National Drug List

39525CAMENABC

National Drug List Drug list — Four (4) Tier Drug Plan

Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company (Anthem) prescription drug benefits include medications on the Anthem National Drug List. Your coverage has limitations and exclusions. For example, provider administered drugs are not covered under your prescription benefit and drugs used for cosmetic purposes may not be covered. Always refer to your Certificate or Evidence of Coverage for details about what’s covered and what’s not. Then if you have additional questions, call Customer Service at the number on your member ID card.

Anthem Blue Cross Drug List

Your prescription drug benefit includes coverage for medications that you’ll find on the Anthem National Drug List. You can often find more savings when your doctor prescribes medicine that in our National Drug List. Here are some commonly asked questions and answers about how the National Drug List works with your prescription drug plan.

Q. What is a Drug List?A. The Anthem National Drug List, also called a formulary,

has drugs on it that are approved by the U.S. Food and Drug Administration (FDA). This includes brand-name and generic drugs, reviewed and recommended for their quality and for how well they work. The review is done by the National Pharmacy and Therapeutics (P&T) Process. The P&T process involves an independent group of practicing doctors and pharmacists in charge of the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs. They choose the top drugs for our list — based on their safety, how they work and their value. Drugs on our list are reviewed from time to time. Sometimes this results in drugs being added or removed. So now and then, it’s a good idea to check the status of any drugs you may be taking. You can see the list by going to anthem.com/ca. Also, we will always try to notify you of any changes to the formulary that impact you.

Q. How do we determine the tier of a drug?A. Medications on the Anthem National Drug List are

grouped into tiers. Drugs on the lowest tier have the lowest cost share, which is what you pay. Drugs on the highest tier cost you more. Several factors determine what tier a drug is placed in, including:

}} Clinical considerations.

}} Cost of the drug in comparison to other drugs used for the same type of treatment.

}} Availability of over-the-counter options.

Q. Is this list a complete listing of all covered drugs under the Anthem National Drug List?

A. Yes, this is a complete listing of all covered drugs.

Preventive care drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA). We cover contraceptives for members enrolled in a California plan according to state regulations.

For more information about your drug plan, you can do the following:}} Go to anthem.com/ca

}} Call Customer Service at the number on your ID card

}} Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET

Tier definitions

Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions.

Tier 2 drugs have a medium cost share. These may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier 2 drugs have a higher cost share than Tier 1.

Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA. Tier 3 drugs have a higher cost share than Tier 2.

Tier 4 drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA or drugs that are used to treat complex, chronic conditions and may need special handling.

Anthem National FormularyFour-Tier

Table of Contents

Table of Contents

ANALGESICS ........................................................................................................................................................................................................................................................................................................................... 6ANESTHETICS .................................................................................................................................................................................................................................................................................................................... 11ANTIARTHRITICS ......................................................................................................................................................................................................................................................................................................... 14ANTIASTHMATICS ...................................................................................................................................................................................................................................................................................................... 16ANTIBIOTICS ....................................................................................................................................................................................................................................................................................................................... 19ANTICOAGULANTS .................................................................................................................................................................................................................................................................................................... 30ANTIDOTES ............................................................................................................................................................................................................................................................................................................................ 31ANTIFUNGALS ................................................................................................................................................................................................................................................................................................................... 31ANTIHISTAMINE AND DECONGESTANT COMBINATION ............................................................................................................................................................................... 34ANTIHISTAMINES ........................................................................................................................................................................................................................................................................................................ 34ANTIHYPERGLYCEMICS .................................................................................................................................................................................................................................................................................. 34ANTIINFECTIVES .......................................................................................................................................................................................................................................................................................................... 38ANTIINFECTIVES/MISCELLANEOUS .............................................................................................................................................................................................................................................. 37ANTINEOPLASTICS .................................................................................................................................................................................................................................................................................................... 38ANTI-OBESITY DRUGS .......................................................................................................................................................................................................................................................................................... 44ANTIPARKINSON DRUGS .................................................................................................................................................................................................................................................................................. 44ANTIPLATELET DRUGS ...................................................................................................................................................................................................................................................................................... 45ANTIVIRALS .......................................................................................................................................................................................................................................................................................................................... 46AUTONOMIC DRUGS ................................................................................................................................................................................................................................................................................................ 49BIOLOGICALS .................................................................................................................................................................................................................................................................................................................... 51BLOOD ........................................................................................................................................................................................................................................................................................................................................... 57CARDIAC DRUGS ........................................................................................................................................................................................................................................................................................................... 61CARDIOVASCULAR ................................................................................................................................................................................................................................................................................................... 64CNS DRUGS ............................................................................................................................................................................................................................................................................................................................. 72COLONY STIMULATING FACTORS ................................................................................................................................................................................................................................................... 76CONTRACEPTIVES ..................................................................................................................................................................................................................................................................................................... 76COUGH/COLD PREPARATIONS ............................................................................................................................................................................................................................................................... 80DIAGNOSTIC ......................................................................................................................................................................................................................................................................................................................... 82DIURETICS .............................................................................................................................................................................................................................................................................................................................. 84EENT PREPS ........................................................................................................................................................................................................................................................................................................................... 85ELECT/CALORIC/H2O ............................................................................................................................................................................................................................................................................................ 89GASTROINTESTINAL .............................................................................................................................................................................................................................................................................................. 99HERBALS ................................................................................................................................................................................................................................................................................................................................ 105HORMONES ......................................................................................................................................................................................................................................................................................................................... 105IMMUNOSUPPRESANT ...................................................................................................................................................................................................................................................................................... 111MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ......................................................................................................................................................... 112MUSCLE RELAXANTS ......................................................................................................................................................................................................................................................................................... 115PRE-NATAL VITAMINS ...................................................................................................................................................................................................................................................................................... 116PSYCHOTHERAPEUTIC DRUGS .......................................................................................................................................................................................................................................................... 119SEDATIVE/HYPNOTICS ..................................................................................................................................................................................................................................................................................... 126SKIN PREPS ......................................................................................................................................................................................................................................................................................................................... 126SMOKING DETERRENTS ................................................................................................................................................................................................................................................................................ 137THYROID PREPS .......................................................................................................................................................................................................................................................................................................... 137UNCLASSIFIED DRUG PRODUCTS ................................................................................................................................................................................................................................................... 138VITAMINS .............................................................................................................................................................................................................................................................................................................................. 145

4

Anthem National FormularyFour-Tier

Drug Name Tier NotesANALGESICS

ABSTRAL SUBLINGUAL TABLET 3 PA; QL

acetaminophen-codeine oral solution

1

acetaminophen-codeine oral tablet 300-15 mg

1

acetaminophen-codeine oral tablet 300-30 mg, 300-60 mg

1 QL

ACTIQ BUCCAL LOZENGE ON A HANDLE

3 PA; QL

ALFENTA INJECTION SOLUTION 3

alfentanil injection solution 1

ALLZITAL ORAL TABLET 3

almotriptan malate oral tablet 1 QL

ALSUMA SUBCUTANEOUS PEN INJECTOR

3 ST; QL

AMERGE ORAL TABLET 3 ST; QL

ascomp with codeine oral capsule

1

ASTRAMORPH-PF INJECTION SOLUTION 3

AXERT ORAL TABLET 3 ST; QL

BELBUCA BUCCAL FILM 3 PA; QL

belladonna alkaloids-opium rectal suppository

1

belladonna-opium rectal suppository

1

BUPAP ORAL TABLET 3

Drug Name Tier NotesBUPRENEX INJECTION SOLUTION 3

buprenorphine hcl injection solution

1

buprenorphine hcl injection syringe

1

butalbital compound w/codeine oral capsule

1

butalbital-acetaminop-caf-cod oral capsule

1 QL

butalbital-acetaminophen oral tablet

1

butalbital-acetaminophen-caff oral capsule

1

butalbital-acetaminophen-caff oral tablet

1

butalbital-aspirin-caffeine oral capsule

1

butorphanol tartrate injection solution

1

butorphanol tartrate nasal spray,non-aerosol

1 QL

BUTRANS TRANSDERMAL PATCH WEEKLY

3 QL

CAFERGOT ORAL TABLET 3

CAMBIA ORAL POWDER IN PACKET 3 QL

capacet oral capsule 1

CAPITAL WITH CODEINE ORAL SUSPENSION

3 QL

carisoprodol-asa-codeine oral tablet

1

choline,magnesium salicylate oral liquid

1

clonidine (pf) epidural solution

1

codeine sulfate oral tablet 1

codeine-butalbital-asa-caff oral capsule

1

CONZIP ORAL CAPSULE,ER BIPHASE 24 HR 17-83

3 QL

Brand name drug = Uppercase in bold typeGeneric drug = Lowercase in plain type PA = Prior Authorization RequiredST = Step Therapy RequiredQL = Quantity LimitDO = Dose Optimization Limit

Effective 4/1/16

6

Drug Name Tier NotesCONZIP ORAL CAPSULE,ER BIPHASE 24 HR 25-75

3 QL

D.H.E.45 INJECTION SOLUTION 3 PA

DEMEROL (PF) INJECTION SOLUTION100 MG/2 ML, 25 MG/0.5 ML, 50 MG/ML, 75 MG/1.5 ML

3

demerol (pf) injection solution 100 mg/ml

1

DEMEROL (PF) INJECTION SYRINGE 3

DEMEROL INJECTION SOLUTION 3

DEMEROL ORAL TABLET 3

diclofenac potassium oral tablet

1

diflunisal oral tablet 1

dihydrocode-acetaminophen-caff oral capsule

1 QL

dihydrocodeine-aspirin-caff oral capsule

1

dihydroergotamine injection solution

1 PA

dihydroergotamine nasal spray,non-aerosol

1 QL

DILAUDID (PF) INJECTION SOLUTION 3

DILAUDID ORAL LIQUID 3

DILAUDID ORAL TABLET 3

DILAUDID-HP (PF) INJECTION SOLUTION 3

diskets oral tablet,soluble 1 QL

DOLOPHINE ORAL TABLET 3 QL

DURACLON (PF) EPIDURAL SOLUTION 3

DURAGESIC TRANSDERMAL PATCH 72 HOUR

3 ST; QL

Drug Name Tier Notesduramorph (pf) injection solution

1

ELMIRON ORAL CAPSULE 3

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

3 PA; QL

endocet oral tablet 1 QL

endodan oral tablet 1

ERGOMAR SUBLINGUAL TABLET 3

ESGIC ORAL CAPSULE 3

ESGIC ORAL TABLET 3

EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR

3 ST; QL

fentanyl citrate (pf) injection solution

1

fentanyl citrate (pf) intravenous syringe

1

fentanyl citrate buccal lozenge on a handle

1 PA; QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 QL

FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR

3 QL

FENTORA BUCCAL TABLET, EFFERVESCENT

3 PA; QL

FIORICET ORAL CAPSULE 3

FIORICET WITH CODEINE ORAL CAPSULE

3 QL

FIORINAL ORAL CAPSULE 3

FIORINAL-CODEINE #3 ORAL CAPSULE 3

FROVA ORAL TABLET 3 ST; QL

frovatriptan oral tablet 1 QL


Effective 4/1/16

7

Drug Name Tier NotesHYCET ORAL SOLUTION 3 QL

hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163 mg/7.5ml(7.5ml)

1 QL

HYDROCODONE-ACETAMINOPHEN ORAL SOLUTION 7.5-325 MG/15 ML

3 QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

1 QL

hydrocodone-acetaminophen oral tablet 2.5-325 mg

1

hydrocodone-ibuprofen oral tablet 10-200 mg, 7.5-200 mg

1

hydrocodone-ibuprofen oral tablet 5-200 mg

1 QL

hydromorphone (pf) injection solution

1

hydromorphone injection solution

1

HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML

3

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

1

hydromorphone oral liquid 1

hydromorphone oral tablet 1

hydromorphone oral tablet extended release 24 hr

1 QL

hydromorphone rectal suppository

1

HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR

3 PA; QL

IBUDONE ORAL TABLET 10-200 MG 3

IBUDONE ORAL TABLET 5-200 MG 3 QL

ibuprofen-oxycodone oral tablet

1 QL

Drug Name Tier NotesIMITREX NASAL SPRAY,NON-AEROSOL 3 ST; QL

IMITREX ORAL TABLET 3 ST; QL

IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE

3 ST; QL

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR

3 ST; QL

IMITREX SUBCUTANEOUS SOLUTION

3 ST; QL

INFUMORPH P/F INJECTION SOLUTION 3

IONSYS TRANSDERMAL SYSTEM,TRANSDERMAL PCA

3

isometh-dichloral-acetaminophn oral capsule

1

isomethepten-caf-acetaminophen oral tablet

1

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS

3 ST; QL

ketorolac injection cartridge 1 QL

ketorolac injection solution 1 QL

ketorolac injection syringe 1 QL

ketorolac intramuscular solution

1 QL

ketorolac intramuscular syringe

1 QL

ketorolac oral tablet 1 QL

LAZANDA NASAL SPRAY,NON-AEROSOL 3 PA; QL

levorphanol tartrate oral tablet

1

lorcet (hydrocodone) oral tablet

1 QL

lorcet hd oral tablet 1 QL

lorcet plus oral tablet 1 QL

lortab 10-325 oral tablet 1 QL

lortab 5-325 oral tablet 1 QL

lortab 7.5-325 oral tablet 1 QL


Effective 4/1/16

8

Drug Name Tier NotesLORTAB ELIXIR ORAL SOLUTION 3 QL

margesic oral capsule 1

marten-tab oral tablet 1

MAXALT ORAL TABLET 3 QL

MAXALT-MLT ORAL TABLET,DISINTEGRATING

3 QL

mefenamic acid oral capsule 1

meperidine (pf) injection solution

1

meperidine injection cartridge

1

meperidine oral solution 1

meperidine oral tablet 1

methadone injection solution 1 QL

methadone intensol oral concentrate

1 QL

methadone oral concentrate 1 QL

methadone oral solution 1 QL

methadone oral tablet 1 QL

methadone oral tablet,soluble 1 QL

methadose oral concentrate 1 QL

methadose oral tablet,soluble 1 QL

migergot rectal suppository 1

MIGRANAL NASAL SPRAY,NON-AEROSOL 3 QL

morphine (pf) in dextrose 5 % intravenous solution

1

morphine (pf) injection solution

1

morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml

1

morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml

1 QL

morphine concentrate oral solution

1 QL

morphine injection solution 1

morphine injection syringe 1

Drug Name Tier NotesMORPHINE INTRAMUSCULAR PEN INJECTOR

3

morphine intravenous cartridge 10 mg/ml, 15 mg/ml, 2 mg/ml, 4 mg/ml

1

MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML

3

morphine intravenous pt controlled analgesia syring

1

morphine intravenous solution 10 mg/ml, 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml, 50 mg/ml

1 QL

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML

3 QL

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML

3

morphine intravenous syringe 2 mg/ml, 4 mg/ml

1

morphine oral capsule, er multiphase 24 hr

1 QL

morphine oral capsule,extend.release pellets

1 QL

morphine oral solution 10 mg/5 ml

1

morphine oral solution 20 mg/5 ml

1 QL

morphine oral tablet 1 QL

morphine oral tablet extended release

1 QL

morphine rectal suppository 10 mg, 30 mg, 5 mg

1

morphine rectal suppository 20 mg

1 QL

MS CONTIN ORAL TABLET EXTENDED RELEASE

3 QL

nalbuphine injection solution 1

naratriptan oral tablet 1 QL

nodolor oral capsule 1


Effective 4/1/16

9

Drug Name Tier NotesNORCO ORAL TABLET 3 QL

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

3 ST; QL

NUCYNTA ORAL TABLET 3 QL

OFIRMEV INTRAVENOUS SOLUTION

3

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3 ST; QL

OPANA INJECTION SOLUTION 3

OPANA ORAL TABLET 3 QL

OXAYDO ORAL TABLET, ORAL ONLY 3

oxycodone oral capsule 1

oxycodone oral concentrate 1

oxycodone oral solution 1

oxycodone oral tablet 1

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3 QL

oxycodone-acetaminophen oral tablet

1 QL

oxycodone-aspirin oral tablet 1 QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

2 QL

oxymorphone oral tablet 1 QL

oxymorphone oral tablet extended release 12 hr

1 QL

pentazocine-naloxone oral tablet

1

PERCOCET ORAL TABLET 3 QL

PONSTEL ORAL CAPSULE 3

PRIALT INTRATHECAL SOLUTION 4 PA

PRIMLEV ORAL TABLET 3 QL

PRODRIN ORAL TABLET 3

Drug Name Tier NotesRELPAX ORAL TABLET 2 QL

reprexain oral tablet 10-200 mg, 2.5-200 mg

1

reprexain oral tablet 5-200 mg

1 QL

RIMSO-50 INTRAVESICAL SOLUTION

3

rizatriptan oral tablet 1 QL

rizatriptan oral tablet,disintegrating

1 QL

ROXICODONE ORAL TABLET 3

SPRIX NASAL SPRAY,NON-AEROSOL 3

SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 3 PA; QL

sufenta intravenous solution 1

SUFENTANIL CITRATE INTRAVENOUS SOLUTION

3

sumatriptan nasal spray,non-aerosol

1 QL

sumatriptan succinate oral tablet

1 QL

sumatriptan succinate subcutaneous cartridge

1 QL

sumatriptan succinate subcutaneous pen injector

1 QL

sumatriptan succinate subcutaneous solution

1 QL

sumatriptan succinate subcutaneous syringe

1 QL

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR

3 ST; QL

SYNALGOS-DC ORAL CAPSULE 3

TALWIN INJECTION SOLUTION 3

tencon oral tablet 1

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83

3 QL


Effective 4/1/16

10

Drug Name Tier NotesTRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75

3 QL

tramadol oral tablet 1 QL

tramadol oral tablet extended release 24 hr

1 QL

tramadol oral tablet, er multiphase 24 hr

1 QL

tramadol-acetaminophen oral tablet

1 QL

TREXIMET ORAL TABLET 3 ST; QL

TREZIX ORAL CAPSULE 3 QL

TYLENOL-CODEINE #3 ORAL TABLET 3 QL

TYLENOL-CODEINE #4 ORAL TABLET 3 QL

ULTIVA INTRAVENOUS RECON SOLN 3

ULTRACET ORAL TABLET 3 QL

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR

3 QL

ULTRAM ORAL TABLET 3 QL

VANATOL LQ ORAL SOLUTION 3

verdrocet oral tablet 1

vicodin es oral tablet 1 QL

vicodin hp oral tablet 1 QL

vicodin oral tablet 1 QL

VICOPROFEN ORAL TABLET 3 QL

XARTEMIS XR ORAL TAB,ORAL ONLY,IR - ER, BIPHASE

3 ST; QL

XODOL 10/300 ORAL TABLET 3 QL

XODOL 5/300 ORAL TABLET 3 QL

XODOL 7.5/300 ORAL TABLET 3 QL

xylon 10 oral tablet 1

zamicet oral solution 1 QL

Drug Name Tier Noteszebutal oral capsule 1

ZECUITY TRANSDERMAL PATCH, IONTOPHORETIC

3 ST; QL

ZEMBRACE SYMTOUCH SUBCUTANEOUS PEN INJECTOR

3 ST; QL

ZIPSOR ORAL CAPSULE 3 ST

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR

3 PA; QL

zolmitriptan oral tablet 1 QL

zolmitriptan oral tablet,disintegrating

1 QL

ZOMIG NASAL SPRAY,NON-AEROSOL 3 ST; QL

ZOMIG ORAL TABLET 3 ST; QL

ZOMIG ZMT ORAL TABLET,DISINTEGRATING

3 ST; QL

ANESTHETICS

AMIDATE INTRAVENOUS SOLUTION

3

AMIDATE INTRAVENOUS SYRINGE

3

ARTICADENT DENTAL INJECTION CARTRIDGE

3

BREVITAL INJECTION RECON SOLN 3

BUCALSEP MUCOUS MEMBRANE AEROSOL,SPRAY

3

BUCALSEP MUCOUS MEMBRANE SOLUTION 3

bupivacaine (pf) injection solution

1

bupivacaine injection solution

1

bupivacaine-dextrose-water(pf) injection solution

1

bupivacaine-epinephrine (pf) injection solution

1


Effective 4/1/16

11

Drug Name Tier NotesBUPIVACAINE-EPINEPHRINE BITART INJECTION CARTRIDGE

3

bupivacaine-epinephrine injection solution

1

CARBOCAINE (PF) INJECTION SOLUTION10 MG/ML (1 %), 20 MG/ML (2 %)

3

carbocaine (pf) injection solution 15 mg/ml (1.5 %)

1

CARBOCAINE INJECTION SOLUTION 3

CETACAINE TOPICAL AEROSOL,SPRAY 3

CITANEST FORTE DENTAL INJECTION CARTRIDGE

3

CITANEST PLAIN DENTAL INJECTION CARTRIDGE

3

cocaine topical solution 1

compound 347 inhalation gas 1

DIPRIVAN INTRAVENOUS EMULSION

3

EMLA TOPICAL CREAM 3

ethyl chloride topical aerosol,spray

1

etomidate intravenous solution

1

EXPAREL (PF) LOCAL INFILTRATION SUSPENSION

3

forane inhalation liquid 1

glydo mucous membrane jelly in applicator

1

isoflurane inhalation liquid 1

IV INFUSION CPI KIT 3

KETALAR INJECTION SOLUTION 3

KETAMINE IN 0.9 % SOD CHLORIDE INTRAVENOUS SYRINGE

3

Drug Name Tier Notesketamine injection solution 1

LDO PLUS TOPICAL GEL 3

lidocaine (pf) in d7.5w intrathecal solution

1

lidocaine (pf) injection solution 10 mg/ml (1 %), 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

1

LIDOCAINE (PF) INJECTION SOLUTION20 MG/ML (2 %)

3

lidocaine hcl injection solution

1

lidocaine hcl laryngotracheal solution

1

lidocaine hcl mucous membrane gel

1

lidocaine hcl mucous membrane jelly in applicator

1

lidocaine hcl mucous membrane solution

1

lidocaine topical adhesive patch,medicated

1

lidocaine topical ointment 1

lidocaine viscous mucous membrane solution

1

lidocaine-epinephrine (pf) injection solution

1

LIDOCAINE-EPINEPHRINE BIT INJECTION CARTRIDGE

3

lidocaine-epinephrine injection solution

1

lidocaine-prilocaine topical cream

1

lidocaine-prilocaine topical kit

1

LIDOCAINE-TETRACAINE TOPICAL CREAM 3

LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED

3

LIVIXIL PAK TOPICAL KIT 3


Effective 4/1/16

12

Drug Name Tier NotesLP LITE PAK TOPICAL KIT 3

lta pre-attached laryngotracheal solution

1

MARCAINE (PF) INJECTION SOLUTION0.25 % (2.5 MG/ML), 0.5 % (5 MG/ML)

3

marcaine (pf) injection solution 0.75 % (7.5 mg/ml)

1

MARCAINE INJECTION SOLUTION 3

MARCAINE SPINAL (PF) INJECTION SOLUTION 3

MARCAINE-EPINEPHRINE (PF) INJECTION SOLUTION

3

MARCAINE-EPINEPHRINE INJECTION SOLUTION

3

MEPIVACAINE (PF) INJECTION CARTRIDGE

3

midazolam (pf) injection cartridge

1

midazolam (pf) injection solution

1

midazolam (pf) injection syringe 2 mg/2 ml (1 mg/ml)

1

MIDAZOLAM (PF) INJECTION SYRINGE 5 MG/ML

3

midazolam injection solution 1

NAROPIN (PF) INJECTION SOLUTION 3

NESACAINE INJECTION SOLUTION 3

NESACAINE-MPF INJECTION SOLUTION 3

PAIN EASE TOPICAL AEROSOL,SPRAY 3

phenazopyridine oral tablet 1

PLIAGLIS TOPICAL CREAM 3

polocaine injection solution 1 % (10 mg/ml)

1

Drug Name Tier NotesPOLOCAINE INJECTION SOLUTION 2 % 3

polocaine-mpf injection solution

1

PONTOCAINE TOPICAL SOLUTION 3

propofol intravenous emulsion

1

PROPOVEN (PF) INTRAVENOUS EMULSION

3

PYRIDIUM ORAL TABLET 3

relador pak plus topical kit 1

relador pak topical kit 1

ropivacaine (pf) injection solution

1

SENSORCAINE INJECTION SOLUTION0.25 % (2.5 MG/ML)

3

sensorcaine injection solution 0.5 % (5 mg/ml)

1

sensorcaine/epinephrine injection solution

1

SENSORCAINE-MPF INJECTION SOLUTION 3

SENSORCAINE-MPF SPINAL INJECTION SOLUTION

3

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION

3

sevoflurane inhalation liquid 1

sojourn inhalation liquid 1

SPRAY AND STRETCH TOPICAL AEROSOL,SPRAY

3

SUPRANE INHALATION LIQUID 3

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

3

terrell inhalation liquid 1

tetracaine hcl (pf) injection solution

1


Effective 4/1/16

13

Drug Name Tier NotesULTANE INHALATION LIQUID 3

xylocaine dental-epinephrine injection cartridge

1

XYLOCAINE INJECTION SOLUTION 3

XYLOCAINE-EPINEPHRINE INJECTION SOLUTION

3

XYLOCAINE-MPF INJECTION SOLUTION 3

XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION

3

ZINGO INTRADERMAL PEN INJECTOR 3

ANTIARTHRITICS

allopurinol oral tablet 1

aloprim intravenous recon soln

1

ANAPROX DS ORAL TABLET 3

ARAVA ORAL TABLET 3

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC

3 ST

ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC

3 ST

CALDOLOR INTRAVENOUS RECON SOLN

3

CELEBREX ORAL CAPSULE 3 ST; QL

celecoxib oral capsule 1 ST; QL

COLCHICINE ORAL CAPSULE 3 PA; QL

COLCHICINE ORAL TABLET 3 PA; QL

colchicine-probenecid oral tablet

1

COLCRYS ORAL TABLET 3 PA; QL

COMFORT PAC-IBUPROFEN KIT 3

Drug Name Tier NotesCOMFORT PAC-MELOXICAM KIT 3 QL

COMFORT PAC-NAPROXEN KIT 3

CUPRIMINE ORAL CAPSULE 2

DAYPRO ORAL TABLET 3

DEPEN TITRATABS ORAL TABLET 3

diclofenac sodium oral tablet extended release 24 hr

1

diclofenac sodium oral tablet,delayed release (dr/ec)

1

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

1 ST

DISALCID ORAL TABLET 3

DUEXIS ORAL TABLET 3 ST; QL

DYLOJECT INTRAVENOUS SOLUTION

3

EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC)

3

ELITEK INTRAVENOUS RECON SOLN 3

ENBREL SUBCUTANEOUS RECON SOLN

4 PA; QL

ENBREL SUBCUTANEOUS SYRINGE

4 PA; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

4 PA; QL

etodolac oral capsule 1

etodolac oral tablet 1

etodolac oral tablet extended release 24 hr

1

EUFLEXXA INTRA-ARTICULAR SYRINGE

4 PA

FELDENE ORAL CAPSULE 3

FENOPROFEN ORAL CAPSULE 3 ST


Effective 4/1/16

14

Drug Name Tier Notesfenoprofen oral tablet 1

flurbiprofen oral tablet 1

GEL-ONE INTRA-ARTICULAR SYRINGE

4 PA

GENVISC 850 INTRA-ARTICULAR SYRINGE

4 PA

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

4 PA; QL

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT

4 PA; QL

HUMIRA PEN PSORIASIS STARTER SUBCUTANEOUS PEN INJECTOR KIT

4 PA; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

4 PA; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT

4 PA; QL

HYALGAN INTRA-ARTICULAR SOLUTION

4 PA

HYALGAN INTRA-ARTICULAR SYRINGE

4 PA

ibuprofen oral suspension 1

ibuprofen oral tablet 1

INDOCIN ORAL SUSPENSION 3 ST

INDOCIN RECTAL SUPPOSITORY 3 ST

indomethacin oral capsule 1

indomethacin oral capsule, extended release

1

ketoprofen oral capsule 1

ketoprofen oral capsule,ext rel. pellets 24 hr

1

Drug Name Tier NotesKINERET SUBCUTANEOUS SYRINGE

4 PA

KRYSTEXXA INTRAVENOUS SOLUTION

4 PA

leflunomide oral tablet 1

meclofenamate oral capsule 1

meloxicam oral suspension 1 QL

meloxicam oral tablet 1 QL

MITIGARE ORAL CAPSULE 3 PA; QL

MOBIC ORAL SUSPENSION 3 QL

MOBIC ORAL TABLET 3 QL

MONOVISC INTRA-ARTICULAR SYRINGE

4 PA

nabumetone oral tablet 1

NALFON ORAL CAPSULE 3 ST

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR

3

NAPROSYN ORAL TABLET 3

naproxen oral suspension 1

naproxen oral tablet 1

naproxen oral tablet,delayed release (dr/ec)

1

naproxen sodium oral tablet 1

naproxen sodium oral tablet, er multiphase 24 hr

1

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN

4 PA

ORENCIA SUBCUTANEOUS SYRINGE

4 PA; QL

ORTHOVISC INTRA-ARTICULAR SYRINGE

4 PA

OTEZLA ORAL TABLET 4 PA; QL


Effective 4/1/16

15

Drug Name Tier NotesOTEZLA STARTER ORAL TABLETS,DOSE PACK

4 PA; QL

OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR

4 PA; QL

oxaprozin oral tablet 1

piroxicam oral capsule 1

probenecid oral tablet 1

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR

4 PA; QL

RHEUMATREX ORAL TABLETS,DOSE PACK 2

RIDAURA ORAL CAPSULE 2

salsalate oral tablet 1

SIMPONI ARIA INTRAVENOUS SOLUTION

4 PA

SIMPONI SUBCUTANEOUS PEN INJECTOR

4 PA; QL

SIMPONI SUBCUTANEOUS SYRINGE

4 PA; QL

sulindac oral tablet 1

SUPARTZ FX INTRA-ARTICULAR SYRINGE

4 PA

SYNVISC INTRA-ARTICULAR SYRINGE

4 PA

SYNVISC-ONE INTRA-ARTICULAR SYRINGE

4 PA

TIVORBEX ORAL CAPSULE 3 ST; QL

tolmetin oral capsule 1

tolmetin oral tablet 1

TREPADONE (WITH BROMELAIN) ORAL CAPSULE

3

ULORIC ORAL TABLET 3 ST

Drug Name Tier NotesVIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC

3 ST; QL

VIVLODEX ORAL CAPSULE 3 QL

VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR

3

XELJANZ ORAL TABLET 4 PA; QL

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

4

ZORVOLEX ORAL CAPSULE 3 ST; QL

ZYLOPRIM ORAL TABLET 3

ANTIASTHMATICS

ACCOLATE ORAL TABLET 3

acetylcysteine solution 1

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

2 QL

ADVAIR HFA INHALATION HFA AEROSOL INHALER

2 QL

AEROSPAN INHALATION HFA AEROSOL INHALER

3 QL

albuterol sulfate inhalation solution for nebulization

1

albuterol sulfate oral syrup 1

albuterol sulfate oral tablet 1

albuterol sulfate oral tablet extended release 12 hr

1

ALVESCO INHALATION HFA AEROSOL INHALER

3 QL

aminophylline intravenous solution 250 mg/10 ml

1

AMINOPHYLLINE INTRAVENOUS SOLUTION 500 MG/20 ML

3


Effective 4/1/16

16

Drug Name Tier NotesANORO ELLIPTA INHALATION BLISTER WITH DEVICE

2 QL

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

3 QL

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE

2 QL

ASMANEX HFA INHALATION HFA AEROSOL INHALER

2 QL

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

2 QL

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)

2

ATROVENT HFA INHALATION HFA AEROSOL INHALER

2 QL

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

2 QL

BROVANA INHALATION SOLUTION FOR NEBULIZATION

3 QL

budesonide inhalation suspension for nebulization

1 QL

CINQAIR INTRAVENOUS SOLUTION

3

COMBIVENT RESPIMAT INHALATION MIST 2 QL

cromolyn inhalation solution for nebulization

1

cromolyn oral concentrate 1

Drug Name Tier NotesDALIRESP ORAL TABLET 3 QL

DULERA INHALATION HFA AEROSOL INHALER

2 QL

ELIXOPHYLLIN ORAL ELIXIR 2

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

2 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER

2 QL

FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE

2 QL

GASTROCROM ORAL CONCENTRATE 3

INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE

3 QL

ipratropium bromide inhalation solution

1 QL

ipratropium-albuterol inhalation solution for nebulization

1

levalbuterol hcl inhalation solution for nebulization

1

metaproterenol oral syrup 1

metaproterenol oral tablet 1

montelukast oral granules in packet

1 QL

montelukast oral tablet 1 QL

montelukast oral tablet,chewable

1 QL

NUCALA SUBCUTANEOUS RECON SOLN

4 PA

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

2 QL

PROAIR HFA INHALATION HFA AEROSOL INHALER

2 QL


Effective 4/1/16

17

Drug Name Tier NotesPROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

2 QL

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

3 QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

2 QL

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION

3 QL

QVAR INHALATION AEROSOL 2 QL

SEEBRI NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

3 QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

2 QL

SINGULAIR ORAL GRANULES IN PACKET 3 QL

SINGULAIR ORAL TABLET 3 QL

SINGULAIR ORAL TABLET,CHEWABLE 3 QL

SPIRIVA RESPIMAT INHALATION MIST 2 QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

2 QL

STIOLTO RESPIMAT INHALATION MIST 2 QL

STRIVERDI RESPIMAT INHALATION MIST 3 QL

SYMBICORT INHALATION HFA AEROSOL INHALER

2 QL

terbutaline oral tablet 1

terbutaline subcutaneous solution

1

Drug Name Tier NotesTHEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR

2

theochron oral tablet extended release 12 hr

1

theophylline in dextrose 5 % intravenous parenteral solution

1

theophylline oral elixir 1

theophylline oral solution 1

theophylline oral tablet extended release

1

theophylline oral tablet extended release 12 hr

1

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

3 QL

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

3 QL

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

2 QL

VOSPIRE ER ORAL TABLET EXTENDED RELEASE 12 HR

3

XOLAIR SUBCUTANEOUS RECON SOLN

4 PA

XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION

3 QL

XOPENEX HFA INHALATION HFA AEROSOL INHALER

3 QL

XOPENEX INHALATION SOLUTION FOR NEBULIZATION

3 QL

zafirlukast oral tablet 1

ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR

3

ZYFLO ORAL TABLET 3


Effective 4/1/16

18

Drug Name Tier NotesANTIBIOTICS

ACTICLATE ORAL TABLET 3 ST

ADOXA ORAL CAPSULE 3 ST

amikacin injection solution 1

amoxicillin oral capsule 1

amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet 1

AMOXICILLIN ORAL TABLET, ER MULTIPHASE 24 HR

3

amoxicillin oral tablet,chewable

1

amoxicillin-pot clavulanate oral suspension for reconstitution

1

amoxicillin-pot clavulanate oral tablet

1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

1

amoxicillin-pot clavulanate oral tablet,chewable

1

ampicillin oral capsule 1

ampicillin oral suspension for reconstitution

1

ampicillin sodium injection recon soln

1

ampicillin sodium intravenous recon soln

1

ampicillin-sulbactam injection recon soln

1

ampicillin-sulbactam intravenous recon soln

1

AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION

3

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION125-31.25 MG/5 ML

2

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION250-62.5 MG/5 ML

3

Drug Name Tier NotesAUGMENTIN ORAL TABLET 3

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR

3

AVAR LS TOPICAL CLEANSER 3

AVAR LS TOPICAL FOAM 3 PA

AVAR LS TOPICAL PADS, MEDICATED 3

avar topical cleanser 1 PA

AVAR TOPICAL FOAM 3 PA

AVAR TOPICAL PADS, MEDICATED 3

AVAR-E GREEN TOPICAL CREAM 3

AVAR-E LS TOPICAL CREAM 3 PA

AVAR-E TOPICAL CREAM 3

AVELOX ABC PACK ORAL TABLET 3 QL

AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK

3

AVELOX ORAL TABLET 3 QL

AVIDOXY DK KIT 3

avidoxy oral tablet 1

AVYCAZ INTRAVENOUS RECON SOLN

3

AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK

3

AZACTAM INJECTION RECON SOLN 3

AZASITE OPHTHALMIC DROPS 2

azithromycin intravenous recon soln

1

azithromycin oral packet 1 QL


Effective 4/1/16

19

Drug Name Tier Notesazithromycin oral suspension for reconstitution

1 QL

azithromycin oral tablet 1 QL

aztreonam injection recon soln

1

azuphen mb oral capsule 1

baciim intramuscular recon soln

1

bacitracin intramuscular recon soln

1

bacitracin ophthalmic ointment

1

bacitracin-polymyxin b ophthalmic ointment

1

BACTRIM DS ORAL TABLET 3

BACTRIM ORAL TABLET 3

BACTROBAN NASAL NASAL OINTMENT 2

BACTROBAN TOPICAL CREAM 3

BENZAMYCIN TOPICAL GEL 3

BENZAMYCINPAK TOPICAL GEL 3 ST

BENZODOX 30 KIT, CLEANSER ER AND TABLET

3

BENZODOX 60 KIT, CLEANSER ER AND TABLET

3

BESIVANCE OPHTHALMIC DROPS,SUSPENSION

3

BETHKIS INHALATION SOLUTION FOR NEBULIZATION

4

BIAXIN ORAL SUSPENSION FOR RECONSTITUTION

3

BIAXIN ORAL TABLET 3

BICILLIN C-R INTRAMUSCULAR SYRINGE

3

Drug Name Tier NotesBICILLIN L-A INTRAMUSCULAR SYRINGE

3

BLEPH-10 OPHTHALMIC DROPS 3

BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION

3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT

3

bp 10-1 topical cleanser 1

CAPASTAT INJECTION RECON SOLN 3

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

4

CEDAX ORAL CAPSULE 3

CEDAX ORAL SUSPENSION FOR RECONSTITUTION

3

cefaclor oral capsule 1

cefaclor oral suspension for reconstitution

1

cefaclor oral tablet extended release 12 hr

1

cefadroxil oral capsule 1

cefadroxil oral suspension for reconstitution

1

cefadroxil oral tablet 1

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

1

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

3

cefazolin injection recon soln 1

cefazolin intravenous recon soln

1

cefdinir oral capsule 1

cefdinir oral suspension for reconstitution

1

cefditoren pivoxil oral tablet 1


Effective 4/1/16

20

Drug Name Tier NotesCEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

3

cefepime in dextrose,iso-osm intravenous piggyback

1

cefepime injection recon soln 1

cefixime oral suspension for reconstitution

1

CEFOTAN INJECTION RECON SOLN 3

cefotaxime injection recon soln

1

CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK

3

cefotetan injection recon soln 1

cefotetan intravenous recon soln

1

cefoxitin in dextrose, iso-osm intravenous piggyback

1

cefoxitin intravenous recon soln

1

cefpodoxime oral suspension for reconstitution

1

cefpodoxime oral tablet 1

cefprozil oral suspension for reconstitution

1

cefprozil oral tablet 1

CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK

3

ceftazidime injection recon soln

1

ceftibuten oral capsule 1

ceftibuten oral suspension for reconstitution

1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

3

CEFTIN ORAL TABLET 3

ceftriaxone in dextrose,iso-os intravenous piggyback

1

Drug Name Tier Notesceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

1

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

3

ceftriaxone intravenous recon soln

1

cefuroxime axetil oral tablet 1

cefuroxime sodium injection recon soln

1

cefuroxime sodium intravenous recon soln

1

CENTANY AT TOPICAL OINTMENT KIT 3

CENTANY TOPICAL OINTMENT 3

cephalexin oral capsule 1

cephalexin oral suspension for reconstitution

1

cephalexin oral tablet 1

CETRAXAL OTIC DROPPERETTE 3

chloramphenicol sod succinate intravenous recon soln

1

CILOXAN OPHTHALMIC DROPS 3

CILOXAN OPHTHALMIC OINTMENT

3

CIPRO HC OTIC DROPS,SUSPENSION 3

CIPRO IN D5W INTRAVENOUS PIGGYBACK

3

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON

3 QL

CIPRO ORAL TABLET 3 QL

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR

3 QL

CIPRODEX OTIC DROPS,SUSPENSION 2


Effective 4/1/16

21

Drug Name Tier Notesciprofloxacin (mixture) oral tablet, er multiphase 24 hr

1 QL

ciprofloxacin hcl ophthalmic drops

1

ciprofloxacin hcl oral tablet 1 QL

ciprofloxacin hcl otic dropperette

1

ciprofloxacin in 5 % dextrose intravenous piggyback

1

ciprofloxacin lactate intravenous solution

1

ciprofloxacin oral suspension,microcapsule recon

1 QL

CLAFORAN IN DEXTROSE(ISO-OSM) INTRAVENOUS PIGGYBACK

3

CLAFORAN INJECTION RECON SOLN 3

CLAFORAN INTRAVENOUS RECON SOLN

3

clarithromycin oral suspension for reconstitution

1

clarithromycin oral tablet 1

clarithromycin oral tablet extended release 24 hr

1

cleansing wash topical cleanser

1

CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

3

CLEOCIN INJECTION SOLUTION 3

CLEOCIN INTRAVENOUS SOLUTION

3

CLEOCIN ORAL CAPSULE 3

CLEOCIN ORAL RECON SOLN 3

CLEOCIN T TOPICAL GEL 3

Drug Name Tier NotesCLEOCIN T TOPICAL LOTION 3

CLEOCIN T TOPICAL SOLUTION 3

CLEOCIN T TOPICAL SWAB 3

CLEOCIN VAGINAL CREAM 3

CLEOCIN VAGINAL SUPPOSITORY 2

CLIN SINGLE USE INJECTION KIT 3

CLINDACIN ETZ TOPICAL KIT 3 ST

clindacin etz topical swab 1

clindacin p topical swab 1

CLINDACIN PAC TOPICAL KIT 3 ST

CLINDAGEL TOPICAL GEL 3 ST

clindamycin hcl oral capsule 1

clindamycin in 5 % dextrose intravenous piggyback

1

clindamycin palmitate hcl oral recon soln

1

clindamycin pediatric oral recon soln

1

clindamycin phosphate injection solution

1

clindamycin phosphate intravenous solution

1

clindamycin phosphate topical foam

1

clindamycin phosphate topical gel

1

clindamycin phosphate topical lotion

1

clindamycin phosphate topical solution

1

clindamycin phosphate topical swab

1

clindamycin phosphate vaginal cream

1


Effective 4/1/16

22

Drug Name Tier NotesCLINDESSE VAGINAL CREAM,EXTENDED RELEASE

3

colistin (colistimethate na) injection recon soln

1

COLY-MYCIN M PARENTERAL INJECTION RECON SOLN

3

COLY-MYCIN S OTIC DROPS,SUSPENSION 3

CORTISPORIN TOPICAL CREAM 3

CORTISPORIN TOPICAL OINTMENT 3

CORTISPORIN-TC OTIC DROPS,SUSPENSION 3

CUBICIN INTRAVENOUS RECON SOLN

3

CYCLOSERINE ORAL CAPSULE 3

DALVANCE INTRAVENOUS SOLUTION

3

DAPSONE ORAL TABLET 3

demeclocycline oral tablet 1

dicloxacillin oral capsule 1

DIFICID ORAL TABLET 3

DORIBAX INTRAVENOUS RECON SOLN

3

DORYX ORAL TABLET,DELAYED RELEASE (DR/EC)

