Ariseealt
`
`HEALTH PLAN
`
`Health insurance Partner
`of the Green Bay Packers
`
`IPR2015-01099
`|PR2015'01099 © 2015 WPS Health Plan, Inc. All rights reserved. 27429-085-1510
`IPR2015-01097
`IPR2015-01097
`|PR2015-01100
`IPR2015-01100
`IPR2015-01105
`IPR2015-01105
`
`7701XE.mD.UL
`Lupin EX1077
`1egaDr
`Page 1
`
`
`

`
`Table of Contents
`
`ANTI - INFECTIVES ........................................................................................................................................ ..3
`ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... ..7
`
`AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... ..9
`CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................... .. 17
`DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................. ..23
`DIAGNOSTICS & MISCELLANEOUS AGENTS ........................................................................................ ..30
`
`EAR, NOSE & THROAT MEDICATIONS .................................................................................................... ..31
`ENDOCRINE/DIABETES .............................................................................................................................. ..32
`GASTROENTEROLOGY ............................................................................................................................... ..47
`
`IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ................................................................................ ..52
`MUSCULOSKELETAL & RHEUMATOLOGY ........................................................................................... ..54
`OBSTETRICS & GYNECOLOGY ................................................................................................................. ..55
`OPHTHALMOLOGY ...................................................................................................................................... ..6O
`
`RESPIRATORY, ALLERGY, COUGH & COLD .......................................................................................... ..62
`UROLOGICALS .............................................................................................................................................. ..66
`
`VITAMINS, HEMATINICS & ELECTROLYTES ........................................................................................ ..67
`Index ................................................................................................................................................................. ..76
`
`1
`
`Page 2
`
`

`
`List of Abbreviations
`
`ACA: Affordable Care Act.
`
`LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
`information, please call Customer Service.
`
`PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
`This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we
`may not cover the drug.
`
`QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
`
`ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
`condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
`your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
`you, we will then cover Drug B.
`
`Drug Tier: Identifies the member’s cost sharing requirement.
`
`Tier 1 Preferred generic drug.
`
`Tier 3 Preferred brand drug.
`
`Tier 4 Brand drug.
`
`Tier 5 Oral chemotherapy drug where member cost sharing will not exceed $100 for a
`continuous 30 day supply.
`Tier 6 Specialty drug
`
`Tier 7 Preventive drug available at no cost to the member.
`
`I\)
`
`Page 3
`
`

`
`DrugName
`
`Drug
`Tier
`
`Requirements
`/Limits
`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`2
`
`ANTI _ [NFECTIVES
`
`amantadine he!
`
`APTIVUS
`
`3
`
`czommazoze
`
`CRESEMBA
`fluconazole oral
`suspension for
`reconstitution
`I
`c:‘;,::73z‘;;:“m
`
`I
`
`mg, 50 mg
`
`fluconazole oral
`tablet 150 mg
`fl”‘y’°Si"e
`gr.’S""’f31””
`mzcroszze
`
`griseofulvin
`ultramicrosize
`
`itracorzazole
`
`ketoconazole
`
`V
`
`3
`2
`
`2
`
`2
`
`2
`2
`
`2
`
`2
`
`2
`
`3
`
`P
`
`3
`
`A
`
`QL
`
`QL
`
`3 Amm
`
`BARACLUDE
`COMPI-‘ERA
`CRIXIVAN
`DAKLINZA
`
`EDURANT
`
`EMTRJVA
`entecavir
`EPIVIR HBV
`EPZICOM
`
`EVOTAZ
`famciclovir
`
`FUZEON
`
`HARVONI '
`
`3
`
`3
`3
`3
`6
`2
`
`3
`
`3
`2
`3
`3
`
`4
`2
`
`3
`
`6
`
`PA
`
`PA
`
`PA
`
`QL
`
`PA
`
`LAMISIL
`
`NOXAFIL
`
`nystatirz
`
`ONMEL
`
`ORAVIG
`
`SPORANOX
`
`terbinafine hcl
`.
`vorzconazole
`
`M
`
`A
`
`QL
`
`3
`
`3
`
`2
`
`4
`
`4
`
`3
`
`2
`2
`
`INTELENCE
`
`INVIRASE
`
`ISENTRESS
`
`KALETRA
`
`lamivudine
`
`lamivudine-
`
`Zldovudme
`LEXIVA
`
`
`abacavir
`2
`.
`abacavzr—
`
`2
`
`nevirapine
`
`NORVIR
`OLYSIO
`
`lamz'vudine—
`
`Zl.CIOV7./[all-}’le
`
`“"VC"’V”
`adefovir
`
`2
`2
`
`PREZCOBIX
`
`RELENZA
`DISKHALER
`
`3
`
`3
`
`3
`
`3
`
`2
`
`2
`
`3
`
`2
`
`3
`6
`
`4
`
`3
`
`3
`
`PA
`
`QL
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`3
`
`Page 4
`
`

`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/Limits
`
`RESCRIPTOR
`
`REYATAZ
`
`rimantadirze
`
`SELZENTRY
`
`SOVALDI
`
`stavudine
`
`STRIBILD
`SUSTIVA
`
`TAMIFLU
`
`TECHNIVIE
`
`TIVICAY
`
`TRIUMEQ
`
`TRUVADA
`
`3
`
`3
`
`2
`
`3
`
`6
`
`2
`
`43
`3
`
`3
`
`6
`
`3
`
`3
`
`3
`
`PA
`
`QL
`
`PA
`
`cefditoren pivoxil
`
`cefixime
`
`cefpodoxime
`
`cefprozil
`
`ceftibuten
`
`CEFTIN
`
`cefuroxime axetil
`cephalexin
`
`SUPRAX
`
`2
`
`2
`
`2
`
`2
`
`2
`
`4
`
`2 3
`5 2
`
`4
`
`
`
`azithromycin oral
`packet
`
`2
`
`3
`*2
`
`PA
`
`' QL
`
`PA
`
`TYBOST
`TYZEKA
`
`valacyclow-V
`
`VALCYTE
`
`valganciclovir
`VIDEX 2 GRAM
`PEDIATRIC
`
`VIEKIRA PAK
`
`VIRACEPT
`
`VIRAMUNE XR
`
`VIREAD
`
`VITEKTA
`
`ZIAGEN
`Zidovudine
`
`3
`
`3
`
`4
`3
`
`2
`
`3
`
`2
`3
`
`3
`
`6
`
`3
`
`3
`
`3
`
`4
`
`3
`2
`
`
`
`QL
`
`ST
`
`azithromycin oral
`suspensionfor
`reconstitution
`
`azithromycin oral
`tablet 250 mg
`
`azithromycin oral
`tablet 500 mg’ 600
`mg
`clarithromycin
`
`DIFICID
`
`e.e.s. 400
`
`E.E.S. GRANULES
`
`ERYPED 200
`
`ERYPED 400
`
`ery-tab oral
`tablet,delayed
`release (dr/ec) 25 0
`mg, 333 mg
`
`ERY—TAB ORAL
`
`2
`
`E 2
`
`2
`
`4
`
`2
`
`4
`
`4
`
`4
`
`2
`
`4
`
`TABLET,DELAYE
`2
`cefadmxil
`——_—_—~—'—*——m-:——-— D RELEASE
`cefdln”
`2
`(DR/EC) 500 MG
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`4
`
`Page 5
`
`

