2016 Drug FormularyProvider Directory2016 Drug FormularyProvider Directory For the most up-to-date formulary coverage, search the drug formulary on the plan website at > Provider >

2016 Provider DirectoryDrug FormularyFor the most up-to-date formulary coverage, search the drug formulary on the plan website at www.amerihealthcaritasdc.com > Provider > Provider Directories and Drug Formularies > Searchable Drug Formulary.

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For the most up to date formulary coverage search, please use the searchable formulary website

1

lowercase italics= Generic drugs

UPPERCASE BOLD= Brand

name drugs

Tier Alt= Alt

Benefit Exclusion= Benefit

Exclusion

Non-formulary= Non-formulary

Not covered= Not covered

T1= Formulary

T2= Non-Preferred Brand,

Generic Available

T3= Non-Formulary

T4= Specialty

Notes AL= Age limit applies

PA= Prior Authorization Applies

QL= Quantity Limit

ST= Step Therapy Applies

Drug Tier Notes

acetaminophen oral elixir T1

calcium-vitamin d3 oral tablet 600-125 mg-unit T1

loratadine allergy relief oral syrup T1 ST

NIZORAL A-D T1

Antihistamine Drugs

Ethanolamine Derivatives

diphenhydramine cough T1

diphenhydramine hcl injection T1

diphenhydramine hcl oral capsule T1

diphenhydramine hcl oral elixir T1

diphenhydramine hcl oral tablet 25 mg T1

sleep aid oral tablet T1

First Gen. Antihist. Derivatives, Misc.

cyproheptadine hcl oral T1

First Generation Antihistamines

allergy oral tablet 4 mg T1






2

Drug Tier Notes




Phenothiazine Derivatives

promethazine hcl injection T1

promethazine hcl oral syrup T1

promethazine hcl oral tablet T1

promethazine hcl rectal suppository 12.5 mg, 25

mg

T1

promethazine vc plain oral solution T1

promethazine vc/codeine T1 QL (120 ML per 30 days)

promethazine-dm oral syrup T1

Piperazine Derivatives

hydroxyzine hcl oral syrup T1

hydroxyzine hcl oral tablet T1

hydroxyzine pamoate oral T1

meclizine hcl oral T1

Propylamine Derivatives


hydrocod polst-cpm polst er oral suspension

extended release

T1 QL (120 ML per 30 days)

m-end dmx T1

Second Generation Antihistamines

all day allergy oral capsule T1 ST

allergy relief oral tablet dispersible T1 ST

cetirizine hcl oral solution 5 mg/5ml T1

cetirizine hcl oral tablet 10 mg T1

cetirizine-pseudoephedrine er T1 ST

CLARINEX T3 PA

fexofenadine hcl childrens T1 ST

hm loratadine childrens T1 ST

kp cetirizine hcl oral tablet 5 mg T1

kp fexofenadine hcl oral tablet 180 mg T1 ST


3

Drug Tier Notes

levocetirizine dihydrochloride oral solution T3 PA

levocetirizine dihydrochloride oral tablet T1

loratadine allergy relief oral tablet dispersible T1 ST

loratadine childrens oral solution T1 ST

loratadine oral capsule T1 ST

loratadine oral tablet T1

sm loratadine oral tablet dispersible T1 ST

Anti-Infective Agents

1St Generation Cephalosporin Antibiotics

cefadroxil T1

cephalexin oral capsule 250 mg, 500 mg T1

cephalexin oral suspension reconstituted T1

2Nd Generation Cephalosporin Antibiotics

cefaclor oral capsule T1

cefprozil oral suspension reconstituted T1

CEFTIN ORAL SUSPENSION

RECONSTITUTED 250 MG/5ML

T1

cefuroxime axetil oral suspension reconstituted

125 mg/5ml

T1

cefuroxime axetil oral tablet T1

3Rd Generation Cephalosporin Antibiotics

cefdinir oral suspension reconstituted T1

cefpodoxime proxetil oral suspension reconstituted T1

ceftriaxone sodium injection solution reconstituted

250 mg

T1

SUPRAX ORAL CAPSULE T1

Adamantane Antivirals

amantadine hcl oral capsule T1

amantadine hcl oral syrup T1

Allylamine Antifungals

terbinafine hcl oral T1 QL (90 DS per 365 DYs)

Amebicides


4

Drug Tier Notes

metronidazole oral tablet T1

paromomycin sulfate oral T1 PA; QL (10 DS per 30 DYs)

Aminoglycoside Antibiotics

ARIKAYCE T3 PA

paromomycin sulfate oral T1 PA; QL (10 DS per 30 DYs)

