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Select Drug List Drug list — Four Tier Drug Plan
Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). Here are a few things to remember about the list:
o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket.
o Your coverage has limitations and exclusions, which means there are certain rules about what’s covered by your plan and what isn’t. To find out more, read your Certificate or Evidence of Coverage or your Summary Plan Description. To download those documents, log in to anthem.com and select Plan Information from the menu.
o To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) about how the list is set up and what to do if a drug you take isn't on it.go
o The most up-to-date drug list for your plan - including drugs that have been added, generic drugs and more - is available at anthem.com/pharmacyinformation. Select the Select Drug List.
If you have questions about your pharmacy benefits, we're here to help. Just call us at the Member Services number on your ID card.
05267MEMENABS IND
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What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes hundreds of brand-name and generic drugs approved by the U.S. Food & Drug Administration (FDA). Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan. How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:
o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for. o Drug class, using the categories listed in alphabetical order.
The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST). When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:
o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions.
o Tier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they’re newer to the market.
o Tier 3 drugs have a higher cost share. They often include non-preferred brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.
o Tier 4 drugs have the highest cost share and usually include specialty brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.
How will I know how much my drug will cost? You can go online to estimate your share of a drug’s cost and compare prices at different pharmacies. Here’s how:
o At the top right of the anthem.com home page, select Manage Prescriptions from the Popular Tasks icon, then log in using your user name and password. If you haven’t signed up on the site, you’ll need to do that first.
o On your personal Pharmacy Overview page, select Price a Medication, then select one or more pharmacies and enter the name of the drug you’d like to price.
Please note: This tool will provide you with an estimate of your cost, but may not reflect the actual amount you pay at the pharmacy. Actual prices are based on your plan design and also include sales tax where applicable.
Select Drug List
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If my medicine isn’t on the drug list, what are my options? Here are a few things to think about:
o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.
o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.
o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list.
o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval
or prior authorization. Your doctor can get the process started by calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.
Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members. What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent. A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug.
Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier. You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com. Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA). A note about opioid analgesics. The member cost share for certain abuse-deterrent opioid analgesics may be lower in some states because of laws in those states. Opioid analgesics are a type of painkiller. In response to the global opioid epidemic, the U.S. Food and Drug Administration (FDA) has encouraged drug manufacturers to develop opioids with properties that help deter their misuse and abuse.
Drug(s) may be excluded from the list based on your plan's benefit design.
Search for a drug online
The most up-to-date drug list — including drugs that have been added, generic drugs and more — is always
available online when you log in at anthem.com. At the top right of the home page, choose Manage Prescriptions
from the Popular Tasks icon, then log in. On your personal Pharmacy Overview page, choose Search Your Drug
List and you can easily look up drugs by name, class or brand versus generic.
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KEY Here are some terms and notes you’ll find on the drug list.
Brand name drugs are in UPPER CASE, bold type.
Generic drugs are in lower case, plain type.
$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a
prescription from your provider if specified criteria are met.
DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once
a day at a higher strength.
LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on
what the manufacturer decides.
PA = prior authorization. You may need to get benefits approved before certain prescr iptions can be filled.
QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time.
SP = specialty drugs. Specialty drugs are used to treat difficult, long -term conditions. You may need to get this drug
through a specialty pharmacy.
ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered.
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2018 Maine Select Drug List
Table of Contents
ANALGESICS ...........................................................................................................................................................................7ANESTHETICS .........................................................................................................................................................................9ANTIARTHRITICS .................................................................................................................................................................... 9ANTIASTHMATICS ................................................................................................................................................................ 10ANTIBIOTICS ......................................................................................................................................................................... 11ANTICOAGULANTS .............................................................................................................................................................. 15ANTIDOTES ........................................................................................................................................................................... 16ANTIFUNGALS ...................................................................................................................................................................... 16ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 17ANTIHISTAMINES ..................................................................................................................................................................17ANTIHYPERGLYCEMICS ...................................................................................................................................................... 17ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................20ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ....................................................................................20ANTINEOPLASTICS .............................................................................................................................................................. 20ANTI-OBESITY DRUGS .........................................................................................................................................................22ANTIPARKINSON DRUGS .................................................................................................................................................... 22ANTIPLATELET DRUGS ....................................................................................................................................................... 23ANTIVIRALS ...........................................................................................................................................................................23AUTONOMIC DRUGS ............................................................................................................................................................ 25BIOLOGICALS ....................................................................................................................................................................... 25BLOOD ................................................................................................................................................................................... 28CARDIAC DRUGS ..................................................................................................................................................................28CARDIOVASCULAR .............................................................................................................................................................. 30CNS DRUGS ...........................................................................................................................................................................32COLONY STIMULATING FACTORS .....................................................................................................................................34CONTRACEPTIVES ............................................................................................................................................................... 34COUGH/COLD PREPARATIONS .......................................................................................................................................... 37DIAGNOSTIC ..........................................................................................................................................................................37DIURETICS .............................................................................................................................................................................38EENT PREPS ......................................................................................................................................................................... 38ELECT/CALORIC/H2O ...........................................................................................................................................................39GASTROINTESTINAL ............................................................................................................................................................41HORMONES ........................................................................................................................................................................... 43IMMUNOSUPPRESSANTS ....................................................................................................................................................45MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 45MUSCLE RELAXANTS .......................................................................................................................................................... 46PRE-NATAL VITAMINS ......................................................................................................................................................... 46PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................47SEDATIVE/HYPNOTICS ........................................................................................................................................................ 50SKIN PREPS .......................................................................................................................................................................... 50SMOKING DETERRENTS ......................................................................................................................................................53THYROID PREPS ...................................................................................................................................................................53UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................54VITAMINS ............................................................................................................................................................................... 55
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2018 Maine Select Drug List
CURRENT AS OF 4/1/2018
Drug Name Tier Notes
ANALGESICS
acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml
Tier 1 QL
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg
Tier 1 QL
almotriptan malate oral tablet
Tier 1 QL
asa-butalb-caff-cod #3 capsule
Tier 1 QL
ascomp with codeine oral capsule
Tier 1 QL
buprenorphine hcl injection solution
Tier 2 QL
buprenorphine hcl injection syringe
Tier 2 QL
butalbital compound w/codeine oral capsule
Tier 1 QL
butalbital compound-codeine oral capsule
Tier 1 QL
butalbital-acetaminop-caf-cod oral capsule
Tier 1 QL
butalbital-acetaminophen oral tablet
Tier 1
butalbital-acetaminophen-caff oral capsule
Tier 1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Tier 1
butalbital-aspirin-caffeine oral capsule
Tier 1
butalbital-aspirin-caffeine oral tablet
Tier 1
butorphanol tartrate nasal spray,non-aerosol
Tier 1 PA; QL
capacet oral capsule Tier 1
