2 Tier
2018 Formulary
(List of covered drugs)
For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy.
Effective: October 1, 2018
©2018 HealthPartners
What’s the GenericsAdvantageRx drug list?
This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates.
Who decides what’s on the drug list?
The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.
How do you use the drug list?
The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3.
Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you less. Some generic medicines are very low-cost.
Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.
The Tier Status can be used to determine how much a medicine will cost you. For exact cost information, • Find the tier status for your medicine. • Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or, • Log on to your myHealthPartners account to check your pharmacy benefits.
• Tier 1 – Formulary Generics & Brands • Tier 2 – Specialty Generics & Brands
What’s a Specialty Medicine?
Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines.
What do the abbreviations in the More details column mean?
This column gives special information about the medicine you’re searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list:
• Prior Authorization Required PA • Step Therapy Required ST • Age Edit AE • Gender Edit Female GE Female • Gender Edit Male GE Male
• Quantity Limit QL • Smoking Cessation Benefit SC • Trial Drug Program TD • Weight Loss Benefit WL • Oncology Benefit ONC
The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (10/18) ©2018 HealthPartners
Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits.
What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance.
What’s an Age Edit (AE)? An age edit means some medicines are only covered if you’re within a specific age range. If you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered.
What’s a Gender Edit (GE)? A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners for your medicine to be covered.
What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description.
What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for certain medicines that may not be well tolerated due to:
• Side effects • High cost • High potential for waste
Your first 6 fills of a trial drug may be limited to less than a month supply. If the medicine works well, you’ll get the rest of your month supply. If a copay applies to the medicine, you’ll pay no more than one copay for each one month supply.
What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount you get or may not be covered under all plans. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category.
What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.
List of Covered Drugs
Table of Contents
Alcohol Dependency .................................................................................................................................................6Allergy .......................................................................................................................................................................6Alpha-1 Antitrypsin Deficiency ................................................................................................................................ 7Anti-Addiction/Substance Abuse Treatment Agents .............................................................................................. 7Anti-Infective ............................................................................................................................................................7Arthritis ...................................................................................................................................................................15Asthma & Copd .......................................................................................................................................................16Behavioral Health ...................................................................................................................................................18Birth Control ........................................................................................................................................................... 22Bleeding Disorders ................................................................................................................................................. 27Blood Modifier ........................................................................................................................................................27Blood Thinner ......................................................................................................................................................... 30Bone Health ............................................................................................................................................................ 31Cancer ..................................................................................................................................................................... 32Corticosteroids ....................................................................................................................................................... 35Cough & Cold .......................................................................................................................................................... 36Cystic Fibrosis ......................................................................................................................................................... 36Dementia ................................................................................................................................................................ 37Diabetes ..................................................................................................................................................................37Ear Conditions ........................................................................................................................................................ 40Enzyme Replacement ............................................................................................................................................. 41Eye Conditions ........................................................................................................................................................ 41Gout ........................................................................................................................................................................ 44Heart Health ........................................................................................................................................................... 44Hereditary Angioedema ......................................................................................................................................... 50Idiopathic Pulmonary Fibrosis ............................................................................................................................... 51Immune Deficiency .................................................................................................................................................51Immune Suppressant ............................................................................................................................................. 52Kidney Failure .........................................................................................................................................................52Men's Health .......................................................................................................................................................... 53Migraine ..................................................................................................................................................................53Mouth & Throat ......................................................................................................................................................54Multiple Sclerosis ................................................................................................................................................... 54Muscle Relaxant ..................................................................................................................................................... 55Other Conditions .................................................................................................................................................... 55Pain ......................................................................................................................................................................... 57Parkinson's ..............................................................................................................................................................60Pulmonary Hypertension ....................................................................................................................................... 61Seizures / Epilepsy ..................................................................................................................................................61Skin Conditions .......................................................................................................................................................64Sleep Disorders .......................................................................................................................................................68Smoking Cessation ................................................................................................................................................. 68Stomach / Gastrointestinal .................................................................................................................................... 68Thyroid ....................................................................................................................................................................72Urinary & Bladder Health .......................................................................................................................................72Vaccines .................................................................................................................................................................. 72
4
Vitamins And Minerals ...........................................................................................................................................76Weight Loss .............................................................................................................................................................78Women's Health .....................................................................................................................................................78
5
List of Covered Drugs
Drug Tier Status More Details
Alcohol Dependency
Alcohol Dependency
acamprosate oral tablet,delayed release (dr/ec)333 mg
Tier 1
disulfiram oral tablet 250 mg, 500 mg Tier 1
naltrexone oral tablet 50 mg Tier 1
Allergy
Allergy, Eye
azelastine ophthalmic (eye) drops 0.05 % Tier 1
cromolyn ophthalmic (eye) drops 4 % Tier 1
epinastine ophthalmic (eye) drops 0.05 % Tier 1
olopatadine ophthalmic (eye) drops 0.1 % Tier 1
Allergy, Injection
epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml
Tier 1
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR0.15 MG/0.3 ML
Tier 1
Allergy, Other Nasal
azelastine nasal aerosol,spray 137 mcg (0.1 %) Tier 1
ipratropium bromide nasal spray,non-aerosol0.03 %, 42 mcg (0.06 %)
Tier 1
Allergy, Other Oral
GRASTEK SUBLINGUAL TABLET 2,800 BAU Tier 1 PA
ODACTRA SUBLINGUAL TABLET 12 SQ-HDM Tier 1 PA
RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT
Tier 1 PA
Antihistamines, Oral
cyproheptadine oral syrup 2 mg/5 ml Tier 1
cyproheptadine oral tablet 4 mg Tier 1
hydroxyzine hcl oral solution 10 mg/5 ml Tier 1 QL; AE
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 QL; AE
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg
Tier 1 QL; AE
promethazine oral syrup 6.25 mg/5 ml Tier 1 QL; AE
promethazine oral tablet 12.5 mg, 25 mg, 50 mg Tier 1 QL; AE
GenericsAdvantageRx: October 1, 20186
Drug Tier Status More Details
Corticosteroids, Nasal
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
Tier 1
fluticasone nasal spray,suspension 50 mcg/actuation
Tier 1
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG
Tier 2 PA; Specialty
GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %)
Tier 2 PA; Specialty
PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG
Tier 2 PA; Specialty
PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML
Tier 2 PA; Specialty
ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Tier 2 PA; Specialty
Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
naloxone injection syringe 1 mg/ml Tier 1
NARCAN NASAL SPRAY,NON-AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION
Tier 1
Anti-Infective
Antibiotics, Cephalosporins
cefadroxil oral capsule 500 mg Tier 1
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
Tier 1
cefadroxil oral tablet 1 gram Tier 1
cefdinir oral capsule 300 mg Tier 1
cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml
Tier 1
cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml
Tier 1
cefprozil oral tablet 250 mg, 500 mg Tier 1
CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML
Tier 1
cefuroxime axetil oral tablet 250 mg, 500 mg Tier 1
GenericsAdvantageRx: October 1, 20187
Drug Tier Status More Details
cephalexin oral capsule 250 mg, 500 mg Tier 1
cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml
Tier 1
SUPRAX ORAL CAPSULE 400 MG Tier 1 QL
Antibiotics, Macrolides
azithromycin oral suspension for reconstitution100 mg/5 ml, 200 mg/5 ml
Tier 1
azithromycin oral tablet 250 mg, 500 mg Tier 1
azithromycin oral tablet 600 mg Tier 1
clarithromycin oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml
Tier 1
clarithromycin oral tablet 250 mg, 500 mg Tier 1
DIFICID ORAL TABLET 200 MG Tier 1 PA
Antibiotics, Other
clindamycin hcl oral capsule 150 mg, 300 mg Tier 1
clindamycin hcl oral capsule 75 mg Tier 1
clindamycin palmitate hcl oral recon soln 75 mg/5 ml
Tier 1
FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML
Tier 1
linezolid oral suspension for reconstitution 100 mg/5 ml
Tier 1 PA
linezolid oral tablet 600 mg Tier 1 PA
neomycin oral tablet 500 mg Tier 1
sulfamethoxazole-trimethoprim oral suspension200-40 mg/5 ml
Tier 1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg
Tier 1
trimethoprim oral tablet 100 mg Tier 1
vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg
Tier 1
vancomycin oral capsule 125 mg, 250 mg Tier 1
XIFAXAN ORAL TABLET 200 MG, 550 MG Tier 1 PA
Antibiotics, Penicillins
amoxicillin oral capsule 250 mg, 500 mg Tier 1
amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
Tier 1
GenericsAdvantageRx: October 1, 20188
Drug Tier Status More Details
amoxicillin oral tablet 500 mg, 875 mg Tier 1
amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1
amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml
Tier 1
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg
Tier 1
amoxicillin-pot clavulanate oral tablet,chewable200-28.5 mg, 400-57 mg
Tier 1
ampicillin oral capsule 250 mg, 500 mg Tier 1
ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml
Tier 1
dicloxacillin oral capsule 250 mg, 500 mg Tier 1
penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml
Tier 1
penicillin v potassium oral tablet 250 mg, 500 mg Tier 1
Antibiotics, Quinolones
CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML
Tier 1
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg
Tier 1
ciprofloxacin oral suspension,microcapsule recon250 mg/5 ml, 500 mg/5 ml
Tier 1
levofloxacin oral solution 250 mg/10 ml Tier 1
levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 1
moxifloxacin oral tablet 400 mg Tier 1
Antibiotics, Tetracyclines
demeclocycline oral tablet 150 mg, 300 mg Tier 1
doxycycline hyclate oral capsule 100 mg, 50 mg Tier 1
doxycycline hyclate oral tablet 100 mg, 20 mg Tier 1
doxycycline monohydrate oral capsule 100 mg, 50 mg
Tier 1
doxycycline monohydrate oral tablet 100 mg, 50 mg
Tier 1
minocycline oral capsule 100 mg, 50 mg, 75 mg Tier 1
tetracycline oral capsule 250 mg, 500 mg Tier 1
Antifungals
clotrimazole mucous membrane troche 10 mg Tier 1
GenericsAdvantageRx: October 1, 20189
Drug Tier Status More Details
CRESEMBA ORAL CAPSULE 186 MG Tier 1 PA
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml
Tier 1
fluconazole oral tablet 100 mg, 200 mg Tier 1
fluconazole oral tablet 150 mg, 50 mg Tier 1
griseofulvin microsize oral suspension 125 mg/5 ml
Tier 1
griseofulvin microsize oral tablet 500 mg Tier 1
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg
Tier 1
itraconazole oral capsule 100 mg Tier 1 PA
ketoconazole oral tablet 200 mg Tier 1
NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML)
Tier 1 PA
NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG
Tier 1 PA
nystatin oral suspension 100,000 unit/ml Tier 1
nystatin oral tablet 500,000 unit Tier 1
terbinafine hcl oral tablet 250 mg Tier 1
voriconazole oral suspension for reconstitution200 mg/5 ml (40 mg/ml)
Tier 1 PA
voriconazole oral tablet 200 mg, 50 mg Tier 1 PA
Anti-Infective, Other
ALBENZA ORAL TABLET 200 MG Tier 1 PA
atovaquone oral suspension 750 mg/5 ml Tier 1
dapsone oral tablet 100 mg, 25 mg Tier 1
ivermectin oral tablet 3 mg Tier 1
praziquantel oral tablet 600 mg Tier 1
rifabutin oral capsule 150 mg Tier 1
SIVEXTRO ORAL TABLET 200 MG Tier 1 PA
Antiprotozoals
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML
Tier 1 PA
ALINIA ORAL TABLET 500 MG Tier 1 PA
atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg
Tier 1
chloroquine phosphate oral tablet 250 mg, 500 mg
Tier 1
GenericsAdvantageRx: October 1, 201810
Drug Tier Status More Details
hydroxychloroquine oral tablet 200 mg Tier 1
mefloquine oral tablet 250 mg Tier 1
metronidazole oral tablet 250 mg, 500 mg Tier 1
Antiviral, Hepatitis B
adefovir oral tablet 10 mg Tier 1
BARACLUDE ORAL SOLUTION 0.05 MG/ML Tier 1
entecavir oral tablet 0.5 mg, 1 mg Tier 1
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML)
Tier 1
lamivudine oral tablet 100 mg Tier 1
VEMLIDY ORAL TABLET 25 MG Tier 1
Antiviral, Hepatitis C
EPCLUSA ORAL TABLET 400-100 MG Tier 2 PA; Specialty
HARVONI ORAL TABLET 90-400 MG Tier 2 PA; Specialty
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)
Tier 2 Specialty
INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML
Tier 2 Specialty
MAVYRET ORAL TABLET 100-40 MG Tier 2 PA; Specialty
OLYSIO ORAL CAPSULE 150 MG Tier 2 PA; Specialty
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML
Tier 2 PA; Specialty
PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML
Tier 2 PA; Specialty
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML
Tier 2 PA; Specialty
PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML
Tier 2 PA; Specialty
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
Tier 2 PA; Specialty
REBETOL ORAL SOLUTION 40 MG/ML Tier 2 Specialty
ribavirin oral capsule 200 mg Tier 2 Specialty
ribavirin oral tablet 200 mg Tier 2 Specialty
VOSEVI ORAL TABLET 400-100-100 MG Tier 2 PA; Specialty
Antiviral, Hiv
abacavir oral solution 20 mg/ml Tier 1
GenericsAdvantageRx: October 1, 201811
Drug Tier Status More Details
abacavir oral tablet 300 mg Tier 1
abacavir-lamivudine oral tablet 600-300 mg Tier 1
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
Tier 1
APTIVUS ORAL CAPSULE 250 MG Tier 1
APTIVUS ORAL SOLUTION 100 MG/ML Tier 1
atazanavir oral capsule 150 mg, 200 mg, 300 mg Tier 1
ATRIPLA ORAL TABLET 600-200-300 MG Tier 1
BIKTARVY ORAL TABLET 50-200-25 MG Tier 1
COMPLERA ORAL TABLET 200-25-300 MG Tier 1
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Tier 1
DESCOVY ORAL TABLET 200-25 MG Tier 1
didanosine oral capsule,delayed release(dr/ec)125 mg, 200 mg, 250 mg, 400 mg
Tier 1
