2 02 1 List of Cover ed Drugs (Formulary)

Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)

2021 List of Covered Drugs (Formulary) Counties Los Angeles amp San Diego

This formulary was updated on 08252020 For more recent information or other questions please contact Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week the call is free orvisit wwwblueshieldcacompromisecalmediconnect

Formulary ID 21409 Version 9

H0148_20_167a_RX Approved 08182020

25

11222021

If you have questions please call Blue Shield Promise Cal MediConnect Plan at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is free For more information visit wwwblueshieldcacompromisecalmediconnect

ii

Blue Shield Promise Cal MediConnect Plan | 2021 List of Covered Drugs (Formulary)

Introduction

This document is called the List of Covered Drugs (also known as the Drug List) It tells you which prescription drugs and Over-the-Counter (OTC) drugs and items are covered by Blue Shield Promise Cal MediConnect Plan The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Blue Shield Promise Cal MediConnect Plan Key terms and their definitions appear in the last chapter of the Member Handbook You can request a copy by calling Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week the call is free

Table of Contents

A Disclaimers iv

B Frequently Asked Questions (FAQ) vi

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short) vi

B2 Does the Drug List ever change vi

B3 What happens when there is a change to the Drug List vii

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs viii

B5 How will you know if the drug you want has limits or if there are required actions to take to get the drug ix

B6 What happens if we change our rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions) ix

B7 How can you find a drug on the Drug List ix

B8 What if the drug you want to take is not on the Drug List ix

B9 What if you are a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find your drug on the Drug List or have a problem getting your drug x

B10 Can you ask for an exception to cover your drug xi


iii

B11 How can you ask for an exception xi

B12 How long does it take to get an exception xi

B13 What are generic drugs xi

B14 What are OTC drugs xii

B15 Does Blue Shield Promise Cal MediConnect Plan cover OTC non-drug products xii

B16 What is your copay xii

B17 What are drug tiers xiii

C Overview of the List of Covered Drugs xiii

C1 Drugs Grouped by Medical Condition xv

D Index of Covered Drugs 888 123


iv

A Disclaimers

This is a list of drugs that members can get in Blue Shield Promise Cal MediConnect

Blue Shield Promise Cal MediConnect is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees

The List of Covered Drugs andor pharmacy and provider networks may change throughout the year We will send you a notice before we make a change that affects you

Benefits andor copays may change on January 1 of each year

You can always check Blue Shield Promise Cal MediConnectrsquos up-to-date List of Covered Drugs online at wwwblueshieldcacompromisecalmediconnect or by calling 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is free

Limits copays and restrictions may apply For more information call Blue Shield Promise Cal MediConnect Customer Care or read the Blue Shield Promise Cal MediConnect Member Handbook

Copays for prescription drugs may vary based on the level of Extra Help you get Please contact the plan for more details

ATTENTION If you speak English language assistance services free of charge are available to you Call 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week The call is free

Espantildeol (Spanish) ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame a Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711) De 800 am a 800 pm los siete diacuteas de la semana

繁體中文 (Chinese) 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電

Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711) 每周七天办公每

天早上 800 至晚上 800这是免费电话

Tiếng Việt (Vietnamese) CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711) 8 giờ saacutengndash8 giờ tối 7 ngagravey trong tuần HOẶC Ban

Tagalog (Tagalog ndash Filipino) PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711) Mula 8am-8pm 7 araw sa isang lingo


v

한국어 (Korean) 주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711)번으로 전화해 주십시오 번으로 전화해 주십시오오후 8시 7 일 주일 오전 8시

Հայերեն (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY (հեռատիպ) 711) Ից 800 ndash 2000 շաբաթը յոթ օր

فارسی (PersianFarsi)

3825-905-855-1 اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد با توجھ (TTY 711) صبح تا 8 شب ھمھ روزه ھفتھ 8 تماس بگیرید

Русский (Russian) ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (телетайп 711) С 800 до 2000 без выходных

العربیة (Arabic)

711(رقم ھاتف الصم والبكم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم(

1-855-905-3825 Blue Shield Promise Cal MediConnect Plan من )711(رقم ھاتف الصم والبكم

الساعة 800 صباحا حتى 800 مساء طوال أیام الأسبوع

ែខរ (CambodianKhmer) របយត េបើសនអកនយ ែខរ េសជនយែផក េយមនគតឈ ល គចនសបបេរ អក ចរ ទរសព Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY711)បពេងេង 800 រពក ដល េង 800 យប រពរៃថក ងមយស ហ

You can get this document for free in other formats such as large print braille or audio Call Customer Care at 1-855-905-3825 (TTY 711) 800 am ndash 800 pm seven days a week The call is free

You can make a standing request to get materials in a language other than English or in an alternate format now and in the future To make a request please contact Blue Shield Promise Cal MediConnect Plan Customer Care


vi

B Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs You can read all of the FAQ to learn more or look for a question and answer

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short)

The drugs on the Drug List are the drugs covered by Blue Shield Promise Cal MediConnect Plan The drugs are available at pharmacies within our network A pharmacy is in our network if we have an agreement with them to work with us and provide you services We refer to these pharmacies as ldquonetwork pharmaciesrdquo

bull Blue Shield Promise Cal MediConnect Plan will cover all medically necessary drugs on the Drug List if

o your doctor or other prescriber says you need them to get better or stay healthy and

o you fill the prescription at a Blue Shield Promise Cal MediConnect Plan network pharmacy

bull In some cases you have to do something before you can get a drug (see question B4 below)

You can also see an up-to-date list of drugs that we cover on our website at wwwblueshieldcacompromisecalmediconnect or call Customer Care at 1-855-905-3825

B2 Does the Drug List ever change Yes and Blue Shield Promise Cal MediConnect Plan must follow Medicare and Medicaid rules when making changes We may add or remove drugs on the Drug List during the year

We may also change our rules about drugs For example we could

bull Decide to require or not require prior approval for a drug (Prior approval is permission from Blue Shield Promise Cal MediConnect Plan before you can get a drug)

bull Add or change the amount of a drug you can get (called quantity limits)

bull Add or change step therapy restrictions on a drug (Step therapy means you must try one drug before we will cover another drug)

For more information on these drug rules see question B4


vii

If you are taking a drug that was covered at the beginning of the year we will generally not remove or change coverage of that drug during the rest of the year unless

bull a new cheaper drug comes on the market that works as well as a drug on the Drug List now or

bull we learn that a drug is not safe or

bull a drug is removed from the market

Questions B3 and B6 below have more information on what happens when the Drug List changes

bull You can always check Blue Shield Promise Cal MediConnect Planrsquos up to date Drug List online at wwwblueshieldcacompromisecalmediconnect

bull You can also call Customer Care to check the current Drug List at 1-855-905-3825 (TTY 711) 800 am to 800 pm seven days a week

B3 What happens when there is a change to the Drug List Some changes to the Drug List will happen immediately For example

bull A new generic drug becomes available Sometimes a new generic drug comes on the market that works as well as a brand name drug on the Drug List now When that happens we may remove the brand name drug and add the new generic drug but your cost for the new drug will stay the same or will be lower When we add the new generic drug we may also decide to keep the brand name drug on the list but change its coverage rules or limits

o We may not tell you before we make this change but we will send you information about the specific change we made once it happens

o You or your provider can ask for an exception from these changes We will send you a notice with the steps you can take to ask for an exception Please see question B10 for more information on exceptions

bull A drug is taken off the market If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drugrsquos manufacturer takes a drug off the market we will take it off the Drug List If you are taking the drug we will let you know that the drug has been taken off the Drug List and instruct you on what to do next

We may make other changes that affect the drugs you take We will tell you in advance about these other changes to the Drug List These changes might happen if


viii

bull The FDA provides new guidance or there are new clinical guidelines abouta drug

bull We add a generic drug that is not new to the market and

o Replace a brand name drug currently on the Drug List or

o Change the coverage rules or limits for the brand name drug

When these changes happen we will

bull Tell you at least 30 days before we make the change to the Drug List or

bull Let you know and give you a 30-day supply of the drug after you ask for a refill

This will give you time to talk to your doctor or other prescriber He or she can help you decide

bull If there is a similar drug on the Drug List you can take instead or

bull Whether to ask for an exception from these changes To learn more aboutexceptions see question B10

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs

Yes some drugs have coverage rules or have limits on the amount you can get In some cases you or your doctor or other prescriber must do something before you can get the drug For example

bull Prior approval (or prior authorization) For some drugs you or your doctor or otherprescriber must get approval from Blue Shield Promise Cal MediConnect Planbefore you fill your prescription Blue Shield Promise Cal MediConnect Plan maynot cover the drug if you do not get approval

bull Quantity limits Sometimes Blue Shield Promise Cal MediConnect Plan limitsthe amount of a drug you can get

bull Step therapy Sometimes Blue Shield Promise Cal MediConnect Planrequires you to do step therapy This means you will have to try drugs in acertain order for your medical condition You might have to try one drugbefore we will cover another drug If your doctor thinks the first drug doesnrsquotwork for you then we will cover the second

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1 ndash 120 You can also get more information by visiting our website at wwwblueshieldcacompromisecalmediconnect We have posted online documents that explain our prior authorization and step therapy restrictions You may also ask us to send you a copy

1 - 122


ix

You can ask for an exception from these limits This will give you time to talk to your doctor or other prescriber He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception Please see questions B10-B12 for more information about exceptions

B5 How will you know if the drug you want has limits or if there are required actions to take to get the drug

The List of Covered Drugs on page 1 ndash 120 has a column labeled ldquoNecessary actions restrictions or limits on userdquo

B6 What happens if we change our rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions)

In some cases we will tell you in advance if we add or change prior approval quantity limits andor step therapy restrictions on a drug See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change

B7 How can you find a drug on the Drug List There are two ways to find a drug

bull You can search alphabetically (if you know how to spell the drug) or

bull You can search by medical condition

To search alphabetically go to the Index of Covered Drugs section You can find it in the index that begins on page 120 The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list

To search by medical condition find the section labeled ldquoList of drugs by medical conditionrdquo on page xv The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat For example if you have a heart condition you should look in the category Cardiovascular agents That is where you will find drugs that treat heart conditions

B8 What if the drug you want to take is not on the Drug List If you donrsquot see your drug on the Drug List call Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week and ask about it the call is free If youlearn that Blue Shield Promise Cal MediConnect Plan will not cover the drug you can doone of these things

123

1 - 122


x

bull Ask Customer Care for a list of drugs like the one you want to take Then show the list to your doctor or other prescriber He or she can prescribe a drug on the Drug List that is like the one you want to take Or

bull You can ask the health plan to make an exception to cover your drug Please see questions B10-B12 for more information about exceptions

B9 What if you are a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find your drug on the Drug List or have a problem getting your drug

We can help We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Blue Shield Promise Cal MediConnect Plan This will give you time to talk to your doctor or other prescriber He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception

If your prescription is written for fewer days we will allow multiple refills to provide up to a maximum of 30 days of medication

We will cover a 30 day supply of your drug if

bull you are taking a drug that is not on our Drug List or

bull health plan rules do not let you get the amount ordered by your prescriber or

bull the drug requires prior approval by Blue Shield Promise Cal MediConnect Plan or

bull you are taking a drug that is part of a step therapy restriction

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need we can help If you have been in the plan for more than 90 days live in a long-term care facility and need a supply right away

bull We will cover one 31 day supply of the drug you need (unless you have a prescription for fewer days) whether or not you are a new Blue Shield Promise Cal MediConnect Plan member

bull This is in addition to the temporary supply during the first 90 days you are a member of Blue Shield Promise Cal MediConnect Plan

Transition Policy In circumstances where a beneficiary is changing from one treatment setting to another Blue Shield Promise Cal MediConnect Plan will ensure a fast process for approving non-formulary Part D drugs This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy Examples of level of care


xi

changes are beneficiaries who are discharged from a hospital to a home beneficiaries who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary beneficiaries who end a long-term care facility stay and return to the community and beneficiaries who are discharged from psychiatric hospitals with medication regimens that are highly individualized

B10 Can you ask for an exception to cover your drug Yes You can ask Blue Shield Promise Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List

You can also ask us to change the rules on your drug

bull For example Blue Shield Promise Cal MediConnect Plan may limit the amount of a drug we will cover If your drug has a limit you can ask us to change the limit and cover more

bull Other examples You can ask us to drop step therapy restrictions or prior approval requirements

B11 How can you ask for an exception To ask for an exception call Customer Care Customer Care will work with you and your provider to help you ask for an exception You can also read Chapter 9 of the Member Handbook to learn more about exceptions

B12 How long does it take to get an exception First we must get a statement from your prescriber supporting your request for an exception After we get the statement we will give you a decision on your exception request within 72 hours

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision you can ask for an expedited exception This is a faster decision If your prescriber supports your request we will give you a decision within 24 hours of getting your prescriberrsquos supporting statement

B13 What are generic drugs Generic drugs are made up of the same ingredients as brand name drugs They usually cost less than the brand name drug and their names are less commonly known Generic drugs are approved by the Food and Drug Administration (FDA)

Blue Shield Promise Cal MediConnect Plan covers both brand name drugs and generic drugs


xii

B14 What are OTC drugs OTC stands for ldquoover-the-counterrdquo Blue Shield Promise Cal MediConnect Plan covers some OTC drugs when they are written as prescriptions by your provider

You can read the Blue Shield Promise Cal MediConnect Plan Drug List to see what OTC drugs are covered

B15 Does Blue Shield Promise Cal MediConnect Plan cover non-drug OTC products

Blue Shield Promise Cal MediConnect Plan covers some non-drug OTC products when they are written as prescriptions by your provider

Examples of non-drug OTC products include Vortex Adult Mask or Microchamber

You can read the Blue Shield Promise Cal MediConnect Plan Drug List to see what non-drug OTC products are covered

B16 What is your copay You can read the Blue Shield Promise Cal MediConnect Plan Drug List to learn about the copay for each drug Blue Shield Promise Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no copays Some members getting long-term care in the community will also have no copays

Copays are listed by tiers Tiers are groups of drugs with the same copay Co-pay amount will vary depending on your level of Medi-Cal eligibility

Tier Description Co-payment

30-day supply 90-day supply 100-day supply

Tier 1 Preferred Generic drugs

$0 $0 $0

Tier 2 Generic drugs $0 to $370 copay

$0 to $370 copay

Not available

Tier 3 Brand name drugs $0 to $920 copay

$0 to $920 copay

Not available

Tier 4 Non-Medicare Rx Over-the-counter (OTC) drugs

$0 copay $0 copay Not available


xiii

B17 What are drug tiers Tiers are groups of drugs on our Drug List

bull Tier 1 drugs are preferred generic drugsbull Tier 2 drugs are generic drugsbull Tier 3 drugs are brand name drugsbull Tier 4 drugs are Non-Medicare RX drugs and Over-the-Counter (OTC) drugs

C Overview of the List of Covered Drugs

The following list of covered drugs gives you information about the drugs covered by Blue Shield Promise Cal MediConnect Plan If you have trouble finding your drug in the list turn to the Index of Covered Drugs that begins on page 120 The Index alphabetically lists all drugs covered by Blue Shield Promise Cal MediConnect Plan

The first column of the chart lists the name of the drug Brand name drugs are capitalized (eg ELIQUIS) and generic drugs are listed in lower-case italics (eg simvastatin)

The information in the ldquoNecessary actions restrictions or limits on userdquo column tells you if Blue Shield Promise Cal MediConnect Plan has any rules for covering your drug

123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand

4 Non-Medicare RxOTC Drugs

SYMBOL NAME DESCRIPTION

LA Limited Access This prescription may be available only at certain pharmacies For more information call Blue Shield Promise Cal MediConnect Plan Customer Care

PA Prior Authorization

You (or your physician) are required to get prior authorization from Blue Shield Promise Cal MediConnect Plan before you fill your prescription for this drug Without prior approval Blue Shield Promise Cal MediConnect Plan may not cover this drug

QL Quantity Limit Blue Shield Promise Cal MediConnect Plan limits the quantity to be covered within a specific time frame for this drug

ST Step Therapy

Before Blue Shield Promise Cal MediConnect Plan will provide coverage for this drug you must first try another drug(s) on the formulary to treat your medical condition This drug may only be covered if the other drug(s) does not work for you


xv


BvD Part B vs Part D

This drug may be eligible for payment under Medicare Part B or Part D You (or your physician) are required to get prior authorization from Blue Shield Promise Cal MediConnect Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug Without prior approval Blue Shield Promise Cal MediConnect Plan may not cover this drug

NPD Non-Part D Drug This drug is covered by Medi-Cal and is not a ldquoPart D drugrdquo If you have questions call Blue Shield Promise Cal MediConnect Plan Customer Care

NDS Non-Extended Day Supply

Medication is NOT available for long-term supply

Note The NPD next to a drug means the drug is not a ldquoPart D drugrdquo You will not be required to pay a copay for these drugs These drugs also have different rules for appeals

bull An appeal is a formal way of asking us to review a decision we madeabout your coverage and to change it if you think we made a mistake Forexample we might decide that a drug that you want is not covered or is nolonger covered by Medicare or Medi-Cal

bull If you or your doctor disagrees with our decision you can appeal If youever have a question call Customer Care at 1-855-905-3825 (TTY 711) 800am to 800 pm seven days a week You can also read Chapter 9 of theMember Handbook to learn how to appeal a decision

C1 Drugs Grouped by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat For example if you have a heart condition you should look in the category Cardiovascular Agents That is where you will find drugs that treat heart conditions

Drugs Grouped by Medical ConditionANALGESICS 1

ANESTHETICS 4

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS 4

ANTIBACTERIALS 6

ANTICONVULSANTS 13

ANTIDEMENTIA AGENTS 16

ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23

ANTIMIGRAINE AGENTS 23

ANTIMYASTHENIC AGENTS 24

ANTIMYCOBACTERIALS 24

ANTINEOPLASTICS 25

ANTIPARASITICS 34

ANTIPARKINSON AGENTS 36

ANTIPSYCHOTICS 37

ANTISPASTICITY AGENTS 40

ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48

BLOOD GLUCOSE REGULATORS 48

BLOOD PRODUCTS AND MODIFIERS 52

CARDIOVASCULAR AGENTS 55

CENTRAL NERVOUS SYSTEM AGENTS 65

DENTAL AND ORAL AGENTS 68

DERMATOLOGICAL AGENTS 69

ELECTROLYTESMINERALSMETALSVITAMINS 72

GASTROINTESTINAL AGENTS 76

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERS TREATMENT 77

GENITOURINARY AGENTS 79

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) 80

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) 82

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) 82

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) 86

HORMONAL AGENTS SUPPRESSANT (PITUITARY) 86

HORMONAL AGENTS SUPPRESSANT (THYROID) 87

IMMUNOLOGICAL AGENTS 88

INFLAMMATORY BOWEL DISEASE AGENTS 94

METABOLIC BONE DISEASE AGENTS 94

MISCELLANEOUS THERAPEUTIC AGENTS 95

Non-Part D Drugs 110

OPHTHALMIC AGENTS 99

OTIC AGENTS 102

RESPIRATORY TRACTPULMONARY AGENTS 103

SKELETAL MUSCLE RELAXANTS 108

SLEEP DISORDER AGENTS 108

ANALGESICS

Name of drug What the drug will costyou(tier level)

Necessary actionsrestrictions or limits onuse

NONSTEROIDAL ANTI-INFLAMMATORY DRUGScelecoxib (cap 100 mg cap 200mg cap 50 mg)

Tier 2 QL (2 PER 1 DAYS)

celecoxib cap 400 mg Tier 2 QL (1 PER 1 DAYS)

diclofenac potassium tab 50 mg Tier 2

diclofenac sodium (tab delayedrelease 25 mg tab delayed release50 mg tab delayed release 75 mgtab er 24hr 100 mg)

Tier 2

diclofenac sodium gel 1 Tier 2

diflunisal tab 500 mg Tier 2

etodolac (tab 400 mg tab 500 mgtab er 24hr 400 mg tab er 24hr 500mg tab er 24hr 600 mg)

Tier 2

flurbiprofen tab 100 mg Tier 2

ibuprofen (tab 400 mg tab 600 mgtab 800 mg)

Tier 2

indomethacin (cap 25 mg cap 50mg)

Tier 2 PA

ketoprofen (25 mg cap 50 mg cap75 mg cap cap 50 mg cap 75 mg)

Tier 2

meloxicam (tab 15 mg tab 75 mg) Tier 2

nabumetone (tab 500 mg tab 750mg)

Tier 2

naproxen (tab 250 mg tab 375 mgtab 500 mg tab ec 375 mg tab ec500 mg)

Tier 2

piroxicam (cap 10 mg cap 20 mg) Tier 2

sulindac (tab 150 mg tab 200 mg) Tier 2

OPIOID ANALGESICS LONG-ACTINGfentanyl (patch 72hr 100 mcghrpatch 72hr 12 mcghr patch 72hr 25mcghr patch 72hr 50 mcghrpatch 72hr 75 mcghr)

Tier 2 PA QL (10 PER 30 OVERTIME) NDS

methadone hcl (10 mg5ml solutionsoln 10 mg5ml)


You can find information on what the symbols and abbreviations in this table meanby going to pages xiv - xv and reading the explanation provided in the legends

1

ANALGESICS



methadone hcl (10 mgml solutioninj 10 mgml)

Tier 2 PA NDS



methadone hcl tab 10 mg Tier 2 PA QL (90 PER 30 OVERTIME) NDS


morphine sulfate (tab er 100 mgtab er 200 mg tab er 60 mg)

Tier 2 QL (60 PER 30 OVER TIME)NDS

morphine sulfate tab er 15 mg Tier 2 QL (180 PER 30 OVERTIME) NDS

morphine sulfate tab er 30 mg Tier 2 QL (90 PER 30 OVER TIME)NDS

OXYCODONE HCL ER (ER 10 MGTB12 DETER ER 15 MG TB12 DETER ER20 MG TB12 DETER ER 30 MG TB12DETER ER 40 MG TB12 DETER)

Tier 2 PA QL (2 PER 1 DAYS)NDS

OXYCONTIN (10 MG TB12 DETER 20MG TB12 DETER 40 MG TB12 DETER)


OPIOID ANALGESICS SHORT-ACTINGacetaminophen w codeine (tab300-15 mg tab 300-30 mg)

Tier 2 QL (12 PER 1 DAYS) NDS

acetaminophen w codeine soln120-12 mg5ml

Tier 2 QL (1800 PER 30 OVERTIME) NDS

acetaminophen w codeine tab300-60 mg


butalbital-acetaminophen-caff wcod cap 50-325-40-30 mg


codeine sulfate (30 mg tab tab 30mg)




CODEINE SULFATE 15 MG TAB Tier 2 QL (336 PER 30 OVERTIME) NDS


2

ANALGESICS



fentanyl citrate (100 mcg tab 200mcg tab 400 mcg tab 600 mcgtab 800 mcg tab lozenge on ahandle 1200 mcg lozenge on ahandle 1600 mcg lozenge on ahandle 200 mcg lozenge on ahandle 400 mcg lozenge on ahandle 600 mcg lozenge on ahandle 800 mcg)


hydrocodone-acetaminophen (tab10-325 mg tab 75-325 mg)


hydrocodone-acetaminophen soln75-325 mg15ml


hydrocodone-acetaminophen tab5-325 mg


hydromorphone hcl liqd 1 mgml Tier 2 QL (675 PER 30 OVERTIME) NDS

hydromorphone hcl tab 2 mg Tier 2 QL (154 PER 30 OVERTIME) NDS

hydromorphone hcl tab 4 mg Tier 2 QL (84 PER 30 OVER TIME)NDS


morphine sulfate (15 mg tab 30 mgtab tab 15 mg tab 30 mg)


morphine sulfate oral soln 10mg5ml


morphine sulfate oral soln 100mg5ml (20 mgml)




oxycodone hcl (tab 15 mg tab 30mg)


oxycodone hcl soln 5 mg5ml Tier 2 QL (840 PER 30 OVERTIME) NDS

oxycodone hcl tab 10 mg Tier 2 QL (84 PER 30 OVER TIME)NDS

oxycodone hcl tab 20 mg Tier 2 QL (120 PER 30 OVERTIME) NDS


3

ANALGESICS




oxycodone w acetaminophen (tab25-325 mg tab 5-325 mg)


oxycodone w acetaminophen tab10-325 mg




tramadol hcl (100 mg tab tab 50mg)


tramadol-acetaminophen tab 375-325 mg


ANESTHETICS



LOCAL ANESTHETICSlidocaine hcl (4 solution soln 4) Tier 2

lidocaine hcl viscous soln 2 Tier 2

lidocaine oint 5 Tier 2 QL (50 PER 30 OVER TIME)

lidocaine patch 5 Tier 2 PA QL (3 PER 1 DAYS)

lidocaine-prilocaine cream 25-25 Tier 2 QL (30 PER 30 OVER TIME)

NAYZILAM 5 MG01ML SOLUTION Tier 3 QL (10 PER 30 OVER TIME)

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS



ALCOHOL DETERRENTSANTI-CRAVINGacamprosate calcium tab delayedrelease 333 mg

Tier 2

disulfiram (tab 250 mg tab 500 mg) Tier 2


4




OPIOID DEPENDENCEbuprenorphine hcl sl tab 2 mg (baseequiv)

Tier 2 QL (84 PER 90 OVER TIME)

buprenorphine hcl sl tab 8 mg (baseequiv)


buprenorphine hcl-naloxone hcldihydrate (-naloxone sl film 2-05 mg(base equiv) -naloxone sl film 4-1mg (base equiv))


buprenorphine hcl-naloxone hcldihydrate (-naloxone sl film 8-2 mg(base equiv) -naloxone sl tab 8-2mg (base equiv))


buprenorphine hcl-naloxone hcl slfilm 12-3 mg (base equiv)


buprenorphine hcl-naloxone hcl sltab 2-05 mg (base equiv)


ZUBSOLV (07-018 MG SL TAB 14-036 MG SL TAB 57-14 MG SL TAB)


ZUBSOLV (114-29 MG SL TAB 29-071 MG SL TAB)


ZUBSOLV 86-21 MG SL TAB Tier 3 QL (2 PER 1 DAYS)

OPIOID REVERSAL AGENTSnaloxone hcl (inj 04 mgml inj 4mg10ml soln prefilled syringe 2mg2ml)

Tier 2

NALOXONE HCL 04 MGML SOLNCART


naltrexone hcl tab 50 mg Tier 2

NARCAN 4 MG01ML LIQUID Tier 3 QL (2 PER 30 OVER TIME)

SMOKING CESSATION AGENTSbupropion hcl (smoking deterrent)tab er 12hr 150 mg


CHANTIX STARTING MONTH PAK 05MG X 11 amp 1 MG X 42 TAB



5




NICOTROL 10 MG INHALER Tier 3

NICOTROL NS 10 MGML SOLUTION Tier 3

VARENICLINE TARTRATE (05 MG TAB1 MG TAB)


ANTIBACTERIALS



AMINOGLYCOSIDESamikacin sulfate inj 500 mg2ml (250mgml)

Tier 2

gentamicin sulfate (topical) (cream01 oint 01)

Tier 2

gentamicin sulfate inj 40 mgml Tier 2

neomycin sulfate tab 500 mg Tier 2

paromomycin sulfate cap 250 mg Tier 2

STREPTOMYCIN SULFATE 1 GMRECON SOLN

Tier 2

tobramycin sulfate (10 mgmlsolution 2 gm50ml solution for inj12 gm inj 12 gm30ml (40 mgml)(base equiv) inj 80 mg2ml (40mgml) (base equiv))

Tier 2

ANTIBACTERIALS OTHERacetic acid otic soln 2 Tier 2

aztreonam (inj 1 gm inj 2 gm) Tier 2

clindamycin hcl (cap 150 mg cap300 mg cap 75 mg)

Tier 2

clindamycin palmitate hcl for soln75 mg5ml (base equiv)

Tier 2


6

ANTIBACTERIALS



clindamycin phosphate (inj 300mg2ml inj 600 mg4ml inj 9gm60ml inj 900 mg6ml iv soln 300mg2ml iv soln 600 mg4ml iv soln900 mg6ml)

Tier 2

clindamycin phosphate in d5w (soln300 mg50ml soln 600 mg50ml soln900 mg50ml)

Tier 2

CLINDAMYCIN PHOSPHATE IN NACL(300-09 MG50ML- SOLUTION 600-09 MG50ML- SOLUTION 900-09MG50ML- SOLUTION)

Tier 2

clindamycin phosphate swab 1 Tier 2

clindamycin phosphate vaginalcream 2

Tier 2

colistimethate sod for inj 150 mg(colistin base activity)

Tier 2

daptomycin (350 mg recon soln foriv soln 350 mg for iv soln 500 mg)

Tier 2

fosfomycin tromethamine powdpack 3 gm (base equivalent)


linezolid (for susp 100 mg5ml tab600 mg)

Tier 2 PA

LINEZOLID IN SODIUM CHLORIDE 600-09 MG300ML- SOLUTION

Tier 2

linezolid iv soln 600 mg300ml (2mgml)

Tier 2

methenamine hippurate tab 1 gm Tier 2

metronidazole (5 mgml solutiontab 250 mg tab 500 mg)

Tier 2

metronidazole (topical) (cream075 gel 075 gel 1 lotion075)

Tier 2

metronidazole in nacl (074 iv soln500 mg100ml 079 iv soln 500mg100ml)

Tier 2

metronidazole vaginal gel 075 Tier 3

nitrofurantoin macrocrystal (cap 100mg cap 25 mg cap 50 mg)

Tier 2


7

ANTIBACTERIALS



nitrofurantoin monohydratemacrocrystalline cap 100 mg

Tier 2

ORBACTIV 400 MG RECON SOLN Tier 3 PA QL (9 PER 30 OVERTIME)

SYNERCID 150-350 MG RECON SOLN Tier 3

tigecycline (50 mg recon soln for ivsoln 50 mg)

Tier 2

trimethoprim (100 mg tab tab 100mg)

Tier 2

vancomycin hcl (125 gm reconsoln 15 gm recon soln 250 mgrecon soln 750 mg recon soln cap125 mg (base equivalent) cap 250mg (base equivalent) for iv soln 1gm (base equivalent) for iv soln 10gm (base equivalent) for iv soln 500mg (base equivalent) for iv soln 750mg (base equivalent))

Tier 2

XIFAXAN 200 MG TAB Tier 3 PA QL (9 PER 30 OVERTIME)

XIFAXAN 550 MG TAB Tier 3 PA QL (3 PER 1 DAYS)

BETA-LACTAM CEPHALOSPORINScefaclor (125 mg5ml recon susp250 mg cap 250 mg5ml reconsusp 375 mg5ml recon susp 500mg cap cap 250 mg cap 500 mg)

Tier 2

cefadroxil (1 gm tab cap 500 mgfor susp 250 mg5ml for susp 500mg5ml tab 1 gm)

Tier 2

cefazolin sodium (1 gm recon soln100 gm recon soln 20 gm reconsoln 300 gm recon soln for inj 1 gmfor inj 10 gm for inj 500 mg)

Tier 2

cefdinir (cap 300 mg for susp 125mg5ml for susp 250 mg5ml)

Tier 2

cefepime hcl (inj 1 gm inj 2 gm) Tier 2

cefixime (cap 400 mg for susp 100mg5ml for susp 200 mg5ml)

Tier 2


8

ANTIBACTERIALS



cefotaxime sodium (1 gm reconsoln for inj 1 gm)

Tier 2

cefotetan disodium (inj 1 gm inj 2gm)

Tier 2

cefoxitin sodium (soln 1 gm soln 10gm soln 2 gm)

Tier 2

cefpodoxime proxetil (for susp 100mg5ml for susp 50 mg5ml tab 100mg tab 200 mg)

Tier 2

cefprozil (for susp 125 mg5ml forsusp 250 mg5ml tab 250 mg tab500 mg)

Tier 2

ceftazidime (inj 1 gm inj 6 gm ivsoln 2 gm)

Tier 2

ceftriaxone sodium (inj 1 gm inj 10gm inj 2 gm inj 250 mg inj 500 mgiv soln 1 gm iv soln 2 gm)

Tier 2

cefuroxime axetil (tab 250 mg tab500 mg)

Tier 2

cefuroxime sodium (inj 75 gm inj750 mg iv soln 15 gm)

Tier 2

cephalexin (cap 250 mg cap 500mg for susp 125 mg5ml for susp250 mg5ml)

Tier 2

TAZICEF (1 GM RECON SOLN 6 GMRECON SOLN)

Tier 2

TEFLARO (400 MG RECON SOLN 600MG RECON SOLN)

Tier 3

BETA-LACTAM PENICILLINSamoxicillin amp pot clavulanate (forsusp 200-285 mg5ml for susp 250-625 mg5ml for susp 400-57mg5ml for susp 600-429 mg5mltab 250-125 mg tab 500-125 mgtab 875-125 mg)

Tier 2


9

ANTIBACTERIALS



AMOXICILLIN ((TRIHYDRATE) CAP 250MG (TRIHYDRATE) CAP 500 MG(TRIHYDRATE) FOR SUSP 125MG5ML (TRIHYDRATE) FOR SUSP200 MG5ML (TRIHYDRATE) FORSUSP 250 MG5ML (TRIHYDRATE)FOR SUSP 400 MG5ML(TRIHYDRATE) TAB 500 MG(TRIHYDRATE) TAB 875 MG 125 MGCHEW TAB 250 MG CHEW TAB)

Tier 2

AMOXICILLIN-POT CLAVULANATE(200-285 MG CHEW TAB 400-57 MGCHEW TAB)

Tier 2

ampicillin amp sulbactam sodium (inj15 (1-05) gm inj 3 (2-1) gm iv soln15 (10-5) gm)

Tier 2

AMPICILLIN 500 MG CAP Tier 2

ampicillin sodium (1 gm recon soln125 mg recon soln 2 gm recon solnfor inj 1 gm for inj 2 gm for inj 250mg for inj 500 mg for iv soln 10 gmfor iv soln 2 gm)

Tier 2

AMPICILLIN-SULBACTAM SODIUM(15 (1-05) GM RECON SOLN 3 (2-1)GM RECON SOLN)

Tier 2

BICILLIN L-A (1200000 UNIT2MLSUSPENSION 2400000 UNIT4MLSUSPENSION 600000 UNITMLSUSPENSION)

Tier 3

dicloxacillin sodium (cap 250 mgcap 500 mg)

Tier 2

nafcillin sodium (1 gm recon soln 2gm recon soln for inj 1 gm for inj 2gm for iv soln 10 gm)

Tier 2

penicillin g potassium (inj 20000000unit inj 5000000 unit)

Tier 2

PENICILLIN G SODIUM 5000000 UNITRECON SOLN

Tier 2

penicillin v potassium (125 mg5mlrecon soln 250 mg5ml recon solntab 250 mg tab 500 mg)

Tier 2


10

ANTIBACTERIALS



PFIZERPEN (20000000 UNIT RECONSOLN 5000000 UNIT RECON SOLN)

Tier 2

piperacillin sodium-tazobactamsodium (na for inj 3375 gm (3-0375gm) sod for inj 135 gm (12-15 gm)sod for inj 225 gm (2-025 gm) sodfor inj 45 gm (4-05 gm) sod for inj405 gm (36-45 gm))

Tier 2

CARBAPENEMSertapenem sodium for inj 1 gm(base equivalent)

Tier 2

imipenem-cilastatin (250 mg reconsoln intravenous for soln 250 mgintravenous for soln 500 mg)

Tier 2

meropenem (soln 1 gm soln 500mg)

Tier 2

MACROLIDESazithromycin (1 gm packet for susp100 mg5ml for susp 200 mg5ml ivfor soln 500 mg tab 250 mg tab 500mg tab 600 mg)

Tier 2

clarithromycin (125 mg5ml reconsusp 250 mg5ml recon susp tab250 mg tab 500 mg tab er 24hr 500mg)

Tier 2

EES 400 400 MG TAB Tier 2

ERYTHROCIN LACTOBIONATE 500MG RECON SOLN

Tier 3

erythromycin base (base 250 mg cpdr part tab 250 mg tab 500 mg wdelayed release particles cap 250mg)

Tier 2

ERYTHROMYCIN ETHYLSUCCINATE400 MG TAB

Tier 2

QUINOLONESBESIVANCE 06 SUSPENSION Tier 3

CILOXAN 03 OINTMENT Tier 3


11

ANTIBACTERIALS



ciprofloxacin (susp 250 mg5ml (5)(5 gm100ml) susp 500 mg5ml(10) (10 gm100ml))

Tier 2

ciprofloxacin 200 mg100ml in d5w Tier 2

ciprofloxacin hcl (100 mg tab tab250 mg (base equiv) tab 500 mg(base equiv) tab 750 mg (baseequiv))

Tier 2

ciprofloxacin hcl ophth soln 03(base equivalent)

Tier 2

levofloxacin (iv soln 25 mgml oralsoln 25 mgml tab 250 mg tab 500mg tab 750 mg)

Tier 2

levofloxacin in d5w (soln 500mg100ml soln 750 mg150ml)

Tier 2

moxifloxacin hcl tab 400 mg (baseequiv)

Tier 2

ofloxacin (300 mg tab tab 400 mg) Tier 2

SULFONAMIDESsulfacetamide sodium lotion 10(acne)

Tier 2

SULFADIAZINE 500 MG TAB Tier 2

sulfamethoxazole-trimethoprim (ivsoln 400-80 mg5ml susp 200-40mg5ml tab 400-80 mg tab 800-160mg)

Tier 2

TETRACYCLINESdoxycycline (monohydrate) (cap100 mg cap 50 mg tab 100 mgtab 50 mg tab 75 mg)

Tier 2

doxycycline hyclate (cap 100 mgcap 50 mg for inj 100 mg tab 100mg tab 20 mg)

Tier 2

minocycline hcl (cap 100 mg cap50 mg cap 75 mg tab 100 mg tab50 mg tab 75 mg)

Tier 2

tetracycline hcl (cap 250 mg cap500 mg)

Tier 2


12

ANTICONVULSANTS



ANTICONVULSANTS OTHERBRIVIACT (10 MG TAB 100 MG TAB25 MG TAB 50 MG TAB 75 MG TAB)

Tier 3 ST QL (2 PER 1 DAYS)

BRIVIACT 10 MGML SOLUTION Tier 3 ST QL (20 PER 1 DAYS)

DIACOMIT (250 MG CAP 250 MGPACKET)

Tier 3 PA LA QL (3 PER 1 DAYS)



divalproex sodium (cap delayedrelease sprinkle 125 mg tabdelayed release 125 mg tabdelayed release 250 mg tabdelayed release 500 mg tab er 24hr 250 mg tab er 24 hr 500 mg)

Tier 2

EPIDIOLEX 100 MGML SOLUTION Tier 3 PA LA

felbamate (susp 600 mg5ml tab400 mg tab 600 mg)

Tier 2

FINTEPLA 22 MGML SOLUTION Tier 3 PA LA QL (12 PER 1 DAYS)

FYCOMPA (10 MG TAB 12 MG TAB 4MG TAB 6 MG TAB 8 MG TAB)


FYCOMPA 05 MGML SUSPENSION Tier 3 ST QL (24 PER 1 DAYS)

FYCOMPA 2 MG TAB Tier 3 ST QL (3 PER 1 DAYS)

lamotrigine (tab 100 mg tab 150mg tab 200 mg tab 25 mg tabchewable dispersible 25 mg tabchewable dispersible 5 mg)

Tier 2

levetiracetam (oral soln 100 mgmltab 1000 mg tab 250 mg tab 500mg tab 750 mg)

Tier 2

levetiracetam tab er 24hr 500 mg Tier 2 QL (6 PER 1 DAYS)


SPRITAM (250 MG TAB 500 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

SPRITAM 1000 MG TAB Tier 3 PA QL (3 PER 1 DAYS)



13

ANTICONVULSANTS



topiramate (cap er 24hr sprinkle 100mg cap er 24hr sprinkle 150 mgcap er 24hr sprinkle 200 mg cap er24hr sprinkle 25 mg cap er 24hrsprinkle 50 mg)

