Access Medicare (HMO) 2015 Formulary (List of Covered Drugs)

Transcripción

Access Medicare (HMO)
2015 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File Submission ID 15483.000, Version Number 5
This formulary was updated on 01/01/2015. For more recent information or other questions, please contact
Access Medicare Member Services at 1-877-696-1121 or, for TTY users, 1-800-662-1220, 8am to 8pm 7
days a week, or visit www.accessmedicareny.com.
Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Cuatro, LLC. When it refers to
“plan” or “our plan,” it means Access Medicare.
This document includes list of the drugs (formulary) for our plan which is current as of 01/01/2015. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time
during the year.
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Formulario de medicamentos 2015
What is the Access Medicare Formulary?
A formulary is a list of covered drugs selected by in consultation with a team of health care providers, which
represents the prescription therapies believed to be a necessary part of a quality treatment program. Access
Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the
prescription is filled at a Access Medicare network pharmacy, and other plan rules are followed. For more
information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of
the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of 01/01/2015. To get updated information about
the drugs covered by Access Medicare, please contact us. Our contact information appears on the front and
back cover pages. In the event of a mid-year non-maintenance formulary changes, Access Medicare will
provide all members notice of those changes in writing.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used
for, look for the category name in the list that begins on page number 1. Then look under the category
name for your drug.
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Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand
name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your
drug, you will see the page number where you can find coverage information. Turn to the page listed in
the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Access Medicare covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:

Prior Authorization: Access Medicare requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from Access Medicare before you fill
your prescriptions. If you don’t get approval, Access Medicare may not cover the drug.

Quantity Limits: For certain drugs, Access Medicare limits the amount of the drug that Access
Medicare will cover. For example, Access Medicare provides nine (9) 200mg tablets per prescription
for XIFAXAN. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Access Medicare 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, Access Medicare may not cover Drug B unless you try
Drug A first. If Drug A does not work for you, Access Medicare will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered drugs
by visiting our Web site. We have posted on line a document that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
You can ask Access Medicare to make an exception to these restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See the section, “How do I request an exception to the Access
Medicare’s formulary?” on page iii for information about how to request an exception.
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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 Access Medicare does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Access Medicare. When
you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is
covered by Access Medicare.

You can ask Access Medicare 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 Access Medicare’s Formulary?
You can ask Access Medicare 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,
Access Medicare 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, Access Medicare will only approve your request for an exception if the alternative drugs 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, tiering or utilization
restriction exception. When you request a formulary, tiering, or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
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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 30-day supply (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with 91-day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days
you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
exception.
For those members who have transitioned from one level of care to another such as a
hospital admission to home:
 We will cover a temporary supply of your drug during the first 90 days of this transition
period. The first supply will be for a maximum of a 31-day supply, or less if your
prescription is written for fewer days. If needed, we will cover additional refills during
your first 90 days in the plan.
For more information
For more detailed information about your Access Medicare prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about Access Medicare, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,
visit http://www.medicare.gov.
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Access Medicare’s Formulary
The formulary that begins on the page 1 provides coverage information about the drugs covered by Access
Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (BUTRANS) and generic
drugs are listed in lower-case italics (e.g., fentanyl citrate).
The information in the Requirements/Limits column tells you if Access Medicare has any special
requirements for coverage of your drug.
The second column indicates the tier level.

Tier 1 Preferred Generic Drugs

Tier 2 Non-Preferred Generic Drugs

Tier 3 Preferred Brand Drugs

Tier 4 Non-Preferred Brand Drugs

Tier 5 Specialty Drugs
Until your Part D total drug cost reaches $2,960 for Platinum, $2,500 for Gold, or $4700 for Pearl, your
copayments or coinsurances for formulary drug tiers are noted in the table below in the following format: 30
day Retail / 90 day Retail / Mail Order.
Plan Name
Tier 1
Tier 2
Tier 3
Tier 4
Access
$4/$12/$6
Medicare Gold
$8/$24/$12
$35/$105/$52.50 $75/$225/$112.50
33%
Access
Medicare
Platinum
25%
25%
25%
25%
25%
Access
Medicare
Pearl
$0/$1.20/$2.65
$0/$1.20/$2.65
$0/$3.60/$6.60
$0/$3.60/$6.60
$0/$3.60/$6.60
Please refer to our Evidence of Coverage for more information about this coverage.
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The information in the Requirements/Limits column tells you if Access Medicare has any special
requirements for coverage of your drug.
The following Utilization Management abbreviations may be found within the body of this document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
DESCRIPTION
EXPLANATION
Utilization Management Restrictions
PA
You (or your physician) are required to get prior
authorization from Access Medicare before you
Prior Authorization Restriction fill your prescription for this drug. Without prior
approval, Access Medicare may not cover this
drug.
PA BvD
This drug may be eligible for payment under
Medicare Part B or Part D. You (or your
Prior Authorization Restriction physician) are required to get prior authorization
from Access Medicare to determine that this drug
for
is covered under Medicare Part D before you fill
Part B vs Part D
your prescription for this drug. Without prior
Determination
approval, Access Medicare may not cover this
drug.
PA-HRM
This drug has been deemed by CMS to be
potentially harmful and therefore, a High Risk
Medication for Medicare beneficiaries 65 years or
Prior Authorization Restriction
older. Members age 65 yrs or older are required
for
to get prior authorization from Access Medicare
High Risk Medications
before you fill your prescription for this
drug. Without prior approval, Access Medicare
may not cover this drug
PA NSO
If you are a new member, you (or your physician)
Prior Authorization Restriction are required to get prior authorization from
Access Medicare before you fill your prescription
for
for this drug. Without prior approval, Access
New Starts Only
Medicare may not cover this drug.
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ABBREVIATION
DESCRIPTION
QL
Quantity Limit Restriction
Access Medicare limits the amount of this drug
that is covered per prescription, or within
a specific time frame.
Step Therapy Restriction
Before Access Medicare will provide coverage
for this drug, you must first try another drug(s)
to treat your medical condition. This drug may
only be covered if the other drug(s) does not
work for you.
ST
EXPLANATION
The following additional coverage note abbreviations may be found within the body of this document
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
ABBREVIATION
DESCRIPTION
EXPLANATION
EX
Excluded Part D Drug
This prescription drug is not normally covered in
a Medicare Prescription Drug Plan. The amount
you pay when you fill a prescription for this drug
does not count towards your total drug costs
(that is, the amount you pay does not help you
qualify for catastrophic coverage). In addition, if
you are receiving extra help to pay for your
prescriptions, you will not get any extra help to
pay for this drug
FF
Free First Fill
(Generic Use Incentive)
This prescription drug will be provided at reduced
cost-sharing the first time you fill it.
Limited Access Drug
This prescription may be available only at certain
pharmacies. For more information consult your
Pharmacy Directory or call Member Services at
1-877-696-1121, 8am to 8pm, 7 days a week.
TTY/TDD users should call 1-800-662-1220.
Gap Coverage
We provide coverage of this prescription drug in
the coverage gap. Please refer to our Evidence of
Coverage for more information about this
coverage.
LA
GC
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ABBREVIATION
NM
HI
DESCRIPTION
EXPLANATION
Non-Mail Order Drug
You may be able to receive greater than a 1month supply of most of the drugs on your
formulary via mail order at a reduced cost share.
Drugs not available via your mail order benefit
are noted with “NM” in the Requirements/Limits
column of your formulary.
Home Infusion Drug
This prescription drug may be covered under our
medical benefit. For more information, call
Member Services at 1-877-696-1121, 8am to
8pm, 7 days a week. TTY/TDD users should call
1-800-662-1220.
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STRENGTH AND DOSAGE FORM ABBREVIATIONS
ABBREVIATION
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
DESCRIPTION
adhesive patch
aerosol, breath activated
aerosol, powder
aerosol powder, breath activated
aerosol refill
aerosol with adapter
ampule
bulk bag injection
capsule, delayed release multiphasic
capsule, dose pack
capsule, 12 hour extended release
capsule, 24 hour extended release
capsule, extended release degradable
capsule, extended release pellets
capsule, multiphasic
capsule, 24 hour sustained action
capsule, 12 hour sustained release
capsule, 24 hour sustained release
capsule, 24 hour controlled-onset pellets
capsule, 24 hour sustained release pellets
capsule, sprinkle
capsule sustained release pellets
capsule with device
capsule, delayed release
capsule, extended release
capsule, sustained action
combination: capsule, pad
combination: ointment, foam
combination: ointment, lotion
combination: tablet, pad
combination package
capsule, 12 hour multiphasic
capsule, 24 hour multiphasic
capsule, multiphasic, 30%-70%
capsule, multiphasic, 50%-50%
cream (grams)
cream (milliliters)
cream with applicator
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ABBREVIATION
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
DESCRIPTION
cream, extended release (grams)
cream, package
di(2-ethylhexyl)phthalate free bag
disposable needle
disk with inhalation device
disposable syringe
drops, suspension
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleanser and cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
medicated pad
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ABBREVIATION
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
DESCRIPTION
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
patch, 72 hour transdermal
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
suspension, delayed release packet
suspension, reconstituted
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ABBREVIATION
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPTION
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersible
tablet, dose pack
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
tablet, extended release
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dose pack
tablet, multiphasic dose pack
tablet, rapid disintegrating dose pack
tablet, 3-month dose pack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
Index of Drugs
This formulary was updated on 01/01/2015. For more recent information or other questions, please contact
Access Medicare Member Services at 1-877-696-1121 or, for TTY users, 1-800-662-1220, 8am to 8pm 7
days a week, or visit www.accessmedicareny.com.
Access Medicare is an HMO with a Medicare Contract. Enrollment in Access Medicare depends on contract
renewal.
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Nombre del plan de Access Medicare
Formulario para 2015
(Lista de medicamentos cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN
ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
HPMS Approved Formulary File Submission ID 15483.000, Version Number 5
Este formulario se actualizó el 01/01/2015. Para obtener información más reciente o si tiene alguna
pregunta, póngase en contacto con el Servicio para los miembros de Access Medicare al 1-877-696-1121
(los usuarios de TTY deben llamar al 1-800-662-1220) de 8:00 a. m. a 8:00 p. m., los 7 días de la semana, o
visite www.accessmedicareny.com.
Nota para los miembros actuales: este Formulario ha cambiado con respecto al año pasado. Revise
este documento para asegurarse de que aún contenga los medicamentos que toma.
Cuando esta lista de medicamentos (Formulario) menciona “nosotros,” “nos” o “nuestro”, hace referencia a
Cuatro, LLC. Cuando menciona “plan” o “nuestro plan,” hace referencia a Access Medicare.
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual estará en
vigencia a partir del 01/01/2015. Para obtener un Formulario actualizado, póngase en contacto con nosotros.
Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las
páginas de la portada y la portada posterior.
Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta.
Los beneficios, el formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el 1 de enero de
2016 y periódicamente durante el año.
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¿En qué consiste el Formulario de Access Medicare?
Un Formulario es una lista de medicamentos cubiertos seleccionados con la colaboración de un equipo de
proveedores de salud, que representa los tratamientos con receta que se cree que son parte necesaria de un
programa de tratamiento de calidad. Por lo general, Access Medicare cubrirá los medicamentos enumerados
en nuestro Formulario siempre y cuando el medicamento sea médicamente necesario, se obtenga el
medicamento en una farmacia de la red de Access Medicare y se cumpla con otras normas del plan. Para
obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de
cobertura.
¿Puede cambiar el Formulario (lista de medicamentos)?
En general, si usted toma un medicamento de nuestro Formulario para 2015 que estaba cubierto al comienzo
del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de
cobertura 2015, excepto cuando esté disponible un nuevo medicamento genérico de menor costo o cuando se
dé a conocer nueva información adversa acerca de la seguridad o eficacia del medicamento. Otros tipos de
cambios en el Formulario, como por ejemplo, la eliminación de un medicamento de nuestro Formulario, no
afectarán a los miembros que estén actualmente tomando el medicamento. Continuará disponible al mismo
costo compartido para aquellos miembros que estén tomándolo por el resto del año de cobertura.
Consideramos que es importante que tenga acceso continuo a los medicamentos del Formulario que estaban
disponibles cuando eligió nuestro plan durante el resto del año de cobertura, salvo en los casos en los que
usted podría ahorrar más dinero o que nosotros podríamos garantizarle su seguridad.
Si retiramos medicamentos de nuestro Formulario, [o] agregamos autorizaciones previas, límites de cantidad
o restricciones en el Programa de terapia en etapas en relación con un medicamento, o si pasamos un
medicamento a un nivel superior de costo compartido, debemos notificar sobre el cambio a los miembros
afectados por el cambio al menos 60 días antes de que entre en vigencia dicho cambio, o cuando el miembro
solicite un resurtido del medicamento, momento en el cual el miembro recibirá un suministro del
medicamento para 60 días. Si la Administración de Drogas y Alimentos considera que un medicamento de
nuestro Formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de
inmediato dicho medicamento de nuestro Formulario y notificaremos a los miembros que toman el
medicamento en cuestión. El formulario adjunto está vigente a partir del 01/01/2015. Para recibir
información actualizada sobre los medicamentos cubiertos por Access Medicare, póngase en contacto con
nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. En
caso de que a mitad de año se realicen cambios en el Formulario que no sean de mantenimiento, Access
Medicare les proporcionará a todos los miembros un aviso por escrito sobre dichos cambios.
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¿Cómo utilizo el Formulario?
Hay dos formas para encontrar su medicamento dentro del Formulario:
Afección médica
El Formulario empieza en la página 1. Los medicamentos de este Formulario están agrupados en
categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los
medicamentos utilizados para tratar una afección cardíaca se enumeran dentro de la categoría “Agentes
Cardiovasculares”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la
lista que empieza en la página 1. Luego busque su medicamento debajo del nombre de la categoría.
Listado alfabético
Si no está seguro de qué categoría debe consultar, debe buscar su medicamento en el Índice que
comienza en la página I-1. El Índice proporciona una lista alfabética de todos los medicamentos
incluidos en este documento. En el Índice, están tanto los medicamentos de marca como los genéricos.
Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página
donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y
encuentre el nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Access Medicare cubre tanto los medicamentos de marca como los genéricos. La FDA aprueba un
medicamento genérico que tiene los mismos principios activos que el medicamento de marca.
Normalmente, los medicamentos genéricos cuestan menos que los de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos
y límites pueden incluir:

Autorización previa: Access Medicare exige que usted o su médico obtengan una autorización
previa para determinados medicamentos. Esto significa que necesitará contar con la aprobación de
Access Medicare antes de obtener sus medicamentos con receta. Si no consigue la autorización, es
posible que Access Medicare no cubra el medicamento.

Límites de cantidad: para ciertos medicamentos, Access Medicare limita la cantidad del
medicamento que cubrirá. Por ejemplo, Access Medicare proporciona nueve (9) comprimidos de
200 mg por receta de XIFAXAN. Esto puede ser complementario a un suministro estándar para
un mes o tres meses.
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
Programa de terapia en etapas: en algunos casos, Access Medicare requiere que usted primero
pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro
medicamento para esa afección médica. Por ejemplo, si el medicamento A y el medicamento B tratan
su afección médica, es posible que Access Medicare no cubra el medicamento B a menos que usted
pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces Access
Medicare cubrirá el medicamento B.
Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el Formulario que
empieza en la página 1. También puede obtener más información sobre las restricciones que se aplican a
medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado en línea un documento que
explica nuestras restricciones de autorización previa y de Programa de terapia en etapas. También puede
pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última
actualización del Formulario, aparece en las páginas de la portada y la portada posterior.
Puede pedirle a Access Medicare que haga una excepción a estas restricciones o límites o puede solicitarle
una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección “¿Cómo
solicito una excepción al Formulario de Access Medicare?” en la página iii para obtener información acerca
de cómo solicitar una excepción.
¿Qué pasa si mi medicamento no está en el Formulario?
Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos cubiertos), primero
debe ponerse en contacto con el Servicio para los miembros y preguntar si su medicamento está cubierto.
Si resulta que Access Medicare no cubre el medicamento que toma, tiene dos alternativas:

Puede solicitar al Servicio para los miembros una lista de medicamentos similares que Access
Medicare cubra. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un
medicamento similar que esté cubierto por Access Medicare.

Puede solicitarle a Access Medicare que haga una excepción y cubra el medicamento. Consulte más
abajo para obtener información sobre cómo solicitar una excepción.
¿Cómo puedo solicitar que se haga una excepción al Formulario de Access Medicare?
Puede solicitarle a Access Medicare que haga una excepción a nuestras normas de cobertura. Hay varios
tipos de excepciones que puede solicitarnos.
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
Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se
aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no
podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor.

Puede pedirnos que cubramos un medicamento del Formulario a un nivel de costo compartido menor
si este medicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, esto
reduciría el monto que usted debe pagar por su medicamento.

Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por
ejemplo: para ciertos medicamentos, Access Medicare limita la cantidad del medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una
excepción al límite y cubramos una cantidad mayor.
Por lo general, Access Medicare solo aprobará su solicitud de excepción si los demás medicamentos
incluidos en el Formulario del plan, el medicamento de menor costo compartido o las restricciones de uso
adicionales no fueran tan efectivos para tratar su enfermedad o pudieran causarle efectos médicos adversos.
Debe ponerse en contacto con nosotros para solicitarnos una decisión inicial de cobertura respecto de una
excepción al Formulario, al nivel o a la restricción de uso. Cuando solicita una excepción al Formulario,
al nivel o a la restricción de uso, debe presentar una declaración de su médico o de la persona
autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro
de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la
persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico
consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le
concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de
las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona
autorizada a dar recetas.
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos
que tomo o la solicitud de una excepción?
Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no
están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el
Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización
previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe
cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al Formulario
para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado
a seguir en su caso, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que
usted sea miembro de nuestro plan.
Para cada uno de los medicamentos que no están incluidos en el Formulario o si su capacidad para conseguir
los medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta
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para menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días,
no pagaremos los medicamentos, incluso si ha sido miembro del plan durante menos de 90 días.
Si reside en un centro de atención a largo plazo, le permitiremos obtener sus medicamentos con receta hasta
que le hayamos provisto un suministro de transición para 91 días, de manera consistente con el incremento
de provisión (a menos que tenga una receta para menos días). Cubriremos más de un resurtido de estos
medicamentos durante los primeros 90 días en que usted sea miembro del plan. Si necesita un medicamento
que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron
los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del
medicamento para 30 días (a menos que tenga una receta para menos días) mientras solicita la excepción al
Formulario.
Para aquellos miembros que se han transferido de un nivel de atención a otro, como de una estadía
en el hospital al hogar:

Cubriremos un suministro temporal del medicamento durante los primeros 90 días de
este período de transición. El primer suministro será para un suministro máximo de
31 días, o menos, si su receta está indicada para menos días. Si es necesario,
cubriremos resurtidos adicionales durante sus primeros 90 días en el plan.
Para obtener más información
Para obtener información más detallada sobre la cobertura para medicamentos con receta de
Access Medicare, consulte la Evidencia de cobertura y la demás documentación del plan.
Si tiene alguna pregunta sobre Access Medicare, póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y
la portada posterior.
Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-4227), durante las 24 horas, los 7 días de la semana. Los
usuarios de TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.
Formulario de Access Medicare
El Formulario que empieza en la página 1 proporciona información de cobertura acerca de los medicamentos
cubiertos por Access Medicare. Si tiene alguna dificultad para encontrar en la lista el medicamento que
toma, consulte el Índice que comienza en la página I-1.
La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en
letra mayúscula (BUTRANS), y los medicamentos genéricos están en letra minúscula y cursiva (p. ej.,
citrato de fentanilo).
La información incluida en la columna de Requisitos/Límites indica si Access Medicare tiene algún requisito
especial para la cobertura del medicamento.
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La segunda columna indica el nivel del medicamento.

