Blue Shield of California Promise Health Plan 2020 ...

H5928_19_510A_C 08222019

ltInsert cover artgt

Blue Shield of California Promise Health Plan

2020 Formulary (List of Covered Drugs)

For Blue Shield Promise AdvantageOptimum Plan (HMO) Blue Shield Promise AdvantageOptimum

Plan 1 (HMO) Blue Shield Promise AdvantageOptimum Plan 2 (HMO) Blue Shield Promise

Coordinated Choice Plan (HMO) and Blue Shield Promise TotalDual Plan (HMO D-SNP)

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID 20417 Version

This formulary was updated on For more recent information or other questions please contact Blue Shield of California Promise Health Plan Member Services at (800) 544-0088 or for TTY users 711 800 am to 800 pm seven days a week from October 1 ndash March 31 and 800 am to 800 pm weekdays from April 1 ndash September 30 or visit wwwblueshieldcacompromisemedicare

31

11242020

ii

Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take

When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Blue Shield of California Promise Health Plan When it refers to ldquoplanrdquo or ldquoour planrdquo it means Blue Shield Promise AdvantageOptimum Plan Blue Shield Promise AdvantageOptimum Plan 1 Blue Shield Promise AdvantageOptimum Plan 2 Blue Shield Promise Coordinated Choice Plan or Blue Shield Promise TotalDual Plan

This document includes list of the drugs (formulary) for our plan which is current as of For an updated formulary please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages

You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2021 and from time to time during the year

What is the Blue Shield of California Promise Health Plan Formulary A formulary is a list of covered drugs selected by Blue Shield of California Promise Health Plan in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program Blue Shield of California Promise Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a Blue Shield of California Promise Health Plan network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Formulary (drug list) change Most changes in drug coverage happen on January 1 but Blue Shield of California Promise Health Plan may add or remove drugs on the Drug List during the year move them to different cost-sharing tiers or add new restrictions

Changes that can affect you this year In the below cases you will be affected by coverage changes during the year

bull New generic drugs We may immediately remove a brand name drug on our Drug List ifwe are replacing it with a new generic drug that will appear on the same or lower costsharing tier and with the same or fewer restrictions Also when adding the new genericdrug we may decide to keep the brand name drug on our Drug List but immediatelymove it to a different cost-sharing tier or add new restrictions If you are currently takingthat brand name drug we may not tell you in advance before we make that change butwe will later provide you with information about the specific change(s) we have made

o If we make such a change you or your prescriber can ask us to make an exceptionand continue to cover the brand name drug for you The notice we provide you willalso include information on how to request an exception and you can also findinformation in the section below entitled ldquoHow do I request an exception to the BlueShield of California Promise Health Planrsquos Formularyrdquo

bull Drugs removed from the market If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drugrsquos manufacturer removes the drug from the market wewill immediately remove the drug from our formulary and provide notice to members whotake the drug

11242020

iii

bull Other changes We may make other changes that affect members currently taking a drugFor instance we may add a generic drug that is not new to market to replace a brandname drug currently on the formulary or add new restrictions to the brand name drug ormove it to a different cost-sharing tier Or we may make changes based on new clinicalguidelines If we remove drugs from our formulary or add prior authorization quantity limitsandor step therapy restrictions on a drug or move a drug to a higher cost-sharing tier wemust notify affected members of the change at least 30 days before the change becomeseffective or at the time the member requests a refill of the drug at which time themember will receive a 30-day supply of the drug

o If we make these other changes you or your prescriber can ask us to make anexception and continue to cover the brand name drug for you The notice weprovide you will also include information on how to request an exception and youcan also find information in the section below entitled ldquoHow do I request anexception to the Blue Shield of California Promise Health Planrsquos Formularyrdquo

Changes that will not affect you if you are currently taking the drug Generally if you are taking a drug on our 2020 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year

The enclosed formulary is current as of To get updated information about the drugs covered by Blue Shield of California Promise Health Plan please contact us Our contact information appears on the front and back cover pages If we make any other negative formulary changes during the year you will receive a 30 days notice via mail and the changes will be posted on our website All formulary changes will be included on the monthly updated formulary available on our web site at wwwblueshieldcacompromisemedicare

How do I use the Formulary There are two ways to find your drug within the formulary

Medical Condition The formulary begins on page 2 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category ldquoCardiovascular Agentsrdquo If you know what your drug is used for look for the category name in the list that begins on page number 2 Then look under the category name for your drug

Alphabetical Listing If you are not sure what category to look under you should look for your drug in the Index that begins on page 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

11242020

85

iv

What are generic drugs Blue Shield of California Promise Health Plan covers both brand name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand name drug Generally generic drugs cost less than brand name drugs

Are there any restrictions on my coverage Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include

bull Prior Authorization Blue Shield of California Promise Health Plan requires you or your physician to get prior authorization for certain drugs This means that you will need to get approval from Blue Shield of California Promise Health Plan before you fill your prescriptions If you donrsquot get approval Blue Shield of California Promise Health Plan may not cover the drug

bull Quantity Limits For certain drugs Blue Shield of California Promise Health Plan limits the

amount of the drug that Blue Shield of California Promise Health Plan will cover For example Blue Shield of California Promise Health Plan provides 30 capsules per prescription for Memantine Extended Release Capsule This may be in addition to a standard one-month or three-month supply

bull Step Therapy In some cases Blue Shield of California Promise Health Plan requires you to

first try certain drugs to treat your medical condition before we will cover another drug for that condition For example if Drug A and Drug B both treat your medical condition Blue Shield of California Promise Health Plan may not cover Drug B unless you try Drug A first If Drug A does not work for you Blue Shield of California Promise Health Plan will then cover Drug B

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2 You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site We have posted on line documents that explain our prior authorization and step therapy restrictions You may also ask us to send you a copy Our contact information along with the date we last updated the formulary appears on the front and back cover pages

You can ask Blue Shield of California Promise Health Plan to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Blue Shield of California Promise Health Plan formularyrdquo on page v for information about how to request an exception

What if my drug is not on the Formulary If your drug is not included in this formulary (list of covered drugs) you should first contact Member Services and ask if your drug is covered

If you learn that Blue Shield of California Promise Health Plan does not cover your drug you have two options

v

bull You can ask Member Services for a list of similar drugs that are covered by Blue Shield of California Promise Health Plan When you receive the list show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Shield of California Promise Health Plan

bull You can ask Blue Shield of California Promise Health Plan to make an exception and cover

your drug See below for information about how to request an exception

How do I request an exception to the Blue Shield of California Promise Health Plans Formulary You can ask Blue Shield of California Promise Health Plan to make an exception to our coverage rules There are several types of exceptions that you can ask us to make

bull You can ask us to cover a drug even if it is not on our formulary If approved this drug will be covered at a pre-determined cost-sharing level and you would not be able to ask us to provide the drug at a lower cost-sharing level

bull You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier If approved this would lower the amount you must pay for your drug

bull You can ask us to waive coverage restrictions or limits on your drug For example for

certain drugs Blue Shield of California Promise Health Plan limits the amount of the drug that we will cover If your drug has a quantity limit you can ask us to waive the limit and cover a greater amount

Generally Blue Shield of California Promise Health Plan will only approve your request for an exception if the alternative drugs included on the planrsquos formulary the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition andor would cause you to have adverse medical effects

You should contact us to ask us for an initial coverage decision for a formulary tiering or utilization restriction exception When you request a formulary tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber

What do I do before I can talk to my doctor about changing my drugs or requesting an exception As a new or continuing member in our plan you may be taking drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your doctor to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan

vi

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum 30- day supply of medication After your first 30-day supply we will not pay for these drugs even if you have been a member of the plan less than 90 days

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception

In circumstances where a beneficiary is changing from one treatment setting to another Blue Shield of California Promise Health 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 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

For more information For more detailed information about your Blue Shield of California Promise Health Plan prescription drug coverage please review your Evidence of Coverage and other plan materials

If you have questions about Blue Shield of California Promise Health Plan please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages

If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov

Blue Shield of California Promise Health Planrsquos Formulary The formulary below provides coverage information about the drugs covered by Blue Shield of California Promise Health Plan If you have trouble finding your drug in the list turn to the Index that begins on page

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

The information in the RequirementsLimits column tells you if Blue Shield of California Promise Health Plan has any special requirements for coverage of your drug

85

vii

CopaymentsCoinsurance for members of Blue Shield Promise AdvantageOptimum Plan (HMO)

TIER SUPPLY

COST SHARE

Los Angeles and Orange counties

Fresno and Santa Clara counties

Merced County

Stanislaus and San Joaquin counties

1 Preferred Generic Drugs

Preferred retail cost-sharing (in-network) (30-day supply) $0 Copay $0 Copay $0 Copay $0 Copay

Preferred retail cost-sharing (in-network) or the planrsquos mail service cost-sharing (90-day supply)

$0 Copay $0 Copay $0 Copay $0 Copay

Standard retail cost-sharing (in-network) (30-day supply) $5 Copay $3 Copay $3 Copay $3 Copay


2 Generic Drugs



$750 Copay $1250 Copay



Standard retail cost-sharing (in-network) (90-day supply)


3 Preferred Brand Drugs







$11750 Copay

$11750 Copay

$11750 Copay

$11750 Copay

viii

TIER SUPPLY

COST SHARE

Los Angeles and Orange

counties

Fresno and Santa Clara

counties

Merced County


4 Non- Preferred Drugs

Preferred retail cost-sharing (in-network) (30-day supply)







$21750 Copay

$21750 Copay $250 Copay $250 Copay

5 Specialty Tier Drugs

Preferred retail cost-sharing (in-network) standard retail cost-sharing (in-network) (30-day supply)

33 of Blue Shield

Promisersquos contracted

rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield


rate Preferred retail cost-sharing (in-network) standard retail cost-sharing (in-network) or the planrsquos mail service cost-sharing (90-day supply)

A long-term supply is not available for drugs in Tier

5


5


5


5

ix

CopaymentsCoinsurance for members of Blue Shield Promise AdvantageOptimum Plan 1 and Blue Shield Promise Advantage Optimum Plan 2 in San Diego County

TIER SUPPLY

COST SHARE

Blue Shield Promise AdvantageOptimum Plan 1



Preferred retail cost-sharing (in-network) (30-day supply) $0 Copay $0 Copay


$0 Copay $0 Copay


$3 Copay $3 Copay Standard retail cost-sharing (in-network) (90-day supply)

$3 Copay $3 Copay

2 Generic Drugs




Standard retail cost-sharing (in-network) (30-day supply) $10 Copay $17 Copay








$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE












33 of Blue Shield Promisersquos contracted

rate



A long-term supply is not available for

drugs in Tier 5


drugs in Tier 5

xi

CopaymentsCoinsurance for members of Blue Shield Promise Coordinated Choice Plan in Fresno Los Angeles Merced Orange Riverside San Bernardino San Diego San Joaquin Santa Clara and Stanislaus Counties

TIER SUPPLY COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


25 of Blue Shield Promisersquos

contracted rate Standard retail cost-sharing (in-network) (90-day supply)


contracted rate






contracted rate




contracted rate



contracted rate




contracted rate Standard retail cost-sharing (in-network) or the planrsquos mail service cost-sharing (90-day supply)

A long-term supply is not available for drugs in Tier 5

xii

CopaymentsCoinsurance for members of Blue Shield Promise TotalDual Plan in Los Angeles Orange San Bernardino San Diego Fresno San Joaquin and Stanislaus

TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay

or 15 or 25 of Blue Shield Promisersquos contracted rate


$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay




$0 $390 $895 Copay or 15 or 25 of Blue Shield Promisersquos contracted rate




Standard retail cost-sharing (in-network) (30-day supply) $0 $390 $895 Copay


Standard retail cost-sharing (in-network) or the planrsquos mail service cost-sharing (90-day supply)


Please refer to your Low Income Subsidy rider for the exact cost that applies to you

LEGENDTIER NAME


2 Generic Drugs


4 Non-Preferred Drugs


SYMBOL NAME DESCRIPTION

QL Quantity Limit

This medication has a dosing or prescription quantitylimit Maximum daily dose limits are defined by theFDA and listed in the drug package insert Otherquantity limits encourage consolidated dosing whenpossible

PA Prior Authorization

Coverage for this prescription requires priorauthorization from Blue Shield of California PromiseHealth Plan Call Blue Shield of California PromiseHealth Plan to provide the necessary information todetermine coverage

BvD Part B vs Part DRequires a prior authorization to perform a Part B vsPart D coverage determination

ST Step TherapyCoverage for this prescription is provided when otherfirst-line or preferred drug therapies have been tried(step therapy)

LA Limited Access

This prescription may be available only at certainpharmacies For more information consult yourPharmacy Directory or call our Member Servicesnumber at (800) 544-0088 [TTY 711] 8 am to 8 pmseven days a week from Oct 1st ndash March 31st and 8am ndash 8 pm weekdays from April 1st ndash Sept 30th

MO Maintenance Drug

Up to a 90-day supply of this drug is available throughour network mail-order pharmacy and through someof our network retail pharmacies For more informationcall Member Services

1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGScelecoxib (50 mg capsule 100 mg capsule200 mg capsule 400 mg capsule)

TIER 2 MO

diclofenac potassium 50 mg tablet TIER 2

diclofenac sodium (25 mg tablet dr 50 mgtablet dr 75 mg tablet dr 100 mg tab er24h)

TIER 2

diflunisal 500 mg tablet TIER 2

etodolac (200 mg capsule 300 mgcapsule 400 mg tab er 24h 400 mg tablet500 mg tab er 24h 500 mg tablet 600 mgtab er 24h)

TIER 2 MO

flurbiprofen (50 mg tablet 100 mg tablet) TIER 2

ibuprofen (400 mg tablet 600 mg tablet800 mg tablet)

TIER 2 MO

indomethacin (25 mg capsule 50 mgcapsule 75 mg capsule er)

TIER 2 PA

ketoprofen (50 mg capsule 75 mg capsule) TIER 2

ketorolac tromethamine 10 mg tablet TIER 2 PA QL (20 PER 30 DAYS)

meclofenamate sodium (50 mg capsule100 mg capsule)

TIER 2

meloxicam (75 mg tablet 15 mg tablet) TIER 2 MO

nabumetone (500 mg tablet 750 mgtablet)

TIER 2

naproxen (250 mg tablet 375 mg tablet dr375 mg tablet 500 mg tablet 500 mgtablet dr)

TIER 2 MO

piroxicam (10 mg capsule 20 mg capsule) TIER 2

sulindac (150 mg tablet 200 mg tablet) TIER 2

OPIOID ANALGESICS LONG-ACTINGfentanyl (12 mcghr patch td72 25 mcghrpatch td72 50mcghr patch td7275mcghr patch td72 100 mcghr patchtd72)

TIER 2 ST QL (10 PER 30 DAYS OVER TIME)

methadone hcl (5 mg tablet 10 mg tablet) TIER 2 QL (120 PER 30 DAYS)

methadone hcl 10 mg5 ml solution TIER 2 QL (600 PER 30 DAYS)

You can find information on what the symbols and abbreviationson this table mean by going to page 1

2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


morphine sulfate (15 mg tablet er 30 mgtablet er)

TIER 2 QL (90 PER 30 DAYS)

morphine sulfate 100 mg tablet er TIER 2 QL (30 PER 30 DAYS)


oxycodone hcl (10 mg tab er 12h 15 mgtab er 12h 20 mg tab er 12h 30 mg tab er12h 40 mg tab er 12h)

TIER 4 PA QL (60 PER 30 DAYS)

OXYCONTIN (ER 15 MG TABLET ER 30 MGTABLET)


OPIOID ANALGESICS SHORT-ACTINGacetaminophen with codeine 120-12mg5solution


acetaminophen with codeine phosphate(300mg-15mg tablet 300mg-60mg tablet300mg-30mg tablet)


butalbitacetamincaffcodeine 50-325-30capsule

TIER 2 PA - FOR NEW STARTS ONLY QL(180 PER 30 DAYS)

codeine sulfate (15 mg tablet 30 mgtablet 60 mg tablet)


fentanyl citrate (600 mcg lozenge hd 800mcg lozenge hd)


fentanyl citrate 200 mcg lozenge hd TIER 4 PA QL (120 PER 30 DAYS)


hydrocodone bitartrateacetaminophen(hydrocodoneacetaminophen 25-1085solution hydrocodoneacetaminophen 5-217mg10 solutionhydrocodoneacetaminophen 75-32515solution)


hydrocodone bitartrateacetaminophen(hydrocodoneacetaminophen 5 mg-325mg tablethydrocodoneacetaminophen 75-325 mgtablet hydrocodoneacetaminophen10mg-325mg tablet)


hydrocodoneibuprofen(hydrocodoneibuprofen 5mg-200mgtablet hydrocodoneibuprofen 75-200 mgtablet hydrocodoneibuprofen 10mg-200mg tablet)


hydromorphone hcl (2 mg tablet 4 mgtablet)



3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

hydromorphone hcl 8 mg tablet TIER 2 QL (90 PER 30 DAYS)

hydromorphone hclpf (hclpf 10 mgmlvial hclpf 10 mgml ampul)

TIER 2

LAZANDA (100 MCG SPRAY 300 MCGSPRAY)


meperidine hcl (50 mg tablet 100 mgtablet)


meperidine hcl 50 mg5 ml solution TIER 2 PA QL (600 PER 30 DAYS)

morphine sulfate (15 mg tablet 30 mgtablet)


morphine sulfate 10 mg5 ml solution TIER 2 QL (1800 PER 30 DAYS)

morphine sulfate 100 mg5ml solution TIER 2 QL (180 PER 30 DAYS)


oxycodone hcl (5 mg capsule 5 mg tablet10 mg tablet 15 mg tablet 20 mgml oralconc 20 mg tablet)


oxycodone hcl 30 mg tablet TIER 2 QL (60 PER 30 DAYS)

oxycodone hcl 5 mg5 ml solution TIER 2 QL (250 PER 30 DAYS)

oxycodone hclacetaminophen(hclacetaminophen 5 mg-325mg tablethclacetaminophen 75-325 mg tablethclacetaminophen 10mg-325mg tablet)


oxycodone hclaspirin 48355-325 tablet TIER 2 QL (120 PER 30 DAYS)

tramadol hcl 100 mg tablet TIER 2 QL (4 PER 1 DAYS)


tramadol hclacetaminophen 375-325mgtablet


ANESTHETICS

LOCAL ANESTHETICSlidocaine 5 adh patch TIER 4 PA QL (90 PER 30 DAYS OVER TIME)

lidocaine 5 oint (g) TIER 2 QL (50 PER 30 DAYS OVER TIME)

lidocaine hcl (2 jelly(ml) 2 jelpf app 2 solution 4 solution 40 mgml solution)

TIER 2

lidocaineprilocaine 25 -25 cream (g) TIER 2 QL (30 PER 30 DAYS OVER TIME)

NAYZILAM 5 MG NASAL SPRAY TIER 5 QL (10 PER 30 DAYS)


4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTSANTI-CRAVINGacamprosate calcium 333 mg tablet dr TIER 4 MO

disulfiram (250 mg tablet 500 mg tablet) TIER 2 MO

naltrexone hcl 50 mg tablet TIER 2

VIVITROL 380 MG VIAL + DILUENT TIER 5 BvD

OPIOID DEPENDENCE TREATMENTSbuprenorphine hcl 2 mg tab subl TIER 2 QL (12 PER 1 DAYS)

buprenorphine hcl 8 mg tab subl TIER 2 QL (3 PER 1 DAYS)

buprenorphine hclnaloxone hcl(naloxone 2 mg-05mg film naloxone4mg-1mg film)

TIER 2 QL (5 PER 1 DAYS) MO

buprenorphine hclnaloxone hcl(naloxone 8 mg tab subl naloxone 8 mgfilm)


buprenorphine hclnaloxone hcl 12 mg-3mg film


buprenorphine hclnaloxone hcl 2 mg-05mg tab subl


OPIOID REVERSAL AGENTSnaloxone hcl (04 mgml vial 04 mgmlcartridge 1 mgml syringe)

TIER 2

NARCAN 4 MG NASAL SPRAY TIER 3 QL (2 PER 1 DAYS)

SMOKING CESSATION AGENTSbupropion hcl 150 mg tab er 12h TIER 2

CHANTIX (05 MG TABLET 1 MG CONTMONTH BOX 1 MG TABLET STARTINGMONTH BOX)

TIER 4

NICOTROL CARTRIDGE INHALER TIER 3

NICOTROL NS 10 MGML SPRAY TIER 3

ANTIBACTERIALS

AMINOGLYCOSIDESamikacin sulfate 500 mg2ml vial TIER 2


5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

gentamicin sulfate (03 drops 03 oint(g) 40 mgml vial)

TIER 2

neomycin sulfate 500 mg tablet TIER 2

paromomycin sulfate 250 mg capsule TIER 2

streptomycin sulfate 1 g vial TIER 2

tobramycin 03 drops TIER 2

tobramycin sulfate (12 g vial 40 mgmlvial)

TIER 2

ANTIBACTERIALS OTHERbacitracin 500 unitg oint (g) TIER 2

clindamycin hcl (150 mg capsule 300 mgcapsule)

TIER 2

clindamycin phosphate (1 solution 1 lotion 1 med swab 1 gel (gram) 2 creamappl 150 mgml vial 300 mg2mlvial port)

TIER 2

colistin (colistimethate na) 150 mg vial TIER 2

daptomycin 500 mg vial TIER 5

erythromycinbenzoyl peroxide 3 -5 gel(gram)

TIER 2

fosfomycin tromethamine 3 g packet TIER 4 QL (1 PER 30 DAYS OVER TIME)

linezolid 100 mg5ml susp recon TIER 5 PA

linezolid 600 mg tablet TIER 4 PA

linezolid in 09 sodium chlor 600mg300piggyback

TIER 5

linezolid in dextrose 5 600mg300piggyback

TIER 5

methenamine hippurate 1 g tablet TIER 2

METRO IV 500 MG100 ML TIER 2

metronidazole (075 gel wappl 250 mgtablet 500 mg tablet)

TIER 2

metronidazolesodium chloride 500mg01lpiggyback

TIER 2

mupirocin 2 oint (g) TIER 2 QL (22 PER 30 DAYS OVER TIME)

nitrofurantoin macrocrystal (25 mg capsule50 mg capsule 100 mg capsule)

TIER 2

nitrofurantoin monohydm-cryst 100 mgcapsule

TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

SIVEXTRO 200 MG TABLET TIER 5 PA

SIVEXTRO 200 MG VIAL TIER 5 BvD

tigecycline 50 mg vial TIER 5

trimethoprim 100 mg tablet TIER 2

vancomycin hcl (1 g vial 1 g vial port 10 gvial)

TIER 2

vancomycin hcl 125 mg capsule TIER 4


XIFAXAN 200 MG TABLET TIER 3 PA

XIFAXAN 550 MG TABLET TIER 3 PA MO

BETA-LACTAM CEPHALOSPORINScefaclor (125 mg5ml susp recon 250 mgcapsule 250 mg5ml susp recon 375mg5ml susp recon 500 mg capsule 500mg tab er 12h)

TIER 2

cefadroxil (1 g tablet 250 mg5ml susprecon 500 mg5ml susp recon 500 mgcapsule)

TIER 2

cefazolin sodium (1 g vial port 1 g vial 10 gvial 20 g vial 100 g bulkbaginj 300gbulkbaginj 500 mg vial)

TIER 2

cefazolin sodiumdextrose iso-osmotic(sodiumdextroseiso 1 g50 ml piggybacksodiumdextroseiso 1 g50 ml frozpiggy)

TIER 2

cefdinir 300 mg capsule TIER 2

cefepime hcl (1 g vial 2 g vial) TIER 3

cefepime hcl in dextrose 5 in water ( 5 1 g50 ml piggyback 5 2 g50 mlpiggyback)

TIER 3

cefepime hcl in iso-osmotic dextrose ( 1g50 ml frozpiggy 2 g100 ml frozpiggy)

TIER 3

cefoxitin sodium 1 g vial TIER 4 BvD

cefoxitin sodiumdextroseiso 1 g50 mlpiggyback

TIER 4 BvD

cefpodoxime proxetil (50 mg5 ml susprecon 100 mg tablet 100 mg5ml susprecon 200 mg tablet)

TIER 2

cefprozil (125 mg5ml susp recon 250 mgtablet 250 mg5ml susp recon 500 mgtablet)

TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ceftazidime (1 g vial 1 g vial port 2 g vial 2g vial port 6 g vial)

TIER 2

ceftazidime in dextrose 5 and water ( 1g50 ml piggyback 2 g50 ml piggyback)

TIER 2

ceftriaxone sodium (1 g vial 1 g vial port 2g vial port 2 g vial 10 g vial 100 gbulkbaginj 250 mg vial 500 mg vial)

TIER 2

ceftriaxone sodium in iso-osmotic dextrose (1 g50 ml frozpiggy 1 g50 ml piggyback 2g50 ml piggyback 2 g50 ml frozpiggy)

TIER 2

cefuroxime axetil (250 mg tablet 500 mgtablet)

TIER 2

cefuroxime sodium (15 g vial 75 g vial 750mg vial)

TIER 2

cephalexin (125 mg5ml susp recon 250mg5ml susp recon 250 mg capsule 250mg tablet 500 mg tablet 500 mg capsule750 mg capsule)

TIER 2

TEFLARO (400 MG VIAL 600 MG VIAL) TIER 5

BETA-LACTAM OTHERaztreonam 1 g vial TIER 5

ertapenem sodium 1 g vial TIER 4

imipenemcilastatin sodium(imipenemcilastatin 250 mg vialimipenemcilastatin 500 mg vial)

TIER 2

meropenem (1 g vial 500 mg vial) TIER 2

meropenem in 09 sodium chloride (1g50 ml piggyback 500mg50mlpiggyback)

TIER 2

BETA-LACTAM PENICILLINSamoxicillin (125 mg5ml susp recon 125 mgtab chew 200 mg5ml susp recon 250 mgcapsule 250 mg5ml susp recon 250 mgtab chew 400 mg5ml susp recon 500 mgtablet 500 mg capsule 875 mg tablet)

TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

amoxicillinpotassium clavulanate(amoxicillinpotassium 200-2855 susprecon amoxicillinpotassium 200-285mgtab chew amoxicillinpotassium 250-125mg tablet amoxicillinpotassium 250-6255susp recon amoxicillinpotassium 400-57mg5 susp recon amoxicillinpotassium400-57mg tab chew amoxicillinpotassium500-125 mg tablet amoxicillinpotassium600-4295 susp reconamoxicillinpotassium 875-125 mg tablet)

TIER 2

ampicillin sodium (1 g vial port 1 g vial 10 gvial 125 mg vial)

TIER 3

ampicillin sodiumsulbactam sodium(sodiumsulbactam 15 g vialsodiumsulbactam 15 g vial portsodiumsulbactam 3 g vialsodiumsulbactam 3 g vial portsodiumsulbactam 15 g vial)

TIER 2

ampicillin trihydrate 500 mg capsule TIER 2

BICILLIN C-R (12 MILLION UNIT 900-300SYRINGE)

TIER 3

BICILLIN L-A (600000 UNITML 1200000UNITS 2400000 UNITS)

TIER 3

dicloxacillin sodium (250 mg capsule 500mg capsule)

TIER 2

nafcillin in dextroseiso-osm 1 g50 mlfrozpiggy

TIER 2

nafcillin sodium (1 g vial port 1 g vial) TIER 2

penicillin g potassium (g 5mm vial g 20mmvial)

TIER 2

penicillin g sodium 5mm unit vial TIER 2

penicillin v potassium (125 mg5ml solnrecon 250 mg tablet 250 mg5ml solnrecon 500 mg tablet)

TIER 2

piperacillin sodiumtazobactam sodium(sodiumtazobactam 225 g vial portsodiumtazobactam 225 g vialsodiumtazobactam 3375 g vialsodiumtazobactam 3375 g vial portsodiumtazobactam 45 g vialsodiumtazobactam 45 g vial portsodiumtazobactam 135 g vialsodiumtazobactam 405 g vial)

TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

MACROLIDESazithromycin (1 g packet 100 mg5ml susprecon 200 mg5ml susp recon 250 mgtablet 500 mg tablet 500 mg vial port 500mg vial)

TIER 2

azithromycin 600 mg tablet TIER 2 QL (8 PER 30 DAYS OVER TIME)

clarithromycin (125 mg5ml susp recon 250mg tablet 250 mg5ml susp recon 500 mgtab er 24h 500 mg tablet)

TIER 2

EES 400 FILMTAB TIER 2

ERYTHROCIN 250 MG FILMTAB TIER 2

ERYTHROCIN LACTOBIONATE (LACT 500 MGVIAL 500 MG ADDVAN VIAL)

TIER 4

erythromycin base (5 mggram oint (g)250 mg tablet 250 mg capsule dr 500 mgtablet)

TIER 2

erythromycin base in ethanol ( 2 medswab 2 gel (gram) 2 solution)

TIER 2

erythromycin ethylsuccinate 400 mg tablet TIER 2

QUINOLONESciprofloxacin 500 mg5ml sus mc rec TIER 2

ciprofloxacin hcl (02 droperette 03 drops 100 mg tablet 250 mg tablet 500mg tablet 750 mg tablet)

TIER 2

ciprofloxacin in 5 dextrose 200mg01lpiggyback

TIER 2

ciprofloxacinciprofloxacin hcl(ciprofloxacinciprofloxa 500 mg tbmp 24hrciprofloxacinciprofloxa 1000 mg tbmp24hr)

TIER 2

levofloxacin (25 mgml vial 250mg10mlsolution 250 mg tablet 500mg20mlsolution 500 mg tablet 750 mg tablet)

TIER 2

levofloxacindextrose 5 in water ( 5 500mg01l piggyback 5 750mg15lpiggyback)

TIER 2

moxifloxacin hcl 05 drops TIER 2

moxifloxacin hcl 400 mg tablet TIER 4

ofloxacin (03 drops 300 mg tablet 400mg tablet)

TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

SULFONAMIDESBLEPH-10 10 EYE DROPS TIER 2

silver sulfadiazine 1 cream (g) TIER 2

SSD 1 CREAM TIER 2

sulfacetamide sodium (10 drops 10 oint (g))

TIER 2

sulfadiazine 500 mg tablet TIER 2

sulfamethoxazoletrimethoprim(sulfamethoxazoletrimethoprim 200-40mg5 oral suspsulfamethoxazoletrimethoprim 400mg-80mg tabletsulfamethoxazoletrimethoprim 800-16020oral susp sulfamethoxazoletrimethoprim800-160 mg tablet)

TIER 2

TETRACYCLINESdemeclocycline hcl (150 mg tablet 300 mgtablet)

TIER 2

doxycycline hyclate (20 mg tablet 50 mgcapsule 75 mg tablet 100 mg tablet 100mg capsule 150 mg tablet)

TIER 2

doxycycline hyclate 100 mg vial TIER 2 BvD

doxycycline monohydrate (50 mg tablet50 mg capsule 100 mg capsule 100 mgtablet)

TIER 2

minocycline hcl (50 mg capsule 50 mgtablet 75 mg tablet 75 mg capsule 100mg capsule 100 mg tablet)

TIER 2

tetracycline hcl (250 mg capsule 500 mgcapsule)

TIER 2

ANTICONVULSANTS

ANTICONVULSANTS OTHERBRIVIACT (10 MG TABLET 10 MGML ORALSOLN 25 MG TABLET 50 MG TABLET 75 MGTABLET 100 MG TABLET)

TIER 4 PA - FOR NEW STARTS ONLY MO

EPIDIOLEX 100 MGML SOLUTION TIER 5 PA - FOR NEW STARTS ONLY LA

FINTEPLA 22 MGML SOLUTION TIER 5 PA - FOR NEW STARTS ONLY LA QL(12 PER 1 DAYS)


11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

levetiracetam (100 mgml solution 250 mgtablet 500 mg tablet 500 mg5ml solution750 mg tablet 1000 mg tablet)

TIER 2 MO

levetiracetam 500 mg tab er 24h TIER 2 QL (180 PER 30 DAYS) MO


SPRITAM (250 MG TABLET 500 MG TABLET750 MG TABLET 1000 MG TABLET)


XCOPRI (150 MG TABLET 200 MG TABLET250 MG DAILY DOSE PACK 350 MG DAILYDOSE PACK)

TIER 5 PA - FOR NEW STARTS ONLY QL (2PER 1 DAYS)

XCOPRI (50 MG TABLET 100 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY QL (1PER 1 DAYS)

XCOPRI (50-100 MG PAK 150-200 MG PK) TIER 5 PA - FOR NEW STARTS ONLY QL (28PER 28 DAYS OVER TIME)

XCOPRI 125-25 MG TITRATION PK TIER 4 PA - FOR NEW STARTS ONLY QL (28PER 28 DAYS OVER TIME)

CALCIUM CHANNEL MODIFYING AGENTSCELONTIN 300 MG KAPSEAL TIER 3 MO

ethosuximide (250 mg5ml solution 250 mgcapsule)

TIER 2 MO

zonisamide (25 mg capsule 50 mg capsule100 mg capsule)

TIER 2 MO

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam (25 mgml oral susp 10 mgtablet 20 mg tablet)


diazepam (5-75-10mg kit 125-15-20 kit) TIER 2

diazepam 25 mg kit TIER 2 QL (5 PER 30 DAYS)

divalproex sodium (125 mg tablet dr 125mg cap dr spr 250 mg tablet dr 250 mgtab er 24h 500 mg tab er 24h 500 mgtablet dr)

TIER 2 MO

gabapentin (100 mg capsule 250 mg5mlsolution 300 mg capsule 300 mg6mlsolution 400 mg capsule 600 mg tablet800 mg tablet)

TIER 2 MO

GABITRIL (12 MG TABLET 16 MG TABLET) TIER 4 MO

phenobarbital (15 mg tablet 162 mgtablet 20 mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mg tablet972mg tablet 100 mg tablet)



12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

primidone (50 mg tablet 250 mg tablet) TIER 2 MO

SYMPAZAN (10 MG FILM 20 MG FILM) TIER 5 PA - FOR NEW STARTS ONLY QL (2PER 1 DAYS)

SYMPAZAN 5 MG FILM TIER 4 PA - FOR NEW STARTS ONLY QL (2PER 1 DAYS) MO

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

TIER 4 MO

valproic acid (as sodium salt) (valproatesodium) (salt) 250 mg5ml solution salt)500mg10ml solution)

TIER 2 MO

valproic acid 250 mg capsule TIER 2 MO

VALTOCO (5 MG SPRAY 10 MG SPRAY 15MG SPRAY 20 MG SPRAY)


vigabatrin 500 mg powd pack TIER 5 PA - FOR NEW STARTS ONLY LA

vigabatrin 500 mg tablet TIER 5 PA - FOR NEW STARTS ONLY

GLUTAMATE REDUCING AGENTSfelbamate (400 mg tablet 600 mg5ml oralsusp 600 mg tablet)


FYCOMPA (2 MG TABLET 4 MG TABLET 8MG TABLET 10 MG TABLET 12 MG TABLET)

TIER 4 PA - FOR NEW STARTS ONLY QL (30PER 30 DAYS) MO

FYCOMPA 05 MGML ORAL SUSP TIER 4 PA - FOR NEW STARTS ONLY QL(720 PER 30 DAYS) MO

FYCOMPA 6 MG TABLET TIER 4 PA - FOR NEW STARTS ONLY QL (60PER 30 DAYS) MO

lamotrigine (5 mg tb chw dsp 25 mg tbchw dsp 25 mg tablet 100 mg tablet 150mg tablet 200 mg tablet)

TIER 2 MO

lamotrigine 25mg (35) tab ds pk TIER 2

topiramate (15 mg cap sprink 25 mg capsprink 25 mg tablet 50 mg tablet 100 mgtablet 200 mg tablet)

TIER 2 MO

topiramate (25 mg cap spr 24 50 mg capspr 24 100 mg cap spr 24 150 mg cap spr24 200 mg cap spr 24)


SODIUM CHANNEL AGENTSAPTIOM (200 MG TABLET 400 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY QL (30

PER 30 DAYS)

APTIOM 600 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY QL (60PER 30 DAYS)


13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

APTIOM 800 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY

BANZEL (40 MGML SUSPENSION 200 MGTABLET)


BANZEL 400 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY

carbamazepine (100 mg tab er 12h 100mg5ml oral susp 100 mg cpmp 12hr 100mg tab chew 200 mg tab er 12h 200 mgtablet 200 mg cpmp 12hr 300 mg cpmp12hr 400 mg tab er 12h)

TIER 2 MO

DILANTIN (30 MG CAPSULE 50 MG INFATAB100 MG CAPSULE)

TIER 3 MO

DILANTIN 125 MG5 ML SUSP TIER 3 MO

oxcarbazepine (150 mg tablet 300 mg5mloral susp 300 mg tablet 600 mg tablet)

TIER 2 MO

OXTELLAR XR (150 MG TABLET 300 MGTABLET 600 MG TABLET)


PEGANONE 250 MG TABLET TIER 3 MO

PHENYTEK (200 MG CAPSULE 300 MGCAPSULE)

TIER 3 MO

phenytoin (50 mg tab chew 100 mg4mloral susp 125 mg5ml oral susp)

TIER 2 MO

phenytoin sodium extended (100 mgcapsule 200 mg capsule 300 mg capsule)

TIER 2 MO

rufinamide 40 mgml oral susp TIER 4 PA - FOR NEW STARTS ONLY MO

TEGRETOL XR 100 MG TABLET TIER 3 MO

VIMPAT (10 MGML SOLUTION 50 MGTABLET 100 MG TABLET 150 MG TABLET 200MG TABLET)


ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS OTHERergoloid mesylates 1 mg tablet TIER 2 PA MO

CHOLINESTERASE INHIBITORSdonepezil hcl (5 mg tablet 5 mg tab rapdis10 mg tablet 10 mg tab rapdis)

TIER 2 MO

rivastigmine (46mg24hr patch td2495mg24hr patch td24 133mg24h patchtd24)

TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

rivastigmine tartrate (15 mg capsule 3 mgcapsule 45 mg capsule 6 mg capsule)

TIER 2 MO

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (2 mgml solution 5 mgtablet 10 mg tablet)

TIER 2 MO

memantine hcl (7 mg cap spr 24 14 mgcap spr 24 21 mg cap spr 24 28 mg capspr 24)


memantine hcl 5 mg-10 mg tab ds pk TIER 2

ANTIDEPRESSANTS

ANTIDEPRESSANTS OTHERamitriptyline hclchlordiazepoxide(amitriptylinechlordiazepoxide 125mg-5mg tablet amitriptylinechlordiazepoxide25 mg-10mg tablet)

TIER 2 MO

bupropion hcl (75 mg tablet 100 mg tab sr12h 100 mg tablet 150 mg tab sr 12h 200mg tab sr 12h 300 mg tab er 24h)

TIER 2 MO

bupropion hcl 150 mg tab er 24h TIER 2 QL (30 PER 30 DAYS) MO

mirtazapine (75 mg tablet 15 mg tabrapdis 15 mg tablet 30 mg tablet 30 mgtab rapdis 45 mg tablet 45 mg tab rapdis)

TIER 2 MO

perphenazineamitriptyline hcl(perphenazineamitriptyline 2 mg-10 mgtablet perphenazineamitriptyline 2 mg-25mg tablet perphenazineamitriptyline 4mg-50 mg tabletperphenazineamitriptyline 4 mg-25 mgtablet perphenazineamitriptyline 4mg-10mg tablet)


MONOAMINE OXIDASE INHIBITORSEMSAM (6 MG24 PATCH 9 MG24 PATCH12 MG24 PATCH)

TIER 5 PA - FOR NEW STARTS ONLY

MARPLAN 10 MG TABLET TIER 3 MO

phenelzine sulfate 15 mg tablet TIER 2 MO

tranylcypromine sulfate 10 mg tablet TIER 2 MO


15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORSEROTONINAND NOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide (10 mg5 mlsolution 10 mg tablet 20 mg tablet 20mg10ml solution 40 mg tablet)

TIER 2 MO

desvenlafaxine (50 mg tab er 24 50 mg taber 24h 100 mg tab er 24 100 mg tab er24h)


desvenlafaxine succinate (25 mg tab er24h 50 mg tab er 24h 100 mg tab er 24h)


escitalopram oxalate (5 mg tablet 5 mg5ml solution 10 mg tablet 20 mg tablet)

TIER 2 MO

FETZIMA (ER 20 MG CAPSULE ER 40 MGCAPSULE ER 80 MG CAPSULE ER 120 MGCAPSULE)


FETZIMA 20-40 MG TITRATION PAK TIER 4 PA - FOR NEW STARTS ONLY

fluoxetine hcl (10 mg tablet 10 mg capsule20 mg tablet 20 mg capsule 20 mg5 mlsolution 40 mg capsule 90 mg capsule dr)

TIER 2 MO

fluvoxamine maleate (25 mg tablet 50 mgtablet 100 mg tablet)

TIER 2 MO

maprotiline hcl (25 mg tablet 50 mg tablet75 mg tablet)

TIER 2 MO

nefazodone hcl (50 mg tablet 100 mgtablet 150 mg tablet 200 mg tablet 250mg tablet)

TIER 2 MO

paroxetine hcl (10 mg tablet 20 mg tablet30 mg tablet 40 mg tablet)

TIER 2 MO

PAXIL 10 MG5 ML SUSPENSION TIER 3 MO

sertraline hcl (20 mgml oral conc 25 mgtablet 50 mg tablet 100 mg tablet)

TIER 2 MO

trazodone hcl (50 mg tablet 100 mg tablet150 mg tablet 300 mg tablet)

TIER 2 MO

TRINTELLIX (5 MG TABLET 10 MG TABLET 20MG TABLET)


venlafaxine hcl (25 mg tablet 375 mg caper 24h 375 mg tablet 50 mg tablet 75 mgcap er 24h 75 mg tablet 100 mg tablet150 mg cap er 24h)

TIER 2 MO

VIIBRYD (10 MG TABLET 20 MG TABLET 40MG TABLET)



16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

VIIBRYD 10-20 MG STARTER PACK TIER 4 PA - FOR NEW STARTS ONLY

TRICYCLICSamitriptyline hcl (10 mg tablet 25 mgtablet 50 mg tablet 75 mg tablet 100 mgtablet 150 mg tablet)


amoxapine (25 mg tablet 50 mg tablet100 mg tablet 150 mg tablet)

TIER 2 MO

clomipramine hcl (25 mg capsule 50 mgcapsule 75 mg capsule)


desipramine hcl (10 mg tablet 25 mgtablet 50 mg tablet 75 mg tablet 100 mgtablet 150 mg tablet)

TIER 2 MO

doxepin hcl (10 mgml oral conc 10 mgcapsule 25 mg capsule 50 mg capsule 75mg capsule 100 mg capsule 150 mgcapsule)


imipramine hcl (10 mg tablet 25 mg tablet50 mg tablet)


imipramine pamoate (75 mg capsule 100mg capsule 125 mg capsule 150 mgcapsule)


nortriptyline hcl (10 mg5 ml solution 10 mgcapsule 20 mg10ml solution 25 mgcapsule 50 mg capsule 75 mg capsule)

TIER 2 MO

protriptyline hcl (5 mg tablet 10 mg tablet) TIER 2 MO

trimipramine maleate (25 mg capsule 50mg capsule 100 mg capsule)


ANTIEMETICS

ANTIEMETICS OTHERmeclizine hcl (125 mg tablet 25 mg tablet) TIER 2

metoclopramide hcl (5 mg5 ml solution 5mg tablet 10 mg10ml solution 10 mgtablet)

TIER 2

perphenazine (2 mg tablet 4 mg tablet 8mg tablet 16 mg tablet)

TIER 2 MO

prochlorperazine 25 mg supprect TIER 2

prochlorperazine maleate (5 mg tablet 10mg tablet)

TIER 2

promethazine hcl (125 mg supprect 25mg supprect 50 mg tablet 50 mgsupprect)

TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

scopolamine 1 mg3 day patch td 3 TIER 3 PA

EMETOGENIC THERAPY ADJUNCTSaprepitant (80 mg capsule 125mg-80mgcap ds pk 125 mg capsule)

TIER 3 BvD

aprepitant 40 mg capsule TIER 3 PA

dronabinol (25 mg capsule 5 mg capsule10 mg capsule)

TIER 4 PA

EMEND 125 MG POWDER PACKET TIER 3 PA

granisetron hcl 1 mg tablet TIER 2 BvD

ondansetron (4 mg tab rapdis 8 mg tabrapdis)

TIER 2 BvD

ondansetron hcl (4 mg tablet 4 mg5 mlsolution 8 mg tablet 24 mg tablet)

TIER 2 BvD

ANTIFUNGALSABELCET 100 MG20 ML VIAL TIER 3 BvD

AMBISOME 50 MG VIAL TIER 3 BvD

amphotericin b 50 mg vial TIER 4 BvD

caspofungin acetate (50 mg vial 70 mgvial)

TIER 5 PA

ciclopirox (077 gel (gram) 8 solution) TIER 2

ciclopirox olamine (077 cream (g) 077 suspension)

TIER 2

clotrimazole (1 cream (g) 1 solution 10mg troche)

TIER 2

econazole nitrate 1 cream (g) TIER 2

ERAXIS(WATER DIL) 100 MG VIAL TIER 5


fluconazole (10 mgml susp recon 40mgml susp recon 50 mg tablet 100 mgtablet 150 mg tablet 200 mg tablet)

TIER 2

fluconazole in dextrose iso-osmotic (200mg01l piggyback 400mg02lpiggyback)

TIER 2

fluconazole in sodium chloride iso-osmotic( 200mg01l piggyback 200mg01lpggybk btl 400mg02l pggybk btl400mg02l piggyback)

TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

flucytosine (250 mg capsule 500 mgcapsule)

TIER 5

griseofulvin ultramicrosize (125 mg tablet250 mg tablet)

TIER 2

griseofulvin microsize (125 mg5ml oralsusp 500 mg tablet)

TIER 2

itraconazole 100 mg capsule TIER 2 PA

ketoconazole (2 cream (g) 2 shampoo 200 mg tablet)

TIER 2

miconazole nitrate 200 mg suppvag TIER 2

NATACYN EYE DROPS TIER 4

nystatin (500k unit tablet 100000g oint (g)100000g powder 100000ml oral susp100000g cream (g))

TIER 2

nystatintriamcinolone acetonide(nystatintriamcin 100000-01 cream (g)nystatintriamcin 100000-01 oint (g))

TIER 2

terbinafine hcl 250 mg tablet TIER 2

terconazole (04 creamappl 08 creamappl 80 mg suppvag)

TIER 2

voriconazole (50 mg tablet 200 mg5mlsusp recon)

TIER 5 PA

voriconazole 200 mg tablet TIER 4 PA

voriconazole 200 mg vial TIER 4

ANTIGOUT AGENTSallopurinol (100 mg tablet 300 mg tablet) TIER 2 MO

colchicine 06 mg tablet TIER 3 QL (4 PER 1 DAYS) MO

COLCRYS 06 MG TABLET TIER 3 QL (4 PER 1 DAYS) MO

probenecid 500 mg tablet TIER 2 MO

probenecidcolchicine 500-05 mg tablet TIER 2 MO

ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS OTHERAIMOVIG AUTOINJECTOR (70 MGML 140MGML)

TIER 3 PA QL (1 PER 28 DAYS OVER TIME)MO


19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ERGOT ALKALOIDSdihydroergotamine mesylate 05mgspryspraypump

TIER 4 PA

ergotamine tartratecaffeine 1 mg-100mgtablet


ergotamine tartratecaffeine 2-100mgsupprect

TIER 3

SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate (5 mg tab rapdis 5 mgtablet 10 mg tab rapdis 10 mg tablet)


sumatriptan 20 mg spray TIER 2 QL (9 PER 30 DAYS)


sumatriptan succinate (25 mg tablet 50 mgtablet 100 mg tablet)


sumatriptan succinate (4 mg05mlcartridge 4 mg05ml pen injctr 6 mg05mlcartridge 6 mg05ml pen injctr)


ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICSguanidine hcl 125 mg tablet TIER 2

pyridostigmine bromide 60 mg tablet TIER 2 MO

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS OTHERdapsone (25 mg tablet 100 mg tablet) TIER 3 MO

rifabutin 150 mg capsule TIER 2

ANTITUBERCULARSethambutol hcl (100 mg tablet 400 mgtablet)

TIER 2

isoniazid (50 mg5 ml solution 100 mgtablet 300 mg tablet)

TIER 2

PASER GRANULES 4 GM PACKET TIER 4

PRIFTIN 150 MG TABLET TIER 3


20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

pyrazinamide 500 mg tablet TIER 2

rifampin (150 mg capsule 300 mg capsule) TIER 2

rifampin 600 mg vial TIER 4

RIFATER TABLET TIER 3

SIRTURO 20 MG TABLET TIER 5 QL (120 PER 28 DAYS OVER TIME)

TRECATOR 250 MG TABLET TIER 3

ANTINEOPLASTICS

ALKYLATING AGENTScyclophosphamide (25 mg capsule 50 mgcapsule)

TIER 3 BvD

GLEOSTINE (10 MG CAPSULE 40 MGCAPSULE 100 MG CAPSULE)

TIER 4

LEUKERAN 2 MG TABLET TIER 5

MATULANE 50 MG CAPSULE TIER 5 LA

VALCHLOR 0016 GEL TIER 5 PA - FOR NEW STARTS ONLY LA

ANTIANDROGENSabiraterone acetate 250 mg tablet TIER 5 PA - FOR NEW STARTS ONLY

bicalutamide 50 mg tablet TIER 2 MO

ERLEADA 60 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

flutamide 125 mg capsule TIER 2 MO

nilutamide 150 mg tablet TIER 3 MO

NUBEQA 300 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY QL (4PER 1 DAYS)

XTANDI 40 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA

YONSA 125 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

ZYTIGA 500 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

ANTIANGIOGENIC AGENTSPOMALYST (1 MG CAPSULE 2 MG CAPSULE3 MG CAPSULE 4 MG CAPSULE)

TIER 5 PA - FOR NEW STARTS ONLY LA

REVLIMID (25 MG CAPSULE 5 MG CAPSULE10 MG CAPSULE 15 MG CAPSULE 20 MGCAPSULE 25 MG CAPSULE)


THALOMID (50 MG CAPSULE 100 MGCAPSULE 150 MG CAPSULE 200 MGCAPSULE)



21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANTIESTROGENSMODIFIERSEMCYT 140 MG CAPSULE TIER 3

SOLTAMOX (10 MG5 ML SOLN 20 MG10ML SOLN)


tamoxifen citrate (10 mg tablet 20 mgtablet)

TIER 2 MO

toremifene citrate 60 mg tablet TIER 5

ANTIMETABOLITESDROXIA (200 MG CAPSULE 300 MGCAPSULE 400 MG CAPSULE)

TIER 3 MO

fluorouracil (2 solution 5 cream (g) 5 solution)

TIER 2

hydroxyurea 500 mg capsule TIER 2 MO

LONSURF (15 MG-614 MG TABLET 20 MG-819 MG TABLET)


mercaptopurine 50 mg tablet TIER 2 MO

PURIXAN 20 MGML ORAL SUSP TIER 4 PA - FOR NEW STARTS ONLY LA MO

TABLOID 40 MG TABLET TIER 3

ANTINEOPLASTICS OTHERALUNBRIG (30 MG TABLET 90 MG-180 MGTAB PACK 90 MG TABLET 180 MG TABLET)


AYVAKIT (100 MG TABLET 200 MG TABLET300 MG TABLET)

TIER 5 PA - FOR NEW STARTS ONLY LA QL(1 PER 1 DAYS)

BALVERSA 3 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA QL(3 PER 1 DAYS)



BRUKINSA 80 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA QL(4 PER 1 DAYS)

COPIKTRA (15 MG CAPSULE 25 MGCAPSULE)


IDHIFA (50 MG TABLET 100 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

INQOVI 35 MG-100 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA QL(5 PER 28 DAYS OVER TIME)

INREBIC 100 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY QL (4PER 1 DAYS)


22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

leucovorin calcium (5 mg tablet 10 mgtablet 15 mg tablet 25 mg tablet)

TIER 2

LYSODREN 500 MG TABLET TIER 3 MO

NINLARO (23 MG CAPSULE 3 MG CAPSULE4 MG CAPSULE)


PEMAZYRE (45 MG TABLET 9 MG TABLET135 MG TABLET)

TIER 5 PA - FOR NEW STARTS ONLY LA QL(14 PER 21 DAYS OVER TIME)

RETEVMO 40 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY QL (6PER 1 DAYS)


ROZLYTREK 100 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY QL (5PER 1 DAYS)


RUBRACA (200 MG TABLET 250 MG TABLET300 MG TABLET)


RYDAPT 25 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY

SYLATRON (200 MCG KIT 300 MCG KIT 600MCG KIT)


SYNRIBO 35 MGML VIAL TIER 5 BvD

TABRECTA (150 MG TABLET 200 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY QL (4PER 1 DAYS)

TAZVERIK 200 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA QL(8 PER 1 DAYS)

TIBSOVO 250 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

TUKYSA (50 MG TABLET 150 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA QL(4 PER 1 DAYS)

TURALIO 200 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA QL(4 PER 1 DAYS)

VITRAKVI (20 MGML SOLUTION 25 MGCAPSULE 100 MG CAPSULE)


VIZIMPRO (15 MG TABLET 30 MG TABLET 45MG TABLET)


XOSPATA 40 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

XPOVIO 100 MG ONCE WEEKLY DOSE TIER 5 PA - FOR NEW STARTS ONLY QL (20PER 28 DAYS OVER TIME)

XPOVIO 40 MG ONCE WEEKLY DOSE TIER 5 PA - FOR NEW STARTS ONLY LA QL(8 PER 28 DAYS OVER TIME)

XPOVIO 40 MG TWICE WEEKLY DOSE TIER 5 PA - FOR NEW STARTS ONLY LA QL(16 PER 28 DAYS OVER TIME)


23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




XPOVIO 80 MG TWICE WEEKLY DOSE TIER 5 PA - FOR NEW STARTS ONLY QL (32PER 28 DAYS OVER TIME)

ZOLINZA 100 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY

AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet TIER 2 MO

exemestane 25 mg tablet TIER 2 MO

letrozole 25 mg tablet TIER 2 MO

ENZYME INHIBITORSGAVRETO 100 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA QL

(4 PER 1 DAYS)

LORBRENA (25 MG TABLET 100 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

PIQRAY (250 MG DAILY 300 MG DAILY) TIER 5 PA - FOR NEW STARTS ONLY QL (2PER 1 DAYS)

PIQRAY 200 MG DAILY DOSE TIER 5 PA - FOR NEW STARTS ONLY QL (1PER 1 DAYS)

MOLECULAR TARGET INHIBITORSAFINITOR 10 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY

AFINITOR DISPERZ (2 MG TABLET 3 MGTABLET 5 MG TABLET)


ALECENSA 150 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA

BOSULIF (100 MG TABLET 400 MG TABLET500 MG TABLET)


BRAFTOVI (50 MG CAPSULE 75 MGCAPSULE)


CABOMETYX (20 MG TABLET 40 MG TABLET60 MG TABLET)


CALQUENCE 100 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA

CAPRELSA (100 MG TABLET 300 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

COMETRIQ (60 MG PACK 100 MG PK 140MG PK)



