Select Drug List
Transcript of Select Drug List
Select Drug List Drug list — Four Tier Drug Plan
Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA).
Here are a few things to remember about the list:
o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this listmay not be covered by your plan and may cost you more out of pocket.
o Your coverage has limitations and exclusions, which means there are certain rules about what’s covered byyour plan and what isn’t. To find out more, read your Certificate or Evidence of Coverage or your SummaryPlan Description. If you’re not sure where to find it, ask your employer for a copy.
o To help you see how the drug list works with your drug benefit, we've included some frequently askedquestions (FAQ) about how the list is set up and what to do if a drug you take isn't on it.
o The most up-to-date drug list for your plan - including drugs that have been added, generic drugs and more- is available at anthem.com/pharmacyinformation. Select the Select Drug List.
If you have questions about your pharmacy benefits, we're here to help. Just call us at the Member Services number on your ID card.
40627MEMENABS SG
What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes hundreds of brand-name and generic drugs approved by the U.S. Food & Drug Administration (FDA).
Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan.
How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:
o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for.o Drug class, using the categories listed in alphabetical order.
The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).
When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:
o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions. Some plans split Tier 1 into Tier 1a and Tier 1b:
oTier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they workand their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may costmore because they’re newer to the market.
o Tier 3 drugs have a higher cost share. They often include non-preferred brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.
o Tier 4 drugs have the highest cost share and usually include specialty brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.
How will I know how much my drug will cost? You can go online to estimate your share of a drug’s cost and compare prices at different pharmacies. Here’s how:
o At the top right of the anthem.com home page, select Manage Prescriptions from the Popular Tasks icon, then log in using your user name and password. If you haven’t signed up on the site, you’ll need to do that first.
o On your personal Pharmacy Overview page, select Price a Medication, then select one or more pharmacies and enter the name of the drug you’d like to price.
Select Drug List
Please note: This tool will provide you with an estimate of your cost, but may not reflect the actual amount you pay at the pharmacy. Actual prices are based on your plan design and also include sales tax where applicable.
If my medicine isn’t on the drug list, what are my options? Here are a few things to think about:
o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.
o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just aswell, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.
o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list.
o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapprovalor prior authorization. Your doctor can get the process started by calling the Member Services number on the back ofyour member ID card or by downloading a prior authorization form from our website and submitting it. If your request isapproved, the amount you pay for the drug will depend on your plan’s benefit.
Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members.
What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent.
A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug.
Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier.
You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com.
Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).
A note about opioid analgesics. The member cost share for certain abuse-deterrent opioid analgesics may be lower in some states because of laws in those states. Opioid analgesics are a type of painkiller. In response to the global opioid epidemic, the U.S. Food and Drug Administration (FDA) has encouraged drug manufacturers to develop opioids with properties that help deter their misuse and abuse.
Drug(s) may be excluded from the list based on your plan's benefit design.
Search for a drug online
The most up-to-date drug list — including drugs that have been added, generic drugs and more — is always
available online when you log in at anthem.com. At the top right of the home page, choose Manage Prescriptions
from the Popular Tasks icon, then log in. On your personal Pharmacy Overview page, choose Search Your Drug
List and you can easily look up drugs by name, class or brand versus generic.
KEY Here are some terms and notes you’ll find on the drug list.
Brand name drugs are in UPPER CASE, bold type.
Generic drugs are in lower case, plain type.
$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription
from your provider if specified criteria are met.
DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once
a day at a higher strength.
LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on
what the manufacturer decides.
PA = prior authorization. You may need to get benefits approved before certain prescriptions can be filled.
QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time.
SP = specialty drugs. Specialty drugs are used to treat difficult, long -term conditions. You may need to get this drug
through a specialty pharmacy.
ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered.
2018 Maine Select Drug List
Table of Contents
ANALGESICS ...........................................................................................................................................................................7ANESTHETICS .........................................................................................................................................................................8ANTIARTHRITICS .................................................................................................................................................................... 9ANTIASTHMATICS .................................................................................................................................................................. 9ANTIBIOTICS ......................................................................................................................................................................... 11ANTICOAGULANTS .............................................................................................................................................................. 14ANTIDOTES ........................................................................................................................................................................... 15ANTIFUNGALS ...................................................................................................................................................................... 15ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 16ANTIHISTAMINES ..................................................................................................................................................................16ANTIHYPERGLYCEMICS ...................................................................................................................................................... 17ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................19ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ....................................................................................19ANTINEOPLASTICS .............................................................................................................................................................. 20ANTI-OBESITY DRUGS .........................................................................................................................................................21ANTIPARKINSON DRUGS .................................................................................................................................................... 21ANTIPLATELET DRUGS ....................................................................................................................................................... 22ANTIVIRALS ...........................................................................................................................................................................22AUTONOMIC DRUGS ............................................................................................................................................................ 24BIOLOGICALS ....................................................................................................................................................................... 24BLOOD ................................................................................................................................................................................... 27CARDIAC DRUGS ..................................................................................................................................................................27CARDIOVASCULAR .............................................................................................................................................................. 29CNS DRUGS ...........................................................................................................................................................................31COLONY STIMULATING FACTORS .....................................................................................................................................33CONTRACEPTIVES ............................................................................................................................................................... 33COUGH/COLD PREPARATIONS .......................................................................................................................................... 36DIAGNOSTIC ..........................................................................................................................................................................37DIURETICS .............................................................................................................................................................................37EENT PREPS ......................................................................................................................................................................... 37ELECT/CALORIC/H2O ...........................................................................................................................................................39GASTROINTESTINAL ............................................................................................................................................................40HORMONES ........................................................................................................................................................................... 42IMMUNOSUPPRESSANTS ....................................................................................................................................................44MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 44MUSCLE RELAXANTS .......................................................................................................................................................... 45PRE-NATAL VITAMINS ......................................................................................................................................................... 45PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................46SEDATIVE/HYPNOTICS ........................................................................................................................................................ 49SKIN PREPS .......................................................................................................................................................................... 49SMOKING DETERRENTS ......................................................................................................................................................52THYROID PREPS ...................................................................................................................................................................52UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................53VITAMINS ............................................................................................................................................................................... 54
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2018 Maine Select Drug List
CURRENT AS OF 10/1/2018
Drug Name Tier Notes
ANALGESICS
acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml
Tier 1a QL
acetaminophen-codeine oral tablet
Tier 1a QL
almotriptan malate oral tablet
Tier 1b QL
ascomp with codeine oral capsule
Tier 1b QL
buprenorphine hcl injection solution
Tier 2 QL
buprenorphine hcl injection syringe
Tier 2 QL
butalbital compound w/codeine oral capsule
Tier 1b QL
butalbital compound-codeine oral capsule
Tier 1b QL
butalbital-acetaminop-caf-cod oral capsule
Tier 1b QL
butalbital-acetaminophen oral tablet
Tier 1b
butalbital-acetaminophen-caff oral capsule
