVENT HFA 16 eplerenone 37 EXJADE 29 fluconazole 31 EPOGEN 79 EXONDYS 51 89 fluconazole in dextrose 31 eprosartan mesylate 36 EXTAVIA 97 fluconazole in nacl 31 EQ OMEPRAZOLE 101 ezetimibe 34 flucytosine 30 EQL OMEPRAZOLE 101 FABRAZYME 73 fludarabine phosphate 39 EQUETRO 49 famciclovir 56 fludrocortisone acetate 63 ERAXIS 30 famotidine 101 flunisolide (nasal) 89 ERBITUX 40 famotidine-calcium carbonate- magnesium hydroxide 102 fluocinolone acetonide 68
Index 5 fluocinolone acetonide (otic) 93 GATTEX 77 guanfacine hcl 36 fluocinonide 68 gauze pads 2"x2" 83 guanfacine hcl (adhd) 1 fluocinonide emulsified base 68 GAVISCON 10 GUANIDINE HCL 37 fluorometholone (ophth) 92 GAVISCON EXTRA H.P. ACTHAR 72 fluorouracil 39 STRENGTH 10 HAEGARDA 78 GAVISCON EXTRA FLUOROURACIL 66 STRENGTH RELIEF HALAVEN 47 fluorouracil (topical) 66 FORMULA 10 halobetasol propionate 68 fluoxetine hcl 22 GAZYVA 40 haloperidol 50 fluoxymesterone 9 gemcitabine hcl 40 haloperidol decanoate 50 fluphenazine decanoate 51 GEMCITABINE haloperidol lactate 50 HYDROCHLORIDE 40 fluphenazine hcl 51 HARVONI 56 gemfibrozil 34 flurbiprofen 4 HAVRIX 104 GENOTROPIN 72 flurbiprofen sodium 93 GENOTROPIN heparin sodium (porcine) 18 flutamide 41 MINIQUICK 72 HERCEPTIN 40 fluticasone propionate 68 gentamicin in saline 2 HETLIOZ 81 fluticasone propionate gentamicin sulfate 2 HEXALEN 39 (nasal) 89 gentamicin sulfate (ophth) 91 HIBERIX 103 fluvastatin sodium 34 gentamicin sulfate (topical) 64 HISTAFLEX 5 fluvoxamine maleate 22 GENTEAL MILD TO HISTEX 31 FOLOTYN 39 MODERATE 90 HISTEX PD 31 fondaparinux sodium 18 GENTEAL SEVERE 90 HIZENTRA 94 FORFIVO XL 21 GENTEAL TEARS HM OMEPRAZOLE 102 FORTEO 72 MODERATE PF 90 GENTEAL TEARS HUMALOG 27 fosamprenavir calcium 53 MODERATEPF 90 HUMALOG JUNIOR fosinopril sodium 35 GENVOYA 53 KWIKPEN 27 fosinopril sodium & GEODON 49 HUMALOG KWIKPEN 27 hydrochlorothiazide 36 GILENYA 97 HUMALOG MIX 50/50 27 fosphenytoin sodium 20 GILOTRIF 44 HUMALOG MIX 50/50 FOSRENOL 77 KWIKPEN 27 glatiramer acetate 97 FRAGMIN 18 HUMALOG MIX 75/25 27 GLEEVEC 44 FUNGOID TINCTURE 65 HUMALOG MIX 75/25 GLEOSTINE 38,39 furosemide 71 KWIKPEN 27 glimepiride 28 HUMATROPE 72 FUZEON 53 glipizide 28 HUMATROPE COMBO FYCOMPA 18 glipizide-metformin hcl 24 PACK 72 gabapentin 19 HUMIRA 2 GLUCAGEN HYPOKIT 26 GABITRIL 20 HUMIRA PEDIATRIC CROHNS GLUCAGON EMERGENCY DISEASE STARTER PACK 2 galantamine hydrobromide 96 KIT 26 HUMIRA PEN 2 GAMASTAN 94 glyburide 28 HUMIRA PEN-CD/UC/HS GAMASTAN S/D 94 glyburide micronized 28 STARTER 2 GAMMAGARD LIQUID 94 glyburide-metformin 24 HUMIRA PEN-PS/UV GAMMAKED 94 glycopyrrolate 100 STARTER 2 GAMMAPLEX 94 GNP OMEPRAZOLE 101 HUMULIN 70/30 27 GAMUNEX-C 94 GONAK 90 HUMULIN 70/30 KWIKPEN 27 ganciclovir sodium 55 granisetron hcl 29 HUMULIN N 27 GARDASIL 104 GRANIX 79 HUMULIN N KWIKPEN 27 GARDASIL 9 104 griseofulvin microsize 30 HUMULIN R 27 gatifloxacin (ophth) 91 HUMULIN R U-500 griseofulvin ultramicrosize 30 (CONCENTRATED) 27
