Drug Formulary - Keystone First · For the most up to date formulary coverage search, please use...

Drug FormularyFebruary 2018Drug Formulary

For the most up to date formulary coverage search, please use the searchable formulary website

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lowercase italics= Generic drugs

UPPERCASE= Brand name

drugs

Tier T1= Formulary

T2= Non-Preferred Brand,

Generic Available

T3= Non-Formulary

T4= Specialty

Notes AL= Age limit applies

PA= PA Applies

QL= Quantity Limit

ST= ST applies

Drug Tier Notes

Antihistamine Drugs

Ethanolamine Derivatives

CHILDREN'S BENADRYL ALLERGY T1

dimenhydrinate T1

DIPHENHIST T1

diphenhydramine hcl injection T1 QL (20 ML per 25 days)

diphenhydramine hcl oral T1

SLEEP AID (DOXYLAMINE) T1

First Gen. Antihist. Derivatives, Misc.

cyproheptadine T1

First Generation Antihistamines

ALLER-CHLOR T1


chlorpheniramine maleate T1

cyproheptadine T1

dimenhydrinate T1

DIPHENHIST T1




Phenothiazine Derivatives

PHENERGAN T2

promethazine T1

PROMETHAZINE VC T1

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Drug Tier Notes

PROMETHAZINE VC-CODEINE T1 QL (120 ML per 30 days); AL

Piperazine Derivatives

ANTIVERT T2

hydroxyzine hcl T1

hydroxyzine pamoate T1

meclizine T1

VISTARIL T2

Propylamine Derivatives

ALLER-CHLOR T1


M-END DMX T1

SUDOGEST COLD AND ALLERGY T1

ZODRYL AC 25 T1

ZODRYL AC 30 T1

ZODRYL AC 35 T1

ZODRYL AC 40 T1

ZODRYL AC 50 T1

ZODRYL AC 60 T1

ZODRYL AC 80 T1

Second Generation Antihistamines

ALAVERT T2

ALLEGRA-D 12 HOUR T3 PA


ALLERGY RELIEF (CETIRIZINE) T1 ST

cetirizine oral solution T1

cetirizine oral tablet T1

cetirizine oral tablet,chewable T3 PA

cetirizine-pseudoephedrine T1 ST

CHILDREN'S ZYRTEC ALLERGY T1 ST

CLARINEX T3 PA

CLARITIN T2

CLARITIN REDITABS T3 PA


3

Drug Tier Notes

desloratadine T3 PA

fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)

fexofenadine oral tablet 180 mg T1 ST

fexofenadine oral tablet 60 mg T3 PA

levocetirizine oral solution T3 PA

levocetirizine oral tablet T1

loratadine oral capsule T1 ST

loratadine oral solution T1 ST

loratadine oral tablet T1

loratadine oral tablet,disintegrating T1 ST

LORATADINE-D T3 PA

SEMPREX-D T3 PA

ZYRTEC T2

Anti-Infective Agents

1St Generation Cephalosporin Antibiotics

cefadroxil T1

cephalexin T1

KEFLEX T2

2Nd Generation Cephalosporin Antibiotics

cefaclor T1

cefprozil T1

CEFTIN ORAL SUSPENSION FOR

RECONSTITUTION

T1 QL (100 QY per 1 day)

CEFTIN ORAL TABLET T2

cefuroxime axetil oral suspension for

reconstitution

T1 QL (100 QY per 1 day)

cefuroxime axetil oral tablet 250 mg T1 QL (2 EA per 1 day)

cefuroxime axetil oral tablet 500 mg T1

3Rd Generation Cephalosporin Antibiotics

cefdinir T1

cefpodoxime T1

ceftriaxone T1


4

Drug Tier Notes

ZERBAXA T4 PA

5Th Generation Cephalosporin Antibiotics

TEFLARO T4 PA

Adamantane Antivirals

amantadine hcl T1

Allylamine Antifungals

LAMISIL T2 QL (90 DS per 365 DYs)

terbinafine hcl T1 QL (90 DS per 365 DYs)

Amebicides

FLAGYL T2

metronidazole T1

paromomycin T1 PA; QL (10 DS per 30 DYs)

YODOXIN T1

Aminoglycoside Antibiotics

ARIKAYCE T4 PA

BETHKIS T4 PA

paromomycin T1 PA; QL (10 DS per 30 DYs)

TOBI T4 PA

TOBI PODHALER T4 PA

tobramycin with nebulizer T4 PA

ZEMDRI T4 PA

Aminomethylcyclines

NUZYRA T4 PA

NUZYRA (7 DAY WITH LOAD DOSE) T4 PA

NUZYRA (7 DAY) T4 PA

Aminopenicillin Antibiotics

amoxicillin T1

amoxicillin-pot clavulanate T1

ampicillin T1

AUGMENTIN T2

Anthelmintics

albendazole T1


5

Drug Tier Notes

EMVERM T1

ivermectin T1

praziquantel T1

STROMECTOL T2

Antifungals, Miscellaneous

griseofulvin microsize T1

griseofulvin ultramicrosize T1

GRIS-PEG (ULTRAMICROSIZE) T2

SSKI T1

Antimalarials

ARALEN T2

chloroquine phosphate T1

DARAPRIM T4 PA

hydroxychloroquine T1

mefloquine T1

PLAQUENIL T2

primaquine T1

quinidine sulfate T1

Antimycobacterials, Miscellaneous

dapsone T1

Antiprotozoals, Miscellaneous

atovaquone T1 PA

dapsone T1

FLAGYL T2

MEPRON T2 PA

metronidazole T1

NEBUPENT T4 PA

Antituberculosis Agents

AVELOX T2 QL (10 QY per 30 DYs)

AVELOX ABC PACK T2 QL (1 FL per 30 DYs)

BIAXIN T2 QL (1 FL per 30 DYs)


6

Drug Tier Notes

BIAXIN XL T2 QL (1 FL per 30 DYs)

CIPRO ORAL SUSPENSION,MICROCAPSULE

RECON

T2

CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)

ciprofloxacin T1

ciprofloxacin hcl oral tablet 100 mg T1 QL (28 EA per 30 DYs)


ciprofloxacin hcl oral tablet 500 mg T1 QL (68 QY per 34 DYs)


clarithromycin T1 QL (1 FL per 30 DYs)

ethambutol T1

isoniazid T1

LEVAQUIN ORAL SOLUTION T2 QL (1 FL per 30 DYs)

LEVAQUIN ORAL TABLET T2 QL (14 QY per 30 DYs)

levofloxacin oral solution T1 QL (1 FL per 30 DYs)

levofloxacin oral tablet T1 QL (14 QY per 30 DYs)

moxifloxacin T1 QL (10 QY per 30 DYs)

pyrazinamide T1

rifabutin T1

RIFADIN INTRAVENOUS T4 PA

RIFADIN ORAL T2

rifampin T1

Antivirals, Miscellaneous

PREVYMIS T4 PA

Azole Antifungals

CRESEMBA T4 PA

DIFLUCAN ORAL SUSPENSION FOR

RECONSTITUTION

T2

DIFLUCAN ORAL TABLET 100 MG, 200 MG,

50 MG

T2

DIFLUCAN ORAL TABLET 150 MG T2 QL (2 QY per 30 DYs)

fluconazole oral suspension for reconstitution T1

fluconazole oral tablet 100 mg, 200 mg, 50 mg T1


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Drug Tier Notes

fluconazole oral tablet 150 mg T1 QL (2 QY per 30 DYs)

ketoconazole T1

TOLSURA T4 PA

Carbapenem Antibiotics

INVANZ T4 PA

Chloramphenicol Antibiotics

chloramphenicol sod succinate T1

Cyclic Lipopeptide Antibiotics

CUBICIN T4 PA

daptomycin T4 PA

Erythromycin Antibiotics

ERYPED 400 T1

ERY-TAB T1

ERYTHROCIN (AS STEARATE) T1

erythromycin T1

erythromycin ethylsuccinate T1

erythromycin-sulfisoxazole T1

Glycopeptide Antibiotics

DALVANCE T4 PA

FIRVANQ T1

vancomycin T1

Glycylcycline Antibiotics

TYGACIL T4 PA

Hcv Polymerase Inhibitor Antivirals

EPCLUSA T4 PA

HARVONI T4 PA

ledipasvir-sofosbuvir T4 PA

sofosbuvir-velpatasvir T4 PA

SOVALDI T4 PA

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA


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Drug Tier Notes

VOSEVI T4 PA

Hcv Protease Inhibitor Antivirals

MAVYRET T4 PA

OLYSIO T4 PA

TECHNIVIE T4 PA

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA

ZEPATIER T4 PA

Hcv Replication Complex Inhibitors

DAKLINZA T4 PA

EPCLUSA T4 PA

HARVONI T4 PA

ledipasvir-sofosbuvir T4 PA

MAVYRET T4 PA

sofosbuvir-velpatasvir T4 PA

TECHNIVIE T4 PA

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA

VOSEVI T4 PA

ZEPATIER T4 PA

Hiv Entry And Fusion Inhibitors

FUZEON T4 PA

SELZENTRY ORAL TABLET 150 MG T1 QL (2 EA per 1 day)

SELZENTRY ORAL TABLET 25 MG, 300 MG,

75 MG

T1

Hiv Integrase Inhibitor Antiretrovirals

BIKTARVY T1

GENVOYA T1

ISENTRESS T1

ISENTRESS HD T1

JULUCA T1

STRIBILD T1


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Drug Tier Notes

TIVICAY T1

TRIUMEQ T1

Hiv Nonnucleoside Rev.Transcrip. Inhib.

EDURANT T1

efavirenz oral capsule 200 mg T1

efavirenz oral capsule 50 mg T1 QL (3 EA per 1 day)

efavirenz oral tablet T1

INTELENCE ORAL TABLET 100 MG T1 QL (2 EA per 1 day)

INTELENCE ORAL TABLET 200 MG, 25 MG T1

JULUCA T1

nevirapine oral suspension T1

nevirapine oral tablet T1

nevirapine oral tablet extended release 24 hr 100

mg

T1 QL (4 EA per 1 day)

nevirapine oral tablet extended release 24 hr 400

mg

T1

ODEFSEY T1

RESCRIPTOR T1

SYMFI T1

SYMFI LO T1

Hiv Nucleoside, Nucleotide Rt Inhibitors

abacavir T1

abacavir-lamivudine T1

abacavir-lamivudine-zidovudine T1

BIKTARVY T1

CIMDUO T1

COMBIVIR T2

DESCOVY T1

didanosine T1

EMTRIVA T1

EPIVIR T2

EPIVIR HBV ORAL SOLUTION T1


10

Drug Tier Notes

EPIVIR HBV ORAL TABLET T2

EPZICOM T2

GENVOYA T1

lamivudine T1

lamivudine-zidovudine T1

ODEFSEY T1

RETROVIR T2

stavudine oral capsule 15 mg, 20 mg T1 QL (2 EA per 1 day)

stavudine oral capsule 30 mg, 40 mg T1

STRIBILD T1

SYMFI T1

SYMFI LO T1

tenofovir disoproxil fumarate T1

TRIZIVIR T2

TRUVADA T1

VIDEX 2 GRAM PEDIATRIC T1

VIDEX EC T2

ZERIT T2

zidovudine T1

Hiv Protease Inhibitor Antiretrovirals

APTIVUS T1

atazanavir T1

CRIXIVAN T1

fosamprenavir T1

INVIRASE T1

KALETRA ORAL SOLUTION T2

KALETRA ORAL TABLET T1

LEXIVA T1

lopinavir-ritonavir T1

NORVIR T1

PREZCOBIX T1

PREZISTA ORAL SUSPENSION T1


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Drug Tier Notes

PREZISTA ORAL TABLET 150 MG T1 QL (6 EA per 1 day)

PREZISTA ORAL TABLET 600 MG, 800 MG T1

PREZISTA ORAL TABLET 75 MG T1 QL (4 EA per 1 day)

REYATAZ T1

ritonavir T1

TECHNIVIE T4 PA

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA

VIRACEPT T1

Interferon Antivirals

ALFERON N T4 PA

INTRON A T4 PA

PEGASYS T4 PA

PEGASYS PROCLICK T4 PA

PEGINTRON T4 PA

PEGINTRON REDIPEN T4 PA

SYLATRON T4 PA

Lincomycin Antibiotics

CLEOCIN HCL T2

CLEOCIN PEDIATRIC T2

clindamycin hcl T1

clindamycin palmitate hcl T1

Macrolide Antibiotics

ERYPED 400 T1

ERY-TAB T1

ERYTHROCIN (AS STEARATE) T1

erythromycin T1

erythromycin ethylsuccinate T1

Monobactam Antibiotics

CAYSTON T4 PA

Monoclonal Antibody Antivirals


12

Drug Tier Notes

SYNAGIS T4 PA

Natural Penicillin Antibiotics

penicillin v potassium T1

Neuraminidase Inhibitor Antivirals

oseltamivir oral capsule T1 QL (1 Fill per 180 days)

oseltamivir oral suspension for reconstitution T1 QL (180 ML per 6 Months)

RELENZA DISKHALER T1 QL (1 FL per 180 DYs)

Nucleoside And Nucleotide Antivirals

acyclovir T1

adefovir T4 PA

BARACLUDE T4 PA

cidofovir T4 PA

COPEGUS T4 PA

CYTOVENE T4 PA

entecavir T1

HEPSERA T3 PA

MODERIBA DOSE PACK T4 PA

PREVYMIS T4 PA

REBETOL T4 PA

RIBASPHERE T4 PA

RIBASPHERE RIBAPAK T4 PA

valacyclovir oral tablet 1 gram T1

valacyclovir oral tablet 500 mg T1 QL (3 EA per 1 day)

VALCYTE T4 PA

valganciclovir T4 PA

VALTREX T2

VIRAZOLE T4 PA

ZOVIRAX T2

Other Macrolide Antibiotics

azithromycin oral packet T1 QL (1 FL per 30 DYs)

azithromycin oral suspension for reconstitution T1 QL (1 FL per 30 DYs)

azithromycin oral tablet 250 mg T1 QL (6 QY per 30 DYs)


13

Drug Tier Notes

azithromycin oral tablet 500 mg T1 QL (1 FL per 30 DYs)

azithromycin oral tablet 600 mg T1 QL (8 QY per 24 DYs)

BIAXIN T2 QL (1 FL per 30 DYs)

BIAXIN XL T2 QL (1 FL per 30 DYs)

clarithromycin T1 QL (1 FL per 30 DYs)

DIFICID T1 PA

ZITHROMAX T2 QL (1 FL per 30 DYs)

ZITHROMAX TRI-PAK T2 QL (1 FL per 30 DYs)

ZMAX T1 QL (1 QY per 30 DYs)

Oxazolidinone Antibiotics

linezolid T3 PA

SIVEXTRO T4 PA

ZYVOX T3 PA

Penicillinase-Resistant Penicillins

dicloxacillin T1

Polyene Antifungals

nystatin T1

Polymyxin Antibiotics

colistin (colistimethate na) T4 PA

Pyrimidine Antifungals

flucytosine T4 PA

Quinolone Antibiotics

AVELOX T2 QL (10 QY per 30 DYs)

CIPRO ORAL SUSPENSION,MICROCAPSULE

RECON

T2

CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)

ciprofloxacin T1





LEVAQUIN T2 QL (14 QY per 30 DYs)


14

Drug Tier Notes

levofloxacin oral solution T1 QL (1 FL per 30 DYs)

levofloxacin oral tablet T1 QL (14 QY per 30 DYs)

moxifloxacin T1 QL (10 QY per 30 DYs)

Rifamycin Antibiotics

rifabutin T1

RIFADIN INTRAVENOUS T4 PA

RIFADIN ORAL T2

rifampin T1

Sulfonamide Antibiotics (Systemic)

AZULFIDINE T2

AZULFIDINE EN-TABS T2

BACTRIM T2

BACTRIM DS T2

erythromycin-sulfisoxazole T1

sulfadiazine T1

sulfamethoxazole-trimethoprim T1

sulfasalazine T1

Tetracycline Antibiotics

doxycycline monohydrate T1

minocycline T1

tetracycline T1

Urinary Anti-Infectives

MACROBID T2

MACRODANTIN T2

nitrofurantoin T1

nitrofurantoin macrocrystal T1

nitrofurantoin monohyd/m-cryst T1

trimethoprim T1

Antineoplastic Agents

Antineoplastic Agents

ABRAXANE T4 PA

ADCETRIS T4 PA


15

Drug Tier Notes

ADRUCIL T4 PA

AFINITOR T4 PA

AFINITOR DISPERZ T4 PA

ALECENSA T4 PA

ALFERON N T4 PA

ALIMTA T4 PA

ALIQOPA T4 PA

ALKERAN T4 PA

ALKERAN (AS HCL) T4 PA

ALUNBRIG T4 PA

anastrozole T1

ARIMIDEX T2

AROMASIN T4 PA

arsenic trioxide T4 PA

ARZERRA T4 PA

AVASTIN T4 PA

azacitidine T4 PA

AZEDRA DOSIMETRIC T4 PA

AZEDRA THERAPEUTIC T4 PA

BAVENCIO T4 PA

BELEODAQ T4 PA

BENDEKA T4 PA

BESPONSA T4 PA

bicalutamide T1

BICNU T4 PA

bleomycin T4 PA

BLINCYTO T4 PA

bortezomib T4 PA

BOSULIF T4 PA

BRAFTOVI T4 PA

BUSULFEX T4 PA

CABOMETYX T4 PA


16

Drug Tier Notes

CALQUENCE T4 PA

CAMPTOSAR T4 PA

CAPRELSA T4 PA

carboplatin T4 PA

CASODEX T2

CEENU T1

cisplatin T4 PA

COMETRIQ T4 PA

COPIKTRA T4 PA

COSMEGEN T4 PA

COTELLIC T4 PA

cyclophosphamide intravenous T4 PA

cyclophosphamide oral T1

CYRAMZA T4 PA

cytarabine T4 PA

cytarabine (pf) T4 PA

dacarbazine T4 PA

DARZALEX T4 PA

daunorubicin T4 PA

DAURISMO T4 PA

decitabine T4 PA

DOCEFREZ T4 PA

docetaxel T4 PA

doxorubicin T4 PA

doxorubicin, peg-liposomal T4 PA

DROXIA T1

ELIGARD T4 PA

ELIGARD (3 MONTH) T4 PA



ELLENCE T4 PA

ELOXATIN T4 PA

ELZONRIS T4 PA


17

Drug Tier Notes

EMCYT T1

EMPLICITI T4 PA

epirubicin T4 PA

ERBITUX T4 PA

ERIVEDGE T4 PA

ERLEADA T4 PA

ERWINAZE T4 PA

ETOPOPHOS T4 PA

etoposide T4 PA

EVOMELA T4 PA

FARESTON T1 ST

FARYDAK T4 PA

FASLODEX T4 PA

FEMARA T2 QL (1 QY per 1 DY)