Tier 1b
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Tier 1b
butalbital-aspirin-caffeine oral capsule
Tier 1b
butalbital-aspirin-caffeine oral tablet
Tier 1b
butorphanol tartrate nasal spray,non-aerosol
Tier 1b PA; QL
capacet oral capsule Tier 1b
codeine sulfate oral tablet Tier 2 QL
codeine-butalbital-asa-caff oral capsule
Tier 1b QL
diclofenac potassium oral tablet
Tier 1b
diflunisal oral tablet Tier 1b
Drug Name Tier Notes
dihydroergotamine nasal spray,non-aerosol
Tier 2 QL
diskets oral tablet,soluble Tier 1b PA; QL
eletriptan oral tablet Tier 2 QL
ELMIRON ORAL CAPSULE
Tier 3
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL
Tier 1b PA; QL
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 2 QL
ergotamine-caffeine oral tablet
Tier 1b
fentanyl transdermal patch 72 hour
Tier 2 PA; QL
frovatriptan oral tablet Tier 2 QL
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
Tier 1b QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
Tier 1b QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
Tier 1b QL
hydromorphone oral liquid Tier 1b QL
hydromorphone oral tablet Tier 1b QL
hydromorphone oral tablet extended release 24 hr
Tier 2 PA; QL
hydromorphone rectal suppository
Tier 2 QL
ibuprofen-oxycodone oral tablet
Tier 1a QL
ketorolac oral tablet Tier 1a QL
levorphanol tartrate oral tablet
Tier 2 PA; QL
mefenamic acid oral capsule
Tier 1b QL
meperidine oral solution Tier 1b QL
meperidine oral tablet Tier 1b QL
methadone intensol oral concentrate
Tier 1b PA; QL
Effective 10/1/2018
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Drug Name Tier Notes
methadone oral concentrate
Tier 1b PA; QL
methadone oral solution Tier 1b PA; QL
methadone oral tablet Tier 1b PA; QL
methadone oral tablet,soluble
Tier 1b PA; QL
methadose oral concentrate
Tier 1b PA; QL
methadose oral tablet,soluble
Tier 1b PA; QL
migergot rectal suppository
Tier 1b
morphine concentrate oral solution
Tier 1b QL
morphine oral capsule,extend.release pellets
Tier 2 PA; QL
morphine oral solution Tier 1b QL
morphine oral tablet Tier 1b QL
morphine oral tablet extended release
Tier 2 PA; QL
morphine rectal suppository
Tier 1b QL
naratriptan oral tablet Tier 1b QL
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 PA; QL
NUCYNTA ORAL TABLET
Tier 3 QL
oxycodone oral capsule Tier 2 QL
oxycodone oral concentrate
Tier 2 QL
oxycodone oral solution Tier 2 QL
oxycodone oral syringe Tier 2 QL
oxycodone oral tablet Tier 2 QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1b QL
oxycodone-aspirin oral tablet
Tier 1b QL
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR
Tier 1b PA; QL
oxymorphone oral tablet Tier 2 QL
Drug Name Tier Notes
oxymorphone oral tablet extended release 12 hr
Tier 2 PA; QL
pentazocine-naloxone oral tablet
Tier 1b QL
rizatriptan oral tablet Tier 1b QL
rizatriptan oral tablet,disintegrating
Tier 1b QL
sumatriptan nasal spray,non-aerosol
Tier 1b QL
sumatriptan succinate oral tablet
Tier 1b QL
sumatriptan succinate subcutaneous cartridge
Tier 2 QL
sumatriptan succinate subcutaneous pen injector
Tier 2 QL
sumatriptan succinate subcutaneous solution
Tier 2 QL
tencon oral tablet 50-325 mg
Tier 1b
tramadol oral tablet Tier 1b QL
tramadol oral tablet extended release 24 hr
Tier 2 PA; QL
tramadol oral tablet, er multiphase 24 hr
Tier 2 PA; QL
vicodin es oral tablet Tier 2 QL
vicodin hp oral tablet Tier 2 QL
vicodin oral tablet Tier 2 QL
zebutal oral capsule 50-325-40 mg
Tier 2
ZIPSOR ORAL CAPSULE Tier 3 QL
ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR
Tier 3 PA; QL
zolmitriptan oral tablet Tier 1b QL
zolmitriptan oral tablet,disintegrating
Tier 1b QL
ANESTHETICS
lidocaine viscous mucous membrane solution
Tier 1a QL
lidocaine-prilocaine topical cream
Tier 1b QL
lidocaine-prilocaine topical kit
Tier 1b
phenazopyridine oral tablet 100 mg, 200 mg
Tier 1a
Effective 10/1/2018
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Drug Name Tier Notes
SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING
Tier 3
ANTIARTHRITICS
allopurinol oral tablet Tier 1a
celecoxib oral capsule Tier 2 ST; QL
COLCRYS ORAL TABLET
Tier 3 PA; QL
CUPRIMINE ORAL CAPSULE
Tier 3
diclofenac sodium oral tablet extended release 24 hr
Tier 1b
diclofenac sodium oral tablet,delayed release (dr/ec)
Tier 1b
etodolac oral capsule Tier 1b
etodolac oral tablet Tier 1b
etodolac oral tablet extended release 24 hr
Tier 1b
fenoprofen oral tablet Tier 1b QL
flurbiprofen oral tablet Tier 1b
ibu oral tablet Tier 1a
ibuprofen oral suspension Tier 1a QL
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1a
indomethacin oral capsule Tier 1b QL
indomethacin oral capsule, extended release
Tier 1b QL
ketoprofen oral capsule Tier 1b
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
Tier 1b QL
meclofenamate oral capsule
Tier 1b
meloxicam oral suspension
Tier 1b QL
meloxicam oral tablet Tier 1b QL
nabumetone oral tablet Tier 1b
naproxen oral suspension Tier 1b
naproxen oral tablet Tier 1b
naproxen oral tablet,delayed release (dr/ec)
Tier 1b
Drug Name Tier Notes
naproxen sodium oral tablet 275 mg, 550 mg
Tier 1b
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN
Tier 4 PA; SP; QL
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR
Tier 4 PA; SP; QL
ORENCIA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
oxaprozin oral tablet Tier 1b
piroxicam oral capsule Tier 1b
probenecid oral tablet Tier 1b
probenecid-colchicine oral tablet
Tier 1b
RIDAURA ORAL CAPSULE
Tier 3
sulindac oral tablet Tier 1b
tolmetin oral capsule Tier 2
tolmetin oral tablet Tier 2
ULORIC ORAL TABLET Tier 3 ST
XELJANZ ORAL TABLET10 MG
Tier 4 PA; SP
XELJANZ ORAL TABLET5 MG
Tier 4 PA; SP; QL
ANTIASTHMATICS
acetylcysteine solution Tier 2
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
ADVAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
albuterol sulfate inhalation solution for nebulization
Tier 1b
albuterol sulfate oral syrup Tier 1b
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
Effective 10/1/2018
9
Drug Name Tier Notes
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
Tier 2 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)
Tier 2
BREO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
BROVANA INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
budesonide inhalation suspension for nebulization
Tier 1b QL
cromolyn inhalation solution for nebulization
Tier 2
DALIRESP ORAL TABLET
Tier 3 QL
DULERA INHALATION HFA AEROSOL INHALER
Tier 2 QL
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
FLOVENT HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
ipratropium bromide inhalation solution
Tier 1b QL
ipratropium-albuterol inhalation solution for nebulization
Tier 2
levalbuterol hcl inhalation solution for nebulization
Tier 2
metaproterenol oral syrup Tier 1a
metaproterenol oral tablet Tier 1a
montelukast oral granules in packet
Tier 1b QL
montelukast oral tablet Tier 1b QL
Drug Name Tier Notes
montelukast oral tablet,chewable
Tier 1b QL
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
PROAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
PROVENTIL HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
SPIRIVA RESPIMAT INHALATION MIST
Tier 3 QL
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
STRIVERDI RESPIMAT INHALATION MIST
Tier 3 QL
SYMBICORT INHALATION HFA AEROSOL INHALER
Tier 2 QL
terbutaline oral tablet Tier 2
theochron oral tablet extended release 12 hr
Tier 1b
theophylline oral elixir Tier 1b
theophylline oral solution Tier 1b
theophylline oral tablet extended release 12 hr
Tier 1b
theophylline oral tablet extended release 24 hr
Tier 1b
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 3 QL
Effective 10/1/2018
10
Drug Name Tier Notes
VENTOLIN HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
XOPENEX HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
zafirlukast oral tablet Tier 1b
zileuton oral tablet, er multiphase 12 hr
Tier 2 PA
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment
Tier 1a
amoxicillin oral capsule Tier 1a
amoxicillin oral suspension for reconstitution
Tier 1a
amoxicillin oral tablet Tier 1a
amoxicillin oral tablet,chewable 125 mg, 250 mg
Tier 1a
amoxicillin-pot clavulanate oral suspension for reconstitution
Tier 1b
amoxicillin-pot clavulanate oral tablet
Tier 1b
amoxicillin-pot clavulanate oral tablet extended release 12 hr
Tier 1b
amoxicillin-pot clavulanate oral tablet,chewable
Tier 1b
ampicillin oral capsule Tier 1a
avidoxy oral tablet Tier 1b
AZASITE OPHTHALMIC (EYE) DROPS
Tier 3
azithromycin oral packet Tier 1b QL
azithromycin oral suspension for reconstitution
Tier 1b QL
azithromycin oral tablet Tier 1b QL
bacitracin ophthalmic (eye) ointment
Tier 1b
bacitracin-polymyxin b ophthalmic (eye) ointment
Tier 1a
BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
bp 10-1 topical cleanser Tier 1b
Drug Name Tier Notes
CAYSTON INHALATION SOLUTION FOR NEBULIZATION
Tier 4 SP; LD
cefaclor oral capsule Tier 1b
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Tier 1b
cefaclor oral tablet extended release 12 hr
Tier 2
cefadroxil oral capsule Tier 1b
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
Tier 1b
cefadroxil oral tablet Tier 1b
cefdinir oral capsule Tier 1b
cefdinir oral suspension for reconstitution
Tier 1b
cefditoren pivoxil oral tablet
Tier 2
cefpodoxime oral suspension for reconstitution
Tier 2
cefpodoxime oral tablet Tier 2
cefprozil oral suspension for reconstitution
Tier 1b
cefprozil oral tablet Tier 1b
cefuroxime axetil oral tablet
Tier 1b
cephalexin oral capsule Tier 1a
cephalexin oral suspension for reconstitution
Tier 1a
cephalexin oral tablet Tier 1a
CIPRO HC OTIC (EAR) DROPS,SUSPENSION
Tier 3
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
Tier 3 PA
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr
Tier 1b QL
ciprofloxacin hcl ophthalmic (eye) drops
Tier 1a
ciprofloxacin hcl oral tablet Tier 1b QL
ciprofloxacin hcl otic (ear) dropperette
Tier 1b
Effective 10/1/2018
11
Drug Name Tier Notes
clarithromycin oral suspension for reconstitution
Tier 1b
clarithromycin oral tablet Tier 1b
clarithromycin oral tablet extended release 24 hr
Tier 1b
cleansing wash topical cleanser
Tier 1b
clindamycin hcl oral capsule
Tier 1b
clindamycin palmitate hcl oral recon soln
Tier 1b
clindamycin pediatric oral recon soln
Tier 1b
clindamycin phosphate topical foam
Tier 1b
clindamycin phosphate topical gel
Tier 1b
clindamycin phosphate topical lotion
Tier 1b
clindamycin phosphate topical solution
Tier 1b
clindamycin phosphate topical swab
Tier 1b
clindamycin phosphate vaginal cream
Tier 1b
COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION
Tier 3
CORTISPORIN TOPICAL CREAM
Tier 3
CORTISPORIN TOPICAL OINTMENT
Tier 3
CYCLOSERINE ORAL CAPSULE
Tier 3
DAPSONE ORAL TABLET
Tier 2
demeclocycline oral tablet Tier 2
dicloxacillin oral capsule Tier 1b
DIFICID ORAL TABLET Tier 3 PA
doxycycline hyclate oral capsule
Tier 1b
doxycycline hyclate oral tablet 100 mg, 50 mg
Tier 1b
Drug Name Tier Notes
doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg
Tier 1b PA
doxycycline monohydrate oral capsule
Tier 1b
doxycycline monohydrate oral suspension for reconstitution
Tier 1b
doxycycline monohydrate oral tablet
Tier 1b
e.e.s. 400 oral tablet Tier 2
ertapenem injection recon soln
Tier 2
ery pads topical swab Tier 1b
erygel topical gel Tier 1b
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
Tier 1b
erythrocin (as stearate) oral tablet 250 mg
Tier 1b
erythromycin ethylsuccinate oral tablet
Tier 2
erythromycin ophthalmic (eye) ointment
Tier 1a
erythromycin oral capsule,delayed release(dr/ec)
Tier 2
erythromycin oral tablet Tier 2
erythromycin with ethanol topical gel
Tier 1b
erythromycin with ethanol topical solution
Tier 1b
erythromycin with ethanol topical swab
Tier 1b
erythromycin-benzoyl peroxide topical gel
Tier 1b
ethambutol oral tablet Tier 2
FACTIVE ORAL TABLET Tier 3 QL
gatifloxacin ophthalmic (eye) drops
Tier 1b
gentak ophthalmic (eye) ointment
Tier 1a
gentamicin ophthalmic (eye) drops
Tier 1a
gentamicin ophthalmic (eye) ointment
Tier 1a
Effective 10/1/2018
12
Drug Name Tier Notes
gentamicin topical cream Tier 1b
gentamicin topical ointment
Tier 1b
INVANZ INTRAVENOUS RECON SOLN
Tier 3
isoniazid oral solution Tier 1a
isoniazid oral tablet Tier 1a
levofloxacin ophthalmic (eye) drops
Tier 1b
levofloxacin oral tablet Tier 2 QL
linezolid oral suspension for reconstitution
Tier 2 PA; QL
linezolid oral tablet Tier 2 PA; QL
mafenide acetate topical packet
Tier 2
methenamine hippurate oral tablet
Tier 2
methenamine mandelate oral tablet
Tier 2
metronidazole oral capsule
Tier 1a
metronidazole oral tablet Tier 1a
metronidazole vaginal gel Tier 1b
minocycline oral capsule Tier 1b
minocycline oral tablet Tier 1b
minocycline oral tablet extended release 24 hr
Tier 1b PA
MONUROL ORAL PACKET
Tier 3
morgidox oral capsule 100 mg
Tier 1b
MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR
Tier 3
moxifloxacin ophthalmic (eye) drops
Tier 1b
mupirocin topical ointment Tier 1b
neomycin oral tablet Tier 1a
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment
Tier 1b
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment
Tier 1b
Drug Name Tier Notes
neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension
Tier 1a
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment
Tier 1a
neomycin-polymyxin-gramicidin ophthalmic (eye) drops
Tier 1b
neomycin-polymyxin-hc ophthalmic (eye) drops,suspension
Tier 1b
neomycin-polymyxin-hc otic (ear) drops,suspension
Tier 1b
neomycin-polymyxin-hc otic (ear) solution
Tier 1b
neo-polycin hc ophthalmic (eye) ointment
Tier 1b
neo-polycin ophthalmic (eye) ointment
Tier 1b
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
Tier 1b
nitrofurantoin monohyd/m-cryst oral capsule
Tier 1b
