6-Tier Drug Formulary - Avera Health1 Avera Health Plans 2019 6-Tier Drug Formulary Effective April...

2019

6-Tier Drug Formulary

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Avera Health Plans

2019 6-Tier Drug Formulary

Effective April 1, 2019

PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee

coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs.

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What is the Avera Health Plans Drug Formulary?

The Drug Formulary is a list of covered prescription drugs, which are approved for use for specific treatments and dispensed through participating pharmacies. Avera Health Plans works with a team of health care providers to choose drugs that provide quality treatment. Avera Health Plans covers drugs on the Drug Formulary that are:

Medically necessary

Approved by the United States Food and Drug Administration (FDA)

Filled at a participating pharmacy

For more information on how to fill your prescriptions and determine if your drug is covered, please review your Certificate of Coverage, Master Contract, Plan Document or other plan materials.

Can the Drug Formulary change?

The Drug Formulary may change from time to time as described in the Certificate of Coverage, Master Contract, Plan Document or other plan materials. The enclosed Drug Formulary is the most current Drug Formulary covered by Avera Health Plans. To get updated information about the drugs covered by Avera Health Plans, please visit us online at AveraHealthPlans.com or call our Service Center at 605-322-4545 or toll-free at 1-888-322-2115, 8 a.m. to 5 p.m. CT, Monday through Friday.

How do I use the Drug Formulary?

There are two ways to find your drug on the drug list: 1. Medical Condition The Drug Formulary starts on page 5. The drugs on this Drug Formulary are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under CARDIOVASCULAR.

If you know what your drug is used for, look for the category name in the list that starts on page 5.

Then look under the category name for your drug

2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 169. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.

Look in the Index and find your drug

Next to your drug, 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

For more information about your Avera Health Plans prescription drug coverage, please look at your Certificate of Coverage, Master Contract, Plan Document or other plan materials. If you have questions about this Drug Formulary, please call our Service Center at 605-322-4545 or toll-free at 1-888-322-2115, 8 a.m. to 5 p.m. CT, Monday through Friday. You may also visit us online at AveraHealthPlans.com.

Avera Health Plans Drug Formulary

The Drug Formulary that starts on the page 5, gives you information about the drugs covered by Avera Health Plans. A generic drug is a drug that has the same active ingredients as its brand-name counterpart, and has been approved by the FDA as being interchangeable with the brand-name drug as approved by your provider. Upon release of a generic drug to the market, the generic drug will generally be added to the formulary and the associated brand drug will be considered non-preferred or not covered. However, some generic drugs do not cost less than brand-name drugs and may not be added to your formulary. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin).

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The second column (labeled Drug Tier) will list what tier the drug is placed on in the Drug Formulary. Refer to your Summary of Benefits and Coverage to find the associated co-pay for that drug tier. The information in the Requirements/Limits column tells you if Avera Health Plans has any special requirements for coverage of your drug. These requirements and limits may include:

Preauthorization (MN-PA and PA): Avera Health Plans needs your healthcare provider to get preauthorization for certain drugs. This means that approval from Avera Health Plans must be obtained before you fill your drug. If you don't get approval, Avera Health Plans will not cover the cost of the drug. There are two types of preauthorizations, standard preauthorizations (PA) and medical necessity preauthorizations (MN-PA). The main difference between these two types of preauthorizations is that drugs requiring medical necessity preauthorization require you to try at least one alternative drug before they are approved. Additional information can be found online at AveraHealthPlans.com.

Quantity Limits (QL): For certain drugs, Avera Health Plans limits the amount of the drug that it will cover. For example, Avera Health Plans only covers 18 tablets of sumatriptan 50 mg per 30 days. Avera Health Plans also limits the amount of drugs you may receive within a class of drugs. These classes have an "§" next to them on the drug list. For these classes, only one drug should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply.

Step Therapy (ST): Avera Health Plans utilizes step therapy to provide the most cost-effective and safest drugs available for a specific medical condition. Step therapy programs require your healthcare provider to prescribe a step-one drug before a step-two drug will be covered. If the step-one drugs do not work for you, Avera Health Plans will cover the step-two drugs. Visit us online at AveraHealthPlans.com to review a list of Step Therapy Programs.

Age Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on age.

Gender Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on gender.

What if my drug is not on the Drug Formulary?

If your drug is not on this Drug Formulary, you have two choices:

Your healthcare provider can prescribe a drug that is similar that is covered on the Drug Formulary. Similar drugs that are preferred and covered on the Drug Formulary may be easier to obtain and lower cost to you.

You can request a formulary exception if you believe the drug you take should be covered because other treatment options on the Drug Formulary do not work for you. To request a formulary exception, you or your healthcare provider must provide written documentation to include the following:

• Why no other prescription on the Drug Formulary will work as well as the requested drug • A list of other drugs that have been tried and how you responded to these drugs • Medical documentation to support the medical necessity

How likely is it that I will get the formulary exception?

We will review the information and when a decision has been made, you and your healthcare provider will receive a letter that states the decision. If a formulary exception is approved, the non-preferred co-pay (for the applicable drug type) will be applied. The prescription must be a covered benefit on your plan. Formulary exceptions do not include reductions on prescriptions co-pays.

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What do the tiers mean on the Drug Formulary?

Tier

Type of Drugs Included

Tier 1

Preventive drugs (covered at no cost to you)

Tier 2

Preferred generic drugs

Tier 3

Non-preferred generic drugs

Tier 4

Preferred brand drugs

Tier 5

Non-preferred brand drugs

Tier 6

Specialty drugs (brand and generic)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MN-PA - Medical Necessity Prior Authorization This document contains content that is copyrighted by CVS Health and/or one of its affiliates and reprinted with permission. ©2019. All rights reserved.

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Drug Name Drug Tier Requirements/Limits

ANALGESICS COX-II INHIBITORS

celecoxib cap 50 mg 2 QL celecoxib cap 100 mg 2 QL celecoxib cap 200 mg 2 QL celecoxib cap 400 mg 2 QL

GOUT allopurinol tab 100 mg 2 allopurinol tab 300 mg 2 colchicine cap 0.6 mg 3

colchicine tab 0.6 mg 3 QL colchicine w/ probenecid tab 0.5-500 mg 2 probenecid tab 500 mg 2 ULORIC TAB 40MG 4 QL ULORIC TAB 80MG 4 QL ZURAMPIC TAB 200MG 5 QL, ST

NON-OPIOID ANALGESICS bupap tab 50-300mg 2 QL butalbital-acetaminophen tab 50-300 mg 2 QL butalbital-acetaminophen tab 50-325 mg 2 QL butalbital-acetaminophen-caffeine cap 50-

300-40 mg 2

butalbital-acetaminophen-caffeine cap 50-325-40 mg

2 QL

butalbital-acetaminophen-caffeine tab 50-325-40 mg

2 QL

butalbital-aspirin-caffeine cap 50-325-40 mg

2

esgic cap 2 QL phrenilin cap forte 2 tencon tab 50-325mg 2 QL zebutal cap 2 QL

NSAIDS diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25

mg 2

diclofenac sodium tab delayed release 50 mg

2

diclofenac sodium tab delayed release 75 mg

2

diclofenac sodium tab er 24hr 100 mg 2

diflunisal tab 500 mg 2 etodolac cap 200 mg 2


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Drug Name Drug Tier Requirements/Limits etodolac cap 300 mg 2 etodolac tab 400 mg 2 etodolac tab 500 mg 2 etodolac tab er 24hr 400 mg 2

etodolac tab er 24hr 500 mg 2 etodolac tab er 24hr 600 mg 2 fenoprofen calcium tab 600 mg 3 FENOPROFEN CAP 200MG 5 FENORTHO CAP 200MG 5

flurbiprofen tab 50 mg 2 flurbiprofen tab 100 mg 2 ibu tab 400mg 2 ibu tab 600mg 2

ibu tab 800mg 2 ibuprofen tab 400 mg 2 ibuprofen tab 600 mg 2 ibuprofen tab 800 mg 2

INDOCIN SUP 50MG 4 INDOCIN SUS 25MG/5ML 4 indomethacin cap 25 mg 2 QL indomethacin cap 50 mg 2 QL indomethacin cap er 75 mg 2 ketoprofen cap er 24hr 200 mg 2 ketorolac tromethamine tab 10 mg 2 QL; Max of 5 days per

fill meclofenamate sodium cap 50 mg 2 meclofenamate sodium cap 100 mg 2

mefenamic acid cap 250 mg 2 meloxicam tab 7.5 mg 2 meloxicam tab 15 mg 2 nabumetone tab 500 mg 2

nabumetone tab 750 mg 2 NALFON CAP 400MG 5 NAPRELAN TAB 750MG CR 5 naproxen dr tab 375mg 2

naproxen dr tab 500mg 2 naproxen sodium tab 275 mg 2 naproxen sodium tab 550 mg 2 naproxen sodium tab er 24hr 500 mg

(base equiv) 3

naproxen tab 250 mg 2

naproxen tab 375 mg 2 naproxen tab 500 mg 2


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Drug Name Drug Tier Requirements/Limits oxaprozin tab 600 mg 2 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 profeno tab 600mg 3

salsalate tab 500 mg 2 salsalate tab 750 mg 2 SPRIX SPR 15.75MG 5 QL sulindac tab 150 mg 2 sulindac tab 200 mg 2

tolmetin sodium cap 400 mg 2 tolmetin sodium tab 200 mg 2 tolmetin sodium tab 600 mg 2 ZIPSOR CAP 25MG 5

NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed

release 50-0.2 mg 3

diclofenac w/ misoprostol tab delayed release 75-0.2 mg

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DUEXIS TAB 800-26.6 5

VIMOVO TAB 375-20MG 5 QL VIMOVO TAB 500-20MG 5 QL

NSAIDS, TOPICAL diclofenac epolamine patch 1.3% 3 QL diclofenac sodium gel 1% 3 QL FLECTOR DIS 1.3% 5 QL PENNSAID SOL 2% 5 QL

