PRESCRIPTION2020 DRUG FORMULARY
Federal Exchange Plans
This formulary was updated on 12/07/2020. For more recent information or other questions, please contact Florida Health Care Plans Member Services at 1-877-615-4022. TTY users, call 1-800-955-8770. Hours of operation are Monday through Friday, 8:00a.m. to 5:00p.m. or visit www.fhcp.com/QHP-2020 Note to existing members: Please review this document to make sure that it contains the drugs you take. When this drug list refers to “we,” “us”, or “our,” it means Florida Health Care Plans (FHCP). When it refers to “plan” or “our plan,” it means Florida Health Care Plans (FHCP).
Note: This formulary applies only to Qualified Health Plans (QHP). Qualified Health Plans are plans that are subject to the provisions of the Federal Affordable Care Act (ACA) and are submitted to the Federal and/or applicable State agencies by an Insurer that has been approved for inclusion in the Federal and/or State Insurance Exchange Marketplace(s). For more information call Member Services at 1-877-615-4022, 7 days a week, 8 am – 8 pm. TTY users should call TRS Relay 711.
This document includes a list of the drugs covered by FHCP which is effective 12/01/2020. The drug list begins on page 5. For an updated formulary, please contact us. Our contact information appears on the front cover page.
Disclaimers: − You must use network pharmacies to receive your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change upon renewal of your plan. − This information is available for free in other languages. Please contact our Member Services number at 1-877-615-4022 for additional information. (TTY users should call TRS Relay 711). Hours are 8 am to 8 pm, 7 days a week. Member Services also has free language interpreter services available for non-English speakers. − Esta informacion esta disponible gratis en otros lenguajes. Por favor pongase en contacto con nuestro Servicios de Miembros a 1-877-615-4022 para informacion adicional. Usuarios de TTY deben de llamar TRS Relay 711. Horas son de 8 am hasta 8 pm, 7 dias de la semana. Servicios de Miembros tambien tiene servicios de interpretacion de lenguajes gratis disponible para personas que no hablan ingles.
Formulary introduction The Florida Health Care Plans formulary is an extensive list of FDA approved brand and generic drugs used to treat the most common medical conditions. The FHCP Formulary is developed by FHCP's Pharmacy and Therapeutics Committee (P&T). The committee consists of physicians, pharmacists, and nurses who review drugs on the basis of safety, efficacy, tolerability, and cost. The P&T Committee reviews and updates the drug list quarterly. New drugs and newly available generics are added as needed, and drugs that are deemed unsafe by the Food and Drug Administration (FDA) are immediately removed. Your prescription drug benefit provides coverage for drugs listed in each of the therapeutic classes of the FHCP Formulary. The FHCP Formulary represents the major therapeutic classes and should serve as a quick reference to you, your physician, or pharmacist for those covered drugs within the classes listed. Information on drug coverage for a non- listed therapeutic drug class should be directed to an FHCP pharmacist or physician. If your physician prescribes a drug that is not covered, show your physician this list, and ask the physician to prescribe a drug from within the FHCP Formulary.
i Any drug not listed in the FHCP Formulary is considered a non-covered drug and is subject to a higher out of pocket costs.
What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.
If you learn that FHCP does not cover your drug, you have two options: • You can ask Member Services for a list of similar drugs that are covered by FHCP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by FHCP.
• You can ask FHCP to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Formulary? You can ask FHCP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, FHCP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, FHCP will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition, and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tier or utilization restriction exception. When you request a formulary, tier or utilization restriction exception you must submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 14 days of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 14 days for a decision. If your request to expedite is granted, we must give you a decision no later than 24 to 72 hours after we get a supporting statement from your doctor or other prescriber.
ii What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing Member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a Member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to an FHCP pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a Member of the plan less than 90-days.
Drug transition for new FHCP members FHCP pharmacies will dispense a one-time 31-day supply of the current transition drug, excluding specialty drugs, to allow you and our physician(s) to discuss possible formulary alternatives, request a prior authorization, or, in the event the physician(s) deems the non-formulary drug to be medically necessary, request a formulary exception. Specialty drugs will require review and authorization through the Referral Department prior to coverage.
How much will my prescriptions cost? Your pharmacy benefit and the drugs listed in the formulary are assigned a “TIER.” There are seven (7) Tiers in the Formulary. Generally, the higher the “Tier,” the higher your cost will be. Carefully review your Summary of Benefits Coverage to ascertain if you have a pharmacy benefit and/or any pharmacy benefit limitations.
For more information For more detailed information about your FHCP prescription drug coverage, please review your Certificate of Coverage, your Summary of Benefits Coverage and other plan materials for your cost sharing and any benefit limitations (such as “Generic Only" option). If you have questions, please contact us.
Note: FHCP’s Formulary can also be found on our website at www.fhcp.com/QHP-2020. If you are unable to find a certain drug within this booklet, please check out our website.
How to search for a drug in the Florida Health Care Plan preferred drug list (formulary) Go to www.fhcp.com/QHP-2020. When the PDF file comes up, press Control F. A pop- up search text box will appear at the top of the page. Type the drug name for which you are searching and click the right arrow in the pop-up search text box to begin the search. To close the pop-up search text box, click on the “x” in the pop-up search text box.
iii Affordable Care Act - Preventive drugs available for $0 cost-sharing The Affordable Care Act (ACA) requires coverage of certain preventive drugs without any patient cost-sharing to ACA compliant and non-grandfathered plans. “ACA compliant” and “non-grandfathered” plan means any health plan available to subscribers created by FHCP on or after March 23, 2010. For more information call Member Services at 1-877- 615-4022, 7 days a week, 8 am – 8 pm. TTY users should call TRS Relay 711.
The products listed below are available for $0 cost-sharing when applicable requirements are met. Some products may have restrictions such as age or gender limits.
In order for $0 cost-sharing to apply, all products in the following tables must be filled at an FHCP pharmacy and require a prescription for coverage, including over the counter items.
Category Example of Covered Product Antihyperlipidemics Lovastatin Tablet 10MG, 20MG, 40MG Oral Tablet Aspirin Aspirin 81 MG Delayed Release Oral Tablet Covered for ages 79 and under Aspirin 81 MG Chewable Oral Tablet Multivitamins w/ Fluoride Multivitamin/Fluoride 0.25 MG/ML, 0.5 MG/ML Oral Covered for ages 12 months Solution and under Multivitamin/Fluoride/Iron 0.25-10 MG/ML Oral Solution Multivitamin/Fluoride 0.25 MG Chewable Tablet Fluoride Sodium Fluoride 0.55 MG, 1.1 MG, 2.2 MG Chewable Covered for ages 6 months to 6 Tablet years Sodium Fluoride 1.1 (0.5 F) MG/ML Oral Solution Folic Acid Folic Acid 400 MCG, 800 MCG Oral Tablet Covered for ages 11 to 49 years Smoking Cessation Bupropion ER (Smoking Det) 150 MG Oral Tablet Quantity limit of 90 days per 1 Nicotine 14 MG/24HR, 21 MG/24HR, 7 MG/24HR year Transdermal Patch Nicotine Polacrilex 2 MG, 4 MG Gum Nicotine Polacrilex 2 MG, 4 MG Lozenge Vitamin D Supplements Covered for ages 65 years and Vitamin D3 1000 UNIT, 400 UNIT Oral Capsule up
iv Affordable Care Act - Preventive drugs available for $0 cost-sharing (continued)
Contraceptives Below are the 16 FDA-approved contraceptive methods and a covered example of each.
Oral contraceptives may be obtained at non-preferred pharmacies; however a Tier 2 copay will apply.
Cervical Cap FemCap Device 22 MM, 26 MM, 30 MM Vaginal Contraceptive Sponge Today Sponge 1000 MG Vaginal Diaphragm Caya Diaphragm Vaginal Emergency Contraceptives Levonorgestrel Levonorgestrel Tablet 1.5 MG Oral Ulipristal Acetate Ella Tablet 30 MG Oral Female Condom FC2 Female Condom Implantable Rods Etonogestrel Nexplanon Implant 68 MG Subcutaneous Injectable Medroxyprogesterone Acetate Suspension 150 MG/ML Medroxyprogesterone Intramuscular IUD Copper Paragard Copper Intrauterine Device Kyleena Intrauterine Device 19.5 MG Levonorgestrel Mirena (52 MG) Intrauterine Device 20 MCG/24HR Skyla Intrauterine Device 13.5 MG
v Contraceptives (Continued) Oral-Combination Desogestrel-Ethinyl Estradiol Apri Tablet 0.15-30 MG-MCG Drospirenone-Ethinyl Estradiol Nikki Tablet 3-0.02 MG Ethynodiol Diacetate-Ethinyl Estradiol Tablet 1-50 MG-MCG Ethynodiol Diacetate-Ethinyl Estradiol Kelnor 1/35 Tablet 1-35 MG-MCG Zovia 1/35E (28) Tablet 1-35 MG-MCG Levonorgestrel-Ethinyl Estradiol Tablet 0.15- Levonorgestrel-Ethinyl Estradiol 30 MG-MCG Orsythia Tablet 0.1-20 MG-MCG Levonorg-Ethinyl Estradiol Triphasic Enpresse-28 Tablet Junel FE 1.5/30 Tablet 1.5-30 MG-MCG Norethindrone Ace-Ethinyl Estradiol-FE Junel FE 1/20 Tablet 1-20 MG-MCG Nortrel 0.5/35 (28) Tablet 0.5-35 MG-MCG Norethindrone-Ethinyl Estradiol Nortrel 1/35 (28) Tablet 1-35 MG-MCG Norethindrone-Mestranol Necon 1/50 (28) Tablet 1-50 MG-MCG Norethin-Ethinyl Estradiol Biphasic Necon 10/11 (28) Tablet 35 MCG Norgestimate-Ethinyl Estradiol Sprintec 28 Tablet 0.25-35 MG-MCG Tri-Lo-Sprintec Tablet 0.18/0.215/0.25 MG- 25 MCG Norgestim-Ethinyl Estradiol Triphasic Tri-Sprintec Tablet 0.18/0.215/0.25 MG-35 MCG Cryselle-28 Tablet 0.3-30 MG-MCG Norgestrel-Ethinyl Estradiol Ogestrel Tablet 0.5-50 MG-MCG Oral-Extended/ Continuous Use Levonorgestrel-Ethinyl Estradiol 91-Day Tablet 0.1-0.02 & 0.01 MG Levonorgestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Estradiol 91-Day Tablet 0.15-0.03 &0.01 MG Oral-Progestin Only Norethindrone Camila Tablet 0.35 MG Spermicides Encare Suppository 100 MG VCF Vaginal Contraceptive Gel 4 % Nonoxynol-9 Options Gynol II Contraceptive Gel 3 % VCF Vaginal Contraceptive Foam 12.5 % Transdermal Patch Norelgestromin-Ethinyl Estradiol Xulane Patch Weekly 150-35 MCG/24HR Vaginal Ring Etonogestrel-Ethinyl Estradiol Etonogestrel-Eth Estrad. 0.12-0.015MG/24HR
vi Our Plan’s Formulary The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.
Usage Rules • 75% Usage Rule: Prescription refills will not be covered unless at least 75% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician).
• 90% Usage Rule: Prescription refills for narcotics or controlled substances will not be covered unless at least 90% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician).
List of Abbreviations
Tier 1: Preferred Generic
Tier 2: Non-Preferred Generic
Tier 3: Preferred Brand, some high cost generic
Tier 4: Non-Preferred Brand, some high cost generic
Tier 5: Preferred Specialty
Tier 6: Non-Preferred Specialty
Tier 7: Preventive ($0) – With the exception of flu vaccines, in order for $0 cost-sharing to apply, all products in this tier must be filled at an FHCP pharmacy and require a prescription for coverage, including over the counter items. Additionally, some products may have restrictions such as age or gender limits.
(AL) Age Limit: This drug is covered only if member satisfies age requirements for coverage.
(DDL) Discount Drug List: Some low-cost drugs are available at a discounted rate when filled at an FHCP pharmacy. For more information and to see a complete list of these drugs, go to www.fhcp.com/DDL-2020
(DL) Dispensing Limit: Cannot be dispensed for more than a 31-day supply.
(FHCP) FHCP Only: Must be filled at an FHCP pharmacy.
(PA) Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, our plan may not cover the drug. Prior authorization drugs must be obtained from FHCP pharmacies.
vii List of Abbreviations (Continued)
(QL) Quantity Limit: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 31 tablets per prescription for Januvia 50mg. This appears on the formulary as “31 EA per 31 days” which means coverage is limited to 31 tablets every 31 days, or 1 tablet per day.
(SH) Safe Harbor Drug: Copays for anti-retroviral drugs follow OIR guidelines and may be different from the copays assigned to each tier in your summary of benefits. Applicable deductibles must be met before Safe Harbor copays apply. To view the 2020 Safe Harbor Guidelines for HIV/AIDS Drugs, go to: http://www.floir.com/sitedocuments/2020HIV-AIDSSafeHarborInstructions.pdf
(ST) Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. Step therapy drugs must be obtained from FHCP pharmacies.
Distribution Types • (RM) Retail and Mail: May be filled at a retail pharmacy or the FHCP mail order pharmacy. • (RO) Retail Only: Must be filled at a retail pharmacy. Mail order delivery not available. • (SP) Specialty Pharmacy Only: Certain drugs can only be filled via specialty pharmacies. In most cases, the name of the specialty pharmacy that must be used will be listed in the Requirements/Limits column on the formulary. The contact information for those pharmacies is listed below. Specialty Pharmacy Phone Biologics - Biologics, Inc. 1-800-850-4306 CVS Caremark - CVS Caremark Specialty 1-866-278-5108 Diplomat - Diplomat Specialty Pharmacy 1-954-527-0440 Dohmen - Dohmen Life Science Services, LLC 1-866-849-4481 Express Scripts - Express Scripts Specialty 1-866-997-3688 Optime - Optime Care, Inc. 1-610-597-4421
Some Specialty Pharmacy Only drugs will not have a specialty pharmacy name listed. For more information about where to fill those drugs, please contact Pharmacy Services at 1-888-676-7173
Medical Pharmacy Medical pharmacy includes those drugs /medications that require administration by a health care provider. These types of medications are listed in the “Medical Pharmacy Formulary” and are covered under your Group Plan’s medical services benefits. The Medical Pharmacy Formulary can be accessed by going to: www.fhcp.com/Medical-Rx-2020. viii Members with Diabetes Covered services include all medically appropriate and necessary insulin, equipment and supplies, when used to treat diabetes, if the Member's Primary Care Physician, or a Contracted Specialist who specializes in the treatment of diabetes, certifies that such services are necessary.
Insulin and Insulin syringes/needles that are included on this formulary are available through your prescription drug coverage when filled at an FHCP Pharmacy and are subject to the appropriate co-payment, co-insurance and/or deductible.
The additional diabetic supplies below are covered under your plan’s medical benefit and can be found in the Medical Pharmacy Formulary.
All item listed below must be obtained from FHCP pharmacies.
Contour Glucometer - $0
Test Strips - $10 per box of 50 strips
o No Prior Authorization Required: . Contour Test Strips . Contour Next Test Strips
o Prior Authorization Required: . Accu-Chek Aviva Plus Strip . FreeStyle Lite Test Strip . FreeStyle Test Strip . Nova Max Glucose Test Strip . OneTouch Ultra Blue Strip . OneTouch Verio Strip . Prodigy No Coding Blood Glucose Strip
Lancets - $4 per box of 100
Continuous Blood Glucose Monitoring - Prior Authorization Required o Freestyle Libre Reader - $40 o FreeStyle Libre Sensor - $20 per sensor (14-day supply)
Note: Specialized Diabetic Supplies such as insulin pumps, pump supplies, “Dexcom Continuous Monitoring System” and supplies require Prior Authorization and are subject to the applicable DME or Medical Pharmacy cost-sharing.
ix Florida Health Care Plans 2020 Prescription Drug Formulary Federal Exchange Plans
Table of Contents ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants...... 3 Aminoglycosides...... 4 Analgesics - Anti-Inflammatory...... 4 Analgesics - Nonnarcotic...... 6 Analgesics - Opioid...... 6 Androgens-Anabolic...... 8 Anorectal Agents...... 9 Anthelmintics...... 9 Antianginal Agents...... 9 Antianxiety Agents...... 10 Antiarrhythmics...... 10 Antiasthmatic And Bronchodilator Agents...... 11 Anticoagulants...... 14 Anticonvulsants...... 14 Antidepressants...... 17 Antidiabetics...... 19 Antidiarrheal/Probiotic Agents...... 22 Antidiarrheals...... 22 Antidotes...... 22 Antidotes And Specific Antagonists...... 22 Antiemetics...... 22 Antifungals...... 23 Antihistamines...... 24 Antihyperlipidemics...... 24 Antihypertensives...... 25 Anti-Infective Agents - Misc...... 27 Antimalarials...... 28 Antimyasthenic Agents...... 28 Antimyasthenic/Cholinergic Agents...... 28 Antimycobacterial Agents...... 28 Antineoplastics And Adjunctive Therapies...... 29 Antiparkinson Agents...... 33 Antiparkinson And Related Therapy Agents...... 33 Antipsychotics/Antimanic Agents...... 34 Antivirals...... 36 Assorted Classes...... 40 Beta Blockers...... 41 Calcium Channel Blockers...... 42 Cardiotonics...... 42 Cardiovascular Agents - Misc...... 42 Cephalosporins...... 43 Contraceptives...... 43 Corticosteroids...... 45
1 Cough/Cold/Allergy...... 46 Dermatologicals...... 46 Digestive Aids...... 53 Diuretics...... 53 Endocrine And Metabolic Agents - Misc...... 54 Estrogens...... 56 Fluoroquinolones...... 56 Gastrointestinal Agents - Misc...... 57 Genitourinary Agents - Miscellaneous...... 58 Gout Agents...... 58 Hematological Agents - Misc...... 59 Hematopoietic Agents...... 59 Hemostatics...... 60 Hypnotics...... 60 Hypnotics/Sedatives/Sleep Disorder Agents...... 60 Laxatives...... 61 Macrolides...... 61 Medical Devices...... 61 Medical Devices And Supplies...... 62 Migraine Products...... 62 Minerals & Electrolytes...... 63 Miscellaneous Therapeutic Classes...... 63 Mouth/Throat/Dental Agents...... 64 Multivitamins...... 64 Musculoskeletal Therapy Agents...... 65 Nasal Agents - Systemic And Topical...... 65 Neuromuscular Agents...... 65 Ophthalmic Agents...... 65 Otic Agents...... 69 Oxytocics...... 70 Penicillins...... 70 Progestins...... 71 Psychotherapeutic And Neurological Agents - Misc...... 71 Respiratory Agents - Misc...... 73 Sulfonamides...... 73 Tetracyclines...... 73 Thyroid Agents...... 74 Toxoids...... 74 Ulcer Drugs...... 74 Urinary Antispasmodics...... 75 Vaccines...... 76 Vaginal Products...... 78 Vasopressors...... 79 Vitamins...... 79
2 2020 Prescription Drug Formulary
Federal Exchange Plans