24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

COTELLIC 20 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

DAURISMO (25 MG TABLET 100 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

ERIVEDGE 150 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA

erlotinib hcl (100 mg tablet 150 mg tablet) TIER 5 PA - FOR NEW STARTS ONLY QL (1PER 1 DAYS)

erlotinib hcl 25 mg tablet TIER 5 PA - FOR NEW STARTS ONLY QL (3PER 1 DAYS)

everolimus (25 mg tablet 5 mg tablet 75mg tablet)


FARYDAK (10 MG CAPSULE 15 MGCAPSULE 20 MG CAPSULE)


GILOTRIF (20 MG TABLET 30 MG TABLET 40MG TABLET)


IBRANCE (75 MG CAPSULE 100 MGCAPSULE 125 MG CAPSULE)


IBRANCE (75 MG TABLET 100 MG TABLET125 MG TABLET)

TIER 5 PA - FOR NEW STARTS ONLY QL (21PER 28 DAYS OVER TIME)

ICLUSIG (15 MG TABLET 45 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

imatinib mesylate (100 mg tablet 400 mgtablet)


IMBRUVICA (70 MG CAPSULE 140 MGTABLET 140 MG CAPSULE 280 MG TABLET420 MG TABLET 560 MG TABLET)


INLYTA (1 MG TABLET 5 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

IRESSA 250 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

JAKAFI (5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MG TABLET)


KISQALI (200 MG DAILY 400 MG DAILY 600MG DAILY)


KOSELUGO 10 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA QL(8 PER 1 DAYS)


lapatinib ditosylate 250 mg tablet TIER 5 PA - FOR NEW STARTS ONLY LA

LENVIMA (4 MG CAPSULE 8 MG DAILYDOSE 10 MG DAILY DOSE 12 MG DAILYDOSE 14 MG DAILY DOSE 18 MG DAILYDOSE 20 MG DAILY DOSE 24 MG DAILYDOSE)


LYNPARZA (100 MG TABLET 150 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA


25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

MEKINIST (05 MG TABLET 2 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

MEKTOVI 15 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

NERLYNX 40 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

NEXAVAR 200 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

ODOMZO 200 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA

QINLOCK 50 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA QL(3 PER 1 DAYS)

SPRYCEL (20 MG TABLET 50 MG TABLET 70MG TABLET 80 MG TABLET 100 MG TABLET140 MG TABLET)


STIVARGA 40 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

SUTENT (125 MG CAPSULE 25 MG CAPSULE375 MG CAPSULE 50 MG CAPSULE)


TAFINLAR (50 MG CAPSULE 75 MGCAPSULE)


TAGRISSO (40 MG TABLET 80 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

TALZENNA (025 MG CAPSULE 1 MGCAPSULE)


TASIGNA (50 MG CAPSULE 150 MGCAPSULE 200 MG CAPSULE)


TYKERB 250 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

VENCLEXTA (10 MG TABLET 10 MG TAB(10MG X 2) 50 MG TABLET)

TIER 3 PA - FOR NEW STARTS ONLY LA MO

VENCLEXTA 100 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

VENCLEXTA STARTING PACK TIER 5 PA - FOR NEW STARTS ONLY LA

VERZENIO (50 MG TABLET 100 MG TABLET150 MG TABLET 200 MG TABLET)


VOTRIENT 200 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

XALKORI (200 MG CAPSULE 250 MGCAPSULE)


ZEJULA 100 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY

ZELBORAF 240 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

ZYDELIG (100 MG TABLET 150 MG TABLET) TIER 5 PA - FOR NEW STARTS ONLY LA

ZYKADIA 150 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA QL(3 PER 1 DAYS)

ZYKADIA 150 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY QL (3PER 1 DAYS)


26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

RETINOIDSbexarotene 75 mg capsule TIER 5

PANRETIN 01 GEL TIER 5 PA - FOR NEW STARTS ONLY

TARGRETIN 1 GEL TIER 5

tretinoin 10 mg capsule TIER 5

TREATMENT ADJUNCTSMESNEX 400 MG TABLET TIER 3

ANTIPARASITICS

ANTIHELMINTHICSalbendazole 200 mg tablet TIER 3

BILTRICIDE 600 MG TABLET TIER 3

ivermectin 3 mg tablet TIER 3

praziquantel 600 mg tablet TIER 3

ANTIPROTOZOALSALINIA 500 MG TABLET TIER 4 PA

atovaquone 750 mg5ml oral susp TIER 5

atovaquoneproguanil hcl(atovaquoneproguanil 625-25 mg tabletatovaquoneproguanil 250-100 mg tablet)

TIER 3

chloroquine phosphate (250 mg tablet 500mg tablet)

TIER 2

hydroxychloroquine sulfate 200 mg tablet TIER 2 MO

mefloquine hcl 250 mg tablet TIER 2

pentamidine isethionate 300 mg vial TIER 4

pentamidine isethionate 300 mg vial-neb TIER 4 BvD MO

primaquine phosphate 263 mg tablet TIER 3

pyrimethamine 25 mg tablet TIER 3

PEDICULICIDESSCABICIDESlindane 1 shampoo TIER 2

permethrin 5 cream (g) TIER 2


27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANTIPARKINSON AGENTS

ANTICHOLINERGICSbenztropine mesylate (05 mg tablet 1 mgtablet 2 mg tablet)

TIER 2 PA MO

trihexyphenidyl hcl (2 mg5 ml elixir 2 mgtablet 5 mg tablet)

TIER 2 PA MO

ANTIPARKINSON AGENTS OTHERamantadine hcl (50 mg5 ml solution 100mg tablet 100 mg capsule)

TIER 2 MO

carbidopalevodopaentacapone(carbidopalevodopaentacapone 125-50mg tabletcarbidopalevodopaentacapone 1875-75mg tabletcarbidopalevodopaentacapone 25-100-200 tabletcarbidopalevodopaentacapone 3125-125 tabletcarbidopalevodopaentacapone 375-150mg tabletcarbidopalevodopaentacapone 50-200-200 tablet)

TIER 4 ST MO

entacapone 200 mg tablet TIER 3 MO

tolcapone 100 mg tablet TIER 3 ST MO

DOPAMINE AGONISTSAPOKYN 30 MG3 ML CARTRIDGE TIER 5 PA LA

bromocriptine mesylate (25 mg tablet 5mg capsule)

TIER 2 MO

pramipexole di-hcl (0125 mg tablet 025mg tablet 05 mg tablet 075 mg tablet 1mg tablet 15 mg tablet)

TIER 2 MO

ropinirole hcl (025 mg tablet 05 mg tablet1 mg tablet 2 mg tablet 3 mg tablet 4 mgtablet 5 mg tablet)

TIER 2 MO

DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASE INHIBITORScarbidopa 25 mg tablet TIER 4 MO


28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

carbidopalevodopa(carbidopalevodopa 10mg-100mg tabletcarbidopalevodopa 25mg-100mg tabletcarbidopalevodopa 25mg-100mg tableter carbidopalevodopa 25mg-250mgtablet carbidopalevodopa 50mg-200mgtablet er)

TIER 2 MO

MONOAMINE OXIDASE B (MAO-B) INHIBITORSrasagiline mesylate 05 mg tablet TIER 4 QL (30 PER 30 DAYS) MO

rasagiline mesylate 1 mg tablet TIER 4 MO

selegiline hcl (5 mg capsule 5 mg tablet) TIER 2 MO

ANTIPSYCHOTICS

1ST GENERATIONTYPICALchlorpromazine hcl (10 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet 200 mgtablet)

TIER 2 MO

fluphenazine decanoate 25 mgml vial TIER 2 BvD MO

fluphenazine hcl (1 mg tablet 25 mgtablet 25 mg5ml elixir 5 mg tablet 10 mgtablet)

TIER 2 MO

fluphenazine hcl 25 mgml vial TIER 2 BvD

fluphenazine hcl 5 mgml oral conc TIER 2

haloperidol (05 mg tablet 1 mg tablet 2mg tablet 5 mg tablet 10 mg tablet 20 mgtablet)

TIER 2 MO

haloperidol decanoate (100 mgml vial100 mgml ampul)

TIER 2 MO

haloperidol decanoate (50 mgml ampul50 mgml vial)

TIER 2 BvD MO

haloperidol lactate (5 mgml vial 5 mgmlampul)

TIER 2 BvD

haloperidol lactate 2 mgml oral conc TIER 2 MO

loxapine succinate (5 mg capsule 10 mgcapsule 25 mg capsule 50 mg capsule)

TIER 2 MO

molindone hcl (5 mg tablet 10 mg tablet25 mg tablet)

TIER 4 MO

pimozide (1 mg tablet 2 mg tablet) TIER 4 MO

thioridazine hcl (10 mg tablet 25 mg tablet50 mg tablet 100 mg tablet)



29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

thiothixene (1 mg capsule 2 mg capsule 5mg capsule 10 mg capsule)

TIER 2 MO

trifluoperazine hcl (1 mg tablet 2 mgtablet 5 mg tablet 10 mg tablet)

TIER 2 MO

2ND GENERATIONATYPICALABILIFY MAINTENA (ER 300 MG VL ER 300MG SYR ER 400 MG SYR ER 400 MG VL)


aripiprazole (2 mg tablet 5 mg tablet 10mg tablet 15 mg tablet)


aripiprazole (20 mg tablet 30 mg tablet) TIER 2 MO

aripiprazole 1 mgml solution TIER 4 QL (900 PER 30 DAYS) MO

aripiprazole 10 mg tab rapdis TIER 5 QL (30 PER 30 DAYS)


ARISTADA (ER 441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32 ML SYRNER 1064 MG39 ML SYR)


ARISTADA INITIO ER 675 MG24 TIER 5 PA - FOR NEW STARTS ONLY

CAPLYTA 42 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY QL (1PER 1 DAYS)

FANAPT (1 MG TABLET 2 MG TABLET 4 MGTABLET 6 MG TABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET)


FANAPT TITRATION PACK TIER 4 PA - FOR NEW STARTS ONLY

INVEGA SUSTENNA (117 MG075 ML 156MGML SYRG 234 MG15 ML)


INVEGA SUSTENNA (39 MG025 ML 78MG05 ML)


INVEGA TRINZA (273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML)


LATUDA (20 MG TABLET 40 MG TABLET 60MG TABLET 80 MG TABLET 120 MG TABLET)


NUPLAZID (10 MG TABLET 34 MG CAPSULE) TIER 5 PA - FOR NEW STARTS ONLY LA

olanzapine (25 mg tablet 5 mg tab rapdis5 mg tablet 75 mg tablet 10 mg tablet 10mg tab rapdis 15 mg tablet 15 mg tabrapdis 20 mg tab rapdis)


olanzapine 10 mg vial TIER 2 BvD

olanzapine 20 mg tablet TIER 3 QL (30 PER 30 DAYS) MO


30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

paliperidone (6 mg tab er 24 9 mg tab er24)


paliperidone 15 mg tab er 24 TIER 4 PA - FOR NEW STARTS ONLY QL(240 PER 30 DAYS) MO


PERSERIS (ER 90 MG SYRINGE KIT ER 120 MGSYRINGE KIT)


quetiapine fumarate (25 mg tablet 50 mgtablet 100 mg tablet 200 mg tablet 300mg tablet 400 mg tablet)


REXULTI (025 MG TABLET 05 MG TABLET 1MG TABLET 2 MG TABLET 3 MG TABLET 4MG TABLET)


RISPERDAL CONSTA (125 MG VIAL 25 MGVIAL)

TIER 3 BvD MO


TIER 5 BvD

risperidone (025 mg tab rapdis 025 mgtablet 05 mg tab rapdis 05 mg tablet 1mg tablet 1 mg tab rapdis 2 mg tablet 2mg tab rapdis 3 mg tab rapdis 3 mgtablet 4 mg tab rapdis 4 mg tablet)


risperidone 1 mgml solution TIER 2 QL (240 PER 30 DAYS) MO

SAPHRIS (25 MG TAB 5 MG TAB 10 MGTAB)


SECUADO (38 MG24 HR PATCH 57 MG24HR PATCH 76 MG24 HR PATCH)


VRAYLAR (15 MG CAPSULE 3 MG CAPSULE45 MG CAPSULE 6 MG CAPSULE)


ziprasidone hcl (20 mg capsule 40 mgcapsule)




ziprasidone mesylate fnl 20mg1 vial TIER 3

ZYPREXA RELPREVV 210 MG VL KIT TIER 4 PA - FOR NEW STARTS ONLY MO

TREATMENT-RESISTANTclozapine (125 mg tab rapdis 25 mg tabrapdis 100 mg tab rapdis 150 mg tabrapdis 200 mg tab rapdis)

TIER 3 MO

clozapine (25 mg tablet 50 mg tablet 100mg tablet 200 mg tablet)

TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

VERSACLOZ 50 MGML SUSPENSION TIER 5 PA - FOR NEW STARTS ONLY QL (18PER 1 DAYS)

ANTISPASTICITY AGENTSbaclofen (10 mg tablet 20 mg tablet) TIER 2 MO

dantrolene sodium (25 mg capsule 50 mgcapsule 100 mg capsule)

TIER 2 MO

tizanidine hcl (2 mg tablet 4 mg tablet) TIER 2 MO

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTSvalganciclovir hcl 450 mg tablet TIER 5

ZIRGAN 015 OPHTHALMIC GEL TIER 4

ANTI-HEPATITIS B (HBV) AGENTSadefovir dipivoxil 10 mg tablet TIER 5 PA

BARACLUDE 005 MGML SOLUTION TIER 3 PA MO

entecavir (05 mg tablet 1 mg tablet) TIER 5

EPIVIR HBV 25 MG5 ML SOLN TIER 3 PA MO

lamivudine 100 mg tablet TIER 2 MO

VEMLIDY 25 MG TABLET TIER 5 PA

ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSEPCLUSA 400 MG-100 MG TABLET TIER 5 PA

HARVONI 3375-150 MG PELLET PK TIER 5 PA QL (1 PER 1 DAYS)

HARVONI 45-200 MG PELLET PACKT TIER 5 PA QL (2 PER 1 DAYS)

HARVONI 90-400 MG TABLET TIER 5 PA

MAVYRET 100-40 MG TABLET TIER 5 PA

VOSEVI 400-100-100 MG TABLET TIER 5 PA

ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (10 MILLION UNITS VIL 18 MILLIONUNITS VIL 18 MILLION UNIT3 ML 25 MILLIONUNIT25ML 50 MILLION UNITS VIL)


PEGASYS (180 MCG05 ML SYRINGE 180MCGML VIAL)

TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

PEGASYS PROCLICK 180 MCG05 TIER 5 PA

ribavirin (200 mg capsule 200 mg tablet600 mg tablet)

TIER 2 PA

ANTI-HIV AGENTSCIMDUO 300-300 MG TABLET TIER 5

efavirenzlamivutenofov disop 600-300mgtablet

TIER 5

SYMFI 600-300-300 MG TABLET TIER 5

TEMIXYS 300-300 MG TABLET TIER 5 QL (1 PER 1 DAYS)

ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY 50-200-25 MG TABLET TIER 5

GENVOYA TABLET TIER 5

ISENTRESS 100 MG POWDER PACKET TIER 3 QL (300 PER 30 DAYS) MO

ISENTRESS 100 MG TABLET CHEW TIER 3 QL (180 PER 30 DAYS) MO


ISENTRESS 400 MG TABLET TIER 5

ISENTRESS HD 600 MG TABLET TIER 5

STRIBILD TABLET TIER 5

TIVICAY (25 MG TABLET 50 MG TABLET) TIER 5

TIVICAY 10 MG TABLET TIER 3 MO

TIVICAY PD 5 MG TAB FOR SUSP TIER 3 QL (5 PER 1 DAYS)

ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)

ATRIPLA TABLET TIER 5

COMPLERA TABLET TIER 5

DELSTRIGO 100-300-300 MG TAB TIER 5

EDURANT 25 MG TABLET TIER 5 QL (30 PER 30 DAYS)

efavirenz (200 mg capsule 600 mg tablet) TIER 5

efavirenz 50 mg capsule TIER 2 MO

efavirenzemtricittenofovr df 600-200mgtablet

TIER 5

efavirenzlamivutenofov disop 400-300 mgtablet

TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

INTELENCE (100 MG TABLET 200 MG TABLET) TIER 5

INTELENCE 25 MG TABLET TIER 3 MO

nevirapine (50 mg5 ml oral susp 100 mgtab er 24h 200 mg tablet 400 mg tab er24h)

TIER 2 MO

ODEFSEY TABLET TIER 5

PIFELTRO 100 MG TABLET TIER 5

RESCRIPTOR 200 MG TABLET TIER 3 MO

SYMFI LO 400-300-300 MG TABLET TIER 5

VIRAMUNE 50 MG5 ML SUSP TIER 3 MO

ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate 20 mgml solution TIER 3 MO

abacavir sulfate 300 mg tablet TIER 2 MO

abacavir sulfatelamivudine 600-300mgtablet

TIER 4 MO

abacavirlamivudinezidovudine 150-300mg tablet

TIER 5

didanosine (200 mg capsule dr 250 mgcapsule dr 400 mg capsule dr)

TIER 2 MO

emtricitabine 200 mg capsule TIER 3

emtricitabinetenofovir (tdf) 200-300 mgtablet

TIER 5

EMTRIVA 10 MGML SOLUTION TIER 3 MO

lamivudine (150 mg tablet 300 mg tablet) TIER 2 MO

lamivudine 10 mgml solution TIER 3 MO

lamivudinezidovudine(lamivudinezidovudine 150-300 mg tabletlamivudinezidovudine 150-300mg tablet)

TIER 2 MO

stavudine (15 mg capsule 20 mg capsule30 mg capsule 40 mg capsule)

TIER 2 MO

tenofovir disoproxil fumarate 300 mg tablet TIER 4 MO

TRUVADA (100 MG-150 MG TABLET 133 MG-200 MG TABLET 167 MG-250 MG TABLET 200MG-300 MG TABLET)

TIER 5

VIDEX (2 GM SOLN 4 GM SOLN) TIER 3 MO

VIDEX EC 125 MG CAPSULE TIER 3 MO


34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

VIREAD (150 MG TABLET 200 MG TABLET250 MG TABLET POWDER)

TIER 5

zidovudine (10 mgml syrup 100 mgcapsule 300 mg tablet)

TIER 2 MO

ANTI-HIV AGENTS OTHERDESCOVY 200-25 MG TABLET TIER 5

DOVATO 50-300 MG TABLET TIER 5 QL (30 PER 30 DAYS)

FUZEON 90 MG VIAL TIER 5

JULUCA 50-25 MG TABLET TIER 5

RUKOBIA ER 600 MG TABLET TIER 5 QL (2 PER 1 DAYS)

SELZENTRY (20 MGML ORAL SOLN 25 MGTABLET)

TIER 3 MO

SELZENTRY (75 MG TABLET 150 MG TABLET300 MG TABLET)

TIER 5

TRIUMEQ 600-50-300 MG TABLET TIER 5

TYBOST 150 MG TABLET TIER 3 MO

ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (100 MGML SOLUTION 250 MGCAPSULE)

TIER 5

atazanavir sulfate (150 mg capsule 200 mgcapsule 300 mg capsule)

TIER 5

CRIXIVAN (200 MG CAPSULE 400 MGCAPSULE)

TIER 3 MO

EVOTAZ 300 MG-150 MG TABLET TIER 5

fosamprenavir calcium 700 mg tablet TIER 5

INVIRASE 500 MG TABLET TIER 5

KALETRA 100-25 MG TABLET TIER 3 MO

KALETRA 200-50 MG TABLET TIER 5

LEXIVA 50 MGML SUSPENSION TIER 3 MO

lopinavirritonavir 400-1005 solution TIER 2 MO

NORVIR (80 MGML SOLUTION 100 MGPOWDER PACKET)

TIER 3 MO

PREZCOBIX 800 MG-150 MG TABLET TIER 5

PREZISTA (600 MG TABLET 800 MG TABLET) TIER 5

PREZISTA (75 MG TABLET 150 MG TABLET) TIER 3 MO


35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

PREZISTA 100 MGML SUSPENSION TIER 3 QL (360 PER 30 DAYS) MO

REYATAZ 50 MG POWDER PACKET TIER 5

ritonavir 100 mg tablet TIER 3 MO

SYMTUZA 800-150-200-10 MG TAB TIER 5

VIRACEPT (250 MG TABLET 625 MG TABLET) TIER 5

ANTI-INFLUENZA AGENTSoseltamivir phosphate (45 mg capsule 75mg capsule)

TIER 2 QL (42 PER 180 DAYS OVER TIME)

oseltamivir phosphate 30 mg capsule TIER 2 QL (84 PER 180 DAYS OVER TIME)

oseltamivir phosphate 6 mgml susp recon TIER 2 QL (1080 PER 365 DAYS OVER TIME)

RELENZA 5 MG DISKHALER TIER 4 QL (60 PER 180 DAYS OVER TIME)

rimantadine hcl 100 mg tablet TIER 2

TAMIFLU 6 MGML SUSPENSION TIER 3 QL (1080 PER 365 DAYS OVER TIME)

ANTIHERPETIC AGENTSacyclovir (200 mg5ml oral susp 200 mgcapsule 400 mg tablet 800 mg tablet)

TIER 2 MO

acyclovir 5 cream (g) TIER 3 QL (30 PER 30 DAYS OVER TIME)

acyclovir 5 oint (g) TIER 3 QL (30 PER 30 DAYS)

acyclovir sodium 50 mgml vial TIER 2 BvD

DENAVIR 1 CREAM TIER 3 PA

trifluridine 1 drops TIER 2

valacyclovir hcl (500 mg tablet 1000 mgtablet)

TIER 2 MO

ANXIOLYTICS

ANXIOLYTICS OTHERbuspirone hcl (5 mg tablet 75 mg tablet10 mg tablet 15 mg tablet 30 mg tablet)

TIER 2 MO

meprobamate (200 mg tablet 400 mgtablet)

TIER 4 PA

BENZODIAZEPINESalprazolam (025 mg tablet 05 mg tablet 1mg tablet 2 mg tablet)



36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

clonazepam (0125 mg tab rapdis 025 mgtab rapdis 05 mg tab rapdis 05 mg tablet1 mg tab rapdis 1 mg tablet 2 mg tabrapdis 2 mg tablet)

TIER 2 MO

clorazepate dipotassium (375 mg tablet75 mg tablet)


clorazepate dipotassium 15 mg tablet TIER 2 QL (180 PER 30 DAYS)

diazepam (2 mg tablet 5 mg tablet 10 mgtablet)


diazepam 5 mg5 ml solution TIER 2 QL (1200 PER 30 DAYS)

lorazepam (05 mg tablet 1 mg tablet 2mg tablet)


BIPOLAR AGENTS

MOOD STABILIZERSlithium carbonate (150 mg capsule 300 mgcapsule 300 mg tablet 300 mg tablet er450 mg tablet er 600 mg capsule)

TIER 2 MO

lithium citrate 8 meq5 ml solution TIER 2 MO

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTSacarbose 100 mg tablet TIER 2 QL (90 PER 30 DAYS) MO

acarbose 25 mg tablet TIER 2 QL (360 PER 30 DAYS) MO


AVANDIA (2 MG TABLET 4 MG TABLET) TIER 3 PA MO

CYCLOSET 08 MG TABLET TIER 4 PA MO

glimepiride 1 mg tablet TIER 1 QL (240 PER 30 DAYS) MO



glipizide (5 mg tab er 24 10 mg tablet) TIER 1 QL (120 PER 30 DAYS) MO

glipizide (5 mg tablet 10 mg tab er 24) TIER 1 QL (60 PER 30 DAYS) MO

glipizide 25 mg tab er 24 TIER 1 QL (240 PER 30 DAYS) MO

glipizidemetformin hcl (glipizidemetformin25-500 mg tablet glipizidemetformin 5mg-500mg tablet)



37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

glipizidemetformin hcl 25-250 mg tablet TIER 1 QL (240 PER 30 DAYS) MO

glyburide 125 mg tablet TIER 1 PA QL (480 PER 30 DAYS) MO



glyburidemicronized 15 mg tablet TIER 1 PA QL (240 PER 30 DAYS) MO



glyburidemetformin hcl(glyburidemetformin 25-500 mg tabletglyburidemetformin 5 mg-500mg tablet)

TIER 1 PA QL (120 PER 30 DAYS) MO

glyburidemetformin hcl 125-250mg tablet TIER 1 PA QL (240 PER 30 DAYS) MO

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


INVOKAMET 50-500 MG TABLET TIER 3 QL (4 PER 1 DAYS) MO

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


INVOKANA 100 MG TABLET TIER 3 QL (2 PER 1 DAYS) MO


JANUMET (50-500 MG TABLET 50-1000 MGTABLET)


JANUMET XR (50-1000 MG TABLET 100-1000MG TABLET)


JANUMET XR 50-500 MG TABLET TIER 3 QL (30 PER 30 DAYS) MO

JANUVIA (25 MG TABLET 50 MG TABLET 100MG TABLET)


JARDIANCE (10 MG TABLET 25 MG TABLET) TIER 3 QL (1 PER 1 DAYS) MO

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


JENTADUETO XR 25 MG-1000 MG TIER 3 QL (60 PER 30 DAYS) MO

JENTADUETO XR 5 MG-1000 MG TB TIER 3 QL (30 PER 30 DAYS) MO

metformin hcl (750 mg tab er 24h 1000 mgtablet)


metformin hcl 500 mg tab er 24h TIER 1 QL (120 PER 30 DAYS) MO

metformin hcl 500 mg tablet TIER 1 QL (150 PER 30 DAYS) MO


miglitol 100 mg tablet TIER 4 QL (90 PER 30 DAYS) MO


38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



nateglinide (60 mg tablet 120 mg tablet) TIER 2 MO

OZEMPIC 025-05 MG DOSE PEN TIER 3 QL (15 PER 28 DAYS OVER TIME)MO

OZEMPIC 1 MG DOSE PEN TIER 3 QL (3 PER 28 DAYS OVER TIME) MO

pioglitazone hcl (15 mg tablet 30 mgtablet 45 mg tablet)


repaglinide (05 mg tablet 1 mg tablet 2mg tablet)

TIER 2 MO

SYMLINPEN 120 PEN INJECTOR TIER 4 PA MO


SYNJARDY (5-1000 MG TABLET 5-500 MGTABLET 125-500 MG TABLET 125-1000 MGTABLET)


SYNJARDY XR (5-1000 MG TABLET 10-1000MG TABLET 125-1000 MG TAB)


SYNJARDY XR 25-1000 MG TABLET TIER 3 QL (1 PER 1 DAYS) MO

tolazamide (250 mg tablet 500 mg tablet) TIER 2 QL (60 PER 30 DAYS) MO

tolbutamide 500 mg tablet TIER 2 QL (180 PER 30 DAYS) MO

TRADJENTA 5 MG TABLET TIER 3 QL (30 PER 30 DAYS) MO

TRULICITY (075 MG05 ML PEN 15 MG05ML PEN 3 MG05 ML PEN 45 MG05 MLPEN)

TIER 3 QL (2 PER 28 DAYS OVER TIME) MO

VICTOZA 2-PAK 18 MG3 ML PEN TIER 3 QL (6 PER 30 DAYS OVER TIME) MO


GLYCEMIC AGENTSBAQSIMI (3 MG SPRAY TWO PACK 3 MGSPRAY ONE PACK)


diazoxide 50 mgml oral susp TIER 2 MO

GLUCAGEN 1 MG HYPOKIT TIER 3

GLUCAGON 1 MG EMERGENCY KIT TIER 3 QL (2 PER 30 DAYS OVER TIME)

INSULINSHUMALOG (100 UNITML CARTRIDGE 100UNITML VIAL)