EDURANT ORAL TABLET 25 MG Tier 1
efavirenz oral capsule 200 mg, 50 mg Tier 1
efavirenz oral tablet 600 mg Tier 1
EMTRIVA ORAL CAPSULE 200 MG Tier 1
EMTRIVA ORAL SOLUTION 10 MG/ML Tier 1
EVOTAZ ORAL TABLET 300-150 MG Tier 1
fosamprenavir oral tablet 700 mg Tier 1
FUZEON SUBCUTANEOUS RECON SOLN 90 MG Tier 2 Specialty
GENVOYA ORAL TABLET 150-150-200-10 MG Tier 1
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG
Tier 1
INVIRASE ORAL CAPSULE 200 MG Tier 1
INVIRASE ORAL TABLET 500 MG Tier 1
ISENTRESS HD ORAL TABLET 600 MG Tier 1
ISENTRESS ORAL POWDER IN PACKET 100 MG Tier 1
ISENTRESS ORAL TABLET 400 MG Tier 1
ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG
Tier 1
JULUCA ORAL TABLET 50-25 MG Tier 1
KALETRA ORAL TABLET 100-25 MG, 200-50 MG Tier 1
lamivudine oral solution 10 mg/ml Tier 1
lamivudine oral tablet 150 mg, 300 mg Tier 1
lamivudine-zidovudine oral tablet 150-300 mg Tier 1
GenericsAdvantageRx: October 1, 201812
Drug Tier Status More Details
LEXIVA ORAL SUSPENSION 50 MG/ML Tier 1
lopinavir-ritonavir oral solution 400-100 mg/5 ml Tier 1
nevirapine oral suspension 50 mg/5 ml Tier 1
nevirapine oral tablet 200 mg Tier 1
nevirapine oral tablet extended release 24 hr 100 mg, 400 mg
Tier 1
NORVIR ORAL SOLUTION 80 MG/ML Tier 1
ODEFSEY ORAL TABLET 200-25-25 MG Tier 1
PREZCOBIX ORAL TABLET 800-150 MG-MG Tier 1
PREZISTA ORAL SUSPENSION 100 MG/ML Tier 1
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Tier 1
RESCRIPTOR ORAL TABLET 200 MG Tier 1
RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG Tier 1
REYATAZ ORAL POWDER IN PACKET 50 MG Tier 1
ritonavir oral tablet 100 mg Tier 1
SELZENTRY ORAL SOLUTION 20 MG/ML Tier 1
SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG
Tier 1
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg
Tier 1
STRIBILD ORAL TABLET 150-150-200-300 MG Tier 1
SYMTUZA ORAL TABLET 800-150-200-10 MG Tier 1
tenofovir disoproxil fumarate oral tablet 300 mg Tier 1
TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Tier 1
TRIUMEQ ORAL TABLET 600-50-300 MG Tier 1
TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG
Tier 1
TYBOST ORAL TABLET 150 MG Tier 1
VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)
Tier 1
VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)
Tier 1
VIRACEPT ORAL TABLET 250 MG, 625 MG Tier 1
VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM)
Tier 1
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Tier 1
VITEKTA ORAL TABLET 150 MG, 85 MG Tier 1
GenericsAdvantageRx: October 1, 201813
Drug Tier Status More Details
ZERIT ORAL RECON SOLN 1 MG/ML Tier 1
zidovudine oral capsule 100 mg Tier 1
zidovudine oral syrup 10 mg/ml Tier 1
zidovudine oral tablet 300 mg Tier 1
Antiviral, Other
acyclovir oral capsule 200 mg Tier 1
acyclovir oral suspension 200 mg/5 ml Tier 1
acyclovir oral tablet 400 mg, 800 mg Tier 1
amantadine hcl oral capsule 100 mg Tier 1
amantadine hcl oral solution 50 mg/5 ml Tier 1
amantadine hcl oral tablet 100 mg Tier 1
famciclovir oral tablet 125 mg, 250 mg, 500 mg Tier 1
oseltamivir oral capsule 30 mg, 45 mg, 75 mg Tier 1 QL
oseltamivir oral suspension for reconstitution 6 mg/ml
Tier 1 QL
PREVYMIS ORAL TABLET 240 MG, 480 MG Tier 1
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION
Tier 1 QL
rimantadine oral tablet 100 mg Tier 1
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG Tier 1 QL
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML
Tier 1 QL
valacyclovir oral tablet 1 gram, 500 mg Tier 1
valganciclovir oral recon soln 50 mg/ml Tier 1
valganciclovir oral tablet 450 mg Tier 1
Tuberculosis
cycloserine oral capsule 250 mg Tier 1 PA
ethambutol oral tablet 100 mg, 400 mg Tier 1
isoniazid oral solution 50 mg/5 ml Tier 1
isoniazid oral tablet 100 mg, 300 mg Tier 1
PRIFTIN ORAL TABLET 150 MG Tier 1
pyrazinamide oral tablet 500 mg Tier 1
rifampin oral capsule 150 mg, 300 mg Tier 1
SIRTURO ORAL TABLET 100 MG Tier 1 PA
TRECATOR ORAL TABLET 250 MG Tier 1 PA
GenericsAdvantageRx: October 1, 201814
Drug Tier Status More Details
Urinary Anti-Infectives
MONUROL ORAL PACKET 3 GRAM Tier 1
nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg
Tier 1 QL; AE
nitrofurantoin monohyd/m-cryst oral capsule 100 mg
Tier 1 QL; AE
nitrofurantoin oral suspension 25 mg/5 ml Tier 1 QL; AE
Arthritis
Arthritis, Other
DEPEN TITRATABS ORAL TABLET 250 MG Tier 2 PA; Specialty
Disease Modifying Agents
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML
Tier 2 PA; Specialty
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
Tier 2 PA; Specialty
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
Tier 2 PA; Specialty
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML)
Tier 2 PA; Specialty
KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML
Tier 2 PA; Specialty
leflunomide oral tablet 10 mg, 20 mg Tier 1
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML
Tier 2 PA; Specialty
ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML
Tier 2 PA; Specialty
OTEZLA ORAL TABLET 30 MG Tier 2 PA; Specialty
OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19)
Tier 2 PA; Specialty
RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML
Tier 1 PA
RIDAURA ORAL CAPSULE 3 MG Tier 1
GenericsAdvantageRx: October 1, 201815
Drug Tier Status More Details
Asthma & Copd
Asthma & Copd, Other
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION
Tier 1
cromolyn inhalation solution for nebulization 20 mg/2 ml
Tier 1
DALIRESP ORAL TABLET 250 MCG Tier 1 PA
DALIRESP ORAL TABLET 500 MCG Tier 1 PA
ipratropium bromide inhalation solution 0.02 % Tier 1
montelukast oral granules in packet 4 mg Tier 1
montelukast oral tablet 10 mg Tier 1
montelukast oral tablet,chewable 4 mg, 5 mg Tier 1
Bronchodilators, Inhaled
albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml
Tier 1
INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION
Tier 1
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE
Tier 1
STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION
Tier 1
VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION
Tier 1
Bronchodilators, Oral
albuterol sulfate oral syrup 2 mg/5 ml Tier 1
albuterol sulfate oral tablet 2 mg, 4 mg Tier 1
albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg
Tier 1
theophylline oral tablet extended release 12 hr100 mg, 200 mg, 300 mg, 450 mg
Tier 1
theophylline oral tablet extended release 24 hr400 mg
Tier 1
theophylline oral tablet extended release 600 mg Tier 1
Combination Agents, Inhaled
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE
Tier 1
GenericsAdvantageRx: October 1, 201816
Drug Tier Status More Details
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION
Tier 1
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION
Tier 1
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE
Tier 1
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION
Tier 1
DULERA INHALATION HFA AEROSOL INHALER100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION
Tier 1 PA
fluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation
Tier 1
ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml
Tier 1
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG
Tier 1
Corticosteroids, Inhaled
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION
Tier 1
ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION
Tier 1
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
Tier 1
budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
Tier 1
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION
Tier 1
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION
Tier 1
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION
Tier 1
GenericsAdvantageRx: October 1, 201817
Drug Tier Status More Details
QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION
Tier 1
QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION
Tier 1
Behavioral Health
Antipsychotic
aripiprazole oral solution 1 mg/ml Tier 1 AE
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg
Tier 1 AE
aripiprazole oral tablet,disintegrating 10 mg, 15 mg
Tier 1 PA; AE
chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg
Tier 1 PA
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
Tier 1 AE
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg
Tier 1 PA; AE
FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
Tier 1 PA
FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
Tier 1 PA
fluphenazine hcl oral concentrate 5 mg/ml Tier 1 AE
fluphenazine hcl oral elixir 2.5 mg/5 ml Tier 1 AE
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg
Tier 1 AE
haloperidol lactate oral concentrate 2 mg/ml Tier 1 AE
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg
Tier 1 AE
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG
Tier 1 PA; QL
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg
Tier 1 AE
NUPLAZID ORAL CAPSULE 34 MG Tier 2 PA; Specialty
NUPLAZID ORAL TABLET 10 MG, 17 MG Tier 2 PA; Specialty
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg
Tier 1 AE
olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg
Tier 1 PA; AE
GenericsAdvantageRx: October 1, 201818
Drug Tier Status More Details
paliperidone oral tablet extended release 24hr1.5 mg, 3 mg, 6 mg, 9 mg
Tier 1 PA
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
Tier 1 AE
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg
Tier 1 AE
quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg
Tier 1 PA; AE
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
Tier 1 PA
risperidone oral solution 1 mg/ml Tier 1 AE
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Tier 1 AE
risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Tier 1 PA; AE
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET10 MG, 5 MG
Tier 1 PA
SAPHRIS SUBLINGUAL TABLET 2.5 MG Tier 1 PA
thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg
Tier 1 AE
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 AE
trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg
Tier 1 AE
VERSACLOZ ORAL SUSPENSION 50 MG/ML Tier 1 PA; AE
VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG
Tier 1 PA
VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6)
Tier 1 PA
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg
Tier 1 AE
Anxiety
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg
Tier 1 QL
alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg
Tier 1 QL
buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg
Tier 1
chlordiazepoxide hcl oral capsule 10 mg, 25 mg Tier 1 QL
chlordiazepoxide hcl oral capsule 5 mg Tier 1 QL
GenericsAdvantageRx: October 1, 201819
Drug Tier Status More Details
lorazepam oral concentrate 2 mg/ml Tier 1 QL
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 QL
Attention Deficit/Hyperactivity Disorder (Adhd)
adderall xr oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg
Tier 1 QL
atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg
Tier 1 QL
dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg
Tier 1 QL
dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg
Tier 1 QL
dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg
Tier 1 QL
dextroamphetamine oral tablet 10 mg, 5 mg Tier 1 QL
dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
Tier 1 QL
guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg
Tier 1 QL
metadate er oral tablet extended release 20 mg Tier 1 QL
methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg
Tier 1 QL
methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg, 60 mg
Tier 1 QL
methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg
Tier 1 QL
methylphenidate hcl oral tablet extended release10 mg, 20 mg
Tier 1 QL
methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg
Tier 1 QL
QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG
Tier 1 QL
QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML)
Tier 1 QL
VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG
Tier 1 QL
VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG
Tier 1 QL
GenericsAdvantageRx: October 1, 201820
Drug Tier Status More Details
Bipolar Disorder
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg
Tier 1
lithium carbonate oral tablet 300 mg Tier 1
lithium carbonate oral tablet extended release300 mg, 450 mg
Tier 1
lithium citrate oral solution 8 meq/5 ml Tier 1
Depression, Atypical Antidepressants
bupropion hcl oral tablet 100 mg, 75 mg Tier 1
bupropion hcl oral tablet extended release 24 hr150 mg, 300 mg
Tier 1
bupropion hcl oral tablet sustained-release 12 hr100 mg, 150 mg, 200 mg
Tier 1
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg
Tier 1
Depression, Maois
phenelzine oral tablet 15 mg Tier 1
tranylcypromine oral tablet 10 mg Tier 1
Depression, Serotonin Modulators
nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg
Tier 1
trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg
Tier 1
Depression, Snris
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg
Tier 1
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg
Tier 1
venlafaxine oral capsule,extended release 24hr150 mg, 37.5 mg, 75 mg
Tier 1
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
Tier 1
Depression, Ssris
citalopram oral solution 10 mg/5 ml Tier 1
citalopram oral tablet 10 mg, 20 mg, 40 mg Tier 1
escitalopram oxalate oral solution 5 mg/5 ml Tier 1
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg
Tier 1
GenericsAdvantageRx: October 1, 201821
Drug Tier Status More Details
fluoxetine oral capsule 10 mg, 20 mg, 40 mg Tier 1
fluoxetine oral solution 20 mg/5 ml (4 mg/ml) Tier 1
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg Tier 1
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
Tier 1
PAXIL ORAL SUSPENSION 10 MG/5 ML Tier 1
sertraline oral concentrate 20 mg/ml Tier 1
sertraline oral tablet 100 mg, 25 mg, 50 mg Tier 1
Depression, Tricyclic & Tetracyclic Antidepressants
amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
Tier 1 AE
clomipramine oral capsule 25 mg, 50 mg, 75 mg Tier 1 AE
desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
Tier 1
doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg
Tier 1 AE
doxepin oral concentrate 10 mg/ml Tier 1 AE
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 AE
nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg
Tier 1
nortriptyline oral solution 10 mg/5 ml Tier 1
Birth Control
Contraceptives, Other
NUVARING VAGINAL RING 0.12-0.015 MG/24 HR
Tier 1
xulane transdermal patch weekly 150-35 mcg/24 hr
Tier 1
Emergency Contraception
ELLA ORAL TABLET 30 MG Tier 1
levonorgestrel oral tablet 1.5 mg Tier 1
my way oral tablet 1.5 mg Tier 1
next choice one dose oral tablet 1.5 mg Tier 1
Oral Contraceptives
altavera (28) oral tablet 0.15-0.03 mg Tier 1
alyacen 1/35 (28) oral tablet 1-35 mg-mcg Tier 1
GenericsAdvantageRx: October 1, 201822
Drug Tier Status More Details
alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
Tier 1
apri oral tablet 0.15-0.03 mg Tier 1
aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg Tier 1
aubra oral tablet 0.1-20 mg-mcg Tier 1
aviane oral tablet 0.1-20 mg-mcg Tier 1
azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5
Tier 1
balziva (28) oral tablet 0.4-35 mg-mcg Tier 1
blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)
Tier 1
blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)
Tier 1
brevicon (28) oral tablet 0.5-35 mg-mcg Tier 1
briellyn oral tablet 0.4-35 mg-mcg Tier 1
camila oral tablet 0.35 mg Tier 1
caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg Tier 1
chateal oral tablet 0.15-0.03 mg Tier 1
cryselle (28) oral tablet 0.3-30 mg-mcg Tier 1
cyclafem 1/35 (28) oral tablet 1-35 mg-mcg Tier 1
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
Tier 1
dasetta 1/35 (28) oral tablet 1-35 mg-mcg Tier 1
dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
Tier 1
desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg
Tier 1
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg
Tier 1
elinest oral tablet 0.3-30 mg-mcg Tier 1
emoquette oral tablet 0.15-0.03 mg Tier 1
enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10)
Tier 1
enskyce oral tablet 0.15-0.03 mg Tier 1
errin oral tablet 0.35 mg Tier 1
estarylla oral tablet 0.25-35 mg-mcg Tier 1
falmina (28) oral tablet 0.1-20 mg-mcg Tier 1
gianvi (28) oral tablet 3-0.02 mg Tier 1
GenericsAdvantageRx: October 1, 201823
Drug Tier Status More Details
gildagia oral tablet 0.4-35 mg-mcg Tier 1
heather oral tablet 0.35 mg Tier 1
introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg
Tier 1
jencycla oral tablet 0.35 mg Tier 1
jolessa oral tablets,dose pack,3 month 0.15 mg-30 mcg
Tier 1
jolivette oral tablet 0.35 mg Tier 1
junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg Tier 1
junel 1/20 (21) oral tablet 1-20 mg-mcg Tier 1
junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)
Tier 1
junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)
Tier 1
kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5
Tier 1
kelnor 1/35 (28) oral tablet 1-35 mg-mcg Tier 1
kurvelo oral tablet 0.15-0.03 mg Tier 1
larin 1/20 (21) oral tablet 1-20 mg-mcg Tier 1
larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)
Tier 1
larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)
Tier 1
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg Tier 1
lessina oral tablet 0.1-20 mg-mcg Tier 1
levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10)
Tier 1
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg
Tier 1
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg
Tier 1
levora-28 oral tablet 0.15-0.03 mg Tier 1
loryna (28) oral tablet 3-0.02 mg Tier 1
low-ogestrel (28) oral tablet 0.3-30 mg-mcg Tier 1
lutera (28) oral tablet 0.1-20 mg-mcg Tier 1
lyza oral tablet 0.35 mg Tier 1
marlissa oral tablet 0.15-0.03 mg Tier 1
GenericsAdvantageRx: October 1, 201824
Drug Tier Status More Details
microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg
Tier 1
microgestin 1/20 (21) oral tablet 1-20 mg-mcg Tier 1
microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)
Tier 1
microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)
Tier 1
mono-linyah oral tablet 0.25-35 mg-mcg Tier 1
mononessa (28) oral tablet 0.25-35 mg-mcg Tier 1
myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10)
Tier 1
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg Tier 1
necon 1/35 (28) oral tablet 1-35 mg-mcg Tier 1
necon 1/50 (28) oral tablet 1-50 mg-mcg Tier 1
necon 10/11 (28) oral tablet 0.5-35/1-35 mg-mcg/mg-mcg
Tier 1
necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
Tier 1
nora-be oral tablet 0.35 mg Tier 1
norethindrone (contraceptive) oral tablet 0.35 mg Tier 1
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
Tier 1
norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg
Tier 1
norinyl 1/35 (28) oral tablet 1-35 mg-mcg Tier 1
nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg Tier 1
nortrel 1/35 (21) oral tablet 1-35 mg-mcg Tier 1
nortrel 1/35 (28) oral tablet 1-35 mg-mcg Tier 1
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
Tier 1
ocella oral tablet 3-0.03 mg Tier 1
ogestrel (28) oral tablet 0.5-50 mg-mcg Tier 1
orsythia oral tablet 0.1-20 mg-mcg Tier 1
philith oral tablet 0.4-35 mg-mcg Tier 1
pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5
Tier 1
GenericsAdvantageRx: October 1, 201825
Drug Tier Status More Details
pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg
Tier 1
portia oral tablet 0.15-0.03 mg Tier 1
previfem oral tablet 0.25-35 mg-mcg Tier 1
quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg
Tier 1
reclipsen (28) oral tablet 0.15-0.03 mg Tier 1
sprintec (28) oral tablet 0.25-35 mg-mcg Tier 1
sronyx oral tablet 0.1-20 mg-mcg Tier 1
syeda oral tablet 3-0.03 mg Tier 1
tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9)
Tier 1
tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1
tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9)
Tier 1
tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1
tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg
Tier 1
tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg
Tier 1
trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1
trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg
Tier 1
tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1
tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1
trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10)
Tier 1
velivet triphasic regimen (28) oral tablet0.1/.125/.15-25 mg-mcg
Tier 1
vestura (28) oral tablet 3-0.02 mg Tier 1
viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5
Tier 1
vyfemla (28) oral tablet 0.4-35 mg-mcg Tier 1
wera (28) oral tablet 0.5-35 mg-mcg Tier 1
GenericsAdvantageRx: October 1, 201826
Drug Tier Status More Details
zarah oral tablet 3-0.03 mg Tier 1
zenchent (28) oral tablet 0.4-35 mg-mcg Tier 1
zovia 1/35e (28) oral tablet 1-35 mg-mcg Tier 1
zovia 1/50e (28) oral tablet 1-50 mg-mcg Tier 1
Bleeding Disorders
Bleeding Disorders, Hemophilia
STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML)
Tier 1 PA
Bleeding Disorders, Other
AMICAR ORAL SOLUTION 250 MG/ML (25 %) Tier 1
AMICAR ORAL TABLET 500 MG Tier 1
Blood Modifier
Blood Modifiers
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
Tier 2 Specialty
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML
Tier 2 Specialty
FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML
Tier 2 Specialty
GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML
Tier 1 Specialty; ONC
HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7 ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML
Tier 2 PA; Specialty
LEUKINE INJECTION RECON SOLN 250 MCG Tier 2 Specialty
NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML
Tier 2 Specialty
NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML
Tier 2 Specialty
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML
Tier 2 Specialty
NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML
Tier 2 Specialty
GenericsAdvantageRx: October 1, 201827
Drug Tier Status More Details
PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML
Tier 2 Specialty
PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG
Tier 2 PA; Specialty
REBINYN INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML
Tier 2 Specialty
ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML
Tier 2 Specialty
Clotting Disorders
ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT
Tier 2 Specialty
AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE
Tier 2 Specialty
ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML
Tier 2 Specialty
ALPHANINE SD INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT
Tier 2 Specialty
BEBULIN INTRAVENOUS RECON SOLN 700 (+/-) UNIT
Tier 2 Specialty
BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT
Tier 2 Specialty
GenericsAdvantageRx: October 1, 201828
Drug Tier Status More Details
COAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE
Tier 2 Specialty
CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT
Tier 2 Specialty
ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT
Tier 2 Specialty
FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT
Tier 2 Specialty
HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
HEMOFIL M HIGH INTRAVENOUS RECON SOLN801-1,500 UNIT
Tier 2 Specialty
HEMOFIL M LOW INTRAVENOUS RECON SOLN220-400 UNIT
Tier 2 Specialty
HEMOFIL M MID INTRAVENOUS RECON SOLN401-800 UNIT
Tier 2 Specialty
HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501-2,000 UNIT
Tier 2 Specialty
HUMATE-P INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, 250-600 UNIT, 500-1,200 UNIT
Tier 2 Specialty
IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,500 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT
Tier 2 Specialty
JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
KOATE-DVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
KOGENATE FS INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
MONOCLATE-P INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 1,500 (+/-) UNIT
Tier 2 Specialty
GenericsAdvantageRx: October 1, 201829
Drug Tier Status More Details
NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG)
Tier 2 Specialty
NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT
Tier 2 Specialty
OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE
Tier 2 Specialty
PLASMANATE INTRAVENOUS PARENTERAL SOLUTION 5 %
Tier 2 Specialty
PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
RECOMBINATE INTRAVENOUS RECON SOLN1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT
Tier 2 Specialty
THROMBATE III INTRAVENOUS RECON SOLN 500 (+/-) UNIT
Tier 2 Specialty
TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT
Tier 2 Specialty
VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE
Tier 2 Specialty
WILATE INTRAVENOUS RECON SOLN 1,000-1,000 UNIT, 450-450 UNIT, 500-500 UNIT, 900-900 UNIT
Tier 2 Specialty
XYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
XYNTHA SOLOFUSE INTRAVENOUS SYRINGE1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT
Tier 2 Specialty
Blood Thinner
Anticoagulants
ELIQUIS ORAL TABLET 2.5 MG, 5 MG Tier 1
ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS)
Tier 1
GenericsAdvantageRx: October 1, 201830
Drug Tier Status More Details
enoxaparin subcutaneous solution 300 mg/3 ml Tier 1 QL
enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml
Tier 1 QL
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
Tier 1 PA
heparin (porcine) injection cartridge 5,000 unit/ml (1 ml)
Tier 1
heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml
Tier 1
heparin (porcine) injection syringe 5,000 unit/ml Tier 1
heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml
Tier 1
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
Tier 1
PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG
Tier 1 PA
warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
Tier 1
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Tier 1
XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)
Tier 1
Platelet Inhibitors
anagrelide oral capsule 0.5 mg, 1 mg Tier 1
aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg
Tier 1
BRILINTA ORAL TABLET 60 MG, 90 MG Tier 1
cilostazol oral tablet 100 mg, 50 mg Tier 1
clopidogrel oral tablet 75 mg Tier 1
dipyridamole oral tablet 25 mg, 50 mg, 75 mg Tier 1
pentoxifylline oral tablet extended release 400 mg
Tier 1
prasugrel oral tablet 10 mg, 5 mg Tier 1
ZONTIVITY ORAL TABLET 2.08 MG Tier 1 PA
Bone Health
Bone Health, Other
etidronate disodium oral tablet 200 mg, 400 mg Tier 1
GenericsAdvantageRx: October 1, 201831
Drug Tier Status More Details
Osteoporosis
alendronate oral solution 70 mg/75 ml Tier 1
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg
Tier 1
alendronate oral tablet 40 mg Tier 1
calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation
Tier 1
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML
Tier 2 PA; Specialty
ibandronate oral tablet 150 mg Tier 1
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML)
Tier 2 PA; Specialty
Cancer
Cancer, Alkylating Agents
EMCYT ORAL CAPSULE 140 MG Tier 1
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG
Tier 1
HEXALEN ORAL CAPSULE 50 MG Tier 1 Specialty; ONC
LEUKERAN ORAL TABLET 2 MG Tier 1
MATULANE ORAL CAPSULE 50 MG Tier 1 PA; Specialty; ONC
melphalan oral tablet 2 mg Tier 1
MYLERAN ORAL TABLET 2 MG Tier 1
temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg
Tier 1 Specialty; ONC
VALCHLOR TOPICAL GEL 0.016 % Tier 1 PA; Specialty; ONC; QL
Cancer, Antiandrogens
bicalutamide oral tablet 50 mg Tier 1
ERLEADA ORAL TABLET 60 MG Tier 1 PA; Specialty; ONC
flutamide oral capsule 125 mg Tier 1
XTANDI ORAL CAPSULE 40 MG Tier 1 PA; Specialty; TD; ONC
ZYTIGA ORAL TABLET 250 MG, 500 MG Tier 1 PA; Specialty; TD; ONC
Cancer, Antimetabolites
capecitabine oral tablet 150 mg, 500 mg Tier 1 Specialty; ONC
hydroxyurea oral capsule 500 mg Tier 1
LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG Tier 1 PA; Specialty; ONC
mercaptopurine oral tablet 50 mg Tier 1
GenericsAdvantageRx: October 1, 201832
Drug Tier Status More Details
TABLOID ORAL TABLET 40 MG Tier 1
Cancer, Aromatase Inhibitors
anastrozole oral tablet 1 mg Tier 1
exemestane oral tablet 25 mg Tier 1
letrozole oral tablet 2.5 mg Tier 1
Cancer, Hdac Inhibitors
ZOLINZA ORAL CAPSULE 100 MG Tier 1 PA; Specialty; TD; ONC
Cancer, Immunosuppressives
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG
Tier 1 Specialty; TD; ONC
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG
Tier 1 Specialty; TD; ONC
cyclophosphamide oral capsule 25 mg, 50 mg Tier 1
methotrexate sodium (pf) injection solution 25 mg/ml
Tier 1
methotrexate sodium injection solution 25 mg/ml Tier 1
methotrexate sodium oral tablet 2.5 mg Tier 1
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
Tier 1 PA; Specialty; ONC
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG
Tier 1 Specialty; ONC
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
Tier 1 Specialty; ONC
Cancer, Interferons
SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG
Tier 1 Specialty; ONC
Cancer, Natural And Semi-Synthetic
etoposide oral capsule 50 mg Tier 1
HYCAMTIN INTRAVENOUS RECON SOLN 4 MG Tier 1 Specialty; ONC
HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG Tier 1 Specialty; ONC
Cancer, Other Agents
LYSODREN ORAL TABLET 500 MG Tier 1 PA; Specialty; ONC
megestrol oral tablet 20 mg, 40 mg Tier 1
ODOMZO ORAL CAPSULE 200 MG Tier 1 PA; Specialty; ONC
ZEJULA ORAL CAPSULE 100 MG Tier 1 PA; Specialty; ONC
GenericsAdvantageRx: October 1, 201833
Drug Tier Status More Details
Cancer, Retinoids
tretinoin (chemotherapy) oral capsule 10 mg Tier 1 Specialty; ONC
Cancer, Serms
SOLTAMOX ORAL SOLUTION 10 MG/5 ML Tier 1
tamoxifen oral tablet 10 mg, 20 mg Tier 1
Cancer, Signal Transduction Inhibitors
ALECENSA ORAL CAPSULE 150 MG Tier 1 PA; Specialty; ONC
BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG
Tier 1 PA; Specialty; TD; ONC
CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG
Tier 1 PA; Specialty; TD; ONC
CAPRELSA ORAL TABLET 100 MG, 300 MG Tier 1 Specialty; ONC
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)
Tier 1 PA; Specialty; ONC
COTELLIC ORAL TABLET 20 MG Tier 1 PA; Specialty; ONC
ERIVEDGE ORAL CAPSULE 150 MG Tier 1 PA; Specialty; TD; ONC
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG Tier 1 PA; Specialty; ONC
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG
Tier 1 PA; Specialty; ONC
ICLUSIG ORAL TABLET 15 MG, 45 MG Tier 1 PA; Specialty; ONC
IDHIFA ORAL TABLET 100 MG, 50 MG Tier 1 PA; Specialty; ONC
imatinib oral tablet 100 mg, 400 mg Tier 1 Specialty; TD; ONC
IMBRUVICA ORAL CAPSULE 140 MG, 70 MG Tier 1 PA; Specialty; ONC
IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG
Tier 1 PA; Specialty; ONC
INLYTA ORAL TABLET 1 MG, 5 MG Tier 1 PA; Specialty; TD; ONC
IRESSA ORAL TABLET 250 MG Tier 1 PA; Specialty; TD; ONC
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG
Tier 1 PA; Specialty; TD; ONC
KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG
Tier 1 PA; Specialty; ONC
KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3)
Tier 1 PA; Specialty; ONC
MEKINIST ORAL TABLET 0.5 MG, 2 MG Tier 1 PA; Specialty; ONC
GenericsAdvantageRx: October 1, 201834
Drug Tier Status More Details
NERLYNX ORAL TABLET 40 MG Tier 1 PA; Specialty; ONC
NEXAVAR ORAL TABLET 200 MG Tier 1 Specialty; TD; ONC
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG Tier 1 PA; Specialty; ONC
RYDAPT ORAL CAPSULE 25 MG Tier 1 PA; Specialty; ONC
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
Tier 1 Specialty; TD; ONC
STIVARGA ORAL TABLET 40 MG Tier 1 PA; Specialty; ONC
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
Tier 1 Specialty; TD; ONC
TAFINLAR ORAL CAPSULE 50 MG, 75 MG Tier 1 PA; Specialty; ONC
TAGRISSO ORAL TABLET 40 MG, 80 MG Tier 1 PA; Specialty; TD; ONC
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG Tier 1 Specialty; TD; ONC
TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG
Tier 1 Specialty; TD; ONC
TYKERB ORAL TABLET 250 MG Tier 1 Specialty; ONC
VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG
Tier 1 PA; Specialty; ONC
VOTRIENT ORAL TABLET 200 MG Tier 1 Specialty; TD; ONC
XALKORI ORAL CAPSULE 200 MG, 250 MG Tier 1 PA; Specialty; TD; ONC
ZELBORAF ORAL TABLET 240 MG Tier 1 PA; Specialty; ONC
ZYKADIA ORAL CAPSULE 150 MG Tier 1 PA; Specialty; TD; ONC
Corticosteroids
Corticosteroids, Injectable
dexamethasone sodium phosphate injection solution 4 mg/ml
Tier 1
Corticosteroids, Oral
DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML
Tier 1
dexamethasone oral elixir 0.5 mg/5 ml Tier 1
dexamethasone oral solution 0.5 mg/5 ml Tier 1
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 4 mg, 6 mg
Tier 1
dexamethasone oral tablet 2 mg Tier 1
fludrocortisone oral tablet 0.1 mg Tier 1
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Tier 1
MEDROL ORAL TABLET 2 MG Tier 1
GenericsAdvantageRx: October 1, 201835
Drug Tier Status More Details
methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg
Tier 1
methylprednisolone oral tablets,dose pack 4 mg Tier 1
MILLIPRED ORAL TABLET 5 MG Tier 1
prednisolone oral solution 15 mg/5 ml Tier 1
prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
Tier 1
PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML
Tier 1
prednisone oral solution 5 mg/5 ml Tier 1
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg
Tier 1
prednisone oral tablets,dose pack 10 mg, 5 mg Tier 1
Cough & Cold
Cough & Cold
benzonatate oral capsule 100 mg, 200 mg Tier 1
codeine-guaifenesin oral liquid 10-100 mg/5 ml Tier 1 QL; AE
promethazine vc oral syrup 6.25-5 mg/5 ml Tier 1
promethazine-dm oral syrup 6.25-15 mg/5 ml Tier 1
Cystic Fibrosis
Cystic Fibrosis
acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)
Tier 1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML
Tier 2 PA; Specialty
KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG
Tier 2 PA; Specialty
KALYDECO ORAL TABLET 150 MG Tier 2 PA; Specialty
ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG
Tier 2 PA; Specialty
ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG
Tier 2 PA; Specialty
PULMOZYME INHALATION SOLUTION 1 MG/ML Tier 2 PA; Specialty; QL
SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N)
Tier 2 PA; Specialty
tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml
Tier 2 PA; Specialty
GenericsAdvantageRx: October 1, 201836
Drug Tier Status More Details
Dementia
Dementia
donepezil oral tablet 10 mg, 5 mg Tier 1
donepezil oral tablet,disintegrating 10 mg, 5 mg Tier 1
galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg
Tier 1
galantamine oral solution 4 mg/ml Tier 1
galantamine oral tablet 12 mg, 4 mg, 8 mg Tier 1
memantine oral solution 2 mg/ml Tier 1
memantine oral tablet 10 mg, 5 mg Tier 1
memantine oral tablets,dose pack 5-10 mg Tier 1
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg
Tier 1
Diabetes
Diabetes, Alpha-Glucosidase Inhibitors
acarbose oral tablet 100 mg, 25 mg, 50 mg Tier 1
miglitol oral tablet 100 mg, 25 mg, 50 mg Tier 1
Diabetes, Biguanides
metformin oral tablet 1,000 mg, 500 mg, 850 mg Tier 1
metformin oral tablet extended release 24 hr 500 mg, 750 mg
Tier 1
Diabetes, Dpp-4 Inhibitor / Biguanide Combinations
JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG
Tier 1
JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG
Tier 1
Diabetes, Dpp-4 Inhibitors
TRADJENTA ORAL TABLET 5 MG Tier 1
Diabetes, Glp-1 Agonists
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML
Tier 1 QL
BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML
Tier 1 QL
BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG
Tier 1 QL
GenericsAdvantageRx: October 1, 201837
Drug Tier Status More Details
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML
Tier 1 QL
OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/0.75 ML (2 MG/1.5 ML)
Tier 1 QL
TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML
Tier 1 QL
VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR0.6 MG/0.1 ML (18 MG/3 ML)
Tier 1 QL
VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR0.6 MG/0.1 ML (18 MG/3 ML)
Tier 1 QL
Diabetes, Intermediate-Acting Insulins
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)
Tier 1
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML
Tier 1
Diabetes, Long-Acting Insulins
BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)
Tier 1
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)
Tier 1 PA
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML
Tier 1 PA
Diabetes, Meglitinides
nateglinide oral tablet 120 mg, 60 mg Tier 1
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1
Diabetes, Other Oral Agents
CYCLOSET ORAL TABLET 0.8 MG Tier 1 PA
Diabetes, Pre-Mixed Insulins
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)
Tier 1
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)
Tier 1
GenericsAdvantageRx: October 1, 201838
Drug Tier Status More Details
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)
Tier 1
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)
Tier 1
HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)
Tier 1
HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)
Tier 1
Diabetes, Rapid-Acting Insulins
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML
Tier 1
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML)
Tier 1
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML
Tier 1
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML
Tier 1
Diabetes, Rescue Agents
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG
Tier 1
GLUCAGEN INJECTION RECON SOLN 1 MG Tier 1
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG
Tier 1
Diabetes, Sglt2 Inhibitor / Biguanide Combinations
INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG
Tier 1
INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG
Tier 1
SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG
Tier 1
SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG
Tier 1
GenericsAdvantageRx: October 1, 201839
Drug Tier Status More Details
Diabetes, Sglt2 Inhibitors
INVOKANA ORAL TABLET 100 MG, 300 MG Tier 1
JARDIANCE ORAL TABLET 10 MG, 25 MG Tier 1
Diabetes, Short-Acting Insulins
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML
Tier 1
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML
Tier 1
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML)
Tier 1
Diabetes, Sulfonylurea / Biguanide Combination
glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg
Tier 1
Diabetes, Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1
glipizide oral tablet 10 mg, 5 mg Tier 1
glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg
Tier 1
glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg
Tier 1 PA
glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 1 PA
Diabetes, Thiazolidinedione / Biguanide Combinations
pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg
Tier 1
Diabetes, Thiazolidinedione / Sulfonylurea Combinations
pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg
Tier 1
Diabetes, Thiazolidinediones
pioglitazone oral tablet 15 mg, 30 mg, 45 mg Tier 1
Ear Conditions
Anti-Infectives, Ear
acetic acid otic (ear) solution 2 % Tier 1
GenericsAdvantageRx: October 1, 201840
Drug Tier Status More Details
CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 %
Tier 1
CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %
Tier 1
neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%
Tier 1
neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 mg/ml-unit/ml-%
Tier 1
ofloxacin otic (ear) drops 0.3 % Tier 1
Ear Conditions, Other
fluocinolone acetonide oil otic (ear) drops 0.01 % Tier 1
Enzyme Replacement
Enzyme Replacement
CERDELGA ORAL CAPSULE 84 MG Tier 2 PA; Specialty
CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT
Tier 1
miglustat oral capsule 100 mg Tier 2 PA; Specialty
STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML
Tier 2 PA; Specialty
SUCRAID ORAL SOLUTION 8,500 UNIT/ML Tier 2 PA; Specialty
Eye Conditions
Anti-Infectives, Eye
bacitracin ophthalmic (eye) ointment 500 unit/gram
Tier 1
bacitracin-polymyxin b ophthalmic (eye) ointment500-10,000 unit/gram
Tier 1
BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 %
Tier 1 PA
BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 %
Tier 1
CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 1
ciprofloxacin hcl ophthalmic (eye) drops 0.3 % Tier 1
erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %)
Tier 1
gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram)
Tier 1
GenericsAdvantageRx: October 1, 201841
Drug Tier Status More Details
moxifloxacin ophthalmic (eye) drops 0.5 % Tier 1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g
Tier 1
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %
Tier 1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml
Tier 1
ofloxacin ophthalmic (eye) drops 0.3 % Tier 1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml
Tier 1
sulfacetamide sodium ophthalmic (eye) drops 10 %
Tier 1
sulfacetamide sodium ophthalmic (eye) ointment10 %
Tier 1
sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %)
Tier 1
TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 %
Tier 1
tobramycin ophthalmic (eye) drops 0.3 % Tier 1
tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %
Tier 1
TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 1
trifluridine ophthalmic (eye) drops 1 % Tier 1
ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % Tier 1
Anti-Inflammatories, Eye
bromfenac ophthalmic (eye) drops 0.09 % Tier 1
dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 %
Tier 1
diclofenac sodium ophthalmic (eye) drops 0.1 % Tier 1
fluorometholone ophthalmic (eye) drops,suspension 0.1 %
Tier 1
flurbiprofen sodium ophthalmic (eye) drops 0.03 %
Tier 1
FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % Tier 1
ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % Tier 1
PRED FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 1 %
Tier 1
PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %
Tier 1
GenericsAdvantageRx: October 1, 201842
Drug Tier Status More Details
prednisolone acetate ophthalmic (eye) drops,suspension 1 %
Tier 1
prednisolone sodium phosphate ophthalmic (eye) drops 1 %
Tier 1
Eye Conditions, Other
atropine ophthalmic (eye) drops 1 % Tier 1
atropine ophthalmic (eye) ointment 1 % Tier 1
cyclopentolate ophthalmic (eye) drops 1 % Tier 1
CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % Tier 2 PA; Specialty
homatropaire ophthalmic (eye) drops 5 % Tier 1
phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 %
Tier 1
RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 %
Tier 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE0.05 %
Tier 1
Glaucoma
betaxolol ophthalmic (eye) drops 0.5 % Tier 1
bimatoprost ophthalmic (eye) drops 0.03 % Tier 1
brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % Tier 1
carteolol ophthalmic (eye) drops 1 % Tier 1
dorzolamide ophthalmic (eye) drops 2 % Tier 1
dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-0.5 %
Tier 1 PA
dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml
Tier 1
latanoprost ophthalmic (eye) drops 0.005 % Tier 1
levobunolol ophthalmic (eye) drops 0.5 % Tier 1
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % Tier 1
methazolamide oral tablet 25 mg, 50 mg Tier 1
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
Tier 1
timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 %
Tier 1
timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 %
Tier 1
TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % Tier 1
GenericsAdvantageRx: October 1, 201843
Drug Tier Status More Details
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE0.0015 %
Tier 1 PA
Gout
Gout
allopurinol oral tablet 100 mg, 300 mg Tier 1
colchicine oral capsule 0.6 mg Tier 1
colchicine oral tablet 0.6 mg Tier 1
probenecid oral tablet 500 mg Tier 1
probenecid-colchicine oral tablet 500-0.5 mg Tier 1
ULORIC ORAL TABLET 40 MG, 80 MG Tier 1 ST
Heart Health
Angina
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg
Tier 1
isosorbide dinitrate oral tablet extended release40 mg
Tier 1
isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1
isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg
Tier 1
NITRO-BID TRANSDERMAL OINTMENT 2 % Tier 1
nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg
Tier 1
nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
Tier 1
Antiarrhythmics
amiodarone oral tablet 100 mg, 200 mg, 400 mg Tier 1
disopyramide phosphate oral capsule 100 mg, 150 mg
Tier 1
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg
Tier 1
flecainide oral tablet 100 mg, 150 mg, 50 mg Tier 1
mexiletine oral capsule 150 mg, 200 mg, 250 mg Tier 1
MULTAQ ORAL TABLET 400 MG Tier 1 PA
NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG
Tier 1
propafenone oral tablet 150 mg, 225 mg, 300 mg Tier 1
GenericsAdvantageRx: October 1, 201844
Drug Tier Status More Details
quinidine gluconate oral tablet extended release324 mg
Tier 1
quinidine sulfate oral tablet 200 mg, 300 mg Tier 1
sotalol af oral tablet 120 mg, 160 mg, 80 mg Tier 1
sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg
Tier 1
Blood Pressure, Acei & Arb
amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
Tier 1
benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
Tier 1
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
Tier 1
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
Tier 1
DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG
Tier 1
DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG
Tier 1
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg
Tier 1
fosinopril oral tablet 10 mg, 20 mg, 40 mg Tier 1
fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg
Tier 1
irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg
Tier 1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg
Tier 1
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg
Tier 1
losartan oral tablet 100 mg, 25 mg, 50 mg Tier 1
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg
Tier 1
moexipril oral tablet 15 mg, 7.5 mg Tier 1
GenericsAdvantageRx: October 1, 201845
Drug Tier Status More Details
moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg
Tier 1
olmesartan oral tablet 20 mg, 40 mg, 5 mg Tier 1
olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg
Tier 1
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg
Tier 1
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg
Tier 1
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg
Tier 1
trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg
Tier 1
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
Tier 1
Blood Pressure, Beta Blockers
atenolol oral tablet 100 mg, 25 mg, 50 mg Tier 1
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg
Tier 1
bisoprolol fumarate oral tablet 10 mg, 5 mg Tier 1
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
Tier 1
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg
Tier 1
labetalol oral tablet 100 mg, 200 mg, 300 mg Tier 1
metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg
Tier 1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
Tier 1
nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 1
propranolol oral capsule,extended release 24 hr120 mg, 160 mg, 60 mg, 80 mg
Tier 1
propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)
Tier 1
GenericsAdvantageRx: October 1, 201846
Drug Tier Status More Details
propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
Tier 1
propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 mg
Tier 1
Blood Pressure, Calcium Channel Blockers
amlodipine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1
amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg
Tier 1
amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg
Tier 1
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg
Tier 1
diltiazem hcl oral capsule,ext.rel 24h degradable120 mg, 180 mg, 240 mg
Tier 1
diltiazem hcl oral capsule,extended release 24 hr120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
Tier 1
diltiazem hcl oral capsule,extended release 24hr120 mg, 180 mg, 240 mg, 300 mg
Tier 1
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
Tier 1
dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1
nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg
Tier 1
nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg
Tier 1
nimodipine oral capsule 30 mg Tier 1
taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
Tier 1
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg
Tier 1
verapamil oral tablet 120 mg, 40 mg, 80 mg Tier 1
verapamil oral tablet extended release 120 mg, 180 mg, 240 mg
Tier 1
Blood Pressure, Other
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Tier 1
GenericsAdvantageRx: October 1, 201847
Drug Tier Status More Details
clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr
Tier 1
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg Tier 1
guanfacine oral tablet 1 mg, 2 mg Tier 1
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg
Tier 1
methyldopa oral tablet 250 mg, 500 mg Tier 1
midodrine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1
minoxidil oral tablet 10 mg, 2.5 mg Tier 1
phenoxybenzamine oral capsule 10 mg Tier 1 PA
prazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1
Cholesterol Lowering, Bile Acid Resins
cholestyramine (with sugar) oral powder 4 gram Tier 1
cholestyramine (with sugar) oral powder in packet 4 gram
Tier 1
cholestyramine light oral powder 4 gram Tier 1
cholestyramine light oral powder in packet 4 gram
Tier 1
colestipol oral tablet 1 gram Tier 1
prevalite oral powder 4 gram Tier 1
prevalite oral powder in packet 4 gram Tier 1
Cholesterol Lowering, Other
ezetimibe oral tablet 10 mg Tier 1
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG
Tier 2 PA; Specialty
KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML
Tier 2 PA; Specialty
REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML
Tier 2 PA; Specialty
REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML
Tier 2 PA; Specialty
REPATHA SYRINGE SUBCUTANEOUS SYRINGE140 MG/ML
Tier 2 PA; Specialty
Cholesterol Lowering, Statins
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg
Tier 1
lovastatin oral tablet 10 mg, 20 mg, 40 mg Tier 1
GenericsAdvantageRx: October 1, 201848
Drug Tier Status More Details
pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg
Tier 1
rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1
simvastatin oral tablet 10 mg, 20 mg, 5 mg Tier 1
simvastatin oral tablet 40 mg Tier 1 QL
simvastatin oral tablet 80 mg Tier 1 PA
Diuretics
acetazolamide oral capsule, extended release 500 mg
Tier 1
acetazolamide oral tablet 125 mg, 250 mg Tier 1
amiloride oral tablet 5 mg Tier 1
amiloride-hydrochlorothiazide oral tablet 5-50 mg
Tier 1
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1
chlorothiazide oral tablet 250 mg, 500 mg Tier 1
chlorthalidone oral tablet 25 mg, 50 mg Tier 1
eplerenone oral tablet 25 mg, 50 mg Tier 1
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
Tier 1
furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1
hydrochlorothiazide oral capsule 12.5 mg Tier 1
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg
Tier 1
indapamide oral tablet 1.25 mg, 2.5 mg Tier 1
metolazone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1
spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
Tier 1
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg
Tier 1
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg
Tier 1
triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg
Tier 1
Heart Health, Other
DIGOXIN ORAL SOLUTION 50 MCG/ML Tier 1
digoxin oral tablet 125 mcg Tier 1
GenericsAdvantageRx: October 1, 201849
Drug Tier Status More Details
digoxin oral tablet 250 mcg Tier 1 AE
ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG
Tier 1
klor-con m10 oral tablet,er particles/crystals 10 meq
Tier 1
klor-con m15 oral tablet,er particles/crystals 15 meq
Tier 1
KLOR-CON/25 ORAL PACKET 25 MEQ Tier 1
potassium chloride oral capsule, extended release10 meq, 8 meq
Tier 1
potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml
Tier 1
potassium chloride oral packet 20 meq Tier 1
potassium chloride oral tablet extended release10 meq, 20 meq, 8 meq
Tier 1
potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq
Tier 1
Triglyceride Lowering
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1
fenofibrate nanocrystallized oral tablet 145 mg, 48 mg
Tier 1
fenofibrate oral tablet 160 mg, 54 mg Tier 1
gemfibrozil oral tablet 600 mg Tier 1
omega-3 acid ethyl esters oral capsule 1 gram Tier 1
Hereditary Angioedema
Hereditary Angioedema
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) Tier 2 PA; Specialty
BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 ML)
Tier 2 PA; Specialty
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
Tier 2 PA; Specialty
FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML Tier 2 PA; Specialty; QL
HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT
Tier 2 PA; Specialty
KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML (1 ML)
Tier 2 PA; Specialty
RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT
Tier 2 PA; Specialty
GenericsAdvantageRx: October 1, 201850
Drug Tier Status More Details
Idiopathic Pulmonary Fibrosis
Idiopathic Pulmonary Fibrosis
ESBRIET ORAL CAPSULE 267 MG Tier 2 PA; Specialty
ESBRIET ORAL TABLET 267 MG, 801 MG Tier 2 PA; Specialty
OFEV ORAL CAPSULE 100 MG, 150 MG Tier 2 PA; Specialty
Immune Deficiency
Immune Deficiency
BIVIGAM INTRAVENOUS SOLUTION 10 % Tier 2 PA; Specialty
CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM
Tier 2 PA; Specialty
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %)
Tier 2 PA; Specialty
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 %
Tier 2 PA; Specialty
GAMASTAN S/D INTRAMUSCULAR SOLUTION15-18 % RANGE
Tier 2 PA; Specialty
GAMMAGARD LIQUID INJECTION SOLUTION 10 %
Tier 2 PA; Specialty
GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM
Tier 2 PA; Specialty
GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)
Tier 2 PA; Specialty
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 %
Tier 2 PA; Specialty
GAMMAPLEX INTRAVENOUS SOLUTION 10 % Tier 2 PA; Specialty
GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %)
Tier 2 PA; Specialty
HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)
Tier 2 PA; Specialty
HYQVIA HY COMPONENT SUBCUTANEOUS SOLUTION 1,600 UNIT/10 ML, 2,400 UNIT/15 ML, 200 UNIT/1.25 ML, 400 UNIT/2.5 ML, 800 UNIT/5 ML
Tier 2 PA; Specialty
GenericsAdvantageRx: October 1, 201851
Drug Tier Status More Details
HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %)
Tier 2 PA; Specialty
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %)
Tier 2 PA; Specialty
OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % Tier 2 PA; Specialty
PRIVIGEN INTRAVENOUS SOLUTION 10 % Tier 2 PA; Specialty
Immune Suppressant
Immune Suppressant
azathioprine oral tablet 50 mg Tier 1
cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg
Tier 1
cyclosporine modified oral solution 100 mg/ml Tier 1
cyclosporine oral capsule 100 mg, 25 mg Tier 1
gengraf oral capsule 100 mg, 25 mg Tier 1
gengraf oral solution 100 mg/ml Tier 1
mycophenolate mofetil oral capsule 250 mg Tier 1
mycophenolate mofetil oral suspension for reconstitution 200 mg/ml
Tier 1
mycophenolate mofetil oral tablet 500 mg Tier 1
RAPAMUNE ORAL SOLUTION 1 MG/ML Tier 1
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Tier 1
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Tier 1
Kidney Failure
Kidney Failure
calcium acetate oral capsule 667 mg Tier 1
PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML
Tier 1
SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG Tier 1
sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram
Tier 1
sevelamer carbonate oral tablet 800 mg Tier 1
GenericsAdvantageRx: October 1, 201852
Drug Tier Status More Details
Men's Health
Benign Prostatic Hypertrophy
alfuzosin oral tablet extended release 24 hr 10 mg
Tier 1
dutasteride oral capsule 0.5 mg Tier 1
finasteride oral tablet 5 mg Tier 1
tamsulosin oral capsule 0.4 mg Tier 1
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1
Testosterone Deficiency
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)
Tier 1 PA
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
Tier 1 PA
androxy oral tablet 10 mg Tier 1 QL
testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml
Tier 1 PA
testosterone enanthate intramuscular oil 200 mg/ml
Tier 1 PA
testosterone transdermal gel 50 mg/5 gram (1 %) Tier 1 PA
testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1 %)
Tier 1 PA
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)
Tier 1 PA
Migraine
Migraine, Other
isometh-dichloral-acetaminophn oral capsule 65-100-325 mg
Tier 1 QL
Migraine, Preventives
AIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML
Tier 2 PA; Specialty; QL
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML
Tier 2 PA; Specialty; QL
Migraine, Triptans
eletriptan oral tablet 20 mg, 40 mg Tier 1 PA; QL
naratriptan oral tablet 1 mg, 2.5 mg Tier 1 QL
rizatriptan oral tablet 10 mg, 5 mg Tier 1 QL
GenericsAdvantageRx: October 1, 201853
Drug Tier Status More Details
rizatriptan oral tablet,disintegrating 10 mg, 5 mg Tier 1 QL
sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation
Tier 1 QL
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg
Tier 1 QL
sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml
Tier 1 QL
sumatriptan succinate subcutaneous pen injector4 mg/0.5 ml, 6 mg/0.5 ml
Tier 1 QL
sumatriptan succinate subcutaneous solution 6 mg/0.5 ml
Tier 1 QL
Mouth & Throat
Dental Health
chlorhexidine gluconate mucous membrane mouthwash 0.12 %
Tier 1
periogard mucous membrane mouthwash 0.12 % Tier 1
triamcinolone acetonide dental paste 0.1 % Tier 1
Dry Mouth
cevimeline oral capsule 30 mg Tier 1
pilocarpine hcl oral tablet 5 mg, 7.5 mg Tier 1
Pain
lidocaine hcl mucous membrane jelly 2 % Tier 1
lidocaine hcl mucous membrane jelly in applicator 2 %
Tier 1
lidocaine hcl mucous membrane solution 4 % (40 mg/ml)
Tier 1
lidocaine viscous mucous membrane solution 2 % Tier 1
Multiple Sclerosis
Multiple Sclerosis, Injection
AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT30 MCG
Tier 2 Specialty; QL
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML
Tier 2 Specialty; QL
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML
Tier 2 Specialty; QL
EXTAVIA SUBCUTANEOUS KIT 0.3 MG Tier 2 Specialty; QL
glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml
Tier 2 Specialty; QL
GenericsAdvantageRx: October 1, 201854
Drug Tier Status More Details
glatopa subcutaneous syringe 20 mg/ml Tier 2 Specialty; QL
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML
Tier 2 Specialty; QL
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML
Tier 2 Specialty; QL
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML
Tier 2 Specialty; QL
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)
Tier 2 Specialty; QL
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)
Tier 2 Specialty; QL
Multiple Sclerosis, Oral
AUBAGIO ORAL TABLET 14 MG, 7 MG Tier 2 Specialty; QL
dalfampridine oral tablet extended release 12 hr10 mg
Tier 2 PA; Specialty
GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG Tier 2 Specialty; QL
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG
Tier 2 Specialty; QL
Muscle Relaxant
Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg, 5 mg Tier 1
chlorzoxazone oral tablet 500 mg Tier 1 AE
cyclobenzaprine oral tablet 10 mg, 5 mg Tier 1 AE
dantrolene oral capsule 100 mg, 25 mg, 50 mg Tier 1
methocarbamol oral tablet 500 mg, 750 mg Tier 1 AE
tizanidine oral tablet 2 mg, 4 mg Tier 1
Other Conditions
Other Agents
ACTHAR H.P. INJECTION GEL 80 UNIT/ML Tier 2 PA; Specialty
ALFERON N INJECTION SOLUTION 5 MILLION UNIT/ML
Tier 2 Specialty
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
Tier 2 PA; Specialty
AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 2 PA; Specialty
CARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML
Tier 1
GenericsAdvantageRx: October 1, 201855
Drug Tier Status More Details
CHEMET ORAL CAPSULE 100 MG Tier 1
CYSTAGON ORAL CAPSULE 150 MG, 50 MG Tier 1
desmopressin nasal spray with pump 10 mcg/spray (0.1 ml)
Tier 1 PA
desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)
Tier 1 PA
desmopressin oral tablet 0.1 mg, 0.2 mg Tier 1 AE
ergoloid oral tablet 1 mg Tier 1 PA
EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG
Tier 2 PA; Specialty; TD
FERRIPROX ORAL SOLUTION 100 MG/ML Tier 2 PA; Specialty
FERRIPROX ORAL TABLET 500 MG Tier 2 PA; Specialty