Drug Name Drug Tier Requirements/Limits ADHD/Anti-Narcolepsy/Anti- Obesity/Anorexiants Amphetamine-Dextroamphet ER Oral RM; QL (31 EA per 31 Capsule Extended Release 24 Hour 10 Tier 2 days) MG, 15 MG, 5 MG Amphetamine-Dextroamphet ER Oral RM; QL (62 EA per 31 Capsule Extended Release 24 Hour 20 Tier 2 days) MG, 25 MG, 30 MG Armodafinil Oral Tablet 150 MG, 200 RM; FHCP; QL (31 EA per Tier 2 MG, 250 MG, 50 MG 31 days) Atomoxetine HCl Oral Capsule 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, Tier 2 RM 80 MG Dexmethylphenidate HCl Oral Tablet 10 RM; QL (60 EA per 30 Tier 2 MG, 2.5 MG, 5 MG days) Dextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 10 Tier 2 RM MG, 15 MG, 5 MG Dextroamphetamine Sulfate Oral Tablet Tier 2 RM 10 MG, 5 MG Guanfacine HCl ER Oral Tablet Extended Release 24 Hour 1 MG, 2 MG, Tier 2 RM 3 MG, 4 MG Methamphetamine HCl Oral Tablet 5 Tier 2 RM MG Methylphenidate HCl ER (CD) Oral RM; QL (31 EA per 31 Capsule Extended Release 10 MG, 20 Tier 2 days) MG, 30 MG, 40 MG, 50 MG, 60 MG Methylphenidate HCl ER Oral Tablet RM; QL (93 EA per 31 Tier 2 Extended Release 20 MG days) Methylphenidate HCl ER Oral Tablet RM; QL (31 EA per 31 Extended Release 24 Hour 18 MG, 27 Tier 2 days) MG, 54 MG Methylphenidate HCl ER Oral Tablet RM; QL (62 EA per 31 Tier 2 Extended Release 24 Hour 36 MG days) Methylphenidate HCl Oral Solution 10 Tier 2 RO; DL MG/5ML, 5 MG/5ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 3 Drug Name Drug Tier Requirements/Limits Methylphenidate HCl Oral Tablet 10 Tier 2 RM MG, 20 MG, 5 MG RM; FHCP; QL (31 EA per Modafinil Oral Tablet 100 MG, 200 MG Tier 2 31 days) Aminoglycosides Neomycin Sulfate Oral Tablet 500 MG Tier 2 RO; DL Paromomycin Sulfate Oral Capsule 250 Tier 3 RO; DL MG Tobi Podhaler Inhalation Capsule Tier 6 PA; RO; DL 28 MG Tobramycin Sulfate Injection Solution Tier 2 RO 10 MG/ML, 80 MG/2ML Analgesics - Anti-Inflammatory Arcalyst Subcutaneous Solution Tier 5 PA; SP; DL Reconstituted 220 MG Celecoxib Oral Capsule 100 MG, 200 Tier 2 RM; FHCP MG, 400 MG, 50 MG Diclofenac Sodium Oral Tablet Delayed Tier 2 RM Release 25 MG Diclofenac Sodium Oral Tablet Delayed Tier 2 RM; DDL Release 50 MG, 75 MG Enbrel Mini Subcutaneous Solution Tier 5 PA; RO; DL Cartridge 50 MG/ML Enbrel Subcutaneous Solution 25 Tier 5 PA; RO; DL MG/0.5ML Enbrel Subcutaneous Solution Prefilled Syringe 25 MG/0.5ML, 50 Tier 5 PA; RO; DL MG/ML Enbrel Subcutaneous Solution Tier 5 PA; RO; DL Reconstituted 25 MG Enbrel SureClick Subcutaneous Tier 5 PA; RO; DL Solution Auto-Injector 50 MG/ML Etodolac ER Oral Tablet Extended Release 24 Hour 400 MG, 500 MG, 600 Tier 2 RM MG Etodolac Oral Capsule 200 MG, 300 MG Tier 2 RM Etodolac Oral Tablet 400 MG, 500 MG Tier 2 RM Fenoprofen Calcium Oral Tablet 600 MG Tier 2 RM Flurbiprofen Oral Tablet 100 MG, 50 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 4 Drug Name Drug Tier Requirements/Limits Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit Tier 6 PA; RO; DL 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML Humira Pen Subcutaneous Pen- Injector Kit 40 MG/0.4ML, 40 Tier 6 PA; RO; DL MG/0.8ML Humira Pen-CD/UC/HS Starter Subcutaneous Pen-Injector Kit 40 Tier 6 PA; RO; DL MG/0.8ML, 80 MG/0.8ML Humira Pen-Ps/UV/Adol HS Start Subcutaneous Pen-Injector Kit 40 Tier 6 PA; RO; DL MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML Humira Subcutaneous Prefilled Syringe Kit 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 Tier 6 PA; RO; DL MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML Ibuprofen Oral Tablet 400 MG, 600 MG, Tier 1 RM 800 MG Indomethacin ER Oral Capsule Tier 2 RM Extended Release 75 MG Indomethacin Oral Capsule 25 MG, 50 Tier 2 RM MG Ketoprofen Oral Capsule 50 MG, 75 MG Tier 2 RM Ketorolac Tromethamine Injection Tier 3 RM Solution 15 MG/ML, 30 MG/ML Ketorolac Tromethamine Oral Tablet 10 RM; QL (20 EA per 31 Tier 2 MG days) Kevzara Subcutaneous Solution Auto-Injector 150 MG/1.14ML, 200 Tier 5 PA; RO; DL MG/1.14ML Kevzara Subcutaneous Solution Prefilled Syringe 150 MG/1.14ML, Tier 5 PA; RO; DL 200 MG/1.14ML Kineret Subcutaneous Solution Tier 5 PA; RO; DL Prefilled Syringe 100 MG/0.67ML Leflunomide Oral Tablet 10 MG, 20 MG Tier 1 RM Meclofenamate Sodium Oral Capsule Tier 2 RM 100 MG, 50 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 5 Drug Name Drug Tier Requirements/Limits RM; QL (30 EA per 30 Mefenamic Acid Oral Capsule 250 MG Tier 2 days) Meloxicam Oral Tablet 15 MG, 7.5 MG Tier 1 RM Nabumetone Oral Tablet 500 MG, 750 Tier 2 RM MG Naproxen Oral Suspension 125 MG/5ML Tier 2 RO; DL Naproxen Oral Tablet 250 MG, 375 MG, Tier 1 RM 500 MG Orencia Intravenous Solution Tier 6 PA; RO; DL Reconstituted 250 MG Piroxicam Oral Capsule 10 MG, 20 MG Tier 2 RM Simponi Subcutaneous Solution Auto-Injector 100 MG/ML, 50 Tier 5 PA; RO; DL MG/0.5ML Simponi Subcutaneous Solution Prefilled Syringe 100 MG/ML, 50 Tier 5 PA; RO; DL MG/0.5ML Sulindac Oral Tablet 150 MG, 200 MG Tier 2 RM Tolmetin Sodium Oral Capsule 400 MG Tier 2 RM Tolmetin Sodium Oral Tablet 600 MG Tier 2 RM Xeljanz Oral Tablet 10 MG, 5 MG Tier 5 PA; RO; DL Xeljanz XR Oral Tablet Extended Tier 5 PA; RO; DL Release 24 Hour 11 MG, 22 MG Analgesics - Nonnarcotic RM; (Prescription Adult Aspirin EC Low Strength Oral Tier 7 Required); AL (Max 79 Tablet Delayed Release 81 MG Years) RM; (Prescription Aspirin Adult Low Strength Oral Tablet Tier 7 Required); AL (Max 79 Chewable 81 MG Years) Butalbital-APAP-Caffeine Oral Tablet Tier 2 RM 50-325-40 MG Butalbital-Aspirin-Caffeine Oral Capsule Tier 2 RM 50-325-40 MG Diflunisal Oral Tablet 500 MG Tier 2 RM Salsalate Oral Tablet 500 MG, 750 MG Tier 2 RM Analgesics - Opioid Acetaminophen-Codeine #2 Oral Tablet Tier 2 RM 300-15 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 6 Drug Name Drug Tier Requirements/Limits Acetaminophen-Codeine #3 Oral Tablet Tier 2 RM 300-30 MG Acetaminophen-Codeine #4 Oral Tablet Tier 2 RM 300-60 MG Acetaminophen-Codeine Oral Solution Tier 2 RO; DL 120-12 MG/5ML Buprenorphine HCl Injection Solution Tier 2 RO; DL 0.3 MG/ML Buprenorphine HCl Sublingual Tablet Tier 2 RO; DL Sublingual 2 MG, 8 MG Buprenorphine HCl-Naloxone HCl Sublingual Tablet Sublingual 2-0.5 MG, Tier 2 RO; DL 8-2 MG Butalbital-ASA-Caff-Codeine Oral Tier 2 RM Capsule 50-325-40-30 MG Codeine Sulfate Oral Tablet 15 MG, 30 Tier 2 RM MG Fentanyl Citrate (PF) Injection Solution Tier 2 RO; DL 100 MCG/2ML, 250 MCG/5ML Fentanyl Transdermal Patch 72 Hour 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, Tier 2 PA; RO; DL 50 MCG/HR, 75 MCG/HR Hydrocodone-Acetaminophen Oral RO; QL (2700 ML per 30 Tier 2 Solution 7.5-325 MG/15ML days); DL Hydrocodone-Acetaminophen Oral Tablet 10-325 MG, 5-325 MG, 7.5-325 Tier 2 RM MG Hydrocodone-Ibuprofen Oral Tablet Tier 2 RM 7.5-200 MG Hydromorphone HCl Oral Liquid 1 Tier 2 RO; DL MG/ML Hydromorphone HCl Oral Tablet 2 MG, Tier 2 RM 4 MG, 8 MG Levorphanol Tartrate Oral Tablet 2 MG Tier 2 RM Meperidine HCl Oral Tablet 100 MG, 50 Tier 2 RM MG Methadone HCl Oral Solution 5 MG/5ML Tier 2 RO; DL Methadone HCl Oral Tablet 10 MG, 5 Tier 2 RM MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 7 Drug Name Drug Tier Requirements/Limits Morphine Sulfate (Concentrate) Oral Tier 2 RO; DL Solution 100 MG/5ML Morphine Sulfate ER Oral Tablet Extended Release 100 MG, 15 MG, 200 Tier 2 RM MG, 30 MG, 60 MG Morphine Sulfate Oral Solution 10 Tier 2 RO; DL MG/5ML, 20 MG/5ML Morphine Sulfate Oral Tablet 15 MG, 30 Tier 2 RM MG Nalbuphine HCl Injection Solution 10 Tier 2 RM MG/ML, 20 MG/ML Nucynta ER Oral Tablet Extended Release 12 Hour 100 MG, 150 MG, Tier 4 PA; RM 200 MG, 250 MG, 50 MG Oxycodone HCl Oral Solution 5 MG/5ML Tier 2 RO; DL Oxycodone HCl Oral Tablet 10 MG, 15 Tier 2 RM MG, 20 MG, 30 MG, 5 MG Oxycodone-Acetaminophen Oral Tier 2 RO; DL Solution 5-325 MG/5ML Oxycodone-Acetaminophen Oral Tablet 10-325 MG, 2.5-325 MG, 5-325 MG, Tier 2 RM 7.5-325 MG oxyCODONE-Ibuprofen Oral Tablet 5- Tier 2 RM 400 MG Oxymorphone HCl ER Oral Tablet Extended Release 12 Hour 10 MG, 15 Tier 2 PA; RM MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG Tramadol HCl ER Oral Tablet Extended Release 24 Hour 100 MG, 200 MG, 300 Tier 2 PA; RM MG Tramadol HCl Oral Tablet 50 MG Tier 2 RM Xartemis XR Oral Tablet Extended Tier 4 PA; RM Release 7.5-325 MG Androgens-Anabolic Anadrol-50 Oral Tablet 50 MG Tier 5 PA; RO; DL Androxy Oral Tablet 10 MG Tier 4 RM Danazol Oral Capsule 100 MG, 200 MG, Tier 2 RM 50 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 8 Drug Name Drug Tier Requirements/Limits Oxandrolone Oral Tablet 10 MG, 2.5 Tier 2 PA; RM MG Testosterone Cypionate Intramuscular Tier 2 RM Solution 100 MG/ML, 200 MG/ML Testosterone Enanthate Intramuscular Tier 4 RM Solution 200 MG/ML Testosterone Transdermal Gel 25 RM; QL (75 GM per 30 Tier 3 MG/2.5GM (1%) days) Testosterone Transdermal Gel 50 RM; QL (300 GM per 30 Tier 3 MG/5GM (1%) days) Anorectal Agents Hydrocortisone Acetate Rectal Tier 2 RO; DL Suppository 25 MG Hydrocortisone Rectal Enema 100 RO; QL (1680 ML per 28 Tier 2 MG/60ML days); DL RO; QL (30 GM per 30 Proctozone-HC Rectal Cream 2.5 % Tier 2 days); DL Anthelmintics Albendazole Oral Tablet 200 MG Tier 4 RO; DL Ivermectin Oral Tablet 3 MG Tier 2 RO; DL RO; QL (6 EA per 30 days); Praziquantel Oral Tablet 600 MG Tier 2 DL Antianginal Agents Isosorbide Dinitrate Oral Tablet 10 MG, Tier 2 RM 20 MG, 30 MG, 5 MG Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 120 MG, 30 Tier 2 RM MG, 60 MG Nitro-Bid Transdermal Ointment 2 Tier 3 RO; DL % Nitroglycerin ER Oral Capsule Extended Tier 2 RM Release 2.5 MG, 6.5 MG, 9 MG Nitroglycerin Sublingual Tablet Tier 2 RM Sublingual 0.3 MG, 0.4 MG, 0.6 MG Nitroglycerin Transdermal Patch 24 Hour 0.1 MG/HR, 0.2 MG/HR, 0.4 Tier 2 RM MG/HR, 0.6 MG/HR Nitrostat Sublingual Tablet Tier 3 RM Sublingual 0.3 MG, 0.4 MG, 0.6 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 9 Drug Name Drug Tier Requirements/Limits Ranolazine ER Oral Tablet Extended Tier 2 RM; FHCP Release 12 Hour 1000 MG, 500 MG Antianxiety Agents Alprazolam Oral Tablet 0.25 MG, 0.5 Tier 2 RM MG, 1 MG, 2 MG Buspirone HCl Oral Tablet 10 MG, 15 Tier 2 RM MG, 30 MG, 5 MG Chlordiazepoxide HCl Oral Capsule 10 Tier 2 RM MG, 25 MG, 5 MG Clorazepate Dipotassium Oral Tablet 15 Tier 2 RM MG, 3.75 MG, 7.5 MG Diazepam Oral Solution 1 MG/ML Tier 2 RO; DL Diazepam Oral Tablet 10 MG, 2 MG, 5 Tier 2 RM MG Hydroxyzine HCl Oral Syrup 10 MG/5ML Tier 2 RO; DL Hydroxyzine HCl Oral Tablet 10 MG, 25 Tier 2 RM MG, 50 MG Hydroxyzine Pamoate Oral Capsule 100 Tier 2 RM MG, 25 MG, 50 MG Lorazepam Oral Concentrate 2 MG/ML Tier 2 RO; DL Lorazepam Oral Tablet 0.5 MG, 1 MG, 2 Tier 2 RM MG Meprobamate Oral Tablet 200 MG, 400 Tier 2 RM MG Antiarrhythmics Amiodarone HCl Oral Tablet 100 MG, Tier 2 RM 200 MG, 400 MG Disopyramide Phosphate Oral Capsule Tier 2 RM 100 MG, 150 MG Dofetilide Oral Capsule 125 MCG, 250 Tier 2 RM MCG, 500 MCG Flecainide Acetate Oral Tablet 100 MG, Tier 2 RM 150 MG, 50 MG Mexiletine HCl Oral Capsule 150 MG, Tier 2 RM 200 MG, 250 MG Multaq Oral Tablet 400 MG Tier 4 PA; RM Norpace CR Oral Capsule Extended Tier 4 RM Release 12 Hour 100 MG, 150 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 10 Drug Name Drug Tier Requirements/Limits Propafenone HCl Oral Tablet 150 MG, Tier 2 RM 225 MG, 300 MG Quinidine Gluconate ER Oral Tablet Tier 2 RM Extended Release 324 MG Quinidine Sulfate Oral Tablet 200 MG, Tier 2 RM 300 MG Antiasthmatic And Bronchodilator Agents Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) Tier 2 RM MCG/ACT Albuterol Sulfate Inhalation RM; QL (1 BOX Max Qty Per Nebulization Solution (2.5 MG/3ML) Tier 2 Fill Retail) 0.083%, 0.63 MG/3ML, 1.25 MG/3ML Albuterol Sulfate Oral Syrup 2 MG/5ML Tier 2 RO; DL Albuterol Sulfate Oral Tablet 2 MG, 4 Tier 2 RM MG Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 Tier 3 RM MCG/INH Arnuity Ellipta Inhalation Aerosol Powder Breath Activated 100 Tier 3 RM MCG/ACT, 200 MCG/ACT, 50 MCG/ACT Asmanex (120 Metered Doses) Inhalation Aerosol Powder Breath Tier 3 RM; QL (1 EA per 30 days) Activated 220 MCG/INH Asmanex (30 Metered Doses) Inhalation Aerosol Powder Breath Tier 3 RM; QL (1 EA per 30 days) Activated 110 MCG/INH, 220 MCG/INH Asmanex (60 Metered Doses) Inhalation Aerosol Powder Breath Tier 3 RM; QL (1 EA per 30 days) Activated 220 MCG/INH Asmanex HFA Inhalation Aerosol RM; QL (13 GM per 30 100 MCG/ACT, 200 MCG/ACT, 50 Tier 3 days) MCG/ACT Atrovent HFA Inhalation Aerosol Tier 3 RM Solution 17 MCG/ACT
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 11 Drug Name Drug Tier Requirements/Limits Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 Tier 3 RM MCG/INH, 200-25 MCG/INH PA; RM; QL (1 box Max Qty Budesonide Inhalation Suspension 0.25 Tier 2 Per Fill Retail); AL (Max 8 MG/2ML, 0.5 MG/2ML, 1 MG/2ML Years) Cromolyn Sodium Inhalation RM; QL (1 BOX Max Qty Per Tier 2 Nebulization Solution 20 MG/2ML Fill Retail) Daliresp Oral Tablet 250 MCG, 500 PA; RM; QL (31 EA per 31 Tier 3 MCG days) Flovent Diskus Inhalation Aerosol Powder Breath Activated 100 Tier 3 RM MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST Flovent HFA Inhalation Aerosol 110 RM; QL (12 GM per 30 Tier 3 MCG/ACT days) Flovent HFA Inhalation Aerosol 220 RM; QL (24 GM per 30 Tier 3 MCG/ACT days) Flovent HFA Inhalation Aerosol 44 RM; QL (10.6 GM per 30 Tier 3 MCG/ACT days) Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 113- Tier 2 RM 14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 Tier 3 RM MCG/INH Ipratropium Bromide Inhalation RM; QL (1 BOX Max Qty Per Tier 2 Solution 0.02 % Fill Retail) Ipratropium-Albuterol Inhalation RM; QL (1 BOX Max Qty Per Tier 2 Solution 0.5-2.5 (3) MG/3ML Fill Retail) Levalbuterol Tartrate Inhalation Aerosol Tier 3 RM 45 MCG/ACT Metaproterenol Sulfate Oral Syrup 10 Tier 2 RM MG/5ML Metaproterenol Sulfate Oral Tablet 10 Tier 2 RM MG, 20 MG Montelukast Sodium Oral Packet 4 MG Tier 2 RM Montelukast Sodium Oral Tablet 10 MG Tier 1 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 12 Drug Name Drug Tier Requirements/Limits Montelukast Sodium Oral Tablet Tier 1 RM Chewable 4 MG, 5 MG Nucala Subcutaneous Solution Tier 5 PA; RO Reconstituted 100 MG Qvar RediHaler Inhalation Aerosol PA; RM; QL (10.6 GM per Tier 4 Breath Activated 40 MCG/ACT 30 days) Qvar RediHaler Inhalation Aerosol PA; RM; QL (21.2 GM per Tier 4 Breath Activated 80 MCG/ACT 30 days) Serevent Diskus Inhalation Aerosol Powder Breath Activated 50 Tier 3 RM MCG/DOSE Striverdi Respimat Inhalation Tier 3 RM Aerosol Solution 2.5 MCG/ACT Terbutaline Sulfate Oral Tablet 2.5 MG, Tier 2 RM 5 MG Theophylline ER Oral Tablet Extended Release 12 Hour 100 MG, 200 MG, 300 Tier 2 RM MG, 450 MG Theophylline ER Oral Tablet Extended Tier 2 RM Release 24 Hour 400 MG, 600 MG Theophylline Oral Solution 80 MG/15ML Tier 2 RO; DL Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5- Tier 3 ST; RM 25 MCG/INH, 200-62.5-25 MCG/INH Ventolin HFA Inhalation Aerosol Tier 3 RM Solution 108 (90 Base) MCG/ACT Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 Tier 2 RM; FHCP MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE Xolair Subcutaneous Solution Prefilled Syringe 150 MG/ML, 75 Tier 6 PA; RO; DL MG/0.5ML Xolair Subcutaneous Solution Tier 6 PA; RO; DL Reconstituted 150 MG Zafirlukast Oral Tablet 10 MG, 20 MG Tier 2 RM Zileuton ER Oral Tablet Extended Tier 5 PA; RO; DL Release 12 Hour 600 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 13 Drug Name Drug Tier Requirements/Limits Anticoagulants Eliquis DVT/PE Starter Pack Oral Tier 3 RO; DL Tablet 5 MG Eliquis Oral Tablet 2.5 MG, 5 MG Tier 3 RM Enoxaparin Sodium Subcutaneous Solution 100 MG/ML, 120 MG/0.8ML, Tier 2 RO; DL 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80 MG/0.8ML Fondaparinux Sodium Subcutaneous Solution 10 MG/0.8ML, 2.5 MG/0.5ML, Tier 4 RO; FHCP; DL 5 MG/0.4ML, 7.5 MG/0.6ML Heparin Sodium (Porcine) Injection Solution 1000 UNIT/ML, 10000 Tier 2 RO; DL UNIT/ML, 20000 UNIT/ML, 5000 UNIT/ML Pradaxa Oral Capsule 110 MG, 150 Tier 4 RM MG, 75 MG Warfarin Sodium Oral Tablet 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, Tier 1 RM 6 MG, 7.5 MG Xarelto Oral Tablet 10 MG, 15 MG, Tier 3 RM 20 MG RM; QL (60 EA per 30 Xarelto Oral Tablet 2.5 MG Tier 3 days) Xarelto Starter Pack Oral Tablet Tier 3 RO; DL Therapy Pack 15 & 20 MG Anticonvulsants Aptiom Oral Tablet 200 MG, 400 Tier 4 PA; RM MG, 600 MG, 800 MG Banzel Oral Tablet 200 MG, 400 MG Tier 4 PA; RM Carbamazepine ER Oral Capsule Extended Release 12 Hour 100 MG, Tier 3 RM 200 MG, 300 MG Carbamazepine ER Oral Tablet Extended Release 12 Hour 100 MG, Tier 2 RM 200 MG, 400 MG Carbamazepine Oral Suspension 100 Tier 2 RO; DL MG/5ML Carbamazepine Oral Tablet 200 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 14 Drug Name Drug Tier Requirements/Limits Carbamazepine Oral Tablet Chewable Tier 2 RM 100 MG Celontin Oral Capsule 300 MG Tier 4 RM Clobazam Oral Suspension 2.5 MG/ML Tier 2 PA; RO; DL Clobazam Oral Tablet 10 MG, 20 MG Tier 2 PA; RM Clonazepam Oral Tablet 0.5 MG, 1 MG, Tier 2 RM 2 MG Clonazepam Oral Tablet Dispersible 0.125 MG, 0.25 MG, 0.5 MG, 1 MG, 2 Tier 2 RM MG Diazepam Rectal Gel 10 MG, 2.5 MG, RO; QL (4 EA per 30 days); Tier 4 20 MG DL Dilantin Oral Capsule 30 MG Tier 3 RM Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 250 MG, Tier 2 RM 500 MG Divalproex Sodium Oral Capsule Tier 2 RM Delayed Release Sprinkle 125 MG Divalproex Sodium Oral Tablet Delayed Tier 2 RM; DDL Release 125 MG, 250 MG, 500 MG Ethosuximide Oral Capsule 250 MG Tier 2 RM Ethosuximide Oral Solution 250 Tier 2 RO; DL MG/5ML Felbamate Oral Suspension 600 Tier 2 RO; DL MG/5ML Felbamate Oral Tablet 400 MG, 600 MG Tier 2 RM Fycompa Oral Tablet 10 MG, 12 MG, PA; RO; QL (31 EA per 31 Tier 5 2 MG, 4 MG, 6 MG, 8 MG days); DL Gabapentin Oral Capsule 100 MG, 300 Tier 2 RM MG, 400 MG Gabapentin Oral Solution 250 MG/5ML Tier 2 RO; DL Gabapentin Oral Tablet 600 MG, 800 Tier 2 RM MG Lamotrigine Oral Tablet 100 MG, 150 Tier 2 RM MG, 200 MG, 25 MG Lamotrigine Oral Tablet Chewable 25 Tier 2 RM MG, 5 MG Lamotrigine Starter Kit-Blue Oral Kit 35 Tier 2 RO; DL x 25 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 15 Drug Name Drug Tier Requirements/Limits Lamotrigine Starter Kit-Green Oral Kit Tier 2 RO; DL 84 x 25 MG & 14x100 MG Lamotrigine Starter Kit-Orange Oral Kit Tier 2 RO; DL 42 x 25 MG & 7 x 100 MG Levetiracetam ER Oral Tablet Extended Tier 2 RM Release 24 Hour 500 MG, 750 MG Levetiracetam Oral Solution 100 MG/ML Tier 2 RO; DL Levetiracetam Oral Tablet 1000 MG, Tier 2 RM 250 MG, 500 MG, 750 MG Oxcarbazepine Oral Suspension 300 Tier 2 RO; DL MG/5ML Oxcarbazepine Oral Tablet 150 MG, 300 Tier 2 RM MG, 600 MG Peganone Oral Tablet 250 MG Tier 5 RO; DL Phenytoin Oral Suspension 125 Tier 2 RO; DL MG/5ML Phenytoin Oral Tablet Chewable 50 MG Tier 2 RM Phenytoin Sodium Extended Oral Tier 2 RM Capsule 100 MG Potiga Oral Tablet 200 MG, 300 MG, Tier 4 SP 400 MG, 50 MG Pregabalin Oral Capsule 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, Tier 2 RM; FHCP 50 MG, 75 MG Primidone Oral Tablet 250 MG, 50 MG Tier 2 RM Rufinamide Oral Suspension 40 MG/ML Tier 4 PA; RO; DL Tiagabine HCl Oral Tablet 12 MG, 16 Tier 2 RM MG, 2 MG, 4 MG Topiramate Oral Capsule Sprinkle 15 Tier 2 RM MG, 25 MG Topiramate Oral Tablet 100 MG, 200 Tier 2 RM MG, 25 MG, 50 MG Valproate Sodium Oral Solution 250 Tier 2 RO; DL MG/5ML Valproic Acid Oral Capsule 250 MG Tier 2 RM Vimpat Oral Solution 10 MG/ML Tier 5 PA; RO; DL Vimpat Oral Tablet 100 MG, 150 Tier 5 PA; RO; DL MG, 200 MG, 50 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 16 Drug Name Drug Tier Requirements/Limits Zonisamide Oral Capsule 100 MG, 25 Tier 2 RM MG, 50 MG Antidepressants Amitriptyline HCl Oral Tablet 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 Tier 1 RM MG Amoxapine Oral Tablet 100 MG, 150 Tier 2 RM MG, 25 MG, 50 MG Bupropion HCl ER (SR) Oral Tablet Extended Release 12 Hour 100 MG, Tier 2 RM 150 MG, 200 MG Bupropion HCl ER (XL) Oral Tablet Extended Release 24 Hour 150 MG, Tier 2 RM 300 MG Bupropion HCl Oral Tablet 100 MG, 75 Tier 2 RM MG Citalopram Hydrobromide Oral Solution Tier 1 RO; DL 10 MG/5ML Citalopram Hydrobromide Oral Tablet Tier 1 RM 10 MG, 20 MG, 40 MG Clomipramine HCl Oral Capsule 25 MG, Tier 2 RM 50 MG, 75 MG Desipramine HCl Oral Tablet 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 Tier 2 RM MG Desvenlafaxine Succinate ER Oral Tablet Extended Release 24 Hour 100 Tier 2 RM MG, 25 MG, 50 MG Doxepin HCl Oral Capsule 10 MG, 100 Tier 2 RM MG, 150 MG, 25 MG, 50 MG, 75 MG Doxepin HCl Oral Concentrate 10 Tier 