2017 Formulary Annual Notice of Change - … Formulary Annual Notice of Change ... determination and...

Updated: October 10, 2016

2017 Formulary Annual Notice of Change

Commercial 5 Tier - Qualified Health Plans (QHP)

This is a listing of the changes that have occurred to the 2017 Commercial Qualified Health Plans 5 Tier formulary. For a complete list, please refer to our website and review the 2017 QHP Comprehensive Formulary (Drug List). Click here to view the comprehensive formulary. Please carefully review these changes. If you have any questions or need to obtain updated coverage determination and exception information, please call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m. or visit myFHCA.org. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and copayments/co-insurance may change on January 1 of each year. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. The Formulary and pharmacy network may change at any time. You will receive notice when necessary.

Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

36194_MPINFO165FH (11/2016)

http://www.health-first.org/fhca/group/2017_qhp_sm_grp_ind_5_tier_formulary_fh.pdf

http://www.myfhca.org/

MEDICATIONS REMOVED FROM THE 2016 QHP FORMULARY

Medication Name Medication Name

Abilify Discmelt 10mg tablet,disintegrating donepezil 10mg tablet,disintegrating

Aggrenox 25-200mg capsule, ER multiphase 12 hr donepezil 5mg tablet,disintegrating

amiodarone 400mg tablet Edarbi 40mg tablet

AndroGel 1 %(25 mg/2.5gram) gel in packet Edarbi 80mg tablet

AndroGel 1 %(50 mg/5 gram) gel in packet EEMT HS 0.625-1.25mg tablet

AndroGel 1.25 gram/actuation (1 %) gel in metered-dose pump

Enablex 15mg tablet extended release 24 hr

Atralin 0.05% gel Enablex 7.5mg tablet extended release 24 hr

Avodart 0.5mg capsule eprosartan 600mg tablet

Axert 12.5mg tablet FazaClo 100mg tablet,disintegrating

Axert 6.25mg tablet FazaClo 12.5mg tablet,disintegrating

betamethasone valerate 0.12% foam FazaClo 150mg tablet,disintegrating

Carac 0.5% cream FazaClo 200mg tablet,disintegrating

Cardizem LA 120mg tablet extended release 24 hr FazaClo 25mg tablet,disintegrating

cefaclor 500mg tablet extended release 12 hr Fluoroplex 1% cream

Celebrex 100mg capsule fluorouracil 0.5% cream

Celebrex 200mg capsule Frova 2.5mg tablet

Celebrex 400mg capsule Gleevec 100mg tablet

Celebrex 50mg capsule Gleevec 400mg tablet

ClindaMax 1% gel Glyset 100mg tablet

clindamycin HCl 75mg capsule Glyset 25mg tablet

clindamycin phosphate 1% foam Glyset 50mg tablet

clobetasol 0.05% foam Gralise 30-Day Starter Pack 300 mg (9)-600 mg (69) tablet extended release 24 hr

clobetasol-emollient 0.05% foam Ibudone 5-200mg tablet

Cloderm 0.1% cream Jalyn 0.5-0.4mg capsule, ER multiphase 24 hr

Colcrys 0.6mg tablet Januvia 100mg tablet

Cormax 0.05% solution Januvia 25mg tablet

Crestor 10mg tablet Januvia 50mg tablet

Crestor 20mg tablet Lamictal ODT 100mg tablet,disintegrating



cyclobenzaprine 7.5mg tablet Lamictal ODT 50mg tablet,disintegrating

Dibenzyline 10mg capsule Lamictal ODT Starter (Blue) 25 mg (21)-50 mg (7) tablet disintegrating, dose pk

diltiazem HCl 360mg capsule,extended release 24hr Lamictal ODT Starter (Green) 50 mg (42)-100 mg (14) tablet disintegrating, dose pk


Medication Name Medication Name Lamictal ODT Starter (Orange) 25 mg(14)-50 mg(14)-100 mg (7) tablet disintegrating, dose pk

Niaspan Extended-Release 500mg tablet extended release 24 hr

Liptruzet 10-10mg tablet Niaspan Extended-Release 750mg tablet extended release 24 hr

Liptruzet 10-20mg tablet Nuvigil 150mg tablet



Lodosyn 25mg tablet Nuvigil 50mg tablet

Lotronex 0.5mg tablet Onglyza 2.5mg tablet

Lotronex 1mg tablet Onglyza 5mg tablet

Luxiq 0.12% foam Orap 1mg tablet

Mestinon Timespan 180mg tablet extended release Orap 2mg tablet

metformin 1,000mg tablet extended release 24hr Orapred ODT 10mg tablet,disintegrating

metformin 500mg tablet extended release 24hr Orapred ODT 15mg tablet,disintegrating

methylphenidate 10mg tablet,chewable Orapred ODT 30mg tablet,disintegrating

methylphenidate 2.5mg tablet,chewable Ovace Plus Shampoo 10% shampoo

methylphenidate 5mg tablet,chewable Ovace Plus Wash 10% cleanser,gel extended release

Migranol Oxistat 1% cream

Minivelle 0.025mg/24 hr patch semiweekly OxyContin 10mg tablet extended release 12 hr

Minivelle 0.0375mg/24 hr patch semiweekly OxyContin 10mg tablet,oral only,ext.rel.12 hr


Minivelle 0.075mg/24 hr patch semiweekly OxyContin 15mg tablet,oral only,ext.rel.12 hr


minocycline 100mg tablet OxyContin 20mg tablet extended release 12 hr

minocycline 50mg tablet OxyContin 20mg tablet,oral only,ext.rel.12 hr

minocycline 75mg tablet OxyContin 30mg tablet extended release 12 hr

Naftin 2% cream OxyContin 30mg tablet,oral only,ext.rel.12 hr

Namenda 10mg tablet OxyContin 40mg tablet extended release 12 hr

Namenda 2mg/mL solution OxyContin 40mg tablet,oral only,ext.rel.12 hr

Namenda 5mg tablet OxyContin 60mg tablet extended release 12 hr

Namenda Titration Pak 5-10mg tablets,dose pack OxyContin 60mg tablet,oral only,ext.rel.12 hr

naproxen sodium 275mg tablet OxyContin 80mg tablet extended release 12 hr

naproxen sodium 550mg tablet OxyContin 80mg tablet,oral only,ext.rel.12 hr

Nasonex 50mcg/actuation spray,non-aerosol Patanol 0.1% drops

Niaspan Extended-Release 1,000mg tablet extended release 24 hr

Proventil HFA 90mcg/actuation HFA aerosol inhaler


Medication Name Medication Name

ranitidine HCl 150mg capsule Tasmar 100mg tablet

ranitidine HCl 300mg capsule temazepam 22.5mg capsule

Rapamune 0.5mg tablet temazepam 7.5mg capsule

Rapamune 1mg tablet Testim 50mg/5 gram (1 %) gel

Rapamune 2mg tablet Tikosyn 125mcg capsule

Rea Lo 39 39% cream Tikosyn 250mcg capsule

Rea Lo 40 40% cream Tikosyn 500mcg capsule

Reclast 5mg/100 mL solution timolol maleate 0.25% gel forming solution

Remicade 100mg recon soln timolol maleate 0.5% gel forming solution

Rosadan 0.75% cream tizanidine 2mg capsule

Rosadan 0.75% gel tizanidine 4mg capsule

Soriatane 10mg capsule tizanidine 6mg capsule

Soriatane 17.5mg capsule Treximet 85-500mg tablet

Soriatane 25mg capsule Valcyte 450mg tablet

Stromectol 3mg tablet Vandazole 0.75% gel

Suprax 100mg/5 mL suspension for reconstitution Vectical 3mcg/gram ointment

Suprax 200mg/5 mL suspension for reconstitution Voltaren 1% gel

Sure-Touch Lancet misc Xenazine 12.5mg tablet

Surmontil 100mg capsule Xenazine 25mg tablet

Surmontil 25mg capsule Zovirax 5% cream

Surmontil 50mg capsule Zymaxid 0.5% drops

Taclonex 0.005-0.064% ointment Zyvox 100mg/5 mL suspension for reconstitution

Targretin 75mg capsule Zyvox 600mg tablet

MEDICATIONS ADDED TO THE 2017 QHP FORMULARY

Medication Name Benefit

Tier Quantity Limit

(QL)

Prior Authorization (PA) or Step Therapy (ST)

Requirement

acetaminophen-codeine 120 mg-12 mg/5 mL (5 mL) solution

Tier 3 QL(2700 ML per 30

days) None

acetaminophen-codeine 240 mg-24 mg/10 mL (10 mL) solution


days) None

acetaminophen-codeine 300 mg-30 mg/12.5 mL solution


days) None

acetic acid-aluminum acetate 2% drops Tier 2 None None



Tier Quantity Limit

(QL)


Requirement

Addyi 100mg tablet Tier 5 None PA

Adempas 0.5mg tablet Tier 5 None PA


Adempas 1mg tablet Tier 5 None PA


Adempas 2mg tablet Tier 5 None PA

Adrucil 500mg/10 mL solution Tier 3 None None

Afeditab CR 30mg tablet extended release Tier 2 None None

Afeditab CR 60mg tablet extended release Tier 2 None None

AK-Poly-Bac 500-10,000unit/gram ointment Tier 2 None None

albuterol sulfate 5mg/mL solution for nebulization

Tier 2 None None

aluminum chloride 20% solution Tier 2 None None

aminophylline 100mg tablet Tier 2 None None

aminophylline 200mg tablet Tier 2 None None

Ampyra 10mg tablet extended release 12 hr Tier 5 None PA

Amturnide 150-5-12.5mg tablet Tier 3 None None


Amturnide 300-10-25mg tablet Tier 3 None None



Tier Quantity Limit

(QL)


Requirement


Amturnide 300-5-25mg tablet Tier 3 None None

antipyrine-benzocaine 5.4-1.4% drops Tier 2 None None

Aptiom 200mg tablet Tier 4 None PA




Aranesp (in albumin) 100mcg/0.5 mL syringe Tier 5 None PA

Aranesp (in albumin) 100mcg/mL solution Tier 5 None PA


Aranesp (in albumin) 150mcg/0.75 mL solution

Tier 5 None PA









Tier Quantity Limit

(QL)


Requirement



Aranesp (in albumin) 500mcg/mL syringe Tier 5 None PA



Aranesp (in polysorbate) 100mcg/0.5 mL syringe

Tier 5 None PA

Aranesp (in polysorbate) 100mcg/mL solution Tier 5 None PA


Tier 5 None PA


Tier 5 None PA

Aranesp (in polysorbate) 150mcg/0.75 mL solution

Tier 5 None PA


Tier 5 None PA



Tier 5 None PA



Tier 5 None PA



Tier 5 None PA



Tier Quantity Limit

(QL)


Requirement


Aranesp (in polysorbate) 500mcg/mL syringe Tier 5 None PA


Tier 5 None PA


Aranesp SureClick (polysorbat) 100mcg/0.5 mL pen injector

Tier 5 None PA


Tier 5 None PA


Tier 5 None PA


Tier 5 None PA


Tier 5 None PA


Tier 5 None PA

Aranesp SureClick (polysorbat) 500mcg/mL pen injector

Tier 5 None PA


Tier 5 None PA

aripiprazole 10mg tablet,disintegrating Tier 5 QL(60 EA per 30

days) None

aripiprazole 15mg tablet,disintegrating Tier 5 QL(60 EA per 30

days) None

armodafinil 150mg tablet Tier 4 QL (30 EA per 30

days) PA


days) PA


days) PA



Tier Quantity Limit

(QL)


Requirement


days) PA

atropine in 0.9 % sod chloride 0.25 mg/5 mL(0.05 mg/mL) syringe

Tier 4 None None

atropine sulfate (PF) 1% drops Tier 2 None None

Aubagio 14mg tablet Tier 5 None PA

Aubagio 7mg tablet Tier 5 QL(30 EA per 30

days) PA

Avandia 8mg tablet Tier 4 None None

BD Lancet Device misc Tier 3 None None

bimatoprost 0.03% drops Tier 4 QL(5 ML per 31

days) 0 None

Butalbital Compound-Codeine 30-50-325-40mg capsule

Tier 4 QL(180 EA per 30

days) None

butalbital-acetaminop-caf-cod 50-325-40-30mg capsule


days) None

calcitriol 3mcg/gram ointment Tier 5 None PA

carbamazepine 100mg tablet extended release 12 hr

Tier 3 None None

carbamazepine 100mg/5 mL (5 mL) suspension

Tier 3 None None

carbamazepine 200mg/10 mL suspension Tier 3 None None

Cayston 75mg/mL solution for nebulization Tier 5 None PA

Cedax 400mg capsule Tier 4 None None

cefazolin 10gram recon soln Tier 3 None None



Tier Quantity Limit

(QL)


Requirement

cefazolin 1gram recon soln Tier 2 None None

cefazolin 500mg recon soln Tier 2 None None

cefazolin in dextrose (iso-os) 1gram/50 mL piggyback

Tier 3 None None

cefditoren pivoxil 200mg tablet Tier 2 None None

cefditoren pivoxil 400mg tablet Tier 2 None None

cefpodoxime 100mg/5 mL suspension for reconstitution

Tier 3 None None

cefpodoxime 50mg/5 mL suspension for reconstitution

Tier 3 None None

ceftriaxone 100gram recon soln Tier 2 None None

cefuroxime sodium 1.5gram recon soln Tier 2 None None

cefuroxime sodium 7.5gram recon soln Tier 2 None None

cefuroxime sodium 750mg recon soln Tier 2 None None

cevimeline 30mg capsule Tier 2 None None

Chantix Starting Month Pak 0.5 mg (11)-1 mg (42) tablets,dose pack

Tie 6 QL(106 EA per 365

days) None

Cialis 2.5mg tablet Tier 4 None PA

Cialis 5mg tablet Tier 4 None PA

ciclopirox-ure-camph-menth-euc 8% solution Tier 3 None None

ciclopirox-vitE-nail lacq remo 8-5% kit Tier 3 None None



Tier Quantity Limit

(QL)