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML
Tier 2 PA; Specialty
INGREZZA ORAL CAPSULE 40 MG, 80 MG Tier 2 PA; Specialty
JADENU ORAL TABLET 180 MG, 360 MG, 90 MG Tier 2 PA; Specialty; TD
JADENU SPRINKLE ORAL GRANULES IN PACKET180 MG, 360 MG, 90 MG
Tier 2 PA; Specialty; TD
kionex oral powder Tier 1
KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG
Tier 2 PA; Specialty
KUVAN ORAL TABLET,SOLUBLE 100 MG Tier 2 PA; Specialty
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg
Tier 1
levocarnitine (with sugar) oral solution 100 mg/ml
Tier 1
levocarnitine oral tablet 330 mg Tier 1
megestrol oral suspension 400 mg/10 ml (40 mg/ml)
Tier 1
octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
Tier 2 Specialty
octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)
Tier 2 Specialty
oxandrolone oral tablet 10 mg, 2.5 mg Tier 1 PA; QL
pyridostigmine bromide oral tablet 60 mg Tier 1
pyridostigmine bromide oral tablet extended release 180 mg
Tier 1
riluzole oral tablet 50 mg Tier 1
GenericsAdvantageRx: October 1, 201856
Drug Tier Status More Details
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG
Tier 2 Specialty
SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)
Tier 2 PA; Specialty
sodium phenylbutyrate oral powder 0.94 gram/gram
Tier 1 PA
sodium polystyrene (sorb free) oral suspension 15 gram/60 ml
Tier 1
sodium polystyrene sulfonate oral powder Tier 1
sodium polystyrene sulfonate oral suspension 15 gram/60 ml
Tier 1
tetrabenazine oral tablet 12.5 mg, 25 mg Tier 2 PA; Specialty
THIOLA ORAL TABLET 100 MG Tier 2 PA; Specialty
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
Tier 2 PA; Specialty
Pain
Fibromyalgia / Neuropathic Pain
gabapentin oral capsule 100 mg, 300 mg, 400 mg Tier 1 QL
gabapentin oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)
Tier 1 QL
gabapentin oral tablet 600 mg, 800 mg Tier 1 QL
Non-Steroidal Anti-Inflammatories
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
Tier 1
diclofenac potassium oral tablet 50 mg Tier 1
diclofenac sodium oral tablet extended release 24 hr 100 mg
Tier 1
diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg
Tier 1
etodolac oral capsule 200 mg, 300 mg Tier 1
etodolac oral tablet 400 mg, 500 mg Tier 1
etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg
Tier 1
flurbiprofen oral tablet 100 mg, 50 mg Tier 1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1
indomethacin oral capsule 25 mg, 50 mg Tier 1 QL; AE
GenericsAdvantageRx: October 1, 201857
Drug Tier Status More Details
ketorolac oral tablet 10 mg Tier 1 QL
meloxicam oral suspension 7.5 mg/5 ml Tier 1
meloxicam oral tablet 15 mg, 7.5 mg Tier 1
nabumetone oral tablet 500 mg, 750 mg Tier 1
naproxen oral suspension 125 mg/5 ml Tier 1
naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1
naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg
Tier 1
piroxicam oral capsule 10 mg, 20 mg Tier 1
salsalate oral tablet 500 mg, 750 mg Tier 1
sulindac oral tablet 150 mg, 200 mg Tier 1
tolmetin oral capsule 400 mg Tier 1 PA
tolmetin oral tablet 200 mg, 600 mg Tier 1 PA
Pain, Opioids
acetaminophen-codeine oral solution 120-12 mg/5 ml
Tier 1 QL; AE
acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml
Tier 1 QL; AE
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg
Tier 1 QL; AE
buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour
Tier 1 PA; QL
buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg
Tier 1 QL
codeine sulfate oral tablet 15 mg, 30 mg, 60 mg Tier 1 QL; AE
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
Tier 1 QL
fentanyl transdermal patch 72 hour 100 mcg/hr, 75 mcg/hr
Tier 1 PA
fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr
Tier 1 PA; QL
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
Tier 1 QL
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
Tier 1 QL
hydrocodone-ibuprofen oral tablet 7.5-200 mg Tier 1 QL
hydromorphone oral liquid 1 mg/ml Tier 1 QL
GenericsAdvantageRx: October 1, 201858
Drug Tier Status More Details
hydromorphone oral tablet 2 mg, 4 mg, 8 mg Tier 1 QL
hydromorphone rectal suppository 3 mg Tier 1 QL
methadone oral concentrate 10 mg/ml Tier 1 PA; QL
methadone oral solution 10 mg/5 ml, 5 mg/5 ml Tier 1 PA; QL
methadone oral tablet 10 mg, 5 mg Tier 1 PA; QL
methadone oral tablet,soluble 40 mg Tier 1 PA
morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)
Tier 1 QL
morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)
Tier 1 QL
MORPHINE ORAL TABLET 15 MG, 30 MG Tier 1 QL
morphine oral tablet extended release 100 mg, 200 mg, 60 mg
Tier 1 PA
morphine oral tablet extended release 15 mg, 30 mg
Tier 1 PA; QL
morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg
Tier 1 QL
oxycodone oral capsule 5 mg Tier 1 QL
oxycodone oral concentrate 20 mg/ml Tier 1 QL
oxycodone oral solution 5 mg/5 ml Tier 1 QL
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 5 mg Tier 1 QL
oxycodone oral tablet 30 mg Tier 1 PA
oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg
Tier 1 PA; QL
oxycodone oral tablet,oral only,ext.rel.12 hr 30 mg, 40 mg, 60 mg, 80 mg
Tier 1 PA
oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
Tier 1 QL
oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 QL
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG
Tier 1 PA; QL
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 MG, 40 MG, 60 MG, 80 MG
Tier 1 PA
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG
Tier 1 QL
Pain, Other
butalbital-acetaminophen oral tablet 50-325 mg Tier 1 QL
GenericsAdvantageRx: October 1, 201859
Drug Tier Status More Details
butalbital-acetaminophen-caff oral capsule 50-325-40 mg
Tier 1 QL
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Tier 1 QL
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
Tier 1 QL
tramadol oral tablet 50 mg Tier 1 QL; AE
Pain, Topical
diclofenac sodium topical gel 1 % Tier 1
lidocaine-prilocaine topical cream 2.5-2.5 % Tier 1 QL
Parkinson's
Parkinson's
benztropine oral tablet 0.5 mg, 1 mg, 2 mg Tier 1
bromocriptine oral capsule 5 mg Tier 1
bromocriptine oral tablet 2.5 mg Tier 1
carbidopa oral tablet 25 mg Tier 1
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg
Tier 1
carbidopa-levodopa oral tablet extended release25-100 mg, 50-200 mg
Tier 1
carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg
Tier 1
carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg
Tier 1
entacapone oral tablet 200 mg Tier 1
NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR
Tier 1 PA
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
Tier 1
rasagiline oral tablet 0.5 mg, 1 mg Tier 1 PA
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg
Tier 1
RYTARY ORAL CAPSULE, EXTENDED RELEASE23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG
Tier 1 PA
GenericsAdvantageRx: October 1, 201860
Drug Tier Status More Details
selegiline hcl oral capsule 5 mg Tier 1
selegiline hcl oral tablet 5 mg Tier 1
trihexyphenidyl oral elixir 0.4 mg/ml Tier 1
trihexyphenidyl oral tablet 2 mg, 5 mg Tier 1
Pulmonary Hypertension
Pulmonary Hypertension
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG
Tier 2 PA; Specialty
epoprostenol (glycine) intravenous recon soln 1.5 mg
Tier 2 PA; Specialty
FLOLAN INTRAVENOUS RECON SOLN 1.5 MG Tier 2 PA; Specialty
LETAIRIS ORAL TABLET 10 MG, 5 MG Tier 2 PA; Specialty
OPSUMIT ORAL TABLET 10 MG Tier 2 PA; Specialty
REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML
Tier 2 PA; Specialty
sildenafil (antihypertensive) oral tablet 20 mg Tier 1 PA; QL
TRACLEER ORAL TABLET 125 MG, 62.5 MG Tier 2 PA; Specialty
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
Tier 2 PA; Specialty
TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)
Tier 2 PA; Specialty
TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)
Tier 2 PA; Specialty
TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML
Tier 2 PA; Specialty
UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG
Tier 2 PA; Specialty
UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60)
Tier 2 PA; Specialty
VELETRI INTRAVENOUS RECON SOLN 0.5 MG, 1.5 MG
Tier 2 PA; Specialty
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML
Tier 2 PA; Specialty
Seizures / Epilepsy
Seizures / Epilepsy
APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG
Tier 1 PA
GenericsAdvantageRx: October 1, 201861
Drug Tier Status More Details
BANZEL ORAL SUSPENSION 40 MG/ML Tier 1 PA; QL
BANZEL ORAL TABLET 200 MG, 400 MG Tier 1 PA; QL
BRIVIACT ORAL SOLUTION 10 MG/ML Tier 1 PA
BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG
Tier 1 PA
carbamazepine oral capsule, er multiphase 12 hr100 mg, 200 mg, 300 mg
Tier 1
carbamazepine oral suspension 100 mg/5 ml, 100 mg/5 ml (5 ml)
Tier 1
carbamazepine oral tablet 200 mg Tier 1
carbamazepine oral tablet extended release 12 hr100 mg, 200 mg, 400 mg
Tier 1
carbamazepine oral tablet,chewable 100 mg Tier 1
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 QL
clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg
Tier 1 QL
diazepam intensol oral concentrate 5 mg/ml Tier 1 QL
diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 QL
diazepam oral tablet 10 mg, 2 mg, 5 mg Tier 1 QL
diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg
Tier 1 QL
DILANTIN KAPSEAL ORAL CAPSULE 30 MG Tier 1
DILANTIN ORAL CAPSULE 30 MG Tier 1
divalproex oral capsule, delayed rel sprinkle 125 mg
Tier 1
divalproex oral tablet extended release 24 hr 250 mg, 500 mg
Tier 1
divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg
Tier 1
ethosuximide oral capsule 250 mg Tier 1
ethosuximide oral solution 250 mg/5 ml Tier 1
felbamate oral suspension 600 mg/5 ml Tier 1
felbamate oral tablet 400 mg, 600 mg Tier 1
FYCOMPA ORAL SUSPENSION 0.5 MG/ML Tier 1 PA
FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
Tier 1 PA
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg
Tier 1
GenericsAdvantageRx: October 1, 201862
Drug Tier Status More Details
lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7)
Tier 1 PA
lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg
Tier 1
lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg
Tier 1 PA
levetiracetam oral solution 100 mg/ml Tier 1
levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg
Tier 1
levetiracetam oral tablet extended release 24 hr500 mg, 750 mg
Tier 1
ONFI ORAL SUSPENSION 2.5 MG/ML Tier 1 QL
ONFI ORAL TABLET 10 MG, 20 MG Tier 1 QL
oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)
Tier 1
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
Tier 1
phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) Tier 1
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 60 mg
Tier 1
phenytoin oral suspension 125 mg/5 ml Tier 1
phenytoin oral tablet,chewable 50 mg Tier 1
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg
Tier 1
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG
Tier 1 QL
primidone oral tablet 250 mg, 50 mg Tier 1
SABRIL ORAL TABLET 500 MG Tier 2 PA; Specialty
tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg Tier 1
topiramate oral capsule, sprinkle 15 mg, 25 mg Tier 1
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml)
Tier 1
valproic acid oral capsule 250 mg Tier 1
VIGABATRIN ORAL POWDER IN PACKET 500 MG Tier 2 PA; Specialty
VIMPAT ORAL SOLUTION 10 MG/ML Tier 1 QL
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG
Tier 1 QL
GenericsAdvantageRx: October 1, 201863
Drug Tier Status More Details
zonisamide oral capsule 100 mg, 25 mg, 50 mg Tier 1
Skin Conditions
Acne, Oral
amnesteem oral capsule 10 mg, 20 mg, 40 mg Tier 1
claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg Tier 1
myorisan oral capsule 10 mg, 20 mg, 40 mg Tier 1
zenatane oral capsule 10 mg, 20 mg, 40 mg Tier 1
Acne, Topical
adapalene topical cream 0.1 % Tier 1
adapalene topical gel 0.3 % Tier 1
adapalene topical gel with pump 0.3 % Tier 1
avita topical cream 0.025 % Tier 1
avita topical gel 0.025 % Tier 1
clindamycin phosphate topical gel 1 % Tier 1
clindamycin phosphate topical lotion 1 % Tier 1
clindamycin phosphate topical solution 1 % Tier 1
clindamycin phosphate topical swab 1 % Tier 1
DIFFERIN TOPICAL GEL 0.1 % Tier 1 PA
erythromycin with ethanol topical gel 2 % Tier 1
erythromycin with ethanol topical solution 2 % Tier 1
sulfacetamide sodium (acne) topical suspension10 %
Tier 1
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical cream 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)
Tier 1
sulfacetamide sod-sulfur-urea topical cleanser10-5-10 %
Tier 1
tretinoin topical cream 0.025 %, 0.05 %, 0.1 % Tier 1
tretinoin topical gel 0.01 %, 0.025 % Tier 1
Antifungals, Topical
ciclopirox topical cream 0.77 % Tier 1
ciclopirox topical gel 0.77 % Tier 1
ciclopirox topical solution 8 % Tier 1
GenericsAdvantageRx: October 1, 201864
Drug Tier Status More Details
ciclopirox topical suspension 0.77 % Tier 1
ketoconazole topical cream 2 % Tier 1
ketoconazole topical shampoo 2 % Tier 1
nystatin topical cream 100,000 unit/gram Tier 1
nystatin topical ointment 100,000 unit/gram Tier 1
nystatin topical powder 100,000 unit/gram Tier 1
Anti-Infectives, Topical
gentamicin topical cream 0.1 % Tier 1
gentamicin topical ointment 0.1 % Tier 1
mupirocin topical ointment 2 % Tier 1
silver sulfadiazine topical cream 1 % Tier 1
Corticosteroids, Topical
alclometasone topical cream 0.05 % Tier 1
alclometasone topical ointment 0.05 % Tier 1
betamethasone dipropionate topical cream 0.05 %
Tier 1
betamethasone dipropionate topical lotion 0.05 %
Tier 1
betamethasone dipropionate topical ointment0.05 %
Tier 1
betamethasone valerate topical cream 0.1 % Tier 1
betamethasone valerate topical lotion 0.1 % Tier 1
betamethasone valerate topical ointment 0.1 % Tier 1
betamethasone, augmented topical cream 0.05 %
Tier 1
betamethasone, augmented topical gel 0.05 % Tier 1
betamethasone, augmented topical lotion 0.05 % Tier 1
betamethasone, augmented topical ointment0.05 %
Tier 1
clobetasol scalp solution 0.05 % Tier 1
clobetasol topical cream 0.05 % Tier 1
clobetasol topical gel 0.05 % Tier 1
clobetasol topical ointment 0.05 % Tier 1
clobetasol-emollient topical cream 0.05 % Tier 1
desonide topical cream 0.05 % Tier 1
desonide topical lotion 0.05 % Tier 1
desonide topical ointment 0.05 % Tier 1
GenericsAdvantageRx: October 1, 201865
Drug Tier Status More Details
desoximetasone topical cream 0.05 %, 0.25 % Tier 1
desoximetasone topical gel 0.05 % Tier 1
desoximetasone topical ointment 0.25 % Tier 1
fluocinolone and shower cap scalp oil 0.01 % Tier 1
fluocinolone topical cream 0.01 %, 0.025 % Tier 1
fluocinolone topical oil 0.01 % Tier 1
fluocinolone topical ointment 0.025 % Tier 1
fluocinonide topical cream 0.05 % Tier 1
fluocinonide topical gel 0.05 % Tier 1
fluocinonide topical ointment 0.05 % Tier 1
fluocinonide topical solution 0.05 % Tier 1
fluocinonide-e topical cream 0.05 % Tier 1
fluticasone topical cream 0.05 % Tier 1
fluticasone topical ointment 0.005 % Tier 1
hydrocortisone topical cream 2.5 % Tier 1
hydrocortisone topical lotion 2.5 % Tier 1
hydrocortisone topical ointment 2.5 % Tier 1
hydrocortisone valerate topical cream 0.2 % Tier 1
hydrocortisone valerate topical ointment 0.2 % Tier 1
hydrocortisone-pramoxine topical cream 2.5-1 % Tier 1
iodoquinol-hc topical cream 1-1 % Tier 1
mometasone topical cream 0.1 % Tier 1
mometasone topical ointment 0.1 % Tier 1
mometasone topical solution 0.1 % Tier 1
triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 %
Tier 1
triamcinolone acetonide topical lotion 0.025 %, 0.1 %
Tier 1
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
Tier 1
trianex topical ointment 0.05 % Tier 1
triderm topical cream 0.1 %, 0.5 % Tier 1
Lice / Scabies, Topical
malathion topical lotion 0.5 % Tier 1
permethrin topical cream 5 % Tier 1
GenericsAdvantageRx: October 1, 201866
Drug Tier Status More Details
Psoriasis, Other
acitretin oral capsule 10 mg, 17.5 mg, 25 mg Tier 1
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR150 MG/ML
Tier 2 PA; Specialty
COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML
Tier 2 PA; Specialty
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (0.98 ML)
Tier 2 PA; Specialty
HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML
Tier 2 PA; Specialty
Psoriasis, Topical
calcipotriene scalp solution 0.005 % Tier 1
calcipotriene topical cream 0.005 % Tier 1
calcipotriene topical ointment 0.005 % Tier 1
Rosacea
metronidazole topical cream 0.75 % Tier 1
metronidazole topical gel 0.75 % Tier 1
metronidazole topical lotion 0.75 % Tier 1
Skin Conditions, Other
ammonium lactate topical cream 12 % Tier 1
ammonium lactate topical lotion 12 % Tier 1
DRYSOL DAB-O-MATIC TOPICAL SOLUTION 20 % Tier 1
DRYSOL TOPICAL SOLUTION 20 % Tier 1
DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML
Tier 2 PA; Specialty
ELIDEL TOPICAL CREAM 1 % Tier 1
EUCRISA TOPICAL OINTMENT 2 % Tier 1 PA; QL
fluorouracil topical cream 5 % Tier 1
fluorouracil topical solution 2 %, 5 % Tier 1
imiquimod topical cream in packet 5 % Tier 1
PICATO TOPICAL GEL 0.015 %, 0.05 % Tier 1 PA
podofilox topical solution 0.5 % Tier 1
selenium sulfide topical lotion 2.5 % Tier 1
tacrolimus topical ointment 0.03 %, 0.1 % Tier 1
urea topical cream 40 % Tier 1
urea topical gel 40 % Tier 1
GenericsAdvantageRx: October 1, 201867
Drug Tier Status More Details
urea topical lotion 40 % Tier 1
Sleep Disorders
Insomnia
eszopiclone oral tablet 1 mg, 2 mg, 3 mg Tier 1 QL; AE
temazepam oral capsule 15 mg, 30 mg Tier 1 QL
zaleplon oral capsule 10 mg, 5 mg Tier 1 QL; AE
zolpidem oral tablet 10 mg, 5 mg Tier 1 QL; AE
Narcolepsy / Excessive Sleepiness
armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg
Tier 1 QL
modafinil oral tablet 100 mg, 200 mg Tier 1 QL
XYREM ORAL SOLUTION 500 MG/ML Tier 2 PA; Specialty; QL
Smoking Cessation
Nicotine Replacement
nicotine (polacrilex) buccal gum 2 mg, 4 mg Tier 1 SC
nicotine (polacrilex) buccal lozenge 2 mg, 4 mg Tier 1 SC
nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 22 mg/24 hr, 7 mg/24 hr
Tier 1 SC
NICOTROL INHALATION CARTRIDGE 10 MG Tier 1 SC
NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML
Tier 1 SC
Smoking Cessation, Other
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg
Tier 1
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
Tier 1 SC; QL
CHANTIX ORAL TABLET 0.5 MG, 1 MG Tier 1 SC; QL
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)
Tier 1 SC; QL
Stomach / Gastrointestinal
Bowel Prep
gavilyte-c oral recon soln 240-22.72-6.72 -5.84 gram
Tier 1
gavilyte-g oral recon soln 236-22.74-6.74 -5.86 gram
Tier 1
gavilyte-n oral recon soln 420 gram Tier 1
GenericsAdvantageRx: October 1, 201868
Drug Tier Status More Details
Constipation
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG Tier 1 QL
enulose oral solution 10 gram/15 ml Tier 1
lactulose oral solution 10 gram/15 ml Tier 1
LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG
Tier 1 QL
polyethylene glycol 3350 oral powder 17 gram/dose
Tier 1
SYMPROIC ORAL TABLET 0.2 MG Tier 1 PA
Crohn's Disease / Ulcerative Colitis
balsalazide oral capsule 750 mg Tier 1
budesonide oral capsule,delayed,extend.release 3 mg
Tier 1
CANASA RECTAL SUPPOSITORY 1,000 MG Tier 1
DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG
Tier 1
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML
Tier 2 PA; Specialty
HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML
Tier 2 PA; Specialty
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML
Tier 2 PA; Specialty
HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML
Tier 2 PA; Specialty
lialda oral tablet,delayed release (dr/ec) 1.2 gram Tier 1
mesalamine oral tablet,delayed release (dr/ec)800 mg
Tier 1
mesalamine rectal enema 4 gram/60 ml Tier 1
PENTASA ORAL CAPSULE, EXTENDED RELEASE250 MG, 500 MG
Tier 1
sulfasalazine oral tablet 500 mg Tier 1
sulfasalazine oral tablet,delayed release (dr/ec)500 mg
Tier 1
Nausea / Vomiting
aprepitant oral capsule 125 mg, 40 mg, 80 mg Tier 1
GenericsAdvantageRx: October 1, 201869
Drug Tier Status More Details
aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2)
Tier 1
dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Tier 1 QL
EMEND ORAL CAPSULE 125 MG, 40 MG Tier 1
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.)