2 RO; DL MG/ML Duloxetine HCl Oral Capsule Delayed Tier 2 RM Release Particles 20 MG, 30 MG, 60 MG Emsam Transdermal Patch 24 Hour 12 MG/24HR, 6 MG/24HR, 9 Tier 4 PA; RM MG/24HR Escitalopram Oxalate Oral Solution 5 Tier 2 RO; DL MG/5ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 17 Drug Name Drug Tier Requirements/Limits Escitalopram Oxalate Oral Tablet 10 Tier 2 RM; DDL MG, 20 MG, 5 MG Fetzima Oral Capsule Extended Release 24 Hour 120 MG, 20 MG, 40 Tier 4 PA; RM MG, 80 MG Fetzima Titration Oral Capsule ER Tier 4 PA; RO; DL 24 Hour Therapy Pack 20 & 40 MG Fluoxetine HCl Oral Capsule 10 MG, 20 Tier 1 RM; DDL MG Fluoxetine HCl Oral Capsule 40 MG Tier 1 RM Fluoxetine HCl Oral Solution 20 Tier 2 RO; DL MG/5ML Fluvoxamine Maleate Oral Tablet 100 Tier 2 RM MG, 25 MG, 50 MG Imipramine HCl Oral Tablet 10 MG, 25 Tier 2 RM MG, 50 MG Maprotiline HCl Oral Tablet 25 MG, 50 Tier 2 RM MG, 75 MG Marplan Oral Tablet 10 MG Tier 4 RM Mirtazapine Oral Tablet 15 MG, 30 MG, Tier 2 RM 45 MG, 7.5 MG Mirtazapine Oral Tablet Dispersible 15 Tier 2 RM MG, 30 MG, 45 MG Nefazodone HCl Oral Tablet 100 MG, Tier 2 RM 150 MG, 200 MG, 250 MG, 50 MG Nortriptyline HCl Oral Capsule 10 MG, Tier 1 RM 25 MG, 50 MG, 75 MG Nortriptyline HCl Oral Solution 10 Tier 2 RO; DL MG/5ML Paroxetine HCl ER Oral Tablet Extended Release 24 Hour 12.5 MG, 25 MG, 37.5 Tier 2 RM MG Paroxetine HCl Oral Tablet 10 MG, 20 Tier 1 RM; DDL MG, 30 MG, 40 MG Paxil Oral Suspension 10 MG/5ML Tier 4 RO; DL Phenelzine Sulfate Oral Tablet 15 MG Tier 2 RM Protriptyline HCl Oral Tablet 10 MG, 5 Tier 2 RM MG Sertraline HCl Oral Concentrate 20 Tier 2 RO; DL MG/ML You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 18 Drug Name Drug Tier Requirements/Limits Sertraline HCl Oral Tablet 100 MG, 25 Tier 1 RM; DDL MG, 50 MG Tranylcypromine Sulfate Oral Tablet 10 Tier 2 RM MG Trazodone HCl Oral Tablet 100 MG, 150 Tier 1 RM MG, 50 MG Trimipramine Maleate Oral Capsule 100 Tier 2 RM MG, 25 MG, 50 MG Trintellix Oral Tablet 10 MG, 20 MG, Tier 4 PA; RM 5 MG Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 150 MG, Tier 2 RM 37.5 MG, 75 MG Venlafaxine HCl Oral Tablet 100 MG, 25 Tier 1 RM MG, 37.5 MG, 50 MG, 75 MG Viibryd Oral Tablet 10 MG, 20 MG, Tier 4 RM 40 MG Viibryd Starter Pack Oral Kit 10 & Tier 4 RO; DL 20 MG Antidiabetics Acarbose Oral Tablet 100 MG, 25 MG, Tier 2 RM 50 MG Baqsimi One Pack Nasal Powder 3 Tier 3 PA; RO MG/DOSE Basaglar KwikPen Subcutaneous Tier 4 RM; FHCP Solution Pen-Injector 100 UNIT/ML Bydureon BCise Subcutaneous Tier 3 ST; RM Auto-Injector 2 MG/0.85ML Bydureon Subcutaneous Pen- Tier 3 ST; RM Injector 2 MG Byetta 10 MCG Pen Subcutaneous Solution Pen-Injector 10 Tier 3 ST; RM MCG/0.04ML Byetta 5 MCG Pen Subcutaneous Solution Pen-Injector 5 Tier 3 ST; RM MCG/0.02ML Chlorpropamide Oral Tablet 100 MG, Tier 2 RM 250 MG Diazoxide Oral Suspension 50 MG/ML Tier 4 RO; DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 19 Drug Name Drug Tier Requirements/Limits RM; QL (31 EA per 31 Farxiga Oral Tablet 10 MG, 5 MG Tier 3 days) Fiasp FlexTouch Subcutaneous Tier 3 RM; FHCP Solution Pen-Injector 100 UNIT/ML Fiasp PenFill Subcutaneous Tier 3 RM Solution Cartridge 100 UNIT/ML Fiasp Subcutaneous Solution 100 Tier 3 RM UNIT/ML Glimepiride Oral Tablet 1 MG, 2 MG, 4 Tier 1 RM; DDL MG Glipizide ER Oral Tablet Extended Tier 2 RM Release 24 Hour 10 MG, 2.5 MG, 5 MG Glipizide Oral Tablet 10 MG, 5 MG Tier 1 RM RO; QL (1 EA per 15 days); Glucagon Emergency Injection Kit 1 MG Tier 3 DL Glyburide Micronized Oral Tablet 1.5 Tier 2 RM MG, 3 MG, 6 MG Glyburide Oral Tablet 1.25 MG Tier 2 RM Glyburide Oral Tablet 2.5 MG, 5 MG Tier 1 RM Humulin R U-500 (Concentrated) Subcutaneous Solution 500 Tier 5 PA; RO UNIT/ML Humulin R U-500 KwikPen Subcutaneous Solution Pen- Tier 5 PA; RO Injector 500 UNIT/ML Januvia Oral Tablet 100 MG, 25 MG, PA; RM; QL (31 EA per 31 Tier 4 50 MG days) Kombiglyze XR Oral Tablet Extended Release 24 Hour 2.5- Tier 3 ST; RM 1000 MG, 5-1000 MG, 5-500 MG Levemir FlexTouch Subcutaneous Tier 3 RM; FHCP Solution Pen-Injector 100 UNIT/ML Levemir Subcutaneous Solution Tier 3 RM 100 UNIT/ML Metformin HCl ER Oral Tablet Extended Tier 7 RM Release 24 Hour 500 MG, 750 MG Metformin HCl Oral Tablet 1000 MG, Tier 7 RM 500 MG, 850 MG Nateglinide Oral Tablet 120 MG, 60 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 20 Drug Name Drug Tier Requirements/Limits Novolin 70/30 Flexpen Subcutaneous Suspension Pen- Tier 7 RM; FHCP Injector (70-30) 100 UNIT/ML Novolin 70/30 Subcutaneous Tier 7 RM Suspension (70-30) 100 UNIT/ML NovoLIN N FlexPen Subcutaneous Suspension Pen-Injector 100 Tier 7 RM; FHCP UNIT/ML Novolin N Subcutaneous Tier 7 RM Suspension 100 UNIT/ML NovoLIN R FlexPen Injection Tier 7 RM; FHCP Solution Pen-Injector 100 UNIT/ML Novolin R Injection Solution 100 Tier 7 RM UNIT/ML Novolog Flexpen Subcutaneous Tier 3 RM; FHCP Solution Pen-Injector 100 UNIT/ML Novolog Mix 70/30 Flexpen Subcutaneous Suspension Pen- Tier 3 RM; FHCP Injector (70-30) 100 UNIT/ML Novolog Mix 70/30 Subcutaneous Tier 3 RM Suspension (70-30) 100 UNIT/ML Novolog Penfill Subcutaneous Tier 3 RM; FHCP Solution Cartridge 100 UNIT/ML Novolog Subcutaneous Solution Tier 3 RM 100 UNIT/ML ST; RM; QL (31 EA per 31 Onglyza Oral Tablet 2.5 MG, 5 MG Tier 3 days) Pioglitazone HCl Oral Tablet 15 MG, 30 Tier 2 RM; DDL MG, 45 MG ST; RM; QL (31 EA per 31 Qtern Oral Tablet 10-5 MG, 5-5 MG Tier 3 days) Repaglinide Oral Tablet 0.5 MG, 1 MG, Tier 2 RM 2 MG SymlinPen 120 Subcutaneous Solution Pen-Injector 2700 Tier 3 PA; RM MCG/2.7ML SymlinPen 60 Subcutaneous Solution Pen-Injector 1500 Tier 3 PA; RM MCG/1.5ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 21 Drug Name Drug Tier Requirements/Limits Tolazamide Oral Tablet 250 MG, 500 Tier 2 RM MG Tolbutamide Oral Tablet 500 MG Tier 2 RM Tresiba FlexTouch Subcutaneous Solution Pen-Injector 100 Tier 3 RM; FHCP UNIT/ML, 200 UNIT/ML Tresiba Subcutaneous Solution 100 Tier 3 RM UNIT/ML Victoza Subcutaneous Solution Tier 6 PA; RO; DL Pen-Injector 18 MG/3ML Xigduo XR Oral Tablet Extended Release 24 Hour 10-1000 MG, 10- Tier 3 ST; RM 500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG Antidiarrheal/Probiotic Agents Diphenoxylate-Atropine Oral Liquid 2.5- Tier 2 RO; DL 0.025 MG/5ML Loperamide HCl Oral Capsule 2 MG Tier 2 RO; DL Antidiarrheals Diphenoxylate-Atropine Oral Tablet Tier 2 RM 2.5-0.025 MG Motofen Oral Tablet 1-0.025 MG Tier 6 RO; DL Antidotes Chemet Oral Capsule 100 MG Tier 5 RO; DL Deferasirox Oral Tablet Soluble 250 MG Tier 2 PA; RM Naloxone HCl Injection Solution 0.4 Tier 2 RO; DL MG/ML RM; MAX 2 FILLS PER 365 Narcan Nasal Liquid 4 MG/0.1ML Tier 4 DAYS; QL (2 EA Max Qty Per Fill Retail) Antidotes And Specific Antagonists Deferasirox Oral Tablet Soluble 125 Tier 2 PA; RM MG, 500 MG Ferriprox Oral Tablet 500 MG Tier 5 PA; RO; DL Naltrexone HCl Oral Tablet 50 MG Tier 2 RM Radiogardase Oral Capsule 0.5 GM Tier 5 RO; DL Antiemetics Anzemet Intravenous Solution 20 Tier 5 RO; DL MG/ML You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 22 Drug Name Drug Tier Requirements/Limits Aprepitant Oral Capsule 125 MG, 40 Tier 3 PA; RO; DL MG, 80 & 125 MG, 80 MG Cesamet Oral Capsule 1 MG Tier 5 PA; RO; DL Dronabinol Oral Capsule 10 MG, 2.5 PA; RO; QL (60 EA per 30 Tier 2 MG, 5 MG days); DL Emend Oral Suspension Tier 4 PA; RO; DL Reconstituted 125 MG/5ML Granisetron HCl Oral Tablet 1 MG Tier 2 RM Meclizine HCl Oral Tablet 25 MG Tier 1 RM Ondansetron HCl Oral Solution 4 Tier 2 RO; DL MG/5ML Ondansetron HCl Oral Tablet 4 MG, 8 RM; QL (90 EA per 30 Tier 2 MG days) Ondansetron Oral Tablet Dispersible 4 RM; QL (90 EA per 30 Tier 2 MG, 8 MG days) Trimethobenzamide HCl Oral Capsule Tier 2 RM 300 MG Antifungals PA; RO; QL (70 EA per 31 Cresemba Oral Capsule 186 MG Tier 5 days); DL Fluconazole Oral Suspension Tier 2 RO; DL Reconstituted 10 MG/ML, 40 MG/ML Fluconazole Oral Tablet 100 MG, 200 Tier 2 RM MG, 50 MG RO; QL (4 EA per 28 days); Fluconazole Oral Tablet 150 MG Tier 2 DL Flucytosine Oral Capsule 250 MG, 500 Tier 5 RO; DL MG Griseofulvin Microsize Oral Suspension Tier 2 RO; DL 125 MG/5ML Itraconazole Oral Capsule 100 MG Tier 2 PA; RM Itraconazole Oral Solution 10 MG/ML Tier 4 PA; RO; DL Ketoconazole Oral Tablet 200 MG Tier 2 RM Noxafil Oral Suspension 40 MG/ML Tier 6 PA; RO; DL Nystatin Oral Tablet 500000 UNIT Tier 2 RM Posaconazole Oral Tablet Delayed Tier 6 PA; RO; DL Release 100 MG Terbinafine HCl Oral Tablet 250 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 23 Drug Name Drug Tier Requirements/Limits Voriconazole Oral Suspension Tier 5 PA; RO; DL Reconstituted 40 MG/ML Voriconazole Oral Tablet 200 MG, 50 Tier 2 PA; RO; DL MG Antihistamines Carbinoxamine Maleate Oral Tablet 4 Tier 2 RM MG Clemastine Fumarate Oral Syrup 0.67 Tier 2 RM MG/5ML Cyproheptadine HCl Oral Syrup 2 RO; QL (120 ML per 3 Tier 2 MG/5ML days) Cyproheptadine HCl Oral Tablet 4 MG Tier 2 RM Desloratadine Oral Tablet 5 MG Tier 2 RM Diphenhydramine HCl Injection Tier 2 RO; DL Solution 50 MG/ML Levocetirizine Dihydrochloride Oral Tier 2 RM Tablet 5 MG Promethazine HCl Oral Syrup 6.25 RO; QL (120 ML per 3 Tier 2 MG/5ML days) Promethazine HCl Oral Tablet 12.5 MG, Tier 2 RM 25 MG, 50 MG Promethazine HCl Rectal Suppository RO; QL (12 EA per 2 days); Tier 2 12.5 MG, 25 MG, 50 MG DL Antihyperlipidemics Atorvastatin Calcium Oral Tablet 10 Tier 1 RM; DDL MG, 20 MG, 40 MG, 80 MG Cholestyramine Light Oral Powder 4 Tier 2 RM GM/DOSE Cholestyramine Oral Powder 4 Tier 2 RM GM/DOSE Colesevelam HCl Oral Tablet 625 MG Tier 4 PA; RM Colestipol HCl Oral Tablet 1 GM Tier 2 RM Ezetimibe Oral Tablet 10 MG Tier 2 RM Fenofibrate Oral Tablet 145 MG, 48 MG Tier 2 RM Fenofibric Acid Oral Capsule Delayed Tier 2 RM Release 135 MG, 45 MG Fluvastatin Sodium Oral Capsule 20 Tier 2 RM MG, 40 MG Gemfibrozil Oral Tablet 600 MG Tier 2 RM; DDL You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 24 Drug Name Drug Tier Requirements/Limits Kynamro Subcutaneous Solution Tier 5 PA; SP; DL Prefilled Syringe 200 MG/ML Livalo Oral Tablet 1 MG, 2 MG, 4 MG Tier 4 PA; RM Lovastatin Oral Tablet 10 MG, 20 MG, Tier 7 RM 40 MG Niacin ER (Antihyperlipidemic) Oral Tablet Extended Release 1000 MG, 500 Tier 2 RM MG, 750 MG Omega-3-acid Ethyl Esters Oral Tier 2 RM Capsule 1 GM Pravastatin Sodium Oral Tablet 10 MG, Tier 1 RM; DDL 20 MG, 40 MG, 80 MG Repatha Pushtronex System Subcutaneous Solution Cartridge Tier 6 PA; RO; DL 420 MG/3.5ML Repatha Subcutaneous Solution Tier 6 PA; RO; DL Prefilled Syringe 140 MG/ML Repatha SureClick Subcutaneous Tier 6 PA; RO; DL Solution Auto-Injector 140 MG/ML Rosuvastatin Calcium Oral Tablet 10 Tier 1 RM MG, 20 MG, 40 MG, 5 MG Simvastatin Oral Tablet 10 MG, 20 MG, Tier 1 RM; DDL 40 MG, 5 MG, 80 MG Vascepa Oral Capsule 0.5 GM, 1 GM Tier 4 RM Antihypertensives Aliskiren Fumarate Oral Tablet 150 MG, Tier 2 ST; RM 300 MG Benazepril HCl Oral Tablet 10 MG, 20 Tier 1 RM MG, 40 MG, 5 MG Candesartan Cilexetil Oral Tablet 16 Tier 2 RM MG, 32 MG, 4 MG, 8 MG Captopril Oral Tablet 100 MG, 12.5 MG, Tier 2 RM 25 MG, 50 MG Clonidine HCl Oral Tablet 0.1 MG, 0.2 Tier 1 RM MG, 0.3 MG Corlopam Intravenous Solution 10 Tier 5 RO; DL MG/ML, 20 MG/2ML Doxazosin Mesylate Oral Tablet 1 MG, 2 Tier 2 RM MG, 4 MG, 8 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 25 Drug Name Drug Tier Requirements/Limits Enalapril Maleate Oral Tablet 10 MG, Tier 2 RM 2.5 MG, 20 MG, 5 MG Eplerenone Oral Tablet 25 MG, 50 MG Tier 2 RM Eprosartan Mesylate Oral Tablet 600 Tier 2 RM MG Fosinopril Sodium Oral Tablet 10 MG, Tier 2 RM 20 MG, 40 MG Guanfacine HCl Oral Tablet 1 MG, 2 MG Tier 2 RM Hydralazine HCl Oral Tablet 10 MG, 100 Tier 2 RM MG, 25 MG, 50 MG Irbesartan Oral Tablet 150 MG, 300 Tier 2 RM MG, 75 MG Lisinopril Oral Tablet 10 MG, 2.5 MG, Tier 1 RM; DDL 20 MG, 30 MG, 40 MG, 5 MG Lisinopril-Hydrochlorothiazide Oral Tablet 10-12.5 MG, 20-12.5 MG, 20-25 Tier 1 RM MG Losartan Potassium Oral Tablet 100 Tier 1 RM MG, 25 MG, 50 MG Losartan Potassium-HCTZ Oral Tablet Tier 1 RM 100-12.5 MG, 100-25 MG, 50-12.5 MG Methyldopa Oral Tablet 250 MG, 500 Tier 2 RM MG Minoxidil Oral Tablet 10 MG, 2.5 MG Tier 2 RM Moexipril HCl Oral Tablet 15 MG, 7.5 Tier 2 RM MG Olmesartan Medoxomil Oral Tablet 20 Tier 1 RM; FHCP MG, 40 MG, 5 MG Olmesartan Medoxomil-HCTZ Oral Tablet 20-12.5 MG, 40-12.5 MG, 40-25 Tier 1 RM MG Perindopril Erbumine Oral Tablet 2 MG, Tier 2 RM 4 MG, 8 MG Phenoxybenzamine HCl Oral Capsule 10 Tier 5 PA; RO; DL MG Prazosin HCl Oral Capsule 1 MG, 2 MG, Tier 2 RM 5 MG Quinapril HCl Oral Tablet 10 MG, 20 Tier 1 RM MG, 40 MG, 5 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 26 Drug Name Drug Tier Requirements/Limits Ramipril Oral Capsule 1.25 MG, 10 MG, Tier 1 RM 2.5 MG, 5 MG Telmisartan Oral Tablet 20 MG, 40 MG, Tier 1 RM 80 MG Terazosin HCl Oral Capsule 1 MG, 10 Tier 1 RM MG, 2 MG, 5 MG Trandolapril Oral Tablet 1 MG, 2 MG, 4 Tier 2 RM MG Valsartan Oral Tablet 160 MG, 320 MG, Tier 1 RM 40 MG, 80 MG Anti-Infective Agents - Misc. Alinia Oral Tablet 500 MG Tier 5 RO; DL Atovaquone Oral Suspension 750 Tier 2 RO; DL MG/5ML Cayston Inhalation Solution Tier 5 PA; SP; DL Reconstituted 75 MG Clindamycin HCl Oral Capsule 150 MG, Tier 2 RO; DL 300 MG Clindamycin Palmitate HCl Oral Solution Tier 2 RO; DL Reconstituted 75 MG/5ML Dapsone Oral Tablet 100 MG, 25 MG Tier 2 RM Fosfomycin Tromethamine Oral Packet Tier 4 RO; DL 3 GM Linezolid Oral Suspension Reconstituted Tier 2 RO; DL 100 MG/5ML Linezolid Oral Tablet 600 MG Tier 2 RO; DL Methenamine Hippurate Oral Tablet 1 Tier 2 RM GM Metronidazole Oral Tablet 250 MG, 500 Tier 2 RO; DL MG Nitrofurantoin Macrocrystal Oral Tier 2 RM Capsule 100 MG, 25 MG, 50 MG Nitrofurantoin Monohyd Macro Oral Tier 2 RM Capsule 100 MG Pentamidine Isethionate Inhalation Tier 4 PA; RO; DL Solution Reconstituted 300 MG Sulfamethoxazole-Trimethoprim Oral Tier 2 RO; DL Suspension 200-40 MG/5ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 27 Drug Name Drug Tier Requirements/Limits Sulfamethoxazole-Trimethoprim Oral Tier 2 RM Tablet 400-80 MG, 800-160 MG Trimethoprim Oral Tablet 100 MG Tier 2 RM Vancomycin HCl Intravenous Solution Tier 2 RO; DL Reconstituted 1000 MG, 500 MG Antimalarials Atovaquone-Proguanil HCl Oral Tablet Tier 2 RM 250-100 MG, 62.5-25 MG Chloroquine Phosphate Oral Tablet 250 Tier 2 RM MG, 500 MG Coartem Oral Tablet 20-120 MG Tier 4 RO; DL Hydroxychloroquine Sulfate Oral Tablet Tier 1 RM 200 MG Mefloquine HCl Oral Tablet 250 MG Tier 2 RM Primaquine Phosphate Oral Tablet 26.3 Tier 2 RO; DL MG Pyrimethamine Oral Tablet 25 MG Tier 5 PA; RO; DL Quinine Sulfate Oral Capsule 324 MG Tier 2 PA; RM Antimyasthenic Agents Guanidine HCl Oral Tablet 125 MG Tier 2 RM Pyridostigmine Bromide ER Oral Tablet Tier 2 RM Extended Release 180 MG Pyridostigmine Bromide Oral Tablet 30 Tier 2 RM MG Antimyasthenic/Cholinergic Agents Pyridostigmine Bromide Oral Tablet 60 Tier 2 RM MG Antimycobacterial Agents Cycloserine Oral Capsule 250 MG Tier 2 RM Ethambutol HCl Oral Tablet 100 MG, Tier 2 RM 400 MG Isoniazid Oral Tablet 100 MG, 300 MG Tier 2 RM Paser Oral Packet 4 GM Tier 4 RM Priftin Oral Tablet 150 MG Tier 4 RM Pyrazinamide Oral Tablet 500 MG Tier 2 RM Rifabutin Oral Capsule 150 MG Tier 2 RM rifAMPin Oral Capsule 150 MG, 300 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 28 Drug Name Drug Tier Requirements/Limits Sirturo Oral Tablet 100 MG Tier 4 RM Trecator Oral Tablet 250 MG Tier 4 RM Antineoplastics And Adjunctive Therapies Abiraterone Acetate Oral Tablet 250 MG Tier 2 PA; RO; DL Actimmune Subcutaneous Solution Tier 5 PA; SP; DL 2000000 UNIT/0.5ML Alecensa Oral Capsule 150 MG Tier 5 PA; RO; DL Anastrozole Oral Tablet 1 MG Tier 1 RM Bexarotene Oral Capsule 75 MG Tier 5 PA; RO; DL Bicalutamide Oral Tablet 50 MG Tier 2 RM Bosulif Oral Tablet 100 MG, 400 Tier 5 PA; RO; DL MG, 500 MG Capecitabine Oral Tablet 150 MG, 500 Tier 2 RM MG Caprelsa Oral Tablet 100 MG, 300 Tier 5 PA; RO; DL MG Cometriq (100 mg Daily Dose) Oral Tier 5 PA; RO; DL Kit 1 X 80 & 1 X 20 MG Cometriq (140 mg Daily Dose) Oral Tier 5 PA; RO; DL Kit 1 X 80 & 3 X 20 MG Cometriq (60 mg Daily Dose) Oral Tier 5 PA; RO; DL Kit 20 MG Cotellic Oral Tablet 20 MG Tier 5 PA; SP; DL Cyclophosphamide Oral Capsule 25 MG, Tier 1 RM 50 MG Eligard Subcutaneous Kit 22.5 MG, Tier 4 RO 7.5 MG Emcyt Oral Capsule 140 MG Tier 5 RO; DL Erivedge Oral Capsule 150 MG Tier 5 PA; RO; DL Erlotinib HCl Oral Tablet 100 MG, 150 Tier 5 PA; RO; DL MG, 25 MG Etoposide Oral Capsule 50 MG Tier 5 RO; DL Everolimus Oral Tablet 2.5 MG, 5 MG, Tier 5 PA; RO; DL 7.5 MG Exemestane Oral Tablet 25 MG Tier 2 RM Farydak Oral Capsule 10 MG, 15 Tier 5 PA; RO; DL MG, 20 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 29 Drug Name Drug Tier Requirements/Limits Firmagon Subcutaneous Solution Tier 6 PA; RO; DL Reconstituted 120 MG Firmagon Subcutaneous Solution Tier 4 PA; RO; DL Reconstituted 80 MG Flutamide Oral Capsule 125 MG Tier 2 RM Gilotrif Oral Tablet 20 MG, 30 MG, Tier 5 PA; RO; DL 40 MG Gleostine Oral Capsule 10 MG, 100 Tier 5 RO; DL MG, 40 MG, 5 MG Hexalen Oral Capsule 50 MG Tier 5 RO; DL Hydroxyurea Oral Capsule 500 MG Tier 2 RM Ibrance Oral Capsule 100 MG, 125 Tier 5 PA; SP; CVS Caremark; DL MG, 75 MG Ibrance Oral Tablet 100 MG, 125 Tier 5 PA; SP; CVS Caremark; DL MG, 75 MG Iclusig Oral Tablet 15 MG, 45 MG Tier 5 PA; SP; DL Idhifa Oral Tablet 100 MG, 50 MG Tier 5 PA; SP; DL Imatinib Mesylate Oral Tablet 100 MG, Tier 2 RO; FHCP 400 MG Imbruvica Oral Capsule 140 MG, 70 Tier 5 PA; SP; Diplomat; DL MG PA; SP; Diplomat; QL (31 Imbruvica Oral Tablet 420 MG Tier 5 EA per 31 days); DL Imbruvica Oral Tablet 560 MG Tier 5 PA; SP; Diplomat; DL Inlyta Oral Tablet 1 MG, 5 MG Tier 5 PA; SP; DL Intron A Injection Solution 10000000 UNIT/ML, 6000000 Tier 5 RO; DL UNIT/ML Intron A Injection Solution Reconstituted 10000000 UNIT, Tier 5 RO; DL 18000000 UNIT, 50000000 UNIT Iressa Oral Tablet 250 MG Tier 5 PA; RO; DL Irinotecan HCl Intravenous Solution Tier 2 RO; DL 100 MG/5ML, 40 MG/2ML Jakafi Oral Tablet 10 MG, 15 MG, 20 Tier 5 PA; SP; CVS Caremark; DL MG, 25 MG, 5 MG Lenvima (10 MG Daily Dose) Oral Tier 5 PA; SP; DL Capsule Therapy Pack 10 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 30 Drug Name Drug Tier Requirements/Limits Lenvima (12 MG Daily Dose) Oral Tier 5 PA; SP; DL Capsule Therapy Pack 3 x 4 MG Lenvima (14 MG Daily Dose) Oral Tier 5 PA; SP; DL Capsule Therapy Pack 10 & 4 MG Lenvima (18 MG Daily Dose) Oral Capsule Therapy Pack 10 MG & 2 x Tier 5 PA; SP; DL 4 MG Lenvima (20 MG Daily Dose) Oral Tier 5 PA; SP; DL Capsule Therapy Pack 2 x 10 MG Lenvima (24 MG Daily Dose) Oral Capsule Therapy Pack 2 x 10 MG & Tier 5 PA; SP; DL 4 MG Lenvima (4 MG Daily Dose) Oral Tier 5 PA; SP; DL Capsule Therapy Pack 4 MG Lenvima (8 MG Daily Dose) Oral Tier 5 PA; SP; DL Capsule Therapy Pack 2 x 4 MG Letrozole Oral Tablet 2.5 MG Tier 2 RM Leucovorin Calcium Oral Tablet 10 MG, Tier 2 RM 15 MG, 25 MG, 5 MG Leukeran Oral Tablet 2 MG Tier 3 RM Leuprolide Acetate Injection Kit 1 Tier 5 RO; DL MG/0.2ML Lonsurf Oral Tablet 15-6.14 MG, Tier 5 PA; RO; DL 20-8.19 MG Lynparza Oral Capsule 50 MG Tier 5 PA; RO; DL Lynparza Oral Tablet 100 MG, 150 Tier 5 PA; RO; DL MG Lysodren Oral Tablet 500 MG Tier 3 RM Matulane Oral Capsule 50 MG Tier 3 RM Megestrol Acetate Oral Suspension 40 Tier 2 RO; DL MG/ML Megestrol Acetate Oral Tablet 20 MG, Tier 2 RM 40 MG Mekinist Oral Tablet 0.5 MG, 2 MG Tier 5 PA; RO; DL Melphalan Oral Tablet 2 MG Tier 5 RO; DL Mercaptopurine Oral Tablet 50 MG Tier 1 RM Mesnex Oral Tablet 400 MG Tier 4 RM Methotrexate Oral Tablet 2.5 MG Tier 1 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 31 Drug Name Drug Tier Requirements/Limits Methotrexate Sodium (PF) Injection Tier 1 RM Solution 50 MG/2ML Methotrexate Sodium Injection Solution Tier 1 RM 250 MG/10ML Nerlynx Oral Tablet 40 MG Tier 5 PA; SP; CVS Caremark; DL NexAVAR Oral Tablet 200 MG Tier 5 PA; SP; CVS Caremark; DL