codeine sulfate oral tablet 15 mg, 30 mg, 60 mg
Tier 2 QL
diclofenac potassium oral tablet
Tier 1
Drug Name Tier Notes
diflunisal oral tablet Tier 1
dihydroergotamine nasal spray,non-aerosol
Tier 2 QL
diskets oral tablet,soluble Tier 1 PA; QL
eletriptan hbr oral tablet Tier 2 QL
ELMIRON ORAL CAPSULE
Tier 3
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL
Tier 1 PA; QL
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 2 QL
ergotamine-caffeine oral tablet
Tier 1
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Tier 2 PA; QL
frovatriptan oral tablet Tier 2 QL
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
Tier 1 QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
Tier 1 QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
Tier 1 QL
hydromorphone oral liquid Tier 1 QL
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
Tier 1 QL
hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg
Tier 2 PA; QL
hydromorphone rectal suppository
Tier 2 QL
ibuprofen-oxycodone oral tablet
Tier 1 QL
isometh-dichloral-acetaminophn oral capsule
Tier 1
ketorolac oral tablet Tier 1 QL
levorphanol tartrate oral tablet
Tier 2 PA; QL
Effective 4/1/2018
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Drug Name Tier Notes
marten-tab oral tablet Tier 1
mefenamic acid oral capsule
Tier 1 QL
meperidine oral solution Tier 1 QL
meperidine oral tablet 100 mg, 50 mg
Tier 1 QL
methadone intensol oral concentrate
Tier 1 PA; QL
methadone oral concentrate
Tier 1 PA; QL
methadone oral solution 10 mg/5 ml, 5 mg/5 ml
Tier 1 PA; QL
methadone oral tablet 10 mg, 5 mg
Tier 1 PA; QL
methadone oral tablet,soluble
Tier 1 PA; QL
methadose oral concentrate
Tier 1 PA; QL
methadose oral tablet,soluble
Tier 1 PA; QL
migergot rectal suppository
Tier 1
morphine concentrate oral solution
Tier 1 QL
morphine oral capsule,extend.release pellets
Tier 2 PA; QL
morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)
Tier 1 QL
morphine oral tablet 15 mg, 30 mg
Tier 1 QL
morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg
Tier 2 PA; QL
morphine rectal suppository
Tier 1 QL
naratriptan oral tablet Tier 1 QL
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 PA; QL
NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG
Tier 3 QL
oxycodone oral capsule Tier 2 QL
Drug Name Tier Notes
oxycodone oral concentrate
Tier 2 QL
oxycodone oral solution Tier 2 QL
oxycodone oral syringe Tier 2 QL
oxycodone oral tablet Tier 2 QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1 QL
oxycodone-aspirin oral tablet
Tier 1 QL
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG
Tier 1 PA; QL
oxymorphone oral tablet 10 mg, 5 mg
Tier 2 QL
oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg
Tier 2 PA; QL
pentazocine-naloxone oral tablet
Tier 1 QL
rizatriptan oral tablet Tier 1 QL
rizatriptan oral tablet,disintegrating
Tier 1 QL
sumatriptan nasal spray,non-aerosol
Tier 1 QL
sumatriptan succinate oral tablet
Tier 1 QL
sumatriptan succinate subcutaneous cartridge
Tier 2 QL
sumatriptan succinate subcutaneous pen injector
Tier 2 QL
sumatriptan succinate subcutaneous solution
Tier 2 QL
tencon oral tablet 50-325 mg
Tier 1
tramadol oral tablet Tier 1 QL
tramadol oral tablet extended release 24 hr
Tier 2 PA; QL
tramadol oral tablet, er multiphase 24 hr
Tier 2 PA; QL
vicodin es oral tablet Tier 2 QL
vicodin hp oral tablet Tier 2 QL
Effective 4/1/2018
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Drug Name Tier Notes
vicodin oral tablet Tier 2 QL
zebutal oral capsule 50-325-40 mg
Tier 2
ZIPSOR ORAL CAPSULE Tier 3 QL
ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG
Tier 3 PA; QL
zolmitriptan oral tablet Tier 1 QL
zolmitriptan oral tablet,disintegrating
Tier 1 QL
ANESTHETICS
lidocaine viscous mucous membrane solution
Tier 1 QL
lidocaine-prilocaine topical cream
Tier 1 QL
lidocaine-prilocaine topical kit
Tier 1
phenazopyridine oral tablet 100 mg, 200 mg
Tier 1
SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING
Tier 3
ANTIARTHRITICS
allopurinol oral tablet Tier 1
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
Tier 2 ST; QL
COLCRYS ORAL TABLET
Tier 3 PA; QL
CUPRIMINE ORAL CAPSULE
Tier 3
diclofenac sodium oral tablet extended release 24 hr
Tier 1
diclofenac sodium oral tablet,delayed release (dr/ec)
Tier 1
etodolac oral capsule Tier 1
etodolac oral tablet Tier 1
etodolac oral tablet extended release 24 hr
Tier 1
fenoprofen oral tablet Tier 1 QL
flurbiprofen oral tablet Tier 1
ibuprofen oral suspension Tier 1 QL
Drug Name Tier Notes
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
indomethacin oral capsule 25 mg, 50 mg
Tier 1 QL
indomethacin oral capsule, extended release
Tier 1 QL
ketoprofen oral capsule Tier 1
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
Tier 1 QL
meclofenamate oral capsule
Tier 1
meloxicam oral suspension
Tier 1 QL
meloxicam oral tablet Tier 1 QL
nabumetone oral tablet Tier 1
naproxen oral suspension Tier 1
naproxen oral tablet Tier 1
naproxen oral tablet,delayed release (dr/ec)
Tier 1
naproxen sodium oral tablet 275 mg, 550 mg
Tier 1
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN
Tier 4 PA; SP; QL
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR
Tier 4 PA; SP; QL
ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML
Tier 4 PA; SP; QL
ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML
Tier 4 PA; QL
oxaprozin oral tablet Tier 1
piroxicam oral capsule Tier 1
probenecid oral tablet Tier 1
probenecid-colchicine oral tablet
Tier 1
RIDAURA ORAL CAPSULE
Tier 3
sulindac oral tablet Tier 1
tolmetin oral capsule Tier 2
Effective 4/1/2018
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Drug Name Tier Notes
tolmetin oral tablet Tier 2
ULORIC ORAL TABLET Tier 3 ST
XELJANZ ORAL TABLET Tier 4 PA; SP; QL
ANTIASTHMATICS
acetylcysteine solution Tier 2
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
ADVAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
albuterol sulfate inhalation solution for nebulization
Tier 1
albuterol sulfate oral syrup Tier 1
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
Tier 2 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)
Tier 2
BREO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
BROVANA INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
Tier 1 QL
cromolyn inhalation solution for nebulization
Tier 2
DALIRESP ORAL TABLET
Tier 3 QL
Drug Name Tier Notes
DULERA INHALATION HFA AEROSOL INHALER
Tier 2 QL
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION
Tier 2 QL
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION
Tier 2 QL
ipratropium bromide inhalation solution
Tier 1 QL
ipratropium-albuterol inhalation solution for nebulization
Tier 2
levalbuterol hcl inhalation solution for nebulization
Tier 2
metaproterenol oral syrup Tier 1
metaproterenol oral tablet Tier 1
montelukast oral granules in packet
Tier 1 QL
montelukast oral tablet Tier 1 QL
montelukast oral tablet,chewable
Tier 1 QL
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
PROAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
PROVENTIL HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
Effective 4/1/2018
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Drug Name Tier Notes
QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION
Tier 2 QL
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
SPIRIVA RESPIMAT INHALATION MIST
Tier 3 QL
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
STRIVERDI RESPIMAT INHALATION MIST
Tier 3 QL
SYMBICORT INHALATION HFA AEROSOL INHALER
Tier 2 QL
terbutaline oral tablet Tier 2
theochron oral tablet extended release 12 hr
Tier 1
theophylline oral elixir Tier 1
theophylline oral solution Tier 1
theophylline oral tablet extended release 12 hr
Tier 1
theophylline oral tablet extended release 24 hr
Tier 1
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 3 QL
VENTOLIN HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
XOPENEX HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
zafirlukast oral tablet Tier 1
zileuton oral tablet, er multiphase 12 hr
Tier 2 PA
ANTIBIOTICS
amoxicillin oral capsule Tier 1
amoxicillin oral suspension for reconstitution
Tier 1
amoxicillin oral tablet Tier 1
Drug Name Tier Notes
amoxicillin oral tablet,chewable 125 mg, 250 mg
Tier 1
amoxicillin-pot clavulanate oral suspension for reconstitution
Tier 1
amoxicillin-pot clavulanate oral tablet
Tier 1
amoxicillin-pot clavulanate oral tablet extended release 12 hr
Tier 1
amoxicillin-pot clavulanate oral tablet,chewable
Tier 1
ampicillin oral capsule Tier 1
avidoxy oral tablet Tier 1
AZASITE OPHTHALMIC (EYE) DROPS
Tier 3
azithromycin oral packet Tier 1 QL
azithromycin oral suspension for reconstitution
Tier 1 QL
azithromycin oral tablet 250 mg, 500 mg, 600 mg
Tier 1 QL
bacitracin ophthalmic (eye) ointment
Tier 1
bacitracin-polymyxin b ophthalmic (eye) ointment
Tier 1
BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
bp 10-1 topical cleanser Tier 1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION
Tier 4 SP; LD
cefaclor oral capsule Tier 1
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Tier 1
cefaclor oral tablet extended release 12 hr
Tier 2
cefadroxil oral capsule Tier 1
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
Tier 1
cefadroxil oral tablet Tier 1
Effective 4/1/2018
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Drug Name Tier Notes
cefazolin in dextrose 5 % intravenous solution
Tier 1
cefdinir oral capsule Tier 1
cefdinir oral suspension for reconstitution
Tier 1
cefditoren pivoxil oral tablet
Tier 2
cefpodoxime oral suspension for reconstitution
Tier 2
cefpodoxime oral tablet Tier 2
cefprozil oral suspension for reconstitution
Tier 1
cefprozil oral tablet Tier 1
cefuroxime axetil oral tablet
Tier 1
cephalexin oral capsule Tier 1
cephalexin oral suspension for reconstitution
Tier 1
cephalexin oral tablet Tier 1
CIPRO HC OTIC (EAR) DROPS,SUSPENSION
Tier 3
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
Tier 3 PA
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg
Tier 1 QL
ciprofloxacin hcl ophthalmic (eye) drops
Tier 1
ciprofloxacin hcl oral tablet Tier 1 QL
ciprofloxacin hcl otic (ear) dropperette
Tier 1
clarithromycin oral suspension for reconstitution
Tier 1
clarithromycin oral tablet Tier 1
clarithromycin oral tablet extended release 24 hr
Tier 1
cleansing wash topical cleanser
Tier 1
clindamycin hcl oral capsule
Tier 1
clindamycin palmitate hcl oral recon soln
Tier 1
Drug Name Tier Notes
clindamycin pediatric oral recon soln
Tier 1
clindamycin phosphate topical foam
Tier 1
clindamycin phosphate topical gel
Tier 1
clindamycin phosphate topical lotion
Tier 1
clindamycin phosphate topical solution
Tier 1
clindamycin phosphate topical swab
Tier 1
clindamycin phosphate vaginal cream
Tier 1
COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION
Tier 3
CORTISPORIN TOPICAL CREAM
Tier 3
CORTISPORIN TOPICAL OINTMENT
Tier 3
CYCLOSERINE ORAL CAPSULE
Tier 3
DAPSONE ORAL TABLET
Tier 2
demeclocycline oral tablet Tier 2
dicloxacillin oral capsule Tier 1
DIFICID ORAL TABLET Tier 3 PA
doxycycline hyclate oral capsule
Tier 1
doxycycline hyclate oral tablet 100 mg
Tier 1
doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg
Tier 1 PA
doxycycline monohydrate oral capsule
Tier 1
doxycycline monohydrate oral suspension for reconstitution
Tier 1
doxycycline monohydrate oral tablet
Tier 1
e.e.s. 400 oral tablet Tier 2
ery pads topical swab Tier 1
erygel topical gel Tier 1
Effective 4/1/2018
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Drug Name Tier Notes
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
Tier 1
erythrocin (as stearate) oral tablet 250 mg
Tier 1
erythromycin ethylsuccinate oral tablet
Tier 2
erythromycin ophthalmic (eye) ointment
Tier 1
erythromycin oral capsule,delayed release(dr/ec)
Tier 2
erythromycin oral tablet Tier 2
erythromycin with ethanol topical gel
Tier 1
erythromycin with ethanol topical solution
Tier 1
erythromycin with ethanol topical swab
Tier 1
erythromycin-benzoyl peroxide topical gel
Tier 1
ethambutol oral tablet Tier 2
FACTIVE ORAL TABLET Tier 3 QL
gatifloxacin ophthalmic (eye) drops
Tier 1
gentak ophthalmic (eye) ointment
Tier 1
gentamicin ophthalmic (eye) drops
Tier 1
gentamicin ophthalmic (eye) ointment
Tier 1
gentamicin topical cream Tier 1
gentamicin topical ointment
Tier 1
INVANZ INJECTION RECON SOLN
Tier 3
INVANZ INTRAVENOUS RECON SOLN
Tier 3
isoniazid oral solution Tier 1
isoniazid oral tablet Tier 1
levofloxacin ophthalmic (eye) drops
Tier 1
levofloxacin oral tablet Tier 2 QL
linezolid oral suspension for reconstitution
Tier 2 PA; QL
linezolid oral tablet Tier 2 PA; QL
Drug Name Tier Notes
mafenide acetate topical packet
Tier 2
methenamine hippurate oral tablet
Tier 2
methenamine mandelate oral tablet
Tier 2
metronidazole oral capsule
Tier 1
metronidazole oral tablet Tier 1
metronidazole vaginal gel Tier 1
minocycline oral capsule Tier 1
minocycline oral tablet Tier 1
minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg
Tier 1 PA
MONUROL ORAL PACKET
Tier 3
morgidox oral capsule 100 mg
Tier 1
MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR
Tier 3
moxifloxacin ophthalmic (eye) drops
Tier 1
mupirocin topical ointment Tier 1
neomycin oral tablet Tier 1
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment
Tier 1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment
Tier 1
neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension
Tier 1
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment
Tier 1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops
Tier 1
neomycin-polymyxin-hc ophthalmic (eye) drops,suspension
Tier 1
neomycin-polymyxin-hc otic (ear) drops,suspension
Tier 1
Effective 4/1/2018
13
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Drug Name Tier Notes
neomycin-polymyxin-hc otic (ear) solution
Tier 1
neo-polycin hc ophthalmic (eye) ointment
Tier 1