Index 6 HUMULIN R U-500 IMODIUM A-D 29 JADENU 29 KWIKPEN 27 IMOGAM RABIES-HT 94 JADENU SPRINKLE 29 hydralazine hcl 37 IMOVAX RABIES JAKAFI 44 hydrochlorothiazide 71 (H.D.C.V.) 104 JANUMET 25 hydrocodone-acetaminophen 9 IMPAVIDO 11 JANUMET XR 25 hydrocodone-ibuprofen 9 INCRELEX 73 JANUVIA 26 hydrocortisone 62 indapamide 71 JARDIANCE 28 hydrocortisone (intrarectal) 10 indomethacin 4 JENTADUETO 25 hydrocortisone (rectal) 10 INFANRIX 100 JENTADUETO XR 25 hydrocortisone (topical) 68 INFLECTRA 76 JEVTANA 47 hydrocortisone butyrate 69 INLYTA 44 JULUCA 53 hydrocortisone butyrate INSULIN SYRINGES AND PEN hydrophilic lipo base 69 NEEDLES 83 JUXTAPID 34,35 hydrocortisone valerate 69 INTELENCE 53 JYNARQUE 74 hydrocortisone w/acetic acid 93 INTRON A 46 K-TAB 84 hydrocortisone-aloe vera 69 INVANZ 12 KADCYLA 40 hydromorphone hcl 6 INVEGA SUSTENNA 49 KALBITOR 78 HYDROMORPHONE INVEGA TRINZA 49 KALETRA 53 HYDROCHLORIDE 6 INVIRASE 53 KALYDECO 99 hydroxychloroquine sulfate 37 INVOKAMET 24 KANUMA 73 HYDROXYPROGESTERONE CAPROATE 41 INVOKAMET XR 24 KAZANO 25 hydroxyurea 46 INVOKANA 28 KEDRAB 94 hydroxyzine hcl 14 IPOL INACTIVATED IPV 104 KENALOG-10 62 hydroxyzine pamoate 14 ipratropium bromide 15 KENALOG-40 62 HYPERRAB S/D 94 ipratropium bromide KEPIVANCE 46 (nasal) 89 hypromellose (gonioscopic) 90 ketoconazole 31 ipratropium-albuterol 17 hypromellose (ophth) 90 ketoconazole (topical) 65 IPRIVASK 18 HYQVIA 94 ketoprofen 4 irbesartan 36 ketorolac tromethamine 4 ibandronate sodium 72 irbesartan-hydrochlorothiazide IBRANCE 44 ketorolac tromethamine 36 (ophth) 93 ibuprofen 4 IRESSA 44 ketotifen fumarate (ophth) 93 ICLUSIG 44 irinotecan hcl 47 KEVZARA 3 irrigation solutions, idarubicin hcl 43 KEYTRUDA 40 IDHIFA 44 physiological 86 ISENTRESS 53 KHEDEZLA 23 IFEX 39 ISENTRESS HD 53 KINERET 3 ifosfamide 39 isoniazid 38 KINRIX 100 IFOSFAMIDE 39 isoniazid & rifampin 38 KISQALI 44 ILARIS 3 ISOPTO TEARS 90 KISQALI FEMARA 200 ILEVRO 93 DOSE 43 isosorbide dinitrate 14 imatinib mesylate 44 KISQALI FEMARA 400 isosorbide mononitrate 14 DOSE 43 IMBRUVICA 44 isotretinoin 64 KISQALI FEMARA 600 IMFINZI 40 DOSE 43 ISTODAX (OVERFILL) 44 imipenem-cilastatin 12 KITABIS PAK 2 itraconazole 31 imipramine hcl 24 KLS OMEPRAZOLE 102 ivermectin 11 imipramine pamoate 24 KOMBIGLYZE XR 25 IXEMPRA KIT 47 imiquimod 70 KORLYM 26 IXIARO 104 IMIQUIMOD PUMP 70 KUVAN 73
