Select Drug List - MMIT · Select Drug List Drug list — Four Tier Drug Plan Your plan includes...
Transcript of Select Drug List - MMIT · Select Drug List Drug list — Four Tier Drug Plan Your plan includes...
Select Drug List Drug list — Four Tier Drug Plan Your plan includes coverage for medications you’ll find on this drug list. The drug list includes brand-name and generic prescription medications approved by the FDA. Drugs that are not on this list may cost you more out of pocket. You and your doctor can use this list as a guide to choose the medications that are best for you. Your coverage has limitations and exclusions. It’s best to refer to your Certificate/Evidence of Coverage or Summary Plan Description (SPD) for details about what’s covered and what’s not. Inside you will find more information about how this drug list works with your prescription drug coverage.
This booklet is updated on a quarterly basis. For the most up to date information, including newly added
medications, generics and more, you can visit anthem.com/pharmacyinformation. For additional
information, please call the Member Services number on your ID card.
40627MEMENABS
What is a drug list? The drug list (also called a formulary) is a list of prescription medications approved by the U.S. Food and Drug Administration (FDA). The list is made up of hundreds of brand-name and generic medications that have been reviewed and recommended for their quality and effectiveness through our Pharmacy and Therapeutics (P&T) process. Our P&T process involves an independent group of practicing doctors, pharmacists, and other health care professionals responsible for the research and decisions surrounding our drug lists. This group meets regularly to review new and existing drugs and chooses the top medications for our drug lists, based on their safety, effectiveness and value. The drug list is organized in tiers; medications on Tier 1 have the lowest member cost share while members pay more for drugs on higher tiers. How will I know about changes to the drug list? Drugs on our list are reviewed regularly. Sometimes this results in drugs being added or removed. We will always try to notify you of changes to the drug list that impact you. Now and then, it’s a good idea to check the status of any medications you are taking. On our website, you can view and search the drug list to see which drugs are covered and at what tier level, as well as information on dosage/strength options and prior authorization or step therapy requirements. You can also see if a brand-name drug has a generic equivalent. What’s the difference between brand-name and generic medications? A brand-name drug is usually available from only one manufacturer and may have patent protection. A generic drug is also FDA-approved and has the same active ingredients as its brand-name counterpart, but a generic is typically available only after the brand-name drug’s patent protection expires. Although it may look different, a generic drug works the same as its brand-name counterpart.
Is this a complete listing of all covered drugs? Yes, this is a complete listing of all drugs on the drug list; however, a drug(s) may be excluded based on your plan's benefit design. If a medication isn’t on this list, this means your plan doesn’t cover the medication(s), so you may have to pay out of pocket or switch to a covered prescription medication or an over the counter (OTC) option. If my medication is not included on the drug list, what are my options? The drug list includes many brand-name and generic drugs. You may have to pay the full cost of a medication that isn’t included on the drug list. When you visit our website, you can get more information about generic equivalent options, if available; however, OTC options will not be displayed. If an alternative isn’t listed, please talk to your doctor or pharmacist about whether another medication that is included on the drug list or an OTC may be right for you. Only you and your doctor can decide what drugs are right for you. If a medication you’re taking is not covered, your doctor can ask us to keep covering the drug(s) you take now by submitting a request for an exception. This process, called prior authorization, requires your doctor to call the member services number on your member ID card or go to our website to download and submit the prior authorization form. How will I know how much my drug will cost? Medications on the drug list are grouped into tiers. Your cost will depend on what tier the medication your doctor prescribes for you falls in and could be a set cost or a percentage of the total drug cost. In general, drugs on the lowest tier have the lowest member cost share, which is what you pay. Drugs on a higher tier may 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.
Select Drug List
What types of drugs can I expect to find in the different tiers? Tier 1 drugs have the lowest member cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions. Some plans may separate Tier 1 into Tier 1a & Tier 1b which will be labeled in the Tier column.
Tier 1a - Tier 1a drugs have the lowest member cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions.
Tier 1b - Tier 1b drugs have a low member cost share. These are typically generic drugs that offer the greatest value compared to others that treat the same conditions.
Tier 2 drugs have a medium cost share. They may be preferred brand drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier 3 drugs have a higher cost share. They generally include non-preferred brand and generic drugs. They may cost more than drugs placed on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA. Tier 4 specialty drugs have the highest cost share and typically consist of specialty (brand and generic) drugs. They may cost more than drugs placed on lower tiers that are used to treat the same condition. Tier 4 may also include drugs that were recently approved by the FDA or specialty drugs used to treat complex, chronic conditions and may need special handling.
Member cost share amount for certain abuse-deterrent opioid analgesics may be lower due to state law requirements. We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA). In selecting medications for the prescription drug formulary, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the formulary by at least one medication. When a closed formulary is in effect, only medications that are included on the formulary are a covered service. In certain clinical situations, a member may require use of a non-formulary product. Anthem has criteria that permits a member to obtain a non-formulary medication in a closed formulary plan. If specific criteria are met, a member can receive a non-formulary drug for a formulary copay. The criteria preserves the clinical integrity of the drug formulary and provides a process by which deviations from the formulary may be allowed. An appeals process is in place for any medications that do not meet the criteria.
2017 Maine Select Drug List
Table of Contents
ANALGESICS ...........................................................................................................................................................................6ANESTHETICS .........................................................................................................................................................................8ANTIARTHRITICS .................................................................................................................................................................... 8ANTIASTHMATICS .................................................................................................................................................................. 9ANTIBIOTICS ......................................................................................................................................................................... 11ANTICOAGULANTS .............................................................................................................................................................. 15ANTIDOTES ........................................................................................................................................................................... 16ANTIFUNGALS ...................................................................................................................................................................... 16ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 18ANTIHISTAMINES ..................................................................................................................................................................18ANTIHYPERGLYCEMICS ...................................................................................................................................................... 18ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................20ANTINEOPLASTICS .............................................................................................................................................................. 20ANTI-OBESITY DRUGS .........................................................................................................................................................22ANTIPARKINSON DRUGS .................................................................................................................................................... 22ANTIPLATELET DRUGS ....................................................................................................................................................... 23ANTIVIRALS ...........................................................................................................................................................................23AUTONOMIC DRUGS ............................................................................................................................................................ 25BIOLOGICALS ....................................................................................................................................................................... 25BLOOD ................................................................................................................................................................................... 28CARDIAC DRUGS ..................................................................................................................................................................28CARDIOVASCULAR .............................................................................................................................................................. 29CNS DRUGS ...........................................................................................................................................................................32COLONY STIMULATING FACTORS .....................................................................................................................................34CONTRACEPTIVES ............................................................................................................................................................... 34COUGH/COLD PREPARATIONS .......................................................................................................................................... 37DIAGNOSTIC ..........................................................................................................................................................................37DIURETICS .............................................................................................................................................................................37EENT PREPS ......................................................................................................................................................................... 38ELECT/CALORIC/H2O ...........................................................................................................................................................39GASTROINTESTINAL ............................................................................................................................................................41HORMONES ........................................................................................................................................................................... 43IMMUNOSUPPRESSANTS ....................................................................................................................................................45MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 45MUSCLE RELAXANTS .......................................................................................................................................................... 46PRE-NATAL VITAMINS ......................................................................................................................................................... 46PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................47SEDATIVE/HYPNOTICS ........................................................................................................................................................ 50SKIN PREPS .......................................................................................................................................................................... 50SMOKING DETERRENTS ......................................................................................................................................................53THYROID PREPS ...................................................................................................................................................................53UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................54VITAMINS ............................................................................................................................................................................... 55
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2017 Maine Select Drug List
CURRENT AS OF 10/1/2017
Drug Name Tier Notes
ANALGESICS
acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml
Tier 1a QL
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg
Tier 1a QL
almotriptan malate oral tablet
Tier 1b QL
asa-butalb-caff-cod #3 capsule
Tier 1b QL
ascomp with codeine oral capsule
Tier 1b QL
buprenorphine hcl injection solution
Tier 2 QL
buprenorphine hcl injection syringe
Tier 2 QL
butalbital compound w/codeine oral capsule
Tier 1b QL
butalbital compound-codeine oral capsule
Tier 1b QL
butalbital-acetaminop-caf-cod oral capsule
Tier 1b QL
butalbital-acetaminophen oral tablet
Tier 1b