OPIOID ANALGESICS ABSTRAL SUB 100MCG 5 QL ABSTRAL SUB 200MCG 5 QL ABSTRAL SUB 300MCG 5 QL ABSTRAL SUB 400MCG 5 QL ABSTRAL SUB 600MCG 5 QL ABSTRAL SUB 800MCG 5 QL acetaminophen w/ codeine soln 120-12

mg/5ml 2

acetaminophen w/ codeine tab 300-15 mg 2 QL; Covered for ages 12 years and older



acetaminophen-caffeine-dihydrocodeine tab 325-30-16 mg

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Drug Name Drug Tier Requirements/Limits ascomp/cod cap 30mg 2 QL; Covered for ages 12

years and older BELBUCA MIS 75MCG 5 QL BELBUCA MIS 150MCG 5 QL BELBUCA MIS 300MCG 5 QL BELBUCA MIS 450MCG 5 QL BELBUCA MIS 600MCG 5 QL BELBUCA MIS 750MCG 5 QL BELBUCA MIS 900MCG 5 QL buprenorphine td patch weekly 5 mcg/hr 3 QL buprenorphine td patch weekly 7.5 mcg/hr 3 QL buprenorphine td patch weekly 10 mcg/hr 3 QL buprenorphine td patch weekly 15 mcg/hr 3 QL buprenorphine td patch weekly 20 mcg/hr 3 QL butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg 2 QL; Covered for ages 12

years and older butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg 2 QL; Covered for ages 12

years and older butalbital-aspirin-caff w/ codeine cap 50-

325-40-30 mg 2 QL; Covered for ages 12

years and older butorphanol tartrate nasal soln 10 mg/ml 3 QL BUTRANS DIS 7.5/HR 5 QL, ST codeine sulfate tab 15 mg 2 QL; Covered for ages 12

years and older codeine sulfate tab 30 mg 2 QL; Covered for ages 12

years and older codeine sulfate tab 60 mg 2 QL; Covered for ages 12

years and older EMBEDA CAP 20-0.8MG 5 QL, ST EMBEDA CAP 30-1.2MG 5 QL, ST EMBEDA CAP 50-2MG 5 QL, ST EMBEDA CAP 60-2.4MG 5 QL, ST EMBEDA CAP 80-3.2MG 5 QL, ST EMBEDA CAP 100-4MG 5 QL, ST endocet tab 2.5-325 2 QL endocet tab 5-325mg 2 QL endocet tab 7.5-325 2 QL endocet tab 10-325mg 2 QL fentanyl citrate lozenge on a handle 200

mcg 3 QL

fentanyl citrate lozenge on a handle 400 mcg

3 QL


3 QL


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Drug Name Drug Tier Requirements/Limits fentanyl citrate lozenge on a handle 800

mcg 3 QL


3 QL


3 QL

fentanyl td patch 72hr 12 mcg/hr 3 QL fentanyl td patch 72hr 25 mcg/hr 3 QL fentanyl td patch 72hr 37.5 mcg/hr 3 QL fentanyl td patch 72hr 50 mcg/hr 3 QL fentanyl td patch 72hr 62.5 mcg/hr 3 QL fentanyl td patch 72hr 75 mcg/hr 3 QL fentanyl td patch 72hr 87.5 mcg/hr 3 QL fentanyl td patch 72hr 100 mcg/hr 3 QL FENTORA TAB 100MCG 5 QL FENTORA TAB 200MCG 5 QL FENTORA TAB 400MCG 5 QL FENTORA TAB 600MCG 5 QL FENTORA TAB 800MCG 5 QL hydrocodone-acetaminophen soln 7.5-325

mg/15ml 2 QL

hydrocodone-acetaminophen tab 2.5-325 mg

2 QL

hydrocodone-acetaminophen tab 5-300 mg 2 QL hydrocodone-acetaminophen tab 5-325 mg 2 QL hydrocodone-acetaminophen tab 7.5-300

mg 2 QL

hydrocodone-acetaminophen tab 7.5-325 mg

2 QL

hydrocodone-acetaminophen tab 10-300 mg

2 QL

hydrocodone-acetaminophen tab 10-325 mg

2 QL

hydrocodone-ibuprofen tab 5-200 mg 3 QL hydrocodone-ibuprofen tab 7.5-200 mg 2 QL hydrocodone-ibuprofen tab 10-200 mg 3 QL HYDROMORPHON SUP 3MG 3 QL hydromorphone hcl liqd 1 mg/ml 3 QL hydromorphone hcl tab 2 mg 3 QL hydromorphone hcl tab 4 mg 3 QL hydromorphone hcl tab 8 mg 3 QL hydromorphone hcl tab er 24hr deter 8 mg 3 QL hydromorphone hcl tab er 24hr deter 12

mg 3 QL


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Drug Name Drug Tier Requirements/Limits hydromorphone hcl tab er 24hr deter 16

mg 3 QL

hydromorphone hcl tab er 24hr deter 32 mg

3 QL

HYSINGLA ER TAB 20 MG 5 QL, ST HYSINGLA ER TAB 30 MG 5 QL, ST HYSINGLA ER TAB 40 MG 5 QL, ST HYSINGLA ER TAB 60 MG 5 QL, ST HYSINGLA ER TAB 80 MG 5 QL, ST HYSINGLA ER TAB 100 MG 5 QL, ST HYSINGLA ER TAB 120 MG 5 QL, ST ibudone tab 5-200mg 3 QL ibudone tab 10-200mg 3 QL KADIAN CAP 200MG ER 5 QL, ST LAZANDA SPR 100MCG 5 QL LAZANDA SPR 300MCG 5 QL LAZANDA SPR 400MCG 5 QL levorphanol tartrate tab 2 mg 3 QL lorcet hd tab 10-325mg 2 QL lorcet plus tab 7.5-325 2 QL lorcet tab 5-325mg 2 QL LORTAB ELX 10-300MG 3 QL meperidine hcl oral soln 50 mg/5ml 3 QL meperidine hcl tab 50 mg 3 QL meperidine hcl tab 100 mg 3 QL methadone con 10mg/ml 3 QL methadone hcl conc 10 mg/ml 3 QL methadone hcl soln 5 mg/5ml 3 QL methadone hcl soln 10 mg/5ml 3 QL methadone hcl tab 5 mg 3 QL methadone hcl tab 10 mg 3 QL methadone hcl tab for oral susp 40 mg 3 QL methadose tab 40mg 2 QL morphine sulfate beads cap er 24hr 30 mg 3 morphine sulfate beads cap er 24hr 45 mg 3 morphine sulfate beads cap er 24hr 60 mg 3 morphine sulfate beads cap er 24hr 75 mg 3

morphine sulfate beads cap er 24hr 90 mg 3 morphine sulfate beads cap er 24hr 120

mg 3

morphine sulfate cap er 24hr 10 mg 3 QL morphine sulfate cap er 24hr 20 mg 3 QL morphine sulfate cap er 24hr 30 mg 3 QL morphine sulfate cap er 24hr 40 mg 3 QL


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Drug Name Drug Tier Requirements/Limits morphine sulfate cap er 24hr 50 mg 3 QL morphine sulfate cap er 24hr 60 mg 3 QL morphine sulfate cap er 24hr 80 mg 3 QL morphine sulfate cap er 24hr 100 mg 3 QL morphine sulfate oral soln 10 mg/5ml 3 QL morphine sulfate oral soln 20 mg/5ml 3 QL morphine sulfate oral soln 100 mg/5ml (20

mg/ml) 3 QL

morphine sulfate suppos 5 mg 3 QL morphine sulfate suppos 10 mg 3 QL morphine sulfate suppos 20 mg 3 QL MORPHINE SULFATE SUPPOS 30 MG 3 QL, ST morphine sulfate tab 15 mg 3 QL morphine sulfate tab 30 mg 3 QL morphine sulfate tab er 15 mg 3 QL morphine sulfate tab er 30 mg 3 QL morphine sulfate tab er 60 mg 3 QL morphine sulfate tab er 100 mg 3 QL morphine sulfate tab er 200 mg 3 QL NUCYNTA ER TAB 50MG 5 QL, ST NUCYNTA ER TAB 100MG 5 QL, ST NUCYNTA ER TAB 150MG 5 QL, ST NUCYNTA ER TAB 200MG 5 QL, ST NUCYNTA ER TAB 250MG 5 QL, ST NUCYNTA TAB 50MG 5 QL NUCYNTA TAB 75MG 5 QL NUCYNTA TAB 100MG 5 QL oxycodone hcl cap 5 mg 3 QL oxycodone hcl conc 100 mg/5ml (20

mg/ml) 3 QL

oxycodone hcl soln 5 mg/5ml 3 QL oxycodone hcl tab 5 mg 3 QL oxycodone hcl tab 10 mg 3 QL oxycodone hcl tab 15 mg 3 QL oxycodone hcl tab 20 mg 3 QL oxycodone hcl tab 30 mg 3 QL oxycodone hcl tab er 12hr deter 10 mg 3 QL oxycodone hcl tab er 12hr deter 15 mg 3 QL oxycodone hcl tab er 12hr deter 20 mg 3 QL oxycodone hcl tab er 12hr deter 30 mg 3 QL oxycodone hcl tab er 12hr deter 40 mg 3 QL oxycodone hcl tab er 12hr deter 60 mg 3 QL oxycodone hcl tab er 12hr deter 80 mg 3 QL


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Drug Name Drug Tier Requirements/Limits oxycodone w/ acetaminophen tab 2.5-325

mg 2 QL

oxycodone w/ acetaminophen tab 5-325 mg

2 QL

oxycodone w/ acetaminophen tab 7.5-325 mg

2 QL

oxycodone w/ acetaminophen tab 10-325 mg

2 QL

oxycodone-aspirin tab 4.8355-325 mg 2 QL oxycodone-ibuprofen tab 5-400 mg 2 QL OXYCONTIN TAB 10MG CR 4 QL, ST OXYCONTIN TAB 15MG CR 4 QL, ST OXYCONTIN TAB 20MG CR 4 QL, ST OXYCONTIN TAB 30MG CR 4 QL, ST OXYCONTIN TAB 40MG CR 4 QL, ST OXYCONTIN TAB 60MG CR 4 QL, ST OXYCONTIN TAB 80MG CR 4 QL, ST oxymorphone hcl tab 5 mg 3 QL oxymorphone hcl tab 10 mg 3 QL oxymorphone hcl tab er 12hr 5 mg 3 QL oxymorphone hcl tab er 12hr 7.5 mg 3 QL oxymorphone hcl tab er 12hr 10 mg 3 QL oxymorphone hcl tab er 12hr 15 mg 3 QL oxymorphone hcl tab er 12hr 20 mg 3 QL oxymorphone hcl tab er 12hr 30 mg 3 QL oxymorphone hcl tab er 12hr 40 mg 3 QL pentazocine w/ naloxone tab 50-0.5 mg 3 QL SUBSYS SPR 100MCG 5