Tier 1
metoclopramide hcl oral solution 5 mg/5 ml Tier 1
metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1
ondansetron hcl oral solution 4 mg/5 ml Tier 1
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg Tier 1
ondansetron oral tablet,disintegrating 4 mg, 8 mg
Tier 1
prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1
prochlorperazine rectal suppository 25 mg Tier 1
promethazine rectal suppository 12.5 mg, 25 mg, 50 mg
Tier 1
scopolamine base transdermal patch 3 day 1 mg over 3 days
Tier 1
trimethobenzamide oral capsule 300 mg Tier 1
Stomach / Gastrointestinal Other
L-GLUTAMINE POWDER Tier 1 PA
Stomach / Gastrointestinal, Other
alosetron oral tablet 0.5 mg, 1 mg Tier 1 PA
CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG Tier 2 PA; Specialty
CHOLBAM ORAL CAPSULE 250 MG, 50 MG Tier 2 PA; Specialty
CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML)
Tier 1 PA
dicyclomine oral capsule 10 mg Tier 1
dicyclomine oral solution 10 mg/5 ml Tier 1
dicyclomine oral tablet 20 mg Tier 1
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml
Tier 1 QL
diphenoxylate-atropine oral tablet 2.5-0.025 mg Tier 1 QL
glycopyrrolate oral tablet 1 mg, 2 mg Tier 1
hyoscyamine sulfate oral drops 0.125 mg/ml Tier 1
hyoscyamine sulfate oral elixir 0.125 mg/5 ml Tier 1
GenericsAdvantageRx: October 1, 201870
Drug Tier Status More Details
hyoscyamine sulfate oral tablet 0.125 mg Tier 1
hyoscyamine sulfate oral tablet extended release 12 hr 0.375 mg
Tier 1
hyoscyamine sulfate oral tablet,disintegrating0.125 mg
Tier 1
hyoscyamine sulfate sublingual tablet 0.125 mg Tier 1
MOVANTIK ORAL TABLET 12.5 MG, 25 MG Tier 1 PA; QL
paregoric oral liquid 2 mg/5 ml Tier 1 QL
propantheline oral tablet 15 mg Tier 1
ursodiol oral capsule 300 mg Tier 1
ursodiol oral tablet 250 mg, 500 mg Tier 1
XERMELO ORAL TABLET 250 MG Tier 2 PA; Specialty
Stomach / Gastrointestinal, Rectal
hydrocortisone acetate rectal suppository 25 mg Tier 1
hydrocortisone rectal enema 100 mg/60 ml Tier 1
hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 %
Tier 1
proctosol hc rectal cream with applicator 2.5 % Tier 1
proctozone-hc topical cream with perineal applicator 2.5 %
Tier 1
Ulcers / Heartburn / Gerd
CARAFATE ORAL SUSPENSION 100 MG/ML Tier 1
famotidine oral tablet 20 mg, 40 mg Tier 1
lansoprazole oral capsule,delayed release(dr/ec)15 mg, 30 mg
Tier 1
lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 mg
Tier 1 AE
misoprostol oral tablet 100 mcg, 200 mcg Tier 1
omeprazole oral capsule,delayed release(dr/ec)10 mg, 20 mg, 40 mg
Tier 1
pantoprazole oral tablet,delayed release (dr/ec)20 mg, 40 mg
Tier 1
rabeprazole oral tablet,delayed release (dr/ec) 20 mg
Tier 1
ranitidine hcl oral syrup 15 mg/ml Tier 1
ranitidine hcl oral tablet 150 mg, 300 mg Tier 1
sucralfate oral suspension 100 mg/ml Tier 1
sucralfate oral tablet 1 gram Tier 1
GenericsAdvantageRx: October 1, 201871
Drug Tier Status More Details
Thyroid
Antithyroid Agents
methimazole oral tablet 10 mg, 5 mg Tier 1
propylthiouracil oral tablet 50 mg Tier 1
Thyroid Agents
levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1
liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg Tier 1
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
Tier 1
Urinary & Bladder Health
Overactive Bladder
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG
Tier 1
oxybutynin chloride oral syrup 5 mg/5 ml Tier 1
oxybutynin chloride oral tablet 5 mg Tier 1
oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg
Tier 1
tolterodine oral capsule,extended release 24hr 2 mg, 4 mg
Tier 1
tolterodine oral tablet 1 mg, 2 mg Tier 1
trospium oral tablet 20 mg Tier 1
Urinary & Bladder Health, Other
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg
Tier 1
ELMIRON ORAL CAPSULE 100 MG Tier 1
phenazopyridine oral tablet 100 mg, 200 mg Tier 1
potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg)
Tier 1
Vaccines
Vaccines
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML
Tier 1
GenericsAdvantageRx: October 1, 201872
Drug Tier Status More Details
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
Tier 1
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
Tier 1
ADENOVIRUS VAC LIVE TYPE-4, 7 ORAL TABLET,DELAYED RELEASE (DR/EC)
Tier 1
ADENOVIRUS VACCINE LIVE TYPE-4 ORAL TABLET,DELAYED RELEASE (DR/EC)
Tier 1
ADENOVIRUS VACCINE LIVE TYPE-7 ORAL TABLET,DELAYED RELEASE (DR/EC)
Tier 1
AFLURIA 2018-2019 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML
Tier 1
AFLURIA 2018-2019 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML
Tier 1
AFLURIA QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML
Tier 1
AFLURIA QUAD 2018-2019 INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML
Tier 1
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML
Tier 1
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION2.5-8-5 LF-MCG-LF/0.5ML
Tier 1
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML
Tier 1
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML
Tier 1
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION20 MCG/ML
Tier 1
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML
Tier 1
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML
Tier 1
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML
Tier 1
FLUAD 2018-2019 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML
Tier 1
GenericsAdvantageRx: October 1, 201873
Drug Tier Status More Details
FLUBLOK QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML
Tier 1
FLUCELVAX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML
Tier 1
FLUCELVAX QUAD 2018-2019 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML
Tier 1
FLULAVAL QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML
Tier 1
FLULAVAL QUAD 2018-2019 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML
Tier 1
FLUMIST QUAD 2018-2019 NASAL NASAL SPRAY SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML
Tier 1
FLUZONE HIGH-DOSE 2018-19 (PF) INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML
Tier 1
FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML
Tier 1
FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML
Tier 1
FLUZONE QUAD PEDI 2018-19 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML
Tier 1
GARDASIL (PF) INTRAMUSCULAR SUSPENSION20-40-40-20 MCG/0.5 ML
Tier 1
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION0.5 ML
Tier 1
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML
Tier 1
HAVRIX (PF) INTRAMUSCULAR SUSPENSION1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML
Tier 1
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML
Tier 1
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML
Tier 1
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML
Tier 1
GenericsAdvantageRx: October 1, 201874
Drug Tier Status More Details
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML
Tier 1
KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML
Tier 1
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML
Tier 1
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML
Tier 1
MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN5-2.5 MCG/0.5 ML
Tier 1
MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG
Tier 1
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML
Tier 1
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML
Tier 1
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION7.5 MCG/0.5 ML
Tier 1
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML
Tier 1
PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML
Tier 1
PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML
Tier 1
PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML
Tier 1
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML
Tier 1
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5
Tier 1
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 40 MCG/ML
Tier 1
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML
Tier 1
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML
Tier 1
SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION
Tier 1
GenericsAdvantageRx: October 1, 201875
Drug Tier Status More Details
SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG
Tier 1
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML
Tier 1
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML
Tier 1
TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML
Tier 1
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML
Tier 1
TWINRIX (PF) INTRAMUSCULAR SUSPENSION720 ELISA UNIT- 20 MCG/ML
Tier 1
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML
Tier 1
VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML
Tier 1
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML
Tier 1
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML
Tier 1
VAXCHORA BUFFER COMPONENT ORAL SUSPENSION FOR RECONSTITUTION
Tier 1
VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT
Tier 1
VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2 BILLION UNIT
Tier 1
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML
Tier 1
Vitamins And Minerals
Vitamins And Minerals
calcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1
calcitriol oral solution 1 mcg/ml Tier 1
completenate oral tablet,chewable 29 mg iron- 1 mg
Tier 1
cyanocobalamin (vitamin b-12) injection solution1,000 mcg/ml
Tier 1
GenericsAdvantageRx: October 1, 201876
Drug Tier Status More Details
denta 5000 plus dental cream 1.1 % Tier 1
dentagel dental gel 1.1 % Tier 1
fluoridex daily defense dental gel 1.1 % Tier 1
folic acid oral tablet 1 mg Tier 1
mynatal advance oral tablet 90-1-50 mg Tier 1
mynatal oral tablet 90-1-50 mg Tier 1
mynatal plus oral tablet 65 mg iron- 1 mg Tier 1
mynatal-z oral tablet 65 mg iron- 1 mg Tier 1
mynate 90 plus oral tablet extended release 90 mg iron-1 mg
Tier 1
o-cal prenatal oral tablet 15 mg iron- 1,000 mcg Tier 1
phytonadione (vitamin k1) oral tablet 5 mg Tier 1 QL
PRENATA ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG
Tier 1
prenatabs fa oral tablet 29-1 mg Tier 1
prenatabs rx oral tablet 29 mg iron- 1 mg Tier 1
prenatal plus (calcium carb) oral tablet 27 mg iron- 1 mg
Tier 1
prenatal plus oral tablet 29 mg iron- 1 mg Tier 1
prenatal rx oral tablet 60 mg iron-1 mg Tier 1
prenatal-u oral capsule 106.5-1 mg Tier 1 PA
PRENATE ELITE ORAL TABLET 26 MG IRON- 1 MG Tier 1
purefe ob plus oral capsule 106 mg iron- 1 mg Tier 1
se-natal 19 (with docusate) oral tablet 29 mg iron- 1 mg-25 mg
Tier 1
se-natal 19 oral tablet,chewable 29 mg iron- 1 mg
Tier 1
sf 5000 plus dental cream 1.1 % Tier 1
sf dental gel 1.1 % Tier 1
triadvance oral tablet 90-1-50 mg Tier 1
trinatal gt oral tablet 90-1-50 mg Tier 1
trinate oral tablet 28 mg iron- 1 mg Tier 1
triveen-prx rnf oral capsule 26-1.2-55-300 mg Tier 1
vinate care oral tablet,chewable 40 mg iron- 1 mg
Tier 1
vinate gt oral tablet 90-1-50 mg Tier 1
vinate m oral tablet 27 mg iron-1 mg Tier 1
GenericsAdvantageRx: October 1, 201877
Drug Tier Status More Details
vinate one oral tablet 60 mg iron-1 mg Tier 1
vinate ultra oral tablet 90-1-50 mg Tier 1
vitamin b-12 injection solution 1,000 mcg/ml Tier 1
vitamin d2 oral capsule 50,000 unit Tier 1
Weight Loss
Weight Loss
ALLI ORAL CAPSULE 60 MG Tier 1 PA; WL
lomaira oral tablet 8 mg Tier 1 WL; QL
phentermine oral capsule 15 mg, 30 mg, 37.5 mg Tier 1 WL; QL
phentermine oral tablet 37.5 mg Tier 1 WL; QL
XENICAL ORAL CAPSULE 120 MG Tier 1 PA; WL
Women's Health
Anti-Infectives, Vaginal
CLEOCIN VAGINAL SUPPOSITORY 100 MG Tier 1
clindamycin phosphate vaginal cream 2 % Tier 1
metronidazole vaginal gel 0.75 % Tier 1
terconazole vaginal cream 0.4 %, 0.8 % Tier 1
terconazole vaginal suppository 80 mg Tier 1
Estrogens, Vaginal
estradiol vaginal cream 0.01 % (0.1 mg/gram) Tier 1
PREMARIN VAGINAL CREAM 0.625 MG/GRAM Tier 1
yuvafem vaginal tablet 10 mcg Tier 1
Hormone Replacement
estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1
estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
Tier 1
estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
Tier 1
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg Tier 1
medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg
Tier 1
norethindrone acetate oral tablet 5 mg Tier 1
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG
Tier 1
GenericsAdvantageRx: October 1, 201878
Drug Tier Status More Details
progesterone micronized oral capsule 100 mg, 200 mg
Tier 1
Women's Health, Other
cabergoline oral tablet 0.5 mg Tier 1
danazol oral capsule 100 mg, 200 mg, 50 mg Tier 1
methylergonovine oral tablet 0.2 mg Tier 1
nifedipine oral capsule 10 mg, 20 mg Tier 1 GE Female; AE
raloxifene oral tablet 60 mg Tier 1
tranexamic acid oral tablet 650 mg Tier 1 QL
GenericsAdvantageRx: October 1, 201879
Index abacavir ................................ 11, 12abacavir-lamivudine ................... 12abacavir-lamivudine-zidovudine .12acamprosate .................................6acarbose ..................................... 37acetaminophen-codeine ............. 58acetazolamide ............................ 49acetic acid ...................................40acetylcysteine ............................. 36acitretin ...................................... 67ACTEMRA ................................... 15ACTHAR H.P. ...............................55ACTHIB (PF) ................................ 72acyclovir ......................................14ADACEL(TDAP ADOLESN/ADULT)(PF) ................73adapalene ................................... 64adderall xr ...................................20adefovir .......................................11ADEMPAS ................................... 61ADENOVIRUS VAC LIVE TYPE-4, 7 ..................................................73ADENOVIRUS VACCINE LIVE TYPE-4 .........................................73ADENOVIRUS VACCINE LIVE TYPE-7 .........................................73ADVAIR DISKUS .......................... 16ADVAIR HFA ............................... 17ADVATE ...................................... 28ADYNOVATE ............................... 28AFINITOR .................................... 33AFINITOR DISPERZ ......................33AFLURIA 2018-2019 ....................73AFLURIA 2018-2019 (PF) ............ 73AFLURIA QUAD 2018-2019 ........ 73AFLURIA QUAD 2018-2019 (PF) . 73AFSTYLA ......................................28AIMOVIG AUTOINJECTOR ..........53AIMOVIG AUTOINJECTOR (2 PACK) ..........................................53ALBENZA .....................................10albuterol sulfate ......................... 16alclometasone ............................ 65ALECENSA ................................... 34alendronate ................................ 32ALFERON N ................................. 55alfuzosin ......................................53
ALINIA .........................................10ALLI ............................................. 78allopurinol ...................................44alosetron .....................................70ALPHANATE ................................28ALPHANINE SD ........................... 28alprazolam ..................................19ALPROLIX ....................................28altavera (28) ............................... 22alyacen 1/35 (28) ........................22alyacen 7/7/7 (28) ...................... 23amantadine hcl ...........................14AMICAR ...................................... 27amiloride .....................................49amiloride-hydrochlorothiazide ... 49amiodarone ................................ 44AMITIZA ......................................69amitriptyline ............................... 22amlodipine .................................. 47amlodipine-benazepril ................ 45amlodipine-valsartan ..................47amlodipine-valsartan-hcthiazid ..47ammonium lactate ..................... 67amnesteem ................................. 64amoxicillin .................................8, 9amoxicillin-pot clavulanate ...........9ampicillin ...................................... 9anagrelide ...................................31anastrozole ................................. 33ANDROGEL ................................. 53androxy .......................................53ANORO ELLIPTA ..........................17aprepitant ............................. 69, 70apri ..............................................23APTIOM ...................................... 61APTIVUS ......................................12ARALAST NP ................................. 7aranelle (28) ............................... 23ARANESP (IN POLYSORBATE) .....27ARCALYST ................................... 55aripiprazole .................................18armodafinil ................................. 68ARNUITY ELLIPTA ....................... 17ASMANEX HFA ........................... 17ASMANEX TWISTHALER .............17aspirin-dipyridamole ...................31atazanavir ...................................12
atenolol .......................................46atenolol-chlorthalidone .............. 46atomoxetine ................................20atorvastatin ................................ 48atovaquone .................................10atovaquone-proguanil ................ 10ATRIPLA ...................................... 12atropine ...................................... 43ATROVENT HFA .......................... 16AUBAGIO .................................... 55aubra .......................................... 23AUSTEDO .................................... 55aviane ......................................... 23avita ............................................64AVONEX ......................................54AVONEX (WITH ALBUMIN) ........ 54azathioprine ................................52azelastine ......................................6azithromycin ................................. 8azurette (28) ............................... 23bacitracin ....................................41bacitracin-polymyxin b ............... 41baclofen ...................................... 55balsalazide .................................. 69balziva (28) ................................. 23BANZEL ....................................... 62BARACLUDE ................................11BASAGLAR KWIKPEN U-100 INSULIN ...................................... 38BEBULIN ......................................28benazepril ................................... 45benazepril-hydrochlorothiazide .. 45BENEFIX ...................................... 28benzonatate ................................36benztropine .................................60BERINERT ....................................50BESIVANCE ................................. 41betamethasone dipropionate ..... 65betamethasone valerate ............ 65betamethasone, augmented ...... 65betaxolol ..................................... 43bethanechol chloride .................. 72BEXSERO .....................................73bicalutamide ............................... 32BIKTARVY ................................... 12bimatoprost ................................ 43bisoprolol fumarate .................... 46
GenericsAdvantageRx: October 1, 201880
bisoprolol-hydrochlorothiazide ...46BIVIGAM .....................................51BLEPHAMIDE S.O.P. ................... 41blisovi fe 1.5/30 (28) ................... 23blisovi fe 1/20 (28) ...................... 23BOOSTRIX TDAP ......................... 73BOSULIF ...................................... 34BREO ELLIPTA ............................. 17brevicon (28) ...............................23briellyn ........................................ 23BRILINTA .....................................31brimonidine .................................43BRIVIACT .....................................62bromfenac .................................. 42bromocriptine ............................. 60budesonide ............................17, 69bumetanide .................................49buprenorphine ............................ 58buprenorphine-naloxone ............ 58bupropion hcl ..............................21bupropion hcl (smoking deter) ....68buspirone .................................... 19butalbital-acetaminophen .......... 59butalbital-acetaminophen-caff ...60butalbital-aspirin-caffeine .......... 60BYDUREON ................................. 37BYDUREON BCISE ....................... 37BYETTA ....................................... 38cabergoline ................................. 79CABOMETYX ...............................34calcipotriene ............................... 67calcitonin (salmon) ..................... 32calcitriol ...................................... 76calcium acetate .......................... 52camila ......................................... 23CANASA ...................................... 69capecitabine ............................... 32CAPRELSA ................................... 34captopril ......................................45captopril-hydrochlorothiazide .... 45CARAFATE ...................................71CARBAGLU ..................................70carbamazepine ........................... 62carbidopa ....................................60carbidopa-levodopa ....................60carbidopa-levodopa-entacapone .................................60CARIMUNE NF NANOFILTERED ..51
CARNITOR (SUGAR-FREE) .......... 55carteolol ......................................43cartia xt .......................................47carvedilol .................................... 46CAYSTON .................................... 36caziant (28) ................................. 23cefadroxil ...................................... 7cefdinir ..........................................7cefprozil ........................................ 7CEFTIN .......................................... 7cefuroxime axetil .......................... 7celecoxib ..................................... 57cephalexin .....................................8CERDELGA ...................................41cevimeline ...................................54CHANTIX ..................................... 68CHANTIX CONTINUING MONTH BOX .............................................68CHANTIX STARTING MONTH BOX .............................................68chateal ........................................ 23CHEMET ...................................... 56chlordiazepoxide hcl ................... 19chlorhexidine gluconate ..............54chloroquine phosphate ............... 10chlorothiazide ............................. 49chlorpromazine ...........................18chlorthalidone .............................49chlorzoxazone ............................. 55CHOLBAM ...................................70cholestyramine (with sugar) ....... 48cholestyramine light ................... 48ciclopirox ...............................64, 65cilostazol ..................................... 31CILOXAN ..................................... 41CINRYZE ...................................... 50CIPRO ............................................9CIPRO HC .................................... 41CIPRODEX ................................... 41ciprofloxacin ................................. 9ciprofloxacin hcl ...................... 9, 41citalopram .................................. 21claravis ........................................64clarithromycin ...............................8CLEOCIN ......................................78clindamycin hcl ............................. 8clindamycin palmitate hcl .............8clindamycin phosphate ......... 64, 78
