Formulario Completo
2016
2016POR FAVOR LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Lista de Medicamentos Cubiertos
HPMS Approved Formulary File 00016391, Version 7
Este formulario fue actualizado el 07/27/2015. Para la información más reciente y otras preguntas, por
favor póngase en contacto con Servicios para Miembros de KelseyCare Advantage al 1-866-589-5222 o, para usuarios TTY, al 1-888-206-8041, las 24 horas del día, los 7 días de la semana, o visite
www.kelseycareadvantage.com.
Nota para los miembros actuales: Este formulario ha cambiado desde el año pasado. Por favor revise este documento para asegurarse de que aún contiene los medicamentos que usted usa.
Cuando esta lista de medicamentos (formulario) dice “nosotros”, “nos”, o “nuestro/a”, se refiere a KelseyCare Advantage. Cuando dice “plan” o “nuestro plan”, hace referencia a KelseyCare Advantage Rx o Rx+Choice.
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, que es vigente al 7/27/15. Para un formulario actualizado, por favor póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha en la que se actualizó el formulario por última vez, aparece en la portada y la portada posterior.
Por lo general, usted debe usar farmacias de la red para usar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el 1 de Enero de 2017 u ocasionalmente durante el año.
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¿Qué es el Formulario de KelseyCare Advantage?
Un formulario es una lista de medicamentos cubiertos seleccionados por KelseyCare Advantage con el asesoramiento de un equipo de proveedores del cuidado de la salud, que representa las terapias recetadas que son consideradas como una parte necesaria de un programa de tratamiento de calidad. Por lo general, KelseyCare Advantage cubrirá los medicamentos incluidos en nuestro formulario, siempre y cuando sean necesarios por razones médicas, la receta se surta en una farmacia de la red KelseyCare Advantage, y se cumplan otras reglas del plan. Para obtener más información sobre cómo surtir sus recetas, por favor consulte su Evidencia de Cobertura.
¿Puede cambiar el Formulario (Lista de Medicamentos)?
Por lo general, si usted está tomando un medicamento de nuestro formulario 2016 que estaba cubierto a comienzos del año, no suspenderemos ni reduciremos la cobertura del medicamento durante el año de cobertura 2016, salvo que un medicamento genérico nuevo y menos costoso se vuelva disponible, o que se publique información nueva y desfavorable acerca de la seguridad o efectividad de un medicamento. Otros tipos de cambios al formulario, tales como retirar un medicamento de nuestro formulario, no afectará a los miembros que estén actualmente tomando el medicamento. Seguirá disponible al mismo costo compartido para los miembros que lo estén tomando, durante el resto del año de cobertura. Consideramos importante que usted tenga acceso continuo, durante el resto del año de cobertura, a los medicamentos del formulario que estaban disponibles cuando usted escogió nuestro plan, a excepción de los casos donde usted pueda ahorrar dinero o podamos garantizar su seguridad.
Si eliminamos medicamentos de nuestro formulario, o imponemos restricciones de autorización previa, límites de cantidades, o terapia escalonada para un medicamento, o si transferimos un medicamento a un nivel de costo compartido más alto, nosotros debemos notificar a los miembros afectados por el cambio por lo menos 60 días antes de que entre en vigencia, o en el momento en que el miembro requiera una renovación del medicamento, en cuyo caso recibirá un suministro del medicamento para 60 días. Si la Administración de Alimentos y Medicamentos considera que un medicamento en nuestro formulario es inseguro, o si el fabricante del medicamento retira el medicamento del mercado, nosotros retiraremos el medicamento de nuestro formulario de inmediato y daremos aviso a los miembros que estén tomando dicho medicamento. El formulario anexo es vigente al 07/27/15. Para obtener información actualizada acerca de los medicamentos cubiertos por KelseyCare Advantage, comuníquese por favor con nosotros. Nuestra información de contacto aparece en la portada y en la portada posterior. Para leer o imprimir los cambios en el formulario durante el año, por favor visite nuestro sitio web en www.kelseycareadvantage.com y consulte el Apéndice del Formulario en la página “Find a Prescription Drug” (Buscar un medicamento recetado). Usted también puede solicitarnos que se le envíe por correo a su hogar una copia. Nuestra información de contacto está en las portadas anterior y posterior de este folleto.
¿Cómo utilizo el formulario?
Existen dos maneras de encontrar un medicamento en el formulario:
Condición médica
El formulario comienza en la página 7. Los medicamentos en este formulario están agrupados en categorías según el tipo de condiciones médicas para las que se utilizan. Por ejemplo, los medicamentos usados para tratar una condición cardiaca aparecen bajo la categoría “Agentes Cardiovasculares”. Si usted conoce para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 7. Luego busque su medicamento bajo el nombre de dicha categoría.
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Lista por orden alfabético
Si no está seguro bajo cuál categoría buscar, usted debería buscar su medicamento en el Índice que
comienza en la página 101. El índice presenta una lista en orden alfabético de todos los medicamentos
incluidos en este documento. En el índice aparecen tanto los medicamentos de marca como los
medicamentos genéricos. Busque en el índice para encontrar su medicamento. Junto a su medicamento,
usted verá el número de la página donde puede encontrar información de cobertura. Diríjase a la página
indicada en el índice y busque el nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
KelseyCare Advantage cubre tanto medicamentos de marca como medicamentos genéricos. Un
medicamento genérico es aquel que, según lo aprobado por la Administración de Alimentos y
Medicamentos (FDA), tiene el mismo ingrediente activo que un medicamento de marca. Por lo general,
los medicamentos genéricos cuestan menos que los medicamentos de marca.
¿Existe alguna restricción en mi cobertura?
Es posible que algunos medicamentos cubiertos tengan requisitos o límites adicionales de cobertura. Estos
requisitos y límites pueden incluir:
Autorización previa: KelseyCare Advantage requiere que usted o su médico obtengan autorización
previa para determinados medicamentos. Esto significa que usted deberá obtener la aprobación de
KelseyCare Advantage antes de surtir sus recetas. Si no la obtiene, es posible que KelseyCare
Advantage no cubra el medicamento.
Límites de cantidad: KelseyCare Advantage limita la cantidad que cubrirá para determinados
medicamentos. Por ejemplo, KelseyCare Advantage suministra 30 comprimidos por receta de
CRESTOR. Esto puede ser en adición al suministro estándar de un mes o tres meses.
Terapia escalonada: En algunos casos, KelseyCare Advantage requiere que usted pruebe primero
determinados medicamentos para tratar su condición médica, antes de cubrir otro medicamento para
dicha condición. Por ejemplo, si el Medicamento A y el Medicamento B sirven para tratar su
condición médica, es posible que KelseyCare Advantage no cubra el Medicamento B, a menos que
usted pruebe primero el Medicamento A. Si el Medicamento A no funciona en su caso, KelseyCare
Advantage cubrirá entonces el Medicamento B.
Usted puede consultar el formulario que comienza en la página 7 para averiguar si su medicamento tiene
requisitos o límites adicionales. También puede visitar nuestro sitio web para obtener más información sobre
las restricciones que se aplican a medicamentos cubiertos específicos. Hemos publicado documentos
electrónicos que explican nuestras restricciones de autorización previa y terapia escalonada. Usted también
puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en que
actualizamos el formulario por última vez, aparece en la portada y en la portada posterior.
Usted puede solicitar a KelseyCare Advantage que haga una excepción a estas restricciones o límites, o para
una lista de otros medicamentos similares que pueden tratar su condición de salud. Consulte la sección
“¿Cómo solicitar una excepción al formulario de KelseyCare Advantage?” en la página 3 para obtener
información acerca de cómo solicitar una excepción.
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¿Qué pasa si mi medicamento no aparece en el formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), usted debe comunicarse primero con Servicios para Miembros y preguntar si está cubierto.
Si le informan que KelseyCare Advantage no cubre su medicamento, usted tiene dos opciones:
Usted puede solicitar a Servicios para Miembros una lista de medicamentos similares que estén cubiertos por KelseyCare Advantage. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por KelseyCare Advantage.
Usted puede solicitar a KelseyCare Advantage que haga una excepción y cubra su medicamento. Consulte la información a continuación sobre cómo solicitar una excepción.
¿Cómo solicito una excepción al Formulario de KelseyCare Advantage?
Usted puede solicitar a KelseyCare Advantage que haga una excepción a nuestras reglas de cobertura. Hay varios tipos de excepciones que puede solicitarnos que hagamos.
Usted puede solicitarnos que cubramos un medicamento aun cuando no esté en nuestro formulario. De aprobarse, este medicamento será cubierto a un nivel de costo compartido pre-determinado, y usted no podrá solicitarnos que proporcionemos el medicamento a un nivel de costo compartido menor.
Usted puede solicitarnos que cubramos un medicamento del formulario a un nivel de costo compartido menor si dicho medicamento no se encuentra en el nivel de especialidad. De aprobarse, esto reduciría el monto que debe pagar por su medicamento.
Usted puede solicitarnos que eliminemos las restricciones o los límites de cobertura para su medicamento. Por ejemplo, para determinados medicamentos, KelseyCare Advantage limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, usted puede solicitarnos que eliminemos el límite y que cubramos una cantidad mayor.
Por lo general, KelseyCare Advantage únicamente aprobará su solicitud de excepción si los medicamentos alternos incluidos en el formulario del plan, el medicamento de costo compartido más bajo, o las restricciones adicionales de uso no fueran tan eficaces para tratar su condición o le causaran efectos médicos adversos.
Usted debe ponerse en contacto con nosotros para solicitarnos una decisión de cobertura inicial para una excepción de formulario, de nivel, o de restricción de uso. Cuando usted pide una excepción de
formulario, de nivel, o de restricción de uso, usted debe presentar una declaración del profesional que
emite sus recetas o médico respaldando su solicitud. Por lo general, nosotros debemos tomar nuestra decisión dentro de 72 horas después de haber recibido la declaración de respaldo del profesional que emite sus recetas. Puede pedir una excepción acelerada (rápida) si usted o su médico consideran que su salud puede verse seriamente perjudicada esperando hasta 72 horas para una decisión. Si su solicitud para acelerar es aceptada, nosotros debemos darle una decisión dentro de 24 horas después de haber recibido la declaración de respaldo de su médico u otro profesional que emite sus recetas.
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¿Qué hago antes de poder hablar con mi médico sobre el cambio de mis medicamentos
o de solicitar una excepción?
Como miembro nuevo o antiguo de nuestro plan, es posible usted que esté tomando medicamentos que no están incluidos en nuestro formulario. O, es posible que usted esté tomando un medicamento que sí aparece en nuestro formulario, pero su habilidad para obtenerlo es limitada. Por ejemplo, es posible que necesite una autorización previa por parte de nosotros antes de que pueda surtir su receta. Usted debe hablar con su médico para decidir si debería cambiar a un medicamento adecuado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras usted habla con su médico para determinar el curso de acción indicado en su caso, es posible que cubramos su medicamento en determinados casos, durante los primeros 90 días de su inscripción a nuestro plan.
Para cada uno de sus medicamentos que no estén incluidos en nuestro formulario o si su habilidad para obtenerlos es limitada, nosotros cubriremos un suministro temporal de 30 días (salvo que en su receta se indiquen menos días) cuando usted acuda a una farmacia de la red. Después de su primer suministro de 30 días, nosotros no pagaremos por estos medicamentos, aun cuando haya sido miembro del plan por menos de 90 días.
Si usted reside en un centro de cuidado a largo plazo, nosotros le permitiremos renovar su receta hasta que le hayamos brindado un suministro de transición de 91 días, consistente con el incremento de entrega, (salvo que en la receta se indiquen menos días). Nosotros cubriremos más de una renovación de estos medicamentos durante los primeros 90 días de su inscripción a nuestro plan. Si necesita un medicamento que no está incluido en nuestro formulario o si su habilidad para obtenerlo es limitada, pero ya han transcurrido los primeros 90 días de su inscripción en nuestro plan, nosotros cubriremos un suministro de emergencia de 31 días de dicho medicamento (salvo que en la receta se indiquen menos días), mientras usted solicita una excepción al formulario.
Cambios imprevistos en los medicamentos debido a cambios en el nivel de cuidado
Se denomina cambio en el nivel de cuidado cuando se transfiere de un entorno de tratamiento a otro, tal como trasladarse de paciente interno en un hospital a su hogar. Con frecuencia, este tipo de cambios no le da tiempo suficiente para determinar si una nueva receta contiene un medicamento que esté incluido en el formulario del plan. En estas situaciones imprevistas, KelseyCare Advantage cubrirá un suministro temporal de transición de 30 días (salvo que en la receta se indiquen menos días). Si el cambio en su nivel de cuidado implica el traslado a un centro de cuidado a largo plazo y le recetan un nuevo medicamento, el plan cubre un suministro temporal de 31 días (salvo que en la receta se indiquen menos días).
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados de KelseyCare Advantage, por favor consulte su Evidencia de Cobertura y otros materiales del plan.
Si usted tiene preguntas sobre KelseyCare Advantage, por favor comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos el formulario por última vez, aparece en la portada y en la portada posterior.
Si usted tiene preguntas generales relacionadas con la cobertura de Medicare para medicamentos recetados, por favor llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas al día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O, visite www.medicare.gov.
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Formulario de KelseyCare Advantage
El formulario que comienza en la página 7 presenta información de cobertura sobre algunos de
los medicamentos cubiertos por KelseyCare Advantage. Si tiene problemas encontrando un
medicamento en la lista, consulte el índice que comienza en la página 101.
La primera columna de la tabla contiene el nombre del medicamento. Los medicamentos de
marca aparecen en mayúsculas (p.ej., CRESTOR) y los medicamentos genéricos aparecen en
minúsculas y cursiva (p.ej., simvastatin).
La información en la columna “Requisitos/Límites” le indica si KelseyCare Advantage tiene
algún requisito especial para la cobertura de su medicamento.
Las abreviaturas representan requisitos especiales para los medicamentos, límites y otra
información.
GAP = Proporcionamos cobertura adicional para este medicamento recetado durante el intervalo sin
cobertura. Por favor consulte nuestra Evidencia de Cobertura para obtener más información sobre
esta cobertura.
LA = Acceso limitado.
PA = Se aplica autorización previa.
QL = Se aplican límites de cantidad.
ST = Se aplica terapia escalonada.
Los medicamentos con “LA” tienen distribución limitada. Esta receta puede estar disponible solamente en
determinadas farmacias. Para obtener mayor información, consulte su Directorio de Farmacias o llame a
Servicios para Miembros al 1-866-589-5222, las 24 horas del día, los 7 días de la semana. Los usuarios
TTY/TDD deben llamar al 1-888-206-8041.
La columna llamada “Nivel” está junto a la columna llamada “Nombre del Medicamento”. Esto identifica el
nivel al que su medicamento ha sido asignado y determinará el monto que usted paga por su receta. El
monto que usted paga por sus medicamentos recetados depende del nivel del medicamento. Cada
medicamento en la Lista de Medicamentos del plan se encuentra en uno de cinco niveles de costo
compartido. Por lo general, mientras más alto sea el número del nivel de costo compartido, más alto será su
costo por el medicamento.
Nivel de Costo Compartido Medicamentos incluidos en el Nivel
Nivel 1 (más bajo) Genérico Preferido
Nivel 2 Genérico
Nivel 3 Marca Preferida
Nivel 4 Marca No Preferida
Nivel 5 (más alto) Especialidad
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Nivel 1 – Genérico Preferido
Nivel de costo más bajo – Los medicamentos genéricos tienen la misma fórmula de ingrediente activo que un medicamento de marca. Los medicamentos genéricos usualmente cuestan menos que los de marca y están calificados por la Administración de Drogas y Alimentos (FDA) de ser seguros y eficaces como los de marca. No todos los medicamentos genéricos en esta lista de medicamentos (formulario) están incluidos en este nivel.
Nivel 2 – Genérico
Nivel de costo medio – Incluye genéricos que constituyen medicamentos genéricos de alto costo y/o medicamentos genéricos disponibles solamente de un fabricante.
Nivel 3 – Marca Preferida
Nivel de costo medio – Incluye los medicamentos de marcas preferidas.
Nivel 4 – Marca No Preferida
Nivel de costo mayor – Incluye los medicamentos de marcas no preferidas.
Nivel 5 – Especialidad
Nivel de costo más alto – Contiene medicamentos de marca y genéricos de costo muy alto que pueden requerir manejo especial y/o monitoreo cercano. Los medicamentos de especialidad pueden ser genéricos o de marca.
Rx y Rx+Choice
Costo Compartido Preferido
Nivel Suministro de
30 días
Suministro de
90 días
1 $3 $7.50
2 $17 $42.50
3 $40 $100
4 $60 $150
5 31% 31%
Costo Compartido Estándar
Nivel Suministro de
30 días
Suministro de
90 días
1 $8 $24
2 $20 $60
3 $45 $135
4 $70 $210
5 31% 31%
La red de farmacias de KelseyCare Advantage incluye farmacias que ofrecen costo compartido estándar y otras que ofrecen costo compartido preferido. Usted puede ir a cualquier tipo de farmacia de la red para recibir sus medicamentos recetados cubiertos. Es posible que su costo compartido sea menor en farmacias con costo compartido preferido.
Por favor tome en cuenta: La red de farmacias de KelseyCare Advantage ofrece acceso limitado a farmacias con costo compartido preferido en áreas urbanas y suburbanas dentro de Texas. Es posible que los costos bajos anunciados en los materiales de nuestro plan para estas farmacias no estén disponibles en la farmacia que usted usa. Para obtener información actualizada sobre nuestra red de farmacias, incluyendo farmacias con costo compartido preferido, por favor visite nuestra página web o llámenos. Nuestra información de contacto aparece en la portada anterior y posterior
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Drug Table
Drug Name Tier Requirements/Limits
Analgesics - Drugs To Treat Pain, Inflammation, And Muscle And Joint Conditions
acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml 1 GAP; QL (5000 ML per 30 days)
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg,
300-60 mg
1 GAP; QL (390 EA per 30 days)
ascomp with codeine oral capsule 30-50-325-40 mg 2
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg,
50-325-40-30 mg
2 QL (180 EA per 30 days)
butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml 1 GAP
butorphanol tartrate nasal spray,non-aerosol 10 mg/ml 1 GAP; QL (10 ML per 30 days)
carisoprodol-asa-codeine oral tablet 200-325-16 mg 1 PA; GAP
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 2 PA; QL (60 EA per 30 days)
codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 GAP
diclofenac potassium oral tablet 50 mg 1 GAP
diclofenac sodium oral tablet extended release 24 hr 100 mg 1 GAP
diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg,
50 mg, 75 mg
1 GAP
diclofenac-misoprostol oral tablet,ir & delay rel,biphasic 50-
200 mg-mcg, 75-200 mg-mcg
2
diflunisal oral tablet 500 mg 1 GAP
duramorph (pf) injection solution 0.5 mg/ml, 1 mg/ml 2
endocet oral tablet 10-325 mg, 7.5-325 mg 2 QL (360 EA per 30 days)
endocet oral tablet 5-325 mg 1 GAP; QL (360 EA per 30 days)
endodan oral tablet 4.8355-325 mg 1 GAP; QL (360 EA per 30 days)
etodolac oral capsule 200 mg, 300 mg 1 GAP
etodolac oral tablet 400 mg, 500 mg 1 GAP
etodolac oral tablet extended release 24 hr 400 mg, 500 mg,
600 mg
2
fenoprofen oral tablet 600 mg 1 GAP
fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600
mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg
5 PA; QL (120 EA per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 8
Drug Name Tier Requirements/Limits
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25
mcg/hr, 50 mcg/hr, 75 mcg/hr
2 QL (10 EA per 30 days)
FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG
5 PA; QL (112 EA per 28 days)
flurbiprofen oral tablet 100 mg, 50 mg 1 GAP
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml 2
hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300
mg, 7.5-300 mg
2 QL (390 EA per 30 days)
hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg
1 GAP; QL (360 EA per 30 days)
hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 GAP
hydromorphone (pf) injection solution 10 mg/ml 2
hydromorphone oral liquid 1 mg/ml 2
hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 GAP
ibuprofen oral suspension 100 mg/5 ml 1 GAP
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 GAP
ibuprofen-oxycodone oral tablet 400-5 mg 2 QL (150 EA per 30 days)
INDOCIN ORAL SUSPENSION 25 MG/5 ML 4
indomethacin oral capsule 25 mg, 50 mg 1 GAP
indomethacin oral capsule, extended release 75 mg 1 GAP
ketoprofen oral capsule 50 mg, 75 mg 1 GAP
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg 2
LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY
5 PA; QL (30 EA per 30 days)
levorphanol tartrate oral tablet 2 mg 1 GAP
lorcet (hydrocodone) oral tablet 5-325 mg 1 GAP; QL (360 EA per 30 days)
lorcet hd oral tablet 10-325 mg 1 GAP; QL (360 EA per 30 days)
lorcet plus oral tablet 7.5-325 mg 1 GAP; QL (360 EA per 30 days)
lortab 10-325 oral tablet 10-325 mg 1 GAP; QL (360 EA per 30 days)
lortab 5-325 oral tablet 5-325 mg 1 GAP; QL (360 EA per 30 days)
lortab 7.5-325 oral tablet 7.5-325 mg 1 GAP; QL (360 EA per 30 days)
Drug Name Tier Requirements/Limits
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meclofenamate oral capsule 100 mg, 50 mg 2
mefenamic acid oral capsule 250 mg 2
meloxicam oral suspension 7.5 mg/5 ml 1 GAP
meloxicam oral tablet 15 mg, 7.5 mg 1 GAP
methadone oral solution 10 mg/5 ml, 5 mg/5 ml 1 GAP
methadone oral tablet 10 mg, 5 mg 1 GAP
morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) 2
morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45
mg, 60 mg, 75 mg, 90 mg
2 QL (30 EA per 30 days)
morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30
mg, 50 mg, 60 mg
2 QL (60 EA per 30 days)
morphine oral capsule,extend.release pellets 100 mg, 80 mg 5 QL (60 EA per 30 days)
morphine oral solution 10 mg/5 ml, 20 mg/5 ml 2
morphine oral tablet 15 mg, 30 mg 1 GAP
morphine oral tablet extended release 100 mg, 15 mg, 200 mg,
30 mg, 60 mg
2 QL (90 EA per 30 days)
nabumetone oral tablet 500 mg, 750 mg 1 GAP
nalbuphine injection solution 10 mg/ml 1 GAP
nalbuphine injection solution 20 mg/ml 2
naproxen oral suspension 125 mg/5 ml 1 GAP
naproxen oral tablet 250 mg, 375 mg, 500 mg 1 GAP
naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg 1 GAP
naproxen sodium oral tablet 275 mg, 550 mg 1 GAP
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG
4 QL (60 EA per 30 days)
NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG 4 QL (180 EA per 30 days)
oxaprozin oral tablet 600 mg 2
oxycodone oral capsule 5 mg 1 GAP
oxycodone oral solution 5 mg/5 ml 1 GAP
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg 1 GAP
oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 20 mg, 40
mg
2 PA; QL (120 EA per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 10
Drug Name Tier Requirements/Limits
oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg 5 PA; QL (120 EA per 30 days)
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg,
7.5-325 mg
2 QL (360 EA per 30 days)
oxycodone-acetaminophen oral tablet 5-325 mg 1 GAP; QL (360 EA per 30 days)
oxycodone-aspirin oral tablet 4.8355-325 mg 1 GAP; QL (360 EA per 30 days)
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG
4 PA; QL (120 EA per 30 days)
oxymorphone oral tablet 10 mg 2 QL (240 EA per 30 days)
oxymorphone oral tablet 5 mg 2 QL (480 EA per 30 days)
oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg,
20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg
2 QL (60 EA per 30 days)
pentazocine-naloxone oral tablet 50-0.5 mg 2
piroxicam oral capsule 10 mg, 20 mg 1 GAP
SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY
5 PA; QL (120 EA per 30 days)
SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 600 MCG/SPRAY, 800 MCG/SPRAY
5 PA; QL (720 EA per 30 days)
sulindac oral tablet 150 mg, 200 mg 1 GAP
tramadol oral tablet 50 mg 1 GAP; QL (240 EA per 30 days)
tramadol oral tablet extended release 24 hr 100 mg, 200 mg 2 QL (30 EA per 30 days)
tramadol oral tablet, er multiphase 24 hr 300 mg 2 QL (30 EA per 30 days)
tramadol-acetaminophen oral tablet 37.5-325 mg 1 GAP; QL (240 EA per 30 days)
vicodin es oral tablet 7.5-300 mg 2 QL (390 EA per 30 days)
vicodin hp oral tablet 10-300 mg 2 QL (390 EA per 30 days)
vicodin oral tablet 5-300 mg 2 QL (390 EA per 30 days)
zamicet oral solution 10-325 mg/15 ml 2 QL (5550 ML per 30 days)
Anesthetics - Drugs for Numbing
lidocaine (pf) injection solution 5 mg/ml (0.5 %) 1 GAP
lidocaine hcl mucous membrane gel 2 % 2
lidocaine hcl mucous membrane jelly in applicator 2 % 2
lidocaine hcl mucous membrane solution 2 % 1 GAP
11
Drug Name Tier Requirements/Limits
lidocaine hcl mucous membrane solution 4 % (40 mg/ml) 2
lidocaine hcl urethral gel 2 % 2
lidocaine topical adhesive patch,medicated 5 %(700
mg/patch)
2 PA; QL (90 EA per 30 days)
lidocaine topical ointment 5 % 2
lidocaine-prilocaine topical cream 2.5-2.5 % 2
Anti-Addiction/Substance Abuse Treatment Agents - Drugs Use To Treat Substance Abuse
acamprosate oral tablet,delayed release (dr/ec) 333 mg 2
buprenorphine hcl injection syringe 0.3 mg/ml 2
buprenorphine hcl sublingual tablet 2 mg 2 PA; QL (240 EA per 30 days)
buprenorphine hcl sublingual tablet 8 mg 2 PA; QL (90 EA per 30 days)
buprenorphine-naloxone sublingual tablet 2-0.5 mg 2 PA; QL (360 EA per 30 days)