`
`Drug Name
`
`Drug Requirements
`Tier 6
`/ Limits
`
`Drug Name
`
`Drug
`‘Tier
`
`Requirements
`/ Limits
`
`ivermectin
`2
`erythrocin (as
` _j_j_?_ KETEK
` i_*: KJTABIS PAK
`Z?Z§’}§§53§Z7e
`2
`"'"m"“’
`PCB
`4
`mefloquine
`ZMAX
`4
`metronidazole
`NEBUPENT
`
`
`
`ALBENZA
`
`ALINIA
`
`atovaquone
`
`atovaquone-
`Proguanil
`
`BETHKIS
`
`BILTRICIDE
`
`CAYSTON
`
`chloroquine
`phosphate
`
`3
`
`3
`
`2
`
`2
`
`6
`
`4
`
`6
`
`2
`
`PA; LA
`
`PA; LA; QL
`
`neomycin
`
`P‘"‘0m0mJ’ci”
`
`PASER
`
`PRIFTIN
`
`PRIMAQUINE
`pyrazinamide
`
`quinine sulfate
`
`rt-fabun-n
`
`,.,-famp,-n
`
`RIFATER
`SIRTURO
`
`2
`4
`L 6
`2 A
`2
`
`E 3
`
`2
`
`2
`
`A 4
`
`6 3
`
`3
`2
`
`22
`
`A 2
`
`2 L
`
`A 4
`3
`
`;
`
`PA; LA
`
`QL
`
`LA
`
`2
`
`tinidazole
`clmdamycin
`TOBI PODHALER
`palm,-fate hcl
` 7—::-.é: tobramycin in 0.225
`pediatric
`% "ac!
`
`2 be
`6 ‘ PA; LA; QL
`6
`PA; QL
`
`COARTEM
`
`CYCLOSERINE
`
`DAPSONE
`DARAPRIM
`
`ethambutol
`FLAGYL ER
`
`hydroxychloroquine
`
`isoniazid
`
`3
`
`4
`
`3
`3
`
`2
`4
`
`1
`
`2
`
`TRECATOR
`
`XIFAXAN
`
`4
`
`3
`
`ZYVOX
`3
`
`1‘
`
`
`amoxicillin oral
`Capsule
`
`1
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`5
`
`Page 6
`
`

`
`
`
`Drug Name
`
`penicillin v
`potassium oral
`tablet
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`I 1
`
`
`/
`.
`,
`AVELOX ABC
`4
`PACK
`
`g
`
`ciprofloxacin
`ciprofloxacin
`(mixture)
`ciprofloxacin hcl
`FACTIVE
`levofloxacin
`moxifloxacm
`
`Ooxcm
`
`2;
`: 2
`
`2
`o 4
`I 2
`o
`is p
`2
`
`QL
`
`
`
`Sulfameth0xaZ0le_
`.
`h
`.
`I
`trimet oprim ora
`suspension
`sulfamethoxazole-
`.
`.
`trimethoprzm oral
`tablet
`sulfatrim
`
`*
`
`272
`o
`L
`
`I
`ll
`
`~
`
`f
`
`o
`
`
`
`
`
`ACTICLAT
`
`avidoxy
`
`AVIDOXY DK
`
`demeclocycline
`
`DORYX
`
`.
`doxycycline lzyclate
`a’
`*
`'1'
`m:):)z:l)7;aZ7aete
`
`MINOCIN KIT
`WITH WIPES-
`
`4
`
`2
`
`4
`
`2
`
`4
`
`2
`2
`
`4
`
`ST
`
`ST
`
`ST
`
`ST
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`amoxicillin oral
`suspension for
`reconstitution 125
`
`mg/5 ml, 200 mg/5
`ml
`
`.
`.
`.
`amoxzcillin oral
`suspensionfor
`reconstitution 250
`mg/5 ml, 400 mg/5
`ml
`.
`'
`'
`::Z?;mllln oral
`AMOXICILLIN
`ORAL TABLET,
`ER MULTIPHASE
`24 HR
`amoxicillin oral
`tablet,chewable 125
`mg
`
`amoxicillin oral
`tablet,chewable 250
`mg
`
`amoxicimn-pot
`clavulanate
`
`ampicillin oral
`capsule
`ampicillin oral
`suspension for
`reconstitution
`
`AUGMENTIN
`
`dicloxacillin
`
`MOXATAG
`
`penicillin v
`potassium oral recon
`Sol” 125 mg/5 ml
`.
`.
`.
`penicillin v
`potassium oral recon
`soln 250 mg/5 ml
`
`2
`
`1
`
`1
`4
`
`2
`
`1
`
`2
`
`1
`
`2
`
`3
`
`2
`
`4
`
`2
`
`1
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`6
`
`Page 7
`
`

`
`
`
`
`
`leucovorm calcium
`
`MESNEX
`
`2
`
`3
`
`XGEVA
`
`6
`
`PA
`
`AFINITOR
`
`AFINITOR
`DISPERZ
`
`ALKERAN
`
`anastrozole
`
`ASTAGRAF XL
`
`AZASAN
`
`_
`_
`azathzoprme
`bexarotene
`_
`_
`btcalutamzde
`
`PA
`
`PA
`
`PA
`
`I
`
`A 5
`
`5
`
`5
`
`2
`
`4
`
`3
`
`2
`6
`
`*
`
`A
`A 2
`
`Drug Name
`
`Drug
`
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drugs Requirements
`Tier
`/Limits
`
`minocyclirze oral
`
`fnagsule 100 mg’ 50
`
`.
`.
`mmocyclme oral
`capsule 75 mg
`
`minocycline oral
`tablet
`
`minocycline oral
`tablet extended
`release 24 hr
`
`morgidox
`
`MORGIDOX 1X100
`
`SOLODYN
`
`1
`
`2
`
`2
`
`2
`
`2
`
`4
`
`3
`
`ST
`
`ST
`
`tetracycline
`
`L 2
`
`VIBRAMYCIN
`‘ 4
`
`
`’
`
`MACRODANTIN
`
`4
`
`'
`
`Z’.‘”he”"’"’”e
`zppurate
`methenamine
`
`mandelate
`
`MONUROL
`
`nitrofurantoin
`nitrofurantoin
`macrocrystal
`
`rzitrofurantoin
`monohyd/m-cryst
`
`PRIMSOL
`
`trimethoprim
`
`A 2
`2
`
`‘V
`
`L
`
`4 V‘
`
`5
`
`“ 2
`2 A
`
`A
`
`2
`
`4
`
`2
`
`
`
`vartcomycin
`
`2
`
`BOSULIF
`capecztabme
`
`CAPRELSA
`
`COMETRIQ
`
`CYCLOPHOSPHA
`MIDE
`cyclosporine
`
`cyclosporine
`modified
`
`DROXIA
`
`ELIGARD
`
`EMCYT
`
`ERIVEDGE
`
`5
`6
`
`5
`
`5
`
`5
`
`2
`
`2
`
`3
`
`6
`
`5
`
`5
`
`PA; LA
`PA
`
`PA; LA
`
`PA; LA
`
`PA
`
`PA; LA
`
`5
`
`exemestane
`
`FARESTON
`
`2
`
`2
`
`ANTINEOPLASTIC &
`
`ef0P0Sl'd€
`
`IMMUNOSUPPRESSANT
`
`DRUGS
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`7
`
`Page 8
`
`