FIRMAGON T4 PA

floxuridine T4 PA

fludarabine T4 PA

fluorouracil T4 PA

flutamide T1

FOLOTYN T4 PA

GAZYVA T4 PA

gemcitabine T4 PA

GEMZAR T4 PA

GILOTRIF T4 PA

GLEEVEC T4 PA

GLEOSTINE T4 PA

HALAVEN T4 PA

HERCEPTIN T4 PA

HEXALEN T4 PA

HYCAMTIN T4 PA

HYDREA T2

hydroxyurea T1


18

Drug Tier Notes

IBRANCE T4 PA

ICLUSIG T4 PA

IDAMYCIN PFS T4 PA

IDHIFA T4 PA

IFEX T4 PA

ifosfamide T4 PA

ifosfamide-mesna T4 PA

imatinib T4 PA

IMBRUVICA T4 PA

IMFINZI T4 PA

IMLYGIC T4 PA

INFUGEM T4 PA

INLYTA T4 PA

INTRON A T4 PA

IRESSA T4 PA

irinotecan T4 PA

ISTODAX T4 PA

IXEMPRA T4 PA

JAKAFI T4 PA

JEVTANA T4 PA

KADCYLA T4 PA

KEYTRUDA T4 PA

KISQALI T4 PA

KISQALI FEMARA CO-PACK T4 PA

KYMRIAH T4 PA

KYPROLIS T4 PA

LARTRUVO T4 PA

LENVIMA T4 PA

letrozole T1 QL (1 QY per 1 DY)

LEUKERAN T4 PA

leuprolide T4 PA

LIBTAYO T4 PA

lomustine T4 PA


19

Drug Tier Notes

LONSURF T4 PA

LORBRENA T4 PA

LUMOXITI T4 PA

LUPANETA PACK (1 MONTH) T4 PA


LUPRON DEPOT T4 PA

LUPRON DEPOT (3 MONTH) T4 PA



LUPRON DEPOT-PED T4 PA

LUPRON DEPOT-PED (3 MONTH) T4 PA

LYNPARZA T4 PA

LYSODREN T4 PA

MARQIBO T4 PA

MATULANE T4 PA

MEGACE T2

MEGACE ES T2 QL (150 QY per 30 DYs)

megestrol oral suspension 400 mg/10 ml (40

mg/ml)

T1

megestrol oral suspension 625 mg/5 ml T1 QL (150 ML per 30 DYs)

megestrol oral tablet T1

MEKINIST T4 PA

MEKTOVI T4 PA

mercaptopurine T1

methotrexate sodium (pf) T4 PA

methotrexate sodium injection T4 PA

methotrexate sodium oral T1

mitomycin T4 PA

mitoxantrone T4 PA

MUSTARGEN T4 PA

MYLERAN T1

MYLOTARG T4 PA


20

Drug Tier Notes

NERLYNX T4 PA

NEXAVAR T4 PA

nilutamide T4 PA

NINLARO T4 PA

NIPENT T4 PA

ODOMZO T4 PA

ONCASPAR T4 PA

ONIVYDE T4 PA

OPDIVO T4 PA

OTREXUP (PF) T4 PA

oxaliplatin T4 PA

paclitaxel T4 PA

PERJETA T4 PA

PHOTOFRIN T4 PA

POMALYST T4 PA

PORTRAZZA T4 PA

POTELIGEO T4 PA

PROLEUKIN T4 PA

REVLIMID T4 PA

RITUXAN T4 PA

RITUXAN HYCELA T4 PA

RUBRACA T4 PA

RYDAPT T4 PA

SPRYCEL T4 PA

STIVARGA T4 PA

SUPPRELIN LA T4 PA

SUTENT T4 PA

SYLATRON T4 PA

SYLVANT T4 PA

SYNRIBO T4 PA

TABLOID T4 PA

TAFINLAR T4 PA

TAGRISSO T4 PA


21

Drug Tier Notes

TALZENNA T4 PA

tamoxifen T1

TARCEVA T4 PA

TARGRETIN T4 PA

TASIGNA T4 PA

TAXOTERE T4 PA

TECENTRIQ T4 PA

TEMODAR T4 PA

teniposide T4 PA

TEPADINA T4 PA

THERACYS T4 PA

thiotepa T4 PA

TIBSOVO T4 PA

TICE BCG T4 PA

TOPOSAR T4 PA

topotecan T4 PA

TREANDA T4 PA

TRELSTAR T4 PA

TRELSTAR DEPOT T4 PA

TRELSTAR LA T4 PA

tretinoin (chemotherapy) T4 PA

TREXALL ORAL TABLET 10 MG, 5 MG T4 PA

TREXALL ORAL TABLET 7.5 MG T1

TRIPTODUR T4 PA

TRISENOX T4 PA

TYKERB T4 PA

UNITUXIN T4 PA

VALSTAR T4 PA

VANTAS T4 PA

VECTIBIX T4 PA

VELCADE T4 PA

VENCLEXTA T4 PA


22

Drug Tier Notes

VENCLEXTA STARTING PACK T4 PA

VERZENIO T4 PA

vinblastine T4 PA

VINCASAR PFS T4 PA

vinorelbine T4 PA

VITRAKVI T4 PA

VIZIMPRO T4 PA

VOTRIENT T4 PA

VYXEOS T4 PA

XALKORI T4 PA

XELODA T4 PA

XOSPATA T4 PA

XTANDI T4 PA

YERVOY T4 PA

YESCARTA T4 PA

YONDELIS T4 PA

YONSA T4 PA

ZALTRAP T4 PA

ZEJULA T4 PA

ZELBORAF T4 PA

ZEVALIN (Y-90) T4 PA

ZOLADEX T4 PA

ZOLINZA T4 PA

ZYDELIG T4 PA

ZYKADIA T4 PA

ZYTIGA T4 PA

Antitoxins,Immune Glob,Toxoids,Vaccines

Allergenic Extracts (Therapeutic)

ORALAIR T4 PA

Antitoxins And Immune Globulins

BABYBIG T4 PA

BIVIGAM T4 PA


23

Drug Tier Notes

CARIMUNE NF NANOFILTERED T4 PA

CUVITRU T4 PA

CYTOGAM T4 PA

FLEBOGAMMA DIF T4 PA

GAMASTAN S/D T4 PA

GAMMAGARD LIQUID T4 PA

GAMMAGARD S/D T4 PA

GAMMAPLEX T4 PA

GAMMAPLEX (WITH SORBITOL) T4 PA

GAMUNEX-C T4 PA

HEPAGAM B T4 PA

HIZENTRA T4 PA

HYPERHEP B S/D T4 PA

HYPERHEP B S-D NEONATAL T4 PA

HYPERRAB S/D (PF) T4 PA

HYPERRHO S/D T4 PA

HYPERTET S/D (PF) T4 PA

HYQVIA T4 PA

MICRHOGAM ULTRA-FILTERED PLUS T4 PA

NABI-HB T4 PA

OCTAGAM T4 PA

PANZYGA T4 PA

PRIVIGEN T4 PA

RHOGAM ULTRA-FILTERED PLUS T4 PA

RHOPHYLAC T4 PA

VARIZIG T4 PA

WINRHO SDF T4 PA

Toxoids

ADACEL(TDAP ADOLESN/ADULT)(PF) T1 AL

BOOSTRIX TDAP T1 AL

Vaccines

AFLURIA 2018-2019 T1 QL (0.5 ML per 180 days); AL


24

Drug Tier Notes

AFLURIA 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL

AFLURIA QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL

ENGERIX-B (PF) T1

ENGERIX-B PEDIATRIC (PF) T1

FLUAD 2018-2019 (65 YR UP)(PF) T1 QL (0.5 ML per 180 days); AL

FLUARIX QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL

FLUBLOK QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL

FLUCELVAX QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL

FLUCELVAX QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL

FLULAVAL QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL

FLULAVAL QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL

FLUMIST QUAD 2018-2019 T1 QL (0.2 EA per 180 days); AL

FLUZONE HIGH-DOSE 2018-19 (PF) T1 QL (0.5 ML per 180 days); AL

FLUZONE QUAD 2018-2019 T1 QL (0.5 ML per 180 days); AL

FLUZONE QUAD 2018-2019 (PF) T1 QL (0.5 ML per 180 days); AL

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML

T1 AL

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 720 ELISA UNIT/0.5 ML

T1

HAVRIX (PF) INTRAMUSCULAR SYRINGE

1,440 ELISA UNIT/ML

T1 AL

HAVRIX (PF) INTRAMUSCULAR SYRINGE

720 ELISA UNIT/0.5 ML

T1

PNEUMOVAX 23 INJECTION SOLUTION T1 AL

PNEUMOVAX 23 INJECTION SYRINGE T1

PREVNAR 13 (PF) T1 AL

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION 10 MCG/ML, 40 MCG/ML

T1 AL


SUSPENSION 5 MCG/0.5 ML

T1


SYRINGE 10 MCG/ML

T1 AL


SYRINGE 5 MCG/0.5 ML

T1


25

Drug Tier Notes

SHINGRIX (PF) T1 QL (2 Doses Max Qty Per Fill Retail);

AL

THERACYS T4 PA

TICE BCG T4 PA

TWINRIX (PF) INTRAMUSCULAR

SUSPENSION

T1 AL

TWINRIX (PF) INTRAMUSCULAR SYRINGE T1

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 25 UNIT/0.5 ML

T1

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 50 UNIT/ML

T1 AL

VAQTA (PF) INTRAMUSCULAR SYRINGE 25

UNIT/0.5 ML

T1

VAQTA (PF) INTRAMUSCULAR SYRINGE 50

UNIT/ML

T1 AL

ZOSTAVAX (PF) T1 QL (1 QY per 365 DYs)

Autonomic Drugs

Alpha- And Beta-Adrenergic Agonists



BROMFED DM T1

BROTAPP DM T1


CHERATUSSIN DAC T1

CONGEST-EZE T1

epinephrine T1 QL (2 EA per 30 DYs)

LORATADINE-D T3 PA

M-END DMX T1

MUCINEX D MAXIMUM STRENGTH T1

pseudoephedrine hcl T1

pseudoephedrine-guaifenesin T1

SEMPREX-D T3 PA



26

Drug Tier Notes

Alpha-Adrenergic Agonists

CATAPRES T2

CATAPRES-TTS-1 T2

CATAPRES-TTS-2 T2

CATAPRES-TTS-3 T2

CHILDREN'S STUFFY NOSE-COLD T1

clonidine T1

clonidine hcl T1

CLORPRES T1

ED BRON GP T1

methyldopa T1

methyldopa-hydrochlorothiazide T1

MUCUS RELIEF CONGESTION-COUGH T1

phenylephrine-chlophedianol-gg T1

PROMETHAZINE VC T1


ROBAFEN CF (PHENYLEPHRINE) T1

Antimuscarinics/Antispasmodics

ANORO ELLIPTA T1

ATROVENT HFA T1

BENTYL T2

COMBIVENT RESPIMAT T1

dicyclomine T1

diphenoxylate-atropine T1

glycopyrrolate T1

hydrocodone-homatropine T1

hyoscyamine sulfate T1

ipratropium bromide T1

LEVBID T2

LOMOTIL T2

propantheline T1

ROBINUL T2


27

Drug Tier Notes

ROBINUL FORTE T2

SPIRIVA RESPIMAT T1 AL

STIOLTO RESPIMAT T1

TUSSIGON T1

Antiparkinsonian Agents

benztropine T1

trihexyphenidyl T1

Autonomic Drugs, Miscellaneous

CHANTIX T1 QL (360 QY per 365 DYs); AL

CHANTIX CONTINUING MONTH BOX T1 QL (360 EA per 365 DYs)

CHANTIX CONTINUING MONTH PAK T1 QL (360 EA per 365 DYs)

CHANTIX STARTING MONTH BOX T1 QL (360 QY per 365 DYs); AL

NICODERM CQ T2

NICORETTE T2

nicotine T1

nicotine (polacrilex) buccal gum T1

nicotine (polacrilex) buccal lozenge T1 QL (20 EA per 1 day)

nicotine (polacrilex) buccal mini lozenge T1 QL (20 EA per 1 day)

Centrally Acting Skeletal Muscle Relaxnt

carisoprodol T1

chlorzoxazone T1

cyclobenzaprine T1

methocarbamol T1

ROBAXIN T2

ROBAXIN-750 T2

SOMA T2

tizanidine T1

ZANAFLEX T2

Gaba-Derivative Skeletal Muscle Relaxant

baclofen T1

GABLOFEN T4 PA


28

Drug Tier Notes

LIORESAL T4 PA

Non-Sel. Beta-Adrenergic Blocking Agents

BETAPACE T2

BETAPACE AF T2

carvedilol T1

COREG T2

CORGARD T2

CORZIDE T2

INDERAL LA T2

labetalol T1

nadolol T1

nadolol-bendroflumethiazide T1

pindolol T1

propranolol T1

propranolol-hydrochlorothiazid T1

sotalol T1

SOTALOL AF T1

timolol maleate T1

TRANDATE T2

Non-Sel.Alpha-1-Adrenergic Blocking Agts

CARDURA T2

doxazosin T1

MINIPRESS T2

prazosin T1

terazosin T1

Non-Sel.Alpha-Adrenergic Blocking Agents

CAFERGOT T2

D.H.E.45 T2

DIBENZYLINE T2

dihydroergotamine injection T1 QL (12 ML per 30 days)

dihydroergotamine nasal T1 QL (1 QY per 30 DYs)

ERGOMAR T1 QL (20 EA per 30 days)


29

Drug Tier Notes

ergotamine-caffeine T1

MIGRANAL T2 QL (1 QY per 30 DYs)

phenoxybenzamine T1 PA

Parasympathomimetic (Cholinergic Agents)

ARICEPT T2 AL

ARICEPT ODT T2 AL

bethanechol chloride T1

donepezil oral tablet 10 mg T1 AL

donepezil oral tablet 23 mg T1 ST; QL (1 EA per 1 day)

donepezil oral tablet 5 mg T1 QL (1 EA per 1 DY); AL

donepezil oral tablet,disintegrating T1 AL

EXELON ORAL T2 AL

EXELON TRANSDERMAL PATCH 24 HOUR

4.6 MG/24 HR

T2 QL (1 EA per 1 day); AL

EXELON TRANSDERMAL PATCH 24 HOUR

9.5 MG/24 HR

T2 AL

MESTINON T2

MESTINON TIMESPAN T2

PROSTIGMIN T1 AL

pyridostigmine bromide oral syrup T1

pyridostigmine bromide oral tablet T1 AL

pyridostigmine bromide oral tablet extended

release

T1 AL

rivastigmine tartrate oral capsule 1.5 mg, 3 mg T1 QL (2 EA per 1 day); AL

rivastigmine tartrate oral capsule 4.5 mg, 6 mg T1 AL

rivastigmine transdermal patch 24 hour 13.3

mg/24 hour

T1 AL

rivastigmine transdermal patch 24 hour 4.6 mg/24

hr


rivastigmine transdermal patch 24 hour 9.5 mg/24

hr

T1

URECHOLINE T2

Selective Alpha-1-Adrenergic Block.Agent

alfuzosin T1


30

Drug Tier Notes

carvedilol T1

COREG T2

labetalol T1

tamsulosin T1

TRANDATE T2

Selective Beta-2-Adrenergic Agonists

albuterol sulfate inhalation hfa aerosol inhaler T1 QL (1 QY per 30 days)

albuterol sulfate inhalation solution for

nebulization

T1

albuterol sulfate oral T1

ANORO ELLIPTA T1


DULERA T3 QL (13 QY per 30 DYs); AL

fluticasone propion-salmeterol inhalation aerosol

powdr breath activated

T1

fluticasone propion-salmeterol inhalation blister

with device

T1 QL (1 EA per 30 days)

levalbuterol tartrate T1 ST

SEREVENT DISKUS T1

STIOLTO RESPIMAT T1

terbutaline T1

WIXELA INHUB T1 QL (1 EA per 30 days)

Selective Beta-Adrenergic Blocking Agent

atenolol T1

atenolol-chlorthalidone T1

bisoprolol fumarate T1

bisoprolol-hydrochlorothiazide T1

LOPRESSOR T2

LOPRESSOR HCT T2

metoprolol succinate T1

metoprolol ta-hydrochlorothiaz T1

metoprolol tartrate T1

TENORMIN T2


31

Drug Tier Notes

TOPROL XL T2

ZEBETA T2

ZIAC T2

Skeletal Muscle Relaxants, Miscellaneous

BOTOX T4 PA

BOTOX COSMETIC T4 PA

DYSPORT T4 PA

MYOBLOC T4 PA

XEOMIN T4 PA

Blood Formation, Coagulation, Thrombosis

Anticoagulants, Miscellaneous

ARIXTRA T4 PA

Antihemorrhagic Agents, Miscellaneous

ANDEXXA T4 PA

Antithrombotic Agents, Miscellaneous

CABLIVI T4 PA

Blood Form.,Coag,Thrombosis Agents Misc.