neo-polycin ophthalmic (eye) ointment
Tier 1
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
Tier 1
nitrofurantoin monohyd/m-cryst oral capsule
Tier 1
nitrofurantoin oral suspension
Tier 1
ofloxacin ophthalmic (eye) drops
Tier 1
ofloxacin oral tablet 300 mg, 400 mg
Tier 1 QL
ofloxacin otic (ear) drops Tier 1
ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE
Tier 3
penicillin v potassium oral recon soln
Tier 1
penicillin v potassium oral tablet
Tier 1
polycin ophthalmic (eye) ointment
Tier 1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops
Tier 1
PRIFTIN ORAL TABLET Tier 3
PRIMSOL ORAL SOLUTION
Tier 3
pyrazinamide oral tablet Tier 2
rifabutin oral capsule Tier 2
rifampin oral capsule Tier 2
RIFATER ORAL TABLET Tier 3
silver sulfadiazine topical cream
Tier 1
SIRTURO ORAL TABLET Tier 3
SIVEXTRO ORAL TABLET
Tier 3 PA; QL
ssd topical cream Tier 1
sss 10-5 topical cream Tier 1
sss 10-5 topical foam Tier 1
Drug Name Tier Notes
sulfacetamide sodium ophthalmic (eye) drops
Tier 1
sulfacetamide sodium ophthalmic (eye) ointment
Tier 1
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %
Tier 1
sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical pads, medicated 10-4 %
Tier 1
sulfacetamide sodium-sulfur topical suspension
Tier 1
sulfacetamide sod-sulfur-urea topical cleanser
Tier 1
sulfacetamide-prednisolone ophthalmic (eye) drops
Tier 1
sulfacetamide-sulfur-cleansr23 topical kit
Tier 1
sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream
Tier 1
sulfadiazine oral tablet Tier 2
sulfamethoxazole-trimethoprim oral suspension
Tier 1
sulfamethoxazole-trimethoprim oral tablet
Tier 1
SULFAMYLON TOPICAL CREAM
Tier 3
sulfatrim oral suspension Tier 1
SUPRAX ORAL CAPSULE
Tier 3
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML
Tier 3
tetracycline oral capsule Tier 1
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
Tier 4 PA; SP; QL
Effective 4/1/2018
14
Page 15
Drug Name Tier Notes
TOBRADEX OPHTHALMIC (EYE) OINTMENT
Tier 3
tobramycin in 0.225 % nacl inhalation solution for nebulization
Tier 4 SP
tobramycin ophthalmic (eye) drops
Tier 1
tobramycin-dexamethasone ophthalmic (eye) drops,suspension
Tier 1
TRECATOR ORAL TABLET
Tier 3
trimethoprim oral tablet Tier 1
vancomycin oral capsule Tier 2 PA
vandazole vaginal gel Tier 1
XIFAXAN ORAL TABLET200 MG, 550 MG
Tier 3 PA; QL
ANTICOAGULANTS
ELIQUIS ORAL TABLET2.5 MG, 5 MG
Tier 3 QL
ELIQUIS ORAL TABLETS,DOSE PACK
Tier 3 QL
enoxaparin subcutaneous solution
Tier 4 QL
enoxaparin subcutaneous syringe
Tier 4 QL
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
Tier 4 PA; QL
FRAGMIN SUBCUTANEOUS SOLUTION
Tier 4 QL
FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML
Tier 4 QL
hep flush-10 (pf) intravenous solution
Tier 1
Drug Name Tier Notes
heparin (porcine) in 0.9% nacl intravenous parenteral solution 10,000 unit/1,000 ml, 100 unit/100 ml (1 unit/ml), 2,500 unit/500 ml (5 unit/ml), 250 unit/250 ml (1 unit/ml), 3,000 unit/500 ml (6 unit/ml), 30,000 unit/1,000 ml, 5,000 unit/1,000 ml
Tier 1
heparin (porcine) in 0.9% nacl intravenous syringe 30 unit/3 ml (10 unit/ml)
Tier 1
heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)
Tier 1
heparin (porcine) in nacl (pf) intravenous parenteral solution
Tier 1
heparin (porcine) injection cartridge
Tier 1
heparin (porcine) injection solution
Tier 1
heparin flush(porcine)-0.9nacl intravenous kit
Tier 1
heparin lock flush (porcine) intravenous solution
Tier 1
heparin lock flush (porcine) intravenous syringe
Tier 1
heparin lock flush intravenous solution
Tier 1
heparin lock flush intravenous syringe
Tier 1
heparin lock intravenous solution
Tier 1
heparin lockflush(porcine)(pf) intravenous syringe
Tier 1
heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml, 5,000 unit/1,000 ml
Tier 1
Effective 4/1/2018
15
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Drug Name Tier Notes
heparin, porcine (pf) injection solution
Tier 1
heparin, porcine (pf) injection syringe
Tier 1
heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)
Tier 1
heparin, porcine (pf) intravenous syringe
Tier 1
jantoven oral tablet Tier 1
PRADAXA ORAL CAPSULE
Tier 3 QL
warfarin oral tablet Tier 1
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG
Tier 3 PA; QL
XARELTO ORAL TABLETS,DOSE PACK
Tier 3 PA; QL
ANTIDOTES
naloxone injection solution Tier 2 QL
naloxone injection syringe Tier 2 QL
naltrexone oral tablet Tier 1
ANTIFUNGALS
ciclopirox topical cream Tier 1
ciclopirox topical gel Tier 1
ciclopirox topical shampoo Tier 1
ciclopirox topical solution Tier 1
ciclopirox topical suspension
Tier 1
clotrimazole mucous membrane troche
Tier 2 QL
clotrimazole topical cream Tier 1
clotrimazole topical solution
Tier 1
clotrimazole-betamethasone topical cream
Tier 1
clotrimazole-betamethasone topical lotion
Tier 1
econazole topical cream Tier 1
ERTACZO TOPICAL CREAM
Tier 3
EXELDERM TOPICAL CREAM
Tier 3
Drug Name Tier Notes
EXELDERM TOPICAL SOLUTION
Tier 3
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml
Tier 1 QL
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
Tier 1 QL
flucytosine oral capsule Tier 2
griseofulvin microsize oral suspension
Tier 1
griseofulvin microsize oral tablet
Tier 1
griseofulvin ultramicrosize oral tablet
Tier 1
GYNAZOLE-1 VAGINAL CREAM
Tier 3
itraconazole oral capsule Tier 2 PA; QL
JUBLIA TOPICAL SOLUTION WITH APPLICATOR
Tier 3
KERYDIN TOPICAL SOLUTION WITH APPLICATOR
Tier 3
ketoconazole oral tablet Tier 1 QL
ketoconazole topical cream
Tier 1
ketoconazole topical foam Tier 1
ketoconazole topical shampoo
Tier 1
LUZU TOPICAL CREAM Tier 3
MENTAX TOPICAL CREAM
Tier 3
miconazole-3 vaginal suppository
Tier 1
NAFTIFINE TOPICAL CREAM 1 %
Tier 2
naftifine topical cream 2 % Tier 2
NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
NOXAFIL ORAL SUSPENSION
Tier 3 QL
nyamyc topical powder Tier 1
Effective 4/1/2018
16
Page 17
Drug Name Tier Notes
nystatin oral powder 150 million unit, 500 million unit
Tier 1
nystatin oral suspension Tier 1
nystatin oral tablet Tier 1
nystatin topical cream Tier 1
nystatin topical ointment Tier 1
nystatin topical powder Tier 1
nystatin-triamcinolone topical cream
Tier 1
nystatin-triamcinolone topical ointment
Tier 1
nystop topical powder Tier 1
ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET
Tier 3
oxiconazole topical cream Tier 2
OXISTAT TOPICAL LOTION
Tier 3
terbinafine hcl oral tablet Tier 1 PA; QL
terconazole vaginal cream Tier 1
terconazole vaginal suppository
Tier 1
voriconazole oral suspension for reconstitution
Tier 2 PA; QL
voriconazole oral tablet 200 mg, 50 mg
Tier 2 PA; QL
ANTIHISTAMINE AND DECONGESTANT COMBINATION
promethazine vc oral syrup
Tier 1
promethazine-phenylephrine syr
Tier 1
ANTIHISTAMINES
azelastine ophthalmic (eye) drops
Tier 1 QL
BEPREVE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
carbinoxamine maleate oral liquid
Tier 1
carbinoxamine maleate oral tablet
Tier 1
cetirizine oral solution 1 mg/ml
Tier 1
Drug Name Tier Notes
clemastine oral tablet 2.68 mg
Tier 1
cyproheptadine oral syrup Tier 1
cyproheptadine oral tablet Tier 1
desloratadine oral tablet Tier 1
desloratadine oral tablet,disintegrating
Tier 1
diphenhydramine hcl injection solution 50 mg/ml
Tier 2
diphenhydramine hcl injection syringe
Tier 2
diphenhydramine hcl oral capsule 50 mg
Tier 1
EMADINE OPHTHALMIC (EYE) DROPS
Tier 3 ST; QL
epinastine ophthalmic (eye) drops
Tier 1 QL
fexofenadine oral tablet 180 mg
Tier 1
hydroxyzine hcl oral solution 10 mg/5 ml
Tier 1
hydroxyzine hcl oral tablet Tier 1
hydroxyzine pamoate oral capsule
Tier 1
LASTACAFT OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
levocetirizine oral solution Tier 1
levocetirizine oral tablet Tier 1
olopatadine ophthalmic (eye) drops 0.1 %, 0.2 %
Tier 2 PA; QL
promethazine oral syrup Tier 1
promethazine oral tablet Tier 1
ANTIHYPERGLYCEMICS
acarbose oral tablet Tier 1
APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 3 ST
APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 3 ST
AVANDIA ORAL TABLET2 MG, 4 MG
Tier 3 ST; QL
Effective 4/1/2018
17
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Drug Name Tier Notes
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON
Tier 3 ST; QL
chlorpropamide oral tablet Tier 1
CYCLOSET ORAL TABLET
Tier 3
FARXIGA ORAL TABLET Tier 3 ST; QL
glimepiride oral tablet Tier 1
glipizide oral tablet Tier 1
glipizide oral tablet extended release 24hr
Tier 1
glipizide-metformin oral tablet
Tier 1
glyburide micronized oral tablet
Tier 1
glyburide oral tablet Tier 1
glyburide-metformin oral tablet
Tier 1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT
Tier 2
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
Drug Name Tier Notes
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE
Tier 2
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION
Tier 2
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
INVOKAMET ORAL TABLET
Tier 3 ST; QL
INVOKANA ORAL TABLET
Tier 3 ST; QL
JANUMET ORAL TABLET
Tier 2 ST; QL
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG
Tier 2 ST; QL
Effective 4/1/2018
18
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Drug Name Tier Notes
JANUVIA ORAL TABLET Tier 2 ST; QL
JARDIANCE ORAL TABLET
Tier 2 ST; QL
JENTADUETO ORAL TABLET
Tier 2 ST; QL
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN
Tier 2
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
metformin oral tablet Tier 1
metformin oral tablet extended release 24 hr
Tier 1
metformin oral tablet extended release 24hr
Tier 1
miglitol oral tablet Tier 2
nateglinide oral tablet Tier 2 PA
NESINA ORAL TABLET Tier 3 ST; QL
NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION
Tier 2
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION
Tier 2
Drug Name Tier Notes
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE
Tier 2
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION
Tier 2
ONGLYZA ORAL TABLET 2.5 MG
Tier 3 ST; DO
ONGLYZA ORAL TABLET 5 MG
Tier 3 ST; QL
pioglitazone oral tablet Tier 1 QL
repaglinide oral tablet Tier 2
repaglinide-metformin oral tablet
Tier 2
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYNJARDY ORAL TABLET
Tier 2 ST; QL
TANZEUM SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
tolazamide oral tablet Tier 1
tolbutamide oral tablet Tier 2
TRADJENTA ORAL TABLET
Tier 2 ST; DO
TRULICITY SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
Effective 4/1/2018
19
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Drug Name Tier Notes
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 2.5-1,000 MG, 5-1,000 MG, 5-500 MG
Tier 3 ST; QL
ANTIINFECTIVES/MISCELLANEOUS
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
ALINIA ORAL TABLET Tier 3
atovaquone oral suspension
Tier 2
atovaquone-proguanil oral tablet
Tier 1
BILTRICIDE ORAL TABLET
Tier 3
chloroquine phosphate oral tablet
Tier 1
COARTEM ORAL TABLET
Tier 3
DARAPRIM ORAL TABLET
Tier 3 PA; LD; QL
hydroxychloroquine oral tablet
Tier 1
ivermectin oral tablet Tier 1
mefloquine oral tablet Tier 1
NEBUPENT INHALATION RECON SOLN
Tier 4
paromomycin oral capsule Tier 1
PRIMAQUINE ORAL TABLET
Tier 3
quinine sulfate oral capsule
Tier 2 PA; QL
ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT
Tier 4 PA; SP; LD; QL
CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
CIMZIA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; LD; QL
Drug Name Tier Notes
ENBREL SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; QL
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
Tier 4 PA; SP; QL
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; SP; QL
HUMIRA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; SP; QL
SIMPONI ARIA INTRAVENOUS SOLUTION
Tier 4 PA; SP
SIMPONI SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
SIMPONI SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
ANTINEOPLASTICS
ACTIMMUNE SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION
Tier 4 PA; SP
AFINITOR ORAL TABLET
Tier 4 PA; SP
anastrozole oral tablet Tier 2 QL
bexarotene oral capsule Tier 4 PA; SP
Effective 4/1/2018
20
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Drug Name Tier Notes
bicalutamide oral tablet Tier 2
BOSULIF ORAL TABLET100 MG, 500 MG
Tier 4 PA; SP; QL
BOSULIF ORAL TABLET400 MG
Tier 4 PA; QL
capecitabine oral tablet Tier 4 PA; SP
CAPRELSA ORAL TABLET 100 MG, 300 MG
Tier 4 PA; QL
CARAC TOPICAL CREAM
Tier 2 QL
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)
Tier 4 PA; LD; QL
CYCLOPHOSPHAMIDE ORAL CAPSULE
Tier 4 SP
diclofenac sodium topical gel 3 %
Tier 2 QL
EMCYT ORAL CAPSULE Tier 4 PA
ERIVEDGE ORAL CAPSULE
Tier 4 PA; SP; QL
etoposide oral capsule Tier 4 SP
exemestane oral tablet Tier 2 PA; QL
FARESTON ORAL TABLET
Tier 4 QL
FARYDAK ORAL CAPSULE
Tier 4 PA; SP; QL
FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG
Tier 4 PA; SP; QL
fluorouracil topical cream 5 %
Tier 1 QL
fluorouracil topical solution Tier 1 QL
flutamide oral capsule Tier 2
GILOTRIF ORAL TABLET
Tier 4 PA; SP; LD; QL
GLEOSTINE ORAL CAPSULE
Tier 4 PA
HEXALEN ORAL CAPSULE
Tier 4
HYCAMTIN ORAL CAPSULE
Tier 4 SP
hydroxyurea oral capsule Tier 2
Drug Name Tier Notes
IBRANCE ORAL CAPSULE
Tier 4 PA; SP; QL
ICLUSIG ORAL TABLET15 MG, 45 MG
Tier 4 PA; QL
imatinib oral tablet 100 mg, 400 mg
Tier 4 PA; SP; QL
IMBRUVICA ORAL CAPSULE 140 MG
Tier 4 PA; LD; QL
IMBRUVICA ORAL CAPSULE 70 MG
Tier 4 PA; QL
INLYTA ORAL TABLET 1 MG, 5 MG
Tier 4 PA; SP; QL
INTRON A INJECTION RECON SOLN
Tier 4 PA; SP
INTRON A INJECTION SOLUTION
Tier 4 PA; SP
JAKAFI ORAL TABLET10 MG, 15 MG, 20 MG, 25 MG, 5 MG
Tier 4 PA; SP; LD; QL
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)
Tier 4 PA; SP; LD; QL
letrozole oral tablet Tier 2 QL
LEUKERAN ORAL TABLET
Tier 4
leuprolide subcutaneous kit
Tier 4 PA; SP
LYNPARZA ORAL CAPSULE
Tier 4 PA; SP; LD; QL
LYNPARZA ORAL TABLET
Tier 4 PA; LD; QL
LYSODREN ORAL TABLET
Tier 4 QL
MATULANE ORAL CAPSULE
Tier 4 LD