Nivel 1: medicamentos genéricos preferidos

Nivel 2: medicamentos genéricos no preferidos

Nivel 3: medicamentos de marca preferidos

Nivel 4: medicamentos de marca no preferidos

Nivel 5: medicamentos especializados
Hasta que el costo total de su medicamento de la Parte D no alcance $2,960 para Platinum, $2,500 para Gold
o $4,700 para Pearl, se describen los copagos o coseguros para los niveles de medicamentos del Formulario
en la tabla a continuación en el siguiente formato: 30 días farmacia minorista/90 días farmacia minorista/de
pedido por correo.
Nombre del
plan
Nivel 1
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Access
$4/$12/$6
Medicare Gold
$8/$24/$12
$35/$105/$52.50 $75/$225/$112.50
33 %
Access
Medicare
Platinum
25 %
25 %
25 %
25 %
25 %
Access
Medicare
Pearl
$0/$1.20/$2.65
$0/$1.20/$2.65
$0/$3.60/$6.60
$0/$3.60/$6.60
$0/$3.60/$6.60
Consulte la Evidencia de cobertura para obtener más información sobre esta cobertura.
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La información incluida en la columna de Requisitos/Límites indica si Access Medicare tiene algún
requisito especial para la cobertura del medicamento.
Las siguientes abreviaturas de administración de la utilización se pueden encontrar en el cuerpo
de este documento.
ABREVIATURAS DE LAS NOTAS DE COBERTURA
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Restricciones de la administración de la utilización
Restricción de autorización
previa
Usted (o su médico) tiene que obtener
autorización previa de Access Medicare antes de
obtener este medicamento con receta. Sin
autorización previa, Access Medicare puede no
cubrir este medicamento.
previa
para
determinación de la Parte B
frente a la Parte D
Este medicamento puede ser elegible para pago
según la Parte B o la Parte D de Medicare. Usted
(o su médico) tiene que obtener autorización
previa de Access Medicare para determinar si este
medicamento está cubierto por la Parte D de
Medicare antes de obtener este medicamento con
receta. Sin autorización previa, Access Medicare
puede no cubrir este medicamento.
PA-HRM
previa para
medicamentos de alto riesgo
Según los Centros de Servicios de Medicare y
Medicaid (CMS, por sus siglas en inglés), este
medicamento se considera potencialmente
perjudicial y, por lo tanto, un medicamento de
alto riesgo para los beneficiarios de Medicare de
65 años o más. Los miembros de 65 años o más
tienen que obtener autorización previa de Access
Medicare antes de obtener este medicamento con
receta. Sin autorización previa, Access Medicare
puede no cubrir este medicamento.
PA NSO
previa
solo por primera vez
Si usted es un miembro nuevo, usted (o su
médico) tiene que obtener autorización previa de
Access Medicare antes de obtener este
medicamento con receta. Sin autorización previa,
PA
PA BvD
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ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Access Medicare puede no cubrir este
medicamento.
QL
ST
Restricciones del límite de
cantidad
Access Medicare limita la cantidad de este
medicamento que se cubre por receta o dentro
de un plazo de tiempo específico.
Restricción del Programa de
terapia en etapas
Antes de que Access Medicare brinde cobertura
para este medicamento, primero debe probar
otro(s) medicamento(s) para el tratamiento de
su afección médica. Este medicamento solo
podrá cubrirse si el/los otro(s) medicamento(s)
no funciona(n) para usted.
Las siguientes abreviaturas adicionales de las notas de cobertura se pueden encontrar en el cuerpo de
este documento.
OTROS REQUISITOS ESPECIALES DE COBERTURA
DESCRIPCIÓN
EXPLICACIÓN
EX
Medicamento de la Parte D
excluido
Este medicamento con receta generalmente no
está cubierto en un plan de medicamentos con
receta de Medicare. El monto que paga cuando
obtiene uno de estos medicamentos con receta no
se tiene en cuenta en sus costos totales de
medicamentos (es decir, el monto que usted paga
no lo ayuda a calificar para la cobertura en
situaciones catastróficas). Además, si recibe
ayuda adicional para pagar sus medicamentos
con receta, no recibirá ninguna ayuda adicional
para pagar este medicamento.
FF
Primer surtido gratis
(Incentivo de uso genérico)
Este medicamento con receta se ofrecerá a un
costo compartido (de) reducido la primera vez
que lo obtenga.
LA
Medicamento de acceso
limitado
ABREVIATURA
Este medicamento con receta puede estar
disponible solamente en determinadas farmacias.
Para obtener más información, consulte el
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ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Directorio de farmacias o llame al Servicio para
los miembros al 1-877-696-1121, de 8:00 a. m. a
8:00 p. m., los 7 días de la semana. Los usuarios
de TTY/TDD deben llamar al 1-800-662-1220.
GC
NM
HI
Período sin cobertura
Proporcionamos cobertura para este medicamento
con receta durante el período sin cobertura.
Consulte la Evidencia de cobertura para obtener
más información sobre esta cobertura.
Medicamento no disponible
para pedido por correo
Podrá recibir un suministro para más de 1 mes
de la mayoría de los medicamentos incluidos en
el Formulario por correo a un costo compartido
reducido. Los medicamentos no disponibles a
través de su beneficio de pedido por correo
se indican con “NM” en la columna de
Requisitos/Límites de su Formulario.
Este medicamento con receta puede ser cubierto
por nuestro beneficio médico. Para obtener más
Medicamento de infusión en el información, llame al Servicio para los miembros
al 1-877-696-1121, de 8:00 a. m. a 8:00 p. m., los
hogar
7 días de la semana. Los usuarios de TTY/TDD
deben llamar al 1-800-662-1220.
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ABREVIATURAS DE FORMA DE DOSIFICACIÓN Y CONCENTRACIÓN
ABREVIATURA
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
DESCRIPCIÓN
parche adhesivo
aerosol activado por respiración
aerosol en polvo
aerosol en polvo activado por respiración
aerosol recarga
aerosol con adaptador
ampolla
inyección en bolsa a granel
cápsula multifásica de liberación retardada
cápsula en paquete de dosis
cápsula de liberación prolongada de 12 horas
cápsula de liberación prolongada de 24 horas
cápsula de liberación prolongada degradable
cápsula en gránulos de liberación prolongada
cápsula multifásica
cápsula de acción sostenida de 24 horas
cápsula de liberación sostenida de 12 horas
cápsula de liberación sostenida de 24 horas
cápsula en gránulos de inicio controlado de 24 horas
cápsula en gránulos de liberación sostenida de 24 horas
cápsula granulada
cápsula en gránulos de liberación sostenida
cápsula con dispositivo
cápsula de liberación retardada
cápsula de liberación prolongada
cápsula de acción sostenida
combinación: cápsula y almohadilla
combinación: ungüento y espuma
combinación: ungüento y loción
combinación: comprimido y almohadilla
paquete combinado
cápsula multifásica de 12 horas
cápsula multifásica de 24 horas
cápsula multifásica, 30 %-70 %
cápsula multifásica, 50 %-50 %
crema (gramos)
crema (mililitros)
crema con aplicador
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ABREVIATURA
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
DESCRIPCIÓN
crema de liberación prolongada (gramos)
crema en paquete
bolsa libre de di(2-etilhexil) ftalato
aguja descartable
disco con dispositivo de inhalación
jeringa descartable
gotas en suspensión
gotas hiperviscosas
emulsión adhesiva
paquete de emulsión
emulsión (gramos)
espuma con aplicador
infusión intravenosa congelada
gramo
gel con aplicador prellenado
gel (gramos)
gel (mililitros)
gel en bomba de dosis medida
gel con aplicador
gel con bomba
paquete de gránulos
adaptador de aerosol con inhalador de HFA
infusión en botella
pluma de insulina
solución intraperitoneal
solución de irrigación
solución intravenosa
jalea
jalea con aplicador
jalea con aplicador prellenado
kit de limpiador y crema
kit de crema y loción emoliente
kit de loción y crema emoliente
kit de ungüento y loción emoliente
loción de liberación prolongada
comprimido para chupar con aplicador bucal
parche caliente medicinal
comprimido bucal mucoadhesivo
microgramo
almohadilla medicinal
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ABREVIATURA
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
DESCRIPCIÓN
hisopo medicinal
cinta medicinal
miligramo
mililitro
sistema mucoadhesivo de liberación prolongada de 12 horas
aguja para inyección
suspensión en película para uñas
ungüento (gramos)
concentrado oral
suspensión oral
pasta (gramos)
parche transdérmico de 24 horas
parche transdérmico de 72 horas
parche transdérmico quincenal
parche transdérmico semanal
jeringa con analgésico controlada por el paciente
frasco con analgésico controlado por el paciente
gránulo (cada uno)
kit de pluma de inyección
pluma de inyección
frasco de infusión intravenosa
bolsa de plástico
polvo en paquete
solución con bomba de dosis múltiples
solución con aplicador
solución con aplicador prellenado
solución formadora de gel
solución reconstituida
solución (gramos)
suspensión en aerosol
aerosol con bomba
varilla (cada una)
supositorio rectal
supositorio vaginal
supositorio
suspensión de liberación prolongada de 24 horas
suspensión de liberación prolongada reconstituida
suspensión con microcápsulas reconstituida
suspensión con paquete de liberación retardada
suspensión reconstituida
xxv
H4866_AM4011 Accepted 09132014
H4866_AM4011_SP Accepted 09132014
2015 Drug Formulary
ABREVIATURA
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPCIÓN
kit de jeringas
comprimido masticable
comprimido de liberación prolongada de 12 horas
comprimido con partículas de liberación prolongada
comprimido Sequels de liberación prolongada
comprimido de disolución
comprimido en paquete de dosis
comprimido multifásico
comprimido con partículas
comprimido de desintegración rápida de liberación retardada
comprimido de desintegración rápida
comprimido sublingual
comprimido de liberación sostenida de 12 horas
comprimido de liberación sostenida de 24 horas
comprimido de liberación prolongada gradual de 24 horas
comprimido de liberación retardada
comprimido de liberación prolongada
comprimido efervescente
comprimido de acción sostenida
comprimido soluble
comprimido en paquete de dosis de liberación prolongada
comprimido multifásico en paquete de dosis
comprimido en paquete de dosis de desintegración rápida
comprimido en paquete de dosis de 3 meses
comprimido multifásico de 12 horas
comprimido multifásico de 24 horas
unidad
anillo vaginal
Índice de medicamentos
Este Formulario se actualizó el 01/01/2015. Para obtener información más reciente o si tiene
otras preguntas, póngase en contacto con el Servicio para los miembros de Access Medicare
llamando al 1-877-696-1121 (los usuarios de TTY deben llamar al 1-800-662-1220) de 8:00 a.
m. a 8:00 p. m., los 7 días de la semana, o visite www.accessmedicareny.com.
Access Medicare es una Organización para el mantenimiento de la salud (HMO, por sus siglas
en inglés) que tiene un contrato con Medicare. La inscripción en Access Medicare depende de
la renovación del contrato.
x x vi
H4866_AM4011 Accepted 09132014
H4866_AM4011_SP Accepted 09132014
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine oral solution
(Acetaminophen with
Codeine)
acetaminophen-codeine oral tablet 300-15 (Tylenol-Codeine No.3)
mg, 300-30 mg
acetaminophen-codeine oral tablet 300-60 (Tylenol-Codeine No.3)
mg
buprenorphine hcl injection
(Buprenorphine HCl)
butalb-acetaminophen-caffeine oral
(Esgic)
capsule 50-325-40 mg
butalb-acetaminophen-caffeine oral
(Butalb/Acetaminophen/
solution 50-325-40 mg/15 ml
Caffeine)
butalbital-acetaminop-caf-cod
(Fioricet with Codeine)
1
QL (2700 per 30 days)
1
1
butalbital-acetaminophen
(Tencon)
1
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
butalbital-aspirin-caffeine oral capsule
(Esgic)
1
(Fiorinal)
1
butorphanol tartrate nasal
BUTRANS
codeine sulfate oral tablet
codeine-butalbital-asa-caffein oral
capsule 30-50-325-40 mg
DURAMORPH (PF)
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL 100-4 MG, 803.2 MG
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL 20-0.8 MG, 301.2 MG, 50-2 MG, 60-2.4 MG
fentanyl citrate
(Butorphanol Tartrate)
2
3
1
1
fentanyl transdermal patch 72 hour 100
mcg/hr
(Codeine Sulfate)
(Fiorinal with Codeine
#3)
2
1
1
1
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (2700 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
QL (5 per 28 days)
QL (4 per 28 days)
PA-HRM; QL (180 per
30 days)
4
4
4
QL (60 per 30 days)
(Actiq)
5
(Duragesic)
2
PA; QL (120 per 30
days)
PA; QL (20 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
1
Access Medicare 2015 Part D Formulary
Effective: December 01, 2015
Formulary ID: 15483.000, Version: 17
Drug Name
Drug Tier
Requirements/Limits
fentanyl transdermal patch 72 hour 12
(Duragesic)
mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50
mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5
mcg/hour
hydrocodone-acetaminophen oral solution (Hycet)
hydrocodone-acetaminophen oral tablet
(Norco)
10-300 mg, 5-300 mg, 7.5-300 mg
2
1
1
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
hydrocodone-ibuprofen
hydromorphone (pf) injection solution 10
mg/ml
hydromorphone (pf) injection solution 4
mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2 mg/ml
hydromorphone oral liquid
hydromorphone oral tablet 2 mg, 4 mg
hydromorphone oral tablet 8 mg
LAZANDA
levorphanol tartrate
methadone hcl oral tablet,soluble 40 mg
methadone injection
methadone oral
methadone oral
morphine concentrate oral solution
morphine concentrate oral syringe
morphine injection solution 15 mg/ml, 8
mg/ml
morphine injection syringe 10 mg/ml, 2
mg/ml
morphine intramuscular
morphine intravenous
morphine intravenous solution 25 mg/ml,
50 mg/ml
(Norco)
1
(includes Vicodin,
Vicodin ES and Vicodin
HP); QL (390 per 30
days)
(Ibudone)
(Hydromorphone
HCl/PF)
(Dilaudid)
1
2
(Hydromorphone HCl)
(Hydromorphone HCl)
(Dilaudid)
(Dilaudid)
(Dilaudid)
(Levorphanol Tartrate)
(Diskets)
(Methadone HCl)
(Methadone HCl)
(Diskets)
(Msir)
(Morphine Sulfate)
(Morphine Sulfate)
2
2
1
1
1
5
2
1
1
1
1
1
1
1
(Morphine Sulfate)
1
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
2
QL (90 per 30 days)
2
Drug Name
morphine intravenous
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml
MORPHINE ORAL TABLET
morphine oral tablet extended release 100
mg, 30 mg, 60 mg
morphine oral tablet extended release 15
mg, 200 mg
morphine rectal
NUCYNTA
NUCYNTA ER
oxycodone hcl-acetaminophen oral
solution 5-325 mg/5 ml
oxycodone hcl-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
oxycodone hcl-aspirin
oxycodone oral capsule
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet
oxycodone-acetaminophen oral tablet 10325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
oxycodone-acetaminophen oral tablet 10650 mg
oxycodone-acetaminophen oral tablet 7.5500 mg
oxycodone-aspirin
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15 MG,
20 MG, 30 MG, 40 MG, 60 MG
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
Drug Tier
(Morphine Sulfate)
(Msir)
(Msir)
Requirements/Limits
(MS Contin)
1
1
1
1
1
(MS Contin)
1
(Morphine Sulfate)
2
3
3
1
QL (60 per 30 days)
1
(Percodan)
(Oxycodone HCl)
(Oxycodone HCl)
(Oxycodone HCl)
(Percolone)
(Xolox)
2
2
1
1
1
1
(Xolox)
1
(Xolox)
1
(Percodan)
2
3
QL (60 per 30 days)
3
2
2
QL (60 per 30 days)
(Oxycodone
HCl/Acetaminophen)
(Xolox)
(Opana)
(Opana ER)
3
Drug Name
Drug Tier
Requirements/Limits
oxymorphone oral tablet extended release (Opana ER)
12 hr 30 mg, 40 mg
tramadol oral tablet
(Ultram)
tramadol-acetaminophen
(Ultracet)
XARTEMIS XR
xylon 10
(Ibudone)
Nonsteroidal Anti-Inflammatory Agents
CALDOLOR INTRAVENOUS RECON
SOLN
celecoxib
(Celebrex)
choline,magnesium salicylate
(Choline Sal/Mag
Salicylate)
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac potassium
(Cataflam)
diclofenac sodium oral tablet extended
(Voltaren-XR)
release 24 hr
diclofenac sodium oral tablet,delayed
(Diclofenac Sodium)
release (dr/ec)
diclofenac sodium topical gel
(Solaraze)
diclofenac-misoprostol
(Arthrotec 50)
diflunisal
(Diflunisal)
etodolac oral capsule
(Etodolac)
etodolac oral tablet
(Etodolac)
etodolac oral tablet extended release 24 hr (Etodolac)
fenoprofen oral tablet
(Fenoprofen Calcium)
FLECTOR
flurbiprofen
(Ansaid)
ibuprofen oral
(Ibuprofen)
ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen)
mg
indomethacin oral capsule 25 mg
(Indomethacin)
2
1
1
3
1
indomethacin oral capsule 50 mg
(Indomethacin)
1
indomethacin oral capsule, extended
release
(Indomethacin)
2
4
2
1
QL (60 per 30 days)
1
1
1
1
1
1
5
2
2
1
1
2
2
3
1
1
1
1
PA
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per 30
days)
4
Drug Name
indomethacin sodium
ketoprofen oral capsule
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
ketorolac injection cartridge 15 mg/ml
ketorolac injection cartridge 30 mg/ml
ketorolac injection solution 15 mg/ml
ketorolac injection solution 30 mg/ml (1
ml)
ketorolac intramuscular solution
ketorolac oral
mefenamic acid
meloxicam oral suspension
meloxicam oral tablet
nabumetone
naproxen oral suspension
naproxen oral tablet
naproxen oral tablet,delayed release
(dr/ec)
naproxen sodium oral tablet 275 mg, 550
mg
piroxicam
salsalate
sulindac oral
tolmetin
VOLTAREN TOPICAL
Drug Tier
Requirements/Limits
(Indocin I.V.)
(Ketoprofen)
(Ketoprofen)
1
1
2
PA-HRM
(Toradol)
(Toradol)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
(Ec-Naprosyn)
1
1
1
QL (40 per 30 days)
QL (20 per 30 days)
QL (40 per 30 days)
1
QL (20 per 30 days)
1
QL (20 per 30 days)
1
QL (20 per 30 days)
(Anaprox)
1
(Feldene)
(Salsalate)
(Sulindac)
(Tolmetin Sodium)
2
2
1
2
3
(Lidocaine HCl)
(Xylocaine-MPF)
1
1
(Lidocaine HCl/PF)
1
(Xylocaine)
1
2
2
1
1
1
1
1
Anesthetics
Local Anesthetics
glydo
lidocaine (pf) injection solution
lidocaine (pf) intravenous syringe 100
mg/5 ml (2 %)
lidocaine hcl injection solution
PA BvD; (PA for ESRD
Only)
Only)
5
Drug Name
Drug Tier
Requirements/Limits
lidocaine hcl laryngotracheal
lidocaine hcl mucous membrane gel
lidocaine hcl mucous membrane jelly in
applicator
lidocaine hcl mucous membrane solution
lidocaine hcl urethral
lidocaine topical adhesive
patch,medicated
lidocaine topical ointment
(Xylocaine)
(Lidocaine HCl)
(Lidocaine HCl)
1
1
1
(Xylocaine)
(Lidocaine HCl)
(Lidoderm)
1
1
2
(Lidocaine)
2
lidocaine-prilocaine topical
(EMLA)
1
lidocaine-prilocaine topical kit
RELADOR PAK
(Relador Pak)
1
1
Only)
Only)
PA BvD
PA BvD
2
2
2
2
3
3
QL (56 per 28 days)
PA
Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate
(Campral)
buprenorphine hcl sublingual
(Subutex)
buprenorphine-naloxone
(Buprenorphine
HCl/Naloxone HCl)
bupropion hcl sr 150 mg tablet f/c
(Zyban)
CHANTIX
CHANTIX CONTINUING MONTH
BOX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH BOX
disulfiram
(Antabuse)
naloxone
(Naloxone HCl)
naltrexone hcl
(Revia)
naltrexone
(Revia)
NICOTROL
ZUBSOLV SUBLINGUAL TABLET 1.40.36 MG
ZUBSOLV SUBLINGUAL TABLET
11.4-2.9 MG
ZUBSOLV SUBLINGUAL TABLET 2.90.71 MG, 8.6-2.1 MG
3
3
2
1
2
2
4
3
QL (56 per 28 days)
QL (53 per 28 days)
3
PA; QL (120 per 30
days)
3
6
Drug Name
Drug Tier
Requirements/Limits
3
(Xanax)
(Xanax XR)
1
1
QL (90 per 30 days)
QL (90 per 30 days)
(Xanax XR)
1
QL (60 per 30 days)
(Alprazolam)
(Chlordiazepoxide HCl)
(Klonopin)
(Klonopin)
(Clonazepam)
2
1
1
1
1
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
(Clonazepam)
1
(Tranxene T-Tab)
(Tranxene T-Tab)
1
1
QL (60 per 30 days)
ZUBSOLV SUBLINGUAL TABLET 5.71.4 MG
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
alprazolam oral tablet extended release 24
hr 0.5 mg
alprazolam oral tablet extended release 24
hr 1 mg, 2 mg, 3 mg
alprazolam oral tablet,disintegrating
chlordiazepoxide hcl
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
clonazepam oral tablet,disintegrating
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2
mg
clorazepate dipotassium oral tablet 15 mg
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
DIASTAT ACUDIAL RECTAL KIT
12.5-15-17.5-20 MG
diazepam injection
diazepam intensol
diazepam oral solution
diazepam oral tablet
diazepam rectal
estazolam oral tablet 1 mg
4
(Diazepam)
(Diazepam)
(Diazepam)
(Valium)
(Diastat Acudial)
(Estazolam)
1
1
1
1
2
1
QL (10 per 28 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (60
per 30 days)
7
Drug Name
Drug Tier
Requirements/Limits
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (90 per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
estazolam oral tablet 2 mg
(Estazolam)
1
flurazepam oral capsule 15 mg
(Flurazepam HCl)
1
flurazepam oral capsule 30 mg
(Flurazepam HCl)
1
lorazepam oral solution
lorazepam injection solution
lorazepam injection syringe
lorazepam oral tablet
midazolam (pf) injection
midazolam (pf) injection syringe 2 mg/2
ml (1 mg/ml)
midazolam oral syrup 2 mg/ml
ONFI ORAL SUSPENSION
(Ativan)
(Ativan)
(Ativan)
(Ativan)
(Midazolam HCl/PF)
(Midazolam HCl/PF)
1
1
1
1
1
1
(Midazolam HCl)
1
4
ONFI ORAL TABLET 10 MG, 20 MG
4
QL (10 per 30 days)
PA NSO; QL (480 per 30
days)
days)
8
Drug Name
Drug Tier
Requirements/Limits
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
temazepam oral capsule 15 mg, 22.5 mg,
30 mg
(Restoril)
1
temazepam oral capsule 7.5 mg
(Restoril)
1
triazolam oral tablet 0.125 mg
(Halcion)
1
triazolam oral tablet 0.25 mg
(Halcion)
1
Antibacterials
Aminoglycosides
BETHKIS
5
PA BvD
9
Drug Name
gentamicin in nacl (iso-osm) intravenous
piggyback
gentamicin injection solution
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf) intravenous
solution
neomycin
streptomycin intramuscular
TOBI PODHALER INHALATION
tobramycin in 0.225 % nacl
tobramycin in 0.9 % nacl
tobramycin sulfate injection solution 10
mg/ml
tobramycin sulfate injection solution 40
mg/ml
Antibacterials, Miscellaneous
bacitracin intramuscular
chloramphenicol sod succinate
clindamycin hcl
clindamycin in 5 % dextrose
clindamycin palmitate hcl
clindamycin phosphate injection
clindamycin phosphate intravenous
solution
colistin (colistimethate na)
CUBICIN
linezolid
methenamine hippurate
methenamine mandelate oral tablet 1
gram
nitrofurantoin macrocrystal oral capsule
100 mg
Drug Tier
(Gentamicin In Nacl,
Iso-Osm)
(Garamycin)
(Gentamicin Sulfate/PF)
(Gentamicin Sulfate/PF)
1
(Neomycin Sulfate)
(Streptomycin Sulfate)
1
2
5
5
1
(Tobi)
(Tobramycin/Sodium
Chloride)
(Nebcin)
1
1
1
PA BvD
1
(Nebcin)
2
(Bacitracin)
(Chloramphenicol Sod
Succ)
(Cleocin HCl)
(Cleocin Phosphate In
D5w)
(Cleocin Palmitate)
(Cleocin Phosphate)
(Cleocin Phosphate)
2
1
(Coly-Mycin M
Parenteral)
2
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
(Macrodantin/Macrobid)
Requirements/Limits
1
1
2
1
1
5
5
2
2
2
PA-HRM; QL (120 per
30 days)
10
Drug Name
Drug Tier
Requirements/Limits
PA-HRM; (High Risk
with over 90 days
cumulative use of
nitrofurantoin drugs); QL
(120 per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use of
(120 per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use of
(2400 per 30 days)
nitrofurantoin macrocrystal oral capsule
(Macrodantin/Macrobid)
2
nitrofurantoin monohyd/m-cryst
(Macrobid)
2
nitrofurantoin oral
(Furadantin)
2
polymyxin b sulfate
(Polymyxin B Sulfate)
SYNERCID
trimethoprim
(Trimethoprim)
vancomycin in d5w intravenous piggyback (Vancomycin
HCl/D5W)
vancomycin intravenous recon soln 1,000 (Vancomycin HCl)
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500
(Vancomycin
mg
HCl/D5W)
vancomycin oral capsule
(Vancocin HCl)
XIFAXAN ORAL TABLET 200 MG
XIFAXAN ORAL TABLET 550 MG
ZYVOX ORAL
Cephalosporins
1
5
1
2
2
2
5
5
5
5
ST; QL (60 per 30 days)
11
Drug Name
CEDAX ORAL SUSPENSION FOR
RECONSTITUTION 90 MG/5 ML
cefaclor oral capsule
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefaclor oral tablet extended release 12 hr
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml
cefazolin in dextrose (iso-os) intravenous
cefazolin injection recon soln
cefazolin injection recon soln 100 gram,
300 g
cefazolin intravenous
cefdinir
cefditoren pivoxil
cefepime
CEFEPIME IN DEXTROSE 5 %
CEFEPIME IN DEXTROSE,ISO-OSM
INTRAVENOUS PIGGYBACK
cefixime
cefotaxime
cefoxitin
cefoxitin in dextrose, iso-osm intravenous
cefpodoxime oral suspension for
reconstitution 100 mg/5 ml
cefpodoxime oral suspension for
reconstitution 50 mg/5 ml
cefpodoxime oral tablet
cefprozil
ceftazidime
ceftazidime injection recon soln 2 gram, 6
gram
Drug Tier
Requirements/Limits
4
(Cefaclor)
(Cefaclor)
2
1
(Cefaclor)
(Cefadroxil)
(Cefadroxil)
2
1
1
(Cefadroxil)
(Cefazolin Sodium)
1
2
(Cefazolin
Sodium/Dextrose, Iso)
(Ancef)
(Cefazolin Sodium)
2
(Cefazolin Sodium)
(Cefdinir)
(Spectracef)
(Maxipime)
2
2
2
2
4
4
(Suprax)
(Claforan)
(Mefoxin)
(Cefoxitin
(Cefpodoxime Proxetil)
2
1
2
2
1
(Cefprozil)
(Fortaz)
(Fortaz)
2
2
2
2
2
2
2
12
Drug Name
ceftibuten
ceftriaxone in dextrose,iso-os intravenous
CEFTRIAXONE IN DEXTROSE,ISO-OS
INTRAVENOUS PIGGYBACK 2
GRAM/50 ML
ceftriaxone injection recon soln
ceftriaxone intravenous recon soln 1 gram
CEFTRIAXONE INTRAVENOUS
RECON SOLN 2 GRAM
cefuroxime axetil oral tablet
cefuroxime sodium injection recon soln
1.5 gram, 750 mg
cefuroxime sodium intravenous
cefuroxime-dextrose (iso-osm)
cephalexin oral capsule
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
MEFOXIN IN DEXTROSE (ISO-OSM)
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION
SUPRAX ORAL TABLET
SUPRAX ORAL TABLET,CHEWABLE
TEFLARO
Macrolides
azithromycin
clarithromycin oral suspension for
reconstitution
clarithromycin oral tablet
clarithromycin oral tablet extended
release 24 hr
DIFICID
ERYTHROCIN
erythromycin base oral tablet,delayed
release (dr/ec) 250 mg, 500 mg
Drug Tier
(Cedax)
(Ceftriaxone
Na/Dextrose, Iso)
Requirements/Limits
2
2
2
(Rocephin)
(Ceftriaxone
Na/Dextrose, Iso)
2
2
2
(Ceftin)
(Zinacef)
1
2
(Zinacef)
(Cefuroxime
(Keflex)
(Cephalexin)
1
1
(Cephalexin)
1
4
4
1
1
4
4
4
(Zithromax)
(Biaxin)
1
2
(Biaxin)
(Biaxin XL)
2
2
(Erythromycin Base)
5
4
1
QL (20 per 10 days)
13
Drug Name
Drug Tier
ERYTHROMYCIN BASE ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythromycin ethylsuccinate oral
(Eryped 200)
suspension for reconstitution 200 mg/5 ml
erythromycin ethylsuccinate oral tablet
(Erythromycin
400 mg
Ethylsuccinate)
erythromycin oral capsule,delayed