3 ST

doxy-100 intravenous recon soln

1

doxycycline hyclate intravenous recon soln

1

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet

1

doxycycline hyclate oral tablet,delayed release (dr/ec)

1 ST

Drug Name Tier Notesdoxycycline monohydrate oral capsule

1

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE

3 ST

doxycycline monohydrate oral suspension for reconstitution

1

doxycycline monohydrate oral tablet

1

e.e.s. 400 oral tablet 1

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION

3

ery pads topical swab 1

erygel topical gel 1

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION

3

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

3

erythrocin (as stearate) oral tablet

1

ERYTHROCIN INTRAVENOUS RECON SOLN

3

erythromycin ethylsuccinate oral tablet

1

erythromycin ophthalmic ointment

1

erythromycin oral capsule,delayed release(dr/ec)

1

erythromycin oral tablet 1

erythromycin with ethanol topical gel

1


Effective 4/1/16

23

Drug Name Tier Noteserythromycin with ethanol topical solution

1

erythromycin with ethanol topical swab

1

erythromycin-benzoyl peroxide topical gel

1

ethambutol oral tablet 1

EVOCLIN TOPICAL FOAM 3

FACTIVE ORAL TABLET 3 QL

FLAGYL ER ORAL TABLET EXTENDED RELEASE

3

FLAGYL ORAL CAPSULE 3

FLAGYL ORAL TABLET 3

FORTAZ IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

3

FORTAZ INJECTION RECON SOLN 3

FORTAZ INTRAVENOUS RECON SOLN 3

FURADANTIN ORAL SUSPENSION 3

gatifloxacin ophthalmic drops

1

gentak ophthalmic ointment 1

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

1

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML

3

gentamicin injection solution 1

gentamicin ophthalmic drops 1

gentamicin ophthalmic ointment

1

gentamicin sulfate (ped) (pf) injection solution

1

Drug Name Tier Notesgentamicin sulfate (pf) intravenous solution 100 mg/10 ml

1

GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML

3

gentamicin topical cream 1

gentamicin topical ointment 1

HIPREX ORAL TABLET 3

hyolev mb oral tablet 1

hyophen oral tablet 1

ILOTYCIN OPHTHALMIC OINTMENT

3

imipenem-cilastatin intravenous recon soln

1

INDIOMIN MB ORAL CAPSULE 3

INVANZ INJECTION RECON SOLN 3

INVANZ INTRAVENOUS RECON SOLN 3

isoniazid injection solution 1

isoniazid oral solution 1

isoniazid oral tablet 1

KEFLEX ORAL CAPSULE 3

KETEK ORAL TABLET 3

KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION

4

LEVAQUIN ORAL TABLET 3 QL

levofloxacin in d5w intravenous piggyback

1

levofloxacin intravenous solution

1

levofloxacin ophthalmic drops

1

LEVOFLOXACIN ORAL SOLUTION 3 QL

levofloxacin oral tablet 1 QL


Effective 4/1/16

24

Drug Name Tier NotesLINCOCIN INJECTION SOLUTION 3

lincomycin injection solution 1

linezolid intravenous parenteral solution

1

linezolid oral suspension for reconstitution

1 PA; QL

linezolid oral tablet 1 PA; QL

linezolid-0.9% sodium chloride intravenous parenteral solution

1

MACROBID ORAL CAPSULE 3

MACRODANTIN ORAL CAPSULE 3

MAXIPIME INJECTION RECON SOLN 3

MAXIPIME INTRAVENOUS RECON SOLN

3

MAXITROL OPHTHALMIC DROPS,SUSPENSION

3

MAXITROL OPHTHALMIC OINTMENT

3

MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK

3

meropenem intravenous recon soln

1

MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK

3

MERREM INTRAVENOUS RECON SOLN

3

methenamine hippurate oral tablet

1

methenamine mandelate oral tablet

1

methen-sod phos-meth blue-hyos oral tablet

1

Drug Name Tier Notesmetro i.v. intravenous piggyback

1

METROGEL VAGINAL VAGINAL GEL 3

metronidazole in nacl (iso-os) intravenous piggyback

1

metronidazole oral capsule 1

metronidazole oral tablet 1

metronidazole vaginal gel 1

MINOCIN INTRAVENOUS RECON SOLN

3 ST

MINOCIN ORAL CAPSULE 3 ST

minocycline oral capsule 1 ST

minocycline oral tablet 1 ST

minocycline oral tablet extended release 24 hr

1 ST

mondoxyne nl oral capsule 1

MONODOX ORAL CAPSULE 3 ST

MONUROL ORAL PACKET 3

MORGIDOX 1X100 KIT 3

MORGIDOX 2X100 KIT 3

morgidox oral capsule 1

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR

3

MOXEZA OPHTHALMIC DROPS, VISCOUS 2

moxifloxacin oral tablet 1 QL

MOXIFLOXACIN-SOD.ACE,SUL-WATER INTRAVENOUS PIGGYBACK

3

mupirocin calcium topical cream

1

mupirocin topical ointment 1

MYAMBUTOL ORAL TABLET 3

MYCOBUTIN ORAL CAPSULE 3


Effective 4/1/16

25

Drug Name Tier Notesnafcillin in dextrose iso-osm intravenous piggyback

1

nafcillin injection recon soln 1

nafcillin intravenous recon soln

1

neomycin oral tablet 1

neomycin-bacitracin-poly-hc ophthalmic ointment

1

neomycin-bacitracin-polymyxin ophthalmic ointment

1

neomycin-polymyxin b-dexameth ophthalmic drops,suspension

1

neomycin-polymyxin b-dexameth ophthalmic ointment

1

neomycin-polymyxin-gramicidin ophthalmic drops

1

neomycin-polymyxin-hc ophthalmic drops,suspension

1

neomycin-polymyxin-hc otic drops,suspension

1

neomycin-polymyxin-hc otic solution

1

neo-polycin hc ophthalmic ointment

1

neo-polycin ophthalmic ointment

1

NEOSPORIN (NEO-POLYM-GRAMICID) OPHTHALMIC DROPS

3

NEO-SYNALAR KIT TOPICAL CREAM 3

NEO-SYNALAR TOPICAL CREAM 3

nitrofurantoin macrocrystal oral capsule

1

nitrofurantoin monohyd/m-cryst oral capsule

1

nitrofurantoin oral suspension

1

NUVESSA VAGINAL GEL 3

Drug Name Tier NotesOCUFLOX OPHTHALMIC DROPS 3

ofloxacin ophthalmic drops 1

ofloxacin oral tablet 1 QL

ofloxacin otic drops 1

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE

3

ORBACTIV INTRAVENOUS RECON SOLN

3

OTIPRIO INTRATYMPANIC SUSPENSION

3

oxacillin in dextrose(iso-osm) intravenous piggyback

1

oxacillin injection recon soln 1

oxacillin intravenous recon soln

1

PASER ORAL GRANULES DR FOR SUSP IN PACKET

3

PCE ORAL TABLET, PARTICLES/CRYSTALS 3

PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK

3

penicillin g potassium injection recon soln

1

penicillin g procaine intramuscular syringe

1

penicillin g sodium injection recon soln

1

penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet

1

pfizerpen-g injection recon soln

1

phosphasal oral tablet 1

piperacillin-tazobactam intravenous recon soln

1


Effective 4/1/16

26

Drug Name Tier NotesPLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED

3

PLEXION TOPICAL CLEANSER 3

PLEXION TOPICAL CREAM 3

PLEXION TOPICAL LOTION 3

polycin ophthalmic ointment 1

polymyxin b sulfate injection recon soln

1

polymyxin b sulf-trimethoprim ophthalmic drops

1

POLYTRIM OPHTHALMIC DROPS 3

PRED-G OPHTHALMIC DROPS,SUSPENSION 3

PRED-G S.O.P. OPHTHALMIC OINTMENT

3

PRIFTIN ORAL TABLET 2

PRIMAXIN IV INTRAVENOUS RECON SOLN

3

PRIMSOL ORAL SOLUTION 3 QL

pyrazinamide oral tablet 1

rifabutin oral capsule 1

RIFADIN INTRAVENOUS RECON SOLN

3

RIFADIN ORAL CAPSULE 3

RIFAMATE ORAL CAPSULE 3

rifampin intravenous recon soln

1

rifampin oral capsule 1

RIFATER ORAL TABLET 2

ROSANIL TOPICAL CLEANSER 3 PA

Drug Name Tier Notesrosula cleansing cloths topical pads, medicated

1

ROSULA TOPICAL CLEANSER 3

SILVADENE TOPICAL CREAM 3

silver sulfadiazine topical cream

1

SIRTURO ORAL TABLET 3

SIVEXTRO INTRAVENOUS RECON SOLN

3

SIVEXTRO ORAL TABLET 3 PA; QL

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR

3 ST

SPECTRACEF ORAL TABLET 3

ss 10-2 topical cleanser 1

ssd topical cream 1

sss 10-5 topical cream 1

sss 10-5 topical foam 1

STREPTOMYCIN INTRAMUSCULAR RECON SOLN

3

sulfacetamide sodium ophthalmic drops

1

sulfacetamide sodium ophthalmic ointment

1

sulfacetamide sodium-sulfur topical cleanser 10-2 %, 9.8-4.8 %

1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %

1 PA

sulfacetamide sodium-sulfur topical cream 10-2 %

1 PA

sulfacetamide sodium-sulfur topical cream 10-5 % (w/w), 9.8-4.8 %

1

sulfacetamide sodium-sulfur topical foam

1

sulfacetamide sodium-sulfur topical lotion

1


Effective 4/1/16

27

Drug Name Tier Notessulfacetamide sodium-sulfur topical pads, medicated

1 PA

sulfacetamide sodium-sulfur topical suspension 10-5 %

1

sulfacetamide sodium-sulfur topical suspension 8-4 %

1 PA

sulfacetamide sod-sulfur-urea topical cleanser

1

sulfacetamide-prednisolone ophthalmic drops

1

sulfacetamide-sulfur-cleansr23 topical kit

1 PA

sulfacleanse 8-4 topical suspension

1 PA

sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream

1

sulfadiazine oral tablet 1

sulfamethoxazole-trimethoprim intravenous solution

1

sulfamethoxazole-trimethoprim oral suspension

1

sulfamethoxazole-trimethoprim oral tablet

1

SULFAMYLON TOPICAL CREAM 3

SULFAMYLON TOPICAL PACKET 3

sulfatrim oral suspension 1

SUMADAN TOPICAL CLEANSER 3 PA

SUMADAN TOPICAL KIT 3 PA

SUMADAN XLT TOPICAL COMBO PACK,CLEANSER AND CREAM

3

SUMAXIN CP TOPICAL KIT 3 PA

SUMAXIN TOPICAL CLEANSER 3 PA

SUMAXIN TOPICAL PADS, MEDICATED 3 PA

Drug Name Tier NotesSUMAXIN TS TOPICAL SUSPENSION 3 PA

SUPRAX ORAL CAPSULE 3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

3

SUPRAX ORAL TABLET,CHEWABLE 3

SYNERCID INTRAVENOUS RECON SOLN

3

TAZICEF INJECTION RECON SOLN 3

TAZICEF INTRAVENOUS RECON SOLN

3

TEFLARO INTRAVENOUS RECON SOLN

3

tetracycline oral capsule 1

THALOMID ORAL CAPSULE 2 PA; QL

thermazene topical cream 1

TOBI INHALATION SOLUTION FOR NEBULIZATION

4

TOBI PODHALER INHALATION CAPSULE 4

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE

4

TOBRADEX OPHTHALMIC DROPS,SUSPENSION

3

TOBRADEX OPHTHALMIC OINTMENT

2

TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION

3

tobramycin in 0.225 % nacl inhalation solution for nebulization

4

tobramycin in 0.9 % nacl intravenous piggyback

1


Effective 4/1/16

28

Drug Name Tier Notestobramycin ophthalmic drops 1

tobramycin sulfate injection recon soln

1

tobramycin sulfate injection solution

1

tobramycin-dexamethasone ophthalmic drops,suspension

1

TOBREX OPHTHALMIC DROPS 3

TOBREX OPHTHALMIC OINTMENT 3

TRECATOR ORAL TABLET 3

trimethoprim oral tablet 1

TYGACIL INTRAVENOUS RECON SOLN

3

UNASYN INJECTION RECON SOLN 3

ur n-c oral tablet 1

uramit mb oral capsule 1

URELLE ORAL TABLET 3

uretron d-s oral tablet 1

URIBEL ORAL CAPSULE 3

urimar-t oral tablet 1

urin ds oral tablet 1

uro-blue oral tablet 1

urogesic-blue oral tablet 1

uro-l oral tablet 1

urolet mb oral tablet 1

uro-mp oral capsule 1

urophen mb oral tablet 1

uryl oral tablet 1

ustell oral capsule 1

UTA ORAL CAPSULE 3

utira-c oral tablet 1

VANCOCIN ORAL CAPSULE 3

VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK

3

Drug Name Tier NotesVANCOMYCIN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK

3

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg

1

VANCOMYCIN INTRAVENOUS RECON SOLN 750 MG

3

vancomycin oral capsule 1

vandazole vaginal gel 1

VIBATIV INTRAVENOUS RECON SOLN

3

VIBRAMYCIN ORAL CAPSULE 3

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

3

VIBRAMYCIN ORAL SYRUP 3 ST

VIGAMOX OPHTHALMIC DROPS 2

XIFAXAN ORAL TABLET 3 PA; QL

zencia topical cleanser 1 PA

ZERBAXA INTRAVENOUS RECON SOLN

3

ZINACEF IN STERILE WATER INTRAVENOUS PIGGYBACK

3

ZINACEF INJECTION RECON SOLN 3

ZINACEF INTRAVENOUS RECON SOLN

3

ZITHROMAX INTRAVENOUS RECON SOLN

3

ZITHROMAX ORAL PACKET 3 QL

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION

3 QL


Effective 4/1/16

29

Drug Name Tier NotesZITHROMAX ORAL TABLET 3 QL

ZITHROMAX TRI-PAK ORAL TABLET 3 QL

ZITHROMAX Z-PAK ORAL TABLET 3 QL

ZMAX ORAL SUSPENSION,EXTENDED REL RECON

3 QL

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK

3

ZOSYN INTRAVENOUS RECON SOLN 3

ZYLET OPHTHALMIC DROPS,SUSPENSION 2

ZYMAXID OPHTHALMIC DROPS 3

ZYVOX INTRAVENOUS PARENTERAL SOLUTION

3

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION

3 PA; QL

ZYVOX ORAL TABLET 3 PA; QL

ANTICOAGULANTS

ACD SOLUTION 3

ACD-A SOLUTION 3

ANGIOMAX INTRAVENOUS RECON SOLN

3

ANTICOAG CITRATE PHOS DEXTROSE SOLUTION

3

ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS PARENTERAL SOLUTION

3

ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS SOLUTION

3

ARGATROBAN IN NACL (ISO-OS) INTRAVENOUS SOLUTION

3

Drug Name Tier NotesARGATROBAN INTRAVENOUS SOLUTION

3

ARIXTRA SUBCUTANEOUS SYRINGE

4

BIVALIRUDIN INTRAVENOUS RECON SOLN

3

COUMADIN ORAL TABLET 2

ELIQUIS ORAL TABLET 2 QL

enoxaparin subcutaneous solution

4

enoxaparin subcutaneous syringe

4

fondaparinux subcutaneous syringe

4

FRAGMIN SUBCUTANEOUS SOLUTION

4

FRAGMIN SUBCUTANEOUS SYRINGE

4

hep flush-10 (pf) intravenous solution

1

heparin (porcine) in 5 % dex intravenous parenteral solution

1

heparin (porcine) in nacl (pf) intravenous parenteral solution

1

heparin (porcine) injection cartridge

1

heparin (porcine) injection solution

1

heparin flush intravenous kit 1

heparin flush(porcine)-0.9nacl intravenous kit

1

heparin lock flush (porcine) intravenous solution

1

heparin lock flush (porcine) intravenous syringe

1

heparin lock flush intravenous solution

1


Effective 4/1/16

30

Drug Name Tier Notesheparin lock flush intravenous syringe

1

heparin lock intravenous solution

1

heparin lockflush(porcine)(pf) intravenous syringe

1

HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML

3

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

1

heparin, porcine (pf) injection solution

1

heparin, porcine (pf) injection syringe

1

heparin, porcine (pf) intravenous solution

1

heparin, porcine (pf) intravenous syringe

1

IPRIVASK SUBCUTANEOUS RECON SOLN

4

jantoven oral tablet 1

LOVENOX SUBCUTANEOUS SOLUTION

4

LOVENOX SUBCUTANEOUS SYRINGE

4

monoject prefill (pf) intravenous syringe

1

monoject prefill advanced (pf) intravenous syringe

1

PRADAXA ORAL CAPSULE 2 QL

SAVAYSA ORAL TABLET 3 QL

SODIUM CITRATE SOLUTION 3

Drug Name Tier NotesTRICITRASOL INJECTION CONCENTRATE

3

warfarin oral tablet 1

XARELTO ORAL TABLET 2 QL

XARELTO ORAL TABLETS,DOSE PACK 2

ANTIDOTES

EVZIO INJECTION AUTO-INJECTOR 3 PA; QL

MOVANTIK ORAL TABLET 3

naloxone injection solution 1

naloxone injection syringe 1

naltrexone oral tablet 1

NARCAN NASAL SPRAY,NON-AEROSOL 3 PA

RELISTOR SUBCUTANEOUS SOLUTION

3

RELISTOR SUBCUTANEOUS SYRINGE

3

REVIA ORAL TABLET 3

ANTIFUNGALS

ABELCET INTRAVENOUS SUSPENSION

3

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION

3

amphotericin b injection recon soln

1

ANCOBON ORAL CAPSULE 3

CANCIDAS INTRAVENOUS RECON SOLN

3

CICLODAN KIT TOPICAL COMBO PACK 3

CICLODAN KIT TOPICAL SOLUTION 3

ciclodan topical cream 1


Effective 4/1/16

31

Drug Name Tier Notesciclodan topical solution 1

ciclopirox topical cream 1

ciclopirox topical gel 1

ciclopirox topical shampoo 1

ciclopirox topical solution 1

ciclopirox topical suspension 1

ciclopirox-ure-camph-menth-euc topical solution

1

clotrimazole mucous membrane troche

1

clotrimazole topical cream 1

clotrimazole topical solution 1

clotrimazole-betamethasone topical cream

1

clotrimazole-betamethasone topical lotion

1

CNL 8 NAIL TOPICAL KIT 3

CRESEMBA INTRAVENOUS RECON SOLN

3

CRESEMBA ORAL CAPSULE 3 PA

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

3

DIFLUCAN ORAL TABLET 3

econazole topical cream 1

ECOZA TOPICAL FOAM 3

ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN

3

ERTACZO TOPICAL CREAM 3

EXELDERM TOPICAL CREAM 3

EXELDERM TOPICAL SOLUTION 3

EXODERM TOPICAL LOTION 3

EXTINA TOPICAL FOAM 3

Drug Name Tier Notesfluconazole in dextrose(iso-o) intravenous piggyback

1

FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

3

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

1

fluconazole oral suspension for reconstitution

1

fluconazole oral tablet 1

flucytosine oral capsule 1

griseofulvin microsize oral suspension

1

griseofulvin microsize oral tablet

1

griseofulvin ultramicrosize oral tablet

1

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET

3

GYNAZOLE-1 VAGINAL CREAM 3

itraconazole oral capsule 1 PA

JUBLIA TOPICAL SOLUTION WITH APPLICATOR

3

KERYDIN TOPICAL SOLUTION WITH APPLICATOR

3

ketoconazole oral tablet 1

ketoconazole topical cream 1

ketoconazole topical foam 1

ketoconazole topical shampoo

1

LAMISIL ORAL GRANULES IN PACKET 3

LAMISIL ORAL TABLET 3

LOPROX TOPICAL SHAMPOO 3

LOTRISONE TOPICAL CREAM 3


Effective 4/1/16

32

Drug Name Tier NotesLUZU TOPICAL CREAM 3

MENTAX TOPICAL CREAM 3

miconazole-3 vaginal suppository

1

MYCAMINE INTRAVENOUS RECON SOLN

3

NAFTIFINE TOPICAL CREAM 1 % 3

naftifine topical cream 2 % 1

NAFTIN TOPICAL CREAM 3

NAFTIN TOPICAL GEL 3

NATACYN OPHTHALMIC DROPS,SUSPENSION

3

NIZORAL TOPICAL SHAMPOO 3

NOXAFIL INTRAVENOUS SOLUTION

3

NOXAFIL ORAL SUSPENSION 3

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

3

nyamyc topical powder 1

NYATA TOPICAL COMBO PACK,GEL AND POWDER

3

nystatin oral powder 1

nystatin oral suspension 1

nystatin oral tablet 1

nystatin topical cream 1

nystatin topical ointment 1

nystatin topical powder 1

nystatin-triamcinolone topical cream

1

nystatin-triamcinolone topical ointment

1

nystop topical powder 1

ONMEL ORAL TABLET 3

Drug Name Tier NotesORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

3

oxiconazole topical cream 1

OXISTAT TOPICAL CREAM 3

OXISTAT TOPICAL LOTION 3

PEDIADERM AF TOPICAL CREAM 3

PENLAC TOPICAL SOLUTION 3

SPORANOX ORAL CAPSULE 3 PA

SPORANOX ORAL SOLUTION 3 PA

SPORANOX PULSEPAK ORAL CAPSULE 3 PA

TERAZOL 3 VAGINAL CREAM 3

TERAZOL 7 VAGINAL CREAM 3

terbinafine hcl oral tablet 1

terconazole vaginal cream 1

terconazole vaginal suppository

1

TRIACETIN LIQUID 3 QL

TRIPLE DYE TOPICAL SWAB 3

VFEND IV INTRAVENOUS SOLUTION

3

VFEND ORAL SUSPENSION FOR RECONSTITUTION

3

VFEND ORAL TABLET 3

voriconazole intravenous solution

1

voriconazole oral suspension for reconstitution

1

voriconazole oral tablet 1

VUSION TOPICAL OINTMENT 3

XOLEGEL TOPICAL GEL 3


Effective 4/1/16

33

Drug Name Tier NotesANTIHISTAMINE AND DECONGESTANT COMBINATION

ALLEGRA-D 24 HOUR ORAL TABLET EXTENDED RELEASE 24 HR

3 ST; QL

centergy oral drops 1

CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR

3 ST; QL

promethazine vc oral syrup 1

promethazine-phenylephrine oral syrup

1

SEMPREX-D ORAL CAPSULE 3 ST

ANTIHISTAMINES

arbinoxa oral liquid 1

arbinoxa oral tablet 1

azelastine ophthalmic drops 1 QL

BEPREVE OPHTHALMIC DROPS 3 ST; QL

carbinoxamine maleate oral liquid

1

carbinoxamine maleate oral tablet

1

cetirizine oral solution 1 QL

CLARINEX ORAL SYRUP 3 ST; QL

CLARINEX ORAL TABLET 3 ST; QL

clemastine oral tablet 1

CYPROHEPTADINE ORAL SYRUP 3

cyproheptadine oral tablet 1

desloratadine oral tablet 1 QL

desloratadine oral tablet,disintegrating

1 QL

diphenhydramine hcl injection solution

1

diphenhydramine hcl injection syringe

1

diphenhydramine hcl oral capsule

1

Drug Name Tier Notesdiphenhydramine hcl oral elixir

1

ELESTAT OPHTHALMIC DROPS 3 ST; QL

EMADINE OPHTHALMIC DROPS 3 ST; QL

epinastine ophthalmic drops 1 QL

hydroxyzine hcl intramuscular solution

1

HYDROXYZINE HCL ORAL SOLUTION 3

hydroxyzine hcl oral tablet 1

hydroxyzine pamoate oral capsule

1

KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 HR

3

LASTACAFT OPHTHALMIC DROPS 3 ST; QL

levocetirizine oral solution 1 QL

levocetirizine oral tablet 1 QL

olopatadine ophthalmic drops 1 ST; QL

PATADAY OPHTHALMIC DROPS 3 ST; QL

PATANOL OPHTHALMIC DROPS 3 ST; QL

PAZEO OPHTHALMIC DROPS 3 ST; QL

PHENERGAN INJECTION SOLUTION 3

promethazine injection solution

1

promethazine oral syrup 1

promethazine oral tablet 1

VISTARIL ORAL CAPSULE 3

XYZAL ORAL SOLUTION 3 ST; QL

XYZAL ORAL TABLET 3 ST; QL

ANTIHYPERGLYCEMICS

acarbose oral tablet 1

ACTOPLUS MET ORAL TABLET 3 QL


Effective 4/1/16

34

Drug Name Tier NotesACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR

2 QL

ACTOS ORAL TABLET 3 QL

AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE

3 PA; QL

ALOGLIPTIN ORAL TABLET 3 ST; QL

ALOGLIPTIN-METFORMIN ORAL TABLET 3 ST; QL

ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 3 ST; QL

AMARYL ORAL TABLET 3

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN

3 ST

APIDRA SUBCUTANEOUS SOLUTION

3 ST

AVANDAMET ORAL TABLET 3 ST; QL

AVANDIA ORAL TABLET 3 ST; QL

BYDUREON SUBCUTANEOUS PEN INJECTOR

2 ST

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

2 ST; QL

BYETTA SUBCUTANEOUS PEN INJECTOR

2 ST; QL

chlorpropamide oral tablet 1 PA

CYCLOSET ORAL TABLET 3

DUETACT ORAL TABLET 3 QL

FARXIGA ORAL TABLET 3 ST; QL

FORTAMET ORAL TABLET EXTENDED RELEASE 24HR

3

Drug Name Tier Notesglimepiride oral tablet 1

glipizide oral tablet 1

glipizide oral tablet extended release 24hr

1

glipizide-metformin oral tablet

1

GLUCOPHAGE ORAL TABLET 3

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR

3

GLUCOTROL ORAL TABLET 3

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR

3

GLUCOVANCE ORAL TABLET 3

GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR

3 ST

glyburide micronized oral tablet

1

glyburide oral tablet 1

glyburide-metformin oral tablet

1

GLYNASE ORAL TABLET 3

GLYSET ORAL TABLET 2

GLYXAMBI ORAL TABLET 3 ST; QL

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

2

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

2

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

2


Effective 4/1/16

35

Drug Name Tier NotesHUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

2

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

2

HUMALOG SUBCUTANEOUS CARTRIDGE

2

HUMALOG SUBCUTANEOUS SOLUTION

2

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN

2

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

2

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

2

HUMULIN N SUBCUTANEOUS SUSPENSION

2

HUMULIN R INJECTION SOLUTION 2

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

2

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

2

INVOKAMET ORAL TABLET 3 ST; QL

INVOKANA ORAL TABLET 3 ST; QL

JANUMET ORAL TABLET 2 ST; QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

2 ST; QL

JANUVIA ORAL TABLET 2 ST; QL

Drug Name Tier NotesJARDIANCE ORAL TABLET 2 ST; QL

JENTADUETO ORAL TABLET 2 ST; QL

KAZANO ORAL TABLET 3 ST; QL

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR

3 ST; QL

KORLYM ORAL TABLET 4 PA

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

2

LANTUS SUBCUTANEOUS SOLUTION

2

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

2

LEVEMIR SUBCUTANEOUS SOLUTION

2

metformin oral tablet 1

metformin oral tablet extended release 24 hr

1

metformin oral tablet extended release 24hr

1

metformin oral tablet,er gast.retention 24 hr

3 ST

nateglinide oral tablet 1

NESINA ORAL TABLET 3 ST; QL

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

2

NOVOLIN N SUBCUTANEOUS SUSPENSION

2

NOVOLIN R INJECTION SOLUTION 2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN

2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

2


Effective 4/1/16

36

Drug Name Tier NotesNOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE

2

NOVOLOG SUBCUTANEOUS SOLUTION

2

ONGLYZA ORAL TABLET 2.5 MG 3 ST; DO

ONGLYZA ORAL TABLET 5 MG 3 ST; QL

OSENI ORAL TABLET 3 ST; QL

pioglitazone oral tablet 1 QL

pioglitazone-glimepiride oral tablet

1 QL

pioglitazone-metformin oral tablet

1 QL

PRANDIN ORAL TABLET 3

PRECOSE ORAL TABLET 3

repaglinide oral tablet 1

repaglinide-metformin oral tablet

1

RIOMET ORAL SOLUTION 3

STARLIX ORAL TABLET 3

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

2

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

2

SYNJARDY ORAL TABLET 2 ST; QL

TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML

3 ST; QL

TANZEUM SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML

3 ST

tolazamide oral tablet 1

tolbutamide oral tablet 1

Drug Name Tier NotesTOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN

3

TRADJENTA ORAL TABLET 2 ST; DO

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN

3 ST

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN

3 ST

TRULICITY SUBCUTANEOUS PEN INJECTOR

3 ST; QL

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

2 ST; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

2 ST; QL

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

3 ST; QL

ANTIINFECTIVES/MISCELLANEOUS

ALBENZA ORAL TABLET 3

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

3

ALINIA ORAL TABLET 3

atovaquone oral suspension 1

atovaquone-proguanil oral tablet

1

BILTRICIDE ORAL TABLET 3

chloroquine phosphate oral tablet

1

COARTEM ORAL TABLET 3

DARAPRIM ORAL TABLET 3 PA; QL

EMVERM ORAL TABLET,CHEWABLE 3

fem ph vaginal gel 1

formadon topical solution 1


Effective 4/1/16

37

Drug Name Tier Notesformadon topical solution with applicator

1

formaldehyde topical solution with applicator

1

GLUTARALDEHYDE SOLUTION 2

glycine irrigation solution 1

glycine urologic irrigation solution

1

hydroxychloroquine oral tablet

1

ivermectin oral tablet 1

MALARONE ORAL TABLET 3

MALARONE PEDIATRIC ORAL TABLET 3

mefloquine oral tablet 1

MEPRON ORAL SUSPENSION 3

NEBUPENT INHALATION RECON SOLN

2

paromomycin oral capsule 1

PENTAM INJECTION RECON SOLN 2

PLAQUENIL ORAL TABLET 3

PRIMAQUINE ORAL TABLET 2

QUALAQUIN ORAL CAPSULE 3 PA; QL

quinine sulfate oral capsule 1 PA; QL

RELAGARD VAGINAL GEL 3

STROMECTOL ORAL TABLET 3

TINDAMAX ORAL TABLET 3

tinidazole oral tablet 1

ANTIINFECTIVES

ARESTIN DENTAL CARTRIDGE 3

AVC VAGINAL VAGINAL CREAM 3

Drug Name Tier NotesANTINEOPLASTICS

ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION

3

ACTIMMUNE SUBCUTANEOUS SOLUTION

4 PA; QL

ADCETRIS INTRAVENOUS RECON SOLN

3 PA

adrucil intravenous solution 1

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

3 PA

AFINITOR ORAL TABLET 2 PA

ALECENSA ORAL CAPSULE 3

ALFERON N INJECTION SOLUTION 4

ALIMTA INTRAVENOUS RECON SOLN 3 PA

ALKERAN INTRAVENOUS RECON SOLN

3

ALKERAN ORAL TABLET 2

anastrozole oral tablet 1 PA; QL

ARIMIDEX ORAL TABLET 3 PA; QL

AROMASIN ORAL TABLET 3 PA; QL

ARRANON INTRAVENOUS SOLUTION

3

ARZERRA INTRAVENOUS SOLUTION

3 PA

AVASTIN INTRAVENOUS SOLUTION

3 PA

azacitidine injection recon soln

1 QL


Effective 4/1/16

38

Drug Name Tier NotesBELEODAQ INTRAVENOUS RECON SOLN

3 PA

BENDEKA INTRAVENOUS SOLUTION

3

bexarotene oral capsule 1 PA; QL

bicalutamide oral tablet 1

BICNU INTRAVENOUS RECON SOLN 3

bleomycin injection recon soln

1

BLINCYTO INTRAVENOUS KIT 3 PA

BOSULIF ORAL TABLET 2 PA; QL

BUSULFEX INTRAVENOUS SOLUTION

3

CAMPATH INTRAVENOUS SOLUTION

3

CAMPTOSAR INTRAVENOUS SOLUTION

3

capecitabine oral tablet 1 PA; QL

CAPRELSA ORAL TABLET 2 PA; QL

CARAC TOPICAL CREAM 2

carboplatin intravenous recon soln

1

carboplatin intravenous solution

1

CASODEX ORAL TABLET 3

cisplatin intravenous solution 1

cladribine intravenous solution

1

CLOLAR INTRAVENOUS SOLUTION

3

COMETRIQ ORAL CAPSULE 3 PA; QL

COSMEGEN INTRAVENOUS RECON SOLN

3

Drug Name Tier NotesCOTELLIC ORAL TABLET 3 PA; QL

cyclophosphamide intravenous recon soln

1

CYCLOPHOSPHAMIDE ORAL CAPSULE 3

CYRAMZA INTRAVENOUS SOLUTION

3 PA

cytarabine (pf) injection solution

1

cytarabine injection solution 1

dacarbazine intravenous recon soln

1

DACOGEN INTRAVENOUS RECON SOLN

3

DARZALEX INTRAVENOUS SOLUTION

3

daunorubicin intravenous recon soln

1

daunorubicin intravenous solution

1

decitabine intravenous recon soln

1

DEPOCYT (PF) INTRATHECAL SUSPENSION

3

diclofenac sodium topical gel 1 PA; QL

DOCEFREZ INTRAVENOUS RECON SOLN

3

docetaxel intravenous solution

1 PA

DOXIL INTRAVENOUS SUSPENSION 3

doxorubicin intravenous recon soln

1

doxorubicin intravenous solution

1

doxorubicin, peg-liposomal intravenous suspension

1

EFUDEX TOPICAL CREAM 3


Effective 4/1/16

39

Drug Name Tier NotesELIGARD SUBCUTANEOUS SYRINGE

3 PA; QL

ELLENCE INTRAVENOUS SOLUTION

3

EMCYT ORAL CAPSULE 2 PA

EMPLICITI INTRAVENOUS RECON SOLN

3

epirubicin intravenous recon soln

1

epirubicin intravenous solution

1

ERBITUX INTRAVENOUS SOLUTION

3 PA

ERIVEDGE ORAL CAPSULE 2 PA; QL

ERWINAZE INJECTION RECON SOLN 3 PA

ETOPOPHOS INTRAVENOUS RECON SOLN

3

etoposide intravenous solution

1

etoposide oral capsule 1

exemestane oral tablet 1 PA; QL

FARESTON ORAL TABLET 2 QL

FARYDAK ORAL CAPSULE 3 PA; QL

FASLODEX INTRAMUSCULAR SYRINGE

3

FEMARA ORAL TABLET 3 PA; QL

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN

3 PA

floxuridine injection recon soln

1

fludarabine intravenous recon soln

1

fludarabine intravenous solution

1

Drug Name Tier NotesFLUOROPLEX TOPICAL CREAM 3 PA

fluorouracil intravenous solution

1

FLUOROURACIL TOPICAL CREAM 0.5 % 3

fluorouracil topical cream 5 %

1

fluorouracil topical solution 1

flutamide oral capsule 1

FOLOTYN INTRAVENOUS SOLUTION

3

GAZYVA INTRAVENOUS SOLUTION

3 PA

gemcitabine intravenous recon soln

1

gemcitabine intravenous solution

1

GEMZAR INTRAVENOUS RECON SOLN

3

GILOTRIF ORAL TABLET 3 PA; QL

GLEEVEC ORAL TABLET 3 PA; QL

GLEOSTINE ORAL CAPSULE 3 PA

GLIADEL WAFER IMPLANT WAFER 3

HALAVEN INTRAVENOUS SOLUTION

3 PA

HERCEPTIN INTRAVENOUS RECON SOLN

3 PA

HEXALEN ORAL CAPSULE 2

HYCAMTIN INTRAVENOUS RECON SOLN

3 PA

HYCAMTIN ORAL CAPSULE 2 PA

HYDREA ORAL CAPSULE 3


Effective 4/1/16

40

Drug Name Tier Noteshydroxyurea oral capsule 1

IBRANCE ORAL CAPSULE 3 PA; QL

ICLUSIG ORAL TABLET 2 PA; QL

IDAMYCIN PFS INTRAVENOUS SOLUTION

3

idarubicin intravenous solution

1

IFEX INTRAVENOUS RECON SOLN 3

ifosfamide intravenous recon soln

1

ifosfamide intravenous solution

1

ifosfamide-mesna intravenous kit

1

imatinib oral tablet 1 PA; QL

IMBRUVICA ORAL CAPSULE 3 PA; QL

IMLYGIC INJECTION SUSPENSION 3

INLYTA ORAL TABLET 2 PA; QL

INTRON A INJECTION RECON SOLN 4 PA

INTRON A INJECTION SOLUTION 4 PA

IRESSA ORAL TABLET 2 PA; QL

irinotecan intravenous solution

1

ISTODAX INTRAVENOUS RECON SOLN

3

IXEMPRA INTRAVENOUS RECON SOLN

3

JAKAFI ORAL TABLET 2 PA; QL

JEVTANA INTRAVENOUS SOLUTION

3

KADCYLA INTRAVENOUS RECON SOLN

3 PA

Drug Name Tier NotesKEYTRUDA INTRAVENOUS RECON SOLN

3 PA

KEYTRUDA INTRAVENOUS SOLUTION

3 PA

KYPROLIS INTRAVENOUS RECON SOLN

3 PA

LENVIMA ORAL CAPSULE 3 PA; QL

letrozole oral tablet 1 PA; QL

LEUKERAN ORAL TABLET 2

leuprolide subcutaneous kit 1 PA

LEVULAN TOPICAL SOLUTION 3

lipodox 50 intravenous suspension

1

lipodox intravenous suspension

1

LONSURF ORAL TABLET 3 PA

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT

3 PA


3 PA


3 PA; QL

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT

3 PA

LYNPARZA ORAL CAPSULE 3 PA; QL

LYSODREN ORAL TABLET 2 QL

MARQIBO INTRAVENOUS KIT 3

MATULANE ORAL CAPSULE 2


Effective 4/1/16

41

Drug Name Tier Notesmegestrol oral tablet 1

MEKINIST ORAL TABLET 3 PA; QL

melphalan hcl intravenous recon soln

1

mercaptopurine oral tablet 1

methotrexate sodium (pf) injection recon soln

1

methotrexate sodium (pf) injection solution

1

methotrexate sodium injection solution

1

methotrexate sodium oral tablet

1

mitomycin intravenous recon soln

1

mitoxantrone intravenous concentrate

1

MUSTARGEN INJECTION RECON SOLN

3

MYLERAN ORAL TABLET 2

NAVELBINE INTRAVENOUS SOLUTION

3

NEXAVAR ORAL TABLET 2 PA; QL

NILANDRON ORAL TABLET 2 QL

NINLARO ORAL CAPSULE 3 PA; QL

NIPENT INTRAVENOUS RECON SOLN 3

ODOMZO ORAL CAPSULE 3 PA; QL

ONCASPAR INJECTION SOLUTION 3 PA

ONIVYDE INTRAVENOUS DISPERSION

3

OPDIVO INTRAVENOUS SOLUTION 3 PA

oxaliplatin intravenous recon soln

1

Drug Name Tier Notesoxaliplatin intravenous solution

1

paclitaxel intravenous concentrate

1

PANRETIN TOPICAL GEL 3

PERJETA INTRAVENOUS SOLUTION

3 PA

PHOTOFRIN INTRAVENOUS RECON SOLN

3

PICATO TOPICAL GEL 3 PA; QL

POMALYST ORAL CAPSULE 3 PA; QL

PORTRAZZA INTRAVENOUS SOLUTION

3

PROLEUKIN INTRAVENOUS RECON SOLN

3

PROVENGE INTRAVENOUS SUSPENSION

4 PA

PURIXAN ORAL SUSPENSION 3 PA

REVLIMID ORAL CAPSULE 2 PA; QL

RITUXAN INTRAVENOUS CONCENTRATE

3 PA

SOLARAZE TOPICAL GEL 3 PA; QL

SOLTAMOX ORAL SOLUTION 2

SPRYCEL ORAL TABLET 2 PA; QL

STIVARGA ORAL TABLET 2 PA; QL

SUTENT ORAL CAPSULE 2 PA; QL

SYLATRON SUBCUTANEOUS KIT 3

SYLVANT INTRAVENOUS RECON SOLN

4 PA


Effective 4/1/16

42

Drug Name Tier NotesSYNRIBO SUBCUTANEOUS RECON SOLN

3

TABLOID ORAL TABLET 2

TAFINLAR ORAL CAPSULE 3 PA; QL

TAGRISSO ORAL TABLET 3 PA; QL

tamoxifen oral tablet 1

TARCEVA ORAL TABLET 2 PA; QL

TARGRETIN ORAL CAPSULE 3 PA

TARGRETIN TOPICAL GEL 2 PA

TASIGNA ORAL CAPSULE 2 PA; QL

TAXOTERE INTRAVENOUS SOLUTION

3 PA

TEMODAR INTRAVENOUS RECON SOLN

2 PA

TEMODAR ORAL CAPSULE 3 PA; QL

temozolomide oral capsule 1 PA; QL

TENIPOSIDE INTRAVENOUS SOLUTION

3

THERACYS INTRAVESICAL SUSPENSION FOR RECONSTITUTION

3

thiotepa injection recon soln 1

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION

4

TOLAK TOPICAL CREAM 3

toposar intravenous solution 1

topotecan intravenous recon soln

1

topotecan intravenous solution

1

Drug Name Tier NotesTORISEL INTRAVENOUS RECON SOLN

2

TREANDA INTRAVENOUS RECON SOLN

3 PA

TRELSTAR INTRAMUSCULAR SYRINGE

3 PA; QL

tretinoin (chemotherapy) oral capsule

1

TREXALL ORAL TABLET 2

TRISENOX INTRAVENOUS SOLUTION

3

TYKERB ORAL TABLET 2 PA; QL

UNITUXIN INTRAVENOUS SOLUTION

3

UVADEX INJECTION SOLUTION 3

VALCHLOR TOPICAL GEL 3

VALSTAR INTRAVESICAL SOLUTION

2

VANTAS IMPLANT KIT 3 PA

VECTIBIX INTRAVENOUS SOLUTION

3 PA

VELCADE INJECTION RECON SOLN 3 PA

VIDAZA INJECTION RECON SOLN 3

vinblastine intravenous solution

1

vincasar pfs intravenous solution

1

vincristine intravenous solution

1

vinorelbine intravenous solution

1

VOTRIENT ORAL TABLET 2 PA; QL


Effective 4/1/16

43

Drug Name Tier NotesXALKORI ORAL CAPSULE 2 PA; QL

XELODA ORAL TABLET 3 PA

XTANDI ORAL CAPSULE 2 PA; QL

YERVOY INTRAVENOUS SOLUTION

3 PA

YONDELIS INTRAVENOUS RECON SOLN

3

ZALTRAP INTRAVENOUS SOLUTION

3 PA

ZANOSAR INTRAVENOUS RECON SOLN

3

ZELBORAF ORAL TABLET 2 PA; QL

ZEVALIN (Y-90) INTRAVENOUS KIT 3

ZOLADEX SUBCUTANEOUS IMPLANT

3 PA; QL

ZOLINZA ORAL CAPSULE 2 PA; QL

ZYDELIG ORAL TABLET 3 PA; QL

ZYKADIA ORAL CAPSULE 3 PA; QL

ZYTIGA ORAL TABLET 2 PA; QL

ANTI-OBESITY DRUGS

ADIPEX-P ORAL CAPSULE 3 PA

ADIPEX-P ORAL TABLET 3 PA

BELVIQ ORAL TABLET 3 PA

benzphetamine oral tablet 1 PA

CONTRAVE ORAL TABLET EXTENDED RELEASE

3 PA

diethylpropion oral tablet 1 PA

diethylpropion oral tablet extended release

1 PA

Drug Name Tier Notesphendimetrazine tartrate oral capsule, extended release

1 PA

phendimetrazine tartrate oral tablet

1 PA

phentermine oral capsule 1 PA

phentermine oral tablet 1 PA

QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR

3 PA

REGIMEX ORAL TABLET 3 PA

SAXENDA SUBCUTANEOUS PEN INJECTOR

3 PA

SUPRENZA ORAL TABLET,DISINTEGRATING

3 PA

XENICAL ORAL CAPSULE 3

ANTIPARKINSON DRUGS

amantadine hcl oral capsule 1

amantadine hcl oral solution 1

amantadine hcl oral tablet 1

APOKYN SUBCUTANEOUS CARTRIDGE

4 PA

AZILECT ORAL TABLET 2

benztropine injection solution

1

benztropine oral tablet 1

bromocriptine oral capsule 1

bromocriptine oral tablet 1

carbidopa oral tablet 1

carbidopa-levodopa oral tablet

1

carbidopa-levodopa oral tablet extended release

1

carbidopa-levodopa oral tablet,disintegrating

1

carbidopa-levodopa-entacapone oral tablet

1


Effective 4/1/16

44

Drug Name Tier NotesCOGENTIN INJECTION SOLUTION 3

COMTAN ORAL TABLET 3

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

3 PA

ELDEPRYL ORAL CAPSULE 3

entacapone oral tablet 1

LODOSYN ORAL TABLET 3

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR

3

MIRAPEX ORAL TABLET 3

NEUPRO TRANSDERMAL PATCH 24 HOUR

3 QL

PARLODEL ORAL CAPSULE 3

PARLODEL ORAL TABLET 3

pramipexole oral tablet 1

pramipexole oral tablet extended release 24 hr

1

REQUIP ORAL TABLET0.25 MG 3 QL

REQUIP ORAL TABLET0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG

3

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR

3

ropinirole oral tablet 1

ropinirole oral tablet extended release 24 hr

1

RYTARY ORAL CAPSULE, EXTENDED RELEASE

3

selegiline hcl oral capsule 1

selegiline hcl oral tablet 1

SINEMET CR ORAL TABLET EXTENDED RELEASE

3

Drug Name Tier NotesSINEMET ORAL TABLET 3

STALEVO 100 ORAL TABLET 3 QL






TASMAR ORAL TABLET 3

tolcapone oral tablet 1

trihexyphenidyl oral elixir 1

trihexyphenidyl oral tablet 1

ZELAPAR ORAL TABLET,DISINTEGRATING

3

ANTIPLATELET DRUGS

AGGRASTAT IN SODIUM CHLORIDE INTRAVENOUS SOLUTION

3

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR

3 QL

AGRYLIN ORAL CAPSULE 3

anagrelide oral capsule 1

aspirin-dipyridamole oral capsule, er multiphase 12 hr

1 QL

BRILINTA ORAL TABLET 2 QL

cilostazol oral tablet 1

clopidogrel oral tablet 300 mg

1

clopidogrel oral tablet 75 mg 1 QL

dipyridamole oral tablet 1

DURLAZA ORAL CAPSULE,EXTENDED RELEASE 24HR

3 QL


Effective 4/1/16

45

Drug Name Tier NotesEFFIENT ORAL TABLET10 MG 2 QL

EFFIENT ORAL TABLET5 MG 2 DO

eptifibatide intravenous solution

1

INTEGRILIN INTRAVENOUS SOLUTION

3

KENGREAL INTRAVENOUS RECON SOLN

3

PERSANTINE ORAL TABLET 3

PLAVIX ORAL TABLET300 MG 3

PLAVIX ORAL TABLET75 MG 3 QL

REOPRO INTRAVENOUS SOLUTION

3

ticlopidine oral tablet 1

ZONTIVITY ORAL TABLET 3 QL

ANTIVIRALS

abacavir oral tablet 1

abacavir-lamivudine-zidovudine oral tablet

1

acyclovir oral capsule 1

acyclovir oral suspension 1

acyclovir oral tablet 1

acyclovir sodium intravenous recon soln

1

acyclovir sodium intravenous solution

1

acyclovir topical ointment 1

adefovir oral tablet 4

APTIVUS ORAL CAPSULE 2

APTIVUS ORAL SOLUTION 2

ATRIPLA ORAL TABLET 2

Drug Name Tier NotesBARACLUDE ORAL SOLUTION 4

BARACLUDE ORAL TABLET 4

cidofovir intravenous solution

1

COMBIVIR ORAL TABLET 3

COMPLERA ORAL TABLET 2

COPEGUS ORAL TABLET 4

CRIXIVAN ORAL CAPSULE 2

CYTOVENE INTRAVENOUS RECON SOLN

4

DAKLINZA ORAL TABLET 4 PA; QL

DENAVIR TOPICAL CREAM 3 PA

DESCOVY ORAL TABLET 3

didanosine oral capsule,delayed release(dr/ec)

1

EDURANT ORAL TABLET 2

EMTRIVA ORAL CAPSULE 2

EMTRIVA ORAL SOLUTION 2

entecavir oral tablet 4

EPIVIR HBV ORAL SOLUTION 4

EPIVIR HBV ORAL TABLET 4

EPIVIR ORAL SOLUTION 3

EPIVIR ORAL TABLET 3

EPZICOM ORAL TABLET 2

EVOTAZ ORAL TABLET 3

famciclovir oral tablet 1

FAMVIR ORAL TABLET 3


Effective 4/1/16

46

Drug Name Tier NotesFLUMADINE ORAL TABLET 3

foscarnet intravenous solution

1

FOSCAVIR INTRAVENOUS SOLUTION

3

FUZEON SUBCUTANEOUS RECON SOLN

2

ganciclovir sodium intravenous recon soln

4

GENVOYA ORAL TABLET 2

HARVONI ORAL TABLET 4 PA; QL

HEPSERA ORAL TABLET 4

INTELENCE ORAL TABLET 2

INVIRASE ORAL CAPSULE 2

INVIRASE ORAL TABLET 2

ISENTRESS ORAL POWDER IN PACKET 3

ISENTRESS ORAL TABLET 2

ISENTRESS ORAL TABLET,CHEWABLE 2

KALETRA ORAL SOLUTION 2

KALETRA ORAL TABLET 2

lamivudine oral solution 1

lamivudine oral tablet 100 mg

4

lamivudine oral tablet 150 mg, 300 mg

1

lamivudine-zidovudine oral tablet

1

LEXIVA ORAL SUSPENSION 2

LEXIVA ORAL TABLET 2

Drug Name Tier Notesmoderiba dose pack oral tablets,dose pack

4

moderiba oral tablet 4

nevirapine oral suspension 1

nevirapine oral tablet 1

nevirapine oral tablet extended release 24 hr

1

NORVIR ORAL CAPSULE 2

NORVIR ORAL SOLUTION 2

NORVIR ORAL TABLET 2

ODEFSEY ORAL TABLET 3

OLYSIO ORAL CAPSULE 4 PA; QL

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

4 PA; QL

PEGASYS SUBCUTANEOUS SOLUTION

4 PA; QL

PEGASYS SUBCUTANEOUS SYRINGE

4 PA; QL

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

4 PA

PEGINTRON SUBCUTANEOUS KIT 4 PA

PREZCOBIX ORAL TABLET 3

PREZISTA ORAL SUSPENSION 2

PREZISTA ORAL TABLET 2

RAPIVAB INTRAVENOUS SOLUTION

3

REBETOL ORAL SOLUTION 4

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

2 QL

RESCRIPTOR ORAL TABLET 2


Effective 4/1/16

47

Drug Name Tier NotesRESCRIPTOR ORAL TABLET, DISPERSIBLE 2

RETROVIR INTRAVENOUS SOLUTION

2

RETROVIR ORAL CAPSULE 3

RETROVIR ORAL SYRUP 3

REYATAZ ORAL CAPSULE 2

REYATAZ ORAL POWDER IN PACKET 2

ribasphere oral capsule 4

ribasphere oral tablet 4

ribasphere ribapak oral tablets,dose pack

4

RIBATAB DOSE PACK ORAL TABLETS,DOSE PACK

4

ribavirin oral capsule 4

ribavirin oral tablet 4

rimantadine oral tablet 1

SELZENTRY ORAL TABLET 2

SITAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

3 PA

SOVALDI ORAL TABLET 4 PA; QL

stavudine oral capsule 1

stavudine oral recon soln 1

STRIBILD ORAL TABLET 2

SUSTIVA ORAL CAPSULE 2

SUSTIVA ORAL TABLET 2

SYNAGIS INTRAMUSCULAR SOLUTION

4 PA

TAMIFLU ORAL CAPSULE 2 QL

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

2 QL

Drug Name Tier NotesTECHNIVIE ORAL TABLET 4 PA; QL

TIVICAY ORAL TABLET 3

trifluridine ophthalmic drops 1

TRIUMEQ ORAL TABLET 2

TRIZIVIR ORAL TABLET 3

TRUVADA ORAL TABLET 2

TYZEKA ORAL TABLET 4 QL

valacyclovir oral tablet 1

VALCYTE ORAL RECON SOLN 3

VALCYTE ORAL TABLET 3

valganciclovir oral tablet 1

VALTREX ORAL TABLET 3

VEREGEN TOPICAL OINTMENT 3

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

2

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN

2

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

VIEKIRA PAK ORAL TABLETS,DOSE PACK 4 PA; QL

VIRACEPT ORAL TABLET 2

VIRAMUNE ORAL SUSPENSION 3

VIRAMUNE ORAL TABLET 3

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR

3

VIRAZOLE INHALATION RECON SOLN

3

VIREAD ORAL POWDER 2


Effective 4/1/16

48

Drug Name Tier NotesVIREAD ORAL TABLET 2

VIROPTIC OPHTHALMIC DROPS 3

VISTIDE INTRAVENOUS SOLUTION 3

VITEKTA ORAL TABLET 3

XERESE TOPICAL CREAM 3 PA

ZEPATIER ORAL TABLET 4 PA; QL

ZERIT ORAL CAPSULE 3

ZERIT ORAL RECON SOLN 3

ZIAGEN ORAL SOLUTION 2

ZIAGEN ORAL TABLET 3

zidovudine oral capsule 1

zidovudine oral syrup 1

zidovudine oral tablet 1

ZIRGAN OPHTHALMIC GEL 3

ZOVIRAX ORAL CAPSULE 3

ZOVIRAX ORAL SUSPENSION 3

ZOVIRAX ORAL TABLET 3

ZOVIRAX TOPICAL CREAM 3 PA; QL

ZOVIRAX TOPICAL OINTMENT 3

AUTONOMIC DRUGS

ADDERALL ORAL TABLET 3

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR

1 PA

ADRENACLICK INJECTION AUTO-INJECTOR

3

adrenalin injection solution 1

Drug Name Tier NotesADZENYS XR-ODT ORAL TABLET,DISINTIG ER BIPHASE 24H

3

anectine injection solution 1

ARICEPT ORAL TABLET 3

atracurium intravenous solution

1

bethanechol chloride oral tablet

1

BLOXIVERZ INTRAVENOUS SOLUTION

3

BOTOX COSMETIC INJECTION RECON SOLN

4 PA

BOTOX COSMETIC INTRAMUSCULAR RECON SOLN

4 PA

BOTOX INJECTION RECON SOLN 4 PA

cevimeline oral capsule 1

cisatracurium intravenous solution

1

DESOXYN ORAL TABLET 3

dexedrine oral tablet 1 PA

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE

3 ST

dextroamphetamine oral capsule, extended release

1 PA

dextroamphetamine oral solution

1 PA

dextroamphetamine oral tablet

1 PA

dextroamphetamine-amphetamine oral capsule,extended release 24hr

1 PA

dextroamphetamine-amphetamine oral tablet

1 PA

DIBENZYLINE ORAL CAPSULE 3

donepezil oral tablet 1


Effective 4/1/16

49

Drug Name Tier Notesdonepezil oral tablet,disintegrating

1

dopamine in 5 % dextrose intravenous solution

1

dopamine intravenous solution

1

DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR

3 ST

DYSPORT INTRAMUSCULAR RECON SOLN

4 PA

enlon injection solution 1

ENLON-PLUS INTRAVENOUS SOLUTION

3

EPINEPHRINE HCL (PF) INTRAVENOUS SOLUTION

3

epinephrine injection auto-injector

1

epinephrine injection solution

1

epinephrine injection syringe 1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

2

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

2

EPISNAP INJECTION KIT 3

EVEKEO ORAL TABLET 3 ST

EVOXAC ORAL CAPSULE 3

EXELON ORAL CAPSULE 3

EXELON TRANSDERMAL PATCH 24 HOUR

3 ST

galantamine oral capsule,ext rel. pellets 24 hr

1

galantamine oral solution 1

galantamine oral tablet 1

guanidine oral tablet 1

Drug Name Tier NotesISUPREL INJECTION SOLUTION 3

LEVOPHED (BITARTRATE) INTRAVENOUS SOLUTION

3

MESTINON ORAL SYRUP 2

MESTINON ORAL TABLET 3

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE

3

methamphetamine oral tablet 1

midodrine oral tablet 1

MYOBLOC INTRAMUSCULAR SOLUTION

4 PA

neostigmine methylsulfate injection solution

1

neostigmine methylsulfate intravenous solution 0.5 mg/ml

1

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 1 MG/ML

3

NIMBEX INTRAVENOUS SOLUTION 3

norepinephrine bitartrate intravenous solution

1

NORTHERA ORAL CAPSULE 3

pancuronium intravenous solution

1

phenoxybenzamine oral capsule

1

phentolamine injection recon soln

1

physostigmine salicylate injection solution

1

pilocarpine hcl oral tablet 1

procentra oral solution 1

pyridostigmine bromide oral tablet

1


Effective 4/1/16

50

Drug Name Tier Notespyridostigmine bromide oral tablet extended release

1

QUELICIN INJECTION SOLUTION 3

RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR

3

RAZADYNE ORAL TABLET 3

regonol injection solution 1

rivastigmine tartrate oral capsule

1

rivastigmine transdermal patch 24 hour

1

rocuronium intravenous solution

1

SALAGEN ORAL TABLET 3

URECHOLINE ORAL TABLET 3

vecuronium bromide intravenous recon soln

1

XEOMIN INTRAMUSCULAR RECON SOLN

4 PA

zenzedi oral tablet 10 mg, 5 mg

1 ST

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

3 ST

BIOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

3

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

3

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

3

AFLURIA 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2 QL

Drug Name Tier NotesAFLURIA 2015-2016 INTRAMUSCULAR SUSPENSION

2 QL

ALL EXT-CAL PEPPER TREE POLLEN INJECTION SOLUTION

3

ALL XT-WEED POL-RUSSIAN THISTL INJECTION SOLUTION

3

ALL.XT,KBLUE-JUNE GRASS POLLEN INJECTION SOLUTION

3

ALLER EXT-ALTERNARIA ALTERNATA INJECTION SOLUTION

3

ALLER EXT-AMERICAN COCKROACH INJECTION SOLUTION

3

ALLER EXT-TREE POLL,RED CEDAR INJECTION SOLUTION

3

ALLER EXT-TREE POLLEN,AM ELM INJECTION SOLUTION

3

ALLER EXT-TREE POLLEN,BAYBERRY INJECTION SOLUTION

3

ALLER EXT-TREE POLLEN,MESQUITE INJECTION SOLUTION

3

ALLER XT-SHAGBARK HICKORY POLL INJECTION SOLUTION

3

ALLER XT-TREE POL,E.COTTONWOOD INJECTION SOLUTION

3

ALLER XT-TREE POLLEN,BOX ELDER INJECTION SOLUTION

3

ALLER XT-TREE POLLEN,HACKBERRY INJECTION SOLUTION

3

ALLER XT-TREE POLLEN,RED BIRCH INJECTION SOLUTION

3


Effective 4/1/16

51

Drug Name Tier NotesALLER XT-TREE POLLEN,WHITE ASH INJECTION SOLUTION

3

ALLER XT-TREE POLLEN-WHITE OAK INJECTION SOLUTION

3

ALLER XT-WEED POLLEN-COCKLEBUR INJECTION SOLUTION

3

ALLER XT-WEED POLLEN-SAGEBRUSH INJECTION SOLUTION

3

ALLERG EX,GRASS POLLEN-BERMUDA INJECTION SOLUTION

3

ALLERG EX,GRASS POLLEN-ORCHARD INJECTION SOLUTION

3

ALLERG EX-GRASS POLLEN-JOHNSON INJECTION SOLUTION

3

ALLERG EXT,GRASS POLLEN-REDTOP INJECTION SOLUTION

3

ALLERG EXT-ACREMONIUM STRICTUM INJECTION SOLUTION

3

ALLERG EXT-BLACK WALNUT POLLEN INJECTION SOLUTION

3

ALLERG EXT-GRASS,PERENNIAL RYE INJECTION SOLUTION

3

ALLERG EXT-PENICILLIUM NOTATUM INJECTION SOLUTION

3

ALLERG EXT-TREE POLLEN-ACACIA INJECTION SOLUTION

3

ALLERG EXT-TREE POLLEN-ALDER INJECTION SOLUTION

3

ALLERG EXT-TREE POLL-JUN, WEST INJECTION SOLUTION

3

Drug Name Tier NotesALLERG EXT-WEED POLLEN-MUGWORT INJECTION SOLUTION

3

ALLERG EX-WEED POL-RGH PIGWEED INJECTION SOLUTION

3

ALLERG XT,GRASS POLLEN-TIMOTHY INJECTION SOLUTION

3 PA

ALLERG XT,GRASS-MEADOW FESCUE INJECTION SOLUTION

3

ALLERG XT-SHEEP SOR,YELLW DOCK INJECTION SOLUTION

3

ALLERG XT-WEED POLL-DOG FENNEL INJECTION SOLUTION

3

ALLERGEN EX-FUSARIUM OXYSPORUM INJECTION SOLUTION

3

ALLERGEN EXT-ASPERGILLUS FUMIG INJECTION SOLUTION

3

ALLERGEN EXT-ASPERGILLUS,MIXED INJECTION SOLUTION

3

ALLERGEN EXT-AUREOBA.PULLULANS INJECTION SOLUTION

3

ALLERGEN EXT-BOTRYTIS CINEREA INJECTION SOLUTION

3

ALLERGEN EXT-C.CLADOSPORIOIDES INJECTION SOLUTION

3

ALLERGEN EXT-C.SPHAEROSPERMUM INJECTION SOLUTION

3


Effective 4/1/16

52

Drug Name Tier NotesALLERGEN EXT-CANDIDA ALBICANS INJECTION SOLUTION

3

ALLERGEN EXT-CATTLE EPITHELIUM INJECTION SOLUTION

3

ALLERGEN EXT-ENGLISH PLANTAIN INJECTION SOLUTION

3

ALLERGEN EXT-GERMAN COCKROACH INJECTION SOLUTION

3

ALLERGEN EXTRACT-D.SOROKINIANA INJECTION SOLUTION

3

ALLERGEN EXTRACT-S. CEREVISIAE INJECTION SOLUTION

3

ALLERGEN EXT-T. MENTAGROPHYTES INJECTION SOLUTION

3

ALLERGEN EXT-TREE POLLEN,PECAN INJECTION SOLUTION

3

ALLERGEN XT-AM.SYCAMORE POLLEN INJECTION SOLUTION

3

ALLERGEN XT-GRASS POLLEN-BAHIA INJECTION SOLUTION

3

ALLERGEN XT-QUEEN PALM POLLEN INJECTION SOLUTION

3

ALLERGEN XT-VIRGINIA LIVE OAK INJECTION SOLUTION

3

ALLERGENIC EX-HORSE EPITHELIUM INJECTION SOLUTION

3

ALLERGENIC EXT-DOG EPITHELIUM INJECTION SOLUTION

3

Drug Name Tier NotesALLERGENIC EXT-MITE, D FARINAE INJECTION SOLUTION

3

ALLERGENIC EXT-MITE, D.PTERONY INJECTION SOLUTION

3

ALLERGENIC EXT-MIXED RAGWEED INJECTION SOLUTION

3

ALLERGENIC EXT-MUCOR PLUMBEUS INJECTION SOLUTION

3 QL

ALLERGENIC EXT-PHOMA HERBARUM INJECTION SOLUTION

3

ALLERGENIC EXT-RHIZOPUS ORYZAE INJECTION SOLUTION

3

ALLERGENIC XT-EPICOCCUM NIGRUM INJECTION SOLUTION

3

ALLERGEN-WEED-LAMBSQUARTERS INJECTION SOLUTION

3

ALLERGN EXT-MOUNT.CEDAR POLLEN INJECTION SOLUTION

3

ANASCORP INTRAVENOUS RECON SOLN

3

ANTIVENIN LATRODECTUS MACTANS INJECTION RECON SOLN

3

ANTIVENIN MICRURUS FULVIUS INJECTION COMBO PACK

3

APLISOL INTRADERMAL SOLUTION

3

ATGAM INTRAVENOUS SOLUTION 4


Effective 4/1/16

53

Drug Name Tier NotesBCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

BEXSERO (PF) INTRAMUSCULAR SYRINGE

3

BIOTHRAX INTRAMUSCULAR SUSPENSION

3

BIVIGAM INTRAVENOUS SOLUTION

4 PA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

3

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

3

candin intradermal allergen 1

CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN

4 PA

CAT HAIR STD ALLERGENIC EXT INJECTION SOLUTION

3

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE

2

CROFAB INJECTION RECON SOLN 3

CYTOGAM INTRAVENOUS SOLUTION

4

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

3

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

3

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

3

Drug Name Tier NotesENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3

EPIFIX AMNIOTIC MEMBRANE TOPICAL SHEET

3

EZ FLU 2015-16 (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT

2 QL

EZ FLU 2015-16(FLUCELVAX)(PF) INTRAMUSCULAR SYRINGE KIT

2 QL

FLEBOGAMMA DIF INTRAVENOUS SOLUTION

4 PA

FLUARIX QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2 QL

FLUBLOK 2015-2016 (PF) INTRAMUSCULAR SOLUTION

2 QL

FLUCELVAX 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2 QL

FLULAVAL QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

2 QL

FLUMIST QUAD 2015-2016 NASAL NASAL SPRAY SYRINGE

2 QL

FLUVIRIN 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2 QL

FLUVIRIN 2015-2016 INTRAMUSCULAR SUSPENSION

2 QL

FLUZONE 2015-2016 INTRAMUSCULAR SUSPENSION

2 QL

FLUZONE HIGH-DOSE 2015-16 (PF) INTRAMUSCULAR SYRINGE

2 QL


Effective 4/1/16

54

Drug Name Tier NotesFLUZONE INTRADERM QUAD 2015-16 INTRADERMAL SYRINGE

2 QL

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SUSPENSION

2 QL

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

2 QL

FLUZONE QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

2 QL

FLUZONE QUAD PEDI 2015-16 (PF) INTRAMUSCULAR SYRINGE

2 QL

GAMASTAN S/D INTRAMUSCULAR SOLUTION

4 PA

GAMMAGARD LIQUID INJECTION SOLUTION 4 PA

GAMMAGARD S-D (IGA &LT< 1 MCG/ML) INTRAVENOUS RECON SOLN

4 PA

GAMMAKED INJECTION SOLUTION 4 PA

GAMMAPLEX INTRAVENOUS SOLUTION

4 PA

GAMUNEX-C INJECTION SOLUTION 4 PA

GARDASIL (PF) INTRAMUSCULAR SUSPENSION

2

GARDASIL (PF) INTRAMUSCULAR SYRINGE

2

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

2

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

2

Drug Name Tier NotesGRAFIX CORE TOPICAL SHEET 3

GRAFIX PRIME TOPICAL SHEET 3

GRASTEK SUBLINGUAL TABLET 3 PA; QL

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

3

HAVRIX (PF) INTRAMUSCULAR SYRINGE

3

HEPAGAM B INJECTION SOLUTION 4

HIZENTRA SUBCUTANEOUS SOLUTION

4 PA

HYPERHEP B S/D INTRAMUSCULAR SOLUTION

4

HYPERHEP B S/D INTRAMUSCULAR SYRINGE

4

HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE

4

HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION

4

HYPERRHO S/D INTRAMUSCULAR SYRINGE

4

HYPERTET S/D (PF) INTRAMUSCULAR SYRINGE

3

HYQVIA SUBCUTANEOUS SOLUTION

4 PA

IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION

4

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

3


Effective 4/1/16

55

Drug Name Tier NotesINFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

3

IPOL INJECTION SUSPENSION 3

IXIARO (PF) INTRAMUSCULAR SYRINGE

3

KINRIX (PF) INTRAMUSCULAR SUSPENSION

3

KINRIX (PF) INTRAMUSCULAR SYRINGE

3

MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

3

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN

3

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN

3

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT

3

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE

4

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

3

NABI-HB INTRAMUSCULAR SOLUTION

4

OCTAGAM INTRAVENOUS SOLUTION

4 PA

Drug Name Tier NotesORALAIR SUBLINGUAL TABLET 3 PA; QL

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

3

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

3

PENTACEL (PF) INTRAMUSCULAR KIT 3

PNEUMOVAX 23 INJECTION SOLUTION 2

PNEUMOVAX 23 INJECTION SYRINGE 2

PRE-PEN INTRADERMAL SOLUTION

3

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

2

PRIVIGEN INTRAVENOUS SOLUTION

4 PA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

3

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

3

RAGWITEK SUBLINGUAL TABLET 3 PA; QL

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

3

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SYRINGE

4

RHOPHYLAC INJECTION SYRINGE 4


Effective 4/1/16

56

Drug Name Tier NotesROTARIX ORAL SUSPENSION FOR RECONSTITUTION

3

ROTATEQ VACCINE ORAL SUSPENSION 3

SPHERUSOL INTRADERMAL SOLUTION

3

STD GRASS POLLEN-SWEET VERNAL INJECTION SOLUTION

3

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

3

TENIVAC (PF) INTRAMUSCULAR SYRINGE

3

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

3

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

3

THYMOGLOBULIN INTRAVENOUS RECON SOLN

4

TRUMENBA INTRAMUSCULAR SYRINGE

3

TUBERSOL INTRADERMAL SOLUTION

3

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

3

TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI INTRAMUSCULAR SOLUTION

3 QL

TYPHIM VI INTRAMUSCULAR SYRINGE

3

Drug Name Tier NotesVAQTA (PF) INTRAMUSCULAR SUSPENSION

3

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

VARIZIG INTRAMUSCULAR RECON SOLN

3

VARIZIG INTRAMUSCULAR SOLUTION

3

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

WEED POLLEN-TRUE MARSH ELDER INJECTION SOLUTION

3

WINRHO SDF INJECTION SOLUTION 4

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

2

BLOOD

ACTIVASE INTRAVENOUS RECON SOLN

3

ADVATE INTRAVENOUS RECON SOLN 4 PA

ADYNOVATE INTRAVENOUS SOLUTION

4

ALBUKED-25 INTRAVENOUS PARENTERAL SOLUTION

3


Effective 4/1/16

57

Drug Name Tier NotesALBUKED-5 INTRAVENOUS PARENTERAL SOLUTION

3

albumin, human 25 % intravenous parenteral solution

1

ALBUMIN, HUMAN 5 % INTRAVENOUS PARENTERAL SOLUTION

2

albuminar 25 % intravenous parenteral solution

1

albuminar 5 % intravenous parenteral solution

1

alburx (human) 25 % intravenous parenteral solution

1

alburx (human) 5 % intravenous parenteral solution

1

albutein 25 % intravenous parenteral solution

1

albutein 5 % intravenous parenteral solution

1

ALPHANATE INTRAVENOUS RECON SOLN

4 PA

ALPHANINE SD INTRAVENOUS RECON SOLN

4 PA

ALPROLIX INTRAVENOUS RECON SOLN

4 PA

AMICAR ORAL SOLUTION 3

AMICAR ORAL TABLET 3

aminocaproic acid intravenous solution

1

ASTRINGYN TOPICAL SOLUTION 3

AVITENE FLOUR TOPICAL POWDER 3

AVITENE TOPICAL POWDER IN PACKET 3

AVITENE TOPICAL SHEET 3

Drug Name Tier NotesBEBULIN INTRAVENOUS RECON SOLN

4 PA

BENEFIX INTRAVENOUS KIT 4 PA

buminate 25 % intravenous parenteral solution

1

buminate 5 % intravenous parenteral solution

1

CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN

3

CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN

4

CEPROTIN (GREEN BAR) INTRAVENOUS RECON SOLN

4

COAGADEX INTRAVENOUS RECON SOLN

4 PA

CORIFACT INTRAVENOUS KIT 4 PA

CYKLOKAPRON INTRAVENOUS SOLUTION

3

DEFITELIO INTRAVENOUS SOLUTION

3

DROXIA ORAL CAPSULE 2

ELOCTATE INTRAVENOUS RECON SOLN

4 PA

ENDO AVITENE TOPICAL SHEET 3

EVICEL TOPICAL SOLUTION 3

FEIBA NF INTRAVENOUS RECON SOLN

4 PA

FLEXBUMIN 25 % INTRAVENOUS PARENTERAL SOLUTION

3


Effective 4/1/16

58

Drug Name Tier NotesFLEXBUMIN 5 % INTRAVENOUS PARENTERAL SOLUTION

3

GELFOAM COMPRESSED SIZE 100 TOPICAL SPONGE

3

GELFOAM MUCOUS MEMBRANE POWDER 3

GELFOAM SPONGE SIZE 100 TOPICAL SPONGE

3

GELFOAM SPONGE SIZE 12-7MM TOPICAL SPONGE

3


3


3

GELFOAM TOPICAL SPONGE 3

HELIXATE FS INTRAVENOUS RECON SOLN

4 PA

HEMOFIL M HIGH INTRAVENOUS RECON SOLN

4 PA

HEMOFIL M LOW INTRAVENOUS RECON SOLN

4 PA

HEMOFIL M MID INTRAVENOUS RECON SOLN

4 PA

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN

4 PA

HESPAN 6 % IN NS INTRAVENOUS SOLUTION

3

hetastarch 6 % in 0.9 % nacl intravenous solution

1

HEXTEND INTRAVENOUS SOLUTION

3

HUMATE-P INTRAVENOUS KIT 4 PA

Drug Name Tier NotesIDELVION INTRAVENOUS RECON SOLN

4

IXINITY INTRAVENOUS RECON SOLN 4 PA

KCENTRA INTRAVENOUS KIT 3

KEDBUMIN INTRAVENOUS PARENTERAL SOLUTION

3

KOATE-DVI INTRAVENOUS RECON SOLN

4 PA

KOGENATE FS INTRAVENOUS RECON SOLN

4 PA

KOVALTRY INTRAVENOUS RECON SOLN

4

lmd 10 % in 0.9 % sodium chlor intravenous parenteral solution

1

lmd 10 % in 5 % dextrose intravenous parenteral solution

1

LYSTEDA ORAL TABLET 3

MONOCLATE-P INTRAVENOUS KIT 4 PA

MONONINE INTRAVENOUS KIT 4 PA

MONSEL'S TOPICAL SOLUTION 3

MONSEL'S TOPICAL SOLUTION WITH APPLICATOR

3

NOVOEIGHT INTRAVENOUS RECON SOLN

4 PA

NOVOSEVEN RT INTRAVENOUS RECON SOLN

4 PA

NUWIQ INTRAVENOUS RECON SOLN 4 PA

OBIZUR INTRAVENOUS RECON SOLN 4 PA


Effective 4/1/16

59

Drug Name Tier NotesOCTAPLAS (BLOOD GROUP A) INTRAVENOUS SOLUTION

3

OCTAPLAS (BLOOD GROUP AB) INTRAVENOUS SOLUTION

3

OCTAPLAS (BLOOD GROUP B) INTRAVENOUS SOLUTION

3

OCTAPLAS (BLOOD GROUP O) INTRAVENOUS SOLUTION

3

OXYCEL COTTON-TYPE PLEDGET PAD 3

pentoxifylline oral tablet extended release

1

plasbumin 25 % intravenous parenteral solution

1

plasbumin 5 % intravenous parenteral solution

1

plasmanate intravenous parenteral solution

1

PRAXBIND INTRAVENOUS SOLUTION

3

PROFILNINE INTRAVENOUS RECON SOLN

4 PA

protamine intravenous solution

1

RECOMBINATE INTRAVENOUS RECON SOLN

4 PA

RECOTHROM SPRAY KIT TOPICAL RECON SOLN

3

RECOTHROM TOPICAL RECON SOLN 3

RIASTAP INTRAVENOUS RECON SOLN

3 PA

RIXUBIS INTRAVENOUS RECON SOLN 4 PA

Drug Name Tier NotesSOLIRIS INTRAVENOUS SOLUTION 4 PA

SYRINGE AVITENE TOPICAL POWDER 3

TACHOSIL TOPICAL ADHESIVE PATCH,MEDICATED

3

THROMBATE III INTRAVENOUS RECON SOLN

3

THROMBI-GEL TOPICAL PADS, MEDICATED

3

THROMBIN-JMI NASAL NASAL SPRAY SYRINGE 3

THROMBIN-JMI TOPICAL RECON SOLN 3

THROMBIN-JMI TOPICAL SPRAY SYRINGE

3

THROMBIN-JMI TOPICAL SPRAY,NON-AEROSOL

3

THROMBI-PAD TOPICAL PADS, MEDICATED

3

TISSEEL VHSD TOPICAL KIT 3

TISSEEL VHSD TOPICAL SYRINGE 3

TNKASE INTRAVENOUS KIT 3

tranexamic acid intravenous solution

1 QL

tranexamic acid oral tablet 1 QL

TRETTEN INTRAVENOUS RECON SOLN

4 PA

ULTRAFOAM TOPICAL SPONGE 3

VOLUVEN 6 % INTRAVENOUS SOLUTION

3

WILATE INTRAVENOUS KIT 4 PA


Effective 4/1/16

60

Drug Name Tier NotesXYNTHA INTRAVENOUS SOLUTION

4 PA

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE

4 PA

CARDIAC DRUGS

ADALAT CC ORAL TABLET EXTENDED RELEASE 30 MG

3 DO

ADALAT CC ORAL TABLET EXTENDED RELEASE 60 MG, 90 MG

3 QL

ADENOCARD INTRAVENOUS SYRINGE

3

adenosine intravenous solution

1

adenosine intravenous syringe

1

afeditab cr oral tablet extended release 30 mg

1 DO

afeditab cr oral tablet extended release 60 mg

1 QL

amiodarone intravenous solution

1

amiodarone intravenous syringe

1

amiodarone oral tablet 1

amlodipine oral tablet 10 mg 1 QL

amlodipine oral tablet 2.5 mg, 5 mg

1 DO

CALAN ORAL TABLET 3 QL

CALAN SR ORAL TABLET EXTENDED RELEASE

3 QL

CARDENE IV IN DEXTROSE INTRAVENOUS PIGGYBACK

3

CARDENE IV IN SODIUM CHLORIDE INTRAVENOUS PIGGYBACK

3

Drug Name Tier NotesCARDENE IV INTRAVENOUS SOLUTION

3

cardioplegic soln perfusion solution

1

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG

3 DO

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 240 MG, 300 MG, 360 MG

3 QL

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG, 180 MG

3 DO

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 240 MG, 300 MG, 360 MG, 420 MG