TIER 3 MO

HUMALOG 100 UNITML KWIKPEN TIER 3 MO


39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


HUMALOG MIX 50-50 KWIKPEN TIER 3 MO

HUMALOG MIX 50-50 VIAL TIER 3 MO



HUMULIN 70-30 VIAL TIER 3 MO

HUMULIN 7030 KWIKPEN TIER 3 MO

HUMULIN N 100 UNITML KWIKPEN TIER 3 MO

HUMULIN N 100 UNITML VIAL TIER 3 MO

HUMULIN R 100 UNITML VIAL TIER 3 MO

HUMULIN R 500 UNITML VIAL TIER 5

LANTUS 100 UNITML VIAL TIER 3 MO

LANTUS SOLOSTAR 100 UNITML TIER 3 MO

NOVOLIN 70-30 (RELION 70-30 VIAL 70-30100 UNITML VIAL)

TIER 3 MO

NOVOLIN N (N 100 UNITML VIAL RELION N100 UNITML)

TIER 3 MO

NOVOLIN R (R 100 UNITML VIAL RELION R100 UNITML)

TIER 3 MO

NOVOLOG (100 UNITML VIAL 100 UNITMLCARTRIDGE)

TIER 3 MO

NOVOLOG 100 UNITML FLEXPEN TIER 3 MO

NOVOLOG MIX 70-30 FLEXPEN TIER 3 MO

NOVOLOG MIX 70-30 VIAL TIER 3 MO

TOUJEO MAX SOLOSTR 300 UNITML TIER 3 MO

TOUJEO SOLOSTAR 300 UNITML TIER 3 MO

BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS

ANTICOAGULANTSCOUMADIN (1 MG TABLET 2 MG TABLET 25MG TABLET 3 MG TABLET 4 MG TABLET 5MG TABLET 6 MG TABLET 75 MG TABLET 10MG TABLET)

TIER 4 MO

ELIQUIS (25 MG TABLET 5 MG TABLET) TIER 3 MO

ELIQUIS DVT-PE TREAT START 5MG TIER 3


40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

enoxaparin sodium (30mg03ml syringe40mg04ml syringe 60mg06ml syringe)

TIER 3

enoxaparin sodium (80mg08ml syringe100 mgml syringe 120mg8ml syringe 150mgml syringe)

TIER 2

fondaparinux sodium (25 mg05 syringe5mg04ml syringe 75mg06 syringe10mg08ml syringe)

TIER 3 PA

FRAGMIN (2500 UNIT02 ML SYR 5000UNIT02 ML SYR 7500 UNIT03 ML SYR10000 UNITML SYRINGE 12500 UNIT05 MLSYR 15000 UNIT06 ML SYR 18000UNIT072 ML 95000 UNIT38 ML VL)

TIER 4

heparin sodiumporcine (1000ml vial5000ml vial 10000ml vial 20000ml vial)

TIER 2

PRADAXA (75 MG CAPSULE 110 MGCAPSULE 150 MG CAPSULE)


warfarin sodium (1 mg tablet 2 mg tablet25 mg tablet 3 mg tablet 4 mg tablet 5mg tablet 6 mg tablet 75 mg tablet 10mg tablet)

TIER 2 MO

XARELTO (25 MG TABLET 10 MG TABLET 15MG TABLET 20 MG TABLET)

TIER 3 MO

XARELTO DVT-PE TREAT START 30D TIER 3

BLOOD FORMATION MODIFIERSanagrelide hcl (05 mg capsule 1 mgcapsule)

TIER 2 MO

DOPTELET ((10 TAB PK) 20 MG TAB (15 TABPK) 20 MG TAB)

TIER 5 PA LA

DOPTELET (30 TAB PK) 20 MG TAB TIER 5 PA LA QL (2 PER 1 DAYS)

GRANIX (300 MCG05 ML SYRINGE 300MCG05 ML SAFE SYR 480 MCG08 MLSYRINGE 480 MCG08 ML SAFE SYR)

TIER 5 PA

LEUKINE 250 MCG VIAL TIER 5 PA

NEULASTA 6 MG06 ML SYRINGE TIER 5 PA - FOR NEW STARTS ONLY

NEULASTA ONPRO 6 MG06 ML KIT TIER 5 PA - FOR NEW STARTS ONLY

NEUPOGEN (300 MCG05 ML SYR 300MCGML VIAL 480 MCG16 ML VIAL 480MCG08 ML SYR)


PROCRIT (10000 UNITSML VIAL 20000UNITSML VIAL 40000 UNITSML VIAL)

TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO

PROMACTA (125 MG SUSPEN PACKET 125MG TABLET 25 MG TABLET 50 MG TABLET 75MG TABLET)

TIER 5 PA LA

PROMACTA 25 MG SUSPENSION PCKT TIER 5 PA LA QL (6 PER 1 DAYS)

RETACRIT (10000 UNITML VIAL 40000UNITML VIAL)

TIER 4 PA MO

RETACRIT (2000 UNITML VIAL 3000UNITML VIAL 4000 UNITML VIAL)

TIER 3 PA MO

TAVALISSE (100 MG TABLET 150 MG TABLET) TIER 5 PA LA

ZARXIO (300 MCG05 ML SYRINGE 480MCG08 ML SYRINGE)


HEMOSTASIS AGENTStranexamic acid 650 mg tablet TIER 3 MO

PLATELET MODIFYING AGENTSaspirindipyridamole 25mg-200mg cpmp12hr

TIER 4 MO

BRILINTA (60 MG TABLET 90 MG TABLET) TIER 3 QL (2 PER 1 DAYS) MO

cilostazol (50 mg tablet 100 mg tablet) TIER 2 MO

clopidogrel bisulfate 75 mg tablet TIER 2 MO

dipyridamole (25 mg tablet 50 mg tablet75 mg tablet)

TIER 2 PA MO

OXBRYTA 500 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA QL(3 PER 1 DAYS)

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTSclonidine (01mg24hr patch tdwk02mg24hr patch tdwk 03mg24hr patchtdwk)

TIER 4 MO

clonidine hcl (01 mg tablet 02 mg tablet03 mg tablet)

TIER 2 MO

guanfacine hcl (1 mg tablet 2 mg tablet) TIER 2 MO

methyldopa (250 mg tablet 500 mg tablet) TIER 2 PA MO

midodrine hcl (25 mg tablet 5 mg tablet10 mg tablet)

TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

NORTHERA (100 MG CAPSULE 200 MGCAPSULE 300 MG CAPSULE)

TIER 5 PA LA

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

TIER 2 MO

prazosin hcl (1 mg capsule 2 mg capsule 5mg capsule)

TIER 2 MO

terazosin hcl (1 mg capsule 2 mg capsule5 mg capsule 10 mg capsule)

TIER 2 MO

ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan cilexetil (4 mg tablet 8 mgtablet 16 mg tablet 32 mg tablet)

TIER 2 MO

irbesartan (75 mg tablet 150 mg tablet 300mg tablet)

TIER 1 MO

losartan potassium (25 mg tablet 50 mgtablet 100 mg tablet)

TIER 1 MO

olmesartan medoxomil (5 mg tablet 20 mgtablet 40 mg tablet)

TIER 2 MO

telmisartan (20 mg tablet 40 mg tablet 80mg tablet)

TIER 1 MO

valsartan (40 mg tablet 80 mg tablet 160mg tablet 320 mg tablet)

TIER 1 MO

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl (5 mg tablet 10 mg tablet20 mg tablet 40 mg tablet)

TIER 1 MO

captopril (125 mg tablet 25 mg tablet 50mg tablet 100 mg tablet)

TIER 1 MO

enalapril maleate (25 mg tablet 5 mgtablet 10 mg tablet 20 mg tablet)

TIER 1 MO

fosinopril sodium (10 mg tablet 20 mgtablet 40 mg tablet)

TIER 1 MO

lisinopril (25 mg tablet 5 mg tablet 10 mgtablet 20 mg tablet 30 mg tablet 40 mgtablet)

TIER 1 MO

moexipril hcl (75 mg tablet 15 mg tablet) TIER 1 MO

perindopril erbumine (2 mg tablet 4 mgtablet 8 mg tablet)

TIER 1 MO

quinapril hcl (5 mg tablet 10 mg tablet 20mg tablet 40 mg tablet)

TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ramipril (125 mg capsule 25 mg capsule 5mg capsule 10 mg capsule)

TIER 1 MO

trandolapril (1 mg tablet 2 mg tablet 4 mgtablet)

TIER 1 MO

ANTIARRHYTHMICSamiodarone hcl (100 mg tablet 200 mgtablet 400 mg tablet)

TIER 2 MO

disopyramide phosphate (100 mg capsule150 mg capsule)

TIER 2 PA MO

dofetilide (125 mcg capsule 250 mcgcapsule 500 mcg capsule)

TIER 4 MO

flecainide acetate (50 mg tablet 100 mgtablet 150 mg tablet)

TIER 2 MO

mexiletine hcl (150 mg capsule 200 mgcapsule 250 mg capsule)

TIER 2 MO

MULTAQ 400 MG TABLET TIER 4 PA MO

PACERONE (100 MG TABLET 400 MGTABLET)

TIER 2 MO

propafenone hcl (150 mg tablet 225 mgtablet 300 mg tablet)

TIER 2 MO

quinidine gluconate 324 mg tablet er TIER 2 MO

quinidine sulfate (200 mg tablet 300 mgtablet)

TIER 2 MO

sotalol hcl (80 mg tablet 120 mg tablet 160mg tablet 240 mg tablet)

TIER 2 MO

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl (200 mg capsule 400 mgcapsule)

TIER 2 MO

atenolol (25 mg tablet 50 mg tablet 100mg tablet)

TIER 1 MO

betaxolol hcl (10 mg tablet 20 mg tablet) TIER 2 MO

bisoprolol fumarate (5 mg tablet 10 mgtablet)

TIER 2 MO

carvedilol (3125 mg tablet 625 mg tablet125 mg tablet 25 mg tablet)

TIER 1 MO

labetalol hcl (100 mg tablet 200 mg tablet300 mg tablet)

TIER 2 MO

metoprolol succinate (25 mg tab er 24h 50mg tab er 24h 100 mg tab er 24h)



44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

metoprolol succinate 200 mg tab er 24h TIER 2 QL (60 PER 30 DAYS) MO

metoprolol tartrate (25 mg tablet 50 mgtablet 100 mg tablet)

TIER 1 MO

nadolol (20 mg tablet 40 mg tablet 80 mgtablet)

TIER 1 MO

pindolol (5 mg tablet 10 mg tablet) TIER 1 MO

propranolol hcl (10 mg tablet 20 mg tablet40 mg tablet 60 mg tablet 60 mg cap sa24h 80 mg cap sa 24h 80 mg tablet 120mg cap sa 24h 160 mg cap sa 24h)

TIER 2 MO

timolol maleate (5 mg tablet 10 mg tablet20 mg tablet)

TIER 2 MO

CALCIUM CHANNEL BLOCKING AGENTSamlodipine besylate (25 mg tablet 5 mgtablet 10 mg tablet)

TIER 1 MO

diltiazem hcl (30 mg tablet 60 mg tablet60 mg cap er 12h 90 mg cap er 12h 90 mgtablet 120 mg cap sa 24h 120 mg cap er24h 120 mg cap er deg 120 mg tablet 120mg cap er 12h 180 mg cap sa 24h 180 mgcap er 24h 180 mg cap er deg 240 mgcap er deg 240 mg cap er 24h 240 mgcap sa 24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h 360 mgcap er 24h 420 mg cap sa 24h)

TIER 2 MO

felodipine (25 mg tab er 24h 5 mg tab er24h 10 mg tab er 24h)

TIER 2 MO

isradipine (25 mg capsule 5 mg capsule) TIER 2 MO

nicardipine hcl (20 mg capsule 30 mgcapsule)

TIER 2 MO

nifedipine (30 mg tablet er 30 mg tab er24 60 mg tablet er 60 mg tab er 24 90 mgtab er 24 90 mg tablet er)

TIER 2 MO

verapamil hcl (40 mg tablet 80 mg tablet100 mg cap24h pct 120 mg cap24h pel120 mg tablet 120 mg tablet er 180 mgtablet er 180 mg cap24h pel 200 mgcap24h pct 240 mg tablet er 240 mgcap24h pel 300 mg cap24h pct 360 mgcap24h pel)

TIER 2 MO

CARDIOVASCULAR AGENTS OTHERaliskiren hemifumarate 150 mg tablet TIER 3 PA QL (2 PER 1 DAYS) MO

aliskiren hemifumarate 300 mg tablet TIER 3 PA QL (1 PER 1 DAYS) MO


45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

amiloridehydrochlorothiazide 5 mg-50 mgtablet

TIER 2 MO

amlodipine besylatebenazepril hcl(besylatebenazepril 25mg-10mg capsulebesylatebenazepril 5 mg-40 mg capsulebesylatebenazepril 5 mg-20 mg capsulebesylatebenazepril 5 mg-10 mg capsulebesylatebenazepril 10 mg-40mg capsulebesylatebenazepril 10 mg-20mg capsule)


amlodipine besylateolmesartanmedoxomil (besolmesartan 5 mg-20 mgtablet besolmesartan 5 mg-40 mg tabletbesolmesartan 10 mg-20mg tabletbesolmesartan 10 mg-40mg tablet)

TIER 2 MO

amlodipine besylatevalsartan(besylatevalsartan 5 mg-160mg tabletbesylatevalsartan 5 mg-320mg tabletbesylatevalsartan 10mg-160mg tabletbesylatevalsartan 10mg-320mg tablet)

TIER 1 MO

amlodipinebesylatevalsartanhydrochlorothiazide(amlodipinevalsartanhcthiazid 5-160-125tablet amlodipinevalsartanhcthiazid 5-160-25mg tabletamlodipinevalsartanhcthiazid 10-320-25tablet amlodipinevalsartanhcthiazid 10-160-25 tabletamlodipinevalsartanhcthiazid 10mg-160mg tablet)

TIER 2 MO

atenololchlorthalidone(atenololchlorthalidone 50 mg-25mgtablet atenololchlorthalidone 100mg-25mg tablet)

TIER 1 MO

benazepril hclhydrochlorothiazide(benazeprilhydrochlorothiazide 5-625mgtablet benazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20-125 mgtablet benazeprilhydrochlorothiazide 20mg-25mg tablet)

TIER 1 MO

bisoprolol fumaratehydrochlorothiazide(bisoprololhydrochlorothiazide 25-625mgtablet bisoprololhydrochlorothiazide 5-625mg tabletbisoprololhydrochlorothiazide 10-625mgtablet)

TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

candesartan cilexetilhydrochlorothiazide(candesartanhydrochlorothiazid 16-125mg tabletcandesartanhydrochlorothiazid 32mg-25mg tabletcandesartanhydrochlorothiazid 32-125mgtablet)

TIER 2 MO

captoprilhydrochlorothiazide(captoprilhydrochlorothiazide 25 mg-25mgtablet captoprilhydrochlorothiazide 25mg-15mg tabletcaptoprilhydrochlorothiazide 50 mg-15mgtablet captoprilhydrochlorothiazide 50mg-25mg tablet)

TIER 1 MO

CORLANOR (5 MG TABLET 75 MG TABLET) TIER 4 PA MO

CORLANOR 5 MG5 ML ORAL SOLN TIER 4 PA QL (20 PER 1 DAYS) MO

DEMSER 250 MG CAPSULE TIER 5

digoxin 125 mcg tablet TIER 2 QL (30 PER 30 DAYS) MO

digoxin 250 mcg tablet TIER 2 MO

digoxin 50 mcgml solution TIER 3 MO

enalapril maleatehydrochlorothiazide(enalaprilhydrochlorothiazide 5mg-125mgtablet enalaprilhydrochlorothiazide 10mg-25mg tablet)

TIER 1 MO

ENTRESTO (24 MG-26 MG TABLET 49 MG-51MG TABLET 97 MG-103 MG TABLET)


fosinopril sodiumhydrochlorothiazide(fosinoprilhydrochlorothiazide 10-125mgtablet fosinoprilhydrochlorothiazide 20-125 mg tablet)

TIER 1 MO

irbesartanhydrochlorothiazide(irbesartanhydrochlorothiazide 150-125mgtablet irbesartanhydrochlorothiazide 300-125mg tablet)

TIER 1 MO

lisinoprilhydrochlorothiazide(lisinoprilhydrochlorothiazide 10-125mgtablet lisinoprilhydrochlorothiazide 20 mg-25mg tablet lisinoprilhydrochlorothiazide20-125 mg tablet)

TIER 1 MO

losartan potassiumhydrochlorothiazide(losartanhydrochlorothiazide 50-125 mgtablet losartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mgtablet)

TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

methyldopahydrochlorothiazide(methyldopahydrochlorothiazide 250mg-25mg tabletmethyldopahydrochlorothiazide 250mg-15mg tablet)

TIER 2 PA MO

metoprolol tartratehydrochlorothiazide(metoprololhydrochlorothiazide 50 mg-25mg tabletmetoprololhydrochlorothiazide 100mg-25mg tabletmetoprololhydrochlorothiazide 100mg-50mg tablet)

TIER 1 MO

metyrosine 250 mg capsule TIER 5

olmesartan medoxomilhydrochlorothiazide(olmesartanhydrochlorothiazide 20-125mg tablet olmesartanhydrochlorothiazide40-125 mg tabletolmesartanhydrochlorothiazide 40 mg-25mg tablet)

TIER 2 MO

pentoxifylline 400 mg tablet er TIER 2 MO

propranolol hclhydrochlorothiazide(propranololhydrochlorothiazid 40 tabletpropranololhydrochlorothiazid 80 tablet)

TIER 2 MO

quinapril hclhydrochlorothiazide(quinaprilhydrochlorothiazide 10-125mgtablet quinaprilhydrochlorothiazide 20-125 mg tabletquinaprilhydrochlorothiazide 20 mg-25mgtablet)

TIER 1 MO

RANEXA (ER 500 MG TABLET ER 1000 MGTABLET)

TIER 3 MO

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

TIER 3 MO

spironolacthydrochlorothiazid 25 mg-25mgtablet

TIER 2 MO

TEKTURNA HCT (150-125 MG TAB 150-25MG TABLET 300-125 MG TAB 300-25 MGTABLET)

TIER 3 PA MO

triamterenehydrochlorothiazide(triamterenehydrochlorothiazid 375-25 mgcapsule triamterenehydrochlorothiazid375-25 mg tablettriamterenehydrochlorothiazid 75 mg-50mg tablet)

TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

valsartanhydrochlorothiazide(valsartanhydrochlorothiazide 80-125mgtablet valsartanhydrochlorothiazide 160-125mg tabletvalsartanhydrochlorothiazide 160mg-25mgtablet valsartanhydrochlorothiazide320mg-25mg tabletvalsartanhydrochlorothiazide 320-125mgtablet)

TIER 1 MO

VYNDAMAX 61 MG CAPSULE TIER 5 PA QL (1 PER 1 DAYS)

VYNDAQEL 20 MG CAPSULE TIER 5 PA QL (4 PER 1 DAYS)

DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide (125 mg tablet 250 mgtablet)

TIER 2 MO

acetazolamide 500 mg capsule er TIER 4 MO

DIURETICS LOOPbumetanide (05 mg tablet 1 mg tablet 2mg tablet)

TIER 2 MO

bumetanide 025 mgml vial TIER 2

furosemide (10 mgml solution 20 mgtablet 40 mg tablet 80 mg tablet)

TIER 1 MO

furosemide (10 mgml vial 10 mgmlsyringe)

TIER 2

torsemide (5 mg tablet 10 mg tablet 20mg tablet 100 mg tablet)

TIER 2 MO

DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet TIER 2 MO

eplerenone (25 mg tablet 50 mg tablet) TIER 4 MO

spironolactone (25 mg tablet 50 mg tablet100 mg tablet)

TIER 2 MO

DIURETICS THIAZIDEchlorothiazide (250 mg tablet 500 mgtablet)

TIER 2 MO

chlorthalidone (25 mg tablet 50 mg tablet) TIER 2 MO

hydrochlorothiazide (125 mg capsule 125mg tablet 25 mg tablet 50 mg tablet)

TIER 2 MO

indapamide (125 mg tablet 25 mg tablet) TIER 2 MO

methyclothiazide 5 mg tablet TIER 2 MO


49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

metolazone (25 mg tablet 5 mg tablet 10mg tablet)

TIER 2 MO

DYSLIPIDEMICS FIBRIC ACID DERIVATIVESfenofibrate (40 mg tablet 54 mg tablet 120mg tablet 160 mg tablet)

TIER 2 MO

fenofibrate nanocrystallized (48 mg tablet145 mg tablet 145mg tablet 160 mgtablet)

TIER 2 MO

fenofibratemicronized (67 mg capsule 134mg capsule 200 mg capsule)

TIER 2 MO

gemfibrozil 600 mg tablet TIER 2 MO

DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORSatorvastatin calcium (10 mg tablet 20 mgtablet 40 mg tablet 80 mg tablet)

TIER 1 MO

lovastatin (10 mg tablet 20 mg tablet 40mg tablet)

TIER 1 MO

pravastatin sodium (10 mg tablet 20 mgtablet 40 mg tablet 80 mg tablet)

TIER 1 MO

rosuvastatin calcium (5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet)

TIER 1 MO

simvastatin (5 mg tablet 10 mg tablet 20mg tablet 40 mg tablet 80 mg tablet)

TIER 1 MO

DYSLIPIDEMICS OTHERcholestyramine (with sugar) (sugar) 4 gpowd pack sugar) 4 g powder)

TIER 2 MO

cholestyramineaspartame(cholestyramineaspartame 4 g powdpack cholestyramineaspartame 4 gpowder)

TIER 2 MO

colesevelam hcl (375 g powd pack 625mg tablet)

TIER 4 PA MO

colestipol hcl (1 g tablet 5 g granules 5 gpacket)

TIER 2 MO

ezetimibe 10 mg tablet TIER 3 MO

ezetimibesimvastatin(ezetimibesimvastatin 10 mg-20mg tabletezetimibesimvastatin 10 mg-80mg tabletezetimibesimvastatin 10 mg-40mg tabletezetimibesimvastatin 10 mg-10mg tablet)

TIER 2 MO

icosapent ethyl 1 g capsule TIER 4 MO


50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

niacin (500 mg tab er 24h 750 mg tab er24h 1000 mg tab er 24h)

TIER 4 MO

omega-3 acid ethyl esters 1 g capsule TIER 4 MO

REPATHA 140 MGML SURECLICK TIER 3 PA MO

REPATHA 140 MGML SYRINGE TIER 3 PA MO

REPATHA 420 MG35ML PUSHTRONX TIER 3 PA MO

VASCEPA (05 GM CAPSULE 1 GMCAPSULE)

TIER 4 MO

VASODILATORS DIRECT-ACTING ARTERIALhydralazine hcl (10 mg tablet 25 mg tablet50 mg tablet 100 mg tablet)

TIER 2 MO

minoxidil (25 mg tablet 10 mg tablet) TIER 2 MO

VASODILATORS DIRECT-ACTING ARTERIALVENOUSisosorbide dinitrate (5 mg tablet 10 mgtablet 20 mg tablet 30 mg tablet 40 mgtablet er)

TIER 1 MO

isosorbide mononitrate (10 mg tablet 20mg tablet 30 mg tab er 24h 60 mg tab er24h 120 mg tab er 24h)

TIER 2 MO

nitroglycerin (01mghr patch td2402mghr patch td24 04mghr patch td2406mghr patch td24)

TIER 2 MO

nitroglycerin (03 mg tab subl 04 mg tabsubl 06 mg tab subl)

TIER 3 MO

NITROSTAT (03 MG TABLET 04 MG TABLET06 MG TABLET)

TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS AMPHETAMINESdextroamphetamine sulf-saccharateamphetamine sulf-aspartate(dextroamphetamineamphetamine 5 mgtablet dextroamphetamineamphetamine5 mg cap er 24hdextroamphetamineamphetamine 75 mgtablet dextroamphetamineamphetamine10 mg cap er 24hdextroamphetamineamphetamine 10 mgtablet dextroamphetamineamphetamine125 mg tabletdextroamphetamineamphetamine 15 mgcap er 24hdextroamphetamineamphetamine 15 mgtablet dextroamphetamineamphetamine20 mg cap er 24hdextroamphetamineamphetamine 20 mgtablet dextroamphetamineamphetamine25 mg cap er 24hdextroamphetamineamphetamine 30 mgcap er 24hdextroamphetamineamphetamine 30 mgtablet)

TIER 2 MO

dextroamphetamine sulfate (5 mg capsuleer 5 mg tablet 10 mg capsule er 10 mgtablet 15 mg capsule er)

TIER 2 MO

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES

atomoxetine hcl (10 mg capsule 18 mgcapsule 25 mg capsule 40 mg capsule 60mg capsule 80 mg capsule 100 mgcapsule)

TIER 3 MO

clonidine hcl 01 mg tab er 12h TIER 3 PA MO

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

TIER 2 ST MO

dexmethylphenidate hcl (5 mg cpbp 50-5010 mg cpbp 50-50 15 mg cpbp 50-50 20mg cpbp 50-50 25 mg cpbp 50-50 30 mgcpbp 50-50 35 mg cpbp 50-50 40 mgcpbp 50-50)

TIER 4 ST MO

guanfacine hcl (1 mg tab er 24h 2 mg taber 24h 3 mg tab er 24h 4 mg tab er 24h)

TIER 3 MO

methylphenidate hcl (18 mg tab er 24 27mg tab er 24 36 mg tab er 24 54 mg tab er24)

TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

methylphenidate hcl (5 mg tablet 10 mgtablet er 10 mg tablet 20 mg tablet er 20mg tablet)

TIER 2 MO

CENTRAL NERVOUS SYSTEM OTHERNUEDEXTA 20-10 MG CAPSULE TIER 5 PA

riluzole 50 mg tablet TIER 2 MO

tetrabenazine (125 mg tablet 25 mgtablet)

TIER 5

FIBROMYALGIA AGENTSDRIZALMA SPRINKLE (DR 20 MG CAP DR 30MG CAP)


DRIZALMA SPRINKLE (DR 40 MG CAP DR 60MG CAP)


duloxetine hcl (20 mg capsule dr 30 mgcapsule dr 60 mg capsule dr)

TIER 2 MO

duloxetine hcl 40 mg capsule dr TIER 4 ST MO

pregabalin (20 mgml solution 25 mgcapsule 50 mg capsule 75 mg capsule100 mg capsule 150 mg capsule 200 mgcapsule 225 mg capsule 300 mg capsule)

TIER 3 MO

SAVELLA (125 MG TABLET 25 MG TABLET 50MG TABLET 100 MG TABLET)

TIER 3 PA MO

SAVELLA TITRATION PACK TIER 3 PA

MULTIPLE SCLEROSIS AGENTSAUBAGIO (7 MG TABLET 14 MG TABLET) TIER 5 PA LA

AVONEX (30 MCG VIAL KIT PREFILLED SYR30 MCG KT)

TIER 5 PA

AVONEX PEN 30 MCG05 ML KIT TIER 5 PA

BETASERON 03 MG KIT TIER 5 PA

dalfampridine 10 mg tab er 12h TIER 3 PA MO

EXTAVIA (03 MG VIAL 03 MG KIT) TIER 5 PA

GILENYA 05 MG CAPSULE TIER 5 PA

glatiramer acetate (20 mgml syringe 40mgml syringe)

TIER 5 PA

PLEGRIDY (125 MCG05 ML SYRINGSYRINGE STARTER PACK)

TIER 5 PA LA

PLEGRIDY PEN (125 MCG05 ML PEN PENINJ STARTER PACK)

TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

REBIF (22 MCG05 ML SYRINGE 44MCG05 ML SYRINGE TITRATION PACK)

TIER 5 PA

REBIF REBIDOSE (22 MCG05 ML 44MCG05 ML TITRATION PACK)

TIER 5 PA

TECFIDERA (DR 120 MG CAPSULE DR 240MG CAPSULE STARTER PACK)