Index 7 KYNAMRO 33 LEVEMIR 27 LOTEMAX 92 KYPROLIS 44 LEVEMIR FLEXTOUCH 27 LOTRIMIN AF 65 labetalol hcl 57 levetiracetam 19 LOTRIMIN AF FOR HER 65 LAC-HYDRIN TWELVE 69 levetiracetam in sodium LOTRIMIN AF JOCK ITCH 65 lactated ringer's 84 chloride 19 lovastatin 34 levobunolol hcl 91 lactic acid (ammonium loxapine succinate 50 levocarnitine (metabolic lactate) 69 LUMIGAN 93 lactulose 81 modifiers) 73 levocetirizine LUMIZYME 73 lactulose (encephalopathy) 76 dihydrochloride 32 LUPRON DEPOT (1- LAMICTAL XR 19 levofloxacin 75 MONTH) 42 LAMISIL AT 65 levofloxacin (ophth) 91 LUPRON DEPOT (3- LAMISIL AT JOCK ITCH 65 MONTH) 42 levofloxacin in d5w 75 LUPRON DEPOT (4- lamivudine 53 LEVOLEUCOVORIN 46 MONTH) 42 lamivudine (hbv) 56 levoleucovorin calcium 46 LUPRON DEPOT (6- lamivudine-zidovudine 53 levonorgestrel & eth MONTH) 42 LUPRON DEPOT-PED (1- lamotrigine 19 estradiol 61 levonorgestrel (emergency MONTH) 73 LANOXIN 58 oc) 61 LUPRON DEPOT-PED (3- lansoprazole 102 levonorgestrel-eth estradiol MONTH) 73 lanthanum carbonate 77 (triphasic) 61 LYNPARZA 44 LANTUS 27 levonorgestrel-ethinyl estradiol LYRICA 19,20 (91-day) 61 LYSODREN 42 LANTUS SOLOSTAR 27 levothyroxine sodium 100 M-M-R II 104 LARTRUVO 40 LEXIVA 53 mafenide acetate 67 latanoprost 93 lidocaine 70 MAG-AL 10 LATUDA 49 lidocaine hcl 70 magnesium oxide 11 LAZANDA 6 lidocaine hcl (local leflunomide 5 anesth.) 82 magnesium oxide (mg lidocaine hcl (mouth- supplement) 84 LEMTRADA 97 MAGNESIUM SULFATE 84 LENVIMA 10 MG DAILY throat) 86 DOSE 44 lidocaine-prilocaine 70 magnesium sulfate 84 LENVIMA 12MG DAILY lincomycin hcl 13 MAGNESIUM SULFATE 84 DOSE 44 linezolid 13 malathion 70 LENVIMA 14 MG DAILY maprotiline hcl 22 DOSE 44 LINEZOLID 13 LENVIMA 18 MG DAILY linezolid 13 MARPLAN 22 DOSE 44 LINZESS 77 MARQIBO 47 LENVIMA 20 MG DAILY liothyronine sodium 100 MATULANE 46 DOSE 44 LENVIMA 24 MG DAILY lisinopril 35 MAVYRET 56 DOSE 44 lisinopril & meclizine hcl 29 LENVIMA 4 MG DAILY hydrochlorothiazide 37 MEDROL 62 DOSE 44 LITHIUM 49 medroxyprogesterone LENVIMA 8 MG DAILY lithium carbonate 49 acetate 95 DOSE 44 LONSURF 43 medroxyprogesterone acetate LETAIRIS 59 (contraceptive) 61 loperamide hcl 29 letrozole 41 mefenamic acid 4 lopinavir-ritonavir 53 leucovorin calcium 46 mefloquine hcl 37 loratadine 32,33 LEUKERAN 39 megestrol acetate 42 lorazepam 15 LEUKINE 79 megestrol acetate (appetite) 96 losartan potassium 36 leuprolide acetate 42 MEKINIST 44 losartan potassium & levalbuterol hcl 17 hydrochlorothiazide 37 MEKTOVI 44
Index 8 meloxicam 4 miconazole nitrate naftifine hcl 65 melphalan 39 vaginal 104,105 NAFTIN 65 midodrine hcl 105 melphalan hcl 39 NAGLAZYME 73 miglitol 24 memantine hcl 96 nalbuphine hcl 9 miglustat 79 MENACTRA 103 naloxone hcl 29 MIGRANAL 83 MENOMUNE-A/C/Y/W-135 naltrexone hcl 29 minocycline hcl 99 103 NAMENDA XR 96 MENVEO 103 minoxidil 37 NAMENDA XR TITRATION meperidine hcl 7 MIRALAX 81 PACK 96 mercaptopurine 40 mirtazapine 21 naproxen 4 meropenem 12 