Aminopenicillin Antibiotics

amoxicillin oral capsule T1

amoxicillin oral suspension reconstituted T1

amoxicillin oral tablet T1

amoxicillin oral tablet chewable 125 mg, 250 mg T1

amoxicillin-pot clavulanate oral suspension

reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml,

600-42.9 mg/5ml

T1

amoxicillin-pot clavulanate oral tablet T1

amoxicillin-pot clavulanate oral tablet chewable T1

ampicillin oral capsule T1

Anthelmintics

praziquantel oral T1

Antifungals, Miscellaneous

griseofulvin microsize oral suspension T1

griseofulvin ultramicrosize T1

SSKI T1

Antimalarials

chloroquine phosphate oral T1

DARAPRIM T1 PA

hydroxychloroquine sulfate oral T1

mefloquine hcl T1

primaquine phosphate oral T1

quinidine gluconate er T1

quinidine sulfate oral T1

Antimycobacterials, Miscellaneous

dapsone oral T1


5

Drug Tier Notes

Antiprotozoals, Miscellaneous

atovaquone oral T1 PA

dapsone oral T1

metronidazole oral tablet T1

Antituberculosis Agents

ciprofloxacin hcl oral tablet 250 mg, 500 mg T1 QL (68 QY per 34 DYs)

ciprofloxacin hcl oral tablet 750 mg T1 QL (28 QY per 30 DYs)

ciprofloxacin oral T1

clarithromycin er T1 QL (1 FL per 30 DYs)

clarithromycin oral T1 QL (1 FL per 30 DYs)

ethambutol hcl oral T1

isoniazid oral T1

levofloxacin oral solution T1 QL (1 FL per 30 DYs)

levofloxacin oral tablet T1 QL (14 QY per 30 DYs)

moxifloxacin hcl oral T1 QL (10 QY per 30 DYs)

pyrazinamide oral T1

rifampin oral T1

Azole Antifungals

fluconazole oral suspension reconstituted T1

fluconazole oral tablet 100 mg, 200 mg, 50 mg T1

fluconazole oral tablet 150 mg T1 QL (2 QY per 30 DYs)

ketoconazole oral T1

VFEND T3 PA

Chloramphenicol Antibiotics

chloramphenicol sod succinate T1

Erythromycin Antibiotics

ERY-TAB T1

ERYTHROCIN STEARATE ORAL TABLET

250 MG

T1

erythromycin base oral capsule delayed release

particles

T1

erythromycin ethylsuccinate oral tablet T1


6

Drug Tier Notes

Glycopeptide Antibiotics

FIRVANQ T1

vancomycin hcl oral T1

Hcv Polymerase Inhibitor Antivirals

ledipasvir-sofosbuvir T1 PA

sofosbuvir-velpatasvir T1 PA

Hcv Protease Inhibitor Antivirals

MAVYRET T1 PA

Hcv Replication Complex Inhibitors

ledipasvir-sofosbuvir T1 PA

MAVYRET T1 PA

sofosbuvir-velpatasvir T1 PA

Lincomycin Antibiotics

clindamycin hcl oral capsule 150 mg, 300 mg T1

clindamycin palmitate hcl T1

Macrolide Antibiotics

ERY-TAB T1

ERYTHROCIN STEARATE ORAL TABLET

250 MG

T1

erythromycin base oral capsule delayed release

particles

T1

erythromycin ethylsuccinate oral tablet T1

Natural Penicillin Antibiotics

penicillin v potassium T1

Neuraminidase Inhibitor Antivirals

oseltamivir phosphate oral capsule 30 mg T1 QL (20 CAPS per 180 DYs)

oseltamivir phosphate oral capsule 45 mg, 75 mg T1 QL (10 CAPS per 180 DYs)

oseltamivir phosphate oral suspension

reconstituted

T1 QL (180 ML per 180 DYs)

RELENZA DISKHALER T1 QL (1 FL per 180 DYs)

Nucleoside And Nucleotide Antivirals

acyclovir oral T1

adefovir dipivoxil T3 PA


7

Drug Tier Notes

entecavir T1

HEPSERA T3 PA

valacyclovir hcl oral tablet 1 gm T1

valacyclovir hcl oral tablet 500 mg T1 QL (2 EA per 1 day)

Other Macrolide Antibiotics

azithromycin oral packet T1 QL (1 FL per 30 DYs)

azithromycin oral suspension reconstituted T1 QL (1 FL per 30 DYs)

azithromycin oral tablet 250 mg, 500 mg T1 QL (6 QY per 30 DYs)

azithromycin oral tablet 600 mg T1 QL (8 QY per 30 DYs)

clarithromycin er T1 QL (1 FL per 30 DYs)

clarithromycin oral T1 QL (1 FL per 30 DYs)

DIFICID T1 PA

ZMAX T1 QL (1 QY per 30 DYs)

Oxazolidinone Antibiotics

linezolid oral T3 PA

Penicillinase-Resistant Penicillins

dicloxacillin sodium T1

Polyene Antifungals

nystatin mouth/throat T1

nystatin oral T1

Quinolone Antibiotics

ciprofloxacin hcl oral tablet 250 mg, 500 mg T1 QL (68 QY per 34 DYs)

ciprofloxacin hcl oral tablet 750 mg T1 QL (28 QY per 30 DYs)

ciprofloxacin oral T1

levofloxacin oral solution T1 QL (1 FL per 30 DYs)

levofloxacin oral tablet T1 QL (14 QY per 30 DYs)

moxifloxacin hcl oral T1 QL (10 QY per 30 DYs)