3 QL

CARDIZEM ORAL TABLET 3 QL

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg

1 DO

cartia xt oral capsule,extended release 24hr 240 mg, 300 mg

1 QL

CLEVIPREX INTRAVENOUS EMULSION

3

CORDARONE ORAL TABLET 2

CORLANOR ORAL TABLET 2 PA; QL

CORVERT INTRAVENOUS SOLUTION

3

digitek oral tablet 1

digox oral tablet 1

digoxin injection solution 1

digoxin injection syringe 1

digoxin oral solution 1

digoxin oral tablet 1


Effective 4/1/16

61

Drug Name Tier NotesDILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE

2

diltiazem hcl intravenous recon soln

1

diltiazem hcl intravenous solution

1

diltiazem hcl oral capsule, extended release 120 mg, 180 mg

1 DO

diltiazem hcl oral capsule, extended release 240 mg, 300 mg, 360 mg, 420 mg

1 QL

diltiazem hcl oral capsule,ext release degradable 120 mg, 180 mg

1 DO

diltiazem hcl oral capsule,ext release degradable 240 mg

1 QL

diltiazem hcl oral capsule,extended release 12 hr

1 QL

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg

1 DO

diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg

1 QL

diltiazem hcl oral tablet 1 QL

diltiazem hcl oral tablet extended release 24 hr 180 mg

1 DO

diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

1 QL

dilt-xr oral capsule,ext release degradable 120 mg, 180 mg

1 DO

dilt-xr oral capsule,ext release degradable 240 mg

1 QL

disopyramide phosphate oral capsule

1

dobutamine in d5w intravenous parenteral solution

1

dobutamine intravenous solution

1

Drug Name Tier Notesfelodipine oral tablet extended release 24 hr 10 mg

1 QL

felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg

1 DO

flecainide oral tablet 1

ibutilide fumarate intravenous solution

1

ISOCHRON ORAL TABLET EXTENDED RELEASE

3

ISORDIL ORAL TABLET 2

ISORDIL TITRADOSE ORAL TABLET 3

isosorbide dinitrate oral tablet

1

isosorbide dinitrate oral tablet extended release

1

isosorbide mononitrate oral tablet

1

isosorbide mononitrate oral tablet extended release 24 hr

1

isradipine oral capsule 1 QL

LANOXIN INJECTION SOLUTION 3

LANOXIN ORAL TABLET 2

LANOXIN PEDIATRIC INJECTION SOLUTION 2

lidocaine (pf) intravenous solution

1

lidocaine (pf) intravenous syringe

1

lidocaine in 5 % dextrose (pf) intravenous parenteral solution

1

matzim la oral tablet extended release 24 hr 180 mg

1 DO

matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

1 QL

mexiletine oral capsule 1

milrinone in 5 % dextrose intravenous piggyback

1


Effective 4/1/16

62

Drug Name Tier Notesmilrinone intravenous solution

1

MINITRAN TRANSDERMAL PATCH 24 HOUR

3

MULTAQ ORAL TABLET 3

NEXTERONE INTRAVENOUS SOLUTION

3

nicardipine intravenous solution

1

nicardipine oral capsule 1 QL

nifedical xl oral tablet extended release 24hr 30 mg

1 DO

nifedical xl oral tablet extended release 24hr 60 mg

1 QL

nifedipine oral capsule 1 QL

nifedipine oral tablet extended release 24hr 30 mg

1 DO

nifedipine oral tablet extended release 24hr 60 mg, 90 mg

1 QL

nifedipine oral tablet extended release 30 mg

1 DO

nifedipine oral tablet extended release 60 mg, 90 mg

1 QL

nimodipine oral capsule 1 QL

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg

1 DO

nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg

1 QL

nitro-bid transdermal ointment

1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

Drug Name Tier Notesnitroglycerin in 5 % dextrose intravenous solution

1

nitroglycerin intravenous solution

1

nitroglycerin oral capsule, extended release

1

nitroglycerin transdermal patch 24 hour

1

nitroglycerin translingual aerosol,spray

1

nitroglycerin translingual spray,non-aerosol

1

NITROLINGUAL TRANSLINGUAL SPRAY,NON-AEROSOL

3

NITROMIST TRANSLINGUAL AEROSOL,SPRAY

3

NITRONAL INTRAVENOUS SOLUTION

3

NITROSTAT SUBLINGUAL TABLET 2

nitro-time oral capsule, extended release

1

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

2

NORPACE ORAL CAPSULE 3

NORVASC ORAL TABLET 10 MG 3 QL

NORVASC ORAL TABLET 2.5 MG, 5 MG 3 DO

NYMALIZE ORAL SOLUTION 3

pacerone oral tablet 1

PLEGISOL PERFUSION SOLUTION 3

procainamide injection solution

1

PROCARDIA ORAL CAPSULE 3 QL

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG

3 DO


Effective 4/1/16

63

Drug Name Tier NotesPROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 60 MG, 90 MG

3 QL

propafenone oral capsule,extended release 12 hr

1

propafenone oral tablet 1

quinidine gluconate injection solution

1

quinidine gluconate oral tablet extended release

1

quinidine sulfate oral tablet 1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

2

RYTHMOL ORAL TABLET 3

RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR

3

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 8.5 MG

3 DO

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 34 MG

3 QL

taztia xt oral capsule, extended release 120 mg, 180 mg

1 DO

taztia xt oral capsule, extended release 240 mg, 300 mg, 360 mg

1 QL

TIAZAC ORAL CAPSULE, EXTENDED RELEASE 120 MG, 180 MG

3 DO

TIAZAC ORAL CAPSULE, EXTENDED RELEASE 240 MG, 300 MG, 360 MG, 420 MG

3 QL

TIKOSYN ORAL CAPSULE 3

verapamil intravenous solution

1

verapamil intravenous syringe

1

Drug Name Tier Notesverapamil oral capsule, 24 hr er pellet ct 100 mg

1 DO

verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg

1 QL

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg

1 DO

verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg

1 QL

verapamil oral tablet 1 QL

verapamil oral tablet extended release

1 QL

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR 120 MG, 180 MG

3 DO

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR 240 MG, 360 MG

3 QL

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT 100 MG

3 DO

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT 200 MG, 300 MG

3 QL

XYLOCAINE (CARDIAC) (PF) INTRAVENOUS SOLUTION

3

CARDIOVASCULAR

ACCUPRIL ORAL TABLET 3

ACCURETIC ORAL TABLET 3

acebutolol oral capsule 1

ACEON ORAL TABLET 3

ADCIRCA ORAL TABLET 4 PA; QL

ADEMPAS ORAL TABLET 4 PA; QL

ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR1,000-20 MG, 1,000-40 MG, 750-20 MG

2 QL


Effective 4/1/16

64

Drug Name Tier NotesADVICOR ORAL TABLET, ER MULTIPHASE 24 HR500-20 MG

2 DO

alprostadil injection solution 1

ALTACE ORAL CAPSULE 3

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG

3 ST; DO

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 60 MG

3 ST; QL

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg

1 QL

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg

1 DO

amlodipine-benazepril oral capsule

1

amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-320 mg

1 QL

amlodipine-valsartan oral tablet 5-160 mg

1 DO

amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-25 mg

1 QL

amlodipine-valsartan-hcthiazid oral tablet 5-160-12.5 mg

1 DO

ANTARA ORAL CAPSULE 3

ASCLERA INTRAVENOUS SOLUTION

3

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG

3 QL

ATACAND HCT ORAL TABLET 32-25 MG 3

ATACAND ORAL TABLET 3 QL

Drug Name Tier Notesatenolol oral tablet 1

atenolol-chlorthalidone oral tablet

1

atorvastatin oral tablet 10 mg, 20 mg, 40 mg

1 DO

atorvastatin oral tablet 80 mg 1 QL

ATROPEN INTRAMUSCULAR PEN INJECTOR

3

AVALIDE ORAL TABLET 150-12.5 MG 3 QL

AVALIDE ORAL TABLET 300-12.5 MG 3

AVAPRO ORAL TABLET150 MG, 75 MG 3 DO

AVAPRO ORAL TABLET300 MG 3 QL

AZOR ORAL TABLET10-20 MG, 10-40 MG, 5-40 MG

2 QL

AZOR ORAL TABLET5-20 MG 2 DO

benazepril oral tablet 1

benazepril-hydrochlorothiazide oral tablet

1

BENICAR HCT ORAL TABLET 20-12.5 MG 2 DO

BENICAR HCT ORAL TABLET 40-12.5 MG, 40-25 MG

2 QL

BENICAR ORAL TABLET 20 MG 2 DO

BENICAR ORAL TABLET 40 MG, 5 MG 2 QL

BETAPACE AF ORAL TABLET 3

BETAPACE ORAL TABLET 3

betaxolol oral tablet 1

BIDIL ORAL TABLET 2

bisoprolol fumarate oral tablet

1

bisoprolol-hydrochlorothiazide oral tablet

1


Effective 4/1/16

65

Drug Name Tier NotesBREVIBLOC IN NACL (ISO-OSM) INTRAVENOUS PARENTERAL SOLUTION

3

BREVIBLOC INTRAVENOUS SOLUTION

3

BYSTOLIC ORAL TABLET 3

CADUET ORAL TABLET10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-80 MG

3 QL

CADUET ORAL TABLET2.5-10 MG, 2.5-20 MG, 2.5-40 MG, 5-10 MG, 5-20 MG, 5-40 MG

3 DO

candesartan oral tablet 1 QL

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg

1 QL

candesartan-hydrochlorothiazid oral tablet 32-25 mg

1

captopril oral tablet 1

captopril-hydrochlorothiazide oral tablet

1

CARDURA ORAL TABLET 3

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

3

carvedilol oral tablet 1

CATAPRES ORAL TABLET 3

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY

3


3


3

cholestyramine (with sugar) oral powder

1

Drug Name Tier Notescholestyramine (with sugar) oral powder in packet

1

cholestyramine light oral powder

1

cholestyramine light oral powder in packet

1

clonidine hcl oral tablet 1

clonidine transdermal patch weekly

1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg

1

CLORPRES ORAL TABLET 0.3-15 MG 3

COLESTID FLAVORED ORAL GRANULES 3

COLESTID FLAVORED ORAL PACKET 3

COLESTID ORAL GRANULES 3

COLESTID ORAL PACKET 3

COLESTID ORAL TABLET 3

colestipol oral granules 1

colestipol oral packet 1

colestipol oral tablet 1

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR

2

COREG ORAL TABLET 3

CORGARD ORAL TABLET 3

CORLOPAM INTRAVENOUS SOLUTION

3

CORZIDE ORAL TABLET 3

COZAAR ORAL TABLET 3 QL

CRESTOR ORAL TABLET 10 MG, 20 MG, 5 MG

2 DO

CRESTOR ORAL TABLET 40 MG 2 QL

DEMSER ORAL CAPSULE 3


Effective 4/1/16

66

Drug Name Tier NotesDIOVAN HCT ORAL TABLET 160-12.5 MG, 80-12.5 MG

3 DO

DIOVAN HCT ORAL TABLET 160-25 MG, 320-12.5 MG, 320-25 MG

3 QL

DIOVAN ORAL TABLET 3 QL

doxazosin oral tablet 1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR

3

EDARBI ORAL TABLET 3

EDARBYCLOR ORAL TABLET 3 QL

enalapril maleate oral tablet 1

enalaprilat intravenous solution

1

enalapril-hydrochlorothiazide oral tablet

1

ENTRESTO ORAL TABLET 2 PA; QL

EPANED ORAL RECON SOLN 3

epoprostenol (glycine) intravenous recon soln

4 PA

eprosartan oral tablet 1 QL

ergoloid oral tablet 1

esmolol intravenous solution 1

ETHAMOLIN INTRAVENOUS SOLUTION

3

EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-25 MG

3 QL

EXFORGE HCT ORAL TABLET 5-160-12.5 MG 3 DO

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-320 MG

3 QL

EXFORGE ORAL TABLET 5-160 MG 3 DO

fenofibrate micronized oral capsule

1

Drug Name Tier Notesfenofibrate nanocrystallized oral tablet

1

FENOFIBRATE ORAL CAPSULE 3

FENOFIBRATE ORAL TABLET 120 MG, 40 MG 3

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

1

fenofibric acid oral tablet 1

FENOGLIDE ORAL TABLET 3

FIBRICOR ORAL TABLET 3

FLOLAN INTRAVENOUS RECON SOLN 4 PA

fluvastatin oral capsule 1 DO

fluvastatin oral tablet extended release 24 hr

1

fosinopril oral tablet 1

fosinopril-hydrochlorothiazide oral tablet

1

gemfibrozil oral tablet 1

guanfacine oral tablet 1

HEMANGEOL ORAL SOLUTION 3

hydralazine injection solution 1

hydralazine oral tablet 1

HYZAAR ORAL TABLET100-12.5 MG, 100-25 MG 3 QL

HYZAAR ORAL TABLET50-12.5 MG 3 DO

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR

3

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR

3

indomethacin sodium intravenous recon soln

1

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR

3


Effective 4/1/16

67

Drug Name Tier Notesirbesartan oral tablet 150 mg, 75 mg

1 DO

irbesartan oral tablet 300 mg 1 QL

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg

1 QL

irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg

1

isoxsuprine oral tablet 1

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG

3 PA

JUXTAPID ORAL CAPSULE 40 MG, 60 MG 3 PA; QL

KYNAMRO SUBCUTANEOUS SYRINGE

3 PA; QL

labetalol intravenous solution 1

labetalol intravenous syringe 1

labetalol oral tablet 1

LESCOL ORAL CAPSULE 3 ST; DO

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR

3 ST

LETAIRIS ORAL TABLET 4 PA; QL

LEVATOL ORAL TABLET 3

LIPITOR ORAL TABLET10 MG, 20 MG, 40 MG 3 ST; DO

LIPITOR ORAL TABLET80 MG 3 ST; QL

LIPOCHOL PLUS ORAL TABLET 3

LIPOFEN ORAL CAPSULE 3

lisinopril oral tablet 1

lisinopril-hydrochlorothiazide oral tablet

1

LIVALO ORAL TABLET1 MG, 2 MG 3 ST; DO

LIVALO ORAL TABLET4 MG 3 ST; QL

LOFIBRA ORAL CAPSULE 3

Drug Name Tier NotesLOFIBRA ORAL TABLET 3

LOPID ORAL TABLET 3

LOPRESSOR HCT ORAL TABLET 3

LOPRESSOR INTRAVENOUS SOLUTION

3

LOPRESSOR ORAL TABLET 3

losartan oral tablet 1 QL

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

1 QL

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

1 DO

LOTENSIN HCT ORAL TABLET 3

LOTENSIN ORAL TABLET 3

LOTREL ORAL CAPSULE 3

lovastatin oral tablet 10 mg, 20 mg

1 DO

lovastatin oral tablet 40 mg 1 QL

MAVIK ORAL TABLET 3

methyldopa oral tablet 1

methyldopa-hydrochlorothiazide oral tablet

1

methyldopate intravenous solution

1

metoprolol succinate oral tablet extended release 24 hr

1

metoprolol ta-hydrochlorothiaz oral tablet

1

metoprolol tartrate intravenous solution

1

metoprolol tartrate intravenous syringe

1

metoprolol tartrate oral tablet 1

MICARDIS HCT ORAL TABLET 40-12.5 MG 3 DO


Effective 4/1/16

68

Drug Name Tier NotesMICARDIS HCT ORAL TABLET 80-12.5 MG, 80-25 MG

3 QL

MICARDIS ORAL TABLET 20 MG, 40 MG 3 DO

MICARDIS ORAL TABLET 80 MG 3 QL

MINIPRESS ORAL CAPSULE 3

minoxidil oral tablet 1

moexipril oral tablet 1

moexipril-hydrochlorothiazide oral tablet

1

nadolol oral tablet 1

nadolol-bendroflumethiazide oral tablet

1

NATRECOR INTRAVENOUS RECON SOLN

4

NEOPROFEN (IBUPROFEN LYSN)(PF) INTRAVENOUS SOLUTION

3

niacin oral tablet extended release 24 hr

1 QL

NIACOR ORAL TABLET 3

NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR

3 ST; QL

NITROPRESS INTRAVENOUS SOLUTION

3

OPSUMIT ORAL TABLET 4 PA; QL

ORENITRAM ORAL TABLET EXTENDED RELEASE

4 PA

papaverine injection solution 1 QL

perindopril erbumine oral tablet

1

phenylephrine hcl injection solution

1

Drug Name Tier NotesPHENYLEPHRINE IN 0.9% NACL(PF) INTRAVENOUS SYRINGE

3

pindolol oral tablet 1

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR

4 PA; QL

PRALUENT SYRINGE SUBCUTANEOUS SYRINGE

4 PA; QL

PRAVACHOL ORAL TABLET 20 MG 3 DO

PRAVACHOL ORAL TABLET 40 MG 3

PRAVACHOL ORAL TABLET 80 MG 3 QL

pravastatin oral tablet 10 mg, 20 mg

1 DO

pravastatin oral tablet 40 mg 1

pravastatin oral tablet 80 mg 1 QL

prazosin oral capsule 1

PRESTALIA ORAL TABLET 14-10 MG 3 QL

PRESTALIA ORAL TABLET 3.5-2.5 MG, 7-5 MG

3 DO

prevalite oral powder 1

prevalite oral powder in packet

1

PRINIVIL ORAL TABLET 3 QL

propranolol intravenous solution

1

propranolol oral capsule,extended release 24 hr

1

propranolol oral solution 1

propranolol oral tablet 1

propranolol-hydrochlorothiazid oral tablet

1

PROSTIN VR PEDIATRIC INJECTION SOLUTION

3


Effective 4/1/16

69

Drug Name Tier NotesQUESTRAN LIGHT ORAL POWDER 3

QUESTRAN ORAL POWDER 3

QUESTRAN ORAL POWDER IN PACKET 3

quinapril oral tablet 1

quinapril-hydrochlorothiazide oral tablet

1

ramipril oral capsule 1

REMODULIN INJECTION SOLUTION 4 PA

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

4 PA; QL

REPATHA SYRINGE SUBCUTANEOUS SYRINGE

4 PA; QL

reserpine oral tablet 1

REVATIO INTRAVENOUS SOLUTION

4 PA; QL

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

4 PA; QL

REVATIO ORAL TABLET 4 PA; QL

SECTRAL ORAL CAPSULE 3

sildenafil intravenous solution

4 PA; QL

sildenafil oral tablet 4 PA; QL

SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 3 QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1 DO

simvastatin oral tablet 80 mg 1 PA; QL

sorine oral tablet 1

sotalol af oral tablet 1

SOTALOL INTRAVENOUS SOLUTION

3

sotalol oral tablet 1

Drug Name Tier NotesSOTRADECOL INTRAVENOUS SOLUTION

3

SOTYLIZE ORAL SOLUTION 3

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR1-240 MG

3 DO

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR2-180 MG, 2-240 MG, 4-240 MG

3 QL

TEKAMLO ORAL TABLET 150-10 MG, 300-10 MG, 300-5 MG

3 QL

TEKAMLO ORAL TABLET 150-5 MG 3 DO

TEKTURNA HCT ORAL TABLET 150-12.5 MG 3 DO

TEKTURNA HCT ORAL TABLET 150-25 MG, 300-12.5 MG, 300-25 MG

3 QL

TEKTURNA ORAL TABLET 150 MG 3 DO

TEKTURNA ORAL TABLET 300 MG 3 QL

telmisartan oral tablet 20 mg, 40 mg

1 DO

telmisartan oral tablet 80 mg 1 QL

telmisartan-amlodipine oral tablet 40-10 mg, 80-10 mg, 80-5 mg

1 QL

telmisartan-amlodipine oral tablet 40-5 mg

1 DO

telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg

1 DO

telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg, 80-25 mg

1 QL

TENEX ORAL TABLET 3

TENORETIC 100 ORAL TABLET 3

TENORETIC 50 ORAL TABLET 3

TENORMIN ORAL TABLET 3


Effective 4/1/16

70

Drug Name Tier Notesterazosin oral capsule 1

timolol maleate oral tablet 1

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR

3

TRACLEER ORAL TABLET 4 PA; QL

trandolapril oral tablet 1 QL

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg

1 DO; QL

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg

1 QL

TRIBENZOR ORAL TABLET 2

TRICOR ORAL TABLET 3

TRIGLIDE ORAL TABLET 3

TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

TWYNSTA ORAL TABLET 40-10 MG, 80-10 MG, 80-5 MG

3 QL

TWYNSTA ORAL TABLET 40-5 MG 3 DO

TYVASO INHALATION SOLUTION FOR NEBULIZATION

4 PA; QL

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

4 PA; QL

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

4 PA; QL

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

4 PA; QL

UPTRAVI ORAL TABLET 4

Drug Name Tier NotesUPTRAVI ORAL TABLETS,DOSE PACK 4

valsartan oral tablet 1 QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg

1 DO

valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg

1 QL

VARITHENA INTRAVENOUS FOAM 3

VASERETIC ORAL TABLET 3

VASOTEC ORAL TABLET 3

VAYAROL ORAL CAPSULE 3

VAZCULEP INJECTION SOLUTION 3

VECAMYL ORAL TABLET 3

veletri intravenous recon soln 4 PA

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

4 PA

VYTORIN 10-10 ORAL TABLET 3 ST; QL




WELCHOL ORAL POWDER IN PACKET 2

WELCHOL ORAL TABLET 2

ZEBETA ORAL TABLET 3

ZESTORETIC ORAL TABLET 3

ZESTRIL ORAL TABLET 3

ZETIA ORAL TABLET 3 ST; QL

ZIAC ORAL TABLET 3


Effective 4/1/16

71

Drug Name Tier NotesZOCOR ORAL TABLET10 MG, 20 MG, 40 MG, 5 MG

3 DO

ZOCOR ORAL TABLET80 MG 3 PA; QL

CNS DRUGS

ACTIVE-PAC KIT,GEL AND CAPSULE 3

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

4 PA; QL

APTIOM ORAL TABLET 3

AUBAGIO ORAL TABLET 4 PA; QL

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

4 PA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

4 PA

AVONEX INTRAMUSCULAR SYRINGE

4 PA

AVONEX INTRAMUSCULAR SYRINGE KIT

4 PA

BANZEL ORAL SUSPENSION 3

BANZEL ORAL TABLET 3

BETASERON SUBCUTANEOUS KIT 4 PA

CAFCIT INTRAVENOUS SOLUTION 3

caffeine citrated intravenous solution

1

caffeine citrated oral solution 1

caffeine-sodium benzoate injection solution

1

carbamazepine oral capsule, er multiphase 12 hr

1

carbamazepine oral suspension

1

carbamazepine oral tablet 1

carbamazepine oral tablet extended release 12 hr

1

Drug Name Tier Notescarbamazepine oral tablet,chewable

1

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR

2

CELONTIN ORAL CAPSULE 3

CEREBYX INJECTION SOLUTION 3

clonazepam oral tablet 1

clonazepam oral tablet,disintegrating

1

COPAXONE SUBCUTANEOUS SYRINGE

4 PA

DEHYDRATED ALCOHOL INJECTION SOLUTION

3

DEPACON INTRAVENOUS SOLUTION

2

DEPAKENE ORAL CAPSULE 2

DEPAKENE ORAL SOLUTION 2

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR

2

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC)

2

DEPAKOTE SPRINKLES ORAL CAPSULE, SPRINKLE

2

DIASTAT ACUDIAL RECTAL KIT 2 QL

DIASTAT RECTAL KIT 2 QL

diazepam rectal kit 1 QL

DILANTIN EXTENDED ORAL CAPSULE 2

DILANTIN INFATABS ORAL TABLET,CHEWABLE

2

DILANTIN ORAL CAPSULE 2


Effective 4/1/16

72

Drug Name Tier NotesDILANTIN-125 ORAL SUSPENSION 2

divalproex oral capsule, sprinkle

1

divalproex oral tablet extended release 24 hr

1

divalproex oral tablet,delayed release (dr/ec)

1

DOPRAM INTRAVENOUS SOLUTION

3

doxapram intravenous solution

1

epitol oral tablet 1

ethanol (ethyl alcohol) injection solution

1

ethosuximide oral capsule 1

ethosuximide oral solution 1

EXTAVIA SUBCUTANEOUS KIT 4 ST

EXTAVIA SUBCUTANEOUS RECON SOLN

4 ST

felbamate oral suspension 1

felbamate oral tablet 1

FELBATOL ORAL SUSPENSION 2

FELBATOL ORAL TABLET 2

fosphenytoin injection solution

1

FYCOMPA ORAL TABLET 3

gabapentin oral capsule 1

gabapentin oral solution 1

gabapentin oral tablet 1

GABITRIL ORAL TABLET 2

GILENYA ORAL CAPSULE 4 PA; QL

glatopa subcutaneous syringe 4 PA

Drug Name Tier NotesGRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR

3

GRALISE ORAL TABLET EXTENDED RELEASE 24 HR

3

HORIZANT ORAL TABLET EXTENDED RELEASE

3

KEPPRA INTRAVENOUS SOLUTION 2

KEPPRA ORAL SOLUTION 2

KEPPRA ORAL TABLET 2

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

2

KLONOPIN ORAL TABLET 3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING

2

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK

2

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK

2

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK

2

LAMICTAL ORAL TABLET 2

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE

2

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

2


Effective 4/1/16

73

Drug Name Tier NotesLAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

2

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

2

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR

3

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK

3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK

3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK

3

lamotrigine oral tablet 1

lamotrigine oral tablet disintegrating, dose pk

1

lamotrigine oral tablet extended release 24hr

1

lamotrigine oral tablet, chewable dispersible

1

lamotrigine oral tablet,disintegrating

1

lamotrigine oral tablets,dose pack

1

LEMTRADA INTRAVENOUS SOLUTION

4 PA

LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK

3

levetiracetam intravenous solution

1

levetiracetam oral solution 1

levetiracetam oral tablet 1

levetiracetam oral tablet extended release 24 hr

1

Drug Name Tier NotesLYRICA ORAL CAPSULE 3 PA; QL

LYRICA ORAL SOLUTION 3 PA; QL

memantine oral solution 1

memantine oral tablet 1

MEMANTINE ORAL TABLETS,DOSE PACK 3

MYSOLINE ORAL TABLET 3

NAMENDA ORAL SOLUTION 3

NAMENDA ORAL TABLET 3

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

2

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

2

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

2

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

3

NEURONTIN ORAL CAPSULE 3

NEURONTIN ORAL SOLUTION 3

NEURONTIN ORAL TABLET 3

NUEDEXTA ORAL CAPSULE 3

ONFI ORAL SUSPENSION 3

ONFI ORAL TABLET 3

oxcarbazepine oral suspension

1

oxcarbazepine oral tablet 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR

3

PEGANONE ORAL TABLET 3


Effective 4/1/16

74

Drug Name Tier NotesPHENYTEK ORAL CAPSULE 2

phenytoin oral suspension 1

phenytoin oral tablet,chewable

1

phenytoin sodium extended oral capsule

1

phenytoin sodium intravenous solution

1

phenytoin sodium intravenous syringe

1

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

4 PA

PLEGRIDY SUBCUTANEOUS SYRINGE

4 PA

POTIGA ORAL TABLET 3

primidone oral tablet 1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR

3

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

4 ST

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

4 ST

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

4 ST

RILUTEK ORAL TABLET 4

riluzole oral tablet 4

SABRIL ORAL POWDER IN PACKET 3

SABRIL ORAL TABLET 3

SMARTRX GABAKIT KIT, CREAM AND CAPSULE

3

SPRITAM ORAL TABLET FOR SUSPENSION

3

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

4 PA; QL

Drug Name Tier NotesTEGRETOL ORAL SUSPENSION 2

TEGRETOL ORAL TABLET 2

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR

2

tetrabenazine oral tablet 1 PA

tiagabine oral tablet 1

TOPAMAX ORAL CAPSULE, SPRINKLE 2

TOPAMAX ORAL TABLET 2

topiramate oral capsule, sprinkle

1

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

3

topiramate oral tablet 1

TRILEPTAL ORAL SUSPENSION 2

TRILEPTAL ORAL TABLET 3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR

3

valproate sodium intravenous solution

1

valproic acid (as sodium salt) oral solution

1

valproic acid oral capsule 1

VIMPAT INTRAVENOUS SOLUTION 3

VIMPAT ORAL SOLUTION 3

VIMPAT ORAL TABLET 3

XENAZINE ORAL TABLET 3 PA

ZARONTIN ORAL CAPSULE 2

ZARONTIN ORAL SOLUTION 2

ZONEGRAN ORAL CAPSULE 3

zonisamide oral capsule 1


Effective 4/1/16

75

Drug Name Tier NotesCOLONY STIMULATING FACTORS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