SUBSYS SPR 200MCG 5 SUBSYS SPR 400MCG 5 SUBSYS SPR 600MCG 5 SUBSYS SPR 800MCG 5

SUBSYS SPR 1200MCG 5 SUBSYS SPR 1600MCG 5 TRAMADOL HCL CAP 150MG ER 5 QL; Covered for ages 12

years and older tramadol hcl cap er 24hr biphasic release

100 mg 5 QL; Covered for ages 12





years and older tramadol hcl tab 50 mg 2 QL; Covered for ages 12

years and older


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Drug Name Drug Tier Requirements/Limits tramadol hcl tab er 24hr 100 mg 3 QL; Covered for ages 12

years and older tramadol hcl tab er 24hr 200 mg 3 QL; Covered for ages 12

years and older tramadol hcl tab er 24hr 300 mg 3 QL; Covered for ages 12

years and older tramadol hcl tab er 24hr biphasic release






years and older tramadol-acetaminophen tab 37.5-325 mg 3 QL; Covered for ages 12

years and older verdrocet tab 2.5-325 2 QL vicodin es tab 7.5-300 2 QL vicodin hp tab 10-300mg 2 QL vicodin tab 5-300mg 2 QL ZOHYDRO ER CAP 10MG 5 QL, ST ZOHYDRO ER CAP 15MG 5 QL, ST ZOHYDRO ER CAP 20MG 5 QL, ST ZOHYDRO ER CAP 30MG 5 QL, ST ZOHYDRO ER CAP 40MG 5 QL, ST ZOHYDRO ER CAP 50MG 5 QL, ST

ANTI-INFECTIVES AMINOGLYCOSIDES

ARIKAYCE SUS 6 QL neomycin sulfate tab 500 mg 3 paromomycin sulfate cap 250 mg 3

ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2

cephalexin cap 250 mg 2 cephalexin cap 500 mg 2 cephalexin cap 750 mg 3 cephalexin for susp 125 mg/5ml 2

cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 2

ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefaclor cap 250 mg 2


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Drug Name Drug Tier Requirements/Limits cefaclor cap 500 mg 2 cefaclor for susp 125 mg/5ml 3 cefaclor for susp 250 mg/5ml 3 cefaclor for susp 375 mg/5ml 3

cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 cefuroxime axetil tab 250 mg 2

cefuroxime axetil tab 500 mg 2

ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefditoren pivoxil tab 200 mg (base

equivalent) 3

cefditoren pivoxil tab 400 mg (base equivalent)

3

cefixime for susp 100 mg/5ml 3

cefixime for susp 200 mg/5ml 3 cefpodoxime proxetil for susp 50 mg/5ml 3 cefpodoxime proxetil for susp 100 mg/5ml 3 cefpodoxime proxetil tab 100 mg 3

cefpodoxime proxetil tab 200 mg 3 SUPRAX CAP 400MG 5 SUPRAX CHW 100MG 5 SUPRAX CHW 200MG 5

SUPRAX SUS 100/5ML 5 SUPRAX SUS 200/5ML 5 SUPRAX SUS 500/5ML 5

ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 2 azithromycin for susp 200 mg/5ml 2 azithromycin powd pack for susp 1 gm 2

azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 3

clarithromycin for susp 250 mg/5ml 3 clarithromycin tab 250 mg 3 clarithromycin tab 500 mg 3 clarithromycin tab er 24hr 500 mg 3

DIFICID TAB 200MG 4 QL


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Drug Name Drug Tier Requirements/Limits e.e.s. 400 tab 400mg 3 ery-tab tab 250mg ec 2 ery-tab tab 333mg ec 2 ery-tab tab 500mg ec 2

ERYPED SUS 400/5ML 5 erythrocin tab 250mg 2 erythromycin ethylsuccinate for susp 200

mg/5ml 3

erythromycin ethylsuccinate for susp 400 mg/5ml

3

erythromycin ethylsuccinate tab 400 mg 3 erythromycin tab 250 mg 2

erythromycin tab 500 mg 2 erythromycin w/ delayed release particles

cap 250 mg 2

ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin for oral susp 500 mg/5ml

(10%) (10 gm/100ml) 3

ciprofloxacin hcl tab 100 mg (base equiv) 2 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 2 ciprofloxacin hcl tab 750 mg (base equiv) 2

ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)

2

ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)

2

levofloxacin oral soln 25 mg/ml 3 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2

moxifloxacin hcl tab 400 mg (base equiv) 3 ofloxacin tab 300 mg 3 ofloxacin tab 400 mg 3

ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-

28.5 mg 2

amoxicillin & k clavulanate chew tab 400-57 mg

2

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml

2

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

2

amoxicillin & k clavulanate for susp 400-57 mg/5ml

2


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Drug Name Drug Tier Requirements/Limits amoxicillin & k clavulanate for susp 600-

42.9 mg/5ml 2

amoxicillin & k clavulanate tab 250-125 mg 2 amoxicillin & k clavulanate tab 500-125 mg 2 amoxicillin & k clavulanate tab 875-125 mg 2 amoxicillin & k clavulanate tab er 12hr

1000-62.5 mg 2

amoxicillin (trihydrate) cap 250 mg 2

amoxicillin (trihydrate) cap 500 mg 2 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) for susp 125

mg/5ml 2

amoxicillin (trihydrate) for susp 200 mg/5ml

2


2


2

amoxicillin (trihydrate) tab 500 mg 2 amoxicillin (trihydrate) tab 875 mg 2 ampicillin cap 500 mg 2 AUGMENTIN SUS 125/5ML 5

dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 penicillin v potassium for soln 125 mg/5ml 2 penicillin v potassium for soln 250 mg/5ml 2

penicillin v potassium tab 250 mg 2 penicillin v potassium tab 500 mg 2

ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 3 sulfamethoxazole-trimethoprim susp 200-

40 mg/5ml 2

sulfamethoxazole-trimethoprim tab 400-80 mg

2

sulfamethoxazole-trimethoprim tab 800-160 mg

2

sulfatrim pd sus 200-40/5 2

ANTIBACTERIALS, TETRACYCLINES avidoxy tab 100mg 3 demeclocycline hcl tab 150 mg 3 demeclocycline hcl tab 300 mg 3

doxycycline hyclate cap 50 mg 2 doxycycline hyclate cap 100 mg 2


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Drug Name Drug Tier Requirements/Limits doxycycline hyclate tab 20 mg 3 doxycycline hyclate tab 75 mg 3 doxycycline hyclate tab 100 mg 3 doxycycline hyclate tab 150 mg 3

doxycycline hyclate tab delayed release 50 mg

3


3


3


3


3

doxycycline monohydrate cap 50 mg 3 doxycycline monohydrate cap 75 mg 3 doxycycline monohydrate cap 100 mg 3

doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25

mg/5ml 3

doxycycline monohydrate tab 50 mg 3 doxycycline monohydrate tab 75 mg 3 doxycycline monohydrate tab 100 mg 3

doxycycline monohydrate tab 150 mg 3 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2

minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 minocycline hcl tab er 24hr 55 mg 3

minocycline hcl tab er 24hr 65 mg 3 minocycline hcl tab er 24hr 115 mg 3 MINOLIRA TAB 105MG 5 MINOLIRA TAB 135MG 5 mondoxyne nl cap 50mg 3

mondoxyne nl cap 75mg 3 mondoxyne nl cap 100mg 3 morgidox cap 1x50mg 2 morgidox cap 1x100mg 2

morgidox cap 2x100mg 2 NUZYRA TAB 150MG 5 okebo cap 75mg 3 tetracycline hcl cap 250 mg 2


18

Drug Name Drug Tier Requirements/Limits tetracycline hcl cap 500 mg 2 VIBRAMYCIN SYP 50MG/5ML 5

ANTIFUNGALS clotrimazole troche 10 mg 3 CRESEMBA CAP 186 MG 5 QL; Restricted to

infectious disease

specialists fluconazole for susp 10 mg/ml 2

fluconazole for susp 40 mg/ml 2 fluconazole tab 50 mg 2 fluconazole tab 100 mg 2 fluconazole tab 150 mg 2

fluconazole tab 200 mg 2 flucytosine cap 250 mg 3 flucytosine cap 500 mg 3 griseofulvin microsize susp 125 mg/5ml 3

griseofulvin microsize tab 500 mg 3 griseofulvin ultramicrosize tab 125 mg 3 griseofulvin ultramicrosize tab 250 mg 3 itraconazole cap 100 mg 3 QL; Restricted to

infectious disease specialists

itraconazole oral soln 10 mg/ml 3 QL ketoconazole tab 200 mg 2 NOXAFIL SUS 40MG/ML 4 QL; Restricted to


NOXAFIL TAB 100MG 4 QL; Restricted to infectious disease specialists

nystatin susp 100000 unit/ml 4 nystatin tab 500000 unit 2

ORAVIG TAB 50MG 5 terbinafine hcl tab 250 mg 2 voriconazole for susp 40 mg/ml 3 QL; Restricted to

infectious disease

specialists voriconazole tab 50 mg 3 QL; Restricted to


voriconazole tab 200 mg 3 QL; Restricted to infectious disease

specialists


19


ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg 3 atovaquone-proguanil hcl tab 250-100 mg 3 chloroquine phosphate tab 250 mg 2

chloroquine phosphate tab 500 mg 2 COARTEM TAB 20-120MG 4 QL mefloquine hcl tab 250 mg 3 primaquine phosphate tab 26.3 mg (15 mg

base) 3

quinine sulfate cap 324 mg 3 QL

ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 5 QL

ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 600-300

mg 6 QL

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

6 QL

ATRIPLA TAB 6 QL BIKTARVY TAB 6 QL CIMDUO TAB 300-300 6 QL COMBIVIR TAB 150-300 6 QL COMPLERA TAB 6 QL DELSTRIGO TAB 6 QL DESCOVY TAB 200/25 6 QL EPZICOM TAB 600-300 6 QL EVOTAZ TAB 300-150 6 QL GENVOYA TAB 6 QL JULUCA TAB 50-25MG 6 QL lamivudine-zidovudine tab 150-300 mg 6 QL ODEFSEY TAB 6 QL PREZCOBIX TAB 800-150 6 QL STRIBILD TAB 6 QL SYMFI LO TAB 6 QL SYMFI TAB 6 QL SYMTUZA TAB 6 QL TRIUMEQ TAB 6 QL TRIZIVIR TAB 6 QL TRUVADA TAB 100-150 6 QL TRUVADA TAB 133-200 6 QL TRUVADA TAB 167-250 6 QL TRUVADA TAB 200-300 6 QL

ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 6 QL


20

Drug Name Drug Tier Requirements/Limits SELZENTRY TAB 25MG 6 QL SELZENTRY TAB 75MG 6 QL SELZENTRY TAB 150MG 6 QL SELZENTRY TAB 300MG 6 QL

ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 6 QL

ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 6 QL ISENTRESS CHW 100MG 6 QL ISENTRESS HD TAB 600MG 6 QL ISENTRESS POW 100MG 6 QL ISENTRESS TAB 400MG 6 QL TIVICAY TAB 10MG 6 QL TIVICAY TAB 25MG 6 QL TIVICAY TAB 50MG 6 QL

ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS EDURANT TAB 25MG 6 QL efavirenz cap 50 mg 6 QL efavirenz cap 200 mg 6 QL efavirenz tab 600 mg 6 QL INTELENCE TAB 25MG 6 QL INTELENCE TAB 100MG 6 QL INTELENCE TAB 200MG 6 QL nevirapine tab 200 mg 6 QL nevirapine tab er 24hr 100 mg 6 QL nevirapine tab er 24hr 400 mg 6 QL PIFELTRO TAB 100MG 6 QL RESCRIPTOR TAB 200MG 6 QL SUSTIVA CAP 50MG 6 QL SUSTIVA CAP 200MG 6 QL SUSTIVA TAB 600MG 6 QL VIRAMUNE SUS 50MG/5ML 6 QL VIRAMUNE TAB 200MG 6 QL VIRAMUNE XR TAB 100MG 6 QL VIRAMUNE XR TAB 400MG 6 QL

ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS abacavir sulfate soln 20 mg/ml (base

equiv) 6 QL

abacavir sulfate tab 300 mg (base equiv) 6 QL didanosine delayed release capsule 200 mg 6 QL didanosine delayed release capsule 250 mg 6 QL


21

Drug Name Drug Tier Requirements/Limits didanosine delayed release capsule 400 mg 6 QL EMTRIVA CAP 200MG 6 QL EMTRIVA SOL 10MG/ML 6 QL EPIVIR SOL 10MG/ML 6 QL EPIVIR TAB 150MG 6 QL EPIVIR TAB 300MG 6 QL lamivudine oral soln 10 mg/ml 6 QL lamivudine tab 150 mg 6 QL lamivudine tab 300 mg 6 QL RETROVIR CAP 100MG 6 QL RETROVIR SYP 50MG/5ML 6 QL stavudine cap 15 mg 6 QL stavudine cap 20 mg 6 QL stavudine cap 30 mg 6 QL stavudine cap 40 mg 6 QL VIDEX EC CAP 125MG 6 QL VIDEX EC CAP 200MG 6 QL VIDEX EC CAP 250MG 6 QL VIDEX EC CAP 400MG 6 QL VIDEX SOL 2GM 6 QL VIDEX SOL 4GM 6 QL ZERIT CAP 15MG 6 QL ZERIT CAP 20MG 6 QL ZERIT CAP 30MG 6 QL ZERIT CAP 40MG 6 QL ZIAGEN SOL 20MG/ML 6 QL ZIAGEN TAB 300MG 6 QL zidovudine cap 100 mg 6 QL zidovudine syrup 10 mg/ml 6 QL zidovudine tab 300 mg 6 QL

ANTIRETROVIRALS, NUCLEOTIDE REVERSE TRANSCRIPTASE

INHIBITORS tenofovir disoproxil fumarate tab 300 mg 6 QL VIREAD POW 40MG/GM 6 QL VIREAD TAB 150MG 6 QL VIREAD TAB 200MG 6 QL VIREAD TAB 250MG 6 QL VIREAD TAB 300MG 6 QL

ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 6 QL APTIVUS SOL 6 QL atazanavir sulfate cap 150 mg (base equiv) 6 QL atazanavir sulfate cap 200 mg (base equiv) 6 QL


22

Drug Name Drug Tier Requirements/Limits atazanavir sulfate cap 300 mg (base equiv) 6 QL CRIXIVAN CAP 200MG 6 QL CRIXIVAN CAP 400MG 6 QL fosamprenavir calcium tab 700 mg (base

equiv) 6 QL

INVIRASE TAB 500MG 6 QL KALETRA SOL 6 QL KALETRA TAB 100-25MG 6 QL KALETRA TAB 200-50MG 6 QL LEXIVA SUS 50MG/ML 6 QL LEXIVA TAB 700MG 6 QL lopinavir-ritonavir soln 400-100 mg/5ml

(80-20 mg/ml) 6 QL

NORVIR POW 100MG 6 NORVIR SOL 80MG/ML 6 QL NORVIR TAB 100MG 6 QL PREZISTA SUS 100MG/ML 6 QL PREZISTA TAB 75MG 6 QL PREZISTA TAB 150MG 6 QL PREZISTA TAB 600MG 6 QL PREZISTA TAB 800MG 6 QL REYATAZ CAP 150MG 6 QL REYATAZ CAP 200MG 6 QL REYATAZ CAP 300MG 6 QL REYATAZ POW 50MG 6 QL ritonavir tab 100 mg 6 VIRACEPT TAB 250MG 6 QL VIRACEPT TAB 625MG 6 QL

ANTITUBERCULAR AGENTS cycloserine cap 250 mg 3 ethambutol hcl tab 100 mg 3

ethambutol hcl tab 400 mg 3 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 2 PASER GRA 4GM 3

PRIFTIN TAB 150MG 5 pyrazinamide tab 500 mg 3 RIFAMATE CAP 5 rifampin cap 150 mg 3

rifampin cap 300 mg 3 RIFATER TAB 5 SIRTURO TAB 100MG 6 QL


23

Drug Name Drug Tier Requirements/Limits TRECATOR TAB 250MG 5

ANTIVIRALS, CYTOMEGALOVIRUS AGENTS PREVYMIS TAB 240MG 6 QL PREVYMIS TAB 480MG 6 QL VALCYTE SOL 50MG/ML 6 QL VALCYTE TAB 450MG 6 QL valganciclovir hcl for soln 50 mg/ml (base

equiv) 6 QL

valganciclovir hcl tab 450 mg (base equivalent)

6 QL

ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg 6 QL BARACLUDE SOL .05MG/ML 6 QL BARACLUDE TAB 0.5MG 6 QL BARACLUDE TAB 1MG 6 QL entecavir tab 0.5 mg 6 QL entecavir tab 1 mg 6 QL EPIVIR HBV SOL 5MG/ML 6 QL EPIVIR HBV TAB 100MG 6 QL HEPSERA TAB 10MG 6 QL lamivudine tab 100 mg (hbv) 6 QL VEMLIDY TAB 25MG 6

ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C EPCLUSA TAB 400-100 6 QL, PA HARVONI TAB 90-400MG 6 QL, PA MAVYRET TAB 100-40MG 6 QL, PA moderiba tab 200mg 6 QL ribasphere cap 200mg 6 QL ribasphere tab 200mg 6 QL ribavirin cap 200 mg 6 QL ribavirin tab 200 mg 6 QL VOSEVI TAB 6 QL, PA

ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 2 acyclovir susp 200 mg/5ml 2

acyclovir tab 400 mg 2 acyclovir tab 800 mg 2 famciclovir tab 125 mg 3 famciclovir tab 250 mg 3 famciclovir tab 500 mg 3

valacyclovir hcl tab 1 gm 3 valacyclovir hcl tab 500 mg 3


24


ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base

equiv) 2 QL

oseltamivir phosphate cap 45 mg (base equiv)

2 QL

oseltamivir phosphate cap 75 mg (base equiv)

2 QL

oseltamivir phosphate for susp 6 mg/ml (base equiv)

2 QL

RELENZA MIS DISKHALE 5 QL rimantadine hydrochloride tab 100 mg 2

TAMIFLU CAP 30MG 5 QL TAMIFLU CAP 45MG 5 QL TAMIFLU CAP 75MG 5 QL TAMIFLU SUS 6MG/ML 5 QL XOFLUZA TAB 20MG 5 QL XOFLUZA TAB 40MG 5 QL

MISCELLANEOUS AEMCOLO TAB 194MG 5 albendazole tab 200 mg 3 ALINIA SUS 100/5ML 4 ALINIA TAB 500MG 4

atovaquone susp 750 mg/5ml 3 BENZNIDAZOLE TAB 12.5MG 5 BENZNIDAZOLE TAB 100MG 5 clindamycin hcl cap 75 mg 2

clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75

mg/5ml (base equiv) 2

dapsone tab 25 mg 2 dapsone tab 100 mg 2

DARAPRIM TAB 25MG 5 FIRVANQ SOL 25MG/ML 5 FIRVANQ SOL 50MG/ML 5 IMPAVIDO CAP 50MG 6 QL ivermectin tab 3 mg 2 linezolid for susp 100 mg/5ml 3 Restricted to infectious

disease specialists linezolid tab 600 mg 3 QL; Restricted to

infectious disease

specialists methenamine hippurate tab 1 gm 3

methenamine mandelate tab 0.5 gm 3


25

Drug Name Drug Tier Requirements/Limits methenamine mandelate tab 1 gm 3 metronidazole cap 375 mg 2 metronidazole tab 250 mg 2 metronidazole tab 500 mg 2

MONUROL PAK GRANULES 5 nitrofurantoin macrocrystalline cap 25 mg 3 nitrofurantoin macrocrystalline cap 50 mg 2 nitrofurantoin macrocrystalline cap 100 mg 2 nitrofurantoin monohydrate

macrocrystalline cap 100 mg 2

nitrofurantoin susp 25 mg/5ml 2 praziquantel tab 600 mg 1 PRIMSOL SOL 50MG/5ML 5 rifabutin cap 150 mg 3

SIVEXTRO TAB 200MG 4 QL tinidazole tab 250 mg 3 tinidazole tab 500 mg 3 trimethoprim tab 100 mg 2 XIFAXAN TAB 200MG 4

XIFAXAN TAB 550MG 4

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS

ALKERAN TAB 2MG 6 QL, PA CYCLOPHOSPH CAP 25MG 6 CYCLOPHOSPH CAP 50MG 6

EMCYT CAP 140MG 6 QL, PA GLEOSTINE CAP 100MG 6 QL, PA LEUKERAN TAB 2MG 4 PA melphalan tab 2 mg 6 QL, PA MYLERAN TAB 2MG 5 TEMODAR CAP 5MG 6 QL, PA TEMODAR CAP 20MG 6 QL, PA TEMODAR CAP 100MG 6 QL, PA TEMODAR CAP 140MG 6 QL, PA TEMODAR CAP 180MG 6 QL, PA TEMODAR CAP 250MG 6 QL, PA temozolomide cap 5 mg 6 QL, PA temozolomide cap 20 mg 6 QL, PA temozolomide cap 100 mg 6 QL, PA temozolomide cap 140 mg 6 QL, PA temozolomide cap 180 mg 6 QL, PA temozolomide cap 250 mg 6 QL, PA VALCHLOR GEL 0.016% 6 QL


