Medicare Part D Formulary For the 2016 Medicare Part D Formulary, please click here. For the 2017 Medicare Part D Formulary, please click here.
Medicare Part D Formulary
For the 2016 Medicare Part D Formulary, please click here.
For the 2017 Medicare Part D Formulary, please click here.
2016 Plan Formularies
Select your location
Pennsylvania Residents:
If you live in one of the counties below, please click here:
Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion,
Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson,
Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and
Westmoreland.
If you live in one of the counties below, please click here:
Adams, Berks, Bradford, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin,
Franklin, Fulton, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming,
Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Schuylkill,
Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, and York.
West Virginia Residents, please click here.
2016 Plan Formularies – Western PA
For Security Blue HMO Deluxe, Standard, and ValueRx, Community Blue Medicare
HMO Prestige and Signature, Freedom Blue PPO Classic, Select, and ValueRx, and Blue
Rx PDP Complete and Plus plans, please review this formulary.
For Prior Authorization criteria, please review this information.
2016 Plan Formularies – Central and Northeastern PA
For Freedom Blue PPO Deluxe, Standard, and ValueRx, Community Blue Medicare HMO Signature, and Blue Rx PDP Complete and Plus, please review this formulary.
For Prior Authorization criteria, please review this information.
2016 Plan Formularies – West Virginia
For Freedom Blue PPO Standard and ValueRx, and Blue Rx PDP Complete and Plus, please review
this formulary.
For Prior Authorization criteria, please review this information.
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
8-Mop capsule 10 mg PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSabacavir tablet 300 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
abacavir-
lamivudine-
zidovudine
tablet 300-150-
300 mg
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Abelcet suspension
5
mg/mLSpecialty-5 YES
ANTI - INFECTIVES
ANTIFUNGAL
AGENTS
Abilify tablet 10 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abilify tablet 15 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abilify tablet 20 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abilify tablet 30 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abilify tablet 5 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
1 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Abilify tablet 2 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abilify
Maintena
suspension,ex
tended rel
recon 300 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abilify
Maintena
suspension,ex
tended rel
syring 300 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abilify
Maintena
suspension,ex
tended rel
syring 400 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Abraxane suspension
for
reconstitution
100 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Abstral tablet
100
mcg
NonPrefBrand-4
124 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Abstral tablet
200
mcg
Specialty-5
124 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Abstral tablet
300
mcg
Specialty-5
124 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
2 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Abstral tablet
400
mcg
Specialty-5
119 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Abstral tablet
600
mcg
Specialty-5
79 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Abstral tablet
800
mcg
Specialty-5
60 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
acamprosate tablet,delayed
release
(DR/EC)
333 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Acanya gel with
pump
1.2-2.5
%
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
acarbose tablet 25 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYacarbose tablet 50 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYacarbose tablet 100 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
acebutolol capsule 400 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
acebutolol capsule 200 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
3 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
acetaminophe
n-codeine solution
300 mg-
30 mg
/12.5
mL
PrefGen-1
5167 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
acetaminophe
n-codeine tablet
300-15
mg
Generic-2
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
acetaminophe
n-codeine tablet
300-30
mg
Generic-2
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
acetaminophe
n-codeine tablet
300-60
mg
Generic-2
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Acetasol HC drops 1-2 % Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
OTIC
PREPARATIONSacetazolamide tablet 125 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR
GLAUCOMAacetazolamide tablet 250 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR
GLAUCOMAacetazolamide capsule,
extended
release
500 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR
GLAUCOMA
acetazolamide
sodium
recon soln 500 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR
GLAUCOMAacetic acid solution 2 % Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
OTIC
PREPARATIONS
4 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
acetylcysteine solution 100
mg/mL
(10 %)
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
acetylcysteine solution 200
mg/mL
(20 %)
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
acitretin capsule 10 mg Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
acitretin capsule 25 mg Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
acitretin capsule 17.5 mg Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Actemra solution 200
mg/10
mL (20
mg/mL)
Specialty-5 40 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Actemra syringe
162
mg/0.9
mL
Specialty-5
3.6 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Actemra solution
80 mg/4
mL (20
mg/mL)
Specialty-5
40 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Actemra solution
400
mg/20
mL (20
mg/mL)
Specialty-5
40 28
YESMUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Acthar H.P. gel
80
unit/mLSpecialty-5 YES ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
5 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ActHIB (PF) recon soln
10
mcg/0.5
mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Actimmune solution 100
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Actiq lozenge on a
handle
200
mcg
Specialty-5 124 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Actiq lozenge on a
handle
600
mcg
Specialty-5 79 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Actiq lozenge on a
handle
800
mcg
Specialty-5 60 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Actiq lozenge on a
handle
1,200
mcg
Specialty-5 40 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Actiq lozenge on a
handle
1,600
mcg
Specialty-5 30 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Actiq lozenge on a
handle
400
mcg
Specialty-5 119 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
6 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Actoplus Met
XR
tablet, ER
multiphase 24
hr
15-
1,000
mg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Actoplus Met
XR
tablet, ER
multiphase 24
hr
30-
1,000
mg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Acuvail (PF) dropperette 0.45 % NonPrefBrand-4 NO OPHTHALMOLOGY NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTSacyclovir capsule 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
acyclovir tablet 400 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
acyclovir ointment 5 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIVIRALS
acyclovir tablet 800 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
acyclovir suspension 200
mg/5
mL
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
acyclovir
sodium
solution 50
mg/mL
Generic-2 YES ANTI - INFECTIVES ANTIVIRALS
Aczone gel 5 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Adacel(Tdap
Adolesn/Adul
t)(PF) suspension
2 Lf-
(2.5-5-3-
5 mcg)-
5Lf/0.5
mL PrefBrand-3
NO
IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
7 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Adagen solution 250
unit/mL
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
adapalene gel 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
adapalene cream 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
adapalene gel 0.3 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Adcirca tablet 20 mg Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSadefovir tablet 10 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Adempas tablet 0.5 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Adempas tablet 1 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Adempas tablet 1.5 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Adempas tablet 2 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Adempas tablet 2.5 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Adrenalin solution
1
mg/mL
(1 mL) Generic-2
NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Adrucil solution 500
mg/10
mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
8 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Advair
Diskus
blister with
device
100-50
mcg/dos
e
NonPrefBrand-4 60 30 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Advair
Diskus
blister with
device
250-50
mcg/dos
e
NonPrefBrand-4 60 30 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Advair
Diskus
blister with
device
500-50
mcg/dos
e
NonPrefBrand-4 60 30 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Advair HFA HFA aerosol
inhaler
45-21
mcg/act
uation
NonPrefBrand-4 12 30 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Advair HFA HFA aerosol
inhaler
115-21
mcg/act
uation
NonPrefBrand-4 12 30 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Advair HFA HFA aerosol
inhaler
230-21
mcg/act
uation
NonPrefBrand-4 12 30 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Afeditab CR tablet
extended
release
30 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Afeditab CR tablet
extended
release
60 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Afinitor tablet 10 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Afinitor tablet 5 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
9 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Afinitor tablet 2.5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Afinitor tablet 7.5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Afinitor
Disperz
tablet for
suspension 2 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Afinitor
Disperz
tablet for
suspension 3 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Afinitor
Disperz
tablet for
suspension 5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Aggrenox
capsule, ER
multiphase 12
hr
25-200
mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
A-Hydrocort recon soln 100 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Akynzeo capsule
300-0.5
mg
NonPrefBrand-4 YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Ala-Cort cream 1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Albenza tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
10 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
albuterol
sulfate
tablet 2 mg PrefGen-1 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSalbuterol
sulfate
tablet 4 mg PrefGen-1 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSalbuterol
sulfate
solution for
nebulization
5
mg/mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSalbuterol
sulfate
solution for
nebulization
1.25
mg/3
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
albuterol
sulfate
solution for
nebulization
0.63
mg/3
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
albuterol
sulfate
tablet
extended
release 12 hr
4 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
albuterol
sulfate
tablet
extended
release 12 hr
8 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
albuterol
sulfate
solution for
nebulization
2.5 mg
/3 mL
(0.083
%)
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
albuterol
sulfate
syrup 2 mg/5
mL
PrefGen-1 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSalclometasone cream 0.05 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
alclometasone ointment 0.05 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Alcohol Pads pads,
medicated
Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
11 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Aldurazyme solution 2.9
mg/5
mL
Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Alecensa capsule 150 mg
Specialty-5
248 31
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
alendronate tablet 35 mg PrefGen-1 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
alendronate tablet 40 mg PrefGen-1 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
alendronate tablet 10 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
alendronate tablet 5 mg PrefGen-1 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
alendronate tablet 70 mg PrefGen-1 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
alendronate solution 70
mg/75
mL
PrefGen-1 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
alfuzosin tablet
extended
release 24 hr
10 mg Generic-2 NO UROLOGICALS BENIGN
PROSTATIC
HYPERPLASIA(BPH
) THERAPYAlimta recon soln 500 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
12 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Alinia suspension
for
reconstitution
100
mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Alinia tablet 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESallopurinol tablet 100 mg PrefGen-1 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
allopurinol tablet 300 mg PrefGen-1 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
Allzital tablet
25-325
mg
NonPrefBrand-4
372 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
almotriptan
malate
tablet 6.25 mg Generic-2 16 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYalmotriptan
malate
tablet 12.5 mg Generic-2 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYAlocril drops 2 % NonPrefBrand-4 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CS
alogliptin tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
alogliptin tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
alogliptin tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
13 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
alogliptin-
metformin tablet
12.5-
1,000
mg
NonPrefBrand-4 NOENDOCRINE/DIABE
TES
DIABETES
THERAPYalogliptin-
metformin tablet
12.5-
500 mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYalogliptin-
pioglitazone tablet
12.5-15
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYalogliptin-
pioglitazone tablet
12.5-30
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYalogliptin-
pioglitazone tablet
12.5-45
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYalogliptin-
pioglitazone tablet
25-15
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYalogliptin-
pioglitazone tablet
25-30
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYalogliptin-
pioglitazone tablet
25-45
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Alomide drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CSAloprim recon soln 500 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
alosetron tablet 1 mg Specialty-5 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSalosetron tablet 0.5 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSAloxi solution 0.25
mg/5
mL
NonPrefBrand-4 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
14 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Alphagan P drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY SYMPATHOMIMETI
CSalprazolam tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet 2 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet
extended
release 24 hr
0.5 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet
extended
release 24 hr
2 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet
extended
release 24 hr
1 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
15 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
alprazolam tablet
extended
release 24 hr
3 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet,disinteg
rating
0.25 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet,disinteg
rating
1 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet,disinteg
rating
0.5 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
alprazolam tablet,disinteg
rating
2 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Alprazolam
Intensol
concentrate 1
mg/mL
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Altabax ointment 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
Altoprev tablet
extended
release 24 hr
60 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Altoprev
tablet
extended
release 24 hr 20 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
16 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Altoprev
tablet
extended
release 24 hr 40 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
amantadine
HCl
solution 50 mg/5
mL
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
amantadine
HCl
capsule 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
amantadine
HCl
tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
AmBisome
suspension
for
reconstitution 50 mg
NonPrefBrand-4 YES
ANTI - INFECTIVES
ANTIFUNGAL
AGENTS
amcinonide cream 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
amcinonide ointment 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
amcinonide lotion 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Amerge tablet 1 mg NonPrefBrand-4 20 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYAmerge tablet 2.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Amethia
tablets,dose
pack,3 month
0.15 mg-
30 mcg
(84)/10
mcg (7)
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
17 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Amethyst tablet
90-20
mcg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
amifostine
crystalline
recon soln 500 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
amikacin solution 500
mg/2
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
amiloride tablet 5 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPYamiloride-
hydrochloroth
iazide tablet 5-50 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amino acids
15 %
parenteral
solution 15 % Generic-2
YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn 7
% with
electrolytes
parenteral
solution 7 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn 8.5
%-
electrolytes
parenteral
solution 8.5 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Aminosyn II
10 %
parenteral
solution
10 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn II
15 %
parenteral
solution
15 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
18 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Aminosyn II
7 %
parenteral
solution
7 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn II
8.5 %
parenteral
solution
8.5 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn II
8.5 %-
electrolytes
parenteral
solution 8.5 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Aminosyn M
3.5 %
parenteral
solution
3.5 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn-
HBC 7%
parenteral
solution
7 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn-PF
10 %
parenteral
solution
10 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSAminosyn-PF
7 % (sulfite-
free)
parenteral
solution
7 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Aminosyn-RF
5.2 %
parenteral
solution 5.2 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
amiodarone tablet 200 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
amiodarone solution 50
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
amiodarone tablet 400 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
19 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Amitiza capsule 24 mcg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSAmitiza capsule 8 mcg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSamitriptyline tablet 100 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amitriptyline tablet 150 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amitriptyline tablet 10 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amitriptyline tablet 25 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amitriptyline tablet 50 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amitriptyline tablet 75 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
20 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
amitriptyline-
chlordiazepox
ide
tablet 12.5-5
mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amitriptyline-
chlordiazepox
ide
tablet 25-10
mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amlodipine tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
atorvastatin
tablet 5-80 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 10-80
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 10-20
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 2.5-10
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 2.5-20
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
21 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
amlodipine-
atorvastatin
tablet 5-10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 5-20 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 5-40 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 10-10
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 10-40
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
atorvastatin
tablet 2.5-40
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSamlodipine-
benazepril
capsule 10-20
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
benazepril
capsule 10-40
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
benazepril
capsule 2.5-10
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
benazepril
capsule 5-10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
benazepril
capsule 5-20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
22 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
amlodipine-
benazepril
capsule 5-40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan
tablet 10-160
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan
tablet 10-320
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan
tablet 5-160
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan
tablet 5-320
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan-
hcthiazid
tablet 10-160-
12.5 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan-
hcthiazid
tablet 10-320-
25 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan-
hcthiazid
tablet 5-160-
12.5 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan-
hcthiazid
tablet 5-160-
25 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
amlodipine-
valsartan-
hcthiazid
tablet 10-160-
25 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
ammonium
chloride
solution 5
mEq/m
L
NonPrefBrand-4 NO UROLOGICALS MISCELLANEOUS
UROLOGICALS
23 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ammonium
lactate
lotion 12 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSammonium
lactate
cream 12 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSamoxapine tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amoxapine tablet 150 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amoxapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amoxapine tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
amoxicil-
clarithromy-
lansopraz
combo pack 500-500-
30 mg
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
amoxicillin suspension
for
reconstitution
250
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin tablet,chewab
le
125 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin capsule 250 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
24 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
amoxicillin suspension
for
reconstitution
400
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin capsule 500 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin tablet 875 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin suspension
for
reconstitution
125
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin suspension
for
reconstitution
200
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin tablet,chewab
le
250 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
tablet 250-125
mg
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
tablet 875-125
mg
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
tablet 500-125
mg
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
tablet,chewab
le
200-
28.5 mg
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
tablet,chewab
le
400-57
mg
Generic-2 NO ANTI - INFECTIVES PENICILLINS
25 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
amoxicillin-
pot
clavulanate
suspension
for
reconstitution
250-
62.5
mg/5
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
suspension
for
reconstitution
200-
28.5
mg/5
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
suspension
for
reconstitution
400-57
mg/5
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
suspension
for
reconstitution
600-
42.9
mg/5
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amoxicillin-
pot
clavulanate
tablet
extended
release 12 hr
1,000-
62.5 mg
Generic-2 NO ANTI - INFECTIVES PENICILLINS
amphotericin
B
recon soln 50 mg Generic-2 YES ANTI - INFECTIVES ANTIFUNGAL
AGENTSampicillin suspension
for
reconstitution
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin suspension
for
reconstitution
125
mg/5
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin
sodium
recon soln 125 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS
26 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ampicillin
sodium
recon soln 1 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin
sodium
recon soln 10 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin-
sulbactam
recon soln 15 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin-
sulbactam
recon soln 3 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin-
sulbactam recon soln
1.5
gramGeneric-2 NO
ANTI - INFECTIVES PENICILLINS
Ampyra tablet
extended
release 12 hr
10 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Anadrol-50 tablet 50 mg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESanagrelide capsule 0.5 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
anagrelide capsule 1 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
anastrozole tablet 1 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Androderm patch 24 hour
2 mg/24
hour PrefBrand-3YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Androderm patch 24 hour
4 mg/24
hr PrefBrand-3YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
27 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
AndroGel
gel in metered-
dose pump
20.25
mg/1.25
gram
(1.62
%) PrefBrand-3
YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
AndroGel gel in packet
1.62 %
(20.25
mg/1.25
gram) PrefBrand-3
YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
AndroGel gel in packet
1 % (25
mg/2.5g
ram) PrefBrand-3
YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
AndroGel gel in packet
1.62 %
(40.5
mg/2.5
gram) PrefBrand-3
YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
AndroGel gel in packet
1 % (50
mg/5
gram) PrefBrand-3
YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Android capsule 10 mg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Angeliq tablet
0.5-1
mgNonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Antara capsule 30 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Antara capsule 90 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Anzemet tablet 50 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
28 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Anzemet tablet 100 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSAnzemet solution 100
mg/5
mL
NonPrefBrand-4 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
ApexiCon E cream 0.05 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Apidra solution 100
unit/mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYApidra
SoloStar
insulin pen 100
unit/mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Aplenzin
tablet
extended
release 24 hr 174 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aplenzin
tablet
extended
release 24 hr 348 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aplenzin
tablet
extended
release 24 hr 522 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
APOKYN cartridge 10
mg/mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
apraclonidine drops 0.5 % Generic-2 NO OPHTHALMOLOGY SYMPATHOMIMETI
CS
29 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Apri tablet 0.15-
0.03 mg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSApriso capsule,exten
ded release
24hr
0.375
gram
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Aptensio XR
cap,ER
sprinkle,bipha
sic 40-60 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aptensio XR
cap,ER
sprinkle,bipha
sic 40-60 15 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aptensio XR
cap,ER
sprinkle,bipha
sic 40-60 20 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aptensio XR
cap,ER
sprinkle,bipha
sic 40-60 30 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aptensio XR
cap,ER
sprinkle,bipha
sic 40-60 40 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aptensio XR
cap,ER
sprinkle,bipha
sic 40-60 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
30 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Aptensio XR
cap,ER
sprinkle,bipha
sic 40-60 60 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aptiom tablet 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Aptiom tablet 400 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Aptiom tablet 600 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Aptiom tablet 800 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Aptivus capsule 250 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Aptivus solution 100
mg/mL
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Aralast NP recon soln 500 mg
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Aranelle (28) tablet 0.5/1/0.
5-35 mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
31 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Aranesp (in
polysorbate)
solution 25
mcg/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
solution 40
mcg/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
solution 60
mcg/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
solution 100
mcg/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
solution 200
mcg/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
solution 300
mcg/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
syringe 100
mcg/0.5
mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
syringe 40
mcg/0.4
mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
syringe 300
mcg/0.6
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
syringe 150
mcg/0.3
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
syringe 200
mcg/0.4
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
32 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Aranesp (in
polysorbate)
syringe 500
mcg/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
syringe 25
mcg/0.4
2 mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate)
syringe 60
mcg/0.3
mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Aranesp (in
polysorbate) syringe
10
mcg/0.4
mL PrefBrand-3
YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Arava tablet 10 mg Specialty-5 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSArava tablet 20 mg Specialty-5 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Arbinoxa liquid
4 mg/5
mL
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Arbinoxa tablet 4 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Arcalyst recon soln 220 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Arimidex tablet 1 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
33 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
aripiprazole tablet 15 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
aripiprazole tablet 10 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
aripiprazole tablet 30 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
aripiprazole tablet 20 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
aripiprazole tablet 5 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
aripiprazole tablet 2 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
aripiprazole tablet,disinteg
rating
10 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
aripiprazole tablet,disinteg
rating
15 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
34 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Aristada
suspension,ex
tended rel
syring
441
mg/1.6
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aristada
suspension,ex
tended rel
syring
662
mg/2.4
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aristada
suspension,ex
tended rel
syring
882
mg/3.2
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Arixtra syringe 10
mg/0.8
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Arixtra syringe 5
mg/0.4
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Arixtra syringe 7.5
mg/0.6
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
armodafinil tablet 150 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
armodafinil tablet 250 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
armodafinil tablet 50 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
35 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
armodafinil tablet 200 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Aromasin tablet 25 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Arranon solution 250
mg/50
mL
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Asacol HD tablet,delayed
release
(DR/EC)
800 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Ascomp with
Codeine capsule
30-50-
325-40
mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Ashlyna
tablets,dose
pack,3 month
0.15 mg-
30 mcg
(84)/10
mcg (7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Asmanex
HFA
HFA aerosol
inhaler
100
mcg/act
uation PrefBrand-3
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Asmanex
HFA
HFA aerosol
inhaler
200
mcg/act
uation PrefBrand-3
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Asmanex
Twisthaler
aerosol powdr
breath
activated
220
mcg
(120
doses)
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
36 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Asmanex
Twisthaler
aerosol powdr
breath
activated
220
mcg (30
doses)
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Asmanex
Twisthaler
aerosol powdr
breath
activated
220
mcg (60
doses)
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Asmanex
Twisthaler
aerosol powdr
breath
activated
110
mcg (30
doses)
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
aspirin-
dipyridamole
capsule, ER
multiphase 12
hr
25-200
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Assure ID
Insulin Safety
syringe 1 mL 29
gauge x
1/2"
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Astagraf XL
capsule,exten
ded release
24hr 0.5 mg PrefBrand-3
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Astagraf XL
capsule,exten
ded release
24hr 1 mg PrefBrand-3
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Astagraf XL
capsule,exten
ded release
24hr 5 mg PrefBrand-3
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
atenolol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
37 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
atenolol tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
atenolol tablet 50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
atenolol-
chlorthalidon
e
tablet 100-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
atenolol-
chlorthalidon
e
tablet 50-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Atgam solution 50
mg/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
atorvastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSatorvastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSatorvastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSatorvastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSatovaquone suspension 750
mg/5
mL
Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
atovaquone-
proguanil
tablet 250-100
mg
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
38 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
atovaquone-
proguanil
tablet 62.5-25
mg
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESAtralin gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
ATRIPLA tablet 600-200-
300 mg
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
atropine syringe
0.05
mg/mL
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
atropine syringe
0.1
mg/mL
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
atropine drops 1 %Generic-2 NO
OPHTHALMOLOGY
CYCLOPLEGIC
MYDRIATICS
Atrovent
HFA
HFA aerosol
inhaler
17
mcg/act
uation
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Aubagio tablet 14 mg
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Aubagio tablet 7 mg
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Augmentin suspension
for
reconstitution
125-
31.25
mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES PENICILLINS
39 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Auryxia tablet
210 mg
iron
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Avandia tablet 2 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYAvandia tablet 4 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYAvastin solution 25
mg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Avastin solution
25
mg/mL
(16 mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
AVC Vaginal cream 15 % NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYN
Aveed solution
750
mg/3
mL
(250
mg/mL)
NonPrefBrand-4 YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Avelox ABC
Pack
tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES QUINOLONES
Avelox in
NaCl (iso-
osmotic)
piggyback 400
mg/250
mL
PrefBrand-3 NO ANTI - INFECTIVES QUINOLONES
Aviane tablet 0.1-20
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
40 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Avita cream 0.025 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Avita gel 0.025 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Avonex syringe kit 30
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Avonex
pen injector
kit
30
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Avonex (with
albumin)
kit 30 mcg Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Avycaz recon soln
2.5
gramSpecialty-5 NO
ANTI - INFECTIVES CEPHALOSPORINS
Axert tablet 6.25 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYAxert tablet 12.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Axiron
solution in
metered pump
w/app
30
mg/actu
ation
(1.5
mL)
NonPrefBrand-4 YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
41 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
azacitidine recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Azactam in
dextrose (iso-
osm)
piggyback 1
gram/50
mL
PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Azactam in
dextrose (iso-
osm)
piggyback 2
gram/50
mL
PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Azasan tablet 75 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Azasan tablet 100 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Azasite drops 1 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIBIOTICS
azathioprine tablet 50 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
azathioprine
sodium
recon soln 100 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
azelastine aerosol,spray 137
mcg
(0.1 %)
Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
42 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
azelastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CSazelastine spray,non-
aerosol
0.15 %
(205.5
mcg)
Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
Azelex cream 20 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Azilect tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Azilect tablet 0.5 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
azithromycin suspension
for
reconstitution
200
mg/5
mL
Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESazithromycin tablet 600 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESazithromycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESazithromycin suspension
for
reconstitution
100
mg/5
mL
Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESazithromycin tablet 250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDES
43 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
azithromycin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESazithromycin tablet 250 mg
(6 pack)
Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESazithromycin packet 1 gram Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESazithromycin recon soln 500 mg
(2
mg/ml)
Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESAzopt drops,suspens
ion
1 % PrefBrand-3 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGSAzor tablet 10-20
mg
PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Azor tablet 10-40
mg
PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Azor tablet 5-20 mg PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Azor tablet 5-40 mg PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
aztreonam recon soln 1 gram Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESBACiiM recon soln 50,000
unit
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
44 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
bacitracin ointment 500
unit/gra
m
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
bacitracin recon soln 50,000
unit
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESbacitracin-
polymyxin B
ointment 500-
10,000
unit/gra
m
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
baclofen tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYbaclofen tablet 20 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYBactroban
Nasal
ointment 2 % PrefBrand-3 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
balsalazide capsule 750 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Balziva (28) tablet
0.4-35
mg-mcg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Banzel tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
45 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Banzel tablet 400 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Banzel suspension
40
mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Baraclude tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Baraclude tablet 1 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Baraclude solution 0.05
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
BCG vaccine,
live (PF)
suspension
for
reconstitution
50 mg NonPrefBrand-4 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Beconase AQ spray,non-
aerosol
42 mcg
(0.042
%)
NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Bekyree (28) tablet
0.15-
0.02
mgx21
/0.01
mg x 5 Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Belbuca film
150
mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
46 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Belbuca film
300
mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Belbuca film
450
mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Belbuca film
600
mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Belbuca film 75 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Belbuca film
750
mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Belbuca film
900
mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Beleodaq recon soln 500 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
benazepril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
47 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
benazepril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
benazepril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
benazepril tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
benazepril-
hydrochloroth
iazide
tablet 10-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
benazepril-
hydrochloroth
iazide
tablet 20-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
benazepril-
hydrochloroth
iazide
tablet 20-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
benazepril-
hydrochloroth
iazide
tablet 5-6.25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Benicar tablet 5 mg PrefBrand-3 93 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Benicar tablet 20 mg PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Benicar tablet 40 mg PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Benicar HCT tablet 40-25
mg
PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
48 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Benicar HCT tablet 40-12.5
mg
PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Benicar HCT tablet 20-12.5
mg
PrefBrand-3 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Benlysta recon soln 120 mg
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Benlysta recon soln 400 mg
Specialty-5 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
benztropine solution 2 mg/2
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
benztropine tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
benztropine tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
benztropine tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Berinert kit 500 unit
(10 mL)
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSBesivance drops,suspens
ion
0.6 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIBIOTICS
49 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
betamethason
e
dipropionate
ointment 0.05 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e
dipropionate
cream 0.05 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e
dipropionate
lotion 0.05 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e valerate
cream 0.1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e valerate
lotion 0.1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e valerate
ointment 0.1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e valerate foam 0.12 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e, augmented
cream 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e, augmented
lotion 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e, augmented
ointment 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
betamethason
e, augmented
gel 0.05 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
50 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Betaseron kit 0.3 mg Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
betaxolol drops 0.5 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS
betaxolol tablet 10 mg Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
betaxolol tablet 20 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bethanechol
chloride
tablet 10 mg Generic-2 NO UROLOGICALS CHOLINERGIC
STIMULANTSbethanechol
chloride
tablet 25 mg Generic-2 NO UROLOGICALS CHOLINERGIC
STIMULANTSbethanechol
chloride
tablet 5 mg Generic-2 NO UROLOGICALS CHOLINERGIC
STIMULANTSbethanechol
chloride
tablet 50 mg Generic-2 NO UROLOGICALS CHOLINERGIC
STIMULANTS
Bethkis
solution for
nebulization
300
mg/4
mL
NonPrefBrand-4 YES
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
Betimol drops 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS
Betimol drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS
Betoptic S drops,suspens
ion
0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS
bexarotene capsule 75 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
51 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Bexsero (PF) syringe
50-50-
50-25
mcg/0.5
mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Beyaz tablet
3-0.02-
0.451
mg (24)
NonPrefBrand-4 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
bicalutamide tablet 50 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Bicillin C-R syringe 1,200,0
00 unit/
2
mL(600
k/600k)
PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS
Bicillin C-R syringe 1,200,0
00 unit/
2
mL(900
k/300k)
PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS
Bicillin L-A syringe 600,000
unit/mL
PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS
Bicillin L-A syringe 1,200,0
00
unit/2
mL
PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS
Bicillin L-A syringe 2,400,0
00
unit/4
mL
PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS
52 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
BiCNU recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
BiDil tablet 20-37.5
mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Biltricide tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESbimatoprost drops 0.03 % Generic-2 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGSbisoprolol
fumarate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bisoprolol
fumarate
tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bisoprolol-
hydrochloroth
iazide
tablet 10-6.25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bisoprolol-
hydrochloroth
iazide
tablet 2.5-6.25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bisoprolol-
hydrochloroth
iazide
tablet 5-6.25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Bivigam solution 10 %
Specialty-5 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
53 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
bleomycin recon soln 30 unit Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Bleph-10 drops 10 %NonPrefBrand-4 NO
OPHTHALMOLOGY SULFONAMIDES
Blephamide
drops,suspens
ion
10-0.2
% PrefBrand-3
NO
OPHTHALMOLOGY
STEROID-
SULFONAMIDE
COMBINATIONS
Blephamide
S.O.P. ointment
10-0.2
% PrefBrand-3
NO
OPHTHALMOLOGY
STEROID-
SULFONAMIDE
COMBINATIONS
Blisovi 24 Fe tablet
1 mg-20
mcg
(24)/75
mg (4) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Blisovi Fe
1.5/30 (28) tablet
1.5 mg-
30 mcg
(21)/75
mg (7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Blisovi Fe
1/20 (28) tablet
1 mg-20
mcg
(21)/75
mg (7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Boniva syringe 3 mg/3
mL
NonPrefBrand-4 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
Boostrix
Tdap syringe
2.5-8-5
Lf-mcg-
Lf/0.5m
L
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
54 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Boostrix
Tdap suspension
2.5-8-5
Lf-mcg-
Lf/0.5m
L
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Bosulif tablet 100 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Bosulif tablet 500 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Botox recon soln 100 unit NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Botox recon soln 200 unit NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Breo Ellipta
blister with
device
100-25
mcg/dos
e
NonPrefBrand-4
60 30
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Breo Ellipta
blister with
device
200-25
mcg/dos
e
NonPrefBrand-4
60 30
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Briellyn tablet
0.4-35
mg-mcg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Brilinta tablet 90 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
55 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Brilinta tablet 60 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
brimonidine drops 0.2 % Generic-2 NO OPHTHALMOLOGY SYMPATHOMIMETI
CSbrimonidine drops 0.15 % Generic-2 NO OPHTHALMOLOGY SYMPATHOMIMETI
CS
Brisdelle capsule 7.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Briviact solution
50 mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Briviact tablet 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Briviact tablet 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Briviact tablet 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Briviact tablet 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
56 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Briviact tablet 75 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Briviact solution
10
mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
bromfenac drops 0.09 % Generic-2 NO OPHTHALMOLOGY NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTSbromocriptine tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
bromocriptine capsule 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Brovana solution for
nebulization
15
mcg/2
mL
NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
budesonide suspension
for
nebulization
1 mg/2
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
budesonide suspension
for
nebulization
0.25
mg/2
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
budesonide suspension
for
nebulization
0.5
mg/2
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
57 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
budesonide spray,non-
aerosol
32
mcg/act
uation
Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
budesonide
capsule,delay
ed,extend.rele
ase 3 mg
NonPrefBrand-4 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
bumetanide tablet 0.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bumetanide tablet 1 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bumetanide tablet 2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
bumetanide solution 0.25
mg/mL
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Bunavail film
2.1-0.3
mg
NonPrefBrand-4
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Bunavail film
4.2-0.7
mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Bunavail film
6.3-1
mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
58 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Bupap tablet
50-300
mg
NonPrefBrand-4
403 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Buphenyl tablet 500 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Buphenyl powder
0.94
gram/gr
am
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Buprenex solution 0.3
mg/mL
NonPrefBrand-4 267 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
buprenorphin
e HCl
syringe 0.3
mg/mL
PrefGen-1 267 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
buprenorphin
e HCl
tablet 2 mg Generic-2 15 60 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
buprenorphin
e HCl
tablet 8 mg Generic-2 15 60 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
buprenorphin
e-naloxone
tablet 2-0.5
mg
Generic-2 93 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
59 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
buprenorphin
e-naloxone
tablet 8-2 mg Generic-2 93 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Buproban
tablet
extended
release 150 mg
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
SMOKING
DETERRENTS
bupropion
HCl
tablet
extended
release 100 mg
PrefBrand-3
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
bupropion
HCl
tablet
extended
release 150 mg
PrefBrand-3
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
bupropion
HCl
tablet
extended
release 200 mg
PrefBrand-3
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
bupropion
HCl
tablet
extended
release 24 hr 150 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
bupropion
HCl
tablet
extended
release 24 hr 300 mg
Generic-2
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
bupropion
HCl tablet 100 mg
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
60 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
bupropion
HCl tablet 75 mg
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
buspirone tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
buspirone tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
buspirone tablet 30 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
buspirone tablet 5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
buspirone tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Busulfex solution 60
mg/10
mL
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Butalbital
Compound
W/Codeine capsule
30-50-
325-40
mg
Generic-2
372 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
61 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
butalbital-
acetaminop-
caf-cod capsule
50-325-
40-30
mg
Generic-2
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
butalbital-
acetaminop-
caf-cod capsule
50-300-
40-30
mg Generic-2 403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
butalbital-
acetaminophe
n
tablet 50-325
mg
Generic-2 372 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
butalbital-
acetaminophe
n-caff
capsule 50-325-
40 mg
Generic-2 372 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
butalbital-
acetaminophe
n-caff
tablet 50-325-
40 mg
Generic-2 372 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
butalbital-
acetaminophe
n-caff
capsule 50-300-
40 mg
Generic-2 403 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
butalbital-
aspirin-
caffeine
capsule 50-325-
40 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Butisol tablet 30 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
62 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
butorphanol
tartrate
solution 2
mg/mL
Generic-2 360 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
butorphanol
tartrate
solution 1
mg/mL
Generic-2 720 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
butorphanol
tartrate
spray,non-
aerosol
10
mg/mL
Generic-2 5 28 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Butrans patch weekly 10
mcg/ho
ur
NonPrefBrand-4 4 28 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Butrans patch weekly 20
mcg/ho
ur
NonPrefBrand-4 4 28 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Butrans patch weekly 5
mcg/ho
ur
NonPrefBrand-4 4 28 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Butrans patch weekly
15
mcg/ho
ur
NonPrefBrand-4
4 28
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Butrans patch weekly
7.5
mcg/ho
ur
NonPrefBrand-4
4 28
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
63 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Bydureon
suspension,ex
tended rel
recon 2 mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Bydureon pen injector
2
mg/0.65
mL PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Bystolic tablet 10 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Bystolic tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Bystolic tablet 5 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Bystolic tablet 20 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
cabergoline tablet 0.5 mg Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Cabometyx tablet 20 mg
Specialty-5
31 31
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cabometyx tablet 40 mg
Specialty-5
31 31
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cabometyx tablet 60 mg
Specialty-5
31 31
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
64 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cafergot tablet
1-100
mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
calcipotriene ointment 0.005 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
calcipotriene solution 0.005 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
calcipotriene cream 0.005 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
calcipotriene-
betamethason
e
ointment 0.005-
0.064 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
calcitonin
(salmon)
spray,non-
aerosol
200
unit/act
uation
Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
calcitriol capsule 0.25
mcg
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONEScalcitriol capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONEScalcitriol solution 1
mcg/mL
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONEScalcitriol solution 1
mcg/mL
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONEScalcitriol ointment 3
mcg/gra
m
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
calcium
acetate
capsule 667 mg Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
65 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cambia powder in
packet
50 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Camila tablet 0.35 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSCanasa suppository 1,000
mg
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSCancidas recon soln 70 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSCancidas recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTScandesartan tablet 4 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
candesartan tablet 8 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
candesartan tablet 16 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
candesartan tablet 32 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
candesartan-
hydrochloroth
iazid
tablet 16-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
candesartan-
hydrochloroth
iazid
tablet 32-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
66 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
candesartan-
hydrochloroth
iazid
tablet 32-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Capastat recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Capex shampoo 0.01 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Capital with
Codeine suspension
120-12
mg/5
mL
PrefBrand-3
5167 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Caprelsa tablet 100 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Caprelsa tablet 300 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
captopril tablet 100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
captopril tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
captopril tablet 50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
captopril tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
67 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
captopril-
hydrochloroth
iazide
tablet 25-15
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
captopril-
hydrochloroth
iazide
tablet 25-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
captopril-
hydrochloroth
iazide
tablet 50-15
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
captopril-
hydrochloroth
iazide
tablet 50-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Carac cream 0.5 % Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSCarafate suspension 100
mg/mL
PrefBrand-3 NO GASTROENTEROL
OGY
ULCER THERAPY
Carbaglu tablet,
dispersible
200 mg Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
carbamazepin
e
capsule, ER
multiphase 12
hr
300 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbamazepin
e
capsule, ER
multiphase 12
hr
200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbamazepin
e
tablet
extended
release 12 hr
100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
68 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
carbamazepin
e
tablet,chewab
le
100 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbamazepin
e
suspension 100
mg/5
mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbamazepin
e
tablet 200 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbamazepin
e
capsule, ER
multiphase 12
hr
100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbamazepin
e
tablet
extended
release 12 hr
200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbamazepin
e
tablet
extended
release 12 hr
400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Carbatrol capsule, ER
multiphase 12
hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Carbatrol capsule, ER
multiphase 12
hr
300 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
69 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Carbatrol capsule, ER
multiphase 12
hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
carbidopa tablet 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa
tablet 10-100
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa
tablet 25-100
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa
tablet 25-250
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa
tablet
extended
release
25-100
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa
tablet
extended
release
50-200
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa
tablet,disinteg
rating
25-100
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
70 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
carbidopa-
levodopa
tablet,disinteg
rating
25-250
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa
tablet,disinteg
rating
10-100
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa-
entacapone
tablet 12.5-50-
200 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa-
entacapone
tablet 25-100-
200 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa-
entacapone
tablet 37.5-
150-200
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa-
entacapone
tablet 50-200-
200 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa-
entacapone
tablet 31.25-
125-200
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
carbidopa-
levodopa-
entacapone
tablet 18.75-
75-200
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
71 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
carboplatin solution 10
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cardene IV in
sodium
chloride
piggyback 40
mg/200
mL
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Cardizem LA tablet
extended
release 24 hr
120 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Carimune NF
Nanofiltered
recon soln 6 gram Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
carisoprodol-
ASA-codeine tablet
200-325-
16 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
Carnitor solution 100
mg/mL
NonPrefBrand-4 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Carnitor solution 200
mg/mL
NonPrefBrand-4 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Carnitor tablet 330 mg NonPrefBrand-4 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
carteolol drops 1 %Generic-2 NO
OPHTHALMOLOGY BETA-BLOCKERS
Cartia XT capsule,exten
ded release
24hr
120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
72 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cartia XT capsule,exten
ded release
24hr
180 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Cartia XT capsule,exten
ded release
24hr
240 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Cartia XT capsule,exten
ded release
24hr
300 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
carvedilol tablet 6.25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
carvedilol tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
carvedilol tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
carvedilol tablet 3.125
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Casodex tablet 50 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cayston solution for
nebulization
75
mg/mL
Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVEScefaclor capsule 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefaclor suspension
for
reconstitution
375
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
73 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cefaclor tablet
extended
release 12 hr
500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefaclor suspension
for
reconstitution
125
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefaclor capsule 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefaclor suspension
for
reconstitution
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefadroxil suspension
for
reconstitution
500
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefadroxil tablet 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefadroxil suspension
for
reconstitution
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefadroxil capsule 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefazolin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefazolin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefazolin recon soln 1 gram Generic-2NO
ANTI - INFECTIVES CEPHALOSPORINS
cefazolin in
dextrose (iso-
os)
piggyback 1
gram/50
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefdinir capsule 300 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
74 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cefdinir suspension
for
reconstitution
125
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefdinir suspension
for
reconstitution
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefepime recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefepime recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefepime in
dextrose 5 %
piggyback 1
gram/50
mL
NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
cefepime in
dextrose 5 %
piggyback 2
gram/50
mL
NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
cefixime suspension
for
reconstitution
100
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefixime suspension
for
reconstitution
200
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefotaxime recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefotaxime recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefotaxime recon soln 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefotetan recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefotetan recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
75 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cefotetan recon soln 10 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefoxitin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefoxitin recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefoxitin recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefoxitin in
dextrose, iso-
osm
piggyback 1
gram/50
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefoxitin in
dextrose, iso-
osm
piggyback 2
gram/50
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefpodoxime tablet 100 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefpodoxime suspension
for
reconstitution
100
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefpodoxime tablet 200 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefpodoxime suspension
for
reconstitution
50 mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefprozil tablet 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefprozil tablet 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefprozil suspension
for
reconstitution
125
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
76 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cefprozil suspension
for
reconstitution
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftazidime recon soln 6 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftazidime recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftazidime recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftazidime in
D5W
piggyback 1
gram/50
mL
NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftazidime in
D5W
piggyback 2
gram/50
mL
NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
Ceftin suspension
for
reconstitution
125
mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
Ceftin suspension
for
reconstitution
250
mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftriaxone recon soln 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftriaxone recon soln 10 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftriaxone recon soln 1 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftriaxone recon soln 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
ceftriaxone recon soln 2 gram Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefuroxime
axetil
tablet 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
77 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cefuroxime
axetil
tablet 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefuroxime
sodium
recon soln 1.5
gram
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefuroxime
sodium
recon soln 7.5
gram
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cefuroxime
sodium recon soln 750 mgGeneric-2 NO
ANTI - INFECTIVES CEPHALOSPORINS
celecoxib capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
celecoxib capsule 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
celecoxib capsule 400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
celecoxib capsule 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
CellCept tablet 500 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
CellCept suspension
for
reconstitution
200
mg/mL
Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
78 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
CellCept capsule 250 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
CellCept
Intravenous
recon soln 500 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Celontin capsule 300 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
cephalexin tablet 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cephalexin suspension
for
reconstitution
125
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cephalexin capsule 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cephalexin suspension
for
reconstitution
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cephalexin capsule 500 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cephalexin tablet 250 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
cephalexin capsule 750 mg Generic-2 NO ANTI - INFECTIVES CEPHALOSPORINS
Cerdelga capsule 84 mgSpecialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
79 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cerebyx solution 500 mg
PE/10
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Cerezyme recon soln 400 unit Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Cervarix
Vaccine (PF) syringe
20-20
mcg/0.5
mL
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Cesamet capsule 1 mg NonPrefBrand-4 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
cetirizine solution
1
mg/mL
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
cevimeline capsule 30 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Chantix tablet 0.5 mg NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
SMOKING
DETERRENTS
Chantix tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
SMOKING
DETERRENTS
Chantix
Continuing
Month Box
tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
SMOKING
DETERRENTS
Chantix
Starting
Month Box
tablets,dose
pack
0.5 mg
(11)- 1
mg (42)
NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
SMOKING
DETERRENTS
80 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Chemet capsule 100 mg PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Chenodal tablet 250 mg Specialty-5 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSchlorampheni
col sod
succinate
recon soln 1 gram Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
chlordiazepox
ide HCl
capsule 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlordiazepox
ide HCl
capsule 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlordiazepox
ide HCl
capsule 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlorhexidine
gluconate
mouthwash 0.12 % PrefGen-1 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
chloroquine
phosphate tablet 500 mgGeneric-2 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVESchloroquine
phosphate tablet 250 mgGeneric-2 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
chlorothiazid
e
tablet 250 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
81 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
chlorothiazid
e
tablet 500 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
chlorothiazid
e sodium
recon soln 500 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
chlorpromazi
ne tablet 10 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlorpromazi
ne tablet 100 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlorpromazi
ne tablet 200 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlorpromazi
ne tablet 25 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlorpromazi
ne solution
25
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlorpromazi
ne tablet 50 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
chlorthalidon
e
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
82 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
chlorthalidon
e
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Cholbam capsule 250 mg
Specialty-5 YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Cholbam capsule 50 mg
Specialty-5 YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Cholestyrami
ne Light
powder in
packet
4 gram Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSchorionic
gonadotropin,
human
recon soln 10,000
unit
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Cialis tablet 5 mg NonPrefBrand-4 31 31 YES UROLOGICALS MISCELLANEOUS
UROLOGICALSCialis tablet 2.5 mg NonPrefBrand-4 62 31 YES UROLOGICALS MISCELLANEOUS
UROLOGICALSciclopirox shampoo 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
ciclopirox cream 0.77 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
ciclopirox suspension 0.77 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
ciclopirox solution 8 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
83 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ciclopirox gel 0.77 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
cidofovir solution 75
mg/mL
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
cilostazol tablet 100 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
cilostazol tablet 50 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Ciloxan ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY ANTIBIOTICS
cimetidine tablet 200 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
cimetidine tablet 300 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
cimetidine tablet 400 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
cimetidine tablet 800 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
cimetidine
HCl
solution 300
mg/5
mL
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
Cimzia syringe kit 400
mg/2
mL
(200
mg/mL
x 2)
Specialty-5 2 28 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
84 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cimzia
Powder for
Reconst
kit 400 mg
(200 mg
x 2
vials)
Specialty-5 6 28 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Cinryze recon soln 500 unit
(5 mL)
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSCipro HC drops,suspens
ion
0.2-1 % NonPrefBrand-4 NO EAR, NOSE /
THROAT
MEDICATIONS
OTIC STEROID /
ANTIBIOTIC
Ciprodex drops,suspens
ion
0.3-0.1
%
PrefBrand-3 NO EAR, NOSE /
THROAT
MEDICATIONS
OTIC STEROID /
ANTIBIOTIC
ciprofloxacin suspension,mi
crocapsule
recon
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin suspension,mi
crocapsule
recon
500
mg/5
mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
(mixture)
tablet, ER
multiphase 24
hr
500 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
(mixture)
tablet, ER
multiphase 24
hr
1,000
mg
Generic-2 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
HCl
tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
HCl
tablet 750 mg PrefGen-1 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
HCl
tablet 100 mg PrefGen-1 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
HCl
drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY ANTIBIOTICS
85 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ciprofloxacin
HCl
tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
in 5 %
dextrose
piggyback 200
mg/100
mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
ciprofloxacin
lactate solution
400
mg/40
mL
PrefGen-1 NO
ANTI - INFECTIVES QUINOLONES
cisplatin solution 1
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
citalopram tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
citalopram tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
citalopram solution 10 mg/5
mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
citalopram tablet 40 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
cladribine solution 10
mg/10
mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
86 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Claforan recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
Claravis capsule 10 mg Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Claravis capsule 20 mg Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Claravis capsule 40 mg Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Claravis capsule 30 mg Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Clarinex-D
12 HOUR
tablet, ER
multiphase 12
hr
2.5-120
mg
NonPrefBrand-4 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
clarithromyci
n
tablet 250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESclarithromyci
n
tablet 500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESclarithromyci
n
suspension
for
reconstitution
125
mg/5
mL
Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESclarithromyci
n
suspension
for
reconstitution
250
mg/5
mL
Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESclarithromyci
n
tablet
extended
release 24 hr
500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDES
87 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cleocin capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESCleocin suppository 100 mg NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNClimara Pro patch weekly 0.045-
0.015
mg/24
hr
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
clindamycin
HCl
capsule 150 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESclindamycin
HCl
capsule 300 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESclindamycin
HCl
capsule 75 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESclindamycin
in 5 %
dextrose
piggyback 600
mg/50
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
clindamycin
in 5 %
dextrose
piggyback 900
mg/50
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
clindamycin
in 5 %
dextrose
piggyback 300
mg/50
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Clindamycin
Pediatric
recon soln 75 mg/5
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESclindamycin
phosphate
lotion 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
clindamycin
phosphate
solution 600
mg/4
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
88 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
clindamycin
phosphate
gel 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
clindamycin
phosphate
solution 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
clindamycin
phosphate
cream 2 % Generic-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNclindamycin
phosphate
foam 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
clindamycin
phosphate
swab 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
clindamycin-
benzoyl
peroxide
gel 1-5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Clindesse cream,extend
ed release
2 % NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNClinimix
5%/D15W
Sulfite Free
parenteral
solution
5 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinimix
5%/D25W
sulfite-free
parenteral
solution
5 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinimix
2.75%/D5W
Sulfit Free
parenteral
solution
2.75 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinimix
4.25%/D10W
Sulf Free
parenteral
solution
4.25 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
89 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Clinimix
4.25%/D5W
Sulfit Free
parenteral
solution
4.25 % PrefBrand-3 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Clinimix
4.25%-D20W
sulf-free
parenteral
solution
4.25 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Clinimix
4.25%-D25W
sulf-free
parenteral
solution
4.25 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Clinimix 5%-
D20W(sulfite-
free)
parenteral
solution
5 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinimix E
2.75%/D10W
Sul Free
parenteral
solution
2.75 % NonPrefBrand-4 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Clinimix E
2.75%/D5W
Sulf Free
parenteral
solution
2.75 % NonPrefBrand-4 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Clinimix E
4.25%/D10W
Sul Free
parenteral
solution 4.25 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Clinimix E
4.25%/D25W
Sul Free
parenteral
solution
4.25 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinimix E
4.25%/D5W
Sulf Free
parenteral
solution
4.25 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinimix E
5%/D15W
Sulfit Free
parenteral
solution
5 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
90 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Clinimix E
5%/D20W
Sulfit Free
parenteral
solution
5 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinimix E
5%/D25W
Sulfit Free
parenteral
solution
5 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSClinisol SF
15 %
parenteral
solution
15 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSclobetasol foam 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
clobetasol gel 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
clobetasol ointment 0.05 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
clobetasol solution 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
clobetasol shampoo 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
clobetasol lotion 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
clobetasol spray,non-
aerosol
0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
clobetasol-
emollient
cream 0.05 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
91 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Clodan shampoo 0.05 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Cloderm cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Clolar solution 20
mg/20
mL
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
clomipramine capsule 25 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clomipramine capsule 50 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clomipramine capsule 75 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clonazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
clonazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
92 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
clonazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
clonazepam tablet,disinteg
rating
0.125
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
clonazepam tablet,disinteg
rating
0.25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
clonazepam tablet,disinteg
rating
1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
clonazepam tablet,disinteg
rating
2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
clonazepam tablet,disinteg
rating
0.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
clonidine patch weekly
0.1
mg/24
hr
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
clonidine patch weekly
0.2
mg/24
hr
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
clonidine patch weekly
0.3
mg/24
hr
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
93 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
clonidine HCl tablet 0.1 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
clonidine HCl tablet 0.2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
clonidine HCl tablet 0.3 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
clonidine HCl
tablet
extended
release 12 hr 0.1 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clopidogrel tablet 75 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
clopidogrel tablet 300 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
clorazepate
dipotassium
tablet 15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clorazepate
dipotassium
tablet 3.75 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clorazepate
dipotassium
tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
94 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Clorpres tablet 0.1-15
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Clorpres tablet 0.2-15
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Clorpres tablet 0.3-15
mg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
clotrimazole cream 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
clotrimazole solution 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
clotrimazole troche 10 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSclotrimazole-
betamethason
e
cream 1-0.05
%
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
clotrimazole-
betamethason
e
lotion 1-0.05
%
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
clozapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clozapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
95 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
clozapine tablet 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clozapine tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clozapine tablet,disinteg
rating
100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clozapine tablet,disinteg
rating
25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clozapine tablet,disinteg
rating
12.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clozapine
tablet,disinteg
rating 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
clozapine
tablet,disinteg
rating 150 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Clozaril tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
96 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Clozaril tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Coartem tablet 20-120
mg
NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
codeine
sulfate tablet 15 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
codeine
sulfate tablet 30 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
codeine
sulfate tablet 60 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
colchicine tablet 0.6 mg NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
colchicine capsule 0.6 mg
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY GOUT THERAPY
colchicine-
probenecid
tablet 0.5-500
mg
Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
Colcrys tablet 0.6 mg PrefBrand-3 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
colestipol tablet 1 gram
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
97 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
colestipol granules 5 gram
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTScolistin
(colistimethat
e Na) recon soln 150 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
Colocort enema 100
mg/60
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSColy-Mycin S drops,suspens
ion
3.3-3-10-
0.5
mg/mL
NonPrefBrand-4 NO EAR, NOSE /
THROAT
MEDICATIONS
OTIC STEROID /
ANTIBIOTIC
Combigan drops 0.2-0.5
%
PrefBrand-3 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGSCombivir tablet 150-300
mg
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Cometriq capsule
140
mg/day(
80 mg
x1-20
mg x3)
Specialty-5 YES
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cometriq capsule
100
mg/day(
80 mg
x1-20
mg x1)
Specialty-5 YES
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cometriq capsule
60
mg/day
(20 mg
x 3/day)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Complera tablet
200-25-
300 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
98 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Compro suppository 25 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSCondylox gel 0.5 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSConstulose solution 10
gram/15
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Copaxone syringe
20
mg/mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Copaxone syringe
40
mg/mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Copegus tablet 200 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Cordran Tape
Large Roll
tape 4
mcg/cm
2
PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Corlanor tablet 5 mg
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTS
Corlanor tablet 7.5 mg
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTS
Cormax solution 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
cortisone tablet 25 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
99 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cortisporin ointment 1 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
Cortisporin cream
3.5-
10,000-
0.5
mg/g-
unit/g-
% PrefBrand-3
NO
DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
Cosentyx syringe
150
mg/mL
Specialty-5
2 28
YES DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Cosentyx Pen pen injector
150
mg/mL
Specialty-5
2 28
YES DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Cotellic tablet 20 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Coumadin tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Coumadin tablet 10 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Coumadin tablet 2 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Coumadin tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
100 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Coumadin tablet 3 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Coumadin tablet 4 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Coumadin tablet 5 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Coumadin tablet 6 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Coumadin tablet 7.5 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Creon capsule,delay
ed
release(DR/E
C)
24,000-
76,000 -
120,000
unit
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Creon capsule,delay
ed
release(DR/E
C)
6,000-
19,000 -
30,000
unit
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Creon capsule,delay
ed
release(DR/E
C)
12,000-
38,000 -
60,000
unit
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Creon
capsule,delay
ed
release(DR/E
C)
3,000-
9,500-
15,000
unit PrefBrand-3
NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
101 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Creon
capsule,delay
ed
release(DR/E
C)
36,000-
114,000-
180,000
unit PrefBrand-3
NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Cresemba capsule 186 mgSpecialty-5 NO
ANTI - INFECTIVES
ANTIFUNGAL
AGENTS
Cresemba recon soln 372 mgSpecialty-5 NO
ANTI - INFECTIVES
ANTIFUNGAL
AGENTS
Crestor tablet 40 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSCrestor tablet 5 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSCrestor tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSCrestor tablet 20 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Crinone gel 8 %NonPrefBrand-4 YES OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Crinone gel 4 %NonPrefBrand-4 YES OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Crixivan capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Crixivan capsule 400 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
cromolyn drops 4 % Generic-2 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CS
102 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cromolyn solution for
nebulization
20 mg/2
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTScromolyn concentrate 100
mg/5
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSCryselle (28) tablet 0.3-30
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSCubicin recon soln 500 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESCuprimine capsule 250 mg Specialty-5 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSCutivate lotion 0.05 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Cuvposa solution
1 mg/5
mL (0.2
mg/mL)
NonPrefBrand-4 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
Cyclafem
1/35 (28) tablet
1-35 mg-
mcg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Cyclafem
7/7/7 (28) tablet
0.5/0.75
/1 mg-
35 mcg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
cyclobenzapri
ne
tablet 7.5 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
103 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cyclobenzapri
ne
tablet 5 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYcyclobenzapri
ne
tablet 10 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
cyclophospha
mide capsule 25 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cyclophospha
mide capsule 50 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cycloset tablet 0.8 mg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYcyclosporine capsule 25 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cyclosporine solution 250
mg/5
mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cyclosporine capsule 100 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
104 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
cyclosporine
modified
capsule 100 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cyclosporine
modified
solution 100
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cyclosporine
modified
capsule 25 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cyclosporine
modified
capsule 50 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cyproheptadi
ne
syrup 2 mg/5
mL
Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTScyproheptadi
ne
tablet 4 mg Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Cyramza solution
10
mg/mL
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cyramza solution
10
mg/mL
(50 mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cystadane powder 1
gram/1.
7 mL
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
105 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Cystagon capsule 150 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS
UROLOGICALSCystagon capsule 50 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS
UROLOGICALS
Cystaran drops 0.44 %
Specialty-5 NO
OPHTHALMOLOGY
MISCELLANEOUS
OPHTHALMOLOGI
CS
cytarabine solution 20
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
cytarabine
(PF)
solution 2
gram/20
mL
(100
mg/mL)
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Cytovene recon soln 500 mg NonPrefBrand-4 YES ANTI - INFECTIVES ANTIVIRALS
D10 %-0.45
% sodium
chloride
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
D2.5 %-0.45
% sodium
chloride
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
D5 % and 0.9
% sodium
chloride
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
D5 %-0.45 %
sodium
chloride
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
106 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dacarbazine recon soln 200 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Dacogen recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Daklinza tablet 30 mgSpecialty-5
28 28YES
ANTI - INFECTIVES ANTIVIRALS
Daklinza tablet 60 mgSpecialty-5
28 28YES
ANTI - INFECTIVES ANTIVIRALS
Daklinza tablet 90 mgSpecialty-5
28 28YES
ANTI - INFECTIVES ANTIVIRALS
Daliresp tablet
500
mcg PrefBrand-3NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Dalvance solution 500 mgSpecialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
danazol capsule 100 mg Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdanazol capsule 200 mg Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdanazol capsule 50 mg Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdantrolene capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYdantrolene capsule 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
107 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dantrolene capsule 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYdapsone tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESdapsone tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Daptacel
(DTaP
Pediatric)
(PF) suspension
15-10-5
Lf-mcg-
Lf/0.5m
L
NonPrefBrand-4 NO
IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Daraprim tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESdarifenacin tablet
extended
release 24 hr
15 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
darifenacin tablet
extended
release 24 hr
7.5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
Darzalex solution
20
mg/mL
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
daunorubicin solution 5
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
108 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Daytrana patch 24 hour 10 mg/9
hr
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Daytrana patch 24 hour 15 mg/9
hr
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Daytrana patch 24 hour 20 mg/9
hr
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Daytrana patch 24 hour 30 mg/9
hr
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
DDAVP solution 0.1
mg/mL
(refriger
ate)
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
decitabine recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Delzicol
capsule,delay
ed
release(DR/E
C) 400 mg PrefBrand-3
NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
demeclocycli
ne
tablet 150 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
demeclocycli
ne
tablet 300 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
109 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Demser capsule 250 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Denavir cream 1 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIVIRALS
Depacon solution
500
mg/5
mL
(100
mg/mL)
NonPrefBrand-4 NOAUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depakene capsule 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depakene solution
250
mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depakote
tablet,delayed
release
(DR/EC) 125 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depakote
tablet,delayed
release
(DR/EC) 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depakote
tablet,delayed
release
(DR/EC) 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
110 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Depakote ER
tablet
extended
release 24 hr 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depakote ER
tablet
extended
release 24 hr 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depakote
Sprinkles
capsule,
sprinkle 125 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Depen
Titratabs
tablet 250 mg Specialty-5 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSDepo-
Estradiol
oil 5
mg/mL
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Depo-Medrol suspension
20
mg/mLNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Depo-Medrol suspension
40
mg/mLNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Depo-Medrol suspension
80
mg/mLNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Depo-Provera solution
400
mg/mLNonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Depo-
Testosterone
oil 100
mg/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESDepo-
Testosterone
oil 200
mg/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Descovy tablet
200-25
mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
111 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
desipramine tablet 10 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
desipramine tablet 100 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
desipramine tablet 150 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
desipramine tablet 25 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
desipramine tablet 50 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
desipramine tablet 75 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
desloratadine tablet 5 mg Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTSdesloratadine tablet,disinteg
rating
5 mg Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTSdesloratadine tablet,disinteg
rating
2.5 mg Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
112 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
desmopressin tablet 0.2 mg Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdesmopressin solution 4
mcg/mL
Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdesmopressin spray,non-
aerosol
10
mcg/spr
ay (0.1
mL)
Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
desmopressin tablet 0.1 mg Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdesmopressin solution 0.1
mg/mL
(refriger
ate)
Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Desonate gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desonide lotion 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desonide ointment 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desonide cream 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desoximetaso
ne
ointment 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desoximetaso
ne
cream 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
113 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
desoximetaso
ne
cream 0.25 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desoximetaso
ne
ointment 0.25 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desoximetaso
ne
gel 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
desvenlafaxin
e
tablet
extended
release 24 hr
100 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
desvenlafaxin
e
tablet
extended
release 24 hr
50 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexamethaso
ne
tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESdexamethaso
ne
tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESdexamethaso
ne
tablet 1.5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESdexamethaso
ne
tablet 2 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESdexamethaso
ne
tablet 4 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESdexamethaso
ne
tablet 6 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESdexamethaso
ne
elixir 0.5
mg/5
mL
PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
114 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dexamethaso
ne
tablet 0.75 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESDexamethaso
ne Intensol
drops 1
mg/mL
Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESdexamethaso
ne sodium
phosphate
drops 0.1 % Generic-2 NO OPHTHALMOLOGY STEROIDS
dexamethaso
ne sodium
phosphate
solution 10
mg/mL
Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
dexamethaso
ne sodium
phosphate solution
4
mg/mL
Generic-2 NOENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Dexedrine tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Dexedrine tablet 10 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
capsule,ER
biphasic 50-
50
10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
capsule,ER
biphasic 50-
50
15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
capsule,ER
biphasic 50-
50
20 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
115 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dexmethylphe
nidate
capsule,ER
biphasic 50-
50
30 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
capsule,ER
biphasic 50-
50
5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dexmethylphe
nidate
capsule,ER
biphasic 50-
50 40 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
DexPak 13
Day
tablets,dose
pack
1.5 mg
(51
tabs)
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
dexrazoxane
HCl
recon soln 250 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
116 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dextroamphet
amine
tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine
tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine
capsule,
extended
release
10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine
capsule,
extended
release
15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine
capsule,
extended
release
5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
tablet 30 mg Generic-2 62 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
tablet 5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
tablet 10 mg Generic-2 62 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
117 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dextroamphet
amine-
amphetamine
tablet 15 mg PrefGen-1 62 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
tablet 20 mg Generic-2 93 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
tablet 12.5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
capsule,exten
ded release
24hr
10 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
capsule,exten
ded release
24hr
15 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
capsule,exten
ded release
24hr
20 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
capsule,exten
ded release
24hr
25 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine
capsule,exten
ded release
24hr
30 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
118 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dextroamphet
amine-
amphetamine
capsule,exten
ded release
24hr
5 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextroamphet
amine-
amphetamine tablet 7.5 mg
PrefGen-1
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
dextrose 10
% and 0.2 %
NaCl
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
dextrose 10
% in water
(D10W)
parenteral
solution
10 % Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
dextrose 5 %
in water
(D5W)
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
dextrose 5 %-
lactated
ringers
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
dextrose 5%-
0.2 % sod
chloride
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
dextrose 5%-
0.3 %
sod.chloride
parenteral
solution
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Dextrose
With Sodium
Chloride
parenteral
solution
5-0.2 % Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Dextrose-KCl-
NaCl
solution 5-0.224-
0.225 %
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
119 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Diastat kit 2.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Diastat
AcuDial
kit 5-7.5-10
mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Diastat
AcuDial
kit 12.5-15-
17.5-20
mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
diazepam tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
diazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
diazepam tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
diazepam solution 5 mg/5
mL (1
mg/mL)
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
diazepam kit 2.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
120 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
diazepam kit 5-7.5-10
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
diazepam kit 12.5-15-
17.5-20
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Diazepam
Intensol
concentrate 5
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Dibenzyline capsule 10 mg Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diclofenac
potassium
tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac
sodium
drops 0.1 % PrefGen-1 NO OPHTHALMOLOGY NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTSdiclofenac
sodium
gel 1 % Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac
sodium
gel 3 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
121 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
diclofenac
sodium
tablet
extended
release 24 hr
100 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac
sodium
tablet,delayed
release
(DR/EC)
25 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac
sodium
tablet,delayed
release
(DR/EC)
50 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac
sodium
tablet,delayed
release
(DR/EC)
75 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac
sodium
drops 1.5 % Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac-
misoprostol
tablet,IR,dela
yed
rel,biphasic
50-200
mg-mcg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
diclofenac-
misoprostol
tablet,IR,dela
yed
rel,biphasic
75-200
mg-mcg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
dicloxacillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS
dicloxacillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES PENICILLINS
122 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dicyclomine capsule 10 mg
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
dicyclomine solution
10
mg/mL
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
dicyclomine solution
10 mg/5
mL
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
dicyclomine tablet 20 mg
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
didanosine capsule,delay
ed
release(DR/E
C)
125 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
didanosine capsule,delay
ed
release(DR/E
C)
250 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
didanosine capsule,delay
ed
release(DR/E
C)
200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
didanosine capsule,delay
ed
release(DR/E
C)
400 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
123 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Differin lotion 0.1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Dificid tablet 200 mg
Specialty-5 NO
ANTI - INFECTIVES
ERYTHROMYCINS /
OTHER
MACROLIDES
diflorasone cream 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
diflorasone ointment 0.05 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
diflunisal tablet 500 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Digitek tablet 125
mcg
PrefGen-1 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
Digitek tablet 250
mcg
Generic-2 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
digoxin solution 250
mcg/mL
Generic-2 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
digoxin tablet 125
mcg
PrefGen-1 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
digoxin tablet 250
mcg
Generic-2 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
124 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
digoxin solution 50
mcg/mL
Generic-2 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
dihydroergota
mine
spray,non-
aerosol
0.5
mg/pum
p act. (4
mg/mL)
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
dihydroergota
mine
solution 1
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYDilantin capsule 30 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Dilantin
Extended
capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Dilantin
Infatabs
tablet,chewab
le 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Dilantin-125 suspension
125
mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Dilaudid liquid 1
mg/mL
NonPrefBrand-4 1550 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
125 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Dilaudid tablet 2 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Dilaudid tablet 4 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Dilaudid tablet 8 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
diltiazem HCl capsule,
extended
release
360 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl capsule,exten
ded release
24hr
300 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl capsule,exten
ded release
24hr
240 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl capsule,
extended
release
180 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl capsule,exten
ded release
24hr
120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl capsule,exten
ded release 12
hr
60 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl capsule,exten
ded release 12
hr
90 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
126 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
diltiazem HCl capsule,exten
ded release 12
hr
120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl tablet 120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl tablet 90 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl tablet 60 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl capsule,
extended
release
420 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl recon soln 100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl tablet 30 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
diltiazem HCl solution 5
mg/mL
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
DILT-XR capsule,ext
release
degradable
120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
DILT-XR capsule,ext
release
degradable
180 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
DILT-XR capsule,ext
release
degradable
240 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
127 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Dipentum capsule 250 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
diphenhydra
mine HCl solution
50
mg/mL
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
diphenoxylate-
atropine liquid
2.5-
0.025
mg/5
mL
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
diphenoxylate-
atropine tablet
2.5-
0.025
mg
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
disulfiram tablet 250 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
disulfiram tablet 500 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Diuril suspension 250
mg/5
mL
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
divalproex
tablet
extended
release 24 hr 250 mg PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
divalproex
tablet
extended
release 24 hr 500 mg PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
128 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
divalproex
capsule,
sprinkle 125 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
divalproex
tablet,delayed
release
(DR/EC) 125 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
divalproex
tablet,delayed
release
(DR/EC) 250 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
divalproex
tablet,delayed
release
(DR/EC) 500 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Divigel gel in packet 0.5 mg
(0.1 %)
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Docefrez recon soln 20 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
docetaxel solution
80 mg/4
mL (20
mg/mL)
Generic-2 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
docetaxel solution
80 mg/8
mL (10
mg/mL)
Generic-2 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
dofetilide capsule 125
mcg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
129 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dofetilide capsule 250
mcg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
dofetilide capsule 500
mcg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Dolophine tablet 10 mg NonPrefBrand-4 206 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Dolophine tablet 5 mg NonPrefBrand-4 248 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
donepezil
tablet,disinteg
rating 10 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
donepezil tablet 10 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
donepezil
tablet,disinteg
rating 5 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
donepezil tablet 5 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
130 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
donepezil tablet 23 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Doribax recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESdorzolamide drops 2 % Generic-2 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGSdorzolamide-
timolol
drops 22.3-6.8
mg/mL
Generic-2 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGSdoxazosin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
doxazosin tablet 2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
doxazosin tablet 4 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
doxazosin tablet 8 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
doxepin capsule 10 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
doxepin concentrate
10
mg/mL
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
131 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
doxepin capsule 100 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
doxepin capsule 150 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
doxepin capsule 25 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
doxepin capsule 50 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
doxepin cream 5 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
doxepin capsule 75 mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
doxercalcifer
ol
solution 4 mcg/2
mL
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdoxercalcifer
ol
capsule 2.5 mcg Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdoxercalcifer
ol
capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESdoxercalcifer
ol
capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
132 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
doxorubicin solution
50
mg/25
mL
Generic-2 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
doxorubicin,
peg-
liposomal suspension
2
mg/mL Generic-2
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Doxy-100 recon soln 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
tablet 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
capsule 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
capsule 50 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
tablet 20 mg PrefGen-1 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
recon soln 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
tablet 50 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
tablet,delayed
release
(DR/EC)
75 mg PrefGen-1 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
tablet,delayed
release
(DR/EC)
100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
tablet,delayed
release
(DR/EC)
150 mg PrefGen-1 NO ANTI - INFECTIVES TETRACYCLINES
133 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
doxycycline
hyclate
tablet,delayed
release
(DR/EC) 200 mg Generic-2
NO
ANTI - INFECTIVES TETRACYCLINES
doxycycline
hyclate
tablet,delayed
release
(DR/EC) 50 mg Generic-2
NO
ANTI - INFECTIVES TETRACYCLINES
doxycycline
monohydrate
suspension
for
reconstitution
25 mg/5
mL
Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
monohydrate
tablet 75 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
monohydrate
tablet 150 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
monohydrate
capsule 75 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
monohydrate
capsule 150 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline
monohydrate capsule 50 mg Generic-2NO
ANTI - INFECTIVES TETRACYCLINESdoxycycline
monohydrate capsule 100 mg Generic-2NO
ANTI - INFECTIVES TETRACYCLINESdoxycycline
monohydrate tablet 100 mg Generic-2NO
ANTI - INFECTIVES TETRACYCLINESdoxycycline
monohydrate tablet 50 mg Generic-2NO
ANTI - INFECTIVES TETRACYCLINES
dronabinol capsule 10 mg Specialty-5 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSdronabinol capsule 2.5 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
134 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
dronabinol capsule 5 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSdrospirenone-
ethinyl
estradiol
tablet 3-0.02
mg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSdrospirenone-
ethinyl
estradiol
tablet 3-0.03
mg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSDroxia capsule 200 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Droxia capsule 300 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Droxia capsule 400 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Duexis tablet
800-
26.6 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Dulera
HFA aerosol
inhaler
100-5
mcg/act
uation
NonPrefBrand-4
13 30
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Dulera
HFA aerosol
inhaler
200-5
mcg/act
uation
NonPrefBrand-4
13 30
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
135 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
duloxetine capsule,delay
ed
release(DR/E
C)
20 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
duloxetine capsule,delay
ed
release(DR/E
C)
30 mg PrefBrand-3 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
duloxetine capsule,delay
ed
release(DR/E
C)
60 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
duloxetine capsule,delay
ed
release(DR/E
C)
40 mg PrefBrand-3 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Duopa
intestinal
pump
suspension
4.63-20
mg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Duragesic patch 72 hour 25
mcg/hr
NonPrefBrand-4 20 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Duragesic patch 72 hour 50
mcg/hr
NonPrefBrand-4 17 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Duragesic patch 72 hour 75
mcg/hr
NonPrefBrand-4 12 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
136 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Duragesic patch 72 hour 100
mcg/hr
NonPrefBrand-4 10 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Duragesic patch 72 hour 12
mcg/hr
NonPrefBrand-4 20 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Duramorph
(PF)
solution 0.5
mg/mL
Generic-2 4000 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Duramorph
(PF)
solution 1
mg/mL
Generic-2 2000 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Durezol drops 0.05 % PrefBrand-3 NO OPHTHALMOLOGY STEROIDS
dutasteride capsule 0.5 mg PrefBrand-3 NO UROLOGICALS BENIGN
PROSTATIC
HYPERPLASIA(BPH
) THERAPY
dutasteride-
tamsulosin
capsule, ER
multiphase 24
hr
0.5-0.4
mg
PrefBrand-3 NO
UROLOGICALS
BENIGN
PROSTATIC
HYPERPLASIA(BPH
) THERAPY
Dymista
spray,non-
aerosol
137-50
mcg/spr
ay
NonPrefBrand-4 NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Dyrenium capsule 100 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
137 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Dyrenium capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Dysport recon soln 300 unit NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Dysport recon soln 500 unit
NonPrefBrand-4 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
E.E.S. 400 tablet 400 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESE.E.S.