MIRVASO 70 naproxen sodium 4 mesalamine 76 misoprostol 102 naratriptan hcl 83 mesalamine w/ cleanser 76 mitomycin 43 NASACORT ALLERGY mesna 46 mitoxantrone hcl 43 24HR 89 NASACORT ALLERGY 24HR MESNEX 47 modafinil 2 CHILDRENS 89 metaxalone 88 moexipril hcl 35 NATACYN 91 metformin hcl 25 moexipril-hydrochlorothiazide nateglinide 27 37 methadone hcl 7 NATPARA 72 mometasone furoate 69 methamphetamine hcl 1 MONISTAT SOOTHING CARE NEBUPENT 12 methazolamide 71 ITCH RELIEF 69 nefazodone hcl 22 methenamine hippurate 103 montelukast sodium 16 NEOMULTIVITE 88 methimazole 100 morphine sulfate 7 neomycin sulfate 2 methocarbamol 88 MORPHINE SULFATE 7 neomycin-bacitracin zn- methotrexate sodium 40 morphine sulfate 7 polymyxin 92 neomycin-bacitracin-polymyxin methoxsalen rapid 66 MOVANTIK 77 64 methscopolamine bromide 100 moxifloxacin hcl (ophth) 91 neomycin-polymy-dexameth 92 methylergonovine maleate 94 MOZOBIL 80 neomycin-polymyxin-gramicidin methylphenidate hcl 1 MULTAQ 15 92 methylprednisolone 62 neomycin-polymyxin-hc MULTI VITAMIN 87 (otic) 93 methylprednisolone acetate 62 MULTI VITAMIN/D-3 88 neomycin/polymyxin b gu 77 methylprednisolone sod multiple vitamin 88 succ 62 NERLYNX 44 mupirocin 64 methyltestosterone 9 NESINA 26 mupirocin calcium (topical) 64 metoclopramide hcl 76 NESTABS 88 MUSTARGEN 39 metolazone 71 NEULASTA 79 metoprolol & MYALEPT 73 NEULASTA ONPRO KIT 79 hydrochlorothiazide 37 MYCAMINE 30 NEUPOGEN 79 metoprolol succinate 57 mycophenolate mofetil 85 NEUPRO 48 metoprolol tartrate 57 mycophenolate mofetil hcl 85 NEVANAC 93 METOPROLOL TARTRATE 57 mycophenolate sodium 85 nevirapine 53 metronidazole 11,12 MYLOTARG 41 NEXAVAR 45 metronidazole (topical) 70 MYRBETRIQ 103 NEXIUM 102 metronidazole in nacl 12 nabumetone 4 niacin 105 metronidazole vaginal 104 nadolol 57 niacin (antihyperlipidemic) 35 mexiletine hcl 15 nadolol & nicardipine hcl 58 MIACALCIN 72 bendroflumethiazide 37 NAFCILLIN SODIUM 95 NICODERM CQ 98 miconazole nitrate (topical) 65 nafcillin sodium 95 NICORETTE 98
Index 9 NICORETTE MINI 98 NULOJIX 85 OTEZLA 5 NICORETTE STARTER KIT 98 NUPLAZID 49 OTREXUP 3 nicotine 98 NUTROPIN AQ NUSPIN oxacillin sodium 95 nicotine polacrilex 98 20 72 oxaliplatin 39 NUVARING 61 NICOTINE TRANSDERMAL oxandrolone 9 NYMALIZE 58 SYSTEM 98 oxaprozin 4 NICOTROL INHALER 98 nystatin 30 oxazepam 15 NICOTROL NS 98 nystatin (mouth-throat) 86 oxcarbazepine 20 nifedipine 58 nystatin (topical) 65 oxybutynin chloride 103 nilutamide 42 nystatin-triamcinolone 65 oxycodone hcl 7,8 nimodipine 58 OCALIVA 75 oxycodone w/ acetaminophen 9 NINLARO 45 OCREVUS 97 oxycodone-aspirin 9 NIPENT 46 OCTAGAM 94 oxymorphone hcl 8 nisoldipine 58 octreotide acetate 74 oyster shell 84 nitrofurantoin macrocrystal 103 ODEFSEY 54 paclitaxel 47 