26


ANTIMETABOLITES capecitabine tab 150 mg 6 QL, PA capecitabine tab 500 mg 6 QL, PA mercaptopurine tab 50 mg 2

methotrexate sodium inj 50 mg/2ml (25 mg/ml)

2

methotrexate sodium inj 250 mg/10ml (25 mg/ml)

2

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)

2


2


2

methotrexate sodium tab 2.5 mg (base equiv)

2

PURIXAN SUS 20MG/ML 5 TABLOID TAB 40MG 5 PA TREXALL TAB 5MG 4

TREXALL TAB 7.5MG 4 TREXALL TAB 10MG 4 TREXALL TAB 15MG 4 XELODA TAB 150MG 6 QL, PA XELODA TAB 500MG 6 QL, PA

HORMONAL ANTINEOPLASTICS, ANTIANDROGENS abiraterone acetate tab 250 mg 6 QL, PA bicalutamide tab 50 mg 2 QL ERLEADA TAB 60MG 6 PA flutamide cap 125 mg 3 NILANDRON TAB 150MG 6 QL, PA nilutamide tab 150 mg 6 QL, PA XTANDI CAP 40MG 6 QL, PA YONSA TAB 125MG 6 PA ZYTIGA TAB 250MG 6 QL, PA ZYTIGA TAB 500MG 6 QL, PA

HORMONAL ANTINEOPLASTICS, ANTIESTROGENS tamoxifen citrate tab 10 mg (base

equivalent) 2 Covered at Tier 0 for

ages 35 and older tamoxifen citrate tab 20 mg (base

equivalent) 2 Covered at Tier 0 for

ages 35 and older toremifene citrate tab 60 mg (base

equivalent) 3 PA

HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg 2 QL


27

Drug Name Drug Tier Requirements/Limits exemestane tab 25 mg 3 PA letrozole tab 2.5 mg 2

HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE-

RELEASING HORMONE (LHRH) AGONISTS leuprolide acetate inj kit 5 mg/ml 6 QL, PA

HORMONAL ANTINEOPLASTICS, PROGESTINS hydroxyprogesterone caproate im in oil

1.25 gm/5ml 3

megestrol acetate tab 20 mg 3 megestrol acetate tab 40 mg 3

IMMUNOMODULATORS POMALYST CAP 1MG 6 QL, PA POMALYST CAP 2MG 6 QL, PA POMALYST CAP 3MG 6 QL, PA POMALYST CAP 4MG 6 QL, PA REVLIMID CAP 2.5MG 6 QL, PA REVLIMID CAP 5MG 6 QL, PA REVLIMID CAP 10MG 6 QL, PA REVLIMID CAP 15MG 6 QL, PA REVLIMID CAP 20MG 6 QL, PA REVLIMID CAP 25MG 6 QL, PA THALOMID CAP 50MG 6 QL, PA THALOMID CAP 100MG 6 QL, PA THALOMID CAP 150MG 6 QL, PA THALOMID CAP 200MG 6 QL, PA

KINASE INHIBITORS AFINITOR DIS TAB 2MG 6 QL, PA AFINITOR DIS TAB 3MG 6 QL, PA AFINITOR DIS TAB 5MG 6 QL, PA AFINITOR TAB 2.5MG 6 QL, PA AFINITOR TAB 5MG 6 QL, PA AFINITOR TAB 7.5MG 6 QL, PA AFINITOR TAB 10MG 6 QL, PA ALECENSA CAP 150MG 6 QL, PA ALUNBRIG PAK 6 QL, PA ALUNBRIG TAB 30MG 6 QL, PA ALUNBRIG TAB 90MG 6 QL, PA ALUNBRIG TAB 180MG 6 QL, PA BOSULIF TAB 100MG 6 QL, PA BOSULIF TAB 400MG 6 QL, PA BOSULIF TAB 500MG 6 QL, PA BRAFTOVI CAP 50MG 6 QL, PA BRAFTOVI CAP 75MG 6 QL, PA


28

Drug Name Drug Tier Requirements/Limits CALQUENCE CAP 100MG 6 PA CAPRELSA TAB 100MG 6 QL, PA CAPRELSA TAB 300MG 6 QL, PA COMETRIQ KIT 60MG 6 QL, PA COMETRIQ KIT 100MG 6 QL, PA COMETRIQ KIT 140MG 6 QL, PA COPIKTRA CAP 15MG 6 PA COPIKTRA CAP 25MG 6 PA COTELLIC TAB 20MG 6 QL, PA GILOTRIF TAB 20MG 6 QL, PA GILOTRIF TAB 30MG 6 QL, PA GILOTRIF TAB 40MG 6 QL, PA GLEEVEC TAB 100MG 6 QL, PA GLEEVEC TAB 400MG 6 QL, PA IBRANCE CAP 75MG 6 QL, PA IBRANCE CAP 100MG 6 QL, PA IBRANCE CAP 125MG 6 QL, PA ICLUSIG TAB 15MG 6 QL, PA ICLUSIG TAB 45MG 6 QL, PA imatinib mesylate tab 100 mg (base

equivalent) 6 QL, PA

imatinib mesylate tab 400 mg (base equivalent)

6 QL, PA

IMBRUVICA CAP 70MG 6 QL, PA IMBRUVICA CAP 140MG 6 QL, PA IMBRUVICA TAB 140MG 6 QL, PA IMBRUVICA TAB 280MG 6 QL, PA IMBRUVICA TAB 420MG 6 QL, PA IMBRUVICA TAB 560MG 6 QL, PA INLYTA TAB 1MG 6 QL, PA INLYTA TAB 5MG 6 QL, PA JAKAFI TAB 5MG 6 QL, PA JAKAFI TAB 10MG 6 QL, PA JAKAFI TAB 15MG 6 QL, PA JAKAFI TAB 20MG 6 QL, PA JAKAFI TAB 25MG 6 QL, PA LENVIMA CAP 4MG 6 QL, PA LENVIMA CAP 8 MG 6 QL, PA LENVIMA CAP 10 MG 6 QL, PA LENVIMA CAP 12MG 6 QL, PA LENVIMA CAP 14 MG 6 QL, PA LENVIMA CAP 18 MG 6 QL, PA LENVIMA CAP 20 MG 6 QL, PA


29

Drug Name Drug Tier Requirements/Limits LENVIMA CAP 24 MG 6 QL, PA LORBRENA TAB 25MG 6 QL, PA LORBRENA TAB 100MG 6 QL, PA MEKINIST TAB 0.5MG 6 QL, PA MEKINIST TAB 2MG 6 QL, PA MEKTOVI TAB 15MG 6 PA NERLYNX TAB 40MG 6 PA NEXAVAR TAB 200MG 6 QL, PA RYDAPT CAP 25MG 6 QL, PA SPRYCEL TAB 20MG 6 QL, PA SPRYCEL TAB 50MG 6 QL, PA SPRYCEL TAB 70MG 6 QL, PA SPRYCEL TAB 80MG 6 QL, PA SPRYCEL TAB 100MG 6 QL, PA SPRYCEL TAB 140MG 6 QL, PA STIVARGA TAB 40MG 6 QL, PA SUTENT CAP 12.5MG 6 QL, PA SUTENT CAP 25MG 6 QL, PA SUTENT CAP 37.5MG 6 QL, PA SUTENT CAP 50MG 6 QL, PA TAFINLAR CAP 50MG 6 QL, PA TAFINLAR CAP 75MG 6 QL, PA TAGRISSO TAB 40MG 6 QL, PA TAGRISSO TAB 80MG 6 QL, PA TARCEVA TAB 25MG 6 QL, PA TARCEVA TAB 100MG 6 QL, PA TARCEVA TAB 150MG 6 QL, PA TASIGNA CAP 50MG 6 PA TASIGNA CAP 150MG 6 QL, PA TASIGNA CAP 200MG 6 QL, PA TYKERB TAB 250MG 6 QL, PA VERZENIO TAB 50MG 6 PA VERZENIO TAB 100MG 6 PA VERZENIO TAB 150MG 6 PA VERZENIO TAB 200MG 6 PA VITRAKVI CAP 25MG 6 PA VITRAKVI CAP 100MG 6 PA VITRAKVI SOL 20MG/ML 6 PA VIZIMPRO TAB 15MG 6 QL, PA VIZIMPRO TAB 30MG 6 QL, PA VIZIMPRO TAB 45MG 6 QL, PA VOTRIENT TAB 200MG 6 QL, PA XALKORI CAP 200MG 6 QL, PA


30

Drug Name Drug Tier Requirements/Limits XALKORI CAP 250MG 6 QL, PA XOSPATA TAB 40MG 6 PA ZELBORAF TAB 240MG 6 QL, PA ZYDELIG TAB 100MG 6 QL, PA ZYDELIG TAB 150MG 6 QL, PA ZYKADIA CAP 150MG 6 QL, PA

MISCELLANEOUS bexarotene cap 75 mg 6 QL, PA DAURISMO TAB 25MG 6 PA DAURISMO TAB 100MG 6 PA DROXIA CAP 200MG 5

DROXIA CAP 300MG 5 DROXIA CAP 400MG 5 ERIVEDGE CAP 150MG 6 QL, PA FARYDAK CAP 10MG 6 QL, PA FARYDAK CAP 15MG 6 QL, PA FARYDAK CAP 20MG 6 QL, PA hydroxyurea cap 500 mg 3 IDHIFA TAB 50MG 6 PA IDHIFA TAB 100MG 6 PA leucovorin calcium tab 5 mg 3 leucovorin calcium tab 10 mg 3 leucovorin calcium tab 15 mg 3 leucovorin calcium tab 25 mg 3

LONSURF TAB 15-6.14 6 QL, PA LONSURF TAB 20-8.19 6 QL, PA LYSODREN TAB 500MG 6 QL, PA MATULANE CAP 50MG 6 QL, PA MESNEX TAB 400MG 6 QL NINLARO CAP 2.3MG 6 QL, PA NINLARO CAP 3MG 6 QL, PA NINLARO CAP 4MG 6 QL, PA ODOMZO CAP 200MG 6 QL, PA RUBRACA TAB 200MG 6 QL, PA RUBRACA TAB 250MG 6 QL, PA RUBRACA TAB 300MG 6 QL, PA SIKLOS TAB 100MG 5 SIKLOS TAB 1000MG 5 TALZENNA CAP 0.25MG 6 PA TALZENNA CAP 1MG 6 PA TARGRETIN CAP 75MG 6 QL, PA TARGRETIN GEL 1% 6 QL TIBSOVO TAB 250MG 6 PA