Granules
suspension
for
reconstitution
200
mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESeconazole cream 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Edarbyclor tablet
40-12.5
mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Edarbyclor tablet
40-25
mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Edecrin tablet 25 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Edurant tablet 25 mgNonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
138 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Effient tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Effient tablet 5 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Egrifta recon soln 1 mg
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Elaprase solution 6 mg/3
mL
Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Elelyso recon soln 200 unitSpecialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Elidel cream 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSEligard syringe 45 mg
(6
month)
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Eligard syringe 30 mg
(4
month)
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Eligard syringe 7.5 mg
(1
month)
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Eligard syringe 22.5 mg
(3
month)
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
139 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Eliphos tablet 667 mg Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
Eliquis tablet 2.5 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Eliquis tablet 5 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Elitek recon soln 1.5 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Elitek recon soln 7.5 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Elixophyllin elixir 80
mg/15
mL
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Ellence solution 200
mg/100
mL
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Elmiron capsule 100 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS
UROLOGICALSEmadine drops 0.05 % NonPrefBrand-4 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CSEmbeda capsule,oral
only,ext.rel
pell
100-4
mg
NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
140 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Embeda capsule,oral
only,ext.rel
pell
20-0.8
mg
NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Embeda capsule,oral
only,ext.rel
pell
30-1.2
mg
NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Embeda capsule,oral
only,ext.rel
pell
50-2 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Embeda capsule,oral
only,ext.rel
pell
60-2.4
mg
NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Embeda capsule,oral
only,ext.rel
pell
80-3.2
mg
NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Emcyt capsule 140 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Emend capsule 80 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSEmend capsule 125 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSEmend capsule 40 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
141 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Emend capsule,dose
pack
125 mg
(1)- 80
mg (2)
NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Emend recon soln 150 mg
NonPrefBrand-4 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Emoquette tablet
0.15-
0.03 mg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Empliciti recon soln 300 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Empliciti recon soln 400 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Emsam patch 24 hour 6 mg/24
hr
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Emsam patch 24 hour 9 mg/24
hr
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Emsam patch 24 hour 12
mg/24
hr
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Emtriva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
142 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Emtriva solution 10
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Emverm
tablet,chewab
le 100 mgNonPrefBrand-4 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
enalapril
maleate
tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
enalapril
maleate
tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
enalapril
maleate
tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
enalapril
maleate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
enalapril-
hydrochloroth
iazide
tablet 5-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
enalapril-
hydrochloroth
iazide
tablet 10-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Enbrel recon soln 25 mg
(1 mL)
Specialty-5 8 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSEnbrel syringe 50
mg/mL
(0.98
mL)
Specialty-5 7.84 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Enbrel syringe 25
mg/0.5
mL
(0.51)
Specialty-5 4 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
143 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Enbrel
SureClick pen injector
50
mg/mL
(0.98
mL)
Specialty-5
7.84 28
YESMUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Endocet tablet
10-325
mg
Generic-2
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Endocet tablet
5-325
mg
Generic-2
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Endocet tablet
7.5-325
mg
Generic-2
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Engerix-B
(PF)
syringe 20
mcg/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Engerix-B
Pediatric (PF)
suspension 10
mcg/0.5
mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Engerix-B
Pediatric (PF)
syringe 10
mcg/0.5
mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
enoxaparin syringe 30
mg/0.3
mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
144 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
enoxaparin syringe 40
mg/0.4
mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
enoxaparin syringe 60
mg/0.6
mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
enoxaparin syringe 80
mg/0.8
mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
enoxaparin syringe 120
mg/0.8
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
enoxaparin syringe 100
mg/mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
enoxaparin syringe 150
mg/mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
enoxaparin solution 300
mg/3
mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Enpresse tablet 50-30
(6)/75-
40
(5)/125-
30(10)
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
entacapone tablet 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
entecavir tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
145 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
entecavir tablet 1 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Entresto tablet
24-26
mg PrefBrand-3 62 31
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTS
Entresto tablet
49-51
mg PrefBrand-3 62 31
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTS
Entresto tablet
97-103
mg PrefBrand-3 62 31
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTS
Enulose solution 10
gram/15
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Envarsus XR
tablet
extended
release 24 hr 4 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Envarsus XR
tablet
extended
release 24 hr 0.75 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Envarsus XR
tablet
extended
release 24 hr 1 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Epiduo gel with
pump
0.1-2.5
%
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Epiduo Forte
gel with
pump
0.3-2.5
%
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
146 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
epinastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CSepinephrine auto-injector 0.3
mg/0.3
mL
Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTSepinephrine auto-injector 0.15
mg/0.15
mL
Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTSEpiPen 2-Pak auto-injector 0.3
mg/0.3
mL
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTSEpiPen Jr 2-
Pak
auto-injector 0.15
mg/0.3
mL
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTSepirubicin solution 50
mg/25
mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Epitol tablet 200 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Epivir tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Epivir solution 10
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Epivir tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Epivir HBV tablet 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
147 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Epivir HBV solution 25 mg/5
mL (5
mg/mL)
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
eplerenone tablet 25 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
eplerenone tablet 50 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Epogen solution 20,000
unit/2
mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Epogen solution 2,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Epogen solution 3,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Epogen solution 4,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Epogen solution 20,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
eprosartan tablet 600 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Epzicom tablet 600-300
mg
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Equetro capsule, ER
multiphase 12
hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
148 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Equetro capsule, ER
multiphase 12
hr
300 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Equetro capsule, ER
multiphase 12
hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Eraxis(Water
Diluent)
recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSErbitux solution 100
mg/50
mL
PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ergoloid tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Ergomar tablet 2 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Erivedge capsule 150 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Errin tablet 0.35 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Erwinaze recon soln
10,000
unit
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
149 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ery Pads swab 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Erygel gel 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
EryPed 200 suspension
for
reconstitution
200
mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESEryPed 400 suspension
for
reconstitution
400
mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESEry-Tab tablet,delayed
release
(DR/EC)
250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESEry-Tab tablet,delayed
release
(DR/EC)
333 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESEry-Tab tablet,delayed
release
(DR/EC)
500 mg PrefBrand-3 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDES
Erythrocin recon soln 500 mg
PrefBrand-3 NO
ANTI - INFECTIVES
ERYTHROMYCINS /
OTHER
MACROLIDES
Erythrocin (as
stearate)
tablet 250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESerythromycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDES
150 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
erythromycin ointment 5
mg/gra
m (0.5
%)
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
erythromycin capsule,delay
ed
release(DR/E
C)
250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDES
erythromycin tablet 250 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESerythromycin
ethylsuccinate
tablet 400 mg Generic-2 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESerythromycin
with ethanol
gel 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
erythromycin
with ethanol
solution 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
erythromycin-
benzoyl
peroxide
gel 3-5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Esbriet capsule 267 mgSpecialty-5
279 31YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
escitalopram
oxalate
tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
escitalopram
oxalate
tablet 5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
151 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
escitalopram
oxalate
tablet 20 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
escitalopram
oxalate
solution 5 mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
esomeprazole
magnesium
capsule,delay
ed
release(DR/E
C)
20 mg Generic-2 31 31 NO GASTROENTEROL
OGY
ULCER THERAPY
esomeprazole
sodium
recon soln 20 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
esomeprazole
sodium
recon soln 40 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
estazolam tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
estazolam tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Estrace cream 0.01 %
(0.1
mg/gra
m)
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol tablet 0.5 mg PrefGen-1 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSestradiol tablet 1 mg PrefGen-1 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
152 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
estradiol tablet 2 mg PrefGen-1 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSestradiol patch weekly 0.05
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch weekly 0.1
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch weekly 0.075
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch
semiweekly
0.0375
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch weekly 0.025
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch
semiweekly
0.05
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch
semiweekly
0.1
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch
semiweekly
0.025
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch weekly 0.0375
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol patch weekly 0.06
mg/24
hr
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
153 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
estradiol
patch
semiweekly
0.075
mg/24
hr
Generic-2 NOOBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
estradiol
valerate
oil 20
mg/mL
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSestradiol-
norethindrone
acet tablet
0.5-0.1
mg Generic-2
NOOBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSestradiol-
norethindrone
acet tablet
1-0.5
mg Generic-2
NOOBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Estring ring 2 mg NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSestropipate tablet 0.75 mg PrefGen-1 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSestropipate tablet 1.5 mg PrefGen-1 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSestropipate tablet 3 mg PrefGen-1 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSeszopiclone tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
eszopiclone tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
eszopiclone tablet 3 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
154 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ethacrynate
sodium
recon soln 50 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
ethambutol tablet 100 mgGeneric-2 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
ethambutol tablet 400 mgGeneric-2 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
ethosuximide capsule 250 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
ethosuximide solution 250
mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
etidronate
disodium
tablet 200 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
etidronate
disodium
tablet 400 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
etodolac capsule 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
etodolac capsule 300 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
etodolac tablet 400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
155 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
etodolac tablet 500 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
etodolac tablet
extended
release 24 hr
400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
etodolac tablet
extended
release 24 hr
600 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
etodolac tablet
extended
release 24 hr
500 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Etopophos recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
etoposide solution 20
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Eurax cream 10 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
SCABICIDES /
PEDICULICIDESEurax lotion 10 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
SCABICIDES /
PEDICULICIDES
156 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Evamist spray,non-
aerosol
1.53
mg/spra
y
(1.7%)
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Evekeo tablet 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Evekeo tablet 5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Evotaz tablet
300-150
mg PrefBrand-3NO
ANTI - INFECTIVES ANTIVIRALS
Evzio auto-injector
0.4
mg/0.4
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Exalgo ER tablet
extended
release 24 hr
12 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Exalgo ER tablet
extended
release 24 hr
16 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Exalgo ER tablet
extended
release 24 hr
8 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
157 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Exalgo ER
tablet
extended
release 24 hr 32 mg
NonPrefBrand-4
48 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Exelderm cream 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Exelderm solution 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Exelon patch 24 hour 9.5
mg/24
hr
PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Exelon patch 24 hour 4.6
mg/24
hr
PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Exelon patch 24 hour
13.3
mg/24
hour PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
exemestane tablet 25 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Exjade tablet,
dispersible
125 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Exjade tablet,
dispersible
250 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
158 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Exjade tablet,
dispersible
500 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Extavia kit 0.3 mg Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Fabrazyme recon soln 35 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESfamciclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
famciclovir tablet 125 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
famciclovir tablet 250 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
famotidine tablet 40 mg PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
famotidine tablet 20 mg PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
famotidine suspension 40 mg/5
mL (8
mg/mL)
PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
famotidine
(PF)
solution 20 mg/2
mL
PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
famotidine
(PF)-NaCl
(iso-os)
piggyback 20
mg/50
mL
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
Fanapt tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
159 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Fanapt tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fanapt tablet 12 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fanapt tablet 2 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fanapt tablet 4 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fanapt tablet 6 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fanapt tablet 8 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fanapt tablets,dose
pack
1mg(2)-
2mg(2)-
4mg(2)-
6mg(2)
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fareston tablet 60 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
160 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Farxiga tablet 10 mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Farxiga tablet 5 mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Farydak capsule 10 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Farydak capsule 15 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Farydak capsule 20 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Faslodex syringe 250
mg/5
mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
FazaClo tablet,disinteg
rating
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
FazaClo tablet,disinteg
rating
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
FazaClo tablet,disinteg
rating
12.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
161 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
FazaClo
tablet,disinteg
rating 200 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
FazaClo
tablet,disinteg
rating 150 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
felbamate tablet 400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
felbamate tablet 600 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
felbamate suspension 600
mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Felbatol tablet 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Felbatol tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Felbatol suspension 600
mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
162 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
felodipine tablet
extended
release 24 hr
10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
felodipine tablet
extended
release 24 hr
5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
felodipine tablet
extended
release 24 hr
2.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Femara tablet 2.5 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Femring ring 0.05
mg/24
hr
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Femring ring 0.1
mg/24
hr
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
fenofibrate tablet 160 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate tablet 54 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
163 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fenofibrate
micronized
capsule 67 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate
micronized
capsule 134 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate
micronized
capsule 200 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate
micronized
capsule 130 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate
micronized
capsule 43 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate
nanocrystalliz
ed
tablet 145 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibrate
nanocrystalliz
ed
tablet 48 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibric
acid
tablet 105 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibric
acid
tablet 35 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenofibric
acid (choline)
capsule,delay
ed
release(DR/E
C)
135 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
164 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fenofibric
acid (choline)
capsule,delay
ed
release(DR/E
C)
45 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Fenoglide tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSFenoglide tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfenoprofen tablet 600 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
fenoprofen capsule 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
fentanyl patch 72 hour 75
mcg/hr
PrefBrand-3 12 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl patch 72 hour 25
mcg/hr
Generic-2 20 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl patch 72 hour 50
mcg/hr
Generic-2 17 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
165 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fentanyl patch 72 hour 100
mcg/hr
PrefBrand-3 10 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl patch 72 hour 12
mcg/hr
PrefBrand-3 20 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl patch 72 hour
37.5
mcg/ho
ur
NonPrefBrand-4
20 30
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl patch 72 hour
62.5
mcg/ho
ur
NonPrefBrand-4
15 30
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl patch 72 hour
87.5
mcg/ho
ur
NonPrefBrand-4
11 30
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl
citrate
lozenge on a
handle
1,200
mcg
Specialty-5 40 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl
citrate
lozenge on a
handle
1,600
mcg
Specialty-5 30 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl
citrate
lozenge on a
handle
200
mcg
Generic-2 124 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
166 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fentanyl
citrate
lozenge on a
handle
400
mcg
Specialty-5 119 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl
citrate
lozenge on a
handle
600
mcg
Specialty-5 79 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
fentanyl
citrate
lozenge on a
handle
800
mcg
Specialty-5 59 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Fentora tablet,
effervescent
100
mcg
Specialty-5 124 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Fentora tablet,
effervescent
200
mcg
Specialty-5 124 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Fentora tablet,
effervescent
400
mcg
Specialty-5 119 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Fentora tablet,
effervescent
600
mcg
Specialty-5 79 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Fentora tablet,
effervescent
800
mcg
Specialty-5 59 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
167 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ferriprox tablet 500 mg
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Ferriprox solution
100
mg/mL
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Fetzima
capsule,exten
ded release 24
hr 120 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fetzima
capsule,exten
ded release 24
hr 20 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fetzima
capsule,exten
ded release 24
hr 40 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fetzima
capsule,exten
ded release 24
hr 80 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Fetzima
capsule,Ext
Rel 24hr dose
pack
20 mg
(2)- 40
mg (26)
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Finacea gel 15 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Finacea foam 15 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
168 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
finasteride tablet 5 mg Generic-2 NO UROLOGICALS BENIGN
PROSTATIC
HYPERPLASIA(BPH
) THERAPY
Firazyr syringe
30 mg/3
mLSpecialty-5
9 30YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Firmagon kit
w diluent
syringe
recon soln 80 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Firmagon kit
w diluent
syringe
recon soln 120 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
flavoxate tablet 100 mg
Generic-2 NO
UROLOGICALS
ANTICHOLINERGIC
S /
ANTISPASMODICS
Flebogamma
DIF solution 10 %
Specialty-5 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
flecainide tablet 50 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
flecainide tablet 100 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
flecainide tablet 150 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
169 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Flector patch 12 hour 1.3 % NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
fluconazole tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSfluconazole tablet 150 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSfluconazole tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSfluconazole tablet 50 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSfluconazole suspension
for
reconstitution
10
mg/mL
Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
fluconazole suspension
for
reconstitution
40
mg/mL
Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
fluconazole in
dextrose(iso-
o) piggyback
400
mg/200
mL Generic-2
NO
ANTI - INFECTIVES
ANTIFUNGAL
AGENTSfluconazole in
NaCl (iso-
osm) piggyback
200
mg/100
mL Generic-2
NO
ANTI - INFECTIVES
ANTIFUNGAL
AGENTS
flucytosine capsule 250 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSflucytosine capsule 500 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSfludarabine recon soln 50 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
170 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fludrocortison
e
tablet 0.1 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
flunisolide
spray,non-
aerosol
25 mcg
(0.025
%) Generic-2
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
fluocinolone ointment 0.025 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluocinolone cream 0.01 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluocinolone oil 0.01 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluocinolone solution 0.01 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluocinolone cream 0.025 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluocinolone
acetonide oil drops 0.01 %
Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
OTIC
PREPARATIONS
fluocinonide ointment 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluocinonide gel 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluocinonide solution 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
171 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fluocinonide cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Fluocinonide-
E
cream 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluoromethol
one
drops,suspens
ion
0.1 % Generic-2 NO OPHTHALMOLOGY STEROIDS
fluorouracil cream 5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSfluorouracil solution 2.5
gram/50
mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
fluorouracil cream 0.5 % Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSfluorouracil solution 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSfluorouracil solution 5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSfluoxetine tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluoxetine capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
172 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fluoxetine capsule 20 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluoxetine solution 20 mg/5
mL (4
mg/mL)
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluoxetine capsule 40 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluoxetine tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluoxetine capsule,delay
ed
release(DR/E
C)
90 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluoxetine tablet 60 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluphenazine
decanoate
solution 25
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluphenazine
HCl
elixir 2.5
mg/5
mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
173 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fluphenazine
HCl
tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluphenazine
HCl
tablet 5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluphenazine
HCl
concentrate 5
mg/mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluphenazine
HCl
tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluphenazine
HCl
tablet 2.5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluphenazine
HCl
solution 2.5
mg/mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
flurandrenoli
de
cream 0.05 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
flurazepam capsule 15 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
174 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
flurazepam capsule 30 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
flurbiprofen tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
flurbiprofen tablet 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
flurbiprofen
sodium drops 0.03 %
Generic-2 NO
OPHTHALMOLOGY
NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTS
flutamide capsule 125 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
fluticasone ointment 0.005 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluticasone cream 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluticasone lotion 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
fluticasone spray,suspens
ion
50
mcg/act
uation
Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
175 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fluvastatin capsule 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfluvastatin capsule 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfluvastatin tablet
extended
release 24 hr
80 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSfluvoxamine capsule,exten
ded release
24hr
100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluvoxamine capsule,exten
ded release
24hr
150 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluvoxamine tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluvoxamine tablet 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
fluvoxamine tablet 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Focalin XR capsule,ER
biphasic 50-
50
20 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
176 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Focalin XR
capsule,ER
biphasic 50-
50 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Focalin XR
capsule,ER
biphasic 50-
50 35 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Folotyn solution 40 mg/2
mL (20
mg/mL)
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
fomepizole solution 1
gram/m
L
PrefGen-1 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
fondaparinux syringe 10
mg/0.8
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
fondaparinux syringe 2.5
mg/0.5
mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
fondaparinux syringe 5
mg/0.4
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
fondaparinux syringe 7.5
mg/0.6
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Foradil
Aerolizer
capsule,
w/inhalation
device 12 mcg PrefBrand-3
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Fortaz recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
177 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Fortaz recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
Fortaz recon soln 2 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
Forteo pen injector
20
mcg/dos
e - 600
mcg/2.4
mL
Specialty-5
2.4 28
YES
MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
Fortesta
gel in metered-
dose pump
10
mg/0.5
gram
/actuatio
n
NonPrefBrand-4 YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
FORTICAL spray,non-
aerosol
200
unit/act
uation
Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
fosinopril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
fosinopril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
fosinopril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
fosinopril-
hydrochloroth
iazide
tablet 10-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
fosinopril-
hydrochloroth
iazide
tablet 20-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
178 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
fosphenytoin solution 100 mg
PE/2
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Fosrenol tablet,chewab
le
500 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Fosrenol tablet,chewab
le
1,000
mg
NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Fosrenol tablet,chewab
le
750 mg NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Fosrenol
powder in
packet
1,000
mg
NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Fosrenol
powder in
packet 750 mg
NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Fragmin syringe
2,500
anti-Xa
unit/0.2
mL
PrefBrand-3 NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Fragmin syringe
5,000
anti-Xa
unit/0.2
mL
PrefBrand-3 NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Fragmin syringe
7,500
anti-Xa
unit/0.3
mL
Specialty-5 NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
179 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Fragmin syringe
12,500
anti-Xa
unit/0.5
mL
PrefBrand-3 NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Fragmin syringe
15,000
anti-Xa
unit/0.6
mL
PrefBrand-3 NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Fragmin syringe
18,000
anti-Xa
unit/0.7
2 mL
Specialty-5 NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Fragmin syringe
10,000
anti-Xa
unit/mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Fragmin solution
25,000
anti-Xa
unit/mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Freamine
HBC 6.9 %
parenteral
solution
6.9 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSFrova tablet 2.5 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYfrovatriptan tablet 2.5 mg PrefBrand-3 12 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYfurosemide solution 10
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
180 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
furosemide solution 40 mg/5
mL (8
mg/mL)
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
furosemide tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
furosemide solution 10
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
furosemide tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
furosemide tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
furosemide syringe 10
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Fusilev recon soln 50 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Fuzeon recon soln 90 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Fyavolv tablet
0.5-2.5
mg-mcg Generic-2NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Fyavolv tablet
1-5 mg-
mcg Generic-2NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Fycompa tablet 2 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
181 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Fycompa tablet 4 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Fycompa tablet 6 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Fycompa tablet 8 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Fycompa tablet 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Fycompa tablet 12 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Fycompa suspension
0.5
mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
gabapentin solution 250
mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
gabapentin capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
182 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
gabapentin capsule 300 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
gabapentin capsule 400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
gabapentin tablet 600 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
gabapentin tablet 800 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Gabitril tablet 12 mg PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Gabitril tablet 16 mg PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Gabitril tablet 2 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Gabitril tablet 4 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
183 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Gablofen solution
40,000
mcg/20
mL
(2,000
mcg/mL
)
NonPrefBrand-4 YES
AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
Gablofen syringe
50
mcg/mL
(1 mL)
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
Gablofen solution
10,000
mcg/20
mL
(500
mcg/mL
)
NonPrefBrand-4 YES
AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
galantamine tablet 4 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
galantamine tablet 8 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
galantamine tablet 12 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
galantamine capsule,ext
rel. pellets 24
hr
16 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
184 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
galantamine capsule,ext
rel. pellets 24
hr
24 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
galantamine capsule,ext
rel. pellets 24
hr
8 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
galantamine solution 4
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
GamaSTAN
S/D
solution 15-18 %
range
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Gammagard
Liquid
solution 10 % Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Gammaked solution
1
gram/10
mL (10
%)
Specialty-5 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Gammaplex solution 5 %
Specialty-5 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Gamunex-C solution 1
gram/10
mL (10
%)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
185 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ganciclovir
sodium
recon soln 500 mg Generic-2 YES ANTI - INFECTIVES ANTIVIRALS
Gardasil (PF) suspension 20-40-
40-20
mcg/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Gardasil (PF) syringe 20-40-
40-20
mcg/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Gardasil 9
(PF) suspension 0.5 mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Gardasil 9
(PF) syringe 0.5 mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
gatifloxacin drops 0.5 %Generic-2 NO
OPHTHALMOLOGY ANTIBIOTICS
Gattex One-
Vial kit 5 mg
Specialty-5 YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Gauze Pad bandage 2 X 2 " PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Gavilyte-C recon soln
240-
22.72-
6.72 -
5.84
gram
Generic-2 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
186 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
GaviLyte-G recon soln
236-
22.74-
6.74 -
5.86
gram
Generic-2 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
GaviLyte-H
and Bisacodyl kit
5-210
mg-
gram Generic-2
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
GaviLyte-N recon soln
420
gram
Generic-2 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Gelnique gel in packet 10 %
(100
mg/gra
m)
PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
gemcitabine recon soln 1 gram
Generic-2 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
gemfibrozil tablet 600 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSGenerlac solution 10
gram/15
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSGengraf capsule 100 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Gengraf solution 100
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
187 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Gengraf capsule 25 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Genotropin cartridge 5
mg/mL
(15
unit/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin cartridge
12
mg/mL
(36
unit/mL
Specialty-5 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 0.2
mg/0.25
mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 0.4
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 0.6
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 0.8
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 1.2
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 1.4
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 1.6
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
188 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Genotropin
MiniQuick
syringe 1.8
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 1
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Genotropin
MiniQuick
syringe 2
mg/0.25
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Gentak ointment 0.3 % (3
mg/gra
m)
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
gentamicin cream 0.1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
gentamicin ointment 0.1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
gentamicin ointment 0.3 % (3
mg/gra
m)
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
gentamicin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY ANTIBIOTICS
gentamicin solution 40
mg/mL
PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESgentamicin in
NaCl (iso-
osm)
piggyback 100
mg/100
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
gentamicin in
NaCl (iso-
osm)
piggyback 80
mg/100
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
189 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
gentamicin in
NaCl (iso-
osm)
piggyback 90
mg/100
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
gentamicin in
NaCl (iso-
osm)
piggyback 60
mg/50
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
gentamicin in
NaCl (iso-
osm)
piggyback 70
mg/50
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
gentamicin in
NaCl (iso-
osm)
piggyback 80
mg/50
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Genvoya tablet
150-150-
200-10
mg
Specialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Geodon recon soln 20
mg/mL
(final
conc.)
PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Gildagia tablet
0.4-35
mg-mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Gildess 24 Fe tablet
1 mg-20
mcg
(24)/75
mg (4) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Gilenya capsule 0.5 mg
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
190 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Gilotrif tablet 20 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Gilotrif tablet 30 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Gilotrif tablet 40 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Glassia solution
1
gram/50
mL (2
%)
Specialty-5 YESDIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Glatopa syringe
20
mg/mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Gleevec tablet 100 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Gleevec tablet 400 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Gleostine capsule 10 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
191 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Gleostine capsule 100 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Gleostine capsule 40 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Gleostine capsule 5 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
glimepiride tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYglimepiride tablet 2 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYglimepiride tablet 4 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYglipizide tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYglipizide tablet
extended
release 24hr
2.5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
glipizide tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYglipizide tablet
extended
release 24hr
5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
glipizide tablet
extended
release 24hr
10 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
glipizide-
metformin
tablet 2.5-250
mg
PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
192 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
glipizide-
metformin
tablet 2.5-500
mg
PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYglipizide-
metformin
tablet 5-500
mg
PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYGlucaGen
HypoKit
recon soln 1 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYGlucagon
Emergency
Kit (human)
kit 1 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Glumetza tablet,ER
gast.retention
24 hr
500 mg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
glyburide tablet 1.25 mg Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide tablet 5 mg Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide
micronized
tablet 3 mg Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide
micronized
tablet 6 mg Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide
micronized
tablet 1.5 mg Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide-
metformin
tablet 1.25-
250 mg
Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide-
metformin
tablet 2.5-500
mg
Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPYglyburide-
metformin
tablet 5-500
mg
Generic-2 YES ENDOCRINE/DIABE
TES
DIABETES
THERAPY
193 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
glycopyrrolat
e
tablet 1 mg Generic-2 NO GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
glycopyrrolat
e
tablet 2 mg Generic-2 NO GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
glycopyrrolat
e
solution 0.2
mg/mL
Generic-2 NO GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
Glyset tablet 25 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYGlyset tablet 50 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYGlyset tablet 100 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Golytely
powder in
packet
227.1-
21.5-
6.36
gram
NonPrefBrand-4 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Gralise
tablet
extended
release 24 hr 300 mg PrefBrand-3
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Gralise
tablet
extended
release 24 hr 600 mg PrefBrand-3
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
194 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Gralise 30-
Day Starter
Pack
tablet
extended
release 24 hr
300 mg
(9)- 600
mg (69) PrefBrand-3
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
granisetron
(PF)
solution 100
mcg/mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSgranisetron
HCl
solution 1
mg/mL
(1 mL)
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSgranisetron
HCl
tablet 1 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Granix syringe
300
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Granix syringe
480
mcg/0.8
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Grastek tablet
2,800
BAU
NonPrefBrand-4 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
griseofulvin
microsize
suspension 125
mg/5
mL
Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
griseofulvin
microsize
tablet 500 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSgriseofulvin
ultramicrosize
tablet 250 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSgriseofulvin
ultramicrosize
tablet 125 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
195 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
guanfacine tablet
extended
release 24 hr
1 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
guanfacine tablet
extended
release 24 hr
2 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
guanfacine tablet
extended
release 24 hr
3 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
guanfacine tablet
extended
release 24 hr
4 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
guanidine tablet 125 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Gynazole-1 cream 2 % NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYN
Halaven solution
1 mg/2
mL (0.5
mg/mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Halcion tablet 0.25 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
halobetasol
propionate ointment 0.05 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
196 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
halobetasol
propionate cream 0.05 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Halog cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Halog ointment 0.1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
haloperidol tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol tablet 5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol tablet 2 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
197 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
haloperidol
decanoate
solution 50
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol
decanoate
solution 100
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol
lactate
concentrate 2
mg/mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
haloperidol
lactate
solution 5
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Harvoni tablet
90-400
mgSpecialty-5
28 28YES
ANTI - INFECTIVES ANTIVIRALS
Havrix (PF) suspension 1,440
Elisa
unit/mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Havrix (PF) syringe 720
Elisa
unit/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Hectorol capsule 2.5 mcg Specialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESHectorol solution 4 mcg/2
mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESHectorol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
198 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Hectorol capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
heparin
(porcine) solution
1,000
unit/mL Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
heparin
(porcine) solution
20,000
unit/mL Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
heparin
(porcine) solution
5,000
unit/mL Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
heparin
(porcine) solution
10,000
unit/mL Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
heparin
(porcine) in 5
% dex
parenteral
solution
25,000
unit/250
mL(100
unit/mL Generic-2
NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
heparin
(porcine) in 5
% dex
parenteral
solution
20,000
unit/500
mL (40
unit/mL Generic-2
NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
heparin
(porcine) in 5
% dex
parenteral
solution
25,000
unit/500
mL (50
unit/mL Generic-2
NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Hepatamine
8%
parenteral
solution
8 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSHepsera tablet 10 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
199 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Herceptin recon soln 440 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Hetlioz capsule 20 mg
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Hexalen capsule 50 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Hiberix (PF) recon soln
10
mcg/0.5
mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Horizant
tablet
extended
release 600 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Horizant
tablet
extended
release 300 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Humalog solution 100
unit/mL
(prefille
d
syringe)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humalog solution 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humalog cartridge
100
unit/mL PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
200 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Humalog
KwikPen insulin pen
200
unit/mL
(3 mL) PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPYHumalog
KwikPen insulin pen
100
unit/mL PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humalog Mix
50-50
suspension 100
unit/mL
(50-50)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humalog Mix
50-50
KwikPen
insulin pen 100
unit/mL
(50-50)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humalog Mix
75-25
suspension 100
unit/mL
(75-25)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humalog Mix
75-25
KwikPen
insulin pen 100
unit/mL
(75-25)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humatrope recon soln 5 (15
unit) mg
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Humatrope cartridge 12 mg
(36
unit)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Humatrope cartridge 24 mg
(72
unit)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Humatrope cartridge 6 mg
(18
unit)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Humira syringe kit 40
mg/0.8
mL
Specialty-5 1.6 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
201 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Humira syringe kit 20
mg/0.4
mL
Specialty-5 0.8 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Humira syringe kit
10
mg/0.2
mL
Specialty-5
0.4 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Humira
Pediatric
Crohn's Start syringe kit
40
mg/0.8
mL (6
pack)
Specialty-5
4.8 28
YESMUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSHumira
Pediatric
Crohn's Start syringe kit
40
mg/0.8
mL
Specialty-5
2.4 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Humira Pen
pen injector
kit
40
mg/0.8
mL
Specialty-5
1.6 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Humira Pen
Crohn's-UC-
HS Start
pen injector
kit
40
mg/0.8
mL
Specialty-5 4.8 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSHumulin
70/30
suspension 100
unit/mL
(70-30)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humulin
70/30
KwikPen
insulin pen 100
unit/mL
(70-30)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humulin N suspension 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYHumulin N
KwikPen
insulin pen 100
unit/mL
(3 mL)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humulin R solution 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
202 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
ClassHumulin R U-
500 (Conc)
Kwikpen insulin pen
500
unit/mL
(3 mL) PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Humulin R U-
500
(Concentrated
)
solution 500
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Hycet solution 7.5-325
mg/15
mL
NonPrefBrand-4 5723 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydralazine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydralazine tablet 100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydralazine tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydralazine tablet 50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydralazine solution 20
mg/mL
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydrochloroth
iazide
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydrochloroth
iazide
capsule 12.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
203 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
hydrochloroth
iazide
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydrochloroth
iazide
tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
hydrocodone-
acetaminophe
n
solution 7.5-325
mg/15
mL
Generic-2 5723 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
acetaminophe
n
tablet 10-300
mg
Generic-2 403 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
acetaminophe
n
tablet 5-300
mg
Generic-2 403 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
acetaminophe
n
tablet 7.5-300
mg
Generic-2 403 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
acetaminophe
n
tablet 10-325
mg
Generic-2 372 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
acetaminophe
n
tablet 5-325
mg
Generic-2 372 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
204 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
hydrocodone-
acetaminophe
n
tablet 7.5-325
mg
Generic-2 372 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
acetaminophe
n
tablet 2.5-325
mg
Generic-2 372 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
ibuprofen
tablet 5-200
mg
Generic-2 155 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
ibuprofen
tablet 7.5-200
mg
Generic-2 150 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocodone-
ibuprofen
tablet 10-200
mg
Generic-2 155 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydrocortison
e
ointment 2.5 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e
cream 1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e
ointment 1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e
tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONEShydrocortison
e
tablet 20 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
205 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
hydrocortison
e
lotion 2.5 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e
tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONEShydrocortison
e
enema 100
mg/60
mL
PrefGen-1 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTShydrocortison
e
cream 2.5 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e butyrate ointment 0.1 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e butyrate solution 0.1 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDShydrocortison
e butyr-
emollient cream 0.1 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e valerate ointment 0.2 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e valerate cream 0.2 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
hydrocortison
e-acetic acid
drops 1-2 % Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
OTIC
PREPARATIONShydromorpho
ne
liquid 1
mg/mL
Generic-2 1550 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
206 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
hydromorpho
ne
tablet 2 mg Generic-2 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydromorpho
ne
tablet 4 mg Generic-2 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydromorpho
ne
tablet 8 mg Generic-2 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydromorpho
ne
syringe 2
mg/mL
Generic-2 155 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydromorpho
ne
tablet
extended
release 24 hr
12 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydromorpho
ne
tablet
extended
release 24 hr
16 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydromorpho
ne
tablet
extended
release 24 hr
8 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydromorpho
ne
tablet
extended
release 24 hr 32 mg Generic-2 48 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
207 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
hydromorpho
ne (PF)
solution 10
mg/mL
Generic-2 120 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
hydroxychlor
oquine tablet 200 mgGeneric-2 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVEShydroxyproge
sterone
caproate oil
250
mg/mL
Specialty-5 NOOBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
hydroxyurea capsule 500 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
hydroxyzine
HCl solution
25
mg/mL
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
hydroxyzine
HCl solution
50
mg/mL
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
HyperRAB
S/D (PF) solution
150
unit/mL
NonPrefBrand-4 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
HyperRAB
S/D (PF) solution
150
unit/mL
(10 ml)
NonPrefBrand-4 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Hysingla ER
tablet,oral
only,ext.rel.2
4 hr 20 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
208 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Hysingla ER
tablet,oral
only,ext.rel.2
4 hr 30 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Hysingla ER
tablet,oral
only,ext.rel.2
4 hr 40 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Hysingla ER
tablet,oral
only,ext.rel.2
4 hr 60 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Hysingla ER
tablet,oral
only,ext.rel.2
4 hr 80 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Hysingla ER
tablet,oral
only,ext.rel.2
4 hr 100 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Hysingla ER
tablet,oral
only,ext.rel.2
4 hr 120 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
ibandronate tablet 150 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
ibandronate solution 3 mg/3
mL
Generic-2 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
209 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ibrance capsule 100 mg
Specialty-5
21 28
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Ibrance capsule 125 mg
Specialty-5
21 28
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Ibrance capsule 75 mg
Specialty-5
21 28
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ibuprofen suspension 100
mg/5
mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ibuprofen tablet 400 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ibuprofen tablet 600 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ibuprofen tablet 800 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ibuprofen-
oxycodone tablet
400-5
mg
Generic-2
30 30
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
210 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Iclusig tablet 15 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Iclusig tablet 45 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
idarubicin solution
1
mg/mL
Generic-2 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ifosfamide recon soln 1 gram Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Ilaris (PF) recon soln 180
mg/1.2
mL
(150
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Ilevro
drops,suspens
ion 0.3 % PrefBrand-3
NO
OPHTHALMOLOGY
NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTS
imatinib tablet 100 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
imatinib tablet 400 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
211 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Imbruvica capsule 140 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
imipenem-
cilastatin
recon soln 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESimipenem-
cilastatin
recon soln 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESimipramine
HCl
tablet 25 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
imipramine
HCl
tablet 50 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
imipramine
HCl
tablet 10 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
imipramine
pamoate
capsule 75 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
imipramine
pamoate
capsule 150 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
imipramine
pamoate
capsule 125 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
212 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
imipramine
pamoate
capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
imiquimod cream in
packet
5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSImitrex tablet 25 mg NonPrefBrand-4 36 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYImitrex solution 6
mg/0.5
mL
NonPrefBrand-4 4 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYImitrex tablet 50 mg NonPrefBrand-4 18 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYImitrex tablet 100 mg NonPrefBrand-4 9 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYImitrex spray,non-
aerosol
20
mg/actu
ation
NonPrefBrand-4 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYImitrex spray,non-
aerosol
5
mg/actu
ation
NonPrefBrand-4 32 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
213 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Imitrex
STATdose
Kit Refill
cartridge 4
mg/0.5
mL
NonPrefBrand-4 6 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYImitrex
STATdose
Kit Refill
cartridge 6
mg/0.5
mL
NonPrefBrand-4 4 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYImovax
Rabies
Vaccine (PF)
recon soln 2.5 unit NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Imuran tablet 50 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Increlex solution 10
mg/mL
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
indapamide tablet 1.25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
indapamide tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Indocin suspension 25 mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
indomethacin capsule 25 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
214 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
indomethacin capsule 50 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
indomethacin capsule,
extended
release
75 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Infanrix
(DTaP) (PF) suspension
25-58-
10 Lf-
mcg-
Lf/0.5m
L PrefBrand-3
NO
IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Inlyta tablet 1 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Inlyta tablet 5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
InnoPran XL capsule,exten
ded release
24hr
120 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
InnoPran XL capsule,exten
ded release
24hr
80 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
insulin
syringe-
needle U-100
syringe 1/2 mL
28
gauge
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
215 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
insulin
syringe-
needle U-100
syringe 1 mL 29
gauge x
1/2"
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
insulin
syringe-
syringe 0.3 mL
29
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYIntelence tablet 100 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Intelence tablet 200 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Intelence tablet 25 mgNonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
Intralipid emulsion 20 % Generic-2 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSIntralipid emulsion 30 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSIntron A solution 6
million
unit/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Intron A recon soln 50
million
unit (1
mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Intron A recon soln 10
million
unit (1
mL)
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Intron A recon soln
18
million
unit (1
mL)
Specialty-5 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
216 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Introvale
tablets,dose
pack,3 month
0.15-30
mg-mcg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Intuniv ER tablet
extended
release 24 hr
1 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Intuniv ER tablet
extended
release 24 hr
2 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Intuniv ER tablet
extended
release 24 hr
3 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Intuniv ER tablet
extended
release 24 hr
4 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invanz recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESInvega tablet
extended
release 24hr
3 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega tablet
extended
release 24hr
6 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
217 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Invega tablet
extended
release 24hr
9 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega tablet
extended
release 24hr
1.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega
Sustenna
syringe 78
mg/0.5
mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega
Sustenna
syringe 234
mg/1.5
mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega
Sustenna
syringe 156
mg/mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega
Sustenna
syringe 117
mg/0.75
mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega
Sustenna
syringe 39
mg/0.25
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega Trinza syringe
273
mg/0.87
5 mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
218 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Invega Trinza syringe
410
mg/1.31
5 mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega Trinza syringe
546
mg/1.75
mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invega Trinza syringe
819
mg/2.62
5 mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Invirase capsule 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Invirase tablet 500 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Invokamet tablet
150-
1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Invokamet tablet
150-500
mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Invokamet tablet
50-
1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Invokamet tablet
50-500
mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Invokana tablet 100 mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Invokana tablet 300 mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Ionosol-B in
D5W
parenteral
solution
5 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
219 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ionosol-MB
in D5W
parenteral
solution
5 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSIopidine dropperette 1 % PrefBrand-3 NO OPHTHALMOLOGY SYMPATHOMIMETI
CSIPOL suspension 40-8-32
unit/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
ipratropium
bromide
spray,non-
aerosol
0.06 % PrefGen-1 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
ipratropium
bromide
spray,non-
aerosol
0.03 % PrefGen-1 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
ipratropium
bromide
solution 0.02 % PrefGen-1 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
ipratropium-
albuterol
solution for
nebulization
0.5 mg-
3
mg(2.5
mg
base)/3
mL Generic-2
YES
RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
irbesartan tablet 75 mg PrefGen-1 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
irbesartan tablet 150 mg PrefGen-1 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
irbesartan tablet 300 mg PrefGen-1 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
220 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
irbesartan-
hydrochloroth
iazide
tablet 150-
12.5 mg
Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
irbesartan-
hydrochloroth
iazide
tablet 300-
12.5 mg
Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Iressa tablet 250 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
irinotecan solution 100
mg/5
mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Isentress tablet 400 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Isentress
tablet,chewab
le 100 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Isentress
tablet,chewab
le 25 mg PrefBrand-3NO
ANTI - INFECTIVES ANTIVIRALS
Isentress
powder in
packet 100 mgNonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
Isolyte-P in 5
% dextrose
parenteral
solution
5 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSIsolyte-S parenteral
solution
PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSisoniazid solution 50 mg/5
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESisoniazid solution 100
mg/mL
PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
221 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
isoniazid tablet 300 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESisoniazid tablet 100 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESIsordil tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
dinitrate
tablet 30 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
dinitrate
tablet 20 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
dinitrate
tablet
extended
release
40 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
dinitrate
tablet 5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
dinitrate
tablet 10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
mononitrate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
mononitrate
tablet
extended
release 24 hr
120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
mononitrate
tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
222 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
isosorbide
mononitrate
tablet
extended
release 24 hr
30 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isosorbide
mononitrate
tablet
extended
release 24 hr
60 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
isradipine capsule 2.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
isradipine capsule 5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Istalol drops, once
daily
0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS
Istodax recon soln 10 mg/2
mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
itraconazole capsule 100 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSivermectin tablet 3 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESIxempra recon soln 45 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Ixiaro (PF) syringe
6
mcg/0.5
mL
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
223 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Jakafi tablet 10 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Jakafi tablet 5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Jakafi tablet 15 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Jakafi tablet 20 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Jakafi tablet 25 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Jantoven tablet 1 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Jantoven tablet 10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Jantoven tablet 2 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Jantoven tablet 2.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
224 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Jantoven tablet 3 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Jantoven tablet 4 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Jantoven tablet 5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Jantoven tablet 6 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Jantoven tablet 7.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Janumet tablet 50-
1,000
mg
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Janumet tablet 50-500
mg
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Janumet XR
tablet, ER
multiphase 24
hr
100-
1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Janumet XR
tablet, ER
multiphase 24
hr
50-
1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Janumet XR
tablet, ER
multiphase 24
hr
50-500
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Januvia tablet 100 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYJanuvia tablet 25 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
225 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Januvia tablet 50 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Jentadueto tablet
2.5-
1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Jentadueto tablet
2.5-500
mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Jentadueto tablet
2.5-850
mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Jentadueto
XR
tablet, IR -
ER, biphasic
24hr
2.5-
1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Jentadueto
XR
tablet, IR -
ER, biphasic
24hr
5-1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Jevtana solution
10
mg/mL
(first
dilution)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Jinteli tablet
1-5 mg-
mcgGeneric-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Jolivette tablet 0.35 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Juleber tablet
0.15-
0.03 mg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Junel 1.5/30
(21) tablet
1.5-30
mg-mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
226 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Junel 1/20
(21) tablet
1-20 mg-
mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Junel FE
1.5/30 (28) tablet
1.5 mg-
30 mcg
(21)/75
mg (7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Junel FE 1/20
(28) tablet
1 mg-20
mcg
(21)/75
mg (7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Junel Fe 24 tablet
1 mg-20
mcg
(24)/75
mg (4) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Juxtapid capsule 10 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Juxtapid capsule 20 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Juxtapid capsule 5 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Juxtapid capsule 30 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Juxtapid capsule 40 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
227 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Juxtapid capsule 60 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Kadcyla recon soln 100 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Kadian capsule,exten
d.release
pellets
10 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kadian capsule,exten
d.release
pellets
100 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kadian capsule,exten
d.release
pellets
20 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kadian capsule,exten
d.release
pellets
200 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kadian capsule,exten
d.release
pellets
30 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kadian capsule,exten
d.release
pellets
50 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
228 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Kadian capsule,exten
d.release
pellets
60 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kadian capsule,exten
d.release
pellets
80 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kadian
capsule,exten
d.release
pellets 40 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Kaitlib Fe
tablet,chewab
le
0.8mg-
25mcg(
24) and
75 mg
(4) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Kaletra tablet 200-50
mg
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Kaletra tablet 100-25
mg
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Kaletra solution 400-100
mg/5
mL
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Kalydeco tablet 150 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Kalydeco
granules in
packet 50 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Kalydeco
granules in
packet 75 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Kanuma solution
2
mg/mLSpecialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
229 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Kapvay
tablet
extended
release 12 hr 0.1 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Karbinal ER
suspension,ex
tended rel 12
hr
4 mg/5
mL
NonPrefBrand-4 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Kariva (28) tablet 0.15-
0.02
mgx21
/0.01
mg x 5
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Kelnor 1/35
(28)
tablet 1-35 mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Kenalog aerosol
0.147
mg/gra
m PrefBrand-3
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Kepivance recon soln 6.25 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Keppra tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Keppra tablet 500 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
230 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Keppra tablet 750 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Keppra solution 100
mg/mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Keppra tablet 1,000
mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Keppra XR tablet
extended
release 24 hr
500 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Keppra XR tablet
extended
release 24 hr
750 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Ketek tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESKetek tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESketoconazole shampoo 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
ketoconazole cream 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
ketoconazole tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
231 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ketoconazole foam 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
ketoprofen capsule 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ketoprofen capsule 75 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ketoprofen capsule,ext
rel. pellets 24
hr
200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ketorolac tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ketorolac solution 15
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ketorolac solution 30
mg/mL
(1 mL)
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
ketorolac drops 0.4 % Generic-2 NO OPHTHALMOLOGY NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTS
232 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ketorolac drops 0.5 % Generic-2 NO OPHTHALMOLOGY NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTS
ketorolac cartridge
30
mg/mL Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Keveyis tablet 50 mg
NonPrefBrand-4
124 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Keytruda recon soln 50 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Keytruda solution
100
mg/4
mL (25
mg/mL)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Khedezla
tablet
extended
release 24hr 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Khedezla
tablet
extended
release 24hr 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Kimidess (28) tablet
0.15-
0.02
mgx21
/0.01
mg x 5 Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
233 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Kineret syringe 100
mg/0.67
mL
Specialty-5 18.76 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSKionex powder Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Klor-Con 10 tablet
extended
release
10 mEq Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
Klor-Con 8 tablet
extended
release
8 mEq Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
Klor-Con
M15
tablet,ER
particles/cryst
als
15 mEq Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
Klor-Con
M20
tablet,ER
particles/cryst
als
20 mEq Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
Klor-Con
Sprinkle
capsule,
extended
release 8 mEq Generic-2
NO VITAMINS,
HEMATINICS /
ELECTROLYTES ELECTROLYTES
Klor-Con
Sprinkle
capsule,
extended
release 10 mEq Generic-2
NO VITAMINS,
HEMATINICS /
ELECTROLYTES ELECTROLYTES
Kombiglyze
XR
tablet, ER
multiphase 24
hr
2.5-
1,000
mg
NonPrefBrand-4 NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Kombiglyze
XR
tablet, ER
multiphase 24
hr
5-1,000
mg
NonPrefBrand-4 NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Kombiglyze
XR
tablet, ER
multiphase 24
hr
5-500
mg
NonPrefBrand-4 NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
234 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Korlym tablet 300 mgSpecialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
K-Tab tablet
extended
release
10 mEq NonPrefBrand-4 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
K-Tab
tablet
extended
release 20 mEq
NonPrefBrand-4 NO VITAMINS,
HEMATINICS /
ELECTROLYTES ELECTROLYTES
K-Tab
tablet
extended
release 8 mEq
PrefGen-1 NO VITAMINS,
HEMATINICS /
ELECTROLYTES ELECTROLYTES
Kuvan tablet,soluble 100 mgSpecialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Kynamro syringe
200
mg/mL
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
L
norgest/e.estr
adiol-e.estrad
tablets,dose
pack,3 month
0.15 mg-
30 mcg
(84)/10
mcg (7)
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSlabetalol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
labetalol tablet 200 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
labetalol tablet 300 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
labetalol solution 5
mg/mL
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
235 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lacrisert insert 5 mg NonPrefBrand-4 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CSlactated
ringers
solution Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
IRRIGATING
SOLUTIONS
lactated
ringers
parenteral
solution
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
lactulose solution 10
gram/15
mL
PrefGen-1 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSLamictal tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal tablet,
chewable
dispersible
5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal tablet,
chewable
dispersible
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
236 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lamictal tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal
ODT
tablet,disinteg
rating
100 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal
ODT
tablet,disinteg
rating
200 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal
ODT
tablet,disinteg
rating
25 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal
ODT
tablet,disinteg
rating
50 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal
Starter (Blue)
Kit
tablets,dose
pack
25 mg
(35)
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal
Starter
(Green) Kit
tablets,dose
pack
25 mg
(84) -
100 mg
(14)
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal
Starter
(Orange) Kit
tablets,dose
pack
25 mg
(42) -
100 mg
(7)
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
237 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lamictal XR tablet
extended
release 24hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal XR tablet
extended
release 24hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal XR tablet
extended
release 24hr
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal XR tablet
extended
release 24hr
50 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal XR
tablet
extended
release 24hr 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal XR
Starter (Blue)
tablet
extended
rel,dose pack
25 mg
(21) -50
mg (7)
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamictal XR
Starter
(Green)
tablet
extended
rel,dose pack
50
mg(14)-
100mg
(14)-
200 mg
(7)
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
238 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lamictal XR
Starter
(Orange)
tablet
extended
rel,dose pack
25mg
(14)-50
mg (14)-
100mg
(7)
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lamisil tablet 250 mg NonPrefBrand-4 90 180 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSLamisil granules in
packet
125 mg NonPrefBrand-4 180 180 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSLamisil granules in
packet
187.5
mg
NonPrefBrand-4 120 180 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSlamivudine tablet 150 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
lamivudine solution 10
mg/mL
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
lamivudine tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
lamivudine tablet 300 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
lamivudine-
zidovudine
tablet 150-300
mg
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
lamotrigine tablet,disinteg
rating
100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet 150 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
239 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
lamotrigine tablet 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet,disinteg
rating
25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet,disinteg
rating
50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet,disinteg
rating
200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet,
chewable
dispersible
25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet,
chewable
dispersible
5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet
extended
release 24hr
100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
240 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
lamotrigine tablet
extended
release 24hr
50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet
extended
release 24hr
200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine tablet
extended
release 24hr
25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine
tablet
extended
release 24hr 300 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
lamotrigine
tablet
extended
release 24hr 250 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lanoxin tablet 62.5
mcg
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
Lanoxin solution 250
mcg/mL
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
Lanoxin tablet 125
mcg
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
Lanoxin tablet 250
mcg
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
241 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lanoxin tablet
187.5
mcg
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
CARDIAC
GLYCOSIDES
lansoprazole capsule,delay
ed
release(DR/E
C)
30 mg PrefBrand-3 62 31 NO GASTROENTEROL
OGY
ULCER THERAPY
lansoprazole capsule,delay
ed
release(DR/E
C)
15 mg PrefBrand-3 31 31 NO GASTROENTEROL
OGY
ULCER THERAPY
Lantus solution 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYLantus
Solostar
insulin pen 100
unit/mL
(3 mL)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Lastacaft drops 0.25 %
NonPrefBrand-4 NO
OPHTHALMOLOGY
MISCELLANEOUS
OPHTHALMOLOGI
CS
latanoprost drops 0.005 % PrefGen-1 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGS
Latuda tablet 40 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Latuda tablet 80 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
242 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Latuda tablet 20 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Latuda tablet 120 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Latuda tablet 60 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Layolis Fe
tablet,chewab
le
0.8mg-
25mcg(
24) and
75 mg
(4) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Lazanda
spray,non-
aerosol
100
mcg/spr
ay
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Lazanda
spray,non-
aerosol
400
mcg/spr
ay
Specialty-5
12 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Lazanda
spray,non-
aerosol
300
mcg/spr
ay
Specialty-5
16 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
leflunomide tablet 10 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
243 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
leflunomide tablet 20 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Lenvima capsule
14
mg/day(
10 mg x
1-4 mg
x 1)
Specialty-5 YES
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lenvima capsule
24
mg/day(
10 mg x
2-4 mg
x 1)
Specialty-5 YES
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lenvima capsule
10
mg/day
(10 mg
x 1/day)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lenvima capsule
20
mg/day
(10 mg
x 2)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lenvima capsule
8
mg/day
(4 mg x
2)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lenvima capsule
18
mg/day
(10 mg
x 1-4
mg x2)
Specialty-5 YES
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
244 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lenvima capsule
8
mg/day
(4 mg x
2) (60
pack)
Specialty-5 YES
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lescol XL tablet
extended
release 24 hr
80 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSLessina tablet 0.1-20
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSLetairis tablet 10 mg Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSLetairis tablet 5 mg Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSletrozole tablet 2.5 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
leucovorin
calcium
tablet 10 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
leucovorin
calcium
tablet 15 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
leucovorin
calcium
tablet 25 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
245 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
leucovorin
calcium
tablet 5 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
leucovorin
calcium
recon soln 350 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
leucovorin
calcium
recon soln 100 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Leukeran tablet 2 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Leukine recon soln 250
mcg
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
leuprolide kit 1
mg/0.2
mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
levalbuterol
HCl
solution for
nebulization
1.25
mg/0.5
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
levalbuterol
HCl
solution for
nebulization
0.63
mg/3
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
levalbuterol
HCl
solution for
nebulization
0.31
mg/3
mL
Generic-2 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
246 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Levemir solution 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYLevemir
FlexTouch
insulin pen 100
unit/mL
(3 mL)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
levetiracetam tablet 250 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam tablet 500 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam tablet 750 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam tablet 1,000
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam solution 100
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam solution 500
mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam tablet
extended
release 24 hr
500 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
247 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
levetiracetam tablet
extended
release 24 hr
750 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam
in NaCl (iso-
os) piggyback
1,000
mg/100
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam
in NaCl (iso-
os) piggyback
1,500
mg/100
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levetiracetam
in NaCl (iso-
os) piggyback
500
mg/100
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
levobunolol drops 0.5 %PrefGen-1 NO
OPHTHALMOLOGY BETA-BLOCKERS
levocarnitine tablet 330 mg Generic-2 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
levocarnitine solution 200
mg/mL
Generic-2 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
levocarnitine
(with sugar)
solution 100
mg/mL
Generic-2 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
levocetirizine solution 2.5
mg/5
mL
Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTSlevocetirizine tablet 5 mg Generic-2 NO RESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
248 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
levofloxacin tablet 250 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES
levofloxacin tablet 500 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES
levofloxacin tablet 750 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES
levofloxacin drops 0.5 % Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
levofloxacin solution 250
mg/10
mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
levofloxacin solution 25
mg/mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
levofloxacin
in D5W
piggyback 500
mg/100
mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
levofloxacin
in D5W piggyback
750
mg/150
mL Generic-2
NO
ANTI - INFECTIVES QUINOLONES
levoleucovori
n calcium solution
10
mg/mL
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Levonest (28) tablet
50-30
(6)/75-
40
(5)/125-
30(10)
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
levonorgestre
l-ethinyl
estrad
tablet 0.1-20
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
249 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
levonorgestre
l-ethinyl
estrad
tablet 90-20
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSlevonorgestre
l-ethinyl
estrad
tablets,dose
pack,3 month
0.15-30
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSlevonorg-eth
estrad
triphasic
tablet 50-30
(6)/75-
40
(5)/125-
30(10)
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Levora-28 tablet 0.15-
0.03 mg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSlevorphanol
tartrate
tablet 2 mg PrefGen-1 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
levothyroxine tablet 100
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 200
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 300
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 25 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 50 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 75 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONES
250 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
levothyroxine tablet 125
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 150
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 112
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 175
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 88 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESlevothyroxine tablet 137
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 25 mcg Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 50 mcg Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 75 mcg Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 88 mcg Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 112
mcg
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 125
mcg
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 137
mcg
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 150
mcg
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 175
mcg
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLevoxyl tablet 200
mcg
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONES
251 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Levoxyl tablet 100
mcg
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLexiva tablet 700 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Lexiva suspension 50
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Lialda tablet,delayed
release
(DR/EC)
1.2
gram
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
lidocaine
adhesive
patch,medicat
ed 5 %
Generic-2 YES DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine ointment 5 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine (PF) solution
5
mg/mL
(0.5 %)
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine HCl solution
20
mg/mL
(2 %)
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine HCl solution 2 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine HCl solution
4 % (40
mg/mL)
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine HCl gel 2 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine HCl gel 2 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
252 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
lidocaine HCl
jelly in
applicator 2 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
lidocaine-
prilocaine
cream 2.5-2.5
%
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
Lidoderm
adhesive
patch,medicat
ed 5 %
NonPrefBrand-4 YES DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANESTHETICS
Lincocin solution 300
mg/mL
NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESlincomycin solution 300
mg/mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESlindane shampoo 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
SCABICIDES /
PEDICULICIDESlinezolid suspension
for
reconstitution
100
mg/5
mL
Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
linezolid parenteral
solution
600
mg/300
mL
Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
linezolid tablet 600 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Linzess capsule
145
mcg PrefBrand-3
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Linzess capsule
290
mcg PrefBrand-3
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
253 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lioresal solution 500
mcg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYLioresal solution 50
mcg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYLioresal solution 2,000
mcg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYliothyronine tablet 5 mcg Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESliothyronine solution 10
mcg/mL
Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESliothyronine tablet 25 mcg Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESliothyronine tablet 50 mcg Generic-2 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESLipofen capsule 150 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSLipofen capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSlisinopril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lisinopril tablet 30 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
254 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
lisinopril tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lisinopril tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lisinopril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lisinopril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lisinopril-
hydrochloroth
iazide
tablet 10-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lisinopril-
hydrochloroth
iazide
tablet 20-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lisinopril-
hydrochloroth
iazide
tablet 20-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
lithium
carbonate
capsule 300 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
lithium
carbonate
tablet 300 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
lithium
carbonate
tablet
extended
release
300 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
255 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
lithium
carbonate
tablet
extended
release
450 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
lithium
carbonate
capsule 600 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
lithium
carbonate
capsule 150 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
lithium citrate solution 8 mEq/5
mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Lithostat tablet 250 mg NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Livalo tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSLivalo tablet 2 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSLivalo tablet 4 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Lo Loestrin
Fe tablet
1 mg-10
mcg
(24)/10
mcg (2)
NonPrefBrand-4 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
256 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lonsurf tablet
15-6.14
mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lonsurf tablet
20-8.19
mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
loperamide capsule 2 mg
Generic-2 NO
GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
lorazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
lorazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
lorazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Lorazepam
Intensol
concentrate 2
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Lorcet
(hydrocodone
) tablet
5-325
mg Generic-2 372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
257 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lorcet HD tablet
10-325
mg Generic-2 372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Lorcet Plus tablet
7.5-325
mg Generic-2 372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Lortab 10-
325 tablet
10-325
mg Generic-2 372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Lortab 5-325 tablet
5-325
mg Generic-2 372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Lortab 7.5-
325 tablet
7.5-325
mg Generic-2 372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Loryna (28) tablet
3-0.02
mg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
losartan tablet 100 mg
PrefGen-1
31 31
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
losartan tablet 25 mg
PrefGen-1
93 31
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
losartan tablet 50 mg
PrefGen-1
62 31
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
258 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Classlosartan-
hydrochloroth
iazide tablet
100-
12.5 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPYlosartan-
hydrochloroth
iazide tablet
50-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPYlosartan-
hydrochloroth
iazide tablet
100-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Lotronex tablet 1 mg Specialty-5 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSLotronex tablet 0.5 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSlovastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSlovastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSlovastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSLovenox syringe 60
mg/0.6
mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Lovenox syringe 150
mg/mL
Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
259 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
loxapine
succinate
capsule 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
loxapine
succinate
capsule 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
loxapine
succinate
capsule 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
loxapine
succinate
capsule 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Lumigan drops 0.01 % PrefBrand-3 2.5 31
NO
OPHTHALMOLOGY
OTHER
GLAUCOMA
DRUGS
Lumizyme recon soln 50 mgSpecialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESLupaneta
Pack (1
month)
kit. syringe
and tablet
3.75 mg
-5 mg
(30)
Specialty-5 NOOBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNLupaneta
Pack (3
month)
kit. syringe
and tablet
11.25
mg -5
mg (90)
Specialty-5 NOOBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYN
Lupron Depot syringe kit 3.75 mg PrefBrand-3
NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
260 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lupron Depot syringe kit 7.5 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lupron Depot
(3 Month) syringe kit 22.5 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lupron Depot
(3 Month) syringe kit
11.25
mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lupron Depot
(4 Month) syringe kit 30 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lupron Depot
(6 Month) syringe kit 45 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lupron Depot-
Ped kit
11.25
mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lupron Depot-
Ped kit 15 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lutera (28) tablet 0.1-20
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
261 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lynparza capsule 50 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lyrica capsule 100 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lyrica capsule 150 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lyrica capsule 200 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lyrica capsule 225 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lyrica capsule 25 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lyrica capsule 300 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lyrica capsule 50 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
262 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Lyrica capsule 75 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lyrica solution 20
mg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Lysodren tablet 500 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Lyza tablet 0.35 mg Generic-2NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
magnesium
sulfate
solution 4
mEq/m
L (50
%)
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
magnesium
sulfate
syringe 4
mEq/m
L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
Makena oil
250
mg/mL
(1 mL)
Specialty-5 NOOBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
malathion lotion 0.5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
SCABICIDES /
PEDICULICIDES
maprotiline tablet 25 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
263 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
maprotiline tablet 50 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
maprotiline tablet 75 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Marinol capsule 2.5 mg Specialty-5 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSMarinol capsule 5 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSMarinol capsule 10 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Marlissa tablet
0.15-
0.03 mg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Marplan tablet 10 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Matulane capsule 50 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Matzim LA
tablet
extended
release 24 hr 420 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
264 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Matzim LA
tablet
extended
release 24 hr 240 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Matzim LA
tablet
extended
release 24 hr 180 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Matzim LA
tablet
extended
release 24 hr 300 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Matzim LA
tablet
extended
release 24 hr 360 mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Maxalt tablet 5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYMaxalt tablet 10 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYMaxalt-MLT tablet,disinteg
rating
5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYMaxalt-MLT tablet,disinteg
rating
10 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
meclizine tablet 12.5 mg
Generic-2 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
265 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
meclizine tablet 25 mg
Generic-2 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
meclofenamat
e
capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
meclofenamat
e
capsule 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Medrol tablet 2 mg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESmedroxyprog
esterone tablet 10 mgGeneric-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSmedroxyprog
esterone suspension
150
mg/mLGeneric-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSmedroxyprog
esterone tablet 2.5 mgGeneric-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSmedroxyprog
esterone tablet 5 mgGeneric-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
mefenamic
acid
capsule 250 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
mefloquine tablet 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESMegace ES suspension 625
mg/5
mL
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
266 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
megestrol suspension 625
mg/5
mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
megestrol tablet 20 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
megestrol tablet 40 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
megestrol suspension 400
mg/10
mL (40
mg/mL)
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Mekinist tablet 0.5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Mekinist tablet 2 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
meloxicam tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
meloxicam tablet 7.5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
267 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
meloxicam suspension 7.5
mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
melphalan
HCl
recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
memantine tablet 10 mg
PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
memantine tablet 5 mg
PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
memantine
tablets,dose
pack 5-10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
memantine solution
2
mg/mL
PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Menactra
(PF)
solution 4
mcg/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Menest tablet 0.3 mg NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSMenest tablet 0.625
mg
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
268 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Menest tablet 1.25 mg NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSMenest tablet 2.5 mg NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Menhibrix
(PF) recon soln
5-2.5
mcg/0.5
mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Menomune -
A/C/Y/W-
135 (PF)
recon soln 50 mcg PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Mentax cream 1 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Menveo A-C-
Y-W-135-Dip
(PF)
kit 10-5
mcg/0.5
mL
NonPrefBrand-4 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Mepron suspension 750
mg/5
mL
Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
mercaptopuri
ne
tablet 50 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
meropenem recon soln 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESmesalamine
with
cleansing
enema kit 4
gram/60
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
269 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
mesna solution 100
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Mesnex tablet 400 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Mestinon syrup 60 mg/5
mL
PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYMestinon
Timespan
tablet
extended
release
180 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
Metadate ER
tablet
extended
release 20 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGSmetaproteren
ol tablet 10 mgGeneric-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSmetaproteren
ol syrup
10 mg/5
mLGeneric-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSmetaproteren
ol tablet 20 mgGeneric-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Metaxall tablet 800 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
270 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
metaxalone tablet 400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYmetaxalone tablet 800 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYmetformin tablet
extended
release 24 hr
500 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
metformin tablet
extended
release 24 hr
750 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
metformin tablet
extended
release 24hr
1,000
mg
PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
metformin tablet 1,000
mg
PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYmetformin tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYmetformin tablet 850 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYmethadone tablet 10 mg Generic-2 206 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
methadone solution 10
mg/mL
Generic-2 160 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
271 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
methadone tablet 5 mg Generic-2 248 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
methadone solution 5 mg/5
mL
Generic-2 2066 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
methadone solution 10 mg/5
mL
Generic-2 1033 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
methampheta
mine tablet 5 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methazolamid
e
tablet 25 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR
GLAUCOMAmethazolamid
e
tablet 50 mg Generic-2 NO OPHTHALMOLOGY ORAL DRUGS FOR
GLAUCOMAmethenamine
hippurate tablet 1 gramGeneric-2 NO
ANTI - INFECTIVES
URINARY TRACT
AGENTS
methimazole tablet 10 mg Generic-2 NO ENDOCRINE/DIABE
TES
ANTITHYROID
AGENTSmethimazole tablet 5 mg Generic-2 NO ENDOCRINE/DIABE
TES
ANTITHYROID
AGENTSMethitest tablet 10 mg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESmethotrexate
sodium
tablet 2.5 mg PrefGen-1 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
272 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
methotrexate
sodium (PF)
recon soln 1 gram Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
methotrexate
sodium (PF)
solution 25
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
methoxsalen
rapid
capsule 10 mg Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSmethscopola
mine
tablet 2.5 mg Generic-2 NO GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
methscopola
mine
tablet 5 mg Generic-2 NO GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
methyclothiaz
ide
tablet 5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
methyldopa-
hydrochloroth
iazide
tablet 250-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
methyldopa-
hydrochloroth
iazide
tablet 250-15
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
methylergono
vine tablet 0.2 mgGeneric-2 NO OBSTETRICS /
GYNECOLOGY OXYTOCICS
273 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Methylin
tablet,chewab
le 10 mg
NonPrefBrand-4
186 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Methylin
tablet,chewab
le 5 mg
NonPrefBrand-4
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Methylin
tablet,chewab
le 2.5 mg
NonPrefBrand-4
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate solution
10 mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
capsule, ER
biphasic 30-
70 10 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet
extended
release 10 mg
Generic-2
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate tablet 10 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet,chewab
le 10 mg
Generic-2
186 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
274 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
methylphenid
ate
tablet
extended
release 24hr 18 mg
Generic-2
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
capsule,ER
biphasic 50-
50 20 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet
extended
release 24hr 27 mg
Generic-2
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
capsule, ER
biphasic 30-
70 30 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet
extended
release 24hr 36 mg
Generic-2
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
capsule,ER
biphasic 50-
50 40 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
capsule, ER
biphasic 30-
70 50 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet
extended
release 24hr 54 mg
Generic-2
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
275 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
methylphenid
ate
capsule, ER
biphasic 30-
70 60 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet
extended
release 20 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet,chewab
le 5 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate solution
5 mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate
tablet,chewab
le 2.5 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate tablet 20 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylphenid
ate tablet 5 mg
Generic-2
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
methylprednis
olone
tablet 32 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESmethylprednis
olone
tablet 8 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
276 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
methylprednis
olone
tablet 4 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESmethylprednis
olone
tablet 16 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESmethylprednis
olone
tablets,dose
pack
4 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESmethylprednis
olone acetate suspension
40
mg/mL Generic-2NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESmethylprednis
olone acetate suspension
80
mg/mL Generic-2NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
methylprednis
olone sodium
succ
recon soln 40 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
methylprednis
olone sodium
succ
recon soln 125 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
methyltestost
erone
capsule 10 mg Specialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESmetipranolol drops 0.3 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS
metocloprami
de HCl
solution 5 mg/5
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSmetocloprami
de HCl
tablet 10 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSmetocloprami
de HCl
tablet 5 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSmetocloprami
de HCl
solution 5
mg/mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
277 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
metocloprami
de HCl
tablet,disinteg
rating
10 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSmetocloprami
de HCl
tablet,disinteg
rating
5 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSmetolazone tablet 10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metolazone tablet 2.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metolazone tablet 5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
succinate
tablet
extended
release 24 hr
100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
succinate
tablet
extended
release 24 hr
200 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
succinate
tablet
extended
release 24 hr
25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
succinate
tablet
extended
release 24 hr
50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol ta-
hydrochloroth
iaz
tablet 100-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol ta-
hydrochloroth
iaz
tablet 50-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
278 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
metoprolol ta-
hydrochloroth
iaz
tablet 100-50
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
tartrate
solution 5 mg/5
mL
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
tartrate
tablet 100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
tartrate
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
tartrate
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metoprolol
tartrate syringe
5 mg/5
mL
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
metronidazol
e
gel 0.75 % Generic-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNmetronidazol
e
capsule 375 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESmetronidazol
e
lotion 0.75 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
metronidazol
e
cream 0.75 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
metronidazol
e
gel 0.75 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
metronidazol
e
tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
279 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
metronidazol
e
tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESmetronidazol
e
gel 1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
metronidazol
e in NaCl (iso-
os)
piggyback 500
mg/100
mL
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
mexiletine capsule 150 mg Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
mexiletine capsule 200 mg Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
mexiletine capsule 250 mg Generic-2
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Miacalcin solution 200
unit/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Miconazole-3 suppository 200 mgGeneric-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYN
Microgestin
1.5/30 (21) tablet
1.5-30
mg-mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Microgestin
1/20 (21) tablet
1-20 mg-
mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Microgestin
Fe 1.5/30
(28) tablet
1.5 mg-
30 mcg
(21)/75
mg (7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
280 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Microgestin
FE 1/20 (28) tablet
1 mg-20
mcg
(21)/75
mg (7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
midodrine tablet 10 mg
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
midodrine tablet 2.5 mg
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
midodrine tablet 5 mg
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Migergot suppository
2-100
mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
miglitol tablet 25 mg Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYmiglitol tablet 50 mg Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYmiglitol tablet 100 mg Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYMigranal spray,non-
aerosol
0.5
mg/pum
p act. (4
mg/mL)
NonPrefBrand-4 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Millipred solution 10 mg/5
mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESMillipred tablet 5 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
281 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
minocycline capsule 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline capsule 50 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline tablet 50 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline tablet 100 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline capsule 75 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline tablet 75 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline tablet
extended
release 24 hr
135 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline tablet
extended
release 24 hr
45 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minocycline tablet
extended
release 24 hr
90 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
minoxidil tablet 10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
minoxidil tablet 2.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Mirapex ER tablet
extended
release 24 hr
4.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
282 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Mirapex ER tablet
extended
release 24 hr
0.375
mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Mirapex ER tablet
extended
release 24 hr
3 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Mirapex ER
tablet
extended
release 24 hr 2.25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Mirapex ER
tablet
extended
release 24 hr 3.75 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Mircera syringe
50
mcg/0.3
mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Mircera syringe
75
mcg/0.3
mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Mircera syringe
100
mcg/0.3
mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Mircera syringe
200
mcg/0.3
mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
mirtazapine tablet,disinteg
rating
15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
283 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
mirtazapine tablet,disinteg
rating
30 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
mirtazapine tablet,disinteg
rating
45 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
mirtazapine tablet 15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
mirtazapine tablet 45 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
mirtazapine tablet 30 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
mirtazapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
misoprostol tablet 100
mcg
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
misoprostol tablet 200
mcg
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
Mitigare capsule 0.6 mg
NonPrefBrand-4
62 31
NO MUSCULOSKELET
AL /
RHEUMATOLOGY GOUT THERAPY
284 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
mitomycin recon soln 20 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
mitoxantrone concentrate 2
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
M-M-R II
(PF)
recon soln 1,000-
12,500
TCID50
/0.5 mL
NonPrefBrand-4 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
modafinil tablet 200 mg Generic-2 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
modafinil tablet 100 mg Generic-2 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Moderiba tablet 200 mg Generic-2NO
ANTI - INFECTIVES ANTIVIRALS
Moderiba
Dose Pack
tablets,dose
pack
400 mg
(7)- 400
mg (7) Generic-2
NO
ANTI - INFECTIVES ANTIVIRALS
Moderiba
Dose Pack
tablets,dose
pack
600 mg
(7)- 600
mg (7) Generic-2
NO
ANTI - INFECTIVES ANTIVIRALS
285 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
moexipril tablet 15 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
moexipril tablet 7.5 mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPYmoexipril-
hydrochloroth
iazide tablet
15-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPYmoexipril-
hydrochloroth
iazide tablet
7.5-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPYmoexipril-
hydrochloroth
iazide tablet
15-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
molindone tablet 10 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
molindone tablet 25 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
molindone tablet 5 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
mometasone ointment 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
mometasone solution 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
286 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
mometasone cream 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
mometasone spray,non-
aerosol
50
mcg/act
uation
Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Mononessa
(28)
tablet 0.25-35
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSmontelukast tablet 10 mg PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSmontelukast tablet,chewab
le
5 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSmontelukast tablet,chewab
le
4 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSmontelukast granules in
packet
4 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSMonurol packet 3 gram NonPrefBrand-4 NO ANTI - INFECTIVES URINARY TRACT
AGENTSmorphine tablet
extended
release
100 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine tablet
extended
release
15 mg Generic-2 100 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine tablet
extended
release
30 mg Generic-2 100 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
287 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
morphine tablet
extended
release
60 mg Generic-2 100 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule, ER
multiphase 24
hr
120 mg Generic-2 51 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule, ER
multiphase 24
hr
30 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule,exten
d.release
pellets
30 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule, ER
multiphase 24
hr
60 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule,exten
d.release
pellets
60 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule, ER
multiphase 24
hr
90 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule,exten
d.release
pellets
10 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
288 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
morphine capsule,exten
d.release
pellets
100 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine tablet 15 mg Generic-2 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine solution 10 mg/5
mL
Generic-2 2800 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule,exten
d.release
pellets
20 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine tablet
extended
release
200 mg Generic-2 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine tablet 30 mg Generic-2 186 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine solution 20 mg/5
mL (4
mg/mL)
Generic-2 1400 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule,exten
d.release
pellets
50 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
289 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
morphine capsule,exten
d.release
pellets
80 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine syringe 10
mg/mL
NonPrefBrand-4 200 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine syringe 8
mg/mL
NonPrefBrand-4 250 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule, ER
multiphase 24
hr
45 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine capsule, ER
multiphase 24
hr
75 mg Generic-2 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine syringe
2
mg/mL
Generic-2
1000 30
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine syringe
4
mg/mL
Generic-2
500 30
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
morphine
concentrate
solution 100
mg/5
mL (20
mg/mL)
Generic-2 310 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
290 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Movantik tablet 12.5 mg PrefBrand-3
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Movantik tablet 25 mg PrefBrand-3
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
MoviPrep powder in
packet
100-7.5-
2.691
gram
NonPrefBrand-4 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSMoxatag tablet, ER
multiphase 24
hr
775 mg NonPrefBrand-4 NO ANTI - INFECTIVES PENICILLINS
Moxeza drops, viscous 0.5 %NonPrefBrand-4 NO
OPHTHALMOLOGY ANTIBIOTICS
moxifloxacin tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES QUINOLONES
moxifloxacin-
sod.ace,sul-
water
piggyback 400
mg/250
mL
NonPrefBrand-4 NO ANTI - INFECTIVES QUINOLONES
Mozobil solution 24
mg/1.2
mL (20
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
MS Contin tablet
extended
release
100 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
MS Contin tablet
extended
release
15 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
291 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
MS Contin tablet
extended
release
200 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
MS Contin tablet
extended
release
30 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
MS Contin tablet
extended
release
60 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Multaq tablet 400 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
mupirocin ointment 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
mupirocin
calcium
cream 2 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
Mustargen recon soln 10 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Myalept recon soln
5
mg/mL
(final
conc.)