MEKINIST ORAL TABLET 0.5 MG, 2 MG
Tier 4 PA; SP; QL
melphalan oral tablet Tier 4
mercaptopurine oral tablet Tier 2
methotrexate sodium oral tablet
Tier 2
Effective 4/1/2018
21
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Drug Name Tier Notes
MYLERAN ORAL TABLET
Tier 4
NEXAVAR ORAL TABLET
Tier 4 PA; SP; QL
nilutamide oral tablet Tier 4 QL
ODOMZO ORAL CAPSULE
Tier 4 PA; SP; QL
PICATO TOPICAL GEL0.015 %, 0.05 %
Tier 3 PA; QL
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
Tier 4 PA; SP; QL
REVLIMID ORAL CAPSULE
Tier 4 PA; SP; QL
SPRYCEL ORAL TABLET
Tier 4 PA; SP; QL
STIVARGA ORAL TABLET
Tier 4 PA; SP; QL
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
Tier 4 PA; SP; QL
TABLOID ORAL TABLET Tier 4
TAFINLAR ORAL CAPSULE
Tier 4 PA; SP; QL
tamoxifen oral tablet Tier 2 $0
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
Tier 4 PA; SP; QL
TARGRETIN TOPICAL GEL
Tier 4 PA; SP
TASIGNA ORAL CAPSULE
Tier 4 PA; SP; QL
temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg
Tier 4 PA; SP; QL
tretinoin (chemotherapy) oral capsule
Tier 2
TYKERB ORAL TABLET Tier 4 PA; SP; QL
VOTRIENT ORAL TABLET
Tier 4 PA; SP; QL
XALKORI ORAL CAPSULE
Tier 4 PA; SP; QL
XTANDI ORAL CAPSULE Tier 4 PA; SP; QL
ZELBORAF ORAL TABLET
Tier 4 PA; SP; QL
ZOLINZA ORAL CAPSULE
Tier 4 PA; SP; QL
Drug Name Tier Notes
ZYDELIG ORAL TABLET Tier 4 PA; LD; QL
ZYKADIA ORAL CAPSULE
Tier 4 PA; SP; QL
ZYTIGA ORAL TABLET250 MG
Tier 4 PA; SP; QL
ZYTIGA ORAL TABLET500 MG
Tier 4 PA; QL
ANTI-OBESITY DRUGS
BELVIQ ORAL TABLET Tier 3 PA
phendimetrazine tartrate oral capsule, extended release
Tier 1 PA
phendimetrazine tartrate oral tablet
Tier 1 PA
phentermine oral capsule Tier 1 PA
phentermine oral tablet Tier 1 PA
ANTIPARKINSON DRUGS
amantadine hcl oral capsule
Tier 2 QL
amantadine hcl oral solution
Tier 2
amantadine hcl oral tablet Tier 2 QL
APOKYN SUBCUTANEOUS CARTRIDGE
Tier 4 SP; LD; QL
benztropine oral tablet Tier 1
bromocriptine oral capsule Tier 1
bromocriptine oral tablet Tier 1
carbidopa oral tablet Tier 2
carbidopa-levodopa oral tablet
Tier 1
carbidopa-levodopa oral tablet extended release
Tier 2
carbidopa-levodopa oral tablet,disintegrating
Tier 2
entacapone oral tablet Tier 2 QL
pramipexole oral tablet Tier 2 QL
rasagiline oral tablet Tier 2
ropinirole oral tablet Tier 1
ropinirole oral tablet extended release 24 hr
Tier 2
selegiline hcl oral capsule Tier 2
selegiline hcl oral tablet Tier 2
Effective 4/1/2018
22
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Drug Name Tier Notes
tolcapone oral tablet Tier 2 QL
trihexyphenidyl oral elixir Tier 1
trihexyphenidyl oral tablet Tier 1
ANTIPLATELET DRUGS
anagrelide oral capsule Tier 2
aspirin-dipyridamole oral capsule, er multiphase 12 hr
Tier 2 QL
BRILINTA ORAL TABLET
Tier 3 QL
cilostazol oral tablet Tier 2
clopidogrel oral tablet 300 mg
Tier 2
clopidogrel oral tablet 75 mg
Tier 2 QL
dipyridamole oral tablet Tier 2
prasugrel oral tablet 10 mg Tier 2 QL
prasugrel oral tablet 5 mg Tier 2 DO
ticlopidine oral tablet Tier 1
ZONTIVITY ORAL TABLET
Tier 3 QL
ANTIVIRALS
abacavir oral solution Tier 4
abacavir oral tablet Tier 4
abacavir-lamivudine oral tablet
Tier 4
abacavir-lamivudine-zidovudine oral tablet
Tier 4
acyclovir oral capsule Tier 1
acyclovir oral suspension 200 mg/5 ml
Tier 1
acyclovir oral tablet Tier 1
acyclovir topical ointment Tier 3 QL
adefovir oral tablet Tier 4 SP
APTIVUS ORAL CAPSULE
Tier 4
APTIVUS ORAL SOLUTION
Tier 4
atazanavir oral capsule Tier 4
BARACLUDE ORAL SOLUTION
Tier 4 SP
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 4
Drug Name Tier Notes
DENAVIR TOPICAL CREAM
Tier 3 QL
didanosine oral capsule,delayed release(dr/ec)
Tier 4
EDURANT ORAL TABLET
Tier 4
efavirenz oral capsule Tier 4
efavirenz oral tablet Tier 4
EMTRIVA ORAL CAPSULE
Tier 4
EMTRIVA ORAL SOLUTION
Tier 4
entecavir oral tablet Tier 4 SP
EPCLUSA ORAL TABLET
Tier 4 PA; SP; QL
EPIVIR HBV ORAL SOLUTION
Tier 4 SP
EVOTAZ ORAL TABLET Tier 4
famciclovir oral tablet Tier 1
FUZEON SUBCUTANEOUS RECON SOLN
Tier 4
GENVOYA ORAL TABLET
Tier 4
HARVONI ORAL TABLET
Tier 4 PA; SP; QL
INTELENCE ORAL TABLET
Tier 4
INVIRASE ORAL CAPSULE
Tier 4
INVIRASE ORAL TABLET
Tier 4
ISENTRESS ORAL TABLET
Tier 4
ISENTRESS ORAL TABLET,CHEWABLE
Tier 4
KALETRA ORAL TABLET
Tier 4
lamivudine oral tablet 150 mg, 300 mg
Tier 4
lamivudine-zidovudine oral tablet
Tier 4
lopinavir-ritonavir oral solution
Tier 4
Effective 4/1/2018
23
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Drug Name Tier Notes
MAVYRET ORAL TABLET
Tier 4 PA; QL
MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (28)- 400 MG (28), 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)
Tier 4
moderiba dose pack oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)
Tier 4 SP
moderiba oral tablet Tier 4 SP
nevirapine oral suspension Tier 4
nevirapine oral tablet Tier 4
NORVIR ORAL CAPSULE
Tier 4
NORVIR ORAL SOLUTION
Tier 4
NORVIR ORAL TABLET Tier 4
oseltamivir oral capsule 30 mg, 45 mg, 75 mg
Tier 2 QL
oseltamivir oral suspension for reconstitution
Tier 2 QL
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
PEGASYS SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; QL
PEGASYS SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
Tier 4 PA; SP
PREZISTA ORAL SUSPENSION
Tier 4
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Tier 4
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE
Tier 2 QL
Drug Name Tier Notes
RESCRIPTOR ORAL TABLET
Tier 4
RESCRIPTOR ORAL TABLET, DISPERSIBLE
Tier 4
ribasphere oral capsule Tier 4 SP
ribasphere oral tablet Tier 4 SP
ribasphere ribapak oral tablets,dose pack
Tier 4 SP
ribavirin oral capsule Tier 4 SP
ribavirin oral tablet 200 mg Tier 4 SP
rimantadine oral tablet Tier 1
SELZENTRY ORAL TABLET
Tier 4
SOVALDI ORAL TABLET Tier 4 PA; SP; QL
stavudine oral capsule Tier 4
stavudine oral recon soln Tier 4
STRIBILD ORAL TABLET
Tier 4
SUSTIVA ORAL TABLET Tier 4
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG
Tier 2 QL
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION
Tier 2 QL
TECHNIVIE ORAL TABLET
Tier 4 PA; SP; QL
tenofovir disoproxil fumarate oral tablet
Tier 4
TIVICAY ORAL TABLET Tier 4
trifluridine ophthalmic (eye) drops
Tier 1
TRIUMEQ ORAL TABLET
Tier 4
TRUVADA ORAL TABLET
Tier 4
valacyclovir oral tablet Tier 1
valganciclovir oral recon soln
Tier 2 SP
valganciclovir oral tablet Tier 2 SP
VEREGEN TOPICAL OINTMENT
Tier 3
VIEKIRA PAK ORAL TABLETS,DOSE PACK
Tier 4 PA; SP; QL
Effective 4/1/2018
24
Page 25
Drug Name Tier Notes
VIRACEPT ORAL TABLET
Tier 4
VIREAD ORAL TABLET150 MG, 200 MG, 250 MG
Tier 4
ZEPATIER ORAL TABLET
Tier 4 PA; SP; QL
zidovudine oral capsule Tier 4
zidovudine oral syrup Tier 4
zidovudine oral tablet Tier 4
ZIRGAN OPHTHALMIC (EYE) GEL
Tier 3
AUTONOMIC DRUGS
bethanechol chloride oral tablet
Tier 2
cevimeline oral capsule Tier 2
dextroamphetamine oral capsule, extended release
Tier 1 PA
dextroamphetamine oral solution
Tier 1 PA
dextroamphetamine oral tablet
Tier 1 PA
dextroamphetamine-amphetamine oral capsule,extended release 24hr
Tier 1 PA
dextroamphetamine-amphetamine oral tablet
Tier 1 PA
donepezil oral tablet Tier 2
donepezil oral tablet,disintegrating
Tier 2
epinephrine 0.3 mg auto-inject
Tier 1 QL
epinephrine 0.3 mg auto-inject inner
Tier 1 QL
epinephrine 0.3 mg auto-inject latex-free, sdv
Tier 1 QL
epinephrine 0.3 mg auto-inject latex-free, suv
Tier 1 QL
epinephrine 0.3 mg auto-inject no latex, auto-injct
Tier 1 QL
epinephrine 0.3 mg auto-inject no latex, two-pack
Tier 1 QL
epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml
Tier 1 QL
Drug Name Tier Notes
EPIPEN 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR
Tier 2 QL
EPIPEN JR INJECTION AUTO-INJECTOR
Tier 2 QL
galantamine oral capsule,ext rel. pellets 24 hr
Tier 2
galantamine oral solution Tier 2
galantamine oral tablet Tier 2
guanidine oral tablet Tier 1
methamphetamine oral tablet
Tier 2 PA
midodrine oral tablet Tier 2
NORTHERA ORAL CAPSULE
Tier 3 SP; LD
phenoxybenzamine oral capsule
Tier 2
pilocarpine hcl oral tablet Tier 2
procentra oral solution Tier 1 PA
pyridostigmine bromide oral tablet
Tier 2
rivastigmine tartrate oral capsule
Tier 2
zenzedi oral tablet 10 mg, 5 mg
Tier 1 PA
BIOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
Effective 4/1/2018
25
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Drug Name Tier Notes
AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
BEXSERO INTRAMUSCULAR SYRINGE
Tier 2 $0
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION
Tier 3 $0
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE
Tier 3 $0
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION
Tier 1 $0; QL
FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
Drug Name Tier Notes
FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE
Tier 1 $0; QL
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION
Tier 2 $0
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
Effective 4/1/2018
26
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Drug Name Tier Notes
GRASTEK SUBLINGUAL TABLET
Tier 3 PA; QL
HAVRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
HAVRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
HYQVIA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN
Tier 3
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
IPOL INJECTION SUSPENSION
Tier 3 $0
IXIARO (PF) INTRAMUSCULAR SYRINGE
Tier 3
KINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
KINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
MENACTRA (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT
Tier 3 $0
M-M-R II (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
PENTACEL (PF) INTRAMUSCULAR KIT
Tier 3 $0
Drug Name Tier Notes
PNEUMOVAX 23 INJECTION SOLUTION
Tier 2 $0
PNEUMOVAX 23 INJECTION SYRINGE
Tier 2 $0
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 3
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3 $0
ROTATEQ VACCINE ORAL SOLUTION
Tier 3 $0
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 2 $0
SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 2 $0
TENIVAC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION
Tier 3 $0
Effective 4/1/2018
27
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Drug Name Tier Notes
TRUMENBA INTRAMUSCULAR SYRINGE
Tier 2 $0
TWINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TYPHIM VI INTRAMUSCULAR SOLUTION
Tier 3
TYPHIM VI INTRAMUSCULAR SYRINGE
Tier 3
VAQTA (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
VAQTA (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 2 $0
BLOOD
DROXIA ORAL CAPSULE
Tier 4
pentoxifylline oral tablet extended release
Tier 1
tranexamic acid oral tablet Tier 1
CARDIAC DRUGS
afeditab cr oral tablet extended release 30 mg
Tier 2 DO
afeditab cr oral tablet extended release 60 mg
Tier 2 QL
amiodarone oral tablet Tier 1
amlodipine oral tablet 10 mg
Tier 1 QL
Drug Name Tier Notes
amlodipine oral tablet 2.5 mg, 5 mg
Tier 1 DO
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
cartia xt oral capsule,extended release 24hr 240 mg, 300 mg
Tier 1 QL
digox oral tablet Tier 1
digoxin oral solution 50 mcg/ml
Tier 1
digoxin oral tablet Tier 1
diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 12 hr
Tier 2 QL
diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg
Tier 1 QL
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
Tier 1 QL
diltiazem hcl oral tablet extended release 24 hr 180 mg
Tier 1 DO
diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1 DO
Effective 4/1/2018
28
Page 29
Drug Name Tier Notes
dilt-xr oral capsule,ext.rel 24h degradable 240 mg
Tier 1 QL
disopyramide phosphate oral capsule
Tier 2
dofetilide oral capsule Tier 2
felodipine oral tablet extended release 24 hr 10 mg
Tier 1 QL
felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg
Tier 1 DO
flecainide oral tablet Tier 2
isosorbide dinitrate oral tablet
Tier 1
isosorbide dinitrate oral tablet extended release
Tier 1
isosorbide mononitrate oral tablet
Tier 1
isosorbide mononitrate oral tablet extended release 24 hr
Tier 1
isradipine oral capsule 2.5 mg, 5 mg
Tier 1 QL
LANOXIN ORAL TABLET Tier 3
matzim la oral tablet extended release 24 hr 180 mg
Tier 1 DO
matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
mexiletine oral capsule Tier 2
MULTAQ ORAL TABLET Tier 3
nicardipine oral capsule 20 mg, 30 mg
Tier 2 QL
nifedipine oral capsule Tier 2 QL
nifedipine oral tablet extended release 24hr 30 mg
Tier 2 DO
nifedipine oral tablet extended release 24hr 60 mg, 90 mg
Tier 2 QL
nifedipine oral tablet extended release 30 mg
Tier 2 DO
nifedipine oral tablet extended release 60 mg, 90 mg
Tier 2 QL
Drug Name Tier Notes
nimodipine oral capsule Tier 2 QL
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg
Tier 1 DO
nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg
Tier 1 QL
nitro-bid transdermal ointment
Tier 1
nitroglycerin oral capsule, extended release
Tier 2
nitroglycerin sublingual tablet
Tier 1
nitroglycerin translingual spray,non-aerosol
Tier 2
nitro-time oral capsule, extended release
Tier 1
pacerone oral tablet 100 mg, 200 mg, 400 mg
Tier 2
propafenone oral capsule,extended release 12 hr
Tier 2
propafenone oral tablet Tier 2
quinidine sulfate oral tablet Tier 1
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3
taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1 DO
taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg
Tier 1 QL
verapamil oral capsule, 24 hr er pellet ct 100 mg
Tier 1 DO
verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg
Tier 1 QL
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg
Tier 1 DO
verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg
Tier 1 QL
verapamil oral tablet 120 mg, 40 mg, 80 mg
Tier 1 QL
Effective 4/1/2018
29
Page 30
Drug Name Tier Notes
verapamil oral tablet extended release
Tier 1 QL
CARDIOVASCULAR
acebutolol oral capsule Tier 1
ADCIRCA ORAL TABLET
Tier 4 PA; SP; QL
ADEMPAS ORAL TABLET
Tier 4 PA; SP; LD; QL