`
`Drug Name
`
`FARYDAK
`
`flutamide
`
`gengraf
`GILOTRIF
`
`GLEEVEC
`
`GLEOSTINE
`HEXALEN
`HYCAMTIN
`
`hydmxyurea
`IBRANCE
`
`ICLUSIG
`
`IMBRUVICA
`
`INLYTA
`
`Drug
`Tier
`
`Requirements
`/Limits
`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`5
`
`2
`
`2
`5
`
`5
`
`5 5
`5
`5
`
`2
`5
`
`5
`
`5; L
`
`5
`
`g
`
`A
`
`PA; LA
`
`MATULANE
`
`megeszrol
`
`MEKINI ST
`mercaptopurine
`
`methotrexate sodium
`
`methotrexate sodium
`(P19
`’"y‘°°1”’e”°"”‘*
`mofetil
`mycophenolate
`sodium
`
`MYLERAN
`
`NEORAL
`
`NEXAVAR
`
`PA; LA
`
`PA
`
`PA- LA
`’
`
`PA; LA
`
`PA; LA
`
`PA; LA
`
`PA; LA
`
`LA
`
`i
`
`PA; LA
`
`T 5
`
`22
`
`5
`A 2
`
`2 2
`
`2 i
`
`2
`
`2
`
`5
`
`4
`
`5 _ 5 PA; LA
`
`6 “P
`
`IRESSA
`
`JAKAFI
`LENVIMA
`
`letrozole
`LEUKERAN
`leuprolide
`LOMUSTINE
`
`LUPRON DEPOT
`
`LUPRON DEPOT
`(3 MONTH)
`LUPRON DEPOT
`
`(4 MONTH)
`LUPRON DEPOT
`(6 MONTH)
`
`LUPRON DEPOT-
`FED
`%1l3J11;I:§)§I(1))1i3],l;(P)I)T'
`LYNPARZA
`LYSODREN
`
`5
`
`PA; LA
`
`PA;LA
`5 V;
`:5 A PA; LA
`
`octreotide acetate
`
`V
`
`PURIXAN
`RAPAMUNE
`
`LA
`
`5 M
`4 3i
`
`2
`
`A
`
`2
`5
`6
`
`«5
`6
`6
`
`6
`
`6
`
`6
`
`6
`5
`5
`
`PA
`
`PA
`
`PA
`
`PA
`
`PA
`
`PA
`
`PA
`PA; LA
`
`RHEUMATREX
`SANDIMMUNE
`ORAL CAPSULE
`SANDIMMUNE
`ORAL SOLUTION T
`SIGNIFOR
`.
`,
`szroltmus
`SOLTAMOX
`
`SOMATULINE
`DEPOT
`SPRYCEL
`
`STIVARGA
`SUTENT
`SYNRIBO
`TABLOID
`tacrolimus
`
`H 5
`L
`A ~
`A
`
`L
`
`A
`
`V
`
`A
`
`6
`
`2
`5
`
`6
`
`5
`
`5
`5
`6
`5
`2
`
`V
`
`5
`
`‘
`PA; LA
`
`‘
`
`LA
`
`PA; LA
`
`PA
`
`PA; LA
`PA; LA
`PA; LA
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning Of this table.
`
`8
`
`Page 9
`
`

`
`Drug Name
`
`TAFINLAR
`
`tamoxifen
`
`TARCEVA
`
`TARGRETIN
`
`TASIGNA
`
`temozolomide
`
`THALOMID
`
`tretinoin
`("”"”""”’e"’Py)
`TREXALL
`
`TYKERB
`VOTRIENT
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`PA; LA
`
`epitol
`
`EQUETRO
`
`PA; LA
`
`ethosuximide
`
`PA
`
`PA
`
`PA
`
`PA; LA
`
`PA
`
`felbamate
`
`FYCOMPA
`
`gabapentin
`
`GABITRIL
`
`GRALISE
`GRALISE 30-DAY
`STARTER PACK
`
`5
`
`2
`
`5
`
`6
`
`5
`
`6
`
`6
`
`2
`
`5
`
`5
`5
`
`x
`
`2
`
`4
`
`2
`
`2
`
`3
`
`2
`
`3
`
`3
`3
`
`4
`
`4
`
`ST
`ST
`
`XALKORI
`XTAND1
`
`PA; LA
`PA; LA
`.
`PA, LA
`PA; LA
`
`5
`5
`
`ZELBORAF
`
`5
`
`PA; LA
`
`5
`
`PA‘ LA
`’
`
`LAMICTAL ODT
`STARTER (BLUE)
`LAMICTAL ODT
`STARTER
`(GREEN)
`
`LAMICTAL ODT
`STARTER
`(ORANGE)
`LAMICTAL
`STARTER (BLUE)
`K”
`
`L
`
`(GREEN)K1T
`LAMICTAL
`STARTER
`
`(ORANGE) KIT
`LAMICTAL XR
`STARTER (BLUE)
`
`LAMICTAL XR
`
`STARTER
`(GREEN)
`
`LAMICTAL XR
`STARTER
`
`(ORANGE)
`
`lamotrigine
`
`4
`
`A 4
`
`4
`
`4
`
`3
`
`3
`
`3
`
`2
`
`
`
`ZOLINZ
`
`S
`
`A
`Z R RES
`3 ;
`0 T
`ZYDELIG
`5
`PA; LA
`
`ZYTIGA
`A
`A 5 T
`PA; LA
`AUTONOMIC & CNS DRUGS,
`NEUROLOGY & PSYCH
`
`A
`
`APTIOM
`
`BAN EL
`2
`carbamazepine
`
`CELONTIN
`
`clonazepam
`
`DIASTAT
`
`diazepam
`
`DILANTIN
`
`dz-valpmex
`
`PA
`
`4
`
`3
`2
`
`3
`
`2
`
`4
`
`2
`
`3
`
`2
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning Ofthis table.
`
`9
`
`Page 10
`
`

`
`Drug Requirements
`Tier
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`ST
`
`benztropine
`
`bromocriptine
`
`carbidopa
`
`carbidopa—levodopa
`
`carbidopa-levodopw
`entacapone
`e”’“""P"”e
`MIRAPEX ER
`
`NEUPRO
`pramipexole
`ropinirole
`
`RYTARY
`
`selegiline he]
`
`LA
`
`tolcapone
`
`trihexyphenidyl
`
`ZELAPAR
`
`2
`
`L 2
`
`A 2
`
`L 2
`
`2
`
`2
`3
`
`4
`2
`2
`
`4
`
`2
`
`2
`
`2
`
`4
`
`Drug Name
`
`levetiracetam
`
`LYRICA
`
`ONFI
`
`oxcarbazepine
`
`OXTELLAR XR
`PEGANONE
`phenobarbital
`.
`phenytozn
`phenytoin sodium
`extended
`POTIGA
`
`primidone
`
`QUDEXY XR
`
`SABRIL
`
`TEGRETOL XR
`
`tiagabine
`topiramate oral
`capsule, sprinkle
`TOPIRAMATE
`ORAL
`CAPSULE,SPR1NK
`LE7ER 24HR
`topiramate oral
`tablet
`TROKENDI XR
`
`valproic acid
`valproic acid (as
`S0di“m 5511‘)
`
`Z0nisam1-are
`
`2
`
`3
`
`3
`
`2
`
`3
`3
`2
`
`2
`2
`*
`A 3.
`
`_
`
`g
`
`2
`
`4
`
`6
`
`3
`
`j
`i gt
`A 4i
`
`2
`
`4
`
`2
`2
`
`3
`
`2
`
`,
`
`s
`
`
`
`almotrzptan malate
`
`CAFERGOT
`dihydroergotamine
`injection
`dihydroergotamine
`"0501
`
`ERGOMAR
`FROVA
`is0meth-dichloral-
`aCetaWli7l0phn
`
`isomethepten-caf—
`acetaminophen
`
`migergot
`naratriptan
`nodolor
`
`QL
`
`QL
`
`ST; Q1‘
`
`QL
`
`2
`
`4
`2
`
`2
`
`4
`4
`2
`
`2
`
`2
`2
`2
`
`
`
`
`r
`/ »~
`6
`LA
`3
`
`2
`« ~
`AP K
`O YN
`AZILECT
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`10
`
`Page 11
`
`

