2016 Preferred Drug List - Ambetter from Sunshine Health
2016 Prescription Drug List Effective January 1, 2016 Ambetter.SunshineHealth.com Formulary Introduction FORMULARY The Ambetter from Sunshine Health Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-effective treatment options, if a generic medication on the formulary is not suitable for your condition. Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed, or additional requirements may be added in order to approve continued usage of a specific drug. Specific prescription benefit plan designs may not cover certain products or categories, regardless of their appearance in this document. Please check your benefits for coverage limitations and your share of cost for your drugs. Drug List Key: Brand name drugs are listed in CAPS and generic drugs are lower case. Drugs are covered under different copay tiers depending on your benefit: Tier 0 - No copayment for those drugs that are used for prevention and are mandated by Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply. Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similar conditions. Select over-the-counter (OTC), generic or brand name drugs may be covered under this tier. Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions. Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage. Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. For members who do not have a four Tier plan, these drugs may be covered under Tier 3. Prior Authorization for Non-Formulary Drugs To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. US Script will respond via fax or phone within 48 hours of receipt of all necessary information, except during weekends and holidays. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request. LEGEND TIER DESCRIPTION 0 Preventative 1 Generics 2 Preferred Brands 3 Non-Preferred Generics 4 Specialty TYPE DESCRIPTION QL Quantity Limit There is a limit on the amount of drug covered per prescription, or within a specific time frame. PA Prior Authorization Prior Authorization required before prescription can be filled. ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage. GL Gender Limit Drug is limited to specific gender. AL Age Limit Drug is limited to specific age. MDD Max Daily Dose A limit on the number of times the drug can be taken per day. MPL Max Package Limit A limit on the amount of drug covered per prescription. MDS Max Days Supply There is a limit on the amount of this drug that is covered. Custom This drug has unique restrictions. Specialty Drug Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. FAL Female Age Limit This prescription drug may only be covered if you are a female and meet the minimum or maximum age limit. MAL Male Age Limit This prescription drug may only be covered if you are a male and meet the minimum or maximum age limit. C S PAGE 2 LAST UPDATED 10/2015 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS aspirin tab delayed release 81 mg ibuprofen susp 100 mg/5ml MAL Female - 55 to 79 yrs old Male - 45 to 79 yrs old MDD 1 per day MPL 1 / 30 DAYS FAL generic generic 0 1 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS SMOKING CESSATION AGENTS nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr, patch 24hr 14 mg/24hr) generic 0 NICOTINE KIT 21-14-7 MG/24HR BRAND 0 nicotine polacrilex generic 0 generic 1 clotrimazole (topical) generic 1 LOTRIMIN ULTRA BRAND 2 generic 0 benzoyl peroxide (foam 5.3%, gel 5%, gel 10%, liq 4%, liq 10%, lotion 6%) generic 1 hydrocortisone (topical) (cream, oint) generic 1 lactic acid (ammonium lactate) (cream, lotion) generic 1 lidocaine hcl gel 2% generic 1 ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl (tab 12.5 mg, tab 25 mg) ANTIFUNGALS DENTAL AND ORAL AGENTS stannous fluoride conc 0.63% DERMATOLOGICAL AGENTS PAGE 3 AL At least 12 yrs old LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS GASTROINTESTINAL AGENTS GASTROINTESTINAL AGENTS, OTHER loperamide hcl cap 2 mg generic 1 cimetidine generic 1 famotidine tab 20 mg generic 1 ranitidine hcl tab 150 mg generic 1 bisacodyl tab delayed release 5 mg generic 1 calcium polycarbophil generic 1 docusate calcium generic 1 docusate sodium (cap 100 mg, cap 250 mg) generic 1 lansoprazole generic 1 QL 30 / 30 DAYS NEXIUM 24HR BRAND 3 QL 60 / 30 DAYS omeprazole delayed release tab 20 mg generic 1 QL 60 / 30 DAYS omeprazole magnesium generic 1 QL 120 / 30 DAYS omeprazole-sodium bicarbonate generic 1 QL 30 / 30 DAYS PRILOSEC OTC BRAND 1 QL 120 / 30 DAYS HISTAMINE2 (H2) RECEPTOR ANTAGONISTS LAXATIVES PROTON PUMP INHIBITORS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) ESTROGENS levonorgestrel (emergency oc) generic 0 AIMSCO LUBRICATED BRAND 0 ELEXA NATURAL FEEL BRAND 0 ELEXA STIMULATING BRAND 0 ELEXA ULTRA SENSITIVE BRAND 0 GL Female MISCELLANEOUS THERAPEUTIC AGENTS PAGE 4 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN FANTASY LUBRICATED BRAND 0 FANTASY LUBRICATED/SPERMICIDE BRAND 0 FC FEMALE CONDOM BRAND 0 FC2 FEMALE CONDOM BRAND 0 KAMELEON LUBRICATED BRAND 0 KIMONO BRAND 0 KIMONO MICRO THIN PLUS BRAND 0 KIMONO PLUS BRAND 0 KIMONO PS BRAND 0 KIMONO PS PLUS BRAND 0 KIMONO SENSATION BRAND 0 KIMONO SENSATION PLUS BRAND 0 MAXX BRAND 0 MAXX PLUS BRAND 0 NOVA MAX PLUS KETONE TEST BRAND 1 PRECISION XTRA KETONE BRAND 1 PREMIUM CONDOMS LUBRICATED BRAND 0 PTS PANELS KETONE TEST BRAND 1 REALITY LATEX/ULTRA TEXTURED BRAND 0 REALITY LATEX/ULTRA THIN BRAND 0 TROJAN MAGNUM WARM SENSATIONS BRAND 0 TROJAN SUPRAS SPERMICIDAL BRAND 0 TROJAN TWISTED PLEASURE BRAND 0 TRUSTEX COLOR CONDOMS + LUBE BRAND 0 TRUSTEX LUB/RIBBED/STUDDED BRAND 0 TRUSTEX LUB/SPERMICIDE EX ST BRAND 0 TRUSTEX LUB/SPERMICIDE XL BRAND 0 TRUSTEX LUBRICATED BRAND 0 TRUSTEX LUBRICATED EX LARGE BRAND 0 TRUSTEX LUBRICATED EXTRA ST BRAND 0 TRUSTEX LUBRICATED/SPERMICIDE BRAND 0 PAGE 5 TIER LIMITS & RESTRICTIONS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER TRUSTEX NATURAL CONDOMS + LUBE BRAND 0 TRUSTEX RIA LUB/SPERMICIDE BRAND 0 TRUSTEX RIA LUBRICATED BRAND 0 TRUSTEX-NONOXYNOL-9/RIB/STUD BRAND 0 generic 1 LIMITS & RESTRICTIONS OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER ketotifen fumarate (ophth) RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS fluticasone propionate (nasal) generic 1 MPL 1 / 30 DAYS ALLEGRA ALLERGY CHILDRENS (TAB 30 MG, TAB DISP 30 MG) BRAND 1 QL 60 / 30 DAYS cetirizine hcl (cap 10 mg, chew tab 5 mg, chew tab 10 mg, tab 5 mg, tab 10 mg) generic 1 QL 30 / 30 DAYS cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) generic 1 QL 300 / 30 DAYS CLARITIN (CAP 10 MG, CHEW TAB 5 MG) BRAND 1 CLARITIN REDITABS TAB DISP 5 MG BRAND 1 diphenhydramine hcl (cap 50 mg, elixir 12.5 mg/5ml) generic 1 fexofenadine hcl susp 30 mg/5ml (6 mg/ml) generic 1 QL 900 / 30 DAYS fexofenadine hcl tab 180 mg generic 1 QL 30 / 30 DAYS fexofenadine hcl tab 60 mg generic 1 QL 60 / 30 DAYS loratadine generic 1 cetirizine-pseudoephedrine generic 1 QL 60 / 30 DAYS fexofenadine-pseudoephedrine tab sr 12hr 60120 mg generic 1 QL 60 / 30 DAYS fexofenadine-pseudoephedrine tab sr 24hr 180240 mg generic 1 QL 30 / 30 DAYS ANTIHISTAMINES RESPIRATORY TRACT AGENTS, OTHER PAGE 6 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS loratadine & pseudoephedrine tab sr 12hr 5120 mg generic 1 QL 60 / 30 DAYS loratadine & pseudoephedrine tab sr 24hr 10240 mg generic 1 QL 30 / 30 DAYS AL Up to 1 yrs old At least 65 yrs old THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ELECTROLYTE/MINERAL REPLACEMENT ferrous sulfate (tab 325 mg mg elemental fe), tab ec 325 mg mg fe equivalent)) generic 0 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) generic 0 cholecalciferol tab 400 unit generic 0 ergocalciferol soln 8000 unit/ml generic 0 ergocalciferol tab 400 unit generic 0 AL folic acid (tab 1 mg, tab 400 mcg) generic 0 FAL PAGE 7 Female - 17 to 55 yrs old LAST UPDATED 10/2015 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS QL celecoxib (cap 50 mg, cap 100 mg, cap 200 mg) generic celecoxib cap 400 mg generic 60 / 30 DAYS 1 PA QL 30 / 30 DAYS 1 PA choline & magnesium salicylates tab 1000 mg generic 1 diclofenac potassium generic 1 diclofenac sodium (tab delayed release 25 mg, tab delayed release 50 mg, tab delayed release 75 mg, tab sr 24hr 100 mg) generic 1 diclofenac w/ misoprostol generic 1 diflunisal tab 500 mg generic 1 etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500 mg) generic 1 fenoprofen calcium tab 600 mg generic 1 FLECTOR BRAND 3 MDD 1 per day PA MDD flurbiprofen (tab 50 mg, tab 100 mg) generic 1 ibuprofen (susp 100 mg/5ml, tab 400 mg, tab 600 mg, tab 800 mg) generic 1 indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg) generic 1 ketoprofen (cap 50 mg, cap 75 mg) generic 1 ketorolac tromethamine tab 10 mg generic 1 meclofenamate sodium (cap 50 mg, cap 100 mg) generic 1 mefenamic acid cap 250 mg generic 1 meloxicam (tab 7.5 mg, tab 15 mg) generic 1 meloxicam susp 7.5 mg/5ml generic 1 PAGE 8 2 per day QL 20 / 30 DAYS QL 30 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER nabumetone generic 1 naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab 500 mg, tab ec 500 mg) generic 1 naproxen sodium tab 550 mg generic 1 oxaprozin generic 1 piroxicam (cap 10 mg, cap 20 mg) generic 1 salsalate generic 1 sulindac (tab 150 mg, tab 200 mg) generic 1 tolmetin sodium generic 1 BRAND 3 LIMITS & RESTRICTIONS OPIOID ANALGESICS, LONG-ACTING QL BUTRANS 4 / 28 DAYS PA QL EMBEDA BRAND 60 / 30 DAYS 3 PA fentanyl (patch 72hr 25 mcg/hr, patch 72hr 100 mcg/hr, patch 72hr 12 mcg/hr, patch 72hr 50 mcg/hr, patch 72hr 75 mcg/hr) generic 1 hydromorphone hcl (tab er 24hr deter 12 mg, tab er 24hr deter 16 mg) generic 1 HYDROMORPHONE HCL ER BRAND QL 10 / 30 DAYS QL 60 / 30 DAYS PA QL 60 / 30 DAYS 2 PA hydromorphone hcl tab er 24hr deter 8 mg QL generic 30 / 30 DAYS 1 PA levorphanol tartrate generic 1 methadone hcl (conc 10 mg/ml, tab 10 mg) generic 1 QL 300 / 30 DAYS methadone hcl soln 10 mg/5ml generic 1 QL 1500 / 30 DAYS methadone hcl soln 5 mg/5ml generic 1 QL 3000 / 30 DAYS METHADONE HCL SOLUTION 10 MG/ML BRAND 1 methadone hcl tab 5 mg generic 1 QL 120 / 30 DAYS methadone hcl tab for oral susp 40 mg generic 1 QL 60 / 30 DAYS PAGE 9 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER morphine sulfate (cap 24hr 80 mg, cap 24hr 20 mg, cap 24hr 50 mg, cap 24hr 30 mg, cap 24hr 60 mg, cap 24hr 100 mg) generic morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) generic 1 NUCYNTA ER BRAND 2 LIMITS & RESTRICTIONS QL 60 / 30 DAYS 1 PA QL 60 / 30 DAYS QL 60 / 30 DAYS PA PA oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab er deter 40 mg, tab er deter 80 mg) generic OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 30 MG, TB12 DETER 15 MG) BRAND oxymorphone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg) generic oxymorphone hcl tab sr 12hr 40 mg generic 1 MDD 2 per day PA 3 MDD QL 2 per day 60 / 30 DAYS 3 PA QL 120 / 30 DAYS 3 PA tramadol hcl (tab 24hr biphasic release 300 mg, tab 24hr 300 mg, tab 24hr 200 mg, tab 24hr 100 mg) generic ZOHYDRO ER BRAND QL 30 / 30 DAYS 1 PA QL 60 / 30 DAYS 3 PA OPIOID ANALGESICS, SHORT-ACTING acetaminophen w/ codeine soln 120-12 mg/5ml generic 1 QL 2250 / 30 DAYS acetaminophen w/ codeine tab 300-15 mg generic 1 QL 390 / 30 DAYS acetaminophen w/ codeine tab 300-30 mg generic 1 QL 360 / 30 DAYS acetaminophen w/ codeine tab 300-60 mg generic 1 QL 180 / 30 DAYS butalbital-acetaminophen-caff w/ cod cap 50325-40-30 mg generic 1 QL 180 / 30 DAYS butalbital-aspirin-caffeine w/cod generic 1 QL 180 / 30 DAYS butorphanol tartrate (inj 1 mg/ml, inj 2 mg/ml) generic 1 butorphanol tartrate nasal soln 10 mg/ml generic 1 PA MPL PAGE 10 1 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN codeine sulfate (oral soln 30 mg/5ml, tab 15 mg) generic 1 fentanyl citrate (fentnyl citrte lozenge hndle 200 mcg, fentnyl citrte lozenge hndle 400 mcg, fentnyl citrte lozenge hndle 600 mcg, fentnyl citrte lozenge hndle 800 mcg, fentnyl citrte lozenge hndle 1200 mcg, fentnyl citrte lozenge hndle 1600 mcg) generic 1 hydrocodone-acetaminophen (soln 7.5-500 mg/15ml, soln 10-325 mg/15ml, tab 2.5-325 mg) generic 1 hydrocodone-acetaminophen (tab 2.5-500 mg, tab 5-500 mg, tab 7.5-500 mg, tab 10-500 mg) generic 1 QL 240 / 30 DAYS hydrocodone-acetaminophen (tab 5-300 mg, tab 7.5-300 mg, tab 10-300 mg) generic 1 QL 390 / 30 DAYS hydrocodone-acetaminophen (tab 5-325 mg, tab 7.5-325 mg, tab 10-325 mg) generic 1 QL 360 / 30 DAYS hydrocodone-acetaminophen (tab 7.5-650 mg, tab 10-660 mg, tab 10-650 mg) generic 1 QL 180 / 30 DAYS hydrocodone-acetaminophen (tab 7.5-750 mg, tab 10-750 mg) generic 1 QL 150 / 30 DAYS hydrocodone-acetaminophen soln 7.5-325 mg/15ml generic 1 QL 5400 / 30 DAYS hydrocodone-ibuprofen (tab 2.5-200 mg, tab 5200 mg, tab 10-200 mg) generic 1 hydrocodone-ibuprofen tab 7.5-200 mg generic 1 QL 150 / 30 DAYS hydromorphone hcl (liqd 1 mg/ml, preservative free (pf) inj 10 mg/ml) generic 1 hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg) generic 1 QL 240 / 30 DAYS meperidine hcl (inj 25 mg/ml, inj 50 mg/ml, inj 100 mg/ml) generic 1 meperidine hcl (tab 50 mg, tab 100 mg) generic 1 QL 180 / 30 DAYS meperidine hcl oral soln 50 mg/5ml generic 1 QL 500 / claim morphine sulfate (inj 0.5 mg/ml, inj 1 mg/ml) generic 1 morphine sulfate (tab 15 mg, tab 30 mg) generic 1 QL 180 / 30 DAYS morphine sulfate oral soln 10 mg/5ml generic 1 QL 3000 / 30 DAYS PAGE 11 TIER LIMITS & RESTRICTIONS QL 120 / 30 DAYS PA LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS morphine sulfate oral soln 20 mg/5ml generic 1 QL 1500 / 30 DAYS nalbuphine hcl generic 1 QL 240 / 30 DAYS QL NUCYNTA BRAND 180 / 30 DAYS 2 PA oxycodone hcl (tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg) generic 1 QL 360 / 30 DAYS oxycodone hcl tab 30 mg generic 1 QL 720 / 30 DAYS oxycodone w/ acetaminophen (w/ tab 5-325 mg, w/ tab 7.5-325 mg, w/ tab 10-325 mg) generic 1 QL 360 / 30 DAYS oxycodone w/ acetaminophen tab 7.5-500 mg generic 1 QL 240 / 30 DAYS oxycodone-ibuprofen generic 1 QL 28 / 30 DAYS oxymorphone hcl (tab 5 mg, tab 10 mg) generic 1 QL 360 / 30 DAYS pentazocine w/ naloxone generic 1 TALWIN BRAND 3 tramadol hcl tab 50 mg generic 1 QL 240 / 30 DAYS tramadol-acetaminophen generic 1 QL 240 / 30 DAYS ZOLVIT BRAND 2 lidocaine hcl (local anesth.) (inj 0.5%, inj 1%, inj 4%, preservative free (pf) inj 0.5%, preservative free (pf) inj 1%, preservative free (pf) inj 2%) generic 1 lidocaine hcl laryngotracheal soln 4% generic 1 lidocaine hcl viscous soln 2% generic 1 QL 120 / 30 DAYS ANESTHETICS LOCAL ANESTHETICS ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calcium generic 1 disulfiram generic 1 naltrexone hcl tab 50 mg generic 1 PAGE 12 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS OPIOID DEPENDENCE TREATMENTS buprenorphine hcl (sl tab 2 mg, sl tab 8 mg) QL generic 90 / 30 DAYS 1 PA buprenorphine hcl inj 0.3 mg/ml (base equiv) generic 1 buprenorphine hcl-naloxone hcl dihydrate generic 3 QL 90 / 30 DAYS PA QL SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG) BRAND 90 / 30 DAYS 3 PA QL SUBOXONE (FILM 8-2 MG, FILM 12-3 MG) BRAND 60 / 30 DAYS 3 PA OPIOID REVERSAL AGENTS naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml) generic 1 bupropion hcl (smoking deterrent) generic 0 QL CHANTIX BRAND 0 MDD 2 per day CHANTIX CONTINUING MONTH PAK BRAND 0 MDD 2 per day CHANTIX STARTING MONTH PAK BRAND 0 NICOTROL BRAND 0 MPL 1 / claim NICOTROL NS BRAND 0 MPL 1 / claim amikacin sulfate (inj 1 gm/4ml mg/ml), inj 500 mg/2ml mg/ml)) generic 1 gentamicin in saline (gentamicsale j 0.8 mg/ml, gentamicsale j 1 mg/ml, gentamicsale j 1.2 mg/ml, gentamicsale j 1.6 mg/ml) generic 1 GENTAMICIN IN SALINE (GENTAMICSALE SOLUTION 0.9-0.9 MG/ML-%, GENTAMICSALE SOLUTION 1.4-0.9 MG/ML%) BRAND 1 SMOKING CESSATION AGENTS 60 / 30 DAYS ANTIBACTERIALS AMINOGLYCOSIDES PAGE 13 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER gentamicin sulfate (inj 40 mg/ml, iv soln 10 mg/ml) generic 1 gentamicin sulfate (ophth) generic 1 kanamycin sulfate generic 3 neomycin sulfate generic 1 paromomycin sulfate generic 1 streptomycin sulfate for inj 1 gm generic 3 TOBRADEX OINTMENT 0.3-0.1 % BRAND 3 tobramycin (ophth) generic 1 tobramycin sulfate (inj 10 mg/ml, inj 80 mg/2ml (40 mg/ml)) generic 1 TOBRAMYCIN SULFATE IN SALINE BRAND 1 acetic acid generic 1 ALTABAX BRAND 2 bacitracin (ophthalmic) generic 3 bacitracin intramuscular for soln 50000 unit generic 3 chloramphenicol sodium succinate generic 4 clindamycin hcl (cap 75 mg, cap 150 mg, cap 300 mg) generic 1 clindamycin palmitate hydrochloride generic 1 clindamycin phosphate (inj 9 gm/60ml, inj 300 mg/2ml, inj 600 mg/4ml, inj 900 mg/6ml, iv soln 300 mg/2ml, iv soln 600 mg/4ml, iv soln 900 mg/6ml) generic 1 clindamycin phosphate (topical) (foam, soln) generic 1 clindamycin phosphate (topical) (gel, lotion) generic 1 clindamycin phosphate vaginal generic 1 CUBICIN BRAND 3 LINCOCIN BRAND 3 LIMITS & RESTRICTIONS ANTIBACTERIALS, OTHER S Specialty Drug AL At least 12 yrs old PA linezolid iv soln 2 mg/ml PAGE 14 generic 1 MDD 600 per day MDS 14 / DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS PA linezolid tab 600 mg generic 1 mafenide acetate generic 3 methenamine hippurate generic 1 metronidazole (tab 250 mg, tab 500 mg) generic 1 metronidazole (topical) generic 1 metronidazole vaginal generic 1 MONUROL BRAND 3 mupirocin calcium (topical) generic 1 mupirocin oint 2% generic 1 nitrofurantoin generic 1 nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg) generic 1 nitrofurantoin monohyd macro generic 1 polymyxin b sulfate for inj 500000 unit generic 1 SULFAMYLON CREAM 85 MG/GM BRAND 3 trimethoprim tab 100 mg generic 1 TYGACIL BRAND 3 vancomycin hcl (cap 125 mg, cap 250 mg) generic 1 vancomycin hcl (inj 10 gm, inj 500 mg, inj 1000 mg) generic 1 VIBATIV RECON SOLN 750 MG BRAND 3 XIFAXAN BRAND 3 MDD 2 per day MDS 14 DAYS MDD 4 per day MDS 10 / DAYS PA AL At least 12 yrs old BETA-LACTAM, CEPHALOSPORINS CEDAX BRAND 3 cefaclor (cap 250 mg, cap 500 mg) generic 1 CEFACLOR (RECON SUSP 125 MG/5ML, RECON SUSP 250 MG/5ML, RECON SUSP 375 MG/5ML) BRAND 1 PAGE 15 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER cefaclor monohydrate generic 1 cefadroxil generic 1 cefazolin sodium (inj 1 gm, inj 10 gm, inj 20 gm, inj 500 mg) generic 1 cefdinir (susp 125 mg/5ml, susp 250 mg/5ml) generic 1 cefdinir cap 300 mg generic 1 cefditoren pivoxil (tab 200 mg, tab 400 mg) generic 3 cefepime hcl (inj 1 gm, inj 2 gm) generic 1 cefixime generic 1 cefotaxime sodium (inj 1 gm, inj 2 gm, inj 10 gm) generic 1 cefotetan disodium generic 3 cefoxitin sodium generic 1 cefpodoxime proxetil generic 1 cefprozil generic 1 ceftazidime (inj 1 gm, inj 2 gm, inj 6 gm) generic 1 CEFTIBUTEN CAP 