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1 Analgesics Gout Miscellaneous Nsaids Opioid Analgesics 2016 State of New York eff 08/01/2016 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits ANALGESICS NAPRELAN 3 GOUT NAPROSYN TABS 3 allopurinol tab 1 naproxen SUSP; TABS; 1 ALOPRIM 3 TBEC naproxen sodium colchicine w/ probenecid 1 TABS 1 275mg, 550mg COLCRYS 2 naproxen sodium TB24 3 probenecid 1 375mg ULORIC 2 NAPROXEN SODIUM TB24 3 ZYLOPRIM 3 500mg MISCELLANEOUS oxaprozin 1 ARTHROTEC 50 3 piroxicam CAPS 1 ARTHROTEC 75 3 PONSTEL 3 diclofenac w/ misoprostol 1 sulindac TABS 1 NSAIDS tolmetin sodium 1 ANAPROX DS 3 VIVLODEX 3 CELEBREX CAP 50MG 3 OPIOID ANALGESICS CELEBREX CAP 100MG 3 acetaminophen w/ codeine 1 QL SOLN CELEBREX CAP 200MG 3 QL (5000 mL / 30 days) CELEBREX CAP 400MG 3 acetaminophen w/ codeine 1 QL celecoxib CAPS 1 TABS DAYPRO 3 QL (400 tabs / 30 days) diclofenac potassium 1 acetaminophen-caff- 1 QL dihydrocod diclofenac sodium TB24; 1 QL (360 caps / 30 days) TBEC ASPIRIN-CAFFEINE- 1 diflunisal 1 DIHYDROCODEINE EC-NAPROSYN 3 BITARTRATE etodolac 1 BELBUCA 3 etodolac er 1 butorphanol nasal spray 1 FELDENE 3 butorphanol tartrate SOLN 1 FENOPROFEN CALCIUM 1 BUTRANS 5mcg/hr 2 QL CAPS 400mg QL (16 patches / 28 fenoprofen calcium TABS 1 days) flurbiprofen TABS 1 BUTRANS 7.5mcg/hr, 2 QL 10mcg/hr ibuprofen SUSP 1 QL (8 patches / 28 days) ibuprofen TABS 400mg, 1 BUTRANS 15mcg/hr, 2 QL 600mg, 800mg 20mcg/hr ketoprofen CAPS; CP24 1 QL (4 patches / 28 days) mefenamic acid CAPS 1 capital and codeine 3 QL QL (5000 mL / 30 days) MELOXICAM SUSP 1 nalbuphine hcl SOLN 1 meloxicam tabs 1 SYNALGOS-DC 3 MOBIC 3 TRAMADOL HCL CP24 1 nabumetone TABS 1 tramadol hcl er TB24 100mg, 1 NALFON 3 200mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 1 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits TRAMADOL HCL ER TB24 1 fentanyl citrate LPOP 3 QL PA 300mg QL (120 lozenges / 30 tramadol hcl er (biphasic) 1 days) 100mg fentanyl patch 12 mcg/hr 1 QL tramadol hcl er (biphasic) 1 QL (10 patches / 30 200mg days) tramadol hcl er (biphasic) 1 fentanyl patch 25 mcg/hr 1 QL 300mg QL (10 patches / 30 days) tramadol hcl tab 50 mg 1 fentanyl patch 50 mcg/hr 1 QL tramadol-acetaminophen 1 QL QL (10 patches / 30 QL (240 tabs / 30 days) days) trezix 3 QL fentanyl patch 75 mcg/hr 1 QL QL (360 caps / 30 days) QL (10 patches / 30 tylenol with codeine 3 QL days) QL (400 tabs / 30 days) fentanyl patch 100 mcg/hr 1 QL ULTRACET 3 QL QL (10 patches / 30 QL (240 tabs / 30 days) days) ULTRAM 3 FENTORA 3 QL PA ULTRAM ER 3 QL (120 tabs / 30 days) ULTRAM ER TAB 100MG 3 hycet 3 QL QL (5400 mL / 30 days) ULTRAM ER TAB 200MG 3 hydrocodone-acetaminophen 1 QL OPIOID ANALGESICS, CII 2.5-325mg ABSTRAL 3 QL PA QL (360 tabs / 30 days) QL (120 tabs / 30 days) hydrocodone-acetaminophen 1 QL ACTIQ 3 QL PA 5-300mg QL (120 lozenges / 30 QL (400 tabs / 30 days) days) hydrocodone-acetaminophen 1 QL CODEINE SULFATE 1 5-325mg QL (360 tabs / 30 days) DILAUDID INJ 3 B/D hydrocodone-acetaminophen 1 QL DILAUDID TAB 3 7.5-300mg DILAUDID-5 ORAL LIQD 3 QL (400 tabs / 30 days) DILAUDID-HP INJ 10MG/ML 