Nilutamide Oral Tablet 150 MG Tier 5 RO; DL Ninlaro Oral Capsule 2.3 MG, 3 MG, Tier 5 PA; RO; DL 4 MG Odomzo Oral Capsule 200 MG Tier 5 PA; RO; DL Pomalyst Oral Capsule 1 MG, 2 MG, PA; SP; CVS Caremark; QL Tier 5 3 MG, 4 MG (21 EA per 28 days); DL Rozlytrek Oral Capsule 100 MG, Tier 5 PA; RO; DL 200 MG Rydapt Oral Capsule 25 MG Tier 5 PA; RO; DL Sprycel Oral Tablet 100 MG, 140 Tier 6 PA; RO; DL MG, 20 MG, 50 MG, 70 MG, 80 MG Stivarga Oral Tablet 40 MG Tier 5 PA; SP; CVS Caremark; DL Sutent Oral Capsule 12.5 MG, 25 Tier 5 PA; SP; CVS Caremark; DL MG, 37.5 MG, 50 MG Sylatron Subcutaneous Kit 200 Tier 5 PA; RO; DL MCG, 300 MCG, 600 MCG Tafinlar Oral Capsule 50 MG, 75 MG Tier 5 PA; RO; DL Tagrisso Oral Tablet 40 MG, 80 MG Tier 5 PA; RO; DL Tamoxifen Citrate Oral Tablet 10 MG, Tier 2 RM 20 MG Tasigna Oral Capsule 150 MG, 200 Tier 6 PA; RO; DL MG, 50 MG Temozolomide Oral Capsule 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 Tier 5 RO; DL MG Tretinoin Oral Capsule 10 MG Tier 5 PA; RO; DL Tykerb Oral Tablet 250 MG Tier 5 PA; RO; DL Venclexta Oral Tablet 10 MG, 100 Tier 5 PA; RO; DL MG, 50 MG Venclexta Starting Pack Oral Tablet Tier 5 PA; RO; DL Therapy Pack 10 & 50 & 100 MG Votrient Oral Tablet 200 MG Tier 5 PA; RO; DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 32 Drug Name Drug Tier Requirements/Limits Xalkori Oral Capsule 200 MG, 250 Tier 5 PA; SP; CVS Caremark; DL MG Xtandi Oral Capsule 40 MG Tier 6 PA; RO; DL Zejula Oral Capsule 100 MG Tier 5 PA; RO; DL Zelboraf Oral Tablet 240 MG Tier 5 PA; SP; CVS Caremark; DL Zolinza Oral Capsule 100 MG Tier 5 PA; RO; DL Zydelig Oral Tablet 100 MG, 150 MG Tier 5 PA; RO; DL Zykadia Oral Capsule 150 MG Tier 5 PA; RO; DL Antiparkinson Agents Amantadine HCl Oral Capsule 100 MG Tier 2 RM Benztropine Mesylate Oral Tablet 0.5 Tier 2 RM MG, 2 MG Bromocriptine Mesylate Oral Capsule 5 Tier 2 RM MG Carbidopa Oral Tablet 25 MG Tier 5 RO; DL Carbidopa-Levodopa Oral Tablet 25- Tier 2 RM 100 MG Entacapone Oral Tablet 200 MG Tier 2 RM Neupro Transdermal Patch 24 Hour 1 MG/24HR, 2 MG/24HR, 6 Tier 4 PA; RM MG/24HR, 8 MG/24HR Pramipexole Dihydrochloride Oral Tablet 0.125 MG, 0.5 MG, 0.75 MG, 1.5 Tier 2 RM MG Rasagiline Mesylate Oral Tablet 0.5 MG Tier 4 PA; RM Ropinirole HCl ER Oral Tablet Extended Release 24 Hour 12 MG, 2 MG, 6 MG, 8 Tier 2 RM MG Ropinirole HCl Oral Tablet 0.25 MG, 0.5 Tier 2 RM MG, 2 MG, 3 MG Selegiline HCl Oral Capsule 5 MG Tier 2 RM Selegiline HCl Oral Tablet 5 MG Tier 2 RM Trihexyphenidyl HCl Oral Elixir 0.4 Tier 2 RO; DL MG/ML Trihexyphenidyl HCl Oral Tablet 5 MG Tier 2 RM Antiparkinson And Related Therapy Agents Amantadine HCl Oral Syrup 50 MG/5ML Tier 2 RO; DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 33 Drug Name Drug Tier Requirements/Limits Benztropine Mesylate Injection Solution Tier 2 RO; DL 1 MG/ML Benztropine Mesylate Oral Tablet 1 MG Tier 2 RM Bromocriptine Mesylate Oral Tablet 2.5 Tier 2 RM MG Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG, 50-200 Tier 2 RM MG Carbidopa-Levodopa Oral Tablet 10- Tier 2 RM 100 MG, 25-250 MG Neupro Transdermal Patch 24 Hour Tier 4 PA; RM 3 MG/24HR, 4 MG/24HR Pramipexole Dihydrochloride Oral Tier 2 RM Tablet 0.25 MG, 1 MG Rasagiline Mesylate Oral Tablet 1 MG Tier 4 PA; RM Ropinirole HCl ER Oral Tablet Extended Tier 2 RM Release 24 Hour 4 MG Ropinirole HCl Oral Tablet 1 MG, 4 MG, Tier 2 RM 5 MG Tolcapone Oral Tablet 100 MG Tier 5 PA; RO; DL Trihexyphenidyl HCl Oral Tablet 2 MG Tier 2 RM Antipsychotics/Antimanic Agents Abilify Maintena Intramuscular Tier 5 PA; RO; DL Prefilled Syringe 300 MG, 400 MG Aripiprazole Oral Solution 1 MG/ML Tier 2 RO; FHCP; DL Aripiprazole Oral Tablet 10 MG, 15 MG, Tier 2 RM; FHCP 2 MG, 20 MG, 30 MG, 5 MG Chlorpromazine HCl Oral Tablet 10 MG, Tier 2 RM 100 MG, 200 MG, 25 MG, 50 MG Clozapine Oral Tablet 100 MG, 200 MG, Tier 2 RM 25 MG, 50 MG Clozapine Oral Tablet Dispersible 100 Tier 2 RM MG, 12.5 MG, 150 MG, 200 MG, 25 MG Fanapt Oral Tablet 1 MG, 10 MG, 12 PA; RO; QL (60 EA per 30 Tier 5 MG, 2 MG, 4 MG, 6 MG, 8 MG days); DL Fanapt Titration Pack Oral Tablet 1 Tier 5 PA; RO; DL & 2 & 4 & 6 MG Fluphenazine Decanoate Injection Tier 2 RM Solution 25 MG/ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 34 Drug Name Drug Tier Requirements/Limits Fluphenazine HCl Injection Solution 2.5 Tier 2 RM MG/ML Fluphenazine HCl Oral Concentrate 5 Tier 2 RO; DL MG/ML Fluphenazine HCl Oral Elixir 2.5 Tier 2 RO; DL MG/5ML Fluphenazine HCl Oral Tablet 1 MG, 10 Tier 2 RM MG, 2.5 MG, 5 MG Haloperidol Decanoate Intramuscular Tier 2 RM Solution 100 MG/ML, 50 MG/ML Haloperidol Lactate Oral Concentrate 2 Tier 2 RO; DL MG/ML Haloperidol Oral Tablet 0.5 MG, 1 MG, Tier 2 RM 10 MG, 2 MG, 20 MG, 5 MG Invega Sustenna Intramuscular Suspension Prefilled Syringe 117 MG/0.75ML, 156 MG/ML, 234 Tier 6 PA; RO; DL MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML Latuda Oral Tablet 120 MG, 20 MG, PA; RO; QL (30 EA per 30 Tier 5 40 MG, 60 MG days); DL PA; RO; QL (60 EA per 30 Latuda Oral Tablet 80 MG Tier 5 days); DL Lithium Carbonate ER Oral Tablet Tier 2 RM Extended Release 300 MG, 450 MG Lithium Carbonate Oral Capsule 150 Tier 1 RM MG, 300 MG Lithium Oral Solution 8 MEQ/5ML Tier 2 RO; DL Loxapine Succinate Oral Capsule 10 Tier 2 RM MG, 25 MG, 5 MG, 50 MG Olanzapine Intramuscular Solution Tier 2 RO; DL Reconstituted 10 MG Olanzapine Oral Tablet 10 MG, 15 MG, Tier 1 RM 2.5 MG, 20 MG, 5 MG, 7.5 MG Olanzapine Oral Tablet Dispersible 10 Tier 2 RM MG, 15 MG, 20 MG, 5 MG Paliperidone ER Oral Tablet Extended Release 24 Hour 1.5 MG, 3 MG, 6 MG, Tier 2 RM 9 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 35 Drug Name Drug Tier Requirements/Limits Perphenazine Oral Tablet 16 MG, 2 MG, Tier 2 RM 4 MG, 8 MG Prochlorperazine Maleate Oral Tablet 10 Tier 2 RM MG, 5 MG Prochlorperazine Rectal Suppository 25 Tier 2 RO; DL MG Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG, Tier 2 RM; FHCP 200 MG, 300 MG, 400 MG, 50 MG Quetiapine Fumarate Oral Tablet 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, Tier 1 RM 50 MG RisperDAL Consta Intramuscular Suspension Reconstituted 12.5 MG, Tier 5 PA; RO; DL 25 MG, 37.5 MG, 50 MG Risperidone Oral Solution 1 MG/ML Tier 2 RO; DL Risperidone Oral Tablet 0.25 MG, 0.5 Tier 1 RM MG, 1 MG, 2 MG, 3 MG, 4 MG Risperidone Oral Tablet Dispersible 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 Tier 2 RM MG Saphris Sublingual Tablet PA; RO; QL (60 EA per 30 Tier 5 Sublingual 10 MG, 2.5 MG, 5 MG days); DL Thioridazine HCl Oral Tablet 10 MG, Tier 2 RM 100 MG, 25 MG, 50 MG Thiothixene Oral Capsule 1 MG, 10 MG, Tier 2 RM 2 MG, 5 MG Trifluoperazine HCl Oral Tablet 1 MG, Tier 2 RM 10 MG, 2 MG, 5 MG Ziprasidone HCl Oral Capsule 20 MG, Tier 2 RM 40 MG, 60 MG, 80 MG Ziprasidone Mesylate Intramuscular Tier 3 PA; RO; DL Solution Reconstituted 20 MG Zyprexa Relprevv Intramuscular Suspension Reconstituted 210 MG, Tier 6 PA; RO; DL 300 MG, 405 MG Antivirals Abacavir Sulfate Oral Solution 20 Tier 2 RO; DL MG/ML Abacavir Sulfate Oral Tablet 300 MG Tier 2 RM; SH
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 36 Drug Name Drug Tier Requirements/Limits Abacavir Sulfate-lamiVUDine Oral Tier 2 RM Tablet 600-300 MG Abacavir-Lamivudine-Zidovudine Oral Tier 2 RM; SH Tablet 300-150-300 MG Acyclovir Oral Capsule 200 MG Tier 2 RM Acyclovir Oral Suspension 200 MG/5ML Tier 2 RO; DL Acyclovir Oral Tablet 400 MG, 800 MG Tier 2 RM Adefovir Dipivoxil Oral Tablet 10 MG Tier 5 RO; DL Aptivus Oral Capsule 250 MG Tier 3 RM; SH Aptivus Oral Solution 100 MG/ML Tier 3 RO; SH; DL Atazanavir Sulfate Oral Capsule 150 Tier 2 RM MG, 200 MG, 300 MG Biktarvy Oral Tablet 50-200-25 MG Tier 3 RM Cimduo Oral Tablet 300-300 MG Tier 3 RM Complera Oral Tablet 200-25-300 Tier 3 RM; SH MG Crixivan Oral Capsule 200 MG, 400 Tier 3 RM; SH MG Delstrigo Oral Tablet 100-300-300 Tier 3 RM MG Descovy Oral Tablet 200-25 MG Tier 3 RM; SH Didanosine Oral Capsule Delayed Tier 2 RM; SH Release 200 MG, 250 MG, 400 MG Dovato Oral Tablet 50-300 MG Tier 3 RM Edurant Oral Tablet 25 MG Tier 3 RM; SH Efavirenz Oral Capsule 200 MG, 50 MG Tier 2 RM Efavirenz Oral Tablet 600 MG Tier 2 RM Efavirenz-Emtricitab-Tenofovir Oral Tier 2 RM Tablet 600-200-300 MG Efavirenz-lamiVUDine-Tenofovir Oral Tablet 400-300-300 MG, 600-300-300 Tier 2 RM MG Emtricitabine Oral Capsule 200 MG Tier 2 RM Emtricitabine-Tenofovir DF Oral Tablet Tier 2 RM 200-300 MG Emtriva Oral Solution 10 MG/ML Tier 3 RO; SH; DL Entecavir Oral Tablet 0.5 MG, 1 MG Tier 2 RO; DL Epivir HBV Oral Solution 5 MG/ML Tier 3 RO; SH; DL You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 37 Drug Name Drug Tier Requirements/Limits Evotaz Oral Tablet 300-150 MG Tier 3 RM; SH Famciclovir Oral Tablet 125 MG, 250 Tier 2 RM MG, 500 MG Fosamprenavir Calcium Oral Tablet 700 Tier 2 RM MG Fuzeon Subcutaneous Solution Tier 5 RO; SH; DL Reconstituted 90 MG Genvoya Oral Tablet 150-150-200- Tier 3 RM; SH 10 MG Intelence Oral Tablet 100 MG, 200 Tier 3 RM; SH MG, 25 MG Invirase Oral Tablet 500 MG Tier 3 RM; SH Isentress HD Oral Tablet 600 MG Tier 3 RM Isentress Oral Packet 100 MG Tier 3 RM Isentress Oral Tablet 400 MG Tier 3 RM; SH Isentress Oral Tablet Chewable 100 Tier 3 RM; SH MG, 25 MG Juluca Oral Tablet 50-25 MG Tier 3 RM Kaletra Oral Tablet 100-25 MG, Tier 3 RM; SH 200-50 MG Lamivudine Oral Solution 10 MG/ML Tier 2 RO; DL Lamivudine Oral Tablet 100 MG, 150 Tier 2 RM; SH MG, 300 MG lamiVUDine-Zidovudine Oral Tablet Tier 2 RM; SH 150-300 MG Lexiva Oral Suspension 50 MG/ML Tier 3 RO; SH; DL Lopinavir-Ritonavir Oral Solution 400- Tier 2 RO; DL 100 MG/5ML Mavyret Oral Tablet 100-40 MG Tier 5 PA; RO; DL Nevirapine ER Oral Tablet Extended Tier 2 RM Release 24 Hour 100 MG, 400 MG Nevirapine Oral Suspension 50 MG/5ML Tier 2 RO; SH; DL Nevirapine Oral Tablet 200 MG Tier 2 RM; SH Norvir Oral Packet 100 MG Tier 3 RM Norvir Oral Solution 80 MG/ML Tier 3 RO; SH; DL Odefsey Oral Tablet 200-25-25 MG Tier 3 RM; SH Oseltamivir Phosphate Oral Capsule 30 Tier 3 RO; DL MG, 45 MG, 75 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 38 Drug Name Drug Tier Requirements/Limits Oseltamivir Phosphate Oral Suspension Tier 3 RO; DL Reconstituted 6 MG/ML Pegasys Subcutaneous Solution Tier 5 RO; DL 180 MCG/0.5ML, 180 MCG/ML PegIntron Subcutaneous Kit 50 Tier 5 RO; DL MCG/0.5ML Pifeltro Oral Tablet 100 MG Tier 3 RM Prezcobix Oral Tablet 800-150 MG Tier 3 RM; SH Prezista Oral Suspension 100 Tier 3 RO; SH; DL MG/ML Prezista Oral Tablet 150 MG, 600 Tier 3 RM; SH MG, 75 MG, 800 MG Relenza Diskhaler Inhalation Aerosol Powder Breath Activated 5 Tier 3 RO; DL MG/BLISTER Rescriptor Oral Tablet 100 MG, 200 Tier 3 RM MG Reyataz Oral Packet 50 MG Tier 3 RM Ribavirin Oral Capsule 200 MG Tier 2 RM riMANTAdine HCl Oral Tablet 100 MG Tier 2 RM Ritonavir Oral Tablet 100 MG Tier 2 RM Selzentry Oral Solution 20 MG/ML Tier 3 RO; DL Selzentry Oral Tablet 150 MG, 300 Tier 3 RM; SH MG Selzentry Oral Tablet 25 MG, 75 MG Tier 3 RM Stavudine Oral Capsule 15 MG, 20 MG, Tier 2 RM 30 MG, 40 MG Stribild Oral Tablet 150-150-200- Tier 3 RM; SH 300 MG Symtuza Oral Tablet 800-150-200- Tier 3 RM 10 MG Temixys Oral Tablet 300-300 MG Tier 3 RM Tenofovir Disoproxil Fumarate Oral Tier 2 RM Tablet 300 MG Tivicay Oral Tablet 10 MG, 25 MG Tier 3 RM Tivicay Oral Tablet 50 MG Tier 3 RM; SH Triumeq Oral Tablet 600-50-300 Tier 3 RM; SH MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 39 Drug Name Drug Tier Requirements/Limits Truvada Oral Tablet 100-150 MG, Tier 3 RM 133-200 MG, 167-250 MG Tybost Oral Tablet 150 MG Tier 3 RM; SH Tyzeka Oral Tablet 600 MG Tier 5 PA; RO; DL Valacyclovir HCl Oral Tablet 1 GM, 500 Tier 2 RM MG Valganciclovir HCl Oral Solution Tier 5 RO; DL Reconstituted 50 MG/ML Valganciclovir HCl Oral Tablet 450 MG Tier 2 RM Victrelis Oral Capsule 200 MG Tier 6 PA; RO; DL Videx EC Oral Capsule Delayed Tier 3 RM; SH Release 125 MG Videx Oral Solution Reconstituted 4 Tier 3 RO; SH; DL GM Viracept Oral Tablet 250 MG Tier 3 RM; SH Viracept Oral Tablet 625 MG Tier 3 RM Viread Oral Powder 40 MG/GM Tier 3 RO; SH; DL Viread Oral Tablet 150 MG, 200 MG, Tier 3 RM; SH 250 MG Zepatier Oral Tablet 50-100 MG Tier 6 PA; RO; DL Zerit Oral Solution Reconstituted 1 Tier 3 RO; DL MG/ML Zidovudine Oral Capsule 100 MG Tier 2 RM; SH Zidovudine Oral Syrup 50 MG/5ML Tier 2 RO; SH; DL Zidovudine Oral Tablet 300 MG Tier 2 RM; SH Assorted Classes Azathioprine Oral Tablet 50 MG Tier 1 RM Cyclosporine Modified Oral Capsule 50 Tier 2 RM MG Cyclosporine Modified Oral Solution 100 Tier 2 RO; DL MG/ML Cyclosporine Oral Capsule 25 MG Tier 2 RM Everolimus Oral Tablet 0.5 MG, 0.75 Tier 5 PA; RO; DL MG Lokelma Oral Packet 5 GM Tier 4 PA; RO; DL Mycophenolate Mofetil Oral Suspension Tier 2 RO; DL Reconstituted 200 MG/ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 40 Drug Name Drug Tier Requirements/Limits Mycophenolate Sodium Oral Tablet Tier 2 RM Delayed Release 180 MG Revlimid Oral Capsule 10 MG, 25 PA; SP; CVS Caremark; QL Tier 5 MG (31 EA per 31 days); DL Sodium Polystyrene Sulfonate Oral Tier 2 RO; DL Powder Tacrolimus Oral Capsule 5 MG Tier 2 RM Thalomid Oral Capsule 100 MG, 150 Tier 5 PA; SP; CVS Caremark; DL MG, 50 MG Beta Blockers Acebutolol HCl Oral Capsule 200 MG, Tier 2 RM 400 MG Atenolol Oral Tablet 100 MG, 25 MG, 50 Tier 1 RM; DDL MG Betaxolol HCl Oral Tablet 10 MG, 20 MG Tier 2 RM Bisoprolol Fumarate Oral Tablet 10 MG, Tier 2 RM 5 MG Bystolic Oral Tablet 10 MG, 2.5 MG, Tier 4 PA; RM 20 MG, 5 MG Carvedilol Oral Tablet 12.5 MG, 25 MG, Tier 1 RM; DDL 3.125 MG, 6.25 MG Labetalol HCl Oral Tablet 100 MG, 200 Tier 2 RM MG, 300 MG Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG, Tier 2 RM 200 MG, 25 MG, 50 MG Metoprolol Tartrate Oral Tablet 100 MG, Tier 1 RM; DDL 25 MG, 50 MG Nadolol Oral Tablet 20 MG, 40 MG, 80 Tier 2 RM MG Pindolol Oral Tablet 10 MG, 5 MG Tier 2 RM Propranolol HCl ER Oral Capsule Extended Release 24 Hour 120 MG, Tier 2 RM 160 MG, 60 MG, 80 MG Propranolol HCl Oral Solution 20 Tier 2 RO; DL MG/5ML, 40 MG/5ML Propranolol HCl Oral Tablet 10 MG, 20 Tier 2 RM MG, 40 MG, 60 MG, 80 MG Sotalol HCl Oral Tablet 120 MG, 160 Tier 2 RM MG, 240 MG, 80 MG You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 41 Drug Name Drug Tier Requirements/Limits Timolol Maleate Oral Tablet 10 MG, 20 Tier 2 RM MG, 5 MG Calcium Channel Blockers Amlodipine Besylate Oral Tablet 10 MG, Tier 1 RM; DDL 2.5 MG, 5 MG Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 120 Tier 2 RM MG, 180 MG, 240 MG, 300 MG Diltiazem HCl Oral Tablet 120 MG, 30 Tier 2 RM MG, 60 MG, 90 MG Felodipine ER Oral Tablet Extended Tier 2 RM Release 24 Hour 10 MG, 2.5 MG, 5 MG Isradipine Oral Capsule 2.5 MG, 5 MG Tier 2 RM Nicardipine HCl Oral Capsule 20 MG, 30 Tier 2 RM MG Nifedipine ER Oral Tablet Extended Tier 2 RM Release 24 Hour 30 MG, 60 MG, 90 MG Nifedipine Oral Capsule 10 MG, 20 MG Tier 2 RM Nimodipine Oral Capsule 30 MG Tier 4 RO; DL Nisoldipine ER Oral Tablet Extended Release 24 Hour 17 MG, 25.5 MG, 34 Tier 2 PA; RM MG, 8.5 MG Verapamil HCl ER Oral Tablet Extended Tier 2 RM Release 120 MG, 180 MG, 240 MG Verapamil HCl Oral Tablet 120 MG, 40 Tier 2 RM MG, 80 MG Cardiotonics Digoxin Oral Solution 0.05 MG/ML Tier 2 RO; DL Digoxin Oral Tablet 125 MCG, 250 MCG Tier 2 RM Cardiovascular Agents - Misc. Adempas Oral Tablet 0.5 MG, 1 MG, Tier 6 PA; SP; DL 1.5 MG, 2 MG, 2.5 MG Ambrisentan Oral Tablet 10 MG, 5 MG Tier 2 PA; SP; FHCP Specialty; DL Bosentan Oral Tablet 125 MG, 62.5 MG Tier 5 PA; SP; DL Opsumit Oral Tablet 10 MG Tier 6 PA; SP; CVS Caremark; DL Orenitram Oral Tablet Extended Release 0.125 MG, 0.25 MG, 1 MG, Tier 6 PA; SP; CVS Caremark; DL 2.5 MG, 5 MG Sildenafil Citrate Oral Tablet 20 MG Tier 2 PA; RM You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 42 Drug Name Drug Tier Requirements/Limits Tadalafil (PAH) Oral Tablet 20 MG Tier 2 PA; RO; FHCP; DL Tadalafil Oral Tablet 2.5 MG, 5 MG Tier 2 PA; RM Ventavis Inhalation Solution 10 Tier 6 PA; RO; DL MCG/ML, 20 MCG/ML Cephalosporins Cefaclor Oral Capsule 250 MG, 500 MG Tier 2 RO; DL Cefadroxil Oral Suspension Reconstituted 250 MG/5ML, 500 Tier 2 RO; DL MG/5ML Cefdinir Oral Capsule 300 MG Tier 2 RO; DL Cefdinir Oral Suspension Reconstituted Tier 2 RO; DL 125 MG/5ML, 250 MG/5ML Cefditoren Pivoxil Oral Tablet 200 MG, Tier 2 RO; DL 400 MG Cefixime Oral Capsule 400 MG Tier 4 RO; DL Cefixime Oral Suspension Reconstituted Tier 2 RO; DL 100 MG/5ML, 200 MG/5ML Cefpodoxime Proxetil Oral Suspension Tier 2 RO; DL Reconstituted 100 MG/5ML, 50 MG/5ML Cefpodoxime Proxetil Oral Tablet 100 Tier 2 RO; DL MG, 200 MG Cefprozil Oral Suspension Reconstituted Tier 2 RO; DL 125 MG/5ML, 250 MG/5ML Cefprozil Oral Tablet 250 MG, 500 MG Tier 2 RO; DL Ceftriaxone Sodium Injection Solution Reconstituted 1 GM, 2 GM, 250 MG, Tier 2 RO; DL 500 MG Cefuroxime Axetil Oral Tablet 250 MG, Tier 2 RO; DL 500 MG Cephalexin Oral Capsule 250 MG, 500 Tier 2 RO; DL MG Cephalexin Oral Suspension Reconstituted 125 MG/5ML, 250 Tier 2 RO; DL MG/5ML Contraceptives Apri Oral Tablet 0.15-30 MG-MCG Tier 7 RM Camila Oral Tablet 0.35 MG Tier 7 RM Cryselle-28 Oral Tablet 0.3-30 MG- Tier 7 RM MCG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 43 Drug Name Drug Tier Requirements/Limits Ella Oral Tablet 30 MG Tier 7 RO; (Prescription Required) Enpresse-28 Oral Tablet 50-30/75- Tier 7 RM 40/ 125-30 MCG Ethynodiol Diac-Eth Estradiol Oral Tier 7 RM Tablet 1-50 MG-MCG Etonogestrel-Ethinyl Estradiol Vaginal Tier 7 RM Ring 0.12-0.015 MG/24HR Junel FE 1.5/30 Oral Tablet 1.5-30 Tier 7 RM MG-MCG Junel FE 1/20 Oral Tablet 1-20 MG- Tier 7 RM MCG Kelnor 1/35 Oral Tablet 1-35 MG- Tier 7 RM MCG Kyleena Intrauterine Intrauterine Tier 7 SP; CVS Caremark Device 19.5 MG Levonorgest-Eth Estrad 91-Day Oral Tablet 0.1-0.02 & 0.01 MG, 0.15-0.03 Tier 7 RM &0.01 MG Levonorgestrel Oral Tablet 1.5 MG Tier 7 RO; (Prescription Required) Levonorgestrel-Ethinyl Estrad Oral Tier 7 RM Tablet 0.15-30 MG-MCG Medroxyprogesterone Acetate Tier 7 RO Intramuscular Suspension 150 MG/ML Mirena (52 MG) Intrauterine Tier 7 SP; CVS Caremark Intrauterine Device 20 MCG/24HR Necon 1/50 (28) Oral Tablet 1-50 Tier 7 RM MG-MCG Necon 10/11 (28) Oral Tablet 35 Tier 7 RM MCG Nexplanon Subcutaneous Implant Tier 7 SP; CVS Caremark 68 MG Nikki Oral Tablet 3-0.02 MG Tier 7 RM Nortrel 0.5/35 (28) Oral Tablet Tier 7 RM 0.5-35 MG-MCG Nortrel 1/35 (28) Oral Tablet 1-35 Tier 7 RM MG-MCG Ogestrel Oral Tablet 0.5-50 MG- Tier 7 RM MCG Orsythia Oral Tablet 0.1-20 MG- Tier 7 RM MCG You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 44 Drug Name Drug Tier Requirements/Limits Paragard Intrauterine Copper Tier 7 SP; Biologics Intrauterine Intrauterine Device Skyla Intrauterine Intrauterine Tier 7 SP; CVS Caremark Device 13.5 MG Sprintec 28 Oral Tablet 0.25-35 Tier 7 RM MG-MCG Tri-Lo-Sprintec Oral Tablet Tier 7 RM 0.18/0.215/0.25 MG-25 MCG Tri-Sprintec Oral Tablet Tier 7 RM 0.18/0.215/0.25 MG-35 MCG Xulane Transdermal Patch Weekly Tier 7 RM 150-35 MCG/24HR Zovia 1/35E (28) Oral Tablet 1-35 Tier 7 RM MG-MCG Corticosteroids Budesonide Oral Capsule Delayed Tier 2 PA; RM Release Particles 3 MG Cortisone Acetate Oral Tablet 25 MG Tier 2 RM Dexamethasone Intensol Oral Tier 2 RO; DL Concentrate 1 MG/ML Dexamethasone Oral Elixir 0.5 MG/5ML Tier 2 RO; DL Dexamethasone Oral Solution 0.5 Tier 2 RO; DL MG/5ML Dexamethasone Oral Tablet 0.5 MG, 0.75 MG, 1 MG, 1.5 MG, 2 MG, 4 MG, 6 Tier 2 RM MG Dexamethasone Sodium Phosphate Tier 2 RO; DL Injection Solution 10 MG/ML, 4 MG/ML Fludrocortisone Acetate Oral Tablet 0.1 Tier 2 RM MG Hydrocortisone Oral Tablet 10 MG, 20 Tier 2 RM MG, 5 MG Kenalog Injection Suspension 10 Tier 4 RO; DL MG/ML Methylprednisolone Acetate Injection Tier 2 RO; DL Suspension 40 MG/ML, 80 MG/ML Methylprednisolone Oral Tablet 16 MG, Tier 2 RM 32 MG, 4 MG, 8 MG Methylprednisolone Oral Tablet Therapy Tier 2 RO; DL Pack 4 MG You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 45 Drug Name Drug