Tier 2 PA

topiramate (sprinkle cap 15 mgsprinkle cap 25 mg tab 100 mg tab200 mg tab 25 mg tab 50 mg)

Tier 2

valproate sodium (inj 100 mgmloral soln 250 mg5ml (base equiv))

Tier 2

valproic acid cap 250 mg Tier 2

XCOPRI (100 MG TAB 50 MG TAB) Tier 3 PA QL (1 PER 1 DAYS)


XCOPRI (250 MG DAILY DOSE) (MGDAILY DOSE) 100 amp 150 MG TABTHPK MG DAILY DOSE) 50 amp 200 MGTAB THPK)

Tier 3 PA QL (2 PER 1 DAYS)

XCOPRI (350 MG DAILY DOSE) 150 amp200 MG TAB THPK


XCOPRI (COPRI 14 125 MG amp 14 25MG TAB THPK COPRI 14 150 MG amp14 200 MG TAB THPK COPRI 14 50MG amp 14 100 MG TAB THPK)

Tier 3 PA QL (28 PER 28 OVERTIME)

CALCIUM CHANNEL MODIFYING AGENTSCELONTIN 300 MG CAP Tier 3

ethosuximide (cap 250 mg soln 250mg5ml)

Tier 2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam suspension 25 mgml Tier 2 PA QL (16 PER 1 DAYS)

clobazam tab 10 mg Tier 2 PA QL (4 PER 1 DAYS)


DIAZEPAM 10 MG GEL Tier 2 QL (20 PER 30 OVER TIME)



gabapentin (tab 600 mg tab 800mg)



14

ANTICONVULSANTS



gabapentin cap 100 mg Tier 2 QL (12 PER 1 DAYS)



gabapentin oral soln 250 mg5ml Tier 2 QL (72 PER 1 DAYS)

phenobarbital (elixir 20 mg5ml tab100 mg tab 15 mg tab 162 mg tab30 mg tab 324 mg tab 60 mg tab648 mg tab 972 mg)

Tier 2 PA

primidone (tab 250 mg tab 50 mg) Tier 2

SYMPAZAN (10 MG FILM 20 MGFILM 5 MG FILM)


tiagabine hcl (tab 12 mg tab 16mg tab 2 mg tab 4 mg)

Tier 2 PA

VALTOCO 10 MG DOSE 10MG01ML LIQUID


VALTOCO 15 MG DOSE 75MG01ML LIQD THPK




VALTOCO 5 MG DOSE 5 MG01MLLIQUID


vigabatrin (powd pack 500 mg tab500 mg)


SODIUM CHANNEL AGENTSAPTIOM (200 MG TAB 400 MG TAB) Tier 3 ST QL (1 PER 1 DAYS)

APTIOM (600 MG TAB 800 MG TAB) Tier 3 ST QL (2 PER 1 DAYS)

carbamazepine (cap er 12hr 100mg cap er 12hr 200 mg cap er 12hr300 mg chew tab 100 mg susp 100mg5ml tab 200 mg tab er 12hr 100mg tab er 12hr 200 mg tab er 12hr400 mg)

Tier 2

DILANTIN (100 MG CAP 30 MG CAP) Tier 3

DILANTIN INFATABS 50 MG CHEWTAB

Tier 3


15

ANTICONVULSANTS



oxcarbazepine (susp 300 mg5ml(60 mgml) tab 150 mg tab 300mg tab 600 mg)

Tier 2

PEGANONE 250 MG TAB Tier 3

PHENYTEK (200 MG CAP 300 MGCAP)

Tier 3

phenytoin (chew tab 50 mg susp125 mg5ml)

Tier 2

phenytoin sodium extended (cap100 mg cap 200 mg cap 300 mg)

Tier 2

rufinamide susp 40 mgml Tier 2 ST QL (80 PER 1 DAYS)

rufinamide tab 200 mg Tier 2 ST QL (16 PER 1 DAYS)


VIMPAT (100 MG TAB 150 MG TAB200 MG TAB 50 MG TAB)


VIMPAT 10 MGML SOLUTION Tier 3 ST QL (40 PER 1 DAYS)

VIMPAT 200 MG20ML SOLUTION Tier 3 PA

zonisamide (cap 100 mg cap 25mg cap 50 mg)

Tier 2

ANTIDEMENTIA AGENTS



ANTIDEMENTIA AGENTS OTHERERGOLOID MESYLATES 1 MG TAB Tier 2

CHOLINESTERASE INHIBITORSdonepezil hydrochloride (orallydisintegrating tab 10 mg orallydisintegrating tab 5 mg tab 10 mgtab 5 mg)

Tier 2

rivastigmine (patch 24hr 133mg24hr patch 24hr 46 mg24hrpatch 24hr 95 mg24hr)



16

ANTIDEMENTIA AGENTS



rivastigmine tartrate (cap 15 mg(base equivalent) cap 3 mg (baseequivalent) cap 45 mg (baseequivalent) cap 6 mg (baseequivalent))

Tier 2

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (cap er 24hr 14 mgcap er 24hr 21 mg cap er 24hr 28mg cap er 24hr 7 mg oral solution 2mgml tab 10 mg tab 28 x 5 mg amp21 x 10 mg titration pack tab 5 mg)

Tier 2

ANTIDEPRESSANTS



ANTIDEPRESSANTS OTHERbupropion hcl (tab 100 mg tab er12hr 100 mg)


bupropion hcl (tab er 12hr 150 mgtab er 24hr 150 mg)


bupropion hcl tab 75 mg Tier 2 QL (6 PER 1 DAYS)

bupropion hcl tab er 12hr 200 mg Tier 2 QL (2 PER 1 DAYS)


LYBALVI (10-10 MG TAB 15-10 MGTAB 20-10 MG TAB 5-10 MG TAB)


MAPROTILINE HCL (25 MG TAB 50MG TAB 75 MG TAB)

Tier 2

mirtazapine (orally disintegratingtab 15 mg orally disintegrating tab30 mg orally disintegrating tab 45mg tab 15 mg tab 30 mg tab 45mg tab 75 mg)

Tier 2

MONOAMINE OXIDASE INHIBITORSEMSAM (12 MG24HR PATCH 24HR 6MG24HR PATCH 24HR 9 MG24HRPATCH 24HR)

Tier 3 PA


17

ANTIDEPRESSANTS



MARPLAN 10 MG TAB Tier 3

phenelzine sulfate tab 15 mg Tier 2

tranylcypromine sulfate tab 10 mg Tier 2

SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORSEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR)citalopram hydrobromide (oral soln10 mg5ml tab 10 mg (base equiv)tab 20 mg (base equiv) tab 40 mg(base equiv))

Tier 2

DESVENLAFAXINE ER (ER 100 MG TABER 24H ER 50 MG TAB ER 24H)


desvenlafaxine succinate (tab er24hr 25 mg (base equiv) tab er 24hr50 mg (base equiv))


desvenlafaxine succinate tab er24hr 100 mg (base equiv)


escitalopram oxalate (soln 5 mg5ml(base equiv) tab 10 mg (baseequiv) tab 20 mg (base equiv) tab5 mg (base equiv))

Tier 2

FETZIMA (120 MG CAP ER 24H 20MG CAP ER 24H 40 MG CAP ER 24H80 MG CAP ER 24H)


FETZIMA TITRATION 20 amp 40 MG CP24THPK


fluoxetine hcl (cap 10 mg cap 20mg cap 40 mg solution 20 mg5ml)

Tier 2

FLUOXETINE HCL (PMDD) (10 MGCAP 20 MG CAP)

Tier 2

FLUOXETINE HCL 90 MG CAP DR Tier 2 QL (4 PER 28 OVER TIME)

fluvoxamine maleate (tab 100 mgtab 25 mg tab 50 mg)

Tier 2

nefazodone hcl (100 mg tab 150mg tab 200 mg tab 250 mg tab 50mg tab tab 250 mg tab 50 mg)

Tier 2

paroxetine hcl (tab 10 mg tab 20mg tab 30 mg tab 40 mg)

Tier 2


18

ANTIDEPRESSANTS



paroxetine hcl oral susp 10 mg5ml(base equiv)


PAXIL 10 MG5ML SUSPENSION Tier 3 QL (30 PER 1 DAYS)

sertraline hcl (oral concentrate forsolution 20 mgml tab 100 mg tab25 mg tab 50 mg)

Tier 2

trazodone hcl (tab 100 mg tab 150mg tab 300 mg tab 50 mg)

Tier 2

TRINTELLIX (10 MG TAB 20 MG TAB 5MG TAB)


venlafaxine hcl (cap er 24hr 150 mg(base equivalent) cap er 24hr 375mg (base equivalent))


venlafaxine hcl (tab 100 mg (baseequivalent) tab 25 mg (baseequivalent) tab 375 mg (baseequivalent) tab 50 mg (baseequivalent) tab 75 mg (baseequivalent))

Tier 2

venlafaxine hcl cap er 24hr 75 mg(base equivalent)


VIIBRYD (10 MG TAB 20 MG TAB 40MG TAB)


VIIBRYD STARTER PACK 10 amp 20 MGKIT

Tier 3 ST QL (30 PER 30 OVERTIME)

TRICYCLICSamitriptyline hcl (tab 10 mg tab 100mg tab 150 mg tab 25 mg tab 50mg tab 75 mg)

Tier 2 PA

AMOXAPINE (100 MG TAB 150 MGTAB 25 MG TAB 50 MG TAB)

Tier 2

clomipramine hcl (cap 25 mg cap50 mg cap 75 mg)

Tier 2 PA

desipramine hcl (tab 10 mg tab 100mg tab 150 mg tab 25 mg tab 50mg tab 75 mg)

Tier 2

doxepin hcl (150 mg cap cap 10mg cap 100 mg cap 25 mg cap50 mg cap 75 mg conc 10 mgml)

Tier 2 PA


19

ANTIDEPRESSANTS



imipramine hcl (tab 10 mg tab 25mg tab 50 mg)

Tier 2 PA

nortriptyline hcl (10 mg5ml solutioncap 10 mg cap 25 mg cap 50 mgcap 75 mg soln 10 mg5ml)

Tier 2

nortriptyline oral solution (unit dose) Tier 2

protriptyline hcl (tab 10 mg tab 5mg)

Tier 2

trimipramine maleate (cap 100 mgcap 25 mg cap 50 mg)

Tier 2 PA

ANTIEMETICS



ANTIEMETICS OTHERmeclizine hcl (tab 125 mg tab 25mg)

Tier 2

metoclopramide hcl (inj 5 mgml(base equivalent) soln 5 mg5ml (10mg10ml) (base equiv) tab 10 mg(base equivalent) tab 5 mg (baseequivalent))

Tier 2

perphenazine (tab 16 mg tab 2 mgtab 4 mg tab 8 mg)

Tier 2

prochlorperazine edisylate inj 10mg2ml

Tier 2

prochlorperazine maleate (tab 10mg (base equivalent) tab 5 mg(base equivalent))

Tier 2

prochlorperazine suppos 25 mg Tier 2

promethazine hcl (tab 125 mg tab25 mg tab 50 mg)

Tier 2 PA

scopolamine td patch 72hr 1mg3days

Tier 2 PA


20

ANTIEMETICS



EMETOGENIC THERAPY ADJUNCTSaprepitant (capsule 125 mgcapsule 80 mg capsule therapypack 80 amp 125 mg)

Tier 2 BvD

aprepitant capsule 40 mg Tier 2 PA QL (1 PER 30 OVERTIME)

dronabinol (cap 10 mg cap 25 mgcap 5 mg)


granisetron hcl (01 mgml solutioninj 1 mgml inj 4 mg4ml (1 mgml))

Tier 2 BvD

granisetron hcl tab 1 mg Tier 2 QL (2 PER 1 DAYS) BvD

ondansetron (tab 4 mg tab 8 mg) Tier 2 QL (3 PER 1 DAYS) BvD

ondansetron hcl (24 mg tab tab 24mg)

Tier 2 QL (15 PER 30 OVER TIME)BvD

ondansetron hcl (tab 4 mg tab 8mg)

Tier 2 QL (3 PER 1 DAYS) BvD

ondansetron hcl oral soln 4 mg5ml Tier 2 QL (30 PER 1 DAYS) BvD

ANTIFUNGALS



ANTIFUNGALSABELCET 5 MGML SUSPENSION Tier 3 BvD

AMBISOME 50 MG RECON SUSP Tier 3 BvD

AMPHOTERICIN B 50 MG RECONSOLN

Tier 2 BvD

caspofungin acetate (50 mg reconsoln 70 mg recon soln for iv soln 50mg for iv soln 70 mg)

Tier 2 PA

ciclopirox olamine (cream 077(base equiv) susp 077 (baseequiv))

Tier 2

clotrimazole (topical) (cream 1soln 1)

Tier 2


21

ANTIFUNGALS



clotrimazole troche 10 mg Tier 2

CRESEMBA (186 MG CAP 372 MGRECON SOLN)

Tier 3 PA

econazole nitrate cream 1 Tier 2

fluconazole (for susp 10 mgml forsusp 40 mgml tab 100 mg tab 150mg tab 200 mg tab 50 mg)

Tier 2

fluconazole in dextrose (j 200mg100ml j 400 mg200ml)

Tier 2

fluconazole in nacl (j 200 mg100mlj 400 mg200ml)

Tier 2

flucytosine (cap 250 mg cap 500mg)

Tier 2

griseofulvin microsize (susp 125mg5ml tab 500 mg)

Tier 2

griseofulvin ultramicrosize (tab 125mg tab 250 mg)

Tier 2

itraconazole cap 100 mg Tier 2 PA

ketoconazole (topical) (cream 2shampoo 2)

Tier 2

ketoconazole tab 200 mg Tier 2

micafungin sodium (soln 100 mgsoln 50 mg)

Tier 2

MICONAZOLE 3 200 MG SUPPOS Tier 2

nystatin (topical) (cream 100000unitgm oint 100000 unitgmtopical powder 100000 unitgm)

Tier 2

nystatin susp 100000 unitml Tier 2

nystatin tab 500000 unit Tier 2

posaconazole tab delayed release100 mg


terbinafine hcl tab 250 mg Tier 2 QL (1 PER 1 DAYS)

terconazole vaginal (cream 04cream 08 suppos 80 mg)

Tier 2

voriconazole (for susp 40 mgml tab200 mg tab 50 mg)

Tier 2 PA


22

ANTIFUNGALS



voriconazole for inj 200 mg Tier 2

ANTIGOUT AGENTS



ANTIGOUT AGENTSallopurinol (tab 100 mg tab 300 mg) Tier 2

colchicine (06 mg cap tab 06 mg) Tier 2 QL (4 PER 1 DAYS)

colchicine w probenecid tab 05-500 mg

Tier 2

COLCRYS 06 MG TAB Tier 3 QL (4 PER 1 DAYS)

KRYSTEXXA 8 MGML SOLUTION Tier 3 PA LA

probenecid tab 500 mg Tier 2

ANTIMIGRAINE AGENTS



ERGOT ALKALOIDSdihydroergotamine mesylate inj 1mgml

Tier 2 PA

dihydroergotamine mesylate nasalspray 4 mgml


MIGERGOT 2-100 MG SUPPOS Tier 3 QL (20 PER 30 OVER TIME)

PROPHYLACTICAIMOVIG (140 MG DOSE) 70 MGMLSOLN A-INJ


AIMOVIG (140 MGML SOLN A-INJ70 MGML SOLN A-INJ)


timolol maleate (10 mg tab tab 10mg tab 20 mg tab 5 mg)

Tier 2


23

ANTIMIGRAINE AGENTS



SEROTONIN (5-HT) RECEPTOR AGONISTnaratriptan hcl (tab 1 mg (baseequiv) tab 25 mg (base equiv))


rizatriptan benzoate (oraldisintegrating tab 10 mg (base eq)oral disintegrating tab 5 mg (baseeq) tab 10 mg (base equivalent)tab 5 mg (base equivalent))


sumatriptan (20 mgact 5 mgact) Tier 2 QL (18 PER 30 OVER TIME)

sumatriptan succinate (6 mg05mlsoln prsyr inj 6 mg05ml solutionauto-injector 4 mg05ml solutionauto-injector 6 mg05ml solutioncartridge 4 mg05ml solutioncartridge 6 mg05ml)


sumatriptan succinate (tab 100 mgtab 25 mg tab 50 mg)


zolmitriptan (orally disintegrating tab25 mg orally disintegrating tab 5mg tab 25 mg tab 5 mg)


ANTIMYASTHENIC AGENTS



PARASYMPATHOMIMETICSGUANIDINE HCL 125 MG TAB Tier 2

pyridostigmine bromide tab 60 mg Tier 2 QL (25 PER 1 DAYS)

ANTIMYCOBACTERIALS



ANTIMYCOBACTERIALS OTHERdapsone (tab 100 mg tab 25 mg) Tier 2


24

ANTIMYCOBACTERIALS



rifabutin cap 150 mg Tier 2

ANTITUBERCULARSCAPASTAT SULFATE 1 GM RECONSOLN

Tier 3

ethambutol hcl (tab 100 mg tab400 mg)

Tier 2

isoniazid (100 mg tab 100 mgmlsolution 50 mg5ml syrup tab 100mg tab 300 mg)

Tier 2

PASER 4 GM PACKET Tier 3

PRIFTIN 150 MG TAB Tier 3

pyrazinamide tab 500 mg Tier 2

rifampin (cap 150 mg cap 300 mgfor inj 600 mg)

Tier 2

RIFATER 50-120-300 MG TAB Tier 3

SIRTURO 100 MG TAB Tier 3 PA QL (24 PER 28 OVERTIME)


TRECATOR 250 MG TAB Tier 3

ANTINEOPLASTICS



ALKYLATING AGENTScyclophosphamide (25 mg cap 25mg tab 50 mg cap 50 mg tab cap25 mg cap 50 mg)

Tier 3 BvD

GLEOSTINE (10 MG CAP 100 MGCAP 40 MG CAP 5 MG CAP)

Tier 3

LEUKERAN 2 MG TAB Tier 3

MATULANE 50 MG CAP Tier 3 LA


25

ANTINEOPLASTICS



VALCHLOR 0016 GEL Tier 3 PA LA QL (60 PER 30OVER TIME)

ANTIANDROGENSabiraterone acetate tab 250 mg Tier 2 PA QL (4 PER 1 DAYS)

abiraterone acetate tab 500 mg Tier 2 PA QL (2 PER 1 DAYS)

bicalutamide tab 50 mg Tier 2

ERLEADA 60 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

flutamide (125 mg cap cap 125mg)

Tier 2

nilutamide tab 150 mg Tier 2 QL (1 PER 1 DAYS)

NUBEQA 300 MG TAB Tier 3 PA QL (4 PER 1 DAYS)

XTANDI (40 MG CAP 40 MG TAB) Tier 3 PA LA QL (4 PER 1 DAYS)

XTANDI 80 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

ANTIANGIOGENIC AGENTSPOMALYST (1 MG CAP 2 MG CAP 3MG CAP 4 MG CAP)


REVLIMID (10 MG CAP 15 MG CAP25 MG CAP 20 MG CAP 25 MGCAP 5 MG CAP)


THALOMID (100 MG CAP 50 MGCAP)




ANTIESTROGENSMODIFIERSEMCYT 140 MG CAP Tier 3

fulvestrant (250 mg5ml solution inj250 mg5ml)

Tier 2

SOLTAMOX 10 MG5ML SOLUTION Tier 3 PA

tamoxifen citrate (tab 10 mg (baseequivalent) tab 20 mg (baseequivalent))

Tier 2

toremifene citrate tab 60 mg (baseequivalent)

Tier 2


26

ANTINEOPLASTICS



ANTIMETABOLITESDROXIA (200 MG CAP 300 MG CAP400 MG CAP)

Tier 3

hydroxyurea cap 500 mg Tier 2

INQOVI 35-100 MG TAB Tier 3 PA LA QL (5 PER 28 OVERTIME)

mercaptopurine tab 50 mg Tier 2

PURIXAN 2000 MG100MLSUSPENSION

Tier 3 PA LA

TABLOID 40 MG TAB Tier 3

ANTINEOPLASTICS OTHERAYVAKIT (100 MG TAB 200 MG TAB25 MG TAB 300 MG TAB 50 MG TAB)


BRUKINSA 80 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

EXKIVITY 40 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

FOTIVDA (089 MG CAP 134 MGCAP)

Tier 3 PA LA QL (21 PER 28OVER TIME)

IDHIFA (100 MG TAB 50 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

INREBIC 100 MG CAP Tier 3 PA QL (4 PER 1 DAYS)

KISQALI FEMARA (400 MG DOSE) 200amp 25 MG TAB THPK




KISQALI FEMARA(200 MG DOSE) 200amp 25 MG TAB THPK


KOSELUGO 10 MG CAP Tier 3 PA LA QL (8 PER 1 DAYS)


leucovorin calcium (for inj 100 mgfor inj 350 mg tab 10 mg tab 15 mgtab 25 mg tab 5 mg)

Tier 2

levoleucovorin calcium (for inj 50mg (base equ) soln pf 175mg175ml (base equ) soln pf 250mg25ml (base equ))

Tier 2 PA


27

ANTINEOPLASTICS



LONSURF 15-614 MG TAB Tier 3 PA LA QL (100 PER 28OVER TIME)


LUMAKRAS 120 MG TAB Tier 3 PA QL (8 PER 1 DAYS)

LYSODREN 500 MG TAB Tier 3

NINLARO (23 MG CAP 3 MG CAP 4MG CAP)


ONUREG (200 MG TAB 300 MG TAB) Tier 3 PA QL (14 PER 28 OVERTIME)

QINLOCK 50 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

RETEVMO 40 MG CAP Tier 3 PA QL (6 PER 1 DAYS)


ROZLYTREK 100 MG CAP Tier 3 PA QL (5 PER 1 DAYS)


SYNRIBO 35 MG RECON SOLN Tier 3 BvD

TABRECTA (150 MG TAB 200 MGTAB)


TAZVERIK 200 MG TAB Tier 3 PA LA QL (8 PER 1 DAYS)

WELIREG 40 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

XPOVIO (100 MG ONCE WEEKLY) 20MG TAB THPK



Tier 3 PA LA QL (8 PER 28 OVERTIME)





XPOVIO (40 MG TWICE WEEKLY) 20MG TAB THPK







28

ANTINEOPLASTICS













ZOLINZA 100 MG CAP Tier 3 PA QL (4 PER 1 DAYS)

AROMATASE INHIBITORS 3RD GENERATIONanastrozole tab 1 mg Tier 2

exemestane tab 25 mg Tier 2

letrozole tab 25 mg Tier 2

ENZYME INHIBITORSGAVRETO 100 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

MOLECULAR TARGET INHIBITORSAFINITOR 10 MG TAB Tier 3 PA QL (2 PER 1 DAYS)

AFINITOR DISPERZ (2 MG TAB SOL 3MG TAB SOL 5 MG TAB SOL)

Tier 3 PA

ALECENSA 150 MG CAP Tier 3 PA LA QL (8 PER 1 DAYS)

ALUNBRIG (180 MG TAB 90 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

ALUNBRIG 30 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

ALUNBRIG 90 amp 180 MG TAB THPK Tier 3 PA LA QL (30 PER 30OVER TIME)

BALVERSA 3 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)



BOSULIF (400 MG TAB 500 MG TAB) Tier 3 PA QL (1 PER 1 DAYS)

BOSULIF 100 MG TAB Tier 3 PA QL (4 PER 1 DAYS)


29

ANTINEOPLASTICS



BRAFTOVI 50 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)


CABOMETYX (20 MG TAB 40 MGTAB 60 MG TAB)


CALQUENCE 100 MG CAP Tier 3 PA LA QL (2 PER 1 DAYS)

CAPRELSA 100 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)


COMETRIQ (100 MG DAILY DOSE) 80amp 20 MG KIT


COMETRIQ (140 MG DAILY DOSE) 3 X20 MG amp 80 MG KIT


COMETRIQ (60 MG DAILY DOSE) 20MG KIT


COPIKTRA (15 MG CAP 25 MG CAP) Tier 3 PA LA QL (56 PER 28OVER TIME)

COTELLIC 20 MG TAB Tier 3 PA LA QL (63 PER 28OVER TIME)

DAURISMO 100 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)


ERIVEDGE 150 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

erlotinib hcl (tab 100 mg (baseequivalent) tab 150 mg (baseequivalent))


erlotinib hcl tab 25 mg (baseequivalent)


everolimus (tab 10 mg tab 75 mg) Tier 2 PA QL (2 PER 1 DAYS)


everolimus (tab for oral susp 2 mgtab for oral susp 3 mg tab for oralsusp 5 mg)

Tier 2 PA

FARYDAK (10 MG CAP 15 MG CAP20 MG CAP)


GILOTRIF (20 MG TAB 30 MG TAB 40MG TAB)



30

ANTINEOPLASTICS



IBRANCE (100 MG CAP 100 MG TAB125 MG CAP 125 MG TAB 75 MGCAP 75 MG TAB)


ICLUSIG (10 MG TAB 30 MG TAB 45MG TAB)


ICLUSIG 15 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

imatinib mesylate tab 100 mg (baseequivalent)




IMBRUVICA (280 MG TAB 420 MGTAB 560 MG TAB 70 MG CAP)


IMBRUVICA 140 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

INLYTA 1 MG TAB Tier 3 PA LA QL (6 PER 1 DAYS)


IRESSA 250 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

JAKAFI (10 MG TAB 15 MG TAB 20MG TAB 25 MG TAB 5 MG TAB)


KISQALI (200 MG DOSE) 200 MG TABTHPK






lapatinib ditosylate tab 250 mg(base equiv)


LENVIMA (10 MG DAILY DOSE) 10MG CAP THPK


LENVIMA (12 MG DAILY DOSE) 3 X 4MG CAP THPK


LENVIMA (14 MG DAILY DOSE) 10 amp4 MG CAP THPK


LENVIMA (18 MG DAILY DOSE) 10MG amp 2 X 4 MG CAP THPK





31

ANTINEOPLASTICS



LENVIMA (24 MG DAILY DOSE) 2 X 10MG amp 4 MG CAP THPK


LENVIMA (4 MG DAILY DOSE) 4 MGCAP THPK




LORBRENA 100 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)


LYNPARZA (100 MG TAB 150 MGTAB)


MEKINIST 05 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)


MEKTOVI 15 MG TAB Tier 3 PA LA QL (6 PER 1 DAYS)

NERLYNX 40 MG TAB Tier 3 PA LA QL (6 PER 1 DAYS)

NEXAVAR 200 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

ODOMZO 200 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

PEMAZYRE (135 MG TAB 45 MGTAB 9 MG TAB)


PIQRAY (200 MG DAILY DOSE) 200MG TAB THPK


PIQRAY (250 MG DAILY DOSE) 200 amp50 MG TAB THPK


PIQRAY (300 MG DAILY DOSE) 2 X150 MG TAB THPK


RUBRACA (200 MG TAB 250 MG TAB300 MG TAB)


RYDAPT 25 MG CAP Tier 3 PA QL (8 PER 1 DAYS)

SPRYCEL (100 MG TAB 140 MG TAB) Tier 3 PA QL (1 PER 1 DAYS)


SPRYCEL 20 MG TAB Tier 3 PA QL (6 PER 1 DAYS)


STIVARGA 40 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

sunitinib malate (cap 375 mg (baseequivalent) cap 50 mg (baseequivalent))



32

ANTINEOPLASTICS



sunitinib malate cap 125 mg (baseequivalent)




TAFINLAR (50 MG CAP 75 MG CAP) Tier 3 PA LA QL (4 PER 1 DAYS)

TAGRISSO (40 MG TAB 80 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

TALZENNA 025 MG CAP Tier 3 PA LA QL (3 PER 1 DAYS)


TASIGNA (150 MG CAP 200 MGCAP 50 MG CAP)


TEPMETKO 225 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

TIBSOVO 250 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

TRUSELTIQ (100MG DAILY DOSE) 100MG CAP THPK


TRUSELTIQ (125MG DAILY DOSE) 100amp 25 MG CAP THPK






TUKYSA (150 MG TAB 50 MG TAB) Tier 3 PA LA QL (4 PER 1 DAYS)

TURALIO 200 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

UKONIQ 200 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

VENCLEXTA 10 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)



VENCLEXTA STARTING PACK 10 amp 50amp 100 MG TAB THPK


VERZENIO (100 MG TAB 150 MG TAB200 MG TAB 50 MG TAB)


VITRAKVI 100 MG CAP Tier 3 PA LA QL (2 PER 1 DAYS)

VITRAKVI 20 MGML SOLUTION Tier 3 PA LA QL (10 PER 1 DAYS)



33

ANTINEOPLASTICS



VIZIMPRO (15 MG TAB 30 MG TAB45 MG TAB)


VOTRIENT 200 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

XALKORI (200 MG CAP 250 MGCAP)


XOSPATA 40 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

ZEJULA 100 MG CAP Tier 3 PA LA QL (3 PER 1 DAYS)

ZELBORAF 240 MG TAB Tier 3 PA LA QL (8 PER 1 DAYS)

ZYDELIG (100 MG TAB 150 MG TAB) Tier 3 PA LA QL (2 PER 1 DAYS)

ZYKADIA 150 MG TAB Tier 3 PA QL (3 PER 1 DAYS)

RETINOIDSbexarotene cap 75 mg Tier 2 PA QL (10 PER 1 DAYS)

PANRETIN 01 GEL Tier 3 PA

TARGRETIN 1 GEL Tier 3 PA QL (60 PER 30 OVERTIME)

tretinoin cap 10 mg Tier 2

TREATMENT ADJUNCTSmesna inj 100 mgml Tier 2

MESNEX (100 MGML SOLUTION 400MG TAB)

Tier 3

ANTIPARASITICS



ANTHELMINTHICSalbendazole tab 200 mg Tier 2

ivermectin tab 3 mg Tier 2 QL (16 PER 365 OVER TIME)

praziquantel tab 600 mg Tier 2


34

ANTIPARASITICS



ANTIPROTOZOALSALINIA 100 MG5ML RECON SUSP Tier 3 PA QL (180 PER 3 OVER

TIME)

atovaquone susp 750 mg5ml Tier 2 PA

atovaquone-proguanil hcl (tab 250-100 mg tab 625-25 mg)

Tier 2

BENZNIDAZOLE 100 MG TAB Tier 3 QL (240 PER 365 OVERTIME)


chloroquine phosphate (500 mgtab tab 500 mg)


chloroquine phosphate tab 250 mg Tier 2 QL (50 PER 30 OVER TIME)

COARTEM 20-120 MG TAB Tier 3 QL (24 PER 2 OVER TIME)

HYDROXYCHLOROQUINE SULFATE100 MG TAB






hydroxychloroquine sulfate tab 200mg


KRINTAFEL 150 MG TAB Tier 3 QL (4 PER 28 OVER TIME)

mefloquine hcl tab 250 mg Tier 2

nitazoxanide tab 500 mg Tier 2 PA QL (6 PER 3 OVERTIME)

pentamidine isethionate fornebulization soln 300 mg

Tier 2 BvD

pentamidine isethionate for soln 300mg

Tier 2

primaquine phosphate (263 (15base) mg tab tab 263 mg (15 mgbase))

Tier 3

pyrimethamine tab 25 mg Tier 2 PA

quinine sulfate cap 324 mg Tier 2 PA QL (6 PER 1 DAYS)


35

ANTIPARKINSON AGENTS



ANTICHOLINERGICSbenztropine mesylate (inj 1 mgmltab 05 mg tab 1 mg tab 2 mg)

Tier 2

trihexyphenidyl hcl (oral soln 04mgml tab 2 mg tab 5 mg)

Tier 2

ANTIPARKINSON AGENTS OTHERamantadine hcl (cap 100 mg soln50 mg5ml syrup 50 mg5ml tab100 mg)

Tier 2

CARBIDOPA-LEVODOPA-ENTACAPONE (125-50-200 MG TAB1875-75-200 MG TAB 25-100-200MG TAB 3125-125-200 MG TAB375-150-200 MG TAB 50-200-200MG TAB)

Tier 2

entacapone tab 200 mg Tier 2 QL (8 PER 1 DAYS)

DOPAMINE AGONISTSAPOKYN 30 MG3ML SOLN CART Tier 3 PA LA

bromocriptine mesylate (cap 5 mg(base equivalent) tab 25 mg (baseequivalent))

Tier 2

pramipexole dihydrochloride (tab0125 mg tab 025 mg tab 05 mgtab 075 mg tab 1 mg tab 15 mg)

Tier 2

ropinirole hydrochloride (tab 025mg tab 05 mg tab 1 mg tab 2 mgtab 3 mg tab 4 mg tab 5 mg)

Tier 2

DOPAMINE PRECURSORS ANDOR L-AMINO ACID DECARBOXYLASE INHIBITORScarbidopa tab 25 mg Tier 2

carbidopa-levodopa (tab 10-100mg tab 25-100 mg tab 25-250 mgtab er 25-100 mg tab er 50-200 mg)

Tier 2

MONOAMINE OXIDASE B (MAO-B) INHIBITORSrasagiline mesylate (tab 05 mg(base equiv) tab 1 mg (baseequiv))



36




selegiline hcl (5 mg tab cap 5 mgtab 5 mg)

Tier 2

ANTIPSYCHOTICS



1ST GENERATIONTYPICALchlorpromazine hcl (100 mgmlconc 30 mgml conc 50 mg2mlsolution inj 25 mgml tab 10 mgtab 100 mg tab 200 mg tab 25 mgtab 50 mg)

Tier 2

fluphenazine decanoate inj 25mgml

Tier 2

fluphenazine hcl (25 mg5ml elixir25 mgml solution 5 mgml conctab 1 mg tab 10 mg tab 25 mgtab 5 mg)

Tier 2

haloperidol (tab 05 mg tab 1 mgtab 10 mg tab 2 mg tab 20 mgtab 5 mg)

Tier 2

haloperidol decanoate (soln 100mgml soln 50 mgml)

Tier 2

haloperidol lactate (inj 5 mgml oralconc 2 mgml)

Tier 2

loxapine succinate (cap 10 mg cap25 mg cap 5 mg cap 50 mg)

Tier 2

MOLINDONE HCL 10 MG TAB Tier 2 QL (8 PER 1 DAYS)



PIMOZIDE (1 MG TAB 2 MG TAB) Tier 2

thioridazine hcl (tab 10 mg tab 100mg tab 25 mg tab 50 mg)

Tier 2 PA

thiothixene (cap 1 mg cap 10 mgcap 2 mg cap 5 mg)

Tier 2


37

ANTIPSYCHOTICS



trifluoperazine hcl (tab 1 mg (baseequivalent) tab 10 mg (baseequivalent) tab 2 mg (baseequivalent) tab 5 mg (baseequivalent))

Tier 2

2ND GENERATIONATYPICALABILIFY MAINTENA (300 MG PRSYR300 MG SRER 400 MG PRSYR 400MG SRER)

Tier 3 PA

aripiprazole (orally disintegrating tab10 mg orally disintegrating tab 15mg tab 5 mg)


aripiprazole (tab 10 mg tab 15 mgtab 20 mg tab 30 mg)


aripiprazole oral solution 1 mgml Tier 2 QL (25 PER 1 DAYS)

aripiprazole tab 2 mg Tier 2 QL (4 PER 1 DAYS)

ARISTADA (1064 MG39ML PRSYR441 MG16ML PRSYR 662 MG24MLPRSYR 882 MG32ML PRSYR)

Tier 3 PA

ARISTADA INITIO 675 MG24MLPRSYR


asenapine maleate (sl tab 10 mg(base equiv) sl tab 25 mg (baseequiv) sl tab 5 mg (base equiv))


CAPLYTA 42 MG CAP Tier 3 PA QL (1 PER 1 DAYS)

FANAPT (1 MG TAB 10 MG TAB 12MG TAB 2 MG TAB 4 MG TAB 6 MGTAB 8 MG TAB)


FANAPT TITRATION PACK 1 amp 2 amp 4 amp6 MG TAB


INVEGA HAFYERA 1092 MG35MLSUSP PRSYR




INVEGA SUSTENNA 117 MG075MLSUSP PRSYR


INVEGA SUSTENNA 156 MGML SUSPPRSYR



38

ANTIPSYCHOTICS









INVEGA TRINZA (273 MG0875MLSUSP PRSYR 410 MG1315ML SUSPPRSYR 546 MG175ML SUSP PRSYR819 MG2625ML SUSP PRSYR)


LATUDA (120 MG TAB 80 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

LATUDA (20 MG TAB 40 MG TAB 60MG TAB)


NUPLAZID (10 MG TAB 34 MG CAP) Tier 3 PA LA QL (1 PER 1 DAYS)

NUPLAZID 17 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

olanzapine (for im inj 10 mg orallydisintegrating tab 10 mg orallydisintegrating tab 15 mg orallydisintegrating tab 20 mg orallydisintegrating tab 5 mg tab 10 mgtab 15 mg tab 25 mg tab 20 mgtab 5 mg tab 75 mg)

Tier 2

paliperidone (tab er 24hr 15 mgtab er 24hr 3 mg tab er 24hr 9 mg)


paliperidone tab er 24hr 6 mg Tier 2 PA QL (2 PER 1 DAYS)

PERSERIS (120 MG PRSYR 90 MGPRSYR)


quetiapine fumarate (tab 100 mgtab 200 mg tab 25 mg tab 300 mgtab 400 mg tab 50 mg tab er 24hr150 mg tab er 24hr 200 mg tab er24hr 300 mg tab er 24hr 400 mg taber 24hr 50 mg)

Tier 2

REXULTI (025 MG TAB 05 MG TAB 1MG TAB 2 MG TAB 3 MG TAB 4 MGTAB)


RISPERDAL CONSTA (125 MG SRER25 MG SRER 375 MG SRER 50 MGSRER)

Tier 3


39

ANTIPSYCHOTICS



risperidone (025 mg tab disp orallydisintegrating tab 05 mg orallydisintegrating tab 1 mg orallydisintegrating tab 2 mg orallydisintegrating tab 3 mg orallydisintegrating tab 4 mg soln 1mgml tab 025 mg tab 05 mg tab1 mg tab 2 mg tab 3 mg tab 4mg)

Tier 2

SECUADO (38 MG24HR PATCH24HR 57 MG24HR PATCH 24HR 76MG24HR PATCH 24HR)


VRAYLAR (15 MG CAP 3 MG CAP45 MG CAP 6 MG CAP)


VRAYLAR 15 amp 3 MG CAP THPK Tier 3 PA QL (7 PER 30 OVERTIME)

ziprasidone hcl (cap 20 mg cap 40mg cap 60 mg cap 80 mg)

Tier 2

ziprasidone mesylate for inj 20 mg(base equivalent)

Tier 2

ZYPREXA RELPREVV (210 MG RECONSUSP 300 MG RECON SUSP 405 MGRECON SUSP)

Tier 3 PA

TREATMENT-RESISTANTclozapine (125 mg tab disp 150 mgtab disp 200 mg tab disp orallydisintegrating tab 100 mg orallydisintegrating tab 25 mg tab 100mg tab 200 mg tab 25 mg tab 50mg)

Tier 2

VERSACLOZ 50 MGML SUSPENSION Tier 3 PA QL (18 PER 1 DAYS)

ANTISPASTICITY AGENTS



ANTISPASTICITY AGENTSbaclofen tab 10 mg Tier 2 QL (8 PER 1 DAYS)


40




baclofen tab 20 mg Tier 2 QL (4 PER 1 DAYS)


dantrolene sodium (cap 100 mgcap 25 mg cap 50 mg)

Tier 2

tizanidine hcl (tab 2 mg (baseequivalent) tab 4 mg (baseequivalent))

Tier 2

ANTIVIRALS



ANTI-CYTOMEGALOVIRUS (CMV) AGENTSvalganciclovir hcl for soln 50 mgml(base equiv)


valganciclovir hcl tab 450 mg (baseequivalent)