Specialty-5 YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Mycamine recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSMycamine recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
292 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
mycophenolat
e mofetil
tablet 500 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
mycophenolat
e mofetil
capsule 250 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
mycophenolat
e mofetil
suspension
for
reconstitution
200
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
mycophenolat
e sodium
tablet,delayed
release
(DR/EC)
180 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
mycophenolat
e sodium
tablet,delayed
release
(DR/EC)
360 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Myfortic tablet,delayed
release
(DR/EC)
360 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Myfortic tablet,delayed
release
(DR/EC)
180 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Myorisan capsule 10 mg
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
293 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Myorisan capsule 20 mg
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Myorisan capsule 40 mg
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Myorisan capsule 30 mg Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Myrbetriq
tablet
extended
release 24 hr 25 mg PrefBrand-3
NO
UROLOGICALS
ANTICHOLINERGIC
S /
ANTISPASMODICS
Myrbetriq
tablet
extended
release 24 hr 50 mg PrefBrand-3
NO
UROLOGICALS
ANTICHOLINERGIC
S /
ANTISPASMODICS
Mysoline tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Mysoline tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
nabumetone tablet 500 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
nabumetone tablet 750 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
294 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
nadolol tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nadolol tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nadolol tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nadolol-
bendroflumet
hiazide
tablet 40-5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nadolol-
bendroflumet
hiazide
tablet 80-5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nafcillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
nafcillin recon soln 1 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
nafcillin in
dextrose iso-
osm
piggyback 1
gram/50
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
naftifine cream 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
naftifine cream 2 % PrefBrand-3
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Naftin gel 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
295 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Naftin cream 2 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Naftin gel 2 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Naglazyme solution 5 mg/5
mL
Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESnalbuphine solution 10
mg/mL
Generic-2 200 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
nalbuphine solution 20
mg/mL
Generic-2 100 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naloxone syringe
1
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naloxone solution
0.4
mg/mL Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naltrexone tablet 50 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Namenda tablet 10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
296 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Namenda tablet 5 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namenda solution
2
mg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namenda
Titration Pak
tablets,dose
pack 5-10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namenda XR
capsule,sprink
le,ER 24hr 14 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namenda XR
capsule,sprink
le,ER 24hr 21 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namenda XR
capsule,sprink
le,ER 24hr 28 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namenda XR
capsule,sprink
le,ER 24hr 7 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namenda XR
cap,sprinkle,E
R 24hr dose
pack
7-14-21-
28 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
297 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Namzaric
capsule,sprink
le,ER 24hr
14-10
mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Namzaric
capsule,sprink
le,ER 24hr
28-10
mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Naprelan CR
tablet, ER
multiphase 24
hr 375 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Naprelan CR
tablet, ER
multiphase 24
hr 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Naprelan CR
tablet, ER
multiphase 24
hr 750 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen tablet 375 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen tablet 250 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen tablet 500 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
298 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
naproxen suspension 125
mg/5
mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen tablet,delayed
release
(DR/EC)
500 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen tablet,delayed
release
(DR/EC)
375 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen
sodium
tablet 275 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen
sodium
tablet 550 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen
sodium
tablet, ER
multiphase 24
hr 375 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naproxen
sodium
tablet, ER
multiphase 24
hr 500 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
naratriptan tablet 1 mg Generic-2 20 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
299 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
naratriptan tablet 2.5 mg Generic-2 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Narcan
spray,non-
aerosol
4
mg/actu
ation
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nasonex spray,non-
aerosol
50
mcg/act
uation
NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Natacyn drops,suspens
ion
5 % PrefBrand-3 NO OPHTHALMOLOGY ANTIBIOTICS
nateglinide tablet 120 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYnateglinide tablet 60 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Natesto
gel in metered-
dose pump
5.5
mg/0.12
2
gram/ac
tuation
NonPrefBrand-4 YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Natpara cartridge
25
mcg/dos
e
Specialty-5 YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Natpara cartridge
50
mcg/dos
e
Specialty-5 YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Natpara cartridge
75
mcg/dos
e
Specialty-5 YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
300 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Natpara cartridge
100
mcg/dos
e
Specialty-5 YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Nebupent recon soln 300 mg NonPrefBrand-4 YES ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESNecon 0.5/35
(28)
tablet 0.5-35
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSNecon 1/35
(28)
tablet 1-35 mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSNecon 10/11
(28)
tablet 0.5-35/1-
35 mg-
mcg/mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Necon 7/7/7
(28)
tablet 0.5/0.75
/1 mg-
35 mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
nefazodone tablet 100 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
nefazodone tablet 150 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
301 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
nefazodone tablet 200 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
nefazodone tablet 250 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
nefazodone tablet 50 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
neomycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
neomycin-
bacitracin-
poly-HC ointment
3.5-400-
10,000
mg-
unit/g-
1%
Generic-2 NO
OPHTHALMOLOGY
STEROID-
ANTIBIOTIC
COMBINATIONS
neomycin-
bacitracin-
polymyxin
ointment 3.5-400-
10,000
mg-unit-
unit/g
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
neomycin-
polymyxin B
GU
solution 40 mg-
200,000
unit/mL
PrefGen-1 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
IRRIGATING
SOLUTIONS
neomycin-
polymyxin B-
dexameth
ointment 3.5
mg/g-
10,000
unit/g-
0.1 %
Generic-2 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONS
302 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
neomycin-
polymyxin B-
dexameth
drops,suspens
ion
3.5mg/
mL-
10,000
unit/mL-
0.1 %
Generic-2 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONS
neomycin-
polymyxin-
gramicidin
drops 1.75 mg-
10,000
unit-
0.025m
g/mL
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
neomycin-
polymyxin-
HC
solution 3.5-
10,000-
1
mg/mL-
unit/mL-
%
Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
OTIC STEROID /
ANTIBIOTIC
neomycin-
polymyxin-
HC
drops,suspens
ion
3.5-
10,000-
10 mg-
unit-
mg/mL
Generic-2 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONS
neomycin-
polymyxin-
HC
drops,suspens
ion
3.5-
10,000-
1
mg/mL-
unit/mL-
%
Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
OTIC STEROID /
ANTIBIOTIC
Neoral solution 100
mg/mL
PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
303 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Neoral capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Neoral capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Neo-Synalar cream
0.5 %
(0.35 %
base)-
0.025 %
NonPrefBrand-4 NO
DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
Nephramine
5.4 %
parenteral
solution
5.4 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Nesina tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Nesina tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Nesina tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Neuac gel
1.2 %(1
% base) -
5 % Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Neulasta syringe 6
mg/0.6
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Neupogen solution 480
mcg/1.6
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
304 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Neupogen syringe 300
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Neupogen syringe 480
mcg/0.8
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Neupogen solution
300
mcg/mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Neupro patch 24 hour 2 mg/24
hour
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Neupro patch 24 hour 4 mg/24
hour
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Neupro patch 24 hour 6 mg/24
hour
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Neupro patch 24 hour
1 mg/24
hour
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Neupro patch 24 hour
3 mg/24
hour
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Neupro patch 24 hour
8 mg/24
hour
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
305 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Neurontin capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Neurontin capsule 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Neurontin capsule 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Neurontin tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Neurontin tablet 800 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Neurontin solution 250
mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Nevanac drops,suspens
ion
0.1 % NonPrefBrand-4 NO OPHTHALMOLOGY NON-STEROIDAL
ANTI-
INFLAMMATORY
AGENTSnevirapine tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
nevirapine suspension 50 mg/5
mL
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
306 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
nevirapine
tablet
extended
release 24 hr 400 mg
Generic-2 NO
ANTI - INFECTIVES ANTIVIRALS
nevirapine
tablet
extended
release 24 hr 100 mg Generic-2
NO
ANTI - INFECTIVES ANTIVIRALS
Nexavar tablet 200 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
niacin
tablet
extended
release 24 hr
1,000
mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
niacin
tablet
extended
release 24 hr 500 mg PrefBrand-3 31 31
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
niacin
tablet
extended
release 24 hr 750 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Niacor tablet 500 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSnicardipine solution 25
mg/10
mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nicardipine capsule 20 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nicardipine capsule 30 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
307 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Nicotrol cartridge 10 mg
NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
SMOKING
DETERRENTS
Nicotrol NS spray,non-
aerosol
10
mg/mL
PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
SMOKING
DETERRENTS
Nifedical XL tablet
extended
release 24hr
60 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Nifedical XL tablet
extended
release 24hr
30 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nifedipine tablet
extended
release 24hr
30 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nifedipine tablet
extended
release 24hr
60 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nifedipine tablet
extended
release 24hr
90 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Nilandron tablet 150 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
nimodipine capsule 30 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Ninlaro capsule 2.3 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
308 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ninlaro capsule 3 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Ninlaro capsule 4 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Nipent recon soln 10 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
nisoldipine tablet
extended
release 24 hr
20 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nisoldipine tablet
extended
release 24 hr
30 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nisoldipine tablet
extended
release 24 hr
40 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nisoldipine tablet
extended
release 24 hr
17 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nisoldipine tablet
extended
release 24 hr
25.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nisoldipine tablet
extended
release 24 hr
34 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
nisoldipine tablet
extended
release 24 hr
8.5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
309 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Nitro-Bid ointment 2 % Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.2
mg/hr
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.4
mg/hr
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.6
mg/hr
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.1
mg/hr
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.3
mg/hr
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.8
mg/hr
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
nitrofurantoin suspension 25 mg/5
mL
Generic-2 1800 365 YES ANTI - INFECTIVES URINARY TRACT
AGENTSnitrofurantoin
macrocrystal
capsule 25 mg Generic-2 360 365 YES ANTI - INFECTIVES URINARY TRACT
AGENTSnitrofurantoin
macrocrystal
capsule 50 mg Generic-2 180 365 YES ANTI - INFECTIVES URINARY TRACT
AGENTSnitrofurantoin
macrocrystal capsule 100 mg Generic-2 90 365YES
ANTI - INFECTIVES
URINARY TRACT
AGENTS
nitrofurantoin
monohyd/m-
cryst
capsule 100 mg Generic-2 90 365 YES ANTI - INFECTIVES URINARY TRACT
AGENTS
310 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Classnitrofurantoin
monohyd/m-
cryst capsule
100 mg
(75/25) Generic-2 90 365
YES
ANTI - INFECTIVES
URINARY TRACT
AGENTS
nitroglycerin solution 50
mg/10
mL (5
mg/mL)
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
nitroglycerin patch 24 hour 0.6
mg/hr
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
nitroglycerin patch 24 hour 0.2
mg/hr
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
nitroglycerin patch 24 hour 0.4
mg/hr
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
nitroglycerin spray,non-
aerosol
400
mcg/spr
ay
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
nitroglycerin patch 24 hour 0.1
mg/hr
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitrostat tablet 0.3 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitrostat tablet 0.4 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
Nitrostat tablet 0.6 mg NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
NITRATES
nizatidine capsule 300 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
311 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
nizatidine capsule 150 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
nizatidine solution 150
mg/10
mL
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
Norco tablet 10-325
mg
NonPrefBrand-4 372 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Norco tablet 5-325
mg
NonPrefBrand-4 372 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Norco tablet 7.5-325
mg
NonPrefBrand-4 372 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Norditropin
FlexPro
pen injector 15
mg/1.5
mL (10
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Norditropin
FlexPro
pen injector 5
mg/1.5
mL (3.3
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Norditropin
FlexPro
pen injector 10
mg/1.5
mL (6.7
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Norditropin
FlexPro
pen injector 30 mg/3
mL (10
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
312 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
noreth-ethinyl
estradiol-iron
tablet,chewab
le
0.8mg-
25mcg(
24) and
75 mg
(4) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
norethindrone
(contraceptiv
e)
tablet 0.35 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
norethindrone
acetate tablet 5 mgGeneric-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSnorethindrone
ac-eth
estradiol tablet
1-5 mg-
mcg
Generic-2 NOOBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSnorethindrone
ac-eth
estradiol tablet
0.5-2.5
mg-mcg Generic-2
NOOBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
norgestimate-
ethinyl
estradiol
tablet 0.18/0.2
15/0.25
mg-25
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSNoritate cream 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Normosol-M
in 5 %
dextrose
parenteral
solution
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSNormosol-R
in 5 %
dextrose
parenteral
solution 5 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES ELECTROLYTES
Normosol-R
pH 7.4
parenteral
solution
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
313 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Northera capsule 100 mg
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Northera capsule 200 mg
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Northera capsule 300 mg
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Nortrel 0.5/35
(28)
tablet 0.5-35
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSNortrel 1/35
(21)
tablet 1-35 mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSNortrel 1/35
(28)
tablet 1-35 mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSNortrel 7/7/7
(28)
tablet 0.5/0.75
/1 mg-
35 mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSnortriptyline capsule 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
nortriptyline capsule 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
314 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
nortriptyline capsule 75 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
nortriptyline solution 10 mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
nortriptyline capsule 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Norvir capsule 100 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Norvir solution 80
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Norvir tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Novarel recon soln 10,000
unit
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESNovolin
70/30
suspension 100
unit/mL
(70-30)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Novolin N suspension 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYNovolin R solution 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYNovolog solution 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYNovolog
Flexpen
insulin pen 100
unit/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
315 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Novolog Mix
70-30 solution
100
unit/mL
(70-30)
PrefBrand-3 NOENDOCRINE/DIABE
TES
DIABETES
THERAPYNovolog Mix
70-30
FlexPen insulin pen
100
unit/mL
(70-30)
PrefBrand-3 NOENDOCRINE/DIABE
TES
DIABETES
THERAPYNovolog
PenFill cartridge
100
unit/mL PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Noxafil suspension 200
mg/5
mL (40
mg/mL)
Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
Nucala recon soln 100 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Nucynta tablet 100 mg NonPrefBrand-4 186 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nucynta tablet 50 mg NonPrefBrand-4 186 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nucynta tablet 75 mg NonPrefBrand-4 186 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nucynta ER
tablet
extended
release 12 hr 100 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
316 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Nucynta ER
tablet
extended
release 12 hr 150 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nucynta ER
tablet
extended
release 12 hr 200 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nucynta ER
tablet
extended
release 12 hr 250 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nucynta ER
tablet
extended
release 12 hr 50 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Nuedexta capsule
20-10
mg PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Nulojix recon soln 250 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Nuplazid tablet 17 mg
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Nutrestore
powder in
packet 5 gram
NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
317 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Nutrilipid emulsion 20 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Nutrilipid emulsion 20 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Nutropin AQ cartridge 10 mg/2
mL (5
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Nutropin AQ cartridge 20 mg/2
mL (10
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Nutropin AQ
Nuspin pen injector
5 mg/2
mL (2.5
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Nutropin AQ
Nuspin pen injector
20 mg/2
mL (10
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Nutropin AQ
Nuspin pen injector
10 mg/2
mL (5
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
NuvaRing ring
0.12-
0.015
mg/24
hr PrefBrand-3
NO
OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYN
Nuvessa gel 1.3 %NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYN
Nuvigil tablet 150 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
318 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Nuvigil tablet 250 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Nuvigil tablet 50 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Nuvigil tablet 200 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Nyamyc powder 100,000
unit/gra
m
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
nystatin suspension 100,000
unit/mL
Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
nystatin tablet 500,000
unit
Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSnystatin cream 100,000
unit/gra
m
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
nystatin powder 100,000
unit/gra
m
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
nystatin ointment 100,000
unit/gra
m
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
319 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
nystatin-
triamcinolone ointment
100,000-
0.1
unit/gra
m-% PrefBrand-3
NODERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
nystatin-
triamcinolone cream
100,000-
0.1
unit/g-
% PrefBrand-3
NODERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Nystop powder 100,000
unit/gra
m
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Octagam solution 5 % Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Octagam solution 10 %
Specialty-5 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
octreotide
acetate
solution 50
mcg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
octreotide
acetate
solution 100
mcg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
octreotide
acetate
solution 500
mcg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
320 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
octreotide
acetate
solution 1,000
mcg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
octreotide
acetate
solution 200
mcg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Odefsey tablet
200-25-
25 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Odomzo capsule 200 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Ofev capsule 100 mgSpecialty-5
62 31YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Ofev capsule 150 mgSpecialty-5
62 31YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
ofloxacin tablet 400 mg Generic-2 NO ANTI - INFECTIVES QUINOLONES
ofloxacin drops 0.3 % Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
OTIC
PREPARATIONSofloxacin drops 0.3 % Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
Ogestrel (28) tablet 0.5-50
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSolanzapine tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
321 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
olanzapine tablet 20 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine tablet,disinteg
rating
10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine tablet 15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine tablet 5 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine tablet,disinteg
rating
5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine tablet,disinteg
rating
15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
322 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
olanzapine tablet,disinteg
rating
20 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine recon soln 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine-
fluoxetine
capsule 6-25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine-
fluoxetine
capsule 12-25
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine-
fluoxetine
capsule 12-50
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine-
fluoxetine
capsule 6-50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olanzapine-
fluoxetine
capsule 3-25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
olopatadine
spray,non-
aerosol 0.6 %
Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
323 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
olopatadine drops 0.1 % PrefBrand-3
NO
OPHTHALMOLOGY
MISCELLANEOUS
OPHTHALMOLOGI
CS
Olysio capsule 150 mgSpecialty-5
28 28YES
ANTI - INFECTIVES ANTIVIRALS
omega-3 acid
ethyl esters
capsule 1 gram PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSomeprazole capsule,delay
ed
release(DR/E
C)
40 mg PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
omeprazole capsule,delay
ed
release(DR/E
C)
20 mg PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
omeprazole capsule,delay
ed
release(DR/E
C)
10 mg PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
omeprazole-
sodium
bicarbonate
capsule 20-1.1
mg-
gram
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
omeprazole-
sodium
bicarbonate
capsule 40-1.1
mg-
gram
Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
Omnaris spray,non-
aerosol
50 mcg NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSOmnitrope recon soln 5.8 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
324 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Omnitrope cartridge 10
mg/1.5
mL (6.7
mg/mL)
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Omnitrope cartridge 5
mg/1.5
mL (3.3
mg/mL)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Oncaspar solution 750
unit/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ondansetron tablet,disinteg
rating
4 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSondansetron tablet,disinteg
rating
8 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSondansetron
HCl
tablet 4 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSondansetron
HCl
tablet 24 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSondansetron
HCl
solution 4 mg/5
mL
Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSondansetron
HCl
tablet 8 mg Generic-2 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSondansetron
HCl (PF)
solution 4 mg/2
mL
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
325 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ondansetron
HCl (PF) syringe
4 mg/2
mL Generic-2
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Onfi tablet 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Onfi tablet 20 mg
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Onfi suspension
2.5
mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Onglyza tablet 5 mg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYOnglyza tablet 2.5 mg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Onzetra Xsail
aerosol powdr
breath
activated 11 mg
NonPrefBrand-4
16 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Opana tablet 5 mg
NonPrefBrand-4
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opana tablet 10 mg
NonPrefBrand-4
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
326 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Opana ER
tablet,oral
only,ext.rel.1
2 hr 10 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opana ER
tablet,oral
only,ext.rel.1
2 hr 15 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opana ER
tablet,oral
only,ext.rel.1
2 hr 20 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opana ER
tablet,oral
only,ext.rel.1
2 hr 30 mg
NonPrefBrand-4
69 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opana ER
tablet,oral
only,ext.rel.1
2 hr 40 mg
NonPrefBrand-4
51 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opana ER
tablet,oral
only,ext.rel.1
2 hr 5 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opana ER
tablet,oral
only,ext.rel.1
2 hr 7.5 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Opdivo solution
40 mg/4
mL
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
327 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Opsumit tablet 10 mgSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Oralair tablet
300
indx
reactivit
y
NonPrefBrand-4 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Orap tablet 2 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Orap tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Oravig
muco-
adhesive
buccal tablet 50 mg
NonPrefBrand-4 NO
ANTI - INFECTIVES
ANTIFUNGAL
AGENTS
Orbactiv recon soln 400 mgSpecialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
Orencia syringe
125
mg/mL
Specialty-5
4 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Orencia (with
maltose)
recon soln 250 mg Specialty-5 40 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Orenitram
tablet
extended
release
0.125
mg
NonPrefBrand-4 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Orenitram
tablet
extended
release 0.25 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
328 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Orenitram
tablet
extended
release 1 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Orenitram
tablet
extended
release 2.5 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Orfadin capsule 2 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Orfadin capsule 5 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Orfadin capsule 10 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Orfadin suspension
4
mg/mL
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Orkambi tablet
200-125
mgSpecialty-5
124 31YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Orsythia tablet
0.1-20
mg-mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Ortho Tri-
Cyclen Lo
(28)
tablet 0.18/0.2
15/0.25
mg-25
mcg
PrefBrand-3 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Oseni tablet
12.5-15
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Oseni tablet
12.5-30
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
329 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Oseni tablet
12.5-45
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Oseni tablet
25-15
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Oseni tablet
25-30
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Oseni tablet
25-45
mgNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
OsmoPrep tablet 1.5
gram
NonPrefBrand-4 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Otezla tablet 30 mg
Specialty-5 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Otezla Starter
tablets,dose
pack
10 mg
(4)-20
mg (4)-
30 mg
(47)
Specialty-5 YES
MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Otrexup (PF) auto-injector
10
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Otrexup (PF) auto-injector
15
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Otrexup (PF) auto-injector
20
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Otrexup (PF) auto-injector
25
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
330 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Otrexup (PF) auto-injector
7.5
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Otrexup (PF) auto-injector
17.5
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Otrexup (PF) auto-injector
22.5
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
oxacillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
oxacillin recon soln 2 gram Generic-2 NO ANTI - INFECTIVES PENICILLINS
oxacillin in
dextrose(iso-
osm)
piggyback 2
gram/50
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
oxacillin in
dextrose(iso-
osm)
piggyback 1
gram/50
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
oxaliplatin solution 100
mg/20
mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
oxandrolone tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESoxandrolone tablet 10 mg Specialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESoxaprozin tablet 600 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
331 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
oxazepam capsule 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
oxazepam capsule 30 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
oxazepam capsule 15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
oxcarbazepin
e
suspension 300
mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
oxcarbazepin
e
tablet 150 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
oxcarbazepin
e
tablet 300 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
oxcarbazepin
e
tablet 600 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
oxiconazole cream 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
332 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Oxistat cream 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Oxistat lotion 1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIFUNGALS
Oxtellar XR
tablet
extended
release 24 hr 150 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Oxtellar XR
tablet
extended
release 24 hr 300 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Oxtellar XR
tablet
extended
release 24 hr 600 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
oxybutynin
chloride
syrup 5 mg/5
mL
Generic-2 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
oxybutynin
chloride
tablet
extended
release 24hr
10 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
oxybutynin
chloride
tablet
extended
release 24hr
15 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
333 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
oxybutynin
chloride
tablet
extended
release 24hr
5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
oxybutynin
chloride
tablet 5 mg Generic-2 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
oxycodone
tablet,oral
only,ext.rel.1
2 hr 10 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone
tablet,oral
only,ext.rel.1
2 hr 15 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone
tablet,oral
only,ext.rel.1
2 hr 20 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone
tablet,oral
only,ext.rel.1
2 hr 30 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone
tablet,oral
only,ext.rel.1
2 hr 40 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone
tablet,oral
only,ext.rel.1
2 hr 60 mg
NonPrefBrand-4
69 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
334 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
oxycodone
tablet,oral
only,ext.rel.1
2 hr 80 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone solution
5 mg/5
mL
Generic-2
4133 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone tablet 15 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone concentrate
20
mg/mL
Generic-2
180 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone tablet 30 mg PrefBrand-3 138 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone tablet 5 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone tablet 10 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone tablet 20 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
335 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
oxycodone capsule 5 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone-
acetaminophe
n tablet
10-325
mg PrefBrand-3 372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone-
acetaminophe
n tablet
5-325
mg
Generic-2
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone-
acetaminophe
n tablet
7.5-325
mg
Generic-2
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone-
acetaminophe
n solution
5-325
mg/5
mL
Generic-2
1860 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone-
acetaminophe
n tablet
2.5-325
mg
Generic-2
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxycodone-
aspirin
tablet 4.8355-
325 mg
Generic-2 360 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
OxyContin
tablet,oral
only,ext.rel.1
2 hr 10 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
336 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
OxyContin
tablet,oral
only,ext.rel.1
2 hr 15 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
OxyContin
tablet,oral
only,ext.rel.1
2 hr 20 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
OxyContin
tablet,oral
only,ext.rel.1
2 hr 30 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
OxyContin
tablet,oral
only,ext.rel.1
2 hr 40 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
OxyContin
tablet,oral
only,ext.rel.1
2 hr 60 mg
NonPrefBrand-4
69 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
OxyContin
tablet,oral
only,ext.rel.1
2 hr 80 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone
tablet
extended
release 12 hr 10 mg
Generic-2
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone
tablet
extended
release 12 hr 15 mg
Generic-2
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
337 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
oxymorphone
tablet
extended
release 12 hr 20 mg
Generic-2
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone
tablet
extended
release 12 hr 30 mg
Generic-2
69 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone
tablet
extended
release 12 hr 40 mg
Generic-2
51 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone
tablet
extended
release 12 hr 5 mg
Generic-2
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone
tablet
extended
release 12 hr 7.5 mg
Generic-2
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone tablet 5 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
oxymorphone tablet 10 mg
Generic-2
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Oxytrol patch
semiweekly
3.9
mg/24
hr
NonPrefBrand-4 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
338 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Pacerone tablet 200 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Pacerone tablet 400 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Pacerone tablet 100 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
paclitaxel concentrate 6
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
paliperidone tablet
extended
release 24hr
3 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paliperidone tablet
extended
release 24hr
6 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paliperidone tablet
extended
release 24hr
9 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paliperidone tablet
extended
release 24hr
1.5 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
pamidronate solution 30
mg/10
mL (3
mg/mL)
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
339 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
pamidronate solution 60
mg/10
mL (6
mg/mL)
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
pamidronate solution 90
mg/10
mL (9
mg/mL)
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Pancreaze
capsule,delay
ed
release(DR/E
C)
10,500-
25,000-
43,750
unit
PrefBrand-3 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Pancreaze
capsule,delay
ed
release(DR/E
C)
16,800-
40,000-
70,000
unit
PrefBrand-3 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Pancreaze
capsule,delay
ed
release(DR/E
C)
21,000-
37,000 -
61,000
unit
PrefBrand-3 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Pancreaze
capsule,delay
ed
release(DR/E
C)
4,200-
10,000-
17,500
unit
PrefBrand-3 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Pandel cream 0.1 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
Panretin gel 0.1 % Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSpantoprazole tablet,delayed
release
(DR/EC)
20 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
340 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
pantoprazole recon soln 40 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
pantoprazole tablet,delayed
release
(DR/EC)
40 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
paricalcitol solution 5
mcg/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESparicalcitol solution 2
mcg/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESparicalcitol capsule 1 mcg Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESparicalcitol capsule 2 mcg PrefGen-1 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESparicalcitol capsule 4 mcg PrefGen-1 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESparomomycin capsule 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESparoxetine
HCl
tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paroxetine
HCl
tablet 30 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paroxetine
HCl
tablet 40 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paroxetine
HCl
tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
341 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
paroxetine
HCl
tablet
extended
release 24 hr
12.5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paroxetine
HCl
tablet
extended
release 24 hr
25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
paroxetine
HCl
tablet
extended
release 24 hr
37.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Paser granules DR
for susp in
packet
4 gram NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Pataday drops 0.2 % PrefBrand-3
NO
OPHTHALMOLOGY
MISCELLANEOUS
OPHTHALMOLOGI
CS
Paxil suspension 10 mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Pazeo drops 0.7 % PrefBrand-3
NO
OPHTHALMOLOGY
MISCELLANEOUS
OPHTHALMOLOGI
CS
PCE tablet,
particles/cryst
als
333 mg NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESPCE tablet,
particles/cryst
als
500 mg NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDES
342 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Pedvax HIB
(PF)
solution 7.5
mcg/0.5
mL
NonPrefBrand-4 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
peg 3350-
electrolytes recon soln
236-
22.74-
6.74 -
5.86
gram
Generic-2 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Peganone tablet 250 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Pegasys solution 180
mcg/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Pegasys syringe 180
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Pegasys
ProClick pen injector
135
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Pegasys
ProClick pen injector
180
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
peg-
electrolyte
soln
recon soln 420
gram
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSPegIntron kit 50
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
343 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
PegIntron kit 80
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
PegIntron kit 120
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
PegIntron kit 150
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
PegIntron
Redipen
pen injector
kit
120
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
PegIntron
Redipen
pen injector
kit
80
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
PegIntron
Redipen
pen injector
kit
150
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
PegIntron
Redipen
pen injector
kit
50
mcg/0.5
mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
pen needle,
diabetic
needle 29
gauge x
1/2"
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
penicillin G
pot in
dextrose
piggyback 2
million
unit/50
NonPrefBrand-4 NO ANTI - INFECTIVES PENICILLINS
penicillin G
pot in
dextrose
piggyback 3
million
unit/50
NonPrefBrand-4 NO ANTI - INFECTIVES PENICILLINS
penicillin G
potassium
recon soln 5
million
Generic-2 NO ANTI - INFECTIVES PENICILLINS
344 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
penicillin G
procaine
syringe 1.2
million
unit/2
mL
Generic-2 NO ANTI - INFECTIVES PENICILLINS
penicillin G
sodium
recon soln 5
million
Generic-2 NO ANTI - INFECTIVES PENICILLINS
penicillin V
potassium
recon soln 250
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
penicillin V
potassium
recon soln 125
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
penicillin V
potassium
tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
penicillin V
potassium
tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES PENICILLINS
Pentam recon soln 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESPentasa capsule,
extended
release
250 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSPentasa capsule,
extended
release
500 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSpentazocine-
naloxone
tablet 50-0.5
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
pentoxifylline tablet
extended
release
400 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
345 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Percocet tablet
10-325
mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Percocet tablet
2.5-325
mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Percocet tablet
5-325
mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Percocet tablet
7.5-325
mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Perforomist
solution for
nebulization
20
mcg/2
mL
NonPrefBrand-4 YESRESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
perindopril
erbumine
tablet 8 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
perindopril
erbumine
tablet 2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
perindopril
erbumine
tablet 4 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Periogard mouthwash 0.12 % Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
346 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Perjeta solution
420
mg/14
mL (30
mg/mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
permethrin cream 5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
SCABICIDES /
PEDICULICIDESperphenazine tablet 16 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
perphenazine tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
perphenazine tablet 4 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
perphenazine tablet 8 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
perphenazine-
amitriptyline
tablet 2-10 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
perphenazine-
amitriptyline
tablet 4-10 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
347 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
perphenazine-
amitriptyline
tablet 2-25 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
perphenazine-
amitriptyline
tablet 4-25 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
perphenazine-
amitriptyline
tablet 4-50 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Phenadoz suppository 12.5 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
phenelzine tablet 15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Phenergan suppository 12.5 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Phenergan suppository 25 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Phenergan suppository 50 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
phenobarbital tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
348 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
phenobarbital tablet 16.2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenobarbital tablet 60 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenobarbital tablet 97.2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenobarbital tablet 32.4 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenobarbital tablet 64.8 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenobarbital tablet 15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenobarbital tablet 30 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenobarbital elixir 20 mg/5
mL (4
mg/mL)
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
349 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
phenoxybenz
amine
capsule 10 mg Specialty-5 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Phenytek capsule 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Phenytek capsule 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenytoin suspension
125
mg/5
mL Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenytoin
tablet,chewab
le 50 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenytoin
sodium
solution 50
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenytoin
sodium
extended
capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
phenytoin
sodium
extended
capsule 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
350 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
phenytoin
sodium
extended
capsule 300 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Phoslyra solution
667 mg
(169 mg
calcium
)/5 mL
NonPrefBrand-4 NO
VITAMINS,
HEMATINICS /
ELECTROLYTES ELECTROLYTES
Phospholine
Iodide
drops 0.125 % PrefBrand-3 NO OPHTHALMOLOGY CHOLINESTERASE
INHIBITOR
MIOTICS
Picato gel 0.05 % PrefBrand-3
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
Picato gel 0.015 % PrefBrand-3
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSpilocarpine
HCl drops 1 %Generic-2 NO
OPHTHALMOLOGY
DIRECT ACTING
MIOTICSpilocarpine
HCl drops 2 %Generic-2 NO
OPHTHALMOLOGY
DIRECT ACTING
MIOTICSpilocarpine
HCl drops 4 %Generic-2 NO
OPHTHALMOLOGY
DIRECT ACTING
MIOTICS
pilocarpine
HCl tablet 5 mg
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
pilocarpine
HCl tablet 7.5 mg
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
351 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
pimozide tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
pimozide tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Pimtrea (28) tablet
0.15-
0.02
mgx21
/0.01
mg x 5 Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
pindolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
pindolol tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
pioglitazone tablet 30 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYpioglitazone tablet 45 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYpioglitazone tablet 15 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYpioglitazone-
glimepiride
tablet 30-2 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYpioglitazone-
glimepiride
tablet 30-4 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYpioglitazone-
metformin
tablet 15-500
mg
PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYpioglitazone-
metformin
tablet 15-850
mg
PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
352 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
piperacillin-
tazobactam
recon soln 3.375
gram
Generic-2 NO ANTI - INFECTIVES PENICILLINS
piperacillin-
tazobactam recon soln
4.5
gramGeneric-2 NO
ANTI - INFECTIVES PENICILLINS
Pirmella tablet
1-35 mg-
mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
piroxicam capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
piroxicam capsule 20 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Plasma-Lyte
148
parenteral
solution
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSPlasma-Lyte
A
parenteral
solution
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSPlasma-Lyte-
56 in 5 %
dextrose
parenteral
solution 5 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Plegridy syringe
125
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Plegridy syringe
63
mcg/0.5
mL- 94
mcg/0.5
mL
Specialty-5 NO
IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
353 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Plegridy pen injector
125
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Plegridy pen injector
63
mcg/0.5
mL- 94
mcg/0.5
mL
Specialty-5 NO
IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
podofilox solution 0.5 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSpolyethylene
glycol 3350
powder 17
gram/do
se
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSpolymyxin B
sulfate
recon soln 500,000
unit
Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESpolymyxin B
sulf-
trimethoprim
drops 10,000
unit- 1
mg/mL
Generic-2 NO OPHTHALMOLOGY ANTIBIOTICS
Pomalyst capsule 1 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Pomalyst capsule 2 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Pomalyst capsule 3 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
354 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Pomalyst capsule 4 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Portia tablet 0.15-
0.03 mg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSpotassium
chlorid-D5-
0.45%NaCl
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chlorid-D5-
0.45%NaCl
parenteral
solution
30
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chlorid-D5-
0.45%NaCl
parenteral
solution
40
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chlorid-D5-
0.45%NaCl
parenteral
solution
10
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
solution 2
mEq/m
L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
tablet,ER
particles/cryst
als
20 mEq PrefGen-1 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
capsule,
extended
release
10 mEq PrefGen-1 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
piggyback 10
mEq/10
0 mL
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
355 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
potassium
chloride
piggyback 20
mEq/10
0 mL
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
liquid 20
mEq/15
mL
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
piggyback 40
mEq/10
0 mL
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
tablet
extended
release
8 mEq PrefGen-1 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
liquid 40
mEq/15
mL
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
capsule,
extended
release
8 mEq PrefGen-1 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride
tablet,ER
particles/cryst
als
10 mEq PrefGen-1 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride in
0.9%NaCl
parenteral
solution
40
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride in
0.9%NaCl
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride in 5
% dex
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride in 5
% dex
parenteral
solution
40
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
356 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
potassium
chloride in
LR-D5
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride-0.45
% NaCl
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride-D5-
0.2%NaCl
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride-D5-
0.3%NaCl
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride-D5-
0.9%NaCl
parenteral
solution
20
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
chloride-D5-
0.9%NaCl
parenteral
solution
40
mEq/L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
potassium
citrate
tablet
extended
release
5 mEq
(540
mg)
Generic-2 NO UROLOGICALS MISCELLANEOUS
UROLOGICALS
potassium
citrate
tablet
extended
release
10 mEq
(1,080
mg)
PrefBrand-3 NO UROLOGICALS MISCELLANEOUS
UROLOGICALS
potassium
citrate
tablet
extended
release
15 mEq Generic-2 NO UROLOGICALS MISCELLANEOUS
UROLOGICALS
Potiga tablet 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
357 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Potiga tablet 300 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Potiga tablet 400 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Potiga tablet 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Pradaxa capsule 150 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Pradaxa capsule 75 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Pradaxa capsule 110 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Praluent Pen pen injector
150
mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Praluent Pen pen injector
75
mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Praluent
Syringe syringe
150
mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Praluent
Syringe syringe
75
mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
358 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
pramipexole tablet 0.75 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet 0.125
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet 1.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet
extended
release 24 hr
4.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet
extended
release 24 hr
0.375
mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
359 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
pramipexole tablet
extended
release 24 hr
0.75 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet
extended
release 24 hr
1.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole tablet
extended
release 24 hr
3 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pramipexole
tablet
extended
release 24 hr 2.25 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
pravastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSpravastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSpravastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSpravastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSprazosin capsule 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
360 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
prazosin capsule 1 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
prazosin capsule 2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Pred-G drops,suspens
ion
0.3-1 % NonPrefBrand-4 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONSPred-G
S.O.P.
ointment 0.3-0.6
%
NonPrefBrand-4 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONSprednicarbate cream 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
prednicarbate ointment 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
prednisolone
acetate
drops,suspens
ion 1 % PrefBrand-3NO
OPHTHALMOLOGY STEROIDS
prednisolone
sodium
phosphate
solution 25 mg/5
mL (5
mg/mL)
Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
prednisolone
sodium
phosphate
solution 15 mg/5
mL (3
mg/mL)
Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
prednisolone
sodium
phosphate
solution 5 mg
base/5
mL (6.7
mg/5
mL)
Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
361 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
prednisolone
sodium
phosphate
drops 1 % Generic-2 NO OPHTHALMOLOGY STEROIDS
prednisolone
sodium
phosphate
tablet,disinteg
rating
10 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
prednisolone
sodium
phosphate
tablet,disinteg
rating
15 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
prednisolone
sodium
phosphate
tablet,disinteg
rating
30 mg Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
prednisone tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESprednisone tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESprednisone tablet 2.5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESprednisone tablet 50 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESprednisone tablet 20 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESprednisone tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESprednisone solution 5 mg/5
mL
PrefGen-1 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESPrednisone
Intensol
concentrate 5
mg/mL
Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESPrefest tablet 1 mg
(15)/1
mg-
0.09 mg
(15)
NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
362 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Pregnyl recon soln 10,000
unit
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESPremarin cream 0.625
mg/gra
m
PrefBrand-3 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINS
Premasol 10
%
parenteral
solution
10 % Generic-2 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSPremasol 6 % parenteral
solution
6 % PrefBrand-3 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSPrenatal
Vitamin Plus
Low Iron
tablet 27 mg
iron- 1
mg
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
VITAMINS /
HEMATINICS
Prepopik
powder in
packet
10 mg-
3.5
gram-12
gram
NonPrefBrand-4 NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Prevalite powder 4 gram Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSPrevifem tablet 0.25-35
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Prezcobix tablet
800-150
mg-mg PrefBrand-3
NO
ANTI - INFECTIVES ANTIVIRALS
Prezista tablet 600 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Prezista tablet 75 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
363 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Prezista tablet 150 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Prezista suspension
100
mg/mL PrefBrand-3NO
ANTI - INFECTIVES ANTIVIRALS
Prezista tablet 800 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Priftin tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESprimaquine tablet 26.3 mg PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESprimidone tablet 250 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
primidone tablet 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Primlev tablet
5-300
mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Primlev tablet
10-300
mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Primlev tablet
7.5-300
mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
364 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Pristiq tablet
extended
release 24 hr
100 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Pristiq tablet
extended
release 24 hr
50 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Pristiq
tablet
extended
release 24 hr 25 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Privigen solution 10 % Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
ProAir HFA HFA aerosol
inhaler
90
mcg/act
uation
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
ProAir
RespiClick
aerosol powdr
breath
activated
90
mcg/act
uation PrefBrand-3
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
probenecid tablet 500 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
procainamide solution 100
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
procainamide solution 500
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
365 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Procalamine
3%
parenteral
solution
3 % NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSProCentra solution 5 mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
prochlorperaz
ine
suppository 25 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSprochlorperaz
ine Edisylate
solution 10 mg/2
mL (5
mg/mL)
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSprochlorperaz
ine maleate
tablet 10 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSprochlorperaz
ine maleate
tablet 5 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSProcrit solution 10,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Procrit solution 2,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Procrit solution 3,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Procrit solution 4,000
unit/mL
PrefBrand-3 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
366 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Procrit solution 20,000
unit/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Procrit solution 40,000
unit/mL
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Procto-Med
HC cream 2.5 % Generic-2
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Procto-Pak cream 1 % Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Proctosol HC cream 2.5 % Generic-2
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Proctozone-
HC cream 2.5 % Generic-2
NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Procysbi
capsule,
delayed rel
sprinkle 25 mg
Specialty-5 YES
UROLOGICALS
MISCELLANEOUS
UROLOGICALS
Procysbi
capsule,
delayed rel
sprinkle 75 mg
Specialty-5 YES
UROLOGICALS
MISCELLANEOUS
UROLOGICALS
progesterone
micronized
capsule 100 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSprogesterone
micronized
capsule 200 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSProglycem suspension 50
mg/mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
367 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Prograf capsule 1 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Prograf capsule 5 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Prograf solution 5
mg/mL
PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Prograf capsule 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Prolastin-C recon soln
1,000
mg
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Proleukin recon soln 22
million
unit
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Prolia syringe
60
mg/mL
NonPrefBrand-4
1 180
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
Promacta tablet 25 mg Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Promacta tablet 50 mg Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
368 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Promacta tablet 12.5 mg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
promethazine syrup
6.25
mg/5
mL
Generic-2 YESRESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
promethazine suppository 12.5 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
promethazine suppository 25 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
promethazine solution
25
mg/mL
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
promethazine suppository 50 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
promethazine solution
50
mg/mL
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Promethazine
VC syrup
6.25-5
mg/5
mL Generic-2
NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Promethegan suppository 25 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Promethegan suppository 50 mg
Generic-2 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
propafenone capsule,exten
ded release 12
hr
225 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
369 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
propafenone capsule,exten
ded release 12
hr
325 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
propafenone capsule,exten
ded release 12
hr
425 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
propafenone tablet 150 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
propafenone tablet 225 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
propafenone tablet 300 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
propantheline tablet 15 mg Generic-2 NO GASTROENTEROL
OGY
ANTIDIARRHEALS /
ANTISPASMODICS
propranolol solution 1
mg/mL
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol capsule,exten
ded release 24
hr
120 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
370 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
propranolol capsule,exten
ded release 24
hr
160 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol capsule,exten
ded release 24
hr
60 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol tablet 60 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol capsule,exten
ded release 24
hr
80 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol solution 20 mg/5
mL (4
mg/mL)
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol solution 40 mg/5
mL (8
mg/mL)
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol-
hydrochloroth
iazid
tablet 40-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propranolol-
hydrochloroth
iazid
tablet 80-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
propylthioura
cil
tablet 50 mg Generic-2 NO ENDOCRINE/DIABE
TES
ANTITHYROID
AGENTS
371 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ProQuad (PF)
suspension
for
reconstitution
10exp3-
4.3-3-
3.99
TCID50
/0.5 PrefBrand-3
NO
IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Prosol 20 % parenteral
solution
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSprotriptyline tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
protriptyline tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Provigil tablet 200 mg Specialty-5 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Provigil tablet 100 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Prudoxin cream 5 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
Pulmicort suspension
for
nebulization
0.5
mg/2
mL
NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Pulmicort suspension
for
nebulization
1 mg/2
mL
NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
372 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Pulmicort suspension
for
nebulization
0.25
mg/2
mL
NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Pulmozyme solution 1
mg/mL
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Purixan suspension
20
mg/mL
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Pylera capsule
140-125-
125 mg
NonPrefBrand-4 NOGASTROENTEROL
OGY ULCER THERAPY
pyrazinamide tablet 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESpyridostigmin
e bromide
tablet
extended
release
180 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYpyridostigmin
e bromide
tablet 60 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYQuasense tablets,dose
pack,3 month
0.15-30
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSquetiapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
373 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
quetiapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
quetiapine tablet 300 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
quetiapine tablet 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
quetiapine tablet 400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
quetiapine tablet 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Quillivant XR
suspension,ex
t rel
24hr,recon
5
mg/mL
(25
mg/5
mL)
NonPrefBrand-4 NOAUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
quinapril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
quinapril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
374 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
quinapril tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
quinapril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
quinapril-
hydrochloroth
iazide
tablet 10-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
quinapril-
hydrochloroth
iazide
tablet 20-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
quinapril-
hydrochloroth
iazide
tablet 20-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
quinidine
gluconate
tablet
extended
release
324 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
quinidine
gluconate
solution 80
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
quinidine
sulfate
tablet 200 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
quinidine
sulfate
tablet 300 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
quinine
sulfate capsule 324 mgGeneric-2 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
Qvar aerosol 40
mcg/act
uation
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
375 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Qvar aerosol
80
mcg/act
uation PrefBrand-3
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
RabAvert
(PF)
suspension
for
reconstitution
2.5 unit NonPrefBrand-4 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
rabeprazole tablet,delayed
release
(DR/EC)
20 mg Generic-2 62 31 NO GASTROENTEROL
OGY
ULCER THERAPY
Ragwitek tablet
12 Amb
a 1 unit
NonPrefBrand-4 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
raloxifene tablet 60 mg PrefBrand-3
NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
ramipril capsule 2.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
ramipril capsule 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
ramipril capsule 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
ramipril capsule 1.25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Ranexa tablet
extended
release 12 hr
1,000
mg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTS
376 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ranexa tablet
extended
release 12 hr
500 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTSranitidine
HCl
capsule 150 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
ranitidine
HCl
tablet 150 mg PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
ranitidine
HCl
capsule 300 mg Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
ranitidine
HCl
tablet 300 mg PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
ranitidine
HCl
solution 25
mg/mL
PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
ranitidine
HCl
syrup 15
mg/mL
PrefGen-1 NO GASTROENTEROL
OGY
ULCER THERAPY
Rapaflo capsule 8 mg PrefBrand-3 NO UROLOGICALS BENIGN
PROSTATIC
HYPERPLASIA(BPH
) THERAPYRapaflo capsule 4 mg PrefBrand-3 NO UROLOGICALS BENIGN
PROSTATIC
HYPERPLASIA(BPH
) THERAPYRapamune solution 1
mg/mL
PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Rapamune tablet 1 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
377 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Rapamune tablet 2 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Rapamune tablet 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Rapivab solution
200
mg/20
mL (10
mg/mL)
NonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
Rasuvo (PF) auto-injector
10
mg/0.2
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
12.5
mg/0.25
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
15
mg/0.3
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
17.5
mg/0.35
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
20
mg/0.4
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
22.5
mg/0.45
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
25
mg/0.5
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
378 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Rasuvo (PF) auto-injector
27.5
mg/0.55
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
30
mg/0.6
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Rasuvo (PF) auto-injector
7.5
mg/0.15
mL
NonPrefBrand-4 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Ravicti liquid
1.1
gram/m
L
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
REBETOL solution 40
mg/mL
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Rebif (with
albumin)
syringe 44
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Rebif (with
albumin)
syringe 22
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Rebif
Rebidose pen injector
22
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Rebif
Rebidose pen injector
44
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Rebif
Rebidose pen injector
8.8mcg/
0.2mL-
22
mcg/0.5
mL (6)
Specialty-5 NO
IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
379 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Rebif
Titration Pack
syringe 8.8mcg/
0.2mL-
22
mcg/0.5
mL (6)
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Reclipsen
(28)
tablet 0.15-
0.03 mg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSRecombivax
HB (PF)
suspension 10
mcg/mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Recombivax
HB (PF)
syringe 10
mcg/mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Recombivax
HB (PF)
syringe 5
mcg/0.5
mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Recombivax
HB (PF)
suspension 40
mcg/mL
NonPrefBrand-4 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Rectiv ointment
0.4 %
(w/w)
NonPrefBrand-4 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Regranex gel 0.01 % Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
380 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Relenza
Diskhaler
blister with
device
5
mg/actu
ation
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Relistor solution
12
mg/0.6
mL
NonPrefBrand-4 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Relistor syringe
12
mg/0.6
mL
NonPrefBrand-4 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Relistor syringe
8
mg/0.4
mL
NonPrefBrand-4 NOGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Relpax tablet 20 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYRelpax tablet 40 mg NonPrefBrand-4 6 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYRemicade recon soln 100 mg Specialty-5 80 28 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSRemodulin solution 1
mg/mL
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Remodulin solution 2.5
mg/mL
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Remodulin solution 5
mg/mL
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
381 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Remodulin solution 10
mg/mL
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Renagel tablet 400 mg PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Renagel tablet 800 mg PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Renvela tablet 800 mg PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Renvela powder in
packet
2.4
gram
PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Renvela powder in
packet
0.8
gram
PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
repaglinide tablet 1 mg Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYrepaglinide tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYrepaglinide tablet 2 mg Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYrepaglinide-
metformin
tablet 1-500
mg
Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYrepaglinide-
metformin
tablet 2-500
mg
Generic-2 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Repatha
SureClick pen injector
140
mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
382 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Repatha
Syringe syringe
140
mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Reprexain tablet 5-200
mg
Generic-2 50 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Reprexain tablet 10-200
mg
Generic-2 50 30 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Rescriptor tablet,
dispersible
100 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Rescriptor tablet 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
reserpine tablet 0.1 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
reserpine tablet 0.25 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Restasis dropperette 0.05 % PrefBrand-3 NO OPHTHALMOLOGY MISCELLANEOUS
OPHTHALMOLOGI
CS
Retin-A
Micro Pump
gel with
pump 0.08 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Retrovir solution 10
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Retrovir capsule 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Retrovir syrup 10
mg/mL
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
383 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Revatio tablet 20 mg Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSRevatio solution 10
mg/12.5
mL
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Revatio
suspension
for
reconstitution
10
mg/mL
Specialty-5 YESRESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Revlimid capsule 10 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Revlimid capsule 5 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Revlimid capsule 15 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Revlimid capsule 25 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Revlimid capsule 2.5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Revlimid capsule 20 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
384 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Rexulti tablet 0.25 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Rexulti tablet 0.5 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Rexulti tablet 1 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Rexulti tablet 2 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Rexulti tablet 3 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Rexulti tablet 4 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Reyataz capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Reyataz capsule 150 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Reyataz capsule 300 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Reyataz
powder in
packet 50 mgNonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
385 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Rheumatrex
tablets,dose
pack
2.5 mg
(dose
pack 8)
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Rheumatrex
tablets,dose
pack
2.5 mg
(dose
pack
12)
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Rheumatrex
tablets,dose
pack
2.5 mg
(dose
pack
16)
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Rheumatrex
tablets,dose
pack
2.5 mg
(dose
pack
20)
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Rheumatrex
tablets,dose
pack 2.5 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Ribasphere capsule 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Ribasphere tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Ribasphere tablet 400 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Ribasphere tablet 600 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Ribasphere
RibaPak
tablets,dose
pack
600-400
mg (28)-
mg (28)
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
386 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ribasphere
RibaPak
tablets,dose
pack
400-400
mg (28)-
mg (28)
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Ribasphere
RibaPak
tablets,dose
pack
600-600
mg (28)-
mg (28)
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
ribavirin tablet 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
ribavirin capsule 200 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Ridaura capsule 3 mg PrefBrand-3 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSrifabutin capsule 150 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESrifampin capsule 150 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESrifampin capsule 300 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESrifampin recon soln 600 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESRifater tablet 50-120-
300 mg
NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESRilutek tablet 50 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
riluzole tablet 50 mg Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
rimantadine tablet 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
387 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ringers parenteral
solution
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
ringers solution Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
IRRIGATING
SOLUTIONS
Riomet solution 500
mg/5
mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
risedronate tablet 35 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
risedronate tablet 150 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
risedronate tablet 30 mg Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
risedronate tablet 5 mg Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
risedronate tablet 35 mg
(4 pack)
Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
risedronate tablet 35 mg
(12
pack)
Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
risedronate
tablet,delayed
release
(DR/EC) 35 mg
Generic-2 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
OSTEOPOROSIS
THERAPY
388 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Risperdal tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal tablet 2 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal tablet 3 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal tablet 4 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal solution 1
mg/mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal tablet 0.25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal tablet 0.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal
Consta
syringe 12.5
mg/2
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
389 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Risperdal
Consta
syringe 37.5
mg/2
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal
Consta
syringe 50 mg/2
mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal
Consta
syringe 25 mg/2
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal M-
TAB
tablet,disinteg
rating
3 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal M-
TAB
tablet,disinteg
rating
4 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal M-
TAB
tablet,disinteg
rating
0.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal M-
TAB
tablet,disinteg
rating
1 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Risperdal M-
TAB
tablet,disinteg
rating
2 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
390 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
risperidone solution 1
mg/mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet 0.25 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet 2 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet 3 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet 4 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet,disinteg
rating
1 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
391 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
risperidone tablet,disinteg
rating
2 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet,disinteg
rating
0.5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet,disinteg
rating
3 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet,disinteg
rating
4 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
risperidone tablet,disinteg
rating
0.25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Ritalin LA
capsule,ER
biphasic 50-
50 10 mg
NonPrefBrand-4
186 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Rituxan concentrate 10
mg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
rivastigmine patch 24 hour 4.6
mg/24
hr
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
392 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
rivastigmine patch 24 hour 9.5
mg/24
hr
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
rivastigmine patch 24 hour
13.3
mg/24
hour Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
rivastigmine
tartrate
capsule 3 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
rivastigmine
tartrate
capsule 6 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
rivastigmine
tartrate
capsule 1.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
rivastigmine
tartrate
capsule 4.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
rizatriptan tablet,disinteg
rating
10 mg Generic-2 12 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYrizatriptan tablet,disinteg
rating
5 mg Generic-2 24 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
393 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
rizatriptan tablet 5 mg Generic-2 24 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYrizatriptan tablet 10 mg Generic-2 12 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYRocaltrol capsule 0.25
mcg
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESRocaltrol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESRocaltrol solution 1
mcg/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESropinirole tablet 3 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
394 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ropinirole tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet 4 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet
extended
release 24 hr
8 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet
extended
release 24 hr
2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet
extended
release 24 hr
4 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet
extended
release 24 hr
12 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
ropinirole tablet
extended
release 24 hr
6 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
395 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
rosuvastatin tablet 40 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSrosuvastatin tablet 5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSrosuvastatin tablet 10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSrosuvastatin tablet 20 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSRotarix suspension
for
reconstitution
10exp6
CCID50
/mL
NonPrefBrand-4 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
RotaTeq
Vaccine
suspension 2 mL PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Roweepra tablet 500 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Roxicodone tablet 15 mg
NonPrefBrand-4
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Roxicodone tablet 30 mg
NonPrefBrand-4
138 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
396 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Roxicodone tablet 5 mg
NonPrefBrand-4
186 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Rozerem tablet 8 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Ruconest recon soln
2,100
unitSpecialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Sabril tablet 500 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Sabril powder in
packet
500 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Safyral tablet
3-0.03-
0.451
mg
(21/7)
NonPrefBrand-4 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Saizen recon soln 5 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Saizen recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Saizen
click.easy
cartridge 8.8
mg/1.5
mL
(Fnl)
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
397 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Samsca tablet 15 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSamsca tablet 30 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSancuso patch weekly 3.1
mg/24
hour
Specialty-5 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSSandimmune capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandimmune capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandimmune solution 250
mg/5
mL
PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandimmune solution 100
mg/mL
PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandostatin solution 100
mcg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandostatin solution 200
mcg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
398 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Sandostatin solution 1,000
mcg/mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandostatin
LAR Depot
suspension,ex
tended rel
recon
20 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandostatin
LAR Depot
suspension,ex
tended rel
recon
30 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sandostatin
LAR Depot
suspension,ex
tended rel
recon
10 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Santyl ointment
250
unit/gra
m PrefBrand-3
NO DERMATOLOGICA
LS/TOPICAL
THERAPY TOPICAL ENZYMES
Saphris
(black cherry)
tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Saphris
(black cherry)
tablet 5 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Saphris
(black cherry) tablet 2.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
399 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Savaysa tablet 15 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Savaysa tablet 30 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Savaysa tablet 60 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Savella tablet 100 mg NonPrefBrand-4 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSSavella tablet 12.5 mg NonPrefBrand-4 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSSavella tablet 50 mg NonPrefBrand-4 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSSavella tablet 25 mg NonPrefBrand-4 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALSSavella tablets,dose
pack
12.5 mg
(5)-25
mg(8)-
50
mg(42)
NonPrefBrand-4 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Seconal
Sodium
capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
400 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
selegiline
HCl
capsule 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
selegiline
HCl
tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
selenium
sulfide
lotion 2.5 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Selzentry tablet 150 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Selzentry tablet 300 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Semprex-D capsule 8-60 mg
NonPrefBrand-4 NORESPIRATORY AND
ALLERGY
ANTIHISTAMINE /
ANTIALLERGENIC
AGENTS
Sensipar tablet 30 mg PrefBrand-3 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSensipar tablet 60 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSensipar tablet 90 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSerevent
Diskus
blister with
device
50
mcg/dos
e
NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Seroquel XR tablet
extended
release 24 hr
200 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
401 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Seroquel XR tablet
extended
release 24 hr
300 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Seroquel XR tablet
extended
release 24 hr
400 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Seroquel XR tablet
extended
release 24 hr
50 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Seroquel XR tablet
extended
release 24 hr
150 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Serostim recon soln 4 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Serostim recon soln 5 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Serostim recon soln 6 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
sertraline tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
sertraline tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
402 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
sertraline tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
sertraline concentrate 20
mg/mL
PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Setlakin
tablets,dose
pack,3 month
0.15-30
mg-mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Signifor solution
0.3
mg/mL
(1 mL)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Signifor solution
0.6
mg/mL
(1 mL)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Signifor solution
0.9
mg/mL
(1 mL)
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Signifor LAR
suspension
for
reconstitution 20 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Signifor LAR
suspension
for
reconstitution 40 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
403 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Signifor LAR
suspension
for
reconstitution 60 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
sildenafil tablet 20 mg PrefBrand-3 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSsildenafil solution 10
mg/12.5
mL
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Silenor tablet 3 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Silenor tablet 6 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
silver
sulfadiazine
cream 1 % PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
BURN THERAPY
Simbrinza
drops,suspens
ion 1-0.2 % PrefBrand-3
NO
OPHTHALMOLOGY
OTHER
GLAUCOMA
DRUGS
Simponi syringe 50
mg/0.5
mL
Specialty-5 0.5 28 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Simponi syringe
100
mg/mL
Specialty-5
1 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Simponi pen injector
50
mg/0.5
mL
Specialty-5
0.5 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
404 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Simponi pen injector
100
mg/mL
Specialty-5
1 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Simponi
ARIA solution
12.5
mg/mL
Specialty-5
16 28
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Simulect recon soln 20 mg NonPrefBrand-4 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
simvastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSsimvastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSsimvastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSsimvastatin tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSsimvastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSsirolimus tablet 1 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
sirolimus tablet 2 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
405 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
sirolimus tablet 0.5 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sirturo tablet 100 mgSpecialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
Sivextro tablet 200 mgSpecialty-5
6 31NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
Sivextro recon soln 200 mgSpecialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
sodium
chloride
parenteral
solution
2.5
mEq/m
L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
sodium
chloride
solution 0.9 % Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
sodium
chloride 0.45
%
parenteral
solution
0.45 % Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
sodium
chloride 0.9
%
parenteral
solution
0.9 % Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
sodium
chloride 3 %
parenteral
solution
3 % Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
sodium
chloride 5 %
parenteral
solution
5 % Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
sodium
fluoride
tablet 1 mg
fluoride
(2.2 mg)
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
VITAMINS /
HEMATINICS
406 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
sodium
lactate
solution 5
mEq/m
L
Generic-2 NO VITAMINS,
HEMATINICS /
ELECTROLYTES
ELECTROLYTES
sodium
phenylbutyrat
e powder
0.94
gram/gr
am
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
sodium
polystyrene
(sorb free)
suspension 15
gram/60
mL
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Soltamox solution 10 mg/5
mL
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Solu-Cortef
(PF)
recon soln 100
mg/2
mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Solu-Cortef
(PF)
recon soln 250
mg/2
mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Solu-Medrol recon soln 2 gramNonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Solu-Medrol
(PF)
recon soln 500
mg/4
mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Solu-Medrol
(PF)
recon soln 40
mg/mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONESSolu-Medrol
(PF)
recon soln 125
mg/2
mL
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Somatuline
Depot
syringe 60
mg/0.2
mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
407 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Somatuline
Depot
syringe 120
mg/0.5
mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Somatuline
Depot
syringe 90
mg/0.3
mL
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Somavert recon soln 10 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSomavert recon soln 15 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSomavert recon soln 20 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Somavert recon soln 30 mgSpecialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Somavert recon soln 25 mgSpecialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Soriatane capsule 10 mg Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Soriatane capsule 25 mg Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Soriatane capsule 17.5 mg Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Sorine tablet 120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Sorine tablet 160 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
408 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Sorine tablet 240 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Sorine tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
sotalol tablet 160 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
sotalol tablet 240 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
sotalol tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Sotalol AF tablet 120 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Sotylize solution
5
mg/mL
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Sovaldi tablet 400 mgSpecialty-5
28 28YES
ANTI - INFECTIVES ANTIVIRALS
Spiriva
Respimat mist
2.5
mcg/act
uation PrefBrand-3
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Spiriva
Respimat mist
1.25
mcg/act
uation PrefBrand-3
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Spiriva with
HandiHaler
capsule,
w/inhalation
device
18 mcg PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
409 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
spironolacton
e
tablet 100 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
spironolacton
e
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
spironolacton
e
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
spironolacton-
hydrochloroth
iaz
tablet 25-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Sporanox solution 10
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSSprintec (28) tablet 0.25-35
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Spritam
tablet for
suspension
1,000
mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Spritam
tablet for
suspension 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Spritam
tablet for
suspension 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
410 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Spritam
tablet for
suspension 750 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Sprycel tablet 20 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sprycel tablet 50 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sprycel tablet 70 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sprycel tablet 100 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sprycel tablet 140 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sprycel tablet 80 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sronyx tablet 0.1-20
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
411 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
SSD cream 1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
BURN THERAPY
stavudine capsule 15 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
stavudine capsule 20 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
stavudine capsule 30 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
stavudine capsule 40 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
stavudine recon soln 1
mg/mL
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Stelara syringe 45
mg/0.5
mL
Specialty-5 0.5 28 YES DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Stelara syringe 90
mg/mL
Specialty-5 1 28 YES DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Stimate spray,non-
aerosol
150
mcg/spr
ay (0.1
mL)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Stiolto
Respimat mist
2.5-2.5
mcg/act
uation PrefBrand-3 4 30
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Stivarga tablet 40 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
412 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Strattera capsule 10 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Strattera capsule 18 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Strattera capsule 25 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Strattera capsule 40 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Strattera capsule 60 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Strattera capsule 100 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Strattera capsule 80 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Strensiq solution
40
mg/mLSpecialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Strensiq solution
100
mg/mLSpecialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
413 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
streptomycin recon soln 1 gram PrefBrand-3 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESStriant mucoadhesive
System ER 12
hr
30 mg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Stribild tablet
150-150-
200-300
mg
Specialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Striverdi
Respimat mist
2.5
mcg/act
uation
NonPrefBrand-4 NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Suboxone film
2-0.5
mg PrefBrand-3 93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Suboxone film 8-2 mg PrefBrand-3 93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Suboxone film 4-1 mg PrefBrand-3 93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Suboxone film 12-3 mg PrefBrand-3 62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Subsys
spray,non-
aerosol
100
mcg/spr
ay
Specialty-5
124 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
414 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Subsys
spray,non-
aerosol
200
mcg/spr
ay
Specialty-5
124 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Subsys
spray,non-
aerosol
400
mcg/spr
ay
Specialty-5
86 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Subsys
spray,non-
aerosol
600
mcg/spr
ay
Specialty-5
57 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Subsys
spray,non-
aerosol
800
mcg/spr
ay
Specialty-5
43 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Sucraid solution 8,500
unit/mL
Specialty-5 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSsucralfate tablet 1 gram Generic-2 NO GASTROENTEROL
OGY
ULCER THERAPY
sulfacetamide
sodium ointment 10 %PrefGen-1 NO
OPHTHALMOLOGY SULFONAMIDESsulfacetamide
sodium drops 10 %Generic-2 NO
OPHTHALMOLOGY SULFONAMIDES
sulfacetamide
sodium (acne) suspension 10 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
sulfacetamide-
prednisolone drops
10 %-
0.23 %
(0.25
%)
Generic-2 NO
OPHTHALMOLOGY
STEROID-
SULFONAMIDE
COMBINATIONS
415 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
sulfadiazine tablet 500 mg Generic-2 NO ANTI - INFECTIVES SULFA'S / RELATED
AGENTSsulfamethoxa
zole-
trimethoprim
tablet 400-80
mg
PrefGen-1 NO ANTI - INFECTIVES SULFA'S / RELATED
AGENTS
sulfamethoxa
zole-
trimethoprim
tablet 800-160
mg
PrefGen-1 NO ANTI - INFECTIVES SULFA'S / RELATED
AGENTS
sulfamethoxa
zole-
trimethoprim
suspension 200-40
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES SULFA'S / RELATED
AGENTS
sulfamethoxa
zole-
trimethoprim
solution 400-80
mg/5
mL
PrefGen-1 NO ANTI - INFECTIVES SULFA'S / RELATED
AGENTS
Sulfamylon cream 85 mg/g PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIBACTERIALS
sulfasalazine tablet 500 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSsulfasalazine tablet,delayed
release
(DR/EC)
500 mg Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSsulindac tablet 150 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
sulindac tablet 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
416 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
sumatriptan spray,non-
aerosol
5
mg/actu
ation
Generic-2 32 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYsumatriptan spray,non-
aerosol
20
mg/actu
ation
Generic-2 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYsumatriptan
succinate
tablet 100 mg Generic-2 9 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYsumatriptan
succinate
tablet 50 mg Generic-2 18 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYsumatriptan
succinate
solution 6
mg/0.5
mL
Generic-2 4 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYsumatriptan
succinate
tablet 25 mg Generic-2 36 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYsumatriptan
succinate
pen injector 6
mg/0.5
mL
Generic-2 4 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
417 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
sumatriptan
succinate pen injector
6
mg/0.5
mL
(auto-
Injector) Generic-2 4 31
NO
AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
sumatriptan
succinate cartridge
6
mg/0.5
mL Generic-2 4 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
sumatriptan
succinate cartridge
4
mg/0.5
mL Generic-2 6 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Sumavel
DosePro
needle-free
injector
6
mg/0.5
mL
NonPrefBrand-4 4 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Sumavel
DosePro
needle-free
injector
4
mg/0.5
mL
NonPrefBrand-4
6 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Suprax suspension
for
reconstitution
100
mg/5
mL
PrefBrand-3 NO ANTI - INFECTIVES CEPHALOSPORINS
Suprax suspension
for
reconstitution
200
mg/5
mL
PrefBrand-3 NO ANTI - INFECTIVES CEPHALOSPORINS
Suprax capsule 400 mg PrefBrand-3NO
ANTI - INFECTIVES CEPHALOSPORINS
Suprax
suspension
for
reconstitution
500
mg/5
mL PrefBrand-3
NO
ANTI - INFECTIVES CEPHALOSPORINS
418 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Suprep
Bowel Prep
Kit recon soln
17.5-
3.13-1.6
gram PrefBrand-3
NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Surmontil capsule 50 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Surmontil capsule 100 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Surmontil capsule 25 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Sustiva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Sustiva capsule 50 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Sustiva tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Sutent capsule 12.5 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sutent capsule 25 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
419 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Sutent capsule 50 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sutent capsule 37.5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Sylatron kit
300
mcg
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Sylatron kit
600
mcg
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Sylatron kit
200
mcg
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Sylvant recon soln 100 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Symbicort
HFA aerosol
inhaler
80-4.5
mcg/act
uation PrefBrand-3 10.2 30
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Symbicort
HFA aerosol
inhaler
160-4.5
mcg/act
uation PrefBrand-3 10.2 30
NORESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
SymlinPen
120
pen injector 2,700
mcg/2.7
mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
SymlinPen 60 pen injector 1,500
mcg/1.5
mL
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
420 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Synagis solution 50
mg/0.5
mL
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Synalgos-DC capsule
16-
356.4-
30 mg
NonPrefBrand-4
300 30
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Synarel spray,non-
aerosol
2
mg/mL
Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESSynercid recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Synribo recon soln 3.5 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Synthroid tablet 25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 75 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 112
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 125
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 150
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 175
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 300
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 50 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 100
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONES
421 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Synthroid tablet 200
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 137
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSynthroid tablet 88 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESSyprine capsule 250 mg PrefBrand-3 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Tabloid tablet 40 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Taclonex suspension 0.005-
0.064 %
Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
tacrolimus capsule 1 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
tacrolimus capsule 5 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
tacrolimus ointment 0.03 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LStacrolimus capsule 0.5 mg Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
422 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tacrolimus ointment 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
Tafinlar capsule 50 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tafinlar capsule 75 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tagrisso tablet 40 mg
Specialty-5
31 31
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tagrisso tablet 80 mg
Specialty-5
31 31
YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Taltz
Autoinjector auto-injector
80
mg/mL
Specialty-5
1 28
YES DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Taltz Syringe syringe
80
mg/mL
Specialty-5
1 28
YES DERMATOLOGICA
LS/TOPICAL
THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
Tamiflu capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Tamiflu capsule 30 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Tamiflu capsule 45 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
423 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tamiflu
suspension
for
reconstitution
6
mg/mL PrefBrand-3
NO
ANTI - INFECTIVES ANTIVIRALS
tamoxifen tablet 10 mg PrefGen-1 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
tamoxifen tablet 20 mg PrefGen-1 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
tamsulosin capsule,exten
ded release
24hr
0.4 mg PrefGen-1 NO UROLOGICALS BENIGN
PROSTATIC
HYPERPLASIA(BPH
) THERAPY
Tarceva tablet 100 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tarceva tablet 150 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tarceva tablet 25 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Targretin capsule 75 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
424 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Targretin gel 1 %
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tasigna capsule 200 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tasigna capsule 150 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tasmar tablet 100 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
TAZICEF recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
TAZICEF recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES CEPHALOSPORINS
TAZICEF recon soln 2 gramNonPrefBrand-4 NO
ANTI - INFECTIVES CEPHALOSPORINS
Tazorac gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Tazorac gel 0.1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Tazorac cream 0.05 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
425 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tazorac cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Taztia XT capsule,
extended
release
120 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Taztia XT capsule,
extended
release
180 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Taztia XT capsule,
extended
release
240 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Taztia XT capsule,
extended
release
300 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Taztia XT capsule,
extended
release
360 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tecentriq solution
1,200
mg/20
mL (60
mg/mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tecfidera
capsule,delay
ed
release(DR/E
C) 120 mg
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Tecfidera
capsule,delay
ed
release(DR/E
C) 240 mg
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
426 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tecfidera
capsule,delay
ed
release(DR/E
C)
120 mg
(14)-
240 mg
(46)
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Technivie tablet
12.5-75-
50 mgSpecialty-5
56 28YES
ANTI - INFECTIVES ANTIVIRALS
Teflaro recon soln 400 mgNonPrefBrand-4 NO
ANTI - INFECTIVES CEPHALOSPORINS
Teflaro recon soln 600 mgNonPrefBrand-4 NO
ANTI - INFECTIVES CEPHALOSPORINS
Tegretol suspension 100
mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Tegretol tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Tegretol XR tablet
extended
release 12 hr
100 mg PrefBrand-3 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Tegretol XR tablet
extended
release 12 hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Tegretol XR tablet
extended
release 12 hr
400 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Tekturna tablet 150 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
427 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tekturna tablet 300 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tekturna
HCT tablet
150-
12.5 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tekturna
HCT tablet
150-25
mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tekturna
HCT tablet
300-
12.5 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tekturna
HCT tablet
300-25
mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan tablet 40 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan tablet 80 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan-
amlodipine
tablet 40-10
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan-
amlodipine
tablet 80-10
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan-
amlodipine
tablet 40-5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
428 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
telmisartan-
amlodipine
tablet 80-5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan-
hydrochloroth
iazid
tablet 40-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan-
hydrochloroth
iazid
tablet 80-12.5
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
telmisartan-
hydrochloroth
iazid
tablet 80-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
temazepam capsule 15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
temazepam capsule 30 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
temazepam capsule 7.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
temazepam capsule 22.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Tencon tablet
50-325
mg Generic-2 372 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
429 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tenivac (PF) syringe
5-2 Lf
unit/0.5
mL
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
terazosin capsule 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
terazosin capsule 1 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
terazosin capsule 2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
terazosin capsule 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
terbinafine
HCl
tablet 250 mg PrefGen-1 90 180 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSterbutaline solution 1
mg/mL
Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSterbutaline tablet 2.5 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSterbutaline tablet 5 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSterconazole suppository 80 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNterconazole cream 0.4 % Generic-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNterconazole cream 0.8 % Generic-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYN
Testim gel
50 mg/5
gram (1
%)
NonPrefBrand-4 YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
430 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
testosterone
gel in metered-
dose pump
1.25
gram/
actuatio
n (1 %) PrefBrand-3
YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
testosterone
gel in metered-
dose pump
10
mg/0.5
gram
/actuatio
n PrefBrand-3
YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
testosterone gel in packet
1 % (25
mg/2.5g
ram) PrefBrand-3
YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
testosterone gel in packet
1 % (50
mg/5
gram) PrefBrand-3
YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
testosterone
cypionate
oil 100
mg/mL
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONEStestosterone
cypionate
oil 200
mg/mL
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONEStestosterone
enanthate
oil 200
mg/mL
Generic-2 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESTestred capsule 10 mg Specialty-5 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
tetanus,diphth
eria tox
ped(PF) suspension
5-25 Lf
unit/0.5
mL
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
tetanus-
diphtheria
toxoids-Td
suspension 2-2 Lf
unit/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
431 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tetrabenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
tetrabenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
tetracycline capsule 250 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
tetracycline capsule 500 mg Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
Thalomid capsule 50 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Thalomid capsule 100 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Thalomid capsule 200 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Thalomid capsule 150 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Theo-24 capsule,exten
ded release
24hr
100 mg NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
432 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Theo-24 capsule,exten
ded release
24hr
300 mg NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Theo-24 capsule,exten
ded release
24hr
200 mg NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Theo-24 capsule,exten
ded release
24hr
400 mg NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
theophylline tablet
extended
release 12 hr
100 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
theophylline tablet
extended
release
400 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
theophylline solution 80
mg/15
mL
Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
theophylline tablet
extended
release 12 hr
450 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
theophylline tablet
extended
release 12 hr
300 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
theophylline tablet
extended
release 12 hr
200 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
theophylline tablet
extended
release
600 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Thiola tablet 100 mg NonPrefBrand-4 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
433 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
thioridazine tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
thioridazine tablet 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
thioridazine tablet 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
thioridazine tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
thiotepa recon soln 15 mg
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
thiothixene capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
thiothixene capsule 1 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
thiothixene capsule 2 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
434 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
thiothixene capsule 5 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Thymoglobuli
n
recon soln 25 mg NonPrefBrand-4 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Thyrolar-1 tablet 12.5-50
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESThyrolar-1/2 tablet 6.25-25
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESThyrolar-1/4 tablet 3.1-12.5
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONES
Thyrolar-2 tablet 25-100
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESThyrolar-3 tablet 37.5-
150
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONES
tiagabine tablet 2 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
tiagabine tablet 4 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Tikosyn capsule 125
mcg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
435 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tikosyn capsule 250
mcg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
Tikosyn capsule 500
mcg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIARRHYTHMIC
AGENTS
timolol
maleate
drops 0.25 % PrefGen-1 NO OPHTHALMOLOGY BETA-BLOCKERS
timolol
maleate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
timolol
maleate
tablet 20 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
timolol
maleate
tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
timolol
maleate
gel forming
solution
0.25 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS
timolol
maleate
gel forming
solution
0.5 % Generic-2 NO OPHTHALMOLOGY BETA-BLOCKERS
timolol
maleate
drops 0.5 % PrefGen-1 NO OPHTHALMOLOGY BETA-BLOCKERS
Timoptic
Ocudose (PF)
dropperette 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS
Timoptic
Ocudose (PF)
dropperette 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY BETA-BLOCKERS
tinidazole tablet 500 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVEStinidazole tablet 250 mg Generic-2 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
436 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tirosint capsule 112
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 137
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 75 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 88 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 100
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 125
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 150
mcg
NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 50 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESTirosint capsule 13 mcg NonPrefBrand-4 NO ENDOCRINE/DIABE
TES
THYROID
HORMONES
Tivicay tablet 50 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Tivicay tablet 10 mgNonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
Tivicay tablet 25 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
tizanidine tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPY
437 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tizanidine tablet 4 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYtizanidine capsule 6 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYtizanidine capsule 4 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYtizanidine capsule 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MUSCLE
RELAXANTS /
ANTISPASMODIC
THERAPYTobi solution for
nebulization
300
mg/5
mL
NonPrefBrand-4 YES ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Tobi
Podhaler
capsule,
w/inhalation
device 28 mg
Specialty-5 YES
ANTI - INFECTIVES
MISCELLANEOUS
ANTIINFECTIVES
TobraDex ointment 0.3-0.1
%
PrefBrand-3 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONS
Tobradex ST
drops,suspens
ion
0.3-0.05
% PrefBrand-3
NO
OPHTHALMOLOGY
STEROID-
ANTIBIOTIC
COMBINATIONS
tobramycin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY ANTIBIOTICS
tobramycin in
0.225 %
NaCl
solution for
nebulization
300
mg/5
mL
Specialty-5 YES ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
438 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tobramycin
sulfate
solution 10
mg/mL
PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVEStobramycin
sulfate
solution 40
mg/mL
PrefGen-1 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVEStobramycin-
dexamethaso
ne
drops,suspens
ion
0.3-0.1
%
Generic-2 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONSTobrex ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY ANTIBIOTICS
Tolak cream 4 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
tolazamide tablet 250 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYtolazamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYtolbutamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPYtolcapone tablet 100 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
tolmetin capsule 400 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tolmetin tablet 600 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
439 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tolterodine tablet 1 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
tolterodine capsule,exten
ded release
24hr
2 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
tolterodine capsule,exten
ded release
24hr
4 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
tolterodine tablet 2 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
Topamax tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Topamax tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Topamax tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Topamax tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
440 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Topamax capsule,
sprinkle
15 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Topamax capsule,
sprinkle
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate tablet 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate tablet 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate tablet 200 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate capsule,
sprinkle
25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate capsule,
sprinkle
15 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
441 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
topiramate
capsule,sprink
le,ER 24hr 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate
capsule,sprink
le,ER 24hr 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate
capsule,sprink
le,ER 24hr 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate
capsule,sprink
le,ER 24hr 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
topiramate
capsule,sprink
le,ER 24hr 150 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Toposar solution 20
mg/mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
topotecan recon soln 4 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Torisel recon soln 30 mg/3
mL (10
mg/mL)
(first)
Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
442 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
torsemide tablet 10 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
torsemide tablet 100 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
torsemide tablet 20 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
torsemide tablet 5 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Toujeo
SoloStar insulin pen
300
unit/mL
(1.5
mL) PrefBrand-3
NO
ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Toviaz tablet
extended
release 24 hr
4 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
Toviaz tablet
extended
release 24 hr
8 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
Tracleer tablet 62.5 mg Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSTracleer tablet 125 mg Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Tradjenta tablet 5 mg PrefBrand-3NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
443 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tramadol tablet
extended
release 24 hr
100 mg Generic-2 30 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tramadol tablet
extended
release 24 hr
200 mg Generic-2 30 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tramadol tablet, ER
multiphase 24
hr
300 mg Generic-2 30 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tramadol tablet 50 mg PrefGen-1 240 30 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tramadol
capsule,ER
biphase 24 hr
25-75 100 mg
NonPrefBrand-4
30 30
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tramadol
capsule,ER
biphase 24 hr
25-75 200 mg
NonPrefBrand-4
30 30
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tramadol
capsule,ER
biphase 24 hr
17-83 300 mg
NonPrefBrand-4
30 30
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
tramadol-
acetaminophe
n
tablet 37.5-
325 mg
Generic-2 372 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
444 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
trandolapril tablet 2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
trandolapril tablet 4 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
trandolapril tablet 1 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
trandolapril-
verapamil
tablet, IR -
ER, biphasic
24hr
1-240
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
trandolapril-
verapamil
tablet, IR -
ER, biphasic
24hr
2-180
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
trandolapril-
verapamil
tablet, IR -
ER, biphasic
24hr
2-240
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
trandolapril-
verapamil
tablet, IR -
ER, biphasic
24hr
4-240
mg
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
tranexamic
acid
solution 1,000
mg/10
mL
(100
mg/mL)
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
tranexamic
acid
tablet 650 mg Generic-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNTransderm-
Scop
patch 3 day 1.5 mg
(1 mg
over 3
days)
NonPrefBrand-4 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
445 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tranylcypromi
ne
tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Travasol 10
%
parenteral
solution
10 % Generic-2 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTSTravatan Z drops 0.004 % PrefBrand-3 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGStravoprost
(benzalkoniu
m)
drops 0.004 % Generic-2 NO OPHTHALMOLOGY OTHER
GLAUCOMA
DRUGStrazodone tablet 150 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trazodone tablet 300 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trazodone tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trazodone tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Treanda recon soln 100 mg
NonPrefBrand-4 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
446 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Trecator tablet 250 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESTrelstar suspension
for
reconstitution
22.5 mg PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Trelstar syringe 3.75
mg/2
mL
PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Trelstar syringe 11.25
mg/2
mL
PrefBrand-3 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tresiba
FlexTouch U-
100 insulin pen
100
unit/mL
(3 mL)
NonPrefBrand-4 NOENDOCRINE/DIABE
TES
DIABETES
THERAPYTresiba
FlexTouch U-
200 insulin pen
200
unit/mL
(3 mL)
NonPrefBrand-4 NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
tretinoin cream 0.025 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
tretinoin cream 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
tretinoin cream 0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
tretinoin gel 0.05 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
447 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
tretinoin gel 0.01 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
tretinoin gel 0.025 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
tretinoin
(chemotherap
y)
capsule 10 mg Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
tretinoin
microspheres
gel with
pump
0.1 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
tretinoin
microspheres
gel with
pump
0.04 % Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Trexall tablet 5 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Trexall tablet 10 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Trexall tablet 7.5 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Trexall tablet 15 mg PrefBrand-3 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
448 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Treximet tablet 85-500
mg
NonPrefBrand-4 10 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
triamcinolone
acetonide cream 0.1 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamcinolone
acetonide ointment 0.025 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamcinolone
acetonide ointment 0.1 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamcinolone
acetonide ointment 0.5 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamcinolone
acetonide cream 0.025 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamcinolone
acetonide cream 0.5 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamcinolone
acetonide paste 0.1 %
Generic-2 NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
triamcinolone
acetonide aerosol
0.147
mg/gra
m
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamcinolone
acetonide lotion 0.025 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
449 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
triamcinolone
acetonide lotion 0.1 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triamterene-
hydrochloroth
iazid
capsule 50-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
triamterene-
hydrochloroth
iazid
capsule 37.5-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
triamterene-
hydrochloroth
iazid
tablet 37.5-25
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
triamterene-
hydrochloroth
iazid
tablet 75-50
mg
PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Trianex ointment 0.05 %
Generic-2 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
triazolam tablet 0.125
mg
Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
triazolam tablet 0.25 mg Generic-2 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Tribenzor tablet
20-5-
12.5 mg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tribenzor tablet
40-10-
12.5 mg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
450 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tribenzor tablet
40-10-
25 mg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tribenzor tablet
40-5-
12.5 mg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Tribenzor tablet
40-5-25
mg
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Triderm cream 0.1 %
PrefGen-1 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
CORTICOSTEROIDS
trifluoperazin
e
tablet 1 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trifluoperazin
e
tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trifluoperazin
e
tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trifluoperazin
e
tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trifluridine drops 1 % Generic-2 NO OPHTHALMOLOGY ANTIVIRALS
451 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
trihexyphenid
yl
tablet 2 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
trihexyphenid
yl
elixir 0.4
mg/mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
trihexyphenid
yl
tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
Tri-Legest Fe tablet
1-
20(5)/1-
30(7)
/1mg-
35mcg
(9) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Trileptal tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Trileptal tablet 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Trileptal tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
452 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Trileptal suspension 300
mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Tri-Lo-
Estarylla tablet
0.18/0.2
15/0.25
mg-25
mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Tri-Lo-
Sprintec
tablet 0.18/0.2
15/0.25
mg-25
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSTriLyte With
Flavor
Packets
recon soln 420
gram
Generic-2 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTStrimethoprim tablet 100 mg Generic-2 NO ANTI - INFECTIVES URINARY TRACT
AGENTStrimipramine capsule 100 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trimipramine capsule 25 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
trimipramine capsule 50 mg PrefBrand-3 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
453 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
TriNessa (28) tablet 0.18/0.2
15/0.25
mg-35
mcg
(28)
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Trintellix tablet 10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Trintellix tablet 20 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Trintellix tablet 5 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Tri-Previfem
(28)
tablet 0.18/0.2
15/0.25
mg-35
mcg
(28)
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Trisenox solution 10
mg/10
mL
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Tri-Sprintec
(28)
tablet 0.18/0.2
15/0.25
mg-35
mcg
(28)
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Triumeq tablet
600-50-
300 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
454 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Trivora (28) tablet 50-30
(6)/75-
40
(5)/125-
30(10)
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Trizivir tablet 300-150-
300 mg
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Trokendi XR
capsule,exten
ded release
24hr 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Trokendi XR
capsule,exten
ded release
24hr 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Trokendi XR
capsule,exten
ded release
24hr 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Trokendi XR
capsule,exten
ded release
24hr 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
TrophAmine
10 %
parenteral
solution 10 %
NonPrefBrand-4 YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
Trophamine
6%
parenteral
solution 6 % PrefBrand-3
YES VITAMINS,
HEMATINICS /
ELECTROLYTES
MISCELLANEOUS
NUTRITION
PRODUCTS
455 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
trospium tablet 20 mg Generic-2 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
trospium capsule,exten
ded release
24hr
60 mg Generic-2 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
Trumenba syringe
120
mcg/0.5
mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Truvada tablet 200-300
mg
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Truvada tablet
100-150
mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Truvada tablet
133-200
mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Truvada tablet
167-250
mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Twinrix (PF) suspension 720
Elisa
unit -20
mcg/mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Tybost tablet 150 mg PrefBrand-3NO
ANTI - INFECTIVES ANTIVIRALS
Tygacil recon soln 50 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESTykerb tablet 250 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
456 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Tylenol-
Codeine #3 tablet
300-30
mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Tylenol-
Codeine #4 tablet
300-60
mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Typhim VI solution 25
mcg/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Typhim VI syringe
25
mcg/0.5
mL
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Tysabri solution 300
mg/15
mL
Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Tyvaso solution for
nebulization
1.74
mg/2.9
mL (0.6
mg/mL)
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Tyzeka tablet 600 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Tyzine drops 0.05 % PrefBrand-3
NO EAR, NOSE /
THROAT
MEDICATIONS
MISCELLANEOUS
AGENTS
Uloric tablet 40 mg PrefBrand-3 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
457 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Uloric tablet 80 mg PrefBrand-3 NO MUSCULOSKELET
AL /
RHEUMATOLOGY
GOUT THERAPY
Unithroid tablet 25 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 88 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 100
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 112
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 125
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 150
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 200
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 300
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 50 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 175
mcg
PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONESUnithroid tablet 75 mcg PrefGen-1 NO ENDOCRINE/DIABE
TES
THYROID
HORMONES
Uptravi tablet
1,000
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Uptravi tablet
1,200
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
458 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Uptravi tablet
1,400
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Uptravi tablet
1,600
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Uptravi tablet
200
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Uptravi tablet
400
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Uptravi tablet
600
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Uptravi tablet
800
mcg
Specialty-5 YES CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Uptravi
tablets,dose
pack
200
mcg
(140)-
800
mcg
(60)
Specialty-5 YES
CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
ursodiol tablet 500 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSursodiol capsule 300 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSursodiol tablet 250 mg PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
459 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Uvadex solution 20
mcg/mL
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSVagifem tablet 10 mcg NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGY
ESTROGENS /
PROGESTINSvalacyclovir tablet 1 gram Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
valacyclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Valchlor gel 0.016 %
NonPrefBrand-4 YES DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
Valcyte tablet 450 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Valcyte recon soln 50
mg/mL
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
valganciclovir tablet 450 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
valproate
sodium solution
500
mg/5
mL
(100
mg/mL)
Generic-2 NOAUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
valproic acid capsule 250 mg
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
valproic acid
(as sodium
salt) solution
250
mg/5
mL
Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
460 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
valsartan tablet 80 mg Generic-2 62 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan tablet 320 mg Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan tablet 160 mg Generic-2 62 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan tablet 40 mg Generic-2 62 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan-
hydrochloroth
iazide
tablet 80-12.5
mg
Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan-
hydrochloroth
iazide
tablet 160-
12.5 mg
Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan-
hydrochloroth
iazide
tablet 160-25
mg
Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan-
hydrochloroth
iazide
tablet 320-
12.5 mg
Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
valsartan-
hydrochloroth
iazide
tablet 320-25
mg
Generic-2 31 31 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Vancocin capsule 125 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN
Vancocin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN
vancomycin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES VANCOMYCIN
461 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
vancomycin capsule 125 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN
vancomycin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES VANCOMYCIN
vancomycin recon soln 1,000
mg
Generic-2 NO ANTI - INFECTIVES VANCOMYCIN
vancomycin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES VANCOMYCIN
Vandazole gel 0.75 % Generic-2 NO OBSTETRICS /
GYNECOLOGY
MISCELLANEOUS
OB/GYNVaqta (PF) syringe 50
unit/mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Vaqta (PF) syringe 25
unit/0.5
mL
PrefBrand-3 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Varivax (PF)
suspension
for
reconstitution
1,350
unit/0.5
mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Varizig solution
125
unit/1.2
mL
NonPrefBrand-4 NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Varubi tablet 90 mg
NonPrefBrand-4 YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Vascepa capsule 1 gram
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
462 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Vecamyl tablet 2.5 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
MISCELLANEOUS
CARDIOVASCULAR
AGENTS
Vectibix solution 100
mg/5
mL (20
mg/mL)
NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Velcade recon soln 3.5 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Velivet
Triphasic
Regimen (28)
tablet 0.1/.125
/.15-25
mg-mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Velphoro
tablet,chewab
le 500 mg
Specialty-5 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Veltassa
powder in
packet
8.4
gram
NonPrefBrand-4
30 30
YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Veltassa
powder in
packet
16.8
gram
NonPrefBrand-4
30 30
YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Veltassa
powder in
packet
25.2
gram
NonPrefBrand-4
30 30
YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Venclexta tablet 100 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
463 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Venclexta tablet 10 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Venclexta tablet 50 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Venclexta
Starting Pack
tablets,dose
pack
10 mg-
50 mg-
100 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
venlafaxine tablet 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine capsule,exten
ded release
24hr
150 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine capsule,exten
ded release
24hr
37.5 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet 37.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
464 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
venlafaxine capsule,exten
ded release
24hr
75 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet 75 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet
extended
release 24hr
150 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet
extended
release 24hr
225 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet
extended
release 24hr
37.5 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
venlafaxine tablet
extended
release 24hr
75 mg Generic-2 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Ventavis solution for
nebulization
10
mcg/mL
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSVentavis solution for
nebulization
20
mcg/mL
Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
465 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Ventolin
HFA
HFA aerosol
inhaler
90
mcg/act
uation
PrefBrand-3 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Veramyst spray,suspens
ion
27.5
mcg/act
uation
NonPrefBrand-4 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
verapamil capsule, 24 hr
ER pellet CT
100 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil capsule, 24 hr
ER pellet CT
200 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil capsule, 24 hr
ER pellet CT
300 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil capsule,ext
rel. pellets 24
hr
120 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil capsule,ext
rel. pellets 24
hr
180 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil capsule,ext
rel. pellets 24
hr
240 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil capsule,ext
rel. pellets 24
hr
360 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil tablet
extended
release
180 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil tablet
extended
release
240 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
466 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
verapamil tablet
extended
release
120 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil tablet 120 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil tablet 80 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil solution 2.5
mg/mL
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil tablet 40 mg Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
verapamil tablet
extended
release
120 mg
(24
hours)
Generic-2 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
ANTIHYPERTENSIV
E THERAPY
Veregen ointment 15 % NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LSVeripred 20 solution 20 mg/5
mL (4
mg/mL)
Generic-2 NO ENDOCRINE/DIABE
TES
ADRENAL
HORMONES
Versacloz suspension
50
mg/mL PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vesicare tablet 10 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
467 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Vesicare tablet 5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGIC
S /
ANTISPASMODICS
Vestura (28) tablet
3-0.02
mg
Generic-2 NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Vfend tablet 50 mg Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSVfend tablet 200 mg Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSVfend suspension
for
reconstitution
200
mg/5
mL (40
mg/mL)
Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
Viberzi tablet 75 mg
Specialty-5
62 31
YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Viberzi tablet 100 mg
Specialty-5
62 31
YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Vicodin tablet
5-300
mg Generic-2 403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Vicodin ES tablet
7.5-300
mg Generic-2 403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
468 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Vicodin HP tablet
10-300
mg Generic-2 403 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Victoza 3-Pak pen injector 0.6
mg/0.1
mL (18
mg/3
mL)
PrefBrand-3 NO ENDOCRINE/DIABE
TES
DIABETES
THERAPY
Vidaza recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Videx 2 gram
Pediatric
recon soln 10
mg/mL
(Final)
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Videx EC capsule,delay
ed
release(DR/E
C)
125 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Videx EC capsule,delay
ed
release(DR/E
C)
200 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Videx EC capsule,delay
ed
release(DR/E
C)
400 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Videx EC capsule,delay
ed
release(DR/E
C)
250 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
469 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Viekira Pak
tablets,dose
pack
12.5 mg-
75 mg -
50
mg/250
mg
Specialty-5
112 28
YES
ANTI - INFECTIVES ANTIVIRALS
Vienva tablet
0.1-20
mg-mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Vigamox drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIBIOTICS
Viibryd tablet 10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Viibryd tablet 20 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Viibryd tablet 40 mg
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Viibryd
tablets,dose
pack
10 mg
(7)- 20
mg (23)
NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vimovo
tablet,IR,dela
yed
rel,biphasic
375-20
mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
470 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Vimovo
tablet,IR,dela
yed
rel,biphasic
500-20
mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Vimpat solution 200
mg/20
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Vimpat tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Vimpat tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Vimpat tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Vimpat tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Vimpat solution
10
mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
vinblastine solution 1
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
471 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Vincasar PFS solution 1
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
vincristine solution 1
mg/mL
Generic-2 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
vinorelbine solution 50 mg/5
mL
Generic-2 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Viracept tablet 250 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Viracept tablet 625 mg Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Viramune suspension 50 mg/5
mL
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Viramune XR
tablet
extended
release 24 hr 400 mg
NonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
Viramune XR
tablet
extended
release 24 hr 100 mg
NonPrefBrand-4 NO
ANTI - INFECTIVES ANTIVIRALS
Virazole recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Viread tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Viread tablet 250 mg PrefBrand-3NO
ANTI - INFECTIVES ANTIVIRALS
Viread tablet 150 mg PrefBrand-3NO
ANTI - INFECTIVES ANTIVIRALS
472 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Viread tablet 200 mg PrefBrand-3NO
ANTI - INFECTIVES ANTIVIRALS
Viread powder
40
mg/scoo
p (40
mg/gra
m) PrefBrand-3
NO
ANTI - INFECTIVES ANTIVIRALS
Vitekta tablet 85 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Vitekta tablet 150 mgSpecialty-5 NO
ANTI - INFECTIVES ANTIVIRALS
Vivitrol suspension,ex
tended rel
recon
380 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Vogelxo
gel in metered-
dose pump
1.25
gram/
actuatio
n (1 %)
NonPrefBrand-4 YES
ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Vogelxo gel
50 mg/5
gram (1
%)
NonPrefBrand-4 YESENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Voltaren gel 1 % NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
voriconazole tablet 200 mg Specialty-5 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSvoriconazole tablet 50 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTSvoriconazole solution 200 mg Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
473 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
voriconazole suspension
for
reconstitution
200
mg/5
mL (40
mg/mL)
Generic-2 NO ANTI - INFECTIVES ANTIFUNGAL
AGENTS
Votrient tablet 200 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
VPRIV recon soln 400 unit Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Vraylar capsule 1.5 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vraylar capsule 3 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vraylar capsule 4.5 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vraylar capsule 6 mg
Specialty-5
31 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vraylar
capsule,dose
pack
1.5 mg
(1)- 3
mg (6)
NonPrefBrand-4
14 365
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
474 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Vyfemla (28) tablet
0.4-35
mg-mcg Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Vyvanse capsule 20 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vyvanse capsule 30 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vyvanse capsule 40 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vyvanse capsule 70 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vyvanse capsule 60 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vyvanse capsule 50 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Vyvanse capsule 10 mg
NonPrefBrand-4
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
475 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
warfarin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 2 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 3 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 4 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 6 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
warfarin tablet 7.5 mg PrefGen-1 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
water for
irrigation,
sterile
solution Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
WelChol powder in
packet
3.75
gram
PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
476 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
WelChol tablet 625 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTS
Wellbutrin
SR
tablet
extended
release 100 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Wellbutrin
SR
tablet
extended
release 150 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Wellbutrin
SR
tablet
extended
release 200 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Wellbutrin
XL
tablet
extended
release 24 hr 150 mg
NonPrefBrand-4
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Wellbutrin
XL
tablet
extended
release 24 hr 300 mg
NonPrefBrand-4
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xalkori capsule 200 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Xalkori capsule 250 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
477 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Xanax tablet 0.25 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xanax tablet 0.5 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xanax tablet 1 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xanax tablet 2 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xanax XR tablet
extended
release 24 hr
3 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xanax XR tablet
extended
release 24 hr
2 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xanax XR tablet
extended
release 24 hr
1 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Xanax XR tablet
extended
release 24 hr
0.5 mg NonPrefBrand-4 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
478 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Xarelto tablet 10 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Xarelto tablet 15 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Xarelto tablet 20 mg PrefBrand-3
NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Xarelto
tablets,dose
pack
15 mg
(42)- 20
mg (9) PrefBrand-3
NOCARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
Xeljanz tablet 5 mg
Specialty-5 YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Xeljanz XR
tablet
extended
release 24 hr 11 mg
Specialty-5
31 31
YES MUSCULOSKELET
AL /
RHEUMATOLOGY
OTHER
RHEUMATOLOGIC
ALS
Xenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Xenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MISCELLANEOUS
NEUROLOGICAL
THERAPY
Xeomin recon soln 50 unit
NonPrefBrand-4 YESIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
479 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Xgeva solution
120
mg/1.7
mL (70
mg/mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Xifaxan tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESXifaxan tablet 550 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Xigduo XR
tablet, IR -
ER, biphasic
24hr
10-
1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Xigduo XR
tablet, IR -
ER, biphasic
24hr
5-500
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Xigduo XR
tablet, IR -
ER, biphasic
24hr
5-1,000
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Xigduo XR
tablet, IR -
ER, biphasic
24hr
10-500
mg PrefBrand-3
NOENDOCRINE/DIABE
TES
DIABETES
THERAPY
Xodol 10/300 tablet 10-300
mg
NonPrefBrand-4 403 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Xodol 5/300 tablet 5-300
mg
NonPrefBrand-4 403 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Xodol
7.5/300
tablet 7.5-300
mg
NonPrefBrand-4 403 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
480 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Xolair recon soln 150 mg Specialty-5 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSXopenex solution for
nebulization
0.63
mg/3
mL
NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Xopenex solution for
nebulization
0.31
mg/3
mL
NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Xopenex solution for
nebulization
1.25
mg/3
mL
NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Xtampza ER
capsule,sprink
le,ER 12hr
tmprr 9 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Xtampza ER
capsule,sprink
le,ER 12hr
tmprr 13.5 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Xtampza ER
capsule,sprink
le,ER 12hr
tmprr 18 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Xtampza ER
capsule,sprink
le,ER 12hr
tmprr 27 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Xtampza ER
capsule,sprink
le,ER 12hr
tmprr 36 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
481 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Xtandi capsule 40 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Xyrem solution 500
mg/mL
Specialty-5 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Yervoy solution
50
mg/10
mL (5
mg/mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
YF-Vax (PF)
suspension
for
reconstitution
10
exp4.74
unit/0.5
mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
zafirlukast tablet 20 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSzafirlukast tablet 10 mg Generic-2 NO RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSzaleplon capsule 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
zaleplon capsule 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zaltrap solution
100
mg/4
mL (25
mg/mL)
Specialty-5 NOANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
482 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zamicet solution 10-325
mg/15
mL
Generic-2 5723 31 YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Zanosar recon soln 1 gram NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zarontin capsule 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Zarontin solution 250
mg/5
mL
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Zarxio syringe
300
mcg/0.5
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Zarxio syringe
480
mcg/0.8
mL
Specialty-5 NO IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Zavesca capsule 100 mg Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Zebutal capsule
50-325-
40 mg Generic-2 372 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Zelapar tablet,disinteg
rating
1.25 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTIPARKINSONIS
M AGENTS
483 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zelboraf tablet 240 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zemaira recon soln
1,000
mg
Specialty-5 YES DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Zembrace
Symtouch pen injector
3
mg/0.5
mL
NonPrefBrand-4
8 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Zemplar solution 5
mcg/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESZemplar solution 2
mcg/mL
NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESZemplar capsule 1 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESZemplar capsule 2 mcg NonPrefBrand-4 YES ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Zenatane capsule 30 mg Generic-2
NO DERMATOLOGICA
LS/TOPICAL
THERAPY
THERAPY FOR
ACNE
Zenchent Fe
tablet,chewab
le
0.4mg-
35mcg(
21) and
75 mg
(7) Generic-2
NO
OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
Zenpep capsule,delay
ed
release(DR/E
C)
10,000-
34,000 -
55,000
unit
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
484 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zenpep capsule,delay
ed
release(DR/E
C)
15,000-
51,000 -
82,000
unit
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zenpep capsule,delay
ed
release(DR/E
C)
20,000-
68,000 -
109,000
unit
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zenpep capsule,delay
ed
release(DR/E
C)
5,000-
17,000 -
27,000
unit
PrefBrand-3 NO GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zenpep
capsule,delay
ed
release(DR/E
C)
3,000-
10,000-
16,000
unit PrefBrand-3
NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zenpep
capsule,delay
ed
release(DR/E
C)
25,000-
85,000-
136,000
unit PrefBrand-3
NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zenpep
capsule,delay
ed
release(DR/E
C)
40,000-
136,000-
218,000
unit PrefBrand-3
NO
GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zenzedi tablet 10 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zenzedi tablet 5 mg Generic-2
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
485 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zenzedi tablet 2.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zenzedi tablet 7.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zenzedi tablet 15 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zenzedi tablet 20 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zenzedi tablet 30 mg
NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zepatier tablet
50-100
mgSpecialty-5
28 28YES
ANTI - INFECTIVES ANTIVIRALS
Zerbaxa recon soln
1.5
gramSpecialty-5 NO
ANTI - INFECTIVES CEPHALOSPORINS
Zerit capsule 15 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Zerit capsule 20 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Zerit capsule 30 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Zerit capsule 40 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
486 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zerit recon soln 1
mg/mL
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Zetia tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
LIPID/CHOLESTER
OL LOWERING
AGENTSZiagen tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Ziagen solution 20
mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
zidovudine capsule 100 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
zidovudine tablet 300 mg Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
zidovudine syrup 10
mg/mL
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Zinecard (as
HCl)
recon soln 250 mg NonPrefBrand-4 NO ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ADJUNCTIVE
AGENTS
Zioptan (PF) dropperette
0.0015
%
NonPrefBrand-4 NO
OPHTHALMOLOGY
OTHER
GLAUCOMA
DRUGS
ziprasidone
HCl
capsule 40 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
ziprasidone
HCl
capsule 60 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
487 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
ziprasidone
HCl
capsule 80 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
ziprasidone
HCl
capsule 20 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zirgan gel 0.15 % NonPrefBrand-4 NO OPHTHALMOLOGY ANTIVIRALS
Zmax suspension,ex
tended rel
recon
2
gram/60
mL
NonPrefBrand-4 NO ANTI - INFECTIVES ERYTHROMYCINS /
OTHER
MACROLIDESZofran (as
hydrochloride
)
tablet 4 mg Specialty-5 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSZofran (as
hydrochloride
)
tablet 8 mg Specialty-5 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSZofran (as
hydrochloride
)
solution 4 mg/5
mL
Specialty-5 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSZofran ODT tablet,disinteg
rating
4 mg NonPrefBrand-4 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTSZofran ODT tablet,disinteg
rating
8 mg Specialty-5 YES GASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zohydro ER
capsule, oral
only, ER 12hr 10 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
488 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zohydro ER
capsule, oral
only, ER 12hr 15 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Zohydro ER
capsule, oral
only, ER 12hr 20 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Zohydro ER
capsule, oral
only, ER 12hr 30 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Zohydro ER
capsule, oral
only, ER 12hr 40 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
Zohydro ER
capsule, oral
only, ER 12hr 50 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NARCOTIC
ANALGESICS
zoledronic
acid
solution 4 mg/5
mL
Generic-2 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONESzoledronic
acid-mannitol-
water
solution 5
mg/100
mL
Generic-2 NO DIAGNOSTICS /
MISCELLANEOUS
AGENTS
MISCELLANEOUS
AGENTS
Zolinza capsule 100 mg Specialty-5 YES ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
zolmitriptan tablet 2.5 mg Generic-2 16 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
489 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
zolmitriptan tablet 5 mg Generic-2 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYzolmitriptan tablet,disinteg
rating
2.5 mg Generic-2 16 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYzolmitriptan tablet,disinteg
rating
5 mg Generic-2 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYzolpidem tablet 10 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
zolpidem tablet 5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
zolpidem tablet,ext
release
multiphase
12.5 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
zolpidem tablet,ext
release
multiphase
6.25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
zolpidem tablet 1.75 mg PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
490 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
zolpidem tablet 3.5 mg PrefBrand-3
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zomacton recon soln 10 mg
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Zomacton recon soln 5 mg
Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Zometa solution 4 mg/5
mL
Specialty-5 NO ENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Zometa solution
4
mg/100
mL
Specialty-5 NOENDOCRINE/DIABE
TES
MISCELLANEOUS
HORMONES
Zomig tablet 2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYZomig tablet 5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYZomig spray,non-
aerosol
5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
Zomig
spray,non-
aerosol 2.5 mg
NonPrefBrand-4
16 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPY
491 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zomig ZMT tablet,disinteg
rating
2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYZomig ZMT tablet,disinteg
rating
5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
MIGRAINE /
CLUSTER
HEADACHE
THERAPYZonegran capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Zonegran capsule 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
zonisamide capsule 100 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
zonisamide capsule 25 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
zonisamide capsule 50 mg Generic-2 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
ANTICONVULSANT
S
Zontivity tablet 2.08 mg
NonPrefBrand-4 NO CARDIOVASCULAR
, HYPERTENSION /
LIPIDS
COAGULATION
THERAPY
492 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zorbtive recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY
DRUGS
Zortress tablet 0.25 mg
NonPrefBrand-4 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zortress tablet 0.5 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zortress tablet 0.75 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zostavax (PF)
suspension
for
reconstitution
19,400
unit/0.6
5 mL PrefBrand-3
NOIMMUNOLOGY,
VACCINES /
BIOTECHNOLOGY
VACCINES /
MISCELLANEOUS
IMMUNOLOGICALS
Zosyn in
dextrose (iso-
osm)
piggyback 2.25
gram/50
mL
PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS
Zosyn in
dextrose (iso-
osm)
piggyback 3.375
gram/50
mL
PrefBrand-3 NO ANTI - INFECTIVES PENICILLINS
Zovia 1/35E
(28)
tablet 1-35 mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTSZovia 1/50E
(28)
tablet 1-50 mg-
mcg
Generic-2 NO OBSTETRICS /
GYNECOLOGY
ORAL
CONTRACEPTIVES
/ RELATED
AGENTS
493 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zovirax cream 5 % PrefBrand-3 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
TOPICAL
ANTIVIRALS
Zubsolv tablet
1.4-0.36
mg
NonPrefBrand-4
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Zubsolv tablet
5.7-1.4
mg
NonPrefBrand-4
31 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Zubsolv tablet
11.4-2.9
mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Zubsolv tablet
8.6-2.1
mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Zubsolv tablet
2.9-0.71
mg
NonPrefBrand-4
93 31
NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
NON-NARCOTIC
ANALGESICS
Zuplenz film 8 mg
NonPrefBrand-4 YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zuplenz film 4 mg
NonPrefBrand-4 YESGASTROENTEROL
OGY
MISCELLANEOUS
GASTROINTESTINA
L AGENTS
Zyclara
cream in
packet 3.75 %
Specialty-5 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
494 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zyclara
cream in
metered-dose
pump 2.5 %
NonPrefBrand-4 NO DERMATOLOGICA
LS/TOPICAL
THERAPY
MISCELLANEOUS
DERMATOLOGICA
LS
Zydelig tablet 100 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zydelig tablet 150 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zyflo tablet 600 mg NonPrefBrand-4 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTSZyflo CR tablet, ER
multiphase 12
hr
600 mg Specialty-5 YES RESPIRATORY AND
ALLERGY
PULMONARY
AGENTS
Zykadia capsule 150 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
Zylet drops,suspens
ion
0.3-0.5
%
NonPrefBrand-4 NO OPHTHALMOLOGY STEROID-
ANTIBIOTIC
COMBINATIONSZyprexa
Relprevv
suspension
for
reconstitution
210 mg Specialty-5 NO AUTONOMIC / CNS
DRUGS,
NEUROLOGY /
PSYCH
PSYCHOTHERAPEU
TIC DRUGS
Zytiga tablet 250 mg
Specialty-5 YESANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
ANTINEOPLASTIC /
IMMUNOSUPPRESS
ANT DRUGS
495 Formulary ID: 16256 Version: 17 Updated 09/2016
5T Medicare Part D: 5 Tier Closed Formulary
Drug Name Dosage Form Strength Tier Level
Quantity Limit
Amount
Quantity
Limit Days
Prior
Authorization
HPMS Therapeutic
Category
HPMS Therapeutic
Class
Zyvox parenteral
solution
600
mg/300
mL
Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
Zyvox tablet 600 mg Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVESZyvox suspension
for
reconstitution
100
mg/5
mL
Specialty-5 NO ANTI - INFECTIVES MISCELLANEOUS
ANTIINFECTIVES
496 Formulary ID: 16256 Version: 17 Updated 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
actemra All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Kineret,
Remicade,
Humira,
Orencia, Enbrel,
Simponi, Cimzia
Documentation of moderate to
severe rheumatoid arthritis -OR-
documentation of moderate to
severe juvenile idiopathic
rheumatoid arthritis (Actemra IV
only)
12 months For Actemra SubQ,
patients must have an
adequate trial or
intolerance to the
preferred SubQ
products, Enbrel and
Humira, for
rheumatoid arthritis.