400 MG BRAND 1 CEFTIBUTEN RECON SUSP 180 MG/5ML BRAND 3 ceftriaxone sodium (inj 1 gm, inj 2 gm, inj 250 mg, inj 500 mg) generic 1 cefuroxime axetil generic 1 cefuroxime sodium (inj 1.5 gm, inj 7.5 gm, inj 750 mg) generic 1 cephalexin generic 1 SUPRAX TAB 400 MG BRAND 2 TEFLARO BRAND 3 AZACTAM IN DEXTROSE BRAND 3 aztreonam generic 1 imipenem-cilastatin generic 1 INVANZ BRAND 3 meropenem generic 1 LIMITS & RESTRICTIONS AL At least 2 yrs old BETA-LACTAM, OTHER PAGE 16 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS BETA-LACTAM, PENICILLINS amoxicillin & pot clavulanate generic 1 amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg, chew tab 250 mg, for susp 125 mg/5ml, for susp 200 mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab 500 mg, tab 875 mg) generic 1 ampicillin & sulbactam sodium (inj 1-0.5 gm, inj 2-1 gm, iv soln 10-5 gm) generic 1 ampicillin (cap 250 mg, cap 500 mg) generic 1 AMPICILLIN (RECON SUSP 125 MG/5ML, RECON SUSP 250 MG/5ML) BRAND 1 ampicillin sodium (inj 1 gm, iv soln 10 gm) generic 1 dicloxacillin sodium generic 1 nafcillin sodium (inj 1 gm, inj 10 gm) generic 1 oxacillin sodium (inj 1 gm, inj 10 gm) generic 1 PENICILLIN G POT IN DEXTROSE (PENICILLSOLUTION 40000 UNIT/ML, PENICILLSOLUTION 60000 UNIT/ML) BRAND 1 penicillin g potassium for inj 5000000 unit generic 1 PENICILLIN G PROCAINE BRAND 3 penicillin g sodium generic 3 penicillin v potassium generic 1 piperacillin sodium-tazobactam sodium generic 1 TIMENTIN RECON SOLN 3.1 GM BRAND 3 AZASITE BRAND 3 azithromycin (susp 100 mg/5ml, susp 200 mg/5ml) generic 1 azithromycin iv for soln 500 mg generic 1 azithromycin powd pack for susp 1 gm generic azithromycin tab 250 mg azithromycin tab 500 mg MACROLIDES PAGE 17 MPL 1 / claim 1 QL 2 / claim generic 1 QL 6 / claim generic 1 QL 4 / claim LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN azithromycin tab 600 mg generic 1 clarithromycin generic 1 DIFICID BRAND 2 E.E.S. 400 BRAND 3 E.E.S. GRANULES BRAND 3 ERY-TAB BRAND 3 ERYPED 200 BRAND 3 ERYPED 400 BRAND 3 erythromycin (acne aid) (pads, soln) generic 1 erythromycin (ophth) generic 1 ERYTHROMYCIN BASE (TAB 250 MG, TAB 500 MG) BRAND 3 ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG BRAND 3 erythromycin w/ delayed release particles cap 250 mg generic 3 KETEK TAB 300 MG BRAND 3 KETEK TAB 400 MG BRAND TIER LIMITS & RESTRICTIONS QL 8 / 28 DAYS AL At least 12 yrs old MDD 2 per day MDS 10 DAYS MDD 2 per day MDS 10 / DAYS 3 QUINOLONES AVELOX SOLUTION 400 MG/250ML BRAND 3 BESIVANCE BRAND 3 ciprofloxacin (for oral susp 250 mg/5ml (5%) (5 gm/100ml), for oral susp 500 mg/5ml (10%) (10 gm/100ml), iv soln 400 mg/40ml (1%)) generic 1 ciprofloxacin 200 mg/100ml in d5w generic 3 ciprofloxacin hcl (ophth) generic 1 ciprofloxacin hcl (otic) generic 1 ciprofloxacin hcl (tab 100 mg, tab 250 mg, tab 500 mg, tab 750 mg) generic 1 ciprofloxacin-ciprofloxacin hcl generic 1 PAGE 18 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER FACTIVE BRAND 3 gatifloxacin (ophth) generic 1 levofloxacin (iv soln 25 mg/ml, oral soln 25 mg/ml, tab 250 mg, tab 500 mg, tab 750 mg) generic 1 levofloxacin (ophth) generic 1 levofloxacin in d5w iv soln 500 mg/100ml generic 1 moxifloxacin hcl tab 400 mg (base equiv) generic 1 NOROXIN BRAND 3 ofloxacin generic 1 ofloxacin (ophth) generic 1 ofloxacin (otic) generic 1 silver sulfadiazine generic 1 sulfacetamide sodium ophth soln 10% generic 1 sulfadiazine tab 500 mg generic 1 sulfamethoxazole-trimethoprim generic 1 demeclocycline hcl (tab 150 mg, tab 300 mg) generic 1 doxycycline (monohydrate) (cap 50 mg, cap 100 mg, tab 100 mg) generic doxycycline hyclate (cap 50 mg, cap 100 mg, tab 20 mg, tab 100 mg) LIMITS & RESTRICTIONS SULFONAMIDES MPL 1 / claim 1 MDD 2 per day generic 1 MDD 2 per day doxycycline hyclate for inj 100 mg generic 1 minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg, tab 50 mg, tab 75 mg, tab 100 mg) generic 1 MDD 3 per day tetracycline hcl (cap 250 mg, cap 500 mg) generic 1 MDD 8 per day levetiracetam (inj 500 mg/5ml (100 mg/ml), oral soln 100 mg/ml) generic 1 QL 900 / 30 DAYS levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg, tab sr 24hr 750 mg, tab sr 24hr 500 mg) generic 1 QL 120 / 30 DAYS TETRACYCLINES ANTICONVULSANTS ANTICONVULSANTS, OTHER PAGE 19 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER levetiracetam tab 1000 mg generic 1 POTIGA BRAND 3 LIMITS & RESTRICTIONS QL 90 / 30 DAYS QL 90 / 30 DAYS PA CALCIUM CHANNEL MODIFYING AGENTS CELONTIN BRAND 3 QL 120 / 30 DAYS ethosuximide cap 250 mg generic 1 QL 180 / 30 DAYS ethosuximide soln 250 mg/5ml generic 1 QL 900 / 30 DAYS zonisamide (cap 25 mg, cap 50 mg, cap 100 mg) generic 1 QL 180 / 30 DAYS QL 1 / claim GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS diazepam (anticonvulsant) generic 3 PA divalproex sodium (tab delayed release 125 mg, tab delayed release 250 mg, tab delayed release 500 mg, tab sr 24 hr 500 mg, tab sr 24 hr 250 mg) generic 1 gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, tab 600 mg, tab 800 mg) generic 1 gabapentin oral soln 250 mg/5ml generic 1 ONFI (TAB 5 MG, TAB 10 MG, TAB 20 MG) BRAND 3 QL 1800 / 30 DAYS QL 60 / 30 DAYS PA QL ONFI SUSPENSION 2.5 MG/ML BRAND 480 / 30 DAYS 3 PA phenobarbital (elixir 20 mg/5ml, tab 16.2 mg, tab 30 mg, tab 32.4 mg, tab 64.8 mg, tab 97.2 mg, tab 100 mg) generic 1 primidone generic 1 QL SABRIL BRAND 4 PA S tiagabine hcl generic 1 valproate sodium generic 1 PAGE 20 180 / 30 DAYS Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS valproic acid generic 1 felbamate susp 600 mg/5ml generic 1 QL 3600 / 30 DAYS felbamate tab 400 mg generic 1 QL 270 / 30 DAYS felbamate tab 600 mg generic 1 QL 180 / 30 DAYS lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200 mg, tab chewable dispersible 5 mg, tab chewable dispersible 25 mg) generic 1 topiramate (tab 100 mg, tab 200 mg) generic 1 QL 60 / 30 DAYS topiramate (tab 25 mg, tab 50 mg) generic 1 QL 120 / 30 DAYS topiramate sprinkle cap 15 mg generic 1 QL 180 / 30 DAYS topiramate sprinkle cap 25 mg generic 1 QL 480 / 30 DAYS QL BRAND 2400 / 30 DAYS 2 GLUTAMATE REDUCING AGENTS SODIUM CHANNEL AGENTS BANZEL SUSPENSION 40 MG/ML PA QL BANZEL TAB 200 MG BRAND 60 / 30 DAYS 2 PA QL BANZEL TAB 400 MG BRAND 240 / 30 DAYS 2 PA carbamazepine (cap 200 mg, tab 200 mg) QL generic 180 / 30 DAYS 1 ST carbamazepine (cap 300 mg, tab 400 mg) QL generic 120 / 30 DAYS 1 ST carbamazepine (chew tab 100 mg, susp 100 mg/5ml, tab 200 mg) generic 1 carbamazepine cap sr 12hr 100 mg generic 1 DILANTIN CAP 30 MG BRAND 2 EQUETRO CAP ER 12H 100 MG BRAND 3 ST QL 60 / 30 DAYS ST PAGE 21 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN EQUETRO CAP ER 12H 200 MG BRAND TIER LIMITS & RESTRICTIONS QL 240 / 30 DAYS 3 ST QL EQUETRO CAP ER 12H 300 MG BRAND 120 / 30 DAYS 3 ST fosphenytoin sodium generic 1 oxcarbazepine (tab 150 mg, tab 300 mg) generic 1 QL 90 / 30 DAYS oxcarbazepine susp 300 mg/5ml (60 mg/ml) generic 1 QL 1200 / 30 DAYS oxcarbazepine tab 600 mg generic 1 QL 120 / 30 DAYS PEGANONE BRAND 3 phenytoin generic 1 phenytoin sodium extended generic 1 phenytoin sodium inj 50 mg/ml generic 1 VIMPAT (TAB 50 MG, TAB 100 MG, TAB 150 MG, TAB 200 MG) QL BRAND 60 / 30 DAYS 3 VIMPAT SOLUTION 10 MG/ML BRAND PA QL 1200 / 30 DAYS 3 PA VIMPAT SOLUTION 200 MG/20ML BRAND 3 generic 3 donepezil hydrochloride (orally disintegrating tab 10 mg, tab 10 mg) generic 1 MDD 2 per day donepezil hydrochloride (orally disintegrating tab 5 mg, tab 5 mg) generic 1 MDD 1 per day galantamine hydrobromide (cap 24hr 8 mg, cap 24hr 24 mg, cap 24hr 16 mg) generic 1 MDD 1 per day galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg) generic 1 MDD 2 per day galantamine hydrobromide oral soln 4 mg/ml generic 1 MDD 6 per day QL 1200 / 30 DAYS ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates CHOLINESTERASE INHIBITORS PAGE 22 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN rivastigmine tartrate generic TIER LIMITS & RESTRICTIONS 1 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl (oral solution 2 mg/ml, tab 5 mg (28) & 10 mg (21) titration pak) generic 1 memantine hcl tab 10 mg generic 1 QL 60 / 30 DAYS memantine hcl tab 5 mg generic 1 QL 30 / 30 DAYS bupropion hcl (tab 100 mg, tab 150 mg, tab 200 mg) generic 1 QL 60 / 30 DAYS bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg) generic 1 QL 30 / 30 DAYS bupropion hcl (tab 75 mg, tab 100 mg) generic 1 QL 90 / 30 DAYS mirtazapine (orally disintegrating tab 15 mg, orally disintegrating tab 30 mg, orally disintegrating tab 45 mg, tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg) generic 1 QL 30 / 30 DAYS perphenazine-amitriptyline generic 3 QL 120 / 30 DAYS QL BRAND 30 / 30 DAYS 3 ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER MONOAMINE OXIDASE INHIBITORS EMSAM PA QL MARPLAN BRAND 180 / 30 DAYS 2 ST phenelzine sulfate generic 1 tranylcypromine sulfate generic 1 SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR QL BRINTELLIX BRAND 30 / 30 DAYS 3 PA citalopram hydrobromide (tab 10 mg, tab 20 mg) PAGE 23 generic 1 QL 45 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS citalopram hydrobromide oral soln 10 mg/5ml generic 1 QL 600 / 30 DAYS citalopram hydrobromide tab 40 mg (base equiv) generic 1 QL 30 / 30 DAYS escitalopram oxalate (tab 5 mg, tab 10 mg) QL generic 45 / 30 DAYS 1 PA QL escitalopram oxalate soln 5 mg/5ml (base equiv) generic escitalopram oxalate tab 20 mg (base equiv) generic 600 / 30 DAYS 1 PA QL 30 / 30 DAYS 1 PA fluoxetine hcl (cap 10 mg, tab 10 mg, tab 60 mg) generic 1 QL 30 / 30 DAYS fluoxetine hcl (cap 20 mg, tab 20 mg) generic 1 QL 90 / 30 DAYS fluoxetine hcl (pmdd) cap 10 mg generic 1 QL 30 / 30 DAYS fluoxetine hcl (pmdd) cap 20 mg generic 1 QL 90 / 30 DAYS fluoxetine hcl cap 40 mg generic 1 QL 60 / 30 DAYS fluoxetine hcl solution 20 mg/5ml generic 1 QL 600 / 30 DAYS fluvoxamine maleate (tab 25 mg, tab 50 mg) generic 1 QL 60 / 30 DAYS fluvoxamine maleate tab 100 mg generic 1 QL 90 / 30 DAYS maprotiline hcl generic 3 nefazodone hcl generic 3 QL OLEPTRO BRAND 30 / 30 DAYS 3 ST paroxetine hcl (tab 10 mg, tab 20 mg, tab 40 mg) generic 1 paroxetine hcl (tab 24hr 37.5 mg, tab 24hr 25 mg) generic 1 paroxetine hcl oral susp 10 mg/5ml (base equiv) generic paroxetine hcl tab 30 mg generic 1 paroxetine hcl tab sr 24hr 12.5 mg generic 1 QL 30 / 30 DAYS QL 60 / 30 DAYS PA QL 900 / 30 DAYS 3 PA QL 60 / 30 DAYS QL 30 / 30 DAYS PA PAGE 24 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN PRISTIQ TAB ER 24H 100 MG BRAND TIER LIMITS & RESTRICTIONS QL 120 / 30 DAYS 2 ST QL PRISTIQ TAB ER 24H 50 MG BRAND 30 / 30 DAYS 2 ST sertraline hcl (tab 25 mg, tab 50 mg) generic 1 QL 45 / 30 DAYS sertraline hcl oral conc 20 mg/ml generic 1 QL 300 / 30 DAYS sertraline hcl tab 100 mg generic 1 QL 60 / 30 DAYS trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab 300 mg) generic 1 venlafaxine hcl (cap 24hr 150 mg, tab 24hr 150 mg) generic 1 QL 60 / 30 DAYS venlafaxine hcl (cap 24hr 37.5 mg, cap 24hr 75 mg, tab 24hr 75 mg, tab 24hr 37.5 mg) generic 1 QL 30 / 30 DAYS venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75 mg, tab 100 mg) generic 1 QL 90 / 30 DAYS VENLAFAXINE HCL ER TAB ER 24H 225 MG BRAND 1 QL 30 / 30 DAYS VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG) BRAND 2 QL 30 / 30 DAYS VIIBRYD KIT 10 & 20 & 40 MG BRAND 2 QL 1 / 365 DAYS amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) generic 1 amoxapine generic 3 clomipramine hcl generic 1 desipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) generic 1 doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg, cap 100 mg, cap 150 mg, conc 10 mg/ml) generic 1 imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg) generic 1 imipramine pamoate generic 1 nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg) generic 1 TRICYCLICS PAGE 25 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER protriptyline hcl generic 1 trimipramine maleate (cap 25 mg, cap 50 mg, cap 100 mg) generic 1 meclizine hcl (tab 12.5 mg, tab 25 mg) generic 1 metoclopramide hcl (tab 5 mg, tab 10 mg) generic 1 LIMITS & RESTRICTIONS ANTIEMETICS ANTIEMETICS, OTHER metoclopramide hcl inj 5 mg/ml generic 1 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) generic 1 perphenazine generic 1 prochlorperazine generic 1 prochlorperazine maleate (tab 5 mg, tab 10 mg) generic 1 TRANSDERM-SCOP BRAND 2 trimethobenzamide hcl cap 300 mg generic 1 ALOXI BRAND 3 ANZEMET (TAB 50 MG, TAB 100 MG) BRAND 3 MDD 6 per day MDS 84 / 365 DAYS MDD 60 per day MDS 84 / 365 DAYS EMETOGENIC THERAPY ADJUNCTS ST QL 5 / 30 DAYS PA ANZEMET SOLUTION 20 MG/ML BRAND 3 CESAMET BRAND 3 dronabinol generic 1 EMEND (CAP 40 MG, CAP 125 MG) BRAND 2 QL 2 / 30 DAYS PA QL EMEND CAP 80 MG BRAND 4 / 30 DAYS 2 PA granisetron hcl (inj 0.1 mg/ml, inj 1 mg/ml) generic 1 granisetron hcl tab 1 mg generic 1 PAGE 26 QL 10 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ondansetron generic 1 QL 30 / 30 DAYS ondansetron hcl (tab 4 mg, tab 8 mg) generic 1 QL 30 / 30 DAYS ondansetron hcl inj 4 mg/2ml (2 mg/ml) generic 1 ondansetron hcl oral soln 4 mg/5ml generic 1 QL 100 / 30 DAYS ondansetron hcl tab 24 mg generic 1 QL 4 / 28 DAYS ABELCET BRAND 3 AMBISOME BRAND 3 AMPHOTEC RECON SUSP 50 MG BRAND 3 amphotericin b for inj 50 mg generic 3 CANCIDAS BRAND 3 ciclopirox & vitamin e generic 1 ciclopirox (gel 0.77%, shampoo 1%, solution 8%) generic 1 ciclopirox olamine (cream, susp) generic 1 clotrimazole generic 1 clotrimazole (topical) (cream, soln) generic 1 econazole nitrate generic 1 ERAXIS BRAND 3 ERTACZO BRAND 3 MPL 1 / 30 DAYS EXELDERM BRAND 3 MPL 1 / 30 DAYS fluconazole (for susp 10 mg/ml, for susp 40 mg/ml, tab 50 mg, tab 100 mg, tab 150 mg, tab 200 mg) generic 1 flucytosine generic 1 griseofulvin microsize susp 125 mg/5ml generic 1 ANTIFUNGALS ST AL griseofulvin microsize tab 500 mg generic 1 griseofulvin ultramicrosize generic 1 GYNAZOLE-1 BRAND 3 PAGE 27 At least 2 yrs old LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN itraconazole cap 100 mg generic TIER LIMITS & RESTRICTIONS QL 120 / 30 DAYS 1 PA ketoconazole (topical) (cream, shampoo) generic 1 ketoconazole tab 200 mg generic 1 MENTAX BRAND 2 MYCAMINE BRAND 3 naftifine hcl generic 1 NAFTIN (CREAM 2 %, GEL 1 %) BRAND NATACYN MPL 1 / 30 DAYS 3 MPL 1 / 30 DAYS BRAND 2 MPL 1 / 30 DAYS NOXAFIL SUSPENSION 40 MG/ML BRAND 3 QL nystatin (mouth-throat) generic 1 nystatin (topical) (*nystatin topical powder**, nystatin cream 100000 unit/gm, nystatin oint 100000 unit/gm) generic 1 nystatin tab 500000 unit generic 1 nystatin-triamcinolone generic 1 OXISTAT BRAND 2 SPORANOX SOLUTION 10 MG/ML BRAND 3 MPL QL 600 / 30 DAYS 1 / 30 DAYS 600 / 30 DAYS PA terbinafine hcl generic 1 QL terconazole vaginal generic 1 MPL voriconazole (tab 50 mg, tab 200 mg) generic 1 QL 120 / 30 DAYS allopurinol generic 1 colchicine tab 0.6 mg generic 2 QL 6 / claim colchicine w/ probenecid generic 1 probenecid generic 1 QL ULORIC BRAND 30 / 30 DAYS 3 30 / 30 DAYS 1 / claim ANTIGOUT AGENTS PA PAGE 28 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ANTIMIGRAINE AGENTS ERGOT ALKALOIDS CAFERGOT BRAND 2 dihydroergotamine mesylate inj 1 mg/ml generic 1 dihydroergotamine mesylate nasal spray 4 mg/ml generic 1 ERGOMAR BRAND QL 8 / 30 DAYS ST 3 QL 20 / 30 DAYS QL 12 / 30 DAYS AL At least 12 yrs old QL 9 / 30 DAYS AL At least 12 yrs old QL 12 / 30 DAYS SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS almotriptan malate tab 12.5 mg almotriptan malate tab 6.25 mg FROVA naratriptan hcl RELPAX generic generic BRAND generic BRAND rizatriptan benzoate (orally disintegrating tab 10 mg, tab 10 mg) generic rizatriptan benzoate (orally disintegrating tab 5 mg, tab 5 mg) generic sumatriptan (5 mg/act, 20 mg/act) generic PAGE 29 3 3 3 ST AL At least 18 yrs old QL 9 / 30 DAYS AL At least 18 yrs old QL 6 / 30 DAYS 1 3 ST AL At least 18 yrs old QL 18 / 30 DAYS AL At least 6 yrs old QL 12 / 30 DAYS AL At least 6 yrs old QL 6 / 30 DAYS AL At least 18 yrs old 1 1 1 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN sumatriptan succinate (inj 4 mg/0.5ml, inj 6 mg/0.5ml, solution auto-injector 4 mg/0.5ml, solution auto-injector 6 mg/0.5ml, solution cartridge 6 mg/0.5ml, solution prefilled syringe 4 mg/0.5ml, solution prefilled syringe 6 mg/0.5ml) generic sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg) generic sumatriptan succinate solution cartridge 4 mg/0.5ml generic zolmitriptan (orally disintegrating tab 2.5 mg, orally disintegrating tab 5 mg, tab 2.5 mg, tab 5 mg) ZOMIG (SOLUTION 2.5 MG, SOLUTION 5 MG) generic BRAND TIER LIMITS & RESTRICTIONS QL 4 / 30 DAYS AL At least 18 yrs old QL 9 / 30 DAYS AL At least 18 yrs old QL 4 / 30 DAYS QL 9 / 30 DAYS 1 1 1 1 2 ST AL At least 12 yrs old QL 6 / 30 DAYS ST AL At least 12 yrs old ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS GUANIDINE HCL BRAND 2 MESTINON SYRUP 60 MG/5ML BRAND 2 MYTELASE BRAND 3 pyridostigmine bromide generic 1 dapsone (tab 25 mg, tab 100 mg) generic 3 rifabutin generic 1 CAPASTAT SULFATE BRAND 3 CYCLOSERINE BRAND 3 ethambutol hcl (tab 100 mg, tab 400 mg) generic 1 isoniazid (inj 100 mg/ml, tab 100 mg, tab 300 mg) generic 1 ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER PA ANTITUBERCULARS PAGE 30 QL 120 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER ISONIAZID SYRUP 50 MG/5ML BRAND 1 PASER BRAND 3 PRIFTIN BRAND 3 pyrazinamide generic 1 RIFAMATE BRAND 3 rifampin (cap 150 mg, cap 300 mg, for inj 600 mg) generic 1 RIFATER BRAND SEROMYCIN TRECATOR LIMITS & RESTRICTIONS QL 90 / 30 DAYS 3 QL 180 / 30 DAYS BRAND 3 QL 120 / 30 DAYS BRAND 3 QL 120 / 30 DAYS ALKERAN TAB 2 MG BRAND 2 BICNU BRAND 4 S Specialty Drug BUSULFEX BRAND 4 S Specialty Drug cyclophosphamide generic 4 S Specialty Drug dacarbazine for inj 200 mg generic 4 S Specialty Drug DAUNOXOME BRAND 4 S Specialty Drug HEXALEN BRAND 4 S Specialty Drug ifosfamide & mesna generic 4 S Specialty Drug ifosfamide (for inj 1 gm, iv inj 1 gm/20ml (50 mg/ml)) generic 4 S Specialty Drug LEUKERAN BRAND 4 S Specialty Drug lomustine generic 4 S Specialty Drug MATULANE BRAND 4 S Specialty Drug melphalan hcl generic 1 MUSTARGEN BRAND 4 S Specialty Drug MYLERAN BRAND 4 S Specialty Drug ANTINEOPLASTICS ALKYLATING AGENTS PAGE 31 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TEMODAR RECON SOLN 100 MG BRAND TIER LIMITS & RESTRICTIONS PA 4 S temozolomide Specialty Drug PA generic 4 S Specialty Drug PA TREANDA (RECON SOLN 25 MG, RECON SOLN 100 MG) BRAND ZANOSAR BRAND bicalutamide 4 S Specialty Drug 4 S Specialty Drug generic 4 S Specialty Drug flutamide generic 4 S Specialty Drug NILANDRON BRAND 3 MDD XTANDI BRAND 4 ANTIANDROGENS 2 per day PA S Specialty Drug PA ZYTIGA BRAND 4 S Specialty Drug ANTIANGIOGENIC AGENTS PA REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10 MG, CAP 15 MG, CAP 25 MG) BRAND THALOMID BRAND 4 S Specialty Drug PA 4 S Specialty Drug ANTIESTROGENS/MODIFIERS PA EMCYT BRAND 4 S Specialty Drug Specialty Drug FARESTON BRAND 2 FASLODEX BRAND 4 S SOLTAMOX BRAND 3 PA tamoxifen citrate (tab 10 mg, tab 20 mg) generic 0 PAGE 32 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ANTIMETABOLITES PA ALIMTA RECON SOLN 500 MG BRAND 4 S capecitabine PA generic 4 S cladribine Specialty Drug Specialty Drug PA generic 4 S Specialty Drug CLOLAR BRAND 4 S Specialty Drug cytarabine (for inj 100 mg, for inj 500 mg, inj pf 20 mg/ml, inj pf 100 mg/ml) generic 4 S Specialty Drug DEPOCYT BRAND 4 S Specialty Drug DROXIA BRAND 3 floxuridine for inj 0.5 gm generic 4 S Specialty Drug fluorouracil inj 500 mg/10ml (50 mg/ml) generic 4 S Specialty Drug FOLOTYN SOLUTION 20 MG/ML BRAND 4 S Specialty Drug gemcitabine hcl (inj 2 gm, inj 200 mg) generic 4 S Specialty Drug hydroxyurea generic 1 mercaptopurine generic 1 pentostatin generic 4 S Specialty Drug TABLOID BRAND 4 PA S Specialty Drug ANTINEOPLASTICS, OTHER PA ABRAXANE BRAND 4 ARRANON BRAND 4 azacitidine generic 4 bleomycin sulfate for inj 15 unit PAGE 33 S Specialty Drug S Specialty Drug PA generic 4 S Specialty Drug S Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS CAMPATH BRAND 4 S Specialty Drug carboplatin iv soln 50 mg/5ml generic 4 S Specialty Drug cisplatin inj 100 mg/100ml (1 mg/ml) generic 4 S Specialty Drug dactinomycin generic 4 S Specialty Drug daunorubicin hcl generic 4 S Specialty Drug decitabine generic 4 PA S Specialty Drug DOCEFREZ BRAND 4 S Specialty Drug docetaxel (inj conc 20 mg/ml, inj conc 20 mg/0.5ml (40 mg/ml), soln iv infusion 20 mg/2ml) generic 4 S Specialty Drug doxorubicin hcl for inj 10 mg generic 4 S Specialty Drug doxorubicin hcl liposomal generic 4 S Specialty Drug ELSPAR BRAND 4 PA epirubicin hcl inj 50 mg/25ml (2 mg/ml) generic 4 ERWINAZE BRAND 4 S Specialty Drug S Specialty Drug PA fludarabine phosphate generic 4 HALAVEN BRAND 4 S Specialty Drug S Specialty Drug PA S Specialty Drug idarubicin hcl (inj 5 mg/5ml mg/ml), inj 10 mg/10ml mg/ml)) generic 4 S Specialty Drug irinotecan hcl (inj 40 mg/2ml mg/ml), inj 100 mg/5ml mg/ml)) generic 4 S Specialty Drug ISTODAX BRAND 4 PA S Specialty Drug PA IXEMPRA KIT RECON SOLN 15 MG BRAND 4 S Specialty Drug PA JEVTANA BRAND 4 S PAGE 34 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS leucovorin calcium (for inj 50 mg, for inj 100 mg, for inj 200 mg, for inj 350 mg, for inj 500 mg, inj 10 mg/ml, tab 5 mg, tab 10 mg, tab 15 mg, tab 25 mg) generic 1 LYSODREN BRAND 4 S Specialty Drug mitomycin for inj 20 mg generic 4 S Specialty Drug mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) generic 4 OFORTA BRAND PA S Specialty Drug PA 4 S Specialty Drug PA ONCASPAR BRAND 4 S Specialty Drug ONTAK BRAND 4 S Specialty Drug oxaliplatin (soln50mg/10ml, soln100mg/20ml) generic 4 S Specialty Drug paclitaxel (conc 100 mg/16.7ml mg/ml), conc 150 mg/25ml mg/ml)) generic 4 S Specialty Drug PHOTOFRIN BRAND 4 S Specialty Drug PROLEUKIN BRAND 4 PA S Specialty Drug PA SYLATRON BRAND 4 S Specialty Drug PA SYNRIBO BRAND 4 S Specialty Drug TENIPOSIDE BRAND 4 S Specialty Drug thiotepa generic 4 S Specialty Drug TRISENOX BRAND 4 S Specialty Drug UVADEX BRAND 4 S Specialty Drug VALSTAR BRAND 4 PA S Specialty Drug PA VELCADE BRAND 4 S PAGE 35 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS vinblastine sulfate for inj 10 mg generic 4 S Specialty Drug vincristine sulfate generic 4 S Specialty Drug vinorelbine tartrate (inj 10 mg/ml, inj 10 mg/ml (base equiv)) generic 4 S Specialty Drug VORAXAZE BRAND 4 PA VUMON BRAND 4 ZALTRAP SOLUTION 100 MG/4ML BRAND 4 S Specialty Drug S Specialty Drug PA S Specialty Drug PA ZOLINZA BRAND 4 S Specialty Drug AROMATASE INHIBITORS, 3RD GENERATION anastrozole tab 1 mg generic 1 exemestane generic 4 PA S letrozole tab 2.5 mg Specialty Drug PA generic 4 S Specialty Drug ENZYME INHIBITORS ETOPOPHOS BRAND 4 S Specialty Drug etoposide generic 4 S Specialty Drug HYCAMTIN (CAP 0.25 MG, CAP 1 MG) BRAND 4 PA S topotecan hcl for inj 4 mg Specialty Drug PA generic 4 S Specialty Drug MOLECULAR TARGET INHIBITORS PA AFINITOR BRAND 4 S Specialty Drug PA BOSULIF BRAND 4 S PAGE 36 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN CAPRELSA BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA COMETRIQ (100 MG DAILY DOSE) BRAND 4 S Specialty Drug PA COMETRIQ (140 MG DAILY DOSE) BRAND 4 S Specialty Drug PA COMETRIQ (60 MG DAILY DOSE) BRAND 4 S Specialty Drug PA ERIVEDGE BRAND 4 S Specialty Drug PA GLEEVEC BRAND 4 S Specialty Drug PA INLYTA BRAND 4 S Specialty Drug PA JAKAFI BRAND 4 S Specialty Drug PA KYPROLIS BRAND 4 S Specialty Drug PA NEXAVAR BRAND 4 S Specialty Drug PA SPRYCEL BRAND 4 S Specialty Drug PA STIVARGA BRAND 4 S Specialty Drug PA SUTENT (CAP 12.5 MG, CAP 25 MG, CAP 50 MG) BRAND TARCEVA BRAND 4 S Specialty Drug PA 4 S Specialty Drug PA TASIGNA BRAND 4 S PAGE 37 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER TORISEL BRAND 4 TYKERB BRAND 4 LIMITS & RESTRICTIONS S Specialty Drug PA S Specialty Drug PA VANDETANIB BRAND 4 S Specialty Drug PA VOTRIENT BRAND 4 S Specialty Drug PA XALKORI BRAND 4 S Specialty Drug PA ZELBORAF BRAND 4 S Specialty Drug MONOCLONAL ANTIBODIES PA ADCETRIS BRAND 4 S Specialty Drug PA ARZERRA BRAND 4 S Specialty Drug PA AVASTIN SOLUTION 100 MG/4ML BRAND 4 S Specialty Drug PA BEXXAR BRAND 4 S Specialty Drug PA ERBITUX BRAND 4 S Specialty Drug PA HERCEPTIN BRAND 4 S Specialty Drug PA PERJETA BRAND 4 S Specialty Drug PA RITUXAN BRAND 4 S Specialty Drug PA VECTIBIX SOLUTION 100 MG/5ML BRAND 4 S PAGE 38 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN YERVOY BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug RETINOIDS bexarotene PA generic 4 S PANRETIN BRAND Specialty Drug 3 PA TARGRETIN GEL 1 % BRAND 4 MPL S tretinoin (chemotherapy) generic 1 ALBENZA BRAND 3 BILTRICIDE BRAND 3 ivermectin generic 1 mebendazole chew tab 100 mg generic 1 SKLICE BRAND 3 ALINIA BRAND 2 atovaquone-proguanil hcl generic 1 1 / 30 DAYS Specialty Drug ANTIPARASITICS ANTIHELMINTHICS ANTIPROTOZOALS QL MDS chloroquine phosphate (tab 250 mg, tab 500 mg) generic 1 COARTEM BRAND 2 QL DARAPRIM BRAND 3 hydroxychloroquine sulfate generic 1 mefloquine hcl generic 1 MEPRON BRAND 3 PAGE 39 12 / 3 DAYS 3 / 180 DAYS 24 / 3 DAYS MDS 3 / 180 DAYS QL 90 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER NEBUPENT BRAND 3 PENTAM BRAND 3 primaquine phosphate tab 26.3 mg (15 mg base) generic 3 quinine sulfate cap 324 mg generic 1 EURAX BRAND 3 lindane generic 3 malathion generic 1 NATROBA BRAND 1 permethrin generic 1 SPINOSAD BRAND 2 ULESFIA BRAND 3 benztropine mesylate (inj 1 mg/ml, tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1 trihexyphenidyl hcl generic 1 amantadine hcl (cap 100 mg, syrup 50 mg/5ml, tab 100 mg) generic 1 carbidopa-levodopa-entacapone (tabs 12.5-50200 mg, tabs 18.75-75-200 mg, tabs 25-100200 mg, tabs 31.25-125-200 mg, tabs 37.5150-200 mg, tabs 50-200-200 mg) generic 1 entacapone generic 1 tolcapone generic 3 BRAND 4 LIMITS & RESTRICTIONS QL 84 / 365 DAYS PEDICULICIDES/SCABICIDES ANTIPARKINSON AGENTS ANTICHOLINERGICS ANTIPARKINSON AGENTS, OTHER MDD 8 per day DOPAMINE AGONISTS PA APOKYN S bromocriptine mesylate (cap 5 mg, tab 2.5 mg) PAGE 40 generic Specialty Drug 1 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER NEUPRO BRAND 2 pramipexole dihydrochloride (tab 0.25 mg, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg) generic 1 pramipexole dihydrochloride tab 0.125 mg generic 1 ropinirole hydrochloride (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg, tab 5 mg) generic 1 ropinirole hydrochloride (tab 24hr 12 mg, tab 24hr 8 mg) generic 1 ropinirole hydrochloride (tab 24hr 2 mg, tab 24hr 4 mg, tab 24hr 6 mg) generic LIMITS & RESTRICTIONS MDD QL 4 per day 60 / 30 DAYS ST QL 30 / 30 DAYS 1 ST DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa generic 1 carbidopa-levodopa generic 1 BRAND 2 MONOAMINE OXIDASE B (MAO-B) INHIBITORS QL AZILECT 30 / 30 DAYS PA selegiline hcl (cap 5 mg, tab 5 mg) generic 1 chlorpromazine hcl (inj 25 mg/ml, inj 50 mg/2ml) generic 3 chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) generic 1 fluphenazine hcl generic 1 haloperidol generic 1 haloperidol decanoate generic 1 haloperidol lactate inj 5 mg/ml generic 1 loxapine succinate generic 1 ORAP BRAND 3 thioridazine hcl generic 1 ANTIPSYCHOTICS 1ST GENERATION/TYPICAL PAGE 41 QL 1 / 28 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER thiothixene generic 1 trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10 mg) generic 1 LIMITS & RESTRICTIONS 2ND GENERATION/ATYPICAL QL aripiprazole (tab 2 mg, tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg) aripiprazole oral solution 1 mg/ml FANAPT generic generic BRAND 3 3 30 / 30 DAYS PA AL At least 6 yrs old QL 900 / 30 DAYS PA AL At least 6 yrs old QL 60 / 30 DAYS 2 PA QL FANAPT TITRATION PACK BRAND 16 / 365 DAYS 2 PA QL INVEGA (TAB ER 24H 1.5 MG, TAB ER 24H 3 MG, TAB ER 24H 9 MG) BRAND INVEGA TAB ER 24H 6 MG BRAND 30 / 30 DAYS 2 PA QL 60 / 30 DAYS 2 PA QL LATUDA BRAND 30 / 30 DAYS 3 PA olanzapine (tab 15 mg, tab 20 mg) generic 1 QL 60 / 30 DAYS olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab 10 mg) generic 1 QL 30 / 30 DAYS olanzapine for im inj 10 mg generic 1 QL 6 / 28 DAYS quetiapine fumarate QL generic 60 / 30 DAYS 1 AL At least 10 yrs old QL 2 / 28 DAYS RISPERDAL CONSTA BRAND 2 PA risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg) generic 1 risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg) generic 1 PAGE 42 QL 60 / 30 DAYS QL 60 / 30 DAYS PA LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN risperidone soln 1 mg/ml generic TIER LIMITS & RESTRICTIONS QL 240 / 30 DAYS 1 PA risperidone tab 4 mg generic 1 SAPHRIS (SL TAB 5 MG, SL TAB 10 MG) BRAND 2 QL 120 / 30 DAYS QL 60 / 30 DAYS PA QL SEROQUEL XR (TAB ER 24H 200 MG, TAB ER 24H 150 MG) SEROQUEL XR (TAB ER 24H 400 MG, TAB ER 24H 300 MG) BRAND BRAND 2 2 30 / 30 DAYS PA AL At least 10 yrs old QL 60 / 30 DAYS PA AL At least 10 yrs old PA SEROQUEL XR TAB ER 24H 50 MG ziprasidone hcl BRAND generic 2 AL At least 10 yrs old QL 60 / 30 DAYS AL At least 18 yrs old QL 540 / 30 DAYS 1 TREATMENT-RESISTANT clozapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) generic 1 cidofovir iv inj 75 mg/ml generic 3 FOSCAVIR BRAND 3 ganciclovir sodium generic 1 VALCYTE RECON SOLN 50 MG/ML BRAND 2 ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS PA valganciclovir hcl QL generic 120 / 30 DAYS 1 PA ZIRGAN PAGE 43 BRAND 2 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ANTI-HEPATITIS B (HBV) AGENTS QL adefovir dipivoxil BARACLUDE SOLUTION 0.05 MG/ML entecavir generic BRAND generic 4 4 4 PA S Specialty Drug QL 600 / 30 DAYS PA S Specialty Drug QL 30 / 30 DAYS PA S QL EPIVIR HBV SOLUTION 5 MG/ML lamivudine (hbv) BRAND generic 30 / 30 DAYS 2 Specialty Drug 1800 / 30 DAYS S Specialty Drug QL 90 / 30 DAYS 1 PA QL TYZEKA BRAND 4 30 / 30 DAYS PA S Specialty Drug ANTI-HEPATITIS C (HCV) AGENTS PA HARVONI INCIVEK BRAND BRAND 4 4 MDD 1 per day S Specialty Drug QL 180 / 30 DAYS PA S Specialty Drug PA INFERGEN BRAND 4 S Specialty Drug PA INTRON A RECON SOLN 18000000 UNIT BRAND 4 S QL PEG-INTRON BRAND 4 4 / 28 DAYS PA S PAGE 44 Specialty Drug Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS QL PEG-INTRON REDIPEN BRAND 4 PA S QL PEG-INTRON REDIPEN PAK 4 BRAND 4 QL BRAND 4 QL BRAND 4 QL BRAND 4 QL BRAND 4 QL BRAND 4 QL ribavirin (hepatitis c) BRAND generic 4 2 / 28 DAYS Specialty Drug 2 / 28 DAYS Specialty Drug 4 / 28 DAYS Specialty Drug 4 / 28 DAYS PA S REBETOL SOLUTION 40 MG/ML Specialty Drug PA S PEGINTRON 1 / 28 DAYS PA S PEGASYS SOLUTION 180 MCG/ML Specialty Drug PA S PEGASYS SOLUTION 180 MCG/0.5ML 4 / 28 DAYS PA S PEGASYS PROCLICK Specialty Drug PA S PEGASYS KIT 180 MCG/0.5ML 4 / 28 DAYS Specialty Drug 1050 / 30 DAYS PA S Specialty Drug QL 210 / 30 DAYS 1 PA QL SOVALDI VICTRELIS BRAND BRAND 4 4 PA S Specialty Drug QL 360 / 30 DAYS PA S PAGE 45 28 / 28 DAYS Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) ISENTRESS (CHEW TAB 25 MG, CHEW TAB 100 MG) BRAND 2 ISENTRESS TAB 400 MG BRAND 2 QL 60 / 30 DAYS STRIBILD BRAND 2 QL 30 / 30 DAYS TIVICAY BRAND 2 QL 60 / 30 DAYS ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA BRAND 3 QL 30 / 30 DAYS COMPLERA BRAND 2 QL 30 / 30 DAYS EDURANT BRAND 2 QL 30 / 30 DAYS INTELENCE TAB 100 MG BRAND 2 QL 120 / 30 DAYS INTELENCE TAB 200 MG BRAND 2 QL 60 / 30 DAYS INTELENCE TAB 25 MG BRAND 2 QL 240 / 30 DAYS nevirapine susp 50 mg/5ml generic 1 QL 1200 / 30 DAYS nevirapine tab 200 mg generic 1 QL 60 / 30 DAYS nevirapine tab sr 24hr 400 mg generic 1 QL 30 / 30 DAYS RESCRIPTOR TAB 100 MG BRAND 2 QL 360 / 30 DAYS RESCRIPTOR TAB 200 MG BRAND 2 QL 180 / 30 DAYS SUSTIVA CAP 200 MG BRAND 2 QL 60 / 30 DAYS SUSTIVA CAP 50 MG BRAND 2 QL 90 / 30 DAYS SUSTIVA TAB 600 MG BRAND 2 QL 30 / 30 DAYS VIRAMUNE XR TAB ER 24H 100 MG BRAND 2 QL 90 / 30 DAYS ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate generic 1 QL 60 / 30 DAYS abacavir sulfate-lamivudine-zidovudine generic 1 QL 60 / 30 DAYS didanosine (capsule 125 mg, capsule 200 mg) generic 1 QL 60 / 30 DAYS PAGE 46 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS didanosine (capsule 250 mg, capsule 400 mg) generic 1 QL 30 / 30 DAYS EMTRIVA CAP 200 MG BRAND 2 QL 30 / 30 DAYS EMTRIVA SOLUTION 10 MG/ML BRAND 2 EPZICOM BRAND 2 QL 30 / 30 DAYS lamivudine oral soln 10 mg/ml generic 1 QL 900 / 30 DAYS lamivudine tab 150 mg generic 1 QL 60 / 30 DAYS lamivudine tab 300 mg generic 1 QL 30 / 30 DAYS lamivudine-zidovudine generic 1 QL 60 / 30 DAYS RETROVIR SOLUTION 10 MG/ML BRAND 1 stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg) generic 1 QL 60 / 30 DAYS stavudine for oral soln 1 mg/ml generic 1 QL 2400 / 30 DAYS QL TRUVADA BRAND 30 / 30 DAYS 2 PA VIDEX BRAND 2 VIREAD (TAB 150 MG, TAB 200 MG, TAB 250 MG, TAB 300 MG) BRAND 2 VIREAD POWDER 40 MG/GM BRAND 2 ZIAGEN SOLUTION 20 MG/ML BRAND 2 zidovudine cap 100 mg generic zidovudine syrup 10 mg/ml zidovudine tab 300 mg QL 30 / 30 DAYS 1 QL 180 / 30 DAYS generic 1 QL 1800 / 30 DAYS generic 1 QL 60 / 30 DAYS QL 1 / 30 DAYS ANTI-HIV AGENTS, OTHER FUZEON BRAND 4 PA S Specialty Drug SELZENTRY TAB 150 MG BRAND 2 QL 60 / 30 DAYS SELZENTRY TAB 300 MG BRAND 2 QL 120 / 30 DAYS TYBOST BRAND 2 QL 30 / 30 DAYS PAGE 47 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS CAP 250 MG BRAND 2 QL 120 / 30 DAYS APTIVUS SOLUTION 100 MG/ML BRAND 2 QL 300 / 30 DAYS CRIXIVAN CAP 200 MG BRAND 2 QL 270 / 30 DAYS CRIXIVAN CAP 400 MG BRAND 2 QL 180 / 30 DAYS INVIRASE CAP 200 MG BRAND 2 QL 300 / 30 DAYS INVIRASE TAB 500 MG BRAND 2 QL 120 / 30 DAYS KALETRA (TAB 100-25 MG, TAB 200-50 MG) BRAND 2 QL 120 / 30 DAYS KALETRA SOLUTION 400-100 MG/5ML BRAND 2 QL 375 / 30 DAYS LEXIVA SUSPENSION 50 MG/ML BRAND 2 QL 1680 / 30 DAYS LEXIVA TAB 700 MG BRAND 2 QL 120 / 30 DAYS NORVIR (CAP 100 MG, TAB 100 MG) BRAND 2 QL 360 / 30 DAYS NORVIR SOLUTION 80 MG/ML BRAND 2 QL 450 / 30 DAYS PREZISTA (TAB 75 MG, TAB 150 MG, TAB 400 MG, TAB 600 MG) BRAND 2 QL 60 / 30 DAYS PREZISTA SUSPENSION 100 MG/ML BRAND 2 QL 360 / 30 DAYS PREZISTA TAB 800 MG BRAND 2 MDD REYATAZ (CAP 150 MG, CAP 200 MG) BRAND 2 QL 60 / 30 DAYS REYATAZ CAP 100 MG BRAND 2 QL 120 / 30 DAYS REYATAZ CAP 300 MG BRAND 2 QL 30 / 30 DAYS VIRACEPT TAB 250 MG BRAND 2 QL 300 / 30 DAYS VIRACEPT TAB 625 MG BRAND 2 QL 120 / 30 DAYS RELENZA DISKHALER BRAND 2 QL 20 / 30 DAYS rimantadine hydrochloride generic 1 QL 60 / 30 DAYS TAMIFLU (CAP 45 MG, CAP 75 MG) BRAND 2 QL 10 / 30 DAYS 1 per day ANTI-INFLUENZA AGENTS PAGE 48 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS TAMIFLU CAP 30 MG BRAND 2 QL 20 / 30 DAYS TAMIFLU RECON SUSP 6 MG/ML BRAND 2 QL 120 / 30 DAYS acyclovir cap 200 mg generic 1 QL 50 / 30 DAYS acyclovir susp 200 mg/5ml generic 1 QL 400 / 30 DAYS acyclovir tab 400 mg generic 1 QL 150 / 30 DAYS acyclovir tab 800 mg generic 1 QL 150 / 30 days acyclovir topical generic 1 DENAVIR BRAND 3 famciclovir (tab 125 mg, tab 250 mg) QL generic 90 / 30 DAYS 1 ANTIHERPETIC AGENTS PA famciclovir tab 500 mg QL generic 120 / 30 DAYS 1 PA trifluridine generic 1 valacyclovir hcl tab 1 gm generic 1 QL 120 / 30 DAYS PA valacyclovir hcl tab 500 mg QL generic 60 / 30 DAYS 1 PA ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl (tab 7.5 mg, tab 10 mg, tab 15 mg, tab 30 mg) generic 1 buspirone hcl tab 5 mg generic 1 meprobamate generic 1 alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1 clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1 MDD 1 per day MDD 4 per day BENZODIAZEPINES PAGE 49 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS diazepam (tab 2 mg, tab 5 mg, tab 10 mg) generic 1 MDD 4 per day lorazepam (tab 0.5 mg, tab 2 mg) generic 1 MDD 3 per day lorazepam tab 1 mg generic 1 MDD 4 per day lithium generic 1 lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg, tab 300 mg, tab cr 300 mg, tab cr 450 mg) generic 1 acarbose generic 1 MDD 3 per day AVANDIA BRAND 3 QL 30 / 30 DAYS QL BYETTA 10 MCG PEN BRAND 2.4 / 30 DAYS 2 BIPOLAR AGENTS MOOD STABILIZERS BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS PA QL BYETTA 5 MCG PEN BRAND 1.2 / 30 DAYS 2 PA chlorpropamide tab 100 mg generic 1 MDD 3 per day CYCLOSET BRAND 3 MDD 6 per day glimepiride (tab 1 mg, tab 2 mg) generic 1 MDD 1 per day glimepiride tab 4 mg generic 1 MDD 2 per day glipizide (tab 24hr 2.5 mg, tab 24hr 5 mg, tab 24hr 10 mg) generic 1 MDD 2 per day glipizide (tab 5 mg, tab 10 mg) generic 1 MDD 4 per day glipizide-metformin hcl (tab 2.5-500 mg, tab 2.5-250 mg) generic 1 QL 60 / 30 DAYS glipizide-metformin hcl tab 5-500 mg generic 1 QL 120 / 30 DAYS glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg) generic 1 MDD PAGE 50 4 per day LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS glyburide micronized generic 1 MDD glyburide-metformin (tab 1.25-250 mg, tab 2.5500 mg) generic 1 QL 60 / 30 DAYS glyburide-metformin tab 5-500 mg generic 1 QL 120 / 30 DAYS GLYSET BRAND 3 MDD INVOKANA BRAND 3 QL 4 per day 3 per day 30 / 30 DAYS PA QL JANUVIA BRAND 30 / 30 DAYS 2 PA metformin hcl (tab 24hr osmotic 1000 mg, tab 24hr 750 mg) generic 1 MDD 2 per day metformin hcl tab 1000 mg generic 1 MDD 2.5 per day metformin hcl tab 500 mg generic 1 MDD 5 per day metformin hcl tab 850 mg generic 1 MDD 3 per day metformin hcl tab sr 24hr 500 mg generic 1 MDD 4 per day nateglinide generic 1 MDD 3 per day ONGLYZA BRAND 3 QL 30 / 30 DAYS pioglitazone hcl generic 1 QL 30 / 30 DAYS pioglitazone hcl-metformin hcl generic 1 QL 60 / 30 DAYS PRANDIMET BRAND 3 QL 60 / 30 DAYS repaglinide generic 1 MDD SYMLINPEN 120 BRAND 2 QL 4 per day 10.8 / 30 DAYS PA QL SYMLINPEN 