ZIRGAN 015 GEL Tier 3 QL (5 PER 30 OVER TIME)

ANTI-HEPATITIS B (HBV) AGENTSadefovir dipivoxil tab 10 mg Tier 2 QL (1 PER 1 DAYS)

BARACLUDE 005 MGML SOLUTION Tier 3 QL (21 PER 1 DAYS)

entecavir (tab 05 mg tab 1 mg) Tier 2 QL (1 PER 1 DAYS)

EPIVIR HBV 5 MGML SOLUTION Tier 3

lamivudine tab 100 mg (hbv) Tier 2

VEMLIDY 25 MG TAB Tier 3 QL (1 PER 1 DAYS)

ANTI-HEPATITIS C (HCV) AGENTSEPCLUSA (150-375 MG PACKET 200-50 MG TAB 400-100 MG TAB)


EPCLUSA 200-50 MG PACKET Tier 3 PA QL (2 PER 1 DAYS)

HARVONI (3375-150 MG PACKET45-200 MG TAB 90-400 MG TAB)


HARVONI 45-200 MG PACKET Tier 3 PA QL (2 PER 1 DAYS)


41

ANTIVIRALS



LEDIPASVIR-SOFOSBUVIR 90-400 MGTAB


MAVYRET 100-40 MG TAB Tier 3 PA QL (3 PER 1 DAYS)

MAVYRET 50-20 MG PACKET Tier 3 PA QL (6 PER 1 DAYS)

PEGINTRON 50 MCG05ML KIT Tier 3

ribavirin (hepatitis c) (cap 200 mgtab 200 mg)

Tier 2

SOFOSBUVIR-VELPATASVIR 400-100MG TAB


VOSEVI 400-100-100 MG TAB Tier 3 PA QL (1 PER 1 DAYS)

ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY 50-200-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

DOVATO 50-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

GENVOYA 150-150-200-10 MG TAB Tier 3 QL (1 PER 1 DAYS)

ISENTRESS (100 MG CHEW TAB 25MG CHEW TAB)


ISENTRESS 100 MG PACKET Tier 3 QL (2 PER 1 DAYS)

ISENTRESS 400 MG TAB Tier 3 QL (4 PER 1 DAYS)

ISENTRESS HD 600 MG TAB Tier 3 QL (2 PER 1 DAYS)

JULUCA 50-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

STRIBILD 150-150-200-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

TIVICAY (10 MG TAB 25 MG TAB 50MG TAB)


TIVICAY PD 5 MG TAB SOL Tier 3 QL (5 PER 1 DAYS)

ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)COMPLERA 200-25-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

DELSTRIGO 100-300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

EDURANT 25 MG TAB Tier 3 QL (2 PER 1 DAYS)

efavirenz cap 200 mg Tier 2 QL (3 PER 1 DAYS)


efavirenz tab 600 mg Tier 2 QL (1 PER 1 DAYS)


42

ANTIVIRALS



efavirenz-emtricitabine-tenofovir dftab 600-200-300 mg


efavirenz-lamivudine-tenofovirdisoproxil fumarate (tab 400-300-300mg tab 600-300-300 mg)


etravirine tab 100 mg Tier 2 QL (4 PER 1 DAYS)


INTELENCE 25 MG TAB Tier 3 QL (12 PER 1 DAYS)

NEVIRAPINE 50 MG5ML SUSPENSION Tier 2 QL (40 PER 1 DAYS)

NEVIRAPINE ER 100 MG TAB ER 24H Tier 2 QL (3 PER 1 DAYS)

nevirapine tab 200 mg Tier 2 QL (2 PER 1 DAYS)

nevirapine tab er 24hr 100 mg Tier 2 QL (3 PER 1 DAYS)


ODEFSEY 200-25-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

PIFELTRO 100 MG TAB Tier 3 QL (2 PER 1 DAYS)

RESCRIPTOR 100 MG TAB Tier 3 QL (12 PER 1 DAYS)


ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS(NRTI)abacavir sulfate soln 20 mgml(base equiv)


abacavir sulfate tab 300 mg (baseequiv)


abacavir sulfate-lamivudine tab600-300 mg


abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg


CIMDUO 300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

DESCOVY 200-25 MG TAB Tier 3 QL (1 PER 1 DAYS)

didanosine (200 mg cap dr 250 mgcap dr 400 mg cap dr delayedrelease capsule 200 mg delayedrelease capsule 250 mg delayedrelease capsule 400 mg)



43

ANTIVIRALS



emtricitabine caps 200 mg Tier 2 QL (1 PER 1 DAYS)

emtricitabine-tenofovir disoproxilfumarate (tab 100-150 mg tab 133-200 mg tab 167-250 mg tab 200-300 mg)


EMTRIVA 10 MGML SOLUTION Tier 3 QL (24 PER 1 DAYS)

lamivudine oral soln 10 mgml Tier 2 QL (30 PER 1 DAYS)

lamivudine tab 150 mg Tier 2 QL (2 PER 1 DAYS)


lamivudine-zidovudine tab 150-300mg


stavudine (15 mg cap 20 mg cap30 mg cap 40 mg cap cap 15 mgcap 20 mg cap 30 mg cap 40 mg)


TEMIXYS 300-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

tenofovir disoproxil fumarate tab 300mg


TRIUMEQ 600-50-300 MG TAB Tier 3 QL (1 PER 1 DAYS)

VIDEX 2 GM RECON SOLN Tier 3

VIDEX EC 125 MG CAP DR Tier 3 QL (1 PER 1 DAYS)

VIREAD (200 MG TAB 250 MG TAB) Tier 3 QL (1 PER 1 DAYS)

VIREAD 150 MG TAB Tier 3 QL (2 PER 1 DAYS)

VIREAD 40 MGGM POWDER Tier 3 QL (240 PER 30 OVER TIME)

ZERIT 1 MGML RECON SOLN Tier 3 QL (80 PER 1 DAYS)

zidovudine cap 100 mg Tier 2 QL (6 PER 1 DAYS)

zidovudine syrup 10 mgml Tier 2 QL (60 PER 1 DAYS)

zidovudine tab 300 mg Tier 2 QL (2 PER 1 DAYS)

ANTI-HIV AGENTS OTHERCABENUVA 400 amp 600 MG2ML SUSP Tier 3 QL (4 PER 30 OVER TIME)

BvD

CABENUVA 600 amp 900 MG3ML SUSP Tier 3 QL (6 PER 30 OVER TIME)BvD


44

ANTIVIRALS



FUZEON 90 MG RECON SOLN Tier 3 QL (60 PER 30 OVER TIME)

RUKOBIA 600 MG TAB ER 12H Tier 3 QL (2 PER 1 DAYS)

SELZENTRY (150 MG TAB 75 MG TAB) Tier 3 QL (2 PER 1 DAYS)

SELZENTRY 20 MGML SOLUTION Tier 3 QL (60 PER 1 DAYS)

SELZENTRY 25 MG TAB Tier 3 QL (8 PER 1 DAYS)


TYBOST 150 MG TAB Tier 3 QL (1 PER 1 DAYS)

ANTI-HIV AGENTS PROTEASE INHIBITORS (PI)APTIVUS 100 MGML SOLUTION Tier 3 QL (10 PER 1 DAYS)

APTIVUS 250 MG CAP Tier 3 QL (4 PER 1 DAYS)

atazanavir sulfate (cap 150 mg(base equiv) cap 200 mg (baseequiv))


atazanavir sulfate cap 300 mg(base equiv)


CRIXIVAN 200 MG CAP Tier 3 QL (9 PER 1 DAYS)


EVOTAZ 300-150 MG TAB Tier 3 QL (1 PER 1 DAYS)

fosamprenavir calcium tab 700 mg(base equiv)


INVIRASE 200 MG CAP Tier 3 QL (10 PER 1 DAYS)

INVIRASE 500 MG TAB Tier 3 QL (4 PER 1 DAYS)

LEXIVA 50 MGML SUSPENSION Tier 3 QL (56 PER 1 DAYS)

lopinavir-ritonavir soln 400-100mg5ml (80-20 mgml)


lopinavir-ritonavir tab 100-25 mg Tier 2 QL (10 PER 1 DAYS)


NORVIR (100 MG CAP 100 MGPACKET)


NORVIR 80 MGML SOLUTION Tier 3 QL (15 PER 1 DAYS)

PREZCOBIX 800-150 MG TAB Tier 3 QL (1 PER 1 DAYS)


45

ANTIVIRALS



PREZISTA (600 MG TAB 75 MG TAB) Tier 3 QL (2 PER 1 DAYS)

PREZISTA 100 MGML SUSPENSION Tier 3 QL (12 PER 1 DAYS)

PREZISTA 150 MG TAB Tier 3 QL (8 PER 1 DAYS)


REYATAZ 50 MG PACKET Tier 3 QL (8 PER 1 DAYS)

ritonavir tab 100 mg Tier 2 QL (12 PER 1 DAYS)

SYMTUZA 800-150-200-10 MG TAB Tier 3 QL (1 PER 1 DAYS)

VIRACEPT 250 MG TAB Tier 3 QL (9 PER 1 DAYS)


ANTI-INFLUENZA AGENTSoseltamivir phosphate cap 30 mg(base equiv)

Tier 2 QL (120 PER 180 OVERTIME)

oseltamivir phosphate cap 45 mg(base equiv)




oseltamivir phosphate for susp 6mgml (base equiv)


RELENZA DISKHALER 5 MGBLISTERAER POW BA


RIMANTADINE HCL 100 MG TAB Tier 2

XOFLUZA (40 MG DOSE) (MG DOSE)1 X 40 MG TAB THPK MG DOSE) 2 X20 MG TAB THPK)


XOFLUZA (80 MG DOSE) 1 X 80 MGTAB THPK




ANTIHERPETIC AGENTSacyclovir (cap 200 mg susp 200mg5ml tab 400 mg tab 800 mg)

Tier 2

acyclovir sodium iv soln 50 mgml Tier 2 BvD

famciclovir (tab 125 mg tab 250mg tab 500 mg)

Tier 2


46

ANTIVIRALS



trifluridine (1 solution ophth soln1)

Tier 2

valacyclovir hcl (tab 1 gm tab 500mg)

Tier 2

ANXIOLYTICS



ANXIOLYTICS OTHERbuspirone hcl (tab 10 mg tab 15mg tab 30 mg tab 5 mg tab 75mg)

Tier 2

meprobamate (tab 200 mg tab 400mg)

Tier 2 PA

BENZODIAZEPINESalprazolam (tab 025 mg tab 05mg tab 1 mg)


alprazolam tab 2 mg Tier 2 QL (5 PER 1 DAYS)

chlordiazepoxide hcl cap 10 mg Tier 2 PA QL (30 PER 1 DAYS)



clonazepam (orally disintegratingtab 0125 mg orally disintegratingtab 025 mg orally disintegratingtab 05 mg tab 05 mg)


clonazepam (orally disintegratingtab 1 mg tab 1 mg)




clorazepate dipotassium tab 15 mg Tier 2 QL (6 PER 1 DAYS)

clorazepate dipotassium tab 375mg




47

ANXIOLYTICS



diazepam (conc 5 mgml tab 5mg)


diazepam oral soln 1 mgml Tier 2 QL (60 PER 1 DAYS)

diazepam tab 10 mg Tier 2 QL (6 PER 1 DAYS)


lorazepam tab 05 mg Tier 2 QL (20 PER 1 DAYS)



BIPOLAR AGENTS



MOOD STABILIZERSLITHIUM 8 MEQ5ML SOLUTION Tier 2

lithium carbonate (150 mg cap 300mg cap 600 mg cap cap 150 mgcap 300 mg cap 600 mg tab 300mg tab er 300 mg tab er 450 mg)

Tier 2

BLOOD GLUCOSE REGULATORS



ANTIDIABETIC AGENTSacarbose (tab 100 mg tab 25 mgtab 50 mg)

Tier 2

glimepiride (tab 1 mg tab 2 mg tab4 mg)

Tier 1

glipizide (tab 10 mg tab 5 mg taber 24hr 10 mg tab er 24hr 25 mgtab er 24hr 5 mg)

Tier 1

glipizide-metformin hcl (tab 25-250mg tab 25-500 mg tab 5-500 mg)

Tier 1


48




glyburide (tab 125 mg tab 25 mgtab 5 mg)

Tier 1 PA

glyburide micronized (tab 15 mgtab 3 mg tab 6 mg)

Tier 1 PA

glyburide-metformin (tab 125-250mg tab 25-500 mg tab 5-500 mg)

Tier 1 PA

GLYXAMBI (10-5 MG TAB 25-5 MGTAB)


INVOKAMET (150-1000 MG TAB 150-500 MG TAB 50-1000 MG TAB)


INVOKAMET 50-500 MG TAB Tier 3 QL (4 PER 1 DAYS)

INVOKAMET XR (150-1000 MG TAB ER24H 150-500 MG TAB ER 24H 50-1000 MG TAB ER 24H 50-500 MG TABER 24H)


INVOKANA 100 MG TAB Tier 3 QL (2 PER 1 DAYS)


JANUMET (50-1000 MG TAB 50-500MG TAB)


JANUMET XR (100-1000 MG TAB ER24H 50-500 MG TAB ER 24H)


JANUMET XR 50-1000 MG TAB ER 24H Tier 3 QL (2 PER 1 DAYS)

JANUVIA (100 MG TAB 25 MG TAB50 MG TAB)


JARDIANCE (10 MG TAB 25 MG TAB) Tier 3 QL (1 PER 1 DAYS)

JENTADUETO (25-1000 MG TAB 25-500 MG TAB 25-850 MG TAB)


JENTADUETO XR 25-1000 MG TAB ER24H




metformin hcl (tab 1000 mg tab 500mg tab 850 mg tab er 24hr 500 mgtab er 24hr 750 mg)

Tier 1

miglitol (tab 100 mg tab 25 mg tab50 mg)



49




nateglinide (tab 120 mg tab 60 mg) Tier 2

OZEMPIC (025 OR 05 MGDOSE) 2MG15ML SOLN PEN


OZEMPIC (1 MGDOSE) (2 MG15MLSOLN PEN 4 MG3ML SOLN PEN)


pioglitazone hcl (tab 15 mg (baseequiv) tab 30 mg (base equiv) tab45 mg (base equiv))

Tier 2

repaglinide (tab 05 mg tab 1 mgtab 2 mg)

Tier 2

RYBELSUS (14 MG TAB 3 MG TAB 7MG TAB)


SYMLINPEN 120 2700 MCG27MLSOLN PEN




SYNJARDY (125-1000 MG TAB 125-500 MG TAB 5-1000 MG TAB 5-500MG TAB)


SYNJARDY XR (10-1000 MG TAB ER24H 125-1000 MG TAB ER 24H 5-1000 MG TAB ER 24H)


SYNJARDY XR 25-1000 MG TAB ER24H


TRADJENTA 5 MG TAB Tier 3 QL (1 PER 1 DAYS)

TRULICITY (075 MG05ML SOLN PEN15 MG05ML SOLN PEN 3MG05ML SOLN PEN 45 MG05MLSOLN PEN)


VICTOZA 18 MG3ML SOLN PEN Tier 3 QL (9 PER 30 OVER TIME)

GLYCEMIC AGENTSBAQSIMI ONE PACK 3 MGDOSEPOWDER


BAQSIMI TWO PACK 3 MGDOSEPOWDER


diazoxide susp 50 mgml Tier 2


50




GLUCAGEN HYPOKIT 1 MG RECONSOLN


glucagon (rdna) for inj kit 1 mg Tier 3 QL (2 PER 2 OVER TIME)

GLUCAGON EMERGENCY (1 MG KIT1 MGML RECON SOLN)


INSULINSHUMALOG (100 UNITML SOLN CART100 UNITML SOLUTION)

Tier 3

HUMALOG KWIKPEN (100 UNITMLSOLN PEN 200 UNITML SOLN PEN)

Tier 3

HUMALOG MIX 5050 (50-50) 100UNITML SUSPENSION

Tier 3

HUMALOG MIX 5050 KWIKPEN (50-50) 100 UNITML SUSP PEN

Tier 3


Tier 3


Tier 3

HUMULIN 7030 (70-30) 100 UNITMLSUSPENSION

Tier 3

HUMULIN 7030 KWIKPEN (70-30) 100UNITML SUSP PEN

Tier 3

HUMULIN N 100 UNITML SUSPENSION Tier 3

HUMULIN N KWIKPEN 100 UNITMLSUSP PEN

Tier 3

HUMULIN R 100 UNITML SOLUTION Tier 3

HUMULIN R U-500 (CONCENTRATED)500 UNITML SOLUTION

Tier 3

LANTUS 100 UNITML SOLUTION Tier 3 QL (40 PER 30 OVER TIME)

LANTUS SOLOSTAR 100 UNITML SOLNPEN


NOVOLIN 7030 (70-30) 100 UNITMLSUSPENSION

Tier 3

NOVOLIN 7030 RELION (70-30) 100UNITML SUSPENSION

Tier 3


51




NOVOLIN N 100 UNITMLSUSPENSION

Tier 3

NOVOLIN N RELION 100 UNITMLSUSPENSION

Tier 3

NOVOLIN R 100 UNITML SOLUTION Tier 3

NOVOLIN R RELION 100 UNITMLSOLUTION

Tier 3

NOVOLOG 100 UNITML SOLUTION Tier 3

NOVOLOG 7030 FLEXPEN RELION(70-30) 100 UNITML SUSP PEN

Tier 3

NOVOLOG FLEXPEN 100 UNITMLSOLN PEN

Tier 3

NOVOLOG FLEXPEN RELION 100UNITML SOLN PEN

Tier 3

NOVOLOG MIX 7030 (70-30) 100UNITML SUSPENSION

Tier 3

NOVOLOG MIX 7030 FLEXPEN (70-30) 100 UNITML SUSP PEN

Tier 3

NOVOLOG MIX 7030 RELION (70-30)100 UNITML SUSPENSION

Tier 3

NOVOLOG PENFILL 100 UNITMLSOLN CART

Tier 3

NOVOLOG RELION 100 UNITMLSOLUTION

Tier 3

TOUJEO MAX SOLOSTAR 300 UNITMLSOLN PEN


TOUJEO SOLOSTAR 300 UNITMLSOLN PEN


BLOOD PRODUCTS AND MODIFIERS



ANTICOAGULANTSELIQUIS 25 MG TAB Tier 3


52




ELIQUIS 5 MG TAB Tier 3 QL (60 PER 30 DAYS)

ELIQUIS DVTPE STARTER PACK 5 MGTAB THPK


enoxaparin sodium (inj 100 mgmlinj 150 mgml inj 300 mg3ml)


enoxaparin sodium (inj 120mg08ml inj 80 mg08ml)


enoxaparin sodium inj 30 mg03ml Tier 2 QL (18 PER 30 OVER TIME)



fondaparinux sodium subcutaneousinj 10 mg08ml








heparin sodium (porcine) (inj 1000unitml inj 10000 unitml inj 20000unitml inj 5000 unitml)

Tier 2 BvD

PRADAXA (110 MG CAP 150 MGCAP 75 MG CAP)


warfarin sodium (tab 1 mg tab 10mg tab 2 mg tab 25 mg tab 3 mgtab 4 mg tab 5 mg tab 6 mg tab75 mg)

Tier 2

XARELTO (10 MG TAB 15 MG TAB 20MG TAB)


XARELTO 25 MG TAB Tier 3 QL (2 PER 1 DAYS)

XARELTO STARTER PACK 15 amp 20 MGTAB THPK


ZONTIVITY 208 MG TAB Tier 3 QL (1 PER 1 DAYS)

BLOOD PRODUCTS AND MODIFIERS OTHERanagrelide hcl (cap 05 mg cap 1mg)

Tier 2


53




ARANESP (ALBUMIN FREE) (10MCG04ML SOLN PRSYR 100MCG05ML SOLN PRSYR 100MCGML SOLUTION 150MCG03ML SOLN PRSYR 200MCG04ML SOLN PRSYR 200MCGML SOLUTION 25MCG042ML SOLN PRSYR 25MCGML SOLUTION 300MCG06ML SOLN PRSYR 300MCGML SOLUTION 40 MCG04MLSOLN PRSYR 40 MCGML SOLUTION500 MCGML SOLN PRSYR 60MCG03ML SOLN PRSYR 60MCGML SOLUTION)

Tier 3 PA

LEUKINE 250 MCG RECON SOLN Tier 3 PA

MOZOBIL 24 MG12ML SOLUTION Tier 3 PA LA

NEULASTA 6 MG06ML SOLN PRSYR Tier 3 PA

NEULASTA ONPRO 6 MG06ML PREFSY KT

Tier 3 PA

PROMACTA (125 MG PACKET 125MG TAB)


PROMACTA (25 MG TAB 50 MG TAB) Tier 3 PA LA QL (3 PER 1 DAYS)

PROMACTA 25 MG PACKET Tier 3 PA LA QL (6 PER 1 DAYS)

PROMACTA 75 MG TAB Tier 3 PA LA QL (2 PER 1 DAYS)

RETACRIT (10000 UNITML SOLUTION2000 UNITML SOLUTION 20000UNITML SOLUTION 3000 UNITMLSOLUTION 4000 UNITML SOLUTION40000 UNITML SOLUTION)

Tier 3 PA

ZARXIO (300 MCG05ML SOLNPRSYR 480 MCG08ML SOLN PRSYR)

Tier 3 PA

HEMOSTASIS AGENTStranexamic acid iv soln 1000mg10ml (100 mgml)

Tier 2

tranexamic acid tab 650 mg Tier 2 QL (1 PER 1 DAYS)


54




PLATELET MODIFYING AGENTSaspirin-dipyridamole cap er 12hr 25-200 mg

Tier 2

BRILINTA (60 MG TAB 90 MG TAB) Tier 3 QL (2 PER 1 DAYS)

CABLIVI 11 MG KIT Tier 3 PA LA QL (1 PER 1 DAYS)

cilostazol (tab 100 mg tab 50 mg) Tier 2

clopidogrel bisulfate tab 75 mg(base equiv)


dipyridamole (tab 25 mg tab 50mg tab 75 mg)

Tier 2 PA

OXBRYTA 500 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

TAVALISSE (100 MG TAB 150 MGTAB)


CARDIOVASCULAR AGENTS



ALPHA-ADRENERGIC AGONISTSclonidine (patch weekly 01mg24hr patch weekly 02 mg24hrpatch weekly 03 mg24hr)

Tier 2

clonidine hcl (tab 01 mg tab 02mg tab 03 mg)

Tier 2

droxidopa cap 100 mg Tier 2 PA QL (252 PER 90 OVERTIME)



guanfacine hcl (tab 1 mg tab 2mg)

Tier 2

methyldopa (250 mg tab 500 mgtab tab 250 mg tab 500 mg)

Tier 2


55




midodrine hcl (tab 10 mg tab 25mg tab 5 mg)

Tier 2

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate (tab 1 mg tab 2mg tab 4 mg tab 8 mg)

Tier 2

prazosin hcl (cap 1 mg cap 2 mgcap 5 mg)

Tier 2

terazosin hcl (cap 1 mg (baseequivalent) cap 10 mg (baseequivalent) cap 2 mg (baseequivalent) cap 5 mg (baseequivalent))

Tier 2

ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan cilexetil (tab 16 mgtab 32 mg tab 4 mg tab 8 mg)

Tier 2

EPROSARTAN MESYLATE 600 MG TAB Tier 1 QL (1 PER 1 DAYS)

irbesartan (tab 150 mg tab 300 mgtab 75 mg)

Tier 1

losartan potassium (tab 100 mg tab25 mg tab 50 mg)

Tier 1

olmesartan medoxomil (tab 20 mgtab 40 mg tab 5 mg)

Tier 2

telmisartan (tab 20 mg tab 40 mgtab 80 mg)

Tier 1

valsartan (tab 160 mg tab 320 mgtab 40 mg tab 80 mg)

Tier 1

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl (tab 10 mg tab 20mg tab 40 mg tab 5 mg)

Tier 1

captopril (tab 100 mg tab 125 mgtab 25 mg tab 50 mg)

Tier 1

enalapril maleate (tab 10 mg tab25 mg tab 20 mg tab 5 mg)

Tier 1

fosinopril sodium (tab 10 mg tab 20mg tab 40 mg)

Tier 1


56




lisinopril (tab 10 mg tab 25 mg tab20 mg tab 30 mg tab 40 mg tab 5mg)

Tier 1

moexipril hcl (tab 15 mg tab 75mg)

Tier 1

perindopril erbumine (tab 2 mg tab4 mg tab 8 mg)

Tier 1

quinapril hcl (tab 10 mg tab 20 mgtab 40 mg tab 5 mg)

Tier 1

ramipril (cap 125 mg cap 10 mgcap 25 mg cap 5 mg)

Tier 1

trandolapril (tab 1 mg tab 2 mgtab 4 mg)

Tier 1

ANTIARRHYTHMICSamiodarone hcl (tab 100 mg tab200 mg tab 400 mg)

Tier 2

disopyramide phosphate (cap 100mg cap 150 mg)

Tier 2

dofetilide (cap 125 mcg (0125 mg)cap 250 mcg (025 mg) cap 500mcg (05 mg))

Tier 2

flecainide acetate (tab 100 mg tab150 mg tab 50 mg)

Tier 2

mexiletine hcl (cap 150 mg cap 200mg cap 250 mg)

Tier 2

MULTAQ 400 MG TAB Tier 3 QL (2 PER 1 DAYS)

propafenone hcl (tab 150 mg tab225 mg tab 300 mg)

Tier 2

quinidine gluconate tab er 324 mg Tier 2

QUINIDINE SULFATE (200 MG TAB 300MG TAB)

Tier 2

sotalol hcl (afibafl) (tab 120 mgtab 160 mg tab 80 mg)

Tier 2

sotalol hcl (tab 120 mg tab 160 mgtab 240 mg tab 80 mg)

Tier 2


57




BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl (cap 200 mg cap400 mg)

Tier 2

atenolol (tab 100 mg tab 25 mgtab 50 mg)

Tier 1

betaxolol hcl (tab 10 mg tab 20mg)

Tier 2

bisoprolol fumarate (tab 10 mg tab5 mg)

Tier 2

carvedilol (tab 125 mg tab 25 mgtab 3125 mg tab 625 mg)

Tier 1

labetalol hcl (tab 100 mg tab 200mg tab 300 mg)

Tier 2

metoprolol succinate (tab er 24hr100 mg (tartrate equiv) tab er 24hr200 mg (tartrate equiv) tab er 24hr25 mg (tartrate equiv) tab er 24hr50 mg (tartrate equiv))

Tier 2

metoprolol tartrate (tab 100 mg tab25 mg tab 375 mg tab 50 mg tab75 mg)

Tier 1

nadolol (tab 20 mg tab 40 mg tab80 mg)

Tier 1

nebivolol hcl (tab 10 mg (baseequivalent) tab 25 mg (baseequivalent) tab 20 mg (baseequivalent) tab 5 mg (baseequivalent))

Tier 2

pindolol (tab 10 mg tab 5 mg) Tier 1

propranolol hcl (cap er 24hr 120 mgcap er 24hr 160 mg cap er 24hr 60mg cap er 24hr 80 mg tab 10 mgtab 20 mg tab 40 mg tab 60 mgtab 80 mg)

Tier 2

CALCIUM CHANNEL BLOCKING AGENTS DIHYDROPYRIDINESamlodipine besylate (tab 10 mg(base equivalent) tab 25 mg (baseequivalent) tab 5 mg (baseequivalent))

Tier 1


58




felodipine (tab er 24hr 10 mg tab er24hr 25 mg tab er 24hr 5 mg)

Tier 2

nicardipine hcl (cap 20 mg cap 30mg)

Tier 2

nifedipine (cap 10 mg cap 20 mgtab er 24hr 30 mg tab er 24hr 60mg tab er 24hr 90 mg tab er 24hrosmotic release 30 mg tab er 24hrosmotic release 60 mg tab er 24hrosmotic release 90 mg)

Tier 2

nimodipine cap 30 mg Tier 2

NYMALIZE 6 MGML SOLUTION Tier 3 QL (1260 PER 21 OVERTIME)

CALCIUM CHANNEL BLOCKING AGENTS NONDIHYDROPYRIDINESdiltiazem hcl (cap er 12hr 120 mgcap er 12hr 60 mg cap er 12hr 90mg cap er 24hr 120 mg cap er 24hr180 mg cap er 24hr 240 mg tab 120mg tab 30 mg tab 60 mg tab 90mg)

Tier 2

diltiazem hcl coated beads (beadscap er 24hr 120 mg beads cap er24hr 180 mg beads cap er 24hr 240mg beads cap er 24hr 300 mgbeads cap er 24hr 360 mg beadstab er 24hr 180 mg beads tab er24hr 240 mg beads tab er 24hr 300mg beads tab er 24hr 360 mgbeads tab er 24hr 420 mg)

Tier 2

diltiazem hcl extended releasebeads (beads cap er 24hr 120 mgbeads cap er 24hr 180 mg beadscap er 24hr 240 mg beads cap er24hr 300 mg beads cap er 24hr 360mg beads cap er 24hr 420 mg)

Tier 2

verapamil hcl (cap er 24hr 100 mgcap er 24hr 120 mg cap er 24hr 180mg cap er 24hr 200 mg cap er 24hr240 mg cap er 24hr 300 mg tab 120mg tab 40 mg tab 80 mg tab er120 mg tab er 180 mg tab er 240mg)

Tier 2


59




VERAPAMIL HCL ER (ER 100 MG CAPER 24H ER 200 MG CAP ER 24H ER300 MG CAP ER 24H ER 360 MGCAP ER 24H)

Tier 2

CARDIOVASCULAR AGENTS OTHERacetazolamide (tab 125 mg tab250 mg)

Tier 2

aliskiren fumarate (tab 150 mg(base equivalent) tab 300 mg(base equivalent))

Tier 2 PA

amiloride amp hydrochlorothiazide tab5-50 mg

Tier 2

amlodipine besylate-benazepril hcl(cap 10-20 mg cap 10-40 mg cap25-10 mg cap 5-10 mg cap 5-20mg cap 5-40 mg)

Tier 1

amlodipine besylate-olmesartanmedoxomil (tab 10-20 mg tab 10-40mg tab 5-20 mg tab 5-40 mg)

Tier 2

amlodipine besylate-valsartan (tab10-160 mg tab 10-320 mg tab 5-160mg tab 5-320 mg)

Tier 1

amlodipine-valsartan-hydrochlorothiazide (tab 10-160-125mg tab 10-160-25 mg tab 10-320-25mg tab 5-160-125 mg tab 5-160-25mg)

Tier 2

atenolol amp chlorthalidone (tab 100-25 mg tab 50-25 mg)

Tier 1

benazepril amp hydrochlorothiazide(tab 10-125 mg tab 20-125 mg tab20-25 mg tab 5-625 mg)

Tier 1

BENAZEPRIL-HYDROCHLOROTHIAZIDE5-625 MG TAB

Tier 1

bisoprolol amp hydrochlorothiazide(tab 10-625 mg tab 25-625 mgtab 5-625 mg)

Tier 2

candesartan cilexetil-hydrochlorothiazide (tab 16-125mg tab 32-125 mg tab 32-25 mg)

Tier 2


60




CAPTOPRIL-HYDROCHLOROTHIAZIDE(25-15 MG TAB 25-25 MG TAB 50-15MG TAB 50-25 MG TAB)

Tier 1

CORLANOR (5 MG TAB 75 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

CORLANOR 5 MG5ML SOLUTION Tier 3 PA QL (20 PER 1 DAYS)

digoxin (005 mgml solution oralsoln 005 mgml)

Tier 3

digoxin tab 125 mcg (0125 mg) Tier 2 QL (1 PER 1 DAYS)

digoxin tab 250 mcg (025 mg) Tier 2 PA QL (1 PER 1 DAYS)

enalapril maleate amphydrochlorothiazide (tab 10-25 mgtab 5-125 mg)

Tier 1

ENTRESTO (24-26 MG TAB 49-51 MGTAB 97-103 MG TAB)


fosinopril sodium amphydrochlorothiazide (tab 10-125mg tab 20-125 mg)

Tier 1

irbesartan-hydrochlorothiazide (tab150-125 mg tab 300-125 mg)

Tier 1

lisinopril amp hydrochlorothiazide (tab10-125 mg tab 20-125 mg tab 20-25 mg)

Tier 1

losartan potassium amphydrochlorothiazide (tab 100-125mg tab 100-25 mg tab 50-125 mg)

Tier 1

metoprolol amp hydrochlorothiazide(tab 100-25 mg tab 50-25 mg)

Tier 2

METOPROLOL-HYDROCHLOROTHIAZIDE 100-50 MGTAB

Tier 2

metyrosine cap 250 mg Tier 2

olmesartan medoxomil-amlodipine-hydrochlorothiazide (tab 20-5-125mg tab 40-10-125 mg tab 40-10-25mg tab 40-5-125 mg tab 40-5-25mg)

Tier 2

olmesartan medoxomil-hydrochlorothiazide (tab 20-125mg tab 40-125 mg tab 40-25 mg)

Tier 2


61




pentoxifylline tab er 400 mg Tier 2

PROPRANOLOL-HCTZ (40-25 MG TAB80-25 MG TAB)

Tier 2

quinapril-hydrochlorothiazide (tab10-125 mg tab 20-125 mg tab 20-25 mg)

Tier 1

ranolazine (tab er 12hr 1000 mg taber 12hr 500 mg)


spironolactone amphydrochlorothiazide tab 25-25 mg

Tier 2

TEKTURNA HCT (150-125 MG TAB150-25 MG TAB 300-125 MG TAB300-25 MG TAB)

Tier 3 PA

telmisartan-hydrochlorothiazide (tab40-125 mg tab 80-125 mg tab 80-25 mg)

Tier 1

triamterene amp hydrochlorothiazide(cap 375-25 mg tab 375-25 mgtab 75-50 mg)

Tier 2

valsartan-hydrochlorothiazide (tab160-125 mg tab 160-25 mg tab320-125 mg tab 320-25 mg tab 80-125 mg)

Tier 1

VYNDAMAX 61 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

DIURETICS LOOPbumetanide (inj 025 mgml tab 05mg tab 1 mg tab 2 mg)

Tier 2

furosemide (8 mgml solution inj 10mgml oral soln 10 mgml)

Tier 2

furosemide (tab 20 mg tab 40 mgtab 80 mg)

Tier 1

torsemide (tab 10 mg tab 100 mgtab 20 mg tab 5 mg)

Tier 2

DIURETICS POTASSIUM-SPARINGamiloride hcl tab 5 mg Tier 2

eplerenone (tab 25 mg tab 50 mg) Tier 2


62




spironolactone (tab 100 mg tab 25mg tab 50 mg)

Tier 2

DIURETICS THIAZIDEchlorothiazide (500 mg tab tab 500mg)

Tier 2

chlorthalidone (tab 25 mg tab 50mg)

Tier 2

hydrochlorothiazide (cap 125 mgtab 125 mg tab 25 mg tab 50 mg)

Tier 1

indapamide (tab 125 mg tab 25mg)

Tier 2

metolazone (tab 10 mg tab 25 mgtab 5 mg)

Tier 2

DYSLIPIDEMICS FIBRIC ACID DERIVATIVESfenofibrate (tab 120 mg tab 145mg tab 160 mg tab 40 mg tab 48mg tab 54 mg)

Tier 2

fenofibrate micronized (cap 134mg cap 200 mg cap 67 mg)

Tier 2

gemfibrozil tab 600 mg Tier 2

DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORSatorvastatin calcium (tab 10 mg(base equivalent) tab 20 mg (baseequivalent) tab 40 mg (baseequivalent) tab 80 mg (baseequivalent))

Tier 1

fluvastatin sodium (cap 20 mg (baseequivalent) cap 40 mg (baseequivalent))

Tier 1

fluvastatin sodium tab er 24 hr 80 mg(base equivalent)

Tier 2

lovastatin (tab 10 mg tab 20 mgtab 40 mg)

Tier 1

pravastatin sodium (tab 10 mg tab20 mg tab 40 mg tab 80 mg)

Tier 1

rosuvastatin calcium (tab 10 mgtab 20 mg tab 40 mg tab 5 mg)

Tier 1


63




simvastatin (tab 10 mg tab 20 mgtab 40 mg tab 5 mg tab 80 mg)

Tier 1

DYSLIPIDEMICS OTHERcholestyramine (powder 4 gmdosepowder packets 4 gm)

Tier 2

cholestyramine light (powder 4gmdose powder packets 4 gm)

Tier 2

colesevelam hcl (packet for susp375 gm tab 625 mg)

Tier 2

colestipol hcl (granule packets 5gm granules 5 gm tab 1 gm)

Tier 2

ezetimibe tab 10 mg Tier 2

ezetimibe-simvastatin (tab 10-10mg tab 10-20 mg tab 10-40 mgtab 10-80 mg)

Tier 2

icosapent ethyl cap 1 gm Tier 2

JUXTAPID (10 MG CAP 20 MG CAP30 MG CAP 40 MG CAP 5 MG CAP60 MG CAP)


niacin (antihyperlipidemic) (tab er1000 mg (antihyperlipidemic) tab er750 mg (antihyperlipidemic))


NIACIN (ANTIHYPERLIPIDEMIC) 500MG TAB

Tier 2

niacin tab er 500 mg(antihyperlipidemic)


NIACOR 500 MG TAB Tier 2

omega-3-acid ethyl esters cap 1 gm Tier 2

REPATHA 140 MGML SOLN PRSYR Tier 3 PA QL (2 PER 28 OVERTIME)

REPATHA PUSHTRONEX SYSTEM 420MG35ML SOLN CART


REPATHA SURECLICK 140 MGMLSOLN A-INJ


VASCEPA 05 GM CAP Tier 3


64




VASODILATORS DIRECT-ACTING ARTERIALhydralazine hcl (tab 10 mg tab 100mg tab 25 mg tab 50 mg)

Tier 2

minoxidil (tab 10 mg tab 25 mg) Tier 2

VASODILATORS DIRECT-ACTING ARTERIALVENOUSisosorbide dinitrate (tab 10 mg tab20 mg tab 30 mg tab 40 mg tab 5mg)

Tier 2

ISOSORBIDE DINITRATE ER 40 MG TABER

Tier 2

isosorbide mononitrate (tab 10 mgtab 20 mg tab er 24hr 120 mg taber 24hr 30 mg tab er 24hr 60 mg)

Tier 2

NITRO-BID 2 OINTMENT Tier 3

nitroglycerin (sl tab 03 mg sl tab 04mg sl tab 06 mg td patch 24hr 01mghr td patch 24hr 02 mghr tdpatch 24hr 04 mghr td patch 24hr06 mghr)

Tier 2

NITROSTAT (03 MG SL TAB 04 MG SLTAB 06 MG SL TAB)

Tier 3

RECTIV 04 OINTMENT Tier 3 PA QL (30 PER 30 OVERTIME)

CENTRAL NERVOUS SYSTEM AGENTS



ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS AMPHETAMINESamphetamine-dextroamphetamine(cap er 24hr 10 mg cap er 24hr 15mg cap er 24hr 20 mg cap er 24hr25 mg cap er 24hr 30 mg cap er24hr 5 mg tab 30 mg)


amphetamine-dextroamphetamine(tab 10 mg tab 15 mg tab 5 mgtab 75 mg)



65




amphetamine-dextroamphetaminetab 125 mg




dextroamphetamine sulfate (cap er24hr 10 mg tab 10 mg tab 5 mg)


dextroamphetamine sulfate (cap er24hr 15 mg tab 15 mg)


dextroamphetamine sulfate cap er24hr 5 mg


dextroamphetamine sulfate tab 20mg




ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINESatomoxetine hcl (cap 10 mg (baseequiv) cap 18 mg (base equiv)cap 25 mg (base equiv))


atomoxetine hcl (cap 100 mg (baseequiv) cap 60 mg (base equiv)cap 80 mg (base equiv))


atomoxetine hcl cap 40 mg (baseequiv)


clonidine hcl tab er 12hr 01 mg Tier 2

dexmethylphenidate hcl (tab 10mg tab 25 mg tab 5 mg)


guanfacine hcl (adhd) (tab er 24hr1 mg (base equiv) tab er 24hr 2 mg(base equiv) tab er 24hr 3 mg (baseequiv) tab er 24hr 4 mg (baseequiv))


methylphenidate hcl (tab 10 mgtab er 10 mg)




methylphenidate hcl tab 5 mg Tier 2 QL (12 PER 1 DAYS)