nitrofurantoin oral suspension
Tier 1b
ofloxacin ophthalmic (eye) drops
Tier 1a
ofloxacin oral tablet 300 mg, 400 mg
Tier 1b QL
ofloxacin otic (ear) drops Tier 1b
ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE
Tier 3
penicillin v potassium oral recon soln
Tier 1b
penicillin v potassium oral tablet
Tier 1b
polycin ophthalmic (eye) ointment
Tier 1a
polymyxin b sulf-trimethoprim ophthalmic (eye) drops
Tier 1a
PRIFTIN ORAL TABLET Tier 3
PRIMSOL ORAL SOLUTION
Tier 3
Effective 10/1/2018
13
Drug Name Tier Notes
pyrazinamide oral tablet Tier 2
rifabutin oral capsule Tier 2
rifampin oral capsule Tier 2
RIFATER ORAL TABLET Tier 3
silver sulfadiazine topical cream
Tier 1a
SIRTURO ORAL TABLET Tier 3
SIVEXTRO ORAL TABLET
Tier 3 PA; QL
ssd topical cream Tier 1a
sss 10-5 topical cream Tier 1b
sss 10-5 topical foam Tier 1b
sulfacetamide sodium ophthalmic (eye) drops
Tier 1b
sulfacetamide sodium ophthalmic (eye) ointment
Tier 1b
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %
Tier 1b
sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)
Tier 1b
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)
Tier 1b
sulfacetamide sodium-sulfur topical pads, medicated 10-4 %
Tier 1b
sulfacetamide sodium-sulfur topical suspension
Tier 1b
sulfacetamide sod-sulfur-urea topical cleanser
Tier 1b
sulfacetamide-prednisolone ophthalmic (eye) drops
Tier 1a
sulfacetamide-sulfur-cleansr23 topical kit
Tier 1b
sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream
Tier 1b
sulfadiazine oral tablet Tier 2
sulfamethoxazole-trimethoprim oral suspension
Tier 1a
sulfamethoxazole-trimethoprim oral tablet
Tier 1a
Drug Name Tier Notes
SULFAMYLON TOPICAL CREAM
Tier 3
sulfatrim oral suspension Tier 1a
SUPRAX ORAL CAPSULE
Tier 3
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML
Tier 3
tetracycline oral capsule Tier 1b
THALOMID ORAL CAPSULE
Tier 4 PA; SP; QL
tigecycline intravenous recon soln
Tier 2
TOBRADEX OPHTHALMIC (EYE) OINTMENT
Tier 3
tobramycin in 0.225 % nacl inhalation solution for nebulization
Tier 4 SP
tobramycin ophthalmic (eye) drops
Tier 1a
tobramycin-dexamethasone ophthalmic (eye) drops,suspension
Tier 1b
TRECATOR ORAL TABLET
Tier 3
trimethoprim oral tablet Tier 1a
vancomycin oral capsule Tier 2 PA
vandazole vaginal gel Tier 1b
XIFAXAN ORAL TABLET Tier 3 PA; QL
ANTICOAGULANTS
ELIQUIS ORAL TABLET Tier 3 QL
ELIQUIS ORAL TABLETS,DOSE PACK
Tier 3 QL
enoxaparin subcutaneous solution
Tier 4 QL
enoxaparin subcutaneous syringe
Tier 4 QL
fondaparinux subcutaneous syringe
Tier 4 PA; QL
FRAGMIN SUBCUTANEOUS SOLUTION
Tier 4 QL
Effective 10/1/2018
14
Drug Name Tier Notes
FRAGMIN SUBCUTANEOUS SYRINGE
Tier 4 QL
hep flush-10 (pf) intravenous solution
Tier 1b
heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)
Tier 1b
heparin (porcine) in nacl (pf) intravenous parenteral solution
Tier 1b
heparin (porcine) injection cartridge
Tier 1b
heparin (porcine) injection solution
Tier 1b
heparin flush(porcine)-0.9nacl intravenous kit
Tier 1b
heparin lock flush (porcine) intravenous solution
Tier 1b
heparin lock flush (porcine) intravenous syringe
Tier 1b
heparin lock flush intravenous solution
Tier 1b
heparin lock flush intravenous syringe
Tier 1b
heparin lock intravenous solution
Tier 1b
heparin lockflush(porcine)(pf) intravenous syringe
Tier 1b
heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml
Tier 1b
heparin, porcine (pf) injection solution
Tier 1b
heparin, porcine (pf) injection syringe
Tier 1b
heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)
Tier 1b
Drug Name Tier Notes
heparin, porcine (pf) intravenous syringe
Tier 1b
jantoven oral tablet Tier 1a
PRADAXA ORAL CAPSULE
Tier 3 QL
warfarin oral tablet Tier 1a
XARELTO ORAL TABLET
Tier 3 QL
XARELTO ORAL TABLETS,DOSE PACK
Tier 3 QL
ANTIDOTES
naloxone injection solution Tier 2 QL
naloxone injection syringe Tier 2 QL
naltrexone oral tablet Tier 1b
ANTIFUNGALS
ciclopirox topical cream Tier 1b
ciclopirox topical gel Tier 1b
ciclopirox topical shampoo Tier 1b
ciclopirox topical solution Tier 1b
ciclopirox topical suspension
Tier 1b
clotrimazole mucous membrane troche
Tier 2 QL
clotrimazole topical cream Tier 1b
clotrimazole topical solution
Tier 1b
clotrimazole-betamethasone topical cream
Tier 1b
clotrimazole-betamethasone topical lotion
Tier 1b
econazole topical cream Tier 1b
ERTACZO TOPICAL CREAM
Tier 3
EXELDERM TOPICAL CREAM
Tier 3
EXELDERM TOPICAL SOLUTION
Tier 3
fluconazole oral suspension for reconstitution
Tier 1b QL
fluconazole oral tablet Tier 1b QL
flucytosine oral capsule Tier 2
Effective 10/1/2018
15
Drug Name Tier Notes
griseofulvin microsize oral suspension
Tier 1b
griseofulvin microsize oral tablet
Tier 1b
griseofulvin ultramicrosize oral tablet
Tier 1b
GYNAZOLE-1 VAGINAL CREAM
Tier 3
itraconazole oral capsule Tier 2 PA; QL
JUBLIA TOPICAL SOLUTION WITH APPLICATOR
Tier 3
KERYDIN TOPICAL SOLUTION WITH APPLICATOR
Tier 3
ketoconazole oral tablet Tier 1b QL
ketoconazole topical cream
Tier 1b
ketoconazole topical foam Tier 1b
ketoconazole topical shampoo
Tier 1b
LUZU TOPICAL CREAM Tier 3
MENTAX TOPICAL CREAM
Tier 3
miconazole-3 vaginal suppository
Tier 1b
NAFTIFINE TOPICAL CREAM 1 %
Tier 2
naftifine topical cream 2 % Tier 2
NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
NOXAFIL ORAL SUSPENSION
Tier 3 QL
nyamyc topical powder Tier 1b
nystatin oral powder 150 million unit, 500 million unit
Tier 1b
nystatin oral suspension Tier 1b
nystatin oral tablet Tier 1b
nystatin topical cream Tier 1b
nystatin topical ointment Tier 1b
nystatin topical powder Tier 1b
nystatin-triamcinolone topical cream
Tier 1b
Drug Name Tier Notes
nystatin-triamcinolone topical ointment
Tier 1b
nystop topical powder Tier 1b
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET
Tier 3
oxiconazole topical cream Tier 2
OXISTAT TOPICAL LOTION
Tier 3
terbinafine hcl oral tablet Tier 1b PA; QL
terconazole vaginal cream Tier 1b
terconazole vaginal suppository
Tier 1b
voriconazole oral suspension for reconstitution
Tier 2 PA; QL
voriconazole oral tablet Tier 2 PA; QL
ANTIHISTAMINE AND DECONGESTANT COMBINATION
promethazine vc oral syrup
Tier 1b
promethazine-phenylephrine syr
Tier 1b
ANTIHISTAMINES
azelastine ophthalmic (eye) drops
Tier 1b QL
BEPREVE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
carbinoxamine maleate oral liquid
Tier 1b
carbinoxamine maleate oral tablet
Tier 1b
cetirizine oral solution 1 mg/ml
Tier 1b
clemastine oral tablet 2.68 mg
Tier 1b
cyproheptadine oral syrup Tier 1b
cyproheptadine oral tablet Tier 1b
desloratadine oral tablet Tier 1b
desloratadine oral tablet,disintegrating
Tier 1b
diphenhydramine hcl injection solution 50 mg/ml
Tier 2
diphenhydramine hcl injection syringe
Tier 2
Effective 10/1/2018
16
Drug Name Tier Notes
diphenhydramine hcl oral capsule 50 mg
Tier 1a
EMADINE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
epinastine ophthalmic (eye) drops
Tier 1b QL
fexofenadine oral tablet 180 mg
Tier 1b
hydroxyzine hcl oral solution 10 mg/5 ml
Tier 1b
hydroxyzine hcl oral tablet Tier 1b
hydroxyzine pamoate oral capsule
Tier 1a
LASTACAFT OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
levocetirizine oral solution Tier 1b
levocetirizine oral tablet Tier 1b
olopatadine ophthalmic (eye) drops
Tier 2 PA; QL
promethazine oral syrup Tier 1a
promethazine oral tablet Tier 1a
ANTIHYPERGLYCEMICS
acarbose oral tablet Tier 1b
APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 3 ST
APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 3 ST
AVANDIA ORAL TABLET2 MG, 4 MG
Tier 3 ST; QL
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON
Tier 3 ST; QL
chlorpropamide oral tablet Tier 1b
CYCLOSET ORAL TABLET
Tier 3
FARXIGA ORAL TABLET Tier 3 ST; QL
Drug Name Tier Notes
glimepiride oral tablet Tier 1b
glipizide oral tablet Tier 1a
glipizide oral tablet extended release 24hr
Tier 1a
glipizide-metformin oral tablet
Tier 1b
glyburide micronized oral tablet
Tier 1b
glyburide oral tablet Tier 1b
glyburide-metformin oral tablet
Tier 1b
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT
Tier 2
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE
Tier 2
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
Effective 10/1/2018
17
Drug Name Tier Notes
HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION
Tier 2
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
INVOKAMET ORAL TABLET
Tier 3 ST; QL
INVOKANA ORAL TABLET
Tier 3 ST; QL
JANUMET ORAL TABLET
Tier 2 ST; QL
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR
Tier 2 ST; QL
JANUVIA ORAL TABLET Tier 2 ST; QL
JARDIANCE ORAL TABLET
Tier 2 ST; QL
JENTADUETO ORAL TABLET
Tier 2 ST; QL
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN
Tier 2
Drug Name Tier Notes
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
metformin oral tablet Tier 1b
metformin oral tablet extended release 24 hr
Tier 1b
metformin oral tablet extended release 24hr
Tier 1b
miglitol oral tablet Tier 2
nateglinide oral tablet Tier 2
NESINA ORAL TABLET Tier 3 ST; QL
NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION
Tier 2
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION
Tier 2
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE
Tier 2
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION
Tier 2
ONGLYZA ORAL TABLET 2.5 MG
Tier 3 ST; DO
ONGLYZA ORAL TABLET 5 MG
Tier 3 ST; QL
pioglitazone oral tablet Tier 1b QL
repaglinide oral tablet Tier 2
Effective 10/1/2018
18
Drug Name Tier Notes
repaglinide-metformin oral tablet
Tier 2
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYNJARDY ORAL TABLET
Tier 2 ST; QL
TANZEUM SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
tolazamide oral tablet Tier 1b
tolbutamide oral tablet Tier 2
TRADJENTA ORAL TABLET
Tier 2 ST; DO
TRULICITY SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR
Tier 3 ST; QL
ANTIINFECTIVES/MISCELLANEOUS
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
ALINIA ORAL TABLET Tier 3
atovaquone oral suspension
Tier 2
atovaquone-proguanil oral tablet
Tier 1b
chloroquine phosphate oral tablet
Tier 1a
COARTEM ORAL TABLET
Tier 3
DARAPRIM ORAL TABLET
Tier 3 PA; LD; QL
hydroxychloroquine oral tablet
Tier 1b
Drug Name Tier Notes
ivermectin oral tablet Tier 1b
mefloquine oral tablet Tier 1b
NEBUPENT INHALATION RECON SOLN
Tier 4
paromomycin oral capsule Tier 1b
praziquantel oral tablet Tier 2
PRIMAQUINE ORAL TABLET
Tier 3
quinine sulfate oral capsule
Tier 2 PA; QL
ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT
Tier 4 PA; SP; LD; QL
CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
CIMZIA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
ENBREL MINI SUBCUTANEOUS CARTRIDGE
Tier 4 PA; SP; QL
ENBREL SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; QL
ENBREL SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
Effective 10/1/2018
19
Drug Name Tier Notes
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
SIMPONI ARIA INTRAVENOUS SOLUTION
Tier 4 PA; SP
SIMPONI SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
SIMPONI SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
ANTINEOPLASTICS
ACTIMMUNE SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION
Tier 4 PA; SP
AFINITOR ORAL TABLET
Tier 4 PA; SP
anastrozole oral tablet Tier 2 QL
bexarotene oral capsule Tier 4 PA; SP; QL
bicalutamide oral tablet Tier 2
BOSULIF ORAL TABLET Tier 4 PA; SP; QL
capecitabine oral tablet Tier 4 PA; SP
CAPRELSA ORAL TABLET
Tier 4 PA; QL
CARAC TOPICAL CREAM
Tier 2 QL
COMETRIQ ORAL CAPSULE
Tier 4 PA; LD; QL
CYCLOPHOSPHAMIDE ORAL CAPSULE
Tier 4 SP
diclofenac sodium topical gel 3 %
Tier 2 QL
EMCYT ORAL CAPSULE Tier 4 PA
ERIVEDGE ORAL CAPSULE
Tier 4 PA; SP; QL
etoposide oral capsule Tier 4 SP
exemestane oral tablet Tier 2 PA; QL
FARESTON ORAL TABLET
Tier 4 QL
Drug Name Tier Notes
FARYDAK ORAL CAPSULE
Tier 4 PA; SP; QL
FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG
Tier 4 PA; SP; QL
fluorouracil topical cream 5 %
Tier 1b QL
fluorouracil topical solution Tier 1b QL
flutamide oral capsule Tier 2
GILOTRIF ORAL TABLET
Tier 4 PA; SP; LD; QL
GLEOSTINE ORAL CAPSULE
Tier 4 PA
HEXALEN ORAL CAPSULE
Tier 4
HYCAMTIN ORAL CAPSULE
Tier 4 SP
hydroxyurea oral capsule Tier 2
IBRANCE ORAL CAPSULE
Tier 4 PA; SP; QL
ICLUSIG ORAL TABLET Tier 4 PA; QL
imatinib oral tablet Tier 4 PA; SP; QL
IMBRUVICA ORAL CAPSULE
Tier 4 PA; LD; QL
IMBRUVICA ORAL TABLET
Tier 4 PA; LD; QL
INLYTA ORAL TABLET Tier 4 PA; SP; QL
INTRON A INJECTION RECON SOLN
Tier 4 SP
INTRON A INJECTION SOLUTION
Tier 4 SP
JAKAFI ORAL TABLET Tier 4 PA; SP; LD; QL
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)
Tier 4 PA; SP; LD; QL
LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 4 MG
Tier 4 PA; SP
letrozole oral tablet Tier 2 QL
Effective 10/1/2018
20
Drug Name Tier Notes
LEUKERAN ORAL TABLET
Tier 4
leuprolide subcutaneous kit
Tier 4 PA; SP
LYNPARZA ORAL TABLET
Tier 4 PA; SP; LD; QL
LYSODREN ORAL TABLET
Tier 4 QL
MATULANE ORAL CAPSULE
Tier 4 LD
MEKINIST ORAL TABLET
Tier 4 PA; SP; QL
melphalan oral tablet Tier 4 SP
mercaptopurine oral tablet Tier 2
methotrexate sodium oral tablet
Tier 2
MYLERAN ORAL TABLET
Tier 4
NEXAVAR ORAL TABLET
Tier 4 PA; SP; QL
nilutamide oral tablet Tier 4 QL
ODOMZO ORAL CAPSULE
Tier 4 PA; SP; QL
PICATO TOPICAL GEL Tier 3 PA; QL
POMALYST ORAL CAPSULE
Tier 4 PA; SP; QL
REVLIMID ORAL CAPSULE
Tier 4 PA; SP; QL
SPRYCEL ORAL TABLET
Tier 4 PA; SP; QL
STIVARGA ORAL TABLET
Tier 4 PA; SP; QL
SUTENT ORAL CAPSULE
Tier 4 PA; SP; QL
TABLOID ORAL TABLET Tier 4
TAFINLAR ORAL CAPSULE
Tier 4 PA; SP; QL
tamoxifen oral tablet Tier 2 $0
TARCEVA ORAL TABLET
Tier 4 PA; SP; QL
TARGRETIN TOPICAL GEL
Tier 4 PA; SP
TASIGNA ORAL CAPSULE
Tier 4 PA; SP; QL
temozolomide oral capsule Tier 4 PA; SP; QL
Drug Name Tier Notes
tretinoin (chemotherapy) oral capsule
Tier 2
TYKERB ORAL TABLET Tier 4 PA; SP; QL
VOTRIENT ORAL TABLET
Tier 4 PA; SP; QL
XALKORI ORAL CAPSULE
Tier 4 PA; SP; QL