(Erythromycin Base)
release(dr/ec)
erythromycin oral tablet
(Erythromycin Base)
erythromycin stearate oral tablet 250 mg (Erythromycin Stearate)
Miscellaneous B-Lactam Antibiotics
aztreonam
(Azactam)
CAYSTON
imipenem-cilastatin
(Primaxin)
INVANZ
meropenem
(Merrem)
Penicillins
amoxicillin oral capsule
(Amoxicillin)
amoxicillin oral suspension for
(Amoxil)
reconstitution
amoxicillin oral tablet
(Amoxicillin)
amoxicillin oral tablet,chewable 125 mg, (Amoxicillin)
250 mg
amoxicillin-pot clavulanate oral
(Augmentin)
suspension for reconstitution
amoxicillin-pot clavulanate oral tablet
(Augmentin)
amoxicillin-pot clavulanate oral tablet
(Augmentin XR)
extended release 12 hr
amoxicillin-pot clavulanate oral
(Amoxicillin/Potassium
tablet,chewable
Clav)
ampicillin
(Ampicillin Trihydrate)
ampicillin sodium injection recon soln
(Totacillin-N)
ampicillin sodium intravenous recon soln (Totacillin-N)
ampicillin-sulbactam injection recon soln (Unasyn)
1.5 gram, 3 gram
ampicillin-sulbactam injection recon soln (Unasyn)
15 gram
2
Requirements/Limits
1
2
1
1
2
2
5
2
4
2
LA
1
1
1
1
1
1
1
1
1
2
2
2
1
14
Drug Name
ampicillin-sulbactam intravenous recon
soln
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin in dextrose iso-osm
nafcillin injection
nafcillin intravenous recon soln
oxacillin in dextrose(iso-osm)
oxacillin injection recon soln
oxacillin intravenous recon soln
penicillin g pot in dextrose
penicillin g potassium
penicillin g procaine
penicillin v potassium
piperacillin-tazobactam
Quinolones
ciprofloxacin
ciprofloxacin (mixture)
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate intravenous solution
400 mg/40 ml
levofloxacin in d5w intravenous piggyback
levofloxacin intravenous
levofloxacin oral solution
levofloxacin oral tablet
moxifloxacin
ofloxacin oral
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
sulfamethoxazole-trimethoprim oral
suspension
Drug Tier
(Unasyn)
(Dicloxacillin Sodium)
(Nafcillin In
Dextrose,Iso-Osm)
(Unipen)
(Nallpen)
(Oxacillin
(Oxacillin Sodium)
(Oxacillin Sodium)
(Pen G Pot/DextroseWater)
(Penicillin G Potassium)
(Penicillin G Procaine)
(Penicillin V Potassium)
(Zosyn)
Requirements/Limits
2
4
4
1
4
2
2
2
2
2
2
2
2
1
2
(Cipro)
(Cipro XR)
(Cipro)
(Cipro I.V.)
(Cipro I.V.)
2
2
1
1
1
(Levaquin)
(Levofloxacin)
(Levaquin)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
2
1
2
2
(Sulfadiazine)
(Sulfamethoxazole/Trim
ethoprim)
ethoprim)
2
1
1
15
Drug Name
Drug Tier
sulfamethoxazole-trimethoprim oral tablet (Bactrim)
sulfasalazine
(Azulfidine)
sulfatrim
ethoprim)
sulfazine
(Azulfidine)
sulfazine ec
(Azulfidine)
Tetracyclines
demeclocycline oral
(Demeclocycline HCl)
doxycycline hyclate oral capsule 100 mg
(Morgidox)
doxycycline hyclate 100 mg tab f/c
(Doryx)
doxycycline hyclate intravenous
(Doxycycline Hyclate)
(Adoxa)
(Morgidox)
doxycycline hyclate oral tablet 100 mg, 50 (Adoxa)
mg
doxycycline hyclate oral tablet 20 mg
(Doryx)
doxycycline hyclate oral tablet,delayed
(Doryx)
release (dr/ec)
doxycycline mono 100 mg cap
(Adoxa)
doxycycline mono 100 mg tablet
(Adoxa)
doxycycline monohydrate oral capsule 150 (Adoxa)
mg, 75 mg
doxycycline monohydrate oral capsule 50 (Adoxa)
mg
doxycycline monohydrate oral suspension (Vibramycin)
for reconstitution
doxycycline monohydrate oral tablet 150 (Adoxa)
mg, 75 mg
doxycycline monohydrate oral tablet 50
(Adoxa)
mg
MINOCIN INTRAVENOUS
minocycline oral capsule
(Minocin)
minocycline oral tablet
(Minocycline HCl)
minocycline oral tablet extended release
(Minocycline HCl)
24 hr
tetracycline
(Ala-Tet)
TYGACIL
1
1
1
Requirements/Limits
1
1
2
1
1
2
1
1
1
2
2
1
1
2
1
2
2
1
5
1
2
2
1
5
Anticancer Agents
16
Drug Name
Drug Tier
Anticancer Agents
ABRAXANE
ADCETRIS
5
5
AFINITOR DISPERZ
5
AFINITOR ORAL TABLET 10 MG
5
AFINITOR ORAL TABLET 2.5 MG, 5
MG, 7.5 MG
ALIMTA INTRAVENOUS RECON
SOLN
anastrozole
ARRANON
ARZERRA
AVASTIN
azacitidine
BELEODAQ
bexarotene
5
bicalutamide
bleomycin
BLINCYTO
Requirements/Limits
days)
days)
days)
days)
5
(Arimidex)
(Vidaza)
(Targretin)
(Casodex)
(Bleomycin Sulfate)
1
5
5
5
5
5
5
2
1
5
BOSULIF ORAL TABLET 100 MG
5
BOSULIF ORAL TABLET 500 MG
5
CAPRELSA ORAL TABLET 100 MG
5
CAPRELSA ORAL TABLET 300 MG
5
carboplatin intravenous solution
cisplatin
cladribine
COMETRIQ
(Carboplatin)
(Cisplatin)
(Cladribine)
2
1
2
5
cyclophosphamide intravenous recon soln
(Cyclophosphamide)
2
PA NSO
PA NSO
PA NSO
days)
PA BvD
PA NSO; QL (140 per
365 days)
days)
days)
days)
days)
PA BvD
days)
PA BvD
17
Drug Name
CYCLOPHOSPHAMIDE ORAL
CAPSULE
cyclophosphamide oral tablet
CYRAMZA
cytarabine
cytarabine (pf) injection recon soln
cytarabine (pf) injection solution
dacarbazine intravenous recon soln
dactinomycin
daunorubicin intravenous
DAUNOXOME
decitabine
docetaxel intravenous solution
doxorubicin hcl intravenous recon soln 10
mg
doxorubicin hcl peg-liposomal intravenous
suspension 2 mg/ml
doxorubicin, peg-liposomal
DROXIA
ELIGARD SUBCUTANEOUS SYRINGE
22.5 MG (3 MONTH)
30 MG (4 MONTH)
45 MG (6 MONTH)
7.5 MG (1 MONTH)
EMCYT
epirubicin intravenous solution 50 mg/25
ml
ERBITUX
ERIVEDGE
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
Drug Tier
Requirements/Limits
4
PA BvD; ST
PA BvD; ST
PA NSO
PA BvD
PA BvD
PA BvD
(Dacogen)
(Taxotere)
(Doxorubicin HCl)
2
5
1
1
1
1
1
2
3
5
5
2
(Doxil)
5
PA BvD
(Doxil)
5
3
4
PA BvD
4
QL (1 per 112 days)
5
QL (1 per 168 days)
4
QL (1 per 28 days)
(Cyclophosphamide)
(Cytarabine)
(Cytarabine/PF)
(Cytarabine/PF)
(Dtic-Dome IV)
(Dactinomycin)
(Cerubidine)
(Ellence)
QL (1 per 84 days)
3
1
5
5
(Etoposide)
(Aromasin)
PA BvD
PA NSO
days)
4
2
2
5
18
Drug Name
Drug Tier
FARYDAK
5
FASLODEX
FIRMAGON KIT W DILUENT
SYRINGE
floxuridine
fludarabine
fluorouracil intravenous solution 2.5
gram/50 ml, 5 gram/100 ml, 500 mg/10 ml
flutamide
GAZYVA
5
4
gemcitabine intravenous recon soln 1
gram
GILOTRIF
(FUDR)
(Fludara)
(Fluorouracil)
1
2
2
(Flutamide)
2
5
(Gemzar)
GLEEVEC ORAL TABLET 100 MG
5
GLEEVEC ORAL TABLET 400 MG
5
HALAVEN
5
HERCEPTIN
HEXALEN
hydroxyurea
IBRANCE
5
5
1
5
ICLUSIG ORAL TABLET 15 MG
5
ICLUSIG ORAL TABLET 45 MG
5
idarubicin
ifosfamide intravenous recon soln
ifosfamide intravenous solution
ifosfamide-mesna
IMBRUVICA
(Idamycin Pfs)
(Ifex)
(Ifex)
(Ifosfamide/Mesna)
days)
PA BvD
PA BvD
days)
5
5
(Hydrea)
Requirements/Limits
2
2
2
5
5
days)
days)
days)
days)
PA NSO
days)
days)
days)
PA BvD
PA BvD
PA BvD
days)
19
Drug Name
Drug Tier
Requirements/Limits
INLYTA ORAL TABLET 1 MG
5
INLYTA ORAL TABLET 5 MG
5
IRESSA
5
days)
days)
days)
irinotecan intravenous solution
ISTODAX
IXEMPRA
JAKAFI
(Camptosar)
5
5
5
5
JEVTANA
KADCYLA
KEYTRUDA
KYPROLIS
5
5
5
5
LENVIMA
letrozole
LEUKERAN
leuprolide
lomustine
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
LYNPARZA
5
1
4
2
2
5
5
5
5
5
5
(Femara)
(Leuprolide Acetate)
(Gleostine)
5
LYSODREN
MARQIBO
3
5
MATULANE
MEGACE ES
megestrol oral suspension
megestrol oral suspension 625 mg/5 ml
megestrol oral tablet
5
5
1
5
1
(Megace Es)
(Megace Es)
(Megestrol Acetate)
PA NSO
days)
PA NSO
PA NSO
days)
PA NSO
QL (1 per 28 days)
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
QL (1 per 28 days)
QL (1 per 84 days)
days)
days)
20
Drug Name
Drug Tier
Requirements/Limits
MEKINIST ORAL TABLET 0.5 MG
5
MEKINIST ORAL TABLET 2 MG
5
days)
days)
melphalan hcl intravenous
mercaptopurine
methotrexate sodium (pf) injection recon
soln
methotrexate sodium (pf) injection
solution
methotrexate sodium injection
methotrexate sodium oral
mitomycin intravenous recon soln
mitoxantrone
MUSTARGEN
NEXAVAR
NILANDRON
ONCASPAR
OPDIVO INTRAVENOUS SOLUTION
40 MG/4 ML
oxaliplatin intravenous solution 100
mg/20 ml
paclitaxel
PERJETA
POMALYST
(Alkeran)
(Purinethol)
(Methotrexate
Sodium/PF)
(Methotrexate Sodium)
5
2
1
PA BvD
1
PA BvD
(Mitomycin)
(Mitoxantrone HCl)
1
1
1
1
3
5
PA BvD
PA BvD; ST
PA BvD
3
5
5
(Eloxatin)
5
(Paclitaxel)
2
5
5
PROLEUKIN
PURIXAN
REVLIMID
5
5
5
RITUXAN
SOLTAMOX
SPRYCEL ORAL TABLET 100 MG, 140
MG, 50 MG, 70 MG, 80 MG
SPRYCEL ORAL TABLET 20 MG
5
4
5
5
days)
PA NSO
PA NSO
PA NSO
days)
PA NSO; LA; QL (21
per 28 days)
PA NSO
days)
days)
21
Drug Name
Drug Tier
Requirements/Limits
STIVARGA
5
SUTENT
5
SYLVANT
SYNRIBO
5
5
days)
days)
PA NSO
days)
TABLOID
TAFINLAR
3
5
tamoxifen
TARCEVA ORAL TABLET 100 MG, 25
MG
TARCEVA ORAL TABLET 150 MG
(Tamoxifen Citrate)
1
5
5
TARGRETIN TOPICAL
5
TASIGNA
5
TEMODAR INTRAVENOUS
teniposide
toposar intravenous
topotecan intravenous
TORISEL
5
5
2
5
5
(Teniposide)
(Etoposide)
(Hycamtin)
TREANDA INTRAVENOUS RECON
SOLN
TREANDA INTRAVENOUS
SOLUTION
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION
SYRINGE 11.25 MG/2 ML
tretinoin (chemotherapy)
(Tretinoin)
TREXALL
days)
days)
days)
days)
days)
PA NSO; (vial only)
PA BvD; QL (4 per 28
days)
5
5
5
QL (1 per 168 days)
5
QL (1 per 84 days)
5
QL (1 per 168 days)
5
QL (1 per 28 days)
5
4
(capsule: 10mg)
PA BvD; ST
22
Drug Name
TYKERB
UNITUXIN
VALSTAR
VECTIBIX
VELCADE
vinblastine intravenous
vincristine
vincristine sulfate intravenous solution 1
mg/ml
vinorelbine intravenous solution
VOTRIENT
Drug Tier
(Vinblastine Sulfate)
(Vincristine Sulfate)
(Vincristine Sulfate)
(Navelbine)
5
5
5
5
5
2
1
1
1
5
Requirements/Limits
PA NSO
PA NSO
PA NSO
PA BvD
PA BvD
PA BvD
XALKORI
5
XTANDI
5
YERVOY
ZALTRAP INTRAVENOUS SOLUTION
ZELBORAF
5
5
5
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA
ZYDELIG
4
days)
days)
days)
PA NSO
PA NSO
days)
QL (1 per 84 days)
4
QL (1 per 28 days)
ZYKADIA
5
ZYTIGA
5
5
5
days)
days)
days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine 0.1 mg/ml syringe luer-jet syr
atropine injection solution
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
propantheline
(Atropine Sulfate)
(Atropine Sulfate)
(Atropine Sulfate)
1
1
1
(Propantheline Bromide)
1
23
Drug Name
Drug Tier
Requirements/Limits
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension
carbamazepine oral tablet extended
release 12 hr
carbamazepine oral tablet,chewable
CELONTIN ORAL CAPSULE 300 MG
DILANTIN
divalproex oral capsule, sprinkle
divalproex oral tablet extended release 24
hr
divalproex oral tablet,delayed release
(dr/ec)
ethosuximide oral capsule
ethosuximide oral solution
felbamate
fosphenytoin
FYCOMPA ORAL TABLET
gabapentin oral capsule
gabapentin oral solution
gabapentin oral tablet 600 mg, 800 mg
GABITRIL ORAL TABLET 12 MG, 16
MG
GRALISE
GRALISE 30-DAY STARTER PACK
LAMICTAL ODT STARTER (BLUE)
LAMICTAL ODT STARTER (GREEN)
LAMICTAL ODT STARTER (ORANGE)
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
lamotrigine oral tablet
lamotrigine oral tablet extended release
24hr
(Tegretol)
(Carbatrol)
4
4
1
2
(Tegretol)
(Tegretol XR)
2
2
(Carbamazepine)
(Depakote Sprinkle)
(Depakote ER)
1
3
3
2
2
(Depakote)
1
(Zarontin)
(Zarontin)
(Felbatol)
(Cerebyx)
2
1
2
1
4
1
2
2
3
(Neurontin)
(Neurontin)
(Neurontin)
4
4
4
4
4
4
(Lamictal)
(Lamictal XR)
1
2
24
Drug Name
lamotrigine oral tablet, chewable
dispersible
lamotrigine oral tablet,disintegrating
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam in nacl (iso-os)
levetiracetam intravenous
levetiracetam oral solution
levetiracetam oral tablet
levetiracetam oral tablet extended release
24 hr
LYRICA ORAL CAPSULE
LYRICA ORAL SOLUTION
oxcarbazepine oral suspension
oxcarbazepine oral tablet
OXTELLAR XR
PEGANONE
phenobarbital oral elixir
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2
mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection solution
PHENYTEK
phenytoin oral suspension 125 mg/5 ml
phenytoin oral
phenytoin sodium
phenytoin sodium extended
POTIGA ORAL TABLET 200 MG, 300
MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone
QUDEXY XR
SABRIL
TEGRETOL XR ORAL TABLET
EXTENDED RELEASE 12 HR 100 MG
tiagabine
Drug Tier
(Lamictal)
1
(Lamictal Odt)
(Lamictal (Blue))
2
2
(Levetiracetam In Nacl
(Iso-Os))
(Keppra)
(Keppra)
(Keppra)
(Keppra XR)
1
(Trileptal)
(Trileptal)
(Phenobarbital)
(Phenobarbital)
(Phenobarbital)
(Phenobarbital Sodium)
(Dilantin-125)
(Dilantin)
(Phenytoin Sodium)
(Phenytek)
(Mysoline)
(Gabitril)
Requirements/Limits
1
2
2
2
3
3
2
1
4
3
1
1
QL (90 per 30 days)
1
1
3
1
1
1
1
4
QL (2 per 30 days)
4
1
4
5
3
QL (90 per 30 days)
QL (90 per 30 days)
2
25
Drug Name
topiramate
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er 24hr
TRILEPTAL ORAL SUSPENSION
TROKENDI XR
valproate sodium
valproic acid
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
VIMPAT INTRAVENOUS
VIMPAT ORAL SOLUTION
VIMPAT ORAL TABLET
zonisamide
Drug Tier
(Topamax)
(Topamax)
(Qudexy XR)
Requirements/Limits
(Depacon)
(Depakene)
(Depakene)
1
2
2
4
4
1
1
1
QL (200 per 5 days)
QL (60 per 30 days)
(Zonegran)
4
4
4
1
1
2
1
2
2
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
2
2
2
2
3
3
3
3
QL (60 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
3
QL (30 per 30 days)
(Exelon)
3
2
QL (60 per 30 days)
(Amitriptyline HCl)
1
PA NSO-HRM
Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 5 mg
donepezil oral tablet 23 mg
donepezil oral tablet,disintegrating
EXELON TRANSDERMAL
galantamine oral capsule,ext rel. pellets
24 hr
galantamine oral solution
galantamine oral tablet
memantine oral tablet
memantine oral tablets,dose pack
NAMENDA ORAL SOLUTION
NAMENDA ORAL TABLET
NAMENDA TITRATION PAK
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
NAMZARIC
rivastigmine tartrate
(Aricept)
(Aricept)
(Aricept Odt)
(Razadyne ER)
(Razadyne)
(Razadyne)
(Namenda)
(Namenda)
Antidepressants
Antidepressants
amitriptyline
26
Drug Name
amoxapine
BRINTELLIX
bupropion hcl oral tablet
bupropion hcl oral tablet extended release
, 150 mg
bupropion hcl oral tablet extended release
24 hr
citalopram oral solution
citalopram oral tablet
clomipramine
desipramine oral
DESVENLAFAXINE FUMARATE
DESVENLAFAXINE ORAL
doxepin oral
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
release(dr/ec) 30 mg
release(dr/ec) 40 mg
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine oral capsule
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60 MG
fluvoxamine oral capsule,extended release
24hr
fluvoxamine oral tablet
imipramine hcl
imipramine pamoate
IRENKA
KHEDEZLA
maprotiline
Drug Tier
(Amoxapine)
(Wellbutrin)
(Wellbutrin SR)
2
4
1
2
(Wellbutrin XL)
2
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
2
Requirements/Limits
QL (30 per 30 days)
PA NSO-HRM
(Doxepin HCl)
(Irenka)
1
2
2
3
3
1
2
(Irenka)
2
QL (30 per 30 days)
(Irenka)
4
QL (30 per 30 days)
4
2
4
1
2
QL (30 per 30 days)
(Lexapro)
(Prozac)
(Prozac Weekly)
(Fluoxetine HCl)
(Fluoxetine HCl)
(Luvox CR)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-Pm)
(Maprotiline HCl)
QL (30 per 30 days)
QL (30 per 30 days)
PA NSO-HRM
QL (60 per 30 days)
1
1
2
2
1
1
2
4
4
2
PA NSO-HRM
PA NSO-HRM
QL (30 per 30 days)
QL (30 per 30 days)
27
Drug Name
MARPLAN
mirtazapine
nefazodone
nortriptyline oral capsule
nortriptyline oral solution
olanzapine-fluoxetine
paroxetine hcl oral tablet
paroxetine hcl oral tablet extended release
24 hr
PAXIL ORAL SUSPENSION
perphenazine-amitriptyline
phenelzine
PRISTIQ
protriptyline
sertraline oral concentrate
sertraline oral tablet
SILENOR
SURMONTIL
tranylcypromine
trazodone
venlafaxine oral capsule,extended release
24hr
venlafaxine oral tablet
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet extended release
24hr 225 mg
VIIBRYD
Drug Tier
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Nortriptyline HCl)
(Symbyax)
(Paxil)
(Paxil CR)
(Perphenazine/Amitripty
line HCl)
(Nardil)
4
1
2
1
1
2
1
2
4
1
(Parnate)
(Trazodone HCl)
(Effexor XR)
2
4
2
2
1
3
4
2
1
1
(Venlafaxine HCl)
(Venlafaxine HCl)
1
2
(Venlafaxine HCl)
3
(Vivactil)
(Zoloft)
(Zoloft)
Requirements/Limits
PA NSO-HRM
QL (30 per 30 days)
QL (30 per 30 days)
PA NSO-HRM
4
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
ACTOPLUS MET XR
BYDUREON
BYETTA SUBCUTANEOUS PEN
INJECTOR 10 MCG/DOSE(250
MCG/ML) 2.4 ML
2
3
3
3
QL (90 per 30 days)
QL (60 per 30 days)
QL (4 per 28 days)
QL (2.4 per 28 days)
28
Drug Name
Drug Tier
BYETTA SUBCUTANEOUS PEN
INJECTOR 5 MCG/DOSE (250
MCG/ML) 1.2 ML
CYCLOSET
GLYSET
GLYXAMBI
INVOKAMET ORAL TABLET 1501,000 MG, 150-500 MG, 50-1,000 MG
INVOKAMET ORAL TABLET 50-500
MG
INVOKANA ORAL TABLET 100 MG
INVOKANA ORAL TABLET 300 MG
JANUMET
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG, 50500 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG
JANUVIA
JARDIANCE
JENTADUETO
KAZANO
KORLYM
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended release 24
hr 500 mg
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release
24hr
nateglinide
NESINA
OSENI
pioglitazone
pioglitazone-glimepiride
Requirements/Limits
3
4
3
3
3
QL (90 per 30 days)
QL (30 per 30 days)
3
3
3
3
3
ST; QL (120 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
3
QL (60 per 30 days)
3
3
3
4
5
(Glucophage)
(Glucophage)
(Glucophage)
(Glucophage XR)
1
1
1
1
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (90 per 30 days)
(Glucophage XR)
1
QL (90 per 30 days)
(Fortamet)
1
QL (60 per 30 days)
(Starlix)
2
4
4
2
2
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Actos)
(Duetact)
29
Drug Name
pioglitazone-metformin
PRANDIMET
repaglinide
SYMLINPEN 120
SYMLINPEN 60
TRADJENTA
TRULICITY
VICTOZA
Insulins
HUMALOG KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML
HUMALOG KWIKPEN
SUBCUTANEOUS INSULIN PEN 200
UNIT/ML (3 ML)
HUMALOG MIX 50-50
HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 75-25
HUMALOG MIX 75-25 KWIKPEN
HUMALOG SUBCUTANEOUS
CARTRIDGE
HUMALOG SUBCUTANEOUS
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500
(CONCENTRATED)
LANTUS
LANTUS SOLOSTAR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
Drug Tier
(Actoplus Met)
(Prandin)
Requirements/Limits
2
3
2
4
4
3
3
4
QL (90 per 30 days)
QL (6 per 28 days)
QL (30 per 30 days)
QL (4 per 28 days)
3
QL (30 per 28 days)
3
QL (12 per 28 days)
3
3
3
3
3
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (30 per 28 days)
3
3
3
3
3
3
3
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
3
3
3
3
3
3
3
3
3
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
30
Drug Name
NOVOLOG PENFILL
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended release 24hr
10 mg
glipizide oral tablet extended release 24hr
2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5-250 mg
Drug Tier
Requirements/Limits
3
3
QL (30 per 28 days)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
(Glucotrol XL)
1
1
1
1
1
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
1
QL (30 per 30 days)
2
QL (60 per 30 days)
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
glyburide micronized oral tablet 1.5 mg
(Glipizide/Metformin
HCl)
(Glipizide/Metformin
HCl)
(Glynase)
2
1
glyburide micronized oral tablet 3 mg
(Glynase)
1
glyburide micronized oral tablet 6 mg
(Glynase)
1
glyburide oral tablet 1.25 mg
(Glyburide)
1
glyburide oral tablet 2.5 mg
(Glyburide)
1
glyburide oral tablet 5 mg
(Glyburide)
1
glyburide-metformin oral tablet 1.25-250
mg
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
(Glucovance)
1
(Glucovance)
1
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
QL (60 per 30 days)
5
5
PA BvD
PA BvD
Antifungals
Antifungals
ABELCET
AMBISOME
31
Drug Name
amphotericin b
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
ciclopirox-ure-camph-menth-euc
clotrimazole mucous membrane
clotrimazole topical cream
clotrimazole topical solution
clotrimazole-betamethasone topical cream
clotrimazole-betamethasone topical lotion
econazole topical
EXELDERM
fluconazole
fluconazole in dextrose(iso-o) intravenous
piggyback
fluconazole in nacl (iso-osm) intravenous
piggyback
flucytosine
griseofulvin microsize oral suspension
griseofulvin microsize oral tablet
griseofulvin ultramicrosize
itraconazole
ketoconazole oral
ketoconazole topical cream
ketoconazole topical shampoo
miconazole nitrate vaginal suppository
200 mg
NOXAFIL
NYSTATIN (BULK) POWDER 1
BILLION UNIT
nystatin oral
nystatin oral
nystatin topical
Drug Tier
(Amphotericin B)
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox Olamine)
(Ciclodan)
(Clotrimazole)
(Clotrimazole)
(Lotrimin)
(Lotrisone)
(Clotrimazole/Betameth
asone Dip)
(Econazole Nitrate)
(Diflucan)
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Griseofulvin,
Microsize)
(Grifulvin V)
(Gris-Peg)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Monistat 3)
2
5
2
2
2
2
1
2
1
1
1
2
2
Requirements/Limits
PA BvD
1
4
1
1
1
5
2
2
2
2
1
1
1
1
5
1
(Nystatin)
(Nystatin)
(Nystatin)
1
1
1
32
Drug Name
nystatin-triamcinolone
SPORANOX ORAL SOLUTION
terbinafine hcl oral
voriconazole intravenous
voriconazole oral
Drug Tier
(Nystatin/Triamcin)
(Lamisil)
(Vfend IV)
(Vfend)
Requirements/Limits
2
4
1
2
5
Antihistamines
Antihistamines
carbinoxamine maleate oral liquid 4 mg/5
ml
carbinoxamine maleate oral tablet
clemastine oral syrup
clemastine oral tablet 2.68 mg
cyproheptadine
diphenhydramine hcl injection solution 50
mg/ml
diphenhydramine hcl injection syringe
levocetirizine oral solution
levocetirizine oral tablet
promethazine oral syrup
(Carbinoxamine
Maleate)
(Palgic)
(Clemastine Fumarate)
(Clemastine Fumarate)
(Cyproheptadine HCl)
(Diphenhydramine HCl)
1
PA-HRM
1
1
1
2
1
PA-HRM
PA-HRM
PA-HRM
PA-HRM
(Diphenhydramine HCl)
(Xyzal)
(Xyzal)
(Promethazine HCl)
1
2
1
1
PA-HRM
Anti-Infectives (Skin And Mucous Membrane)
Anti-Infectives (Skin And Mucous Membrane)
AVC VAGINAL
clindamycin phosphate vaginal
(Cleocin)
metronidazole vaginal
(Metrogel-Vaginal)
terconazole vaginal cream
(Terazol 7)
terconazole vaginal suppository
(Terconazole)
3
1
1
1
1
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
dihydroergotamine nasal
ERGOMAR
naratriptan
rizatriptan oral tablet
rizatriptan oral tablet,disintegrating
sumatriptan nasal spray
sumatriptan oral tablet
(D.H.E.45)
(Migranal)
(Amerge)
(Maxalt)
(Maxalt Mlt)
(Imitrex)
(Imitrex)
2
2
4
2
2
2
2
1
QL (30 per 28 days)
QL (4 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (12 per 28 days)
QL (18 per 28 days)
33
Drug Name
sumatriptan succinate subcutaneous
cartridge
sumatriptan succinate subcutaneous pen
injector
sumatriptan succinate subcutaneous
solution
zolmitriptan oral tablet
zolmitriptan oral tablet,disintegrating
Drug Tier
Requirements/Limits
(Imitrex)
2
QL (4 per 28 days)
(Imitrex)
2
QL (4 per 28 days)
(Imitrex)
2
QL (4 per 28 days)
(Zomig)
(Zomig Zmt)
2
2
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin
rifampin
RIFATER
SIRTURO
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
TRECATOR
4
1
2
1
4
4
2
2
2
2
4
5
PA; QL (188 per 168
days)
4
Antinausea Agents
Antinausea Agents
dimenhydrinate injection solution
dronabinol
EMEND INTRAVENOUS
EMEND ORAL CAPSULE 125 MG
(Dimenhydrinate)
(Marinol)
1
2
4
4
4
4
EMEND ORAL CAPSULE,DOSE PACK
4
granisetron (pf) intravenous solution
(Granisetron HCl/PF)
QL (2 per 28 days)
PA BvD; QL (1 per 1
day)
QL (1 per 1 day)
PA BvD; QL (2 per 1
day)
PA BvD; QL (3 per 1
day)
1
34
Drug Name
granisetron hcl intravenous solution 1
mg/ml (1 ml)
granisetron hcl oral
meclizine oral tablet 12.5 mg, 25 mg
ondansetron
ondansetron hcl (pf)
ondansetron hcl oral solution
ondansetron hcl oral tablet
prochlorperazine
prochlorperazine edisylate injection
solution
prochlorperazine maleate
prochlorperazine maleate oral
promethazine hcl
promethazine oral tablet
promethazine rectal
TRANSDERM-SCOP
Drug Tier
(Kytril)
2
(Granisetron HCl)
(Antivert)
(Zofran Odt)
(Ondansetron HCl/PF)
(Zofran)
(Zofran)
(Compazine)
(Compazine)
2
1
1
1
2
1
1
1
(Compazine)
(Compazine)
(Phenergan)
(Promethazine HCl)
(Phenergan)
1
1
2
1
2
4
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
atovaquone-proguanil
BILTRICIDE
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
metronidazole in nacl (iso-os)
metronidazole oral capsule
metronidazole oral tablet
NEBUPENT
paromomycin
PENTAM
(Mepron)
(Malarone)
(Aralen Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Metronidazole/Sodium
Chloride)
(Flagyl)
(Flagyl)
(Paromomycin Sulfate)
4
4
5
2
4
2
4
4
1
2
2
1
2
1
4
2
4
PA BvD
35
Drug Name
PRIMAQUINE
quinine sulfate
tinidazole
Drug Tier
(Qualaquin)
(Tindamax)
4
2
2
Requirements/Limits
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine injection
benztropine oral
bromocriptine
cabergoline
carbidopa
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet extended
release
carbidopa-levodopa oral
tablet,disintegrating
carbidopa-levodopa-entacapone
entacapone
NEUPRO
pramipexole oral tablet
ropinirole oral tablet
ropinirole oral tablet extended release 24
hr
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
(Amantadine HCl)
(Cogentin)
(Benztropine Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
(Sinemet CR)
2
5
3
2
1
2
2
2
1
2
(Carbidopa/Levodopa)
2
(Stalevo 50)
(Comtan)
(Mirapex)
(Requip)
(Requip XL)
2
2
3
2
1
2
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl HCl)
2
2
1
PA-HRM
3
QL (90 per 30 days)
3
QL (60 per 30 days)
3
5
3
QL (1 per 28 days)
QL (60 per 30 days)
PA-HRM
PA-HRM
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10 MG
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 15 MG
ABILIFY INTRAMUSCULAR
ABILIFY MAINTENA
ABILIFY ORAL SOLUTION
36
Drug Name
aripiprazole oral solution
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
chlorpromazine injection
chlorpromazine oral
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating 100
mg, 12.5 mg, 25 mg
mg
mg
FANAPT ORAL TABLET
FANAPT ORAL TABLETS,DOSE
PACK
fluphenazine decanoate
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 6 MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML
INVEGA SUSTENNA
MG/ML
Drug Tier
Requirements/Limits
(Abilify)
(Abilify)
2
2
QL (30 per 30 days)
(Abilify)
(Chlorpromazine HCl)
(Chlorpromazine HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
2
1
2
2
2
2
2
QL (60 per 30 days)
(Fazaclo)
2
(Fazaclo)
2
ST; QL (180 per 30
days)
ST; QL (120 per 30
days)
4
4
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
QL (90 per 30 days)
2
(Haloperidol)
(Haloperidol Decanoate)
1
4
1
1
(Haldol Decanoate 50)
1
(Haloperidol Lactate)
1
4
4
5
5
QL (1 per 28 days)
QL (6 per 28 days)
37
Drug Name
INVEGA SUSTENNA
MG/1.5 ML
INVEGA SUSTENNA
MG/0.25 ML
INVEGA SUSTENNA
MG/0.5 ML
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML
LATUDA ORAL TABLET 120 MG, 20
MG, 40 MG, 60 MG
LATUDA ORAL TABLET 80 MG
loxapine succinate
olanzapine intramuscular
olanzapine oral tablet
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating 20
mg
ORAP