66




CENTRAL NERVOUS SYSTEM OTHERbutalbital-acetaminophen-caffeinetab 50-325-40 mg


FIRDAPSE 10 MG TAB Tier 3 PA LA QL (8 PER 1 DAYS)

riluzole tab 50 mg Tier 2

tetrabenazine tab 125 mg Tier 2 PA LA QL (8 PER 1 DAYS)


FIBROMYALGIA AGENTSDRIZALMA SPRINKLE (20 MG CAP DR30 MG CAP DR)


DRIZALMA SPRINKLE (40 MG CAP DR60 MG CAP DR)


duloxetine hcl (cap 20 mg (baseeq) cap 60 mg (base eq))


duloxetine hcl enteric coatedpellets cap 30 mg (base eq)


pregabalin (cap 100 mg cap 150mg cap 25 mg cap 50 mg cap 75mg)


pregabalin (cap 200 mg cap 225mg cap 300 mg)


pregabalin soln 20 mgml Tier 2 QL (30 PER 1 DAYS)

SAVELLA (100 MG TAB 125 MG TAB25 MG TAB 50 MG TAB)


SAVELLA TITRATION PACK 125 amp 25amp 50 MG MISC


MULTIPLE SCLEROSIS AGENTSAUBAGIO (14 MG TAB 7 MG TAB) Tier 3 PA LA QL (1 PER 1 DAYS)

AVONEX 30 MCG KIT Tier 3 PA QL (4 PER 28 OVERTIME)

AVONEX PEN 30 MCG05ML AUT-IJKIT


AVONEX PREFILLED 30 MCG05MLPREF SY KT



67




BETASERON 03 MG KIT Tier 3 PA QL (15 PER 30 OVERTIME)

dalfampridine tab er 12hr 10 mg Tier 2 PA QL (2 PER 1 DAYS)

dimethyl fumarate (capsuledelayed release 120 mg capsuledelayed release 240 mg capsule drstarter pack 120 mg amp 240 mg)


EXTAVIA 03 MG KIT Tier 3 PA QL (15 PER 30 OVERTIME)

GILENYA 05 MG CAP Tier 3 PA QL (1 PER 1 DAYS)

glatiramer acetate soln prefilledsyringe 20 mgml


PLEGRIDY (125 MCG05ML SOLNPEN 125 MCG05ML SOLN PRSYR)

Tier 3 PA LA

PLEGRIDY STARTER PACK 63 amp 94MCG05ML SOLN PEN

Tier 3 PA LA

PLEGRIDY STARTER PACK 63 amp 94MCG05ML SOLN PRSYR


REBIF (22 MCG05ML SOLN PRSYR44 MCG05ML SOLN PRSYR)


REBIF REBIDOSE (22 MCG05MLSOLN A-INJ 44 MCG05ML SOLN A-INJ)


REBIF REBIDOSE TITRATION PACK6X88 amp 6X22 MCG SOLN A-INJ


REBIF TITRATION PACK 6X88 amp 6X22MCG SOLN PRSYR


TYSABRI 300 MG15ML CONC Tier 3 PA LA

DENTAL AND ORAL AGENTS



DENTAL AND ORAL AGENTSchlorhexidine gluconate soln 012 Tier 2


68




KEPIVANCE 625 MG RECON SOLN Tier 3 BvD

pilocarpine hcl (oral) (tab 5 mg tab75 mg)

Tier 2

triamcinolone acetonide dentalpaste 01

Tier 2

DERMATOLOGICAL AGENTS



ACNE AND ROSACEA AGENTSacitretin (cap 10 mg cap 175 mgcap 25 mg)

Tier 2

adapalene gel 01 Tier 2

isotretinoin (cap 10 mg cap 20 mgcap 30 mg cap 40 mg)

Tier 2

tazarotene cream 01 Tier 2

TAZORAC 005 CREAM Tier 3

tretinoin (cream 0025 cream005 cream 01 gel 001 gel0025)

Tier 2 PA

DERMATITIS AND PRURITUS AGENTSalclometasone dipropionate oint005

Tier 2

betamethasone dipropionate(topical) (cream 005 lotion 005)

Tier 2

BETAMETHASONE DIPROPIONATEAUG 005 GEL

Tier 2

betamethasone dipropionateaugmented oint 005

Tier 2

betamethasone valerate (cream01 (base equivalent) lotion 01(base equivalent) oint 01 (baseequivalent))

Tier 2

clobetasol propionate (cream005 gel 005 oint 005 soln005)

Tier 2


69




clobetasol propionate emollientbase cream 005

Tier 2

desonide (cream 005 oint 005) Tier 2 ST

desoximetasone (cream 025 oint025)

Tier 2

fluocinolone acetonide (cream001 cream 0025 oil 001(body oil) oil 001 (scalp oil) oint0025 soln 001)

Tier 2

fluocinonide (cream 005 gel005 oint 005 soln 005)

Tier 2

fluocinonide emulsified base cream005

Tier 2

fluticasone propionate (cream005 oint 0005)

Tier 2

halobetasol propionate (cream005 oint 005)


hydrocortisone (rectal) (cream 1cream 25)

Tier 2

hydrocortisone (topical) (cream25 lotion 25 oint 1 oint 25)

Tier 2

hydrocortisone butyrate (01 solution soln 01)

Tier 2 ST

hydrocortisone valerate cream 02 Tier 2 ST

lactic acid (ammonium lactate)(cream 12 lotion 12)

Tier 2

mometasone furoate solution 01(lotion)

Tier 2

selenium sulfide lotion 25 Tier 2

tacrolimus (topical) (oint 003 oint01)


triamcinolone acetonide (topical)(cream 0025 cream 01 cream05 lotion 0025 lotion 01 oint0025 oint 01 oint 05)

Tier 2


70




DERMATOLOGICAL AGENTS OTHERcalcipotriene (cream 0005 oint0005 soln 0005 (50 mcgml))

Tier 2

clotrimazole w betamethasone(cream 1-005 lotion 1-005)

Tier 2

diclofenac sodium (actinickeratoses) gel 3


DUOBRII 001-0045 LOTION Tier 3 PA QL (200 PER 28 OVERTIME)

FLUOROURACIL (2 SOLUTION 5 SOLUTION)

Tier 2

fluorouracil cream 5 Tier 2

imiquimod cream 5 Tier 2 QL (24 PER 30 OVER TIME)

nystatin-triamcinolone (cream100000-01 unitgm- oint 100000-01 unitgm-)

Tier 2

podofilox soln 05 Tier 2

REGRANEX 001 GEL Tier 3 PA QL (15 PER 2 OVERTIME)

SANTYL 250 UNITGM OINTMENT Tier 3 QL (180 PER 30 OVER TIME)

silver sulfadiazine cream 1 Tier 2

TOLAK 4 CREAM Tier 3

PEDICULICIDESSCABICIDESLINDANE 1 SHAMPOO Tier 2

malathion lotion 05 Tier 3

permethrin cream 5 Tier 2

TOPICAL ANTI-INFECTIVESacyclovir oint 5 Tier 2 PA QL (30 PER 30 OVER

TIME)

ciclopirox solution 8 Tier 2

clindamycin phosphate (topical)(gel 1 lotion 1 soln 1)

Tier 2

ERY 2 PAD Tier 2


71




erythromycin (acne aid) (gel 2pads 2 soln 2)

Tier 2

mupirocin oint 2 Tier 2

SULFAMYLON 85 MGGM CREAM Tier 3

ELECTROLYTESMINERALSMETALSVITAMINS



ELECTROLYTEMINERAL REPLACEMENTamino acid electrolyte infusion85

Tier 2 BvD

amino acid infusion 15 Tier 2 BvD

AMINO ACID 10 SOLUTION Tier 2 BvD

AMINOSYN (10 SOLUTION 85 SOLUTION)

Tier 2 BvD

AMINOSYN II (10 SOLUTION 85 SOLUTION)

Tier 2 BvD

AMINOSYN II 15 SOLUTION Tier 3 BvD

AMINOSYN-HBC 7 SOLUTION Tier 3 BvD

AMINOSYN-PF 10 SOLUTION Tier 2 BvD


AMINOSYN-RF 52 SOLUTION Tier 2 BvD

AMINOSYNELECTROLYTES (7 SOLUTION 85 SOLUTION)

Tier 2 BvD

CARBAGLU 200 MG TAB Tier 3 PA LA

CRYSVITA 10 MGML SOLUTION Tier 3 PA LA QL (2 PER 28 OVERTIME)



FREAMINE III 10 SOLUTION Tier 2 BvD


72




HEPATAMINE 8 SOLUTION Tier 3 BvD

INTRALIPID (20 EMULSION 30 EMULSION)

Tier 3 BvD

KCL IN DEXTROSE-NACL (20-5-0225MEQL-- SOLUTION 20-5-033MEQL-- SOLUTION 40-5-09MEQL-- SOLUTION)

Tier 2

NORMOSOL-M IN D5W SOLUTION Tier 2

NUTRILIPID 20 EMULSION Tier 3 BvD

potassium chloride (10 meq100mlsolution 20 meq100ml solution 40meq100ml solution cap er 10 meqcap er 8 meq inj 10 meq100ml inj2 meqml inj 20 meq100ml inj 40meq100ml oral soln 10 (20meq15ml) oral soln 20 (40meq15ml) tab er 10 meq tab er 20meq (1500 mg) tab er 8 meq (600mg))

Tier 2

POTASSIUM CHLORIDE ER (ER 20MEQ TAB ER ER 8 MEQ TAB ER)

Tier 2

potassium chloride in dextrose ampsodium chloride (20 meql (015) indextrose 5 amp nacl 02 inj 20meql (015) in dextrose 5 amp nacl033 inj 20 meql (015) indextrose 5 amp nacl 045 inj 20meql (015) in dextrose 5 amp nacl09 inj)

Tier 2

POTASSIUM CHLORIDE IN NACL (KCL20 MEQL (015) 09 J KCL 40MEQL (03) 09 J POTASSIUMCHLORIDE 40-09 MEQL-SOLUTION)

Tier 2

potassium chloridemicroencapsulated crystals er (cryser tab 10 meq crys er tab 15 meqcrys er tab 20 meq)

Tier 2

potassium citrate (alkalinizer) (tab er10 meq (1080 mg) tab er 15 meq(1620 mg) tab er 5 meq (540 mg))

Tier 2


73




PREMASOL 10 SOLUTION Tier 2 BvD

sodium chloride (09 solution inj25 meqml (146) iv soln 045 ivsoln 09 iv soln 3 iv soln 5preservative free (pf) inj 09)

Tier 2

sodium fluoride (chew tab 025 mg f(from 055 mg naf) chew tab 05mg f (from 11 mg naf) chew tab 1mg f (from 22 mg naf))

Tier 2

SYNTHAMIN 17 10 SOLUTION Tier 2 BvD

TRAVASOL 10 SOLUTION Tier 2 BvD

TROPHAMINE 10 SOLUTION Tier 2 BvD

ELECTROLYTEMINERALMETAL MODIFIERSdeferasirox (tab 180 mg tab 360mg tab 90 mg tab for oral susp 125mg tab for oral susp 250 mg tab fororal susp 500 mg)

Tier 2

deferiprone tab 500 mg Tier 2 PA LA

FERRIPROX (100 MGML SOLUTION1000 MG TAB)

Tier 3 PA LA

FERRIPROX TWICE-A-DAY 1000 MGTAB

Tier 3 PA LA

trientine hcl cap 250 mg Tier 2 PA QL (8 PER 1 DAYS)

PHOSPHATE BINDERSAURYXIA 1 GM 210 MG(FE) TAB Tier 3 PA QL (12 PER 1 DAYS)

calcium acetate (phosphatebinder) (cap 667 mg (169 mg ca)tab 667 mg)

Tier 2

sevelamer carbonate tab 800 mg Tier 2

POTASSIUM BINDERSsodium polystyrene sulfonate(sodium powder sodium oral susp15 gm60ml)

Tier 2

SPS 15 GM60ML SUSPENSION Tier 2

VELTASSA (168 GM PACKET 252GM PACKET 84 GM PACKET)

Tier 3


74




VITAMINSdextrose (inj 10 inj 5) Tier 2

dextrose 5 in lactated ringers Tier 2

dextrose w sodium chloride (25w sodium chloride 045 5 wsodium chloride 02 5 w sodiumchloride 0225 5 w sodiumchloride 03 5 w sodiumchloride 033 5 w sodiumchloride 045 5 w sodiumchloride 09)

Tier 2

DEXTROSE-NACL (10-02 SOLUTION 10-045 SOLUTION 25-045 SOLUTION 5-0225 SOLUTION 5-03 SOLUTION)

Tier 2

DEXTROSE-SODIUM CHLORIDE (5-0225 SOLUTION 5-03 SOLUTION)

Tier 2

KCL-LACTATED RINGERS-D5W 20MEQL SOLUTION

Tier 2

lactated ringers for irrigation Tier 2

lactated ringers solution Tier 2

LACTATED RINGERS SOLUTION Tier 2

levocarnitine tab 330 mg Tier 2

NEONATAL PLUS 27-1 MG TAB Tier 3

POTASSIUM CHLORIDE IN DEXTROSE(20 MEQL (015) 5 J 40-5 MEQL- SOLUTION)

Tier 2

prenatal vitamins Tier 3

ringers solution Tier 2

ringers solution for irrigation Tier 2

SMOFLIPID 20 EMULSION Tier 3 BvD

TPN ELECTROLYTES CONC Tier 3 BvD


75

GASTROINTESTINAL AGENTS



ANTI-CONSTIPATION AGENTSAMITIZA (24 MCG CAP 8 MCG CAP) Tier 3 QL (2 PER 1 DAYS)

lactulose (encephalopathy) solution10 gm15ml

Tier 2

lactulose solution 10 gm15ml Tier 2

LINZESS (145 MCG CAP 290 MCGCAP 72 MCG CAP)


MOVANTIK (125 MG TAB 25 MGTAB)


peg 3350-kcl-sod bicarb-nacl forsoln 420 gm

Tier 2

RELISTOR (12 MG06ML SOLUTION 8MG04ML SOLUTION)

Tier 3 PA

SUPREP BOWEL PREP KIT 175-313-16GM177ML SOLUTION

Tier 3

ANTI-DIARRHEAL AGENTSalosetron hcl (tab 05 mg (baseequiv) tab 1 mg (base equiv))

Tier 2 PA

diphenoxylate w atropine tab 25-0025 mg

Tier 2

DIPHENOXYLATE-ATROPINE 25-0025MG5ML LIQUID

Tier 2

loperamide hcl cap 2 mg Tier 2

ANTISPASMODICS GASTROINTESTINALdicyclomine hcl (cap 10 mg tab 20mg)

Tier 2 PA

glycopyrrolate (tab 1 mg tab 2 mg) Tier 2

GASTROINTESTINAL AGENTS OTHERGATTEX 5 MG KIT Tier 3 PA LA

GAVILYTE-C 240 GM RECON SOLN Tier 2

MYALEPT 113 MG RECON SOLN Tier 3 PA LA QL (60 PER 30OVER TIME)

peg 3350-kcl-sod bicarb-sodchloride-sod sulfate (soln 236 gmsoln 240 gm)

Tier 2


76




ursodiol (cap 300 mg tab 250 mgtab 500 mg)

Tier 2

HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine (tab 200 mg tab 300 mgtab 400 mg tab 800 mg)

Tier 2

cimetidine hcl (300 mg5ml solutionsoln 300 mg5ml)

Tier 2

famotidine (tab 20 mg tab 40 mg) Tier 2

nizatidine (150 mg cap 300 mgcap cap 150 mg cap 300 mg)

Tier 2

PROTECTANTSmisoprostol (tab 100 mcg tab 200mcg)

Tier 2

sucralfate tab 1 gm Tier 2

PROTON PUMP INHIBITORSlansoprazole (cap delayed release15 mg cap delayed release 30 mg)

Tier 2

omeprazole (cap delayed release10 mg cap delayed release 20 mgcap delayed release 40 mg)

Tier 2

pantoprazole sodium (ec tab 20 mg(base equiv) ec tab 40 mg (baseequiv))

Tier 2

rabeprazole sodium ec tab 20 mg Tier 2

GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERSTREATMENT



GENETIC OR ENZYME OR PROTEIN DISORDER REPLACEMENT MODIFIERS TREATMENTALDURAZYME 29 MG5ML SOLUTION Tier 3 LA BvD

ARALAST NP (1000 MG RECON SOLN500 MG RECON SOLN)

Tier 3 LA BvD


77




BYLVAY (PELLETS) 200 MCG CAPSPRINK




BYLVAY 1200 MCG CAP Tier 3 PA LA QL (5 PER 1 DAYS)


CERDELGA 84 MG CAP Tier 3 PA LA QL (2 PER 1 DAYS)

CEREZYME 400 UNIT RECON SOLN Tier 3 PA LA

CHOLBAM 250 MG CAP Tier 3 PA QL (5 PER 1 DAYS)


CREON (12000 UNIT CP DR PART24000-76000 UNIT CP DR PART 3000-9500 UNIT CP DR PART 36000 UNITCP DR PART 6000 UNIT CP DR PART)

Tier 3

cromolyn sodium oral conc 100mg5ml

Tier 2

CYSTADANE POWDER Tier 3 LA

CYSTAGON (150 MG CAP 50 MGCAP)

Tier 3 PA LA

CYSTARAN 044 SOLUTION Tier 3 PA LA QL (60 PER 28OVER TIME)

FABRAZYME 35 MG RECON SOLN Tier 3 LA BvD

LUMIZYME 50 MG RECON SOLN Tier 3 LA BvD

miglustat cap 100 mg Tier 2 PA LA QL (3 PER 1 DAYS)

NAGLAZYME 1 MGML SOLUTION Tier 3 LA BvD

nitisinone (cap 10 mg cap 2 mgcap 5 mg)

Tier 2 PA

NITYR (10 MG TAB 2 MG TAB 5 MGTAB)

Tier 3 PA LA

PROCYSBI (25 MG CAP DR 300 MGPACKET 75 MG CAP DR 75 MGPACKET)

Tier 3 PA LA

PROLASTIN-C (1000 MG RECONSOLN 1000 MG20ML SOLUTION)

Tier 3 LA BvD


78




RAVICTI 11 GMML LIQUID Tier 3 PA LA QL (525 PER 30OVER TIME)

sapropterin dihydrochloride(powder packet 100 mg powderpacket 500 mg tab 100 mg)

Tier 2 PA

sodium phenylbutyrate (oralpowder 3 gmteaspoonful tab 500mg)

Tier 2 PA

STRENSIQ (18 MG045ML SOLUTION28 MG07ML SOLUTION 40 MGMLSOLUTION)

Tier 3 PA LA

STRENSIQ 80 MG08ML SOLUTION Tier 3 PA LA QL (384 PER 28OVER TIME)

VYNDAQEL 20 MG CAP Tier 3 PA LA QL (4 PER 1 DAYS)

ZENPEP (10000-32000 UNIT CP DRPART 15000-47000 UNIT CP DR PART20000-63000 UNIT CP DR PART25000-79000 UNIT CP DR PART 3000-10000 UNIT CP DR PART 3000-14000UNIT CP DR PART 40000-126000 UNITCP DR PART 5000-24000 UNIT CP DRPART)

Tier 3

GENITOURINARY AGENTS



ANTISPASMODICS URINARYMYRBETRIQ (25 MG TAB ER 24H 50MG TAB ER 24H)

Tier 3

oxybutynin chloride (syrup 5mg5ml tab 5 mg tab er 24hr 10mg tab er 24hr 15 mg tab er 24hr 5mg)

Tier 2

solifenacin succinate (tab 10 mgtab 5 mg)


tolterodine tartrate (cap er 24hr 2mg cap er 24hr 4 mg tab 1 mg tab2 mg)

Tier 2 ST


79




trospium chloride tab 20 mg Tier 2

BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl tab er 24hr 10 mg Tier 2

dutasteride cap 05 mg Tier 2 QL (1 PER 1 DAYS)

finasteride tab 5 mg Tier 2

tamsulosin hcl cap 04 mg Tier 2

GENITOURINARY AGENTS OTHERbethanechol chloride (tab 10 mgtab 25 mg tab 5 mg tab 50 mg)

Tier 2

penicillamine tab 250 mg Tier 2 PA

THIOLA EC (EC 100 MG TAB DR EC300 MG TAB DR)

Tier 3 PA LA

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL)



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL)ACTHAR 80 UNITML GEL Tier 3 PA LA

alclometasone dipropionate cream005

Tier 2

betamethasone dipropionateaugmented (cream 005 lotion005)

Tier 2

betamethasone dipropionate oint005

Tier 2


Tier 2

CORTISONE ACETATE 25 MG TAB Tier 2

dexamethasone (05 mg5mlsolution 1 mg tab 2 mg tab elixir05 mg5ml tab 05 mg tab 075mg tab 15 mg tab 4 mg tab 6mg)

Tier 2


80




dexamethasone sodium phosphate(inj 120 mg30ml inj 20 mg5ml inj 4mgml)

Tier 2

dexamethasone sodium phosphate(sod phosphate preservative free inj10 mgml sodium phosphate inj 10mgml sodium phosphate inj 100mg10ml)

Tier 2 BvD

fludrocortisone acetate tab 01 mg Tier 2

HEMADY 20 MG TAB Tier 3 PA QL (2 PER 1 DAYS)

hydrocortisone butyrate oint 01 Tier 2 ST

hydrocortisone valerate oint 02 Tier 2

KORLYM 300 MG TAB Tier 3 PA LA QL (4 PER 1 DAYS)

methylprednisolone (tab 16 mg tab32 mg tab 4 mg tab 8 mg tabtherapy pack 4 mg (21))

Tier 2

methylprednisolone acetate (injsusp 40 mgml inj susp 80 mgml)

Tier 2

methylprednisolone sod succ (inj 125mg (base equiv) inj 40 mg (baseequiv))

Tier 2

mometasone furoate (cream 01oint 01)

Tier 2

prednisolone (15 mg5ml solutionsyrup 15 mg5ml (usp solutionequivalent))

Tier 2

PREDNISOLONE SODIUM PHOSPHATE(SOD PHOSPH ORAL SOLN 67MG5ML (5 MG5ML BASE) SODIUMPHOSPHATE 25 MG5ML SOLUTION)

Tier 2

prednisone (5 mg5ml solution tab 1mg tab 10 mg tab 25 mg tab 20mg tab 5 mg tab 50 mg)

Tier 2

PREDNISONE INTENSOL 5 MGMLCONC

Tier 2


81

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY)



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY)desmopressin acetate (inj 4 mcgmlpreservative free (pf) inj 4 mcgmltab 01 mg tab 02 mg)

Tier 2

desmopressin acetate nasal spraysoln 001

Tier 2

desmopressin acetate nasal spraysoln 001 (refrigerated)

Tier 2

EGRIFTA 1 MG RECON SOLN Tier 3 PA LA QL (60 PER 30OVER TIME)

EGRIFTA SV 2 MG RECON SOLN Tier 3 PA LA QL (30 PER 30OVER TIME)

INCRELEX 40 MG4ML SOLUTION Tier 3 PA LA

NORDITROPIN FLEXPRO (10MG15ML SOLN PEN 15 MG15MLSOLN PEN 30 MG3ML SOLN PEN 5MG15ML SOLN PEN)

Tier 3 PA

SEROSTIM (4 MG RECON SOLN 5 MGRECON SOLN 6 MG RECON SOLN)

Tier 3 PA LA

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS)



ANABOLIC STEROIDSANADROL-50 50 MG TAB Tier 3

oxandrolone (tab 10 mg tab 25mg)

Tier 2 PA

ANDROGENSANDRODERM (2 MG24HR PATCH24HR 4 MG24HR PATCH 24HR)


danazol (cap 100 mg cap 200 mgcap 50 mg)

Tier 2


82




testosterone (125 mgact (1) gel25 mg25gm (1) gel 50 mg5gm(1) gel td gel 125 mgact (1) tdgel 25 mg25gm (1) td gel 50mg5gm (1))


testosterone cypionate (100 mgmlsolution 200 mgml solution im inj inoil 100 mgml im inj in oil 200 mgml)

Tier 2

testosterone enanthate (200 mgmlsolution im inj in oil 200 mgml)


ESTROGENSCOMBIPATCH (005-014 MGDAYPATCH TW 005-025 MGDAYPATCH TW)


DEPO-ESTRADIOL 5 MGML OIL Tier 3

desogest-eth estrad amp eth estradtab 015-002001 mg(215)

Tier 2

desogest-ethin est tab 01-00250125-0025015-0025mg-mg

Tier 2

desogestrel amp ethinyl estradiol tab015 mg-30 mcg

Tier 2

drospirenone-ethinyl estradiol (tab3-002 mg tab 3-003 mg)

Tier 2

estradiol amp norethindrone acetate(tab 05-01 mg tab 1-05 mg)

Tier 2 PA

estradiol (patch twice weekly 0025mg24hr patch twice weekly 00375mg24hr patch twice weekly 005mg24hr patch twice weekly 0075mg24hr patch twice weekly 01mg24hr)


estradiol (patch weekly 0025mg24hr patch weekly 00375mg24hr (375 mcg24hr) patchweekly 005 mg24hr patch weekly006 mg24hr patch weekly 0075mg24hr patch weekly 01 mg24hr)


estradiol (tab 05 mg tab 1 mg tab2 mg)

Tier 2 PA


83




estradiol vaginal (cream 01 mggmtab 10 mcg)

Tier 2

ESTRING 2 MG RING Tier 3 QL (1 PER 84 OVER TIME)

ethynodiol diacet amp eth estrad (tab1 mg-35 mcg tab 1 mg-50 mcg)

Tier 2

etonogestrel-ethinyl estradiol va ring0120-0015 mg24hr


levonorgestrel amp eth estradiol (tab01 mg-20 mcg tab 015 mg-30mcg)

Tier 2

levonorgestrel amp ethinyl estradiol(91-day) tab 015-003 mg

Tier 2

levonorgestrel-eth estra tab 005-300075-400125-30mg-mcg

Tier 2

MENEST (03 MG TAB 0625 MG TAB125 MG TAB 25 MG TAB)

Tier 3 PA

norethin acet amp estrad-fe (tab 1 mg-20 mcg tab 15 mg-30 mcg)

Tier 2

norethindrone amp eth estradiol (tab04 mg-35 mcg tab 05 mg-35 mcgtab 1 mg-35 mcg)

Tier 2

norethindrone amp ethinyl estradiol-fechew tab 04 mg-35 mcg

Tier 2

norethindrone acet amp eth estra (tab1 mg-20 mcg tab 15 mg-30 mcg)

Tier 2

norethindrone acetate-ethinylestradiol (tab 05 mg-25 mcg tab 1mg-5 mcg)

Tier 2 PA

norethindrone-eth estradiol(triphasic) (tab 05-35075-351-35mg-mcg tab 05-351-3505-35 mg-mcg)

Tier 2

norgestimate amp ethinyl estradiol tab025 mg-35 mcg

Tier 2

norgestimate-eth estrad tab 018-350215-35025-35 mg-mcg

Tier 2


84




norgestrel amp ethinyl estradiol tab 03mg-30 mcg

Tier 2

PREMARIN (03 MG TAB 045 MGTAB 0625 MG TAB 09 MG TAB 125MG TAB)

Tier 3 PA

PREMARIN 0625 MGGM CREAM Tier 3

PREMPHASE 0625-5 MG TAB Tier 3 PA

PREMPRO (03-15 MG TAB 045-15MG TAB 0625-25 MG TAB 0625-5MG TAB)


PROGESTINSDEPO-PROVERA 400 MGMLSUSPENSION

Tier 3

HYDROXYPROGESTERONECAPROATE 125 GM5ML SOLUTION

Tier 2

medroxyprogesterone acetate(contraceptive) (susp 150 mgmlsusp prefilled syr 150 mgml)

Tier 2

medroxyprogesterone acetate (tab10 mg tab 25 mg tab 5 mg)

Tier 2

megestrol acetate (susp 40 mgmltab 20 mg tab 40 mg)

Tier 2 PA

megestrol acetate susp 625 mg5ml Tier 2 PA

norethindrone acetate tab 5 mg Tier 2

norethindrone tab 035 mg Tier 2

progesterone (cap 100 mg cap 200mg)

Tier 2

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSOSPHENA 60 MG TAB Tier 3 PA QL (1 PER 1 DAYS)

raloxifene hcl tab 60 mg Tier 2 QL (1 PER 1 DAYS)


85

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID)



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID)levothyroxine sodium (tab 100 mcgtab 112 mcg tab 125 mcg tab 137mcg tab 150 mcg tab 175 mcgtab 200 mcg tab 25 mcg tab 300mcg tab 50 mcg tab 75 mcg tab88 mcg)

Tier 2

liothyronine sodium (tab 25 mcgtab 5 mcg tab 50 mcg)

Tier 2

SYNTHROID (100 MCG TAB 112 MCGTAB 125 MCG TAB 137 MCG TAB150 MCG TAB 175 MCG TAB 200MCG TAB 25 MCG TAB 300 MCGTAB 50 MCG TAB 75 MCG TAB 88MCG TAB)

Tier 3

HORMONAL AGENTS SUPPRESSANT (PITUITARY)



HORMONAL AGENTS SUPPRESSANT (PITUITARY)cabergoline tab 05 mg Tier 2 QL (16 PER 30 OVER TIME)

FIRMAGON (240 MG DOSE) 120MGVIAL RECON SOLN

Tier 3

FIRMAGON 80 MG RECON SOLN Tier 3

leuprolide acetate inj kit 5 mgml Tier 2

LUPRON DEPOT (1-MONTH) (375 MGKIT 75 MG KIT)

Tier 3

LUPRON DEPOT (3-MONTH) (1125MG KIT 225 MG KIT)

Tier 3

LUPRON DEPOT (4-MONTH) 30 MGKIT

Tier 3


Tier 3

LUPRON DEPOT-PED (1-MONTH)(1125 MG KIT 15 MG KIT 75 MG KIT)

Tier 3


86




LUPRON DEPOT-PED (3-MONTH)(1125 MG (PED) KIT 30 MG (PED)KIT)

Tier 3

octreotide acetate (100 mcgmlsoln prsyr 1000 mcgml solution 200mcgml solution 50 mcgml solnprsyr 500 mcgml soln prsyr inj 100mcgml (01 mgml) inj 1000mcgml (1 mgml) inj 200 mcgml(02 mgml) inj 50 mcgml (005mgml) inj 500 mcgml (05 mgml))

Tier 2 PA

ORGOVYX 120 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

SANDOSTATIN LAR DEPOT (10 MGKIT 20 MG KIT 30 MG KIT)

Tier 3 PA

SIGNIFOR (03 MGML SOLUTION 06MGML SOLUTION 09 MGMLSOLUTION)


SOMATULINE DEPOT (120 MG05MLSOLUTION 60 MG02ML SOLUTION90 MG03ML SOLUTION)

Tier 3 PA

SOMAVERT (10 MG RECON SOLN 15MG RECON SOLN 20 MG RECONSOLN 25 MG RECON SOLN 30 MGRECON SOLN)


SYNAREL 2 MGML SOLUTION Tier 3

HORMONAL AGENTS SUPPRESSANT (THYROID)



ANTITHYROID AGENTSmethimazole (tab 10 mg tab 5 mg) Tier 2

propylthiouracil tab 50 mg Tier 2


87

IMMUNOLOGICAL AGENTS



ANGIOEDEMA AGENTSBERINERT 500 UNIT KIT Tier 3 PA LA

CINRYZE 500 UNIT RECON SOLN Tier 3 PA LA

HAEGARDA (2000 UNIT RECONSOLN 3000 UNIT RECON SOLN)

Tier 3 PA LA

icatibant acetate inj 30 mg3ml(base equivalent)


RUCONEST 2100 UNIT RECON SOLN Tier 3 PA LA

IMMUNOGLOBULINSBIVIGAM (10 GM100ML SOLUTION 5GM50ML SOLUTION)

Tier 3 PA LA

FLEBOGAMMA DIF (05 GM10MLSOLUTION 10 GM100ML SOLUTION10 GM200ML SOLUTION 25GM50ML SOLUTION 20 GM200MLSOLUTION 20 GM400ML SOLUTION5 GM100ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA

GAMMAGARD (1 GM10MLSOLUTION 10 GM100ML SOLUTION25 GM25ML SOLUTION 20GM200ML SOLUTION 30 GM300MLSOLUTION 5 GM50ML SOLUTION)

Tier 3 PA

GAMMAGARD SD LESS IGA (10 GMRECON SOLN 5 GM RECON SOLN)

Tier 3 PA

GAMMAKED (1 GM10ML SOLUTION10 GM100ML SOLUTION 20GM200ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA

GAMMAPLEX (10 GM100MLSOLUTION 20 GM200ML SOLUTION20 GM400ML SOLUTION 5GM100ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA LA

GAMMAPLEX 10 GM200MLSOLUTION

Tier 3 PA

GAMUNEX-C (1 GM10ML SOLUTION10 GM100ML SOLUTION 25GM25ML SOLUTION 20 GM200MLSOLUTION 40 GM400ML SOLUTION5 GM50ML SOLUTION)

Tier 3 PA


88




HIZENTRA (1 GM5ML SOLN PRSYR 1GM5ML SOLUTION 10 GM50MLSOLUTION 2 GM10ML SOLN PRSYR2 GM10ML SOLUTION 4 GM20MLSOLN PRSYR 4 GM20ML SOLUTION)

Tier 3 PA LA

PRIVIGEN (10 GM100ML SOLUTION20 GM200ML SOLUTION 40GM400ML SOLUTION 5 GM50MLSOLUTION)

Tier 3 PA

VARIZIG 125 UNIT12ML SOLUTION Tier 3

IMMUNOLOGICAL AGENTS OTHERARCALYST 220 MG RECON SOLN Tier 3 PA LA

BENLYSTA (200 MGML SOLN A-INJ200 MGML SOLN PRSYR)


ILARIS (150 MG RECON SOLN 150MGML SOLUTION)

Tier 3 PA LA

STELARA (45 MG05ML SOLN PRSYR45 MG05ML SOLUTION 90 MGMLSOLN PRSYR)

Tier 3 PA

TALTZ (80 MGML SOLN A-INJ 80MGML SOLN PRSYR)


XELJANZ (10 MG TAB 5 MG TAB) Tier 3 PA QL (2 PER 1 DAYS)

XELJANZ 1 MGML SOLUTION Tier 3 PA QL (10 PER 1 DAYS)

XOLAIR (150 MG RECON SOLN 150MGML SOLN PRSYR 75 MG05MLSOLN PRSYR)

Tier 3 PA LA

IMMUNOSTIMULANTSACTIMMUNE 2000000 UNIT05MLSOLUTION

Tier 3 PA LA

INTRON A (10000000 UNIT RECONSOLN 10000000 UNITML SOLUTION18000000 UNIT RECON SOLN50000000 UNIT RECON SOLN6000000 UNITML SOLUTION)

Tier 3 LA

PEGASYS 180 MCG05ML SOLNPRSYR


PEGASYS 180 MCGML SOLUTION Tier 3 PA QL (4 PER 30 OVERTIME)


89




PEGASYS PROCLICK 180 MCG05MLSOLN A-INJ


SYLATRON (200 MCG KIT 300 MCGKIT)

Tier 3

SYLATRON 600 MCG KIT Tier 3 LA

IMMUNOSUPPRESSANTSAZATHIOPRINE SODIUM 100 MGRECON SOLN

Tier 2 BvD

azathioprine tab 50 mg Tier 2 BvD

cyclosporine (cap 100 mg cap 25mg iv soln 50 mgml)

Tier 2 BvD

cyclosporine modified (formicroemulsion) (cap 100 mg cap25 mg cap 50 mg oral soln 100mgml)

Tier 2 BvD

ENBREL (25 MG RECON SOLN 25MG05ML SOLN PRSYR 25MG05ML SOLUTION 50 MGMLSOLN PRSYR)

Tier 3 PA

ENBREL SURECLICK 50 MGML SOLNA-INJ

Tier 3 PA

ENVARSUS XR (075 MG TAB ER 24H1 MG TAB ER 24H 4 MG TAB ER 24H)

Tier 3 PA

everolimus (immunosuppressant)(tab 025 mg tab 05 mg tab 075mg)

Tier 2 PA

HUMIRA (10 MG01ML PREF SY KT 10MG02ML PREF SY KT 20 MG02MLPREF SY KT 20 MG04ML PREF SY KT40 MG04ML PREF SY KT 40MG08ML PREF SY KT 80 MG08MLPEN KIT)

Tier 3 PA

HUMIRA PEDIATRIC CROHNS START(40 MG08ML PREF SY KT 80MG08ML amp 40MG04ML PREF SYKT 80 MG08ML PREF SY KT)

Tier 3 PA

HUMIRA PEN (PEN 40 MG04ML PENKIT PEN 40 MG08ML PEN KIT)

Tier 3 PA


90




HUMIRA PEN-CDUCHS STARTER (40MG08ML PEN KIT 80 MG08MLPEN KIT)

Tier 3 PA

HUMIRA PEN-PEDIATRIC UC START 80MG08ML PEN KIT

Tier 3 PA

HUMIRA PEN-PSUVADOL HS START40 MG08ML PEN KIT

Tier 3 PA

HUMIRA PEN-PSORUVEIT STARTER 80MG08ML amp 40MG04ML PEN KIT

Tier 3 PA

leflunomide (tab 10 mg tab 20 mg) Tier 2

methotrexate sodium (250 mg10mlsolution for inj 1 gm inj 50 mg2ml(25 mgml) inj pf 1000 mg40ml (25mgml) inj pf 250 mg10ml (25mgml) inj pf 50 mg2ml (25mgml))

Tier 2 BvD

methotrexate sodium tab 25 mg(base equiv)

Tier 2

mycophenolate mofetil (cap 250mg for oral susp 200 mgml tab 500mg)

Tier 2 BvD

mycophenolate mofetil hcl for ivsoln 500 mg (base equiv)

Tier 2 BvD

mycophenolate sodium (tab dr 180mg (mycophenolic acid equiv) tabdr 360 mg (mycophenolic acidequiv))

Tier 2 BvD

PROGRAF (02 MG PACKET 1 MGPACKET)

Tier 3 PA

REZUROCK 200 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

SANDIMMUNE 100 MGML SOLUTION Tier 3 BvD

sirolimus (oral soln 1 mgml tab 05mg tab 1 mg tab 2 mg)

Tier 2 BvD

tacrolimus (cap 05 mg cap 1 mgcap 5 mg)

Tier 2 BvD

XATMEP 25 MGML SOLUTION Tier 3 PA

XELJANZ XR (11 MG TAB ER 24H 22MG TAB ER 24H)



91




ZORTRESS 1 MG TAB Tier 3 PA

VACCINESACTHIB RECON SOLN Tier 3

ADACEL 5-2-155 LF-MCG05SUSPENSION

Tier 3

BCG VACCINE INJECTABLE Tier 3

BEXSERO SUSP PRSYR Tier 3

BOOSTRIX (SUSP PRSYR SUSPENSION) Tier 3

DAPTACEL 23-15-5 SUSPENSION Tier 3

DIPHTHERIA-TETANUS TOXOIDS DT 25-5 LFU05ML SUSPENSION

Tier 3

ENGERIX-B (10 MCG05MLINJECTABLE 10 MCG05MLSUSPENSION 20 MCGMLINJECTABLE 20 MCGMLSUSPENSION)

Tier 3 BvD

GARDASIL 9 (9 SUSP PRSYR 9SUSPENSION)