Tier Requirements/Limits Prednisolone Oral Solution 15 MG/5ML Tier 2 RO; DL Prednisolone Sodium Phosphate Oral Solution 15 MG/5ML, 6.7 (5 Base) Tier 2 RO; DL MG/5ML Prednisone Oral Solution 5 MG/5ML Tier 2 RO; DL Prednisone Oral Tablet 1 MG, 10 MG, Tier 1 RM 2.5 MG, 20 MG, 5 MG, 50 MG Triamcinolone Acetonide Injection Tier 2 RO; DL Suspension 40 MG/ML Cough/Cold/Allergy Acetylcysteine Inhalation Solution 10 Tier 2 RO %, 20 % Benzonatate Oral Capsule 100 MG, 200 Tier 2 RO; DL MG Guaifenesin DAC Oral Solution 30-10- RO; QL (120 ML per 3 Tier 2 100 MG/5ML days) Guaifenesin-Codeine Oral Solution 100- RO; QL (120 ML per 3 Tier 2 10 MG/5ML days) Hydrocodone-Homatropine Oral Syrup RO; QL (120 ML per 3 Tier 2 5-1.5 MG/5ML days) Promethazine VC Oral Syrup 6.25-5 RO; QL (120 ML per 3 Tier 2 MG/5ML days) Promethazine VC/Codeine Oral Syrup RO; QL (120 ML per 3 Tier 2 6.25-5-10 MG/5ML days) Promethazine-Codeine Oral Syrup RO; QL (120 ML per 3 Tier 2 6.25-10 MG/5ML days) Promethazine-DM Oral Syrup 6.25-15 RO; QL (120 ML per 3 Tier 2 MG/5ML days) Pseudoeph-Bromphen-DM Oral Syrup RO; QL (120 ML per 3 Tier 2 30-2-10 MG/5ML days); AL (Min 2 Years) Dermatologicals Acitretin Oral Capsule 10 MG, 17.5 MG, Tier 2 RO; FHCP; DL 25 MG RO; QL (30 GM per 30 Acyclovir External Ointment 5 % Tier 2 days); DL RO; QL (45 GM per 30 Adapalene External Gel 0.1 %, 0.3 % Tier 2 days); DL Adapalene-Benzoyl Peroxide External RO; QL (45 GM per 30 Tier 2 Gel 0.1-2.5 % days); DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 46 Drug Name Drug Tier Requirements/Limits Alclometasone Dipropionate External RO; QL (120 GM per 30 Tier 2 Cream 0.05 % days); DL Alclometasone Dipropionate External RO; QL (120 GM per 30 Tier 2 Ointment 0.05 % days); DL RO; QL (15 GM per 30 Altabax External Ointment 1 % Tier 4 days); DL RO; QL (120 GM per 30 Amcinonide External Cream 0.1 % Tier 2 days); DL RO; QL (60 ML per 30 Amcinonide External Lotion 0.1 % Tier 2 days); DL RO; QL (120 GM per 30 Amcinonide External Ointment 0.1 % Tier 2 days); DL Ammonium Lactate External Cream 12 RO; QL (140 GM per 30 Tier 2 % days); DL Benzoyl Peroxide-Erythromycin RO; QL (23.3 GM per 30 Tier 2 External Gel 5-3 % days); DL Betamethasone Dipropionate External RO; QL (120 GM per 30 Tier 2 Cream 0.05 % days); DL Betamethasone Dipropionate External RO; QL (60 ML per 30 Tier 2 Lotion 0.05 % days); DL Betamethasone Dipropionate External RO; QL (120 GM per 30 Tier 2 Ointment 0.05 % days); DL Betamethasone Valerate External RO; QL (120 GM per 30 Tier 2 Cream 0.1 % days); DL Betamethasone Valerate External RO; QL (60 ML per 30 Tier 2 Lotion 0.1 % days); DL Betamethasone Valerate External RO; QL (120 GM per 30 Tier 2 Ointment 0.1 % days); DL RO; QL (120 GM per 30 Butenafine HCl External Cream 1 % Tier 4 days); DL RO; QL (60 GM per 30 Calcipotriene External Cream 0.005 % Tier 2 days); DL Calcipotriene External Ointment 0.005 RO; QL (60 GM per 30 Tier 2 % days); DL RO; QL (60 ML per 30 Calcipotriene External Solution 0.005 % Tier 2 days); DL RO; QL (120 GM per 30 Ciclopirox External Gel 0.77 % Tier 2 days); DL RO; QL (6.6 ML per 30 Ciclopirox External Solution 8 % Tier 2 days); DL You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 47 Drug Name Drug Tier Requirements/Limits Ciclopirox Olamine External Cream 0.77 RO; QL (120 GM per 30 Tier 2 % days); DL Ciclopirox Olamine External Suspension RO; QL (60 ML per 30 Tier 2 0.77 % days); DL Clindamycin Phos-Benzoyl Perox RM; QL (25 GM per 30 Tier 2 External Gel 1-5 % days) Clindamycin Phosphate External Gel 1 Tier 1 RO; DL % Clindamycin Phosphate External Swab Tier 2 RO; DL 1 % Clobetasol Propionate E External Cream RO; QL (120 GM per 30 Tier 2 0.05 % days); DL Clobetasol Propionate External Cream RO; QL (120 GM per 30 Tier 2 0.05 % days); DL Clobetasol Propionate External Gel 0.05 RO; QL (120 GM per 30 Tier 2 % days); DL Clobetasol Propionate External Lotion RO; QL (60 ML per 30 Tier 2 0.05 % days); DL Clobetasol Propionate External RO; QL (120 GM per 30 Tier 2 Ointment 0.05 % days); DL Clobetasol Propionate External Solution RO; QL (60 ML per 30 Tier 2 0.05 % days); DL Clotrimazole-Betamethasone External RO; QL (120 GM per 30 Tier 2 Cream 1-0.05 % days); DL Clotrimazole-Betamethasone External RO; QL (60 ML per 30 Tier 2 Lotion 1-0.05 % days); DL Cortisporin External Cream 3.5- Tier 3 RO; DL 10000-0.5 Cortisporin External Ointment 1 % Tier 3 RO; DL PA; RO; QL (5 GM per 30 Denavir External Cream 1 % Tier 6 days); DL RO; QL (120 GM per 30 Desonide External Cream 0.05 % Tier 2 days); DL RO; QL (60 ML per 30 Desonide External Lotion 0.05 % Tier 2 days); DL RO; QL (120 GM per 30 Desonide External Ointment 0.05 % Tier 2 days); DL Desoximetasone External Cream 0.05 RO; QL (120 GM per 30 Tier 2 %, 0.25 % days); DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 48 Drug Name Drug Tier Requirements/Limits RO; QL (120 GM per 30 Desoximetasone External Gel 0.05 % Tier 2 days); DL Desoximetasone External Ointment RO; QL (120 GM per 30 Tier 2 0.05 %, 0.25 % days); DL Diclofenac Sodium Transdermal Gel 1 Tier 2 RO; FHCP; DL % Diclofenac Sodium Transdermal Gel 3 PA; RO; QL (100 GM per 30 Tier 2 % days); DL PA; RO; QL (45 GM per 30 Doxepin HCl External Cream 5 % Tier 5 days); DL RO; QL (120 GM per 30 Econazole Nitrate External Cream 1 % Tier 2 days); DL PA; RO; QL (120 GM per 30 Ertaczo External Cream 2 % Tier 5 days); DL Erythromycin External Solution 2 % Tier 2 RO; DL ST; RO; QL (60 GM per 30 Eucrisa External Ointment 2 % Tier 3 days); DL RO; QL (60 GM per 30 Eurax External Cream 10 % Tier 4 days); DL RO; QL (60 GM per 30 Eurax External Lotion 10 % Tier 4 days); DL PA; RO; QL (120 GM per 30 Exelderm External Cream 1 % Tier 4 days); DL PA; RO; QL (60 ML per 30 Exelderm External Solution 1 % Tier 4 days); DL PA; RO; QL (50 GM per 30 Finacea External Foam 15 % Tier 4 days); DL Finasteride Oral Tablet 1 MG Tier 2 RM Fluocinolone Acetonide External Cream RO; QL (120 GM per 30 Tier 2 0.01 %, 0.025 % days); DL Fluocinolone Acetonide External RO; QL (120 GM per 30 Tier 2 Ointment 0.025 % days); DL Fluocinolone Acetonide External RO; QL (60 ML per 30 Tier 2 Solution 0.01 % days); DL Fluocinonide Emulsified Base External RO; QL (120 GM per 30 Tier 2 Cream 0.05 % days); DL RO; QL (120 GM per 30 Fluocinonide External Cream 0.05 % Tier 2 days); DL RO; QL (120 GM per 30 Fluocinonide External Gel 0.05 % Tier 2 days); DL You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 49 Drug Name Drug Tier Requirements/Limits RO; QL (120 GM per 30 Fluocinonide External Ointment 0.05 % Tier 2 days); DL RO; QL (60 ML per 30 Fluocinonide External Solution 0.05 % Tier 2 days); DL RO; QL (40 GM per 15 Fluorouracil External Cream 5 % Tier 2 days); DL RO; QL (60 ML per 30 Fluorouracil External Solution 2 % Tier 2 days); DL RO; QL (40 ML per 30 Fluorouracil External Solution 5 % Tier 2 days); DL Fluticasone Propionate External Cream RO; QL (120 GM per 30 Tier 2 0.05 % days); DL Fluticasone Propionate External Lotion RO; QL (60 ML per 30 Tier 2 0.05 % days); DL Fluticasone Propionate External RO; QL (120 GM per 30 Tier 2 Ointment 0.005 % days); DL Gentamicin Sulfate External Cream 0.1 Tier 2 RO; DL % Gentamicin Sulfate External Ointment Tier 2 RO; DL 0.1 % Halobetasol Propionate External Cream RO; QL (120 GM per 30 Tier 2 0.05 % days); DL Halobetasol Propionate External RO; QL (120 GM per 30 Tier 2 Ointment 0.05 % days); DL Hydrocortisone External Cream 2.5 % Tier 1 RO; DL Hydrocortisone External Lotion 2.5 % Tier 1 RO; DL Hydrocortisone External Ointment 2.5 Tier 1 RO; DL % Imiquimod External Cream 5 % Tier 2 RO; DL Isotretinoin Oral Capsule 10 MG, 20 RO; FHCP; QL (5 Fills per Tier 2 MG, 30 MG, 40 MG 12 Months); DL RO; QL (45 GM per 30 Ivermectin External Cream 1 % Tier 4 days); DL Ketoconazole External Cream 2 % Tier 1 RO; DL RO; QL (120 GM per 30 Lidocaine External Ointment 5 % Tier 2 days); DL Lidocaine External Patch 5 % Tier 2 PA; RO; DL Lidocaine-Prilocaine External Cream RO; QL (30 GM per 30 Tier 2 2.5-2.5 % days); DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 50 Drug Name Drug Tier Requirements/Limits RO; QL (60 ML per 7 days); Lindane External Shampoo 1 % Tier 2 DL RO; QL (60 ML per 7 days); Malathion External Lotion 0.5 % Tier 2 DL Methoxsalen Rapid Oral Capsule 10 MG Tier 5 RO; DL RO; QL (45 GM per 30 Metronidazole External Cream 0.75 % Tier 2 days); DL Metronidazole External Gel 0.75 %, 1 RO; QL (60 GM per 30 Tier 2 % days); DL RO; QL (60 ML per 30 Metronidazole External Lotion 0.75 % Tier 2 days); DL Mometasone Furoate External Cream RO; QL (120 GM per 30 Tier 2 0.1 % days); DL Mometasone Furoate External Ointment RO; QL (120 GM per 30 Tier 2 0.1 % days); DL Mometasone Furoate External Solution RO; QL (60 ML per 30 Tier 2 0.1 % days); DL RO; QL (44 GM per 30 Mupirocin External Ointment 2 % Tier 2 days); DL RO; QL (120 GM per 30 Naftifine HCl External Cream 1 %, 2 % Tier 2 days); DL RO; QL (120 GM per 30 Naftifine HCl External Gel 1 % Tier 2 days); DL Nystatin External Cream 100000 Tier 1 RO; DL UNIT/GM Nystatin External Ointment 100000 Tier 1 RO; DL UNIT/GM Nystatin-Triamcinolone External Cream Tier 1 RO; DL 100000-0.1 UNIT/GM-% Nystatin-Triamcinolone External Tier 1 RO; DL Ointment 100000-0.1 UNIT/GM-% Oxiconazole Nitrate External Cream 1 RO; QL (120 GM per 30 Tier 2 % days); DL RO; QL (30 ML per 30 Oxistat External Lotion 1 % Tier 4 days); DL PA; SP; QL (60 GM per 30 Panretin External Gel 0.1 % Tier 5 days); DL RO; QL (60 GM per 7 Permethrin External Cream 5 % Tier 2 days); DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 51 Drug Name Drug Tier Requirements/Limits RO; QL (30 GM per 30 Pimecrolimus External Cream 1 % Tier 4 days); DL Podofilox External Solution 0.5 % Tier 2 RO; DL RO; QL (120 GM per 30 Prednicarbate External Cream 0.1 % Tier 2 days); DL RO; QL (120 GM per 30 Prednicarbate External Ointment 0.1 % Tier 2 days); DL RO; QL (15 GM per 30 Regranex External Gel 0.01 % Tier 5 days); DL Santyl External Ointment 250 RO; QL (60 GM per 30 Tier 4 UNIT/GM days); DL RO; QL (120 ML per 30 Selenium Sulfide External Lotion 2.5 % Tier 2 days); DL Silver Sulfadiazine External Cream 1 % Tier 2 RO; DL RO; QL (120 ML per 30 Spinosad External Suspension 0.9 % Tier 2 days); DL Sulfamylon External Cream 85 RO; QL (113.4 GM per 30 Tier 4 MG/GM days); DL Synera External Patch 70-70 MG Tier 4 PA; RM Tacrolimus External Ointment 0.03 %, RO; QL (30 GM per 30 Tier 2 0.1 % days); DL PA; RO; QL (30 GM per 30 Tazarotene External Cream 0.1 % Tier 2 days); DL PA; RO; QL (30 GM per 30 Tazorac External Cream 0.05 % Tier 4 days); DL PA; RO; QL (30 GM per 30 Tazorac External Gel 0.05 %, 0.1 % Tier 4 days); DL PA; RO; QL (20 GM per 30 Tretinoin External Cream 0.025 %, Tier 2 days); AL (Max 30 Years); 0.05 %, 0.1 % DL PA; RO; QL (15 GM per 30 Tretinoin External Gel 0.01 %, 0.025 % Tier 2 days); AL (Max 30 Years); DL Triamcinolone Acetonide External Tier 1 RO; DL Cream 0.025 %, 0.1 %, 0.5 % Triamcinolone Acetonide External Tier 1 RO; DL Lotion 0.025 %, 0.1 % Triamcinolone Acetonide External Tier 1 RO; DL Ointment 0.025 %, 0.1 %, 0.5 %
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 52 Drug Name Drug Tier Requirements/Limits RO; QL (85 GM per 30 Urea External Cream 40 % Tier 2 days); DL Digestive Aids Creon Oral Capsule Delayed Release Particles 12000 UNIT, Tier 3 RM 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT Pancreaze Oral Capsule Delayed Release Particles 10500 UNIT, Tier 3 RM 16800 UNIT, 21000 UNIT, 2600 UNIT, 4200 UNIT Zenpep Oral Capsule Delayed Release Particles 10000-32000 UNIT, 15000-47000 UNIT, 20000- Tier 4 RM 63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT Diuretics Acetazolamide ER Oral Capsule Tier 2 RM Extended Release 12 Hour 500 MG Acetazolamide Oral Tablet 125 MG, 250 Tier 2 RM MG Amiloride HCl Oral Tablet 5 MG Tier 2 RM Bumetanide Oral Tablet 0.5 MG, 1 MG, Tier 2 RM 2 MG Chlorothiazide Oral Tablet 250 MG, 500 Tier 2 RM MG Chlorthalidone Oral Tablet 25 MG, 50 Tier 2 RM MG Diuril Oral Suspension 250 MG/5ML Tier 4 RO; DL Ethacrynic Acid Oral Tablet 25 MG Tier 5 RO; DL Furosemide Oral Solution 10 MG/ML Tier 2 RO; DL Furosemide Oral Tablet 20 MG, 40 MG, Tier 1 RM 80 MG Hydrochlorothiazide Oral Capsule 12.5 Tier 1 RM MG Hydrochlorothiazide Oral Tablet 12.5 Tier 1 RM; DDL MG, 25 MG, 50 MG Indapamide Oral Tablet 1.25 MG, 2.5 Tier 2 RM MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 53 Drug Name Drug Tier Requirements/Limits methazolAMIDE Oral Tablet 25 MG, 50 Tier 2 RM MG Methyclothiazide Oral Tablet 5 MG Tier 2 RM Metolazone Oral Tablet 10 MG, 2.5 MG, Tier 2 RM 5 MG Spironolactone Oral Tablet 100 MG, 25 Tier 2 RM MG, 50 MG Spironolactone-HCTZ Oral Tablet 25-25 Tier 2 RM MG Torsemide Oral Tablet 10 MG, 100 MG, Tier 1 RM 20 MG, 5 MG Triamterene Oral Capsule 100 MG, 50 Tier 4 RM MG Triamterene-HCTZ Oral Capsule 37.5- Tier 2 RM 25 MG Triamterene-HCTZ Oral Tablet 37.5-25 Tier 1 RM MG, 75-50 MG Endocrine And Metabolic Agents - Misc. Alendronate Sodium Oral Tablet 10 MG, Tier 2 RM 5 MG Alendronate Sodium Oral Tablet 35 MG, Tier 1 RM 70 MG Cabergoline Oral Tablet 0.5 MG Tier 2 RM Calcitonin (Salmon) Nasal Solution 200 Tier 2 RM UNIT/ACT Calcitriol Oral Capsule 0.25 MCG, 0.5 Tier 2 RM MCG Calcitriol Oral Solution 1 MCG/ML Tier 2 RO; DL Carbaglu Oral Tablet 200 MG Tier 5 PA; RO; DL Cinacalcet HCl Oral Tablet 30 MG, 60 Tier 2 PA; RM MG, 90 MG Desmopressin Acetate Oral Tablet 0.1 Tier 2 RM MG, 0.2 MG Desmopressin Acetate Spray Nasal Tier 2 RM Solution 0.01 % Doxercalciferol Oral Capsule 0.5 MCG, Tier 5 RO; DL 1 MCG, 2.5 MCG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 54 Drug Name Drug Tier Requirements/Limits Etidronate Disodium Oral Tablet 200 Tier 2 RM MG, 400 MG Ibandronate Sodium Intravenous Tier 4 PA; RO; DL Solution 3 MG/3ML Ibandronate Sodium Oral Tablet 150 Tier 2 RM; QL (1 EA per 28 days) MG Increlex Subcutaneous Solution 40 Tier 5 PA; RO; DL MG/4ML Nitisinone Oral Capsule 10 MG, 2 MG, 5 Tier 5 PA; SP; DL MG Octreotide Acetate Injection Solution 100 MCG/ML, 1000 MCG/ML, 200 Tier 5 RO; DL MCG/ML, 50 MCG/ML, 500 MCG/ML Omnitrope Subcutaneous Solution Tier 5 PA; RO; DL 10 MG/1.5ML, 5 MG/1.5ML Omnitrope Subcutaneous Solution Tier 5 PA; RO; DL Reconstituted 5.8 MG Orilissa Oral Tablet 150 MG, 200 Tier 3 PA; RM MG Paricalcitol Oral Capsule 1 MCG, 2 MCG, Tier 2 RM 4 MCG Prolia Subcutaneous Solution Tier 6 PA; RO Prefilled Syringe 60 MG/ML Raloxifene HCl Oral Tablet 60 MG Tier 2 RM Risedronate Sodium Oral Tablet 35 MG Tier 2 ST; RM Samsca Oral Tablet 15 MG Tier 6 PA; RO; DL Sapropterin Dihydrochloride Oral Tier 5 PA; RO; DL Packet 100 MG, 500 MG Sapropterin Dihydrochloride Oral Tablet Tier 5 PA; RO; DL Soluble 100 MG Somatuline Depot Subcutaneous Solution 120 MG/0.5ML, 60 Tier 6 PA; RO; DL MG/0.2ML, 90 MG/0.3ML Stimate Nasal Solution 1.5 MG/ML Tier 5 RO; DL Synarel Nasal Solution 2 MG/ML Tier 6 PA; RO; DL Tolvaptan Oral Tablet 30 MG Tier 6 PA; RO; DL Tymlos Subcutaneous Solution Tier 5 PA; RO; DL Pen-Injector 3120 MCG/1.56ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 55 Drug Name Drug Tier Requirements/Limits Zoledronic Acid Intravenous Solution 5 Tier 2 RO MG/100ML Estrogens Delestrogen Intramuscular Oil 10 Tier 4 RO MG/ML Depo-Estradiol Intramuscular Oil 5 Tier 4 RO MG/ML Duavee Oral Tablet 0.45-20 MG Tier 3 RM Enjuvia Oral Tablet 0.3 MG Tier 4 RM Est Estrogens-Methyltest HS Oral Tier 2 RM Tablet 0.625-1.25 MG Est Estrogens-Methyltest Oral Tablet Tier 2 RM 1.25-2.5 MG Estradiol Oral Tablet 0.5 MG, 1 MG, 2 Tier 1 RM MG Estradiol Transdermal Patch Twice Weekly 0.025 MG/24HR, 0.0375 Tier 2 RM; QL (8 EA per 28 days) MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR Estradiol Transdermal Patch Weekly 0.025 MG/24HR, 0.0375 MG/24HR, Tier 2 RM; QL (4 EA per 28 days) 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR Estradiol Valerate Intramuscular Oil 20 Tier 2 RO MG/ML, 40 MG/ML Estropipate Oral Tablet 0.75 MG, 1.5 Tier 2 RM MG, 3 MG Menest Oral Tablet 0.3 MG, 0.625 Tier 4 PA; RM MG, 1.25 MG Oriahnn Oral Capsule Therapy Pack Tier 3 PA; RM 300-1-0.5 & 300 MG Premarin Oral Tablet 0.3 MG, 0.45 Tier 3 RM MG, 0.625 MG, 0.9 MG, 1.25 MG Premphase Oral Tablet 0.625-5 MG Tier 3 RM Prempro Oral Tablet 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625- Tier 3 RM 5 MG Fluoroquinolones Baxdela Intravenous Solution Tier 6 RO; DL Reconstituted 300 MG You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 56 Drug Name Drug Tier Requirements/Limits Ciprofloxacin HCl Oral Tablet 250 MG, Tier 2 RO; DL 500 MG, 750 MG Factive Oral Tablet 320 MG Tier 4 RO; DL Levofloxacin Oral Solution 25 MG/ML Tier 2 RO; DL Levofloxacin Oral Tablet 250 MG, 500 Tier 2 RO; DL MG, 750 MG Gastrointestinal Agents - Misc. Alosetron HCl Oral Tablet 0.5 MG, 1 MG Tier 5 PA; RO; DL Amitiza Oral Capsule 24 MCG, 8 Tier 4 PA; RM MCG Balsalazide Disodium Oral Capsule 750 Tier 1 RM MG Calcium Acetate (Phos Binder) Oral Tier 2 RM Capsule 667 MG Cromolyn Sodium Oral Concentrate 100 Tier 2 RO MG/5ML Dipentum Oral Capsule 250 MG Tier 4 RM Lactulose Encephalopathy Oral Solution Tier 2 RM 10 GM/15ML Lanthanum Carbonate Oral Tablet Tier 5 PA; RO; DL Chewable 1000 MG, 500 MG, 750 MG Linzess Oral Capsule 145 MCG, 290 PA; RM; QL (31 EA per 31 Tier 3 MCG, 72 MCG days) Mesalamine Oral Tablet Delayed Tier 2 RM; FHCP Release 1.2 GM Mesalamine Oral Tablet Delayed Tier 2 RM Release 800 MG RO; QL (1680 ML per 28 Mesalamine Rectal Enema 4 GM Tier 2 days); DL Mesalamine Rectal Suppository 1000 RO; QL (30 EA per 30 Tier 3 MG days); DL Metoclopramide HCl Oral Solution 5 Tier 2 RO; DL MG/5ML Metoclopramide HCl Oral Tablet 10 MG, Tier 1 RM 5 MG Movantik Oral Tablet 12.5 MG, 25 PA; RM; QL (31 EA per 31 Tier 3 MG days) Relistor Subcutaneous Kit 12 Tier 5 PA; RO; DL MG/0.6ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 57 Drug Name Drug Tier Requirements/Limits Relistor Subcutaneous Solution 12 Tier 5 PA; RO; DL MG/0.6ML, 8 MG/0.4ML Sevelamer Carbonate Oral Packet 0.8 Tier 5 RO; DL GM, 2.4 GM Sevelamer Carbonate Oral Tablet 800 Tier 2 RM; FHCP MG Sulfasalazine Oral Tablet 500 MG Tier 1 RM Sulfasalazine Oral Tablet Delayed Tier 1 RM Release 500 MG Ursodiol Oral Capsule 300 MG Tier 2 RM Velphoro Oral Tablet Chewable 500 Tier 5 PA; RO; DL MG Genitourinary Agents - Miscellaneous Alfuzosin HCl ER Oral Tablet Extended Tier 2 RM Release 24 Hour 10 MG Cystagon Oral Capsule 150 MG, 50 Tier 5 SP; DL MG Cytra K Crystals Oral Packet 3300-1002 Tier 2 RM MG Dutasteride Oral Capsule 0.5 MG Tier 2 RM Elmiron Oral Capsule 100 MG Tier 4 RM Finasteride Oral Tablet 5 MG Tier 2 RM Potassium Citrate ER Oral Tablet Extended Release 10 MEQ (1080 MG), Tier 2 RM 15 MEQ (1620 MG), 5 MEQ (540 MG) Potassium Citrate-Citric Acid Oral Tier 2 RM Solution 1100-334 MG/5ML Silodosin Oral Capsule 4 MG, 8 MG Tier 4 PA; RM Tamsulosin HCl Oral Capsule 0.4 MG Tier 1 RM; DDL Gout Agents Allopurinol Oral Tablet 100 MG, 300 MG Tier 1 RM RM; QL (120 EA per 30 Colchicine Oral Tablet 0.6 MG Tier 2 days) Colchicine-Probenecid Oral Tablet 0.5- Tier 1 RM 500 MG Febuxostat Oral Tablet 40 MG, 80 MG Tier 2 RM Probenecid Oral Tablet 500 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 58 Drug Name Drug Tier Requirements/Limits Hematological Agents - Misc. Anagrelide HCl Oral Capsule 0.5 MG, 1 Tier 2 RM MG Aspirin-Dipyridamole ER Oral Capsule Tier 2 RM Extended Release 12 Hour 25-200 MG BeneFIX Intravenous Kit 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 Tier 5 PA; RO UNIT, 500 UNIT Berinert Intravenous Kit 500 UNIT Tier 5 PA; SP; DL Brilinta Oral Tablet 60 MG, 90 MG Tier 4 RM Cilostazol Oral Tablet 100 MG, 50 MG Tier 2 RM Clopidogrel Bisulfate Oral Tablet 75 MG Tier 1 RM; DDL Dipyridamole Oral Tablet 25 MG, 50 Tier 2 RM MG, 75 MG Icatibant Acetate Subcutaneous Tier 6 PA; RO; DL Solution 30 MG/3ML Pentoxifylline ER Oral Tablet Extended Tier 2 RM Release 400 MG Prasugrel