Requirement

Cinryze 500unit (5 mL) recon soln Tier 5 None PA

Clindacin Pac 1% kit Tier 2 None None

clotrimazole 10mg troche Tier 2 None None

clozapine 100mg tablet,disintegrating Tier 4 None PA

clozapine 12.5mg tablet,disintegrating Tier 4 None PA




codeine-butalbital-ASA-caff 30-50-325-40mg capsule


days) None

Cometriq 100 mg/day(80mg x1-20 mg x1) capsule

Tier 5 None PA

Cometriq 140 mg/day(80mg x1-20 mg x3) capsule

Tier 5 None PA

Cometriq 60 mg/day(20 mg x 3/day) capsule Tier 5 None PA

Copaxone 20mg/mL syringe Tier 5 None PA

Cordran Tape Large Roll 4mcg/cm2 tape Tier 4 None None

Cresemba 186mg capsule Tier 5 None PA

Cresemba 372mg recon soln Tier 5 None PA

cyclosporine 250mg/5 mL solution Tier 3 None None



Tier Quantity Limit

(QL)


Requirement

Cystaran 0.44% drops Tier 4 None PA

Daklinza 30mg tablet Tier 5 None PA

Daklinza 60mg tablet Tier 5 None PA

Daliresp 500mcg tablet Tier 4 QL(30 EA per 30

days) None

darifenacin 15mg tablet extended release 24 hr

Tier 4 None None

darifenacin 7.5mg tablet extended release 24 hr

Tier 4 None None

Decara 50,000unit capsule Tier 3 None None

Descovy 200-25mg tablet Tier 3 None None

desloratadine 5mg tablet Tier 2 QL(30 EA per 30

days) None

desmopressin 10 mcg/spray(0.1 mL) aerosol,spray

Tier 3 None None

desoximetasone 0.05% ointment Tier 3 None None

dexamethasone sodium phosphate 4mg/mL solution

Tier 2 None None

dexamethasone sodium phosphate 4mg/mL syringe

Tier 3 None None

dexchlorpheniramine maleate 2mg/5 mL syrup Tier 4 None None

dextroamphetamine-amphetamine 10mg capsule,extended release 24hr


days) None

dextroamphetamine-amphetamine 10mg tablet


days) None



days) None



Tier Quantity Limit

(QL)


Requirement



days) None



days) None



days) None



days) None



days) None



days) None

dextroamphetamine-amphetamine 5mg tablet Tier 2 QL(90 EA per 30

days) None

diclofenac sodium 1% gel Tier 3 None None

dicyclomine 10mg/5 mL syrup Tier 2 None None

digoxin 0.25 mg/5 mL(5 mL) solution Tier 3 None None

dihydrocode-acetaminophen-caff 16-320.5-30mg capsule

Tier 4 None None

dihydroergotamine 0.5 mg/pumpact. (4 mg/mL) spray,non-aerosol

Tier 4 None None

DILT-CD 120mg capsule,extended release 24hr

Tier 2 None None


Tier 2 None None


Tier 2 None None

diphenhydramine HCl 50mg/mL solution Tier 2 None None

diphenoxylate-atropine 2.5-0.025mg tablet Tier 2 None None



Tier Quantity Limit

(QL)


Requirement

dipivefrin 0.1% drops Tier 4 None None

dofetilide 125mcg capsule Tier 4 None None



Donnatal 16.2-0.1037-0.0194 mg/5 mL elixir Tier 4 None None

E.E.S. 200 200mg/5 mL suspension for reconstitution

Tier 4 None None

Eliquis 2.5mg tablet Tier 4 None None

Eliquis 5mg tablet Tier 4 None None

Epiduo 0.1-2.5% gel Tier 4 None None

EpiPen 0.3mg/0.3 mL auto-injector Tier 3 QL(4 EA per 30

days) None

EpiPen Jr 0.15mg/0.3 mL auto-injector Tier 3 QL(4 EA per 30

days) None

erythromycin 2% solution Tier 2 None None

erythromycin 250mg capsule,delayed release(DR/EC)

Tier 4 None None

Evotaz 300-150mg tablet Tier 3 None None

Farydak 10mg capsule Tier 5 QL(6 EA per 21

days) PA


days) PA


days) PA



Tier Quantity Limit

(QL)


Requirement

Fetzima 120mg capsule,extended release 24 hr


days) PA

Fetzima 20 mg (2)-40 mg (26) capsule,Ext Rel 24hr dose pack


days) PA

Fetzima 20mg capsule,extended release 24 hr Tier 4 QL(30 EA per 30

days) PA


days) PA


days) PA

fexofenadine 30mg/5 mL suspension Tier 2 None None

fexofenadine-pseudoephedrine 60-120mg tablet extended release 12 hr

Tier 3 None None

Finacea Plus 15% kit Tier 4 None None

fluocinolone 0.025% cream Tier 3 None None

fluocinolone 0.025% ointment Tier 3 None None

fluorouracil 50mg/mL solution Tier 3 None None

fluoxetine 10mg capsule Tier 2 None None

fluoxetine 10mg tablet Tier 3 QL(240 EA per 30

days) None

fluoxetine 20mg capsule Tier 2 QL(90 EA per 30

days) None

fluoxetine 20mg tablet Tier 3 QL(120 EA per 30

days) None

frovatriptan 2.5mg tablet Tier 4 QL(18 EA per 30

days) ST Applies

furosemide 40mg/4 mL solution Tier 1 None None



Tier Quantity Limit

(QL)


Requirement

Fycompa 0.5mg/mL suspension Tier 4 None PA

Fycompa 10mg tablet Tier 4 QL(30 EA per 30

days) PA


days) PA

Fycompa 2 mg (7)-4 mg (7) tablets,dose pack Tier 4 None PA


days) PA


days) PA


days) PA


days) PA

gabapentin 250mg/5 mL (5 mL) solution Tier 2 QL(2160 ML per 30

days) None

gabapentin 300mg/6 mL (6 mL) solution Tier 2 QL(2160 ML per 30

days) None

Gammagard Liquid 10% solution Tier 5 None PA

Gammagard S-D (IgA < 1 mcg/mL) 10gram recon soln

Tier 5 None PA

Gammagard S-D (IgA < 1 mcg/mL) 5gram recon soln

Tier 5 None PA

Gengraf 100mg capsule Tier 3 None None



Genvoya 150-150-200-10mg tablet Tier 3 None None



Tier Quantity Limit

(QL)


Requirement

Gilotrif 20mg tablet Tier 5 QL(30 EA per 30

days) PA


days) PA


days) PA

GlucaGen 1mg recon soln Tier 3 None None

heparin (porcine) 20,000unit/mL syringe Tier 2 None None

hydrocodone-acetaminophen 2.5-325mg tablet


days) None

hydrocodone-acetaminophen 5-300mg tablet Tier 3 QL(240 EA per 30

days) None

hydrocodone-ibuprofen 10-200mg tablet Tier 3 QL(50 EA per 30

days) None

hydrocortisone 1% cream Tier 2 None None

hydrocortisone 1% packet Tier 2 None None

hydrocortisone 2.5% cream Tier 2 None None

hydrocortisone-aloe vera 1% cream Tier 2 None None

hydrocortisone-aloe vera 1% ointment Tier 2 None None

hydrocortisone-min oil-wht pet 1% ointment Tier 2 None None

hydrocortisone-oatmeal-aloe-E 1% cream Tier 2 None None

hydroxyzine HCl 10mg/5 mL (5 mL) solution Tier 2 None None

HyQvia 10 gram/100 mL (10 %) solution Tier 5 None PA

HyQvia 2.5 gram/25 mL (10 %) solution Tier 5 None PA



Tier Quantity Limit

(QL)


Requirement




Ibrance 100mg capsule Tier 5 QL(21 EA per 28

days) PA


days) PA


days) PA

Iclusig 15mg tablet Tier 5 QL(60 EA per 30

days) PA

Iclusig 45mg tablet Tier 5 QL(30 EA per 30

days) PA

imatinib 100mg tablet Tier 5 QL(180 EA per 30

days) PA

imatinib 400mg tablet Tier 5 QL(60 EA per 30

days) PA

Imbruvica 140mg capsule Tier 5 QL(120 EA per 30

days) PA

Incruse Ellipta 62.5mcg/actuation blister with device

Tier 3 None None

Kalydeco 150mg tablet Tier 5 QL(60 EA per 30

days) PA

Kalydeco 50mg granules in packet Tier 5 QL(56 EA per 28

days) PA

Kalydeco 75mg granules in packet Tier 5 QL(56 EA per 28

days) PA

Kapidex 30mg capsule,biphase delayed releas

Tier 3 None None

Ketek Pak 400mg tablet Tier 5 None None



Tier Quantity Limit

(QL)


Requirement

Klor-Con Sprinkle 10mEq capsule, extended release

Tier 2 None None

Klor-Con Sprinkle 8mEq capsule, extended release

Tier 2 None None

Lacrisert 5mg insert Tier 5 None PA

lactulose 10 gram/15 mL(15 mL) solution Tier 2 None None

lamotrigine 25 mg (21)-50 mg (7) tablet disintegrating, dose pk

Tier 3 None None

lamotrigine 25 mg (42)-100 mg (7) tablets,dose pack

Tier 3 None None

lamotrigine 25 mg (84)-100 mg (14) tablets,dose pack

Tier 3 None None

lamotrigine 25 mg(14)-50 mg(14)-100 mg (7) tablet disintegrating, dose pk

Tier 3 None None

lamotrigine 25mg (35) tablets,dose pack Tier 3 None None

lamotrigine 50 mg (42)-100 mg (14) tablet disintegrating, dose pk

Tier 3 None None

lancets misc Tier 3 QL(200 EA per 30

days) None

Lenvima 10 mg/day (10mg x 1/day) capsule Tier 5 QL(30 EA per 30

days) PA

Lenvima 14 mg/day(10 mgx 1-4 mg x 1) capsule


days) PA

Lenvima 18 mg/day (10mg x 1-4 mg x2) capsule


days) PA

Lenvima 20 mg/day(10 mg x 2) capsule Tier 5 QL(30 EA per 30

days) PA

Lenvima 24 mg/day(10 mgx 2-4 mg x 1) capsule


days) PA

Lenvima 8 mg/day(4 mg x 2) capsule Tier 5 QL(30 EA per 30

days) PA



Tier Quantity Limit

(QL)


Requirement

leuprolide 1mg/0.2 mL solution Tier 5 None PA

levetiracetam 500mg/5 mL (5 mL) solution Tier 2 None None

Levoxyl 100mcg tablet Tier 2 None None











lidocaine HCl 2% solution Tier 2 None None

Lipofen 150mg capsule Tier 3 None None

Lipofen 50mg capsule Tier 3 None None

lithium citrate 8mEq/5 mL (5 mL) solution Tier 2 None None



Tier Quantity Limit

(QL)


Requirement

lomustine 100mg capsule Tier 4 None None



Lotemax 0.5% drops,gel Tier 4 None None

Lupaneta Pack (1 month) 3.75 mg-5 mg (30) kit. syringe and tablet

Tier 5 None PA

Lupaneta Pack (3 month) 11.25 mg-5 mg (90) kit. syringe and tablet

Tier 5 None PA

Lynparza 50mg capsule Tier 5 QL(480 EA per 30

days) PA

Mekinist 0.5mg tablet Tier 5 QL(120 EA per 30

days) PA

Mekinist 2mg tablet Tier 5 QL(30 EA per 30

days) PA

methenamine mandelate 1gram tablet Tier 3 None None

metronidazole 1% gel with pump Tier 4 None None

mexiletine 150mg capsule Tier 2 None None



miglitol 100mg tablet Tier 4 QL(90 EA per 30

days) None


days) None


days) None



Tier Quantity Limit

(QL)


Requirement

misoprostol 100mcg tablet Tier 2 None None

Moderiba 200mg tablet Tier 4 None PA

mometasone 50mcg/actuation spray,non-aerosol

Tier 4 None None

morphine concentrate 20mg/mL syringe Tier 3 QL(600 EA per 30

days) None

Movantik 12.5mg tablet Tier 4 None PA

Movantik 25mg tablet Tier 4 None PA

mycophenolate mofetil 200mg/mL suspension for reconstitution

Tier 4 None None

Myrbetriq 25mg tablet extended release 24 hr Tier 3 None None

Myrbetriq 50mg tablet extended release 24 hr Tier 3 None None

naftifine 2% cream Tier 4 None None

naloxone 1mg/mL syringe Tier 2 None None

Namenda XR 14mg capsule,sprinkle,ER 24hr Tier 3 QL(30 EA per 30

days) None


days) None


days) None

Namenda XR 7-14-21-28mg cap,sprinkle,ER 24hr dose pack

Tier 3 None None


days) None

Natpara 100mcg/dose cartridge Tier 5 None PA



Tier Quantity Limit

(QL)


Requirement




Neulasta 6mg/0.6 mL syringe, w/ wearable injector

Tier 5 None PA

Neupogen 300mcg/0.5 mL syringe Tier 5 None PA

Neupogen 480mcg/0.8 mL syringe Tier 5 None PA

niacin 500mg tablet Tier 2 None None

Northera 100mg capsule Tier 5 None PA



Norvir Soft Gelatin 100mg capsule Tier 3 None None

Noxafil 100mg tablet,delayed release (DR/EC) Tier 5 None PA

Noxafil 300mg/16.7 mL solution Tier 5 None PA

Nuedexta 20-10mg capsule Tier 5 QL QL(60 EA per

30 days) PA

nystatin 150 millionunit powder Tier 2 None None

nystatin 2 billionunit powder Tier 2 None None




Tier Quantity Limit

(QL)


Requirement


Odefsey 200-25-25mg tablet Tier 3 None None

Odomzo 200mg capsule Tier 5 QL(30 EA per 30

days) PA

omega 3-dha-epa-fish oil 1,000 mg (120mg-180 mg) capsule

Tier 4 None None

omeprazole magnesium 20mg capsule,delayed release(DR/EC)