XTANDI ORAL CAPSULE Tier 4 PA; SP; QL
ZELBORAF ORAL TABLET
Tier 4 PA; SP; QL
ZOLINZA ORAL CAPSULE
Tier 4 PA; SP; QL
ZYDELIG ORAL TABLET Tier 4 PA; SP; LD; QL
ZYKADIA ORAL CAPSULE
Tier 4 PA; SP; QL
ZYTIGA ORAL TABLET Tier 4 PA; SP; QL
ANTI-OBESITY DRUGS
BELVIQ ORAL TABLET Tier 3 PA
phendimetrazine tartrate oral capsule, extended release
Tier 1b PA
phendimetrazine tartrate oral tablet
Tier 1b PA
phentermine oral capsule Tier 1b PA
phentermine oral tablet Tier 1b PA
ANTIPARKINSON DRUGS
amantadine hcl oral capsule
Tier 2 QL
amantadine hcl oral solution
Tier 2
amantadine hcl oral tablet Tier 2 QL
APOKYN SUBCUTANEOUS CARTRIDGE
Tier 4 SP; LD; QL
benztropine oral tablet Tier 1a
bromocriptine oral capsule Tier 1b
bromocriptine oral tablet Tier 1b
carbidopa oral tablet Tier 2
carbidopa-levodopa oral tablet
Tier 1b
carbidopa-levodopa oral tablet extended release
Tier 2
carbidopa-levodopa oral tablet,disintegrating
Tier 2
Effective 10/1/2018
21
Drug Name Tier Notes
entacapone oral tablet Tier 2 QL
pramipexole oral tablet Tier 2 QL
rasagiline oral tablet Tier 2
ropinirole oral tablet Tier 1b
ropinirole oral tablet extended release 24 hr
Tier 2
selegiline hcl oral capsule Tier 2
selegiline hcl oral tablet Tier 2
tolcapone oral tablet Tier 2 QL
trihexyphenidyl oral elixir Tier 1a
trihexyphenidyl oral tablet Tier 1a
ANTIPLATELET DRUGS
anagrelide oral capsule Tier 2
aspirin-dipyridamole oral capsule, er multiphase 12 hr
Tier 2 QL
BRILINTA ORAL TABLET
Tier 3 QL
cilostazol oral tablet Tier 2
clopidogrel oral tablet 300 mg
Tier 2
clopidogrel oral tablet 75 mg
Tier 2 QL
dipyridamole oral tablet Tier 2
prasugrel oral tablet 10 mg Tier 2 QL
prasugrel oral tablet 5 mg Tier 2 DO
ZONTIVITY ORAL TABLET
Tier 3 QL
ANTIVIRALS
abacavir oral solution Tier 4
abacavir oral tablet Tier 4
abacavir-lamivudine oral tablet
Tier 4
abacavir-lamivudine-zidovudine oral tablet
Tier 4
acyclovir oral capsule Tier 1b
acyclovir oral suspension 200 mg/5 ml
Tier 1b
acyclovir oral tablet Tier 1b
acyclovir topical ointment Tier 3 QL
adefovir oral tablet Tier 4 SP
APTIVUS ORAL CAPSULE
Tier 4
Drug Name Tier Notes
APTIVUS ORAL SOLUTION
Tier 4
atazanavir oral capsule Tier 4
BARACLUDE ORAL SOLUTION
Tier 4 SP
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 4
DENAVIR TOPICAL CREAM
Tier 3 QL
didanosine oral capsule,delayed release(dr/ec)
Tier 4
EDURANT ORAL TABLET
Tier 4
efavirenz oral capsule Tier 4
efavirenz oral tablet Tier 4
EMTRIVA ORAL CAPSULE
Tier 4
EMTRIVA ORAL SOLUTION
Tier 4
entecavir oral tablet Tier 4 SP
EPCLUSA ORAL TABLET
Tier 4 PA; SP; QL
EPIVIR HBV ORAL SOLUTION
Tier 4 SP
EVOTAZ ORAL TABLET Tier 4
famciclovir oral tablet Tier 1b
FUZEON SUBCUTANEOUS RECON SOLN
Tier 4
GENVOYA ORAL TABLET
Tier 4
HARVONI ORAL TABLET
Tier 4 PA; SP; QL
INTELENCE ORAL TABLET
Tier 4
INVIRASE ORAL CAPSULE
Tier 4
INVIRASE ORAL TABLET
Tier 4
ISENTRESS ORAL TABLET
Tier 4
ISENTRESS ORAL TABLET,CHEWABLE
Tier 4
Effective 10/1/2018
22
Drug Name Tier Notes
KALETRA ORAL TABLET
Tier 4
lamivudine oral tablet 150 mg, 300 mg
Tier 4
lamivudine-zidovudine oral tablet
Tier 4
lopinavir-ritonavir oral solution
Tier 4
MAVYRET ORAL TABLET
Tier 4 PA; SP; QL
MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (28)- 400 MG (28), 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)
Tier 4 SP
moderiba dose pack oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)
Tier 4 SP
moderiba oral tablet Tier 4 SP
nevirapine oral suspension Tier 4
nevirapine oral tablet Tier 4
NORVIR ORAL CAPSULE
Tier 4
NORVIR ORAL SOLUTION
Tier 4
oseltamivir oral capsule Tier 2 QL
oseltamivir oral suspension for reconstitution
Tier 2 QL
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 SP; QL
PEGASYS SUBCUTANEOUS SOLUTION
Tier 4 SP; QL
PEGASYS SUBCUTANEOUS SYRINGE
Tier 4 SP; QL
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
Tier 4 SP
PREZISTA ORAL SUSPENSION
Tier 4
Drug Name Tier Notes
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Tier 4
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE
Tier 2 QL
RESCRIPTOR ORAL TABLET
Tier 4
RESCRIPTOR ORAL TABLET, DISPERSIBLE
Tier 4
ribasphere oral capsule Tier 4 SP
ribasphere oral tablet Tier 4 SP
ribasphere ribapak oral tablets,dose pack
Tier 4 SP
ribavirin oral capsule Tier 4 SP
ribavirin oral tablet 200 mg Tier 4 SP
rimantadine oral tablet Tier 1b
ritonavir oral tablet Tier 4
SELZENTRY ORAL TABLET
Tier 4
SOVALDI ORAL TABLET Tier 4 PA; SP; QL
stavudine oral capsule Tier 4
STRIBILD ORAL TABLET
Tier 4
TECHNIVIE ORAL TABLET
Tier 4 PA; SP; QL
tenofovir disoproxil fumarate oral tablet
Tier 4
TIVICAY ORAL TABLET Tier 4
trifluridine ophthalmic (eye) drops
Tier 1b
TRIUMEQ ORAL TABLET
Tier 4
TRUVADA ORAL TABLET
Tier 4
valacyclovir oral tablet Tier 1b
valganciclovir oral recon soln
Tier 2 SP
valganciclovir oral tablet Tier 2 SP
VEREGEN TOPICAL OINTMENT
Tier 3
VIEKIRA PAK ORAL TABLETS,DOSE PACK
Tier 4 PA; SP; QL
VIRACEPT ORAL TABLET
Tier 4
Effective 10/1/2018
23
Drug Name Tier Notes
VIREAD ORAL TABLET150 MG, 200 MG, 250 MG
Tier 4
ZEPATIER ORAL TABLET
Tier 4 PA; SP; QL
zidovudine oral capsule Tier 4
zidovudine oral syrup Tier 4
zidovudine oral tablet Tier 4
ZIRGAN OPHTHALMIC (EYE) GEL
Tier 3
AUTONOMIC DRUGS
bethanechol chloride oral tablet
Tier 2
cevimeline oral capsule Tier 2
dextroamphetamine oral capsule, extended release
Tier 1b PA
dextroamphetamine oral solution
Tier 1b PA
dextroamphetamine oral tablet
Tier 1b PA
dextroamphetamine-amphetamine oral capsule,extended release 24hr
Tier 1b PA
dextroamphetamine-amphetamine oral tablet
Tier 1b PA
donepezil oral tablet Tier 2
donepezil oral tablet,disintegrating
Tier 2
epinephrine 0.3 mg auto-inject
Tier 1b QL
epinephrine 0.3 mg auto-inject inner, suv
Tier 1b QL
epinephrine 0.3 mg auto-inject latex-free, sdv
Tier 1b QL
epinephrine 0.3 mg auto-inject latex-free, suv
Tier 1b QL
epinephrine 0.3 mg auto-inject no latex, auto-injct
Tier 1b QL
epinephrine 0.3 mg auto-inject no latex, two-pack
Tier 1b QL
epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml
Tier 1b QL
EPIPEN 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
Drug Name Tier Notes
EPIPEN INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR INJECTION AUTO-INJECTOR
Tier 2 QL
galantamine oral capsule,ext rel. pellets 24 hr
Tier 2
galantamine oral solution Tier 2
galantamine oral tablet Tier 2
guanidine oral tablet Tier 1b
methamphetamine oral tablet
Tier 2 PA
midodrine oral tablet Tier 2
NORTHERA ORAL CAPSULE
Tier 3 SP; LD
phenoxybenzamine oral capsule
Tier 2
pilocarpine hcl oral tablet Tier 2
procentra oral solution Tier 1b PA
pyridostigmine bromide oral tablet
Tier 2
rivastigmine tartrate oral capsule
Tier 2
zenzedi oral tablet 10 mg, 5 mg
Tier 1b PA
BIOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
AFLURIA 2018-2019 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
AFLURIA 2018-2019 INTRAMUSCULAR SUSPENSION
Tier 1b $0; QL
Effective 10/1/2018
24
Drug Name Tier Notes
AFLURIA QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
AFLURIA QUAD 2018-2019 INTRAMUSCULAR SUSPENSION
Tier 1b $0; QL
BEXSERO INTRAMUSCULAR SYRINGE
Tier 2 $0
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION
Tier 3 $0
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE
Tier 3 $0
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
FLUAD 2018-2019 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
FLUARIX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
FLUBLOK QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
FLUCELVAX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
FLUCELVAX QUAD 2018-2019 INTRAMUSCULAR SUSPENSION
Tier 1b $0; QL
Drug Name Tier Notes
FLULAVAL QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
FLULAVAL QUAD 2018-2019 INTRAMUSCULAR SUSPENSION
Tier 1b $0; QL
FLUMIST QUAD 2018-2019 NASAL NASAL SPRAY SYRINGE
Tier 1b QL
FLUZONE HIGH-DOSE 2018-19 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SUSPENSION
Tier 1b $0; QL
FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
FLUZONE QUAD 2018-2019 INTRAMUSCULAR SUSPENSION
Tier 1b $0; QL
FLUZONE QUAD PEDI 2018-19 (PF) INTRAMUSCULAR SYRINGE
Tier 1b $0; QL
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION
Tier 2 $0
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
GRASTEK SUBLINGUAL TABLET
Tier 3 PA; QL
HAVRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
HAVRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
Effective 10/1/2018
25
Drug Name Tier Notes
HIBERIX (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
HYQVIA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN
Tier 3
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
IPOL INJECTION SUSPENSION
Tier 3 $0
IXIARO (PF) INTRAMUSCULAR SYRINGE
Tier 3
KINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
KINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
MENACTRA (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT
Tier 3 $0
M-M-R II (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
PENTACEL (PF) INTRAMUSCULAR KIT
Tier 3 $0
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
Drug Name Tier Notes
PNEUMOVAX 23 INJECTION SOLUTION
Tier 2 $0
PNEUMOVAX 23 INJECTION SYRINGE
Tier 2 $0
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 3
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3 $0
ROTATEQ VACCINE ORAL SOLUTION
Tier 3 $0
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 2 $0
SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 2 $0
TENIVAC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
Effective 10/1/2018
26
Drug Name Tier Notes
TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION
Tier 3 $0
TRUMENBA INTRAMUSCULAR SYRINGE
Tier 2 $0
TWINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TYPHIM VI INTRAMUSCULAR SOLUTION
Tier 3
TYPHIM VI INTRAMUSCULAR SYRINGE
Tier 3
VAQTA (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
VAQTA (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 2 $0
BLOOD
DROXIA ORAL CAPSULE
Tier 4
pentoxifylline oral tablet extended release
Tier 1b
tranexamic acid oral tablet Tier 1b
CARDIAC DRUGS
afeditab cr oral tablet extended release 30 mg
Tier 2 DO
afeditab cr oral tablet extended release 60 mg
Tier 2 QL
amiodarone oral tablet Tier 1b
Drug Name Tier Notes
amlodipine oral tablet 10 mg
Tier 1b QL
amlodipine oral tablet 2.5 mg, 5 mg
Tier 1b DO
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1b DO
cartia xt oral capsule,extended release 24hr 240 mg, 300 mg
Tier 1b QL
digox oral tablet Tier 1b
digoxin oral solution 50 mcg/ml
Tier 1b
digoxin oral tablet Tier 1b
diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1b DO
diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg
Tier 1b QL
diltiazem hcl oral capsule,extended release 12 hr
Tier 2 QL
diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1b DO
diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1b QL
diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1b DO
diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg
Tier 1b QL
diltiazem hcl oral tablet Tier 1b QL
diltiazem hcl oral tablet extended release 24 hr 180 mg
Tier 1b DO
diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1b QL
dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1b DO
Effective 10/1/2018
27
Drug Name Tier Notes
dilt-xr oral capsule,ext.rel 24h degradable 240 mg
Tier 1b QL
disopyramide phosphate oral capsule
Tier 2
dofetilide oral capsule Tier 2
felodipine oral tablet extended release 24 hr 10 mg
Tier 1b QL
felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg
Tier 1b DO
flecainide oral tablet Tier 2
isosorbide dinitrate oral tablet
Tier 1b
isosorbide dinitrate oral tablet extended release
Tier 1b
isosorbide mononitrate oral tablet
Tier 1b
isosorbide mononitrate oral tablet extended release 24 hr
Tier 1b
isradipine oral capsule Tier 1b QL
LANOXIN ORAL TABLET Tier 3
matzim la oral tablet extended release 24 hr 180 mg
Tier 1b DO
matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1b QL
mexiletine oral capsule Tier 2
MULTAQ ORAL TABLET Tier 3
nicardipine oral capsule Tier 2 QL
nifedipine oral capsule Tier 2 QL
nifedipine oral tablet extended release 24hr 30 mg
Tier 2 DO
nifedipine oral tablet extended release 24hr 60 mg, 90 mg
Tier 2 QL
nifedipine oral tablet extended release 30 mg
Tier 2 DO
nifedipine oral tablet extended release 60 mg, 90 mg
Tier 2 QL
nimodipine oral capsule Tier 2 QL
Drug Name Tier Notes
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg
Tier 1b DO
nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg
Tier 1b QL
nitro-bid transdermal ointment
Tier 1b
nitroglycerin oral capsule, extended release
Tier 2
nitroglycerin sublingual tablet
Tier 1b
nitroglycerin translingual spray,non-aerosol
Tier 2
nitro-time oral capsule, extended release
Tier 1b
pacerone oral tablet 100 mg, 200 mg, 400 mg
Tier 2
propafenone oral capsule,extended release 12 hr
Tier 2
propafenone oral tablet Tier 2
quinidine sulfate oral tablet Tier 1a
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3
taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1b DO
taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg
Tier 1b QL
verapamil oral capsule, 24 hr er pellet ct 100 mg
Tier 1b DO
verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg
Tier 1b QL
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg
Tier 1b DO
verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg
Tier 1b QL
verapamil oral tablet Tier 1b QL
verapamil oral tablet extended release
Tier 1b QL
Effective 10/1/2018
28
Drug Name Tier Notes
CARDIOVASCULAR
acebutolol oral capsule Tier 1b
ADCIRCA ORAL TABLET
Tier 4 PA; SP; QL
ADEMPAS ORAL TABLET
Tier 4 PA; SP; LD; QL
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg
Tier 1b QL
amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg
Tier 1b DO
amlodipine-benazepril oral capsule
Tier 1b
atenolol oral tablet Tier 1a