HCl Oral Tablet 10 MG, 5 MG Tier 2 RM Ticlopidine HCl Oral Tablet 250 MG Tier 2 RM Zontivity Oral Tablet 2.08 MG Tier 4 RM Hematopoietic Agents Cyanocobalamin Injection Solution Tier 2 RM 1000 MCG/ML Ferocon Oral Capsule Tier 2 RM Folic Acid Oral Tablet 1 MG Tier 2 RM RM; (Prescription Folic Acid Oral Tablet 400 MCG, 800 Tier 7 Required); AL (Min 11 MCG Years and Max 49 Years) Fulphila Subcutaneous Solution Tier 5 PA; RO; DL Prefilled Syringe 6 MG/0.6ML Miglustat Oral Capsule 100 MG Tier 5 PA; SP; DL Nivestym Injection Solution 300 Tier 5 RO; DL MCG/ML, 480 MCG/1.6ML Nivestym Injection Solution Prefilled Syringe 300 MCG/0.5ML, Tier 5 RO; DL 480 MCG/0.8ML Promacta Oral Packet 12.5 MG Tier 5 PA; RO; DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 59 Drug Name Drug Tier Requirements/Limits Promacta Oral Tablet 12.5 MG, 25 Tier 5 PA; RO; DL MG, 50 MG, 75 MG Retacrit Injection Solution 10000 UNIT/ML, 2000 UNIT/ML, 3000 Tier 5 PA; RO; DL UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML Udenyca Subcutaneous Solution Tier 5 PA; RO; DL Prefilled Syringe 6 MG/0.6ML Zarxio Injection Solution Prefilled Syringe 300 MCG/0.5ML, 480 Tier 5 PA; RO; DL MCG/0.8ML Hemostatics Aminocaproic Acid Oral Solution 0.25 Tier 5 RO; DL GM/ML Aminocaproic Acid Oral Tablet 500 MG Tier 5 RO; DL Tranexamic Acid Oral Tablet 650 MG Tier 2 RO; DL Hypnotics Doxepin HCl Oral Tablet 6 MG Tier 4 PA; RM Eszopiclone Oral Tablet 1 MG, 3 MG Tier 2 RM Flurazepam HCl Oral Capsule 15 MG Tier 2 RM Phenobarbital Oral Elixir 20 MG/5ML Tier 2 RO; DL Phenobarbital Oral Tablet 32.4 MG, Tier 2 RM 97.2 MG Ramelteon Oral Tablet 8 MG Tier 3 RM Temazepam Oral Capsule 15 MG Tier 2 RM Zaleplon Oral Capsule 5 MG Tier 2 RM Zolpidem Tartrate Oral Tablet 10 MG Tier 2 RM Hypnotics/Sedatives/Sleep Disorder Agents Doxepin HCl Oral Tablet 3 MG Tier 4 PA; RM Eszopiclone Oral Tablet 2 MG Tier 2 RM Flurazepam HCl Oral Capsule 30 MG Tier 2 RM Phenobarbital Oral Tablet 16.2 MG, Tier 2 RM 64.8 MG Temazepam Oral Capsule 30 MG Tier 2 RM Zaleplon Oral Capsule 10 MG Tier 2 RM Zolpidem Tartrate Oral Tablet 5 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 60 Drug Name Drug Tier Requirements/Limits Laxatives Lactulose Oral Solution 10 GM/15ML Tier 2 RM OsmoPrep Oral Tablet 1.102-0.398 Tier 4 RM GM PEG-3350/Electrolytes Oral Solution Tier 2 RO; DL Reconstituted 236 GM Plenvu Oral Solution Reconstituted Tier 3 RO; DL 140 GM Prepopik Oral Packet 10-3.5-12 Tier 4 RO MG-GM-GM Suprep Bowel Prep Kit Oral Tier 4 RO Solution 17.5-3.13-1.6 GM/177ML Macrolides Azithromycin Oral Suspension Reconstituted 100 MG/5ML, 200 Tier 2 RO; DL MG/5ML Azithromycin Oral Tablet 250 MG, 500 Tier 2 RO; DL MG, 600 MG Clarithromycin Oral Suspension Reconstituted 125 MG/5ML, 250 Tier 2 RO; DL MG/5ML Clarithromycin Oral Tablet 250 MG, 500 Tier 2 RO; DL MG Dificid Oral Tablet 200 MG Tier 5 PA; RO; DL Erythrocin Stearate Oral Tablet 250 Tier 4 RO MG Erythromycin Base Oral Capsule Tier 4 RO Delayed Release Particles 250 MG Erythromycin Base Oral Tablet Delayed Tier 4 RM Release 250 MG, 333 MG, 500 MG Erythromycin Ethylsuccinate Oral Tier 3 RM Tablet 400 MG Medical Devices BD Insulin Syringe U-500 31G X Tier 3 RM 6MM 0.5 ML BD Safety-Lok Insulin Syringe 29G Tier 3 RM X 1/2" 1 ML RO; (Prescription FC2 Female Condom Tier 7 Required); QL (12 EA per 30 days) You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 61 Drug Name Drug Tier Requirements/Limits FemCap Vaginal Device 22 MM, 30 Tier 7 RO; QL (1 EA per 1 Year) MM Insulin Syringe 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" Tier 2 RM 0.5 ML, 31G X 5/16" 0.3 ML Pen Needle 31G X 5 MM , 31G X 6 MM , Tier 3 RM 31G X 8 MM Medical Devices And Supplies Caya Vaginal Diaphragm Tier 7 RO; QL (1 EA per 1 Year) FemCap Vaginal Device 26 MM Tier 7 RO; QL (1 EA per 1 Year) Insulin Syringe 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 1 Tier 2 RM ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML Migraine Products Almotriptan Malate Oral Tablet 12.5 PA; RM; FHCP; QL (6 EA Tier 2 MG, 6.25 MG per 31 days) Dihydroergotamine Mesylate Injection Tier 5 RO; DL Solution 1 MG/ML Eletriptan Hydrobromide Oral Tablet 20 RM; FHCP; QL (6 EA per 31 Tier 2 MG, 40 MG days) Emgality (300 MG Dose) Subcutaneous Solution Prefilled Tier 5 PA; RO; DL Syringe 100 MG/ML Emgality Subcutaneous Solution Tier 5 PA; RO; DL Auto-Injector 120 MG/ML Emgality Subcutaneous Solution Tier 5 PA; RO; DL Prefilled Syringe 120 MG/ML Frovatriptan Succinate Oral Tablet 2.5 PA; RM; FHCP; QL (9 EA Tier 2 MG per 30 days) Isometheptene-Dichloral-APAP Oral Tier 2 RM Capsule 65-100-325 MG Migergot Rectal Suppository 2-100 RO; QL (12 EA per 14 Tier 5 MG days); DL Naratriptan HCl Oral Tablet 1 MG, 2.5 RM; FHCP; QL (9 EA per 31 Tier 2 MG days) Rizatriptan Benzoate Oral Tablet 10 RM; QL (18 EA per 31 Tier 2 MG, 5 MG days) Rizatriptan Benzoate Oral Tablet RM; QL (18 EA per 31 Tier 2 Dispersible 10 MG, 5 MG days) You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 62 Drug Name Drug Tier Requirements/Limits Sumatriptan Nasal Solution 20 Tier 2 RM; QL (6 EA per 31 days) MG/ACT, 5 MG/ACT Sumatriptan Succinate Oral Tablet 100 RM; QL (12 EA per 31 Tier 2 MG, 25 MG, 50 MG days) Sumatriptan Succinate Subcutaneous Solution Auto-Injector 4 MG/0.5ML, 6 Tier 2 RM; QL (4 ML per 31 days) MG/0.5ML Zolmitriptan Oral Tablet 2.5 MG, 5 MG Tier 2 RM; QL (6 EA per 31 days) Zolmitriptan Oral Tablet Dispersible 2.5 Tier 2 RM; QL (6 EA per 31 days) MG, 5 MG Minerals & Electrolytes K-Phos Oral Tablet 500 MG Tier 4 RM Phospha 250 Neutral Oral Tablet Tier 2 RM 155-852-130 MG Potassium Bicarbonate Oral Tablet Tier 2 RM Effervescent 25 MEQ Potassium Chloride ER Oral Tablet Extended Release 10 MEQ, 20 MEQ, 8 Tier 2 RM MEQ Potassium Chloride Oral Packet 20 MEQ Tier 2 RM Potassium Chloride Oral Solution 20 MEQ/15ML (10%), 40 MEQ/15ML Tier 2 RO (20%) Sodium Fluoride Oral Solution 1.1 (0.5 RM; AL (Min 6 Months and Tier 7 F) MG/ML Max 6 Years) Sodium Fluoride Oral Tablet Chewable RM; AL (Min 6 Months and 0.55 (0.25 F) MG, 1.1 (0.5 F) MG, 2.2 Tier 7 Max 6 Years) (1 F) MG Miscellaneous Therapeutic Classes Cyclosporine Modified Oral Capsule 100 Tier 2 RM MG, 25 MG Cyclosporine Oral Capsule 100 MG Tier 2 RM Everolimus Oral Tablet 0.25 MG Tier 5 PA; RO; DL Lokelma Oral Packet 10 GM Tier 4 PA; RO; DL Mycophenolate Mofetil Oral Capsule Tier 2 RM 250 MG Mycophenolate Mofetil Oral Tablet 500 Tier 2 RM MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 63 Drug Name Drug Tier Requirements/Limits Mycophenolate Sodium Oral Tablet Tier 2 RM Delayed Release 360 MG Penicillamine Oral Capsule 250 MG Tier 6 PA; RO; DL Revlimid Oral Capsule 15 MG, 2.5 PA; SP; CVS Caremark; QL Tier 5 MG, 20 MG, 5 MG (31 EA per 31 days); DL Sirolimus Oral Solution 1 MG/ML Tier 5 RO; DL Sirolimus Oral Tablet 0.5 MG, 1 MG, 2 Tier 2 RM; FHCP MG Sodium Polystyrene Sulfonate Oral Tier 2 RO; DL Suspension 15 GM/60ML Tacrolimus Oral Capsule 0.5 MG, 1 MG Tier 2 RM Thalomid Oral Capsule 200 MG Tier 5 PA; SP; CVS Caremark; DL Zortress Oral Tablet 1 MG Tier 5 PA; RO; DL Mouth/Throat/Dental Agents Cevimeline HCl Oral Capsule 30 MG Tier 2 RM; FHCP Chlorhexidine Gluconate Mouth/Throat RM; QL (1 BTL Max Qty Per Tier 2 Solution 0.12 % Fill Retail) Clotrimazole Mouth/Throat Lozenge 10 Tier 2 RO; DL MG Lidocaine Viscous Mouth/Throat Tier 2 RO; DL Solution 2 % Nystatin Mouth/Throat Suspension Tier 2 RO; DL 100000 UNIT/ML Pilocarpine HCl Oral Tablet 5 MG, 7.5 Tier 2 RM MG RM; QL (56 GM per 30 SF Dental Gel 1.1 % Tier 2 days) Triamcinolone Acetonide Mouth/Throat Tier 2 RO; DL Paste 0.1 % Multivitamins Multi-Vit/Fluoride Oral Solution 0.25 Tier 7 RM; AL (Max 12 Months) MG/ML, 0.5 MG/ML Multi-Vit/Fluoride/Iron Oral Solution Tier 7 RM; AL (Max 12 Months) 0.25-10 MG/ML Multivitamin/Fluoride Oral Tablet Tier 7 RM; AL (Max 12 Months) Chewable 0.25 MG PNV Prenatal Plus Multivitamin Oral Tier 2 RM Tablet 27-1 MG Trinate Oral Tablet Tier 2 RM You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 64 Drug Name Drug Tier Requirements/Limits Musculoskeletal Therapy Agents Baclofen Oral Tablet 10 MG, 20 MG Tier 2 RM Carisoprodol Oral Tablet 350 MG Tier 2 RM Chlorzoxazone Oral Tablet 500 MG Tier 2 RM Cyclobenzaprine HCl Oral Tablet 10 MG, Tier 2 RM 5 MG Dantrolene Sodium Oral Capsule 100 Tier 2 RM MG, 25 MG, 50 MG Metaxalone Oral Tablet 800 MG Tier 2 RM Methocarbamol Oral Tablet 500 MG, Tier 2 RM 750 MG Orphenadrine Citrate ER Oral Tablet Tier 2 RM Extended Release 12 Hour 100 MG Tizanidine HCl Oral Tablet 2 MG, 4 MG Tier 2 RM Nasal Agents - Systemic And Topical Azelastine HCl Nasal Solution 0.1 % Tier 2 RM Flunisolide Nasal Solution 25 MCG/ACT Tier 2 RM (0.025%) Fluticasone Propionate Nasal Tier 2 RM; DDL Suspension 50 MCG/ACT Ipratropium Bromide Nasal Solution Tier 2 RM 0.03 %, 0.06 % Mometasone Furoate Nasal Suspension Tier 2 RM 50 MCG/ACT Olopatadine HCl Nasal Solution 0.6 % Tier 2 RM Neuromuscular Agents Botox Injection Solution Tier 5 PA; RO Reconstituted 100 UNIT, 200 UNIT Riluzole Oral Tablet 50 MG Tier 2 PA; RM Xeomin Intramuscular Solution Reconstituted 100 UNIT, 200 UNIT, Tier 6 PA; RO; DL 50 UNIT Ophthalmic Agents RO; QL (5 ML per 25 days); Alocril Ophthalmic Solution 2 % Tier 4 DL Alomide Ophthalmic Solution 0.1 % Tier 3 RO; DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 65 Drug Name Drug Tier Requirements/Limits Alrex Ophthalmic Suspension 0.2 Tier 4 RO; DL % Apraclonidine HCl Ophthalmic Solution Tier 2 RM 0.5 % Atropine Sulfate Ophthalmic Ointment Tier 2 RO; DL 1 % Atropine Sulfate Ophthalmic Solution 1 Tier 2 RO; DL % Azelastine HCl Ophthalmic Solution Tier 2 RO; DL 0.05 % Azopt Ophthalmic Suspension 1 % Tier 4 RO; DL Bacitracin Ophthalmic Ointment 500 Tier 2 RO; DL UNIT/GM Bacitracin-Polymyxin B Ophthalmic Tier 2 RO; DL Ointment 500-10000 UNIT/GM Bacitra-Neomycin-Polymyxin-HC Tier 2 RO; DL Ophthalmic Ointment 1 % RO; QL (5 ML per 25 days); Bepreve Ophthalmic Solution 1.5 % Tier 4 DL Betaxolol HCl Ophthalmic Solution 0.5 Tier 2 RM % Betoptic-S Ophthalmic Suspension Tier 3 RM 0.25 % Blephamide Ophthalmic Suspension Tier 3 RO; DL 10-0.2 % Blephamide S.O.P. Ophthalmic Tier 3 RO; DL Ointment 10-0.2 % Brimonidine Tartrate Ophthalmic Tier 2 RM Solution 0.2 % Bromfenac Sodium (Once-Daily) RO; QL (1.7 ML per 15 Tier 2 Ophthalmic Solution 0.09 % days); DL Carteolol HCl Ophthalmic Solution 1 % Tier 2 RM Ciloxan Ophthalmic Ointment 0.3 Tier 3 RO; DL % Ciprofloxacin HCl Ophthalmic Solution Tier 2 RO; DL 0.3 % Combigan Ophthalmic Solution 0.2- Tier 3 RM 0.5 % Cromolyn Sodium Ophthalmic Solution Tier 2 RO; DL 4 % You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 66 Drug Name Drug Tier Requirements/Limits Cyclopentolate HCl Ophthalmic Solution Tier 2 RM 0.5 %, 1 %, 2 % Dexamethasone Sodium Phosphate Tier 2 RO; DL Ophthalmic Solution 0.1 % Diclofenac Sodium Ophthalmic Solution Tier 2 RO; DL 0.1 % Dorzolamide HCl Ophthalmic Solution 2 Tier 2 RM % Dorzolamide HCl-Timolol Mal Tier 2 RM Ophthalmic Solution 22.3-6.8 MG/ML Durezol Ophthalmic Emulsion 0.05 Tier 4 RO; DL % Emadine Ophthalmic Solution 0.05 RO; QL (5 ML per 25 days); Tier 4 % DL Epinastine HCl Ophthalmic Solution Tier 2 RM; QL (5 ML per 25 days) 0.05 % Erythromycin Ophthalmic Ointment 5 Tier 2 RO; DL MG/GM Fluorometholone Ophthalmic Tier 2 RO; DL Suspension 0.1 % Flurbiprofen Sodium Ophthalmic Tier 2 RO; DL Solution 0.03 % FML Forte Ophthalmic Suspension Tier 3 RO; DL 0.25 % FML Ophthalmic Ointment 0.1 % Tier 3 RO; DL RO; QL (2.5 ML per 3 Gatifloxacin Ophthalmic Solution 0.5 % Tier 2 days); DL Gentak Ophthalmic Ointment 0.3 % Tier 2 RO; DL Gentamicin Sulfate Ophthalmic Solution Tier 2 RO; DL 0.3 % Homatropine HBr Ophthalmic Solution Tier 2 RO; DL 5 % Ilevro Ophthalmic Suspension 0.3 Tier 3 RO; DL % Ketorolac Tromethamine Ophthalmic Tier 2 RO; DL Solution 0.4 %, 0.5 % Lastacaft Ophthalmic Solution 0.25 Tier 4 RM; QL (3 ML per 30 days) % Latanoprost Ophthalmic Solution 0.005 Tier 2 RM % You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 67 Drug Name Drug Tier Requirements/Limits Levobunolol HCl Ophthalmic Solution Tier 1 RM 0.5 % Levofloxacin Ophthalmic Solution 0.5 % Tier 2 RO; DL Lotemax Ophthalmic Ointment 0.5 RO; QL (3.5 GM per 3 Tier 4 % days); DL Loteprednol Etabonate Ophthalmic Tier 3 RO; DL Suspension 0.5 % Lumigan Ophthalmic Solution 0.01 RM; QL (2.5 ML per 25 Tier 4 % days) Metipranolol Ophthalmic Solution 0.3 % Tier 2 RO; DL Moxifloxacin HCl Ophthalmic Solution Tier 2 RO; DL 0.5 % Natacyn Ophthalmic Suspension 5 Tier 3 RO; DL % Neomycin-Bacitracin Zn-Polymyx Tier 2 RO; DL Ophthalmic Ointment 5-400-10000 Neomycin-Polymyxin-Dexameth Tier 2 RO; DL Ophthalmic Ointment 3.5-10000-0.1 Neomycin-Polymyxin-Dexameth Tier 2 RO; DL Ophthalmic Suspension 3.5-10000-0.1 Neomycin-Polymyxin-Gramicidin Tier 2 RO; DL Ophthalmic Solution 1.75-10000-.025 Neomycin-Polymyxin-HC Ophthalmic Tier 2 RO; DL Suspension 3.5-10000-1 Nevanac Ophthalmic Suspension Tier 3 RO; DL 0.1 % Ofloxacin Ophthalmic Solution 0.3 % Tier 2 RO; DL Olopatadine HCl Ophthalmic Solution Tier 2 RM; QL (5 ML per 25 days) 0.1 % Phospholine Iodide Ophthalmic Tier 3 RO; DL Solution Reconstituted 0.125 % Pilocarpine HCl Ophthalmic Solution 1 Tier 2 RM %, 2 %, 4 % Polymyxin B-Trimethoprim Ophthalmic Tier 2 RO; DL Solution 10000-0.1 UNIT/ML-% Pred Mild Ophthalmic Suspension Tier 3 RO; DL 0.12 % Pred-G Ophthalmic Suspension 0.3- Tier 3 RO; DL 1 %
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 68 Drug Name Drug Tier Requirements/Limits Pred-G S.O.P. Ophthalmic Ointment Tier 3 RO; DL 0.3-0.6 % Prednisolone Acetate Ophthalmic Tier 2 RO; DL Suspension 1 % Prednisolone Sodium Phosphate Tier 2 RO; DL Ophthalmic Solution 1 % Proparacaine HCl Ophthalmic Solution Tier 2 RO; DL 0.5 % Restasis Ophthalmic Emulsion 0.05 RO; QL (30 EA per 15 Tier 3 % days); DL Sulfacetamide Sodium Ophthalmic Tier 2 RO; DL Solution 10 % Sulfacetamide-Prednisolone Ophthalmic Tier 2 RO; DL Solution 10-0.23 % Tetracaine HCl Ophthalmic Solution 0.5 Tier 2 RO; DL % Timolol Maleate Ophthalmic Solution Tier 1 RM 0.25 %, 0.5 % TobraDex Ophthalmic Ointment Tier 3 RO; DL 0.3-0.1 % Tobramycin Ophthalmic Solution 0.3 % Tier 2 RO; DL Tobramycin-Dexamethasone Tier 2 RO; DL Ophthalmic Suspension 0.3-0.1 % Tobrex Ophthalmic Ointment 0.3 % Tier 3 RO; DL Travoprost (BAK Free) Ophthalmic Tier 3 RM Solution 0.004 % Trifluridine Ophthalmic Solution 1 % Tier 2 RO; DL Tropicamide Ophthalmic Solution 0.5 Tier 2 RO; DL %, 1 % Vexol Ophthalmic Suspension 1 % Tier 4 RM Zirgan Ophthalmic Gel 0.15 % Tier 4 RO; DL Otic Agents Acetic Acid Otic Solution 2 % Tier 2 RO; DL Acetic Acid-Aluminum Acetate Otic Tier 2 RO; DL Solution 2 % RO; QL (10 ML per 7 days); Cipro HC Otic Suspension 0.2-1 % Tier 4 DL Ciprofloxacin HCl Otic Solution 0.2 % Tier 2 RO; DL
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 69 Drug Name Drug Tier Requirements/Limits Ciprofloxacin-Dexamethasone Otic Tier 2 RO; DL Suspension 0.3-0.1 % Coly-Mycin S Otic Suspension 3.3- Tier 4 RO; DL 3-10-0.5 MG/ML Fluocinolone Acetonide Otic Oil 0.01 % Tier 2 RO; DL Hydrocortisone-Acetic Acid Otic Tier 2 RO; DL Solution 1-2 % Neomycin-Polymyxin-HC Otic Solution Tier 2 RO; DL 1 % Neomycin-Polymyxin-HC Otic Tier 2 RO; DL Suspension 3.5-10000-1 Ofloxacin Otic Solution 0.3 % Tier 2 RO; DL Oxytocics Methergine Oral Tablet 0.2 MG Tier 5 RO; DL Penicillins Amoxicillin Oral Capsule 250 MG, 500 Tier 2 RO; DL MG Amoxicillin Oral Suspension Reconstituted 125 MG/5ML, 200 Tier 2 RO; DL MG/5ML, 250 MG/5ML, 400 MG/5ML Amoxicillin Oral Tablet 875 MG Tier 2 RO; DL Amoxicillin Oral Tablet Chewable 125 Tier 2 RO; DL MG, 250 MG Amoxicillin-Pot Clavulanate ER Oral Tablet Extended Release 12 Hour 1000- Tier 2 RO; DL 62.5 MG Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 200-28.5 Tier 2 RO; DL MG/5ML, 250-62.5 MG/5ML, 400-57 MG/5ML, 600-42.9 MG/5ML Amoxicillin-Pot Clavulanate Oral Tablet Tier 2 RO; DL 250-125 MG, 500-125 MG, 875-125 MG Amoxicillin-Pot Clavulanate Oral Tablet Tier 2 RO; DL Chewable 200-28.5 MG, 400-57 MG Ampicillin Oral Capsule 500 MG Tier 2 RO; DL Dicloxacillin Sodium Oral Capsule 250 Tier 2 RO; DL MG, 500 MG Penicillin V Potassium Oral Solution Reconstituted 125 MG/5ML, 250 Tier 2 RO; DL MG/5ML You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 70 Drug Name Drug Tier Requirements/Limits Penicillin V Potassium Oral Tablet 250 Tier 2 RO; DL MG, 500 MG Progestins Medroxyprogesterone Acetate Oral Tier 1 RM Tablet 10 MG, 2.5 MG, 5 MG Norethindrone Acetate Oral Tablet 5 Tier 2 RM MG Progesterone Intramuscular Oil 50 Tier 2 RO; DL MG/ML Progesterone Micronized Oral Capsule Tier 2 RM 100 MG, 200 MG Psychotherapeutic And Neurological Agents - Misc. Acamprosate Calcium Oral Tablet Tier 2 RM Delayed Release 333 MG Avonex Pen Intramuscular Auto- Tier 5 PA; RO; DL Injector Kit 30 MCG/0.5ML Avonex Prefilled Intramuscular Tier 5 PA; RO; DL Prefilled Syringe Kit 30 MCG/0.5ML Betaseron Subcutaneous Kit 0.3 MG Tier 5 PA; RO; DL Bupropion HCl ER (Smoking Det) Oral RM; QL (90 DAYS per 1 Tablet Extended Release 12 Hour 150 Tier 7 Year) MG Chantix Continuing Month Pak Oral Tier 4 RO; DL Tablet 1 MG Chantix Oral Tablet 0.5 MG, 1 MG Tier 4 RM Chantix Starting Month Pak Oral Tier 4 RO; DL Tablet 0.5 MG X 11 & 1 MG X 42 Dalfampridine ER Oral Tablet Extended Tier 2 PA; RO; FHCP Release 12 Hour 10 MG Dimethyl Fumarate Oral Capsule Tier 1 PA; RM; DL Delayed Release 120 MG, 240 MG Dimethyl Fumarate Starter Pack Oral Tier 1 PA; RM; DL 120 & 240 MG Disulfiram Oral Tablet 250 MG, 500 MG Tier 2 RM Donepezil HCl Oral Tablet 10 MG, 5 MG Tier 1 RM Donepezil HCl Oral Tablet Dispersible Tier 2 RM 10 MG, 5 MG Ergoloid Mesylates Oral Tablet 1 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 71 Drug Name Drug Tier Requirements/Limits Galantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 16 Tier 2 RM MG, 24 MG, 8 MG Galantamine Hydrobromide Oral Tier 2 RM Solution 4 MG/ML Galantamine Hydrobromide Oral Tablet Tier 2 RM 12 MG, 4 MG, 8 MG PA; RO; QL (28 EA per 28 Gilenya Oral Capsule 0.5 MG Tier 5 days); DL Glatopa Subcutaneous Solution Prefilled Syringe 20 MG/ML, 40 Tier 5 RO; DL MG/ML Memantine HCl Oral Solution 2 MG/ML Tier 2 RO; DL Memantine HCl Oral Tablet 10 MG, 5 Tier 2 RM MG Memantine HCl Oral Tablet 28 x 5 MG & Tier 2 RO; DL 21 x 10 MG RO; (Prescription Nicotine Polacrilex Mouth/Throat Gum 2 Tier 7 Required); QL (90 Days per MG, 4 MG 1 Year) RO; (Prescription Nicotine Polacrilex Mouth/Throat Tier 7 Required); QL (90 Days per Lozenge 2 MG, 4 MG 1 Year) RO; (Prescription Nicotine Transdermal Patch 24 Hour 14 Tier 7 Required); QL (90 Days per MG/24HR, 21 MG/24HR, 7 MG/24HR 1 Year) PA; RO; QL (168 EA per 10 Nicotrol Inhalation Inhaler 10 MG Tier 3 days); DL Nuedexta Oral Capsule 20-10 MG Tier 5 PA; RO; DL Ocrevus Intravenous Solution 300 Tier 6 PA; RO; DL MG/10ML Pimozide Oral Tablet 1 MG, 2 MG Tier 2 RM Rebif Rebidose Subcutaneous Solution Auto-Injector 22 Tier 5 PA; RO; DL MCG/0.5ML, 44 MCG/0.5ML Rebif Rebidose Titration Pack Subcutaneous Solution Auto- Tier 5 PA; RO; DL Injector 6X8.8 & 6X22 MCG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 72 Drug Name Drug Tier Requirements/Limits Rebif Subcutaneous Solution Prefilled Syringe 22 MCG/0.5ML, 44 Tier 5 PA; RO; DL MCG/0.5ML Rebif Titration Pack Subcutaneous Solution Prefilled Syringe 6X8.8 & Tier 5 PA; RO; DL 6X22 MCG Rivastigmine Tartrate Oral Capsule 1.5 Tier 2 RM MG, 3 MG, 4.5 MG, 6 MG Savella Oral Tablet 100 MG, 12.5 Tier 3 RM MG, 25 MG, 50 MG Savella Titration Pack Oral 12.5 & Tier 3 RO; DL 25 & 50 MG Tetrabenazine Oral Tablet 12.5 MG, 25 Tier 2 PA; RO; DL MG Xyrem Oral Solution 500 MG/ML Tier 5 PA; SP; Express Scripts; DL Zinbryta Subcutaneous Solution Tier 5 RO; DL Prefilled Syringe 150 MG/ML Respiratory Agents - Misc. Kalydeco Oral Packet 50 MG, 75 MG Tier 5 PA; SP; DL Kalydeco Oral Tablet 150 MG Tier 5 PA; SP; DL Pulmozyme Inhalation Solution 1 PA; RO; QL (150 ML per 28 Tier 5 MG/ML days); DL Sulfonamides Sulfadiazine Oral Tablet 500 MG Tier 2 RM Tetracyclines Demeclocycline HCl Oral Tablet 150 Tier 2 RM; FHCP MG, 300 MG Doxycycline Hyclate Oral Capsule 100 Tier 2 RM MG, 50 MG Doxycycline Hyclate Oral Tablet 100 Tier 2 RM MG, 20 MG Doxycycline Monohydrate Oral Capsule Tier 2 RM 100 MG, 50 MG Minocycline HCl Oral Capsule 100 MG, Tier 2 RM 50 MG Tetracycline HCl Oral Capsule 250 MG, Tier 2 RM 500 MG