Tier 2 None None

Onfi 10mg tablet Tier 5 None PA

Onfi 2.5mg/mL suspension Tier 5 None PA

Onfi 20mg tablet Tier 5 None PA

Opsumit 10mg tablet Tier 5 None PA

Orencia ClickJect 125mg/mL auto-injector Tier 5 None PA

Orenitram 0.125mg tablet extended release Tier 5 None PA


Orenitram 1mg tablet extended release Tier 5 None PA


Osphena 60mg tablet Tier 4 None PA

oxiconazole 1% cream Tier 4 None None

oxycodone 10mg tablet,oral only,ext.rel.12 hr Tier 4 QL (60 EA per 30

days) PA



Tier Quantity Limit

(QL)


Requirement


days) PA


days) PA


days) PA


days) PA


days) PA


days) PA

paliperidone 1.5mg tablet extended release 24hr


days) PA

paliperidone 3mg tablet extended release 24hr


days) PA



days) PA



days) PA

Pazeo 0.7% drops Tier 3 None None

PegIntron 120mcg/0.5 mL kit Tier 5 None PA




Pentasa 250mg capsule, extended release Tier 3 QL(240 EA per 30

days) None

Pentasa 500mg capsule, extended release Tier 3 QL(240 EA per 30

days) None



Tier Quantity Limit

(QL)


Requirement

Phenergan 12.5mg suppository Tier 3 None None

Phenergan 25mg suppository Tier 3 None None

Phenergan 50mg suppository Tier 3 None None

phenobarb-hyoscy-atropine-scop 16.2-0.1037-0.0194 mg tablet

Tier 4 None None

phenoxybenzamine 10mg capsule Tier 3 None None

phenytoin 100mg/4 mL suspension Tier 2 None None

phenytoin 100mg/4 mL syringe Tier 2 None None

pilocarpine HCl 1% drops Tier 3 None None



pioglitazone-metformin 15-500mg tablet Tier 3 QL(90 EA per 30

days) None

pioglitazone-metformin 15-850mg tablet Tier 3 QL(90 EA per 30

days) None

Pomalyst 1mg capsule Tier 5 None PA




prednisolone 15mg/5 mL solution Tier 2 None None



Tier Quantity Limit

(QL)


Requirement

prednisolone sodium phosphate 15mg/5 mL (5 mL) solution

Tier 2 None None

Prepopik 10 mg-3.5gram-12 gram powder in packet

Tier 4 None None

Prezcobix 800-150mg-mg tablet Tier 3 None None

Prezista 300mg tablet Tier 3 None None

prochlorperazine Edisylate 5mg/mL solution Tier 2 None None

Prolensa 0.07% drops Tier 3 None None

promethazine 25mg/mL syringe Tier 3 None None

rabeprazole 20mg tablet,delayed release (DR/EC)


days) None

Renvela 0.8gram powder in packet Tier 5 None None

Renvela 2.4gram powder in packet Tier 5 None None

Retrovir 300mg tablet Tier 4 None None

Reyataz 100mg capsule Tier 3 None None

Ribasphere 200mg capsule Tier 4 None PA

Ribasphere 200mg tablet Tier 4 None PA

Rifamate 300-150mg capsule Tier 4 None None

ringers solution Tier 2 None None

risperidone 0.5mg tablet,disintegrating Tier 3 QL(120 EA per 30

days) None



Tier Quantity Limit

(QL)


Requirement

risperidone 1mg tablet,disintegrating Tier 3 QL(120 EA per 30

days) None

risperidone 1mg/mL syringe Tier 2 None None


days) None


days) None


days) None

rosuvastatin 10mg tablet Tier 4 QL(30 EA per 30

days) None


days) None


days) None


days) None

Sandostatin LAR Depot 10mg kit Tier 5 None PA



Saphris 10mg tablet Tier 4 None PA

Saphris 5mg tablet Tier 4 None None

selenium sulfide 2.5% shampoo Tier 2 None None

Signifor 0.3mg/mL (1 mL) solution Tier 5 None PA




Tier Quantity Limit

(QL)


Requirement


Signifor LAR 20mg suspension for reconstitution

Tier 5 None PA


Tier 5 None PA


Tier 5 None PA

Silenor 3mg tablet Tier 4 None None

sodium chloride 0.9 % 0.9% solution Tier 2 None None

sodium fluoride 1 mg fluoride(2.2 mg) tablet Tie 6 None None

sodium polystyrene (sorb free) 15gram/60 mL suspension

Tier 3 None None

Sorine 120mg tablet Tier 2 None None




Stiolto Respimat 2.5-2.5mcg/actuation mist Tier 3 QL(4 GM per 30

days) None

Stivarga 40mg tablet Tier 5 QL(84 EA per 28

days) PA

sulfacetamide sodium 10% cleanser,gel extended release

Tier 4 None None

sulfacetamide sodium-urea 10-10% lotion Tier 2 None None

sulfasalazine 500mg tablet,delayed release (DR/EC)

Tier 2 None None



Tier Quantity Limit

(QL)


Requirement

Suprax 100mg tablet,chewable Tier 4 None None

Suprax 200mg tablet,chewable Tier 4 None None

Suprax 400mg capsule Tier 4 None None

Synjardy 12.5-1,000mg tablet Tier 3 None None

Synjardy 12.5-500mg tablet Tier 3 None None

Synjardy 5-1,000mg tablet Tier 3 None None

Synjardy 5-500mg tablet Tier 3 None None

Tafinlar 50mg capsule Tier 5 None PA

Tafinlar 75mg capsule Tier 5 None PA

tetrabenazine 25mg tablet Tier 5 None PA

Tis-U-Sol solution Tier 3 None None

Tivicay 10mg tablet Tier 3 None None

Tivicay 25mg tablet Tier 3 None None

tobramycin in 0.225 % NaCl 300mg/5 mL solution for nebulization

Tier 5 None PA

Transderm-Scop 1.5 mg (1 mgover 3 days) patch 3 day

Tier 4 None None

travoprost (benzalkonium) 0.004% drops Tier 3 QL(5 ML per 31

days) None

tretinoin (emollient) 0.05% cream Tier 3 None None

triamcinolone acetonide 55mcg aerosol,spray Tier 2 None None

Trintellix 10mg tablet Tier 3 QL(30 EA per 30

days) None


days) None



Tier Quantity Limit

(QL)


Requirement


days) None

Triumeq 600-50-300mg tablet Tier 3 None None

Truvada 100-150mg tablet Tier 3 None None



Tudorza Pressair 400mcg/actuation aerosol powdr breath activated

Tier 4 None None

Tybost 150mg tablet Tier 3 QL(30 EA per 30

days) None

valproic acid (as sodium salt) 250mg/5 mL (5 mL) solution

Tier 2 None None

valproic acid (as sodium salt) 250mg/5 mL syringe

Tier 2 None None

valproic acid (as sodium salt) 500 mg/10 mL(10 mL) solution

Tier 2 None None

vancomycin 1,000mg recon soln Tier 2 None None

vancomycin 500mg recon soln Tier 2 None None

Varubi 90mg tablet Tier 5 None PA

Victoza 3-Pak 0.6 mg/0.1 mL(18 mg/3 mL) pen injector

Tier 4 None PA

Viibryd 10 mg (7)-20 mg(7)-40 mg (16) tablets,dose pack


days) ST

Vimpat 50 mg (14)-100 mg (14) tablets,dose pack

Tier 5 None PA

Visicol 1.5gram tablet Tier 2 None None

Vitekta 150mg tablet Tier 3 QL(30 EA per 30

days) None

Vitekta 85mg tablet Tier 3 QL(30 EA per 30

days) None

voriconazole 200 mg/5 mL(40 mg/mL) suspension for reconstitution

Tier 5 None PA



Tier Quantity Limit

(QL)