nitrofurantoin monohyd ODOMZO 41 paliperidone 49,50 macro 103 OFEV 99 nitroglycerin 14 PANCREAZE 71 ofloxacin (ophth) 92 NITROGLYCERIN LINGUAL 14 PANRETIN 66 ofloxacin (otic) 93 NITROSTAT 14 pantoprazole sodium 102 olanzapine 50 nizatidine 101 parenteral electrolytes 84 olanzapine-fluoxetine hcl 97 NORDITROPIN FLEXPRO 72 paricalcitol 73 olopatadine hcl 93 norelgestromin-ethinyl paromomycin sulfate 2 olopatadine hcl (nasal) 89 estradiol 61 paroxetine hcl 22 norethin acet & estrad-fe 61 OMECLAMOX-PAK 102 paroxetine mesylate norethindrone & eth estradiol61 omega-3-acid ethyl esters 33 (vasomotor) 98 norethindrone & ethinyl estradiol- omeprazole 102 PAXIL 22 fe 61 OMEPRAZOLE 102 PEDIARIX 100 norethindrone (contraceptive) 61 omeprazole magnesium 102 PEDIAVENT 31 norethindrone acet & eth omeprazole-sodium PEDVAX HIB 103 estra 61 bicarbonate 102 peg 3350-kcl-sod bicarb-sod norethindrone acetate 96 OMNICAP 88 chloride-sod sulfate 81 norethindrone acetate-ethinyl OMNITROPE 73 peg 3350-potassium chloride-sod estradiol 74 ONCASPAR 45 bicarbonate-sod chloride 81 PEG-INTRON REDIPEN 56 norethindrone-eth estradiol ondansetron 29 (triphasic) 61 PEGANONE 21 ondansetron hcl 29 norgestimate-ethinyl PEGASYS 56 estradiol 61 ONFI 18 PEGASYS PROCLICK 56 norgestimate-ethinyl estradiol ONGLYZA 26 (triphasic) 61 PEGINTRON 56 ONIVYDE 47 norgestrel & ethinyl estradiol 61 penicillin g potassium 95 OPDIVO 41 NORTHERA 105 penicillin v potassium 95 OPSUMIT 59 nortriptyline hcl 24 PENTACEL 100 ORBACTIV 12 NORVIR 54 PENTAM 300 12 ORENCIA 5 NOVAREL 72 pentoxifylline 78 ORENCIA CLICKJECT 5 NOXAFIL 31 PEPCID AC MAXIMUM ORFADIN 73 NU-MAG 84 STRENGTH 101 ORKAMBI 99 NUCALA 15 perindopril erbumine 35 oseltamivir phosphate 56 NUEDEXTA 98 PERJETA 41 OSENI 25 permethrin 70
Index 10 perphenazine 51 PRADAXA 18 proparacaine hcl 92 perphenazine-amitriptyline 97 PRALUENT 35 propranolol hcl 57 phenelzine sulfate 22 pramipexole propylthiouracil 100 phenobarbital 80 dihydrochloride 48 PROQUAD 104 prasugrel hcl 78 phenoxybenzamine hcl 36 protriptyline hcl 24 pravastatin sodium 34 phenytoin 21 PROVENTIL HFA 17 prazosin hcl 36 phenytoin sodium 21 psyllium 81 prednicarbate 69 phenytoin sodium extended 21 PULMOZYME 99 prednisolone 62 PHOSPHOLINE IODIDE 91 PURIXAN 40 prednisolone acetate PICATO 66 (ophth) 92 PX OMEPRAZOLE 102 PIFELTRO 54 prednisolone sodium pyrazinamide 38 pilocarpine hcl 91 phosphate 62 pyrethrins-piperonyl butoxide70 pilocarpine hcl (oral) 87 prednisone 62,63 pyridostigmine bromide 37,38 pimozide 98 PREMARIN 75,105 QUADRACEL 100 pindolol 57 PREMPHASE 75 quetiapine fumarate 50 pioglitazone hcl 26,27 PREMPRO 75 quinapril hcl 35 pioglitazone hcl-glimepiride 25 PRENATE 88 quinapril-hydrochlorothiazide pioglitazone hcl-metformin PRENATE AM 88 