Rifamycin Antibiotics

rifampin oral T1

Sulfonamide Antibiotics (Systemic)

sulfadiazine oral T1


8

Drug Tier Notes

sulfamethoxazole-trimethoprim oral suspension

200-40 mg/5ml

T1

sulfamethoxazole-trimethoprim oral tablet T1

sulfasalazine oral T1

Tetracycline Antibiotics

doxycycline monohydrate oral capsule 100 mg, 50

mg

T1

doxycycline monohydrate oral tablet 100 mg, 50

mg

T1

minocycline hcl oral capsule 100 mg, 50 mg T1

tetracycline hcl oral T1

Urinary Anti-Infectives

nitrofurantoin macrocrystal oral T1

nitrofurantoin monohyd macro T1

nitrofurantoin oral suspension T1

trimethoprim oral T1

Antineoplastic Agents

Antineoplastic Agents

ALKERAN ORAL T1

bicalutamide T1

cyclophosphamide oral capsule T1

DROXIA T1

EMCYT T1 PA

FARESTON T1 PA

flutamide T1

GLEOSTINE ORAL CAPSULE 10 MG, 100

MG, 40 MG

T1 PA

HEXALEN T1 PA

hydroxyurea oral T1

letrozole oral T1 QL (1 QY per 1 DY)

LEUKERAN T1

LYSODREN T1 PA

MATULANE T1 PA


9

Drug Tier Notes

megestrol acetate oral suspension 40 mg/ml T1

megestrol acetate oral suspension 625 mg/5ml T1 QL (150 ML per 30 days)

megestrol acetate oral tablet T1

mercaptopurine oral T1

methotrexate oral T1

methotrexate sodium (pf) injection solution 50

mg/2ml

T1 PA

methotrexate sodium injection solution 50 mg/2ml T1

MYLERAN T1

TABLOID T1

tamoxifen citrate oral T1

TREXALL ORAL TABLET 7.5 MG T1

Antitoxins,Immune Glob,Toxoids,Vaccines

Toxoids

ADACEL INTRAMUSCULAR SUSPENSION

5-2-15.5 LF-MCG/0.5

T1 Min 19 Years

BOOSTRIX INTRAMUSCULAR

SUSPENSION 5-2.5-18.5 LF-MCG/0.5

T1 Min 19 Years

Vaccines

AFLURIA T1 QL (0.5 ML per 180 days); Min 18

Years

AFLURIA PRESERVATIVE FREE

INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

T1 QL (0.5 ML per 180 days); Min 18

Years

AFLURIA QUADRIVALENT



Years

AFLURIA QUADRIVALENT


PREFILLED SYRINGE 0.5 ML


Years

FLUARIX QUADRIVALENT


PREFILLED SYRINGE


Years

FLUCELVAX QUADRIVALENT T1 QL (0.5 ML per 180 days); Min 18

Years

FLULAVAL QUADRIVALENT



Years


10

Drug Tier Notes

FLULAVAL QUADRIVALENT


PREFILLED SYRINGE


Years

FLUMIST QUADRIVALENT T1 QL (0.5 EA per 180 days); Min 18

Years

FLUZONE QUADRIVALENT

INTRAMUSCULAR SUSPENSION , 0.5 ML


Years

FLUZONE QUADRIVALENT


PREFILLED SYRINGE 0.5 ML


Years

PNEUMOVAX 23 T1

SHINGRIX INTRAMUSCULAR

SUSPENSION RECONSTITUTED 50

MCG/0.5ML

T1 QL (2 Doses Max Qty Per Fill Retail);

Min 50 Years

Autonomic Drugs

Alpha- And Beta-Adrenergic Agonists

BROMFED DM T1


epinephrine injection solution auto-injector 0.15

mg/0.3ml, 0.3 mg/0.3ml

T1 QL (2 EA per 30 days)

guaifenesin dac T1 QL (120 ML per 30 days)

kp pseudoephedrine hcl oral tablet 60 mg T1

LORTUSS EX ORAL LIQUID 30-10-100

MG/5ML


m-end dmx T1

pseudoeph-bromphen-dm oral syrup 30-2-10

mg/5ml

T1

pseudoephedrine-guaifenesin er T1

TUSNEL C T1 QL (120 ML per 30 days)

Alpha-Adrenergic Agonists

clonidine T1

clonidine hcl oral T1

CLORPRES T1

LUCEMYRA T1 QL (16 EA per 1 day)

methyldopa oral T1

methyldopa-hydrochlorothiazide T1


11

Drug Tier Notes



robafen cf multi-symptom cold T1

Antimuscarinics/Antispasmodics

ANORO ELLIPTA T1

ATROVENT HFA T1

COMBIVENT RESPIMAT T1

dicyclomine hcl oral capsule T1

dicyclomine hcl oral tablet T1

diphenoxylate-atropine T1

glycopyrrolate oral tablet 1 mg, 2 mg T1

hydrocodone-homatropine T1

hyoscyamine sulfate er oral tablet extended

release 12 hour

T1

hyoscyamine sulfate oral T1

ipratropium bromide inhalation T1

ipratropium-albuterol T1

propantheline bromide oral T1

SPIRIVA RESPIMAT INHALATION

AEROSOL SOLUTION 1.25 MCG/ACT, 2.5

MCG/ACT

T1

STIOLTO RESPIMAT INHALATION

AEROSOL SOLUTION 2.5-2.5 MCG/ACT

T1

Antiparkinsonian Agents

benztropine mesylate oral T1

trihexyphenidyl hcl T1

Autonomic Drugs, Miscellaneous

CHANTIX T1 QL (360 QY per 365 DYs); Min 18

Years

CHANTIX STARTING MONTH PAK T1 QL (360 QY per 365 DYs); Min 18

Years

cvs nicotine transdermal patch 24 hour 21

mg/24hr

T1

goodsense nicotine mouth/throat gum T1


12

Drug Tier Notes

nicotine mini T1

nicotine polacrilex mouth/throat gum 2 mg T1

nicotine transdermal patch 24 hour 7 mg/24hr T1

Centrally Acting Skeletal Muscle Relaxnt

carisoprodol oral tablet 350 mg T1 QL (120 EA per 30 days)