31

Drug Name Drug Tier Requirements/Limits tretinoin cap 10 mg 6 QL, PA VENCLEXTA TAB 10MG 6 QL, PA VENCLEXTA TAB 50MG 6 QL, PA VENCLEXTA TAB 100MG 6 QL, PA VENCLEXTA TAB START PK 6 QL, PA VISTOGARD PAK 10GM 6 QL ZEJULA CAP 100MG 6 QL, PA ZOLINZA CAP 100MG 6 QL, PA

TOPOISOMERASE INHIBITORS HYCAMTIN CAP 0.25MG 6 QL, PA HYCAMTIN CAP 1MG 6 QL, PA

CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine besylate-benazepril hcl cap 2.5-10 mg

2

amlodipine besylate-benazepril hcl cap 5-10 mg

2


2


2


2


2

trandolapril-verapamil hcl tab er 1-240 mg 3 trandolapril-verapamil hcl tab er 2-180 mg 3 trandolapril-verapamil hcl tab er 2-240 mg 3

trandolapril-verapamil hcl tab er 4-240 mg 3

ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5-

6.25 mg 2

benazepril & hydrochlorothiazide tab 10-12.5 mg

2

benazepril & hydrochlorothiazide tab 20-12.5 mg

2

benazepril & hydrochlorothiazide tab 20-25 mg

2

captopril & hydrochlorothiazide tab 25-15 mg

2


2


2


32

Drug Name Drug Tier Requirements/Limits captopril & hydrochlorothiazide tab 50-25

mg 2

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

2

enalapril maleate & hydrochlorothiazide tab 10-25 mg

2

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

2

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

2

lisinopril & hydrochlorothiazide tab 10-12.5 mg

2

lisinopril & hydrochlorothiazide tab 20-12.5 mg

2

lisinopril & hydrochlorothiazide tab 20-25 mg

2

moexipril-hydrochlorothiazide tab 7.5-12.5 mg

2

moexipril-hydrochlorothiazide tab 15-12.5 mg

2

moexipril-hydrochlorothiazide tab 15-25 mg

2

quinapril-hydrochlorothiazide tab 10-12.5 mg

2

quinapril-hydrochlorothiazide tab 20-12.5 mg

2

quinapril-hydrochlorothiazide tab 20-25 mg 2

ACE INHIBITORS benazepril hcl tab 5 mg 2 benazepril hcl tab 10 mg 2

benazepril hcl tab 20 mg 2 benazepril hcl tab 40 mg 2 captopril tab 12.5 mg 2 captopril tab 25 mg 2

captopril tab 50 mg 2 captopril tab 100 mg 2 enalapril maleate tab 2.5 mg 2 enalapril maleate tab 5 mg 2

enalapril maleate tab 10 mg 2 enalapril maleate tab 20 mg 2 fosinopril sodium tab 10 mg 2 fosinopril sodium tab 20 mg 2

fosinopril sodium tab 40 mg 2 lisinopril tab 2.5 mg 2 lisinopril tab 5 mg 2


33

Drug Name Drug Tier Requirements/Limits lisinopril tab 10 mg 2 lisinopril tab 20 mg 2 lisinopril tab 30 mg 2 lisinopril tab 40 mg 2

moexipril hcl tab 7.5 mg 2 moexipril hcl tab 15 mg 2 perindopril erbumine tab 2 mg 2 perindopril erbumine tab 4 mg 2 perindopril erbumine tab 8 mg 2

QBRELIS SOL 1MG/ML 5 quinapril hcl tab 5 mg 2 quinapril hcl tab 10 mg 2 quinapril hcl tab 20 mg 2

quinapril hcl tab 40 mg 2 ramipril cap 1.25 mg 2 ramipril cap 2.5 mg 2 ramipril cap 5 mg 2

ramipril cap 10 mg 2 trandolapril tab 1 mg 2 trandolapril tab 2 mg 2 trandolapril tab 4 mg 2

ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg 2 clonidine hcl tab 0.2 mg 2

clonidine hcl tab 0.3 mg 2 clonidine td patch weekly 0.1 mg/24hr 3 QL clonidine td patch weekly 0.2 mg/24hr 3 QL clonidine td patch weekly 0.3 mg/24hr 3 QL guanfacine hcl tab 1 mg 2 guanfacine hcl tab 2 mg 2 methyldopa tab 250 mg 2 methyldopa tab 500 mg 2

ADRENOLYTICS, CENTRAL/DIURETIC COMBINATIONS methyldopa & hydrochlorothiazide tab 250-

15 mg 2

methyldopa & hydrochlorothiazide tab 250-25 mg

2

ALDOSTERONE RECEPTOR ANTAGONISTS CAROSPIR SUS 25MG/5ML 5 Covered for ages 12

years and under eplerenone tab 25 mg 3 QL eplerenone tab 50 mg 3 QL spironolactone tab 25 mg 2


34

Drug Name Drug Tier Requirements/Limits spironolactone tab 50 mg 2 spironolactone tab 100 mg 2

ALPHA BLOCKERS doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2

prazosin hcl cap 1 mg 2 prazosin hcl cap 2 mg 2 prazosin hcl cap 5 mg 2 terazosin hcl cap 1 mg (base equivalent) 2

terazosin hcl cap 2 mg (base equivalent) 2 terazosin hcl cap 5 mg (base equivalent) 2 terazosin hcl cap 10 mg (base equivalent) 2

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS amlodipine besylate-olmesartan medoxomil

tab 5-20 mg 3

amlodipine besylate-olmesartan medoxomil tab 5-40 mg

3


3


3

amlodipine besylate-valsartan tab 5-160 mg

3


3


3


3

telmisartan-amlodipine tab 40-5 mg 3 telmisartan-amlodipine tab 40-10 mg 3 telmisartan-amlodipine tab 80-5 mg 3 telmisartan-amlodipine tab 80-10 mg 3

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide

tab 5-160-12.5 mg 3

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg

3

amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg

3


35

Drug Name Drug Tier Requirements/Limits amlodipine-valsartan-hydrochlorothiazide

tab 10-160-25 mg 3

amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg

3

olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg

3


3

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg

3


3

olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg

3

ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS candesartan cilexetil-hydrochlorothiazide

tab 16-12.5 mg 2

candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg

2

candesartan cilexetil-hydrochlorothiazide tab 32-25 mg

2

EDARBYCLOR TAB 40-12.5 5 EDARBYCLOR TAB 40-25MG 5

irbesartan-hydrochlorothiazide tab 150-12.5 mg

2

irbesartan-hydrochlorothiazide tab 300-12.5 mg

2

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

2

losartan potassium & hydrochlorothiazide tab 100-12.5 mg

2

losartan potassium & hydrochlorothiazide tab 100-25 mg

2

olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg

3

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg

3

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg

3

telmisartan-hydrochlorothiazide tab 40-12.5 mg

3

telmisartan-hydrochlorothiazide tab 80-12.5 mg

3


36

Drug Name Drug Tier Requirements/Limits telmisartan-hydrochlorothiazide tab 80-25

mg 3

valsartan-hydrochlorothiazide tab 80-12.5 mg

2


2

valsartan-hydrochlorothiazide tab 160-25 mg

2


2

valsartan-hydrochlorothiazide tab 320-25 mg

2

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg 2 candesartan cilexetil tab 8 mg 2 candesartan cilexetil tab 16 mg 2 candesartan cilexetil tab 32 mg 2 EDARBI TAB 40MG 5

EDARBI TAB 80MG 5 eprosartan mesylate tab 600 mg 2 irbesartan tab 75 mg 2 irbesartan tab 150 mg 2

irbesartan tab 300 mg 2 losartan potassium tab 25 mg 2 losartan potassium tab 50 mg 2 losartan potassium tab 100 mg 2

olmesartan medoxomil tab 5 mg 3 olmesartan medoxomil tab 20 mg 3 olmesartan medoxomil tab 40 mg 3 telmisartan tab 20 mg 3

telmisartan tab 40 mg 3 telmisartan tab 80 mg 3 valsartan tab 40 mg 2 valsartan tab 80 mg 2

valsartan tab 160 mg 2 valsartan tab 320 mg 2

ANTIARRHYTHMICS amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 3 disopyramide phosphate cap 100 mg 3

disopyramide phosphate cap 150 mg 3 dofetilide cap 125 mcg (0.125 mg) 3 dofetilide cap 250 mcg (0.25 mg) 3


37

Drug Name Drug Tier Requirements/Limits dofetilide cap 500 mcg (0.5 mg) 3 flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2

mexiletine hcl cap 150 mg 3 mexiletine hcl cap 200 mg 3 mexiletine hcl cap 250 mg 3 MULTAQ TAB 400MG 5 QL NORPACE CAP 100MG CR 5

NORPACE CAP 150MG CR 5 pacerone tab 100mg 2 pacerone tab 200mg 2 pacerone tab 400mg 3

propafenone hcl cap er 12hr 225 mg 2 propafenone hcl cap er 12hr 325 mg 2 propafenone hcl cap er 12hr 425 mg 2 propafenone hcl tab 150 mg 2

propafenone hcl tab 225 mg 2 propafenone hcl tab 300 mg 2 quinidine gluconate tab er 324 mg 3 quinidine sulfate tab 200 mg 3

quinidine sulfate tab 300 mg 3 sorine tab 80mg 2 sorine tab 120mg 2 sorine tab 160mg 2

sorine tab 240mg 2 sotalol hcl (afib/afl) tab 80 mg 2 sotalol hcl (afib/afl) tab 120 mg 2 sotalol hcl (afib/afl) tab 160 mg 2

sotalol hcl tab 80 mg 2 sotalol hcl tab 120 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2

SOTYLIZE SOL 5MG/ML 5

ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2

cholestyramine light powder packets 4 gm 2 cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 colesevelam hcl packet for susp 3.75 gm 3

colesevelam hcl tab 625 mg 1 colestipol hcl granule packets 5 gm 3 colestipol hcl granules 5 gm 3


38

Drug Name Drug Tier Requirements/Limits colestipol hcl tab 1 gm 3 prevalite pow 4gm 2 prevalite pow 4gm pk 2 WELCHOL PAK 3.75GM 4

ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 3

ANTILIPEMICS, FIBRATES ANTARA CAP 30MG 5 ANTARA CAP 90MG 5 choline fenofibrate cap dr 45 mg (fenofibric

acid equiv) 2

choline fenofibrate cap dr 135 mg (fenofibric acid equiv)