37 hcl 25 PREVACID 24HR 102 quinidine gluconate 15 piperacillin sodium-tazobactam PREVYMIS 55 quinidine sulfate 15 sodium 95 PREZCOBIX 54 quinine sulfate 37 piroxicam 4 PREZISTA 54 QUINTABS 88 PLAN B ONE-STEP 61 PRIFTIN 38 QVAR 16 PLEGRIDY 97 RA OMEPRAZOLE 102 PLEGRIDY STARTER PRILOSEC OTC 102 PACK 97 primaquine phosphate 37 RABAVERT 104 podofilox 70 PRIMAQUINE RADICAVA 89 polyethylene glycol 3350 81 PHOSPHATE 37 raloxifene hcl 73 primidone 20 polymyxin b sulfate 14 ramipril 35 PRIVIGEN 94 polymyxin b-trimethoprim 92 RANEXA 14 PROAIR HFA 17 polyvinyl alcohol 90 ranitidine hcl 101 polyvinyl alcohol-povidone PROAIR RESPICLICK 17 RAPAMUNE 86 (ophth) 90 probenecid 78 rasagiline mesylate 48 POMALYST 42 prochlorperazine 51 RASUVO 3 PORTRAZZA 41 prochlorperazine edisylate 51 RAVICTI 73 potassium chloride 84,85 prochlorperazine maleate 51 RAYALDEE 73 POTASSIUM CHLORIDE 85 PROCRIT 79 REBIF 97 potassium chloride 85 progesterone micronized 96 REBIF REBIDOSE 97 POTASSIUM CHLORIDE PROGLYCEM 26 REBIF REBIDOSE ER 84 PROGRAF 86 TITRATIONPACK 97 potassium chloride in dextrose & sodium chloride 84 PROLASTIN-C 99 REBIF TITRATION PACK 98 potassium chloride PROLEUKIN 46 RECOMBIVAX HB 104 microencapsulated crystals PROLIA 72 RECTIV 10 er 84 REFRESH LIQUIGEL 90 potassium citrate PROMACTA 79 (alkalinizer) 77 promethazine & REFRESH PLUS 90 POTELIGEO 41 phenylephrine 63 REFRESH TEARS 90 promethazine hcl 33 POTIGA 20 REGRANEX 70 propafenone hcl 15 povidone-iodine 52 RELENZA DISKHALER 56
Index 11 RELISTOR 77 SANDIMMUNE 86 sotalol hcl 57 REMICADE 76 SANDOSTATIN LAR sotalol hcl (afib/afl) 57 REMODULIN 58 DEPOT 74 SOTYLIZE 57 SANTYL 69 RENVELA 77 SOVALDI 56 SAPHRIS 50 repaglinide 28 SPIRIVA HANDIHALER 16 SB OMEPRAZOLE 102 REPAGLINIDE/METFORMIN SPIRIVA RESPIMAT 16 scopolamine 29 HYDROCHLORIDE 25 spironolactone 71 REPATHA 35 selegiline hcl 48 spironolactone & REPATHA PUSHTRONEX selenium sulfide 66 hydrochlorothiazide 71 SYSTEM 35 SELZENTRY 54 SPRITAM 20 REPATHA SURECLICK 35 SENSIPAR 73 SPRYCEL 45 RESCRIPTOR 54 SEREVENT DISKUS 17 STAMARIL 104 RESTASIS 92 SEROSTIM 73 stavudine 54 RESTASIS MULTIDOSE 92 sertraline hcl 22 STELARA 66,76 RETROVIR IV INFUSION 54 sevelamer carbonate 77 STIOLTO RESPIMAT 17 REVLIMID 85 SHINGRIX 104 STIVARGA 45 REXULTI 52 SIGNIFOR 74 STRENSIQ 73 REYATAZ 54 SIGNIFOR LAR 74 STRIBILD 54 ribavirin 56 sildenafil citrate (pulmonary STRIVERDI RESPIMAT 17 ribavirin (hepatitis c) 56 hypertension) 59 SUBSYS 8 RIDAURA 3 SILENOR 80 SUCRAID 71 rifabutin 38 SILIQ 66 sucralfate 101 rifampin 38 SILPHEN COUGH 32 sulfacetamide sod- RIFATER 38 silver sulfadiazine 67 prednisolone 92 riluzole 89 SIMPONI 2 sulfacetamide sodium (acne)64 rimantadine hydrochloride 56 SIMPONI ARIA 2 sulfacetamide sodium RISPERDAL CONSTA 50 SIMULECT 