4 PA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

4 PA

EPOGEN INJECTION SOLUTION 4 PA

GRANIX SUBCUTANEOUS SYRINGE

4 PA

LEUKINE INJECTION RECON SOLN 4 PA

MIRCERA INJECTION SYRINGE 4 PA

MOZOBIL SUBCUTANEOUS SOLUTION

4 PA

NEULASTA SUBCUTANEOUS SYRINGE

4 PA; QL

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

4 PA; QL

NEUPOGEN INJECTION SOLUTION 4 PA

NEUPOGEN INJECTION SYRINGE 4 PA

NPLATE SUBCUTANEOUS RECON SOLN

4 PA

PROCRIT INJECTION SOLUTION 4 PA

PROMACTA ORAL TABLET 4 PA

ZARXIO INJECTION SYRINGE 4 PA

CONTRACEPTIVES

altavera (28) oral tablet 1 PA

alyacen 1/35 (28) oral tablet 1 PA

alyacen 7/7/7 (28) oral tablet 1 PA

amethia lo oral tablets,dose pack,3 month

1 PA

Drug Name Tier Notesamethia oral tablets,dose pack,3 month

1 PA

amethyst oral tablet 1 PA

apri oral tablet 1 PA

aranelle (28) oral tablet 1 PA

ashlyna oral tablets,dose pack,3 month

1

aubra oral tablet 1 PA

aviane oral tablet 1 PA

azurette (28) oral tablet 1 PA

balziva (28) oral tablet 1 PA

bekyree (28) oral tablet 1 PA

BEYAZ ORAL TABLET 3 PA

blisovi 24 fe oral tablet 1 PA

blisovi fe 1.5/30 (28) oral tablet

1

blisovi fe 1/20 (28) oral tablet

1 PA

BREVICON (28) ORAL TABLET 3 PA

briellyn oral tablet 1 PA

camila oral tablet 1 PA

camrese lo oral tablets,dose pack,3 month

1 PA

camrese oral tablets,dose pack,3 month

1 PA

CAYA CONTOURED VAGINAL DIAPHRAGM 2

caziant (28) oral tablet 1

chateal oral tablet 1 PA

cryselle (28) oral tablet 1 PA

cyclafem 1/35 (28) oral tablet 1

cyclafem 7/7/7 (28) oral tablet

1

CYCLESSA (28) ORAL TABLET 3 PA

cyred oral tablet 1 PA

dasetta 1/35 (28) oral tablet 1 PA

dasetta 7/7/7 (28) oral tablet 1 PA

daysee oral tablets,dose pack,3 month

1 PA

deblitane oral tablet 1 PA


Effective 4/1/16

76

Drug Name Tier Notesdelyla (28) oral tablet 1 PA

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

3 PA

DEPO-PROVERA INTRAMUSCULAR SYRINGE

3 PA

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

3 PA

desog-e.estradiol/e.estradiol oral tablet

1 PA

DESOGEN ORAL TABLET 3 PA

desogestrel-ethinyl estradiol oral tablet

1 PA

drospirenone-ethinyl estradiol oral tablet

1 PA

elinest oral tablet 1 PA

ELLA ORAL TABLET 3

emoquette oral tablet 1

enpresse oral tablet 1 PA

enskyce oral tablet 1 PA

errin oral tablet 1 PA

estarylla oral tablet 1 PA

ESTROSTEP FE-28 ORAL TABLET 3 PA

falmina (28) oral tablet 1 PA

FEMCAP VAGINAL DEVICE 2

FEMCON FE ORAL TABLET,CHEWABLE 3 PA

GENERESS FE ORAL TABLET,CHEWABLE 3 PA

gianvi (28) oral tablet 1 PA

gildagia oral tablet 1

gildess 1.5/30 (21) oral tablet 1 PA

gildess 1/20 (21) oral tablet 1 PA

gildess 24 fe oral tablet 1

gildess fe 1.5/30 (28) oral tablet

1

gildess fe 1/20 (28) oral tablet

1

Drug Name Tier Notesheather oral tablet 1 PA

introvale oral tablets,dose pack,3 month

1 PA

jencycla oral tablet 1 PA

jolessa oral tablets,dose pack,3 month

1 PA

jolivette oral tablet 1 PA

juleber oral tablet 1

junel 1.5/30 (21) oral tablet 1 PA

junel 1/20 (21) oral tablet 1 PA

junel fe 1.5/30 (28) oral tablet

1 PA

junel fe 1/20 (28) oral tablet 1 PA

junel fe 24 oral tablet 1 PA

kaitlib fe oral tablet,chewable 1

kariva (28) oral tablet 1 PA

kelnor 1/35 (28) oral tablet 1 PA

kimidess (28) oral tablet 1

kurvelo oral tablet 1 PA

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

1 PA

larin 1.5/30 (21) oral tablet 1 PA

larin 1/20 (21) oral tablet 1 PA

larin 24 fe oral tablet 1 PA

larin fe 1.5/30 (28) oral tablet 1 PA

larin fe 1/20 (28) oral tablet 1 PA

layolis fe oral tablet,chewable

1 PA

leena 28 oral tablet 1 PA

lessina oral tablet 1 PA

levonest (28) oral tablet 1 PA

levonorgestrel-ethinyl estrad oral tablet

1 PA

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

1 PA

levonorg-eth estrad triphasic oral tablet

1

levora-28 oral tablet 1 PA


Effective 4/1/16

77

Drug Name Tier NotesLILETTA INTRAUTERINE INTRAUTERINE DEVICE

3

LO LOESTRIN FE ORAL TABLET 2 PA

LOESTRIN 1.5/30 (21) ORAL TABLET 3 PA

LOESTRIN 1/20 (21) ORAL TABLET 3 PA

LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET 3 PA

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET 3 PA

lomedia 24 fe oral tablet 1

loryna (28) oral tablet 1 PA

LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

3 PA

low-ogestrel (28) oral tablet 1 PA

lutera (28) oral tablet 1 PA

lyza oral tablet 1

marlissa oral tablet 1 PA

medroxyprogesterone intramuscular suspension

1 PA

medroxyprogesterone intramuscular syringe

1 PA

microgestin 1.5/30 (21) oral tablet

1 PA

microgestin 1/20 (21) oral tablet

1 PA

MICROGESTIN 24 FE ORAL TABLET 3

microgestin fe 1.5/30 (28) oral tablet

1 PA

microgestin fe 1/20 (28) oral tablet

1 PA

MINASTRIN 24 FE ORAL TABLET,CHEWABLE 2 PA

MIRCETTE (28) ORAL TABLET 3 PA

MIRENA INTRAUTERINE INTRAUTERINE DEVICE

3

Drug Name Tier NotesMODICON (28) ORAL TABLET 3

mono-linyah oral tablet 1 PA

mononessa (28) oral tablet 1 PA

my way oral tablet 1 QL

myzilra oral tablet 1

NATAZIA ORAL TABLET 3 PA

necon 0.5/35 (28) oral tablet 1 PA

necon 1/35 (28) oral tablet 1 PA



necon 7/7/7 (28) oral tablet 1 PA

NEXPLANON SUBDERMAL IMPLANT 4

next choice one dose oral tablet

1 QL

nikki (28) oral tablet 1

nora-be oral tablet 1 PA

noreth-ethinyl estradiol-iron oral tablet,chewable

1 PA

norethindrone (contraceptive) oral tablet

1 PA

norethindrone ac-eth estradiol oral tablet

1 PA

norethindrone-e.estradiol-iron oral tablet

1 PA

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg

1

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

1 PA

NORINYL 1+35 (28) ORAL TABLET 3 PA

NORINYL 1+50 (28) ORAL TABLET 3 PA

norlyroc oral tablet 1 PA

NOR-QD ORAL TABLET 3 PA

nortrel 0.5/35 (28) oral tablet 1 PA

nortrel 1/35 (21) oral tablet 1 PA

nortrel 1/35 (28) oral tablet 1 PA


Effective 4/1/16

78

Drug Name Tier Notesnortrel 7/7/7 (28) oral tablet 1 PA

NUVARING VAGINAL RING 2 PA

ocella oral tablet 1 PA

ogestrel (28) oral tablet 1 PA

orsythia oral tablet 1

ORTHO MICRONOR ORAL TABLET 3

ORTHO TRI-CYCLEN (28) ORAL TABLET 3 PA

ORTHO TRI-CYCLEN LO (28) ORAL TABLET 3 PA

ORTHO-CYCLEN (28) ORAL TABLET 3 PA

ORTHO-NOVUM 1/35 (28) ORAL TABLET 3

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 3

OVCON-35 (28) ORAL TABLET 3 PA

PARAGARD T 380A INTRAUTERINE INTRAUTERINE DEVICE

3 QL

philith oral tablet 1 PA

pimtrea (28) oral tablet 1 PA

pirmella oral tablet 0.5/0.75/1 mg- 35 mcg

1

pirmella oral tablet 1-35 mg-mcg

1 PA

PLAN B ONE-STEP ORAL TABLET 3 QL

portia oral tablet 1 PA

previfem oral tablet 1

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH

3 PA

quasense oral tablets,dose pack,3 month

1 PA

reclipsen (28) oral tablet 1 PA

SAFYRAL ORAL TABLET 3

Drug Name Tier NotesSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

3 PA

setlakin oral tablets,dose pack,3 month

1 PA

sharobel oral tablet 1 PA

SKYLA INTRAUTERINE INTRAUTERINE DEVICE

3

sprintec (28) oral tablet 1 PA

sronyx oral tablet 1 PA

syeda oral tablet 1 PA

tarina fe 1/20 (28) oral tablet 1 PA

tilia fe oral tablet 1 PA

tri-estarylla oral tablet 1 PA

tri-legest fe oral tablet 1 PA

tri-linyah oral tablet 1 PA

tri-lo-estarylla oral tablet 1

tri-lo-marzia oral tablet 1

tri-lo-sprintec oral tablet 1

trinessa (28) oral tablet 1 PA

trinessa lo oral tablet 1

TRI-NORINYL (28) ORAL TABLET 3 PA

tri-previfem (28) oral tablet 1

tri-sprintec (28) oral tablet 1 PA

trivora (28) oral tablet 1 PA

velivet triphasic regimen (28) oral tablet

1 PA

vestura (28) oral tablet 1 PA

vienva oral tablet 1

viorele (28) oral tablet 1 PA

vyfemla (28) oral tablet 1

wera (28) oral tablet 1 PA

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM

2


2


Effective 4/1/16

79

Drug Name Tier NotesWIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM

2


2


2


2


2


2

wymzya fe oral tablet,chewable

1

xulane transdermal patch weekly

1 QL

YASMIN (28) ORAL TABLET 3 PA

YAZ (28) ORAL TABLET 3 PA

zarah oral tablet 1

zenchent (28) oral tablet 1 PA

zenchent fe oral tablet,chewable

1 PA

zovia 1/35e (28) oral tablet 1 PA

zovia 1/50e (28) oral tablet 1 PA

COUGH/COLD PREPARATIONS

benzonatate oral capsule 1

BROMFED DM ORAL SYRUP 3

brompheniramine-pseudoeph-dm oral syrup

1

CAPCOF ORAL LIQUID 3

centergy dm oral drops 1

cheratussin ac oral liquid 1

cheratussin dac oral syrup 1

CODEINE-GUAIFENESIN ORAL LIQUID 3

Drug Name Tier Notesephedrine sulfate injection solution

1

EPHEDRINE SULFATE-0.9%NACL(PF) INTRAVENOUS SYRINGE

3

FLOWTUSS ORAL SOLUTION 3

guaiatussin ac oral liquid 1

guaifenesin ac oral liquid 1

guaifenesin dac oral syrup 1

HISTEX-AC ORAL SYRUP 3

HYCOFENIX ORAL SOLUTION 3

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

1

hydrocodone-cpm-pseudoephed oral solution

1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

1

HYDROCODONE-HOMATROPINE ORAL SYRUP5-1.5 MG/5 ML (5 ML)

3

hydrocodone-homatropine oral tablet

1

hydromet oral syrup 1

iophen c-nr oral liquid 1

lortuss ex oral syrup 1

MAR-COF BP ORAL LIQUID 3

MAR-COF CG ORAL LIQUID 3

m-clear wc oral liquid 1

M-END MAX D ORAL LIQUID 3

M-END PE ORAL LIQUID 3

NINJACOF-XG ORAL LIQUID 3

OBREDON ORAL SOLUTION 3

phenylhistine dh oral liquid 1


Effective 4/1/16

80

Drug Name Tier NotesPOLY-TUSSIN AC ORAL LIQUID 2

PRO-CLEAR AC ORAL LIQUID 2

PRO-CLEAR CAPS ORAL CAPSULE 2

promethazine vc-codeine oral syrup

1

promethazine-codeine oral syrup

1

promethazine-dm oral syrup 1

promethazine-phenyleph-codeine oral syrup

1

PRO-RED AC (W/ DEXCHLORPHENIR) ORAL LIQUID

3

relcof c oral liquid 1

RESPA-AR ORAL TABLET EXTENDED RELEASE 12 HR

3

REZIRA ORAL SOLUTION 3

rydex oral liquid 1

TESSALON PERLES ORAL CAPSULE 3

tusnel c oral syrup 1

TUSNEL PEDIATRIC ORAL LIQUID 3

TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 HR

2

tussigon oral tablet 1

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION,EXTENDED REL 12 HR

3

TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR

3

virtussin ac oral liquid 1

virtussin dac oral syrup 1

VITUZ ORAL SOLUTION 3

ZODRYL AC 25 ORAL SUSPENSION 3

Drug Name Tier NotesZODRYL AC 30 ORAL SUSPENSION 3






ZODRYL DAC 25 ORAL SUSPENSION 3







ZODRYL DEC 25 ORAL SUSPENSION 3







ZONATUSS ORAL CAPSULE 3

Z-TUSS AC ORAL LIQUID 2


Effective 4/1/16

81

Drug Name Tier NotesZUTRIPRO ORAL SOLUTION 3

DIAGNOSTIC

ACCU-CHEK AVIVA PLUS TEST STRP STRIP 2 QL

ACCU-CHEK AVIVA STRIP 2 QL

ACCU-CHEK COMPACT PLUS TEST STRIP 2 QL

ACCU-CHEK COMPACT TEST STRIP 2 QL

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

2 QL

ACCUTREND GLUCOSE STRIP 3 QL

ACURA TEST STRIPS STRIP 3 ST; QL

ADVANCED GLUC METER TEST STRIP STRIP

3 ST; QL

ADVOCATE REDI-CODE STRIP 3 ST; QL

ADVOCATE REDI-CODE+ STRIP 3 ST; QL

ADVOCATE TEST STRIPS STRIP 3 ST; QL

AGAMATRIX AMP TEST STRIPS STRIP 3 ST; QL

ASSURE 4 STRIPS STRIP 3 ST; QL

ASSURE PLATINUM STRIP 3 ST; QL

ASSURE PRISM MULTI STRIP STRIP 3 ST; QL

BG-STAR STRIP 3 ST; QL

BIONIME RIGHTEST TEST STRIPS STRIP 3 ST; QL

BLOOD GLUCOSE TEST STRIP 3 ST; QL

BREEZE 2 TEST STRIPS STRIP 3 ST; QL

CARESENS N TEST STRIPS STRIP 3 ST; QL

Drug Name Tier NotesCLEVER CHOICE MICRO TEST STRIP STRIP

3 ST; QL

CLEVER CHOICE PRO STRIP 3 ST; QL

CLEVER CHOICE TEST STRIPS STRIP 3 ST; QL

CLEVER CHOICE VOICE+ TEST STRIP 3 ST; QL

CONTOUR NEXT STRIPS STRIP 3 ST; QL

CONTOUR TEST STRIPS STRIP 3 ST; QL

CONTROL G3 STRIP 3 ST; QL

CONTROL TEST STRIP 3 ST; QL

COOL GLUCOSE TEST STRIP STRIP 3 ST; QL

DIATRUE PLUS TEST STRIP STRIP 3 ST; QL

EASY GLUCO G2 STRIP 3 ST; QL

EASY PLUS II TEST STRIP 3 ST; QL

EASY STEP STRIP 3 ST; QL

EASY TALK GLUCOSE TEST STRIP 3 ST; QL

EASY TOUCH STRIP 3 ST; QL

EASY TRAK GLUCOSE TEST STRIP 3 ST; QL

EASYGLUCO PLUS STRIP 3 ST; QL

EASYGLUCO TEST STRIP 3 ST; QL

EASYMAX 15 STRIP 3 ST; QL

EASYMAX STRIP 3 ST; QL

ELEMENT COMPACT TEST STRIPS STRIP 3 ST; QL

ELEMENT TEST STRIPS STRIP 3 ST; QL

EMBRACE BLOOD GLUCOSE SYSTEM STRIP

3 ST; QL

EMBRACE EVO TEST STRIPS STRIP 3 ST; QL


Effective 4/1/16

82

Drug Name Tier NotesEMBRACE PRO TEST STRIPS STRIP 3 ST; QL

EVENCARE G2 STRIP 3 ST; QL

EVENCARE G3 TEST STRIP 3 ST; QL

EVENCARE MINI GLUCOSE TEST STR STRIP

3 ST; QL

EVENCARE TEST STRIP 3 ST; QL

EVOLUTION TEST STRIPS STRIP 3 ST; QL

EZ SMART PLUS TEST STRIP 3 ST; QL

EZ SMART TEST STRIP 3 ST; QL

FIFTY50 TEST STRIP STRIP 3 ST; QL

FORA D10 STRIP 3 ST; QL

FORA D15G STRIP 3 ST; QL

FORA D20 STRIP 3 ST; QL

FORA D40-G31 TEST STRIPS STRIP 3 ST; QL

FORA G20 STRIP 3 ST; QL

FORA G30A STRIP 3 ST; QL

FORA GD50 TEST STRIPS STRIP 3 ST; QL

FORA TEST STRIP STRIP 3 ST; QL

FORA TN'G VOICE TEST STRIPS STRIP 3 ST; QL

FORA V10 STRIP 3 ST; QL

FORA V12 GLUCOSE STRIP 3 ST; QL

FORA V20 STRIP 3 ST; QL

FORA V30A STRIP 3 ST; QL

FORACARE GD20 STRIP 3 ST; QL

FORACARE GD40 STRIP 3 ST; QL

FORTISCARE GLUCOSE TEST STRIPS STRIP 3 ST; QL

FREESTYLE INSULINX STRIP 3 ST; QL

FREESTYLE INSULINX TEST STRIPS STRIP 3 ST; QL

Drug Name Tier NotesFREESTYLE LITE STRIPS STRIP 3 ST; QL

FREESTYLE PRECISION NEO STRIPS STRIP 3 ST; QL

FREESTYLE TEST STRIP 3 ST; QL

G-4 TEST STRIP 3 ST; QL

GE100 BLOOD GLUCOSE TEST STRIP STRIP

3 ST; QL

GENSTRIP TEST STRIP STRIP 3 ST; QL

GLUCO NAVII TEST STRIP STRIP 3 ST; QL

GLUCOCARD 01 SENSOR PLUS STRIP 3 ST; QL

GLUCOCARD EXPRESSION STRIP 3 ST; QL

GLUCOCARD SHINE TEST STRIPS STRIP 3 ST; QL

GLUCOCARD VITAL SENSOR STRIP 3 ST; QL

GLUCOCARD VITAL TEST STRIPS STRIP 3 ST; QL

GLUCOCOM GLUCOSE STRIP 3 ST; QL

GM100 STRIP 3 ST; QL

GMATE TEST STRIPS STRIP 3 ST; QL

HEALTHPRO TEST STRIPS STRIP 3 ST; QL

INFINITY TEST STRIPS STRIP 3 ST; QL

LIBERTY TEST STRIP 3 ST; QL

MAXIMA STRIP 3 ST; QL

MICRO BLOOD GLUCOSE STRIP 3 ST; QL

MICRODOT BLOOD GLUCOSE SYSTEM STRIP

3 ST; QL

MYGLUCOHEALTH STRIP 3 ST; QL

NEUTEK 2TEK TEST STRIPS STRIP 3 ST; QL


Effective 4/1/16

83

Drug Name Tier NotesNOVA MAX GLUCOSE TEST STRIP 3 ST; QL

ON CALL EXPRESS TEST STRIP STRIP 3 ST; QL

ON CALL PLUS TEST STRIP STRIP 3 ST; QL

ON CALL VIVID TEST STRIP STRIP 3 ST; QL

ONETOUCH ULTRA TEST STRIP 2 QL

ONETOUCH VERIO STRIP 2 QL

OPTIUM EZ STRIP 3 ST; QL

OPTIUM TEST STRIP 3 ST; QL

OPTUMRX STRIP 3 ST; QL

PHARMACIST CHOICE STRIP 3 ST; QL

PRECISION PCX PLUS TEST STRIP 3 ST; QL

PRECISION PCX TEST STRIP 3 ST; QL

PRECISION POINT OF CARE TEST STRIP 3 ST; QL

PRECISION Q-I-D TEST STRIP 3 ST; QL

PRECISION XTRA TEST STRIP 3 ST; QL

PREMIUM V10 STRIP 3 ST; QL

PRODIGY NO CODING STRIP 3 ST; QL

QUINTET AC STRIP 3 ST; QL

REFUAH PLUS STRIP 3 ST; QL

RELION CONFIRM-MICRO STRIP

3 ST; QL

RELION PRIME TEST STRIPS STRIP 3 ST; QL

RELION ULTIMA STRIP 3 ST; QL

REVEAL TEST STRIP STRIP 3 ST; QL

RIGHTEST GS550 TEST STRIPS STRIP 3 ST; QL

SMART SENSE TEST STRIPS STRIP 3 ST; QL

Drug Name Tier NotesSMARTEST TEST STRIP 3 ST; QL

SOLUS V2 TEST STRIPS STRIP 3 ST; QL

SURE-TEST EASYPLUS MINI STRIP 3 ST; QL

TELCARE TEST STRIPS STRIP 3 ST; QL

TEST N'GO TEST STRIP 3 ST; QL

TRUE METRIX GLUCOSE TEST STRIP STRIP

3 ST; QL

TRUETEST TEST STRIPS STRIP 3 ST; QL

TRUETRACK SMART SYSTEM STRIP 3 ST; QL

TRUETRACK TEST STRIP 3 ST; QL

ULTIMA TEST STRIPS STRIP 3 ST; QL

ULTRATRAK STRIP 3 ST; QL

ULTRATRAK ULTIMATE STRIP 3 ST; QL

UNISTRIP1 TEST STRIP STRIP 3 ST; QL

WAVESENSE JAZZ STRIP 3 ST; QL

WAVESENSE PRESTO STRIP 3 ST; QL

DIURETICS

acetazolamide oral capsule, extended release

1

acetazolamide oral tablet 1

acetazolamide sodium injection recon soln

1

ALDACTAZIDE ORAL TABLET 3

ALDACTONE ORAL TABLET 3

amiloride oral tablet 1

amiloride-hydrochlorothiazide oral tablet

1

AMMONIUM CHLORIDE INTRAVENOUS SOLUTION

3


Effective 4/1/16

84

Drug Name Tier Notesbumetanide injection solution 1

bumetanide oral tablet 1

chlorothiazide oral tablet 1

chlorothiazide sodium intravenous recon soln

1

chlorthalidone oral tablet 1

DEMADEX ORAL TABLET 3

DIAMOX SEQUELS ORAL CAPSULE, EXTENDED RELEASE

3

DIURIL IV INTRAVENOUS RECON SOLN

3

DIURIL ORAL SUSPENSION 3

DYAZIDE ORAL CAPSULE 3

DYRENIUM ORAL CAPSULE 3

EDECRIN ORAL TABLET 3

eplerenone oral tablet 1

ethacrynate sodium intravenous recon soln

1

furosemide injection solution 1

furosemide injection syringe 1

furosemide oral solution 1

furosemide oral tablet 1

hydrochlorothiazide oral capsule

1

hydrochlorothiazide oral tablet

1

indapamide oral tablet 1

INSPRA ORAL TABLET 3

LASIX ORAL TABLET 3

mannitol 10 % intravenous parenteral solution

1


1

mannitol 25 % intravenous solution

1


1

Drug Name Tier NotesMAXZIDE ORAL TABLET 3

MAXZIDE-25MG ORAL TABLET 3

methazolamide oral tablet 1

methyclothiazide oral tablet 1

metolazone oral tablet 1

MICROZIDE ORAL CAPSULE 3

NEPTAZANE ORAL TABLET 3

OSMITROL 10 % INTRAVENOUS PARENTERAL SOLUTION

3

osmitrol 15 % intravenous parenteral solution

1

osmitrol 20 % intravenous parenteral solution

1

OSMITROL 5 % INTRAVENOUS PARENTERAL SOLUTION

3

RESECTISOL URETHRAL SOLUTION 3

SAMSCA ORAL TABLET 3

SODIUM EDECRIN INTRAVENOUS RECON SOLN

3

spironolactone oral tablet 1

spironolacton-hydrochlorothiaz oral tablet

1

torsemide oral tablet 1

triamterene-hydrochlorothiazid oral capsule

1

triamterene-hydrochlorothiazid oral tablet

1

VAPRISOL INTRAVENOUS SOLUTION

3

EENT PREPS

acetasol hc otic drops 1

acetic acid otic solution 1

acetic acid-aluminum acetate otic drops

1


Effective 4/1/16

85

Drug Name Tier Notesacuicyn topical spray,non-aerosol

1

ACULAR LS OPHTHALMIC DROPS 3

ACULAR OPHTHALMIC DROPS 3

ACUVAIL (PF) OPHTHALMIC DROPPERETTE

3

ADRENALIN NASAL SOLUTION 3

AKTEN (PF) OPHTHALMIC GEL 3

ALCAINE OPHTHALMIC DROPS 3

ALOCRIL OPHTHALMIC DROPS 3 ST; QL

ALOMIDE OPHTHALMIC DROPS 3 ST; QL

ALPHAGAN P OPHTHALMIC DROPS0.1 %

2

ALPHAGAN P OPHTHALMIC DROPS0.15 %

3

ALREX OPHTHALMIC DROPS,SUSPENSION 3

altacaine ophthalmic drops 1

altafluor ophthalmic drops 1

AMVISC INTRAOCULAR SYRINGE 4

AMVISC PLUS INTRAOCULAR SYRINGE

4

apraclonidine ophthalmic drops

1

ASTEPRO NASAL SPRAY,NON-AEROSOL 2 QL

atropine ophthalmic drops 1

atropine ophthalmic ointment 1

ATROVENT NASAL SPRAY,NON-AEROSOL 3 QL

AVENOVA TOPICAL SPRAY,NON-AEROSOL 3

azelastine nasal aerosol,spray 1 QL

Drug Name Tier Notesazelastine nasal spray,non-aerosol

1 QL

AZOPT OPHTHALMIC DROPS,SUSPENSION 2

balanced salt intraocular solution

1

BECONASE AQ NASAL SPRAY,NON-AEROSOL 3 ST; QL

BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION

3

BETAGAN OPHTHALMIC DROPS 3

betaxolol ophthalmic drops 1

BETIMOL OPHTHALMIC DROPS 3

BETOPTIC S OPHTHALMIC DROPS,SUSPENSION

2

bimatoprost ophthalmic drops

1

brimonidine ophthalmic drops

1

bromfenac ophthalmic drops 1

bss intraocular solution 1

BSS PLUS INTRAOCULAR SOLUTION

3

budesonide nasal spray,non-aerosol

1 QL

carteolol ophthalmic drops 1

CELLUGEL INTRAOCULAR SYRINGE

3

COMBIGAN OPHTHALMIC DROPS 2

CORTANE-B TOPICAL LOTION 3

COSOPT (PF) OPHTHALMIC DROPPERETTE

3

COSOPT OPHTHALMIC DROPS 3

cromolyn ophthalmic drops 1 QL


Effective 4/1/16

86

Drug Name Tier NotesCYCLOGYL OPHTHALMIC DROPS 3

CYCLOMYDRIL OPHTHALMIC DROPS 3

cyclopentolate ophthalmic drops

1

CYSTARAN OPHTHALMIC DROPS 3

DERMOTIC OIL OTIC DROPS 3

dexamethasone sodium phosphate ophthalmic drops

1

diclofenac sodium ophthalmic drops

1

DISCOVISC INTRAOCULAR SYRINGE

3

dorzolamide ophthalmic drops

1

dorzolamide-timolol ophthalmic drops

1

DUOVISC VISCO ELASTIC INTRAOCULAR SYRINGE

3

DUREZOL OPHTHALMIC DROPS 2 QL

DYMISTA NASAL SPRAY,NON-AEROSOL 3 QL

EYLEA INTRAVITREAL SOLUTION 4 PA

FLAREX OPHTHALMIC DROPS,SUSPENSION 3

flucaine ophthalmic drops 1

flunisolide nasal spray,non-aerosol

1 ST; QL

fluocinolone acetonide oil otic drops

1

fluorescein-benoxinate ophthalmic drops

1

fluorescein-proparacaine ophthalmic drops

1

fluorometholone ophthalmic drops,suspension

1

flurbiprofen sodium ophthalmic drops

1

Drug Name Tier Notesflurox ophthalmic drops 1

FML FORTE OPHTHALMIC DROPS,SUSPENSION

3

FML LIQUIFILM OPHTHALMIC DROPS,SUSPENSION

3

FML S.O.P. OPHTHALMIC OINTMENT

3

GELFILM OPHTHALMIC FILM 3

homatropaire ophthalmic drops

1

homatropine hbr ophthalmic drops

1

hydrocortisone-acetic acid otic drops

1

ILEVRO OPHTHALMIC DROPS,SUSPENSION 2

ILUVIEN INTRAVITREAL IMPLANT

4 PA

IOPIDINE OPHTHALMIC DROPPERETTE

3

IOPIDINE OPHTHALMIC DROPS 3

ipratropium bromide nasal spray,non-aerosol

1 QL

ISOPTO ATROPINE OPHTHALMIC DROPS 3

ISOPTO CARPINE OPHTHALMIC DROPS 3

ISTALOL OPHTHALMIC DROPS, ONCE DAILY 3

JETREA (PF) INTRAVITREAL SOLUTION

3 PA

ketorolac ophthalmic drops 1

LACRISERT OPHTHALMIC INSERT 3

latanoprost ophthalmic drops 1

levobunolol ophthalmic drops

1


Effective 4/1/16

87

Drug Name Tier NotesLOTEMAX OPHTHALMIC DROPS,GEL

3

LOTEMAX OPHTHALMIC DROPS,SUSPENSION

2

LOTEMAX OPHTHALMIC OINTMENT

2

LUCENTIS INTRAVITREAL SOLUTION

4 PA

LUMIGAN OPHTHALMIC DROPS 2

MACUGEN INTRAVITREAL SYRINGE

4 PA

MAXIDEX OPHTHALMIC DROPS,SUSPENSION

3

MEMBRANEBLUE INTRAOCULAR SYRINGE

3

metipranolol ophthalmic drops

1

MIOCHOL-E INTRAOCULAR KIT 3

miostat intraocular solution 1

MITOSOL OPHTHALMIC KIT 3

mometasone nasal spray,non-aerosol

1 ST; QL

MYDRIACYL OPHTHALMIC DROPS 3

naphazoline ophthalmic drops

1

NASONEX NASAL SPRAY,NON-AEROSOL 3 ST; QL

NEVANAC OPHTHALMIC DROPS,SUSPENSION

3

ocucoat intraocular syringe 1

OCUFEN OPHTHALMIC DROPS 3

olopatadine nasal spray,non-aerosol

1 QL

Drug Name Tier NotesOMIDRIA INTRAOCULAR CONCENTRATE

3

OMNARIS NASAL SPRAY,NON-AEROSOL 3 ST; QL

OMNIPRED OPHTHALMIC DROPS,SUSPENSION

3

OZURDEX INTRAVITREAL IMPLANT

3 PA

PAREMYD OPHTHALMIC DROPS 3 QL

PATANASE NASAL SPRAY,NON-AEROSOL 3 QL

phenylephrine hcl ophthalmic drops

1

PHOSPHOLINE IODIDE OPHTHALMIC DROPS 3

pilocarpine hcl ophthalmic drops

1

PRED FORTE OPHTHALMIC DROPS,SUSPENSION

3

PRED MILD OPHTHALMIC DROPS,SUSPENSION

3

prednisolone acetate ophthalmic drops,suspension

1

prednisolone sodium phosphate ophthalmic drops

1

PROLENSA OPHTHALMIC DROPS 3

proparacaine ophthalmic drops

1

PROVISC INTRAOCULAR SYRINGE

4

QNASL NASAL HFA AEROSOL INHALER 3 ST; QL

RESCULA OPHTHALMIC DROPS 3

RESTASIS OPHTHALMIC DROPPERETTE

2


Effective 4/1/16

88

Drug Name Tier NotesRETISERT INTRAVITREAL IMPLANT

3

RHINOCORT AQUA NASAL SPRAY,NON-AEROSOL

3 ST; QL

SIMBRINZA OPHTHALMIC DROPS,SUSPENSION

2

tetcaine ophthalmic drops 1

tetracaine hcl (pf) ophthalmic drops

1

tetracaine hcl ophthalmic drops

1

TETRAVISC FORTE OPHTHALMIC DROPPERETTE,HYPERVISCOUS

3

TETRAVISC FORTE OPHTHALMIC DROPS,HYPERVISCOUS

3

TETRAVISC OPHTHALMIC DROPPERETTE,VISCOUS

3

TETRAVISC OPHTHALMIC DROPS, VISCOUS

3

TICANASE NASAL KIT,SPRAY SUSPENSION AND SPRAY

3 ST; QL

timolol maleate ophthalmic drops

1

timolol maleate ophthalmic gel forming solution

1

TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE

3

TIMOPTIC OPHTHALMIC DROPS 3

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION

3

TRAVATAN Z OPHTHALMIC DROPS 2

Drug Name Tier Notestravoprost (benzalkonium) ophthalmic drops

1

TRIESENCE (PF) INTRAOCULAR SUSPENSION

3

tropicamide ophthalmic drops

1

TRUSOPT OPHTHALMIC DROPS 3

TYZINE NASAL DROPS0.05 % 3

TYZINE NASAL DROPS0.1 % 3 QL

TYZINE NASAL SPRAY,NON-AEROSOL 3

VERAMYST NASAL SPRAY,SUSPENSION 3 ST; QL

VEXOL OPHTHALMIC DROPS,SUSPENSION 3

VISCOAT INTRAOCULAR SYRINGE

3

VISIONBLUE INTRAOCULAR SYRINGE

3

XALATAN OPHTHALMIC DROPS 3

ZETONNA NASAL HFA AEROSOL INHALER 3 ST; QL

ZIOPTAN (PF) OPHTHALMIC DROPPERETTE

3

ELECT/CALORIC/H2O

ACTIVE FE ORAL TABLET 3

ADDAMEL N INTRAVENOUS SOLUTION

3

amino acids 15 % intravenous parenteral solution

1

AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION

2


Effective 4/1/16

89

Drug Name Tier NotesAMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION

2

AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION

2

AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION

2

AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION

2

AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION

3


3


3

AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION

3

Drug Name Tier NotesAMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION

3

AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION

3

AURYXIA ORAL TABLET 3

bd posiflush normal saline injection syringe

1

bd posiflush saline blunt cann injection syringe

1

bd pre-filled normal saline injection syringe

1

bd pre-filled saline blunt can injection syringe

1

BIFERA RX ORAL TABLET 3

calcium acetate oral capsule 1

calcium acetate oral tablet 1

calcium chloride intravenous solution

1

calcium chloride intravenous syringe

1

calcium gluconate intravenous solution

1

calcium-folic acid-vitamin d oral wafer

1

centratex oral capsule 1

chromium chloride intravenous solution

1

CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION

3


Effective 4/1/16

90

Drug Name Tier NotesCLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION

3

Drug Name Tier NotesCLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION

3

CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION

3


3


3

CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION

3

CLINPRO 5000 DENTAL PASTE 3

copper chloride intravenous solution

1

corvita 150 oral tablet 1

CORVITE 150 ORAL TABLET 3

CORVITE FE ORAL TABLET 3

cysteine (l-cysteine) intravenous solution

1

cytra k crystals oral packet 1

cytra-2 oral solution 1

cytra-3 oral solution 1

cytra-k oral solution 1

d10 %-0.45 % sodium chloride intravenous parenteral solution

1


Effective 4/1/16

91

Drug Name Tier Notesd2.5 %-0.45 % sodium chloride intravenous parenteral solution

1

d5 % and 0.9 % sodium chloride intravenous parenteral solution

1

d5 %-0.45 % sodium chloride intravenous parenteral solution

1

delflex with 2.5 % dextrose intraperitoneal solution

1

delflex-lc/1.5% dextrose intraperitoneal solution

1


1


1

DELFLEX-SM WITH 1.5% DEXTROSE INTRAPERITONEAL SOLUTION

2

denta 5000 plus dental cream 1

dentagel dental gel 1

dextrose 10 % and 0.2 % nacl intravenous parenteral solution

1

dextrose 10 % in water (d10w) intravenous parenteral solution

1


1

dextrose 25 % in water (d25w) intravenous syringe

1


1


1

dextrose 5 % in ringers intravenous parenteral solution

1


1

Drug Name Tier Notesdextrose 5 % in water (d5w) intravenous piggyback

1

dextrose 5 %-lactated ringers intravenous parenteral solution

1

dextrose 5%-0.2 % sod chloride intravenous parenteral solution

1

dextrose 5%-0.3 % sod.chloride intravenous parenteral solution

1


1

dextrose 50 % in water (d50w) intravenous syringe

1


1

DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION

3

DIANEAL LOW CALCIUM/4.25% DEX INTRAPERITONEAL SOLUTION

3

DIANEAL PD-2 WITH 2.5 % DEX INTRAPERITONEAL SOLUTION

3

DIANEAL PD-2 WITH 4.25 % DEX INTRAPERITONEAL SOLUTION

3

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION

3

DIANEAL WITH 1.5% DEXTROSE INTRAPERITONEAL SOLUTION

3

DIANEAL WITH 2.5 % DEXTROSE INTRAPERITONEAL SOLUTION

3


Effective 4/1/16

92

Drug Name Tier NotesDIANEAL WITH 4.25 % DEXTROSE INTRAPERITONEAL SOLUTION

3

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet, effervescent 25 meq

1

electrolyte-48 in d5w intravenous parenteral solution

1

eliphos oral tablet 1

EXTRANEAL 7.5 % INTRAPERITONEAL SOLUTION

3

fe c plus oral tablet 1

FERAHEME INTRAVENOUS SOLUTION

3

FERIVA 21-7 TABLET ORAL TABLET 3

FERIVA FA (SUMALATE) ORAL CAPSULE

3

FERIVA ORAL CAPSULE,EXT RELEASE MULTIPHASE

3

ferocon oral capsule 1

FERRALET 90 DUAL-IRON DELIVERY ORAL TABLET

3

ferraplus 90 oral tablet 1

ferrex 150 forte oral capsule 1

ferrex 150 forte plus oral capsule

1

ferrex 28 oral tablet 1

FERRLECIT INTRAVENOUS SOLUTION

3

ferrocite plus oral tablet 1

ferrogels forte oral capsule 1

FLORIVA (FLUORIDE-VITAMIN D3) ORAL DROPS

3

Drug Name Tier NotesFLUORABON ORAL DROPS 3

fluor-a-day (with xylitol) oral tablet,chewable

1

FLUOR-A-DAY ORAL DROPS 3

fluoridex daily defense dental gel

1

FLUORIDEX SENSITIVITY RELIEF DENTAL GEL

3

FLUORITAB ORAL DROPS 3

fluoritab oral tablet,chewable 1

FLURA-DROPS ORAL DROPS 3

focalgin dss oral tablet 1

FOLGARD OS ORAL TABLET 3

folivane-f oral capsule 1

folivane-plus oral capsule 1

FOSRENOL ORAL POWDER IN PACKET 3 ST

FOSRENOL ORAL TABLET,CHEWABLE 3 ST

FOSTEUM ORAL CAPSULE 3

FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION

3

freamine iii 10 % intravenous parenteral solution

1

FUSION PLUS ORAL CAPSULE 3

FUSION SPRINKLES ORAL POWDER IN PACKET

3

GLUCAGEN HYPOKIT INJECTION RECON SOLN

2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

2


Effective 4/1/16

93

Drug Name Tier NotesGLYCOPHOS INTRAVENOUS SOLUTION

3

hematinic plus vit/minerals oral tablet

1

hematinic/folic acid oral tablet

1

hematogen fa oral capsule 1

hematogen forte oral capsule 1

hematogen oral capsule 1

HEMATRON ORAL LIQUID 3

HEMATRON-AF ORAL TABLET EXTENDED RELEASE 24 HR

3

HEMAX ORAL TABLET EXTENDED RELEASE 24 HR

3

hemetab oral tablet 1

HEMOCYTE-F ORAL TABLET 3

HEMOCYTE-PLUS ORAL CAPSULE 3

HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION

3

HYDROCHLORIC ACID (BULK) LIQUID 3

HYPERLYTE CR INTRAVENOUS SOLUTION

3

ICAR-C PLUS ORAL TABLET 3

iferex 150 forte oral capsule 1

infed injection solution 1

INJECTAFER INTRAVENOUS SOLUTION

3

INTEGRA F ORAL CAPSULE 3

INTEGRA PLUS ORAL CAPSULE 3

IODOPEN INTRAVENOUS SOLUTION

3

Drug Name Tier NotesIONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION

3

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION

3

IROSPAN 24/6 ORAL TABLET 3

ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

3

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

3

KABIVEN INTRAVENOUS EMULSION

3

KAYEXALATE ORAL POWDER 3

k-effervescent oral tablet, effervescent

1

kionex oral powder 1

kionex oral suspension 1

klor-con 10 oral tablet extended release

1

klor-con 8 oral tablet extended release

1

klor-con m10 oral tablet,er particles/crystals

1


1


1

klor-con oral packet 1

klor-con sprinkle oral capsule, extended release

1

KLOR-CON/25 ORAL PACKET 3


Effective 4/1/16

94

Drug Name Tier Notesklor-con/ef oral tablet, effervescent

1

K-PHOS NO 2 ORAL TABLET 3

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

2

k-phos-neutral oral tablet 1

k-sol oral liquid 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

3

k-tab oral tablet extended release 8 meq

1

lactated ringers intravenous parenteral solution

1

ludent fluoride oral tablet,chewable

1

lugols oral solution 1

LYSIPLEX PLUS ORAL TABLET 3

MAGNEBIND 400 ORAL TABLET 3

magnesium chloride injection solution

1

MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK

3

magnesium sulfate in water intravenous parenteral solution

1

magnesium sulfate in water intravenous piggyback

1

magnesium sulfate injection solution

1

magnesium sulfate injection syringe

1

manganese chloride intravenous solution

1

manganese sulfate intravenous solution

1

marlexate oral powder 1

MAXARON FORTE ORAL TABLET 3

Drug Name Tier NotesMAXFE (FOLATE-DOCUSATE) ORAL TABLET

3

monoject 0.9% sodium chloride injection syringe

1

monoject prefill advanced ns injection syringe

1

monoject prefill saline flush injection syringe

1

multigen folic oral tablet 1

multigen oral tablet 1

multigen plus oral tablet 1

MULTITRACE-4 CONCENTRATE INTRAVENOUS SOLUTION

3

MULTITRACE-4 INTRAVENOUS SOLUTION

3

MULTITRACE-4 NEONATAL INTRAVENOUS SOLUTION

3

multitrace-4 pediatric intravenous solution

1

MULTITRACE-5 CONCENTRATE INTRAVENOUS SOLUTION

3

MULTITRACE-5 INTRAVENOUS SOLUTION

3

myferon 150 forte oral capsule

1

NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION

3

NEPHRON FA ORAL TABLET 3

NEUT INTRAVENOUS SOLUTION 3

normal saline flush injection syringe

1


Effective 4/1/16

95

Drug Name Tier NotesNORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION

3

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

3

NUFERA ORAL TABLET 3

NUTRESTORE ORAL POWDER IN PACKET 3

nutrilyte intravenous solution 1

ORACIT ORAL SOLUTION 3

PEDITRACE INTRAVENOUS SOLUTION

3

PERIKABIVEN INTRAVENOUS EMULSION

3

perio med dental solution 1

PHOSLO ORAL CAPSULE 3 ST

PHOSLYRA ORAL SOLUTION 3 ST

phospha 250 neutral oral tablet

1

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

3

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

3

Drug Name Tier NotesPLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

3

poly-iron 150 forte oral capsule

1

pot,sodium citrate-citric acid oral solution

1

potassium acetate intravenous solution

1

potassium bicarb and chloride oral tablet, effervescent

1

potassium bicarb-citric acid oral tablet, effervescent

1

potassium chlorid-d5-0.45%nacl intravenous parenteral solution

1

potassium chloride in 0.9%nacl intravenous parenteral solution

1

potassium chloride in 5 % dex intravenous parenteral solution

1

potassium chloride in lr-d5 intravenous parenteral solution

1

potassium chloride intravenous piggyback

1

potassium chloride intravenous solution

1

potassium chloride oral capsule, extended release

1

potassium chloride oral liquid

1

potassium chloride oral packet

1

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

potassium chloride-0.45 % nacl intravenous parenteral solution

1


Effective 4/1/16

96

Drug Name Tier Notespotassium chloride-d5-0.2%nacl intravenous parenteral solution