Requirement

Vraylar 1.5 mg (1)-3 mg (6) capsule,dose pack

Tier 5 None PA

Vraylar 1.5mg capsule Tier 5 None PA

Vraylar 3mg capsule Tier 5 None PA

Vraylar 4.5mg capsule Tier 5 None PA

Vraylar 6mg capsule Tier 5 None PA

WelChol 3.75gram powder in packet Tier 4 None None

Xarelto 15 mg (42)-20 mg (9) tablets,dose pack

Tier 4 None None

Xeljanz 5mg tablet Tier 5 None PA

Xeljanz XR 11mg tablet extended release 24 hr

Tier 5 None PA

Xgeva 120 mg/1.7 mL(70 mg/mL) solution Tier 5 None PA

zoledronic acid-mannitol-water 5mg/100 mL piggyback

Tier 5 None PA

Zydelig 100mg tablet Tier 5 QL(60 EA per 30

days) PA

Zydelig 150mg tablet Tier 5 QL(60 EA per 30

days) PA

Zyflo 600mg tablet Tier 5 QL(120 EA per 30

days) PA

Zykadia 150mg capsule Tier 5 QL(150 EA per 30

days) PA

MEDICATIONS WITH TIERING CHANGES

Medication Name 2016 Tier 2017 Tier

acamprosate 333mg tablet,delayed release (DR/EC) Tier 2 Tier 4

acetaminophen-codeine 120-12mg/5 mL solution Tier 2 Tier 3

acetaminophen-codeine 300-15mg tablet Tier 2 Tier 3





Acetasol HC 1-2% drops Tier 2 Tier 3

acetazolamide 125mg tablet Tier 2 Tier 3

acetazolamide 250mg tablet Tier 2 Tier 3

acyclovir 200mg/5 mL suspension Tier 2 Tier 3

adapalene 0.1% cream Tier 2 Tier 3

adapalene 0.1% gel Tier 2 Tier 3

Adderall XR 10mg capsule,extended release 24hr Tier 3 Tier 4






Albenza 200mg tablet Tier 3 Tier 5

albuterol sulfate 2mg tablet Tier 2 Tier 4

albuterol sulfate 4mg tablet Tier 2 Tier 4

alendronate 35mg tablet Tier 2 Tier 1

alendronate 70mg tablet Tier 2 Tier 1

alfuzosin 10mg tablet extended release 24 hr Tier 3 Tier 2

Alphagan P 0.1% drops Tier 3 Tier 4

alprazolam 0.5mg tablet extended release 24 hr Tier 2 Tier 3

alprazolam 1mg tablet extended release 24 hr Tier 2 Tier 3



Altabax 1% ointment Tier 3 Tier 4

amantadine HCl 100mg capsule Tier 2 Tier 3

amantadine HCl 100mg tablet Tier 2 Tier 3

amcinonide 0.1% cream Tier 2 Tier 4

amlodipine 10mg tablet Tier 2 Tier 1



amlodipine 2.5mg tablet Tier 2 Tier 1

amlodipine 5mg tablet Tier 2 Tier 1

amlodipine-benazepril 10-20mg capsule Tier 4 Tier 2


amlodipine-benazepril 2.5-10mg capsule Tier 4 Tier 2




amlodipine-valsartan 10-160mg tablet Tier 3 Tier 2




amoxapine 100mg tablet Tier 3 Tier 2




amoxicillin 125mg tablet,chewable Tier 1 Tier 2

amoxicillin-pot clavulanate 1,000-62.5mg tablet extended release 12 hr

Tier 2 Tier 3

amoxicillin-pot clavulanate 250-125mg tablet Tier 2 Tier 3

amoxicillin-pot clavulanate 250-62.5mg/5 mL suspension for reconstitution

Tier 2 Tier 3

anagrelide 0.5mg capsule Tier 2 Tier 3

anagrelide 1mg capsule Tier 2 Tier 3

Anucort-HC 25mg suppository Tier 2 Tier 3

Ascomp with Codeine 30-50-325-40mg capsule Tier 2 Tier 3

aspirin-dipyridamole 25-200mg capsule, ER multiphase 12 hr

Tier 3 Tier 4

atenolol-chlorthalidone 100-25mg tablet Tier 1 Tier 2

atenolol-chlorthalidone 50-25mg tablet Tier 1 Tier 2



atovaquone 750mg/5 mL suspension Tier 4 Tier 5

atovaquone-proguanil 250-100mg tablet Tier 2 Tier 4

atovaquone-proguanil 62.5-25mg tablet Tier 2 Tier 4

Avar 10-5% (w/w) cleanser Tier 2 Tier 4

Avar-E 10-5% (w/w) cream Tier 2 Tier 4

Avar-E Green 10-5% (w/w) cream Tier 2 Tier 4

azelastine 0.15 %(205.5 mcg) spray,non-aerosol Tier 2 Tier 3

azelastine 137 mcg(0.1 %) aerosol,spray Tier 2 Tier 3

azithromycin 250mg tablet Tier 2 Tier 1



bacitracin 500unit/gram ointment Tier 2 Tier 3

Bactroban Nasal 2% ointment Tier 3 Tier 4

balsalazide 750mg capsule Tier 2 Tier 3

betamethasone dipropionate 0.05% cream Tier 2 Tier 3

betamethasone dipropionate 0.05% ointment Tier 2 Tier 3

betamethasone valerate 0.1% lotion Tier 2 Tier 3

betamethasone, augmented 0.05% lotion Tier 2 Tier 3

bethanechol chloride 10mg tablet Tier 2 Tier 3




Betoptic S 0.25% drops,suspension Tier 3 Tier 4

Beyaz 3-0.02-0.451mg (24) tablet Tier 3 Tier 4

brimonidine 0.15% drops Tier 2 Tier 3

brimonidine 0.2% drops Tier 2 Tier 1

Bromfed DM 2-30-10mg/5 mL syrup Tier 2 Tier 3



bromocriptine 2.5mg tablet Tier 2 Tier 4

bromocriptine 5mg capsule Tier 2 Tier 4

brompheniramine-pseudoeph-DM 2-30-10mg/5 mL syrup

Tier 2 Tier 3

Brovana 15mcg/2 mL solution for nebulization Tier 5 Tier 4

budesonide 0.25mg/2 mL suspension for nebulization Tier 2 Tier 4

budesonide 0.5mg/2 mL suspension for nebulization Tier 2 Tier 4

budesonide 1mg/2 mL suspension for nebulization Tier 2 Tier 4

buprenorphine HCl 2mg tablet Tier 2 Tier 3

buprenorphine HCl 8mg tablet Tier 2 Tier 3

Butalbital Compound W/Codeine 30-50-325-40mg capsule

Tier 2 Tier 4

butalbital-acetaminop-caf-cod 50-300-40-30mg capsule

Tier 2 Tier 4

butalbital-acetaminophen 50-325mg tablet Tier 2 Tier 4

butalbital-acetaminophen-caff 50-300-40mg capsule Tier 2 Tier 4

butalbital-acetaminophen-caff 50-325-40mg capsule Tier 2 Tier 4

butalbital-acetaminophen-caff 50-325-40mg tablet Tier 2 Tier 4

butalbital-aspirin-caffeine 50-325-40mg capsule Tier 2 Tier 4

butorphanol tartrate 1mg/mL solution Tier 2 Tier 3

butorphanol tartrate 2mg/mL solution Tier 2 Tier 3

cabergoline 0.5mg tablet Tier 2 Tier 3

calcipotriene 0.005% cream Tier 2 Tier 4

calcipotriene 0.005% ointment Tier 2 Tier 4

calcipotriene 0.005% solution Tier 2 Tier 4

calcitonin (salmon) 200unit/actuation spray,non-aerosol

Tier 4 Tier 3

Canasa 1,000mg suppository Tier 4 Tier 5

captopril 100mg tablet Tier 1 Tier 2

captopril 12.5mg tablet Tier 1 Tier 2





captopril-hydrochlorothiazide 25-15mg tablet Tier 1 Tier 2




Carafate 100mg/mL suspension Tier 3 Tier 4

carbamazepine 100mg capsule, ER multiphase 12 hr Tier 2 Tier 3

carbamazepine 100mg/5 mL suspension Tier 2 Tier 3


carbamazepine 200mg tablet extended release 12 hr Tier 2 Tier 3


carbamazepine 400mg tablet extended release 12 hr Tier 2 Tier 3

carbidopa 25mg tablet Tier 3 Tier 4

carvedilol 12.5mg tablet Tier 2 Tier 1

carvedilol 25mg tablet Tier 2 Tier 1



cefaclor 250mg capsule Tier 2 Tier 3

cefaclor 500mg capsule Tier 2 Tier 3

cefadroxil 1gram tablet Tier 2 Tier 3

cefadroxil 250mg/5 mL suspension for reconstitution Tier 2 Tier 3

cefadroxil 500mg/5 mL suspension for reconstitution Tier 2 Tier 3

cefdinir 125mg/5 mL suspension for reconstitution Tier 2 Tier 3

cefdinir 250mg/5 mL suspension for reconstitution Tier 2 Tier 3

cefpodoxime 100mg tablet Tier 2 Tier 3

cefpodoxime 200mg tablet Tier 2 Tier 3

cefprozil 125mg/5 mL suspension for reconstitution Tier 2 Tier 3



cefprozil 250mg/5 mL suspension for reconstitution Tier 2 Tier 3

cefuroxime axetil 250mg tablet Tier 2 Tier 3

cefuroxime axetil 500mg tablet Tier 2 Tier 3

cephalexin 125mg/5 mL suspension for reconstitution Tier 1 Tier 2

cephalexin 250mg/5 mL suspension for reconstitution Tier 1 Tier 2

chlordiazepoxide-clidinium 5-2.5mg capsule Tier 2 Tier 3

chlorpromazine 100mg tablet Tier 2 Tier 3





cholestyramine (with sugar) 4gram powder Tier 2 Tier 3

cholestyramine (with sugar) 4gram powder in packet Tier 2 Tier 3

Cholestyramine Light 4gram powder Tier 1 Tier 3

Cholestyramine Light 4gram powder in packet Tier 1 Tier 3

ciclopirox 0.77% cream Tier 2 Tier 3

ciclopirox 0.77% gel Tier 2 Tier 3

ciclopirox 0.77% suspension Tier 2 Tier 3

ciclopirox 1% shampoo Tier 2 Tier 3

Cipro HC 0.2-1% drops,suspension Tier 3 Tier 4

ciprofloxacin (mixture) 1,000mg tablet, ER multiphase 24 hr

Tier 2 Tier 3

ciprofloxacin (mixture) 500mg tablet, ER multiphase 24 hr

Tier 2 Tier 3

ciprofloxacin HCl 0.3% drops Tier 2 Tier 1

ciprofloxacin HCl 100mg tablet Tier 2 Tier 4






citalopram 10mg tablet Tier 2 Tier 1



Claravis 10mg capsule Tier 5 Tier 4




clemastine 2.68mg tablet Tier 2 Tier 3

Cleocin 100mg suppository Tier 3 Tier 4

clindamycin HCl 150mg capsule Tier 2 Tier 1

clindamycin HCl 300mg capsule Tier 2 Tier 1

clindamycin palmitate HCl 75mg/5 mL recon soln Tier 2 Tier 3

clindamycin phosphate 1% gel Tier 2 Tier 3

clindamycin phosphate 1% lotion Tier 2 Tier 3

clindamycin phosphate 1% solution Tier 2 Tier 3

clindamycin phosphate 2% cream Tier 2 Tier 3

clindamycin-benzoyl peroxide 1.2 %(1 % base)-5 % gel

Tier 2 Tier 4

clindamycin-benzoyl peroxide 1-5% gel Tier 2 Tier 4

clobetasol 0.05% cream Tier 2 Tier 4

clobetasol 0.05% gel Tier 2 Tier 4

clobetasol 0.05% lotion Tier 2 Tier 4

clobetasol 0.05% ointment Tier 2 Tier 4

clobetasol 0.05% shampoo Tier 2 Tier 4

clobetasol 0.05% solution Tier 2 Tier 3

clobetasol-emollient 0.05% cream Tier 2 Tier 4

clocortolone pivalate 0.1% cream Tier 2 Tier 4

Clodan 0.05% shampoo Tier 2 Tier 4

clomipramine 25mg capsule Tier 2 Tier 4





clonidine 0.1mg/24 hr patch weekly Tier 2 Tier 3



clonidine HCl 0.1mg tablet Tier 2 Tier 1



clotrimazole-betamethasone 1-0.05% lotion Tier 2 Tier 3

codeine sulfate 15mg tablet Tier 2 Tier 3



colestipol 1gram tablet Tier 2 Tier 3

colestipol 5gram granules Tier 2 Tier 3

Compro 25mg suppository Tier 2 Tier 4

cyclosporine 100mg capsule Tier 2 Tier 3

cyclosporine 25mg capsule Tier 2 Tier 3

cyclosporine modified 100mg capsule Tier 2 Tier 3

cyclosporine modified 100mg/mL solution Tier 2 Tier 3



Cystaran 0.44% drops Tier 4 Tier 5

danazol 100mg capsule Tier 2 Tier 4



dantrolene 100mg capsule Tier 2 Tier 3



Denavir 1% cream Tier 3 Tier 4

Depen Titratabs 250mg tablet Tier 4 Tier 5

Dermazene 1-1% cream Tier 2 Tier 3

desmopressin 0.1mg tablet Tier 2 Tier 3

desmopressin 0.2mg tablet Tier 2 Tier 3

desmopressin 10 mcg/spray(0.1 mL) spray,non-aerosol

Tier 2 Tier 3

desonide 0.05% cream Tier 2 Tier 4



desonide 0.05% lotion Tier 2 Tier 4

desonide 0.05% ointment Tier 2 Tier 4

desoximetasone 0.05% cream Tier 2 Tier 3

desoximetasone 0.05% gel Tier 2 Tier 3

desoximetasone 0.25% cream Tier 2 Tier 3

desoximetasone 0.25% ointment Tier 2 Tier 3

dexmethylphenidate 10mg tablet Tier 2 Tier 3

dexmethylphenidate 2.5mg tablet Tier 2 Tier 3

dexmethylphenidate 5mg tablet Tier 2 Tier 3

dextroamphetamine 10mg capsule, extended release Tier 2 Tier 4

dextroamphetamine 10mg tablet Tier 2 Tier 3



dextroamphetamine 5mg tablet Tier 2 Tier 3

diazepam 5 mg/5 mL(1 mg/mL) solution Tier 2 Tier 4

diclofenac potassium 50mg tablet Tier 1 Tier 2

dicyclomine 10mg capsule Tier 2 Tier 1

dicyclomine 20mg tablet Tier 2 Tier 1

Dipentum 250mg capsule Tier 4 Tier 5

doxycycline hyclate 100mg capsule Tier 2 Tier 3

doxycycline hyclate 100mg tablet Tier 2 Tier 3

doxycycline hyclate 50mg capsule Tier 2 Tier 3

doxycycline monohydrate 100mg tablet Tier 2 Tier 3



dronabinol 2.5mg capsule Tier 5 Tier 4

dronabinol 5mg capsule Tier 5 Tier 4

Droxia 200mg capsule Tier 3 Tier 4



Durezol 0.05% drops Tier 3 Tier 4

econazole 1% cream Tier 2 Tier 4

Elidel 1% cream Tier 3 Tier 4



Elmiron 100mg capsule Tier 3 Tier 4

enalapril-hydrochlorothiazide 10-25mg tablet Tier 2 Tier 1

enalapril-hydrochlorothiazide 5-12.5mg tablet Tier 2 Tier 1

Endocet 10-325mg tablet Tier 2 Tier 3

Endocet 2.5-325mg tablet Tier 2 Tier 3

Endocet 5-325mg tablet Tier 2 Tier 3

Endocet 7.5-325mg tablet Tier 2 Tier 3

enoxaparin 100mg/mL syringe Tier 5 Tier 4

enoxaparin 120mg/0.8 mL syringe Tier 5 Tier 4

enoxaparin 150mg/mL syringe Tier 5 Tier 4

enoxaparin 300mg/3 mL solution Tier 5 Tier 4





entacapone 200mg tablet Tier 3 Tier 4

eplerenone 25mg tablet Tier 2 Tier 3

eplerenone 50mg tablet Tier 2 Tier 3

ergoloid 1mg tablet Tier 2 Tier 3

Ery Pads 2% swab Tier 2 Tier 3

erythromycin 250mg tablet Tier 2 Tier 4

erythromycin 500mg tablet Tier 2 Tier 4

erythromycin ethylsuccinate 400mg tablet Tier 2 Tier 4

erythromycin-benzoyl peroxide 3-5% gel Tier 2 Tier 4

escitalopram oxalate 5mg/5 mL solution Tier 2 Tier 3

estradiol 0.025mg/24 hr patch semiweekly Tier 3 Tier 4

estradiol 0.025mg/24 hr patch weekly Tier 2 Tier 3












estrogens-methyltestosterone 0.625-1.25mg tablet Tier 2 Tier 3

estrogens-methyltestosterone 1.25-2.5mg tablet Tier 2 Tier 3

eszopiclone 1mg tablet Tier 3 Tier 2



ethambutol 100mg tablet Tier 2 Tier 3

ethambutol 400mg tablet Tier 2 Tier 3

ethosuximide 250mg capsule Tier 2 Tier 3

ethosuximide 250mg/5 mL solution Tier 2 Tier 3

etodolac 200mg capsule Tier 2 Tier 3

etodolac 300mg capsule Tier 2 Tier 3

etodolac 400mg tablet Tier 2 Tier 3

etodolac 400mg tablet extended release 24 hr Tier 2 Tier 4

etodolac 500mg tablet Tier 2 Tier 3



exemestane 25mg tablet Tier 2 Tier 4

famciclovir 125mg tablet Tier 4 Tier 3



famotidine 40 mg/5 mL(8 mg/mL) suspension Tier 2 Tier 4

fenofibrate nanocrystallized 145mg tablet Tier 3 Tier 2

fenofibrate nanocrystallized 48mg tablet Tier 3 Tier 2

fenofibric acid (choline) 45mg capsule,delayed release(DR/EC)

Tier 3 Tier 2

fentanyl 100mcg/hr patch 72 hour Tier 2 Tier 3





flunisolide 25mcg (0.025 %) spray,non-aerosol Tier 2 Tier 3



fluocinolone 0.01% cream Tier 2 Tier 3

fluocinolone 0.01% oil Tier 2 Tier 3

fluocinolone 0.01% solution Tier 2 Tier 3

fluocinolone acetonide oil 0.01% drops Tier 2 Tier 3

fluocinolone and shower cap 0.01% oil Tier 2 Tier 3

fluocinonide 0.05% cream Tier 2 Tier 3

fluocinonide 0.05% gel Tier 2 Tier 3

fluocinonide 0.05% ointment Tier 2 Tier 3

fluocinonide 0.05% solution Tier 2 Tier 3

Fluocinonide-E 0.05% cream Tier 2 Tier 3

fluorouracil 2% solution Tier 2 Tier 3

fluorouracil 5% cream Tier 2 Tier 3

fluorouracil 5% solution Tier 2 Tier 3

flutamide 125mg capsule Tier 2 Tier 3

fluvastatin 20mg capsule Tier 2 Tier 3

fluvastatin 40mg capsule Tier 2 Tier 3

Focalin XR 25mg capsule,ER biphasic 50-50 Tier 3 Tier 4

Focalin XR 35mg capsule,ER biphasic 50-50 Tier 3 Tier 4

furosemide 10mg/mL solution Tier 1 Tier 2

galantamine 12mg tablet Tier 2 Tier 3

galantamine 16mg capsule,ext rel. pellets 24 hr Tier 2 Tier 3



galantamine 4mg/mL solution Tier 2 Tier 4



Gavilyte-C 240-22.72-6.72-5.84 gram recon soln Tier 2 Tier 6 ($0)

GaviLyte-G 236-22.74-6.74-5.86 gram recon soln Tier 2 Tier 6 ($0)

GaviLyte-N 420gram recon soln Tier 2 Tier 6 ($0)