`
`DrugName
`
`RELPAX
`rizatriptan
`
`sumatriptan
`
`sumatriptan
`succinate oral
`sumatriptan
`succinate
`
`subcutaneous
`cartridge
`sumatriptan
`Succl-mate
`subcutaneous pen
`injector
`
`sumatriptan
`Suca-"ate
`subcutaneous
`
`solution
`
`sumatriptan
`succinate
`b
`:;‘n;’::”e””S
`
`DOSEPRO
`SUBCUTANEOUS
`NEEDLEFREE
`INJECTOR 4
`MG/0.5 ML
`
`SUMAVEL
`DOSEPRO
`SUBCUTANEOUS
`
`‘Drug Requirements
`Tier
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`3
`2
`
`2
`
`2
`
`2
`
`2
`
`2
`
`2
`
`‘
`
`3
`
`QL
`ZOMIG NASAL
`QL G
`
`3
`
`QL
`
`QL
`
`QL
`
`QL
`
`QL
`
`QL
`
`E
`
`QL
`
`
`
`6
`
`ST
`
`_
`donepezll
`
`galamam,-ne
`HORIZANT
`_
`memantme oral
`tablet
`MEMANTINE
`
`ORAL
`TABLETS,DOSE
`PACK
`
`NAMENDA
`
`NAMENDA
`TITRATION PAK
`NAMENDA XR
`
`*
`
`L
`
`2
`
`2 2
`4
`
`R
`
`a
`
`2
`
`4
`
`3
`
`O
`
`T 3
`
`g
`‘
`3 2
`
`.
`
`rivastigmine
`.
`.
`.
`rzvastzgmme tartrate 2 W
`tetrabenazine
`
`R.
`
`* 2
`L
`22 2
`L 6
`
`2 PA
`
`
`
`AMRIX
`
`4
`
`baclofen
`INJECTOR 6
`d I
`_
`MG/0'5 ML
`carzsopro 0
`
`3 ST; QL carisoprodol-asa-TREXIMET 2—e codeine
`l
`'
`'
`2
`L
`Z0 mlmptan
`Q
`carisoprodol-aspirin
`2
`ZOMIG NASAL
`SPRAY,NON_
`AEROSOL 2.5 MG
`
`1
`2
`
`2
`1
`
`chlorzoxazone
`cyclobenzaprine oral
`tablet 10 mg, 5 mg
`
`
`
`
`
`
`
`3
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`11
`
`Page 12
`
`

`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`cyclobenzaprine oral
`tablet 7.5 mg
`
`dantrolene
`LORZONE
`meprobamate
`MESTINON
`metaxalone
`methocarbamol
`orphenadrine citrate
`.
`.
`.
`
`’;f;:;if;;’gm’"e
`
`tizanidine
`
`g
`2
`
`e
`
`2
`
`2
`4
`2
`3
`2
`2
`2
`
`2
`
`2
`
`
`ABSTRAL
`4
`
`1
`
`acetamz'nophen-
`codeine
`ascom with codeine
`1’
`BUPAP
`.
`buprenorphme hcl
`butalbital compound
`W/codeme
`butalbital-
`acetammop—caf-co
`'
`1-
`Zzftzclzilziiophen
`butalbital—
`acetaminophemcajj’
`
`d
`
`butalbital—aspirz'n-
`""fl"””e
`BUTRANS
`capacet
`gggg§gWITH
`codeine sulfate
`
`2
`
`2
`
`4
`2
`
`2
`
`*
`, 2
`
`2
`
`2
`
`2
`
`3
`2
`4
`2
`
`dihydrocode-
`acetaminophen-cafl
`
`dihydrocodeine—
`aspirin-caff
`diskets
`EMBEDA
`endocet
`endodan
`femanyl citrate
`fentanyl transdermal
`
`patch 72 hour 100
`
`mcg/hr, 12 mcg/hr,
`25 mcg/hr, 50
`mcg/hr, 75 mcg/hr
`
`FENTANYL
`TRANSDERMAL
`
`PATCH 72 HOUR
`37.5 MCG/HOUR,
`625 MCG/HOUR’
`87.5 MCG/HOUR
`FENTORA
`hydr0c0d0ne_
`acetaminophen
`hydrocodone-
`jbupro/én
`hydmmorphone
`HYSINGLA ER
`IBUDONE
`ibuprofen-oxycodone
`
`KADIAN
`LAZANDA
`levorphanol tartrate
`lorcet (hydrocodone)
`hd
`[meetplus
`
`L
`
`M
`
`V
`2
`
`2
`
`2
`
`a
`2 2
`
`2 2
`2
`2
`2
`
`4
`
`4
`g 2
`V
`
`e 2
`
` 3
` 4
`2
`
`4
`3
`2
`2
`2
`2
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`12
`
`Page 13
`
`

`
`Drug Name
`
`lortab 10-325
`
`lortab 5-325
`
`lortab 7.5—325
`
`LORTAB ELIXIR
`
`margesic
`
`marten-tab
`
`meperidine
`
`meperitab
`methadone
`
`methadose
`
`morphine
`
`morphine
`concentrate
`
`OPANA ER
`OXAYDO
`OXECTA
`g;g§;;;°"e0m’
`oxycodone oral
`
`concentrate
`
`oxycodone oral
`solution
`
`oxycodone oral
`tablet
`
`OXYCODONE
`ORAL
`TABLET,ORAL
`ONLY,EXT.REL.12
`
`HR
`0xycodone—
`acetaminophen
`
`oxycodone-aspirin
`
`OXYCONTIN
`
`oxymorphone
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`2
`
`2
`
`2
`
`2
`
`4
`
`22
`
`2
`
`2
`
`2
`2
`
`2
`
`2
`
`2
`
`2
`
`3
`4
`4 s
`
`42
`
`g
`
`2
`
`2
`
`2
`
`4
`
`2
`
`2
`
`3
`
`2
`
`PRIMLEV
`
`reprexain
`
`SUBSYS
`
`SYNALGOS—DC
`
`tencon
`
`TREZIX
`
`verdrocet
`
`vicodin
`vicodin es
`
`vicodin hp
`
`XARTEMIS XR
`
`xylon I0
`.
`zamzcet
`
`4
`
`2
`
`4
`
`4
`
`2
`
`4
`
`2
`
`g 2
` 2
`
`2
`
`4
`
`2
`
`2
`
`2
`zebutal
`4
`ZOHYDRO ER
`“E ., a
`
`
`aspirin
`7
`ACA
`aspmlow
`7 M
`ACA
`
`BUNAVAIL
`
`4
`
`QL
`
`QL
`
`QL
`
`buprenorphine—
`naloxone
`
`butorphanol tartrate
`injection
`
`butorphanol tartrate
`nasal
`celecoxib
`
`choline, magnesium
`wlicylate
`CONZIP
`
`depade
`
`diclofenac potassium
`
`diclofenac sodium
`
`2
`
`2 2
`
`2
`
`2
`
`2
`
`4
`
`2
`
`2
`
`2
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`13
`
`Page 14
`
`