For Actemra IV,
patients must have an
adequate trial or
intolerance to one of
the preferred IV
products, Remicade or
Simponi Aria, for
rheumatoid arthritis.
1 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Covered for the following
indications: 1. Infantile spasms
(West syndrome) 2. Acute
exacerbations of multiple sclerosis
(MS) for patients receiving
concurrent immunomodulator
therapy (e.g., interferon beta,
glatiramer acetate, dimethyl
fumerate, fingolimod,
teriflunomide) 3. Rheumatic
disorders 4. Collagen diseases 5.
Dermatologic diseases 6. Allergic
states 7. Ophthalmic diseases 8.
Respiratory diseases 9.
Transfusion reaction due to serum
protein reaction 10. Proteinuria in
nephrotic syndrome and
trial/failure or contraindication to
two therapies from any of the
following different classes:
corticosteroids (e.g., cortisone or
dexamethasone), calcineurin
inhibitors (e.g, cyclosporine or
tacrolimus, per DRUGDEX). 11.
Diagnosis for adrenal insufficiency
with trial/failure or
acthar h.p. All medically
accepted
indications
not otherwise
excluded from
Part D
neurologist for
infantile
spasm
1 month
2 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteriawith trial/failure or
contraindication to cosyntropin.
12. Gout and intolerance or
contraindication to at least two
first-line gout therapies (e.g,
allopurinol, probenecid,
colchicine). 13. Pediatric acquired
epileptic aphasia. For covered
indications 2 through 9,
limited/unsatisfactory response or
intolerance (i.e. severe
anaphylaxis) to two corticosteroids
(i.e. IV methylprednisolone, IV
dexamethasone, or high dose oral
steroids) must be documented.
3 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
actimmune All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis 12 months Applies to new starts
only
Diagnosis of pulmonary
hypertension, substantiated by
results from Doppler
echocardiography and/or direct
measurement of pulmonary arterial
pressure, defined as a mean
pulmonary arterial pressure of
greater than or equal to 25 mmHg,
with a pulmonary capillary wedge
pressure of less than 15 mmHg -
OR- diagnosis of chronic
thromboembolic pulmonary
hypertension (CTEPH) (WHO
group 4) after surgical treatment or
inoperable CTEPH.
adempas All FDA
approved
indications
not otherwise
excluded from
Part D
cardiologist,
pulmonologist
12 months
4 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
ADHD
Drugs
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of ADHD -AND-
trial/failure, intolerance or
contraindication to a stimulant
12 months
5 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
afinitor All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of advanced renal
cell carcinoma -OR-
documentation of patients with
progressive neuroendocrine
tumors of pancreatic origin
(PNET) that is unresectable,
locally advanced or metastatic -OR-
documentation of renal
angiomyolipoma and tuberous
sclerosis complex (TSC) -OR-
documentation of use in
postmenopausal advanced
hormone receptor-positive, HER2-
negative breast cancer in
combination with exemestane after
failure of treatment with letrozole
or anastrozole -OR-
documentation of SEGA
associated with tuberous sclerosis
for those not a candidate for
surgical resection.
oncologist 12 months Applies to new starts
only
6 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
alecensa All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of metastatic non-
small cell lung cancer (NSCLC)
that is anaplastic lymphoma kinase
(ALK) positive AND previous
trial and failure or intolerance to
crizotinib (Xalkori)
12 months Applies to new starts
only
ALPHA1-
PROTEIN
ASE
INHIBITO
RS
All FDA
approved
indications
not otherwise
excluded from
Part D
Diagnosis of panacinar
emphysema AND documentation
of a decline in forced expiratory
volume in 1 second (fev1) despite
optimal medical therapy
(bronchodilators, corticosteroids,
oxygen if indicated) AND
documentation of phenotype
(pi*zz, pi*znull or pi*nullnull)
associated with causing serum
alpha 1-antitrypsin of less than 80
mg/dl AND documentation of an
alpha 1-antitrypsin serum level
below the value of 35% of normal
(less than 80 mg/dl).
Deny if less
than 18 years
of age
12 months Covered under Part B
when furnished
incident to a physician
service and is not self-
administered.
7 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
ampyra All FDA
approved
indications
not otherwise
excluded from
Part D
history of
seizure disorder,
Cr Cl less than
50ml/min
Documentation of diagnosis and
functional status score (EDSS
score)
12 months doses greater than 20
mg/day will not be
approved
anabolic
steroids
All medically
accepted
indications
not otherwise
excluded from
Part D
Documentation of diagnosis 12 months
atypical
antipsychot
ics
All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis. If
medication is being used for major
depressive disorder,
documentation of adjunctive
therapy and an adequate trial of 1
alternative antidepressant is
required (e.g. SSRI, SNRI, NDRIs,
TCA, MAOI).
12 months Applies to new starts
only
8 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
aubagio All FDA
approved
indications
not otherwise
excluded from
Part D
Concomitant use
of Aubagio and
other disease
modifying
agents such as
fingolimod,
interferons,
Copaxone ,
Tysabri
Documentation of relapsing-
remitting or relapsing secondary
progressive multiple sclerosis
neurologist 12 months Doses greater than 14
mg per day will not be
approved
belbuca All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of moderate to
severe chronic pain -AND- trial
and failure of at least two previous
federal legend medications for
pain, including NSAIDs, tramadol,
or opioid analgesics
12 months Belbuca should not be
used concomitantly
with substance abuse
therapies.
BELEODA
Q
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of relapsed or
refractory peripheral T-cell
lymphoma (PTCL)
12 months Applies to new starts
only
9 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
berinert All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of use for
treatment of acute abdominal,
facial, or laryngeal attacks of
hereditary angioedema (HAE)
Deny is less
than 12 years
of age
12 months
bosulif All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of chronic
myelogenous leukemia (CML) of
any phase and lack of response or
intolerance to prior therapy (e.g.
imatinib, dasatinib, nilotinib)
12 months Applies to new starts
only
botulinum
toxin
All medically
accepted
indications
not otherwise
excluded from
Part D
Use for cosmetic
purposes
Documentation of diagnosis 12 months
10 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
butrans All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of moderate to
severe chronic pain -AND- trial
and failure of at least two previous
federal legend medications for
pain, including NSAIDs, tramadol,
or opioid analgesics
12 months Butrans should not be
used concomitantly
with substance abuse
therapies.
cabometyx All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of advanced renal
cell carcinoma (RCC) and failure
of one prior anti-angiogenic
therapy
12 months Applies to new starts
only
caprelsa All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of symptomatic or
progressive medullary thyroid
cancer in patients with
unresectable locally advanced or
metastatic disease
12 months Applies to new starts
only
11 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
carbaglu All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of use as an
adjunct therapy for acute
hyperammonemia or maintenance
therapy for chronic
hyperammonemia due to hepatic
enzyme N-acetylglutamate
synthase (NAGS) deficiency
12 months
CERDELG
A
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of type 1 Gaucher
disease
Deny if less
than 18 years
of age
12 months
CF drugs All FDA
approved
indications
not otherwise
excluded from
Part D
Diagnosis of cystic fibrosis. For
Bethkis: failure on, intolerance to,
or contraindication to generic
tobramycin inhalation solution
12 months Inhalation solutions
covered under Part B
when administered in
the home setting using
a covered nebulizer
(i.e. DME).
12 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
chenodal All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of small (less than
15mm in diameter), floatable
radiolucent gallstones AND an
inadequate response to ursodiol
therapy
12 months for
initial
approval with
an additional
12 months
upon renewal
Safety of use beyond
24 months is not
established
cholbam All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of bile acid
synthesis disorders due to single
enzyme defects (SEDs) -OR-
documentation of use as
adjunctive therapy for peroxisomal
disorders (PDs), including
Zellweger spectrum disorders, in
patients who exhibit
manifestations of liver disease,
steatorrhea, or complications from
decreased fat soluble vitamin
absorption.
12 months
13 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
cialis All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of benign prostatic
hyperplasia (BPH) and alternatives
tried/failed (one or more alpha-1
adrenergic blocker)
12 months
14 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Documentation of moderate to
severe rheumatoid arthritis -OR-
moderate to severe Crohn's disease
-OR- psoriatic arthritis -OR-
ankylosing spondylitis
concomitant use
of Enbrel,
Remicade,
Humira,
Orencia,
Simponi,
Actemra,
Kineret
All FDA
approved
indications
not otherwise
excluded from
Part D
cimzia Patients must have an
adequate trial or
intolerance to one
corticosteorid (e.g.,
prednisone or
hydrocortisone) and
the preferred biologic
product, Humira, for a
diagnosis of Crohn's
disease. Patients must
have an adequate trial
or intolerance to both
preferred products,
Enbrel and Humira,
for rheumatoid
arthritis, psoriatic
arthritis and
ankylosing
spondylitis. For initial
and indication therapy
dosing, doses above
plan quantity limit
will be approved
aligned with
recommended initial
12 monthsGastroenterolo
gist/
Rheumatologi
st
15 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteriarecommended initial
and induction therapy
dosing regimens per
indication.
16 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
cinryze All FDA
approved
indications
not otherwise
excluded from
Part D
Coverage for the following two
indications: 1. Use as prophylaxis
for hereditary angioedema (HAE)
type I & II -AND- documentation
that clinical laboratory
performance C4 below lower limit
of laboratory reference range -
AND- C1 inhibitor level below
lower limit of laboratory reference
range -OR- normal C1 inhibitor
level and a low C1INH functional
level below laboratory reference
range -AND- documentation of at
least 1 symptom of angioedema
attack -AND- medications that
cause angioedema have been
evaluated and discontinued. 2.
Use as prophylaxis for hereditary
angioedema (HAE) type III -AND-
documentation that clinical
laboratory performance C4, C1
inhibitor, and C1INH functional
level are within normal limits of
laboratory reference ranges -AND-
documentation of family history of
HAE -OR- FXII mutation -AND-
12 months
17 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
cometriq All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of progressive,
metastatic medullary thyroid
cancer
12 months Applies to new starts
only
HAE -OR- FXII mutation -AND-
documentation of at least 1
symptom of angioedema attack -
AND- medications that cause
angioedema have been evaluated
and discontinued.
18 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
corlanor All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of stable,
symptomatic heart failure and
normal sinus rhythm AND left
ventricular ejection fraction less
than or equal to 35 percent AND
resting heart rate greater than or
equal to 70 beats per minute AND
trial/failure of maximum tolerated
dose of one beta-blocker used for
treatment of heart failure (e.g.,
bisoprolol, carvedilol, metoprolol
succinate) OR contraindication to
beta-blocker use
12 months
19 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Cosentyx All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of moderate to
severe psoriasis and failure of one
systemic therapy (e.g.
methotrexate, cyclosporine) or
phototherapy -OR- active psoriatic
arthritis -OR- active ankylosing
spondylitis
12 months Patients must have an
adequate trial or
intolerance to the
preferred product,
Humira, for psoriasis
and the preferred
products, Enbrel and
Humira, for psoriatic
arthritis and
ankylosing
spondylitis. For
induction therapy
dosing, doses above
plan quantity limit
will be approved
aligned with
recommended
induction therapy
dosing regimens per
indication.
20 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
cotellic All FDA
approved
indications
not otherwise
excluded from
Part D
Disease
progression on
prior BRAF
inhibitor therapy
Documentation of unresectable or
metastatic melanoma in patients
with a BRAF V600E or V600K
mutation AND used in
combination with vemurafenib
oncologist,
hematologist
12 months Applies to new starts
only
crinone All medically
accepted
indications
not otherwise
excluded from
Part D
Use to promote
fertility
Documentation of diagnosis 12 months
21 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
daklinza All FDA
approved
indications
not otherwise
excluded from
Part D
Covered for the following: 1.
Chronic hepatitis C (CHC) gt 1a,
1b, 2 or 3 infection in adults -
AND- documentation that
Daklinza will be used with Sovaldi
-AND- documentation that
Daklinza and Sovaldi will not be
used with other agents to treat
hepatitis C, except ribavirin. 2.
CHC gt 1, 2, 3, or 4 in an allograft -
AND- using with Sovaldi -AND-
using with ribavirin unless
intolerant or ineligible
Deny if less
than 18 years
of age
G1,3:12w
txnncr,txexncr
,24w
txncr,txexcr,R
/INFinel.G2:1
2w txn,24w
txex
INFinel.G1-
4al:12w,24w
Rinel
darzalex All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation for use in the
treatment of multiple myeloma in
patients who have received at least
3 prior lines of therapy including a
proteasome inhibitor (PI) and an
immunomodulatory agent OR for
use in multiple myeloma patients
who are double-refractory to a PI
and an immunomodulatory agent
oncologist,
hematologist
12 months Applies to new starts
only
22 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
egfr
tyrosine
kinase
inhibitors
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of diagnosis,
alternatives tried and failed and
concomitant therapy, if applicable
to diagnosis
oncologist,
hematologist
12 months Coverage of
pancreatic cancer
diagnosis applies only
to erlotinib (Tarceva).
The use of Tarceva
and Gilotrif for non-
small cell lung cancer
(NSCLC) will be
approved as a first-
line therapy. Applies
to new starts only.
egrifta All FDA
approved
indications
not otherwise
excluded from
Part D
Documented diagnosis of HIV and
lipodystrophy, member must
actively be receiving antiretroviral
therapy including protease
inhibitors, nucleoside reverse
transcriptase inhibitors, or non-
nucleoside reverse transcriptase
inhibitors
12 months Applies to new starts
only
23 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
enbrel All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Remicade,
Cimzia, Humira,
Orencia,
Simponi,
Actemra,
Kineret, Stelara
Documentation of moderate to
severe rheumatoid arthritis -OR-
psoriatic arthritis -OR- ankylosing
spondylitis -OR- moderate to
severe juvenile idiopathic
rheumatoid arthritis and an
inadequate response or intolerance
to at least one DMARD (e.g.,
methotrexate, leflunamide) -OR-
moderate to severe psoriasis after
failure of either systemic therapy
(e.g., methotrexate or
cyclosporine) or phototherapy.
Deny if less
than 2 years
old
rheumatologist
, dermatologist
12 months For psoriasis trial of 1
alternative therapy,
either systemic
therapy (e.g.
methotrexate or
cyclosporine) or
phototherapy, is
required.
entresto All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of an ACE
inhibitor or
ARB
Documentation of chronic heart
failure (NYHA Class II to IV)
AND systolic dysfunction (LVEF
less than or equal to 40 percent)
12 months
24 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
erivedge All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of advanced basal
cell carcinoma (BCC), which
includes metastatic and locally
advanced basal cell carcinoma, for
whom surgery is inappropriate
oncologist,
dermatologist
12 months Applies to new starts
only, doses greater
than 150mg/day will
not be approved
farydak All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of use in
combination with bortezomib and
dexamethasone for patients with
multiple myeloma who have
received at least 2 prior regimens,
including bortezomib and an
immunomodulatory agent (i.e.
Thalomid, Revlimid, Pomolyst)
12 months Applies to new starts
only
25 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Acute hereditary angioedema
(HAE) type I & II: Documentation
that clinical laboratory
performance C4 below lower limit
of laboratory reference range -
AND- C1 inhibitor level below
lower limit of laboratory reference
range -OR- normal C1 inhibitor
level and a low C1INH functional
level below laboratory reference
range -AND- documentation of at
least 1 symptom of angioedema
attack -AND- medications that
cause angioedema have been
evaluated and discontinued. Acute
hereditary angioedema (HAE) type
III: Documentation that clinical
laboratory performance C4, C1
inhibitor level and C1INH
functional level are within normal
limits of the laboratory's reference
range -AND- documentation of
HAE family history -OR- FXL
mutation -AND- documentation of
at least 1 symptom of angioedema
attack -AND- medications that
All FDA
approved
indications
not otherwise
excluded from
Part D
firazyr Deny if less
than 18 years
of age
12 months
26 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
flector All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of diagnosis 1 month
attack -AND- medications that
cause angioedema have been
evaluated and discontinued
27 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
forteo All FDA
approved
indications
not otherwise
excluded from
Part D
Diagnosis of
underlying
hypercalcemic
disorder such as
hypercalcemia,
hyperparathyroi
dism or
hypoparathyroid
ism, or high risk
for
osteosarcoma
(Paget's disease,
prior radiation
therapy, bone
metastases, open
epiphyses, etc.).
Treatment
duration greater
than 24 months.
Documentation to support use for
treatment of osteoporosis and the
prevention of fractures in
postmenopausal women and men
having a T score of less than -2.5
and a trial and failure or
contraindication to at least one
bisphosphonate -OR- use to
prevent fractures in men and
postmenopausal women with a
low bone mass (T score between -
1.0 and -2.5) and history of
previous osteoporotic fracture or
those who are found to have a 10-
year risk of major osteoporotic
fracture greater than or equal to 20
percent or a risk of hip fracture
greater than or equal to 3 percent
and had a trial and failure or
contraindication to at least one
bisphosphonate
24 months
28 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
gattex All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of short bowel
syndrome (SBS) AND dependence
on parenteral nutrition or
intravenous nutritional support for
at least 12 months AND requiring
parenteral nutrition at least 3 times
per week
12 months
29 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
All FDA
approved
indications
not otherwise
excluded from
Part D
gilenya neurologist 12 months Doses greater than
0.5mg/day will not be
approved
Members must have a documented
diagnosis of relapsing-remitting,
relapsing secondary progressive or
progressive relapsing multiple
sclerosis -AND- new starts to
therapy have the following
baseline information documented
within 6 months of initiating
therapy: ophthalmologic
evaluation, liver transaminase and
bilirubin, complete blood count,
and electrocardiogram if using an
antiarrhythmic agent or have
second degree or greater AV block
-AND- new starts to therapy do
not have any of the following
comorbid conditions or
concomitant therapies:
bradycardia, congestive heart
failure, sick sinus syndrome,
prolonged QT interval, ischemic
cardiac disease, irregular
heartbeat, current neutropenia,
current chronic or acute infections,
use of antineoplastics,
immunosuppressive or immune
Concomitant
use of Gilenya
and other
disease
modifying
agents such as
interferons,
Copaxone ,
Tysabri
30 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
gleevec All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis and
alternatives tried or concomitant
therapy, if applicable for diagnosis
12 months Applies to new starts
only
gralise All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of diagnosis 12 months Applies to new starts
only
immunosuppressive or immune
modulating therapies
31 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
GRASTEK All FDA
approved
indications
not otherwise
excluded from
Part D
Asthma (severe,
unstable or
unconrolled),
concomitant
sublingual or
subcutaneous
immunotherapy,
therapy
initiation during
active allergy
season
Documentation of allergic rhinitis
and use for Timothy grass pollen
or cross reactive grass pollens
(Sweet Vernal, Orchard, Perennial
Rye, Timothy, Kentucky Blue
Grass pollen, Redtop, or meadow
fescue) -AND- allergic rhinitis
with or without conjunctivitis has
been confirmed by a pollen
specific positive skin test or in
vitro testing for pollen-specific IgE
antibodies -AND- trial and failure
or intolerance to an intranasal
steroid and an oral non-sedating
antihistamine, intranasal
antihistamine or intranasal
anticholinergic agent
Deny if less
than 5 years
of age or
greater than
65 years of
age
allergy
specialist,
otolaryngologi
st
12 months Member must also be
prescribed an
epinephrine auto
injector
growth
hormone
All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis,
growth chart, bone age, growth
velocity, and response to
stimulation test, when applicable
12 months
32 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
HARVONI All FDA
approved
indications
not otherwise
excluded from
Part D
CHC gt 1a, 1b, 4, 5, or 6 infection
in adults (18 years and older) -
AND- Harvoni will not be used
with another agent to treat hep C
unless tx-exp and using with RBV -
AND- HCV RNA level
documented prior to tx (within
past 6 months of request) -AND-
if cirrhotic, member has comp
cirrhosis -OR- recurrent CHC gt 1
or 4 infection post-liver
transplantation in adults -AND-
using with RBV unless RBV
intolerant or ineligible -OR- CHC
gt 1 or 4 in adults -AND-
decompensated cirrhosis -AND-
using with RBV -AND-
documentation of previous HCV
regimens used
Deny if less
than 18 years
of age
G1:12w txn
nocir, t/f
PR.24w txex
cir,
t/fPI,SOF.G4,
5,6:12w.Dcp
G1,4:12,24w
t/fSOF.Posttx
G1,4:12,24w
Doses greater than
one tablet per day will
not be approved.
33 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
HETLIOZ All FDA
approved
indications
not otherwise
excluded from
Part D
Documented diagnosis of Non-24
Sleep-Wake disorder -AND-
patient is totally blind
12 months
34 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
high-risk
meds
All FDA
approved
indications
not otherwise
excluded from
Part D
Automatic
approval if
less than 65
years of age
12 months Applies to new starts
only for protected
class drugs. Digoxin
doses less than or
equal to 0.125 mg per
day and doxepin
doses less than or
equal to 6 mg per day
will receive automatic
approval.
For all medications subject to this
PA group, the following
information (1 through 3) is
required: 1. Documentation of
diagnosis 2. Explanation of risk-
benefit profile favoring use of the
high-risk medication 3.
Documentation of ongoing
monitoring plan to identify and
address treatment-related adverse
events. In addition to requirements
1 through 3 above, for digoxin
doses exceeding 0.125 mg daily,
provider confirmation that a lower
dose of digoxin has or would be
ineffective in managing the
member's condition is required.
For the target high-risk
medications glyburide, TCAs and
nitrofurantoin, in addition to
criteria 1 through 3 above, trial
and failure or documentation of
intolerance or contraindication to
at least 2 non-high risk alternative
drugs for the same indication, if
available, is required. Non-high
35 Formulary ID: 16256 Version: 17 Update: 09/2016
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteriaavailable, is required. Non-high
risk alternative medications for
those target high-risk medications
include the following: 1.
Glyburide (non-high risk
alternatives include glipizide and
glimepiride) 2. TCAs (non-high
risk alternatives include SSRIs and
SNRIs) 3. Nitrofurantoin (non-
high risk alternatives include
Bactrim, Cipro, or cephalexin). If
using one of the above 3 high-risk
medications for a medically-
accepted indication not shared by
the safer alternatives listed, then
no trial of alternatives is required
for that target high-risk
medication.
36 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
homozygou
s fh
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of homozygous
familial hypercholesterolemia
(HoFH) confirmed by genetic
testing showing functional
mutation(s) in both LDL receptor
alleles or alleles known to affect
LDL receptor functionality -OR-
untreated LDL-C concentrations
greater than 500 mg/dL, treated
LDL-C concentrations greater than
or equal to 300 mg/dL, or a non-
HDL-C concentration greater than
or equal to 330mg/dL -AND- the
presence of Xanthomas in the first
decade of life -OR- documentation
of elevated LDL-C greater than
190 mg/dL prior to lipid-lowering
therapy consistent with HoFH in
both parents
6 months
37 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
horizant All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of moderate to
severe active primary restless leg
syndrome and trial and failure of
two accepted medications for the
treatment of this condition one of
which must include pramipexole
or ropinirole -OR- documentation
of post herpetic neuralgia
12 months Applies to new starts
only
38 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
concomitant use
of Remicade,
Cimzia, Enbrel,
Orencia,
Simponi,
Actemra,
Kineret, Stelara
All FDA
approved
indications
not otherwise
excluded from
Part D
humira For psoriasis trial of 1
alternative therapy,
either systemic
therapy (e.g.
methotrexate or
cyclosporine) or
phototherapy, is
required. For Crohn's
disease, trial of 2
immunosuppressants
(e.g. corticosteroids,
azathioprine) or
monotherapy with
infliximab is required.
For Ulcerative Colitis,
trial of 2
immunosuppressants
(e.g. corticosteroids,
azathioprine or 6-
mercaptopurine) is
required. For plaque
psoriasis induction
therapy, doses above
plan quantity limit
will be approved
aligned with
12 monthsrheumatologist
,
dermatologist,
or
gastroenterolo
gist
Deny if less
than 2 years
old
Documentation of moderate to
severe hidradenitis suppurativa -
OR- moderate to severe
rheumatoid arthritis -OR- psoriatic
arthritis -OR- ankylosing
spondylitis -OR- moderate to
severe juvenile idiopathic
rheumatoid arthritis and an
inadequate response or intolerance
to at least one DMARD (e.g.,
methotrexate, leflunamide) -OR-
moderate to severe psoriasis after
failure of either systemic therapy
(e.g., methotrexate or
cyclosporine) or phototherapy. -
OR- moderate to severe Crohn's
disease after failure of two
immunosuppressants (e.g.,
corticosteroids, azathioprine) or
monotherapy with infliximab -OR-
moderate to severe ulcerative
colitis after failure of two
immunosuppressants (e.g.
corticosteroids, azathioprine or 6-
mercaptopurine).
39 Formulary ID: 16256 Version: 17 Update: 09/2016
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Ibrance All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of ER-positive,
HER2-negative metastatic breast
cancer in postmenopausal women
AND used as initial endocrine-
based therapy for metastatic
disease in combination with
letrozole (Femara)
12 months Applies to new starts
only
aligned with
recommended
induction therapy
dosing regimen. For
rheumatoid arthritis
therapy without
concomitant
methotrexate, doses
above plan quantity
limit will be approved
aligned with
recommended weekly
dosing regimen.
Induction therapy or
treatment regimens
for other indications
are aligned with plan
quantity limit on
Humira starter kit.
40 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
iclusig All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of T3151 chronic
phase, accelerated phase or blast
phase CML -OR- documentation
of T3151 Ph+ ALL -OR-
documentation of chronic phase,
accelerated phase or blast phase
CML in patients for whom no
other tyrosine kinase inhibitor
therapy is indicated -OR-
documentation of Ph+ ALL in
patients for whom no other
tyrosine kinase inhibitor therapy is
indicated.
12 months Applies to new starts
only
ig All medically
accepted
indications
not otherwise
excluded from
Part D
Documentation of diagnosis 12 months Covered under Part B
when administered in
the home to a member
with a diagnosis of
primary
immunodeficiency
disease
41 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
imbruvica All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of mantle cell
lymphoma and treatment with at
least one prior therapy -OR-
documentation of chronic
lymphocytic leukemia and
treatment with at least one prior
therapy -OR- documentation of
Waldenstrom macroglobulinemia
12 months Applies to new starts
only
increlex All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis,
growth chart, stimulation test
results, growth velocity, IGF-1
level
Deny if
greater than
18 years old
12 months
inlyta All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of advanced renal
cell carcinoma (RCC) and failure
one prior systemic therapy
oncologist 12 months Applies to new starts
only
42 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
interferon
alfa
All medically
accepted
indications
not otherwise
excluded from
Part D
documentation of diagnosis only 12 months
interleukin-
1b blockers
All FDA
approved
indications
not otherwise
excluded from
Part D
Concomitant use
with agents that
inhibit IL-1 or
TNF including
Remicade,
Humira, Enbrel,
Orencia, or
Kineret
documentation of diagnosis Deny if less
than 12 years
of age
(Arcalyst) or
less than 2
years of age
(Ilaris)
12 months
43 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
IPF
AGENTS
All FDA
approved
indications
not otherwise
excluded from
Part D
Concomitant use
of pirfenidone
and nintedanib
Documentation of idiopathic
pulmonary fibrosis -AND-
baseline forced vital capacity
(FVC) of at least 50% and a
percent predicted diffusing
capacity of the lungs of carbon
monoxide (DLCO) of at least
30%.
pulmonologist 12 months
iressa All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of metastatic non-
small cell lung cancer (NSCLC) in
patients whose tumors express
EGFR exon 19 deletion mutations
or exon 21 (L858R) mutations as
detected by an FDA-approved test
oncologist,
hematologist
12 months Applies to new starts
only
jakafi All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of intermediate or
high-risk myelofibrosis, including
primary myelofibrosis, post-
polycythemia vera myelofibrosis
and post-essential
thrombocythemia myelofibrosis
oncologist,
hematologist
12 months Applies to new starts
only. Platelet count to
be provided.
44 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
kalydeco All FDA
approved
indications
not otherwise
excluded from
Part D
Homozygous for
the F508del
mutation in the
CFTR gene
Documentation of cystic fibrosis
(CF) in patients who have one of
the following mutations in the
cystic fibrosis transmembrane
conductance regulator (CFTR)
gene, G551D, G1244E, G1349D,
G178R, G551S, S1251N, S1255P,
S549N, S549R or R117H.
Deny if less
than 6 years
of age for oral
tablets and
less than 2
years of age
for oral
granules
pulmonologist 12 months Doses greater than
300mg/day will not be
approved
kanuma All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of diagnosis of
Lysosomal Acid Lipase (LAL)
deficiency
12 months
keveyis All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of one of the
following: 1. Primary
hyperkalemic periodic paralysis 2.
Primary hypokalemic periodic
paralysis 3. Related variants of
primary periodic paralysis
Deny if less
than 18 years
of age
12 months Doses exceeding 200
mg per day will not be
approved.
45 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
KEYTRUD
A
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of unresectable or
metastatic melanoma and disease
progression following ipilimumab
(Yervoy) and, if BRAF V600
mutation positive, a BRAF
inhibitor -OR- metastatic non-
small cell lung cancer (NSCLC)
with PD-L1-positive expressing
tumor, as determined by an FDA-
approved test, after failure of prior
platinum-based chemotherapy
12 months Applies to new starts
only
kineret All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Actemra,
Remicade,
Humira,
Orencia, Enbrel,
Simponi, Cimzia
Documentation of moderate to
severe rheumatoid arthritis and
trial and failure of one DMARD -
OR- neonatal-onset multisystem
inflammatory disease (NOMID) or
chronic infantile neurological,
cutaneous and articular (CINCA)
syndrome
rheumatologist 12 months Patients must have an
adequate trial or
intolerance to the
preferred products,
Enbrel and Humira,
for rheumatoid
arthritis.
46 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
korlym All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of hyperglycemia
secondary to hypercortisolism in
patients with endogenous
Cushing's syndrome who have
Type 2 Diabetes Mellitus or
glucose intolerance AND patient is
not a candidate for surgery or
radiotherapy or where surgery or
radiotherapy has failed
Deny if less
than 18 years
of age
12 months
lenvima All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of locally recurrent
or metastatic, progressive,
radioactive iodine refractory
differentiated thyroid cancer
12 months Applies to new starts
only
leukotriene
modifiers
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of asthma -OR-
documentation of exercise-induced
bronchoconstriction
12 months
47 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
lidoderm All medically
accepted
indications
not otherwise
excluded from
Part D
documentation of postherpetic
neuralgia (PHN) and trial and
failure of 1 other agent used to
treat PHN (e.g. gabapentin) -OR-
documentation of diabetic
neuropathy
12 months
lonsurf All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of metastatic
colorectal cancer in patients who
have previously been treated with
fluoropyrimidine-, oxaliplatin-,
and irinotecan-based
chemotherapy, an anti-VEGF
therapy, and if RAS wild-type, an
anti-EGFR therapy
oncologist 12 months Applies to new starts
only
lynparza All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of use as
monotherapy in patients with
deleterious or suspected
deleterious germline BRCA
mutated advanced ovarian cancer
after trial of three or more prior
lines of chemotherapy (e.g.
carboplatin, cisplatin, paclitaxel,
gemcitabine)
12 months Applies to new starts
only
48 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
lyrica All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of DPN -OR- PHN
-OR- seizures and trial/failure or
intolerance to two AEDS -OR-
neuropathic pain associated with
spinal cord injury -OR-
documentation to support a
diagnosis of fibromyalgia and
trial/failure or intolerance to
duloxetine
12 months Applies to new starts
only
mekinist All FDA
approved
indications
not otherwise
excluded from
Part D
Disease
progression on
prior BRAF
inhibitor therapy
Documentation of unresectable or
metastatic melanoma with
BRAFV600E or BRAFV600K
mutations
12 months Applies to new starts
only
mozobil All FDA
approved
indications
not otherwise
excluded from
Part D
used in combination with
granulocyte-colony stimulating
factor (G-CSF) to mobilize
hematopoietic stem cells to the
peripheral blood for collection and
subsequent autologous
transplantation in patients with
multiple myeloma (MM) and non-
Hodgkins lymphoma (NHL).
oncologist,
hematologist
12 months Applies to new starts
only
49 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
myalept All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of congenital or
acquired generalized lipodystrophy
with absence or loss of
subcutaneous body fat -AND-
Leptin levels less than 8 ng/mL for
males or less than 12 ng/mL for
females -AND- the patient has
been optimized on current diabetic
medication and/or
hypertriglyceridemia medication as
needed -AND- the member has a
diagnosis of diabetes or fasting
insulin levels greater than
30uU/mL or fasting
hypertriglyceridemia greater than
200mg/dL.
12 months For initial
reauthorization, the
member should have a
decreased A1C level
by at least 0.8 or
decreased
triglycerides by 25
percent or decreased
fasting plasma
glucose by 25 percent.
namenda All medically
accepted
indications
not otherwise
excluded from
Part D
Documentation of diagnosis Automatic
approval if 18
years of age
or older
12 months
50 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
namzaric All medically
accepted
indications
not otherwise
excluded from
Part D
Documentation of diagnosis Automatic
approval if 18
years of age
or older
12 months
natpara All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of use as an
adjunct to calcium and vitamin D
to control hypocalcemia in patients
with hypoparathyroidism
12 months
nexavar All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of hepatocellular
carcinoma -OR- advanced renal
cell carcinoma after treatment of 1
other systemic therapy -OR-
locally recurrent or metastatic,
progressive, differentiated thyroid
carcinoma refractory to radioactive
iodine treatment
oncologist,
hematologist
12 months Applies to new starts
only
51 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
ninlaro All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of multiple
myeloma AND previous treatment
with at least 1 prior therapy AND
used in combination with
lenalidomide and dexamethasone
oncologist,
hematologist
12 months Applies to new starts
only
NORTHER
A
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of neurogenic
orthostatic hypotension caused by
primary autonomic failure (e.g.,
Parkinson's disease, multiple
system atrophy, or pure autonomic
failure), dopamine beta-
hydroxylase deficiency or non-
diabetic autonomic neuropathy
12 months
52 Formulary ID: 16256 Version: 17 Update: 09/2016
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Documentation of diagnosis of
severe asthma evidenced by
pretreatment forced expiratory
volume in 1 second (FEV1) less
than 80% predicted and FEV1
reversibility of at least 12% after
albuterol administration -AND-
Either 1 or 2. 1)History of 2 or
more exacerbations in the previous
year despite at least 12 months of
high-dose inhaled corticosteroid
(ICS) given in combination with at
least 3 months of controller
medication (e.g. long-acting beta2-
agonist [LABA], leukotriene
receptor antagonist [LTRA], or
theophylline), unless intolerant of
or contraindication to all of these
agents. 2)Symptoms are
inadequately controlled with use
of 6 months of ICS with daily oral
glucocorticoids given in
combination with a minimum of 3
months of controller medication
(e.g. LABA, LTRA, or
theophylline), unless intolerant of
nucala Deny if less
than 12 years
old
12 monthsAll FDA
approved
indications
not otherwise
excluded from
Part D
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
nuplazid All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of hallucinations
and delusions associated with
Parkinson's disease psychosis
Deny if less
than 18 years
of age
12 months Applies to new starts
only
theophylline), unless intolerant of
or contraindication to all of these
agents. -AND- 3 or 4. 3)Greater
than or equal to 150 cells/uL
screening within 6 weeks of
dosing. 4)Greater than or equal to
300 cells/uL within 12 months of
screening.
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
odomzo All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of locally
advanced basal cell carcinoma
(laBCC) that has recurred
following surgery or radiation
therapy or for use in patients who
are not candidates for surgery or
radiation therapy
12 months Applies to new starts
only
olysio All FDA
approved
indications
not otherwise
excluded from
Part D
Previous failure
of a Protease
Inhibitor used in
hepatitis C
(boceprevir,
telaprevir or
simeprevir) -OR-
decompensated
cirrhosis
Documentation of chronic
hepatitis C genotype 1 infection in
adult patients with compensated
liver disease, including cirrhosis,
who are previously untreated or
who have failed previous
interferon and ribavirin therapy -
AND- used in combination with
peginterferon alfa and ribavirin -
AND- the genotype 1A patient has
been screened and is negative for
the NS3 Q80K polymorphism -OR-
Documentation of chronic
hepatitis C genotype 1infection -
AND- patient will be using
concomitantly with sofosbuvir -
AND- documentation stating
absence or presence of cirrhosis
Deny if less
than 18 years
old
12 wks or 24
wks
depending on
treatment
regimen and
presence or
absence of
cirrhosis
Doses greater than or
less than 150mg/day
will not be approved
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
opdivo All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of unresectable or
metastatic melanoma in patients
previously treated with ipilimumab
(Yervoy) and, if BRAF V600
mutation positive, a BRAF
inhibitor -OR- documentation of
metastatic squamous non-small
cell lung cancer (NSCLC) with
progression on or after platinum-
based chemotherapy -OR-
advanced renal cell carcinoma in
patients who have received prior
antiangiogenic therapy.
12 months Applies to new starts
only
oralair All FDA
approved
indications
not otherwise
excluded from
Part D
Asthma (severe,
unstable or
unconrolled),
concomitant
sublingual or
subcutaneous
immunotherapy,
therapy
initiation during
active allergy
season
Documentation of allergic rhinitis
and use for Sweet Vernal,
Orchard, Perennial Rye, or
Kentucky Blue Grass pollens -
AND- allergic rhinitis with or
without conjunctivitis has been
confirmed by a pollen specific
positive skin test or in vitro testing
for pollen-specific IgE antibodies -
AND- trial and failure or
intolerance to an intranasal steroid
and an oral non-sedating
antihistamine, intranasal
antihistamine or intranasal
anticholinergic agent
Deny if less
than 10 years
of age or
greater than
65 years of
age
allergy
specialist,
otolaryngologi
st
12 months Member must also be
prescribed an
epinephrine auto
injector
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
orencia All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Enbrel,
Remicade,
Humira,
Orencia,
Simponi,
Kineret, Cimzia
Documentation of moderate to
severe rheumatoid arthritis -OR-
documentation of moderate to
severe juvenile idiopathic
rheumatoid arthritis (Orencia IV
only)
rheumatologist 12 months For Orencia SubQ,
patients must have an
adequate trial or
intolerance to the
preferred SubQ
products, Enbrel and
Humira, for
rheumatoid arthritis.
For Orencia IV,
patients must have an
adequate trial or
intolerance to one of
the preferred IV
products, Remicade or
Simponi Aria, for
rheumatoid arthritis.
orkambi All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of cystic fibrosis
and homozygous F508del
mutation
Deny if less
than 12 years
of age
6 months
initial
authorization,
12 months
reauthorizatio
n
For reauthorization,
documentation
showing a FEV1
improvement from
baseline must be
provided.
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
OTEZLA All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Enbrel,
Remicade,
Humira, Cimzia,
Simponi, Stelara
Documentation of active psoriatic
arthritis -OR- documentation of
moderate to severe psoriasis
Deny if less
than 18 years
of age
rheumatologist
, dermatologist
12 months Maintenance doses
greater than 60 mg per
day will not be
approved. Patients
must have an adequate
trial or intolerance to
the preferred
products, Enbrel and
Humira, for psoriatic
arthritis and psoriasis.
pomalyst All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of multiple
myeloma, previous trial of at least
2 therapies including lenalidomide
and bortezomib, and disease
progression on or within 60 days
of last therapy
12 months Applies to new starts
only
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Documentation of the following:
1. Heterozygous Familial
Hypercholesterolemia (HeFH) as
supported by the presence of
causal mutation of familial
hypercholesterolemia by genetic
testing, physical signs of FD (e.g.
xanthomas, xanthelasma), clinical
diagnosis based on WHO
criteria/Dutch Lipid Clinical
Network criteria with score greater
than 8 points, or Simon Broome
register diagnostic criteria AND
LDL-C greater than or equal to
190 mg/dL prior to lipid lowering
therapy (greater than or equal to
160 mg/dL if age less than 20) or
LDL-C greater than or equal to
160 mg/dL after treatment with
antihyperlipidemic agents but prior
to Praluent therapy AND Previous
treatment with at least two trials of
different high-intensity statins (e.g.
atorvastatin, rosuvastatin) has been
ineffective in achieving LDL-C
goal AND Praluent must be used
Prescribed by
or in
consultation
with a
cardiologist,
lipid
specialist, or
endocrinologis
t
6 months
initial
authorization,
12 months
reauthorizatio
n
For reauthorization,
documentation
showing an LDL-C
reduction on Praluent
therapy from baseline
must be provided.
praluent All FDA
approved
indications
not otherwise
excluded from
Part D
Deny if less
than 18 years
of age
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteriagoal AND Praluent must be used
concomitantly with a statin which
is dosed at maximally tolerated
dose OR documentation of statin
intolerance is provided as defined
by statin related rhabdomyolysis or
skeletal-related muscle symptoms
while receiving at least 2 separate
trials of different high intensity
statin which resolved upon
discontinuation of statin. 2.
Hypercholesterolemia ASCVD
(e.g. acute coronary syndrome,
history of myocardial infarction)
AND Previous treatment with at
least two trials of different high-
intensity statins (e.g. atorvastatin,
rosuvastatin) has been ineffective
in achieving LDL-C goal (LDL-C
is still greater than or equal to 100
mg/dL) AND Praluent must be
used concomitantly with a statin
which is dosed at maximally
tolerated dose OR documentation
of statin intolerance is provided as
defined by statin related
rhabdomyolysis or skeletal-related
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteriarhabdomyolysis or skeletal-related
muscle symptoms while receiving
at least 2 separate trials of
different high intensity statin
which resolved upon
discontinuation of statin.
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
For concomitant use of an opiate
agonist and substance abuse
therapy, documentation that the
member has a documented acute
pain condition (e.g. acute
traumatic injury) in which
treatment with other agents would
cause insufficient pain control or if
the member requires treatment for
pain related to a terminal illness.
For concomitant use of an opiate
agonist, benzodiazepine and a
centrally acting skeletal muscle
relaxant, documentation that the
member has tried/failed at least 2
other skeletal muscle relaxant (e.g,
methocarbamol, metaxalone),
understanding these skeletal
muscle relaxants are high-risk
medications in geriatric patients
AND documentation of an
ongoing monitoring plan to
identify and address concomitant
drug-drug interaction adverse
events
Opiate agonists will
receive automatic
approval if no recent
claims for a substance
abuse therapy (e.g,
buprenorphine-
naloxone) OR a
benzodiazepine (e.g.,
triazolam, alprazolam)
AND a centrally
acting skeletal muscle
relaxant (e.g.,
carisoprodol).
Benzodiazepines (e.g,
triazolam, alprazolam)
will receive automatic
approval if no recent
claims for an opiate
agonist (e.g.,
oxycodone,
hydrocodone,
oxymorphone) AND a
centrally acting
skeletal muscle
relaxant (e.g.,
carisoprodol).
1 mo.
opiate/substan
ce abuse
therapy use,
12 mo.
opiate/benzod
iazepine/skele
tal muscle
relaxant use
All FDA
approved
indications
not otherwise
excluded from
Part D
prescriptio
n drug
combo
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
pristiq All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of major
depressive disorder and trial and
failure of two other
antidepressants.
12 months Applies to new starts
only
PROCYSB
I
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of nephropathic
cystinosis AND previous trial and
failure or intolerance to immediate-
release cysteamine bitartrate
(Cystagon)
Deny if less
than 2 years
of age
12 months
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Documentation of use to increase
bone mass in men at high risk for
fracture receiving androgen
deprivation therapy or women at
high risk for fracture receiving
adjuvant aromatase inhibitor
therapy -OR- use for treatment of
osteoporosis and the prevention of
fractures in postmenopausal
women and men having a T score
of less than -2.5 and a trial and
failure or contraindication to at
least one bisphosphonate -OR- use
to prevent fractures in men and
postmenopausal women with a
low bone mass (T score between -
1.0 and -2.5) and history of
previous osteoporotic fracture or
those who are found to have a 10-
year risk of major osteoporotic
fracture greater than or equal to 20
percent or a risk of hip fracture
greater than or equal to 3 percent
and had a trial and failure or
contraindication to at least one
bisphosphonate
Covered under Part B
for female patients
eligible for home
health services when
provider certifies that
patient sustained bone
fracture related to post-
menopausal
osteoporosis and is
unable to learn the
skills needed to self-
administer the drug or
is otherwise
physically or mentally
incapable of
administering the drug
or family/caregivers
are unable or
unwilling to
administer the drug
12 monthsDiagnosis of
underlying
hypercalcemic
disorder such as
hypercalcemia,
hyperparathyroi
dism or
hypoparathyroid
ism, or high risk
for
osteosarcoma
(Paget's disease,
prior radiation
therapy, bone
metastases, open
epiphyses, etc.)
All FDA
approved
indications
not otherwise
excluded from
Part D
prolia
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
provigil All medically
accepted
indications
not otherwise
excluded from
Part D
Diagnosis of shift work sleep
disorder (SWSD) -OR- diagnosis
of narcolepsy documented by
MSLT less than 10 min or other
appropriate testing -OR- Diagnosis
of obstructive sleep
apnea/hypopnea syndrome
(OSAHS) documented by
objective polysomnography and
continuous positive airway
pressure (CPAP) history and
status. Diagnosis established in
accordance with ICSD or DSM IV
criteria acceptable for all
indications.
12 months
pulmonary
arterial
hypertensio
n
All FDA
approved
indications
not otherwise
excluded from
Part D
Diagnosis of pulmonary
hypertension, substantiated by
results from Doppler
echocardiography and/or direct
measurement of pulmonary arterial
pressure, defined as a mean
pulmonary arterial pressure of
greater than or equal to 25 mmHg,
with a pulmonary capillary wedge
pressure of less than 15 mmHg.
cardiologist,
pulmonologist
12 months
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
RAGWITE
K
All FDA
approved
indications
not otherwise
excluded from
Part D
Asthma (severe,
unstable or
unconrolled),
concomitant
sublingual or
subcutaneous
immunotherapy,
therapy
initiation during
active allergy
season
Documentation of allergic rhinitis
and use for ragweed pollen -AND-
allergic rhinitis with or without
conjunctivitis has been confirmed
by a pollen specific positive skin
test or in vitro testing for pollen-
specific IgE antibodies -AND-
trial and failure or intolerance to
an intranasal steroid and an oral
non-sedating antihistamine,
intranasal antihistamine or
intranasal anticholinergic agent
Deny if less
than 18 years
of age or
greater than
65 years of
age
allergy
specialist,
otolaryngologi
st
12 months Member must also be
prescribed an
epinephrine auto
injector
ravicti All FDA
approved
indications
not otherwise
excluded from
Part D
Urea cycle
disorders due to
N-
acetylglutamates
ynthetase
deficiency
Documentation of use with dietary
protein restriction for chronic
management of a urea cycle
disorders (UCDs) when the
condition cannot be managed by
dietary protein restriction alone
12 months
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
remicade All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Humira,
Cimzia, Enbrel,
Orencia,
Simponi,
Actemra,
Kineret, Stelara
Documentation of moderate to
severe rheumatoid arthritis and use
in combination with methotrexate -
OR- psoriatic arthritis -OR-
ankylosing spondylitis -OR-
moderate to severe psoriasis after
failure of systemic therapy or
phototherapy -OR- moderate to
severe Crohn's disease after failure
of two immunosuppressants -OR-
moderate to severe ulcerative
colitis after failure of two
immunosuppressants
For Crohn's
disease and
ulcerative
colitis, deny if
less than 6
years old
rheumatologist
,
dermatologist,
or
gastroenterolo
gist
12 months For psoriasis trial of 1
alternative therapy,
either systemic
therapy (e.g.
methotrexate or
cyclosporine) or
phototherapy, is
required. For Crohn's
disease and ulcerative
colitis, trial of 2
immunosuppressants
(e.g. corticosteroids,
azathioprine, 6-
mercaptopurine) is
required.
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
repatha All FDA
approved
indications
not otherwise
excluded from
Part D
1.Homozygous Familial
Hypercholesterolemia(HoFH)
supported by genetic confirmation
of two mutant alleles at LDLR,
APOB, OCSK9, or LDLRAP1
gene or untreated LDL-C greater
than 500mg/dL(or treated LDL-C
greater than 300mg/dL) with
cutaneous or tendon xanthoma
before age 10 yrs or heterozygous
familial hypercholesterolemia
(HeFH) in both parents AND
Repatha will be used with a
maximally tolerated statin unless
all statins are contraindicated or
not tolerated AND Repatha will
not be used with lomitapide,
mipomersen, or another PCSK9
inhibitor. 2.HeFH supported by
presence of causal mutation of FH
by genetic testing, physical signs
of FD(e.g. xanthomas,
xanthelasma), diagnosis based on
WHO criteria/Dutch Lipid Clinical
Network criteria with score greater
than 8 points, or Simon Broome
Deny if less
than 18 years
of age for
HeFH and
ASCVD or
less than 13
years of age
for HoFH
Prescribed by
or in
consultation
with a
cardiologist,
lipid
specialist, or
endocrinologis
t
6 months
initial
authorization,
12 months
reauthorizatio
n
For reauthorization,
documentation
showing an LDL-C
reduction on Repatha
therapy from baseline
must be provided.
For HoFH diagnosis,
3 syringes per month
will be approved
aligned with
recommended dosing
regimen for this
indication.
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteriathan 8 points, or Simon Broome
register criteria AND LDL-C
greater than or equal to 190mg/dL
prior to lipid lowering therapy
(greater than or equal to 160mg/dL
if age less than 20) or LDL-C
greater than or equal to 160mg/dL
after treatment with
antihyperlipidemic agents but prior
to Repatha therapy AND Prior
therapy with at least 2 trials of
different high-intensity statins(e.g.
atorvastatin, rosuvastatin) has not
achieved LDL-C goal AND must
be used with maximally tolerated
statin dose OR documentation of
statin intolerance as defined by
statin related rhabdomyolysis or
skeletal muscle symptoms while
receiving at least 2 separate trials
of different high intensity statin
which resolved upon
discontinuation of statin. 3.
Hypercholesterolemia ASCVD
AND Prior therapy with at least 2
trials of different high-intensity
statins (e.g. atorvastatin,
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Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteriastatins (e.g. atorvastatin,
rosuvastatin) has not achieved
LDL-C goal(LDL-C is still greater
than or equal to 100mg/dL) AND
must be used with maximally
tolerated statin dose OR
documentation of statin
intolerance as defined by statin
related rhabdomyolysis or skeletal
muscle symptoms while receiving
at least 2 separate trials of
different high intensity statin
which resolved upon
discontinuation of statin.
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
revlimid All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation
of severe
neutropenia,
severe
thrombocytopeni
a, or treatment-
related MDS
Diagnosis of multiple myeloma -
OR- diagnosis of myelodyplastic
syndrome (MDS) with 5-q
deletion along with documentation
of transfusion-dependent anemia
or an anemia with documented
hemoglobin of less than 10g/dL -
OR- diagnosis of mantle cell
lymphoma (MCL) in which
disease has relapsed or progressed
after two prior therapies (e.g.
anthracycline, mitoxantrone,
cyclophosphamide, rituximab,
bortezomib) one of which included
bortezomib
12 months Applies to new starts
only
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Acute hereditary angioedema
(HAE) type I & II: Documentation
that clinical laboratory
performance C4 below lower limit
of laboratory reference range -
AND- C1 inhibitor level below
lower limit of laboratory reference
range -OR- normal C1 inhibitor
level and a low C1INH functional
level below laboratory reference
range -AND- documentation of at
least 1 symptom of angioedema
attack -AND- medications that
cause angioedema have been
evaluated and discontinued. Acute
hereditary angioedema (HAE) type
III: Documentation that clinical
laboratory performance C4, C1
inhibitor level and C1INH
functional level are within normal
limits of the laboratory's reference
range -AND- documentation HAE
family history -OR- FXL mutation -
AND- documentation of at least 1
symptom of angioedema attack -
AND- medications that cause
angioedema have been evaluated
and discontinued
12 monthsruconest All FDA
approved
indications
not otherwise
excluded from
Part D
Deny if less
than 13 years
of age
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
savella All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation to support a
diagnosis of fibromyalgia and
trial/failure or intolerance to
duloxetine
12 months
signifor All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of Cushing's
disease AND patient is not a
candidate for pituitary surgery or
surgery has not been curative
Deny if less
than 18 years
of age
12 months
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PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
simponi Alternatives for
Ulcerative Colitis
include
immunosuppressants
such as
corticosteroids,
azathioprine or 6-
mercaptopurine.
Patients must have an
adequate trial or
intolerance to the
preferred product,
Humira, for ulcerative
colitis and the
preferred products,
Enbrel and Humira,
for rheumatoid
arthritis, psoriatic
arthritis and
ankylosing
spondylitis. For
ulcerative colitis
indication therapy,
doses above plan
quantity limit will be
approved aligned with
recommended
induction therapy
dosing regimen.
12 monthsDocumentation of moderate to
severe rheumatoid arthritis and use
in combination with methotrexate -
OR- psoriatic arthritis -OR-
ankylosing spondylitis -OR-
moderate to severe ulcerative
colitis and an inadequate response
to two immunosupressants or in
those patients requiring continuous
steroid therapy
concomitant use
of Actemra,
Kineret,
Remicade,
Humira,
Orencia, Enbrel,
Cimzia
All FDA
approved
indications
not otherwise
excluded from
Part D
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
simponi
aria
All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Actemra,
Kineret,
Remicade,
Humira,
Orencia, Enbrel,
Cimzia
Documentation of moderate to
severe rheumatoid arthritis and use
in combination with methotrexate
12 months
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Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
CHC gt 1 infection in adults -AND-
using with SMV -AND- the
patient may or may not also be
taking RBV concomitantly if
cirrhotic and tx-exp -OR- CHC gt
2 infection in adults -AND- SOF is
being used with RBV -AND- SOF
is being used with PEG if pt tx-
exp with SOF -OR- CHC gt 3 -
AND- using with PEG/RBV -OR-
CHC genotype 4 in adults -AND-
using with RBV -AND- using with
PEG if tx-exp with P/R and PEG
eligible -OR- Gt 5 or 6 infection in
adults -AND- using with P/R -
AND- if tx-exp, only failed P/R
OR- CHC gt 1, 2, 3, or 4 in
allograft AND- tx-naïve or exp
AND- comp cirrh AND- using
with daclatasvir AND- using with
RBV unless intolerant or ineligible
OR- CHC gt 2 or 3 -AND-
decomp cirrhosis -AND- using
with RBV -OR- Recurrent CHC gt
2 or 3 post-liver transplant -AND-
using with RBV -AND- with or
without decompensated or
compensated cirrhosis
All FDA
approved
indications
not otherwise
excluded from
Part D
sovaldi Deny if less
than 18 years
of age
12w:G1nocr.
G2nocr
txn,t/fSOF.G3
,5,6,G4wPR.1
6w:G2cr,t/fP
R.24w:G1cr,
G2txe,G4
wR,G2,3allo.
48w:G2,3dcp
Doses greater than or
less than 400 mg/day
will not be approved.
76 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
sprycel All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of diagnosis and
failure of Gleevec therapy (failure
of Gleevec is not necessary for the
indication of newly diagnosed
adults with chronic phase PH+
CML).
12 months Applies to new starts
only
77 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
All FDA
approved
indications
not otherwise
excluded from
Part D
stelara Patients must have an
adequate trial or
intolerance to the
preferred product,
Humira, for psoriasis
and the preferred
products, Enbrel and
Humira, for psoriatic
arthritis. Must follow
recommended dosing
guidelines based upon
weight. Psoriasis: For
patients weighing less
than 100 kilograms
(220 pounds), 45 mg
dosing will be
approved. For patients
weighing more than
100 kilograms (220
pounds), 90 mg
dosing will be
approved. Psoriatic
Arthritis: 45 mg
dosing will be
approved. For patients
with co-existent
12 monthsdermatologistDocumentation of moderate to
severe plaque psoriasis and failure
of one systemic therapy (e.g.
methotrexate, cyclosporine) or
phototherapy OR psoriatic arthritis
AND documentation of member
weight and prescribed dose
concomitant use
of Enbrel,
Remicade,
Humira,
Simponi
78 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
stivarga All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of metastatic
colorectal cancer and trial of a
fluoropyrimidine-, oxaliplatin-,
and irinotecan-containing
chemotherapy (i.e.
FOLFIRINOX), AND an anti-
VEGF therapy (i.e. aflibercept)
AND if KRAS wild type, an anti-
EGFR therapy (i.e. cetuximab,
panitumumab) -OR-
documentation of locally
advanced, unresectable or
metastatic gastrointestinal stromal
tumor (GIST) after treatment with
both imatinib and sunitinib
12 months Applies to new starts
only
with co-existent
moderate to severe
plaque psoriasis
weighing greater than
100 kilograms (220
pounds), 90 mg
dosing will be
approved.
79 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
strensiq All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of
perinatal/infantile-onset or
juvenile-onset hypophosphatasia
(HPP)
12 months
sutent All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis and
failure of Gleevec therapy, if
applicable
oncologist,
hematologist
12 months Applies to new starts
only
sylvant All FDA
approved
indications
not otherwise
excluded from
Part D
Documented diagnosis of
multicentric Castleman's disease -
AND- negative HIV and HHV-8
test -AND- baseline absolute
neutrophil count greater than or
equal to 1.0x10*9/L -AND-
baseline platelet count greater than
or equal to 75x10*9/L -AND-
baseline hemoglobin less than
17g/dL.
12 months Applies to new starts
only
80 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
tagrisso All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of metastatic
EGFR T790M mutation-positive
NSCLC AND progression on or
after EGFR TKI therapy
oncologist,
hematologist
12 months Applies to new starts
only
taltz All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Enbrel,
Remicade,
Humira,
Simponi, Stelara
Documentation of moderate to
severe psoriasis and failure of one
systemic therapy (e.g.
methotrexate, cyclosporine) or
phototherapy
Deny if less
than 18 years
of age
dermatologist 12 months Patients must have an
adequate trial or
intolerance to the
preferred product,
Humira, for psoriasis.
For psoriasis
induction therapy,
doses above plan
quantity limit will be
approved aligned with
recommended
induction therapy
dosing regimen.
tasigna All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of diagnosis and
failure of Gleevec therapy (failure
of Gleevec is not necessary for the
indication of newly diagnosed
adults with chronic phase PH+
CML).
oncologist,
hematologist
12 months Applies to new starts
only
81 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
tecfidera All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
with other
disease
modifying
agents such as
interferons,
Copaxone ,
Tysabri,
Aubagio,
Gilenya
Documentation of relapsing form
of multiple sclerosis (relapsing-
remitting, relapsing secondary
progressive, or progressive
relapsing multiple sclerosis)
neurologist 12 months Doses greater than
240 mg twice-daily
will not be approved
technivie All FDA
approved
indications
not otherwise
excluded from
Part D
Severe hepatic
impairment
(Child-Pugh C)
Documentation of chronic
hepatitis C genotype 4 without
cirrhosis AND using with ribavirin
unless the member is treatement-
naive and has a contraindication or
intolerance to ribavirin
Deny if less
than 18 years
of age
12 weeks
82 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
Documentation of primary or
secondary hypogonadism in males
with testicular failure due to
cryptorchidism, bilateral torsions,
orchitis, vanishing testis
syndrome, orchidectomy,
Klinefelter's syndrome,
chemotherapy, radiation or toxic
damage -OR- documentation of
primary or secondary
hypogonadism in males with
multiple symptoms of
hypogonadism including at least
one of the following specific
symptoms: height loss due to
vertebral fractures, low trauma
fractures, low bone density,
incomplete or delayed sexual
development, breast discomfort,
loss of axillar and/or pubic body
hair, hot flushes -OR-
documentation of HIV infection
in men with weight loss -OR-
documentation of chronic steroid
treatment in men. In all previously
noted indications, members must
All medically
accepted
indications
not otherwise
excluded from
Part D
testosterone
(androgens
)
Deny if less
than
recommended
age per FDA
product
labeling
12 months
83 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
thalomid All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of multiple
myeloma -OR- documentation for
use in the treatment or prophylaxis
of cutaneous manifestations of
moderate to severe erythema
nodosum leprosum
12 months Applies to new starts
only
noted indications, members must
also have documented low
testosterone level below the
normal range for the laboratory -
OR- a total testosterone level near
the lower limit of the normal range
with a low free testosterone level
which is less than normal based
upon the laboratory reference
range. Additional approvable
indications include vulvar
dystrophies in women (topical
ointment only) -AND- palliative
treatment in female patients with
metastatic breast cancer
(testosterone enanthate only).
84 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
thrombopoi
esis
stimulating
agents
All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis of
chronic immune idiopathic
thrombocytopenia purpura and
trial and failure of corticosteroid
or immunoglobulin therapy or
splenectomy -OR- documentation
of thrombocytopenia in patients
with chronic hepatitis C to allow
the initiation and maintenance of
interferon-based therapy
(eltrombopag only)
12 months Platelet count to be
provided
transmucos
al fentanyl
citrate
All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of therapeutic use
and long acting opioid therapy
12 months
85 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
tykerb All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of Tykerb in
combination with Xeloda
(capecitabine) for patients with
advanced, metastatic breast cancer
that is HER2 positive who have
received prior therapy, including a
taxane, an anthracycline and
trastuzumab (Herceptin) -OR-
documentation of Tykerb in
combination with Femara
(letrozole) for the treatment of
postmenopausal women with
hormone receptor positive
metastatic breast cancer that over
expresses the HER2 receptor for
whom hormonal therapy is
indicated
oncologist 12 months Applies to new starts
only
86 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
VALCHLO
R
All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of cutaneous
manifestations in patients with
cutaneous T-cell lymphoma who
have limited localized or
generalized skin involvement who
received at least one prior skin
directed therapy -OR-
documentation of cutaneous
manifestations in patients with
cutaneous T-cell lymphoma who
have limited localized or
generalized skin involvement and
mechlorethamine gel will be used
in combination with other skin
directed therapies. Skin directed
therapies may include but are not
limited to topical corticosteroids,
topical chemotherapy, local
radiation and topical retinoids.
12 months Applies to new starts
only
87 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
veltassa All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of hyperkalemia as
defined by serum potassium level
between 5.1 and 6.4 mmol/L on at
least two (2) screenings -AND-
modification of medications to
reduce serum potassium levels,
when applicable -AND- trial and
failure, intolerance, or
contraindication to sodium
polystyrene sulfonate
Deny if less
than 18 years
of age
6 months For reauthorization,
documentation of
reduction in serum
potassium levels
following Veltassa
administration is
required.
venclexta All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of chronic
lymphocytic leukemia (CLL) with
17p deletion -AND- previous
treatment with at least one prior
therapy
12 months Applies to new starts
only
88 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
viberzi All FDA
approved
indications
not otherwise
excluded from
Part D
Severe (Child-
Pugh C) hepatic
impairment
Documentation of diarrhea
predominant, irritable bowel
syndrome (IBS-D) -AND- no
alcohol abuse in the previous six
months.