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg
Tier 1 QL
amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg
Tier 1 DO
amlodipine-benazepril oral capsule
Tier 1
atenolol oral tablet Tier 1
atenolol-chlorthalidone oral tablet
Tier 1
atorvastatin oral tablet 10 mg, 20 mg
Tier 1 DO; $0
atorvastatin oral tablet 40 mg
Tier 1 DO
atorvastatin oral tablet 80 mg
Tier 1 QL
benazepril oral tablet Tier 1
benazepril-hydrochlorothiazide oral tablet
Tier 1
betaxolol oral tablet Tier 1
bisoprolol fumarate oral tablet
Tier 1
bisoprolol-hydrochlorothiazide oral tablet
Tier 1
BYSTOLIC ORAL TABLET
Tier 3
candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg
Tier 1 QL
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg
Tier 1 QL
Drug Name Tier Notes
candesartan-hydrochlorothiazid oral tablet 32-25 mg
Tier 1
captopril oral tablet Tier 2
captopril-hydrochlorothiazide oral tablet
Tier 2
carvedilol oral tablet Tier 1
cholestyramine (with sugar) oral powder
Tier 2 QL
cholestyramine (with sugar) oral powder in packet
Tier 2 QL
cholestyramine light oral powder
Tier 2 QL
cholestyramine light oral powder in packet
Tier 2
clonidine hcl oral tablet Tier 1
colestipol oral granules Tier 1
colestipol oral packet Tier 1
colestipol oral tablet Tier 1
doxazosin oral tablet Tier 1
EDARBI ORAL TABLET40 MG
Tier 3 DO
EDARBI ORAL TABLET80 MG
Tier 3 QL
enalapril maleate oral tablet
Tier 1
enalapril-hydrochlorothiazide oral tablet
Tier 1
eprosartan oral tablet Tier 1 QL
ergoloid oral tablet Tier 2
ezetimibe oral tablet Tier 2 PA; QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 1
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1 QL
fenofibrate nanocrystallized oral tablet
Tier 1 QL
fenofibrate oral tablet 160 mg, 54 mg
Tier 1 QL
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
Tier 1 QL
Effective 4/1/2018
30
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Drug Name Tier Notes
fenofibric acid oral tablet Tier 1 QL
fluvastatin oral capsule Tier 1 DO; $0
fluvastatin oral tablet extended release 24 hr
Tier 1 $0
fosinopril oral tablet Tier 1
fosinopril-hydrochlorothiazide oral tablet
Tier 1
gemfibrozil oral tablet Tier 1
guanfacine oral tablet Tier 1
hydralazine oral tablet Tier 1
irbesartan oral tablet 150 mg, 75 mg
Tier 1 DO
irbesartan oral tablet 300 mg
Tier 1 QL
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg
Tier 1 QL
irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg
Tier 1
labetalol oral tablet Tier 1
LETAIRIS ORAL TABLET Tier 4 PA; SP; LD; QL
LEVATOL ORAL TABLET
Tier 3
lisinopril oral tablet Tier 1
lisinopril-hydrochlorothiazide oral tablet
Tier 1
LIVALO ORAL TABLET 1 MG, 2 MG
Tier 3 ST; DO
LIVALO ORAL TABLET 4 MG
Tier 3 ST; QL
losartan oral tablet 100 mg, 25 mg, 50 mg
Tier 1 QL
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg
Tier 1 QL
losartan-hydrochlorothiazide oral tablet 50-12.5 mg
Tier 1 DO
lovastatin oral tablet 10 mg, 20 mg
Tier 1 DO; $0
lovastatin oral tablet 40 mg
Tier 1 $0; QL
Drug Name Tier Notes
methyldopa oral tablet Tier 1
methyldopa-hydrochlorothiazide oral tablet
Tier 1
metoprolol succinate oral tablet extended release 24 hr
Tier 1
metoprolol ta-hydrochlorothiaz oral tablet
Tier 1
metoprolol tartrate oral tablet
Tier 1
minoxidil oral tablet Tier 1
moexipril oral tablet Tier 1
moexipril-hydrochlorothiazide oral tablet
Tier 1
nadolol oral tablet Tier 2
nadolol-bendroflumethiazide oral tablet
Tier 1
niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg
Tier 1 QL
olmesartan oral tablet 20 mg
Tier 2 DO
olmesartan oral tablet 40 mg, 5 mg
Tier 2 QL
OPSUMIT ORAL TABLET Tier 4 PA; SP; LD; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG
Tier 4 PA; SP; LD
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG
Tier 4 PA; LD
perindopril erbumine oral tablet
Tier 1
pindolol oral tablet Tier 2
pravastatin oral tablet 10 mg, 20 mg
Tier 1 DO; $0
pravastatin oral tablet 40 mg
Tier 1 $0
pravastatin oral tablet 80 mg
Tier 1 $0; QL
prazosin oral capsule Tier 1
prevalite oral powder Tier 2 QL
Effective 4/1/2018
31
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Drug Name Tier Notes
prevalite oral powder in packet
Tier 2
propranolol oral capsule,extended release 24 hr
Tier 1
propranolol oral solution Tier 1
propranolol oral tablet Tier 1
propranolol-hydrochlorothiazid oral tablet
Tier 1
quinapril oral tablet Tier 1
quinapril-hydrochlorothiazide oral tablet
Tier 1
ramipril oral capsule Tier 1
REMODULIN INJECTION SOLUTION
Tier 4 PA; SP; LD
rosuvastatin oral tablet 10 mg, 5 mg
Tier 2 DO; $0
rosuvastatin oral tablet 20 mg
Tier 2 DO
rosuvastatin oral tablet 40 mg
Tier 2 QL
sildenafil (antihypertensive) oral tablet
Tier 4 PA; SP; QL
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1 DO; $0
simvastatin oral tablet 80 mg
Tier 1 PA; QL
sorine oral tablet Tier 2
sotalol af oral tablet Tier 2
sotalol oral tablet Tier 2
TEKTURNA ORAL TABLET 150 MG
Tier 3 DO
TEKTURNA ORAL TABLET 300 MG
Tier 3 QL
telmisartan oral tablet 20 mg, 40 mg
Tier 1 DO
telmisartan oral tablet 80 mg
Tier 1 QL
terazosin oral capsule Tier 1
timolol maleate oral tablet Tier 1
TRACLEER ORAL TABLET
Tier 4 PA; SP; QL
trandolapril oral tablet Tier 1
Drug Name Tier Notes
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg
Tier 1 DO
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg
Tier 1 QL
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg
Tier 1 QL
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg
Tier 1 DO
valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg
Tier 1 QL
VECAMYL ORAL TABLET
Tier 3
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
Tier 4 PA; SP; LD; QL
WELCHOL ORAL POWDER IN PACKET
Tier 3
WELCHOL ORAL TABLET
Tier 3
CNS DRUGS
APTIOM ORAL TABLET Tier 3
AUBAGIO ORAL TABLET
Tier 4 PA; SP; QL
BANZEL ORAL SUSPENSION
Tier 3
BANZEL ORAL TABLET Tier 3
carbamazepine oral capsule, er multiphase 12 hr
Tier 1
carbamazepine oral suspension 100 mg/5 ml
Tier 1
carbamazepine oral tablet Tier 1
carbamazepine oral tablet extended release 12 hr
Tier 1
carbamazepine oral tablet,chewable
Tier 1
CELONTIN ORAL CAPSULE 300 MG
Tier 3
clonazepam oral tablet Tier 1
Effective 4/1/2018
32
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Drug Name Tier Notes
clonazepam oral tablet,disintegrating
Tier 1
DIASTAT ACUDIAL RECTAL KIT
Tier 2 QL
DIASTAT RECTAL KIT Tier 2 QL
diazepam rectal kit Tier 2 QL
divalproex oral capsule, delayed rel sprinkle
Tier 2
divalproex oral tablet extended release 24 hr
Tier 2
divalproex oral tablet,delayed release (dr/ec)
Tier 2
epitol oral tablet Tier 1
ethosuximide oral capsule Tier 1
ethosuximide oral solution Tier 1
EXTAVIA SUBCUTANEOUS KIT
Tier 4 PA; SP
EXTAVIA SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
felbamate oral suspension Tier 2
felbamate oral tablet Tier 2
FYCOMPA ORAL TABLET
Tier 3
gabapentin oral capsule Tier 2
gabapentin oral solution Tier 2
gabapentin oral tablet 600 mg, 800 mg
Tier 2
GILENYA ORAL CAPSULE
Tier 4 PA; SP; QL
glatiramer subcutaneous syringe 20 mg/ml
Tier 4 PA
glatopa subcutaneous syringe 20 mg/ml
Tier 4 PA; SP
HORIZANT ORAL TABLET EXTENDED RELEASE
Tier 3 PA; QL
lamotrigine oral tablet Tier 1
lamotrigine oral tablet, chewable dispersible
Tier 1
levetiracetam oral solution Tier 2
levetiracetam oral tablet Tier 2
levetiracetam oral tablet extended release 24 hr
Tier 2 PA
Drug Name Tier Notes
LYRICA ORAL CAPSULE100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG
Tier 3 PA; QL
LYRICA ORAL SOLUTION
Tier 3 PA; QL
memantine oral solution Tier 2
memantine oral tablet Tier 2
memantine oral tablets,dose pack
Tier 3
NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK
Tier 3
ONFI ORAL SUSPENSION
Tier 3
ONFI ORAL TABLET 10 MG, 20 MG
Tier 3
oxcarbazepine oral suspension
Tier 2
oxcarbazepine oral tablet Tier 2
PEGANONE ORAL TABLET
Tier 3
phenytoin sodium extended oral capsule
Tier 1
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
PLEGRIDY SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
primidone oral tablet Tier 1
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
Tier 4 PA; SP
riluzole oral tablet Tier 4 SP
SABRIL ORAL TABLET Tier 3 SP; LD
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG
Tier 4 PA; SP; QL
Effective 4/1/2018
33
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Drug Name Tier Notes
tetrabenazine oral tablet Tier 2 PA; SP; LD
tiagabine oral tablet Tier 2
topiramate oral capsule, sprinkle
Tier 1
topiramate oral tablet Tier 1
valproic acid (as sodium salt) oral solution
Tier 1
valproic acid oral capsule Tier 1
vigabatrin oral powder in packet
Tier 2 LD
VIMPAT ORAL SOLUTION
Tier 3
VIMPAT ORAL TABLET Tier 3
ZINBRYTA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
zonisamide oral capsule Tier 2
COLONY STIMULATING FACTORS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION
Tier 4 PA; SP
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
Tier 4 PA; SP
NEULASTA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR
Tier 4 PA; SP; QL
NEUPOGEN INJECTION SOLUTION
Tier 4 PA; SP
NEUPOGEN INJECTION SYRINGE
Tier 4 PA; SP
PROCRIT INJECTION SOLUTION
Tier 4 PA; SP
PROMACTA ORAL TABLET
Tier 4 PA; SP
CONTRACEPTIVES
AFTERA ORAL TABLET Tier 1 $0; QL
altavera (28) oral tablet Tier 1 $0
alyacen 1/35 (28) oral tablet
Tier 1 $0
Drug Name Tier Notes
alyacen 7/7/7 (28) oral tablet
Tier 1 $0
amethia lo oral tablets,dose pack,3 month
Tier 1 $0
amethia oral tablets,dose pack,3 month
Tier 1 $0
amethyst oral tablet Tier 1 $0
apri oral tablet Tier 1 $0
aranelle (28) oral tablet Tier 1 $0
ashlyna oral tablets,dose pack,3 month
Tier 1 $0
aubra oral tablet Tier 1 $0
aviane oral tablet Tier 1 $0
azurette (28) oral tablet Tier 1 $0
balziva (28) oral tablet Tier 1 $0
BEKYREE (28) ORAL TABLET
Tier 1 $0
BLISOVI 24 FE ORAL TABLET
Tier 1 $0
BLISOVI FE 1.5/30 (28) ORAL TABLET
Tier 1 $0
BLISOVI FE 1/20 (28) ORAL TABLET
Tier 1 $0
briellyn oral tablet Tier 1 $0
camila oral tablet Tier 1 $0
camrese lo oral tablets,dose pack,3 month
Tier 1 $0
camrese oral tablets,dose pack,3 month
Tier 1 $0
caziant (28) oral tablet Tier 1 $0
chateal oral tablet Tier 1 $0
cryselle (28) oral tablet Tier 1 $0
cyclafem 1/35 (28) oral tablet
Tier 1 $0
cyclafem 7/7/7 (28) oral tablet
Tier 1 $0
cyred oral tablet Tier 1 $0
dasetta 1/35 (28) oral tablet
Tier 1 $0
dasetta 7/7/7 (28) oral tablet
Tier 1 $0
daysee oral tablets,dose pack,3 month
Tier 1 $0
deblitane oral tablet Tier 1 $0
Effective 4/1/2018
34
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Drug Name Tier Notes
delyla (28) oral tablet Tier 1 $0
desog-e.estradiol/e.estradiol oral tablet
Tier 1 $0
desogestrel-ethinyl estradiol oral tablet
Tier 1 $0
drospirenone-e.estradiol-lm.fa oral tablet
Tier 1 $0
drospirenone-ethinyl estradiol oral tablet
Tier 1 $0
econtra ez oral tablet Tier 1 $0; QL
elinest oral tablet Tier 1 $0
ELLA ORAL TABLET Tier 3 $0
emoquette oral tablet Tier 1 $0
enpresse oral tablet Tier 1 $0
enskyce oral tablet Tier 1 $0
errin oral tablet Tier 1 $0
estarylla oral tablet Tier 1 $0
ethynodiol diac-eth estradiol oral tablet
Tier 1 $0
falmina (28) oral tablet Tier 1 $0
FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1 $0
femynor oral tablet Tier 1 $0
gianvi (28) oral tablet Tier 1 $0
heather oral tablet Tier 1 $0
introvale oral tablets,dose pack,3 month
Tier 1 $0
isibloom oral tablet Tier 1 $0
jencycla oral tablet Tier 1 $0
jolessa oral tablets,dose pack,3 month
Tier 1 $0
jolivette oral tablet Tier 1 $0
JULEBER ORAL TABLET
Tier 1 $0
junel 1.5/30 (21) oral tablet Tier 1 $0
junel 1/20 (21) oral tablet Tier 1 $0
junel fe 1.5/30 (28) oral tablet
Tier 1 $0
junel fe 1/20 (28) oral tablet
Tier 1 $0
junel fe 24 oral tablet Tier 1 $0
Drug Name Tier Notes
KAITLIB FE ORAL TABLET,CHEWABLE
Tier 1 $0
kariva (28) oral tablet Tier 1 $0
kelnor 1/35 (28) oral tablet Tier 1 $0
kimidess (28) oral tablet Tier 1 $0
kurvelo oral tablet Tier 1 $0
l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month
Tier 1 $0
larin 1.5/30 (21) oral tablet Tier 1 $0
larin 1/20 (21) oral tablet Tier 1 $0
larin 24 fe oral tablet Tier 1 $0
larin fe 1.5/30 (28) oral tablet
Tier 1 $0
larin fe 1/20 (28) oral tablet
Tier 1 $0
larissia oral tablet Tier 1 $0
layolis fe oral tablet,chewable
Tier 1 $0
leena 28 oral tablet Tier 1 $0
lessina oral tablet Tier 1 $0
levonest (28) oral tablet Tier 1 $0
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg
Tier 1 $0
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
Tier 1 $0
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
Tier 1 $0
levonorg-eth estrad triphasic oral tablet
Tier 1 $0
levora-28 oral tablet Tier 1 $0
lillow oral tablet Tier 1 $0
LO LOESTRIN FE ORAL TABLET
Tier 3 $0
loryna (28) oral tablet Tier 1 $0
low-ogestrel (28) oral tablet
Tier 1 $0
lutera (28) oral tablet Tier 1 $0
lyza oral tablet Tier 1 $0
marlissa oral tablet Tier 1 $0
medroxyprogesterone intramuscular suspension
Tier 1 $0
Effective 4/1/2018
35
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Drug Name Tier Notes
medroxyprogesterone intramuscular syringe
Tier 1 $0
MELODETTA 24 FE ORAL TABLET,CHEWABLE
Tier 1 $0
MIBELAS 24 FE ORAL TABLET,CHEWABLE
Tier 1 $0
microgestin 1.5/30 (21) oral tablet
Tier 1 $0
microgestin 1/20 (21) oral tablet
Tier 1 $0
microgestin fe 1.5/30 (28) oral tablet
Tier 1 $0
microgestin fe 1/20 (28) oral tablet
Tier 1 $0
mono-linyah oral tablet Tier 1 $0
mononessa (28) oral tablet Tier 1 $0
my way oral tablet Tier 1 $0; QL
myzilra oral tablet Tier 1 $0
NATAZIA ORAL TABLET Tier 3 $0
necon 0.5/35 (28) oral tablet
Tier 1 $0
necon 7/7/7 (28) oral tablet
Tier 1 $0
next choice one dose oral tablet
Tier 1 $0; QL
nikki (28) oral tablet Tier 1 $0
nora-be oral tablet Tier 1 $0
noreth-ethinyl estradiol-iron oral tablet,chewable
Tier 1 $0
norethindrone (contraceptive) oral tablet
Tier 1 $0
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
Tier 1 $0
norethindrone-e.estradiol-iron oral tablet
Tier 1 $0