Tier 3

HAVRIX (1440 EL UML SUSPENSION720 EL U05ML SUSPENSION)

Tier 3

HIBERIX 10 MCG RECON SOLN Tier 3

IMOVAX RABIES 25 UNITMLINJECTABLE

Tier 3

INFANRIX 25-58-10 SUSPENSION Tier 3

IPOL INJECTABLE Tier 3

IXIARO SUSPENSION Tier 3

KINRIX (05 ML SUSP PRSYRSUSPENSION)

Tier 3

M-M-R II RECON SOLN Tier 3

MENACTRA SOLUTION Tier 3

MENQUADFI SOLUTION Tier 3

MENVEO RECON SOLN Tier 3

PEDIARIX SUSPENSION Tier 3


92




PEDVAX HIB 75 MCG05MLSUSPENSION

Tier 3

PROQUAD RECON SUSP Tier 3

QUADRACEL SUSPENSION Tier 3

RABAVERT RECON SUSP Tier 3

RECOMBIVAX HB (10 MCGMLSUSPENSION 40 MCGMLSUSPENSION 5 MCG05MLSUSPENSION)

Tier 3 BvD

ROTARIX RECON SUSP Tier 3

ROTATEQ SOLUTION Tier 3

SHINGRIX 50 MCG05ML RECONSUSP


TDVAX 2-2 LF05ML SUSPENSION Tier 3

TENIVAC 5-2 LFU INJECTABLE Tier 3

TICOVAC 24 MCG05ML SUSPPRSYR

Tier 3

TRUMENBA SUSP PRSYR Tier 3

TWINRIX 720-20 ELU-MCGML SUSPPRSYR

Tier 3 BvD

TYPHIM VI 25 MCG05ML SOLUTION Tier 3

VAQTA (25 UNIT05ML SUSPENSION50 UNITML SUSPENSION)

Tier 3

VARIVAX 1350 PFU05MLINJECTABLE

Tier 3

YF-VAX INJECTABLE Tier 3

ZOSTAVAX 19400 UNT065MLRECON SUSP



93

INFLAMMATORY BOWEL DISEASE AGENTS



AMINOSALICYLATESbalsalazide disodium cap 750 mg Tier 2

mesalamine (cap er 24hr 0375 gmtab delayed release 12 gm)


mesalamine (enema 4 gm suppos1000 mg)

Tier 2

sulfasalazine (tab 500 mg tabdelayed release 500 mg)

Tier 2

GLUCOCORTICOIDSbudesonide delayed releaseparticles cap 3 mg


budesonide tab er 24hr 9 mg Tier 2 PA QL (1 PER 1 DAYS)

hydrocortisone (tab 10 mg tab 20mg tab 5 mg)

Tier 2

hydrocortisone enema 100 mg60ml Tier 2

METABOLIC BONE DISEASE AGENTS



METABOLIC BONE DISEASE AGENTSalendronate sodium (40 mg tab 5mg tab tab 10 mg tab 35 mg tab5 mg tab 70 mg)

Tier 1

calcitonin (salmon) nasal soln 200unitact


calcitriol (1 mcgml solution cap025 mcg cap 05 mcg oral soln 1mcgml)

Tier 2 BvD

cinacalcet hcl (tab 30 mg (baseequiv) tab 60 mg (base equiv) tab90 mg (base equiv))

Tier 2 BvD

doxercalciferol (cap 05 mcg cap 1mcg cap 25 mcg inj 4 mcg2ml (2mcgml))

Tier 2 BvD


94




ETIDRONATE DISODIUM 200 MG TAB Tier 2

ibandronate sodium iv soln 3mg3ml (base equivalent)

Tier 2 PA

ibandronate sodium tab 150 mg(base equivalent)

Tier 2

NATPARA (100 MCG CARTRIDGE 25MCG CARTRIDGE 50 MCGCARTRIDGE 75 MCG CARTRIDGE)


paricalcitol (cap 1 mcg cap 2 mcgcap 4 mcg iv soln 2 mcgml iv soln5 mcgml)

Tier 2 BvD

PROLIA 60 MGML SOLN PRSYR Tier 3 PA

risedronate sodium (tab 150 mg tab35 mg tab 5 mg tab delayedrelease 35 mg)

Tier 2

TYMLOS 3120 MCG156ML SOLNPEN


XGEVA 120 MG17ML SOLUTION Tier 3 PA QL (17 PER 28 OVERTIME)

zoledronic acid (4 mg recon soln 4mg100ml solution inj conc for ivinfusion 4 mg5ml iv soln 5mg100ml)

Tier 2 BvD

MISCELLANEOUS THERAPEUTIC AGENTS



MISCELLANEOUS THERAPEUTIC AGENTSALCOH-WIPE SHEET Tier 2

ALCOHOL 70 PADS Tier 2

ALCOHOL PREP (70 PAD PAD) Tier 2

ALCOHOL WIPES 70 MISC Tier 2

BD ECLIPSE SYRINGE 30G X 12 1 MLMISC

Tier 2


95




BD INSULIN SYRINGE 275G X 58 2ML MISC

Tier 2

BD Pen Needle Mini UF 31G X 5 MMMISC

Tier 2

BD Pen Needle Nano UF 32G X 4MM MISC

Tier 2

BD Pen Needle Original UF 29G X127MM MISC

Tier 2

BD Pen Needle Short UF 31G X 8MM MISC

Tier 2

BIOGUARD GAUZE SPONGES 2X2PAD

Tier 2

CAREONE UNIFINE PENTIPS PLUS 33GX 4 MM MISC

Tier 2

COMFORT TOUCH ALCOHOL PREP70 PAD

Tier 2

COMFORT TOUCH INSULIN PEN NEED(PEN NEED 31G X 4 MM MISC PENNEED 31G X 5 MM MISC PEN NEED31G X 6 MM MISC PEN NEED 31G X8 MM MISC PEN NEED 32G X 4 MMMISC PEN NEED 32G X 5 MM MISCPEN NEED 32G X 6 MM MISC PENNEED 32G X 8 MM MISC)

Tier 2

CURITY GAUZE SPONGE (3X3 PAD3X4 PAD 4X4 PAD 4X8 PAD)

Tier 2

CVS ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

EASY TOUCH INSULIN SYRINGE (27GX 12 05 ML MISC 27G X 12 1 MLMISC 28G X 12 05 ML MISC 28G X12 1 ML MISC 29G X 12 05 MLMISC 29G X 12 1 ML MISC)

Tier 2

EASY TOUCH PEN NEEDLES 30G X 6MM MISC

Tier 2

ESSENTRA WIPES 9X9 70 SHEET Tier 2

gauze pads 2x2 Tier 2

GNP ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2


96




GNP STERILE GAUZE (2X2 PAD3X3 PAD)

Tier 2

H-E-B INCONTROL PEN NEEDLES 31GX 5 MM MISC

Tier 2

H-E-B INCONTROL UNIFINE PENTIP(31G X 5 MM MISC 31G X 6 MMMISC 31G X 8 MM MISC 32G X 4MM MISC 33G X 4 MM MISC)

Tier 2

HM ULTICARE MINI PEN NEEDLES 31GX 5 MM MISC

Tier 2

INSULIN PEN NEEDLES Tier 2

INSULIN SYRINGE 03 ML Tier 2



INSULIN SYRINGE-NEEDLE U-100 30GX 516 1 ML MISC

Tier 2

ISOPROPYL ALCOHOL 70 MISC Tier 2

ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

MEDPURA ALCOHOL PADS 70 MISC

Tier 2

methylergonovine maleate tab 02mg

Tier 2

novofine 32g x 6 mm misc Tier 2

novotwist 32g x 5 mm misc Tier 2

RA ISOPROPYL ALCOHOL WIPES 70 MISC

Tier 2

RELION PEN NEEDLES (PEN NEEDLES31G X 6 MM MISC PEN NEEDLES31G X 8 MM MISC PEN NEEDLES32G X 4 MM MISC)

Tier 2

RUZURGI 10 MG TAB Tier 3 PA LA QL (10 PER 1 DAYS)


97




TRUE COMFORT PEN NEEDLES (PENNEEDLES 31G X 8 MM MISC PENNEEDLES 32G X 5 MM MISC PENNEEDLES 32G X 6 MM MISC PENNEEDLES 33G X 4 MM MISC PENNEEDLES 33G X 5 MM MISC PENNEEDLES 33G X 6 MM MISC)

Tier 2

TRUE COMFORT PRO ALCOHOL PREP70 PAD

Tier 2

TRUE COMFORT PRO INSULIN SYR(30G X 12 05 ML MISC 30G X 121 ML MISC 30G X 516 05 ML MISC30G X 516 1 ML MISC 31G X 51605 ML MISC 31G X 516 1 ML MISC32G X 516 05 ML MISC 32G X 5161 ML MISC)

Tier 2

TRUE COMFORT PRO PEN NEEDLES(PEN NEEDLES 31G X 5 MM MISCPEN NEEDLES 31G X 6 MM MISC PENNEEDLES 32G X 4 MM MISC)

Tier 2

ULTICARE MINI PEN NEEDLES 30G X 5MM MISC

Tier 2

ULTICARE SHORT PEN NEEDLES 30G X8 MM MISC

Tier 2

ULTIGUARD SAFEPACK PEN NEEDLE(PEN NEEDLE 29G X 127MM MISCPEN NEEDLE 31G X 5 MM MISC PENNEEDLE 31G X 8 MM MISC PENNEEDLE 32G X 4 MM MISC PENNEEDLE 32G X 6 MM MISC)

Tier 2

ULTIGUARD SAFEPACK SYRNEEDLE(30G X 12 03 ML MISC 30G X 1205 ML MISC 30G X 12 1 ML MISC31G X 516 03 ML MISC 31G X 51605 ML MISC 31G X 516 1 ML MISC)

Tier 2

ULTRA FLO INSULIN PEN NEEDLES(PEN NEEDLES 31G X 5 MM MISCPEN NEEDLES 31G X 8 MM MISC PENNEEDLES 32G X 4 MM MISC PENNEEDLES 33G X 4 MM MISC)

Tier 2

ULTRA FLO INSULIN SYR 12 UNIT (30GX 03 ML MISC 30G X 516 03 MLMISC 31G X 516 03 ML MISC)

Tier 2


98




ULTRA FLO INSULIN SYRINGE (29G X12 05 ML MISC 29G X 12 1 MLMISC 30G X 12 03 ML MISC 30G X12 05 ML MISC 30G X 12 1 MLMISC 30G X 516 03 ML MISC 30GX 516 05 ML MISC 30G X 516 1ML MISC 31G X 516 03 ML MISC31G X 516 05 ML MISC 31G X 5161 ML MISC)

Tier 2

UNIFINE PEN NEEDLES 32G X 4 MMMISC

Tier 2

UNIFINE PENTIPS (31G X 5 MM MISC31G X 6 MM MISC 31G X 8 MMMISC 32G X 4 MM MISC)

Tier 2

water for irrigation sterile irrigationsoln

Tier 2

ZEVRX STERILE ALCOHOL PREP PAD70 PAD

Tier 2

OPHTHALMIC AGENTS



OPHTHALMIC AGENTS OTHERATROPINE SULFATE 1 SOLUTION Tier 2

bacitracin-polymyxin b ophth oint Tier 2

bacitracin-polymyxin-neomycin-hcophth oint 1

Tier 2

COMBIGAN 02-05 SOLUTION Tier 3

DORZOLAMIDE HCL-TIMOLOL MAL223-68 MGML SOLUTION

Tier 2

dorzolamide hcl-timolol maleateophth soln 223-68 mgml

Tier 2

neomycin-bacitrac zn-polymyx5(35)mg-400unt-10000unt op oin

Tier 2

neomycin-polymy-dexameth (oint01 susp 01)

Tier 2


99

OPHTHALMIC AGENTS



NEOMYCIN-POLYMYXIN-GRAMICIDIN 175-10000-025SOLUTION

Tier 2

RESTASIS 005 EMULSION Tier 3 QL (60 PER 30 OVER TIME)

RESTASIS MULTIDOSE 005 EMULSION


sulfacetamide sodium-prednisoloneophth soln 10-023(025)

Tier 2

SULFACETAMIDE-PREDNISOLONE 10-023 SOLUTION

Tier 2

tobramycin-dexamethasone ophthsusp 03-01

Tier 2

OPHTHALMIC ANTI-ALLERGY AGENTSazelastine hcl ophth soln 005 Tier 2

cromolyn sodium ophth soln 4 Tier 2

olopatadine hcl (soln 01 (baseequivalent) soln 02 (baseequivalent))

Tier 2

OPHTHALMIC ANTI-INFECTIVESBACITRACIN 500 UNITGM OINTMENT Tier 2

erythromycin ophth oint 5 mggm Tier 2

GENTAK 03 OINTMENT Tier 2

gentamicin sulfate ophth soln 03 Tier 2

levofloxacin ophth soln 05 Tier 2

moxifloxacin hcl (ophth) (soln 05(base eq) (2 times daily) soln 05(base equiv))

Tier 2

NATACYN 5 SUSPENSION Tier 3

ofloxacin ophth soln 03 Tier 2

polymyxin b-trimethoprim ophth soln10000 unitml-01

Tier 2

SULFACETAMIDE SODIUM 10 OINTMENT

Tier 2

sulfacetamide sodium ophth soln10

Tier 2


100

OPHTHALMIC AGENTS



tobramycin ophth soln 03 Tier 2

OPHTHALMIC ANTI-INFLAMMATORIESALREX 02 SUSPENSION Tier 3

DEXAMETHASONE SODIUMPHOSPHATE 01 SOLUTION

Tier 2

diclofenac sodium ophth soln 01 Tier 2

fluorometholone ophth susp 01 Tier 2

flurbiprofen sodium (003 solutionophth soln 003)

Tier 2

ILEVRO 03 SUSPENSION Tier 3 QL (17 PER 30 OVER TIME)

ketorolac tromethamine (ophth)(soln 04 soln 05)

Tier 2

loteprednol etabonate ophth susp05

Tier 2

PREDNISOLONE ACETATE 1 SUSPENSION

Tier 2

PREDNISOLONE SODIUM PHOSPHATE1 SOLUTION

Tier 2

PROLENSA 007 SOLUTION Tier 3

OPHTHALMIC BETA-ADRENERGIC BLOCKING AGENTSbetaxolol hcl ophth soln 05 Tier 2

CARTEOLOL HCL 1 SOLUTION Tier 2

carteolol hcl ophth soln 1 Tier 2

levobunolol hcl (05 solutionophth soln 05)

Tier 2

METIPRANOLOL 03 SOLUTION Tier 2

TIMOLOL MALEATE (025 GEL FSOLN 05 GEL F SOLN)

Tier 2

timolol maleate (ophth) (gel formingsoln 025 gel forming soln 05soln 025 soln 05)

Tier 2


101

OPHTHALMIC AGENTS



OPHTHALMIC INTRAOCULAR PRESSURE LOWERING AGENTS OTHERacetazolamide cap er 12hr 500 mg Tier 2

ALPHAGAN P 01 SOLUTION Tier 3

apraclonidine hcl ophth soln 05(base equivalent)

Tier 2

AZOPT 1 SUSPENSION Tier 3

brimonidine tartrate (soln 015 soln02)

Tier 2

brinzolamide ophth susp 1 Tier 2

dorzolamide hcl ophth soln 2 Tier 2

methazolamide (tab 25 mg tab 50mg)

Tier 2

PHOSPHOLINE IODIDE 0125 RECON SOLN

Tier 3

pilocarpine hcl (soln 1 soln 2soln 4)

Tier 2

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSlatanoprost (0005 solution ophthsoln 0005)

Tier 2

LUMIGAN 001 SOLUTION Tier 3 QL (5 PER 30 DAYS)

travoprost ophth soln 0004(benzalkonium free) (bak free)


OTIC AGENTS



OTIC AGENTSCIPROFLOXACIN HCL 02 SOLUTION

Tier 2

ciprofloxacin-dexamethasone oticsusp 03-01

Tier 2

COLY-MYCIN S 33-3-10-05 MGMLSUSPENSION

Tier 3


102

OTIC AGENTS



CORTISPORIN-TC 33-3-10-05 MGMLSUSPENSION

Tier 3

DERMOTIC 001 OIL Tier 3

hydrocortisone w acetic acid oticsoln 1-2

Tier 2

neomycin-polymyxin-hc (otic) (soln1 susp 35 mgml-10000 unitml-1)

Tier 2

ofloxacin otic soln 03 Tier 2

RESPIRATORY TRACTPULMONARY AGENTS



ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDSbudesonide (inhalation) (susp 025mg2ml susp 05 mg2ml susp 1mg2ml)

Tier 2 BvD

FLOVENT DISKUS (100 MCGBLIST AERPOW BA 50 MCGBLIST AER POWBA)


FLOVENT DISKUS 250 MCGBLIST AERPOW BA


FLOVENT HFA 110 MCGACTAEROSOL






FLUNISOLIDE 25 MCGACT (0025)SOLUTION


fluticasone propionate nasal susp 50mcgact


PULMICORT FLEXHALER 180MCGACT AER POW BA


PULMICORT FLEXHALER 90 MCGACTAER POW BA



103




QVAR REDIHALER (40 MCGACTAERO BA 80 MCGACT AERO BA)


ANTIHISTAMINESazelastine hcl (01 (137 mcg)015 (2055 mcg))


cyproheptadine hcl tab 4 mg Tier 2 PA

hydroxyzine hcl (tab 10 mg tab 25mg tab 50 mg)

Tier 2 PA

levocetirizine dihydrochloride tab 5mg

Tier 2

promethazine hcl (inj 25 mgml inj50 mgml syrup 625 mg5ml)

Tier 2 PA

ANTILEUKOTRIENESmontelukast sodium (chew tab 4mg (base equiv) chew tab 5 mg(base equiv) oral granules packet 4mg (base equiv) tab 10 mg (baseequiv))


zafirlukast (tab 10 mg tab 20 mg) Tier 2 QL (2 PER 1 DAYS)

BRONCHODILATORS ANTICHOLINERGICATROVENT HFA 17 MCGACT AEROSOLN


INCRUSE ELLIPTA 625 MCGINH AERPOW BA


ipratropium bromide inhal soln 002 Tier 2 BvD

ipratropium bromide nasal soln003 (21 mcgspray)




SPIRIVA HANDIHALER 18 MCG CAP Tier 3 QL (30 PER 30 DAYS)

SPIRIVA RESPIMAT (125 MCGACTAERO SOLN 25 MCGACT AEROSOLN)



104




BRONCHODILATORS SYMPATHOMIMETICalbuterol 90mcg hfa inhaler(generic proair)


albuterol 90mg hfa inhaler (genericproair)


albuterol 90mg hfa inhaler (genericproventil)


albuterol 90mg hfa inhaler (genericventolin)


albuterol sulfate (soln nebu 0083(25 mg3ml) soln nebu 05 (5mgml) soln nebu 063 mg3ml(base equiv) soln nebu 125 mg3ml(base equiv))

Tier 2 BvD

albuterol sulfate (tab 2 mg tab 4mg)

Tier 2

epinephrine (anaphylaxis) (solutionauto-injector 015 mg03ml (12000)solution auto-injector 03 mg03ml(11000))


EPINEPHRINE 03 MG03ML SOLN A-INJ


EPINEPHRINE AUTOINJECTOR(GENERIC ADRENACLICK)


levalbuterol hcl (soln nebu 031mg3ml (base equiv) soln nebu 063mg3ml (base equiv) soln nebu 125mg3ml (base equiv) soln nebuconc 125 mg05ml (base equiv))

Tier 2 PA

LEVALBUTEROL TARTRATE 45MCGACT AEROSOL


SEREVENT DISKUS 50 MCGDOSE AERPOW BA


STRIVERDI RESPIMAT 25 MCGACTAERO SOLN


terbutaline sulfate (inj 1 mgml tab25 mg tab 5 mg)

Tier 2


105




CYSTIC FIBROSIS AGENTSCAYSTON 75 MG RECON SOLN Tier 3 PA LA QL (84 PER 28

OVER TIME)

KALYDECO (150 MG TAB 25 MGPACKET 50 MG PACKET 75 MGPACKET)


PULMOZYME 25 MG25MLSOLUTION

Tier 3 QL (150 PER 30 OVERTIME) BvD

SYMDEKO (100-150 amp 150 MG TABTHPK 50-75 amp 75 MG TAB THPK)


TOBI PODHALER 28 MG CAP Tier 3 PA LA QL (224 PER 28OVER TIME)

tobramycin nebu soln 300 mg4ml Tier 2 PA QL (224 PER 28 OVERTIME)


TRIKAFTA (100-50-75 amp 150 MG TABTHPK 50-25-375 amp 75 MG TAB THPK)


MAST CELL STABILIZERScromolyn sodium soln nebu 20mg2ml

Tier 2 BvD

PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASEDALIRESP 250 MCG TAB Tier 3 PA QL (28 PER 180 OVER

TIME)

DALIRESP 500 MCG TAB Tier 3 PA QL (1 PER 1 DAYS)

theophylline (soln 80 mg15ml taber 12hr 100 mg tab er 12hr 200 mgtab er 12hr 300 mg tab er 12hr 450mg tab er 24hr 400 mg tab er 24hr600 mg)

Tier 2

THEOPHYLLINE ER (ER 300 MG TAB ER12H ER 450 MG TAB ER 12H)

Tier 2

PULMONARY ANTIHYPERTENSIVESADEMPAS (05 MG TAB 1 MG TAB15 MG TAB 2 MG TAB 25 MG TAB)



106




ambrisentan (tab 10 mg tab 5 mg) Tier 2 PA LA QL (1 PER 1 DAYS)

bosentan tab 125 mg Tier 2 PA LA QL (2 PER 1 DAYS)


OPSUMIT 10 MG TAB Tier 3 PA LA QL (1 PER 1 DAYS)

sildenafil citrate for suspension 10mgml


sildenafil citrate tab 20 mg Tier 3 PA QL (3 PER 1 DAYS)

tadalafil tab 20 mg (pah) Tier 2 PA QL (2 PER 1 DAYS)

TRACLEER 32 MG TAB SOL Tier 3 PA LA QL (4 PER 1 DAYS)

VENTAVIS 10 MCGML SOLUTION Tier 3 LA QL (270 PER 30 OVERTIME) BvD


PULMONARY FIBROSIS AGENTSESBRIET (267 MG CAP 267 MG TAB) Tier 3 PA LA QL (9 PER 1 DAYS)

ESBRIET 801 MG TAB Tier 3 PA LA QL (3 PER 1 DAYS)

OFEV (100 MG CAP 150 MG CAP) Tier 3 PA LA QL (2 PER 1 DAYS)

RESPIRATORY TRACT AGENTS OTHERacetylcysteine (soln 10 soln 20) Tier 2 BvD

ANORO ELLIPTA 625-25 MCGINHAER POW BA


BEVESPI AEROSPHERE 9-48MCGACT AEROSOL


COMBIVENT RESPIMAT 20-100MCGACT AERO SOLN


FLUTICASONE-SALMETEROL (113-14MCGACT AER POW BA 232-14MCGACT AER POW BA 55-14MCGACT AER POW BA)


fluticasone-salmeterol (aer powderba 100-50 mcgdose aer powderba 250-50 mcgdose aer powderba 500-50 mcgdose)


ipratropium-albuterol nebu soln 05-25(3) mg3ml

Tier 2 BvD


107




NUCALA (100 MGML SOLN A-INJ100 MGML SOLN PRSYR)


NUCALA 100 MG RECON SOLN Tier 3 PA LA QL (3 PER 28 OVERTIME)

ribavirin for inhal soln 6 gm Tier 2 BvD

TRELEGY ELLIPTA 100-625-25MCGINH AER POW BA




SKELETAL MUSCLE RELAXANTS



SKELETAL MUSCLE RELAXANTScarisoprodol tab 350 mg Tier 2 PA QL (4 PER 1 DAYS)

cyclobenzaprine hcl (tab 10 mgtab 5 mg)

Tier 2 PA

methocarbamol (tab 500 mg tab750 mg)

Tier 2 PA

SLEEP DISORDER AGENTS



SLEEP PROMOTING AGENTSestazolam (tab 1 mg tab 2 mg) Tier 2 QL (1 PER 1 DAYS)

HETLIOZ 20 MG CAP Tier 3 PA LA QL (1 PER 1 DAYS)

ramelteon tab 8 mg Tier 2 QL (1 PER 1 DAYS)

temazepam cap 15 mg Tier 2 QL (2 PER 1 DAYS)


triazolam tab 0125 mg Tier 2 QL (4 PER 1 DAYS)


108





zaleplon cap 10 mg Tier 2 QL (2 PER 1 DAYS)


zolpidem tartrate tab 10 mg Tier 2 QL (1 PER 1 DAYS)


WAKEFULNESS PROMOTING AGENTSmodafinil tab 100 mg Tier 2 QL (3 PER 1 DAYS)

modafinil tab 200 mg Tier 2 QL (2 PER 1 DAYS)

XYREM 500 MGML SOLUTION Tier 3 PA LA QL (540 PER 30OVER TIME)


109

Non-Part D Drugs



ABREVA 10 CREAM Tier 4 NPD

ADULT MASK LARGE MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER MINI CHAMBERDEVICE

Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER MV MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER PLUS FLO-VU MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER PLUS FLO-VU LARGEMISC


AEROCHAMBER PLUS FLO-VUMEDIUM MISC


AEROCHAMBER PLUS FLO-VU SMALLMISC


AEROCHAMBER PLUS FLO-VUWMASK MISC


AEROCHAMBER PLUS FLOW VUMISC


AEROCHAMBER WFLOWSIGNALMISC


AEROCHAMBER Z-STAT PLUS MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

AEROCHAMBER Z-STAT PLUSCHAMBR MISC


AEROCHAMBER Z-STAT PLUSLARGEMISC


AEROCHAMBER Z-STAT PLUSMEDIUMMISC


AEROCHAMBER Z-STAT PLUSSMALLMISC


AEROVENT PLUS DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

ALLI 60 MG CAP Tier 4 PA NPD


110

Non-Part D Drugs



alum amp mag hydrox-simethicone(hydrox-simethicone (susp 200-200-20 mg5ml susp 400-400-40mg5ml) hydroxide-simethiconesusp 200-200-20 mg5ml)

Tier 4 NPD

ALUMINUM HYDROXIDE GEL 320MG5ML SUSPENSION

Tier 4 NPD

aluminum hydroxide-magnesiumcarbonate chew tab 160-105 mg

Tier 4 NPD

aluminum hydroxide-magnesiumtrisilicate chew tab 80-20 mg

Tier 4 NPD

ANTI-DIARRHEAL 1 MG5ML LIQUID Tier 4 NPD

ARIAL CHAMBER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

ascorbic acid ((tab 1000 mg tab250 mg) tab 1000 mg)

Tier 4 NPD

aspirin ((300 mg suppos 600 mgsuppos chew tab 81 mg tab 325mg tab delayed release 325 mgtab delayed release 81 mg) 300 mgsuppos 600 mg suppos chew tab81 mg tab 325 mg tab delayedrelease 325 mg)

Tier 4 NPD

aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg

Tier 4 NPD

B-12 5000 MCG TAB DISP Tier 4 NPD

B-12 DOTS 500 MCG TAB DISP Tier 4 NPD

bacitracin oint 500 unitgm Tier 4 NPD

bacitracin zinc oint 500 unitgm Tier 4 NPD

bacitracin-polymyxin b oint Tier 4 NPD

BAYER PLUS 500 MG TAB Tier 4 NPD

BENADRYL ALLERGY 25 MG CAP Tier 4 NPD

benzonatate ((cap 100 mg cap 200mg) cap 100 mg)

Tier 4 NPD

benzoyl peroxide ((cream 10 gel10 liq 10) cream 10 gel 10)

Tier 4 NPD


111

Non-Part D Drugs



bisacodyl ((suppos 10 mg tabdelayed release 5 mg) suppos 10mg)

Tier 4 NPD

bismuth subsalicylate ((chew tab262 mg susp 525 mg15ml tab 262mg) chew tab 262 mg susp 525mg15ml)

Tier 4 NPD

BREATHE EASE LARGE DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHE EASE MEDIUM DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHE EASE SMALL DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITE MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITE COLL SPACER ADULTMISC


BREATHERITE COLL SPACER CHILDMISC


BREATHERITE COLL SPACER INFANTMISC


BREATHERITE RIGID SPACERMASKMISC


BREATHERITE SPACER NEONATEMISC


BREATHERITE SPACER SMALL CHILDMISC


BREATHERITELARGE MASK MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITEMEDIUM MASK MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

BREATHERITESMALL MASK MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

CALAMINE LOTION Tier 4 NPD


CALAMINE-ZINC OXIDE 8-8 SUSPENSION

Tier 4 NPD


112

Non-Part D Drugs



CALCI-CHEW 1250 (500 CA) MGCHEW TAB

Tier 4 NPD

calcium ascorbate tab 500 mg Tier 4 NPD

calcium carbonate ((1250 (500 ca)mg chew tab tab 1250 mg (500 mgelemental ca) tab 1500 mg (600mg elemental ca) tab 600 mg)1250 (500 ca) mg chew tab tab1250 mg (500 mg elemental ca)tab 1500 mg (600 mg elementalca))

Tier 4 NPD

calcium carbonate (antacid) chewtab 750 mg

Tier 4 NPD

CALCIUM CARBONATE ANTACID 648MG TAB

Tier 4 NPD

calcium carbonate-cholecalciferol((tab 250 mg-125 unit tab 500 mg-125 unit tab 500 mg-200 unit tab500 mg-400 unit tab 500 mg-600unit) tab 250 mg-125 unit tab 500mg-125 unit tab 500 mg-200 unittab 500 mg-400 unit)

Tier 4 NPD

calcium carbonate-ergocalciferoltab 500mg-200 unit

Tier 4 NPD

calcium carbonate-vitamin d ((tab250 mg-125 unit tab 500 mg-125unit tab 500 mg-200 unit) tab 250mg-125 unit tab 500 mg-125 unit)

Tier 4 NPD

CALCIUM GLUCONATE ((50 MG TAB500 MG TAB) 50 MG TAB)

Tier 4 NPD

calcium tab 600 mg Tier 4 NPD

CALCIUMCD 500-10-250 MG-MG-UNIT CHEW TAB

Tier 4 NPD

carbamide peroxide 65 otic soln Tier 4 NPD

cetirizine hcl ((tab 10 mg tab 5 mg)tab 10 mg)

Tier 4 NPD

CHEWABLE CALCIUMD3 500-15 MG-MCG WAFER

Tier 4 NPD

chlorpheniramine maleate syrup 2mg5ml

Tier 4 NPD


113

Non-Part D Drugs



CLEVER CHOICE HOLDINGCHAMBER DEVICE


clotrimazole vaginal ((cream 1cream 2) cream 1)

Tier 4 NPD

COMPACT SPACE CHAMBERDEVICE


COMPACT SPACE CHAMBERLGMASK DEVICE


COMPACT SPACE CHAMBERMEDMASK DEVICE


COMPACT SPACE CHAMBERSMMASK DEVICE


CONDOMS LATEX LUBRICATED Tier 4 NPD

cromolyn sodium nasal aerosol soln52 mgact (4)

Tier 4 NPD

CVS LICE SOLUTION 3-STEP KIT Tier 4 NPD

diphenhydramine hcl ((cap 25 mgelixir 125 mg5ml liquid 125mg5ml tab 25 mg) cap 25 mgelixir 125 mg5ml liquid 125mg5ml)

Tier 4 NPD

docusate sodium ((cap 100 mgcap 250 mg liquid 150 mg15ml)cap 100 mg cap 250 mg)

Tier 4 NPD

EASIVENT MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EASIVENT MASK LARGE MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EASIVENT MASK MEDIUM MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EASIVENT MASK SMALL MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

EQ CALAMINE 8-8 SUSPENSION Tier 4 NPD

EQ SPACE CHAMBER ANTI-STATICDEVICE


EQ SPACE CHAMBER ANTI-STATIC LDEVICE



114

Non-Part D Drugs



EQ SPACE CHAMBER ANTI-STATIC MDEVICE


EQ SPACE CHAMBER ANTI-STATIC SDEVICE


ergocalciferol ((cap 125 mg (50000unit) soln 200 mcgml (8000unitml)) cap 125 mg (50000 unit))

Tier 4 NPD

famotidine tab 10 mg Tier 4 NPD

ferrous sulfate ((220 (44 fe) liquidelixir 220 (44 fe) soln 75 mgml (15mgml fe) syrup 300 (60 fe) tab ec325 mg (65 mg fe equivalent)) 220(44 fe) liquid elixir 220 (44 fe) soln 75mgml (15 mgml fe) syrup 300 (60fe))

Tier 4 NPD

ferrous sulfate ((tab 27 mg(elemental fe) tab 325 mg (65 mgelemental fe)) tab 27 mg(elemental fe))

Tier 4 NPD

ferrous sulfate dried tab 200 mg (65mg elemental fe)

Tier 4 NPD

fexofenadine hcl ((tab 180 mg tab60 mg) tab 180 mg)

Tier 4 NPD

FLEXICHAMBER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

folic acid ((cap 08 mg tab 1 mgtab 400 mcg tab 800 mcg) cap 08mg tab 1 mg tab 400 mcg)

Tier 4 NPD

GLUCOSE CHEW TAB 4 GM Tier 4 NPD

GLUCOSE-VITAMIN C CHEW TAB 4-6GM-MG

Tier 4 NPD

glycerin (laxative) ((laxative)(suppos 1 gm suppos 12 gmsuppos 2 gm suppos 21 gm suppos807) suppos 1 gm suppos 12 gmsuppos 2 gm suppos 21 gm)

Tier 4 NPD

GOODSENSE CALAMINE 8-8 SUSPENSION

Tier 4 NPD

guaifenesin-codeine soln 100-10mg5ml

Tier 4 QL (420 PER 30 OVERTIME) NDS NPD


115

Non-Part D Drugs



HYCODAN 5-15 MG5ML SYRUP Tier 4 QL (210 PER 30 OVERTIME) NDS NPD

hydrocodone w homatropine syrup5-15 mg5ml


hydrocortisone (topical) ((topical)(cream 05 cream 1 oint 05)cream 05 cream 1)

Tier 4 NPD

HYDROCORTISONE-ALOE 05 CREAM

Tier 4 NPD

hydrocortisone-aloe vera ((cream05 cream 1) cream 05)

Tier 4 NPD

ibuprofen ((cap 200 mg chew tab100 mg susp 40 mgml tab 100 mgtab 200 mg) cap 200 mg chew tab100 mg susp 40 mgml tab 100 mg)

Tier 4 NPD

INSPIRACHAMBERLARGE DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

INSPIRACHAMBERMEDIUM DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

INSPIRACHAMBERMOUTHPIECEDEVICE


INSPIRACHAMBERSMALL DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

INSPIREASE MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

ketotifen fumarate ophth soln0025 (base equiv)

Tier 4 NPD

levonorgestrel tab 15 mg Tier 4 NPD

LITEAIRE DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

loperamide hcl ((liq 1 mg5ml (02mgml) liq 1 mg75ml tab 2 mg)liq 1 mg5ml (02 mgml) liq 1mg75ml)

Tier 4 NPD

loratadine ((rapidly-disintegratingtab 10 mg tab 10 mg) rapidly-disintegrating tab 10 mg)

Tier 4 NPD

MAG-G 500 (27 MG) MG TAB Tier 4 NPD


116

Non-Part D Drugs



magnesium citrate soln Tier 4 NPD

magnesium gluconate tab 500 mg(27 mg elemental mg)

Tier 4 NPD

meclizine hcl chew tab 25 mg Tier 4 NPD

miconazole nitrate vaginal ((cream2 suppos 100 mg) cream 2)

Tier 4 NPD

MICROCHAMBER ((DEVICE MISC)DEVICE)


MICROSPACER MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

MIRALAX 17 GMSCOOP POWDER Tier 4 NPD

MURO 128 2 SOLUTION Tier 4 NPD

naphazoline w pheniramine ophthsoln 0027-0315

Tier 4 NPD

NASACORT ALLERGY 24HR 55MCGACT AEROSOL

Tier 4 NPD

NASACORT ALLERGY 24HRCHILDREN 55 MCGACT AEROSOL

Tier 4 NPD

NASAL DECONGESTANT ((30MG5ML LIQUID 30 MG5ML SYRUP)30 MG5ML LIQUID)

Tier 4 NPD

NASALCROM 52 MGACT AEROSOLN

Tier 4 NPD

neomycin-bacitracin-polymyxin oint Tier 4 NPD

neomycin-polymyxin w pramoxinecream 1

Tier 4 NPD

niacin ((cap er 250 mg cap er 500mg tab 100 mg tab 250 mg tab 50mg tab 500 mg tab er 250 mg taber 500 mg tab er 750 mg) cap er250 mg cap er 500 mg tab 100 mgtab 250 mg tab 50 mg tab 500 mgtab er 250 mg tab er 500 mg)

Tier 4 NPD

NIACIN ER 1000 MG TAB ER Tier 4 NPD

niacinamide tab 500 mg Tier 4 NPD


117

Non-Part D Drugs



nicotine ((patch 24hr 14 mg24hrpatch 24hr 21 mg24hr patch 24hr 7mg24hr) td patch 24hr 14 mg24hrtd patch 24hr 21 mg24hr)

Tier 4 NPD

nicotine polacrilex ((gum 2 mg gum4 mg lozenge 2 mg lozenge 4 mg)gum 2 mg gum 4 mg lozenge 2mg)

Tier 4 NPD

NIX COMPLETE LICE TREATMENT 1 amp025 KIT

Tier 4 NPD

omega-3 fatty acids cap 1000 mg Tier 4 NPD

omeprazole delayed release tab 20mg

Tier 4 NPD

OPTICHAMBER ADVANTAGE-LGMASK MISC


OPTICHAMBER ADVANTAGE-MEDMASK MISC


OPTICHAMBER ADVANTAGE-SMMASK MISC


OPTICHAMBER DIAMOND MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

OPTICHAMBER DIAMOND-LG MASKDEVICE


OPTICHAMBER DIAMOND-MD MASKMISC


OPTICHAMBER DIAMOND-SM MASKMISC


OPTICHAMBER FACE MASK-LARGEMISC


OPTICHAMBER FACE MASK-MEDIUMMISC


OPTICHAMBER FACE MASK-SMALLMISC


OPTIHALER ((DEVICE MISC) DEVICE) Tier 4 QL (2 PER 365 OVER TIME)NPD

OPTIONS GYNOL II CONTRACEPTIVE3 GEL

Tier 4 NPD


118

Non-Part D Drugs



oral electrolyte solution Tier 4 NPD

OYSTER SHELL CALCIUM 500 + D 500-125 MG-UNIT TAB

Tier 4 NPD

oyster shell calcium tab 500 mg Tier 4 NPD

OYSTER SHELL CALCIUMD 500-200MG-UNIT TAB

Tier 4 NPD

PARI VORTEX ADULT MASK MISC Tier 4 QL (2 PER 365 OVER TIME)NPD

permethrin ((creme rinse 1 lotion1) creme rinse 1)

Tier 4 NPD

phentermine hcl ((cap 15 mg cap30 mg) cap 15 mg)

Tier 4 PA NPD

phytonadione tab 100 mcg Tier 4 NPD

phytonadione tab 5 mg Tier 4 QL (5 PER 7 OVER TIME)NPD

POCKET CHAMBER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

POCKET SPACER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

polyethylene glycol 3350 (3350 (3350oral packet 17 gm 3350 oralpowder 17 gmscoop) 3350 oralpacket 17 gm)