clobetasol ....................................65clobetasol-emollient ................... 65clomipramine ..............................22clonazepam .................................62clonidine ..................................... 48clonidine hcl ................................ 47clopidogrel .................................. 31clotrimazole .................................. 9clozapine .....................................18COAGADEX ................................. 29codeine sulfate ............................58codeine-guaifenesin ....................36colchicine .................................... 44colestipol .....................................48COMBIVENT RESPIMAT ..............17COMETRIQ ..................................34COMPLERA ................................. 12completenate ..............................76CORIFACT ....................................29COSENTYX .................................. 67COSENTYX PEN ...........................67COTELLIC .....................................34CREON ........................................ 41CRESEMBA ..................................10CRIXIVAN ....................................12cromolyn ................................. 6, 16cryselle (28) .................................23CUVITRU ..................................... 51CUVPOSA ....................................70cyanocobalamin (vitamin b-12) .. 76cyclafem 1/35 (28) ......................23cyclafem 7/7/7 (28) .................... 23cyclobenzaprine .......................... 55cyclopentolate ............................ 43cyclophosphamide ...................... 33cycloserine .................................. 14CYCLOSET ....................................38cyclosporine ................................ 52cyclosporine modified ................. 52cyproheptadine .............................6CYSTAGON ..................................56CYSTARAN .................................. 43dalfampridine ............................. 55DALIRESP .................................... 16danazol ....................................... 79dantrolene .................................. 55dapsone ...................................... 10
GenericsAdvantageRx: October 1, 201881
DAPTACEL (DTAP PEDIATRIC) (PF) ............................................. 73dasetta 1/35 (28) ........................23dasetta 7/7/7 (28) ...................... 23DELZICOL .................................... 69demeclocycline ..............................9denta 5000 plus .......................... 77dentagel ......................................77DEPEN TITRATABS ......................15DESCOVY .................................... 12desipramine ................................ 22desmopressin ..............................56desogestrel-ethinyl estradiol ...... 23desonide ......................................65desoximetasone ..........................66desvenlafaxine succinate ............ 21dexamethasone .......................... 35DEXAMETHASONE INTENSOL .... 35dexamethasone sodium phosphate ............................. 35, 42dexmethylphenidate ...................20dextroamphetamine ................... 20dextroamphetamine-amphetamine ............................. 20diazepam .................................... 62diazepam intensol .......................62diclofenac potassium .................. 57diclofenac sodium ........... 42, 57, 60dicloxacillin ................................... 9dicyclomine ................................. 70didanosine .................................. 12DIFFERIN .....................................64DIFICID ..........................................8DIGOXIN ..................................... 49digoxin .................................. 49, 50DILANTIN .................................... 62DILANTIN KAPSEAL .....................62diltiazem hcl ................................47dilt-xr .......................................... 47DIOVAN ...................................... 45DIOVAN HCT ...............................45diphenoxylate-atropine .............. 70dipyridamole ...............................31disopyramide phosphate ............ 44disulfiram ......................................6divalproex ................................... 62dofetilide .....................................44donepezil .....................................37
dorzolamide ................................43dorzolamide-timolol ................... 43dorzolamide-timolol (pf) .............43doxazosin .................................... 48doxepin ....................................... 22doxycycline hyclate ....................... 9doxycycline monohydrate .............9dronabinol .................................. 70drospirenone-ethinyl estradiol ....23DRYSOL .......................................67DRYSOL DAB-O-MATIC ...............67DULERA .......................................17duloxetine ................................... 21DUPIXENT ...................................67dutasteride ................................. 53EDURANT ....................................12efavirenz ..................................... 12eletriptan .................................... 53ELIDEL ......................................... 67elinest ......................................... 23ELIQUIS ....................................... 30ELLA ............................................ 22ELMIRON .................................... 72ELOCTATE ................................... 29EMCYT ........................................ 32EMEND ....................................... 70emoquette .................................. 23EMTRIVA .................................... 12enalapril maleate ........................45enalapril-hydrochlorothiazide .....45ENBREL ....................................... 15ENBREL MINI .............................. 67ENBREL SURECLICK .....................15endocet ....................................... 58ENGERIX-B (PF) ...........................73ENGERIX-B PEDIATRIC (PF) ........ 73enoxaparin ..................................31enpresse ......................................23enskyce ....................................... 23entacapone .................................60entecavir ..................................... 11ENTRESTO ...................................50enulose ........................................69EPCLUSA ..................................... 11epinastine ..................................... 6epinephrine ...................................6EPIPEN JR 2-PAK ...........................6EPIVIR HBV ................................. 11
eplerenone ..................................49epoprostenol (glycine) ................ 61ergoloid .......................................56ERIVEDGE ................................... 34ERLEADA .....................................32errin ............................................ 23erythromycin ...............................41erythromycin with ethanol ......... 64ESBRIET .......................................51escitalopram oxalate .................. 21estarylla ...................................... 23estradiol ......................................78estropipate ................................. 78eszopiclone ................................. 68ethambutol ................................. 14ethosuximide .............................. 62etidronate disodium ................... 31etodolac ...................................... 57etoposide .................................... 33EUCRISA ......................................67EVOTAZ .......................................12exemestane .................................33EXJADE ........................................56EXTAVIA ......................................54ezetimibe .................................... 48falmina (28) ................................ 23famciclovir .................................. 14famotidine .................................. 71FANAPT .......................................18FEIBA NF ..................................... 29felbamate ................................... 62fenofibrate ..................................50fenofibrate micronized ............... 50fenofibrate nanocrystallized ....... 50fentanyl .......................................58FERRIPROX ................................. 56finasteride ...................................53FIRAZYR ...................................... 50FIRVANQ .......................................8FLEBOGAMMA DIF ..................... 51flecainide .................................... 44FLOLAN ....................................... 61FLOVENT DISKUS ........................17FLOVENT HFA ............................. 17FLUAD 2018-2019 (65 YR UP)(PF) ........................................73FLUBLOK QUAD 2018-2019 (PF) 74FLUCELVAX QUAD 2018-2019 ....74
GenericsAdvantageRx: October 1, 201882
FLUCELVAX QUAD 2018-2019 (PF) ............................................. 74fluconazole ..................................10fludrocortisone ............................35FLULAVAL QUAD 2018-2019 ...... 74FLULAVAL QUAD 2018-2019 (PF) ............................................. 74FLUMIST QUAD 2018-2019 ........ 74flunisolide ..................................... 7fluocinolone ................................ 66fluocinolone acetonide oil ...........41fluocinolone and shower cap ......66fluocinonide ................................ 66fluocinonide-e ............................. 66fluoridex daily defense ................77fluorometholone ......................... 42fluorouracil ................................. 67fluoxetine ....................................22fluphenazine hcl ..........................18flurbiprofen .................................57flurbiprofen sodium .................... 42flutamide .................................... 32fluticasone .............................. 7, 66fluticasone-salmeterol ................ 17fluvoxamine ................................ 22FLUZONE HIGH-DOSE 2018-19 (PF) ............................................. 74FLUZONE QUAD 2018-2019 (PF) ............................................. 74FLUZONE QUAD PEDI 2018-19 (PF) ............................................. 74FML S.O.P. .................................. 42folic acid ......................................77fondaparinux .............................. 31FORTEO .......................................32fosamprenavir .............................12fosinopril .....................................45fosinopril-hydrochlorothiazide ....45FULPHILA .................................... 27furosemide ..................................49FUZEON ...................................... 12FYCOMPA ................................... 62gabapentin ................................. 57galantamine ............................... 37GAMASTAN S/D ......................... 51GAMMAGARD LIQUID ............... 51GAMMAGARD S-D (IGA < 1 MCG/ML) ............ 51
GAMMAKED ............................... 51GAMMAPLEX ..............................51GAMMAPLEX (WITH SORBITOL) .................................. 51GAMUNEX-C ...............................51GARDASIL (PF) ............................74GARDASIL 9 (PF) ......................... 74gavilyte-c .................................... 68gavilyte-g .................................... 68gavilyte-n .................................... 68gemfibrozil ..................................50gengraf ....................................... 52gentamicin ............................ 41, 65GENVOYA ................................... 12gianvi (28) ...................................23gildagia ....................................... 24GILENYA ......................................55GILOTRIF .....................................34GLASSIA ........................................ 7glatiramer ...................................54glatopa ....................................... 55GLEOSTINE ..................................32glimepiride ..................................40glipizide .......................................40glipizide-metformin .................... 40GLUCAGEN ..................................39GLUCAGEN HYPOKIT .................. 39GLUCAGON EMERGENCY KIT (HUMAN) ....................................39glyburide .....................................40glyburide micronized .................. 40glycopyrrolate .............................70GRANIX .......................................27GRASTEK .......................................6griseofulvin microsize ................. 10griseofulvin ultramicrosize ..........10guanfacine ............................ 20, 48HAEGARDA ................................. 50haloperidol ..................................18haloperidol lactate ......................18HARVONI .................................... 11HAVRIX (PF) ................................74heather ....................................... 24HELIXATE FS ................................29HEMLIBRA .................................. 27HEMOFIL M HIGH .......................29HEMOFIL M LOW ........................29HEMOFIL M MID ........................ 29
HEMOFIL M SUPER HIGH ........... 29heparin (porcine) ........................ 31heparin, porcine (pf) ................... 31HEXALEN .....................................32HIBERIX (PF) ............................... 74HIZENTRA ................................... 51homatropaire ..............................43HUMALOG JUNIOR KWIKPEN U-100 .......................................... 39HUMALOG KWIKPEN INSULIN ... 39HUMALOG MIX 50-50 INSULN U-100 .......................................... 38HUMALOG MIX 50-50 KWIKPEN .................................... 38HUMALOG MIX 75-25 KWIKPEN .................................... 39HUMALOG MIX 75-25(U-100)INSULN ................................ 39HUMALOG U-100 INSULIN .........39HUMATE-P ..................................29HUMIRA ......................................69HUMIRA PEDIATRIC CROHN'S START ......................................... 69HUMIRA PEN .............................. 69HUMIRA PEN CROHN'S-UC-HS START ......................................... 69HUMIRA PEN PSORIASIS-UVEITIS ....................................... 67HUMULIN 70/30 U-100 INSULIN ...................................... 39HUMULIN 70/30 U-100 KWIKPEN .................................... 39HUMULIN N NPH INSULIN KWIKPEN .................................... 38HUMULIN N NPH U-100 INSULIN ...................................... 38HUMULIN R REGULAR U-100 INSULN ....................................... 40HUMULIN R U-500 (CONC) INSULIN ...................................... 40HUMULIN R U-500 (CONC) KWIKPEN .................................... 40HYCAMTIN ..................................33hydralazine ................................. 48hydrochlorothiazide ....................49hydrocodone-acetaminophen .....58hydrocodone-ibuprofen .............. 58hydrocortisone ................ 35, 66, 71
GenericsAdvantageRx: October 1, 201883
hydrocortisone acetate ...............71hydrocortisone valerate ..............66hydrocortisone-pramoxine ....66, 71hydromorphone .................... 58, 59hydroxychloroquine .................... 11hydroxyurea ................................32hydroxyzine hcl ............................. 6hydroxyzine pamoate ................... 6hyoscyamine sulfate ............. 70, 71HYQVIA .......................................52HYQVIA HY COMPONENT .......... 51HYQVIA IG COMPONENT ........... 52ibandronate ................................ 32IBRANCE ..................................... 34ibuprofen .................................... 57ICLUSIG ....................................... 34IDELVION .................................... 29IDHIFA .........................................34ILARIS (PF) .................................. 56imatinib .......................................34IMBRUVICA ................................ 34imipramine hcl ............................ 22imiquimod ...................................67INCRUSE ELLIPTA ........................16indapamide .................................49indomethacin ..............................57INFANRIX (DTAP) (PF) .......... 74, 75INGREZZA ................................... 56INLYTA ........................................ 34INTELENCE .................................. 12INTRON A ................................... 11introvale ......................................24INVIRASE .................................... 12INVOKAMET ............................... 39INVOKAMET XR ..........................39INVOKANA ..................................40iodoquinol-hc .............................. 66ipratropium bromide .............. 6, 16ipratropium-albuterol .................17irbesartan ................................... 45irbesartan-hydrochlorothiazide .. 45IRESSA .........................................34ISENTRESS ...................................12ISENTRESS HD .............................12isometh-dichloral-acetaminophn .............................53isoniazid ......................................14isosorbide dinitrate .....................44
isosorbide mononitrate ...............44itraconazole ................................ 10ivermectin ................................... 10IXINITY ........................................29JADENU .......................................56JADENU SPRINKLE ...................... 56JAKAFI .........................................34jantoven ......................................31JARDIANCE ................................. 40jencycla ....................................... 24JENTADUETO .............................. 37JENTADUETO XR .........................37JIVI .............................................. 29jolessa ......................................... 24jolivette .......................................24JULUCA ....................................... 12junel 1.5/30 (21) ......................... 24junel 1/20 (21) ............................ 24junel fe 1.5/30 (28) ..................... 24junel fe 1/20 (28) ........................ 24JUXTAPID ....................................48KALBITOR ................................... 50KALETRA ..................................... 12KALYDECO .................................. 36kariva (28) ...................................24kelnor 1/35 (28) .......................... 24ketoconazole .........................10, 65ketorolac ...............................42, 58KINERET ...................................... 15KINRIX (PF) ................................. 75kionex ......................................... 56KISQALI .......................................34KISQALI FEMARA CO-PACK ........ 34klor-con m10 ...............................50klor-con m15 ...............................50KLOR-CON/25 .............................50KOATE-DVI ..................................29KOGENATE FS ............................. 29KOVALTRY .................................. 29kurvelo ........................................ 24KUVAN ........................................56KYNAMRO .................................. 48labetalol ......................................46lactulose ......................................69lamivudine ............................ 11, 12lamivudine-zidovudine ................12lamotrigine ........................... 62, 63lansoprazole ............................... 71
larin 1/20 (21) .............................24larin fe 1.5/30 (28) ......................24larin fe 1/20 (28) .........................24latanoprost ................................. 43LATUDA ...................................... 18leena 28 ...................................... 24leflunomide .................................15lessina ......................................... 24LETAIRIS ......................................61letrozole ...................................... 33leucovorin calcium ...................... 56LEUKERAN .................................. 32LEUKINE ......................................27LEVEMIR FLEXTOUCH U-100 INSULN ....................................... 38LEVEMIR U-100 INSULIN ............ 38levetiracetam ..............................63levobunolol ................................. 43levocarnitine ............................... 56levocarnitine (with sugar) ...........56levofloxacin ...................................9levonest (28) ............................... 24levonorgestrel .............................22levonorgestrel-ethinyl estrad ......24levora-28 .....................................24levothyroxine .............................. 72LEXIVA ........................................ 13L-GLUTAMINE .............................70lialda ........................................... 69lidocaine hcl ................................ 54lidocaine viscous ......................... 54lidocaine-prilocaine .................... 60linezolid .........................................8LINZESS ....................................... 69liothyronine .................................72lisinopril ...................................... 45lisinopril-hydrochlorothiazide ..... 45lithium carbonate ....................... 21lithium citrate ............................. 21lomaira ....................................... 78LONSURF .................................... 32lopinavir-ritonavir .......................13lorazepam ...................................20loryna (28) .................................. 24losartan .......................................45losartan-hydrochlorothiazide ..... 45lovastatin .................................... 48low-ogestrel (28) .........................24
GenericsAdvantageRx: October 1, 201884
loxapine succinate ...................... 18LUMIGAN ....................................43lutera (28) ................................... 24LYSODREN .................................. 33lyza ..............................................24malathion ................................... 66marlissa ...................................... 24MATULANE .................................32MAVYRET ................................... 11MEDROL ..................................... 35medroxyprogesterone ................ 78mefloquine ..................................11megestrol ..............................33, 56MEKINIST ....................................34meloxicam .................................. 58melphalan ...................................32memantine ................................. 37MENACTRA (PF) ......................... 75MENHIBRIX (PF) ......................... 75MENOMUNE - A/C/Y/W-135 ..... 75MENVEO A-C-Y-W-135-DIP (PF) .75mercaptopurine .......................... 32mesalamine ................................ 69metadate er ................................ 20metformin ...................................37methadone ................................. 59methazolamide ...........................43methimazole ............................... 72methocarbamol .......................... 55methotrexate sodium ................. 33methotrexate sodium (pf) ...........33methyldopa .................................48methylergonovine .......................79methylphenidate hcl ................... 20methylprednisolone .................... 36metoclopramide hcl .................... 70metolazone ................................. 49metoprolol succinate .................. 46metoprolol ta-hydrochlorothiaz ..46metoprolol tartrate .....................46metronidazole .................11, 67, 78mexiletine ................................... 44microgestin 1.5/30 (21) .............. 25microgestin 1/20 (21) ................. 25microgestin fe 1.5/30 (28) .......... 25microgestin fe 1/20 (28) ............. 25midodrine ....................................48miglitol ........................................37
miglustat .....................................41MILLIPRED .................................. 36minocycline ................................... 9minoxidil ..................................... 48mirtazapine .................................21misoprostol ................................. 71modafinil .....................................68moexipril ..................................... 45moexipril-hydrochlorothiazide ....46mometasone ...............................66MONOCLATE-P ........................... 29mono-linyah ................................25mononessa (28) .......................... 25montelukast ................................16MONUROL .................................. 15morphine .................................... 59MORPHINE ................................. 59morphine concentrate ................ 59MOVANTIK ................................. 71moxifloxacin ............................9, 42MULTAQ ..................................... 44mupirocin ....................................65my way ....................................... 22mycophenolate mofetil ...............52MYLERAN ....................................32mynatal .......................................77mynatal advance ........................ 77mynatal plus ............................... 77mynatal-z ....................................77mynate 90 plus ........................... 77myorisan ..................................... 64MYRBETRIQ ................................ 72myzilra ........................................ 25nabumetone ............................... 58nadolol ........................................46naloxone ....................................... 7naltrexone .....................................6naproxen .....................................58naratriptan ................................. 53NARCAN ........................................7nateglinide ..................................38necon 0.5/35 (28) ....................... 25necon 1/35 (28) .......................... 25necon 1/50 (28) .......................... 25necon 10/11 (28) ........................ 25necon 7/7/7 (28) .........................25nefazodone ................................. 21neomycin ...................................... 8