norethindrone-e.estradiol-iron oral tablet,chewable
Tier 1 $0
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1 $0
norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg
Tier 1 $0
Drug Name Tier Notes
NORLYDA ORAL TABLET
Tier 1 $0
norlyroc oral tablet Tier 1 $0
nortrel 0.5/35 (28) oral tablet
Tier 1 $0
nortrel 1/35 (21) oral tablet Tier 1 $0
nortrel 1/35 (28) oral tablet Tier 1 $0
nortrel 7/7/7 (28) oral tablet
Tier 1 $0
NUVARING VAGINAL RING
Tier 3 $0
ocella oral tablet Tier 1 $0
ogestrel (28) oral tablet Tier 1 $0
opcicon one-step oral tablet
Tier 1 $0; QL
orsythia oral tablet Tier 1 $0
philith oral tablet Tier 1 $0
pimtrea (28) oral tablet Tier 1 $0
pirmella oral tablet Tier 1 $0
PLAN B ONE-STEP ORAL TABLET
Tier 1 $0; QL
portia oral tablet Tier 1 $0
previfem oral tablet Tier 1 $0
quasense oral tablets,dose pack,3 month
Tier 1 $0
RAJANI ORAL TABLET Tier 1 $0
reclipsen (28) oral tablet Tier 1 $0
RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1 $0
SAFYRAL ORAL TABLET
Tier 3
setlakin oral tablets,dose pack,3 month
Tier 1 $0
sharobel oral tablet Tier 1 $0
sprintec (28) oral tablet Tier 1 $0
sronyx oral tablet Tier 1 $0
syeda oral tablet Tier 1 $0
TAKE ACTION ORAL TABLET
Tier 1 $0; QL
tarina fe 1/20 (28) oral tablet
Tier 1 $0
TAYTULLA ORAL CAPSULE
Tier 3 $0
Effective 4/1/2018
36
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Drug Name Tier Notes
tilia fe oral tablet Tier 1 $0
TRI FEMYNOR ORAL TABLET
Tier 1 $0
tri-estarylla oral tablet Tier 1 $0
tri-legest fe oral tablet Tier 1 $0
tri-linyah oral tablet Tier 1 $0
TRI-LO-ESTARYLLA ORAL TABLET
Tier 1 $0
tri-lo-marzia oral tablet Tier 1 $0
TRI-LO-SPRINTEC ORAL TABLET
Tier 1 $0
trinessa (28) oral tablet Tier 1 $0
TRINESSA LO ORAL TABLET
Tier 1 $0
tri-previfem (28) oral tablet Tier 1 $0
tri-sprintec (28) oral tablet Tier 1 $0
trivora (28) oral tablet Tier 1 $0
tri-vylibra oral tablet Tier 1 $0
velivet triphasic regimen (28) oral tablet
Tier 1 $0
vestura (28) oral tablet Tier 1 $0
VIENVA ORAL TABLET Tier 1 $0
viorele (28) oral tablet Tier 1 $0
vyfemla (28) oral tablet Tier 1 $0
vylibra oral tablet Tier 1 $0
wera (28) oral tablet Tier 1 $0
wymzya fe oral tablet,chewable
Tier 1 $0
xulane transdermal patch weekly
Tier 1 $0
zarah oral tablet Tier 1 $0
zenchent (28) oral tablet Tier 1 $0
zovia 1/35e (28) oral tablet Tier 1 $0
zovia 1/50e (28) oral tablet Tier 1 $0
COUGH/COLD PREPARATIONS
benzonatate oral capsule 100 mg, 200 mg
Tier 1
cheratussin ac oral liquid Tier 1
codeine-guaifen 10-100 mg/5 ml (otc)
Tier 1
codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)
Tier 1
Drug Name Tier Notes
g tussin ac oral liquid Tier 1
guaiatussin ac oral liquid Tier 1
guaifen-codeine 100-10 mg/5 ml (otc)
Tier 1
guaifen-codeine 100-10 mg/5 ml inner (otc)
Tier 1
guaifen-codeine 100-10 mg/5 ml outer (otc)
Tier 1
guaifen-codeine 200-20 mg/10 ml inner (otc)
Tier 1
guaifen-codeine 200-20 mg/10 ml outer (otc)
Tier 1
guaifenesin ac oral liquid Tier 1
guaifenesin-codeine syrup (otc)
Tier 1
guaifenesin-codeine syrup (otc)
Tier 1
hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr
Tier 1
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
Tier 1
promethazine vc-codeine oral syrup
Tier 1
promethazine-codeine oral syrup
Tier 1
promethazine-dm oral syrup
Tier 1
promethazine-phenyleph-codeine oral syrup
Tier 1
TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR
Tier 3
virtussin ac oral liquid Tier 1
VITUZ ORAL SOLUTION Tier 3
DIAGNOSTIC
ACCU-CHEK AVIVA PLUS TEST STRP STRIP
Tier 2 QL
ACCU-CHEK COMPACT PLUS TEST STRIP
Tier 2 QL
ACCU-CHEK GUIDE STRIP
Tier 2 QL
ACCU-CHEK SMARTVIEW TEST STRIP STRIP
Tier 2 QL
Effective 4/1/2018
37
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Drug Name Tier Notes
ACCUTREND GLUCOSE STRIP
Tier 2 QL
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN
Tier 2
GLUCAGON HCL INJECTION RECON SOLN
Tier 2
ONETOUCH ULTRA TEST STRIP
Tier 2 QL
ONETOUCH VERIO STRIP
Tier 2 QL
DIURETICS
acetazolamide oral capsule, extended release
Tier 1
acetazolamide oral tablet Tier 1
amiloride oral tablet Tier 2
AMMONIUM CHLORIDE INTRAVENOUS SOLUTION
Tier 3
bumetanide oral tablet Tier 1
chlorothiazide oral tablet Tier 1
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
DYRENIUM ORAL CAPSULE
Tier 3
eplerenone oral tablet Tier 2
ethacrynic acid oral tablet Tier 2
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
Tier 1
furosemide oral tablet Tier 1
hydrochlorothiazide oral capsule
Tier 1
hydrochlorothiazide oral tablet
Tier 1
indapamide oral tablet Tier 1
methazolamide oral tablet Tier 2
methyclothiazide oral tablet
Tier 1
metolazone oral tablet Tier 1
SAMSCA ORAL TABLET Tier 3 SP; LD
spironolactone oral tablet Tier 1
torsemide oral tablet Tier 1
Drug Name Tier Notes
triamterene-hydrochlorothiazid oral capsule
Tier 1
triamterene-hydrochlorothiazid oral tablet
Tier 1
EENT PREPS
acetic acid otic (ear) solution
Tier 1
ALOCRIL OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
ALOMIDE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
apraclonidine ophthalmic (eye) drops
Tier 1
azelastine nasal aerosol,spray
Tier 1 QL
AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
betaxolol ophthalmic (eye) drops
Tier 1
bimatoprost ophthalmic (eye) drops
Tier 2
brimonidine ophthalmic (eye) drops
Tier 1
bromfenac ophthalmic (eye) drops
Tier 2
carteolol ophthalmic (eye) drops
Tier 1
COMBIGAN OPHTHALMIC (EYE) DROPS
Tier 3
cromolyn ophthalmic (eye) drops
Tier 1 QL
dexamethasone sodium phosphate ophthalmic (eye) drops
Tier 1
diclofenac sodium ophthalmic (eye) drops
Tier 1
dorzolamide ophthalmic (eye) drops
Tier 1
dorzolamide-timolol ophthalmic (eye) drops
Tier 1
DUREZOL OPHTHALMIC (EYE) DROPS
Tier 3 QL
Effective 4/1/2018
38
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Drug Name Tier Notes
DYMISTA NASAL SPRAY,NON-AEROSOL
Tier 3 QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
Tier 1 ST; QL
fluocinolone acetonide oil otic (ear) drops
Tier 1
fluorometholone ophthalmic (eye) drops,suspension
Tier 1
flurbiprofen sodium ophthalmic (eye) drops
Tier 1
fluticasone nasal spray,suspension
Tier 1 QL
FML S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
hydrocortisone-acetic acid otic (ear) drops
Tier 1
ketorolac ophthalmic (eye) drops
Tier 1
LACRISERT OPHTHALMIC (EYE) INSERT
Tier 3
latanoprost ophthalmic (eye) drops
Tier 1
levobunolol ophthalmic (eye) drops 0.5 %
Tier 1
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL
Tier 3
LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
LOTEMAX OPHTHALMIC (EYE) OINTMENT
Tier 3
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
Tier 3
metipranolol ophthalmic (eye) drops
Tier 1
NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
olopatadine nasal spray,non-aerosol
Tier 1 QL
OMNARIS NASAL SPRAY,NON-AEROSOL
Tier 3 ST; QL
Drug Name Tier Notes
PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS
Tier 3
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
Tier 1
prednisolone acetate ophthalmic (eye) drops,suspension
Tier 1
prednisolone sodium phosphate ophthalmic (eye) drops
Tier 1
RESTASIS OPHTHALMIC (EYE) DROPPERETTE
Tier 3
SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
timolol maleate ophthalmic (eye) drops
Tier 1
timolol maleate ophthalmic (eye) gel forming solution
Tier 1
TRAVATAN Z OPHTHALMIC (EYE) DROPS
Tier 3
tropicamide ophthalmic (eye) drops
Tier 1
TYZINE NASAL DROPS0.05 %
Tier 3
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE
Tier 3
ELECT/CALORIC/H2O
calcium acetate oral tablet 667 mg
Tier 2
cytra k crystals oral packet Tier 1
cytra-k oral solution Tier 1
dentagel dental gel Tier 1
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
Tier 3
effer-k oral tablet, effervescent 25 meq
Tier 1
eliphos oral tablet Tier 2 PA
fe c plus oral tablet Tier 1
fluoride (sodium) oral drops
Tier 1 $0
Effective 4/1/2018
39
Page 40
Drug Name Tier Notes
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
fluoridex daily defense dental paste
Tier 1
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
FOSRENOL ORAL POWDER IN PACKET
Tier 3 PA
GLUCAGEN HYPOKIT INJECTION RECON SOLN
Tier 2
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT
Tier 2
k-effervescent oral tablet, effervescent
Tier 1
kionex (with sorbitol) oral suspension
Tier 2
kionex oral powder Tier 2
klor-con 10 oral tablet extended release
Tier 1
klor-con 8 oral tablet extended release
Tier 1
klor-con m10 oral tablet,er particles/crystals
Tier 1
klor-con m15 oral tablet,er particles/crystals
Tier 1
klor-con m20 oral tablet,er particles/crystals
Tier 1
klor-con/ef oral tablet, effervescent
Tier 1
lanthanum oral tablet,chewable
Tier 2 PA
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
Drug Name Tier Notes
ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
magnesium sulfate in 0.9 %nacl intravenous solution 40 gram/1,000ml (40 mg/ml)
Tier 2
NUTRAMINE ORAL POWDER
Tier 3
potassium bicarb and chloride oral tablet, effervescent
Tier 1
potassium bicarb-citric acid oral tablet, effervescent
Tier 1
potassium chloride oral capsule, extended release
Tier 1
potassium chloride oral tablet extended release
Tier 1
potassium chloride oral tablet,er particles/crystals
Tier 1
potassium citrate oral tablet extended release
Tier 2
potassium citrate-citric acid oral solution
Tier 1
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE
Tier 3
PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE
Tier 3
PREVIDENT DENTAL GEL
Tier 3
sevelamer carbonate oral powder in packet
Tier 1
sevelamer carbonate oral tablet
Tier 1
sf dental gel Tier 1
SHOHL'S MODIFIED ORAL SOLUTION
Tier 3
sodium chloride 0.45 % intravenous parenteral solution
Tier 1
sodium chloride 0.45 % intravenous piggyback
Tier 1
sodium chloride 0.9 % injection solution
Tier 1
Effective 4/1/2018
40
Page 41
Drug Name Tier Notes
sodium chloride 0.9 % intravenous parenteral solution
Tier 1
sodium chloride 0.9 % intravenous piggyback
Tier 1
sodium chloride 3 % intravenous parenteral solution
Tier 1
sodium chloride 5 % intravenous parenteral solution
Tier 1
sodium chloride intravenous parenteral solution 2.5 meq/ml
Tier 1
sodium polystyrene (sorb free) oral suspension
Tier 2
sodium polystyrene sulfonate oral powder
Tier 2
sodium polystyrene sulfonate oral suspension
Tier 2
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
Tier 1
sps (with sorbitol) oral suspension
Tier 2
sps (with sorbitol) rectal enema
Tier 1
SSKI ORAL SOLUTION Tier 3
VELPHORO ORAL TABLET,CHEWABLE
Tier 3 PA
GASTROINTESTINAL
AKYNZEO ORAL CAPSULE
Tier 3 QL
alosetron oral tablet Tier 2 QL
AMITIZA ORAL CAPSULE
Tier 3
anaspaz oral tablet,disintegrating
Tier 2
anucort-hc rectal suppository
Tier 1
ANZEMET ORAL TABLET
Tier 3 QL
aprepitant oral capsule 125 mg, 40 mg, 80 mg
Tier 2 QL
aprepitant oral capsule,dose pack
Tier 2 QL
Drug Name Tier Notes
APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR
Tier 3 QL
balsalazide oral capsule Tier 1 QL
carafate oral suspension Tier 1
CESAMET ORAL CAPSULE
Tier 3
CHOLBAM ORAL CAPSULE
Tier 3 PA; LD; QL
cimetidine hcl oral solution Tier 1
cimetidine oral tablet Tier 1
COMPAZINE ORAL TABLET
Tier 1
constulose oral solution Tier 1
DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS
Tier 3 PA; QL
dicyclomine oral capsule Tier 1
dicyclomine oral solution Tier 1
dicyclomine oral tablet Tier 1
DIPENTUM ORAL CAPSULE
Tier 3 QL
diphenoxylate-atropine oral liquid
Tier 1
diphenoxylate-atropine oral tablet
Tier 1
dronabinol oral capsule Tier 2
enulose oral solution Tier 1
famotidine oral suspension Tier 1
famotidine oral tablet 20 mg, 40 mg
Tier 1
gavilyte-c oral recon soln Tier 1 $0
gavilyte-g oral recon soln Tier 1 $0
gavilyte-n oral recon soln Tier 1 $0
generlac oral solution Tier 1
glycopyrrolate oral tablet 1 mg, 2 mg
Tier 1
granisetron hcl oral tablet Tier 2 QL
hydrocortisone acetate rectal suppository
Tier 1
hydrocortisone-pramoxine rectal cream
Tier 1
hyoscyamine sulfate oral tablet
Tier 1
Effective 4/1/2018
41
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Drug Name Tier Notes
hyoscyamine sulfate oral tablet extended release 12 hr
Tier 1
hyoscyamine sulfate oral tablet,disintegrating
Tier 1
hyoscyamine sulfate sublingual tablet
Tier 1
lactulose oral solution Tier 1
lansoprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
laxaclear powder Tier 1 $0
LINZESS ORAL CAPSULE
Tier 2
meclizine oral tablet 12.5 mg, 25 mg
Tier 1
methscopolamine oral tablet
Tier 1
metoclopramide hcl oral solution
Tier 1
metoclopramide hcl oral tablet
Tier 1
metoclopramide hcl oral tablet,disintegrating
Tier 1
misoprostol oral tablet Tier 1
MOTOFEN ORAL TABLET
Tier 3
MOVIPREP ORAL POWDER IN PACKET
Tier 3
nizatidine oral capsule Tier 1
nizatidine oral solution Tier 1
omega-3 acid ethyl esters oral capsule
Tier 1 QL
omeprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
ondansetron hcl oral solution
Tier 2 QL
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
Tier 2 QL
ondansetron oral tablet,disintegrating 4 mg, 8 mg
Tier 2 QL
OSMOPREP ORAL TABLET
Tier 3
Drug Name Tier Notes
pantoprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
peg 3350-electrolytes oral recon soln
Tier 1 $0
peg-3350 with flavor packs oral recon soln
Tier 1 $0
phenadoz rectal suppository
Tier 2
polyethylene glycol 3350 oral powder in packet
Tier 1 $0
pramcort rectal cream Tier 1
PREPOPIK ORAL POWDER IN PACKET
Tier 3
prochlorperazine maleate oral tablet
Tier 1
promethazine rectal suppository
Tier 2
promethegan rectal suppository
Tier 2
rabeprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
ranitidine hcl oral capsule Tier 1
ranitidine hcl oral syrup Tier 1
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1
RECTIV RECTAL OINTMENT
Tier 3
SANCUSO TRANSDERMAL PATCH WEEKLY
Tier 3 QL
scopolamine base transdermal patch 3 day
Tier 2
sodium phenylbutyrate oral tablet
Tier 2 PA; QL
sucralfate oral tablet Tier 1
sulfasalazine oral tablet Tier 1 QL