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 73 Drug Name Drug Tier Requirements/Limits Thyroid Agents Levothyroxine Sodium Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 Tier 1 RM MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG Liothyronine Sodium Oral Tablet 25 Tier 2 RM MCG, 5 MCG, 50 MCG Methimazole Oral Tablet 10 MG, 5 MG Tier 2 RM Propylthiouracil Oral Tablet 50 MG Tier 2 RM Thyrolar-1 Oral Tablet 60 (12.5-50) Tier 4 RM MG (MCG) Thyrolar-1/2 Oral Tablet 30 (6.25- Tier 4 RM 25) MG (MCG) Thyrolar-1/4 Oral Tablet 15 (3.1- Tier 4 RM 12.5) MG (MCG) Thyrolar-2 Oral Tablet 120 (25- Tier 4 RM 100) MG (MCG) Thyrolar-3 Oral Tablet 180 (37.5- Tier 4 RM 150) MG (MCG) Toxoids Adacel Intramuscular Suspension Tier 3 RO 5-2-15.5 LF-MCG/0.5 Boostrix Intramuscular Suspension Tier 3 RO 5-2.5-18.5 , 5-2.5-18.5 LF-MCG/0.5 Tetanus-Diphtheria Toxoids Td Intramuscular Suspension 2-2 Tier 3 RO LF/0.5ML Ulcer Drugs chlordiazePOXIDE-Clidinium Oral Tier 2 RM Capsule 5-2.5 MG Cimetidine HCl Oral Solution 300 Tier 2 RO; DL MG/5ML Cimetidine Oral Tablet 300 MG, 400 Tier 2 RM MG, 800 MG Dicyclomine HCl Oral Capsule 10 MG Tier 2 RM Dicyclomine HCl Oral Solution 10 Tier 2 RO; DL MG/5ML Dicyclomine HCl Oral Tablet 20 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 74 Drug Name Drug Tier Requirements/Limits Famotidine Oral Suspension Tier 2 RO; DL Reconstituted 40 MG/5ML Famotidine Oral Tablet 20 MG, 40 MG Tier 2 RM Glycopyrrolate Oral Tablet 1 MG, 2 MG Tier 2 RM Hyoscyamine Sulfate ER Oral Tablet Tier 2 RM Extended Release 12 Hour 0.375 MG Hyoscyamine Sulfate Oral Elixir 0.125 Tier 2 RO; DL MG/5ML Hyoscyamine Sulfate Oral Solution Tier 2 RO; DL 0.125 MG/ML Hyoscyamine Sulfate Oral Tablet 0.125 Tier 2 RM MG Hyoscyamine Sulfate Sublingual Tablet Tier 2 RM Sublingual 0.125 MG Lansoprazole Oral Capsule Delayed Tier 2 RM Release 15 MG, 30 MG Methscopolamine Bromide Oral Tablet Tier 2 RM 2.5 MG, 5 MG Misoprostol Oral Tablet 100 MCG, 200 Tier 2 RM MCG Nizatidine Oral Capsule 150 MG, 300 Tier 2 RM MG Nizatidine Oral Solution 15 MG/ML Tier 2 RO; DL Omeprazole Oral Capsule Delayed Tier 2 RM; DDL Release 10 MG, 20 MG, 40 MG Pantoprazole Sodium Oral Packet 40 Tier 4 RM MG Pantoprazole Sodium Oral Tablet Tier 2 RM; DDL Delayed Release 20 MG, 40 MG Propantheline Bromide Oral Tablet 15 Tier 2 RM MG Rabeprazole Sodium Oral Tablet Tier 2 RM Delayed Release 20 MG Sucralfate Oral Suspension 1 GM/10ML Tier 2 RO; DL Sucralfate Oral Tablet 1 GM Tier 2 RM Urinary Antispasmodics Bethanechol Chloride Oral Tablet 10 Tier 2 RM MG, 25 MG, 5 MG, 50 MG Flavoxate HCl Oral Tablet 100 MG Tier 2 RM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 75 Drug Name Drug Tier Requirements/Limits Myrbetriq Oral Tablet Extended Tier 4 PA; RM Release 24 Hour 25 MG, 50 MG Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 10 MG, 15 Tier 2 RM MG, 5 MG Oxybutynin Chloride Oral Syrup 5 Tier 2 RO; DL MG/5ML Oxybutynin Chloride Oral Tablet 5 MG Tier 2 RM Solifenacin Succinate Oral Tablet 10 Tier 2 RM; FHCP MG, 5 MG Tolterodine Tartrate Oral Tablet 1 MG, Tier 2 RM 2 MG Toviaz Oral Tablet Extended Tier 3 RM Release 24 Hour 4 MG, 8 MG Trospium Chloride ER Oral Capsule Tier 2 RM; FHCP Extended Release 24 Hour 60 MG Trospium Chloride Oral Tablet 20 MG Tier 2 RM; FHCP Vaccines Afluria Intramuscular Suspension Tier 7 RO Afluria Preservative Free Tier 7 RO Intramuscular Suspension Afluria Preservative Free Intramuscular Suspension Prefilled Tier 7 RO Syringe 0.5 ML Afluria Quadrivalent Intramuscular Tier 7 RO Suspension Bexsero Intramuscular Suspension Tier 3 RO; AL (Max 25 Years) Prefilled Syringe Engerix-B Injection Suspension 10 Tier 3 RO; AL (Max 19 Years) MCG/0.5ML Engerix-B Injection Suspension 20 Tier 3 RO; AL (Min 20 Years) MCG/ML EZ Flu Shot-Flucelvax Quad Intramuscular Prefilled Syringe Kit Tier 7 RO 0.5 ML Fluad Intramuscular Suspension Tier 7 RO; AL (Min 65 Years) Prefilled Syringe 0.5 ML Fluad Quadrivalent Intramuscular Tier 7 RO; AL (Min 65 Years) Prefilled Syringe 0.5 ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 76 Drug Name Drug Tier Requirements/Limits Fluarix Quadrivalent Intramuscular Tier 7 RO Suspension Prefilled Syringe 0.5 ML Flublok Quadrivalent Intramuscular Tier 7 RO Solution Prefilled Syringe 0.5 ML Flucelvax Quadrivalent Tier 7 RO Intramuscular Suspension Flucelvax Quadrivalent Intramuscular Suspension Prefilled Tier 7 RO Syringe 0.5 ML Flulaval Quadrivalent Tier 7 RO Intramuscular Suspension Flulaval Quadrivalent Intramuscular Suspension Prefilled Tier 7 RO Syringe 0.5 ML Fluzone High-Dose Intramuscular Tier 7 RO; AL (Min 65 Years) Suspension Fluzone High-Dose Intramuscular Tier 7 RO; AL (Min 65 Years) Suspension Prefilled Syringe 0.5 ML Fluzone High-Dose Quadrivalent Intramuscular Suspension Prefilled Tier 7 RO; AL (Min 65 Years) Syringe 0.7 ML Fluzone Intramuscular Injectable Tier 7 RO Fluzone Intramuscular Suspension Tier 7 RO Fluzone Preservative Free Tier 7 RO Intramuscular Suspension Fluzone Preservative Free Intramuscular Suspension Prefilled Tier 7 RO Syringe 0.5 ML Fluzone Quadrivalent Tier 7 RO Intramuscular Suspension , 0.5 ML Fluzone Quadrivalent Intramuscular Suspension Prefilled Tier 7 RO Syringe 0.5 ML Gardasil 9 Intramuscular Tier 3 RO; AL (Max 46 Years) Suspension Gardasil 9 Intramuscular Tier 3 RO; AL (Max 46 Years) Suspension Prefilled Syringe Havrix Intramuscular Suspension Tier 3 RO; AL (Min 19 Years) 1440 EL U/ML
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 77 Drug Name Drug Tier Requirements/Limits Havrix Intramuscular Suspension Tier 3 RO; AL (Max 18 Years) 720 EL U/0.5ML Menactra Intramuscular Injectable Tier 3 RO Menveo Intramuscular Solution Tier 3 RO Reconstituted Pneumovax 23 Injection Injectable Tier 3 RO 25 MCG/0.5ML Prevnar 13 Intramuscular Tier 3 RO; AL (Min 65 Years) Suspension Recombivax HB Injection Tier 3 RO; AL (Min 20 Years) Suspension 10 MCG/ML Recombivax HB Injection Tier 3 RO; AL (Max 19 Years) Suspension 5 MCG/0.5ML Shingrix Intramuscular Suspension Tier 3 RO; AL (Min 50 Years) Reconstituted 50 MCG/0.5ML Trumenba Intramuscular Tier 3 RO; AL (Max 25 Years) Suspension Prefilled Syringe Vaqta Intramuscular Suspension Tier 3 RO; AL (Max 18 Years) 25 UNIT/0.5ML Vaqta Intramuscular Suspension Tier 3 RO; AL (Min 19 Years) 50 UNIT/ML Vaginal Products Clindamycin Phosphate Vaginal Cream Tier 2 RO; DL 2 % RO; (Prescription Encare Vaginal Suppository 100 MG Tier 7 Required); QL (12 EA per 30 days) Estradiol Vaginal Cream 0.1 MG/GM Tier 2 RM Estradiol Vaginal Tablet 10 MCG Tier 2 RM RO; QL (5.8 GM per 7 Gynazole-1 Vaginal Cream 2 % Tier 4 days) Intrarosa Vaginal Insert 6.5 MG Tier 4 RM RO; QL (70 GM per 7 Metronidazole Vaginal Gel 0.75 % Tier 2 days); DL RO; (Prescription Options Gynol II Contraceptive Tier 7 Required); QL (81 GM per Vaginal Gel 3 % 30 days) Premarin Vaginal Cream 0.625 Tier 3 RM MG/GM
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 78 Drug Name Drug Tier Requirements/Limits Terconazole Vaginal Cream 0.4 %, 0.8 Tier 2 RO; DL % Terconazole Vaginal Suppository 80 MG Tier 2 RO; DL RO; (Prescription Today Sponge Vaginal 1000 MG Tier 7 Required); QL (12 EA per 30 days) RO; (Prescription VCF Vaginal Contraceptive Vaginal Tier 7 Required); QL (17 GM per Foam 12.5 % 30 days) RO; (Prescription VCF Vaginal Contraceptive Vaginal Tier 7 Required); QL (2.55 GM per Gel 4 % 30 days) Vasopressors Epinephrine Injection Solution Auto- RO; QL (2 EA per 30 days); Tier 3 Injector 0.15 MG/0.3ML, 0.3 MG/0.3ML DL Midodrine HCl Oral Tablet 10 MG, 2.5 Tier 2 RM MG, 5 MG Symjepi Injection Solution Prefilled RO; QL (2 EA per 30 days); Syringe 0.15 MG/0.3ML, 0.3 Tier 4 DL MG/0.3ML Vitamins Phytonadione Oral Tablet 5 MG Tier 3 RO Vitamin D (Ergocalciferol) Oral Capsule Tier 2 RM 1.25 MG (50000 UT) RM; (Prescription Vitamin D3 Oral Capsule 10 MCG (400 Tier 7 Required); AL (Min 65 UNIT), 25 MCG (1000 UT) Years)
You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 79 You can find more information on what the symbols and abbreviations on this table mean by going to the list of abbreviations that begins on page vii. 80 Index Abacavir Sulfate...... 36 Allopurinol...... 58 Asmanex HFA...... 11 Abacavir Sulfate- Almotriptan Malate...... 62 Aspirin Adult Low lamiVUDine...... 37 Alocril...... 65 Strength...... 6 Abacavir-Lamivudine- Alomide...... 65 Aspirin-Dipyridamole ER. 59 Zidovudine...... 37 Alosetron HCl...... 57 Atazanavir Sulfate...... 37 Abilify Maintena...... 34 Alprazolam...... 10 Atenolol...... 41 Abiraterone Acetate...... 29 Alrex...... 66 Atomoxetine HCl...... 3 Acamprosate Calcium..... 71 Altabax...... 47 Atorvastatin Calcium...... 24 Acarbose...... 19 Amantadine HCl...... 33 Atovaquone...... 27 Acebutolol HCl...... 41 Ambrisentan...... 42 Atovaquone-Proguanil Acetaminophen-Codeine... 7 Amcinonide...... 47 HCl...... 28 Acetaminophen-Codeine Amiloride HCl...... 53 Atropine Sulfate...... 66 #2...... 6 Aminocaproic Acid...... 60 Atrovent HFA...... 11 Acetaminophen-Codeine Amiodarone HCl...... 10 Avonex Pen...... 71 #3...... 7 Amitiza...... 57 Avonex Prefilled...... 71 Acetaminophen-Codeine Amitriptyline HCl...... 17 Azathioprine...... 40 #4...... 7 Amlodipine Besylate...... 42 Azelastine HCl...... 65, 66 Acetazolamide...... 53 Ammonium Lactate...... 47 Azithromycin...... 61 Acetazolamide ER...... 53 Amoxapine...... 17 Azopt...... 66 Acetic Acid...... 69 Amoxicillin...... 70 Bacitracin...... 66 Acetic Acid-Aluminum Amoxicillin-Pot Bacitracin-Polymyxin B... 66 Acetate...... 69 Clavulanate...... 70 Bacitra-Neomycin- Acetylcysteine...... 46 Amoxicillin-Pot Polymyxin-HC...... 66 Acitretin...... 46 Clavulanate ER...... 70 Baclofen...... 65 Actimmune...... 29 Amphetamine- Balsalazide Disodium...... 57 Acyclovir...... 37, 46 Dextroamphet ER...... 3 Banzel...... 14 Adacel...... 74 Ampicillin...... 70 Baqsimi One Pack...... 19 Adapalene...... 46 Anadrol-50...... 8 Basaglar KwikPen...... 19 Adapalene-Benzoyl Anagrelide HCl...... 59 Baxdela...... 56 Peroxide...... 46 Anastrozole...... 29 BD Insulin Syringe U- Adefovir Dipivoxil...... 37 Androxy...... 8 500...... 61 Adempas...... 42 Anoro Ellipta...... 11 BD Safety-Lok Insulin Adult Aspirin EC Low Anzemet...... 22 Syringe...... 61 Strength...... 6 Apraclonidine HCl...... 66 Benazepril HCl...... 25 Afluria...... 76 Aprepitant...... 23 BeneFIX...... 59 Afluria Preservative Apri...... 43 Benzonatate...... 46 Free...... 76 Aptiom...... 14 Benzoyl Peroxide- Afluria Quadrivalent....76 Aptivus...... 37 Erythromycin...... 47 Albendazole...... 9 Arcalyst...... 4 Benztropine Mesylate 33, 34 Albuterol Sulfate...... 11 Aripiprazole...... 34 Bepreve...... 66 Albuterol Sulfate HFA..... 11 Armodafinil...... 3 Berinert...... 59 Alclometasone Arnuity Ellipta...... 11 Betamethasone Dipropionate...... 47 Asmanex (120 Dipropionate...... 47 Alecensa...... 29 Metered Doses)...... 11 Betamethasone Valerate.47 Alendronate Sodium...... 54 Asmanex (30 Metered Betaseron...... 71 Alfuzosin HCl ER...... 58 Doses)...... 11 Betaxolol HCl...... 41, 66 Alinia...... 27 Asmanex (60 Metered Bethanechol Chloride..... 75 Aliskiren Fumarate...... 25 Doses)...... 11 Betoptic-S...... 66
81 Bexarotene...... 29 Caprelsa...... 29 Ciloxan...... 66 Bexsero...... 76 Captopril...... 25 Cimduo...... 37 Bicalutamide...... 29 Carbaglu...... 54 Cimetidine...... 74 Biktarvy...... 37 Carbamazepine...... 14, 15 Cimetidine HCl...... 74 Bisoprolol Fumarate...... 41 Carbamazepine ER...... 14 Cinacalcet HCl...... 54 Blephamide...... 66 Carbidopa...... 33 Cipro HC...... 69 Blephamide S.O.P...... 66 Carbidopa-Levodopa. 33, 34 Ciprofloxacin HCl 57, 66, 69 Boostrix...... 74 Carbidopa-Levodopa ER..34 Ciprofloxacin- Bosentan...... 42 Carbinoxamine Maleate.. 24 Dexamethasone...... 70 Bosulif...... 29 Carisoprodol...... 65 Citalopram Botox...... 65 Carteolol HCl...... 66 Hydrobromide...... 17 Breo Ellipta...... 12 Carvedilol...... 41 Clarithromycin...... 61 Brilinta...... 59 Caya...... 62 Clemastine Fumarate..... 24 Brimonidine Tartrate...... 66 Cayston...... 27 Clindamycin HCl...... 27 Bromfenac Sodium Cefaclor...... 43 Clindamycin Palmitate (Once-Daily)...... 66 Cefadroxil...... 43 HCl...... 27 Bromocriptine Mesylate Cefdinir...... 43 Clindamycin Phos- ...... 33, 34 Cefditoren Pivoxil...... 43 Benzoyl Perox...... 48 Budesonide...... 12, 45 Cefixime...... 43 Clindamycin Phosphate Bumetanide...... 53 Cefpodoxime Proxetil..... 43 ...... 48, 78 Buprenorphine HCl...... 7 Cefprozil...... 43 Clobazam...... 15 Buprenorphine HCl- Ceftriaxone Sodium...... 43 Clobetasol Propionate.....48 Naloxone HCl...... 7 Cefuroxime Axetil...... 43 Clobetasol Propionate E.. 48 Bupropion HCl...... 17 Celecoxib...... 4 Clomipramine HCl...... 17 Bupropion HCl ER Celontin...... 15 Clonazepam...... 15 (Smoking Det)...... 71 Cephalexin...... 43 Clonidine HCl...... 25 Bupropion HCl ER (SR).. 17 Cesamet...... 23 Clopidogrel Bisulfate...... 59 Bupropion HCl ER (XL)...17 Cevimeline HCl...... 64 Clorazepate Dipotassium 10 Buspirone HCl...... 10 Chantix...... 71 Clotrimazole...... 64 Butalbital-APAP-Caffeine...6 Chantix Continuing Clotrimazole- Butalbital-ASA-Caff- Month Pak...... 71 Betamethasone...... 48 Codeine...... 7 Chantix Starting Clozapine...... 34 Butalbital-Aspirin- Month Pak...... 71 Coartem...... 28 Caffeine...... 6 Chemet...... 22 Codeine Sulfate...... 7 Butenafine HCl...... 47 Chlordiazepoxide HCl...... 10 Colchicine...... 58 Bydureon...... 19 chlordiazePOXIDE- Colchicine-Probenecid.....58 Bydureon BCise...... 19 Clidinium...... 74 Colesevelam HCl...... 24 Byetta 10 MCG Pen..... 19 Chlorhexidine Gluconate. 64 Colestipol HCl...... 24 Byetta 5 MCG Pen...... 19 Chloroquine Phosphate... 28 Coly-Mycin S...... 70 Bystolic...... 41 Chlorothiazide...... 53 Combigan...... 66 Cabergoline...... 54 Chlorpromazine HCl...... 34 Cometriq (100 mg Calcipotriene...... 47 Chlorpropamide...... 19 Daily Dose)...... 29 Calcitonin (Salmon)...... 54 Chlorthalidone...... 53 Cometriq (140 mg Calcitriol...... 54 Chlorzoxazone...... 65 Daily Dose)...... 29 Calcium Acetate (Phos Cholestyramine...... 24 Cometriq (60 mg Binder)...... 57 Cholestyramine Light..... 24 Daily Dose)...... 29 Camila...... 43 Ciclopirox...... 47 Complera...... 37 Candesartan Cilexetil..... 25 Ciclopirox Olamine...... 48 Corlopam...... 25 Capecitabine...... 29 Cilostazol...... 59 Cortisone Acetate...... 45
82 Cortisporin...... 48 Diazepam...... 10, 15 Efavirenz-lamiVUDine- Cotellic...... 29 Diazoxide...... 19 Tenofovir...... 37 Creon...... 53 Diclofenac Sodium 4, 49, 67 Eletriptan Hydrobromide. 62 Cresemba...... 23 Dicloxacillin Sodium...... 70 Eligard...... 29 Crixivan...... 37 Dicyclomine HCl...... 74 Eliquis...... 14 Cromolyn Sodium Didanosine...... 37 Eliquis DVT/PE ...... 12, 57, 66 Dificid...... 61 Starter Pack...... 14 Cryselle-28...... 43 Diflunisal...... 6 Ella...... 44 Cyanocobalamin...... 59 Digoxin...... 42 Elmiron...... 58 Cyclobenzaprine HCl...... 65 Dihydroergotamine Emadine...... 67 Cyclopentolate HCl...... 67 Mesylate...... 62 Emcyt...... 29 Cyclophosphamide...... 29 Dilantin...... 15 Emend...... 23 Cycloserine...... 28 Diltiazem HCl...... 42 Emgality...... 62 Cyclosporine...... 40, 63 Diltiazem HCl ER Coated Emgality (300 MG Cyclosporine Modified40, 63 Beads...... 42 Dose)...... 62 Cyproheptadine HCl...... 24 Dimethyl Fumarate...... 71 Emsam...... 17 Cystagon...... 58 Dimethyl Fumarate Emtricitabine...... 37 Cytra K Crystals...... 58 Starter Pack...... 71 Emtricitabine-Tenofovir Dalfampridine ER...... 71 Dipentum...... 57 DF...... 37 Daliresp...... 12 Diphenhydramine HCl.....24 Emtriva...... 37 Danazol...... 8 Diphenoxylate-Atropine.. 22 Enalapril Maleate...... 26 Dantrolene Sodium...... 65 Dipyridamole...... 59 Enbrel...... 4 Dapsone...... 27 Disopyramide Phosphate.10 Enbrel Mini...... 4 Deferasirox...... 22 Disulfiram...... 71 Enbrel SureClick...... 4 Delestrogen...... 56 Diuril...... 53 Encare...... 78 Delstrigo...... 37 Divalproex Sodium...... 15 Engerix-B...... 76 Demeclocycline HCl...... 73 Divalproex Sodium ER.... 15 Enjuvia...... 56 Denavir...... 48 Dofetilide...... 10 Enoxaparin Sodium...... 14 Depo-Estradiol...... 56 Donepezil HCl...... 71 Enpresse-28...... 44 Descovy...... 37 Dorzolamide HCl...... 67 Entacapone...... 33 Desipramine HCl...... 17 Dorzolamide HCl-Timolol Entecavir...... 37 Desloratadine...... 24 Mal...... 67 Epinastine HCl...... 67 Desmopressin Acetate.... 54 Dovato...... 37 Epinephrine...... 79 Desmopressin Acetate Doxazosin Mesylate...... 25 Epivir HBV...... 37 Spray...... 54 Doxepin HCl...... 17, 49, 60 Eplerenone...... 26 Desonide...... 48 Doxercalciferol...... 54 Eprosartan Mesylate...... 26 Desoximetasone...... 48, 49 Doxycycline Hyclate...... 73 Ergoloid Mesylates...... 71 Desvenlafaxine Doxycycline Erivedge...... 29 Succinate ER...... 17 Monohydrate...... 73 Erlotinib HCl...... 29 Dexamethasone...... 45 Dronabinol...... 23 Ertaczo...... 49 Dexamethasone Duavee...... 56 Erythrocin Stearate.....61 Intensol...... 45 Duloxetine HCl...... 17 Erythromycin...... 49, 67 Dexamethasone Sodium Durezol...... 67 Erythromycin Base...... 61 Phosphate...... 45, 67 Dutasteride...... 58 Erythromycin Dexmethylphenidate HCl.. 3 Econazole Nitrate...... 49 Ethylsuccinate...... 61 Dextroamphetamine Edurant...... 37 Escitalopram Oxalate 17, 18 Sulfate...... 3 Efavirenz...... 37 Est Estrogens-Methyltest 56 Dextroamphetamine Efavirenz-Emtricitab- Est Estrogens-Methyltest Sulfate ER...... 3 Tenofovir...... 37 HS...... 56
83 Estradiol...... 56, 78 Finasteride...... 49, 58 Fosfomycin Estradiol Valerate...... 56 Firmagon...... 30 Tromethamine...... 27 Estropipate...... 56 Flavoxate HCl...... 75 Fosinopril Sodium...... 26 Eszopiclone...... 60 Flecainide Acetate...... 10 Frovatriptan Succinate....62 Ethacrynic Acid...... 53 Flovent Diskus...... 12 Fulphila...... 59 Ethambutol HCl...... 28 Flovent HFA...... 12 Furosemide...... 53 Ethosuximide...... 15 Fluad...... 76 Fuzeon...... 38 Ethynodiol Diac-Eth Fluad Quadrivalent..... 76 Fycompa...... 15 Estradiol...... 44 Fluarix Quadrivalent... 77 Gabapentin...... 15 Etidronate Disodium...... 55 Flublok Quadrivalent...77 Galantamine Etodolac...... 4 Flucelvax Hydrobromide...... 72 Etodolac ER...... 4 Quadrivalent...... 77 Galantamine Etonogestrel-Ethinyl Fluconazole...... 23 Hydrobromide ER...... 72 Estradiol...... 44 Flucytosine...... 23 Gardasil 9...... 77 Etoposide...... 29 Fludrocortisone Acetate.. 45 Gatifloxacin...... 67 Eucrisa...... 49 Flulaval Quadrivalent.. 77 Gemfibrozil...... 24 Eurax...... 49 Flunisolide...... 65 Gentak...... 67 Everolimus...... 29, 40, 63 Fluocinolone Acetonide Gentamicin Sulfate... 50, 67 Evotaz...... 38 ...... 49, 70 Genvoya...... 38 Exelderm...... 49 Fluocinonide...... 49, 50 Gilenya...... 72 Exemestane...... 29 Fluocinonide Emulsified Gilotrif...... 30 EZ Flu Shot-Flucelvax Base...... 49 Glatopa...... 72 Quad...... 76 Fluorometholone...... 67 Gleostine...... 30 Ezetimibe...... 24 Fluorouracil...... 50 Glimepiride...... 20 Factive...... 57 Fluoxetine HCl...... 18 Glipizide...... 20 Famciclovir...... 38 Fluphenazine Decanoate. 34 Glipizide ER...... 20 Famotidine...... 75 Fluphenazine HCl...... 35 Glucagon Emergency...... 20 Fanapt...... 34 Flurazepam HCl...... 60 Glyburide...... 20 Fanapt Titration Pack..34 Flurbiprofen...... 4 Glyburide Micronized...... 20 Farxiga...... 20 Flurbiprofen Sodium...... 67 Glycopyrrolate...... 75 Farydak...... 29 Flutamide...... 30 Granisetron HCl...... 23 FC2 Female Condom... 61 Fluticasone Propionate Griseofulvin Microsize.....23 Febuxostat...... 58 ...... 50, 65 Guaifenesin DAC...... 46 Felbamate...... 15 Fluticasone-Salmeterol... 12 Guaifenesin-Codeine...... 46 Felodipine ER...... 42 Fluvastatin Sodium...... 24 Guanfacine HCl...... 26 FemCap...... 62 Fluvoxamine Maleate...... 18 Guanfacine HCl ER...... 3 Fenofibrate...... 24 Fluzone...... 77 Guanidine HCl...... 28 Fenofibric Acid...... 24 Fluzone High-Dose...... 77 Gynazole-1...... 78 Fenoprofen Calcium...... 4 Fluzone High-Dose Halobetasol Propionate... 50 Fentanyl...... 7 Quadrivalent...... 77 Haloperidol...... 35 Fentanyl Citrate (PF)...... 7 Fluzone Preservative Haloperidol Decanoate....35 Ferocon...... 59 Free...... 77 Haloperidol Lactate...... 35 Ferriprox...... 22 Fluzone Quadrivalent.. 77 Havrix...... 77, 78 Fetzima...... 18 FML...... 67 Heparin Sodium Fetzima Titration...... 18 FML Forte...... 67 (Porcine)...... 14 Fiasp...... 20 Folic Acid...... 59 Hexalen...... 30 Fiasp FlexTouch...... 20 Fondaparinux Sodium.....14 Homatropine HBr...... 67 Fiasp PenFill...... 20 Fosamprenavir Calcium.. 38 Humira...... 5 Finacea...... 49