12 months
VIEKIRA
PAK
All FDA
approved
indications
not otherwise
excluded from
Part D
Severe (Child-
Pugh C) hepatic
impairment
CHC genotype 1a or 1b infection
in adults -AND- using RBV for
gt1a -AND- past HCV therapies
documented -OR- Documentation
of recurrent CHC gt 1 infection
post-liver transplantation -AND-
concomitant use of RBV -AND-
has no fibrosis to mild fibrosis
(Metavir F0, F1, F2)
Deny if less
than 18 years
of age
12wk: gt 1a
noncirr -OR-
gt 1b. 24wk:
gt1a cirr -OR-
gt 1 in
allograft
Doses greater than
four tablets per day
will not be approved.
viibryd All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis major
depressive disorder and trial and
failure of any two antidepressants
12 months Applies to new starts
only
89 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
votrient All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis (renal
cell carcinoma) -OR-
documentation of advanced soft-
tissue sarcoma excluding
adipocytic soft tissue sarcoma or
gastrointestinal stromal tumors
after failure of at least one prior
chemotherapy regimen
oncologist,
hematologist
12 months Applies to new starts
only
vraylar All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of schizophrenia
OR acute treatment of manic or
mixed episodes associated with
bipolar I disorder
Deny if less
than 18 years
of age
12 months Applies to new starts
only
xalkori All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of locally
advanced or metastatic non-small
cell lung cancer (NSCLC) that is
anaplastic lymphoma kinase
(ALK) positive
oncologist,
hematologist
12 months Applies to new starts
only
90 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
xeljanz All FDA
approved
indications
not otherwise
excluded from
Part D
concomitant use
of Enbrel,
Remicade,
Humira, Kineret,
Simponi,
Orencia, Stelara,
Actemra,
azathioprine,
cyclosporine
Documentation of moderate to
severe rheumatoid arthritis and an
inadequate response or intolerance
to methotrexate
12 months Doses greater than 10
mg per day for
Xeljanz and 11 mg
per day for Xeljanz
XR will not be
approved. Patients
must have an adequate
trial or intolerance to
the preferred
products, Enbrel and
Humira, for
rheumatoid arthritis.
xenazine All FDA
approved
indications
not otherwise
excluded from
Part D
documentation of diagnosis 12 months Patients with
comorbid depression
should be on an
antidepressant
medication.
xtandi All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of metastatic
castration-resistant prostate cancer
and prior therapy with docetaxel
12 months Applies to new starts
only
91 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
xyrem All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of excessive
daytime sleepiness in patients with
a diagnosis of narcolepsy as
documented by MSLT less than 10
min or other appropriate testing -
OR- documentation of cataplexy
associated with narcolepsy as
documented by MSLT or other
appropriate testing.
12 months
zelboraf All FDA
approved
indications
not otherwise
excluded from
Part D
Wild-type
BRAF
melanoma
Documentation of unresectable or
metastatic melanoma with
BRAFV600E mutation
oncologist,
hematologist
12 months Applies to new starts
only
zepatier All FDA
approved
indications
not otherwise
excluded from
Part D
Severe (Child-
Pugh C) hepatic
impairment
Criteria will be applied consistent
with current AASLD/IDSA
guidance
Deny if less
than 18 years
of age
12wk:gt1a
without NS5A-
OR-gt1b-OR-
gt4 tx naive.
16wk:gt1a
with NS5A-
OR-gt4 tx
exp.
92 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
zolinza All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of cutaneous
manifestations in patients with
cutaneous T-cell lymphoma
(CTCL) who have progressive,
persistent, or recurrent disease on
or following 2 systemic therapies.
Systemic therapies include
bexarotene, interferon alpha,
extracorpeal photochemotherapy,
PUVA, single agent or
combination chemotherapies (e.g.
cyclophosphamide, vinblastine,
romidepsin)
oncologist,
hematologist
12 months Applies to new starts
only
93 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
ZYDELIG All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of relapsed
chronic lymphocytic leukemia
(CLL) and use in combination
with rituximab in patients for
whom rituximab alone would be
considered appropriate therapy
due to other co-morbidities -OR-
documentation of relapsed
follicular B-cell non-Hodgkin
lymphoma (FL) in patients who
have received at least two prior
systemic therapies (e.g. alkylating
agents, single or multi-drug
chemotherapy, target
immunotherapy) -OR-
documentation of relapsed small
lymphocytic lymphoma (SLL) in
patients who have received at least
two prior systemic therapies (e.g.
alkylating agents, single or multi-
drug chemotherapy, target
immunotherapy)
12 months Applies to new starts
only
94 Formulary ID: 16256 Version: 17 Update: 09/2016
Medicare Part D: PA Criteria
PA Group Covered Use
Exclusion
Criteria Required Medical Information
Age
Restriction
Prescriber
Restriction
Coverage
Duration Other Criteria
zykadia All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of non-small cell
lung cancer (NSCLC) that is
anaplastic lymphoma kinase
(ALK) positive AND previous
trial and failure or intolerance to
crizotinib (Xalkori)
12 months Applies to new starts
only
zytiga All FDA
approved
indications
not otherwise
excluded from
Part D
Documentation of metastatic
castration resistant prostate cancer
and concurrent use with
prednisone
12 months Applies to new starts
only
95 Formulary ID: 16256 Version: 17 Update: 09/2016
2017 Plan Formularies
Select your location
Pennsylvania Residents:
If you live in one of the counties below, please click here:
Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion,
Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson,
Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and
Westmoreland.
If you live in one of the counties below, please click here:
Adams, Berks, Bradford, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin,
Franklin, Fulton, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming,
Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Schuylkill,
Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, and York.
West Virginia Residents, please click here.
2017 Plan Formularies – Western PA
For Security Blue HMO Deluxe, Standard, and ValueRx, Community Blue Medicare
HMO Prestige and Signature, Freedom Blue PPO Classic, Select, and ValueRx, and Blue
Rx PDP Complete and Plus plans, please review this formulary.
For Prior Authorization criteria, please review this information.
2017 Plan Formularies – Central and Northeastern PA
For Freedom Blue PPO Deluxe, Standard, and ValueRx, Community Blue Medicare HMO Signature, and Blue Rx PDP Complete and Plus, please review this formulary.
For Prior Authorization criteria, please review this information.
2017 Plan Formularies – West Virginia
For Freedom Blue PPO Standard and Blue Rx PDP Complete and Plus, please review this
formulary.
For Prior Authorization criteria, please review this information.
5T Medicare Part D: 5 Tier Closed Formulary
1 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
8-Mop capsule 10 mg PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
abacavir tablet 300 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
abacavir-lamivudine-zidovudine
tablet 300-150-300 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Abelcet suspension 5 mg/mL Specialty-5 YES ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Abilify tablet 10 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abilify tablet 15 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abilify tablet 20 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abilify tablet 30 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abilify tablet 5 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
2 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Abilify tablet 2 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abilify Maintena
suspension,extended rel syring 300 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abilify Maintena
suspension,extended rel syring 400 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abilify Maintena
suspension,extended rel recon 300 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Abraxane suspension for reconstitution
100 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Abstral tablet 100 mcg
NonPrefBrand-4
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Abstral tablet 200 mcg
Specialty-5
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Abstral tablet 300 mcg
Specialty-5
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
3 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Abstral tablet 400 mcg
Specialty-5
119 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Abstral tablet 600 mcg
Specialty-5
79 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Abstral tablet 800 mcg
Specialty-5
60 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
acamprosate tablet,delayed release (DR/EC)
333 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Acanya gel with pump 1.2-2.5 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
acarbose tablet 50 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
acarbose tablet 100 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
acarbose tablet 25 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
acebutolol capsule 400 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
acebutolol capsule 200 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
4 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
acetaminophen-codeine
solution 300 mg-30 mg /12.5 mL
PrefGen-1 5167 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
acetaminophen-codeine
tablet 300-15 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
acetaminophen-codeine
tablet 300-30 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
acetaminophen-codeine
tablet 300-60 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Acetasol HC drops 1-2 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS OTIC PREPARATIONS
acetazolamide
tablet 125 mg Generic-2 NO OPHTHALMOLOGY
ORAL DRUGS FOR GLAUCOMA
acetazolamide
tablet 250 mg Generic-2 NO OPHTHALMOLOGY
ORAL DRUGS FOR GLAUCOMA
acetazolamide
capsule, extended release
500 mg Generic-2 NO OPHTHALMOLOGY
ORAL DRUGS FOR GLAUCOMA
acetazolamide sodium
recon soln 500 mg Generic-2 NO OPHTHALMOLOGY
ORAL DRUGS FOR GLAUCOMA
5T Medicare Part D: 5 Tier Closed Formulary
5 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
acetic acid solution 2 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS OTIC PREPARATIONS
acetylcysteine
solution 100 mg/mL (10 %)
Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
acetylcysteine
solution 200 mg/mL (20 %)
Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
acitretin capsule 10 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin capsule 25 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin capsule 17.5 mg NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Actemra syringe 162 mg/0.9 mL
Specialty-5
3.6 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Actemra solution80 mg/4 mL (20 mg/mL)
Specialty-5
40 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Actemra solution200 mg/10 mL (20 mg/mL)
Specialty-5
40 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
6 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Actemra solution400 mg/20 mL (20 mg/mL)
Specialty-5
40 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Acthar H.P. gel 80 unit/mLSpecialty-5 YES ENDOCRINE/DIA
BETESADRENAL HORMONES
ActHIB (PF) recon soln 10 mcg/0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Actimmune solution 100 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Actiq lozenge on a handle
400 mcg Specialty-5 119 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Actiq lozenge on a handle
200 mcg Specialty-5 124 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Actiq lozenge on a handle
600 mcg Specialty-5 79 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Actiq lozenge on a handle
800 mcg Specialty-5 59 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
7 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Actiq lozenge on a handle
1,200 mcg Specialty-5 40 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Actiq lozenge on a handle
1,600 mcg Specialty-5 30 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Actoplus Met XR
tablet, ER multiphase 24 hr
15-1,000 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Actoplus Met XR
tablet, ER multiphase 24 hr
30-1,000 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Acuvail (PF) dropperette 0.45 % NonPrefBrand-4 NO OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
acyclovir capsule 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
acyclovir tablet 400 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
acyclovir ointment 5 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIVIRALS
acyclovir tablet 800 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
acyclovir suspension 200 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
acyclovir sodium solution 50 mg/mL
Generic-2 YES ANTI - INFECTIVES ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
8 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aczone gel 5 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Adacel(Tdap Adolesn/Adult)(PF) suspension
2 Lf-(2.5-5-3-5 mcg)-5Lf/0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Adagen solution 250 unit/mL Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
adapalene gel 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
adapalene cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
adapalene gel 0.3 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Adcirca tablet 20 mg Specialty-5 62 31 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
adefovir tablet 10 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Adempas tablet 0.5 mgSpecialty-5
93 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Adempas tablet 1 mgSpecialty-5
93 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Adempas tablet 1.5 mgSpecialty-5
93 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Adempas tablet 2 mgSpecialty-5
93 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
9 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Adempas tablet 2.5 mgSpecialty-5
93 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Adrenalin solution 1 mg/mL (1 mL)
Generic-2 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Adrucil solution 500 mg/10 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Advair Diskus
blister with device
100-50 mcg/dose NonPrefBrand-4 60 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Advair Diskus
blister with device
250-50 mcg/dose NonPrefBrand-4 60 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Advair Diskus
blister with device
500-50 mcg/dose NonPrefBrand-4 60 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Advair HFA HFA aerosol inhaler
45-21 mcg/actuation
NonPrefBrand-4 12 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Advair HFA HFA aerosol inhaler
115-21 mcg/actuation
NonPrefBrand-4 12 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Advair HFA HFA aerosol inhaler
230-21 mcg/actuation
NonPrefBrand-4 12 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Afeditab CR tablet extended release
30 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Afeditab CR tablet extended release
60 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
10 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Afinitor tablet 10 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Afinitor tablet 5 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Afinitor tablet 2.5 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Afinitor tablet 7.5 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Afinitor Disperz
tablet for suspension 2 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Afinitor Disperz
tablet for suspension 3 mg
Specialty-5
93 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Afinitor Disperz
tablet for suspension 5 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Aggrenox
capsule, ER multiphase 12 hr 25-200 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
11 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
A-Hydrocort recon soln 100 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Akynzeo capsule 300-0.5 mg
NonPrefBrand-4 YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Ala-Cort cream 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Albenza tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
albuterol sulfate
tablet 2 mg PrefGen-1 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
tablet 4 mg PrefGen-1 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
solution for nebulization
5 mg/mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
solution for nebulization
1.25 mg/3 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
solution for nebulization
0.63 mg/3 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
tablet extended release 12 hr
4 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
tablet extended release 12 hr
8 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
solution for nebulization
2.5 mg /3 mL (0.083 %)
Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
albuterol sulfate
syrup 2 mg/5 mL PrefGen-1 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
12 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
alclometasone
cream 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
alclometasone
ointment 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Alcohol Pads
pads, medicated Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Aldurazyme solution 2.9 mg/5 mL Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Alecensa capsule 150 mg
Specialty-5
248 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
alendronate tablet 35 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
alendronate tablet 40 mg PrefGen-1 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
alendronate tablet 10 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
alendronate tablet 5 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
alendronate tablet 70 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
13 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
alendronate solution 70 mg/75 mL PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
alfuzosin tablet extended release 24 hr
10 mg Generic-2 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
Alimta recon soln 500 mg
PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Alinia suspension for reconstitution
100 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Alinia tablet 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
allopurinol tablet 100 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
allopurinol tablet 300 mg PrefGen-1 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
Allzital tablet 25-325 mg
NonPrefBrand-4
372 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
14 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
almotriptan malate
tablet 6.25 mg Generic-2 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
almotriptan malate
tablet 12.5 mg Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Alocril drops 2 % NonPrefBrand-4 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
alogliptin tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
alogliptin tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
alogliptin tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
alogliptin-metformin tablet 12.5-1,000 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
alogliptin-metformin tablet 12.5-500 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
alogliptin-pioglitazone tablet 12.5-15 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
alogliptin-pioglitazone tablet 12.5-30 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
alogliptin-pioglitazone tablet 12.5-45 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
alogliptin-pioglitazone tablet 25-15 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
alogliptin-pioglitazone tablet 25-30 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
15 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
alogliptin-pioglitazone tablet 25-45 mg
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Alomide drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
Aloprim recon soln 500 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
alosetron tablet 1 mg Specialty-5 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
alosetron tablet 0.5 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Aloxi solution 0.25 mg/5 mL
NonPrefBrand-4 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Alphagan P drops 0.1 % PrefBrand-3 NO OPHTHALMOLOGY
SYMPATHOMIMETICS
alprazolam tablet 1 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet 2 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
16 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
alprazolam tablet 0.25 mg Generic-2 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet 0.5 mg Generic-2 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet extended release 24 hr
0.5 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet extended release 24 hr
2 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet extended release 24 hr
1 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet extended release 24 hr
3 mg Generic-2 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet,disintegrating
0.25 mg Generic-2 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet,disintegrating
1 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
17 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
alprazolam tablet,disintegrating
0.5 mg Generic-2 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
alprazolam tablet,disintegrating
2 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Alprazolam Intensol
concentrate 1 mg/mL Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Altabax ointment 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
Altoprevtablet extended release 24 hr 20 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Altoprevtablet extended release 24 hr 40 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amantadine HCl
solution 50 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
amantadine HCl
capsule 100 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
amantadine HCl
tablet 100 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
AmBisome suspension for reconstitution
50 mg NonPrefBrand-4 YES ANTI - INFECTIVES
ANTIFUNGAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
18 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amcinonide cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
amcinonide ointment 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
amcinonide lotion 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Amerge tablet 1 mg NonPrefBrand-4 20 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Amerge tablet 2.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Amethiatablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Amethyst tablet 90-20 mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
amifostine crystalline
recon soln 500 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amikacin solution 500 mg/2 mL
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
19 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amiloride tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amiloride-hydrochlorothiazide
tablet 5-50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amino acids 15 %
parenteral solution 15 %
Generic-2 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn 7 % with electrolytes
parenteral solution 7 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn 8.5 %-electrolytes
parenteral solution 8.5 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn II 10 %
parenteral solution
10 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn II 15 %
parenteral solution
15 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn II 7 %
parenteral solution
7 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn II 8.5 %
parenteral solution
8.5 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn II 8.5 %-electrolytes
parenteral solution 8.5 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
5T Medicare Part D: 5 Tier Closed Formulary
20 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aminosyn-HBC 7%
parenteral solution
7 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn-PF 10 %
parenteral solution
10 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn-PF 7 % (sulfite-free)
parenteral solution
7 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Aminosyn-RF 5.2 %
parenteral solution 5.2 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
amiodarone tablet 200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone tablet 400 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone solution 50 mg/mL
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Amitiza capsule 24 mcg PrefBrand-3 62 31 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Amitiza capsule 8 mcg PrefBrand-3 62 31 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
21 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amitriptyline tablet 100 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amitriptyline tablet 150 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amitriptyline tablet 10 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amitriptyline tablet 25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amitriptyline tablet 50 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amitriptyline tablet 75 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amitriptyline-chlordiazepoxide
tablet 12.5-5 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amitriptyline-chlordiazepoxide
tablet 25-10 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
22 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amlodipine tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-atorvastatin
tablet 5-80 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 10-80 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 10-20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 2.5-10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 2.5-20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
23 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amlodipine-atorvastatin
tablet 5-10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 5-20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 5-40 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 10-10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 10-40 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
tablet 2.5-40 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-benazepril
capsule 10-20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-benazepril
capsule 10-40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
24 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amlodipine-benazepril
capsule 2.5-10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-benazepril
capsule 5-10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-benazepril
capsule 5-20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-benazepril
capsule 5-40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan
tablet 10-160 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan
tablet 10-320 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan
tablet 5-160 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan
tablet 5-320 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
25 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amlodipine-valsartan-hcthiazid
tablet 10-160-12.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan-hcthiazid
tablet 10-320-25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan-hcthiazid
tablet 5-160-12.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan-hcthiazid
tablet 5-160-25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
amlodipine-valsartan-hcthiazid
tablet 10-160-25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
ammonium chloride
solution 5 mEq/mL NonPrefBrand-4 NO UROLOGICALS MISCELLANEOUS UROLOGICALS
ammonium lactate
lotion 12 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
ammonium lactate
cream 12 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
26 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amoxapine tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amoxapine tablet 150 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amoxapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amoxapine tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
amoxicil-clarithromy-lansopraz
combo pack 500-500-30 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
amoxicillin suspension for reconstitution
250 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin tablet,chewable 125 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin capsule 250 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin suspension for reconstitution
400 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin capsule 500 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin tablet 875 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
5T Medicare Part D: 5 Tier Closed Formulary
27 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amoxicillin suspension for reconstitution
125 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin suspension for reconstitution
200 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin tablet,chewable 250 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
tablet 250-125 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
tablet 875-125 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
tablet 500-125 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
tablet,chewable 200-28.5 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
tablet,chewable 400-57 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
suspension for reconstitution
250-62.5 mg/5 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
suspension for reconstitution
200-28.5 mg/5 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
suspension for reconstitution
400-57 mg/5 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amoxicillin-pot clavulanate
suspension for reconstitution
600-42.9 mg/5 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
5T Medicare Part D: 5 Tier Closed Formulary
28 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
amoxicillin-pot clavulanate
tablet extended release 12 hr
1,000-62.5 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
amphotericin B
recon soln 50 mg Generic-2 YES ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ampicillin suspension for reconstitution
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
ampicillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
ampicillin suspension for reconstitution
125 mg/5 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
ampicillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
ampicillin sodium
recon soln 125 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
ampicillin sodium
recon soln 10 gram Generic-2 NO ANTI - INFECTIVES
PENICILLINS
ampicillin sodium recon soln 1 gram
Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin-sulbactam
recon soln 15 gram Generic-2 NO ANTI - INFECTIVES
PENICILLINS
ampicillin-sulbactam recon soln 1.5 gram
Generic-2 NO ANTI - INFECTIVES PENICILLINS
ampicillin-sulbactam recon soln 3 gram
Generic-2 NO ANTI - INFECTIVES PENICILLINS
Ampyra tablet extended release 12 hr
10 mg Specialty-5 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Anadrol-50 tablet 50 mg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
29 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
anagrelide capsule 0.5 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
anagrelide capsule 1 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
anastrozole tablet 1 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Androderm patch 24 hour 2 mg/24 hourPrefBrand-3 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Androderm patch 24 hour 4 mg/24 hrPrefBrand-3 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
AndroGelgel in metered-dose pump
20.25 mg/1.25 gram (1.62 %)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
AndroGel gel in packet1.62 % (20.25 mg/1.25 gram)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
AndroGel gel in packet1 % (25 mg/2.5gram)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
AndroGel gel in packet1.62 % (40.5 mg/2.5 gram)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
AndroGel gel in packet1 % (50 mg/5 gram)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Angeliq tablet 0.5-1 mgNonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGYESTROGENS / PROGESTINS
Antara capsule 30 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
30 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Antara capsule 90 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Anzemet tablet 50 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Anzemet tablet 100 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Anzemet solution 100 mg/5 mL NonPrefBrand-4 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ApexiCon E cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Apidra solution 100 unit/mL NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Apidra SoloStar
insulin pen 100 unit/mL NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Aplenzin tablet extended release 24 hr
174 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aplenzin tablet extended release 24 hr
348 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
31 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aplenzin tablet extended release 24 hr
522 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
APOKYN cartridge 10 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
apraclonidine
drops 0.5 % Generic-2 NO OPHTHALMOLOGY
SYMPATHOMIMETICS
Apri tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Apriso capsule,extended release 24hr
0.375 gram PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Aptensio XR
cap,ER sprinkle,biphasic 40-60 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aptensio XR
cap,ER sprinkle,biphasic 40-60 15 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aptensio XR
cap,ER sprinkle,biphasic 40-60 20 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
32 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aptensio XR
cap,ER sprinkle,biphasic 40-60 30 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aptensio XR
cap,ER sprinkle,biphasic 40-60 40 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aptensio XR
cap,ER sprinkle,biphasic 40-60 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aptensio XR
cap,ER sprinkle,biphasic 40-60 60 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aptiom tablet 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Aptiom tablet 400 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Aptiom tablet 600 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Aptiom tablet 800 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
33 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aptivus capsule 250 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Aptivus solution 100 mg/mL Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Aralast NP recon soln 500 mg
Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Aranelle (28)
tablet 0.5/1/0.5-35 mg-mcg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Aranesp (in polysorbate)
solution 25 mcg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
solution 40 mcg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
solution 60 mcg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
solution 100 mcg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
solution 300 mcg/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
34 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aranesp (in polysorbate)
syringe 100 mcg/0.5 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
syringe 40 mcg/0.4 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
syringe 300 mcg/0.6 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
syringe 150 mcg/0.3 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
syringe 200 mcg/0.4 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
syringe 500 mcg/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
syringe 25 mcg/0.42 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate)
syringe 60 mcg/0.3 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
35 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aranesp (in polysorbate) syringe 10 mcg/0.4 mL
PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Aranesp (in polysorbate) solution 200 mcg/mL
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Arava tablet 10 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Arava tablet 20 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Arbinoxa liquid 4 mg/5 mL
Generic-2 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Arbinoxa tablet 4 mg
Generic-2 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Arcalyst recon soln 220 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Arimidex tablet 1 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
36 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
aripiprazole tablet 15 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
aripiprazole tablet 10 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
aripiprazole tablet 30 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
aripiprazole tablet 20 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
aripiprazole tablet 5 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
aripiprazole tablet 2 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
aripiprazole tablet,disintegrating
10 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
aripiprazole tablet,disintegrating
15 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
37 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Aristadasuspension,extended rel syring 441 mg/1.6 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aristadasuspension,extended rel syring 662 mg/2.4 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aristadasuspension,extended rel syring 882 mg/3.2 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Arixtra syringe 10 mg/0.8 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Arixtra syringe 5 mg/0.4 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Arixtra syringe 7.5 mg/0.6 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
armodafinil tablet 150 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
armodafinil tablet 250 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
38 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
armodafinil tablet 50 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
armodafinil tablet 200 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Aromasin tablet 25 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Arranon solution 250 mg/50 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Asacol HD tablet,delayed release (DR/EC)
800 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Ascomp with Codeine
capsule 30-50-325-40 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Ashlynatablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Asmanex HFA
HFA aerosol inhaler 100 mcg/actuation
PrefBrand-313 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Asmanex HFA
HFA aerosol inhaler 200 mcg/actuation
PrefBrand-313 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
39 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Asmanex Twisthaler
aerosol powdr breath activated
220 mcg (120 doses)
PrefBrand-3 1 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Asmanex Twisthaler
aerosol powdr breath activated
220 mcg (30 doses)
PrefBrand-3 1 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Asmanex Twisthaler
aerosol powdr breath activated
220 mcg (60 doses)
PrefBrand-3 1 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Asmanex Twisthaler
aerosol powdr breath activated
110 mcg (30 doses)
PrefBrand-3 1 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
aspirin-dipyridamole
capsule, ER multiphase 12 hr
25-200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Assure ID Insulin Safety
syringe 1 mL 29 gauge x 1/2"
NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Astagraf XLcapsule,extended release 24hr 0.5 mg
PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Astagraf XLcapsule,extended release 24hr 1 mg
PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Astagraf XLcapsule,extended release 24hr 5 mg
PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
40 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
atenolol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
atenolol tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
atenolol tablet 50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
atenolol-chlorthalidone
tablet 100-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
atenolol-chlorthalidone
tablet 50-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Atgam solution 50 mg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
atorvastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
atorvastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
41 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
atorvastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
atorvastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
atovaquone suspension 750 mg/5 mL Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
atovaquone-proguanil
tablet 250-100 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
atovaquone-proguanil
tablet 62.5-25 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Atralin gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
ATRIPLA tablet 600-200-300 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
atropine syringe 0.05 mg/mL
Generic-2 NO
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
atropine syringe 0.1 mg/mL
Generic-2 NO
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
5T Medicare Part D: 5 Tier Closed Formulary
42 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
atropine drops 1 %Generic-2 NO OPHTHALMOLO
GYCYCLOPLEGIC MYDRIATICS
Atrovent HFA
HFA aerosol inhaler
17 mcg/actuation PrefBrand-3 25.8 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Aubagio tablet 14 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Aubagio tablet 7 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Augmentin suspension for reconstitution
125-31.25 mg/5 mL
NonPrefBrand-4 NO ANTI - INFECTIVES
PENICILLINS
Auryxia tablet 210 mg iron
NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Avandia tablet 2 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Avandia tablet 4 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Avastin solution 25 mg/mL
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Avastin solution25 mg/mL (16 mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
AVC Vaginal
cream 15 % NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Aveed solution750 mg/3 mL (250 mg/mL)
NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
43 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Avelox ABC Pack
tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES
QUINOLONES
Avelox in NaCl (iso-osmotic)
piggyback 400 mg/250 mL PrefBrand-3 NO ANTI - INFECTIVES
QUINOLONES
Aviane tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Avita cream 0.025 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Avita gel 0.025 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Avonex syringe kit 30 mcg/0.5 mL Specialty-5 4 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Avonex pen injector kit 30 mcg/0.5 mL
Specialty-5
4 28
NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Avonex (with albumin)
kit 30 mcg Specialty-5 1 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Avycaz recon soln 2.5 gramSpecialty-5 NO ANTI -
INFECTIVESCEPHALOSPORINS
Axert tablet 6.25 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
44 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Axert tablet 12.5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Axiron
solution in metered pump w/app
30 mg/actuation (1.5 mL)
NonPrefBrand-4 YESENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
azacitidine recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Azactam in dextrose (iso-osm) piggyback 2 gram/50 mL
PrefBrand-3 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Azasan tablet 75 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Azasan tablet 100 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Azasite drops 1 % NonPrefBrand-4 NO OPHTHALMOLOGY
ANTIBIOTICS
azathioprine tablet 50 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
azathioprine sodium
recon soln 100 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
45 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
azelastine aerosol,spray 137 mcg (0.1 %) Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
azelastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
azelastine spray,non-aerosol
0.15 % (205.5 mcg)
Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
Azelex cream 20 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Azilect tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Azilect tablet 0.5 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
azithromycin suspension for reconstitution
200 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin tablet 600 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin suspension for reconstitution
100 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
5T Medicare Part D: 5 Tier Closed Formulary
46 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
azithromycin tablet 250 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin tablet 250 mg (6 pack) Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin packet 1 gram Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin recon soln 500 mg
Generic-2 NOANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Azopt drops,suspension
1 % PrefBrand-3 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
Azor tablet 10-20 mg PrefBrand-3 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Azor tablet 10-40 mg PrefBrand-3 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Azor tablet 5-20 mg PrefBrand-3 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Azor tablet 5-40 mg PrefBrand-3 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
47 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
aztreonam recon soln 1 gram
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
BACiiM recon soln 50,000 unit Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
bacitracin ointment 500 unit/gram Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
bacitracin recon soln 50,000 unit Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
bacitracin-polymyxin B
ointment 500-10,000 unit/gram
Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
baclofen tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
baclofen tablet 20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Bactroban Nasal
ointment 2 % PrefBrand-3 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
balsalazide capsule 750 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
48 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Balziva (28) tablet 0.4-35 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Banzel tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Banzel tablet 400 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Banzel suspension 40 mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Baraclude tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Baraclude tablet 1 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Baraclude solution 0.05 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
BCG vaccine, live (PF)
suspension for reconstitution 50 mg
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Beconase AQ
spray,non-aerosol
42 mcg (0.042 %) NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Bekyree (28) tablet0.15-0.02 mgx21 /0.01 mg x 5
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
49 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Belbuca film 150 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Belbuca film 300 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Belbuca film 450 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Belbuca film 600 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Belbuca film 75 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Belbuca film 750 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Belbuca film 900 mcg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Beleodaq recon soln 500 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
50 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
benazepril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
benazepril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
benazepril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
benazepril tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
benazepril-hydrochlorothiazide
tablet 10-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
benazepril-hydrochlorothiazide
tablet 20-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
benazepril-hydrochlorothiazide
tablet 20-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
benazepril-hydrochlorothiazide
tablet 5-6.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
51 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Benicar tablet 5 mg NonPrefBrand-4 93 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Benicar tablet 20 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Benicar tablet 40 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Benicar HCT
tablet 40-25 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Benicar HCT
tablet 40-12.5 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Benicar HCT
tablet 20-12.5 mg NonPrefBrand-4 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Benlysta recon soln 120 mg
NonPrefBrand-4 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Benlysta recon soln 400 mg
Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
52 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
benztropine solution 2 mg/2 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
benztropine tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
benztropine tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
benztropine tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Berinert kit 500 unit (10 mL) Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Besivance drops,suspension
0.6 % NonPrefBrand-4 NO OPHTHALMOLOGY
ANTIBIOTICS
betamethasone dipropionate
ointment 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone dipropionate
cream 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone dipropionate
lotion 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone valerate
cream 0.1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
53 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
betamethasone valerate
lotion 0.1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone valerate
ointment 0.1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone valerate foam 0.12 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone, augmented
cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone, augmented
lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone, augmented
ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
betamethasone, augmented
gel 0.05 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Betaseron kit 0.3 mg Specialty-5 15 31 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
betaxolol drops 0.5 % Generic-2 NO OPHTHALMOLOGY
BETA-BLOCKERS
betaxolol tablet 10 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
54 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
betaxolol tablet 20 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bethanechol chloride
tablet 10 mg Generic-2 NO UROLOGICALS CHOLINERGIC STIMULANTS
bethanechol chloride
tablet 25 mg Generic-2 NO UROLOGICALS CHOLINERGIC STIMULANTS
bethanechol chloride
tablet 5 mg Generic-2 NO UROLOGICALS CHOLINERGIC STIMULANTS
bethanechol chloride
tablet 50 mg Generic-2 NO UROLOGICALS CHOLINERGIC STIMULANTS
Bethkissolution for nebulization 300 mg/4 mL
NonPrefBrand-4 YES
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Betimol drops 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY
BETA-BLOCKERS
Betimol drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY
BETA-BLOCKERS
Betoptic S drops,suspension
0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY
BETA-BLOCKERS
bexarotene capsule 75 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Bexsero (PF) syringe50-50-50-25 mcg/0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
55 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Beyaz tablet3-0.02-0.451 mg (24)
NonPrefBrand-4 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
bicalutamide tablet 50 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Bicillin C-R syringe 1,200,000 unit/ 2 mL(600k/600k)
PrefBrand-3 NO ANTI - INFECTIVES
PENICILLINS
Bicillin C-R syringe 1,200,000 unit/ 2 mL(900k/300k)
PrefBrand-3 NO ANTI - INFECTIVES
PENICILLINS
Bicillin L-A syringe 600,000 unit/mL PrefBrand-3 NO ANTI - INFECTIVES
PENICILLINS
Bicillin L-A syringe 1,200,000 unit/2 mL
PrefBrand-3 NO ANTI - INFECTIVES
PENICILLINS
Bicillin L-A syringe 2,400,000 unit/4 mL
PrefBrand-3 NO ANTI - INFECTIVES
PENICILLINS
BiCNU recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
BiDil tablet 20-37.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Biltricide tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
bimatoprost drops 0.03 % Generic-2 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
56 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
bisoprolol fumarate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bisoprolol fumarate
tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bisoprolol-hydrochlorothiazide
tablet 10-6.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bisoprolol-hydrochlorothiazide
tablet 2.5-6.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bisoprolol-hydrochlorothiazide
tablet 5-6.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Bivigam solution 10 %
Specialty-5 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
bleomycin recon soln 30 unit
Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Bleph-10 drops 10 %NonPrefBrand-4 NO OPHTHALMOLO
GY SULFONAMIDES
5T Medicare Part D: 5 Tier Closed Formulary
57 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Blephamidedrops,suspension 10-0.2 %
PrefBrand-3 NO
OPHTHALMOLOGY
STEROID-SULFONAMIDE COMBINATIONS
Blephamide S.O.P. ointment 10-0.2 %
PrefBrand-3 NO
OPHTHALMOLOGY
STEROID-SULFONAMIDE COMBINATIONS
Blisovi 24 Fe tablet
1 mg-20 mcg (24)/75 mg (4)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Blisovi Fe 1.5/30 (28) tablet
1.5 mg-30 mcg (21)/75 mg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Blisovi Fe 1/20 (28) tablet
1 mg-20 mcg (21)/75 mg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Boniva syringe 3 mg/3 mL NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
Boostrix Tdap syringe
2.5-8-5 Lf-mcg-Lf/0.5mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
58 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Boostrix Tdap suspension
2.5-8-5 Lf-mcg-Lf/0.5mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Bosulif tablet 100 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Bosulif tablet 500 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Botox recon soln 100 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Botox recon soln 200 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Breo Elliptablister with device 100-25 mcg/dose
PrefBrand-360 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Breo Elliptablister with device 200-25 mcg/dose
PrefBrand-360 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Briellyn tablet 0.4-35 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
59 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Brilinta tablet 90 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Brilinta tablet 60 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
brimonidine drops 0.2 % Generic-2 NO OPHTHALMOLOGY
SYMPATHOMIMETICS
brimonidine drops 0.15 % Generic-2 NO OPHTHALMOLOGY
SYMPATHOMIMETICS
Brisdelle capsule 7.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Briviact solution 50 mg/5 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Briviact tablet 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Briviact tablet 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Briviact tablet 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
60 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Briviact tablet 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Briviact tablet 75 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Briviact solution 10 mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
bromfenac drops 0.09 % Generic-2 NO OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
bromocriptine
tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
bromocriptine
capsule 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Brovana solution for nebulization
15 mcg/2 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
budesonide suspension for nebulization
1 mg/2 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
budesonide suspension for nebulization
0.25 mg/2 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
budesonide suspension for nebulization
0.5 mg/2 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
61 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
budesonide spray,non-aerosol
32 mcg/actuation Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
budesonidecapsule,delayed,extend.release 3 mg
NonPrefBrand-4 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
bumetanide tablet 0.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bumetanide tablet 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bumetanide tablet 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
bumetanide solution 0.25 mg/mL
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Bunavail film 2.1-0.3 mg
NonPrefBrand-4
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Bunavail film 4.2-0.7 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
62 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Bunavail film 6.3-1 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Bupap tablet 50-300 mg
NonPrefBrand-4
403 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Buphenyl tablet 500 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Buphenyl powder 0.94 gram/gram Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Buprenex solution 0.3 mg/mL NonPrefBrand-4 267 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
buprenorphine HCl
solution 0.3 mg/mL PrefGen-1 267 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
buprenorphine HCl
tablet 2 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
buprenorphine HCl
tablet 8 mg Generic-2 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
63 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
buprenorphine HCl syringe 0.3 mg/mL
PrefGen-1
267 30
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
buprenorphine-naloxone
tablet 2-0.5 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
buprenorphine-naloxone
tablet 8-2 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Buproban tablet extended release
150 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
SMOKING DETERRENTS
bupropion HCl
tablet extended release
100 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
bupropion HCl
tablet extended release
150 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
bupropion HCl
tablet extended release
200 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
bupropion HCl
tablet extended release 24 hr
150 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
64 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
bupropion HCl
tablet extended release 24 hr
300 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
bupropion HCl
tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
bupropion HCl
tablet 75 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
buspirone tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
buspirone tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
buspirone tablet 30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
buspirone tablet 5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
buspirone tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
65 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Busulfex solution 60 mg/10 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Butalbital Compound W/Codeine
capsule 30-50-325-40 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
butalbital-acetaminop-caf-cod
capsule 50-325-40-30 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
butalbital-acetaminop-caf-cod capsule 50-300-40-30 mg
Generic-2
403 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
butalbital-acetaminophen
tablet 50-325 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
butalbital-acetaminophen-caff
capsule 50-325-40 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
butalbital-acetaminophen-caff
tablet 50-325-40 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
butalbital-acetaminophen-caff
capsule 50-300-40 mg Generic-2 403 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
66 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
butalbital-aspirin-caffeine
capsule 50-325-40 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Butisol tablet 30 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
butorphanol tartrate
solution 1 mg/mL Generic-2 720 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
butorphanol tartrate
spray,non-aerosol
10 mg/mL Generic-2 5 28 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
butorphanol tartrate solution 2 mg/mL
Generic-2
360 30
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Butrans patch weekly 10 mcg/hour NonPrefBrand-4 4 28 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Butrans patch weekly 20 mcg/hour NonPrefBrand-4 4 28 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Butrans patch weekly 5 mcg/hour NonPrefBrand-4 4 28 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
67 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Butrans patch weekly 15 mcg/hour
NonPrefBrand-4
4 28
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Butrans patch weekly 7.5 mcg/hour
NonPrefBrand-4
4 28
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Bydureonsuspension,extended rel recon 2 mg
PrefBrand-34 28
NO ENDOCRINE/DIABETES
DIABETES THERAPY
Bydureon pen injector 2 mg/0.65 mLPrefBrand-3
4 28NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Bystolic tablet 10 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Bystolic tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Bystolic tablet 5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Bystolic tablet 20 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
cabergoline tablet 0.5 mg Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
68 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Cabometyx tablet 20 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cabometyx tablet 40 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cabometyx tablet 60 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cafergot tablet 1-100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
calcipotriene ointment 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
calcipotriene solution 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
calcipotriene cream 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
calcipotriene-betamethasone
ointment 0.005-0.064 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
5T Medicare Part D: 5 Tier Closed Formulary
69 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
calcitonin (salmon)
spray,non-aerosol
200 unit/actuation Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
calcitriol capsule 0.25 mcg Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
calcitriol capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
calcitriol solution 1 mcg/mL Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
calcitriol solution 1 mcg/mL Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
calcitriol ointment 3 mcg/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
calcium acetate
capsule 667 mg Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
Cambia powder in packet
50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Camila tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Canasa suppository 1,000 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Cancidas recon soln 70 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Cancidas recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
70 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
candesartan tablet 4 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
candesartan tablet 8 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
candesartan tablet 16 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
candesartan tablet 32 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
candesartan-hydrochlorothiazid
tablet 16-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
candesartan-hydrochlorothiazid
tablet 32-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
candesartan-hydrochlorothiazid
tablet 32-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Capastat recon soln 1 gram NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
71 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Capex shampoo 0.01 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Capital with Codeine
suspension 120-12 mg/5 mL PrefBrand-3 5167 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Caprelsa tablet 100 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Caprelsa tablet 300 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
captopril tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
captopril tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
captopril tablet 50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
captopril tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
72 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
captopril-hydrochlorothiazide
tablet 25-15 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
captopril-hydrochlorothiazide
tablet 25-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
captopril-hydrochlorothiazide
tablet 50-15 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
captopril-hydrochlorothiazide
tablet 50-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Carac cream 0.5 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Carafate suspension 100 mg/mL PrefBrand-3 NO GASTROENTEROLOGY
ULCER THERAPY
Carbaglu tablet, dispersible
200 mg Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
carbamazepine
tablet extended release 12 hr
100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine
capsule, ER multiphase 12 hr
300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
73 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
carbamazepine
capsule, ER multiphase 12 hr
200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine
tablet,chewable 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine
suspension 100 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine
tablet 200 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine
capsule, ER multiphase 12 hr
100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine
tablet extended release 12 hr
200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine
tablet extended release 12 hr
400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Carbatrol capsule, ER multiphase 12 hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
74 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Carbatrol capsule, ER multiphase 12 hr
300 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Carbatrol capsule, ER multiphase 12 hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbidopa tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa
tablet 10-100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa
tablet 25-100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa
tablet 25-250 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa
tablet extended release
25-100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa
tablet extended release
50-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
75 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
carbidopa-levodopa
tablet,disintegrating
25-100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa
tablet,disintegrating
25-250 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa
tablet,disintegrating
10-100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa-entacapone
tablet 12.5-50-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa-entacapone
tablet 25-100-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa-entacapone
tablet 37.5-150-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa-entacapone
tablet 50-200-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carbidopa-levodopa-entacapone
tablet 31.25-125-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
76 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
carbidopa-levodopa-entacapone
tablet 18.75-75-200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
carboplatin solution 10 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cardene IV in sodium chloride
piggyback 40 mg/200 mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Cardizem LA
tablet extended release 24 hr
120 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Carimune NF Nanofiltered
recon soln 6 gram Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
carisoprodol-ASA-codeine
tablet 200-325-16 mg Generic-2 2582 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Carnitor solution 100 mg/mL NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Carnitor solution 200 mg/mL NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
77 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Carnitor tablet 330 mg NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
carteolol drops 1 % Generic-2 NO OPHTHALMOLOGY
BETA-BLOCKERS
Cartia XT capsule,extended release 24hr
120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Cartia XT capsule,extended release 24hr
180 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Cartia XT capsule,extended release 24hr
240 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Cartia XT capsule,extended release 24hr
300 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
carvedilol tablet 6.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
carvedilol tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
carvedilol tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
78 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
carvedilol tablet 3.125 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Casodex tablet 50 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cayston solution for nebulization
75 mg/mL Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
cefaclor capsule 500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefaclor suspension for reconstitution
375 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefaclor tablet extended release 12 hr
500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefaclor suspension for reconstitution
125 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefaclor capsule 250 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefaclor suspension for reconstitution
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefadroxil suspension for reconstitution
500 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefadroxil tablet 1 gram Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefadroxil suspension for reconstitution
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefadroxil capsule 500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
5T Medicare Part D: 5 Tier Closed Formulary
79 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
cefazolin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefazolin recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefazolin recon soln 500 mgGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefdinir capsule 300 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefdinir suspension for reconstitution
125 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefdinir suspension for reconstitution
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefepime recon soln 2 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefepime recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefixime suspension for reconstitution
100 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefixime suspension for reconstitution
200 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefotaxime recon soln 500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefotaxime recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefotaxime recon soln 2 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefotetan recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefotetan recon soln 2 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefoxitin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
5T Medicare Part D: 5 Tier Closed Formulary
80 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
cefoxitin recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefoxitin recon soln 2 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefpodoxime tablet 100 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefpodoxime suspension for reconstitution
100 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefpodoxime tablet 200 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefpodoxime suspension for reconstitution
50 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefprozil tablet 250 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefprozil tablet 500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefprozil suspension for reconstitution
125 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefprozil suspension for reconstitution
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
ceftazidime recon soln 6 gram Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
ceftazidime recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
ceftazidime recon soln 2 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
Ceftin suspension for reconstitution
125 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES
CEPHALOSPORINS
Ceftin suspension for reconstitution
250 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES
CEPHALOSPORINS
ceftriaxone recon soln 10 gram Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
5T Medicare Part D: 5 Tier Closed Formulary
81 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ceftriaxone recon soln 250 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
ceftriaxone recon soln 500 mgGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
ceftriaxone recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
ceftriaxone recon soln 2 gramGeneric-2 NO ANTI -
INFECTIVESCEPHALOSPORINS
cefuroxime axetil
tablet 250 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefuroxime axetil
tablet 500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefuroxime sodium
recon soln 7.5 gram Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefuroxime sodium recon soln 1.5 gram
Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cefuroxime sodium recon soln 750 mg
Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
celecoxib capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
celecoxib capsule 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
celecoxib capsule 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
82 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
celecoxib capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
CellCept tablet 500 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
CellCept suspension for reconstitution
200 mg/mL NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
CellCept capsule 250 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
CellCept Intravenous
recon soln 500 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Celontin capsule 300 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
cephalexin tablet 500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cephalexin suspension for reconstitution
125 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cephalexin capsule 250 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cephalexin suspension for reconstitution
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
5T Medicare Part D: 5 Tier Closed Formulary
83 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
cephalexin capsule 500 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cephalexin tablet 250 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
cephalexin capsule 750 mg Generic-2 NO ANTI - INFECTIVES
CEPHALOSPORINS
Cerdelga capsule 84 mgSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Cerebyx solution 500 mg PE/10 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Cerezyme recon soln 400 unitSpecialty-5 NO ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Cervarix Vaccine (PF) syringe 20-20 mcg/0.5 mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Cesamet capsule 1 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
cetirizine solution 1 mg/mL
Generic-2 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
cevimeline capsule 30 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Chantix tablet 0.5 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
SMOKING DETERRENTS
5T Medicare Part D: 5 Tier Closed Formulary
84 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Chantix tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
SMOKING DETERRENTS
Chantix Continuing Month Box
tablet 1 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
SMOKING DETERRENTS
Chantix Starting Month Box
tablets,dose pack
0.5 mg (11)- 1 mg (42)
NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
SMOKING DETERRENTS
Chemet capsule 100 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Chenodal tablet 250 mg Specialty-5 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
chloramphenicol sod succinate
recon soln 1 gram Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
chlordiazepoxide HCl
capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
chlordiazepoxide HCl
capsule 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
chlordiazepoxide HCl
capsule 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
85 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
chlorhexidine gluconate
mouthwash 0.12 % PrefGen-1 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
chloroquine phosphate tablet 500 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
chloroquine phosphate tablet 250 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
chlorothiazide
tablet 250 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
chlorothiazide
tablet 500 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
chlorothiazide sodium
recon soln 500 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
chlorpromazine
tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
chlorpromazine
tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
86 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
chlorpromazine
tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
chlorpromazine
tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
chlorpromazine
tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
chlorpromazine solution 25 mg/mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
chlorthalidone
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
chlorthalidone
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Cholbam capsule 250 mg
Specialty-5 YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Cholbam capsule 50 mg
Specialty-5 YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
87 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Cholestyramine Light
powder in packet
4 gram Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
chorionic gonadotropin, human
recon soln 10,000 unit Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Cialis tablet 5 mg NonPrefBrand-4 31 31 YES UROLOGICALS MISCELLANEOUS UROLOGICALS
Cialis tablet 2.5 mg NonPrefBrand-4 62 31 YES UROLOGICALS MISCELLANEOUS UROLOGICALS
ciclopirox shampoo 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
ciclopirox cream 0.77 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
ciclopirox suspension 0.77 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
ciclopirox solution 8 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
ciclopirox gel 0.77 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
cidofovir solution 75 mg/mL Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
88 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
cilostazol tablet 100 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
cilostazol tablet 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Ciloxan ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY
ANTIBIOTICS
cimetidine tablet 200 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
cimetidine tablet 300 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
cimetidine tablet 400 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
cimetidine tablet 800 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
cimetidine HCl
solution 300 mg/5 mL Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
Cimzia syringe kit 400 mg/2 mL (200 mg/mL x 2)
Specialty-5 2 28 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Cimzia Powder for Reconst
kit 400 mg (200 mg x 2 vials)
Specialty-5 6 28 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Cinryze recon soln 500 unit (5 mL) Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Cipro HC drops,suspension
0.2-1 % NonPrefBrand-4 NO EAR, NOSE / THROAT MEDICATIONS
OTIC STEROID / ANTIBIOTIC
5T Medicare Part D: 5 Tier Closed Formulary
89 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Ciprodex drops,suspension
0.3-0.1 % PrefBrand-3 NO EAR, NOSE / THROAT MEDICATIONS
OTIC STEROID / ANTIBIOTIC
ciprofloxacin
suspension,microcapsule recon
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin
suspension,microcapsule recon
500 mg/5 mL Generic-2 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin (mixture)
tablet, ER multiphase 24 hr
500 mg Generic-2 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin (mixture)
tablet, ER multiphase 24 hr
1,000 mg Generic-2 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin HCl
tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin HCl
tablet 750 mg PrefGen-1 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin HCl
tablet 100 mg PrefGen-1 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin HCl
drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY
ANTIBIOTICS
ciprofloxacin HCl
tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES
QUINOLONES
ciprofloxacin in 5 % dextrose piggyback 200 mg/100 mL
Generic-2 NOANTI - INFECTIVES QUINOLONES
ciprofloxacin lactate solution 400 mg/40 mL
PrefGen-1 NO ANTI - INFECTIVES QUINOLONES
cisplatin solution 1 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
90 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
citalopram tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
citalopram tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
citalopram solution 10 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
citalopram tablet 40 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
cladribine solution 10 mg/10 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Claforan recon soln 1 gramNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
Claravis capsule 10 mg Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Claravis capsule 20 mg Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Claravis capsule 40 mg Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
5T Medicare Part D: 5 Tier Closed Formulary
91 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Claravis capsule 30 mg Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Clarinex-D 12 HOUR
tablet, ER multiphase 12 hr 2.5-120 mg
NonPrefBrand-4 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
clarithromycin
tablet 250 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
clarithromycin
tablet 500 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
clarithromycin
suspension for reconstitution
125 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
clarithromycin
suspension for reconstitution
250 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
clarithromycin
tablet extended release 24 hr
500 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Cleocin capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Cleocin suppository 100 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Climara Pro patch weekly 0.045-0.015 mg/24 hr
NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Clindacin Pac kit 1 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
5T Medicare Part D: 5 Tier Closed Formulary
92 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clindamycin HCl
capsule 150 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin HCl
capsule 300 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin HCl
capsule 75 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin in 5 % dextrose
piggyback 600 mg/50 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin in 5 % dextrose
piggyback 900 mg/50 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin in 5 % dextrose
piggyback 300 mg/50 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Clindamycin Pediatric
recon soln 75 mg/5 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin phosphate
lotion 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
5T Medicare Part D: 5 Tier Closed Formulary
93 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clindamycin phosphate
gel 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
clindamycin phosphate
solution 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
clindamycin phosphate
cream 2 % Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
clindamycin phosphate
foam 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
clindamycin phosphate
swab 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
clindamycin phosphate solution 150 mg/mL
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin phosphate solution 600 mg/4 mL
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin phosphate solution
150 (mg/mL) (6 ml)
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
clindamycin-benzoyl peroxide
gel 1-5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Clindesse cream,extended release
2 % NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
5T Medicare Part D: 5 Tier Closed Formulary
94 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Clinimix 5%/D15W Sulfite Free
parenteral solution
5 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix 5%/D25W sulfite-free
parenteral solution
5 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix 2.75%/D5W Sulfit Free
parenteral solution
2.75 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix 4.25%/D10W Sulf Free
parenteral solution
4.25 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix 4.25%/D5W Sulfit Free
parenteral solution
4.25 % PrefBrand-3 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Clinimix 4.25%-D20W sulf-free
parenteral solution
4.25 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix 4.25%-D25W sulf-free
parenteral solution
4.25 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix 5%-D20W(sulfite-free)
parenteral solution
5 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix E 2.75%/D10W Sul Free
parenteral solution
2.75 % NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
95 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Clinimix E 2.75%/D5W Sulf Free
parenteral solution
2.75 % NonPrefBrand-4 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Clinimix E 4.25%/D10W Sul Free
parenteral solution 4.25 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix E 4.25%/D25W Sul Free
parenteral solution
4.25 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix E 4.25%/D5W Sulf Free
parenteral solution
4.25 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix E 5%/D15W Sulfit Free
parenteral solution
5 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix E 5%/D20W Sulfit Free
parenteral solution
5 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinimix E 5%/D25W Sulfit Free
parenteral solution
5 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Clinisol SF 15 %
parenteral solution
15 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
clobetasol foam 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
clobetasol gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
clobetasol ointment 0.05 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
96 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clobetasol solution 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
clobetasol shampoo 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
clobetasol lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
clobetasol spray,non-aerosol
0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
clobetasol-emollient
cream 0.05 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Clodan shampoo 0.05 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Cloderm cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Clolar solution 20 mg/20 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
clomipramine
capsule 25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clomipramine
capsule 50 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
97 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clomipramine
capsule 75 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clonazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
clonazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
clonazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
clonazepam tablet,disintegrating
0.125 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
clonazepam tablet,disintegrating
0.25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
clonazepam tablet,disintegrating
1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
clonazepam tablet,disintegrating
2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
98 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clonazepam tablet,disintegrating
0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
clonidine patch weekly 0.1 mg/24 hr
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
clonidine patch weekly 0.2 mg/24 hr
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
clonidine patch weekly 0.3 mg/24 hr
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
clonidine HCl
tablet 0.1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
clonidine HCl
tablet 0.2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
clonidine HCl
tablet 0.3 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
clonidine HCl
tablet extended release 12 hr 0.1 mg
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
99 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clopidogrel tablet 75 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
clopidogrel tablet 300 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
clorazepate dipotassium
tablet 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clorazepate dipotassium
tablet 3.75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clorazepate dipotassium
tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Clorpres tablet 0.1-15 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Clorpres tablet 0.2-15 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Clorpres tablet 0.3-15 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
100 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clotrimazole cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
clotrimazole solution 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
clotrimazole troche 10 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
clotrimazole-betamethasone
cream 1-0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
clotrimazole-betamethasone
lotion 1-0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
clozapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clozapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clozapine tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clozapine tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
101 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
clozapine tablet,disintegrating
100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clozapine tablet,disintegrating
25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clozapine tablet,disintegrating
12.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clozapinetablet,disintegrating 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
clozapinetablet,disintegrating 150 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Clozaril tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Clozaril tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Coartem tablet 20-120 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
102 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
codeine sulfate tablet 15 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
codeine sulfate tablet 30 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
codeine sulfate tablet 60 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
colchicine tablet 0.6 mg NonPrefBrand-4 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
colchicine capsule 0.6 mg
NonPrefBrand-4 NO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY
colchicine-probenecid
tablet 0.5-500 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
Colcrys tablet 0.6 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
colestipol tablet 1 gram
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
103 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
colestipol granules 5 gram
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
colistin (colistimethate Na) recon soln 150 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Colocort enema 100 mg/60 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Coly-Mycin S
drops,suspension
3.3-3-10-0.5 mg/mL
NonPrefBrand-4 NO EAR, NOSE / THROAT MEDICATIONS
OTIC STEROID / ANTIBIOTIC
Combigan drops 0.2-0.5 % PrefBrand-3 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
Combivent Respimat mist
20-100 mcg/actuation
NonPrefBrand-44 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Combivir tablet 150-300 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Cometriq capsule140 mg/day(80 mg x1-20 mg x3)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cometriq capsule100 mg/day(80 mg x1-20 mg x1)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
104 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Cometriq capsule60 mg/day (20 mg x 3/day)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Complera tablet 200-25-300 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALSCompro suppository 25 mg Generic-2 NO GASTROENTERO
LOGYMISCELLANEOUS GASTROINTESTINAL AGENTS
Condylox gel 0.5 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Constulose solution 10 gram/15 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Copaxone syringe 20 mg/mL
Specialty-5
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Copaxone syringe 40 mg/mL
Specialty-5
12 28
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Copegus tablet 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Cordran Tape Large Roll
tape 4 mcg/cm2 PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
105 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Corlanor tablet 5 mg
NonPrefBrand-4
93 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
Corlanor tablet 7.5 mg
NonPrefBrand-4
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
Cormax solution 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
cortisone tablet 25 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Cortisporin ointment 1 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
Cortisporin cream3.5-10,000-0.5 mg/g-unit/g-%
PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
Cosentyx syringe 150 mg/mL
Specialty-5
2 28
YESDERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Cosentyx Pen pen injector 150 mg/mL
Specialty-5
2 28
YESDERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Cotellic tablet 20 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
106 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Coumadin tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Coumadin tablet 10 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Coumadin tablet 2 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Coumadin tablet 2.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Coumadin tablet 3 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Coumadin tablet 4 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Coumadin tablet 5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Coumadin tablet 6 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
107 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Coumadin tablet 7.5 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Creon capsule,delayed release(DR/EC)
24,000-76,000 -120,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Creon capsule,delayed release(DR/EC)
6,000-19,000 -30,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Creon capsule,delayed release(DR/EC)
12,000-38,000 -60,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Creoncapsule,delayed release(DR/EC)
3,000-9,500- 15,000 unit
PrefBrand-3 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Creoncapsule,delayed release(DR/EC)
36,000-114,000- 180,000 unit
PrefBrand-3 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Cresemba capsule 186 mgSpecialty-5 NO ANTI -
INFECTIVESANTIFUNGAL AGENTS
Cresemba recon soln 372 mgSpecialty-5 NO ANTI -
INFECTIVESANTIFUNGAL AGENTS
Crinone gel 8 %NonPrefBrand-4 YES OBSTETRICS /
GYNECOLOGYESTROGENS / PROGESTINS
Crinone gel 4 %NonPrefBrand-4 YES OBSTETRICS /
GYNECOLOGYESTROGENS / PROGESTINS
5T Medicare Part D: 5 Tier Closed Formulary
108 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Crixivan capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Crixivan capsule 400 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
cromolyn drops 4 % Generic-2 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
cromolyn solution for nebulization
20 mg/2 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
cromolyn concentrate 100 mg/5 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Cryselle (28) tablet 0.3-30 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Cubicin recon soln 500 mg Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Cuprimine capsule 250 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Cutivate lotion 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Cuvposa solution1 mg/5 mL (0.2 mg/mL)
NonPrefBrand-4 NO
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
5T Medicare Part D: 5 Tier Closed Formulary
109 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Cyclafem 1/35 (28) tablet 1-35 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Cyclafem 7/7/7 (28) tablet
0.5/0.75/1 mg- 35 mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
cyclobenzaprine
tablet 7.5 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
cyclobenzaprine
tablet 5 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
cyclobenzaprine
tablet 10 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
cyclophosphamide capsule 25 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyclophosphamide capsule 50 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cycloset tablet 0.8 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
110 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
cyclosporine capsule 25 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyclosporine solution 250 mg/5 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyclosporine capsule 100 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyclosporine modified
capsule 100 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyclosporine modified
solution 100 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyclosporine modified
capsule 25 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyclosporine modified
capsule 50 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
cyproheptadine
syrup 2 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
111 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
cyproheptadine
tablet 4 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Cyramza solution 10 mg/mL
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cyramza solution10 mg/mL (50 mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cystadane powder 1 gram/1.7 mL PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Cystagon capsule 150 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS
Cystagon capsule 50 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS
Cystaran drops 0.44 %
Specialty-5 NO
OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
cytarabine solution 20 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
112 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
cytarabine (PF)
solution 2 gram/20 mL (100 mg/mL)
Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Cytovene recon soln 500 mg NonPrefBrand-4 YES ANTI - INFECTIVES
ANTIVIRALS
D10 %-0.45 % sodium chloride
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
D2.5 %-0.45 % sodium chloride
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
D5 % and 0.9 % sodium chloride
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
D5 %-0.45 % sodium chloride
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
dacarbazine recon soln 200 mg
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Dacogen recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Daklinza tablet 30 mgSpecialty-5
28 28YES ANTI -
INFECTIVES ANTIVIRALS
Daklinza tablet 60 mgSpecialty-5
28 28YES ANTI -
INFECTIVES ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
113 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Daklinza tablet 90 mgSpecialty-5
28 28YES ANTI -
INFECTIVES ANTIVIRALS
Daliresp tablet 500 mcgPrefBrand-3
31 31NO RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Dalvance solution 500 mg
Specialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
danazol capsule 100 mg Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
danazol capsule 200 mg Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
danazol capsule 50 mg Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
dantrolene capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
dantrolene capsule 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
dantrolene capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
dapsone tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
114 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dapsone tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Daptacel (DTaP Pediatric) (PF) suspension
15-10-5 Lf-mcg-Lf/0.5mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Daraprim tablet 25 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
darifenacin tablet extended release 24 hr
15 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
darifenacin tablet extended release 24 hr
7.5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
Darzalex solution 20 mg/mL
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
daunorubicin solution 5 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Daytrana patch 24 hour 10 mg/9 hr NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
115 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Daytrana patch 24 hour 15 mg/9 hr NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Daytrana patch 24 hour 20 mg/9 hr NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Daytrana patch 24 hour 30 mg/9 hr NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
DDAVP solution 0.1 mg/mL (refrigerate)
NonPrefBrand-4 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
decitabine recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Delzicolcapsule,delayed release(DR/EC) 400 mg
PrefBrand-3 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
demeclocycline
tablet 150 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
demeclocycline
tablet 300 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
Demser capsule 250 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Denavir cream 1 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
116 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Depacon solution500 mg/5 mL (100 mg/mL)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depakene capsule 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depakene solution 250 mg/5 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depakote
tablet,delayed release (DR/EC) 125 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depakote
tablet,delayed release (DR/EC) 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depakote
tablet,delayed release (DR/EC) 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depakote ER
tablet extended release 24 hr 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depakote ER
tablet extended release 24 hr 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
117 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Depakote Sprinkles
capsule, sprinkle 125 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Depen Titratabs
tablet 250 mg Specialty-5 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Depo-Estradiol
oil 5 mg/mL NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Depo-Medrol suspension 20 mg/mL
NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Depo-Medrol suspension 40 mg/mL
NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Depo-Medrol suspension 80 mg/mL
NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Depo-Provera solution 400 mg/mL
NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Depo-Testosterone
oil 100 mg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Depo-Testosterone
oil 200 mg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Descovy tablet 200-25 mgSpecialty-5
31 31NO ANTI -
INFECTIVES ANTIVIRALS
desipramine tablet 10 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
118 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
desipramine tablet 100 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
desipramine tablet 150 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
desipramine tablet 25 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
desipramine tablet 50 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
desipramine tablet 75 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
desloratadine tablet 5 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
desloratadine tablet,disintegrating
5 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
desloratadine tablet,disintegrating
2.5 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
119 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
desmopressin
tablet 0.2 mg Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
desmopressin
solution 4 mcg/mL Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
desmopressin
spray,non-aerosol
10 mcg/spray (0.1 mL)
Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
desmopressin
tablet 0.1 mg Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
desmopressin
solution 0.1 mg/mL (refrigerate)
Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Desonate gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desonide lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desonide ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desonide cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desoximetasone
ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desoximetasone
cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desoximetasone
cream 0.25 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
120 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
desoximetasone
ointment 0.25 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desoximetasone
gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
desvenlafaxine
tablet extended release 24 hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
desvenlafaxine
tablet extended release 24 hr
50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexamethasone
tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone
tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone
tablet 1.5 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone
tablet 2 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone
tablet 4 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone
tablet 6 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone
elixir 0.5 mg/5 mL PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone
tablet 0.75 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Dexamethasone Intensol
drops 1 mg/mL Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
121 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dexamethasone sodium phosphate
drops 0.1 % Generic-2 NO OPHTHALMOLOGY
STEROIDS
dexamethasone sodium phosphate
solution 10 mg/mL Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexamethasone sodium phosphate solution 4 mg/mL
Generic-2 NOENDOCRINE/DIABETES
ADRENAL HORMONES
Dexedrine tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Dexedrine tablet 10 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
capsule,ER biphasic 50-50
10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
capsule,ER biphasic 50-50
15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
capsule,ER biphasic 50-50
20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
capsule,ER biphasic 50-50
30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
122 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dexmethylphenidate
capsule,ER biphasic 50-50
5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dexmethylphenidate
capsule,ER biphasic 50-50 40 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
DexPak 13 Day
tablets,dose pack
1.5 mg (51 tabs) NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
dexrazoxane HCl recon soln 250 mg
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
dextroamphetamine
tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
123 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dextroamphetamine
tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine
capsule, extended release
10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine
capsule, extended release
15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine
capsule, extended release
5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
tablet 30 mg Generic-2 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
tablet 5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
tablet 10 mg Generic-2 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
tablet 15 mg PrefGen-1 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
124 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dextroamphetamine-amphetamine
tablet 20 mg Generic-2 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
tablet 12.5 mg PrefGen-1 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
capsule,extended release 24hr
10 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
capsule,extended release 24hr
15 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
capsule,extended release 24hr
20 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
capsule,extended release 24hr
25 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
capsule,extended release 24hr
30 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextroamphetamine-amphetamine
capsule,extended release 24hr
5 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
125 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dextroamphetamine-amphetamine tablet 7.5 mg
PrefGen-1
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
dextrose 10 % and 0.2 % NaCl
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
dextrose 10 % in water (D10W)
parenteral solution
10 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
dextrose 5 % in water (D5W)
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
dextrose 5 %-lactated ringers
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
dextrose 5%-0.2 % sod chloride
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
dextrose 5%-0.3 % sod.chloride
parenteral solution
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Dextrose With Sodium Chloride
parenteral solution
5-0.2 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Dextrose-KCl-NaCl
solution 5-0.224-0.225 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
Diastat kit 2.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
126 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Diastat AcuDial
kit 5-7.5-10 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Diastat AcuDial
kit 12.5-15-17.5-20 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
diazepam tablet 10 mg Generic-2 124 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
diazepam tablet 2 mg Generic-2 124 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
diazepam tablet 5 mg Generic-2 124 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
diazepam solution 5 mg/5 mL (1 mg/mL)
Generic-2 1500 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
diazepam kit 2.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
diazepam kit 5-7.5-10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
127 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
diazepam kit 12.5-15-17.5-20 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Diazepam Intensol
concentrate 5 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Dibenzyline capsule 10 mg Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diclofenac potassium
tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
diclofenac sodium
drops 0.1 % PrefGen-1 NO OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
diclofenac sodium
gel 1 % PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
diclofenac sodium
gel 3 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
diclofenac sodium
tablet extended release 24 hr
100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
128 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
diclofenac sodium
tablet,delayed release (DR/EC)
25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
diclofenac sodium
tablet,delayed release (DR/EC)
50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
diclofenac sodium
tablet,delayed release (DR/EC)
75 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
diclofenac sodium
drops 1.5 % Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
diclofenac-misoprostol
tablet,IR,delayed rel,biphasic
50-200 mg-mcg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
diclofenac-misoprostol
tablet,IR,delayed rel,biphasic 75-200 mg-mcg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
dicloxacillin capsule 250 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
dicloxacillin capsule 500 mg Generic-2 NO ANTI - INFECTIVES
PENICILLINS
dicyclomine capsule 10 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
5T Medicare Part D: 5 Tier Closed Formulary
129 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dicyclomine solution 10 mg/mL Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
dicyclomine solution 10 mg/5 mL Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
dicyclomine tablet 20 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
didanosine capsule,delayed release(DR/EC)
125 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
didanosine capsule,delayed release(DR/EC)
250 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
didanosine capsule,delayed release(DR/EC)
200 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
didanosine capsule,delayed release(DR/EC)
400 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Differin lotion 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
5T Medicare Part D: 5 Tier Closed Formulary
130 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Dificid tablet 200 mg
Specialty-5
20 10
NOANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
diflorasone cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
diflorasone ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
diflunisal tablet 500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Digitek tablet 125 mcg PrefGen-1 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
Digitek tablet 250 mcg Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
digoxin solution 250 mcg/mL Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
digoxin tablet 125 mcg PrefGen-1 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
digoxin tablet 250 mcg Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
5T Medicare Part D: 5 Tier Closed Formulary
131 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
digoxin solution 50 mcg/mL Generic-2 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
dihydroergotamine
spray,non-aerosol
0.5 mg/pump act. (4 mg/mL)
Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
dihydroergotamine
solution 1 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Dilantin capsule 30 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Dilantin Extended
capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Dilantin Infatabs tablet,chewable 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Dilantin-125 suspension 125 mg/5 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Dilaudid liquid 1 mg/mL NonPrefBrand-4 1550 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
132 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Dilaudid tablet 2 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Dilaudid tablet 4 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Dilaudid tablet 8 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
diltiazem HCl
capsule, extended release
360 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
capsule,extended release 24hr
300 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
capsule,extended release 24hr
240 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
capsule, extended release
180 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
capsule,extended release 24hr
120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
133 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
diltiazem HCl
capsule,extended release 12 hr
60 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
capsule,extended release 12 hr
90 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
capsule,extended release 12 hr
120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
tablet 120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
tablet 90 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
tablet 60 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
capsule, extended release
420 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
recon soln 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
134 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
diltiazem HCl
tablet 30 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
diltiazem HCl
solution 5 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
DILT-XR capsule,ext release degradable
120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
DILT-XR capsule,ext release degradable
180 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
DILT-XR capsule,ext release degradable
240 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Dipentum capsule 250 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
diphenhydramine HCl solution 50 mg/mL
Generic-2 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
diphenoxylate-atropine liquid
2.5-0.025 mg/5 mL
Generic-2 NO
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
5T Medicare Part D: 5 Tier Closed Formulary
135 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
diphenoxylate-atropine tablet 2.5-0.025 mg
Generic-2 NO
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
disulfiram tablet 250 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
disulfiram tablet 500 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Diuril suspension 250 mg/5 mL PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
divalproextablet extended release 24 hr 250 mg
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
divalproextablet extended release 24 hr 500 mg
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
divalproexcapsule, sprinkle 125 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
divalproex
tablet,delayed release (DR/EC) 125 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
136 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
divalproex
tablet,delayed release (DR/EC) 250 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
divalproex
tablet,delayed release (DR/EC) 500 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Divigel gel in packet 0.5 mg (0.1 %) NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Docefrez recon soln 20 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
docetaxel solution80 mg/4 mL (20 mg/mL)
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
docetaxel solution80 mg/8 mL (10 mg/mL)
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
dofetilide capsule 125 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
dofetilide capsule 250 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
137 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dofetilide capsule 500 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Dolophine tablet 10 mg NonPrefBrand-4 206 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Dolophine tablet 5 mg NonPrefBrand-4 248 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
donepeziltablet,disintegrating 10 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
donepezil tablet 10 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
donepeziltablet,disintegrating 5 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
donepezil tablet 5 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
donepezil tablet 23 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
138 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Doribax recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
dorzolamide drops 2 % Generic-2 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
dorzolamide-timolol
drops 22.3-6.8 mg/mL Generic-2 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
doxazosin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
doxazosin tablet 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
doxazosin tablet 4 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
doxazosin tablet 8 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
doxepin capsule 10 mg
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
139 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
doxepin concentrate 10 mg/mL
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
doxepin capsule 100 mg
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
doxepin capsule 150 mg
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
doxepin capsule 25 mg
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
doxepin capsule 50 mg
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
doxepin cream 5 %
Generic-2 NODERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
doxepin capsule 75 mg
Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
doxercalciferol
solution 4 mcg/2 mL Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
doxercalciferol
capsule 2.5 mcg Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
140 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
doxercalciferol
capsule 0.5 mcg Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
doxercalciferol
capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
doxorubicin solution 50 mg/25 mL
Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
doxorubicin, peg-liposomal suspension 2 mg/mL
Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Doxy-100 recon soln 100 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline hyclate
tablet 20 mg PrefGen-1 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline hyclate
recon soln 100 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline hyclate
tablet,delayed release (DR/EC)
75 mg PrefGen-1 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline hyclate
tablet,delayed release (DR/EC)
100 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline hyclate
tablet,delayed release (DR/EC)
150 mg PrefGen-1 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline hyclate
tablet,delayed release (DR/EC) 200 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
doxycycline hyclate capsule 50 mg
Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
5T Medicare Part D: 5 Tier Closed Formulary
141 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
doxycycline hyclate capsule 100 mg
Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline hyclate tablet 100 mg
Generic-2 NO ANTI - INFECTIVES TETRACYCLINES
doxycycline hyclate
tablet,delayed release (DR/EC) 50 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
doxycycline monohydrate
capsule 75 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline monohydrate
capsule 150 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
doxycycline monohydrate capsule 50 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
doxycycline monohydrate tablet 75 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
doxycycline monohydrate capsule 100 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
doxycycline monohydrate
suspension for reconstitution 25 mg/5 mL
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
doxycycline monohydrate tablet 100 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
doxycycline monohydrate tablet 150 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
5T Medicare Part D: 5 Tier Closed Formulary
142 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
doxycycline monohydrate tablet 50 mg
Generic-2 NOANTI - INFECTIVES TETRACYCLINES
dronabinol capsule 10 mg Specialty-5 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
dronabinol capsule 2.5 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
dronabinol capsule 5 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
drospirenone-ethinyl estradiol
tablet 3-0.02 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
drospirenone-ethinyl estradiol
tablet 3-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Droxia capsule 200 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Droxia capsule 300 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
143 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Droxia capsule 400 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Duexis tablet 800-26.6 mg
NonPrefBrand-4
93 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
duloxetine capsule,delayed release(DR/EC)
20 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
duloxetine capsule,delayed release(DR/EC)
30 mg PrefBrand-3 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
duloxetine capsule,delayed release(DR/EC)
60 mg PrefBrand-3 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
duloxetine capsule,delayed release(DR/EC)
40 mg PrefBrand-3 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Duopaintestinal pump suspension 4.63-20 mg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Duragesic patch 72 hour 25 mcg/hr NonPrefBrand-4 20 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
144 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Duragesic patch 72 hour 50 mcg/hr NonPrefBrand-4 17 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Duragesic patch 72 hour 75 mcg/hr NonPrefBrand-4 12 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Duragesic patch 72 hour 100 mcg/hr NonPrefBrand-4 10 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Duragesic patch 72 hour 12 mcg/hr NonPrefBrand-4 20 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Duramorph (PF)
solution 0.5 mg/mL Generic-2 4000 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Duramorph (PF)
solution 1 mg/mL Generic-2 2000 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Durezol drops 0.05 % PrefBrand-3 NO OPHTHALMOLOGY
STEROIDS
dutasteride capsule 0.5 mg PrefBrand-3 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
145 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
dutasteride-tamsulosin
capsule, ER multiphase 24 hr 0.5-0.4 mg
PrefBrand-3 NO
UROLOGICALS
BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
Dymistaspray,non-aerosol 137-50 mcg/spray
NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Dyrenium capsule 100 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Dyrenium capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Dysport recon soln 300 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Dysport recon soln 500 unit
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
E.E.S. 400 tablet 400 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
E.E.S. Granules
suspension for reconstitution
200 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
econazole cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
5T Medicare Part D: 5 Tier Closed Formulary
146 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Edarbyclor tablet 40-12.5 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Edarbyclor tablet 40-25 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Edecrin tablet 25 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Edurant tablet 25 mgNonPrefBrand-4 NO ANTI -
INFECTIVES ANTIVIRALSEffient tablet 10 mg PrefBrand-3 NO CARDIOVASCUL
AR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Effient tablet 5 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Egrifta recon soln 1 mg
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Elaprase solution 6 mg/3 mL Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Elelyso recon soln 200 unitSpecialty-5 NO ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
147 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Elidel cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Eligard syringe 45 mg (6 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Eligard syringe 30 mg (4 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Eligard syringe 7.5 mg (1 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Eligard syringe 22.5 mg (3 month) NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Eliphos tablet 667 mg Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
Eliquis tablet 2.5 mg
PrefBrand-3
62 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Eliquis tablet 5 mg
PrefBrand-3
74 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
148 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Elitek recon soln 1.5 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Elitek recon soln 7.5 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Elixophyllin elixir 80 mg/15 mL PrefBrand-3 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Ellence solution 200 mg/100 mL
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Elmiron capsule 100 mg PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS
Emadine drops 0.05 % NonPrefBrand-4 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
Embeda capsule,oral only,ext.rel pell
100-4 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Embeda capsule,oral only,ext.rel pell
20-0.8 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Embeda capsule,oral only,ext.rel pell
30-1.2 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
149 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Embeda capsule,oral only,ext.rel pell
50-2 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Embeda capsule,oral only,ext.rel pell
60-2.4 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Embeda capsule,oral only,ext.rel pell
80-3.2 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Emcyt capsule 140 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Emend capsule 80 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Emend capsule 125 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Emend capsule 40 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Emend capsule,dose pack
125 mg (1)- 80 mg (2)
NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
150 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Emend recon soln 150 mg
NonPrefBrand-4 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Emoquette tablet 0.15-0.03 mg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Empliciti recon soln 300 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Empliciti recon soln 400 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Emsam patch 24 hour 6 mg/24 hr Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Emsam patch 24 hour 9 mg/24 hr Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Emsam patch 24 hour 12 mg/24 hr Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Emtriva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Emtriva solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
151 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Emverm tablet,chewable 100 mg
NonPrefBrand-4 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
enalapril maleate
tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
enalapril maleate
tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
enalapril maleate
tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
enalapril maleate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
enalapril-hydrochlorothiazide
tablet 5-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
enalapril-hydrochlorothiazide
tablet 10-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Enbrel recon soln 25 mg (1 mL) Specialty-5 8 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
152 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Enbrel syringe 50 mg/mL (0.98 mL)
Specialty-5 7.84 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Enbrel syringe 25 mg/0.5mL (0.51)
Specialty-5 4 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Enbrel SureClick pen injector
50 mg/mL (0.98 mL)
Specialty-5
7.84 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Endocet tablet 10-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Endocet tablet 5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Endocet tablet 7.5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Engerix-B (PF)
syringe 20 mcg/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
153 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Engerix-B Pediatric (PF)
syringe 10 mcg/0.5 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Engerix-B Pediatric (PF) suspension 10 mcg/0.5 mL
PrefBrand-3 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
enoxaparin syringe 30 mg/0.3 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
enoxaparin syringe 40 mg/0.4 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
enoxaparin syringe 60 mg/0.6 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
enoxaparin syringe 80 mg/0.8 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
enoxaparin syringe 120 mg/0.8 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
154 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
enoxaparin syringe 100 mg/mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
enoxaparin syringe 150 mg/mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
enoxaparin solution 300 mg/3 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Enpresse tablet 50-30 (6)/75-40 (5)/125-30(10)
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
entacapone tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
entecavir tablet 0.5 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
entecavir tablet 1 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Entresto tablet 24-26 mg
PrefBrand-3
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
Entresto tablet 49-51 mg
PrefBrand-3
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
155 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Entresto tablet 97-103 mg
PrefBrand-3
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
Enulose solution 10 gram/15 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Envarsus XRtablet extended release 24 hr 4 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Envarsus XRtablet extended release 24 hr 0.75 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Envarsus XRtablet extended release 24 hr 1 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Epiduo gel with pump 0.1-2.5 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Epiduo Forte gel with pump 0.3-2.5 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
epinastine drops 0.05 % Generic-2 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
5T Medicare Part D: 5 Tier Closed Formulary
156 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
epinephrine auto-injector 0.3 mg/0.3 mL NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
epinephrine auto-injector 0.15 mg/0.15 mL NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
EpiPen 2-Pak
auto-injector 0.3 mg/0.3 mL PrefBrand-3 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
EpiPen Jr 2-Pak
auto-injector 0.15 mg/0.3 mL PrefBrand-3 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Epitol tablet 200 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Epivir tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Epivir solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Epivir tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Epivir HBV tablet 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Epivir HBV solution 25 mg/5 mL (5 mg/mL)
PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
157 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
eplerenone tablet 25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
eplerenone tablet 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Epogen solution 3,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Epogen solution 4,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Epogen solution 20,000 unit/2 mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Epogen solution 2,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Epogen solution 20,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
eprosartan tablet 600 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
158 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Epzicom tablet 600-300 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Equetro capsule, ER multiphase 12 hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Equetro capsule, ER multiphase 12 hr
300 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Equetro capsule, ER multiphase 12 hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Eraxis(Water Diluent)
recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Erbitux solution 100 mg/50 mL
PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ergoloid tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Ergomar tablet 2 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Erivedge capsule 150 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
159 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Errin tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Erwinaze recon soln 10,000 unit
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ery Pads swab 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Erygel gel 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
EryPed 200 suspension for reconstitution
200 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
EryPed 400 suspension for reconstitution
400 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Ery-Tab tablet,delayed release (DR/EC)
250 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Ery-Tab tablet,delayed release (DR/EC)
333 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Ery-Tab tablet,delayed release (DR/EC)
500 mg PrefBrand-3 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Erythrocin recon soln 500 mg
PrefBrand-3 NOANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Erythrocin (as stearate)
tablet 250 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
5T Medicare Part D: 5 Tier Closed Formulary
160 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
erythromycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
erythromycin ointment 5 mg/gram (0.5 %) Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
erythromycin capsule,delayed release(DR/EC)
250 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
erythromycin tablet 250 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
erythromycin ethylsuccinate
tablet 400 mg Generic-2 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
erythromycin with ethanol
gel 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
erythromycin with ethanol
solution 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
erythromycin-benzoyl peroxide
gel 3-5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Esbriet capsule 267 mgSpecialty-5
279 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
escitalopram oxalate
tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
161 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
escitalopram oxalate
tablet 5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
escitalopram oxalate
tablet 20 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
escitalopram oxalate
solution 5 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
esomeprazole magnesium
capsule,delayed release(DR/EC)
20 mg Generic-2 31 31 NO GASTROENTEROLOGY
ULCER THERAPY
esomeprazole magnesium
capsule,delayed release(DR/EC)
40 mg Generic-2 31 31 NO GASTROENTEROLOGY
ULCER THERAPY
esomeprazole sodium
recon soln 20 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
esomeprazole sodium
recon soln 40 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
estazolam tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
estazolam tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
162 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Estrace cream 0.01 % (0.1 mg/gram)
NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol tablet 0.5 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol tablet 1 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol tablet 2 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch weekly 0.05 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch weekly 0.1 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch weekly 0.075 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch semiweekly
0.0375 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch weekly 0.025 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch semiweekly
0.05 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch semiweekly
0.1 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch semiweekly
0.025 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch weekly 0.0375 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol patch weekly 0.06 mg/24 hr Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiolpatch semiweekly 0.075 mg/24 hr
Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol valerate
oil 20 mg/mL Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
5T Medicare Part D: 5 Tier Closed Formulary
163 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
estradiol-norethindrone acet tablet 0.5-0.1 mg
Generic-2 NOOBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estradiol-norethindrone acet tablet 1-0.5 mg
Generic-2 NOOBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Estring ring 2 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estropipate tablet 0.75 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estropipate tablet 1.5 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
estropipate tablet 3 mg PrefGen-1 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
eszopiclone tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
eszopiclone tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
eszopiclone tablet 3 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
ethacrynate sodium
recon soln 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
164 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ethambutol tablet 100 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
ethambutol tablet 400 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
ethosuximide
capsule 250 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
ethosuximide
solution 250 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
etidronate disodium
tablet 200 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
etidronate disodium
tablet 400 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
etodolac capsule 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
etodolac capsule 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
165 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
etodolac tablet 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
etodolac tablet 500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
etodolac tablet extended release 24 hr
400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
etodolac tablet extended release 24 hr
600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
etodolac tablet extended release 24 hr
500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Etopophos recon soln 100 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
etoposide solution 20 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Eurax cream 10 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL SCABICIDES / PEDICULICIDES
5T Medicare Part D: 5 Tier Closed Formulary
166 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Eurax lotion 10 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL SCABICIDES / PEDICULICIDES
Evamist spray,non-aerosol
1.53 mg/spray (1.7%)
NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Evotaz tablet 300-150 mgPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALS
Evzio auto-injector 0.4 mg/0.4 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Exalgo ER tablet extended release 24 hr
12 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Exalgo ER tablet extended release 24 hr
16 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Exalgo ER tablet extended release 24 hr
8 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Exalgo ERtablet extended release 24 hr 32 mg
NonPrefBrand-4
48 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Exelderm cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Exelderm solution 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
5T Medicare Part D: 5 Tier Closed Formulary
167 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Exelon patch 24 hour 9.5 mg/24 hr PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Exelon patch 24 hour 4.6 mg/24 hr PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Exelon patch 24 hour 13.3 mg/24 hour
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
exemestane tablet 25 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Exjade tablet, dispersible
125 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Exjade tablet, dispersible
250 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Exjade tablet, dispersible
500 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Extavia kit 0.3 mg Specialty-5 15 31 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Fabrazyme recon soln 35 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
famciclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
168 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
famciclovir tablet 125 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
famciclovir tablet 250 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
famotidine tablet 40 mg PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
famotidine tablet 20 mg PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
famotidine suspension 40 mg/5 mL (8 mg/mL)
PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
famotidine (PF)
solution 20 mg/2 mL PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
famotidine (PF)-NaCl (iso-os)
piggyback 20 mg/50 mL Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
Fanapt tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fanapt tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fanapt tablet 12 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fanapt tablet 2 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
169 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Fanapt tablet 4 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fanapt tablet 6 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fanapt tablet 8 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fanapt tablets,dose pack
1mg(2)-2mg(2)- 4mg(2)-6mg(2)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fareston tablet 60 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Farxiga tablet 10 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Farxiga tablet 5 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Farydak capsule 10 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Farydak capsule 15 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
170 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Farydak capsule 20 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Faslodex syringe 250 mg/5 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
FazaClo tablet,disintegrating
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
FazaClo tablet,disintegrating
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
FazaClo tablet,disintegrating
12.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
FazaClotablet,disintegrating 200 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
FazaClotablet,disintegrating 150 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
felbamate tablet 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
171 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
felbamate tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
felbamate suspension 600 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Felbatol tablet 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Felbatol tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Felbatol suspension 600 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
felodipine tablet extended release 24 hr
10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
felodipine tablet extended release 24 hr
5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
felodipine tablet extended release 24 hr
2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
172 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Femara tablet 2.5 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Femring ring 0.05 mg/24 hr NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Femring ring 0.1 mg/24 hr NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
fenofibrate tablet 160 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate tablet 54 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate micronized
capsule 67 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate micronized
capsule 134 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
173 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fenofibrate micronized
capsule 200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate micronized
capsule 130 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate micronized
capsule 43 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate nanocrystallized
tablet 145 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibrate nanocrystallized
tablet 48 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibric acid
tablet 105 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibric acid
tablet 35 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenofibric acid (choline)
capsule,delayed release(DR/EC)
135 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
174 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fenofibric acid (choline)
capsule,delayed release(DR/EC)
45 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Fenoglide tablet 120 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Fenoglide tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fenoprofen tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
fenoprofen capsule 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
fentanyl patch 72 hour 75 mcg/hr PrefBrand-3 12 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl patch 72 hour 25 mcg/hr Generic-2 20 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl patch 72 hour 50 mcg/hr Generic-2 17 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
175 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fentanyl patch 72 hour 100 mcg/hr PrefBrand-3 10 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl patch 72 hour 12 mcg/hr PrefBrand-3 20 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl patch 72 hour 37.5 mcg/hour
NonPrefBrand-4
20 30
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl patch 72 hour 62.5 mcg/hour
NonPrefBrand-4
15 30
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl patch 72 hour 87.5 mcg/hour
NonPrefBrand-4
11 30
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl citrate
lozenge on a handle
1,200 mcg Specialty-5 40 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl citrate
lozenge on a handle
1,600 mcg Specialty-5 30 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl citrate
lozenge on a handle
200 mcg Generic-2 124 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
176 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fentanyl citrate
lozenge on a handle
400 mcg Specialty-5 119 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl citrate
lozenge on a handle
600 mcg Specialty-5 79 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
fentanyl citrate
lozenge on a handle
800 mcg Specialty-5 59 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Fentora tablet, effervescent
100 mcg Specialty-5 124 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Fentora tablet, effervescent
200 mcg Specialty-5 124 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Fentora tablet, effervescent
400 mcg Specialty-5 119 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Fentora tablet, effervescent
600 mcg Specialty-5 79 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Fentora tablet, effervescent
800 mcg Specialty-5 59 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
177 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Ferriprox tablet 500 mg
Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Ferriprox solution 100 mg/mL
Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Fetzimacapsule,extended release 24 hr 120 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fetzimacapsule,extended release 24 hr 20 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fetzimacapsule,extended release 24 hr 40 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fetzimacapsule,extended release 24 hr 80 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Fetzimacapsule,Ext Rel 24hr dose pack
20 mg (2)- 40 mg (26)
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Finacea gel 15 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Finacea foam 15 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
5T Medicare Part D: 5 Tier Closed Formulary
178 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
finasteride tablet 5 mg Generic-2 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
Firazyr syringe 30 mg/3 mLSpecialty-5
18 30YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Firmagon kit w diluent syringe
recon soln 80 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Firmagon kit w diluent syringe
recon soln 120 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
flavoxate tablet 100 mg
Generic-2 NO
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
Flebogamma DIF solution 10 %
Specialty-5 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
flecainide tablet 50 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
flecainide tablet 100 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
179 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
flecainide tablet 150 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Flector patch 12 hour 1.3 % NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
fluconazole tablet 100 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
fluconazole tablet 150 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
fluconazole tablet 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
fluconazole tablet 50 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
fluconazole suspension for reconstitution
10 mg/mL Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
fluconazole suspension for reconstitution
40 mg/mL Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
fluconazole in NaCl (iso-osm) piggyback 400 mg/200 mL
Generic-2 NOANTI - INFECTIVES
ANTIFUNGAL AGENTS
fluconazole in NaCl (iso-osm) piggyback 200 mg/100 mL
Generic-2 NOANTI - INFECTIVES
ANTIFUNGAL AGENTS
flucytosine capsule 250 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
flucytosine capsule 500 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
180 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fludarabine recon soln 50 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
fludrocortisone
tablet 0.1 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
flunisolidespray,non-aerosol 25 mcg (0.025 %)
Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
fluocinolone ointment 0.025 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluocinolone cream 0.01 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluocinolone oil 0.01 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluocinolone solution 0.01 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluocinolone cream 0.025 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluocinolone acetonide oil drops 0.01 %
Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS OTIC PREPARATIONS
fluocinonide ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluocinonide gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
181 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fluocinonide solution 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluocinonide cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Fluocinonide-E
cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluorometholone
drops,suspension
0.1 % Generic-2 NO OPHTHALMOLOGY
STEROIDS
fluorouracil cream 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
fluorouracil solution 2.5 gram/50 mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
fluorouracil cream 0.5 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
fluorouracil solution 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
fluorouracil solution 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
182 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fluoxetine tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluoxetine capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluoxetine capsule 20 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluoxetine solution 20 mg/5 mL (4 mg/mL)
PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluoxetine capsule 40 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluoxetine tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluoxetine capsule,delayed release(DR/EC)
90 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluoxetine tablet 60 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
183 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fluphenazine decanoate
solution 25 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluphenazine HCl
elixir 2.5 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluphenazine HCl
tablet 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluphenazine HCl
tablet 5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluphenazine HCl
concentrate 5 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluphenazine HCl
tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluphenazine HCl
tablet 2.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluphenazine HCl
solution 2.5 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
184 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
flurandrenolide
cream 0.05 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
flurazepam capsule 15 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
flurazepam capsule 30 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
flurbiprofen tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
flurbiprofen tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
flurbiprofen sodium drops 0.03 %
Generic-2 NO
OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
flutamide capsule 125 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
fluticasone ointment 0.005 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
185 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fluticasone cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluticasone lotion 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
fluticasone spray,suspension
50 mcg/actuation Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
fluvastatin capsule 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fluvastatin capsule 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fluvastatin tablet extended release 24 hr
80 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
fluvoxamine capsule,extended release 24hr
100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluvoxamine capsule,extended release 24hr
150 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluvoxamine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
186 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fluvoxamine tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
fluvoxamine tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Focalin XR capsule,ER biphasic 50-50
20 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Focalin XRcapsule,ER biphasic 50-50 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Focalin XRcapsule,ER biphasic 50-50 35 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Folotyn solution 40 mg/2 mL (20 mg/mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
fomepizole solution 1 gram/mL PrefGen-1 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
fondaparinux
syringe 10 mg/0.8 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
187 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fondaparinux
syringe 2.5 mg/0.5 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
fondaparinux
syringe 5 mg/0.4 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
fondaparinux
syringe 7.5 mg/0.6 mL Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Foradil Aerolizer
capsule, w/inhalation device 12 mcg
PrefBrand-3
60 30
NORESPIRATORY AND ALLERGY
PULMONARY AGENTS
Fortaz recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES
CEPHALOSPORINS
Fortaz recon soln 1 gramNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
Fortaz recon soln 2 gramNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
Forteo pen injector20 mcg/dose - 600 mcg/2.4 mL
Specialty-5
2.4 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
Fortestagel in metered-dose pump
10 mg/0.5 gram /actuation
NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
FORTICAL spray,non-aerosol
200 unit/actuation Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
fosinopril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
188 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
fosinopril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
fosinopril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
fosinopril-hydrochlorothiazide
tablet 10-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
fosinopril-hydrochlorothiazide
tablet 20-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
fosphenytoin solution 100 mg PE/2 mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Fosrenol tablet,chewable 500 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Fosrenol tablet,chewable 1,000 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Fosrenol tablet,chewable 750 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Fosrenolpowder in packet 1,000 mg
NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
189 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Fosrenolpowder in packet 750 mg
NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Fragmin syringe 2,500 anti-Xa unit/0.2 mL
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Fragmin syringe 5,000 anti-Xa unit/0.2 mL
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Fragmin syringe 7,500 anti-Xa unit/0.3 mL
Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Fragmin syringe 12,500 anti-Xa unit/0.5 mL
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Fragmin syringe 15,000 anti-Xa unit/0.6 mL
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Fragmin syringe 18,000 anti-Xa unit/0.72 mL
Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Fragmin syringe 10,000 anti-Xa unit/mL
Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
190 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Fragmin solution 25,000 anti-Xa unit/mL
Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Freamine HBC 6.9 %
parenteral solution
6.9 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Frova tablet 2.5 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
frovatriptan tablet 2.5 mg PrefBrand-3 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
furosemide solution 10 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
furosemide solution 40 mg/5 mL (8 mg/mL)
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
furosemide tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
furosemide tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
191 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
furosemide tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
furosemide syringe 10 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
furosemide solution 10 mg/mL
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Fusilev recon soln 50 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Fuzeon recon soln 90 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Fyavolv tablet 0.5-2.5 mg-mcgGeneric-2 NO OBSTETRICS /
GYNECOLOGYESTROGENS / PROGESTINS
Fyavolv tablet 1-5 mg-mcgGeneric-2 NO OBSTETRICS /
GYNECOLOGYESTROGENS / PROGESTINS
Fycompa tablet 2 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Fycompa tablet 4 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
192 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Fycompa tablet 6 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Fycompa tablet 8 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Fycompa tablet 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Fycompa tablet 12 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Fycompa suspension 0.5 mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
gabapentin solution 250 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
gabapentin capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
gabapentin capsule 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
193 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
gabapentin capsule 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
gabapentin tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
gabapentin tablet 800 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Gabitril tablet 12 mg
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Gabitril tablet 16 mg
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Gabitril tablet 2 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Gabitril tablet 4 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Gablofen syringe50 mcg/mL (1 mL)
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
194 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Gablofen solution10,000 mcg/20mL (500 mcg/mL)
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Gablofen solution40,000 mcg/20mL (2,000 mcg/mL)
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
galantamine tablet 4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
galantamine tablet 8 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
galantamine tablet 12 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
galantamine capsule,ext rel. pellets 24 hr
16 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
galantamine capsule,ext rel. pellets 24 hr
24 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
galantamine capsule,ext rel. pellets 24 hr
8 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
195 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
galantamine solution 4 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
GamaSTAN S/D
solution 15-18 % range NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Gammagard Liquid
solution 10 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Gammaked solution1 gram/10 mL (10 %)
Specialty-5 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Gammaplex solution 5 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Gamunex-C solution 1 gram/10 mL (10 %)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ganciclovir sodium
recon soln 500 mg Generic-2 YES ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
196 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Gardasil (PF)
suspension 20-40-40-20 mcg/0.5 mL
PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Gardasil (PF)
syringe 20-40-40-20 mcg/0.5 mL
PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Gardasil 9 (PF) suspension 0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Gardasil 9 (PF) syringe 0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
gatifloxacin drops 0.5 % Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
Gattex One-Vial kit 5 mg
Specialty-5 YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Gauze Pad bandage 2 X 2 " PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Gavilyte-C recon soln 240-22.72-6.72 -5.84 gram
Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
197 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
GaviLyte-G recon soln 236-22.74-6.74 -5.86 gram
Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
GaviLyte-H and Bisacodyl kit 5-210 mg-gram
Generic-2 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
GaviLyte-N recon soln 420 gram Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Gelnique gel in packet 10 % (100 mg/gram)
PrefBrand-3 30 30 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
gemcitabine recon soln 1 gram
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
gemfibrozil tablet 600 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Generlac solution 10 gram/15 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Gengraf capsule 100 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
198 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Gengraf solution 100 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gengraf capsule 25 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Genotropin cartridge 5 mg/mL (15 unit/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin cartridge12 mg/mL (36 unit/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 0.2 mg/0.25 mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 0.4 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 0.6 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 0.8 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
199 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Genotropin MiniQuick
syringe 1.2 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 1.4 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 1.6 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 1.8 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 1 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Genotropin MiniQuick
syringe 2 mg/0.25 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Gentak ointment 0.3 % (3 mg/gram) Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
gentamicin cream 0.1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
gentamicin ointment 0.1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
5T Medicare Part D: 5 Tier Closed Formulary
200 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
gentamicin ointment 0.3 % (3 mg/gram) Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
gentamicin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY
ANTIBIOTICS
gentamicin solution 40 mg/mL PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
gentamicin in NaCl (iso-osm)
piggyback 100 mg/100 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
gentamicin in NaCl (iso-osm)
piggyback 80 mg/100 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
gentamicin in NaCl (iso-osm)
piggyback 60 mg/50 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
gentamicin in NaCl (iso-osm)
piggyback 80 mg/50 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Genvoya tablet150-150-200-10 mg
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Geodon recon soln 20 mg/mL (final conc.)