1

potassium chloride-d5-0.3%nacl intravenous parenteral solution

1

potassium chloride-d5-0.9%nacl intravenous parenteral solution

1

potassium citrate oral tablet extended release

1

potassium citrate-citric acid oral packet

1

potassium citrate-citric acid oral solution

1

potassium phosphate m-/d-basic intravenous solution

1

premasol 10 % intravenous parenteral solution

1

PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION

3

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

3

PREVIDENT 5000 DRY MOUTH DENTAL GEL 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

3

PREVIDENT 5000 PLUS DENTAL CREAM 3

PREVIDENT 5000 SENSITIVE DENTAL PASTE

3

PREVIDENT DENTAL GEL 3

PREVIDENT DENTAL SOLUTION 3

PRISMASOL B22GK HEMODIALYSIS SOLUTION

3

Drug Name Tier NotesPRISMASOL BGK HEMODIALYSIS SOLUTION

3

PRISMASOL BK HEMODIALYSIS SOLUTION

3

PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION

3

PROFERRIN-FORTE ORAL TABLET 3

PROGLYCEM ORAL SUSPENSION 3

PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION

3

purevit dualfe plus oral capsule

1

RENAGEL ORAL TABLET 3 ST

RENVELA ORAL POWDER IN PACKET 2

RENVELA ORAL TABLET 2

ringers intravenous parenteral solution

1

SACCHARIN POWDER 3

selenium intravenous solution

1

se-tan plus oral capsule 1

sf 5000 plus dental cream 1

sf dental gel 1

SHOHL'S MODIFIED ORAL SOLUTION 3

sodium acetate intravenous solution

1

sodium bicarbonate intravenous solution

1

sodium bicarbonate intravenous syringe

1

sodium chloride 0.45 % intravenous parenteral solution

1


Effective 4/1/16

97

Drug Name Tier Notessodium chloride 0.45 % intravenous piggyback

1

sodium chloride 0.9 % injection solution

1

sodium chloride 0.9 % injection syringe

1

SODIUM CHLORIDE 0.9 % INJECTION SYRINGE, WITH SWAB CAP

3

sodium chloride 0.9 % intravenous parenteral solution

1

sodium chloride 0.9 % intravenous piggyback

1

sodium chloride 3 % intravenous parenteral solution

1

sodium chloride 5 % intravenous parenteral solution

1

sodium chloride intravenous parenteral solution

1

sodium citrate-citric acid oral solution

1

sodium ferric gluconat-sucrose intravenous solution

1

sodium fluoride dental solution

1

sodium fluoride oral drops 1

sodium fluoride oral tablet,chewable

1

sodium lactate intravenous solution

1

sodium phosphate intravenous solution

1

sodium polystyrene (sorb free) oral suspension

1

sodium polystyrene sulfonate oral powder

1

sodium polystyrene sulfonate oral suspension

1

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

1

Drug Name Tier NotesSODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

3

SORBITOL POWDER 3

sps oral suspension 1

sps rectal enema 1

SSKI ORAL SOLUTION 3

strong iodine oral solution 1

SWABFLUSH INJECTION SYRINGE, WITH SWAB CAP

3

syrex sodium chloride 0.9% injection syringe

1

TANDEM PLUS ORAL CAPSULE 3

taron forte oral capsule 1

THAM INTRAVENOUS SOLUTION 3

tl g-fol os oral tablet 1

tl icon oral capsule 1

tl-hem 150 oral tablet extended release 24 hr

1

TPN ELECTROLYTES II INTRAVENOUS SOLUTION

3

TPN ELECTROLYTES INTRAVENOUS SOLUTION

3

TRACE ELEMENTS 4/PEDIATRIC INTRAVENOUS SOLUTION

3

travasol 10 % intravenous parenteral solution

1

tricitrates oral solution 1

tricon oral capsule 1

TRIFERIC HEMODIALYSIS SOLUTION

3

trigels-f forte oral capsule 1

TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION

3


Effective 4/1/16

98

Drug Name Tier NotesTROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION

3

ULTRABAG/DIANEAL PD-2/1.5% DEX INTRAPERITONEAL SOLUTION

3

ULTRABAG/DIANEAL PD-2/2.5% DEX INTRAPERITONEAL SOLUTION

3

ULTRABAG/DIANEAL PD-2/4.25%DEX INTRAPERITONEAL SOLUTION

3

ULTRABAG/DIANEAL/2.5% DEXTROSE INTRAPERITONEAL SOLUTION

3

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE

3


3


3

UROQID-ACID NO.2 ORAL TABLET 3

VELPHORO ORAL TABLET,CHEWABLE 3 ST

VELTASSA ORAL POWDER IN PACKET 3

VENOFER INTRAVENOUS SOLUTION

3

virt-phos 250 neutral oral tablet

1

virtrate-2 oral solution 1

virtrate-3 oral solution 1

virtrate-k oral solution 1

VITAFOL ORAL TABLET 3

vp-gstn oral capsule 1

Drug Name Tier NotesXURIDEN ORAL GRANULES IN PACKET 3

zinc chloride intravenous solution

1

zinc sulfate intravenous solution

1

zinc sulfate oral capsule 1

GASTROINTESTINAL

ACIPHEX ORAL TABLET,DELAYED RELEASE (DR/EC)

3 ST; QL

ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE

3 ST; QL

ACTIGALL ORAL CAPSULE 3

AKYNZEO ORAL CAPSULE 3 QL

alosetron oral tablet 1

ALOXI INTRAVENOUS SOLUTION 3 PA

AMITIZA ORAL CAPSULE 2

AMMONUL INTRAVENOUS SOLUTION

3

amoxicil-clarithromy-lansopraz oral combo pack

1

ANA-LEX KIT RECTAL KIT 3

ANALPRAM ADVANCED KIT 3

ANALPRAM E RECTAL KIT,CREAM AND TOWELETTE

3

ANALPRAM-HC RECTAL CREAM 3

ANALPRAM-HC SINGLES RECTAL CREAM

3

anaspaz oral tablet,disintegrating

1

ANTIVERT ORAL TABLET 3

anucort-hc rectal suppository 1


Effective 4/1/16

99

Drug Name Tier NotesANUSOL-HC RECTAL CREAM 3

ANUSOL-HC RECTAL SUPPOSITORY 3

ANZEMET INTRAVENOUS SOLUTION 100 MG/5 ML, 12.5 MG/0.625 ML

3

ANZEMET INTRAVENOUS SOLUTION 20 MG/ML

3 QL

ANZEMET ORAL TABLET 3 QL

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

3 ST

ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC)

2

atropine injection solution 1

atropine injection syringe 1

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC)

3

AZULFIDINE ORAL TABLET 3

balsalazide oral capsule 1

BENTYL INTRAMUSCULAR SOLUTION

3

BENTYL ORAL CAPSULE 3

BENTYL ORAL TABLET 3

BUPHENYL ORAL POWDER 3

BUPHENYL ORAL TABLET 3 PA

CANASA RECTAL SUPPOSITORY 2

carafate oral suspension 1

CARAFATE ORAL TABLET 3

CESAMET ORAL CAPSULE 3

Drug Name Tier NotesCHENODAL ORAL TABLET 3

chlordiazepoxide-clidinium oral capsule

1

CHOLBAM ORAL CAPSULE 3 PA; QL

cimetidine hcl oral solution 1

cimetidine oral tablet 1

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

4 PA; QL

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

4 PA; QL

CIMZIA SUBCUTANEOUS SYRINGE KIT

4 PA; QL

COLAZAL ORAL CAPSULE 3

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN

3

COMPAZINE ORAL TABLET 3

COMPAZINE RECTAL SUPPOSITORY 3

compro rectal suppository 1

constulose oral solution 1

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

CUVPOSA ORAL SOLUTION 3

CYTOTEC ORAL TABLET 3

DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

3 ST; QL

DICLEGIS ORAL TABLET,DELAYED RELEASE (DR/EC)

3 PA; QL

dicyclomine intramuscular solution

1


Effective 4/1/16

100

Drug Name Tier Notesdicyclomine oral capsule 1

dicyclomine oral solution 1

dicyclomine oral tablet 1

dimenhydrinate injection solution

1

DIPENTUM ORAL CAPSULE 3 ST

diphenoxylate-atropine oral liquid

1

diphenoxylate-atropine oral tablet

1

DONNATAL ORAL ELIXIR 3

DONNATAL ORAL TABLET 3

dronabinol oral capsule 1

ed-spaz oral tablet,disintegrating

1

EMEND INTRAVENOUS RECON SOLN 3 PA

EMEND ORAL CAPSULE 3 QL

EMEND ORAL CAPSULE,DOSE PACK 3 QL

ENTEREG ORAL CAPSULE 3

ENTYVIO INTRAVENOUS RECON SOLN

4 PA; QL

enulose oral solution 1

esomeprazole magnesium oral capsule,delayed release(dr/ec)

3 ST; QL

esomeprazole sodium intravenous recon soln

1

famotidine (pf) intravenous solution

1

famotidine (pf)-nacl (iso-os) intravenous piggyback

1

famotidine intravenous solution

1

famotidine oral suspension 1

famotidine oral tablet 1

GATTEX 30-VIAL SUBCUTANEOUS KIT 3 PA

Drug Name Tier NotesGATTEX ONE-VIAL SUBCUTANEOUS KIT 3 PA

gavilyte-c oral recon soln 1

gavilyte-g oral recon soln 1

gavilyte-h and bisacodyl oral kit

1

gavilyte-n oral recon soln 1

generlac oral solution 1

GIAZO ORAL TABLET 3

glycopyrrolate injection solution

1

glycopyrrolate oral tablet 1

GOLYTELY ORAL POWDER IN PACKET 3

GOLYTELY ORAL RECON SOLN 3

granisetron (pf) intravenous solution

1

granisetron hcl intravenous solution

1

granisetron hcl oral tablet 1 QL

hemmorex-hc rectal suppository

1

hydrocortisone acetate rectal suppository

1

hydrocortisone rectal cream 1

hydrocortisone-pramoxine rectal cream

1

hyoscyamine sulfate oral drops

1

hyoscyamine sulfate oral elixir

1

hyoscyamine sulfate oral tablet

1

hyoscyamine sulfate oral tablet extended release 12 hr

1

hyoscyamine sulfate oral tablet,disintegrating

1

hyoscyamine sulfate sublingual tablet

1

hyosyne oral drops 1

hyosyne oral elixir 1

intralipid intravenous emulsion 20 %

1


Effective 4/1/16

101

Drug Name Tier NotesINTRALIPID INTRAVENOUS EMULSION 30 %

3

ipecac oral syrup 1

KEPIVANCE INTRAVENOUS RECON SOLN

4

KINEVAC INJECTION RECON SOLN 3

KRISTALOSE ORAL PACKET 3

lactulose oral solution 1

lansoprazole oral capsule,delayed release(dr/ec)

3 QL

LEVBID ORAL TABLET EXTENDED RELEASE 12 HR

3

LEVSIN INJECTION SOLUTION 2

LEVSIN ORAL TABLET 3

LEVSIN/SL SUBLINGUAL TABLET 3

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC)

2

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE

3

LIDOCAINE HCL-HYDROCORTISON AC RECTAL CREAM 3 %-1 % (7 GRAM)

3

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

1

LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL

3

lidocaine hcl-hydrocortison ac rectal kit

1

lidocaine-hydrocortisone-aloe rectal gel

1

LIDOCAINE-HYDROCORTISONE-ALOE RECTAL KIT 2-2 %

3

Drug Name Tier Noteslidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 gram)

1

LINZESS ORAL CAPSULE 2

LIPOSYN II INTRAVENOUS EMULSION

3

liposyn iii intravenous emulsion

1

LITHOSTAT ORAL TABLET 3

LOMOTIL ORAL TABLET 3

loperamide oral capsule 1

LOTRONEX ORAL TABLET 3

LOVAZA ORAL CAPSULE 3 ST; QL

MARINOL ORAL CAPSULE 3

meclizine oral tablet 1

mesalamine rectal enema 1

mesalamine with cleansing wipe rectal enema kit

1

methscopolamine oral tablet 1

metoclopramide hcl injection solution

1

metoclopramide hcl injection syringe

1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet,disintegrating

1

METOZOLV ODT ORAL TABLET,DISINTEGRATING

3

misoprostol oral tablet 1

MOTOFEN ORAL TABLET 3

MOVIPREP ORAL POWDER IN PACKET 3


Effective 4/1/16

102

Drug Name Tier NotesNEXIUM IV INTRAVENOUS RECON SOLN

3

NEXIUM ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3 ST; QL

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

2 QL

nizatidine oral capsule 1

nizatidine oral solution 1

NULEV ORAL TABLET,DISINTEGRATING

3

NULYTELY WITH FLAVOR PACKS ORAL RECON SOLN

3

NUTRILIPID INTRAVENOUS EMULSION

3

NUTRIPORT BALLOON KIT 2

OMECLAMOX-PAK ORAL COMBO PACK 3

omega-3 acid ethyl esters oral capsule

1 ST; QL

omeprazole oral capsule,delayed release(dr/ec)

1 QL

omeprazole-sodium bicarbonate oral capsule

1 QL

ondansetron hcl (pf) injection solution

1

ondansetron hcl (pf) injection syringe

1

ondansetron hcl intravenous solution

1

ondansetron hcl oral solution 1 QL

ondansetron hcl oral tablet 1 QL

ondansetron oral tablet,disintegrating

1 QL

opium tincture oral tincture 1

oscimin oral tablet 1

oscimin oral tablet,disintegrating

1

Drug Name Tier Notesoscimin sl sublingual tablet 1

oscimin sr oral tablet extended release 12 hr

1

OSMOPREP ORAL TABLET 3

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

pantoprazole intravenous recon soln

1 QL

pantoprazole oral tablet,delayed release (dr/ec)

1 QL

paregoric oral liquid 1 QL

peg 3350-electrolytes oral recon soln

1

peg-3350 with flavor packs oral recon soln

1

peg-electrolyte soln oral recon soln

1

peg-prep oral kit 1

PENTASA ORAL CAPSULE, EXTENDED RELEASE

2

PEPCID ORAL SUSPENSION 3

PEPCID ORAL TABLET 3

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

phenadoz rectal suppository 1

phenergan rectal suppository 1

phenobarb-hyoscy-atropine-scop oral tablet

1

phenohytro oral tablet 1

polyethylene glycol 3350 oral powder

1

polyethylene glycol 3350 oral powder in packet

1

pramcort rectal cream 1

PREPOPIK ORAL POWDER IN PACKET 3

PREVACID ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3 ST; QL


Effective 4/1/16

103

Drug Name Tier NotesPREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL

3 ST; QL

PREVPAC ORAL COMBO PACK 3

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

3 QL

prochlorperazine edisylate injection solution

1

prochlorperazine maleate oral tablet

1

prochlorperazine rectal suppository

1

PROCORT RECTAL CREAM 3

PROCTOCORT RECTAL CREAM 3

PROCTOCORT RECTAL SUPPOSITORY 3

PROCTOFOAM HC RECTAL FOAM 3

procto-pak rectal cream 1

proctosol hc rectal cream 1

proctozone-hc rectal cream 1

promethazine rectal suppository

1

promethegan rectal suppository

1

propantheline oral tablet 1

PROTONIX INTRAVENOUS RECON SOLN

3 ST

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

3 ST; QL

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC)

3 ST; QL

PYLERA ORAL CAPSULE 3

rabeprazole oral tablet,delayed release (dr/ec)

1 ST; QL

ranitidine hcl injection solution

1

Drug Name Tier Notesranitidine hcl oral capsule 1

ranitidine hcl oral syrup 1

ranitidine hcl oral tablet 1

RAVICTI ORAL LIQUID 3 PA; QL

RECTIV RECTAL OINTMENT 3

REGLAN ORAL TABLET 3

REMICADE INTRAVENOUS RECON SOLN

4 PA

RESTORA RX ORAL CAPSULE 3

RESTORA SPRINKLES ORAL POWDER IN PACKET

3

ROBINUL FORTE ORAL TABLET 3

ROBINUL INJECTION SOLUTION 3 QL

ROBINUL ORAL TABLET 3 QL

ROWASA RECTAL ENEMA KIT 3

SANCUSO TRANSDERMAL PATCH WEEKLY

3 QL

SCOPOLAMINE HBR INJECTION SOLUTION 3

SENSURA CLICK OSTOMY POUCH 3

SENSURA OSTOMY BASE PLATE 3

SFROWASA RECTAL ENEMA 3

sodium phenylbutyrate oral powder

1

SUCRAID ORAL SOLUTION 4

sucralfate oral tablet 1

sulfasalazine oral tablet 1

sulfasalazine oral tablet,delayed release (dr/ec)

1

sulfazine oral tablet 1


Effective 4/1/16

104

Drug Name Tier NotesSUPREP BOWEL PREP KIT ORAL RECON SOLN 3

SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE

3

symax fastabs oral tablet,disintegrating

1

symax-sl sublingual tablet 1

symax-sr oral tablet extended release 12 hr

1

TIGAN INTRAMUSCULAR SOLUTION

3

TIGAN ORAL CAPSULE 3

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

2

trilyte with flavor packets oral recon soln

1

trimethobenzamide oral capsule

1

URSO 250 ORAL TABLET 3

URSO FORTE ORAL TABLET 3

ursodiol oral capsule 1

ursodiol oral tablet 1

VARUBI ORAL TABLET 3 QL

VASCAZEN ORAL CAPSULE 3

VASCEPA ORAL CAPSULE 3 ST; QL

VIBERZI ORAL TABLET 3 PA; QL

VIOKACE ORAL TABLET 3

VSL#3 DS ORAL POWDER IN PACKET 3

ZANTAC INJECTION SOLUTION 3

ZANTAC ORAL TABLET 3

ZEGERID ORAL CAPSULE 3 ST; QL

ZEGERID ORAL PACKET 3 ST; QL

Drug Name Tier NotesZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

ZOFRAN (AS HYDROCHLORIDE) INTRAVENOUS SOLUTION

3

ZOFRAN (AS HYDROCHLORIDE) ORAL SOLUTION

3 QL

ZOFRAN (AS HYDROCHLORIDE) ORAL TABLET

3 QL

ZOFRAN ODT ORAL TABLET,DISINTEGRATING

3 QL

ZUPLENZ ORAL FILM 3 QL

ZYPRAM RECTAL KIT,CREAM AND TOWELETTE

3

HERBALS

TEARS AGAIN HYDRATE ORAL CAPSULE

3

VP-PRECIP ORAL CAPSULE 3

HORMONES

ACTHAR H.P. INJECTION GEL 4 PA

ACTHREL INTRAVENOUS RECON SOLN

3

ACTIVE INJECTION KIT D INJECTION KIT 3

ACTIVELLA ORAL TABLET 3

a-hydrocort injection recon soln

1

ALORA TRANSDERMAL PATCH SEMIWEEKLY 3

ANADROL-50 ORAL TABLET 3

ANDRODERM TRANSDERMAL PATCH 24 HOUR

3 PA; QL


Effective 4/1/16

105

Drug Name Tier NotesANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP1.25 GRAM/ ACTUATION (1 %)

3 PA; QL

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)

2 PA; QL

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

3 PA; QL

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

2 PA; QL

ANDROID ORAL CAPSULE 3

androxy oral tablet 1

ANGELIQ ORAL TABLET 3

ARISTOSPAN INTRA-ARTICULAR INJECTION SUSPENSION

3

ARISTOSPAN INTRALESIONAL INJECTION SUSPENSION

3

AVEED INTRAMUSCULAR SOLUTION

3

AXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP

3 PA; QL

AYGESTIN ORAL TABLET 3

BETA-1 INJECTION KIT 3

betamethasone acet,sod phos injection suspension

1

BRAVELLE INJECTION RECON SOLN 4 ST

Drug Name Tier Notesbudesonide oral capsule,delayed,extend.release

1

cabergoline oral tablet 1

calcitonin (salmon) nasal spray,non-aerosol

1 QL

CELESTONE SOLUSPAN INJECTION SUSPENSION

3

CERVIDIL VAGINAL INSERT, EXTENDED RELEASE

3

CETROTIDE SUBCUTANEOUS KIT 4 PA

chorionic gonadotropin, human intramuscular recon soln

4 PA

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

2

CLIMARA TRANSDERMAL PATCH WEEKLY

3

clomiphene citrate oral tablet 1 PA

colocort rectal enema 1

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY

2

CORTEF ORAL TABLET 3

CORTENEMA RECTAL ENEMA 3

CORTIFOAM RECTAL FOAM 3

cortisone oral tablet 1

CORTROSYN INJECTION RECON SOLN

3

cosyntropin injection recon soln

1

COSYNTROPIN INTRAVENOUS SOLUTION

3

covaryx h.s. oral tablet 1

covaryx oral tablet 1

CRINONE VAGINAL GEL 4 PA


Effective 4/1/16

106

Drug Name Tier Notesdanazol oral capsule 1

DDAVP INJECTION SOLUTION 3

DDAVP NASAL AEROSOL,SPRAY 3

DDAVP NASAL SOLUTION 3

DDAVP ORAL TABLET 3

DELESTROGEN INTRAMUSCULAR OIL 3

deltasone oral tablet 1

DEPO-ESTRADIOL INTRAMUSCULAR OIL 3

DEPO-MEDROL INJECTION SUSPENSION

3

DEPO-PROVERA INTRAMUSCULAR SOLUTION

3 PA

DEPO-TESTOSTERONE INTRAMUSCULAR OIL 3

desmopressin injection solution

1

desmopressin nasal aerosol,spray

1

desmopressin nasal solution 1

desmopressin nasal spray,non-aerosol

1

desmopressin oral tablet 1

dexamethasone intensol oral drops

1

dexamethasone oral elixir 1

dexamethasone oral solution 1

dexamethasone oral tablet 1

dexamethasone sodium phos (pf) injection solution

1

dexamethasone sodium phosphate injection solution

1

dexamethasone sodium phosphate injection syringe

1

DEXPAK 10 DAY ORAL TABLETS,DOSE PACK 3

DEXPAK 13 DAY ORAL TABLETS,DOSE PACK 3

Drug Name Tier NotesDEXPAK 6 DAY ORAL TABLETS,DOSE PACK 3

DIVIGEL TRANSDERMAL GEL IN PACKET

2

DOUBLEDEX INJECTION KIT 3

DUAVEE ORAL TABLET 3

eemt hs oral tablet 1

eemt oral tablet 1

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

4 PA; QL

EGRIFTA SUBCUTANEOUS RECON SOLN 2 MG

4 PA

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP

3

ENDOMETRIN VAGINAL INSERT 3

ENJUVIA ORAL TABLET 3

ENTOCORT EC ORAL CAPSULE,DELAYED,EXTEND.RELEASE

3

ESTRACE ORAL TABLET 3

ESTRACE VAGINAL CREAM 3

estradiol oral tablet 1

estradiol transdermal patch semiweekly

1

estradiol transdermal patch weekly

1

estradiol valerate intramuscular oil

1

estradiol-norethindrone acet oral tablet

1

ESTRING VAGINAL RING 2

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

3

estrogens-methyltestosterone oral tablet

1


Effective 4/1/16

107

Drug Name Tier Notesestropipate oral tablet 1

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL

2

FEMHRT LOW DOSE ORAL TABLET 3

FEMRING VAGINAL RING 3

fludrocortisone oral tablet 1

FOLLISTIM AQ INJECTION SOLUTION 4 PA

FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE

4 PA

FORTESTA TRANSDERMAL GEL IN METERED-DOSE PUMP

3 PA; QL

fortical nasal spray,non-aerosol

1 QL

fyavolv oral tablet 1

GANIRELIX SUBCUTANEOUS SYRINGE

4 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE

4 PA

GENOTROPIN SUBCUTANEOUS CARTRIDGE

4 PA

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

4 ST

GONAL-F RFF SUBCUTANEOUS RECON SOLN

4 ST

GONAL-F SUBCUTANEOUS RECON SOLN

4 ST

HEMABATE INTRAMUSCULAR SOLUTION

3

HUMATROPE INJECTION CARTRIDGE

4 PA

Drug Name Tier NotesHUMATROPE INJECTION RECON SOLN

4 PA

hydrocortisone oral tablet 1

hydrocortisone rectal enema 1

INCRELEX SUBCUTANEOUS SOLUTION

4 PA

jevantique lo oral tablet 1

jinteli oral tablet 1

KENALOG INJECTION SUSPENSION 3

lopreeza oral tablet 1

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

4 PA

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

4 PA


4 PA

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT

4 PA; QL

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT

4 PA

LUPRON DEPOT-PED INTRAMUSCULAR KIT11.25 MG, 15 MG

4 PA

LUPRON DEPOT-PED INTRAMUSCULAR KIT7.5 MG (PED)

4 PA; QL

MAKENA INTRAMUSCULAR OIL250 MG/ML

4 PA

MAKENA INTRAMUSCULAR OIL250 MG/ML (1 ML)

4

MEDROL (PAK) ORAL TABLETS,DOSE PACK 3

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

3


Effective 4/1/16

108

Drug Name Tier NotesMEDROL ORAL TABLET 2 MG 2

medroxyprogesterone oral tablet

1

MENEST ORAL TABLET 2

MENOPUR SUBCUTANEOUS RECON SOLN

4 PA

MENOSTAR TRANSDERMAL PATCH WEEKLY

3

methergine oral tablet 1

METHITEST ORAL TABLET 3

METHYLERGONOVINE INJECTION SOLUTION 3

methylergonovine oral tablet 1

methylprednisolone acetate injection suspension

1

methylprednisolone oral tablet

1

methylprednisolone oral tablets,dose pack

1

methylprednisolone sodium succ injection recon soln

1

methylprednisolone sodium succ intravenous recon soln

1

methyltestosterone oral capsule

1

MIACALCIN INJECTION SOLUTION 4

MIACALCIN NASAL SPRAY,NON-AEROSOL 3 QL

millipred dp oral tablets,dose pack

1

MILLIPRED ORAL SOLUTION 3

millipred oral tablet 1

mimvey lo oral tablet 1

mimvey oral tablet 1

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY

3

Drug Name Tier NotesMYALEPT SUBCUTANEOUS RECON SOLN

4

NATESTO NASAL GEL IN METERED-DOSE PUMP

3 PA; QL

NATPARA SUBCUTANEOUS CARTRIDGE

3 PA; QL

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

4 PA

norethindrone acetate oral tablet

1

norethindrone ac-eth estradiol oral tablet

1

novarel intramuscular recon soln

4 PA

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR

4 PA

NUTROPIN AQ SUBCUTANEOUS CARTRIDGE

4 PA

octreotide acetate injection solution

4 PA

octreotide acetate injection syringe

4 PA

OMNITROPE SUBCUTANEOUS CARTRIDGE

4 PA

OMNITROPE SUBCUTANEOUS RECON SOLN

4 PA

ORAPRED ODT ORAL TABLET,DISINTEGRATING

3 PA

OVIDREL SUBCUTANEOUS SYRINGE

4 PA

OXANDRIN ORAL TABLET 3 PA

oxandrolone oral tablet 1 PA

oxytocin injection solution 1

PEDIAPRED ORAL SOLUTION 3


Effective 4/1/16

109

Drug Name Tier NotesPITOCIN INJECTION SOLUTION 3

prednisolone oral solution 1

prednisolone sodium phosphate oral solution

1

prednisolone sodium phosphate oral tablet,disintegrating

1

prednisone intensol oral concentrate

1

prednisone oral solution 1

prednisone oral tablet 1

prednisone oral tablets,dose pack

1

PREFEST ORAL TABLET 3

PREGNYL INTRAMUSCULAR RECON SOLN

4 PA

PREMARIN INJECTION RECON SOLN 2

PREMARIN ORAL TABLET 2

PREMARIN VAGINAL CREAM 2

PREMPHASE ORAL TABLET 2

PREMPRO ORAL TABLET 2

PREPIDIL VAGINAL GEL 3

PRO-C-DURE 5 INJECTION KIT 3

PRO-C-DURE 6 INJECTION KIT 3

progesterone in oil intramuscular oil

1

progesterone intramuscular oil

1

progesterone micronized oral capsule

1

PROMETRIUM ORAL CAPSULE 3

PROSTIN E2 VAGINAL SUPPOSITORY 3

Drug Name Tier NotesPROVERA ORAL TABLET 3

RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC)

3

SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE

4 PA

SAIZEN SUBCUTANEOUS RECON SOLN

4 PA

SANDOSTATIN INJECTION SOLUTION 4 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT

4 PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

4 PA

serophene oral tablet 1 PA

SEROSTIM SUBCUTANEOUS RECON SOLN

4 PA

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

4

SIGNIFOR SUBCUTANEOUS SOLUTION

4 PA

SOLU-CORTEF (PF) INJECTION RECON SOLN

3

SOLU-CORTEF INJECTION RECON SOLN

3

SOLU-MEDROL (PF) INJECTION RECON SOLN

3

SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN

3

SOLU-MEDROL INTRAVENOUS RECON SOLN

3


Effective 4/1/16

110

Drug Name Tier NotesSOMATULINE DEPOT SUBCUTANEOUS SYRINGE

4

STIMATE NASAL SPRAY,NON-AEROSOL 3

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR

3 PA; QL

SUPPRELIN LA IMPLANT KIT 4 PA

SYNAREL NASAL SPRAY,NON-AEROSOL 4 PA

TESTIM TRANSDERMAL GEL 3 PA; QL

TESTONE CIK INTRAMUSCULAR KIT 3

TESTOPEL IMPLANT PELLET 3 PA

testosterone cypionate intramuscular oil

1

testosterone enanthate intramuscular oil

1

TESTOSTERONE TRANSDERMAL GEL 3 PA; QL

TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP

3 PA; QL

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

1 PA; QL

TESTOSTERONE TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)

3 PA; QL

TESTRED ORAL CAPSULE 3

triamcinolone acetonide injection suspension

1

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE

3

VAGIFEM VAGINAL TABLET 2

vasopressin injection solution 1

Drug Name Tier NotesVASOSTRICT INTRAVENOUS SOLUTION

3

veripred 20 oral solution 1

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY

3

VOGELXO TRANSDERMAL GEL 3 PA; QL

VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP

3 PA; QL

VOGELXO TRANSDERMAL GEL IN PACKET

3 PA; QL

ZOMACTON SUBCUTANEOUS RECON SOLN

4 PA

ZORBTIVE SUBCUTANEOUS RECON SOLN

4 PA

IMMUNOSUPPRESANT

ACTEMRA INTRAVENOUS SOLUTION

4 PA

ACTEMRA SUBCUTANEOUS SYRINGE

4 PA

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR

3 PA

AZASAN ORAL TABLET 2 PA

azathioprine oral tablet 1 PA

CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN

3 PA

CELLCEPT ORAL CAPSULE 2 PA

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION

2 PA

CELLCEPT ORAL TABLET 2 PA

cyclosporine intravenous solution

1 PA


Effective 4/1/16

111

Drug Name Tier Notescyclosporine modified oral capsule

1 PA

cyclosporine modified oral solution

1 PA

cyclosporine oral capsule 1 PA

ELIDEL TOPICAL CREAM 2 ST

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR

3 PA

gengraf oral capsule 1 PA

gengraf oral solution 1 PA

IMURAN ORAL TABLET 3 PA

mycophenolate mofetil oral capsule

1 PA

mycophenolate mofetil oral suspension for reconstitution

1 PA

mycophenolate mofetil oral tablet

1 PA

mycophenolate sodium oral tablet,delayed release (dr/ec)

1 PA

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC)

3 PA

NEORAL ORAL CAPSULE 2 PA

NEORAL ORAL SOLUTION 2 PA

NULOJIX INTRAVENOUS RECON SOLN

3 PA

PROGRAF INTRAVENOUS SOLUTION

2 PA

PROGRAF ORAL CAPSULE 2 PA

PROTOPIC TOPICAL OINTMENT 3 ST

RAPAMUNE ORAL SOLUTION 2 PA

RAPAMUNE ORAL TABLET 2 PA

SANDIMMUNE INTRAVENOUS SOLUTION

3 PA

Drug Name Tier NotesSANDIMMUNE ORAL CAPSULE 2 PA

SANDIMMUNE ORAL SOLUTION 2 PA

SIMULECT INTRAVENOUS RECON SOLN

3 PA

sirolimus oral tablet 1 PA

STELARA SUBCUTANEOUS SYRINGE

4 PA; QL

tacrolimus oral capsule 1 PA

tacrolimus topical ointment 1 ST

ZORTRESS ORAL TABLET 2 PA

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

1ST TIER UNILET COMFORTOUCH 2

ACCU-CHEK FASTCLIX 2

ACCU-CHEK FASTCLIX KIT 2

ACCU-CHEK MULTICLIX LANCET 2

ACCU-CHEK MULTICLIX LANCET KIT

2

ACCU-CHEK SAFE-T-PRO 2

ACCU-CHEK SAFE-T-PRO PLUS 2

ACCU-CHEK SOFT DEV LANCETS KIT 2

ACCU-CHEK SOFTCLIX LANCETS 2

acti-lance lancets 17 gauge, 28 gauge

1

ACTI-LANCE LANCETS23 GAUGE 2

ADVANCED LANCING DEVICE KIT 2

ADVANCED TRAVEL LANCETS 2

ADVOCATE LANCET 2


Effective 4/1/16

112

Drug Name Tier NotesALTERNATE SITE LANCET 2

ASSURE HAEMOLANCE PLUS 2

ASSURE LANCE 2

ASSURE LANCE PLUS 2

AUTOLET IMPRESSION LANC DEV KIT 2

BD MICROTAINER LANCET 2

BD ULTRA FINE LANCETS 2

BD ULTRA-FINE II LANCETS 2

BULLSEYE MINI SAFETY LANCETS 2

CAREONE THIN LANCET 2

CAREONE ULTRA THIN LANCET 2

CLEVER CHEK LANCETS 2

COAGUCHEK LANCETS 2

COLOR LANCETS 2

COMFORT LANCETS 2

DROPLET LANCETS 2

EASY COMFORT LANCETS 2

EASY TOUCH LANCETS 2

EASY TOUCH SAFETY LANCETS 2

EASY TOUCH TWIST LANCETS 2

EASY TWIST AND CAP LANCETS 2

EMBRACE LANCETS 2

e-z ject lancets 1

E-Z JECT THIN LANCETS 2

EZ SMART LANCETS 2

FIFTY50 SAFETY SEAL LANCETS 2

FINE 30 UNIVERSAL LANCETS 2

Drug Name Tier NotesFINGERSTIX LANCETS 2

FIRST CHOICE LANCETS THIN 2

FORA V10-V12-D10-D20 COMBO PACK 3

FORACARE LANCETS 2

FREESTYLE LANCETS 2

FREESTYLE UNISTIK 2 2

GLUCOCOM LANCETS 2

GLUCOLET 2 AUTOMATIC LANCING KIT

2

GMATE LANCETS 2

HEALTHY ACCENTS UNILET LANCET 2

HYPOLANCE AST LANCING KIT 2

INCONTROL SUPER THIN LANCETS 2

INCONTROL ULTRA THIN LANCETS 2

INJECT EASE LANCETS 2

INVACARE LANCETS 2

KINNEY BRAND LANCETS 2

LANCETS 2

LANCETS, SUPER THIN 2

LANCETS,THIN 2

LANCETS,ULTRA THIN 2

LANCING DEVICE WITH LANCETS KIT 2

LANZO LANCING DEVICE KIT 3

LITE TOUCH LANCETS 2

MEDISENSE THIN LANCETS 2

MEDLANCE PLUS LANCETS 2

MICRO THIN LANCETS 2

MICROLET 2 LANCING DEVICE KIT 2

MICROLET LANCET 2

MONOLET LANCETS 2


Effective 4/1/16

113

Drug Name Tier NotesMONOLET THIN LANCETS 2

MULTI-LANCET DEVICE 2 KIT 2

MYGLUCOHEALTH LANCETS 2

NOVA SAFETY LANCETS 2

NOVA SUREFLEX LANCETS 2

ON CALL LANCET 2

ON CALL PLUS LANCET 2

ONETOUCH DELICA LANC DEVICE KIT 2

ONETOUCH DELICA LANCETS 2

ONETOUCH SURESOFT LANCING DEV 2

ONETOUCH ULTRASOFT LANCETS 2

ON-THE-GO LANCETS 2

PRESSURE ACTIVATED LANCETS 2

PRODIGY LANCETS 2

PRODIGY TWIST TOP LANCET 2

RELIAMED LANCET 2

RELIAMED SAFETY SEAL LANCETS 2

RELION THIN LANCETS 2

RELION ULTRA THIN PLUS LANCETS 2

RIGHTEST GL300 LANCETS 2

SAFETY LANCETS 2

SAFETY SEAL LANCETS 2

SAFETY-LET LANCETS 2

SINGLE-LET 2

SMART SENSE LANCETS 2

SMARTEST LANCET 2

SOFT TOUCH LANCETS 2

SOLUS V2 LANCETS 2

Drug Name Tier NotesSOLUS V2 LANCING DEVICE KIT 2

STERILANCE TL 2

SUPER THIN LANCETS 2

SURE COMFORT LANCETS 2

SUREFLEX DEVICE WITH LANCETS KIT 2

SURE-LANCE 2

SURE-LANCE ULTRA THIN 2

SURE-TOUCH LANCET 2

TECHLITE LANCETS 2

TELCARE LANCETS 2

THIN LANCETS 2

TOPCARE UNIVERSAL1 LANCET 2

TRUEPLUS LANCETS 2

ULTI-LANCE KIT 2

ULTILET BASIC LANCETS 2

ULTILET CLASSIC LANCETS 2

ULTILET LANCETS 2

ULTILET SAFETY LANCETS 2

ULTRA THIN II LANCETS 2

ULTRA THIN LANCETS 2

ULTRA THIN PLUS LANCETS 2

ULTRA TLC LANCETS 2

ULTRALANCE LANCETS 2

ULTRA-THIN II LANCETS 2

UNILET COMFORTOUCH LANCET

2

UNILET EXCELITE II LANCET 2

UNILET EXCELITE LANCET 2


Effective 4/1/16

114

Drug Name Tier NotesUNILET GP LANCET 2

UNILET LANCET 2

UNILET LANCETS 2

UNILET SUPER THIN LANCETS 2

UNISTIK 2 DEVICE KIT 2

UNISTIK 2 NORMAL LANCET,DEVICE KIT 2

UNISTIK 3 COMFORT DEVICE KIT 2

UNISTIK 3 COMFORT LANCET 2

UNISTIK 3 EXTRA LANCET 2

UNISTIK 3 GENTLE 2

UNISTIK 3 KIT 2

UNISTIK 3 LANCETS 2

UNISTIK 3 NEONATAL DEVICE KIT 2

UNISTIK 3 NEONATAL KIT 2

UNISTIK 3 NORMAL LANCET 2

UNISTIK CZT LANCET 2

UNISTIK SAFETY 2

UNISTIK TOUCH LANCETS 2

UNIVERSAL 1 LANCETS 2

MUSCLE RELAXANTS

AMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR

3

baclofen oral tablet 1

carisoprodol oral tablet 1

carisoprodol-aspirin oral tablet

1

chlorzoxazone oral tablet 1

COMFORT PAC-CYCLOBENZAPRINE KIT

3

COMFORT PAC-TIZANIDINE KIT 3

cyclobenzaprine oral tablet 1

Drug Name Tier NotesDANTRIUM INTRAVENOUS RECON SOLN

3

DANTRIUM ORAL CAPSULE 3

dantrolene oral capsule 1

FEXMID ORAL TABLET 3

GABLOFEN INTRATHECAL SOLUTION

4

GABLOFEN INTRATHECAL SYRINGE

4

LIORESAL INTRATHECAL SOLUTION

3

LORZONE ORAL TABLET 3

metaxall oral tablet 1

metaxalone oral tablet 1

methocarbamol injection solution

1

methocarbamol oral tablet 1

orphenadrine citrate injection solution

1

orphenadrine citrate oral tablet extended release

1

PARAFON FORTE DSC ORAL TABLET 3 QL

revonto intravenous recon soln

1

ROBAXIN INJECTION SOLUTION 3 QL

ROBAXIN ORAL TABLET 3 QL

ROBAXIN-750 ORAL TABLET 3 QL

RYANODEX INTRAVENOUS SUSPENSION FOR RECONSTITUTION

3

SKELAXIN ORAL TABLET 3

SOMA ORAL TABLET 3

tizanidine oral capsule 1


Effective 4/1/16

115

Drug Name Tier Notestizanidine oral tablet 1

ZANAFLEX ORAL CAPSULE 3

ZANAFLEX ORAL TABLET 3

PRE-NATAL VITAMINS

ACTIVE OB ORAL CAPSULE 3

ATABEX EC ORAL TABLET,DELAYED RELEASE (DR/EC)