buprenorphine-naloxone sublingual tablet 8-2 mg 2 PA; QL (90 EA per 30 days)
buproban oral tablet extended release 150 mg 1 GAP
CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG
4 QL (504 EA per 365 days)
CHANTIX ORAL TABLET 0.5 MG, 1 MG 4 QL (504 EA per 365 days)
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)
4 QL (159 EA per 365 days)
disulfiram oral tablet 250 mg, 500 mg 2
naloxone injection syringe 1 mg/ml 2
naltrexone oral tablet 50 mg 2
NICOTROL INHALATION CARTRIDGE 10 MG 4
VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG
5
Antibacterials - Drugs Used To Treat Bacterial Infections
amikacin injection solution 500 mg/2 ml 2
amoxicillin oral capsule 250 mg, 500 mg 1 GAP
amoxicillin oral suspension for reconstitution 125 mg/5 ml,
200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
1 GAP
amoxicillin oral tablet 500 mg, 875 mg 1 GAP
amoxicillin oral tablet,chewable 125 mg, 250 mg 1 GAP
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 12
amoxicillin-pot clavulanate oral suspension for reconstitution
200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-
42.9 mg/5 ml
1 GAP
amoxicillin-pot clavulanate oral tablet 250-125 mg 2
amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125
mg
1 GAP
amoxicillin-pot clavulanate oral tablet extended release 12 hr
1,000-62.5 mg
2
amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg,
400-57 mg
1 GAP
ampicillin oral capsule 250 mg, 500 mg 1 GAP
ampicillin oral suspension for reconstitution 125 mg/5 ml, 250
mg/5 ml
1 GAP
ampicillin sodium injection recon soln 1 gram, 10 gram, 125
mg
2
ampicillin-sulbactam injection recon soln 15 gram, 3 gram 2
ampicillin-sulbactam intravenous recon soln 1.5 gram 2
AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 400 MG/250 ML
3
AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML
5
AZASITE OPHTHALMIC DROPS 1 % 3
azithromycin intravenous recon soln 500 mg, 500 mg (2
mg/ml)
2
azithromycin oral packet 1 gram 2
azithromycin oral suspension for reconstitution 100 mg/5 ml,
200 mg/5 ml
1 GAP
azithromycin oral tablet 250 mg, 500 mg 1 GAP
azithromycin oral tablet 600 mg 2
aztreonam injection recon soln 1 gram 2
baciim intramuscular recon soln 50,000 unit 2
bacitracin intramuscular recon soln 50,000 unit 2
bacitracin ophthalmic ointment 500 unit/gram 2
13
Drug Name Tier Requirements/Limits
BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K)
4
BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML
4
cefaclor oral capsule 250 mg, 500 mg 1 GAP
cefadroxil oral capsule 500 mg 1 GAP
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500
mg/5 ml
1 GAP
cefadroxil oral tablet 1 gram 2
cefazolin in dextrose (iso-os) intravenous piggyback 1
gram/50 ml
2
cefazolin injection recon soln 1 gram, 10 gram, 500 mg 2
cefdinir oral capsule 300 mg 1 GAP
cefdinir oral suspension for reconstitution 125 mg/5 ml, 250
mg/5 ml
1 GAP
cefepime in dextrose 5 % intravenous piggyback 1 gram/50
ml, 2 gram/50 ml
2
cefepime injection recon soln 1 gram, 2 gram 2
cefixime oral suspension for reconstitution 100 mg/5 ml, 200
mg/5 ml
2
cefotaxime injection recon soln 1 gram, 2 gram, 500 mg 2
cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram 2
cefpodoxime oral suspension for reconstitution 100 mg/5 ml,
50 mg/5 ml
2
cefpodoxime oral tablet 100 mg, 200 mg 2
cefprozil oral suspension for reconstitution 125 mg/5 ml, 250
mg/5 ml
1 GAP
cefprozil oral tablet 250 mg, 500 mg 1 GAP
ceftazidime in d5w intravenous piggyback 1 gram/50 ml, 2
gram/50 ml
2
ceftazidime injection recon soln 1 gram, 2 gram, 6 gram 2
ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg 2
ceftriaxone intravenous recon soln 1 gram, 2 gram 2
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 14
cefuroxime axetil oral tablet 250 mg, 500 mg 1 GAP
cefuroxime sodium injection recon soln 1.5 gram, 750 mg 2
cefuroxime sodium intravenous recon soln 7.5 gram 2
cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 GAP
cephalexin oral suspension for reconstitution 125 mg/5 ml,
250 mg/5 ml
1 GAP
chloramphenicol sod succinate intravenous recon soln 1 gram 2
CILOXAN OPHTHALMIC OINTMENT 0.3 % 3
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000
mg, 500 mg
2
ciprofloxacin hcl ophthalmic drops 0.3 % 1 GAP
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 GAP
ciprofloxacin in 5 % dextrose intravenous piggyback 200
mg/100 ml
1 GAP
ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 GAP
ciprofloxacin oral suspension,microcapsule recon 250 mg/5
ml, 500 mg/5 ml
2
clarithromycin oral suspension for reconstitution 125 mg/5
ml, 250 mg/5 ml
1 GAP
clarithromycin oral tablet 250 mg, 500 mg 2
clarithromycin oral tablet extended release 24 hr 500 mg 2
CLEOCIN VAGINAL SUPPOSITORY 100 MG 4
clindamax topical gel 1 % 1 GAP
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 GAP
clindamycin in 5 % dextrose intravenous piggyback 300
mg/50 ml, 600 mg/50 ml, 900 mg/50 ml
1 GAP
clindamycin pediatric oral recon soln 75 mg/5 ml 1 GAP
clindamycin phosphate intravenous solution 600 mg/4 ml 1 GAP
clindamycin phosphate topical foam 1 % 2
clindamycin phosphate topical gel 1 % 1 GAP
clindamycin phosphate topical lotion 1 % 1 GAP
Drug Name Tier Requirements/Limits
15
clindamycin phosphate topical solution 1 % 1 GAP
clindamycin phosphate topical swab 1 % 1 GAP
clindamycin phosphate vaginal cream 2 % 2
colistin (colistimethate na) injection recon soln 150 mg 2
CUBICIN INTRAVENOUS RECON SOLN 500 MG 5
demeclocycline oral tablet 150 mg 1 GAP
demeclocycline oral tablet 300 mg 2
dicloxacillin oral capsule 250 mg, 500 mg 1 GAP
DIFICID ORAL TABLET 200 MG 5 ST; QL (20 EA per 10 days)
doxy-100 intravenous recon soln 100 mg 2
doxycycline hyclate intravenous recon soln 100 mg 2
doxycycline hyclate oral capsule 100 mg, 50 mg 1 GAP
doxycycline hyclate oral tablet 100 mg, 20 mg 1 GAP
doxycycline hyclate oral tablet 50 mg 2
doxycycline hyclate oral tablet,delayed release (dr/ec) 100
mg, 150 mg, 75 mg
2
doxycycline monohydrate oral capsule 100 mg, 50 mg 1 GAP
doxycycline monohydrate oral capsule 75 mg 2
doxycycline monohydrate oral suspension for reconstitution
25 mg/5 ml
1 GAP
doxycycline monohydrate oral tablet 100 mg, 75 mg 1 GAP
doxycycline monohydrate oral tablet 150 mg, 50 mg 2
e.e.s. 400 oral tablet 400 mg 2
E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML
3
ery pads topical swab 2 % 1 GAP
ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML
3
erythrocin (as stearate) oral tablet 250 mg 2
ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 4
erythromycin ethylsuccinate oral tablet 400 mg 2
erythromycin ophthalmic ointment 5 mg/gram (0.5 %) 1 GAP
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 16
erythromycin oral tablet 250 mg, 500 mg 2
erythromycin with ethanol topical gel 2 % 1 GAP
erythromycin with ethanol topical solution 2 % 1 GAP
gatifloxacin ophthalmic drops 0.5 % 2
gentak ophthalmic ointment 0.3 % (3 mg/gram) 1 GAP
gentamicin in nacl (iso-osm) intravenous piggyback 100
mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80
mg/50 ml, 90 mg/100 ml
1 GAP
gentamicin injection solution 40 mg/ml 1 GAP
gentamicin ophthalmic drops 0.3 % 1 GAP
gentamicin ophthalmic ointment 0.3 % (3 mg/gram) 1 GAP
gentamicin sulfate (pf) intravenous solution 80 mg/8 ml 1 GAP
gentamicin topical cream 0.1 % 1 GAP
gentamicin topical ointment 0.1 % 1 GAP
ilotycin ophthalmic ointment 5 mg/gram (0.5 %) 1 GAP
imipenem-cilastatin intravenous recon soln 250 mg, 500 mg 2
INVANZ INJECTION RECON SOLN 1 GRAM 4
isopropyl alcohol-benzocaine topical pads, medicated 70-6 % 1 GAP
levofloxacin in d5w intravenous piggyback 500 mg/100 ml 1 GAP
levofloxacin ophthalmic drops 0.5 % 2
levofloxacin oral solution 250 mg/10 ml 1 GAP
levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 GAP
LINCOCIN INJECTION SOLUTION 300 MG/ML 3
linezolid intravenous parenteral solution 600 mg/300 ml 5
linezolid oral tablet 600 mg 5 QL (60 EA per 30 days)
MACRODANTIN ORAL CAPSULE 25 MG 4
meropenem intravenous recon soln 500 mg 2
methenamine hippurate oral tablet 1 gram 2
metronidazole in nacl (iso-os) intravenous piggyback 500
mg/100 ml
1 GAP
17
Drug Name Tier Requirements/Limits
metronidazole oral capsule 375 mg 1 GAP
metronidazole oral tablet 250 mg, 500 mg 1 GAP
metronidazole topical cream 0.75 % 2
metronidazole topical gel 0.75 %, 1 % 2
metronidazole topical lotion 0.75 % 2
metronidazole vaginal gel 0.75 % 1 GAP
minocycline oral capsule 100 mg, 50 mg, 75 mg 1 GAP
minocycline oral tablet 100 mg, 50 mg, 75 mg 2
minocycline oral tablet extended release 24 hr 135 mg, 45 mg,
90 mg
2
MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % 3
moxifloxacin oral tablet 400 mg 2
mupirocin calcium topical cream 2 % 2
mupirocin topical ointment 2 % 1 GAP
nafcillin injection recon soln 1 gram, 10 gram 2
neomycin oral tablet 500 mg 1 GAP
neomycin-bacitracin-poly-hc ophthalmic ointment 3.5-400-
10,000 mg-unit/g-1%
2
neomycin-polymyxin b gu irrigation solution 40 mg-200,000
unit/ml
2
neomycin-polymyxin-hc ophthalmic drops,suspension 3.5-
10,000-10 mg-unit-mg/ml
2
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg 1 GAP
nitrofurantoin monohyd/m-cryst oral capsule 100 mg 1 GAP
nitrofurantoin oral suspension 25 mg/5 ml 2
ofloxacin ophthalmic drops 0.3 % 1 GAP
ofloxacin oral tablet 400 mg 2
ofloxacin otic drops 0.3 % 2
paromomycin oral capsule 250 mg 2
penicillin g potassium injection recon soln 5 million unit 2
penicillin g procaine intramuscular syringe 1.2 million unit/2
ml
2
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 18
penicillin g sodium injection recon soln 5 million unit 2
penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5
ml
1 GAP
penicillin v potassium oral tablet 250 mg, 500 mg 1 GAP
piperacillin-tazobactam intravenous recon soln 3.375 gram,
4.5 gram
2
polymyxin b sulfate injection recon soln 500,000 unit 1 GAP
silver sulfadiazine topical cream 1 % 1 GAP
ssd topical cream 1 % 1 GAP
STREPTOMYCIN INTRAMUSCULAR RECON SOLN 1 GRAM
3
sulfacetamide sodium (acne) topical suspension 10 % 1 GAP
sulfacetamide sodium ophthalmic drops 10 % 1 GAP
sulfacetamide sodium ophthalmic ointment 10 % 2
sulfadiazine oral tablet 500 mg 2
sulfamethoxazole-trimethoprim intravenous solution 400-80
mg/5 ml
1 GAP
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5
ml
1 GAP
sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-
160 mg
1 GAP
SUPRAX ORAL CAPSULE 400 MG 4
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML
4
SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG 4
SYNERCID INTRAVENOUS RECON SOLN 500 MG 5
tazicef injection recon soln 1 gram, 2 gram, 6 gram 2
TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG
4
tetracycline oral capsule 250 mg, 500 mg 2
tobramycin ophthalmic drops 0.3 % 1 GAP
tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml 1 GAP
19
Drug Name Tier Requirements/Limits
trimethoprim oral tablet 100 mg 1 GAP
TYGACIL INTRAVENOUS RECON SOLN 50 MG 5
vancomycin intravenous recon soln 1,000 mg, 10 gram, 500
mg
2
vancomycin oral capsule 125 mg, 250 mg 5
vandazole vaginal gel 0.75 % 1 GAP
VIGAMOX OPHTHALMIC DROPS 0.5 % 3
XIFAXAN ORAL TABLET 200 MG 4 ST
XIFAXAN ORAL TABLET 550 MG 5 ST; QL (60 EA per 30 days)
ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 3.375 GRAM/50 ML
3
ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML
5 QL (2400 ML per 30 days)
Anticonvulsants - Drugs Used To Treat Seizures
APTIOM ORAL TABLET 200 MG, 400 MG 4 QL (30 EA per 30 days)
APTIOM ORAL TABLET 600 MG 4 QL (60 EA per 30 days)
APTIOM ORAL TABLET 800 MG 4 QL (45 EA per 30 days)
BANZEL ORAL SUSPENSION 40 MG/ML 5
BANZEL ORAL TABLET 200 MG 4
BANZEL ORAL TABLET 400 MG 5
carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200
mg, 300 mg
2
carbamazepine oral suspension 100 mg/5 ml 2
carbamazepine oral tablet 200 mg 1 GAP
carbamazepine oral tablet extended release 12 hr 200 mg, 400
mg
2
carbamazepine oral tablet,chewable 100 mg 1 GAP
CELONTIN ORAL CAPSULE 300 MG 4
CEREBYX INJECTION SOLUTION 500 MG PE/10 ML 4
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 GAP
clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5
mg, 1 mg, 2 mg
2
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 20
diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg 2 QL (100 EA per 30 days)
DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG
3
DILANTIN ORAL CAPSULE 30 MG 3
divalproex oral capsule, sprinkle 125 mg 1 GAP
divalproex oral tablet extended release 24 hr 250 mg, 500 mg 2
divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg,
500 mg
1 GAP
epitol oral tablet 200 mg 1 GAP
ethosuximide oral capsule 250 mg 1 GAP
ethosuximide oral solution 250 mg/5 ml 1 GAP
felbamate oral suspension 600 mg/5 ml 5
felbamate oral tablet 400 mg, 600 mg 2
fosphenytoin injection solution 100 mg pe/2 ml 1 GAP
FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
4
gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 GAP
gabapentin oral solution 250 mg/5 ml 2
gabapentin oral tablet 600 mg, 800 mg 1 GAP
GABITRIL ORAL TABLET 12 MG, 16 MG 4
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 GAP
lamotrigine oral tablet extended release 24hr 100 mg, 200 mg,
25 mg, 250 mg, 300 mg, 50 mg
2
lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg 1 GAP
lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg,
50 mg
2
levetiracetam in nacl (iso-os) intravenous piggyback 1,000
mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml
2
levetiracetam intravenous solution 500 mg/5 ml 2
levetiracetam oral solution 100 mg/ml 2
levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg 1 GAP
Drug Name Tier Requirements/Limits
21
levetiracetam oral tablet extended release 24 hr 500 mg, 750
mg
2
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG
3 QL (90 EA per 30 days)
LYRICA ORAL CAPSULE 225 MG, 300 MG 3 QL (60 EA per 30 days)
LYRICA ORAL SOLUTION 20 MG/ML 3 QL (900 ML per 30 days)
ONFI ORAL SUSPENSION 2.5 MG/ML 4
ONFI ORAL TABLET 10 MG, 20 MG 4
oxcarbazepine oral suspension 300 mg/5 ml 2
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 GAP
PEGANONE ORAL TABLET 250 MG 4
phenobarbital oral elixir 20 mg/5 ml 2
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg,
32.4 mg, 60 mg, 64.8 mg, 97.2 mg
1 GAP
phenytoin oral suspension 125 mg/5 ml 1 GAP
phenytoin oral tablet,chewable 50 mg 1 GAP
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300
mg
1 GAP
phenytoin sodium intravenous solution 50 mg/ml 1 GAP
POTIGA ORAL TABLET 200 MG 5
POTIGA ORAL TABLET 300 MG, 400 MG, 50 MG 4
primidone oral tablet 250 mg, 50 mg 1 GAP
SABRIL ORAL POWDER IN PACKET 500 MG 5
SABRIL ORAL TABLET 500 MG 5
TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG
3
tiagabine oral tablet 2 mg, 4 mg 2
topiramate oral capsule, sprinkle 15 mg, 25 mg 2
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 GAP
valproate sodium intravenous solution 500 mg/5 ml (100
mg/ml)
1 GAP
valproic acid (as sodium salt) oral solution 250 mg/5 ml 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 22
Drug Name Tier Requirements/Limits
VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML 4
VIMPAT ORAL SOLUTION 10 MG/ML 4
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG
4
zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 GAP
Antidementia Agents - Drugs Used To Treat Alzheimer’s Disease And Dementia
donepezil oral tablet 10 mg, 5 mg 1 GAP
donepezil oral tablet 23 mg 2
donepezil oral tablet,disintegrating 10 mg, 5 mg 2
ergoloid oral tablet 1 mg 2
EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24 HOUR, 4.6 MG/24 HR, 9.5 MG/24 HR
3
galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg,
8 mg
2
galantamine oral solution 4 mg/ml 2
galantamine oral tablet 12 mg, 4 mg, 8 mg 2
NAMENDA ORAL SOLUTION 10 MG/5 ML 3
NAMENDA ORAL TABLET 10 MG, 5 MG 3
NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK 5-10 MG
3
NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG
3 QL (56 EA per 365 days)
NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG
3 QL (30 EA per 30 days)
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 2
Antidepressants - Drugs To Treat Depression
amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50
mg, 75 mg
1 GAP
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 GAP
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG
4 ST; QL (30 EA per 30 days)
BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 4 ST; QL (30 EA per 30 days)
23
Drug Name Tier Requirements/Limits
bupropion hcl oral tablet 100 mg, 75 mg 1 GAP
bupropion hcl oral tablet extended release 100 mg, 150 mg,
200 mg
1 GAP
bupropion hcl oral tablet extended release 24 hr 150 mg, 300
mg
1 GAP
citalopram oral solution 10 mg/5 ml 1 GAP
citalopram oral tablet 10 mg, 20 mg, 40 mg 1 GAP
clomipramine oral capsule 25 mg, 50 mg, 75 mg 2
desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50
mg, 75 mg
2
doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg,
75 mg
1 GAP
doxepin oral concentrate 10 mg/ml 1 GAP
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg,
60 mg
2 QL (60 EA per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 30 mg 2 QL (90 EA per 30 days)
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR
5 QL (30 EA per 30 days)
EMSAM TRANSDERMAL PATCH 24 HOUR 6 MG/24 HR, 9 MG/24 HR
4 QL (30 EA per 30 days)
escitalopram oxalate oral solution 5 mg/5 ml 2
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 2
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)
4 ST; QL (56 EA per 365 days)
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG
4 ST; QL (30 EA per 30 days)
fluoxetine oral capsule 10 mg, 20 mg, 40 mg 1 GAP
fluoxetine oral capsule,delayed release(dr/ec) 90 mg 2 QL (4 EA per 28 days)
fluoxetine oral solution 20 mg/5 ml 1 GAP
fluoxetine oral tablet 10 mg 1 GAP
fluoxetine oral tablet 20 mg, 60 mg 2
fluvoxamine oral capsule,extended release 24hr 100 mg, 150
mg
2 QL (60 EA per 30 days)
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg 1 GAP
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 24
FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG
4 ST; QL (30 EA per 30 days)
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 GAP
imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg,
75 mg
2
irenka oral capsule,delayed release(dr/ec) 40 mg 2 QL (60 EA per 30 days)
maprotiline oral tablet 25 mg, 50 mg, 75 mg 2
MARPLAN ORAL TABLET 10 MG 4
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 GAP
mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg 1 GAP
nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50
mg
1 GAP
nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 GAP
nortriptyline oral solution 10 mg/5 ml 1 GAP
olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25
mg, 6-50 mg
2 QL (30 EA per 30 days)
olanzapine-fluoxetine oral capsule 6-25 mg 2 QL (90 EA per 30 days)
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 GAP
paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25
mg, 37.5 mg
2
PAXIL ORAL SUSPENSION 10 MG/5 ML 4 ST
perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10
mg, 4-25 mg, 4-50 mg
2
phenelzine oral tablet 15 mg 1 GAP
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG
3 QL (120 EA per 30 days)
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG
3 QL (30 EA per 30 days)
protriptyline oral tablet 10 mg, 5 mg 1 GAP
sertraline oral concentrate 20 mg/ml 2
sertraline oral tablet 100 mg, 25 mg, 50 mg 1 GAP
SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG 4
25
Drug Name Tier Requirements/Limits
tranylcypromine oral tablet 10 mg 2
trazodone oral tablet 100 mg, 150 mg, 50 mg 1 GAP
trazodone oral tablet 300 mg 2
venlafaxine oral capsule,extended release 24hr 150 mg, 37.5
mg, 75 mg
1 GAP
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 GAP
venlafaxine oral tablet extended release 24hr 150 mg, 225 mg,
37.5 mg, 75 mg
2
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 4 ST; QL (30 EA per 30 days)
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16)
4 ST; QL (30 EA per 30 days)
Antiemetics - Drugs To Treat Nausea And Vomiting
ANZEMET INTRAVENOUS SOLUTION 100 MG/5 ML 4 PA
ANZEMET ORAL TABLET 100 MG, 50 MG 5 PA; QL (5 EA per 30 days)
compro rectal suppository 25 mg 2
dronabinol oral capsule 10 mg 5 PA; QL (60 EA per 30 days)
dronabinol oral capsule 2.5 mg, 5 mg 2 PA; QL (60 EA per 30 days)
EMEND ORAL CAPSULE 125 MG 3 PA; QL (2 EA per 30 days)
EMEND ORAL CAPSULE 40 MG 3 PA; QL (1 EA per 30 days)
EMEND ORAL CAPSULE 80 MG 3 PA; QL (8 EA per 30 days)
EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2)
3 PA; QL (6 EA per 30 days)
granisetron (pf) intravenous solution 100 mcg/ml 2 PA
granisetron hcl intravenous solution 1 mg/ml (1 ml) 2 PA; QL (60 ML per 30 days)
granisetron hcl oral tablet 1 mg 2 PA; QL (30 EA per 30 days)
meclizine oral tablet 12.5 mg, 25 mg 1 GAP
ondansetron hcl (pf) injection solution 4 mg/2 ml 1 PA; GAP
ondansetron hcl oral solution 4 mg/5 ml 1 PA; GAP; QL (450 ML per 30 days)
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 PA; GAP
ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 PA; GAP
phenadoz rectal suppository 12.5 mg 2
phenergan rectal suppository 12.5 mg, 25 mg, 50 mg 2
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 26
prochlorperazine edisylate injection solution 10 mg/2 ml (5
mg/ml)
1 GAP
prochlorperazine maleate oral tablet 10 mg, 5 mg 1 GAP
prochlorperazine rectal suppository 25 mg 2
promethazine oral tablet 12.5 mg, 25 mg, 50 mg 2
promethazine rectal suppository 12.5 mg, 25 mg, 50 mg 2
promethegan rectal suppository 25 mg, 50 mg 2
SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 HOUR
5 PA; QL (4 EA per 28 days)
TRANSDERM-SCOP TRANSDERMAL PATCH 72 HOUR 1.5 MG (1 MG OVER 3 DAYS)
4
Antifungals - Drugs To Treat Fungal Infections
ABELCET INTRAVENOUS SUSPENSION 5 MG/ML 5 PA
AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG
5
amphotericin b injection recon soln 50 mg 2
CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG
5
ciclopirox topical cream 0.77 % 1 GAP
ciclopirox topical gel 0.77 % 2
ciclopirox topical shampoo 1 % 2
ciclopirox topical solution 8 % 1 GAP
ciclopirox topical suspension 0.77 % 1 GAP
clotrimazole mucous membrane troche 10 mg 1 GAP
clotrimazole topical cream 1 % 1 GAP
clotrimazole topical solution 1 % 1 GAP
econazole topical cream 1 % 1 GAP
ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG
4
fluconazole in dextrose(iso-o) intravenous piggyback 400
mg/200 ml
1 GAP
27
Drug Name Tier Requirements/Limits
fluconazole oral suspension for reconstitution 10 mg/ml, 40
mg/ml
1 GAP
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 GAP
flucytosine oral capsule 250 mg, 500 mg 2
griseofulvin microsize oral suspension 125 mg/5 ml 2
griseofulvin microsize oral tablet 500 mg 2
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 2
itraconazole oral capsule 100 mg 2
ketoconazole oral tablet 200 mg 1 GAP
ketoconazole topical cream 2 % 1 GAP
ketoconazole topical shampoo 2 % 1 GAP
miconazole-3 vaginal suppository 200 mg 2
naftifine topical cream 1 % 2
NAFTIN TOPICAL CREAM 2 % 4
NAFTIN TOPICAL GEL 2 % 4
NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % 4
NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML)
5 PA
NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG
5 PA
nyamyc topical powder 100,000 unit/gram 1 GAP
nystatin oral suspension 100,000 unit/ml 1 GAP
nystatin oral tablet 500,000 unit 2
nystatin topical cream 100,000 unit/gram 1 GAP
nystatin topical ointment 100,000 unit/gram 1 GAP
nystatin topical powder 100,000 unit/gram 1 GAP
nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% 2
nystatin-triamcinolone topical ointment 100,000-0.1
unit/gram-%
2
nystop topical powder 100,000 unit/gram 1 GAP
ONMEL ORAL TABLET 200 MG 4 PA
OXISTAT TOPICAL CREAM 1 % 4
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 28
OXISTAT TOPICAL LOTION 1 % 4
SPORANOX ORAL SOLUTION 10 MG/ML 5 PA
terbinafine hcl oral tablet 250 mg 1 GAP; QL (84 EA per 168 days)
terconazole vaginal cream 0.4 %, 0.8 % 1 GAP
terconazole vaginal suppository 80 mg 2
voriconazole intravenous solution 200 mg 2
voriconazole oral suspension for reconstitution 200 mg/5 ml
(40 mg/ml)
5
voriconazole oral tablet 200 mg, 50 mg 5
zazole vaginal cream 0.4 %, 0.8 % 1 GAP
Antigout Agents - Drugs To Treat Gout
allopurinol oral tablet 100 mg, 300 mg 1 GAP
colchicine oral tablet 0.6 mg 2
colchicine-probenecid oral tablet 0.5-500 mg 1 GAP
probenecid oral tablet 500 mg 1 GAP
ULORIC ORAL TABLET 40 MG, 80 MG 4 ST
Anti-Inflammatory Agents - Drugs Used To Reduce Inflammation
diclofenac sodium topical gel 3 % 5
FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % 4 PA; QL (30 EA per 15 days)
tolmetin oral capsule 400 mg 2
tolmetin oral tablet 600 mg 2
Antimigraine Agents - Drugs To Treat Migraines
dihydroergotamine injection solution 1 mg/ml 2
DIHYDROERGOTAMINE NASAL SPRAY,NON-AEROSOL 0.5 MG/PUMP ACT. (4 MG/ML)
5 QL (8 ML per 28 days)
MIGERGOT RECTAL SUPPOSITORY 2-100 MG 4
naratriptan oral tablet 1 mg, 2.5 mg 1 GAP; QL (9 EA per 30 days)
RELPAX ORAL TABLET 20 MG, 40 MG 4 QL (9 EA per 30 days)
rizatriptan oral tablet 10 mg, 5 mg 2 QL (18 EA per 30 days)
29
Drug Name Tier Requirements/Limits
rizatriptan oral tablet,disintegrating 10 mg, 5 mg 2 QL (18 EA per 30 days)
sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5
mg/actuation
2 QL (18 EA per 30 days)
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 GAP; QL (18 EA per 30 days)
sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml 2 QL (8 ML per 30 days)
sumatriptan succinate subcutaneous solution 6 mg/0.5 ml 2 QL (10 ML per 30 days)
valproic acid oral capsule 250 mg 1 GAP
zolmitriptan oral tablet 2.5 mg, 5 mg 2 QL (12 EA per 30 days)
zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg 2 QL (12 EA per 30 days)
Antimyasthenic Agents - Drugs To Treat Myasthenia Gravis
guanidine oral tablet 125 mg 1 GAP
MESTINON ORAL SYRUP 60 MG/5 ML 4
MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG
4
pyridostigmine bromide oral tablet 60 mg 1 GAP
Antimycobacterials - Drugs To Treat Infections
CAPASTAT INJECTION RECON SOLN 1 GRAM 3
dapsone oral tablet 100 mg, 25 mg 1 GAP
ethambutol oral tablet 100 mg, 400 mg 1 GAP
isoniazid injection solution 100 mg/ml 2
isoniazid oral solution 50 mg/5 ml 2
isoniazid oral tablet 100 mg, 300 mg 1 GAP
PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM
4
PRIFTIN ORAL TABLET 150 MG 4
pyrazinamide oral tablet 500 mg 2
rifabutin oral capsule 150 mg 2
rifampin intravenous recon soln 600 mg 2
rifampin oral capsule 150 mg, 300 mg 1 GAP
RIFATER ORAL TABLET 50-120-300 MG 4
SIRTURO ORAL TABLET 100 MG 5
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 30
Drug Name Tier Requirements/Limits
TRECATOR ORAL TABLET 250 MG 4
Antineoplastics - Drugs To Treat Cancer And Cancer Treatment Side Effects
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG
5
adrucil intravenous solution 500 mg/10 ml 1 PA; GAP
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG
5 PA
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 5 PA
ALIMTA INTRAVENOUS RECON SOLN 500 MG 5
amifostine crystalline intravenous recon soln 500 mg 5
anastrozole oral tablet 1 mg 1 GAP
ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML 5
ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML 5 PA
AVASTIN INTRAVENOUS SOLUTION 25 MG/ML 5 PA
azacitidine injection recon soln 100 mg 5 PA
