EXCHANGE_VA_9 Drug Name Drug Tier Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 5 mg amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 10 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 15 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 20 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 25 mg amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 30 mg amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 7.5 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days) 12.5 mg amphetamine-dextroamphetamine tab 15 1 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 20 1 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 30 1 QL (30 tabs / 25 days) mg dextroamphetamine sulfate cap sr 24hr 5 1 QL (120 caps / 25 days) mg dextroamphetamine sulfate cap sr 24hr 10 1 QL (120 caps / 25 days) mg dextroamphetamine sulfate cap sr 24hr 15 1 QL (60 tabs / 25 days) mg dextroamphetamine sulfate tab 5 mg 1 QL (120 tabs / 25 days) dextroamphetamine sulfate tab 10 mg 1 QL (120 tabs / 25 days) methamphetamine hcl tab 5 mg 1 QL (150 tabs / 25 days) VYVANSE CAP 20MG 3 PA VYVANSE CAP 30MG 3 PA VYVANSE CAP 40MG 3 PA VYVANSE CAP 50MG 3 PA VYVANSE CAP 60MG 3 PA VYVANSE CAP 70MG 3 PA Attention-Deficit/Hyperactivity Disorder (ADHD) Agents INTUNIV TAB 1MG 3 ST INTUNIV TAB 2MG 3 ST INTUNIV TAB 3MG 3 ST 1 Drug Name Drug Tier Requirements/Limits INTUNIV TAB 4MG 3 ST STRATTERA CAP 10MG 2 QL (120 caps / 25 days) STRATTERA CAP 18MG 2 QL (120 caps / 25 days) STRATTERA CAP 25MG 2 QL (120 caps / 25 days) STRATTERA CAP 40MG 2 QL (60 caps / 25 days) STRATTERA CAP 60MG 2 QL (30 caps / 25 days) STRATTERA CAP 80MG 2 QL (30 caps / 25 days) STRATTERA CAP 100MG 2 QL (30 caps / 25 days) Stimulants - Misc. DAYTRANA DIS 10MG/9HR 3 QL (30 patches per 25 days) DAYTRANA DIS 15MG/9HR 3 QL (30 patches per 25 days) DAYTRANA DIS 20MG/9HR 3 QL (30 patches per 25 days) DAYTRANA DIS 30MG/9HR 3 QL (30 patches per 25 days) dexmethylphenidate hcl tab 2.5 mg 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 5 mg 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 10 mg 1 QL (60 tabs / 25 days) FOCALIN XR CAP 5MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 10MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 15MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 20MG 3 QL (60 caps per 25 days) FOCALIN XR CAP 25MG 3 QL (30 caps per 25 days) FOCALIN XR CAP 30MG 3 QL (30 caps per 25 days) FOCALIN XR CAP 35MG 3 QL (30 caps per 25 days) FOCALIN XR CAP 40MG 3 QL (30 caps per 25 days) metadate tab 20mg er 1 QL (90 tabs / 25 days) METHYLIN CHW 2.5MG 3 QL (180 tabs per 25 days) METHYLIN CHW 5MG 3 QL (180 tabs per 25 days) METHYLIN CHW 10MG 3 QL (180 tabs per 25 days) methylin tab 5mg 1 QL (180 tabs / 25 days) 2 Drug Name Drug Tier Requirements/Limits methylin tab 10mg 1 QL (180 tabs / 25 days) methylin tab 10mg er 1 QL (90 tabs / 25 days) methylin tab 20mg 1 QL (90 tabs / 25 days) methylin tab 20mg er 1 QL (90 tabs / 25 days) methylphenidate hcl cap sr 24hr 20 mg 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 30 