TIER 5 PA LA

DENTAL AND ORAL AGENTSchlorhexidine gluconate 012 mouthwash TIER 2

pilocarpine hcl (5 mg tablet 75 mg tablet) TIER 2 MO

triamcinolone acetonide 01 paste (g) TIER 2

DERMATOLOGICAL AGENTSacitretin (10 mg capsule 25 mg capsule) TIER 4

acitretin 175 mg capsule TIER 5

adapalene 01 gel (gram) TIER 2

ammonium lactate 12 lotion TIER 2

AVITA 0025 GEL TIER 2 PA

calcipotriene (0005 solution 0005 cream (g))

TIER 2

calcipotriene 0005 oint (g) TIER 3

clotrimazolebetamethasone dipropionate(clotrimazolebetamethasone 1 cream(g) clotrimazolebetamethasone 1 lotion)

TIER 2

diclofenac sodium 1 gel (gram) TIER 3 MO

diclofenac sodium 3 gel (gram) TIER 5 PA - FOR NEW STARTS ONLY

fluorouracil 05 cream (g) TIER 2

imiquimod 375 crm md pmp TIER 4 PA - FOR NEW STARTS ONLY

imiquimod 5 cream pack TIER 2 QL (24 PER 30 DAYS OVER TIME)

isotretinoin (10 mg capsule 20 mg capsule30 mg capsule 40 mg capsule)

TIER 4

methoxsalen 10 mg cap lq rap TIER 3

metronidazole (075 gel (gram) 075 cream (g) 075 lotion)

TIER 2

PICATO (0015 GEL 005 GEL) TIER 5 PA - FOR NEW STARTS ONLY


54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

pimecrolimus 1 cream (g) TIER 3 PA QL (30 PER 30 DAYS)

podofilox 05 solution TIER 2

RECTIV 04 OINTMENT TIER 4 PA

REGRANEX 001 GEL TIER 5 PA QL (15 PER 30 DAYS OVER TIME)

SANTYL OINTMENT TIER 3 QL (180 PER 30 DAYS OVER TIME)

selenium sulfide 25 lotion TIER 2

STELARA (45 MG05 ML SYRINGE 45 MG05ML VIAL 90 MGML SYRINGE)

TIER 5 PA

tacrolimus (003 oint (g) 01 oint (g)) TIER 2 PA

TALTZ 80 MGML AUTOINJ (2-PK) TIER 5 PA LA QL (1 PER 28 DAYS OVERTIME)


TALTZ 80 MGML AUTOINJECTOR TIER 5 PA LA QL (1 PER 28 DAYS OVERTIME)

TALTZ 80 MGML SYRINGE TIER 5 PA LA QL (1 PER 28 DAYS OVERTIME)

TALTZ 80 MGML SYRINGE (2-PK) TIER 5 PA LA QL (1 PER 28 DAYS OVERTIME)


tazarotene 01 cream (g) TIER 4 PA

TAZORAC (005 CREAM 005 GEL 01GEL)

TIER 4 PA

TOLAK 4 CREAM TIER 4 PA - FOR NEW STARTS ONLY

tretinoin (001 gel (gram) 0025 gel(gram) 0025 cream (g) 005 gel(gram) 005 cream (g) 01 cream (g))

TIER 2 PA

ZYCLARA 25 CREAM PUMP TIER 4 PA - FOR NEW STARTS ONLY

ELECTROLYTESMINERALSMETALSVITAMINS

ELECTROLYTEMINERALMETAL MODIFIERSdeferasirox (90 mg tablet 360 mg tablet) TIER 5

09 sodium chloride (09 09 iv soln09 pggybk prt 09 pgy vl prt)

TIER 2

AMINOSYN II 15 IV SOLUTION TIER 3 BvD

AMINOSYN-PF 7 IV SOLUTION TIER 3 BvD


55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

deferasirox (125 mg tab disper 250 mg tabdisper 500 mg tab disper)

TIER 5 PA

deferasirox 180 mg tablet TIER 5

dextrose 10 in water (10 in 10 dehp frbg 10 in 10 iv soln)

TIER 2

dextrose 25 and 045 nacl 25-045iv soln

TIER 2

dextrose 5 and 09 nacl 5 -09 iv soln TIER 2

dextrose 5 in water (5 in pggybk prt 5 in pgy vl prt 5 in 5 iv soln 5 in 5 vial)

TIER 2

dextrose 5 -02 sod chlorid 5 -02 ivsoln

TIER 2

dextrose 5 -045 sod chlord 5 -045 ivsoln

TIER 2

fluoride (sodium) ((sodium) 025(055) tabchew (sodium) 05(11)mg tab chew(sodium) 1mg(22mg) tab chew)

TIER 2 MO

FLUORITAB 1 MG TABLET CHEW TIER 2 MO

FREAMINE HBC 69 IV SOLN TIER 3 BvD

INTRALIPID (20 IV EMUL 30 IV EMUL) TIER 3 BvD

KLOR-CON M15 TABLET TIER 2 MO

magnesium sulfate 4 meqml vial TIER 2

NEPHRAMINE 54 IV SOLUTION TIER 3 BvD

potassium chloride (2 meqml vial 2meqml ampul)

TIER 2

potassium chloride (8 meq tablet er 8 meqcapsule er 10 meq capsule er 10 meq taber prt 10 meq tablet er 20 meq tablet er20meq15ml liquid 20 meq tab er prt40meq15ml liquid)

TIER 2 MO

potassium chloride in 09nacl 20 meql ivsoln

TIER 2

potassium chloride in d5w 20 meql iv soln TIER 2

potassium chloride in dextrose 5 -045 sodium chloride (chlorided5-045nacl 30meql iv soln chlorided5-045nacl 20 meqliv soln chlorided5-045nacl 40 meql ivsoln)

TIER 2

potassium chloride in lr-d5 20 meql iv soln TIER 2


56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

potassium chlorided5-02nacl 20 meql ivsoln

TIER 2


TIER 2

PREMASOL 10 IV SOLUTION TIER 3 BvD

PRENATAL PLUS IRON TABLET TIER 2 MO

sodium chloride 045 (045 pggybk prt045 045 iv soln)

TIER 2

sodium chloride irrig solution 09 irrig soln TIER 2

sodium polystyrene sulfonsorb 15 g60 mloral susp

TIER 2

sodium polystyrene sulfonate (15 g60 mloral susp 30 g120ml enema 50 g200mlenema powder)

TIER 2

SPS (15 GM60 ML SUSPENSION 30 GM120ML ENEMA SUSP)

TIER 2

SYPRINE 250 MG CAPSULE TIER 5 PA

TPN ELECTROLYTES VIAL TIER 3 BvD

TRAVASOL 10 SOLN VIAFLEX TIER 3 BvD

trientine hcl 250 mg capsule TIER 5 PA

TROPHAMINE 10 IV SOLUTION TIER 3 BvD

VITAMINSAMINOSYN-HBC 7 IV SOLUTION TIER 3 BvD


potassium chloride 8 meq capsule er TIER 2 MO



TIER 2


GASTROINTESTINAL AGENTS

ANTISPASMODICS GASTROINTESTINALdicyclomine hcl (10 mg capsule 20 mgtablet)

TIER 2 MO

glycopyrrolate (1 mg tablet 2 mg tablet) TIER 2 MO


57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

GASTROINTESTINAL AGENTS OTHERcromolyn sodium 20 mgml oral conc TIER 5

diphenoxylate hclatropine sulfate(hclatropine 25-025mg tablethclatropine 25-0255 liquid)

TIER 2

loperamide hcl 2 mg capsule TIER 2 MO

MOVANTIK (125 MG TABLET 25 MG TABLET) TIER 3 QL (1 PER 1 DAYS)

RELISTOR (8 MG04 ML SYRINGE 12 MG06ML VIAL 12 MG06 ML SYRINGE)

TIER 4 PA

ursodiol (250 mg tablet 300 mg capsule500 mg tablet)

TIER 2 MO

HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine (200 mg tablet 300 mg tablet400 mg tablet 800 mg tablet)

TIER 2 MO

cimetidine hcl 300 mg5ml solution TIER 2 MO

famotidine (20 mg tablet 40 mg tablet) TIER 2 MO

nizatidine (150 mg capsule 300 mgcapsule)

TIER 2 MO

ranitidine hcl (15 mgml syrup 150 mgcapsule 150 mg tablet 300 mg tablet 300mg capsule)

TIER 2 MO

IRRITABLE BOWEL SYNDROME AGENTSalosetron hcl (05 mg tablet 1 mg tablet) TIER 5 PA

AMITIZA (8 MCG CAPSULE 24 MCGCAPSULES)

TIER 3 MO

LAXATIVESlactulose (10 g15 ml solution 20 g30 mlsolution)

TIER 2 MO

peg 3350sod sulfsod bicarbsodchloridepotassium chloride (peg3350sodsulfbicarbclkcl 236-2274g soln reconpeg3350sod sulfbicarbclkcl 240-2272gsoln recon)

TIER 2

sodium chloridenahco3kclpeg 420g solnrecon

TIER 2

PROTECTANTSmisoprostol (100 mcg tablet 200 mcgtablet)

TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

sucralfate 1 g tablet TIER 2 MO

PROTON PUMP INHIBITORSlansoprazole (15 mg capsule dr 30 mgcapsule dr)

TIER 2 MO

omeprazole (10 mg capsule dr 20 mgcapsule dr)


omeprazole 40 mg capsule dr TIER 2 QL (30 PER 30 DAYS) MO

pantoprazole sodium (20 mg tablet dr 40mg tablet dr)

TIER 2 MO

GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT

CARBAGLU 200 MG DISPER TABLET TIER 5 PA LA

CREON (DR 3000 CAPSULE DR 6000CAPSULE DR 12000 CAPSULE DR 24000CAPSULE)

TIER 3 MO

CREON DR 36000 UNITS CAPSULE TIER 5

CYSTADANE 1 GRAM17 ML POWDER TIER 3 LA MO

KUVAN (100 MG TABLET 100 MG POWDERPACKET 500 MG POWDER PACKET)

TIER 5 PA LA

miglustat 100 mg capsule TIER 5 PA

nitisinone (2 mg capsule 5 mg capsule 10mg capsule)

TIER 3 PA MO

ORFADIN 20 MG CAPSULE TIER 3 PA LA MO

sapropterin dihydrochloride (100 mg tabletsol 100 mg powd pack 500 mg powdpack)

TIER 5 PA LA

sodium phenylbutyrate 500 mg tablet TIER 3 PA MO

SUCRAID 8500 UNITSML SOLN TIER 3 PA LA MO

ZENPEP (DR 3000 CAPSULE DR 5000CAPSULE DR 10000 CAPSULE DR 15000CAPSULE DR 20000 CAPSULE DR 25000CAPSULE DR 40000 CAPSULE)

TIER 3 MO

GENITOURINARY AGENTS

ANTISPASMODICS URINARYMYRBETRIQ (ER 25 MG TABLET ER 50 MGTABLET)

TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

oxybutynin chloride (5 mg tablet 5 mg5 mlsyrup 5 mg tab er 24 10 mg tab er 24 15mg tab er 24)

TIER 2 MO

tolterodine tartrate (1 mg tablet 2 mgtablet)

TIER 2 ST QL (60 PER 30 DAYS) MO

tolterodine tartrate (2 mg cap er 24h 4 mgcap er 24h)


trospium chloride 20 mg tablet TIER 2 ST MO

BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h TIER 2 QL (30 PER 30 DAYS) MO

dutasteride 05 mg capsule TIER 4 QL (30 PER 30 DAYS) MO

finasteride 5 mg tablet TIER 2 QL (30 PER 30 DAYS) MO

tamsulosin hcl 04 mg capsule TIER 2 QL (60 PER 30 DAYS) MO

GENITOURINARY AGENTS OTHERbethanechol chloride (5 mg tablet 10 mgtablet 25 mg tablet 50 mg tablet)

TIER 2

CYSTAGON (50 MG CAPSULE 150 MGCAPSULE)

TIER 3 PA LA MO

penicillamine 250 mg capsule TIER 5 PA QL (16 PER 1 DAYS)

penicillamine 250 mg tablet TIER 5 PA

potassium citrate (5 tablet er 10 tablet er) TIER 2 MO

THIOLA 100 MG TABLET TIER 3 MO

THIOLA EC (EC 100 MG TABLET EC 300 MGTABLET)

TIER 5 PA

PHOSPHATE BINDERScalcium acetate (667 mg capsule 667 mgtablet)

TIER 2 MO

RENAGEL 400 MG TABLET TIER 4 MO

sevelamer carbonate 800 mg tablet TIER 4 MO

sevelamer hcl (400 mg tablet 800 mgtablet)

TIER 4 MO

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL)

alclometasone dipropionate (005 oint(g) 005 cream (g))

TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

betamethasone dipropionate (005 lotion 005 cream (g) 005 gel (gram))

TIER 2

betamethasone dipropionate 005 oint(g)

TIER 3

betamethasone dipropionatepropyleneglycol (betamethasonepropylene 005 oint (g) betamethasonepropylene 005 cream (g) betamethasonepropylene 005 lotion)

TIER 2

betamethasone valerate (01 cream (g)01 lotion 01 oint (g))

TIER 2

clobetasol propionate (005 solution 005 cream (g))

TIER 2

clobetasol propionate 005 oint (g) TIER 3

clobetasol propionateemoll 005 cream(g)

TIER 2

cortisone acetate 25 mg tablet TIER 2

desonide (005 lotion 005 oint (g) 005 cream (g))

TIER 2

desoximetasone (005 cream (g) 005 gel (gram) 025 oint (g) 025 cream(g))

TIER 2

dexamethasone (05 mg5ml elixir 05mg5ml solution 05 mg tablet 075 mgtablet 1 mg tablet 15 mg tablet 2 mgtablet 4 mg tablet 6 mg tablet)

TIER 2

diflorasone diacetate (005 oint (g) 005 cream (g))

TIER 2

fludrocortisone acetate 01 mg tablet TIER 2 MO

fluocinolone acetonide (001 cream (g)0025 oint (g) 0025 cream (g))

TIER 2

fluocinolone acetonide 001 solution TIER 4

fluocinonide (005 oint (g) 005 solution)

TIER 2

fluocinonide 005 gel (gram) TIER 4

fluocinonideemollient base 005 cream(g)

TIER 2

fluticasone propionate (0005 oint (g)005 cream (g))

TIER 2

halobetasol propionate (005 oint (g)005 cream (g))

TIER 2


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

hydrocortmin oilpetrolatwht 1 oint (g) TIER 2

hydrocortisone (1 crmpe app 1 oint(g) 1 cream (g) 25 crmpe app 25 cream (g) 25 lotion 25 oint (g))

TIER 2

hydrocortisone (5 mg tablet 10 mg tablet20 mg tablet)

TIER 2 MO

hydrocortisone valerate (02 cream (g)02 oint (g))

TIER 2

KORLYM 300 MG TABLET TIER 5 PA LA

methylprednisolone (4 mg tablet 4 mg tabds pk 8 mg tablet 16 mg tablet 32 mgtablet)

TIER 2

mometasone furoate (01 oint (g) 01 cream (g) 01 solution)

TIER 2

prednisolone 15 mg5 ml solution TIER 2

prednisolone sodium phosphate (5 mg5 mlsolution 10 mg5 ml solution 15 mg5 mlsolution 20 mg5 ml solution 25 mg5 mlsolution)

TIER 2

prednisone (1 mg tablet 25 mg tablet 5mg tablet 10 mg tablet 20 mg tablet)

TIER 2

triamcinolone acetonide (0025 oint (g)0025 cream (g) 0025 lotion 01 oint(g) 01 lotion 01 cream (g) 05 oint(g) 05 cream (g))

TIER 2

TRIDESILON 005 CREAM TIER 2

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY)

desmopressin (nonrefrigerated) 10sprayspraypump

TIER 2 MO

desmopressin acetate (01 mg tablet 01mgml solution 02 mg tablet 10sprayspraypump)

TIER 2 MO

GENOTROPIN (MINIQUICK 04 MGMINIQUICK 06 MG MINIQUICK 08 MGMINIQUICK 1 MG MINIQUICK 12 MGMINIQUICK 14 MG MINIQUICK 16 MGMINIQUICK 18 MG MINIQUICK 2 MG 5 MGCARTRIDGE 12 MG CARTRIDGE)

TIER 5 PA

GENOTROPIN MINIQUICK 02 MG TIER 3 PA MO

HUMATROPE (5 MG VIAL 12 MGCARTRIDGE 24 MG CARTRIDGE)

TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

HUMATROPE 6 MG CARTRIDGE TIER 3 PA MO

INCRELEX 40 MG4 ML VIAL TIER 5 PA LA

NORDITROPIN FLEXPRO (5 MG15 10MG15 15 MG15 30 MG3 ML)

TIER 5 PA

NUTROPIN AQ NUSPIN (10 20) TIER 5 PA

SAIZEN (5 MG VIAL 88 MG CLICKEASYCARTG 88 MG VIAL)

TIER 5 PA

SAIZEN 88 MG SAIZENPREP CART TIER 5 PA

SEROSTIM (4 MG VIAL 5 MG VIAL 6 MGVIAL)

TIER 5 PA LA

ZORBTIVE 88 MG VIAL TIER 5 PA

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS)

ANABOLIC STEROIDSANADROL-50 TABLET TIER 5

oxandrolone (25 mg tablet 10 mg tablet) TIER 2 PA MO

ANDROGENSANDRODERM (2 MG24HR PATCH 4MG24HR PATCH)

TIER 3 PA MO

AVEED 750 MG3 ML VIAL TIER 4 PA MO

danazol (50 mg capsule 100 mg capsule200 mg capsule)

TIER 2

methyltestosterone 10 mg capsule TIER 2 PA MO

testosterone (125125g gel md pmp 50mg (1) gel (gram) 50 mg (1) gel packet)

TIER 3 PA MO

testosterone cypionate (100 mgml vial 200mgml vial)

TIER 2 PA MO

ESTROGENSALORA (0025 MG PATCH 01 MG PATCH) TIER 3 MO

COMBIPATCH (005-025 MG 005-014 MG) TIER 3 MO

desog-eestradioleestradiol 21-5 (28)tablet

TIER 2 MO

desogestrel-ethinyl estradiol (015-003tablet 7 days x 3 tablet)

TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

estradiol (025mg24h patch tdwk0375mg24 patch tdwk 005mg24h patchtdwk 006mg24h patch tdwk 075mg24hpatch tdwk 01mg24hr patch tdwk 05mg tablet 1 mg tablet 2 mg tablet)

TIER 2 PA MO

estradiol (001 creamappl 025mg24hpatch tdsw 0375mg24 patch tdsw005mg24h patch tdsw 075mg24h patchtdsw 01mg24hr patch tdsw)

TIER 2 MO

estradiolnorethindrone acetate(estradiolnorethindrone 05-01 mg tabletestradiolnorethindrone 1 mg-05mg tablet)

TIER 2 MO

ethinyl estradioldrospirenone(estradioldrospirenone 002-3(28) tabletestradioldrospirenone 003mg-3mg tablet)

TIER 2 MO

ethynodiol diacetate-ethinyl estradiol (1mg-35mcg tablet 1 mg-50mcg tablet)

TIER 2 MO

levonorgestrelethinyl estradiol(levonorgestrelethinestradiol 01-002mgtablet levonorgestrelethinestradiol 015-003 tablet levonorgestrelethinestradiol015-003 tbdspk 3molevonorgestrelethinestradiol 6-5-10 tabletlevonorgestrelethinestradiol 90-20 mcgtablet)

TIER 2 MO

MENEST (03 MG TABLET 0625 MG TABLET125 MG TABLET)

TIER 4 PA MO

norethindrone acetate-ethinyl estradiol(05mg-25 tablet 1mg-20mcg tablet 1mg-5mcg tablet 15-003mg tablet)

TIER 2 MO

norethindrone acetate-ethinylestradiolferrous fumarate (1mg-20(21)tablet 1mg-20(24) tablet 15-30(21) tablet5-7-9-7 tablet)

TIER 2 MO

norethindrone-ethinyl estradiol (04-0035tablet 05-0035 tablet 1 mg-35mcg tablet7-9-5 tablet 7 days x 3 tablet)

TIER 2 MO

norgestimate-ethinyl estradiol (025-0035tablet 7daysx3 28 tablet 7daysx3 lo tablet)

TIER 2 MO

norgestrel-ethinyl estradiol (03-003mgtablet 05 mg-50 tablet)

TIER 2 MO

PREMARIN (03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET 125 MGTABLET)

TIER 3 PA MO

PREMARIN VAGINAL CREAM-APPL TIER 3 MO


64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

PREMPHASE 0625-5 MG TABLET TIER 3 PA MO

PREMPRO (03 MG-15 MG TABLET 045-15MG TABLET 0625-5 MG TABLET 0625-25MG TABLET)

TIER 3 PA MO

PROGESTINSDEPO-PROVERA 400 MGML VIAL TIER 3 MO

medroxyprogesterone acetate (25 mgtablet 5 mg tablet 10 mg tablet 150mgml vial 150 mgml syringe)

TIER 2 MO

megestrol acetate (20 mg tablet 40 mgtablet)

TIER 2

megestrol acetate (400mg10ml oral susp625mg5ml oral susp)

TIER 2 MO

norethindrone 035 mg tablet TIER 2 MO

norethindrone acetate 5 mg tablet TIER 2 MO

progesterone micronized (100 mg capsule200 mg capsule)

TIER 2 MO

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSOSPHENA 60 MG TABLET TIER 4 PA MO

raloxifene hcl 60 mg tablet TIER 2 QL (30 PER 30 DAYS) MO

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID)

levothyroxine sodium (25 mcg tablet 50mcg tablet 75 mcg tablet 88 mcg tablet100 mcg tablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcg tablet 175mcg tablet 200 mcg tablet 300 mcgtablet)

TIER 2 MO

LEVOXYL (25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCG TABLET137 MCG TABLET 150 MCG TABLET 175MCG TABLET 200 MCG TABLET)

TIER 3 MO

liothyronine sodium (5 mcg tablet 25 mcgtablet 50 mcg tablet)

TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

SYNTHROID (25 MCG TABLET 50 MCGTABLET 75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCG TABLET300 MCG TABLET)

TIER 3 MO

UNITHROID (25 MCG TABLET 50 MCGTABLET 75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET 125MCG TABLET 150 MCG TABLET 175 MCGTABLET 200 MCG TABLET 300 MCG TABLET)

TIER 3 MO

HORMONAL AGENTS SUPPRESSANT (PITUITARY)cabergoline 05 mg tablet TIER 2 MO

ELIGARD (225 MG SYRINGE KIT 30 MGSYRINGE KIT 45 MG SYRINGE KIT)

TIER 4 MO

ELIGARD 75 MG SYRINGE KIT TIER 3 MO

FIRMAGON 2 X 120 MG KIT TIER 5

FIRMAGON 80 MG KIT TIER 4 MO

leuprolide acetate 1 mg02ml kit TIER 5

LUPRON DEPOT (DEPOT-4 MONTH KIT DEPOT75 MG KIT DEPOT 1125 MG 3MO KITDEPOT 225 MG 3MO KIT DEPOT 45 MG6MO KIT)

TIER 5

LUPRON DEPOT 375 MG KIT TIER 3

LUPRON DEPOT-PED (75 MG KIT 1125 MG3MO)

TIER 5

octreotide acetate (50 mcgml ampul 50mcgml vial 100 mcgml vial 100 mcgmlampul 200 mcgml vial 500 mcgml vial500 mcgml ampul)

TIER 4 BvD MO

octreotide acetate 1000mcgml vial TIER 5 BvD MO

SIGNIFOR (03 MGML 06 MGML 09MGML)

TIER 5 PA LA

SOMATULINE DEPOT (60 MG02 ML 90MG03 ML 120 MG05 ML)


SOMAVERT (10 MG VIAL 15 MG VIAL 20MG VIAL 25 MG VIAL 30 MG VIAL)

TIER 5 PA

SYNAREL 2 MGML NASAL SPRAY TIER 5

TRELSTAR (375 MG VIAL 1125 MG VIAL225 MG VIAL)

TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

HORMONAL AGENTS SUPPRESSANT (THYROID)

ANTITHYROID AGENTSmethimazole (5 mg tablet 10 mg tablet) TIER 2 MO

propylthiouracil 50 mg tablet TIER 2 MO

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTSHAEGARDA (2000 VIAL 3000 VIAL) TIER 5 PA LA

icatibant acetate 30 mg3 ml syringe TIER 5 PA

RUCONEST 2100 UNIT VIAL TIER 5 PA

IMMUNE SUPPRESSANTSASTAGRAF XL (05 MG CAPSULE 1 MGCAPSULE 5 MG CAPSULE)


azathioprine 50 mg tablet TIER 2 BvD MO

cyclosporine (25 mg capsule 100 mgcapsule)

TIER 4 BvD MO

cyclosporine modified (25 mg capsule 50mg capsule 100 mg capsule 100 mgmlsolution)

TIER 2 BvD MO

ENBREL (25 MG05 ML SYRINGE 25 MG05ML VIAL 25 MG KIT 50 MGML SYRINGE)

TIER 5 PA

ENBREL 50 MGML SURECLICK TIER 5 PA

ENVARSUS XR (075 MG TABLET 1 MGTABLET 4 MG TABLET)


everolimus (025 mg tablet 05 mg tablet075 mg tablet)


HUMIRA (10 MG02 ML SYRINGE 20 MG04ML SYRINGE 40 MG08 ML SYRINGE)

TIER 5 PA

HUMIRA PEDI CROHN 40 MG08 ML TIER 5 PA

HUMIRA PEN 40 MG08 ML TIER 5 PA

HUMIRA PEN CROHN-UC-HS 40 MG TIER 5 PA

HUMIRA PEN PS-UV-ADOL HS 40 MG TIER 5 PA

HUMIRA(CF) (HUMIRA(CF) 10 MG01 MLSYRING HUMIRA(CF) 20 MG02 ML SYRINGHUMIRA(CF) 40 MG04 ML SYRING)

TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

HUMIRA(CF) PEDIATRIC CROHNS(HUMIRA(CF) 80-40 MG HUMIRA(CF)80MG08)

TIER 5 PA

HUMIRA(CF) PEN 40 MG04 ML TIER 5 PA

HUMIRA(CF) PEN CRHN-UC-HS 80MG TIER 5 PA

HUMIRA(CF) PEN PS-UV-AHS 80-40 TIER 5 PA

KINERET 100 MG067 ML SYRINGE TIER 5 PA

methotrexate sodium 25 mg tablet TIER 2 MO

methotrexate sodium 25 mgml vial TIER 2

methotrexate sodiumpf 25 mgml vial TIER 2

mycophenolate mofetil (200 mgml susprecon 250 mg capsule 500 mg tablet)

TIER 2 BvD MO

mycophenolate sodium (180 mg tablet dr360 mg tablet dr)

TIER 4 BvD MO

PROGRAF (02 MG GRANULE PACKET 1 MGGRANULE PACKET)


sirolimus (1 mgml solution 2 mg tablet) TIER 5 BvD

sirolimus 05 mg tablet TIER 2 QL (30 PER 30 DAYS) BvD MO

sirolimus 1 mg tablet TIER 3 BvD MO

tacrolimus (05 mg capsule 1 mg capsule5 mg capsule)

TIER 2 BvD MO

XATMEP 25 MGML ORAL SOLUTION TIER 4 PA - FOR NEW STARTS ONLY MO

XELJANZ (5 MG TABLET 10 MG TABLET) TIER 5 PA

XELJANZ XR (11 MG TABLET 22 MG TABLET) TIER 5 PA

ZORTRESS 1 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY

IMMUNIZING AGENTS PASSIVEBIVIGAM (LIQUID VIAL VIAL) TIER 5 PA

GAMMAGARD LIQUID 10 VIAL TIER 5 PA

GAMMAGARD S-D (5 G (IGAlt1) SOLN 10 G(IGAlt1) SOL)

TIER 5 PA

GAMUNEX-C 1 GRAM10 ML VIAL TIER 5 PA

IMMUNOMODULATORSACTIMMUNE 100 MCG05 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY LA