BELEODAQ INTRAVENOUS RECON SOLN 500 MG 5 PA
bicalutamide oral tablet 50 mg 1 GAP
BICNU INTRAVENOUS RECON SOLN 100 MG 3
bleomycin injection recon soln 30 unit 2 PA
BOSULIF ORAL TABLET 100 MG, 500 MG 5 PA
BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML 5
CAPRELSA ORAL TABLET 100 MG 5 PA; QL (60 EA per 30 days)
CAPRELSA ORAL TABLET 300 MG 5 PA; QL (90 EA per 30 days)
carboplatin intravenous solution 10 mg/ml 1 GAP
cisplatin intravenous solution 1 mg/ml 1 GAP
cladribine intravenous solution 10 mg/10 ml 5 PA
CLOLAR INTRAVENOUS SOLUTION 20 MG/20 ML 4
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY (20 MG [3]/DAY)
5 PA
31
Drug Name Tier Requirements/Limits
cyclophosphamide oral capsule 25 mg, 50 mg 2 PA
cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) 1 PA; GAP
cytarabine injection solution 20 mg/ml 1 PA; GAP
dacarbazine intravenous recon soln 200 mg 2
daunorubicin intravenous solution 5 mg/ml 2
DAUNOXOME INTRAVENOUS SOLUTION 2 MG/ML 5
decitabine intravenous recon soln 50 mg 5
dexrazoxane hcl intravenous recon soln 250 mg 5
DOCEFREZ INTRAVENOUS RECON SOLN 20 MG 5
docetaxel intravenous solution 80 mg/4 ml (20 mg/ml) 5
DOCETAXEL INTRAVENOUS SOLUTION 80 MG/8 ML (10 MG/ML)
5
doxorubicin intravenous solution 50 mg/25 ml 1 PA; GAP
DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 3
ELITEK INTRAVENOUS RECON SOLN 1.5 MG 5
EMCYT ORAL CAPSULE 140 MG 4
epirubicin intravenous solution 50 mg/25 ml 1 GAP
ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML 5 PA
ERIVEDGE ORAL CAPSULE 150 MG 5 PA
ERWINAZE INTRAMUSCULAR RECON SOLN 10,000 UNIT
5 PA
ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG 4
etoposide intravenous solution 20 mg/ml 1 GAP
exemestane oral tablet 25 mg 2
FARESTON ORAL TABLET 60 MG 5
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 5 PA; QL (6 EA per 21 days)
FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML 5
fludarabine intravenous recon soln 50 mg 2
fluorouracil intravenous solution 2.5 gram/50 ml 1 PA; GAP
flutamide oral capsule 125 mg 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 32
Drug Name Tier Requirements/Limits
FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML)
5 PA
gemcitabine intravenous recon soln 1 gram 5
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 5 PA
GLEEVEC ORAL TABLET 100 MG, 400 MG 5 PA
HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML)
5 PA
HERCEPTIN INTRAVENOUS RECON SOLN 440 MG 5 PA
HEXALEN ORAL CAPSULE 50 MG 5 PA
hydroxyurea oral capsule 500 mg 1 GAP
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 5 PA
ICLUSIG ORAL TABLET 15 MG 5 PA; QL (60 EA per 30 days)
ICLUSIG ORAL TABLET 45 MG 5 PA
idarubicin intravenous solution 1 mg/ml 5
ifosfamide intravenous recon soln 1 gram 2
IMBRUVICA ORAL CAPSULE 140 MG 5 PA
INLYTA ORAL TABLET 1 MG, 5 MG 5 PA
IRINOTECAN INTRAVENOUS SOLUTION 100 MG/5 ML 4
ISTODAX INTRAVENOUS RECON SOLN 10 MG/2 ML 5 PA
IXEMPRA INTRAVENOUS RECON SOLN 45 MG 5 PA
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG
5 PA
JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION)
5 PA
KADCYLA INTRAVENOUS RECON SOLN 100 MG 5 PA
KEYTRUDA INTRAVENOUS RECON SOLN 50 MG 5 PA
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY), 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY), 24 MG (10 MG[2] -4 MG[1])/DAY
5 PA
letrozole oral tablet 2.5 mg 1 GAP
leucovorin calcium injection recon soln 100 mg, 350 mg 2
33
Drug Name Tier Requirements/Limits
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg 2
leucovorin calcium oral tablet 5 mg 1 GAP
LEUKERAN ORAL TABLET 2 MG 3
LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION 10 MG/ML
5
lomustine oral capsule 10 mg, 100 mg, 40 mg 2
LYNPARZA ORAL CAPSULE 50 MG 5 PA
MATULANE ORAL CAPSULE 50 MG 5
MEKINIST ORAL TABLET 0.5 MG, 2 MG 5 PA
melphalan hcl intravenous recon soln 50 mg 5
mercaptopurine oral tablet 50 mg 1 GAP
mesna intravenous solution 100 mg/ml 2
MESNEX ORAL TABLET 400 MG 5
mitomycin intravenous recon soln 20 mg 2
mitoxantrone intravenous concentrate 2 mg/ml 2
MUSTARGEN INJECTION RECON SOLN 10 MG 3
NEXAVAR ORAL TABLET 200 MG 5 PA
NILANDRON ORAL TABLET 150 MG 5
ONCASPAR INJECTION SOLUTION 750 UNIT/ML 5
OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML 5 PA
oxaliplatin intravenous solution 100 mg/20 ml 5
paclitaxel intravenous concentrate 6 mg/ml 1 GAP
PANRETIN TOPICAL GEL 0.1 % 5
PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML)
5 PA
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 5 PA; QL (21 EA per 28 days)
PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT
5
PURIXAN ORAL SUSPENSION 20 MG/ML 5
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG
5 PA
RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML 5 PA
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 34
Drug Name Tier Requirements/Limits
SOLTAMOX ORAL SOLUTION 10 MG/5 ML 4
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
5 PA
STIVARGA ORAL TABLET 40 MG 5 PA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
5 PA
SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG
5 PA
SYLVANT INTRAVENOUS RECON SOLN 100 MG 5 PA
SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 5 PA
TABLOID ORAL TABLET 40 MG 4
TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA
tamoxifen oral tablet 10 mg, 20 mg 1 GAP
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG 5 PA
TARGRETIN ORAL CAPSULE 75 MG 5 PA
TARGRETIN TOPICAL GEL 1 % 5 PA
TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
5 PA
toposar intravenous solution 20 mg/ml 1 GAP
topotecan intravenous recon soln 4 mg 5
TREANDA INTRAVENOUS RECON SOLN 100 MG 5
TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML 5
tretinoin (chemotherapy) oral capsule 10 mg 5
TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML 4
TYKERB ORAL TABLET 250 MG 5 PA
VALCHLOR TOPICAL GEL 0.016 % 5 PA
VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML)
5 PA
VELCADE INJECTION RECON SOLN 3.5 MG 5 PA
vinblastine intravenous solution 1 mg/ml 1 PA; GAP
Drug Name Tier Requirements/Limits
35
vincasar pfs intravenous solution 1 mg/ml 1 PA; GAP
vincristine intravenous solution 1 mg/ml 1 PA; GAP
vinorelbine intravenous solution 50 mg/5 ml 1 GAP
VOTRIENT ORAL TABLET 200 MG 5 PA
XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA
XTANDI ORAL CAPSULE 40 MG 5 PA
YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML)
5 PA
ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML)
5 PA
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM 4
ZELBORAF ORAL TABLET 240 MG 5 PA
ZOLINZA ORAL CAPSULE 100 MG 5 PA
ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA; QL (60 EA per 30 days)
ZYKADIA ORAL CAPSULE 150 MG 5 PA
ZYTIGA ORAL TABLET 250 MG 5 PA
Antiparasitics - Drugs To Treat Parasitic Infections
ALBENZA ORAL TABLET 200 MG 5
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML
4
ALINIA ORAL TABLET 500 MG 4
atovaquone oral suspension 750 mg/5 ml 5
atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg 2
chloroquine phosphate oral tablet 250 mg, 500 mg 2
COARTEM ORAL TABLET 20-120 MG 3 QL (24 EA per 30 days)
DARAPRIM ORAL TABLET 25 MG 4
EURAX TOPICAL CREAM 10 % 3
EURAX TOPICAL LOTION 10 % 3
hydroxychloroquine oral tablet 200 mg 1 GAP
ivermectin oral tablet 3 mg 2
lindane topical lotion 1 % 2
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 36
lindane topical shampoo 1 % 2
malathion topical lotion 0.5 % 2
mefloquine oral tablet 250 mg 2
NEBUPENT INHALATION RECON SOLN 300 MG 4 PA
PENTAM INJECTION RECON SOLN 300 MG 4
permethrin topical cream 5 % 2
PRIMAQUINE ORAL TABLET 26.3 MG 4
quinine sulfate oral capsule 324 mg 2
SKLICE TOPICAL LOTION 0.5 % 4
tinidazole oral tablet 250 mg, 500 mg 2
Antiparkinson Agents - Drugs To Treat Parasitic Infections
APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML 5 PA
AZILECT ORAL TABLET 0.5 MG, 1 MG 4
benztropine injection solution 2 mg/2 ml 2
benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 GAP
bromocriptine oral capsule 5 mg 2
bromocriptine oral tablet 2.5 mg 2
carbidopa oral tablet 25 mg 2
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-
250 mg
1 GAP
carbidopa-levodopa oral tablet extended release 25-100 mg,
50-200 mg
1 GAP
carbidopa-levodopa oral tablet,disintegrating 10-100 mg, 25-
100 mg, 25-250 mg
2
carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg,
18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-
150-200 mg, 50-200-200 mg
2
entacapone oral tablet 200 mg 2
NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR
4 ST
37
Drug Name Tier Requirements/Limits
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1
mg, 1.5 mg
1 GAP
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg, 5 mg
1 GAP
ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4
mg, 6 mg, 8 mg
2
selegiline hcl oral capsule 5 mg 2
selegiline hcl oral tablet 5 mg 2
tolcapone oral tablet 100 mg 5
trihexyphenidyl oral elixir 0.4 mg/ml 1 GAP
trihexyphenidyl oral tablet 2 mg, 5 mg 1 GAP
Antipsychotics - Drugs To Treat Mood Disorders
ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG
5 ST; QL (60 EA per 30 days)
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG
5 ST
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG
5 ST
aripiprazole oral tablet 10 mg, 15 mg 2 QL (30 EA per 30 days)
aripiprazole oral tablet 2 mg, 5 mg 2 QL (60 EA per 30 days)
aripiprazole oral tablet 20 mg, 30 mg 5 QL (30 EA per 30 days)
chlorpromazine injection solution 25 mg/ml 2
chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50
mg
2
clozapine oral tablet 100 mg, 25 mg 2 QL (270 EA per 30 days)
clozapine oral tablet 200 mg 2 QL (120 EA per 30 days)
clozapine oral tablet 50 mg 2 QL (180 EA per 30 days)
clozapine oral tablet,disintegrating 100 mg, 25 mg 2 QL (270 EA per 30 days)
clozapine oral tablet,disintegrating 12.5 mg 2 QL (90 EA per 30 days)
clozapine oral tablet,disintegrating 150 mg 2 QL (180 EA per 30 days)
clozapine oral tablet,disintegrating 200 mg 2 QL (120 EA per 30 days)
FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG 4 ST; QL (60 EA per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 38
Drug Name Tier Requirements/Limits
FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG 5 ST; QL (60 EA per 30 days)
FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)
4 ST; QL (8 EA per 180 days)
fluphenazine decanoate injection solution 25 mg/ml 2
fluphenazine hcl injection solution 2.5 mg/ml 2
fluphenazine hcl oral concentrate 5 mg/ml 1 GAP
fluphenazine hcl oral elixir 2.5 mg/5 ml 1 GAP
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 GAP
GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.)
4
haloperidol decanoate intramuscular solution 100 mg/ml, 50
mg/ml
2
haloperidol lactate injection solution 5 mg/ml 2
haloperidol lactate oral concentrate 2 mg/ml 1 GAP
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5
mg
1 GAP
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG
5 ST; QL (30 EA per 30 days)
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG
5 ST; QL (60 EA per 30 days)
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML
5 ST
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML
4 ST
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG 5 ST; QL (30 EA per 30 days)
LATUDA ORAL TABLET 80 MG 5 ST; QL (60 EA per 30 days)
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1 GAP
olanzapine intramuscular recon soln 10 mg 2
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5
mg
1 GAP; QL (30 EA per 30 days)
olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5
mg
2 QL (30 EA per 30 days)
ORAP ORAL TABLET 1 MG, 2 MG 3
39
Drug Name Tier Requirements/Limits
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 2
quetiapine oral tablet 100 mg, 200 mg, 300 mg, 400 mg 1 GAP; QL (60 EA per 30 days)
quetiapine oral tablet 25 mg, 50 mg 1 GAP; QL (90 EA per 30 days)
RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML
4
RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML, 50 MG/2 ML
5
risperidone oral solution 1 mg/ml 2 QL (240 ML per 30 days)
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg
1 GAP; QL (60 EA per 30 days)
risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
2 QL (60 EA per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG
5 ST; QL (60 EA per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG, 5 MG
4 ST; QL (60 EA per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG
4 QL (30 EA per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 50 MG
4 QL (60 EA per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG
5 QL (60 EA per 30 days)
thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 GAP
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 GAP
trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg 2
VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 QL (540 ML per 30 days)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 2 QL (60 EA per 30 days)
ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG
4
Antispasticity Agents - Drugs To Treat Spasms
baclofen oral tablet 10 mg, 20 mg 1 GAP
dantrolene oral capsule 100 mg, 25 mg, 50 mg 1 GAP
tizanidine oral capsule 2 mg, 4 mg, 6 mg 2
tizanidine oral tablet 2 mg, 4 mg 1 GAP
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 40
Antivirals - Drugs To Treat Viral Infections
abacavir oral tablet 300 mg 2
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg 5 QL (60 EA per 30 days)
acyclovir oral capsule 200 mg 1 GAP
acyclovir oral suspension 200 mg/5 ml 2
acyclovir oral tablet 400 mg, 800 mg 1 GAP
acyclovir sodium intravenous solution 50 mg/ml 1 PA; GAP
acyclovir topical ointment 5 % 2
adefovir oral tablet 10 mg 5 PA; QL (30 EA per 30 days)
amantadine hcl oral capsule 100 mg 1 GAP
amantadine hcl oral solution 50 mg/5 ml 1 GAP
amantadine hcl oral tablet 100 mg 1 GAP
APTIVUS ORAL CAPSULE 250 MG 5 QL (120 EA per 30 days)
APTIVUS ORAL SOLUTION 100 MG/ML 5 QL (300 ML per 30 days)
ATRIPLA ORAL TABLET 600-200-300 MG 5 QL (30 EA per 30 days)
BARACLUDE ORAL SOLUTION 0.05 MG/ML 4 PA; QL (630 ML per 30 days)
cidofovir intravenous solution 75 mg/ml 5
COMPLERA ORAL TABLET 200-25-300 MG 5 QL (30 EA per 30 days)
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 4
DENAVIR TOPICAL CREAM 1 % 5
didanosine oral capsule,delayed release(dr/ec) 125 mg, 200
mg, 250 mg, 400 mg
2
EDURANT ORAL TABLET 25 MG 5
EMTRIVA ORAL CAPSULE 200 MG 4
EMTRIVA ORAL SOLUTION 10 MG/ML 4
entecavir oral tablet 0.5 mg, 1 mg 5 PA; QL (30 EA per 30 days)
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) 3
EPZICOM ORAL TABLET 600-300 MG 5
EVOTAZ ORAL TABLET 300-150 MG 5 QL (30 EA per 30 days)
41
Drug Name Tier Requirements/Limits
famciclovir oral tablet 125 mg, 250 mg 2 QL (60 EA per 30 days)
famciclovir oral tablet 500 mg 2
foscarnet intravenous solution 24 mg/ml 2 PA
FUZEON SUBCUTANEOUS RECON SOLN 90 MG 5 QL (60 EA per 30 days)
ganciclovir sodium intravenous recon soln 500 mg 2 PA
HARVONI ORAL TABLET 90-400 MG 5 PA; QL (168 EA per 365 days)
INTELENCE ORAL TABLET 100 MG 5 QL (120 EA per 30 days)
INTELENCE ORAL TABLET 200 MG 5 QL (60 EA per 30 days)
INTELENCE ORAL TABLET 25 MG 4 QL (240 EA per 30 days)
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)
5 PA
INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML 5 PA
INVIRASE ORAL CAPSULE 200 MG 5
INVIRASE ORAL TABLET 500 MG 5
ISENTRESS ORAL POWDER IN PACKET 100 MG 4
ISENTRESS ORAL TABLET 400 MG 5 QL (60 EA per 30 days)
ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG 3
KALETRA ORAL SOLUTION 400-100 MG/5 ML 5
KALETRA ORAL TABLET 100-25 MG 4
KALETRA ORAL TABLET 200-50 MG 5
lamivudine oral solution 10 mg/ml 2
lamivudine oral tablet 100 mg, 150 mg, 300 mg 2
lamivudine-zidovudine oral tablet 150-300 mg 2
LEXIVA ORAL SUSPENSION 50 MG/ML 4
LEXIVA ORAL TABLET 700 MG 5
moderiba dose pack oral tablets,dose pack 400 mg (7)- 400
mg (7), 600 mg (7)- 600 mg (7)
5
moderiba oral tablet 200 mg 2
nevirapine oral suspension 50 mg/5 ml 2
nevirapine oral tablet 200 mg 2
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 42
nevirapine oral tablet extended release 24 hr 400 mg 2
NORVIR ORAL CAPSULE 100 MG 3
NORVIR ORAL SOLUTION 80 MG/ML 3
NORVIR ORAL TABLET 100 MG 3
OLYSIO ORAL CAPSULE 150 MG 5 PA
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML
5 PA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML 5 PA
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML 5 PA
PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML
5 PA
PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML
5 PA
PREZCOBIX ORAL TABLET 800-150 MG-MG 5 QL (30 EA per 30 days)
PREZISTA ORAL SUSPENSION 100 MG/ML 5
PREZISTA ORAL TABLET 150 MG, 75 MG 4
PREZISTA ORAL TABLET 600 MG, 800 MG 5
REBETOL ORAL SOLUTION 40 MG/ML 5
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION
4 QL (112 EA per 365 days)
RESCRIPTOR ORAL TABLET 200 MG 4
RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG 4
RETROVIR INTRAVENOUS SOLUTION 10 MG/ML 4
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 5
REYATAZ ORAL POWDER IN PACKET 50 MG 4
ribasphere oral capsule 200 mg 2
ribasphere oral tablet 200 mg, 400 mg 2
RIBASPHERE ORAL TABLET 600 MG 5
Drug Name Tier Requirements/Limits
43
RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)
5
ribavirin oral capsule 200 mg 2
ribavirin oral tablet 200 mg 2
rimantadine oral tablet 100 mg 2
SELZENTRY ORAL TABLET 150 MG 5 QL (60 EA per 30 days)
SELZENTRY ORAL TABLET 300 MG 5 QL (120 EA per 30 days)
SOVALDI ORAL TABLET 400 MG 5 PA
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 GAP
stavudine oral recon soln 1 mg/ml 1 GAP
STRIBILD ORAL TABLET 150-150-200-300 MG 5 QL (30 EA per 30 days)
SUSTIVA ORAL CAPSULE 200 MG, 50 MG 4
SUSTIVA ORAL TABLET 600 MG 5
TAMIFLU ORAL CAPSULE 30 MG 3 QL (112 EA per 365 days)
TAMIFLU ORAL CAPSULE 45 MG 3 QL (60 EA per 365 days)
TAMIFLU ORAL CAPSULE 75 MG 3 QL (110 EA per 365 days)
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML
3 QL (720 ML per 365 days)
TIVICAY ORAL TABLET 50 MG 5
trifluridine ophthalmic drops 1 % 2
TRIUMEQ ORAL TABLET 600-50-300 MG 5 QL (30 EA per 30 days)
TRUVADA ORAL TABLET 200-300 MG 5 QL (30 EA per 30 days)
TYBOST ORAL TABLET 150 MG 3
TYZEKA ORAL TABLET 600 MG 5 PA; QL (30 EA per 30 days)
valacyclovir oral tablet 1 gram 2 QL (90 EA per 30 days)
valacyclovir oral tablet 500 mg 2 QL (60 EA per 30 days)
valganciclovir oral tablet 450 mg 5
VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)
4
VIRACEPT ORAL TABLET 250 MG, 625 MG 5
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 44
Drug Name Tier Requirements/Limits
VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG
4
VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) 5
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG
5
VITEKTA ORAL TABLET 150 MG, 85 MG 5 QL (30 EA per 30 days)
ZIAGEN ORAL SOLUTION 20 MG/ML 4
zidovudine oral capsule 100 mg 1 GAP
zidovudine oral syrup 10 mg/ml 1 GAP
zidovudine oral tablet 300 mg 1 GAP
ZIRGAN OPHTHALMIC GEL 0.15 % 4
ZOVIRAX TOPICAL CREAM 5 % 5
Anxiolytics - Drugs To Treat Anxiety
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 GAP
buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 GAP
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 GAP
diazepam intensol oral concentrate 5 mg/ml 2
diazepam oral solution 5 mg/5 ml 2
diazepam oral tablet 10 mg, 2 mg, 5 mg 1 GAP
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 GAP
meprobamate oral tablet 200 mg, 400 mg 2
Bipolar Agents - Drugs To Treat Mood Disorders
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1 GAP
lithium carbonate oral tablet 300 mg 1 GAP
lithium carbonate oral tablet extended release 300 mg, 450
mg
1 GAP
lithium citrate oral solution 8 meq/5 ml 1 GAP
Blood Glucose Regulators - Drugs To Regulate Blood Sugar
acarbose oral tablet 100 mg, 25 mg, 50 mg 1 GAP
Drug Name Tier Requirements/Limits
45
APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML
3
APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML 3
AVANDIA ORAL TABLET 2 MG 4 QL (120 EA per 30 days)
AVANDIA ORAL TABLET 4 MG 4 QL (60 EA per 30 days)
AVANDIA ORAL TABLET 8 MG 4 QL (30 EA per 30 days)
BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML
3 ST; QL (4 EA per 28 days)
BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG
3 ST; QL (4 EA per 28 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML
3 ST; QL (2.4 ML per 28 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML
3 ST; QL (4.8 ML per 28 days)
CYCLOSET ORAL TABLET 0.8 MG 4
glimepiride oral tablet 1 mg 1 GAP; QL (240 EA per 30 days)
glimepiride oral tablet 2 mg 1 GAP; QL (120 EA per 30 days)
glimepiride oral tablet 4 mg 1 GAP; QL (60 EA per 30 days)
glipizide oral tablet 10 mg 1 GAP; QL (120 EA per 30 days)
glipizide oral tablet 5 mg 1 GAP; QL (240 EA per 30 days)
glipizide oral tablet extended release 24hr 10 mg 1 GAP; QL (60 EA per 30 days)
glipizide oral tablet extended release 24hr 2.5 mg 1 GAP; QL (240 EA per 30 days)
glipizide oral tablet extended release 24hr 5 mg 1 GAP; QL (120 EA per 30 days)
glipizide-metformin oral tablet 2.5-250 mg 1 GAP; QL (240 EA per 30 days)
glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg 1 GAP; QL (120 EA per 30 days)
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG 4
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG
3
glyburide micronized oral tablet 1.5 mg 1 GAP; QL (240 EA per 30 days)
glyburide micronized oral tablet 3 mg 1 GAP; QL (120 EA per 30 days)
glyburide micronized oral tablet 6 mg 1 GAP; QL (60 EA per 30 days)
glyburide oral tablet 1.25 mg 1 GAP; QL (480 EA per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 46
Drug Name Tier Requirements/Limits
glyburide oral tablet 2.5 mg 1 GAP; QL (240 EA per 30 days)
glyburide oral tablet 5 mg 1 GAP; QL (120 EA per 30 days)
glyburide-metformin oral tablet 1.25-250 mg 1 GAP; QL (240 EA per 30 days)
glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg 1 GAP; QL (120 EA per 30 days)
GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG 4 QL (90 EA per 30 days)
HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML)
3
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50)
3
HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50)
3
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25)
3
HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25)
3
HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML
3
HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML, 100 UNIT/ML (PREFILLED SYRINGE)
3
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)
3
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)
3
HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)
3
HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML
3
HUMULIN R INJECTION SOLUTION 100 UNIT/ML 3
HUMULIN R U-500 "CONCENTRATED" SUBCUTANEOUS SOLUTION 500 UNIT/ML
3
INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG
3 ST
INVOKANA ORAL TABLET 100 MG, 300 MG 3 ST
JANUMET ORAL TABLET 50-1,000 MG 3 ST; QL (60 EA per 30 days)
47
Drug Name Tier Requirements/Limits
JANUMET ORAL TABLET 50-500 MG 3 ST; QL (120 EA per 30 days)
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG
3 ST; QL (30 EA per 30 days)
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG
3 ST; QL (60 EA per 30 days)
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 3 ST; QL (30 EA per 30 days)
KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG, 5-1,000 MG
3 ST; QL (60 EA per 30 days)
KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-500 MG
3 ST; QL (120 EA per 30 days)
LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)
3
LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML 3
metformin oral tablet 1,000 mg 1 GAP; QL (60 EA per 30 days)
metformin oral tablet 500 mg 1 GAP; QL (150 EA per 30 days)
metformin oral tablet 850 mg 1 GAP; QL (90 EA per 30 days)
metformin oral tablet extended release 24 hr 500 mg 1 GAP; QL (120 EA per 30 days)
metformin oral tablet extended release 24 hr 750 mg 1 GAP; QL (60 EA per 30 days)
nateglinide oral tablet 120 mg, 60 mg 2
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)
3
NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML
3
NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 3
NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML
3
NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)
3
NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)
3
NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML
3
NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 3
ONGLYZA ORAL TABLET 2.5 MG 3 ST; QL (60 EA per 30 days)
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 48
ONGLYZA ORAL TABLET 5 MG 3 ST; QL (30 EA per 30 days)
pioglitazone oral tablet 15 mg 2 QL (60 EA per 30 days)
pioglitazone oral tablet 30 mg 2 QL (45 EA per 30 days)
pioglitazone oral tablet 45 mg 2 QL (30 EA per 30 days)
pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg 2 QL (45 EA per 30 days)
pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg 2 QL (90 EA per 30 days)
PROGLYCEM ORAL SUSPENSION 50 MG/ML 4
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 2
RIOMET ORAL SOLUTION 500 MG/5 ML 4 QL (675 ML per 30 days)
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML
3 PA
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML
3 PA
tolazamide oral tablet 250 mg 2 QL (120 EA per 30 days)
tolazamide oral tablet 500 mg 2 QL (60 EA per 30 days)
tolbutamide oral tablet 500 mg 2 QL (180 EA per 30 days)
VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)
4 ST; QL (9 ML per 30 days)
Blood Products/Modifiers/Volume Expanders - Drugs To Treat Blood Disorders
AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR 25-200 MG
3
anagrelide oral capsule 0.5 mg, 1 mg 1 GAP
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML
5 PA
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML
4 PA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML
4 PA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML
5 PA
Drug Name Tier Requirements/Limits
49
argatroban in 0.9 % sod chlor intravenous solution 125
mg/125 ml (1 mg/ml)
2
argatroban intravenous solution 100 mg/ml 2
BRILINTA ORAL TABLET 90 MG 4
cilostazol oral tablet 100 mg, 50 mg 1 GAP
clopidogrel oral tablet 300 mg 2
clopidogrel oral tablet 75 mg 1 GAP
COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
3
dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 GAP
EFFIENT ORAL TABLET 10 MG, 5 MG 4
ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3 QL (60 EA per 30 days)
enoxaparin subcutaneous solution 300 mg/3 ml 5 QL (105 ML per 90 days)
enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml 5 QL (35 ML per 90 days)
enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8
ml
5 QL (28 ML per 90 days)
enoxaparin subcutaneous syringe 30 mg/0.3 ml 2 QL (10.5 ML per 90 days)
enoxaparin subcutaneous syringe 40 mg/0.4 ml 2 QL (14 ML per 90 days)
enoxaparin subcutaneous syringe 60 mg/0.6 ml 2 QL (21 ML per 90 days)
EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML
4 PA
EPOGEN INJECTION SOLUTION 20,000 UNIT/ML 5 PA
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4
ml, 7.5 mg/0.6 ml
5
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 2
FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML
5 QL (22.8 ML per 90 days)
FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML
5 QL (35 ML per 90 days)
FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML
5 QL (17.5 ML per 90 days)
FRAGMIN SUBCUTANEOUS SYRINGE 15,000 ANTI-XA UNIT/0.6 ML
5 QL (21 ML per 90 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 50
Drug Name Tier Requirements/Limits
FRAGMIN SUBCUTANEOUS SYRINGE 18,000 ANTI-XA UNIT/0.72 ML
5 QL (25.3 ML per 90 days)
FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML
4 QL (7 ML per 90 days)
FRAGMIN SUBCUTANEOUS SYRINGE 7,500 ANTI-XA UNIT/0.3 ML
5 QL (10.5 ML per 90 days)
GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML
5 PA
heparin (porcine) in 5 % dex intravenous parenteral solution
20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100
unit/ml)
1 GAP
heparin (porcine) injection solution 1,000 unit/ml, 10,000
unit/ml, 20,000 unit/ml, 5,000 unit/ml
1 GAP
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 6 mg, 7.5 mg
1 GAP
LEUKINE INJECTION RECON SOLN 250 MCG 5 PA
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML)
5 PA; QL (9.6 ML per 30 days)
NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML 5 PA
NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG 5 PA
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML
5 PA
NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML
5 PA
PRADAXA ORAL CAPSULE 150 MG, 75 MG 4 PA; QL (60 EA per 30 days)
PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML
4 PA
PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML
5 PA
PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG
5 PA
ticlopidine oral tablet 250 mg 1 GAP
tranexamic acid intravenous solution 1,000 mg/10 ml (100
mg/ml)
2
Drug Name Tier Requirements/Limits
51
tranexamic acid oral tablet 650 mg 2
warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 6 mg, 7.5 mg
1 GAP
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG 3
XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)
3 QL (102 EA per 365 days)
Cardiovascular Agents - Drugs To Treat Heart And Circulation Conditions
acebutolol oral capsule 200 mg, 400 mg 1 GAP
acetazolamide oral tablet 125 mg, 250 mg 2
afeditab cr oral tablet extended release 30 mg, 60 mg 1 GAP
ALDACTAZIDE ORAL TABLET 50-50 MG 4
amiloride oral tablet 5 mg 1 GAP
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 GAP
amiodarone intravenous solution 50 mg/ml 1 GAP
amiodarone oral tablet 200 mg 1 GAP
amiodarone oral tablet 400 mg 2
amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1 GAP
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-
40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg,
5-20 mg, 5-40 mg, 5-80 mg
2
amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-
10 mg, 5-10 mg, 5-20 mg, 5-40 mg
1 GAP
amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-
160 mg, 5-320 mg
2 QL (30 EA per 30 days)
amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg,
10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg
2 QL (30 EA per 30 days)
atenolol oral tablet 100 mg, 25 mg, 50 mg 1 GAP
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 GAP
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 GAP
AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG
4 ST; QL (30 EA per 30 days)
benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 52
Drug Name Tier Requirements/Limits
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-
12.5 mg, 20-25 mg, 5-6.25 mg
1 GAP
BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG
3 QL (60 EA per 30 days)
BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG 3 QL (60 EA per 30 days)
betaxolol oral tablet 10 mg, 20 mg 2
bisoprolol fumarate oral tablet 10 mg, 5 mg 2
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-
6.25 mg, 5-6.25 mg
1 GAP
bumetanide injection solution 0.25 mg/ml 1 GAP
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 GAP
BYSTOLIC ORAL TABLET 10 MG 3 QL (120 EA per 30 days)
BYSTOLIC ORAL TABLET 2.5 MG 3 QL (30 EA per 30 days)
BYSTOLIC ORAL TABLET 20 MG 3 QL (60 EA per 30 days)
BYSTOLIC ORAL TABLET 5 MG 3 QL (90 EA per 30 days)
candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg 2
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-
12.5 mg, 32-25 mg
2
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 GAP
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg,
50-15 mg, 50-25 mg
2
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg,
240 mg, 300 mg
1 GAP
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 GAP
chlorothiazide oral tablet 250 mg, 500 mg 1 GAP
chlorothiazide sodium intravenous recon soln 500 mg 2
chlorthalidone oral tablet 25 mg, 50 mg 1 GAP
cholestyramine light oral powder in packet 4 gram 2
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 GAP
clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24
hr, 0.3 mg/24 hr
2 QL (8 EA per 28 days)
53
Drug Name Tier Requirements/Limits
colestipol oral granules 5 gram 2
colestipol oral tablet 1 gram 2
COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG
3 QL (30 EA per 30 days)
CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 QL (30 EA per 30 days)
DEMSER ORAL CAPSULE 250 MG 4
digitek oral tablet 125 mcg 1 GAP; QL (30 EA per 30 days)
digitek oral tablet 250 mcg 1 GAP
digoxin injection solution 250 mcg/ml 1 GAP
digoxin oral solution 50 mcg/ml 1 GAP
digoxin oral tablet 125 mcg 1 GAP; QL (30 EA per 30 days)
digoxin oral tablet 250 mcg 1 GAP
diltiazem hcl intravenous solution 5 mg/ml 1 GAP
diltiazem hcl oral capsule, extended release 180 mg, 360 mg,
420 mg
1 GAP
diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60
mg, 90 mg
1 GAP
diltiazem hcl oral capsule,extended release 24hr 120 mg, 240
mg, 300 mg
1 GAP
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 GAP
dilt-xr oral capsule,ext release degradable 120 mg, 180 mg,
240 mg
1 GAP
disopyramide phosphate oral capsule 100 mg, 150 mg 1 GAP
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 GAP
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 GAP
eplerenone oral tablet 25 mg, 50 mg 2
eprosartan oral tablet 600 mg 2
felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5
mg
1 GAP
fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg,
43 mg
2
fenofibrate micronized oral capsule 67 mg 1 GAP
fenofibrate nanocrystallized oral tablet 145 mg 2
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 54
Drug Name Tier Requirements/Limits
fenofibrate nanocrystallized oral tablet 48 mg 1 GAP
fenofibrate oral tablet 160 mg, 54 mg 1 GAP
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
135 mg, 45 mg
2
flecainide oral tablet 100 mg, 150 mg, 50 mg 1 GAP
fluvastatin oral capsule 20 mg, 40 mg 2
fosinopril oral tablet 10 mg, 20 mg, 40 mg 1 GAP
fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg
1 GAP
furosemide injection solution 10 mg/ml 1 GAP
furosemide injection syringe 10 mg/ml 1 GAP
furosemide oral solution 10 mg/ml, 40 mg/5 ml 1 GAP
furosemide oral tablet 20 mg, 40 mg, 80 mg 1 GAP
gemfibrozil oral tablet 600 mg 1 GAP
guanfacine oral tablet 1 mg, 2 mg 1 GAP
hydralazine injection solution 20 mg/ml 2
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 GAP
hydrochlorothiazide oral capsule 12.5 mg 1 GAP
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 GAP
indapamide oral tablet 1.25 mg, 2.5 mg 1 GAP
irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 GAP
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-
12.5 mg
2
ISORDIL ORAL TABLET 40 MG 3
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 1 GAP
isosorbide dinitrate oral tablet extended release 40 mg 1 GAP
isosorbide mononitrate oral tablet 10 mg, 20 mg 1 GAP
isosorbide mononitrate oral tablet extended release 24 hr 120
mg, 30 mg, 60 mg
1 GAP
isradipine oral capsule 2.5 mg, 5 mg 1 GAP
55
Drug Name Tier Requirements/Limits
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG
5 PA; QL (30 EA per 30 days)
KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML 5 PA; QL (4 ML per 28 days)
labetalol intravenous solution 5 mg/ml 1 GAP
labetalol oral tablet 100 mg, 200 mg, 300 mg 1 GAP
LANOXIN INJECTION SOLUTION 250 MCG/ML 3
LANOXIN ORAL TABLET 125 MCG 3 QL (30 EA per 30 days)
LANOXIN ORAL TABLET 250 MCG 3
LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR 80 MG
4 ST
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5
mg
1 GAP
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg
1 GAP
losartan oral tablet 100 mg, 25 mg, 50 mg 1 GAP
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25
mg, 50-12.5 mg
1 GAP
lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 GAP
matzim la oral tablet extended release 24 hr 180 mg, 240 mg,
300 mg, 360 mg, 420 mg
2
methazolamide oral tablet 25 mg, 50 mg 1 GAP
methyclothiazide oral tablet 5 mg 1 GAP
methyldopa oral tablet 250 mg, 500 mg 1 GAP
methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-
25 mg
1 GAP
metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 GAP
metoprolol succinate oral tablet extended release 24 hr 100
mg, 200 mg, 25 mg, 50 mg
2
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50
mg, 50-25 mg
1 GAP
metoprolol tartrate intravenous solution 5 mg/5 ml 1 GAP
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 GAP
mexiletine oral capsule 150 mg, 200 mg, 250 mg 1 GAP
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 56
midodrine oral tablet 10 mg, 2.5 mg, 5 mg 2
minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr
1 GAP
minoxidil oral tablet 10 mg, 2.5 mg 1 GAP
moexipril oral tablet 15 mg, 7.5 mg 2
moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25
mg, 7.5-12.5 mg
1 GAP
MULTAQ ORAL TABLET 400 MG 4
nadolol oral tablet 20 mg, 40 mg, 80 mg 2
nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg 2
niacin oral tablet extended release 24 hr 1,000 mg, 500 mg,
750 mg
2 QL (60 EA per 30 days)
niacor oral tablet 500 mg 1 GAP
nicardipine intravenous solution 25 mg/10 ml 2
nicardipine oral capsule 20 mg, 30 mg 1 GAP
nifedical xl oral tablet extended release 24hr 30 mg, 60 mg 1 GAP
nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90
mg
1 GAP
nimodipine oral capsule 30 mg 2
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg,
25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
2
nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) 1 GAP
nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr
1 GAP
nitroglycerin translingual spray,non-aerosol 400 mcg/spray 2
NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG
3
NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG 5 PA
omega-3 acid ethyl esters oral capsule 1 gram 2
pacerone oral tablet 100 mg, 400 mg 2
pacerone oral tablet 200 mg 1 GAP
57
Drug Name Tier Requirements/Limits
pentoxifylline oral tablet extended release 400 mg 1 GAP
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 2
pindolol oral tablet 10 mg, 5 mg 2
pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 GAP
prazosin oral capsule 1 mg, 2 mg, 5 mg 1 GAP
prevalite oral powder 4 gram 2
procainamide injection solution 100 mg/ml, 500 mg/ml 2
propafenone oral capsule,extended release 12 hr 225 mg, 325
mg, 425 mg
2
propafenone oral tablet 150 mg, 225 mg, 300 mg 1 GAP
propranolol intravenous solution 1 mg/ml 1 GAP
propranolol oral capsule,extended release 24 hr 120 mg, 160
mg, 60 mg, 80 mg
2
propranolol oral solution 20 mg/5 ml, 40 mg/5 ml 1 GAP
propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 GAP
propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25
mg
1 GAP
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 GAP
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg
1 GAP
quinidine gluconate injection solution 80 mg/ml 2
quinidine gluconate oral tablet extended release 324 mg 2
quinidine sulfate oral tablet 200 mg, 300 mg 1 GAP
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 GAP
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG
4 PA; QL (120 EA per 30 days)
reserpine oral tablet 0.1 mg 1 GAP; QL (30 EA per 30 days)
reserpine oral tablet 0.25 mg 1 GAP
SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-20 MG, 1,000-40 MG, 500-40 MG
4 ST; QL (60 EA per 30 days)
SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 500-20 MG, 750-20 MG
4 ST; QL (30 EA per 30 days)
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 58
Drug Name Tier Requirements/Limits
sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 2
sotalol af oral tablet 120 mg 2
sotalol oral tablet 160 mg, 240 mg, 80 mg 2
spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 GAP
spironolacton-hydrochlorothiaz oral tablet 25-25 mg 1 GAP
taztia xt oral capsule, extended release 120 mg, 180 mg, 240
mg, 300 mg, 360 mg
1 GAP
TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG
4 ST; QL (30 EA per 30 days)
TEKTURNA ORAL TABLET 150 MG, 300 MG 4 ST; QL (30 EA per 30 days)
telmisartan oral tablet 20 mg, 40 mg, 80 mg 2
telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10
mg, 80-5 mg
2
telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-
12.5 mg, 80-25 mg
2 QL (60 EA per 30 days)
TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG
4
timolol maleate oral tablet 10 mg, 20 mg, 5 mg 2
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 GAP
trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 GAP
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-
25 mg
1 GAP
triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50
mg
1 GAP
TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG
4 ST
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 2
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-
25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
2
verapamil intravenous solution 2.5 mg/ml 2
verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300
mg
1 GAP
59
Drug Name Tier Requirements/Limits
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg,
240 mg, 360 mg
1 GAP
verapamil oral tablet 120 mg, 40 mg, 80 mg 1 GAP
verapamil oral tablet extended release 120 mg, 180 mg, 240
mg
1 GAP
VYTORIN 10-10 ORAL TABLET 10-10 MG 3 QL (30 EA per 30 days)
VYTORIN 10-20 ORAL TABLET 10-20 MG 3 QL (30 EA per 30 days)
VYTORIN 10-40 ORAL TABLET 10-40 MG 3 QL (30 EA per 30 days)
VYTORIN 10-80 ORAL TABLET 10-80 MG 3 QL (30 EA per 30 days)
ZETIA ORAL TABLET 10 MG 3 QL (30 EA per 30 days)
Central Nervous System Agents - Drugs That Act On All Tissues Of The Body
amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg,
20 mg, 30 mg, 5 mg, 7.5 mg
2 QL (60 EA per 30 days)
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG
5 PA; QL (60 EA per 30 days)
AUBAGIO ORAL TABLET 14 MG, 7 MG 5 PA; QL (30 EA per 30 days)
AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG
5 PA; QL (2 EA per 28 days)
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML
5 PA; QL (2 EA per 28 days)
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML
5 PA; QL (2 EA per 28 days)
BETASERON SUBCUTANEOUS KIT 0.3 MG 5 PA; QL (15 EA per 30 days)
clonidine hcl oral tablet extended release 12 hr 0.1 mg 2
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 5 PA; QL (12 ML per 28 days)
dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15
mg, 30 mg, 40 mg, 5 mg
2 QL (30 EA per 30 days)
dexmethylphenidate oral capsule,er biphasic 50-50 20 mg 2 QL (60 EA per 30 days)
dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg 1 GAP; QL (60 EA per 30 days)
dextroamphetamine oral capsule, extended release 10 mg 2 QL (180 EA per 30 days)
dextroamphetamine oral capsule, extended release 15 mg 2 QL (120 EA per 30 days)
dextroamphetamine oral capsule, extended release 5 mg 2 QL (90 EA per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 60
Drug Name Tier Requirements/Limits
dextroamphetamine-amphetamine oral capsule,extended
release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg
2 QL (30 EA per 30 days)
EXTAVIA SUBCUTANEOUS KIT 0.3 MG 5 PA; QL (15 EA per 30 days)
GILENYA ORAL CAPSULE 0.5 MG 5 PA; QL (28 EA per 28 days)
glatopa subcutaneous syringe 20 mg/ml 5 PA; QL (30 ML per 30 days)
HETLIOZ ORAL CAPSULE 20 MG 5 PA; QL (30 EA per 30 days)
metadate er oral tablet extended release 20 mg 2 QL (90 EA per 30 days)
methylphenidate oral capsule, er biphasic 30-70 10 mg 2 QL (60 EA per 30 days)
methylphenidate oral capsule, er biphasic 30-70 50 mg, 60 mg 2 QL (30 EA per 30 days)
methylphenidate oral tablet 10 mg, 20 mg, 5 mg 1 GAP; QL (90 EA per 30 days)
methylphenidate oral tablet extended release 10 mg 2 QL (180 EA per 30 days)
methylphenidate oral tablet extended release 20 mg 2 QL (90 EA per 30 days)
methylphenidate oral tablet extended release 24hr 18 mg 2 QL (120 EA per 30 days)
methylphenidate oral tablet extended release 24hr 27 mg, 54
mg
2 QL (30 EA per 30 days)
methylphenidate oral tablet extended release 24hr 36 mg 2 QL (60 EA per 30 days)
NUEDEXTA ORAL CAPSULE 20-10 MG 3
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML
5 PA; QL (2 ML per 365 days)
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML
5 PA; QL (2 ML per 28 days)
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML
5 PA; QL (6 ML per 28 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML
5 PA; QL (6 ML per 28 days)
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)
5 PA; QL (4.2 ML per 28 days)
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)
5 PA; QL (4.2 ML per 28 days)
riluzole oral tablet 50 mg 2 PA; QL (60 EA per 30 days)
SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG
3 PA; QL (60 EA per 30 days)
61
Drug Name Tier Requirements/Limits
SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42)
3 PA; QL (55 EA per 28 days)
STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG
3 QL (30 EA per 30 days)
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG
5 PA; QL (60 EA per 30 days)
TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML 5 PA; QL (15 ML per 28 days)
XENAZINE ORAL TABLET 12.5 MG, 25 MG 5 PA; QL (125 EA per 25 days)
Dental And Oral Agents - Drugs To Treat Mouth And Throat Conditions
cevimeline oral capsule 30 mg 2
chlorhexidine gluconate mucous membrane mouthwash 0.12
%
1 GAP
KEPIVANCE INTRAVENOUS RECON SOLN 6.25 MG 5
periogard mucous membrane mouthwash 0.12 % 1 GAP
pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 GAP
triamcinolone acetonide dental paste 0.1 % 2
Dermatological Agents - Drugs To Treat Skin Conditions
ACANYA TOPICAL GEL 1.2-2.5 % 4
acitretin oral capsule 10 mg, 17.5 mg, 25 mg 5 PA
ACZONE TOPICAL GEL 5 % 4
adapalene topical cream 0.1 % 2 PA
adapalene topical gel 0.1 %, 0.3 % 2 PA
ammonium lactate topical cream 12 % 1 GAP
ammonium lactate topical lotion 12 % 1 GAP
amnesteem oral capsule 10 mg, 20 mg, 40 mg 2
ATRALIN TOPICAL GEL 0.05 % 4 PA
avita topical cream 0.025 % 2 PA
avita topical gel 0.025 % 2 PA
AZELEX TOPICAL CREAM 20 % 4
calcipotriene topical cream 0.005 % 2
calcipotriene topical ointment 0.005 % 2
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 62
Drug Name Tier Requirements/Limits
calcipotriene topical solution 0.005 % 2
calcitriol topical ointment 3 mcg/gram 2
claravis oral capsule 10 mg, 20 mg, 40 mg 2
CLARAVIS ORAL CAPSULE 30 MG 5
clindamycin-benzoyl peroxide topical gel 1-5 % 2
clotrimazole-betamethasone topical cream 1-0.05 % 2
clotrimazole-betamethasone topical lotion 1-0.05 % 2
CONDYLOX TOPICAL GEL 0.5 % 4
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML
5 PA
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML
5 PA
ELIDEL TOPICAL CREAM 1 % 4 ST
erythromycin-benzoyl peroxide topical gel 3-5 % 1 GAP
FINACEA TOPICAL GEL 15 % 4
fluocinolone topical cream 0.01 %, 0.025 % 2
fluocinolone topical oil 0.01 % 2
fluocinolone topical ointment 0.025 % 2
fluocinolone topical solution 0.01 % 2
fluorouracil topical cream 0.5 % 5
fluorouracil topical cream 5 % 2
fluorouracil topical solution 2 %, 5 % 2
gauze pad topical bandage 2 x 2 " 1 GAP
imiquimod topical cream in packet 5 % 2
methoxsalen rapid oral capsule 10 mg 5
myorisan oral capsule 10 mg, 20 mg, 40 mg 2
neuac topical gel 1.2 %(1 % base) -5 % 2
podofilox topical solution 0.5 % 1 GAP
PRUDOXIN TOPICAL CREAM 5 % 4
SANTYL TOPICAL OINTMENT 250 UNIT/GRAM 4
Drug Name Tier Requirements/Limits
63
selenium sulfide topical suspension 2.5 % 1 GAP
STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML
5 PA
tacrolimus topical ointment 0.03 %, 0.1 % 2 ST
TAZORAC TOPICAL CREAM 0.05 %, 0.1 % 4 PA; QL (100 GM per 30 days)
TAZORAC TOPICAL GEL 0.05 %, 0.1 % 4 PA; QL (100 GM per 30 days)
tretinoin microspheres topical gel with pump 0.04 %, 0.1 % 2 PA
tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 2 PA
tretinoin topical gel 0.01 %, 0.025 % 2 PA
VEREGEN TOPICAL OINTMENT 15 % 4
VOLTAREN TOPICAL GEL 1 % 3
zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg 2
ZONALON TOPICAL CREAM 5 % 4
ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 %
4
ZYCLARA TOPICAL CREAM IN PACKET 3.75 % 5
Enzyme Replacement/Modifiers - Drug To Treat Enzyme Deficiency
ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML 5 PA
ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML
5 PA
CERDELGA ORAL CAPSULE 84 MG 5 PA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 5 PA
CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT
3
CYSTADANE ORAL POWDER 1 GRAM/1.7 ML 5
CYSTAGON ORAL CAPSULE 150 MG, 50 MG 4
ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML 5 PA
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT 5 PA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 PA
KUVAN ORAL POWDER IN PACKET 500 MG 5 PA
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 64
Drug Name Tier Requirements/Limits
KUVAN ORAL TABLET,SOLUBLE 100 MG 5 PA
LUMIZYME INTRAVENOUS RECON SOLN 50 MG 5 PA
MYOZYME INTRAVENOUS RECON SOLN 50 MG 5 PA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML 5 PA
PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-25,000 -43,750 UNIT, 16,800-40,000 -70,000 UNIT, 21,000-37,000 -61,000 UNIT, 4,200-10,000 -17,500 UNIT
4
PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 8,000-28,750- 30,250 UNIT
4
RAVICTI ORAL LIQUID 1.1 GRAM/ML 5 PA
sodium phenylbutyrate oral powder 0.94 gram/gram 5
ULTRESA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 13,800-27,600 UNIT
4
ULTRESA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20,700-41,400 UNIT, 23,000-46,000 UNIT
5
VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT
4
VPRIV INTRAVENOUS RECON SOLN 400 UNIT 5 PA
ZAVESCA ORAL CAPSULE 100 MG 5 PA
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-136,000- 218,000 UNIT, 5,000-17,000 -27,000 UNIT
3
Gastrointestinal Agents - Drugs To Treat Bowel, Intestine, And Stomach Conditions
alosetron oral tablet 0.5 mg, 1 mg 2 QL (60 EA per 30 days)
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 4 PA; QL (60 EA per 30 days)
amoxicil-clarithromy-lansopraz oral combo pack 500-500-30
mg
2
CARAFATE ORAL SUSPENSION 100 MG/ML 3
CHENODAL ORAL TABLET 250 MG 5
Drug Name Tier Requirements/Limits
65
cimetidine hcl oral solution 300 mg/5 ml 1 GAP
cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg 1 GAP
constulose oral solution 10 gram/15 ml 1 GAP
cromolyn oral concentrate 100 mg/5 ml 1 GAP
DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG
3 QL (30 EA per 30 days)
dicyclomine oral capsule 10 mg 1 GAP
dicyclomine oral tablet 20 mg 1 GAP
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml 1 GAP
diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 GAP
enulose oral solution 10 gram/15 ml 1 GAP
esomeprazole magnesium oral capsule,delayed release(dr/ec)
20 mg, 40 mg
2 QL (30 EA per 30 days)
esomeprazole sodium intravenous recon soln 20 mg, 40 mg 2
famotidine (pf) intravenous solution 20 mg/2 ml 2
famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50
ml
2
famotidine oral suspension 40 mg/5 ml 2
famotidine oral tablet 20 mg, 40 mg 1 GAP
GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG 5 PA
gavilyte-c oral recon soln 240-22.72-6.72 -5.84 gram 1 GAP
gavilyte-g oral recon soln 236-22.74-6.74 -5.86 gram 1 GAP
gavilyte-n oral recon soln 420 gram 1 GAP
generlac oral solution 10 gram/15 ml 1 GAP
glycopyrrolate injection solution 0.2 mg/ml 2
glycopyrrolate oral tablet 1 mg, 2 mg 2
KRISTALOSE ORAL PACKET 10 GRAM, 20 GRAM 4
lactulose oral solution 10 gram/15 ml 1 GAP
lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30
mg
2 QL (30 EA per 30 days)
LINZESS ORAL CAPSULE 145 MCG, 290 MCG 4 PA; QL (30 EA per 30 days)
loperamide oral capsule 2 mg 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 66
Drug Name Tier Requirements/Limits
methscopolamine oral tablet 2.5 mg, 5 mg 2
metoclopramide hcl injection solution 5 mg/ml 1 GAP
metoclopramide hcl oral solution 5 mg/5 ml 1 GAP
metoclopramide hcl oral tablet 10 mg, 5 mg 1 GAP
metoclopramide hcl oral tablet,disintegrating 5 mg 2
misoprostol oral tablet 100 mcg, 200 mcg 2
MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 GRAM
3
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG
3 QL (30 EA per 30 days)
nizatidine oral capsule 150 mg, 300 mg 2
nizatidine oral solution 150 mg/10 ml 2
OMECLAMOX-PAK ORAL COMBO PACK 20 MG (20)- 500 MG (20)
4
omeprazole oral capsule,delayed release(dr/ec) 10 mg, 40 mg 1 GAP; QL (30 EA per 30 days)
omeprazole oral capsule,delayed release(dr/ec) 20 mg 1 GAP; QL (60 EA per 30 days)
omeprazole-sodium bicarbonate oral capsule 20-1.1 mg-
gram, 40-1.1 mg-gram
2 QL (30 EA per 30 days)
OSMOPREP ORAL TABLET 1.5 GRAM 3
pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg 1 GAP; QL (30 EA per 30 days)
peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86
gram
1 GAP
polyethylene glycol 3350 oral powder 17 gram/dose 1 GAP
propantheline oral tablet 15 mg 1 GAP
rabeprazole oral tablet,delayed release (dr/ec) 20 mg 2 QL (30 EA per 30 days)
ranitidine hcl injection solution 25 mg/ml 1 GAP
ranitidine hcl oral capsule 150 mg, 300 mg 2
ranitidine hcl oral syrup 15 mg/ml 1 GAP
ranitidine hcl oral tablet 150 mg, 300 mg 1 GAP
RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML 4 PA
RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML 4 PA
67
Drug Name Tier Requirements/Limits
sucralfate oral tablet 1 gram 1 GAP
SUPREP BOWEL PREP KIT ORAL RECON SOLN 17.5-3.13-1.6 GRAM
3
trilyte with flavor packets oral recon soln 420 gram 1 GAP
ursodiol oral capsule 300 mg 2
ursodiol oral tablet 250 mg, 500 mg 2
Genitourinary Agents - Drugs To Treat Bladder, Genital, And Kidney Conditions
alfuzosin oral tablet extended release 24 hr 10 mg 2
AVODART ORAL CAPSULE 0.5 MG 3
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1 GAP
calcium acetate oral capsule 667 mg 2
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 GAP
ELMIRON ORAL CAPSULE 100 MG 4
ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR 15 MG, 7.5 MG
4 ST; QL (30 EA per 30 days)
finasteride oral tablet 5 mg 1 GAP
flavoxate oral tablet 100 mg 1 GAP
FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG
5
JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR 0.5-0.4 MG
3
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG
4 ST
oxybutynin chloride oral syrup 5 mg/5 ml 1 GAP
oxybutynin chloride oral tablet 5 mg 1 GAP
oxybutynin chloride oral tablet extended release 24hr 10 mg,
15 mg, 5 mg
2
OXYTROL TRANSDERMAL PATCH SEMIWEEKLY 3.9 MG/24 HR
4 ST; QL (8 EA per 28 days)
RENVELA ORAL POWDER IN PACKET 0.8 GRAM 3
RENVELA ORAL POWDER IN PACKET 2.4 GRAM 5
tamsulosin oral capsule,extended release 24hr 0.4 mg 1 GAP
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 68
Drug Name Tier Requirements/Limits
tolterodine oral capsule,extended release 24hr 2 mg, 4 mg 2 QL (30 EA per 30 days)