`
`Drug Name
`
`dicl0fenac-
`misoprostol
`
`dzflumsal
`
`elodolac
`
`EVZIO
`
`FENOPROFEN
`
`ORAL CAPSULE
`J::Z(l)§tr0fen Om]
`
`FLECTOR
`
`flurbiprofen
`ibuprofen
`
`INDOCIN
`indomethacin
`
`kempmfen
`
`Drug Requirements
`Tier
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`LA
`
`2
`
`QL
`
`2
`
`2
`
`2 .
`
`6
`
`4
`
`2
`
`4
`
`2
`2
`
`4
`2
`
`2
`
`2
`
`2
`
`2
`
`3
`
`2
`
`4
`2
`
`QL
`
`4 A
`
`QL
`
`4
`
`4
`
`A
`
`QL
`
`pentaz0cine—
`naloxone
`
`piroxicam
`
`salsalate
`
`SUBOXONE
`
`sulindac
`
`TIVORBEX
`tolmetirz
`
`TRAMADOL
`ORAL
`
`CAPS ULE,ER
`BIPHASE 24 HR
`17-83
`TRAMADOL
`ORAL
`
`CAPSULE,ER
`BIPHASE 24 HR
`
`QL
`
`25-75
`
`V
`
`ketorolac
`
`‘ 2
`
`meclofenamate
`mefenamic acid
`meloxicam Om]
`suspension
`meloxicam 0m]
`tablet 15 mg
`meloxicam oral
`tablet 75 mg
`nabumetone
`
`NALFON
`
`naltrexone
`
`NAPRELAN CR
`
`naproxen
`
`naproxen sodium
`
`NUCYNTA
`
`NUCYNTA ER
`
`oxaprozl-,1
`
`4
`
`2
`2
`2%
`2
`
`2
`
`2
`
`2
`
`4
`
`2
`
`4
`
`2
`
`2
`
`3
`
`3
`
`2
`
`4
`
`‘V
`A
`
`o QL
`
`lramadol oral tablet
`tramadol oral tablet
`extended release 24 4
`hr
`tramadol oral tablet,
`er multiphase 24 hr
`tmmad‘?l'
`acetammophen
`VOLTAREN
`
`A
`
`ZIPSOR
`
`ZORVOLEX
`
`s QL
`AQL
`
`L
`
`2 V
`_
`
`A
`
`QL
`
`A
`
`2
`
`2
`
`3
`
`4
`
`3
`
`ZVUBSQLY,
`3
`
`1
`
`ADASUVE
`4
`
`QL
`
`allmzolam
`
`alprazolam irztensol
`
`amitriplyline
`
`2
`
`2
`
`1
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`14
`
`Page 15
`
`

`
`Drug Name
`
`Drug
`Tier s
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`amitriptylirze—
`chlordiazepoxide
`oral tablet 12. 5-5 mg
`.
`.
`.
`amztrzptylme-
`chlordiazepoxide
`oral tablet 25-10 mg
`
`amoxapine
`
`amphetamine salt
`combo
`
`APLENZIN
`.
`.
`arzpzprazole
`BELSOMRA
`BRINTELUX
`BRISDELLE
`.
`bupropzon he]
`buspirorze
`BUTISOL
`chlordiazepoxjde he]
`chlorpromazine
`0””
`citalopram oral
`tablet J 0 mg
`
`citalopram oral
`tablet 20 mg, 40 mg
`clomzpramme
`clomdme lzcl
`
`clorazepate
`dzpotasszum
`clozapine oral tablet
`.
`clozapme oral
`tablet, disintegrating
`100 mg, 12.5 mg, 25
`mg
`
`2
`
`1
`
`2
`
`2
`
`4
`
`ST
`
`,
`
`2
`4
`ST
`4 4 j ST
`3
`ST
`
`2
`2
`
`2
`
`-
`
`52 it
`« 2 4‘
`2
`1
`
`L
`2
`k
`
`1
`
`2
`2
`
`2
`
`2
`
`2
`
`QL
`
`CLOZAPINE
`ORAL
`TABLET,DISINTE
`GRATING 150 MG,
`200 MG
`
`DAYTRANA
`
`desipramine
`
`DESVENLAFAXIN
`E
`
`DESVENLAFAXIN
`E FUMARATE
`
`‘’‘’’‘e‘’’’”‘“’
`dexmethylphemdate
`dextroamplzetamine
`dextroamphetam1'ne—
`amphetamine
`diazepam
`diazepam intensol
`doxepin
`duloxefine
`EDLUAR
`EMSAM
`ergoloid
`
`escitalopram oxalate
`esmzolam
`eszopiclone
`EVEKEO
`
`FANAPT
`
`FAZACLO
`FETZIMA
`
`fluoxeline Oral
`capsule
`
`4
`
`3
`
`2
`
`4
`
`'4
`
`2
`2
`2
`2
`
`2
`2 2
`2 2
`2
`4
`4
`2
`
`2
`2
`2
`4
`
`4
`
`4
`4
`
`1
`
`ST
`
`ST
`
`ST
`
`ST; QL
`
`QL
`
`ST
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`15
`
`Page 16
`
`

`
`Drug Name
`
`Drug sRequirements
`Tier
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`fluoxetine oral
`capsule,delayea’
`releasddr/QC)
`fluoxetine oral
`solution
`
`L
`
`2
`
`2
`
`lithium carbonate
`.
`.
`.
`lithium citrate
`lomzepam
`lorazepam intensol
`
`lwcapine Succirlate
`fluoxetine oral tablet
`ma
`.
`.
`a
`2
`10 mg
` _j__: protilme
`fluoxetine oral tablet
`22
`L
`MARPLAN
`20 mg
`FLUOXETINE
`ORAL TABLET 60
`MG
`fluphenazine hcl
`/lumzepam
`fluvoxamirie oral
`capsule, extended
`release 24h,»
`fluvoxamine oral
`tablet 100 mg, 50 mg
`fluvoxamine oral
`table; 25 mg
`
`T
`
`L
`
`2
`
`1
`
`4
`
`V
`t
`
`«
`
`:
`L ST
`
`,
`
`E
`
`2
`
`22 i
`2
`2
`
`a
`
`is
`
`2
`~
`
`fla««
`47
`‘
`‘
`
`so
`
`ye QL
`2
`i
`T
`
`d
`met“ ‘me er
`methamphetamine
`methylphenidate
`ml-rtazapl-ne
`modafinil
`nefazodone
`
`nortriptyline oral
`Caps” 6
`nortriplyline oral
`I
`'
`S0 mm”
`NUVIGIL
`
`1
`
`2
`2
`2
`
`2
`
`2
`4
`
`2
`
`2
`2
`2
`2
`2
`
`1
`
`2
`
`3
`
`2
`
`2
`
`4
`
`4
`
`2
`
`1
`
`2
`
`4
`2
`2
`
`»
`f _
`L
`
`V
`
`2
`
`PA
`
`PA
`
`QL
`
`ST
`
`Olanzapme
`
`01anzapine-
`fluoxetine
`
`OLEPTRO ER
`
`ORAP
`
`oxazepam
`paroxetme hcl oral
`tablet
`
`paroxetirze hcl oral
`tablet extended
`release 24 hr
`PAXIL
`perphenazme
`p”1.’h.e”"Z.’”“"
`amztrzptylme
`
`L ST
`
`j ST
`
`a PA_ LA
`9
`
`ST; QL
`
`ST
`
`s
`
`3
`
`4
`
`2
`
`22
`
`2
`2
`2 6
`
`1
`2
`4
`4
`4
`3
`
`F OCALIN XR
`
`FORFIVO XL
`_
`guanfaczne
`
`guanidine
`
`haloperidol
`haloperidol lactate
`HETLIOZ
`
`imipmmme hcl
`imipramine pamoate
`INTERMEZZO
`INVEGA
`KHEDEZLA
`LATUDA
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`16
`
`Page 17
`
`