atenolol-chlorthalidone oral tablet
Tier 1b
atorvastatin oral tablet 10 mg, 20 mg
Tier 1b DO; $0
atorvastatin oral tablet 40 mg
Tier 1b DO
atorvastatin oral tablet 80 mg
Tier 1b QL
benazepril oral tablet Tier 1a
benazepril-hydrochlorothiazide oral tablet
Tier 1b
betaxolol oral tablet Tier 1b
bisoprolol fumarate oral tablet
Tier 1b
bisoprolol-hydrochlorothiazide oral tablet
Tier 1b
BYSTOLIC ORAL TABLET
Tier 3
candesartan oral tablet Tier 1b QL
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg
Tier 1b QL
candesartan-hydrochlorothiazid oral tablet 32-25 mg
Tier 1b
captopril oral tablet Tier 2
Drug Name Tier Notes
captopril-hydrochlorothiazide oral tablet
Tier 2
carvedilol oral tablet Tier 1b
cholestyramine (with sugar) oral powder
Tier 2 QL
cholestyramine (with sugar) oral powder in packet
Tier 2 QL
cholestyramine light oral powder
Tier 2 QL
cholestyramine light oral powder in packet
Tier 2
clonidine hcl oral tablet Tier 1a
colesevelam oral powder in packet
Tier 2
colesevelam oral tablet Tier 2
colestipol oral granules Tier 1b
colestipol oral packet Tier 1b
colestipol oral tablet Tier 1b
doxazosin oral tablet Tier 1b
EDARBI ORAL TABLET40 MG
Tier 3 DO
EDARBI ORAL TABLET80 MG
Tier 3 QL
enalapril maleate oral tablet
Tier 1b
enalapril-hydrochlorothiazide oral tablet
Tier 1b
eprosartan oral tablet Tier 1b QL
ergoloid oral tablet Tier 2
ezetimibe oral tablet Tier 2 PA; QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 1b
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1b QL
fenofibrate nanocrystallized oral tablet
Tier 1b QL
fenofibrate oral tablet 160 mg, 54 mg
Tier 1b QL
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
Tier 1b QL
fenofibric acid oral tablet Tier 1b QL
Effective 10/1/2018
29
Drug Name Tier Notes
fluvastatin oral capsule Tier 1b DO; $0
fluvastatin oral tablet extended release 24 hr
Tier 1b $0
fosinopril oral tablet Tier 1b
fosinopril-hydrochlorothiazide oral tablet
Tier 1b
gemfibrozil oral tablet Tier 1b
guanfacine oral tablet Tier 1b
hydralazine oral tablet Tier 1b
irbesartan oral tablet 150 mg, 75 mg
Tier 1b DO
irbesartan oral tablet 300 mg
Tier 1b QL
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg
Tier 1b QL
irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg
Tier 1b
labetalol oral tablet Tier 1b
LETAIRIS ORAL TABLET Tier 4 PA; SP; LD; QL
LEVATOL ORAL TABLET
Tier 3
lisinopril oral tablet Tier 1a
lisinopril-hydrochlorothiazide oral tablet
Tier 1b
LIVALO ORAL TABLET 1 MG, 2 MG
Tier 3 ST; DO
LIVALO ORAL TABLET 4 MG
Tier 3 ST; QL
losartan oral tablet Tier 1b QL
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg
Tier 1b QL
losartan-hydrochlorothiazide oral tablet 50-12.5 mg
Tier 1b DO
lovastatin oral tablet 10 mg, 20 mg
Tier 1b DO; $0
lovastatin oral tablet 40 mg
Tier 1b $0; QL
methyldopa oral tablet Tier 1b
Drug Name Tier Notes
methyldopa-hydrochlorothiazide oral tablet
Tier 1b
metoprolol succinate oral tablet extended release 24 hr
Tier 1b
metoprolol ta-hydrochlorothiaz oral tablet
Tier 1b
metoprolol tartrate oral tablet
Tier 1a
minoxidil oral tablet Tier 1b
moexipril oral tablet Tier 1b
moexipril-hydrochlorothiazide oral tablet
Tier 1b
nadolol oral tablet Tier 2
nadolol-bendroflumethiazide oral tablet
Tier 1b
niacin oral tablet extended release 24 hr
Tier 1b QL
olmesartan oral tablet 20 mg
Tier 2 DO
olmesartan oral tablet 40 mg, 5 mg
Tier 2 QL
OPSUMIT ORAL TABLET Tier 4 PA; SP; LD; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE
Tier 4 PA; SP; LD
perindopril erbumine oral tablet
Tier 1b
pindolol oral tablet Tier 2
pravastatin oral tablet 10 mg, 20 mg
Tier 1b DO; $0
pravastatin oral tablet 40 mg
Tier 1b $0
pravastatin oral tablet 80 mg
Tier 1b $0; QL
prazosin oral capsule Tier 1b
prevalite oral powder Tier 2 QL
prevalite oral powder in packet
Tier 2
propranolol oral capsule,extended release 24 hr
Tier 1b
propranolol oral solution Tier 1b
Effective 10/1/2018
30
Drug Name Tier Notes
propranolol oral tablet Tier 1b
propranolol-hydrochlorothiazid oral tablet
Tier 1b
quinapril oral tablet Tier 1b
quinapril-hydrochlorothiazide oral tablet
Tier 1b
ramipril oral capsule Tier 1b
REMODULIN INJECTION SOLUTION
Tier 4 PA; SP; LD
rosuvastatin oral tablet 10 mg, 5 mg
Tier 2 DO; $0
rosuvastatin oral tablet 20 mg
Tier 2 DO
rosuvastatin oral tablet 40 mg
Tier 2 QL
sildenafil (antihypertensive) oral tablet
Tier 4 PA; SP; QL
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1b DO; $0
simvastatin oral tablet 80 mg
Tier 1b PA; QL
sorine oral tablet Tier 2
sotalol af oral tablet Tier 2
sotalol oral tablet Tier 2
tadalafil (antihypertensive) oral tablet
Tier 4 PA; SP; QL
TEKTURNA ORAL TABLET 150 MG
Tier 3 DO
TEKTURNA ORAL TABLET 300 MG
Tier 3 QL
telmisartan oral tablet 20 mg, 40 mg
Tier 1b DO
telmisartan oral tablet 80 mg
Tier 1b QL
terazosin oral capsule Tier 1b
timolol maleate oral tablet Tier 1b
TRACLEER ORAL TABLET
Tier 4 PA; SP; QL
trandolapril oral tablet Tier 1b
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg
Tier 1b DO
Drug Name Tier Notes
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg
Tier 1b QL
valsartan oral tablet Tier 1b QL
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg
Tier 1b DO
valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg
Tier 1b QL
VECAMYL ORAL TABLET
Tier 3
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
Tier 4 PA; SP; LD; QL
CNS DRUGS
APTIOM ORAL TABLET Tier 3
AUBAGIO ORAL TABLET
Tier 4 PA; SP; QL
BANZEL ORAL SUSPENSION
Tier 3
BANZEL ORAL TABLET Tier 3
carbamazepine oral capsule, er multiphase 12 hr
Tier 1b
carbamazepine oral suspension 100 mg/5 ml
Tier 1b
carbamazepine oral tablet Tier 1b
carbamazepine oral tablet extended release 12 hr
Tier 1b
carbamazepine oral tablet,chewable
Tier 1b
CELONTIN ORAL CAPSULE 300 MG
Tier 3
clonazepam oral tablet Tier 1b
clonazepam oral tablet,disintegrating
Tier 1b
DIASTAT ACUDIAL RECTAL KIT
Tier 2 QL
DIASTAT RECTAL KIT Tier 2 QL
diazepam rectal kit Tier 2 QL
divalproex oral capsule, delayed rel sprinkle
Tier 2
Effective 10/1/2018
31
Drug Name Tier Notes
divalproex oral tablet extended release 24 hr
Tier 2
divalproex oral tablet,delayed release (dr/ec)
Tier 2
epitol oral tablet Tier 1b
ethosuximide oral capsule Tier 1b
ethosuximide oral solution Tier 1b
EXTAVIA SUBCUTANEOUS KIT
Tier 4 PA; SP
EXTAVIA SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
felbamate oral suspension Tier 2
felbamate oral tablet Tier 2
FYCOMPA ORAL TABLET
Tier 3
gabapentin oral capsule Tier 2
gabapentin oral solution Tier 2
gabapentin oral tablet 600 mg, 800 mg
Tier 2
GILENYA ORAL CAPSULE 0.5 MG
Tier 4 PA; SP; QL
glatiramer subcutaneous syringe 20 mg/ml
Tier 4 PA; SP
glatopa subcutaneous syringe 20 mg/ml
Tier 4 PA; SP
HORIZANT ORAL TABLET EXTENDED RELEASE
Tier 3 PA; QL
lamotrigine oral tablet Tier 1b
lamotrigine oral tablet, chewable dispersible
Tier 1b
levetiracetam oral solution Tier 2
levetiracetam oral tablet Tier 2
levetiracetam oral tablet extended release 24 hr
Tier 2 PA
LYRICA ORAL CAPSULE Tier 3 PA; QL
LYRICA ORAL SOLUTION
Tier 3 PA; QL
memantine oral solution Tier 2
memantine oral tablet Tier 2
memantine oral tablets,dose pack
Tier 3
Drug Name Tier Notes
NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK
Tier 3
ONFI ORAL SUSPENSION
Tier 3
ONFI ORAL TABLET 10 MG, 20 MG
Tier 3
oxcarbazepine oral suspension
Tier 2
oxcarbazepine oral tablet Tier 2
PEGANONE ORAL TABLET
Tier 3
phenytoin sodium extended oral capsule
Tier 1b
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
PLEGRIDY SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
primidone oral tablet Tier 1b
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
riluzole oral tablet Tier 4 SP
SABRIL ORAL TABLET Tier 3 SP; LD
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 4 PA; SP; QL
tetrabenazine oral tablet Tier 2 PA; SP; LD
tiagabine oral tablet Tier 2
topiramate oral capsule, sprinkle
Tier 1b
topiramate oral tablet Tier 1b
valproic acid (as sodium salt) oral solution
Tier 1b
valproic acid oral capsule Tier 1b
vigabatrin oral powder in packet
Tier 2 SP; LD
VIMPAT ORAL SOLUTION
Tier 3
Effective 10/1/2018
32
Drug Name Tier Notes
VIMPAT ORAL TABLET Tier 3
zonisamide oral capsule Tier 2
COLONY STIMULATING FACTORS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION
Tier 4 PA; SP
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
Tier 4 PA; SP
NEULASTA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR
Tier 4 PA; SP; QL
NEUPOGEN INJECTION SOLUTION
Tier 4 PA; SP
NEUPOGEN INJECTION SYRINGE
Tier 4 PA; SP
PROCRIT INJECTION SOLUTION
Tier 4 PA; SP
PROMACTA ORAL TABLET
Tier 4 PA; SP
CONTRACEPTIVES
AFTERA ORAL TABLET Tier 1b $0; QL
altavera (28) oral tablet Tier 1a $0
alyacen 1/35 (28) oral tablet
Tier 1a $0
alyacen 7/7/7 (28) oral tablet
Tier 1a $0
amethia lo oral tablets,dose pack,3 month
Tier 1b $0
amethia oral tablets,dose pack,3 month
Tier 1b $0
amethyst oral tablet Tier 1b $0
apri oral tablet Tier 1a $0
aranelle (28) oral tablet Tier 1a $0
ashlyna oral tablets,dose pack,3 month
Tier 1b $0
aubra eq oral tablet Tier 1a
aubra oral tablet Tier 1a $0
aviane oral tablet Tier 1a $0
azurette (28) oral tablet Tier 1b $0
Drug Name Tier Notes
BALCOLTRA ORAL TABLET
Tier 3 $0
balziva (28) oral tablet Tier 1a $0
BEKYREE (28) ORAL TABLET
Tier 1b $0
BLISOVI 24 FE ORAL TABLET
Tier 1a $0
BLISOVI FE 1.5/30 (28) ORAL TABLET
Tier 1a $0
BLISOVI FE 1/20 (28) ORAL TABLET
Tier 1a $0
briellyn oral tablet Tier 1a $0
camila oral tablet Tier 1b $0
camrese lo oral tablets,dose pack,3 month
Tier 1b $0
camrese oral tablets,dose pack,3 month
Tier 1b $0
CAYA CONTOURED VAGINAL DIAPHRAGM
Tier 3 $0
caziant (28) oral tablet Tier 1a $0
chateal eq oral tablet Tier 1a $0
chateal oral tablet Tier 1a $0
cryselle (28) oral tablet Tier 1a $0
cyclafem 1/35 (28) oral tablet
Tier 1a $0
cyclafem 7/7/7 (28) oral tablet
Tier 1a $0
cyred oral tablet Tier 1a $0
dasetta 1/35 (28) oral tablet
Tier 1a $0
dasetta 7/7/7 (28) oral tablet
Tier 1a $0
daysee oral tablets,dose pack,3 month
Tier 1b $0
deblitane oral tablet Tier 1b $0
delyla (28) oral tablet Tier 1a $0
desog-e.estradiol/e.estradiol oral tablet
Tier 1b $0
desogestrel-ethinyl estradiol oral tablet
Tier 1a $0
drospirenone-e.estradiol-lm.fa oral tablet
Tier 1b $0
drospirenone-ethinyl estradiol oral tablet
Tier 1b $0
Effective 10/1/2018
33
Drug Name Tier Notes
econtra ez oral tablet Tier 1b $0; QL
econtra one-step oral tablet
Tier 1b $0; QL
elinest oral tablet Tier 1a $0
ELLA ORAL TABLET Tier 3 $0
emoquette oral tablet Tier 1a $0
enpresse oral tablet Tier 1a $0
enskyce oral tablet Tier 1a $0
errin oral tablet Tier 1b $0
estarylla oral tablet Tier 1a $0
ethynodiol diac-eth estradiol oral tablet
Tier 1a $0
falmina (28) oral tablet Tier 1a $0
FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1b $0
FEMCAP VAGINAL DEVICE
Tier 3 $0
femynor oral tablet Tier 1a $0
gianvi (28) oral tablet Tier 1b $0
heather oral tablet Tier 1b $0
incassia oral tablet Tier 1b $0
introvale oral tablets,dose pack,3 month
Tier 1b $0
isibloom oral tablet Tier 1a $0
jencycla oral tablet Tier 1b $0
jolessa oral tablets,dose pack,3 month
Tier 1b $0
jolivette oral tablet Tier 1b $0
JULEBER ORAL TABLET
Tier 1a $0
junel 1.5/30 (21) oral tablet Tier 1a $0
junel 1/20 (21) oral tablet Tier 1a $0
junel fe 1.5/30 (28) oral tablet
Tier 1a $0
junel fe 1/20 (28) oral tablet
Tier 1a $0
junel fe 24 oral tablet Tier 1a $0
KAITLIB FE ORAL TABLET,CHEWABLE
Tier 1b $0
kariva (28) oral tablet Tier 1b $0
kelnor 1/35 (28) oral tablet Tier 1a $0
kelnor 1-50 oral tablet Tier 1a $0
Drug Name Tier Notes
kurvelo oral tablet Tier 1a $0
l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month
Tier 1b $0
larin 1.5/30 (21) oral tablet Tier 1a $0
larin 1/20 (21) oral tablet Tier 1a $0
larin 24 fe oral tablet Tier 1a $0
larin fe 1.5/30 (28) oral tablet
Tier 1a $0
larin fe 1/20 (28) oral tablet
Tier 1a $0
larissia oral tablet Tier 1a $0
layolis fe oral tablet,chewable
Tier 1b $0
leena 28 oral tablet Tier 1a $0
lessina oral tablet Tier 1a $0
levonest (28) oral tablet Tier 1a $0
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg
Tier 1a $0
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
Tier 1b $0
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
Tier 1b $0
levonorg-eth estrad triphasic oral tablet
Tier 1a $0
levora-28 oral tablet Tier 1a $0
lillow oral tablet Tier 1a $0
LO LOESTRIN FE ORAL TABLET
Tier 3 $0
loryna (28) oral tablet Tier 1b $0
low-ogestrel (28) oral tablet
Tier 1a $0
lutera (28) oral tablet Tier 1a $0
lyza oral tablet Tier 1b $0
marlissa oral tablet Tier 1a $0
medroxyprogesterone intramuscular suspension
Tier 1b $0
medroxyprogesterone intramuscular syringe
Tier 1b $0
MELODETTA 24 FE ORAL TABLET,CHEWABLE
Tier 1a $0
Effective 10/1/2018
34
Drug Name Tier Notes
MIBELAS 24 FE ORAL TABLET,CHEWABLE
Tier 1a $0
microgestin 1.5/30 (21) oral tablet
Tier 1a $0
microgestin 1/20 (21) oral tablet
Tier 1a $0
microgestin fe 1.5/30 (28) oral tablet
Tier 1a $0
microgestin fe 1/20 (28) oral tablet
Tier 1a $0
mili oral tablet Tier 1a $0
mono-linyah oral tablet Tier 1a $0
mononessa (28) oral tablet Tier 1a $0
my way oral tablet Tier 1b $0; QL
myzilra oral tablet Tier 1a $0
NATAZIA ORAL TABLET Tier 3 $0
necon 0.5/35 (28) oral tablet
Tier 1a $0
next choice one dose oral tablet
Tier 1b $0; QL
nikki (28) oral tablet Tier 1b $0
nora-be oral tablet Tier 1b $0
noreth-ethinyl estradiol-iron oral tablet,chewable
Tier 1b $0
norethindrone (contraceptive) oral tablet
Tier 1b $0
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
Tier 1a $0
norethindrone-e.estradiol-iron oral tablet
Tier 1a $0
norethindrone-e.estradiol-iron oral tablet,chewable
Tier 1a $0
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1b $0
norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg
Tier 1a $0
NORLYDA ORAL TABLET
Tier 1b $0
norlyroc oral tablet Tier 1b $0