tolterodine oral tablet 1 mg, 2 mg 2 QL (60 EA per 30 days)
trospium oral capsule,extended release 24hr 60 mg 2 QL (30 EA per 30 days)
trospium oral tablet 20 mg 2
VESICARE ORAL TABLET 10 MG, 5 MG 4 ST; QL (30 EA per 30 days)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs To Regulate Hormones And Treat Diabetes And Bone Conditions
a-hydrocort injection recon soln 100 mg 1 GAP
ala-cort topical cream 1 % 1 GAP
alclometasone topical cream 0.05 % 2
alclometasone topical ointment 0.05 % 2
amcinonide topical cream 0.1 % 2
amcinonide topical lotion 0.1 % 2
amcinonide topical ointment 0.1 % 2
apexicon topical ointment 0.05 % 2
betamethasone dipropionate topical cream 0.05 % 2
betamethasone dipropionate topical lotion 0.05 % 2
betamethasone dipropionate topical ointment 0.05 % 2
betamethasone valerate topical cream 0.1 % 1 GAP
betamethasone valerate topical foam 0.12 % 2
betamethasone valerate topical lotion 0.1 % 1 GAP
betamethasone valerate topical ointment 0.1 % 1 GAP
betamethasone, augmented topical cream 0.05 % 1 GAP
betamethasone, augmented topical gel 0.05 % 1 GAP
betamethasone, augmented topical lotion 0.05 % 2
betamethasone, augmented topical ointment 0.05 % 2
clobetasol topical foam 0.05 % 2
clobetasol topical gel 0.05 % 1 GAP
clobetasol topical lotion 0.05 % 2
69
Drug Name Tier Requirements/Limits
clobetasol topical ointment 0.05 % 1 GAP
clobetasol topical shampoo 0.05 % 2
clobetasol topical solution 0.05 % 1 GAP
clobetasol-emollient topical cream 0.05 % 1 GAP
clodan topical shampoo 0.05 % 2
CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2
4
cormax topical solution 0.05 % 1 GAP
cortisone oral tablet 25 mg 2
desonide topical cream 0.05 % 2
desonide topical lotion 0.05 % 2
desonide topical ointment 0.05 % 2
desoximetasone topical cream 0.05 %, 0.25 % 2
desoximetasone topical gel 0.05 % 2
desoximetasone topical ointment 0.05 %, 0.25 % 2
dexamethasone intensol oral drops 1 mg/ml 1 GAP
dexamethasone oral elixir 0.5 mg/5 ml 1 GAP
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2
mg, 4 mg, 6 mg
1 GAP
dexamethasone sodium phosphate injection solution 10 mg/ml,
4 mg/ml
1 GAP
diflorasone topical cream 0.05 % 2
diflorasone topical ointment 0.05 % 2
fludrocortisone oral tablet 0.1 mg 1 GAP
fluocinolone acetonide oil otic drops 0.01 % 2
fluocinonide topical gel 0.05 % 1 GAP
fluocinonide topical ointment 0.05 % 1 GAP
fluocinonide topical solution 0.05 % 1 GAP
fluocinonide-e topical cream 0.05 % 1 GAP
fluticasone topical cream 0.05 % 1 GAP
fluticasone topical ointment 0.005 % 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 70
Drug Name Tier Requirements/Limits
halobetasol propionate topical cream 0.05 % 2
halobetasol propionate topical ointment 0.05 % 2
hydrocortisone butyrate topical ointment 0.1 % 1 GAP
hydrocortisone butyrate topical solution 0.1 % 1 GAP
hydrocortisone butyr-emollient topical cream 0.1 % 2
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 GAP
hydrocortisone topical cream 1 %, 2.5 % 1 GAP
hydrocortisone topical lotion 2.5 % 1 GAP
hydrocortisone topical ointment 1 %, 2.5 % 1 GAP
hydrocortisone valerate topical cream 0.2 % 2
hydrocortisone valerate topical ointment 0.2 % 2
lokara topical lotion 0.05 % 2
methylprednisolone acetate injection suspension 40 mg/ml, 80
mg/ml
2
methylprednisolone oral tablet 16 mg, 32 mg 2
methylprednisolone oral tablet 4 mg, 8 mg 1 GAP
methylprednisolone oral tablets,dose pack 4 mg 1 GAP
methylprednisolone sodium succ injection recon soln 125 mg,
40 mg
2
mometasone topical cream 0.1 % 1 GAP
mometasone topical ointment 0.1 % 1 GAP
mometasone topical solution 0.1 % 1 GAP
prednicarbate topical cream 0.1 % 1 GAP
prednicarbate topical ointment 0.1 % 1 GAP
prednisolone sodium phosphate oral solution 15 mg/5 ml, 25
mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
1 GAP
prednisone intensol oral concentrate 5 mg/ml 1 GAP
prednisone oral solution 5 mg/5 ml 1 GAP
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50
mg
1 GAP
Drug Name Tier Requirements/Limits
71
procto-pak rectal cream 1 % 1 GAP
proctosol hc rectal cream 2.5 % 1 GAP
proctozone-hc rectal cream 2.5 % 1 GAP
SOLU-CORTEF (PF) INJECTION RECON SOLN 250 MG/2 ML
4
triamcinolone acetonide topical aerosol 0.147 mg/gram 2
triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 % 1 GAP
triamcinolone acetonide topical lotion 0.025 %, 0.1 % 1 GAP
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5
%
1 GAP
triderm topical cream 0.1 % 1 GAP
UCERIS ORAL TABLET, DELAYED & EXT.RELEASE 9 MG
5
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs To Regulate Hormone Conditions
ACTHAR H.P. INJECTION GEL 80 UNIT/ML 5 PA
chorionic gonadotropin, human intramuscular recon soln
10,000 unit
2 PA
desmopressin injection solution 4 mcg/ml 2
desmopressin nasal solution 0.1 mg/ml (refrigerate) 2
desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) 2
desmopressin oral tablet 0.1 mg, 0.2 mg 2
EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG 5
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML
4 PA
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML
5 PA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)
5 PA
HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT)
5 PA
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 72
Drug Name Tier Requirements/Limits
HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG
5 PA
INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML 5
NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
5 PA
NORDITROPIN NORDIFLEX SUBCUTANEOUS PEN INJECTOR 30 MG/3 ML (10 MG/ML)
5 PA
novarel intramuscular recon soln 10,000 unit 2 PA
NUTROPIN AQ NUSPIN SUBCUTANEOUS CARTRIDGE 5 MG/2 ML (2.5 MG/ML)
5 PA
NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML)
5 PA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
5 PA
OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG 5 PA
pregnyl intramuscular recon soln 10,000 unit 2 PA
SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.5 ML (FNL)
5 PA
SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG 5 PA
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG
5 PA
STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML)
4
ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 MG
5 PA
ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG 5 PA
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs To Regulate Hormone Conditions
KORLYM ORAL TABLET 300 MG 5 PA; QL (120 EA per 30 days)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs To Regulate Hormone Conditions
amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg
(84)/10 mcg (7)
2 QL (91 EA per 91 days)
73
Drug Name Tier Requirements/Limits
ANADROL-50 ORAL TABLET 50 MG 4
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)
4
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM)
3
apri oral tablet 0.15-0.03 mg 1 GAP
aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg 2
ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg
(84)/10 mcg (7)
2 QL (91 EA per 91 days)
aubra oral tablet 0.1-20 mg-mcg 1 GAP
aviane oral tablet 0.1-20 mg-mcg 1 GAP
balziva (28) oral tablet 0.4-35 mg-mcg 1 GAP
briellyn oral tablet 0.4-35 mg-mcg 1 GAP
camila oral tablet 0.35 mg 1 GAP
CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/24 HR
4
COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR
3 QL (8 EA per 28 days)
cryselle (28) oral tablet 0.3-30 mg-mcg 2
cyclafem 1/35 (28) oral tablet 1-35 mg-mcg 1 GAP
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 2
danazol oral capsule 100 mg, 200 mg, 50 mg 2
deblitane oral tablet 0.35 mg 1 GAP
DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML 4
delyla (28) oral tablet 0.1-20 mg-mcg 1 GAP
DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML
3
desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 /0.01
mg x 5
1 GAP
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg 2
DUAVEE ORAL TABLET 0.45-20 MG 4
emoquette oral tablet 0.15-0.03 mg 1 GAP
enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10) 2
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 74
Drug Name Tier Requirements/Limits
errin oral tablet 0.35 mg 1 GAP
ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) 4
estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 GAP
estradiol transdermal patch semiweekly 0.025 mg/24 hr,
0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
2 QL (8 EA per 28 days)
estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375
mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1
mg/24 hr
2 QL (4 EA per 28 days)
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 2
estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 2
ESTRING VAGINAL RING 2 MG 4 QL (1 EA per 90 days)
falmina (28) oral tablet 0.1-20 mg-mcg 1 GAP
FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR
4 QL (1 EA per 90 days)
gianvi (28) oral tablet 3-0.02 mg 2
gildagia oral tablet 0.4-35 mg-mcg 1 GAP
gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) 2
gildess oral tablet 1.5-30 mg-mcg 2
introvale oral tablets,dose pack,3 month 0.15-30 mg-mcg 1 GAP; QL (91 EA per 91 days)
jinteli oral tablet 1-5 mg-mcg 2
jolivette oral tablet 0.35 mg 1 GAP
junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg 2
junel 1/20 (21) oral tablet 1-20 mg-mcg 1 GAP
junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) 1 GAP
junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) 1 GAP
junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) 2
kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GAP
kelnor 1/35 (28) oral tablet 1-35 mg-mcg 1 GAP
l norgest&e estradiol-e estrad oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
2 QL (91 EA per 91 days)
larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 2
75
Drug Name Tier Requirements/Limits
larin 1/20 (21) oral tablet 1-20 mg-mcg 1 GAP
larin fe oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30
mcg (21)/75 mg (7)
1 GAP
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg 2
lessina oral tablet 0.1-20 mg-mcg 1 GAP
levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) 2
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg 1 GAP
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
0.15-30 mg-mcg
1 GAP; QL (91 EA per 91 days)
levora-28 oral tablet 0.15-0.03 mg 1 GAP
lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) 2
lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg 2
loryna (28) oral tablet 3-0.02 mg 2
lutera (28) oral tablet 0.1-20 mg-mcg 1 GAP
lyza oral tablet 0.35 mg 1 GAP
marlissa oral tablet 0.15-0.03 mg 1 GAP
medroxyprogesterone intramuscular suspension 150 mg/ml 1 GAP
medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg 1 GAP
megestrol oral suspension 400 mg/10 ml (40 mg/ml) 2 PA
megestrol oral tablet 20 mg, 40 mg 1 PA; GAP
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG
4
microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 2
microgestin 1/20 (21) oral tablet 1-20 mg-mcg 1 GAP
microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75
mg (7)
1 GAP
microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg
(7)
1 GAP
mimvey lo oral tablet 0.5-0.1 mg 2
mimvey oral tablet 1-0.5 mg 2
mononessa (28) oral tablet 0.25-35 mg-mcg 1 GAP
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 2
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 76
Drug Name Tier Requirements/Limits
necon 1/35 (28) oral tablet 1-35 mg-mcg 1 GAP
necon 10/11 (28) oral tablet 0.5-35/1-35 mg-mcg/mg-mcg 2
necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 2
nikki (28) oral tablet 3-0.02 mg 2
nora-be oral tablet 0.35 mg 1 GAP
norethindrone (contraceptive) oral tablet 0.35 mg 1 GAP
norethindrone acetate oral tablet 5 mg 2
norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5
mg-mcg
2
norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg
(24)/75 mg (4)
2
norlyroc oral tablet 0.35 mg 1 GAP
nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 2
nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 GAP
nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 GAP
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 2
NUVARING VAGINAL RING 0.12-0.015 MG/24 HR 4 QL (1 EA per 28 days)
ocella oral tablet 3-0.03 mg 2
ogestrel (28) oral tablet 0.5-50 mg-mcg 2
orsythia oral tablet 0.1-20 mg-mcg 1 GAP
oxandrolone oral tablet 10 mg 5 PA; QL (60 EA per 30 days)
oxandrolone oral tablet 2.5 mg 2 PA; QL (120 EA per 30 days)
pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 1 GAP
pirmella oral tablet 1-35 mg-mcg 1 GAP
portia oral tablet 0.15-0.03 mg 1 GAP
PREFEST ORAL TABLET 1 MG (15)/1 MG- 0.09 MG (15) 4
PREMARIN VAGINAL CREAM 0.625 MG/GRAM 3
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG
3 QL (28 EA per 28 days)
previfem oral tablet 0.25-35 mg-mcg 1 GAP
77
Drug Name Tier Requirements/Limits
progesterone micronized oral capsule 100 mg, 200 mg 2
quasense oral tablets,dose pack,3 month 0.15-30 mg-mcg 1 GAP; QL (91 EA per 91 days)
raloxifene oral tablet 60 mg 2
reclipsen (28) oral tablet 0.15-0.03 mg 1 GAP
sharobel oral tablet 0.35 mg 1 GAP
sprintec (28) oral tablet 0.25-35 mg-mcg 1 GAP
sronyx oral tablet 0.1-20 mg-mcg 1 GAP
tarina fe oral tablet 1 mg-20 mcg (21)/75 mg (7) 1 GAP
testosterone cypionate intramuscular oil 100 mg/ml, 200
mg/ml
2
testosterone enanthate intramuscular oil 200 mg/ml 2
testosterone transdermal gel in metered-dose pump 1.25
gram/ actuation (1 %)
2
testosterone transdermal gel in packet 1 % (25 mg/2.5gram),
1 % (50 mg/5 gram)
2
tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) 2
trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GAP
tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GAP
tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) 1 GAP
trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) 2
VAGIFEM VAGINAL TABLET 10 MCG 3
velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 mg-
mcg
2
vestura (28) oral tablet 3-0.02 mg 2
vyfemla (28) oral tablet 0.4-35 mg-mcg 1 GAP
wymzya fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg
(7)
2
xulane transdermal patch weekly 150-35 mcg/24 hr 2
zenchent (28) oral tablet 0.4-35 mg-mcg 1 GAP
zenchent fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg
(7)
2
zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 78
Drug Name Tier Requirements/Limits
zovia 1/50e (28) oral tablet 1-50 mg-mcg 2
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs To Replace Thyroid Hormones
levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg,
75 mcg, 88 mcg
1 GAP
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
1 GAP
liothyronine intravenous solution 10 mcg/ml 2
liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1 GAP
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
3
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg,
175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
1 GAP
Hormonal Agents, Suppressant (Adrenal) - Drugs To Regulate Hormones Conditions
LYSODREN ORAL TABLET 500 MG 3
Hormonal Agents, Suppressant (Parathyroid) - Drugs To Regulate Hormones Conditions
SENSIPAR ORAL TABLET 30 MG 3
SENSIPAR ORAL TABLET 60 MG, 90 MG 5
Hormonal Agents, Suppressant (Pituitary) - Drugs To Regulate Hormones Conditions
cabergoline oral tablet 0.5 mg 2
ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH)
4 PA; QL (1 EA per 84 days)
ELIGARD SUBCUTANEOUS SYRINGE 30 MG (4 MONTH)
4 PA; QL (1 EA per 112 days)
ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH)
4 PA; QL (1 EA per 168 days)
ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH)
4 PA; QL (1 EA per 28 days)
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG
5 PA; QL (6 EA per 365 days)
79
Drug Name Tier Requirements/Limits
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG
4 PA; QL (4 EA per 28 days)
leuprolide subcutaneous kit 1 mg/0.2 ml 2
LUPANETA PACK (1 MONTH) KIT. SYRINGE & TABLET 3.75 MG -5 MG (30)
5 PA; QL (1 EA per 28 days)
LUPANETA PACK (3 MONTH) KIT. SYRINGE & TABLET 11.25 MG -5 MG (90)
5 PA; QL (1 EA per 84 days)
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG
5 PA; QL (1 EA per 84 days)
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
5 PA; QL (1 EA per 112 days)
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG
5 PA; QL (1 EA per 168 days)
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG
5 PA; QL (1 EA per 28 days)
LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG
5 QL (1 EA per 28 days)
octreotide acetate injection solution 1,000 mcg/ml, 100
mcg/ml, 200 mcg/ml, 500 mcg/ml
5 PA
octreotide acetate injection solution 50 mcg/ml 2 PA
SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG
5 PA
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 40 MG, 60 MG
5 PA
SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)
5 PA; QL (60 ML per 30 days)
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML
5 PA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG
5 PA
SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML 5
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG
5 PA; QL (1 EA per 168 days)
TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML
5 PA; QL (1 EA per 84 days)
TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML 5 PA; QL (1 EA per 28 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 80
Drug Name Tier Requirements/Limits
Hormonal Agents, Suppressant (Thyroid) - Drugs To Replace Thyroid Hormones
methimazole oral tablet 10 mg, 5 mg 1 GAP
propylthiouracil oral tablet 50 mg 1 GAP
Immunological Agents - Drugs That Stimulate Or Suppress The Immune System
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML)
5 PA
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML 5 PA; QL (3.6 ML per 28 days)
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML
3
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML
5
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
3
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG 5 PA
ATGAM INTRAVENOUS INJECTABLE 50 MG/ML 5 PA
AZASAN ORAL TABLET 100 MG, 75 MG 4 PA
azathioprine oral tablet 50 mg 1 PA; GAP
BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
3
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 5 PA
BEXSERO (PF) INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML
3
BIVIGAM INTRAVENOUS SOLUTION 10 % 5 PA
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML
3
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML
3
CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM
5 PA
CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG
4 PA
81
Drug Name Tier Requirements/Limits
CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML
3
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
5 PA
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)
5 PA
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)
5 PA
COMVAX (PF) INTRAMUSCULAR SUSPENSION 5-7.5-125 MCG/0.5 ML
3
cyclosporine intravenous solution 250 mg/5 ml 2 PA
cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 2 PA
cyclosporine modified oral solution 100 mg/ml 2 PA
cyclosporine oral capsule 100 mg, 25 mg 2 PA
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML
3
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) 5 PA
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
5 PA
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML)
5 PA
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML
3 PA
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML
3 PA
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML
3 PA
FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML 5 PA
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 % 5 PA
GAMASTAN S/D INTRAMUSCULAR SOLUTION 15-18 % RANGE
3 PA
GAMMAGARD LIQUID INJECTION SOLUTION 10 % 5 PA
GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %)
5 PA
GAMMAPLEX INTRAVENOUS SOLUTION 5 % 5 PA
Drug Name Tier Requirements/Limits
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 82
GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %)
5 PA
GARDASIL (PF) INTRAMUSCULAR SUSPENSION 20-40-40-20 MCG/0.5 ML
3
GARDASIL (PF) INTRAMUSCULAR SYRINGE 20-40-40-20 MCG/0.5 ML
3
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML
3
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML 3
gengraf oral capsule 100 mg, 25 mg 2 PA
gengraf oral solution 100 mg/ml 2 PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML
3
HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML
3
HUMIRA CROHN'S DIS START PCK SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML
5 PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML
5 PA
HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML)
3 PA
ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML)
5 PA
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT
3 PA
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML
3
IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML 3
IPOL INJECTION SYRINGE 40-8-32 UNIT/0.5 ML 3
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML
3
KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML 5 PA
leflunomide oral tablet 10 mg, 20 mg 2
83
Drug Name Tier Requirements/Limits
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML
3
MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG
3
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML
3
methotrexate sodium (pf) injection recon soln 1 gram 1 GAP
methotrexate sodium (pf) injection solution 25 mg/ml 1 GAP
methotrexate sodium oral tablet 2.5 mg 1 GAP
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML
3
mycophenolate mofetil oral capsule 250 mg 2 PA
mycophenolate mofetil oral suspension for reconstitution 200
mg/ml
5 PA
mycophenolate mofetil oral tablet 500 mg 2 PA
mycophenolate sodium oral tablet,delayed release (dr/ec) 180
mg, 360 mg
2 PA
NULOJIX INTRAVENOUS RECON SOLN 250 MG 5 PA
OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % 5 PA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
5 PA
ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML 5 PA
OTEZLA ORAL TABLET 30 MG 5 PA
OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19)
5 PA
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML
3
PRIVIGEN INTRAVENOUS SOLUTION 10 % 5 PA
PROGRAF INTRAVENOUS SOLUTION 5 MG/ML 4 PA
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5
3
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML
3
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT
3 PA
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 84
Drug Name Tier Requirements/Limits
RAPAMUNE ORAL SOLUTION 1 MG/ML 5 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML
3 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML
3 PA
REMICADE INTRAVENOUS RECON SOLN 100 MG 5 PA
RIDAURA ORAL CAPSULE 3 MG 5
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML
3
ROTATEQ VACCINE ORAL SUSPENSION 2 ML 3
SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML 5 PA
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML
5 PA
SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML
5 PA
SIMULECT INTRAVENOUS RECON SOLN 20 MG 5 PA
sirolimus oral tablet 0.5 mg, 1 mg 2 PA
sirolimus oral tablet 2 mg 5 PA
SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML 5
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 2 PA
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML
3 PA
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML
3
TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML
3 PA
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG
5 PA
TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST)
5 PA
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML
3
85
Drug Name Tier Requirements/Limits
TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT -20 MCG/ML
3
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML
3
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML
3
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML
3
XELJANZ ORAL TABLET 5 MG 5 PA; QL (60 EA per 30 days)
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML
3
ZORTRESS ORAL TABLET 0.25 MG 4 PA
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 5 PA
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML
3 QL (1 EA per 365 days)
Inflammatory Bowel Disease Agents - Drugs To Treat Inflammatory Bowel Disease
APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM
3
ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG
3
balsalazide oral capsule 750 mg 2
budesonide oral capsule,delayed,extend.release 3 mg 5
CANASA RECTAL SUPPOSITORY 1,000 MG 4
colocort rectal enema 100 mg/60 ml 1 GAP
DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 400 MG
3
DIPENTUM ORAL CAPSULE 250 MG 4
hydrocortisone rectal enema 100 mg/60 ml 1 GAP
mesalamine with cleansing wipe rectal enema kit 4 gram/60
ml
2
PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG
3
sulfasalazine oral tablet 500 mg 1 GAP
sulfazine ec oral tablet,delayed release (dr/ec) 500 mg 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 86
Drug Name Tier Requirements/Limits
Metabolic Bone Disease Agents - Drugs To Regulate Hormones And Treat Bone Conditions
alendronate oral solution 70 mg/75 ml 1 GAP
alendronate oral tablet 10 mg, 40 mg, 5 mg 1 GAP
alendronate oral tablet 35 mg, 70 mg 1 GAP; QL (4 EA per 28 days)
calcitonin (salmon) nasal spray,non-aerosol 200
unit/actuation
2 QL (3.7 ML per 30 days)
calcitriol intravenous solution 1 mcg/ml 2
calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 GAP
calcitriol oral solution 1 mcg/ml 2
doxercalciferol intravenous solution 4 mcg/2 ml 2
doxercalciferol oral capsule 0.5 mcg 2
doxercalciferol oral capsule 1 mcg, 2.5 mcg 5
etidronate disodium oral tablet 200 mg, 400 mg 2
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML
5 PA; QL (2.4 ML per 28 days)
FORTICAL NASAL SPRAY,NON-AEROSOL 200 UNIT/ACTUATION
3 QL (3.7 ML per 30 days)
ibandronate intravenous solution 3 mg/3 ml 2
ibandronate oral tablet 150 mg 2
MIACALCIN INJECTION SOLUTION 200 UNIT/ML 4
pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 90
mg/10 ml (9 mg/ml)
2
paricalcitol hemodialysis port injection solution 2 mcg/ml, 5
mcg/ml
2
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 2
PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML 4 PA; QL (2 ML per 365 days)
risedronate oral tablet 150 mg, 30 mg, 5 mg 2
risedronate oral tablet 35 mg, 35 mg (12 pack) 2 QL (4 EA per 28 days)
risedronate oral tablet,delayed release (dr/ec) 35 mg 2 QL (4 EA per 28 days)
XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML)
5 PA; QL (1.7 ML per 28 days)
87
Drug Name Tier Requirements/Limits
zoledronic acid intravenous solution 4 mg/5 ml 2 PA
zoledronic acid-mannitol-water intravenous solution 5 mg/100
ml
2 PA
ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML 5 PA
Miscellaneous Therapeutic Agents
FERRIPROX ORAL TABLET 500 MG 5 PA
fomepizole intravenous solution 1 gram/ml 5
insulin pen needle needle 29 gauge x 1/2 " 1 GAP; QL (200 EA per 30 days)
insulin syringe-needle u-100 syringe 0.3 ml 29, 1 ml 29 x 1/2",
1/2 ml 28
1 GAP; QL (200 EA per 30 days)
intralipid intravenous emulsion 20 % 1 PA; GAP
lactated ringers irrigation solution 1 GAP
levocarnitine (with sugar) oral solution 100 mg/ml 1 GAP
levocarnitine intravenous solution 200 mg/ml 1 GAP
levocarnitine oral tablet 330 mg 1 GAP
liposyn ii intravenous emulsion 20 % 1 PA; GAP
methylergonovine oral tablet 0.2 mg 2
MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.)