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
201 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Gildagia tablet 0.4-35 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Gildess 24 Fe tablet
1 mg-20 mcg (24)/75 mg (4)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Gilenya capsule 0.5 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Gilotrif tablet 20 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gilotrif tablet 30 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gilotrif tablet 40 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Glassia solution1 gram/50 mL (2 %)
Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Glatopa syringe 20 mg/mL
Specialty-5
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
202 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Gleevec tablet 100 mg Specialty-5 93 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gleevec tablet 400 mg Specialty-5 62 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gleostine capsule 10 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gleostine capsule 100 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gleostine capsule 40 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Gleostine capsule 5 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
glimepiride tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glimepiride tablet 2 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glimepiride tablet 4 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glipizide tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
203 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
glipizide tablet extended release 24hr
2.5 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glipizide tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glipizide tablet extended release 24hr
5 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glipizide tablet extended release 24hr
10 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glipizide-metformin
tablet 2.5-250 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glipizide-metformin
tablet 2.5-500 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
glipizide-metformin
tablet 5-500 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
GlucaGen HypoKit
recon soln 1 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Glucagon Emergency Kit (human)
kit 1 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Glumetza tablet,ER gast.retention 24 hr
500 mg NonPrefBrand-4 124 31 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide tablet 1.25 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide tablet 5 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide micronized
tablet 3 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide micronized
tablet 6 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
204 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
glyburide micronized
tablet 1.5 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide-metformin
tablet 1.25-250 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide-metformin
tablet 2.5-500 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glyburide-metformin
tablet 5-500 mg Generic-2 YES ENDOCRINE/DIABETES
DIABETES THERAPY
glycopyrrolate
tablet 1 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
glycopyrrolate
tablet 2 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
glycopyrrolate
solution 0.2 mg/mL Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
Glyset tablet 25 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Glyset tablet 50 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Glyset tablet 100 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Golytely powder in packet
227.1-21.5-6.36 gram
NonPrefBrand-4 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
205 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Gralisetablet extended release 24 hr 300 mg
PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Gralisetablet extended release 24 hr 600 mg
PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Gralise 30-Day Starter Pack
tablet extended release 24 hr
300 mg (9)- 600 mg (69)
PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
granisetron (PF)
solution 100 mcg/mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
granisetron HCl
solution 1 mg/mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
granisetron HCl
tablet 1 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
granisetron HCl solution 1 mg/mL (1 mL)
Generic-2 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Granix syringe 300 mcg/0.5 mL
Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
206 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Granix syringe 480 mcg/0.8 mL
Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Grastek tablet 2,800 BAU
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
griseofulvin microsize
suspension 125 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
griseofulvin microsize
tablet 500 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
griseofulvin ultramicrosize
tablet 250 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
griseofulvin ultramicrosize
tablet 125 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
guanfacine tablet extended release 24 hr
1 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
guanfacine tablet extended release 24 hr
2 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
guanfacine tablet extended release 24 hr
3 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
207 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
guanfacine tablet extended release 24 hr
4 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
guanidine tablet 125 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Gynazole-1 cream 2 % NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Halaven solution1 mg/2 mL (0.5 mg/mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Halcion tablet 0.25 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
halobetasol propionate
ointment 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
halobetasol propionate
cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Halog cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Halog ointment 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
208 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
haloperidol tablet 20 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol tablet 5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol tablet 2 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol decanoate
solution 100 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol decanoate solution 50 mg/mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
209 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
haloperidol lactate
concentrate 2 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
haloperidol lactate
solution 5 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Harvoni tablet 90-400 mgSpecialty-5
28 28YES ANTI -
INFECTIVES ANTIVIRALSHavrix (PF) syringe 720 Elisa unit/0.5
mLPrefBrand-3 NO IMMUNOLOGY,
VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Havrix (PF) suspension1,440 Elisa unit/mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Hectorol capsule 2.5 mcg Specialty-5 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Hectorol solution 4 mcg/2 mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Hectorol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Hectorol capsule 1 mcg Specialty-5 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
heparin (porcine) solution 20,000 unit/mL
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
210 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
heparin (porcine) solution 5,000 unit/mL
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
heparin (porcine) solution 10,000 unit/mL
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
heparin (porcine) solution 1,000 unit/mL
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
heparin (porcine) in 5 % dex
parenteral solution
20,000 unit/500 mL (40 unit/mL)
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
heparin (porcine) in 5 % dex
parenteral solution
25,000 unit/250 mL(100 unit/mL)
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
heparin (porcine) in 5 % dex
parenteral solution
25,000 unit/500 mL (50 unit/mL)
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Hepatamine 8%
parenteral solution
8 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Hepsera tablet 10 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Herceptin recon soln 440 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
211 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Hetlioz capsule 20 mg
Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Hexalen capsule 50 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Hiberix (PF) recon soln 10 mcg/0.5 mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Horizanttablet extended release 600 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Horizanttablet extended release 300 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Humalog solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humalog cartridge 100 unit/mLPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Humalog KwikPen insulin pen
200 unit/mL (3 mL)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humalog KwikPen insulin pen 100 unit/mL
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humalog Mix 50-50
suspension 100 unit/mL (50-50)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
212 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Humalog Mix 50-50 KwikPen
insulin pen 100 unit/mL (50-50)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humalog Mix 75-25
suspension 100 unit/mL (75-25)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humalog Mix 75-25 KwikPen
insulin pen 100 unit/mL (75-25)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humatrope recon soln 5 (15 unit) mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Humatrope cartridge 12 mg (36 unit) Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Humatrope cartridge 24 mg (72 unit) Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Humatrope cartridge 6 mg (18 unit) NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Humira syringe kit 40 mg/0.8 mL Specialty-5 2 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Humira syringe kit 20 mg/0.4 mL Specialty-5 2 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
213 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Humira syringe kit 10 mg/0.2 mL
Specialty-5
2 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Humira Pediatric Crohn's Start syringe kit
40 mg/0.8 mL (6 pack)
Specialty-5
6 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Humira Pediatric Crohn's Start syringe kit 40 mg/0.8 mL
Specialty-5
3 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Humira Pen pen injector kit 40 mg/0.8 mL
Specialty-5
2 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Humira Pen Crohn's-UC-HS Start
pen injector kit 40 mg/0.8 mL Specialty-5 6 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Humulin 70/30
suspension 100 unit/mL (70-30)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humulin 70/30 KwikPen
insulin pen 100 unit/mL (70-30)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humulin N suspension 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humulin N KwikPen
insulin pen 100 unit/mL (3 mL)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Humulin R solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
214 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Humulin R U-500 (Conc) Kwikpen insulin pen
500 unit/mL (3 mL)
PrefBrand-3 NO
ENDOCRINE/DIABETES
DIABETES THERAPY
Humulin R U-500 (Concentrated)
solution 500 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Hycet solution 7.5-325 mg/15 mL NonPrefBrand-4 5723 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydralazine tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydralazine tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydralazine tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydralazine tablet 50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydralazine solution 20 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
215 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
hydrochlorothiazide
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydrochlorothiazide
capsule 12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydrochlorothiazide
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydrochlorothiazide
tablet 12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
hydrocodone-acetaminophen
solution 7.5-325 mg/15 mL Generic-2 5723 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-acetaminophen
tablet 10-300 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-acetaminophen
tablet 5-300 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-acetaminophen
tablet 7.5-300 mg Generic-2 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
216 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
hydrocodone-acetaminophen
tablet 10-325 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-acetaminophen
tablet 5-325 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-acetaminophen
tablet 7.5-325 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-acetaminophen
tablet 2.5-325 mg Generic-2 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-ibuprofen
tablet 5-200 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-ibuprofen
tablet 7.5-200 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocodone-ibuprofen
tablet 10-200 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydrocortisone
ointment 2.5 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
217 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
hydrocortisone
cream 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone
tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
hydrocortisone
tablet 20 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
hydrocortisone
lotion 2.5 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone
tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
hydrocortisone
ointment 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone
enema 100 mg/60 mL PrefGen-1 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
hydrocortisone
cream 2.5 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone butyrate ointment 0.1 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone butyrate solution 0.1 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone butyr-emollient cream 0.1 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
218 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
hydrocortisone valerate ointment 0.2 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone valerate cream 0.2 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
hydrocortisone-acetic acid
drops 1-2 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS OTIC PREPARATIONS
hydromorphone
liquid 1 mg/mL Generic-2 1550 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone
tablet 2 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone
tablet 4 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone
tablet 8 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone
syringe 2 mg/mL Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone
tablet extended release 24 hr
12 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
219 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
hydromorphone
tablet extended release 24 hr
16 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone
tablet extended release 24 hr
8 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone
tablet extended release 24 hr 32 mg
Generic-2
48 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone (PF) solution 10 mg/mL
Generic-2
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydromorphone (PF) solution 10 (mg/mL) (5 ml)
Generic-2
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
hydroxychloroquine
tablet 200 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
hydroxyprogesterone caproate oil 250 mg/mL
Specialty-5 NOOBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
hydroxyurea capsule 500 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
220 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
hydroxyzine HCl
tablet 10 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
hydroxyzine HCl
solution 10 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
hydroxyzine HCl
tablet 25 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
hydroxyzine HCl
solution 25 mg/mL Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
hydroxyzine HCl
tablet 50 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
hydroxyzine HCl
solution 50 mg/mL Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
HyperRAB S/D (PF) solution 150 unit/mL
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
221 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
HyperRAB S/D (PF) solution
150 unit/mL (10 ml)
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Hysingla ER
tablet,oral only,ext.rel.24 hr 20 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Hysingla ER
tablet,oral only,ext.rel.24 hr 30 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Hysingla ER
tablet,oral only,ext.rel.24 hr 40 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Hysingla ER
tablet,oral only,ext.rel.24 hr 60 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Hysingla ER
tablet,oral only,ext.rel.24 hr 80 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Hysingla ER
tablet,oral only,ext.rel.24 hr 100 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Hysingla ER
tablet,oral only,ext.rel.24 hr 120 mg
NonPrefBrand-4
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
222 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ibandronate tablet 150 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
ibandronate solution 3 mg/3 mL Generic-2 YES MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
Ibrance capsule 100 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ibrance capsule 125 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ibrance capsule 75 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ibuprofen suspension 100 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ibuprofen tablet 400 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ibuprofen tablet 600 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
223 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ibuprofen tablet 800 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ibuprofen-oxycodone tablet 400-5 mg
Generic-2
30 30
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Iclusig tablet 15 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Iclusig tablet 45 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
idarubicin solution 1 mg/mL
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ifosfamide recon soln 1 gram Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ilaris (PF) recon soln 180 mg/1.2 mL (150 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Ilevrodrops,suspension 0.3 %
PrefBrand-3 NO
OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
224 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
imatinib tablet 100 mg Specialty-5 93 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
imatinib tablet 400 mg Specialty-5 62 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Imbruvica capsule 140 mg
Specialty-5
124 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
imipenem-cilastatin recon soln 250 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
imipenem-cilastatin recon soln 500 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
imipramine HCl
tablet 25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
imipramine HCl
tablet 50 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
imipramine HCl
tablet 10 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
225 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
imipramine pamoate
capsule 75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
imipramine pamoate
capsule 150 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
imipramine pamoate
capsule 125 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
imipramine pamoate
capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
imiquimod cream in packet 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Imitrex tablet 25 mg NonPrefBrand-4 36 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Imitrex solution 6 mg/0.5 mL NonPrefBrand-4 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Imitrex tablet 50 mg NonPrefBrand-4 18 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
226 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Imitrex tablet 100 mg NonPrefBrand-4 9 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Imitrex spray,non-aerosol
20 mg/actuation NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Imitrex spray,non-aerosol
5 mg/actuation NonPrefBrand-4 32 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Imitrex STATdose Kit Refill
cartridge 4 mg/0.5 mL NonPrefBrand-4 6 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Imitrex STATdose Kit Refill
cartridge 6 mg/0.5 mL NonPrefBrand-4 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Imovax Rabies Vaccine (PF)
recon soln 2.5 unit NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Imuran tablet 50 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Increlex solution 10 mg/mL Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
227 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
indapamide tablet 1.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
indapamide tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Indocin suspension 25 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
indomethacin
capsule 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
indomethacin
capsule 50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
indomethacin
capsule, extended release
75 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Infanrix (DTaP) (PF) suspension
25-58-10 Lf-mcg-Lf/0.5mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Inlyta tablet 1 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
228 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Inlyta tablet 5 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
InnoPran XL capsule,extended release 24hr
120 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
InnoPran XL capsule,extended release 24hr
80 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
insulin syringe-needle U-100
syringe 1/2 mL 28 gauge PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
insulin syringe-needle U-100
syringe 1 mL 29 gauge x 1/2"
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
insulin syringe-needle U-100
syringe 0.3 mL 29 PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Intelence tablet 100 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Intelence tablet 200 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
Intelence tablet 25 mgNonPrefBrand-4 NO ANTI -
INFECTIVES ANTIVIRALSIntralipid emulsion 20 % Generic-2 YES VITAMINS,
HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
5T Medicare Part D: 5 Tier Closed Formulary
229 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Intralipid emulsion 30 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Intron A solution 6 million unit/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Intron A recon soln 50 million unit (1 mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Intron A recon soln18 million unit (1 mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Intron A recon soln10 million unit (1 mL)
PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Introvaletablets,dose pack,3 month 0.15-30 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Intuniv ER tablet extended release 24 hr
1 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Intuniv ER tablet extended release 24 hr
2 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
230 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Intuniv ER tablet extended release 24 hr
3 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Intuniv ER tablet extended release 24 hr
4 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invanz recon soln 1 gram
NonPrefBrand-4 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Invega tablet extended release 24hr
3 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega tablet extended release 24hr
6 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega tablet extended release 24hr
9 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega tablet extended release 24hr
1.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Sustenna
syringe 78 mg/0.5 mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
231 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Invega Sustenna
syringe 234 mg/1.5 mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Sustenna
syringe 156 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Sustenna
syringe 117 mg/0.75 mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Sustenna
syringe 39 mg/0.25 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Trinza syringe 273 mg/0.875 mL
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Trinza syringe 410 mg/1.315 mL
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Trinza syringe 546 mg/1.75 mL
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Invega Trinza syringe 819 mg/2.625 mL
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
232 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Invirase capsule 200 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Invirase tablet 500 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Invokamet tablet 150-1,000 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Invokamet tablet 150-500 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Invokamet tablet 50-1,000 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Invokamet tablet 50-500 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Invokana tablet 100 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Invokana tablet 300 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Ionosol-B in D5W
parenteral solution
5 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Ionosol-MB in D5W
parenteral solution
5 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Iopidine dropperette 1 % PrefBrand-3 NO OPHTHALMOLOGY
SYMPATHOMIMETICS
IPOL suspension 40-8-32 unit/0.5 mL
PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ipratropium bromide
spray,non-aerosol
0.06 % PrefGen-1 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
233 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ipratropium bromide
spray,non-aerosol
0.03 % PrefGen-1 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
ipratropium bromide
solution 0.02 % PrefGen-1 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
ipratropium-albuterol
solution for nebulization
0.5 mg-3 mg(2.5 mg base)/3 mL
Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
irbesartan tablet 75 mg PrefGen-1 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
irbesartan tablet 150 mg PrefGen-1 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
irbesartan tablet 300 mg PrefGen-1 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
irbesartan-hydrochlorothiazide
tablet 150-12.5 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
irbesartan-hydrochlorothiazide
tablet 300-12.5 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Iressa tablet 250 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
234 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
irinotecan solution 100 mg/5 mL
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Isentress tablet 400 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Isentress tablet,chewable 100 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
Isentress tablet,chewable 25 mgPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALS
Isentresspowder in packet 100 mg
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Isolyte-P in 5 % dextrose
parenteral solution
5 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Isolyte-S parenteral solution
PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
isoniazid solution 50 mg/5 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
isoniazid tablet 300 mg PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
isoniazid solution 100 mg/mL PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
235 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
isoniazid tablet 100 mg PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Isordil tablet 40 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide dinitrate
tablet 30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide dinitrate
tablet 20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide dinitrate
tablet extended release
40 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide dinitrate
tablet 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide dinitrate
tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide mononitrate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
5T Medicare Part D: 5 Tier Closed Formulary
236 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
isosorbide mononitrate
tablet extended release 24 hr
120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide mononitrate
tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide mononitrate
tablet extended release 24 hr
30 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isosorbide mononitrate
tablet extended release 24 hr
60 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
isradipine capsule 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
isradipine capsule 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Istalol drops, once daily
0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY
BETA-BLOCKERS
Istodax recon soln 10 mg/2 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
itraconazole capsule 100 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
237 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ivermectin tablet 3 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Ixiaro (PF) syringe 6 mcg/0.5 mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Jakafi tablet 10 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Jakafi tablet 5 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Jakafi tablet 15 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Jakafi tablet 20 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Jakafi tablet 25 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Jantoven tablet 1 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
238 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Jantoven tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Jantoven tablet 2 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Jantoven tablet 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Jantoven tablet 3 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Jantoven tablet 4 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Jantoven tablet 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Jantoven tablet 6 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Jantoven tablet 7.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
239 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Janumet tablet 50-1,000 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Janumet tablet 50-500 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Janumet XR
tablet, ER multiphase 24 hr 100-1,000 mg
PrefBrand-3 NOENDOCRINE/DIABETES
DIABETES THERAPY
Janumet XR
tablet, ER multiphase 24 hr 50-1,000 mg
PrefBrand-3 NOENDOCRINE/DIABETES
DIABETES THERAPY
Janumet XR
tablet, ER multiphase 24 hr 50-500 mg
PrefBrand-3 NOENDOCRINE/DIABETES
DIABETES THERAPY
Januvia tablet 100 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Januvia tablet 25 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Januvia tablet 50 mg PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Jentadueto tablet 2.5-1,000 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Jentadueto tablet 2.5-500 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Jentadueto tablet 2.5-850 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Jentadueto XR
tablet, IR - ER, biphasic 24hr 2.5-1,000 mg
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Jentadueto XR
tablet, IR - ER, biphasic 24hr 5-1,000 mg
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Jevtana solution10 mg/mL (first dilution)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
240 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Jinteli tablet 1-5 mg-mcgGeneric-2 NO OBSTETRICS /
GYNECOLOGYESTROGENS / PROGESTINS
Jolivette tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Juleber tablet 0.15-0.03 mg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Junel 1.5/30 (21) tablet 1.5-30 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Junel 1/20 (21) tablet 1-20 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Junel FE 1.5/30 (28) tablet
1.5 mg-30 mcg (21)/75 mg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Junel FE 1/20 (28) tablet
1 mg-20 mcg (21)/75 mg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Junel Fe 24 tablet1 mg-20 mcg (24)/75 mg (4)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Juxtapid capsule 10 mg
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
241 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Juxtapid capsule 20 mg
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Juxtapid capsule 5 mg
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Juxtapid capsule 30 mg
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Juxtapid capsule 40 mg
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Juxtapid capsule 60 mg
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Kadcyla recon soln 100 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Kadian capsule,extend.release pellets
10 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kadian capsule,extend.release pellets
100 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
242 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Kadian capsule,extend.release pellets
20 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kadian capsule,extend.release pellets
200 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kadian capsule,extend.release pellets
30 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kadian capsule,extend.release pellets
50 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kadian capsule,extend.release pellets
60 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kadian capsule,extend.release pellets
80 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kadiancapsule,extend.release pellets 40 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Kaitlib Fe tablet,chewable0.8mg-25mcg(24) and 75 mg (4)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
243 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Kaletra tablet 200-50 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Kaletra tablet 100-25 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Kaletra solution 400-100 mg/5 mL Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Kalydeco tablet 150 mgSpecialty-5
62 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Kalydecogranules in packet 50 mg
Specialty-556 28
YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Kalydecogranules in packet 75 mg
Specialty-556 28
YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Kanuma solution 2 mg/mLSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Kapvaytablet extended release 12 hr 0.1 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Karbinal ERsuspension,extended rel 12 hr 4 mg/5 mL
NonPrefBrand-4 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Kariva (28) tablet 0.15-0.02 mgx21 /0.01 mg x 5
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Kelnor 1/35 (28)
tablet 1-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Kenalog aerosol 0.147 mg/gram
PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
244 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Kepivance recon soln 6.25 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Keppra tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Keppra tablet 500 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Keppra tablet 750 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Keppra solution 100 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Keppra tablet 1,000 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Keppra XR tablet extended release 24 hr
500 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Keppra XR tablet extended release 24 hr
750 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
245 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Ketek tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Ketek tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
ketoconazole shampoo 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
ketoconazole tablet 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ketoconazole cream 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
ketoconazole foam 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
ketoprofen capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ketoprofen capsule 75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ketoprofen capsule,ext rel. pellets 24 hr
200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
246 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ketorolac tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ketorolac solution 15 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ketorolac drops 0.4 % Generic-2 NO OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ketorolac drops 0.5 % Generic-2 NO OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
ketorolac solution 30 mg/mL (1 mL)
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
ketorolac cartridge 30 mg/mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Keveyis tablet 50 mg
NonPrefBrand-4
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
247 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Keytruda recon soln 50 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Keytruda solution100 mg/4 mL (25 mg/mL)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Khedezlatablet extended release 24hr 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Khedezlatablet extended release 24hr 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Kimidess (28) tablet
0.15-0.02 mgx21 /0.01 mg x 5
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Kineret syringe 100 mg/0.67 mL Specialty-5 18.76 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Kionex powder Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Klor-Con 10 tablet extended release
10 mEq Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
Klor-Con 8 tablet extended release
8 mEq Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
5T Medicare Part D: 5 Tier Closed Formulary
248 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Klor-Con M15
tablet,ER particles/crystals
15 mEq Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
Klor-Con M20
tablet,ER particles/crystals
20 mEq Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
Klor-Con Sprinkle
capsule, extended release 8 mEq
Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES
Klor-Con Sprinkle
capsule, extended release 10 mEq
Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES
Kombiglyze XR
tablet, ER multiphase 24 hr 2.5-1,000 mg
NonPrefBrand-4 NOENDOCRINE/DIABETES
DIABETES THERAPY
Kombiglyze XR
tablet, ER multiphase 24 hr 5-1,000 mg
NonPrefBrand-4 NOENDOCRINE/DIABETES
DIABETES THERAPY
Kombiglyze XR
tablet, ER multiphase 24 hr 5-500 mg
NonPrefBrand-4 NOENDOCRINE/DIABETES
DIABETES THERAPY
Korlym tablet 300 mgSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
K-Tab tablet extended release
10 mEq NonPrefBrand-4 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
K-Tabtablet extended release 20 mEq
NonPrefBrand-4 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES
K-Tabtablet extended release 8 mEq
PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES
5T Medicare Part D: 5 Tier Closed Formulary
249 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Kuvan tablet,soluble 100 mgSpecialty-5 NO ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Kynamro syringe 200 mg/mL
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
L norgest/e.estradiol-e.estrad
tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
labetalol tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
labetalol tablet 200 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
labetalol tablet 300 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
labetalol solution 5 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Lacrisert insert 5 mg NonPrefBrand-4 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
lactated ringers
solution Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
5T Medicare Part D: 5 Tier Closed Formulary
250 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lactated ringers
parenteral solution
Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
lactulose solution 10 gram/15 mL PrefGen-1 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Lamictal tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal tablet, chewable dispersible
5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal tablet, chewable dispersible
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
251 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lamictal ODT
tablet,disintegrating
100 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal ODT
tablet,disintegrating
200 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal ODT
tablet,disintegrating
25 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal ODT
tablet,disintegrating
50 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal Starter (Blue) Kit
tablets,dose pack
25 mg (35) NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal Starter (Green) Kit
tablets,dose pack
25 mg (84) -100 mg (14)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal Starter (Orange) Kit
tablets,dose pack
25 mg (42) -100 mg (7)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal XR tablet extended release 24hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
252 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lamictal XR tablet extended release 24hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal XR tablet extended release 24hr
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal XR tablet extended release 24hr
50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal XRtablet extended release 24hr 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal XR Starter (Blue)
tablet extended rel,dose pack
25 mg (21) -50 mg (7)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal XR Starter (Green)
tablet extended rel,dose pack
50 mg(14)-100mg (14)-200 mg (7)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamictal XR Starter (Orange)
tablet extended rel,dose pack
25mg (14)-50 mg (14)-100mg (7)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lamisil tablet 250 mg NonPrefBrand-4 90 180 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Lamisil granules in packet
125 mg NonPrefBrand-4 182 180 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
253 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lamisil granules in packet
187.5 mg NonPrefBrand-4 126 180 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
lamivudine tablet 150 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
lamivudine solution 10 mg/mL Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
lamivudine tablet 100 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
lamivudine tablet 300 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
lamivudine-zidovudine
tablet 150-300 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
lamotrigine tablet,disintegrating
100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet 150 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet,disintegrating
25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
254 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lamotrigine tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet,disintegrating
50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet,disintegrating
200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet, chewable dispersible
25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet, chewable dispersible
5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet extended release 24hr
100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet extended release 24hr
50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotrigine tablet extended release 24hr
200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
255 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lamotrigine tablet extended release 24hr
25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotriginetablet extended release 24hr 300 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
lamotriginetablet extended release 24hr 250 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lanoxin tablet 62.5 mcg NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
Lanoxin solution 250 mcg/mL NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
Lanoxin tablet 125 mcg NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
Lanoxin tablet 250 mcg NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
Lanoxin tablet 187.5 mcg
NonPrefBrand-4 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
CARDIAC GLYCOSIDES
5T Medicare Part D: 5 Tier Closed Formulary
256 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lansoprazole capsule,delayed release(DR/EC)
30 mg PrefBrand-3 62 31 NO GASTROENTEROLOGY
ULCER THERAPY
lansoprazole capsule,delayed release(DR/EC)
15 mg PrefBrand-3 31 31 NO GASTROENTEROLOGY
ULCER THERAPY
Lantus solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Lantus Solostar
insulin pen 100 unit/mL (3 mL)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Lastacaft drops 0.25 %
NonPrefBrand-4 NO
OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
latanoprost drops 0.005 % PrefGen-1 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
Latuda tablet 40 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Latuda tablet 80 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Latuda tablet 20 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
257 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Latuda tablet 120 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Latuda tablet 60 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Layolis Fe tablet,chewable0.8mg-25mcg(24) and 75 mg (4)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Lazandaspray,non-aerosol 100 mcg/spray
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Lazandaspray,non-aerosol 400 mcg/spray
Specialty-5
12 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Lazandaspray,non-aerosol 300 mcg/spray
Specialty-5
16 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
leflunomide tablet 10 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
leflunomide tablet 20 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
258 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lenvima capsule14 mg/day(10 mg x 1-4 mg x 1)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lenvima capsule24 mg/day(10 mg x 2-4 mg x 1)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lenvima capsule10 mg/day (10 mg x 1/day)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lenvima capsule20 mg/day (10 mg x 2)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lenvima capsule18 mg/day (10 mg x 1-4 mg x2)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lenvima capsule8 mg/day (4 mg x 2)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lescol XL tablet extended release 24 hr
80 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Lessina tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
259 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Letairis tablet 10 mg Specialty-5 31 31 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Letairis tablet 5 mg Specialty-5 31 31 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
letrozole tablet 2.5 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
leucovorin calcium
tablet 10 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
tablet 15 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
tablet 25 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
tablet 5 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
recon soln 350 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
recon soln 100 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
260 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Leukeran tablet 2 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Leukine recon soln 250 mcg Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
leuprolide kit 1 mg/0.2 mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
levalbuterol HCl
solution for nebulization
1.25 mg/0.5 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
levalbuterol HCl
solution for nebulization
0.63 mg/3 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
levalbuterol HCl
solution for nebulization
0.31 mg/3 mL Generic-2 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Levemir solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Levemir FlexTouch
insulin pen 100 unit/mL (3 mL)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
levetiracetam
tablet 250 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam
tablet 500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
261 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
levetiracetam
tablet 750 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam
tablet 1,000 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam
solution 100 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam
solution 500 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam
tablet extended release 24 hr
500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam
tablet extended release 24 hr
750 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam in NaCl (iso-os) piggyback 1,000 mg/100 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levetiracetam in NaCl (iso-os) piggyback 1,500 mg/100 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
262 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
levetiracetam in NaCl (iso-os) piggyback 500 mg/100 mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
levobunolol drops 0.5 %PrefGen-1 NO OPHTHALMOLO
GY BETA-BLOCKERSlevocarnitine tablet 330 mg Generic-2 YES DIAGNOSTICS /
MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
levocarnitine (with sugar)
solution 100 mg/mL Generic-2 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
levocetirizine
solution 2.5 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
levocetirizine
tablet 5 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
levofloxacin tablet 250 mg Generic-2 NO ANTI - INFECTIVES
QUINOLONES
levofloxacin tablet 500 mg Generic-2 NO ANTI - INFECTIVES
QUINOLONES
levofloxacin tablet 750 mg Generic-2 NO ANTI - INFECTIVES
QUINOLONES
levofloxacin drops 0.5 % Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
levofloxacin solution 250 mg/10 mL Generic-2 NO ANTI - INFECTIVES
QUINOLONES
levofloxacin solution 25 mg/mLGeneric-2 NO ANTI -
INFECTIVES QUINOLONES
5T Medicare Part D: 5 Tier Closed Formulary
263 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
levofloxacin in D5W piggyback 500 mg/100 mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
levofloxacin in D5W piggyback 750 mg/150 mL
Generic-2 NO ANTI - INFECTIVES QUINOLONES
levoleucovorin calcium solution 10 mg/mL
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Levonest (28) tablet
50-30 (6)/75-40 (5)/125-30(10)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
levonorgestrel-ethinyl estrad
tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
levonorgestrel-ethinyl estrad
tablet 90-20 mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
levonorgestrel-ethinyl estrad
tablets,dose pack,3 month
0.15-30 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
levonorg-eth estrad triphasic
tablet 50-30 (6)/75-40 (5)/125-30(10)
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Levora-28 tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
264 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
levorphanol tartrate
tablet 2 mg PrefGen-1 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
levothyroxine
tablet 100 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 200 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 300 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 25 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 50 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 75 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 125 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 150 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 112 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 175 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 88 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
levothyroxine
tablet 137 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 25 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 50 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
265 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Levoxyl tablet 75 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 88 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 112 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 125 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 137 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 150 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 175 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 200 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Levoxyl tablet 100 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Lexiva tablet 700 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Lexiva suspension 50 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Lialda tablet,delayed release (DR/EC)
1.2 gram PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
lidocaineadhesive patch,medicated 5 %
Generic-2
124 31
YES DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine ointment 5 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
5T Medicare Part D: 5 Tier Closed Formulary
266 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lidocaine (PF) solution 5 mg/mL (0.5 %)
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine HCl solution 20 mg/mL (2 %)
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine HCl solution 2 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine HCl solution 4 % (40 mg/mL)
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine HCl gel 2 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine HCl gel 2 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine HCl
jelly in applicator 2 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
lidocaine-prilocaine
cream 2.5-2.5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
Lidodermadhesive patch,medicated 5 %
NonPrefBrand-4
124 31
YES DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANESTHETICS
Lincocin solution 300 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
267 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lincomycin solution 300 mg/mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
lindane shampoo 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL SCABICIDES / PEDICULICIDES
linezolid suspension for reconstitution
100 mg/5 mL Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
linezolid tablet 600 mg Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
linezolidparenteral solution 600 mg/300 mL
NonPrefBrand-4 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Linzess capsule 145 mcg
PrefBrand-3
31 31
NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Linzess capsule 290 mcg
PrefBrand-3
31 31
NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Lioresal solution 500 mcg/mL NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
268 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lioresal solution 50 mcg/mL NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Lioresal solution 2,000 mcg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
liothyronine tablet 5 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
liothyronine solution 10 mcg/mL Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
liothyronine tablet 25 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
liothyronine tablet 50 mcg Generic-2 NO ENDOCRINE/DIABETES
THYROID HORMONES
Lipofen capsule 150 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Lipofen capsule 50 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
lisinopril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lisinopril tablet 30 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
269 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lisinopril tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lisinopril tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lisinopril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lisinopril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lisinopril-hydrochlorothiazide
tablet 10-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lisinopril-hydrochlorothiazide
tablet 20-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lisinopril-hydrochlorothiazide
tablet 20-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
lithium carbonate
capsule 300 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
270 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lithium carbonate
tablet 300 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
lithium carbonate
tablet extended release
300 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
lithium carbonate
tablet extended release
450 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
lithium carbonate
capsule 600 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
lithium carbonate
capsule 150 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
lithium citrate
solution 8 mEq/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Lithostat tablet 250 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Livalo tablet 1 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
271 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Livalo tablet 2 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Livalo tablet 4 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Lo Loestrin Fe tablet
1 mg-10 mcg (24)/10 mcg (2)
NonPrefBrand-4 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Lonsurf tablet 15-6.14 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lonsurf tablet 20-8.19 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
loperamide capsule 2 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
lorazepam tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
lorazepam tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
272 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lorazepam tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Lorazepam Intensol
concentrate 2 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Lorcet (hydrocodone) tablet 5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Lorcet Plus tablet 7.5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Lortab 10-325 tablet 10-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Lortab 5-325 tablet 5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Lortab 7.5-325 tablet 7.5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Loryna (28) tablet 3-0.02 mg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
273 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
losartan tablet 100 mg PrefGen-1 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
losartan tablet 25 mg PrefGen-1 93 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
losartan tablet 50 mg PrefGen-1 62 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
losartan-hydrochlorothiazide
tablet 100-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
losartan-hydrochlorothiazide
tablet 50-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
losartan-hydrochlorothiazide
tablet 100-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Lotronex tablet 1 mg Specialty-5 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Lotronex tablet 0.5 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
274 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
lovastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
lovastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
lovastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Lovenox syringe 60 mg/0.6 mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Lovenox syringe 150 mg/mL NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
loxapine succinate
capsule 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
loxapine succinate
capsule 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
loxapine succinate
capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
275 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
loxapine succinate
capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Lumigan drops 0.01 %
PrefBrand-3
5 31
NOOPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
Lumizyme recon soln 50 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Lupaneta Pack (1 month)
kit. syringe and tablet
3.75 mg -5 mg (30)
Specialty-5 NOOBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Lupaneta Pack (3 month)
kit. syringe and tablet
11.25 mg -5 mg (90)
Specialty-5 NOOBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Lupron Depot syringe kit 3.75 mg
PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lupron Depot syringe kit 7.5 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lupron Depot (3 Month) syringe kit 22.5 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lupron Depot (3 Month) syringe kit 11.25 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
276 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lupron Depot (4 Month) syringe kit 30 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lupron Depot (6 Month) syringe kit 45 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lupron Depot-Ped kit 11.25 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lupron Depot-Ped kit 15 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lutera (28) tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Lynparza capsule 50 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Lyrica capsule 100 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lyrica capsule 150 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
277 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lyrica capsule 200 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lyrica capsule 225 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lyrica capsule 25 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lyrica capsule 300 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lyrica capsule 50 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lyrica capsule 75 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lyrica solution 20 mg/mL NonPrefBrand-4 930 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Lysodren tablet 500 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
278 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Lyza tablet 0.35 mgGeneric-2 NO OBSTETRICS /
GYNECOLOGYESTROGENS / PROGESTINS
magnesium sulfate
syringe 4 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
magnesium sulfate solution 4 mEq/mL (50 %)
Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES
Makena oil250 mg/mL (1 mL)
Specialty-5 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
malathion lotion 0.5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL SCABICIDES / PEDICULICIDES
maprotiline tablet 25 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
maprotiline tablet 50 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
maprotiline tablet 75 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Marinol capsule 2.5 mg Specialty-5 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Marinol capsule 5 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
279 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Marinol capsule 10 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Marlissa tablet 0.15-0.03 mg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Marplan tablet 10 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Matulane capsule 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Matzim LAtablet extended release 24 hr 420 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Matzim LAtablet extended release 24 hr 240 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Matzim LAtablet extended release 24 hr 180 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Matzim LAtablet extended release 24 hr 300 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
280 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Matzim LAtablet extended release 24 hr 360 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Maxalt tablet 5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Maxalt tablet 10 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Maxalt-MLT tablet,disintegrating
5 mg NonPrefBrand-4 24 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Maxalt-MLT tablet,disintegrating
10 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
meclizine tablet 12.5 mg
Generic-2 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
meclizine tablet 25 mg
Generic-2 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
meclofenamate
capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
281 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
meclofenamate
capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Medrol tablet 2 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
medroxyprogesterone tablet 10 mg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
medroxyprogesterone suspension 150 mg/mL
Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
medroxyprogesterone tablet 2.5 mg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
medroxyprogesterone tablet 5 mg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
mefenamic acid
capsule 250 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
mefloquine tablet 250 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Megace ES suspension 625 mg/5 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
megestrol suspension 625 mg/5 mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
282 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
megestrol tablet 20 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
megestrol tablet 40 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
megestrol suspension 400 mg/10 mL (40 mg/mL)
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Mekinist tablet 0.5 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Mekinist tablet 2 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
meloxicam tablet 15 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
meloxicam tablet 7.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
meloxicam suspension 7.5 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
283 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
melphalan HCl
recon soln 50 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
memantine tablet 10 mg
PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
memantine tablet 5 mg
PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
memantinetablets,dose pack 5-10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
memantine solution 2 mg/mL
PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Menactra (PF)
solution 4 mcg/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Menest tablet 0.3 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Menest tablet 0.625 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Menest tablet 1.25 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Menest tablet 2.5 mg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
5T Medicare Part D: 5 Tier Closed Formulary
284 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Menhibrix (PF) recon soln 5-2.5 mcg/0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Menomune - A/C/Y/W-135 (PF) recon soln 50 mcg
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Mentax cream 1 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Menveo A-C-Y-W-135-Dip (PF)
kit 10-5 mcg/0.5 mL NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Mepron suspension 750 mg/5 mL Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
mercaptopurine
tablet 50 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
meropenem recon soln 500 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
285 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
mesalamine with cleansing wipe
enema kit 4 gram/60 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
mesna solution 100 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Mesnex tablet 400 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Mestinon syrup 60 mg/5 mL PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Mestinon Timespan
tablet extended release
180 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Metadate ERtablet extended release 20 mg
Generic-2
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
metaproterenol
tablet 10 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
metaproterenol
syrup 10 mg/5 mL Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
metaproterenol
tablet 20 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
286 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Metaxall tablet 800 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
metaxalone tablet 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
metaxalone tablet 800 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
metformin tablet extended release 24 hr
500 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
metformin tablet extended release 24 hr
750 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
metformin tablet extended release 24hr
1,000 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
metformin tablet 1,000 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
metformin tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
metformin tablet 850 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
methadone tablet 10 mg Generic-2 206 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
methadone solution 10 mg/mL Generic-2 160 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
287 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
methadone tablet 5 mg Generic-2 248 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
methadone solution 5 mg/5 mL Generic-2 2066 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
methadone solution 10 mg/5 mL Generic-2 1033 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
methamphetamine
tablet 5 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methazolamide
tablet 25 mg Generic-2 NO OPHTHALMOLOGY
ORAL DRUGS FOR GLAUCOMA
methazolamide
tablet 50 mg Generic-2 NO OPHTHALMOLOGY
ORAL DRUGS FOR GLAUCOMA
methenamine hippurate
tablet 1 gram Generic-2 NO ANTI - INFECTIVES
URINARY TRACT AGENTS
methimazole tablet 10 mg Generic-2 NO ENDOCRINE/DIABETES
ANTITHYROID AGENTS
methimazole tablet 5 mg Generic-2 NO ENDOCRINE/DIABETES
ANTITHYROID AGENTS
Methitest tablet 10 mg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
288 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
methotrexate sodium
tablet 2.5 mg PrefGen-1 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
methotrexate sodium (PF)
recon soln 1 gram Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
methotrexate sodium (PF) solution 25 mg/mL
Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
methoxsalen rapid
capsule 10 mg Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
methscopolamine
tablet 2.5 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
methscopolamine
tablet 5 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
methyclothiazide
tablet 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
methyldopa-hydrochlorothiazide
tablet 250-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
289 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
methyldopa-hydrochlorothiazide
tablet 250-15 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
methylergonovine tablet 0.2 mg
Generic-2 NO OBSTETRICS / GYNECOLOGY OXYTOCICS
methylphenidate solution 10 mg/5 mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
capsule, ER biphasic 30-70 10 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
tablet extended release 10 mg
Generic-2
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate tablet 10 mg
Generic-2
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate tablet,chewable 10 mg
Generic-2
186 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
tablet extended release 24hr 18 mg
Generic-2
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
290 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
methylphenidate
capsule,ER biphasic 50-50 20 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
tablet extended release 24hr 27 mg
Generic-2
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
capsule, ER biphasic 30-70 30 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
tablet extended release 24hr 36 mg
Generic-2
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
capsule,ER biphasic 50-50 40 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
capsule, ER biphasic 30-70 50 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
tablet extended release 24hr 54 mg
Generic-2
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate
capsule, ER biphasic 30-70 60 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
291 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
methylphenidate
tablet extended release 20 mg
Generic-2
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate tablet,chewable 5 mg
Generic-2
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate solution 5 mg/5 mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate tablet,chewable 2.5 mg
Generic-2
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate tablet 20 mg
Generic-2
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylphenidate tablet 5 mg
Generic-2
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
methylprednisolone
tablet 32 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
methylprednisolone
tablet 8 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
methylprednisolone
tablet 4 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
methylprednisolone
tablet 16 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
292 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
methylprednisolone
tablets,dose pack
4 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
methylprednisolone acetate suspension 40 mg/mL
Generic-2 NOENDOCRINE/DIABETES
ADRENAL HORMONES
methylprednisolone acetate suspension 80 mg/mL
Generic-2 NOENDOCRINE/DIABETES
ADRENAL HORMONES
methylprednisolone sodium succ
recon soln 40 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
methylprednisolone sodium succ
recon soln 125 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
methyltestosterone
capsule 10 mg Specialty-5 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
metipranolol drops 0.3 % Generic-2 NO OPHTHALMOLOGY
BETA-BLOCKERS
metoclopramide HCl
solution 5 mg/5 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
metoclopramide HCl
tablet 10 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
metoclopramide HCl
tablet 5 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
293 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
metoclopramide HCl
solution 5 mg/mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
metoclopramide HCl
tablet,disintegrating
10 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
metoclopramide HCl
tablet,disintegrating
5 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
metolazone tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metolazone tablet 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metolazone tablet 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol succinate
tablet extended release 24 hr
100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol succinate
tablet extended release 24 hr
200 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
294 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
metoprolol succinate
tablet extended release 24 hr
25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol succinate
tablet extended release 24 hr
50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol ta-hydrochlorothiaz
tablet 100-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol ta-hydrochlorothiaz
tablet 50-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol ta-hydrochlorothiaz
tablet 100-50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol tartrate
solution 5 mg/5 mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol tartrate
tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol tartrate
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
295 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
metoprolol tartrate
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metoprolol tartrate syringe 5 mg/5 mL
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
metronidazole
gel 0.75 % Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
metronidazole
capsule 375 mg PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
metronidazole
cream 0.75 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
metronidazole
gel 0.75 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
metronidazole
tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
metronidazole
lotion 0.75 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
metronidazole
tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
296 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
metronidazole
gel 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
metronidazole in NaCl (iso-os)
piggyback 500 mg/100 mL Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
mexiletine capsule 150 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
mexiletine capsule 200 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
mexiletine capsule 250 mg
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Miacalcin solution 200 unit/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Miconazole-3
suppository 200 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Microgestin 1.5/30 (21) tablet 1.5-30 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Microgestin 1/20 (21) tablet 1-20 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
297 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Microgestin Fe 1.5/30 (28) tablet
1.5 mg-30 mcg (21)/75 mg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Microgestin FE 1/20 (28) tablet
1 mg-20 mcg (21)/75 mg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
midodrine tablet 10 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
midodrine tablet 2.5 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
midodrine tablet 5 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Migergot suppository 2-100 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
miglitol tablet 25 mg Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
miglitol tablet 50 mg Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
miglitol tablet 100 mg Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Migranal spray,non-aerosol
0.5 mg/pump act. (4 mg/mL)
NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Millipred solution 10 mg/5 mL NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
298 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Millipred tablet 5 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
minocycline capsule 100 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline capsule 50 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline tablet 50 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline tablet 100 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline capsule 75 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline tablet 75 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline tablet extended release 24 hr
135 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline tablet extended release 24 hr
45 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minocycline tablet extended release 24 hr
90 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
minoxidil tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
minoxidil tablet 2.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Mirapex ER tablet extended release 24 hr
4.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
299 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Mirapex ER tablet extended release 24 hr
0.375 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Mirapex ER tablet extended release 24 hr
3 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Mirapex ERtablet extended release 24 hr 2.25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Mirapex ERtablet extended release 24 hr 3.75 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Mircera syringe 50 mcg/0.3 mL
NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Mircera syringe 75 mcg/0.3 mL
NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Mircera syringe 100 mcg/0.3 mL
NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Mircera syringe 200 mcg/0.3 mL
NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
300 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
mirtazapine tablet,disintegrating
15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
mirtazapine tablet,disintegrating
30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
mirtazapine tablet,disintegrating
45 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
mirtazapine tablet 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
mirtazapine tablet 45 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
mirtazapine tablet 30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
mirtazapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
misoprostol tablet 100 mcg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
misoprostol tablet 200 mcg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
301 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Mitigare capsule 0.6 mg
NonPrefBrand-4
62 31
NO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY
mitomycin recon soln 5 mg
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
mitomycin recon soln 40 mg
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
mitomycin recon soln 20 mg
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
mitoxantrone
concentrate 2 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
M-M-R II (PF)
recon soln 1,000-12,500 TCID50/0.5 mL
NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
modafinil tablet 200 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
modafinil tablet 100 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
302 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Moderiba tablet 200 mgGeneric-2 NO ANTI -
INFECTIVES ANTIVIRALSModeriba Dose Pack
tablets,dose pack
400 mg (7)- 400 mg (7)
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
Moderiba Dose Pack
tablets,dose pack
600 mg (7)- 600 mg (7)
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
moexipril tablet 15 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
moexipril tablet 7.5 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
moexipril-hydrochlorothiazide tablet 15-12.5 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
moexipril-hydrochlorothiazide tablet 7.5-12.5 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
moexipril-hydrochlorothiazide tablet 15-25 mg
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
molindone tablet 10 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
303 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
molindone tablet 25 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
molindone tablet 5 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
mometasone ointment 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
mometasone solution 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
mometasone cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
mometasone spray,non-aerosol
50 mcg/actuation PrefBrand-3 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Mononessa (28)
tablet 0.25-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
montelukast tablet 10 mg PrefBrand-3 31 31 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
montelukast tablet,chewable 5 mg Generic-2 31 31 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
montelukast tablet,chewable 4 mg Generic-2 31 31 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
montelukast granules in packet
4 mg Generic-2 31 31 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Monurol packet 3 gram NonPrefBrand-4 NO ANTI - INFECTIVES
URINARY TRACT AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
304 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
morphine tablet extended release
100 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine tablet extended release
15 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine tablet extended release
30 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine tablet extended release
60 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule, ER multiphase 24 hr
120 mg Generic-2 51 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule, ER multiphase 24 hr
30 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule,extend.release pellets
30 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule, ER multiphase 24 hr
60 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
305 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
morphine capsule,extend.release pellets
60 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule, ER multiphase 24 hr
90 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule,extend.release pellets
10 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule,extend.release pellets
100 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine tablet 15 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine solution 10 mg/5 mL Generic-2 2800 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule,extend.release pellets
20 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine tablet extended release
200 mg Generic-2 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
306 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
morphine tablet 30 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine solution 20 mg/5 mL (4 mg/mL)
Generic-2 1400 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule,extend.release pellets
50 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule,extend.release pellets
80 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine syringe 10 mg/mL NonPrefBrand-4 200 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine syringe 8 mg/mL NonPrefBrand-4 250 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule, ER multiphase 24 hr
45 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine capsule, ER multiphase 24 hr
75 mg Generic-2 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
307 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
morphine syringe 2 mg/mL
Generic-2
1000 30
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine syringe 4 mg/mL
Generic-2
500 30
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
morphine concentrate
solution 100 mg/5 mL (20 mg/mL)
Generic-2 310 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Movantik tablet 12.5 mg
PrefBrand-3
31 31
NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Movantik tablet 25 mg
PrefBrand-3
31 31
NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
MoviPrep powder in packet
100-7.5-2.691 gram
NonPrefBrand-4 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Moxeza drops, viscous 0.5 %NonPrefBrand-4 NO OPHTHALMOLO
GY ANTIBIOTICSmoxifloxacin
tablet 400 mg PrefBrand-3 NO ANTI - INFECTIVES
QUINOLONES
moxifloxacin-sod.ace,sul-water
piggyback 400 mg/250 mL NonPrefBrand-4 NO ANTI - INFECTIVES
QUINOLONES
5T Medicare Part D: 5 Tier Closed Formulary
308 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Mozobil solution 24 mg/1.2 mL (20 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
MS Contin tablet extended release
100 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
MS Contin tablet extended release
15 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
MS Contin tablet extended release
200 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
MS Contin tablet extended release
30 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
MS Contin tablet extended release
60 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Multaq tablet 400 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
mupirocin ointment 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
5T Medicare Part D: 5 Tier Closed Formulary
309 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
mupirocin calcium
cream 2 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
Mustargen recon soln 10 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Myalept recon soln5 mg/mL (final conc.)