Tier 4 NPD

polyvinyl alcohol ophth soln 14 Tier 4 NPD

PRE-NATAL FORMULA TAB Tier 4 NPD

PRENATAL (WIRON amp FA) 27-08 MGTAB

Tier 4 NPD

PRENATAL FORTE TAB Tier 4 NPD

PRENATAL VITAMIN WITH IRON TAB27-08 MG

Tier 4 NPD


Tier 4 NPD

PRENATALIRON TAB Tier 4 NPD

PRIMEAIRE HOLDING CHAMBERDEVICE



119

Non-Part D Drugs



PRO COMFORT SPACER ADULTMISC


PRO COMFORT SPACER CHILDMISC


PRO COMFORT SPACER INFANTDEVICE


PROCARE SPACERADULT MASKDEVICE


PROCARE SPACERCHILD MASKDEVICE


promethazine w codeine syrup625-10 mg5ml

Tier 4 PA QL (240 PER 30 OVERTIME) NDS NPD

promethazine-dm ((solution syrup )solution)

Tier 4 PA NPD

promethazine-phenylephrine-codeine syrup 625-5-10 mg5ml


pseudoephedrine hcl tab 60 mg Tier 4 NPD

pyrantel pamoate susp 144 mgml(50 mgml base equiv)

Tier 4 NPD

pyreth-piperonyl butox sham-permeth aero-nit remover gel kit

Tier 4 NPD

pyrethrins-piperonyl butoxide ((liq033-4 shampoo 033-4) liq 033-4)

Tier 4 NPD

pyridoxine hcl ((tab 100 mg tab 50mg) tab 100 mg)

Tier 4 NPD

QSYMIA ((1125-69 MG CAP ER 24H15-92 MG CAP ER 24H 375-23 MGCAP ER 24H 75-46 MG CAP ER 24H)1125-69 MG CAP ER 24H 15-92 MGCAP ER 24H 375-23 MG CAP ER24H)

Tier 4 PA NPD

RA CALAMINE 8-8 SUSPENSION Tier 4 NPD

RA DAYLOGIC ACNE FOAMINGWASH 10 FOAM

Tier 4 NPD

RA OYSTER SHELL CALCIUMD2 500-200 MG-UNIT TAB

Tier 4 NPD


120

Non-Part D Drugs



riboflavin ((tab 100 mg tab 50 mg)tab 100 mg)

Tier 4 NPD

RID 033-4 LIQUID Tier 4 NPD

RID COMPLETE LICE ELIMINATIONKIT

Tier 4 NPD

RID ESSENTIAL LICE ELIMINATION033-4 KIT

Tier 4 NPD

RITEFLO DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD

saline nasal spray 065 Tier 4 NPD

SAXENDA 18 MG3ML SOLN PEN Tier 4 PA NPD

selenium sulfide lotion 1 Tier 4 NPD

sennosides tab 86 mg Tier 4 NPD

simethicone ((cap 125 mg chewtab 80 mg susp 40 mg06ml) cap125 mg chew tab 80 mg)

Tier 4 NPD

SM FOAMING ANTACID 80-20 MGCHEW TAB

Tier 4 NPD

sodium bicarbonate tab 325 mg Tier 4 NPD

sodium chloride hypertonic ophthsoln 5

Tier 4 NPD

thiamine hcl tab 100 mg Tier 4 NPD

thiamine mononitrate tab 100 mg Tier 4 NPD

tioconazole vaginal oint 65 Tier 4 NPD

tolnaftate cream 1 Tier 4 NPD

triamcinolone acetonide nasalaerosol suspension 55 mcgact

Tier 4 NPD

triprolidine amp pseudoephedrine tab25-60 mg

Tier 4 NPD

TUMS 500 MG CHEW TAB Tier 4 NPD

TUMS LASTING EFFECTS 500 MGCHEW TAB

Tier 4 NPD

VALVED HOLDING CHAMBERDEVICE



121

Non-Part D Drugs



VCF VAGINAL CONTRACEPTIVE((125 FOAM 4 GEL) 125 FOAM)

Tier 4 NPD

vitamin a cap 3 mg (10000 unit) Tier 4 NPD

VITAMIN D2 10 MCG (400 UNIT) TAB Tier 4 NPD

vitamin e ((cap 180 mg (400 unit)cap 268 mg (400 unit) cap 400unit) cap 180 mg (400 unit) cap268 mg (400 unit))

Tier 4 NPD

VITAMIN K 100 MCG TAB Tier 4 NPD

VORTEX HOLD CHMBRMASKCHILDDEVICE


VORTEX VALVED HOLDINGCHAMBER DEVICE


WATCHHALER DEVICE Tier 4 QL (2 PER 365 OVER TIME)NPD


122

Index of Covered Drugs

Aabacavir sulfate 43abacavir sulfate-lamivudine 43abacavir sulfate-lamivudine-zidovudine 43ABELCET 21ABILIFY MAINTENA 38abiraterone acetate 26ABREVA 110acamprosate calcium 4acarbose 48acebutolol hcl 58acetaminophen w codeine 2acetazolamide 60102acetic acid (otic) 6acetylcysteine 107acitretin 69ACTHAR 80ACTHIB 92ACTIMMUNE 89acyclovir 46acyclovir sodium 46acyclovir topical 71ADACEL 92adapalene 69adefovir dipivoxil 41ADEMPAS 106ADULT MASK LARGE 110AEROCHAMBER MINI CHAMBER 110AEROCHAMBER MV 110AEROCHAMBER PLUS FLO-VU 110AEROCHAMBER PLUS FLO-VU LARGE 110AEROCHAMBER PLUS FLO-VU MEDIUM 110AEROCHAMBER PLUS FLO-VU SMALL 110AEROCHAMBER PLUS FLO-VU WMASK 110AEROCHAMBER PLUS FLOW VU 110AEROCHAMBER WFLOWSIGNAL 110AEROCHAMBER Z-STAT PLUS 110AEROCHAMBER Z-STAT PLUS CHAMBR 110AEROCHAMBER Z-STAT PLUSLARGE 110AEROCHAMBER Z-STAT PLUSMEDIUM 110

AEROCHAMBER Z-STAT PLUSSMALL 110AEROVENT PLUS 110AFINITOR 29AFINITOR DISPERZ 29AIMOVIG 23AIMOVIG (140 MG DOSE) 23albendazole 34albuterol 90mcg hfa inhaler (genericproair) 105albuterol 90mg hfa inhaler (generic proair)105albuterol 90mg hfa inhaler (genericproventil) 105Albuterol 90mg HFA inhaler (GenericVentolin) 105albuterol sulfate 105alclometasone dipropionate 6980ALCOH-WIPE 95ALCOHOL 70 PADS 95ALCOHOL PREP 95ALCOHOL WIPES 95ALDURAZYME 77ALECENSA 29alendronate sodium 94alfuzosin hcl 80ALINIA 35aliskiren fumarate 60ALLI 110allopurinol 23alosetron hcl 76ALPHAGAN P 102alprazolam 47ALREX 101alum amp mag hydrox-simethicone 111ALUMINUM HYDROXIDE GEL 111aluminum hydroxide-mag carb 111aluminum hydroxide-mag trisil 111ALUNBRIG 29amantadine hcl 36AMBISOME 21ambrisentan 107amikacin sulfate 6

123

amiloride amp hydrochlorothiazide 60amiloride hcl 62AMINO ACID 72amino acid electrolyte infusion 72amino acid infusion 72AMINOSYN 72AMINOSYN II 72AMINOSYN-HBC 72AMINOSYN-PF 72AMINOSYN-RF 72AMINOSYNELECTROLYTES 72amiodarone hcl 57AMITIZA 76amitriptyline hcl 19amlodipine besylate 58amlodipine besylate-benazepril hcl 60amlodipine besylate-olmesartanmedoxomil 60amlodipine besylate-valsartan 60amlodipine-valsartan-hydrochlorothiazide 60AMOXAPINE 19AMOXICILLIN 10amoxicillin amp pot clavulanate 9AMOXICILLIN-POT CLAVULANATE 10amphetamine-dextroamphetamine 6566AMPHOTERICIN B 21AMPICILLIN 10ampicillin amp sulbactam sodium 10ampicillin sodium 10AMPICILLIN-SULBACTAM SODIUM 10ANADROL-50 82anagrelide hcl 53anastrozole 29ANDRODERM 82ANORO ELLIPTA 107ANTI-DIARRHEAL 111APOKYN 36apraclonidine hcl 102aprepitant 21APTIOM 15APTIVUS 45

ARALAST NP 77ARANESP (ALBUMIN FREE) 54ARCALYST 89ARIAL CHAMBER 111aripiprazole 38ARISTADA 38ARISTADA INITIO 38ascorbic acid 111asenapine maleate 38aspirin 111aspirin buffered (cal carb-mag carb-magoxide) 111aspirin-dipyridamole 55atazanavir sulfate 45atenolol 58atenolol amp chlorthalidone 60atomoxetine hcl 66atorvastatin calcium 63atovaquone 35atovaquone-proguanil hcl 35ATROPINE SULFATE 99ATROVENT HFA 104AUBAGIO 67AURYXIA 74AVONEX 67AVONEX PEN 67AVONEX PREFILLED 67AYVAKIT 27azathioprine 90AZATHIOPRINE SODIUM 90azelastine hcl 104azelastine hcl (ophth) 100azithromycin 11AZOPT 102aztreonam 6

BB-12 111B-12 DOTS 111BACITRACIN 100bacitracin (topical) 111

124

bacitracin zinc 111bacitracin-poly-neomycin-hc 99bacitracin-polymyxin b (ophth) 99bacitracin-polymyxin b oint 111baclofen 4041balsalazide disodium 94BALVERSA 29BAQSIMI ONE PACK 50BAQSIMI TWO PACK 50BARACLUDE 41BAYER PLUS 111BCG VACCINE 92BD ECLIPSE SYRINGE 95BD INSULIN SYRINGE 96BD Pen Needle Mini UF 31G X 5 MM MISC 96BD Pen Needle Nano UF 32G X 4 MMMISC 96BD Pen Needle Original UF 29G X 127MMMISC 96BD Pen Needle Short UF 31G X 8 MM MISC 96BENADRYL ALLERGY 111benazepril amp hydrochlorothiazide 60benazepril hcl 56BENAZEPRIL-HYDROCHLOROTHIAZIDE 60BENLYSTA 89BENZNIDAZOLE 35benzonatate 111benzoyl peroxide 111benztropine mesylate 36BERINERT 88BESIVANCE 11betamethasone dipropionate (topical) 6980BETAMETHASONE DIPROPIONATE AUG 69betamethasone dipropionateaugmented 6980betamethasone valerate 69BETASERON 68betaxolol hcl 58betaxolol hcl (ophth) 101bethanechol chloride 80BEVESPI AEROSPHERE 107

bexarotene 34BEXSERO 92bicalutamide 26BICILLIN L-A 10BIKTARVY 42BIOGUARD GAUZE SPONGES 96bisacodyl 112bismuth subsalicylate 112bisoprolol amp hydrochlorothiazide 60bisoprolol fumarate 58BIVIGAM 88BOOSTRIX 92bosentan 107BOSULIF 29BRAFTOVI 30BREATHE EASE LARGE 112BREATHE EASE MEDIUM 112BREATHE EASE SMALL 112BREATHERITE 112BREATHERITE COLL SPACER ADULT 112BREATHERITE COLL SPACER CHILD 112BREATHERITE COLL SPACER INFANT 112BREATHERITE RIGID SPACERMASK 112BREATHERITE SPACER NEONATE 112BREATHERITE SPACER SMALL CHILD 112BREATHERITELARGE MASK 112BREATHERITEMEDIUM MASK 112BREATHERITESMALL MASK 112BRILINTA 55brimonidine tartrate 102brinzolamide 102BRIVIACT 13bromocriptine mesylate 36BRUKINSA 27budesonide 94budesonide (inhalation) 103bumetanide 62buprenorphine hcl 5buprenorphine hcl-naloxone hcl dihydrate 5bupropion hcl 17bupropion hcl (smoking deterrent) 5

125

buspirone hcl 47butalbital-acetaminophen-caffeine 67butalbital-acetaminophen-caffeine wcodeine 2BYLVAY 78BYLVAY (PELLETS) 78

CCABENUVA 44cabergoline 86CABLIVI 55CABOMETYX 30CALAMINE LOTION 112CALAMINE-ZINC OXIDE 112CALCI-CHEW 113calcipotriene 71calcitonin (salmon) 94calcitriol 94calcium 113calcium acetate (phosphate binder) 74calcium ascorbate 113calcium carbonate 113calcium carbonate (antacid) 113CALCIUM CARBONATE ANTACID 113calcium carbonate-cholecalciferol 113calcium carbonate-ergocalciferol 113calcium carbonate-vitamin d 113CALCIUM GLUCONATE 113CALCIUMCD 113CALQUENCE 30candesartan cilexetil 56candesartan cilexetil-hydrochlorothiazide 60CAPASTAT SULFATE 25CAPLYTA 38CAPRELSA 30captopril 56CAPTOPRIL-HYDROCHLOROTHIAZIDE 61CARBAGLU 72carbamazepine 15carbamide peroxide (otic) 113carbidopa 36

carbidopa-levodopa 36CARBIDOPA-LEVODOPA-ENTACAPONE 36CAREONE UNIFINE PENTIPS PLUS 96carisoprodol 108CARTEOLOL HCL 101carteolol hcl (ophth) 101carvedilol 58caspofungin acetate 21CAYSTON 106cefaclor 8cefadroxil 8cefazolin sodium 8cefdinir 8cefepime hcl 8cefixime 8cefotaxime sodium 9cefotetan disodium 9cefoxitin sodium 9cefpodoxime proxetil 9cefprozil 9ceftazidime 9ceftriaxone sodium 9cefuroxime axetil 9cefuroxime sodium 9celecoxib 1CELONTIN 14cephalexin 9CERDELGA 78CEREZYME 78cetirizine hcl 113CHANTIX STARTING MONTH PAK 5CHEWABLE CALCIUMD3 113chlordiazepoxide hcl 47chlorhexidine gluconate (mouth-throat) 68chloroquine phosphate 35chlorothiazide 63chlorpheniramine maleate 113chlorpromazine hcl 37chlorthalidone 63CHOLBAM 78cholestyramine 64

126

cholestyramine light 64ciclopirox 71ciclopirox olamine 21cilostazol 55CILOXAN 11CIMDUO 43cimetidine 77cimetidine hcl 77cinacalcet hcl 94CINRYZE 88ciprofloxacin 12ciprofloxacin hcl 12CIPROFLOXACIN HCL 102ciprofloxacin hcl (ophth) 12ciprofloxacin in d5w 12ciprofloxacin-dexamethasone 102citalopram hydrobromide 18clarithromycin 11CLEVER CHOICE HOLDING CHAMBER 114clindamycin hcl 6clindamycin palmitate hydrochloride 6clindamycin phosphate 7clindamycin phosphate (topical) 771clindamycin phosphate in d5w 7CLINDAMYCIN PHOSPHATE IN NACL 7clindamycin phosphate vaginal 7clobazam 14clobetasol propionate 69clobetasol propionate emollient base 7080clomipramine hcl 19clonazepam 47clonidine 55clonidine hcl 55clonidine hcl (adhd) 66clopidogrel bisulfate 55clorazepate dipotassium 47clotrimazole 22clotrimazole (topical) 21clotrimazole vaginal 114clotrimazole w betamethasone 71clozapine 40

COARTEM 35codeine sulfate 2CODEINE SULFATE 2colchicine 23colchicine w probenecid 23COLCRYS 23colesevelam hcl 64colestipol hcl 64colistimethate sodium 7COLY-MYCIN S 102COMBIGAN 99COMBIPATCH 83COMBIVENT RESPIMAT 107COMETRIQ (100 MG DAILY DOSE) 30COMETRIQ (140 MG DAILY DOSE) 30COMETRIQ (60 MG DAILY DOSE) 30COMFORT TOUCH ALCOHOL PREP 96COMFORT TOUCH INSULIN PEN NEED 96COMPACT SPACE CHAMBER 114COMPACT SPACE CHAMBERLG MASK 114COMPACT SPACE CHAMBERMED MASK 114COMPACT SPACE CHAMBERSM MASK 114COMPLERA 42CONDOMS LATEX LUBRICATED 114COPIKTRA 30CORLANOR 61CORTISONE ACETATE 80CORTISPORIN-TC 103COTELLIC 30CREON 78CRESEMBA 22CRIXIVAN 45cromolyn sodium 106cromolyn sodium (mastocytosis) 78cromolyn sodium (nasal) 114cromolyn sodium (ophth) 100CRYSVITA 72CURITY GAUZE SPONGE 96CVS ISOPROPYL ALCOHOL WIPES 96CVS LICE SOLUTION 3-STEP 114cyclobenzaprine hcl 108

127

cyclophosphamide 25cyclosporine 90cyclosporine modified (for microemulsion) 90cyproheptadine hcl 104CYSTADANE 78CYSTAGON 78CYSTARAN 78

Ddalfampridine 68DALIRESP 106danazol 82dantrolene sodium 41dapsone 24DAPTACEL 92daptomycin 7DAURISMO 30deferasirox 74deferiprone 74DELSTRIGO 42DEPO-ESTRADIOL 83DEPO-PROVERA 85DERMOTIC 103DESCOVY 43desipramine hcl 19desmopressin acetate 82desmopressin acetate spray 82desmopressin acetate spray refrigerated 82desogestrel amp ethinyl estradiol 83desogestrel-ethinyl estradiol (biphasic) 83desogestrel-ethinyl estradiol (triphasic) 83desonide 70desoximetasone 70DESVENLAFAXINE ER 18desvenlafaxine succinate 18dexamethasone 80dexamethasone sodium phosphate 81DEXAMETHASONE SODIUM PHOSPHATE 101dexmethylphenidate hcl 66dextroamphetamine sulfate 66dextrose 75

dextrose in lactated ringers 75dextrose w sodium chloride 75DEXTROSE-NACL 75DEXTROSE-SODIUM CHLORIDE 75DIACOMIT 13DIAZEPAM 14diazepam 48diazoxide 50diclofenac potassium 1diclofenac sodium 1diclofenac sodium (actinic keratoses) 71diclofenac sodium (ophth) 101diclofenac sodium (topical) 1dicloxacillin sodium 10dicyclomine hcl 76didanosine 43diflunisal 1digoxin 61dihydroergotamine mesylate 23DILANTIN 15DILANTIN INFATABS 15diltiazem hcl 59diltiazem hcl coated beads 59diltiazem hcl extended release beads 59dimethyl fumarate 68diphenhydramine hcl 114diphenoxylate w atropine 76DIPHENOXYLATE-ATROPINE 76DIPHTHERIA-TETANUS TOXOIDS DT 92dipyridamole 55disopyramide phosphate 57disulfiram 4divalproex sodium 13docusate sodium 114dofetilide 57donepezil hydrochloride 16dorzolamide hcl 102DORZOLAMIDE HCL-TIMOLOL MAL 99dorzolamide hcl-timolol maleate 99DOVATO 42doxazosin mesylate 56

128

doxepin hcl 19doxercalciferol 94doxycycline (monohydrate) 12doxycycline hyclate 12DRIZALMA SPRINKLE 67dronabinol 21drospirenone-ethinyl estradiol 83DROXIA 27droxidopa 55duloxetine hcl 67DUOBRII 71dutasteride 80

EEES 400 11EASIVENT 114EASIVENT MASK LARGE 114EASIVENT MASK MEDIUM 114EASIVENT MASK SMALL 114EASY TOUCH INSULIN SYRINGE 96EASY TOUCH PEN NEEDLES 96econazole nitrate 22EDURANT 42efavirenz 42efavirenz-emtricitabine-tenofovir disoproxilfumarate 43efavirenz-lamivudine-tenofovir disoproxilfumarate 43EGRIFTA 82EGRIFTA SV 82ELIQUIS 5253ELIQUIS DVTPE STARTER PACK 53EMCYT 26EMSAM 17emtricitabine 44emtricitabine-tenofovir disoproxil fumarate 44EMTRIVA 44enalapril maleate 56enalapril maleate amp hydrochlorothiazide 61ENBREL 90ENBREL SURECLICK 90

ENGERIX-B 92enoxaparin sodium 53entacapone 36entecavir 41ENTRESTO 61ENVARSUS XR 90EPCLUSA 41EPIDIOLEX 13EPINEPHRINE 105epinephrine (anaphylaxis) 105EPINEPHRINE AUTOINJECTOR (GENERICADRENACLICK) 105EPIVIR HBV 41eplerenone 62EPROSARTAN MESYLATE 56EQ CALAMINE 114EQ SPACE CHAMBER ANTI-STATIC 114EQ SPACE CHAMBER ANTI-STATIC L 114EQ SPACE CHAMBER ANTI-STATIC M 115EQ SPACE CHAMBER ANTI-STATIC S 115ergocalciferol 115ERGOLOID MESYLATES 16ERIVEDGE 30ERLEADA 26erlotinib hcl 30ertapenem sodium 11ERY 71ERYTHROCIN LACTOBIONATE 11erythromycin (acne aid) 72erythromycin (ophth) 100erythromycin base 11ERYTHROMYCIN ETHYLSUCCINATE 11ESBRIET 107escitalopram oxalate 18ESSENTRA WIPES 9X9 96estazolam 108estradiol 83estradiol amp norethindrone acetate 83estradiol vaginal 84ESTRING 84ethambutol hcl 25

129

ethosuximide 14ethynodiol diacet amp eth estrad 84ETIDRONATE DISODIUM 95etodolac 1etonogestrel-ethinyl estradiol 84etravirine 43everolimus 30everolimus (immunosuppressant) 90EVOTAZ 45exemestane 29EXKIVITY 27EXTAVIA 68ezetimibe 64ezetimibe-simvastatin 64

FFABRAZYME 78famciclovir 46famotidine 77115FANAPT 38FANAPT TITRATION PACK 38FARYDAK 30felbamate 13felodipine 59fenofibrate 63fenofibrate micronized 63fentanyl 1fentanyl citrate 3FERRIPROX 74FERRIPROX TWICE-A-DAY 74ferrous sulfate 115ferrous sulfate dried 115FETZIMA 18FETZIMA TITRATION 18fexofenadine hcl 115finasteride 80FINTEPLA 13FIRDAPSE 67FIRMAGON 86FIRMAGON (240 MG DOSE) 86FLEBOGAMMA DIF 88

flecainide acetate 57FLEXICHAMBER 115FLOVENT DISKUS 103FLOVENT HFA 103fluconazole 22fluconazole in dextrose 22fluconazole in nacl 22flucytosine 22fludrocortisone acetate 81FLUNISOLIDE 103fluocinolone acetonide 70fluocinonide 70fluocinonide emulsified base 70fluorometholone (ophth) 101FLUOROURACIL 71fluorouracil (topical) 71fluoxetine hcl 18FLUOXETINE HCL 18FLUOXETINE HCL (PMDD) 18fluphenazine decanoate 37fluphenazine hcl 37flurbiprofen 1flurbiprofen sodium 101flutamide 26fluticasone propionate 70fluticasone propionate (nasal) 103FLUTICASONE-SALMETEROL 107fluticasone-salmeterol 107fluvastatin sodium 63fluvoxamine maleate 18folic acid 115fondaparinux sodium 53fosamprenavir calcium 45fosfomycin tromethamine 7fosinopril sodium 56fosinopril sodium amp hydrochlorothiazide 61FOTIVDA 27FREAMINE III 72fulvestrant 26furosemide 62FUZEON 45

130

FYCOMPA 13

Ggabapentin 1415GAMMAGARD 88GAMMAGARD SD LESS IGA 88GAMMAKED 88GAMMAPLEX 88GAMUNEX-C 88GARDASIL 9 92GATTEX 76gauze pads 2x2 96GAVILYTE-C 76GAVRETO 29gemfibrozil 63GENTAK 100gentamicin sulfate 6gentamicin sulfate (ophth) 100gentamicin sulfate (topical) 6GENVOYA 42GILENYA 68GILOTRIF 30glatiramer acetate 68GLEOSTINE 25glimepiride 48glipizide 48glipizide-metformin hcl 48GLUCAGEN HYPOKIT 51glucagon (rdna) 51GLUCAGON EMERGENCY 51GLUCOSE CHEW TAB 4 GM 115GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 115glyburide 49glyburide micronized 49glyburide-metformin 49glycerin (laxative) 115glycopyrrolate 76GLYXAMBI 49GNP ISOPROPYL ALCOHOL WIPES 96GNP STERILE GAUZE 97

GOODSENSE CALAMINE 115granisetron hcl 21griseofulvin microsize 22griseofulvin ultramicrosize 22guaifenesin-codeine 115guanfacine hcl 55guanfacine hcl (adhd) 66GUANIDINE HCL 24

HH-E-B INCONTROL PEN NEEDLES 97H-E-B INCONTROL UNIFINE PENTIP 97HAEGARDA 88halobetasol propionate 70haloperidol 37haloperidol decanoate 37haloperidol lactate 37HARVONI 41HAVRIX 92HEMADY 81heparin sodium (porcine) 53HEPATAMINE 73HETLIOZ 108HIBERIX 92HIZENTRA 89HM ULTICARE MINI PEN NEEDLES 97HUMALOG 51HUMALOG KWIKPEN 51HUMALOG MIX 5050 51HUMALOG MIX 5050 KWIKPEN 51HUMALOG MIX 7525 51HUMALOG MIX 7525 KWIKPEN 51HUMIRA 90HUMIRA PEDIATRIC CROHNS START 90HUMIRA PEN 90HUMIRA PEN-CDUCHS STARTER 91HUMIRA PEN-PEDIATRIC UC START 91HUMIRA PEN-PSUVADOL HS START 91HUMIRA PEN-PSORUVEIT STARTER 91HUMULIN 7030 51HUMULIN 7030 KWIKPEN 51

131

HUMULIN N 51HUMULIN N KWIKPEN 51HUMULIN R 51HUMULIN R U-500 (CONCENTRATED) 51HYCODAN 116hydralazine hcl 65hydrochlorothiazide 63hydrocodone w homatropine 116hydrocodone-acetaminophen 3hydrocortisone 94hydrocortisone (intrarectal) 94hydrocortisone (rectal) 70hydrocortisone (topical) 70116hydrocortisone butyrate 7081hydrocortisone valerate 7081hydrocortisone wacetic acid 103HYDROCORTISONE-ALOE 116hydrocortisone-aloe vera 116hydromorphone hcl 3HYDROXYCHLOROQUINE SULFATE 35hydroxychloroquine sulfate 35HYDROXYPROGESTERONE CAPROATE 85hydroxyurea 27hydroxyzine hcl 104

Iibandronate sodium 95IBRANCE 31ibuprofen 1116icatibant acetate 88ICLUSIG 31icosapent ethyl 64IDHIFA 27ILARIS 89ILEVRO 101imatinib mesylate 31IMBRUVICA 31imipenem-cilastatin 11imipramine hcl 20imiquimod 71IMOVAX RABIES 92

INCRELEX 82INCRUSE ELLIPTA 104indapamide 63indomethacin 1INFANRIX 92INLYTA 31INQOVI 27INREBIC 27INSPIRACHAMBERLARGE 116INSPIRACHAMBERMEDIUM 116INSPIRACHAMBERMOUTHPIECE 116INSPIRACHAMBERSMALL 116INSPIREASE 116INSULIN PEN NEEDLES 97INSULIN SYRINGE 03 ML 97INSULIN SYRINGE 05 ML 97INSULIN SYRINGE 1 ML 97INSULIN SYRINGE-NEEDLE U-100 97INTELENCE 43INTRALIPID 73INTRON A 89INVEGA HAFYERA 38INVEGA SUSTENNA 3839INVEGA TRINZA 39INVIRASE 45INVOKAMET 49INVOKAMET XR 49INVOKANA 49IPOL 92ipratropium bromide 104ipratropium bromide (nasal) 104ipratropium-albuterol 107irbesartan 56irbesartan-hydrochlorothiazide 61IRESSA 31ISENTRESS 42ISENTRESS HD 42isoniazid 25ISOPROPYL ALCOHOL 97ISOPROPYL ALCOHOL WIPES 97isosorbide dinitrate 65

132

ISOSORBIDE DINITRATE ER 65isosorbide mononitrate 65isotretinoin 69itraconazole 22ivermectin 34IXIARO 92

JJAKAFI 31JANUMET 49JANUMET XR 49JANUVIA 49JARDIANCE 49JENTADUETO 49JENTADUETO XR 49JULUCA 42JUXTAPID 64

KKALYDECO 106KCL IN DEXTROSE-NACL 73KCL-LACTATED RINGERS-D5W 75KEPIVANCE 69ketoconazole 22ketoconazole (topical) 22ketoprofen 1ketorolac tromethamine (ophth) 101ketotifen fumarate (ophth) 116KINRIX 92KISQALI (200 MG DOSE) 31KISQALI (400 MG DOSE) 31KISQALI (600 MG DOSE) 31KISQALI FEMARA (400 MG DOSE) 27KISQALI FEMARA (600 MG DOSE) 27KISQALI FEMARA(200 MG DOSE) 27KORLYM 81KOSELUGO 27KRINTAFEL 35KRYSTEXXA 23

Llabetalol hcl 58lactated ringers 75lactated ringers (irrigation) 75LACTATED RINGERS 75lactic acid (ammonium lactate) 70lactulose 76lactulose (encephalopathy) 76lamivudine 44lamivudine (hbv) 41lamivudine-zidovudine 44lamotrigine 13lansoprazole 77LANTUS 51LANTUS SOLOSTAR 51lapatinib ditosylate 31latanoprost 102LATUDA 39LEDIPASVIR-SOFOSBUVIR 42leflunomide 91LENVIMA (10 MG DAILY DOSE) 31LENVIMA (12 MG DAILY DOSE) 31LENVIMA (14 MG DAILY DOSE) 31LENVIMA (18 MG DAILY DOSE) 31LENVIMA (20 MG DAILY DOSE) 31LENVIMA (24 MG DAILY DOSE) 32LENVIMA (4 MG DAILY DOSE) 32LENVIMA (8 MG DAILY DOSE) 32letrozole 29leucovorin calcium 27LEUKERAN 25LEUKINE 54leuprolide acetate 86levalbuterol hcl 105LEVALBUTEROL TARTRATE 105levetiracetam 13levobunolol hcl 101levocarnitine (metabolic modifiers) 75levocetirizine dihydrochloride 104levofloxacin 12

133

levofloxacin (ophth) 100levofloxacin in d5w 12levoleucovorin calcium 27levonorgestrel amp eth estradiol 84levonorgestrel (emergency oc) 116levonorgestrel-eth estradiol (triphasic) 84levonorgestrel-ethinyl estradiol (91-day) 84levothyroxine sodium 86LEXIVA 45lidocaine 4lidocaine hcl 4lidocaine hcl (mouth-throat) 4lidocaine-prilocaine 4LINDANE 71linezolid 7LINEZOLID IN SODIUM CHLORIDE 7LINZESS 76liothyronine sodium 86lisinopril 57lisinopril amp hydrochlorothiazide 61LITEAIRE 116LITHIUM 48lithium carbonate 48LONSURF 28loperamide hcl 76116lopinavir-ritonavir 45loratadine 116lorazepam 48LORBRENA 32losartan potassium 56losartan potassium amp hydrochlorothiazide 61loteprednol etabonate 101lovastatin 63loxapine succinate 37LUMAKRAS 28LUMIGAN 102LUMIZYME 78LUPRON DEPOT (1-MONTH) 86LUPRON DEPOT (3-MONTH) 86LUPRON DEPOT (4-MONTH) 86LUPRON DEPOT (6-MONTH) 86

LUPRON DEPOT-PED (1-MONTH) 86LUPRON DEPOT-PED (3-MONTH) 87LYBALVI 17LYNPARZA 32LYSODREN 28

MM-M-R II 92MAG-G 116magnesium citrate 117magnesium gluconate 117malathion 71MAPROTILINE HCL 17MARPLAN 18MATULANE 25MAVYRET 42meclizine hcl 20117MEDPURA ALCOHOL PADS 97medroxyprogesterone acetate 85medroxyprogesterone acetate(contraceptive) 85mefloquine hcl 35megestrol acetate 85megestrol acetate (appetite) 85MEKINIST 32MEKTOVI 32meloxicam 1memantine hcl 17MENACTRA 92MENEST 84MENQUADFI 92MENVEO 92meprobamate 47mercaptopurine 27meropenem 11mesalamine 94mesna 34MESNEX 34metformin hcl 49methadone hcl 12methazolamide 102

134

methenamine hippurate 7methimazole 87methocarbamol 108methotrexate sodium 91methyldopa 55methylergonovine maleate 97methylphenidate hcl 66methylprednisolone 81methylprednisolone acetate 81methylprednisolone sod succ 81METIPRANOLOL 101metoclopramide hcl 20metolazone 63metoprolol amp hydrochlorothiazide 61metoprolol succinate 58metoprolol tartrate 58METOPROLOL-HYDROCHLOROTHIAZIDE 61metronidazole 7metronidazole (topical) 7metronidazole in nacl 7metronidazole vaginal 7metyrosine 61mexiletine hcl 57micafungin sodium 22MICONAZOLE 3 22miconazole nitrate vaginal 117MICROCHAMBER 117MICROSPACER 117midodrine hcl 56MIGERGOT 23miglitol 49miglustat 78minocycline hcl 12minoxidil 65MIRALAX 117mirtazapine 17misoprostol 77modafinil 109moexipril hcl 57MOLINDONE HCL 37mometasone furoate 7081

montelukast sodium 104morphine sulfate 23MOVANTIK 76moxifloxacin hcl 12moxifloxacin hcl (ophth) 100MOZOBIL 54MULTAQ 57mupirocin 72MURO 128 117MYALEPT 76mycophenolate mofetil 91mycophenolate mofetil hcl 91mycophenolate sodium 91MYRBETRIQ 79

Nnabumetone 1nadolol 58nafcillin sodium 10NAGLAZYME 78naloxone hcl 5NALOXONE HCL 5naltrexone hcl 5naphazoline w pheniramine 117naproxen 1naratriptan hcl 24NARCAN 5NASACORT ALLERGY 24HR 117NASACORT ALLERGY 24HR CHILDREN 117NASAL DECONGESTANT 117NASALCROM 117NATACYN 100nateglinide 50NATPARA 95NAYZILAM 4nebivolol hcl 58nefazodone hcl 18neomycin sulfate 6neomycin-bacitracin zn-polymyxin 99neomycin-bacitracin-polymyxin oint 117neomycin-polymy-dexameth 99

135

neomycin-polymyxin w pramoxine 117NEOMYCIN-POLYMYXIN-GRAMICIDIN 100neomycin-polymyxin-hc (otic) 103NEONATAL PLUS 75NERLYNX 32NEULASTA 54NEULASTA ONPRO 54NEVIRAPINE 43nevirapine 43NEVIRAPINE ER 43NEXAVAR 32niacin 117niacin (antihyperlipidemic) 64NIACIN (ANTIHYPERLIPIDEMIC) 64NIACIN ER 117niacinamide 117NIACOR 64nicardipine hcl 59nicotine 118nicotine polacrilex 118NICOTROL 6NICOTROL NS 6nifedipine 59nilutamide 26nimodipine 59NINLARO 28nitazoxanide 35nitisinone 78NITRO-BID 65nitrofurantoin macrocrystal 7nitrofurantoin monohyd macro 8nitroglycerin 65NITROSTAT 65NITYR 78NIX COMPLETE LICE TREATMENT 118nizatidine 77NORDITROPIN FLEXPRO 82norethin acet amp estrad-fe 84norethindrone amp eth estradiol 84norethindrone amp ethinyl estradiol-fe 84norethindrone (contraceptive) 85

norethindrone acet amp eth estra 84norethindrone acetate 85norethindrone acetate-ethinyl estradiol 84norethindrone-eth estradiol (triphasic) 84norgestimate-ethinyl estradiol 84norgestimate-ethinyl estradiol (triphasic) 84norgestrel amp ethinyl estradiol 85NORMOSOL-M IN D5W 73nortriptyline hcl 20nortriptyline oral solution (unit dose) 20NORVIR 45NovoFine 32G X 6 MM MISC 97NOVOLIN 7030 51NOVOLIN 7030 RELION 51NOVOLIN N 52NOVOLIN N RELION 52NOVOLIN R 52NOVOLIN R RELION 52NOVOLOG 52NOVOLOG 7030 FLEXPEN RELION 52NOVOLOG FLEXPEN 52NOVOLOG FLEXPEN RELION 52NOVOLOG MIX 7030 52NOVOLOG MIX 7030 FLEXPEN 52NOVOLOG MIX 7030 RELION 52NOVOLOG PENFILL 52NOVOLOG RELION 52NovoTwist 32G X 5 MM MISC 97NUBEQA 26NUCALA 108NUPLAZID 39NUTRILIPID 73NYMALIZE 59nystatin 22nystatin (mouth-throat) 22nystatin (topical) 22nystatin-triamcinolone 71

Ooctreotide acetate 87ODEFSEY 43

136

ODOMZO 32OFEV 107ofloxacin 12ofloxacin (ophth) 100ofloxacin (otic) 103olanzapine 39olmesartan medoxomil 56olmesartan medoxomil-amlodipine-hydrochlorothiazide 61olmesartan medoxomil-hydrochlorothiazide61olopatadine hcl 100omega-3 fatty acids cap 1000 mg 118omega-3-acid ethyl esters 64omeprazole 77118ondansetron 21ondansetron hcl 21ONUREG 28OPSUMIT 107OPTICHAMBER ADVANTAGE-LG MASK 118OPTICHAMBER ADVANTAGE-MED MASK 118OPTICHAMBER ADVANTAGE-SM MASK 118OPTICHAMBER DIAMOND 118OPTICHAMBER DIAMOND-LG MASK 118OPTICHAMBER DIAMOND-MD MASK 118OPTICHAMBER DIAMOND-SM MASK 118OPTICHAMBER FACE MASK-LARGE 118OPTICHAMBER FACE MASK-MEDIUM 118OPTICHAMBER FACE MASK-SMALL 118OPTIHALER 118OPTIONS GYNOL II CONTRACEPTIVE 118oral electrolyte solution 119ORBACTIV 8ORGOVYX 87oseltamivir phosphate 46OSPHENA 85oxandrolone 82OXBRYTA 55oxcarbazepine 16oxybutynin chloride 79oxycodone hcl 34OXYCODONE HCL ER 2

oxycodone w acetaminophen 4OXYCONTIN 2oyster shell 119OYSTER SHELL CALCIUM 500 + D 119OYSTER SHELL CALCIUMD 119OZEMPIC (025 OR 05 MGDOSE) 50OZEMPIC (1 MGDOSE) 50

Ppaliperidone 39PANRETIN 34pantoprazole sodium 77PARI VORTEX ADULT MASK 119paricalcitol 95paromomycin sulfate 6paroxetine hcl 1819PASER 25PAXIL 19PEDIARIX 92PEDVAX HIB 93peg 3350-kcl-sod bicarb-sod chloride-sodsulfate 76peg 3350-potassium chloride-sodbicarbonate-sod chloride 76PEGANONE 16PEGASYS 89PEGASYS PROCLICK 90PEGINTRON 42PEMAZYRE 32penicillamine 80penicillin g potassium 10PENICILLIN G SODIUM 10penicillin v potassium 10pentamidine isethionate 35pentoxifylline 62perindopril erbumine 57permethrin 71119perphenazine 20PERSERIS 39PFIZERPEN 11phenelzine sulfate 18