5 PA
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE
5 PA; QL (2 EA per 28 days)
nutrilipid intravenous emulsion 20 % 1 PA; GAP
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG 5
physiolyte irrigation solution 140-5-3-98 meq/l 1 GAP
physiosol irrigation irrigation solution 140-5-3-98 meq/l 1 GAP
ringers irrigation solution 1 GAP
safety needles needle 18 x 1 1/2 " 1 GAP; QL (200 EA per 30 days)
water for irrigation, sterile irrigation solution 1 GAP
Ophthalmic Agents - Drugs To Treat Conditions Of The Eye
acetazolamide oral capsule, extended release 500 mg 2
ALOCRIL OPHTHALMIC DROPS 2 % 4
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 88
Drug Name Tier Requirements/Limits
ALOMIDE OPHTHALMIC DROPS 0.1 % 4
ALPHAGAN P OPHTHALMIC DROPS 0.1 % 3
ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % 4
apraclonidine ophthalmic drops 0.5 % 2
azelastine ophthalmic drops 0.05 % 2
AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % 3
bacitracin-polymyxin b ophthalmic ointment 500-10,000
unit/gram
1 GAP
betaxolol ophthalmic drops 0.5 % 2
BETIMOL OPHTHALMIC DROPS 0.5 % 4
BETOPTIC S OPHTHALMIC DROPS,SUSPENSION 0.25 %
3
bimatoprost ophthalmic drops 0.03 % 2 QL (5 ML per 30 days)
BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %
3
brimonidine ophthalmic drops 0.15 % 2
brimonidine ophthalmic drops 0.2 % 1 GAP
bromfenac ophthalmic drops 0.09 % 2
carteolol ophthalmic drops 1 % 1 GAP
COMBIGAN OPHTHALMIC DROPS 0.2-0.5 % 4
cromolyn ophthalmic drops 4 % 1 GAP
dexamethasone sodium phosphate ophthalmic drops 0.1 % 1 GAP
diclofenac sodium ophthalmic drops 0.1 % 1 GAP
dorzolamide ophthalmic drops 2 % 1 GAP
dorzolamide-timolol ophthalmic drops 22.3-6.8 mg/ml 1 GAP
DUREZOL OPHTHALMIC DROPS 0.05 % 4
epinastine ophthalmic drops 0.05 % 2
flurbiprofen sodium ophthalmic drops 0.03 % 1 GAP
FML S.O.P. OPHTHALMIC OINTMENT 0.1 % 3
ketorolac ophthalmic drops 0.4 % 2
89
Drug Name Tier Requirements/Limits
ketorolac ophthalmic drops 0.5 % 1 GAP
LASTACAFT OPHTHALMIC DROPS 0.25 % 4
latanoprost ophthalmic drops 0.005 % 1 GAP; QL (2.5 ML per 25 days)
levobunolol ophthalmic drops 0.5 % 1 GAP
LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % 3
LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % 3
LOTEMAX OPHTHALMIC OINTMENT 0.5 % 3
LUMIGAN OPHTHALMIC DROPS 0.01 % 3 ST; QL (5 ML per 30 days)
metipranolol ophthalmic drops 0.3 % 2
naphazoline ophthalmic drops 0.1 % 1 GAP
neomycin-bacitracin-polymyxin ophthalmic ointment 3.5-400-
10,000 mg-unit-unit/g
2
neomycin-polymyxin b-dexameth ophthalmic drops,suspension
3.5mg/ml-10,000 unit/ml-0.1 %
1 GAP
neomycin-polymyxin b-dexameth ophthalmic ointment 3.5
mg/g-10,000 unit/g-0.1 %
2
neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-
10,000 unit-0.025mg/ml
2
PATADAY OPHTHALMIC DROPS 0.2 % 3
PATANOL OPHTHALMIC DROPS 0.1 % 3
PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.125 % 3
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % 1 GAP
polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit-
1 mg/ml
1 GAP
PRED MILD OPHTHALMIC DROPS,SUSPENSION 0.12 % 3
prednisolone acetate ophthalmic drops,suspension 1 % 1 GAP
prednisolone sodium phosphate ophthalmic drops 1 % 2
proparacaine ophthalmic drops 0.5 % 1 GAP
RESTASIS OPHTHALMIC DROPPERETTE 0.05 % 4 QL (60 EA per 30 days)
sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 %
(0.25 %)
1 GAP
timolol maleate ophthalmic drops 0.25 %, 0.5 % 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 90
Drug Name Tier Requirements/Limits
timolol maleate ophthalmic gel forming solution 0.25 %, 0.5
%
2
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 4
tobramycin-dexamethasone ophthalmic drops,suspension 0.3-
0.1 %
2
TRAVATAN Z OPHTHALMIC DROPS 0.004 % 4 ST; QL (5 ML per 30 days)
travoprost (benzalkonium) ophthalmic drops 0.004 % 2 QL (5 ML per 30 days)
Otic Agents - Drugs To Treat Conditions Of The Ear
acetasol hc otic drops 1-2 % 2
acetic acid otic solution 2 % 1 GAP
CIPRO HC OTIC DROPS,SUSPENSION 0.2-1 % 3
CIPRODEX OTIC DROPS,SUSPENSION 0.3-0.1 % 3
hydrocortisone-acetic acid otic drops 1-2 % 2
neomycin-polymyxin-hc otic drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
1 GAP
neomycin-polymyxin-hc otic solution 3.5-10,000-1 mg/ml-
unit/ml-%
1 GAP
Respiratory Tract/Pulmonary Agents - Drugs To Treat Allergies, Cough, Cold And Lung Conditions
acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) 2 PA
ADCIRCA ORAL TABLET 20 MG 5 PA; QL (60 EA per 30 days)
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG
5 PA; QL (90 EA per 30 days)
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE
4 QL (60 EA per 30 days)
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION
4 QL (16 GM per 30 days)
albuterol sulfate inhalation solution for nebulization 0.63
mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml
1 PA; GAP
albuterol sulfate oral syrup 2 mg/5 ml 1 GAP
albuterol sulfate oral tablet 2 mg, 4 mg 1 GAP
91
Drug Name Tier Requirements/Limits
albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg 1 GAP
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION
4 QL (12.2 GM per 30 days)
aminophylline intravenous solution 250 mg/10 ml 1 GAP
ARALAST NP INTRAVENOUS RECON SOLN 500 MG 5 PA
arbinoxa oral liquid 4 mg/5 ml 1 GAP
arbinoxa oral tablet 4 mg 1 GAP
ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG
4 QL (30 EA per 30 days)
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)
4 QL (2 EA per 30 days)
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION
3 QL (25.8 GM per 30 days)
AUVI-Q INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML (1:1,000)
3
azelastine nasal aerosol,spray 137 mcg (0.1 %) 2 QL (60 ML per 30 days)
azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) 2 QL (60 ML per 30 days)
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML
4 PA
budesonide inhalation suspension for nebulization 0.25 mg/2
ml, 0.5 mg/2 ml
2 PA; QL (120 ML per 30 days)
budesonide nasal spray,non-aerosol 32 mcg/actuation 2 QL (17.2 GM per 30 days)
carbinoxamine maleate oral liquid 4 mg/5 ml 1 GAP
carbinoxamine maleate oral tablet 4 mg 1 GAP
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML
5 PA
cetirizine oral solution 1 mg/ml 1 GAP
CLARINEX ORAL SYRUP 2.5 MG/5 ML (0.5 MG/ML) 4
CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG
4
clemastine oral tablet 2.68 mg 1 GAP
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION
3 QL (8 GM per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 92
Drug Name Tier Requirements/Limits
cromolyn inhalation solution for nebulization 20 mg/2 ml 1 PA; GAP
cyproheptadine oral syrup 2 mg/5 ml 1 GAP
cyproheptadine oral tablet 4 mg 1 GAP
DALIRESP ORAL TABLET 500 MCG 4 PA
desloratadine oral tablet 5 mg 2
desloratadine oral tablet,disintegrating 2.5 mg, 5 mg 2
diphenhydramine hcl injection solution 50 mg/ml 2
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION
3 QL (17.6 GM per 30 days)
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML 3
epinephrine injection auto-injector 0.15 mg/0.15 ml (1:1,000) 2
EPINEPHRINE INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML (1:1,000)
3
EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML (1:1,000)
3
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML (1:2,000)
3
ESBRIET ORAL CAPSULE 267 MG 5 PA
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION
3 QL (60 EA per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION
3 QL (240 EA per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION
3 QL (24 GM per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION
3 QL (21.2 GM per 30 days)
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 1 GAP; QL (50 ML per 30 days)
fluticasone nasal spray,suspension 50 mcg/actuation 1 GAP; QL (16 GM per 25 days)
FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE 12 MCG
3 QL (60 EA per 30 days)
GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %)
5 PA
hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml 2
93
Drug Name Tier Requirements/Limits
ipratropium bromide inhalation solution 0.02 % 1 PA; GAP
ipratropium bromide nasal spray,non-aerosol 0.03 %, 0.06 % 1 GAP
ipratropium-albuterol inhalation solution for nebulization 0.5
mg-3 mg(2.5 mg base)/3 ml
1 PA; GAP
KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG
5 PA
KALYDECO ORAL TABLET 150 MG 5 PA
LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; QL (30 EA per 30 days)
levalbuterol hcl inhalation solution for nebulization 0.31 mg/3
ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml
2 PA
levocetirizine oral solution 2.5 mg/5 ml 1 GAP
levocetirizine oral tablet 5 mg 1 GAP
metaproterenol oral syrup 10 mg/5 ml 1 GAP
metaproterenol oral tablet 10 mg, 20 mg 1 GAP
montelukast oral granules in packet 4 mg 2
montelukast oral tablet 10 mg 1 GAP
montelukast oral tablet,chewable 4 mg, 5 mg 1 GAP
OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA
OPSUMIT ORAL TABLET 10 MG 5 PA; QL (30 EA per 30 days)
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG
4 PA
ORENITRAM ORAL TABLET EXTENDED RELEASE 1 MG, 2.5 MG
5 PA
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML
4 PA
PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION
3 QL (17 GM per 30 days)
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION
3 QL (2 EA per 30 days)
PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG 5 PA
PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION
3 QL (13.4 GM per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 94
Drug Name Requirements/Limits
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION
Tierr 4 QL (1 EA per 30 days)
PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML
4 PA; QL (120 ML per 30 days)
PULMOZYME INHALATION SOLUTION 1 MG/ML 5 PA
QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION
3 QL (17.4 GM per 30 days)
REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML
5 PA
REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML
5 PA
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE
3 QL (60 EA per 30 days)
sildenafil intravenous solution 10 mg/12.5 ml 5 PA; QL (1125 ML per 30 days)
sildenafil oral tablet 20 mg 2 PA; QL (90 EA per 30 days)
SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION
3 QL (4 GM per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG
3 QL (30 EA per 30 days)
STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION
4 QL (4 GM per 30 days)
SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION
3 QL (12 GM per 30 days)
SYMBICORT INHALATION HFA AEROSOL INHALER 80-4.5 MCG/ACTUATION
3 QL (13.8 GM per 30 days)
terbutaline oral tablet 2.5 mg, 5 mg 1 GAP
terbutaline subcutaneous solution 1 mg/ml 2
theophylline oral solution 80 mg/15 ml 1 GAP
theophylline oral tablet extended release 12 hr 100 mg, 200
mg, 300 mg, 450 mg
1 GAP
theophylline oral tablet extended release 400 mg, 600 mg 2
TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG
5 PA; QL (224 EA per 56 days)
95
Drug Name Tier Requirements/Limits
tobramycin in 0.225 % nacl inhalation solution for
nebulization 300 mg/5 ml
5 PA
TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 PA; QL (60 EA per 30 days)
triamcinolone acetonide nasal aerosol,spray 55 mcg 2 QL (16.5 GM per 30 days)
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT)
4 QL (60 EA per 30 days)
TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML)
5 PA; QL (87 ML per 30 days)
TYZINE NASAL DROPS 0.05 % 3
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML
5 PA; QL (270 ML per 30 days)
VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION
3 QL (48 GM per 30 days)
VERAMYST NASAL SPRAY,SUSPENSION 27.5 MCG/ACTUATION
3 QL (10 GM per 30 days)
VIRAZOLE INHALATION RECON SOLN 6 GRAM 5
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 5 PA
XOPENEX HFA INHALATION HFA AEROSOL INHALER 45 MCG/ACTUATION
3 QL (30 GM per 30 days)
zafirlukast oral tablet 10 mg, 20 mg 2
ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG 5 PA
Skeletal Muscle Relaxants - Drugs To Treat Pain, Inflammation, And Muscle And Joint Conditions
chlorzoxazone oral tablet 500 mg 1 GAP
cyclobenzaprine oral tablet 10 mg, 5 mg 1 PA; GAP
Sleep Disorder Agents - Drugs for Sedation and Sleep
eszopiclone oral tablet 1 mg, 2 mg, 3 mg 2 QL (30 EA per 30 days)
modafinil oral tablet 100 mg 2 PA; QL (30 EA per 30 days)
MODAFINIL ORAL TABLET 200 MG 5 PA; QL (30 EA per 30 days)
NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG 4 PA; QL (30 EA per 30 days)
NUVIGIL ORAL TABLET 50 MG 4 PA; QL (60 EA per 30 days)
ROZEREM ORAL TABLET 8 MG 3 QL (30 EA per 30 days)
SILENOR ORAL TABLET 3 MG, 6 MG 4 QL (30 EA per 30 days)
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 96
Drug Name Tier Requirements/Limits
temazepam oral capsule 15 mg, 30 mg 1 GAP
temazepam oral capsule 22.5 mg, 7.5 mg 2
XYREM ORAL SOLUTION 500 MG/ML 5 PA; QL (540 ML per 30 days)
zaleplon oral capsule 10 mg 1 GAP; QL (60 EA per 30 days)
zaleplon oral capsule 5 mg 1 GAP; QL (30 EA per 30 days)
zolpidem oral tablet 10 mg, 5 mg 1 GAP; QL (30 EA per 30 days)
zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg 2 QL (30 EA per 30 days)
Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiency
AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 %
3 PA
aminosyn 8.5 %-electrolytes intravenous parenteral solution
8.5 %
1 PA; GAP
AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %
3 PA
AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 %
3 PA
aminosyn ii 8.5 %-electrolytes intravenous parenteral solution
8.5 %
1 PA; GAP
AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 %
3 PA
AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 %
3 PA
AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %
3 PA
AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 %
3 PA
AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 %
3 PA
CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG 5 PA
CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 %
3 PA
97
Drug Name Tier Requirements/Limits
CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 %
3 PA
CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 %
3 PA
CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %
3 PA
CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 %
3 PA
CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 %
3 PA
d10 % & 0.45 % sodium chloride intravenous parenteral
solution
1 GAP
d2.5 %-0.45 % sodium chloride intravenous parenteral
solution
1 GAP
d5 % and 0.9 % sodium chloride intravenous parenteral
solution
1 GAP
d5 %-0.45 % sodium chloride intravenous parenteral solution 1 GAP
DEPEN TITRATABS ORAL TABLET 250 MG 4
dextrose 10 % and 0.2 % nacl intravenous parenteral solution 1 GAP
dextrose 10 % in water (d10w) intravenous parenteral
solution 10 %
1 GAP
dextrose 5 % in water (d5w) intravenous parenteral solution 1 GAP
dextrose 5 %-lactated ringers intravenous parenteral solution 1 GAP
dextrose 5%-0.2 % sod chloride intravenous parenteral
solution
1 GAP
dextrose 5%-0.3 % sod.chloride intravenous parenteral
solution
1 GAP
dextrose with sodium chloride intravenous parenteral solution
5-0.2 %
1 GAP
dextrose-kcl-nacl intravenous solution 5-0.224-0.225 % 1 GAP
EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG
5 PA
FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 %
3 PA
ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %
3
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 98
Drug Name Tier Requirements/Limits
ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION 3
kionex oral powder 1 GAP
klor-con 10 oral tablet extended release 10 meq 1 GAP
klor-con 8 oral tablet extended release 8 meq 1 GAP
KLOR-CON M15 ORAL TABLET,ER PARTICLES/CRYSTALS 15 MEQ
3
klor-con m20 oral tablet,er particles/crystals 20 meq 1 GAP
k-tab oral tablet extended release 20 meq 1 GAP
lactated ringers intravenous parenteral solution 1 GAP
magnesium sulfate injection solution 4 meq/ml (50 %) 2
magnesium sulfate injection syringe 4 meq/ml 2
NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 %
3 PA
normosol-m in 5 % dextrose intravenous parenteral solution 1 GAP
normosol-r in 5 % dextrose intravenous parenteral solution 5
%
1 GAP
normosol-r ph 7.4 intravenous parenteral solution 1 GAP
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
3
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
3
PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %
3
potassium chlorid-d5-0.45%nacl intravenous parenteral
solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l
1 GAP
potassium chloride in 0.9%nacl intravenous parenteral
solution 20 meq/l
1 GAP
potassium chloride in 5 % dex intravenous parenteral solution
20 meq/l, 40 meq/l
1 GAP
potassium chloride intravenous piggyback 10 meq/100 ml, 40
meq/100 ml
1 GAP
potassium chloride intravenous solution 2 meq/ml 1 GAP
99
Drug Name Tier Requirements/Limits
potassium chloride oral capsule, extended release 10 meq, 8
meq
1 GAP
potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml 1 GAP
potassium chloride oral tablet extended release 8 meq 1 GAP
potassium chloride oral tablet,er particles/crystals 10 meq, 20
meq
1 GAP
potassium chloride-0.45 % nacl intravenous parenteral
solution 20 meq/l
1 GAP
potassium chloride-d5-0.2%nacl intravenous parenteral
solution 20 meq/l
1 GAP
potassium chloride-d5-0.3%nacl intravenous parenteral
solution 20 meq/l
1 GAP
potassium chloride-d5-0.9%nacl intravenous parenteral
solution 20 meq/l, 40 meq/l
1 GAP
potassium citrate oral tablet extended release 10 meq (1,080
mg), 15 meq, 5 meq (540 mg)
2
PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %
3 PA
premasol 6 % intravenous parenteral solution 6 % 1 PA; GAP
prenatal vitamins low iron oral tablet 27 mg iron- 1 mg 1 GAP
PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 %
3 PA
SAMSCA ORAL TABLET 15 MG 5 QL (30 EA per 30 days)
SAMSCA ORAL TABLET 30 MG 5 QL (60 EA per 30 days)
sodium chloride 0.45 % intravenous parenteral solution 0.45
%
1 GAP
sodium chloride 0.9 % intravenous parenteral solution 0.9 % 1 GAP
sodium chloride 3 % intravenous parenteral solution 3 % 1 GAP
sodium chloride 5 % intravenous parenteral solution 5 % 1 GAP
sodium chloride intravenous parenteral solution 2.5 meq/ml 1 GAP
sodium chloride irrigation solution 0.9 % 1 GAP
sodium fluoride oral tablet,chewable 0.5 mg fluoride (1.1 mg) 1 GAP
sodium lactate intravenous solution 5 meq/ml 1 GAP
sodium polystyrene (sorb free) oral suspension 15 gram/60 ml 1 GAP
GAP = We provide coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.