butalbital-acetaminophen-caff oral capsule
Tier 1b
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Tier 1b
butalbital-aspirin-caffeine oral capsule
Tier 1b
butalbital-aspirin-caffeine oral tablet
Tier 1b
butorphanol tartrate nasal spray,non-aerosol
Tier 1b PA; QL
BUTRANS TRANSDERMAL PATCH WEEKLY
Tier 3 QL
CAMBIA ORAL POWDER IN PACKET
Tier 3 QL
capacet oral capsule Tier 1b
codeine sulfate oral tablet Tier 1b QL
Drug Name Tier Notes
diclofenac potassium oral tablet
Tier 1b
diflunisal oral tablet Tier 1b
dihydroergotamine nasal spray,non-aerosol
Tier 2 QL
diskets oral tablet,soluble Tier 1b QL
eletriptan hbr oral tablet Tier 2
ELMIRON ORAL CAPSULE
Tier 3
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL
Tier 1b PA; QL
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 2 QL
ERGOMAR SUBLINGUAL TABLET
Tier 3
ergotamine-caffeine oral tablet
Tier 1b
fentanyl citrate buccal lozenge on a handle
Tier 1b PA; QL
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Tier 2 ST; QL
frovatriptan oral tablet Tier 2 QL
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
Tier 1b QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
Tier 1b QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
Tier 1b QL
hydromorphone oral liquid Tier 1b QL
hydromorphone oral tablet Tier 1b QL
hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg
Tier 2 ST; QL
hydromorphone rectal suppository
Tier 2 QL
Effective 1/1/20176
Drug Name Tier Notes
HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG
Tier 1b PA; QL
ibuprofen-oxycodone oral tablet
Tier 1a QL
isometh-dichloral-acetaminophn oral capsule
Tier 1b
ketorolac injection cartridge 15 mg/ml, 30 mg/ml
Tier 1b QL
ketorolac injection solution 15 mg/ml, 30 mg/ml, 30 mg/ml (1 ml)
Tier 1b QL
ketorolac injection syringe 15 mg/ml, 30 mg/ml
Tier 1b QL
ketorolac intramuscular solution
Tier 1b QL
ketorolac intramuscular syringe
Tier 1b QL
ketorolac oral tablet Tier 1a QL
levorphanol tartrate oral tablet
Tier 2
marten-tab oral tablet Tier 1b
mefenamic acid oral capsule
Tier 1b QL
meperidine oral solution Tier 1b QL
meperidine oral tablet Tier 1b QL
methadone intensol oral concentrate
Tier 1b QL
methadone oral concentrate
Tier 1b QL
methadone oral solution 10 mg/5 ml, 5 mg/5 ml
Tier 1b QL
methadone oral tablet 10 mg, 5 mg
Tier 1b QL
methadone oral tablet,soluble
Tier 1b QL
methadose oral concentrate
Tier 1b QL
methadose oral tablet,soluble
Tier 1b QL
migergot rectal suppository
Tier 1b
morphine concentrate oral solution
Tier 1b QL
Drug Name Tier Notes
morphine oral capsule,extend.release pellets
Tier 2 QL
morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)
Tier 1b QL
morphine oral tablet 15 mg, 30 mg
Tier 1b QL
morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg
Tier 2 QL
morphine rectal suppository
Tier 1b
nalbuphine injection solution
Tier 1b
naratriptan oral tablet Tier 1b QL
nodolor oral capsule Tier 1b
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 ST; QL
NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG
Tier 3 QL
oxycodone oral capsule Tier 1b QL
oxycodone oral concentrate
Tier 1b QL
oxycodone oral solution Tier 1b QL
oxycodone oral tablet Tier 1b QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1b QL
oxycodone-aspirin oral tablet
Tier 1b QL
oxymorphone oral tablet 10 mg, 5 mg
Tier 1b QL
oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg
Tier 1b QL
pentazocine-naloxone oral tablet
Tier 1b QL
rizatriptan oral tablet Tier 1b QL
rizatriptan oral tablet,disintegrating
Tier 1b QL
sumatriptan nasal spray,non-aerosol
Tier 1b QL
Effective 1/1/20177
Drug Name Tier Notes
sumatriptan succinate oral tablet
Tier 1b QL
sumatriptan succinate subcutaneous cartridge
Tier 1b QL
sumatriptan succinate subcutaneous pen injector
Tier 1b QL
sumatriptan succinate subcutaneous solution
Tier 1b QL
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml
Tier 1b QL
TALWIN INJECTION SOLUTION
Tier 3
tencon oral tablet 50-325 mg
Tier 1b
tramadol oral tablet Tier 1b QL
tramadol oral tablet extended release 24 hr
Tier 1b QL
tramadol oral tablet, er multiphase 24 hr
Tier 1b QL
vicodin es oral tablet Tier 2 QL
vicodin hp oral tablet Tier 2 QL
vicodin oral tablet Tier 2 QL
zamicet oral solution Tier 1b QL
zebutal oral capsule 50-325-40 mg
Tier 1b
ZIPSOR ORAL CAPSULE Tier 3 QL
zolmitriptan oral tablet Tier 1b QL
zolmitriptan oral tablet,disintegrating
Tier 1b QL
ANESTHETICS
lidocaine viscous mucous membrane solution
Tier 1a QL
lidocaine-prilocaine topical cream
Tier 1b QL
lidocaine-prilocaine topical kit
Tier 1b
phenazopyridine oral tablet 100 mg, 200 mg
Tier 1a
SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING
Tier 3
ANTIARTHRITICS
allopurinol oral tablet Tier 1a
CALDOLOR INTRAVENOUS RECON SOLN
Tier 3
Drug Name Tier Notes
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
Tier 2 ST; QL
COLCRYS ORAL TABLET
Tier 3 PA; QL
CUPRIMINE ORAL CAPSULE
Tier 3
diclofenac sodium oral tablet extended release 24 hr
Tier 1b
diclofenac sodium oral tablet,delayed release (dr/ec)
Tier 1b
ENBREL SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; QL
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
Tier 4 PA; SP; QL
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
etodolac oral capsule Tier 1b
etodolac oral tablet Tier 1b
etodolac oral tablet extended release 24 hr
Tier 1b
fenoprofen oral tablet Tier 1b QL
flurbiprofen oral tablet Tier 1b
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
ibuprofen oral suspension Tier 1a QL
Effective 1/1/20178
Drug Name Tier Notes
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1a
indomethacin oral capsule 25 mg, 50 mg
Tier 1b QL
indomethacin oral capsule, extended release
Tier 1b QL
ketoprofen oral capsule Tier 1b
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
Tier 1b QL
KINERET SUBCUTANEOUS SYRINGE
Tier 4 PA; LD; QL
meclofenamate oral capsule
Tier 1b
meloxicam oral suspension
Tier 1b QL
meloxicam oral tablet Tier 1b QL
nabumetone oral tablet Tier 1b
naproxen oral suspension Tier 1b
naproxen oral tablet Tier 1b
naproxen oral tablet,delayed release (dr/ec)
Tier 1b
naproxen sodium oral tablet 275 mg, 550 mg
Tier 1b
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN
Tier 4 PA; SP
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR
Tier 4 PA; SP; QL
ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML
Tier 4 PA; SP; QL
ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML
Tier 4 PA
OTEZLA ORAL TABLET Tier 4 PA; SP; QL
OTEZLA STARTER ORAL TABLETS,DOSE PACK
Tier 4 PA; SP; QL
oxaprozin oral tablet Tier 1b
piroxicam oral capsule Tier 1b
probenecid oral tablet Tier 1b
probenecid-colchicine oral tablet
Tier 1b
Drug Name Tier Notes
RIDAURA ORAL CAPSULE
Tier 3
SIMPONI ARIA INTRAVENOUS SOLUTION
Tier 4 PA; SP
SIMPONI SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
SIMPONI SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
sulindac oral tablet Tier 1b
tolmetin oral capsule Tier 1b
tolmetin oral tablet Tier 1b
ULORIC ORAL TABLET Tier 3 ST
XELJANZ ORAL TABLET Tier 4 PA; SP; QL
ANTIASTHMATICS
acetylcysteine solution Tier 2
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
ADVAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
albuterol sulfate inhalation solution for nebulization
Tier 1b
albuterol sulfate oral syrup Tier 1b
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
Tier 2 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)
Tier 2
BREO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
Effective 1/1/20179
Drug Name Tier Notes
BROVANA INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
Tier 1b QL
cromolyn inhalation solution for nebulization
Tier 2
DALIRESP ORAL TABLET
Tier 3 QL
DULERA INHALATION HFA AEROSOL INHALER
Tier 2 QL
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION
Tier 2 QL
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION
Tier 2 QL
ipratropium bromide inhalation solution
Tier 1b QL
ipratropium-albuterol inhalation solution for nebulization
Tier 2
levalbuterol hcl inhalation solution for nebulization
Tier 1b
metaproterenol oral syrup Tier 1b
metaproterenol oral tablet Tier 1b
montelukast oral granules in packet
Tier 1b QL
montelukast oral tablet Tier 1b QL
montelukast oral tablet,chewable
Tier 1b QL
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
PROAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
Drug Name Tier Notes
PROVENTIL HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION
Tier 2 QL
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
SPIRIVA RESPIMAT INHALATION MIST
Tier 3 QL
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
STRIVERDI RESPIMAT INHALATION MIST
Tier 3 QL
SYMBICORT INHALATION HFA AEROSOL INHALER
Tier 2 QL
terbutaline oral tablet Tier 2
theochron oral tablet extended release 12 hr
Tier 1b
theophylline oral elixir Tier 1b
theophylline oral solution Tier 1b
theophylline oral tablet extended release 12 hr
Tier 1b
theophylline oral tablet extended release 24 hr
Tier 1b
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 3 QL
VENTOLIN HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
XOPENEX HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
zafirlukast oral tablet Tier 1b
zileuton oral tablet, er multiphase 12 hr
Tier 2 PA
ZYFLO ORAL TABLET Tier 3 PA
Effective 1/1/201710
Drug Name Tier Notes
ANTIBIOTICS
amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml
Tier 2
amoxicillin oral capsule Tier 1a
amoxicillin oral suspension for reconstitution
Tier 1a
amoxicillin oral tablet Tier 1a
amoxicillin oral tablet,chewable 125 mg, 250 mg
Tier 1a
amoxicillin-pot clavulanate oral suspension for reconstitution
Tier 1b
amoxicillin-pot clavulanate oral tablet
Tier 1b
amoxicillin-pot clavulanate oral tablet extended release 12 hr
Tier 1b
amoxicillin-pot clavulanate oral tablet,chewable
Tier 1b
ampicillin oral capsule Tier 1a
ampicillin sodium injection recon soln
Tier 1b
ampicillin sodium intravenous recon soln
Tier 1b
ampicillin-sulbactam injection recon soln
Tier 2
ampicillin-sulbactam intravenous recon soln
Tier 2
avidoxy oral tablet Tier 1b
AZASITE OPHTHALMIC (EYE) DROPS
Tier 3
azithromycin oral packet Tier 1b QL
azithromycin oral suspension for reconstitution
Tier 1b QL
azithromycin oral tablet 250 mg, 500 mg, 600 mg
Tier 1b QL
aztreonam injection recon soln
Tier 2
bacitracin ophthalmic (eye) ointment
Tier 1b
bacitracin-polymyxin b ophthalmic (eye) ointment
Tier 1a
BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
Drug Name Tier Notes
bp 10-1 topical cleanser Tier 1b
CAPASTAT INJECTION RECON SOLN
Tier 3
CAYSTON INHALATION SOLUTION FOR NEBULIZATION
Tier 4 SP; LD
cefaclor oral capsule Tier 1b
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Tier 1b
cefaclor oral tablet extended release 12 hr
Tier 2
cefadroxil oral capsule Tier 1b
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
Tier 1b
cefadroxil oral tablet Tier 1b
cefazolin in 0.9% sod chloride intravenous piggyback
Tier 1b
cefazolin in 0.9% sod chloride intravenous solution
Tier 1b
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml
Tier 1b
cefazolin in dextrose 5 % intravenous solution
Tier 1b
cefazolin injection recon soln
Tier 1b
cefazolin intravenous recon soln
Tier 1b
cefdinir oral capsule Tier 1b
cefdinir oral suspension for reconstitution
Tier 1b
cefditoren pivoxil oral tablet
Tier 2
CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK
Tier 2
cefepime in dextrose,iso-osm intravenous piggyback
Tier 2
cefepime injection recon soln
Tier 2
cefixime oral suspension for reconstitution
Tier 2
Effective 1/1/201711
Drug Name Tier Notes
cefotaxime injection recon soln
Tier 2
CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK
Tier 2
cefotetan injection recon soln
Tier 2
cefotetan intravenous recon soln
Tier 2
cefoxitin in dextrose, iso-osm intravenous piggyback
Tier 1b
cefoxitin intravenous recon soln
Tier 1b
cefpodoxime oral suspension for reconstitution
Tier 2
cefpodoxime oral tablet Tier 2
cefprozil oral suspension for reconstitution
Tier 1b
cefprozil oral tablet Tier 1b
ceftazidime injection recon soln
Tier 2
ceftibuten oral capsule Tier 1b
ceftibuten oral suspension for reconstitution
Tier 1b
ceftriaxone in dextrose,iso-os intravenous piggyback
Tier 2
ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg
Tier 2
ceftriaxone intravenous recon soln
Tier 2
cefuroxime axetil oral tablet
Tier 1b
cephalexin oral capsule Tier 1a
cephalexin oral suspension for reconstitution
Tier 1a
cephalexin oral tablet Tier 1a
chloramphenicol sod succinate intravenous recon soln
Tier 2
CIPRO HC OTIC (EAR) DROPS,SUSPENSION
Tier 3
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
Tier 3 PA
Drug Name Tier Notes
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg
Tier 1b QL
ciprofloxacin hcl ophthalmic (eye) drops
Tier 1a
ciprofloxacin hcl oral tablet Tier 1b QL
ciprofloxacin hcl otic (ear) dropperette
Tier 1b
ciprofloxacin in 5 % dextrose intravenous piggyback
Tier 1b
ciprofloxacin lactate intravenous solution
Tier 2
clarithromycin oral suspension for reconstitution
Tier 1b
clarithromycin oral tablet Tier 1b
clarithromycin oral tablet extended release 24 hr
Tier 1b
cleansing wash topical cleanser
Tier 1b
clindamycin hcl oral capsule
Tier 1b
clindamycin palmitate hcl oral recon soln
Tier 1b
clindamycin pediatric oral recon soln
Tier 1b
clindamycin phosphate topical foam
Tier 1b
clindamycin phosphate topical gel
Tier 1b
clindamycin phosphate topical lotion
Tier 1b
clindamycin phosphate topical solution
Tier 1b
clindamycin phosphate topical swab
Tier 1b
clindamycin phosphate vaginal cream
Tier 1b
COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION
Tier 3
CORTISPORIN TOPICAL CREAM
Tier 3
CORTISPORIN TOPICAL OINTMENT
Tier 3
CYCLOSERINE ORAL CAPSULE
Tier 3
Effective 1/1/201712
Drug Name Tier Notes
DAPSONE ORAL TABLET
Tier 2
daptomycin intravenous recon soln
Tier 2
demeclocycline oral tablet Tier 2
dicloxacillin oral capsule Tier 1b
DIFICID ORAL TABLET Tier 3 PA
DORIBAX INTRAVENOUS RECON SOLN
Tier 3
doxycycline hyclate oral capsule
Tier 1b
doxycycline hyclate oral tablet 100 mg
Tier 1b
doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg
Tier 1b PA
doxycycline monohydrate oral capsule
Tier 1b
doxycycline monohydrate oral suspension for reconstitution
Tier 1b
doxycycline monohydrate oral tablet
Tier 1b
e.e.s. 400 oral tablet Tier 2
ery pads topical swab Tier 1b
erygel topical gel Tier 1b
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
Tier 1b
erythrocin (as stearate) oral tablet 250 mg
Tier 1b
erythromycin ethylsuccinate oral tablet
Tier 2
erythromycin ophthalmic (eye) ointment
Tier 1a
erythromycin oral capsule,delayed release(dr/ec)
Tier 2
erythromycin oral tablet Tier 2
erythromycin with ethanol topical gel
Tier 1b
erythromycin with ethanol topical solution
Tier 1b
erythromycin with ethanol topical swab
Tier 1b
Drug Name Tier Notes
erythromycin-benzoyl peroxide topical gel
Tier 1b
ethambutol oral tablet Tier 1b