Gengraf 100mg/mL solution Tier 2 Tier 3

glimepiride 1mg tablet Tier 2 Tier 1





glipizide 10mg tablet extended release 24hr Tier 2 Tier 1

glipizide 2.5mg tablet extended release 24hr Tier 2 Tier 1

glipizide 5mg tablet extended release 24hr Tier 2 Tier 1

granisetron HCl 1mg tablet Tier 2 Tier 3

halobetasol propionate 0.05% cream Tier 2 Tier 4

halobetasol propionate 0.05% ointment Tier 2 Tier 4

hydrocodone-acetaminophen 10-300mg tablet Tier 2 Tier 3



hydrocodone-acetaminophen 7.5-300mg tablet Tier 2 Tier 3

hydrocodone-acetaminophen 7.5-325mg tablet Tier 2 Tier 3

hydrocodone-acetaminophen 7.5-325mg/15 mL solution

Tier 2 Tier 4

hydrocodone-ibuprofen 5-200mg tablet Tier 2 Tier 3

hydrocodone-ibuprofen 7.5-200mg tablet Tier 2 Tier 3

hydrocortisone 1% lotion Tier 2 Tier 1

hydrocortisone 100mg/60 mL enema Tier 2 Tier 4

hydrocortisone 2.5% lotion Tier 2 Tier 3

hydrocortisone acetate 25mg suppository Tier 2 Tier 3

hydrocortisone acetate 30mg suppository Tier 2 Tier 3

hydrocortisone butyrate 0.1% ointment Tier 2 Tier 4

hydrocortisone butyrate 0.1% solution Tier 2 Tier 4

hydrocortisone butyr-emollient 0.1% cream Tier 3 Tier 4

hydrocortisone valerate 0.2% cream Tier 2 Tier 4

hydrocortisone-acetic acid 1-2% drops Tier 2 Tier 3

hydrocortisone-pramoxine 1-1% cream Tier 2 Tier 3

hydrocortisone-pramoxine 2.5-1% cream Tier 2 Tier 3

hydromorphone 16mg tablet extended release 24 hr Tier 5 Tier 4

hydromorphone 2mg tablet Tier 2 Tier 3





hydroxychloroquine 200mg tablet Tier 2 Tier 3



ibuprofen-oxycodone 400-5mg tablet Tier 2 Tier 3

imiquimod 5% cream in packet Tier 5 Tier 4

Invega Sustenna 117mg/0.75 mL syringe Tier 4 Tier 5

Invega Sustenna 156mg/mL syringe Tier 4 Tier 5




irbesartan 150mg tablet Tier 2 Tier 1



irbesartan-hydrochlorothiazide 150-12.5mg tablet Tier 2 Tier 1

irbesartan-hydrochlorothiazide 300-12.5mg tablet Tier 2 Tier 1

isosorbide dinitrate 10mg tablet Tier 2 Tier 3



isosorbide dinitrate 40mg tablet extended release Tier 2 Tier 3


itraconazole 100mg capsule Tier 3 Tier 4

ivermectin 3mg tablet Tier 3 Tier 2

Jantoven 10mg tablet Tier 2 Tier 1


Jantoven 2.5mg tablet Tier 2 Tier 1






Jantoven 7.5mg tablet Tier 2 Tier 1

lansoprazole 15mg capsule,delayed release(DR/EC) Tier 3 Tier 2

lansoprazole 30mg capsule,delayed release(DR/EC) Tier 3 Tier 2

latanoprost 0.005% drops Tier 2 Tier 1

leflunomide 10mg tablet Tier 2 Tier 3

leflunomide 20mg tablet Tier 2 Tier 3



letrozole 2.5mg tablet Tier 4 Tier 2

Leukeran 2mg tablet Tier 3 Tier 4

levocarnitine (with sugar) 100mg/mL solution Tier 2 Tier 3

levocarnitine 330mg tablet Tier 2 Tier 3

levocetirizine 2.5mg/5 mL solution Tier 2 Tier 4

levofloxacin 250mg/10 mL solution Tier 2 Tier 4

lidocaine 5% ointment Tier 2 Tier 4

lidocaine HCl-hydrocortison ac 3-0.5% kit Tier 2 Tier 4

lidocaine HCl-hydrocortison ac 3-1% (7 gram) kit Tier 2 Tier 4

lidocaine-hydrocortisone-aloe 2-2% kit Tier 2 Tier 4

lidocaine-hydrocortisone-aloe 3-2.5% (7 gram) kit Tier 2 Tier 4

lindane 1% lotion Tier 2 Tier 3

lindane 1% shampoo Tier 2 Tier 3

lithium carbonate 150mg capsule Tier 2 Tier 1



Livalo 1mg tablet Tier 5 Tier 4



Lopreeza 0.5-0.1mg tablet Tier 2 Tier 3

Lopreeza 1-0.5mg tablet Tier 2 Tier 3

losartan 100mg tablet Tier 2 Tier 1



losartan-hydrochlorothiazide 100-12.5mg tablet Tier 2 Tier 1

losartan-hydrochlorothiazide 100-25mg tablet Tier 2 Tier 1

losartan-hydrochlorothiazide 50-12.5mg tablet Tier 2 Tier 1

Lotemax 0.5% drops,suspension Tier 3 Tier 4

Lumigan 0.01% drops Tier 4 Tier 3

malathion 0.5% lotion Tier 2 Tier 3

mefenamic acid 250mg capsule Tier 2 Tier 4

memantine 10mg tablet Tier 4 Tier 2

memantine 5-10mg tablets,dose pack Tier 4 Tier 2



memantine 5mg tablet Tier 4 Tier 2

meperidine 100mg tablet Tier 2 Tier 3

meperidine 50mg tablet Tier 2 Tier 3

meprobamate 200mg tablet Tier 2 Tier 3

meprobamate 400mg tablet Tier 2 Tier 3

mercaptopurine 50mg tablet Tier 2 Tier 3

mesalamine 4gram/60 mL enema Tier 2 Tier 4

mesalamine with cleansing wipe 4gram/60 mL enema kit

Tier 2 Tier 4

metaxalone 800mg tablet Tier 2 Tier 4

metformin 500mg tablet extended release 24 hr Tier 2 Tier 1

metformin 750mg tablet extended release 24 hr Tier 2 Tier 1

methadone 10mg tablet Tier 2 Tier 3

methadone 5mg tablet Tier 2 Tier 3

methazolamide 25mg tablet Tier 2 Tier 4

methazolamide 50mg tablet Tier 2 Tier 4

methimazole 10mg tablet Tier 2 Tier 1

methimazole 5mg tablet Tier 2 Tier 1

methylergonovine 0.2mg tablet Tier 2 Tier 3

methylphenidate 20mg tablet extended release Tier 3 Tier 4

metronidazole 0.75% cream Tier 2 Tier 3

metronidazole 0.75% gel Tier 2 Tier 3

metronidazole 0.75% lotion Tier 2 Tier 4

metronidazole 1% gel Tier 3 Tier 4

midodrine 10mg tablet Tier 2 Tier 3

midodrine 2.5mg tablet Tier 2 Tier 3

midodrine 5mg tablet Tier 2 Tier 3

Mimvey 1-0.5mg tablet Tier 2 Tier 3

Mimvey Lo 0.5-0.1mg tablet Tier 2 Tier 3

modafinil 100mg tablet Tier 5 Tier 4

modafinil 200mg tablet Tier 5 Tier 4

moexipril 15mg tablet Tier 2 Tier 3

moexipril 7.5mg tablet Tier 2 Tier 3

moexipril-hydrochlorothiazide 15-12.5mg tablet Tier 2 Tier 3



moexipril-hydrochlorothiazide 15-25mg tablet Tier 2 Tier 3

moexipril-hydrochlorothiazide 7.5-12.5mg tablet Tier 2 Tier 3

morphine 10mg/5 mL solution Tier 2 Tier 3

morphine 15mg tablet Tier 2 Tier 3

morphine 20 mg/5 mL(4 mg/mL) solution Tier 2 Tier 3

morphine 30mg tablet Tier 2 Tier 3

morphine concentrate 100 mg/5 mL(20 mg/mL) solution

Tier 2 Tier 3

mycophenolate mofetil 250mg capsule Tier 2 Tier 3

mycophenolate mofetil 500mg tablet Tier 2 Tier 3

mycophenolate sodium 180mg tablet,delayed release (DR/EC)

Tier 5 Tier 4

mycophenolate sodium 360mg tablet,delayed release (DR/EC)

Tier 5 Tier 4

Myorisan 10mg capsule Tier 5 Tier 4




naphazoline 0.1% drops Tier 1 Tier 2

naproxen 500mg tablet,delayed release (DR/EC) Tier 1 Tier 2

nateglinide 120mg tablet Tier 2 Tier 3

nateglinide 60mg tablet Tier 2 Tier 3

Nature-Throid 113.75mg tablet Tier 3 Tier 2

Nature-Throid 130mg tablet Tier 3 Tier 2














nicardipine 20mg capsule Tier 2 Tier 3

nicardipine 30mg capsule Tier 2 Tier 3

Nilandron 150mg tablet Tier 3 Tier 5

nisoldipine 17mg tablet extended release 24 hr Tier 2 Tier 3


nisoldipine 25.5mg tablet extended release 24 hr Tier 2 Tier 3




nisoldipine 8.5mg tablet extended release 24 hr Tier 2 Tier 3

nortriptyline 10mg capsule Tier 2 Tier 1




Nucynta ER 100mg tablet extended release 12 hr Tier 5 Tier 4





nystatin 100,000unit/gram ointment Tier 4 Tier 2

nystatin-triamcinolone 100,000-0.1unit/g-% cream Tier 2 Tier 4

nystatin-triamcinolone 100,000-0.1unit/gram-% ointment

Tier 1 Tier 4

ofloxacin 0.3% drops Tier 2 Tier 4

olanzapine 10mg tablet,disintegrating Tier 2 Tier 3




olanzapine-fluoxetine 12-25mg capsule Tier 2 Tier 4





olopatadine 0.6% spray,non-aerosol Tier 3 Tier 4



ondansetron 4mg tablet,disintegrating Tier 2 Tier 3

ondansetron 8mg tablet,disintegrating Tier 2 Tier 3

Opana ER 10mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4






Opana ER 7.5mg tablet,oral only,ext.rel.12 hr Tier 5 Tier 4

OsmoPrep 1.5gram tablet Tier 3 Tier 4

oxandrolone 10mg tablet Tier 2 Tier 5

oxandrolone 2.5mg tablet Tier 2 Tier 5

oxaprozin 600mg tablet Tier 2 Tier 3

oxybutynin chloride 5mg tablet Tier 1 Tier 2

oxybutynin chloride 5mg tablet extended release 24hr Tier 3 Tier 2

oxycodone 10mg tablet Tier 2 Tier 3





oxycodone-acetaminophen 10-325mg tablet Tier 2 Tier 3

oxycodone-acetaminophen 2.5-325mg tablet Tier 2 Tier 3

oxycodone-acetaminophen 5-325mg tablet Tier 2 Tier 3

oxycodone-acetaminophen 7.5-325mg tablet Tier 2 Tier 3

oxycodone-aspirin 4.8355-325mg tablet Tier 2 Tier 3

oxymorphone 10mg tablet Tier 3 Tier 4

oxymorphone 5mg tablet Tier 3 Tier 4

paromomycin 250mg capsule Tier 2 Tier 3

paroxetine HCl 12.5mg tablet extended release 24 hr Tier 2 Tier 3

paroxetine HCl 25mg tablet extended release 24 hr Tier 2 Tier 3

paroxetine HCl 37.5mg tablet extended release 24 hr Tier 2 Tier 3

peg 3350-electrolytes 236-22.74-6.74-5.86 gram recon soln

Tier 2 Tier 6 ($0)

peg 3350-electrolytes 240-22.72-6.72-5.84 gram recon soln

Tier 2 Tier 6 ($0)



peg-electrolyte soln 420gram recon soln Tier 2 Tier 6 ($0)

pentazocine-naloxone 50-0.5mg tablet Tier 2 Tier 3

permethrin 5% cream Tier 2 Tier 4

Phenadoz 12.5mg suppository Tier 2 Tier 3

Phenadoz 25mg suppository Tier 2 Tier 3

phenelzine 15mg tablet Tier 2 Tier 3

Physiolyte 140-5-3-98mEq/L solution Tier 2 Tier 4

pilocarpine HCl 5mg tablet Tier 2 Tier 3

pilocarpine HCl 7.5mg tablet Tier 2 Tier 3

piroxicam 10mg capsule Tier 2 Tier 3

piroxicam 20mg capsule Tier 2 Tier 3

podofilox 0.5% solution Tier 2 Tier 3

polyethylene glycol 3350 17gram powder in packet Tier 2 Tier 6 ($0)

polyethylene glycol 3350 17gram/dose powder Tier 2 Tier 6 ($0)