137

phenobarbital 15phentermine hcl 119PHENYTEK 16phenytoin 16phenytoin sodium extended 16PHOSPHOLINE IODIDE 102phytonadione 119PIFELTRO 43pilocarpine hcl 102pilocarpine hcl (oral) 69PIMOZIDE 37pindolol 58pioglitazone hcl 50piperacillin sodium-tazobactam sodium 11PIQRAY (200 MG DAILY DOSE) 32PIQRAY (250 MG DAILY DOSE) 32PIQRAY (300 MG DAILY DOSE) 32piroxicam 1PLEGRIDY 68PLEGRIDY STARTER PACK 68POCKET CHAMBER 119POCKET SPACER 119podofilox 71polyethylene glycol 3350 119polymyxin b-trimethoprim 100polyvinyl alcohol 119POMALYST 26posaconazole 22potassium chloride 73POTASSIUM CHLORIDE ER 73POTASSIUM CHLORIDE IN DEXTROSE 75potassium chloride in dextrose amp sodiumchloride 73POTASSIUM CHLORIDE IN NACL 73potassium chloride microencapsulatedcrystals er 73potassium citrate (alkalinizer) 73PRADAXA 53pramipexole dihydrochloride 36pravastatin sodium 63praziquantel 34

prazosin hcl 56PRE-NATAL FORMULA 119prednisolone 81PREDNISOLONE ACETATE 101PREDNISOLONE SODIUM PHOSPHATE 81101prednisone 81PREDNISONE INTENSOL 81pregabalin 67PREMARIN 85PREMASOL 74PREMPHASE 85PREMPRO 85PRENATAL (WIRON amp FA) 119PRENATAL FORTE 119PRENATAL VITAMIN WITH IRON TAB 27-08MG 119PRENATAL VITAMIN WITH IRON TAB 28-08MG 119prenatal vitamins 75PRENATALIRON 119PREZCOBIX 45PREZISTA 46PRIFTIN 25primaquine phosphate 35PRIMEAIRE HOLDING CHAMBER 119primidone 15PRIVIGEN 89PRO COMFORT SPACER ADULT 120PRO COMFORT SPACER CHILD 120PRO COMFORT SPACER INFANT 120probenecid 23PROCARE SPACERADULT MASK 120PROCARE SPACERCHILD MASK 120prochlorperazine 20prochlorperazine edisylate 20prochlorperazine maleate 20PROCYSBI 78progesterone 85PROGRAF 91PROLASTIN-C 78PROLENSA 101

138

PROLIA 95PROMACTA 54promethazine hcl 20104promethazine wcodeine 120promethazine-dm 120promethazine-phenylephrine-codeine 120propafenone hcl 57propranolol hcl 58PROPRANOLOL-HCTZ 62propylthiouracil 87PROQUAD 93protriptyline hcl 20pseudoephedrine hcl 120PULMICORT FLEXHALER 103PULMOZYME 106PURIXAN 27pyrantel pamoate 120pyrazinamide 25pyrethrins-piperonyl butoxide 120pyrethrins-piperonyl butoxide-permethrin-nitremover 120pyridostigmine bromide 24pyridoxine hcl 120pyrimethamine 35

QQINLOCK 28QSYMIA 120QUADRACEL 93quetiapine fumarate 39quinapril hcl 57quinapril-hydrochlorothiazide 62quinidine gluconate 57QUINIDINE SULFATE 57quinine sulfate 35QVAR REDIHALER 104

RRA CALAMINE 120RA DAYLOGIC ACNE FOAMING WASH 120RA ISOPROPYL ALCOHOL WIPES 97

RA OYSTER SHELL CALCIUMD2 120RABAVERT 93rabeprazole sodium 77raloxifene hcl 85ramelteon 108ramipril 57ranolazine 62rasagiline mesylate 36RAVICTI 79REBIF 68REBIF REBIDOSE 68REBIF REBIDOSE TITRATION PACK 68REBIF TITRATION PACK 68RECOMBIVAX HB 93RECTIV 65REGRANEX 71RELENZA DISKHALER 46RELION PEN NEEDLES 97RELISTOR 76repaglinide 50REPATHA 64REPATHA PUSHTRONEX SYSTEM 64REPATHA SURECLICK 64RESCRIPTOR 43RESTASIS 100RESTASIS MULTIDOSE 100RETACRIT 54RETEVMO 28REVLIMID 26REXULTI 39REYATAZ 46REZUROCK 91ribavirin 108ribavirin (hepatitis c) 42riboflavin 121RID 121RID COMPLETE LICE ELIMINATION 121RID ESSENTIAL LICE ELIMINATION 121rifabutin 25rifampin 25RIFATER 25

139

riluzole 67RIMANTADINE HCL 46ringers 75ringers irrigation 75risedronate sodium 95RISPERDAL CONSTA 39risperidone 40RITEFLO 121ritonavir 46rivastigmine 16rivastigmine tartrate 17rizatriptan benzoate 24ropinirole hydrochloride 36rosuvastatin calcium 63ROTARIX 93ROTATEQ 93ROZLYTREK 28RUBRACA 32RUCONEST 88rufinamide 16RUKOBIA 45RUZURGI 97RYBELSUS 50RYDAPT 32

Ssaline 121SANDIMMUNE 91SANDOSTATIN LAR DEPOT 87SANTYL 71sapropterin dihydrochloride 79SAVELLA 67SAVELLA TITRATION PACK 67SAXENDA 121scopolamine 20SECUADO 40selegiline hcl 37selenium sulfide 70121SELZENTRY 45sennosides 121SEREVENT DISKUS 105

SEROSTIM 82sertraline hcl 19sevelamer carbonate 74SHINGRIX 93SIGNIFOR 87sildenafil citrate (pulmonary hypertension) 107silver sulfadiazine 71simethicone 121simvastatin 64sirolimus 91SIRTURO 25SM FOAMING ANTACID 121SMOFLIPID 75sodium bicarbonate (antacid) 121sodium chloride 74sodium chloride hypertonic 121sodium fluoride 74sodium phenylbutyrate 79sodium polystyrene sulfonate 74SOFOSBUVIR-VELPATASVIR 42solifenacin succinate 79SOLTAMOX 26SOMATULINE DEPOT 87SOMAVERT 87sotalol hcl 57sotalol hcl (afibafl) 57SPIRIVA HANDIHALER 104SPIRIVA RESPIMAT 104spironolactone 63spironolactone amp hydrochlorothiazide 62SPRITAM 13SPRYCEL 32SPS 74stavudine 44STELARA 89STIVARGA 32STRENSIQ 79STREPTOMYCIN SULFATE 6STRIBILD 42STRIVERDI RESPIMAT 105sucralfate 77

140

sulfacetamide sod-prednisolone 100SULFACETAMIDE SODIUM 100sulfacetamide sodium (acne) 12sulfacetamide sodium (ophth) 100SULFACETAMIDE-PREDNISOLONE 100SULFADIAZINE 12sulfamethoxazole-trimethoprim 12SULFAMYLON 72sulfasalazine 94sulindac 1sumatriptan 24sumatriptan succinate 24sunitinib malate 3233SUPREP BOWEL PREP KIT 76SYLATRON 90SYMDEKO 106SYMLINPEN 120 50SYMLINPEN 60 50SYMPAZAN 15SYMTUZA 46SYNAREL 87SYNERCID 8SYNJARDY 50SYNJARDY XR 50SYNRIBO 28SYNTHAMIN 17 74SYNTHROID 86

TTABLOID 27TABRECTA 28tacrolimus 91tacrolimus (topical) 70tadalafil (pulmonary hypertension) 107TAFINLAR 33TAGRISSO 33TALTZ 89TALZENNA 33tamoxifen citrate 26tamsulosin hcl 80TARGRETIN 34

TASIGNA 33TAVALISSE 55tazarotene 69TAZICEF 9TAZORAC 69TAZVERIK 28TDVAX 93TEFLARO 9TEKTURNA HCT 62telmisartan 56telmisartan-hydrochlorothiazide 62temazepam 108TEMIXYS 44TENIVAC 93tenofovir disoproxil fumarate 44TEPMETKO 33terazosin hcl 56terbinafine hcl 22terbutaline sulfate 105terconazole vaginal 22testosterone 83testosterone cypionate 83testosterone enanthate 83tetrabenazine 67tetracycline hcl 12THALOMID 26theophylline 106THEOPHYLLINE ER 106thiamine hcl 121thiamine mononitrate 121THIOLA EC 80thioridazine hcl 37thiothixene 37tiagabine hcl 15TIBSOVO 33TICOVAC 93tigecycline 8timolol maleate 23TIMOLOL MALEATE 101timolol maleate (ophth) 101tioconazole vaginal 121

141

TIVICAY 42TIVICAY PD 42tizanidine hcl 41TOBI PODHALER 106tobramycin 106tobramycin (ophth) 101tobramycin sulfate 6tobramycin-dexamethasone 100TOLAK 71tolnaftate 121tolterodine tartrate 79topiramate 14toremifene citrate 26torsemide 62TOUJEO MAX SOLOSTAR 52TOUJEO SOLOSTAR 52TPN ELECTROLYTES 75TRACLEER 107TRADJENTA 50tramadol hcl 4tramadol-acetaminophen 4trandolapril 57tranexamic acid 54tranylcypromine sulfate 18TRAVASOL 74travoprost 102trazodone hcl 19TRECATOR 25TRELEGY ELLIPTA 108tretinoin 69tretinoin (chemotherapy) 34triamcinolone acetonide (mouth) 69triamcinolone acetonide (nasal) 121triamcinolone acetonide (topical) 70triamterene amp hydrochlorothiazide 62triazolam 108109trientine hcl 74trifluoperazine hcl 38trifluridine 47trihexyphenidyl hcl 36TRIKAFTA 106

trimethoprim 8trimipramine maleate 20TRINTELLIX 19triprolidine amp pseudoephedrine 121TRIUMEQ 44TROPHAMINE 74trospium chloride 80TRUE COMFORT PEN NEEDLES 98TRUE COMFORT PRO ALCOHOL PREP 98TRUE COMFORT PRO INSULIN SYR 98TRUE COMFORT PRO PEN NEEDLES 98TRULICITY 50TRUMENBA 93TRUSELTIQ (100MG DAILY DOSE) 33TRUSELTIQ (125MG DAILY DOSE) 33TRUSELTIQ (50MG DAILY DOSE) 33TRUSELTIQ (75MG DAILY DOSE) 33TUKYSA 33TUMS 121TUMS LASTING EFFECTS 121TURALIO 33TWINRIX 93TYBOST 45TYMLOS 95TYPHIM VI 93TYSABRI 68

UUKONIQ 33ULTICARE MINI PEN NEEDLES 98ULTICARE SHORT PEN NEEDLES 98ULTIGUARD SAFEPACK PEN NEEDLE 98ULTIGUARD SAFEPACK SYRNEEDLE 98ULTRA FLO INSULIN PEN NEEDLES 98ULTRA FLO INSULIN SYR 12 UNIT 98ULTRA FLO INSULIN SYRINGE 99UNIFINE PEN NEEDLES 99UNIFINE PENTIPS 99ursodiol 77

142

Vvalacyclovir hcl 47VALCHLOR 26valganciclovir hcl 41valproate sodium 14valproic acid 14valsartan 56valsartan-hydrochlorothiazide 62VALTOCO 10 MG DOSE 15VALTOCO 15 MG DOSE 15VALTOCO 20 MG DOSE 15VALTOCO 5 MG DOSE 15VALVED HOLDING CHAMBER 121vancomycin hcl 8VAQTA 93VARENICLINE TARTRATE 6VARIVAX 93VARIZIG 89VASCEPA 64VCF VAGINAL CONTRACEPTIVE 122VELTASSA 74VEMLIDY 41VENCLEXTA 33VENCLEXTA STARTING PACK 33venlafaxine hcl 19VENTAVIS 107verapamil hcl 59VERAPAMIL HCL ER 60VERSACLOZ 40VERZENIO 33VICTOZA 50VIDEX 44VIDEX EC 44vigabatrin 15VIIBRYD 19VIIBRYD STARTER PACK 19VIMPAT 16VIRACEPT 46VIREAD 44vitamin a 122

VITAMIN D2 122vitamin e 122VITAMIN K 122VITRAKVI 33VIZIMPRO 34voriconazole 2223VORTEX HOLD CHMBRMASKCHILD 122VORTEX VALVED HOLDING CHAMBER 122VOSEVI 42VOTRIENT 34VRAYLAR 40VYNDAMAX 62VYNDAQEL 79

Wwarfarin sodium 53WATCHHALER 122water for irrigation sterile 99WELIREG 28

XXALKORI 34XARELTO 53XARELTO STARTER PACK 53XATMEP 91XCOPRI 14XCOPRI (250 MG DAILY DOSE) 14XCOPRI (350 MG DAILY DOSE) 14XELJANZ 89XELJANZ XR 91XGEVA 95XIFAXAN 8XOFLUZA (40 MG DOSE) 46XOFLUZA (80 MG DOSE) 46XOLAIR 89XOSPATA 34XPOVIO (100 MG ONCE WEEKLY) 28XPOVIO (40 MG ONCE WEEKLY) 28XPOVIO (40 MG TWICE WEEKLY) 28XPOVIO (60 MG ONCE WEEKLY) 2829XPOVIO (60 MG TWICE WEEKLY) 29

143

XPOVIO (80 MG ONCE WEEKLY) 29XPOVIO (80 MG TWICE WEEKLY) 29XTANDI 26XYREM 109

YYF-VAX 93

Zzafirlukast 104zaleplon 109ZARXIO 54ZEJULA 34ZELBORAF 34ZENPEP 79ZERIT 44ZEVRX STERILE ALCOHOL PREP PAD 99zidovudine 44ziprasidone hcl 40ziprasidone mesylate 40ZIRGAN 41zoledronic acid 95ZOLINZA 29zolmitriptan 24zolpidem tartrate 109zonisamide 16ZONTIVITY 53ZORTRESS 92ZOSTAVAX 93ZUBSOLV 5ZYDELIG 34ZYKADIA 34ZYPREXA RELPREVV 40

144

Blue Shield of California Promise Health Plan

601 Potrero Grande Drive Monterey Park CA 91755

H0148_20_503

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A51247-C

MS (

91

8)

Discrimination is Against the Law

Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate exclude people or treat them differently on the basis of race color national origin ethnic group identification medical condition genetic information ancestry religion sex marital status gender gender identity sexual orientation age mental disability or physical disability Blue Shield of California Promise Health Plan provides

Aids and services at no cost to people with disabilities to communicate effectively with us such

as

o Qualified sign language interpreters o Written information in other formats (large print audio accessible electronic formats

other formats) Language services at no cost to people whose primary language is not English such as

o Qualified interpreters

o Information written in other languages If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator

If you believe that Blue Shield of California Promise Health Plan has failed to provide these

services or discriminated in another way on the basis of race color national origin ethnic group

identification medical condition genetic information ancestry religion sex marital status

gender gender identity sexual orientation age mental disability or physical disability you can

file a grievance with


Civil Rights Coordinator

601 Potrero Grande Dr

Monterey Park CA 91755

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

Email BSCPHPCivilRightsblueshieldcacom

You can file a grievance in person or by mail fax or email If you need help filing a grievance the

Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 (TTY 800-537-7697 ) Complaint Portal httpsocrportalhhsgovocrcpwizard_cpjsf

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

H0148_20_253 09092019

Language Assistance Notice

English ATTENTION Language assistance services free of charge are available to you Call 1-855-905-3825 (TTY 711)

繁體中文 (Chinese)

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電1-855-905-3825（TTY711)

한국어 (Korean)

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-855-905-3825 (TTY 711)번으로 전화해 주십시오

Русский (Russian)

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-855-905-3825 (телетайп 711)

Italiano (Italian)

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero 1-855-905-3825 (TTY 711)

(Farsi) فارسیی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ

دیریبگ تماس (TTY 711) 3825-905-855-1 با باشدहद (Hindi)

धयान द यद आप हद बोलत ह तो आपक लए मफत म भाषा सहायता सवाए उपलबध ह 1-855-905-3825 (TTY 711) पर कॉल कर

Hmong (Hmong)

LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau 1-855-905-3825 (TTY 711)

Espantildeol (Spanish)

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-855-905-3825 (TTY 711)

Tiếng Việt (Vietnamese)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-855-905-3825 (TTY 711)

Tagalog (Tagalog - Filipino)

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-905-3825 (TTY 711)

(Arabic) العربیة(رقم 38-905-855-251ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

)117ھاتف الصم والبكم ພາສາລາວ (Lao) ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-855-905-3825 (TTY 711) 日本語 (Japanese)

注意事項日本語を話される場合無料の言語支援をご利用いただけます1-855-905-3825（TTY711）までお電話にてご連絡ください

ภาษาไทย (Thai)

เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-855-905-3825 (TTY 711) ਪਜਾਬੀ ਦ (Punjabi)

ਿਧਆਨ ਿਦਓ ਜ ਤਸ ਪਜਾਬੀ ਬਲਦ ਹ ਤ ਭਾਸ਼ਾ ਿਵਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ 1-855-905-3825

(TTY 711) ਤ ਕਾਲ ਕਰ ែខរ (Cambodian)

របយត េបើសនអកនយ ែខរ េសជនយែផក េយមនគតឈ ល

គចនសបបេរ អក ចរ ទរសព 1-855-905-3825 (TTY 711)

Հայերեն (Armenian)

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-905-3825 (TTY (հեռատիպ)711)

This formulary was updated on 08252020 For more recent information or other questions please contact Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week or visit wwwblueshieldcacompromisecalmediconnect

11222021

Blue Shield Promise Cal MediConnect Plan

A Disclaimers


繁體中文 (Chinese) 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711) 每周七天办公每天早上800 至晚上800这是免费电话


Tagalog (Tagalog ndash Filipino) PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa Blue Shield Promise Cal MediConnect Plan 1-855-905-3825 (TTY 711) Mula 8am-8pm 7 araw sa isa




B2 Does the Drug List ever change

B3 What happens when there is a change to the Drug List




B7 How can you find a drug on the Drug List

To search alphabetically go to the Index of Covered Drugs section You can find it in the index that begins on page 120 The Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic

B8 What if the drug you want to take is not on the Drug List


Transition Policy In circumstances where a beneficiary is changing from one treatment setting to another Blue Shield Promise Cal MediConnect Plan will ensure a fast process for approving non-formulary Part D drugs This process shall also apply to f

B10 Can you ask for an exception to cover your drug

B11 How can you ask for an exception

B12 How long does it take to get an exception

B13 What are generic drugs

B14 What are OTC drugs


B16 What is your copay


B17 What are drug tiers


C1 Drugs Grouped by Medical Condition

List of Covered Drugs


Alphabetical Listing

Category Listing




ii

Blue Shield Promise Cal MediConnect Plan | 2021 List of Covered Drugs (Formulary)

Introduction

This document is called the List of Covered Drugs (also known as the Drug List) It tells you which prescription drugs and Over-the-Counter (OTC) drugs and items are covered by Blue Shield Promise Cal MediConnect Plan The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Blue Shield Promise Cal MediConnect Plan Key terms and their definitions appear in the last chapter of the Member Handbook You can request a copy by calling Blue Shield Promise Cal MediConnect Plan Customer Care at 1-855-905-3825 (TTY 711) from 800 am ndash 800 pm seven days a week the call is free

Table of Contents

A Disclaimers iv

B Frequently Asked Questions (FAQ) vi

B1 What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the ldquoDrug Listrdquo for short) vi

B2 Does the Drug List ever change vi

B3 What happens when there is a change to the Drug List vii

B4 Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs viii

B5 How will you know if the drug you want has limits or if there are required actions to take to get the drug ix

B6 What happens if we change our rules about some drugs (for example prior authorization (approval) quantity limits andor step therapy restrictions) ix

B7 How can you find a drug on the Drug List ix

B8 What if the drug you want to take is not on the Drug List ix

B9 What if you are a new Blue Shield Promise Cal MediConnect Plan member and canrsquot find your drug on the Drug List or have a problem getting your drug x

B10 Can you ask for an exception to cover your drug xi


iii












iv

A Disclaimers
















v














vi

















vii















viii

















1 - 122


ix












123

1 - 122


x
















xi












xii












$0 $0 $0


$0 to $370 copay

Not available


$0 to $920 copay

Not available




xiii







123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand







ST Step Therapy



xv












ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23




ANTINEOPLASTICS 25

ANTIPARASITICS 34


ANTIPSYCHOTICS 37


ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48























OTIC AGENTS 102




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2



Tier 2


Tier 2








1

ANALGESICS




Tier 2 PA NDS



























2

ANALGESICS





























3

ANALGESICS














ANESTHETICS













Tier 2



4






















Tier 2










5








ANTIBACTERIALS




Tier 2


Tier 2





Tier 2


Tier 2




Tier 2


Tier 2


6

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


7

ANTIBACTERIALS




Tier 2




Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




11

ANTIBACTERIALS




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTICONVULSANTS











Tier 2



Tier 2







Tier 2


Tier 2







13

ANTICONVULSANTS




Tier 2 PA


Tier 2


Tier 2












Tier 2










14

ANTICONVULSANTS








Tier 2 PA





Tier 2 PA














Tier 2



Tier 3


15

ANTICONVULSANTS




Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2




16

ANTIDEMENTIA AGENTS




Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


Tier 3 PA


17

ANTIDEPRESSANTS







Tier 2








Tier 2






Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


18

ANTIDEPRESSANTS







Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


Tier 2 PA


Tier 2


Tier 2 PA


19

ANTIDEPRESSANTS




Tier 2 PA


Tier 2



Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2 PA


Tier 2 PA


20

ANTIEMETICS




Tier 2 BvD





Tier 2 BvD








ANTIFUNGALS






Tier 2 BvD


Tier 2 PA


Tier 2


Tier 2


21

ANTIFUNGALS





Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2



Tier 2







Tier 2


Tier 2 PA


22

ANTIFUNGALS




ANTIGOUT AGENTS






Tier 2




ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2


23

ANTIMIGRAINE AGENTS



















ANTIMYCOBACTERIALS





24

ANTIMYCOBACTERIALS





Tier 3


Tier 2


Tier 2





Tier 2





ANTINEOPLASTICS




Tier 3 BvD


Tier 3




25

ANTINEOPLASTICS









Tier 2















Tier 2



Tier 2


Tier 2


26

ANTINEOPLASTICS




Tier 3





Tier 3 PA LA



















Tier 2


Tier 2 PA


27

ANTINEOPLASTICS



































28

ANTINEOPLASTICS




















Tier 3 PA











29

ANTINEOPLASTICS




























Tier 2 PA






30

ANTINEOPLASTICS







































31

ANTINEOPLASTICS






































32

ANTINEOPLASTICS





































33

ANTINEOPLASTICS



















Tier 3

ANTIPARASITICS







34

ANTIPARASITICS




TIME)



Tier 2



















Tier 2 BvD


Tier 2


Tier 3




35





Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2




36





Tier 2

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


37

ANTIPSYCHOTICS




Tier 2


Tier 3 PA








Tier 3 PA



















38

ANTIPSYCHOTICS

















Tier 2







Tier 2




Tier 3


39

ANTIPSYCHOTICS




Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2







40







Tier 2


Tier 2

ANTIVIRALS





















41

ANTIVIRALS









Tier 2
























42

ANTIVIRALS
































43

ANTIVIRALS




























BvD



44

ANTIVIRALS

































45

ANTIVIRALS






























Tier 2



Tier 2


46

ANTIVIRALS




Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA


















47

ANXIOLYTICS











BIPOLAR AGENTS





Tier 2





Tier 2


Tier 1


Tier 1


Tier 1


48





Tier 1 PA


Tier 1 PA


Tier 1 PA

























Tier 1




49










Tier 2


Tier 2























50










Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3



Tier 3



Tier 3





Tier 3


Tier 3


51





Tier 3


Tier 3



Tier 3



Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3










52























Tier 2 BvD




Tier 2








Tier 2


53





Tier 3 PA





Tier 3 PA







Tier 3 PA


Tier 3 PA


Tier 2



54





Tier 2







Tier 2 PA








Tier 2


Tier 2





Tier 2


Tier 2


55





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


56





Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


57





Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 1


Tier 2



Tier 2


Tier 1


58





Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


60





Tier 1




Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



Tier 2


Tier 2


61






Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


Tier 2


Tier 1


Tier 2




62





Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


63





Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2







Tier 2












64





Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


Tier 3










65



































66


































67













Tier 3 PA LA


Tier 3 PA LA

















68






Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST



Tier 2


Tier 2





Tier 2


70





Tier 2


Tier 2





Tier 2




Tier 2










TIME)



Tier 2

ERY 2 PAD Tier 2


71





Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD







Tier 2 BvD







72






Tier 3 BvD


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


73






Tier 2


Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA




Tier 2



Tier 2



Tier 3


74







Tier 2


Tier 2


Tier 2


Tier 2







Tier 2







75






Tier 2







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2



Tier 2 PA






Tier 2


76





Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 2


Tier 2


Tier 2







Tier 3 LA BvD


77















Tier 3


Tier 2



Tier 3 PA LA







Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA BvD


78






Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2




Tier 2 ST


79










Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


80





Tier 2


Tier 2 BvD







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


81





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA






Tier 2 PA




Tier 2


82







Tier 2







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA






Tier 2 PA


83





Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 3 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


84





Tier 2


Tier 3 PA






Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA





Tier 2




85





Tier 2


Tier 2


Tier 3






Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


86





Tier 3


Tier 2 PA



Tier 3 PA




Tier 3 PA










87







Tier 3 PA LA





Tier 3 PA LA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3 PA


88





Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA





89







Tier 3



Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


90





Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA



Tier 2 BvD


Tier 2


Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 2 BvD


Tier 2 BvD





91







Tier 3






Tier 3


Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







92





Tier 3





Tier 3 BvD








Tier 3



Tier 3 BvD



Tier 3


Tier 3





93








Tier 2


Tier 2





Tier 2






Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


94






Tier 2 PA


Tier 2




Tier 2 BvD



Tier 2





Tier 2 BvD









Tier 2


95





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


96





Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



97





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


98





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS






Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


99

OPHTHALMIC AGENTS




Tier 2





Tier 2


Tier 2


Tier 2




Tier 2







Tier 2




Tier 2


Tier 2


Tier 2


100

OPHTHALMIC AGENTS






Tier 2




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


101

OPHTHALMIC AGENTS






Tier 2



Tier 2




Tier 2


Tier 3


Tier 2


Tier 2




OTIC AGENTS




Tier 2


Tier 2


Tier 3


102

OTIC AGENTS




Tier 3



Tier 2


Tier 2






Tier 2 BvD




















103










Tier 2 PA


Tier 2


Tier 2 PA

















104













Tier 2 BvD


Tier 2








Tier 2 PA








Tier 2


105





OVER TIME)













Tier 2 BvD


TIME)



Tier 2


Tier 2




106






























Tier 2 BvD


107

















Tier 2 PA


Tier 2 PA











108













109

Non-Part D Drugs

































110

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD









Tier 4 NPD


Tier 4 NPD


111

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD























Tier 4 NPD


112

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


113

Non-Part D Drugs






Tier 4 NPD











Tier 4 NPD



Tier 4 NPD


Tier 4 NPD











114

Non-Part D Drugs








Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




115

Non-Part D Drugs







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD








Tier 4 NPD




Tier 4 NPD


Tier 4 NPD



116

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD




117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






















Tier 4 NPD


118

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 PA NPD






Tier 4 NPD




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD





119

Non-Part D Drugs
















Tier 4 PA NPD





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD


120

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD







Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




121

Non-Part D Drugs




Tier 4 NPD




Tier 4 NPD








122




123




124



125




126



127




128




129




130

FYCOMPA 13




131




132





133




134




135




136




137



138





139




140




141




142





143


YYF-VAX 93


144



H0148_20_503

Blu

e S

hie

ld o

f C

alif

orn

ia P

rom

ise

He

alt

h P

lan

is a

n in

de

pe

nd

en

t lic

en

see

of

the

Blu

e S

hie

ld A

sso

cia

tio

n

A51247-C

MS (

91

8)




as














Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228






H0148_20_253 09092019





한국어 (Korean)




Italiano (Italian)





Hmong (Hmong)




















11222021


A Disclaimers
































Category Listing




iii












iv

A Disclaimers
















v














vi

















vii















viii

















1 - 122


ix












123

1 - 122


x
















xi












xii












$0 $0 $0


$0 to $370 copay

Not available


$0 to $920 copay

Not available




xiii







123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand







ST Step Therapy



xv












ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23




ANTINEOPLASTICS 25

ANTIPARASITICS 34


ANTIPSYCHOTICS 37


ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48























OTIC AGENTS 102




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2



Tier 2


Tier 2








1

ANALGESICS




Tier 2 PA NDS



























2

ANALGESICS





























3

ANALGESICS














ANESTHETICS













Tier 2



4






















Tier 2










5








ANTIBACTERIALS




Tier 2


Tier 2





Tier 2


Tier 2




Tier 2


Tier 2


6

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


7

ANTIBACTERIALS




Tier 2




Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




11

ANTIBACTERIALS




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTICONVULSANTS











Tier 2



Tier 2







Tier 2


Tier 2







13

ANTICONVULSANTS




Tier 2 PA


Tier 2


Tier 2












Tier 2










14

ANTICONVULSANTS








Tier 2 PA





Tier 2 PA














Tier 2



Tier 3


15

ANTICONVULSANTS




Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2




16

ANTIDEMENTIA AGENTS




Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


Tier 3 PA


17

ANTIDEPRESSANTS







Tier 2








Tier 2






Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


18

ANTIDEPRESSANTS







Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


Tier 2 PA


Tier 2


Tier 2 PA


19

ANTIDEPRESSANTS




Tier 2 PA


Tier 2



Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2 PA


Tier 2 PA


20

ANTIEMETICS




Tier 2 BvD





Tier 2 BvD








ANTIFUNGALS






Tier 2 BvD


Tier 2 PA


Tier 2


Tier 2


21

ANTIFUNGALS





Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2



Tier 2







Tier 2


Tier 2 PA


22

ANTIFUNGALS




ANTIGOUT AGENTS






Tier 2




ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2


23

ANTIMIGRAINE AGENTS



















ANTIMYCOBACTERIALS





24

ANTIMYCOBACTERIALS





Tier 3


Tier 2


Tier 2





Tier 2





ANTINEOPLASTICS




Tier 3 BvD


Tier 3




25

ANTINEOPLASTICS









Tier 2















Tier 2



Tier 2


Tier 2


26

ANTINEOPLASTICS




Tier 3





Tier 3 PA LA



















Tier 2


Tier 2 PA


27

ANTINEOPLASTICS



































28

ANTINEOPLASTICS




















Tier 3 PA











29

ANTINEOPLASTICS




























Tier 2 PA






30

ANTINEOPLASTICS







































31

ANTINEOPLASTICS






































32

ANTINEOPLASTICS





































33

ANTINEOPLASTICS



















Tier 3

ANTIPARASITICS







34

ANTIPARASITICS




TIME)



Tier 2



















Tier 2 BvD


Tier 2


Tier 3




35





Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2




36





Tier 2

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


37

ANTIPSYCHOTICS




Tier 2


Tier 3 PA








Tier 3 PA



















38

ANTIPSYCHOTICS

















Tier 2







Tier 2




Tier 3


39

ANTIPSYCHOTICS




Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2







40







Tier 2


Tier 2

ANTIVIRALS





















41

ANTIVIRALS









Tier 2
























42

ANTIVIRALS
































43

ANTIVIRALS




























BvD



44

ANTIVIRALS

































45

ANTIVIRALS






























Tier 2



Tier 2


46

ANTIVIRALS




Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA


















47

ANXIOLYTICS











BIPOLAR AGENTS





Tier 2





Tier 2


Tier 1


Tier 1


Tier 1


48





Tier 1 PA


Tier 1 PA


Tier 1 PA

























Tier 1




49










Tier 2


Tier 2























50










Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3



Tier 3



Tier 3





Tier 3


Tier 3


51





Tier 3


Tier 3



Tier 3



Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3










52























Tier 2 BvD




Tier 2








Tier 2


53





Tier 3 PA





Tier 3 PA







Tier 3 PA


Tier 3 PA


Tier 2



54





Tier 2







Tier 2 PA








Tier 2


Tier 2





Tier 2


Tier 2


55





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


56





Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


57





Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 1


Tier 2



Tier 2


Tier 1


58





Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


60





Tier 1




Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



Tier 2


Tier 2


61






Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


Tier 2


Tier 1


Tier 2




62





Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


63





Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2







Tier 2












64





Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


Tier 3










65



































66


































67













Tier 3 PA LA


Tier 3 PA LA

















68






Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST



Tier 2


Tier 2





Tier 2


70





Tier 2


Tier 2





Tier 2




Tier 2










TIME)



Tier 2

ERY 2 PAD Tier 2


71





Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD







Tier 2 BvD







72






Tier 3 BvD


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


73






Tier 2


Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA




Tier 2



Tier 2



Tier 3


74







Tier 2


Tier 2


Tier 2


Tier 2







Tier 2







75






Tier 2







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2



Tier 2 PA






Tier 2


76





Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 2


Tier 2


Tier 2







Tier 3 LA BvD


77















Tier 3


Tier 2



Tier 3 PA LA







Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA BvD


78






Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2




Tier 2 ST


79










Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


80





Tier 2


Tier 2 BvD







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


81





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA






Tier 2 PA




Tier 2


82







Tier 2







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA






Tier 2 PA


83





Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 3 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


84





Tier 2


Tier 3 PA






Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA





Tier 2




85





Tier 2


Tier 2


Tier 3






Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


86





Tier 3


Tier 2 PA



Tier 3 PA




Tier 3 PA










87







Tier 3 PA LA





Tier 3 PA LA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3 PA


88





Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA





89







Tier 3



Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


90





Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA



Tier 2 BvD


Tier 2


Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 2 BvD


Tier 2 BvD





91







Tier 3






Tier 3


Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







92





Tier 3





Tier 3 BvD








Tier 3



Tier 3 BvD



Tier 3


Tier 3





93








Tier 2


Tier 2





Tier 2






Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


94






Tier 2 PA


Tier 2




Tier 2 BvD



Tier 2





Tier 2 BvD









Tier 2


95





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


96





Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



97





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


98





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS






Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


99

OPHTHALMIC AGENTS




Tier 2





Tier 2


Tier 2


Tier 2




Tier 2







Tier 2




Tier 2


Tier 2


Tier 2


100

OPHTHALMIC AGENTS






Tier 2




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


101

OPHTHALMIC AGENTS






Tier 2



Tier 2




Tier 2


Tier 3


Tier 2


Tier 2




OTIC AGENTS




Tier 2


Tier 2


Tier 3


102

OTIC AGENTS




Tier 3



Tier 2


Tier 2






Tier 2 BvD




















103










Tier 2 PA


Tier 2


Tier 2 PA

















104













Tier 2 BvD


Tier 2








Tier 2 PA








Tier 2


105





OVER TIME)













Tier 2 BvD


TIME)



Tier 2


Tier 2




106






























Tier 2 BvD


107

















Tier 2 PA


Tier 2 PA











108













109

Non-Part D Drugs

































110

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD









Tier 4 NPD


Tier 4 NPD


111

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD























Tier 4 NPD


112

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


113

Non-Part D Drugs






Tier 4 NPD











Tier 4 NPD



Tier 4 NPD


Tier 4 NPD











114

Non-Part D Drugs








Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




115

Non-Part D Drugs







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD








Tier 4 NPD




Tier 4 NPD


Tier 4 NPD



116

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD




117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






















Tier 4 NPD


118

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 PA NPD






Tier 4 NPD




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD





119

Non-Part D Drugs
















Tier 4 PA NPD





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD


120

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD







Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




121

Non-Part D Drugs




Tier 4 NPD




Tier 4 NPD








122




123




124



125




126



127




128




129




130

FYCOMPA 13




131




132





133




134




135




136




137



138





139




140




141




142





143


YYF-VAX 93


144



H0148_20_503

Blu

e S

hie

ld o

f C

alif

orn

ia P

rom

ise

He

alt

h P

lan

is a

n in

de

pe

nd

en

t lic

en

see

of

the

Blu

e S

hie

ld A

sso

cia

tio

n

A51247-C

MS (

91

8)




as














Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228






H0148_20_253 09092019





한국어 (Korean)




Italiano (Italian)





Hmong (Hmong)




















11222021


A Disclaimers
































Category Listing




iv

A Disclaimers
















v














vi

















vii















viii

















1 - 122


ix












123

1 - 122


x
















xi












xii












$0 $0 $0


$0 to $370 copay

Not available


$0 to $920 copay

Not available




xiii







123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand







ST Step Therapy



xv












ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23




ANTINEOPLASTICS 25

ANTIPARASITICS 34


ANTIPSYCHOTICS 37


ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48























OTIC AGENTS 102




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2



Tier 2


Tier 2








1

ANALGESICS




Tier 2 PA NDS



























2

ANALGESICS





























3

ANALGESICS














ANESTHETICS













Tier 2



4






















Tier 2










5








ANTIBACTERIALS




Tier 2


Tier 2





Tier 2


Tier 2




Tier 2


Tier 2


6

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


7

ANTIBACTERIALS




Tier 2




Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




11

ANTIBACTERIALS




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTICONVULSANTS











Tier 2



Tier 2







Tier 2


Tier 2







13

ANTICONVULSANTS




Tier 2 PA


Tier 2


Tier 2












Tier 2










14

ANTICONVULSANTS








Tier 2 PA





Tier 2 PA














Tier 2



Tier 3


15

ANTICONVULSANTS




Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2




16

ANTIDEMENTIA AGENTS




Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


Tier 3 PA


17

ANTIDEPRESSANTS







Tier 2








Tier 2






Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


18

ANTIDEPRESSANTS







Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


Tier 2 PA


Tier 2


Tier 2 PA


19

ANTIDEPRESSANTS




Tier 2 PA


Tier 2



Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2 PA


Tier 2 PA


20

ANTIEMETICS




Tier 2 BvD





Tier 2 BvD








ANTIFUNGALS






Tier 2 BvD


Tier 2 PA


Tier 2


Tier 2


21

ANTIFUNGALS





Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2



Tier 2







Tier 2


Tier 2 PA


22

ANTIFUNGALS




ANTIGOUT AGENTS






Tier 2




ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2


23

ANTIMIGRAINE AGENTS



















ANTIMYCOBACTERIALS





24

ANTIMYCOBACTERIALS





Tier 3


Tier 2


Tier 2





Tier 2





ANTINEOPLASTICS




Tier 3 BvD


Tier 3




25

ANTINEOPLASTICS









Tier 2















Tier 2



Tier 2


Tier 2


26

ANTINEOPLASTICS




Tier 3





Tier 3 PA LA



















Tier 2


Tier 2 PA


27

ANTINEOPLASTICS



































28

ANTINEOPLASTICS




















Tier 3 PA











29

ANTINEOPLASTICS




























Tier 2 PA






30

ANTINEOPLASTICS







































31

ANTINEOPLASTICS






































32

ANTINEOPLASTICS





































33

ANTINEOPLASTICS



















Tier 3

ANTIPARASITICS







34

ANTIPARASITICS




TIME)



Tier 2



















Tier 2 BvD


Tier 2


Tier 3




35





Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2




36





Tier 2

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


37

ANTIPSYCHOTICS




Tier 2


Tier 3 PA








Tier 3 PA



















38

ANTIPSYCHOTICS

















Tier 2







Tier 2




Tier 3


39

ANTIPSYCHOTICS




Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2







40







Tier 2


Tier 2

ANTIVIRALS





















41

ANTIVIRALS









Tier 2
























42

ANTIVIRALS
































43

ANTIVIRALS




























BvD



44

ANTIVIRALS

































45

ANTIVIRALS






























Tier 2



Tier 2


46

ANTIVIRALS




Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA


















47

ANXIOLYTICS











BIPOLAR AGENTS





Tier 2





Tier 2


Tier 1


Tier 1


Tier 1


48





Tier 1 PA


Tier 1 PA


Tier 1 PA

























Tier 1




49










Tier 2


Tier 2























50










Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3



Tier 3



Tier 3





Tier 3


Tier 3


51





Tier 3


Tier 3



Tier 3



Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3










52























Tier 2 BvD




Tier 2








Tier 2


53





Tier 3 PA





Tier 3 PA







Tier 3 PA


Tier 3 PA


Tier 2



54





Tier 2







Tier 2 PA








Tier 2


Tier 2





Tier 2


Tier 2


55





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


56





Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


57





Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 1


Tier 2



Tier 2


Tier 1


58





Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


60





Tier 1




Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



Tier 2


Tier 2


61






Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


Tier 2


Tier 1


Tier 2




62





Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


63





Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2







Tier 2












64





Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


Tier 3










65



































66


































67













Tier 3 PA LA


Tier 3 PA LA

















68






Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST



Tier 2


Tier 2





Tier 2


70





Tier 2


Tier 2





Tier 2




Tier 2










TIME)