FACTIVE ORAL TABLET Tier 3 QL
gatifloxacin ophthalmic (eye) drops
Tier 1b
gentak ophthalmic (eye) ointment
Tier 1a
gentamicin ophthalmic (eye) drops
Tier 1a
gentamicin ophthalmic (eye) ointment
Tier 1a
gentamicin topical cream Tier 1b
gentamicin topical ointment
Tier 1b
imipenem-cilastatin intravenous recon soln
Tier 2
INVANZ INJECTION RECON SOLN
Tier 3
INVANZ INTRAVENOUS RECON SOLN
Tier 3
isoniazid oral solution Tier 1a
isoniazid oral tablet Tier 1a
levofloxacin ophthalmic (eye) drops
Tier 1b
levofloxacin oral tablet Tier 2 QL
LINCOCIN INJECTION SOLUTION
Tier 3
lincomycin injection solution
Tier 2
linezolid oral suspension for reconstitution
Tier 2 PA; QL
linezolid oral tablet Tier 2 PA; QL
meropenem intravenous recon soln
Tier 2
methenamine hippurate oral tablet
Tier 1b
methenamine mandelate oral tablet
Tier 1b
metronidazole oral capsule
Tier 1a
metronidazole oral tablet Tier 1a
metronidazole vaginal gel Tier 1b
minocycline oral capsule Tier 1b
minocycline oral tablet Tier 1b
minocycline oral tablet extended release 24 hr
Tier 1b PA
Effective 1/1/201713
Drug Name Tier Notes
MONUROL ORAL PACKET
Tier 3
morgidox oral capsule 100 mg
Tier 1b
MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR
Tier 3
moxifloxacin ophthalmic (eye) drops
Tier 1b
mupirocin topical ointment Tier 1b
nafcillin in dextrose iso-osm intravenous piggyback
Tier 2
nafcillin injection recon soln
Tier 2
nafcillin intravenous recon soln
Tier 2
neomycin oral tablet Tier 1a
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment
Tier 1b
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment
Tier 1b
neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension
Tier 1a
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment
Tier 1a
neomycin-polymyxin-gramicidin ophthalmic (eye) drops
Tier 1b
neomycin-polymyxin-hc ophthalmic (eye) drops,suspension
Tier 1b
neomycin-polymyxin-hc otic (ear) drops,suspension
Tier 1b
neomycin-polymyxin-hc otic (ear) solution
Tier 1b
neo-polycin hc ophthalmic (eye) ointment
Tier 1b
neo-polycin ophthalmic (eye) ointment
Tier 1b
NEO-SYNALAR KIT TOPICAL CREAM
Tier 3
NEO-SYNALAR TOPICAL CREAM
Tier 3
Drug Name Tier Notes
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
Tier 1b
nitrofurantoin monohyd/m-cryst oral capsule
Tier 1b
nitrofurantoin oral suspension
Tier 1b
ofloxacin ophthalmic (eye) drops
Tier 1a
ofloxacin oral tablet 300 mg, 400 mg
Tier 1b QL
ofloxacin otic (ear) drops Tier 1b
ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE
Tier 3
oxacillin injection recon soln
Tier 2
oxacillin intravenous recon soln
Tier 2
PASER ORAL GRANULES DR FOR SUSP IN PACKET
Tier 3
penicillin g potassium injection recon soln
Tier 1b
penicillin v potassium oral recon soln
Tier 1b
penicillin v potassium oral tablet
Tier 1b
pfizerpen-g injection recon soln
Tier 1b
piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
Tier 1b
polycin ophthalmic (eye) ointment
Tier 1a
polymyxin b sulfate injection recon soln
Tier 1b
polymyxin b sulf-trimethoprim ophthalmic (eye) drops
Tier 1a
PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
PRIFTIN ORAL TABLET Tier 3
PRIMSOL ORAL SOLUTION
Tier 3
Effective 1/1/201714
Drug Name Tier Notes
pyrazinamide oral tablet Tier 1b
rifabutin oral capsule Tier 2
rifampin oral capsule Tier 1b
RIFATER ORAL TABLET Tier 3
silver sulfadiazine topical cream
Tier 1a
SIRTURO ORAL TABLET Tier 3
SIVEXTRO ORAL TABLET
Tier 3 PA; QL
ssd topical cream Tier 1a
sss 10-5 topical cream Tier 1b
sss 10-5 topical foam Tier 1b
STREPTOMYCIN INTRAMUSCULAR RECON SOLN
Tier 3
sulfacetamide sodium ophthalmic (eye) drops
Tier 1b
sulfacetamide sodium ophthalmic (eye) ointment
Tier 1b
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %
Tier 1b
sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)
Tier 1b
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)
Tier 1b
sulfacetamide sodium-sulfur topical pads, medicated 10-4 %
Tier 1b
sulfacetamide sodium-sulfur topical suspension
Tier 1b
sulfacetamide sod-sulfur-urea topical cleanser
Tier 1b
sulfacetamide-prednisolone ophthalmic (eye) drops
Tier 1b
sulfacetamide-sulfur-cleansr23 topical kit
Tier 1b
sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream
Tier 1b
sulfadiazine oral tablet Tier 2
sulfamethoxazole-trimethoprim oral suspension
Tier 1a
Drug Name Tier Notes
sulfamethoxazole-trimethoprim oral tablet
Tier 1a
SULFAMYLON TOPICAL CREAM
Tier 3
sulfatrim oral suspension Tier 1a
SUPRAX ORAL CAPSULE
Tier 3
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML
Tier 3
TEFLARO INTRAVENOUS RECON SOLN
Tier 3
tetracycline oral capsule Tier 1b
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
Tier 4 PA; SP; QL
thermazene topical cream Tier 1a
TOBRADEX OPHTHALMIC (EYE) OINTMENT
Tier 3
tobramycin in 0.225 % nacl inhalation solution for nebulization
Tier 4 SP
tobramycin ophthalmic (eye) drops
Tier 1a
tobramycin-dexamethasone ophthalmic (eye) drops,suspension
Tier 1b
TRECATOR ORAL TABLET
Tier 3
trimethoprim oral tablet Tier 1a
TYGACIL INTRAVENOUS RECON SOLN
Tier 3
vancomycin oral capsule Tier 2 PA
vandazole vaginal gel Tier 1b
VIBATIV INTRAVENOUS RECON SOLN 750 MG
Tier 3
XIFAXAN ORAL TABLET200 MG, 550 MG
Tier 3 PA; QL
ANTICOAGULANTS
ELIQUIS ORAL TABLET2.5 MG, 5 MG
Tier 3 QL
enoxaparin subcutaneous solution
Tier 4 QL
Effective 1/1/201715
Drug Name Tier Notes
enoxaparin subcutaneous syringe
Tier 4 QL
fondaparinux subcutaneous syringe
Tier 4 PA; QL
FRAGMIN SUBCUTANEOUS SOLUTION
Tier 4 QL
FRAGMIN SUBCUTANEOUS SYRINGE
Tier 4 QL
hep flush-10 (pf) intravenous solution
Tier 1b
heparin (porcine) in 0.9% nacl intravenous parenteral solution 10,000 unit/1,000 ml, 100 unit/100 ml (1 unit/ml), 2,500 unit/500 ml (5 unit/ml), 25,000 unit/250 ml, 250 unit/250 ml (1 unit/ml), 3,000 unit/500 ml (6 unit/ml), 30,000 unit/1,000 ml, 4000 unit/1000 ml (4 unit/ml), 5,000 unit/1,000 ml, 5,000 unit/500 ml (10 unit/ml), 6,000 unit/1000 ml (6 unit/ml)
Tier 1b
heparin (porcine) in 0.9% nacl intravenous syringe
Tier 1b
heparin (porcine) in 5 % dex intravenous parenteral solution
Tier 1b
heparin (porcine) in nacl (pf) intravenous parenteral solution
Tier 1b
heparin (porcine) injection cartridge
Tier 1b
heparin (porcine) injection solution
Tier 1b
heparin flush(porcine)-0.9nacl intravenous kit
Tier 1b
heparin lock flush (porcine) intravenous solution
Tier 1b
heparin lock flush (porcine) intravenous syringe
Tier 1b
heparin lock flush intravenous solution
Tier 1b
heparin lock flush intravenous syringe
Tier 1b
Drug Name Tier Notes
heparin lock intravenous solution
Tier 1b
heparin lockflush(porcine)(pf) intravenous syringe
Tier 1b
heparin(porcine) in 0.45% nacl intravenous parenteral solution 100 unit/100 ml (1 unit/ml), 25,000 unit/250 ml, 25,000 unit/500 ml, 5,000 unit/1,000 ml
Tier 1b
heparin, porcine (pf) injection solution
Tier 1b
heparin, porcine (pf) injection syringe
Tier 1b
heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)
Tier 1b
heparin, porcine (pf) intravenous syringe
Tier 1b
jantoven oral tablet Tier 1a
PRADAXA ORAL CAPSULE
Tier 3 QL
warfarin oral tablet Tier 1a
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG
Tier 3 PA; QL
XARELTO ORAL TABLETS,DOSE PACK
Tier 3 PA
ANTIDOTES
naloxone injection solution Tier 1b QL
naloxone injection syringe Tier 1b QL
naltrexone oral tablet Tier 1b
RELISTOR SUBCUTANEOUS SOLUTION
Tier 3 PA
RELISTOR SUBCUTANEOUS SYRINGE
Tier 3 PA
ANTIFUNGALS
amphotericin b injection recon soln
Tier 2
ciclopirox topical cream Tier 1b
ciclopirox topical gel Tier 1b
ciclopirox topical shampoo Tier 1b
ciclopirox topical solution Tier 1b
Effective 1/1/201716
Drug Name Tier Notes
ciclopirox topical suspension
Tier 1b
clotrimazole mucous membrane troche
Tier 2 QL
clotrimazole topical cream Tier 1b
clotrimazole topical solution
Tier 1b
clotrimazole-betamethasone topical cream
Tier 1b
clotrimazole-betamethasone topical lotion
Tier 1b
econazole topical cream Tier 1b
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN
Tier 3
ERTACZO TOPICAL CREAM
Tier 3
EXELDERM TOPICAL CREAM
Tier 3
EXELDERM TOPICAL SOLUTION
Tier 3
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml
Tier 1b QL
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
Tier 1b QL
flucytosine oral capsule Tier 1b
griseofulvin microsize oral suspension
Tier 1b
griseofulvin microsize oral tablet
Tier 1b
griseofulvin ultramicrosize oral tablet
Tier 1b
GYNAZOLE-1 VAGINAL CREAM
Tier 3
itraconazole oral capsule Tier 2 PA; QL
JUBLIA TOPICAL SOLUTION WITH APPLICATOR
Tier 3
KERYDIN TOPICAL SOLUTION WITH APPLICATOR
Tier 3
ketoconazole oral tablet Tier 1b QL
Drug Name Tier Notes
ketoconazole topical cream
Tier 1b
ketoconazole topical foam Tier 1b
ketoconazole topical shampoo
Tier 1b
LUZU TOPICAL CREAM Tier 3
MENTAX TOPICAL CREAM
Tier 3
miconazole-3 vaginal suppository
Tier 1b
MYCAMINE INTRAVENOUS RECON SOLN
Tier 3
NAFTIFINE TOPICAL CREAM 1 %
Tier 2
naftifine topical cream 2 % Tier 2
NAFTIN TOPICAL GEL Tier 3
NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
NOXAFIL ORAL SUSPENSION
Tier 3 QL
nyamyc topical powder Tier 1b
nystatin oral powder 150 million unit, 500 million unit
Tier 1b
nystatin oral suspension Tier 1b
nystatin oral tablet Tier 1b
nystatin topical cream Tier 1b
nystatin topical ointment Tier 1b
nystatin topical powder Tier 1b
nystatin-triamcinolone topical cream
Tier 1b
nystatin-triamcinolone topical ointment
Tier 1b
nystop topical powder Tier 1b
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET
Tier 3
oxiconazole topical cream Tier 2
OXISTAT TOPICAL LOTION
Tier 3
terbinafine hcl oral tablet Tier 1b PA; QL
terconazole vaginal cream Tier 1b
terconazole vaginal suppository
Tier 1b
Effective 1/1/201717
Drug Name Tier Notes
voriconazole oral suspension for reconstitution
Tier 2 QL
voriconazole oral tablet 200 mg, 50 mg
Tier 2 QL
ANTIHISTAMINE AND DECONGESTANT COMBINATION
promethazine vc oral syrup
Tier 1b
promethazine-phenylephrine syr
Tier 1b
ANTIHISTAMINES
azelastine ophthalmic (eye) drops
Tier 1b QL
BEPREVE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
carbinoxamine maleate oral liquid
Tier 1b
carbinoxamine maleate oral tablet
Tier 1b
cetirizine oral solution 1 mg/ml
Tier 1b
clemastine oral tablet 2.68 mg
Tier 1b
cyproheptadine oral syrup Tier 1b
cyproheptadine oral tablet Tier 1b
desloratadine oral tablet Tier 1b
desloratadine oral tablet,disintegrating
Tier 1b
diphenhydramine hcl injection solution 50 mg/ml
Tier 1b
diphenhydramine hcl injection syringe
Tier 1b
diphenhydramine hcl oral capsule 50 mg
Tier 1b
EMADINE OPHTHALMIC (EYE) DROPS
Tier 3 ST; QL
epinastine ophthalmic (eye) drops
Tier 1b QL
fexofenadine oral tablet 180 mg
Tier 1b
hydroxyzine hcl oral solution 10 mg/5 ml
Tier 1b
hydroxyzine hcl oral tablet Tier 1b
hydroxyzine pamoate oral capsule
Tier 1a
Drug Name Tier Notes
LASTACAFT OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
levocetirizine oral solution Tier 1b
levocetirizine oral tablet Tier 1b
olopatadine ophthalmic (eye) drops
Tier 2 PA; QL
promethazine oral syrup Tier 1a
promethazine oral tablet Tier 1a
ANTIHYPERGLYCEMICS
acarbose oral tablet Tier 1b
APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN
Tier 3 ST
APIDRA SUBCUTANEOUS SOLUTION
Tier 3 ST
AVANDIA ORAL TABLET2 MG, 4 MG
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON
Tier 3 ST; QL
chlorpropamide oral tablet Tier 1b
CYCLOSET ORAL TABLET
Tier 3
FARXIGA ORAL TABLET Tier 3 ST; QL
glimepiride oral tablet Tier 1b
glipizide oral tablet Tier 1a
glipizide oral tablet extended release 24hr
Tier 1a
glipizide-metformin oral tablet
Tier 1b
glyburide micronized oral tablet
Tier 1b
glyburide oral tablet Tier 1b
glyburide-metformin oral tablet
Tier 1b
HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
Effective 1/1/201718
Drug Name Tier Notes
HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG SUBCUTANEOUS CARTRIDGE
Tier 2
HUMALOG SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN R U-100 INJECTION SOLUTION
Tier 2
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION
Tier 2
INVOKAMET ORAL TABLET
Tier 3 ST; QL
INVOKANA ORAL TABLET
Tier 3 ST; QL
JANUMET ORAL TABLET
Tier 2 ST; QL
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG
Tier 2 ST; QL
JANUVIA ORAL TABLET Tier 2 ST; QL
Drug Name Tier Notes
JARDIANCE ORAL TABLET
Tier 2 ST; QL
JENTADUETO ORAL TABLET
Tier 2 ST; QL
LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN
Tier 2
LANTUS SUBCUTANEOUS SOLUTION
Tier 2
LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN
Tier 2
LEVEMIR SUBCUTANEOUS SOLUTION
Tier 2
metformin oral tablet Tier 1b
metformin oral tablet extended release 24 hr
Tier 1b
metformin oral tablet extended release 24hr
Tier 1b
miglitol oral tablet Tier 2
nateglinide oral tablet Tier 2 PA
NESINA ORAL TABLET Tier 3 ST; QL
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN N SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN R INJECTION SOLUTION
Tier 2
NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION
Tier 2
NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE
Tier 2
NOVOLOG SUBCUTANEOUS SOLUTION
Tier 2
ONGLYZA ORAL TABLET 2.5 MG
Tier 3 ST; DO
Effective 1/1/201719
Drug Name Tier Notes
ONGLYZA ORAL TABLET 5 MG
Tier 3 ST; QL
pioglitazone oral tablet Tier 1b QL
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYNJARDY ORAL TABLET
Tier 2 ST; QL
TANZEUM SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
tolazamide oral tablet Tier 1b
tolbutamide oral tablet Tier 1b
TRADJENTA ORAL TABLET
Tier 2 ST; DO
TRULICITY SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG
Tier 3 ST; QL
ANTIINFECTIVES/MISCELLANEOUS
ALBENZA ORAL TABLET
Tier 3
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
ALINIA ORAL TABLET Tier 3
atovaquone oral suspension
Tier 2
atovaquone-proguanil oral tablet
Tier 1b
BILTRICIDE ORAL TABLET
Tier 3
chloroquine phosphate oral tablet
Tier 1a
COARTEM ORAL TABLET
Tier 3
Drug Name Tier Notes
DARAPRIM ORAL TABLET
Tier 3 PA; LD; QL
hydroxychloroquine oral tablet
Tier 1b
ivermectin oral tablet Tier 1b
mefloquine oral tablet Tier 1b
NEBUPENT INHALATION RECON SOLN
Tier 4
paromomycin oral capsule Tier 1b
PRIMAQUINE ORAL TABLET
Tier 3
quinine sulfate oral capsule
Tier 2 PA; QL
ANTINEOPLASTICS
ACTIMMUNE SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION
Tier 4 PA; SP
AFINITOR ORAL TABLET
Tier 4 PA; SP
anastrozole oral tablet Tier 1b QL
bexarotene oral capsule Tier 4 PA; SP
bicalutamide oral tablet Tier 4
BOSULIF ORAL TABLET100 MG, 500 MG
Tier 4 PA; SP; QL
capecitabine oral tablet Tier 4 PA; SP
CAPRELSA ORAL TABLET 100 MG, 300 MG
Tier 4 PA; QL
CARAC TOPICAL CREAM
Tier 2 QL
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)
Tier 4 PA; LD; QL
CYCLOPHOSPHAMIDE ORAL CAPSULE
Tier 4 SP
diclofenac sodium topical gel 3 %
Tier 1b QL
EMCYT ORAL CAPSULE Tier 4 PA
ERIVEDGE ORAL CAPSULE
Tier 4 PA; SP; QL
Effective 1/1/201720
Drug Name Tier Notes
ETOPOPHOS INTRAVENOUS RECON SOLN
Tier 4 SP
etoposide oral capsule Tier 4 SP
exemestane oral tablet Tier 4 PA; QL
FARESTON ORAL TABLET
Tier 4 QL