`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`venlafaxine oral
`tablet extended
`release 24hr
`VERSACLOZ
`VIIBRYD
`VYVANSE
`XYREM
`Zaleplon
`zenzedi oral tablet
`10 mg, 5 mg
`
`ZENZEDI ORAL
`
`2
`
`4
`3
`3
`6
`2
`2
`
`4
`
`ST
`ST
`LA
`QL
`
`5?}:/%T235M“’éG30
`MG, 75’ MG ’
`ziprasidone hcl
`
`zolpidem
`CARDIOVASCULAR,
`HYPERTENSION & LIPIDS
`
`ST
`
`ST
`
`ST
`
`ST
`
`ST; QL
`
`ST
`
`QL
`
`ST; QL
`
`ST
`
`PEXEVA
`henelzme
`
`p
`PRISTIQ
`I”‘’‘’‘'’"”‘'
`protriptyline
`quetlapme
`QUILLIVANT XR
`REXULTI
`risperidone
`
`RITALIN LA
`
`ROZEREM
`SAPHRIS (BLACK
`HERRY
`C
`)
`SARAFEM
`
`seconal sodium
`SERO UEL XR
`Q
`sertraline oral
`concentrate
`
`sertraline oral tablet
`
`SILENOR
`
`STRATTERA
`
`temazepam
`h
`d
`.
`t
`.
`.
`zorz azme
`thiothixene
`
`tranylcypromine
`
`trazodone
`
`triazolam
`
`trtfluoperazine
`
`venlafaxine oral
`capsule, extended
`release 24hr
`
`venlafaxine oral
`tablet
`
`4
`2
`
`3
`2
`2
`2
`L 3
`4
`2
`
`4
`
`3
`4
`
`4
`
`2
`3
`
`2
`
`1
`
`4
`
`3
`
`2
`2
`
`2
`
`2
`
`1
`
`2
`
`2
`
`1
`
`2
`
`
`
`
`
`amiodarone
`
`disopymmide
`phosphate
`
`flecairzide
`
`mexiletine
`MULTAQ
`NORPACE CR
`
`2
`
`2
`4
`4
`
`pacerone
`
`propafenorze
`
`quinidine gluconate
`_
`qumidine sulfate
`
`Somlol
`50,010] af
`
`SQTYLIZE
`
`2
`
`2
`
`2
`
`2
`
`2
`2
`
`3
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`17
`
`Page 18
`
`

`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`bisopr0lol-
`hydrochlorothiazide
`oral tablet 2.5-6.25
`
`mg
`
`bumetanide
`
`BYSTOLIC
`
`candesartan
`candesartan-
`hyclroclzlorothiazid
`captopril oral tablet
`100 mg
`captopril oral tablet
`12.5 mg, 25 mg, 50
`mg
`captopril-
`hydrochlorothiazide
`CARDENE SR
`
`CARDIZEM LA
`CARDURA XL
`carvedilol
`cltlorotlziazide oral
`tablet 250 mg
`chlorothiazide oral
`
`tablet 500 mg
`clzlorthalidone
`clonidme
`clonidine hcl
`
`clorpres oral tablet
`0.1-15 mg, 0.2-J5
`
`mg
`CLORPRES ORAL
`TABLFT 0 3_] 5
`
`MG
`
`COREG CR
`DIURIL
`
`2
`
`2
`
`2
`
`3
`
`2
`2
`
`
`222
`3
`
`1
`
`:
`i 2
`L
`4
`
`L
`
`L
`
`4
`4
`2 1
`‘ 22
`
`M
`
`1
`
`1
` 2
`2 1
`
`2
`
`4
`
`e
`
`3
`4
`
`2
`
`i
`
`ST
`
`V QL
`2
`
`QL
`
`TIKOSYN
`3
`‘
`T‘
`’” ’ ‘
`" '
`
`
`
`
`acebutolol oral
`
`capsule 200 mg
`
`acebutolol oral
`capsule 400 mg
`afeditab Cr
`
`ALDACTAZIDE
`amllonde
`amt'loride-
`hydmchlorothiazide
`amlodipine
`amlodz'pine—
`benazepril
`aml0dl.pl.ne_
`valsartan
`
`amlodipine—
`valsartan-hcthiazid
`atenolol
`a]t;nOtlZl_l.d
`" 0’ " ’ ""9
`AZOR
`
`benazepril
`benazepril—
`lzydrochlorothiazide
`BENICAR
`
`BENICAR HCT
`betaxolol
`
`BIDIL
`.
`bzsoprololfumarate
`
`bisoprolol-
`hydrochlorothiazide
`oral tablet I 0-6.25
`mg, 5-6.25 mg
`
`2
`
`2
`
`4
`2
`1
`
`1
`2
`
`2
`
`2
`
`1
`1
`
`3
`
`1
`2
`
`3
`
`3
`2
`
`4
`
`1
`
`1
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`18
`
`Page 19
`
`

`
`Drug Name
`
`doxazosin
`
`DUTOPROL
`DYRENIUM
`
`EDARBI
`
`EDARBYCLOR
`EDECRIN
`enalapml maleate
`enalapril—
`.
`.
`hydrochlorothzazzde
`EPANED
`eplerenone
`
`eprosartan
`.
`.
`d
`fe10 '1’me
`fosinopril
`
`fosinopril—
`hydrochlorothiazide
`fumseml-de oral
`solution
`
`furosemide oral
`16117191‘
`
`guanfacine
`
`hydralazine
`
`l’lydr0c/’1l0I”0tl’ll‘aZide
`I-ndapaml-de
`
`INDERAL XL
`INNOPRAN XL
`_ b
`tr esartan
`
`irbesartan—
`hydrochlorothiazide
`
`isradipine
`Z b
`I
`I
`a eta 0
`
`LEVATOL
`
`Drug Requirements
`Tier
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`QL
`
`ST
`
`ST
`
`1
`
`4
`4
`
`4
`
`4
`4
`1
`1
`
`4
`2
`
`2
`
`2
`1
`
`2
`
`V 2
`
`1
`
`21
`4
`
`2
`
`1
`1
`
`4
`4
`1
`
`2
`
`2
`1
`
`4
`
`lisinopril
`
`lisir1opril-
`hydroclzlorothiazide
`
`losartan
`losartan-
`hydrochlorothiazide
`malzim la
`methyclothiazide
`
`methyldopa oral
`table’ 250 mg
`methyldopa oral
`tablet 500 mg
`
`methyldopa-
`h drochlorothiazide
`J’
`oral tablet 250-15
`mg
`
`me[hy[d0pa_
`hydrochlorothiazide o
`oral tablet 250—25
`mg
`
`metolazone
`metoprolol succinate
`
`metoprolol ta-
`]’l)/dr0C'I’ll07"0l(hlaZ
`oral tablet I 00-25
`mg’ 100-50 mg
`
`n1e[0pr0l0[[a_
`hydrochlorothiaz
`oral tablet 50-25 mg
`t
`I It
`t
`t
`me opro 0 ar ra e
`
`minoxidil
`moexipril
`_
`.
`m0ex’p”l'
`lzydrochlorothiazide
`
`nadolol
`
`1
`
`1
`
`1
`1
`
`2
`2
`
`2
`
`1
`
`4 2
`
`1
`
`1
`2 t
`
`2 it
`
`1
`
`1
`
`2
`2
`
`. 2
`
`2
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`19
`
`Page 20
`
`