3 B/D hydrocodone-acetaminophen 1 QL DILAUDID-HP INJ 250MG 3 B/D 7.5-325 mg/15ml QL (5400 mL / 30 days) DOLOPHINE 3 QL QL (240 tabs / 30 days) hydrocodone-acetaminophen 1 QL 7.5-325mg DURAGESIC 3 QL QL (360 tabs / 30 days) QL (10 patches / 30 days) hydrocodone-acetaminophen 1 QL 10-300mg DURAMORPH 1 B/D QL (400 tabs / 30 days) EMBEDA 3 QL hydrocodone-acetaminophen 1 QL QL (60 caps / 30 days) tab 10-325mg endocet 1 QL QL (360 tabs / 30 days) QL (360 tabs / 30 days) hydrocodone-ibuprofen tab 1 EXALGO 3 QL 2.5-200mg QL (60 tabs / 30 days) hydrocodone-ibuprofen tab 5- 1 200mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 2 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits hydrocodone-ibuprofen tab 1 methadone hcl SOLN 1 QL 7.5-200 mg QL (600 mL / 30 days) hydrocodone-ibuprofen tab 1 methadone hcl TABS 1 QL 10-200mg QL (240 tabs / 30 days) hydromorphone hcl LIQD 1 METHADONE INJ 10MG/ML 3 HYDROMORPHONE HCL 1 B/D METHADOSE CONC 3 QL SOLN 1mg/ml, 2mg/ml, QL (120 mL / 30 days) 4mg/ml MORPHINE SUL 20MG/ML 1 hydromorphone hcl SOLN 1 B/D ORAL SOL 500mg/50ml morphine sulfate CP24 1 QL hydromorphone hcl TABS 1 10mg, 20mg, 30mg, 50mg, hydromorphone tab 8mg er 1 QL 60mg QL (60 tabs / 30 days) QL (60 caps / 30 days) hydromorphone tab 12mg er 1 QL morphine sulfate CP24 3 QL QL (60 tabs / 30 days) 80mg, 100mg QL (60 caps / 30 days) hydromorphone tab 16mg er 3 QL QL (60 tabs / 30 days) MORPHINE SULFATE SOLN 1 B/D 1mg/ml, 10mg/ml, 15mg/ml HYDROMORPHONE TABS 3 QL 32MG MORPHINE SULFATE SOLN 3 B/D QL (60 tabs / 30 days) 2mg/ml, 4mg/ml, 8mg/ml HYSINGLA ER 20mg, 30mg, 2 QL MORPHINE SULFATE SOLN 1 40mg, 60mg 10mg/5ml, 20mg/5ml QL (60 tabs / 30 days) morphine sulfate SOLN 1 B/D HYSINGLA ER 80mg, 3 QL .5mg/ml, 1mg/ml, 4mg/ml, 100mg, 120mg 8mg/ml QL (30 tabs / 30 days) MORPHINE SULFATE TABS 1 ibudone tab 5-200mg 1 morphine sulfate beads 1 QL ibudone tab 10-200mg 1 QL (60 caps / 30 days) INFUMORPH 200 3 B/D morphine sulfate ext-rel tab 1 QL 15mg, 30mg, 60mg, 100mg INFUMORPH 500 3 B/D QL (90 tabs / 30 days) KADIAN 3 QL morphine sulfate ext-rel tab 1 QL QL (60 caps / 30 days) 200mg LAZANDA 3 QL PA QL (60 tabs / 30 days) QL (30 bottles / 30 days) MS CONTIN 15mg, 30mg, 3 QL levorphanol tartrate TABS 1 60mg, 100mg lorcet hd tab 10-325mg 1 QL QL (90 tabs / 30 days) QL (360 tabs / 30 days) MS CONTIN 200mg 3 QL lorcet plus tab 7.5-325 1 QL QL (60 tabs / 30 days) QL (360 tabs / 30 days) norco 3 QL lorcet tab 5-325mg 1 QL QL (360 tabs / 30 days) QL (360 tabs / 30 days) NUCYNTA 2 lortab tab 5-325mg 1 QL NUCYNTA ER 50mg, 100mg 2 QL QL (360 tabs / 30 days) QL (120 tabs / 30 days) lortab tab 7.5-325 1 QL NUCYNTA ER 150mg, 2 QL QL (360 tabs / 30 days) 200mg, 250mg lortab tab 10-325mg 1 QL QL (60 tabs / 30 days) QL (360 tabs / 30 days) OPANA TABS 3 methadone hcl CONC 1 QL QL (120 mL / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 3 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits OPANA ER (CRUSH 2 QL vicodin hp 1 QL RESISTANT QL (400 tabs / 30 days) QL (120 tabs / 30 days) VICOPROFEN 3 oxycodone hcl CAPS; CONC; 1 XARTEMIS XR 3 QL TABS QL (120 tabs / 30 days) OXYCODONE