chlorzoxazone oral tablet 500 mg T1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg T1

methocarbamol oral T1

tizanidine hcl oral tablet T1

Gaba-Derivative Skeletal Muscle Relaxant

baclofen oral tablet 10 mg, 20 mg T1

Non-Sel. Beta-Adrenergic Blocking Agents

carvedilol T1

labetalol hcl oral T1

nadolol oral tablet 20 mg, 40 mg, 80 mg T1

nadolol-bendroflumethiazide T1

pindolol T1

propranolol hcl er T1

propranolol hcl oral T1

propranolol-hctz T1

sotalol hcl oral T1

timolol maleate oral T1

Non-Sel.Alpha-1-Adrenergic Blocking Agts

doxazosin mesylate oral T1

prazosin hcl oral T1

terazosin hcl oral T1

Non-Sel.Alpha-Adrenergic Blocking Agents

dihydroergotamine mesylate injection T1

dihydroergotamine mesylate nasal T1 QL (1 QY per 30 DYs)

ERGOMAR T1

phenoxybenzamine hcl oral T1 PA

Parasympathomimetic (Cholinergic Agents)


13

Drug Tier Notes

bethanechol chloride oral T1

donepezil hcl oral tablet 10 mg T1 QL (1 EA per 1 DY); Min 18 Years

donepezil hcl oral tablet 23 mg T1 ST; QL (1 EA per 1 day)

donepezil hcl oral tablet 5 mg T1 Min 18 Years

donepezil hcl oral tablet dispersible 10 mg T1 QL (1 EA per 1 DY); Min 18 Years

donepezil hcl oral tablet dispersible 5 mg T1 Min 18 Years

pyridostigmine bromide er T1

pyridostigmine bromide oral solution T1

pyridostigmine bromide oral tablet 60 mg T1

rivastigmine tartrate T1 Min 18 Years

Selective Alpha-1-Adrenergic Block.Agent

alfuzosin hcl er T1

carvedilol T1


tamsulosin hcl T1

Selective Beta-2-Adrenergic Agonists

albuterol sulfate hfa inhalation aerosol solution

108 (90 base) mcg/act

T1 QL (2 EA per 30 DYs)

albuterol sulfate inhalation nebulization solution

(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

T1

albuterol sulfate oral T1

ANORO ELLIPTA T1


fluticasone-salmeterol T1 QL (1 EA per 30 days)


SEREVENT DISKUS T1

STIOLTO RESPIMAT INHALATION

AEROSOL SOLUTION 2.5-2.5 MCG/ACT

T1

terbutaline sulfate oral T1

WIXELA INHUB T1 QL (1 EA per 30 days)

Selective Beta-Adrenergic Blocking Agent

atenolol oral T1

bisoprolol fumarate T1


14

Drug Tier Notes

bisoprolol-hydrochlorothiazide T1

metoprolol succinate er T1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg

T1

metoprolol-hydrochlorothiazide oral tablet 100-25

mg, 50-25 mg

T1

Skeletal Muscle Relaxants, Miscellaneous

XEOMIN INTRAMUSCULAR SOLUTION

RECONSTITUTED 100 UNIT, 50 UNIT

T3 PA

Blood Formation, Coagulation, Thrombosis

Coumarin Derivatives

warfarin sodium oral T1

Direct Factor Xa Inhibitors

ELIQUIS T1

ELIQUIS STARTER PACK T1

XARELTO ORAL TABLET 10 MG, 15 MG,

20 MG

T1

XARELTO ORAL TABLET 2.5 MG T1 QL (60 EA per 30 days)

XARELTO STARTER PACK T1

Direct Thrombin Inhibitors

PRADAXA T1

Hematopoietic Agents

RETACRIT T1 PA

Hemorrheologic Agents

pentoxifylline er T1

Hemostatics

AMICAR ORAL SOLUTION T1

AMICAR ORAL TABLET 500 MG T1

DDAVP RHINAL TUBE T1 QL (15 ML per 30 days)

desmopressin ace rhinal tube T1 PA

desmopressin ace spray refrig T1 PA

desmopressin acetate oral tablet 0.1 mg T1 QL (90 EA per 30 days); Min 4 Years


15

Drug Tier Notes

desmopressin acetate oral tablet 0.2 mg T1 QL (180 EA per 30 days); Min 4

Years

NOVOEIGHT T1 PA

Heparins

enoxaparin sodium injection T1 QL (3 ML per 1 day)

enoxaparin sodium subcutaneous solution 100

mg/ml, 150 mg/ml

T1 QL (2 ML per 1 day)


mg/0.8ml, 80 mg/0.8ml

T1 QL (1.6 ML per 1 day)