60 BRAND 6 / 30 DAYS 2 PA tolazamide generic 1 MDD 4 per day tolbutamide generic 1 MDD 6 per day TRADJENTA BRAND 2 QL PAGE 51 30 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN VICTOZA BRAND TIER LIMITS & RESTRICTIONS QL 6 / 30 DAYS 2 PA GLYCEMIC AGENTS GLUCAGEN DIAGNOSTIC BRAND 3 QL 12 / 365 DAYS GLUCAGEN HYPOKIT BRAND 3 QL 12 / 365 DAYS PROGLYCEM BRAND 3 APIDRA BRAND 2 APIDRA SOLOSTAR BRAND 3 HUMALOG BRAND 2 HUMALOG KWIKPEN SOLN PEN 100 UNIT/ML BRAND 2 HUMALOG MIX 50/50 BRAND 2 HUMALOG MIX 50/50 KWIKPEN BRAND 2 HUMALOG MIX 50/50 PEN BRAND 2 HUMALOG MIX 75/25 BRAND 2 HUMALOG MIX 75/25 KWIKPEN BRAND 2 HUMALOG MIX 75/25 PEN BRAND 2 HUMALOG PEN BRAND 2 HUMULIN 70/30 BRAND 2 HUMULIN 70/30 KWIKPEN BRAND 2 HUMULIN 70/30 PEN BRAND 2 HUMULIN N BRAND 2 HUMULIN N KWIKPEN BRAND 2 HUMULIN N PEN BRAND 2 HUMULIN R BRAND 2 HUMULIN R U-500 (CONCENTRATED) BRAND 2 LANTUS BRAND 2 LANTUS SOLOSTAR BRAND 2 LEVEMIR BRAND 2 INSULINS PAGE 52 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LEVEMIR FLEXPEN BRAND 2 LEVEMIR FLEXTOUCH BRAND 2 NOVOLIN 70/30 BRAND 2 NOVOLIN 70/30 RELION BRAND 2 NOVOLIN N BRAND 2 NOVOLIN N RELION BRAND 2 NOVOLIN R BRAND 2 NOVOLIN R RELION BRAND 2 NOVOLOG BRAND 2 NOVOLOG FLEXPEN BRAND 2 NOVOLOG MIX 70/30 BRAND 2 NOVOLOG MIX 70/30 FLEXPEN BRAND 2 NOVOLOG PENFILL BRAND 2 RELION 70/30 BRAND 2 RELION N BRAND 2 RELION R BRAND 2 LIMITS & RESTRICTIONS BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ANTICOAGULANTS COUMADIN RECON SOLN 5 MG enoxaparin sodium BRAND generic 2 QL 21 / 180 DAYS MDS 21 / 180 DAYS 4 C S fondaparinux sodium generic QL 9 / 180 DAYS MDS 9 / 180 DAYS 4 C S PAGE 53 pa is required for treatment that is longer than 21 DAYS every 180 DAYS Specialty Drug pa is required for treatment that is longer than 9 DAYS every 180 DAYS Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER FRAGMIN (SOLUTION 2500 UNIT/0.2ML, SOLUTION 5000 UNIT/0.2ML, SOLUTION 7500 UNIT/0.3ML, SOLUTION 10000 UNIT/ML, SOLUTION 12500 UNIT/0.5ML, SOLUTION 15000 UNIT/0.6ML, SOLUTION 18000 UNT/0.72ML, SOLUTION 25000 UNIT/ML) BRAND HEPARIN (PORCINE) IN NACL (HEPAR(PORCE) SOLUTION 50-0.45 UNIT/ML-%, HEPAR(PORCE) SOLUTION 1000.45 UNIT/ML-%) BRAND 1 heparin sodium (porcine) (inj 5000 unit/ml, inj 10000 unit/ml, inj 20000 unit/ml) generic 1 heparin sodium (porcine) 40 unit/ml in d5w generic 1 PRADAXA CAP 150 MG BRAND PRADAXA CAP 75 MG LIMITS & RESTRICTIONS PA 4 S Specialty Drug 2 QL 60 / 30 DAYS BRAND 2 QL 30 / 30 DAYS warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg, tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg) generic 1 XARELTO BRAND 2 QL 30 / 30 DAYS anagrelide hcl generic 1 ARANESP (ALBUMIN FREE) (SOLN PRSYR 150 MCG/0.3ML, SOLN PRSYR 200 MCG/0.4ML, SOLN PRSYR 300 MCG/0.6ML, SOLN PRSYR 500 MCG/ML, SOLUTION 25 MCG/ML, SOLUTION 40 MCG/ML, SOLUTION 60 MCG/ML, SOLUTION 100 MCG/ML) BRAND 4 EPOGEN BRAND BLOOD FORMATION MODIFIERS PA S Specialty Drug PA 4 S Specialty Drug PA LEUKINE BRAND 4 S Specialty Drug PA MOZOBIL BRAND 4 S Specialty Drug PA NEULASTA BRAND 4 S PAGE 54 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN NEULASTA DELIVERY KIT BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA NEUPOGEN BRAND 4 S Specialty Drug PA NPLATE BRAND 4 S OMONTYS SOLUTION 10 MG/ML BRAND 3 PROCRIT BRAND 4 Specialty Drug PA S Specialty Drug PA PROMACTA BRAND 4 S Specialty Drug QL 60 / 30 DAYS QL 30 / 30 DAYS COAGULANTS tranexamic acid generic 1 aspirin-dipyridamole generic 1 BRILINTA TAB 90 MG BRAND 2 cilostazol generic 1 clopidogrel bisulfate tab 300 mg (base equiv) generic 1 clopidogrel bisulfate tab 75 mg (base equiv) generic 1 dipyridamole generic 1 EFFIENT TAB 10 MG BRAND 2 QL 35 / 30 DAYS EFFIENT TAB 5 MG BRAND 2 QL 30 / 30 DAYS REOPRO BRAND 3 ticlopidine hcl generic 1 clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg) generic 1 guanabenz acetate generic 1 PLATELET MODIFYING AGENTS CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS PAGE 55 MDD 8 per day LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER guanfacine hcl generic 1 methyldopa (tab 250 mg, tab 500 mg) generic 1 methyldopate hcl generic 3 midodrine hcl generic 1 doxazosin mesylate generic 1 phenoxybenzamine hcl generic 3 prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg) generic BENICAR LIMITS & RESTRICTIONS MDD 6 per day 1 MDD 4 per day BRAND 2 MDD 1 per day candesartan cilexetil generic 1 MDD 1 per day EDARBI BRAND 3 ALPHA-ADRENERGIC BLOCKING AGENTS ANGIOTENSIN II RECEPTOR ANTAGONISTS ST MDD 1 per day eprosartan mesylate generic 1 MDD 1 per day irbesartan generic 1 MDD 1 per day losartan potassium generic 1 MDD 1 per day telmisartan generic 1 MDD 1 per day TEVETEN TAB 400 MG BRAND 3 ST valsartan generic 1 MDD 2 per day MDD 1 per day ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl generic 1 captopril generic 1 enalapril maleate generic 1 fosinopril sodium generic 1 lisinopril generic 1 moexipril hcl generic 1 perindopril erbumine generic 1 PAGE 56 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER quinapril hcl generic 1 ramipril generic 1 trandolapril generic 1 amiodarone hcl (inj 150 mg/3ml (50 mg/ml), tab 100 mg, tab 200 mg, tab 400 mg) generic 1 disopyramide phosphate (cap 100 mg, cap 150 mg) generic 1 flecainide acetate generic 1 mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg) generic 1 MULTAQ BRAND 3 PROCAINAMIDE HCL SOLUTION 500 MG/ML BRAND 1 propafenone hcl generic 1 quinidine sulfate generic 1 sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg) generic 1 sotalol hcl tab 240 mg generic 1 TIKOSYN BRAND 2 acebutolol hcl (cap 200 mg, cap 400 mg) generic 1 atenolol (tab 25 mg, tab 50 mg, tab 100 mg) generic 1 betaxolol hcl generic 1 bisoprolol fumarate generic 1 BYSTOLIC (TAB 2.5 MG, TAB 5 MG, TAB 10 MG) BRAND BYSTOLIC TAB 20 MG LIMITS & RESTRICTIONS ANTIARRHYTHMICS MDD 2 per day 2 MDD 1 per day BRAND 2 MDD 2 per day carvedilol generic 1 labetalol hcl generic 1 LEVATOL BRAND 3 metoprolol succinate generic 1 metoprolol tartrate (inj 1 mg/ml, tab 25 mg, tab 50 mg, tab 100 mg) generic 1 BETA-ADRENERGIC BLOCKING AGENTS PAGE 57 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER nadolol (tab 20 mg, tab 40 mg, tab 80 mg) generic 1 pindolol generic 1 propranolol hcl (cap sr 24hr 80 mg, cap sr 24hr 60 mg, cap sr 24hr 120 mg, cap sr 24hr 160 mg, inj 1 mg/ml, oral soln 20 mg/5ml, oral soln 40 mg/5ml, tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80 mg) generic 1 timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg) generic 1 amlodipine besylate generic 1 diltiazem hcl (cap sr 12hr 90 mg, cap sr 12hr 120 mg, cap sr 12hr 60 mg, cap sr 24hr 240 mg, cap sr 24hr 120 mg, cap sr 24hr 180 mg, iv soln 50 mg/10ml (5 mg/ml), tab 30 mg, tab 60 mg, tab 90 mg, tab 120 mg) generic 1 diltiazem hcl coated beads generic 1 diltiazem hcl extended release beads (beads cap 24hr 360 mg, beads cap 24hr 180 mg, beads cap 24hr 240 mg, beads cap 24hr 300 mg, beads cap 24hr 120 mg) generic 1 DILTIAZEM HCL RECON SOLN 100 MG BRAND 1 felodipine generic 1 isradipine generic 1 nicardipine hcl generic 1 nifedipine (cap 10 mg, cap 20 mg, tab sr 24hr 60 mg, tab sr 24hr osmotic 60 mg, tab sr 24hr osmotic 30 mg, tab sr 24hr osmotic 90 mg, tab sr 24hr 30 mg, tab sr 24hr 90 mg) generic 1 nimodipine generic 1 nisoldipine (tab 24hr 30 mg, tab 24hr 8.5 mg, tab 24hr 17 mg, tab 24hr 34 mg, tab 24hr 40 mg, tab 24hr 20 mg) generic 1 LIMITS & RESTRICTIONS CALCIUM CHANNEL BLOCKING AGENTS PAGE 58 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS verapamil hcl (cap sr 24hr 100 mg, cap sr 24hr 240 mg, cap sr 24hr 120 mg, cap sr 24hr 180 mg, cap sr 24hr 360 mg, cap sr 24hr 200 mg, cap sr 24hr 300 mg, iv soln 2.5 mg/ml, tab 40 mg, tab 80 mg, tab 120 mg, tab cr 120 mg, tab cr 180 mg, tab cr 240 mg) generic 1 amiloride & hydrochlorothiazide generic 1 amlodipine besylate-benazepril hcl generic 1 atenolol & chlorthalidone generic 1 benazepril & hydrochlorothiazide generic 1 BIDIL BRAND 2 digoxin generic 1 enalapril maleate & hydrochlorothiazide generic 1 fosinopril sodium & hydrochlorothiazide generic 1 LANOXIN (TAB 62.5 MCG, TAB 187.5 MCG) BRAND 2 lisinopril & hydrochlorothiazide generic 1 losartan potassium & hydrochlorothiazide generic 1 MDD 1 per day pentoxifylline tab cr 400 mg generic 1 MDD 3 per day RANEXA TAB ER 12H 500 MG BRAND 2 QL spironolactone & hydrochlorothiazide generic 1 TEKTURNA BRAND 2 triamterene & hydrochlorothiazide (cap 37.5-25 mg, tab 37.5-25 mg, tab 75-50 mg) generic 1 valsartan-hydrochlorothiazide generic 1 CARDIOVASCULAR AGENTS, OTHER 90 / 30 DAYS MDD 1 per day MDD 2 per day DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap sr 12hr 500 mg generic 1 acetazolamide sodium generic 1 ACETAZOLAMIDE TAB 125 MG BRAND 1 MDD 8 per day acetazolamide tab 250 mg generic 1 MDD 4 per day PAGE 59 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS DIURETICS, LOOP bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1 bumetanide inj 0.25 mg/ml generic 1 EDECRIN BRAND 3 furosemide (inj 10 mg/ml, oral soln 8 mg/ml, oral soln 10 mg/ml, tab 20 mg, tab 40 mg, tab 80 mg) generic 1 torsemide (iv soln 20 mg/2ml (10 mg/ml), tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg) generic 1 amiloride hcl tab 5 mg generic 1 DYRENIUM BRAND 3 eplerenone generic 1 spironolactone (tab 25 mg, tab 50 mg, tab 100 mg) generic 1 chlorothiazide generic 1 chlorthalidone generic 1 hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab 25 mg, tab 50 mg) generic indapamide tab 1.25 mg MDD 5 per day MDD 16 per day MDD 3 per day 1 MDD 2 per day generic 1 MDD 1 per day indapamide tab 2.5 mg generic 1 MDD 2 per day methyclothiazide tab 5 mg generic 1 metolazone generic 1 MDD 2 per day fenofibrate (tab 48 mg, tab 54 mg, tab 145 mg, tab 160 mg) generic 1 QL 30 / 30 DAYS fenofibrate micronized (cap 67 mg, cap 134 mg, cap 200 mg) generic 1 QL 30 / 30 DAYS gemfibrozil tab 600 mg generic 1 QL 60 / 30 DAYS DIURETICS, POTASSIUM-SPARING DIURETICS, THIAZIDE DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES PAGE 60 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS QL ALTOPREV BRAND 30 / 30 DAYS 3 ST atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab 80 mg) generic 1 CRESTOR BRAND 2 QL 30 / 30 DAYS QL 30 / 30 DAYS ST fluvastatin sodium cap 20 mg generic 3 QL 30 / 30 DAYS fluvastatin sodium cap 40 mg generic 3 QL 60 / 30 DAYS QL LIVALO BRAND 30 / 30 DAYS 3 ST lovastatin (tab 10 mg, tab 20 mg) generic 1 QL 30 / 30 DAYS lovastatin tab 40 mg generic 1 QL 60 / 30 DAYS pravastatin sodium generic 1 QL 30 / 30 DAYS simvastatin generic 1 QL 30 / 30 DAYS ADVICOR (TAB ER 24H 1000-40 MG, TAB ER 24H 750-20 MG, TAB ER 24H 500-20 MG) QL BRAND 30 / 30 DAYS 3 ADVICOR TAB ER 24H 1000-20 MG BRAND DYSLIPIDEMICS, OTHER PA QL 60 / 30 DAYS 3 PA cholestyramine generic 1 QL 180 / 30 DAYS cholestyramine light powder 4 gm/dose generic 1 QL 720 / 30 DAYS cholestyramine light powder packets 4 gm generic 1 QL 180 / 30 DAYS colestipol hcl (granule packets 5 gm, granules 5 gm) generic 1 QL 180 / 30 DAYS colestipol hcl tab 1 gm generic 1 QL 480 / 30 DAYS niacin (antihyperlipidemic) generic 1 QL 60 / 30 DAYS niacin (tab 750 mg, tab 1000 mg) generic 1 PAGE 61 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN omega-3-acid ethyl esters generic TIER LIMITS & RESTRICTIONS QL 120 / 30 DAYS 1 ST SIMCOR (TAB ER 24H 1000-40 MG, TAB ER 24H 500-40 MG, TAB ER 24H 750-20 MG, TAB ER 24H 500-20 MG) BRAND SIMCOR TAB ER 24H 1000-20 MG BRAND QL 30 / 30 DAYS 2 PA QL 60 / 30 DAYS 2 PA QL VYTORIN BRAND 30 / 30 DAYS 2 ST WELCHOL PACKET 3.75 GM BRAND 2 QL 30 / 30 DAYS WELCHOL TAB 625 MG BRAND 2 QL 210 / 30 DAYS QL ZETIA BRAND 30 / 30 DAYS 2 ST VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl generic 1 minoxidil (tab 2.5 mg, tab 10 mg) generic 1 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS isosorbide dinitrate (tab 5 mg, tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40 mg) generic 1 isosorbide mononitrate (tab 20 mg, tab sr 24hr 120 mg, tab sr 24hr 30 mg, tab sr 24hr 60 mg) generic 1 NITRO-BID BRAND 3 nitroglycerin (iv soln 5 mg/ml, td patch 24hr 0.4 mg/hr, td patch 24hr 0.2 mg/hr, td patch 24hr 0.1 mg/hr, td patch 24hr 0.6 mg/hr) generic 1 NITROSTAT BRAND 2 CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES amphetamine-dextroamphetamine (cap 24hr 15 mg, cap 24hr 5 mg, cap 24hr 10 mg) PAGE 62 generic 1 QL 30 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 LAST UPDATED 10/2015 PRODUCT DESCRIPTION amphetamine-dextroamphetamine (cap 24hr 30 mg, cap 24hr 20 mg, cap 24hr 25 mg) BRAND/GEN generic amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg, tab 12.5 mg, tab 15 mg, tab 20 mg, tab 30 mg) generic amphetamine-dextroamphetamine tab 10 mg generic dextroamphetamine sulfate (cap 24hr 15 mg, cap 24hr 10 mg) dextroamphetamine sulfate (tab 5 mg, tab 10 mg) dextroamphetamine sulfate cap sr 24hr 5 mg methamphetamine hcl VYVANSE TIER 1 1 LIMITS & RESTRICTIONS QL 60 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 QL 90 / 30 DAYS AL At least 6 yrs old MDD generic generic generic generic BRAND QL 90 / 30 DAYS AL At least 6 yrs old QL 120 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 1 1 QL 120 / 30 DAYS AL At least 6 yrs old QL 60 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 1 1 QL 150 / 30 DAYS AL At least 6 yrs old QL 30 / 30 DAYS AL At least 6 yrs old C PA required for age greater than 18. 3 2 2 per day ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg) dexmethylphenidate hcl tab 10 mg guanfacine hcl (adhd) generic generic generic QL 60 / 30 DAYS AL At least 6 yrs old QL 60 / 30 days AL At least 6 yrs old QL 30 / 30 DAYS 1 1 1 PA AL PAGE 63 At least 6 yrs old LAST UPDATED 10/2015 PRODUCT DESCRIPTION methylphenidate hcl (cap cr 10 mg, cap cr 20 mg, cap cr 30 mg, cap cr 40 mg, cap cr 50 mg, cap cr 60 mg, tab sa osm 18 mg, tab sa osm 27 mg) methylphenidate hcl (cap sr 24hr 20 mg, tab cr 20 mg) BRAND/GEN generic generic methylphenidate hcl (cap sr 24hr 40 mg, cap sr 24hr 30 mg, tab sa osm 36 mg, tab sa osm 54 mg) generic methylphenidate hcl (soln 5 mg/5ml, soln 10 mg/5ml) generic methylphenidate hcl (tab 24hr 27 mg, tab 24hr 18 mg) generic methylphenidate hcl (tab 24hr 36 mg, tab 24hr 54 mg) methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg) methylphenidate hcl tab cr 10 mg TIER 1 1 1 LIMITS & RESTRICTIONS QL 30 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 QL 90 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 QL 60 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 QL 900 / 30 DAYS AL At least 6 yrs old 1 QL 30 / 30 DAYS generic 1 QL 60 / 30 DAYS QL generic 150 / 30 DAYS 1 AL At least 6 yrs old QL 90 / 30 DAYS AL 6 to 18 yrs old C PA required for age >18 generic 1 1 QL STRATTERA (CAP 10 MG, CAP 18 MG, CAP 25 MG, CAP 40 MG) STRATTERA (CAP 60 MG, CAP 80 MG, CAP 100 MG) BRAND BRAND 2 2 60 / 30 DAYS PA AL At least 6 yrs old QL 30 / 30 DAYS PA AL At least 6 yrs old CENTRAL NERVOUS SYSTEM, OTHER butalbital-acetaminophen-caffeine (cap 50-32540 mg, cap 50-500-40 mg, cap 50-300-40 mg, tab 50-325-40 mg, tab 50-500-40 mg) generic 1 butalbital-aspirin-caffeine cap 50-325-40 mg generic 1 PAGE 64 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS HORIZANT TAB ER 600 MG BRAND 3 NUEDEXTA BRAND 3 riluzole generic 3 tetrabenazine generic 4 S Specialty Drug duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg) generic 1 QL 60 / 30 DAYS QL LYRICA (CAP 225 MG, CAP 300 MG) BRAND 60 / 30 DAYS 2 FIBROMYALGIA AGENTS PA LYRICA (CAP 25 MG, CAP 50 MG, CAP 75 MG, CAP 100 MG, CAP 150 MG, CAP 200 MG) BRAND LYRICA SOLUTION 20 MG/ML BRAND 2 SAVELLA BRAND 2 QL 90 / 30 DAYS 2 PA QL 900 / 30 DAYS QL 60 / 30 DAYS PA SAVELLA TITRATION PACK BRAND 2 BRAND 4 PA MULTIPLE SCLEROSIS AGENTS PA AMPYRA S Specialty Drug PA AVONEX BRAND 4 S Specialty Drug PA AVONEX PEN BRAND 4 S Specialty Drug PA AVONEX PREFILLED BRAND 4 S Specialty Drug PA BETASERON BRAND 4 COPAXONE SOLN PRSYR 40 MG/ML BRAND 4 EXTAVIA BRAND 4 S Specialty Drug S Specialty Drug PA S PAGE 65 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN GILENYA BRAND TIER LIMITS & RESTRICTIONS PA 4 S glatiramer acetate Specialty Drug PA generic 4 S Specialty Drug PA REBIF BRAND 4 S Specialty Drug PA REBIF REBIDOSE BRAND 4 S Specialty Drug PA REBIF REBIDOSE TITRATION PACK BRAND 4 S Specialty Drug PA REBIF TITRATION PACK BRAND 4 S Specialty Drug PA TYSABRI BRAND 4 S Specialty Drug DENTAL AND ORAL AGENTS APHTHASOL BRAND 3 ARESTIN BRAND 3 cevimeline hcl generic 1 chlorhexidine gluconate (mouth-throat) generic 1 KEPIVANCE BRAND 4 pilocarpine hcl (oral) generic 1 stannous fluoride conc 0.63% generic 0 triamcinolone acetonide (mouth) generic 1 acitretin (cap 10 mg, cap 17.5 mg) generic acitretin cap 25 mg adapalene (cream, gel) PA S Specialty Drug 1 QL 30 / 30 DAYS generic 1 QL 60 / 30 DAYS generic 1 DERMATOLOGICAL AGENTS PA AL adapalene gel 0.3% ST generic 1 AL PAGE 66 At least 12 yrs old At least 12 yrs old LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN ADAPALENE LOTION 0.1 % BRAND TIER LIMITS & RESTRICTIONS ST 1 AL At least 12 yrs old PA AMEVIVE BRAND 4 S Specialty Drug ST AZELEX benzoyl peroxide (foam 5.3%, foam 9.8%, gel 5%, gel 10%, liq 4%, liq 7%, liq 10%, lotion 6%) BRAND generic 3 1 AL At least 12 yrs old AL At least 12 yrs old PA benzoyl peroxide-erythromycin generic 1 AL MPL calcipotriene (cream, oint, soln (50 mcg/ml)) generic 1 QL calcipotriene-betamethasone dipropionate generic 1 ST calcitriol (topical) generic 1 MPL clindamycin phosphate swab 1% generic 1 AL clindamycin phosphate-benzoyl peroxide generic 1 At least 12 yrs old 1 / claim 60 / claim 1 / claim At least 12 yrs old PA AL At least 12 yrs old PA clindamycin phosphate-benzoyl peroxide (refrigerate) generic clotrimazole w/ betamethasone generic 1 CORTISPORIN (CREAM 0.5-0.5-10000, OINTMENT 1 %) BRAND 2 diclofenac sodium (actinic keratoses) generic 1 DIFFERIN LOTION 0.1 % BRAND 2 1 AL At least 12 yrs old QL 100 / claim ST ELIDEL BRAND 2 AL At least 12 yrs old QL 30 / 30 DAYS PA AL At least 2 yrs old ST EPIDUO BRAND 3 AL PAGE 67 At least 12 yrs old LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS FINACEA GEL 15 % BRAND 2 finasteride (alopecia) generic 1 fluorouracil (topical) (soln 2%, soln 5%) generic 1 QL fluorouracil cream 5% generic 1 MPL hydrocortisone (topical) (cream 1%, cream 2.5%, lotion 2.5%, oint 1%, oint 2.5%) generic 1 imiquimod cream 5% generic 1 isotretinoin (cap 10 mg, cap 20 mg, cap 30 mg, cap 40 mg) generic 3 lactic acid (ammonium lactate) (cream, lotion) generic 1 lidocaine (oint, patch) generic 1 lidocaine hcl (gel 2%, soln 4%) generic 1 lidocaine-prilocaine cream 2.5-2.5% generic 1 methoxsalen rapid generic 1 OXSORALEN BRAND 2 PICATO BRAND 2 podofilox generic 1 PRUDOXIN BRAND 3 RECTIV