86 (ophth) 92 sulfadiazine 99 risperidone 50 simvastatin 34 sulfamethoxazole-trimethoprim RITALIN LA 2 sirolimus 86 12 ritonavir 54 SIRTURO 38 SULFAMYLON 67 RITUXAN 41 SIVEXTRO 13 sulfasalazine 76 RITUXAN HYCELA 43 SLOW-MAG 84 sulindac 4 rivastigmine 96 SM OMEPRAZOLE 102 sumatriptan succinate 83 rivastigmine tartrate 96 sodium bicarbonate sumatriptan-naproxen rizatriptan benzoate 83 (antacid) 11 sodium 83 sodium chloride 85 ROMIDEPSIN 45 SUPRAX 60 sodium chloride (gu SUPREP BOWEL PREP KIT81 ropinirole hydrochloride 48 irrigant) 77 SURMONTIL 24 rosuvastatin calcium 34 sodium phosphates 81 ROTARIX 104 sodium phosphates (sodium SUSTIVA 54 ROTATEQ 104 phosphate dibasic & SUTENT 45 monobasic) 84 ROZEREM 81 SW OMEPRAZOLE 102 sodium polystyrene SYLATRON 46 RUBRACA 45 sulfonate 86 RUCONEST 78 SOLTAMOX 42 SYMDEKO 99 RYDAPT 45 SOLU-CORTEF 63 SYMFI 54 RYTARY 48 SOLU-MEDROL 63 SYMFI LO 54 SABRIL 20 SOMATULINE DEPOT 74 SYMLINPEN 120 24 SAMSCA 74 SOMAVERT 72 SYMLINPEN 60 24
Index 12 SYMTUZA 54 testosterone 10 TOTECT 47 SYNAGIS 94 TESTOSTERONE 10 TOUJEO MAX SOLOSTAR 27 SYNAREL 73 testosterone cypionate 9 TOUJEO SOLOSTAR 27 SYNDROS 30 testosterone enanthate 10 TRACLEER 59 SYNERCID 14 TESTOSTERONE PUMP 10 TRADJENTA 26 SYNJARDY 25 TETANUS/DIPHTHERIA tramadol hcl 8 SYNJARDY XR 25 TOXOIDS-ADSORBED 100 tramadol-acetaminophen 9 tetrabenazine 97 SYNRIBO 46 trandolapril 35 tetracycline hcl 99 SYPRINE 85 tranexamic acid 80 TGT OMEPRAZOLE 102 SYSTANE OVERNIGHT TRANSDERM-SCOP 29 THALOMID 85 THERAPY LUBRICANT tranylcypromine sulfate 22 EYE 90 theophylline 17 TRAVATAN Z 93 TABLOID 40 THERA 88 trazodone hcl 22 tacrolimus 86 thioridazine hcl 51 TREANDA 39 tacrolimus (topical) 70 thiotepa 39 TRECATOR 38 tadalafil (pulmonary thiothixene 52 hypertension) 59 TRELEGY ELLIPTA 17 THYMOGLOBULIN 86 TAFINLAR 45 TRELSTAR 42 tiagabine hcl 20 TAGAMET HB 101 TRELSTAR MIXJECT 42 TICE BCG 46 TAGRISSO 45 TREMFYA 66 TIGAN 29 TALTZ 66 TRESIBA FLEXTOUCH 27 TIGECYCLINE 13 TAMIFLU 56 tretinoin 64 tigecycline 13 tamoxifen citrate 42 tretinoin (chemotherapy) 46 timolol maleate (ophth) 91 tamsulosin hcl 77 tretinoin microsphere 64 TIMOLOL MALEATE TAPERDEX 6-DAY 63 OPHTHALMIC GEL TREXIMET 83 TARCEVA 45 FORMING 91 triamcinolone acetonide 63 TARGRETIN 66 tinidazole 12 triamcinolone acetonide TASIGNA 45 tioconazole vaginal 105 (mouth) 86 triamcinolone acetonide TAVALISSE 78 TIVICAY 54 (nasal) 89 tazarotene 66 tizanidine hcl 88 triamcinolone acetonide TAZORAC 66 TOBI PODHALER 2 (topical) 69 TECENTRIQ 41 tobramycin 2 triamterene & hydrochlorothiazide 71 TECFIDERA 98 tobramycin (ophth) 92 TRIAZOLAM 80 TECFIDERA STARTER tobramycin sulfate 2 triazolam 80 PACK 98 tobramycin- TEFLARO 60 dexamethasone 92 trientine hcl 85 TEKTURNA 37 tolazamide 28 trifluoperazine