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended release
24hr 6 mg
perphenazine
quetiapine
REXULTI ORAL TABLET 0.25 MG
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG, 2 MG,
3 MG, 4 MG
Drug Tier
Requirements/Limits
5
3
3
5
5
5
5
4
(Loxitane)
(Zyprexa)
(Zyprexa)
(Zyprexa Zydis)
4
1
2
2
2
(Zyprexa Zydis)
2
QL (31 per 30 days)
(Invega)
4
2
QL (30 per 30 days)
(Invega)
2
QL (60 per 30 days)
(Perphenazine)
(Seroquel)
2
1
5
5
5
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
ST; QL (120 per 30
days)
38
Drug Name
RISPERDAL CONSTA
risperidone oral solution
risperidone oral tablet
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg
risperidone oral tablet,disintegrating 3
mg, 4 mg
SAPHRIS (BLACK CHERRY)
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR 150 MG,
300 MG, 400 MG, 50 MG
SEROQUEL XR ORAL TABLET
thioridazine
thiothixene
trifluoperazine
VERSACLOZ
Drug Tier
Requirements/Limits
(Risperdal)
(Risperdal)
(Risperdal M-Tab)
4
1
1
2
QL (4 per 28 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Risperdal M-Tab)
2
4
4
4
1
1
1
5
PA NSO-HRM
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine HCl)
ziprasidone hcl
(Geodon)
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 210 MG, 405 MG
2
5
ST; QL (540 per 30
days)
QL (60 per 30 days)
QL (2 per 28 days)
Antivirals (Systemic)
Antiretrovirals
abacavir
abacavir-lamivudine-zidovudine
APTIVUS ORAL CAPSULE
APTIVUS ORAL SOLUTION
ATRIPLA
COMPLERA
CRIXIVAN ORAL CAPSULE 200 MG,
400 MG
didanosine
EDURANT
EMTRIVA
EPIVIR HBV ORAL SOLUTION
EPZICOM
EVOTAZ
(Ziagen)
(Trizivir)
2
5
5
4
5
5
4
(Videx EC)
2
5
3
4
5
5
39
Drug Name
FUZEON SUBCUTANEOUS
INTELENCE ORAL TABLET 100 MG,
200 MG
INTELENCE ORAL TABLET 25 MG
INVIRASE
ISENTRESS ORAL POWDER IN
PACKET
ISENTRESS ORAL TABLET
ISENTRESS ORAL
TABLET,CHEWABLE
KALETRA ORAL SOLUTION
KALETRA ORAL TABLET 100-25 MG
KALETRA ORAL TABLET 200-50 MG
lamivudine
lamivudine-zidovudine
LEXIVA ORAL SUSPENSION
LEXIVA ORAL TABLET
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended release 24
hr
NORVIR
PREZCOBIX
PREZISTA ORAL SUSPENSION
PREZISTA ORAL TABLET 150 MG, 75
MG
PREZISTA ORAL TABLET 400 MG,
600 MG, 800 MG
RESCRIPTOR
RETROVIR INTRAVENOUS
REYATAZ ORAL CAPSULE 150 MG,
200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET
SELZENTRY
stavudine
STRIBILD
SUSTIVA
Drug Tier
Requirements/Limits
5
5
3
5
3
5
3
(Epivir)
(Combivir)
(Viramune)
(Viramune)
(Viramune XR)
5
3
5
2
5
3
5
2
2
2
4
5
4
3
5
4
3
5
5
(Zerit)
5
2
5
4
40
Drug Name
TIVICAY
TRIUMEQ
TRUVADA
VIDEX 2 GRAM PEDIATRIC
VIRACEPT ORAL TABLET
VIRAMUNE XR ORAL TABLET
VIREAD
VITEKTA
ZIAGEN ORAL SOLUTION
zidovudine oral capsule
zidovudine oral syrup
zidovudine oral tablet
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
SYNAGIS
TAMIFLU
Hcv Antivirals
DAKLINZA
HARVONI
OLYSIO
SOVALDI
TECHNIVIE
VIEKIRA PAK
Interferons
INTRON A INJECTION
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEGINTRON REDIPEN
SYLATRON
Drug Tier
Requirements/Limits
5
5
5
3
3
4
3
(Retrovir)
(Retrovir)
(Zidovudine)
(Foscavir)
(Flumadine)
5
5
4
2
1
1
1
4
1
5
3
PA BvD
5
5
5
5
5
5
PA; QL (112 per 28
days)
4
5
5
5
5
5
PA NSO
PA
PA
PA
PA
days)
Nucleosides And Nucleotides
41
Drug Name
acyclovir oral capsule
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet
acyclovir sodium intravenous recon soln
acyclovir sodium intravenous solution
adefovir
BARACLUDE ORAL SOLUTION
cidofovir
entecavir
famciclovir
ganciclovir sodium
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg, 400 mg, 600
mg
ribavirin oral tablets,dose pack 200 mg
(28)- 400 mg (28), 400-400 mg (28)-mg
(28), 600-400 mg (28)-mg (28)
TYZEKA
valacyclovir
VALCYTE ORAL RECON SOLN
valganciclovir
VIRAZOLE
Drug Tier
(Zovirax)
(Zovirax)
(Zovirax)
(Acyclovir Sodium)
(Acyclovir Sodium)
(Hepsera)
(Vistide)
(Baraclude)
(Famvir)
(Cytovene)
(Rebetol)
(Copegus)
1
2
1
1
1
5
4
5
5
2
1
2
2
(Ribatab)
5
Requirements/Limits
PA BvD
PA BvD
PA BvD
5
2
4
5
5
PA BvD
(Lovenox)
(Lovenox)
5
3
2
5
QL (36 per 30 days)
QL (36 per 30 days)
(Lovenox)
5
(Lovenox)
5
QL (34 per 30 days)
(Lovenox)
2
QL (18 per 30 days)
(Lovenox)
2
(Valtrex)
(Valcyte)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
ELIQUIS
enoxaparin subcutaneous solution
enoxaparin subcutaneous syringe 100
mg/ml
mg/0.8 ml
mg/ml
mg/0.3 ml
mg/0.4 ml
42
Drug Name
mg/0.6 ml
mg/0.8 ml
fondaparinux subcutaneous syringe 10
mg/0.8 ml
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml)
HEPARIN (PORCINE) IN 5 % DEX
INTRAVENOUS PARENTERAL
SOLUTION 25,000 UNIT/250 ML(100
UNIT/ML), 25,000 UNIT/500 ML (50
UNIT/ML)
heparin (porcine) in nacl (pf) intravenous
parenteral solution 1,000 unit/500 ml
heparin (porcine) injection solution 1,000
unit/ml
heparin (porcine) injection solution
10,000 unit/ml, 20,000 unit/ml, 5,000
unit/ml
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
heparin, porcine (pf) injection
heparin, porcine (pf) intravenous syringe
100 unit/ml
HEPARIN-0.45% NACL 25,000
UNITS/250 ML (100 UNITS/ML) BAG
LATEX-FREE, OUTER
HEPARIN-0.45% NACL 25,000
UNITS/500 ML (50 UNITS/ML) BAG
LATEX-FREE, OUTER
Drug Tier
Requirements/Limits
(Lovenox)
2
(Lovenox)
2
(Arixtra)
2
QL (24 per 30 days)
(Arixtra)
2
QL (15 per 30 days)
(Arixtra)
2
QL (12 per 30 days)
(Arixtra)
2
QL (18 per 30 days)
(Heparin Sodium in 5%
Dextrose)
1
1
(Heparin
Sodium,Porcine/Ns/PF)
(Heparin
Sodium,Porcine)
(Heparin
Sodium,Porcine)
1
(Heparin
Sodium,Porcine/PF)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
2
PA BvD
1
Only)
1
2
Only)
Only)
1
1
1
43
Drug Name
Drug Tier
heparin-d5w 25,000 units/250 ml (100
units/ml) bag excel container
Dextrose)
heparin-d5w 25,000 units/500 ml (50
units/ml) bag excel container
Dextrose)
IPRIVASK
jantoven
(Coumadin)
PRADAXA
SAVAYSA
warfarin
(Coumadin)
XARELTO
Blood Formation Modifiers
EPOGEN INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 20,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
GRANIX
LEUKINE INJECTION RECON SOLN
MIRCERA
MOZOBIL
NEULASTA SUBCUTANEOUS
SYRINGE
NEUMEGA
NEUPOGEN
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 3,000 UNIT/ML,
4,000 UNIT/ML
20,000 UNIT/ML
40,000 UNIT/ML
PROMACTA
ZARXIO
Hematologic Agents, Miscellaneous
aminocaproic acid oral solution
(Aminocaproic Acid)
aminocaproic acid oral tablet
(Amicar)
anagrelide
(Agrylin)
1
Requirements/Limits
1
5
1
4
4
1
3
3
5
5
4
5
5
PA; QL (0.6 per 28 days)
QL (60 per 30 days)
QL (30 per 30 days)
5
5
3
5
5
5
5
ST
2
2
2
44
Drug Name
Drug Tier
Requirements/Limits
Only)
protamine
(Protamine Sulfate)
1
tranexamic acid intravenous
tranexamic acid oral
Platelet-Aggregation Inhibitors
AGGRENOX
aspirin-dipyridamole
BRILINTA
cilostazol
clopidogrel
EFFIENT
pentoxifylline
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN, HUMAN 25 %
ALBUMIN, HUMAN 5 %
ALBUMINAR 25 %
ALBUMINAR 5 %
ALBURX (HUMAN) 5 %
ALBUTEIN 25 %
ALBUTEIN 5 %
BUMINATE 25 %
BUMINATE 5 %
FLEXBUMIN 25 %
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
(Tranexamic Acid)
(Lysteda)
2
2
(Aggrenox)
(Pletal)
(Plavix)
(Pentoxifylline)
4
2
3
1
1
3
2
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
AMINOSYN 10 %
AMINOSYN 3.5 %
AMINOSYN 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
45
Drug Name
AMINOSYN 8.5 %
AMINOSYN 8.5 %-ELECTROLYTES
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %-ELECTROLYTES
AMINOSYN M 3.5 %
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 % (SULFITE-FREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE FREE
CLINIMIX 5%/D25W SULFITE-FREE
CLINIMIX 2.75%/D5W SULFIT FREE
CLINIMIX 4.25%/D10W SULF FREE
CLINIMIX 4.25%/D5W SULFIT FREE
CLINIMIX 4.25%-D20W SULF-FREE
CLINIMIX 4.25%-D25W SULF-FREE
CLINIMIX 5%-D20W(SULFITE-FREE)
CLINIMIX E 2.75%/D10W SUL FREE
CLINIMIX E 2.75%/D5W SULF FREE
CLINIMIX E 4.25%/D5W SULF FREE
CLINIMIX E 5%/D15W SULFIT FREE
CLINISOL SF 15 %
cysteine (l-cysteine) intravenous solution
d10 % & 0.45 % sodium chloride
d10 %-0.9 % sodium chloride
d2.5 %-0.45 % sodium chloride
Drug Tier
(Cysteine HCl)
(Dextrose 10 % and 0.45
% NaCl)
% NaCl)
(Dextrose 2.5 % and
0.45 % NaCl)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
1
1
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
46
Drug Name
d5 % and 0.9 % sodium chloride
d5 %-0.45 % sodium chloride
dextrose 10 % and 0.2 % nacl
dextrose 10 % in water (d10w)
intravenous
dextrose 2.5 % in water(d2.5w)
dextrose 5 % in ringers
dextrose 5 % in water (d5w) intravenous
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
FREAMINE HBC 6.9 %
FREAMINE III 10 %
glucose oral tablet,chewable
HEPATAMINE 8%
HEPATASOL 8 %
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN
Drug Tier
(Dextrose 5 % and 0.9 %
NaCl)
(Dextrose 5 %-0.45 %
NaCl)
% NaCl)
(Dextrose 10 % in
Water)
(Dextrose 2.5 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5% In
Ringers)
(Dextrose 5 % in Water)
(Dextrose 5%-Lactated
Ringers)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose 5 % and 0.3 %
NaCl)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose)
Requirements/Limits
1
1
1
1
PA BvD
1
PA BvD
1
PA BvD
1
PA BvD
1
PA BvD
1
1
1
1
1
1
PA BvD
1
PA BvD
1
4
4
1
4
4
4
PA BvD
PA BvD
4
PA BvD
PA BvD
PA BvD
PA BvD
47
Drug Name
LIPOSYN II
LIPOSYN III
NEPHRAMINE 5.4 %
NUTRILIPID
PERIKABIVEN
potassium chloride in lr-d5 intravenous
parenteral solution
PREMASOL 10 %
PREMASOL 6 %
PROCALAMINE 3%
PROSOL 20 %
TRAVASOL 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
Drug Tier
(Potassium Chloride In
Lr-D5)
Requirements/Limits
4
4
4
4
4
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet
clonidine hcl-chlorthalidone
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly 0.3
mg/24 hr
doxazosin
guanfacine oral tablet
midodrine
NORTHERA
(Catapres)
(Clonidine
HCl/Chlorthalidone)
(Catapres-Tts 1)
1
2
2
QL (4 per 28 days)
(Catapres-Tts 1)
2
QL (8 per 28 days)
(Cardura)
(Tenex)
(Midodrine HCl)
1
1
2
5
phenylephrine hcl injection
(Vazculep)
prazosin oral
(Minipress)
Angiotensin Ii Receptor Antagonists
BENICAR
BENICAR HCT
candesartan
(Atacand)
candesartan-hydrochlorothiazid
(Atacand HCT)
EDARBI
EDARBYCLOR
PA-HRM
PA; QL (180 per 30
days)
1
1
3
3
2
2
4
4
ST
ST
ST
ST
48
Drug Name
Drug Tier
Requirements/Limits
ENTRESTO
eprosartan
(Teveten)
irbesartan
(Avapro)
irbesartan-hydrochlorothiazide
(Avalide)
losartan
(Cozaar)
losartan-hydrochlorothiazide
(Hyzaar)
telmisartan
(Micardis)
telmisartan-hydrochlorothiazid
(Micardis HCT)
TEVETEN HCT
TRIBENZOR
valsartan
(Diovan)
valsartan-hydrochlorothiazide
(Diovan HCT)
Angiotensin-Converting Enzyme Inhibitors
benazepril
(Lotensin)
benazepril-hydrochlorothiazide
(Lotensin HCT)
captopril
(Captopril)
captopril-hydrochlorothiazide
(Captopril/Hydrochlorot
hiazide)
enalapril maleate
(Vasotec)
enalaprilat intravenous injectable
(Enalaprilat Dihydrate)
enalapril-hydrochlorothiazide
(Vaseretic)
fosinopril
(Fosinopril Sodium)
fosinopril-hydrochlorothiazide
(Fosinopril/Hydrochloro
thiazide)
lisinopril
(Zestril)
lisinopril-hydrochlorothiazide
(Zestoretic)
moexipril
(Univasc)
moexipril-hydrochlorothiazide
(Uniretic)
perindopril erbumine
(Aceon)
quinapril
(Accupril)
quinapril-hydrochlorothiazide
(Accuretic)
ramipril
(Altace)
trandolapril
(Mavik)
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg, 200
(Cordarone)
mg, 400 mg
amiodarone intravenous
(Amiodarone HCl)
3
2
2
2
1
1
2
2
3
3
2
2
ST
ST
1
1
2
2
1
2
1
1
2
1
1
1
1
1
1
1
1
1
1
1
49
Drug Name
amiodarone oral
disopyramide phosphate oral capsule
flecainide
lidocaine (pf) intravenous syringe 50 mg/5
ml (1 %)
lidocaine in 5 % dextrose (pf) intravenous
parenteral solution 8 mg/ml (0.8 %)
mexiletine
MULTAQ
procainamide injection
propafenone oral capsule,extended release
12 hr
propafenone oral tablet
quinidine gluconate oral
quinidine sulfate
TIKOSYN
Beta-Adrenergic Blocking Agents
acebutolol
atenolol
atenolol-chlorthalidone
betaxolol oral
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
BYSTOLIC
carvedilol
COREG CR
esmolol intravenous
labetalol intravenous solution
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous
metoprolol tartrate oral
nadolol
pindolol
propranolol intravenous
Drug Tier
(Cordarone)
(Norpace)
(Flecainide Acetate)
(Lidocaine HCl/PF)
1
2
1
1
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
1
(Procainamide HCl)
(Rythmol SR)
1
3
1
2
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
2
2
1
3
(Sectral)
(Tenormin)
(Tenoretic 50)
(Kerlone)
(Zebeta)
(Ziac)
1
1
1
2
1
1
3
1
3
1
1
1
1
2
1
1
1
2
1
(Coreg)
(Esmolol HCl)
(Trandate)
(Trandate)
(Toprol XL)
(Lopressor HCT)
(Metoprolol Tartrate)
(Lopressor)
(Corgard)
(Pindolol)
(Propranolol HCl)
Requirements/Limits
PA BvD
50
Drug Name
propranolol oral capsule,extended release
24 hr
propranolol oral solution
propranolol oral tablet
propranolol-hydrochlorothiazid
Drug Tier
(Inderal LA)
1
(Propranolol HCl)
(Propranolol HCl)
(Propranolol/Hydrochlor
othiazid)
(Betapace)
1
1
1
sotalol hcl oral tablet 120 mg, 160 mg,
240 mg, 80 mg
sotalol oral
(Betapace)
timolol maleate oral
(Timolol Maleate)
Calcium-Channel Blocking Agents
cartia xt
(Cardizem CD)
diltiazem hcl intravenous
(Cardizem CD)
diltiazem hcl oral capsule, extended
(Cardizem CD)
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 12 hr
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 24hr
diltiazem hcl oral tablet
(Cardizem CD)
diltiazem hcl oral tablet extended release (Cardizem LA)
24 hr
dilt-xr
(Cardizem CD)
matzim la
(Cardizem CD)
taztia xt
(Cardizem CD)
verapamil intravenous syringe
(Verapamil HCl)
verapamil oral capsule, 24 hr er pellet ct (Verelan Pm)
verapamil oral capsule,ext rel. pellets 24
(Verelan)
hr
verapamil oral tablet
(Calan)
verapamil oral tablet extended release
(Calan SR)
Cardiovascular Agents, Miscellaneous
ADRENALIN 1 MG/ML VIAL SUV
ADRENALIN INJECTION SOLUTION 1
MG/ML (1:1,000)
adrenalin injection solution 1 mg/ml
(Epinephrine)
(1:1,000) (1ml)
CORLANOR
Requirements/Limits
1
1
1
2
1
2
2
2
1
2
2
2
2
1
1
1
1
1
1
1
1
3
ST
51
Drug Name
Drug Tier
Requirements/Limits
DEMSER
digitek oral tablet 125 mcg
(Lanoxin)
4
1
digitek oral tablet 250 mcg
(Lanoxin)
1
digoxin injection
DIGOXIN ORAL SOLUTION
(Digoxin)
1
3
digoxin oral tablet
(Lanoxin)
1
dobutamine in d5w intravenous parenteral
solution 1,000 mg/250 ml (4,000 mcg/ml),
250 mg/250 ml (1 mg/ml), 500 mg/250 ml
(2,000 mcg/ml)
dobutamine intravenous solution
dopamine in 5 % dextrose intravenous
solution
dopamine intravenous solution
ephedrine sulfate injection solution
epinephrine 1 mg/ml ampul latex-free
epinephrine hcl (pf) intravenous
epinephrine injection auto-injector 0.15
mg/0.15 ml (1:1,000)
epinephrine injection auto-injector 0.3
mg/0.3 ml (1:1,000)
epinephrine injection syringe 0.1 mg/ml
(1:10,000)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethamolin
FIRAZYR
(Dobutamine HCl/D5W)
1
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
days)
PA-HRM
PA-HRM; QL (300 per
30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
days)
PA BvD
(Dobutamine HCl)
(Dopamine HCl/D5W)
2
1
PA BvD
PA BvD
(Dopamine HCl)
(Ephedrine Sulfate)
(Epinephrine)
(Epinephrine HCl/PF)
(Adrenaclick)
1
1
1
1
2
PA BvD
(Adrenaclick)
1
(Epinephrine)
1
(Ethanolamine Oleate)
3
3
1
5
52
Drug Name
Drug Tier
hydralazine
LANOXIN ORAL TABLET 187.5 MCG,
62.5 MCG
(Hydralazine HCl)
milrinone
milrinone in 5 % dextrose intravenous
piggyback 40 mg/200 ml (200 mcg/ml)
norepinephrine bitartrate
papaverine injection solution
papaverine oral
RANEXA
Dihydropyridines
amlodipine
amlodipine-benazepril
amlodipine-valsartan
amlodipine-valsartan-hcthiazid
AZOR
CLEVIPREX INTRAVENOUS
EMULSION
felodipine
isradipine
nicardipine oral
nifedipine oral tablet extended release
24hr 30 mg, 60 mg, 90 mg
nifedipine oral tablet extended release 30
mg, 60 mg
Diuretics
amiloride oral
amiloride-hydrochlorothiazide
(Milrinone Lactate)
(Milrinone
Lactate/D5W)
(Levophed Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
5
5
(Norvasc)
(Lotrel)
(Exforge)
(Exforge HCT)
1
2
2
2
3
4
bumetanide
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25 mg, 50 mg
DYRENIUM
1
4
1
1
1
3
(Felodipine)
(Isradipine)
(Nicardipine HCl)
(Procardia XL)
2
2
2
1
(Adalat CC)
1
(Midamor)
(Amiloride/Hydrochloro
thiazide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
(Chlorthalidone)
2
1
Requirements/Limits
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
days)
PA BvD
PA BvD
PA BvD
PA
PA
ST
1
1
1
1
4
53
Drug Name
furosemide injection
furosemide oral solution
furosemide oral tablet
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
capsule
triamterene-hydrochlorothiazid oral tablet
Dyslipidemics
ALTOPREV
amlodipine-atorvastatin
atorvastatin
cholestyramine (with sugar) oral
cholestyramine-aspartame oral powder 4
gram
cholestyramine-aspartame oral powder in
packet 4 gram
colestipol
CRESTOR
fenofibrate micronized
fenofibrate nanocrystallized
fenofibrate oral tablet
fenofibric acid
fenofibric acid (choline)
fluvastatin oral capsule
gemfibrozil oral
lovastatin
niacin
niacin oral tablet extended release 24 hr
omega-3 acid ethyl esters
PRALUENT PEN
PRALUENT SYRINGE
pravastatin
Drug Tier
(Furosemide)
(Furosemide)
(Lasix)
(Microzide)
(Hydrochlorothiazide)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
(Dyazide)
1
1
1
1
1
1
2
1
1
1
(Maxzide)
1
(Caduet)
(Lipitor)
(Questran)
(Cholestyramine/Asparta
me)
(Cholestyramine/Asparta
me)
(Colestid)
(Antara)
(Tricor)
(Lofibra)
(Fibricor)
(Trilipix)
(Lescol)
(Lopid)
(Mevacor)
(Niacin)
(Niaspan)
(Lovaza)
(Pravachol)
Requirements/Limits
4
2
1
2
2
2
2
3
2
2
2
2
2
2
1
1
1
2
2
5
5
1
54
Drug Name
Drug Tier
REPATHA SURECLICK
REPATHA SYRINGE
simvastatin
(Zocor)
VASCEPA
VYTORIN 10-10
VYTORIN 10-20
VYTORIN 10-40
VYTORIN 10-80
WELCHOL
ZETIA
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
spironolactone
(Aldactone)
spironolacton-hydrochlorothiaz
(Aldactazide)
Vasodilators
BIDIL
isosorbide dinitrate oral
(Isochron)
isosorbide dinitrate sublingual
(Isosorbide Dinitrate)
isosorbide mononitrate oral tablet
(Isosorbide Mononitrate)
isosorbide mononitrate oral tablet
(Imdur)
extended release 24 hr
minitran transdermal patch 24 hour 0.1
(Nitro-Dur)
mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour 0.4
(Nitro-Dur)
mg/hr
minoxidil oral
(Minoxidil)
NITRO-BID
nitroglycerin in 5 % dextrose intravenous (Nitroglycerin/D5W)
solution
nitroglycerin intravenous
(Nitroglycerin)
nitroglycerin transdermal patch 24 hour
(Nitro-Dur)
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
nitroglycerin transdermal patch 24 hour
(Nitro-Dur)
0.4 mg/hr
NITROSTAT
PROGLYCEM
5
5
1
3
4
4
4
4
3
3
Requirements/Limits
QL (30 per 30 days)
2
1
1
3
2
1
1
1
1
QL (30 per 30 days)
1
QL (60 per 30 days)
1
3
1
1
1
QL (30 per 30 days)
1
QL (60 per 30 days)
3
4
Central Nervous System Agents
55
Drug Name
Central Nervous System Agents
amphetamine salt combo
AMPYRA
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
clonidine hcl oral tablet extended release
12 hr
dexmethylphenidate oral tablet
dextroamphetamine oral capsule, extended
release
dextroamphetamine oral tablet
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
flumazenil
guanfacine oral tablet extended release 24
hr
lithium carbonate oral capsule
lithium carbonate oral tablet
lithium carbonate oral tablet extended
release
lithium citrate oral solution
methylphenidate oral capsule, er biphasic
30-70 10 mg, 20 mg, 50 mg, 60 mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
methylphenidate oral capsule,er biphasic
50-50 20 mg
50-50 30 mg
50-50 40 mg
methylphenidate oral solution
(Adderall)
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
(Kapvay)
Drug Tier
Requirements/Limits
1
5
1
1
1
QL (60 per 30 days)
2
(Focalin)
(Dexedrine)
2
2
QL (60 per 30 days)
(Dexedrine)
(Adderall XR)
1
2
QL (30 per 30 days)
(Adderall XR)
2
QL (60 per 30 days)
(Romazicon)
(Intuniv)
1
2
(Eskalith)
(Lithobid)
(Lithobid)
1
1
1
(Lithium Citrate)
(Metadate Cd)
1
2
QL (30 per 30 days)
(Metadate Cd)
2
QL (60 per 30 days)
(Metadate Cd)
2
QL (30 per 30 days)
(Metadate Cd)
2
QL (60 per 30 days)
(Ritalin LA)
2
QL (30 per 30 days)
(Methylin)
1
56
Drug Name
methylphenidate oral tablet
methylphenidate oral tablet extended
release
release 24hr 18 mg, 27 mg, 54 mg
release 24hr 36 mg
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
tetrabenazine
Drug Tier
Requirements/Limits
(Ritalin)
(Ritalin-SR)
1
1
QL (90 per 30 days)
QL (90 per 30 days)
(Concerta)
2
QL (30 per 30 days)
(Concerta)
2
QL (60 per 30 days)
3
3
2
3
3
5
QL (60 per 30 days)
(Rilutek)
(Xenazine)
XENAZINE
5
QL (60 per 30 days)
PA; QL (112 per 28
days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
ashlyna
cyred
deblitane
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol oral tablet
0.1/.125/.15-25 mg-mcg, 0.15-0.03 mg
drospirenone-ethinyl estradiol
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
gildess 24 fe
junel fe 24
kimidess (28)
l norgest/e.estradiol-e.estrad
larin 24 fe
levonorgestrel
levonorgestrel oral tablet 1.5 mg
(Seasonique)
(Desogen)
(Nor-Q-D)
(Mircette)
(Desogen)
2
1
1
1
1
(Yaz)
2
3
2
1
(Yaz)
(Ethynodiol D-Ethinyl
Estradiol)
(Loestrin Fe)
(Loestrin Fe)
(Mircette)
(Seasonique)
(Loestrin Fe)
(Plan B One-Step)
(Plan B One-Step)
1
1
1
2
1
1
1
QL (91 per 84 days)
QL (91 per 84 days)
57
Drug Name
levonorgestrel-ethin estradiol oral tablet
0.1-20 mg-mcg, 0.15-0.03 mg, 50-30
(6)/75-40 (5)/125-30(10)
levonorgestrel-ethin estradiol oral
tablets,dose pack,3 month 0.15-30 mg-mcg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg, 90-20 mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
l-norgest-eth estr/ethin estra
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg, 1.5-30 mg-mcg
norethindrone-e.estradiol-iron
norethindrone-e.estradiol-iron oral tablet
1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg30 mcg (21)/75 mg (7)
norethindrone-ethinyl estrad oral tablet
0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/135 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35
mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
setlakin
tarina fe
Drug Tier
Requirements/Limits
(Amethyst)
1
(Levonorgestrel-Ethin
Estradiol)
(Amethyst)
1
Estradiol)
(Seasonique)
(Ortho Evra)
(Femcon Fe)
(Nor-Q-D)
(Nor-Q-D)
(Loestrin)
1
QL (91 per 84 days)
2
2
2
1
1
1
QL (91 per 84 days)
QL (3 per 28 days)
(Loestrin Fe)
(Loestrin Fe)
1
1
(Modicon)
1
(Norinyl 1+50)
(Ortho-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
1
1
1
Estradiol)
(Loestrin Fe)
QL (91 per 84 days)
1
3
1
QL (1 per 28 days)
QL (91 per 84 days)
1
Dental And Oral Agents
Dental And Oral Agents
cevimeline
chlorhexidine gluconate mucous
membrane
pilocarpine hcl oral
(Evoxac)
(Peridex)
2
1
(Salagen)
2
58
Drug Name
triamcinolone acetonide dental
Drug Tier
(Triamcinolone
Acetonide)
Requirements/Limits
1
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acyclovir topical
ALCOHOL PADS
ALCOHOL PREP PADS
ALCOH-WIPE
aluminum chloride
ammonium lactate
ANACAINE
calcipotriene topical cream
calcipotriene topical ointment
calcipotriene topical solution
calcitriol topical
CONDYLOX TOPICAL GEL
COSENTYX (2 SYRINGES)
COSENTYX PEN
COSENTYX PEN (2 PENS)
DENAVIR
DRYSOL DAB-O-MATIC
FLUOROPLEX
fluorouracil topical cream
fluorouracil topical solution
imiquimod
isotretinoin oral capsule 10 mg, 20 mg, 30
mg, 40 mg
mafenide acetate
methoxsalen rapid
PANRETIN
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox
podophyllum resin
(Carac)
(Fluorouracil)
(Aldara)
4
5
2
1
1
1
1
1
4
2
2
2
2
4
5
5
5
4
4
4
2
2
2
(Isotretinoin)
2
(Mafenide Acetate)
(Oxsoralen-Ultra)
2
5
5
3
3
2
2
(Soriatane)
(Zovirax)
(Aluminum Chloride)
(Lac-Hydrin)
(Dovonex)
(Calcipotriene)
(Calcipotriene)
(Vectical)
(Condylox)
(Podophyllum Resin)
QL (30 per 30 days)
PA NSO
PA NSO
PA NSO
days)
QL (3 per 56 days)
QL (2 per 56 days)
59
Drug Name
potassium hydroxide
REGRANEX
SANTYL
silver nitrate applicators
VALCHLOR
VEREGEN
ZOVIRAX TOPICAL CREAM
Dermatological Antibacterials
clindamycin phos-benzoyl perox
clindamycin phosphate topical foam
clindamycin phosphate topical gel
clindamycin phosphate topical lotion
clindamycin phosphate topical solution
clindamycin phosphate topical swab
clindamycin-benzoyl peroxide
erythromycin base-ethanol
Drug Tier
(Potassium Hydroxide)
(Silver Nitrate
Applicator)
(Duac)
(Evoclin)
(Cleocin T)
(Cleocin T)
(Cleocin T)
(Cleocin T)
(Duac)
(Erythromycin
Base/Ethanol)
erythromycin with ethanol topical gel
(Emgel)
erythromycin with ethanol topical solution (Erythromycin
Base/Ethanol)
erythromycin with ethanol topical swab
(Erythromycin
Base/Ethanol)
erythromycin-benzoyl peroxide
(Benzamycin)
gentamicin topical
(Gentamicin Sulfate)
metronidazole topical
(Metrocream)
(Nydamax)
(Metrolotion)
mupirocin
(Centany)
mupirocin calcium
(Bactroban)
neomycin-polymyxin b gu
(Neosporin G.U.
Irrigant)
selenium sulfide
(Selenium Sulfide)
silver nitrate topical
(Silver Nitrate)
silver sulfadiazine topical cream 1 %
(Silvadene)
sulfacetamide sodium (acne)
(Klaron)
Dermatological Anti-Inflammatory Agents
alclometasone topical cream
(Aclovate)
1
4
4
1
5
4
3
Requirements/Limits
QL (15 per 30 days)
2
2
1
1
1
1
2
1
1
1
1
1
1
2
2
2
1
1
1
1
1
1
2
1
60
Drug Name
alclometasone topical ointment
(Alclometasone
Dipropionate)
betamethasone dipropionate topical cream (Diprosone)
betamethasone dipropionate topical lotion (Betamethasone
Dipropionate)
betamethasone dipropionate topical
(Betamethasone
ointment
Dipropionate)
betamethasone valerate topical cream
(Betamethasone
Valerate)
betamethasone valerate topical foam
(Luxiq)
betamethasone valerate topical lotion
(Betamethasone
Valerate)
betamethasone valerate topical ointment
(Betamethasone
Valerate)
betamethasone, augmented topical cream (Diprolene AF)
betamethasone, augmented topical gel
(Betamethasone
Dipropionate)
betamethasone, augmented topical lotion (Diprolene)
betamethasone, augmented topical
(Diprolene)
ointment
clobetasol propionate topical solution 0.05 (Clobetasol Propionate)
%
clobetasol topical cream
(Temovate)
clobetasol topical foam
(Olux)
clobetasol topical gel
(Temovate)
clobetasol topical lotion
(Clobex)
clobetasol topical ointment
(Temovate)
clobetasol topical shampoo
(Clobex)
clobetasol topical solution
(Clobetasol Propionate)
clobetasol-emollient topical
(Temovate)
clocortolone pivalate
(Cloderm)
CORDRAN TAPE LARGE ROLL
CORDRAN TOPICAL CREAM
CORDRAN TOPICAL LOTION
CORDRAN TOPICAL OINTMENT
desonide topical cream
(Desowen)
desonide topical lotion
(Desowen)