TAVALISSE T4 PA

Coumarin Derivatives

COUMADIN T2

warfarin T1

Direct Factor Xa Inhibitors

ARIXTRA T4 PA

ELIQUIS T1

XARELTO ORAL TABLET 10 MG, 15 MG, 20

MG

T1

XARELTO ORAL TABLET 2.5 MG T1 QL (60 EA per 30 days)

XARELTO ORAL TABLETS,DOSE PACK T1

Direct Thrombin Inhibitors

PRADAXA ORAL CAPSULE 110 MG, 150 MG T1

PRADAXA ORAL CAPSULE 75 MG T1 QL (2 EA per 1 day)


32

Drug Tier Notes

Hematopoietic Agents

ARANESP (IN ALBUMIN) T4 PA

ARANESP (IN POLYSORBATE) T4 PA

DOPTELET (10 TAB PACK) T4 PA

DOPTELET (15 TAB PACK) T4 PA

EPOGEN T4 PA

FULPHILA T4 PA

GRANIX T4 PA

LEUKINE T4 PA

MIRCERA T4 PA

MOZOBIL T4 PA

MULPLETA T4 PA

NEULASTA T4 PA

NEUMEGA T4 PA

NEUPOGEN T4 PA

NIVESTYM T4 PA

NPLATE T4 PA

PROCRIT T4 PA

PROMACTA T4 PA

RETACRIT T4 PA

UDENYCA T4 PA

ZARXIO T4 PA

Hemorrheologic Agents

pentoxifylline T1

Hemostatics

ADVATE T4 PA

ADYNOVATE T4 PA

AFSTYLA T4 PA

ALPHANATE T4 PA

ALPHANINE SD T4 PA

ALPROLIX T4 PA

AMICAR T1


33

Drug Tier Notes

aminocaproic acid T1 PA

BEBULIN T4 PA

BENEFIX T4 PA

COAGADEX T4 PA

CORIFACT T4 PA

DDAVP NASAL T2 PA

DDAVP ORAL T2 PA; AL

desmopressin nasal T1 PA

desmopressin oral T1 PA; AL

ELOCTATE T4 PA

FEIBA NF T4 PA

HEMLIBRA T4 PA

HEMOFIL M HIGH T4 PA

HEMOFIL M LOW T4 PA

HEMOFIL M MID T4 PA

HEMOFIL M SUPER HIGH T4 PA

HUMATE-P T4 PA

IDELVION T4 PA

IXINITY T4 PA

JIVI T4 PA

KCENTRA T4 PA

KOATE-DVI T4 PA

KOGENATE FS T4 PA

MONOCLATE-P T4 PA

NOVOEIGHT T4 PA

NOVOSEVEN RT T4 PA

NUWIQ T4 PA

OBIZUR T4 PA

PROFILNINE T4 PA

REBINYN T4 PA

RECOMBINATE T4 PA

RIASTAP T4 PA


34

Drug Tier Notes

RIXUBIS T4 PA

STIMATE T1 PA

TRETTEN T4 PA

VONVENDI T4 PA

WILATE T4 PA

XYNTHA T4 PA

XYNTHA SOLOFUSE T4 PA

Heparins

enoxaparin subcutaneous solution T1 QL (3 ML per 1 day)

enoxaparin subcutaneous syringe 100 mg/ml, 150

mg/ml

T1 QL (2 ML per 1 day)

enoxaparin subcutaneous syringe 120 mg/0.8 ml,

80 mg/0.8 ml

T1 QL (1.6 ML per 1 day)

enoxaparin subcutaneous syringe 30 mg/0.3 ml T1 QL (0.6 ML per 1 day)



FRAGMIN T4 PA

heparin (porcine) T1

Iron Preparations

CADEAU DHA T1

CENTRUM COMPLETE T1

CERTAVITE-ANTIOXID (IRON GLUC) T2

CHILDREN'S CHEWABLE COMPLETE T1

CLASSIC PRENATAL T1

COMPETE T1

COMPLETE MULTIVITAMIN T1

COMPLETE MULTIVITAMIN-MINERAL T1

COMPLETE PREMIUM VITAMIN T1

COMPLETENATE T1

DAILY PRENATAL T1

DAILY VITES/IRON T1

FERAHEME T4 PA

FERRETTS T1


35

Drug Tier Notes

FERRLECIT T4 PA

ferrous fumarate T1

ferrous gluconate T1

ferrous sulfate T1

HIGH POTENCY IRON T1

INFED T1

INJECTAFER T1

iron oral tablet T1

IRON ORAL TABLET EXTENDED RELEASE T1

MULTI-DELYN WITH IRON T1

MULTIGEN T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

MULTI-VIT WITH FLUORIDE-IRON T1

MULTIVITAMIN WITH MINERALS T1

NUTRIVIT T1

OBSTETRIX DHA T1

OBTREX DHA T1

ONE DAILY PRENATAL T1

ONE-A-DAY WOMENS FORMULA T1

ONE-A-DAY WOMEN'S PRENATAL 1 T1

PERRY PRENATAL T1

pnv cmb#95-ferrous fumarate-fa T1

POLY-IRON 150 FORTE T1

polysaccharide iron complex T1

POLYVITAMIN WITH IRON T1 AL

POLY-VITAMIN WITH IRON T1 AL

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENATA T1

PRENATAL + DHA T1


36

Drug Tier Notes

PRENATAL 19 T1

PRENATAL MULTI-DHA (ALGAL OIL) T1

PRENATAL PLUS T1

PRENATAL VITAMIN T1

PRENATAL VITAMIN PLUS LOW IRON T1

prenatal vit-iron fum-folic ac T1

PRORENAL QD T1

THERAPEUTIC-M T1

TRINATAL GT T1

TRIVEEN-DUO DHA T1

TRI-VI-SOL WITH IRON T1 AL

TRI-VIT WITH FLUORIDE AND IRON T1

VENOFER T1

WOMEN'S DAILY FORMULA T1

WOMEN'S PRENATAL PLUS DHA T1

Platelet-Aggregation Inhibitors

aspirin T1

aspirin-caffeine-dihydrocodein T3 AL

aspirin-dipyridamole T1

butalbital-aspirin-caffeine T1

cilostazol T1

clopidogrel T1

dipyridamole T1

PERSANTINE T2

PLAVIX T2

PLETAL T2

prasugrel oral tablet 10 mg T1

prasugrel oral tablet 5 mg T1 QL (1 EA per 1 day)

SYNALGOS-DC T3

ticlopidine T1

Thrombolytic Agents

ACTIVASE T4 PA


37

Drug Tier Notes

aspirin T1



CATHFLO ACTIVASE T4 PA

SYNALGOS-DC T3

Cardiovascular Drugs

Alpha-Adrenergic Blocking Agents

CARDURA T2

carvedilol T1

COREG T2

doxazosin T1

labetalol T1

MINIPRESS T2

prazosin T1

terazosin T1

TRANDATE T2

Alpha-Adrenergic Blocking Agt.(Hypoten)

CARDURA T2

doxazosin T1

labetalol T1

MINIPRESS T2

prazosin T1

terazosin T1

TRANDATE T2

Angiotensin Ii Receptor Antagon.(Hypotn)

amlodipine-valsartan T1 ST

AVALIDE T2 ST

AVAPRO T2 ST

COZAAR T2

HYZAAR T2

irbesartan T1 ST


38

Drug Tier Notes

irbesartan-hydrochlorothiazide T1 ST

losartan T1

losartan-hydrochlorothiazide T1

olmesartan T1 ST

olmesartan-hydrochlorothiazide T1 ST

telmisartan T1 ST

valsartan T1 ST

valsartan-hydrochlorothiazide T1 ST

Angiotensin Ii Receptor Antagonists


AVALIDE T2 ST

AVAPRO T2 ST

COZAAR T2

ENTRESTO T1

HYZAAR T2

irbesartan T1 ST


losartan T1


olmesartan T1 ST


telmisartan T1 ST

valsartan T1 ST


Angiotensin-Convert.Enzyme Inhib(Hypotn)

ACCUPRIL T2

ACCURETIC T2

ACEON T2

benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)

benazepril oral tablet 40 mg T1

benazepril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 5-6.25 mg



39

Drug Tier Notes

benazepril-hydrochlorothiazide oral tablet 20-25

mg

T1

captopril T1

captopril-hydrochlorothiazide T1

enalapril maleate T1

enalapril-hydrochlorothiazide T1

fosinopril T1

lisinopril T1

lisinopril-hydrochlorothiazide T1

LOTENSIN T2

LOTENSIN HCT T2

MAVIK T2

moexipril T1

moexipril-hydrochlorothiazide T1

perindopril erbumine T1

PRINIVIL T2

quinapril T1

quinapril-hydrochlorothiazide T1

trandolapril T1

UNIRETIC T2

UNIVASC T2

VASERETIC T2

VASOTEC T2

ZESTORETIC T2

ZESTRIL T2

Angiotensin-Converting Enzyme Inhibitors

ACCUPRIL T2

ACCURETIC T2

ACEON T2

benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)

benazepril oral tablet 40 mg T1


40

Drug Tier Notes


mg, 20-12.5 mg, 5-6.25 mg



mg

T1

captopril T1


enalapril maleate T1


fosinopril T1

lisinopril T1


LOTENSIN T2

LOTENSIN HCT T2

MAVIK T2

moexipril T1


perindopril erbumine T1

PRINIVIL T2

quinapril T1


trandolapril T1

UNIRETIC T2

UNIVASC T2

VASERETIC T2

VASOTEC T2

ZESTORETIC T2

ZESTRIL T2

Antiarrhythmics, Miscellaneous

digoxin T1

LANOXIN T2

Antilipemic Agents, Miscellaneous

JUXTAPID T4 PA

KYNAMRO T4 PA


41

Drug Tier Notes

niacin T1

NIACOR T1

Beta-Adrenergic Blocking Agents

atenolol T1


BETAPACE T2

BETAPACE AF T2



carvedilol T1

COREG T2

CORGARD T2

CORZIDE T2

INDERAL LA T2

labetalol T1

LOPRESSOR T2

LOPRESSOR HCT T2




nadolol T1


pindolol T1

propranolol T1


sotalol T1

SOTALOL AF T1

TENORMIN T2

timolol maleate T1

TOPROL XL T2

TRANDATE T2

ZEBETA T2


42

Drug Tier Notes

ZIAC T2

Beta-Adrenergic Blocking Agt.(Hypoten)

atenolol T1


BETAPACE T2

BETAPACE AF T2



CORGARD T2

CORZIDE T2

INDERAL LA T2

labetalol T1

LOPRESSOR T2

LOPRESSOR HCT T2




nadolol T1


pindolol T1

propranolol T1


sotalol T1

SOTALOL AF T1

TENORMIN T2

timolol maleate T1

TOPROL XL T2

TRANDATE T2

ZEBETA T2

ZIAC T2

Bile Acid Sequestrants

cholestyramine (with sugar) T1


43

Drug Tier Notes

CHOLESTYRAMINE LIGHT T1

colesevelam oral powder in packet T1

colesevelam oral tablet T1 QL (6 EA per 1 day)

COLESTID T2

colestipol T1

PREVALITE T1

QUESTRAN T2

QUESTRAN LIGHT T2

WELCHOL T2

Calcium-Channel Block.Agt,Misc(Hypoten)

CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2

TAZTIA XT T1

TIAZAC T2

verapamil T1

VERELAN T2

Calcium-Channel Blocking Agents

ADALAT CC T2

amlodipine oral tablet 10 mg T1

amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)


CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2


44

Drug Tier Notes

felodipine T1

ISOPTIN SR T2

NIFEDICAL XL T1

nifedipine oral capsule T1

nifedipine oral tablet extended release 24hr T1

nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)

nifedipine oral tablet extended release 60 mg, 90

mg

T1

nisoldipine oral tablet extended release 24 hr 17

mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

PROCARDIA T2

PROCARDIA XL T2

SULAR T2

TAZTIA XT T1

TIAZAC T2

verapamil T1

VERELAN T2

Calcium-Channel Blocking Agents(Hypoten)

CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2

TAZTIA XT T1

TIAZAC T2

verapamil T1

VERELAN T2

Calcium-Channel Blocking Agents, Misc.


45

Drug Tier Notes

CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2

TAZTIA XT T1

TIAZAC T2

verapamil T1

VERELAN T2

Carbonic Anhydrase Inhibitors(Hypoten)

acetazolamide T1

DIAMOX SEQUELS T2 PA

Cardiotonic Agents

digoxin T1

LANOXIN T2

milrinone T4 PA

Central Alpha-Agonists

CATAPRES T2

CATAPRES-TTS-1 T2

CATAPRES-TTS-2 T2

CATAPRES-TTS-3 T2

clonidine T1

clonidine hcl T1

CLORPRES T1

guanfacine oral tablet T1

guanfacine oral tablet extended release 24 hr T1 AL

methyldopa T1


TENEX T2


46

Drug Tier Notes

Cholesterol Absorption Inhibitors

ezetimibe T1

ezetimibe-simvastatin T1

Class Ia Antiarrhythmics

disopyramide phosphate T1

NORPACE T2

NORPACE CR T1

quinidine gluconate T1

quinidine sulfate T1

Class Ib Antiarrhythmics

DILANTIN T1

DILANTIN EXTENDED T1

DILANTIN INFATABS T2

DILANTIN-125 T2

mexiletine T1

phenytoin T1

phenytoin sodium extended T1

Class Ic Antiarrhythmics

flecainide T1

propafenone T1

RYTHMOL T2

Class Ii Antiarrhythmics

atenolol T1


BETAPACE T2

BETAPACE AF T2



carvedilol T1

COREG T2

CORGARD T2

CORZIDE T2


47

Drug Tier Notes

INDERAL LA T2

labetalol T1

LOPRESSOR T2

LOPRESSOR HCT T2




nadolol T1


pindolol T1

propranolol T1


sotalol T1

SOTALOL AF T1

TENORMIN T2

timolol maleate T1

TOPROL XL T2

TRANDATE T2

ZEBETA T2

ZIAC T2

Class Iii Antiarrhythmics

amiodarone T1

BETAPACE T2

BETAPACE AF T2

CORDARONE T2

MULTAQ T3 PA

sotalol T1

SOTALOL AF T1

Class Iv Antiarrhythmics

CALAN T2

CALAN SR T2

CARDIZEM T2


48

Drug Tier Notes

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2

TAZTIA XT T1

TIAZAC T2

verapamil T1

VERELAN T2

Dihydropyridines

ADALAT CC T2




felodipine T1

NIFEDICAL XL T1





mg

T1


mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

PROCARDIA T2

PROCARDIA XL T2

SULAR T2

Dihydropyridines (Antihypertensive)

ADALAT CC T2





49

Drug Tier Notes

felodipine T1

NIFEDICAL XL T1





mg

T1


mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

PROCARDIA T2

PROCARDIA XL T2

SULAR T2

Direct Vasodilators

BIDIL T1

hydralazine T1

minoxidil T1

Diuretics, Miscellaneous (Hypotensive)

THEO-24 T1

theophylline T1

Fibric Acid Derivatives

fenofibrate T1

fenofibrate micronized T1

fenofibrate nanocrystallized T1

gemfibrozil T1

LOFIBRA T2

LOPID T2

TRICOR T2

Hmg-Coa Reductase Inhibitors

atorvastatin oral tablet 10 mg T1 QL (1 EA per 1 DY)


50

Drug Tier Notes

atorvastatin oral tablet 20 mg, 40 mg, 80 mg T1

ezetimibe-simvastatin T1

fluvastatin T1 ST

LESCOL T2 ST

LESCOL XL T2 ST

LIPITOR T2

lovastatin oral tablet 10 mg, 20 mg T1 QL (3 EA per 1 day)

lovastatin oral tablet 40 mg T1

MEVACOR T2

PRAVACHOL T2 ST

pravastatin oral tablet 10 mg, 20 mg T1 ST; QL (1 EA per 1 day)

pravastatin oral tablet 40 mg T1 ST; QL (2 EA per 1 day)

pravastatin oral tablet 80 mg T1 ST

rosuvastatin T1

simvastatin T1

ZOCOR T2

Hypotensive Agents, Miscellaneous

ADALAT CC T2




BETAPACE T2

BETAPACE AF T2

CARDURA T2

carvedilol T1

COREG T2

DIBENZYLINE T2

doxazosin T1

felodipine T1

INDERAL LA T2

NIFEDICAL XL T1



51

Drug Tier Notes




mg

T1


mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

phenoxybenzamine T1 PA

pindolol T1

PROCARDIA T2

PROCARDIA XL T2

propranolol T1

sotalol T1

SOTALOL AF T1

SULAR T2

terazosin T1

timolol maleate T1

Loop Diuretics (Hypotensive Agents)

bumetanide T1

DEMADEX T2

furosemide T1

LASIX T2

torsemide T1

Mineralocorticoid (Aldosterone) Antagnts

ALDACTAZIDE T2

ALDACTONE T2

spironolactone T1

spironolacton-hydrochlorothiaz T1

Mineralocorticoid(Aldoster.)Antag(Hypot)

ALDACTAZIDE T2

ALDACTONE T2


52

Drug Tier Notes

spironolactone T1


Nitrates And Nitrites

BIDIL T1

ISORDIL T1

isosorbide dinitrate T1

isosorbide mononitrate T1

NITRO-BID T1

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6

MG/HR

T2

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR

T1

nitroglycerin T1

NITROSTAT T2

NITRO-TIME T1

Pcsk9 Inhibitors

PRALUENT PEN T4 PA

REPATHA PUSHTRONEX T4 PA

REPATHA SURECLICK T4 PA

REPATHA SYRINGE T4 PA

Peripheral Adrenergic Inhibitors

reserpine T1

Phosphodiesterase Type 5 Inhibitors

ADCIRCA T4 PA

cilostazol T1

PLETAL T2

REVATIO T4 PA

sildenafil (antihypertensive) T1 PA

Potassium-Sparing Diuretics (Hypoten)

ALDACTAZIDE T2

ALDACTONE T2

amiloride T1


53

Drug Tier Notes

amiloride-hydrochlorothiazide T1

DYAZIDE T2

MAXZIDE T2

MAXZIDE-25MG T2

spironolactone T1


triamterene-hydrochlorothiazid T1

Renin-Angioten.-Aldost. Sys. Inhib, Misc

ENTRESTO T1

Sclerosing Agents

STERITALC T4 PA

Thiazide Diuretics(Hypotensive Agents)

ACCURETIC T2

ALDACTAZIDE T2


AVALIDE T2 ST


mg, 20-12.5 mg, 5-6.25 mg



mg

T1



chlorothiazide T1

CORZIDE T2

DIURIL T1

DYAZIDE T2


hydrochlorothiazide T1

HYZAAR T2



LOPRESSOR HCT T2


54

Drug Tier Notes


LOTENSIN HCT T2

MAXZIDE T2

MAXZIDE-25MG T2










UNIRETIC T2


VASERETIC T2

ZESTORETIC T2

ZIAC T2

Thiazide-Like Diuretics(Hypotensive Agt)


chlorthalidone T1

CLORPRES T1

indapamide T1

metolazone T1

ZAROXOLYN T2

Vasodilating Agents, Miscellaneous

ADALAT CC T2

ADEMPAS T4 PA

ambrisentan T4 PA





55

Drug Tier Notes


CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

dipyridamole T1

epoprostenol (glycine) T4 PA

felodipine T1

FLOLAN T4 PA

ISOPTIN SR T2

LETAIRIS T4 PA

NIFEDICAL XL T1





mg

T1


mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

OPSUMIT T4 PA

ORENITRAM T4 PA

PERSANTINE T2

PROCARDIA T2

PROCARDIA XL T2

REMODULIN T4 PA

SULAR T2

TAZTIA XT T1

TIAZAC T2


56

Drug Tier Notes

TRACLEER T4 PA

TYVASO T4 PA

TYVASO REFILL KIT T4 PA

TYVASO STARTER KIT T4 PA

UPTRAVI T4 PA

VELETRI T4 PA

VENTAVIS T4 PA

verapamil T1

VERELAN T2

Cellular And Gene Therapy

Cellular And Gene Therapy

PROVENGE T4 PA

Cellular Therapy

PROVENGE T4 PA

Gene Therapy

KYMRIAH T4 PA

LUXTURNA T4 PA

YESCARTA T4 PA

Central Nervous System Agents

Adamantanes (Cns)

amantadine hcl T1

Amphetamines

ADDERALL T2

ADDERALL XR T2

DEXEDRINE SPANSULE T2

dextroamphetamine T1 PA; AL

dextroamphetamine-amphetamine T1 PA; AL

VYVANSE T1 AL

Analgesics And Antipyretics, Misc.