hcl 51 TEKTURNA HCT 37 tolbutamide 28 trifluridine 92 temazepam 80 tolcapone 48 TRIGLIDE 34 TEMODAR 39 tolmetin sodium 4 trihexyphenidyl hcl 48 temsirolimus 45 tolnaftate 65 trimethoprim 12 TENIVAC 100 tolterodine tartrate 103 trimipramine maleate 24 tenofovir disoproxil fumarate 54 topiramate 20 TRINTELLIX 22,23 terazosin hcl 36 topotecan hcl 47 triprolidine hcl 31 terbinafine hcl 30 TOPOTECAN HCL 47 TRIPTODUR 73 terbinafine hcl (topical) 65 topotecan hcl 47 TRISENOX 46 terbutaline sulfate 17 TORISEL 45 TRIUMEQ 55 terconazole vaginal 105 torsemide 71 TROGARZO 55
Index 13 trospium chloride 103 VARIVAX 104 white petrolatum-mineral oil 91 TRUMENBA 103 VARIZIG 94 XALKORI 45 TRUVADA 55 VARUBI 30 XARELTO 18 TUDORZA PRESSAIR 16 VASCEPA 33 XARELTO STARTER PACK 18 TUMS 11 VECTIBIX 41 XATMEP 40 TUMS CHEWY BITES 11 VELCADE 45 XELJANZ 3 TUMS CHEWY DELIGHTS 11 VELTASSA 86 XEOMIN 90 TUMS E-X 750 11 VEMLIDY 56 XERMELO 77 TUMS EXTRA STRENGTH VENCLEXTA 41 XGEVA 72 750 11 VENCLEXTA STARTING XIFAXAN 12 TUMS KIDS 11 PACK 41 XOLAIR 15 TUMS LASTING EFFECTS 11 venlafaxine hcl 23 XTANDI 42 TUMS SMOOTHIES 11 VENTAVIS 59 XURIDEN 74 TUMS ULTRA 1000 11 verapamil hcl 58 XYREM 96 TWINRIX 104 VERELAN 58 YERVOY 41 TYBOST 55 VERSACLOZ 50 YF-VAX 104 TYGACIL 13 VERZENIO 45 YONDELIS 39 TYKERB 45 VIBERZI 77 YONSA 42 TYMLOS 72 VICTOZA 26 ZADITOR 93 TYPHIM VI 103 VIDEX EC 55 zafirlukast 16 TYSABRI 98 VIDEXPEDIATRIC 55 zaleplon 80 TYVASO 58 vigabatrin 20 ZALTRAP 40 TYVASO REFILL 58 VIGAMOX 92 ZANOSAR 39 TYVASO STARTER 59 VIIBRYD 23 ZANTAC 150 MAXIMUM UCERIS 10 VIIBRYD STARTER PACK 23 STRENGTH 101 UPTRAVI 59 VIMIZIM 74 ZANTAC 75 101 ursodiol 76 VIMPAT 20 ZARXIO 79 UTIBRON NEOHALER 17 vinblastine sulfate 47 ZATEAN-PN DHA 88 UVADEX 46 vincristine sulfate 47 ZAVESCA 79 VABOMERE 12 vinorelbine tartrate 47 ZEJULA 45 valacyclovir hcl 56 VIRACEPT 55 ZELBORAF 45 VALCHLOR 66 VIRAMUNE 55 ZEMAIRA 99 valganciclovir hcl 55 VIREAD 55 ZEPATIER 56 valproate sodium 21 VIRT-PN DHA 88 ZERIT 55 valproic acid 21 VISTOGARD 29 ZIAGEN 55 valsartan 36 VOGELXO 10 zidovudine 55 valsartan-hydrochlorothiazide VOGELXO PUMP 10 ZINPLAVA 94 37 voriconazole 31 ziprasidone hcl 49 VALSTAR 43 VOSEVI 56 ZIRGAN 92 VANACLEAR PD 31 VOTRIENT 45 ZOHYDRO ER 8 VANAHIST PD 32 VPRIV 79 ZOLADEX 42 VANAMINE PD 32 VRAYLAR 49 zoledronic acid 72 vancomycin hcl 12,13 VYXEOS 43 ZOLINZA 45 VANCOMYCIN HCL IN DEXTROSE 13 warfarin sodium 17 zolmitriptan 83 VANTAS 42 water for irrigation, sterile 86 zolpidem tartrate 80 VAQTA 104 WELCHOL 33 ZOMACTON 73
Index 14 zonisamide 20 ZONTIVITY 79 ZORTRESS 86 ZOSTAVAX 104 ZOVIRAX 66 ZYCLARA 70 ZYCLARA PUMP 70 ZYDELIG 45 ZYKADIA 45 ZYPREXA RELPREVV 51 ZYRTEC CHILDRENS ALLERGY 33 ZYTIGA 42 ZYVOX 13
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