`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`PA; LA
`
`ST
`
`nadol0l-
`bendroflumethiazide
`mcardlpme
`mfedical xl
`
`nifedipine
`
`nimodipine
`
`nisoldipine
`
`NYMALIZE
`
`ORENITRAM
`perindopril
`erbumine
`phenoxybenzamme
`pmdo10I
`.
`prazosm
`PRESTALIA
`propranolol oral
`
`capsule,extena'ed
`release 24 hr
`propranolol oral
`solution
`pmpmnolol 0m]
`tablet
`
`z’:,1:;::;’:::;W
`y
`quinapril oral tablet
`10 mg, 20 mg, 40 mg
`
`quinapril oral tablet
`5 mg
`.
`.
`qumaprzl-
`hydrochlorotlziazide
`
`ramipril oral
`capsule 1.25 mg
`
`ramipril oral
`capsule 10 mg, 2.5
`mg, 5 mg
`
`2
`
`2
`V 2
`
`2
`
`2
`
`2
`
`4
`
`6
`g 2
`
`2
`2
`
`1
`4
`2
`
`2
`
`g
`
`71
`
`~
`
`2
`
`2
`
`1
`
`2
`
`2
`
`2
`
`1
`
`reserpine
`Spimnolactone
`spironolacton-
`hydrochlorothiaz
`
`TEKAMLO
`
`TEKTURNA
`
`TEKTURNA HCT
`
`telmisartan
`
`telmisartan-
`amlodlpme
`telmisartan-
`hyalrochlorothiazid
`terazosm
`timolol maleate
`
`"’”e’"’de
`Zglliojalli21] am]
`
`trarzdolapril oral
`tablet 2 mg’ 4 mg
`triamterene-
`hydrochlorothiazid
`oral capsule 3 7. 5-25
`
`hydrochlorothiazid
`oral capsule 50-25
`mg
`
`triamterene-
`hyalrochlorothiazid
`I tablet
`
`0m
`TRIBENZOR
`
`valsartan
`valsartam
`
`hydrochlorolhiazide
`
`2
`
`2 e
`L 1
`2
`
`L
`
`o
`
`3
`
`35
`
`2
`
`42 L3-
`
`'2
`i
`[2 l
`V
`1
`
`T22
`
`V
`
`7‘:
`i
`
`QL
`
`{Z
`2 52
`
`2
`5
`
`‘
`
`iolg
`4'
`5
`5 1
`
`
`
`2
`
`2 1
`
`5
`
`3
`
`2
`2
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`20
`
`Page 21
`
`

`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`verapamil oral
`capsule, 24 hr er
`
`pellet ct 100 mg
`ZZZ°§Z?Z"§4"Z?’er
`
`pellet ct 200 mg, 300
`mg
`
`verapamil oral
`capsule, ext rel.
`pellets 24 hr
`
`verapamil oral tablet
`
`2
`
`1
`
`1
`
`1
`
`
`
`I
`
`verapamil oral tablet
`extend release
`
`I
`
`I
`
`V
`
`1
`
`
`
`1
`1
`
`digoxin oral solution
`digoxin oral tablet
`
`2
`1
`
`LANOXIN
`
`4
`
`
`
`
`4
`2
`
`I AMAR
`I
`_d
`_
`,
`d_
`aspir1n- ipyrz amo e
`BRILINTA
`
`.
`"""’“Z"’
`clopidogrel
`
`dipyridamole
`
`EFFIENT
`
`ELIQUIS
`
`ELOCTATE
`
`enoxaparin
`fondaparinux
`FRAGMIN
`
`hepflusl/P10 (pfl
`
`3
`
`2
`2
`
`2
`
`3
`
`3
`
`6
`
`6
`6
`6
`
`2
`
`heparin (porcine)
`.
`.
`
`.
`
`geéaériienc (porcine) in
`::1:;”(’;0’°"‘"e)‘"
`
`P
`heparin flush
`
`heparin
`flush(porcz'ne)-
`0.9nacl
`
`heparin lock
`
`heparin lockflush
`heparin lockflush
`(porcine)
`heparin
`lockflush(porcine)(pf
`)
`HEPARIN(PORCIN
`E) IN 0.45% NACL
`INTRAVENOUS
`PARENTERAL
`SOLUTION 12,500
`UNIT/250 ML
`heparin(porcine) in
`045% "ad
`intravenous
`
`parenteral solution
`25, 000 unit/250 ml,
`25,000 unit/500 ml
`
`heparin, porcine (pfl
`
`jantoven
`
`MEPHYTON
`
`2
`
`2
`
`2
`2
`
`2
`
`2
`
` 2
`
`2
`2
`
`2
`
`4
`2
`
`0
`
`‘ 2
`
`2
`
`1
`
`3
`
`2
`
`2
`
`6
`
`2
`3
`
`PA
`
`PA; LA
`
`monojectprefill (pf)
`
`monoject prefill
`advanced (pf)
`NOVOEIGHT
`
`pentoxzfi/lline
`PHYTONADIONE
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`21
`
`Page 22
`
`

`
`Drug
`Tier
`
`Requirements
`/Limits
`
`3
`
`it
`
`6 * 4 PA; LA
`
`
`
`4
`
`2
`
`6
`
`2
`
`2
`
`A
`
`PA; LA
`
`E
`1
`30°
`
`3
`
`Drug Name
`
`PRADAXA
`
`PROMACTA
`
`SAVAYSA
`
`ticlopidine
`
`TRETTEN
`
`vitamink
`
`vitamin k]
`
`warfarin
`XARELTO
`
`ZONTIVITY
`
`
`
`Drug Name
`
`fenofibrate
`micronized
`
`fenofibrate
`nanocrystallized
`
`FEN OFIBRATE
`ORAL CAPSULE
`
`FENOFIBRATE
`ORAL TABLET
`
`120 MG, 40 MG
`
`fenofibrate oral
`tablet 160 mg, 54 mg
`
`fenofibric acid
`
`fenofibric acid
`(choline)
`
`FENOGLIDE
`
`fluvastatin
`
`gemfibrozil
`
`JUXTAPID
`
`KYNAMRO
`
`LIPOFEN
`
`LIVALO
`
`lovastatin
`
`niacin
`
`NIACOR
`
`omega-3 acid ethyl
`esters
`
`PRALUENT PEN
`
`PRALUENT
`SYRINGE
`
`pravastatin
`
`prevalite
`
`SIMCOR
`
`simvastatin
`
`TRIGLIDE
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`2
`
`l\.)
`
`0\l\)-l>l\)r—-|>UJOxiic\Hi\.)l\)-ISM
`
`QL
`
`PA; LA
`
`PA; LA
`
`ST; QL
`
`QL
`
`PA; LA
`
`PA; LA
`
`QL
`
`QL
`
`QL
`
`
`
`ADVICOR ORAL
`
`TABLET, ER
`MULTIPHASE 24
`
`HR 1,000-20 MG,
`500-20 MG, 750-20
`MG
`
`ADVICOR ORAL
`
`TABLET, ER
`MULTIPHASE 24
`
`HR 1,000-40 MG
`
`ALTOPREV
`
`aml0dipine-
`atorvastatin
`
`ANTARA
`
`atorvastatin
`
`, ST; QL
`
`cholestyramine (with
`sugar)
`
`cholestyramine light
`
`COLESTID
`FLAVORED
`
`colestipol
`
`CRESTOR
`
`2
`
`4
`
`2
`
`3
`
`ST; QL
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`22
`
`Page 23
`
`