2

fenofibrate cap 50 mg 2 fenofibrate cap 150 mg 2 fenofibrate micronized cap 43 mg 2 fenofibrate micronized cap 67 mg 2

fenofibrate micronized cap 130 mg 2 fenofibrate micronized cap 134 mg 2 fenofibrate micronized cap 200 mg 2 fenofibrate tab 40 mg 3 fenofibrate tab 48 mg 2

fenofibrate tab 54 mg 2 fenofibrate tab 120 mg 3 fenofibrate tab 145 mg 2 fenofibrate tab 160 mg 2

fenofibric acid tab 35 mg 2 fenofibric acid tab 105 mg 2 gemfibrozil tab 600 mg 2 TRIGLIDE TAB 160MG 5

ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS ALTOPREV TAB 20MG ER 5 QL ALTOPREV TAB 40MG ER 5 QL ALTOPREV TAB 60MG ER 5 QL atorvastatin calcium tab 10 mg (base

equivalent) 2 QL; Covered at Tier 0

for ages 40-74 years old atorvastatin calcium tab 20 mg (base

equivalent) 2 QL; Covered at Tier 0

for ages 40-74 years old atorvastatin calcium tab 40 mg (base

equivalent) 2 QL

atorvastatin calcium tab 80 mg (base equivalent)

2 QL


39

Drug Name Drug Tier Requirements/Limits ezetimibe-simvastatin tab 10-10 mg 3 ezetimibe-simvastatin tab 10-20 mg 3 ezetimibe-simvastatin tab 10-40 mg 3 ezetimibe-simvastatin tab 10-80 mg 3

fluvastatin sodium cap 20 mg (base equivalent)

2 Covered at Tier 0 for ages 40-74 years old

fluvastatin sodium cap 40 mg (base equivalent)


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


LIVALO TAB 1MG 5 QL LIVALO TAB 2MG 5 QL LIVALO TAB 4MG 5 QL lovastatin tab 10 mg 2 Covered at Tier 0 for

ages 40-74 years old lovastatin tab 20 mg 2 Covered at Tier 0 for

ages 40-74 years old lovastatin tab 40 mg 2 Covered at Tier 0 for

ages 40-74 years old pravastatin sodium tab 10 mg 2 Covered at Tier 0 for




ages 40-74 years old rosuvastatin calcium tab 5 mg 2 QL; Covered at Tier 0

for ages 40-74 years old rosuvastatin calcium tab 10 mg 2 QL; Covered at Tier 0

for ages 40-74 years old rosuvastatin calcium tab 20 mg 3 QL rosuvastatin calcium tab 40 mg 3 QL simvastatin tab 5 mg 2 Covered at Tier 0 for

ages 40-74 years old simvastatin tab 10 mg 2 Covered at Tier 0 for



ages 40-74 years old simvastatin tab 80 mg 2

ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN

INHIBITORS JUXTAPID CAP 5MG 6 QL; MN-PA


40

Drug Name Drug Tier Requirements/Limits JUXTAPID CAP 10MG 6 QL; MN-PA JUXTAPID CAP 20MG 6 QL; MN-PA JUXTAPID CAP 30MG 6 QL; MN-PA JUXTAPID CAP 40MG 6 QL; MN-PA JUXTAPID CAP 60MG 6 QL; MN-PA

ANTILIPEMICS, MISCELLANEOUS KYNAMRO INJ 200MG/ML 6 QL; MN-PA

ANTILIPEMICS, NIACINS niacin tab er 500 mg (antihyperlipidemic) 3 QL niacin tab er 750 mg (antihyperlipidemic) 3 QL niacin tab er 1000 mg (antihyperlipidemic) 3 QL niacor tab 500mg 2

ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm 3 QL VASCEPA CAP 0.5GM 5 QL VASCEPA CAP 1GM 5 QL

ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML 6 QL; MN-PA PRALUENT INJ 150MG/ML 6 QL; MN-PA REPATHA INJ 140MG/ML 6 QL, PA REPATHA PUSH INJ 420/3.5 6 QL, PA REPATHA SURE INJ 140MG/ML 6 QL, PA

BETA-BLOCKER/ANGIOTENSIN II RECEPTOR ANTAGONIST

COMBINATIONS BYVALSON TAB 5-80MG 5 QL

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 2 atenolol & chlorthalidone tab 100-25 mg 2 bisoprolol & hydrochlorothiazide tab 2.5-

6.25 mg 2

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

2

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

2

metoprolol & hydrochlorothiazide tab 50-25 mg

2


2


2

nadolol & bendroflumethiazide tab 40-5 mg 2 propranolol & hydrochlorothiazide tab 40-

25 mg 2


41

Drug Name Drug Tier Requirements/Limits propranolol & hydrochlorothiazide tab 80-

25 mg 2

BETA-BLOCKERS acebutolol hcl cap 200 mg 3 acebutolol hcl cap 400 mg 3

atenolol tab 25 mg 2 atenolol tab 50 mg 2 atenolol tab 100 mg 2 betaxolol hcl tab 10 mg 2

betaxolol hcl tab 20 mg 2 bisoprolol fumarate tab 5 mg 2 bisoprolol fumarate tab 10 mg 2 BYSTOLIC TAB 2.5MG 5 QL BYSTOLIC TAB 5MG 5 QL BYSTOLIC TAB 10MG 5 QL BYSTOLIC TAB 20MG 5 QL carvedilol phosphate cap er 24hr 10 mg 3 QL carvedilol phosphate cap er 24hr 20 mg 3 QL carvedilol phosphate cap er 24hr 40 mg 3 QL carvedilol phosphate cap er 24hr 80 mg 3 QL carvedilol tab 3.125 mg 2

carvedilol tab 6.25 mg 2 carvedilol tab 12.5 mg 2 carvedilol tab 25 mg 2 INDERAL XL CAP 80MG 5

INDERAL XL CAP 120MG 5 INNOPRAN XL CAP 80MG 5 INNOPRAN XL CAP 120MG 5 labetalol hcl tab 100 mg 2 labetalol hcl tab 200 mg 2

labetalol hcl tab 300 mg 2 metoprolol succinate tab er 24hr 25 mg

(tartrate equiv) 2

metoprolol succinate tab er 24hr 50 mg (tartrate equiv)

2


2


2

metoprolol tartrate tab 25 mg 2 metoprolol tartrate tab 37.5 mg 2

metoprolol tartrate tab 50 mg 2 metoprolol tartrate tab 75 mg 2 metoprolol tartrate tab 100 mg 2


42

Drug Name Drug Tier Requirements/Limits nadolol tab 20 mg 2 nadolol tab 40 mg 2 nadolol tab 80 mg 2 pindolol tab 5 mg 2

pindolol tab 10 mg 2 propranolol hcl cap er 24hr 60 mg 2 propranolol hcl cap er 24hr 80 mg 2 propranolol hcl cap er 24hr 120 mg 2 propranolol hcl cap er 24hr 160 mg 2

propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 2 propranolol hcl tab 20 mg 2

propranolol hcl tab 40 mg 2 propranolol hcl tab 60 mg 2 propranolol hcl tab 80 mg 2 timolol maleate tab 5 mg 2

timolol maleate tab 10 mg 2 timolol maleate tab 20 mg 2

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

tab 2.5-10 mg 3

amlodipine besylate-atorvastatin calcium tab 2.5-20 mg

3

amlodipine besylate-atorvastatin calcium tab 2.5-40 mg

3

amlodipine besylate-atorvastatin calcium tab 5-10 mg

3


3


3


3


3


3


3


3

CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES afeditab tab 30mg cr 2


43

Drug Name Drug Tier Requirements/Limits afeditab tab 60mg cr 2 amlodipine besylate tab 2.5 mg (base

equivalent) 2

amlodipine besylate tab 5 mg (base equivalent)

2

amlodipine besylate tab 10 mg (base equivalent)

2

felodipine tab er 24hr 2.5 mg 2 felodipine tab er 24hr 5 mg 2 felodipine tab er 24hr 10 mg 2

isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 nicardipine hcl cap 20 mg 3 nicardipine hcl cap 30 mg 3

nifedipine cap 10 mg 3 nifedipine cap 20 mg 3 nifedipine tab er 24hr 30 mg 2 nifedipine tab er 24hr 60 mg 2

nifedipine tab er 24hr 90 mg 2 nifedipine tab er 24hr osmotic release 30

mg 2

nifedipine tab er 24hr osmotic release 60 mg

2

nifedipine tab er 24hr osmotic release 90 mg

2

nimodipine cap 30 mg 3 nisoldipine tab er 24hr 8.5 mg 3

nisoldipine tab er 24hr 17 mg 3 nisoldipine tab er 24hr 20 mg 3 nisoldipine tab er 24hr 25.5 mg 3 nisoldipine tab er 24hr 30 mg 3

nisoldipine tab er 24hr 34 mg 3 nisoldipine tab er 24hr 40 mg 3

CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINES CARDIZEM LA TAB 120MG 5 cartia xt cap 120/24hr 2 cartia xt cap 180/24hr 2 cartia xt cap 240/24hr 2

cartia xt cap 300/24hr 2 dilt-xr cap 120mg 2 dilt-xr cap 180mg 2 dilt-xr cap 240mg 2 diltiazem cap 120mg cd 2

diltiazem cap 180mg cd 2


44

Drug Name Drug Tier Requirements/Limits diltiazem cap 240mg cd 2 diltiazem cap 300mg cd 2 diltiazem hcl cap er 12hr 60 mg 2 diltiazem hcl cap er 12hr 90 mg 2

diltiazem hcl cap er 12hr 120 mg 2 diltiazem hcl cap er 24hr 120 mg 2 diltiazem hcl cap er 24hr 180 mg 2 diltiazem hcl cap er 24hr 240 mg 2 diltiazem hcl coated beads cap er 24hr 120

mg 2

diltiazem hcl coated beads cap er 24hr 180 mg

2


2


2


2

diltiazem hcl coated beads tab er 24hr 180 mg

2


2


2


2


2

diltiazem hcl extended release beads cap er 24hr 120 mg

2


2


2


2


2


2

diltiazem hcl tab 30 mg 2

diltiazem hcl tab 60 mg 2 diltiazem hcl tab 90 mg 2 diltiazem hcl tab 120 mg 2 matzim la tab 180mg/24 2