mg 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 40 mg 1 QL (30 caps / 25 days) methylphenidate hcl soln 5 mg/5ml 1 QL (1800 ml / 25 days) methylphenidate hcl soln 10 mg/5ml 1 QL (900 ml / 25 days) methylphenidate hcl tab 5 mg 1 QL (180 tabs / 25 days) methylphenidate hcl tab 10 mg 1 QL (180 tabs / 25 days) methylphenidate hcl tab 20 mg 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 10 mg 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 20 mg 1 QL (90 tabs / 25 days) methylphenidate hcl tab sa osm 18 mg 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 27 mg 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 36 mg 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 54 mg 1 QL (30 tabs / 25 days) modafinil tab 100 mg 1 PA modafinil tab 200 mg 1 PA NUVIGIL TAB 50MG 2 PA NUVIGIL TAB 150MG 2 PA NUVIGIL TAB 250MG 2 PA RITALIN LA CAP 10MG 2 QL (60 caps / 25 days) AMINOGLYCOSIDES Aminoglycosides amikacin sulfate inj 100 mg/2ml (50 1 mg/ml) amikacin sulfate inj 500 mg/2ml (250 1 mg/ml) GENTAM/NACL INJ 0.9MG/ML 3 GENTAM/NACL INJ 1.4MG/ML 3 gentamicin in saline inj 0.8 mg/ml 1 gentamicin in saline inj 1 mg/ml 1 gentamicin in saline inj 1.2 mg/ml 1 gentamicin in saline inj 1.6 mg/ml 1 gentamicin in saline inj 2 mg/ml 1 gentamicin sulfate inj 10 mg/ml 1 gentamicin sulfate inj 40 mg/ml 1 kanamycin sulfate inj 333 mg/ml 1 NEO-FRADIN SOL 125/5ML 3 neomycin sulfate tab 500 mg 1 paromomycin sulfate cap 250 mg 1 streptomycin sulfate for inj 1 gm 1 TOBI NEB 300/5ML 4 PA 3 Drug Name Drug Tier Requirements/Limits TOBRA/NACL INJ 60/0.9 3 TOBRA/NACL INJ 80/0.9 3 tobramycin sulfate inj 10 mg/ml 1 tobramycin sulfate inj 80 mg/2ml (40 1 mg/ml) ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA KIT 20MG/0.4 4 PA HUMIRA KIT 40MG/0.8 4 PA HUMIRA PEN KIT CROHNS 4 PA SIMPONI INJ 50MG 4 PA Antirheumatic Antimetabolites RHEUMATREX TAB 2.5MG 3 Interleukin-1 Blockers ARCALYST INJ 220MG 4 PA Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET INJ 4 PA Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML 4 PA ACTEMRA INJ 200/10ML 4 PA ACTEMRA INJ 400/20ML 4 PA Nonsteroidal Anti-inflammatory Agents (NSAIDs) CELEBREX CAP 50MG 3 ST CELEBREX CAP 100MG 3 ST CELEBREX CAP 200MG 3 ST CELEBREX CAP 400MG 3 ST diclofenac potassium tab 50 mg 1 diclofenac sodium tab delayed release 25 1 mg diclofenac sodium tab delayed release 50 1 mg diclofenac sodium tab delayed release 75 1 mg diclofenac sodium tab sr 24hr 100 mg 1 diclofenac w/ misoprostol tab delayed 1 release 50-0.2 mg diclofenac w/ misoprostol tab delayed 1 release 75-0.2 mg etodolac cap 200 mg 1 etodolac cap 300 mg 1 etodolac tab 400 mg 1 etodolac tab 500 mg 1 etodolac tab sr 24hr 400 mg 1 etodolac tab sr 24hr 500 mg 1 etodolac tab sr 24hr 600 mg 1 fenoprofen calcium tab 600 mg 1 4 Drug Name Drug Tier Requirements/Limits flurbiprofen tab 50 mg 1 flurbiprofen tab 100 mg 1 ibuprofen sus 100/5ml 1 ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 INDOCIN SUS 25MG/5ML 3 indomethacin cap 25 mg 1 indomethacin cap 50 mg 1 indomethacin cap cr 75 mg 1 ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 ketoprofen cap sr 24hr 200 mg 1 ketorolac tromethamine im inj 30 mg/ml 1 ketorolac tromethamine im inj 60 mg/2ml 1 (30 mg/ml) ketorolac tromethamine inj 15 mg/ml 1 ketorolac tromethamine inj 30 mg/ml 1 ketorolac tromethamine inj 60 mg/2ml (30 1 mg/ml) ketorolac tromethamine inj 300 mg/10ml 1 (30 mg/ml) ketorolac tromethamine tab 10 mg 1 QL (20 tabs per 25 days) meclofenamate sodium cap 50 mg 1 meclofenamate sodium cap 100 mg 1 mefenamic acid cap 250 mg 1 meloxicam susp 7.5 mg/5ml 1 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg 1 nabumetone tab 750 mg 1 NALFON CAP 200MG 2 ST NALFON CAP 400MG 2 ST naproxen dr tab 375mg 1 naproxen dr tab 500mg 1 naproxen sodium tab 275 mg 1 naproxen sodium tab 550 mg 1 naproxen susp 125 mg/5ml 1 naproxen tab 250 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 oxaprozin tab 600 mg 1 piroxicam cap 10 mg 1 piroxicam cap 20 mg 1 SPRIX SPR 15.75MG 3 QL (5 bottles / 25 days) 5 Drug Name Drug Tier Requirements/Limits sulindac tab 150 mg 1 sulindac tab 200 mg 1 tolmetin sodium cap 400 mg 1 tolmetin sodium tab 200 mg 1 tolmetin sodium tab 600 mg 1 ZIPSOR CAP 25MG 3 Pyrimidine Synthesis Inhibitors leflunomide tab 10 mg 1 leflunomide tab 20 mg 1 Selective Costimulation Modulators ORENCIA INJ 250MG 4 PA Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML 4 PA ENBREL INJ 25MG 4 PA ENBREL INJ 50MG/ML 4 PA ANALGESICS - NonNarcotic Salicylates ADULT ASA TAB 81MG QM 0 aspirin chew tab 81 mg 0 aspirin low tab 81mg ec 0 aspirin tab 81 mg 0 aspirin tab 325 mg 0 aspirin tab delayed release 325 mg 0 bayer low chw 81mg 0 diflunisal tab 500 mg 1 ECOTRIN TAB 325MG EC 0 HALFPRIN TAB 162MG EC 0 ST JOSEPH CHW 75MG ADU 0 ANALGESICS - OPIOID Opioid Agonists ABSTRAL SUB 100MCG 3 PA ABSTRAL SUB 200MCG 3 PA ABSTRAL SUB 300MCG 3 PA ABSTRAL SUB 400MCG 3 PA ABSTRAL SUB 600MCG 3 PA ABSTRAL SUB 800MCG 3 PA astramorph inj 1mg/2ml 1 astramorph inj 2mg/2ml 1 AVINZA CAP 30MG 3 QL (60 ea / 25 days) AVINZA CAP 45MG 3 QL (60 ea / 25 days) AVINZA CAP 60MG 3 QL (60 ea / 25 days) AVINZA CAP 75MG 3 QL (60 ea / 25 days) AVINZA CAP 90MG 3 QL (60 ea / 25 days) AVINZA CAP 120MG 3 QL (60 ea / 25 days) 6 Drug Name Drug Tier Requirements/Limits CODEINE SULF SOL 30MG/5ML 2 codeine sulfate tab 15 mg 1 QL (45 tabs / 25 days) codeine sulfate tab 30 mg 1 QL (45 tabs / 25 days) codeine sulfate tab 60 mg 1 QL (45 tabs / 25 days) CONZIP CAP 100MG 3 QL (30 caps per 25 days) CONZIP CAP 200MG 3 QL (30 caps per 25 days) CONZIP CAP 300MG 3 QL (30 caps per 25 days) DILAUDID-HP INJ 250MG 3 EMBEDA CAP 30-1.2MG 3 QL (60 caps per 25 days) EXALGO TAB 8MG 3 QL (60 tabs / 25 days) EXALGO TAB 12MG 3 QL (60 tabs / 25 days) EXALGO TAB 16MG 3 QL (60 tabs / 25 days) EXALGO TAB 32MG 3 QL (60 tabs / 25 days) fentanyl citrate lollipop 200 mcg 1 PA fentanyl citrate lollipop 400 mcg 1 PA fentanyl citrate lollipop 600 mcg 1 PA fentanyl citrate lollipop 800 mcg 1 PA fentanyl citrate lollipop 1200 mcg 1 PA fentanyl citrate lollipop 1600 mcg 1 PA fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 50 mcg/hr