BRAND 3 REGRANEX BRAND 3 SANTYL BRAND 3 selenium sulfide generic 1 STELARA BRAND 4 QL 10 / claim 1 / claim 12 / fill PA AL At least 12 yrs old QL 120 / 30 DAYS MPL 1 / claim PA sulfacetamide sodium (acne) generic S Specialty Drug AL At least 12 yrs old 1 MPL ST sulfacetamide sodium w/ sulfur (w/ cream 105%, w/ wash 9-4.5%) generic sulfacetamide sodium w/ sulfur emulsion 10-5% generic 1 SYNERA BRAND 3 PAGE 68 1 / claim 1 AL At least 12 yrs old AL At least 12 yrs old LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER TACLONEX SUSPENSION 0.005-0.064 % BRAND 3 tacrolimus (topical) generic 1 LIMITS & RESTRICTIONS ST AL MPL TAZORAC BRAND 2 tretinoin (cream 0.025%, cream 0.05%, cream 0.1%, gel 0.01%, gel 0.025%) generic 1 tretinoin microsphere gel 0.1% generic 1 AL At least 2 yrs old 1 / 30 DAYS At least 12 yrs old PA AL At least 12 yrs old ST VELTIN BRAND 3 AL VEREGEN BRAND 3 ZIANA BRAND 3 At least 12 yrs old ST AL ZONALON BRAND 3 BRAND 4 At least 12 yrs old ENZYME REPLACEMENT/MODIFIERS PA ADAGEN S Specialty Drug PA ALDURAZYME BRAND 4 S BUPHENYL TAB 500 MG BRAND 3 CEREZYME BRAND 4 Specialty Drug PA S Specialty Drug Specialty Drug CREON (CP DR PART 6000, CP DR PART 12000, CP DR PART 24000) BRAND 2 CYSTADANE BRAND 4 S CYSTAGON BRAND 3 PA ELAPRASE BRAND 4 PA S Specialty Drug PA ELELYSO BRAND 4 S PAGE 69 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN FABRAZYME RECON SOLN 35 MG BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA KUVAN TAB SOL 100 MG BRAND 4 S Specialty Drug PA LUMIZYME BRAND 4 S Specialty Drug PA MYOZYME BRAND 4 S Specialty Drug PA NAGLAZYME BRAND 4 S Specialty Drug PA ORFADIN BRAND 4 S PANCREAZE BRAND 2 pancrelipase (lipase-protease-amylase) generic 1 sodium phenylbutyrate generic 3 SUCRAID BRAND 3 VPRIV BRAND 4 Specialty Drug PA S Specialty Drug PA ZAVESCA BRAND 4 S ZENPEP (CP DR PART 3000-10000, CP DR PART 10000, CP DR PART 15000, CP DR PART 20000, CP DR PART 25000) BRAND 2 atropine sulfate (inj 0.1 mg/ml, inj 0.4 mg/ml, inj 1 mg/ml) generic 1 ATROPINE SULFATE SOLUTION 0.05 MG/ML BRAND 1 CANTIL BRAND 3 chlordiazepoxide hcl-clidinium bromide generic 1 dicyclomine hcl generic 1 Specialty Drug GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL PAGE 70 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER glycopyrrolate (inj 4 mg/20ml (0.2 mg/ml), tab 1 mg, tab 2 mg) generic 1 methscopolamine bromide generic 1 BRAND 4 LIMITS & RESTRICTIONS GASTROINTESTINAL AGENTS, OTHER PA CHOLBAM diphenoxylate w/ atropine generic 1 ENTEREG BRAND 3 loperamide hcl cap 2 mg generic 1 MOTOFEN BRAND 3 RELISTOR BRAND 2 ursodiol (cap 300 mg, tab 250 mg, tab 500 mg) generic 1 cimetidine (tab 200 mg, tab 300 mg, tab 400 mg, tab 800 mg) generic 1 cimetidine hcl generic 1 famotidine (inj 20 mg/2ml, inj 40 mg/4ml, inj 200 mg/20ml, inj 500 mg/50ml, tab 20 mg, tab 40 mg) generic 1 famotidine for susp 40 mg/5ml generic 1 FAMOTIDINE PREMIXED BRAND 1 nizatidine (cap 150 mg, cap 300 mg) generic 1 nizatidine oral soln 15 mg/ml generic 1 ranitidine hcl (cap 150 mg, cap 300 mg, inj 150 mg/6ml (25 mg/ml), tab 150 mg, tab 300 mg) generic 1 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) generic 1 alosetron hcl generic 1 AMITIZA BRAND 2 S Specialty Drug QL 600 / 30 DAYS QL 300 / 30 DAYS QL 600 / 30 DAYS QL 600 / 30 DAYS QL 60 / 30 DAYS HISTAMINE2 (H2) RECEPTOR ANTAGONISTS IRRITABLE BOWEL SYNDROME AGENTS PA PAGE 71 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS LAXATIVES lactulose generic 1 lactulose (encephalopathy) generic 1 MOVIPREP BRAND 2 OSMOPREP BRAND 3 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm generic 0 PREPOPIK BRAND 3 SUPREP BOWEL PREP BRAND 0 VISICOL BRAND 3 QL 40 / 180 DAYS CARAFATE SUSPENSION 1 GM/10ML BRAND 2 QL 1200 / 30 DAYS misoprostol (tab 100 mcg, tab 200 mcg) generic 1 QL 120 / 30 DAYS sucralfate tab 1 gm generic 1 QL 120 / 30 DAYS QL BRAND 30 / 30 DAYS 3 PROTECTANTS PROTON PUMP INHIBITORS DEXILANT ST esomeprazole magnesium QL generic 30 / 30 DAYS 3 ST lansoprazole cap delayed release 15 mg generic 1 lansoprazole cap delayed release 30 mg generic 1 omeprazole (cap 10 mg, cap 20 mg) generic omeprazole cap delayed release 40 mg QL 30 / 30 DAYS 1 QL 60 / 30 DAYS generic 1 MDD omeprazole-sodium bicarbonate cap 20-1100 mg generic 1 QL 30 / 30 DAYS pantoprazole sodium ec tab 20 mg (base equiv) generic 1 QL 30 / 30 DAYS pantoprazole sodium ec tab 40 mg (base equiv) generic 1 rabeprazole sodium generic 1 QL 30 / 30 DAYS PAGE 72 2 per day LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS GENITOURINARY AGENTS ANTISPASMODICS, URINARY QL ENABLEX BRAND 30 / 30 DAYS 3 PA flavoxate hcl generic 1 MYRBETRIQ BRAND 3 oxybutynin chloride generic 1 tolterodine tartrate (cap 24hr 4 mg, cap 24hr 2 mg) generic 1 tolterodine tartrate (tab 1 mg, tab 2 mg) generic 1 TOVIAZ BRAND 3 PA QL 30 / 30 DAYS QL 30 / 30 DAYS PA trospium chloride cap sr 24hr 60 mg generic 1 trospium chloride tab 20 mg generic 1 VESICARE BRAND 2 QL 30 / 30 DAYS QL 30 / 30 DAYS PA BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl generic 1 CIALIS TAB 5 MG BRAND 3 QL 30 / 30 DAYS QL 30 / 30 DAYS PA dutasteride generic 1 finasteride tab 5 mg generic 1 RAPAFLO BRAND 2 tamsulosin hcl generic 1 terazosin hcl generic 1 bethanechol chloride generic 1 CUPRIMINE BRAND 3 QL 30 / 30 days GENITOURINARY AGENTS, OTHER PAGE 73 MDD 4 per day LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER ELMIRON BRAND 2 glycine irrigation soln 1.5% generic 1 phenazopyridine hcl (tab 100 mg, tab 200 mg) generic 1 potassium citrate tab cr 10 meq (1080 mg) generic 1 RESECTISOL BRAND 1 sodium chloride (gu irrigant) generic 1 sodium chloride iv soln 0.9% generic 1 sodium citrate & citric acid generic 1 SORBITOL (SOLUTION 3 %, SOLUTION 3.3 %) BRAND 1 SORBITOL-MANNITOL BRAND 1 STENDRA BRAND 3 calcium acetate (phosphate binder) generic 1 FOSRENOL (CHEW TAB 500 MG, CHEW TAB 750 MG, CHEW TAB 1000 MG) BRAND 2 PHOSLYRA BRAND 2 RENAGEL BRAND 3 LIMITS & RESTRICTIONS QL 4 / 30 DAYS PHOSPHATE BINDERS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) A-HYDROCORT BRAND 1 alclometasone dipropionate generic 1 amcinonide (lotion, oint) generic 3 amcinonide cream 0.1% generic 1 betamethasone dipropionate (topical) (cream, lotion, oint) generic 1 betamethasone dipropionate augmented (cream, lotion, oint) generic 1 betamethasone valerate (aerosol foam 0.12%, cream 0.1%, lotion 0.1%, oint 0.1%) generic 1 clobetasol propionate (cream, foam, gel, oint, soln) generic 1 clobetasol propionate emollient base generic 1 PAGE 74 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN CLODERM BRAND 3 CLODERM PUMP BRAND 3 CORDRAN BRAND 3 cortisone acetate tab 25 mg generic 1 DEPO-MEDROL SUSPENSION 20 MG/ML BRAND 3 desonide (cream, lotion, oint) generic 1 desoximetasone (cream 0.25%, gel 0.05%, oint 0.25%) generic 1 dexamethasone (elixir 0.5 mg/5ml, soln 0.5 mg/5ml, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 2 mg, tab 4 mg, tab 6 mg) generic 1 DEXAMETHASONE INTENSOL BRAND 1 dexamethasone sodium phosphate (inj 4 mg/ml, inj 20 mg/5ml, inj 120 mg/30ml) generic 1 diflorasone diacetate oint 0.05% generic 1 fludrocortisone acetate tab 0.1 mg generic 1 fluocinolone acetonide (cream 0.01%, cream 0.025%, oil 0.01% (scalp oil), oint 0.025%, soln 0.01%) generic 1 fluocinonide (cream, gel, oint, soln) generic 1 fluocinonide emulsified base generic 1 fluticasone propionate (cream 0.05%, lotion 0.05%, oint 0.005%) generic 1 halobetasol propionate generic 1 HALOG BRAND 3 hydrocortisone generic 1 hydrocortisone acetate (rectal) generic 1 hydrocortisone butyrate generic 1 hydrocortisone valerate generic 1 KENALOG SUSPENSION 40 MG/ML BRAND 3 MEDROL TAB 2 MG BRAND 3 methylprednisolone (tab 4 mg, tab 4 mg dose pack, tab 8 mg, tab 16 mg, tab 32 mg) generic 1 methylprednisolone acetate (inj susp 40 mg/ml, inj susp 80 mg/ml) generic 1 PAGE 75 TIER LIMITS & RESTRICTIONS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER methylprednisolone sod succ generic 1 MILLIPRED BRAND 3 MILLIPRED DP BRAND 3 MILLIPRED DP 12-DAY BRAND 3 mometasone furoate (cream, oint, solution (lotion)) generic 1 prednicarbate generic 1 prednisolone sodium phosphate (phosph soln 6.7 mg/5ml (5 mg/5ml base), phosphate soln 15 mg/5ml (base equiv)) generic 1 prednisolone sodium phosphate (tab 10 mg, tab 15 mg, tab 30 mg) generic 3 PREDNISOLONE SODIUM PHOSPHATE SOLUTION 25 MG/5ML BRAND 1 prednisolone syrup 15 mg/5ml (usp solution equivalent) generic 1 prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab 50 mg) generic 1 SOLU-CORTEF RECON SOLN 250 MG BRAND 3 SOLU-MEDROL RECON SOLN 2 GM BRAND 3 triamcinolone acetonide (topical) (cream 0.025%, cream 0.1%, cream 0.5%, lotion 0.025%, lotion 0.1%, oint 0.025%, oint 0.1%, oint 0.5%) generic 1 VERIPRED 20 BRAND 3 LIMITS & RESTRICTIONS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) chorionic gonadotropin for inj 10000 unit PA generic 4 S desmopressin acetate inj 4 mcg/ml generic 1 desmopressin acetate spray refrigerated generic 1 desmopressin acetate tab 0.1 mg generic 1 Specialty Drug PA QL 180 / 30 DAYS PA desmopressin acetate tab 0.2 mg QL generic 240 / 30 DAYS 1 PA PAGE 76 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN GENOTROPIN MINIQUICK RECON SOLN 0.2 MG BRAND GENOTROPIN RECON SOLN 5 MG BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA 4 S Specialty Drug PA HUMATROPE BRAND 4 S Specialty Drug PA INCRELEX BRAND 4 S Specialty Drug PA NORDITROPIN BRAND 4 S NORDITROPIN FLEXPRO (SOLUTION 5 MG/1.5ML, SOLUTION 10 MG/1.5ML, SOLUTION 15 MG/1.5ML) BRAND NORDITROPIN NORDIFLEX PEN (PEN SOLUTION 5 MG/1.5ML, PEN SOLUTION 10 MG/1.5ML, PEN SOLUTION 15 MG/1.5ML) BRAND NUTROPIN BRAND Specialty Drug PA 4 S Specialty Drug PA 4 S Specialty Drug PA 4 S Specialty Drug PA NUTROPIN AQ BRAND 4 S Specialty Drug PA NUTROPIN AQ NUSPIN 10 BRAND 4 S Specialty Drug PA NUTROPIN AQ PEN SOLUTION 10 MG/2ML BRAND 4 S Specialty Drug PA OMNITROPE (SOLUTION 5 MG/1.5ML, SOLUTION 10 MG/1.5ML) BRAND SAIZEN BRAND 4 S Specialty Drug PA 4 S Specialty Drug PA SAIZEN CLICK.EASY BRAND 4 S Specialty Drug PA SEROSTIM BRAND 4 S PAGE 77 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN STIMATE BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA TEV-TROPIN BRAND 4 S Specialty Drug PA ZOMACTON BRAND 4 S Specialty Drug PA ZORBTIVE BRAND 4 S Specialty Drug HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) ANDROGENS ANADROL-50 BRAND 3 ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR 2 MG/24HR) BRAND 2 ANDROXY BRAND 3 danazol (cap 50 mg, cap 100 mg, cap 200 mg) generic 1 METHITEST BRAND 3 oxandrolone (tab 2.5 mg, tab 10 mg) generic 1 testosterone cypionate (j oil 100 mg/ml, j oil 200 mg/ml) generic 1 testosterone enanthate im inj in oil 200 mg/ml generic 1 BEYAZ BRAND 0 GL Female CENESTIN BRAND 3 GL Female CLIMARA PRO BRAND 3 GL Female DEPO-ESTRADIOL BRAND 3 GL Female desogestrel & ethinyl estradiol generic 0 GL Female desogestrel-ethinyl estradiol (biphasic) generic 0 GL Female desogestrel-ethinyl estradiol (triphasic) generic 0 GL Female QL 30 / 30 DAYS PA ESTROGENS PAGE 78 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN DIVIGEL BRAND 3 GL Female drospirenone-ethinyl estradiol generic 0 GL Female ELESTRIN BRAND 3 GL Female ENJUVIA BRAND 3 GL Female ESTRACE CREAM 0.1 MG/GM BRAND 3 GL Female estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg, td patch twice weekly 0.025 mg/24hr, td patch twice weekly 0.0375 mg/24hr, td patch twice weekly 0.05 mg/24hr, td patch twice weekly 0.075 mg/24hr, td patch twice weekly 0.1 mg/24hr, td patch weekly 0.025 mg/24hr, td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr), td patch weekly 0.05 mg/24hr, td patch weekly 0.06 mg/24hr, td patch weekly 0.075 mg/24hr, td patch weekly 0.1 mg/24hr) generic 1 GL Female estradiol valerate generic 1 GL Female ESTRASORB BRAND 3 GL Female ESTROGEL BRAND 3 GL Female estropipate generic 1 GL Female ethynodiol diacet & eth estrad generic 0 GL Female EVAMIST BRAND 3 GL Female FEMRING BRAND 3 GL Female levonorgestrel & eth estradiol generic 0 GL Female levonorgestrel (emergency oc) generic 0 GL Female levonorgestrel-eth estradiol (triphasic) generic 0 GL Female levonorgestrel-ethinyl estradiol (91-day) generic 0 GL Female levonorgestrel-ethinyl estradiol (continuous) generic 0 GL Female LO LOESTRIN FE BRAND 0 GL Female MENEST BRAND 3 GL Female MENOSTAR BRAND 3 GL Female PAGE 79 TIER LIMITS & RESTRICTIONS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS MINASTRIN 24 FE BRAND 0 GL Female NATAZIA BRAND 0 GL Female NECON 10/11 (28) BRAND 0 GL Female norethin acet & estrad-fe generic 0 GL Female norethindrone & eth estradiol generic 0 GL Female norethindrone & ethinyl estradiol-fe generic 0 GL Female norethindrone acet & eth estra generic 0 GL Female norethindrone acetate-ethinyl estradiol-fe generic 0 GL Female norethindrone-eth estradiol (triphasic) generic 0 GL Female norgestimate-ethinyl estradiol generic 0 GL Female norgestimate-ethinyl estradiol (triphasic) generic 0 GL Female norgestrel & ethinyl estradiol generic 0 GL Female NUVARING BRAND 0 GL Female OGESTREL BRAND 0 GL Female ORTHO EVRA BRAND 0 GL Female ORTHO TRI-CYCLEN LO BRAND 0 GL Female PREMARIN BRAND 2 GL Female PREMPHASE BRAND 2 GL Female PREMPRO BRAND 2 GL Female SAFYRAL BRAND 0 GL Female XULANE BRAND 0 GL Female ZOVIA 1/50E (28) BRAND 0 GL Female BRAND 0 GL Female PROGESTERONE AGONISTS/ANTAGONISTS ELLA PAGE 80 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS PROGESTINS DEPO-SUBQ PROVERA 104 BRAND 0 GL Female IMPLANON BRAND 0 GL Female LILETTA BRAND 0 GL Female medroxyprogesterone acetate generic 1 medroxyprogesterone acetate (contraceptive) generic 0 GL Female megestrol acetate (appetite) generic 3 megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg) generic 1 MIRENA BRAND 0 GL Female NEXPLANON BRAND 0 GL Female norethindrone (contraceptive) generic 0 GL Female norethindrone acetate tab 5 mg generic 0 progesterone micronized (cap 100 mg, cap 200 mg) generic 1 SKYLA BRAND 0 GL Female GL Female SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS raloxifene hcl generic 0 MDD SKELID BRAND 1 per day 3 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) levothyroxine sodium (for iv inj 100 mcg, for iv inj 500 mcg, tab 25 mcg, tab 50 mcg, tab 75 mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab 137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300 mcg) generic 1 liothyronine sodium (iv soln 10 mcg/ml, tab 5 mcg, tab 25 mcg, tab 50 mcg) generic 1 THYROLAR-1 BRAND 3 THYROLAR-1/2 BRAND 3 THYROLAR-1/4 BRAND 3 PAGE 81 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER THYROLAR-2 BRAND 3 THYROLAR-3 BRAND 3 LIMITS & RESTRICTIONS HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) PA SENSIPAR BRAND 4 S Specialty Drug HORMONAL AGENTS, SUPPRESSANT (PITUITARY) cabergoline generic 1 ELIGARD BRAND 4 PA S Specialty Drug PA FIRMAGON BRAND 4 S leuprolide acetate inj kit 5 mg/ml Specialty Drug PA generic 4 S Specialty Drug PA LUPRON DEPOT BRAND 4 S Specialty Drug PA LUPRON DEPOT-PED (KIT 7.5 MG, KIT 11.25 MG, KIT 15 MG, KIT 30 MG (PED)) BRAND octreotide acetate generic 4 S Specialty Drug PA 4 S Specialty Drug PA SOMATULINE DEPOT BRAND 4 S Specialty Drug PA SOMAVERT (RECON SOLN 10 MG, RECON SOLN 15 MG, RECON SOLN 20 MG) BRAND SYNAREL BRAND 4 S Specialty Drug PA 4 S Specialty Drug PA TRELSTAR BRAND 4 S Specialty Drug PA TRELSTAR DEPOT MIXJECT BRAND 4 S PAGE 82 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TRELSTAR LA MIXJECT BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA TRELSTAR MIXJECT BRAND 4 S Specialty Drug PA ZOLADEX BRAND 4 S Specialty Drug HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole (tab 5 mg, tab 10 mg) generic 1 propylthiouracil generic 1 AZASAN BRAND 3 azathioprine sodium generic 1 azathioprine tab 50 mg generic 1 CELLCEPT INTRAVENOUS BRAND 3 CIMZIA BRAND 4 IMMUNOLOGICAL AGENTS IMMUNE SUPPRESSANTS PA S Specialty Drug PA CIMZIA PREFILLED BRAND 4 S Specialty Drug PA CIMZIA STARTER KIT BRAND 4 S cyclosporine generic 1 cyclosporine modified (for microemulsion) generic 1 ENBREL BRAND 4 Specialty Drug PA S Specialty Drug PA ENBREL SURECLICK BRAND 4 S HUMIRA (PREF SY KT 20 MG/0.4ML, PREF SY KT 40 MG/0.8ML) PAGE 83 Specialty Drug PA BRAND 4 S Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN HUMIRA PEDIATRIC CROHNS START BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA HUMIRA PEN BRAND 4 S Specialty Drug PA HUMIRA PEN-CROHNS STARTER BRAND 4 S Specialty Drug PA HUMIRA PEN-PSORIASIS STARTER BRAND 4 S Specialty Drug PA KINERET BRAND 4 S methotrexate sodium generic 1 mycophenolate mofetil (cap 250 mg, tab 500 mg) generic 1 mycophenolate sodium generic 1 NULOJIX BRAND 4 Specialty Drug PA S Specialty Drug PA ORENCIA BRAND 4 S PROGRAF SOLUTION 5 MG/ML BRAND 2 REMICADE BRAND 4 Specialty Drug PA RHEUMATREX BRAND 4 SIMPONI (SOLN A-INJ 50 MG/0.5ML, SOLN PRSYR 50 MG/0.5ML) BRAND 4 sirolimus (tab 0.5 mg, tab 1 mg, tab 2 mg) generic 1 tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg) generic 1 TREXALL BRAND 4 XELJANZ BRAND 4 S Specialty Drug S Specialty Drug PA S Specialty Drug S Specialty Drug PA ZORTRESS PAGE 84 BRAND 4 S Specialty Drug S Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS IMMUNIZING AGENTS, PASSIVE PA ATGAM BRAND 4 S Specialty Drug PA CARIMUNE NF RECON SOLN 3 GM BRAND 4 S Specialty Drug PA GAMMAGARD S/D BRAND 4 S Specialty Drug PA GAMMAGARD S/D LESS IGA BRAND 4 S Specialty Drug PA GAMMAGARD SOLUTION 1 GM/10ML BRAND 4 S Specialty Drug PA GAMMAKED SOLUTION 1 GM/10ML BRAND 4 S Specialty Drug PA GAMUNEX-C SOLUTION 1 GM/10ML BRAND 4 S Specialty Drug PA HIZENTRA BRAND 4 S Specialty Drug PA HIZENTRA 20% BRAND 4 S Specialty Drug PA THYMOGLOBULIN BRAND 4 S Specialty Drug IMMUNOMODULATORS ACTEMRA (SOLUTION 80 MG/4ML, SOLUTION 200 MG/10ML, SOLUTION 400 MG/20ML) BRAND ACTIMMUNE BRAND PA 4 S Specialty Drug PA 4 S Specialty Drug PA ARCALYST BRAND 4 S leflunomide PAGE 85 generic 1 MDD Specialty Drug 1 per day LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER RIDAURA BRAND 3 SIMULECT BRAND 3 ADACEL BRAND 0 AFLURIA BRAND 0 AFLURIA PRESERVATIVE FREE BRAND 0 AGRIFLU BRAND 0 BOOSTRIX BRAND 0 FLUARIX BRAND 0 FLUARIX QUADRIVALENT BRAND 0 FLUCELVAX BRAND 0 FLULAVAL BRAND 0 FLULAVAL QUADRIVALENT BRAND 0 FLUVIRIN BRAND 0 FLUVIRIN PRESERVATIVE FREE BRAND 0 FLUZONE BRAND 0 FLUZONE HIGH-DOSE BRAND 0 FLUZONE PEDIATRIC PF BRAND 0 FLUZONE PRESERVATIVE FREE BRAND 0 FLUZONE QUADRIVALENT (SUSP PRSYR 0.5 ML, SUSPENSION, SUSPENSION 0.5 ML) BRAND 0 MENACTRA BRAND 0 MENOMUNE BRAND 0 MENVEO BRAND 0 PNEUMOVAX 23 BRAND 0 PREVNAR 13 BRAND 0 ZOSTAVAX BRAND 0 BRAND 2 LIMITS & RESTRICTIONS VACCINES AL At least 50 yrs old INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES APRISO PAGE 86 