desonide topical ointment
(Tridesilon)
Drug Tier
Requirements/Limits
1
2
2
2
1
2
1
1
2
2
2
2
2
1
2
1
2
1
2
1
1
2
4
4
4
4
1
2
1
61
Drug Name
desoximetasone
diflorasone topical cream
diflorasone topical ointment
ELIDEL
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-emollient base
fluticasone topical cream
fluticasone topical ointment
halobetasol propionate
hydrocortisone 1% ointment carton (otc)
hydrocortisone acet-aloe vera topical gel
Drug Tier
(Topicort)
(Psorcon)
(Apexicon)
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone Propionate)
(Ultravate)
(Hydrocortisone)
(Hydrocortisone
Acetate/Aloe V)
hydrocortisone acetate-urea
(Hydrocortisone
Acetate/Urea)
hydrocortisone butyrate
(Locoid)
hydrocortisone butyr-emollient
(Locoid)
hydrocortisone rectal cream 1 %
(Anusol-HC)
hydrocortisone rectal cream 2.5 %
(Hydrocortisone)
hydrocortisone rectal enema 100 mg/60 ml (Cortenema)
hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC)
hydrocortisone topical lotion 2 %, 2.5 %
(Rederm)
hydrocortisone topical ointment 1 %, 2.5
(Hydrocortisone)
%
hydrocortisone valerate topical cream
(Hydrocortisone
Valerate)
hydrocortisone valerate topical ointment
(Westcort)
mometasone
(Elocon)
prednicarbate
(Dermatop)
tacrolimus topical
(Protopic)
triamcinolone acetonide topical cream
(Triamcinolone
Acetonide)
triamcinolone acetonide topical lotion
(Kenalog)
triamcinolone acetonide topical ointment (Triderm)
0.025 %, 0.05 %, 0.1 %, 0.5 %
2
2
2
3
1
1
1
1
1
1
1
2
1
1
Requirements/Limits
PA; AGE (Min 2 Years)
2
1
1
1
1
2
1
1
1
2
2
1
1
2
1
1
1
62
Drug Name
triderm topical cream
Dermatological Retinoids
adapalene topical cream
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM
tretinoin microspheres
tretinoin topical cream
tretinoin topical gel 0.01 %, 0.025 %
Scabicides And Pediculicides
EURAX
malathion
permethrin topical cream
spinosad
Drug Tier
(Triamcinolone
Acetonide)
1
(Differin)
(Differin)
(Retin-A Micro)
(Retin-A)
(Retin-A)
2
2
4
2
1
1
(Ovide)
(Elimite)
(Natroba)
3
2
2
2
Requirements/Limits
PA
PA
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE
BD INSULIN PEN NEEDLE UF SHORT
BD INSULIN SYRINGE ULTRA-FINE
SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X
5/16", 1/2 ML 31 X 5/16"
BD LUER-LOK SYRINGE SYRINGE 1
ML 20 X 1"
INSULIN SYRINGE NEEDLELESS
INSULIN SYRINGE SYRINGE
INSULIN SYRINGE-NEEDLE U-100
SYRINGE
PEN NEEDLE, DIABETIC NEEDLE 31
SURE COMFORT INS. SYR. U-100
1
1
1
1
1
1
1
1
1
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
CEREZYME INTRAVENOUS RECON
SOLN 400 UNIT
CIMZIA
5
5
5
5
PA
63
Drug Name
CIMZIA POWDER FOR RECONST
CREON
ELAPRASE
ELITEK INTRAVENOUS RECON
SOLN
FABRAZYME INTRAVENOUS RECON
SOLN
KRYSTEXXA
KUVAN
LINZESS
lipase-protease-amylase
(Zenpep)
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PERTZYE
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
Drug Tier
5
3
5
5
Requirements/Limits
PA
5
5
5
3
2
5
5
5
5
5
4
5
5
5
5
3
QL (30 per 30 days)
PA BvD
PA
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN (PF)
altacaine
(Tetcaine)
apraclonidine
(Iopidine)
atropine ophthalmic drops
(Isopto Atropine)
atropine ophthalmic ointment
(Atropine Sulfate)
azelastine nasal
(Astepro)
azelastine ophthalmic
(Optivar)
BEPREVE
carteolol
(Carteolol HCl)
cromolyn ophthalmic
(Cromolyn Sodium)
CYCLOGYL OPHTHALMIC DROPS 0.5
%
cyclopentolate
(Cyclogyl)
4
1
2
1
1
2
2
4
1
1
3
QL (30 per 25 days)
ST
1
64
Drug Name
CYSTARAN
epinastine
homatropine hbr
ipratropium bromide nasal spray,nonaerosol 0.03 %
ipratropium bromide nasal spray,nonaerosol 0.06 %
LACRISERT
naphazoline
olopatadine
PATADAY
PATANOL
phenylephrine hcl ophthalmic
proparacaine
proparacaine hcl ophthalmic drops 0.5 %
proparacaine-fluorescein sod
Drug Tier
Requirements/Limits
(Elestat)
(Isopto Homatropine)
(Atrovent)
5
2
1
1
QL (30 per 28 days)
(Atrovent)
1
QL (15 per 10 days)
(Naphazoline HCl)
(Patanase)
(Mydfrin)
(Proparacaine HCl)
(Proparacaine HCl)
(Proparacaine/Fluorescei
n Sod)
(Tetcaine)
tetracaine hcl
TYZINE NASAL DROPS 0.1 %
TYZINE NASAL SPRAY,NONAEROSOL
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid otic
(Acetic Acid)
acetic acid-hydrocortisone
(Vosol HC)
bacitracin ophthalmic
(Bacitracin)
bacitracin-polymyxin b ophthalmic
(Bacitracin/Polymyxin B
Sulfate)
BLEPHAMIDE
BLEPHAMIDE S.O.P.
CILOXAN OPHTHALMIC OINTMENT
CIPRODEX
ciprofloxacin hcl ophthalmic
(Ciloxan)
ciprofloxacin hcl otic
(Cetraxal)
COLY-MYCIN S
CORTISPORIN-TC
erythromycin ophthalmic
(Ilotycin)
gatifloxacin
(Zymaxid)
gentamicin ophthalmic
(Garamycin)
3
1
2
3
3
1
1
1
1
ST
ST
1
4
4
1
2
2
1
3
3
4
3
1
2
4
3
1
2
1
65
Drug Name
gentamicin sulfate ophthalmic ointment
0.3 % (3 mg/gram)
hydrocortisone-acetic acid
levofloxacin ophthalmic
MOXEZA
NATACYN
neomy sulf-bacitrac zn-poly-hc
Drug Tier
(Garamycin)
1
(Vosol HC)
(Quixin)
2
2
3
3
1
(Neomycin Su/Baci
Zn/Poly/HC)
neomycin-bacitracin-poly-hc
(Neomycin Su/Baci
Zn/Poly/HC)
neomycin-bacitracin-polymyxin
(Neomycin
Su/Bacitra/Polymyxin)
neomycin-polymyxin b-dexameth
(Maxitrol)
neomycin-polymyxin-gramicidin
(Neosporin)
neomycin-polymyxin-hc
(Oticin HC)
ofloxacin ophthalmic
(Ocuflox)
ofloxacin otic
(Ocuflox)
polymyxin b sulf-trimethoprim
(Polytrim)
sulfacetamide sodium
(Sulfacetamide Sodium)
sulfacetamide sodium ophthalmic drops 10 (Sulfacetamide Sodium)
%
sulfacetamide-prednisolone
(Sulfacetamide/Predniso
lone Sp)
TOBRADEX OPHTHALMIC
OINTMENT
TOBRADEX ST
tobramycin
(Tobrex)
trifluridine
(Viroptic)
VIGAMOX
ZIRGAN
ZYLET
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
ALREX
bromfenac
(Bromfenac Sodium)
dexamethasone sodium phosphate
(Dexasol)
ophthalmic
diclofenac sodium ophthalmic
(Diclofenac Sodium)
DUREZOL
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
4
3
1
2
3
4
3
3
2
1
1
3
66
Drug Name
fluorometholone
flurbiprofen sodium
fluticasone nasal
ILEVRO
ketorolac ophthalmic
LOTEMAX
NASONEX
NEVANAC
prednisolone acetate
prednisolone sodium phosphate
ophthalmic
PROLENSA
QNASL NASAL HFA AEROSOL
INHALER 40 MCG/ACTUATION
QNASL NASAL HFA AEROSOL
INHALER 80 MCG/ACTUATION
RESTASIS
triamcinolone acetonide nasal
Drug Tier
(FML)
(Ocufen)
(Flonase)
(Acular)
(Omnipred)
(Prednisolone Sod
Phosphate)
(Nasacort Aq)
1
1
1
3
1
3
4
3
2
1
Requirements/Limits
QL (16 per 30 days)
QL (34 per 28 days)
3
3
3
3
2
QL (60 per 30 days)
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
amoxicil-clarithromy-lansopraz
(Prevpac)
CARAFATE ORAL SUSPENSION
cimetidine
(Tagamet)
cimetidine hcl oral
(Cimetidine HCl)
DEXILANT
esomeprazole sodium
(Nexium I.V.)
famotidine (pf)
(Famotidine/PF)
famotidine (pf)-nacl (iso-os)
(Famotidine In Nacl,IsoOsm/PF)
famotidine oral suspension
(Pepcid)
famotidine oral tablet 20 mg, 40 mg
(Pepcid)
lansoprazole oral capsule,delayed
(Prevacid)
release(dr/ec)
misoprostol
(Cytotec)
nizatidine oral capsule
(Axid)
nizatidine oral solution
(Nizatidine)
2
3
1
1
3
1
1
1
2
1
2
(Rx Product Only)
ST
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
2
1
1
67
Drug Name
omeprazole oral capsule,delayed
release(dr/ec)
pantoprazole intravenous
pantoprazole oral
ranitidine hcl injection
ranitidine hcl oral capsule
ranitidine hcl oral syrup
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral suspension
sucralfate oral tablet
Gastrointestinal Agents, Other
AMITIZA
BUPHENYL ORAL TABLET
CHOLBAM
cromolyn oral
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
glycopyrrolate
glycopyrrolate
lactulose oral solution
loperamide oral
methscopolamine oral
metoclopramide hcl injection
metoclopramide hcl oral
metoclopramide hcl oral
MOVANTIK
NUTRESTORE
RELISTOR SUBCUTANEOUS
RELISTOR SUBCUTANEOUS
ursodiol oral capsule
ursodiol oral tablet
Laxatives
MOVIPREP
Drug Tier
(Prilosec)
1
(Pantoprazole Sodium)
(Protonix)
(Zantac)
(Ranitidine HCl)
(Ranitidine HCl)
(Zantac)
(Sucralfate)
(Carafate)
1
1
1
1
1
1
2
1
(Gastrocrom)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Robinul)
(Robinul)
(Lactulose)
(Loperamide HCl)
(Pamine)
(Reglan)
(Metoclopramide HCl)
(Reglan)
(Actigall)
(Urso)
3
5
5
5
1
1
1
1
1
1
2
1
1
1
1
1
1
3
4
4
4
2
2
Requirements/Limits
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
QL (60 per 30 days)
QL (30 per 30 days)
3
68
Drug Name
peg 3350-electrolytes
PEG 3350-GRX
peg 3350-na sulf,bicarb,cl-kcl
peg-electrolyte soln
polyethylene glycol 3350 oral
PREPOPIK
sodium chloride-nahco3-kcl-peg oral
recon soln 420 gram
Phosphate Binders
AURYXIA
calcium acetate oral capsule
calcium acetate oral tablet 667 mg
calcium carbonate-mag carb-fa
Drug Tier
(Golytely)
(Golytely)
(Nulytely with Flavor
Packs)
(Gavilyte-N)
(Nulytely with Flavor
Packs)
(Phoslo)
(Calcium Acetate)
(Calcium
Carbonate/Mag Carb/Fa)
FOSRENOL
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene sulfonate oral powder
(Sodium Polystyrene
Sulfonate)
sodium polystyrene sulfonate oral
(Sodium Polystyrene
suspension 15 gram/60 ml
Sulfonate)
sodium polystyrene sulfonate rectal enema (Sodium Polystyrene
30 gram/120 ml
Sulfonate)
VELPHORO
Requirements/Limits
1
1
1
1
1
4
1
4
2
2
1
4
4
3
3
1
1
1
4
Genitourinary Agents
Antispasmodics, Urinary
flavoxate
MYRBETRIQ
oxybutynin chloride oral tablet
oxybutynin chloride oral tablet extended
release 24hr
tolterodine oral capsule,extended release
24hr
tolterodine oral tablet
TOVIAZ
(Flavoxate HCl)
(Oxybutynin Chloride)
(Ditropan XL)
2
3
1
2
(Detrol LA)
2
(Detrol)
2
3
69
Drug Name
trospium oral capsule,extended release
(Sanctura XR)
24hr
trospium oral tablet
(Sanctura)
VESICARE
Genitourinary Agents, Miscellaneous
alfuzosin
(Uroxatral)
tamsulosin
(Flomax)
terazosin
(Terazosin HCl)
Drug Tier
Requirements/Limits
2
2
3
2
1
1
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln
(Desferal)
DEPEN TITRATABS
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG
EXJADE ORAL TABLET,
DISPERSIBLE 250 MG, 500 MG
FERRIPROX
JADENU
sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate)
gram/10 ml (100 mg/ml), 12.5 gram/50 ml
(250 mg/ml)
SYPRINE
1
4
4
PA BvD
5
5
5
2
5
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
ANADROL-50
ANDRODERM
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 1.25 GRAM/
ACTUATION (1 %)
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)
PACKET 1 % (25 MG/2.5GRAM), 1 %
(50 MG/5 GRAM)
PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
5
3
3
PA; QL (300 per 30
days)
3
PA; QL (150 per 30
days)
3
PA; QL (300 per 30
days)
3
PA; QL (150 per 30
days)
70
Drug Name
Drug Tier
AXIRON
danazol oral
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
testosterone transdermal gel in packet 1 %
(25 mg/2.5gram)
Estrogens And Antiestrogens
COMBIPATCH
3
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(Depo-Testosterone)
(Delatestryl)
(Androgel)
2
2
2
2
2
2
3
DUAVEE
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch semiweekly
(Estrace)
(Vivelle-Dot)
3
3
1
2
estradiol transdermal patch weekly
(Climara)
2
estradiol valerate
estradiol/norethindrone acet
estradiol-norethindrone acet
ESTRASORB
(Delestrogen)
(Activella)
(Activella)
2
2
2
4
ESTRING
estropipate
(Ogen)
FEMRING
MENEST
norethindrone ac-eth estradiol oral tablet (Femhrt)
1-5 mg-mcg
PREMARIN INJECTION
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
raloxifene
(Evista)
VAGIFEM
Glucocorticoids/Mineralocorticoids
4
1
4
4
2
3
3
3
3
3
2
3
Requirements/Limits
PA; QL (180 per 28
days)
PA
PA; QL (150 per 30
days)
days)
PA-HRM
PA-HRM
days)
days)
PA-HRM
PA-HRM
PA-HRM; QL (97.44 per
28 days)
QL (1 per 84 days)
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (18 per 28 days)
71
Drug Name
betamethasone acet,sod phos
cortisone
dexamethasone oral
dexamethasone oral
dexamethasone sodium phosphate
injection
fludrocortisone
hydrocortisone oral
hydrocortisone sod succinate
methylprednisolone
methylprednisolone acetate
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
methylprednisolone sodium succ
intravenous
prednisolone sodium phosphate oral
solution
PREDNISONE INTENSOL
prednisone
SOLU-CORTEF (PF) INJECTION
RECON SOLN
triamcinolone acetonide injection
Pituitary
desmopressin injection
desmopressin nasal
desmopressin nasal
desmopressin oral
GENOTROPIN
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML
Drug Tier
(Celestone)
(Cortisone Acetate)
(Dexamethasone)
(Dexamethasone)
(Dexamethasone Sod
Phosphate)
(Fludrocortisone
Acetate)
(Cortef)
(Hydrocortisone Sod
Succinate)
(Medrol)
(Depo-Medrol)
(A-Methapred)
1
1
1
1
1
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
1
PA BvD
PA BvD
1
1
1
PA BvD
PA BvD
PA BvD
(A-Methapred)
1
PA BvD
(Orapred)
1
PA BvD
(Prednisone)
3
1
4
PA BvD
PA BvD
PA BvD
(Triamcinolone
Acetonide)
1
(Desmopressin Acetate)
(DDAVP)
(Desmopressin Acetate)
(DDAVP)
2
2
2
2
5
4
QL (15 per 30 days)
QL (15 per 30 days)
PA
PA
72
Drug Name
SUBCUTANEOUS SYRINGE 0.4
MG/0.25 ML, 0.6 MG/0.25 ML, 0.8
MG/0.25 ML, 1 MG/0.25 ML, 1.2
MG/0.25 ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25 ML, 2
MG/0.25 ML
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
NUTROPIN
NUTROPIN AQ NUSPIN
NUTROPIN AQ SUBCUTANEOUS
octreotide acetate injection solution 1,000
mcg/ml
octreotide acetate injection solution 100
mcg/ml, 200 mcg/ml, 500 mcg/ml
octreotide acetate injection solution 50
mcg/ml
octreotide acetate injection syringe
OMNITROPE SUBCUTANEOUS
CARTRIDGE 10 MG/1.5 ML (6.7
MG/ML)
CARTRIDGE 5 MG/1.5 ML (3.3
MG/ML)
RECON SOLN
PREGNYL
SAIZEN
SAIZEN CLICK.EASY
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
SEROSTIM SUBCUTANEOUS RECON
SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
SOMAVERT
STIMATE
SUPPRELIN LA
Drug Tier
Requirements/Limits
5
PA
PA
(Sandostatin)
5
5
5
5
5
5
5
(Sandostatin)
2
(Octreotide Acetate)
2
(Octreotide Acetate)
2
4
PA
5
PA
5
PA
4
5
5
5
PA
PA
5
PA
5
5
4
5
QL (1 per 28 days)
PA
PA
PA
PA
QL (1 per 360 days)
73
Drug Name
TEV-TROPIN
vasopressin
ZOMACTON
Progestins
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
medroxyprogesterone intramuscular
suspension
medroxyprogesterone intramuscular
syringe
medroxyprogesterone oral
norethindrone acetate
progesterone
progesterone micronized capsules
Thyroid And Antithyroid Agents
levothyroxine intravenous
levothyroxine oral
liothyronine intravenous
liothyronine oral
methimazole oral tablet 10 mg, 5 mg
propylthiouracil
Drug Tier
Requirements/Limits
4
1
5
PA
4
QL (10 per 28 days)
(Depo-Provera)
1
QL (1 per 84 days)
(Medroxyprogesterone
Acetate)
(Provera)
(Aygestin)
(Progesterone)
(Prometrium)
1
QL (1 per 84 days)
(Levothyroxine Sodium)
(Levoxyl)
(Triostat)
(Cytomel)
(Tapazole)
(Propylthiouracil)
2
1
2
2
1
1
(Pitressin)
PA
1
1
1
2
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine
azathioprine sodium
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN
CELLCEPT INTRAVENOUS
cyclosporine intravenous
cyclosporine modified
cyclosporine oral capsule
cyclosporine, modified
ENBREL
ENBREL SURECLICK
(Imuran)
(Azathioprine Sodium)
(Sandimmune)
(Neoral)
(Sandimmune)
(Neoral)
5
4
5
1
1
5
PA BvD
PA BvD
PA BvD
PA BvD
4
2
2
2
2
5
5
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
74
Drug Name
Drug Tier
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C INJECTION SOLUTION
HUMIRA
HUMIRA PEN
HUMIRA PEN CROHN'S-UC-HS
START
HYPERRAB S/D (PF)
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
KINERET
leflunomide
mycophenolate mofetil oral capsule
mycophenolate mofetil oral suspension for
reconstitution
mycophenolate mofetil oral tablet
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA (WITH MALTOSE)
PRIVIGEN
PROGRAF INTRAVENOUS
RAPAMUNE ORAL SOLUTION
RAPAMUNE ORAL TABLET 1 MG, 2
MG
RIDAURA
sirolimus oral tablet 0.5 mg, 1 mg
sirolimus oral tablet 2 mg
tacrolimus oral
TYSABRI
ZORTRESS ORAL TABLET 0.25 MG
5
3
5
5
5
5
5
5
4
5
5
4
5
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA
PA; QL (18.76 per 28
days)
(Arava)
(Cellcept)
(Cellcept)
1
2
5
PA BvD
PA BvD
(Cellcept)
(Myfortic)
2
2
5
5
5
5
5
4
5
5
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA BvD
PA BvD
PA BvD
PA BvD
(Rapamune)
(Rapamune)
(Hecoria)
5
2
5
2
5
4
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
days)
75
Drug Name
ZORTRESS ORAL TABLET 0.5 MG,
0.75 MG
Vaccines
ACTHIB (PF)
ADACEL(TDAP
ADOLESN/ADULT)(PF)
BCG VACCINE, LIVE (PF)
BEXSERO (PF)
BOOSTRIX TDAP
CERVARIX VACCINE (PF)
COMVAX (PF)
DAPTACEL (DTAP PEDIATRIC) (PF)
ENGERIX-B (PF)
ENGERIX-B PEDIATRIC (PF)
GARDASIL (PF)
GARDASIL 9 (PF)
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION
HAVRIX (PF) INTRAMUSCULAR
SYRINGE
IMOVAX RABIES VACCINE (PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
IPOL INJECTION SUSPENSION
IXIARO (PF)
KINRIX (PF)
MENACTRA (PF) INTRAMUSCULAR
SOLUTION
MENHIBRIX (PF)
MENOMUNE - A/C/Y/W-135 (PF)
MENVEO A-C-Y-W-135-DIP (PF)
MENVEO MENA COMPONENT (PF)
MENVEO MENCYW-135 COMPNT
(PF)
M-M-R II (PF)
PEDIARIX (PF)
PEDVAX HIB (PF)
PENTACEL (PF)
Drug Tier
Requirements/Limits
5
days)
3
3
3
3
3
3
3
3
3
3
3
3
3
PA BvD
PA BvD
PA BvD
3
3
3
PA BvD
3
3
3
3
3
3
3
3
3
3
3
3
3
76
Drug Name
Drug Tier
PENTACEL ACTHIB COMPONENT
(PF)
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
RECOMBIVAX HB (PF)
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF) INTRAMUSCULAR
TETANUS TOXOID,ADSORBED (PF)
TETANUS,DIPHTHERIA TOX PED(PF)
TETANUS-DIPHTHERIA TOXOIDS-TD
TICE BCG
TRUMENBA
TWINRIX (PF)
TYPHIM VI
VAQTA (PF)
VARIVAX (PF)
YF-VAX (PF)
ZOSTAVAX (PF)
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PA BvD
PA BvD
PA BvD
PA BvD
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
alosetron
(Alosetron HCl)
APRISO
ASACOL HD
balsalazide
(Colazal)
budesonide oral
(Entocort EC)
DELZICOL
DIPENTUM
5
3
3
2
5
3
4
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
GLYCINE IRRIGATION
LACTATED RINGERS IRRIGATION
ringers irrigation
sodium chloride irrigation
(Acetic Acid)
(Tis-U-Sol)
(Sodium Chloride Irrig
Solution)
1
1
3
1
1
77
Drug Name
sorbitol irrigation
sorbitol-mannitol
water for irrigation, sterile
Drug Tier
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Requirements/Limits
1
1
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL ORAL TABLET 35 MG
alendronate oral solution
alendronate oral tablet 10 mg, 40 mg, 5
mg
alendronate oral tablet 35 mg, 70 mg
calcitonin (salmon)
calcitriol intravenous solution 1 mcg/ml
(Alendronate Sodium)
(Fosamax)
3
2
1
QL (4 per 28 days)
(Fosamax)
(Miacalcin)
(Calcitriol)
1
2
1
calcitriol oral capsule
(Rocaltrol)
1
calcitriol oral solution
(Rocaltrol)
2
doxercalciferol intravenous
(Doxercalciferol)
1
doxercalciferol oral
(Hectorol)
2
QL (4 per 28 days)
Only)
Only)
Only)
Only)
Only)
etidronate disodium
FORTEO
FORTICAL
ibandronate intravenous solution
(Etidronate Disodium)
(Ibandronate Sodium)
2
4
4
2
ibandronate intravenous syringe
(Boniva)
2
ibandronate oral
MIACALCIN INJECTION
(Boniva)
2
3
NATPARA
pamidronate intravenous
(Pamidronate Disodium)
5
1
Only); QL (3 per 84
days)
days)
QL (1 per 28 days)
Only)
Only)
78
Drug Name
paricalcitol oral
PROLIA
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
risedronate oral tablet 35 mg, 35 mg (12
pack)
XGEVA
ZEMPLAR INTRAVENOUS
zoledronic acid intravenous
zoledronic acid-mannitol-water
intravenous piggyback
intravenous solution
ZOMETA INTRAVENOUS SOLUTION
4 MG/100 ML
Drug Tier
Requirements/Limits
(Zemplar)
2
(Actonel)
(Actonel)
(Actonel)
3
2
2
2
Only)
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 30 days)
QL (4 per 28 days)
5
3
(Zometa)
(Zoledronic
Acid/Mannitol and
Water)
(Reclast)
Only)
2
2
2
5
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
ACTEMRA SUBCUTANEOUS
ACTIMMUNE
allopurinol
(Zyloprim)
allopurinol sodium
(Allopurinol Sodium)
amifostine crystalline
(Amifostine Crystalline)
ammonium chloride
(Ammonium Chloride)
anticoag citrate phos dextrose
(Citrate Phosphate
Dextros Soln)
AVODART
AVONEX (WITH ALBUMIN)
AVONEX INTRAMUSCULAR
AVONEX INTRAMUSCULAR
BENLYSTA INTRAVENOUS RECON
SOLN
BETASERON SUBCUTANEOUS
bethanechol chloride
(Urecholine)
5
5
5
1
2
1
1
1
3
5
5
5
5
5
2
ST
ST
ST
PA
ST
79
Drug Name
BOTOX INJECTION RECON SOLN 100
UNIT
BOTOX INJECTION RECON SOLN 200
UNIT
buspirone
CERDELGA
colchicine oral tablet
colchicine-probenecid
COLCRYS
COPAXONE SUBCUTANEOUS
SYRINGE
CURITY GAUZE TOPICAL BANDAGE
2X2"
CYSTADANE
dexrazoxane hcl intravenous recon soln
droperidol injection solution
DYSPORT
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS
finasteride oral tablet 5 mg
fomepizole
FUSILEV
GILENYA
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
guanidine
hydroxyzine hcl intramuscular
hydroxyzine hcl oral solution 10 mg/5 ml
hydroxyzine hcl oral tablet
hydroxyzine pamoate
JALYN
LEMTRADA
leucovorin calcium injection recon soln
100 mg, 200 mg, 350 mg
leucovorin calcium oral
Drug Tier
(Buspirone HCl)
(Colcrys)
(Colchicine/Probenecid)
Requirements/Limits
4
4
1
5
2
1
3
5
PA
1
(Totect)
(Droperidol)
(Ergoloid Mesylates)
(Proscar)
(Fomepizole)
5
1
1
3
4
2
5
1
5
5
5
3
4
(Guanidine HCl)
(Hydroxyzine HCl)
(Hydroxyzine HCl)
(Hydroxyzine HCl)
(Vistaril)
1
1
1
1
1
3
5
(Leucovorin Calcium)
1
(Leucovorin Calcium)
1
PA
ST
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (30 per 30 days)
PA; QL (9.6 per 365
days)
80
Drug Name
Drug Tier
Requirements/Limits
2
levocarnitine intravenous
(Levocarnitine (With
Sugar))
(Carnitor)
levocarnitine oral
(Carnitor)
2
Only)
Only)
Only)
levoleucovorin calcium
(Levoleucovorin
Calcium)
(Mesnex)
5
levocarnitine (with sugar)
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
methylergonovine injection
methylergonovine oral
morrhuate sodium
MYOBLOC INTRAMUSCULAR
SOLUTION
NPLATE SUBCUTANEOUS RECON
SOLN
OTEZLA
OTEZLA STARTER
PLEGRIDY
probenecid
PROCYSBI
pyridostigmine bromide
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
REMICADE
SENSIPAR ORAL TABLET 30 MG
SENSIPAR ORAL TABLET 60 MG, 90
MG
SIMPONI ARIA
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 50 MG/0.5 ML
(Methylergonovine
Maleate)
(Methylergonovine
Maleate)
(Sodium Morrhuate)
(Probenecid)
(Mestinon)
2
1
5
4
1
2
1
4
QL (1 per 90 days)
5
5
5
5
1
5
2
5
5
5
5
3
5
ST
5
5
5
PA
81
Drug Name
Drug Tier
Requirements/Limits
SIMPONI SUBCUTANEOUS SYRINGE
100 MG/ML
SIMPONI SUBCUTANEOUS SYRINGE
50 MG/0.5 ML
SOLIRIS
STELARA SUBCUTANEOUS
SYRINGE
STERILE PADS TOPICAL BANDAGE 2
X2"
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
THALOMID
5
5
5
5
PA
TYBOST
ULORIC
XELJANZ
4
3
5
1
5
5
5
5
days)
QL (30 per 30 days)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release
acetazolamide oral tablet
acetazolamide sodium
ALPHAGAN P OPHTHALMIC DROPS
0.1 %
AZOPT
betaxolol ophthalmic
BETOPTIC S
bimatoprost
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
(Diamox Sequels)
2
(Acetazolamide)
(Acetazolamide Sodium)
1
1
3
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
(Trusopt)
(Cosopt)
3
2
4
2
2
3
1
1
(drops: 0.15%, 0.20%)
82
Drug Name
latanoprost
levobunolol
LUMIGAN OPHTHALMIC DROPS 0.01
%
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1 %, 2
%, 4 %
SIMBRINZA
timolol maleate ophthalmic drops
timolol maleate ophthalmic gel forming
solution
TRAVATAN Z
travoprost (benzalkonium)
Drug Tier
(Xalatan)
(Betagan)
(Neptazane)
(Metipranolol)
1
1
3
(Isopto Carpine)
2
1
3
1
(Timoptic)
(Timoptic-Xe)
3
1
1
(Travoprost
(Benzalkonium))
ZIOPTAN (PF)
Requirements/Limits
3
2
4
QL (30 per 30 days)
Replacement Preparations
Replacement Preparations
calcium chloride intravenous
calcium gluconate intravenous
citric acid-sodium citrate
electrolyte-48 in d5w
HYPERLYTE CR
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE M IN 5 % DEXTROSE
ISOLYTE-H IN 5 % DEXTROSE
ISOLYTE-P IN 5 % DEXTROSE
ISOLYTE-S
KLOR-CON
klor-con 10
KLOR-CON 8
klor-con m10
klor-con m15
(Calcium Chloride)
(Calcium Gluconate)
1
1
(Citric Acid/Sodium
Citrate)
(Electrolyte-48
Solution/D5W)
1
(Potassium Chloride)
Only)
1
4
4
4
4
4
4
4
1
1
1
1
1
83
Drug Name
klor-con m20
klor-con sprinkle
KLOR-CON/EF
magnesium chloride injection
magnesium sulf in 0.45% nacl
magnesium sulfate in d5w intravenous
piggyback 1 gram/100 ml, 4 gram/100 ml
magnesium sulfate in water intravenous
piggyback 4 gram/100 ml (4 %), 4
gram/50 ml (8 %)
magnesium sulfate injection
NORMOSOL-M IN 5 % DEXTROSE
NORMOSOL-R
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 % DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
potassium bicarb-citric acid
potassium bicarbonate-cit ac oral tablet,
effervescent 25 meq
potassium chlorid-d5-0.45%nacl
potassium chloride in 0.9%nacl
intravenous parenteral solution 20 meq/l,
40 meq/l
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40
meq/l
potassium chloride intravenous
potassium chloride oral capsule, extended
release
Drug Tier
(Micro-K)
(Magnesium Chloride)
(Magnesium Sulf In
0.45% NaCl)
(Magnesium
Sulfate/D5W)
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
(K-Phos Neutral)
(Potassium Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Klor-Con-Ef)
Requirements/Limits
1
2
1
1
1
1
1
1
4
4
4
4
4
1
4
4
4
1
1
1
1
(Potassium Chloride/D50.45nacl)
0.9%NaCl)
1
D5w)
1
(Micro-K)
1
2
1
84
Drug Name
potassium chloride oral liquid
potassium chloride oral packet
potassium chloride oral tablet extended
release
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
potassium chloride-0.45 % nacl
potassium chloride-d5-0.2%nacl
intravenous parenteral solution 20 meq/l
potassium citrate-citric acid oral packet
3,300-1,002 mg
potassium citrate-citric acid oral solution
1,100-334 mg/5 ml
potassium phosphate m-/d-basic
ringers intravenous
sodium acetate intravenous
sodium bicarbonate intravenous
sodium chloride 0.45 % intravenous
sodium chloride 0.9 % injection solution
sodium chloride 0.9 % intravenous
sodium chloride 3 %
sodium chloride 5 %
sodium chloride intravenous
sodium citrate-citric acid
sodium lactate intravenous
sodium phosphate
Drug Tier
(Kaochlor)
(Klor-Con)
(Klor-Con 8)
1
1
1
(Klor-Con 8)
1
1
(Potassium Chloride0.45% NaCl)
(Potassium Chloride/D50.2%NaCl)
(Potassium Citrate/Citric
Acid)
(Potassium Citrate/Citric
Acid)
(Potassium Phos,MBasic-D-Basic)
(Ringers Solution)
(Sodium Acetate)
(Sodium Bicarbonate)
(Sodium Chloride 0.45
%)
(0.9 % Sodium
Chloride)
(0.9 % Sodium
Chloride)
(Sodium Chloride 3 %)
(Sodium Chloride 5 %)
(Sodium Chloride)
(Citric Acid/Sodium
Citrate)
(Sodium Lactate)
(Sodium Phos,M-BasicD-Basic)
1
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
85
Drug Name
sod-pot-k cit-sod cit-cit acid
Drug Tier
(Sod/Pot/K Cit/Sod
Cit/Cit Acid)
TPN ELECTROLYTES
TPN ELECTROLYTES II
Requirements/Limits
1
4
4
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 250