`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`
`DERMATOLOGICALS/TOPICA
`
`L THERAPY
`
`/ Limits
`
`V
`
`V
`
`, , _
`
`acltmin
`
`calcipotriene
`
`calcip0triene-
`betamethasone
`
`calcitrene
`
`calcitriol
`
`COAL TAR
`
`COSENTYX
`COSENTYX (2
`SYRINGES)
`COSENTYX PEN
`COSENTYX PEN 1
`(2 PENS)
`
`_
`
`drithocreme hp
`EPIFOAM
`lzydr0c0rtis0ne-
`pmmoxme
`OVACE PLUS
`
`PA; LA
`PA; LA
`
`PA; LA
`PA; LA
`
`2
`
`2
`
`2
`
`2
`
`2
`
`3
`
`6
`6
`
`6
`6
`
`2
`4 M
`2
`
`2
`
`4
`
`4
`
`4
`
`3
`
`3
`
`4
`
`3
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`VASCEPA
`
`VYTORIN 10-10
`
`VYTORIN 10-20
`
`VYTORIN 10-40
`
`VYTORIN 10-80
`
`WELCHOL
`
`3
`
`3
`
`3
`
`3
`
`3
`
`3
`
`ST; QL
`
`ST; QL
`
`ST; QL
`
`ST; QL
`
`ZET1A
`3
`
`
`
`
`
`
`ENTRESTO
`
`RANEXA
`
`VECAMYL
`
`.,
`,, //
`,
`DILATRATESR
`ISORDIL
`isosorbide dinitrate
`
`isosorbide
`1t1:1zl))rl1e()tnztrate oral
`isosorbide
`mononitrate oral
`tablet extended
`
` _*_j OVACE PLUS
`isosorbide
`1
`SHAMPOO
`
`:'$;:;:‘::;;:;“’
`
`x
`
`release 24 hr 30 mg,
`50 mg
`
`MINITRAN
`_
`_
`nztro—bzd
`
`NITROPUR
`
`nitroglycerin
`
`NITROSTAT
`.1
`I.
`’” ’""' ‘me
`
`4
`
`2
`
`4
`
`2
`
`3
`2
`
`WASH
`
`PRAMOSONE E
`
`PRAMOSONE
`TOPICAL CREAM
`0
`1-1 A)
`
`PRAMOSONE
`
`TOPICAL CREAM
`2.5-1 %
`
`PRAMOSONE
`TOPICAL LOTION
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning Ofthis table.
`
`23
`
`Page 24
`
`

`
`Drug Name
`
`PRAMOSONE
`TOPICAL
`
`OINTMENT
`PROMISEB
`
`Seb-prev
`selenium sulfide
`SELRX
`SORILUX
`
`STELARA
`
`sulfacetamide
`sodium topical
`cleanser
`SULFACETAMIDE
`SODIUM TOPICAL
`CLEANSER, GEL
`sulfacetamide
`sodium topical
`cleanser, gel
`extended release
`.
`sulfacetamzde
`sodium topical
`shampoo
`
`PA
`
`3
`
`4
`
`2
`2
`4
`4
`
`6
`
`2
`
`4
`
`2
`
`2
`
`*
`A
`
`3
`TACLONEX
`4
`TERSI FOAM
`4
`ZITHRANOL
`4
`ZITHRANOL-RR
`A
`i
`A
`‘
`A
`A
`A
`
`
`silver sulfadiazine
`2
`Sm,
`2
`
`thermazene
`
`2
`
`
`
`
`LBENASAL HP
`4
`A 4 M
`ii
`A
`
`INOVA 4"]
`INOVA 8-2
`
`4
`4
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning of this table.
`
`24
`
`Page 25
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`KERALYT SCALP
`COMPLETE
`
`PODOCON
`
`E2’$’?§§§§€$t.;
`salacyn
`salicylic acid
`salicylic acid sr-
`ceramides
`
`SALKERA
`
`salvax
`SALVAX DUO
`PLUS
`
`4
`
`4
`
`4
`2
`2
`2
`g
`
`g
`A 4
`
`
`A
`
`L
`
`L
`
`O
`ULTRASALER
`VIRASAL
`7
`4
`i 4
`
`g
`
`A
`' ‘
`'
`8'MOP
`ALEVICYN
`
`4
`
`ANTIPRURITIC
`ALUVEA
`
`ATOPICLAIR
`ATRAPRO CP
`ATRAPRO
`HYDROGEL
`AURSTAT
`
`avg cream
`bp-50% urea
`
`CARAC
`cem-urea
`
`CONDYLOX
`DERMASORB XM
`COMPLETE KIT
`
`‘
`
`L
`
`4
`
`54
`
`2 4
`
`
`4
`
`2
`2
`
`3
`2
`
`3
`4
`
`

`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`diclofenac sodium
`
`eletone
`
`ELIDEL
`
`emulsion Sb
`
`EPICERAM
`
`FLUOROPLEX
`
`FLUOROURACIL
`TOPICAL CREAM
`0.5 %
`
`fluorouracil topical
`cream 5 %
`
`fluorouracil topical
`solution
`GORDONS UREA
`
`hpr
`
`hp’ 171'“
`hprplus hydrogel
`
`moss
`HYLATOPIC
`HYLATOPIC PLUS
`
`KERAFOAM
`
`KERALAC
`lactic acid
`
`lactic acid e
`
`latrix
`
`LEVULAN
`
`LOUTREX
`mb hydrogel
`mb hydrogel
`(cydomethimne)
`methoxsalen rapid
`
`2
`
`2
`
`3
`
`2
`
`4
`
`4
`
`4 g
`2
`
`I 2
`
`2
`
`4
`
`2
`
`2
`2
`V 4
`4
`4
`4
`
`4 I
`
`4
`2
`
`2
`
`2
`
`4
`
`4
`2
`2
`
`2
`
`NEOSALUS
`
`nivatopic plus
`
`OXSORALEN
`
`PANRETIN
`
`PICATO
`
`podofilox
`
`PRESERA
`PROMISEB
`
`pmclair
`prudoxin
`
`prumyx
`pmtect
`rea [0 39
`
`rea lo 40
`
`REGRANEX
`remeven
`silver nitrate
`:;§:,3,;::::;‘e
`Sonafine
`mcrolimus
`
`tl-cermide
`
`TROPAZONE
`LOTION
`
`U-CORT
`
`UMECTA NAIL
`
`FILM PEN
`
`UMECTA PD
`
`EMULSION
`umecta topicalfoam
`
`4
`
`2
`
`3
`
`4
`
`4
`
`2
`
`4
`L 4
`o
`
`2
`2
`
`2
`2
`2
`
`2
`
`3
`2
`2
`2
`2
`2
`
`2
`
`4
`
`4
`
`4
`
`4
`4
`
`2
`
`QL
`
`«
`
`You can find information on what the symbols and abbreviations on this table mean by going to the
`beginning ofthis table.
`
`25
`
`Page 26
`
`

`
`Drug Name
`
`Drug
`Tier
`
`Requirements
`/ Limits
`
`Drug Name
`
`Drug Requirements
`Tier
`/ Limits
`
`UMECTA
`TOPICAL NAIL
`
`FILM
`SUSPENSION
`
`URAMAXIN
`