nortrel 0.5/35 (28) oral tablet
Tier 1a $0
Drug Name Tier Notes
nortrel 1/35 (21) oral tablet Tier 1a $0
nortrel 1/35 (28) oral tablet Tier 1a $0
nortrel 7/7/7 (28) oral tablet
Tier 1a $0
NUVARING VAGINAL RING
Tier 3 $0
ocella oral tablet Tier 1b $0
ogestrel (28) oral tablet Tier 1a $0
opcicon one-step oral tablet
Tier 1b $0; QL
option-2 oral tablet Tier 3 $0; QL
orsythia oral tablet Tier 1a $0
philith oral tablet Tier 1a $0
pimtrea (28) oral tablet Tier 1b $0
pirmella oral tablet Tier 1a $0
PLAN B ONE-STEP ORAL TABLET
Tier 1b $0; QL
portia oral tablet Tier 1a $0
previfem oral tablet Tier 1a $0
quasense oral tablets,dose pack,3 month
Tier 1b $0
RAJANI ORAL TABLET Tier 1b $0
reclipsen (28) oral tablet Tier 1a $0
RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1b $0
setlakin oral tablets,dose pack,3 month
Tier 1b $0
sharobel oral tablet Tier 1b $0
sprintec (28) oral tablet Tier 1a $0
sronyx oral tablet Tier 1a $0
syeda oral tablet Tier 1b $0
TAKE ACTION ORAL TABLET
Tier 1b $0; QL
tarina fe 1/20 (28) oral tablet
Tier 1a $0
TAYTULLA ORAL CAPSULE
Tier 3 $0
tilia fe oral tablet Tier 1b $0
TRI FEMYNOR ORAL TABLET
Tier 1b $0
tri-estarylla oral tablet Tier 1b $0
tri-legest fe oral tablet Tier 1b $0
tri-linyah oral tablet Tier 1b $0
Effective 10/1/2018
35
Drug Name Tier Notes
TRI-LO-ESTARYLLA ORAL TABLET
Tier 1b $0
tri-lo-marzia oral tablet Tier 1b $0
TRI-LO-SPRINTEC ORAL TABLET
Tier 1b $0
tri-mili oral tablet Tier 1b $0
trinessa (28) oral tablet Tier 1b $0
TRINESSA LO ORAL TABLET
Tier 1b $0
tri-previfem (28) oral tablet Tier 1b $0
tri-sprintec (28) oral tablet Tier 1b $0
trivora (28) oral tablet Tier 1a $0
tri-vylibra oral tablet Tier 1b $0
tulana oral tablet Tier 1b $0
tydemy oral tablet Tier 1b $0
velivet triphasic regimen (28) oral tablet
Tier 1a $0
VIENVA ORAL TABLET Tier 1a $0
viorele (28) oral tablet Tier 1b $0
vyfemla (28) oral tablet Tier 1a $0
vylibra oral tablet Tier 1a $0
wera (28) oral tablet Tier 1a $0
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM
Tier 3 $0
Drug Name Tier Notes
wymzya fe oral tablet,chewable
Tier 1b $0
xulane transdermal patch weekly
Tier 1b $0
zarah oral tablet Tier 1b $0
zenchent (28) oral tablet Tier 1a $0
zovia 1/35e (28) oral tablet Tier 1a $0
COUGH/COLD PREPARATIONS
benzonatate oral capsule 100 mg, 200 mg
Tier 1b
cheratussin ac oral liquid Tier 1a
codeine-guaifen 10-100 mg/5 ml (otc)
Tier 1a
codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)
Tier 1a
g tussin ac oral liquid Tier 1a
guaiatussin ac oral liquid Tier 1a
guaifen-codeine 100-10 mg/5 ml (otc)
Tier 1a
guaifen-codeine 100-10 mg/5 ml inner (otc)
Tier 1b
guaifen-codeine 100-10 mg/5 ml outer (otc)
Tier 1b
guaifen-codeine 200-20 mg/10 ml inner (otc)
Tier 1b
guaifen-codeine 200-20 mg/10 ml outer (otc)
Tier 1b
guaifenesin ac oral liquid Tier 1a
guaifenesin-codeine syrup (otc)
Tier 1a
guaifenesin-codeine syrup (otc)
Tier 1b
hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr
Tier 1b
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
Tier 1a
promethazine vc-codeine oral syrup
Tier 1b
promethazine-codeine oral syrup
Tier 1a
promethazine-dm oral syrup
Tier 1a
Effective 10/1/2018
36
Drug Name Tier Notes
promethazine-phenyleph-codeine oral syrup
Tier 1b
TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR
Tier 3
virtussin ac oral liquid Tier 1a
VITUZ ORAL SOLUTION Tier 3
DIAGNOSTIC
ACCU-CHEK AVIVA PLUS TEST STRP STRIP
Tier 2 QL
ACCU-CHEK COMPACT PLUS TEST STRIP
Tier 2 QL
ACCU-CHEK GUIDE STRIP
Tier 2 QL
ACCU-CHEK SMARTVIEW TEST STRIP STRIP
Tier 2 QL
ACCUTREND GLUCOSE STRIP
Tier 2 QL
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN
Tier 2
GLUCAGON HCL INJECTION RECON SOLN
Tier 2
ONETOUCH VERIO STRIP
Tier 2 QL
DIURETICS
acetazolamide oral capsule, extended release
Tier 1b
acetazolamide oral tablet Tier 1b
amiloride oral tablet Tier 2
AMMONIUM CHLORIDE INTRAVENOUS SOLUTION
Tier 3
bumetanide oral tablet Tier 1b
chlorothiazide oral tablet Tier 1b
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1a
DYRENIUM ORAL CAPSULE
Tier 3
eplerenone oral tablet Tier 2
ethacrynic acid oral tablet Tier 2
Drug Name Tier Notes
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
Tier 1a
furosemide oral tablet Tier 1a
hydrochlorothiazide oral capsule
Tier 1a
hydrochlorothiazide oral tablet
Tier 1a
indapamide oral tablet Tier 1b
methazolamide oral tablet Tier 2
methyclothiazide oral tablet
Tier 1b
metolazone oral tablet Tier 1b
SAMSCA ORAL TABLET Tier 3 SP; LD
spironolactone oral tablet Tier 1a
torsemide oral tablet Tier 1b
triamterene-hydrochlorothiazid oral capsule
Tier 1a
triamterene-hydrochlorothiazid oral tablet
Tier 1a
EENT PREPS
acetic acid otic (ear) solution
Tier 1b
ALOCRIL OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
ALOMIDE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
apraclonidine ophthalmic (eye) drops
Tier 1b
azelastine nasal aerosol,spray
Tier 1b QL
AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
betaxolol ophthalmic (eye) drops
Tier 1b
bimatoprost ophthalmic (eye) drops
Tier 2
brimonidine ophthalmic (eye) drops
Tier 1b
bromfenac ophthalmic (eye) drops
Tier 2
carteolol ophthalmic (eye) drops
Tier 1a
Effective 10/1/2018
37
Drug Name Tier Notes
COMBIGAN OPHTHALMIC (EYE) DROPS
Tier 3
cromolyn ophthalmic (eye) drops
Tier 1a QL
dexamethasone sodium phosphate ophthalmic (eye) drops
Tier 1b
diclofenac sodium ophthalmic (eye) drops
Tier 1b
dorzolamide ophthalmic (eye) drops
Tier 1b
dorzolamide-timolol ophthalmic (eye) drops
Tier 1b
DUREZOL OPHTHALMIC (EYE) DROPS
Tier 3 QL
DYMISTA NASAL SPRAY,NON-AEROSOL
Tier 3 QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
Tier 1b ST; QL
fluocinolone acetonide oil otic (ear) drops
Tier 1b
fluorometholone ophthalmic (eye) drops,suspension
Tier 1b
flurbiprofen sodium ophthalmic (eye) drops
Tier 1b
fluticasone nasal spray,suspension
Tier 1b QL
FML S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
hydrocortisone-acetic acid otic (ear) drops
Tier 1b
ketorolac ophthalmic (eye) drops
Tier 1b
LACRISERT OPHTHALMIC (EYE) INSERT
Tier 3
latanoprost ophthalmic (eye) drops
Tier 1b
levobunolol ophthalmic (eye) drops 0.5 %
Tier 1b
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL
Tier 3
Drug Name Tier Notes
LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
LOTEMAX OPHTHALMIC (EYE) OINTMENT
Tier 3
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
Tier 3
metipranolol ophthalmic (eye) drops
Tier 1b
NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
olopatadine nasal spray,non-aerosol
Tier 1b QL
OMNARIS NASAL SPRAY,NON-AEROSOL
Tier 3 ST; QL
PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS
Tier 3
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
Tier 1b
prednisolone acetate ophthalmic (eye) drops,suspension
Tier 1b
prednisolone sodium phosphate ophthalmic (eye) drops
Tier 1b
RESTASIS OPHTHALMIC (EYE) DROPPERETTE
Tier 3
SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
timolol maleate ophthalmic (eye) drops
Tier 1b
timolol maleate ophthalmic (eye) gel forming solution
Tier 1b
TRAVATAN Z OPHTHALMIC (EYE) DROPS
Tier 3
tropicamide ophthalmic (eye) drops
Tier 1b
TYZINE NASAL DROPS0.05 %
Tier 3
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE
Tier 3
Effective 10/1/2018
38
Drug Name Tier Notes
ELECT/CALORIC/H2O
calcium acetate oral tablet 667 mg
Tier 2
dentagel dental gel Tier 1a
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
Tier 3
effer-k oral tablet, effervescent 25 meq
Tier 1b
eliphos oral tablet Tier 2 PA
enfagrow toddler next step oral powder
Tier 3
fe c plus oral tablet Tier 1a
fluoride (sodium) oral drops
Tier 1a $0
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1a $0
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1a
fluoridex daily defense dental paste
Tier 1b
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
Tier 1a $0
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1a
FOSRENOL ORAL POWDER IN PACKET
Tier 3 PA
GLUCAGEN HYPOKIT INJECTION RECON SOLN
Tier 2
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT
Tier 2
k-effervescent oral tablet, effervescent
Tier 1b
kionex (with sorbitol) oral suspension
Tier 2
klor-con 10 oral tablet extended release
Tier 1b
klor-con 8 oral tablet extended release
Tier 1b
Drug Name Tier Notes
klor-con m10 oral tablet,er particles/crystals
Tier 1a
klor-con m15 oral tablet,er particles/crystals
Tier 1a
klor-con m20 oral tablet,er particles/crystals
Tier 1a
klor-con/ef oral tablet, effervescent
Tier 1b
lanthanum oral tablet,chewable
Tier 2 PA
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1a $0
ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1a
magnesium sulfate in 0.9 %nacl intravenous solution 40 gram/1,000ml (40 mg/ml)
Tier 2
NUTRAMINE ORAL POWDER
Tier 3
potassium bicarb and chloride oral tablet, effervescent
Tier 1b
potassium bicarb-citric acid oral tablet, effervescent
Tier 1b
potassium chloride oral capsule, extended release
Tier 1b
potassium chloride oral tablet extended release
Tier 1b
potassium chloride oral tablet,er particles/crystals
Tier 1a
potassium citrate oral tablet extended release
Tier 2
potassium citrate-citric acid oral solution
Tier 1b
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE
Tier 3
PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE
Tier 3
PREVIDENT DENTAL GEL
Tier 3
Effective 10/1/2018
39
Drug Name Tier Notes
sevelamer carbonate oral powder in packet
Tier 1b
sevelamer carbonate oral tablet
Tier 1b
sf dental gel Tier 1a
SHOHL'S MODIFIED ORAL SOLUTION
Tier 3
sodium chloride 0.45 % intravenous parenteral solution
Tier 1b
sodium chloride 0.45 % intravenous piggyback
Tier 1b
sodium chloride 0.9 % injection solution
Tier 1b
sodium chloride 0.9 % intravenous parenteral solution
Tier 1b
sodium chloride 0.9 % intravenous piggyback
Tier 1b
sodium chloride 3 % intravenous parenteral solution
Tier 1b
sodium chloride 5 % intravenous parenteral solution
Tier 1b
sodium chloride intravenous parenteral solution 2.5 meq/ml
Tier 1b
sodium polystyrene (sorb free) oral suspension
Tier 2
sodium polystyrene sulfonate oral powder
Tier 2
sodium polystyrene sulfonate oral suspension
Tier 2
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
Tier 1b
sps (with sorbitol) oral suspension
Tier 2
sps (with sorbitol) rectal enema
Tier 1b
SSKI ORAL SOLUTION Tier 3
VELPHORO ORAL TABLET,CHEWABLE
Tier 3 PA
Drug Name Tier Notes
GASTROINTESTINAL
AKYNZEO (NETUPITANT) ORAL CAPSULE
Tier 3 QL
alosetron oral tablet Tier 2 QL
AMITIZA ORAL CAPSULE
Tier 3
anaspaz oral tablet,disintegrating
Tier 2
ANZEMET ORAL TABLET
Tier 3 QL
aprepitant oral capsule Tier 2 QL
aprepitant oral capsule,dose pack
Tier 2 QL
APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR
Tier 3 QL
balsalazide oral capsule Tier 1b QL
carafate oral suspension Tier 1b
CESAMET ORAL CAPSULE
Tier 3
CHOLBAM ORAL CAPSULE
Tier 3 PA; LD; QL
cimetidine hcl oral solution Tier 1b
cimetidine oral tablet Tier 1b
COMPAZINE ORAL TABLET
Tier 1b
constulose oral solution Tier 1b
DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS
Tier 3 PA; QL
dicyclomine oral capsule Tier 1a
dicyclomine oral solution Tier 1a
dicyclomine oral tablet Tier 1a
DIPENTUM ORAL CAPSULE
Tier 3 QL
diphenoxylate-atropine oral liquid
Tier 1b
diphenoxylate-atropine oral tablet
Tier 1b
dronabinol oral capsule Tier 2
enulose oral solution Tier 1b
famotidine oral suspension Tier 1b
famotidine oral tablet 20 mg, 40 mg
Tier 1b
Effective 10/1/2018
40
Drug Name Tier Notes
fish oil ec 1,000 mg softgel Tier 1b
gavilyte-c oral recon soln Tier 1a $0
gavilyte-g oral recon soln Tier 1a $0
gavilyte-n oral recon soln Tier 1a $0
generlac oral solution Tier 1b
glycopyrrolate oral tablet 1 mg, 2 mg
Tier 1b
granisetron hcl oral tablet Tier 2 QL
hydrocortisone ac 25 mg supp outer
Tier 1b
hydrocortisone-pramoxine rectal cream 1-1 %
Tier 1b
hyoscyamine 0.125 mg odt
Tier 1b
hyoscyamine 0.125 mg tab sl
Tier 1b
hyoscyamine sulf 0.125 mg tab
Tier 1b
hyoscyamine sulfate oral tablet extended release 12 hr
Tier 1b
lactulose oral solution Tier 1b
lansoprazole oral capsule,delayed release(dr/ec)
Tier 1b QL
laxaclear powder Tier 1b $0
LINZESS ORAL CAPSULE
Tier 2
meclizine oral tablet 12.5 mg, 25 mg
Tier 1a
methscopolamine oral tablet
Tier 1b
metoclopramide hcl oral solution
Tier 1a
metoclopramide hcl oral tablet
Tier 1a
metoclopramide hcl oral tablet,disintegrating
Tier 1a
misoprostol oral tablet Tier 1a
MOTOFEN ORAL TABLET
Tier 3
MOVIPREP ORAL POWDER IN PACKET
Tier 3
nizatidine oral capsule Tier 1b
nizatidine oral solution Tier 1b
Drug Name Tier Notes
omega-3 acid ethyl esters oral capsule
Tier 1b QL
omeprazole oral capsule,delayed release(dr/ec)
Tier 1b QL
ondansetron hcl oral solution
Tier 2 QL
ondansetron hcl oral tablet Tier 2 QL
ondansetron oral tablet,disintegrating
Tier 2 QL
OSMOPREP ORAL TABLET
Tier 3
pantoprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
peg 3350-electrolytes oral recon soln
Tier 1a $0
peg-3350 with flavor packs oral recon soln
Tier 1a $0
peg-electrolyte soln oral recon soln
Tier 1a $0
peg-prep oral kit Tier 3 $0
phenadoz rectal suppository
Tier 2
phenobarb-hyoscy-atropine-scop oral elixir
Tier 1b
polyethylene glycol 3350 oral powder in packet
Tier 1b $0
pramcort rectal cream Tier 1b
PREPOPIK ORAL POWDER IN PACKET
Tier 3
prochlorperazine maleate oral tablet
Tier 1a
promethazine rectal suppository
Tier 2
promethegan rectal suppository
Tier 2
rabeprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
ranitidine hcl oral capsule Tier 1b
ranitidine hcl oral syrup Tier 1b
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1b
RECTIV RECTAL OINTMENT
Tier 3
Effective 10/1/2018
41
Drug Name Tier Notes
SANCUSO TRANSDERMAL PATCH WEEKLY
Tier 3 QL
scopolamine base transdermal patch 3 day
Tier 2
sodium phenylbutyrate oral tablet
Tier 2 PA; QL
sucralfate oral tablet Tier 1b
sulfasalazine oral tablet Tier 1b QL