Tier 2

ERY 2 PAD Tier 2


71





Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD







Tier 2 BvD







72






Tier 3 BvD


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


73






Tier 2


Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA




Tier 2



Tier 2



Tier 3


74







Tier 2


Tier 2


Tier 2


Tier 2







Tier 2







75






Tier 2







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2



Tier 2 PA






Tier 2


76





Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 2


Tier 2


Tier 2







Tier 3 LA BvD


77















Tier 3


Tier 2



Tier 3 PA LA







Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA BvD


78






Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2




Tier 2 ST


79










Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


80





Tier 2


Tier 2 BvD







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


81





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA






Tier 2 PA




Tier 2


82







Tier 2







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA






Tier 2 PA


83





Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 3 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


84





Tier 2


Tier 3 PA






Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA





Tier 2




85





Tier 2


Tier 2


Tier 3






Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


86





Tier 3


Tier 2 PA



Tier 3 PA




Tier 3 PA










87







Tier 3 PA LA





Tier 3 PA LA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3 PA


88





Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA





89







Tier 3



Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


90





Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA



Tier 2 BvD


Tier 2


Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 2 BvD


Tier 2 BvD





91







Tier 3






Tier 3


Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







92





Tier 3





Tier 3 BvD








Tier 3



Tier 3 BvD



Tier 3


Tier 3





93








Tier 2


Tier 2





Tier 2






Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


94






Tier 2 PA


Tier 2




Tier 2 BvD



Tier 2





Tier 2 BvD









Tier 2


95





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


96





Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



97





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


98





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS






Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


99

OPHTHALMIC AGENTS




Tier 2





Tier 2


Tier 2


Tier 2




Tier 2







Tier 2




Tier 2


Tier 2


Tier 2


100

OPHTHALMIC AGENTS






Tier 2




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


101

OPHTHALMIC AGENTS






Tier 2



Tier 2




Tier 2


Tier 3


Tier 2


Tier 2




OTIC AGENTS




Tier 2


Tier 2


Tier 3


102

OTIC AGENTS




Tier 3



Tier 2


Tier 2






Tier 2 BvD




















103










Tier 2 PA


Tier 2


Tier 2 PA

















104













Tier 2 BvD


Tier 2








Tier 2 PA








Tier 2


105





OVER TIME)













Tier 2 BvD


TIME)



Tier 2


Tier 2




106






























Tier 2 BvD


107

















Tier 2 PA


Tier 2 PA











108













109

Non-Part D Drugs

































110

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD









Tier 4 NPD


Tier 4 NPD


111

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD























Tier 4 NPD


112

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


113

Non-Part D Drugs






Tier 4 NPD











Tier 4 NPD



Tier 4 NPD


Tier 4 NPD











114

Non-Part D Drugs








Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




115

Non-Part D Drugs







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD








Tier 4 NPD




Tier 4 NPD


Tier 4 NPD



116

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD




117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






















Tier 4 NPD


118

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 PA NPD






Tier 4 NPD




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD





119

Non-Part D Drugs
















Tier 4 PA NPD





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD


120

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD







Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




121

Non-Part D Drugs




Tier 4 NPD




Tier 4 NPD








122




123




124



125




126



127




128




129




130

FYCOMPA 13




131




132





133




134




135




136




137



138





139




140




141




142





143


YYF-VAX 93


144



H0148_20_503

Blu

e S

hie

ld o

f C

alif

orn

ia P

rom

ise

He

alt

h P

lan

is a

n in

de

pe

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see

of

the

Blu

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ld A

sso

cia

tio

n

A51247-C

MS (

91

8)




as














Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228






H0148_20_253 09092019





한국어 (Korean)




Italiano (Italian)





Hmong (Hmong)




















11222021


A Disclaimers
































Category Listing




v














vi

















vii















viii

















1 - 122


ix












123

1 - 122


x
















xi












xii












$0 $0 $0


$0 to $370 copay

Not available


$0 to $920 copay

Not available




xiii







123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand







ST Step Therapy



xv












ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23




ANTINEOPLASTICS 25

ANTIPARASITICS 34


ANTIPSYCHOTICS 37


ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48























OTIC AGENTS 102




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2



Tier 2


Tier 2








1

ANALGESICS




Tier 2 PA NDS



























2

ANALGESICS





























3

ANALGESICS














ANESTHETICS













Tier 2



4






















Tier 2










5








ANTIBACTERIALS




Tier 2


Tier 2





Tier 2


Tier 2




Tier 2


Tier 2


6

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


7

ANTIBACTERIALS




Tier 2




Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




11

ANTIBACTERIALS




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTICONVULSANTS











Tier 2



Tier 2







Tier 2


Tier 2







13

ANTICONVULSANTS




Tier 2 PA


Tier 2


Tier 2












Tier 2










14

ANTICONVULSANTS








Tier 2 PA





Tier 2 PA














Tier 2



Tier 3


15

ANTICONVULSANTS




Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2




16

ANTIDEMENTIA AGENTS




Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


Tier 3 PA


17

ANTIDEPRESSANTS







Tier 2








Tier 2






Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


18

ANTIDEPRESSANTS







Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


Tier 2 PA


Tier 2


Tier 2 PA


19

ANTIDEPRESSANTS




Tier 2 PA


Tier 2



Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2 PA


Tier 2 PA


20

ANTIEMETICS




Tier 2 BvD





Tier 2 BvD








ANTIFUNGALS






Tier 2 BvD


Tier 2 PA


Tier 2


Tier 2


21

ANTIFUNGALS





Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2



Tier 2







Tier 2


Tier 2 PA


22

ANTIFUNGALS




ANTIGOUT AGENTS






Tier 2




ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2


23

ANTIMIGRAINE AGENTS



















ANTIMYCOBACTERIALS





24

ANTIMYCOBACTERIALS





Tier 3


Tier 2


Tier 2





Tier 2





ANTINEOPLASTICS




Tier 3 BvD


Tier 3




25

ANTINEOPLASTICS









Tier 2















Tier 2



Tier 2


Tier 2


26

ANTINEOPLASTICS




Tier 3





Tier 3 PA LA



















Tier 2


Tier 2 PA


27

ANTINEOPLASTICS



































28

ANTINEOPLASTICS




















Tier 3 PA











29

ANTINEOPLASTICS




























Tier 2 PA






30

ANTINEOPLASTICS







































31

ANTINEOPLASTICS






































32

ANTINEOPLASTICS





































33

ANTINEOPLASTICS



















Tier 3

ANTIPARASITICS







34

ANTIPARASITICS




TIME)



Tier 2



















Tier 2 BvD


Tier 2


Tier 3




35





Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2




36





Tier 2

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


37

ANTIPSYCHOTICS




Tier 2


Tier 3 PA








Tier 3 PA



















38

ANTIPSYCHOTICS

















Tier 2







Tier 2




Tier 3


39

ANTIPSYCHOTICS




Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2







40







Tier 2


Tier 2

ANTIVIRALS





















41

ANTIVIRALS









Tier 2
























42

ANTIVIRALS
































43

ANTIVIRALS




























BvD



44

ANTIVIRALS

































45

ANTIVIRALS






























Tier 2



Tier 2


46

ANTIVIRALS




Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA


















47

ANXIOLYTICS











BIPOLAR AGENTS





Tier 2





Tier 2


Tier 1


Tier 1


Tier 1


48





Tier 1 PA


Tier 1 PA


Tier 1 PA

























Tier 1




49










Tier 2


Tier 2























50










Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3



Tier 3



Tier 3





Tier 3


Tier 3


51





Tier 3


Tier 3



Tier 3



Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3










52























Tier 2 BvD




Tier 2








Tier 2


53





Tier 3 PA





Tier 3 PA







Tier 3 PA


Tier 3 PA


Tier 2



54





Tier 2







Tier 2 PA








Tier 2


Tier 2





Tier 2


Tier 2


55





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


56





Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


57





Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 1


Tier 2



Tier 2


Tier 1


58





Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


60





Tier 1




Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



Tier 2


Tier 2


61






Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


Tier 2


Tier 1


Tier 2




62





Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


63





Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2







Tier 2












64





Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


Tier 3










65



































66


































67













Tier 3 PA LA


Tier 3 PA LA

















68






Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST



Tier 2


Tier 2





Tier 2


70





Tier 2


Tier 2





Tier 2




Tier 2










TIME)



Tier 2

ERY 2 PAD Tier 2


71





Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD







Tier 2 BvD







72






Tier 3 BvD


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


73






Tier 2


Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA




Tier 2



Tier 2



Tier 3


74







Tier 2


Tier 2


Tier 2


Tier 2







Tier 2







75






Tier 2







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2



Tier 2 PA






Tier 2


76





Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 2


Tier 2


Tier 2







Tier 3 LA BvD


77















Tier 3


Tier 2



Tier 3 PA LA







Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA BvD


78






Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2




Tier 2 ST


79










Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


80





Tier 2


Tier 2 BvD







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


81





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA






Tier 2 PA




Tier 2


82







Tier 2







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA






Tier 2 PA


83





Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 3 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


84





Tier 2


Tier 3 PA






Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA





Tier 2




85





Tier 2


Tier 2


Tier 3






Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


86





Tier 3


Tier 2 PA



Tier 3 PA




Tier 3 PA










87







Tier 3 PA LA





Tier 3 PA LA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3 PA


88





Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA





89







Tier 3



Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


90





Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA



Tier 2 BvD


Tier 2


Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 2 BvD


Tier 2 BvD





91







Tier 3






Tier 3


Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







92





Tier 3





Tier 3 BvD








Tier 3



Tier 3 BvD



Tier 3


Tier 3





93








Tier 2


Tier 2





Tier 2






Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


94






Tier 2 PA


Tier 2




Tier 2 BvD



Tier 2





Tier 2 BvD









Tier 2


95





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


96





Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



97





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


98





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS






Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


99

OPHTHALMIC AGENTS




Tier 2





Tier 2


Tier 2


Tier 2




Tier 2







Tier 2




Tier 2


Tier 2


Tier 2


100

OPHTHALMIC AGENTS






Tier 2




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


101

OPHTHALMIC AGENTS






Tier 2



Tier 2




Tier 2


Tier 3


Tier 2


Tier 2




OTIC AGENTS




Tier 2


Tier 2


Tier 3


102

OTIC AGENTS




Tier 3



Tier 2


Tier 2






Tier 2 BvD




















103










Tier 2 PA


Tier 2


Tier 2 PA

















104













Tier 2 BvD


Tier 2








Tier 2 PA








Tier 2


105





OVER TIME)













Tier 2 BvD


TIME)



Tier 2


Tier 2




106






























Tier 2 BvD


107

















Tier 2 PA


Tier 2 PA











108













109

Non-Part D Drugs

































110

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD









Tier 4 NPD


Tier 4 NPD


111

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD























Tier 4 NPD


112

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


113

Non-Part D Drugs






Tier 4 NPD











Tier 4 NPD



Tier 4 NPD


Tier 4 NPD











114

Non-Part D Drugs








Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




115

Non-Part D Drugs







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD








Tier 4 NPD




Tier 4 NPD


Tier 4 NPD



116

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD




117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






















Tier 4 NPD


118

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 PA NPD






Tier 4 NPD




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD





119

Non-Part D Drugs
















Tier 4 PA NPD





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD


120

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD







Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




121

Non-Part D Drugs




Tier 4 NPD




Tier 4 NPD








122




123




124



125




126



127




128




129




130

FYCOMPA 13




131




132





133




134




135




136




137



138





139




140




141




142





143


YYF-VAX 93


144



H0148_20_503

Blu

e S

hie

ld o

f C

alif

orn

ia P

rom

ise

He

alt

h P

lan

is a

n in

de

pe

nd

en

t lic

en

see

of

the

Blu

e S

hie

ld A

sso

cia

tio

n

A51247-C

MS (

91

8)




as














Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228






H0148_20_253 09092019





한국어 (Korean)




Italiano (Italian)





Hmong (Hmong)




















11222021


A Disclaimers
































Category Listing




vi

















vii















viii

















1 - 122


ix












123

1 - 122


x
















xi












xii












$0 $0 $0


$0 to $370 copay

Not available


$0 to $920 copay

Not available




xiii







123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand







ST Step Therapy



xv












ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23




ANTINEOPLASTICS 25

ANTIPARASITICS 34


ANTIPSYCHOTICS 37


ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48























OTIC AGENTS 102




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2



Tier 2


Tier 2








1

ANALGESICS




Tier 2 PA NDS



























2

ANALGESICS





























3

ANALGESICS














ANESTHETICS













Tier 2



4






















Tier 2










5








ANTIBACTERIALS




Tier 2


Tier 2





Tier 2


Tier 2




Tier 2


Tier 2


6

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


7

ANTIBACTERIALS




Tier 2




Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




11

ANTIBACTERIALS




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTICONVULSANTS











Tier 2



Tier 2







Tier 2


Tier 2







13

ANTICONVULSANTS




Tier 2 PA


Tier 2


Tier 2












Tier 2










14

ANTICONVULSANTS








Tier 2 PA





Tier 2 PA














Tier 2



Tier 3


15

ANTICONVULSANTS




Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2




16

ANTIDEMENTIA AGENTS




Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


Tier 3 PA


17

ANTIDEPRESSANTS







Tier 2








Tier 2






Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


18

ANTIDEPRESSANTS







Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


Tier 2 PA


Tier 2


Tier 2 PA


19

ANTIDEPRESSANTS




Tier 2 PA


Tier 2



Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2 PA


Tier 2 PA


20

ANTIEMETICS




Tier 2 BvD





Tier 2 BvD








ANTIFUNGALS






Tier 2 BvD


Tier 2 PA


Tier 2


Tier 2


21

ANTIFUNGALS





Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2



Tier 2







Tier 2


Tier 2 PA


22

ANTIFUNGALS




ANTIGOUT AGENTS






Tier 2




ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2


23

ANTIMIGRAINE AGENTS



















ANTIMYCOBACTERIALS





24

ANTIMYCOBACTERIALS





Tier 3


Tier 2


Tier 2





Tier 2





ANTINEOPLASTICS




Tier 3 BvD


Tier 3




25

ANTINEOPLASTICS









Tier 2















Tier 2



Tier 2


Tier 2


26

ANTINEOPLASTICS




Tier 3





Tier 3 PA LA



















Tier 2


Tier 2 PA


27

ANTINEOPLASTICS



































28

ANTINEOPLASTICS




















Tier 3 PA











29

ANTINEOPLASTICS




























Tier 2 PA






30

ANTINEOPLASTICS







































31

ANTINEOPLASTICS






































32

ANTINEOPLASTICS





































33

ANTINEOPLASTICS



















Tier 3

ANTIPARASITICS







34

ANTIPARASITICS




TIME)



Tier 2



















Tier 2 BvD


Tier 2


Tier 3




35





Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2




36





Tier 2

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


37

ANTIPSYCHOTICS




Tier 2


Tier 3 PA








Tier 3 PA



















38

ANTIPSYCHOTICS

















Tier 2







Tier 2




Tier 3


39

ANTIPSYCHOTICS




Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2







40







Tier 2


Tier 2

ANTIVIRALS





















41

ANTIVIRALS









Tier 2
























42

ANTIVIRALS
































43

ANTIVIRALS




























BvD



44

ANTIVIRALS

































45

ANTIVIRALS






























Tier 2



Tier 2


46

ANTIVIRALS




Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA


















47

ANXIOLYTICS











BIPOLAR AGENTS





Tier 2





Tier 2


Tier 1


Tier 1


Tier 1


48





Tier 1 PA


Tier 1 PA


Tier 1 PA

























Tier 1




49










Tier 2


Tier 2























50










Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3



Tier 3



Tier 3





Tier 3


Tier 3


51





Tier 3


Tier 3



Tier 3



Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3










52























Tier 2 BvD




Tier 2








Tier 2


53





Tier 3 PA





Tier 3 PA







Tier 3 PA


Tier 3 PA


Tier 2



54





Tier 2







Tier 2 PA








Tier 2


Tier 2





Tier 2


Tier 2


55





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


56





Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


57





Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 1


Tier 2



Tier 2


Tier 1


58





Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


60





Tier 1




Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



Tier 2


Tier 2


61






Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


Tier 2


Tier 1


Tier 2




62





Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


63





Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2







Tier 2












64





Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


Tier 3










65



































66


































67













Tier 3 PA LA


Tier 3 PA LA

















68






Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST



Tier 2


Tier 2





Tier 2


70





Tier 2


Tier 2





Tier 2




Tier 2










TIME)



Tier 2

ERY 2 PAD Tier 2


71





Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD







Tier 2 BvD







72






Tier 3 BvD


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


73






Tier 2


Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA




Tier 2



Tier 2



Tier 3


74







Tier 2


Tier 2


Tier 2


Tier 2







Tier 2







75






Tier 2







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2



Tier 2 PA






Tier 2


76





Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 2


Tier 2


Tier 2







Tier 3 LA BvD


77















Tier 3


Tier 2



Tier 3 PA LA







Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA BvD


78






Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2




Tier 2 ST


79










Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


80





Tier 2


Tier 2 BvD







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


81





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA






Tier 2 PA




Tier 2


82







Tier 2







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA






Tier 2 PA


83





Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 3 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


84





Tier 2


Tier 3 PA






Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA





Tier 2




85





Tier 2


Tier 2


Tier 3






Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


86





Tier 3


Tier 2 PA



Tier 3 PA




Tier 3 PA










87







Tier 3 PA LA





Tier 3 PA LA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3 PA


88





Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA





89







Tier 3



Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


90





Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA



Tier 2 BvD


Tier 2


Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 2 BvD


Tier 2 BvD





91







Tier 3






Tier 3


Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







92





Tier 3





Tier 3 BvD








Tier 3



Tier 3 BvD



Tier 3


Tier 3





93








Tier 2


Tier 2





Tier 2






Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


94






Tier 2 PA


Tier 2




Tier 2 BvD



Tier 2





Tier 2 BvD









Tier 2


95





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


96





Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



97





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


98





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS






Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


99

OPHTHALMIC AGENTS




Tier 2





Tier 2


Tier 2


Tier 2




Tier 2







Tier 2




Tier 2


Tier 2


Tier 2


100

OPHTHALMIC AGENTS






Tier 2




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


101

OPHTHALMIC AGENTS






Tier 2



Tier 2




Tier 2


Tier 3


Tier 2


Tier 2




OTIC AGENTS




Tier 2


Tier 2


Tier 3


102

OTIC AGENTS




Tier 3



Tier 2


Tier 2






Tier 2 BvD




















103










Tier 2 PA


Tier 2


Tier 2 PA

















104













Tier 2 BvD


Tier 2








Tier 2 PA








Tier 2


105





OVER TIME)













Tier 2 BvD


TIME)



Tier 2


Tier 2




106






























Tier 2 BvD


107

















Tier 2 PA


Tier 2 PA











108













109

Non-Part D Drugs

































110

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD









Tier 4 NPD


Tier 4 NPD


111

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD























Tier 4 NPD


112

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


113

Non-Part D Drugs






Tier 4 NPD











Tier 4 NPD



Tier 4 NPD


Tier 4 NPD











114

Non-Part D Drugs








Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




115

Non-Part D Drugs







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD








Tier 4 NPD




Tier 4 NPD


Tier 4 NPD



116

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD




117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






















Tier 4 NPD


118

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 PA NPD






Tier 4 NPD




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD





119

Non-Part D Drugs
















Tier 4 PA NPD





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD


120

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD







Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




121

Non-Part D Drugs




Tier 4 NPD




Tier 4 NPD








122




123




124



125




126



127




128




129




130

FYCOMPA 13




131




132





133




134




135




136




137



138





139




140




141




142





143


YYF-VAX 93


144



H0148_20_503

Blu

e S

hie

ld o

f C

alif

orn

ia P

rom

ise

He

alt

h P

lan

is a

n in

de

pe

nd

en

t lic

en

see

of

the

Blu

e S

hie

ld A

sso

cia

tio

n

A51247-C

MS (

91

8)




as














Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228






H0148_20_253 09092019





한국어 (Korean)




Italiano (Italian)





Hmong (Hmong)




















11222021


A Disclaimers
































Category Listing




vii















viii

















1 - 122


ix












123

1 - 122


x
















xi












xii












$0 $0 $0


$0 to $370 copay

Not available


$0 to $920 copay

Not available




xiii







123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand







ST Step Therapy



xv












ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23




ANTINEOPLASTICS 25

ANTIPARASITICS 34


ANTIPSYCHOTICS 37


ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48























OTIC AGENTS 102




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2



Tier 2


Tier 2








1

ANALGESICS




Tier 2 PA NDS



























2

ANALGESICS





























3

ANALGESICS














ANESTHETICS













Tier 2



4






















Tier 2










5








ANTIBACTERIALS




Tier 2


Tier 2





Tier 2


Tier 2




Tier 2


Tier 2


6

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


7

ANTIBACTERIALS




Tier 2




Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




11

ANTIBACTERIALS




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTICONVULSANTS











Tier 2



Tier 2







Tier 2


Tier 2







13

ANTICONVULSANTS




Tier 2 PA


Tier 2


Tier 2












Tier 2










14

ANTICONVULSANTS








Tier 2 PA





Tier 2 PA














Tier 2



Tier 3


15

ANTICONVULSANTS




Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2




16

ANTIDEMENTIA AGENTS




Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


Tier 3 PA


17

ANTIDEPRESSANTS







Tier 2








Tier 2






Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


18

ANTIDEPRESSANTS







Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


Tier 2 PA


Tier 2


Tier 2 PA


19

ANTIDEPRESSANTS




Tier 2 PA


Tier 2



Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2 PA


Tier 2 PA


20

ANTIEMETICS




Tier 2 BvD





Tier 2 BvD








ANTIFUNGALS






Tier 2 BvD


Tier 2 PA


Tier 2


Tier 2


21

ANTIFUNGALS





Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2



Tier 2







Tier 2


Tier 2 PA


22

ANTIFUNGALS




ANTIGOUT AGENTS






Tier 2




ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2


23

ANTIMIGRAINE AGENTS



















ANTIMYCOBACTERIALS





24

ANTIMYCOBACTERIALS





Tier 3


Tier 2


Tier 2





Tier 2





ANTINEOPLASTICS




Tier 3 BvD


Tier 3




25

ANTINEOPLASTICS









Tier 2















Tier 2



Tier 2


Tier 2


26

ANTINEOPLASTICS




Tier 3





Tier 3 PA LA



















Tier 2


Tier 2 PA


27

ANTINEOPLASTICS



































28

ANTINEOPLASTICS




















Tier 3 PA











29

ANTINEOPLASTICS




























Tier 2 PA






30

ANTINEOPLASTICS







































31

ANTINEOPLASTICS






































32

ANTINEOPLASTICS





































33

ANTINEOPLASTICS



















Tier 3

ANTIPARASITICS







34

ANTIPARASITICS




TIME)



Tier 2



















Tier 2 BvD


Tier 2


Tier 3




35





Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2




36





Tier 2

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


37

ANTIPSYCHOTICS




Tier 2


Tier 3 PA








Tier 3 PA



















38

ANTIPSYCHOTICS

















Tier 2







Tier 2




Tier 3


39

ANTIPSYCHOTICS




Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2







40







Tier 2


Tier 2

ANTIVIRALS





















41

ANTIVIRALS









Tier 2
























42

ANTIVIRALS
































43

ANTIVIRALS




























BvD



44

ANTIVIRALS

































45

ANTIVIRALS






























Tier 2



Tier 2


46

ANTIVIRALS




Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA


















47

ANXIOLYTICS











BIPOLAR AGENTS





Tier 2





Tier 2


Tier 1


Tier 1


Tier 1


48





Tier 1 PA


Tier 1 PA


Tier 1 PA

























Tier 1




49










Tier 2


Tier 2























50










Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3



Tier 3



Tier 3





Tier 3


Tier 3


51





Tier 3


Tier 3



Tier 3



Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3










52























Tier 2 BvD




Tier 2








Tier 2


53





Tier 3 PA





Tier 3 PA







Tier 3 PA


Tier 3 PA


Tier 2



54





Tier 2







Tier 2 PA








Tier 2


Tier 2





Tier 2


Tier 2


55





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


56





Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


57





Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 1


Tier 2



Tier 2


Tier 1


58





Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


60





Tier 1




Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



Tier 2


Tier 2


61






Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


Tier 2


Tier 1


Tier 2




62





Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


63





Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2







Tier 2












64





Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


Tier 3










65



































66


































67













Tier 3 PA LA


Tier 3 PA LA

















68






Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST



Tier 2


Tier 2





Tier 2


70





Tier 2


Tier 2





Tier 2




Tier 2










TIME)



Tier 2

ERY 2 PAD Tier 2


71





Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD







Tier 2 BvD







72






Tier 3 BvD


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


73






Tier 2


Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA




Tier 2



Tier 2



Tier 3


74







Tier 2


Tier 2


Tier 2


Tier 2







Tier 2







75






Tier 2







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2



Tier 2 PA






Tier 2


76





Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 2


Tier 2


Tier 2







Tier 3 LA BvD


77















Tier 3


Tier 2



Tier 3 PA LA







Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA BvD


78






Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2




Tier 2 ST


79










Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


80





Tier 2


Tier 2 BvD







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


81





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA






Tier 2 PA




Tier 2


82







Tier 2







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA






Tier 2 PA


83





Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 3 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


84





Tier 2


Tier 3 PA






Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA





Tier 2




85





Tier 2


Tier 2


Tier 3






Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


86





Tier 3


Tier 2 PA



Tier 3 PA




Tier 3 PA










87







Tier 3 PA LA





Tier 3 PA LA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3 PA


88





Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA





89







Tier 3



Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


90





Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA



Tier 2 BvD


Tier 2


Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 2 BvD


Tier 2 BvD





91







Tier 3






Tier 3


Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







92





Tier 3





Tier 3 BvD








Tier 3



Tier 3 BvD



Tier 3


Tier 3





93








Tier 2


Tier 2





Tier 2






Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


94






Tier 2 PA


Tier 2




Tier 2 BvD



Tier 2





Tier 2 BvD









Tier 2


95





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


96





Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



97





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


98





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS






Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


99

OPHTHALMIC AGENTS




Tier 2





Tier 2


Tier 2


Tier 2




Tier 2







Tier 2




Tier 2


Tier 2


Tier 2


100

OPHTHALMIC AGENTS






Tier 2




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


101

OPHTHALMIC AGENTS






Tier 2



Tier 2




Tier 2


Tier 3


Tier 2


Tier 2




OTIC AGENTS




Tier 2


Tier 2


Tier 3


102

OTIC AGENTS




Tier 3



Tier 2


Tier 2






Tier 2 BvD




















103










Tier 2 PA


Tier 2


Tier 2 PA

















104













Tier 2 BvD


Tier 2








Tier 2 PA








Tier 2


105





OVER TIME)













Tier 2 BvD


TIME)



Tier 2


Tier 2




106






























Tier 2 BvD


107

















Tier 2 PA


Tier 2 PA











108













109

Non-Part D Drugs

































110

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD









Tier 4 NPD


Tier 4 NPD


111

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD























Tier 4 NPD


112

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


113

Non-Part D Drugs






Tier 4 NPD











Tier 4 NPD



Tier 4 NPD


Tier 4 NPD











114

Non-Part D Drugs








Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




115

Non-Part D Drugs







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD








Tier 4 NPD




Tier 4 NPD


Tier 4 NPD



116

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD




117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






















Tier 4 NPD


118

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 PA NPD






Tier 4 NPD




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD





119

Non-Part D Drugs
















Tier 4 PA NPD





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD


120

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD







Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




121

Non-Part D Drugs




Tier 4 NPD




Tier 4 NPD








122




123




124



125




126



127




128




129




130

FYCOMPA 13




131




132





133




134




135




136




137



138





139




140




141




142





143


YYF-VAX 93


144



H0148_20_503

Blu

e S

hie

ld o

f C

alif

orn

ia P

rom

ise

He

alt

h P

lan

is a

n in

de

pe

nd

en

t lic

en

see

of

the

Blu

e S

hie

ld A

sso

cia

tio

n

A51247-C

MS (

91

8)




as














Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228






H0148_20_253 09092019





한국어 (Korean)




Italiano (Italian)





Hmong (Hmong)




















11222021


A Disclaimers
































Category Listing




viii

















1 - 122


ix












123

1 - 122


x
















xi












xii












$0 $0 $0


$0 to $370 copay

Not available


$0 to $920 copay

Not available




xiii







123


xiv

LEGEND

TIER NAME

1 Preferred Generic

2 Generic

3 Brand







ST Step Therapy



xv












ANESTHETICS 4


ANTIBACTERIALS 6

ANTICONVULSANTS 13


ANTIDEPRESSANTS 17

ANTIEMETICS 20

ANTIFUNGALS 21

ANTIGOUT AGENTS 23




ANTINEOPLASTICS 25

ANTIPARASITICS 34


ANTIPSYCHOTICS 37


ANTIVIRALS 41

ANXIOLYTICS 47

BIPOLAR AGENTS 48























OTIC AGENTS 102




ANALGESICS








Tier 2




Tier 2



Tier 2


Tier 2 PA


Tier 2



Tier 2


Tier 2








1

ANALGESICS




Tier 2 PA NDS



























2

ANALGESICS





























3

ANALGESICS














ANESTHETICS













Tier 2



4






















Tier 2










5








ANTIBACTERIALS




Tier 2


Tier 2





Tier 2


Tier 2




Tier 2


Tier 2


6

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2




Tier 2 PA


Tier 2


Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


7

ANTIBACTERIALS




Tier 2




Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


8

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 3


Tier 2


9

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2



Tier 2


Tier 2


Tier 3


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


10

ANTIBACTERIALS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 3


Tier 2


Tier 2




11

ANTIBACTERIALS




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


12

ANTICONVULSANTS











Tier 2



Tier 2







Tier 2


Tier 2







13

ANTICONVULSANTS




Tier 2 PA


Tier 2


Tier 2












Tier 2










14

ANTICONVULSANTS








Tier 2 PA





Tier 2 PA














Tier 2



Tier 3


15

ANTICONVULSANTS




Tier 2



Tier 3


Tier 2


Tier 2









Tier 2

ANTIDEMENTIA AGENTS





Tier 2




16

ANTIDEMENTIA AGENTS




Tier 2


Tier 2

ANTIDEPRESSANTS













Tier 2


Tier 2


Tier 3 PA


17

ANTIDEPRESSANTS







Tier 2








Tier 2






Tier 2


Tier 2



Tier 2


Tier 2


Tier 2


18

ANTIDEPRESSANTS







Tier 2


Tier 2






Tier 2








Tier 2 PA


Tier 2


Tier 2 PA


Tier 2


Tier 2 PA


19

ANTIDEPRESSANTS




Tier 2 PA


Tier 2



Tier 2


Tier 2 PA

ANTIEMETICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2 PA


Tier 2 PA


20

ANTIEMETICS




Tier 2 BvD





Tier 2 BvD








ANTIFUNGALS






Tier 2 BvD


Tier 2 PA


Tier 2


Tier 2


21

ANTIFUNGALS





Tier 3 PA



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2



Tier 2







Tier 2


Tier 2 PA


22

ANTIFUNGALS




ANTIGOUT AGENTS






Tier 2




ANTIMIGRAINE AGENTS




Tier 2 PA









Tier 2


23

ANTIMIGRAINE AGENTS



















ANTIMYCOBACTERIALS





24

ANTIMYCOBACTERIALS





Tier 3


Tier 2


Tier 2





Tier 2





ANTINEOPLASTICS




Tier 3 BvD


Tier 3




25

ANTINEOPLASTICS









Tier 2















Tier 2



Tier 2


Tier 2


26

ANTINEOPLASTICS




Tier 3





Tier 3 PA LA



















Tier 2


Tier 2 PA


27

ANTINEOPLASTICS



































28

ANTINEOPLASTICS




















Tier 3 PA











29

ANTINEOPLASTICS




























Tier 2 PA






30

ANTINEOPLASTICS







































31

ANTINEOPLASTICS






































32

ANTINEOPLASTICS





































33

ANTINEOPLASTICS



















Tier 3

ANTIPARASITICS







34

ANTIPARASITICS




TIME)



Tier 2



















Tier 2 BvD


Tier 2


Tier 3




35





Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2



Tier 2




36





Tier 2

ANTIPSYCHOTICS




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2






Tier 2 PA


Tier 2


37

ANTIPSYCHOTICS




Tier 2


Tier 3 PA








Tier 3 PA



















38

ANTIPSYCHOTICS

















Tier 2







Tier 2




Tier 3


39

ANTIPSYCHOTICS




Tier 2







Tier 2


Tier 2


Tier 3 PA


Tier 2







40







Tier 2


Tier 2

ANTIVIRALS





















41

ANTIVIRALS









Tier 2
























42

ANTIVIRALS
































43

ANTIVIRALS




























BvD



44

ANTIVIRALS

































45

ANTIVIRALS






























Tier 2



Tier 2


46

ANTIVIRALS




Tier 2


Tier 2

ANXIOLYTICS




Tier 2


Tier 2 PA


















47

ANXIOLYTICS











BIPOLAR AGENTS





Tier 2





Tier 2


Tier 1


Tier 1


Tier 1


48





Tier 1 PA


Tier 1 PA


Tier 1 PA

























Tier 1




49










Tier 2


Tier 2























50










Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3



Tier 3



Tier 3





Tier 3


Tier 3


51





Tier 3


Tier 3



Tier 3



Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


Tier 3










52























Tier 2 BvD




Tier 2








Tier 2


53





Tier 3 PA





Tier 3 PA







Tier 3 PA


Tier 3 PA


Tier 2



54





Tier 2







Tier 2 PA








Tier 2


Tier 2





Tier 2


Tier 2


55





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


56





Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2



Tier 2


Tier 2


Tier 2


57





Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 1


Tier 1


Tier 2



Tier 2


Tier 1


58





Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


59





Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 1


Tier 2


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2


60





Tier 1




Tier 3




Tier 1




Tier 1


Tier 1


Tier 1


Tier 1


Tier 2


Tier 2



Tier 2


Tier 2


61






Tier 2


Tier 1




Tier 2


Tier 3 PA


Tier 1


Tier 2


Tier 1



Tier 2


Tier 2


Tier 1


Tier 2




62





Tier 2


Tier 2


Tier 2


Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 1


Tier 1


Tier 2


Tier 1


Tier 1


Tier 1


63





Tier 1


Tier 2


Tier 2


Tier 2


Tier 2



Tier 2







Tier 2












64





Tier 2



Tier 2


Tier 2


Tier 2



Tier 2


Tier 3










65



































66


































67













Tier 3 PA LA


Tier 3 PA LA

















68






Tier 2


Tier 2





Tier 2



Tier 2




Tier 2 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


69





Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


Tier 2


Tier 2 ST



Tier 2


Tier 2





Tier 2


70





Tier 2


Tier 2





Tier 2




Tier 2










TIME)



Tier 2

ERY 2 PAD Tier 2


71





Tier 2







Tier 2 BvD




Tier 2 BvD


Tier 2 BvD







Tier 2 BvD







72






Tier 3 BvD


Tier 2




Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


73






Tier 2


Tier 2





Tier 2



Tier 3 PA LA


Tier 3 PA LA




Tier 2



Tier 2



Tier 3


74







Tier 2


Tier 2


Tier 2


Tier 2







Tier 2







75






Tier 2







Tier 2


Tier 3 PA


Tier 3


Tier 2 PA


Tier 2


Tier 2



Tier 2 PA






Tier 2


76





Tier 2


Tier 2


Tier 2



Tier 2


Tier 2



Tier 2


Tier 2


Tier 2







Tier 3 LA BvD


77















Tier 3


Tier 2



Tier 3 PA LA







Tier 2 PA


Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA BvD


78






Tier 2 PA


Tier 2 PA


Tier 3 PA LA




Tier 3





Tier 3


Tier 2




Tier 2 ST


79










Tier 2



Tier 3 PA LA






Tier 2


Tier 2


Tier 2


Tier 2



Tier 2


80





Tier 2


Tier 2 BvD







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


81





Tier 2


Tier 2


Tier 2





Tier 3 PA


Tier 3 PA LA






Tier 2 PA




Tier 2


82







Tier 2







Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA






Tier 2 PA


83





Tier 2



Tier 2




Tier 2


Tier 2


Tier 2


Tier 3 PA


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2 PA


Tier 2


Tier 2


Tier 2


84





Tier 2


Tier 3 PA






Tier 3


Tier 2


Tier 2


Tier 2


Tier 2 PA





Tier 2




85





Tier 2


Tier 2


Tier 3






Tier 3




Tier 3


Tier 3


Tier 3


Tier 3


Tier 3


86





Tier 3


Tier 2 PA



Tier 3 PA




Tier 3 PA










87







Tier 3 PA LA





Tier 3 PA LA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA LA


Tier 3 PA


Tier 3 PA


88





Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA






Tier 3 PA LA


Tier 3 PA LA


Tier 3 LA





89







Tier 3



Tier 2 BvD



Tier 2 BvD


Tier 2 BvD


Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 2 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA


90





Tier 3 PA


Tier 3 PA


Tier 3 PA


Tier 3 PA



Tier 2 BvD


Tier 2


Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


Tier 3 PA




Tier 2 BvD


Tier 2 BvD





91







Tier 3






Tier 3


Tier 3 BvD


Tier 3


Tier 3



Tier 3





Tier 3







92





Tier 3





Tier 3 BvD








Tier 3



Tier 3 BvD



Tier 3


Tier 3





93








Tier 2


Tier 2





Tier 2






Tier 1




Tier 2 BvD


Tier 2 BvD


Tier 2 BvD


94






Tier 2 PA


Tier 2




Tier 2 BvD



Tier 2





Tier 2 BvD









Tier 2


95





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2




Tier 2


96





Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


Tier 2




Tier 2


Tier 2



97





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


Tier 2


98





Tier 2


Tier 2


Tier 2


Tier 2


Tier 2

OPHTHALMIC AGENTS






Tier 2



Tier 2


Tier 2


Tier 2


Tier 2


99

OPHTHALMIC AGENTS




Tier 2





Tier 2


Tier 2


Tier 2




Tier 2







Tier 2




Tier 2


Tier 2


Tier 2


100

OPHTHALMIC AGENTS






Tier 2




Tier 2



Tier 2


Tier 2


Tier 2


Tier 2






Tier 2



Tier 2


Tier 2


101

OPHTHALMIC AGENTS






Tier 2



Tier 2




Tier 2


Tier 3


Tier 2


Tier 2




OTIC AGENTS




Tier 2


Tier 2


Tier 3


102

OTIC AGENTS




Tier 3



Tier 2


Tier 2






Tier 2 BvD




















103










Tier 2 PA


Tier 2


Tier 2 PA

















104













Tier 2 BvD


Tier 2








Tier 2 PA








Tier 2


105





OVER TIME)













Tier 2 BvD


TIME)



Tier 2


Tier 2




106






























Tier 2 BvD


107

















Tier 2 PA


Tier 2 PA











108













109

Non-Part D Drugs

































110

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD









Tier 4 NPD


Tier 4 NPD


111

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD























Tier 4 NPD


112

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


113

Non-Part D Drugs






Tier 4 NPD











Tier 4 NPD



Tier 4 NPD


Tier 4 NPD











114

Non-Part D Drugs








Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 NPD


Tier 4 NPD




115

Non-Part D Drugs







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD








Tier 4 NPD




Tier 4 NPD


Tier 4 NPD



116

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD







Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD


Tier 4 NPD




117

Non-Part D Drugs




Tier 4 NPD


Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






















Tier 4 NPD


118

Non-Part D Drugs





Tier 4 NPD



Tier 4 NPD



Tier 4 NPD


Tier 4 PA NPD






Tier 4 NPD




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD





119

Non-Part D Drugs
















Tier 4 PA NPD





Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 NPD


Tier 4 PA NPD



Tier 4 NPD


Tier 4 NPD


120

Non-Part D Drugs




Tier 4 NPD



Tier 4 NPD


Tier 4 NPD







Tier 4 NPD


Tier 4 NPD



Tier 4 NPD






Tier 4 NPD


Tier 4 NPD



Tier 4 NPD




121

Non-Part D Drugs




Tier 4 NPD




Tier 4 NPD








122




123




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125




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FYCOMPA 13




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133




134




135




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143


YYF-VAX 93


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Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228






H0148_20_253 09092019





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Category Listing



2 02 1 List of Cover ed Drugs (Formulary)

Documents

Transcript of 2 02 1 List of Cover ed Drugs (Formulary)