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ASACOL BRAND 2 MDD 12 per day ASACOL HD BRAND 2 MDD 6 per day balsalazide disodium generic 1 CANASA BRAND 2 DIPENTUM BRAND 2 LIALDA BRAND 2 mesalamine enema 4 gm generic 1 PENTASA BRAND 2 budesonide cap sr 24hr 3 mg generic 1 hydrocortisone (intrarectal) generic 1 hydrocortisone rectal cream 2.5% generic 1 generic 1 alendronate sodium (tab 35 mg, tab 70 mg) generic 1 QL 4 / 28 DAYS alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg) generic 1 QL 30 / 30 DAYS calcitonin (salmon) generic 1 QL 3.7 / 30 DAYS calcitriol generic 1 doxercalciferol generic 1 etidronate disodium generic 1 QL 2.4 / 28 DAYS GLUCOCORTICOIDS SULFONAMIDES sulfasalazine (tab 500 mg, tab delayed release 500 mg) METABOLIC BONE DISEASE AGENTS FORTEO BRAND 4 PA S QL FOSAMAX PLUS D BRAND Specialty Drug 4 / 28 DAYS 3 PA ibandronate sodium iv soln 3 mg/3ml (base equivalent) PAGE 87 generic 4 S Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER ibandronate sodium tab 150 mg (base equivalent) generic 1 pamidronate disodium (for inj 30 mg, for inj 90 mg, iv soln 3 mg/ml, iv soln 9 mg/ml) generic 4 PAMIDRONATE DISODIUM SOLUTION 6 MG/ML BRAND paricalcitol (cap 1 mcg, cap 2 mcg, cap 4 mcg, iv soln 5 mcg/ml) generic 3 paricalcitol iv soln 2 mcg/ml generic 3 PROLIA BRAND 4 LIMITS & RESTRICTIONS QL 1 / 28 DAYS PA S Specialty Drug PA 4 S Specialty Drug S Specialty Drug PA risedronate sodium (tab 5 mg, tab 30 mg) generic S Specialty Drug QL 30 / 30 DAYS 1 PA risedronate sodium tab 150 mg QL generic 1 / 28 DAYS 1 PA risedronate sodium tab 35 mg QL generic 4 / 28 DAYS 1 PA risedronate sodium tab delayed release 35 mg generic 1 XGEVA BRAND 4 PA PA S Specialty Drug PA zoledronic acid (inj conc for infusion 4 mg/5ml, soln 5 mg/100ml) generic ZOLEDRONIC ACID (RECON SOLN 4 MG, SOLUTION 4 MG/100ML) BRAND ZOMETA SOLUTION 4 MG/100ML BRAND 4 S Specialty Drug PA 4 S Specialty Drug PA 4 S Specialty Drug MISCELLANEOUS THERAPEUTIC AGENTS *lancets*** generic 1 QL 200 / 30 DAYS 1ST TIER UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS PAGE 88 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER 1ST TIER UNIFINE PENTIPS PLUS (MISC 31G 5, MISC 32G 4) BRAND 1 ACURA CONTROL SOLUTION LOW BRAND 1 ADVOCATE CONTROL SOLUTION LIQUID LOW BRAND 1 ADVOCATE INSULIN PEN NEEDLES (PEN MISC 29G 12.7MM, PEN MISC 31G 5 MM) BRAND 1 ADVOCATE REDI-CODE+ CONTROL SOLUTION LOW BRAND 1 amiodarone hcl (bulk) generic 1 AURORA UNIFINE PENTIPS BRAND 1 BAYER BREEZE 2 CONTROL LIQUID LOW BRAND 1 BAYER CONTOUR LIQUID LOW BRAND 1 BAYER CONTOUR NEXT CONTROL SOLUTION LOW BRAND 1 BD AUTOSHIELD MISC 29G X 8MM BRAND BD INSULIN SYRINGE MISC U-100 1 ML LIMITS & RESTRICTIONS QL 450 / 90 DAYS QL 450 / 90 DAYS QL 450 / 90 DAYS 1 QL 450 / 90 DAYS BRAND 1 QL 450 / 90 DAYS BD PEN NEEDLE MINI U/F BRAND 1 QL 450 / 90 DAYS BD PEN NEEDLE NANO U/F BRAND 1 QL 450 / 90 DAYS BD PEN NEEDLE ULTRAFINE BRAND 1 QL 450 / 90 DAYS blood glucose calibration generic 1 CAREFINE PEN NEEDLES (PEN MISC 30G 8, PEN MISC 32G 5, PEN MISC 32G 4, PEN MISC 32G 6) BRAND 1 QL 450 / 90 DAYS CAREONE UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS CAREONE UNIFINE PENTIPS PLUS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS CAYA BRAND 0 CHEK-STIX CONTROL BRAND 1 CHEMSTRIP K BRAND 1 CLEVER CHOICE GLUCOSE CONTROL LIQUID LOW BRAND 1 CLICKFINE PEN NEEDLES MISC 32G X 4 MM BRAND 1 QL 450 / 90 DAYS PAGE 89 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER clindamycin phosphate (bulk) generic 1 COMFORT EZ PEN NEEDLES (PEN MISC 31G 5, PEN MISC 32G 4, PEN MISC 32G 5, PEN MISC 32G 6) BRAND 1 DIATRUE CONTROL LEVEL 1 BRAND 1 DRUG MART UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4) BRAND DRUG MART UNIFINE PENTIPS PLUS LIMITS & RESTRICTIONS QL 450 / 90 DAYS 1 QL 450 / 90 DAYS BRAND 1 QL 450 / 90 DAYS EASY COMFORT PEN NEEDLES (PEN MISC 31G 5, PEN MISC 32G 4) BRAND 1 QL 450 / 90 DAYS EASY PLUS CONTROL SOLUTION LOW BRAND 1 EASY PLUS II CONTROL SOLUTION LOW BRAND 1 EASY STEP CONTROL SOLUTION LOW BRAND 1 EASY TALK CONTROL SOLUTION LOW BRAND 1 EASY TOUCH PEN NEEDLES (PEN MISC 31G 5, PEN MISC 32G 5, PEN MISC 32G 6, PEN MISC 32G 4) BRAND 1 QL 450 / 90 DAYS EASY TRAK CONTROL SOLUTION LOW BRAND 1 EASYGLUCO CONTROL SOLUTION LOW BRAND 1 EASYMAX CONTROL SOLUTION LOW BRAND 1 ECLIPSE CONTROL LIQUID LOW BRAND 1 ELEMENT CONTROL LIQUID LOW BRAND 1 ELEMENT PLUS CONTROL SOLUTION LOW BRAND 1 EMBRACE CONTROL BRAND 1 EMBRACE EVO CONTROL LEVEL 1 BRAND 1 ENVISION CONTROL SOLUTION LOW BRAND 1 FEMCAP BRAND 0 FIFTY50 PEN NEEDLES MISC 31G X 5 MM BRAND 1 QL 450 / 90 DAYS fluticasone propionate (bulk) generic 1 FORA CONTROL SOLUTION LOW BRAND 1 FORACARE GDH CONTROL SOLUTION LOW BRAND 1 FORTISCARE CONTROL SOLUTION LOW BRAND 1 FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 5 MM BRAND 1 QL 450 / 90 DAYS PAGE 90 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN FREDS PHARMACY UNIFINE PENTIPS BRAND 1 QL 450 / 90 DAYS GLOBAL EASE INJECT PEN NEEDLES (PEN MISC 31G 5, PEN MISC 32G 4) BRAND 1 QL 450 / 90 DAYS GLUCOLAB CONTROL LIQUID LOW BRAND 1 H-E-B INCONTROL PEN NEEDLES (PEN MISC 31G 5, PEN MISC 32G 4) BRAND 1 QL 450 / 90 DAYS HEALTHWISE UNIFINE PENTIPS BRAND 1 QL 450 / 90 DAYS HEALTHY ACCENTS UNIFINE PENTIP (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS INFINITY CONTROL SOLUTION LOW BRAND 1 insulin pen needle generic 1 QL 450 / 90 DAYS INSUPEN PEN NEEDLES MISC 32G X 4 MM BRAND 1 QL 450 / 90 DAYS INSUPEN SENSITIVE MISC 32G X 6 MM BRAND 1 QL 450 / 90 DAYS INSUPEN ULTRAFIN MISC 30G X 8 MM BRAND 1 QL 450 / 90 DAYS KETOCARE BRAND 1 KETOSTIX BRAND 1 KMART VALU INSULIN SYRINGE 29G MISC U-100 1 ML BRAND 1 QL 450 / 90 DAYS KMART VALU INSULIN SYRINGE 30G MISC U-100 1 ML BRAND 1 QL 450 / 90 DAYS lancet devices generic 1 LEADER UNIFINE PENTIPS BRAND 1 QL 450 / 90 DAYS LEADER UNIFINE PENTIPS PLUS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS LITE TOUCH PEN NEEDLES BRAND 1 QL 450 / 90 DAYS LITETOUCH PEN NEEDLES MISC 29G X 12.7MM BRAND 1 QL 450 / 90 DAYS metaproterenol sulfate powder generic 1 MONOJECT INSULIN SYRINGE MISC U-100 1 ML BRAND 1 QL 450 / 90 DAYS NOVOFINE BRAND 1 QL 450 / 90 DAYS NOVOFINE AUTOCOVER BRAND 1 QL 450 / 90 DAYS PAGE 91 TIER LIMITS & RESTRICTIONS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN NOVOFINE PLUS BRAND 1 QL 450 / 90 DAYS NOVOTWIST BRAND 1 QL 450 / 90 DAYS nystatin (bulk) powder generic 1 OMNIFLEX DIAPHRAGM BRAND 0 ORTHO DIAPHRAGM ALL-FLEX BRAND 0 ORTHO DIAPHRAGM COIL BRAND 0 ORTHO DIAPHRAGM FLAT BRAND 0 PARAGARD INTRAUTERINE COPPER BRAND 0 GL Female PC UNIFINE PENTIPS MISC 31G X 5 MM BRAND 1 QL 450 / 90 DAYS PEN NEEDLES 3/16" BRAND 1 QL 450 / 90 DAYS PEN NEEDLES 5/16" MISC 30G X 8 MM BRAND 1 QL 450 / 90 DAYS PENTIPS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS PHISOHEX BRAND 1 PREFERRED PLUS UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS PRENTIF FITTING SET BRAND 0 PRESTIGE GLUCOSE CONTROL LIQUID LOW BRAND 1 PRODIGY CONTROL SOLUTION SOLUTION LOW BRAND 1 PRODIGY MINI PEN NEEDLES BRAND 1 QL 450 / 90 DAYS PX MINI PEN NEEDLES BRAND 1 QL 450 / 90 DAYS QC UNIFINE PENTIPS BRAND 1 QL 450 / 90 DAYS RA PEN NEEDLES MISC 31G X 5 MM BRAND 1 QL 450 / 90 DAYS RELION PEN NEEDLES MISC 32G X 4 MM BRAND 1 QL 450 / 90 DAYS SHOPKO UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS sodium polystyrene sulfonate (bulk) generic 1 SOLUS V2 CONTROL SOLUTION LOW BRAND 1 stannous fluoride (bulk) generic 0 PAGE 92 TIER LIMITS & RESTRICTIONS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER SURE COMFORT PEN NEEDLES (PEN MISC 29G 12.7MM, PEN MISC 30G 8 MM, PEN MISC 31G 5 MM, PEN MISC 32G 6 MM, PEN MISC 32G 4 MM) BRAND 1 SURE EDGE GLUCOSE CONTROL SOLUTION LOW BRAND 1 SURE-FINE PEN NEEDLES (PEN MISC 29G 12.7MM, PEN MISC 31G 5 MM) BRAND 1 SURECHEK CONTROL SOLUTION LIQUID LOW BRAND 1 SURESTEP PRO LOW GLUCOSE BRAND 1 TRUE METRIX BLOOD GLUCOSE TEST BRAND 1 TRUE METRIX LEVEL 1 BRAND 1 TRUE METRIX METER BRAND TRUERESULT BLOOD GLUCOSE LIMITS & RESTRICTIONS QL 450 / 90 DAYS QL 450 / 90 DAYS QL 100 / 30 DAYS 1 QL 1 / 730 DAYS BRAND 1 QL 1 / 730 DAYS TRUETEST TEST BRAND 1 QL 100 / 30 DAYS TRUETRACK GLUCOSE CONTROL (LIQUID HIGH, LIQUID LOW) BRAND 1 TRUETRACK TEST BRAND 1 QL 100 / 30 DAYS ULTICARE MICRO PEN NEEDLES BRAND 1 QL 450 / 90 DAYS ULTICARE PEN NEEDLES MISC 29G X 12.7MM BRAND 1 QL 450 / 90 DAYS ULTRA-THIN II MINI PEN NEEDLE BRAND 1 QL 450 / 90 DAYS ULTRA-THIN II PEN NEEDLES BRAND 1 QL 450 / 90 DAYS UNIFINE PENTIPS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS UNIFINE PENTIPS PLUS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS UNISTRIP CONTROL SOLUTION LOW BRAND 1 VIDA MIA UNIFINE PENTIPS MISC 32G X 4 MM BRAND 1 QL 450 / 90 DAYS VOCAL POINT CONTROL SOLUTION LOW BRAND 1 water for irrigation, sterile generic 1 WEGMANS UNIFINE PENTIPS PLUS (MISC 31G 5, MISC 32G 4) BRAND 1 QL 450 / 90 DAYS PAGE 93 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER WIDE-SEAL DIAPHRAGM 60 BRAND 0 WIDE-SEAL DIAPHRAGM 65 BRAND 0 WIDE-SEAL DIAPHRAGM 70 BRAND 0 WIDE-SEAL DIAPHRAGM 75 BRAND 0 WIDE-SEAL DIAPHRAGM 80 BRAND 0 WIDE-SEAL DIAPHRAGM 85 BRAND 0 WIDE-SEAL DIAPHRAGM 90 BRAND 0 WIDE-SEAL DIAPHRAGM 95 BRAND 0 ALAMAST BRAND 2 LACRISERT BRAND 3 LASTACAFT BRAND 2 neomycin-bacitracin zn-polymyxin generic 1 neomycin-polymy-dexameth generic 1 neomycin-polymyxin-hc (ophth) generic 1 polymyxin b-trimethoprim generic 1 proparacaine hcl generic 1 RESTASIS BRAND 2 tobramycin-dexamethasone generic 1 tropicamide (soln 0.5%, soln 1%) generic 1 ALOCRIL BRAND 3 ALOMIDE BRAND 3 azelastine hcl (ophth) generic 1 BEPREVE BRAND 3 cromolyn sodium (ophth) generic 1 EMADINE BRAND 3 epinastine hcl (ophth) generic 1 PATADAY BRAND 2 LIMITS & RESTRICTIONS OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER OPHTHALMIC ANTI-ALLERGY AGENTS PAGE 94 QL 6 / claim LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS PATANOL BRAND 3 ALREX BRAND 2 bromfenac sodium (ophth) generic 1 dexamethasone sodium phosphate (ophth) generic 1 diclofenac sodium (ophth) generic 1 DUREZOL BRAND 2 fluorometholone (ophth) generic 1 flurbiprofen sodium generic 1 FML BRAND 3 FML FORTE BRAND 3 ILEVRO BRAND 3 ketorolac tromethamine ophth soln 0.4% generic 1 MPL 1 / 30 DAYS ketorolac tromethamine ophth soln 0.5% generic 1 MPL 1 / claim LOTEMAX BRAND 2 MAXIDEX BRAND 3 NEVANAC BRAND 3 PRED MILD BRAND 3 prednisolone acetate (ophth) generic 1 PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 % BRAND 3 VEXOL BRAND 3 apraclonidine hcl generic 1 AZOPT BRAND 2 MPL 1 / claim betaxolol hcl (ophth) generic 1 MPL 1 / claim brimonidine tartrate generic 1 MPL 1 / claim carteolol hcl (ophth) generic 1 COMBIGAN BRAND 2 dorzolamide hcl generic 1 MPL 1 / claim OPHTHALMIC ANTI-INFLAMMATORIES OPHTHALMIC ANTIGLAUCOMA AGENTS PAGE 95 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER dorzolamide hcl-timolol maleate generic 1 IOPIDINE SOLUTION 1 % BRAND 3 levobunolol hcl generic methazolamide (tab 25 mg, tab 50 mg) LIMITS & RESTRICTIONS MPL 1 / claim 1 MPL 1 / claim generic 1 MDD 6 per day metipranolol generic 1 PHOSPHOLINE IODIDE BRAND 3 pilocarpine hcl generic 1 timolol maleate (ophth) generic 1 OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS bimatoprost ophth soln 0.03% generic 3 latanoprost ophth soln 0.005% generic 1 LUMIGAN SOLUTION 0.01 % BRAND 3 TRAVATAN Z BRAND 2 ZIOPTAN BRAND 2 acetic acid (otic) generic 1 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) generic 1 CIPRO HC BRAND 3 CIPRODEX BRAND 2 COLY-MYCIN S BRAND 3 CORTISPORIN-TC BRAND 3 fluocinolone acetonide (otic) generic 1 hydrocortisone w/acetic acid generic 1 neomycin-polymyxin-hc (otic) generic 1 ST OTIC AGENTS RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS PA ALVESCO BRAND 3 MPL PAGE 96 1 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS ASMANEX 120 METERED DOSES BRAND 2 QL 1 / 30 DAYS ASMANEX 14 METERED DOSES BRAND 2 QL 1 / 30 DAYS ASMANEX 30 METERED DOSES BRAND 2 QL 1 / 30 DAYS ASMANEX 60 METERED DOSES BRAND 2 QL 1 / 30 DAYS ASMANEX 7 METERED DOSES BRAND 2 QL 1 / 30 DAYS budesonide (inhalation) (susp 0.25 mg/2ml, susp 0.5 mg/2ml) QL generic 120 / 30 DAYS 3 budesonide (nasal) generic 1 budesonide inhalation susp 1 mg/2ml generic 1 PA QL 18 / 30 DAYS QL 120 / 30 DAYS PA PA FLOVENT DISKUS BRAND 3 MPL 1 / 30 DAYS PA FLOVENT HFA BRAND 3 flunisolide nasal soln 25 mcg/act (0.025%) generic 1 flunisolide nasal soln 29 mcg/act (0.025%) generic 1 MPL 1 / 30 DAYS MPL 1 / 30 DAYS QL fluticasone propionate (nasal) generic 1 NASONEX BRAND 2 25 / 30 DAYS MPL 1 / 30 DAYS MPL 1 / 30 DAYS QL 34 / 30 DAYS PA PA PULMICORT FLEXHALER QVAR BRAND 2 MPL 1 / 30 DAYS BRAND 2 MPL 1 / 30 DAYS azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/), 137 mcg/(1 mg/ml)) generic 1 MPL 1 / 30 DAYS carbinoxamine maleate generic 1 cetirizine hcl generic 1 ANTIHISTAMINES PAGE 97 QL 300 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER clemastine fumarate (syrup 0.67 mg/5ml (0.5 mg/5ml base eq), tab 2.68 mg) generic 1 cyproheptadine hcl generic 1 desloratadine generic 1 DEXCHLORPHENIRAMINE MALEATE BRAND 3 diphenhydramine hcl (cap 50 mg, elixir 12.5 mg/5ml, inj 50 mg/ml) generic 1 fexofenadine hcl generic 1 hydroxyzine hcl (im soln 50 mg/ml, syrup 10 mg/5ml, tab 10 mg, tab 25 mg, tab 50 mg) generic 1 hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg) generic 1 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) generic levocetirizine dihydrochloride tab 5 mg LIMITS & RESTRICTIONS QL 30 / 30 DAYS QL 60 / 30 DAYS 1 QL 300 / 30 DAYS generic 1 QL 30 / 30 DAYS olopatadine hcl (nasal) generic 1 promethazine hcl (inj 25 mg/ml, inj 50 mg/ml, suppos 12.5 mg, suppos 25 mg, syrup 6.25 mg/5ml, tab 12.5 mg, tab 25 mg, tab 50 mg) generic 1 montelukast sodium generic 1 QL 30 / 30 DAYS zafirlukast generic 1 QL 60 / 30 DAYS QL ZYFLO CR BRAND 120 / 30 DAYS 3 ANTILEUKOTRIENES PA BRONCHODILATORS, ANTICHOLINERGIC ATROVENT HFA BRAND 3 MPL ipratropium bromide inhal soln 0.02% generic 1 QL 450 / 30 DAYS ipratropium bromide nasal soln 0.03% (21 mcg/spray) generic 1 QL 30 / 30 DAYS ipratropium bromide nasal soln 0.06% (42 mcg/spray) generic 1 SPIRIVA HANDIHALER BRAND 2 QL 30 / 30 DAYS PAGE 98 2 / 30 DAYS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS BRONCHODILATORS, SYMPATHOMIMETIC ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML BRAND 2 QL 1 / fill albuterol sulfate (soln nebu 0.083% (2.5 mg/3ml), soln nebu 0.63 mg/3ml (base equiv), soln nebu 1.25 mg/3ml (base equiv)) generic 1 QL 450 / 30 DAYS albuterol sulfate (syrup 2 mg/5ml, tab 2 mg, tab 4 mg, tab sr 12hr 4 mg, tab sr 12hr 8 mg) generic 1 albuterol sulfate soln nebu 0.5% (5 mg/ml) generic 1 QL 60 / 30 DAYS QL ARCAPTA NEOHALER BRAND 30 / 30 DAYS 2 PA AUVI-Q SOLN A-INJ 0.3 MG/0.3ML BRAND 2 BROVANA BRAND 3 QL 1 / fill QL 120 / 30 DAYS PA epinephrine hcl generic 1 EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML BRAND 2 QL 1 / fill EPIPEN BRAND 2 QL 1 / fill EPIPEN 2-PAK BRAND 2 QL 1 / fill EPIPEN JR BRAND 2 QL 1 / fill EPIPEN JR 2-PAK BRAND 2 QL 1 / fill QL FORADIL AEROLIZER BRAND 60 / 30 DAYS 2 PA levalbuterol hcl (soln nebu 0.31 mg/3ml, soln nebu 0.63 mg/3ml, soln nebu 1.25 mg/3ml) generic 1 QL 360 / 30 DAYS levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) generic 1 QL 60 / 30 DAYS MAXAIR AUTOHALER BRAND 2 MPL 1 / 30 DAYS metaproterenol sulfate (syrup 10 mg/5ml, tab 10 mg, tab 20 mg) generic 1 PROAIR HFA BRAND 2 MPL 2 / 30 DAYS PROVENTIL HFA BRAND 2 MPL 2 / 30 DAYS PAGE 99 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN SEREVENT DISKUS BRAND TIER LIMITS & RESTRICTIONS QL 60 / 30 DAYS 2 PA terbutaline sulfate (inj 1 mg/ml, tab 2.5 mg, tab 5 mg) generic 1 TWINJECT SOLN A-INJ 0.3 MG/0.3ML BRAND 2 QL VENTOLIN HFA BRAND 2 MPL XOPENEX HFA BRAND 3 1 / fill 2 / 30 DAYS PA MPL 2 / 30 DAYS CYSTIC FIBROSIS AGENTS PA CAYSTON BRAND 4 S Specialty Drug PA KALYDECO TAB 150 MG BRAND 4 S tobramycin nebu soln 300 mg/5ml Specialty Drug PA generic 4 S Specialty Drug PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE aminophylline inj 25 mg/ml generic 1 ELIXOPHYLLIN BRAND 1 LUFYLLIN BRAND 3 theophylline (tab 12hr 200 mg, tab 12hr 450 mg, tab 12hr 300 mg, tab 12hr 100 mg, tab 24hr 600 mg, tab 24hr 400 mg) generic 1 BRAND 4 PULMONARY ANTIHYPERTENSIVES PA ADCIRCA S Specialty Drug PA LETAIRIS BRAND 4 S Specialty Drug PA REMODULIN BRAND 4 S sildenafil citrate (pulmonary hypertension) PA generic 4 S PAGE 100 Specialty Drug Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS PA TRACLEER TAB 125 MG BRAND 4 MDD S 2 per day Specialty Drug PA TRACLEER TAB 62.5 MG BRAND 4 MDD S 1 per day Specialty Drug PA VENTAVIS BRAND 4 S Specialty Drug RESPIRATORY TRACT AGENTS, OTHER acetylcysteine (soln 10%, soln 20%) generic 1 ADVAIR DISKUS BRAND 2 PA MPL 1 / 30 DAYS PA ADVAIR HFA BRAND 2 MPL 1 / 30 DAYS PA ARALAST BRAND 4 S ARALAST NP (RECON SOLN 400 MG, RECON SOLN 800 MG, RECON SOLN 1000 MG) BRAND benzonatate cap 100 mg generic Specialty Drug PA 4 S MDD 6 per day MDS 10 / days QL 10 / claim MDD 3 per day 1 benzonatate cap 150 mg generic 1 benzonatate cap 200 mg generic 1 cromolyn sodium soln nebu 20 mg/2ml generic 1 HYPERSAL NEBU SOLN 3.5 % BRAND 1 ipratropium-albuterol generic 1 NEBUSAL BRAND 1 PROLASTIN RECON SUSP 1000 MG BRAND 4 Specialty Drug QL 240 / 30 DAYS QL 540 / 30 DAYS PA S PAGE 101 Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN PROLASTIN-C BRAND TIER LIMITS & RESTRICTIONS PA 4 S Specialty Drug PA PULMOZYME BRAND 4 S sodium chloride soln nebu 7% generic 1 SYMBICORT BRAND 2 Specialty Drug PA MPL TYZINE BRAND 3 XOLAIR BRAND 4 1 / 30 DAYS PA S Specialty Drug PA ZEMAIRA BRAND 4 S Specialty Drug SKELETAL MUSCLE RELAXANTS baclofen (tab 10 mg, tab 20 mg) generic 1 BOTOX BRAND 3 carisoprodol (tab 250 mg, tab 350 mg) generic 1 chlorzoxazone tab 500 mg generic 1 cyclobenzaprine hcl (tab 5 mg, tab 7.5 mg, tab 10 mg) generic 1 QL 90 / 30 DAYS dantrolene sodium (cap 25 mg, cap 50 mg) generic 1 QL 120 / 30 DAYS DANTROLENE SODIUM CAP 100 MG BRAND 1 QL 120 / 30 DAYS DYSPORT BRAND 3 PA DYSPORT (GLABELLAR LINES) BRAND 3 PA metaxalone tab 800 mg generic 1 QL 120 / 30 DAYS methocarbamol (tab 500 mg, tab 750 mg) generic 1 orphenadrine citrate tab sr 12hr 100 mg generic 1 QL 60 / 30 DAYS tizanidine hcl generic 1 XEOMIN RECON SOLN 50 UNIT BRAND 3 PAGE 102 PA PA LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS SLEEP DISORDER AGENTS GABA RECEPTOR MODULATORS estazolam generic 1 QL eszopiclone generic 1 triazolam generic 1 zaleplon cap 10 mg generic 1 zaleplon cap 5 mg zolpidem tartrate (tab 5 mg, tab 10 mg) generic generic 30 / 30 DAYS ST AL At least 18 yrs old QL 60 / 30 DAYS AL At least 18 yrs old QL 30 / 30 DAYS AL At least 18 yrs old QL 30 / 30 DAYS AL At least 18 yrs old QL 30 / 30 DAYS 1 1 SLEEP DISORDERS, OTHER modafinil