sulfasalazine oral tablet,delayed release (dr/ec)
Tier 1 QL
SUPREP BOWEL PREP KIT ORAL RECON SOLN
Tier 3
trilyte with flavor packets oral recon soln
Tier 1 $0
trimethobenzamide oral capsule
Tier 1
Effective 4/1/2018
42
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Drug Name Tier Notes
ursodiol oral capsule Tier 2
ursodiol oral tablet Tier 2
VARUBI ORAL TABLET Tier 3 QL
VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM
Tier 3 QL
VIBERZI ORAL TABLET Tier 3 PA; QL
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT
Tier 2
HORMONES
AMABELZ ORAL TABLET
Tier 1
ANADROL-50 ORAL TABLET
Tier 3
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)
Tier 3 PA; QL
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
Tier 3 PA; QL
budesonide oral capsule,delayed,extend.release
Tier 2 QL
cabergoline oral tablet Tier 1
calcitonin (salmon) nasal spray,non-aerosol
Tier 2 QL
chorionic gonadotropin, human intramuscular recon soln
Tier 4 PA; SP
cortisone oral tablet Tier 1
covaryx h.s. oral tablet Tier 1
covaryx oral tablet Tier 1
Drug Name Tier Notes
danazol oral capsule Tier 2
DELTASONE ORAL TABLET 20 MG
Tier 1
desmopressin nasal aerosol,spray
Tier 2
desmopressin nasal solution
Tier 2
desmopressin nasal spray,non-aerosol
Tier 2
desmopressin oral tablet Tier 1
dexamethasone intensol oral drops
Tier 1
dexamethasone oral elixir Tier 1
dexamethasone oral solution
Tier 1
dexamethasone oral tablet Tier 1
DUAVEE ORAL TABLET Tier 3 QL
eemt hs oral tablet Tier 1
eemt oral tablet Tier 1
estradiol oral tablet Tier 1
estradiol transdermal patch semiweekly
Tier 1 QL
estradiol transdermal patch weekly
Tier 1
estradiol vaginal cream Tier 2
estradiol vaginal tablet Tier 2 QL
estradiol-norethindrone acet oral tablet
Tier 1
ESTRING VAGINAL RING
Tier 3 QL
estrogens-methyltestosterone oral tablet
Tier 1
estropipate oral tablet Tier 1
fludrocortisone oral tablet Tier 1
GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
GONAL-F RFF SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
GONAL-F SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP
hydrocortisone oral tablet Tier 1
Effective 4/1/2018
43
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Drug Name Tier Notes
hydrocortisone rectal enema
Tier 2
INCRELEX SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD
jinteli oral tablet Tier 1
LOPREEZA ORAL TABLET
Tier 1
LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET
Tier 4 PA; SP; QL
medroxyprogesterone oral tablet
Tier 1 QL
MENEST ORAL TABLET0.3 MG, 0.625 MG, 1.25 MG
Tier 3
METHITEST ORAL TABLET
Tier 3
methylprednisolone oral tablet
Tier 1
methylprednisolone oral tablets,dose pack
Tier 1
millipred dp oral tablets,dose pack
Tier 1
millipred oral tablet Tier 1
mimvey lo oral tablet Tier 1
mimvey oral tablet Tier 1
MYALEPT SUBCUTANEOUS RECON SOLN
Tier 4 SP; LD
norethindrone acetate oral tablet
Tier 1
NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP
oxandrolone oral tablet Tier 2 PA
prednisolone oral solution 15 mg/5 ml
Tier 1
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
Tier 1
Drug Name Tier Notes
prednisone intensol oral concentrate
Tier 1
prednisone oral solution Tier 1
prednisone oral tablet Tier 1
prednisone oral tablets,dose pack
Tier 1
PREMARIN ORAL TABLET
Tier 3 QL
PREMARIN VAGINAL CREAM
Tier 3 QL
PREMPHASE ORAL TABLET
Tier 3
PREMPRO ORAL TABLET
Tier 3
progesterone micronized oral capsule 100 mg, 200 mg
Tier 1 QL
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG
Tier 4 PA; SP; QL
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 4 PA; SP; LD; QL
SIGNIFOR SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; LD; QL
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
SYNAREL NASAL SPRAY,NON-AEROSOL
Tier 4 PA; SP; QL
testosterone cypionate intramuscular oil
Tier 1
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)
Tier 2 PA; QL
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)
Tier 2 PA; QL
veripred 20 oral solution Tier 1
YUVAFEM VAGINAL TABLET
Tier 2 QL
Effective 4/1/2018
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Drug Name Tier Notes
IMMUNOSUPPRESSANTS
ACTEMRA INTRAVENOUS SOLUTION
Tier 4 PA; SP; QL
ACTEMRA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
azathioprine oral tablet Tier 2
cyclosporine modified oral capsule
Tier 4 SP
cyclosporine modified oral solution
Tier 4 SP
cyclosporine oral capsule Tier 4 SP
ELIDEL TOPICAL CREAM
Tier 3 PA
gengraf oral capsule 100 mg, 25 mg
Tier 4 SP
GENGRAF ORAL CAPSULE 50 MG
Tier 4 SP
gengraf oral solution Tier 4 SP
mycophenolate mofetil oral capsule
Tier 4 SP
mycophenolate mofetil oral tablet
Tier 4 SP
mycophenolate sodium oral tablet,delayed release (dr/ec)
Tier 4 SP
RAPAMUNE ORAL SOLUTION
Tier 4 SP
STELARA INTRAVENOUS SOLUTION
Tier 4 PA; SP; QL
STELARA SUBCUTANEOUS SOLUTION
Tier 4 PA; SP; QL
STELARA SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
tacrolimus oral capsule Tier 4 SP
tacrolimus topical ointment Tier 1 PA
ZORTRESS ORAL TABLET
Tier 4 PA; SP
Drug Name Tier Notes
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG
ACCU-CHEK AVIVA CONNECT METER
Tier 2
ACCU-CHEK AVIVA CONTROL SOLN SOLUTION
Tier 2
ACCU-CHEK AVIVA PLUS METER
Tier 2
ACCU-CHEK COMP BLUE CONT, M-H SOLUTION
Tier 2
ACCU-CHEK COMPACT PLUS CARE KIT
Tier 2
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
Tier 2
ACCU-CHEK FASTCLIX Tier 2
ACCU-CHEK FASTCLIX KIT
Tier 2
ACCU-CHEK GUIDE GLUCOSE METER
Tier 2
ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION
Tier 2
ACCU-CHEK MULTICLIX LANCET
Tier 2
ACCU-CHEK MULTICLIX LANCET KIT
Tier 2
ACCU-CHEK NANO Tier 2
ACCU-CHEK SAFE-T-PRO PLUS
Tier 2
ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION
Tier 2
ACCU-CHEK SOFT DEV LANCETS KIT
Tier 2
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 2
ACCU-CHEK SOFTCLIX LANCETS
Tier 2
ACCU-CHEK VOICEMATE KIT
Tier 2
ACCUTREND GLUCOSE CONTROL SOLUTION
Tier 2
acti-lance lancets 17 gauge, 28 gauge
Tier 1
Effective 4/1/2018
45
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Drug Name Tier Notes
CHEMSTRIP BG LOG BOOK
Tier 2
e-z ject lancets Tier 1
E-Z JECT THIN LANCETS
Tier 1
insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"
Tier 1
ONETOUCH DELICA LANC DEVICE KIT
Tier 2
ONETOUCH DELICA LANCETS
Tier 2
ONETOUCH SURESOFT LANCING DEV
Tier 2
ONETOUCH ULTRA CONTROL SOLUTION
Tier 2
ONETOUCH ULTRA2 KIT Tier 2
ONETOUCH ULTRAMINI KIT
Tier 2
ONETOUCH ULTRASOFT LANCETS
Tier 2
ONETOUCH VERIO FLEX
Tier 2
ONETOUCH VERIO HIGH CONTROL SOLUTION
Tier 2
ONETOUCH VERIO IQ METER
Tier 2
ONETOUCH VERIO MID CONTROL SOLUTION
Tier 2
ONETOUCH VERIO SYSTEM
Tier 2
thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"
Tier 1
MUSCLE RELAXANTS
baclofen oral tablet Tier 2
carisoprodol oral tablet Tier 1
chlorzoxazone oral tablet Tier 1
cyclobenzaprine oral tablet Tier 1
dantrolene oral capsule Tier 2
metaxalone oral tablet Tier 1
methocarbamol oral tablet Tier 1
orphenadrine citrate oral tablet extended release
Tier 1
tizanidine oral capsule Tier 1
Drug Name Tier Notes
tizanidine oral tablet Tier 1
PRE-NATAL VITAMINS
c-nate dha oral capsule Tier 1
completenate oral tablet,chewable
Tier 1
elite ob with dha oral capsule
Tier 1
elite-ob 400 oral capsule Tier 1
ELITE-OB ORAL TABLET
Tier 1
folivane-ob oral capsule Tier 1
hemenatal ob oral tablet Tier 1
mynatal advance oral tablet
Tier 1
mynatal oral capsule Tier 1
mynatal oral tablet Tier 1
mynatal plus oral tablet Tier 1
mynatal-z oral tablet Tier 1
mynate 90 plus oral tablet extended release
Tier 1
pnv-dha + docusate oral capsule
Tier 1
pnv-dha oral capsule Tier 1
pnv-ferrous fumarate-docu-fa oral tablet
Tier 1
pnv-omega oral capsule Tier 1
pnv-select oral tablet Tier 1
pr natal 400 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 400 oral combo pack
Tier 1
pr natal 430 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 430 oral combo pack
Tier 1
prenaissance oral capsule Tier 1
prenaissance plus oral capsule
Tier 1
prenatabs fa oral tablet Tier 1
prenatabs rx oral tablet Tier 1
prenatal 19 (with docusate) oral tablet
Tier 1
Effective 4/1/2018
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Drug Name Tier Notes
PRENATAL 19 CHEWABLE TABLET (RX)
Tier 1
prenatal low iron oral tablet
Tier 1
prenatal multivitamin tablet Tier 1 $0
PRENATAL ONE DAILY ORAL TABLET
Tier 1 $0
prenatal plus (calcium carb) oral tablet
Tier 1
prenatal plus oral tablet Tier 1
prenatal vitamin plus low iron
Tier 1
prenatal-u oral capsule Tier 1
preplus oral tablet Tier 1
relnate dha oral capsule Tier 1
se-natal 19 (with docusate) oral tablet
Tier 1
se-natal 19 oral tablet,chewable
Tier 1
taron-c dha oral capsule Tier 1
taron-prex prenatal-dha oral capsule
Tier 1
tl-select oral capsule Tier 1
triadvance oral tablet Tier 1
trinatal gt oral tablet Tier 1
trinatal rx 1 oral tablet Tier 1
trinate oral tablet Tier 1
triveen-one oral capsule Tier 1
triveen-prx rnf oral capsule Tier 1
ultimatecare one nf oral capsule
Tier 1
ultimatecare one oral capsule
Tier 1
vemavite-prx-2 oral capsule
Tier 1
vinacal oral tablet Tier 1
vinate care oral tablet,chewable
Tier 1
vinate gt oral tablet Tier 1
vinate ii oral tablet Tier 1
vinate m oral tablet Tier 1
vinate one oral tablet Tier 1
vinate pn care oral tablet Tier 1
Drug Name Tier Notes
vinate ultra oral tablet Tier 1
VIRT-NATE DHA ORAL CAPSULE
Tier 1
virt-pn dha oral capsule Tier 1
virt-pn oral tablet Tier 1
virt-pn plus oral capsule Tier 1
virt-select oral capsule Tier 1
vitafol-ob oral tablet Tier 1
vol-nate oral tablet Tier 1
vol-plus oral tablet Tier 1
vol-tab rx oral tablet Tier 1
vp-ch plus oral capsule Tier 1
vp-ch-pnv oral capsule Tier 1
vp-ggr-b6 oral tablet Tier 1
vp-heme ob oral tablet Tier 1
vp-heme one oral capsule Tier 1
zatean-ch oral capsule Tier 1
zatean-pn dha oral capsule
Tier 1
zatean-pn plus oral capsule
Tier 1
zingiber oral tablet Tier 1
PSYCHOTHERAPEUTIC DRUGS
ADDYI ORAL TABLET Tier 3 PA; QL
alprazolam oral tablet Tier 1
amitriptyline oral tablet Tier 1
amoxapine oral tablet Tier 1
aripiprazole oral solution Tier 2
aripiprazole oral tablet Tier 2
armodafinil oral tablet 150 mg, 250 mg, 50 mg
Tier 2 PA; QL
armodafinil oral tablet 200 mg
Tier 2 PA
atomoxetine oral capsule Tier 2 PA
bupropion hcl oral tablet 100 mg
Tier 1 QL
bupropion hcl oral tablet 75 mg
Tier 1 DO
bupropion hcl oral tablet extended release 12 hr 100 mg
Tier 1 DO
Effective 4/1/2018
47
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Drug Name Tier Notes
bupropion hcl oral tablet extended release 12 hr 150 mg
Tier 1 $0
bupropion hcl oral tablet extended release 12 hr 200 mg
Tier 1
bupropion hcl oral tablet extended release 24 hr 150 mg
Tier 1 DO
bupropion hcl oral tablet extended release 24 hr 300 mg
Tier 1 QL
buspirone oral tablet Tier 1
chlorpromazine oral tablet Tier 2
citalopram oral solution Tier 1 QL
citalopram oral tablet 10 mg, 20 mg
Tier 1 DO
citalopram oral tablet 40 mg
Tier 1 QL
clomipramine oral capsule Tier 2
clonidine hcl oral tablet extended release 12 hr
Tier 1 PA
clozapine oral tablet Tier 2
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
Tier 2
desipramine oral tablet Tier 2
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg
Tier 1 QL
desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg
Tier 1 DO
dexmethylphenidate oral capsule,er biphasic 50-50
Tier 1 PA
dexmethylphenidate oral tablet
Tier 1 PA
diazepam intensol oral concentrate
Tier 1
diazepam oral concentrate Tier 1
diazepam oral solution Tier 1
diazepam oral tablet Tier 1
doxepin oral capsule Tier 1
doxepin oral concentrate Tier 1
Drug Name Tier Notes
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg
Tier 2 PA; QL
duloxetine oral capsule,delayed release(dr/ec) 30 mg
Tier 2 PA; DO
EMSAM TRANSDERMAL PATCH 24 HOUR
Tier 3
escitalopram oxalate oral solution
Tier 1 QL
escitalopram oxalate oral tablet 10 mg, 5 mg
Tier 1 DO
escitalopram oxalate oral tablet 20 mg
Tier 1 QL
FANAPT ORAL TABLET Tier 3
FANAPT ORAL TABLETS,DOSE PACK
Tier 3
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
Tier 3 ST; QL
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR
Tier 3 ST; QL
fluoxetine oral capsule 10 mg, 20 mg
Tier 1 DO
fluoxetine oral capsule 40 mg
Tier 1 QL
fluoxetine oral capsule,delayed release(dr/ec)
Tier 1 QL
fluoxetine oral solution Tier 1 QL
fluoxetine oral tablet 10 mg
Tier 1 DO
fluoxetine oral tablet 20 mg
Tier 1
fluphenazine hcl oral concentrate
Tier 1
fluphenazine hcl oral elixir Tier 1
fluphenazine hcl oral tablet Tier 1
fluvoxamine oral tablet 100 mg
Tier 1 QL
fluvoxamine oral tablet 25 mg, 50 mg
Tier 1 DO
guanfacine oral tablet extended release 24 hr
Tier 1 PA
haloperidol oral tablet Tier 1
Effective 4/1/2018
48
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Drug Name Tier Notes
imipramine hcl oral tablet Tier 1
LATUDA ORAL TABLET Tier 3
lithium carbonate oral capsule
Tier 1
lithium carbonate oral tablet
Tier 1
lithium carbonate oral tablet extended release
Tier 1
lithium citrate oral solution Tier 1
loxapine succinate oral capsule
Tier 1
maprotiline oral tablet Tier 1
MARPLAN ORAL TABLET
Tier 3
meprobamate oral tablet Tier 1
metadate er oral tablet extended release
Tier 1 PA
methylphenidate hcl oral capsule, er biphasic 30-70
Tier 1 PA
methylphenidate hcl oral capsule,er biphasic 50-50
Tier 1 PA
methylphenidate hcl oral solution
Tier 1 PA
methylphenidate hcl oral tablet
Tier 1 PA
methylphenidate hcl oral tablet extended release
Tier 1 PA
methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg
Tier 1 PA
mirtazapine oral tablet Tier 1
mirtazapine oral tablet,disintegrating
Tier 1
modafinil oral tablet 100 mg
Tier 2 PA; DO
modafinil oral tablet 200 mg
Tier 2 PA; QL
nefazodone oral tablet Tier 1
nortriptyline oral capsule Tier 1
nortriptyline oral solution Tier 1
olanzapine oral tablet Tier 2
olanzapine oral tablet,disintegrating
Tier 2
paliperidone oral tablet extended release 24hr
Tier 2
Drug Name Tier Notes
paroxetine hcl oral tablet 10 mg, 20 mg