mg/0.3ml



mg/0.4ml



mg/0.6ml


heparin sodium (porcine) injection solution 10000

unit/ml, 5000 unit/ml

T1

Iron Preparations

cadeau dha T1

completenate T1

cvs womens prenatal+dha T1

daily-vite/iron/beta-carotene T1

fe c tab plus T1

ferretts T1

ferrous gluconate oral tablet 324 (38 fe) mg T1

ferrous sulfate oral solution 75 (15 fe) mg/ml T1

ferrous sulfate oral syrup T1

ferrous sulfate oral tablet delayed release 325 (65

fe) mg

T1

gnp daily prenatal T1

INFED T1

INJECTAFER T1

kp ferrous gluconate T1

kp ferrous sulfate T1


16

Drug Tier Notes

MULTIGEN T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

multivitamin/fluoride/iron T1

MYNATAL ADVANCE T1

mynatal plus T1

mynatal-z T1

OBSTETRIX DHA T1

OBTREX DHA T1

ONE-A-DAY WOMENS FORMULA T1

ONE-A-DAY WOMENS PRENATAL 1 T1

pnv prenatal plus multivit+dha T1

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

prenatal 19 oral tablet 29-1 mg T1

prenatal low iron oral tablet 27-1 mg T1

prenatal multi +dha oral capsule 27-0.8-228 mg,

27-0.8-250 mg

T1

PRENATAL MULTIVITAMIN + DHA T1

prenatal oral tablet 27-1 mg T1

prenatal plus iron T1

prenatal vitamins oral tablet 28-0.8 mg T1

PRORENAL + D W/ OMEGA-3 T1

ra one daily T1

se-natal 19 oral tablet chewable T1

TRICARE T1

TRIVEEN-DUO DHA T1

tri-vit/fluoride/iron T1

VENOFER T1

VINATE GT T1

VINATE II T1

VINATE M T1


17

Drug Tier Notes

VINATE ONE T1

vinate ultra T1

vol-nate T1

vol-tab rx T1

Platelet-Aggregation Inhibitors

aspirin ec low dose T1

aspirin ec oral tablet delayed release 325 mg T1

aspirin-dipyridamole er T1

cilostazol T1

clopidogrel bisulfate oral T1

dipyridamole oral T1

goodsense aspirin adult low st T1

goodsense aspirin oral tablet T1

prasugrel hcl T1

ticlopidine hcl T1

Thrombolytic Agents





Cardiovascular Drugs

Alpha-Adrenergic Blocking Agents

carvedilol T1





Alpha-Adrenergic Blocking Agt.(Hypoten)





18

Drug Tier Notes


Angiotensin Ii Receptor Antagon.(Hypotn)

amlodipine besylate-valsartan T1 ST

irbesartan T1 ST

irbesartan-hydrochlorothiazide T1 ST

losartan potassium T1

losartan potassium-hctz T1

olmesartan medoxomil oral T1 ST

olmesartan medoxomil-hctz oral tablet 20-12.5

mg, 40-12.5 mg

T1 ST

telmisartan T1 ST

valsartan T1 ST

valsartan-hydrochlorothiazide T1 ST

Angiotensin Ii Receptor Antagonists


ENTRESTO T1

irbesartan T1 ST


losartan potassium T1


olmesartan medoxomil oral T1 ST


mg, 40-12.5 mg

T1 ST

telmisartan T1 ST

valsartan T1 ST


Angiotensin-Convert.Enzyme Inhib(Hypotn)

benazepril hcl oral T1

benazepril-hydrochlorothiazide T1

captopril oral T1

captopril-hydrochlorothiazide T1

enalapril maleate oral T1

enalapril-hydrochlorothiazide T1


19

Drug Tier Notes

fosinopril sodium T1

fosinopril sodium-hctz T1

lisinopril oral T1

lisinopril-hydrochlorothiazide T1

moexipril hcl T1

moexipril-hydrochlorothiazide T1

perindopril erbumine oral tablet 4 mg, 8 mg T1

quinapril-hydrochlorothiazide T1

trandolapril T1

Angiotensin-Converting Enzyme Inhibitors

benazepril hcl oral T1


captopril oral T1


enalapril maleate oral T1


fosinopril sodium T1


lisinopril oral T1


moexipril hcl T1


perindopril erbumine oral tablet 4 mg, 8 mg T1


trandolapril T1

Antiarrhythmics, Miscellaneous

DIGOX T1

digoxin oral tablet T1

Antilipemic Agents, Miscellaneous

niacin er (antihyperlipidemic) oral tablet extended

release 1000 mg, 750 mg

T1

niacin er oral capsule extended release T1


20

Drug Tier Notes

niacinamide oral tablet 500 mg T1

NIACOR T1

Beta-Adrenergic Blocking Agents

atenolol oral T1



carvedilol T1




mg

T1


mg, 50-25 mg

T1



pindolol T1



propranolol-hctz T1

sotalol hcl oral T1


Beta-Adrenergic Blocking Agt.(Hypoten)

atenolol oral T1






mg

T1


mg, 50-25 mg

T1



pindolol T1


21

Drug Tier Notes



propranolol-hctz T1

sotalol hcl oral T1


Bile Acid Sequestrants

cholestyramine light oral packet T1

cholestyramine oral T1

colestipol hcl oral tablet T1

PREVALITE T1

Calcium-Channel Block.Agt,Misc(Hypoten)

diltiazem hcl er beads T1

diltiazem hcl er coated beads oral capsule

extended release 24 hour 120 mg, 180 mg, 240 mg,

300 mg

T1

diltiazem hcl er oral capsule extended release 12

hour

T1


hour 120 mg, 180 mg, 240 mg

T1

diltiazem hcl oral T1

dilt-xr T1

TAZTIA XT T1

verapamil hcl er oral tablet extended release 120

mg, 180 mg, 240 mg

T1

verapamil hcl oral T1

Calcium-Channel Blocking Agents

amlodipine besylate oral T1





300 mg

T1


hour

T1


22

Drug Tier Notes


hour 120 mg, 180 mg, 240 mg

T1


dilt-xr T1

felodipine er T1

nifedipine er osmotic release T1

nifedipine oral T1

TAZTIA XT T1


mg, 180 mg, 240 mg

T1


Calcium-Channel Blocking Agents(Hypoten)