HCL SOLN 1 xodol tab 5-300mg 3 QL oxycodone w/ acetaminophen 1 QL QL (400 tabs / 30 days) 2.5-325mg xodol tab 7.5-300 3 QL QL (360 tabs / 30 days) QL (400 tabs / 30 days) oxycodone w/ acetaminophen 1 QL xodol tab 10-300mg 3 QL 5-325mg QL (400 tabs / 30 days) QL (360 tabs / 30 days) xylon tab 10-200mg 1 oxycodone w/ acetaminophen 1 QL 7.5-325mg zamicet 1 QL QL (360 tabs / 30 days) QL (5400 mL / 30 days) oxycodone w/ acetaminophen 1 QL ZOHYDRO ER (ABUSE 3 QL 10-325mg DETERRENT) 10mg, 15mg, QL (360 tabs / 30 days) 20mg QL (120 caps / 30 days) oxycodone w/ acetaminophen 1 QL soln 5-325 mg/5ml ZOHYDRO ER (ABUSE 3 QL QL (1800 mL / 30 days) DETERRENT) 30mg, 40mg, 50mg oxycodone-aspirin 1 QL (60 caps / 30 days) oxycodone-ibuprofen 1 ANESTHETICS OXYCONTIN 2 QL QL (120 tabs / 30 days) LOCAL ANESTHETICS lidocaine hcl (local anesth.) 1 oxymorphone hcl TABS 1 4% percocet 2.5/325 3 QL lidocaine hcl (local anesth.) 1 B/D QL (360 tabs / 30 days) .5%, 1% percocet 7.5/325 3 QL lidocaine inj 0.5% 1 B/D QL (360 tabs / 30 days) lidocaine inj 1% 1 B/D percocet 10/325 3 QL QL (360 tabs / 30 days) lidocaine inj 1.5% 1 B/D percocet tab 5-325mg 3 QL lidocaine inj 2% 1 B/D QL (360 tabs / 30 days) XYLOCAINE .5%, 1%, 2% 3 B/D reprexain tab 2.5-200mg 3 XYLOCAINE-MPF 4% 3 reprexain tab 5-200mg 3 XYLOCAINE-MPF .5%, 1%, 3 B/D reprexain tab 10-200mg 1 1.5%, 2% roxicet soln 2 QL ANTI-INFECTIVES QL (1800 mL / 30 days) ANTI-BACTERIALS - MISCELLANEOUS roxicet tab 5-325mg 1 QL amikacin sulfate SOLN 1 QL (360 tabs / 30 days) BETHKIS 3 B/D ROXICODONE 3 gentamicin in saline 0.8 mg/ml 1 SUBSYS 3 QL PA QL (120 sprays / 30 gentamicin in saline 0.9mg/ml 3 days) gentamicin in saline 1 mg/ml 1 vicodin 1 QL gentamicin in saline 1.2 mg/ml 1 QL (400 tabs / 30 days) gentamicin in saline 1.4mg/ml 3 vicodin es 1 QL gentamicin in saline 1.6 mg/ml 1 QL (400 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under 4 Medicare B or D LA - Limited Access 2016 State of New York eff 08/01/2016 Drug Name Drug Requirements/ Drug Name Drug Requirements/ Tier Limits Tier Limits gentamicin in saline 2 mg/ml 1 dapsone TABS 1 gentamicin sulfate SOLN 1 DARAPRIM 3 KITABIS PAK 3 B/D DORIBAX 3 neomycin sulfate TABS 1 FLAGYL 3 paromomycin sulfate CAPS 1 FURADANTIN 3 PA streptomycin sulfate SOLR 1 90 day limit per calendar year if 65 years and older sulfadiazine TABS 3 HIPREX 3 TOBI NEB 3 B/D imipenem-cilastatin 1 TOBI PODHALER 3 LA PA INVANZ 3 tobramycin NEBU 3 B/D ivermectin TABS 1 tobramycin sulfate SOLN; 1 SOLR linezolid SOLN 3 ANTI-INFECTIVES - MISCELLANEOUS LINEZOLID SUSR; TABS 3 ALBENZA 2 LINEZOLID IN SODIUM 3 CHLORIDE ALINIA 2 MACROBID 3 PA atovaquone SUSP 3 90 day limit per calendar AZACTAM 3 year if 65 years and older AZACTAM/DEX INJ 1GM 3 MACRODANTIN 3 PA 90 day limit per calendar AZACTAM/DEX INJ 2GM 3 year if 65 years and older aztreonam 1 MEPRON 3 BACTRIM 3 meropenem 1 BACTRIM DS 3 MEROPENEM/SODIUM 1 BILTRICIDE 2 CHLORIDE CAYSTON 2 LA PA MERREM 3 cleocin SOLR 3 methenamine hippurate 1 CLEOCIN CAP 75MG 3 METRO IV 3 CLEOCIN CAP 150MG 3 metronidazole
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