ACEPHEN T1

acetaminophen T1

acetaminophen-caff-dihydrocod T3 AL


57

Drug Tier Notes

acetaminophen-codeine T1 AL

butalbital-acetaminop-caf-cod oral capsule 50-

300-40-30 mg

T3 AL


325-40-30 mg

T1 AL

butalbital-acetaminophen T1

butalbital-acetaminophen-caff T1

CAPITAL WITH CODEINE T3 AL

CHILDREN'S ACETAMINOPHEN T1

ED-APAP T1

ENDOCET ORAL TABLET 10-325 MG, 2.5-325

MG, 7.5-325 MG

T3

ENDOCET ORAL TABLET 5-325 MG T1

ESGIC T2

FEVERALL T1

FIORICET WITH CODEINE T3 AL

gabapentin oral capsule 100 mg, 400 mg T1

gabapentin oral capsule 300 mg T1 QL (9 EA per 1 day)

gabapentin oral solution T1

gabapentin oral tablet T1

HORIZANT T4 PA

HYCET T3

hydrocodone-acetaminophen oral solution T1

hydrocodone-acetaminophen oral tablet 10-300

mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg

T3


mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,

7.5-750 mg

T1

LORTAB T2

LORTAB ELIXIR T2

MAPAP (ACETAMINOPHEN) T1

MARTEN-TAB T2

NEURONTIN T2

NON-ASPIRIN JR STRENGTH T1


58

Drug Tier Notes

NORTEMP T1

oxycodone-acetaminophen oral capsule T1

oxycodone-acetaminophen oral solution T3

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 7.5-325 mg

T3

oxycodone-acetaminophen oral tablet 5-325 mg T1

PAIN RELIEF T1

PERCOCET ORAL TABLET 10-325 MG, 2.5-

325 MG, 7.5-325 MG

T3

PERCOCET ORAL TABLET 5-325 MG T2

PRIALT T4 PA

PRIMLEV T3

Q-PAP T1

tramadol-acetaminophen T3 AL

TREZIX T3

TYLENOL-CODEINE #4 T2 AL

ULTRACET T3 AL

VERDROCET T3

VICODIN T3

VICODIN ES T3

VICODIN HP T3

XODOL 10/300 T3

XODOL 5/300 T3

XODOL 7.5/300 T3

Anticholinergic Agents (Cns)

benztropine T1

trihexyphenidyl T1

Anticonvulsants, Miscellaneous

BANZEL T1 ST; AL

carbamazepine T1

DEPAKENE T2

DEPAKOTE T2

DEPAKOTE ER T2


59

Drug Tier Notes

DEPAKOTE SPRINKLES T2

divalproex oral capsule, delayed rel sprinkle T1

divalproex oral tablet extended release 24 hr 250

mg



mg

T1

divalproex oral tablet,delayed release (dr/ec) T1

EPIDIOLEX T4 PA

gabapentin oral capsule 100 mg, 400 mg T1

gabapentin oral capsule 300 mg T1 QL (9 EA per 1 day)

gabapentin oral solution T1

gabapentin oral tablet T1

HORIZANT T4 PA

KEPPRA T2

LAMICTAL T2

lamotrigine oral tablet 100 mg T1 QL (5 EA per 1 day)

lamotrigine oral tablet 150 mg, 200 mg T1


lamotrigine oral tablet, chewable dispersible 25

mg


lamotrigine oral tablet, chewable dispersible 5 mg T1 QL (2 EA per 1 day)

lamotrigine oral tablets,dose pack T1

levetiracetam T1

NEURONTIN T2

oxcarbazepine T1

SABRIL T4 PA

TEGRETOL T2

TEGRETOL XR T2

TOPAMAX T2

topiramate oral capsule, sprinkle T1

topiramate oral tablet 100 mg, 200 mg, 25 mg T1

topiramate oral tablet 50 mg T1 QL (6 EA per 1 day)

valproic acid T1


60

Drug Tier Notes

valproic acid (as sodium salt) T1 QL (1000 ML per 30 days)

vigabatrin T4

Antidepressants, Miscellaneous

bupropion hcl T1

bupropion hcl (smoking deter) T1

mirtazapine oral tablet T1 QL (1 EA per 1 day)

mirtazapine oral tablet,disintegrating T1

REMERON T2

REMERON SOLTAB T2

SPRAVATO T4 PA

WELLBUTRIN T2

WELLBUTRIN SR T2

WELLBUTRIN XL T2

ZYBAN T2

Antimanic Agents

ABILIFY T2 AL

ABILIFY MAINTENA T4 PA

aripiprazole oral solution T1 AL

aripiprazole oral tablet 10 mg, 15 mg T1 QL (1 EA per 1 DY); AL

aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg T1 AL

aripiprazole oral tablet,disintegrating 10 mg T1 QL (2 EA per 1 day); AL

aripiprazole oral tablet,disintegrating 15 mg T1 AL

ARISTADA T4 PA

ARISTADA INITIO T4 PA

carbamazepine T1

DEPAKENE T2

DEPAKOTE T2

DEPAKOTE ER T2




mg



61

Drug Tier Notes


mg

T1


GEODON T2 AL

LAMICTAL T2


lamotrigine oral tablet 150 mg, 200 mg T1


lamotrigine oral tablet, chewable dispersible 25

mg


lamotrigine oral tablet, chewable dispersible 5 mg T1 QL (2 EA per 1 day)

lamotrigine oral tablets,dose pack T1

lithium carbonate T1

lithium citrate T1

LITHOBID T2

olanzapine oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg T1 QL (1 EA per 1 day); AL

olanzapine oral tablet 2.5 mg T1 QL (2 EA per 1 day); AL

olanzapine oral tablet 20 mg T1 AL

PERSERIS T4 PA

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50

mg


quetiapine oral tablet 300 mg, 400 mg T1 AL

quetiapine oral tablet extended release 24 hr 150

mg



mg



mg, 400 mg, 50 mg

T1 AL

RISPERDAL T2 AL

RISPERDAL CONSTA T4 PA

risperidone oral solution T1 AL

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg


risperidone oral tablet 3 mg, 4 mg T1 AL


62

Drug Tier Notes

SAPHRIS T1 AL

SAPHRIS (BLACK CHERRY) T1 QL (2 EA per 1 day); AL

SEROQUEL T2 AL

TEGRETOL T2

TEGRETOL XR T2

valproic acid T1


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg T1 QL (2 EA per 1 day); AL

ziprasidone hcl oral capsule 80 mg T1 AL

ZYPREXA INTRAMUSCULAR T4 PA

ZYPREXA ORAL T2 AL

ZYPREXA RELPREVV T4 PA

Antimigraine Agents, Miscellaneous

AIMOVIG AUTOINJECTOR T4 PA

AIMOVIG AUTOINJECTOR (2 PACK) T4 PA

AJOVY T4 PA

ASCOMP WITH CODEINE T3 AL

aspirin T1


BUTALBITAL COMPOUND W/CODEINE T1 AL

BUTALBITAL COMPOUND-CODEINE T3 AL


300-40-30 mg

T3 AL


325-40-30 mg

T1 AL



CAFERGOT T2

codeine-butalbital-asa-caff T3 AL

D.H.E.45 T2

DEPAKENE T2

DEPAKOTE T2

DEPAKOTE ER T2


63

Drug Tier Notes


dihydroergotamine injection T1 QL (12 ML per 30 days)

dihydroergotamine nasal T1 QL (1 QY per 30 DYs)



mg



mg

T1


EMGALITY PEN T4 PA

EMGALITY SYRINGE T4 PA

ERGOMAR T1 QL (20 EA per 30 days)

ergotamine-caffeine T1

ESGIC T2


FIORINAL-CODEINE #3 T2 AL

INDERAL LA T2

MIGRANAL T2 QL (1 QY per 30 DYs)

propranolol T1

SYNALGOS-DC T3

timolol maleate T1


ULTRACET T3 AL

valproic acid T1


Antipsychotics, Miscellaneous

loxapine succinate T1 AL

pimozide T1 AL

Anxiolytics,Sedatives,And Hypnotics,Misc

AMBIEN T2

AMBIEN CR T3 PA

buspirone T1


64

Drug Tier Notes

droperidol T1

EDLUAR T3 PA

eszopiclone T1 ST

HETLIOZ T4 PA

hydroxyzine hcl T1

hydroxyzine pamoate T1

LUNESTA T3 PA

meprobamate T1

PHENERGAN T2

promethazine T1


SONATA T2

VISTARIL T2

zaleplon oral capsule 10 mg T1 QL (14 EA per 25 days)

zaleplon oral capsule 5 mg T1 QL (1 EA per 1 day)

zolpidem T1

Atypical Antipsychotics

ABILIFY T2 AL

ABILIFY MAINTENA T4 PA

aripiprazole oral solution T1 AL

aripiprazole oral tablet 10 mg, 15 mg T1 QL (1 EA per 1 DY); AL

aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg T1 AL

aripiprazole oral tablet,disintegrating 10 mg T1 QL (2 EA per 1 day); AL

aripiprazole oral tablet,disintegrating 15 mg T1 AL

ARISTADA T4 PA

ARISTADA INITIO T4 PA

clozapine oral tablet 100 mg, 200 mg, 50 mg T1 AL

clozapine oral tablet 25 mg T1 QL (3 EA per 1 day); AL

CLOZARIL T2 AL

GEODON T2 AL

INVEGA SUSTENNA T4 PA

INVEGA TRINZA T4 PA


65

Drug Tier Notes

LATUDA ORAL TABLET 120 MG, 20 MG, 40

MG, 60 MG


LATUDA ORAL TABLET 80 MG T1 QL (2 EA per 1 day); AL

NUPLAZID T4 PA

olanzapine oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg T1 QL (1 EA per 1 day); AL

olanzapine oral tablet 2.5 mg T1 QL (2 EA per 1 day); AL

olanzapine oral tablet 20 mg T1 AL

PERSERIS T4 PA

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50

mg


quetiapine oral tablet 300 mg, 400 mg T1 AL


mg



mg



mg, 400 mg, 50 mg

T1 AL

RISPERDAL T2 AL

RISPERDAL CONSTA T4 PA

risperidone oral solution T1 AL

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg


risperidone oral tablet 3 mg, 4 mg T1 AL

SAPHRIS T1 AL

SAPHRIS (BLACK CHERRY) T1 QL (2 EA per 1 day); AL

SEROQUEL T2 AL

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg T1 QL (2 EA per 1 day); AL

ziprasidone hcl oral capsule 80 mg T1 AL

ZYPREXA INTRAMUSCULAR T4 PA

ZYPREXA ORAL T2 AL

ZYPREXA RELPREVV T4 PA

Barbiturates (Anticonvulsants)

MYSOLINE T2

phenobarbital T1


66

Drug Tier Notes

primidone T1

Barbiturates (Anxiolytic, Sedative/Hyp)





300-40-30 mg

T3 AL


325-40-30 mg

T1 AL

butalbital-acetaminophen T1




ESGIC T2



MARTEN-TAB T2

phenobarbital T1

Benzodiazepines (Anticonvulsants)

ATIVAN T2

clobazam T1

clonazepam T1

clorazepate dipotassium T1

diazepam oral T1

diazepam rectal T1 QL (2 EA per 30 DYs)

KLONOPIN T2

lorazepam T1

SYMPAZAN T4 PA

TRANXENE T-TAB T2

Benzodiazepines (Anxiolytic,Sedativ/Hyp)

alprazolam T1 QL (4 EA per 1 day)

amitriptyline-chlordiazepoxide T1

ATIVAN T2


67

Drug Tier Notes

chlordiazepoxide hcl T1

clobazam T1

clonazepam T1

clorazepate dipotassium T1

diazepam oral T1

diazepam rectal T1 QL (2 EA per 30 DYs)

estazolam T1

HALCION T2

KLONOPIN T2

lorazepam T1

oxazepam T1

RESTORIL T2

SYMPAZAN T4 PA

temazepam T1

TRANXENE T-TAB T2

triazolam T1

XANAX T2

Butyrophenones

haloperidol T1 AL

haloperidol decanoate T1

haloperidol lactate injection T1

haloperidol lactate oral T1 AL

Calcitonin Gene-Related Peptide Antag.

AIMOVIG AUTOINJECTOR T4 PA

AIMOVIG AUTOINJECTOR (2 PACK) T4 PA

AJOVY T4 PA

EMGALITY PEN T4 PA

EMGALITY SYRINGE T4 PA

Central Nervous System Agents, Misc.

atomoxetine T1 AL

AUSTEDO T4 PA

guanfacine oral tablet T1


68

Drug Tier Notes

guanfacine oral tablet extended release 24 hr T1 AL

INGREZZA T4 PA

memantine T1 AL

NAMENDA T2 AL

NAMENDA TITRATION PAK T2 AL

RADICAVA T4 PA

riluzole T4 PA

TENEX T2

TIGLUTIK T4 PA

XENAZINE T4 PA

XYREM T4 PA

Cyclooxygenase-2 (Cox-2) Inhibitors

celecoxib oral capsule 100 mg, 200 mg, 50 mg T1 QL (2 EA per 1 day)

celecoxib oral capsule 400 mg T1 QL (1 EA per 1 day)

Dopamine Precursors

carbidopa-levodopa T1

INBRIJA T4 PA

SINEMET T2

SINEMET CR T2

Ergot-Deriv. Dopamine Receptor Agonists

bromocriptine T1

cabergoline T1 ST new

PARLODEL T2

Fibromyalgia Agents

CYMBALTA T2

duloxetine oral capsule,delayed release(dr/ec) 20

mg



mg, 60 mg


SAVELLA ORAL TABLET 100 MG T1

SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50

MG


SAVELLA ORAL TABLETS,DOSE PACK T1


69

Drug Tier Notes

Hydantoins

DILANTIN T1

DILANTIN EXTENDED T1

DILANTIN INFATABS T2

DILANTIN-125 T2

phenytoin T1

phenytoin sodium extended T1

Monoamine Oxidase B Inhibitors

ELDEPRYL T2

selegiline hcl T1

Monoamine Oxidase Inhibitors

ELDEPRYL T2

NARDIL T2

PARNATE T2

phenelzine T1

selegiline hcl T1

tranylcypromine T1

Nonergot-Deriv.Dopamine Receptor Agonist

APOKYN T4 PA

MIRAPEX T2

pramipexole T1

REQUIP T2

ropinirole T1

Opiate Agonists

ABSTRAL T3


acetaminophen-codeine T1 AL

ACTIQ T3



belladonna alkaloids-opium T3


70

Drug Tier Notes




300-40-30 mg

T3 AL


325-40-30 mg

T1 AL

CAPITAL WITH CODEINE T3 AL

CHERATUSSIN AC T2

CHERATUSSIN DAC T1

codeine sulfate T3 AL


codeine-guaifenesin T1 QL (120 ML per 30 days); AL

DEMEROL T2

DILAUDID T2

DOLOPHINE T2

DSUVIA T4 PA

DURAGESIC T2 QL (10 QY per 30 DYs)

ENDOCET ORAL TABLET 10-325 MG, 2.5-325

MG, 7.5-325 MG

T3

ENDOCET ORAL TABLET 5-325 MG T1

fentanyl T1 PA; QL (10 QY per 30 DYs)

fentanyl citrate T3

FENTORA T3



HYCET T3

hydrocodone-acetaminophen oral solution T1


mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg

T3


mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,

7.5-750 mg

T1


hydrocodone-ibuprofen T3

hydromorphone T1


71

Drug Tier Notes

IBUDONE T3

ibuprofen-oxycodone T3

LAZANDA T3

levorphanol tartrate T3

LORTAB T2

LORTAB ELIXIR T2

meperidine T1

methadone oral concentrate T1

methadone oral solution T1

methadone oral tablet T1 PA

methadone oral tablet,soluble T1

morphine concentrate T1

morphine intramuscular T3

morphine oral capsule, er multiphase 24 hr T3 PA

morphine oral solution T1

morphine oral tablet T1

morphine oral tablet extended release T1 PA

MS CONTIN T2

NUCYNTA T3

OPANA T3

OXAYDO T3

oxycodone oral concentrate T1

oxycodone oral solution T1

oxycodone oral tablet 10 mg T1 QL (9 EA per 1 day)


oxycodone oral tablet 20 mg, 30 mg T1


oxycodone-acetaminophen oral capsule T1

oxycodone-acetaminophen oral solution T3

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 7.5-325 mg

T3

oxycodone-acetaminophen oral tablet 5-325 mg T1


72

Drug Tier Notes

oxymorphone T3

PERCOCET ORAL TABLET 10-325 MG, 2.5-

325 MG, 7.5-325 MG

T3

PERCOCET ORAL TABLET 5-325 MG T2

PRIMLEV T3


promethazine-codeine T1 QL (120 ML per 30 days); AL

REPREXAIN T3

ROXICODONE ORAL TABLET 15 MG, 30 MG T2

ROXICODONE ORAL TABLET 5 MG T3

SUBSYS T3

SYNALGOS-DC T3

tramadol T1 AL


TREZIX T3

TUSSIGON T1

TYLENOL-CODEINE #4 T2 AL

ULTRACET T3 AL

ULTRAM T2 AL

VERDROCET T3

VICODIN T3

VICODIN ES T3

VICODIN HP T3

VICOPROFEN T3

XODOL 10/300 T3

XODOL 5/300 T3

XODOL 7.5/300 T3

XYLON 10 T3

ZODRYL AC 25 T1

ZODRYL AC 30 T1

ZODRYL AC 35 T1

ZODRYL AC 40 T1

ZODRYL AC 50 T1


73

Drug Tier Notes

ZODRYL AC 60 T1

ZODRYL AC 80 T1

Opiate Antagonists

naloxone T1

naltrexone T1

NARCAN T1

REVIA T2

VIVITROL T1 QL (1 EA per 30 days)