potassium citrate 10mEq (1,080 mg) tablet extended release

Tier 2 Tier 3

potassium citrate 15mEq tablet extended release Tier 2 Tier 3

potassium citrate 5mEq (540 mg) tablet extended release

Tier 2 Tier 3

prednisolone sodium phosphate 10mg tablet,disintegrating

Tier 3 Tier 4


Tier 3 Tier 4


Tier 3 Tier 4

Prevalite 4gram powder Tier 1 Tier 3

Prevalite 4gram powder in packet Tier 1 Tier 3

prochlorperazine 25mg suppository Tier 2 Tier 4

prochlorperazine Edisylate 10 mg/2 mL(5 mg/mL) solution

Tier 2 Tier 4

Proctofoam HC 1-1% foam Tier 3 Tier 4

Proglycem 50mg/mL suspension Tier 3 Tier 4

promethazine 12.5mg suppository Tier 2 Tier 3

promethazine 12.5mg tablet Tier 1 Tier 2

promethazine 25mg suppository Tier 2 Tier 3

promethazine 25mg tablet Tier 1 Tier 2

promethazine 25mg/mL solution Tier 2 Tier 3

promethazine 50mg suppository Tier 2 Tier 3



promethazine 50mg tablet Tier 1 Tier 2

promethazine 50mg/mL solution Tier 2 Tier 3

promethazine 6.25mg/5 mL syrup Tier 2 Tier 3

Promethazine VC 6.25-5mg/5 mL syrup Tier 2 Tier 3

Promethazine VC-Codeine 6.25-5-10mg/5 mL syrup Tier 2 Tier 3

promethazine-codeine 6.25-10mg/5 mL syrup Tier 2 Tier 3

promethazine-phenyleph-codeine 6.25-5-10mg/5 mL syrup

Tier 2 Tier 3

promethazine-phenylephrine 6.25-5mg/5 mL syrup Tier 2 Tier 3

Promethegan 12.5mg suppository Tier 2 Tier 3

Promethegan 25mg suppository Tier 2 Tier 3

Promethegan 50mg suppository Tier 2 Tier 3

propylthiouracil 50mg tablet Tier 2 Tier 3

protriptyline 10mg tablet Tier 2 Tier 3

protriptyline 5mg tablet Tier 2 Tier 3

pyridostigmine bromide 60mg tablet Tier 2 Tier 3

quinapril 10mg tablet Tier 2 Tier 1




quinidine gluconate 324mg tablet extended release Tier 2 Tier 4

ramipril 1.25mg capsule Tier 2 Tier 1

ramipril 10mg capsule Tier 2 Tier 1

ramipril 2.5mg capsule Tier 2 Tier 1

ramipril 5mg capsule Tier 2 Tier 1

Rapamune 1mg/mL solution Tier 3 Tier 5

Renvela 800mg tablet Tier 4 Tier 5

repaglinide 0.5mg tablet Tier 3 Tier 2

repaglinide 1mg tablet Tier 3 Tier 2

repaglinide 2mg tablet Tier 3 Tier 2

ribavirin 200mg capsule Tier 5 Tier 4

ribavirin 200mg tablet Tier 5 Tier 4

risperidone 0.25mg tablet,disintegrating Tier 2 Tier 3

rivastigmine tartrate 1.5mg capsule Tier 2 Tier 3



rivastigmine tartrate 3mg capsule Tier 2 Tier 3

rivastigmine tartrate 4.5mg capsule Tier 2 Tier 3

rivastigmine tartrate 6mg capsule Tier 2 Tier 3

ropinirole 12mg tablet extended release 24 hr Tier 2 Tier 4





Rosanil 10-5% (w/w) cleanser Tier 2 Tier 4

Savella 100mg tablet Tier 3 Tier 4

Savella 12.5 mg (5)-25mg(8)-50 mg(42) tablets,dose pack

Tier 3 Tier 4

Savella 12.5mg tablet Tier 3 Tier 4



sildenafil 20mg tablet Tier 5 Tier 4

sirolimus 0.5mg tablet Tier 3 Tier 4

sirolimus 1mg tablet Tier 3 Tier 4

sirolimus 2mg tablet Tier 3 Tier 4

Sirturo 100mg tablet Tier 4 Tier 5

SS 10-2 10-2% cleanser Tier 3 Tier 4

SSS 10-5 10-5% (w/w) cream Tier 2 Tier 4

SSS 10-5 10-5% foam Tier 2 Tier 4

sulfacetamide sodium 10% cleanser Tier 2 Tier 4

sulfacetamide sodium-sulfur 10-2% cleanser Tier 3 Tier 4

sulfacetamide sodium-sulfur 10-2% cream Tier 3 Tier 4

sulfacetamide sodium-sulfur 10-5% (w/v) lotion Tier 2 Tier 4

sulfacetamide sodium-sulfur 10-5% (w/w) cleanser Tier 2 Tier 4

sulfacetamide sodium-sulfur 10-5% (w/w) cream Tier 2 Tier 4

sulfacetamide sodium-sulfur 10-5% foam Tier 2 Tier 4

sulfacetamide sodium-sulfur 10-5% suspension Tier 2 Tier 4

sulfacetamide sodium-sulfur 9.8-4.8% cleanser Tier 2 Tier 4

sulfacetamide sodium-sulfur 9.8-4.8% cream Tier 2 Tier 4

sulfacetamide sodium-sulfur 9-4.5% cleanser Tier 2 Tier 4



sulfacetamide sod-sulfur-urea 10-5-10% cleanser Tier 2 Tier 4

sulfamethoxazole-trimethoprim 200-40mg/5 mL suspension

Tier 1 Tier 2

sulfamethoxazole-trimethoprim 400-80mg/5 mL solution

Tier 1 Tier 3

SymlinPen 120 2,700mcg/2.7 mL pen injector Tier 3 Tier 5

SymlinPen 60 1,500mcg/1.5 mL pen injector Tier 3 Tier 5

Syprine 250mg capsule Tier 4 Tier 5

telmisartan 20mg tablet Tier 4 Tier 2



terconazole 0.4% cream Tier 2 Tier 4

terconazole 0.8% cream Tier 2 Tier 4

terconazole 80mg suppository Tier 2 Tier 4

testosterone cypionate 100mg/mL oil Tier 2 Tier 3

testosterone cypionate 200mg/mL oil Tier 2 Tier 3

testosterone enanthate 200mg/mL oil Tier 2 Tier 3

tetracycline 250mg capsule Tier 2 Tier 4

tetracycline 500mg capsule Tier 2 Tier 4

tinidazole 500mg tablet Tier 3 Tier 2

tobramycin-dexamethasone 0.3-0.1% drops,suspension

Tier 2 Tier 3

tolterodine 1mg tablet Tier 2 Tier 3

tolterodine 2mg tablet Tier 2 Tier 3

topiramate 15mg capsule, sprinkle Tier 2 Tier 3

topiramate 25mg capsule, sprinkle Tier 2 Tier 3

Toviaz 4mg tablet extended release 24 hr Tier 3 Tier 4

Toviaz 8mg tablet extended release 24 hr Tier 3 Tier 4

tramadol 100mg tablet extended release 24 hr Tier 3 Tier 4

tramadol 100mg tablet, ER multiphase 24 hr Tier 3 Tier 4

tramadol 200mg tablet extended release 24 hr Tier 3 Tier 4

tramadol 200mg tablet, ER multiphase 24 hr Tier 3 Tier 4

tramadol 50mg tablet Tier 2 Tier 3

tramadol-acetaminophen 37.5-325mg tablet Tier 2 Tier 3

trazodone 100mg tablet Tier 1 Tier 2






tretinoin 0.01% gel Tier 2 Tier 3

tretinoin 0.025% cream Tier 2 Tier 3





triamcinolone acetonide 0.1% paste Tier 2 Tier 3

trifluridine 1% drops Tier 2 Tier 3

TriLyte With Flavor Packets 420gram recon soln Tier 2 Tier 6 ($0)

ursodiol 250mg tablet Tier 2 Tier 4

ursodiol 300mg capsule Tier 2 Tier 4

ursodiol 500mg tablet Tier 2 Tier 4

Veltin 1.2-0.025% gel Tier 4 Tier 5

Victoza 2-Pak 0.6 mg/0.1 mL(18 mg/3 mL) pen injector

Tier 5 Tier 4

Viibryd 10 mg (7)-20 mg (23) tablets,dose pack Tier 5 Tier 4

Viibryd 10mg tablet Tier 5 Tier 4



warfarin 10mg tablet Tier 2 Tier 1


warfarin 2.5mg tablet Tier 2 Tier 1






warfarin 7.5mg tablet Tier 2 Tier 1

Yasmin (28) 3-0.03mg tablet Tier 2 Tier 4

YAZ (28) 3-0.02mg tablet Tier 2 Tier 4

zafirlukast 10mg tablet Tier 2 Tier 3



zafirlukast 20mg tablet Tier 2 Tier 3

Zenatane 10mg capsule Tier 5 Tier 4




Ziana 1.2-0.025% gel Tier 4 Tier 5

Zioptan (PF) 0.0015% dropperette Tier 3 Tier 4

zolmitriptan 2.5mg tablet Tier 3 Tier 4

zolmitriptan 2.5mg tablet,disintegrating Tier 3 Tier 4

zolmitriptan 5mg tablet Tier 3 Tier 4

zolmitriptan 5mg tablet,disintegrating Tier 3 Tier 4

MEDICATIONS WITH QUANTITY LIMIT (QL) CHANGES

DRUG DESCRIPTION 2017 QUANTITY LIMIT (QL)

acetaminophen-codeine 120-12mg/5 mL solution QL(2700 ML per 30 days)

acetaminophen-codeine 300-60mg tablet QL(180 EA per 30 days)

Adderall XR 10mg capsule,extended release 24hr QL(30 EA per 30 days)






Afinitor 10mg tablet QL(60 EA per 30 days)

alfuzosin 10mg tablet extended release 24 hr QL(30 EA per 30 days)

almotriptan malate 12.5mg tablet QL(18 EA per 30 days)

almotriptan malate 6.25mg tablet QL(18 EA per 30 days)

alprazolam 0.25mg tablet QL(120 EA per 30 days)

alprazolam 0.5mg tablet QL(120 EA per 30 days)

alprazolam 0.5mg tablet extended release 24 hr QL(90 EA per 30 days)

alprazolam 1mg tablet QL(240 EA per 30 days)



alprazolam 1mg tablet extended release 24 hr QL(60 EA per 30 days)

alprazolam 2mg tablet QL(150 EA per 30 days)



amlodipine-valsartan 10-160mg tablet QL(30 EA per 30 days)




amlodipine-valsartan-hcthiazid 10-160-12.5mg tablet QL(30 EA per 30 days)

amlodipine-valsartan-hcthiazid 10-160-25mg tablet QL(30 EA per 30 days)


amlodipine-valsartan-hcthiazid 5-160-12.5mg tablet QL(30 EA per 30 days)


Analpram Advanced 2.5 %-1 %/630 mg/1 %-1 % kit QL(4 EA per 30 days)

anastrozole 1mg tablet QL(30 EA per 30 days)

AndroGel 1.62 % (20.25mg/1.25 gram) gel in packet QL Removed

AndroGel 1.62 % (40.5mg/2.5 gram) gel in packet QL Removed

AndroGel 20.25 mg/1.25gram (1.62 %) gel in metered-dose pump

QL Removed

Asmanex HFA 100mcg/actuation HFA aerosol inhaler QL(13 GM per 30 days)

Asmanex HFA 200mcg/actuation HFA aerosol inhaler QL(13 GM per 30 days)

Aubagio 14mg tablet QL(30 EA per 30 days)

Avonex (with albumin) 30mcg kit QL(4 EA per 28 days)

Avonex 30mcg/0.5 mL pen injector kit QL(4 EA per 28 days)

Avonex 30mcg/0.5 mL syringe kit QL(1 EA per 28 days)

azelastine 0.15 %(205.5 mcg) spray,non-aerosol QL(60 ML per 30 days)

azelastine 137 mcg(0.1 %) aerosol,spray QL(60 ML per 30 days)

Banzel 200mg tablet QL(90 EA per 30 days)



Banzel 400mg tablet QL(240 EA per 30 days)

Banzel 40mg/mL suspension QL(2400 ML per 30 days)

Betaseron 0.3mg kit QL(14 EA per 28 days)

Brintellix 10mg tablet QL(30 EA per 30 days)



brompheniramine-pseudoeph-DM 2-30-10mg/5 mL syrup QL(1200 ML per 30 days)

buprenorphine HCl 2mg tablet QL(90 EA per 30 days)

buprenorphine HCl 8mg tablet QL(90 EA per 30 days)

bupropion HCl 150mg tablet extended release QL(90 EA per 30 days)

bupropion HCl 150mg tablet extended release 24 hr QL(90 EA per 30 days)

Butalbital Compound W/Codeine 30-50-325-40mg capsule QL(180 EA per 30 days)

butalbital-acetaminop-caf-cod 50-300-40-30mg capsule QL(180 EA per 30 days)

butalbital-acetaminophen 50-325mg tablet QL(180 EA per 30 days)

butalbital-acetaminophen-caff 50-300-40mg capsule QL(180 EA per 30 days)

butalbital-acetaminophen-caff 50-325-40mg capsule QL(180 EA per 30 days)

butalbital-acetaminophen-caff 50-325-40mg tablet QL(180 EA per 30 days)

butalbital-aspirin-caffeine 50-325-40mg capsule QL(180 EA per 30 days)

Butrans 10mcg/hour patch weekly QL(4 EA per 28 days)




Butrans 7.5mcg/hour patch weekly QL(4 EA per 28 days)

Bydureon 2mg suspension,extended rel recon QL(4 EA per 28 days)



Bydureon 2mg/0.65 mL pen injector QL(4 EA per 28 days)

Byetta 10 mcg/dose(250mcg/mL) 2.4 mL pen injector QL(2.4 ML per 28 days)

Byetta 5 mcg/dose (250mcg/mL) 1.2 mL pen injector QL(1.2 ML per 30 days)

cabergoline 0.5mg tablet QL(16 EA per 28 days)

calcitonin (salmon) 200unit/actuation spray,non-aerosol QL(3.7 ML per 30 days)

Caprelsa 100mg tablet QL(60 EA per 30 days)

Caprelsa 300mg tablet QL(30 EA per 30 days)

carisoprodol 350mg tablet QL(30 EA per 30 days)

chlorzoxazone 500mg tablet QL(120 EA per 30 days)

citalopram 10mg tablet QL(30 EA per 30 days)

citalopram 10mg/5 mL solution QL(600 ML per 30 days)



clonazepam 0.5mg tablet QL(90 EA per 30 days)

clonazepam 1mg tablet QL(90 EA per 30 days)

clonazepam 2mg tablet QL(300 EA per 30 days)

clonidine 0.1mg/24 hr patch weekly QL(4 EA per 28 days)



clorazepate dipotassium 15mg tablet QL(180 EA per 30 days)

clorazepate dipotassium 3.75mg tablet QL(90 EA per 30 days)

clorazepate dipotassium 7.5mg tablet QL(90 EA per 30 days)

codeine sulfate 15mg tablet QL(180 EA per 30 days)



Combivent Respimat 20-100mcg/actuation mist QL(8 GM per 30 days)

cyclobenzaprine 10mg tablet QL(90 EA per 30 days)



cyclobenzaprine 5mg tablet QL(90 EA per 30 days)