FARYDAK ORAL CAPSULE
Tier 4 PA; SP; QL
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG
Tier 4 PA; SP; QL
FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG
Tier 4 PA; SP; QL
fludarabine intravenous recon soln
Tier 4 SP
fludarabine intravenous solution
Tier 4 SP
fluorouracil topical cream 5 %
Tier 1b QL
fluorouracil topical solution Tier 1b QL
flutamide oral capsule Tier 1b
GILOTRIF ORAL TABLET
Tier 4 PA; SP; LD; QL
GLEOSTINE ORAL CAPSULE
Tier 4 PA
HEXALEN ORAL CAPSULE
Tier 4
HYCAMTIN ORAL CAPSULE
Tier 4 SP
hydroxyurea oral capsule Tier 1b
IBRANCE ORAL CAPSULE
Tier 4 PA; SP; QL
ICLUSIG ORAL TABLET15 MG, 45 MG
Tier 4 PA; QL
imatinib oral tablet 100 mg, 400 mg
Tier 4 PA; SP; QL
IMBRUVICA ORAL CAPSULE
Tier 4 PA; LD; QL
INLYTA ORAL TABLET 1 MG, 5 MG
Tier 4 PA; SP; QL
INTRON A INJECTION RECON SOLN
Tier 4 PA; SP
INTRON A INJECTION SOLUTION
Tier 4 PA; SP
Drug Name Tier Notes
JAKAFI ORAL TABLET10 MG, 15 MG, 20 MG, 25 MG, 5 MG
Tier 4 PA; SP; LD; QL
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)
Tier 4 PA; SP; LD; QL
letrozole oral tablet Tier 4 QL
LEUKERAN ORAL TABLET
Tier 4
leuprolide subcutaneous kit
Tier 4 PA; SP
LYNPARZA ORAL CAPSULE
Tier 4 PA; SP; LD; QL
LYSODREN ORAL TABLET
Tier 4 QL
MATULANE ORAL CAPSULE
Tier 4 LD
MEKINIST ORAL TABLET 0.5 MG, 2 MG
Tier 4 PA; SP; QL
melphalan hcl intravenous recon soln
Tier 4 SP
melphalan oral tablet Tier 4
mercaptopurine oral tablet Tier 4
methotrexate sodium oral tablet
Tier 1b
MYLERAN ORAL TABLET
Tier 4
NEXAVAR ORAL TABLET
Tier 4 PA; SP; QL
nilutamide oral tablet Tier 4 QL
ODOMZO ORAL CAPSULE
Tier 4 PA; SP; QL
PANRETIN TOPICAL GEL
Tier 3 SP
PICATO TOPICAL GEL0.015 %, 0.05 %
Tier 3 PA; QL
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
Tier 4 PA; SP; QL
REVLIMID ORAL CAPSULE
Tier 4 PA; SP; QL
Effective 1/1/201721
Drug Name Tier Notes
RITUXAN INTRAVENOUS CONCENTRATE
Tier 4 PA; SP
SPRYCEL ORAL TABLET
Tier 4 PA; SP; QL
STIVARGA ORAL TABLET
Tier 4 PA; SP; QL
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
Tier 4 PA; SP; QL
SYNRIBO SUBCUTANEOUS RECON SOLN
Tier 4 LD
TABLOID ORAL TABLET Tier 4
TAFINLAR ORAL CAPSULE
Tier 4 SP; QL
tamoxifen oral tablet Tier 1b $0
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
Tier 4 PA; SP; QL
TARGRETIN TOPICAL GEL
Tier 4 PA; SP
TASIGNA ORAL CAPSULE
Tier 4 PA; SP; QL
temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg
Tier 4 PA; SP; QL
topotecan intravenous recon soln
Tier 4 SP
topotecan intravenous solution
Tier 4 SP
TORISEL INTRAVENOUS RECON SOLN
Tier 4 SP
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG, 22.5 MG, 3.75 MG
Tier 4 PA; SP; QL
TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML
Tier 4 PA; SP; QL
tretinoin (chemotherapy) oral capsule
Tier 4
TYKERB ORAL TABLET Tier 4 PA; SP; QL
VOTRIENT ORAL TABLET
Tier 4 PA; SP; QL
XALKORI ORAL CAPSULE
Tier 4 PA; SP; LD; QL
Drug Name Tier Notes
XTANDI ORAL CAPSULE Tier 4 PA; SP; QL
YERVOY INTRAVENOUS SOLUTION
Tier 4 PA; SP
ZANOSAR INTRAVENOUS RECON SOLN
Tier 4 SP
ZELBORAF ORAL TABLET
Tier 4 PA; SP; QL
ZOLINZA ORAL CAPSULE
Tier 4 PA; SP; QL
ZYDELIG ORAL TABLET Tier 4 PA; LD; QL
ZYKADIA ORAL CAPSULE
Tier 4 PA; SP; QL
ZYTIGA ORAL TABLET250 MG
Tier 4 PA; SP; QL
ZYTIGA ORAL TABLET500 MG
Tier 4 PA; QL
ANTI-OBESITY DRUGS
BELVIQ ORAL TABLET Tier 3 PA
CONTRAVE ORAL TABLET EXTENDED RELEASE
Tier 3 PA
phendimetrazine tartrate oral capsule, extended release
Tier 1b PA
phendimetrazine tartrate oral tablet
Tier 1b PA
phentermine oral capsule Tier 1b PA
phentermine oral tablet Tier 1b PA
QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR
Tier 3 PA
ANTIPARKINSON DRUGS
amantadine hcl oral capsule
Tier 2 QL
amantadine hcl oral solution
Tier 2
amantadine hcl oral tablet Tier 2 QL
APOKYN SUBCUTANEOUS CARTRIDGE
Tier 4 SP; LD; QL
benztropine oral tablet Tier 1a
bromocriptine oral capsule Tier 1b
bromocriptine oral tablet Tier 1b
carbidopa oral tablet Tier 2
carbidopa-levodopa oral tablet
Tier 1b
Effective 1/1/201722
Drug Name Tier Notes
carbidopa-levodopa oral tablet extended release
Tier 1b
carbidopa-levodopa oral tablet,disintegrating
Tier 1b
entacapone oral tablet Tier 2 QL
pramipexole oral tablet Tier 2 QL
rasagiline oral tablet Tier 2
ropinirole oral tablet Tier 1b
ropinirole oral tablet extended release 24 hr
Tier 2
selegiline hcl oral capsule Tier 1b
selegiline hcl oral tablet Tier 1b
tolcapone oral tablet Tier 2 QL
trihexyphenidyl oral elixir Tier 1a
trihexyphenidyl oral tablet Tier 1a
ANTIPLATELET DRUGS
anagrelide oral capsule Tier 2
aspirin-dipyridamole oral capsule, er multiphase 12 hr
Tier 2 QL
BRILINTA ORAL TABLET
Tier 3 QL
cilostazol oral tablet Tier 1b
clopidogrel oral tablet 300 mg
Tier 2
clopidogrel oral tablet 75 mg
Tier 2 QL
dipyridamole oral tablet Tier 1b
EFFIENT ORAL TABLET10 MG
Tier 3 QL
EFFIENT ORAL TABLET5 MG
Tier 3 DO
prasugrel oral tablet Tier 2
ticlopidine oral tablet Tier 1b
ZONTIVITY ORAL TABLET
Tier 3 QL
ANTIVIRALS
abacavir oral tablet Tier 4
abacavir-lamivudine oral tablet
Tier 4
abacavir-lamivudine-zidovudine oral tablet
Tier 4
acyclovir oral capsule Tier 1b
acyclovir oral suspension 200 mg/5 ml
Tier 1b
acyclovir oral tablet Tier 1b
Drug Name Tier Notes
acyclovir topical ointment Tier 3 QL
adefovir oral tablet Tier 4 SP
APTIVUS ORAL CAPSULE
Tier 4
APTIVUS ORAL SOLUTION
Tier 4
BARACLUDE ORAL SOLUTION
Tier 4 SP
cidofovir intravenous solution
Tier 2 SP
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 4
DENAVIR TOPICAL CREAM
Tier 3 QL
didanosine oral capsule,delayed release(dr/ec)
Tier 4
EDURANT ORAL TABLET
Tier 4
EMTRIVA ORAL CAPSULE
Tier 4
EMTRIVA ORAL SOLUTION
Tier 4
entecavir oral tablet Tier 4 SP
EPCLUSA ORAL TABLET
Tier 4 PA; SP; QL
EPIVIR HBV ORAL SOLUTION
Tier 4 SP
EVOTAZ ORAL TABLET Tier 4
famciclovir oral tablet Tier 1b
foscarnet intravenous solution
Tier 2
FUZEON SUBCUTANEOUS RECON SOLN
Tier 4
ganciclovir sodium intravenous recon soln
Tier 4 SP
GENVOYA ORAL TABLET
Tier 4
HARVONI ORAL TABLET
Tier 4 PA; SP; QL
INTELENCE ORAL TABLET
Tier 4
INVIRASE ORAL CAPSULE
Tier 4
INVIRASE ORAL TABLET
Tier 4
Effective 1/1/201723
Drug Name Tier Notes
ISENTRESS ORAL TABLET
Tier 4
ISENTRESS ORAL TABLET,CHEWABLE
Tier 4
KALETRA ORAL TABLET
Tier 4
lamivudine oral tablet 150 mg, 300 mg
Tier 4
lamivudine-zidovudine oral tablet
Tier 4
lopinavir-ritonavir oral solution
Tier 4
moderiba dose pack oral tablets,dose pack
Tier 4 SP
moderiba oral tablet Tier 4 SP
nevirapine oral suspension Tier 4
nevirapine oral tablet Tier 4
NORVIR ORAL CAPSULE
Tier 4
NORVIR ORAL SOLUTION
Tier 4
NORVIR ORAL TABLET Tier 4
OLYSIO ORAL CAPSULE
Tier 4 PA; SP; QL
oseltamivir oral capsule 30 mg, 45 mg, 75 mg
Tier 2 QL
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
PEGASYS SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; QL
PEGASYS SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
Tier 4 PA; SP
PREZISTA ORAL SUSPENSION
Tier 4
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Tier 4
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE
Tier 2 QL
RESCRIPTOR ORAL TABLET
Tier 4
Drug Name Tier Notes
RESCRIPTOR ORAL TABLET, DISPERSIBLE
Tier 4
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
Tier 4
ribasphere oral capsule Tier 4 SP
ribasphere oral tablet Tier 4 SP
ribasphere ribapak oral tablets,dose pack
Tier 4 SP
ribavirin oral capsule Tier 4 SP
ribavirin oral tablet 200 mg Tier 4 SP
rimantadine oral tablet Tier 1b
SELZENTRY ORAL TABLET
Tier 4
SOVALDI ORAL TABLET Tier 4 PA; SP; QL
stavudine oral capsule Tier 4
stavudine oral recon soln Tier 4
STRIBILD ORAL TABLET
Tier 4
SUSTIVA ORAL CAPSULE
Tier 4
SUSTIVA ORAL TABLET Tier 4
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION
Tier 2 QL
TECHNIVIE ORAL TABLET
Tier 4 PA; SP; QL
TIVICAY ORAL TABLET Tier 4
trifluridine ophthalmic (eye) drops
Tier 1b
TRIUMEQ ORAL TABLET
Tier 4
TRUVADA ORAL TABLET
Tier 4
valacyclovir oral tablet Tier 1b
valganciclovir oral recon soln
Tier 2 SP
valganciclovir oral tablet Tier 2 SP
VEREGEN TOPICAL OINTMENT
Tier 3
VIEKIRA PAK ORAL TABLETS,DOSE PACK
Tier 4 PA; SP; QL
VIRACEPT ORAL TABLET
Tier 4
VIREAD ORAL TABLET Tier 4
zidovudine oral capsule Tier 4
zidovudine oral syrup Tier 4
Effective 1/1/201724
Drug Name Tier Notes
zidovudine oral tablet Tier 4
ZIRGAN OPHTHALMIC (EYE) GEL
Tier 3
AUTONOMIC DRUGS
bethanechol chloride oral tablet
Tier 2
BOTOX INJECTION RECON SOLN
Tier 4 PA; SP
cevimeline oral capsule Tier 2
dextroamphetamine oral capsule, extended release
Tier 1b PA
dextroamphetamine oral solution
Tier 1b PA
dextroamphetamine oral tablet
Tier 1b PA
dextroamphetamine-amphetamine oral capsule,extended release 24hr
Tier 1b PA
dextroamphetamine-amphetamine oral tablet
Tier 1b PA
donepezil oral tablet Tier 2
donepezil oral tablet,disintegrating
Tier 2
epinephrine 0.3 mg auto-inject
Tier 1b QL
epinephrine 0.3 mg auto-inject inner
Tier 1b QL
epinephrine 0.3 mg auto-inject latex-free, sdv
Tier 1b QL
epinephrine 0.3 mg auto-inject latex-free, suv
Tier 1b QL
epinephrine 0.3 mg auto-inject no latex, auto-injct
Tier 1b QL
epinephrine 0.3 mg auto-inject no latex, two-pack
Tier 1b QL
epinephrine injection auto-injector 0.15 mg/0.15 ml
Tier 1b QL
EPIPEN 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR INJECTION AUTO-INJECTOR
Tier 2 QL
Drug Name Tier Notes
galantamine oral capsule,ext rel. pellets 24 hr
Tier 2
galantamine oral solution Tier 2
galantamine oral tablet Tier 2
guanidine oral tablet Tier 1b
methamphetamine oral tablet
Tier 2 PA
midodrine oral tablet Tier 1b
NORTHERA ORAL CAPSULE
Tier 3 SP; LD
phenoxybenzamine oral capsule
Tier 2
pilocarpine hcl oral tablet Tier 2
procentra oral solution Tier 1b PA
pyridostigmine bromide oral tablet
Tier 1b
rivastigmine tartrate oral capsule
Tier 2
zenzedi oral tablet 10 mg, 5 mg
Tier 1b PA
BIOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1b $0
AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1b $0
ATGAM INTRAVENOUS SOLUTION
Tier 4 SP
Effective 1/1/201725
Drug Name Tier Notes
BEXSERO INTRAMUSCULAR SYRINGE
Tier 2 $0
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION
Tier 3 $0
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE
Tier 3 $0
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE
Tier 1b
FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION
Tier 1b $0
FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1b $0
FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
Drug Name Tier Notes
FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1b $0
FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1b $0
FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE
Tier 1b $0
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION
Tier 1b $0
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1b
FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1b $0
FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0
GAMASTAN S/D INTRAMUSCULAR SOLUTION
Tier 4 PA; SP
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION
Tier 2 $0
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
HAVRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
HAVRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
HYQVIA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP
Effective 1/1/201726
Drug Name Tier Notes
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN
Tier 3
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
IPOL INJECTION SUSPENSION
Tier 3 $0
IXIARO (PF) INTRAMUSCULAR SYRINGE
Tier 3
KINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
KINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
MENACTRA (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN
Tier 3 $0
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT
Tier 3 $0
M-M-R II (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
OCTAGAM INTRAVENOUS SOLUTION
Tier 4 PA; SP
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
PENTACEL (PF) INTRAMUSCULAR KIT
Tier 3 $0
Drug Name Tier Notes
PNEUMOVAX 23 INJECTION SOLUTION
Tier 2 $0
PNEUMOVAX 23 INJECTION SYRINGE
Tier 2 $0
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 3
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3 $0
ROTATEQ VACCINE ORAL SOLUTION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION
Tier 3 $0
THYMOGLOBULIN INTRAVENOUS RECON SOLN
Tier 4 SP
TRUMENBA INTRAMUSCULAR SYRINGE
Tier 2 $0
TWINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
Effective 1/1/201727
Drug Name Tier Notes
TYPHIM VI INTRAMUSCULAR SOLUTION
Tier 3
TYPHIM VI INTRAMUSCULAR SYRINGE
Tier 3
VAQTA (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
VAQTA (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 2 $0
BLOOD
DROXIA ORAL CAPSULE
Tier 4
pentoxifylline oral tablet extended release
Tier 1b
tranexamic acid intravenous solution
Tier 2
tranexamic acid oral tablet Tier 1b
CARDIAC DRUGS
afeditab cr oral tablet extended release 30 mg
Tier 1b DO
afeditab cr oral tablet extended release 60 mg
Tier 1b QL
amiodarone oral tablet Tier 1b
amlodipine oral tablet 10 mg
Tier 1b QL
amlodipine oral tablet 2.5 mg, 5 mg
Tier 1b DO
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1b DO
Drug Name Tier Notes
cartia xt oral capsule,extended release 24hr 240 mg, 300 mg
Tier 1b QL
digox oral tablet Tier 1b
digoxin oral solution 50 mcg/ml
Tier 1b
digoxin oral tablet Tier 1b
diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1b DO
diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg
Tier 1b QL
diltiazem hcl oral capsule,extended release 12 hr
Tier 2 QL
diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1b DO
diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1b QL
diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1b DO
diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg
Tier 1b QL
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
Tier 1b QL
diltiazem hcl oral tablet extended release 24 hr 180 mg
Tier 1b DO
diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1b QL
dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1b DO
dilt-xr oral capsule,ext.rel 24h degradable 240 mg
Tier 1b QL
disopyramide phosphate oral capsule
Tier 1b
dofetilide oral capsule Tier 2
Effective 1/1/201728
Drug Name Tier Notes
felodipine oral tablet extended release 24 hr 10 mg
Tier 1b QL
felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg
Tier 1b DO
flecainide oral tablet Tier 2
isosorbide dinitrate oral tablet
Tier 1b
isosorbide dinitrate oral tablet extended release
Tier 1b
isosorbide mononitrate oral tablet
Tier 1b
isosorbide mononitrate oral tablet extended release 24 hr
Tier 1b
isradipine oral capsule 2.5 mg, 5 mg
Tier 1b QL
LANOXIN ORAL TABLET Tier 3
matzim la oral tablet extended release 24 hr 180 mg
Tier 1b DO
matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1b QL
mexiletine oral capsule Tier 2
MULTAQ ORAL TABLET Tier 3
nicardipine oral capsule 20 mg, 30 mg
Tier 2 QL
nifedipine oral capsule Tier 1b QL
nifedipine oral tablet extended release 24hr 30 mg
Tier 1b DO
nifedipine oral tablet extended release 24hr 60 mg, 90 mg
Tier 1b QL
nifedipine oral tablet extended release 30 mg