Opiate Partial Agonists

buprenorphine T3 PA

buprenorphine hcl T3 PA

buprenorphine-naloxone sublingual tablet 2-0.5

mg


buprenorphine-naloxone sublingual tablet 8-2 mg T1 QL (2 EA per 1 day)

nalbuphine T1

SUBLOCADE T1 PA

ZUBSOLV T3 PA

Other Nonsteroidal Anti-Inflam. Agents

ANAPROX T2

ANAPROX DS T2

CATAFLAM T2

CHILDREN'S IBUPROFEN T2

diclofenac potassium T1

diclofenac sodium oral T1

diclofenac sodium topical T1 ST

EC-NAPROSYN T2

FELDENE T2

flurbiprofen T1

hydrocodone-ibuprofen T3

IBUDONE T3

ibuprofen T1

ibuprofen-oxycodone T3


74

Drug Tier Notes

indomethacin T1

INFANT'S IBUPROFEN T1

ketoprofen T1

meloxicam oral tablet 15 mg T1

meloxicam oral tablet 7.5 mg T1 QL (1 EA per 1 DY)

MOBIC T2

NAPROSYN T2

naproxen T1

naproxen sodium T1

piroxicam T1

REPREXAIN T3

sulindac T1

VICOPROFEN T3

XYLON 10 T3

Phenothiazines

chlorpromazine T1 AL

fluphenazine decanoate T1

fluphenazine hcl injection T1

fluphenazine hcl oral T1 AL

perphenazine T1 AL

perphenazine-amitriptyline T1 AL

prochlorperazine T1

prochlorperazine edisylate T1 QL (20 ML per 30 days)

prochlorperazine maleate T1 AL

thioridazine T1 AL

trifluoperazine T1 AL

Respiratory And Cns Stimulants







75

Drug Tier Notes


300-40-30 mg

T3 AL


325-40-30 mg

T1 AL



CAFCIT T2

caffeine citrate T1


CONCERTA T2 PA; AL

dexmethylphenidate oral capsule,er biphasic 50-

50 10 mg, 15 mg, 5 mg

T1 PA; QL (1 EA per 1 day); AL


50 20 mg



50 25 mg, 30 mg, 35 mg, 40 mg

T1 PA; AL

dexmethylphenidate oral tablet 10 mg T1 PA; AL

dexmethylphenidate oral tablet 2.5 mg T1 QL (4 EA per 1 day); AL

dexmethylphenidate oral tablet 5 mg T1 QL (4 EA per 1 day)

ESGIC T2



FOCALIN XR T2 PA; AL

methylphenidate hcl oral capsule, er biphasic 30-

70

T1 AL

methylphenidate hcl oral solution T1 AL

methylphenidate hcl oral tablet T1 PA; AL

methylphenidate hcl oral tablet extended release T1 PA; AL

methylphenidate hcl oral tablet extended release

24hr 18 mg, 27 mg, 54 mg


methylphenidate hcl oral tablet extended release

24hr 36 mg


methylphenidate hcl oral tablet,chewable T1 AL

RITALIN T2 PA; AL


76

Drug Tier Notes

RITALIN SR T2 PA; AL

SYNALGOS-DC T3

TREZIX T3

Salicylates

ARTHRITIS T1


aspirin T1






choline,magnesium salicylate T1



salsalate T1

SYNALGOS-DC T3

Sel.Serotonin,Norepi Reuptake Inhibitor

CYMBALTA T2


mg



mg, 60 mg


EFFEXOR XR T2

SAVELLA ORAL TABLET 100 MG T1

SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50

MG


SAVELLA ORAL TABLETS,DOSE PACK T1

venlafaxine oral capsule,extended release 24hr

150 mg

T1

venlafaxine oral capsule,extended release 24hr

37.5 mg, 75 mg


venlafaxine oral tablet 100 mg T1


77

Drug Tier Notes

venlafaxine oral tablet 25 mg, 37.5 mg, 50 mg, 75

mg


venlafaxine oral tablet extended release 24hr T1

Selective Serotonin Agonists

AMERGE T3 PA; QL (12 QY per 30 DYs)

eletriptan T3 PA; QL (12 EA per 30 days)

FROVA T3 PA; QL (12 QY per 30 DYs)

IMITREX ORAL T2 QL (12 QY per 30 DYs)

IMITREX STATDOSE PEN T2 QL (2 QY per 30 DYs)

IMITREX STATDOSE REFILL T2 QL (2 QY per 30 DYs)

IMITREX SUBCUTANEOUS T2 QL (4 QY per 30 DYs)

MAXALT T2 QL (12 QY per 30 DYs)

MAXALT-MLT T2 QL (12 QY per 30 DYs)

rizatriptan T1 QL (12 QY per 30 DYs)

sumatriptan nasal spray,non-aerosol 20

mg/actuation

T1 QL (6 QY per 30 DYs)

sumatriptan nasal spray,non-aerosol 5

mg/actuation


sumatriptan succinate oral T1 QL (12 QY per 30 DYs)

sumatriptan succinate subcutaneous cartridge T1 QL (2 QY per 30 DYs)

sumatriptan succinate subcutaneous pen injector T1 QL (2 QY per 30 DYs)

sumatriptan succinate subcutaneous solution T1 QL (4 QY per 30 DYs)

ZOMIG T3 PA; QL (1 QY per 30 DYs)

Selective-Serotonin Reuptake Inhibitors

CELEXA T2

citalopram T1

escitalopram oxalate T1

fluoxetine T1

fluvoxamine T1

LEXAPRO T2

paroxetine hcl oral tablet T1 QL (1 EA per 1 day)

paroxetine hcl oral tablet extended release 24 hr

12.5 mg



78

Drug Tier Notes

paroxetine hcl oral tablet extended release 24 hr

25 mg, 37.5 mg


PAXIL T2

PROZAC T2

sertraline oral concentrate T1

sertraline oral tablet 100 mg T1

sertraline oral tablet 25 mg, 50 mg T1 QL (45 EA per 30 days)

ZOLOFT T2

Serotonin Modulators

nefazodone T1

trazodone T1

Succinimides

ethosuximide T1

ZARONTIN T2

Thioxanthenes

thiothixene T1 AL

Tricyclics, Other Norepi-Ru Inhibitors

amitriptyline T1

amitriptyline-chlordiazepoxide T1

amoxapine T1

ANAFRANIL T2

clomipramine T1

desipramine T1

doxepin T1

imipramine hcl T1

maprotiline T1

NORPRAMIN T2

nortriptyline T1

PAMELOR T2

perphenazine-amitriptyline T1

TOFRANIL T2

Vesicular Monoamine Transport2 Inhibitor


79

Drug Tier Notes

AUSTEDO T4 PA

INGREZZA T4 PA

XENAZINE T4 PA

Devices

Devices

ACCU-CHEK AVIVA CONTROL SOLN T1

ACCU-CHEK FASTCLIX LANCET DRUM T1

ACCU-CHEK GUIDE GLUCOSE METER T1

ACCU-CHEK GUIDE L1-L2 CTRL SOL T1

ACCU-CHEK GUIDE ME GLUCOSE MTR T1

ACCU-CHEK MULTICLIX LANCET T1

ACCU-CHEK SMARTVIEW CONTRL SOL T1

ACCU-CHEK SOFT DEV LANCETS T1

ACCU-CHEK SOFTCLIX LANCET DEV T1

ACCU-CHEK SOFTCLIX LANCETS T1

BD AUTOSHIELD DUO PEN NEEDLE T1 QL (200 EA per 34 days)

BD INSULIN SYRINGE HALF UNIT T1 QL (200 EA per 34 days)

BD INSULIN SYRINGE U-500 T1 QL (200 EA per 34 days)

BD INSULIN SYRINGE ULTRA-FINE T1 QL (200 EA per 34 days)

BD NANO 2ND GEN PEN NEEDLE T1 QL (200 EA per 34 days)

BD ULTRA-FINE MICRO PEN NEEDLE T1 QL (200 EA per 34 days)

BD ULTRA-FINE MINI PEN NEEDLE T1 QL (200 EA per 34 days)

BD ULTRA-FINE NANO PEN NEEDLE T1 QL (200 EA per 34 days)

BD ULTRA-FINE ORIG PEN NEEDLE T1 QL (200 EA per 34 days)

BD ULTRA-FINE SHORT PEN NEEDLE T1 QL (200 EA per 34 days)

BD VEO INSULIN SYR HALF UNIT T1 QL (200 EA per 34 days)

BD VEO INSULIN SYRINGE UF T1 QL (200 EA per 34 days)

EUFLEXXA T4 PA

GEL-ONE T4 PA

GELSYN-3 T4 PA

GENVISC 850 T4 PA

HYALGAN T4 PA


80

Drug Tier Notes

NEUROPEN T1 QL (1 EA per 365 days)

NEUROTIPS T1 QL (1 EA per 365 days)

ORTHOVISC T4 PA

sodium chloride T1

SOFT TOUCH LANCETS T1

SOLESTA T4 PA

SUPARTZ FX T4 PA

SYNVISC T4 PA

SYNVISC-ONE T4 PA

Diagnostic Agents

Adrenocortical Insufficiency

ACTHAR H.P. T4 PA

ACTHREL T4 PA

Diabetes Mellitus

ACCU-CHEK AVIVA PLUS TEST STRP T1

ACCU-CHEK GUIDE T1

ACCU-CHEK SMARTVIEW TEST STRIP T1

Ketones

KETOSTIX T1

Pituitary Function

ACTHREL T4 PA

MACRILEN T4 PA

Protein

ALBUSTIX REAGENT T1

Roentgenography And Other Imaging Agents



Thyroid Function

THYROGEN T4 PA

Urine And Feces Contents

KETO-DIASTIX T1


81

Drug Tier Notes

Electrolytic, Caloric, And Water Balance

Alkalinizing Agents

potassium citrate T1

sodium citrate-citric acid T1

UROCIT-K 10 T1

UROCIT-K 5 T2

Ammonia Detoxicants

CARBAGLU T4 PA

lactulose T1

RAVICTI T4 PA

sodium phenylbutyrate T4 PA

Caloric Agents

glucose T1

Carbonic Anhydrase Inhibitors

acetazolamide T1


Diuretics, Miscellaneous

THEO-24 T1

theophylline T1

Electrolytic,Caloric,Water Balance Misc,

CRYSVITA T4 PA

Irrigating Solutions

SEA-CLENS WOUND CLEANSER T1

water for irrigation, sterile T1

Loop Diuretics

bumetanide T1

DEMADEX T2

furosemide T1

LASIX T2

torsemide T1

Phosphate-Removing Agents


82

Drug Tier Notes

calcium acetate T1

lanthanum T1

PHOSLO T2

sevelamer carbonate T1

Potassium-Removing Agents

LOKELMA T3 PA

SPS (WITH SORBITOL) T1

VELTASSA T3 PA

Potassium-Sparing Diuretics

ALDACTAZIDE T2

ALDACTONE T2

amiloride T1


DYAZIDE T2

MAXZIDE T2

MAXZIDE-25MG T2

spironolactone T1



Replacement Preparations

CALCI-MIX T1

CALCITRATE T1

CALCIUM 600 T1

CALCIUM 600 + D(3) T1

CALCIUM 600 + MINERALS T1

CALCIUM ANTACID T1

calcium carbonate T1

calcium carbonate-vitamin d2 T1


calcium citrate T1

calcium citrate-vitamin d3 T1

calcium gluconate T1


83

Drug Tier Notes

calcium lactate T1

CITRACAL + D3 (CALCIUM PHOS) T1

CITRUS CALCIUM T1

CORAL CALCIUM T1

DAILY PRENATAL T1

FOSFREE T1

KLOR-CON T1

KLOR-CON M10 T2

KLOR-CON M20 T2

LIQUID CALCIUM WITH VITAMIN D T1

magnesium chloride T1




OYSTER SHELL CALCIUM 500 T1

OYSTER SHELL CALCIUM-VIT D2 T1


PEDIATRIC ELECTROLYTE T1

PERRY PRENATAL T1

potassium chloride T1

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENATAL PLUS T1

PRENATAL VITAMIN T1



sodium chloride T1

THERAPEUTIC-M T1

TRIVEEN-DUO DHA T1

TUMS T2

TUMS ULTRA T2


84

Drug Tier Notes

Thiazide Diuretics

ACCURETIC T2

ALDACTAZIDE T2


AVALIDE T2 ST


mg, 20-12.5 mg, 5-6.25 mg



mg

T1



chlorothiazide T1

CORZIDE T2

DIURIL T1

DYAZIDE T2


hydrochlorothiazide T1

HYZAAR T2



LOPRESSOR HCT T2


LOTENSIN HCT T2

MAXZIDE T2

MAXZIDE-25MG T2










85

Drug Tier Notes


UNIRETIC T2


VASERETIC T2

ZESTORETIC T2

ZIAC T2

Thiazide-Like Diuretics


chlorthalidone T1

CLORPRES T1

indapamide T1

metolazone T1

ZAROXOLYN T2

Uricosuric Agents

probenecid T1

probenecid-colchicine T1

Vasopressin Antagonists

JYNARQUE T4 PA

SAMSCA T4 PA

Enzymes

Enzymes

ACTIVASE T4 PA

ADAGEN T4 PA

ALDURAZYME T4 PA

BRINEURA T4 PA

CATHFLO ACTIVASE T4 PA

CEREZYME T4 PA

ELAPRASE T4 PA

ELELYSO T4 PA

ELITEK T4 PA

FABRAZYME T4 PA


86

Drug Tier Notes

KANUMA T4 PA

MEPSEVII T4 PA

MYOZYME T4 PA

NAGLAZYME T4 PA

PALYNZIQ T4 PA

PULMOZYME T4 PA

REVCOVI T4 PA

STRENSIQ T4 PA

SUCRAID T4 PA

VIMIZIM T4 PA

VORAXAZE T4 PA

VPRIV T4 PA

XIAFLEX T4 PA

Eye, Ear, Nose And Throat (Eent) Preps.

Alpha-Adrenergic Agonists (Eent)

ALPHAGAN P T2

brimonidine T1

Antiallergic Agents

ALAWAY T2 QL (1 QY per 30 DYs)

ASTELIN T2

ASTEPRO T2

azelastine nasal T1

azelastine ophthalmic (eye) T1 ST

cromolyn T1

ketotifen fumarate T1 QL (1 QY per 30 DYs)

olopatadine T1 ST

ZADITOR T2 QL (1 QY per 30 DYs)

Antibacterials (Eent)

bacitracin T1

bacitracin-polymyxin b T1

BLEPH-10 T2

CILOXAN T2


87

Drug Tier Notes

CIPRODEX T3 PA

ciprofloxacin hcl T1 QL (10 ML per 25 days)

erythromycin T1 QL (3.5 GM per 25 days)

GENTAK T1 QL (4 GM per 30 days)

gentamicin T1

MAXITROL T2

MOXEZA T1

moxifloxacin T1 QL (3 ML per 30 days)

neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)

neomycin-bacitracin-polymyxin T1 QL (4 GM per 30 days)

neomycin-polymyxin b-dexameth ophthalmic (eye)

drops,suspension

T1 QL (5 ML per 30 days)


ointment

T1 QL (4 GM per 30 days)

neomycin-polymyxin-gramicidin T1 QL (10 ML per 25 days)

neomycin-polymyxin-hc T1

NEOSPORIN (NEO-POLYM-GRAMICID) T2

OCUFLOX T2

ofloxacin ophthalmic (eye) T1 QL (10 ML per 25 days)

ofloxacin otic (ear) T1

polymyxin b sulf-trimethoprim T1 QL (10 ML per 30 days)

POLYTRIM T2

sulfacetamide sodium T1

sulfacetamide-prednisolone T1

TOBRADEX T2

tobramycin T1 QL (5 ML per 25 days)

tobramycin-dexamethasone T1

TOBREX OPHTHALMIC (EYE) DROPS T2

TOBREX OPHTHALMIC (EYE) OINTMENT T1 QL (4 GM per 30 days)

Antivirals (Eent)

trifluridine T1 QL (8 ML per 25 days)

VIROPTIC T2


88

Drug Tier Notes

Beta-Adrenergic Blocking Agents (Eent)

BETAGAN T2

carteolol T1

COSOPT T2

dorzolamide-timolol T1

levobunolol T1

timolol maleate T1

TIMOPTIC T2

TIMOPTIC OCUDOSE (PF) T1

TIMOPTIC-XE T2

Carbonic Anhydrase Inhibitors (Eent)

acetazolamide T1

COSOPT T2


dorzolamide T1

dorzolamide-timolol T1

TRUSOPT T2

Corticosteroids (Eent)

ACETASOL HC T2

CIPRODEX T3 PA

dexamethasone sodium phosphate T1

fluorometholone T1

fluticasone propionate T1

FML FORTE T1

FML LIQUIFILM T2

FML S.O.P. T1

hydrocortisone-acetic acid T1

ILUVIEN T4 PA

MAXIDEX T1

MAXITROL T2

neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)


drops,suspension



89

Drug Tier Notes


ointment

T1 QL (4 GM per 30 days)

neomycin-polymyxin-hc T1

OMNARIS T3 PA

OZURDEX T4 PA

PRED FORTE T2

PRED MILD T1

prednisolone acetate T1

prednisolone sodium phosphate T1 QL (10 ML per 30 days)

RETISERT T4 PA

TOBRADEX T2

tobramycin-dexamethasone T1

triamcinolone acetonide T1 ST

Eent Anti-Infectives, Miscellaneous

ACETASOL HC T2

acetic acid T1

acetic acid-aluminum acetate T1

carbamide peroxide T1

chlorhexidine gluconate T1

hydrocortisone-acetic acid T1

PERIOGARD T2

Eent Anti-Inflammatory Agents, Misc.