ARCALYST 220 MG INJECTION TIER 5 PA LA

KEVZARA (150 MG114 ML SYRINGE 200MG114 ML SYRINGE)

TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

leflunomide (10 mg tablet 20 mg tablet) TIER 2 MO

OTEZLA (28 DAY STARTER PACK 30 MGTABLET)

TIER 5 PA

RIDAURA 3 MG CAPSULE TIER 3 MO

VACCINESACTHIB (VIAL WITH DILUENT) TIER 3

ADACEL TDAP (SYRINGE VIAL) TIER 3

BCG VACCINE (TICE STRAIN) VIAL TIER 3

BEXSERO PREFILLED SYRINGE TIER 3

BOOSTRIX TDAP (SYRINGE VIAL) TIER 3

DAPTACEL DTAP VACCINE TIER 3

DIPHTHERIA-TETANUS TOXOIDS-PED TIER 3

ENGERIX-B 20 MCGML SYRN TIER 3 BvD

ENGERIX-B PEDI 10 MCG05 SYRN TIER 3 BvD

GARDASIL 9 (9 SYRINGE 9 VIAL) TIER 3

HAVRIX (720 UNITS05 ML VIAL 720 UNIT05ML SYRINGE 1440 UNITSML SYRINGE 1440UNITSML VIAL)

TIER 3

HIBERIX VACCINE WITH DILUENT TIER 3

IMOVAX RABIES VACCINE VIAL TIER 3

INFANRIX DTAP VIAL TIER 3

IPOL VIAL TIER 3

IXIARO (6 MCG05 ML SYRINGE 6 UNIT(6MCG)05ML SYR)

TIER 4

KINRIX (TIP-LOK SYRINGE VIAL) TIER 3

M-M-R II VACCINE VIAL TIER 3

MENACTRA VIAL TIER 3

MENQUADFI VIAL TIER 3

MENVEO A-C-Y-W-135-DIP VIAL KT TIER 3

PEDIARIX 05 ML SYRINGE TIER 3

PEDVAXHIB VACCINE VIAL TIER 3

PENTACEL ACTHIB COMPONENT VIAL TIER 3

PROQUAD VIAL TIER 3

QUADRACEL DTAP-IPV VIAL TIER 3


69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

RABAVERT RABIES VACC W-DILUENT TIER 3

RECOMBIVAX HB (5 MCG05 ML SYR 10MCGML VIAL 10 MCGML SYR 40MCGML VIAL)

TIER 3 BvD

ROTARIX VACCINE SUSPENSION TIER 3

ROTATEQ VACCINE TIER 3

SHINGRIX VIAL KIT TIER 3 QL (2 PER 365 DAYS OVER TIME)

TDVAX VIAL TIER 3

TENIVAC SYRINGE TIER 3

TRUMENBA 120 MCG05 ML VACCIN TIER 3

TWINRIX VACCINE SYRINGE TIER 3 BvD

TYPHIM VI (25 MCG05 ML AL 25 MCG05ML SYRNG)

TIER 3

VAQTA (25 UNITS05 ML VIAL 25 UNITS05ML SYRINGE 50 UNITSML SYRINGE 50UNITSML VIAL)

TIER 3

VARIVAX VACCINE WITH DILUENT TIER 3

XOFLUZA (20 MG TAB (40 MG DOSE) 40 MGTAB (80 MG DOSE))


YF-VAX (1 VIAL 5 VIAL) TIER 3

ZOSTAVAX VIAL TIER 3

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATESbalsalazide disodium 750 mg capsule TIER 2

DIPENTUM 250 MG CAPSULE TIER 3 MO

mesalamine 0375g cap er 24h TIER 3 QL (4 PER 1 DAYS)

mesalamine 1000 mg supprect TIER 3 MO

mesalamine 4 g60 ml enema TIER 2 MO

mesalamine 400 mg cap(drtab) TIER 3 QL (12 PER 1 DAYS) MO

mesalamine wcleansing wipes 4 g60 mlenema kit

TIER 2 MO

PENTASA (250 MG CAPSULE 500 MGCAPSULE)



70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

GLUCOCORTICOIDSbudesonide 3 mg capdr - er TIER 4

hydrocortisone 100mg60ml enema TIER 2

SULFONAMIDESsulfasalazine (500 mg tablet 500 mg tabletdr)

TIER 2 MO

METABOLIC BONE DISEASE AGENTSalendronate sodium (35 mg tablet 70 mgtablet)


alendronate sodium (5 mg tablet 10 mgtablet 40 mg tablet)


calcitoninsalmonsynthetic 200sprayspraypump

TIER 4 MO

calcitriol (025 mcg capsule 05 mcgcapsule)

TIER 2 BvD MO

cinacalcet hcl (60 mg tablet 90 mg tablet) TIER 5 BvD MO

cinacalcet hcl 30 mg tablet TIER 3 QL (30 PER 30 DAYS) BvD MO

doxercalciferol 05 mcg capsule TIER 3 QL (30 PER 30 DAYS) BvD MO


doxercalciferol 25 mcg capsule TIER 3 BvD MO

FORTEO 600 MCG24 ML PEN INJ TIER 5 PA QL (3 PER 28 DAYS)

ibandronate sodium 150 mg tablet TIER 2 QL (1 PER 30 DAYS) MO

NATPARA (25 MCG CARTRIDGE 50 MCGCARTRIDGE 75 MCG CARTRIDGE 100 MCGCARTRIDGE)

TIER 5 PA LA

paricalcitol (1 mcg capsule 2 mcgcapsule 4 mcg capsule)

TIER 3 MO

PROLIA 60 MGML SYRINGE TIER 4 PA MO

risedronate sodium (35 mg tablet dr 35 mgtablet)


risedronate sodium 150 mg tablet TIER 4 QL (1 PER 30 DAYS) MO


TYMLOS 80 MCG DOSE PEN INJECTR TIER 5 PA

XGEVA 120 MG17 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY


71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

MISCELLANEOUS THERAPEUTIC AGENTSalcohol 70 pads TIER 2

alcohol antiseptic pads med pad TIER 2

gauze bandage 2 x 2 bandage TIER 2

insulin pen needles TIER 2 MO

insulin pen needles TIER 2

insulin syringe 03 ml TIER 2 MO



pen needle diabetic (pen 29 g x12 disneedle pen 31 g x14 dis needle pen 31gx516 dis needle pen 31 gx316 disneedle pen 32gx 532 dis needle pen 33gx532 dis needle)

TIER 2 MO

pen needle diabetic (pen 30 gx316 disneedle pen 30 gx516 dis needle pen 32gx516 dis needle pen 32 gx 14 disneedle pen 32 gx316 dis needle pen 34gx964 dis needle)

TIER 2

pen needle diabetic disposable safety(pen 30 gx516 dis needle pen 30 gx316dis needle)

TIER 2

pen needle diabetic safety 30 gx316 disneedle

TIER 2

syring-needldispinsul03 ml 29 g x12 dispsyrin

TIER 2 MO

syringe with needle insulin safety 1 ml (30gx316 disp syrin 31gx1564 disp syrin)

TIER 2

syringe with needledisposableinsulin 1 ml(syringe 30gx12 disp syrin syringe 31gx516 disp syrin)

TIER 2 MO

syringeneedleinsulnsf 05ml 31gx1564disp syrin

TIER 2

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS OTHERbacitracinpolymyxin b sulfate 500-10kgoint (g)

TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

CYSTARAN 044 EYE DROPS TIER 5 PA LA

LACRISERT 5 MG EYE INSERT TIER 4

neomycin sulfbacitracinpoly 35mg-400oint (g)

TIER 2

neomycinbacitp-myxhydrocort 35-10k-1oint (g)

TIER 2

neomycinpolymyxin bsulfatedexamethasone(neomycinpolymyxin bdexametha 01 drops susp neomycinpolymyxinbdexametha 35-10k-1 oint (g))

TIER 2

neomycinpolymyxin bhydrocort 35-10k-10 drops susp

TIER 2

neomycinpolymyxn bgramicidin 175mg-10k drops

TIER 2

polymyxin b sulftrimethoprim 10000-1mldrops

TIER 2

proparacaine hcl 05 drops TIER 2

RESTASIS 005 EYE EMULSION TIER 3 QL (64 PER 30 DAYS) MO

RESTASIS MULTIDOSE 005 EYE TIER 3 QL (55 PER 30 DAYS) MO

sulfacetamideprednisolone sp 10 -023drops

TIER 2

tobramycindexamethasone 03 -01drops susp

TIER 2

OPHTHALMIC ANTI-ALLERGY AGENTSazelastine hcl 005 drops TIER 2

cromolyn sodium 4 drops TIER 2

olopatadine hcl 01 drops TIER 2 QL (5 PER 30 DAYS)

olopatadine hcl 02 drops TIER 2

OPHTHALMIC ANTI-INFLAMMATORIESbromfenac sodium 009 drops TIER 4

dexamethasone sodium phosphate 01 drops

TIER 2

diclofenac sodium 01 drops TIER 2

fluorometholone 01 drops susp TIER 3

flurbiprofen sodium 003 drops TIER 2

ketorolac tromethamine (04 drops 05 drops)

TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

loteprednol etabonate 05 drops susp TIER 3

MAXIDEX 01 EYE DROPS TIER 3

prednisolone acetate 1 drops susp TIER 2

prednisolone sodium phosphate 1 drops TIER 2

OPHTHALMIC ANTIGLAUCOMA AGENTSALPHAGAN P 01 DROPS TIER 3 MO

AZOPT 1 EYE DROPS TIER 3 MO

betaxolol hcl 05 drops TIER 2 MO

brimonidine tartrate (015 drops 02 drops)

TIER 2 MO

carteolol hcl 1 drops TIER 2 MO

dorzolamide hcl 2 drops TIER 2 QL (10 PER 30 DAYS) MO

dorzolamide hcltimolol maleat 223-681drops


levobunolol hcl 05 drops TIER 2 MO

methazolamide (25 mg tablet 50 mgtablet)

TIER 2 MO

PHOSPHOLINE IODIDE 0125 TIER 3 MO

pilocarpine hcl (1 drops 2 drops 4 drops)

TIER 2 MO

timolol maleate (025 sol-gel 025 drops 05 drops 05 sol-gel)

TIER 2 MO

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSlatanoprost 0005 drops TIER 2 MO

travoprost 0004 drops TIER 3 QL (5 PER 30 DAYS OVER TIME) MO

OTIC AGENTSfluocinolone acetonide oil 001 drops TIER 3

hydrocortisoneacetic acid 1 -2 drops TIER 2

neomycin sulfatepolymyxin bsulfatehydrocortisone(neomycinpolymyxin bhydrocort 35-10k-1drops susp neomycinpolymyxinbhydrocort 35-10k-1 solution)

TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

RESPIRATORY TRACTPULMONARY AGENTS

ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDSbudesonide (025mg2ml ampul-neb 05mg2ml ampul-neb 1 mg2 ml ampul-neb)

TIER 2 PA MO

FLOVENT DISKUS (50 MCG 100 MCG 250MCG)

TIER 3 MO

FLOVENT HFA (HFA 44 MCG INHALER HFA110 MCG INHALER HFA 220 MCG INHALER)

TIER 3 MO

flunisolide 25 mcg spray TIER 2 MO

fluticasone propionate 50 mcg spray susp TIER 2 MO

PULMICORT FLEXHALER (90 MCG 180 MCG) TIER 4 MO

QVAR REDIHALER (40 MCG 80 MCG) TIER 3 MO

ANTIHISTAMINESazelastine hcl 137 mcg spraypump TIER 2 QL (60 PER 30 DAYS) MO

clemastine fumarate 268 mg tablet TIER 2 PA

cyproheptadine hcl 4 mg tablet TIER 2 PA

desloratadine 5 mg tablet TIER 2 MO

hydroxyzine hcl (10 mg tablet 10 mg5 mlsolution 25 mg tablet 50 mg25ml solution50 mg tablet)

TIER 2 PA

promethazine hcl (625mg5ml syrup 125mg tablet 25 mg tablet)

TIER 2 PA

ANTILEUKOTRIENESmontelukast sodium (4 mg tab chew 5 mgtab chew 10 mg tablet)

TIER 2 MO

zafirlukast (10 mg tablet 20 mg tablet) TIER 2 QL (60 PER 30 DAYS) MO

BRONCHODILATORS ANTICHOLINERGICATROVENT 17 MCG HFA INHALER TIER 3 MO

INCRUSE ELLIPTA 625 MCG INH TIER 3 QL (30 PER 30 DAYS OVER TIME)MO

ipratropium bromide 02 mgml solution TIER 2 BvD MO

ipratropium bromide 21 mcg spray TIER 2 MO

ipratropium bromide 42 mcg spray TIER 2


75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

SPIRIVA 18 MCG CP-HANDIHALER TIER 3 QL (30 PER 30 DAYS) MO

SPIRIVA RESPIMAT (125 MCG 25 MCG) TIER 3 QL (4 PER 30 DAYS) MO

BRONCHODILATORS SYMPATHOMIMETICalbuterol 90mcg hfa inhaler (generic proair) TIER 2 QL (17 PER 30 DAYS OVER TIME)

MO

albuterol 90mcg hfa inhaler (genericproventil)

TIER 2 QL (134 PER 30 DAYS OVER TIME)MO

albuterol 90mg hfa inhaler (generic proair) TIER 2 QL (17 PER 30 DAYS OVER TIME)MO

albuterol sulfate (063mg3ml vial-neb125mg3ml vial-neb 25 mg05 vial-neb25 mg3ml vial-neb 5 mgml solution)

TIER 2 BvD MO

albuterol sulfate (2 mg5 ml syrup 2 mgtablet 4 mg tab er 12h 4 mg tablet 8 mgtab er 12h)

TIER 2 MO

epinephrine (015mg03 auto injct015015 auto injct 03mg03 auto injct)

TIER 2

levalbuterol hcl (031mg3ml vial-neb063mg3ml vial-neb 125mg05 vial-neb125mg3ml vial-neb)

TIER 2 PA MO

levalbuterol tartrate 45 mcg hfa aer ad TIER 3 QL (30 PER 30 DAYS OVER TIME)

metaproterenol sulfate (10 mg5 ml syrup10 mg tablet 20 mg tablet)

TIER 2 MO

SEREVENT DISKUS 50 MCG TIER 3 MO

STRIVERDI RESPIMAT INHAL SPRAY TIER 3 MO

terbutaline sulfate (25 mg tablet 5 mgtablet)

TIER 2 MO

CYSTIC FIBROSIS AGENTSCAYSTON 75 MG INHAL SOLUTION TIER 5 PA LA

KALYDECO (25 MG GRANULES PACKET 50MG GRANULES PACKET 75 MG GRANULESPACKET 150 MG TABLET)

TIER 5 PA LA QL (2 PER 1 DAYS)

ORKAMBI (100 MG TABLET 200 MG TABLET) TIER 5 PA LA

SYMDEKO 100150 MG-150 MG TABS TIER 5 PA LA

SYMDEKO 5075 MG-75 MG TABLETS TIER 5 PA LA QL (2 PER 1 DAYS)

TRIKAFTA 1005075 MG-150 MG TIER 5 PA LA QL (3 PER 1 DAYS)


76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

MAST CELL STABILIZERScromolyn sodium 20 mg2 ml ampul-neb TIER 2 BvD MO

PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASEDALIRESP (250 MCG TABLET 500 MCGTABLET)

TIER 4 PA MO

THEO-24 (ER 100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE ER 400 MGCAPSULE)

TIER 3 MO

theophylline anhydrous (80 mg15mlsolution 80 mg15ml elixir 100 mg tab er12h 200 mg tab er 12h 300 mg tab er 12h400 mg tab er 24h 600 mg tab er 24h)

TIER 2 MO

PULMONARY ANTIHYPERTENSIVESADEMPAS (05 MG TABLET 1 MG TABLET 15MG TABLET 2 MG TABLET 25 MG TABLET)

TIER 5 PA LA

ambrisentan (5 mg tablet 10 mg tablet) TIER 5 PA LA QL (1 PER 1 DAYS)

bosentan 125 mg tablet TIER 5 PA LA QL (2 PER 1 DAYS)


sildenafil citrate 20 mg tablet TIER 2 PA MO

tadalafil 20 mg tablet TIER 5 PA

TRACLEER 32 MG TABLET FOR SUSP TIER 5 PA LA QL (120 PER 30 DAYS)

UPTRAVI (200 MCG TABLET 200-800TITRATION PACK 400 MCG TABLET 600MCG TABLET 800 MCG TABLET 1000 MCGTABLET 1200 MCG TABLET 1400 MCGTABLET 1600 MCG TABLET)

TIER 5 PA LA

RESPIRATORY TRACT AGENTS OTHERacetylcysteine 200 mgml vial TIER 2 BvD

ANORO ELLIPTA 625-25 MCG INH TIER 3 QL (60 PER 30 DAYS) MO

BEVESPI AEROSPHERE INHALER TIER 3 QL (107 PER 28 DAYS OVER TIME)MO

COMBIVENT RESPIMAT 20-100 MCG TIER 3 QL (8 PER 30 DAYS) MO

ESBRIET (267 MG TABLET 267 MG CAPSULE801 MG TABLET)

TIER 5 PA LA

fluticasone propionatesalmeterolxinafoate (propionsalmeterol 100-50 mcgblst wdev propionsalmeterol 250-50 mcgblst wdev propionsalmeterol 500-50 mcgblst wdev)



77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

fluticasone propionatesalmeterolxinafoate (propionsalmeterol 55-14 mcgaer pow ba propionsalmeterol 113-14mcg aer pow ba propionsalmeterol 232-14 mcg aer pow ba)


ipratropiumalbuterol sulfate 05-3mg3ampul-neb

TIER 2 BvD MO

OFEV (100 MG CAPSULE 150 MG CAPSULE) TIER 5 PA LA

PULMOZYME 1 MGML AMPUL TIER 5 BvD

tobramycin in 0225 sod chlor 300 mg5mlampul-neb

TIER 5 PA

TRELEGY ELLIPTA 100-625-25 TIER 3 QL (60 PER 30 DAYS OVER TIME)MO

XOLAIR 150 MG VIAL TIER 5 PA - FOR NEW STARTS ONLY

ZEMAIRA 1000 MG VIAL TIER 5 BvD

SKELETAL MUSCLE RELAXANTScarisoprodol 250 mg tablet TIER 2 PA QL (90 PER 30 DAYS)

carisoprodol 350 mg tablet TIER 2 PA QL (90 PER 30 DAYS OVER TIME)

chlorzoxazone 500 mg tablet TIER 2 PA

cyclobenzaprine hcl (5 mg tablet 10 mgtablet)


methocarbamol (500 mg tablet 750 mgtablet)

TIER 2 PA

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORStemazepam (15 mg capsule 30 mgcapsule)


triazolam (0125 mg tablet 025 mg tablet) TIER 2 QL (30 PER 30 DAYS)

zaleplon (5 mg capsule 10 mg capsule) TIER 2

zolpidem tartrate (5 mg tablet 10 mgtablet)


SLEEP DISORDERS OTHERHETLIOZ 20 MG CAPSULE TIER 5 PA LA

modafinil (100 mg tablet 200 mg tablet) TIER 3 PA MO


78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ramelteon 8 mg tablet TIER 3

XYREM 500 MGML ORAL SOLUTION TIER 5 PA LA

Uncategorized

UnclassifiedALIMTA (100 MG VIAL 500 MG VIAL) TIER 5 BvD

ALIQOPA 60 MG VIAL TIER 5 PA - FOR NEW STARTS ONLY

amifostine crystalline 500 mg vial TIER 5 BvD

arsenic trioxide 12 mg6 ml vial TIER 5 BvD

ARZERRA (100 MG5 ML VIAL 1000 MG50ML VIAL)


AVASTIN (100 MG4 ML VIAL 400 MG16 MLVIAL)

TIER 5 BvD

azacitidine 100 mg vial TIER 5 BvD

azathioprine sodium 100 mg vial TIER 2 BvD

BAVENCIO 200 MG10 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

BELEODAQ 500 MG VIAL TIER 5 BvD

BENDEKA 100 MG4 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

BESPONSA 09 MG VIAL TIER 5 PA - FOR NEW STARTS ONLY

bleomycin sulfate (15 vial 30 vial) TIER 2 BvD

BLINCYTO 35MCG VL W-STABILIZER TIER 5 BvD

bortezomib 35 mg vial TIER 5 BvD

BRIVIACT 50 MG5 ML VIAL TIER 4 PA - FOR NEW STARTS ONLY

busulfan 60 mg10ml vial TIER 4 BvD

CARIMUNE NF NANOFILTERED (6 GM VIAL12 GM VIAL)

TIER 5 PA

cefotaxime sodium (1 g vial 2 g vial 500mg vial)

TIER 2

chlorpromazine hcl 25 mgml ampul TIER 2 BvD

cimetidine 200 mg tablet TIER 2 MO

ciprofloxacin lactate 400mg40ml vial TIER 2

clofarabine 20 mg20ml vial TIER 5 BvD

clotrimazole (1 cream (g) 1 solution) TIER 2

cyclosporine 250 mg5ml ampul TIER 2 BvD


79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

CYRAMZA (100 MG10 ML VIAL 500 MG50ML VIAL)


dactinomycin 05 mg vial TIER 5 BvD

DARZALEX (100 MG5 ML VIAL 400 MG20ML VIAL)


decitabine 50 mg vial TIER 5 BvD

docetaxel (20 mg2 ml vial 20mgml(1)vial 80 mg4 ml vial 80 mg8 ml vial 160mg8ml vial 160mg16ml vial 200mg10mlvial)

TIER 5 BvD

ELITEK (15 MG VIAL 75 MG VIAL) TIER 5 BvD

EMPLICITI (300 MG VIAL 400 MG VIAL) TIER 5 PA - FOR NEW STARTS ONLY

EPCLUSA 200 MG-50 MG TABLET TIER 5 PA QL (1 PER 1 DAYS)

ERWINAZE 10000 UNITS VIAL TIER 5 PA - FOR NEW STARTS ONLY

estropipate (075 mg tablet 15 mg tablet3 mg tablet)

TIER 2 PA MO

etidronate disodium (200 mg tablet 400 mgtablet)

TIER 2 MO

famotidine 20 mg tablet TIER 2 MO

FLULAVAL QUAD 2018-2019 SYR TIER 3

fluocinonide 005 cream (g) TIER 2

fluorouracil (1 g20 ml vial 25 g50ml vial 5g100 ml vial 500mg10ml vial)

TIER 3 BvD


FLUZONE QUAD 2018-2019 VIAL TIER 3

FOLOTYN (20 MGML VIAL 40 MG2 MLVIAL)

TIER 5 BvD

fosphenytoin sodium (100mg pe2 vial 500pe10 vial)

TIER 4

fulvestrant 250 mg5ml syringe TIER 4 MO

GAMUNEX-C (25 GRAM25 ML VIAL 5GRAM50 ML VIAL 10 GRAM100 ML VIAL20 GRAM200 ML VIAL)

TIER 5 PA

GAZYVA 1000 MG40 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

gemcitabine hcl (1 g263ml vial 1 g vial 2g vial 2 g526ml vial 100 mgml vial200mg526 vial 200 mg vial)

TIER 5 BvD

HALAVEN 1 MG2 ML VIAL TIER 5 BvD


80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

haloperidol lactate 5 mgml syringe TIER 2 BvD

HARVONI 45-200 MG TABLET TIER 5 PA QL (1 PER 1 DAYS)

HERCEPTIN (150 MG VIAL 440 MG VIAL) TIER 5 BvD

HERCEPTIN HYLECTA 600MG-10000 TIER 5 PA - FOR NEW STARTS ONLY QL (5PER 21 DAYS OVER TIME)

HEXALEN 50 MG CAPSULE TIER 5

hydrocodoneacetaminophen 25-325 mgtablet


hydrocortisone (1 oint (g) 1 cream(g))

TIER 2

IMFINZI (120 MG24 ML VIAL 500 MG10 MLVIAL)


IMLYGIC (1 MILLION PFUML VIAL 100MILLION PFUML VL)


INVIRASE 200 MG CAPSULE TIER 3 QL (300 PER 30 DAYS) MO

ISTODAX 10 MG KIT TIER 5 BvD

JEVTANA 60 MG15 ML KIT TIER 5 BvD

KADCYLA (100 MG VIAL 160 MG VIAL) TIER 5 PA - FOR NEW STARTS ONLY

KEYTRUDA 100 MG4 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

KYPROLIS (10 MG VIAL 30 MG VIAL 60 MGVIAL)


lansoprazole 15 mg capsule dr TIER 2 MO

LARTRUVO (190 MG19 ML VIAL 500 MG50ML VIAL)


leucovorin calcium (50 mg vial 100 mg vial200 mg vial 350 mg vial 500 mg vial)

TIER 2 BvD

levetiracetam 500 mg5ml vial TIER 2

levoleucovorin calcium (10 mgml vial 50mg vial 175 mg vial)

TIER 5 BvD

LIBTAYO 350 MG7 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY


LUMOXITI 1 MG VIAL TIER 5 BvD

LUPRON DEPOT-PED (1125 MG KIT 15 MGKIT 30 MG 3MO KIT)

TIER 5

LYNPARZA 50 MG CAPSULE TIER 5 PA - FOR NEW STARTS ONLY LA

MARQIBO KIT TIER 5 PA - FOR NEW STARTS ONLY

meclizine hcl 125 mg tablet TIER 2


81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

melphalan hcl 50 mg vial TIER 5 BvD

methotrexate sodiumpf 1 g vial TIER 2

metipranolol 03 drops TIER 2 MO

mitoxantrone hcl 2 mgml vial TIER 2 BvD MO

multivit-mins60iron fumfolic 27 mg-1 mgtablet

TIER 2

MYLOTARG 45 MG VIAL TIER 5 BvD

NORVIR 100 MG SOFTGEL CAP TIER 3 MO

NULOJIX 250 MG VIAL TIER 5 BvD

NUPLAZID 17 MG TABLET TIER 5 PA - FOR NEW STARTS ONLY LA

ONCASPAR 3750 UNIT5 ML VIAL TIER 5 BvD

ONIVYDE 43 MG10 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

OPDIVO (40 MG4 ML VIAL 100 MG10 MLVIAL 240 MG24 ML VIAL)


OTEZLA STARTER PACK TIER 5 PA

oxaliplatin (50 mg10ml vial 50 mg vial100mg20ml vial 100 mg vial 200mg40mlvial)

TIER 4 BvD

oxycodone hclacetaminophen 5-3255 mlsolution


paclitaxel 6 mgml vial TIER 4 BvD

pen needle diabetic remover anddisposal unit (pen 31 gx316 dis needlepen 32gx 532 dis needle)

TIER 2 MO

PENTACEL DTAP-IPV COMPONENT VL TIER 3

PENTACEL VIAL KIT TIER 3

PERJETA 420 MG14 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

phenytoin sodium (50 mgml syringe 50mgml ampul 50 mgml vial)

TIER 2 BvD

PNEUMOVAX 23 (23 SYRINGE 23 VIAL) TIER 3

pnv no118iron fumaratefa 29 mg-1 mgtab chew

TIER 2 MO

POLIVY (30 MG VIAL 140 MG VIAL) TIER 5 PA - FOR NEW STARTS ONLY

PORTRAZZA 800 MG50 ML VIAL TIER 5 BvD

POTELIGEO 20 MG5 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

prenatal plus iron tablet TIER 2 MO


82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

PREVNAR 13 SYRINGE TIER 3

prochlorperazine edisylate 5 mgml vial TIER 2

PROGRAF 5 MGML AMPULE TIER 3 BvD

PROLEUKIN 22 MILLION UNIT VIAL TIER 5 BvD

PUREFE PLUS CAPSULE TIER 2

ranitidine hcl 150 mg tablet TIER 2 MO


RETROVIR 200 MG20 ML VIAL TIER 3

ribavirin 400 mg tablet TIER 2 PA

RITUXAN (100 MG10 ML VIAL 500 MG50ML VIAL)


romidepsin 10 mg2 ml vial TIER 5 BvD

RUXIENCE (100 MG10 ML VIAL 500 MG50ML VIAL)