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
AEROSOL INHALER 220
MCG/ACTUATION
AEROSOL INHALER 44
MCG/ACTUATION
QVAR
Antileukotrienes
montelukast
(Singulair)
zafirlukast
(Accolate)
Bronchodilators
albuterol sulfate inhalation solution for
(Albuterol Sulfate)
nebulization
albuterol sulfate oral syrup
(Albuterol Sulfate)
albuterol sulfate oral tablet
(Albuterol Sulfate)
albuterol sulfate oral tablet extended
(Vospire ER)
release 12 hr
ANORO ELLIPTA
3
3
3
3
3
QL (60 per 30 days)
QL (12 per 28 days)
QL (60 per 30 days)
QL (13 per 28 days)
QL (60 per 30 days)
3
3
QL (12 per 28 days)
3
QL (24 per 28 days)
3
3
1
2
1
PA BvD
1
1
2
3
QL (60 per 30 days)
86
Drug Name
ATROVENT HFA
COMBIVENT RESPIMAT
FORADIL AEROLIZER
metaproterenol oral
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
SPIRIVA RESPIMAT INHALATION
MIST 2.5 MCG/ACTUATION
SPIRIVA WITH HANDIHALER
STIOLTO RESPIMAT
STRIVERDI RESPIMAT
terbutaline oral
terbutaline subcutaneous
theophylline anhydrous oral elixir 80
mg/15 ml
theophylline anhydrous oral tablet
extended release 12 hr 100 mg, 200 mg,
300 mg
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500 ml,
800 mg/250 ml
theophylline oral
theophylline oral
theophylline oral
Drug Tier
(Metaproterenol Sulfate)
(Terbutaline Sulfate)
(Terbutaline Sulfate)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
3
3
3
1
3
3
3
3
QL (8 per 30 days)
QL (62 per 30 days)
3
3
3
1
1
1
QL (30 per 30 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (17 per 25 days)
QL (2 per 25 days)
QL (60 per 30 days)
QL (4 per 30 days)
1
(Theophylline/D5W)
1
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
1
TUDORZA PRESSAIR
VENTOLIN HFA
Respiratory Tract Agents, Other
acetylcysteine
(Acetadote)
acetylcysteine
(Acetadote)
ARALAST NP
cromolyn inhalation
(Cromolyn Sodium)
DALIRESP
Requirements/Limits
1
1
3
3
QL (1 per 28 days)
QL (36 per 25 days)
1
1
5
1
3
PA BvD
PA BvD
PA BvD
QL (30 per 30 days)
87
Drug Name
Drug Tier
Requirements/Limits
ESBRIET
5
KALYDECO
OFEV
ORKAMBI
5
5
5
XOLAIR
ZEMAIRA
5
5
PA; QL (270 per 30
days)
PA; QL (120 per 30
days)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
chlorzoxazone
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine oral tablet 10 mg, 5 mg
cyclobenzaprine oral tablet 7.5 mg
dantrolene
dantrolene sodium
metaxalone
methocarbamol oral
tizanidine oral capsule
tizanidine oral tablet
(Baclofen)
(Soma)
1
1
(Parafon Forte DSC)
(Fexmid)
(Fexmid)
(Dantrium)
(Dantrium)
(Skelaxin)
(Robaxin)
(Zanaflex)
(Zanaflex)
1
1
1
1
2
2
1
2
1
2
1
(Sonata)
3
3
5
1
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
NUVIGIL
ROZEREM
XYREM
zaleplon
PA
LA
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
88
Drug Name
zolpidem oral tablet
(Ambien)
zolpidem oral tablet,ext release multiphase (Ambien CR)
Drug Tier
Requirements/Limits
1
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
PA-HRM; (High Risk
with over 90 days
non-benzodiazepine
per 30 days)
2
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
phentolamine injection
(Phentolamine Mesylate)
2
PA
5
5
3
2
PA BvD
5
PA BvD
5
5
3
PA
5
PA
5
5
PA BvD
PA; QL (37.5 per 1 day)
Vasodilating Agents
Vasodilating Agents
ADCIRCA
ADEMPAS
CIALIS ORAL TABLET 2.5 MG, 5 MG
epoprostenol (glycine) intravenous recon (Flolan)
soln 0.5 mg
epoprostenol (glycine) intravenous recon (Flolan)
soln 1.5 mg
LETAIRIS
OPSUMIT
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.25 MG, 1 MG,
2.5 MG
REMODULIN
sildenafil intravenous
(Revatio)
89
Drug Name
sildenafil oral
TRACLEER
(Revatio)
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
VENTAVIS
Drug Tier
Requirements/Limits
2
5
PA; LA; QL (60 per 30
days)
PA BvD
PA BvD
PA BvD
PA BvD
5
5
5
5
Vitamins And Minerals
Vitamins And Minerals
multivit-fluor 0.25 mg/ml drop 0.25 mg/ml (Pedi Mvi No.82 with
Fluoride)
prenatal vitamins oral tablet 27 mg iron- 1 (Pnv with
mg
Ca,No.72/Iron/Fa)
PRENATAL VITAMINS ORAL
TABLET 29 MG IRON- 1 MG-25 MG
sodium fluoride 1 mg (2.2 mg)
(Sodium Fluoride)
sodium fluoride oral tablet 1 mg fluoride
(Pedi Mvi No.82 with
(2.2 mg)
Fluoride)
1
3
(All Rx Prenatal
Vitamins Covered)
3
1
1
90
INDEX
8
8-MOP .................................... 59
A
abacavir .................................. 39
abacavir-lamivudine-zidovudine
............................................ 39
ABELCET .............................. 31
ABILIFY ................................ 36
ABILIFY DISCMELT ........... 36
ABILIFY MAINTENA .......... 36
ABRAXANE .................... 16, 17
acamprosate .............................. 6
acarbose .................................. 28
acebutolol ............................... 50
acetaminophen-codeine ............ 1
acetazolamide ......................... 82
acetazolamide sodium ............ 82
acetic acid ......................... 65, 77
acetic acid-hydrocortisone...... 65
acetylcysteine ......................... 87
acitretin ................................... 59
ACTEMRA ............................ 79
ACTHIB (PF) ......................... 76
ACTIMMUNE ....................... 79
ACTONEL ............................. 78
ACTOPLUS MET XR ........... 28
acyclovir ..................... 41, 42, 59
acyclovir sodium .................... 42
ADACEL(TDAP
ADOLESN/ADULT)(PF) .. 76
ADAGEN ............................... 63
adapalene ................................ 63
ADCETRIS ............................ 17
ADCIRCA .............................. 89
adefovir................................... 42
ADEMPAS ............................. 89
adrenalin ................................. 51
ADRENALIN......................... 51
ADVAIR DISKUS ................ 86
ADVAIR HFA ....................... 86
AFINITOR............................. 17
AFINITOR DISPERZ ........... 17
AGGRENOX ......................... 45
AKTEN (PF).......................... 64
ALBENZA............................. 35
ALBUKED-25 ....................... 45
ALBUKED-5 ......................... 45
ALBUMIN, HUMAN 25 % .. 45
ALBUMIN, HUMAN 5 % .... 45
ALBUMINAR 25 % .............. 45
ALBUMINAR 5 % ................ 45
ALBURX (HUMAN) 5 % ..... 45
ALBUTEIN 25 % .................. 45
ALBUTEIN 5 % .................... 45
albuterol sulfate ..................... 86
alclometasone .................. 60, 61
ALCOHOL PADS ................. 59
ALCOHOL PREP PADS ...... 59
ALCOH-WIPE ...................... 59
ALDURAZYME ................... 63
alendronate............................. 78
alfuzosin................................. 70
ALIMTA ................................ 17
ALINIA ................................. 35
allopurinol .............................. 79
allopurinol sodium ................. 79
alosetron................................. 77
ALPHAGAN P ...................... 82
alprazolam ............................... 7
ALREX .................................. 66
altacaine ................................. 64
ALTOPREV .......................... 54
aluminum chloride ................. 59
amantadine hcl ....................... 36
AMBISOME .......................... 31
amifostine crystalline ............. 79
amiloride ................................ 53
amiloride-hydrochlorothiazide
............................................ 53
AMINO ACIDS 15 % ............ 45
aminocaproic acid .................. 44
AMINOSYN 10 % ................. 45
AMINOSYN 3.5 % ................ 45
AMINOSYN 7 % ................... 45
AMINOSYN 7 % WITH
ELECTROLYTES ............. 45
AMINOSYN 8.5 % ................ 46
AMINOSYN 8.5 %ELECTROLYTES ............. 46
AMINOSYN II 10 % ............. 46
AMINOSYN II 15 % ............. 46
AMINOSYN II 7 % ............... 46
AMINOSYN II 8.5 % ............ 46
AMINOSYN II 8.5 %ELECTROLYTES ............. 46
AMINOSYN M 3.5 % ........... 46
AMINOSYN-HBC 7% .......... 46
AMINOSYN-PF 10 % ........... 46
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 46
AMINOSYN-RF 5.2 % ......... 46
amiodarone ....................... 49, 50
amiodarone hcl ....................... 49
AMITIZA ............................... 68
amitriptyline ........................... 26
amlodipine.............................. 53
amlodipine-atorvastatin.......... 54
amlodipine-benazepril............ 53
amlodipine-valsartan .............. 53
amlodipine-valsartan-hcthiazid
............................................ 53
ammonium chloride ............... 79
ammonium lactate .................. 59
amoxapine .............................. 27
I-1
amoxicil-clarithromy-lansopraz
............................................ 67
amoxicillin.............................. 14
amoxicillin-pot clavulanate .... 14
amphetamine salt combo .. 55, 56
amphotericin b ........................ 32
ampicillin................................ 14
ampicillin sodium ................... 14
ampicillin-sulbactam ........ 14, 15
AMPYRA ............................... 56
ANACAINE ........................... 59
ANADROL-50 ....................... 70
anagrelide ............................... 44
anastrozole .............................. 17
ANDRODERM ...................... 70
ANDROGEL .......................... 70
ANORO ELLIPTA ................ 86
anticoag citrate phos dextrose 79
APOKYN ............................... 36
apraclonidine .......................... 64
APRISO .................................. 77
APTIOM................................. 24
APTIVUS ............................... 39
ARALAST NP ....................... 87
ARCALYST ........................... 74
aripiprazole ............................. 37
ARRANON ............................ 17
ARZERRA ............................. 17
ASACOL HD ......................... 77
ashlyna .................................... 57
aspirin-dipyridamole .............. 45
ASSURE ID INSULIN
SAFETY ............................. 63
ASTAGRAF XL .................... 74
atenolol ................................... 50
atenolol-chlorthalidone........... 50
atorvastatin ............................. 54
atovaquone ............................. 35
atovaquone-proguanil ............. 35
ATRIPLA ............................... 39
atropine ............................. 23, 64
ATROVENT HFA ................. 87
AUBAGIO ............................. 74
AURYXIA ............................. 69
AVASTIN .............................. 17
AVC VAGINAL.................... 33
AVODART ............................ 79
AVONEX .............................. 79
AVONEX (WITH ALBUMIN)
........................................... 79
AXIRON ................................ 71
azacitidine .............................. 17
azathioprine ........................... 74
azathioprine sodium ............... 74
azelastine ............................... 64
AZILECT............................... 36
azithromycin .......................... 13
AZOPT .................................. 82
AZOR .................................... 53
aztreonam............................... 14
B
bacitracin ......................... 10, 65
bacitracin-polymyxin b .......... 65
baclofen ................................. 88
balsalazide ............................. 77
BANZEL ............................... 24
BARACLUDE ....................... 42
BCG VACCINE, LIVE (PF) . 76
BD INSULIN PEN NEEDLE
UF SHORT ........................ 63
BD INSULIN SYRINGE
ULTRA-FINE .................... 63
BD LUER-LOK SYRINGE .. 63
BELEODAQ .......................... 17
benazepril............................... 49
benazepril-hydrochlorothiazide
........................................... 49
BENICAR .............................. 48
BENICAR HCT ..................... 48
BENLYSTA .......................... 79
benztropine ............................ 36
BEPREVE ............................. 64
betamethasone acet,sod phos 71,
72
betamethasone dipropionate... 61
betamethasone valerate .......... 61
betamethasone, augmented .... 61
BETASERON ........................ 79
betaxolol........................... 50, 82
bethanechol chloride .............. 79
BETHKIS ................................. 9
BETOPTIC S ......................... 82
bexarotene .............................. 17
BEXSERO (PF) ..................... 76
bicalutamide ........................... 17
BICILLIN C-R ....................... 15
BICILLIN L-A ....................... 15
BIDIL ..................................... 55
BILTRICIDE ......................... 35
bimatoprost ............................ 82
bisoprolol fumarate ................ 50
bisoprolol-hydrochlorothiazide
............................................ 50
bleomycin ............................... 17
BLEPHAMIDE ...................... 65
BLEPHAMIDE S.O.P. .......... 65
BLINCYTO ........................... 17
BOOSTRIX TDAP ................ 76
BOSULIF ............................... 17
BOTOX .................................. 80
BREO ELLIPTA .................... 86
BRILINTA ............................. 45
brimonidine ............................ 82
BRINTELLIX ........................ 27
bromfenac .............................. 66
bromocriptine ......................... 36
budesonide ............................. 77
bumetanide ............................. 53
BUMINATE 25 % ................. 45
BUMINATE 5 % ................... 45
BUPHENYL .......................... 68
buprenorphine hcl ................ 1, 6
buprenorphine-naloxone .......... 6
bupropion hcl ..................... 6, 27
buspirone ................................ 80
butalb-acetaminophen-caffeine 1
I-2
butalbital-acetaminop-caf-cod .. 1
butalbital-acetaminophen ......... 1
butalbital-acetaminophen-caff .. 1
butalbital-aspirin-caffeine ........ 1
butorphanol tartrate .................. 1
BUTRANS ............................... 1
BYDUREON .......................... 28
BYETTA .......................... 28, 29
BYSTOLIC ............................ 50
C
cabergoline ............................. 36
caffeine citrated ...................... 56
caffeine-sodium benzoate....... 56
calcipotriene ........................... 59
calcitonin (salmon) ................. 78
calcitriol ............................ 59, 78
calcium acetate ....................... 69
calcium carbonate-mag carb-fa
............................................ 69
calcium chloride ..................... 83
calcium gluconate ................... 83
CALDOLOR ............................ 4
CANCIDAS ........................... 32
candesartan ............................. 48
candesartan-hydrochlorothiazid
............................................ 48
CAPASTAT ........................... 34
CAPRELSA ........................... 17
captopril .................................. 49
captopril-hydrochlorothiazide 49
CARAFATE ........................... 67
carbamazepine ........................ 24
carbidopa ................................ 36
carbidopa-levodopa ................ 36
carbidopa-levodopa-entacapone
............................................ 36
carbinoxamine maleate ........... 33
carboplatin .............................. 17
CARIMUNE NF
NANOFILTERED ............. 74
carisoprodol ............................ 88
carteolol .................................. 64
cartia xt .................................. 51
carvedilol ............................... 50
CAYSTON ............................ 14
CEDAX ........................... 11, 12
cefaclor .................................. 12
cefadroxil ............................... 12
cefazolin................................. 12
cefazolin in dextrose (iso-os) . 12
cefdinir ................................... 12
cefditoren pivoxil ................... 12
cefepime................................. 12
CEFEPIME IN DEXTROSE 5
% ........................................ 12
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 12
cefixime ................................. 12
cefotaxime ............................. 12
cefoxitin ................................. 12
cefoxitin in dextrose, iso-osm 12
cefpodoxime .......................... 12
cefprozil ................................. 12
ceftazidime............................. 12
ceftibuten ............................... 13
ceftriaxone ............................. 13
CEFTRIAXONE ................... 13
ceftriaxone in dextrose,iso-os 13
CEFTRIAXONE IN
DEXTROSE,ISO-OS ........ 13
cefuroxime axetil ................... 13
cefuroxime sodium ................ 13
cefuroxime-dextrose (iso-osm)
........................................... 13
celecoxib .................................. 4
CELLCEPT INTRAVENOUS
........................................... 74
CELONTIN ........................... 24
cephalexin .............................. 13
CEPROTIN (BLUE BAR) .... 42
CERDELGA .......................... 80
CEREZYME .......................... 63
CERVARIX VACCINE (PF) 76
cevimeline .............................. 58
CHANTIX................................ 6
CHANTIX CONTINUING
MONTH BOX ..................... 6
CHANTIX CONTINUING
MONTH PAK ...................... 6
CHANTIX STARTING
MONTH BOX ..................... 6
chloramphenicol sod succinate
............................................ 10
chlordiazepoxide hcl ................ 7
chlorhexidine gluconate ......... 58
chloroquine phosphate ........... 35
chlorothiazide ......................... 53
chlorothiazide sodium ............ 53
chlorpromazine ...................... 37
chlorthalidone ........................ 53
chlorzoxazone ........................ 88
CHOLBAM............................ 68
cholestyramine (with sugar) ... 54
cholestyramine-aspartame...... 54
choline,magnesium salicylate .. 4
CIALIS ................................... 89
ciclopirox ............................... 32
ciclopirox-ure-camph-mentheuc ...................................... 32
cidofovir ................................. 42
cilostazol ................................ 45
CILOXAN.............................. 65
cimetidine ............................... 67
cimetidine hcl ......................... 67
CIMZIA ................................. 63
CIMZIA POWDER FOR
RECONST ......................... 64
CIPRODEX............................ 65
ciprofloxacin .......................... 15
ciprofloxacin (mixture) .......... 15
ciprofloxacin hcl .............. 15, 65
ciprofloxacin in 5 % dextrose 15
ciprofloxacin lactate ............... 15
cisplatin .................................. 17
citalopram .............................. 27
citric acid-sodium citrate........ 83
I-3
cladribine ................................ 17
clarithromycin ........................ 13
clemastine ............................... 33
CLEVIPREX .......................... 53
clindamycin hcl ...................... 10
clindamycin in 5 % dextrose .. 10
clindamycin palmitate hcl ...... 10
clindamycin phos-benzoyl perox
............................................ 60
clindamycin phosphate .... 10, 33,
60
clindamycin-benzoyl peroxide
............................................ 60
CLINIMIX 5%/D15W
SULFITE FREE ................. 46
CLINIMIX 5%/D25W
SULFITE-FREE ................. 46
CLINIMIX 2.75%/D5W
SULFIT FREE.................... 46
CLINIMIX 4.25%/D10W SULF
FREE .................................. 46
CLINIMIX 4.25%/D5W
SULFIT FREE.................... 46
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 46
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 46
CLINIMIX 5%D20W(SULFITE-FREE) ... 46
CLINIMIX E 2.75%/D10W
SUL FREE.......................... 46
SULF FREE ....................... 46
SUL FREE.......................... 46
SUL FREE.......................... 46
SULF FREE ....................... 46
CLINIMIX E 5%/D15W
SULFIT FREE.................... 46
CLINIMIX E 5%/D20W
SULFIT FREE ................... 46
CLINIMIX E 5%/D25W
SULFIT FREE ................... 46
CLINISOL SF 15 % .............. 46
clobetasol ............................... 61
clobetasol propionate ............. 61
clobetasol-emollient............... 61
clocortolone pivalate.............. 61
clomipramine ......................... 27
clonazepam .............................. 7
clonidine ................................ 48
clonidine hcl .................... 48, 56
clonidine hcl-chlorthalidone .. 48
clopidogrel ............................. 45
clorazepate dipotassium ........... 7
clotrimazole ........................... 32
clotrimazole-betamethasone .. 32
clozapine ................................ 37
COARTEM ............................ 35
codeine sulfate ......................... 1
codeine-butalbital-asa-caffein . 1
colchicine ............................... 80
colchicine-probenecid ............ 80
COLCRYS ............................. 80
colestipol ................................ 54
colistin (colistimethate na)..... 10
COLY-MYCIN S .................. 65
COMBIGAN ......................... 82
COMBIPATCH ..................... 71
COMBIVENT RESPIMAT ... 87
COMETRIQ .......................... 17
COMFORT PACCYCLOBENZAPRINE ..... 88
COMFORT PAC-IBUPROFEN
............................................. 4
COMFORT PACMELOXICAM..................... 4
COMFORT PAC-NAPROXEN
............................................. 4
COMFORT PAC-TIZANIDINE
........................................... 88
COMPLERA .......................... 39
COMVAX (PF) ...................... 76
CONDYLOX ......................... 59
COPAXONE .......................... 80
CORDRAN ............................ 61
CORDRAN TAPE LARGE
ROLL ................................. 61
COREG CR............................ 50
CORLANOR.......................... 51
cortisone ................................. 72
CORTISPORIN-TC ............... 65
COSENTYX (2 SYRINGES) 59
COSENTYX PEN .................. 59
COSENTYX PEN (2 PENS) . 59
CREON .................................. 64
CRESTOR.............................. 54
CRIXIVAN ............................ 39
cromolyn .................... 64, 68, 87
CUBICIN ............................... 10
CURITY GAUZE .................. 80
cyclobenzaprine ..................... 88
CYCLOGYL .......................... 64
cyclopentolate ........................ 64
cyclophosphamide............ 17, 18
CYCLOPHOSPHAMIDE...... 18
CYCLOSET ........................... 29
cyclosporine ........................... 74
cyclosporine modified ............ 74
cyclosporine, modified ........... 74
cyproheptadine ....................... 33
CYRAMZA............................ 18
cyred ....................................... 57
CYSTADANE ....................... 80
CYSTARAN .......................... 65
cysteine (l-cysteine) ............... 46
cytarabine ............................... 18
cytarabine (pf) ........................ 18
D
d10 % & 0.45 % sodium
chloride .............................. 46
d10 %-0.9 % sodium chloride 46
I-4
d2.5 %-0.45 % sodium chloride
............................................ 46
d5 % and 0.9 % sodium chloride
............................................ 47
d5 %-0.45 % sodium chloride 47
dacarbazine ............................. 18
dactinomycin .......................... 18
DAKLINZA ........................... 41
DALIRESP ............................. 87
danazol ................................... 71
dantrolene ............................... 88
dantrolene sodium .................. 88
dapsone ................................... 34
DAPTACEL (DTAP
PEDIATRIC) (PF).............. 76
DARAPRIM ........................... 35
daunorubicin ........................... 18
DAUNOXOME ...................... 18
deblitane ................................. 57
decitabine ............................... 18
deferoxamine .......................... 70
DELZICOL ............................ 77
demeclocycline ....................... 16
DEMSER................................ 52
DENAVIR .............................. 59
DEPEN TITRATABS ............ 70
DEPO-PROVERA ................. 74
desipramine ............................ 27
desmopressin .......................... 72
desog-e.estradiol/e.estradiol ... 57
desogestrel-ethinyl estradiol... 57
desonide.................................. 61
desoximetasone ...................... 62
DESVENLAFAXINE ............ 27
DESVENLAFAXINE
FUMARATE ...................... 27
dexamethasone ....................... 72
dexamethasone sodium
phosphate...................... 66, 72
DEXILANT ............................ 67
dexmethylphenidate ............... 56
dexrazoxane hcl ...................... 80
dextroamphetamine ............... 56
dextroamphetamineamphetamine ...................... 56
dextrose 10 % and 0.2 % nacl 47
........................................... 47
dextrose 2.5 % in water(d2.5w)
........................................... 47
........................................... 47
........................................... 47
........................................... 47
dextrose 5 % in ringers .......... 47
dextrose 5 % in water (d5w) .. 47
dextrose 5 %-lactated ringers 47
dextrose 5%-0.2 % sod chloride
........................................... 47
dextrose 5%-0.3 % sod.chloride
........................................... 47
........................................... 47
........................................... 47
dextrose with sodium chloride47
DIASTAT ACUDIAL ............. 7
diazepam .................................. 7
diazepam intensol .................... 7
diclofenac potassium ............... 4
diclofenac sodium .............. 4, 66
diclofenac-misoprostol ............ 4
dicloxacillin ........................... 15
dicyclomine ........................... 68
didanosine .............................. 39
DIFICID................................. 13
diflorasone ............................. 62
diflunisal .................................. 4
digitek .................................... 52
digoxin ................................... 52
DIGOXIN .............................. 52
dihydroergotamine ................. 33
DILANTIN ............................ 24
diltiazem hcl ........................... 51
dilt-xr...................................... 51
dimenhydrinate ...................... 34
DIPENTUM ........................... 77
diphenhydramine hcl .............. 33
diphenoxylate-atropine .......... 68
disopyramide phosphate......... 50
disulfiram ................................. 6
divalproex .............................. 24
dobutamine ............................. 52
dobutamine in d5w ................. 52
docetaxel ................................ 18
donepezil ................................ 26