sulfasalazine oral tablet,delayed release (dr/ec)
Tier 1b QL
SUPREP BOWEL PREP KIT ORAL RECON SOLN
Tier 3
trilyte with flavor packets oral recon soln
Tier 1a $0
trimethobenzamide oral capsule
Tier 1b
ursodiol oral capsule Tier 2
ursodiol oral tablet Tier 2
VARUBI ORAL TABLET Tier 3 QL
VASCEPA ORAL CAPSULE
Tier 3 QL
VIBERZI ORAL TABLET Tier 3 PA; QL
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT
Tier 2
HORMONES
AMABELZ ORAL TABLET
Tier 1b
ANADROL-50 ORAL TABLET
Tier 3
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)
Tier 3 PA; QL
Drug Name Tier Notes
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
Tier 3 PA; QL
budesonide oral capsule,delayed,extend.release
Tier 2 QL
cabergoline oral tablet Tier 1b
calcitonin (salmon) nasal spray,non-aerosol
Tier 2 QL
chorionic gonadotropin, human intramuscular recon soln
Tier 4 PA; SP
cortisone oral tablet Tier 1b
danazol oral capsule Tier 2
decadron oral elixir Tier 1a
DELTASONE ORAL TABLET 20 MG
Tier 1a
desmopressin nasal spray with pump
Tier 2
desmopressin nasal spray,non-aerosol
Tier 2
desmopressin oral tablet Tier 1b
dexamethasone intensol oral drops
Tier 1a
dexamethasone oral elixir Tier 1a
dexamethasone oral solution
Tier 1a
dexamethasone oral tablet Tier 1a
DUAVEE ORAL TABLET Tier 3 QL
estradiol oral tablet Tier 1b
estradiol transdermal patch semiweekly
Tier 1b QL
estradiol transdermal patch weekly
Tier 1b
estradiol vaginal cream Tier 2
estradiol vaginal tablet Tier 2 QL
estradiol-norethindrone acet oral tablet
Tier 1b
ESTRING VAGINAL RING
Tier 3 QL
estropipate oral tablet 0.75 mg
Tier 1a
fludrocortisone oral tablet Tier 1b
Effective 10/1/2018
42
Drug Name Tier Notes
GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
GONAL-F RFF SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
GONAL-F SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
hydrocortisone oral tablet Tier 1b
hydrocortisone rectal enema
Tier 2
INCRELEX SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
jinteli oral tablet Tier 1b
LOPREEZA ORAL TABLET
Tier 1b
LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
medroxyprogesterone oral tablet
Tier 1a QL
MENEST ORAL TABLET Tier 3
METHITEST ORAL TABLET
Tier 3
methylergonovine oral tablet
Tier 1b
methylprednisolone oral tablet
Tier 1a
methylprednisolone oral tablets,dose pack
Tier 1a
millipred dp oral tablets,dose pack
Tier 1a
millipred oral tablet Tier 1a
mimvey lo oral tablet Tier 1b
mimvey oral tablet Tier 1b
MYALEPT SUBCUTANEOUS RECON SOLN
Tier 4 SP; LD
norethindrone acetate oral tablet
Tier 1b
Drug Name Tier Notes
NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
oxandrolone oral tablet Tier 2 PA
prednisolone oral solution 15 mg/5 ml
Tier 1a
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
Tier 1a
prednisone intensol oral concentrate
Tier 1a
prednisone oral solution Tier 1a
prednisone oral tablet Tier 1a
prednisone oral tablets,dose pack
Tier 1a
PREMARIN ORAL TABLET
Tier 3 QL
PREMARIN VAGINAL CREAM
Tier 3 QL
PREMPHASE ORAL TABLET
Tier 3
PREMPRO ORAL TABLET
Tier 3
progesterone micronized oral capsule
Tier 1b QL
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON
Tier 4 PA; SP; QL
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG, 30 MG
Tier 4 PA; SP; QL
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 40 MG, 60 MG
Tier 4 PA; SP; LD; QL
SIGNIFOR SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD; QL
Effective 10/1/2018
43
Drug Name Tier Notes
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
SYNAREL NASAL SPRAY,NON-AEROSOL
Tier 4 PA; SP; QL
testosterone 12.5 mg/1.25 gram
Tier 2 PA; QL
testosterone 12.5 mg/1.25 gram outer
Tier 2 PA; QL
testosterone 50 mg/5 gram pkt
Tier 2 PA; QL
testosterone 50 mg/5 gram pkt inner
Tier 2 PA; QL
testosterone 50 mg/5 gram pkt outer
Tier 2 PA; QL
testosterone cypionate intramuscular oil
Tier 1b
testosterone transdermal gel in packet 1 % (25 mg/2.5gram)
Tier 2 PA; QL
veripred 20 oral solution Tier 1a
YUVAFEM VAGINAL TABLET
Tier 2 QL
IMMUNOSUPPRESSANTS
ACTEMRA INTRAVENOUS SOLUTION
Tier 4 PA; SP
ACTEMRA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
azathioprine oral tablet Tier 2
cyclosporine modified oral capsule
Tier 4 SP
cyclosporine modified oral solution
Tier 4 SP
cyclosporine oral capsule Tier 4 SP
ELIDEL TOPICAL CREAM
Tier 3 PA
gengraf oral capsule 100 mg, 25 mg
Tier 4 SP
gengraf oral solution Tier 4 SP
mycophenolate mofetil oral capsule
Tier 4 SP
mycophenolate mofetil oral tablet
Tier 4 SP
Drug Name Tier Notes
mycophenolate sodium oral tablet,delayed release (dr/ec)
Tier 4 SP
RAPAMUNE ORAL SOLUTION
Tier 4 SP
STELARA INTRAVENOUS SOLUTION
Tier 4 PA; SP; QL
STELARA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; QL
STELARA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
tacrolimus oral capsule Tier 4 SP
tacrolimus topical ointment Tier 1b PA
ZORTRESS ORAL TABLET
Tier 4 PA; SP
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG
ACCU-CHEK AVIVA CONTROL SOLN SOLUTION
Tier 2
ACCU-CHEK AVIVA PLUS METER
Tier 2
ACCU-CHEK COMP BLUE CONT, M-H SOLUTION
Tier 2
ACCU-CHEK COMPACT PLUS CARE KIT
Tier 2
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
Tier 2
ACCU-CHEK FASTCLIX LANCING DEV KIT
Tier 2
ACCU-CHEK GUIDE GLUCOSE METER
Tier 2
ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION
Tier 2
ACCU-CHEK MULTICLIX LANCET
Tier 2
ACCU-CHEK MULTICLIX LANCET KIT
Tier 2
ACCU-CHEK NANO Tier 2
ACCU-CHEK SAFE-T-PRO PLUS
Tier 2
Effective 10/1/2018
44
Drug Name Tier Notes
ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION
Tier 2
ACCU-CHEK SOFT DEV LANCETS KIT
Tier 2
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 2
ACCU-CHEK SOFTCLIX LANCETS
Tier 2
ACCU-CHEK VOICEMATE KIT
Tier 2
ACCUTREND GLUCOSE CONTROL SOLUTION
Tier 2
acti-lance lancets 17 gauge, 28 gauge
Tier 1b
CHEMSTRIP BG LOG BOOK
Tier 2
e-z ject lancets Tier 1b
E-Z JECT THIN LANCETS
Tier 1b
insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"
Tier 1b
ONETOUCH DELICA LANC DEVICE KIT
Tier 2
ONETOUCH DELICA LANCETS
Tier 2
ONETOUCH ULTRA CONTROL SOLUTION
Tier 2
ONETOUCH ULTRA2 KIT Tier 2
ONETOUCH ULTRAMINI KIT
Tier 2
ONETOUCH ULTRASOFT LANCETS
Tier 2
ONETOUCH VERIO FLEX
Tier 2
ONETOUCH VERIO HIGH CONTROL SOLUTION
Tier 2
ONETOUCH VERIO IQ METER
Tier 2
ONETOUCH VERIO MID CONTROL SOLUTION
Tier 2
ONETOUCH VERIO SYSTEM
Tier 2
Drug Name Tier Notes
thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"
Tier 1b
MUSCLE RELAXANTS
baclofen oral tablet 10 mg, 20 mg
Tier 2
carisoprodol oral tablet Tier 1b
chlorzoxazone oral tablet Tier 1b
cyclobenzaprine oral tablet Tier 1b
dantrolene oral capsule Tier 2
metaxalone oral tablet Tier 1b
methocarbamol oral tablet Tier 1b
orphenadrine citrate oral tablet extended release
Tier 1b
tizanidine oral capsule Tier 1b
tizanidine oral tablet Tier 1b
PRE-NATAL VITAMINS
bal-care dha oral combo pack,tablet and cap,dr
Tier 1b
c-nate dha oral capsule Tier 1b
complete natal dha oral combo pack
Tier 1b
completenate oral tablet,chewable
Tier 1a
elite ob with dha oral capsule
Tier 1b
elite-ob 400 oral capsule Tier 1b
ELITE-OB ORAL TABLET
Tier 1b
folivane-ob oral capsule Tier 1a
hemenatal ob + dha oral combo pack
Tier 1b
hemenatal ob oral tablet Tier 1b
mynatal advance oral tablet
Tier 1b
mynatal oral capsule Tier 1b
mynatal oral tablet Tier 1b
mynatal plus oral tablet Tier 1a
mynatal-z oral tablet Tier 1a
mynate 90 plus oral tablet extended release
Tier 1a
obstetrix dha oral combo pack,tablet and cap,dr
Tier 1b
Effective 10/1/2018
45
Drug Name Tier Notes
pnv ob+dha oral combo pack 27-1-50-250 mg
Tier 1b
pnv-dha + docusate oral capsule
Tier 1b
pnv-ferrous fumarate-docu-fa oral tablet
Tier 1a
pnv-omega oral capsule Tier 1b
pr natal 400 ec oral combo pack,tablet and cap,dr
Tier 1a
pr natal 400 oral combo pack
Tier 1a
pr natal 430 ec oral combo pack,tablet and cap,dr
Tier 1a
pr natal 430 oral combo pack
Tier 1a
prenaissance oral capsule Tier 1b
prenaissance plus oral capsule
Tier 1b
prenatabs fa oral tablet Tier 1a
prenatabs rx oral tablet Tier 1a
prenatal 19 (with docusate) oral tablet
Tier 1a
prenatal low iron oral tablet
Tier 1a
prenatal multivitamin tablet Tier 1a $0
PRENATAL ONE DAILY ORAL TABLET
Tier 1a $0
prenatal plus (calcium carb) oral tablet
Tier 1a
prenatal plus oral tablet Tier 1a
prenatal vitamin plus low iron
Tier 1a
prenatal-u oral capsule Tier 1a
preplus oral tablet Tier 1a
se-natal 19 (with docusate) oral tablet
Tier 1a
se-natal 19 oral tablet,chewable
Tier 1a
taron-c dha oral capsule Tier 1b
taron-prex prenatal-dha oral capsule
Tier 1b
tl-select oral capsule Tier 1b
triadvance oral tablet Tier 1b
trinatal rx 1 oral tablet Tier 1a
trinate oral tablet Tier 1a
Drug Name Tier Notes
triveen-duo dha oral combo pack
Tier 1b
triveen-one oral capsule Tier 1b
triveen-prx rnf oral capsule Tier 1b
trust natal dha oral combo pack
Tier 1b
vena-bal dha oral combo pack,tablet and cap,dr
Tier 1b
vinacal oral tablet Tier 1b
vinate care oral tablet,chewable
Tier 1a
vinate gt oral tablet Tier 1b
vinate ii oral tablet Tier 1a
vinate one oral tablet Tier 1a
vinate pn care oral tablet Tier 1b
vinate ultra oral tablet Tier 1b
VIRT-NATE DHA ORAL CAPSULE
Tier 1b
virt-pn dha oral capsule Tier 1b
virt-pn oral tablet Tier 1b
virt-pn plus oral capsule Tier 1b
virt-select oral capsule Tier 1b
vitafol-ob oral tablet Tier 1b
vp-ch plus oral capsule Tier 1b
vp-ch-pnv oral capsule Tier 1b
zatean-pn dha oral capsule
Tier 1b
zatean-pn plus oral capsule
Tier 1b
zingiber oral tablet Tier 1a
PSYCHOTHERAPEUTIC DRUGS
ADDYI ORAL TABLET Tier 3 PA; QL
alprazolam oral tablet Tier 1b
amitriptyline oral tablet Tier 1a
amoxapine oral tablet Tier 1b
aripiprazole oral solution Tier 2
aripiprazole oral tablet Tier 2
armodafinil oral tablet 150 mg, 250 mg, 50 mg
Tier 2 PA; QL
armodafinil oral tablet 200 mg
Tier 2 PA
atomoxetine oral capsule Tier 2 PA
Effective 10/1/2018
46
Drug Name Tier Notes
bupropion hcl oral tablet 100 mg
Tier 1b QL
bupropion hcl oral tablet 75 mg
Tier 1b DO
bupropion hcl oral tablet extended release 24 hr 150 mg
Tier 1b DO
bupropion hcl oral tablet extended release 24 hr 300 mg
Tier 1b QL
bupropion hcl oral tablet sustained-release 12 hr 100 mg
Tier 1b DO
bupropion hcl oral tablet sustained-release 12 hr 150 mg
Tier 1b $0
bupropion hcl oral tablet sustained-release 12 hr 200 mg
Tier 1b
buspirone oral tablet Tier 1b
chlorpromazine oral tablet Tier 2
citalopram oral solution Tier 1b QL
citalopram oral tablet 10 mg, 20 mg
Tier 1b DO
citalopram oral tablet 40 mg
Tier 1b QL
clomipramine oral capsule Tier 2
clonidine hcl oral tablet extended release 12 hr
Tier 1b PA
clozapine oral tablet Tier 2
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
Tier 2
desipramine oral tablet Tier 2
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg
Tier 1b QL
desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg
Tier 1b DO
dexmethylphenidate oral capsule,er biphasic 50-50
Tier 1b PA
dexmethylphenidate oral tablet
Tier 1b PA
diazepam intensol oral concentrate
Tier 1a
Drug Name Tier Notes
diazepam oral concentrate Tier 1a
diazepam oral solution Tier 1a
diazepam oral tablet Tier 1a
doxepin oral capsule Tier 1b
doxepin oral concentrate Tier 1b
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg
Tier 2 PA; QL
duloxetine oral capsule,delayed release(dr/ec) 30 mg
Tier 2 PA; DO
EMSAM TRANSDERMAL PATCH 24 HOUR
Tier 3
escitalopram oxalate oral solution
Tier 1b QL
escitalopram oxalate oral tablet 10 mg, 5 mg
Tier 1b DO
escitalopram oxalate oral tablet 20 mg
Tier 1b QL
FANAPT ORAL TABLET Tier 3
FANAPT ORAL TABLETS,DOSE PACK
Tier 3
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
Tier 3 ST; QL
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR
Tier 3 ST; QL
fluoxetine oral capsule 10 mg, 20 mg
Tier 1b DO
fluoxetine oral capsule 40 mg
Tier 1b QL
fluoxetine oral capsule,delayed release(dr/ec)
Tier 1b QL
fluoxetine oral solution Tier 1b QL
fluoxetine oral tablet 10 mg
Tier 1b DO
fluoxetine oral tablet 20 mg
Tier 1b
fluphenazine hcl oral concentrate
Tier 1b
fluphenazine hcl oral elixir Tier 1b
fluphenazine hcl oral tablet Tier 1b
Effective 10/1/2018
47
Drug Name Tier Notes
fluvoxamine oral tablet 100 mg
Tier 1b QL
fluvoxamine oral tablet 25 mg, 50 mg
Tier 1b DO
guanfacine oral tablet extended release 24 hr
Tier 1b PA
haloperidol oral tablet Tier 1b
imipramine hcl oral tablet Tier 1b
LATUDA ORAL TABLET Tier 3
lithium carbonate oral capsule
Tier 1a
lithium carbonate oral tablet
Tier 1a
lithium carbonate oral tablet extended release
Tier 1a
lithium citrate oral solution Tier 1b
loxapine succinate oral capsule
Tier 1b
maprotiline oral tablet Tier 1b
MARPLAN ORAL TABLET
Tier 3
meprobamate oral tablet Tier 1b
metadate er oral tablet extended release
Tier 1b PA
methylphenidate hcl oral capsule, er biphasic 30-70
Tier 1b PA
methylphenidate hcl oral capsule,er biphasic 50-50
Tier 1b PA
methylphenidate hcl oral solution
Tier 1b PA
methylphenidate hcl oral tablet
Tier 1b PA
methylphenidate hcl oral tablet extended release
Tier 1b PA
methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg
Tier 1b PA
mirtazapine oral tablet Tier 1b
mirtazapine oral tablet,disintegrating
Tier 1b
modafinil oral tablet 100 mg
Tier 2 PA; DO
modafinil oral tablet 200 mg
Tier 2 PA; QL
nefazodone oral tablet Tier 1b
Drug Name Tier Notes
nortriptyline oral capsule Tier 1b
nortriptyline oral solution Tier 1b
olanzapine oral tablet Tier 2
olanzapine oral tablet,disintegrating
Tier 2
paliperidone oral tablet extended release 24hr
Tier 2
paroxetine hcl oral tablet 10 mg, 20 mg
Tier 1b DO
paroxetine hcl oral tablet 30 mg, 40 mg
Tier 1b QL
paroxetine hcl oral tablet extended release 24 hr 12.5 mg
Tier 1b DO
paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg
Tier 1b QL
perphenazine oral tablet Tier 1b
phenelzine oral tablet Tier 1b
pimozide oral tablet Tier 2
protriptyline oral tablet Tier 2