SIGNIFOR LAR (10 MG KIT 10 MG VIAL 30MG VIAL 30 MG KIT)

TIER 5 PA

SIMULECT 20 MG VIAL TIER 4 BvD


SPRAVATO (56 MG PACK 84 MG PACK) TIER 5 PA - FOR NEW STARTS ONLY

SYLVANT (100 MG VIAL 400 MG VIAL) TIER 5 PA - FOR NEW STARTS ONLY

TANZEUM (30 MG PEN 50 MG PEN) TIER 3 MO

TECENTRIQ 1200 MG20 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

TEMODAR 100 MG VIAL TIER 5 BvD

thiotepa 15 mg vial TIER 5 BvD

tobramycinnebulizer 300 mg5ml ampul-neb

TIER 5 PA

topotecan hcl (4 mg4 ml vial 4 mg vial) TIER 3 BvD

TREANDA (25 MG VIAL 100 MG VIAL) TIER 5 PA - FOR NEW STARTS ONLY

TRELEGY ELLIPTA 200-625-25 TIER 3 QL (60 PER 30 DAYS OVER TIME)

triamterenehydrochlorothiazid 50 mg-25mg capsule

TIER 2 MO

TROGARZO 200 MG133 ML VIAL TIER 5 BvD

UNITUXIN 175 MG 5 ML VIAL TIER 5 PA - FOR NEW STARTS ONLY

valproic acid (as sodium salt) 500 mg5mlvial

TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

VELCADE 35 MG VIAL TIER 5 BvD

VIMPAT 200 MG20 ML VIAL TIER 4 PA - FOR NEW STARTS ONLY QL(200 PER 5 DAYS)

VYXEOS 44 MG-100 MG VIAL TIER 5 BvD

YERVOY (50 MG10 ML VIAL 200 MG40 MLVIAL)


YONDELIS 1 MG VIAL TIER 5 PA - FOR NEW STARTS ONLY

ZALTRAP (100 MG4 ML VIAL 200 MG8 MLVIAL)


ZERIT 1 MGML SOLUTION TIER 3 MO

ZMAX 2 G60 ML ORAL SUSPENSION TIER 3 QL (60 PER 30 DAYS)

ZOLADEX (36 MG IMPLANT SYRN 108 MGIMPLANT SYRN)

TIER 5 BvD

zoledronic acid 4 mg vial TIER 4 MO

zoledronic acid 4 mg5 ml vial TIER 4 BvD MO

zoledronic acid in mannitol and water forinjection (acidmannitol-water 5 mg100mlpggybk btl acidmannitol-water 5mg100ml piggyback)

TIER 4

ZOMETA 4 MG100 ML INJECTION TIER 5 BvD

ZYPREXA RELPREVV (300 MG VL KIT 405 MGVL KIT)



84

Index of Drugs

009 sodium chloride 55

Aabacavir sulfate 34abacavir sulfatelamivudine 34abacavir sulfatelamivudinezidovudine 34ABELCET 18ABILIFY MAINTENA 30abiraterone acetate 21acamprosate calcium 5acarbose 37acebutolol hcl 44acetaminophen with codeine phosphate 3acetazolamide 49acetylcysteine 77acitretin 54ACTHIB 69ACTIMMUNE 68acyclovir 36acyclovir sodium 36ADACEL TDAP 69adapalene 54adefovir dipivoxil 32ADEMPAS 77AFINITOR 24AFINITOR DISPERZ 24AIMOVIG AUTOINJECTOR 19albendazole 27albuterol 90mcg hfa inhaler (genericproair) 76albuterol 90mcg hfa inhaler (genericproventil) 76albuterol 90mg hfa inhaler (generic proair) 76albuterol sulfate 76alclometasone dipropionate 60alcohol 70 pads 72alcohol antiseptic pads 72ALECENSA 24alendronate sodium 71

alfuzosin hcl 60ALIMTA 79ALINIA 27ALIQOPA 79aliskiren hemifumarate 45allopurinol 19ALORA 63alosetron hcl 58ALPHAGAN P 74alprazolam 36ALUNBRIG 22amantadine hcl 28AMBISOME 18ambrisentan 77amifostine crystalline 79amikacin sulfate 5amiloride hcl 49amiloride hclhydrochlorothiazide 46AMINOSYN II 55AMINOSYN-HBC 57AMINOSYN-PF 55amiodarone hcl 44AMITIZA 58amitriptyline hcl 17amitriptyline hclchlordiazepoxide 15amlodipine besylate 45amlodipine besylatebenazepril hcl 46amlodipine besylateolmesartanmedoxomil 46amlodipine besylatevalsartan 46amlodipinebesylatevalsartanhydrochlorothiazide 46ammonium lactate 54amoxapine 17amoxicillin 8amoxicillinpotassium clavulanate 9amphotericin b 18ampicillin sodium 9ampicillin sodiumsulbactam sodium 9ampicillin trihydrate 9ANADROL-50 63

85

anagrelide hcl 41anastrozole 24ANDRODERM 63ANORO ELLIPTA 77APOKYN 28aprepitant 18APTIOM 1314APTIVUS 35ARCALYST 68aripiprazole 30ARISTADA 30ARISTADA INITIO 30arsenic trioxide 79ARZERRA 79aspirindipyridamole 42ASTAGRAF XL 67atazanavir sulfate 35atenolol 44atenololchlorthalidone 46atomoxetine hcl 52atorvastatin calcium 50atovaquone 27atovaquoneproguanil hcl 27ATRIPLA 33ATROVENT HFA 75AUBAGIO 53AVANDIA 37AVASTIN 79AVEED 63AVITA 54AVONEX 53AVONEX PEN 53AYVAKIT 22azacitidine 79azathioprine 67azathioprine sodium 79azelastine hcl 7375azithromycin 10AZOPT 74aztreonam 8

Bbacitracin 6bacitracinpolymyxin b sulfate 72baclofen 32balsalazide disodium 70BALVERSA 22BANZEL 14BAQSIMI 39BARACLUDE 32BAVENCIO 79BCG VACCINE (TICE STRAIN) 69BELEODAQ 79benazepril hcl 43benazepril hclhydrochlorothiazide 46BENDEKA 79benztropine mesylate 28BESPONSA 79betamethasone dipropionate 61betamethasone dipropionatepropyleneglycol 61betamethasone valerate 61BETASERON 53betaxolol hcl 4474bethanechol chloride 60BEVESPI AEROSPHERE 77bexarotene 27BEXSERO 69bicalutamide 21BICILLIN C-R 9BICILLIN L-A 9BIKTARVY 33BILTRICIDE 27bisoprolol fumarate 44bisoprolol fumaratehydrochlorothiazide 46BIVIGAM 68bleomycin sulfate 79BLEPH-10 11BLINCYTO 79BOOSTRIX TDAP 69bortezomib 79

86

bosentan 77BOSULIF 24BRAFTOVI 24BRILINTA 42brimonidine tartrate 74BRIVIACT 1179bromfenac sodium 73bromocriptine mesylate 28BRUKINSA 22budesonide 7175bumetanide 49buprenorphine hcl 5buprenorphine hclnaloxone hcl 5bupropion hcl 515buspirone hcl 36busulfan 79butalbitalacetaminophencaffeinecodeinephosphate 3

Ccabergoline 66CABOMETYX 24calcipotriene 54calcitoninsalmonsynthetic 71calcitriol 71calcium acetate 60CALQUENCE 24candesartan cilexetil 43candesartan cilexetilhydrochlorothiazide 47CAPLYTA 30CAPRELSA 24captopril 43captoprilhydrochlorothiazide 47CARBAGLU 59carbamazepine 14carbidopa 28carbidopalevodopa 29carbidopalevodopaentacapone 28CARIMUNE NF NANOFILTERED 79carisoprodol 78carteolol hcl 74

carvedilol 44caspofungin acetate 18CAYSTON 76cefaclor 7cefadroxil 7cefazolin sodium 7cefazolin sodiumdextrose iso-osmotic 7cefdinir 7cefepime hcl 7cefepime hcl in dextrose 5 in water 7cefepime hcl in iso-osmotic dextrose 7cefotaxime sodium 79cefoxitin sodium 7cefoxitin sodiumdextrose iso-osmotic 7cefpodoxime proxetil 7cefprozil 7ceftazidime 8ceftazidime in dextrose 5 and water 8ceftriaxone sodium 8ceftriaxone sodium in iso-osmotic dextrose 8cefuroxime axetil 8cefuroxime sodium 8celecoxib 2CELONTIN 12cephalexin 8CHANTIX 5chlorhexidine gluconate 54chloroquine phosphate 27chlorothiazide 49chlorpromazine hcl 2979chlorthalidone 49chlorzoxazone 78cholestyramine (with sugar) 50cholestyramineaspartame 50ciclopirox 18ciclopirox olamine 18cilostazol 42CIMDUO 33cimetidine 5879cimetidine hcl 58cinacalcet hcl 71

87

ciprofloxacin 10ciprofloxacin hcl 10ciprofloxacin lactate 79ciprofloxacin lactatedextrose 5 in water 10ciprofloxacinciprofloxacin hcl 10citalopram hydrobromide 16clarithromycin 10clemastine fumarate 75clindamycin hcl 6clindamycin phosphate 6clobazam 12clobetasol propionate 61clobetasol propionateemollient base 61clofarabine 79clomipramine hcl 17clonazepam 37clonidine 42clonidine hcl 4252clopidogrel bisulfate 42clorazepate dipotassium 37clotrimazole 1879clotrimazolebetamethasone dipropionate 54clozapine 31codeine sulfate 3colchicine 19COLCRYS 19colesevelam hcl 50colestipol hcl 50colistin (as colistimethate sodium) 6COMBIPATCH 63COMBIVENT RESPIMAT 77COMETRIQ 24COMPLERA 33COPIKTRA 22CORLANOR 47cortisone acetate 61COTELLIC 25COUMADIN 40CREON 59CRIXIVAN 35cromolyn sodium 587377

cyclobenzaprine hcl 78cyclophosphamide 21CYCLOSET 37cyclosporine 6779cyclosporine modified 67cyproheptadine hcl 75CYRAMZA 80CYSTADANE 59CYSTAGON 60CYSTARAN 73

Ddactinomycin 80dalfampridine 53DALIRESP 77danazol 63dantrolene sodium 32dapsone 20DAPTACEL DTAP 69daptomycin 6DARZALEX 80DAURISMO 25decitabine 80deferasirox 5556DELSTRIGO 33demeclocycline hcl 11DEMSER 47DENAVIR 36DEPO-PROVERA 65DESCOVY 35desipramine hcl 17desloratadine 75desmopressin acetate 62desmopressin acetate (non-refrigerated) 62desogestrel-ethinyl estradiol 63desogestrel-ethinyl estradiolethinylestradiol 63desonide 61desoximetasone 61desvenlafaxine 16desvenlafaxine succinate 16

88

dexamethasone 61dexamethasone sodium phosphate 73dexmethylphenidate hcl 52dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 52dextroamphetamine sulfate 52dextrose 10 in water 56dextrose 25 and 045 sodium chloride 56dextrose 5 and 02 sodium chloride 56dextrose 5 and 03 sodium chloride 57dextrose 5 and 045 sodium chloride 56dextrose 5 and 09 sodium chloride 56dextrose 5 in water 56diazepam 1237diazoxide 39diclofenac potassium 2diclofenac sodium 25473dicloxacillin sodium 9dicyclomine hcl 57didanosine 34diflorasone diacetate 61diflunisal 2digoxin 47dihydroergotamine mesylate 20DILANTIN 14DILANTIN-125 14diltiazem hcl 45DIPENTUM 70diphenoxylate hclatropine sulfate 58DIPHTHERIA-TETANUS TOXOIDS-PED 69dipyridamole 42disopyramide phosphate 44disulfiram 5divalproex sodium 12docetaxel 80dofetilide 44donepezil hcl 14DOPTELET 41dorzolamide hcl 74dorzolamide hcltimolol maleate 74DOVATO 35

doxazosin mesylate 43doxepin hcl 17doxercalciferol 71doxycycline hyclate 11doxycycline monohydrate 11DRIZALMA SPRINKLE 53dronabinol 18DROXIA 22duloxetine hcl 53dutasteride 60

EEES 400 10econazole nitrate 18EDURANT 33efavirenz 33efavirenzemtricitabinetenofovir disoproxilfumarate 33efavirenzlamivudinetenofovir disoproxilfumarate 33ELIGARD 66ELIQUIS 40ELITEK 80EMCYT 22EMEND 18EMPLICITI 80EMSAM 15emtricitabine 34emtricitabinetenofovir disoproxil fumarate 34EMTRIVA 34enalapril maleate 43enalapril maleatehydrochlorothiazide 47ENBREL 67ENBREL SURECLICK 67ENGERIX-B ADULT 69ENGERIX-B PEDIATRIC-ADOLESCENT 69enoxaparin sodium 41entacapone 28entecavir 32ENTRESTO 47ENVARSUS XR 67

89

EPCLUSA 3280EPIDIOLEX 11epinephrine 76EPIVIR HBV 32eplerenone 49ERAXIS (WATER DILUENT) 18ergoloid mesylates 14ergotamine tartratecaffeine 20ERIVEDGE 25ERLEADA 21erlotinib hcl 25ertapenem sodium 8ERWINAZE 80ERYTHROCIN LACTOBIONATE 10ERYTHROCIN STEARATE 10erythromycin base 10erythromycin base in ethanol 10erythromycin basebenzoyl peroxide 6erythromycin ethylsuccinate 10ESBRIET 77escitalopram oxalate 16estradiol 64estradiolnorethindrone acetate 64estropipate 80ethambutol hcl 20ethinyl estradioldrospirenone 64ethosuximide 12ethynodiol diacetate-ethinyl estradiol 64etidronate disodium 80etodolac 2everolimus 2567EVOTAZ 35exemestane 24EXTAVIA 53ezetimibe 50ezetimibesimvastatin 50

Ffamotidine 5880FANAPT 30FARYDAK 25

felbamate 13felodipine 45fenofibrate 50fenofibrate nanocrystallized 50fenofibratemicronized 50fentanyl 2fentanyl citrate 3FETZIMA 16finasteride 60FINTEPLA 11FIRMAGON 66flecainide acetate 44FLOVENT DISKUS 75FLOVENT HFA 75fluconazole 18fluconazole in dextrose iso-osmotic 18fluconazole in sodium chloride iso-osmotic 18flucytosine 19fludrocortisone acetate 61FLULAVAL QUAD 2018-2019 80flunisolide 75fluocinolone acetonide 61fluocinolone acetonide oil 74fluocinonide 6180fluocinonideemollient base 61fluoride (sodium) 56FLUORITAB 56fluorometholone 73fluorouracil 225480fluoxetine hcl 16fluphenazine decanoate 29fluphenazine hcl 29flurbiprofen 2flurbiprofen sodium 73flutamide 21fluticasone propionate 617580fluticasone propionatesalmeterolxinafoate 7778fluvoxamine maleate 16FLUZONE QUAD 2018-2019 80FOLOTYN 80

90

fondaparinux sodium 41FORTEO 71fosamprenavir calcium 35fosfomycin tromethamine 6fosinopril sodium 43fosinopril sodiumhydrochlorothiazide 47fosphenytoin sodium 80FRAGMIN 41FREAMINE HBC 56fulvestrant 80furosemide 49FUZEON 35FYCOMPA 13

Ggabapentin 12GABITRIL 12GAMMAGARD LIQUID 68GAMMAGARD S-D 68GAMUNEX-C 6880GARDASIL 9 69gauze bandage 72GAVRETO 24GAZYVA 80gemcitabine hcl 80gemfibrozil 50GENOTROPIN 62gentamicin sulfate 6GENVOYA 33GILENYA 53GILOTRIF 25glatiramer acetate 53GLEOSTINE 21glimepiride 37glipizide 37glipizidemetformin hcl 3738GLUCAGEN 39GLUCAGON EMERGENCY KIT 39glyburide 38glyburidemicronized 38glyburidemetformin hcl 38

glycopyrrolate 57granisetron hcl 18GRANIX 41griseofulvin ultramicrosize 19griseofulvin microsize 19guanfacine hcl 4252guanidine hcl 20

HHAEGARDA 67HALAVEN 80halobetasol propionate 61haloperidol 29haloperidol decanoate 29haloperidol lactate 2981HARVONI 3281HAVRIX 69heparin sodiumporcine 41HERCEPTIN 81HERCEPTIN HYLECTA 81HETLIOZ 78HEXALEN 81HIBERIX 69HUMALOG 39HUMALOG KWIKPEN U-100 39HUMALOG KWIKPEN U-200 40HUMALOG MIX 50-50 40HUMALOG MIX 50-50 KWIKPEN 40HUMALOG MIX 75-25 40HUMALOG MIX 75-25 KWIKPEN 40HUMATROPE 6263HUMIRA 67HUMIRA PEDIATRIC CROHNS 67HUMIRA PEN 67HUMIRA PEN CROHNS-UC-HS 67HUMIRA PEN PSOR-UVEITS-ADOL HS 67HUMIRA(CF) 67HUMIRA(CF) PEDIATRIC CROHNS 68HUMIRA(CF) PEN 68HUMIRA(CF) PEN CROHNS-UC-HS 68HUMIRA(CF) PEN PSOR-UV-ADOL HS 68

91

HUMULIN 70-30 40HUMULIN 7030 KWIKPEN 40HUMULIN N 40HUMULIN N KWIKPEN 40HUMULIN R 40HUMULIN R U-500 40hydralazine hcl 51hydrochlorothiazide 49hydrocodone bitartrateacetaminophen 381hydrocodoneibuprofen 3hydrocortisone 627181hydrocortisone valerate 62hydrocortisoneacetic acid 74hydrocortisonemineraloilpetrolatumwhite 62hydromorphone hcl 34hydromorphone hclpf 4hydroxychloroquine sulfate 27hydroxyurea 22hydroxyzine hcl 75

Iibandronate sodium 71IBRANCE 25ibuprofen 2icatibant acetate 67ICLUSIG 25icosapent ethyl 50IDHIFA 22imatinib mesylate 25IMBRUVICA 25IMFINZI 81imipenemcilastatin sodium 8imipramine hcl 17imipramine pamoate 17imiquimod 54IMLYGIC 81IMOVAX RABIES VACCINE 69INCRELEX 63INCRUSE ELLIPTA 75indapamide 49

indomethacin 2INFANRIX DTAP 69INLYTA 25INQOVI 22INREBIC 22insulin pen needles 72insulin syringe 03 ml 72insulin syringe 05 ml 72insulin syringe 1 ml 72INTELENCE 34INTRALIPID 56INTRON A 32INVEGA SUSTENNA 30INVEGA TRINZA 30INVIRASE 3581INVOKAMET 38INVOKAMET XR 38INVOKANA 38IPOL 69ipratropium bromide 75ipratropium bromidealbuterol sulfate 78irbesartan 43irbesartanhydrochlorothiazide 47IRESSA 25ISENTRESS 33ISENTRESS HD 33isoniazid 20isosorbide dinitrate 51isosorbide mononitrate 51isotretinoin 54isradipine 45ISTODAX 81itraconazole 19ivermectin 27IXIARO 69

JJAKAFI 25JANUMET 38JANUMET XR 38JANUVIA 38

92

JARDIANCE 38JENTADUETO 38JENTADUETO XR 38JEVTANA 81JULUCA 35

KKADCYLA 81KALETRA 35KALYDECO 76ketoconazole 19ketoprofen 2ketorolac tromethamine 273KEVZARA 68KEYTRUDA 81KINERET 68KINRIX 69KISQALI 25KLOR-CON M15 56KORLYM 62KOSELUGO 25KUVAN 59KYPROLIS 81

Llabetalol hcl 44LACRISERT 73lactulose 58lamivudine 3234lamivudinezidovudine 34lamotrigine 13lansoprazole 5981LANTUS 40LANTUS SOLOSTAR 40lapatinib ditosylate 25LARTRUVO 81latanoprost 74LATUDA 30LAZANDA 4leflunomide 69LENVIMA 25

letrozole 24leucovorin calcium 2381LEUKERAN 21LEUKINE 41leuprolide acetate 66levalbuterol hcl 76levalbuterol tartrate 76levetiracetam 1281levobunolol hcl 74levofloxacin 10levofloxacindextrose 5 in water 10levoleucovorin calcium 81levonorgestrelethinyl estradiol 64levothyroxine sodium 65LEVOXYL 65LEXIVA 35LIBTAYO 81lidocaine 4lidocaine hcl 4lidocaineprilocaine 4lindane 27linezolid 6linezolid in 09 sodium chloride 6linezolid in dextrose 5 in water 6liothyronine sodium 65lisinopril 43lisinoprilhydrochlorothiazide 47lithium carbonate 37lithium citrate 37LONSURF 22loperamide hcl 5881lopinavirritonavir 35lorazepam 37LORBRENA 24losartan potassium 43losartan potassiumhydrochlorothiazide 47loteprednol etabonate 74lovastatin 50loxapine succinate 29LUMOXITI 81LUPRON DEPOT 66

93

LUPRON DEPOT-PED 6681LYNPARZA 2581LYSODREN 23

MM-M-R II VACCINE 69magnesium sulfate 56maprotiline hcl 16MARPLAN 15MARQIBO 81MATULANE 21MAVYRET 32MAXIDEX 74meclizine hcl 1781meclofenamate sodium 2medroxyprogesterone acetate 65mefloquine hcl 27megestrol acetate 65MEKINIST 26MEKTOVI 26meloxicam 2melphalan hcl 82memantine hcl 15MENACTRA 69MENEST 64MENQUADFI 69MENVEO A-C-Y-W-135-DIP 69meperidine hcl 4meprobamate 36mercaptopurine 22meropenem 8meropenem in 09 sodium chloride 8mesalamine 70mesalamine with cleansing wipes 70MESNEX 27metaproterenol sulfate 76metformin hcl 38methadone hcl 23methazolamide 74methenamine hippurate 6methimazole 67

methocarbamol 78methotrexate sodium 68methotrexate sodiumpf 6882methoxsalen 54methyclothiazide 49methyldopa 42methyldopahydrochlorothiazide 48methylphenidate hcl 5253methylprednisolone 62methyltestosterone 63metipranolol 82metoclopramide hcl 17metolazone 50metoprolol succinate 4445metoprolol tartrate 45metoprolol tartratehydrochlorothiazide 48METRO IV 6metronidazole 654metronidazole in sodium chloride 6metyrosine 48mexiletine hcl 44miconazole nitrate 19midodrine hcl 42miglitol 3839miglustat 59minocycline hcl 11minoxidil 51mirtazapine 15misoprostol 58mitoxantrone hcl 82modafinil 78moexipril hcl 43molindone hcl 29mometasone furoate 62montelukast sodium 75morphine sulfate 34MOVANTIK 58moxifloxacin hcl 10MULTAQ 44multivitamin-minerals no60ferrousfumaratefolic acid 82

94

mupirocin 6mycophenolate mofetil 68mycophenolate sodium 68MYLOTARG 82MYRBETRIQ 59

Nnabumetone 2nadolol 45nafcillin in dextrose iso-osmotic 9nafcillin sodium 9naloxone hcl 5naltrexone hcl 5naproxen 2NARCAN 5NATACYN 19nateglinide 39NATPARA 71NAYZILAM 4nefazodone hcl 16neomycin sulfate 6neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 73neomycin sulfatebacitracinpolymyxin b 73neomycin sulfatepolymyxin bsulfategramicidin d 73neomycin sulfatepolymyxin bsulfatehydrocortisone 7374neomycinpolymyxin bsulfatedexamethasone 73NEPHRAMINE 56NERLYNX 26NEULASTA 41NEULASTA ONPRO 41NEUPOGEN 41nevirapine 34NEXAVAR 26niacin 51nicardipine hcl 45NICOTROL 5NICOTROL NS 5

nifedipine 45nilutamide 21NINLARO 23nitisinone 59nitrofurantoin macrocrystal 6nitrofurantoin monohydratemacrocrystals 6nitroglycerin 51NITROSTAT 51nizatidine 58NORDITROPIN FLEXPRO 63norethindrone 65norethindrone acetate 65norethindrone acetate-ethinyl estradiol 64norethindrone acetate-ethinylestradiolferrous fumarate 64norethindrone-ethinyl estradiol 64norgestimate-ethinyl estradiol 64norgestrel-ethinyl estradiol 64NORTHERA 43nortriptyline hcl 17NORVIR 3582NOVOLIN 70-30 40NOVOLIN N 40NOVOLIN R 40NOVOLOG 40NOVOLOG FLEXPEN 40NOVOLOG MIX 70-30 40NOVOLOG MIX 70-30 FLEXPEN 40NUBEQA 21NUEDEXTA 53NULOJIX 82NUPLAZID 3082NUTROPIN AQ NUSPIN 63nystatin 19nystatintriamcinolone acetonide 19

Ooctreotide acetate 66ODEFSEY 34ODOMZO 26OFEV 78

95

ofloxacin 10olanzapine 30olmesartan medoxomil 43olmesartanmedoxomilhydrochlorothiazide 48olopatadine hcl 73omega-3 acid ethyl esters 51omeprazole 59ONCASPAR 82ondansetron 18ondansetron hcl 18ONIVYDE 82OPDIVO 82ORFADIN 59ORKAMBI 76oseltamivir phosphate 36OSPHENA 65OTEZLA 6982oxaliplatin 82oxandrolone 63OXBRYTA 42oxcarbazepine 14OXTELLAR XR 14oxybutynin chloride 60oxycodone hcl 34oxycodone hclacetaminophen 482oxycodone hclaspirin 4OXYCONTIN 3OZEMPIC 39

PPACERONE 44paclitaxel 82paliperidone 31PANRETIN 27pantoprazole sodium 59paricalcitol 71paromomycin sulfate 6paroxetine hcl 16PASER 20PAXIL 16

PEDIARIX 69PEDVAXHIB 69peg 3350sod sulfsod bicarbsodchloridepotassium chloride 58PEGANONE 14PEGASYS 32PEGASYS PROCLICK 33PEMAZYRE 23pen needle diabetic 72pen needle diabetic disposable safety 72pen needle diabetic remover and disposalunit 82pen needle diabetic safety 72penicillamine 60penicillin g potassium 9penicillin g sodium 9penicillin v potassium 9PENTACEL 82PENTACEL ACTHIB COMPONENT 69PENTACEL DTAP-IPV COMPONENT 82pentamidine isethionate 27PENTASA 70pentoxifylline 48perindopril erbumine 43PERJETA 82permethrin 27perphenazine 17perphenazineamitriptyline hcl 15PERSERIS 31phenelzine sulfate 15phenobarbital 12PHENYTEK 14phenytoin 14phenytoin sodium 82phenytoin sodium extended 14PHOSPHOLINE IODIDE 74PICATO 54PIFELTRO 34pilocarpine hcl 5474pimecrolimus 55pimozide 29

96

pindolol 45pioglitazone hcl 39piperacillin sodiumtazobactam sodium 9PIQRAY 24piroxicam 2PLEGRIDY 53PLEGRIDY PEN 53PNEUMOVAX 23 82podofilox 55POLIVY 82polymyxin b sulfatetrimethoprim 73POMALYST 21PORTRAZZA 82potassium chloride 5657potassium chloride in 09 sodium chloride 56potassium chloride in 5 dextrose inwater 5657potassium chloride in dextrose 5 and 09 sodium chloride 57potassium chloride in dextrose 5 -02 sodium chloride 57potassium chloride in dextrose 5 -045 sodium chloride 56potassium chloride in dextrose 5 and 03 sodium chloride 57potassium chloride in lactated ringers and 5 dextrose 56potassium citrate 60POTELIGEO 82PRADAXA 41pramipexole di-hcl 28pravastatin sodium 50praziquantel 27prazosin hcl 43prednisolone 62prednisolone acetate 74prednisolone sodium phosphate 6274prednisone 62pregabalin 53PREMARIN 64PREMASOL 57