You can find information on what the symbols and abbreviations on this table mean by going to page 5. 100
Drug Name Tier Requirements/Limits
SYPRINE ORAL CAPSULE 250 MG 5
tpn electrolytes intravenous solution 35-20-5 meq/20 ml 1 GAP
TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %
3 PA
TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 %
3 PA
101
Index
A abacavir ................................ 40 abacavir-lamivudine-
zidovudine ........................ 40 ABELCET ............................ 26 ABILIFY DISCMELT ......... 37 ABILIFY MAINTENA ........ 37 ABRAXANE ........................ 30 acamprosate .......................... 11 ACANYA ............................. 61 acarbose ................................ 44 acebutolol ............................. 51 acetaminophen-codeine .......... 7 acetasol hc ............................ 90 acetazolamide ................. 51, 87 acetic acid ............................. 90 acetylcysteine ....................... 90 acitretin ................................. 61 ACTEMRA .......................... 80 ACTHAR H.P. ..................... 71 ACTHIB (PF) ....................... 80 ACTIMMUNE ..................... 80 acyclovir ............................... 40 acyclovir sodium .................. 40 ACZONE .............................. 61 ADACEL(TDAP
ADOLESN/ADULT)(PF) 80 ADAGEN ............................. 63 adapalene .............................. 61 ADCIRCA ............................ 90 adefovir................................. 40 ADEMPAS ........................... 90 adrucil ................................... 30 ADVAIR DISKUS ............... 90 ADVAIR HFA ..................... 90 afeditab cr ............................. 51 AFINITOR ........................... 30 AFINITOR DISPERZ .......... 30 AGGRENOX ....................... 48 a-hydrocort ........................... 68 ala-cort .................................. 68 ALBENZA ........................... 35 albuterol sulfate .............. 90, 91 alclometasone ....................... 68 ALDACTAZIDE .................. 51 ALDURAZYME .................. 63 alendronate ........................... 86
alfuzosin ............................... 67 ALIMTA .............................. 30 ALINIA ................................ 35 allopurinol ............................ 28 ALOCRIL ............................. 87 ALOMIDE............................ 88 alosetron ............................... 64 ALPHAGAN P ..................... 88 alprazolam ............................ 44 ALREX ................................. 88 ALVESCO............................ 91 amantadine hcl ...................... 40 AMBISOME ........................ 26 amcinonide ........................... 68 amethia ................................. 72 amifostine crystalline ........... 30 amikacin ............................... 11 amiloride ............................... 51 amiloride-hydrochlorothiazide
.......................................... 51 aminophylline ....................... 91 AMINOSYN 7 % WITH
ELECTROLYTES............ 96 aminosyn 8.5 %-electrolytes 96 AMINOSYN II 10 % ........... 96 AMINOSYN II 7 % ............. 96 aminosyn ii 8.5 %-electrolytes
.......................................... 96 AMINOSYN M 3.5 %.......... 96 AMINOSYN-HBC 7%......... 96 AMINOSYN-PF 10 % ......... 96 AMINOSYN-PF 7 %
(SULFITE-FREE) ............ 96 AMINOSYN-RF 5.2 % ........ 96 amiodarone ........................... 51 AMITIZA ............................. 64 amitriptyline ......................... 22 amlodipine ............................ 51 amlodipine-atorvastatin ........ 51 amlodipine-benazepril .......... 51 amlodipine-valsartan ............ 51 amlodipine-valsartan-hcthiazid
.......................................... 51 ammonium lactate ................ 61 amnesteem ............................ 61 amoxapine ............................ 22
amoxicil-clarithromy-lansopraz .......................................... 64
amoxicillin ............................ 11 amoxicillin-pot clavulanate .. 12 amphetamine salt combo ...... 59 amphotericin b ...................... 26 ampicillin .............................. 12 ampicillin sodium ................. 12 ampicillin-sulbactam ............ 12 AMPYRA ............................. 59 ANADROL-50 ..................... 73 anagrelide ............................. 48 anastrozole ............................ 30 ANDROGEL ........................ 73 ANZEMET ........................... 25 apexicon ................................ 68 APIDRA ............................... 45 APIDRA SOLOSTAR .......... 45 APLENZIN ........................... 22 APOKYN ............................. 36 apraclonidine ........................ 88 apri ........................................ 73 APRISO ................................ 85 APTIOM ............................... 19 APTIVUS ............................. 40 ARALAST NP ...................... 91 aranelle (28) .......................... 73 ARANESP (IN
POLYSORBATE) ............ 48 arbinoxa ................................ 91 ARCALYST ......................... 80 ARCAPTA NEOHALER ..... 91 argatroban ............................. 49 argatroban in 0.9 % sod chlor
.......................................... 49 aripiprazole ........................... 37 ARRANON .......................... 30 ARZERRA ........................... 30 ASACOL HD ....................... 85 ascomp with codeine .............. 7 ashlyna .................................. 73 ASMANEX TWISTHALER 91 atenolol ................................. 51 atenolol-chlorthalidone ......... 51 ATGAM ............................... 80 atorvastatin ........................... 51 atovaquone ............................ 35
102
atovaquone-proguanil ........... 35 ATRALIN ............................ 61 ATRIPLA ............................. 40 ATROVENT HFA ............... 91 AUBAGIO ........................... 59 aubra ..................................... 73 AUVI-Q ................................ 91 AVANDIA ........................... 45 AVASTIN ............................ 30 AVELOX IN NACL (ISO-
OSMOTIC)....................... 12 aviane ................................... 73 avita ...................................... 61 AVODART .......................... 67 AVONEX ............................. 59 AVONEX (WITH ALBUMIN)
.......................................... 59 azacitidine............................. 30 AZACTAM IN DEXTROSE
(ISO-OSM) ....................... 12 AZASAN .............................. 80 AZASITE ............................. 12 azathioprine .......................... 80 azelastine ........................ 88, 91 AZELEX .............................. 61 AZILECT ............................. 36 azithromycin ......................... 12 AZOPT ................................. 88 AZOR ................................... 51 aztreonam ............................. 12 B baciim ................................... 12 bacitracin .............................. 12 bacitracin-polymyxin b ........ 88 baclofen ................................ 39 balsalazide ............................ 85 balziva (28) ........................... 73 BANZEL .............................. 19 BARACLUDE ..................... 40 BCG VACCINE, LIVE (PF) 80 BELEODAQ ........................ 30 benazepril ............................. 51 benazepril-hydrochlorothiazide
.......................................... 52 BENICAR ............................ 52 BENICAR HCT ................... 52 BENLYSTA ......................... 80 benztropine ........................... 36 betamethasone dipropionate . 68 betamethasone valerate ........ 68
betamethasone, augmented ... 68 BETASERON ...................... 59 betaxolol ......................... 52, 88 bethanechol chloride............. 67 BETIMOL ............................ 88 BETOPTIC S ........................ 88 BEXSERO (PF) .................... 80 bicalutamide ......................... 30 BICILLIN C-R ..................... 13 BICILLIN L-A ..................... 13 BICNU.................................. 30 bimatoprost ........................... 88 bisoprolol fumarate............... 52 bisoprolol-hydrochlorothiazide
.......................................... 52 BIVIGAM ............................ 80 bleomycin ............................. 30 BLEPHAMIDE S.O.P. ......... 88 BOOSTRIX TDAP............... 80 BOSULIF ............................. 30 briellyn.................................. 73 BRILINTA ........................... 49 brimonidine .......................... 88 BRINTELLIX ...................... 22 bromfenac ............................. 88 bromocriptine ....................... 36 BROVANA .......................... 91 budesonide ...................... 85, 91 bumetanide ........................... 52 buprenorphine hcl ................. 11 buprenorphine-naloxone ....... 11 buproban ............................... 11 bupropion hcl ........................ 23 buspirone .............................. 44 BUSULFEX ......................... 30 butalbital-acetaminop-caf-cod 7 butorphanol tartrate ................ 7 BYDUREON ........................ 45 BYETTA .............................. 45 BYSTOLIC .......................... 52 C cabergoline ........................... 78 calcipotriene ................... 61, 62 calcitonin (salmon) ............... 86 calcitriol .......................... 62, 86 calcium acetate ..................... 67 camila ................................... 73 CANASA.............................. 85 CANCIDAS.......................... 26 candesartan ........................... 52
candesartan-hydrochlorothiazid .......................................... 52
CAPASTAT ......................... 29 CAPRELSA .......................... 30 captopril ................................ 52 captopril-hydrochlorothiazide
.......................................... 52 CARAFATE ......................... 64 CARBAGLU ........................ 96 carbamazepine ...................... 19 carbidopa .............................. 36 carbidopa-levodopa .............. 36 carbidopa-levodopa-
entacapone ........................ 36 carbinoxamine maleate ......... 91 carboplatin ............................ 30 CARIMUNE NF
NANOFILTERED ............ 80 carisoprodol-asa-codeine ........ 7 carteolol ................................ 88 cartia xt ................................. 52 carvedilol .............................. 52 CAYSTON ........................... 91 cefaclor ................................. 13 cefadroxil .............................. 13 cefazolin ............................... 13 cefazolin in dextrose (iso-os) 13 cefdinir .................................. 13 cefepime ............................... 13 cefepime in dextrose 5 % ..... 13 cefixime ................................ 13 cefotaxime ............................ 13 cefoxitin ................................ 13 cefpodoxime ......................... 13 cefprozil ................................ 13 ceftazidime ........................... 13 ceftazidime in d5w ............... 13 ceftriaxone ............................ 13 cefuroxime axetil .................. 14 cefuroxime sodium ............... 14 celecoxib ................................. 7 CELLCEPT INTRAVENOUS
.......................................... 80 CELONTIN .......................... 19 cephalexin ............................. 14 CERDELGA ......................... 63 CEREBYX ........................... 19 CEREZYME ......................... 63 CERVARIX VACCINE (PF)
.......................................... 81
103
cetirizine ............................... 91 cevimeline ............................ 61 CHANTIX ............................ 11 CHANTIX CONTINUING
MONTH BOX .................. 11 CHANTIX STARTING
MONTH BOX .................. 11 CHENODAL ........................ 64 chloramphenicol sod succinate
.......................................... 14 chlorhexidine gluconate ....... 61 chloroquine phosphate.......... 35 chlorothiazide ....................... 52 chlorothiazide sodium .......... 52 chlorpromazine ..................... 37 chlorthalidone ....................... 52 chlorzoxazone....................... 95 cholestyramine light ............. 52 chorionic gonadotropin, human
.......................................... 71 ciclopirox .............................. 26 cidofovir ............................... 40 cilostazol............................... 49 CILOXAN ............................ 14 cimetidine ............................. 65 cimetidine hcl ....................... 65 CIMZIA ................................ 81 CIMZIA POWDER FOR
RECONST ........................ 81 CINRYZE............................. 81 CIPRO HC............................ 90 CIPRODEX .......................... 90 ciprofloxacin......................... 14 ciprofloxacin (mixture) ........ 14 ciprofloxacin hcl ................... 14 ciprofloxacin in 5 % dextrose
.......................................... 14 ciprofloxacin lactate ............. 14 cisplatin ................................ 30 citalopram ............................. 23 cladribine .............................. 30 claravis ................................. 62 CLARAVIS .......................... 62 CLARINEX .......................... 91 CLARINEX-D 12 HOUR .... 91 clarithromycin ...................... 14 clemastine ............................. 91 CLEOCIN............................. 14 CLIMARA PRO ................... 73 clindamax ............................. 14
clindamycin hcl .................... 14 clindamycin in 5 % dextrose 14 clindamycin pediatric ........... 14 clindamycin phosphate ... 14, 15 clindamycin-benzoyl peroxide
.......................................... 62 CLINIMIX 5%/D15W
SULFITE FREE ............... 96 CLINIMIX 5%/D25W
SULFITE-FREE ............... 97 CLINIMIX 2.75%/D5W
SULFIT FREE .................. 97 CLINIMIX 4.25%/D5W
SULFIT FREE .................. 97 CLINIMIX 5%-
D20W(SULFITE-FREE).. 97 CLINIMIX E 4.25%/D10W
SUL FREE ........................ 97 clobetasol ........................ 68, 69 clobetasol-emollient ............. 69 clodan ................................... 69 CLOLAR .............................. 30 clomipramine ........................ 23 clonazepam ........................... 19 clonidine ............................... 52 clonidine hcl ................... 52, 59 clopidogrel ............................ 49 clorazepate dipotassium ....... 44 clotrimazole .......................... 26 clotrimazole-betamethasone . 62 clozapine ............................... 37 COARTEM .......................... 35 codeine sulfate ........................ 7 colchicine.............................. 28 colchicine-probenecid .......... 28 colestipol .............................. 53 colistin (colistimethate na) ... 15 colocort ................................. 85 COMBIGAN ........................ 88 COMBIPATCH .................... 73 COMBIVENT RESPIMAT . 91 COMETRIQ ......................... 30 COMPLERA ........................ 40 compro .................................. 25 COMVAX (PF) .................... 81 CONDYLOX........................ 62 constulose ............................. 65 COPAXONE ........................ 59 CORDRAN TAPE LARGE
ROLL................................ 69
COREG CR .......................... 53 cormax .................................. 69 cortisone ............................... 69 COSENTYX PEN ................ 62 COSENTYX PEN (2 PENS) 62 COUMADIN ........................ 49 CREON ................................. 63 CRESTOR ............................ 53 CRIXIVAN ........................... 40 cromolyn ................... 65, 88, 92 cryselle (28) .......................... 73 CUBICIN .............................. 15 cyclafem 1/35 (28) ................ 73 cyclafem 7/7/7 (28) ............... 73 cyclobenzaprine .................... 95 cyclophosphamide ................ 31 CYCLOSET ......................... 45 cyclosporine .......................... 81 cyclosporine modified .......... 81 cyproheptadine ..................... 92 CYSTADANE ...................... 63 CYSTAGON ........................ 63 cytarabine ............................. 31 cytarabine (pf) ...................... 31 D d10 % & 0.45 % sodium
chloride ............................. 97 d2.5 %-0.45 % sodium
chloride ............................. 97 d5 % and 0.9 % sodium
chloride ............................. 97 d5 %-0.45 % sodium chloride
.......................................... 97 dacarbazine ........................... 31 DALIRESP ........................... 92 danazol .................................. 73 dantrolene ............................. 39 dapsone ................................. 29 DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 81 DARAPRIM ......................... 35 daunorubicin ......................... 31 DAUNOXOME .................... 31 deblitane ............................... 73 decitabine .............................. 31 DELESTROGEN ................. 73 delyla (28) ............................. 73 DELZICOL ........................... 85 demeclocycline ..................... 15 DEMSER .............................. 53
104
DENAVIR ............................ 40 DEPEN TITRATABS .......... 97 DEPO-PROVERA ............... 73 desipramine .......................... 23 desloratadine......................... 92 desmopressin ........................ 71 desog-e.estradiol/e.estradiol . 73 desonide ................................ 69 desoximetasone .................... 69 dexamethasone ..................... 69 dexamethasone intensol........ 69 dexamethasone sodium
phosphate .................... 69, 88 DEXILANT .......................... 65 dexmethylphenidate ............. 59 dexrazoxane hcl .................... 31 dextroamphetamine .............. 59 dextroamphetamine-
amphetamine .................... 60 dextrose 10 % and 0.2 % nacl
.......................................... 97 dextrose 10 % in water (d10w)
.......................................... 97 dextrose 5 % in water (d5w) 97 dextrose 5 %-lactated ringers97 dextrose 5%-0.2 % sod
chloride ............................. 97 dextrose 5%-0.3 %
sod.chloride ...................... 97 dextrose with sodium chloride
.......................................... 97 dextrose-kcl-nacl .................. 97 diazepam......................... 20, 44 diazepam intensol ................. 44 diclofenac potassium .............. 7 diclofenac sodium ...... 7, 28, 88 diclofenac-misoprostol ........... 7 dicloxacillin .......................... 15 dicyclomine .......................... 65 didanosine............................. 40 DIFICID ............................... 15 diflorasone ............................ 69 diflunisal ................................. 7 digitek ................................... 53 digoxin .................................. 53 dihydroergotamine ............... 28 DIHYDROERGOTAMINE . 28 DILANTIN ........................... 20 DILANTIN INFATABS ...... 20 diltiazem hcl ......................... 53
dilt-xr .................................... 53 DIPENTUM ......................... 85 diphenhydramine hcl ............ 92 diphenoxylate-atropine ......... 65 dipyridamole ......................... 49 disopyramide phosphate ....... 53 disulfiram.............................. 11 divalproex ............................. 20 DOCEFREZ ......................... 31 docetaxel ............................... 31 DOCETAXEL ...................... 31 donepezil .............................. 22 dorzolamide .......................... 88 dorzolamide-timolol ............. 88 doxazosin .............................. 67 doxepin ................................. 23 doxercalciferol ...................... 86 doxorubicin ........................... 31 doxy-100 ............................... 15 doxycycline hyclate .............. 15 doxycycline monohydrate .... 15 dronabinol ............................. 25 drospirenone-ethinyl estradiol
.......................................... 73 DROXIA .............................. 31 DUAVEE.............................. 73 DULERA .............................. 92 duloxetine ............................. 23 duramorph (pf) ....................... 7 DUREZOL ........................... 88 E e.e.s. 400 ............................... 15 E.E.S. GRANULES.............. 15 econazole .............................. 26 EDURANT ........................... 40 EFFIENT .............................. 49 EGRIFTA ............................. 71 ELAPRASE .......................... 63 ELELYSO ............................ 63 ELIDEL ................................ 62 ELIGARD ............................ 78 ELIQUIS .............................. 49 ELITEK ................................ 31 ELIXOPHYLLIN ................. 92 ELMIRON ............................ 67 EMCYT ................................ 31 EMEND ................................ 25 emoquette ............................. 73 EMSAM ............................... 23 EMTRIVA ............................ 40
ENABLEX ........................... 67 enalapril maleate ................... 53 enalapril-hydrochlorothiazide
.......................................... 53 ENBREL ............................... 81 ENBREL SURECLICK ....... 81 endocet .................................... 7 endodan ................................... 7 ENGERIX-B (PF) ................ 81 ENGERIX-B PEDIATRIC
(PF) ................................... 81 enoxaparin ............................ 49 enpresse ................................ 73 entacapone ............................ 36 entecavir ............................... 40 enulose .................................. 65 epinastine .............................. 88 epinephrine ........................... 92 EPINEPHRINE .................... 92 EPIPEN 2-PAK .................... 92 EPIPEN JR 2-PAK ............... 92 epirubicin .............................. 31 epitol ..................................... 20 EPIVIR HBV ........................ 40 eplerenone ............................. 53 EPOGEN .............................. 49 eprosartan ............................. 53 EPZICOM ............................. 40 ERAXIS(WATER DILUENT)
.......................................... 26 ERBITUX ............................. 31 ergoloid ................................. 22 ERIVEDGE .......................... 31 errin ....................................... 74 ERWINAZE ......................... 31 ery pads ................................. 15 ERYPED 200 ........................ 15 ERYTHROCIN .................... 15 erythrocin (as stearate) ......... 15 erythromycin ................... 15, 16 erythromycin ethylsuccinate . 15 erythromycin with ethanol .... 16 erythromycin-benzoyl peroxide
.......................................... 62 ESBRIET .............................. 92 escitalopram oxalate ............. 23 esomeprazole magnesium ..... 65 esomeprazole sodium ........... 65 ESTRACE ............................ 74 estradiol ................................ 74
105
estradiol valerate .................. 74 estradiol-norethindrone acet . 74 ESTRING ............................. 74 eszopiclone ........................... 95 ethambutol ............................ 29 ethosuximide ........................ 20 etidronate disodium .............. 86 etodolac .................................. 7 ETOPOPHOS ....................... 31 etoposide............................... 31 EURAX ................................ 35 EVOTAZ .............................. 40 EXELON .............................. 22 exemestane ........................... 31 EXJADE ............................... 97 EXTAVIA ............................ 60 F FABRAZYME ..................... 63 falmina (28) .......................... 74 famciclovir ........................... 41 famotidine............................. 65 famotidine (pf)...................... 65 famotidine (pf)-nacl (iso-os) 65 FANAPT ........................ 37, 38 FARESTON ......................... 31 FARYDAK........................... 31 FASLODEX ......................... 31 felbamate .............................. 20 felodipine .............................. 53 FEMRING ............................ 74 fenofibrate ............................ 54 fenofibrate micronized ......... 53 fenofibrate nanocrystallized 53,
54 fenofibric acid (choline) ....... 54 fenoprofen .............................. 7 fentanyl ................................... 8 fentanyl citrate ........................ 7 FENTORA ............................. 8 FERRIPROX ........................ 87 FETZIMA............................. 23 FINACEA............................. 62 finasteride ............................. 67 FIRAZYR ............................. 81 FIRMAGON KIT W
DILUENT SYRINGE 78, 79 flavoxate ............................... 67 FLEBOGAMMA DIF .......... 81 flecainide .............................. 54 FLECTOR ............................ 28
FLOVENT DISKUS ............ 92 FLOVENT HFA ................... 92 fluconazole ........................... 27 fluconazole in dextrose(iso-o)
.......................................... 26 flucytosine ............................ 27 fludarabine ............................ 31 fludrocortisone...................... 69 flunisolide ............................. 92 fluocinolone .......................... 62 fluocinolone acetonide oil .... 69 fluocinonide .......................... 69 fluocinonide-e ....................... 69 fluorouracil ..................... 31, 62 fluoxetine .............................. 23 fluphenazine decanoate ........ 38 fluphenazine hcl ................... 38 flurbiprofen ............................. 8 flurbiprofen sodium .............. 88 flutamide ............................... 31 fluticasone ...................... 69, 92 fluvastatin ............................. 54 fluvoxamine .......................... 23 FML S.O.P. .......................... 88 FOLOTYN ........................... 32 fomepizole ............................ 87 fondaparinux ......................... 49 FORADIL AEROLIZER ..... 92 FORFIVO XL....................... 24 FORTEO .............................. 86 FORTICAL .......................... 86 foscarnet ............................... 41 fosinopril .............................. 54 fosinopril-hydrochlorothiazide
.......................................... 54 fosphenytoin ......................... 20 FOSRENOL ......................... 67 FRAGMIN...................... 49, 50 FREAMINE HBC 6.9 % ...... 97 furosemide ............................ 54 FUZEON .............................. 41 FYCOMPA ........................... 20 G gabapentin ............................ 20 GABITRIL ........................... 20 galantamine .......................... 22 GAMASTAN S/D ................ 81 GAMMAGARD LIQUID .... 81 GAMMAKED ...................... 81 GAMMAPLEX .................... 81
GAMUNEX-C ...................... 82 ganciclovir sodium ............... 41 GARDASIL (PF) .................. 82 GARDASIL 9 (PF) ............... 82 gatifloxacin ........................... 16 GATTEX ONE-VIAL .......... 65 gauze pad .............................. 62 gavilyte-c .............................. 65 gavilyte-g .............................. 65 gavilyte-n .............................. 65 gemcitabine ........................... 32 gemfibrozil ........................... 54 generlac ................................. 65 gengraf .................................. 82 GENOTROPIN ..................... 71 GENOTROPIN MINIQUICK
.......................................... 71 gentak ................................... 16 gentamicin ............................ 16 gentamicin in nacl (iso-osm) 16 gentamicin sulfate (pf) .......... 16 GEODON ............................. 38 gianvi (28) ............................ 74 gildagia ................................. 74 gildess ................................... 74 gildess 24 fe .......................... 74 GILENYA ............................ 60 GILOTRIF ............................ 32 GLASSIA ............................. 92 glatopa .................................. 60 GLEEVEC ............................ 32 glimepiride ............................ 45 glipizide ................................ 45 glipizide-metformin .............. 45 GLUCAGEN HYPOKIT ...... 45 GLUCAGON EMERGENCY
KIT (HUMAN) ................. 45 glyburide ......................... 45, 46 glyburide micronized ............ 45 glyburide-metformin ............. 46 glycopyrrolate ....................... 65 GLYSET ............................... 46 granisetron (pf) ..................... 25 granisetron hcl ...................... 25 GRANIX ............................... 50 griseofulvin microsize .......... 27 griseofulvin ultramicrosize ... 27 guanfacine ............................. 54 guanidine .............................. 29
106
H HALAVEN........................... 32 halobetasol propionate.......... 70 haloperidol ............................ 38 haloperidol decanoate ........... 38 haloperidol lactate ................ 38 HARVONI ........................... 41 HAVRIX (PF) ...................... 82 heparin (porcine) .................. 50 heparin (porcine) in 5 % dex 50 HERCEPTIN ........................ 32 HETLIOZ ............................. 60 HEXALEN ........................... 32 HUMALOG ......................... 46 HUMALOG KWIKPEN ...... 46 HUMALOG MIX 50-50 ...... 46 HUMALOG MIX 50-50
KWIKPEN ....................... 46 HUMALOG MIX 75-25 ...... 46 HUMALOG MIX 75-25
KWIKPEN ....................... 46 HUMATROPE ............... 71, 72 HUMIRA .............................. 82 HUMIRA CROHN'S DIS
START PCK .................... 82 HUMULIN 70/30 ................. 46 HUMULIN 70/30 KWIKPEN
.......................................... 46 HUMULIN N ....................... 46 HUMULIN N KWIKPEN .... 46 HUMULIN R ....................... 46 HUMULIN R U-500 ............ 46 hydralazine ........................... 54 hydrochlorothiazide .............. 54 hydrocodone-acetaminophen . 8 hydrocodone-ibuprofen .......... 8 hydrocortisone ................ 70, 85 hydrocortisone butyrate ........ 70 hydrocortisone butyr-emollient
.......................................... 70 hydrocortisone valerate ........ 70 hydrocortisone-acetic acid.... 90 hydromorphone ...................... 8 hydromorphone (pf) ............... 8 hydroxychloroquine ............. 35 hydroxyurea .......................... 32 hydroxyzine hcl .................... 92 HYPERRAB S/D (PF) ......... 82 I ibandronate ........................... 86
IBRANCE ............................ 32 ibuprofen ................................ 8 ibuprofen-oxycodone.............. 8 ICLUSIG .............................. 32 idarubicin .............................. 32 ifosfamide ............................. 32 ILARIS (PF) ......................... 82 ilotycin .................................. 16 IMBRUVICA ....................... 32 imipenem-cilastatin .............. 16 imipramine hcl ...................... 24 imipramine pamoate ............. 24 imiquimod ............................ 62 IMOVAX RABIES VACCINE
(PF) ................................... 82 INCRELEX .......................... 72 indapamide ........................... 54 INDOCIN ............................... 8 indomethacin .......................... 8 INFANRIX (DTAP) (PF) ..... 82 INLYTA ............................... 32 insulin pen needle ................. 87 insulin syringe-needle u-100 87 INTELENCE ........................ 41 intralipid ............................... 87 INTRON A ........................... 41 introvale ................................ 74 INVANZ ............................... 16 INVEGA ............................... 38 INVEGA SUSTENNA ......... 38 INVIRASE ........................... 41 INVOKAMET ...................... 46 INVOKANA ........................ 46 IPOL ..................................... 82 ipratropium bromide ............. 93 ipratropium-albuterol............ 93 irbesartan .............................. 54 irbesartan-hydrochlorothiazide
.......................................... 54 irenka .................................... 24 IRINOTECAN...................... 32 ISENTRESS ......................... 41 ISOLYTE-P IN 5 %
DEXTROSE ..................... 97 ISOLYTE-S .......................... 98 isoniazid................................ 29 isopropyl alcohol-benzocaine
.......................................... 16 ISORDIL .............................. 54 isosorbide dinitrate ............... 54
isosorbide mononitrate ......... 54 isradipine .............................. 54 ISTODAX ............................. 32 itraconazole ........................... 27 ivermectin ............................. 35 IXEMPRA ............................ 32 IXIARO (PF) ........................ 82 J JAKAFI ................................ 32 JALYN ................................. 67 jantoven ................................ 50 JANUMET ..................... 46, 47 JANUMET XR ..................... 47 JANUVIA ............................. 47 JEVTANA ............................ 32 jinteli ..................................... 74 jolivette ................................. 74 junel 1.5/30 (21) ................... 74 junel 1/20 (21) ...................... 74 junel fe 1.5/30 (28) ............... 74 junel fe 1/20 (28) .................. 74 junel fe 24 ............................. 74 JUXTAPID ........................... 55 K KADCYLA ........................... 32 KALETRA ........................... 41 KALYDECO ........................ 93 kariva (28) ............................ 74 kelnor 1/35 (28) .................... 74 KEPIVANCE ....................... 61 ketoconazole ......................... 27 ketoprofen ............................... 8 ketorolac ......................... 88, 89 KEYTRUDA ........................ 32 KINERET ............................. 82 kionex ................................... 98 klor-con 10 ............................ 98 klor-con 8 .............................. 98 KLOR-CON M15 ................. 98 klor-con m20 ........................ 98 KOMBIGLYZE XR ............. 47 KORLYM ............................. 72 KRISTALOSE ...................... 65 k-tab ...................................... 98 KUVAN .......................... 63, 64 KYNAMRO ......................... 55 L l norgest&e estradiol-e estrad
.......................................... 74 labetalol ................................ 55
107
lactated ringers ............... 87, 98 lactulose ................................ 65 lamivudine ............................ 41 lamivudine-zidovudine ......... 41 lamotrigine ........................... 20 LANOXIN ............................ 55 lansoprazole .......................... 65 LANTUS .............................. 47 LANTUS SOLOSTAR ........ 47 larin 1.5/30 (21) .................... 74 larin 1/20 (21) ....................... 75 larin fe .................................. 75 LASTACAFT ....................... 89 latanoprost ............................ 89 LATUDA ............................. 38 LAZANDA............................. 8 leena 28 ................................ 75 leflunomide........................... 82 LENVIMA ........................... 32 LESCOL XL ........................ 55 lessina ................................... 75 LETAIRIS ............................ 93 letrozole ................................ 32 leucovorin calcium ......... 32, 33 LEUKERAN ........................ 33 LEUKINE............................. 50 leuprolide .............................. 79 levalbuterol hcl ..................... 93 levetiracetam .................. 20, 21 levetiracetam in nacl (iso-os) 20 levobunolol ........................... 89 levocarnitine ......................... 87 levocarnitine (with sugar)..... 87 levocetirizine ........................ 93 levofloxacin .......................... 16 levofloxacin in d5w .............. 16 LEVOLEUCOVORIN