dopamine ................................ 52
dopamine in 5 % dextrose ...... 52
dorzolamide............................ 82
dorzolamide-timolol............... 82
doxazosin ............................... 48
doxepin................................... 27
doxercalciferol ....................... 78
doxorubicin hcl ...................... 18
doxorubicin hcl peg-liposomal
............................................ 18
doxorubicin, peg-liposomal ... 18
doxycycline hyclate ............... 16
doxycycline monohydrate ...... 16
dronabinol .............................. 34
droperidol ............................... 80
drospirenone-ethinyl estradiol 57
DROXIA ................................ 18
DRYSOL DAB-O-MATIC .... 59
DUAVEE ............................... 71
DULERA ............................... 86
duloxetine............................... 27
DURAMORPH (PF) ................ 1
DUREZOL ............................. 66
DYRENIUM .......................... 53
DYSPORT ............................. 80
E
econazole................................ 32
EDARBI................................. 48
I-5
EDARBYCLOR ..................... 48
EDURANT ............................. 39
EFFIENT ................................ 45
ELAPRASE ............................ 64
electrolyte-48 in d5w .............. 83
ELIDEL .................................. 62
ELIGARD .............................. 18
ELIQUIS ................................ 42
ELITEK .................................. 64
ELLA ...................................... 57
ELMIRON .............................. 80
EMBEDA ................................. 1
EMCYT .................................. 18
EMEND.................................. 34
EMSAM ................................. 27
EMTRIVA .............................. 39
enalapril maleate .................... 49
enalaprilat ............................... 49
enalapril-hydrochlorothiazide 49
ENBREL ................................ 74
ENBREL SURECLICK ......... 74
ENGERIX-B (PF) .................. 76
ENGERIX-B PEDIATRIC (PF)
............................................ 76
enoxaparin ........................ 42, 43
entacapone .............................. 36
entecavir ................................. 42
ENTRESTO ........................... 49
ephedrine sulfate .................... 52
epinastine................................ 65
epinephrine ............................. 52
epinephrine hcl (pf) ................ 52
EPIPEN 2-PAK ...................... 52
EPIPEN JR 2-PAK ................. 52
epirubicin ................................ 18
EPIVIR HBV.......................... 39
eplerenone .............................. 55
EPOGEN ................................ 44
epoprostenol (glycine) ............ 89
eprosartan ............................... 49
EPZICOM .............................. 39
ERBITUX............................... 18
ergoloid .................................. 80
ERGOMAR ........................... 33
ERIVEDGE ........................... 18
ERYTHROCIN ..................... 13
erythromycin .................... 14, 65
erythromycin base.................. 13
ERYTHROMYCIN BASE .... 14
erythromycin base-ethanol .... 60
erythromycin ethylsuccinate .. 14
erythromycin stearate ............ 14
erythromycin with ethanol ..... 60
erythromycin-benzoyl peroxide
........................................... 60
ESBRIET ............................... 88
escitalopram oxalate .............. 27
esmolol................................... 50
esomeprazole sodium ............ 67
estazolam ............................. 7, 8
ESTRACE ............................. 71
estradiol ................................. 71
estradiol valerate .................... 71
estradiol/norethindrone acet .. 71
estradiol-norethindrone acet .. 71
ESTRASORB ........................ 71
ESTRING .............................. 71
estropipate .............................. 71
ethambutol ............................. 34
ethamolin ............................... 52
ethinyl estradiol/drospirenone 57
ethosuximide .......................... 24
ethynodiol d-ethinyl estradiol 57
etidronate disodium ............... 78
etodolac .................................... 4
ETOPOPHOS ........................ 18
etoposide ................................ 18
EURAX ................................. 63
EVOTAZ ............................... 39
EXELDERM ......................... 32
EXELON ............................... 26
exemestane............................. 18
EXJADE ................................ 70
EXTAVIA ............................. 80
F
FABRAZYME ....................... 64
famciclovir ............................. 42
famotidine .............................. 67
famotidine (pf) ....................... 67
famotidine (pf)-nacl (iso-os) . 67
FANAPT ................................ 37
FARESTON ........................... 18
FARYDAK ............................ 19
FASLODEX ........................... 19
felbamate ................................ 24
felodipine ............................... 53
FEMRING.............................. 71
fenofibrate .............................. 54
fenofibrate micronized ........... 54
fenofibrate nanocrystallized ... 54
fenofibric acid ........................ 54
fenofibric acid (choline) ......... 54
fenoprofen ................................ 4
fentanyl ................................ 1, 2
fentanyl citrate ......................... 1
FERRIPROX.......................... 70
FETZIMA .............................. 27
finasteride ............................... 80
FIRAZYR .............................. 52
FIRMAGON KIT W DILUENT
SYRINGE .......................... 19
flavoxate................................. 69
FLEBOGAMMA DIF ............ 75
flecainide ................................ 50
FLECTOR ................................ 4
FLEXBUMIN 25 % ............... 45
FLEXBUMIN 5 % ................. 45
FLOVENT DISKUS .............. 86
FLOVENT HFA .................... 86
floxuridine .............................. 19
fluconazole ............................. 32
fluconazole in dextrose(iso-o) 32
fluconazole in nacl (iso-osm) . 32
flucytosine .............................. 32
fludarabine ............................. 19
fludrocortisone ....................... 72
I-6
flumazenil ............................... 56
fluocinonide............................ 62
fluocinonide-emollient base ... 62
fluorometholone ..................... 67
FLUOROPLEX ...................... 59
fluorouracil ....................... 19, 59
fluoxetine................................ 27
FLUOXETINE ....................... 27
fluoxymesterone ..................... 71
fluphenazine decanoate .......... 37
fluphenazine hcl ..................... 37
flurazepam ................................ 8
flurbiprofen............................... 4
flurbiprofen sodium ................ 67
flutamide................................. 19
fluticasone ........................ 62, 67
fluvastatin ............................... 54
fluvoxamine............................ 27
fomepizole .............................. 80
fondaparinux........................... 43
FORADIL AEROLIZER ....... 87
FORTEO ................................ 78
FORTICAL ............................ 78
foscarnet ................................. 41
fosinopril ................................ 49
fosinopril-hydrochlorothiazide
............................................ 49
fosphenytoin ........................... 24
FOSRENOL ........................... 69
FREAMINE HBC 6.9 % ........ 47
FREAMINE III 10 % ............. 47
furosemide .............................. 54
FUSILEV ............................... 80
FUZEON ................................ 40
FYCOMPA ............................ 24
G
gabapentin .............................. 24
GABITRIL ............................. 24
galantamine ............................ 26
GAMASTAN S/D .................. 75
GAMMAGARD LIQUID ...... 75
GAMMAPLEX ...................... 75
GAMUNEX-C ....................... 75
ganciclovir sodium ................ 42
GARDASIL (PF) ................... 76
GARDASIL 9 (PF) ................ 76
gatifloxacin ............................ 65
GAZYVA .............................. 19
gemcitabine ............................ 19
gemfibrozil............................. 54
GENOTROPIN ...................... 72
..................................... 72, 73
gentamicin ................. 10, 60, 65
gentamicin in nacl (iso-osm) . 10
gentamicin sulfate .................. 66
gentamicin sulfate (ped) (pf) . 10
gentamicin sulfate (pf) ........... 10
GEODON .............................. 37
gildess 24 fe ........................... 57
GILENYA ............................. 80
GILOTRIF ............................. 19
GLEEVEC ............................. 19
glimepiride ............................. 31
glipizide ................................. 31
glipizide-metformin ............... 31
GLUCAGEN HYPOKIT ....... 80
GLUCAGON EMERGENCY
KIT (HUMAN) .................. 80
glucose ................................... 47
glyburide ................................ 31
glyburide micronized ............. 31
glyburide-metformin .............. 31
GLYCINE .............................. 77
glycopyrrolate ........................ 68
glydo ........................................ 5
GLYSET ................................ 29
GLYXAMBI .......................... 29
GRALISE .............................. 24
GRALISE 30-DAY STARTER
PACK................................. 24
granisetron (pf) ...................... 34
granisetron hcl ....................... 35
GRANIX ................................ 44
griseofulvin microsize ............ 32
griseofulvin ultramicrosize .... 32
guanfacine ........................ 48, 56
guanidine ................................ 80
H
HALAVEN ............................ 19
halobetasol propionate ........... 62
haloperidol ............................. 37
haloperidol decanoate ............ 37
haloperidol lactate .................. 37
HARVONI ............................. 41
HAVRIX (PF) ........................ 76
heparin (porcine) .................... 43
heparin (porcine) in 5 % dex . 43,
44
HEPARIN (PORCINE) IN 5 %
DEX ................................... 43
heparin (porcine) in nacl (pf) . 43
HEPARIN(PORCINE) IN
0.45% NACL ..................... 43
heparin, porcine (pf)............... 43
HEPATAMINE 8% ............... 47
HEPATASOL 8 % ................. 47
HERCEPTIN.......................... 19
HEXALEN ............................. 19
homatropine hbr ..................... 65
HUMALOG ........................... 30
HUMALOG KWIKPEN ........ 30
HUMALOG MIX 50-50 ........ 30
HUMALOG MIX 50-50
KWIKPEN ......................... 30
HUMALOG MIX 75-25 ........ 30
HUMALOG MIX 75-25
KWIKPEN ......................... 30
HUMATROPE ....................... 73
HUMIRA ............................... 75
HUMIRA PEN ....................... 75
HUMIRA PEN CROHN'S-UCHS START ......................... 75
HUMULIN 70/30................... 30
HUMULIN 70/30 KWIKPEN30
HUMULIN N ......................... 30
I-7
HUMULIN N KWIKPEN ...... 30
HUMULIN R ......................... 30
HUMULIN R U-500
(CONCENTRATED) ......... 30
hydralazine ............................. 53
hydrochlorothiazide ................ 54
hydrocodone-acetaminophen ... 2
hydrocodone-ibuprofen ............ 2
hydrocortisone .................. 62, 72
hydrocortisone acet-aloe vera. 62
hydrocortisone acetate-urea.... 62
hydrocortisone butyrate .......... 62
hydrocortisone butyr-emollient
............................................ 62
hydrocortisone sod succinate . 72
hydrocortisone valerate .......... 62
hydrocortisone-acetic acid...... 66
hydromorphone ........................ 2
hydromorphone (pf) ................. 2
hydroxychloroquine ............... 35
hydroxyurea ............................ 19
hydroxyzine hcl ...................... 80
hydroxyzine pamoate ............. 80
HYPERLYTE CR .................. 83
HYPERRAB S/D (PF) ........... 75
HYQVIA ................................ 75
I
ibandronate ............................. 78
IBRANCE .............................. 19
ibuprofen .................................. 4
ICLUSIG ................................ 19
idarubicin ................................ 19
ifosfamide ............................... 19
ifosfamide-mesna ................... 19
ILARIS (PF) ........................... 75
ILEVRO ................................. 67
IMBRUVICA ......................... 19
imipenem-cilastatin ................ 14
imipramine hcl........................ 27
imipramine pamoate ............... 27
imiquimod .............................. 59
IMOGAM RABIES-HT (PF) . 75
IMOVAX RABIES VACCINE
(PF) .................................... 76
INCRELEX ........................... 73
indapamide............................. 54
indomethacin ........................... 4
indomethacin sodium ............... 5
INFANRIX (DTAP) (PF) ...... 76
INLYTA ................................ 20
INSULIN SYRINGE ............. 63
INSULIN SYRINGE
NEEDLELESS .................. 63
INSULIN SYRINGE-NEEDLE
U-100 ................................. 63
INTELENCE ......................... 40
INTRALIPID ......................... 47
INTRON A ............................ 41
INVANZ ................................ 14
INVEGA ................................ 37
INVEGA SUSTENNA .... 37, 38
INVEGA TRINZA ................ 38
INVIRASE............................. 40
INVOKAMET ....................... 29
INVOKANA .......................... 29
IONOSOL-B IN D5W ........... 83
IONOSOL-MB IN D5W ....... 83
IPOL ...................................... 76
ipratropium bromide .............. 65
IPRIVASK ............................. 44
irbesartan ............................... 49
irbesartan-hydrochlorothiazide
........................................... 49
IRENKA ................................ 27
IRESSA ................................. 20
irinotecan ............................... 20
ISENTRESS .......................... 40
ISOLYTE M IN 5 %
DEXTROSE ...................... 83
ISOLYTE-H IN 5 %
DEXTROSE ...................... 83
ISOLYTE-P IN 5 %
DEXTROSE ...................... 83
ISOLYTE-S ........................... 83
isoniazid ................................. 34
isosorbide dinitrate ................. 55
isosorbide mononitrate ........... 55
isotretinoin ............................. 59
isradipine ................................ 53
ISTODAX .............................. 20
itraconazole ............................ 32
ivermectin .............................. 35
IXEMPRA.............................. 20
IXIARO (PF) ......................... 76
J
JADENU ................................ 70
JAKAFI .................................. 20
JALYN ................................... 80
jantoven .................................. 44
JANUMET ............................. 29
JANUMET XR ...................... 29
JANUVIA .............................. 29
JARDIANCE ......................... 29
JENTADUETO ...................... 29
JEVTANA.............................. 20
junel fe 24 .............................. 57
K
KABIVEN.............................. 47
KADCYLA ............................ 20
KALETRA ............................. 40
KALYDECO.......................... 88
KAZANO ............................... 29
KEDBUMIN .......................... 45
ketoconazole .......................... 32
ketoprofen ................................ 5
ketorolac ............................. 5, 67
KEYTRUDA.......................... 20
KHEDEZLA .......................... 27
kimidess (28) .......................... 57
KINERET .............................. 75
KINRIX (PF) ......................... 76
KLOR-CON ........................... 83
klor-con 10 ............................. 83
KLOR-CON 8 ........................ 83
klor-con m10 .......................... 83
klor-con m15 .......................... 83
I-8
klor-con m20 .......................... 84
klor-con sprinkle .................... 84
KLOR-CON/EF ..................... 84
KORLYM............................... 29
KRYSTEXXA........................ 64
KUVAN ................................. 64
KYPROLIS ............................ 20
L
l norgest/e.estradiol-e.estrad ... 57
labetalol .................................. 50
LACRISERT .......................... 65
LACTATED RINGERS ......... 77
lactulose.................................. 68
LAMICTAL ........................... 24
LAMICTAL ODT STARTER
(BLUE) ............................... 24
(GREEN) ............................ 24
(ORANGE)......................... 24
lamivudine .............................. 40
lamivudine-zidovudine ........... 40
lamotrigine ....................... 24, 25
LANOXIN .............................. 53
lansoprazole ............................ 67
LANTUS ................................ 30
LANTUS SOLOSTAR .......... 30
larin 24 fe ............................... 57
latanoprost .............................. 83
LATUDA ............................... 38
LAZANDA............................... 2
leflunomide............................. 75
LEMTRADA .......................... 80
LENVIMA ............................. 20
LETAIRIS .............................. 89
letrozole .................................. 20
leucovorin calcium ................. 80
LEUKERAN .......................... 20
LEUKINE............................... 44
leuprolide................................ 20
levetiracetam .......................... 25
levetiracetam in nacl (iso-os) . 25
levobunolol ............................ 83
levocarnitine .......................... 81
levocarnitine (with sugar) ...... 81
levocetirizine ......................... 33
levofloxacin ..................... 15, 66
levofloxacin in d5w ............... 15
levoleucovorin calcium.......... 81
levonorgestrel ........................ 57
levonorgestrel-ethin estradiol 58
levonorgestrel-ethinyl estrad . 58
levorphanol tartrate .................. 2
levothyroxine ......................... 74
LEXIVA ................................ 40
lidocaine................................... 6
lidocaine (pf)...................... 5, 50
lidocaine hcl ......................... 5, 6
lidocaine in 5 % dextrose (pf) 50
lidocaine-prilocaine ................. 6
linezolid ................................. 10
LINZESS ............................... 64
liothyronine ............................ 74
lipase-protease-amylase ......... 64
LIPOSYN II........................... 48
LIPOSYN III ......................... 48
lisinopril ................................. 49
lisinopril-hydrochlorothiazide 49
lithium carbonate ................... 56
lithium citrate ......................... 56
l-norgest-eth estr/ethin estra .. 58
lomustine ............................... 20
loperamide ............................. 68
lorazepam oral solution ........... 8
losartan................................... 49
losartan-hydrochlorothiazide . 49
LOTEMAX ............................ 67
LOTRONEX .......................... 64
lovastatin ................................ 54
loxapine succinate.................. 38
LUMIGAN ............................ 83
LUMIZYME .......................... 64
LUPRON DEPOT ................. 20
............................................ 20
............................................ 20
............................................ 20
LUPRON DEPOT-PED ......... 20
LUPRON DEPOT-PED (3
MONTH)............................ 20
LYNPARZA .......................... 20
LYRICA ................................. 25
LYSODREN .......................... 20
M
mafenide acetate..................... 59
magnesium chloride ............... 84
magnesium sulf in 0.45% nacl84
magnesium sulfate ................. 84
magnesium sulfate in d5w ..... 84
magnesium sulfate in water ... 84
malathion................................ 63
maprotiline ............................. 27
MARPLAN ............................ 28
MARQIBO ............................. 20
MATULANE ......................... 20
matzim la................................ 51
meclizine ................................ 35
medroxyprogesterone ............. 74
mefenamic acid ........................ 5
mefloquine ............................. 35
MEFOXIN IN DEXTROSE
(ISO-OSM) ........................ 13
MEGACE ES ......................... 20
megestrol ................................ 20
MEKINIST ............................ 21
meloxicam ................................ 5
melphalan hcl intravenous ..... 21
memantine .............................. 26
MENACTRA (PF) ................. 76
MENEST................................ 71
MENHIBRIX (PF) ................. 76
MENOMUNE - A/C/Y/W-135
(PF) .................................... 76
I-9
MENVEO A-C-Y-W-135-DIP
(PF) ..................................... 76
MENVEO MENA
COMPONENT (PF) ........... 76
MENVEO MENCYW-135
COMPNT (PF) ................... 76
mercaptopurine ....................... 21
meropenem ............................. 14
mesna...................................... 81
MESNEX ............................... 81
MESTINON ........................... 81
metaproterenol ........................ 87
metaxalone ............................. 88
metformin ............................... 29
methadone ................................ 2
methadone hcl .......................... 2
methazolamide ....................... 83
methenamine hippurate .......... 10
methenamine mandelate ......... 10
methimazole ........................... 74
methocarbamol ....................... 88
methotrexate sodium .............. 21
methotrexate sodium (pf) ....... 21
methoxsalen rapid .................. 59
methscopolamine.................... 68
methyclothiazide .................... 54
methylergonovine ................... 81
methylphenidate ............... 56, 57
methylprednisolone ................ 72
methylprednisolone acetate .... 72
methylprednisolone sodium succ
............................................ 72
metipranolol ........................... 83
metoclopramide hcl ................ 68
metolazone ............................. 54
metoprolol succinate .............. 50
metoprolol ta-hydrochlorothiaz
............................................ 50
metoprolol tartrate .................. 50
metronidazole ............. 33, 35, 60
metronidazole in nacl (iso-os) 35
mexiletine ............................... 50
MIACALCIN......................... 78
miconazole nitrate.................. 32
midazolam ............................... 8
midazolam (pf) ........................ 8
midodrine ............................... 48
milrinone................................ 53
milrinone in 5 % dextrose ...... 53
minitran .................................. 55
MINOCIN .............................. 16
minocycline ........................... 16
minoxidil................................ 55
MIRCERA ............................. 44
mirtazapine ............................ 28
misoprostol ............................ 67
mitomycin .............................. 21
mitoxantrone .......................... 21
M-M-R II (PF) ....................... 76
moexipril................................ 49
moexipril-hydrochlorothiazide
........................................... 49
mometasone ........................... 62
montelukast ............................ 86
morphine .............................. 2, 3
MORPHINE ............................ 3
morphine concentrate .............. 2
morrhuate sodium .................. 81
MOVANTIK ......................... 68
MOVIPREP ........................... 68
MOXEZA .............................. 66
moxifloxacin .......................... 15
MOZOBIL ............................. 44
MULTAQ .............................. 50
mupirocin ............................... 60
mupirocin calcium ................. 60
MUSTARGEN ...................... 21
mycophenolate mofetil .......... 75
mycophenolate sodium .......... 75
MYOBLOC ........................... 81
MYOZYME........................... 64
MYRBETRIQ ........................ 69
N
nabumetone .............................. 5
nadolol.................................... 50
nafcillin .................................. 15
nafcillin in dextrose iso-osm .. 15
NAGLAZYME ...................... 64
naloxone ................................... 6
naltrexone................................. 6
naltrexone hcl ........................... 6
NAMENDA ........................... 26
NAMENDA TITRATION PAK
............................................ 26
NAMENDA XR..................... 26
NAMZARIC .......................... 26
naphazoline ............................ 65
naproxen ................................... 5
naproxen sodium ...................... 5
naratriptan .............................. 33
NASONEX ............................ 67
NATACYN ............................ 66
nateglinide .............................. 29
NATPARA ............................. 78
NEBUPENT ........................... 35
nefazodone ............................. 28
neomy sulf-bacitrac zn-poly-hc
............................................ 66
neomycin ................................ 10
neomycin-bacitracin-poly-hc . 66
neomycin-bacitracin-polymyxin
............................................ 66
neomycin-polymyxin b gu ..... 60
neomycin-polymyxin bdexameth ............................ 66
neomycin-polymyxingramicidin .......................... 66
neomycin-polymyxin-hc ........ 66
NEPHRAMINE 5.4 % ........... 48
NESINA ................................. 29
NEULASTA .......................... 44
NEUMEGA............................ 44
NEUPOGEN .......................... 44
NEUPRO................................ 36
NEVANAC ............................ 67
nevirapine ............................... 40
I-10
NEXAVAR ............................ 21
niacin ...................................... 54
nicardipine .............................. 53
NICOTROL.............................. 6
nifedipine................................ 53
NILANDRON ........................ 21
NITRO-BID ........................... 55
nitrofurantoin .......................... 11
nitrofurantoin macrocrystal ... 10,
11
nitrofurantoin monohyd/m-cryst
............................................ 11
nitroglycerin ........................... 55
nitroglycerin in 5 % dextrose . 55