Specialty-5 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Mycamine recon soln 50 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Mycamine recon soln 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
mycophenolate mofetil
capsule 250 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
mycophenolate mofetil
tablet 500 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
mycophenolate mofetil
suspension for reconstitution
200 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
mycophenolate sodium
tablet,delayed release (DR/EC)
180 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
mycophenolate sodium
tablet,delayed release (DR/EC)
360 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
310 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Myfortic tablet,delayed release (DR/EC)
360 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Myfortic tablet,delayed release (DR/EC)
180 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Myorisan capsule 10 mg
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Myorisan capsule 20 mg
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Myorisan capsule 40 mg
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Myorisan capsule 30 mg
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Myrbetriqtablet extended release 24 hr 25 mg
PrefBrand-3
31 31
NO
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
Myrbetriqtablet extended release 24 hr 50 mg
PrefBrand-3
31 31
NO
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
Mysoline tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
311 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Mysoline tablet 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
nabumetone tablet 500 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
nabumetone tablet 750 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
nadolol tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nadolol tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nadolol tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nadolol-bendroflumethiazide
tablet 40-5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nadolol-bendroflumethiazide
tablet 80-5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
312 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nafcillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES
PENICILLINS
nafcillin recon soln 1 gramGeneric-2 NO ANTI -
INFECTIVES PENICILLINSnaftifine cream 1 % NonPrefBrand-4 NO DERMATOLOGIC
ALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
naftifine cream 2 %
PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Naftin gel 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Naftin cream 2 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Naftin gel 2 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Naglazyme solution 5 mg/5 mL Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
nalbuphine solution 10 mg/mL Generic-2 200 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
nalbuphine solution 20 mg/mL Generic-2 100 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naloxone syringe 1 mg/mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
313 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
naloxone solution 0.4 mg/mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naltrexone tablet 50 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Namenda tablet 10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namenda tablet 5 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namenda solution 2 mg/mL
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namenda Titration Pak
tablets,dose pack 5-10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namenda XR
capsule,sprinkle,ER 24hr 14 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namenda XR
capsule,sprinkle,ER 24hr 21 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
314 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Namenda XR
capsule,sprinkle,ER 24hr 28 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namenda XR
capsule,sprinkle,ER 24hr 7 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namenda XR
cap,sprinkle,ER 24hr dose pack 7-14-21-28 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namzariccapsule,sprinkle,ER 24hr 14-10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Namzariccapsule,sprinkle,ER 24hr 28-10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Naprelan CR
tablet, ER multiphase 24 hr 375 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Naprelan CR
tablet, ER multiphase 24 hr 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Naprelan CR
tablet, ER multiphase 24 hr 750 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
315 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
naproxen tablet 375 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen tablet 250 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen tablet 500 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen suspension 125 mg/5 mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen tablet,delayed release (DR/EC)
500 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen tablet,delayed release (DR/EC)
375 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen sodium
tablet 275 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen sodium
tablet 550 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
316 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
naproxen sodium
tablet, ER multiphase 24 hr 375 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naproxen sodium
tablet, ER multiphase 24 hr 500 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
naratriptan tablet 1 mg Generic-2 20 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
naratriptan tablet 2.5 mg Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Narcanspray,non-aerosol 4 mg/actuation
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nasonex spray,non-aerosol
50 mcg/actuation NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Natacyn drops,suspension
5 % PrefBrand-3 NO OPHTHALMOLOGY
ANTIBIOTICS
nateglinide tablet 120 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
nateglinide tablet 60 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Natestogel in metered-dose pump
5.5 mg/0.122 gram/actuation
NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Natpara cartridge 25 mcg/doseSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
317 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Natpara cartridge 50 mcg/doseSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Natpara cartridge 75 mcg/doseSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Natpara cartridge 100 mcg/doseSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Nebupent recon soln 300 mg NonPrefBrand-4 YES ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Necon 0.5/35 (28)
tablet 0.5-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Necon 1/35 (28)
tablet 1-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Necon 10/11 (28)
tablet 0.5-35/1-35 mg-mcg/mg-mcg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Necon 7/7/7 (28)
tablet 0.5/0.75/1 mg- 35 mcg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
nefazodone tablet 100 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
318 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nefazodone tablet 150 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
nefazodone tablet 200 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
nefazodone tablet 250 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
nefazodone tablet 50 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
neomycin tablet 500 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
neomycin-bacitracin-poly-HC ointment
3.5-400-10,000 mg-unit/g-1%
Generic-2 NO
OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-polymyxin
ointment 3.5-400-10,000 mg-unit-unit/g
Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
neomycin-polymyxin B GU
solution 40 mg-200,000 unit/mL
PrefGen-1 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
5T Medicare Part D: 5 Tier Closed Formulary
319 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
neomycin-polymyxin B-dexameth
ointment 3.5 mg/g-10,000 unit/g-0.1 %
Generic-2 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-polymyxin B-dexameth
drops,suspension
3.5mg/mL-10,000 unit/mL-0.1 %
Generic-2 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-polymyxin-gramicidin
drops 1.75 mg-10,000 unit-0.025mg/mL
Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
neomycin-polymyxin-HC
solution 3.5-10,000-1 mg/mL-unit/mL-%
Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
OTIC STEROID / ANTIBIOTIC
neomycin-polymyxin-HC
drops,suspension
3.5-10,000-10 mg-unit-mg/mL
Generic-2 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-polymyxin-HC
drops,suspension
3.5-10,000-1 mg/mL-unit/mL-%
Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
OTIC STEROID / ANTIBIOTIC
Neoral solution 100 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Neoral capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Neoral capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
320 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Neo-Synalar cream0.5 % (0.35 % base)-0.025 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
Nephramine 5.4 %
parenteral solution
5.4 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Nesina tablet 25 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Nesina tablet 6.25 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Nesina tablet 12.5 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Neuac gel1.2 %(1 % base) -5 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Neulasta syringe 6 mg/0.6mL Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Neupogen syringe 300 mcg/0.5 mL Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Neupogen syringe 480 mcg/0.8 mL Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Neupogen solution 300 mcg/mL
NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
321 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Neupogen solution 480 mcg/1.6 mL
Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Neupro patch 24 hour 2 mg/24 hour NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Neupro patch 24 hour 4 mg/24 hour NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Neupro patch 24 hour 6 mg/24 hour NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Neupro patch 24 hour 1 mg/24 hour
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Neupro patch 24 hour 3 mg/24 hour
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Neupro patch 24 hour 8 mg/24 hour
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Neurontin capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
322 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Neurontin capsule 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Neurontin capsule 400 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Neurontin tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Neurontin tablet 800 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Neurontin solution 250 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Nevanac drops,suspension
0.1 % NonPrefBrand-4 NO OPHTHALMOLOGY
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
nevirapine tablet 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
nevirapine suspension 50 mg/5 mL Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
nevirapinetablet extended release 24 hr 400 mg
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
nevirapinetablet extended release 24 hr 100 mg
Generic-2 NO ANTI - INFECTIVES ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
323 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Nexavar tablet 200 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
niacintablet extended release 24 hr 1,000 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
niacintablet extended release 24 hr 500 mg
PrefBrand-3
31 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
niacintablet extended release 24 hr 750 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Niacor tablet 500 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
nicardipine solution 25 mg/10 mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nicardipine capsule 20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nicardipine capsule 30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
324 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Nicotrol cartridge 10 mg
NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
SMOKING DETERRENTS
Nicotrol NS spray,non-aerosol
10 mg/mL PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
SMOKING DETERRENTS
Nifedical XL tablet extended release 24hr
60 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Nifedical XL tablet extended release 24hr
30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nifedipine tablet extended release 24hr
30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nifedipine tablet extended release 24hr
60 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nifedipine tablet extended release 24hr
90 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Nilandron tablet 150 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
325 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nimodipine capsule 30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Ninlaro capsule 2.3 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ninlaro capsule 3 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ninlaro capsule 4 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Nipent recon soln 10 mg NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
nisoldipine tablet extended release 24 hr
20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nisoldipine tablet extended release 24 hr
30 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nisoldipine tablet extended release 24 hr
40 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
326 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nisoldipine tablet extended release 24 hr
17 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nisoldipine tablet extended release 24 hr
25.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nisoldipine tablet extended release 24 hr
34 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
nisoldipine tablet extended release 24 hr
8.5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Nitro-Bid ointment 2 % Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.2 mg/hr NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.4 mg/hr NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.6 mg/hr NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
5T Medicare Part D: 5 Tier Closed Formulary
327 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Nitro-Dur patch 24 hour 0.1 mg/hr NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.3 mg/hr NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitro-Dur patch 24 hour 0.8 mg/hr NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
nitrofurantoin
suspension 25 mg/5 mL Generic-2 1800 365 YES ANTI - INFECTIVES
URINARY TRACT AGENTS
nitrofurantoin macrocrystal
capsule 25 mg Generic-2 360 365 YES ANTI - INFECTIVES
URINARY TRACT AGENTS
nitrofurantoin macrocrystal
capsule 50 mg Generic-2 180 365 YES ANTI - INFECTIVES
URINARY TRACT AGENTS
nitrofurantoin macrocrystal capsule 100 mg
Generic-2
90 365
YESANTI - INFECTIVES
URINARY TRACT AGENTS
nitrofurantoin monohyd/m-cryst capsule 100 mg
Generic-2
90 365
YES
ANTI - INFECTIVES
URINARY TRACT AGENTS
nitroglycerin solution 50 mg/10 mL (5 mg/mL)
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
5T Medicare Part D: 5 Tier Closed Formulary
328 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nitroglycerin patch 24 hour 0.6 mg/hr Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
nitroglycerin patch 24 hour 0.2 mg/hr Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
nitroglycerin patch 24 hour 0.4 mg/hr Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
nitroglycerin spray,non-aerosol
400 mcg/spray Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
nitroglycerin patch 24 hour 0.1 mg/hr Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitrostat tablet 0.3 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitrostat tablet 0.4 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
Nitrostat tablet 0.6 mg NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
NITRATES
5T Medicare Part D: 5 Tier Closed Formulary
329 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nizatidine capsule 300 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
nizatidine capsule 150 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
nizatidine solution 150 mg/10 mL Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
Norco tablet 10-325 mg NonPrefBrand-4 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Norco tablet 5-325 mg NonPrefBrand-4 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Norco tablet 7.5-325 mg NonPrefBrand-4 372 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Norditropin FlexPro
pen injector 15 mg/1.5 mL (10 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Norditropin FlexPro
pen injector 5 mg/1.5 mL (3.3 mg/mL)
NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Norditropin FlexPro
pen injector 10 mg/1.5 mL (6.7 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
330 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Norditropin FlexPro
pen injector 30 mg/3 mL (10 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
noreth-ethinyl estradiol-iron tablet,chewable
0.8mg-25mcg(24) and 75 mg (4)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
norethindrone (contraceptive)
tablet 0.35 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
norethindrone acetate tablet 5 mg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
norethindrone ac-eth estradiol tablet 1-5 mg-mcg
Generic-2 NOOBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
norethindrone ac-eth estradiol tablet 0.5-2.5 mg-mcg
Generic-2 NOOBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
norgestimate-ethinyl estradiol
tablet 0.18/0.215/0.25 mg-25 mcg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Noritate cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Normosol-M in 5 % dextrose
parenteral solution
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Normosol-R in 5 % dextrose
parenteral solution 5 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES
5T Medicare Part D: 5 Tier Closed Formulary
331 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Normosol-R pH 7.4
parenteral solution
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Northera capsule 100 mg
Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Northera capsule 200 mg
Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Northera capsule 300 mg
Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Nortrel 0.5/35 (28)
tablet 0.5-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Nortrel 1/35 (21)
tablet 1-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Nortrel 1/35 (28)
tablet 1-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Nortrel 7/7/7 (28)
tablet 0.5/0.75/1 mg- 35 mcg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
nortriptyline capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
332 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nortriptyline capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
nortriptyline capsule 75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
nortriptyline solution 10 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
nortriptyline capsule 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Norvir capsule 100 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Norvir solution 80 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Norvir tablet 100 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Novarel recon soln 10,000 unit Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Novolin 70/30
suspension 100 unit/mL (70-30)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Novolin N suspension 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Novolin R solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Novolog solution 100 unit/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
333 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Novolog Flexpen insulin pen 100 unit/mL
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Novolog Mix 70-30
solution 100 unit/mL (70-30)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Novolog Mix 70-30 FlexPen
insulin pen 100 unit/mL (70-30)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Novolog PenFill cartridge 100 unit/mL
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Noxafil suspension 200 mg/5 mL (40 mg/mL)
Specialty-5 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Nucala recon soln 100 mgSpecialty-5 YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Nucynta tablet 100 mg NonPrefBrand-4 155 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nucynta tablet 50 mg NonPrefBrand-4 186 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nucynta tablet 75 mg NonPrefBrand-4 186 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nucynta ERtablet extended release 12 hr 100 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nucynta ERtablet extended release 12 hr 150 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
334 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Nucynta ERtablet extended release 12 hr 200 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nucynta ERtablet extended release 12 hr 250 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nucynta ERtablet extended release 12 hr 50 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Nuedexta capsule 20-10 mg
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Nulojix recon soln 250 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Nuplazid tablet 17 mg
Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Nutrestorepowder in packet 5 gram
NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Nutrilipid emulsion 20 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
5T Medicare Part D: 5 Tier Closed Formulary
335 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Nutropin AQ cartridge20 mg/2 mL (10 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Nutropin AQ cartridge10 mg/2 mL (5 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Nutropin AQ Nuspin
pen injector 5 mg/2 mL (2.5 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Nutropin AQ Nuspin pen injector
20 mg/2 mL (10 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Nutropin AQ Nuspin pen injector
10 mg/2 mL (5 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
NuvaRing ring0.12-0.015 mg/24 hr
PrefBrand-3 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Nuvessa gel 1.3 %NonPrefBrand-4 NO OBSTETRICS /
GYNECOLOGYMISCELLANEOUS OB/GYN
Nyamyc powder 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
nystatin suspension 100,000 unit/mL Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
nystatin tablet 500,000 unit Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
336 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
nystatin cream 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
nystatin powder 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
nystatin ointment 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
nystatin-triamcinolone ointment
100,000-0.1 unit/gram-%
PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
nystatin-triamcinolone cream
100,000-0.1 unit/g-%
PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Nystop powder 100,000 unit/gram Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Octagam solution 5 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Octagam solution 10 %
Specialty-5 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
octreotide acetate
solution 50 mcg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
337 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
octreotide acetate
solution 100 mcg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
octreotide acetate
solution 500 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
octreotide acetate
solution 1,000 mcg/mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
octreotide acetate
solution 200 mcg/mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Odefsey tablet 200-25-25 mgSpecialty-5
31 31NO ANTI -
INFECTIVES ANTIVIRALS
Odomzo capsule 200 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ofev capsule 100 mgSpecialty-5
62 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Ofev capsule 150 mgSpecialty-5
62 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
ofloxacin tablet 400 mg Generic-2 NO ANTI - INFECTIVES
QUINOLONES
ofloxacin drops 0.3 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS OTIC PREPARATIONS
ofloxacin drops 0.3 % Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
5T Medicare Part D: 5 Tier Closed Formulary
338 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Ogestrel (28) tablet 0.5-50 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
olanzapine tablet 2.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet 20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet,disintegrating
10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet 5 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
339 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
olanzapine tablet,disintegrating
5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet,disintegrating
15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine tablet,disintegrating
20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine recon soln 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine-fluoxetine
capsule 6-25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine-fluoxetine
capsule 12-25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine-fluoxetine
capsule 12-50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olanzapine-fluoxetine
capsule 6-50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
340 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
olanzapine-fluoxetine
capsule 3-25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
olopatadinespray,non-aerosol 0.6 %
Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
olopatadine drops 0.1 %
PrefBrand-3 NO
OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
Olysio capsule 150 mgSpecialty-5
28 28YES ANTI -
INFECTIVES ANTIVIRALSomega-3 acid ethyl esters
capsule 1 gram PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
omeprazole capsule,delayed release(DR/EC)
20 mg PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
omeprazole capsule,delayed release(DR/EC)
10 mg PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
omeprazole capsule,delayed release(DR/EC)
40 mg PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
omeprazole-sodium bicarbonate
capsule 20-1.1 mg-gram Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
341 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
omeprazole-sodium bicarbonate
capsule 40-1.1 mg-gram Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
Omnaris spray,non-aerosol
50 mcg NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Omnitrope recon soln 5.8 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Omnitrope cartridge 10 mg/1.5 mL (6.7 mg/mL)
NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Omnitrope cartridge 5 mg/1.5 mL (3.3 mg/mL)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ondansetron tablet,disintegrating
4 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ondansetron tablet,disintegrating
8 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ondansetron HCl
tablet 4 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ondansetron HCl
tablet 24 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
342 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ondansetron HCl
solution 4 mg/5 mL Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ondansetron HCl
tablet 8 mg Generic-2 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ondansetron HCl (PF)
solution 4 mg/2 mL Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ondansetron HCl (PF) syringe 4 mg/2 mL
Generic-2 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Onfi tablet 10 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Onfi tablet 20 mg
Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Onfi suspension 2.5 mg/mL
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Onglyza tablet 5 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Onglyza tablet 2.5 mg NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
343 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Onzetra Xsail
aerosol powdr breath activated 11 mg
NonPrefBrand-4
16 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Opana tablet 5 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opana tablet 10 mg NonPrefBrand-4 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opana ER tablet,oral only,ext.rel.12 hr
10 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opana ER tablet,oral only,ext.rel.12 hr
15 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opana ER tablet,oral only,ext.rel.12 hr
20 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opana ER tablet,oral only,ext.rel.12 hr
30 mg NonPrefBrand-4 69 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opana ER tablet,oral only,ext.rel.12 hr
40 mg NonPrefBrand-4 51 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
344 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Opana ER tablet,oral only,ext.rel.12 hr
5 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opana ER tablet,oral only,ext.rel.12 hr
7.5 mg NonPrefBrand-4 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Opdivo solution 40 mg/4 mL
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Opsumit tablet 10 mgSpecialty-5
31 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Oralair tablet 300 indx reactivity
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Orap tablet 1 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Oravigmuco-adhesive buccal tablet 50 mg
NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Orbactiv recon soln 400 mg
Specialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Orencia syringe 125 mg/mL
Specialty-5
4 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
345 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Orencia (with maltose)
recon soln 250 mg Specialty-5 8 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Orenitramtablet extended release 0.125 mg
NonPrefBrand-4
93 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Orenitramtablet extended release 0.25 mg
Specialty-5
186 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Orenitramtablet extended release 1 mg
Specialty-5
186 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Orenitramtablet extended release 2.5 mg
Specialty-5
521 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Orfadin capsule 2 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Orfadin capsule 5 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Orfadin capsule 10 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Orfadin suspension 4 mg/mL
Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
346 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Orkambi tablet 200-125 mgSpecialty-5
124 31YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Orsythia tablet 0.1-20 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Ortho Tri-Cyclen Lo (28)
tablet 0.18/0.215/0.25 mg-25 mcg
PrefBrand-3 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Oseni tablet 12.5-15 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Oseni tablet 12.5-30 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Oseni tablet 12.5-45 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Oseni tablet 25-15 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Oseni tablet 25-30 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
Oseni tablet 25-45 mgNonPrefBrand-4 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
OsmoPrep tablet 1.5 gram NonPrefBrand-4 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Otezla tablet 30 mg
Specialty-5
62 31
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
347 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Otezla Starter
tablets,dose pack
10 mg (4)-20 mg (4)-30 mg (47)
Specialty-5
55 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Otrexup (PF) auto-injector 10 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Otrexup (PF) auto-injector 15 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Otrexup (PF) auto-injector 20 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Otrexup (PF) auto-injector 25 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Otrexup (PF) auto-injector 7.5 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Otrexup (PF) auto-injector 17.5 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Otrexup (PF) auto-injector 22.5 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
348 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
oxacillin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES
PENICILLINS
oxacillin recon soln 2 gram Generic-2 NO ANTI - INFECTIVES
PENICILLINS
oxacillin in dextrose(iso-osm)
piggyback 2 gram/50 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
oxacillin in dextrose(iso-osm)
piggyback 1 gram/50 mL Generic-2 NO ANTI - INFECTIVES
PENICILLINS
oxaliplatin solution 100 mg/20 mL
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
oxandrolone tablet 2.5 mg Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
oxandrolone tablet 10 mg Specialty-5 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
oxaprozin tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
oxazepam capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
oxazepam capsule 30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
349 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
oxazepam capsule 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
oxcarbazepine
suspension 300 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
oxcarbazepine
tablet 150 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
oxcarbazepine
tablet 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
oxcarbazepine
tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
oxiconazole cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Oxistat cream 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Oxistat lotion 1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIFUNGALS
Oxtellar XRtablet extended release 24 hr 150 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
350 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Oxtellar XRtablet extended release 24 hr 300 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Oxtellar XRtablet extended release 24 hr 600 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
oxybutynin chloride
syrup 5 mg/5 mL Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
oxybutynin chloride
tablet extended release 24hr
10 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
oxybutynin chloride
tablet extended release 24hr
15 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
oxybutynin chloride
tablet extended release 24hr
5 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
oxybutynin chloride
tablet 5 mg Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
oxycodone
tablet,oral only,ext.rel.12 hr 10 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
351 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
oxycodone
tablet,oral only,ext.rel.12 hr 15 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone
tablet,oral only,ext.rel.12 hr 20 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone
tablet,oral only,ext.rel.12 hr 30 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone
tablet,oral only,ext.rel.12 hr 40 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone
tablet,oral only,ext.rel.12 hr 60 mg
NonPrefBrand-4
69 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone
tablet,oral only,ext.rel.12 hr 80 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone solution 5 mg/5 mL
Generic-2
4133 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone tablet 15 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
352 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
oxycodone concentrate 20 mg/mL
Generic-2
180 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone tablet 30 mg
PrefBrand-3
138 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone tablet 5 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone tablet 10 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone tablet 20 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone capsule 5 mg
Generic-2
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone-acetaminophen tablet 10-325 mg
PrefBrand-3
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone-acetaminophen tablet 5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
353 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
oxycodone-acetaminophen tablet 7.5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone-acetaminophen solution 5-325 mg/5 mL
Generic-2
1860 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone-acetaminophen tablet 2.5-325 mg
Generic-2
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxycodone-aspirin
tablet 4.8355-325 mg Generic-2 360 30 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
OxyContin
tablet,oral only,ext.rel.12 hr 10 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
OxyContin
tablet,oral only,ext.rel.12 hr 15 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
OxyContin
tablet,oral only,ext.rel.12 hr 20 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
OxyContin
tablet,oral only,ext.rel.12 hr 30 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
354 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
OxyContin
tablet,oral only,ext.rel.12 hr 40 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
OxyContin
tablet,oral only,ext.rel.12 hr 60 mg
NonPrefBrand-4
69 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
OxyContin
tablet,oral only,ext.rel.12 hr 80 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet extended release 12 hr
10 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet extended release 12 hr
15 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet extended release 12 hr
20 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet extended release 12 hr
30 mg Generic-2 69 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet extended release 12 hr
40 mg Generic-2 51 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
355 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
oxymorphone
tablet extended release 12 hr
5 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet extended release 12 hr
7.5 mg Generic-2 100 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet 5 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
oxymorphone
tablet 10 mg Generic-2 186 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Oxytrol patch semiweekly
3.9 mg/24 hr NonPrefBrand-4 8 28 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
Pacerone tablet 200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Pacerone tablet 400 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Pacerone tablet 100 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
356 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
paclitaxel concentrate 6 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
paliperidone tablet extended release 24hr
3 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paliperidone tablet extended release 24hr
6 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paliperidone tablet extended release 24hr
9 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paliperidone tablet extended release 24hr
1.5 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
pamidronate solution30 mg/10 mL (3 mg/mL)
Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
pamidronate solution60 mg/10 mL (6 mg/mL)
Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
pamidronate solution90 mg/10 mL (9 mg/mL)
Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Pancreaze capsule,delayed release(DR/EC)
10,500-25,000- 43,750 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
357 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Pancreaze capsule,delayed release(DR/EC)
16,800-40,000- 70,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Pancreaze capsule,delayed release(DR/EC)
21,000-37,000 -61,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Pancreaze capsule,delayed release(DR/EC)
4,200-10,000- 17,500 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Pandel cream 0.1 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
Panretin gel 0.1 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
pantoprazole tablet,delayed release (DR/EC)
20 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
pantoprazole recon soln 40 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
pantoprazole tablet,delayed release (DR/EC)
40 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
paricalcitol solution 5 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
paricalcitol capsule 1 mcg Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
paricalcitol capsule 2 mcg PrefGen-1 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
358 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
paricalcitol capsule 4 mcg PrefGen-1 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
paricalcitol solution 2 mcg/mLNonPrefBrand-4 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
paromomycin
capsule 250 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
paroxetine HCl tablet 10 mg
PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paroxetine HCl tablet 20 mg
PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paroxetine HCl tablet 30 mg
PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paroxetine HCl tablet 40 mg
PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paroxetine HCl
tablet extended release 24 hr 12.5 mg
PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
paroxetine HCl
tablet extended release 24 hr 25 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
359 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
paroxetine HCl
tablet extended release 24 hr 37.5 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Paser granules DR for susp in packet
4 gram NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Pataday drops 0.2 %
PrefBrand-3 NO
OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
Paxil suspension 10 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Pazeo drops 0.7 %
PrefBrand-3 NO
OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
PCE tablet, particles/crystals
333 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
PCE tablet, particles/crystals
500 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Pedvax HIB (PF)
solution 7.5 mcg/0.5 mL NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
360 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
peg 3350-electrolytes
recon soln 236-22.74-6.74 -5.86 gram
Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Peganone tablet 250 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Pegasys solution 180 mcg/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Pegasys syringe 180 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Pegasys ProClick pen injector 135 mcg/0.5 mL
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Pegasys ProClick pen injector 180 mcg/0.5 mL
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
peg-electrolyte soln
recon soln 420 gram Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
PegIntron kit 50 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
361 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
PegIntron kit 80 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
PegIntron kit 120 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
PegIntron kit 150 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
PegIntron Redipen
pen injector kit 120 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
PegIntron Redipen
pen injector kit 80 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
PegIntron Redipen
pen injector kit 150 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
PegIntron Redipen
pen injector kit 50 mcg/0.5 mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
pen needle, diabetic
needle 29 gauge x 1/2" NonPrefBrand-4 NO ENDOCRINE/DIABETES
DIABETES THERAPY
penicillin G pot in dextrose
piggyback 3 million unit/50 mL
NonPrefBrand-4 NO ANTI - INFECTIVES
PENICILLINS
5T Medicare Part D: 5 Tier Closed Formulary
362 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
penicillin G pot in dextrose
piggyback 2 million unit/50 mL
NonPrefBrand-4 NO ANTI - INFECTIVES
PENICILLINS
penicillin G potassium
recon soln 5 million unit Generic-2 NO ANTI - INFECTIVES
PENICILLINS
penicillin G procaine
syringe 1.2 million unit/2 mL
Generic-2 NO ANTI - INFECTIVES
PENICILLINS
penicillin G sodium
recon soln 5 million unit Generic-2 NO ANTI - INFECTIVES
PENICILLINS
penicillin V potassium
recon soln 250 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
penicillin V potassium
recon soln 125 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
penicillin V potassium
tablet 250 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
penicillin V potassium
tablet 500 mg PrefGen-1 NO ANTI - INFECTIVES
PENICILLINS
Pentam recon soln 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Pentasa capsule, extended release
250 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Pentasa capsule, extended release
500 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
pentazocine-naloxone
tablet 50-0.5 mg Generic-2 335 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
363 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
pentoxifylline
tablet extended release
400 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Percocet tablet 10-325 mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Percocet tablet 2.5-325 mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Percocet tablet 5-325 mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Percocet tablet 7.5-325 mg
NonPrefBrand-4
372 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Perforomistsolution for nebulization 20 mcg/2 mL
NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
perindopril erbumine
tablet 8 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
perindopril erbumine
tablet 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
364 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
perindopril erbumine
tablet 4 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Periogard mouthwash 0.12 % Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
Perjeta solution420 mg/14 mL (30 mg/mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
permethrin cream 5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL SCABICIDES / PEDICULICIDES
perphenazine tablet 16 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
perphenazine tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
perphenazine tablet 4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
perphenazine tablet 8 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
365 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
perphenazine-amitriptyline
tablet 2-10 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
perphenazine-amitriptyline
tablet 4-10 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
perphenazine-amitriptyline
tablet 2-25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
perphenazine-amitriptyline
tablet 4-25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
perphenazine-amitriptyline
tablet 4-50 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Phenadoz suppository 12.5 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
phenelzine tablet 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Phenergan suppository 12.5 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
366 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Phenergan suppository 25 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Phenergan suppository 50 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
phenobarbital
tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenobarbital
tablet 16.2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenobarbital
tablet 60 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenobarbital
tablet 97.2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenobarbital
tablet 32.4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenobarbital
tablet 64.8 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
367 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
phenobarbital
tablet 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenobarbital
tablet 30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenobarbital
elixir 20 mg/5 mL (4 mg/mL)
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenoxybenzamine
capsule 10 mg Specialty-5 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Phenytek capsule 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Phenytek capsule 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenytoin suspension 125 mg/5 mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenytoin tablet,chewable 50 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
368 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
phenytoin sodium solution 50 mg/mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenytoin sodium extended
capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenytoin sodium extended
capsule 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
phenytoin sodium extended
capsule 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Phoslyra solution667 mg (169 mg calcium)/5 mL
NonPrefBrand-4 NO VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES
Phospholine Iodide
drops 0.125 % PrefBrand-3 NO OPHTHALMOLOGY
CHOLINESTERASE INHIBITOR MIOTICS
Picato gel 0.05 %
PrefBrand-3 NODERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Picato gel 0.015 %
PrefBrand-3 NODERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
pilocarpine HCl drops 1 %
Generic-2 NO OPHTHALMOLOGY
DIRECT ACTING MIOTICS
5T Medicare Part D: 5 Tier Closed Formulary
369 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
pilocarpine HCl drops 2 %
Generic-2 NO OPHTHALMOLOGY
DIRECT ACTING MIOTICS
pilocarpine HCl drops 4 %
Generic-2 NO OPHTHALMOLOGY
DIRECT ACTING MIOTICS
pilocarpine HCl tablet 5 mg
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
pilocarpine HCl tablet 7.5 mg
Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
pimozide tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
pimozide tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Pimtrea (28) tablet0.15-0.02 mgx21 /0.01 mg x 5
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
pindolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
pindolol tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
pioglitazone tablet 30 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
370 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
pioglitazone tablet 45 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
pioglitazone tablet 15 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
pioglitazone-glimepiride
tablet 30-2 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
pioglitazone-glimepiride
tablet 30-4 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
pioglitazone-metformin
tablet 15-500 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
pioglitazone-metformin
tablet 15-850 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
piperacillin-tazobactam
recon soln 40.5 gram Generic-2 NO ANTI - INFECTIVES
PENICILLINS
piperacillin-tazobactam recon soln 3.375 gram
Generic-2 NO ANTI - INFECTIVES PENICILLINS
piperacillin-tazobactam recon soln 4.5 gram
Generic-2 NO ANTI - INFECTIVES PENICILLINS
Pirmella tablet 1-35 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
piroxicam capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
piroxicam capsule 20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Plasma-Lyte 148
parenteral solution
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
5T Medicare Part D: 5 Tier Closed Formulary
371 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Plasma-Lyte A
parenteral solution
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Plasma-Lyte-56 in 5 % dextrose
parenteral solution 5 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Plegridy syringe 125 mcg/0.5 mL
Specialty-5
1 28
NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Plegridy pen injector 125 mcg/0.5 mL
Specialty-5
1 28
NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Plegridy pen injector63 mcg/0.5 mL- 94 mcg/0.5 mL
Specialty-5
1 28
NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
podofilox solution 0.5 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
polyethylene glycol 3350
powder 17 gram/dose Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
polymyxin B sulfate
recon soln 500,000 unit Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
polymyxin B sulf-trimethoprim
drops 10,000 unit- 1 mg/mL
Generic-2 NO OPHTHALMOLOGY
ANTIBIOTICS
5T Medicare Part D: 5 Tier Closed Formulary
372 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Pomalyst capsule 1 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Pomalyst capsule 2 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Pomalyst capsule 3 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Pomalyst capsule 4 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Portia tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
potassium chlorid-D5-0.45%NaCl
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chlorid-D5-0.45%NaCl
parenteral solution
30 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chlorid-D5-0.45%NaCl
parenteral solution
40 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chlorid-D5-0.45%NaCl
parenteral solution
10 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
5T Medicare Part D: 5 Tier Closed Formulary
373 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
potassium chloride
tablet,ER particles/crystals
20 mEq PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
solution 2 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
capsule, extended release
10 mEq PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
piggyback 10 mEq/100 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
piggyback 20 mEq/100 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
liquid 20 mEq/15 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
piggyback 40 mEq/100 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
tablet extended release
8 mEq PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
liquid 40 mEq/15 mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
capsule, extended release
8 mEq PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride
tablet,ER particles/crystals
10 mEq PrefGen-1 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
5T Medicare Part D: 5 Tier Closed Formulary
374 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
potassium chloride in 0.9%NaCl
parenteral solution
40 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride in 0.9%NaCl
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride in 5 % dex
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride in 5 % dex
parenteral solution
40 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride in LR-D5
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride-0.45 % NaCl
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride-D5-0.2%NaCl
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride-D5-0.3%NaCl
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride-D5-0.9%NaCl
parenteral solution
20 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
potassium chloride-D5-0.9%NaCl
parenteral solution
40 mEq/L Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
5T Medicare Part D: 5 Tier Closed Formulary
375 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
potassium citrate
tablet extended release
5 mEq (540 mg) Generic-2 NO UROLOGICALS MISCELLANEOUS UROLOGICALS
potassium citrate
tablet extended release
10 mEq (1,080 mg)
PrefBrand-3 NO UROLOGICALS MISCELLANEOUS UROLOGICALS
potassium citrate
tablet extended release
15 mEq Generic-2 NO UROLOGICALS MISCELLANEOUS UROLOGICALS
Potiga tablet 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Potiga tablet 300 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Potiga tablet 400 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Potiga tablet 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Pradaxa capsule 150 mg
PrefBrand-3
62 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Pradaxa capsule 75 mg
PrefBrand-3
62 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
376 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Pradaxa capsule 110 mg
PrefBrand-3
62 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Praluent Pen pen injector 150 mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Praluent Pen pen injector 75 mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Praluent Syringe syringe 150 mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Praluent Syringe syringe 75 mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
pramipexole tablet 0.75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet 0.125 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
377 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
pramipexole tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet 1.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet extended release 24 hr
4.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet extended release 24 hr
0.375 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet extended release 24 hr
0.75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet extended release 24 hr
1.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pramipexole tablet extended release 24 hr
3 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
378 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
pramipexoletablet extended release 24 hr 2.25 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
pravastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
pravastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
pravastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
pravastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
prazosin capsule 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
prazosin capsule 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
prazosin capsule 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
379 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Pred-G drops,suspension
0.3-1 % NonPrefBrand-4 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
Pred-G S.O.P.
ointment 0.3-0.6 % NonPrefBrand-4 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
prednicarbate
cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
prednicarbate
ointment 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
prednisolone acetate
drops,suspension 1 %
PrefBrand-3 NO OPHTHALMOLOGY STEROIDS
prednisolone sodium phosphate
solution 15 mg/5 mL (3 mg/mL)
Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisolone sodium phosphate
solution 25 mg/5 mL (5 mg/mL)
Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisolone sodium phosphate
solution 5 mg base/5 mL (6.7 mg/5 mL)
Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisolone sodium phosphate
drops 1 % Generic-2 NO OPHTHALMOLOGY
STEROIDS
prednisolone sodium phosphate
tablet,disintegrating
10 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
380 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
prednisolone sodium phosphate
tablet,disintegrating
15 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisolone sodium phosphate
tablet,disintegrating
30 mg Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisone tablet 1 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisone tablet 10 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisone tablet 2.5 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisone tablet 50 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisone tablet 20 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisone tablet 5 mg PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
prednisone solution 5 mg/5 mL PrefGen-1 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Prednisone Intensol
concentrate 5 mg/mL Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Prefest tablet 1 mg (15)/1 mg- 0.09 mg (15)
NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Pregnyl recon soln 10,000 unit NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Premarin cream 0.625 mg/gram PrefBrand-3 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Premasol 10 %
parenteral solution
10 % Generic-2 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
5T Medicare Part D: 5 Tier Closed Formulary
381 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Premasol 6 %
parenteral solution
6 % PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Prenatal Vitamin Plus Low Iron
tablet 27 mg iron- 1 mg Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
VITAMINS / HEMATINICS
Prepopikpowder in packet
10 mg-3.5 gram-12 gram
NonPrefBrand-4 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Prevalite powder 4 gram Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Previfem tablet 0.25-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Prezcobix tablet 800-150 mg-mgPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALSPrezista tablet 600 mg Specialty-5 NO ANTI -
INFECTIVESANTIVIRALS
Prezista tablet 75 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Prezista tablet 150 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Prezista suspension 100 mg/mLPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALS
Prezista tablet 800 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
382 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Priftin tablet 150 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
primaquine tablet 26.3 mg PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
primidone tablet 250 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
primidone tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Primlev tablet 5-300 mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Primlev tablet 10-300 mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Primlev tablet 7.5-300 mg
NonPrefBrand-4
403 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Pristiq tablet extended release 24 hr
100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
383 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Pristiq tablet extended release 24 hr
50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Pristiqtablet extended release 24 hr 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Privigen solution 10 % Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ProAir HFA HFA aerosol inhaler
90 mcg/actuation PrefBrand-3 17 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
ProAir RespiClick
aerosol powdr breath activated 90 mcg/actuation
PrefBrand-3
2 30
NORESPIRATORY AND ALLERGY
PULMONARY AGENTS
probenecid tablet 500 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
procainamide
solution 100 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
procainamide
solution 500 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Procalamine 3%
parenteral solution
3 % NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
5T Medicare Part D: 5 Tier Closed Formulary
384 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ProCentra solution 5 mg/5 mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
prochlorperazine
suppository 25 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
prochlorperazine Edisylate
solution 10 mg/2 mL (5 mg/mL)
Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
prochlorperazine maleate
tablet 10 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
prochlorperazine maleate
tablet 5 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Procrit solution 3,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Procrit solution 4,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Procrit solution 2,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
385 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Procrit solution 20,000 unit/mL PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Procrit solution 40,000 unit/mL Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Procrit solution 10,000 unit/mL
PrefBrand-3 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Procto-Pak cream 1 % Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Proctosol HC cream 2.5 %
Generic-2 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Proctozone-HC cream 2.5 %
Generic-2 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Procysbicapsule, delayed rel sprinkle 25 mg
Specialty-5 YES
UROLOGICALSMISCELLANEOUS UROLOGICALS
Procysbicapsule, delayed rel sprinkle 75 mg
Specialty-5 YES
UROLOGICALSMISCELLANEOUS UROLOGICALS
progesterone micronized
capsule 100 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
5T Medicare Part D: 5 Tier Closed Formulary
386 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
progesterone micronized
capsule 200 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
Proglycem suspension 50 mg/mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Prograf capsule 1 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Prograf capsule 5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Prograf solution 5 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Prograf capsule 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Prolastin-C recon soln 1,000 mg
Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Proleukin recon soln 22 million unit Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Prolia syringe 60 mg/mL NonPrefBrand-4 1 180 YES MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
387 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Promacta tablet 25 mg Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Promacta tablet 50 mg Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Promacta tablet 75 mg Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Promacta tablet 12.5 mg
Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
promethazine
syrup 6.25 mg/5 mL Generic-2 YES RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
promethazine
suppository 12.5 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
promethazine
suppository 25 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
promethazine
solution 25 mg/mL Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
388 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
promethazine
suppository 50 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
promethazine
solution 50 mg/mL Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Promethazine VC syrup 6.25-5 mg/5 mL
Generic-2 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Promethegan suppository 25 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Promethegan suppository 50 mg Generic-2 NO RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
propafenone capsule,extended release 12 hr
225 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
propafenone capsule,extended release 12 hr
325 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
propafenone capsule,extended release 12 hr
425 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
389 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
propafenone tablet 150 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
propafenone tablet 225 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
propafenone tablet 300 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
propantheline
tablet 15 mg Generic-2 NO GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
propranolol solution 1 mg/mL PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol capsule,extended release 24 hr
120 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
390 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
propranolol capsule,extended release 24 hr
160 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol capsule,extended release 24 hr
60 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol tablet 60 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol capsule,extended release 24 hr
80 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol solution 20 mg/5 mL (4 mg/mL)
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol solution 40 mg/5 mL (8 mg/mL)
PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
391 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
propranolol-hydrochlorothiazid
tablet 40-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propranolol-hydrochlorothiazid
tablet 80-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
propylthiouracil
tablet 50 mg Generic-2 NO ENDOCRINE/DIABETES
ANTITHYROID AGENTS
ProQuad (PF)
suspension for reconstitution
10exp3-4.3-3- 3.99 TCID50/0.5
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Prosol 20 % parenteral solution
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
protriptyline tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
protriptyline tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Provigil tablet 200 mg Specialty-5 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
392 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Provigil tablet 100 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Prudoxin cream 5 %
Generic-2 NODERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Pulmicort suspension for nebulization
0.5 mg/2 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Pulmicort suspension for nebulization
1 mg/2 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Pulmicort suspension for nebulization
0.25 mg/2 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Pulmozyme solution 1 mg/mL Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Purixan suspension 20 mg/mL
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Pylera capsule 140-125-125 mgNonPrefBrand-4 NO GASTROENTERO
LOGY ULCER THERAPYpyrazinamide
tablet 500 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
pyridostigmine bromide
tablet extended release
180 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
393 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
pyridostigmine bromide
tablet 60 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Quadracel (PF) suspension
15 Lf-48 mcg- 5 Lf unit/0.5mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Quasense tablets,dose pack,3 month
0.15-30 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
quetiapine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
quetiapine tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
quetiapine tablet 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
quetiapine tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
quetiapine tablet 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
394 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
quetiapine tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Quillivant XR
suspension,ext rel 24hr,recon
5 mg/mL (25 mg/5 mL)
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
quinapril tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
quinapril tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
quinapril tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
quinapril tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
quinapril-hydrochlorothiazide
tablet 10-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
quinapril-hydrochlorothiazide
tablet 20-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
395 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
quinapril-hydrochlorothiazide
tablet 20-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
quinidine gluconate
tablet extended release
324 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
quinidine gluconate
solution 80 mg/mL Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
quinidine sulfate
tablet 200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
quinidine sulfate
tablet 300 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
quinine sulfate capsule 324 mg
Generic-2 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Qvar aerosol 40 mcg/actuation PrefBrand-3 8.7 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Qvar aerosol 80 mcg/actuationPrefBrand-3
17.4 30NO RESPIRATORY
AND ALLERGYPULMONARY AGENTS
RabAvert (PF)
suspension for reconstitution
2.5 unit NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
396 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
rabeprazole tablet,delayed release (DR/EC)
20 mg Generic-2 62 31 NO GASTROENTEROLOGY
ULCER THERAPY
Ragwitek tablet 12 Amb a 1 unit
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
raloxifene tablet 60 mg
PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
ramipril capsule 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
ramipril capsule 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
ramipril capsule 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
ramipril capsule 1.25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Ranexa tablet extended release 12 hr
1,000 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
397 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Ranexa tablet extended release 12 hr
500 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
ranitidine HCl
capsule 150 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
ranitidine HCl
tablet 150 mg PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
ranitidine HCl
capsule 300 mg Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
ranitidine HCl
tablet 300 mg PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
ranitidine HCl
solution 25 mg/mL PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
ranitidine HCl
syrup 15 mg/mL PrefGen-1 NO GASTROENTEROLOGY
ULCER THERAPY
Rapaflo capsule 8 mg PrefBrand-3 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
Rapaflo capsule 4 mg PrefBrand-3 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
Rapamune solution 1 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Rapamune tablet 1 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
398 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Rapamune tablet 2 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Rapamune tablet 0.5 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Rasuvo (PF) auto-injector 10 mg/0.2 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 12.5 mg/0.25 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 15 mg/0.3 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 17.5 mg/0.35 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 20 mg/0.4 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 22.5 mg/0.45 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
399 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Rasuvo (PF) auto-injector 25 mg/0.5 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 27.5 mg/0.55 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 30 mg/0.6 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Rasuvo (PF) auto-injector 7.5 mg/0.15 mL
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Ravicti liquid 1.1 gram/mL
Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
REBETOL solution 40 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Rebif (with albumin)
syringe 44 mcg/0.5 mL Specialty-5 6 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Rebif (with albumin)
syringe 22 mcg/0.5 mL Specialty-5 6 28 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Rebif Rebidose pen injector 22 mcg/0.5 mL
Specialty-5
6 28
NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
400 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Rebif Rebidose pen injector 44 mcg/0.5 mL
Specialty-5
6 28
NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Rebif Rebidose pen injector
8.8mcg/0.2mL-22 mcg/0.5mL (6)
Specialty-5
4.2 365
NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Rebif Titration Pack
syringe 8.8mcg/0.2mL-22 mcg/0.5mL (6)
Specialty-5 8.4 365 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Reclipsen (28)
tablet 0.15-0.03 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Recombivax HB (PF)
syringe 10 mcg/mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Recombivax HB (PF)
syringe 5 mcg/0.5 mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Recombivax HB (PF)
suspension 40 mcg/mL NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
401 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Recombivax HB (PF) suspension 10 mcg/mL
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Rectiv ointment 0.4 % (w/w)
NonPrefBrand-4 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Regranex gel 0.01 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Relenza Diskhaler
blister with device
5 mg/actuation PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Relistor solution 12 mg/0.6 mL NonPrefBrand-4 18.6 31 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Relistor syringe 12 mg/0.6 mL
NonPrefBrand-4
18.6 31
NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Relistor syringe 8 mg/0.4 mL
NonPrefBrand-4
12.4 31
NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Relpax tablet 20 mg NonPrefBrand-4 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
402 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Relpax tablet 40 mg NonPrefBrand-4 6 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Remicade recon soln 100 mg Specialty-5 8 28 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Remodulin solution 1 mg/mL Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Remodulin solution 2.5 mg/mL Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Remodulin solution 5 mg/mL Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Remodulin solution 10 mg/mL Specialty-5 YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Renagel tablet 400 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Renagel tablet 800 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Renvela tablet 800 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
403 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Renvela powder in packet
2.4 gram PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Renvela powder in packet
0.8 gram PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
repaglinide tablet 1 mg Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
repaglinide tablet 0.5 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
repaglinide tablet 2 mg Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
repaglinide-metformin
tablet 1-500 mg Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
repaglinide-metformin
tablet 2-500 mg Generic-2 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Repatha SureClick pen injector 140 mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Repatha Syringe syringe 140 mg/mL
Specialty-5
2 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Reprexain tablet 5-200 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Reprexain tablet 10-200 mg Generic-2 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
404 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Rescriptor tablet, dispersible
100 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Rescriptor tablet 200 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
reserpine tablet 0.1 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
reserpine tablet 0.25 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Restasis dropperette 0.05 % PrefBrand-3 NO OPHTHALMOLOGY
MISCELLANEOUS OPHTHALMOLOGICS
Retin-A Micro Pump gel with pump 0.08 %
NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Retrovir solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Retrovir capsule 100 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Retrovir syrup 10 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Revatio tablet 20 mg Specialty-5 93 31 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Revatio solution 10 mg/12.5 mL Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Revatiosuspension for reconstitution 10 mg/mL
Specialty-5224 31
YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
405 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Revlimid capsule 10 mg Specialty-5 21 28 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Revlimid capsule 5 mg Specialty-5 21 28 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Revlimid capsule 15 mg Specialty-5 21 28 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Revlimid capsule 25 mg Specialty-5 21 28 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Revlimid capsule 2.5 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Revlimid capsule 20 mg
Specialty-5
21 28
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Rexulti tablet 0.25 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Rexulti tablet 0.5 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
406 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Rexulti tablet 1 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Rexulti tablet 2 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Rexulti tablet 3 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Rexulti tablet 4 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Reyataz capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Reyataz capsule 150 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Reyataz capsule 300 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Reyatazpowder in packet 50 mg
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Rheumatrextablets,dose pack
2.5 mg (dose pack 8)
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Rheumatrextablets,dose pack
2.5 mg (dose pack 12)
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
407 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Rheumatrextablets,dose pack
2.5 mg (dose pack 16)
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Rheumatrextablets,dose pack
2.5 mg (dose pack 20)
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Rheumatrextablets,dose pack 2.5 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Ribasphere capsule 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Ribasphere tablet 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Ribasphere tablet 400 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Ribasphere tablet 600 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Ribasphere RibaPak
tablets,dose pack
600-400 mg (28)-mg (28)
Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Ribasphere RibaPak
tablets,dose pack
400-400 mg (28)-mg (28)
Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Ribasphere RibaPak
tablets,dose pack
600-600 mg (28)-mg (28)
Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
ribavirin tablet 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
ribavirin capsule 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
408 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Ridaura capsule 3 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
rifabutin capsule 150 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
rifampin capsule 150 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
rifampin capsule 300 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
rifampin recon soln 600 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Rifater tablet 50-120-300 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Rilutek tablet 50 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
riluzole tablet 50 mg Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
rimantadine tablet 100 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
409 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ringers parenteral solution
Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
ringers solution Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
Riomet solution 500 mg/5 mL NonPrefBrand-4 791 31 YES ENDOCRINE/DIABETES
DIABETES THERAPY
risedronate tablet 35 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
risedronate tablet 150 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
risedronate tablet 30 mg Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
risedronate tablet 5 mg Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
risedronate tablet 35 mg (4 pack) Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
risedronate tablet 35 mg (12 pack) Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
410 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
risedronate
tablet,delayed release (DR/EC) 35 mg
Generic-2 NO MUSCULOSKELETAL / RHEUMATOLOGY
OSTEOPOROSIS THERAPY
Risperdal tablet 1 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal tablet 2 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal tablet 3 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal tablet 4 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal tablet 0.25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal tablet 0.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal solution 1 mg/mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
411 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Risperdal Consta
syringe 12.5 mg/2 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal Consta
syringe 37.5 mg/2 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal Consta
syringe 50 mg/2 mL Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal Consta
syringe 25 mg/2 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal M-TAB
tablet,disintegrating
3 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal M-TAB
tablet,disintegrating
4 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal M-TAB
tablet,disintegrating
0.5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Risperdal M-TAB
tablet,disintegrating
1 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
412 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Risperdal M-TAB
tablet,disintegrating
2 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone solution 1 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet 0.25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet 0.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet 1 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet 2 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet 3 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet 4 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
413 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
risperidone tablet,disintegrating
1 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet,disintegrating
2 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet,disintegrating
0.5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet,disintegrating
3 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet,disintegrating
4 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
risperidone tablet,disintegrating
0.25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Ritalin LAcapsule,ER biphasic 50-50 10 mg
NonPrefBrand-4
186 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Rituxan concentrate 10 mg/mL
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
414 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
rivastigmine patch 24 hour 4.6 mg/24 hr Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
rivastigmine patch 24 hour 9.5 mg/24 hr Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
rivastigmine patch 24 hour 13.3 mg/24 hour
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
rivastigmine tartrate
capsule 3 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
rivastigmine tartrate
capsule 6 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
rivastigmine tartrate
capsule 1.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
rivastigmine tartrate
capsule 4.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
rizatriptan tablet,disintegrating
10 mg Generic-2 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
415 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
rizatriptan tablet,disintegrating
5 mg Generic-2 24 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
rizatriptan tablet 5 mg Generic-2 24 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
rizatriptan tablet 10 mg Generic-2 12 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Rocaltrol solution 1 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Rocaltrol capsule 0.25 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Rocaltrol capsule 0.5 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
ropinirole tablet 3 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet 0.25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet 0.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
416 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ropinirole tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet 4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet extended release 24 hr
8 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet extended release 24 hr
2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet extended release 24 hr
4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
ropinirole tablet extended release 24 hr
12 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
417 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ropinirole tablet extended release 24 hr
6 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
rosuvastatin tablet 40 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
rosuvastatin tablet 5 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
rosuvastatin tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
rosuvastatin tablet 20 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Rotarix suspension for reconstitution
10exp6 CCID50/mL
NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
RotaTeq Vaccine
suspension 2 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
418 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Roweepra tablet 500 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Roxicodone tablet 15 mg
NonPrefBrand-4
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Roxicodone tablet 30 mg
NonPrefBrand-4
138 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Roxicodone tablet 5 mg
NonPrefBrand-4
186 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Rozerem tablet 8 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Ruconest recon soln 2,100 unitSpecialty-5 YES RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Sabril tablet 500 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Sabril powder in packet
500 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
419 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Safyral tablet3-0.03-0.451 mg (21/7)
NonPrefBrand-4 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Saizen recon soln 5 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Saizen recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Saizen click.easy
cartridge 8.8 mg/1.5 mL (Fnl)
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Samsca tablet 15 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Samsca tablet 30 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Sancuso patch weekly 3.1 mg/24 hour NonPrefBrand-4 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Sandimmune capsule 100 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandimmune capsule 25 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
420 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sandimmune solution 250 mg/5 mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandimmune solution 100 mg/mL PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandostatin solution 100 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandostatin solution 200 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandostatin solution 1,000 mcg/mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandostatin LAR Depot
suspension,extended rel recon
20 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandostatin LAR Depot
suspension,extended rel recon
30 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sandostatin LAR Depot
suspension,extended rel recon
10 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
421 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Santyl ointment 250 unit/gram
PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ENZYMES
Saphris (black cherry)
tablet 10 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Saphris (black cherry)
tablet 5 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Saphris (black cherry) tablet 2.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Savaysa tablet 15 mg
NonPrefBrand-4
31 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Savaysa tablet 30 mg
NonPrefBrand-4
31 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Savaysa tablet 60 mg
NonPrefBrand-4
31 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Savella tablet 100 mg NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
422 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Savella tablet 12.5 mg NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Savella tablet 50 mg NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Savella tablet 25 mg NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Savella tablets,dose pack
12.5 mg (5)-25 mg(8)-50 mg(42)
NonPrefBrand-4 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
selegiline HCl
capsule 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
selegiline HCl
tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
selenium sulfide
lotion 2.5 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Selzentry tablet 150 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Selzentry tablet 300 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
423 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Semprex-D capsule 8-60 mg
NonPrefBrand-4 NO
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
Sensipar tablet 30 mg PrefBrand-3 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Sensipar tablet 60 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Sensipar tablet 90 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Serevent Diskus
blister with device
50 mcg/dose NonPrefBrand-4 60 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Seroquel XR tablet extended release 24 hr
200 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Seroquel XR tablet extended release 24 hr
300 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Seroquel XR tablet extended release 24 hr
400 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Seroquel XR tablet extended release 24 hr
50 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Seroquel XR tablet extended release 24 hr
150 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
424 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Serostim recon soln 4 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Serostim recon soln 5 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Serostim recon soln 6 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
sertraline tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
sertraline tablet 25 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
sertraline tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
sertraline concentrate 20 mg/mL PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Setlakintablets,dose pack,3 month 0.15-30 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
425 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Signifor solution 0.3 mg/mL (1 mL)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Signifor solution 0.6 mg/mL (1 mL)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Signifor solution 0.9 mg/mL (1 mL)
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Signifor LAR
suspension for reconstitution 20 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Signifor LAR
suspension for reconstitution 40 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Signifor LAR
suspension for reconstitution 60 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
sildenafil tablet 20 mg PrefBrand-3 93 31 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
sildenafil solution 10 mg/12.5 mL Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Silenor tablet 3 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
426 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Silenor tablet 6 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
silver sulfadiazine
cream 1 % PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
BURN THERAPY
Simbrinzadrops,suspension 1-0.2 %
PrefBrand-3 NOOPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
Simponi syringe 50 mg/0.5 mL Specialty-5 0.5 28 YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Simponi syringe 100 mg/mL
Specialty-5
1 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Simponi pen injector 50 mg/0.5 mL
Specialty-5
0.5 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Simponi pen injector 100 mg/mL
Specialty-5
1 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Simponi ARIA solution 12.5 mg/mL
Specialty-5
16 28
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
427 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Simulect recon soln 20 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
simvastatin tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
simvastatin tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
simvastatin tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
simvastatin tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
simvastatin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
sirolimus tablet 1 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
sirolimus tablet 2 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
428 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
sirolimus tablet 0.5 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sirturo tablet 100 mg
Specialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Sivextro tablet 200 mg
Specialty-5
6 31
NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Sivextro recon soln 200 mg
Specialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
sodium chloride
parenteral solution
2.5 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
sodium chloride
solution 0.9 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
sodium chloride 0.45 %
parenteral solution
0.45 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
sodium chloride 0.9 %
parenteral solution
0.9 % Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
sodium chloride 3 %
parenteral solution
3 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
5T Medicare Part D: 5 Tier Closed Formulary
429 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
sodium chloride 5 %
parenteral solution
5 % Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
sodium fluoride
tablet 1 mg fluoride (2.2 mg)
Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
VITAMINS / HEMATINICS
sodium lactate
solution 5 mEq/mL Generic-2 NO VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
sodium phenylbutyrate
powder 0.94 gram/gram Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
sodium polystyrene (sorb free)
suspension 15 gram/60 mL Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Soltamox solution 10 mg/5 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Solu-Cortef (PF)
recon soln 100 mg/2 mL NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Solu-Cortef (PF) recon soln 250 mg/2 mL
NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Solu-Medrol recon soln 2 gramNonPrefBrand-4 NO ENDOCRINE/DIA
BETESADRENAL HORMONES
Solu-Medrol (PF)
recon soln 500 mg/4 mL NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Solu-Medrol (PF)
recon soln 40 mg/mL NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Solu-Medrol (PF)
recon soln 125 mg/2 mL NonPrefBrand-4 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
430 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Somatuline Depot
syringe 60 mg/0.2 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Somatuline Depot
syringe 120 mg/0.5 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Somatuline Depot
syringe 90 mg/0.3 mL Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Somavert recon soln 10 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Somavert recon soln 15 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Somavert recon soln 20 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Somavert recon soln 30 mgSpecialty-5 NO ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Somavert recon soln 25 mgSpecialty-5 NO ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Soriatane capsule 10 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Soriatane capsule 25 mg NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
5T Medicare Part D: 5 Tier Closed Formulary
431 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Soriatane capsule 17.5 mg Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Sorine tablet 120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Sorine tablet 160 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Sorine tablet 240 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Sorine tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
sotalol tablet 160 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
sotalol tablet 240 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
sotalol tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
432 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sotalol AF tablet 120 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Sotylize solution 5 mg/mL
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Sovaldi tablet 400 mgSpecialty-5
28 28YES ANTI -
INFECTIVES ANTIVIRALSSpiriva Respimat mist 2.5 mcg/actuation
PrefBrand-34 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Spiriva Respimat mist
1.25 mcg/actuation
PrefBrand-34 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Spiriva with HandiHaler
capsule, w/inhalation device
18 mcg PrefBrand-3 30 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
spironolactone
tablet 100 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
spironolactone
tablet 50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
spironolactone
tablet 25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
spironolacton-hydrochlorothiaz
tablet 25-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
433 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sporanox solution 10 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Sprintec (28) tablet 0.25-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Spritamtablet for suspension 1,000 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Spritamtablet for suspension 250 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Spritamtablet for suspension 500 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Spritamtablet for suspension 750 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Sprycel tablet 20 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sprycel tablet 50 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
434 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sprycel tablet 70 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sprycel tablet 100 mg Specialty-5 31 31 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sprycel tablet 140 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sprycel tablet 80 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sronyx tablet 0.1-20 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
SSD cream 1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
BURN THERAPY
stavudine capsule 15 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
stavudine capsule 20 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
stavudine capsule 30 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
stavudine capsule 40 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
stavudine recon soln 1 mg/mL Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
435 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Stelara syringe 45 mg/0.5 mL Specialty-5 0.5 28 YES DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Stelara syringe 90 mg/mL Specialty-5 1 28 YES DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Stimate spray,non-aerosol
150 mcg/spray (0.1 mL)
PrefBrand-3 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Stiolto Respimat mist
2.5-2.5 mcg/actuation
PrefBrand-34 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Stivarga tablet 40 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Strattera capsule 10 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Strattera capsule 18 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Strattera capsule 25 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Strattera capsule 40 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
436 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Strattera capsule 60 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Strattera capsule 100 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Strattera capsule 80 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Strensiq solution 40 mg/mLSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Strensiq solution 100 mg/mLSpecialty-5 YES ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
streptomycin recon soln 1 gram PrefBrand-3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Striant mucoadhesive System ER 12 hr
30 mg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Stribild tablet150-150-200-300 mg
Specialty-5 NO ANTI - INFECTIVES ANTIVIRALS
Striverdi Respimat mist 2.5 mcg/actuation
NonPrefBrand-44 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Suboxone film 2-0.5 mg
PrefBrand-3
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
437 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Suboxone film 8-2 mg
PrefBrand-3
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Suboxone film 4-1 mg
PrefBrand-3
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Suboxone film 12-3 mg
PrefBrand-3
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Subsysspray,non-aerosol 100 mcg/spray
Specialty-5
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Subsysspray,non-aerosol 200 mcg/spray
Specialty-5
124 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Subsysspray,non-aerosol 400 mcg/spray
Specialty-5
86 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Subsysspray,non-aerosol 600 mcg/spray
Specialty-5
57 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Subsysspray,non-aerosol 800 mcg/spray
Specialty-5
43 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
438 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sucraid solution 8,500 unit/mL Specialty-5 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
sucralfate tablet 1 gram Generic-2 NO GASTROENTEROLOGY
ULCER THERAPY
sulfacetamide sodium ointment 10 %
PrefGen-1 NO OPHTHALMOLOGY SULFONAMIDES
sulfacetamide sodium drops 10 %
Generic-2 NO OPHTHALMOLOGY SULFONAMIDES
sulfacetamide sodium (acne) suspension 10 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
sulfacetamide-prednisolone drops
10 %-0.23 % (0.25 %)
Generic-2 NO
OPHTHALMOLOGY
STEROID-SULFONAMIDE COMBINATIONS
sulfadiazine tablet 500 mg Generic-2 NO ANTI - INFECTIVES
SULFA'S / RELATED AGENTS
sulfamethoxazole-trimethoprim
tablet 400-80 mg PrefGen-1 NO ANTI - INFECTIVES
SULFA'S / RELATED AGENTS
sulfamethoxazole-trimethoprim
tablet 800-160 mg PrefGen-1 NO ANTI - INFECTIVES
SULFA'S / RELATED AGENTS
sulfamethoxazole-trimethoprim
suspension 200-40 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
SULFA'S / RELATED AGENTS
sulfamethoxazole-trimethoprim
solution 400-80 mg/5 mL PrefGen-1 NO ANTI - INFECTIVES
SULFA'S / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
439 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sulfamylon cream 85 mg/g PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIBACTERIALS
sulfasalazine tablet 500 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
sulfasalazine tablet,delayed release (DR/EC)
500 mg Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
sulindac tablet 150 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
sulindac tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
sumatriptan spray,non-aerosol
5 mg/actuation Generic-2 32 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan spray,non-aerosol
20 mg/actuation Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan succinate
tablet 100 mg Generic-2 9 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
440 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
sumatriptan succinate
tablet 50 mg Generic-2 18 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan succinate
solution 6 mg/0.5 mL Generic-2 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan succinate
tablet 25 mg Generic-2 36 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan succinate
syringe 6 mg/0.5 mL Generic-2 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan succinate pen injector 6 mg/0.5 mL
Generic-2
4 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan succinate cartridge 6 mg/0.5 mL
Generic-2
4 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
sumatriptan succinate cartridge 4 mg/0.5 mL
Generic-2
6 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Sumavel DosePro
needle-free injector
6 mg/0.5 mL NonPrefBrand-4 4 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
441 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sumavel DosePro
needle-free injector 4 mg/0.5 mL
NonPrefBrand-4
6 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Suprax suspension for reconstitution
100 mg/5 mL PrefBrand-3 NO ANTI - INFECTIVES
CEPHALOSPORINS
Suprax suspension for reconstitution
200 mg/5 mL PrefBrand-3 NO ANTI - INFECTIVES
CEPHALOSPORINS
Suprax capsule 400 mgPrefBrand-3 NO ANTI -
INFECTIVESCEPHALOSPORINS
Supraxsuspension for reconstitution 500 mg/5 mL
PrefBrand-3 NO ANTI - INFECTIVES
CEPHALOSPORINS
Suprep Bowel Prep Kit recon soln
17.5-3.13-1.6 gram
PrefBrand-3 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Surmontil capsule 50 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Surmontil capsule 100 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Surmontil capsule 25 mg NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Sustiva capsule 200 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Sustiva capsule 50 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
442 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sustiva tablet 600 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Sutent capsule 12.5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sutent capsule 25 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sutent capsule 50 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sutent capsule 37.5 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Sylatron kit 300 mcg
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Sylatron kit 600 mcg
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Sylatron kit 200 mcg
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
443 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Sylvant recon soln 100 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
SymbicortHFA aerosol inhaler
80-4.5 mcg/actuation
PrefBrand-310.2 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
SymbicortHFA aerosol inhaler
160-4.5 mcg/actuation
PrefBrand-310.2 30
NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
SymlinPen 120
pen injector 2,700 mcg/2.7 mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
SymlinPen 60
pen injector 1,500 mcg/1.5 mL PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Synagis solution 50 mg/0.5 mLSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
Synalgos-DC capsule 16-356.4-30 mg
NonPrefBrand-4
300 30
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Synarel spray,non-aerosol
2 mg/mL Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Synercid recon soln 500 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Synribo recon soln 3.5 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Synthroid tablet 25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 75 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
444 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Synthroid tablet 112 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 125 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 150 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 175 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 300 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 50 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 100 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 200 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 137 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Synthroid tablet 88 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Syprine capsule 250 mg PrefBrand-3 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Tabloid tablet 40 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Taclonex suspension 0.005-0.064 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
5T Medicare Part D: 5 Tier Closed Formulary
445 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
tacrolimus capsule 1 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
tacrolimus capsule 5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
tacrolimus ointment 0.03 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
tacrolimus capsule 0.5 mg Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
tacrolimus ointment 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Tafinlar capsule 50 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tafinlar capsule 75 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tagrisso tablet 40 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
446 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tagrisso tablet 80 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Taltz Autoinjector (3 Pack) auto-injector 80 mg/mL
Specialty-5
1 28
YESDERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Taltz Syringe syringe 80 mg/mL
Specialty-5
1 28
YESDERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
Tamiflu capsule 75 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Tamiflu capsule 30 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Tamiflu capsule 45 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Tamiflususpension for reconstitution 6 mg/mL
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
tamoxifen tablet 10 mg PrefGen-1 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
tamoxifen tablet 20 mg PrefGen-1 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
tamsulosin capsule,extended release 24hr
0.4 mg PrefGen-1 NO UROLOGICALS BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
447 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tarceva tablet 100 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tarceva tablet 150 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tarceva tablet 25 mg
Specialty-5
31 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Targretin capsule 75 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Targretin gel 1 % Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tasigna capsule 200 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tasigna capsule 150 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tasmar tablet 100 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
448 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
TAZICEF recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES
CEPHALOSPORINS
TAZICEF recon soln 1 gramNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
TAZICEF recon soln 2 gramNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
Tazorac gel 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Tazorac gel 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Tazorac cream 0.05 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Tazorac cream 0.1 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Taztia XT capsule, extended release
120 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Taztia XT capsule, extended release
180 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Taztia XT capsule, extended release
240 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
449 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Taztia XT capsule, extended release
300 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Taztia XT capsule, extended release
360 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tecentriq solution1,200 mg/20 mL (60 mg/mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tecfideracapsule,delayed release(DR/EC) 120 mg
Specialty-5
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Tecfideracapsule,delayed release(DR/EC) 240 mg
Specialty-5
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Tecfideracapsule,delayed release(DR/EC)
120 mg (14)- 240 mg (46)
Specialty-5
120 365
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Technivie tablet 12.5-75-50 mgSpecialty-5
56 28YES ANTI -
INFECTIVES ANTIVIRALS
Teflaro recon soln 400 mgNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
Teflaro recon soln 600 mgNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
5T Medicare Part D: 5 Tier Closed Formulary
450 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tegretol suspension 100 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Tegretol tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Tegretol XR tablet extended release 12 hr
100 mg PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Tegretol XR tablet extended release 12 hr
200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Tegretol XR tablet extended release 12 hr
400 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Tekturna tablet 150 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tekturna tablet 300 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tekturna HCT tablet 150-12.5 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
451 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tekturna HCT tablet 150-25 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tekturna HCT tablet 300-12.5 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tekturna HCT tablet 300-25 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan tablet 40 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan tablet 80 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan-amlodipine
tablet 40-10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan-amlodipine
tablet 80-10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
452 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
telmisartan-amlodipine
tablet 40-5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan-amlodipine
tablet 80-5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan-hydrochlorothiazid
tablet 40-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan-hydrochlorothiazid
tablet 80-12.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
telmisartan-hydrochlorothiazid
tablet 80-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
temazepam capsule 15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
temazepam capsule 30 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
temazepam capsule 7.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
453 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
temazepam capsule 22.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Tencon tablet 50-325 mg
Generic-2
372 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Tenivac (PF) syringe 5-2 Lf unit/0.5 mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
terazosin capsule 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
terazosin capsule 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
terazosin capsule 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
terazosin capsule 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
terbinafine HCl
tablet 250 mg PrefGen-1 90 180 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
terbutaline solution 1 mg/mL Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
454 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
terbutaline tablet 2.5 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
terbutaline tablet 5 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
terconazole suppository 80 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
terconazole cream 0.4 % Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
terconazole cream 0.8 % Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Testim gel50 mg/5 gram (1 %)
NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
testosteronegel in metered-dose pump
1.25 gram/ actuation (1 %)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
testosteronegel in metered-dose pump
10 mg/0.5 gram /actuation
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
testosterone gel in packet1 % (25 mg/2.5gram)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
testosterone gel in packet1 % (50 mg/5 gram)
PrefBrand-3 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
testosterone cypionate
oil 100 mg/mL Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
testosterone cypionate
oil 200 mg/mL Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
testosterone enanthate
oil 200 mg/mL Generic-2 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
tetanus,diphtheria tox ped(PF) suspension
5-25 Lf unit/0.5 mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
455 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
tetanus-diphtheria toxoids-Td
suspension 2-2 Lf unit/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
tetrabenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
tetrabenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
tetracycline capsule 250 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
tetracycline capsule 500 mg Generic-2 NO ANTI - INFECTIVES
TETRACYCLINES
Thalomid capsule 50 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Thalomid capsule 100 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Thalomid capsule 200 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Thalomid capsule 150 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
456 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Theo-24 capsule,extended release 24hr
100 mg NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Theo-24 capsule,extended release 24hr
300 mg NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Theo-24 capsule,extended release 24hr
200 mg NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Theo-24 capsule,extended release 24hr
400 mg NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
theophylline tablet extended release 12 hr
100 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
theophylline tablet extended release
400 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
theophylline solution 80 mg/15 mL Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
theophylline tablet extended release 12 hr
450 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
theophylline tablet extended release 12 hr
300 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
theophylline tablet extended release 12 hr
200 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
theophylline tablet extended release
600 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Thiola tablet 100 mg NonPrefBrand-4 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
thioridazine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
thioridazine tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
457 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
thioridazine tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
thioridazine tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
thiotepa recon soln 15 mg
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
thiothixene capsule 10 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
thiothixene capsule 1 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
thiothixene capsule 2 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
thiothixene capsule 5 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Thymoglobulin
recon soln 25 mg NonPrefBrand-4 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
458 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Thyrolar-1 tablet 12.5-50 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Thyrolar-1/2 tablet 6.25-25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Thyrolar-1/4 tablet 3.1-12.5 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Thyrolar-2 tablet 25-100 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Thyrolar-3 tablet 37.5-150 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
tiagabine tablet 2 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
tiagabine tablet 4 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Tikosyn capsule 125 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Tikosyn capsule 250 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
Tikosyn capsule 500 mcg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
timolol maleate
drops 0.25 % PrefGen-1 NO OPHTHALMOLOGY
BETA-BLOCKERS
5T Medicare Part D: 5 Tier Closed Formulary
459 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
timolol maleate
tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
timolol maleate
tablet 20 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
timolol maleate
tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
timolol maleate
gel forming solution
0.25 % Generic-2 NO OPHTHALMOLOGY
BETA-BLOCKERS
timolol maleate
gel forming solution
0.5 % Generic-2 NO OPHTHALMOLOGY
BETA-BLOCKERS
timolol maleate
drops 0.5 % PrefGen-1 NO OPHTHALMOLOGY
BETA-BLOCKERS
Timoptic Ocudose (PF)
dropperette 0.25 % NonPrefBrand-4 NO OPHTHALMOLOGY
BETA-BLOCKERS
Timoptic Ocudose (PF)
dropperette 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY
BETA-BLOCKERS
tinidazole tablet 500 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
tinidazole tablet 250 mg Generic-2 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
5T Medicare Part D: 5 Tier Closed Formulary
460 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tirosint capsule 112 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 137 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 75 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 88 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 100 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 125 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 150 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 25 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 50 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tirosint capsule 13 mcg NonPrefBrand-4 NO ENDOCRINE/DIABETES
THYROID HORMONES
Tivicay tablet 50 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
Tivicay tablet 10 mgNonPrefBrand-4 NO ANTI -
INFECTIVES ANTIVIRALS
Tivicay tablet 25 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALStizanidine tablet 2 mg Generic-2 NO AUTONOMIC /
CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
461 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
tizanidine tablet 4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
tizanidine capsule 6 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
tizanidine capsule 4 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
tizanidine capsule 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
Tobi solution for nebulization
300 mg/5 mL NonPrefBrand-4 YES ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Tobi Podhaler
capsule, w/inhalation device 28 mg
PrefBrand-3 YES
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
TobraDex ointment 0.3-0.1 % PrefBrand-3 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
Tobradex STdrops,suspension 0.3-0.05 %
PrefBrand-3 NO
OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
5T Medicare Part D: 5 Tier Closed Formulary
462 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
tobramycin drops 0.3 % PrefGen-1 NO OPHTHALMOLOGY
ANTIBIOTICS
tobramycin in 0.225 % NaCl
solution for nebulization
300 mg/5 mL Specialty-5 YES ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
tobramycin sulfate
solution 10 mg/mL PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
tobramycin sulfate
solution 40 mg/mL PrefGen-1 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
tobramycin-dexamethasone
drops,suspension
0.3-0.1 % Generic-2 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
Tobrex ointment 0.3 % PrefBrand-3 NO OPHTHALMOLOGY
ANTIBIOTICS
Tolak cream 4 %
NonPrefBrand-4 NODERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
tolazamide tablet 250 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
tolazamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
tolbutamide tablet 500 mg PrefGen-1 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
463 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
tolcapone tablet 100 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
tolmetin capsule 400 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tolmetin tablet 600 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tolterodine tablet 1 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
tolterodine capsule,extended release 24hr
2 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
tolterodine capsule,extended release 24hr
4 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
tolterodine tablet 2 mg PrefBrand-3 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
Topamax tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
464 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Topamax tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Topamax tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Topamax tablet 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Topamax capsule, sprinkle
15 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Topamax capsule, sprinkle
25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramate tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramate tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramate tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
465 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
topiramate tablet 200 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramate capsule, sprinkle
25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramate capsule, sprinkle
15 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramatecapsule,sprinkle,ER 24hr 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramatecapsule,sprinkle,ER 24hr 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramatecapsule,sprinkle,ER 24hr 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramatecapsule,sprinkle,ER 24hr 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
topiramatecapsule,sprinkle,ER 24hr 150 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
466 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Toposar solution 20 mg/mL Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
topotecan recon soln 4 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Torisel recon soln 30 mg/3 mL (10 mg/mL) (first)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
torsemide tablet 10 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
torsemide tablet 100 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
torsemide tablet 20 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
torsemide tablet 5 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Toujeo SoloStar insulin pen
300 unit/mL (1.5 mL)
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
467 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Toviaz tablet extended release 24 hr
4 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
Toviaz tablet extended release 24 hr
8 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
Tracleer tablet 62.5 mg Specialty-5 62 31 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Tracleer tablet 125 mg Specialty-5 62 31 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Tradjenta tablet 5 mgPrefBrand-3 NO ENDOCRINE/DIA
BETESDIABETES THERAPY
tramadol tablet extended release 24 hr
100 mg Generic-2 30 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tramadol tablet extended release 24 hr
200 mg Generic-2 30 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tramadol tablet, ER multiphase 24 hr
300 mg Generic-2 30 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tramadol tablet 50 mg PrefGen-1 240 30 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
468 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
tramadol
capsule,ER biphase 24 hr 25-75 100 mg
NonPrefBrand-4
30 30
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tramadol
capsule,ER biphase 24 hr 25-75 200 mg
NonPrefBrand-4
30 30
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tramadol
capsule,ER biphase 24 hr 17-83 300 mg
NonPrefBrand-4
30 30
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
tramadol-acetaminophen
tablet 37.5-325 mg Generic-2 372 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
trandolapril tablet 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
trandolapril tablet 4 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
trandolapril tablet 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
trandolapril-verapamil
tablet, IR - ER, biphasic 24hr
1-240 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
469 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
trandolapril-verapamil
tablet, IR - ER, biphasic 24hr
2-180 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
trandolapril-verapamil
tablet, IR - ER, biphasic 24hr
2-240 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
trandolapril-verapamil
tablet, IR - ER, biphasic 24hr
4-240 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
tranexamic acid
solution 1,000 mg/10 mL (100 mg/mL)
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
tranexamic acid
tablet 650 mg Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Transderm-Scop
patch 3 day 1.5 mg (1 mg over 3 days)
NonPrefBrand-4 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
tranylcypromine
tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Travasol 10 %
parenteral solution
10 % Generic-2 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Travatan Z drops 0.004 % PrefBrand-3 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
470 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
travoprost (benzalkonium)
drops 0.004 % Generic-2 NO OPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
trazodone tablet 150 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trazodone tablet 300 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trazodone tablet 100 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trazodone tablet 50 mg PrefGen-1 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Treanda recon soln 100 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Trecator tablet 250 mg NonPrefBrand-4 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Trelstar suspension for reconstitution
22.5 mg PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
471 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Trelstar syringe 3.75 mg/2 mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Trelstar syringe 11.25 mg/2 mL PrefBrand-3 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tresiba FlexTouch U-100 insulin pen
100 unit/mL (3 mL)
NonPrefBrand-4 NOENDOCRINE/DIABETES
DIABETES THERAPY
Tresiba FlexTouch U-200 insulin pen
200 unit/mL (3 mL)
NonPrefBrand-4 NOENDOCRINE/DIABETES
DIABETES THERAPY
tretinoin cream 0.025 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
tretinoin cream 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
tretinoin cream 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
tretinoin gel 0.05 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
tretinoin gel 0.01 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
tretinoin gel 0.025 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
5T Medicare Part D: 5 Tier Closed Formulary
472 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
tretinoin (chemotherapy)
capsule 10 mg Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
tretinoin microspheres
gel with pump 0.1 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
tretinoin microspheres
gel with pump 0.04 % Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Trexall tablet 5 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Trexall tablet 10 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Trexall tablet 7.5 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Trexall tablet 15 mg PrefBrand-3 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Treximet tablet 85-500 mg NonPrefBrand-4 10 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
triamcinolone acetonide cream 0.1 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
5T Medicare Part D: 5 Tier Closed Formulary
473 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
triamcinolone acetonide ointment 0.025 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamcinolone acetonide ointment 0.1 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamcinolone acetonide ointment 0.5 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamcinolone acetonide cream 0.025 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamcinolone acetonide cream 0.5 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamcinolone acetonide paste 0.1 %
Generic-2 NO EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
triamcinolone acetonide aerosol 0.147 mg/gram
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamcinolone acetonide lotion 0.025 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamcinolone acetonide lotion 0.1 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triamterene-hydrochlorothiazid
capsule 50-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
474 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
triamterene-hydrochlorothiazid
capsule 37.5-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
triamterene-hydrochlorothiazid
tablet 37.5-25 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
triamterene-hydrochlorothiazid
tablet 75-50 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Trianex ointment 0.05 %
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
triazolam tablet 0.125 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
triazolam tablet 0.25 mg Generic-2 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Tribenzor tablet 20-5-12.5 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tribenzor tablet 40-10-12.5 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
475 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tribenzor tablet 40-10-25 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tribenzor tablet 40-5-12.5 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Tribenzor tablet 40-5-25 mg
PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Triderm cream 0.1 %
PrefGen-1 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL CORTICOSTEROIDS
trifluoperazine
tablet 1 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trifluoperazine
tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trifluoperazine
tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trifluoperazine
tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trifluridine drops 1 % Generic-2 NO OPHTHALMOLOGY
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
476 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
trihexyphenidyl
tablet 2 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
trihexyphenidyl
elixir 0.4 mg/mL Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
trihexyphenidyl
tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
Tri-Legest Fe tablet
1-20(5)/1-30(7) /1mg-35mcg (9)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Trileptal tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Trileptal tablet 300 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Trileptal tablet 600 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Trileptal suspension 300 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
477 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tri-Lo-Estarylla tablet
0.18/0.215/0.25 mg-25 mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Tri-Lo-Sprintec
tablet 0.18/0.215/0.25 mg-25 mcg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
TriLyte With Flavor Packets
recon soln 420 gram Generic-2 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
trimethoprim tablet 100 mg Generic-2 NO ANTI - INFECTIVES
URINARY TRACT AGENTS
trimipramine capsule 100 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trimipramine capsule 25 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
trimipramine capsule 50 mg PrefBrand-3 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
TriNessa (28)
tablet 0.18/0.215/0.25 mg-35 mcg (28)
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
478 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Trintellix tablet 10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Trintellix tablet 20 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Trintellix tablet 5 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Tri-Previfem (28)
tablet 0.18/0.215/0.25 mg-35 mcg (28)
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Trisenox solution 10 mg/10 mL NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tri-Sprintec (28)
tablet 0.18/0.215/0.25 mg-35 mcg (28)
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Triumeq tablet 600-50-300 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALSTrivora (28) tablet 50-30 (6)/75-40
(5)/125-30(10)Generic-2 NO OBSTETRICS /
GYNECOLOGYORAL CONTRACEPTIVES / RELATED AGENTS
Trizivir tablet 300-150-300 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
479 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Trokendi XRcapsule,extended release 24hr 50 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Trokendi XRcapsule,extended release 24hr 25 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Trokendi XRcapsule,extended release 24hr 100 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Trokendi XRcapsule,extended release 24hr 200 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
TrophAmine 10 %
parenteral solution 10 %
NonPrefBrand-4 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
Trophamine 6%
parenteral solution 6 %
PrefBrand-3 YES VITAMINS, HEMATINICS / ELECTROLYTES
MISCELLANEOUS NUTRITION PRODUCTS
trospium tablet 20 mg Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
trospium capsule,extended release 24hr
60 mg Generic-2 NO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
5T Medicare Part D: 5 Tier Closed Formulary
480 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Trumenba syringe 120 mcg/0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Truvada tablet 200-300 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Truvada tablet 100-150 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
Truvada tablet 133-200 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
Truvada tablet 167-250 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALSTwinrix (PF) suspension 720 Elisa unit -20
mcg/mLPrefBrand-3 NO IMMUNOLOGY,
VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Tybost tablet 150 mgPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALSTygacil recon soln 50 mg Specialty-5 NO ANTI -
INFECTIVESMISCELLANEOUS ANTIINFECTIVES
Tykerb tablet 250 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Tylenol-Codeine #3
tablet 300-30 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
481 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Tylenol-Codeine #4
tablet 300-60 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Typhim VI solution 25 mcg/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Typhim VI syringe 25 mcg/0.5 mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Tysabri solution 300 mg/15 mL Specialty-5 15 28 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Tyvaso solution for nebulization
1.74 mg/2.9 mL (0.6 mg/mL)
Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Tyzeka tablet 600 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Uloric tablet 40 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
Uloric tablet 80 mg PrefBrand-3 NO MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
Unithroid tablet 25 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
5T Medicare Part D: 5 Tier Closed Formulary
482 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Unithroid tablet 88 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 100 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 112 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 125 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 150 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 200 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 300 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 50 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 175 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Unithroid tablet 75 mcg PrefGen-1 NO ENDOCRINE/DIABETES
THYROID HORMONES
Uptravi tablet 1,000 mcg
Specialty-5
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Uptravi tablet 1,200 mcg
Specialty-5
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Uptravi tablet 1,400 mcg
Specialty-5
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
483 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Uptravi tablet 1,600 mcg
Specialty-5
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Uptravi tablet 200 mcg
Specialty-5
144 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Uptravi tablet 400 mcg
Specialty-5
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Uptravi tablet 600 mcg
Specialty-5
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Uptravi tablet 800 mcg
Specialty-5
62 31
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Uptravitablets,dose pack
200 mcg (140)- 800 mcg (60)
Specialty-5
200 28
YES CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
ursodiol tablet 500 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
ursodiol capsule 300 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
484 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ursodiol tablet 250 mg PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Uvadex solution 20 mcg/mL NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Vagifem tablet 10 mcg NonPrefBrand-4 NO OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
valacyclovir tablet 1 gram Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
valacyclovir tablet 500 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Valchlor gel 0.016 %
NonPrefBrand-4 YESDERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Valcyte tablet 450 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Valcyte recon soln 50 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
valganciclovir
tablet 450 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
valproate sodium solution
500 mg/5 mL (100 mg/mL)
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
valproic acid capsule 250 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
485 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
valproic acid (as sodium salt) solution 250 mg/5 mL
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
valsartan tablet 80 mg Generic-2 62 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
valsartan tablet 320 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
valsartan tablet 160 mg Generic-2 62 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
valsartan tablet 40 mg Generic-2 62 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
valsartan-hydrochlorothiazide
tablet 80-12.5 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
valsartan-hydrochlorothiazide
tablet 160-12.5 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
valsartan-hydrochlorothiazide
tablet 160-25 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
486 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
valsartan-hydrochlorothiazide
tablet 320-12.5 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
valsartan-hydrochlorothiazide
tablet 320-25 mg Generic-2 31 31 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Vancocin capsule 125 mg Specialty-5 NO ANTI - INFECTIVES
VANCOMYCIN
Vancocin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES
VANCOMYCIN
vancomycin recon soln 10 gram Generic-2 NO ANTI - INFECTIVES
VANCOMYCIN
vancomycin capsule 125 mg NonPrefBrand-4 NO ANTI - INFECTIVES
VANCOMYCIN
vancomycin capsule 250 mg Specialty-5 NO ANTI - INFECTIVES
VANCOMYCIN
vancomycin recon soln 1,000 mg Generic-2 NO ANTI - INFECTIVES
VANCOMYCIN
vancomycin recon soln 500 mg Generic-2 NO ANTI - INFECTIVES
VANCOMYCIN
Vandazole gel 0.75 % Generic-2 NO OBSTETRICS / GYNECOLOGY
MISCELLANEOUS OB/GYN
Vaqta (PF) syringe 50 unit/mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
487 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Vaqta (PF) syringe 25 unit/0.5 mL PrefBrand-3 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Varivax (PF)suspension for reconstitution 1,350 unit/0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Varizig solution 125 unit/1.2 mL
NonPrefBrand-4 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Varubi tablet 90 mg
NonPrefBrand-4 YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Vascepa capsule 1 gram
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Vecamyl tablet 2.5 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
MISCELLANEOUS CARDIOVASCULAR AGENTS
Vectibix solution100 mg/5 mL (20 mg/mL)
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
488 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Velcade recon soln 3.5 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Velivet Triphasic Regimen (28)
tablet 0.1/.125/.15-25 mg-mcg
Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Velphoro tablet,chewable 500 mg
Specialty-5 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Veltassapowder in packet 8.4 gram
NonPrefBrand-4
30 30
YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Veltassapowder in packet 16.8 gram
NonPrefBrand-4
30 30
YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Veltassapowder in packet 25.2 gram
NonPrefBrand-4
30 30
YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Venclexta tablet 100 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Venclexta tablet 10 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Venclexta tablet 50 mg
NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
489 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Venclexta Starting Pack
tablets,dose pack
10 mg-50 mg- 100 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
venlafaxine tablet 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine capsule,extended release 24hr
150 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine tablet 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine capsule,extended release 24hr
37.5 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine tablet 37.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine capsule,extended release 24hr
75 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine tablet 75 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
490 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
venlafaxine tablet 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine tablet extended release 24hr
150 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine tablet extended release 24hr
225 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine tablet extended release 24hr
37.5 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
venlafaxine tablet extended release 24hr
75 mg Generic-2 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Ventavis solution for nebulization
10 mcg/mL Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Ventavis solution for nebulization
20 mcg/mL Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Ventolin HFA
HFA aerosol inhaler
90 mcg/actuation PrefBrand-3 36 30 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Veramyst spray,suspension
27.5 mcg/actuation
NonPrefBrand-4 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
verapamil capsule, 24 hr ER pellet CT
100 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
491 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
verapamil capsule, 24 hr ER pellet CT
200 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil capsule, 24 hr ER pellet CT
300 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil capsule,ext rel. pellets 24 hr
120 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil capsule,ext rel. pellets 24 hr
180 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil capsule,ext rel. pellets 24 hr
240 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil capsule,ext rel. pellets 24 hr
360 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil tablet extended release
180 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil tablet extended release
240 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
492 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
verapamil tablet extended release
120 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil tablet 120 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil tablet 80 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil tablet 40 mg Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
verapamil solution 2.5 mg/mL
Generic-2 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIHYPERTENSIVE THERAPY
Veregen ointment 15 % NonPrefBrand-4 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Veripred 20 solution 20 mg/5 mL (4 mg/mL)
Generic-2 NO ENDOCRINE/DIABETES
ADRENAL HORMONES
Versacloz suspension 50 mg/mL
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
493 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Vesicare tablet 10 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
Vesicare tablet 5 mg NonPrefBrand-4 31 31 YES UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS
Vestura (28) tablet 3-0.02 mg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Vfend tablet 50 mg Specialty-5 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Vfend tablet 200 mg Specialty-5 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Vfend suspension for reconstitution
200 mg/5 mL (40 mg/mL)
Specialty-5 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Viberzi tablet 75 mg
Specialty-5
62 31
YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Viberzi tablet 100 mg
Specialty-5
62 31
YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Vicodin tablet 5-300 mg
Generic-2
403 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
494 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Vicodin ES tablet 7.5-300 mg
Generic-2
403 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Vicodin HP tablet 10-300 mg
Generic-2
403 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Victoza 3-Pak
pen injector 0.6 mg/0.1 mL (18 mg/3 mL)
PrefBrand-3 9 30 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Vidaza recon soln 100 mg Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Videx 2 gram Pediatric
recon soln 10 mg/mL (Final) PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Videx EC capsule,delayed release(DR/EC)
125 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Videx EC capsule,delayed release(DR/EC)
200 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Videx EC capsule,delayed release(DR/EC)
400 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Videx EC capsule,delayed release(DR/EC)
250 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
495 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Viekira Paktablets,dose pack
12.5 mg-75 mg -50 mg/250 mg
Specialty-5112 28
YES ANTI - INFECTIVES ANTIVIRALS
Vienva tablet 0.1-20 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Vigamox drops 0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY
ANTIBIOTICS
Viibryd tablet 10 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Viibryd tablet 20 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Viibryd tablet 40 mg
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Viibrydtablets,dose pack
10 mg (7)- 20 mg (23)
NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vimovo tablet,IR,delayed rel,biphasic
375-20 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Vimovo tablet,IR,delayed rel,biphasic
500-20 mg NonPrefBrand-4 62 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
496 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Vimpat solution 200 mg/20 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Vimpat tablet 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Vimpat tablet 150 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Vimpat tablet 200 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Vimpat tablet 50 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Vimpat solution 10 mg/mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
vinblastine solution 1 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Vincasar PFS
solution 1 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
497 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
vincristine solution 1 mg/mL Generic-2 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
vinorelbine solution 50 mg/5 mL
Generic-2 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Viracept tablet 250 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Viracept tablet 625 mg Specialty-5 NO ANTI - INFECTIVES
ANTIVIRALS
Viramune suspension 50 mg/5 mL NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Viramune XR
tablet extended release 24 hr 400 mg
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Viramune XR
tablet extended release 24 hr 100 mg
NonPrefBrand-4 NO ANTI - INFECTIVES ANTIVIRALS
Virazole recon soln 6 gram NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Viread tablet 300 mg PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
Viread tablet 250 mgPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALS
Viread tablet 150 mgPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALS
Viread tablet 200 mgPrefBrand-3 NO ANTI -
INFECTIVES ANTIVIRALS
Viread powder40 mg/scoop (40 mg/gram)
PrefBrand-3 NO ANTI - INFECTIVES ANTIVIRALS
Vitekta tablet 85 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
498 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Vitekta tablet 150 mgSpecialty-5 NO ANTI -
INFECTIVES ANTIVIRALSVivitrol suspension,exte
nded rel recon380 mg NonPrefBrand-4 NO AUTONOMIC /
CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Vogelxogel in metered-dose pump
1.25 gram/ actuation (1 %)
NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Vogelxo gel50 mg/5 gram (1 %)
NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Voltaren gel 1 % NonPrefBrand-4 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
voriconazole tablet 200 mg Specialty-5 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
voriconazole tablet 50 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
voriconazole solution 200 mg Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
voriconazole suspension for reconstitution
200 mg/5 mL (40 mg/mL)
Generic-2 NO ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Votrient tablet 200 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
VPRIV recon soln 400 unit Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Vraylar capsule 1.5 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
499 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Vraylar capsule 3 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vraylar capsule 4.5 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vraylar capsule 6 mg
Specialty-5
31 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vraylarcapsule,dose pack
1.5 mg (1)- 3 mg (6)
NonPrefBrand-4
14 365
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vyfemla (28) tablet 0.4-35 mg-mcg
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Vyvanse capsule 20 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vyvanse capsule 30 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vyvanse capsule 40 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
500 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Vyvanse capsule 70 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vyvanse capsule 60 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vyvanse capsule 50 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Vyvanse capsule 10 mg
NonPrefBrand-4
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
warfarin tablet 1 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
warfarin tablet 10 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
warfarin tablet 2 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
warfarin tablet 2.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
501 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
warfarin tablet 3 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
warfarin tablet 4 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
warfarin tablet 5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
warfarin tablet 6 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
warfarin tablet 7.5 mg PrefGen-1 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
water for irrigation, sterile
solution Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
WelChol powder in packet
3.75 gram PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
WelChol tablet 625 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
502 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Wellbutrin SR
tablet extended release
100 mg NonPrefBrand-4 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Wellbutrin SR
tablet extended release
150 mg NonPrefBrand-4 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Wellbutrin SR
tablet extended release
200 mg NonPrefBrand-4 62 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Wellbutrin XL
tablet extended release 24 hr
150 mg NonPrefBrand-4 93 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Wellbutrin XL
tablet extended release 24 hr
300 mg NonPrefBrand-4 31 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xalkori capsule 200 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Xalkori capsule 250 mg
Specialty-5
62 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Xanax tablet 0.25 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
503 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Xanax tablet 0.5 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xanax tablet 1 mg NonPrefBrand-4 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xanax tablet 2 mg NonPrefBrand-4 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xanax XR tablet extended release 24 hr
3 mg NonPrefBrand-4 93 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xanax XR tablet extended release 24 hr
2 mg NonPrefBrand-4 155 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xanax XR tablet extended release 24 hr
1 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xanax XR tablet extended release 24 hr
0.5 mg NonPrefBrand-4 31 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Xarelto tablet 10 mg
PrefBrand-3
31 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
504 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Xarelto tablet 15 mg
PrefBrand-3
52 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Xarelto tablet 20 mg
PrefBrand-3
31 31
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Xareltotablets,dose pack
15 mg (42)- 20 mg (9)
PrefBrand-3
51 30
NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Xeljanz tablet 5 mg
Specialty-5
62 31
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Xeljanz XRtablet extended release 24 hr 11 mg
Specialty-5
31 31
YES MUSCULOSKELETAL / RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
Xenazine tablet 25 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Xenazine tablet 12.5 mg Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MISCELLANEOUS NEUROLOGICAL THERAPY
Xeomin recon soln 50 unit
NonPrefBrand-4 YESIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
5T Medicare Part D: 5 Tier Closed Formulary
505 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Xgeva solution120 mg/1.7 mL (70 mg/mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Xifaxan tablet 200 mg NonPrefBrand-4 9 3 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Xifaxan tablet 550 mg Specialty-5 62 31 YES ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Xigduo XRtablet, IR - ER, biphasic 24hr 10-1,000 mg
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Xigduo XRtablet, IR - ER, biphasic 24hr 5-500 mg
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Xigduo XRtablet, IR - ER, biphasic 24hr 5-1,000 mg
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Xigduo XRtablet, IR - ER, biphasic 24hr 10-500 mg
PrefBrand-3 NO ENDOCRINE/DIABETES
DIABETES THERAPY
Xodol 10/300
tablet 10-300 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Xodol 5/300 tablet 5-300 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Xodol 7.5/300
tablet 7.5-300 mg NonPrefBrand-4 403 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
506 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Xolair recon soln 150 mgSpecialty-5 NO RESPIRATORY
AND ALLERGYPULMONARY AGENTS
Xopenex solution for nebulization
0.63 mg/3 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Xopenex solution for nebulization
0.31 mg/3 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Xopenex solution for nebulization
1.25 mg/3 mL NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Xtampza ERcapsule,sprinkle,ER 12hr tmprr 9 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Xtampza ERcapsule,sprinkle,ER 12hr tmprr 13.5 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Xtampza ERcapsule,sprinkle,ER 12hr tmprr 18 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Xtampza ERcapsule,sprinkle,ER 12hr tmprr 27 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Xtampza ERcapsule,sprinkle,ER 12hr tmprr 36 mg
NonPrefBrand-4
62 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Xtandi capsule 40 mg
Specialty-5
124 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
507 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Xyrem solution 500 mg/mL Specialty-5 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Yervoy solution50 mg/10 mL (5 mg/mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
YF-Vax (PF)suspension for reconstitution
10 exp4.74 unit/0.5 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
zafirlukast tablet 20 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
zafirlukast tablet 10 mg Generic-2 NO RESPIRATORY AND ALLERGY
PULMONARY AGENTS
zaleplon capsule 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
zaleplon capsule 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zaltrap solution100 mg/4 mL (25 mg/mL)
Specialty-5 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zamicet solution 10-325 mg/15 mL Generic-2 5723 31 YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
508 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zanosar recon soln 1 gram NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zarontin capsule 250 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Zarontin solution 250 mg/5 mL NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Zarxio syringe 300 mcg/0.5 mL
Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Zarxio syringe 480 mcg/0.8 mL
Specialty-5 NO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Zavesca capsule 100 mg Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Zebutal capsule 50-325-40 mg
Generic-2
372 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Zelapar tablet,disintegrating
1.25 mg Specialty-5 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTIPARKINSONISM AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
509 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zelboraf tablet 240 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zemaira recon soln 1,000 mg Specialty-5 YES DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
Zembrace Symtouch pen injector 3 mg/0.5 mL
NonPrefBrand-4
8 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Zemplar solution 5 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Zemplar solution 2 mcg/mL NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Zemplar capsule 1 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Zemplar capsule 2 mcg NonPrefBrand-4 YES ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Zenatane capsule 30 mg
Generic-2 NO DERMATOLOGICALS/TOPICAL THERAPY
THERAPY FOR ACNE
Zenchent Fe tablet,chewable0.4mg-35mcg(21) and 75 mg (7)
Generic-2 NO
OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Zenpep capsule,delayed release(DR/EC)
10,000-34,000 -55,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
510 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zenpep capsule,delayed release(DR/EC)
15,000-51,000 -82,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zenpep capsule,delayed release(DR/EC)
20,000-68,000 -109,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zenpep capsule,delayed release(DR/EC)
5,000-17,000 -27,000 unit
PrefBrand-3 NO GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zenpepcapsule,delayed release(DR/EC)
3,000-10,000- 16,000 unit
PrefBrand-3 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zenpepcapsule,delayed release(DR/EC)
25,000-85,000- 136,000 unit
PrefBrand-3 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zenpepcapsule,delayed release(DR/EC)
40,000-136,000- 218,000 unit
PrefBrand-3 NO
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zenzedi tablet 10 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zenzedi tablet 5 mg
Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
511 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zenzedi tablet 2.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zenzedi tablet 7.5 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zenzedi tablet 15 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zenzedi tablet 20 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zenzedi tablet 30 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zepatier tablet 50-100 mgSpecialty-5
28 28YES ANTI -
INFECTIVES ANTIVIRALS
Zerbaxa recon soln 1.5 gramNonPrefBrand-4 NO ANTI -
INFECTIVESCEPHALOSPORINS
Zerit capsule 15 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Zerit capsule 20 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Zerit capsule 30 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Zerit capsule 40 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
5T Medicare Part D: 5 Tier Closed Formulary
512 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zerit recon soln 1 mg/mL NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Zetia tablet 10 mg PrefBrand-3 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
LIPID/CHOLESTEROL LOWERING AGENTS
Ziagen tablet 300 mg NonPrefBrand-4 NO ANTI - INFECTIVES
ANTIVIRALS
Ziagen solution 20 mg/mL PrefBrand-3 NO ANTI - INFECTIVES
ANTIVIRALS
zidovudine capsule 100 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
zidovudine tablet 300 mg Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
zidovudine syrup 10 mg/mL Generic-2 NO ANTI - INFECTIVES
ANTIVIRALS
Zinecard (as HCl) recon soln 250 mg
NonPrefBrand-4 NO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
Zioptan (PF) dropperette 0.0015 %
NonPrefBrand-4 NOOPHTHALMOLOGY
OTHER GLAUCOMA DRUGS
ziprasidone HCl
capsule 40 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
ziprasidone HCl
capsule 60 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
513 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
ziprasidone HCl
capsule 80 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
ziprasidone HCl
capsule 20 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zirgan gel 0.15 % NonPrefBrand-4 NO OPHTHALMOLOGY
ANTIVIRALS
Zmax suspension,extended rel recon
2 gram/60 mL NonPrefBrand-4 NO ANTI - INFECTIVES
ERYTHROMYCINS / OTHER MACROLIDES
Zofran (as hydrochloride)
tablet 4 mg Specialty-5 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zofran (as hydrochloride)
tablet 8 mg Specialty-5 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zofran (as hydrochloride)
solution 4 mg/5 mL Specialty-5 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zofran ODT tablet,disintegrating
4 mg NonPrefBrand-4 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zofran ODT tablet,disintegrating
8 mg Specialty-5 YES GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
514 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zohydro ERcapsule, oral only, ER 12hr 10 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Zohydro ERcapsule, oral only, ER 12hr 15 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Zohydro ERcapsule, oral only, ER 12hr 20 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Zohydro ERcapsule, oral only, ER 12hr 30 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Zohydro ERcapsule, oral only, ER 12hr 40 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
Zohydro ERcapsule, oral only, ER 12hr 50 mg
NonPrefBrand-4
100 31
YES AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NARCOTIC ANALGESICS
zoledronic acid
solution 4 mg/5 mL Generic-2 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
zoledronic acid-mannitol-water
solution 5 mg/100 mL Generic-2 NO DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
515 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zolinza capsule 100 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
zolmitriptan tablet 2.5 mg Generic-2 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
zolmitriptan tablet 5 mg Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
zolmitriptan tablet,disintegrating
2.5 mg Generic-2 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
zolmitriptan tablet,disintegrating
5 mg Generic-2 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
zolpidem tablet 10 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
zolpidem tablet 5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
zolpidem tablet,ext release multiphase
12.5 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
5T Medicare Part D: 5 Tier Closed Formulary
516 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
zolpidem tablet,ext release multiphase
6.25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
zolpidem tablet 1.75 mg
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
zolpidem tablet 3.5 mg
PrefBrand-3 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zomacton recon soln 10 mg
Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Zomacton recon soln 5 mg
NonPrefBrand-4 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Zometa solution 4 mg/5 mL Specialty-5 NO ENDOCRINE/DIABETES
MISCELLANEOUS HORMONES
Zometa solution 4 mg/100 mLSpecialty-5 NO ENDOCRINE/DIA
BETESMISCELLANEOUS HORMONES
Zomig tablet 2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Zomig tablet 5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
5T Medicare Part D: 5 Tier Closed Formulary
517 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zomig spray,non-aerosol
5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Zomigspray,non-aerosol 2.5 mg
NonPrefBrand-4
16 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Zomig ZMT tablet,disintegrating
2.5 mg NonPrefBrand-4 16 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Zomig ZMT tablet,disintegrating
5 mg NonPrefBrand-4 8 31 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
MIGRAINE / CLUSTER HEADACHE THERAPY
Zonegran capsule 100 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Zonegran capsule 25 mg NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
zonisamide capsule 100 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
zonisamide capsule 25 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
5T Medicare Part D: 5 Tier Closed Formulary
518 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
zonisamide capsule 50 mg Generic-2 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
Zontivity tablet 2.08 mg
NonPrefBrand-4 NO CARDIOVASCULAR, HYPERTENSION / LIPIDS
COAGULATION THERAPY
Zorbtive recon soln 8.8 mg Specialty-5 YES IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
Zortress tablet 0.25 mg NonPrefBrand-4 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zortress tablet 0.5 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zortress tablet 0.75 mg Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zostavax (PF)
suspension for reconstitution
19,400 unit/0.65 mL
PrefBrand-3 NOIMMUNOLOGY, VACCINES / BIOTECHNOLOGY
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
Zosyn in dextrose (iso-osm) piggyback 2.25 gram/50 mL
PrefBrand-3 NOANTI - INFECTIVES PENICILLINS
5T Medicare Part D: 5 Tier Closed Formulary
519 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zosyn in dextrose (iso-osm) piggyback 3.375 gram/50 mL
PrefBrand-3 NOANTI - INFECTIVES PENICILLINS
Zovia 1/35E (28)
tablet 1-35 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Zovia 1/50E (28)
tablet 1-50 mg-mcg Generic-2 NO OBSTETRICS / GYNECOLOGY
ORAL CONTRACEPTIVES / RELATED AGENTS
Zovirax cream 5 % PrefBrand-3 NO DERMATOLOGICALS/TOPICAL THERAPY
TOPICAL ANTIVIRALS
Zubsolv tablet 1.4-0.36 mg
NonPrefBrand-4
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Zubsolv tablet 5.7-1.4 mg
NonPrefBrand-4
31 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Zubsolv tablet 11.4-2.9 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Zubsolv tablet 8.6-2.1 mg
NonPrefBrand-4
62 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
5T Medicare Part D: 5 Tier Closed Formulary
520 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zubsolv tablet 2.9-0.71 mg
NonPrefBrand-4
93 31
NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
NON-NARCOTIC ANALGESICS
Zuplenz film 8 mg
NonPrefBrand-4 YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zuplenz film 4 mg
NonPrefBrand-4 YES
GASTROENTEROLOGY
MISCELLANEOUS GASTROINTESTINAL AGENTS
Zyclara cream in packet 3.75 % Specialty-5 NO DERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Zyclara
cream in metered-dose pump 2.5 %
NonPrefBrand-4 NODERMATOLOGICALS/TOPICAL THERAPY
MISCELLANEOUS DERMATOLOGICALS
Zydelig tablet 100 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zydelig tablet 150 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zyflo tablet 600 mg NonPrefBrand-4 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
Zyflo CR tablet, ER multiphase 12 hr
600 mg Specialty-5 YES RESPIRATORY AND ALLERGY
PULMONARY AGENTS
5T Medicare Part D: 5 Tier Closed Formulary
521 Formulary ID: 17499 Version: 7 Updated: 01/2017
Drug Name Dosage Form Strength Tier LevelQuantity Limit Amount
Quantity Limit Days
Authorization
HPMS Therapeutic Category
HPMS Therapeutic Class
Zykadia capsule 150 mg
Specialty-5 YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zylet drops,suspension
0.3-0.5 % NonPrefBrand-4 NO OPHTHALMOLOGY
STEROID-ANTIBIOTIC COMBINATIONS
Zyprexa Relprevv
suspension for reconstitution 210 mg
NonPrefBrand-4 NO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
PSYCHOTHERAPEUTIC DRUGS
Zytiga tablet 250 mg
Specialty-5
124 31
YES ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
Zyvox tablet 600 mg Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Zyvox suspension for reconstitution
100 mg/5 mL Specialty-5 NO ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Zyvoxparenteral solution 600 mg/300 mL
Specialty-5 NO
ANTI - INFECTIVES
MISCELLANEOUS ANTIINFECTIVES
Medicare Part D: PA Criteria
1 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
actemra All FDA approved indications not otherwise excluded from Part D
concomitant use of Kineret, Remicade, Humira, Orencia, Enbrel, Simponi, Cimzia
Documentation of moderate to severe rheumatoid arthritis -OR- documentation of moderate to severe juvenile idiopathic rheumatoid arthritis (Actemra IV only)
12 months For Actemra SubQ, patients must have an adequate trial or intolerance to the preferred SubQ products, Enbrel and Humira, for rheumatoid arthritis. For Actemra IV, patients must have an adequate trial or intolerance to one of the preferred IV products, Remicade or Simponi Aria, for rheumatoid arthritis.