Tier 1b DO
nifedipine oral tablet extended release 60 mg, 90 mg
Tier 1b QL
nimodipine oral capsule Tier 2 QL
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg
Tier 1b DO
nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg
Tier 1b QL
Drug Name Tier Notes
nitro-bid transdermal ointment
Tier 1b
nitroglycerin oral capsule, extended release
Tier 2
nitroglycerin sublingual tablet
Tier 1b
nitroglycerin translingual aerosol,spray
Tier 2
nitroglycerin translingual spray,non-aerosol
Tier 2
nitro-time oral capsule, extended release
Tier 1b
pacerone oral tablet 100 mg, 200 mg, 400 mg
Tier 2
procainamide injection solution
Tier 2
propafenone oral capsule,extended release 12 hr
Tier 2
propafenone oral tablet Tier 2
quinidine sulfate oral tablet Tier 1a
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3
taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1b DO
taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg
Tier 1b QL
verapamil oral capsule, 24 hr er pellet ct 100 mg
Tier 1b DO
verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg
Tier 1b QL
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg
Tier 1b DO
verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg
Tier 1b QL
verapamil oral tablet 120 mg, 40 mg, 80 mg
Tier 1b QL
verapamil oral tablet extended release
Tier 1b QL
CARDIOVASCULAR
acebutolol oral capsule Tier 1b
Effective 1/1/201729
Drug Name Tier Notes
ADCIRCA ORAL TABLET
Tier 4 PA; SP; QL
ADEMPAS ORAL TABLET
Tier 4 PA; SP; LD; QL
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg
Tier 1b 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
Tier 1b DO
amlodipine-benazepril oral capsule
Tier 1b
atenolol oral tablet Tier 1a
atenolol-chlorthalidone oral tablet
Tier 1b
atorvastatin oral tablet 10 mg, 20 mg, 40 mg
Tier 1b DO
atorvastatin oral tablet 80 mg
Tier 1b QL
benazepril oral tablet Tier 1a
benazepril-hydrochlorothiazide oral tablet
Tier 1b
betaxolol oral tablet Tier 1b
bisoprolol fumarate oral tablet
Tier 1b
bisoprolol-hydrochlorothiazide oral tablet
Tier 1b
BYSTOLIC ORAL TABLET
Tier 3
candesartan oral tablet 16 mg, 32 mg
Tier 1b QL
candesartan oral tablet 4 mg, 8 mg
Tier 1b DO; QL
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg
Tier 1b QL
candesartan-hydrochlorothiazid oral tablet 32-25 mg
Tier 1b
captopril oral tablet Tier 2
captopril-hydrochlorothiazide oral tablet
Tier 2
carvedilol oral tablet Tier 1b
Drug Name Tier Notes
cholestyramine (with sugar) oral powder
Tier 1b QL
cholestyramine (with sugar) oral powder in packet
Tier 1b QL
cholestyramine light oral powder
Tier 1b QL
cholestyramine light oral powder in packet
Tier 1b
clonidine hcl oral tablet Tier 1a
colestipol oral granules Tier 1b
colestipol oral packet Tier 1b
colestipol oral tablet Tier 1b
doxazosin oral tablet Tier 1b
EDARBI ORAL TABLET40 MG
Tier 3 DO
EDARBI ORAL TABLET80 MG
Tier 3
enalapril maleate oral tablet
Tier 1b
enalapril-hydrochlorothiazide oral tablet
Tier 1b
eprosartan oral tablet Tier 1b QL
ergoloid oral tablet Tier 2
ezetimibe oral tablet Tier 2 PA; QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 1b
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1b QL
fenofibrate nanocrystallized oral tablet
Tier 1b QL
fenofibrate oral tablet 160 mg, 54 mg
Tier 1b QL
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
Tier 1b QL
fenofibric acid oral tablet Tier 1b QL
fluvastatin oral capsule Tier 1b DO
fosinopril oral tablet Tier 1b
fosinopril-hydrochlorothiazide oral tablet
Tier 1b
gemfibrozil oral tablet Tier 1b
guanfacine oral tablet Tier 1b
Effective 1/1/201730
Drug Name Tier Notes
HEMANGEOL ORAL SOLUTION
Tier 4
hydralazine oral tablet Tier 1b
indomethacin sodium intravenous recon soln
Tier 2
irbesartan oral tablet 150 mg, 75 mg
Tier 1b DO
irbesartan oral tablet 300 mg
Tier 1b QL
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg
Tier 1b QL
irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg
Tier 1b
labetalol oral tablet Tier 1b
LETAIRIS ORAL TABLET Tier 4 PA; SP; LD; QL
LEVATOL ORAL TABLET
Tier 3
lisinopril oral tablet Tier 1a
lisinopril-hydrochlorothiazide oral tablet
Tier 1b
LIVALO ORAL TABLET 1 MG, 2 MG
Tier 3 ST; DO
LIVALO ORAL TABLET 4 MG
Tier 3 ST; QL
losartan oral tablet 100 mg, 25 mg, 50 mg
Tier 1b QL
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg
Tier 1b QL
losartan-hydrochlorothiazide oral tablet 50-12.5 mg
Tier 1b DO
lovastatin oral tablet 10 mg, 20 mg
Tier 1b DO
lovastatin oral tablet 40 mg
Tier 1b QL
methyldopa oral tablet Tier 1b
methyldopa-hydrochlorothiazide oral tablet
Tier 1b
methyldopate intravenous solution
Tier 2
metoprolol succinate oral tablet extended release 24 hr
Tier 1b
Drug Name Tier Notes
metoprolol ta-hydrochlorothiaz oral tablet
Tier 1b
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
Tier 1a
minoxidil oral tablet Tier 1b
moexipril oral tablet Tier 1b
moexipril-hydrochlorothiazide oral tablet
Tier 1b
nadolol oral tablet Tier 1b
nadolol-bendroflumethiazide oral tablet
Tier 1b
niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg
Tier 1b QL
olmesartan oral tablet 20 mg
Tier 2 DO
olmesartan oral tablet 40 mg, 5 mg
Tier 2 QL
OPSUMIT ORAL TABLET Tier 4 PA; SP; LD; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG
Tier 4 PA; SP; LD
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG
Tier 4 PA; LD
perindopril erbumine oral tablet
Tier 1b
pindolol oral tablet Tier 1b
pravastatin oral tablet 10 mg, 20 mg
Tier 1b DO
pravastatin oral tablet 40 mg
Tier 1b
pravastatin oral tablet 80 mg
Tier 1b QL
prazosin oral capsule Tier 1b
prevalite oral powder Tier 1b
prevalite oral powder in packet
Tier 1b
propranolol oral capsule,extended release 24 hr
Tier 1b
propranolol oral solution Tier 1b
propranolol oral tablet Tier 1b
Effective 1/1/201731
Drug Name Tier Notes
propranolol-hydrochlorothiazid oral tablet
Tier 1b
quinapril oral tablet Tier 1b
quinapril-hydrochlorothiazide oral tablet
Tier 1b
ramipril oral capsule Tier 1b
REMODULIN INJECTION SOLUTION
Tier 4 PA; SP; LD
rosuvastatin oral tablet 10 mg, 20 mg, 5 mg
Tier 2 DO
rosuvastatin oral tablet 40 mg
Tier 2 QL
sildenafil oral tablet Tier 4 PA; SP; QL
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1b DO
simvastatin oral tablet 80 mg
Tier 1b PA; QL
sorine oral tablet Tier 1b
sotalol af oral tablet Tier 2
sotalol oral tablet Tier 2
TEKTURNA ORAL TABLET 150 MG
Tier 3 DO
TEKTURNA ORAL TABLET 300 MG
Tier 3 QL
telmisartan oral tablet 20 mg, 40 mg
Tier 1b DO
telmisartan oral tablet 80 mg
Tier 1b QL
terazosin oral capsule Tier 1b
timolol maleate oral tablet Tier 1b
TRACLEER ORAL TABLET
Tier 4 PA; SP; QL
trandolapril oral tablet Tier 1b
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg
Tier 1b DO
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg
Tier 1b QL
valsartan oral tablet 160 mg, 320 mg
Tier 1b QL
valsartan oral tablet 40 mg, 80 mg
Tier 1b DO; QL
Drug Name Tier Notes
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg
Tier 1b DO
valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg
Tier 1b QL
VECAMYL ORAL TABLET
Tier 3
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
Tier 4 PA; SP; LD; QL
WELCHOL ORAL POWDER IN PACKET
Tier 3
WELCHOL ORAL TABLET
Tier 3
CNS DRUGS
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR
Tier 4 PA; SP; QL
APTIOM ORAL TABLET Tier 3
AUBAGIO ORAL TABLET
Tier 4 PA; SP; QL
BANZEL ORAL SUSPENSION
Tier 3
BANZEL ORAL TABLET Tier 3
carbamazepine oral capsule, er multiphase 12 hr
Tier 1b
carbamazepine oral suspension 100 mg/5 ml
Tier 1b
carbamazepine oral tablet Tier 1b
carbamazepine oral tablet extended release 12 hr
Tier 1b
carbamazepine oral tablet,chewable
Tier 1b
CELONTIN ORAL CAPSULE 300 MG
Tier 3
clonazepam oral tablet Tier 1b
clonazepam oral tablet,disintegrating
Tier 1b
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
Tier 4 PA; SP
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML
Tier 4 PA; SP
diazepam rectal kit Tier 2
Effective 1/1/201732
Drug Name Tier Notes
divalproex oral capsule, delayed rel sprinkle
Tier 2
divalproex oral tablet extended release 24 hr
Tier 2
divalproex oral tablet,delayed release (dr/ec)
Tier 2
epitol oral tablet Tier 1b
ethosuximide oral capsule Tier 1b
ethosuximide oral solution Tier 1b
EXTAVIA SUBCUTANEOUS KIT
Tier 4 PA; SP
EXTAVIA SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
felbamate oral suspension Tier 1b
felbamate oral tablet Tier 1b
fosphenytoin injection solution
Tier 2
FYCOMPA ORAL TABLET
Tier 3
gabapentin oral capsule Tier 2
gabapentin oral solution Tier 2
gabapentin oral tablet 600 mg, 800 mg
Tier 2
GILENYA ORAL CAPSULE
Tier 4 PA; SP; QL
HORIZANT ORAL TABLET EXTENDED RELEASE
Tier 3 PA; QL
lamotrigine oral tablet Tier 1b
lamotrigine oral tablet, chewable dispersible
Tier 1b
levetiracetam oral solution Tier 2
levetiracetam oral tablet Tier 2
levetiracetam oral tablet extended release 24 hr
Tier 2 PA
LYRICA ORAL CAPSULE100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG
Tier 3 PA; QL
LYRICA ORAL SOLUTION
Tier 3 PA; QL
memantine oral solution Tier 2
memantine oral tablet Tier 2
memantine oral tablets,dose pack
Tier 3
Drug Name Tier Notes
NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK
Tier 3
NUEDEXTA ORAL CAPSULE
Tier 3
ONFI ORAL SUSPENSION
Tier 3
ONFI ORAL TABLET 10 MG, 20 MG
Tier 3
oxcarbazepine oral suspension
Tier 2
oxcarbazepine oral tablet Tier 2
PEGANONE ORAL TABLET
Tier 3
phenytoin sodium extended oral capsule
Tier 1b
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
PLEGRIDY SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
primidone oral tablet Tier 1b
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
riluzole oral tablet Tier 4 SP
SABRIL ORAL POWDER IN PACKET
Tier 3 SP; LD
SABRIL ORAL TABLET Tier 3 SP; LD
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG
Tier 4 PA; SP; QL
tetrabenazine oral tablet Tier 2 PA; SP; LD
tiagabine oral tablet Tier 2
topiramate oral capsule, sprinkle
Tier 1b
topiramate oral tablet Tier 1b
valproic acid (as sodium salt) oral solution
Tier 1b
valproic acid oral capsule Tier 1b
Effective 1/1/201733
Drug Name Tier Notes
vigabatrin oral powder in packet
Tier 2
VIMPAT ORAL SOLUTION
Tier 3
VIMPAT ORAL TABLET Tier 3
zonisamide oral capsule Tier 2
COLONY STIMULATING FACTORS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION
Tier 4 PA; SP
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
Tier 4 PA; SP
LEUKINE INJECTION RECON SOLN
Tier 4 PA; SP
MOZOBIL SUBCUTANEOUS SOLUTION
Tier 4 PA; SP
NEULASTA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR
Tier 4 SP; QL
NEUPOGEN INJECTION SOLUTION
Tier 4 PA; SP
NEUPOGEN INJECTION SYRINGE
Tier 4 PA; SP
PROCRIT INJECTION SOLUTION
Tier 4 PA; SP
PROMACTA ORAL TABLET
Tier 4 PA; SP
CONTRACEPTIVES
AFTERA ORAL TABLET Tier 1b $0; QL
altavera (28) oral tablet Tier 1a $0
alyacen 1/35 (28) oral tablet
Tier 1a $0
alyacen 7/7/7 (28) oral tablet
Tier 1a $0
amethia lo oral tablets,dose pack,3 month
Tier 1b $0
amethia oral tablets,dose pack,3 month
Tier 1b $0
amethyst oral tablet Tier 1b $0
apri oral tablet Tier 1a $0
aranelle (28) oral tablet Tier 1a $0
Drug Name Tier Notes
ashlyna oral tablets,dose pack,3 month
Tier 1b $0
aubra oral tablet Tier 1a $0
aviane oral tablet Tier 1a $0
azurette (28) oral tablet Tier 1b $0
balziva (28) oral tablet Tier 1a $0
BEKYREE (28) ORAL TABLET
Tier 1b $0
BLISOVI 24 FE ORAL TABLET
Tier 1a $0
BLISOVI FE 1.5/30 (28) ORAL TABLET
Tier 1a $0
BLISOVI FE 1/20 (28) ORAL TABLET
Tier 1a $0
briellyn oral tablet Tier 1a $0
camila oral tablet Tier 1b $0
camrese lo oral tablets,dose pack,3 month
Tier 1b $0
camrese oral tablets,dose pack,3 month
Tier 1b $0
caziant (28) oral tablet Tier 1a $0
chateal oral tablet Tier 1a $0
cryselle (28) oral tablet Tier 1a $0
cyclafem 1/35 (28) oral tablet
Tier 1a $0
cyclafem 7/7/7 (28) oral tablet
Tier 1a $0
cyred oral tablet Tier 1a $0
dasetta 1/35 (28) oral tablet
Tier 1a $0
dasetta 7/7/7 (28) oral tablet
Tier 1a $0
daysee oral tablets,dose pack,3 month
Tier 1b $0
deblitane oral tablet Tier 1b $0
delyla (28) oral tablet Tier 1a $0
desog-e.estradiol/e.estradiol oral tablet
Tier 1b $0
desogestrel-ethinyl estradiol oral tablet
Tier 1a $0
drospirenone-e.estradiol-lm.fa oral tablet
Tier 1b
drospirenone-ethinyl estradiol oral tablet
Tier 1b $0
econtra ez oral tablet Tier 1b $0; QL
elinest oral tablet Tier 1a $0
Effective 1/1/201734
Drug Name Tier Notes
ELLA ORAL TABLET Tier 3 $0
emoquette oral tablet Tier 1a $0
enpresse oral tablet Tier 1a $0
enskyce oral tablet Tier 1a $0
errin oral tablet Tier 1b $0
estarylla oral tablet Tier 1a $0
ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg
Tier 1a $0
fallback solo oral tablet Tier 1b $0; QL
falmina (28) oral tablet Tier 1a $0
FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1b $0
femynor oral tablet Tier 1a $0
gianvi (28) oral tablet Tier 1b $0
gildagia oral tablet Tier 1a $0
heather oral tablet Tier 1b $0
introvale oral tablets,dose pack,3 month
Tier 1b $0
isibloom oral tablet Tier 1a
jencycla oral tablet Tier 1b $0
jolessa oral tablets,dose pack,3 month
Tier 1b $0
jolivette oral tablet Tier 1b $0
JULEBER ORAL TABLET
Tier 1a $0
junel 1.5/30 (21) oral tablet Tier 1a $0
junel 1/20 (21) oral tablet Tier 1a $0
junel fe 1.5/30 (28) oral tablet
Tier 1a $0
junel fe 1/20 (28) oral tablet
Tier 1a $0
junel fe 24 oral tablet Tier 1a $0
KAITLIB FE ORAL TABLET,CHEWABLE
Tier 1b $0
kariva (28) oral tablet Tier 1b $0
kelnor 1/35 (28) oral tablet Tier 1a $0
kimidess (28) oral tablet Tier 1b $0
kurvelo oral tablet Tier 1a $0
l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month
Tier 1b $0
larin 1.5/30 (21) oral tablet Tier 1a $0
larin 1/20 (21) oral tablet Tier 1a $0
Drug Name Tier Notes
larin 24 fe oral tablet Tier 1a $0
larin fe 1.5/30 (28) oral tablet
Tier 1a $0
larin fe 1/20 (28) oral tablet
Tier 1a $0
larissia oral tablet Tier 1a $0
layolis fe oral tablet,chewable
Tier 1b $0
leena 28 oral tablet Tier 1a $0
lessina oral tablet Tier 1a $0
levonest (28) oral tablet Tier 1a $0
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg
Tier 1a $0
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
Tier 1b $0
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
Tier 1b $0
levonorg-eth estrad triphasic oral tablet
Tier 1a $0
levora-28 oral tablet Tier 1a $0
lillow oral tablet Tier 1a $0
LO LOESTRIN FE ORAL TABLET
Tier 3 $0
lomedia 24 fe oral tablet Tier 1a $0
loryna (28) oral tablet Tier 1b $0
low-ogestrel (28) oral tablet
Tier 1a $0
lutera (28) oral tablet Tier 1a $0
lyza oral tablet Tier 1b $0
marlissa oral tablet Tier 1a $0
medroxyprogesterone intramuscular suspension
Tier 1b $0
medroxyprogesterone intramuscular syringe
Tier 1b $0
MIBELAS 24 FE ORAL TABLET,CHEWABLE
Tier 1a $0
microgestin 1.5/30 (21) oral tablet
Tier 1a $0
microgestin 1/20 (21) oral tablet
Tier 1a $0
microgestin fe 1.5/30 (28) oral tablet
Tier 1a $0
microgestin fe 1/20 (28) oral tablet
Tier 1a $0
Effective 1/1/201735
Drug Name Tier Notes
mono-linyah oral tablet Tier 1a $0
mononessa (28) oral tablet Tier 1a $0