Cycloset 0.8mg tablet QL(180 EA per 30 days)

Daytrana 10mg/9 hr patch 24 hour QL(30 EA per 30 days)




dexmethylphenidate 10mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)

dexmethylphenidate 10mg tablet QL(60 EA per 30 days)


dexmethylphenidate 2.5mg tablet QL(60 EA per 30 days)





dexmethylphenidate 5mg tablet QL(60 EA per 30 days)

dextroamphetamine 10mg capsule, extended release QL(180 EA per 30 days)

dextroamphetamine 10mg tablet QL(180 EA per 30 days)



dextroamphetamine 5mg tablet QL(180 EA per 30 days)

dextroamphetamine-amphetamine 12.5mg tablet QL(90 EA per 30 days)

dextroamphetamine-amphetamine 15mg tablet QL(90 EA per 30 days)

dextroamphetamine-amphetamine 7.5mg tablet QL(90 EA per 30 days)

diazepam 10mg tablet QL(120 EA per 30 days)



doxazosin 1mg tablet QL(30 EA per 30 days)






dronabinol 10mg capsule QL Removed

dronabinol 2.5mg capsule QL Removed

dronabinol 5mg capsule QL Removed

Emsam 12mg/24 hr patch 24 hour QL(30 EA per 30 days)



Enbrel 25mg/0.5mL (0.51) syringe QL(4 ML per 28 days)

Enbrel 50mg/mL (0.98 mL) syringe QL(8 ML per 28 days)

Enbrel SureClick 50mg/mL (0.98 mL) pen injector QL(8 ML per 28 days)

Endocet 10-325mg tablet QL(180 EA per 30 days)

enoxaparin 100mg/mL syringe QL(28 ML per 30 days)

enoxaparin 120mg/0.8 mL syringe QL(22.4 ML per 30 days)

enoxaparin 150mg/mL syringe QL(28 ML per 30 days)

enoxaparin 300mg/3 mL solution QL(24 ML per 30 days)





entacapone 200mg tablet QL(240 EA per 30 days)

entecavir 0.5mg tablet QL(30 EA per 30 days)

entecavir 1mg tablet QL(30 EA per 30 days)

Entresto 24-26mg tablet QL(60 EA per 30 days)





EpiPen 2-Pak 0.3mg/0.3 mL auto-injector QL(4 EA per 30 days)

EpiPen Jr 2-Pak 0.15mg/0.3 mL auto-injector QL(4 EA per 30 days)

Erivedge 150mg capsule QL(30 EA per 30 days)

escitalopram oxalate 10mg tablet QL(30 EA per 30 days)



escitalopram oxalate 5mg/5 mL solution QL(600 ML per 30 days)

estradiol 0.025mg/24 hr patch semiweekly QL(8 EA per 28 days)

estradiol 0.025mg/24 hr patch weekly QL(4 EA per 28 days)










eszopiclone 1mg tablet QL(30 EA per 30 days)



Fanapt 10mg tablet QL(60 EA per 30 days)



Fanapt 1mg(2)-2mg(2)-4mg(2)-6mg(2) tablets,dose pack QL(8 EA per 28 days)







Fareston 60mg tablet QL(30 EA per 30 days)

fentanyl citrate 1,200mcg lozenge on a handle QL(120 EA per 30 days)

fentanyl citrate 1,600mcg lozenge on a handle QL(120 EA per 30 days)

fentanyl citrate 200mcg lozenge on a handle QL(120 EA per 30 days)




Flovent Diskus 100mcg/actuation blister with device QL(60 EA per 30 days)



Flovent HFA 110mcg/actuation HFA aerosol inhaler QL(12 GM per 30 days)

Flovent HFA 44mcg/actuation HFA aerosol inhaler QL(10.6 GM per 30 days)

fluoxetine 10mg capsule QL(90 EA per 30 days)

fluoxetine 20 mg/5 mL(4 mg/mL) solution QL(600 ML per 30 days)

fluvoxamine 100mg tablet QL(90 EA per 30 days)



Focalin XR 25mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)

Focalin XR 35mg capsule,ER biphasic 50-50 QL(30 EA per 30 days)

fondaparinux 10mg/0.8 mL syringe QL(24 ML per 30 days)

fondaparinux 2.5mg/0.5 mL syringe QL(15 ML per 30 days)

fondaparinux 5mg/0.4 mL syringe QL(12 ML per 30 days)

fondaparinux 7.5mg/0.6 mL syringe QL(18 ML per 30 days)

Forteo 20 mcg/dose -600 mcg/2.4 mL pen injector QL(2.4 ML per 28 days)

FreeStyle Lancets 28gauge misc QL(200 EA per 30 days)



gabapentin 100mg capsule QL(270 EA per 30 days)

gabapentin 300mg capsule QL(270 EA per 30 days)

gabapentin 800mg tablet QL(120 EA per 30 days)

glipizide 10mg tablet extended release 24hr QL(60 EA per 30 days)

glipizide 2.5mg tablet extended release 24hr QL(60 EA per 30 days)

glipizide 5mg tablet extended release 24hr QL(60 EA per 30 days)

GlucaGen 1mg recon soln QL(4 EA per 30 days)

GlucaGen Diagnostic Kit 1mg/mL recon soln QL(4 EA per 30 days)

glyburide 5mg tablet QL(60 EA per 30 days)

guanfacine 1mg tablet extended release 24 hr QL(30 EA per 30 days)




Horizant 300mg tablet extended release QL(60 EA per 30 days)

Horizant 600mg tablet extended release QL(60 EA per 30 days)

Humira 10mg/0.2 mL syringe kit QL(2 EA per 28 days)



Humira Pen 40mg/0.8 mL pen injector kit QL(4 EA per 28 days)

hydrocodone-acetaminophen 10-300mg tablet QL(180 EA per 30 days)



hydrocodone-acetaminophen 7.5-300mg tablet QL(240 EA per 30 days)

hydrocodone-acetaminophen 7.5-325mg tablet QL(84 EA per 30 days)

hydrocodone-acetaminophen 7.5-325mg/15 mL solution QL(2700 ML per 30 days)

hydrocodone-ibuprofen 5-200mg tablet QL(50 EA per 30 days)

hydrocodone-ibuprofen 7.5-200mg tablet QL(50 EA per 30 days)



hydromorphone 2mg tablet QL(180 EA per 30 days)



ibandronate 150mg tablet QL(1 EA per 28 days)

ibuprofen-oxycodone 400-5mg tablet QL(28 EA per 30 days)

imiquimod 5% cream in packet QL(20 EA per 28 days)

ipratropium bromide 0.03% spray,non-aerosol QL(30 ML per 30 days)

ipratropium bromide 0.06% spray,non-aerosol QL(30 ML per 30 days)

itraconazole 100mg capsule QL(120 EA per 30 days)

Jakafi 25mg tablet QL(60 EA per 30 days)

Jardiance 10mg tablet QL(30 EA per 30 days)

Jardiance 25mg tablet QL(30 EA per 30 days)

Jentadueto 2.5-1,000mg tablet QL(60 EA per 30 days)

Jentadueto 2.5-500mg tablet QL(60 EA per 30 days)

Jentadueto 2.5-850mg tablet QL(60 EA per 30 days)

lansoprazole 15mg capsule,delayed release(DR/EC) QL(30 EA per 30 days)

lansoprazole 30mg capsule,delayed release(DR/EC) QL(30 EA per 30 days)

Latuda 120mg tablet QL(30 EA per 30 days)





levetiracetam 1,000mg tablet QL Removed

levetiracetam 250mg tablet QL Removed



levocetirizine 5mg tablet QL(30 EA per 30 days)



levorphanol tartrate 2mg tablet QL(180 EA per 30 days)

Lialda 1.2gram tablet,delayed release (DR/EC) QL(120 EA per 30 days)

lidocaine 5% ointment QL(150 GM per 30 days)

lidocaine HCl-hydrocortison ac 3-0.5% kit QL(4 EA per 30 days)

lidocaine HCl-hydrocortison ac 3-1% (7 gram) kit QL(4 EA per 30 days)

lidocaine-hydrocortisone-aloe 2-2% kit QL(4 EA per 30 days)

lidocaine-hydrocortisone-aloe 3-2.5% (7 gram) kit QL(4 EA per 30 days)

lorazepam 0.5mg tablet QL(180 EA per 30 days)

lorazepam 1mg tablet QL(180 EA per 30 days)

lorazepam 2mg tablet QL(150 EA per 30 days)

losartan 100mg tablet QL(30 EA per 30 days)



losartan-hydrochlorothiazide 100-12.5mg tablet QL(30 EA per 30 days)

losartan-hydrochlorothiazide 100-25mg tablet QL(30 EA per 30 days)

losartan-hydrochlorothiazide 50-12.5mg tablet QL(60 EA per 30 days)

lovastatin 10mg tablet QL(30 EA per 30 days)



Lupron Depot (3 Month) 11.25mg syringe kit QL(1 EA per 84 days)

Lupron Depot (3 Month) 22.5mg syringe kit QL(1 EA per 84 days)

Lupron Depot (4 Month) 30mg syringe kit QL(1 EA per 112 days)

Lupron Depot (6 Month) 45mg syringe kit QL(1 EA per 168 days)

Lupron Depot 3.75mg syringe kit QL(1 EA per 28 days)

Lupron Depot 7.5mg syringe kit QL(1 EA per 28 days)

Lupron Depot-Ped (3 Month) 11.25mg syringe kit QL(1 EA per 84 days)

Lupron Depot-Ped (3 Month) 30mg syringe kit QL(1 EA per 84 days)



Lupron Depot-Ped 11.25mg kit QL(1 EA per 28 days)

Lupron Depot-Ped 15mg kit QL(1 EA per 28 days)

Lupron Depot-Ped 7.5mg (Ped) kit QL(1 EA per 28 days)

memantine 2mg/mL solution QL(300 ML per 30 days)

meperidine 100mg tablet QL(180 EA per 30 days)

meperidine 50mg tablet QL(180 EA per 30 days)

metaxalone 800mg tablet QL(120 EA per 30 days)

methamphetamine 5mg tablet QL(90 EA per 30 days)

methylphenidate 10mg tablet QL(90 EA per 30 days)

methylphenidate 10mg tablet extended release QL(180 EA per 30 days)

methylphenidate 18mg tablet extended release 24hr QL(30 EA per 30 days)

methylphenidate 20mg capsule,ER biphasic 50-50 QL(60 EA per 30 days)


methylphenidate 20mg tablet extended release QL(90 EA per 30 days)







Migergot 2-100mg suppository QL(20 EA per 28 days)

morphine 100mg tablet extended release QL(90 EA per 30 days)

morphine 10mg/5 mL solution QL(2700 ML per 30 days)

morphine 15mg tablet QL(180 EA per 30 days)


morphine 20 mg/5 mL(4 mg/mL) solution QL(1350 ML per 30 days)




morphine 30mg tablet QL(180 EA per 30 days)



morphine concentrate 100 mg/5 mL(20 mg/mL) solution QL(600 ML per 30 days)

naratriptan 1mg tablet QL(18 EA per 30 days)

naratriptan 2.5mg tablet QL(18 EA per 30 days)

Nexavar 200mg tablet QL(120 EA per 30 days)

Nucynta 100mg tablet QL(180 EA per 30 days)



Nucynta ER 100mg tablet extended release 12 hr QL(60 EA per 30 days)





olanzapine 10mg tablet QL(30 EA per 30 days)

olanzapine 10mg tablet,disintegrating QL(30 EA per 30 days)



olanzapine 2.5mg tablet QL(30 EA per 30 days)





olanzapine 7.5mg tablet QL(30 EA per 30 days)

olopatadine 0.1% drops QL(10 ML per 30 days)

orphenadrine citrate 100mg tablet extended release QL(60 EA per 30 days)



oxandrolone 10mg tablet QL(120 EA per 30 days)

oxandrolone 2.5mg tablet QL(60 EA per 30 days)

oxybutynin chloride 10mg tablet extended release 24hr QL(30 EA per 30 days)


oxybutynin chloride 5mg tablet QL(120 EA per 30 days)


oxycodone 10mg tablet QL(180 EA per 30 days)




oxycodone 5mg/5 mL solution QL(5400 ML per 30 days)

oxycodone-aspirin 4.8355-325mg tablet QL(360 EA per 30 days)

oxymorphone 10mg tablet QL(120 EA per 30 days)

oxymorphone 5mg tablet QL(120 EA per 30 days)

pantoprazole 20mg tablet,delayed release (DR/EC) QL(60 EA per 30 days)

pantoprazole 40mg tablet,delayed release (DR/EC) QL(60 EA per 30 days)

paroxetine HCl 10mg tablet QL(90 EA per 30 days)

paroxetine HCl 12.5mg tablet extended release 24 hr QL(30 EA per 30 days)


paroxetine HCl 25mg tablet extended release 24 hr QL(60 EA per 30 days)


paroxetine HCl 37.5mg tablet extended release 24 hr QL(60 EA per 30 days)


Paxil 10mg/5 mL suspension QL(900 ML per 30 days)

Pegasys 180mcg/0.5 mL syringe QL(2 ML per 28 days)

Pegasys 180mcg/mL solution QL(4 ML per 28 days)

Pegasys ProClick 135mcg/0.5 mL pen injector QL(2 ML per 28 days)



Pegasys ProClick 180mcg/0.5 mL pen injector QL(2 ML per 28 days)

pioglitazone 15mg tablet QL(30 EA per 30 days)



Potiga 200mg tablet QL(90 EA per 30 days)




Praluent Pen 150mg/mL pen injector QL(2 ML per 28 days)

Praluent Pen 75mg/mL pen injector QL(2 ML per 28 days)

Praluent Syringe 150mg/mL syringe QL(2 ML per 28 days)

Praluent Syringe 75mg/mL syringe QL(2 ML per 28 days)

primaquine 26.3mg tablet QL(30 EA per 30 days)

Procrit 10,000unit/mL solution QL(14 ML per 30 days)






Prolia 60mg/mL syringe QL(1 ML per 180 days)