neomycin-bacitracin-polymyxin ..42neomycin-polymyxin b-dexameth ....................................42neomycin-polymyxin-gramicidin .42neomycin-polymyxin-hc .............. 41NERLYNX .....................................35NEULASTA .................................. 27NEUPOGEN .................................27NEUPRO ......................................60nevirapine ................................... 13NEXAVAR ....................................35next choice one dose ...................22nicotine ....................................... 68nicotine (polacrilex) .................... 68NICOTROL ...................................68NICOTROL NS ............................. 68nifedipine .............................. 47, 79nimodipine ..................................47NINLARO .....................................35NITRO-BID .................................. 44nitrofurantoin ............................. 15nitrofurantoin macrocrystal ....... 15nitrofurantoin monohyd/m-cryst ............................................ 15nitroglycerin ................................44nora-be ....................................... 25norethindrone (contraceptive) ....25norethindrone acetate ................78norethindrone ac-eth estradiol ...25norgestimate-ethinyl estradiol ... 25norinyl 1/35 (28) ......................... 25NORPACE CR ...............................44nortrel 0.5/35 (28) ...................... 25nortrel 1/35 (21) ......................... 25nortrel 1/35 (28) ......................... 25nortrel 7/7/7 (28) ........................25nortriptyline ................................ 22NORVIR .......................................13NOVOEIGHT ................................30NOVOSEVEN RT ..........................30NOXAFIL ..................................... 10NUPLAZID ................................... 18NUVARING ..................................22NUWIQ ....................................... 30nystatin ................................. 10, 65OBIZUR ....................................... 30o-cal prenatal ..............................77ocella .......................................... 25
GenericsAdvantageRx: October 1, 201885
OCTAGAM .................................. 52octreotide acetate ...................... 56ODACTRA ......................................6ODEFSEY ..................................... 13ODOMZO .................................... 33OFEV ........................................... 51ofloxacin ............................... 41, 42ogestrel (28) ................................25olanzapine .................................. 18olmesartan ..................................46olmesartan-hydrochlorothiazide 46olopatadine ...................................6OLYSIO ........................................11omega-3 acid ethyl esters ...........50omeprazole ................................. 71ondansetron ................................70ondansetron hcl .......................... 70ONFI ............................................63OPSUMIT .................................... 61ORENCIA .....................................15ORENCIA CLICKJECT ....................15ORKAMBI ....................................36orsythia .......................................25oseltamivir .................................. 14OTEZLA ....................................... 15OTEZLA STARTER ........................15oxandrolone ................................56oxcarbazepine .............................63oxybutynin chloride .................... 72oxycodone ...................................59oxycodone-acetaminophen ........ 59oxycodone-aspirin .......................59OXYCONTIN ................................59OZEMPIC .....................................38paliperidone ................................19pantoprazole ...............................71paregoric .....................................71paroxetine hcl ............................. 22PAXIL .......................................... 22PEDIARIX (PF) ............................. 75PEDVAX HIB (PF) ........................ 75PEGASYS ..................................... 11PEGASYS PROCLICK .................... 11PEGINTRON ................................ 11PEGINTRON REDIPEN .................11penicillin v potassium ....................9PENTACEL (PF) ............................75
PENTACEL DTAP-IPV COMPNT (PF) ............................................. 75PENTASA .....................................69pentoxifylline .............................. 31perindopril erbumine .................. 46periogard .................................... 54permethrin ..................................66perphenazine .............................. 19phenazopyridine ......................... 72phenelzine ...................................21phenobarbital ............................. 63phenoxybenzamine .....................48phentermine ............................... 78phenylephrine hcl ........................43phenytoin ....................................63phenytoin sodium extended ....... 63philith ..........................................25PHOSLYRA .................................. 52phytonadione (vitamin k1) ..........77PICATO ........................................67pilocarpine hcl .......................43, 54pimtrea (28) ................................25pioglitazone ................................ 40pioglitazone-glimepiride .............40pioglitazone-metformin ..............40pirmella .......................................26piroxicam .................................... 58PLASMANATE ............................. 30PLEGRIDY ....................................55PNEUMOVAX 23 .........................75podofilox ..................................... 67polyethylene glycol 3350 ............ 69polymyxin b sulf-trimethoprim ... 42POMALYST ..................................33portia .......................................... 26potassium chloride ......................50potassium citrate ........................72POTIGA ....................................... 63PRADAXA ....................................31pramipexole ................................60prasugrel .....................................31pravastatin ................................. 49praziquantel ................................10prazosin ...................................... 48PRED FORTE ................................42PRED MILD ..................................42prednisolone ............................... 36prednisolone acetate .................. 43
prednisolone sodium phosphate.............................................. 36, 43prednisone .................................. 36PREDNISONE INTENSOL ............. 36PREMARIN ..................................78PREMPRO ................................... 78PRENATA .................................... 77prenatabs fa ............................... 77prenatabs rx ................................77prenatal plus ...............................77prenatal plus (calcium carb) ....... 77prenatal rx .................................. 77prenatal-u ................................... 77PRENATE ELITE ........................... 77prevalite ......................................48previfem ......................................26PREVNAR 13 (PF) ........................75PREVYMIS ...................................14PREZCOBIX ................................. 13PREZISTA .................................... 13PRIFTIN ....................................... 14primidone ....................................63PRIVIGEN .................................... 52probenecid .................................. 44probenecid-colchicine ................. 44prochlorperazine .........................70prochlorperazine maleate ...........70PROCRIT ......................................28proctosol hc ................................ 71proctozone-hc ............................. 71PROFILNINE ................................ 30progesterone micronized ............ 79PROLASTIN-C ................................ 7PROMACTA .................................28promethazine ..........................6, 70promethazine vc ......................... 36promethazine-dm ....................... 36propafenone ............................... 44propantheline ............................. 71propranolol ........................... 46, 47propranolol-hydrochlorothiazid ..47propylthiouracil ...........................72PROQUAD (PF) ........................... 75PULMICORT FLEXHALER .............17PULMOZYME .............................. 36purefe ob plus ............................. 77pyrazinamide .............................. 14pyridostigmine bromide ..............56
GenericsAdvantageRx: October 1, 201886
quasense .....................................26quetiapine ...................................19QUILLICHEW ER ..........................20QUILLIVANT XR .......................... 20quinapril ......................................46quinapril-hydrochlorothiazide .... 46quinidine gluconate .................... 45quinidine sulfate ......................... 45QVAR .......................................... 18QVAR REDIHALER .......................18rabeprazole .................................71RAGWITEK .................................... 6raloxifene ....................................79ramipril ....................................... 46ranitidine hcl ...............................71RAPAMUNE ................................ 52rasagiline .................................... 60RASUVO (PF) .............................. 15REBETOL ..................................... 11REBIF (WITH ALBUMIN) ............. 55REBIF REBIDOSE ......................... 55REBIF TITRATION PACK .............. 55REBINYN ..................................... 28reclipsen (28) .............................. 26RECOMBINATE ........................... 30RECOMBIVAX HB (PF) ................ 75RELENZA DISKHALER ..................14REMODULIN ............................... 61repaglinide ..................................38REPATHA PUSHTRONEX .............48REPATHA SURECLICK ..................48REPATHA SYRINGE ..................... 48RESCRIPTOR ............................... 13RESTASIS .....................................43RESTASIS MULTIDOSE ................ 43RETACRIT .................................... 28REVLIMID ....................................33REXULTI ...................................... 19REYATAZ ..................................... 13ribavirin .......................................11RIDAURA .................................... 15rifabutin ...................................... 10rifampin ...................................... 14riluzole ........................................ 56rimantadine ................................ 14risperidone ..................................19ritonavir ...................................... 13rivastigmine tartrate .................. 37
RIXUBIS .......................................30rizatriptan ............................. 53, 54ropinirole .................................... 60rosuvastatin ................................49RUCONEST ..................................50RYDAPT .......................................35RYTARY .......................................60SABRIL ........................................ 63salsalate ......................................58SANDOSTATIN LAR DEPOT .........57SAPHRIS ......................................19SAPHRIS (BLACK CHERRY) ..........19scopolamine base ....................... 70selegiline hcl ............................... 61selenium sulfide .......................... 67SELZENTRY ..................................13se-natal 19 .................................. 77se-natal 19 (with docusate) ........ 77SENSIPAR ....................................52SEREVENT DISKUS ...................... 16sertraline .....................................22sevelamer carbonate .................. 52sf ................................................. 77sf 5000 plus .................................77SHINGRIX (PF) .............................75SHINGRIX ADJUVANT COMPONENT-PF .........................75SHINGRIX GE ANTIGEN COMPONENT ..............................76SIGNIFOR .................................... 57sildenafil (antihypertensive) ....... 61silver sulfadiazine ....................... 65simvastatin ................................. 49sirolimus ......................................52SIRTURO ..................................... 14SIVEXTRO ....................................10sodium phenylbutyrate ...............57sodium polystyrene (sorb free) ... 57sodium polystyrene sulfonate .....57SOLTAMOX ................................. 34sotalol ......................................... 45sotalol af ..................................... 45spironolactone ............................ 49spironolacton-hydrochlorothiaz ..49sprintec (28) ................................26SPRYCEL ......................................35sronyx ......................................... 26stavudine .................................... 13
STIMATE ..................................... 27STIVARGA ................................... 35STRENSIQ ....................................41STRIBILD ..................................... 13STRIVERDI RESPIMAT .................16SUBOXONE ................................. 59SUCRAID ..................................... 41sucralfate ....................................71sulfacetamide sodium .................42sulfacetamide sodium (acne) ......64sulfacetamide sodium-sulfur ...... 64sulfacetamide sod-sulfur-urea ....64sulfacetamide-prednisolone ....... 42sulfamethoxazole-trimethoprim ...8sulfasalazine ............................... 69sulindac .......................................58sumatriptan ................................ 54sumatriptan succinate ................ 54SUPRAX .........................................8SUTENT ....................................... 35syeda ...........................................26SYLATRON .................................. 33SYMDEKO ................................... 36SYMPROIC .................................. 69SYMTUZA ....................................13SYNJARDY ...................................39SYNJARDY XR ..............................39SYNTHROID ................................ 72TABLOID ..................................... 33tacrolimus ............................. 52, 67TAFINLAR ....................................35TAGRISSO ................................... 35TAMIFLU .....................................14tamoxifen ....................................34tamsulosin .................................. 53TARCEVA .....................................35TASIGNA ..................................... 35taztia xt .......................................47TECFIDERA ..................................55temazepam .................................68temozolomide ............................. 32TENIVAC (PF) .............................. 76tenofovir disoproxil fumarate ..... 13terazosin ..................................... 53terbinafine hcl .............................10terconazole ................................. 78testosterone ................................53testosterone cypionate ............... 53
GenericsAdvantageRx: October 1, 201887
testosterone enanthate .............. 53TETANUS,DIPHTHERIA TOX PED(PF) .......................................76TETANUS-DIPHTHERIA TOXOIDS-TD ............................... 76tetrabenazine ..............................57tetracycline ................................... 9THALOMID ..................................33theophylline ................................ 16THIOLA ........................................57thioridazine .................................19thiothixene ..................................19THROMBATE III .......................... 30tiagabine .....................................63tilia fe ..........................................26timolol maleate .......................... 43TIVICAY .......................................13tizanidine .................................... 55TOBRADEX ..................................42tobramycin ..................................42tobramycin in 0.225 % nacl .........36tobramycin-dexamethasone .......42TOBREX .......................................42tolmetin ...................................... 58tolterodine .................................. 72topiramate ..................................63torsemide ....................................49TRACLEER ................................... 61TRADJENTA .................................37tramadol ..................................... 60trandolapril .................................46tranexamic acid .......................... 79tranylcypromine ..........................21TRAVATAN Z ...............................43trazodone ....................................21TRECATOR .................................. 14TRELEGY ELLIPTA ........................17tretinoin ...................................... 64tretinoin (chemotherapy) ............34TRETTEN ..................................... 30triadvance ...................................77triamcinolone acetonide ....... 54, 66triamterene-hydrochlorothiazid . 49trianex .........................................66triderm ........................................66tri-estarylla ................................. 26trifluoperazine ............................ 19trifluridine ................................... 42
trihexyphenidyl ........................... 61tri-legest fe ................................. 26tri-linyah ..................................... 26tri-lo-estarylla ............................. 26tri-lo-sprintec .............................. 26trimethobenzamide .................... 70trimethoprim ................................ 8trinatal gt ....................................77trinate ......................................... 77trinessa (28) ................................26trinessa lo ................................... 26tri-previfem (28) ..........................26tri-sprintec (28) ........................... 26TRIUMEQ ....................................13triveen-prx rnf .............................77trivora (28) ..................................26trospium ......................................72TRULICITY ................................... 38TRUMENBA ................................ 76TRUVADA ................................... 13TWINRIX (PF) ..............................76TYBOST ....................................... 13TYKERB ....................................... 35TYMLOS ...................................... 32TYVASO .......................................61TYVASO REFILL KIT ..................... 61TYVASO STARTER KIT ................. 61ULORIC ........................................44UPTRAVI ..................................... 61urea .......................................67, 68ursodiol ....................................... 71valacyclovir ................................. 14VALCHLOR .................................. 32valganciclovir ..............................14valproic acid ................................63valproic acid (as sodium salt) ..... 63valsartan .....................................46valsartan-hydrochlorothiazide ....46vancomycin ...................................8VAQTA (PF) .................................76VARIVAX (PF) ..............................76VAXCHORA BUFFER COMPONENT ..............................76VAXCHORA VACCINE ..................76VELETRI .......................................61velivet triphasic regimen (28) ..... 26VEMLIDY .....................................11venlafaxine ................................. 21
VENTAVIS ................................... 61VENTOLIN HFA ........................... 16verapamil ....................................47VERSACLOZ .................................19VERZENIO ................................... 35vestura (28) .................................26VICTOZA 2-PAK ...........................38VICTOZA 3-PAK ...........................38VIDEX 2 GRAM PEDIATRIC ......... 13VIDEX 4 GRAM PEDIATRIC ......... 13VIGABATRIN ............................... 63VIMPAT .......................................63vinate care .................................. 77vinate gt ......................................77vinate m ......................................77vinate one ................................... 78vinate ultra ................................. 78viorele (28) ..................................26VIRACEPT ....................................13VIREAD ....................................... 13VISTOGARD ................................ 57vitamin b-12 ................................78vitamin d2 ...................................78VITEKTA ...................................... 13VIVOTIF .......................................76VONVENDI ..................................30voriconazole ................................10VOSEVI ........................................11VOTRIENT ................................... 35VRAYLAR .....................................19vyfemla (28) ................................26VYVANSE .................................... 20warfarin ...................................... 31wera (28) .................................... 26WILATE ....................................... 30XALKORI ..................................... 35XARELTO .....................................31XENICAL ......................................78XERMELO ....................................71XIFAXAN ....................................... 8XTANDI ....................................... 32xulane ......................................... 22XYNTHA ...................................... 30XYNTHA SOLOFUSE .................... 30XYREM ........................................ 68yuvafem ...................................... 78zaleplon ...................................... 68zarah ...........................................27
GenericsAdvantageRx: October 1, 201888
ZARXIO ....................................... 28ZEJULA ........................................ 33ZELBORAF ................................... 35ZEMAIRA .......................................7zenatane ..................................... 64zenchent (28) .............................. 27ZERIT ...........................................14zidovudine ...................................14ZIOPTAN (PF) ..............................44ziprasidone hcl ............................ 19ZIRGAN ....................................... 42ZOLINZA ......................................33zolpidem ..................................... 68zonisamide ..................................64ZONTIVITY .................................. 31ZOSTAVAX (PF) ...........................76zovia 1/35e (28) ..........................27zovia 1/50e (28) ..........................27ZYKADIA ..................................... 35ZYTIGA ........................................ 32
GenericsAdvantageRx: October 1, 201889
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