Tier 1 DO
paroxetine hcl oral tablet 30 mg, 40 mg
Tier 1 QL
paroxetine hcl oral tablet extended release 24 hr 12.5 mg
Tier 1 DO
paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg
Tier 1 QL
perphenazine oral tablet Tier 1
phenelzine oral tablet Tier 1
pimozide oral tablet Tier 2
protriptyline oral tablet Tier 2
quetiapine oral tablet Tier 2
quetiapine oral tablet extended release 24 hr
Tier 2
risperidone oral solution Tier 1
risperidone oral tablet Tier 1
risperidone oral tablet,disintegrating
Tier 2
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
Tier 3
sertraline oral concentrate Tier 1 QL
sertraline oral tablet 100 mg
Tier 1 QL
sertraline oral tablet 25 mg, 50 mg
Tier 1 DO
thioridazine oral tablet Tier 1
thiothixene oral capsule Tier 1
tranylcypromine oral tablet Tier 1
trazodone oral tablet Tier 1
trifluoperazine oral tablet Tier 1
trimipramine oral capsule Tier 1
TRINTELLIX ORAL TABLET 10 MG, 5 MG
Tier 3 ST; DO
TRINTELLIX ORAL TABLET 20 MG
Tier 3 ST; QL
venlafaxine oral capsule,extended release 24hr 150 mg
Tier 1 QL
venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
Effective 4/1/2018
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Drug Name Tier Notes
venlafaxine oral tablet Tier 1 QL
venlafaxine oral tablet extended release 24hr 150 mg, 225 mg
Tier 1 QL
venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
VIIBRYD ORAL TABLET10 MG, 20 MG
Tier 3 ST; DO
VIIBRYD ORAL TABLET40 MG
Tier 3 ST; QL
VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)
Tier 3 ST; QL
VYVANSE ORAL CAPSULE
Tier 3 PA
ziprasidone hcl oral capsule
Tier 2
SEDATIVE/HYPNOTICS
estazolam oral tablet Tier 1
eszopiclone oral tablet 1 mg, 2 mg
Tier 1 QL
eszopiclone oral tablet 3 mg
Tier 1 PA; QL
HETLIOZ ORAL CAPSULE
Tier 4 PA; SP; LD; QL
hm nighttime sleep aid 50 mg softgel,max strength
Tier 1
phenobarbital oral elixir Tier 1
phenobarbital oral tablet Tier 1
ROZEREM ORAL TABLET
Tier 3 ST; QL
SILENOR ORAL TABLET Tier 3 QL
XYREM ORAL SOLUTION
Tier 3 PA; SP; LD; QL
zaleplon oral capsule Tier 1 QL
zolpidem oral tablet Tier 1 QL
SKIN PREPS
acitretin oral capsule Tier 2
adapalene topical cream Tier 1
adapalene topical gel Tier 1
adapalene topical gel with pump
Tier 1
adapalene-benzoyl peroxide topical gel with pump
Tier 2
Drug Name Tier Notes
alclometasone topical cream
Tier 1
alclometasone topical ointment
Tier 1
ALTABAX TOPICAL OINTMENT
Tier 3
amcinonide topical cream Tier 1
amcinonide topical lotion Tier 1
amcinonide topical ointment
Tier 1
ammonium lactate topical cream
Tier 1
ammonium lactate topical lotion
Tier 1
AMNESTEEM ORAL CAPSULE
Tier 2 PA
avita topical cream Tier 1 PA
AZELEX TOPICAL CREAM
Tier 3 PA
benzoyl peroxide 9.8% foam emollient foam (otc)
Tier 1
benzoyl peroxide topical cleanser 3 %, 6 %, 9 %
Tier 1
benzoyl peroxide topical foam 5.3 %
Tier 1
betamethasone dipropionate topical cream
Tier 1
betamethasone dipropionate topical lotion
Tier 1
betamethasone dipropionate topical ointment
Tier 1
betamethasone valerate topical cream
Tier 1
betamethasone valerate topical foam
Tier 1
betamethasone valerate topical lotion
Tier 1
betamethasone valerate topical ointment
Tier 1
betamethasone, augmented topical cream
Tier 1
betamethasone, augmented topical gel
Tier 1
betamethasone, augmented topical lotion
Tier 1
Effective 4/1/2018
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Drug Name Tier Notes
betamethasone, augmented topical ointment
Tier 1
bpo topical gel Tier 1
bpo topical towelette 6 % Tier 1
calcipotriene scalp solution
Tier 1
calcipotriene topical cream Tier 1
calcipotriene topical ointment
Tier 1
calcipotriene-betamethasone topical ointment
Tier 1
calcitrene topical ointment Tier 1
calcitriol topical ointment Tier 1
claravis oral capsule Tier 2 PA
clindamycin-benzoyl peroxide topical gel
Tier 1
clindamycin-benzoyl peroxide topical gel with pump
Tier 1
clindamycin-tretinoin topical gel
Tier 2
clobetasol scalp solution Tier 1
clobetasol topical cream Tier 1
clobetasol topical foam Tier 1
clobetasol topical gel Tier 1
clobetasol topical lotion Tier 1
clobetasol topical ointment Tier 1
clobetasol topical shampoo
Tier 1
clobetasol-emollient topical cream
Tier 1
clobetasol-emollient topical foam
Tier 1
CLODERM TOPICAL CREAM
Tier 3
CORDRAN TAPE LARGE ROLL TOPICAL TAPE
Tier 3
cormax scalp solution Tier 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
Drug Name Tier Notes
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
COSENTYX SUBCUTANEOUS SYRINGE
Tier 4 PA; SP; QL
dapsone topical gel Tier 2
desonide topical cream Tier 1
desonide topical lotion Tier 1
desonide topical ointment Tier 1
desoximetasone topical cream
Tier 1
desoximetasone topical gel
Tier 1
desoximetasone topical ointment
Tier 1
diclofenac sodium topical gel 1 %
Tier 2 QL
diflorasone topical cream Tier 1
diflorasone topical ointment
Tier 1
EURAX TOPICAL CREAM
Tier 3
EURAX TOPICAL LOTION
Tier 3
FINACEA TOPICAL GEL Tier 3
FLECTOR TRANSDERMAL PATCH 12 HOUR
Tier 3 QL
fluocinolone and shower cap scalp oil
Tier 1
fluocinolone topical cream Tier 1
fluocinolone topical oil Tier 1
fluocinolone topical ointment
Tier 1
fluocinolone topical solution
Tier 1
fluocinonide topical cream Tier 1
fluocinonide topical gel Tier 1
fluocinonide topical ointment
Tier 1
fluocinonide topical solution
Tier 1
Effective 4/1/2018
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Drug Name Tier Notes
fluocinonide-e topical cream
Tier 1
fluocinonide-emollient topical cream
Tier 1
flurandrenolide topical cream
Tier 2
flurandrenolide topical lotion
Tier 2
fluticasone topical cream Tier 1
fluticasone topical lotion Tier 1
fluticasone topical ointment
Tier 1
halobetasol propionate topical cream
Tier 1
halobetasol propionate topical ointment
Tier 1
HALOG TOPICAL CREAM
Tier 3
HALOG TOPICAL OINTMENT
Tier 3
hydrocortisone butyrate topical cream
Tier 1
hydrocortisone butyrate topical lotion
Tier 1
hydrocortisone butyrate topical ointment
Tier 1
hydrocortisone butyrate topical solution
Tier 1
hydrocortisone butyr-emollient topical cream
Tier 1
hydrocortisone topical cream 2.5 %
Tier 1
hydrocortisone topical cream with perineal applicator
Tier 1
hydrocortisone topical lotion 2.5 %
Tier 1
hydrocortisone topical ointment 2.5 %
Tier 1
hydrocortisone valerate topical cream
Tier 1
hydrocortisone valerate topical ointment
Tier 1
hydrocortisone-pramoxine topical cream
Tier 1
imiquimod topical cream in packet
Tier 1 PA; QL
Drug Name Tier Notes
iodoquinol-hc topical cream
Tier 1
lindane topical shampoo Tier 1
malathion topical lotion Tier 1
methoxsalen oral capsule,liqd-filled,rapid rel
Tier 2 PA; SP
metronidazole topical 0.75% gl
Tier 1
metronidazole topical cream
Tier 1
metronidazole topical gel 1 %
Tier 1
metronidazole topical gel with pump
Tier 1
metronidazole topical lotion
Tier 1
MIRVASO TOPICAL GEL Tier 3
MIRVASO TOPICAL GEL WITH PUMP
Tier 3
mometasone topical cream
Tier 1
mometasone topical ointment
Tier 1
mometasone topical solution
Tier 1
OVACE TOPICAL CLEANSER
Tier 3
permethrin topical cream Tier 1
PHYSIOLYTE IRRIGATION SOLUTION
Tier 3
podofilox topical solution Tier 1
prednicarbate topical cream
Tier 1
prednicarbate topical ointment
Tier 1
PROCTOSOL-HC 2.5% CREAM
Tier 1
proctozone-hc topical cream with perineal applicator
Tier 1
prudoxin topical cream Tier 2
REGRANEX TOPICAL GEL
Tier 3
rosadan topical cream Tier 1
ROSADAN TOPICAL GEL
Tier 1
Effective 4/1/2018
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Drug Name Tier Notes
salicylic acid topical cream Tier 1
salicylic acid topical cream,extended release
Tier 1
salicylic acid topical foam Tier 1
salicylic acid topical gel Tier 1
salicylic acid topical lotion Tier 1
salicylic acid topical lotion,extended release
Tier 1
salicylic acid topical shampoo
Tier 1
salvax topical foam Tier 1
SANTYL TOPICAL OINTMENT
Tier 3
seb-prev topical cleanser Tier 1
selenium sulfide topical lotion
Tier 1
selenium sulfide topical shampoo 2.25 %
Tier 1
SKLICE TOPICAL LOTION
Tier 3
sodium chloride irrigation solution
Tier 1
spinosad topical suspension
Tier 1
sulfacetamide sodium (acne) topical suspension
Tier 1
sulfacetamide sodium topical cleanser
Tier 1
sulfacetamide sodium topical cleanser, gel
Tier 1
sulfacetamide sodium topical shampoo
Tier 1
tazarotene topical cream Tier 2
TAZORAC TOPICAL CREAM 0.05 %
Tier 3
TAZORAC TOPICAL GEL Tier 3
tretinoin (emollient) topical cream
Tier 1
tretinoin topical cream Tier 1 PA
tretinoin topical gel 0.01 %, 0.025 %
Tier 1 PA
triamcinolone acetonide topical cream
Tier 1
triamcinolone acetonide topical lotion
Tier 1
Drug Name Tier Notes
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
Tier 1
trianex topical ointment Tier 1
triderm topical cream 0.1 %
Tier 1
TRIDERM TOPICAL CREAM 0.5 %
Tier 1
ULESFIA TOPICAL LOTION
Tier 3
zenatane oral capsule Tier 2 PA
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr
Tier 1 $0; QL
CHANTIX CONTINUING MONTH BOX ORAL TABLET
Tier 3 $0; QL
CHANTIX ORAL TABLET Tier 3 $0; QL
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK
Tier 3 $0; QL
NICOTROL INHALATION CARTRIDGE
Tier 3 $0
NICOTROL NS NASAL SPRAY,NON-AEROSOL
Tier 3 $0
ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 $0; QL
THYROID PREPS
ARMOUR THYROID ORAL TABLET
Tier 1
levothyroxine oral tablet Tier 1
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1
liothyronine oral tablet Tier 1
methimazole oral tablet 10 mg, 5 mg
Tier 1
nature-throid oral tablet Tier 1
NP THYROID ORAL TABLET 120 MG, 15 MG
Tier 1
np thyroid oral tablet 30 mg, 60 mg, 90 mg
Tier 1
propylthiouracil oral tablet Tier 1
Effective 4/1/2018
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Drug Name Tier Notes
SYNTHROID ORAL TABLET
Tier 1
THYROLAR-1 ORAL TABLET
Tier 3
THYROLAR-1/2 ORAL TABLET
Tier 3
THYROLAR-1/4 ORAL TABLET
Tier 3
THYROLAR-2 ORAL TABLET
Tier 3
THYROLAR-3 ORAL TABLET
Tier 3
unithroid oral tablet Tier 1
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
Tier 1
WP THYROID ORAL TABLET
Tier 1
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral tablet,delayed release (dr/ec)
Tier 2 QL
alendronate oral solution Tier 1
alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg
Tier 1 QL
alfuzosin oral tablet extended release 24 hr
Tier 1
ARCALYST SUBCUTANEOUS RECON SOLN
Tier 4 PA; SP; LD; QL
BERINERT INTRAVENOUS KIT
Tier 4 PA; LD
BERINERT INTRAVENOUS RECON SOLN
Tier 4 PA; LD
buprenorphine hcl sublingual tablet 2 mg, 8 mg
Tier 2 QL
buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg
Tier 1 QL
CARBAGLU ORAL TABLET, DISPERSIBLE
Tier 4 LD
CERDELGA ORAL CAPSULE
Tier 4 PA; SP
Drug Name Tier Notes
CHEMET ORAL CAPSULE
Tier 3
chlorhexidine gluconate mucous membrane mouthwash
Tier 1
CIALIS ORAL TABLET2.5 MG, 5 MG
Tier 3 PA; QL
CYSTADANE ORAL POWDER
Tier 3 LD
darifenacin oral tablet extended release 24 hr
Tier 2 ST
DEBACTEROL MUCOUS MEMBRANE SOLUTION
Tier 3
DEBACTEROL MUCOUS MEMBRANE SWAB
Tier 3
disulfiram oral tablet Tier 1
doxercalciferol oral capsule
Tier 2
doxycycline hyclate oral tablet 20 mg
Tier 1
dutasteride oral capsule Tier 2 PA
etidronate disodium oral tablet
Tier 2
FERRIPROX ORAL TABLET
Tier 4 PA; LD
finasteride oral tablet 1 mg Tier 1
finasteride oral tablet 5 mg Tier 1 PA
flavoxate oral tablet Tier 1
FORTEO SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; SP; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT
Tier 3 ST; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 5,600 UNIT
Tier 3 ST
ibandronate oral tablet Tier 1 QL
KALYDECO ORAL GRANULES IN PACKET
Tier 4 PA; SP; LD; QL
KALYDECO ORAL TABLET
Tier 4 PA; SP; LD; QL
KEVEYIS ORAL TABLET Tier 4 PA; LD; QL
KUVAN ORAL TABLET,SOLUBLE
Tier 4 PA; SP; LD
Effective 4/1/2018
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Drug Name Tier Notes
leucovorin calcium oral tablet
Tier 2
levocarnitine (with sugar) oral solution
Tier 1
levocarnitine oral tablet Tier 2
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
OFEV ORAL CAPSULE Tier 4 PA; SP; LD; QL
oralone dental paste Tier 1
ORFADIN ORAL CAPSULE
Tier 4 LD
OSPHENA ORAL TABLET
Tier 3 QL
oxybutynin chloride oral syrup
Tier 1
oxybutynin chloride oral tablet
Tier 1
oxybutynin chloride oral tablet extended release 24hr
Tier 1
paricalcitol oral capsule Tier 2
paroex oral rinse mucous membrane mouthwash
Tier 1
periogard mucous membrane mouthwash
Tier 1
raloxifene oral tablet Tier 1 $0
RAPAFLO ORAL CAPSULE
Tier 3
risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg
Tier 1 QL
SAVELLA ORAL TABLET
Tier 3 QL
SAVELLA ORAL TABLETS,DOSE PACK
Tier 3 QL
SENSIPAR ORAL TABLET 30 MG, 60 MG
Tier 4 QL
SENSIPAR ORAL TABLET 90 MG
Tier 4
SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION
Tier 2 $0
sildenafil oral tablet Tier 1 PA; QL
SYPRINE ORAL CAPSULE
Tier 3 SP
Drug Name Tier Notes
tamsulosin oral capsule,extended release 24hr
Tier 1
tolterodine oral tablet Tier 1
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
triamcinolone acetonide dental paste
Tier 1
trientine oral capsule Tier 2
trospium oral capsule,extended release 24hr
Tier 2
VESICARE ORAL TABLET
Tier 3
ZAVESCA ORAL CAPSULE
Tier 4 PA; SP; LD
VITAMINS
calcitriol oral capsule Tier 1
calcitriol oral solution Tier 2
cyanocobalamin (vitamin b-12) injection solution
Tier 1
ergocalciferol (vitamin d2) oral capsule
Tier 1
folic acid oral tablet 1 mg Tier 1
tl gard rx oral tablet Tier 1
vitamin d2 oral capsule Tier 1
Effective 4/1/2018
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Effective 4/1/2018
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Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com or call 866-217-2328.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 3/18
For information about your pharmacy benefit, log in at anthem.com. You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Member Services number on your ID card.
Speech and hearing impaired (TDD/TTY) users Call 1-800-221-6915, Monday through Friday, 8:30 a.m. to 5 p.m.ET.