2

BAL-CARE DHA ESSENTIAL ORAL COMBO PACK,TABLET AND CAP,DR

3

bal-care dha oral combo pack,tablet and cap,dr

1

CADEAU DHA ORAL CAPSULE 3

calcium pnv oral capsule 1

CITRANATAL (DUAL-IRON) ORAL TABLET

3

CITRANATAL 90 DHA (ALGAL OIL) ORAL COMBO PACK

3

CITRANATAL ASSURE ORAL COMBO PACK 3

CITRANATAL B-CALM (FE GLUC) ORAL TABLETS, SEQUENTIAL

3

CITRANATAL DHA (ALGAL OIL) ORAL COMBO PACK

3

CITRANATAL HARMONY (IRON FUM) ORAL CAPSULE

3

c-nate dha oral capsule 1

complete natal dha oral combo pack

1

completenate oral tablet,chewable

1

CONCEPT DHA ORAL CAPSULE 3

CONCEPT OB ORAL CAPSULE 3

Drug Name Tier Notesdothelle dha oral capsule 1

DUET DHA BALANCED ORAL COMBO PACK 3

DUET DHA WITH OMEGA-3 ORAL COMBO PACK

3

elite-ob 400 oral capsule 1

elite-ob oral capsule 1

ENBRACE HR ORAL CAPSULE,IR - DELAY REL,BIPHASE

3

EXTRA-VIRT PLUS DHA ORAL CAPSULE 2

focalgin 90 dha oral combo pack

1

focalgin ca oral combo pack 1

folbecal oral tablet, er multiphase 24 hr

1

FOLET DHA ORAL COMBO PACK 3

FOLET ONE ORAL CAPSULE 3

folivane-ob oral capsule 1

hemenatal ob + dha oral combo pack

1

hemenatal ob oral tablet 1

inatal advance oral tablet 1

inatal ultra oral tablet 1

levomefolate dha oral capsule

1

macnatal cn dha oral capsule 1

MARNATAL-F ORAL CAPSULE 3

MAXINATE ORAL TABLET 3

M-VIT ORAL TABLET 3

mynatal advance oral tablet 1

mynatal oral capsule 1

mynatal oral tablet 1

mynatal plus oral tablet 1

mynatal-z oral tablet 1

mynate 90 plus oral tablet extended release

1


Effective 4/1/16

116

Drug Name Tier NotesNATACHEW (FE BIS-GLYCINATE) ORAL TABLET,CHEWABLE

3

NATALVIT ORAL TABLET 3

NATELLE ONE ORAL CAPSULE 3

NEEVODHA (WITH ALGAL OIL) ORAL CAPSULE

3

NESTABS ABC ORAL COMBO PACK 3

NESTABS DHA ORAL COMBO PACK 3

NESTABS ORAL TABLET 3

newgen oral tablet 1

NEXA PLUS ORAL CAPSULE 3

NIVA-PLUS ORAL TABLET 3

OB COMPLETE GOLD ORAL CAPSULE 3

OB COMPLETE ONE ORAL CAPSULE 3

OB COMPLETE ORAL TABLET 3

OB COMPLETE PETITE ORAL CAPSULE 3

OB COMPLETE PREMIER ORAL TABLET

3

OB COMPLETE WITH DHA ORAL CAPSULE 3

obstetrix dha oral combo pack,tablet and cap,dr

1

OBSTETRIX EC ORAL TABLET,DELAYED RELEASE (DR/EC)

3

OBTREX DHA ORAL COMBO PACK,TABLET AND CAP,DR

3

O-CAL FA ORAL TABLET 3

O-CAL PRENATAL ORAL TABLET 3

Drug Name Tier NotesPAIRE OB PLUS DHA ORAL COMBO PACK 3

pnv 29-1 oral tablet 1

pnv ob+dha oral combo pack 1

pnv-dha + docusate oral capsule

1

pnv-dha oral capsule 1

pnv-ferrous fumarate-docu-fa oral tablet

1

pnv-omega oral capsule 1

pnv-select oral tablet 1

pnv-vp-u oral capsule 1

pr natal 400 ec oral combo pack,tablet and cap,dr

1

pr natal 400 oral combo pack 1

pr natal 430 ec oral combo pack,tablet and cap,dr

1

pr natal 430 oral combo pack 1

PREFERA-OB ONE ORAL CAPSULE 3

PREFERA-OB ORAL TABLET 3

PREFERA-OB PLUS DHA ORAL COMBO PACK 3

prena1 chew oral tablet,chew,ir - dr,biphase

1

prena1 pearl oral capsule,ir - delay rel,biphase

1

prenaissance next oral tablet 1

prenaissance oral capsule 1

prenaissance plus oral capsule

1

PRENATA ORAL TABLET,CHEWABLE 3

prenatabs fa oral tablet 1

prenatabs rx oral tablet 1

PRENATAL 19 (WITH DOCUSATE) ORAL TABLET

3

PRENATAL 19 ORAL TABLET,CHEWABLE 3

prenatal low iron oral tablet 1


Effective 4/1/16

117

Drug Name Tier Notesprenatal plus (calcium carb) oral tablet

1

prenatal plus oral tablet 1

prenatal vitamin plus low iron oral tablet

1

prenatal-u oral capsule 1

PRENATE AM ORAL TABLET 3

PRENATE CHEWABLE ORAL TABLET,CHEWABLE

3

PRENATE DHA (FERR ASP GLYCIN) ORAL CAPSULE

3

PRENATE DHA ORAL CAPSULE 3

PRENATE ELITE (IRON ASP GLYC) ORAL TABLET

3

PRENATE ELITE ORAL TABLET 3

PRENATE ENHANCE ORAL CAPSULE 3

PRENATE ESSENTIAL ORAL CAPSULE 3

PRENATE ESSENTIAL(IRON-ASP-GL) ORAL CAPSULE

3

PRENATE MINI (FERR ASP GLYCIN) ORAL CAPSULE

3

PRENATE MINI ORAL CAPSULE 3

PRENATE PIXIE ORAL CAPSULE 3

PRENATE RESTORE ORAL CAPSULE 3

PRENATE STAR ORAL TABLET 3

preplus oral tablet 1

PREQUE 10 ORAL TABLET 3

pretab oral tablet 1

PROVIDA DHA ORAL CAPSULE 3

Drug Name Tier NotesPROVIDA OB ORAL CAPSULE 3

PUREFE OB PLUS ORAL CAPSULE 3

PUREFE PLUS ORAL CAPSULE 3

relnate dha oral capsule 1

R-NATAL OB ORAL CAPSULE 3 QL

rulavite dha oral capsule 1

SELECT-OB (FOLIC ACID) ORAL TABLET,CHEWABLE

3

SELECT-OB + DHA ORAL COMBO PACK 3

SELECT-OB ORAL TABLET,CHEWABLE 3

se-natal 19 (with docusate) oral tablet

1

se-natal 19 oral tablet,chewable

1

se-tan dha oral capsule 1

taron-c dha oral capsule 1

taron-prex prenatal-dha oral capsule

1

THRIVITE RX ORAL TABLET 3

thrivite-19 oral tablet 1

tl-select oral capsule 1

triadvance oral tablet 1 QL

TRICARE ORAL TABLET 3

TRICARE PRENATAL DHA ONE ORAL CAPSULE

3

trinatal gt oral tablet 1

trinatal rx 1 oral tablet 1

trinate oral tablet 1

TRISTART DHA ORAL CAPSULE 3

tri-tabs dha oral combo pack 1

triveen-duo dha oral combo pack

1

triveen-one oral capsule 1


Effective 4/1/16

118

Drug Name Tier Notestriveen-prx rnf oral capsule 1

trust natal dha oral combo pack

1

ultimatecare one nf oral capsule

1

ultimatecare one oral capsule 1

vemavite-prx-2 oral capsule 1

vena-bal dha oral combo pack,tablet and cap,dr

1

vinacal oral tablet 1

vinate care oral tablet,chewable

1

vinate dha oral capsule 1

VINATE DHA RF ORAL CAPSULE 3

vinate gt oral tablet 1

vinate ii oral tablet 1

vinate m oral tablet 1

vinate one oral tablet 1

vinate pn care oral tablet 1

vinate ultra oral tablet 1

virt nate oral tablet 1

virt-advance oral tablet 1

virt-c dha oral capsule 1

virt-care one oral capsule 1

virt-nate dha oral capsule 1

virt-nate oral tablet 1

virt-pn dha oral capsule 1

virt-pn oral tablet 1

virt-pn plus oral capsule 1

VIRTPREX ORAL CAPSULE 3

virt-select oral capsule 1

virt-vite gt oral tablet 1

VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE

3

VITAFOL GUMMIES ORAL TABLET,CHEWABLE

3

VITAFOL NANO ORAL TABLET 3

Drug Name Tier NotesVITAFOL ULTRA ORAL CAPSULE 3

vitafol-ob oral tablet 1

VITAFOL-OB+DHA ORAL COMBO PACK 3

VITAFOL-ONE ORAL CAPSULE 3

VITAMED MD ONE RX ORAL CAPSULE 3

VITAMED MD PLUS RX ORAL COMBO PACK 3

VITAMEDMD REDICHEW RX ORAL TABLET,CHEW,IR - DR,BIPHASE

3

VITAPEARL ORAL CAPSULE,IR - DELAY REL,BIPHASE

3

VITATRUE ORAL COMBO PACK 3

VIVA DHA ORAL CAPSULE 3

vol-nate oral tablet 1

vol-plus oral tablet 1

vol-tab rx oral tablet 1

vp-ch plus oral capsule 1

vp-ch-pnv oral capsule 1

vp-ggr-b6 oral tablet 1

vp-heme ob + dha oral combo pack

1

vp-heme ob oral tablet 1

vp-heme one oral capsule 1

VP-PNV-DHA ORAL CAPSULE 3

zatean-ch oral capsule 1

zatean-pn dha oral capsule 1

zatean-pn plus oral capsule 1

zingiber oral tablet 1

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

3


Effective 4/1/16

119

Drug Name Tier NotesABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

3

ABILIFY ORAL TABLET 3

ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED

3

ADDYI ORAL TABLET 3 PA; QL

alprazolam intensol oral concentrate

1

alprazolam oral tablet 1

alprazolam oral tablet extended release 24 hr

1

alprazolam oral tablet,disintegrating

1

amitriptyline oral tablet 1

amitriptyline-chlordiazepoxide oral tablet

1

amoxapine oral tablet 1

ANAFRANIL ORAL CAPSULE 3

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG

3 DO

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 348 MG, 522 MG

3 QL

APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60

3 ST

aripiprazole oral solution 1 PA

aripiprazole oral tablet 1 PA

aripiprazole oral tablet,disintegrating

1 PA

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

3

ATIVAN ORAL TABLET 3

BRINTELLIX ORAL TABLET 10 MG, 5 MG 3 ST; DO

BRINTELLIX ORAL TABLET 20 MG 3 ST; QL

Drug Name Tier NotesBRISDELLE ORAL CAPSULE 3

bupropion hcl oral tablet 100 mg

1 QL

bupropion hcl oral tablet 75 mg

1 DO

bupropion hcl oral tablet extended release 100 mg

1 DO


1 QL


1

bupropion hcl oral tablet extended release 24 hr 150 mg

1 DO

bupropion hcl oral tablet extended release 24 hr 300 mg

1 QL

buspirone oral tablet 1

CELEXA ORAL TABLET10 MG, 20 MG 3 ST; DO

CELEXA ORAL TABLET40 MG 3 ST; QL

chlordiazepoxide hcl oral capsule

1

chlorpromazine injection solution

1

chlorpromazine oral tablet 1 PA

citalopram oral solution 1 QL

citalopram oral tablet 10 mg, 20 mg

1 DO

citalopram oral tablet 40 mg 1 QL

clomipramine oral capsule 1

clonidine hcl oral tablet extended release 12 hr

1

clorazepate dipotassium oral tablet

1

clozapine oral tablet 1 PA

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

1 PA

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

3 PA


Effective 4/1/16

120

Drug Name Tier NotesCLOZARIL ORAL TABLET 2 PA

CONCERTA ORAL TABLET EXTENDED RELEASE 24HR

3 ST

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 60 MG

3 QL

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 30 MG

3 DO

DAYTRANA TRANSDERMAL PATCH 24 HOUR

3 ST; QL

desipramine oral tablet 1

DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR

3

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

3 QL

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG

3 DO

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG

3 QL

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG

3 DO

dexmethylphenidate oral capsule,er biphasic 50-50

1 PA

dexmethylphenidate oral tablet

1 PA

diazepam injection solution 1

diazepam injection syringe 1

diazepam intensol oral concentrate

1

diazepam oral concentrate 1

diazepam oral solution 1

diazepam oral tablet 1

Drug Name Tier Notesdoxepin oral capsule 1

doxepin oral concentrate 1

droperidol injection solution 1

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg

1 QL

duloxetine oral capsule,delayed release(dr/ec) 30 mg

1 DO

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG

3 QL

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 37.5 MG, 75 MG

3 DO

EMSAM TRANSDERMAL PATCH 24 HOUR

3

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR

3

escitalopram oxalate oral solution

1 QL

escitalopram oxalate oral tablet 10 mg, 5 mg

1 DO

escitalopram oxalate oral tablet 20 mg

1 QL

FANAPT ORAL TABLET 3 PA

FANAPT ORAL TABLETS,DOSE PACK 3 PA

FAZACLO ORAL TABLET,DISINTEGRATING

2 PA

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

3 QL

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

3 QL

fluoxetine oral capsule 10 mg, 20 mg

1 DO

fluoxetine oral capsule 40 mg 1 QL


Effective 4/1/16

121

Drug Name Tier Notesfluoxetine oral capsule,delayed release(dr/ec)

1 QL

fluoxetine oral solution 1 QL

fluoxetine oral tablet 10 mg 1 DO

fluoxetine oral tablet 20 mg 1

FLUOXETINE ORAL TABLET 60 MG 3 QL

fluphenazine decanoate injection solution

1 PA

fluphenazine hcl injection solution

1 PA

fluphenazine hcl oral concentrate

1 PA

fluphenazine hcl oral elixir 1 PA

fluphenazine hcl oral tablet 1 PA

fluvoxamine oral capsule,extended release 24hr

1 QL

fluvoxamine oral tablet 100 mg

1 QL

fluvoxamine oral tablet 25 mg, 50 mg

1 DO

FOCALIN ORAL TABLET 3 ST

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50

3 ST

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR

3 QL

GEODON INTRAMUSCULAR RECON SOLN

2 PA

GEODON ORAL CAPSULE 3 PA

guanfacine oral tablet extended release 24 hr

1

HALDOL DECANOATE INTRAMUSCULAR SOLUTION

3 PA

HALDOL INJECTION SOLUTION 3 PA

haloperidol decanoate intramuscular solution

1 PA

Drug Name Tier Noteshaloperidol lactate injection solution

1 PA

haloperidol lactate oral concentrate

1 PA

haloperidol oral tablet 1 PA

imipramine hcl oral tablet 1

imipramine pamoate oral capsule

1

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR

3

INVEGA ORAL TABLET EXTENDED RELEASE 24HR

3 PA

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

3 PA

INVEGA TRINZA INTRAMUSCULAR SYRINGE

3 PA

IRENKA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3 QL

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR

3

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG

3 QL

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG

3 DO

LATUDA ORAL TABLET 3 PA

LEXAPRO ORAL SOLUTION 3 ST; QL

LEXAPRO ORAL TABLET 10 MG, 5 MG 3 ST; DO

LEXAPRO ORAL TABLET 20 MG 3 ST; QL

lithium carbonate oral capsule

1

lithium carbonate oral tablet 1

lithium carbonate oral tablet extended release

1

lithium citrate oral solution 1


Effective 4/1/16

122

Drug Name Tier NotesLITHOBID ORAL TABLET EXTENDED RELEASE

2

lorazepam intensol oral concentrate

1

lorazepam oral concentrate 1

lorazepam oral tablet 1

loxapine succinate oral capsule

1 PA

maprotiline oral tablet 1

MARPLAN ORAL TABLET 3

meprobamate oral tablet 1

METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70

3

metadate er oral tablet extended release

1

METHYLIN ORAL SOLUTION 3 ST

METHYLIN ORAL TABLET,CHEWABLE 3 ST

methylphenidate oral capsule, er biphasic 30-70

1 PA

methylphenidate oral capsule,er biphasic 50-50

1 PA

methylphenidate oral solution

1 PA

methylphenidate oral tablet 1 PA

methylphenidate oral tablet extended release

1 PA

methylphenidate oral tablet extended release 24hr

1 PA

methylphenidate oral tablet,chewable

1 PA

mirtazapine oral tablet 1

mirtazapine oral tablet,disintegrating

1

modafinil oral tablet 100 mg 1 PA; DO

modafinil oral tablet 200 mg 1 PA; QL

molindone oral tablet 1 PA

NARDIL ORAL TABLET 3

nefazodone oral tablet 1

Drug Name Tier NotesNORPRAMIN ORAL TABLET 3

nortriptyline oral capsule 1

nortriptyline oral solution 1

NUVIGIL ORAL TABLET150 MG, 250 MG, 50 MG 3 PA; QL

NUVIGIL ORAL TABLET200 MG 3 PA

olanzapine intramuscular recon soln

1 PA

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg

1

olanzapine oral tablet 20 mg 1 PA

olanzapine oral tablet,disintegrating 10 mg, 20 mg

1

olanzapine oral tablet,disintegrating 15 mg, 5 mg

1 PA

olanzapine-fluoxetine oral capsule

1 PA

OLEPTRO ER ORAL TABLET EXTENDED RELEASE 24 HR

3

ORAP ORAL TABLET 3 PA

oxazepam oral capsule 1

paliperidone oral tablet extended release 24hr

1 PA

PAMELOR ORAL CAPSULE 3

PARNATE ORAL TABLET 3

paroxetine hcl oral tablet 10 mg, 20 mg

1 DO

paroxetine hcl oral tablet 30 mg, 40 mg

1 QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

1 DO

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

1 QL

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG

3 ST; DO


Effective 4/1/16

123

Drug Name Tier NotesPAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 37.5 MG

3 ST; QL

PAXIL ORAL SUSPENSION 3 ST; QL

PAXIL ORAL TABLET 10 MG, 20 MG 3 ST; DO

PAXIL ORAL TABLET 30 MG, 40 MG 3 ST; QL

perphenazine oral tablet 1

perphenazine-amitriptyline oral tablet

1

PEXEVA ORAL TABLET10 MG, 20 MG 3 ST; DO

PEXEVA ORAL TABLET30 MG, 40 MG 3 ST; QL

phenelzine oral tablet 1

pimozide oral tablet 1 PA

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG

2 QL

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG

2 DO

protriptyline oral tablet 1

PROVIGIL ORAL TABLET 100 MG 3 PA; DO

PROVIGIL ORAL TABLET 200 MG 3 PA; QL

PROZAC ORAL CAPSULE 10 MG, 20 MG 3 ST; DO

PROZAC ORAL CAPSULE 40 MG 3 ST; QL

PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3 ST; QL

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg

1

quetiapine oral tablet 400 mg, 50 mg

1 PA

QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR

3 ST

Drug Name Tier NotesQUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON

3 ST

REMERON ORAL TABLET 15 MG 3 QL

REMERON ORAL TABLET 30 MG, 45 MG 3

REMERON SOLTAB ORAL TABLET,DISINTEGRATING 15 MG

3 QL

REMERON SOLTAB ORAL TABLET,DISINTEGRATING 30 MG, 45 MG

3

REXULTI ORAL TABLET 3 PA

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE

2 PA

RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING

3 PA

RISPERDAL ORAL SOLUTION 3 PA

RISPERDAL ORAL TABLET 3 PA

risperidone oral solution 1 PA

risperidone oral tablet 1 PA

risperidone oral tablet,disintegrating

1 PA

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 60 MG

3 ST

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 20 MG, 30 MG, 40 MG

3

RITALIN ORAL TABLET 3

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

3 PA

SARAFEM ORAL TABLET 10 MG 3 DO

SARAFEM ORAL TABLET 20 MG 3


Effective 4/1/16

124

Drug Name Tier NotesSEROQUEL ORAL TABLET 3 PA

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

2 PA

sertraline oral concentrate 1 QL

sertraline oral tablet 100 mg 1 QL

sertraline oral tablet 25 mg, 50 mg

1 DO

STRATTERA ORAL CAPSULE 2

SURMONTIL ORAL CAPSULE 3

SYMBYAX ORAL CAPSULE 3 PA

thioridazine oral tablet 1

thiothixene oral capsule 1

TOFRANIL ORAL TABLET 3

TRANXENE T-TAB ORAL TABLET 3

tranylcypromine oral tablet 1

trazodone oral tablet 1

trifluoperazine oral tablet 1

trimipramine oral capsule 1

VALIUM ORAL TABLET 3

venlafaxine oral capsule,extended release 24hr 150 mg

1 QL

venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg

1 DO

venlafaxine oral tablet 1 QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 150 MG, 225 MG

3 QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 37.5 MG, 75 MG

3 DO

VERSACLOZ ORAL SUSPENSION 3 PA

VIIBRYD ORAL TABLET10 MG, 20 MG 3 ST; DO

Drug Name Tier NotesVIIBRYD ORAL TABLET40 MG 3 ST; QL

VIIBRYD ORAL TABLETS,DOSE PACK 3 ST; QL

VRAYLAR ORAL CAPSULE 3 PA

VRAYLAR ORAL CAPSULE,DOSE PACK 3 PA

VYVANSE ORAL CAPSULE 2 PA

WELLBUTRIN ORAL TABLET 3 QL

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 100 MG

3 DO

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 150 MG, 200 MG

3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG

3 DO

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 300 MG

3 QL

XANAX ORAL TABLET 3

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR

3

ziprasidone hcl oral capsule 1 PA

ZOLOFT ORAL CONCENTRATE 3 ST; QL

ZOLOFT ORAL TABLET100 MG 3 ST; QL

ZOLOFT ORAL TABLET25 MG, 50 MG 3 ST; DO

ZYPREXA INTRAMUSCULAR RECON SOLN

3 PA

ZYPREXA ORAL TABLET 10 MG, 2.5 MG, 20 MG, 7.5 MG

3

ZYPREXA ORAL TABLET 15 MG, 5 MG 3 PA


Effective 4/1/16

125

Drug Name Tier NotesZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

3 PA

ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING

3

SEDATIVE/HYPNOTICS

AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE

3 ST; QL

AMBIEN ORAL TABLET 3 ST; QL

AMYTAL INJECTION RECON SOLN 3

ATIVAN INJECTION SOLUTION 3

BELSOMRA ORAL TABLET 3 ST; QL

BUTISOL ORAL TABLET 3

dexmedetomidine intravenous solution

1

EDLUAR SUBLINGUAL TABLET 3 ST; QL

estazolam oral tablet 1

eszopiclone oral tablet 1 mg, 2 mg

1 QL

eszopiclone oral tablet 3 mg 1 PA; QL

flurazepam oral capsule 1

HALCION ORAL TABLET 3

HETLIOZ ORAL CAPSULE 4 PA; QL

INTERMEZZO SUBLINGUAL TABLET 3 ST; QL

lorazepam injection solution 1

lorazepam injection syringe 1

LUNESTA ORAL TABLET 3 ST; QL

midazolam oral syrup 1

NEMBUTAL SODIUM INJECTION SOLUTION 3

phenobarbital oral elixir 1

phenobarbital oral tablet 1

Drug Name Tier Notesphenobarbital sodium injection solution

1

PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION

3

PRECEDEX INTRAVENOUS SOLUTION

3

RESTORIL ORAL CAPSULE 3

ROZEREM ORAL TABLET 3 ST; QL

seconal sodium oral capsule 1

SILENOR ORAL TABLET 3 ST; QL

SONATA ORAL CAPSULE 3 ST; QL

temazepam oral capsule 1

triazolam oral tablet 1

XYREM ORAL SOLUTION 3 PA; QL

zaleplon oral capsule 1 ST; QL

zolpidem oral tablet 1 QL

zolpidem oral tablet,ext release multiphase

1 ST; QL

zolpidem sublingual tablet 1 ST; QL

ZOLPIMIST ORAL SPRAY,NON-AEROSOL 3 ST; QL

SKIN PREPS

8-MOP ORAL CAPSULE 2

ABSORICA ORAL CAPSULE 3 PA; QL

ACANYA TOPICAL GEL 2

acetic acid irrigation solution 1

acitretin oral capsule 1

ACLARO TOPICAL EMULSION 3

ACZONE TOPICAL GEL 3

adapalene topical cream 1 PA

adapalene topical gel 1 PA

adapalene topical gel with pump

1


Effective 4/1/16

126

Drug Name Tier NotesADAPALENE TOPICAL LOTION 3 PA

ADVANCED ALLERGY COLLECT KIT TOPICAL KIT

3 ST

ala-cort topical cream 1

ALA-QUIN TOPICAL CREAM 3

ALA-SCALP TOPICAL LOTION 3 ST

alclometasone topical cream 1

alclometasone topical ointment

1

ALCORTIN A TOPICAL GEL 3

ALCORTIN A TOPICAL GEL IN PACKET 3

ALDARA TOPICAL CREAM IN PACKET 3 PA; QL

ALEVICYN ANTIPRURITIC SG TOPICAL SPRAY GEL

3

ALEVICYN ANTIPRURITIC TOPICAL GEL

3

ALEVICYN DERMAL TOPICAL SPRAY,NON-AEROSOL

3

ALOQUIN TOPICAL GEL 3

alphaquin hp topical cream 1

ALTABAX TOPICAL OINTMENT 2

aluminum acetate topical solution

1

ALUVEA TOPICAL CREAM 3

amcinonide topical cream 3 ST

amcinonide topical lotion 3 ST

amcinonide topical ointment 3 ST

ammonium lactate topical cream

1

ammonium lactate topical lotion

1

Drug Name Tier NotesAMPHADASE INJECTION SOLUTION 3

ANALPRAM-HC TOPICAL LOTION 3

apexicon e topical cream 3 ST

AQUA GLYCOLIC HC TOPICAL COMBO PACK 3 ST

ARTISS TOPICAL SYRINGE 3

ATOPICLAIR TOPICAL CREAM 3

ATRALIN TOPICAL GEL 3 PA

ATRAPRO CP TOPICAL COMBO PACK,CREAM AND GEL

3

ATRAPRO DERMAL SPRAY TOPICAL SPRAY,NON-AEROSOL

3

ATRAPRO HYDROGEL TOPICAL GEL 3

AVAGE TOPICAL CREAM 3 PA

avita topical cream 1 PA

AVITA TOPICAL GEL 3 PA

avo cream topical emulsion 1

AZELEX TOPICAL CREAM 3 PA

BEAU RX TOPICAL GEL 3

BENSAL HP TOPICAL OINTMENT 3

BENZACLIN PUMP TOPICAL GEL 3 ST

BENZACLIN TOPICAL GEL 3 ST

BENZEFOAM TOPICAL FOAM 3 PA

BENZEFOAM ULTRA TOPICAL FOAM 3 PA

BENZEPRO (MICROSPHERES) TOPICAL CLEANSER

3 PA

benzepro topical towelette 1 PA

benzoyl peroxide topical cleanser 6 %, 7 %

1 PA


Effective 4/1/16

127

Drug Name Tier Notesbenzoyl peroxide topical cleanser 9 %

1

benzoyl peroxide topical foam

1 PA

betamethasone dipropionate topical cream

3 ST

betamethasone dipropionate topical lotion

3 ST

betamethasone dipropionate topical ointment

3 ST

betamethasone valerate topical cream

3 ST

betamethasone valerate topical foam

3 ST

betamethasone valerate topical lotion

3 ST

betamethasone valerate topical ointment

3 ST

betamethasone, augmented topical cream

1

betamethasone, augmented topical gel

1 ST

betamethasone, augmented topical lotion

1 ST

betamethasone, augmented topical ointment

1

BIAFINE EMULSION TOPICAL EMULSION 3

BIONECT TOPICAL CREAM 3

BIONECT TOPICAL FOAM 3

BIONECT TOPICAL GEL 3

blanche topical cream 1

bp-50% urea topical emulsion

1

bpo topical gel 1 PA

bpo topical towelette 1 PA

calcipotriene scalp solution 1

calcipotriene topical cream 1

calcipotriene topical ointment

1

calcipotriene-betamethasone topical ointment

1

Drug Name Tier Notescalcitrene topical ointment 1

calcitriol topical ointment 1

CAPEX TOPICAL SHAMPOO 3 ST

celacyn topical gel with pump

1

cem-urea topical gel 1

CERAMAX TOPICAL CREAM 3

claravis oral capsule 2 PA; QL

clindamycin-benzoyl peroxide topical gel

1

clobetasol scalp solution 1

clobetasol topical cream 1

clobetasol topical foam 1

clobetasol topical gel 1

clobetasol topical lotion 1

clobetasol topical ointment 1

clobetasol topical shampoo 1

clobetasol topical spray,non-aerosol

1

clobetasol-emollient topical cream

1

clobetasol-emollient topical foam

1

CLOBEX TOPICAL LOTION 3 ST

CLOBEX TOPICAL SHAMPOO 3 ST

CLOBEX TOPICAL SPRAY,NON-AEROSOL 3 ST

CLOCORTOLONE PIVALATE TOPICAL CREAM

3 ST

CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER

3 ST

clodan topical shampoo 1

CLODERM TOPICAL CREAM 3 ST

COAL TAR TOPICAL SOLUTION 3

CONDYLOX TOPICAL GEL 3


Effective 4/1/16

128

Drug Name Tier NotesCONDYLOX TOPICAL SOLUTION 3

CORDRAN TAPE LARGE ROLL TOPICAL TAPE 3 ST

CORDRAN TAPE SMALL ROLL TOPICAL TAPE 3 ST

CORDRAN TOPICAL CREAM 3 ST

CORDRAN TOPICAL LOTION 3 ST

CORDRAN TOPICAL OINTMENT 3 ST

cormax scalp solution 1

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

4 PA; QL

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

4 PA; QL

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

4 PA; QL

COSENTYX SUBCUTANEOUS SYRINGE

4 PA; QL

CUTIVATE TOPICAL CREAM 3 ST

CUTIVATE TOPICAL LOTION 3 ST

DERMA-SMOOTHE/FS BODY OIL TOPICAL OIL 3 ST

DERMA-SMOOTHE/FS SCALP OIL SCALP OIL 3 ST

DERMASORB AF COMPLETE KIT TOPICAL CREAM

3

DERMASORB HC COMPLETE KIT TOPICAL COMBO PACK,CLEANSER AND LOTION

3 ST

DERMASORB TA COMPLETE KIT TOPICAL CREAM

3 ST

Drug Name Tier NotesDERMASORB XM COMPLETE KIT TOPICAL CREAM

3

DERMATOP TOPICAL CREAM 3 ST

DERMATOP TOPICAL OINTMENT 3 ST

DERMAWERX SDS TOPICAL KIT 3 ST

dermazene topical cream 1

DESONATE TOPICAL GEL 3 ST

desonide topical cream 3 ST

desonide topical lotion 3 ST

desonide topical ointment 3 ST

DESOWEN TOPICAL CREAM 3 ST

DESOWEN TOPICAL LOTION 3 ST

desoximetasone topical cream

3 ST

desoximetasone topical gel 3 ST

desoximetasone topical ointment

3 ST

diclofenac sodium topical drops

1

diclofenac sodium topical gel 1

DICLOTRAL TOPICAL COMBO PACK,SOLUTION AND CREAM

3

DIFFERIN TOPICAL CREAM 3 PA

DIFFERIN TOPICAL GEL 3 PA

DIFFERIN TOPICAL GEL WITH PUMP 3 PA

DIFFERIN TOPICAL LOTION 3 PA

diflorasone topical cream 3 ST

diflorasone topical ointment 3 ST

DIPROLENE AF TOPICAL CREAM 3 ST


Effective 4/1/16

129

Drug Name Tier NotesDIPROLENE TOPICAL LOTION 3 ST

DIPROLENE TOPICAL OINTMENT 3 ST

DOVONEX TOPICAL CREAM 3

doxepin topical cream 1

drithocreme hp topical cream 1

DRYSOL DAB-O-MATIC TOPICAL SOLUTION 3

DRYSOL TOPICAL SOLUTION 3

DUAC TOPICAL GEL 3

eletone topical cream 1

ELIMITE TOPICAL CREAM 3

ELOCON TOPICAL CREAM 3 ST

ELOCON TOPICAL OINTMENT 3 ST

ELOCON TOPICAL SOLUTION 3 ST

emulsion sb topical emulsion 1

ENSTILAR TOPICAL FOAM 3

EPICERAM TOPICAL EMULSION, EXTENDED RELEASE

3

EPIDUO FORTE TOPICAL GEL WITH PUMP

3 PA

EPIDUO TOPICAL GEL 3 PA

EPIDUO TOPICAL GEL WITH PUMP 3 PA

EPIFOAM TOPICAL FOAM 3

EURAX TOPICAL CREAM 3

EURAX TOPICAL LOTION 3

FABIOR TOPICAL FOAM 3 PA

FINACEA TOPICAL FOAM 2 PA

Drug Name Tier NotesFINACEA TOPICAL GEL 2 PA

FLECTOR TRANSDERMAL PATCH 12 HOUR

3 ST

fluocinolone and shower cap scalp oil

3 ST

fluocinolone topical cream 3 ST

fluocinolone topical oil 3 ST

fluocinolone topical ointment 3 ST

fluocinolone topical solution 3 ST

fluocinonide topical cream 1

fluocinonide topical gel 1 ST

fluocinonide topical ointment 1

fluocinonide topical solution 1

fluocinonide-e topical cream 1

fluticasone topical cream 3 ST

fluticasone topical lotion 3 ST

fluticasone topical ointment 3 ST

forma-ray solution 1

GENADUR (WITH LEXINAL) KIT 3

GENADUR TOPICAL LIQUID 3

GORDONS UREA TOPICAL OINTMENT 3

GUAIACOL LIQUID 3

halobetasol propionate topical cream

1

halobetasol propionate topical ointment

1

HALOG TOPICAL CREAM 3 ST

HALOG TOPICAL OINTMENT 3 ST

hpr plus hydrogel topical kit,cream and gel

1

hpr plus topical cream 1

hpr plus topical foam 1

HPR PLUS-MB HYDROGEL TOPICAL COMBO PACK,GEL AND FOAM

3

hpr topical foam 1


Effective 4/1/16

130

Drug Name Tier NotesHYDRO 35 TOPICAL FOAM 3

HYDRO 40 TOPICAL FOAM 3

hydrocortisone butyrate topical cream

3 ST

hydrocortisone butyrate topical ointment

3 ST

hydrocortisone butyrate topical solution

3 ST

hydrocortisone butyr-emollient topical cream

3 ST

hydrocortisone topical cream 1

hydrocortisone topical lotion 1

hydrocortisone topical ointment

1

hydrocortisone valerate topical cream

3 ST

hydrocortisone valerate topical ointment

3 ST

hydrocortisone-iodoquinol-aloe topical cream in packet

1

hydrocortisone-min oil-wht pet topical ointment

1

hydrocortisone-pramoxine topical cream

1

hydroquinone microspheres topical cream,extended release

1

hydroquinone topical cream 1

HYGEL TOPICAL GEL 3

HYLATOPIC PLUS TOPICAL CREAM 3

HYLATOPIC PLUS TOPICAL FOAM 3

HYLATOPIC TOPICAL FOAM 3

imiquimod topical cream in packet

1 PA; QL

INOVA 4-1 TOPICAL COMBO PACK 3

INOVA 8-2 TOPICAL COMBO PACK 3

INOVA TOPICAL COMBO PACK 3

Drug Name Tier NotesIODOFLEX TOPICAL PADS, MEDICATED 3

iodoquinol-hc topical cream 1

IODOSORB TOPICAL GEL 3

KENALOG TOPICAL AEROSOL 3 ST

KERAFOAM TOPICAL FOAM 3

KERALAC TOPICAL CREAM 3

KERALYT RX TOPICAL GEL 3

KERALYT SCALP COMPLETE TOPICAL KIT,SHAMPOO AND GEL

3

KLARON TOPICAL SUSPENSION 3

klofensaid ii topical drops 1

lactated ringers irrigation solution

1

lactic acid e topical cream 1

lactic acid topical lotion 1

LATISSE BASE OF THE EYELASHES DROPS WITH APPLICATOR

3

latrix topical suspension 1

lidocaine hcl-hydrocortison ac topical cream

1

lindane topical shampoo 1

LOCOID LIPOCREAM TOPICAL CREAM 3 ST

LOCOID TOPICAL CREAM 3 ST

LOCOID TOPICAL LOTION 3 ST

LOCOID TOPICAL OINTMENT 3 ST

LOCOID TOPICAL SOLUTION 3 ST

LOUTREX TOPICAL CREAM 3

lugols topical solution 1


Effective 4/1/16

131

Drug Name Tier Notesluxamend topical emulsion 1

LUXIQ TOPICAL FOAM 3 ST

LYCELLE TOPICAL GEL 3

malathion topical lotion 1

mb hydrogel (cyclomethicone) topical kit,cream and gel

1

mb hydrogel topical kit,cream and gel

1

melpaque hp topical cream 1

melquin 3 topical solution 1

methoxsalen rapid oral capsule

1

methyl salicylate topical liquid

1

METROCREAM TOPICAL CREAM 3

METROGEL TOPICAL GEL 3

METROGEL TOPICAL GEL WITH PUMP 3

METROLOTION TOPICAL LOTION 3

metronidazole topical cream 1

metronidazole topical gel 1

metronidazole topical gel with pump

1

metronidazole topical lotion 1

MICROCYN HYDROGEL TOPICAL GEL 3

MICROCYN TOPICAL SPRAY,NON-AEROSOL 3

MIRVASO TOPICAL GEL 3

mometasone topical cream 1

mometasone topical ointment 1

mometasone topical solution 1

myorisan oral capsule 2 PA; QL

NATROBA TOPICAL SUSPENSION 3

neomycin-polymyxin b gu irrigation solution

1

Drug Name Tier NotesNEOSALUS TOPICAL CREAM 3

NEOSALUS TOPICAL FOAM 3

NEOSALUS TOPICAL LOTION 3

NEOSPORIN GU IRRIGANT IRRIGATION SOLUTION

3

NEUAC KIT TOPICAL COMBO PACK,CREAM AND GEL

3 ST

neuac topical gel 1

nivatopic plus topical cream 1

NORITATE TOPICAL CREAM 3 PA

NOVACORT TOPICAL GEL 3

NUOX TOPICAL GEL 3

NUVAIL TOPICAL NAIL FILM SOLUTION 3

OLUX TOPICAL FOAM 3 ST

OLUX-E TOPICAL FOAM 3 ST

ONEXTON TOPICAL GEL 2

OVACE PLUS SHAMPOO TOPICAL SHAMPOO 3

OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE

3

OVACE PLUS TOPICAL CREAM 3

OVACE PLUS TOPICAL FOAM 3

OVACE PLUS TOPICAL LOTION 3

OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE

3

OVACE TOPICAL CLEANSER 3

OVIDE TOPICAL LOTION 3


Effective 4/1/16

132

Drug Name Tier NotesOXSORALEN TOPICAL LOTION 3

OXSORALEN ULTRA ORAL CAPSULE 3

PACNEX HP TOPICAL PADS, MEDICATED 3 PA

PACNEX LP TOPICAL PADS, MEDICATED 3 PA

PACNEX MX TOPICAL CLEANSER 3 PA

PACNEX TOPICAL CLEANSER 3 PA

PANDEL TOPICAL CREAM 3 ST

PEDIADERM HC TOPICAL KIT,LOTION AND CREAM,EMOLLIENT

3 ST

PEDIADERM TA TOPICAL CREAM 3 ST

PEDIAPALM TOPICAL SPRAY,NON-AEROSOL 3

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP

3 ST

permethrin topical cream 1

PHENOL LIQUID 3

PHYSIOLYTE IRRIGATION SOLUTION 3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