RESTASIS T1 ST

RESTASIS MULTIDOSE T1 ST

XIIDRA T1 ST

Eent Drugs, Miscellaneous

apraclonidine T1

ARTIFICIAL TEARS (POLYVIN ALC) T2

ARTIFICIAL TEARS(GLYCERIN-PEG) T1

ATROVENT T2

bevacizumab T4 PA

CYSTARAN T4 PA


90

Drug Tier Notes

EYLEA T4 PA

IOPIDINE OPHTHALMIC (EYE)

DROPPERETTE

T1

IOPIDINE OPHTHALMIC (EYE) DROPS T2


ISOPTO TEARS T1

JETREA (PF) T4 PA

LUBRICATING PLUS T1

LUCENTIS T4 PA

MACUGEN T4 PA

NASAL MIST T1

OXERVATE T4 PA

PHOTREXA T4 PA

PHOTREXA CROSS-LINKING KIT T4 PA

PHOTREXA VISCOUS T4 PA

polyvinyl alcohol T1

REFRESH CLASSIC (PF) T1

REFRESH OPTIVE T1

REFRESH REPAIR T1

REFRESH TEARS T1

SALINE NASAL MIST T1

sodium chloride T1

TEARS NATURALE FREE (PF) T1

TEARS NATURALE II T1

ULTRA FRESH PM T1

VISUDYNE T4 PA

Eent Nonsteroidal Anti-Inflam. Agents

ACULAR T2

ACULAR LS T2

flurbiprofen sodium T1 QL (2.5 ML per 30 days)

ketorolac ophthalmic (eye) drops 0.4 % T1 QL (5 ML per 30 days)

ketorolac ophthalmic (eye) drops 0.5 % T1 QL (20 ML per 25 days)

OCUFEN T2


91

Drug Tier Notes

Local Anesthetics (Eent)

lidocaine hcl T1

LIDOCAINE VISCOUS T1

XYLOCAINE T2

Miotics

PHOSPHOLINE IODIDE T1

pilocarpine hcl T1

PILOPINE HS T1

Mydriatics

atropine T1

cyclopentolate T1

HOMATROPAIRE T1

Prostaglandin Analogs

latanoprost T1 QL (6 ML per 30 days)

travoprost (benzalkonium) T1 ST; QL (5 ML per 30 days)

XALATAN T2

Vasoconstrictors

ADRENALIN T1

MYDFRIN T2

naphazoline T1

NASAL DECONGESTANT (OXYMETAZL) T1

NEO-SYNEPHRINE (PHENYLEPHRINE) T1

NEO-SYNEPHRINE 12 H SPR (OXYM) T1

phenylephrine hcl T1

Gastrointestinal Drugs

5-Ht3 Receptor Antagonists

ALOXI T4 PA

granisetron (pf) T4 PA

granisetron hcl intravenous T4 PA

granisetron hcl oral T1 ST

ondansetron T1


92

Drug Tier Notes

ondansetron hcl intravenous T4 PA

ondansetron hcl oral T1

SUSTOL T4 PA

ZOFRAN T2

ZOFRAN ODT T2

Antacids And Adsorbents

ACID GONE ANTACID T1

aluminum hydroxide gel T1

ANTACID PLUS ANTI-GAS T1

BISMUTH MAXIMUM STRENGTH T1

bismuth subsalicylate T1

CALCIUM ANTACID T1

calcium carbonate T1

FOAMING ANTACID T1

magnesium oxide T1

PEPTO-BISMOL T2

PINK BISMUTH T1

RI-MAG T1

sodium bicarbonate T1

TUMS T2

TUMS ULTRA T2

URO-MAG T1

Antidiarrhea Agents

BISMUTH MAXIMUM STRENGTH T1

bismuth subsalicylate T1


LOMOTIL T2

loperamide T1

PEPTO-BISMOL T2

PINK BISMUTH T1

XERMELO T4 PA

Antiemetics, Miscellaneous


93

Drug Tier Notes

doxylamine-pyridoxine (vit b6) T1 PA

scopolamine base T3 PA

Antiflatulents

ANTACID PLUS ANTI-GAS T1

ANTI-GAS MAXIMUM STRENGTH T1

simethicone T1

Antihistamines (Gi Drugs)

ANTIVERT T2

dimenhydrinate T1


meclizine T1

prochlorperazine T1

prochlorperazine edisylate T1 QL (20 ML per 30 days)

prochlorperazine maleate T1

TIGAN T1

trimethobenzamide T1

Anti-Inflammatory Agents (Gi Drugs)

AZULFIDINE T2


balsalazide T1

CANASA T1

COLAZAL T2

mesalamine T1

PENTASA ORAL CAPSULE, EXTENDED

RELEASE 250 MG


PENTASA ORAL CAPSULE, EXTENDED

RELEASE 500 MG

T1

sulfasalazine T1

Cathartics And Laxatives

AMITIZA ORAL CAPSULE 24 MCG T1

AMITIZA ORAL CAPSULE 8 MCG T1 QL (2 EA per 1 day)

bisacodyl T1


94

Drug Tier Notes

calcium polycarbophil T1

COL-RITE T1

COLYTE WITH FLAVOR PACKS T2

docusate calcium T1

docusate sodium T1

DOCUSOL T1

ENEMA T1

FIBER T1

FIBER (DEXTRIN) T1

FIBER (WITH ASPARTAME) T1

FLEET BISACODYL T1

FLEET LAXATIVE T1

GAVILYTE-G T1

glycerin (adult) T1

glycerin (child) T1

GOLYTELY T2

LAXATIVE (SENNOSIDES) T1

magnesium citrate T1

METAMUCIL (WITH SUGAR) T1

MILK OF MAGNESIA T1

mineral oil T1

MINERAL OIL LAXATIVE T1

MIRALAX T2

NATURAL FIBER LAXATIVE (SUGAR) T1

NATURAL FIBER LAXATIVE THERAPY T1

NULYTELY WITH FLAVOR PACKS T2

PEDIA-LAX T1

peg 3350-electrolytes T1

peg-electrolyte soln T1

polyethylene glycol 3350 T1

SENNA T1

sennosides T1

sennosides-docusate sodium T1


95

Drug Tier Notes

SILACE T2

STOOL SOFTENER T1

TRILYTE WITH FLAVOR PACKETS T2

Cholelitholytic Agents

ACTIGALL T2

URSO 250 T2

URSO FORTE T2

ursodiol T1

Digestants

CREON T1

lactase T1

ZENPEP T1

Gi Drugs, Miscellaneous

CHOLBAM T4 PA

CIMZIA T4 PA

CIMZIA POWDER FOR RECONST T4 PA

ENDARI T4 PA

ENTYVIO T4 PA

GATTEX 30-VIAL T4 PA

HUMIRA T4 PA

HUMIRA PEDIATRIC CROHNS START T4 PA

HUMIRA PEN T4 PA

HUMIRA PEN CROHNS-UC-HS START T4 PA

HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA

HUMIRA(CF) T4 PA

HUMIRA(CF) PEDI CROHNS STARTER T4 PA

HUMIRA(CF) PEN T4 PA

HUMIRA(CF) PEN CROHNS-UC-HS T4 PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS T4 PA

INFLECTRA T4 PA

LINZESS ORAL CAPSULE 145 MCG, 290 MCG T1 AL

LINZESS ORAL CAPSULE 72 MCG T1


96

Drug Tier Notes

OCALIVA T4 PA

REMICADE T4 PA

RENFLEXIS T4 PA

SIMPONI T4 PA

SIMPONI ARIA T4 PA

Histamine H2-Antagonists

cimetidine T1

cimetidine hcl T1

famotidine T1

nizatidine oral capsule 150 mg T1 QL (2 EA per 1 day)

nizatidine oral capsule 300 mg T1

PEPCID T2

ranitidine hcl T1

ZANTAC T2

Lipotropic Agents

choline bitartrate T1

Neurokinin-1 Receptor Antagonists

aprepitant oral capsule 125 mg, 80 mg T1

aprepitant oral capsule 40 mg T1 QL (1 QY per 30 days)

aprepitant oral capsule,dose pack T1

CINVANTI T4 PA

EMEND INTRAVENOUS T4 PA

EMEND ORAL CAPSULE 125 MG, 80 MG T2

EMEND ORAL CAPSULE 40 MG T2 QL (1 QY per 30 DYs)

EMEND ORAL CAPSULE,DOSE PACK T2

VARUBI T4 PA

Prokinetic Agents

metoclopramide hcl T1

REGLAN T2

Prostaglandins

CYTOTEC T2

misoprostol T1


97

Drug Tier Notes

Protectants

CARAFATE ORAL SUSPENSION T1 QL (1200 ML per 30 days)

CARAFATE ORAL TABLET T2

sucralfate T1

Proton-Pump Inhibitors

esomeprazole magnesium T1 ST; QL (2 EA per 1 day)

lansoprazole T1 ST; QL (2 EA per 1 day)

NEXIUM 24HR T1 ST; QL (2 EA per 1 day)

NEXIUM PACKET T3 PA

omeprazole T1 QL (2 EA per 1 day)

omeprazole-sodium bicarbonate T1 ST

pantoprazole T1 QL (2 EA per 1 day)

PRILOSEC T1 QL (2 EA per 1 day); AL

PRILOSEC OTC T3 PA

PROTONIX ORAL GRANULES DR FOR SUSP

IN PACKET

T3 PA

PROTONIX ORAL TABLET,DELAYED

RELEASE (DR/EC)

T2

rabeprazole T1 ST

ZEGERID T3 PA

ZEGERID OTC T2 ST

Heavy Metal Antagonists

Heavy Metal Antagonists

CHEMET T1

CUPRIMINE T4 PA

deferoxamine T4 PA

DEPEN TITRATABS T4 PA

EXJADE T4 PA

FERRIPROX T4 PA

GALZIN T4 PA

JADENU T4 PA

JADENU SPRINKLE T4 PA


98

Drug Tier Notes

trientine T4 PA

Hormones And Synthetic Substitutes

Adrenals

ARMONAIR RESPICLICK T1

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 200

MCG/ACTUATION



WITH DEVICE 50 MCG/ACTUATION

T1 QL (1 EA per 30 DYs)

ASMANEX HFA T1

ASMANEX TWISTHALER INHALATION

AEROSOL POWDR BREATH ACTIVATED 110

MCG (30 DOSES), 220 MCG (120 DOSES), 220

MCG (30 DOSES), 220 MCG (60 DOSES)




MCG (7 DOSES)




MCG (14 DOSES)


budesonide inhalation suspension for nebulization

0.25 mg/2 ml

T1 QL (60 QY per 30 DYs); AL


0.5 mg/2 ml



1 mg/2 ml

T1 QL (60 ML per 30 DYs); AL

CORTEF T2

cortisone T1

dexamethasone T1

DEXAMETHASONE INTENSOL T1

dexamethasone sodium phos (pf) T1

dexamethasone sodium phosphate T1


EMFLAZA T4 PA

ENTOCORT EC T3 PA

FLOVENT DISKUS INHALATION BLISTER




99

Drug Tier Notes







FLOVENT HFA INHALATION HFA AEROSOL

INHALER 110 MCG/ACTUATION







T1 QL (10.6 QY per 30 DYs)

fludrocortisone T1



T1


with device


hydrocortisone T1

INTRAROSA T1

MEDROL (PAK) T2

MEDROL ORAL TABLET 16 MG, 32 MG, 4

MG, 8 MG

T2

MEDROL ORAL TABLET 2 MG T1

methylprednisolone T1

ORAPRED T2

prednisolone T1

prednisolone sodium phosphate T1

prednisone T1

PREDNISONE INTENSOL T1

PRELONE T2

PULMICORT INHALATION SUSPENSION

FOR NEBULIZATION 0.25 MG/2 ML





QVAR INHALATION AEROSOL 40

MCG/ACTUATION



MCG/ACTUATION



100

Drug Tier Notes

QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 40

MCG/ACTUATION

T1 QL (10.6 GM per 30 days)



MCG/ACTUATION



Androgens

AVEED T4 PA

danazol T1 PA

fluoxymesterone T1 PA

TESTOPEL T4 PA

testosterone T1 PA

testosterone cypionate intramuscular oil 100

mg/ml


testosterone cypionate intramuscular oil 200

mg/ml


testosterone enanthate T1 QL (5 QY per 30 DYs)

Antidiabetic Agents, Miscellaneous

colesevelam oral powder in packet T1

colesevelam oral tablet T1 QL (6 EA per 1 day)

WELCHOL T2

Antiestrogens

anastrozole T1

ARIMIDEX T2

AROMASIN T4 PA

FEMARA T2 QL (1 QY per 1 DY)

KISQALI FEMARA CO-PACK T4 PA

letrozole T1 QL (1 QY per 1 DY)

Antigonadtropins

FIRMAGON T4 PA

ganirelix T4 PA

ORILISSA T1 PA

Antiparathyroid Agents


101

Drug Tier Notes

calcitonin (salmon) T1

MIACALCIN INJECTION T4 PA

MIACALCIN NASAL T2

PARSABIV T4 PA

Antithyroid Agents

methimazole T1

propylthiouracil T1

SSKI T1

TAPAZOLE T2

Biguanides

alogliptin-metformin T1 ST

glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)

glipizide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

GLUCOPHAGE T2

GLUCOPHAGE XR T2

GLUCOVANCE T2

glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)

glyburide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

JANUMET T1 ST

JANUMET XR T1 ST

metformin oral tablet T1

metformin oral tablet extended release 24 hr 500

mg

T1

metformin oral tablet extended release 24 hr 750

mg


pioglitazone-metformin T1 ST

SEGLUROMET T1 ST

Contraceptives

ARANELLE (28) T1

BALCOLTRA T1

BALZIVA (28) T1


102

Drug Tier Notes

CAMILA T2

CAMRESE T1

CRYSELLE (28) T1

CYCLESSA (28) T2

desog-e.estradiol/e.estradiol T1

DESOGEN T2

desogestrel-ethinyl estradiol T2

drospirenone-e.estradiol-lm.fa T1

drospirenone-ethinyl estradiol T1

ELLA T1

ENPRESSE T1

ERRIN T2

ESTROSTEP FE-28 T1

FEMCON FE T2

INTROVALE T2

JOLESSA T2

JOLIVETTE T2

JUNEL 1.5/30 (21) T1

JUNEL 1/20 (21) T1

JUNEL FE 1.5/30 (28) T1

JUNEL FE 1/20 (28) T1

KARIVA (28) T1

KELNOR 1/35 (28) T1

KURVELO (28) T1

KYLEENA T1

l norgest/e.estradiol-e.estrad T1

LEENA 28 T1

LESSINA T2

levonorgestrel-ethinyl estrad T1

LEVORA-28 T2

LILETTA T1

LO LOESTRIN FE T1

LOESTRIN 1.5/30 (21) T2


103

Drug Tier Notes

LOESTRIN 1/20 (21) T2

LOESTRIN 24 FE T2

LOESTRIN FE 1.5/30 (28-DAY) T1

LOESTRIN FE 1/20 (28-DAY) T2

LOW-OGESTREL (28) T1

LUTERA (28) T2

MICROGESTIN 1.5/30 (21) T1

MICROGESTIN 1/20 (21) T2

MICROGESTIN FE 1.5/30 (28) T1

MICROGESTIN FE 1/20 (28) T2

MIRCETTE (28) T2

MIRENA T1

MODICON (28) T2

MONONESSA (28) T2

NATAZIA T1

NECON 1/35 (28) T1

NECON 1/50 (28) T1

NECON 7/7/7 (28) T1

NEXPLANON T1

NORA-BE T2

noreth-ethinyl estradiol-iron T1

norethindrone (contraceptive) T1

norethindrone ac-eth estradiol T1

norethindrone-e.estradiol-iron T1

norgestimate-ethinyl estradiol T1

NORINYL 1/35 (28) T2

NORTREL 0.5/35 (28) T1

NORTREL 1/35 (21) T1

NORTREL 1/35 (28) T1

NORTREL 7/7/7 (28) T1

NUVARING T1 QL (1 EA per 28 DYs)

OCELLA T2


104

Drug Tier Notes

OGESTREL (28) T1

ORTHO TRI-CYCLEN (28) T2

ORTHO TRI-CYCLEN LO (28) T2

ORTHO-NOVUM 1/35 (28) T2

PARAGARD T 380A T1

PLAN B ONE-STEP T1

PORTIA 28 T2

QUASENSE T2

RECLIPSEN (28) T1

SEASONIQUE T2

SKYLA T1

SPRINTEC (28) T2

SRONYX T2

TAYTULLA T1

TRINESSA (28) T1

TRI-NORINYL (28) T2

TRI-SPRINTEC (28) T2

TRIVORA (28) T1

VELIVET TRIPHASIC REGIMEN (28) T1

XULANE T1 QL (3 EA per 28 days)

YASMIN (28) T2

ZENCHENT FE T1

ZOVIA 1/35E (28) T1

ZOVIA 1/50E (28) T1

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors

alogliptin T1 ST

alogliptin-metformin T1 ST

alogliptin-pioglitazone T1 ST

JANUMET T1 ST

JANUMET XR T1 ST

JANUVIA T1 ST

Estrogen Agonist-Antagonists


105

Drug Tier Notes

FARESTON T1 ST

raloxifene T1

tamoxifen T1

Estrogens

CLIMARA T2

COMBIPATCH T1

estradiol T1

estropipate T1

FEMHRT LOW DOSE T2

JINTELI T1

MENEST T1


PREMARIN T1

PREMPHASE T1

PREMPRO T1

Glycogenolytic Agents

GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)

GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)

Gonadotropins

BRAVELLE T4 PA

chorionic gonadotropin, human T4 PA

ELIGARD T4 PA




FOLLISTIM AQ T4 PA

GONAL-F T4 PA

GONAL-F RFF T4 PA

GONAL-F RFF REDI-JECT T4 PA

leuprolide T4 PA




106

Drug Tier Notes

LUPRON DEPOT T4 PA






MENOPUR T4 PA

NOVAREL T4 PA

OVIDREL T4 PA

SUPPRELIN LA T4 PA

TRELSTAR T4 PA

TRELSTAR DEPOT T4 PA

TRELSTAR LA T4 PA

TRIPTODUR T4 PA

VANTAS T4 PA

ZOLADEX T4 PA

Gonadotropins And Antigonadotropins

BRAVELLE T4 PA

chorionic gonadotropin, human T4 PA

ELIGARD T4 PA




FOLLISTIM AQ T4 PA

GONAL-F T4 PA

GONAL-F RFF T4 PA

GONAL-F RFF REDI-JECT T4 PA

leuprolide T4 PA



LUPRON DEPOT T4 PA



107

Drug Tier Notes





MENOPUR T4 PA

NOVAREL T4 PA

OVIDREL T4 PA

SUPPRELIN LA T4 PA

TRIPTODUR T4 PA

VANTAS T4 PA

ZOLADEX T4 PA

Incretin Mimetics

OZEMPIC T1 ST

TRULICITY T1 ST

VICTOZA 2-PAK T1 ST

VICTOZA 3-PAK T1 ST

Insulins

ADMELOG SOLOSTAR U-100 INSULIN T1 QL (30 ML per 30 days)

ADMELOG U-100 INSULIN LISPRO T1 QL (30 ML per 30 days)

BASAGLAR KWIKPEN U-100 INSULIN T1 QL (30 ML per 30 DYs)

HUMALOG JUNIOR KWIKPEN U-100 T1 QL (30 ML per 30 days)

HUMALOG MIX 50-50 INSULN U-100 T1 QL (3 QY per 30 DYs)

HUMALOG MIX 50-50 KWIKPEN T1 QL (2 QY per 30 DYs)


HUMALOG MIX 75-25(U-100)INSULN T1 QL (3 QY per 30 DYs)