tab 100 mg modafinil tab 200 mg NUVIGIL ROZEREM generic generic BRAND BRAND 1 1 2 3 PA AL At least 16 yrs old QL 60 / 30 DAYS PA AL At least 16 yrs old QL 30 / 30 DAYS PA AL At least 17 yrs old QL 30 / 30 DAYS ST AL At least 18 yrs old PA XYREM BRAND 4 MDD S PAGE 103 18 per day Specialty Drug LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN TIER LIMITS & RESTRICTIONS THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ELECTROLYTE/MINERAL MODIFIERS CHEMET BRAND 3 EXJADE BRAND 4 PA S FERRIPROX BRAND 3 SAMSCA BRAND 4 Specialty Drug PA S sodium polystyrene sulfonate (*sodium powder**, sodium oral susp 15 gm/60ml) generic 1 SYPRINE BRAND 4 Specialty Drug PA S Specialty Drug S Specialty Drug QL 30 / 30 DAYS ELECTROLYTE/MINERAL REPLACEMENT *parenteral electrolyte conc*** generic 1 *peritoneal dialysis solutions 346 mosm/l** generic 1 AMMONIUM CHLORIDE BRAND 3 calcium chloride inj 10% generic 1 calcium gluconate inj 10% generic 1 CARBAGLU BRAND 4 DEXTROSE 5%/ELECTROLYTE #48 BRAND 1 dextrose in lactated ringers generic 1 dextrose in ringers generic 1 DIANEAL LOW CALCIUM/1.5% DEX BRAND 1 electrolyte-m in dextrose generic 1 ferrous fumarate-folic acid generic 1 IONOSOL-B IN D5W BRAND 1 IONOSOL-MB IN D5W BRAND 1 irrigation solutions, physiological generic 1 ISOLYTE-P IN D5W BRAND 1 PAGE 104 LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN ISOLYTE-S BRAND 1 KCL IN DEXTROSE-NACL SOLUTION 40-50.9 MEQ/L-%-% BRAND 1 KCL-LACTATED RINGERS-D5W BRAND 1 KLOR-CON M15 BRAND 1 lactated ringer's generic 1 MAGNESIUM SULFATE (SOLUTION 2 GM/50ML, SOLUTION 4 GM/50ML, SOLUTION 4 GM/100ML, SOLUTION 20 GM/500ML, SOLUTION 40 GM/1000ML) BRAND 1 magnesium sulfate inj 50% generic 1 NORMOSOL-R PH 7.4 BRAND 1 PLASMA-LYTE 148 BRAND 1 PLASMA-LYTE A BRAND 1 PLASMA-LYTE-56 IN D5W BRAND 1 potassium acetate generic 1 potassium bicarb & chloride generic 1 potassium bicarbonate effer tab 25 meq generic 1 potassium chloride (cap cr 8 meq, cap cr 10 meq, inj 2 meq/ml, inj 10 meq/100 ml, inj 20 meq/50 ml, inj 30 meq/100 ml, oral liq 10% (20 meq/15ml), oral soln 10% (20 meq/15ml), powder packet 20 meq, tab cr 8 meq (600 mg), tab cr 10 meq) generic 1 potassium chloride in dextrose & sodium chloride (10 meq/l (0.07) 0.4j, 20 meq/l (0.1) 0.2% j, 20 meq/l (0.1) 0.33% j, 20 meq/l (0.1) 0.4j, 20 meq/l (0.1) 0.9% j, 30 meq/l (0.224%) 0.4j, 40 meq/l (0.3%) 0.4j) generic 1 potassium chloride in dextrose (20 meq/l (0.1) j, 40 meq/l (0.3%) j) generic 1 potassium chloride in nacl (20 meq/l (0.15%) 0.45% j, 20 meq/l (0.15%) 0.9% j, 40 meq/l (0.3%) 0.9% j) generic 1 potassium chloride microencapsulated crystals cr generic 1 POTASSIUM CHLORIDE SOLUTION 10 MEQ/50ML BRAND 1 PAGE 105 TIER LIMITS & RESTRICTIONS LAST UPDATED 10/2015 PRODUCT DESCRIPTION BRAND/GEN potassium phosphates generic 1 ringer's generic 1 sodium acetate (inj 2 meq/ml, inj 4 meq/ml) generic 1 sodium chloride (inj 0.45%, inj 2.5 meq/ml (14.6%), inj 3%, inj 4 meq/ml (23.4%), inj 5%) generic 1 sodium phosphate generic 1 ULTRABAG/DIANEAL/1.5% DEXTROSE BRAND 1 AMINOSYN II IN DEXTROSE 25% SOLUTION 4.25 % BRAND 3 CLINIMIX E/DEXTROSE (5/20) BRAND 3 CLINIMIX/DEXTROSE (2.75/5) BRAND 3 CLINIMIX/DEXTROSE (4.25/10) BRAND 3 CLINIMIX/DEXTROSE (4.25/25) BRAND 3 CLINIMIX/DEXTROSE (4.25/5) BRAND 3 CLINIMIX/DEXTROSE (5/25) BRAND 3 ergocalciferol cap 50000 unit generic 0 folic acid tab 1 mg generic 0 lactated ringer's (irrigation) generic 1 ringer's irrigation generic 1 PAGE 106 TIER LIMITS & RESTRICTIONS FAL Female - 17 to 55 yrs old LAST UPDATED 10/2015 Index of covered drugs 1 AFINITOR 36 AFLURIA 86 1ST TIER UNIFINE PENTIPS 88 AFLURIA PRESERVATIVE FREE 86 1ST TIER UNIFINE PENTIPS PLUS 89 AGRIFLU 86 AIMSCO LUBRICATED A 4 ALAMAST 94 A-HYDROCORT 74 ALBENZA 39 abacavir sulfate 46 albuterol sulfate 99 abacavir sulfate-lamivudine-zidovudine 46 alclometasone dipropionate 74 ABELCET 27 ALDURAZYME 69 ABRAXANE 33 alendronate sodium 87 acamprosate calcium 12 alfuzosin hcl 73 acarbose 50 ALIMTA 33 acebutolol hcl 57 ALINIA 39 acetaminophen w/ codeine 10 ALKERAN 31 acetazolamide 59 ALLEGRA ALLERGY CHILDRENS ACETAZOLAMIDE 59 allopurinol 28 acetazolamide sodium 59 almotriptan malate 29 acetic acid 14 ALOCRIL 94 acetic acid (otic) 96 ALOMIDE 94 alosetron hcl 71 acetylcysteine 101 6 acitretin 66 ALOXI 26 ACTEMRA 85 alprazolam 49 ACTIMMUNE 85 ALREX 95 ACURA CONTROL 89 ALTABAX 14 acyclovir 49 ALTOPREV 61 acyclovir topical 49 ALVESCO 96 ADACEL 86 amantadine hcl 40 ADAGEN 69 AMBISOME 27 adapalene 66 amcinonide 74 ADAPALENE 67 AMEVIVE 67 ADCETRIS 38 amikacin sulfate 13 ADCIRCA 100 amiloride & hydrochlorothiazide 59 adefovir dipivoxil 44 amiloride hcl 60 ADRENACLICK 99 aminophylline 100 106 ADVAIR DISKUS 101 AMINOSYN II IN DEXTROSE 25% ADVAIR HFA 101 amiodarone hcl 57 ADVICOR 61 amiodarone hcl (bulk) 89 ADVOCATE CONTROL SOLUTION 89 AMITIZA 71 ADVOCATE INSULIN PEN NEEDLES 89 amitriptyline hcl 25 ADVOCATE REDI-CODE+ CONTROL 89 amlodipine besylate 58 PAGE 107 LAST UPDATED 10/2015 amlodipine besylate-benazepril hcl AMMONIUM CHLORIDE 59 ASMANEX 60 METERED DOSES 97 104 ASMANEX 7 METERED DOSES 97 amoxapine 25 aspirin amoxicillin 17 aspirin-dipyridamole 55 amoxicillin & pot clavulanate 17 atenolol 57 atenolol & chlorthalidone 59 amphetamine-dextroamphetamine 62,63 3 AMPHOTEC 27 ATGAM 85 amphotericin b 27 atorvastatin calcium 61 ampicillin 17 atovaquone-proguanil hcl 39 AMPICILLIN 17 ATRIPLA 46 ampicillin & sulbactam sodium 17 atropine sulfate 70 ampicillin sodium 17 ATROPINE SULFATE 70 AMPYRA 65 ATROVENT HFA 98 ANADROL-50 78 AURORA UNIFINE PENTIPS 89 anagrelide hcl 54 AUVI-Q 99 anastrozole 36 AVANDIA 50 ANDRODERM 78 AVASTIN 38 ANDROXY 78 AVELOX 18 antipyrine-benzocaine 96 AVONEX 65 ANZEMET 26 AVONEX PEN 65 APHTHASOL 66 AVONEX PREFILLED 65 APIDRA 52 azacitidine 33 APIDRA SOLOSTAR 52 AZACTAM IN DEXTROSE 16 APOKYN 40 AZASAN 83 apraclonidine hcl 95 AZASITE 17 APRISO 86 azathioprine 83 APTIVUS 48 azathioprine sodium 83 ARALAST 101 azelastine hcl 97 ARALAST NP 101 azelastine hcl (ophth) 94 ARANESP (ALBUMIN FREE) 54 AZELEX 67 ARCALYST 85 AZILECT 41 ARCAPTA NEOHALER 99 azithromycin ARESTIN 66 AZOPT 95 aripiprazole 42 aztreonam 16 ARRANON 33 ARZERRA 38 B ASACOL 87 bacitracin 14 ASACOL HD 87 bacitracin (ophthalmic) 14 ASMANEX 120 METERED DOSES 97 baclofen ASMANEX 14 METERED DOSES 97 balsalazide disodium 87 ASMANEX 30 METERED DOSES 97 BANZEL 21 PAGE 108 17,18 102 LAST UPDATED 10/2015 BARACLUDE 44 brimonidine tartrate 95 BAYER BREEZE 2 CONTROL 89 BRINTELLIX 23 BAYER CONTOUR 89 bromfenac sodium (ophth) 95 BAYER CONTOUR NEXT CONTROL 89 bromocriptine mesylate 40 BD AUTOSHIELD 89 BROVANA 99 BD INSULIN SYRINGE 89 budesonide 87 BD PEN NEEDLE MINI U/F 89 budesonide (inhalation) 97 BD PEN NEEDLE NANO U/F 89 budesonide (nasal) 97 BD PEN NEEDLE ULTRAFINE 89 bumetanide 60 benazepril & hydrochlorothiazide 59 BUPHENYL 69 benazepril hcl 56 buprenorphine hcl 13 BENICAR 56 buprenorphine hcl-naloxone hcl dihydrate 13 benzonatate 101 bupropion hcl 23 benzoyl peroxide 3,67 bupropion hcl (smoking deterrent) 13 benzoyl peroxide-erythromycin 67 buspirone hcl 49 benztropine mesylate 40 BUSULFEX 31 BEPREVE 94 butalbital-acetaminophen-caffeine 64 BESIVANCE 18 butalbital-acetaminophen-caffeine w/ codeine 10 betamethasone dipropionate (topical) 74 butalbital-aspirin-caffeine 64 betamethasone dipropionate augmented 74 butalbital-aspirin-caffeine w/cod 10 betamethasone valerate 74 butorphanol tartrate 10 BETASERON 65 BUTRANS betaxolol hcl 57 BYETTA 10 MCG PEN 50 betaxolol hcl (ophth) 95 BYETTA 5 MCG PEN 50 bethanechol chloride 73 BYSTOLIC 57 bexarotene 39 BEXXAR 38 C BEYAZ 78 cabergoline 82 bicalutamide 32 CAFERGOT 29 BICNU 31 calcipotriene 67 BIDIL 59 calcipotriene-betamethasone dipropionate 67 BILTRICIDE 39 calcitonin (salmon) 87 bimatoprost 96 calcitriol 87 calcitriol (topical) 67 74 bisacodyl 4 9 bisoprolol fumarate 57 calcium acetate (phosphate binder) bleomycin sulfate 33 calcium chloride (dihydrate) 104 blood glucose calibration 89 calcium gluconate 104 BOOSTRIX 86 calcium polycarbophil BOSULIF 36 CAMPATH 34 CANASA 87 CANCIDAS 27 BOTOX BRILINTA PAGE 109 102 55 4 LAST UPDATED 10/2015 candesartan cilexetil 56 cefuroxime axetil 16 CANTIL 70 cefuroxime sodium 16 CAPASTAT SULFATE 30 celecoxib capecitabine 33 CELLCEPT INTRAVENOUS 83 CAPRELSA 37 CELONTIN 20 captopril 56 CENESTIN 78 CARAFATE 72 cephalexin 16 CARBAGLU 104 CEREZYME 69 26 8 carbamazepine 21 CESAMET carbidopa 41 cetirizine hcl carbidopa-levodopa 41 cetirizine-pseudoephedrine carbidopa-levodopa-entacapone 40 cevimeline hcl 66 carbinoxamine maleate 97 CHANTIX 13 carboplatin 34 CHANTIX CONTINUING MONTH PAK 13 CAREFINE PEN NEEDLES 89 CHANTIX STARTING MONTH PAK 13 CAREONE UNIFINE PENTIPS 89 CHEK-STIX CONTROL 89 CAREONE UNIFINE PENTIPS PLUS 89 CHEMET CARIMUNE NF 85 CHEMSTRIP K 89 chloramphenicol sodium succinate 14 carisoprodol 102 6,97 6 104 carteolol hcl (ophth) 95 chlordiazepoxide hcl-clidinium bromide 70 carvedilol 57 chlorhexidine gluconate (mouth-throat) 66 CAYA 89 chloroquine phosphate 39 chlorothiazide 60 CAYSTON 100 CEDAX 15 chlorpromazine hcl 41 cefaclor 15 chlorpropamide 50 CEFACLOR 15 chlorthalidone 60 cefaclor monohydrate 16 chlorzoxazone 102 cefadroxil 16 CHOLBAM cefazolin sodium 16 cholecalciferol 7 cefdinir 16 cholestyramine 61 cefditoren pivoxil 16 cholestyramine light 61 cefepime hcl 16 choline & mag salicylate cefixime 16 chorionic gonadotropin 76 cefotaxime sodium 16 CIALIS 73 cefotetan disodium 16 ciclopirox 27 cefoxitin sodium 16 ciclopirox & vitamin e 27 cefpodoxime proxetil 16 ciclopirox olamine 27 cefprozil 16 cidofovir 43 ceftazidime 16 cilostazol 55 CEFTIBUTEN 16 cimetidine ceftriaxone sodium 16 cimetidine hcl PAGE 110 71 8 4,71 71 LAST UPDATED 10/2015 CIMZIA 83 clomipramine hcl 25 CIMZIA PREFILLED 83 clonazepam 49 CIMZIA STARTER KIT 83 clonidine hcl 55 CIPRO HC 96 clopidogrel bisulfate 55 CIPRODEX 96 clotrimazole 27 ciprofloxacin 18 clotrimazole (topical) ciprofloxacin hcl 18 clotrimazole w/ betamethasone 67 ciprofloxacin hcl (ophth) 18 clozapine 43 ciprofloxacin hcl (otic) 18 COARTEM 39 ciprofloxacin in d5w 18 codeine sulfate 11 ciprofloxacin-ciprofloxacin hcl 18 colchicine 28 cisplatin 34 colchicine w/ probenecid 28 colestipol hcl 61 citalopram hydrobromide 23,24 3,27 cladribine 33 COLY-MYCIN S 96 clarithromycin 18 COMBIGAN 95 CLARITIN 6 COMETRIQ (100 MG DAILY DOSE) 37 CLARITIN REDITABS 6 COMETRIQ (140 MG DAILY DOSE) 37 clemastine fumarate 98 COMETRIQ (60 MG DAILY DOSE) 37 CLEVER CHOICE GLUCOSE CONTROL 89 COMFORT EZ PEN NEEDLES 90 CLICKFINE PEN NEEDLES 89 COMPLERA 46 CLIMARA PRO 78 COPAXONE 65 clindamycin hcl 14 CORDRAN 75 clindamycin palmitate hydrochloride 14 cortisone acetate 75 clindamycin phosphate 14 CORTISPORIN 67 clindamycin phosphate (bulk) 90 CORTISPORIN-TC 96 COUMADIN 53 clindamycin phosphate (topical) 14,67 clindamycin phosphate vaginal 14 CREON 69 clindamycin phosphate-benzoyl peroxide 67 CRESTOR 61 CRIXIVAN 48 clindamycin phosphate-benzoyl peroxide (refrigerate) 67 cromolyn sodium 101 CLINIMIX E/DEXTROSE (5/20) 106 cromolyn sodium (ophth) 94 CLINIMIX/DEXTROSE (2.75/5) 106 CUBICIN 14 CLINIMIX/DEXTROSE (4.25/10) 106 CUPRIMINE 73 CLINIMIX/DEXTROSE (4.25/25) 106 cyclobenzaprine hcl 102 CLINIMIX/DEXTROSE (4.25/5) 106 cyclophosphamide 31 CLINIMIX/DEXTROSE (5/25) 106 CYCLOSERINE 30 clobetasol propionate 74 CYCLOSET 50 clobetasol propionate emollient base 74 cyclosporine 83 CLODERM 75 cyclosporine modified (for microemulsion) 83 CLODERM PUMP 75 cyproheptadine hcl 98 CLOLAR 33 CYSTADANE 69 PAGE 111 LAST UPDATED 10/2015 CYSTAGON 69 DIATRUE CONTROL LEVEL 1 90 cytarabine 33 diazepam 50 diazepam (anticonvulsant) 20 D diclofenac potassium 8 8 dacarbazine 31 diclofenac sodium dactinomycin 34 diclofenac sodium (actinic keratoses) 67 danazol 78 diclofenac sodium (ophth) 95 dantrolene sodium 102 diclofenac w/ misoprostol 8 DANTROLENE SODIUM 102 dicloxacillin sodium 17 70 dapsone 30 dicyclomine hcl DARAPRIM 39 didanosine 46,47 daunorubicin hcl 34 DIFFERIN 67 DAUNOXOME 31 DIFICID 18 decitabine 34 diflorasone diacetate 75 demeclocycline hcl 19 diflunisal DENAVIR 49 digoxin 59 DEPO-ESTRADIOL 78 dihydroergotamine mesylate 29 DEPO-MEDROL 75 DILANTIN 21 DEPO-SUBQ PROVERA 104 81 diltiazem hcl 58 DEPOCYT 33 DILTIAZEM HCL 58 desipramine hcl 25 diltiazem hcl coated beads 58 desloratadine 98 diltiazem hcl extended release beads 58 desmopressin acetate 76 DIPENTUM 87 desmopressin acetate spray refrigerated 76 diphenhydramine hcl desogestrel & ethinyl estradiol 78 diphenoxylate w/ atropine 71 desogestrel-ethinyl estradiol (biphasic) 78 dipyridamole 55 desogestrel-ethinyl estradiol (triphasic) 78 disopyramide phosphate 57 desonide 75 disulfiram 12 desoximetasone 75 divalproex sodium 20 dexamethasone 75 DIVIGEL 79 DEXAMETHASONE INTENSOL 75 DOCEFREZ 34 dexamethasone sodium phosphate 75 docetaxel 34 dexamethasone sodium phosphate (ophth) 95 docusate calcium 4 DEXCHLORPHENIRAMINE MALEATE 98 docusate sodium 4 DEXILANT 72 donepezil hydrochloride 22 dexmethylphenidate hcl 63 dorzolamide hcl 95 dextroamphetamine sulfate 63 dorzolamide hcl-timolol maleate 96 8 6,98 DEXTROSE 5%/ELECTROLYTE #48 104 doxazosin mesylate 56 dextrose in lactated ringers 104 doxepin hcl 25 dextrose in ringers 104 doxercalciferol 87 DIANEAL LOW CALCIUM/1.5% DEX 104 doxorubicin hcl 34 PAGE 112 LAST UPDATED 10/2015 doxorubicin hcl liposomal 34 ELEXA ULTRA SENSITIVE doxycycline (monohydrate) 19 ELIDEL 67 doxycycline hyclate 19 ELIGARD 82 dronabinol 26 ELIXOPHYLLIN drospirenone-ethinyl estradiol 79 ELLA 80 DROXIA 33 ELMIRON 74 DRUG MART UNIFINE PENTIPS 90 ELSPAR 34 DRUG MART UNIFINE PENTIPS PLUS 90 EMADINE 94 duloxetine hcl 65 EMBEDA 9 DUREZOL 95 EMBRACE CONTROL 90 dutasteride 73 EMBRACE EVO CONTROL LEVEL 1 90 DYRENIUM 60 EMCYT 32 DYSPORT 102 EMEND 26 DYSPORT (GLABELLAR LINES) 102 EMSAM 23 EMTRIVA 47 ENABLEX 73 E 4 100 E.E.S. 400 18 enalapril maleate 56 E.E.S. GRANULES 18 enalapril maleate & hydrochlorothiazide 59 EASY COMFORT PEN NEEDLES 90 ENBREL 83 EASY PLUS CONTROL 90 ENBREL SURECLICK 83 EASY PLUS II CONTROL 90 ENJUVIA 79 EASY STEP CONTROL 90 enoxaparin sodium 53 EASY TALK CONTROL 90 entacapone 40 EASY TOUCH PEN NEEDLES 90 entecavir 44 EASY TRAK CONTROL 90 ENTEREG 71 EASYGLUCO CONTROL 90 ENVISION CONTROL 90 EASYMAX CONTROL 90 EPIDUO 67 ECLIPSE CONTROL 90 epinastine hcl (ophth) 94 econazole nitrate 27 EPINEPHRINE 99 EDARBI 56 epinephrine hcl 99 EDECRIN 60 EPIPEN 99 EDURANT 46 EPIPEN 2-PAK 99 EFFIENT 55 EPIPEN JR 99 ELAPRASE 69 EPIPEN JR 2-PAK 99 104 epirubicin hcl 34 ELELYSO 69 EPIVIR HBV 44 ELEMENT CONTROL 90 eplerenone 60 ELEMENT PLUS CONTROL 90 EPOGEN 54 ELESTRIN 79 eprosartan mesylate 56 47 electrolyte-m in dextrose ELEXA NATURAL FEEL 4 EPZICOM ELEXA STIMULATING 4 EQUETRO PAGE 113 21,22 LAST UPDATED 10/2015 ERAXIS 27 ERBITUX 38 ergocalciferol 7,106 F FABRAZYME 70 ergoloid mesylates 22 FACTIVE 19 ERGOMAR 29 famciclovir 49 ERIVEDGE 37 famotidine 4,71 ERTACZO 27 FAMOTIDINE PREMIXED 71 ERWINAZE 34 FANAPT 42 ERY-TAB 18 FANAPT TITRATION PACK 42 ERYPED 200 18 FANTASY LUBRICATED 5 ERYPED 400 18 FANTASY LUBRICATED/SPERMICIDE 5 erythromycin (acne aid) 18 FARESTON 32 erythromycin (ophth) 18 FASLODEX 32 ERYTHROMYCIN BASE 18 FC FEMALE CONDOM 5 erythromycin base 18 FC2 FEMALE CONDOM 5 ERYTHROMYCIN ETHYLSUCCINATE 18 felbamate 21 escitalopram oxalate 24 felodipine 58 esomeprazole magnesium 72 FEMCAP 90 estazolam 103 FEMRING 79 ESTRACE 79 fenofibrate 60 estradiol 79 fenofibrate micronized 60 estradiol valerate 79 fenoprofen calcium 8 ESTRASORB 79 fentanyl 9 ESTROGEL 79 fentanyl citrate estropipate 79 FERRIPROX 104 eszopiclone 103 ferrous fumarate-folic acid 104 11 ethambutol hcl 30 ferrous sulfate ethosuximide 20 fexofenadine hcl ethynodiol diacet & eth estrad 79 fexofenadine-pseudoephedrine etidronate disodium 87 FIFTY50 PEN NEEDLES 90 8 FINACEA 68 ETOPOPHOS 36 finasteride 73 etoposide 36 finasteride (alopecia) 68 EURAX 40 FIRMAGON 82 EVAMIST 79 flavoxate hcl 73 EXELDERM 27 flecainide acetate 57 exemestane 36 FLECTOR etodolac EXJADE 104 EXTAVIA 65 PAGE 114 7 6,98 6 8 FLOVENT DISKUS 97 FLOVENT HFA 97 floxuridine 33 FLUARIX 86 LAST UPDATED 10/2015 FLUARIX QUADRIVALENT 86 FORADIL AEROLIZER 99 FLUCELVAX 86 FORTEO 87 fluconazole 27 FORTISCARE CONTROL 90 flucytosine 27 FOSAMAX PLUS D 87 fludarabine phosphate 34 FOSCAVIR 43 fludrocortisone acetate 75 fosinopril sodium 56 FLULAVAL 86 fosinopril sodium & hydrochlorothiazide 59 FLULAVAL QUADRIVALENT 86 fosphenytoin sodium 22 flunisolide (nasal) 97 FOSRENOL 74 fluocinolone acetonide 75 FRAGMIN 54 fluocinolone acetonide (otic) 96 FREDS PHARMACY UNIFINE PENTIP+ 90 fluocinonide 75 FREDS PHARMACY UNIFINE PENTIPS 91 fluocinonide emulsified base 75 FROVA 29 fluorometholone (ophth) 95 furosemide 60 fluorouracil 33 FUZEON 47 fluorouracil (topical) 68 fluoxetine hcl 24 G fluoxetine hcl (pmdd) 24 gabapentin 20 fluphenazine hcl 41 galantamine hydrobromide 22 GAMMAGARD 85 flurbiprofen 8 flurbiprofen sodium 95 GAMMAGARD S/D 85 flutamide 32 GAMMAGARD S/D LESS IGA 85 fluticasone propionate 75 GAMMAKED 85 fluticasone propionate (bulk) 90 GAMUNEX-C 85 6,97 ganciclovir sodium 43 fluvastatin sodium 61 gatifloxacin (ophth) 19 FLUVIRIN 86 gemcitabine hcl 33 FLUVIRIN PRESERVATIVE FREE 86 gemfibrozil 60 fluvoxamine maleate 24 GENOTROPIN 77 FLUZONE 86 GENOTROPIN MINIQUICK 77 FLUZONE HIGH-DOSE 86 gentamicin in saline 13 FLUZONE PEDIATRIC PF 86 GENTAMICIN IN SALINE 13 FLUZONE PRESERVATIVE FREE 86 gentamicin sulfate 14 FLUZONE QUADRIVALENT 86 gentamicin sulfate (ophth) 14 FML 95 GILENYA 66 FML FORTE 95 glatiramer acetate 66 7,106 GLEEVEC 37 FOLOTYN 33 glimepiride 50 fondaparinux sodium 53 glipizide 50 FORA CONTROL 90 glipizide-metformin hcl 50 FORACARE GDH CONTROL 90 GLOBAL EASE INJECT PEN NEEDLES 91 fluticasone propionate (nasal) folic acid PAGE 115 LAST UPDATED 10/2015 GLUCAGEN DIAGNOSTIC 52 HUMALOG MIX 50/50 PEN 52 GLUCAGEN HYPOKIT 52 HUMALOG MIX 75/25 52 GLUCOLAB CONTROL 91 HUMALOG MIX 75/25 KWIKPEN 52 glyburide 50 HUMALOG MIX 75/25 PEN 52 glyburide micronized 51 HUMALOG PEN 52 glyburide-metformin 51 HUMATROPE 77 glycine (gu irrigant) 74 HUMIRA 83 glycopyrrolate 71 HUMIRA PEDIATRIC CROHNS START 84 GLYSET 51 HUMIRA PEN 84 granisetron hcl 26 HUMIRA PEN-CROHNS STARTER 84 griseofulvin microsize 27 HUMIRA PEN-PSORIASIS STARTER 84 griseofulvin ultramicrosize 27 HUMULIN 70/30 52 guanabenz acetate 55 HUMULIN 70/30 KWIKPEN 52 guanfacine hcl 56 HUMULIN 70/30 PEN 52 guanfacine hcl (adhd) 63 HUMULIN N 52 GUANIDINE HCL 30 HUMULIN N KWIKPEN 52 GYNAZOLE-1 27 HUMULIN N PEN 52 HUMULIN R 52 HUMULIN R U-500 (CONCENTRATED) 52 H H-E-B INCONTROL PEN NEEDLES 91 HYCAMTIN 36 HALAVEN 34 hydralazine hcl 62 halobetasol propionate 75 hydrochlorothiazide 60 HALOG 75 hydrocodone-acetaminophen 11 haloperidol 41 hydrocodone-ibuprofen 11 haloperidol decanoate 41 