NITROSTAT.......................... 55
nizatidine ................................ 67
NORDITROPIN FLEXPRO .. 73
norelgestromin/ethin.estradiol 58
norepinephrine bitartrate ........ 53
noreth-ethinyl estradiol/iron ... 58
norethindrone ......................... 58
norethindrone (contraceptive) 58
norethindrone acetate ............. 74
norethindrone ac-eth estradiol
...................................... 58, 71
norethindrone-e.estradiol-iron 58
norethindrone-ethinyl estrad .. 58
norethindrone-mestranol ........ 58
norgestimate-ethinyl estradiol 58
norgestrel-ethinyl estradiol..... 58
NORMOSOL-M IN 5 %
DEXTROSE ....................... 84
NORMOSOL-R ..................... 84
NORMOSOL-R PH 7.4 ......... 84
NORTHERA .......................... 48
nortriptyline ............................ 28
NORVIR................................. 40
NOVOLIN 70/30.................... 30
NOVOLIN N .......................... 30
NOVOLIN R .......................... 30
NOVOLOG ............................ 30
NOVOLOG FLEXPEN.......... 30
NOVOLOG MIX 70-30 ........ 30
NOVOLOG MIX 70-30
FLEXPEN .......................... 30
NOVOLOG PENFILL .......... 31
NOXAFIL.............................. 32
NPLATE ................................ 81
NUCYNTA .............................. 3
NUCYNTA ER........................ 3
NUEDEXTA ......................... 57
NULOJIX .............................. 75
NUTRESTORE ..................... 68
NUTRILIPID ......................... 48
NUTRILYTE ......................... 84
NUTRILYTE II ..................... 84
NUTROPIN ........................... 73
NUTROPIN AQ .................... 73
NUTROPIN AQ NUSPIN ..... 73
NUVARING .......................... 58
NUVIGIL............................... 88
nystatin................................... 32
NYSTATIN (BULK) ............. 32
nystatin-triamcinolone ........... 33
O
OCTAGAM ........................... 75
octreotide acetate ................... 73
OFEV ..................................... 88
ofloxacin .......................... 15, 66
olanzapine .............................. 38
olanzapine-fluoxetine ............ 28
olopatadine............................. 65
OLYSIO................................. 41
omega-3 acid ethyl esters ...... 54
omeprazole............................. 68
OMNITROPE ........................ 73
ONCASPAR .......................... 21
ondansetron ............................ 35
ondansetron hcl ...................... 35
ondansetron hcl (pf) ............... 35
ONFI ........................................ 8
OPDIVO ................................ 21
OPSUMIT .............................. 89
ORAP..................................... 38
ORENCIA .............................. 75
ORENCIA (WITH MALTOSE)
............................................ 75
ORENITRAM ........................ 89
ORFADIN .............................. 64
ORKAMBI ............................. 88
OSENI .................................... 29
OTEZLA ................................ 81
OTEZLA STARTER ............. 81
oxacillin.................................. 15
oxacillin in dextrose(iso-osm) 15
oxaliplatin .............................. 21
oxandrolone............................ 71
oxcarbazepine ........................ 25
OXTELLAR XR .................... 25
oxybutynin chloride ............... 69
oxycodone ................................ 3
oxycodone hcl-acetaminophen. 3
oxycodone hcl-aspirin .............. 3
oxycodone-acetaminophen ...... 3
oxycodone-aspirin .................... 3
OXYCONTIN .......................... 3
oxymorphone ....................... 3, 4
P
paclitaxel ................................ 21
paliperidone............................ 38
pamidronate............................ 78
PANRETIN ............................ 59
pantoprazole ........................... 68
papaverine .............................. 53
paricalcitol.............................. 79
paromomycin ......................... 35
paroxetine hcl ......................... 28
PASER ................................... 34
PATADAY ............................ 65
PATANOL ............................. 65
PAXIL .................................... 28
pedi m.vit no.17 with fluoride 90
PEDIARIX (PF) ..................... 76
PEDVAX HIB (PF) ............... 76
peg 3350-electrolytes ............. 69
PEG 3350-GRX ..................... 69
I-11
peg 3350-na sulf,bicarb,cl-kcl 69
PEGANONE .......................... 25
PEGASYS .............................. 41
PEGASYS PROCLICK ......... 41
peg-electrolyte soln ................ 69
PEGINTRON ......................... 41
PEGINTRON REDIPEN ....... 41
PEN NEEDLE, DIABETIC ... 63
penicillin g pot in dextrose ..... 15
penicillin g potassium............. 15
penicillin g procaine ............... 15
penicillin v potassium............. 15
PENTACEL (PF) ................... 76
PENTACEL ACTHIB
COMPONENT (PF) ........... 77
PENTAM ............................... 35
pentoxifylline ......................... 45
PERIKABIVEN ..................... 48
perindopril erbumine .............. 49
PERJETA ............................... 21
permethrin .............................. 63
perphenazine........................... 38
perphenazine-amitriptyline..... 28
PERTZYE .............................. 64
phenelzine............................... 28
phenobarbital .......................... 25
phenobarbital sodium ............. 25
phentolamine .......................... 89
phenylephrine hcl ............. 48, 65
PHENYTEK ........................... 25
phenytoin ................................ 25
phenytoin sodium ................... 25
phenytoin sodium extended .... 25
PHOSLYRA ........................... 69
PHOSPHOLINE IODIDE ...... 83
phosphorus #1 ........................ 84
PICATO ................................. 59
pilocarpine hcl .................. 58, 83
pindolol................................... 50
pioglitazone ............................ 29
pioglitazone-glimepiride ........ 29
pioglitazone-metformin .......... 30
piperacillin-tazobactam ......... 15
piroxicam ................................. 5
PLASBUMIN 25 % ............... 45
PLASBUMIN 5 % ................. 45
PLASMA-LYTE 148 ............ 84
PLASMA-LYTE A................ 84
PLASMA-LYTE-56 IN 5 %
DEXTROSE ...................... 84
PLEGRIDY ........................... 81
podofilox ................................ 59
podophyllum resin ................. 59
polyethylene glycol 3350....... 69
polymyxin b sulfate ............... 11
polymyxin b sulf-trimethoprim
........................................... 66
POMALYST .......................... 21
potassium acetate ................... 84
potassium bicarb and chloride 84
potassium bicarb-citric acid ... 84
potassium bicarbonate-cit ac . 84
potassium chlorid-d5-0.45%nacl
........................................... 84
potassium chloride ........... 84, 85
potassium chloride in 0.9%nacl
........................................... 84
potassium chloride in 5 % dex84
potassium chloride in lr-d5 .... 48
potassium chloride-0.45 % nacl
........................................... 85
........................................... 85
........................................... 85
........................................... 85
potassium citrate-citric acid ... 85
potassium hydroxide .............. 60
potassium phosphate m-/d-basic
........................................... 85
POTIGA................................. 25
PRADAXA ............................ 44
PRALUENT PEN .................. 54
PRALUENT SYRINGE ........ 54
pramipexole............................ 36
PRANDIMET ........................ 30
pravastatin .............................. 54
prazosin .................................. 48
prednicarbate .......................... 62
prednisolone acetate ............... 67
prednisolone sodium phosphate
...................................... 67, 72
prednisone .............................. 72
PREDNISONE INTENSOL .. 72
PREGNYL ............................. 73
PREMARIN ........................... 71
PREMASOL 10 % ................. 48
PREMASOL 6 % ................... 48
PREMPHASE ........................ 71
PREMPRO ............................. 71
prenatal vitamins .................... 90
PRENATAL VITAMINS ...... 90
PREPOPIK ............................. 69
PREZCOBIX ......................... 40
PREZISTA ............................. 40
PRIFTIN ................................ 34
PRIMAQUINE ...................... 36
primidone ............................... 25
PRISTIQ ................................ 28
PRIVIGEN ............................. 75
PROAIR HFA ........................ 87
PROAIR RESPICLICK ......... 87
probenecid .............................. 81
procainamide .......................... 50
PROCALAMINE 3% ............ 48
prochlorperazine .................... 35
prochlorperazine edisylate ..... 35
prochlorperazine maleate ....... 35
PROCRIT ............................... 44
PROCYSBI ............................ 81
progesterone ........................... 74
progesterone micronized
capsules .............................. 74
PROGLYCEM ....................... 55
PROGRAF ............................. 75
I-12
PROLENSA ........................... 67
PROLEUKIN ......................... 21
PROLIA ................................. 79
PROMACTA.......................... 44
promethazine .................... 33, 35
promethazine hcl .................... 35
propafenone ............................ 50
propantheline .......................... 23
proparacaine ........................... 65
proparacaine hcl ..................... 65
proparacaine-fluorescein sod.. 65
propranolol ....................... 50, 51
propranolol-hydrochlorothiazid
............................................ 51
propylthiouracil ...................... 74
PROQUAD (PF) .................... 77
PROSOL 20 % ....................... 48
protamine................................ 45
protriptyline ............................ 28
PULMOZYME....................... 64
PURIXAN .............................. 21
pyrazinamide .......................... 34
pyridostigmine bromide ......... 81
Q
QNASL................................... 67
QUADRACEL (PF) ............... 77
QUDEXY XR ........................ 25
quetiapine ............................... 38
QUILLIVANT XR ................. 57
quinapril ................................. 49
quinapril-hydrochlorothiazide 49
quinidine gluconate ................ 50
quinidine sulfate ..................... 50
quinine sulfate ........................ 36
QVAR..................................... 86
R
RABAVERT (PF) .................. 77
raloxifene................................ 71
ramipril ................................... 49
RANEXA ............................... 53
ranitidine hcl ........................... 68
RAPAMUNE ......................... 75
REBIF (WITH ALBUMIN) .. 81
REBIF REBIDOSE ............... 81
REBIF TITRATION PACK .. 81
RECOMBIVAX HB (PF) ...... 77
REGRANEX ......................... 60
RELADOR PAK ..................... 6
RELENZA DISKHALER ..... 41
RELISTOR ............................ 68
REMICADE .......................... 81
REMODULIN ....................... 89
RENAGEL............................. 69
RENVELA............................. 69
repaglinide ............................. 30
REPATHA SURECLICK...... 55
REPATHA SYRINGE .......... 55
RESCRIPTOR ....................... 40
RESTASIS ............................. 67
RETROVIR ........................... 40
REVLIMID ............................ 21
REXULTI .............................. 38
REYATAZ............................. 40
ribavirin ................................. 42
RIDAURA ............................. 75
rifabutin ................................. 34
rifampin ................................. 34
RIFATER............................... 34
riluzole ................................... 57
rimantadine ............................ 41
ringers .............................. 77, 85
risedronate ............................. 79
RISPERDAL CONSTA ........ 39
risperidone ............................. 39
RITUXAN ............................. 21
rivastigmine tartrate ............... 26
rizatriptan ............................... 33
ropinirole ............................... 36
ROTARIX ............................. 77
ROTATEQ VACCINE .......... 77
ROZEREM ............................ 88
S
SABRIL ................................. 25
SAIZEN ................................. 73
SAIZEN CLICK.EASY ......... 73
salsalate .................................... 5
SANDOSTATIN LAR DEPOT
............................................ 73
SANTYL ................................ 60
SAPHRIS (BLACK CHERRY)
............................................ 39
SAVAYSA ............................. 44
SAVELLA ............................. 57
selegiline hcl .......................... 36
selenium sulfide ..................... 60
SELZENTRY ......................... 40
SENSIPAR ............................. 81
SEREVENT DISKUS ............ 87
SEROQUEL XR .................... 39
SEROSTIM ............................ 73
sertraline ................................. 28
setlakin ................................... 58
sildenafil oral tablet 20 mg ... 89,
90
SILENOR ............................... 28
silver nitrate ........................... 60
silver nitrate applicators ......... 60
silver sulfadiazine .................. 60
SIMBRINZA.......................... 83
SIMPONI ......................... 81, 82
SIMPONI ARIA .................... 81
simvastatin ............................. 55
sirolimus................................. 75
SIRTURO .............................. 34
sodium acetate ........................ 85
sodium bicarbonate ................ 85
sodium chloride ................ 77, 85
sodium chloride 0.45 % ......... 85
sodium chloride 0.9 % ........... 85
sodium chloride 3 % .............. 85
sodium chloride 5 % .............. 85
sodium chloride-nahco3-kcl-peg
............................................ 69
sodium citrate-citric acid........ 85
sodium fluoride ...................... 90
sodium lactate ........................ 85
I-13
sodium phosphate ................... 85
sodium polystyrene sulfonate . 69
sodium thiosulfate .................. 70
sod-pot-k cit-sod cit-cit acid ... 86
SOLIRIS ................................. 82
SOLTAMOX .......................... 21
SOLU-CORTEF (PF) ............. 72
SOMATULINE DEPOT ........ 73
SOMAVERT .......................... 73
sorbitol.................................... 78
sorbitol-mannitol .................... 78
sotalol ..................................... 51
sotalol hcl ............................... 51
SOVALDI .............................. 41
spinosad .................................. 63
SPIRIVA RESPIMAT ........... 87
SPIRIVA WITH
HANDIHALER .................. 87
spironolactone ........................ 55
spironolacton-hydrochlorothiaz
............................................ 55
SPORANOX .......................... 33
SPRYCEL .............................. 21
stavudine................................. 40
STELARA .............................. 82
STERILE PADS ..................... 82
STIMATE............................... 73
STIOLTO RESPIMAT .......... 87
STIVARGA ............................ 22
STRATTERA ......................... 57
streptomycin ........................... 10
STRIBILD .............................. 40
STRIVERDI RESPIMAT ...... 87
sucralfate ................................ 68
sulfacetamide sodium ............. 66
sulfacetamide sodium (acne) .. 60
sulfacetamide-prednisolone.... 66
sulfadiazine............................. 15
sulfamethoxazole-trimethoprim
...................................... 15, 16
sulfasalazine ........................... 16
sulfatrim ................................. 16
sulfazine ................................. 16
sulfazine ec ............................ 16
sulindac .................................... 5
sumatriptan nasal spray ......... 33
sumatriptan succinate ...... 33, 34
SUPPRELIN LA.................... 73
SUPRAX ............................... 13
SURE COMFORT INS. SYR.
U-100 ................................. 63
SURMONTIL ........................ 28
SUSTIVA .............................. 40
SUTENT ................................ 22
SYLATRON .......................... 41
SYLVANT............................. 22
SYMLINPEN 120 ................. 30
SYMLINPEN 60 ................... 30
SYNAGIS .............................. 41
SYNAREL ............................. 82
SYNERCID ........................... 11
SYNRIBO .............................. 22
SYPRINE............................... 70
T
TABLOID .............................. 22
tacrolimus ........................ 62, 75
TAFINLAR ........................... 22
TAMIFLU ............................. 41
tamoxifen ............................... 22
tamsulosin .............................. 70
TARCEVA ............................ 22
TARGRETIN......................... 22
tarina fe .................................. 58
TASIGNA .............................. 22
TAZORAC ............................ 63
taztia xt .................................. 51
TECFIDERA ......................... 82
TECHNIVIE .......................... 41
TEFLARO ............................. 13
TEGRETOL XR .................... 25
telmisartan ............................. 49
telmisartan-hydrochlorothiazid
........................................... 49
temazepam ............................... 9
TEMODAR ............................ 22
teniposide ............................... 22
TENIVAC (PF) ...................... 77
terazosin ................................. 70
terbinafine hcl ........................ 33
terbutaline .............................. 87
terconazole ............................. 33
testosterone ............................ 71
testosterone cypionate ............ 71
testosterone enanthate ............ 71
TETANUS
TOXOID,ADSORBED (PF)
............................................ 77
TETANUS,DIPHTHERIA TOX
PED(PF) ............................. 77
TETANUS-DIPHTHERIA
TOXOIDS-TD ................... 77
tetrabenazine .......................... 57
tetracaine hcl .......................... 65
tetracycline ............................. 16
TEVETEN HCT..................... 49
TEV-TROPIN ........................ 74
THALOMID .......................... 82
theophylline............................ 87
theophylline anhydrous .......... 87
theophylline in dextrose 5 %.. 87
thioridazine ............................ 39
thiothixene.............................. 39
tiagabine ................................. 25
TICE BCG ............................. 77
TIKOSYN .............................. 50
timolol maleate................. 51, 83
tinidazole ................................ 36
TIVICAY ............................... 41
tizanidine ................................ 88
TOBI PODHALER ................ 10
TOBRADEX .......................... 66
TOBRADEX ST .................... 66
tobramycin ............................. 66
tobramycin in 0.225 % nacl ... 10
tobramycin in 0.9 % nacl ....... 10
tobramycin sulfate .................. 10
I-14
tolazamide .............................. 31
tolbutamide ............................. 31
tolmetin..................................... 5
tolterodine............................... 69
topiramate ............................... 26
toposar intravenous ................ 22
topotecan ................................ 22
TORISEL ............................... 22
torsemide ................................ 54
TOUJEO SOLOSTAR ........... 31
TOVIAZ ................................. 69
TPN ELECTROLYTES ......... 86
TPN ELECTROLYTES II ..... 86
TRACLEER ........................... 90
TRADJENTA ......................... 30
tramadol .................................... 4
tramadol-acetaminophen .......... 4
trandolapril ............................. 49
tranexamic acid ...................... 45
TRANSDERM-SCOP ............ 35
tranylcypromine ..................... 28
TRAVASOL 10 % ................. 48
TRAVATAN Z ...................... 83
travoprost (benzalkonium) ..... 83
trazodone ................................ 28
TREANDA ............................. 22
TRECATOR ........................... 34
TRELSTAR ............................ 22
tretinoin .................................. 63
tretinoin (chemotherapy) ........ 22
tretinoin microspheres ............ 63
TREXALL.............................. 22
triamcinolone acetonide .. 59, 62,
67, 72
triamterene-hydrochlorothiazid
............................................ 54
triazolam ................................... 9
TRIBENZOR ......................... 49
triderm .................................... 63
trifluoperazine ........................ 39
trifluridine............................... 66
trihexyphenidyl....................... 36
TRILEPTAL .......................... 26
trimethoprim .......................... 11
TRIUMEQ ............................. 41
TROKENDI XR .................... 26
TROPHAMINE 10 % ............ 48
TROPHAMINE 6% ............... 48
trospium ................................. 70
TRULICITY .......................... 30
TRUMENBA ......................... 77
TRUVADA ............................ 41
TUDORZA PRESSAIR ........ 87
TWINRIX (PF) ...................... 77
TYBOST ................................ 82
TYGACIL.............................. 16
TYKERB ............................... 23
TYPHIM VI ........................... 77
TYSABRI .............................. 75
TYVASO ............................... 90
TYVASO REFILL KIT ......... 90
TYVASO STARTER KIT..... 90
TYZEKA ............................... 42
TYZINE ................................. 65
U
ULORIC ................................ 82
UNITUXIN ............................ 23
ursodiol .................................. 68
V
VAGIFEM ............................. 71
valacyclovir ........................... 42
VALCHLOR ......................... 60
VALCYTE............................. 42
valganciclovir ........................ 42
valproate sodium.................... 26
valproic acid .......................... 26
valproic acid (as sodium salt) 26
valsartan ................................. 49
valsartan-hydrochlorothiazide 49
VALSTAR ............................. 23
vancomycin ............................ 11
vancomycin in d5w ................ 11
VAQTA (PF) ......................... 77
VARIVAX (PF) ..................... 77
VASCEPA ............................. 55
vasopressin ............................. 74
VECTIBIX ............................. 23
VELCADE ............................. 23
VELPHORO .......................... 69
venlafaxine ............................. 28
VENTAVIS............................ 90
VENTOLIN HFA .................. 87
verapamil................................ 51
VEREGEN ............................. 60
VERSACLOZ ........................ 39
VESICARE ............................ 70
VICTOZA .............................. 30
............................................ 41
............................................ 41
VIEKIRA PAK ...................... 41
VIGAMOX ............................ 66
VIIBRYD ............................... 28
VIMIZIM ............................... 64
VIMPAT ................................ 26
vinblastine .............................. 23
vincristine............................... 23
vincristine sulfate ................... 23
vinorelbine ............................. 23
VIRACEPT ............................ 41
VIRAMUNE XR ................... 41
VIRAZOLE............................ 42
VIREAD ................................ 41
VITEKTA .............................. 41
VOLTAREN ............................ 5
voriconazole ........................... 33
VOTRIENT............................ 23
VPRIV.................................... 64
VYTORIN 10-10 ................... 55
VYTORIN 10-20 ................... 55
VYTORIN 10-40 ................... 55
VYTORIN 10-80 ................... 55
W
warfarin .................................. 44
water for irrigation, sterile ..... 78
I-15
WELCHOL ............................ 55
X
XALKORI .............................. 23
XARELTO ............................. 44
XARTEMIS XR ....................... 4
XELJANZ .............................. 82
XENAZINE ............................ 57
XGEVA .................................. 79
XIFAXAN .............................. 11
XOLAIR ................................. 88
XTANDI................................. 23
xylon 10 .................................... 4
XYREM ................................. 88
Y
YERVOY ............................... 23
YF-VAX (PF) ......................... 77
Z
zafirlukast ............................... 86
zaleplon .................................. 88
ZALTRAP ............................. 23
ZARXIO ................................ 44
ZAVESCA ............................. 64
ZELBORAF........................... 23
ZEMAIRA ............................. 88
ZEMPLAR............................. 79
ZENPEP................................. 64
ZETIA .................................... 55
ZIAGEN ................................ 41
zidovudine ............................. 41
ZIOPTAN (PF) ...................... 83
ziprasidone hcl ....................... 39
ZIRGAN ................................ 66
ZOLADEX ............................ 23
zoledronic acid ....................... 79
........................................... 79
ZOLINZA .............................. 23
zolmitriptan ............................ 34
zolpidem................................. 89
ZOMACTON ......................... 74
ZOMETA ............................... 79
zonisamide ............................. 26
ZORTRESS...................... 75, 76
ZOSTAVAX (PF) .................. 77
ZOVIRAX.............................. 60
ZUBSOLV ........................... 6, 7
ZYDELIG .............................. 23
ZYKADIA ............................. 23
ZYLET ................................... 66
ZYPREXA RELPREVV ....... 39
ZYTIGA ................................. 23
ZYVOX.................................. 11
I-16

Access Medicare (HMO) 2015 Formulary (List of Covered Drugs)

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