300 mg

T1


hour

T1


hour 120 mg, 180 mg, 240 mg

T1


dilt-xr T1

TAZTIA XT T1


mg, 180 mg, 240 mg

T1


Calcium-Channel Blocking Agents, Misc.




300 mg

T1


hour

T1


hour 120 mg, 180 mg, 240 mg

T1



23

Drug Tier Notes

dilt-xr T1

TAZTIA XT T1


mg, 180 mg, 240 mg

T1


Carbonic Anhydrase Inhibitors(Hypoten)

acetazolamide er T1

acetazolamide oral T1

Cardiotonic Agents

DIGOX T1

digoxin oral tablet T1

Central Alpha-Agonists

clonidine T1

clonidine hcl oral T1

CLORPRES T1

guanfacine hcl er T1

guanfacine hcl oral T1

methyldopa oral T1


Cholesterol Absorption Inhibitors

ZETIA T1

Class Ia Antiarrhythmics

disopyramide phosphate oral T1

NORPACE CR T1

quinidine gluconate er T1

quinidine sulfate oral T1

Class Ib Antiarrhythmics

DILANTIN INFATABS T1

DILANTIN ORAL CAPSULE 30 MG T1

mexiletine hcl oral T1

PHENYTOIN INFATABS T1

phenytoin oral suspension 125 mg/5ml T1


24

Drug Tier Notes

phenytoin sodium extended oral capsule 100 mg T1

Class Ic Antiarrhythmics

flecainide acetate T1

propafenone hcl T1

Class Ii Antiarrhythmics

atenolol oral T1



carvedilol T1




mg

T1


mg, 50-25 mg

T1



pindolol T1



propranolol-hctz T1

sotalol hcl oral T1


Class Iii Antiarrhythmics

amiodarone hcl oral tablet 100 mg, 200 mg T1

sotalol hcl oral T1

Class Iv Antiarrhythmics




300 mg

T1


hour

T1


25

Drug Tier Notes


hour 120 mg, 180 mg, 240 mg

T1


dilt-xr T1

TAZTIA XT T1


mg, 180 mg, 240 mg

T1


Dihydropyridines



felodipine er T1


nifedipine oral T1

Dihydropyridines (Antihypertensive)



felodipine er T1


nifedipine oral T1

Direct Vasodilators

BIDIL T1

hydralazine hcl oral T1

minoxidil oral T1

Diuretics, Miscellaneous (Hypotensive)

THEO-24 T1

theophylline er oral tablet extended release 12

hour 200 mg, 300 mg

T1

Fibric Acid Derivatives

fenofibrate micronized oral capsule 134 mg, 200

mg, 67 mg

T1

fenofibrate oral tablet 160 mg, 54 mg T1

gemfibrozil oral T1


26

Drug Tier Notes

Hmg-Coa Reductase Inhibitors

atorvastatin calcium oral T1

fluvastatin sodium T1 ST

fluvastatin sodium er T1 ST

lovastatin T1

pravastatin sodium T1 ST

rosuvastatin calcium T1

simvastatin oral tablet 10 mg, 20 mg, 5 mg T1

simvastatin oral tablet 40 mg T1 QL (1 EA per 1 day)

Hypotensive Agents, Miscellaneous



carvedilol T1


felodipine er T1


nifedipine oral T1

phenoxybenzamine hcl oral T1 PA

pindolol T1



sotalol hcl oral T1



Loop Diuretics (Hypotensive Agents)

bumetanide oral T1

furosemide oral solution 10 mg/ml, 8 mg/ml T1

furosemide oral tablet T1

torsemide oral T1

Mineralocorticoid (Aldosterone) Antagnts

spironolactone oral T1

spironolactone-hctz T1


27

Drug Tier Notes

Mineralocorticoid(Aldoster.)Antag(Hypot)



Nitrates And Nitrites

BIDIL T1

ISORDIL TITRADOSE ORAL TABLET 40

MG

T1

isosorbide dinitrate er T1

isosorbide dinitrate oral T1

isosorbide mononitrate T1

isosorbide mononitrate er T1

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR

T1

nitroglycerin er T1

nitroglycerin transdermal patch 24 hour T1

NITROSTAT T1

Pcsk9 Inhibitors

REPATHA T1 PA

Phosphodiesterase Type 5 Inhibitors

cilostazol T1

sildenafil citrate oral tablet 20 mg T1 PA

Potassium-Sparing Diuretics (Hypoten)

amiloride hcl oral T1

amiloride-hydrochlorothiazide T1



triamterene-hctz oral tablet T1

Renin-Angioten.-Aldost. Sys. Inhib, Misc

ENTRESTO T1

Thiazide Diuretics(Hypotensive Agents)