my way oral tablet Tier 1b $0; QL
myzilra oral tablet Tier 1a $0
NATAZIA ORAL TABLET Tier 3 $0
necon 0.5/35 (28) oral tablet
Tier 1a $0
necon 1/50 (28) oral tablet Tier 1a $0
necon 7/7/7 (28) oral tablet
Tier 1a $0
next choice one dose oral tablet
Tier 1b $0; QL
nikki (28) oral tablet Tier 1b $0
nora-be oral tablet Tier 1b $0
noreth-ethinyl estradiol-iron oral tablet,chewable
Tier 1b $0
norethindrone (contraceptive) oral tablet
Tier 1b $0
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
Tier 1a $0
norethindrone-e.estradiol-iron oral tablet
Tier 1a $0
norethindrone-e.estradiol-iron oral tablet,chewable
Tier 1a $0
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1b $0
norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg
Tier 1a $0
NORLYDA ORAL TABLET
Tier 1b $0
norlyroc oral tablet Tier 1b $0
nortrel 0.5/35 (28) oral tablet
Tier 1a $0
nortrel 1/35 (21) oral tablet Tier 1a $0
nortrel 1/35 (28) oral tablet Tier 1a $0
nortrel 7/7/7 (28) oral tablet
Tier 1a $0
NUVARING VAGINAL RING
Tier 3 $0
ocella oral tablet Tier 1b $0
ogestrel (28) oral tablet Tier 1a $0
Drug Name Tier Notes
opcicon one-step oral tablet
Tier 1b $0; QL
orsythia oral tablet Tier 1a $0
philith oral tablet Tier 1a $0
pimtrea (28) oral tablet Tier 1b $0
pirmella oral tablet Tier 1a $0
PLAN B ONE-STEP ORAL TABLET
Tier 1b $0; QL
portia oral tablet Tier 1a $0
previfem oral tablet Tier 1a $0
quasense oral tablets,dose pack,3 month
Tier 1b $0
RAJANI ORAL TABLET Tier 1b $0
reclipsen (28) oral tablet Tier 1a $0
RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1b $0
SAFYRAL ORAL TABLET
Tier 3 $0
setlakin oral tablets,dose pack,3 month
Tier 1b $0
sharobel oral tablet Tier 1b $0
sprintec (28) oral tablet Tier 1a $0
sronyx oral tablet Tier 1a $0
syeda oral tablet Tier 1b $0
TAKE ACTION ORAL TABLET
Tier 1b $0; QL
tarina fe 1/20 (28) oral tablet
Tier 1a $0
TAYTULLA ORAL CAPSULE
Tier 3 $0
tilia fe oral tablet Tier 1b $0
TRI FEMYNOR ORAL TABLET
Tier 1b $0
tri-estarylla oral tablet Tier 1b $0
tri-legest fe oral tablet Tier 1b $0
tri-linyah oral tablet Tier 1b $0
TRI-LO-ESTARYLLA ORAL TABLET
Tier 1b $0
tri-lo-marzia oral tablet Tier 1b $0
TRI-LO-SPRINTEC ORAL TABLET
Tier 1b $0
trinessa (28) oral tablet Tier 1b $0
TRINESSA LO ORAL TABLET
Tier 1b $0
tri-previfem (28) oral tablet Tier 1b $0
Effective 1/1/201736
Drug Name Tier Notes
tri-sprintec (28) oral tablet Tier 1b $0
trivora (28) oral tablet Tier 1a $0
velivet triphasic regimen (28) oral tablet
Tier 1a $0
vestura (28) oral tablet Tier 1b $0
VIENVA ORAL TABLET Tier 1a $0
viorele (28) oral tablet Tier 1b $0
vyfemla (28) oral tablet Tier 1a $0
wera (28) oral tablet Tier 1a $0
wymzya fe oral tablet,chewable
Tier 1b $0
xulane transdermal patch weekly
Tier 1b $0
zarah oral tablet Tier 1b $0
zenchent (28) oral tablet Tier 1a $0
zenchent fe oral tablet,chewable
Tier 1b $0
zovia 1/35e (28) oral tablet Tier 1a $0
zovia 1/50e (28) oral tablet Tier 1a $0
COUGH/COLD PREPARATIONS
benzonatate oral capsule 100 mg, 200 mg
Tier 1b
cheratussin ac oral liquid Tier 1a
codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)
Tier 1a
FLOWTUSS ORAL SOLUTION
Tier 3
guaiatussin ac liquid Tier 1a
guaiatussin ac liquid outer Tier 1a
guaifen-codeine 100-10 mg/5 ml (otc)
Tier 1a
guaifenesin ac oral liquid Tier 1a
guaifenesin-codeine syrup (otc)
Tier 1a
HYCOFENIX ORAL SOLUTION
Tier 3
hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr
Tier 1b
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
Tier 1b
OBREDON ORAL SOLUTION
Tier 3
promethazine vc-codeine oral syrup
Tier 1b
Drug Name Tier Notes
promethazine-codeine oral syrup
Tier 1a
promethazine-dm oral syrup
Tier 1a
promethazine-phenyleph-codeine oral syrup
Tier 1b
TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR
Tier 3
VITUZ ORAL SOLUTION Tier 3
DIAGNOSTIC
ACCU-CHEK AVIVA PLUS TEST STRP STRIP
Tier 2 QL
ACCU-CHEK COMPACT PLUS TEST STRIP
Tier 2 QL
ACCU-CHEK GUIDE STRIP
Tier 2 QL
ACCU-CHEK SMARTVIEW TEST STRIP STRIP
Tier 2 QL
ACCUTREND GLUCOSE STRIP
Tier 2 QL
dipyridamole intravenous solution
Tier 2
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN
Tier 2
GLUCAGON HCL INJECTION RECON SOLN
Tier 2
ONETOUCH ULTRA TEST STRIP
Tier 2 QL
ONETOUCH VERIO STRIP
Tier 2 QL
DIURETICS
acetazolamide oral capsule, extended release
Tier 1b
acetazolamide oral tablet Tier 1b
amiloride oral tablet Tier 1b
AMMONIUM CHLORIDE INTRAVENOUS SOLUTION
Tier 3
bumetanide oral tablet Tier 1b
chlorothiazide oral tablet Tier 1b
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1a
Effective 1/1/201737
Drug Name Tier Notes
DYRENIUM ORAL CAPSULE
Tier 3
eplerenone oral tablet Tier 2
ethacrynic acid oral tablet Tier 2
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
Tier 1a
furosemide oral tablet Tier 1a
hydrochlorothiazide oral capsule
Tier 1a
hydrochlorothiazide oral tablet
Tier 1a
indapamide oral tablet Tier 1b
methazolamide oral tablet Tier 1b
methyclothiazide oral tablet
Tier 1b
metolazone oral tablet Tier 1b
SAMSCA ORAL TABLET Tier 3 SP; LD
spironolactone oral tablet Tier 1a
torsemide oral tablet Tier 1b
triamterene-hydrochlorothiazid oral capsule
Tier 1a
triamterene-hydrochlorothiazid oral tablet
Tier 1a
EENT PREPS
acetic acid otic (ear) solution
Tier 1b
ALOCRIL OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
ALOMIDE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
apraclonidine ophthalmic (eye) drops
Tier 1b
azelastine nasal aerosol,spray
Tier 1b QL
AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
betaxolol ophthalmic (eye) drops
Tier 1b
bimatoprost ophthalmic (eye) drops
Tier 2
brimonidine ophthalmic (eye) drops
Tier 1b
bromfenac ophthalmic (eye) drops
Tier 2
Drug Name Tier Notes
carteolol ophthalmic (eye) drops
Tier 1a
COMBIGAN OPHTHALMIC (EYE) DROPS
Tier 3
cromolyn ophthalmic (eye) drops
Tier 1a QL
CYSTARAN OPHTHALMIC (EYE) DROPS
Tier 3 LD
dexamethasone sodium phosphate ophthalmic (eye) drops
Tier 1b
diclofenac sodium ophthalmic (eye) drops
Tier 1b
dorzolamide ophthalmic (eye) drops
Tier 1b
dorzolamide-timolol ophthalmic (eye) drops
Tier 1b
DUREZOL OPHTHALMIC (EYE) DROPS
Tier 3 QL
DYMISTA NASAL SPRAY,NON-AEROSOL
Tier 3 QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
Tier 1b ST; QL
fluocinolone acetonide oil otic (ear) drops
Tier 1b
fluorometholone ophthalmic (eye) drops,suspension
Tier 1b
flurbiprofen sodium ophthalmic (eye) drops
Tier 1b
fluticasone nasal spray,suspension
Tier 1b QL
FML S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
hydrocortisone-acetic acid otic (ear) drops
Tier 1b
ketorolac ophthalmic (eye) drops
Tier 1b
LACRISERT OPHTHALMIC (EYE) INSERT
Tier 3
latanoprost ophthalmic (eye) drops
Tier 1b
levobunolol ophthalmic (eye) drops 0.5 %
Tier 1b
Effective 1/1/201738
Drug Name Tier Notes
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL
Tier 3
LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
LOTEMAX OPHTHALMIC (EYE) OINTMENT
Tier 3
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
Tier 3
metipranolol ophthalmic (eye) drops
Tier 1b
NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
olopatadine nasal spray,non-aerosol
Tier 1b QL
OMNARIS NASAL SPRAY,NON-AEROSOL
Tier 3 ST; QL
PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS
Tier 3
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
Tier 1b
prednisolone acetate ophthalmic (eye) drops,suspension
Tier 1b
prednisolone sodium phosphate ophthalmic (eye) drops
Tier 1b
RESTASIS OPHTHALMIC (EYE) DROPPERETTE
Tier 3
SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
timolol maleate ophthalmic (eye) drops
Tier 1b
timolol maleate ophthalmic (eye) gel forming solution
Tier 1b
TRAVATAN Z OPHTHALMIC (EYE) DROPS
Tier 3
tropicamide ophthalmic (eye) drops
Tier 1b
TYZINE NASAL DROPS Tier 3
TYZINE NASAL SPRAY,NON-AEROSOL
Tier 3
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE
Tier 3
Drug Name Tier Notes
ELECT/CALORIC/H2O
calcium acetate oral tablet 667 mg
Tier 2
cytra k crystals oral packet Tier 1b
cytra-k oral solution Tier 1b
denta 5000 plus dental cream
Tier 1b
dentagel dental gel Tier 1a
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
Tier 3
effer-k oral tablet, effervescent 25 meq
Tier 1b
eliphos oral tablet Tier 1b PA
fe c plus oral tablet Tier 1b
fluoride (sodium) dental solution
Tier 1a
fluoride (sodium) oral drops
Tier 1a $0
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1a $0
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1a
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
Tier 1a $0
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1a
FOSRENOL ORAL POWDER IN PACKET
Tier 3 PA
FOSRENOL ORAL TABLET,CHEWABLE
Tier 3 PA
GLUCAGEN HYPOKIT INJECTION RECON SOLN
Tier 2
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT
Tier 2
ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION
Tier 3
Effective 1/1/201739
Drug Name Tier Notes
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION
Tier 3
k-effervescent oral tablet, effervescent
Tier 1b
kionex (with sorbitol) oral suspension
Tier 1b
kionex oral powder Tier 1b
klor-con 10 oral tablet extended release
Tier 1b
klor-con 8 oral tablet extended release
Tier 1b
klor-con m10 oral tablet,er particles/crystals
Tier 1a
klor-con m15 oral tablet,er particles/crystals
Tier 1a
klor-con m20 oral tablet,er particles/crystals
Tier 1a
klor-con/ef oral tablet, effervescent
Tier 1b
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1a $0
ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1a
magnesium sulfate in water intravenous parenteral solution
Tier 1b
magnesium sulfate in water intravenous piggyback
Tier 1b
magnesium sulfate injection syringe
Tier 1b
NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION
Tier 3
NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION
Tier 3
NUTRAMINE ORAL POWDER
Tier 3
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
Tier 3
Drug Name Tier Notes
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
Tier 3
potassium bicarb and chloride oral tablet, effervescent
Tier 1b
potassium bicarb-citric acid oral tablet, effervescent
Tier 1b
potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l
Tier 2
potassium chloride intravenous piggyback
Tier 1b
potassium chloride intravenous solution
Tier 1b
potassium chloride oral capsule, extended release
Tier 1b
potassium chloride oral tablet extended release
Tier 1b
potassium chloride oral tablet,er particles/crystals
Tier 1a
potassium chloride-0.45 % nacl intravenous parenteral solution
Tier 2
potassium citrate oral tablet extended release
Tier 2
potassium citrate-citric acid oral solution
Tier 1b
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE
Tier 3
PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE
Tier 3
PREVIDENT DENTAL GEL
Tier 3
PROGLYCEM ORAL SUSPENSION
Tier 3
RENVELA ORAL TABLET
Tier 2
sevelamer carbonate oral powder in packet
Tier 1b
sf dental gel Tier 1a
SHOHL'S MODIFIED ORAL SOLUTION
Tier 3
Effective 1/1/201740
Drug Name Tier Notes
sodium chloride 0.45 % intravenous parenteral solution
Tier 1b
sodium chloride 0.45 % intravenous piggyback
Tier 1b
sodium chloride 0.9 % injection solution
Tier 1b
sodium chloride 0.9 % intravenous parenteral solution
Tier 1b
sodium chloride 0.9 % intravenous piggyback
Tier 1b
sodium chloride 3 % intravenous parenteral solution
Tier 1b
sodium chloride 5 % intravenous parenteral solution
Tier 1b
sodium chloride intravenous parenteral solution 2.5 meq/ml
Tier 1b
sodium polystyrene (sorb free) oral suspension
Tier 1b
sodium polystyrene sulfonate oral powder
Tier 1b
sodium polystyrene sulfonate oral suspension
Tier 1b
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
Tier 1b
sps (with sorbitol) oral suspension
Tier 1b
sps (with sorbitol) rectal enema
Tier 1b
SSKI ORAL SOLUTION Tier 3
VELPHORO ORAL TABLET,CHEWABLE
Tier 3 PA
GASTROINTESTINAL
AKYNZEO ORAL CAPSULE
Tier 3 QL
alosetron oral tablet Tier 2 QL
ALOXI INTRAVENOUS SOLUTION
Tier 3
AMITIZA ORAL CAPSULE
Tier 3
anaspaz oral tablet,disintegrating
Tier 2
anucort-hc rectal suppository
Tier 1b
Drug Name Tier Notes
ANZEMET ORAL TABLET
Tier 3 QL
aprepitant oral capsule 125 mg, 40 mg, 80 mg
Tier 2 QL
aprepitant oral capsule,dose pack
Tier 2 QL
APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR
Tier 3 QL
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml
Tier 1b
balsalazide oral capsule Tier 1b QL
BUPHENYL ORAL TABLET
Tier 3 PA
carafate oral suspension Tier 1b
CESAMET ORAL CAPSULE
Tier 3 ST
CHOLBAM ORAL CAPSULE
Tier 3 PA; LD; QL
cimetidine hcl oral solution Tier 1b
cimetidine oral tablet Tier 1b
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT
Tier 4 PA; SP; LD; QL
CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
CIMZIA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
COMPAZINE ORAL TABLET
Tier 1b
constulose oral solution Tier 1b
DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS
Tier 3 PA; QL
dicyclomine oral capsule Tier 1a
dicyclomine oral solution Tier 1a
dicyclomine oral tablet Tier 1a
DIPENTUM ORAL CAPSULE
Tier 3 QL
diphenoxylate-atropine oral liquid
Tier 1b
diphenoxylate-atropine oral tablet
Tier 1b
dronabinol oral capsule Tier 2
enulose oral solution Tier 1b
Effective 1/1/201741
Drug Name Tier Notes
esomeprazole magnesium oral capsule,delayed release(dr/ec)
Tier 2 PA; QL
famotidine oral suspension Tier 1b
famotidine oral tablet 20 mg, 40 mg
Tier 1b
gavilyte-c oral recon soln Tier 1a $0
gavilyte-g oral recon soln Tier 1a $0
gavilyte-n oral recon soln Tier 1a $0
generlac oral solution Tier 1b
glycopyrrolate oral tablet 1 mg, 2 mg
Tier 1b
granisetron hcl oral tablet Tier 2 QL
hydrocortisone acetate rectal suppository
Tier 1b
hydrocortisone-pramoxine rectal cream
Tier 1b
hyoscyamine sulfate oral tablet
Tier 1b
hyoscyamine sulfate oral tablet extended release 12 hr
Tier 1b
hyoscyamine sulfate oral tablet,disintegrating
Tier 1b
hyoscyamine sulfate sublingual tablet
Tier 1b
KEPIVANCE INTRAVENOUS RECON SOLN
Tier 4 LD
lactulose oral solution Tier 1b
lansoprazole oral capsule,delayed release(dr/ec)
Tier 1b QL
laxaclear powder Tier 1b $0
LINZESS ORAL CAPSULE
Tier 2
meclizine oral tablet 12.5 mg, 25 mg
Tier 1a
methscopolamine oral tablet
Tier 1b
metoclopramide hcl oral solution
Tier 1a
metoclopramide hcl oral tablet
Tier 1a
misoprostol oral tablet Tier 1a
MOTOFEN ORAL TABLET
Tier 3
Drug Name Tier Notes
MOVIPREP ORAL POWDER IN PACKET
Tier 3
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET
Tier 3 PA; QL
nizatidine oral capsule Tier 1b
nizatidine oral solution Tier 1b
omega-3 acid ethyl esters oral capsule
Tier 1b QL
omeprazole oral capsule,delayed release(dr/ec)
Tier 1b QL
ondansetron hcl oral solution
Tier 2 QL
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
Tier 2 QL
ondansetron oral tablet,disintegrating 4 mg, 8 mg
Tier 2 QL
OSMOPREP ORAL TABLET
Tier 3
pantoprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
peg 3350-electrolytes oral recon soln
Tier 1a $0
peg-3350 with flavor packs oral recon soln
Tier 1a $0
phenadoz rectal suppository