quetiapine oral tablet Tier 2
quetiapine oral tablet extended release 24 hr
Tier 2
risperidone oral solution Tier 1b
risperidone oral tablet Tier 1b
risperidone oral tablet,disintegrating
Tier 2
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
Tier 3
sertraline oral concentrate Tier 1b QL
sertraline oral tablet 100 mg
Tier 1b QL
sertraline oral tablet 25 mg, 50 mg
Tier 1b DO
thioridazine oral tablet Tier 1b
thiothixene oral capsule Tier 1b
tranylcypromine oral tablet Tier 1b
trazodone oral tablet Tier 1a
trifluoperazine oral tablet Tier 1b
trimipramine oral capsule Tier 1b
TRINTELLIX ORAL TABLET 10 MG, 5 MG
Tier 3 ST; DO
Effective 10/1/2018
48
Drug Name Tier Notes
TRINTELLIX ORAL TABLET 20 MG
Tier 3 ST; QL
venlafaxine oral capsule,extended release 24hr 150 mg
Tier 1b QL
venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg
Tier 1b DO
venlafaxine oral tablet Tier 1b QL
venlafaxine oral tablet extended release 24hr 150 mg, 225 mg
Tier 1b QL
venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg
Tier 1b DO
VIIBRYD ORAL TABLET10 MG, 20 MG
Tier 3 ST; DO
VIIBRYD ORAL TABLET40 MG
Tier 3 ST; QL
VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)
Tier 3 ST; QL
VYVANSE ORAL CAPSULE
Tier 3 PA
ziprasidone hcl oral capsule
Tier 2
SEDATIVE/HYPNOTICS
estazolam oral tablet Tier 1b
eszopiclone oral tablet 1 mg, 2 mg
Tier 1b QL
eszopiclone oral tablet 3 mg
Tier 1b PA; QL
HETLIOZ ORAL CAPSULE
Tier 4 PA; SP; LD; QL
hm nighttime sleep aid 50 mg softgel,max strength
Tier 1a
phenobarbital oral elixir Tier 1b
phenobarbital oral tablet Tier 1b
ROZEREM ORAL TABLET
Tier 3 ST; QL
SILENOR ORAL TABLET Tier 3 QL
XYREM ORAL SOLUTION
Tier 3 PA; SP; LD; QL
zaleplon oral capsule Tier 1b QL
zolpidem oral tablet Tier 1b QL
Drug Name Tier Notes
SKIN PREPS
acitretin oral capsule Tier 2
adapalene topical cream Tier 1b
adapalene topical gel Tier 1b
adapalene topical gel with pump
Tier 1b
adapalene-benzoyl peroxide topical gel with pump
Tier 2
alclometasone topical cream
Tier 1b
alclometasone topical ointment
Tier 1b
ALTABAX TOPICAL OINTMENT
Tier 3
amcinonide topical cream Tier 1b
amcinonide topical lotion Tier 1b
amcinonide topical ointment
Tier 1b
ammonium lactate topical cream
Tier 1b
ammonium lactate topical lotion
Tier 1b
AMNESTEEM ORAL CAPSULE
Tier 2 PA
avita topical cream Tier 1b PA
AZELEX TOPICAL CREAM
Tier 3 PA
benzoyl peroxide 9.8% foam emollient foam (otc)
Tier 1b
benzoyl peroxide topical cleanser 3 %, 6 %, 9 %
Tier 1b
benzoyl peroxide topical foam 5.3 %
Tier 1b
betamethasone dipropionate topical cream
Tier 1b
betamethasone dipropionate topical lotion
Tier 1b
betamethasone dipropionate topical ointment
Tier 1b
betamethasone valerate topical cream
Tier 1b
betamethasone valerate topical foam
Tier 1b
Effective 10/1/2018
49
Drug Name Tier Notes
betamethasone valerate topical lotion
Tier 1b
betamethasone valerate topical ointment
Tier 1b
betamethasone, augmented topical cream
Tier 1b
betamethasone, augmented topical gel
Tier 1b
betamethasone, augmented topical lotion
Tier 1b
betamethasone, augmented topical ointment
Tier 1b
bpo topical gel Tier 1b
bpo topical towelette 6 % Tier 1b
calcipotriene scalp solution
Tier 1b
calcipotriene topical cream Tier 1b
calcipotriene topical ointment
Tier 1b
calcipotriene-betamethasone topical ointment
Tier 1b
calcitrene topical ointment Tier 1b
calcitriol topical ointment Tier 1b
claravis oral capsule Tier 2 PA
clindamycin-benzoyl peroxide topical gel
Tier 1b
clindamycin-benzoyl peroxide topical gel with pump 1-5 %
Tier 1b
clindamycin-tretinoin topical gel
Tier 2
clobetasol scalp solution Tier 1b
clobetasol topical cream Tier 1b
clobetasol topical foam Tier 1b
clobetasol topical gel Tier 1b
clobetasol topical lotion Tier 1b
clobetasol topical ointment Tier 1b
clobetasol topical shampoo
Tier 1b
clobetasol-emollient topical cream
Tier 1b
clobetasol-emollient topical foam
Tier 1b
Drug Name Tier Notes
CLODERM TOPICAL CREAM
Tier 3
CORDRAN TAPE LARGE ROLL TOPICAL TAPE
Tier 3
cormax scalp solution Tier 1b
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
COSENTYX SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
crotan topical lotion Tier 2
dapsone topical gel Tier 2
desonide topical cream Tier 1b
desonide topical lotion Tier 1b
desonide topical ointment Tier 1b
desoximetasone topical cream
Tier 1b
desoximetasone topical gel
Tier 1b
desoximetasone topical ointment
Tier 1b
diclofenac sodium topical gel 1 %
Tier 2 QL
diflorasone topical cream Tier 1b
diflorasone topical ointment
Tier 1b
EURAX TOPICAL CREAM
Tier 3
EURAX TOPICAL LOTION
Tier 3
FINACEA TOPICAL GEL Tier 3
FLECTOR TRANSDERMAL PATCH 12 HOUR
Tier 3 QL
fluocinolone and shower cap scalp oil
Tier 1b
fluocinolone topical cream Tier 1b
fluocinolone topical oil Tier 1b
Effective 10/1/2018
50
Drug Name Tier Notes
fluocinolone topical ointment
Tier 1b
fluocinolone topical solution
Tier 1b
fluocinonide topical cream Tier 1b
fluocinonide topical gel Tier 1b
fluocinonide topical ointment
Tier 1b
fluocinonide topical solution
Tier 1b
fluocinonide-e topical cream
Tier 1b
fluocinonide-emollient topical cream
Tier 1b
flurandrenolide topical cream
Tier 2
flurandrenolide topical lotion
Tier 2
fluticasone topical cream Tier 1b
fluticasone topical lotion Tier 1b
fluticasone topical ointment
Tier 1b
halobetasol propionate topical cream
Tier 1b
halobetasol propionate topical ointment
Tier 1b
HALOG TOPICAL CREAM
Tier 3
HALOG TOPICAL OINTMENT
Tier 3
hydrocortisone butyrate topical cream
Tier 1b
hydrocortisone butyrate topical lotion
Tier 1b
hydrocortisone butyrate topical ointment
Tier 1b
hydrocortisone butyrate topical solution
Tier 1b
hydrocortisone butyr-emollient topical cream
Tier 1b
hydrocortisone topical cream 2.5 %
Tier 1a
hydrocortisone topical cream with perineal applicator
Tier 1b
Drug Name Tier Notes
hydrocortisone topical lotion 2.5 %
Tier 1a
hydrocortisone topical ointment 2.5 %
Tier 1a
hydrocortisone valerate topical cream
Tier 1b
hydrocortisone valerate topical ointment
Tier 1b
imiquimod topical cream in packet
Tier 1b PA; QL
lindane topical shampoo Tier 1b
malathion topical lotion Tier 1b
methoxsalen oral capsule,liqd-filled,rapid rel
Tier 2 PA; SP
metronidazole topical 0.75% gl
Tier 1b
metronidazole topical cream
Tier 1b
metronidazole topical gel 1 %
Tier 1b
metronidazole topical gel with pump
Tier 1b
metronidazole topical lotion
Tier 1b
MIRVASO TOPICAL GEL Tier 3
MIRVASO TOPICAL GEL WITH PUMP
Tier 3
mometasone topical cream
Tier 1b
mometasone topical ointment
Tier 1b
mometasone topical solution
Tier 1b
OVACE TOPICAL CLEANSER
Tier 3
permethrin topical cream Tier 1b
PHYSIOLYTE IRRIGATION SOLUTION
Tier 3
podofilox topical solution Tier 1b
prednicarbate topical cream
Tier 1b
prednicarbate topical ointment
Tier 1b
PROCTOSOL-HC 2.5% CREAM
Tier 1b
Effective 10/1/2018
51
Drug Name Tier Notes
proctozone-hc topical cream with perineal applicator
Tier 1b
prudoxin topical cream Tier 2
REGRANEX TOPICAL GEL
Tier 3
rosadan topical cream Tier 1b
ROSADAN TOPICAL GEL
Tier 1b
salicylic acid 26% liquid Tier 1b
salicylic acid 27.5% liquid Tier 1b
salicylic acid topical cream Tier 1b
salicylic acid topical cream,extended release
Tier 1b
salicylic acid topical foam Tier 1b
salicylic acid topical gel Tier 1b
salicylic acid topical lotion Tier 1b
salicylic acid topical lotion,extended release
Tier 1b
salicylic acid topical shampoo
Tier 1b
salvax topical foam Tier 1b
SANTYL TOPICAL OINTMENT
Tier 3
seb-prev topical cleanser Tier 1b
selenium sulfide topical lotion
Tier 1a
selenium sulfide topical shampoo 2.25 %
Tier 1a
SKLICE TOPICAL LOTION
Tier 3
sodium chloride irrigation solution
Tier 1b
spinosad topical suspension
Tier 1b
sulfacetamide sodium (acne) topical suspension
Tier 1b
sulfacetamide sodium topical cleanser
Tier 1b
sulfacetamide sodium topical cleanser, gel
Tier 1b
sulfacetamide sodium topical shampoo
Tier 1b
tazarotene topical cream Tier 2
Drug Name Tier Notes
TAZORAC TOPICAL CREAM 0.05 %
Tier 3
TAZORAC TOPICAL GEL Tier 3
tretinoin (emollient) topical cream
Tier 1b PA
tretinoin topical cream Tier 1b PA
tretinoin topical gel 0.01 %, 0.025 %
Tier 1b PA
triamcinolone acetonide topical cream
Tier 1a
triamcinolone acetonide topical lotion
Tier 1a
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
Tier 1a
trianex topical ointment Tier 1a
triderm topical cream 0.1 %
Tier 1a
TRIDERM TOPICAL CREAM 0.5 %
Tier 1a
ULESFIA TOPICAL LOTION
Tier 3
zenatane oral capsule Tier 2 PA
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr
Tier 1b $0; QL
CHANTIX CONTINUING MONTH BOX ORAL TABLET
Tier 3 $0; QL
CHANTIX ORAL TABLET Tier 3 $0; QL
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK
Tier 3 $0; QL
NICOTROL INHALATION CARTRIDGE
Tier 3 $0
NICOTROL NS NASAL SPRAY,NON-AEROSOL
Tier 3 $0
ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 $0; QL
THYROID PREPS
ARMOUR THYROID ORAL TABLET
Tier 1b
levothyroxine oral tablet Tier 1a
Effective 10/1/2018
52
Drug Name Tier Notes
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1a
liothyronine oral tablet Tier 1b
methimazole oral tablet 10 mg, 5 mg
Tier 1a
nature-throid oral tablet Tier 1a
NP THYROID ORAL TABLET 120 MG, 15 MG
Tier 1a
np thyroid oral tablet 30 mg, 60 mg, 90 mg
Tier 1a
propylthiouracil oral tablet Tier 1b
SYNTHROID ORAL TABLET
Tier 1b
THYROLAR-1 ORAL TABLET
Tier 3
THYROLAR-1/2 ORAL TABLET
Tier 3
THYROLAR-1/4 ORAL TABLET
Tier 3
THYROLAR-2 ORAL TABLET
Tier 3
THYROLAR-3 ORAL TABLET
Tier 3
unithroid oral tablet Tier 1a
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
Tier 1a
WP THYROID ORAL TABLET
Tier 1b
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral tablet,delayed release (dr/ec)
Tier 2 QL
alendronate oral solution Tier 1b
alendronate oral tablet Tier 1b QL
alfuzosin oral tablet extended release 24 hr
Tier 1b
ARCALYST SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; LD; QL
BERINERT INTRAVENOUS KIT
Tier 4 PA; LD
Drug Name Tier Notes
BERINERT INTRAVENOUS RECON SOLN
Tier 4 PA; LD
buprenorphine hcl sublingual tablet
Tier 2 QL
buprenorphine-naloxone sublingual tablet
Tier 1b QL
CARBAGLU ORAL TABLET, DISPERSIBLE
Tier 4 LD
CERDELGA ORAL CAPSULE
Tier 4 PA; SP
CHEMET ORAL CAPSULE
Tier 3
chlorhexidine gluconate mucous membrane mouthwash
Tier 1a
CIALIS ORAL TABLET2.5 MG, 5 MG
Tier 3 PA; QL
CYSTADANE ORAL POWDER
Tier 3 LD
darifenacin oral tablet extended release 24 hr
Tier 2 ST
DEBACTEROL MUCOUS MEMBRANE SOLUTION
Tier 3
DEBACTEROL MUCOUS MEMBRANE SWAB
Tier 3
disulfiram oral tablet Tier 1b
doxercalciferol oral capsule
Tier 2
doxycycline hyclate oral tablet 20 mg
Tier 1b
dutasteride oral capsule Tier 2
etidronate disodium oral tablet
Tier 2
FERRIPROX ORAL TABLET
Tier 4 PA; LD
finasteride oral tablet Tier 1b
flavoxate oral tablet Tier 1b
FORTEO SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT
Tier 3 ST; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 5,600 UNIT
Tier 3 ST
Effective 10/1/2018
53
Drug Name Tier Notes
ibandronate oral tablet Tier 1b QL
KALYDECO ORAL GRANULES IN PACKET
Tier 4 PA; SP; LD; QL
KALYDECO ORAL TABLET
Tier 4 PA; SP; LD; QL
KEVEYIS ORAL TABLET Tier 4 PA; LD; QL
KUVAN ORAL TABLET,SOLUBLE
Tier 4 PA; SP; LD
leucovorin calcium oral tablet
Tier 2
levocarnitine (with sugar) oral solution
Tier 1b
levocarnitine oral tablet Tier 2
miglustat oral capsule Tier 4 PA; SP
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
OFEV ORAL CAPSULE Tier 4 PA; SP; LD; QL
oralone dental paste Tier 1b
ORFADIN ORAL CAPSULE
Tier 4 LD
OSPHENA ORAL TABLET
Tier 3 QL
oxybutynin chloride oral syrup
Tier 1b
oxybutynin chloride oral tablet
Tier 1b
oxybutynin chloride oral tablet extended release 24hr
Tier 1b
paricalcitol oral capsule Tier 2
paroex oral rinse mucous membrane mouthwash
Tier 1a
periogard mucous membrane mouthwash
Tier 1a
raloxifene oral tablet Tier 1b $0
RAPAFLO ORAL CAPSULE
Tier 3
risedronate oral tablet Tier 1b QL
SAVELLA ORAL TABLET
Tier 3 QL
SAVELLA ORAL TABLETS,DOSE PACK
Tier 3 QL
SENSIPAR ORAL TABLET 30 MG, 60 MG
Tier 4 QL
Drug Name Tier Notes
SENSIPAR ORAL TABLET 90 MG
Tier 4
SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION
Tier 2 $0
sildenafil oral tablet Tier 1b PA; QL
tamsulosin oral capsule Tier 1b
tolterodine oral tablet Tier 1b
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
triamcinolone acetonide dental paste
Tier 1b
trientine oral capsule Tier 2 SP
trospium oral capsule,extended release 24hr
Tier 2
VESICARE ORAL TABLET
Tier 3
VITAMINS
calcitriol oral capsule Tier 1b
calcitriol oral solution Tier 2
cyanocobalamin (vitamin b-12) injection solution
Tier 1a
ergocalciferol (vitamin d2) oral capsule
Tier 1a
folic acid oral tablet 1 mg Tier 1a
multi-vitamin with fluoride oral drops
Tier 3 $0
multivitamin with fluoride oral tablet,chewable
Tier 3 $0
multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 3 $0
multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 3 $0
mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 3 $0
tl gard rx oral tablet Tier 1b
triple vitamin with fluoride oral drops
Tier 3 $0
tri-vitamin with fluoride oral drops
Tier 3 $0
Effective 10/1/2018
54
Drug Name Tier Notes
tri-vite with fluoride oral drops
Tier 3
vinate m oral tablet Tier 1a
vitamin d2 oral capsule Tier 1a
vitamins a,c,d and fluoride oral drops
Tier 3 $0
vol-nate oral tablet Tier 1a
vol-plus oral tablet Tier 1a
vol-tab rx oral tablet Tier 1a
Effective 10/1/2018
55
Most plans include our convenient home delivery program at no extra cost to you. Find out more
at anthem.com or call 866-217-2328.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 3/18
For information about your pharmacy benefit, log in at anthem.com. You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Member Services number on your ID card.
Speech and hearing impaired (TDD/TTY) users Call 1-800-221-6915, Monday through Friday, 8:30 a.m. to 5 p.m.ET.