PREMPHASE 65PREMPRO 65PRENATAL PLUS IRON TABLET 57prenatal plus iron tablet 82prenatal vits with calcium 118ferrousfumaratefolic acid 82PREVNAR 13 83PREZCOBIX 35PREZISTA 3536PRIFTIN 20primaquine phosphate 27primidone 13probenecid 19probenecidcolchicine 19prochlorperazine 17prochlorperazine edisylate 83prochlorperazine maleate 17PROCRIT 4142progesterone micronized 65PROGRAF 6883PROLEUKIN 83PROLIA 71PROMACTA 42promethazine hcl 1775propafenone hcl 44proparacaine hcl 73propranolol hcl 45propranolol hclhydrochlorothiazide 48propylthiouracil 67PROQUAD 69protriptyline hcl 17PULMICORT FLEXHALER 75PULMOZYME 78PUREFE PLUS 83PURIXAN 22pyrazinamide 21pyridostigmine bromide 20pyrimethamine 27

QQINLOCK 26

97

QUADRACEL DTAP-IPV 69quetiapine fumarate 31quinapril hcl 43quinapril hclhydrochlorothiazide 48quinidine gluconate 44quinidine sulfate 44QVAR REDIHALER 75

RRABAVERT 70raloxifene hcl 65ramelteon 79ramipril 44RANEXA 48ranitidine hcl 5883ranolazine 48rasagiline mesylate 29REBIF 54REBIF REBIDOSE 54RECOMBIVAX HB 70RECTIV 55REGRANEX 55RELENZA 36RELISTOR 58RENAGEL 60repaglinide 39REPATHA PUSHTRONEX 51REPATHA SURECLICK 51REPATHA SYRINGE 51RESCRIPTOR 3483RESTASIS 73RESTASIS MULTIDOSE 73RETACRIT 42RETEVMO 23RETROVIR 83REVLIMID 21REXULTI 31REYATAZ 36ribavirin 3383RIDAURA 69rifabutin 20

rifampin 21RIFATER 21riluzole 53rimantadine hcl 36risedronate sodium 71RISPERDAL CONSTA 31risperidone 31ritonavir 36RITUXAN 83rivastigmine 14rivastigmine tartrate 15rizatriptan benzoate 20romidepsin 83ropinirole hcl 28rosuvastatin calcium 50ROTARIX 70ROTATEQ 70ROZLYTREK 23RUBRACA 23RUCONEST 67rufinamide 14RUKOBIA 35RUXIENCE 83RYDAPT 23

SSAIZEN 63SAIZEN-SAIZENPREP 63SANTYL 55SAPHRIS 31sapropterin dihydrochloride 59SAVELLA 53scopolamine 18SECUADO 31selegiline hcl 29selenium sulfide 55SELZENTRY 35SEREVENT DISKUS 76SEROSTIM 63sertraline hcl 16sevelamer carbonate 60

98

sevelamer hcl 60SHINGRIX 70SIGNIFOR 66SIGNIFOR LAR 83sildenafil citrate 77silver sulfadiazine 11SIMULECT 83simvastatin 50sirolimus 68SIRTURO 21SIVEXTRO 7sodium chloride 045 57sodium chloride irrigating solution 5783sodium chloridesodiumbicarbonatepotassium chloridepeg 58sodium phenylbutyrate 59sodium polystyrene sulfonate 57sodium polystyrene sulfonatesorbitolsolution 57SOLTAMOX 22SOMATULINE DEPOT 66SOMAVERT 66sotalol hcl 44SPIRIVA 76SPIRIVA RESPIMAT 76spironolactone 49spironolactonehydrochlorothiazide 48SPRAVATO 83SPRITAM 12SPRYCEL 26SPS 57SSD 11stavudine 34STELARA 55STIVARGA 26streptomycin sulfate 6STRIBILD 33STRIVERDI RESPIMAT 76SUCRAID 59sucralfate 59sulfacetamide sodium 11

sulfacetamide sodiumprednisolone sodiumphosphate 73sulfadiazine 11sulfamethoxazoletrimethoprim 11sulfasalazine 71sulindac 2sumatriptan 20sumatriptan succinate 20SUTENT 26SYLATRON 23SYLVANT 83SYMDEKO 76SYMFI 33SYMFI LO 34SYMLINPEN 120 39SYMLINPEN 60 39SYMPAZAN 13SYMTUZA 36SYNAREL 66SYNJARDY 39SYNJARDY XR 39SYNRIBO 23SYNTHROID 66SYPRINE 57syringe with needle insulin safety 05 ml 72syringe with needle insulin safety 1 ml 72syringe with needledisposableinsulin 1 ml 72syringe with needleinsulin03 ml 72

TTABLOID 22TABRECTA 23tacrolimus 5568tadalafil 77TAFINLAR 26TAGRISSO 26TALTZ AUTOINJECTOR 55TALTZ AUTOINJECTOR (2 PACK) 55TALTZ AUTOINJECTOR (3 PACK) 55TALTZ SYRINGE 55TALTZ SYRINGE (2 PACK) 55

99

TALTZ SYRINGE (3 PACK) 55TALZENNA 26TAMIFLU 36tamoxifen citrate 22tamsulosin hcl 60TANZEUM 83TARGRETIN 27TASIGNA 26TAVALISSE 42tazarotene 55TAZORAC 55TAZVERIK 23TDVAX 70TECENTRIQ 83TECFIDERA 54TEFLARO 8TEGRETOL XR 14TEKTURNA HCT 48telmisartan 43temazepam 78TEMIXYS 33TEMODAR 83TENIVAC 70tenofovir disoproxil fumarate 34terazosin hcl 43terbinafine hcl 19terbutaline sulfate 76terconazole 19testosterone 63testosterone cypionate 63tetrabenazine 53tetracycline hcl 11THALOMID 21THEO-24 77theophylline anhydrous 77THIOLA 60THIOLA EC 60thioridazine hcl 29thiotepa 83thiothixene 30tiagabine hcl 13

TIBSOVO 23tigecycline 7timolol maleate 4574TIVICAY 33TIVICAY PD 33tizanidine hcl 32tobramycin 6tobramycin in 0225 sodium chloride 78tobramycin sulfate 6tobramycindexamethasone 73tobramycinnebulizer 83TOLAK 55tolazamide 39tolbutamide 39tolcapone 28tolterodine tartrate 60topiramate 13topotecan hcl 83toremifene citrate 22torsemide 49TOUJEO MAX SOLOSTAR 40TOUJEO SOLOSTAR 40TPN ELECTROLYTES 57TRACLEER 77TRADJENTA 39tramadol hcl 4tramadol hclacetaminophen 4trandolapril 44tranexamic acid 42tranylcypromine sulfate 15TRAVASOL 57travoprost 74trazodone hcl 16TREANDA 83TRECATOR 21TRELEGY ELLIPTA 7883TRELSTAR 66tretinoin 2755triamcinolone acetonide 5462triamterenehydrochlorothiazide 4883triazolam 78

100

TRIDESILON 62trientine hcl 57trifluoperazine hcl 30trifluridine 36trihexyphenidyl hcl 28TRIKAFTA 76trimethoprim 7trimipramine maleate 17TRINTELLIX 16TRIUMEQ 35TROGARZO 83TROPHAMINE 57trospium chloride 60TRULICITY 39TRUMENBA 70TRUVADA 34TUKYSA 23TURALIO 23TWINRIX 70TYBOST 35TYKERB 26TYMLOS 71TYPHIM VI 70

UUNITHROID 66UNITUXIN 83UPTRAVI 77ursodiol 58

Vvalacyclovir hcl 36VALCHLOR 21valganciclovir hcl 32valproic acid 13valproic acid (as sodium salt) (valproatesodium) 1383valsartan 43valsartanhydrochlorothiazide 49VALTOCO 13vancomycin hcl 7

VAQTA 70VARIVAX VACCINE 70VASCEPA 51VELCADE 84VEMLIDY 32VENCLEXTA 26VENCLEXTA STARTING PACK 26venlafaxine hcl 16verapamil hcl 45VERSACLOZ 32VERZENIO 26VICTOZA 2-PAK 39VICTOZA 3-PAK 39VIDEX 34VIDEX EC 34vigabatrin 13VIIBRYD 1617VIMPAT 1484VIRACEPT 36VIRAMUNE 34VIREAD 35VITRAKVI 23VIVITROL 5VIZIMPRO 23voriconazole 19VOSEVI 32VOTRIENT 26VRAYLAR 31VYNDAMAX 49VYNDAQEL 49VYXEOS 84

Wwarfarin sodium 41

XXALKORI 26XARELTO 41XATMEP 68XCOPRI 12XELJANZ 68

101

XELJANZ XR 68XGEVA 71XIFAXAN 7XOFLUZA 70XOLAIR 78XOSPATA 23XPOVIO 2324XTANDI 21XYREM 79

YYERVOY 84YF-VAX 70YONDELIS 84YONSA 21

Zzafirlukast 75zaleplon 78ZALTRAP 84ZARXIO 42ZEJULA 26ZELBORAF 26ZEMAIRA 78ZENPEP 59ZERIT 84zidovudine 35ziprasidone hcl 31ziprasidone mesylate 31ZIRGAN 32ZMAX 84ZOLADEX 84zoledronic acid 84zoledronic acid in mannitol and water forinjection 84ZOLINZA 24zolpidem tartrate 78ZOMETA 84zonisamide 12ZORBTIVE 63ZORTRESS 68

ZOSTAVAX 70ZYCLARA 55ZYDELIG 26ZYKADIA 26ZYPREXA RELPREVV 3184ZYTIGA 21

102

Blue Shield of California Promise Health Plan 601 Potrero Grande Drive Monterey Park CA 91755

H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-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 on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan provides bull 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) bull 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 ancestry religion sex marital status gender gender identity sexual orientation age or disability you can file a grievance with

Blue Shield of California Promise Health Plan 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 800-537-7697 (TDD)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

H5928_19_290A_C 07162019

Language Assistance Notice

English

ATTENTION Language assistance services free of charge are available to you Call 1-800-544-0088

(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1-800-544-0088（TTY711)

한국어 (Korean)

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-544-0088 (TTY

711)번으로 전화해 주십시오

Русский (Russian)

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги

перевода Звоните 1-800-544-0088 (телетайп 711)

Italiano (Italian)

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica

gratuiti Chiamare il numero 1-800-544-0088 (TTY 711)

(Farsi) فارسی

0088-544-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه (TTY 771) تماس

بگیرید

ह िदी (Hindi)

धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-544-0088 (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-

800-544-0088 (TTY 711)

Espantildeol (Spanish)

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica

Llame al 1-800-544-0088 (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 1-800-

544-0088 (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 1-800-544-0088 (TTY 711)

(Arabic) العربية

0088-544-800-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة (711YTT)

ພາສາລາວ (Lao)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-

800-544-0088 (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1-800-544-0088（TTY711）ま

でお電話にてご連絡ください

ภาษาไทย (Thai)

เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-544-0088 (TTY 711)

ਪਜਾਬੀ ਦ (Punjabi)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-544-0088 (TTY 711)

ਤ ਕਾਲ ਕਰ

ខមែរ (Cambodian)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែ រ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ

ទរសពទ 1-800-544-0088 (TTY 711)

Հայերեն (Armenian)

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են տրամադրվել լեզվական

աջակցության ծառայություններ Զանգահարեք 1-800-544-0088 (TTY (հեռատիպ)711)


Blue Shield of California Promise Health Plan is an HMO and an HMO SNP plan with a Medicare contract Enrollment in Blue Shield of California Promise Health Plan depends on contract renewal

11242020

What is the Blue Shield of California Promise Health Plan Formulary

Can the Formulary (drug list) change

Medical Condition

Alphabetical Listing

What are generic drugs

Are there any restrictions on my coverage

What if my drug is not on the Formulary

How do I request an exception to the Blue Shield of California Promise Health Plans Formulary

What do I do before I can talk to my doctor about changing my drugs or requesting an exception

For more information

Blue Shield of California Promise Health Planrsquos Formulary

Legend

List of Covered Drugs


Discrimination is Against the Law

ii

Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take

When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Blue Shield of California Promise Health Plan When it refers to ldquoplanrdquo or ldquoour planrdquo it means Blue Shield Promise AdvantageOptimum Plan Blue Shield Promise AdvantageOptimum Plan 1 Blue Shield Promise AdvantageOptimum Plan 2 Blue Shield Promise Coordinated Choice Plan or Blue Shield Promise TotalDual Plan

This document includes list of the drugs (formulary) for our plan which is current as of For an updated formulary please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages

You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2021 and from time to time during the year

What is the Blue Shield of California Promise Health Plan Formulary A formulary is a list of covered drugs selected by Blue Shield of California Promise Health Plan in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program Blue Shield of California Promise Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a Blue Shield of California Promise Health Plan network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Formulary (drug list) change Most changes in drug coverage happen on January 1 but Blue Shield of California Promise Health Plan may add or remove drugs on the Drug List during the year move them to different cost-sharing tiers or add new restrictions

Changes that can affect you this year In the below cases you will be affected by coverage changes during the year

bull New generic drugs We may immediately remove a brand name drug on our Drug List ifwe are replacing it with a new generic drug that will appear on the same or lower costsharing tier and with the same or fewer restrictions Also when adding the new genericdrug we may decide to keep the brand name drug on our Drug List but immediatelymove it to a different cost-sharing tier or add new restrictions If you are currently takingthat brand name drug we may not tell you in advance before we make that change butwe will later provide you with information about the specific change(s) we have made

o If we make such a change you or your prescriber can ask us to make an exceptionand continue to cover the brand name drug for you The notice we provide you willalso include information on how to request an exception and you can also findinformation in the section below entitled ldquoHow do I request an exception to the BlueShield of California Promise Health Planrsquos Formularyrdquo

bull Drugs removed from the market If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drugrsquos manufacturer removes the drug from the market wewill immediately remove the drug from our formulary and provide notice to members whotake the drug

11242020

iii








11242020

85

iv












v












vi










85

vii


TIER SUPPLY

COST SHARE



Merced County








2 Generic Drugs















$11750 Copay

$11750 Copay

$11750 Copay

$11750 Copay

viii

TIER SUPPLY

COST SHARE


counties


counties

Merced County










$21750 Copay




33 of Blue Shield


rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield




5


5


5


5

ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




iii








11242020

85

iv












v












vi










85

vii


TIER SUPPLY

COST SHARE



Merced County








2 Generic Drugs















$11750 Copay

$11750 Copay

$11750 Copay

$11750 Copay

viii

TIER SUPPLY

COST SHARE


counties


counties

Merced County










$21750 Copay




33 of Blue Shield


rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield




5


5


5


5

ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




iv












v












vi










85

vii


TIER SUPPLY

COST SHARE



Merced County








2 Generic Drugs















$11750 Copay

$11750 Copay

$11750 Copay

$11750 Copay

viii

TIER SUPPLY

COST SHARE


counties


counties

Merced County










$21750 Copay




33 of Blue Shield


rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield




5


5


5


5

ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




v












vi










85

vii


TIER SUPPLY

COST SHARE



Merced County








2 Generic Drugs















$11750 Copay

$11750 Copay

$11750 Copay

$11750 Copay

viii

TIER SUPPLY

COST SHARE


counties


counties

Merced County










$21750 Copay




33 of Blue Shield


rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield




5


5


5


5

ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




vi










85

vii


TIER SUPPLY

COST SHARE



Merced County








2 Generic Drugs















$11750 Copay

$11750 Copay

$11750 Copay

$11750 Copay

viii

TIER SUPPLY

COST SHARE


counties


counties

Merced County










$21750 Copay




33 of Blue Shield


rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield




5


5


5


5

ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




vii


TIER SUPPLY

COST SHARE



Merced County








2 Generic Drugs















$11750 Copay

$11750 Copay

$11750 Copay

$11750 Copay

viii

TIER SUPPLY

COST SHARE


counties


counties

Merced County










$21750 Copay




33 of Blue Shield


rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield




5


5


5


5

ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




viii

TIER SUPPLY

COST SHARE


counties


counties

Merced County










$21750 Copay




33 of Blue Shield


rate

33 of Blue Shield


rate

29 of Blue Shield


rate

33 of Blue Shield




5


5


5


5

ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




ix


TIER SUPPLY

COST SHARE






$0 Copay $0 Copay



$3 Copay $3 Copay

2 Generic Drugs












$47 Copay $47 Copay



x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




x

TIER SUPPLY

COST SHARE













rate




drugs in Tier 5


drugs in Tier 5

xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




xi





$0 Copay


$0 Copay

2 Generic Drugs





contracted rate






contracted rate




contracted rate



contracted rate






xii


TIER SUPPLY

COST SHARE



$0 Copay


$0 Copay

2 Generic Drugs


$0 $130 $360 Copay



$0 $130 $360 Copay




$0 $390 $895 Copay



$0 $390 $895 Copay













LEGENDTIER NAME


2 Generic Drugs





QL Quantity Limit






LA Limited Access


MO Maintenance Drug


1

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

ANALGESICS


TIER 2 MO



TIER 2



TIER 2 MO



TIER 2 MO


TIER 2 PA




TIER 2



TIER 2


TIER 2 MO








2

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS































3

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2






















ANESTHETICS




TIER 2




4

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS

















TIER 2




TIER 4



ANTIBACTERIALS



5

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






TIER 2



TIER 2


TIER 2




TIER 2





TIER 5


TIER 5




TIER 2


TIER 2



TIER 2


TIER 2


6

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2






TIER 2


TIER 2


TIER 2


TIER 2




TIER 3


TIER 3



TIER 4 BvD


TIER 2


TIER 2


7

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2



TIER 2


TIER 2


8

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


TIER 2



TIER 3


TIER 3


TIER 2


TIER 2



TIER 2



TIER 2


TIER 3


9

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2



TIER 2




TIER 4


TIER 2


TIER 2




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2




TIER 2


10

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



SSD 1 CREAM TIER 2


TIER 2



TIER 2


TIER 2


TIER 2



TIER 2


TIER 2


TIER 2

ANTICONVULSANTS






11

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO












TIER 2 MO


TIER 2 MO






TIER 2 MO


TIER 2 MO





12

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 4 MO


TIER 2 MO













TIER 2 MO



TIER 2 MO




PER 30 DAYS)



13

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2 MO


TIER 3 MO



TIER 2 MO





TIER 3 MO


TIER 2 MO


TIER 2 MO





ANTIDEMENTIA AGENTS



TIER 2 MO


TIER 4 MO


14

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO




ANTIDEPRESSANTS


TIER 2 MO


TIER 2 MO



TIER 2 MO









15

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO






TIER 2 MO





TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO




TIER 2 MO




16

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO




TIER 2 MO








TIER 2 MO




ANTIEMETICS



TIER 2


TIER 2 MO



TIER 2


TIER 2 PA


17

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD



TIER 4 PA




TIER 2 BvD


TIER 2 BvD





TIER 5 PA



TIER 2


TIER 2





TIER 2


TIER 2


TIER 2


18

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2


TIER 2



TIER 2




TIER 2


TIER 2



TIER 2


TIER 5 PA








ANTIMIGRAINE AGENTS




19

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 PA




TIER 3












ANTIMYCOBACTERIALS




TIER 2


TIER 2




20

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS







ANTINEOPLASTICS


TIER 3 BvD


TIER 4




















21

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





TIER 2 MO



TIER 3 MO


TIER 2





















22

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2






























23

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










(4 PER 1 DAYS)



















24

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


































25

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



































26

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






ANTIPARASITICS








TIER 3


TIER 2










27

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 2 PA MO


TIER 2 MO


TIER 4 ST MO





TIER 2 MO


TIER 2 MO


TIER 2 MO



28

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




ANTIPSYCHOTICS


TIER 2 MO



TIER 2 MO




TIER 2 MO


TIER 2 MO


TIER 2 BvD MO


TIER 2 BvD



TIER 2 MO


TIER 4 MO





29

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO






























30

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 3 BvD MO


TIER 5 BvD

















TIER 3 MO


TIER 2 MO


31

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO


ANTIVIRALS


















TIER 5 PA


32

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA



TIER 5






















TIER 5


TIER 5


33

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO










TIER 4 MO


TIER 5


TIER 2 MO



TIER 5





TIER 2 MO


TIER 2 MO



TIER 5




34

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5


TIER 2 MO







TIER 3 MO


TIER 5




TIER 5


TIER 5


TIER 3 MO









TIER 3 MO





35

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS














TIER 2 MO







TIER 2 MO

ANXIOLYTICS


TIER 2 MO


TIER 4 PA




36

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO









BIPOLAR AGENTS


TIER 2 MO

















37

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS





































38

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO





















TIER 3 MO



39

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS















TIER 3 MO


TIER 3 MO


TIER 3 MO


TIER 3 MO








TIER 4 MO




40

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3


TIER 2


TIER 3 PA


TIER 4


TIER 2




TIER 2 MO


TIER 3 MO



TIER 2 MO


TIER 5 PA LA



TIER 5 PA







TIER 5 PA


41

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 PA MO


TIER 5 PA LA



TIER 4 PA MO


TIER 3 PA MO






TIER 4 MO





TIER 2 PA MO




TIER 4 MO


TIER 2 MO




TIER 2


42

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA LA


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO



TIER 1 MO


TIER 1 MO


43

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 PA MO


TIER 4 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 1 MO



TIER 2 MO


TIER 1 MO


TIER 2 MO




44

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 1 MO


TIER 1 MO



TIER 2 MO


TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO



TIER 2 MO


TIER 2 MO


TIER 2 MO




45

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 2 MO


TIER 1 MO


TIER 2 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


46

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 1 MO








TIER 1 MO




TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


47

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 1 MO



TIER 2 MO



TIER 2 MO


TIER 1 MO


TIER 3 MO


TIER 3 MO


TIER 2 MO


TIER 3 PA MO


TIER 2 MO


48

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 1 MO




TIER 2 MO



TIER 2 MO



TIER 1 MO


TIER 2


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 2 MO




49

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO



TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO



TIER 2 MO



50

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 4 MO






TIER 4 MO


TIER 2 MO



TIER 1 MO


TIER 2 MO


TIER 2 MO


TIER 3 MO


TIER 3 MO


51

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO


TIER 2 MO



TIER 3 MO



TIER 2 ST MO


TIER 4 ST MO


TIER 3 MO


TIER 3 ST MO


52

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO




TIER 5






TIER 2 MO



TIER 3 MO


TIER 3 PA MO




TIER 5 PA







TIER 5 PA


TIER 5 PA LA


TIER 5 PA LA


53

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA


TIER 5 PA


TIER 5 PA LA










TIER 2



TIER 2







TIER 4



TIER 2



54

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 PA










TIER 4 PA



TIER 2 PA





TIER 2




55

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2


TIER 2 MO








TIER 2


TIER 2 MO


TIER 2



TIER 2



56

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 2




TIER 2



TIER 2


TIER 2


TIER 2











TIER 2




TIER 2 MO



57

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2




TIER 4 PA


TIER 2 MO


TIER 2 MO




TIER 2 MO


TIER 2 MO



TIER 3 MO


TIER 2 MO


TIER 2


TIER 2


TIER 2 MO


58

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 MO





TIER 2 MO




TIER 3 MO




TIER 5 PA LA



TIER 3 PA MO



TIER 5 PA LA




TIER 3 MO



TIER 4 MO


59

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 MO











TIER 2


TIER 3 PA LA MO






TIER 5 PA


TIER 2 MO




TIER 4 MO



TIER 2


60

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2


TIER 3


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


61

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2


TIER 2 MO


TIER 2



TIER 2


TIER 2



TIER 2


TIER 2


TIER 2




TIER 2 MO


TIER 2 MO


TIER 5 PA



TIER 5 PA


62

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 5 PA



TIER 5 PA



TIER 5 PA LA






TIER 3 PA MO



TIER 2



TIER 3 PA MO


TIER 2 PA MO




TIER 2 MO


TIER 2 MO


63

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 2 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 4 PA MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 2 MO


TIER 3 PA MO



64

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 PA MO



TIER 2 MO


TIER 2


TIER 2 MO




TIER 2 MO





TIER 2 MO


TIER 3 MO


TIER 2 MO


65

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 3 MO


TIER 3 MO



TIER 4 MO






TIER 5



TIER 5


TIER 4 BvD MO



TIER 5 PA LA




TIER 5 PA



TIER 5 BvD


66

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 4 BvD MO


TIER 2 BvD MO


TIER 5 PA







TIER 5 PA






TIER 5 PA


67

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS


TIER 5 PA









TIER 2 BvD MO


TIER 4 BvD MO







TIER 2 BvD MO








TIER 5 PA





TIER 5 PA


68

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 5 PA













TIER 3




IPOL VIAL TIER 3


TIER 4









PROQUAD VIAL TIER 3



69

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 3 BvD




TDVAX VIAL TIER 3





TIER 3


TIER 3














TIER 2 MO




70

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 MO






TIER 4 MO


TIER 2 BvD MO









TIER 5 PA LA


TIER 3 MO









71

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS










TIER 2 MO


TIER 2


TIER 2


TIER 2


TIER 2 MO


TIER 2


TIER 2 MO


TIER 2

OPHTHALMIC AGENTS


TIER 2


72

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2


TIER 2


TIER 2


TIER 2


TIER 2


TIER 2





TIER 2


TIER 2







TIER 2





TIER 2


73

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2 MO







TIER 2 MO



TIER 2 MO


TIER 2 MO






TIER 2


74

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 2 PA MO


TIER 3 MO


TIER 3 MO










TIER 2 PA


TIER 2 PA


TIER 2 MO








75

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




MO





TIER 2 BvD MO


TIER 2 MO


TIER 2


TIER 2 PA MO



TIER 2 MO




TIER 2 MO









76

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



TIER 4 PA MO


TIER 3 MO


TIER 2 MO


TIER 5 PA LA








TIER 5 PA LA






TIER 5 PA LA




77

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS




TIER 2 BvD MO




TIER 5 PA










TIER 2 PA











78

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS



Uncategorized








TIER 5 BvD













TIER 5 PA


TIER 2








79

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS








TIER 5 BvD






TIER 2 PA MO


TIER 2 MO





TIER 3 BvD




TIER 5 BvD


TIER 4



TIER 5 PA



TIER 5 BvD



80

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS









TIER 2
















TIER 2 BvD



TIER 5 BvD





TIER 5





81

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS






TIER 2











TIER 4 BvD





TIER 2 MO





TIER 2 BvD



TIER 2 MO






82

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS
















TIER 5 PA










TIER 5 PA





TIER 2 MO




TIER 2 BvD


83

DRUG NAME DRUGTIER

REQUIREMENTSLIMITS












TIER 5 BvD




TIER 4





84

Index of Drugs




85



86




87




88




89




90





91





92





93




94





95




96



QQINLOCK 26

97





98




99



100





Wwarfarin sodium 41


101





102


H5928_19_269A2_C 08302019

Blue

Shi

eld

of C

alifo

rnia

Pro

mise

Hea

lth P

lan

is an

inde

pend

ent l

icen

see

of th

e Bl

ue S

hiel

d A

ssoc

iatio

n A

5124

7-C

MS

(91

8)











H5928_19_290A_C 07162019


English


(TTY 711)



한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی


بگیرید



Hmong (Hmong)


800-544-0088 (TTY 711)



Llame al 1-800-544-0088 (TTY 711)



544-0088 (TTY 711)








800-544-0088 (TTY 711)











ទរសពទ 1-800-544-0088 (TTY 711)






11242020



Medical Condition









Legend




Blue Shield of California Promise Health Plan 2020 ...

Documents

Transcript of Blue Shield of California Promise Health Plan 2020 ...