28

Drug Tier Notes



chlorothiazide oral T1

DIURIL T1



hydrochlorothiazide oral T1






mg, 50-25 mg

T1




mg, 40-12.5 mg

T1 ST

propranolol-hctz T1





Thiazide-Like Diuretics(Hypotensive Agt)

chlorthalidone oral tablet 25 mg, 50 mg T1

CLORPRES T1

indapamide oral T1

metolazone T1

Vasodilating Agents, Miscellaneous






29

Drug Tier Notes



300 mg

T1


hour

T1


hour 120 mg, 180 mg, 240 mg

T1


dilt-xr T1

dipyridamole oral T1

felodipine er T1

LETAIRIS T1 PA


nifedipine oral T1

TAZTIA XT T1


mg, 180 mg, 240 mg

T1


Central Nervous System Agents

Adamantanes (Cns)

amantadine hcl oral capsule T1

amantadine hcl oral syrup T1

Amphetamines

amphetamine-dextroamphet er T1

amphetamine-dextroamphetamine T1

dextroamphetamine sulfate oral tablet T1

VYVANSE T1

Analgesics And Antipyretics, Misc.

acetaminophen-codeine #2 T1 Min 12 Years



acetaminophen-codeine oral solution T1 Min 12 Years

arthritis pain relief oral T1


30

Drug Tier Notes

butalbital-acetaminophen oral tablet 50-325 mg T1

butalbital-apap-caff-cod oral capsule 50-325-40-

30 mg

T1 Min 18 Years

butalbital-apap-caffeine oral tablet 50-325-40 mg T1

ENDOCET ORAL TABLET 5-325 MG T1

gabapentin oral capsule T1

gabapentin oral solution 250 mg/5ml T1

gabapentin oral tablet T1

hydrocodone-acetaminophen oral solution 7.5-325

mg/15ml

T1

hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg

T1

infants pain relief oral suspension 80 mg/0.8ml T1

oxycodone-acetaminophen oral tablet 5-325 mg T1

tgt childrens acetaminophen T1

Anticholinergic Agents (Cns)

benztropine mesylate oral T1

trihexyphenidyl hcl T1

Anticonvulsants, Miscellaneous

BANZEL T1 ST; Min 1 Years

carbamazepine er T1

carbamazepine oral T1

divalproex sodium er oral tablet extended release

24 hour

T1

divalproex sodium oral capsule delayed release

sprinkle

T1

divalproex sodium oral tablet delayed release T1

gabapentin oral capsule T1

gabapentin oral solution 250 mg/5ml T1

gabapentin oral tablet T1

lamotrigine oral tablet T1

lamotrigine oral tablet chewable T1

lamotrigine starter kit-blue T1

lamotrigine starter kit-green T1


31

Drug Tier Notes

lamotrigine starter kit-orange T1

levetiracetam oral T1

oxcarbazepine T1

topiramate oral T1

valproate sodium oral solution T1

valproic acid oral capsule T1

Antidepressants, Miscellaneous

bupropion hcl er (sr) T1

bupropion hcl er (xl) oral tablet extended release

24 hour 150 mg, 300 mg

T1

bupropion hcl oral T1

mirtazapine oral T1

SPRAVATO (56 MG DOSE) T3 PA

SPRAVATO (84 MG DOSE) T3 PA

Antimanic Agents

aripiprazole T1

carbamazepine er T1

carbamazepine oral T1


24 hour

T1


sprinkle

T1


lamotrigine oral tablet T1

lamotrigine oral tablet chewable T1

lamotrigine starter kit-blue T1

lamotrigine starter kit-green T1

lamotrigine starter kit-orange T1

lithium T1

lithium carbonate er T1

lithium carbonate oral T1

olanzapine oral tablet T1

quetiapine fumarate T1


32

Drug Tier Notes

RISPERDAL CONSTA T1 PA

risperidone oral solution T1

risperidone oral tablet T1

SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 10 MG, 5 MG

T1



ziprasidone hcl T1

Antimigraine Agents, Miscellaneous

AIMOVIG 140 DOSE T3 PA; QL (2 ML per 30 days)

AIMOVIG SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 140 MG/ML

T3 PA



T3 PA; QL (1 ML per 30 days)

AJOVY T3 PA




30 mg

T1 Min 18 Years


butalbital-asa-caff-codeine T1 Min 18 Years

dihydroergotamine mesylate injection T1

dihydroergotamine mesylate nasal T1 QL (1 QY per 30 DYs)


24 hour

T1


sprinkle

T1


EMGALITY T1 PA

ERGOMAR T1






33

Drug Tier Notes




Antipsychotics, Miscellaneous

loxapine succinate oral T1

pimozide T1

Anxiolytics,Sedatives,And Hypnotics,Misc

AMBIEN CR T3 PA

buspirone hcl oral tablet 15 mg, 30 mg, 5 mg, 7.5

mg

T1

droperidol injection T1

EDLUAR T3 PA

eszopiclone T1 ST

hydroxyzine hcl oral syrup T1

hydroxyzine hcl oral tablet T1

hydroxyzine pamoate oral T1

meprobamate T1




promethazine hcl rectal suppository 12.5 mg, 25

mg

T1

ROZEREM T1 ST


zaleplon T1

zolpidem tartrate er oral tablet extended release

12.5 mg

T3 PA

zolpidem tartrate oral T1

Atypical Antipsychotics

aripiprazole T1

clozapine oral tablet T1

INVEGA SUSTENNA INTRAMUSCULAR

SUSPENSION

T1 PA


34

Drug Tier Notes

INVEGA TRINZA INTRAMUSCULAR

SUSPENSION

T1 PA

LATUDA ORAL TABLET 120 MG, 20 MG, 40

MG, 60 MG

T1 QL (1 EA per 1 day)