84 Humira Pediatric Intrarosa...... 78 Lamotrigine Starter Kit- Crohns Start...... 5 Intron A...... 30 Green...... 16 Humira Pen...... 5 Invega Sustenna...... 35 Lamotrigine Starter Kit- Humira Pen- Invirase...... 38 Orange...... 16 CD/UC/HS Starter...... 5 Ipratropium Bromide 12, 65 Lansoprazole...... 75 Humira Pen- Ipratropium-Albuterol.....12 Lanthanum Carbonate.... 57 Ps/UV/Adol HS Start.... 5 Irbesartan...... 26 Lastacaft...... 67 Humulin R U-500 Iressa...... 30 Latanoprost...... 67 (Concentrated)...... 20 Irinotecan HCl...... 30 Latuda...... 35 Humulin R U-500 Isentress...... 38 Leflunomide...... 5 KwikPen...... 20 Isentress HD...... 38 Lenvima (10 MG Daily Hydralazine HCl...... 26 Isometheptene- Dose)...... 30 Hydrochlorothiazide...... 53 Dichloral-APAP...... 62 Lenvima (12 MG Daily Hydrocodone- Isoniazid...... 28 Dose)...... 31 Acetaminophen...... 7 Isosorbide Dinitrate...... 9 Lenvima (14 MG Daily Hydrocodone- Isosorbide Mononitrate Dose)...... 31 Homatropine...... 46 ER...... 9 Lenvima (18 MG Daily Hydrocodone-Ibuprofen....7 Isotretinoin...... 50 Dose)...... 31 Hydrocortisone.....9, 45, 50 Isradipine...... 42 Lenvima (20 MG Daily Hydrocortisone Acetate.... 9 Itraconazole...... 23 Dose)...... 31 Hydrocortisone-Acetic Ivermectin...... 9, 50 Lenvima (24 MG Daily Acid...... 70 Jakafi...... 30 Dose)...... 31 Hydromorphone HCl...... 7 Januvia...... 20 Lenvima (4 MG Daily Hydroxychloroquine Juluca...... 38 Dose)...... 31 Sulfate...... 28 Junel FE 1.5/30...... 44 Lenvima (8 MG Daily Hydroxyurea...... 30 Junel FE 1/20...... 44 Dose)...... 31 Hydroxyzine HCl...... 10 Kaletra...... 38 Letrozole...... 31 Hydroxyzine Pamoate.....10 Kalydeco...... 73 Leucovorin Calcium...... 31 Hyoscyamine Sulfate...... 75 Kelnor 1/35...... 44 Leukeran...... 31 Hyoscyamine Sulfate ER. 75 Kenalog...... 45 Leuprolide Acetate...... 31 Ibandronate Sodium...... 55 Ketoconazole...... 23, 50 Levalbuterol Tartrate...... 12 Ibrance...... 30 Ketoprofen...... 5 Levemir...... 20 Ibuprofen...... 5 Ketorolac Tromethamine Levemir FlexTouch...... 20 Icatibant Acetate...... 59 ...... 5, 67 Levetiracetam...... 16 Iclusig...... 30 Kevzara...... 5 Levetiracetam ER...... 16 Idhifa...... 30 Kineret...... 5 Levobunolol HCl...... 68 Ilevro...... 67 Kombiglyze XR...... 20 Levocetirizine Imatinib Mesylate...... 30 K-Phos...... 63 Dihydrochloride...... 24 Imbruvica...... 30 Kyleena...... 44 Levofloxacin...... 57, 68 Imipramine HCl...... 18 Kynamro...... 25 Levonorgest-Eth Estrad Imiquimod...... 50 Labetalol HCl...... 41 91-Day...... 44 Increlex...... 55 Lactulose...... 61 Levonorgestrel...... 44 Incruse Ellipta...... 12 Lactulose Levonorgestrel-Ethinyl Indapamide...... 53 Encephalopathy...... 57 Estrad...... 44 Indomethacin...... 5 Lamivudine...... 38 Levorphanol Tartrate...... 7 Indomethacin ER...... 5 lamiVUDine-Zidovudine.. 38 Levothyroxine Sodium.... 74 Inlyta...... 30 Lamotrigine...... 15 Lexiva...... 38 Insulin Syringe...... 62 Lamotrigine Starter Kit- Lidocaine...... 50 Intelence...... 38 Blue...... 15 Lidocaine Viscous...... 64
85 Lidocaine-Prilocaine...... 50 Mesalamine...... 57 Morphine Sulfate Lindane...... 51 Mesnex...... 31 (Concentrate)...... 8 Linezolid...... 27 Metaproterenol Sulfate... 12 Morphine Sulfate ER...... 8 Linzess...... 57 Metaxalone...... 65 Motofen...... 22 Liothyronine Sodium...... 74 Metformin HCl...... 20 Movantik...... 57 Lisinopril...... 26 Metformin HCl ER...... 20 Moxifloxacin HCl...... 68 Lisinopril- Methadone HCl...... 7 Multaq...... 10 Hydrochlorothiazide...... 26 Methamphetamine HCl..... 3 Multi-Vit/Fluoride...... 64 Lithium...... 35 methazolAMIDE...... 54 Multi-Vit/Fluoride/Iron.... 64 Lithium Carbonate...... 35 Methenamine Hippurate..27 Multivitamin/Fluoride...... 64 Lithium Carbonate ER.....35 Methergine...... 70 Mupirocin...... 51 Livalo...... 25 Methimazole...... 74 Mycophenolate Mofetil Lokelma...... 40, 63 Methocarbamol...... 65 ...... 40, 63 Lonsurf...... 31 Methotrexate...... 31 Mycophenolate Sodium Loperamide HCl...... 22 Methotrexate Sodium..... 32 ...... 41, 64 Lopinavir-Ritonavir...... 38 Methotrexate Sodium Myrbetriq...... 76 Lorazepam...... 10 (PF)...... 32 Nabumetone...... 6 Losartan Potassium...... 26 Methoxsalen Rapid...... 51 Nadolol...... 41 Losartan Potassium- Methscopolamine Naftifine HCl...... 51 HCTZ...... 26 Bromide...... 75 Nalbuphine HCl...... 8 Lotemax...... 68 Methyclothiazide...... 54 Naloxone HCl...... 22 Loteprednol Etabonate....68 Methyldopa...... 26 Naltrexone HCl...... 22 Lovastatin...... 25 Methylphenidate HCl.... 3, 4 Naproxen...... 6 Loxapine Succinate...... 35 Methylphenidate HCl ER... 3 Naratriptan HCl...... 62 Lumigan...... 68 Methylphenidate HCl ER Narcan...... 22 Lynparza...... 31 (CD)...... 3 Natacyn...... 68 Lysodren...... 31 Methylprednisolone...... 45 Nateglinide...... 20 Malathion...... 51 Methylprednisolone Necon 1/50 (28)...... 44 Maprotiline HCl...... 18 Acetate...... 45 Necon 10/11 (28)...... 44 Marplan...... 18 Metipranolol...... 68 Nefazodone HCl...... 18 Matulane...... 31 Metoclopramide HCl...... 57 Neomycin Sulfate...... 4 Mavyret...... 38 Metolazone...... 54 Neomycin-Bacitracin Zn- Meclizine HCl...... 23 Metoprolol Succinate ER. 41 Polymyx...... 68 Meclofenamate Sodium.... 5 Metoprolol Tartrate...... 41 Neomycin-Polymyxin- Medroxyprogesterone Metronidazole.....27, 51, 78 Dexameth...... 68 Acetate...... 44, 71 Mexiletine HCl...... 10 Neomycin-Polymyxin- Mefenamic Acid...... 6 Midodrine HCl...... 79 Gramicidin...... 68 Mefloquine HCl...... 28 Migergot...... 62 Neomycin-Polymyxin-HC Megestrol Acetate...... 31 Miglustat...... 59 ...... 68, 70 Mekinist...... 31 Minocycline HCl...... 73 Nerlynx...... 32 Meloxicam...... 6 Minoxidil...... 26 Neupro...... 33, 34 Melphalan...... 31 Mirena (52 MG)...... 44 Nevanac...... 68 Memantine HCl...... 72 Mirtazapine...... 18 Nevirapine...... 38 Menactra...... 78 Misoprostol...... 75 Nevirapine ER...... 38 Menest...... 56 Modafinil...... 4 NexAVAR...... 32 Menveo...... 78 Moexipril HCl...... 26 Nexplanon...... 44 Meperidine HCl...... 7 Mometasone Furoate 51, 65 Niacin ER Meprobamate...... 10 Montelukast Sodium. 12, 13 (Antihyperlipidemic)...... 25 Mercaptopurine...... 31 Morphine Sulfate...... 8 Nicardipine HCl...... 42
86 Nicotine...... 72 Odomzo...... 32 Paxil...... 18 Nicotine Polacrilex...... 72 Ofloxacin...... 68, 70 PEG-3350/Electrolytes....61 Nicotrol...... 72 Ogestrel...... 44 Peganone...... 16 Nifedipine...... 42 Olanzapine...... 35 Pegasys...... 39 Nifedipine ER...... 42 Olmesartan Medoxomil... 26 PegIntron...... 39 Nikki...... 44 Olmesartan Medoxomil- Pen Needle...... 62 Nilutamide...... 32 HCTZ...... 26 Penicillamine...... 64 Nimodipine...... 42 Olopatadine HCl...... 65, 68 Penicillin V Potassium70, 71 Ninlaro...... 32 Omega-3-acid Ethyl Pentamidine Isethionate. 27 Nisoldipine ER...... 42 Esters...... 25 Pentoxifylline ER...... 59 Nitisinone...... 55 Omeprazole...... 75 Perindopril Erbumine...... 26 Nitro-Bid...... 9 Omnitrope...... 55 Permethrin...... 51 Nitrofurantoin Ondansetron...... 23 Perphenazine...... 36 Macrocrystal...... 27 Ondansetron HCl...... 23 Phenelzine Sulfate...... 18 Nitrofurantoin Monohyd Onglyza...... 21 Phenobarbital...... 60 Macro...... 27 Opsumit...... 42 Phenoxybenzamine HCl.. 26 Nitroglycerin...... 9 Options Gynol II Phenytoin...... 16 Nitroglycerin ER...... 9 Contraceptive...... 78 Phenytoin Sodium Nitrostat...... 9 Orencia...... 6 Extended...... 16 Nivestym...... 59 Orenitram...... 42 Phospha 250 Neutral.. 63 Nizatidine...... 75 Oriahnn...... 56 Phospholine Iodide..... 68 Norethindrone Acetate....71 Orilissa...... 55 Phytonadione...... 79 Norpace CR...... 10 Orphenadrine Citrate ER. 65 Pifeltro...... 39 Nortrel 0.5/35 (28).... 44 Orsythia...... 44 Pilocarpine HCl...... 64, 68 Nortrel 1/35 (28)...... 44 Oseltamivir Phosphate Pimecrolimus...... 52 Nortriptyline HCl...... 18 ...... 38, 39 Pimozide...... 72 Norvir...... 38 OsmoPrep...... 61 Pindolol...... 41 Novolin 70/30...... 21 Oxandrolone...... 9 Pioglitazone HCl...... 21 Novolin 70/30 Oxcarbazepine...... 16 Piroxicam...... 6 Flexpen...... 21 Oxiconazole Nitrate...... 51 Plenvu...... 61 Novolin N...... 21 Oxistat...... 51 Pneumovax 23...... 78 NovoLIN N FlexPen..... 21 Oxybutynin Chloride...... 76 PNV Prenatal Plus Novolin R...... 21 Oxybutynin Chloride ER.. 76 Multivitamin...... 64 NovoLIN R FlexPen..... 21 Oxycodone HCl...... 8 Podofilox...... 52 Novolog...... 21 Oxycodone- Polymyxin B- Novolog Flexpen...... 21 Acetaminophen...... 8 Trimethoprim...... 68 Novolog Mix 70/30..... 21 oxyCODONE-Ibuprofen.....8 Pomalyst...... 32 Novolog Mix 70/30 Oxymorphone HCl ER...... 8 Posaconazole...... 23 Flexpen...... 21 Paliperidone ER...... 35 Potassium Bicarbonate... 63 Novolog Penfill...... 21 Pancreaze...... 53 Potassium Chloride...... 63 Noxafil...... 23 Panretin...... 51 Potassium Chloride ER....63 Nucala...... 13 Pantoprazole Sodium...... 75 Potassium Citrate ER...... 58 Nucynta ER...... 8 Paragard Intrauterine Potassium Citrate-Citric Nuedexta...... 72 Copper...... 45 Acid...... 58 Nystatin...... 23, 51, 64 Paricalcitol...... 55 Potiga...... 16 Nystatin-Triamcinolone...51 Paromomycin Sulfate...... 4 Pradaxa...... 14 Ocrevus...... 72 Paroxetine HCl...... 18 Pramipexole Octreotide Acetate...... 55 Paroxetine HCl ER...... 18 Dihydrochloride...... 33, 34 Odefsey...... 38 Paser...... 28 Prasugrel HCl...... 59
87 Pravastatin Sodium...... 25 Pyridostigmine Bromide Ropinirole HCl ER..... 33, 34 Praziquantel...... 9 ER...... 28 Rosuvastatin Calcium..... 25 Prazosin HCl...... 26 Pyrimethamine...... 28 Rozlytrek...... 32 Pred Mild...... 68 Qtern...... 21 Rufinamide...... 16 Pred-G...... 68 Quetiapine Fumarate...... 36 Rydapt...... 32 Pred-G S.O.P...... 69 Quetiapine Fumarate ER. 36 Salsalate...... 6 Prednicarbate...... 52 Quinapril HCl...... 26 Samsca...... 55 Prednisolone...... 46 Quinidine Gluconate ER.. 11 Santyl...... 52 Prednisolone Acetate...... 69 Quinidine Sulfate...... 11 Saphris...... 36 Prednisolone Sodium Quinine Sulfate...... 28 Sapropterin Phosphate...... 46, 69 Qvar RediHaler...... 13 Dihydrochloride...... 55 Prednisone...... 46 Rabeprazole Sodium...... 75 Savella...... 73 Pregabalin...... 16 Radiogardase...... 22 Savella Titration Pack. 73 Premarin...... 56, 78 Raloxifene HCl...... 55 Selegiline HCl...... 33 Premphase...... 56 Ramelteon...... 60 Selenium Sulfide...... 52 Prempro...... 56 Ramipril...... 27 Selzentry...... 39 Prepopik...... 61 Ranolazine ER...... 10 Serevent Diskus...... 13 Prevnar 13...... 78 Rasagiline Mesylate.. 33, 34 Sertraline HCl...... 18, 19 Prezcobix...... 39 Rebif...... 73 Sevelamer Carbonate..... 58 Prezista...... 39 Rebif Rebidose...... 72 SF...... 64 Priftin...... 28 Rebif Rebidose Shingrix...... 78 Primaquine Phosphate.... 28 Titration Pack...... 72 Sildenafil Citrate...... 42 Primidone...... 16 Rebif Titration Pack.... 73 Silodosin...... 58 Probenecid...... 58 Recombivax HB...... 78 Silver Sulfadiazine...... 52 Prochlorperazine...... 36 Regranex...... 52 Simponi...... 6 Prochlorperazine Maleate 36 Relenza Diskhaler...... 39 Simvastatin...... 25 Proctozone-HC...... 9 Relistor...... 57, 58 Sirolimus...... 64 Progesterone...... 71 Repaglinide...... 21 Sirturo...... 29 Progesterone Micronized. 71 Repatha...... 25 Skyla...... 45 Prolia...... 55 Repatha Pushtronex Sodium Fluoride...... 63 Promacta...... 59, 60 System...... 25 Sodium Polystyrene Promethazine HCl...... 24 Repatha SureClick...... 25 Sulfonate...... 41, 64 Promethazine VC...... 46 Rescriptor...... 39 Solifenacin Succinate..... 76 Promethazine Restasis...... 69 Somatuline Depot...... 55 VC/Codeine...... 46 Retacrit...... 60 Sotalol HCl...... 41 Promethazine-Codeine....46 Revlimid...... 41, 64 Spinosad...... 52 Promethazine-DM...... 46 Reyataz...... 39 Spironolactone...... 54 Propafenone HCl...... 11 Ribavirin...... 39 Spironolactone-HCTZ..... 54 Propantheline Bromide... 75 Rifabutin...... 28 Sprintec 28...... 45 Proparacaine HCl...... 69 rifAMPin...... 28 Sprycel...... 32 Propranolol HCl...... 41 Riluzole...... 65 Stavudine...... 39 Propranolol HCl ER...... 41 riMANTAdine HCl...... 39 Stimate...... 55 Propylthiouracil...... 74 Risedronate Sodium...... 55 Stivarga...... 32 Protriptyline HCl...... 18 RisperDAL Consta...... 36 Stribild...... 39 Pseudoeph-Bromphen- Risperidone...... 36 Striverdi Respimat...... 13 DM...... 46 Ritonavir...... 39 Sucralfate...... 75 Pulmozyme...... 73 Rivastigmine Tartrate..... 73 Sulfacetamide Sodium....69 Pyrazinamide...... 28 Rizatriptan Benzoate...... 62 Sulfacetamide- Pyridostigmine Bromide.. 28 Ropinirole HCl...... 33, 34 Prednisolone...... 69
88 Sulfadiazine...... 73 Thiothixene...... 36 Trimethoprim...... 28 Sulfamethoxazole- Thyrolar-1...... 74 Trimipramine Maleate.....19 Trimethoprim...... 27, 28 Thyrolar-1/2...... 74 Trinate...... 64 Sulfamylon...... 52 Thyrolar-1/4...... 74 Trintellix...... 19 Sulfasalazine...... 58 Thyrolar-2...... 74 Tri-Sprintec...... 45 Sulindac...... 6 Thyrolar-3...... 74 Triumeq...... 39 Sumatriptan...... 63 Tiagabine HCl...... 16 Tropicamide...... 69 Sumatriptan Succinate... 63 Ticlopidine HCl...... 59 Trospium Chloride...... 76 Suprep Bowel Prep Kit 61 Timolol Maleate...... 42, 69 Trospium Chloride ER..... 76 Sutent...... 32 Tivicay...... 39 Trumenba...... 78 Sylatron...... 32 Tizanidine HCl...... 65 Truvada...... 40 Symjepi...... 79 Tobi Podhaler...... 4 Tybost...... 40 SymlinPen 120...... 21 TobraDex...... 69 Tykerb...... 32 SymlinPen 60...... 21 Tobramycin...... 69 Tymlos...... 55 Symtuza...... 39 Tobramycin Sulfate...... 4 Tyzeka...... 40 Synarel...... 55 Tobramycin- Udenyca...... 60 Synera...... 52 Dexamethasone...... 69 Urea...... 53 Tacrolimus...... 41, 52, 64 Tobrex...... 69 Ursodiol...... 58 Tadalafil...... 43 Today Sponge...... 79 Valacyclovir HCl...... 40 Tadalafil (PAH)...... 43 Tolazamide...... 22 Valganciclovir HCl...... 40 Tafinlar...... 32 Tolbutamide...... 22 Valproate Sodium...... 16 Tagrisso...... 32 Tolcapone...... 34 Valproic Acid...... 16 Tamoxifen Citrate...... 32 Tolmetin Sodium...... 6 Valsartan...... 27 Tamsulosin HCl...... 58 Tolterodine Tartrate...... 76 Vancomycin HCl...... 28 Tasigna...... 32 Tolvaptan...... 55 Vaqta...... 78 Tazarotene...... 52 Topiramate...... 16 Vascepa...... 25 Tazorac...... 52 Torsemide...... 54 VCF Vaginal Telmisartan...... 27 Toviaz...... 76 Contraceptive...... 79 Temazepam...... 60 Tramadol HCl...... 8 Velphoro...... 58 Temixys...... 39 Tramadol HCl ER...... 8 Venclexta...... 32 Temozolomide...... 32 Trandolapril...... 27 Venclexta Starting Tenofovir Disoproxil Tranexamic Acid...... 60 Pack...... 32 Fumarate...... 39 Tranylcypromine Sulfate. 19 Venlafaxine HCl...... 19 Terazosin HCl...... 27 Travoprost (BAK Free)....69 Venlafaxine HCl ER...... 19 Terbinafine HCl...... 23 Trazodone HCl...... 19 Ventavis...... 43 Terbutaline Sulfate...... 13 Trecator...... 29 Ventolin HFA...... 13 Terconazole...... 79 Trelegy Ellipta...... 13 Verapamil HCl...... 42 Testosterone...... 9 Tresiba...... 22 Verapamil HCl ER...... 42 Testosterone Cypionate.... 9 Tresiba FlexTouch...... 22 Vexol...... 69 Testosterone Enanthate....9 Tretinoin...... 32, 52 Victoza...... 22 Tetanus-Diphtheria Triamcinolone Acetonide Victrelis...... 40 Toxoids Td...... 74 ...... 46, 52, 64 Videx...... 40 Tetrabenazine...... 73 Triamterene...... 54 Videx EC...... 40 Tetracaine HCl...... 69 Triamterene-HCTZ...... 54 Viibryd...... 19 Tetracycline HCl...... 73 Trifluoperazine HCl...... 36 Viibryd Starter Pack....19 Thalomid...... 41, 64 Trifluridine...... 69 Vimpat...... 16 Theophylline...... 13 Trihexyphenidyl HCl..33, 34 Viracept...... 40 Theophylline ER...... 13 Tri-Lo-Sprintec...... 45 Viread...... 40 Thioridazine HCl...... 36 Trimethobenzamide HCl..23
89 Vitamin D (Ergocalciferol)...... 79 Vitamin D3...... 79 Voriconazole...... 24 Votrient...... 32 Warfarin Sodium...... 14 Wixela Inhub...... 13 Xalkori...... 33 Xarelto...... 14 Xarelto Starter Pack....14 Xartemis XR...... 8 Xeljanz...... 6 Xeljanz XR...... 6 Xeomin...... 65 Xigduo XR...... 22 Xolair...... 13 Xtandi...... 33 Xulane...... 45 Xyrem...... 73 Zafirlukast...... 13 Zaleplon...... 60 Zarxio...... 60 Zejula...... 33 Zelboraf...... 33 Zenpep...... 53 Zepatier...... 40 Zerit...... 40 Zidovudine...... 40 Zileuton ER...... 13 Zinbryta...... 73 Ziprasidone HCl...... 36 Ziprasidone Mesylate...... 36 Zirgan...... 69 Zoledronic Acid...... 56 Zolinza...... 33 Zolmitriptan...... 63 Zolpidem Tartrate...... 60 Zonisamide...... 17 Zontivity...... 59 Zortress...... 64 Zovia 1/35E (28)...... 45 Zydelig...... 33 Zykadia...... 33 Zyprexa Relprevv...... 36
90
Discrimination is Against the Law
Florida Health Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Health Care Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Florida Health Care Plans: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as: o Qualified Interpreters o Information written in other languages
If you need these services, contact: Florida Health Care Plans : 1-877-615-4022
If you believe that Florida Health Care Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Florida Health Care Plans Civil Rights Coordinator 1340 Ridgewood Avenue, Holly Hill, FL 32117. Phone: 1-844-219-6137, TTY: 1-800-955-8770 Fax: 386-676-7149, Email: [email protected].
You can file grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator 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, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
H1035_NR861 (04/23/2018)
If you or someone you’re helping has questions about Florida Health Care Plans, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-877-615-4022. (TTY: TRS Relay 711)
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Jeśli Ty lub ktoś, komu pomagasz macie pytania dotyczące Florida Health Care Plans, macie prawo uzyskać pomoc i informacje w swoim języku, bez żadnych kosztów. Porozmawiaj z tłumaczem, zadzwoń pod numer 1-877-615-4022. (TTY: TRS Relay 711)
જો તમને અથવા તમે 狇ને મદદ કરી રા廒 છો તેમને Florida Health Care Plans વવશે કોઈ પ્રશ્નો હોય, તો તમને તમારી ભાષામા廒 કોઇ પણ ખર્ચ વવના મદદ અને માહહતી મેળવવાનો હક છે. દુ ભાવષયા સાથે વાત કરવા માટે 1-877-615-4022. (TTY: TRS Relay 711) પર ફોન કરો.
หากคุณ หรือคนที่คุณก าลังช่วยเหลืออยู่มีค าถามเกี่ยวกับ Florida Health Care Plans คุณจะได้รับการช่วยเหลือและได้รับข้อมูลในภาษาของคุณโดยที่ไม่มีค่าใช้จ่ายใดๆ หากต้องการพูดคุยกับล่ามแปลภาษา โทร. 1-877-615-4022. (TTY: TRS Relay 711)
Florida Health Care Plan, Inc. d/b/a Florida Health Care Plans (“FHCP”) offers health insurance coverage products. FHCP is an affiliate of Blue Cross and Blue Shield of Florida, d/b/a Florida Blue. Both companies are Independent Licensees of the Blue Cross and Blue Shield Association. H1035_A5225 CMS Approved (06/08/2016)