Promacta 12.5mg tablet QL(60 EA per 30 days)

Promacta 25mg tablet QL(60 EA per 30 days)



quetiapine 100mg tablet QL(90 EA per 30 days)








Relenza Diskhaler 5mg/actuation blister with device QL(60 EA per 180 days)

Relpax 20mg tablet QL(18 EA per 30 days)

Relpax 40mg tablet QL(18 EA per 30 days)

Repatha SureClick 140mg/mL pen injector QL(3 ML per 28 days)

Repatha Syringe 140mg/mL syringe QL(3 ML per 28 days)

Restasis 0.05% dropperette QL(60 EA per 30 days)

risedronate 150mg tablet QL(1 EA per 30 days)




Risperdal Consta 12.5mg/2 mL syringe QL(4 EA per 28 days)

Risperdal Consta 25mg/2 mL syringe QL(4 EA per 28 days)

Risperdal Consta 37.5mg/2 mL syringe QL(4 EA per 28 days)

Risperdal Consta 50mg/2 mL syringe QL(4 EA per 28 days)

risperidone 0.25mg tablet QL(120 EA per 30 days)

risperidone 0.25mg tablet,disintegrating QL(120 EA per 30 days)

risperidone 0.5mg tablet QL(120 EA per 30 days)

risperidone 1mg tablet QL(120 EA per 30 days)




rizatriptan 10mg tablet QL(18 EA per 30 days)

rizatriptan 10mg tablet,disintegrating QL(18 EA per 30 days)

rizatriptan 5mg tablet QL(18 EA per 30 days)



rizatriptan 5mg tablet,disintegrating QL(18 EA per 30 days)

Rozerem 8mg tablet QL(30 EA per 30 days)

Savella 100mg tablet QL(60 EA per 30 days)

Savella 12.5 mg (5)-25mg(8)-50 mg(42) tablets,dose pack QL(55 EA per 30 days)

Savella 12.5mg tablet QL(60 EA per 30 days)



Sensipar 30mg tablet QL(60 EA per 30 days)



sertraline 20mg/mL concentrate QL(300 ML per 30 days)

Spiriva Respimat 1.25mcg/actuation mist QL(4 GM per 30 days)

Spiriva Respimat 2.5mcg/actuation mist QL(4 GM per 30 days)

Sprycel 100mg tablet QL(30 EA per 30 days)






Strattera 100mg capsule QL(30 EA per 30 days)







Suboxone 12-3mg film QL(60 EA per 30 days)



Suboxone 2-0.5mg film QL(90 EA per 30 days)



Sutent 12.5mg capsule QL(30 EA per 30 days)

Sutent 25mg capsule QL(30 EA per 30 days)

Sutent 37.5mg capsule QL(30 EA per 30 days)

Sutent 50mg capsule QL(30 EA per 30 days)

Symbicort 80-4.5mcg/actuation HFA aerosol inhaler QL(10.2 GM per 30 days)

Tanzeum 30mg/0.5 mL pen injector QL(4 EA per 28 days)

Tanzeum 50mg/0.5 mL pen injector QL(4 EA per 28 days)

Tarceva 100mg tablet QL(30 EA per 30 days)



Tasigna 150mg capsule QL(120 EA per 30 days)

Tasigna 200mg capsule QL(120 EA per 30 days)

temazepam 15mg capsule QL(30 EA per 30 days)

temazepam 30mg capsule QL(30 EA per 30 days)

terazosin 10mg capsule QL(60 EA per 30 days)




testosterone 1 %(25 mg/2.5gram) gel in packet QL Removed

testosterone 1 %(50 mg/5 gram) gel in packet QL Removed

testosterone 1.25 gram/actuation (1 %) gel in metered-dose pump

QL Removed

tiagabine 4mg tablet QL Removed

Tradjenta 5mg tablet QL(30 EA per 30 days)

tramadol 50mg tablet QL(240 EA per 30 days)



tramadol-acetaminophen 37.5-325mg tablet QL(240 EA per 30 days)

Transderm-Scop 1.5 mg (1 mgover 3 days) patch 3 day QL(10 EA per 30 days)

Tresiba FlexTouch U-200 200 unit/mL(3 mL) insulin pen QL(36 ML per 30 days)

Tykerb 250mg tablet QL(180 EA per 30 days)

venlafaxine 150mg capsule,extended release 24hr QL(60 EA per 30 days)

Votrient 200mg tablet QL(120 EA per 30 days)

Vytorin 10-10 10-10mg tablet QL(30 EA per 30 days)




Vyvanse 10mg capsule QL(30 EA per 30 days)







Xalkori 200mg capsule QL(60 EA per 30 days)

Xalkori 250mg capsule QL(60 EA per 30 days)

Xarelto 10mg tablet QL Removed

Xifaxan 550mg tablet QL(90 EA per 30 days)

Xtandi 40mg capsule QL(120 EA per 30 days)

Zetia 10mg tablet QL(30 EA per 30 days)

Zolinza 100mg capsule QL(120 EA per 30 days)

zolmitriptan 2.5mg tablet QL(18 EA per 30 days)

zolmitriptan 2.5mg tablet,disintegrating QL(18 EA per 30 days)

zolmitriptan 5mg tablet QL(18 EA per 30 days)



zolmitriptan 5mg tablet,disintegrating QL(18 EA per 30 days)

Zytiga 250mg tablet QL(120 EA per 30 days)

MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES

Medication Name Change Description

aripiprazole 10mg tablet PA Removed






celecoxib 100mg capsule ST Removed




Cycloset 0.8mg tablet PA Added

eszopiclone 1mg tablet PA Removed



Horizant 300mg tablet extended release PA Added

Horizant 600mg tablet extended release PA Added

lidocaine 5% adhesive patch,medicated PA Added

lidocaine 5% ointment PA Added

Lyrica 100mg capsule ST Removed





MEDICATIONS WITH PRIOR AUTHORIZATION (PA) or STEP THERAPY (ST) REQUIREMENT CHANGES

Medication Name Change Description




meropenem 500mg recon soln PA Added

naratriptan 1mg tablet ST Added

naratriptan 2.5mg tablet ST Added

oxandrolone 10mg tablet PA Added

oxandrolone 2.5mg tablet PA Added

Saphris 5mg tablet PA Added

testosterone 50mg/5 gram (1 %) gel PA Added

Xarelto 10mg tablet PA Removed



36194_MPINFO165FH (11/2016)

Nondiscrimination Notice

Florida Hospital Care Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage:

Provides free aids and services to people with disabilities to communicate effectively with us,

such as:

Qualified sign language interpreters

Written information in other formats (large print, accessible electronic formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, please contact Sherri Wynn. If you believe that Florida Hospital Care Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Sherri Wynn, ADA/Section 504 Coordinator, 6450 US Highway 1, Rockledge, FL 32955, 321-434-4521, 1-800-955-8771 (TTY), Fax: 321-434-4362, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance Sherri Wynn, ADA/Section 504 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. 36194_MPINFO110FH (10/2016_r1)

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

English:

This Notice has Important Information. This notice has important information about your application or

coverage through Florida Hospital Care Advantage. Look for key dates in this notice. You may need to take

action by certain deadlines to keep your health coverage or help with costs. You have the right to get this

information and help in your language at no cost. Call 844-522-5279.

Spanish:

Este Aviso contiene información importante. Este aviso contiene información importante acerca de la solicitud

o cobertura que usted tiene con Florida Hospital Care Advantage. Preste atención a las fechas clave que

contiene este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su

cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma

sin costo alguno. Llame al 844-522-5279.

Haitian Creole:

Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a gen enfòmasyon enpòtan konsènan aplikasyon w lan

oswa konsènan kouvèti asirans lan atravè Florida Hospital Care Advantage. Chèche dat ki enpòtan nan avi sila

a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka

ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen

pou peye pou sa. Rele nan 844-522-5279.

Vietnamese:

Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn đăng ký hoặc hợp

đồng bảo hiểm qua chương trình Florida Hospital Care Advantage của Quý vị. Xin xem các ngày quan trọng

trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức

khỏe hoặc được trợ trúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn

ngữ của mình miễn phí. Xin gọi số 844-522-5279.

Portuguese:

Este aviso contém informações importantes. Este aviso contém informações importantes a respeito da sua

solicitação ou cobertura por meio dos Florida Hospital Care Advantage. Consulte datas importantes neste aviso.

Talvez seja necessário que você tome providências dentro de determinados prazos para manter a sua cobertura

de plano de saúde ou ajuda com custos. Você tem o direito de obter estas informações e ajuda no seu idioma e

sem custos. Ligue para 844-522-5279.

Chinese:

本通知包含重要的資訊。本通知包含關於您透過 Florida Hospital Care Advantage

提交的申請或保險的重要資訊。請留意本通知內的重要日期。您可能需要在截止日期之前採取行動，以

保留您的健康保險或費用補貼。您有權以您的母語免費取得本資訊及幫助。請撥電話 844-522-5279。

French:

Cet avis a d'importantes informations. Cet avis a d'importantes informations sur votre demande ou la couverture

par l'intermédiaire Florida Hospital Care Advantage. Rechercher les dates clés dans le présent avis. Vous devrez

peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les

coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez 844-

522-5279.

Tagalog:

Ang Paunawa na ito ay naglalaman ng Mahalagang Impormasyon. Ang paunawa na ito ay naglalaman ng

mahalagang impormasyon tungkol sa iyong aplikasyon o pagkakasaklaw sa Florida Hospital Care Advantage.

Tingnan ang mga mahalagang petsa dito sa paunawa. Maaring mangailangan kang magsagawa ng hakbang sa

ilang mga itinakdang panahon upang mapanatili ang iyong pagkakasaklaw sa kalusugan o makatulong sa mga

gastusin. May karapatan kang makuha ang impormasyon at tulong na ito sa iyong wika nang libre. Tumawag sa

844-522-5279.

Russian:

Настоящее уведомление содержит важную информацию. Это уведомление содержит важную

информацию о вашем заявлении или страховом покрытии через Florida Hospital Care Advantage.

Посмотрите на ключевые даты в настоящем уведомлении. Вам, возможно, потребуется принять меры к

определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы

имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по

телефону 844-522-5279.

Arabic:

Florida Hospital Careيحوي هذا اإلشعار معلومات هامة. يحوي هذا االشعار معلومات مهمة بخصوص طلبك للحصول على التغطية من خالل Advantageلتغطية الصحية . ابحث عن التواريخ الهامة في هذا االشعار. قد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة في دفع ا

.5279-522-844أو للمساعدة في دفع التكاليف. لك الحق في الحصول على معلومات والمساعدة بلغتك من دون أي تكلفة. اتصل بالرقم

Italian:

Questo avviso contiene informazioni importanti. Questo avviso contiene informazioni importanti sulla sua

domanda o copertura attraverso Florida Hospital Care Advantage. Cerchi le date chiave in questo avviso.

Potrebbe essere necessario un suo intervento entro una scadenza determinata per consentirle di mantenere la sua

copertura o sovvenzione. Ha il diritto di ottenere queste informazioni e assistenza nella sua lingua

gratuitamente. Chiami il numero 844-522-5279.

German:

Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält wichtige

Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Florida Hospital Care

Advantage. Suchen Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten

Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Anspruch auf Hilfe mit den Kosten zu

behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an

unter 844-522-5279.

Korean:

본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고 Florida

Hospital Care Advantage를 통한 보장에 관한 정보를 포함하고 있습니다. 본 통지서에서 핵심이

되는 날짜들을 확인하십시오. 귀하는 건강 보장을 계속 유지하거나 비용을 절감하기 위해서 일정한

마감일까지 조치를 취해야 할 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용

부담없이 얻을 수 있는 권리가 있습니다. 844-522-5279로 전화하십시오.

Polish:

Niniejsze ogłoszenie zawiera ważne informacje. Niniejsze ogłoszenie zawiera ważne informacje dotyczące

Państwa wniosku lub zakresu świadczeń realizowanych poprzez Florida Hospital Care Advantage. Może

zaistnieć potrzeba podjęcia przez Państwa pewnych działań w określonym terminie w celu zachowania

ubezpieczenia zdrowotnego lub otrzymania pomocy związanej z kosztami. Macie Państwo prawo do

bezpłatnego uzyskania informacji i pomocy w języku ojczystym. Prosimy zadzwonić pod numer 844-522-5279.

Gujarati:

આ સચૂનામાાં અગત્યની માહિતી છે. આ સચૂનામાાં દ્વારા તમારી અરજી અથવા કવરેજ વવશેની અગત્યની માહિતી છે. આ સચૂનામાાંની ખાસ તારીખો જુઓ. તમારા આરોગ્ય કવરેજને જાળવી રાખવા અથવા ખચચ અંગે મદદ મેળવવા માટે

ચોક્કસ સમયમયાચદા સધુીમાાં તમારે કાયચવાિી કરવાની જરૂર પડી શકે છે. તમને આ માહિતી અને મદદ તમારી ભાષામાાં વવના મલૂ્યે

મેળવવાનો અવધકાર છે. 844-522-5279 પર કૉલ કરો.

Thai:

ประกาศนีม้ีข้อมลูส าคญั ประกาศนีม้ีข้อมลูที่ส าคญัเก่ียวกบัการสมคัรหรือขอบเขตการประกนัสขุภาพของคณุผา่น Florida Hospital Care

Advantage โปรดดกู าหนดการส าคญัในประกาศนี ้คณุอาจจะต้องด าเนินการภายในเวลาที่ก าหนดเพื่อจะรักษาการประกนัสขุภาพของคณุหรือการชว่ยเหลอืที่มคีา่ใช้จ่าย คณุมีสทิธิที่จะได้รับข้อมลูและความชว่ยเหลอืนีใ้นภาษาของคณุโดยไมม่ีคา่ใช้จา่ย โทร 844-522-5279.

Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage.

Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability,

age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including

enrollment and benefit determinations.

36194_MPINFO112FH (10/2016)

2017 Formulary Annual Notice of Change - … Formulary Annual Notice of Change ... determination and...

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