Medicare Part D: PA Criteria
2 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria1 monthneurologist
for infantile spasm
All medically accepted indications not otherwise excluded from Part D
acthar h.p. Covered for the following indications: 1. Infantile spasms (West syndrome) 2. Acute exacerbations of multiple sclerosis (MS) for patients receiving concurrent immunomodulator therapy (e.g., interferon beta, glatiramer acetate, dimethyl fumerate, fingolimod, teriflunomide) 3. Rheumatic disorders 4. Collagen diseases 5. Dermatologic diseases 6. Allergic states 7. Ophthalmic diseases 8. Respiratory diseases 9. Transfusion reaction due to serum protein
i 10
Medicare Part D: PA Criteria
3 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
reaction 10. Proteinuria in nephrotic syndrome and trial/failure or contraindication to two therapies from any of the following different classes: corticosteroids (e.g., cortisone or dexamethasone), calcineurin inhibitors (e.g, cyclosporine or tacrolimus, per DRUGDEX). 11. Diagnosis for adrenal insufficiency with trial/failure or contraindication to cosyntropin. 12. Gout and intolerance or contraindication to at least two first-line gout therapies (e g
Medicare Part D: PA Criteria
4 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
gout therapies (e.g, allopurinol, probenecid, colchicine). 13. Pediatric acquired epileptic aphasia. For covered indications 2 through 9, limited/unsatisfactory response or intolerance (i.e. severe anaphylaxis) to two corticosteroids (i.e. IV methylprednisolone, IV dexamethasone, or high dose oral steroids) must be documented.
Medicare Part D: PA Criteria
5 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
6 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
actimmune All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis
12 months Applies to new starts only
Medicare Part D: PA Criteria
7 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Diagnosis of pulmonary hypertension, substantiated by results from Doppler echocardiography and/or direct measurement of pulmonary arterial pressure, defined as a mean pulmonary arterial pressure of greater than or equal to 25 mmHg, with a pulmonary capillary wedge pressure of less than 15 mmHg -OR- diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) (WHO group 4) after surgical treatment or inoperable CTEPH.
12 monthscardiologist, pulmonologist
All FDA approved indications not otherwise excluded from Part D
adempas
Medicare Part D: PA Criteria
8 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
ADHD Drugs All FDA approved indications not otherwise excluded from Part D
Documentation of ADHD -AND- trial/failure, intolerance or contraindication to a stimulant
12 months
Medicare Part D: PA Criteria
9 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
oncologist 12 months Applies to new starts only. For renal cell carcinoma with clear cell histology additional trial/failure of cabozantinib or nivolumab per NCCN guidelines.
Documentation of advanced renal cell carcinoma and trial/failure with sunitinib or sorafenib for clear cell histology -OR- documentation of patients with progressive neuroendocrine tumors of pancreatic origin (PNET) that is unresectable, locally advanced or metastatic -OR- documentation of renal angiomyolipoma and tuberous sclerosis complex (TSC) -OR- documentation of use in postmenopausal advanced hormone
i i
All FDA approved indications not otherwise excluded from Part D
afinitor
Medicare Part D: PA Criteria
10 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
receptor-positive, HER2-negative breast cancer in combination with exemestane after failure of treatment with letrozole or anastrozole -OR- documentation of SEGA associated with tuberous sclerosis for those not a candidate for surgical resection.
Medicare Part D: PA Criteria
11 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
12 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
alecensa All FDA approved indications not otherwise excluded from Part D
Documentation of metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK) positive AND previous trial and failure or intolerance to crizotinib (Xalkori)
12 months Applies to new starts only
Medicare Part D: PA Criteria
13 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
ALPHA1-PROTEINASE INHIBITORS
Deny if less than 18 years of age
12 monthsDiagnosis of panacinar emphysema AND documentation of a decline in forced expiratory volume in 1 second (fev1) despite optimal medical therapy (bronchodilators, corticosteroids, oxygen if indicated) AND documentation of phenotype (pi*zz, pi*znull or pi*nullnull) associated with causing serum alpha 1-antitrypsin of less than 80 mg/dl AND documentation of an alpha 1-antitrypsin serum level below the value of 35% of normal (less than 80
/dl)
Covered under Part B when furnished incident to a physician service and is not self-administered.
Medicare Part D: PA Criteria
14 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
mg/dl).
Medicare Part D: PA Criteria
15 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
ampyra All FDA approved indications not otherwise excluded from Part D
history of seizure disorder, Cr Cl less than 50ml/min
Documentation of diagnosis -AND- baseline timed 25-foot walk test -AND- documentation that the patient is ambulatory and has walking impairment as evidenced by one of the following. 1. Functional status score (EDSS score). 2. Timed 25-foot Walk Test (T25W).
3 months initial authorization, 12 months reauthorization
Doses greater than 20 mg/day will not be approved. For reauthorization, documentation supporting 20% improvement in walking impairment from baseline is required.
Medicare Part D: PA Criteria
16 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
anabolic steroids
Documentation of diagnosis -AND- either 1 or 2 when applicable to diagnosis. 1. For the diagnosis of anemia of chronic renal failure the trial/failure, intolerance or contraindication to an erythropoiesis stimulating agent is required. 2. For the diagnosis of osteoporosis the trial/failure, intolerance or contraindication to at least 2 federal legend drugs indicated for use in osteoporisis.
12 monthsAll medically accepted indications not otherwise excluded from Part D
Medicare Part D: PA Criteria
17 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
18 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
atypical antipsychotics
All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis. If medication is being used for major depressive disorder, documentation of adjunctive therapy and an adequate trial of 1 alternative antidepressant is required (e.g. SSRI, SNRI, NDRIs, TCA, MAOI).
12 months Applies to new starts only
aubagio All FDA approved indications not otherwise excluded from Part D
Concomitant use of Aubagio and other disease modifying agents such as fingolimod, interferons, Copaxone , Tysabri
Documentation of relapsing-remitting or relapsing secondary progressive multiple sclerosis
neurologist 12 months Doses greater than 14 mg per day will not be approved
Medicare Part D: PA Criteria
19 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
belbuca All FDA approved indications not otherwise excluded from Part D
documentation of moderate to severe chronic pain -AND- trial and failure of at least two previous federal legend medications for pain, including NSAIDs, tramadol, or opioid analgesics
12 months Belbuca should not be used concomitantly with substance abuse therapies.
BELEODAQ All FDA approved indications not otherwise excluded from Part D
Documentation of relapsed or refractory peripheral T-cell lymphoma (PTCL)
12 months Applies to new starts only
Medicare Part D: PA Criteria
20 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
berinert All FDA approved indications not otherwise excluded from Part D
Documentation of use for treatment of acute abdominal, facial, or laryngeal attacks of hereditary angioedema (HAE)
Deny is less than 12 years of age
12 months
bosulif All FDA approved indications not otherwise excluded from Part D
Documentation of chronic myelogenous leukemia (CML) of any phase and lack of response or intolerance to prior therapy (e.g. imatinib, dasatinib, nilotinib)
12 months Applies to new starts only
botulinum toxin
All medically accepted indications not otherwise excluded from Part D
Use for cosmetic purposes Documentation of diagnosis
12 months
Medicare Part D: PA Criteria
21 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Documentation of diagnosis -AND- Either 1, 2, or 3. 1) For oral immediate release (IR) tablets, trial/failure of generic metformin (IR). 2) For oral extended release (ER) tablets, trial/failure of generic metformin IR and metformin ER (i.e. generic Glucophage XR). 3) For Riomet oral solution, trial/failure of generic metformin IR OR documentation supporting the inability to swallow or difficulty swallowing tablets containing metformin.
All FDA approved indications not otherwise excluded from Part D
brand metformin
12 months
Medicare Part D: PA Criteria
22 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
brand NSAIDs
All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis AND trial/failure of at least 2 generic formulary NSAIDs (e.g. diclofenac, ibuprofen, etc.) or contraindication to all oral NSAIDs.
12 months
Medicare Part D: PA Criteria
23 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
butrans All FDA approved indications not otherwise excluded from Part D
documentation of moderate to severe chronic pain -AND- trial and failure of at least two previous federal legend medications for pain, including NSAIDs, tramadol, or opioid analgesics
12 months Butrans should not be used concomitantly with substance abuse therapies.
cabometyx All FDA approved indications not otherwise excluded from Part D
Documentation of advanced renal cell carcinoma (RCC) and failure of one prior anti-angiogenic therapy
12 months Applies to new starts only
Medicare Part D: PA Criteria
24 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
caprelsa All FDA approved indications not otherwise excluded from Part D
documentation of symptomatic or progressive medullary thyroid cancer in patients with unresectable locally advanced or metastatic disease
12 months Applies to new starts only
carbaglu All FDA approved indications not otherwise excluded from Part D
Documentation of use as an adjunct therapy for acute hyperammonemia or maintenance therapy for chronic hyperammonemia due to hepatic enzyme N-acetylglutamate synthase (NAGS) deficiency
12 months
Medicare Part D: PA Criteria
25 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
CERDELGA All FDA approved indications not otherwise excluded from Part D
Documentation of type 1 Gaucher disease
Deny if less than 18 years of age
12 months
CF drugs All FDA approved indications not otherwise excluded from Part D
Diagnosis of cystic fibrosis. For Bethkis: failure on, intolerance to, or contraindication to generic tobramycin inhalation solution
12 months Inhalation solutions covered under Part B when administered in the home setting using a covered nebulizer (i.e. DME).
Medicare Part D: PA Criteria
26 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
chenodal All FDA approved indications not otherwise excluded from Part D
Documentation of small (less than 15mm in diameter), floatable radiolucent gallstones AND an inadequate response to ursodiol therapy
12 months for initial approval with an additional 12 months upon renewal
Safety of use beyond 24 months is not established
Medicare Part D: PA Criteria
27 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
cholbam Documentation of bile acid synthesis disorders due to single enzyme defects (SEDs) -OR- documentation of use as adjunctive therapy for peroxisomal disorders (PDs), including Zellweger spectrum disorders, in patients who exhibit manifestations of liver disease, steatorrhea, or complications from decreased fat soluble vitamin absorption.
12 monthsAll FDA approved indications not otherwise excluded from Part D
Medicare Part D: PA Criteria
28 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
cialis All FDA approved indications not otherwise excluded from Part D
Documentation of benign prostatic hyperplasia (BPH) and trial/failure of at least two alternative medications in the following classes (alpha-1 adrenergic blockers and/or 5-alpha reductase inhibitors)
12 months
Medicare Part D: PA Criteria
29 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
cimzia All FDA approved indications not otherwise excluded from Part D
concomitant use of Enbrel, Remicade, Humira, Orencia, Simponi, Actemra, Kineret
Documentation of moderate to severe rheumatoid arthritis -OR- moderate to severe Crohn's disease -OR- psoriatic arthritis -OR- ankylosing spondylitis
Gastroenterologist/ Rheumatologist
12 months Patients must have an adequate trial or intolerance to one corticosteorid (e.g., prednisone or hydrocortisone) or Remicade-AND- the preferred biologic product, Humira, for a diagnosis of Crohn's disease. Patients must have an adequate trial or intolerance to both preferred products, Enbrel and Humira, for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. For initial and indication therapy dosing, doses above plan quantity limit will be approved aligned with recommended initial and induction therapy dosing regimens per indication.
Medicare Part D: PA Criteria
30 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
cinryze All FDA approved indications not otherwise excluded from Part D
12 monthsCoverage for the following two indications: 1. Use as prophylaxis for hereditary angioedema (HAE) type I & II -AND- documentation that clinical laboratory performance C4 below lower limit of laboratory reference range -AND- C1 inhibitor level below lower limit of laboratory reference range -OR- normal C1 inhibitor level and a low C1INH functional level below laboratory reference range -AND- documentation of at least 1 symptom of angioedema attack -AND di i
Medicare Part D: PA Criteria
31 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
AND- medications that cause angioedema have been evaluated and discontinued. 2. Use as prophylaxis for hereditary angioedema (HAE) type III -AND- documentation that clinical laboratory performance C4, C1 inhibitor, and C1INH functional level are within normal limits of laboratory reference ranges -AND-documentation of family history of HAE -OR- FXII mutation -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that ca se
Medicare Part D: PA Criteria
32 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
that cause angioedema have been evaluated and discontinued.
Medicare Part D: PA Criteria
33 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
cometriq All FDA approved indications not otherwise excluded from Part D
Documentation of progressive, metastatic medullary thyroid cancer
12 months Applies to new starts only
Medicare Part D: PA Criteria
34 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
corlanor Documentation of stable, symptomatic heart failure and normal sinus rhythm AND left ventricular ejection fraction less than or equal to 35 percent AND resting heart rate greater than or equal to 70 beats per minute AND trial/failure of maximum tolerated dose of one beta-blocker used for treatment of heart failure (e.g., bisoprolol, carvedilol, metoprolol succinate) OR contraindication to beta-blocker use
12 months
Medicare Part D: PA Criteria
35 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Cosentyx All FDA approved indications not otherwise excluded from Part D
Documentation of moderate to severe psoriasis and failure of one systemic therapy (e.g. methotrexate, cyclosporine) or phototherapy -OR- active psoriatic arthritis -OR- active ankylosing spondylitis.
12 months Patients must have an adequate trial or intolerance to the preferred product, Humira, for psoriasis and the preferred products, Enbrel and Humira, for psoriatic arthritis and ankylosing spondylitis. For induction therapy dosing, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimens per indication.
cotellic All FDA approved indications not otherwise excluded from Part D
Disease progression on prior BRAF inhibitor therapy
Documentation of unresectable or metastatic melanoma in patients with a BRAF V600E or V600K mutation AND used in combination with vemurafenib
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
36 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
crinone All medically accepted indications not otherwise excluded from Part D
Use to promote fertility Documentation of diagnosis
12 months
daklinza All FDA approved indications not otherwise excluded from Part D
Criteria will be applied consistent with current AASLD/IDSA guidance
Deny if less than 18 years of age
G1,3:12w txnncr,txexncr,24w txncr,txexcr,R/INFinel.G2:12w txn,24w txex INFinel.G1-4al:12w,24w Rinel
Combination therapy with Sovaldi + Daklinza for 24 weeks in GT3 patients will only be approved if the patient has a contraindication to Sovaldi+ Peginterferon+ Ribavirin therapy.
Medicare Part D: PA Criteria
37 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
darzalex All FDA approved indications not otherwise excluded from Part D
Documentation for use in the treatment of multiple myeloma in patients who have received at least 3 prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent OR for use in multiple myeloma patients who are double-refractory to a PI and an immunomodulatory agent
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
38 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
duexis All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis -AND- Both of the following. 1) Trial/failure of ibuprofen used in combination with famotidine. 2) Trial/failure of one additional generic formulary NSAID (other than ibuprofen) used in combination with one additional generic formulary H2-receptor blocker (other than famotidine).
Deny if less than 18 years of age
12 months
Medicare Part D: PA Criteria
39 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
egfr tyrosine kinase inhibitors
All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis -AND- both of the following. 1) Epidermal growth factor receptor (EGFR) mutations, if applicable to diagnosis. 2) Alternatives tried/failed and concomitant therapy, if applicable to diagnosis
oncologist, hematologist
12 months Coverage of pancreatic cancer diagnosis applies only to erlotinib (Tarceva). The use of Tarceva and Gilotrif for non-small cell lung cancer (NSCLC) will be approved as a first-line therapy. Applies to new starts only.
Medicare Part D: PA Criteria
40 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
egrifta All FDA approved indications not otherwise excluded from Part D
Documented diagnosis of HIV and lipodystrophy, member must actively be receiving antiretroviral therapy including protease inhibitors, nucleoside reverse transcriptase inhibitors, or non-nucleoside reverse transcriptase inhibitors
12 months Applies to new starts only
Medicare Part D: PA Criteria
41 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Documentation of moderate to severe rheumatoid arthritis -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe juvenile idiopathic rheumatoid arthritis and an inadequate response or intolerance to at least one DMARD (e.g., methotrexate, leflunamide) -OR- moderate to severe psoriasis after failure of either systemic therapy (e.g., methotrexate or cyclosporine) or phototherapy.
For psoriasis trial of 1 alternative therapy, either systemic therapy (e.g. methotrexate or cyclosporine) or phototherapy, is required.
12 monthsrheumatologist, dermatologist
Deny if less than 2 years old
concomitant use of Remicade, Cimzia, Humira, Orencia, Simponi, Actemra, Kineret, Stelara
All FDA approved indications not otherwise excluded from Part D
enbrel
Medicare Part D: PA Criteria
42 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
entresto All FDA approved indications not otherwise excluded from Part D
concomitant use of an ACE inhibitor or ARB
Documentation of chronic heart failure (NYHA Class II to IV) AND systolic dysfunction (LVEF less than or equal to 40 percent)
12 months
erivedge All FDA approved indications not otherwise excluded from Part D
Documentation of advanced basal cell carcinoma (BCC), which includes metastatic and locally advanced basal cell carcinoma, for whom surgery is inappropriate
oncologist, dermatologist
12 months Applies to new starts only, doses greater than 150mg/day will not be approved
Medicare Part D: PA Criteria
43 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
farydak All FDA approved indications not otherwise excluded from Part D
Documentation of use in combination with bortezomib and dexamethasone for patients with multiple myeloma who have received at least 2 prior regimens, including bortezomib and an immunomodulatory agent (i.e. Thalomid, Revlimid, Pomolyst)
12 months Applies to new starts only
Medicare Part D: PA Criteria
44 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
firazyr All FDA approved indications not otherwise excluded from Part D
Acute hereditary angioedema (HAE) type I & II: Documentation that clinical laboratory performance C4 below lower limit of laboratory reference range -AND- C1 inhibitor level below lower limit of laboratory reference range -OR- normal C1 inhibitor level and a low C1INH functional level below laboratory reference range -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that cause angioedema have been evaluated and
Deny if less than 18 years of age
12 months
Medicare Part D: PA Criteria
45 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
flector All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis AND trial/failure, intolerance, or contraindication to 3 oral generic NSAIDs one of which must be diclofenac
1 month
Medicare Part D: PA Criteria
46 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Documentation to support use for treatment of osteoporosis and the prevention of fractures in postmenopausal women and men having a T score of less than -2.5 and a trial and failure or contraindication to at least one bisphosphonate -OR- use to prevent fractures in men and postmenopausal women with a low bone mass (T score between -1.0 and -2.5) and history of previous osteoporotic fracture or those who are found to have a 10-year risk of major
i f
Diagnosis of underlying hypercalcemic disorder such as hypercalcemia, hyperparathyroidism or hypoparathyroidism, or high risk for osteosarcoma (Paget's disease, prior radiation therapy, bone metastases, open epiphyses, etc.). Treatment duration greater than 24 months.
All FDA approved indications not otherwise excluded from Part D
forteo 24 months
Medicare Part D: PA Criteria
47 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
osteoporotic fracture greater than or equal to 20 percent or a risk of hip fracture greater than or equal to 3 percent and had a trial and failure or contraindication to at least one bisphosphonate
Medicare Part D: PA Criteria
48 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
gattex All FDA approved indications not otherwise excluded from Part D
Documentation of short bowel syndrome (SBS) AND dependence on parenteral nutrition or intravenous nutritional support for at least 12 months AND requiring parenteral nutrition at least 3 times per week
12 months
Medicare Part D: PA Criteria
49 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Members must have a documented diagnosis of relapsing-remitting, relapsing secondary progressive or progressive relapsing multiple sclerosis -AND- new starts to therapy have the following baseline information documented within 6 months of initiating therapy: ophthalmologic evaluation, liver transaminase and bilirubin, complete blood count, and electrocardiogram if using an antiarrhythmic agent or have second degree or greater AV block -AND-
h
Doses greater than 0.5mg/day will not be approved
12 monthsneurologistConcomitant use of Gilenya and other disease modifying agents such as interferons, Copaxone , Tysabri
All FDA approved indications not otherwise excluded from Part D
gilenya
Medicare Part D: PA Criteria
50 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
new starts to therapy do not have any of the following comorbid conditions or concomitant therapies: bradycardia, congestive heart failure, sick sinus syndrome, prolonged QT interval, ischemic cardiac disease, irregular heartbeat, current neutropenia, current chronic or acute infections, use of antineoplastics, immunosuppressive or immune modulating therapies
Medicare Part D: PA Criteria
51 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
52 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
gleevec All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis and alternatives tried or concomitant therapy, if applicable for diagnosis
12 months Applies to new starts only
gralise All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis
12 months Applies to new starts only
Medicare Part D: PA Criteria
53 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
GRASTEK Documentation of allergic rhinitis and use for Timothy grass pollen or cross reactive grass pollens (Sweet Vernal, Orchard, Perennial Rye, Timothy, Kentucky Blue Grass pollen, Redtop, or meadow fescue) -AND- allergic rhinitis with or without conjunctivitis has been confirmed by a pollen specific positive skin test or in vitro testing for pollen-specific IgE antibodies -AND- trial and failure or intolerance to an intranasal steroid and an oral non-sedating
ihi i
Deny if less than 5 years of age or greater than 65 years of age
allergy specialist, otolaryngologist
12 months Member must also be prescribed an epinephrine auto injector
Asthma (severe, unstable or unconrolled), concomitant sublingual or subcutaneous immunotherapy, therapy initiation during active allergy season
Medicare Part D: PA Criteria
54 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
growth hormone
All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis, growth chart, bone age, growth velocity, and response to stimulation test, when applicable
12 months
antihistamine, intranasal antihistamine or intranasal anticholinergic agent
Medicare Part D: PA Criteria
55 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
HARVONI All FDA approved indications not otherwise excluded from Part D
Criteria will be applied consistent with current AASLD/IDSA guidance
Deny if less than 18 years of age
G1:12w txn nocir, t/f PR.24w txex cir, t/fPI,SOF.G4,5,6:12w.DcpG1,4:12,24w t/fSOF.PosttxG1,4:12,24w
Doses greater than one tablet per day will not be approved.
HETLIOZ All FDA approved indications not otherwise excluded from Part D
Documented diagnosis of Non-24 Sleep-Wake disorder -AND- patient is totally blind
12 months
Medicare Part D: PA Criteria
56 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Applies to new starts only for protected class drugs. Digoxin doses less than or equal to 0.125 mg per day and doxepin doses less than or equal to 6 mg per day will receive automatic approval.
12 monthsAutomatic approval if less than 65 years of age
All FDA approved indications not otherwise excluded from Part D
For all medications subject to this PA group, the following information (1 through 3) is required: 1. Documentation of diagnosis 2. Explanation of risk-benefit profile favoring use of the high-risk medication 3. Documentation of ongoing monitoring plan to identify and address treatment-related adverse events. In addition to requirements 1 through 3 above, for digoxin doses exceeding 0.125 mg daily, provider confirmation that a lower dose of digoxin has or
ld b i ff i
high-risk meds
Medicare Part D: PA Criteria
57 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
would be ineffective in managing the member's condition is required. For the target high-risk medications glyburide, TCAs and nitrofurantoin, in addition to criteria 1 through 3 above, trial and failure or documentation of intolerance or contraindication to at least 2 non-high risk alternative drugs for the same indication, if available, is required. Non-high risk alternative medications for those target high-risk medications include the follo ing: 1
Medicare Part D: PA Criteria
58 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
following: 1. Glyburide (non-high risk alternatives include glipizide and glimepiride) 2. TCAs (non-high risk alternatives include SSRIs and SNRIs) 3. Nitrofurantoin (non-high risk alternatives include Bactrim, Cipro, or cephalexin). If using one of the above 3 high-risk medications for a medically-accepted indication not shared by the safer alternatives listed, then no trial of alternatives is required for that target high-risk medication.
Medicare Part D: PA Criteria
59 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
60 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
homozygous fh
Documentation of homozygous familial hypercholesterolemia (HoFH) confirmed by genetic testing showing functional mutation(s) in both LDL receptor alleles or alleles known to affect LDL receptor functionality -OR- untreated LDL-C concentrations greater than 500 mg/dL, treated LDL-C concentrations greater than or equal to 300 mg/dL, or a non-HDL-C concentration greater than or equal to 330mg/dL -AND- the presence of Xanthomas in the first decade of life -OR d i
Patients must have an adequate trial/failure or contraindication to the preferred product Repatha.
6 months
Medicare Part D: PA Criteria
61 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
OR- documentation of elevated LDL-C greater than 190 mg/dL prior to lipid-lowering therapy consistent with HoFH in both parents -AND- will not be used concomitantly with a PCSK9 inhibitor [e.g. alirocumab (Praluent), evolocumab (Repatha)].
Medicare Part D: PA Criteria
62 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
horizant All FDA approved indications not otherwise excluded from Part D
Documentation of moderate to severe active primary restless leg syndrome and trial and failure of two accepted medications for the treatment of this condition one of which must include pramipexole or ropinirole -OR- documentation of post herpetic neuralgia
12 months Applies to new starts only
Medicare Part D: PA Criteria
63 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
humira Documentation of moderate to severe hidradenitis suppurativa -OR- moderate to severe rheumatoid arthritis -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe juvenile idiopathic rheumatoid arthritis and an inadequate response or intolerance to at least one DMARD (e.g., methotrexate, leflunamide) -OR- moderate to severe psoriasis after failure of either systemic therapy (e.g., methotrexate or cyclosporine) or phototherapy. -OR-
d
For psoriasis trial of 1 alternative therapy, either systemic therapy (e.g. methotrexate or cyclosporine) or phototherapy, is required. For Crohn's disease in adults (18 years or older), trial of 2 immunosuppressants (e.g. corticosteroids, azathioprine) or monotherapy with infliximab is required. For Crohn's disease in pediatrics, trial of 1 immunosuppressant (e.g. corticosteroids, azathioprine) or monotherapy with infliximab is required. For Ulcerative Colitis, trial of 2 immunosuppressants (e.g. corticosteroids, azathioprine or 6-mercaptopurine) is required. For plaque psoriasis induction therapy, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimen. For rheumatoid arthritis therapy without
i h d
12 monthsrheumatologist, dermatologist, or gastroenterologist
Deny if less than 2 years old
concomitant use of Remicade, Cimzia, Enbrel, Orencia, Simponi, Actemra, Kineret, Stelara
Medicare Part D: PA Criteria
64 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
moderate to severe Crohn's disease after failure of two immunosuppressants (e.g., corticosteroids, azathioprine) or monotherapy with infliximab -OR- moderate to severe ulcerative colitis after failure of two immunosuppressants (e.g. corticosteroids, azathioprine or 6-mercaptopurine).
concomitant methotrexate, doses above plan quantity limit will be approved aligned with recommended weekly dosing regimen. Induction therapy or treatment regimens for other indications are aligned with plan quantity limit on Humira starter kit.
Medicare Part D: PA Criteria
65 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
66 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Applies to new starts only12 monthsDocumentation of ER-positive, HER2-negative metastatic breast cancer in postmenopausal women AND used as initial endocrine-based therapy for metastatic disease in combination with letrozole (Femara)-OR- documentation of use with fulvestrant (Faslodex) in women with HR-positive, HER2-negative metastatic breast cancer with disease progression following endocrine therapy.
All FDA approved indications not otherwise excluded from Part D
Ibrance
Medicare Part D: PA Criteria
67 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
iclusig Applies to new starts only12 monthsDocumentation of T3151 chronic phase, accelerated phase or blast phase CML -OR- documentation of T3151 Ph+ ALL -OR- documentation of chronic phase, accelerated phase or blast phase CML in patients for whom no other tyrosine kinase inhibitor therapy is indicated -OR- documentation of Ph+ ALL in patients for whom no other tyrosine kinase inhibitor therapy is indicated.
Medicare Part D: PA Criteria
68 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria12 months Covered under Part B when
administered in the home to a member with a diagnosis of primary immunodeficiency disease
Documentation of diagnosis. For select diagnoses the following apply- 1) For Myasthenia Gravis Syndrome, documentation that the patient is refractory to other standard therapies (e.g., cholinesterase inhibitors, corticosteroids, azathioprine) given in therapeutic doses over at least 3 months OR is intolerant of/has a contraindication to those standard therapies. 2) For Multiple Sclerosis, patient is refractory to other standard therapies (e.g., interferons) given in h i d
ig All medically accepted indications not otherwise excluded from Part D
Medicare Part D: PA Criteria
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Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
therapeutic doses over at least 3 months, OR is intolerant of/has a contraindication to those standard therapies. 3) For Inflammatory Myopathies, the patient is refractory to corticosteroids given in therapeutic doses over at least 4 months, OR is intolerant of/has a contraindication to corticosteroids.
Medicare Part D: PA Criteria
70 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
imbruvica All FDA approved indications not otherwise excluded from Part D
Documentation of mantle cell lymphoma and treatment with at least one prior therapy -OR- documentation of chronic lymphocytic leukemia and treatment with at least one prior therapy -OR- documentation of Waldenstrom macroglobulinemia
12 months Applies to new starts only
Medicare Part D: PA Criteria
71 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
increlex All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis, growth chart, stimulation test results, growth velocity, IGF-1 level
Deny if greater than 18 years old
12 months
inlyta All FDA approved indications not otherwise excluded from Part D
Documentation of advanced renal cell carcinoma (RCC) and failure one prior systemic therapy
oncologist 12 months Applies to new starts only
interferon alfa
All medically accepted indications not otherwise excluded from Part D
documentation of diagnosis only
12 months
Medicare Part D: PA Criteria
72 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
interleukin-1b blockers
All FDA approved indications not otherwise excluded from Part D
Concomitant use with agents that inhibit IL-1 or TNF including Remicade, Humira, Enbrel, Orencia, or Kineret
documentation of diagnosis
Deny if less than 12 years of age (Arcalyst) or less than 2 years of age (Ilaris)
12 months
IPF AGENTS All FDA approved indications not otherwise excluded from Part D
Concomitant use of pirfenidone and nintedanib
Documentation of idiopathic pulmonary fibrosis -AND- baseline forced vital capacity (FVC) of at least 50% and a percent predicted diffusing capacity of the lungs of carbon monoxide (DLCO) of at least 30%.
pulmonologist
12 months
Medicare Part D: PA Criteria
73 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
iressa All FDA approved indications not otherwise excluded from Part D
Documentation of metastatic non-small cell lung cancer (NSCLC) in patients whose tumors express EGFR exon 19 deletion mutations or exon 21 (L858R) mutations as detected by an FDA-approved test
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
74 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
jakafi All FDA approved indications not otherwise excluded from Part D
Documentation of intermediate or high-risk myelofibrosis, including primary myelofibrosis, post-polycythemia vera myelofibrosis and post-essential thrombocythemia myelofibrosis
oncologist, hematologist
12 months Applies to new starts only. Platelet count to be provided.
Medicare Part D: PA Criteria
75 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
kalydeco All FDA approved indications not otherwise excluded from Part D
Homozygous for the F508del mutation in the CFTR gene
Documentation of cystic fibrosis (CF) in patients who have one of the following mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, G551D, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, S549R or R117H.
Deny if less than 6 years of age for oral tablets and less than 2 years of age for oral granules
pulmonologist
12 months Doses greater than 300mg/day will not be approved
kanuma All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis of Lysosomal Acid Lipase (LAL) deficiency
12 months
Medicare Part D: PA Criteria
76 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
keveyis All FDA approved indications not otherwise excluded from Part D
Documentation of one of the following: 1. Primary hyperkalemic periodic paralysis 2. Primary hypokalemic periodic paralysis 3. Related variants of primary periodic paralysis
Deny if less than 18 years of age
12 months Doses exceeding 200 mg per day will not be approved.
Medicare Part D: PA Criteria
77 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
KEYTRUDA Documentation of unresectable or metastatic melanoma and disease progression following ipilimumab (Yervoy) and, if BRAF V600 mutation positive, a BRAF inhibitor -OR- metastatic non-small cell lung cancer (NSCLC) with PD-L1-positive expressing tumor, as determined by an FDA-approved test, after failure of prior platinum-based chemotherapy
Applies to new starts only12 months
Medicare Part D: PA Criteria
78 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
kineret All FDA approved indications not otherwise excluded from Part D
concomitant use of Actemra, Remicade, Humira, Orencia, Enbrel, Simponi, Cimzia
Documentation of moderate to severe rheumatoid arthritis and trial and failure of one DMARD -OR- neonatal-onset multisystem inflammatory disease (NOMID) or chronic infantile neurological, cutaneous and articular (CINCA) syndrome
rheumatologist
12 months Patients must have an adequate trial or intolerance to the preferred products, Enbrel and Humira, for rheumatoid arthritis.
Medicare Part D: PA Criteria
79 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
korlym All FDA approved indications not otherwise excluded from Part D
Documentation of hyperglycemia secondary to hypercortisolism in patients with endogenous Cushing's syndrome who have Type 2 Diabetes Mellitus or glucose intolerance AND patient is not a candidate for surgery or radiotherapy or where surgery or radiotherapy has failed
Deny if less than 18 years of age
12 months
Medicare Part D: PA Criteria
80 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
lenvima All FDA approved indications not otherwise excluded from Part D
Documentation of locally recurrent or metastatic, progressive, radioactive iodine refractory differentiated thyroid cancer
12 months Applies to new starts only
leukotriene modifiers
All FDA approved indications not otherwise excluded from Part D
Documentation of asthma -OR- documentation of exercise-induced bronchoconstriction -AND- trial/failure of generic montelukast
12 months
Medicare Part D: PA Criteria
81 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
lidoderm All medically accepted indications not otherwise excluded from Part D
documentation of postherpetic neuralgia (PHN) and trial and failure of 1 other agent used to treat PHN (e.g. gabapentin) -OR- documentation of diabetic neuropathy
12 months
lonsurf All FDA approved indications not otherwise excluded from Part D
Documentation of metastatic colorectal cancer in patients who have previously been treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-VEGF therapy, and if RAS wild-type, an anti-EGFR therapy
oncologist 12 months Applies to new starts only
Medicare Part D: PA Criteria
82 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
lynparza All FDA approved indications not otherwise excluded from Part D
Documentation of use as monotherapy in patients with deleterious or suspected deleterious germline BRCA mutated advanced ovarian cancer after trial of three or more prior lines of chemotherapy (e.g. carboplatin, cisplatin, paclitaxel, gemcitabine)
12 months Applies to new starts only
Medicare Part D: PA Criteria
83 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
lyrica All FDA approved indications not otherwise excluded from Part D
Documentation of DPN and trial/failure or intolerance to duloxetine-OR- PHN and trial/failure or intolerance to gabapentin -OR- seizures and trial/failure or intolerance to two AEDS -OR- neuropathic pain associated with spinal cord injury -OR- documentation to support a diagnosis of fibromyalgia and trial/failure or intolerance to duloxetine
12 months Applies to new starts only
Medicare Part D: PA Criteria
84 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
mekinist All FDA approved indications not otherwise excluded from Part D
Disease progression on prior BRAF inhibitor therapy
Documentation of unresectable or metastatic melanoma with BRAFV600E or BRAFV600K mutations
12 months Applies to new starts only
methamphetamine
All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis
12 months
Medicare Part D: PA Criteria
85 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
mozobil All FDA approved indications not otherwise excluded from Part D
used in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with multiple myeloma (MM) and non-Hodgkins lymphoma (NHL).
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
86 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria12 months For initial reauthorization, the
member should have a decreased A1C level by at least 0.8 or decreased triglycerides by 25 percent or decreased fasting plasma glucose by 25 percent.
myalept Documentation of congenital or acquired generalized lipodystrophy with absence or loss of subcutaneous body fat -AND- Leptin levels less than 8 ng/mL for males or less than 12 ng/mL for females -AND- the patient has been optimized on current diabetic medication and/or hypertriglyceridemia medication as needed -AND- the member has a diagnosis of diabetes or fasting insulin levels greater than 30uU/mL or fasting hypertriglyceridemia greater than 200 /dL
All FDA approved indications not otherwise excluded from Part D
Medicare Part D: PA Criteria
87 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
namenda All medically accepted indications not otherwise excluded from Part D
Documentation of diagnosis and trial/failure of generic memantine
12 months
namzaric All medically accepted indications not otherwise excluded from Part D
Documentation of diagnosis and trial/failure of generic memantine and generic donepezil
12 months
200mg/dL.
Medicare Part D: PA Criteria
88 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
natpara All FDA approved indications not otherwise excluded from Part D
Documentation of use as an adjunct to calcium and vitamin D to control hypocalcemia in patients with hypoparathyroidism
12 months
nexavar All FDA approved indications not otherwise excluded from Part D
Documentation of hepatocellular carcinoma -OR- advanced renal cell carcinoma after treatment of 1 other systemic therapy -OR- locally recurrent or metastatic, progressive, differentiated thyroid carcinoma refractory to radioactive iodine treatment
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
89 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
ninlaro All FDA approved indications not otherwise excluded from Part D
Documentation of multiple myeloma AND previous treatment with at least 1 prior therapy AND used in combination with lenalidomide and dexamethasone
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
90 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
NORTHERA All FDA approved indications not otherwise excluded from Part D
Documentation of neurogenic orthostatic hypotension caused by primary autonomic failure (e.g., Parkinson's disease, multiple system atrophy, or pure autonomic failure), dopamine beta-hydroxylase deficiency or non-diabetic autonomic neuropathy
12 months
Medicare Part D: PA Criteria
91 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria12 monthsDeny if less
than 12 years old
All FDA approved indications not otherwise excluded from Part D
nucala Documentation of diagnosis of severe asthma evidenced by pretreatment forced expiratory volume in 1 second (FEV1) less than 80% predicted and FEV1 reversibility of at least 12% after albuterol administration -AND- Either 1 or 2. 1)History of 2 or more exacerbations in the previous year despite at least 12 months of high-dose inhaled corticosteroid (ICS) given in combination with at least 3 months of controller medication (e.g. long-acting beta2-
i [LABA]
Medicare Part D: PA Criteria
92 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
agonist [LABA], leukotriene receptor antagonist [LTRA], or theophylline), unless intolerant of or contraindication to all of these agents. 2)Symptoms are inadequately controlled with use of 6 months of ICS with daily oral glucocorticoids given in combination with a minimum of 3 months of controller medication (e.g. LABA, LTRA, or theophylline), unless intolerant of or contraindication to all of these agents. -AND- 3 or 4. 3)Greater than or equal to 150 cells/ L screening
Medicare Part D: PA Criteria
93 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
cells/uL screening within 6 weeks of dosing. 4)Greater than or equal to 300 cells/uL within 12 months of screening.
Medicare Part D: PA Criteria
94 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
nuplazid All FDA approved indications not otherwise excluded from Part D
Documentation of hallucinations and delusions associated with Parkinson's disease psychosis
Deny if less than 18 years of age
12 months Applies to new starts only
OAB drugs All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis -AND- trial/failure of at least 2 generic alternatives (e.g. oxybutynin, trospium, tolterodine)
12 months
Medicare Part D: PA Criteria
95 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
odomzo All FDA approved indications not otherwise excluded from Part D
Documentation of locally advanced basal cell carcinoma (laBCC) that has recurred following surgery or radiation therapy or for use in patients who are not candidates for surgery or radiation therapy
12 months Applies to new starts only
Medicare Part D: PA Criteria
96 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
olysio All FDA approved indications not otherwise excluded from Part D
Previous failure of a Protease Inhibitor used in hepatitis C (boceprevir, telaprevir or simeprevir) -OR- decompensated cirrhosis
Criteria will be applied consistent with current AASLD/IDSA guidance
Deny if less than 18 years old
12 wks or 24 wks depending on treatment regimen and presence or absence of cirrhosis
Doses greater than or less than 150mg/day will not be approved
Medicare Part D: PA Criteria
97 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Documentation of unresectable or metastatic melanoma in patients previously treated with ipilimumab (Yervoy) and, if BRAF V600 mutation positive, a BRAF inhibitor -OR- documentation of metastatic squamous non-small cell lung cancer (NSCLC) with progression on or after platinum-based chemotherapy -OR- advanced renal cell carcinoma in patients who have received prior antiangiogenic therapy.
All FDA approved indications not otherwise excluded from Part D
opdivo 12 months Applies to new starts only
Medicare Part D: PA Criteria
98 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
99 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
oralair Documentation of allergic rhinitis and use for Sweet Vernal, Orchard, Perennial Rye, or Kentucky Blue Grass pollens -AND- allergic rhinitis with or without conjunctivitis has been confirmed by a pollen specific positive skin test or in vitro testing for pollen-specific IgE antibodies -AND- trial and failure or intolerance to an intranasal steroid and an oral non-sedating antihistamine, intranasal antihistamine or intranasal anticholinergic
Member must also be prescribed an epinephrine auto injector
12 monthsallergy specialist, otolaryngologist
Deny if less than 10 years of age or greater than 65 years of age
Asthma (severe, unstable or unconrolled), concomitant sublingual or subcutaneous immunotherapy, therapy initiation during active allergy season
Medicare Part D: PA Criteria
100 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
orencia All FDA approved indications not otherwise excluded from Part D
concomitant use of Enbrel, Remicade, Humira, Orencia, Simponi, Kineret, Cimzia
Documentation of moderate to severe rheumatoid arthritis -OR- documentation of moderate to severe juvenile idiopathic rheumatoid arthritis (Orencia IV only)
rheumatologist
12 months For Orencia SubQ, patients must have an adequate trial or intolerance to the preferred SubQ products, Enbrel and Humira, for rheumatoid arthritis. For Orencia IV, patients must have an adequate trial or intolerance to one of the preferred IV products, Remicade or Simponi Aria, for rheumatoid arthritis.
agent
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orkambi All FDA approved indications not otherwise excluded from Part D
Documentation of cystic fibrosis and homozygous F508del mutation
Deny if less than 12 years of age
6 months initial authorization, 12 months reauthorization
For reauthorization, documentation showing a FEV1 improvement from baseline must be provided.
OTEZLA All FDA approved indications not otherwise excluded from Part D
concomitant use of Enbrel, Remicade, Humira, Cimzia, Simponi, Stelara
Documentation of active psoriatic arthritis -OR- documentation of moderate to severe psoriasis
Deny if less than 18 years of age
rheumatologist, dermatologist
12 months Maintenance doses greater than 60 mg per day will not be approved. Patients must have an adequate trial or intolerance to the preferred products, Enbrel and Humira, for psoriatic arthritis and psoriasis.
otrexup All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis AND trial/failure, intolerance, or contraindication to oral generic methotrexate tablets
12 months
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pomalyst All FDA approved indications not otherwise excluded from Part D
Documentation of multiple myeloma, previous trial of at least 2 therapies including lenalidomide and bortezomib, and disease progression on or within 60 days of last therapy
12 months Applies to new starts only
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Documentation of the following: 1. Heterozygous Familial Hypercholesterolemia (HeFH) as supported by the presence of causal mutation of familial hypercholesterolemia by genetic testing, physical signs of FD (e.g. xanthomas, xanthelasma), clinical diagnosis based on WHO criteria/Dutch Lipid Clinical Network criteria with score greater than 8 points, or Simon Broome register diagnostic criteria AND LDL-C greater than or equal to 190 mg/dL prior to lipid l i h
For reauthorization, documentation showing an LDL-C reduction on Praluent therapy from baseline must be provided.
6 months initial authorization, 12 months reauthorization
Prescribed by or in consultation with a cardiologist, lipid specialist, or endocrinologist
Deny if less than 18 years of age
All FDA approved indications not otherwise excluded from Part D
praluent
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lowering therapy (greater than or equal to 160 mg/dL if age less than 20) or LDL-C greater than or equal to 160 mg/dL after treatment with antihyperlipidemic agents but prior to Praluent therapy AND Previous treatment with at least two trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin) has been ineffective in achieving LDL-C goal AND Praluent must be used concomitantly with a statin which is dosed at maximally tolerated dose OR doc mentation of
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documentation of statin intolerance is provided as defined by statin related rhabdomyolysis or skeletal-related muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin. 2. Hypercholesterolemia ASCVD (e.g. acute coronary syndrome, history of myocardial infarction) AND Previous treatment with at least two trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin) has been ineffective in
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been ineffective in achieving LDL-C goal (LDL-C is still greater than or equal to 100 mg/dL) AND Praluent must be used concomitantly with a statin which is dosed at maximally tolerated dose OR documentation of statin intolerance is provided as defined by statin related rhabdomyolysis or skeletal-related muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin.
Medicare Part D: PA Criteria
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Medicare Part D: PA Criteria
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Medicare Part D: PA Criteria
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Coverage Duration Other Criteria1 mo. opiate/substance abuse therapy use, 12 mo. opiate/benzodiazepine/skeletal muscle relaxant use
Opiate agonists will receive automatic approval if no recent claims for a substance abuse therapy (e.g, buprenorphine-naloxone) OR a benzodiazepine (e.g., triazolam, alprazolam) AND a centrally acting skeletal muscle relaxant (e.g., carisoprodol). Benzodiazepines (e.g, triazolam, alprazolam) will receive automatic approval if no recent claims for an opiate agonist (e.g., oxycodone, hydrocodone, oxymorphone) AND a centrally acting skeletal muscle relaxant (e.g., carisoprodol).
For concomitant use of an opiate agonist and substance abuse therapy, documentation that the member has a documented acute pain condition (e.g. acute traumatic injury) in which treatment with other agents would cause insufficient pain control or if the member requires treatment for pain related to a terminal illness. For concomitant use of an opiate agonist, benzodiazepine and a centrally acting skeletal muscle relaxant, documentation that the member has
i d/f il d l 2
All FDA approved indications not otherwise excluded from Part D
prescription drug combo
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tried/failed at least 2 other skeletal muscle relaxant (e.g, methocarbamol, metaxalone), understanding these skeletal muscle relaxants are high-risk medications in geriatric patients AND documentation of an ongoing monitoring plan to identify and address concomitant drug-drug interaction adverse events
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pristiq All FDA approved indications not otherwise excluded from Part D
Documentation of major depressive disorder and trial and failure of two other antidepressants.
12 months Applies to new starts only
PROCYSBI All FDA approved indications not otherwise excluded from Part D
Documentation of nephropathic cystinosis AND previous trial and failure or intolerance to immediate-release cysteamine bitartrate (Cystagon)
Deny if less than 2 years of age
12 months
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Documentation of use to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy or women at high risk for fracture receiving adjuvant aromatase inhibitor therapy -OR- use for treatment of osteoporosis and the prevention of fractures in postmenopausal women and men having a T score of less than -2.5 and a trial and failure or contraindication to at least one bisphosphonate -OR- use to prevent fractures in men and postmenopausal
i h l
Diagnosis of underlying hypercalcemic disorder such as hypercalcemia, hyperparathyroidism or hypoparathyroidism, or high risk for osteosarcoma (Paget's disease, prior radiation therapy, bone metastases, open epiphyses, etc.)
All FDA approved indications not otherwise excluded from Part D
prolia 12 months Covered under Part B for female patients eligible for home health services when provider certifies that patient sustained bone fracture related to post-menopausal osteoporosis and is unable to learn the skills needed to self-administer the drug or is otherwise physically or mentally incapable of administering the drug or family/caregivers are unable or unwilling to administer the drug
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women with a low bone mass (T score between -1.0 and -2.5) and history of previous osteoporotic fracture or those who are found to have a 10-year risk of major osteoporotic fracture greater than or equal to 20 percent or a risk of hip fracture greater than or equal to 3 percent and had a trial and failure or contraindication to at least one bisphosphonate
Medicare Part D: PA Criteria
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Medicare Part D: PA Criteria
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Coverage Duration Other Criteria12 monthsprovigil All medically
accepted indications not otherwise excluded from Part D
Documentation of 1 of the following. 1) Diagnosis of shift work sleep disorder (SWSD) as defined by a minimum of 5 night shifts per month with at least 3 of those nights occuring consecutively and the shift is 6 to 12 hours in duration occuring between 10pm and 8am. 2) Diagnosis of narcolepsy documented by MSLT less than 8 minutes and 2 sleep-onset rapid eye movement periods (SOREMP) or other appropriate testing. 3) Diagnosis of obstructive sleep
/h
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apnea/hypopnea syndrome (OSAHS) documented by objective polysomnography and continuous positive airway pressure (CPAP) history and status are provided. Diagnosis established in accordance with ICSD or DSM IV criteria acceptable for all indications.
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Medicare Part D: PA Criteria
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Coverage Duration Other Criteria12 monthsDiagnosis of
pulmonary hypertension, substantiated by results from right heart catheterization and/or direct measurement of pulmonary arterial pressure, defined as a mean pulmonary arterial pressure of greater than or equal to 25 mmHg at rest, with a pulmonary capillary wedge pressure of less than 15 mmHg, and a PVR greater than 3 Wood units -AND- WHO Group -AND- WHO Functional Class ll or lll symptoms
pulmonary arterial hypertension
All FDA approved indications not otherwise excluded from Part D
cardiologist, pulmonologist
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Documentation of allergic rhinitis and use for ragweed pollen -AND- allergic rhinitis with or without conjunctivitis has been confirmed by a pollen specific positive skin test or in vitro testing for pollen-specific IgE antibodies -AND- trial and failure or intolerance to an intranasal steroid and an oral non-sedating antihistamine, intranasal antihistamine or intranasal anticholinergic agent
RAGWITEK All FDA approved indications not otherwise excluded from Part D
Asthma (severe, unstable or unconrolled), concomitant sublingual or subcutaneous immunotherapy, therapy initiation during active allergy season
Deny if less than 18 years of age or greater than 65 years of age
allergy specialist, otolaryngologist
12 months Member must also be prescribed an epinephrine auto injector
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rasuvo All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis AND trial/failure, intolerance, or contraindication to oral generic methotrexate tablets
12 months
ravicti All FDA approved indications not otherwise excluded from Part D
Urea cycle disorders due to N-acetylglutamatesynthetase deficiency
Documentation of use with dietary protein restriction for chronic management of a urea cycle disorders (UCDs) when the condition cannot be managed by dietary protein restriction alone
12 months
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Coverage Duration Other Criteria12 months For psoriasis trial of 1 alternative
therapy, either systemic therapy (e.g. methotrexate or cyclosporine) or phototherapy, is required. For Crohn's disease and ulcerative colitis, trial of 2 immunosuppressants (e.g. corticosteroids, azathioprine, 6-mercaptopurine) is required.
Documentation of moderate to severe rheumatoid arthritis and use in combination with methotrexate -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe psoriasis after failure of systemic therapy or phototherapy -OR- moderate to severe Crohn's disease after failure of two immunosuppressants -OR- moderate to severe ulcerative colitis after failure of two immunosuppressants
concomitant use of Humira, Cimzia, Enbrel, Orencia, Simponi, Actemra, Kineret, Stelara
All FDA approved indications not otherwise excluded from Part D
remicade For Crohn's disease and ulcerative colitis, deny if less than 6 years old
rheumatologist, dermatologist, or gastroenterologist
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1.Homozygous Familial Hypercholesterolemia(HoFH) supported by genetic confirmation of two mutant alleles at LDLR, APOB, OCSK9, or LDLRAP1 gene or untreated LDL-C greater than 500mg/dL(or treated LDL-C greater than 300mg/dL) with cutaneous or tendon xanthoma before age 10 yrs or heterozygous familial hypercholesterolemia (HeFH) in both parents AND Repatha will be used with a maximally tolerated
i l ll
repatha All FDA approved indications not otherwise excluded from Part D
Deny if less than 18 years of age for HeFH and ASCVD or less than 13 years of age for HoFH
Prescribed by or in consultation with a cardiologist, lipid specialist, or endocrinologist
6 months initial authorization, 12 months reauthorization
For reauthorization, documentation showing an LDL-C reduction on Repatha therapy from baseline must be provided. For HoFH diagnosis, 3 syringes per month will be approved aligned with recommended dosing regimen for this indication.
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statin unless all statins are contraindicated or not tolerated AND Repatha will not be used with lomitapide, mipomersen, or another PCSK9 inhibitor. 2.HeFH supported by presence of causal mutation of FH by genetic testing, physical signs of FD(e.g. xanthomas, xanthelasma), diagnosis based on WHO criteria/Dutch Lipid Clinical Network criteria with score greater than 8 points, or Simon Broome register criteria AND LDL-C greater than or eq al to
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than or equal to 190mg/dL prior to lipid lowering therapy (greater than or equal to 160mg/dL if age less than 20) or LDL-C greater than or equal to 160mg/dL after treatment with antihyperlipidemic agents but prior to Repatha therapy AND Prior therapy with at least 2 trials of different high-intensity statins(e.g. atorvastatin, rosuvastatin) has not achieved LDL-C goal AND must be used with maximally tolerated statin dose OR documentation of statin intolerance as defined by statin
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defined by statin related rhabdomyolysis or skeletal muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin. 3. Hypercholesterolemia ASCVD AND Prior therapy with at least 2 trials of different high-intensity statins (e.g. atorvastatin, rosuvastatin) has not achieved LDL-C goal(LDL-C is still greater than or equal to 100mg/dL) AND must be used with maximally tolerated statin dose OR
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statin dose OR documentation of statin intolerance as defined by statin related rhabdomyolysis or skeletal muscle symptoms while receiving at least 2 separate trials of different high intensity statin which resolved upon discontinuation of statin.
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Coverage Duration Other Criteria12 months Applies to new starts onlyDiagnosis of
multiple myeloma -OR- diagnosis of myelodyplastic syndrome (MDS) with 5-q deletion along with documentation of transfusion-dependent anemia or an anemia with documented hemoglobin of less than 10g/dL -OR- diagnosis of mantle cell lymphoma (MCL) in which disease has relapsed or progressed after two prior therapies (e.g. anthracycline, mitoxantrone, cyclophosphamide, rituximab, bortezomib) one of which included b ib
Documentation of severe neutropenia, severe thrombocytopenia, or treatment-related MDS
All FDA approved indications not otherwise excluded from Part D
revlimid
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bortezomib
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Acute hereditary angioedema (HAE) type I & II: Documentation that clinical laboratory performance C4 below lower limit of laboratory reference range -AND- C1 inhibitor level below lower limit of laboratory reference range -OR- normal C1 inhibitor level and a low C1INH functional level below laboratory reference range -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that cause angioedema have been evaluated and di i d A
All FDA approved indications not otherwise excluded from Part D
ruconest Deny if less than 13 years of age
12 months
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discontinued. Acute hereditary angioedema (HAE) type III: Documentation that clinical laboratory performance C4, C1 inhibitor level and C1INH functional level are within normal limits of the laboratory's reference range -AND- documentation HAE family history -OR- FXL mutation -AND- documentation of at least 1 symptom of angioedema attack -AND- medications that cause angioedema have been evaluated and discontinued
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savella All FDA approved indications not otherwise excluded from Part D
Documentation to support a diagnosis of fibromyalgia and trial/failure or intolerance to duloxetine
12 months
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signifor All FDA approved indications not otherwise excluded from Part D
Documentation of Cushing's disease AND patient is not a candidate for pituitary surgery or surgery has not been curative
Deny if less than 18 years of age
12 months
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simponi All FDA approved indications not otherwise excluded from Part D
concomitant use of Actemra, Kineret, Remicade, Humira, Orencia, Enbrel, Cimzia
Documentation of moderate to severe rheumatoid arthritis and use in combination with methotrexate -OR- psoriatic arthritis -OR- ankylosing spondylitis -OR- moderate to severe ulcerative colitis and an inadequate response to two immunosupressants or in those patients requiring continuous steroid therapy
12 months Alternatives for Ulcerative Colitis include immunosuppressants such as corticosteroids, azathioprine or 6-mercaptopurine. Patients must have an adequate trial or intolerance to the preferred product, Humira, for ulcerative colitis and the preferred products, Enbrel and Humira, for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. For ulcerative colitis indication therapy, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimen.
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simponi aria All FDA approved indications not otherwise excluded from Part D
concomitant use of Actemra, Kineret, Remicade, Humira, Orencia, Enbrel, Cimzia
Documentation of moderate to severe rheumatoid arthritis and use in combination with methotrexate
12 months
sovaldi All FDA approved indications not otherwise excluded from Part D
Criteria will be applied consistent with current AASLD/IDSA guidance
Deny if less than 18 years of age
12w:G1nocr.G2nocr txn,t/fSOF.G3,5,6,G4wPR.16w:G2cr,t/fPR.24w:G1cr,G2txe,G4 wR,G2,3allo.48w:G2,3dcp
Doses greater than or less than 400 mg/day will not be approved.
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sprycel All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis and failure of Gleevec therapy (failure of Gleevec is not necessary for the indication of newly diagnosed adults with chronic phase PH+ CML).
12 months Applies to new starts only
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Patients must have an adequate trial or intolerance to the preferred product, Humira, for psoriasis and the preferred products, Enbrel and Humira, for psoriatic arthritis. Must follow recommended dosing guidelines based upon weight. Psoriasis: For patients weighing less than 100 kilograms (220 pounds), 45 mg dosing will be approved. For patients weighing more than 100 kilograms (220 pounds), 90 mg dosing will be approved. Psoriatic Arthritis: 45 mg dosing will be approved. For patients with co-existent moderate to severe plaque psoriasis weighing greater than 100 kilograms (220 pounds), 90 mg dosing will be approved.
12 monthsdermatologist
Documentation of moderate to severe plaque psoriasis and failure of one systemic therapy (e.g. methotrexate, cyclosporine) or phototherapy OR psoriatic arthritis AND documentation of member weight and prescribed dose
concomitant use of Enbrel, Remicade, Humira, Simponi
All FDA approved indications not otherwise excluded from Part D
stelara
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Coverage Duration Other Criteria12 months Applies to new starts onlyDocumentation of
metastatic colorectal cancer and trial of a fluoropyrimidine-, oxaliplatin-, and irinotecan-containing chemotherapy (i.e. FOLFIRINOX), AND an anti-VEGF therapy (i.e. aflibercept) AND if KRAS wild type, an anti-EGFR therapy (i.e. cetuximab, panitumumab) -OR- documentation of locally advanced, unresectable or metastatic gastrointestinal stromal tumor (GIST) after treatment with both imatinib and sunitinib
All FDA approved indications not otherwise excluded from Part D
stivarga
Medicare Part D: PA Criteria
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strensiq All FDA approved indications not otherwise excluded from Part D
Documentation of perinatal/infantile-onset or juvenile-onset hypophosphatasia (HPP)
12 months
sutent All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis and failure of Gleevec therapy, if applicable
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
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sylvant All FDA approved indications not otherwise excluded from Part D
Documented diagnosis of multicentric Castleman's disease -AND- negative HIV and HHV-8 test -AND- baseline absolute neutrophil count greater than or equal to 1.0x10*9/L -AND- baseline platelet count greater than or equal to 75x10*9/L -AND- baseline hemoglobin less than 17g/dL.
12 months Applies to new starts only
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tagrisso All FDA approved indications not otherwise excluded from Part D
Documentation of metastatic EGFR T790M mutation-positive NSCLC AND progression on or after EGFR TKI therapy
oncologist, hematologist
12 months Applies to new starts only
taltz All FDA approved indications not otherwise excluded from Part D
concomitant use of Enbrel, Remicade, Humira, Simponi, Stelara
Documentation of moderate to severe psoriasis and failure of one systemic therapy (e.g. methotrexate, cyclosporine) or phototherapy
Deny if less than 18 years of age
dermatologist
12 months Patients must have an adequate trial or intolerance to the preferred product, Humira, for psoriasis. For psoriasis induction therapy, doses above plan quantity limit will be approved aligned with recommended induction therapy dosing regimen.
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tasigna All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis and failure of Gleevec therapy (failure of Gleevec is not necessary for the indication of newly diagnosed adults with chronic phase PH+ CML).
oncologist, hematologist
12 months Applies to new starts only
tecfidera All FDA approved indications not otherwise excluded from Part D
concomitant use with other disease modifying agents such as interferons, Copaxone , Tysabri, Aubagio, Gilenya
Documentation of relapsing form of multiple sclerosis (relapsing-remitting, relapsing secondary progressive, or progressive relapsing multiple sclerosis)
neurologist 12 months Doses greater than 240 mg twice-daily will not be approved
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technivie All FDA approved indications not otherwise excluded from Part D
Severe hepatic impairment (Child-Pugh C)
Documentation of chronic hepatitis C genotype 4 without cirrhosis AND using with ribavirin unless the member is treatement-naive and has a contraindication or intolerance to ribavirin
Deny if less than 18 years of age
12 weeks
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All medically accepted indications not otherwise excluded from Part D
testosterone (androgens)
Documentation of primary or secondary hypogonadism in males with testicular failure due to cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, orchidectomy, Klinefelter's syndrome, chemotherapy, radiation or toxic damage -OR- documentation of primary or secondary hypogonadism in males with multiple symptoms of hypogonadism including at least one of the following specific symptoms: h i h l d
Deny if less than recommended age per FDA product labeling
12 months
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height loss due to vertebral fractures, low trauma fractures, low bone density, incomplete or delayed sexual development, breast discomfort, loss of axillar and/or pubic body hair, hot flushes -OR- documentation of HIV infection in men with weight loss -OR- documentation of chronic steroid treatment in men. In all previously noted indications, members must also have documented low testosterone level below the normal range for the laboratory -OR- a total testosterone
Medicare Part D: PA Criteria
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Prescriber Restrictions
Coverage Duration Other Criteria
total testosterone level near the lower limit of the normal range with a low free testosterone level which is less than normal based upon the laboratory reference range. Additional approvable indications include vulvar dystrophies in women (topical ointment only) -AND- palliative treatment in female patients with metastatic breast cancer (testosterone enanthate only), primary or secondary hypogonadism in males with testicular failure due to double orchidectomy
Medicare Part D: PA Criteria
147 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
orchidectomy
Medicare Part D: PA Criteria
148 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
thalomid All FDA approved indications not otherwise excluded from Part D
documentation of multiple myeloma -OR- documentation for use in the treatment or prophylaxis of cutaneous manifestations of moderate to severe erythema nodosum leprosum
12 months Applies to new starts only
Medicare Part D: PA Criteria
149 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
documentation of diagnosis of chronic immune idiopathic thrombocytopenia purpura and trial and failure of corticosteroid or immunoglobulin therapy or splenectomy -OR- documentation of thrombocytopenia in patients with chronic hepatitis C to allow the initiation and maintenance of interferon-based therapy (eltrombopag only)
Platelet count to be provided12 monthsAll FDA approved indications not otherwise excluded from Part D
thrombopoiesis stimulating agents
Medicare Part D: PA Criteria
150 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
transmucosal fentanyl citrate
All FDA approved indications not otherwise excluded from Part D
documentation of therapeutic use and long acting opioid therapy
12 months
Medicare Part D: PA Criteria
151 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria12 months Applies to new starts onlyDocumentation of
Tykerb in combination with Xeloda (capecitabine) for patients with advanced, metastatic breast cancer that is HER2 positive who have received prior therapy, including a taxane, an anthracycline and trastuzumab (Herceptin) -OR- documentation of Tykerb in combination with Femara (letrozole) for the treatment of postmenopausal women with hormone receptor positive metastatic breast cancer that over expresses the HER2 f
All FDA approved indications not otherwise excluded from Part D
tykerb oncologist
Medicare Part D: PA Criteria
152 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
HER2 receptor for whom hormonal therapy is indicated
Medicare Part D: PA Criteria
153 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Documentation of cutaneous manifestations in patients with cutaneous T-cell lymphoma who have limited localized or generalized skin involvement who received at least one prior skin directed therapy -OR- documentation of cutaneous manifestations in patients with cutaneous T-cell lymphoma who have limited localized or generalized skin involvement and mechlorethamine gel will be used in combination with
h ki di d
All FDA approved indications not otherwise excluded from Part D
VALCHLOR 12 months Applies to new starts only
Medicare Part D: PA Criteria
154 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
other skin directed therapies. Skin directed therapies may include but are not limited to topical corticosteroids, topical chemotherapy, local radiation and topical retinoids.
Medicare Part D: PA Criteria
155 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
veltassa All FDA approved indications not otherwise excluded from Part D
Documentation of hyperkalemia as defined by serum potassium level between 5.1 and 6.4 mmol/L on at least two (2) screenings -AND- modification of medications to reduce serum potassium levels, when applicable -AND- trial and failure, intolerance, or contraindication to sodium polystyrene sulfonate
Deny if less than 18 years of age
6 months For reauthorization, documentation of reduction in serum potassium levels following Veltassa administration is required.
Medicare Part D: PA Criteria
156 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
venclexta All FDA approved indications not otherwise excluded from Part D
Documentation of chronic lymphocytic leukemia (CLL) with 17p deletion -AND- previous treatment with at least one prior therapy
12 months Applies to new starts only
viberzi All FDA approved indications not otherwise excluded from Part D
Severe (Child-Pugh C) hepatic impairment
Documentation of diarrhea predominant, irritable bowel syndrome (IBS-D) -AND- no alcohol abuse in the previous six months.
12 months
Medicare Part D: PA Criteria
157 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
VIEKIRA PAK
All FDA approved indications not otherwise excluded from Part D
Severe (Child-Pugh C) hepatic impairment
Criteria will be applied consistent with current AASLD/IDSA guidance
Deny if less than 18 years of age
12wk: gt 1a noncirr -OR- gt 1b. 24wk: gt1a cirr -OR- gt 1 in allograft
Doses greater than four tablets per day will not be approved.
viibryd All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis major depressive disorder and trial and failure of any two antidepressants
12 months Applies to new starts only
Medicare Part D: PA Criteria
158 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
vimovo All FDA approved indications not otherwise excluded from Part D
Documentation of diagnosis -AND- Both of the following. 1) Trial/failure of naproxen used in combination with omeprazole. 2) Trial/failure of one additional generic formulary NSAID (other than naproxen) used in combination with another generic formulary PPI (other than omeprazole).
Deny if less than 18 years of age
12 months
Medicare Part D: PA Criteria
159 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
votrient All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis (renal cell carcinoma) -OR- documentation of advanced soft- tissue sarcoma excluding adipocytic soft tissue sarcoma or gastrointestinal stromal tumors after failure of at least one prior chemotherapy regimen
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
160 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
vraylar All FDA approved indications not otherwise excluded from Part D
Documentation of schizophrenia OR acute treatment of manic or mixed episodes associated with bipolar I disorder
Deny if less than 18 years of age
12 months Applies to new starts only
xalkori All FDA approved indications not otherwise excluded from Part D
Documentation of locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK) positive
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
161 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
xeljanz All FDA approved indications not otherwise excluded from Part D
concomitant use of Enbrel, Remicade, Humira, Kineret, Simponi, Orencia, Stelara, Actemra, azathioprine, cyclosporine
Documentation of moderate to severe rheumatoid arthritis and an inadequate response or intolerance to methotrexate
12 months Doses greater than 10 mg per day for Xeljanz and 11 mg per day for Xeljanz XR will not be approved. Patients must have an adequate trial or intolerance to the preferred products, Enbrel and Humira, for rheumatoid arthritis.
xenazine All FDA approved indications not otherwise excluded from Part D
documentation of diagnosis
12 months Patients with comorbid depression should be on an antidepressant medication.
Medicare Part D: PA Criteria
162 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Documentation of 1 or 2. 1) Diagnosis of hepatic encephalopathy AND trial/failure, intolerance, or contraindication to lactulose. 2) Diagnosis of Irritable Bowel Syndrome with Diarrhea (IBS-D) AND trial/failure, intolerance to two of the following medications for IBS-D or documentation of contraindication to all: loperamide, cholestyramine, Colestipol, dicyclomine, tricyclic antidepressants, selective serotonin reuptake inhibitors.
All FDA approved indications not otherwise excluded from Part D
xifaxan Deny if less than 18 years of age
Hepatic encephalopathy: 1 year. IBS-D: 14 days.
No more than three courses of rifaximin for the treatment of IBS-D will be approved per lifetime.
Medicare Part D: PA Criteria
163 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
xtandi All FDA approved indications not otherwise excluded from Part D
Documentation of metastatic castration-resistant prostate cancer and prior therapy with docetaxel
12 months Applies to new starts only
Medicare Part D: PA Criteria
164 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
xyrem All FDA approved indications not otherwise excluded from Part D
Documentation of excessive daytime sleepiness in patients with a diagnosis of narcolepsy as documented by MSLT less than 10 min or other appropriate testing -OR- documentation of cataplexy associated with narcolepsy as documented by MSLT or other appropriate testing.
12 months
zelboraf All FDA approved indications not otherwise excluded from Part D
Wild-type BRAF melanoma Documentation of unresectable or metastatic melanoma with BRAFV600E mutation
oncologist, hematologist
12 months Applies to new starts only
Medicare Part D: PA Criteria
165 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
zepatier All FDA approved indications not otherwise excluded from Part D
Severe (Child-Pugh C) hepatic impairment
Criteria will be applied consistent with current AASLD/IDSA guidance
Deny if less than 18 years of age
12wk:gt1a without NS5A-OR-gt1b-OR-gt4 tx naive. 16wk:gt1a with NS5A-OR-gt4 tx exp.
Medicare Part D: PA Criteria
166 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
zolinza Documentation of cutaneous manifestations in patients with cutaneous T-cell lymphoma (CTCL) who have progressive, persistent, or recurrent disease on or following 2 systemic therapies. Systemic therapies include bexarotene, interferon alpha, extracorpeal photochemotherapy, PUVA, single agent or combination chemotherapies (e.g. cyclophosphamide, vinblastine, romidepsin)
Applies to new starts only12 monthsoncologist, hematologist
Medicare Part D: PA Criteria
167 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
Medicare Part D: PA Criteria
168 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
All FDA approved indications not otherwise excluded from Part D
ZYDELIG Documentation of relapsed chronic lymphocytic leukemia (CLL) and use in combination with rituximab in patients for whom rituximab alone would be considered appropriate therapy due to other co-morbidities -OR- documentation of relapsed follicular B-cell non-Hodgkin lymphoma (FL) in patients who have received at least two prior systemic therapies (e.g. alkylating agents, single or multi-drug chemotherapy, target immunotherapy) -OR- documentation f l d ll
Applies to new starts only12 months
Medicare Part D: PA Criteria
169 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
of relapsed small lymphocytic lymphoma (SLL) in patients who have received at least two prior systemic therapies (e.g. alkylating agents, single or multi-drug chemotherapy, target immunotherapy)
Medicare Part D: PA Criteria
170 Formulary ID: 17499 Version 7 Updated 01/2017
PA Group Covered Use Exclusion CriteriaRequired Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration Other Criteria
zykadia All FDA approved indications not otherwise excluded from Part D
Documentation of non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK) positive AND previous trial and failure or intolerance to crizotinib (Xalkori)
12 months Applies to new starts only
zytiga All FDA approved indications not otherwise excluded from Part D
Documentation of metastatic castration resistant prostate cancer and concurrent use with prednisone
12 months Applies to new starts only