HUMULIN 70/30 U-100 INSULIN T1 QL (3 QY per 30 DYs)

HUMULIN 70/30 U-100 KWIKPEN T1

HUMULIN N NPH INSULIN KWIKPEN T1

HUMULIN N NPH U-100 INSULIN T1 QL (3 QY per 30 DYs)

HUMULIN R REGULAR U-100 INSULN T1 QL (3 QY per 30 DYs)

HUMULIN R U-500 (CONC) INSULIN T1

Intermediate-Acting Insulins


108

Drug Tier Notes







HUMULIN N NPH INSULIN KWIKPEN T1

HUMULIN N NPH U-100 INSULIN T1 QL (3 QY per 30 DYs)

Leptins

MYALEPT T4 PA

Long-Acting Insulins

BASAGLAR KWIKPEN U-100 INSULIN T1 QL (30 ML per 30 DYs)

Parathyroid Agents

FORTEO T4 PA

TYMLOS T4 PA

Parathyroid And Antiparathyroid Agents


FORTEO T4 PA


MIACALCIN NASAL T2

TYMLOS T4 PA

Pituitary

ACTHAR H.P. T4 PA

DDAVP NASAL T2 PA

DDAVP ORAL T2 PA; AL

desmopressin nasal T1 PA

desmopressin oral T1 PA; AL

GENOTROPIN T4 PA

GENOTROPIN MINIQUICK T4 PA

HUMATROPE T4 PA

NORDITROPIN FLEXPRO T4 PA

NORDITROPIN NORDIFLEX T4 PA


109

Drug Tier Notes

NUTROPIN AQ T4 PA

NUTROPIN AQ NUSPIN T4 PA

OMNITROPE T4 PA

SAIZEN T4 PA

SAIZEN CLICK.EASY T4 PA

SEROSTIM T4 PA

STIMATE T1 PA

ZOMACTON T4 PA

Progestins

AYGESTIN T2

COMBIPATCH T1

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 150 MG/ML

T2

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/ML

T1

DEPO-SUBQ PROVERA 104 T1

FEMHRT LOW DOSE T2

hydroxyprogest(pf)(preg presv) T4 PA

hydroxyprogesterone cap(ppres) T4 PA

hydroxyprogesterone caproate T4 PA

JINTELI T1



MAKENA T4 PA

MAKENA (PF) T4 PA

medroxyprogesterone intramuscular suspension T1 QL (1 ML per 30 days)

medroxyprogesterone intramuscular syringe T1 QL (1 ML per 30 DYs)

medroxyprogesterone oral T1

MEGACE T2

MEGACE ES T2 QL (150 QY per 30 DYs)

megestrol oral suspension 400 mg/10 ml (40

mg/ml)

T1

megestrol oral suspension 625 mg/5 ml T1 QL (150 ML per 30 DYs)


110

Drug Tier Notes

megestrol oral tablet T1

norethindrone acetate T1


PROVERA T2

Rapid-Acting Insulins

ADMELOG SOLOSTAR U-100 INSULIN T1 QL (30 ML per 30 days)

ADMELOG U-100 INSULIN LISPRO T1 QL (30 ML per 30 days)

HUMALOG JUNIOR KWIKPEN U-100 T1 QL (30 ML per 30 days)





Short-Acting Insulins



HUMULIN R REGULAR U-100 INSULN T1 QL (3 QY per 30 DYs)

HUMULIN R U-500 (CONC) INSULIN T1

Sodium-Gluc Cotransport 2 (Sglt2) Inhib

SEGLUROMET T1 ST

STEGLATRO T1 ST

Somatostatin Agonists

octreotide acetate T4 PA

SANDOSTATIN T4 PA

SANDOSTATIN LAR DEPOT T4 PA

SIGNIFOR T4 PA

SIGNIFOR LAR T4 PA

SOMATULINE DEPOT T4 PA

Somatotropin Agonists

EGRIFTA T4 PA

INCRELEX T4 PA

Somatotropin Antagonists

SOMAVERT T4 PA


111

Drug Tier Notes

Sulfonylureas

AMARYL T2

DIABETA T2

glimepiride oral tablet 1 mg, 2 mg T1 QL (3 EA per 1 day)

glimepiride oral tablet 4 mg T1

glipizide oral tablet 10 mg T1

glipizide oral tablet 5 mg T1 QL (5 EA per 1 day)

glipizide oral tablet extended release 24hr 10 mg T1

glipizide oral tablet extended release 24hr 2.5 mg,

5 mg


glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)

glipizide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

GLUCOTROL T2

GLUCOTROL XL T2

GLUCOVANCE T2

glyburide micronized oral tablet 1.5 mg, 3 mg T1 QL (3 EA per 1 day)

glyburide micronized oral tablet 6 mg T1

glyburide oral tablet 1.25 mg, 2.5 mg T1 QL (3 EA per 1 day)

glyburide oral tablet 5 mg T1

glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)

glyburide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

GLYNASE T2

Thiazolidinediones

alogliptin-pioglitazone T1 ST

pioglitazone T1 ST

pioglitazone-metformin T1 ST

Thyroid Agents

ARMOUR THYROID ORAL TABLET 120 MG,

15 MG, 30 MG, 60 MG, 90 MG

T2

ARMOUR THYROID ORAL TABLET 180 MG,

240 MG, 300 MG

T1


112

Drug Tier Notes

CYTOMEL T2

levothyroxine T1

liothyronine T1

NATURE-THROID T1

SYNTHROID T2

thyroid (pork) T1

THYROLAR-1 T1

THYROLAR-1/2 T1

THYROLAR-1/4 T1

THYROLAR-2 T1

THYROLAR-3 T1

UNITHROID T2

Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors

dutasteride T1

finasteride T1

PROSCAR T2

Alcohol Deterrents

ANTABUSE T2

disulfiram T1

naltrexone T1

REVIA T2

VIVITROL T1 QL (1 EA per 30 days)

Antidotes

CHEMET T1

deferoxamine T4 PA

FUSILEV T4 PA

GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)

GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)

KHAPZORY T4 PA

lanthanum T1

leucovorin calcium T4 PA


113

Drug Tier Notes

naloxone T1

NARCAN T1

phytonadione (vitamin k1) T1

sevelamer carbonate T1

SPS (WITH SORBITOL) T1

SSKI T1

VISTOGARD T4 PA

VORAXAZE T4 PA

Antigout Agents

allopurinol oral tablet 100 mg T1

allopurinol oral tablet 300 mg T1 QL (2 EA per 1 day)

ANAPROX T2

ANAPROX DS T2

colchicine T1 ST; QL (60 EA per 30 days)

EC-NAPROSYN T2

indomethacin T1

KRYSTEXXA T4 PA

NAPROSYN T2

naproxen T1

naproxen sodium T1

probenecid T1

probenecid-colchicine T1

ZYLOPRIM T2

Antisense Oligonucleotides

EXONDYS 51 T4 PA

KYNAMRO T4 PA

SPINRAZA (PF) T4 PA

TEGSEDI T4 PA

Bone Anabolic Agents

FORTEO T4 PA

TYMLOS T4 PA


114

Drug Tier Notes

Bone Resorption Inhibitors

alendronate T1

BONIVA T4 PA


DIDRONEL T2

etidronate disodium T1

FOSAMAX T2


MIACALCIN NASAL T2

pamidronate T4 PA

PROLIA T4 PA

raloxifene T1

RECLAST T4 PA

XGEVA T4 PA

zoledronic acid T4 PA

zoledronic ac-mannitol-0.9nacl T4 PA

ZOMETA T4 PA

Cariostatic Agents

CLINPRO 5000 T1 AL

fluoride (sodium) T1 AL

FLUORITAB T1 AL

FLURA-DROPS T1 AL


MULTI-VITAMIN WITH FLUORIDE T1

MULTIVITAMINS WITH FLUORIDE T1

MVC-FLUORIDE T1

PHOS-FLUR T1 AL

PREVIDENT 5000 ENAMEL PROTECT T1 AL

PREVIDENT 5000 PLUS T2 AL

PREVIDENT DENTAL GEL T2 AL

PREVIDENT DENTAL SOLUTION T1 AL

SF T1 AL


115

Drug Tier Notes

SF 5000 PLUS T1 AL


TRI-VITAMIN WITH FLUORIDE T1

Complement Inhibitors

BERINERT T4 PA

CINRYZE T4 PA

FIRAZYR T4 PA

HAEGARDA T4 PA

KALBITOR T4 PA

RUCONEST T4 PA

SOLIRIS T4 PA

TAKHZYRO T4 PA

ULTOMIRIS T4 PA

Disease-Modifying Antirheumatic Agents

ACTEMRA T4 PA

ACTEMRA ACTPEN T4 PA

ARAVA T2

azathioprine T1

AZULFIDINE T2


CIMZIA T4 PA


CUPRIMINE T4 PA

cyclosporine T1

cyclosporine modified T1

DEPEN TITRATABS T4 PA

ENBREL T4 PA

ENBREL MINI T4 PA

ENBREL SURECLICK T4 PA

GENGRAF T1

HUMIRA T4 PA



116

Drug Tier Notes

HUMIRA PEN T4 PA



HUMIRA(CF) T4 PA






IMURAN T2

INFLECTRA T4 PA

KEVZARA T4 PA

KINERET T4 PA

leflunomide T1




NEORAL T2

OLUMIANT T4 PA

ORENCIA T4 PA

ORENCIA (WITH MALTOSE) T4 PA

ORENCIA CLICKJECT T4 PA

OTEZLA T4 PA

OTEZLA STARTER T4 PA

OTREXUP (PF) T4 PA

PLAQUENIL T2

REMICADE T4 PA

RENFLEXIS T4 PA

SANDIMMUNE ORAL CAPSULE T2

SANDIMMUNE ORAL SOLUTION T1

SIMPONI T4 PA

SIMPONI ARIA T4 PA

STELARA T4 PA


117

Drug Tier Notes

sulfasalazine T1



XELJANZ T4 PA

XELJANZ XR T4 PA

Gonadotropin-Releasing Hormone Antagnts

FIRMAGON T4 PA

ganirelix T4 PA

Immunomodulatory Agents

ACTEMRA T4 PA

ACTEMRA ACTPEN T4 PA

ACTIMMUNE T4 PA

ARAVA T2

AUBAGIO T4 PA

AVONEX T4 PA

AVONEX (WITH ALBUMIN) T4 PA

azathioprine T1

AZULFIDINE T2


BETASERON T4 PA

CIMZIA T4 PA


COPAXONE T4 PA

cyclosporine T1


ENBREL T4 PA

ENBREL MINI T4 PA


ENTYVIO T4 PA

EXTAVIA T4 PA

GENGRAF T1

GILENYA T4 PA


118

Drug Tier Notes

glatiramer T4 PA

GLATOPA T4 PA

HUMIRA T4 PA


HUMIRA PEN T4 PA



HUMIRA(CF) T4 PA






IMURAN T2

INFLECTRA T4 PA

INTRON A T4 PA

KEVZARA T4 PA

KINERET T4 PA

leflunomide T1

LEMTRADA T4 PA

MAYZENT T4 PA

MAYZENT STARTER PACK T4 PA




NEORAL T2

OCREVUS T4 PA

OLUMIANT T4 PA

ORENCIA T4 PA

ORENCIA (WITH MALTOSE) T4 PA

ORENCIA CLICKJECT T4 PA

OTEZLA T4 PA



119

Drug Tier Notes

OTREXUP (PF) T4 PA

PLAQUENIL T2

PLEGRIDY T4 PA

POMALYST T4 PA

PROLEUKIN T4 PA

REBIF (WITH ALBUMIN) T4 PA

REBIF REBIDOSE T4 PA

REBIF TITRATION PACK T4 PA

REMICADE T4 PA

RENFLEXIS T4 PA

REVLIMID T4 PA



SIMPONI T4 PA

SIMPONI ARIA T4 PA

STELARA T4 PA

sulfasalazine T1

TECFIDERA T4 PA

THALOMID T4 PA



TYSABRI T4 PA

XELJANZ T4 PA

XELJANZ XR T4 PA

Immunosuppressive Agents

ASTAGRAF XL T4 PA

ATGAM T4 PA

azathioprine T1

BENLYSTA T4 PA

CELLCEPT T2

CELLCEPT INTRAVENOUS T4 PA

cyclophosphamide intravenous T4 PA


120

Drug Tier Notes

cyclophosphamide oral T1

cyclosporine T1


ELIDEL T1 PA

ENVARSUS XR T4 PA

GAMIFANT T4 PA

GENGRAF T1

IMURAN T2

mercaptopurine T1




mycophenolate mofetil T1

NEORAL T2

NULOJIX T4 PA

OTREXUP (PF) T4 PA

PROGRAF INTRAVENOUS T4 PA

PROGRAF ORAL T2

RAPAMUNE T4 PA



SIMULECT T4 PA

tacrolimus T1

THYMOGLOBULIN T4 PA



ZORTRESS T4 PA

Other Miscellaneous Therapeutic Agents

acetylcysteine T1

AMPYRA T4 PA

ARCALYST T4 PA

BOTOX T4 PA


121

Drug Tier Notes

BOTOX COSMETIC T4 PA

CARNITOR T2

CARNITOR (SUGAR-FREE) T4 PA

CERDELGA T4 PA

choline dihydrogen citrate T1

CYSTADANE T4 PA

DEMSER T4 PA

DYSPORT T4 PA

ENDARI T4 PA

EXONDYS 51 T4 PA

FIRDAPSE T4 PA

GALAFOLD T4 PA

ILARIS (PF) T4 PA

KUVAN T4 PA

levocarnitine T1

MYOBLOC T4 PA

NITYR T4 PA

octreotide acetate T4 PA

ONPATTRO T4 PA

ORALAIR T4 PA

ORFADIN T4 PA

PANHEMATIN T4 PA

PARSABIV T4 PA

PREZCOBIX T1

PROCYSBI T4 PA

REMICADE T4 PA

SANDOSTATIN T4 PA

SANDOSTATIN LAR DEPOT T4 PA

SPINRAZA (PF) T4 PA

THIOLA T4 PA

XEOMIN T4 PA

ZAVESCA T4 PA


122

Drug Tier Notes

Protective Agents

amifostine crystalline T4 PA

dexrazoxane hcl T4 PA

ELMIRON T1 QL (3 EA per 1 day)

MESNEX T4 PA

TOTECT T4 PA

Oxytocics

Oxytocics

METHERGINE T1 QL (28 EA per 7 days)

Pharmaceutical Aids

Pharmaceutical Aids

DILUENT FOR EPOPROSTENOL/FLOLA T4 PA

Radioactive Agents

Radioactive Agents



XOFIGO T4 PA

Respiratory Tract Agents

Alpha And Beta Adrenergic Agonist(Respr)



BROMFED DM T1

BROTAPP DM T1


CHERATUSSIN DAC T1

CONGEST-EZE T1

epinephrine T1 QL (2 EA per 30 DYs)

LORATADINE-D T3 PA

M-END DMX T1


pseudoephedrine hcl T1



123

Drug Tier Notes

SEMPREX-D T3 PA


Anticholinergic Agents (Respir.Tract)

ANORO ELLIPTA T1

ATROVENT HFA T1




LOMOTIL T2

SPIRIVA RESPIMAT T1 AL

Antifibrotic Agents

ESBRIET T4 PA

OFEV T4 PA

Anti-Inflammatory Agents (Respiratory)

NUCALA T4 PA

Antitussives


benzonatate T1

BROMFED DM T1

BROTAPP DM T1

CHERATUSSIN AC T2

CHERATUSSIN DAC T1

codeine sulfate T3 AL



M-END DMX T1

MUCUS DM T1






124

Drug Tier Notes

promethazine-dm T1


ROBAFEN DM T1

ROBITUSSIN PEDIATRIC T1

SYNALGOS-DC T3

TESSALON PERLES T2

TUSSIGON T1

ZODRYL AC 25 T1

ZODRYL AC 30 T1

ZODRYL AC 35 T1

ZODRYL AC 40 T1

ZODRYL AC 50 T1

ZODRYL AC 60 T1

ZODRYL AC 80 T1

Cystic Fibrosis (Cftr) Correctors

ORKAMBI T4 PA

SYMDEKO T4 PA

Cystic Fibrosis (Cftr) Potentiators

KALYDECO T4 PA

ORKAMBI T4 PA

SYMDEKO T4 PA

Expectorants

CHERATUSSIN AC T2

CHERATUSSIN DAC T1

CHILDREN'S STUFFY NOSE-COLD T1


CONGEST-EZE T1

ED BRON GP T1

guaifenesin T1


MUCUS DM T1



125

Drug Tier Notes




ROBAFEN DM T1

SSKI T1

First Generation Antihist.(Respir Tract)

ALLER-CHLOR T1

BROMFED DM T1

BROTAPP DM T1



cyproheptadine T1

dimenhydrinate T1

DIPHENHIST T1




M-END DMX T1

PHENERGAN T2

promethazine T1

PROMETHAZINE VC T1



promethazine-dm T1



ZODRYL AC 25 T1

ZODRYL AC 30 T1

ZODRYL AC 35 T1

ZODRYL AC 40 T1

ZODRYL AC 50 T1

ZODRYL AC 60 T1


126

Drug Tier Notes

ZODRYL AC 80 T1

Interleukin Antagonists

CINQAIR T4 PA

DUPIXENT T4 PA

FASENRA T4 PA

NUCALA T4 PA

Leukotriene Modifiers

montelukast oral granules in packet T1 QL (1 EA per 1 day); AL

montelukast oral tablet T1 QL (1 EA per 1 day)

montelukast oral tablet,chewable T1 QL (1 EA per 1 day)

SINGULAIR ORAL GRANULES IN PACKET T2 AL

SINGULAIR ORAL TABLET T2

SINGULAIR ORAL TABLET,CHEWABLE T2

Mast-Cell Stabilizers

cromolyn T1

Mucolytic Agents

acetylcysteine T1

PULMOZYME T4 PA

Nasal Preparations (Steroids)

fluticasone propionate T1

OMNARIS T3 PA

triamcinolone acetonide T1 ST

Orally Inhaled Preparations (Steroids)

ARMONAIR RESPICLICK T1


WITH DEVICE 100 MCG/ACTUATION, 200

MCG/ACTUATION




T1 QL (1 EA per 30 DYs)

ASMANEX HFA T1



MCG (30 DOSES), 220 MCG (120 DOSES), 220

MCG (30 DOSES), 220 MCG (60 DOSES)



127

Drug Tier Notes



MCG (7 DOSES)




MCG (14 DOSES)