CALCIUM ....................... 33 levonest (28) ......................... 75 levonorgestrel-ethinyl estrad 75 levora-28............................... 75 levorphanol tartrate ................ 8 levothyroxine ........................ 78 levoxyl .................................. 78 LEXIVA ............................... 41 lidocaine ............................... 11 lidocaine (pf) ........................ 10 lidocaine hcl ................... 10, 11 lidocaine-prilocaine .............. 11 LINCOCIN ........................... 16
lindane ............................ 35, 36 linezolid ................................ 16 LINZESS .............................. 65 liothyronine .......................... 78 liposyn ii ............................... 87 lisinopril................................ 55 lisinopril-hydrochlorothiazide
.......................................... 55 lithium carbonate .................. 44 lithium citrate ....................... 44 lokara .................................... 70 lomedia 24 fe ........................ 75 lomustine .............................. 33 loperamide ............................ 65 lopreeza ................................ 75 lorazepam ............................. 44 lorcet (hydrocodone) .............. 8 lorcet hd .................................. 8 lorcet plus ............................... 8 lortab 10-325 .......................... 8 lortab 5-325 ............................ 8 lortab 7.5-325 ......................... 8 loryna (28) ............................ 75 losartan ................................. 55 losartan-hydrochlorothiazide 55 LOTEMAX .......................... 89 lovastatin .............................. 55 loxapine succinate ................ 38 LUMIGAN ........................... 89 LUMIZYME ........................ 64 LUPANETA PACK (1
MONTH) .......................... 79 LUPANETA PACK (3
MONTH) .......................... 79 LUPRON DEPOT ................ 79 LUPRON DEPOT (3
MONTH) .......................... 79 LUPRON DEPOT (4
MONTH) .......................... 79 LUPRON DEPOT (6
MONTH) .......................... 79 LUPRON DEPOT-PED ....... 79 lutera (28) ............................. 75 LYNPARZA ......................... 33 LYRICA ............................... 21 LYSODREN ......................... 78 lyza ....................................... 75 M MACRODANTIN ................ 16 magnesium sulfate ................ 98
malathion .............................. 36 maprotiline ............................ 24 marlissa ................................. 75 MARPLAN ........................... 24 MATULANE ........................ 33 matzim la .............................. 55 meclizine ............................... 25 meclofenamate ........................ 9 medroxyprogesterone ........... 75 mefenamic acid ....................... 9 mefloquine ............................ 36 megestrol .............................. 75 MEKINIST ........................... 33 meloxicam .............................. 9 melphalan hcl ........................ 33 MENACTRA (PF) ................ 83 MENEST .............................. 75 MENOMUNE - A/C/Y/W-135
(PF) ................................... 83 MENVEO A-C-Y-W-135-DIP
(PF) ................................... 83 meprobamate ........................ 44 mercaptopurine ..................... 33 meropenem ........................... 16 mesalamine with cleansing
wipe .................................. 85 mesna .................................... 33 MESNEX .............................. 33 MESTINON ......................... 29 MESTINON TIMESPAN .... 29 metadate er ............................ 60 metaproterenol ...................... 93 metformin ............................. 47 methadone ............................... 9 methazolamide ...................... 55 methenamine hippurate ........ 16 methimazole ......................... 80 methotrexate sodium ............ 83 methotrexate sodium (pf) ..... 83 methoxsalen rapid ................. 62 methscopolamine .................. 66 methyclothiazide ................... 55 methyldopa ........................... 55 methyldopa-
hydrochlorothiazide .......... 55 methylergonovine ................. 87 methylphenidate ................... 60 methylprednisolone .............. 70 methylprednisolone acetate .. 70
108
methylprednisolone sodium succ ................................... 70
metipranolol ......................... 89 metoclopramide hcl .............. 66 metolazone ........................... 55 metoprolol succinate ............ 55 metoprolol ta-hydrochlorothiaz
.......................................... 55 metoprolol tartrate ................ 55 metronidazole ....................... 17 metronidazole in nacl (iso-os)
.......................................... 16 mexiletine ............................. 55 MIACALCIN ....................... 86 miconazole-3 ........................ 27 microgestin 1.5/30 (21) ........ 75 microgestin 1/20 (21) ........... 75 microgestin fe 1.5/30 (28) .... 75 microgestin fe 1/20 (28) ....... 75 midodrine ............................. 56 MIGERGOT ......................... 28 mimvey ................................. 75 mimvey lo ............................. 75 minitran ................................ 56 minocycline .......................... 17 minoxidil .............................. 56 mirtazapine ........................... 24 misoprostol ........................... 66 mitomycin............................. 33 mitoxantrone......................... 33 M-M-R II (PF) ...................... 83 modafinil .............................. 95 MODAFINIL ....................... 95 moderiba ............................... 41 moderiba dose pack .............. 41 moexipril .............................. 56 moexipril-hydrochlorothiazide
.......................................... 56 mometasone .......................... 70 mononessa (28) .................... 75 montelukast .......................... 93 morphine................................. 9 morphine concentrate ............. 9 MOVIPREP .......................... 66 MOXEZA ............................. 17 moxifloxacin......................... 17 MOZOBIL ............................ 50 MULTAQ ............................. 56 mupirocin ............................. 17 mupirocin calcium ................ 17
MUSTARGEN ..................... 33 MYALEPT ........................... 87 mycophenolate mofetil ......... 83 mycophenolate sodium ......... 83 myorisan ............................... 62 MYOZYME ......................... 64 MYRBETRIQ ...................... 67 N nabumetone ............................ 9 nadolol .................................. 56 nadolol-bendroflumethiazide 56 nafcillin ................................. 17 naftifine ................................ 27 NAFTIN ............................... 27 NAGLAZYME ..................... 64 nalbuphine .............................. 9 naloxone ............................... 11 naltrexone ............................. 11 NAMENDA.......................... 22 NAMENDA TITRATION
PAK .................................. 22 NAMENDA XR ................... 22 naphazoline ........................... 89 naproxen ................................. 9 naproxen sodium .................... 9 naratriptan ............................. 28 NATACYN .......................... 27 nateglinide ............................ 47 NATPARA ........................... 87 NEBUPENT ......................... 36 necon 0.5/35 (28) .................. 75 necon 1/35 (28) ..................... 76 necon 10/11 (28) ................... 76 necon 7/7/7 (28).................... 76 nefazodone............................ 24 neomycin .............................. 17 neomycin-bacitracin-poly-hc 17 neomycin-bacitracin-
polymyxin ......................... 89 neomycin-polymyxin b gu.... 17 neomycin-polymyxin b-
dexameth .......................... 89 neomycin-polymyxin-
gramicidin ......................... 89 neomycin-polymyxin-hc 17, 90 NEPHRAMINE 5.4 % ......... 98 neuac ..................................... 62 NEULASTA ......................... 50 NEUMEGA .......................... 50 NEUPOGEN ........................ 50
NEUPRO .............................. 36 nevirapine ....................... 41, 42 NEXAVAR ........................... 33 NEXIUM PACKET .............. 66 niacin .................................... 56 niacor .................................... 56 nicardipine ............................ 56 NICOTROL .......................... 11 nifedical xl ............................ 56 nifedipine .............................. 56 nikki (28) .............................. 76 NILANDRON ...................... 33 nimodipine ............................ 56 nisoldipine ............................ 56 nitrofurantoin ........................ 17 nitrofurantoin macrocrystal .. 17 nitrofurantoin monohyd/m-
cryst .................................. 17 nitroglycerin ......................... 56 NITROSTAT ........................ 56 nizatidine .............................. 66 nora-be .................................. 76 NORDITROPIN FLEXPRO 72 NORDITROPIN NORDIFLEX
.......................................... 72 norethindrone (contraceptive)
.......................................... 76 norethindrone acetate ............ 76 norethindrone ac-eth estradiol
.......................................... 76 norethindrone-e.estradiol-iron
.......................................... 76 norlyroc ................................. 76 normosol-m in 5 % dextrose . 98 normosol-r in 5 % dextrose .. 98 normosol-r ph 7.4 ................. 98 NORTHERA ........................ 56 nortrel 0.5/35 (28) ................. 76 nortrel 1/35 (21) .................... 76 nortrel 1/35 (28) .................... 76 nortrel 7/7/7 (28) ................... 76 nortriptyline .......................... 24 NORVIR ............................... 42 novarel .................................. 72 NOVOLIN 70/30 .................. 47 NOVOLIN N ........................ 47 NOVOLIN R ........................ 47 NOVOLOG .......................... 47 NOVOLOG FLEXPEN ........ 47 NOVOLOG MIX 70-30 ....... 47
109
NOVOLOG MIX 70-30 FLEXPEN ........................ 47
NOVOLOG PENFILL ......... 47 NOXAFIL ............................ 27 NUCYNTA ............................ 9 NUCYNTA ER ...................... 9 NUEDEXTA ........................ 60 NULOJIX ............................. 83 nutrilipid ............................... 87 NUTROPIN AQ ................... 72 NUTROPIN AQ NUSPIN ... 72 NUVARING......................... 76 NUVIGIL ............................. 95 nyamyc ................................. 27 nystatin ................................. 27 nystatin-triamcinolone .......... 27 nystop ................................... 27 O ocella .................................... 76 OCTAGAM .......................... 83 octreotide acetate .................. 79 OFEV ................................... 93 ofloxacin ............................... 17 ogestrel (28).......................... 76 olanzapine............................. 38 olanzapine-fluoxetine ........... 24 OLYSIO ............................... 42 OMECLAMOX-PAK .......... 66 omega-3 acid ethyl esters ..... 56 omeprazole ........................... 66 omeprazole-sodium
bicarbonate ....................... 66 OMNITROPE....................... 72 ONCASPAR ........................ 33 ondansetron .......................... 25 ondansetron hcl .................... 25 ondansetron hcl (pf) ............. 25 ONFI..................................... 21 ONGLYZA..................... 47, 48 ONMEL ................................ 27 OPDIVO ............................... 33 OPSUMIT ............................ 93 ORAP ................................... 38 ORENCIA ............................ 83 ORENCIA (WITH
MALTOSE) ...................... 83 ORENITRAM ...................... 93 ORFADIN ............................ 87 orsythia ................................. 76 OSMOPREP ......................... 66
OTEZLA .............................. 83 OTEZLA STARTER ............ 83 oxaliplatin ............................. 33 oxandrolone .......................... 76 oxaprozin ................................ 9 oxcarbazepine ....................... 21 OXISTAT ....................... 27, 28 oxybutynin chloride .............. 67 oxycodone ........................ 9, 10 oxycodone-acetaminophen ... 10 oxycodone-aspirin ................ 10 OXYCONTIN ...................... 10 oxymorphone ........................ 10 OXYTROL ........................... 67 P pacerone................................ 56 paclitaxel .............................. 33 pamidronate .......................... 86 PANCREAZE ...................... 64 PANRETIN .......................... 33 pantoprazole ......................... 66 paricalcitol ............................ 86 paromomycin ........................ 17 paroxetine hcl ....................... 24 PASER.................................. 29 PATADAY ........................... 89 PATANOL ........................... 89 PAXIL .................................. 24 PEDVAX HIB (PF) .............. 83 peg 3350-electrolytes ........... 66 PEGANONE ........................ 21 PEGASYS ............................ 42 PEGASYS PROCLICK ....... 42 PEGINTRON ....................... 42 PEGINTRON REDIPEN ..... 42 penicillin g potassium ........... 17 penicillin g procaine ............. 17 penicillin g sodium ............... 18 penicillin v potassium ........... 18 PENTAM.............................. 36 PENTASA ............................ 85 pentazocine-naloxone ........... 10 pentoxifylline........................ 57 PERFOROMIST .................. 93 perindopril erbumine ............ 57 periogard ............................... 61 PERJETA ............................. 33 permethrin ............................ 36 perphenazine ......................... 39 perphenazine-amitriptyline ... 24
PERTZYE ............................. 64 phenadoz ............................... 25 phenelzine ............................. 24 phenergan ............................. 25 phenobarbital ........................ 21 phenytoin .............................. 21 phenytoin sodium ................. 21 phenytoin sodium extended .. 21 PHOSPHOLINE IODIDE .... 89 physiolyte ............................. 87 physiosol irrigation ............... 87 pilocarpine hcl ................ 61, 89 pimtrea (28) .......................... 76 pindolol ................................. 57 pioglitazone .......................... 48 pioglitazone-glimepiride ....... 48 pioglitazone-metformin ........ 48 piperacillin-tazobactam ........ 18 pirmella ................................. 76 piroxicam .............................. 10 PLASMA-LYTE 148 ........... 98 PLASMA-LYTE A .............. 98 PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 98 PLEGRIDY .......................... 60 podofilox ............................... 62 polyethylene glycol 3350 ..... 66 polymyxin b sulfate .............. 18 polymyxin b sulf-trimethoprim
.......................................... 89 POMALYST ......................... 33 portia ..................................... 76 potassium chlorid-d5-
0.45%nacl ......................... 98 potassium chloride .......... 98, 99 potassium chloride in 0.9%nacl
.......................................... 98 potassium chloride in 5 % dex
.......................................... 98 potassium chloride-0.45 % nacl
.......................................... 99 potassium chloride-d5-
0.2%nacl ........................... 99 potassium chloride-d5-
0.3%nacl ........................... 99 potassium chloride-d5-
0.9%nacl ........................... 99 potassium citrate ................... 99 POTIGA ............................... 21 PRADAXA ........................... 50
110
pramipexole .......................... 37 pravastatin ............................ 57 prazosin ................................ 57 PRED MILD ........................ 89 prednicarbate ........................ 70 prednisolone acetate ............. 89 prednisolone sodium phosphate
.................................... 70, 89 prednisone ............................ 70 prednisone intensol ............... 70 PREFEST ............................. 76 pregnyl .................................. 72 PREMARIN ......................... 76 PREMASOL 10 % ............... 99 premasol 6 % ........................ 99 PREMPRO ........................... 76 prenatal vitamins low iron .... 99 prevalite ................................ 57 previfem ............................... 76 PREZCOBIX ........................ 42 PREZISTA ........................... 42 PRIFTIN ............................... 29 PRIMAQUINE ..................... 36 primidone ............................. 21 PRISTIQ ............................... 24 PRIVIGEN ........................... 83 PROAIR HFA ...................... 93 PROAIR RESPICLICK ....... 93 probenecid ............................ 28 procainamide ........................ 57 PROCALAMINE 3% ........... 99 prochlorperazine ................... 26 prochlorperazine edisylate.... 26 prochlorperazine maleate ..... 26 PROCRIT ............................. 50 procto-pak............................. 71 proctosol hc .......................... 71 proctozone-hc ....................... 71 progesterone micronized ...... 77 PROGLYCEM ..................... 48 PROGRAF ........................... 83 PROLASTIN-C .................... 93 PROLEUKIN ....................... 33 PROLIA ............................... 86 PROMACTA ........................ 50 promethazine ........................ 26 promethegan ......................... 26 propafenone .......................... 57 propantheline ........................ 66 proparacaine ......................... 89
propranolol ........................... 57 propranolol-hydrochlorothiazid
.......................................... 57 propylthiouracil .................... 80 PROQUAD (PF)................... 83 protriptyline .......................... 24 PROVENTIL HFA ............... 93 PRUDOXIN ......................... 62 PULMICORT ....................... 94 PULMICORT FLEXHALER
.......................................... 94 PULMOZYME ..................... 94 PURIXAN ............................ 33 pyrazinamide ........................ 29 pyridostigmine bromide ....... 29 Q QUADRACEL (PF) ............. 83 quasense................................ 77 quetiapine ............................. 39 quinapril................................ 57 quinapril-hydrochlorothiazide
.......................................... 57 quinidine gluconate .............. 57 quinidine sulfate ................... 57 quinine sulfate ...................... 36 QVAR ................................... 94 R RABAVERT (PF) ................ 83 rabeprazole ........................... 66 raloxifene .............................. 77 ramipril ................................. 57 RANEXA ............................. 57 ranitidine hcl ......................... 66 RAPAMUNE........................ 84 RAVICTI .............................. 64 REBETOL ............................ 42 REBIF (WITH ALBUMIN) . 60 REBIF REBIDOSE .............. 60 REBIF TITRATION PACK . 60 reclipsen (28) ........................ 77 RECOMBIVAX HB (PF) .... 84 RELENZA DISKHALER .... 42 RELISTOR ........................... 66 RELPAX .............................. 28 REMICADE ......................... 84 REMODULIN ...................... 94 RENVELA ........................... 67 repaglinide ............................ 48 RESCRIPTOR ...................... 42 reserpine ............................... 57
RESTASIS ............................ 89 RETROVIR .......................... 42 REVATIO ............................. 94 REVLIMID ........................... 33 REYATAZ ........................... 42 ribasphere ............................. 42 RIBASPHERE ...................... 42 RIBASPHERE RIBAPAK ... 43 ribavirin ................................ 43 RIDAURA ............................ 84 rifabutin ................................ 29 rifampin ................................ 29 RIFATER ............................. 29 riluzole .................................. 60 rimantadine ........................... 43 ringers ................................... 87 RIOMET ............................... 48 risedronate ............................ 86 RISPERDAL CONSTA ....... 39 risperidone ............................ 39 RITUXAN ............................ 33 rivastigmine tartrate .............. 22 rizatriptan ........................ 28, 29 ropinirole .............................. 37 ROTARIX ............................ 84 ROTATEQ VACCINE ......... 84 ROZEREM ........................... 95 S SABRIL ................................ 21 safety needles ........................ 87 SAIZEN ................................ 72 SAIZEN CLICK.EASY ....... 72 SAMSCA .............................. 99 SANCUSO ........................... 26 SANDOSTATIN LAR
DEPOT ............................. 79 SANTYL .............................. 62 SAPHRIS (BLACK
CHERRY) ......................... 39 SAVELLA ...................... 60, 61 selegiline hcl ......................... 37 selenium sulfide .................... 63 SELZENTRY ....................... 43 SENSIPAR ........................... 78 SEREVENT DISKUS .......... 94 SEROQUEL XR ................... 39 SEROSTIM .......................... 72 sertraline ............................... 24 sharobel ................................. 77 SIGNIFOR ............................ 79
111
SIGNIFOR LAR .................. 79 sildenafil ............................... 94 SILENOR ............................. 95 silver sulfadiazine ................. 18 SIMCOR............................... 57 SIMPONI ............................. 84 SIMPONI ARIA ................... 84 SIMULECT .......................... 84 simvastatin ............................ 57 sirolimus ............................... 84 SIRTURO ............................. 29 SKLICE ................................ 36 sodium chloride .................... 99 sodium chloride 0.45 % ........ 99 sodium chloride 0.9 % .......... 99 sodium chloride 3 % ............. 99 sodium chloride 5 % ............. 99 sodium fluoride .................... 99 sodium lactate ....................... 99 sodium phenylbutyrate ......... 64 sodium polystyrene (sorb free)
.......................................... 99 SOLTAMOX ........................ 34 SOLU-CORTEF (PF) ........... 71 SOMATULINE DEPOT ...... 79 SOMAVERT ........................ 79 sorine .................................... 58 sotalol ................................... 58 sotalol af ............................... 58 SOVALDI ............................ 43 SPIRIVA RESPIMAT ......... 94 SPIRIVA WITH
HANDIHALER ................ 94 spironolactone ...................... 58 spironolacton-hydrochlorothiaz
.......................................... 58 SPORANOX ........................ 28 sprintec (28).......................... 77 SPRYCEL ............................ 34 sronyx ................................... 77 ssd ......................................... 18 stavudine............................... 43 STELARA ............................ 63 STIMATE............................. 72 STIVARGA .......................... 34 STRATTERA ....................... 61 STREPTOMYCIN ............... 18 STRIBILD ............................ 43 STRIVERDI RESPIMAT .... 94 SUBSYS ............................... 10
sucralfate .............................. 67 sulfacetamide sodium ........... 18 sulfacetamide sodium (acne) 18 sulfacetamide-prednisolone .. 89 sulfadiazine ........................... 18 sulfamethoxazole-trimethoprim
.......................................... 18 sulfasalazine ......................... 85 sulfazine ec ........................... 85 sulindac ................................. 10 sumatriptan ........................... 29 sumatriptan succinate ........... 29 SUPRAX .............................. 18 SUPREP BOWEL PREP KIT
.......................................... 67 SURMONTIL ....................... 24 SUSTIVA ............................. 43 SUTENT ............................... 34 SYLATRON ......................... 34 SYLVANT ........................... 34 SYMBICORT ....................... 94 SYMLINPEN 120 ................ 48 SYMLINPEN 60 .................. 48 SYNAGIS ............................. 84 SYNAREL............................ 79 SYNERCID .......................... 18 SYNRIBO ............................ 34 SYNTHROID ....................... 78 SYPRINE ........................... 100 T TABLOID ............................ 34 tacrolimus ....................... 63, 84 TAFINLAR .......................... 34 TAMIFLU ............................ 43 tamoxifen .............................. 34 tamsulosin ............................. 67 TARCEVA ........................... 34 TARGRETIN ....................... 34 tarina fe ................................. 77 TASIGNA ............................ 34 tazicef ................................... 18 TAZORAC ........................... 63 taztia xt ................................. 58 TECFIDERA ........................ 61 TEFLARO ............................ 18 TEGRETOL XR ................... 21 TEKTURNA ........................ 58 TEKTURNA HCT ............... 58 telmisartan ............................ 58 telmisartan-amlodipine ......... 58
telmisartan-hydrochlorothiazid .......................................... 58
temazepam ............................ 96 TENIVAC (PF) .................... 84 terazosin ................................ 67 terbinafine hcl ....................... 28 terbutaline ............................. 94 terconazole ............................ 28 testosterone ........................... 77 testosterone cypionate .......... 77 testosterone enanthate ........... 77 TETANUS,DIPHTHERIA
TOX PED(PF) .................. 84 TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 84 tetracycline ........................... 18 THALOMID ......................... 34 theophylline .......................... 94 thioridazine ........................... 39 thiothixene ............................ 39 THYMOGLOBULIN ........... 84 tiagabine ............................... 21 ticlopidine ............................. 50 TIKOSYN ............................. 58 timolol maleate ......... 58, 89, 90 tinidazole .............................. 36 TIVICAY .............................. 43 tizanidine .............................. 39 TOBI PODHALER .............. 94 TOBRADEX ........................ 90 tobramycin ............................ 18 tobramycin in 0.225 % nacl .. 95 tobramycin sulfate ................ 18 tobramycin-dexamethasone .. 90 tolazamide ............................. 48 tolbutamide ........................... 48 tolcapone ............................... 37 tolmetin ................................. 28 tolterodine ............................. 68 topiramate ............................. 21 toposar .................................. 34 topotecan ............................... 34 TORISEL .............................. 84 torsemide .............................. 58 tpn electrolytes .................... 100 TRACLEER ......................... 95 tramadol ................................ 10 tramadol-acetaminophen ...... 10 trandolapril ........................... 58 tranexamic acid ............... 50, 51
112
TRANSDERM-SCOP .......... 26 tranylcypromine ................... 25 TRAVASOL 10 % ............. 100 TRAVATAN Z .................... 90 travoprost (benzalkonium) ... 90 trazodone .............................. 25 TREANDA ........................... 34 TRECATOR ......................... 30 TRELSTAR .......................... 79 tretinoin ................................ 63 tretinoin (chemotherapy) ...... 34 tretinoin microspheres .......... 63 triamcinolone acetonide 61, 71,
95 triamterene-hydrochlorothiazid
.......................................... 58 TRIBENZOR ....................... 58 triderm .................................. 71 trifluoperazine ...................... 39 trifluridine............................. 43 trihexyphenidyl..................... 37 tri-legest fe............................ 77 trilyte with flavor packets ..... 67 trimethoprim ......................... 19 trinessa (28) .......................... 77 tri-previfem (28) ................... 77 TRISENOX .......................... 34 tri-sprintec (28) ..................... 77 TRIUMEQ ............................ 43 trivora (28)............................ 77 TROPHAMINE 10 % ........ 100 trospium ................................ 68 TRUMENBA ....................... 84 TRUVADA .......................... 43 TUDORZA PRESSAIR ....... 95 TWINRIX (PF) .................... 85 TYBOST .............................. 43 TYGACIL ............................ 19 TYKERB .............................. 34 TYPHIM VI ......................... 85 TYSABRI ............................. 61 TYVASO .............................. 95 TYZEKA .............................. 43 TYZINE ............................... 95 U UCERIS ................................ 71 ULORIC ............................... 28 ULTRESA ............................ 64 unithroid ............................... 78 ursodiol ................................. 67
V VAGIFEM ............................ 77 valacyclovir .......................... 43 VALCHLOR ........................ 34 valganciclovir ....................... 43 valproate sodium .................. 21 valproic acid ......................... 29 valproic acid (as sodium salt)
.......................................... 21 valsartan................................ 58 valsartan-hydrochlorothiazide
.......................................... 58 vancomycin .......................... 19 vandazole .............................. 19 VAQTA (PF) ........................ 85 VARIVAX (PF) ................... 85 VECTIBIX ........................... 34 VELCADE ........................... 34 velivet triphasic regimen (28)
.......................................... 77 venlafaxine ........................... 25 VENTAVIS .......................... 95 VENTOLIN HFA ................. 95 VERAMYST ........................ 95 verapamil ........................ 58, 59 VEREGEN ........................... 63 VERSACLOZ ...................... 39 VESICARE .......................... 68 vestura (28) ........................... 77 vicodin .................................. 10 vicodin es .............................. 10 vicodin hp ............................. 10 VICTOZA 3-PAK ................ 48 VIDEX 2 GRAM PEDIATRIC
.......................................... 43 VIGAMOX ........................... 19 VIIBRYD ............................. 25 VIMPAT ............................... 22 vinblastine ............................ 34 vincasar pfs ........................... 35 vincristine ............................. 35 vinorelbine ............................ 35 VIOKACE ............................ 64 VIRACEPT .......................... 43 VIRAMUNE XR .................. 44 VIRAZOLE .......................... 95 VIREAD ............................... 44 VITEKTA ............................. 44 VIVITROL ........................... 11 VOLTAREN ........................ 63
voriconazole ......................... 28 VOTRIENT .......................... 35 VPRIV .................................. 64 vyfemla (28) ......................... 77 VYTORIN 10-10 .................. 59 VYTORIN 10-20 .................. 59 VYTORIN 10-40 .................. 59 VYTORIN 10-80 .................. 59 W warfarin ................................. 51 water for irrigation, sterile .... 87 wymzya fe ............................ 77 X XALKORI ............................ 35 XARELTO ........................... 51 XELJANZ ............................. 85 XENAZINE .......................... 61 XGEVA ................................ 86 XIFAXAN ............................ 19 XOLAIR ............................... 95 XOPENEX HFA .................. 95 XTANDI ............................... 35 xulane ................................... 77 XYREM ................................ 96 Y YERVOY ............................. 35 YF-VAX (PF) ....................... 85 Z zafirlukast ............................. 95 zaleplon ................................. 96 ZALTRAP ............................ 35 zamicet .................................. 10 ZANOSAR ........................... 35 ZAVESCA ............................ 64 zazole .................................... 28 ZELBORAF ......................... 35 ZEMAIRA ............................ 95 zenatane ................................ 63 zenchent (28) ........................ 77 zenchent fe ............................ 77 ZENPEP ............................... 64 ZETIA ................................... 59 ZIAGEN ............................... 44 zidovudine ............................ 44 ziprasidone hcl ...................... 39 ZIRGAN ............................... 44 zoledronic acid ...................... 87 zoledronic acid-mannitol-water
.......................................... 87 ZOLINZA ............................. 35
113
zolmitriptan .......................... 29 zolpidem ............................... 96 ZOMACTON ....................... 72 ZOMETA ............................. 87 ZONALON........................... 63 zonisamide ............................ 22 ZORBTIVE .......................... 72
ZORTRESS .......................... 85 ZOSTAVAX (PF) ................ 85 ZOSYN IN DEXTROSE (ISO-
OSM) ................................ 19 zovia 1/35e (28) .................... 77 zovia 1/50e (28) .................... 78 ZOVIRAX ............................ 44
ZYCLARA ........................... 63 ZYDELIG ............................. 35 ZYKADIA ............................ 35 ZYPREXA RELPREVV ...... 39 ZYTIGA ............................... 35 ZYVOX ................................ 19
KelseyCare Advantage es ofrecido por KS Plan Administrators LLC, un plan Medicare Advantage que tiene un contrato con Medicare. Este formulario abreviado fue actualizado el 07/27/15. Para la información más reciente y otras preguntas, por favor póngase en contacto con Servicios para Miembros de KelseyCare Advantage al 1-866-589-5222 o, para usuarios TTY, al 1-888-206-8041, las 24 horas del día, los 7 días de la semana, o visite www.kelseycareadvantage.com.
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This information is available for free in other languages. Please contact our Member Services number at 713-442-CARE (2273) or toll-free at 1-866-535-8343 for additional information. From October 1 through February 14, hours are 8:00 a.m. to 8:00 p.m., seven days a week. During this time on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system. From February 15 through September 30, hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. During this time on Saturdays, Sundays and holidays, calls are handled by our voicemail system. (TTY users should call 1-866-302-9336).
H0332_SPCF16 ACCEPTED