3

PODOCON TOPICAL LIQUID 3

podofilox topical solution 1

POTASSIUM HYDROXIDE TOPICAL SOLUTION

3

PR BENZOYL PEROXIDE TOPICAL CLEANSER

3 PA

pr cream topical cream 1

PRAMOSONE E TOPICAL CREAM 3

PRAMOSONE TOPICAL CREAM 1-1 % 2

Drug Name Tier NotesPRAMOSONE TOPICAL CREAM 2.5-1 % 3

PRAMOSONE TOPICAL LOTION 2

PRAMOSONE TOPICAL OINTMENT 2

prednicarbate topical cream 3 ST

prednicarbate topical ointment

3 ST

PRESERA TOPICAL FOAM 3

PROMISEB COMPLETE TOPICAL KIT,CLEANSER AND CREAM

3

PROMISEB TOPICAL CREAM 3

pruclair topical cream 1

prudoxin topical cream 1

prumyx topical cream 1

prutect topical emulsion 1

PSORCON TOPICAL CREAM 3 ST

PYROGALLIC ACID TOPICAL OINTMENT 3

QUTENZA TOPICAL KIT 2

RADIAPLEXRX TOPICAL GEL 3

rea lo 39 topical cream 1

rea lo 40 topical cream 1

rea lo 40 topical lotion 1

recedo topical gel 1

refissa topical cream 1 PA

REGRANEX TOPICAL GEL 3

remeven topical cream 1

RENOVA TOPICAL CREAM 3 PA

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP

3 PA

RETIN-A MICRO TOPICAL GEL 3 PA


Effective 4/1/16

133

Drug Name Tier NotesRETIN-A TOPICAL CREAM 3 PA

RETIN-A TOPICAL GEL 3 PA

ringers irrigation solution 1

rosadan topical cream 1

rosadan topical gel 1

ROSADAN TOPICAL KIT, CLEANSER AND GEL

3

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

3

salacyn topical cream 1

salacyn topical lotion 1

SALEX TOPICAL COMBO PACK 3

SALEX TOPICAL KIT,CLEANSER AND CREAM ER

3

SALEX TOPICAL SHAMPOO 3

salicylic acid er-ceramides topical combo pack

1

salicylic acid er-ceramides topical kit,cleanser and cream er

1

salicylic acid topical cream 1

salicylic acid topical cream,extended release

1

salicylic acid topical film forming liquid w/appl

1

salicylic acid topical foam 1

salicylic acid topical gel 1

salicylic acid topical liquid 1

salicylic acid topical lotion 1

salicylic acid topical lotion,extended release

1

salicylic acid topical shampoo

1

SALKERA TOPICAL FOAM 3

SALVAX DUO PLUS TOPICAL FOAM 3

salvax topical foam 1

Drug Name Tier NotesSANADERMRX TOPICAL KIT 3 ST

SANTYL TOPICAL OINTMENT 3

SCALACORT DK TOPICAL COMBO PACK 3 ST

scalacort topical lotion 1

seb-prev topical cleanser 1

selenium sulfide topical lotion

1

selenium sulfide topical shampoo

1

SELRX TOPICAL SHAMPOO 3

SERNIVO TOPICAL SPRAY WITH PUMP 3

SILAZONE-II TOPICAL KIT 3

silver nitrate applicators topical stick

1

silver nitrate topical ointment 1

silver nitrate topical solution 1

SILVRSTAT TOPICAL GEL 3

SKLICE TOPICAL LOTION 3

sodium chloride irrigation solution

1

sonafine topical emulsion 1

SOOLANTRA TOPICAL CREAM 3

SORBITOL IRRIGATION SOLUTION 3

SORBITOL-MANNITOL URETHRAL SOLUTION 3

SORIATANE ORAL CAPSULE 3

SORILUX TOPICAL FOAM 3

spinosad topical suspension 1

sulfacetamide sodium (acne) topical suspension

1

sulfacetamide sodium topical cleanser

1


Effective 4/1/16

134

Drug Name Tier NotesSULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL

3

sulfacetamide sodium topical cleanser,gel extended release

1

sulfacetamide sodium topical shampoo

1

SURE RESULT DSS PREMIUM PACK TOPICAL COMBO PACK,SOLUTION AND CREAM

3

SURE RESULT TAC PAK TOPICAL KIT 3 ST

SYNALAR CREAM KIT TOPICAL CREAM 3 ST

SYNALAR OINTMENT KIT TOPICAL COMBO PACK,OINTMENT AND CREAM

3 ST

SYNALAR TOPICAL CREAM 3 ST

SYNALAR TOPICAL OINTMENT 3 ST

SYNALAR TOPICAL SOLUTION 3 ST

SYNALAR TS TOPICAL KIT 3 ST

TACLONEX TOPICAL OINTMENT 3

TACLONEX TOPICAL SUSPENSION 3

TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR

3

TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR

3

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR

3

TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE

3

Drug Name Tier NotesTALTZ SYRINGE (3 PACK) SUBCUTANEOUS SYRINGE

3

TALTZ SYRINGE SUBCUTANEOUS SYRINGE

3

TAZORAC TOPICAL CREAM 2

TAZORAC TOPICAL GEL 2

TEMOVATE E TOPICAL CREAM 3 ST

TEMOVATE TOPICAL CREAM 3 ST

TEMOVATE TOPICAL OINTMENT 3 ST

TERSI FOAM TOPICAL FOAM 3

TETRIX TOPICAL CREAM 3

TEXACORT TOPICAL SOLUTION 3 ST

TOPICORT TOPICAL CREAM 3 ST

TOPICORT TOPICAL GEL 3 ST

TOPICORT TOPICAL OINTMENT 3 ST

TOPICORT TOPICAL SPRAY,NON-AEROSOL 3 ST

tretinoin (emollient) topical cream

1 PA

tretinoin microspheres topical gel

1 PA

tretinoin microspheres topical gel with pump

1 PA

tretinoin topical cream 1 PA

tretinoin topical gel 1 PA

TRETIN-X CREAM KIT TOPICAL COMBO PACK 3 PA

TRETIN-X TOPICAL CREAM 3 PA

triamcinolone acetonide topical aerosol

1 ST; QL


Effective 4/1/16

135

Drug Name Tier Notestriamcinolone acetonide topical cream 0.025 %, 0.5 %

1 QL

triamcinolone acetonide topical cream 0.1 %

1 ST

triamcinolone acetonide topical lotion 0.025 %

1 QL

triamcinolone acetonide topical lotion 0.1 %

1

triamcinolone acetonide topical ointment

1 QL

trianex topical ointment 1

tri-chlor topical solution 1

TRICHLOROACETIC ACID TOPICAL RECON SOLN

3

triderm topical cream 1

TRI-LUMA TOPICAL CREAM 3

TROPAZONE LOTION TOPICAL LOTION 3

ULESFIA TOPICAL LOTION 3

ULTRASAL-ER TOPICAL FILM-FORMING SOLN ER W/ APPL

3

ULTRAVATE TOPICAL CREAM 3 ST

ULTRAVATE TOPICAL OINTMENT 3 ST

ULTRAVATE X TOPICAL COMBO PACK 3 ST

ULTRAVATE X TOPICAL COMBO PACK,OINTMENT AND CREAM

3 ST

UMECTA NAIL FILM PEN TOPICAL NAIL FILM SUSP, PEN APPLICATOR

3

UMECTA PD TOPICAL EMULSION, ADHESIVE 3

UMECTA PD TOPICAL SUSPENSION,ADHESIVE 3

UMECTA TOPICAL EMULSION 3

Drug Name Tier Notesumecta topical foam 1

UMECTA TOPICAL NAIL FILM SUSPENSION 3

URAMAXIN GT TOPICAL GEL 3

URAMAXIN GT TOPICAL KIT,CREAM AND GEL

3

URAMAXIN TOPICAL CREAM 3

URAMAXIN TOPICAL FOAM 3

URAMAXIN TOPICAL GEL 3

URAMAXIN TOPICAL LOTION 3

urea nail stick topical solution

1

urea topical cream 1

urea topical foam 1

urea topical gel 1

UREA TOPICAL LOTION40 % 3

urea topical lotion 45 % 1

urea topical nail film suspension

1

urea-hyaluronate sodium topical kit

1

ure-k topical cream 1

UREVAZ TOPICAL CREAM 3

UTOPIC TOPICAL CREAM 3

VANIQA TOPICAL CREAM 3

VANOS TOPICAL CREAM 3 ST

VANOXIDE-HC TOPICAL SUSPENSION 3

VASELINE WHITE PETROLEUM TOPICAL OINTMENT IN PACKET

3

VASHE WOUND THERAPY IRRIGATION IRRIGATION SOLUTION

3


Effective 4/1/16

136

Drug Name Tier NotesVECTICAL TOPICAL OINTMENT 3

VELTIN TOPICAL GEL 3 ST

VERDESO TOPICAL FOAM 3 ST

VIRASAL TOPICAL FILM FORMING LIQUID W/APPL

3

VITRASE INJECTION SOLUTION 3

VOLTAREN TOPICAL GEL 3

VYTONE TOPICAL CREAM IN PACKET 3

water for irrigation, sterile irrigation solution

1

WHYTEDERM TDPAK TOPICAL KIT 3 ST

WHYTEDERM TRILASIL PAK TOPICAL KIT

3 ST

XCLAIR TOPICAL CREAM 3

ZANABIN TOPICAL GEL 3

zenatane oral capsule 2 PA; QL

ZIANA TOPICAL GEL 3 ST

ZITHRANOL TOPICAL SHAMPOO 3

ZITHRANOL-RR TOPICAL CREAM, RAPID RELEASE

3

ZONALON TOPICAL CREAM 3

ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP

3 PA; QL

ZYCLARA TOPICAL CREAM IN PACKET 3 PA; QL

SMOKING DETERRENTS

buproban oral tablet extended release

1 QL

CHANTIX CONTINUING MONTH BOX ORAL TABLET

3 QL

Drug Name Tier NotesCHANTIX ORAL TABLET 3 QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

3 QL

NICOTROL INHALATION CARTRIDGE

3

NICOTROL NS NASAL SPRAY,NON-AEROSOL 3

ZYBAN ORAL TABLET EXTENDED RELEASE 3 QL

THYROID PREPS

ARMOUR THYROID ORAL TABLET 2

CYTOMEL ORAL TABLET 3

LEVOTHYROXINE INTRAVENOUS RECON SOLN 100 MCG

3

levothyroxine intravenous recon soln 200 mcg, 500 mcg

1

levothyroxine oral tablet 1

levoxyl oral tablet 1

liothyronine intravenous solution

1

liothyronine oral tablet 1

methimazole oral tablet 1

nature-throid oral tablet 1

np thyroid oral tablet 1

propylthiouracil oral tablet 1

SYNTHROID ORAL TABLET 2

TAPAZOLE ORAL TABLET 3

THYROGEN INTRAMUSCULAR RECON SOLN

3

THYROLAR-1 ORAL TABLET 3

THYROLAR-1/2 ORAL TABLET 3

THYROLAR-1/4 ORAL TABLET 3


Effective 4/1/16

137

Drug Name Tier NotesTHYROLAR-2 ORAL TABLET 3

THYROLAR-3 ORAL TABLET 3

TIROSINT ORAL CAPSULE 3

TRIOSTAT INTRAVENOUS SOLUTION

3

unithroid oral tablet 1

westhroid oral tablet 1

WP THYROID ORAL TABLET 3

UNCLASSIFIED DRUG PRODUCTS

acamprosate oral tablet,delayed release (dr/ec)

1

ACETADOTE INTRAVENOUS SOLUTION

3

acetylcysteine intravenous solution

1

ACTONEL ORAL TABLET 3 QL

ADAGEN INTRAMUSCULAR SOLUTION

4

ALDURAZYME INTRAVENOUS SOLUTION

4 PA

alendronate oral solution 1

alendronate oral tablet 1 QL

alfuzosin oral tablet extended release 24 hr

1

amifostine crystalline intravenous recon soln

1

ANTABUSE ORAL TABLET 3

APLIGRAF TOPICAL DISK 3

APPTRIM ORAL CAPSULE 3

APPTRIM-D ORAL CAPSULE 3

Drug Name Tier NotesAQUORAL MUCOUS MEMBRANE AEROSOL,SPRAY

3

ARALAST NP INTRAVENOUS RECON SOLN

4 PA

ARCALYST SUBCUTANEOUS RECON SOLN

4 PA; QL

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC)

3 QL

AVODART ORAL CAPSULE 3 PA

bacteriostatic water(parabens) injection solution

1

BAL IN OIL INTRAMUSCULAR SOLUTION

3

BENLYSTA INTRAVENOUS RECON SOLN

4 PA

BERINERT INTRAVENOUS KIT 4 PA

BINOSTO ORAL TABLET, EFFERVESCENT

3 QL

BONIVA INTRAVENOUS SYRINGE 4 ST

BONIVA ORAL TABLET 3 ST; QL

BRIDION INTRAVENOUS SOLUTION

3

BUNAVAIL BUCCAL FILM 3 PA; QL

buprenorphine hcl sublingual tablet

1 PA; QL

buprenorphine-naloxone sublingual tablet

1 PA; QL

BUTYLATED HYDROXYTOLUENE POWDER

3

CA-DTPA INTRAVENOUS SOLUTION

3


Effective 4/1/16

138

Drug Name Tier NotesCALCIUM DISODIUM VERSENATE INJECTION SOLUTION

3

calcium folinate (leucovorin) injection solution

1

CAPHOSOL MUCOUS MEMBRANE SOLUTION 3

CARBAGLU ORAL TABLET, DISPERSIBLE 4

CARDIOVID PLUS ORAL CAPSULE 3

CARNITOR (SUGAR-FREE) ORAL SOLUTION

3

CARNITOR INTRAVENOUS SOLUTION

3

CARNITOR ORAL SOLUTION 3

CARNITOR ORAL TABLET 3

CARTICEL IMPLANT SUSPENSION 3

CAVERJECT IMPULSE INTRACAVERNOSAL KIT

3 PA

CAVERJECT INTRACAVERNOSAL RECON SOLN

3 PA

CELACYN POST PROCEDURE TOPICAL COMBO PACK,GEL AND SPRAY

3

CELLULOSE (BULK) POWDER 3

CERDELGA ORAL CAPSULE 4 PA

CEREZYME INTRAVENOUS RECON SOLN

4 PA

CHEMET ORAL CAPSULE 3

chlorhexidine gluconate mucous membrane mouthwash

1

CIALIS ORAL TABLET10 MG, 20 MG 2 PA

Drug Name Tier NotesCIALIS ORAL TABLET2.5 MG, 5 MG 3 PA; QL

CINRYZE INTRAVENOUS RECON SOLN

4 PA; QL

CO-BALAMIN ORAL CAPSULE 3

CONCEPTION KIT 3

CO-VERATROL ORAL CAPSULE 3

cryoserv solution 1

CUROSURF INTRATRACHEAL SUSPENSION

3

CYANOKIT INTRAVENOUS RECON SOLN

3

CYSTADANE ORAL POWDER 3

CYSTAGON ORAL CAPSULE 4

darifenacin oral tablet extended release 24 hr

1

DEBACTEROL MUCOUS MEMBRANE SOLUTION 3

DEBACTEROL MUCOUS MEMBRANE SWAB 3

deferoxamine injection recon soln

4

DERMAGRAFT TOPICAL SHEET 3

DERMANIC ORAL TABLET,IR,DELAYED REL,BIPHASIC

3

DERMAWERX SURGICAL PLUS PAK TOPICAL KIT

3

DESFERAL INJECTION RECON SOLN 4

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR

3 ST

DETROL ORAL TABLET 3 ST

dexrazoxane hcl intravenous recon soln

1


Effective 4/1/16

139

Drug Name Tier NotesDIGIFAB INTRAVENOUS RECON SOLN

3

DILUENT FOR EPOPROSTENOL/FLOLA INTRAVENOUS SOLUTION

3

disulfiram oral tablet 1

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR

3 ST

doxercalciferol intravenous solution

1

doxercalciferol oral capsule 1

doxycycline hyclate oral tablet

1

DUODOTE INTRAMUSCULAR PEN INJECTOR

3

dutasteride oral capsule 1 PA

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

1 PA

EDEX INTRACAVERNOSAL KIT

3 PA

ELAPRASE INTRAVENOUS SOLUTION

4 PA

ELELYSO INTRAVENOUS RECON SOLN

4 PA

ELLIOTTS B (PF) INTRATHECAL SOLUTION

3

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR

3 ST

ENDOFORM FENESTRATED TOPICAL SHEET

3

ENDOFORM TOPICAL SHEET 3

ENTERAGAM ORAL POWDER IN PACKET 3

EPISIL MUCOUS MEMBRANE GEL FORMING SOLUTION

3

Drug Name Tier NotesESBRIET ORAL CAPSULE 4 PA; QL

ethyl acetate liquid 1

etidronate disodium oral tablet

1

EUCALYPTUS FLAVOR OIL 3

EVISTA ORAL TABLET 3

EXJADE ORAL TABLET, DISPERSIBLE 4

FABRAZYME INTRAVENOUS RECON SOLN

4

FERRIPROX ORAL SOLUTION 4

FERRIPROX ORAL TABLET 4

finasteride oral tablet 1 mg 1

finasteride oral tablet 5 mg 1 PA

FIRAZYR SUBCUTANEOUS SYRINGE

4 PA

flavoxate oral tablet 1

FLOMAX ORAL CAPSULE,EXTENDED RELEASE 24HR

3

flumazenil intravenous solution

1

fomepizole intravenous solution

1

FORTEO SUBCUTANEOUS PEN INJECTOR

4 PA; QL

FOSAMAX ORAL TABLET 3 QL

FOSAMAX PLUS D ORAL TABLET 70-2,800 MG-UNIT

2 QL

FOSAMAX PLUS D ORAL TABLET 70-5,600 MG-UNIT

2

FOSTEUM PLUS ORAL CAPSULE 3

FUSILEV INTRAVENOUS RECON SOLN

3


Effective 4/1/16

140

Drug Name Tier NotesGABADONE ORAL CAPSULE 3

GALZIN ORAL CAPSULE 3

GELCLAIR MUCOUS MEMBRANE GEL IN PACKET

3

GELFILM IMPLANT FILM 3

GELNIQUE TRANSDERMAL GEL IN PACKET

3 ST

GELX MUCOUS MEMBRANE GEL 3

GLASSIA INTRAVENOUS SOLUTION

4 PA

HECTOROL INTRAVENOUS SOLUTION

3

HECTOROL ORAL CAPSULE 3

HYLENEX INJECTION SOLUTION 3

HYPER-SAL INHALATION SOLUTION FOR NEBULIZATION

3

HYPERTENSA ORAL CAPSULE 3

ibandronate intravenous solution

1 ST

ibandronate intravenous syringe

4 ST

ibandronate oral tablet 1 ST; QL

ILARIS (PF) SUBCUTANEOUS RECON SOLN

4 PA

INFASURF INTRATRACHEAL SUSPENSION

3

JADENU ORAL TABLET 4

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 3 PA

Drug Name Tier NotesKALBITOR SUBCUTANEOUS SOLUTION

4 PA

KALYDECO ORAL GRANULES IN PACKET 4 PA; QL

KALYDECO ORAL TABLET 4 PA; QL

KANUMA INTRAVENOUS SOLUTION

3

KEVEYIS ORAL TABLET 4 PA; QL

KUVAN ORAL POWDER IN PACKET 4 PA

KUVAN ORAL TABLET,SOLUBLE 4 PA

leucovorin calcium injection recon soln

1

leucovorin calcium oral tablet

1

LEVITRA ORAL TABLET 3 PA

levocarnitine (with sugar) oral solution

1

levocarnitine intravenous solution

1

levocarnitine oral tablet 1

levoleucovorin calcium intravenous solution

1

LIMBREL ORAL CAPSULE 3

LIMBREL250 ORAL CAPSULE 3

LIMBREL500 ORAL CAPSULE 3

LISTER-V ORAL CAPSULE 3

LUMIZYME INTRAVENOUS RECON SOLN

4 PA

MEGACE ES ORAL SUSPENSION 3

MEGACE ORAL SUSPENSION 3

megestrol oral suspension 1


Effective 4/1/16

141

Drug Name Tier Notesmesna intravenous solution 1

MESNEX INTRAVENOUS SOLUTION

3

MESNEX ORAL TABLET 2

METASTRON INTRAVENOUS SOLUTION

3

METHAZEL ORAL CAPSULE 3

methylene blue (antidote) intravenous solution

1

MIFEPREX ORAL TABLET 3

MUCOTROL ORAL WAFER 3 QL

MUGARD MUCOUS MEMBRANE SOLUTION 3 QL

MURI-LUBE OIL 2

MUSE URETHRAL SUPPOSITORY 3 PA

MYOZYME INTRAVENOUS RECON SOLN

4 PA

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

3

NAGLAZYME INTRAVENOUS SOLUTION

4 PA

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION

2

NEUTRASAL MUCOUS MEMBRANE POWDER IN PACKET

3

NEXAVIR INJECTION SOLUTION 3

niacin-aze ac-turmer-fa-b6-zn oral tablet

1

NICADAN ORAL TABLET 3

NICAZEL FORTE ORAL TABLET 3

NICAZEL ORAL TABLET 3

Drug Name Tier NotesNITHIODOTE INTRAVENOUS SOLUTION

3

NUMOISYN MUCOUS MEMBRANE LIQUID 3

NUMOISYN MUCOUS MEMBRANE LOZENGE 3

OFEV ORAL CAPSULE 4 PA; QL

ORAFATE MUCOUS MEMBRANE PASTE 3

oralone dental paste 1

ORAMAGICRX MUCOUS MEMBRANE MOUTHWASH

3

ORFADIN ORAL CAPSULE 4

ORKAMBI ORAL TABLET 4 PA; QL

OSPHENA ORAL TABLET 3 PA; QL

oxybutynin chloride oral syrup

1

oxybutynin chloride oral tablet

1

oxybutynin chloride oral tablet extended release 24hr

1

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY

3 ST

pamidronate intravenous recon soln

4

pamidronate intravenous solution

4

PANHEMATIN INTRAVENOUS RECON SOLN

3

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION

3

paricalcitol oral capsule 1

paroex oral rinse mucous membrane mouthwash

1

PERCURA ORAL CAPSULE 3


Effective 4/1/16

142

Drug Name Tier NotesPERIDEX MUCOUS MEMBRANE MOUTHWASH

3

periogard mucous membrane mouthwash

1

PH 12 DILUENT FOR FLOLAN INTRAVENOUS SOLUTION

3

PRALIDOXIME INTRAMUSCULAR PEN INJECTOR

3

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

4 ST

PROLASTIN-C INTRAVENOUS RECON SOLN

4 PA

PROLIA SUBCUTANEOUS SYRINGE

3 PA; QL

PROPECIA ORAL TABLET 3

PROSCAR ORAL TABLET 3 PA

PROTHELIAL MUCOUS MEMBRANE PASTE 3

PROTOPAM CHLORIDE INJECTION RECON SOLN

3

pulmosal inhalation solution for nebulization

1

PULMOZYME INHALATION SOLUTION

4

Q-CARE RX Q2 KIT 3

Q-CARE RX Q4 KIT 3

RADIAGEL TOPICAL GEL 3

RADIGEL ACEMANNAN HYDROGEL TOPICAL GEL

3

RADIOGARDASE ORAL CAPSULE 3

raloxifene oral tablet 1

RAPAFLO ORAL CAPSULE 3

Drug Name Tier NotesRECLAST INTRAVENOUS SOLUTION

4

RHEUMATE ORAL CAPSULE 3

risedronate oral tablet 1 QL

risedronate oral tablet,delayed release (dr/ec)

1 QL

RUCONEST INTRAVENOUS RECON SOLN

4 PA; QL

SALIVAMAX MUCOUS MEMBRANE POWDER IN PACKET

3

SAVELLA ORAL TABLET 2 QL

SAVELLA ORAL TABLETS,DOSE PACK 2 QL

SCLEROSOL INTRAPLEURAL INTRAPLEURAL AEROSOL POWDER

3

SENSIPAR ORAL TABLET 4

SENTRA AM ORAL CAPSULE 3

SENTRA PM ORAL CAPSULE 3

sodium bisulfite granules 1

sodium chlor 0.9% bacteriostat injection solution

1

sodium chloride inhalation solution for nebulization

1

SODIUM NITRITE INTRAVENOUS SOLUTION

3

sodium succinate powder 1

sodium thiosulfate intravenous solution

1

SOMAVERT SUBCUTANEOUS RECON SOLN

4

sorbitol solution 1

STAXYN ORAL TABLET,DISINTEGRATING

3 PA


Effective 4/1/16

143

Drug Name Tier NotesSTENDRA ORAL TABLET 3 PA

STERILE TALC INTRAPLEURAL SUSPENSION FOR RECONSTITUTION

3

sterile water for injection injection solution

1

STRENSIQ SUBCUTANEOUS SOLUTION

4 PA

SUBOXONE SUBLINGUAL FILM 2 PA; QL

SULFZIX ORAL POWDER 3

SURFAXIN INTRATRACHEAL SUSPENSION

3

SURVANTA INTRATRACHEAL SUSPENSION

3

SYPRINE ORAL CAPSULE 3

tamsulosin oral capsule,extended release 24hr

1

THERAMINE ORAL CAPSULE 3

THERAMINE PLUS ORAL POWDER IN PACKET

3

THIOLA ORAL TABLET 3 PA; QL

TL-ICARE ORAL CAPSULE 3

tolterodine oral capsule,extended release 24hr

1

tolterodine oral tablet 1

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

3

TOZAL ORAL CAPSULE 3

triamcinolone acetonide dental paste

1 QL

Drug Name Tier Notestrospium oral capsule,extended release 24hr

1

trospium oral tablet 1

TYBOST ORAL TABLET 3

TYSABRI INTRAVENOUS SOLUTION

4 PA

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HR

3

VAYACOG ORAL CAPSULE 3

VAYARIN ORAL CAPSULE 3

VENELEX TOPICAL OINTMENT 3

VENELEX TOPICAL OINTMENT IN PACKET 3

VESICARE ORAL TABLET 3

VIAGRA ORAL TABLET 2 PA

VIASPAN (BELZER UW) COLD SS PERFUSION IRRIGATION SOLUTION

3

VIMIZIM INTRAVENOUS SOLUTION

4

VISTOGARD ORAL GRANULES IN PACKET 3

VISUDYNE INTRAVENOUS RECON SOLN

4

VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

4 PA

VORAXAZE INTRAVENOUS RECON SOLN

3

VPRIV INTRAVENOUS RECON SOLN 4 PA

vp-zel oral tablet 1

water for inject, bacteriostat injection solution

1


Effective 4/1/16

144

Drug Name Tier Noteswater for injection, sterile injection solution

1

water for injection, sterile intravenous parenteral solution

1

WHYTEDERM SURGIPAK TOPICAL KIT

3

XGEVA SUBCUTANEOUS SOLUTION

3 PA; QL

XIAFLEX INJECTION RECON SOLN 4 PA

XOFIGO INTRAVENOUS SOLUTION 3 PA

ZAVESCA ORAL CAPSULE 4 PA

ZEMAIRA INTRAVENOUS RECON SOLN

4 PA

ZEMPLAR INTRAVENOUS SOLUTION

2

ZEMPLAR ORAL CAPSULE 3

ZINECARD (AS HCL) INTRAVENOUS RECON SOLN

3

ZN-DTPA INTRAVENOUS SOLUTION

3

zoledronic acid intravenous recon soln

1 PA

zoledronic acid intravenous solution

1 PA

ZOLEDRONIC ACID-MANNITOL-WATER INTRAVENOUS PIGGYBACK

4

zoledronic acid-mannitol-water intravenous solution

4

ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML

3

Drug Name Tier NotesZOMETA INTRAVENOUS SOLUTION 4 MG/5 ML

3 PA

ZUBSOLV SUBLINGUAL TABLET 3 PA; QL

ZYTAZE ORAL CAPSULE 3

VITAMINS

advanced am-pm oral combo pack

1

ANIMI-3 WITH VITAMIN D ORAL CAPSULE 3

AQUASOL A INTRAMUSCULAR SOLUTION

3

ascorbic acid injection solution

1

b complex 100 injection solution

1

B-12 COMPLIANCE INJECTION KIT 3

b-12 kit injection kit 1

BACMIN ORAL TABLET 3

calcitriol intravenous solution

1

calcitriol oral capsule 1

calcitriol oral solution 1

CARDIOTEK-RX (BIOPERINE) ORAL TABLET

3

CEREFOLIN NAC (ALGAL OIL) ORAL TABLET

3

CEREFOLIN ORAL TABLET 3

chewable multivit-a,b,d,e,k,zn oral tablet,chewable

1

ciferex oral capsule 1

COMPLETE FORMULATION D3000 ORAL CAPSULE

3

COMPLETE FORMULATION PEDIATRIC ORAL DROPS

3


Effective 4/1/16

145

Drug Name Tier Notescorvita oral tablet 1

CORVITE FREE ORAL TABLET 3

CORVITE ORAL TABLET 3

cyanocobalamin (vitamin b-12) injection solution

1

DEPLIN (ALGAL OIL) ORAL CAPSULE 3

DIALYVITE 3000 ORAL TABLET 3

DIALYVITE 5000 ORAL TABLET 3

DIALYVITE 800 WITH IRON ORAL TABLET 3

dialyvite oral tablet 1

DIALYVITE SUPREME D ORAL TABLET 3

DRISDOL ORAL CAPSULE 3

DURACHOL ORAL CAPSULE 3

ELDERCAPS ORAL CAPSULE 3

ELIGEN B12 ORAL TABLET 3

ENLYTE (FERROUS GLYCINE) ORAL CAPSULE,IR - DELAY REL,BIPHASE

3

ergocalciferol (vitamin d2) oral capsule

1

ESCAVITE D ORAL TABLET,CHEW,IR - DR,BIPHASE

3

ESCAVITE LQ ORAL DROPS 3

ESCAVITE ORAL TABLET,CHEWABLE 3

fabb oral tablet 1

FLORIVA ORAL TABLET,CHEWABLE 3

FLORIVA PLUS ORAL DROPS 3

folbee oral tablet 1

Drug Name Tier Notesfolbee plus oral tablet 1

folbic oral tablet 1

folbic rf oral tablet 1

FOLGARD RX ORAL TABLET 3

folic acid injection solution 1

folic acid oral tablet 1

folic acid-vit b6-vit b12 oral tablet

1

folplex 2.2 oral tablet 1

foltanx oral tablet 1

foltanx rf oral capsule 1

FOLTRATE ORAL TABLET 3

FOLTX ORAL TABLET 3

FORTAVIT ORAL CAPSULE 3

hydroxocobalamin intramuscular solution

1

INFUVITE ADULT INTRAVENOUS SOLUTION

3

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

3

levomefolate calcium oral tablet

1

levomefolate-algal oil oral capsule

1

levomefol-b6-meb12-algal oil oral capsule

1

lmefol ca-acetyl-meb12-algal oral tablet

1

l-methyl-b6-b12 oral tablet 1

l-methylfolate ca p-5-p me-cbl oral capsule

1

l-methylfolate forte oral capsule

1

l-methylfolate oral tablet 1

l-methyl-mc nac oral tablet 1

l-methyl-mc oral tablet 1

lmthf-pyridoxine-cyanocobalamn oral tablet

1


Effective 4/1/16

146

Drug Name Tier Notesm.v.i. adult intravenous solution

1

M.V.I. PEDIATRIC INTRAVENOUS RECON SOLN

3

M.V.I.-12 (WITHOUT VITAMIN K) INTRAVENOUS SOLUTION

3

MACUVEX ORAL CAPSULE 3

MACUZIN ORAL CAPSULE 3

MEPHYTON ORAL TABLET 2

metafolbic oral tablet 1

metafolbic plus oral tablet 1

metafolbic plus rf oral tablet 1

METANX (ALGAL OIL) ORAL CAPSULE 3

METHAVER ORAL CAPSULE 3

multi-vit with fluoride-iron oral drops

1

multi-vitamin with fluoride oral drops

1

multivitamin with fluoride oral tablet,chewable

1

multi-vitamin with fluoride oral tablet,chewable

1

multivitamins with fluoride oral tablet,chewable

1

mvc-fluoride oral tablet,chewable

1

MYKIDZ IRON FLUORIDE ORAL SUSPENSION

2

mynephrocaps oral capsule 1

NASCOBAL NASAL SPRAY,NON-AEROSOL 3

nephplex rx oral tablet 1

NEPHROCAPS ORAL CAPSULE 3

Drug Name Tier NotesNEPHROCAPS QT ORAL TABLET,DISINTEGRATING

3

nephro-vite rx oral tablet 1

NEURIN-SL SUBLINGUAL TABLET 3

NICOMIDE (SELENIUM-CHROMIUM) ORAL TABLET

3

NICOMIDE ORAL TABLET 3

NIVA-FOL ORAL TABLET 3

NOXIFOL-D3 ORAL TABLET 3

NUTRICAP ORAL TABLET 3

OCUVEL ORAL CAPSULE 3

ortho d oral capsule 1

PED MULTIVITAMINS-A,B,D,E,K,ZN ORAL DROPS

3

PHYSICIANS EZ USE B-12 INJECTION KIT 3

PHYTONADIONE (VITAMIN K1) INJECTION SYRINGE

3

PODIAPN ORAL CAPSULE 3

POLY-VI-FLOR FS ORAL FILM 3

POLY-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

3

POLY-VI-FLOR ORAL TABLET,CHEWABLE 3

POLY-VI-FLOR WITH IRON ORAL DROPS,SUSPENSION BIPHASIC

3

POLY-VI-FLOR WITH IRON ORAL TABLET,CHEWABLE

3

POTABA ORAL CAPSULE 3


Effective 4/1/16

147

Drug Name Tier NotesPROTECT IRON ORAL TABLET 3

PURALOR CI ORAL TABLET,CHEW,IR - DR,BIPHASE

3

pyridoxine (vitamin b6) injection solution

1

QUFLORA PEDIATRIC DROPS ORAL DROPS 3

QUFLORA PEDIATRIC ORAL TABLET,CHEWABLE

3

renal caps oral capsule 1

rena-vite rx oral tablet 1

reno caps oral capsule 1

REQ49+ ORAL TABLET 3 QL

REVESTA ORAL CAPSULE 3

ROCALTROL ORAL CAPSULE 3

ROCALTROL ORAL SOLUTION 3

SOFTGELS MULTIVIT-A,B,D,E,K,ZN ORAL CAPSULE

3

STROVITE FORTE ORAL TABLET 3

STROVITE ONE ORAL TABLET 3

SUPERVITE (EC) ORAL TABLET,DELAYED RELEASE (DR/EC)

3

SUPERVITE ORAL LIQUID 3

TEXAVITE LQ ORAL DROPS 3

thiamine hcl (vitamin b1) injection solution

1

tl gard rx oral tablet 1

triphrocaps oral capsule 1

triple vitamin with fluoride oral drops

1

TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

3

Drug Name Tier Notestri-vit with fluoride and iron oral drops

1

tri-vitamin with fluoride oral drops

1

UDAMIN SP ORAL TABLET 3

VASCULERA ORAL TABLET 3

v-c forte oral capsule 1

vic-forte oral capsule 1

VIRT-CAPS ORAL CAPSULE 3

virt-gard oral tablet 1

virt-vite forte oral tablet 1

virt-vite oral tablet 1

VIRT-VITE PLUS ORAL TABLET 3

vit 3 oral capsule 1

VITAL-D RX ORAL TABLET 3

vitamin d2 oral capsule 1

vitamin k injection solution 1

vitamin k1 injection solution 1

vitamins a,c,d and fluoride oral drops

1

VITA-RESPA ORAL TABLET 3

vol-care rx oral tablet 1

vp-vite rx oral tablet 1

zavara oral capsule 1


Effective 4/1/16

148


Effective 4/1/16

149

KEY

PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.

QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.

ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized.

DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.

Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Customer Service at the telephone number listed on your identification card.

For more information, please visit anthem.com/ca }} If you have additional questions about your prescription benefits please call the Customer Service number on your ID card

}} Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET

}} For the most current version of this prescription drug list, please visit anthem.com/ca

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 02/16

National Drug List

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Transcript of National Drug List