45

Drug Name Drug Tier Requirements/Limits matzim la tab 240mg/24 2 matzim la tab 300mg/24 2 matzim la tab 360mg/24 2 matzim la tab 420mg/24 2

taztia xt cap 120mg/24 2 taztia xt cap 180mg/24 2 taztia xt cap 240mg/24 2 taztia xt cap 300mg/24 2 taztia xt cap 360mg/24 2

verapamil hcl cap er 24hr 100 mg 2 verapamil hcl cap er 24hr 120 mg 2 verapamil hcl cap er 24hr 180 mg 2 verapamil hcl cap er 24hr 200 mg 2

verapamil hcl cap er 24hr 240 mg 2 verapamil hcl cap er 24hr 300 mg 2 verapamil hcl cap er 24hr 360 mg 2 verapamil hcl tab 40 mg 2

verapamil hcl tab 80 mg 2 verapamil hcl tab 120 mg 2 verapamil hcl tab er 120 mg 2 verapamil hcl tab er 180 mg 2

verapamil hcl tab er 240 mg 2

DIGITALIS GLYCOSIDES digitek tab 0.25mg 2

digitek tab 0.125mg 2 digox tab 0.25mg 2 digox tab 0.125mg 2 digoxin oral soln 0.05 mg/ml 5

digoxin tab 125 mcg (0.125 mg) 2 digoxin tab 250 mcg (0.25 mg) 2 LANOXIN TAB 0.25MG 5 LANOXIN TAB 0.125MG 5

LANOXIN TAB 0.0625MG 5 LANOXIN TAB 0.1875MG 5

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS aliskiren fumarate tab 150 mg (base

equivalent) 3 QL

aliskiren fumarate tab 300 mg (base equivalent)

3 QL

TEKTURNA HCT TAB 150-12.5 5 QL TEKTURNA HCT TAB 150-25MG 5 QL TEKTURNA HCT TAB 300-12.5 5 QL TEKTURNA HCT TAB 300-25MG 5 QL


46

Drug Name Drug Tier Requirements/Limits TEKTURNA TAB 150MG 5 QL TEKTURNA TAB 300MG 5 QL

DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg 3 acetazolamide tab 125 mg 3 acetazolamide tab 250 mg 3 KEVEYIS TAB 50MG 6 QL, PA methazolamide tab 25 mg 2 methazolamide tab 50 mg 2

DIURETICS, DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50 5 amiloride & hydrochlorothiazide tab 5-50

mg 2

spironolactone & hydrochlorothiazide tab 25-25 mg

2

triamterene & hydrochlorothiazide cap 37.5-25 mg

2

triamterene & hydrochlorothiazide tab 37.5-25 mg

2

triamterene & hydrochlorothiazide tab 75-50 mg

2

DIURETICS, LOOP DIURETICS bumetanide tab 0.5 mg 2 bumetanide tab 1 mg 2 bumetanide tab 2 mg 2

ethacrynic acid tab 25 mg 3 furosemide oral soln 8 mg/ml 2 furosemide oral soln 10 mg/ml 2 furosemide tab 20 mg 2 furosemide tab 40 mg 2

furosemide tab 80 mg 2 torsemide tab 5 mg 2 torsemide tab 10 mg 2 torsemide tab 20 mg 2

torsemide tab 100 mg 2

DIURETICS, POTASSIUM-SPARING DIURETICS amiloride hcl tab 5 mg 2

DYRENIUM CAP 50MG 5 DYRENIUM CAP 100MG 5

DIURETICS, THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 2 chlorthalidone tab 25 mg 2


47

Drug Name Drug Tier Requirements/Limits chlorthalidone tab 50 mg 2 DIURIL SUS 250/5ML 5 hydrochlorothiazide cap 12.5 mg 2 hydrochlorothiazide tab 12.5 mg 2

hydrochlorothiazide tab 25 mg 2 hydrochlorothiazide tab 50 mg 2 indapamide tab 1.25 mg 2 indapamide tab 2.5 mg 2 methyclothiazide tab 5 mg 3

metolazone tab 2.5 mg 2 metolazone tab 5 mg 2 metolazone tab 10 mg 2

HEART FAILURE CORLANOR TAB 5MG 5 QL CORLANOR TAB 7.5MG 5 QL ENTRESTO TAB 24-26MG 5 ENTRESTO TAB 49-51MG 5 ENTRESTO TAB 97-103MG 5

MISCELLANEOUS DEMSER CAP 250MG 5 hydralazine hcl tab 10 mg 2 hydralazine hcl tab 25 mg 2

hydralazine hcl tab 50 mg 2 hydralazine hcl tab 100 mg 2 minoxidil tab 2.5 mg 2 minoxidil tab 10 mg 2

phenoxybenzamine hcl cap 10 mg 3 ranolazine tab er 12hr 500 mg 3 QL ranolazine tab er 12hr 1000 mg 3 QL

NITRATES, ORAL DILATRATE SR CAP 40MG 4 ISORDIL TAB 40MG 5 isosorbide dinitrate tab 5 mg 2

isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab er 40 mg 2 isosorbide mononitrate tab 10 mg 2

isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab er 24hr 30 mg 2 isosorbide mononitrate tab er 24hr 60 mg 2 isosorbide mononitrate tab er 24hr 120 mg 2

nitro-time cap 2.5mg cr 2


48

Drug Name Drug Tier Requirements/Limits nitro-time cap 6.5mg cr 2 nitro-time cap 9mg cr 2 nitroglycerin cap er 2.5 mg 2 nitroglycerin cap er 6.5 mg 2

nitroglycerin cap er 9 mg 2

NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin sl tab 0.3 mg 2

nitroglycerin sl tab 0.4 mg 2 nitroglycerin sl tab 0.6 mg 2 nitroglycerin tl soln 0.4 mg/spray (400

mcg/spray) 3

NITROMIST AER 400MCG 5

NITRATES, TRANSDERMAL minitran dis 0.1mg/hr 3 minitran dis 0.2mg/hr 3 minitran dis 0.4mg/hr 3

minitran dis 0.6mg/hr 3 NITRO-BID OIN 2% 2 NITRO-DUR DIS 0.3MG/HR 5 NITRO-DUR DIS 0.8MG/HR 5

nitroglycerin td patch 24hr 0.1 mg/hr 3 nitroglycerin td patch 24hr 0.2 mg/hr 3 nitroglycerin td patch 24hr 0.4 mg/hr 3 nitroglycerin td patch 24hr 0.6 mg/hr 3

PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONISTS LETAIRIS TAB 5MG 6 QL; MN-PA LETAIRIS TAB 10MG 6 QL; MN-PA OPSUMIT TAB 10MG 6 QL; MN-PA TRACLEER TAB 32MG 6 QL; MN-PA TRACLEER TAB 62.5MG 6 QL; MN-PA TRACLEER TAB 125MG 6 QL; MN-PA

PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITORS ADCIRCA TAB 20MG 6 QL; MN-PA REVATIO SUS 10MG/ML 6 MN-PA; Covered for

ages 12 years and under sildenafil citrate tab 20 mg 2 QL; MN-PA; Limited to

pulmonologists and cardiologists

tadalafil tab 20 mg (pah) 6 QL; MN-PA


49


PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR

AGONISTS UPTRAVI TAB 200/800 6 QL; MN-PA UPTRAVI TAB 200MCG 6 QL; MN-PA UPTRAVI TAB 400MCG 6 QL; MN-PA UPTRAVI TAB 600MCG 6 QL; MN-PA UPTRAVI TAB 800MCG 6 QL; MN-PA UPTRAVI TAB 1000MCG 6 QL; MN-PA UPTRAVI TAB 1200MCG 6 QL; MN-PA UPTRAVI TAB 1400MCG 6 QL; MN-PA UPTRAVI TAB 1600MCG 6 QL; MN-PA

PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS ORENITRAM TAB 0.25MG 6 QL; MN-PA ORENITRAM TAB 0.125MG 6 QL; MN-PA ORENITRAM TAB 1MG 6 QL; MN-PA ORENITRAM TAB 2.5MG 6 QL; MN-PA ORENITRAM TAB 5MG 6 QL; MN-PA VENTAVIS SOL 10MCG/ML 6 QL; MN-PA

PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 6 QL; MN-PA ADEMPAS TAB 1.5MG 6 QL; MN-PA ADEMPAS TAB 1MG 6 QL; MN-PA ADEMPAS TAB 2.5MG 6 QL; MN-PA ADEMPAS TAB 2MG 6 QL; MN-PA

VASOPRESSORS midodrine hcl tab 2.5 mg 3

midodrine hcl tab 5 mg 3 midodrine hcl tab 10 mg 3

CENTRAL NERVOUS SYSTEM AMYLOIDOSIS AGENTS

TEGSEDI INJ 284/1.5 6 PA

ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 2 alprazolam orally disintegrating tab 0.5 mg 2 alprazolam orally disintegrating tab 0.25

mg 2

alprazolam orally disintegrating tab 1 mg 2

alprazolam orally disintegrating tab 2 mg 2 alprazolam tab 0.5 mg 2 alprazolam tab 0.5mg xr 2


50

Drug Name Drug Tier Requirements/Limits alprazolam tab 0.25 mg 2 alprazolam tab 1 mg 2 alprazolam tab 1mg xr 2 alprazolam tab 2 mg 2

alprazolam tab 2mg xr 2 alprazolam tab 3mg xr 2 alprazolam tab er 24hr 0.5 mg 2 alprazolam tab er 24hr 1 mg 2 alprazolam tab er 24hr 2 mg 2

alprazolam tab er 24hr 3 mg 2 chlordiazepoxide hcl cap 5 mg 2 chlordiazepoxide hcl cap 10 mg 2 chlordiazepoxide hcl cap 25 mg 2

clonazepam orally disintegrating tab 0.5 mg

3


3


3

clonazepam orally disintegrating tab 1 mg 3 clonazepam orally disintegrating tab 2 mg 3 clonazepam tab 0.5 mg 3

clonazepam tab 1 mg 2 clonazepam tab 2 mg 2 clorazepate dipotassium tab 3.75 mg 3 clorazepate dipotassium tab 7.5 mg 3

clorazepate dipotassium tab 15 mg 3 diazepam con 5mg/ml 2 diazepam conc 5 mg/ml 2 diazepam oral soln 1 mg/ml 2

diazepam tab 2 mg 2 diazepam tab 5 mg 2 diazepam tab 10 mg 2 lorazepam con 2mg/ml 2 lorazepam conc 2 mg/ml 2

lorazepam tab 0.5 mg 2 lorazepam tab 1 mg 2 lorazepam tab 2 mg 2 oxazepam cap 10 mg 2

oxazepam cap 15 mg 2 oxazepam cap 30 mg 2

ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg 2


51

Drug Name Drug Tier Requirements/Limits buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 2 buspirone hcl tab 15 mg 2 buspirone hcl tab 30 mg 2

clomipramine hcl cap 25 mg 2 clomipramine hcl cap 50 mg 2 clomipramine hcl cap 75 mg 2 fluvoxamine maleate cap er 24hr 100 mg 3 QL fluvoxamine maleate cap er 24hr 150 mg 3 QL fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg 2 meprobamate tab 200 mg

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