0.25 mg/2 ml



0.5 mg/2 ml



1 mg/2 ml

T1 QL (60 ML per 30 DYs); AL






















T1


with device









MCG/ACTUATION



MCG/ACTUATION



128

Drug Tier Notes



MCG/ACTUATION




MCG/ACTUATION



Phosphodiesterase Type 4 Inhibitors

DALIRESP T1 ST

Respiratory Tract Agents, Miscellaneous

ARALAST NP T4 PA

GLASSIA T4 PA

XOLAIR T4 PA

ZEMAIRA T4 PA

Second Generation Antihist(Respir Tract)

ALAVERT T2



ALLERGY RELIEF (CETIRIZINE) T1 ST

cetirizine oral solution T1

cetirizine oral tablet T1

cetirizine oral tablet,chewable T3 PA


CHILDREN'S ZYRTEC ALLERGY T1 ST

CLARINEX T3 PA

CLARITIN T2

CLARITIN REDITABS T3 PA

desloratadine T3 PA

fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)

fexofenadine oral tablet 180 mg T1 ST

fexofenadine oral tablet 60 mg T3 PA

levocetirizine oral solution T3 PA

levocetirizine oral tablet T1

loratadine oral capsule T1 ST


129

Drug Tier Notes

loratadine oral solution T1 ST

loratadine oral tablet T1

loratadine oral tablet,disintegrating T1 ST

LORATADINE-D T3 PA

SEMPREX-D T3 PA

ZYRTEC T2

Select.Beta-2-Adrenergic Agonist(Respir)

albuterol sulfate inhalation hfa aerosol inhaler T1 QL (1 QY per 30 days)

albuterol sulfate inhalation solution for

nebulization

T1

albuterol sulfate oral T1

ANORO ELLIPTA T1





T1


with device


levalbuterol tartrate T1 ST

SEREVENT DISKUS T1

terbutaline T1


Vasodilating Agents (Respiratory Tract)

ADCIRCA T4 PA

ADEMPAS T4 PA

ambrisentan T4 PA

epoprostenol (glycine) T4 PA

FLOLAN T4 PA

LETAIRIS T4 PA

OPSUMIT T4 PA

ORENITRAM T4 PA

REMODULIN T4 PA

REVATIO T4 PA


130

Drug Tier Notes

sildenafil (antihypertensive) T1 PA

TRACLEER T4 PA

TYVASO T4 PA

TYVASO REFILL KIT T4 PA

TYVASO STARTER KIT T4 PA

UPTRAVI T4 PA

VELETRI T4 PA

VENTAVIS T4 PA

Xanthine Derivatives

THEO-24 T1

theophylline T1

Skin And Mucous Membrane Agents

Antibacterials (Skin, Mucous Membrane)

ANTIBIOTIC (NEOMY-BACIT-POLYM) T1

ANTIBIOTIC-PAIN RELIEF (BACIT) T1

bacitracin T1

bacitracin-polymyxin b T1

BENZAMYCIN T2

CLEOCIN T T2

clindamycin phosphate T1

ERY PADS T1

erythromycin with ethanol T1

erythromycin-benzoyl peroxide T1

gentamicin T1

METROGEL T2

METROGEL VAGINAL T2

metronidazole T1

mupirocin T1

POLYSPORIN T2

Anti-Inflammatory Agents (Skin, Mucous)

amcinonide T1 QL (15 GM per 30 days)

betamethasone dipropionate T1


131

Drug Tier Notes

betamethasone valerate T1

betamethasone, augmented T1

CAPEX T1

clobetasol T1

clobetasol-emollient T1

clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)

desonide T1

desoximetasone T1

diflorasone topical cream T1 QL (15 GM per 25 days)

diflorasone topical ointment T1 QL (15 GM per 30 days)

DIPROLENE T2

DIPROLENE AF T2

ELOCON TOPICAL CREAM T2 QL (45 QY per 30 DYs)

ELOCON TOPICAL OINTMENT T2 QL (45 QY per 30 DYs)

ELOCON TOPICAL SOLUTION T2

fluocinolone T1

fluocinonide T1

FLUOCINONIDE-E T1

hydrocortisone T1

hydrocortisone acetate T1

hydrocortisone valerate T1

hydrocortisone-min oil-wht pet T1

LOTRISONE T1 QL (15 QY per 34 DYs)

mometasone topical cream T1 QL (45 QY per 30 DYs)

mometasone topical ointment T1 QL (45 QY per 30 DYs)

mometasone topical solution T1

PROCTOFOAM HC T1

TEMOVATE T2

TEMOVATE E T2

TOPICORT T2

triamcinolone acetonide T1

TRIANEX T1


132

Drug Tier Notes

WESTCORT T2

Antipruritics And Local Anesthetics

dibucaine T1

lidocaine T3 PA

lidocaine hcl T1

lidocaine-prilocaine T1 QL (30 QY per 30 DYs)

LIDODERM T3 PA

NUPERCAINAL T1

phenazopyridine T1

PRAX T1

PROCTOFOAM HC T1

PYRIDIUM T2

Antivirals (Skin And Mucous Membrane)

ABREVA T1

ZOVIRAX T3 PA

Astringents

DRYSOL DAB-O-MATIC T1

PEDI-BORO SOAK T1

Azoles (Skin And Mucous Membrane)

clotrimazole T1

CLOTRIMAZOLE-3 T1


GYNAZOLE-1 T1

ketoconazole T1

LOTRIMIN AF (CLOTRIMAZOLE) T2


miconazole nitrate T1

MICONAZOLE-3 T1

NIZORAL A-D T1

ZEASORB (MICONAZOLE) T1

Basic Lotions And Liniments

AMLACTIN T1


133

Drug Tier Notes

ammonium lactate T1

LAC-HYDRIN FIVE T1

Basic Ointments And Protectants

ammonium lactate T1

LAC-HYDRIN T2

Benzylamines (Skin And Mucous Membrane)

LOTRIMIN ULTRA T1

MENTAX T2

Cell Stimulants And Proliferants

KEPIVANCE T4 PA

tretinoin T1 AL

tretinoin microspheres T1 AL

Corticosteroids (Skin, Mucous Membrane)

amcinonide T1 QL (15 GM per 30 days)

betamethasone dipropionate T1

betamethasone valerate T1

betamethasone, augmented T1

CAPEX T1

clobetasol T1

clobetasol-emollient T1


desonide T1

desoximetasone T1

diflorasone topical cream T1 QL (15 GM per 25 days)

diflorasone topical ointment T1 QL (15 GM per 30 days)

DIPROLENE T2

DIPROLENE AF T2

ELOCON TOPICAL CREAM T2 QL (45 QY per 30 DYs)

ELOCON TOPICAL OINTMENT T2 QL (45 QY per 30 DYs)

ELOCON TOPICAL SOLUTION T2

fluocinolone T1


134

Drug Tier Notes

fluocinonide T1

FLUOCINONIDE-E T1

hydrocortisone T1

hydrocortisone acetate T1

hydrocortisone valerate T1

hydrocortisone-min oil-wht pet T1


mometasone topical cream T1 QL (45 QY per 30 DYs)

mometasone topical ointment T1 QL (45 QY per 30 DYs)

mometasone topical solution T1

PROCTOFOAM HC T1

TEMOVATE T2

TEMOVATE E T2

TOPICORT T2

triamcinolone acetonide T1

TRIANEX T1

WESTCORT T2

Keratolytic Agents

benzoyl peroxide T1

COMPOUND W T1

DESQUAM-X T2

NEUTROGENA ON THE SPOT T2

NEUTROGENA T-GEL CONDITNER(SA) T1

SELSUN BLUE (SALICYLIC ACID) T1

sulfacetamide sodium-sulfur T1

TARGETED ACNE SPOT TREATMENT T1

urea T1

Keratoplastic Agents

DRITHOCREME HP T1

Local Anti-Infectives, Miscellaneous

alcohol swabs T1

ANTI-DANDRUFF T1


135

Drug Tier Notes

KLARON T2

selenium sulfide T1

SILVADENE T2

silver sulfadiazine T1

sulfacetamide sodium (acne) T1

sulfacetamide sodium-sulfur T1

Nonsteroidal Anti-Inflammat.Agents(Skin)

diclofenac sodium T1 ST

Pigmenting Agents

8-MOP T4 PA

OXSORALEN ULTRA T4 PA

Polyenes (Skin And Mucous Membrane)

nystatin T1

nystatin-triamcinolone T1

Scabicides And Pediculicides

CUTTER BACKWOODS T1 QL (170 GM per 6 days)

CUTTER SKINSATIONS T1 QL (177 ML per 6 days)

LICE BEDDING SPRAY T1 QL (142 GM per 5 days)

LICE KILLING T1 QL (120 QY per 30 DYs)

OFF ACTIVE T1 QL (170 GM per 6 days)

OFF DEEP WOODS T1 QL (170 GM per 6 days)

OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)

OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)

permethrin topical cream T1 QL (60 QY per 1 PD)

permethrin topical liquid T1 QL (118 QY per 30 DYs)

REPEL SPORTSMEN T1 QL (184 GM per 6 days)

REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)

RID COMPLETE LICE ELIM KIT T1 QL (141.8 GM per 5 days)

SKLICE T1

STOP LICE T1 QL (142 GM per 5 days)

Skin And Mucous Membrane Agents, Misc.


136

Drug Tier Notes

ABSORICA T3 PA

ALDARA T2 QL (24 QY per 30 DYs)

AMNESTEEM T1 PA

ARTHRITIS PAIN RELIEF(CAPSAIC) T1

capsaicin T1

CAPZASIN-HP T1

CAVILON SKIN CLEANSER T1

CLARAVIS T1 PA; QL (1 EA per 1 day)

CONDYLOX T2

COSENTYX T4 PA

COSENTYX (2 SYRINGES) T4 PA

COSENTYX PEN T4 PA

COSENTYX PEN (2 PENS) T4 PA

CUTTER BACKWOODS T1 QL (170 GM per 6 days)

CUTTER SKINSATIONS T1 QL (177 ML per 6 days)

diclofenac sodium T1 ST

DUPIXENT T4 PA

ELIDEL T1 PA

ENBREL T4 PA

ENBREL MINI T4 PA


HIGH POTENCY CAPSAICIN T1

HUMIRA T4 PA


HUMIRA PEN T4 PA



HUMIRA(CF) T4 PA





ILUMYA T4 PA


137

Drug Tier Notes

imiquimod T1 QL (24 QY per 30 DYs)

INFLECTRA T4 PA

INSECT REPELLENT (PICARIDIN) T1 QL (118 GM per 4 days)

MYORISAN T1 PA; QL (1 EA per 1 day)

NATRAPEL T1 QL (177 ML per 6 days)

OFF ACTIVE T1 QL (170 GM per 6 days)

OFF DEEP WOODS T1 QL (170 GM per 6 days)

OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)

OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)

OTEZLA T4 PA


podofilox T1

PROTOPIC T2 PA

REMICADE T4 PA

RENFLEXIS T4 PA

REPEL SPORTSMEN T1 QL (184 GM per 6 days)

REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)

SANTYL T1

SILIQ T4 PA

STELARA T4 PA

tacrolimus T1 PA

TALTZ AUTOINJECTOR T4 PA

TALTZ AUTOINJECTOR (2 PACK) T4 PA

TALTZ AUTOINJECTOR (3 PACK) T4 PA

TALTZ SYRINGE T4 PA

TALTZ SYRINGE (2 PACK) T4 PA

TALTZ SYRINGE (3 PACK) T4 PA

TARGRETIN T4 PA

TREMFYA T4 PA

TRIXAICIN HP T1

ZENATANE T1 PA; QL (1 EA per 1 day)

ZOSTRIX-HP FOOT T1


138

Drug Tier Notes

ZOSTRIX-HP TOPICAL CREAM 0.075 % T2

ZOSTRIX-HP TOPICAL CREAM 0.1 % T1

Thiocarbamates(Skin And Mucous Membrane)

tolnaftate T1

Smooth Muscle Relaxants

Antimuscarinics

DETROL T2

flavoxate T1

oxybutynin chloride T1

OXYTROL FOR WOMEN T1

tolterodine oral capsule,extended release 24hr 2

mg


tolterodine oral capsule,extended release 24hr 4

mg

T1

tolterodine oral tablet 1 mg T1 QL (2 EA per 1 day)

tolterodine oral tablet 2 mg T1

trospium T1

Respiratory Smooth Muscle Relaxants

THEO-24 T1

theophylline T1

Vitamins

Multivitamin Preparations

ANTIOXIDANT VITAMINS T1

CADEAU DHA T1

CENTRAL VITE WITH LUTEIN T1

CENTRUM COMPLETE T1

CERTAVITE-ANTIOXID (IRON GLUC) T2


CHILDREN'S CHEWABLE VITAMIN T1

CHILDREN'S CHEWABLES T1

CHILDREN'S MULTI-VIT GUMMIES T1

CHILD'S VITAMIN WITH IRON T1

CHILDS/IRON T1


139

Drug Tier Notes

CLASSIC PRENATAL T1

COMPETE T1

COMPLETE MULTIVITAMIN T1


COMPLETE NATAL DHA T1

COMPLETE PREMIUM VITAMIN T1

COMPLETENATE T1

DAILY PRENATAL T1

DAILY VITES/IRON T1

FLINTSTONES COMPLETE (IRON) T1

GERAVIM T1

MULTI-DELYN WITH IRON T1


multivitamin T1

MULTI-VITAMIN WITH FLUORIDE T1

MULTIVITAMIN WITH MINERALS ORAL

LIQUID

T1

multivitamin with minerals oral tablet T1

MULTIVITAMINS WITH FLUORIDE T1

MVC-FLUORIDE T1

mv-min-folic acid-lutein T1

MY FAVORITE MULTIPLE T1

MY-VITALIFE T1

NUTRIVIT T1

OBSTETRIX DHA T1

OBTREX DHA T1

ONE DAILY PLUS MINERALS T2




PEDIA POLY-VITE T1

PEDIAVIT T1


140

Drug Tier Notes

PERRY PRENATAL T1


POLY-VI-SOL T2 AL

POLY-VITAMIN T1 AL

POLYVITAMIN WITH IRON T1 AL

POLY-VITAMIN WITH IRON T1 AL

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENA1 CHEW (QUATREFOLIC) T1

PRENATA T1

PRENATAL + DHA T1

PRENATAL 19 T1

PRENATAL GUMMY T1


PRENATAL PLUS T1

PRENATAL VITAMIN T1



PRORENAL QD T1

SENTRY SENIOR T1

TAB-A-VITE-MINERALS T1

THERAPEUTIC LIQUID T1

THERAPEUTIC-M T1

THERA-TABS T1

THERATRUM COMPLETE 50 PLUS T1

TRINATAL GT T1

TRIVEEN-DUO DHA T1



TRI-VITAMIN T1 AL


TRUST NATAL DHA T1


141

Drug Tier Notes

VITRUM SENIOR T1

WOMEN'S DAILY FORMULA T1


Vitamin A

beta carotene T1


TRI-VITAMIN T1 AL


vitamin a T1

Vitamin B Complex

B COMPLEX-VITAMIN B12 T1

b complex-vitamin c-folic acid T1

biotin T1

CADEAU DHA T1

CENTRAL VITE WITH LUTEIN T1

CENTRUM COMPLETE T1


CHILDREN'S CHEWABLES T1

CHILDREN'S MULTI-VIT GUMMIES T1

CLASSIC PRENATAL T1


COMPLETENATE T1

cyanocobalamin (vitamin b-12) injection T1

cyanocobalamin (vitamin b-12) oral T1

cyanocobalamin (vitamin b-12) sublingual T1 AL

DAILY PRENATAL T1


ELDERTONIC T1

folic acid T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

mv-min-folic acid-lutein T1


142

Drug Tier Notes

niacinamide T1

NICOMIDE T1

NUTRIVIT T1

OBSTETRIX DHA T1

OBTREX DHA T1



pantothenic acid (vit b5) T1

PERRY PRENATAL T1


POLY-IRON 150 FORTE T1

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENA1 CHEW (QUATREFOLIC) T1

PRENATA T1

PRENATAL + DHA T1

PRENATAL 19 T1

PRENATAL GUMMY T1


PRENATAL PLUS T1

PRENATAL VITAMIN T1



PRORENAL QD T1

PYRI 500 T1

pyridoxine (vitamin b6) T1

riboflavin (vitamin b2) T1 AL

SENTRY SENIOR T1

STRESS B-COMPLEX T1

THERAPEUTIC-M T1

thiamine hcl (vitamin b1) oral tablet 100 mg T1 AL

thiamine hcl (vitamin b1) oral tablet 250 mg T1


143

Drug Tier Notes

thiamine mononitrate (vit b1) T1

TRINATAL GT T1

TRIVEEN-DUO DHA T1

vitamin b complex-folic acid T1

VITAMIN B-1 ORAL TABLET 100 MG T1 AL

VITAMIN B-1 ORAL TABLET 250 MG, 50 MG T1

VITAMIN B-12 ORAL T1

VITAMIN B-12 SUBLINGUAL T1 AL

VITAMIN B-2 ORAL TABLET 100 MG, 25 MG T1

VITAMIN B-2 ORAL TABLET 50 MG T1 AL

VITAMIN B-6 T1

VITAMINS B COMPLEX T1


Vitamin C

ascorbic acid (vitamin c) oral tablet T1 AL

ascorbic acid (vitamin c) oral tablet extended

release 1,500 mg

T1

ascorbic acid (vitamin c) oral tablet extended

release 500 mg

T1 AL

b complex-vitamin c-folic acid T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

STRESS B-COMPLEX T1


TRI-VITAMIN T1 AL


VITAMIN C ORAL SYRUP T1

VITAMIN C ORAL TABLET 1,000 MG, 500

MG

T1

VITAMIN C ORAL TABLET 250 MG T1 AL

VITAMIN C ORAL TABLET EXTENDED

RELEASE

T1 AL

VITAMIN C ORAL TABLET,CHEWABLE T1


144

Drug Tier Notes

Vitamin D

calcitriol T1

CALCIUM 600 + D(3) T1

CALCIUM 600 + MINERALS T1



calcium citrate-vitamin d3 T1

cholecalciferol (vitamin d3) T1

CITRACAL + D3 (CALCIUM PHOS) T1

CITRUS CALCIUM T1

DRISDOL T2

ergocalciferol (vitamin d2) T1

JUST D T2

LIQUID CALCIUM WITH VITAMIN D T1




PRORENAL QD T1

ROCALTROL T2


TRI-VITAMIN T1 AL


VITAMIN D3 T1

Vitamin E

vitamin e T1

vitamin e (dl, acetate) T1

vitamin e mixed T1

Vitamin K Activity

phytonadione (vitamin k1) T1

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