Tier 1b
polyethylene glycol 3350 oral powder in packet
Tier 1b $0
pramcort rectal cream Tier 1b
PREPOPIK ORAL POWDER IN PACKET
Tier 3
prochlorperazine maleate oral tablet
Tier 1a
promethazine rectal suppository
Tier 1b
promethegan rectal suppository
Tier 1b
rabeprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
ranitidine hcl oral capsule Tier 1b
ranitidine hcl oral syrup Tier 1b
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1b
Effective 1/1/201742
Drug Name Tier Notes
RECTIV RECTAL OINTMENT
Tier 3
REMICADE INTRAVENOUS RECON SOLN
Tier 4 PA; SP
SANCUSO TRANSDERMAL PATCH WEEKLY
Tier 3 QL
scopolamine base transdermal patch 3 day
Tier 2
SCOPOLAMINE HBR INJECTION SOLUTION
Tier 3
sucralfate oral tablet Tier 1b
sulfasalazine oral tablet Tier 1b QL
sulfasalazine oral tablet,delayed release (dr/ec)
Tier 1b QL
SUPREP BOWEL PREP KIT ORAL RECON SOLN
Tier 3
trilyte with flavor packets oral recon soln
Tier 1a $0
trimethobenzamide oral capsule
Tier 1b
ursodiol oral capsule Tier 2
ursodiol oral tablet Tier 2
VARUBI ORAL TABLET Tier 3 QL
VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM
Tier 3 QL
VIBERZI ORAL TABLET Tier 3 PA; QL
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
HORMONES
AMABELZ ORAL TABLET
Tier 1b
ANADROL-50 ORAL TABLET
Tier 3
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)
Tier 3 PA; QL
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
Tier 3 PA; QL
Drug Name Tier Notes
budesonide oral capsule,delayed,extend.release
Tier 2 QL
cabergoline oral tablet Tier 1b
calcitonin (salmon) nasal spray,non-aerosol
Tier 1b QL
chorionic gonadotropin, human intramuscular recon soln
Tier 4 PA; SP
cortisone oral tablet Tier 1b
covaryx h.s. oral tablet Tier 1b
covaryx oral tablet Tier 1b
danazol oral capsule Tier 2
desmopressin nasal aerosol,spray
Tier 2
desmopressin nasal solution
Tier 2
desmopressin nasal spray,non-aerosol
Tier 2
desmopressin oral tablet Tier 1b
dexamethasone intensol oral drops
Tier 1a
dexamethasone oral elixir Tier 1a
dexamethasone oral solution
Tier 1a
dexamethasone oral tablet Tier 1a
DUAVEE ORAL TABLET Tier 3 QL
eemt hs oral tablet Tier 1b
eemt oral tablet Tier 1b
ESTRACE VAGINAL CREAM
Tier 3
estradiol oral tablet Tier 1b
estradiol transdermal patch semiweekly
Tier 1b QL
estradiol transdermal patch weekly
Tier 1b
estradiol vaginal tablet Tier 2
estradiol-norethindrone acet oral tablet
Tier 1b
ESTRING VAGINAL RING
Tier 3 QL
estrogens-methyltestosterone oral tablet
Tier 1b
estropipate oral tablet Tier 1a
fludrocortisone oral tablet Tier 1b
Effective 1/1/201743
Drug Name Tier Notes
GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP
GONAL-F RFF SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP
GONAL-F SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP
hydrocortisone oral tablet Tier 1b
hydrocortisone rectal enema
Tier 2
INCRELEX SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
jinteli oral tablet Tier 1b
LOPREEZA ORAL TABLET
Tier 1b
LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
medroxyprogesterone oral tablet
Tier 1a QL
MENEST ORAL TABLET0.3 MG, 0.625 MG, 1.25 MG
Tier 3
METHITEST ORAL TABLET
Tier 3
methylprednisolone oral tablet
Tier 1a
methylprednisolone oral tablets,dose pack
Tier 1a
millipred dp oral tablets,dose pack
Tier 1a
millipred oral tablet Tier 1a
mimvey lo oral tablet Tier 1b
mimvey oral tablet Tier 1b
MYALEPT SUBCUTANEOUS RECON SOLN
Tier 4 SP; LD
norethindrone acetate oral tablet
Tier 1b
NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
oxandrolone oral tablet Tier 2 PA
Drug Name Tier Notes
prednisolone oral solution 15 mg/5 ml
Tier 1a
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
Tier 1a
prednisone intensol oral concentrate
Tier 1a
prednisone oral solution Tier 1a
prednisone oral tablet Tier 1a
prednisone oral tablets,dose pack
Tier 1a
PREMARIN ORAL TABLET
Tier 3 QL
PREMARIN VAGINAL CREAM
Tier 3 QL
PREMPHASE ORAL TABLET
Tier 3
PREMPRO ORAL TABLET
Tier 3
progesterone micronized oral capsule 100 mg, 200 mg
Tier 1b QL
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG
Tier 4 PA; SP; QL
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 4 PA; SP; LD; QL
SIGNIFOR SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD; QL
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE
Tier 4 SP; QL
SYNAREL NASAL SPRAY,NON-AEROSOL
Tier 4 PA; SP; QL
testosterone cypionate intramuscular oil
Tier 1b
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)
Tier 1b PA; QL
Effective 1/1/201744
Drug Name Tier Notes
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)
Tier 1b PA; QL
veripred 20 oral solution Tier 1a
YUVAFEM VAGINAL TABLET
Tier 2 QL
IMMUNOSUPPRESSANTS
ACTEMRA INTRAVENOUS SOLUTION
Tier 4 PA; SP; QL
ACTEMRA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
azathioprine oral tablet Tier 2
cyclosporine modified oral capsule
Tier 4 SP
cyclosporine modified oral solution
Tier 4 SP
cyclosporine oral capsule Tier 4 SP
ELIDEL TOPICAL CREAM
Tier 3 PA
gengraf oral capsule 100 mg, 25 mg
Tier 4 SP
GENGRAF ORAL CAPSULE 50 MG
Tier 4 SP
gengraf oral solution Tier 4 SP
mycophenolate mofetil hcl intravenous recon soln
Tier 4 SP
mycophenolate mofetil oral capsule
Tier 4 SP
mycophenolate mofetil oral tablet
Tier 4 SP
mycophenolate sodium oral tablet,delayed release (dr/ec)
Tier 4 SP
RAPAMUNE ORAL SOLUTION
Tier 4 SP
SIMULECT INTRAVENOUS RECON SOLN
Tier 4 SP
sirolimus oral tablet Tier 4 SP
STELARA INTRAVENOUS SOLUTION
Tier 4 PA; SP; QL
STELARA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; QL
Drug Name Tier Notes
STELARA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
tacrolimus oral capsule Tier 4 SP
tacrolimus topical ointment Tier 1b PA
ZORTRESS ORAL TABLET
Tier 4 PA; SP
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG
ACCU-CHEK AVIVA CONNECT METER
Tier 2
ACCU-CHEK AVIVA CONTROL SOLN SOLUTION
Tier 2
ACCU-CHEK AVIVA PLUS METER
Tier 2
ACCU-CHEK COMP BLUE CONT, M-H SOLUTION
Tier 2
ACCU-CHEK COMPACT PLUS CARE KIT
Tier 2
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
Tier 2
ACCU-CHEK FASTCLIX Tier 2
ACCU-CHEK FASTCLIX KIT
Tier 2
ACCU-CHEK GUIDE GLUCOSE METER
Tier 2
ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION
Tier 2
ACCU-CHEK MULTICLIX LANCET
Tier 2
ACCU-CHEK MULTICLIX LANCET KIT
Tier 2
ACCU-CHEK NANO Tier 2
ACCU-CHEK SAFE-T-PRO PLUS
Tier 2
ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION
Tier 2
ACCU-CHEK SOFT DEV LANCETS KIT
Tier 2
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 2
ACCU-CHEK SOFTCLIX LANCETS
Tier 2
Effective 1/1/201745
Drug Name Tier Notes
ACCU-CHEK VOICEMATE KIT
Tier 2
ACCUTREND GLUCOSE CONTROL SOLUTION
Tier 2
acti-lance lancets 17 gauge, 28 gauge
Tier 1b
CHEMSTRIP BG LOG BOOK
Tier 2
e-z ject lancets Tier 1b
E-Z JECT THIN LANCETS
Tier 1b
insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"
Tier 1b
ONETOUCH DELICA LANC DEVICE KIT
Tier 2
ONETOUCH DELICA LANCETS
Tier 2
ONETOUCH SURESOFT LANCING DEV
Tier 2
ONETOUCH ULTRA CONTROL SOLUTION
Tier 2
ONETOUCH ULTRA2 KIT Tier 2
ONETOUCH ULTRAMINI KIT
Tier 2
ONETOUCH ULTRASOFT LANCETS
Tier 2
ONETOUCH VERIO FLEX
Tier 2
ONETOUCH VERIO HIGH CONTROL SOLUTION
Tier 2
ONETOUCH VERIO IQ METER
Tier 2
ONETOUCH VERIO MID CONTROL SOLUTION
Tier 2
ONETOUCH VERIO SYNC KIT
Tier 2
ONETOUCH VERIO SYSTEM
Tier 2
thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"
Tier 1b
MUSCLE RELAXANTS
baclofen oral tablet Tier 2
carisoprodol oral tablet Tier 1b
chlorzoxazone oral tablet 500 mg
Tier 1b
Drug Name Tier Notes
cyclobenzaprine oral tablet Tier 1b
dantrolene oral capsule Tier 2
metaxalone oral tablet Tier 1b
methocarbamol oral tablet Tier 1b
orphenadrine citrate oral tablet extended release
Tier 1b
tizanidine oral capsule Tier 1b
tizanidine oral tablet Tier 1b
PRE-NATAL VITAMINS
c-nate dha oral capsule Tier 1b
completenate oral tablet,chewable
Tier 1a
elite ob with dha oral capsule
Tier 1b
elite-ob 400 oral capsule Tier 1b
ELITE-OB ORAL TABLET
Tier 1b
folivane-ob oral capsule Tier 1b
hemenatal ob oral tablet Tier 1b
levomefolate dha oral capsule
Tier 1b
mynatal advance oral tablet
Tier 1b
mynatal oral capsule Tier 1b
mynatal oral tablet Tier 1b
mynatal plus oral tablet Tier 1a
mynatal-z oral tablet Tier 1a
mynate 90 plus oral tablet extended release
Tier 1a
pnv-dha + docusate oral capsule
Tier 1b
pnv-dha oral capsule Tier 1b
pnv-ferrous fumarate-docu-fa oral tablet
Tier 1a
pnv-omega oral capsule Tier 1b
pnv-select oral tablet Tier 1b
pr natal 400 ec oral combo pack,tablet and cap,dr
Tier 1a
pr natal 400 oral combo pack
Tier 1a
pr natal 430 ec oral combo pack,tablet and cap,dr
Tier 1a
pr natal 430 oral combo pack
Tier 1a
prenaissance oral capsule Tier 1b
Effective 1/1/201746
Drug Name Tier Notes
prenaissance plus oral capsule
Tier 1b
prenatabs fa oral tablet Tier 1a
prenatabs rx oral tablet Tier 1a
prenatal 19 (with docusate) oral tablet
Tier 1a
prenatal low iron oral tablet
Tier 1a
prenatal multivitamins oral tablet
Tier 1a $0
PRENATAL ONE DAILY ORAL TABLET
Tier 1a $0
prenatal plus (calcium carb) oral tablet
Tier 1a
prenatal plus oral tablet Tier 1a
prenatal vitamin plus low iron
Tier 1a
prenatal-u oral capsule Tier 1a
preplus oral tablet Tier 1a
relnate dha oral capsule Tier 1b
se-natal 19 (with docusate) oral tablet
Tier 1a
se-natal 19 oral tablet,chewable
Tier 1a
taron-c dha oral capsule Tier 1b
taron-prex prenatal-dha oral capsule
Tier 1b
tl-select oral capsule Tier 1b
triadvance oral tablet Tier 1b
trinatal gt oral tablet Tier 1b
trinatal rx 1 oral tablet Tier 1a
trinate oral tablet Tier 1a
triveen-one oral capsule Tier 1b
triveen-prx rnf oral capsule Tier 1b
ultimatecare one nf oral capsule
Tier 1b
ultimatecare one oral capsule
Tier 1b
vemavite-prx-2 oral capsule
Tier 1b
vinacal oral tablet Tier 1b
vinate care oral tablet,chewable
Tier 1a
vinate gt oral tablet Tier 1b
vinate ii oral tablet Tier 1a
vinate m oral tablet Tier 1a
Drug Name Tier Notes
vinate one oral tablet Tier 1a
vinate pn care oral tablet Tier 1b
vinate ultra oral tablet Tier 1b
VIRT-NATE DHA ORAL CAPSULE
Tier 1b
virt-pn dha oral capsule Tier 1b
virt-pn oral tablet Tier 1b
virt-pn plus oral capsule Tier 1b
virt-select oral capsule Tier 1b
vitafol-ob oral tablet Tier 1b
vol-nate oral tablet Tier 1a
vol-plus oral tablet Tier 1a
vol-tab rx oral tablet Tier 1a
vp-ch plus oral capsule Tier 1b
vp-ch-pnv oral capsule Tier 1b
vp-ggr-b6 oral tablet Tier 1a
vp-heme ob oral tablet Tier 1b
vp-heme one oral capsule Tier 1b
zatean-ch oral capsule Tier 1b
zatean-pn dha oral capsule
Tier 1b
zatean-pn plus oral capsule
Tier 1b
zingiber oral tablet Tier 1a
PSYCHOTHERAPEUTIC DRUGS
ADDYI ORAL TABLET Tier 3 PA; QL
alprazolam oral tablet Tier 1b
amitriptyline oral tablet Tier 1a
amoxapine oral tablet Tier 1b
aripiprazole oral solution Tier 2
aripiprazole oral tablet Tier 2
armodafinil oral tablet 150 mg, 250 mg, 50 mg
Tier 2 PA; QL
armodafinil oral tablet 200 mg
Tier 2 PA
atomoxetine oral capsule Tier 2 PA
bupropion hcl oral tablet 100 mg
Tier 1b QL
bupropion hcl oral tablet 75 mg
Tier 1b DO
bupropion hcl oral tablet extended release 12 hr 100 mg
Tier 1b DO
Effective 1/1/201747
Drug Name Tier Notes
bupropion hcl oral tablet extended release 12 hr 150 mg
Tier 1b $0
bupropion hcl oral tablet extended release 12 hr 200 mg
Tier 1b
bupropion hcl oral tablet extended release 24 hr 150 mg
Tier 1b DO
bupropion hcl oral tablet extended release 24 hr 300 mg
Tier 1b QL
buspirone oral tablet Tier 1b
chlorpromazine oral tablet Tier 2
citalopram oral solution Tier 1b QL
citalopram oral tablet 10 mg, 20 mg
Tier 1b DO
citalopram oral tablet 40 mg
Tier 1b QL
clomipramine oral capsule Tier 2
clonidine hcl oral tablet extended release 12 hr
Tier 1b PA
clozapine oral tablet Tier 2
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
Tier 2
desipramine oral tablet Tier 1b
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg
Tier 1b QL
desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg
Tier 1b DO
dexmethylphenidate oral capsule,er biphasic 50-50
Tier 1b PA
dexmethylphenidate oral tablet
Tier 1b PA
diazepam intensol oral concentrate
Tier 1a
diazepam oral concentrate Tier 1a
diazepam oral solution Tier 1a
diazepam oral tablet Tier 1a
doxepin oral capsule Tier 1b
doxepin oral concentrate Tier 1b
Drug Name Tier Notes
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg
Tier 2 PA; QL
duloxetine oral capsule,delayed release(dr/ec) 30 mg
Tier 2 PA; DO
EMSAM TRANSDERMAL PATCH 24 HOUR
Tier 3
escitalopram oxalate oral solution
Tier 1b QL
escitalopram oxalate oral tablet 10 mg, 5 mg
Tier 1b DO
escitalopram oxalate oral tablet 20 mg
Tier 1b QL
FANAPT ORAL TABLET Tier 3
FANAPT ORAL TABLETS,DOSE PACK
Tier 3
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
Tier 3 ST; QL
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR
Tier 3 ST; QL
fluoxetine oral capsule 10 mg, 20 mg
Tier 1b DO
fluoxetine oral capsule 40 mg
Tier 1b QL
fluoxetine oral capsule,delayed release(dr/ec)
Tier 1b QL
fluoxetine oral solution Tier 1b QL
fluoxetine oral tablet 10 mg
Tier 1b DO
fluoxetine oral tablet 20 mg
Tier 1b
fluphenazine hcl oral concentrate
Tier 1b
fluphenazine hcl oral elixir Tier 1b
fluphenazine hcl oral tablet Tier 1b
fluvoxamine oral tablet 100 mg
Tier 1b QL
fluvoxamine oral tablet 25 mg, 50 mg
Tier 1b DO
guanfacine oral tablet extended release 24 hr
Tier 1b PA
haloperidol oral tablet Tier 1b
imipramine hcl oral tablet Tier 1b
Effective 1/1/201748
Drug Name Tier Notes
LATUDA ORAL TABLET Tier 3
lithium carbonate oral capsule
Tier 1a
lithium carbonate oral tablet
Tier 1a
lithium carbonate oral tablet extended release
Tier 1a
lithium citrate oral solution Tier 1b
loxapine succinate oral capsule
Tier 1b
maprotiline oral tablet Tier 1b
MARPLAN ORAL TABLET
Tier 3
meprobamate oral tablet Tier 1b
metadate er oral tablet extended release
Tier 1b PA
methylphenidate hcl oral capsule, er biphasic 30-70
Tier 1b PA
methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg
Tier 1b PA
methylphenidate hcl oral capsule,er biphasic 50-50 60 mg
Tier 1b
methylphenidate hcl oral solution
Tier 1b PA
methylphenidate hcl oral tablet
Tier 1b PA
methylphenidate hcl oral tablet extended release
Tier 1b PA
methylphenidate hcl oral tablet extended release 24hr
Tier 1b PA
mirtazapine oral tablet Tier 1b
mirtazapine oral tablet,disintegrating
Tier 1b
modafinil oral tablet 100 mg
Tier 1b PA; DO
modafinil oral tablet 200 mg
Tier 1b PA; QL
nefazodone oral tablet Tier 1b
nortriptyline oral capsule Tier 1b
nortriptyline oral solution Tier 1b
olanzapine oral tablet Tier 2
olanzapine oral tablet,disintegrating
Tier 2
paliperidone oral tablet extended release 24hr
Tier 2
Drug Name Tier Notes
paroxetine hcl oral tablet 10 mg, 20 mg
Tier 1b DO
paroxetine hcl oral tablet 30 mg, 40 mg
Tier 1b QL
paroxetine hcl oral tablet extended release 24 hr 12.5 mg
Tier 1b DO
paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg
Tier 1b QL
perphenazine oral tablet Tier 1b
phenelzine oral tablet Tier 1b
pimozide oral tablet Tier 2