hydrocortisone 75 haloperidol lactate 41 hydrocortisone (intrarectal) 87 HARVONI 44 hydrocortisone (rectal) 87 HEALTHWISE UNIFINE PENTIPS 91 hydrocortisone (topical) HEALTHY ACCENTS UNIFINE PENTIP 91 hydrocortisone acetate (rectal) 75 HEPARIN (PORCINE) IN NACL 54 hydrocortisone butyrate 75 heparin sod (porcine) in d5w 54 hydrocortisone valerate 75 heparin sodium (porcine) 54 hydrocortisone w/acetic acid 96 HERCEPTIN 38 hydromorphone hcl HEXALEN 31 HYDROMORPHONE HCL ER HIZENTRA 85 hydroxychloroquine sulfate 39 HIZENTRA 20% 85 hydroxyurea 33 HORIZANT 65 hydroxyzine hcl 98 HUMALOG 52 hydroxyzine pamoate 98 HUMALOG KWIKPEN 52 HYPERSAL HUMALOG MIX 50/50 52 HUMALOG MIX 50/50 KWIKPEN 52 PAGE 116 3,68 9,11 9 101 LAST UPDATED 10/2015 ISOLYTE-S I ibandronate sodium 87,88 105 isoniazid 30 ISONIAZID 31 ibuprofen 3,8 isosorbide dinitrate 62 idarubicin hcl 34 isosorbide mononitrate 62 ifosfamide 31 isotretinoin 68 ifosfamide & mesna 31 isradipine 58 ILEVRO 95 ISTODAX 34 imipenem-cilastatin 16 itraconazole 28 imipramine hcl 25 ivermectin 39 imipramine pamoate 25 IXEMPRA KIT 34 imiquimod 68 IMPLANON 81 J INCIVEK 44 JAKAFI 37 INCRELEX 77 JANUVIA 51 indapamide 60 JEVTANA 34 indomethacin 8 INFERGEN 44 K INFINITY CONTROL 91 KALETRA INLYTA 37 KALYDECO insulin pen needle 91 KAMELEON LUBRICATED INSUPEN PEN NEEDLES 91 kanamycin sulfate INSUPEN SENSITIVE 91 KCL IN DEXTROSE-NACL 105 INSUPEN ULTRAFIN 91 KCL-LACTATED RINGERS-D5W 105 INTELENCE 46 KENALOG 75 INTRON A 44 KEPIVANCE 66 INVANZ 16 KETEK 18 INVEGA 42 KETOCARE 91 INVIRASE 48 ketoconazole 28 INVOKANA 51 ketoconazole (topical) 28 48 100 5 14 IONOSOL-B IN D5W 104 ketoprofen 8 IONOSOL-MB IN D5W 104 ketorolac tromethamine 8 IOPIDINE 96 ketorolac tromethamine (ophth) 95 ipratropium bromide 98 KETOSTIX 91 ipratropium bromide (nasal) 98 ketotifen fumarate (ophth) 6 KIMONO 5 ipratropium-albuterol 101 irbesartan 56 KIMONO MICRO THIN PLUS 5 irinotecan hcl 34 KIMONO PLUS 5 KIMONO PS 5 KIMONO PS PLUS 5 KIMONO SENSATION 5 irrigation solutions, physiological ISENTRESS ISOLYTE-P IN D5W PAGE 117 104 46 104 LAST UPDATED 10/2015 KIMONO SENSATION PLUS KINERET KLOR-CON M15 5 84 105 LEVEMIR FLEXPEN 53 LEVEMIR FLEXTOUCH 53 levetiracetam 19,20 KMART VALU INSULIN SYRINGE 29G 91 levobunolol hcl 96 KMART VALU INSULIN SYRINGE 30G 91 levocetirizine dihydrochloride 98 KUVAN 70 levofloxacin 19 KYPROLIS 37 levofloxacin (ophth) 19 levofloxacin in d5w 19 levonorgestrel & eth estradiol 79 L labetalol hcl 57 levonorgestrel (emergency oc) 4,79 LACRISERT 94 levonorgestrel-eth estradiol (triphasic) 79 lactated ringer's 105 levonorgestrel-ethinyl estradiol (91-day) 79 lactated ringer's (irrigation) 106 levonorgestrel-ethinyl estradiol (continuous) 79 lactic acid (ammonium lactate) 3,68 levorphanol tartrate 9 lactulose 72 levothyroxine sodium 81 lactulose (encephalopathy) 72 LEXIVA 48 lamivudine 47 LIALDA 87 lamivudine (hbv) 44 lidocaine 68 lamivudine-zidovudine 47 lidocaine hcl lamotrigine 21 lidocaine hcl (local anesth.) 12 lancet devices 91 lidocaine hcl (mouth-throat) 12 lancets 88 lidocaine-prilocaine 68 LANOXIN 59 LILETTA 81 LINCOCIN 14 40 lansoprazole 4,72 3,68 LANTUS 52 lindane LANTUS SOLOSTAR 52 linezolid LASTACAFT 94 liothyronine sodium 81 latanoprost 96 lisinopril 56 LATUDA 42 lisinopril & hydrochlorothiazide 59 LEADER UNIFINE PENTIPS 91 LITE TOUCH PEN NEEDLES 91 LEADER UNIFINE PENTIPS PLUS 91 LITETOUCH PEN NEEDLES 91 leflunomide 85 lithium 50 lithium carbonate 50 LETAIRIS 100 14,15 letrozole 36 LIVALO 61 leucovorin calcium 35 LO LOESTRIN FE 79 LEUKERAN 31 lomustine 31 LEUKINE 54 loperamide hcl leuprolide acetate 82 loratadine 6 levalbuterol hcl 99 loratadine & pseudoephedrine 7 LEVATOL 57 lorazepam 50 LEVEMIR 52 losartan potassium 56 PAGE 118 4,71 LAST UPDATED 10/2015 losartan potassium & hydrochlorothiazide 59 MENOSTAR 79 LOTEMAX 95 MENTAX 28 3 MENVEO 86 LOTRIMIN ULTRA lovastatin 61 meperidine hcl 11 loxapine succinate 41 meprobamate 49 MEPRON 39 LUFYLLIN 100 LUMIGAN 96 mercaptopurine 33 LUMIZYME 70 meropenem 16 LUPRON DEPOT 82 mesalamine 87 LUPRON DEPOT-PED 82 MESTINON 30 LYRICA 65 metaproterenol sulfate LYSODREN 35 metaxalone M mafenide acetate 15 91,99 102 metformin hcl 51 methadone hcl 9 METHADONE HCL 9 MAGNESIUM SULFATE 105 methamphetamine hcl 63 magnesium sulfate 105 methazolamide 96 malathion 40 methenamine hippurate 15 maprotiline hcl 24 methimazole 83 MARPLAN 23 METHITEST 78 MATULANE 31 methocarbamol MAXAIR AUTOHALER 99 methotrexate sodium 84 MAXIDEX 95 methoxsalen rapid 68 102 MAXX 5 methscopolamine bromide 71 MAXX PLUS 5 methyclothiazide 60 mebendazole 39 methyldopa 56 meclizine hcl 3,26 methyldopate hcl 56 8 methylphenidate hcl 64 MEDROL 75 methylprednisolone 75 medroxyprogesterone acetate 81 methylprednisolone acetate 75 medroxyprogesterone acetate (contraceptive) 81 methylprednisolone sod succ 76 metipranolol 96 meclofenamate sodium mefenamic acid 8 mefloquine hcl 39 metoclopramide hcl 26 megestrol acetate 81 metolazone 60 megestrol acetate (appetite) 81 metoprolol succinate 57 metoprolol tartrate 57 meloxicam 8 melphalan hcl 31 metronidazole 15 memantine hcl 23 metronidazole (topical) 15 MENACTRA 86 metronidazole vaginal 15 MENEST 79 mexiletine hcl 57 MENOMUNE 86 midodrine hcl 56 PAGE 119 LAST UPDATED 10/2015 MILLIPRED 76 nalbuphine hcl 12 MILLIPRED DP 76 naloxone hcl 13 MILLIPRED DP 12-DAY 76 naltrexone hcl 12 MINASTRIN 24 FE 80 naproxen 9 minocycline hcl 19 naproxen sodium 9 minoxidil 62 naratriptan hcl 29 MIRENA 81 NASONEX 97 mirtazapine 23 NATACYN 28 misoprostol 72 NATAZIA 80 mitomycin 35 nateglinide 51 mitoxantrone hcl 35 NATROBA 40 NEBUPENT 40 modafinil 103 moexipril hcl 56 NEBUSAL mometasone furoate 76 NECON 10/11 (28) 80 MONOJECT INSULIN SYRINGE 91 nefazodone hcl 24 montelukast sodium 98 neomycin sulfate 14 MONUROL 15 neomycin-bacitracin zn-polymyxin 94 neomycin-polymy-dexameth 94 morphine sulfate 10,11,12 101 MOTOFEN 71 neomycin-polymyxin-hc (ophth) 94 MOVIPREP 72 neomycin-polymyxin-hc (otic) 96 moxifloxacin hcl 19 NEULASTA 54 MOZOBIL 54 NEULASTA DELIVERY KIT 55 MULTAQ 57 NEUPOGEN 55 mupirocin 15 NEUPRO 41 mupirocin calcium (topical) 15 NEVANAC 95 MUSTARGEN 31 nevirapine 46 MYCAMINE 28 NEXAVAR 37 mycophenolate mofetil 84 NEXIUM 24HR 4 mycophenolate sodium 84 NEXPLANON 81 MYLERAN 31 niacin 61 MYOZYME 70 niacin (antihyperlipidemic) 61 MYRBETRIQ 73 nicardipine hcl 58 MYTELASE 30 nicotine 3 NICOTINE 3 nicotine polacrilex 3 N nabumetone 9 NICOTROL 13 nadolol 58 NICOTROL NS 13 nafcillin sodium 17 nifedipine 58 naftifine hcl 28 NILANDRON 32 NAFTIN 28 nimodipine 58 NAGLAZYME 70 nisoldipine 58 PAGE 120 LAST UPDATED 10/2015 NITRO-BID 62 NOXAFIL 28 nitrofurantoin 15 NPLATE 55 nitrofurantoin macrocrystal 15 NUCYNTA 12 nitrofurantoin monohyd macro 15 NUCYNTA ER 10 nitroglycerin 62 NUEDEXTA 65 NITROSTAT 62 NULOJIX 84 nizatidine 71 NUTROPIN 77 NORDITROPIN 77 NUTROPIN AQ 77 NORDITROPIN FLEXPRO 77 NUTROPIN AQ NUSPIN 10 77 NORDITROPIN NORDIFLEX PEN 77 NUTROPIN AQ PEN 77 norethin acet & estrad-fe 80 NUVARING 80 norethindrone & eth estradiol 80 NUVIGIL 103 norethindrone & ethinyl estradiol-fe 80 nystatin 28 norethindrone (contraceptive) 81 nystatin (mouth-throat) 28 norethindrone acet & eth estra 80 nystatin (topical) norethindrone acetate 81 nystatin-triamcinolone norethindrone acetate-ethinyl estradiol-fe 80 norethindrone-eth estradiol (triphasic) 80 O norgestimate-ethinyl estradiol 80 octreotide acetate 82 norgestimate-ethinyl estradiol (triphasic) 80 ofloxacin 19 norgestrel & ethinyl estradiol 80 ofloxacin (ophth) 19 ofloxacin (otic) 19 NORMOSOL-R PH 7.4 105 28,92 28 NOROXIN 19 OFORTA 35 nortriptyline hcl 25 OGESTREL 80 NORVIR 48 olanzapine 42 5 OLEPTRO 24 NOVA MAX PLUS KETONE TEST NOVOFINE 91 olopatadine hcl (nasal) 98 NOVOFINE AUTOCOVER 91 omega-3-acid ethyl esters 62 NOVOFINE PLUS 92 omeprazole NOVOLIN 70/30 53 omeprazole magnesium NOVOLIN 70/30 RELION 53 omeprazole-sodium bicarbonate NOVOLIN N 53 OMNIFLEX DIAPHRAGM 92 NOVOLIN N RELION 53 OMNITROPE 77 NOVOLIN R 53 OMONTYS 55 NOVOLIN R RELION 53 ONCASPAR 35 NOVOLOG 53 ondansetron 27 NOVOLOG FLEXPEN 53 ondansetron hcl 27 NOVOLOG MIX 70/30 53 ONFI 20 NOVOLOG MIX 70/30 FLEXPEN 53 ONGLYZA 51 NOVOLOG PENFILL 53 ONTAK 35 NOVOTWIST 92 ORAP 41 PAGE 121 4,72 4 4,72 LAST UPDATED 10/2015 ORENCIA 84 PEG-INTRON 44 ORFADIN 70 PEG-INTRON REDIPEN 45 PEG-INTRON REDIPEN PAK 4 45 orphenadrine citrate 102 ORTHO DIAPHRAGM ALL-FLEX 92 PEGANONE 22 ORTHO DIAPHRAGM COIL 92 PEGASYS 45 ORTHO DIAPHRAGM FLAT 92 PEGASYS PROCLICK 45 ORTHO EVRA 80 PEGINTRON 45 ORTHO TRI-CYCLEN LO 80 PEN NEEDLES 3/16" 92 OSMOPREP 72 PEN NEEDLES 5/16" 92 oxacillin sodium 17 PENICILLIN G POT IN DEXTROSE 17 oxaliplatin 35 penicillin g potassium 17 oxandrolone 78 PENICILLIN G PROCAINE 17 penicillin g sodium 17 oxaprozin 9 oxcarbazepine 22 penicillin v potassium 17 OXISTAT 28 PENTAM 40 OXSORALEN 68 PENTASA 87 oxybutynin chloride 73 pentazocine w/ naloxone 12 PENTIPS 92 oxycodone hcl 10,12 oxycodone w/ acetaminophen 12 pentostatin 33 oxycodone-ibuprofen 12 pentoxifylline 59 OXYCONTIN 10 perindopril erbumine 56 oxymorphone hcl 10,12 P peritoneal dialysis solutions 104 PERJETA 38 permethrin 40 paclitaxel 35 perphenazine 26 pamidronate disodium 88 perphenazine-amitriptyline 23 PAMIDRONATE DISODIUM 88 phenazopyridine hcl 74 PANCREAZE 70 phenelzine sulfate 23 pancrelipase (lipase-protease-amylase) 70 phenobarbital 20 PANRETIN 39 phenoxybenzamine hcl 56 pantoprazole sodium 72 phenytoin 22 PARAGARD INTRAUTERINE COPPER 92 phenytoin sodium 22 phenytoin sodium extended 22 parenteral electrolytes 104 paricalcitol 88 PHISOHEX 92 paromomycin sulfate 14 PHOSLYRA 74 paroxetine hcl 24 PHOSPHOLINE IODIDE 96 PASER 31 PHOTOFRIN 35 PATADAY 94 PICATO 68 PATANOL 95 pilocarpine hcl 96 PC UNIFINE PENTIPS 92 pilocarpine hcl (oral) 66 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 72 pindolol 58 PAGE 122 LAST UPDATED 10/2015 pioglitazone hcl 51 PRENTIF FITTING SET 92 pioglitazone hcl-metformin hcl 51 PREPOPIK 72 piperacillin sodium-tazobactam sodium 17 PRESTIGE GLUCOSE CONTROL 92 PREVNAR 13 86 piroxicam 9 PLASMA-LYTE 148 105 PREZISTA 48 PLASMA-LYTE A 105 PRIFTIN 31 PLASMA-LYTE-56 IN D5W 105 PRILOSEC OTC 4 PNEUMOVAX 23 86 primaquine phosphate 40 podofilox 68 primidone 20 polymyxin b sulfate 15 PRISTIQ 25 polymyxin b-trimethoprim 94 PROAIR HFA 99 potassium acetate 105 probenecid 28 potassium bicarb & chloride 105 PROCAINAMIDE HCL 57 potassium bicarbonate 105 prochlorperazine 26 potassium chloride 105 prochlorperazine maleate 26 POTASSIUM CHLORIDE 105 PROCRIT 55 potassium chloride in dextrose 105 PRODIGY CONTROL SOLUTION 92 potassium chloride in dextrose & sodium chloride 105 PRODIGY MINI PEN NEEDLES 92 potassium chloride in nacl 105 progesterone micronized 81 potassium chloride microencapsulated crystals cr 105 PROGLYCEM 52 PROGRAF 84 potassium citrate (alkalinizer) potassium phosphates 74 106 PROLASTIN 101 102 POTIGA 20 PROLASTIN-C PRADAXA 54 PROLEUKIN 35 pramipexole dihydrochloride 41 PROLIA 88 PRANDIMET 51 PROMACTA 55 pravastatin sodium 61 promethazine hcl 98 prazosin hcl 56 propafenone hcl 57 5 proparacaine hcl 94 PRECISION XTRA KETONE PRED MILD 95 propranolol hcl 58 prednicarbate 76 propylthiouracil 83 prednisolone 76 protriptyline hcl 26 prednisolone acetate (ophth) 95 PROVENTIL HFA 99 prednisolone sodium phosphate 76 PRUDOXIN 68 PREDNISOLONE SODIUM PHOSPHATE 76,95 PTS PANELS KETONE TEST 5 prednisone 76 PULMICORT FLEXHALER PREFERRED PLUS UNIFINE PENTIPS 92 PULMOZYME PREMARIN 80 PX MINI PEN NEEDLES 92 pyrazinamide 31 pyridostigmine bromide 30 PREMIUM CONDOMS LUBRICATED 5 PREMPHASE 80 PREMPRO 80 PAGE 123 97 102 LAST UPDATED 10/2015 Q RETROVIR 47 REVLIMID 32 QC UNIFINE PENTIPS 92 REYATAZ 48 quetiapine fumarate 42 RHEUMATREX 84 quinapril hcl 57 ribavirin (hepatitis c) 45 quinidine sulfate 57 RIDAURA 86 quinine sulfate 40 rifabutin 30 QVAR 97 RIFAMATE 31 rifampin 31 RIFATER 31 R RA PEN NEEDLES 92 riluzole 65 rabeprazole sodium 72 rimantadine hydrochloride 48 raloxifene hcl 81 ringer's 106 ramipril 57 ringer's irrigation 106 RANEXA 59 risedronate sodium 88 RISPERDAL CONSTA 42 ranitidine hcl RAPAFLO 4,71 73 risperidone REALITY LATEX/ULTRA TEXTURED 5 RITUXAN 38 REALITY LATEX/ULTRA THIN 5 rivastigmine tartrate 23 REBETOL 45 rizatriptan benzoate 29 REBIF 66 ropinirole hydrochloride 41 REBIF REBIDOSE 66 ROZEREM REBIF REBIDOSE TITRATION PACK 66 REBIF TITRATION PACK 66 S RECTIV 68 SABRIL 20 REGRANEX 68 SAFYRAL 80 RELENZA DISKHALER 48 SAIZEN 77 RELION 70/30 53 SAIZEN CLICK.EASY 77 RELION N 53 salsalate 9 RELION PEN NEEDLES 92 SAMSCA 104 RELION R 53 SANTYL 68 RELISTOR 71 SAPHRIS 43 RELPAX 29 SAVELLA 65 REMICADE 84 SAVELLA TITRATION PACK 65 selegiline hcl 41 REMODULIN 100 42,43 103 RENAGEL 74 selenium sulfide 68 REOPRO 55 SELZENTRY 47 repaglinide 51 SENSIPAR 82 RESCRIPTOR 46 SEREVENT DISKUS RESECTISOL 74 SEROMYCIN 31 RESTASIS 94 SEROQUEL XR 43 PAGE 124 100 LAST UPDATED 10/2015 SEROSTIM 77 STELARA 68 sertraline hcl 25 STENDRA 74 SHOPKO UNIFINE PENTIPS 92 STIMATE 78 STIVARGA 37 sildenafil citrate (pulmonary hypertension) 100 silver sulfadiazine 19 STRATTERA 64 SIMCOR 62 streptomycin sulfate 14 SIMPONI 84 STRIBILD 46 SIMULECT 86 SUBOXONE 13 simvastatin 61 SUCRAID 70 sirolimus 84 sucralfate 72 SKELID 81 sulfacetamide sodium (acne) 68 SKLICE 39 sulfacetamide sodium (ophth) 19 SKYLA 81 sulfacetamide sodium w/ sulfur 68 sulfadiazine 19 sulfamethoxazole-trimethoprim 19 SULFAMYLON 15 sulfasalazine 87 sodium acetate 106 sodium chloride 74,106 sodium chloride (gu irrigant) 74 sodium chloride (inhalant) 102 sodium citrate & citric acid 74 sulindac sodium phenylbutyrate 70 sumatriptan 29 9 sodium phosphate 106 sumatriptan succinate 30 sodium polystyrene sulfonate 104 SUPRAX 16 sodium polystyrene sulfonate (bulk) 92 SUPREP BOWEL PREP 72 SOLTAMOX 32 SURE COMFORT PEN NEEDLES 93 SOLU-CORTEF 76 SURE EDGE GLUCOSE CONTROL 93 SOLU-MEDROL 76 SURE-FINE PEN NEEDLES 93 SOLUS V2 CONTROL 92 SURECHEK CONTROL SOLUTION 93 SOMATULINE DEPOT 82 SURESTEP PRO LOW GLUCOSE 93 SOMAVERT 82 SUSTIVA 46 SORBITOL 74 SUTENT 37 SORBITOL-MANNITOL 74 SYLATRON 35 sotalol hcl 57 SYMBICORT 102 SOVALDI 45 SYMLINPEN 120 51 SPINOSAD 40 SYMLINPEN 60 51 SPIRIVA HANDIHALER 98 SYNAREL 82 spironolactone 60 SYNERA 68 spironolactone & hydrochlorothiazide 59 SYNRIBO 35 SPORANOX 28 SYPRINE 104 SPRYCEL 37 stannous fluoride 3,66 T stannous fluoride (bulk) 92 TABLOID 33 stavudine 47 TACLONEX 69 PAGE 125 LAST UPDATED 10/2015 tacrolimus 84 timolol maleate 58 tacrolimus (topical) 69 timolol maleate (ophth) 96 TALWIN 12 TIVICAY 46 TAMIFLU 48,49 tizanidine hcl 102 tamoxifen citrate 32 TOBRADEX 14 tamsulosin hcl 73 tobramycin TARCEVA 37 tobramycin (ophth) 14 TARGRETIN 39 tobramycin sulfate 14 TASIGNA 37 TOBRAMYCIN SULFATE IN SALINE 14 TAZORAC 69 tobramycin-dexamethasone 94 TEFLARO 16 tolazamide 51 TEKTURNA 59 tolbutamide 51 telmisartan 56 tolcapone 40 TEMODAR 32 tolmetin sodium temozolomide 32 tolterodine tartrate 73 TENIPOSIDE 35 topiramate 21 terazosin hcl 73 topotecan hcl 36 terbinafine hcl 28 TORISEL 38 100 torsemide 60 73 terbutaline sulfate 100 9 terconazole vaginal 28 TOVIAZ testosterone cypionate 78 TRACLEER 101 testosterone enanthate 78 TRADJENTA 51 tetrabenazine 65 tramadol hcl tetracycline hcl 19 tramadol-acetaminophen 12 TEV-TROPIN 78 trandolapril 57 TEVETEN 56 tranexamic acid 55 THALOMID 32 TRANSDERM-SCOP 26 theophylline 100 tranylcypromine sulfate 23 10,12 thioridazine hcl 41 TRAVATAN Z 96 thiotepa 35 trazodone hcl 25 thiothixene 42 TREANDA 32 THYMOGLOBULIN 85 TRECATOR 31 THYROLAR-1 81 TRELSTAR 82 THYROLAR-1/2 81 TRELSTAR DEPOT MIXJECT 82 THYROLAR-1/4 81 TRELSTAR LA MIXJECT 83 THYROLAR-2 82 TRELSTAR MIXJECT 83 THYROLAR-3 82 tretinoin 69 tiagabine hcl 20 tretinoin (chemotherapy) 39 ticlopidine hcl 55 tretinoin microsphere 69 TIKOSYN 57 TREXALL 84 TIMENTIN 17 triamcinolone acetonide (mouth) 66 PAGE 126 LAST UPDATED 10/2015 triamcinolone acetonide (topical) 76 triamterene & hydrochlorothiazide 59 triazolam 103 TYZINE 102 U trifluoperazine hcl 42 ULESFIA 40 trifluridine 49 ULORIC 28 trihexyphenidyl hcl 40 ULTICARE MICRO PEN NEEDLES 93 trimethobenzamide hcl 26 ULTICARE PEN NEEDLES 93 trimethoprim 15 ULTRA-THIN II MINI PEN NEEDLE 93 trimipramine maleate 26 ULTRA-THIN II PEN NEEDLES 93 TRISENOX 35 ULTRABAG/DIANEAL/1.5% DEXTROSE 106 TROJAN MAGNUM WARM SENSATIONS 5 UNIFINE PENTIPS 93 TROJAN SUPRAS SPERMICIDAL 5 UNIFINE PENTIPS PLUS 93 TROJAN TWISTED PLEASURE 5 UNISTRIP CONTROL 93 tropicamide 94 ursodiol 71 trospium chloride 73 UVADEX 35 TRUE METRIX BLOOD GLUCOSE TEST 93 TRUE METRIX LEVEL 1 93 V TRUE METRIX METER 93 valacyclovir hcl 49 TRUERESULT BLOOD GLUCOSE 93 VALCYTE 43 TRUETEST TEST 93 valganciclovir hcl 43 TRUETRACK GLUCOSE CONTROL 93 valproate sodium 20 TRUETRACK TEST 93 valproic acid 21 TRUSTEX COLOR CONDOMS + LUBE 5 valsartan 56 TRUSTEX LUB/RIBBED/STUDDED 5 valsartan-hydrochlorothiazide 59 TRUSTEX LUB/SPERMICIDE EX ST 5 VALSTAR 35 TRUSTEX LUB/SPERMICIDE XL 5 vancomycin hcl 15 TRUSTEX LUBRICATED 5 VANDETANIB 38 TRUSTEX LUBRICATED EX LARGE 5 VECTIBIX 38 TRUSTEX LUBRICATED EXTRA ST 5 VELCADE 35 TRUSTEX LUBRICATED/SPERMICIDE 5 VELTIN 69 TRUSTEX NATURAL CONDOMS + LUBE 6 venlafaxine hcl 25 TRUSTEX RIA LUB/SPERMICIDE 6 VENLAFAXINE HCL ER 25 TRUSTEX RIA LUBRICATED 6 VENTAVIS 101 TRUSTEX-NONOXYNOL-9/RIB/STUD 6 VENTOLIN HFA 100 TRUVADA 47 TWINJECT 100 verapamil hcl 59 VEREGEN 69 TYBOST 47 VERIPRED 20 76 TYGACIL 15 VESICARE 73 TYKERB 38 VEXOL 95 TYSABRI 66 VIBATIV 15 TYZEKA 44 VICTOZA 52 PAGE 127 LAST UPDATED 10/2015 VICTRELIS 45 XIFAXAN VIDA MIA UNIFINE PENTIPS 93 XOLAIR 102 VIDEX 47 XOPENEX HFA 100 VIIBRYD 25 XTANDI 32 VIMPAT 22 XULANE 80 vinblastine sulfate 36 XYREM 103 vincristine sulfate 36 vinorelbine tartrate 36 Y VIRACEPT 48 YERVOY VIRAMUNE XR 46 VIREAD 47 Z VISICOL 72 zafirlukast VOCAL POINT CONTROL 93 zaleplon VORAXAZE 36 ZALTRAP 36 voriconazole 28 ZANOSAR 32 VOTRIENT 38 ZAVESCA 70 VPRIV 70 ZELBORAF 38 VUMON 36 ZEMAIRA 102 VYTORIN 62 ZENPEP 70 VYVANSE 63 ZETIA 62 ZIAGEN 47 ZIANA 69 W 15 39 98 103 warfarin sodium 54 zidovudine 47 water for irrigation, sterile 93 ZIOPTAN 96 WEGMANS UNIFINE PENTIPS PLUS 93 ziprasidone hcl 43 WELCHOL 62 ZIRGAN 43 WIDE-SEAL DIAPHRAGM 60 94 ZOHYDRO ER 10 WIDE-SEAL DIAPHRAGM 65 94 ZOLADEX 83 WIDE-SEAL DIAPHRAGM 70 94 zoledronic acid 88 WIDE-SEAL DIAPHRAGM 75 94 ZOLEDRONIC ACID 88 WIDE-SEAL DIAPHRAGM 80 94 ZOLINZA 36 WIDE-SEAL DIAPHRAGM 85 94 zolmitriptan 30 WIDE-SEAL DIAPHRAGM 90 94 zolpidem tartrate WIDE-SEAL DIAPHRAGM 95 94 ZOLVIT 12 ZOMACTON 78 ZOMETA 88 X 103 XALKORI 38 ZOMIG 30 XARELTO 54 ZONALON 69 XELJANZ 84 zonisamide 20 XEOMIN 102 ZORBTIVE 78 XGEVA 88 ZORTRESS 84 PAGE 128 LAST UPDATED 10/2015 ZOSTAVAX 86 ZOVIA 1/50E (28) 80 ZYFLO CR 98 ZYTIGA 32 PAGE 129 LAST UPDATED 10/2015 © 2015 Celtic Insurance Company. 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