protriptyline oral tablet Tier 1b
quetiapine oral tablet Tier 1b
quetiapine oral tablet extended release 24 hr
Tier 2
risperidone oral solution Tier 1b
risperidone oral tablet Tier 1b
risperidone oral tablet,disintegrating
Tier 1b
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
Tier 3
sertraline oral concentrate Tier 1b QL
sertraline oral tablet 100 mg
Tier 1b QL
sertraline oral tablet 25 mg, 50 mg
Tier 1b DO
thioridazine oral tablet Tier 1b
thiothixene oral capsule Tier 1b
tranylcypromine oral tablet Tier 1b
trazodone oral tablet Tier 1a
trifluoperazine oral tablet Tier 1b
trimipramine oral capsule Tier 1b
TRINTELLIX ORAL TABLET 10 MG, 5 MG
Tier 3 ST; DO
TRINTELLIX ORAL TABLET 20 MG
Tier 3 ST; QL
venlafaxine oral capsule,extended release 24hr 150 mg
Tier 1b QL
venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg
Tier 1b DO
venlafaxine oral tablet Tier 1b QL
Effective 1/1/201749
Drug Name Tier Notes
venlafaxine oral tablet extended release 24hr 150 mg, 225 mg
Tier 1b QL
venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg
Tier 1b DO
VIIBRYD ORAL TABLET10 MG, 20 MG
Tier 3 ST; DO
VIIBRYD ORAL TABLET40 MG
Tier 3 ST; QL
VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)
Tier 3 ST; QL
VYVANSE ORAL CAPSULE
Tier 3 PA
ziprasidone hcl oral capsule
Tier 1b
SEDATIVE/HYPNOTICS
estazolam oral tablet Tier 1b
eszopiclone oral tablet 1 mg, 2 mg
Tier 1b QL
eszopiclone oral tablet 3 mg
Tier 1b PA; QL
HETLIOZ ORAL CAPSULE
Tier 4 PA; SP; LD; QL
hm nighttime sleep aid 50 mg softgel,max strength
Tier 1b
phenobarbital oral elixir Tier 1b
phenobarbital oral tablet Tier 1b
ROZEREM ORAL TABLET
Tier 3 ST; QL
SILENOR ORAL TABLET Tier 3 QL
XYREM ORAL SOLUTION
Tier 3 PA; SP; LD; QL
zaleplon oral capsule Tier 1b QL
zolpidem oral tablet Tier 1b QL
SKIN PREPS
acitretin oral capsule Tier 2
ACZONE TOPICAL GEL Tier 3
adapalene topical cream Tier 1b
adapalene topical gel Tier 1b
adapalene topical gel with pump
Tier 1b
ADAPALENE TOPICAL LOTION
Tier 2
Drug Name Tier Notes
adapalene-benzoyl peroxide topical gel with pump
Tier 2
alclometasone topical cream
Tier 1b
alclometasone topical ointment
Tier 1b
ALTABAX TOPICAL OINTMENT
Tier 3
amcinonide topical cream Tier 1b
amcinonide topical lotion Tier 1b
amcinonide topical ointment
Tier 1b
ammonium lactate topical cream
Tier 1b
ammonium lactate topical lotion
Tier 1b
AMNESTEEM ORAL CAPSULE
Tier 1b
avita topical cream Tier 1b PA
AZELEX TOPICAL CREAM
Tier 3 PA
benzoyl peroxide topical cleanser 3 %, 6 %, 9 %
Tier 1b
benzoyl peroxide topical foam
Tier 1b
betamethasone dipropionate topical cream
Tier 1b
betamethasone dipropionate topical lotion
Tier 1b
betamethasone dipropionate topical ointment
Tier 1b
betamethasone valerate topical cream
Tier 1b
betamethasone valerate topical foam
Tier 1b
betamethasone valerate topical lotion
Tier 1b
betamethasone valerate topical ointment
Tier 1b
betamethasone, augmented topical cream
Tier 1b
betamethasone, augmented topical gel
Tier 1b
betamethasone, augmented topical lotion
Tier 1b
Effective 1/1/201750
Drug Name Tier Notes
betamethasone, augmented topical ointment
Tier 1b
bpo topical gel Tier 1b
bpo topical towelette 6 % Tier 1b
calcipotriene scalp solution
Tier 1b
calcipotriene topical cream Tier 1b
calcipotriene topical ointment
Tier 1b
calcipotriene-betamethasone topical ointment
Tier 1b
calcitrene topical ointment Tier 1b
calcitriol topical ointment Tier 1b
claravis oral capsule Tier 1b PA
clindamycin-benzoyl peroxide topical gel
Tier 1b
clindamycin-tretinoin topical gel
Tier 2
clobetasol emollnt 0.05% foam
Tier 1b
clobetasol scalp solution Tier 1b
clobetasol topical cream Tier 1b
clobetasol topical foam Tier 1b
clobetasol topical gel Tier 1b
clobetasol topical lotion Tier 1b
clobetasol topical ointment Tier 1b
clobetasol topical shampoo
Tier 1b
clobetasol-emollient topical cream
Tier 1b
CLODERM TOPICAL CREAM
Tier 3
CORDRAN TAPE LARGE ROLL TOPICAL TAPE
Tier 3
cormax scalp solution Tier 1b
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
Drug Name Tier Notes
COSENTYX SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
desonide topical cream Tier 1b
desonide topical lotion Tier 1b
desonide topical ointment Tier 1b
desoximetasone topical cream
Tier 1b
desoximetasone topical gel
Tier 1b
desoximetasone topical ointment
Tier 1b
diclofenac sodium topical gel 1 %
Tier 2 QL
diflorasone topical cream Tier 1b
diflorasone topical ointment
Tier 1b
EURAX TOPICAL CREAM
Tier 3
EURAX TOPICAL LOTION
Tier 3
FINACEA TOPICAL GEL Tier 3
FLECTOR TRANSDERMAL PATCH 12 HOUR
Tier 3 QL
fluocinolone and shower cap scalp oil
Tier 1b
fluocinolone topical cream Tier 1b
fluocinolone topical oil Tier 1b
fluocinolone topical ointment
Tier 1b
fluocinolone topical solution
Tier 1b
fluocinonide topical cream Tier 1b
fluocinonide topical gel Tier 1b
fluocinonide topical ointment
Tier 1b
fluocinonide topical solution
Tier 1b
fluocinonide-e topical cream
Tier 1b
fluocinonide-emollient topical cream
Tier 1b
flurandrenolide topical cream
Tier 2
flurandrenolide topical lotion
Tier 2
Effective 1/1/201751
Drug Name Tier Notes
fluticasone topical cream Tier 1b
fluticasone topical lotion Tier 1b
fluticasone topical ointment
Tier 1b
halobetasol propionate topical cream
Tier 1b
halobetasol propionate topical ointment
Tier 1b
HALOG TOPICAL CREAM
Tier 3
HALOG TOPICAL OINTMENT
Tier 3
hydrocortisone butyrate topical cream
Tier 1b
hydrocortisone butyrate topical ointment
Tier 1b
hydrocortisone butyrate topical solution
Tier 1b
hydrocortisone butyr-emollient topical cream
Tier 1b
hydrocortisone topical cream 2.5 %
Tier 1a
hydrocortisone topical cream with perineal applicator
Tier 1b
hydrocortisone topical lotion 2.5 %
Tier 1a
hydrocortisone topical ointment 2.5 %
Tier 1a
hydrocortisone valerate topical cream
Tier 1b
hydrocortisone valerate topical ointment
Tier 1b
hydrocortisone-pramoxine topical cream
Tier 1b
imiquimod topical cream in packet
Tier 1b PA; QL
IODOFLEX TOPICAL PADS, MEDICATED
Tier 3
iodoquinol-hc topical cream
Tier 1b
lindane topical shampoo Tier 1b
malathion topical lotion Tier 1b
methoxsalen oral capsule,liqd-filled,rapid rel
Tier 2 PA; SP
metronidazole topical 0.75% gl
Tier 1b
Drug Name Tier Notes
metronidazole topical cream
Tier 1b
metronidazole topical gel 1 %
Tier 1b
metronidazole topical gel with pump
Tier 1b
metronidazole topical lotion
Tier 1b
MIRVASO TOPICAL GEL Tier 3
MIRVASO TOPICAL GEL WITH PUMP
Tier 3
mometasone topical cream
Tier 1b
mometasone topical ointment
Tier 1b
mometasone topical solution
Tier 1b
NUOX TOPICAL GEL Tier 3
OVACE TOPICAL CLEANSER
Tier 3
permethrin topical cream Tier 1b
PHYSIOLYTE IRRIGATION SOLUTION
Tier 3
podofilox topical solution Tier 1b
prednicarbate topical cream
Tier 1b
prednicarbate topical ointment
Tier 1b
PROCTOSOL-HC 2.5% CREAM
Tier 1b
proctozone-hc topical cream with perineal applicator
Tier 1b
prudoxin topical cream Tier 2
REGRANEX TOPICAL GEL
Tier 3
rosadan topical cream Tier 1b
ROSADAN TOPICAL GEL
Tier 1b
salicylic acid topical cream Tier 1b
salicylic acid topical cream,extended release
Tier 1b
salicylic acid topical foam Tier 1b
salicylic acid topical gel Tier 1b
salicylic acid topical lotion Tier 1b
salicylic acid topical lotion,extended release
Tier 1b
Effective 1/1/201752
Drug Name Tier Notes
salicylic acid topical shampoo
Tier 1b
salvax topical foam Tier 1b
SANTYL TOPICAL OINTMENT
Tier 3
seb-prev topical cleanser Tier 1b
selenium sulfide 2.25% shampoo
Tier 1a
selenium sulfide topical lotion
Tier 1a
selenium sulfide topical shampoo 2.25 %
Tier 1a
SKLICE TOPICAL LOTION
Tier 3
sodium chloride irrigation solution
Tier 1b
spinosad topical suspension
Tier 1b
sulfacetamide sodium (acne) topical suspension
Tier 1b
sulfacetamide sodium topical cleanser
Tier 1b
sulfacetamide sodium topical cleanser, gel
Tier 1b
sulfacetamide sodium topical shampoo
Tier 1b
TACLONEX TOPICAL SUSPENSION
Tier 3
tazarotene topical cream Tier 2
TAZORAC TOPICAL CREAM 0.05 %
Tier 3
TAZORAC TOPICAL GEL Tier 3
TIS-U-SOL PENTALYTE IRRIGATION SOLUTION
Tier 3
tretinoin (emollient) topical cream
Tier 1b
tretinoin topical cream Tier 1b PA
tretinoin topical gel 0.01 %, 0.025 %
Tier 1b PA
triamcinolone acetonide topical cream
Tier 1a
triamcinolone acetonide topical lotion
Tier 1a
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
Tier 1a
trianex topical ointment Tier 1a
Drug Name Tier Notes
triderm topical cream 0.1 %
Tier 1a
TRIDERM TOPICAL CREAM 0.5 %
Tier 1b
ULESFIA TOPICAL LOTION
Tier 3
zenatane oral capsule Tier 1b PA
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr
Tier 1b $0; QL
CHANTIX CONTINUING MONTH BOX ORAL TABLET
Tier 3 $0; QL
CHANTIX ORAL TABLET Tier 3 $0; QL
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK
Tier 3 $0; QL
NICOTROL INHALATION CARTRIDGE
Tier 3
NICOTROL NS NASAL SPRAY,NON-AEROSOL
Tier 3
THYROID PREPS
ARMOUR THYROID ORAL TABLET
Tier 1b
levothyroxine oral tablet Tier 1a
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1a
liothyronine oral tablet Tier 1b
methimazole oral tablet 10 mg, 5 mg
Tier 1a
nature-throid oral tablet Tier 1b
NP THYROID ORAL TABLET 120 MG, 15 MG
Tier 1b
np thyroid oral tablet 30 mg, 60 mg, 90 mg
Tier 1b
propylthiouracil oral tablet Tier 1b
SYNTHROID ORAL TABLET
Tier 1b
THYROLAR-1 ORAL TABLET
Tier 3
THYROLAR-1/2 ORAL TABLET
Tier 3
THYROLAR-1/4 ORAL TABLET
Tier 3
Effective 1/1/201753
Drug Name Tier Notes
THYROLAR-2 ORAL TABLET
Tier 3
THYROLAR-3 ORAL TABLET
Tier 3
unithroid oral tablet Tier 1a
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
Tier 1b
WP THYROID ORAL TABLET
Tier 1b
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral tablet,delayed release (dr/ec)
Tier 2 QL
ADAGEN INTRAMUSCULAR SOLUTION
Tier 4 LD
ALDURAZYME INTRAVENOUS SOLUTION
Tier 4 PA; SP
alendronate oral solution Tier 1b
alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg
Tier 1b QL
alfuzosin oral tablet extended release 24 hr
Tier 1b
amifostine crystalline intravenous recon soln
Tier 4 PA; SP
ARCALYST SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; LD; QL
BENLYSTA INTRAVENOUS RECON SOLN
Tier 4 PA; SP
BERINERT INTRAVENOUS KIT
Tier 4 PA; LD
BERINERT INTRAVENOUS RECON SOLN
Tier 4 PA; LD
buprenorphine hcl sublingual tablet 2 mg, 8 mg
Tier 2 QL
buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg
Tier 1b QL
CARBAGLU ORAL TABLET, DISPERSIBLE
Tier 4 LD
CERDELGA ORAL CAPSULE
Tier 4 PA; SP
Drug Name Tier Notes
CHEMET ORAL CAPSULE
Tier 3
chlorhexidine gluconate mucous membrane mouthwash
Tier 1a
CIALIS ORAL TABLET2.5 MG, 5 MG
Tier 3 PA; QL
CYSTADANE ORAL POWDER
Tier 3 LD
darifenacin oral tablet extended release 24 hr
Tier 2 ST
DEBACTEROL MUCOUS MEMBRANE SOLUTION
Tier 3
DEBACTEROL MUCOUS MEMBRANE SWAB
Tier 3
disulfiram oral tablet Tier 1b
doxercalciferol oral capsule
Tier 2
doxycycline hyclate oral tablet 20 mg
Tier 1b
dutasteride oral capsule Tier 2 PA
ELAPRASE INTRAVENOUS SOLUTION
Tier 4 PA
ELELYSO INTRAVENOUS RECON SOLN
Tier 4 PA; SP; LD
etidronate disodium oral tablet
Tier 2
EXJADE ORAL TABLET, DISPERSIBLE
Tier 4 PA; SP
FABRAZYME INTRAVENOUS RECON SOLN
Tier 4 PA; SP
FERRIPROX ORAL TABLET
Tier 4 PA; LD
finasteride oral tablet 1 mg Tier 1b
finasteride oral tablet 5 mg Tier 1b PA
flavoxate oral tablet Tier 1b
FORTEO SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT
Tier 3 ST; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 5,600 UNIT
Tier 3 ST
ibandronate oral tablet Tier 1b QL
Effective 1/1/201754
Drug Name Tier Notes
KALYDECO ORAL GRANULES IN PACKET
Tier 4 PA; SP; LD; QL
KALYDECO ORAL TABLET
Tier 4 PA; SP; LD; QL
KEVEYIS ORAL TABLET Tier 3 PA; LD; QL
KUVAN ORAL TABLET,SOLUBLE
Tier 4 PA; SP; LD
leucovorin calcium oral tablet
Tier 4
levocarnitine (with sugar) oral solution
Tier 1b
levocarnitine oral tablet Tier 1b
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
NAGLAZYME INTRAVENOUS SOLUTION
Tier 4 PA; SP; LD
oralone dental paste Tier 1b
ORFADIN ORAL CAPSULE
Tier 4 LD
OSPHENA ORAL TABLET
Tier 3 QL
oxybutynin chloride oral syrup
Tier 1b
oxybutynin chloride oral tablet
Tier 1b
oxybutynin chloride oral tablet extended release 24hr
Tier 1b
pamidronate intravenous recon soln
Tier 4 SP
pamidronate intravenous solution
Tier 4 SP
paricalcitol oral capsule Tier 2
paroex oral rinse mucous membrane mouthwash
Tier 1a
periogard mucous membrane mouthwash
Tier 1a
PROLIA SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
raloxifene oral tablet Tier 1b $0
RAPAFLO ORAL CAPSULE
Tier 3
risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg
Tier 1b QL
Drug Name Tier Notes
SAVELLA ORAL TABLET
Tier 3 QL
SAVELLA ORAL TABLETS,DOSE PACK
Tier 3 QL
SENSIPAR ORAL TABLET
Tier 4
sodium chlor 0.9% bacteriostat injection solution
Tier 1b
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG
Tier 4 PA; SP; LD; QL
SYPRINE ORAL CAPSULE
Tier 3 SP
tamsulosin oral capsule,extended release 24hr
Tier 1b
tolterodine oral tablet Tier 1b
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
triamcinolone acetonide dental paste
Tier 1b
trospium oral capsule,extended release 24hr
Tier 2
VESICARE ORAL TABLET
Tier 3
VIAGRA ORAL TABLET Tier 2 PA
VPRIV INTRAVENOUS RECON SOLN
Tier 4 PA; SP
XIAFLEX INJECTION RECON SOLN
Tier 4 PA
ZAVESCA ORAL CAPSULE
Tier 4 PA; SP; LD
ZEMAIRA INTRAVENOUS RECON SOLN
Tier 4 SP; LD
zoledronic acid intravenous recon soln
Tier 4 PA; SP
zoledronic acid intravenous solution
Tier 4 PA; SP
zoledronic acid-mannitol-water intravenous piggyback
Tier 4 PA; SP
VITAMINS
calcitriol oral capsule Tier 1b
Effective 1/1/201755
Drug Name Tier Notes
calcitriol oral solution Tier 1b
cyanocobalamin (vitamin b-12) injection solution
Tier 1a
ergocalciferol (vitamin d2) oral capsule
Tier 1a
folic acid oral tablet 1 mg Tier 1a
tl gard rx oral tablet Tier 1b
vitamin d2 oral capsule Tier 1a
Effective 1/1/201756
Effective 1/1/201757
KEY Brand name drug = Uppercase in bold type Generic drug = Lowercase in plain type SP = SPECIALTY DRUGS. This specialty drug may be required to be dispensed through a specialty pharmacy. LD = LIMITED DISTRIBUTION. Limited distribution drugs are those drugs that are available only through select pharmacies or wholesalers as determined by the manufacturer. 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 medications 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 this means switching from taking a drug twice a day to taking it once a day (at a higher strength). $0: PREVENTIVE DRUGS: For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.
Drug(s) may be excluded based on your plan's benefit design. If you have additional questions about your prescription benefits please call the Member Services number on your ID card. Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com or call 866-217-2328.
For more information, please visit anthem.com/pharmacyinformation If you have additional questions about your prescription benefits please call the Member Services 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/pharmacyinformation.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 2/17