LATUDA ORAL TABLET 80 MG T1 QL (2 EA per 1 day)

olanzapine oral tablet T1

quetiapine fumarate T1

RISPERDAL CONSTA T1 PA

risperidone oral solution T1

risperidone oral tablet T1

SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 10 MG, 5 MG

T1

ziprasidone hcl T1

Barbiturates (Anticonvulsants)

phenobarbital oral elixir T1

phenobarbital oral tablet T1

primidone oral T1

Barbiturates (Anxiolytic, Sedative/Hyp)

butalbital-acetaminophen oral tablet 50-325 mg T1


30 mg

T1 Min 18 Years



phenobarbital oral elixir T1

phenobarbital oral tablet T1

Benzodiazepines (Anticonvulsants)

clobazam oral tablet T1

clonazepam oral tablet T1

clorazepate dipotassium T1

DIASTAT ACUDIAL T1 QL (2 QY per 30 DYs)

DIASTAT PEDIATRIC T1 QL (2 QY per 30 DYs)

diazepam oral tablet T1

diazepam rectal T1 QL (2 EA per 30 DYs)

lorazepam oral tablet T1


35

Drug Tier Notes

Benzodiazepines (Anxiolytic,Sedativ/Hyp)

alprazolam oral tablet T1

chlordiazepoxide hcl T1

chlordiazepoxide-amitriptyline T1

clobazam oral tablet T1

clonazepam oral tablet T1

clorazepate dipotassium T1

DIASTAT ACUDIAL T1 QL (2 QY per 30 DYs)

DIASTAT PEDIATRIC T1 QL (2 QY per 30 DYs)

diazepam oral tablet T1

diazepam rectal T1 QL (2 EA per 30 DYs)

estazolam T1

lorazepam oral tablet T1

oxazepam T1

temazepam oral capsule 15 mg, 30 mg T1

triazolam T1

Butyrophenones

haloperidol decanoate intramuscular solution 100

mg/ml, 50 mg/ml

T1

haloperidol lactate injection solution 5 mg/ml T1

haloperidol lactate oral T1

haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 20 mg,

5 mg

T1

haloperidol oral tablet 10 mg T3

Calcitonin Gene-Related Peptide Antag.

AIMOVIG 140 DOSE T3 PA; QL (2 ML per 30 days)



T3 PA



T3 PA; QL (1 ML per 30 days)

AJOVY T3 PA

EMGALITY T1 PA

Central Nervous System Agents, Misc.


36

Drug Tier Notes

atomoxetine hcl T1

guanfacine hcl er T1

guanfacine hcl oral T1

memantine hcl oral tablet T1 Min 18 Years

riluzole T1

Cyclooxygenase-2 (Cox-2) Inhibitors

celecoxib oral capsule 100 mg, 200 mg, 50 mg T1 QL (2 EA per 1 day)

celecoxib oral capsule 400 mg T1 QL (1 EA per 1 day)

Dopamine Precursors

carbidopa-levodopa er oral tablet extended

release 25-100 mg, 50-200 mg

T1

carbidopa-levodopa oral tablet T1

Ergot-Deriv. Dopamine Receptor Agonists

bromocriptine mesylate oral T1

cabergoline T1 ST

Fibromyalgia Agents

duloxetine hcl oral capsule delayed release

particles 20 mg, 30 mg, 60 mg

T1

SAVELLA T1

SAVELLA TITRATION PACK T1

Hydantoins

DILANTIN INFATABS T1

DILANTIN ORAL CAPSULE 30 MG T1

PHENYTOIN INFATABS T1

phenytoin oral suspension 125 mg/5ml T1

phenytoin sodium extended oral capsule 100 mg T1

Monoamine Oxidase B Inhibitors

selegiline hcl oral T1

Monoamine Oxidase Inhibitors

phenelzine sulfate oral T1

selegiline hcl oral T1

tranylcypromine sulfate T1


37

Drug Tier Notes

Nonergot-Deriv.Dopamine Receptor Agonist

pramipexole dihydrochloride T1

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg

T1

Opiate Agonists




acetaminophen-codeine oral solution T1 Min 12 Years


30 mg

T1 Min 18 Years


cheratussin ac oral syrup T1 QL (120 ML per 30 days); Min 12

Years

ENDOCET ORAL TABLET 5-325 MG T1

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

T1 PA; QL (10 QY per 30 DYs)


guaifenesin-codeine oral solution T1 Min 12 Years


extended release


hydrocodone-acetaminophen oral solution 7.5-325

mg/15ml

T1

hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg

T1


hydrocodone-ibuprofen oral tablet 7.5-200 mg T3 PA

hydromorphone hcl oral T1

hydromorphone hcl rectal T1


MG/5ML


meperidine hcl oral T1

methadone hcl oral solution 10 mg/5ml T1

morphine sulfate (concentrate) oral solution 100

mg/5ml

T1


38

Drug Tier Notes

morphine sulfate er beads T3 PA

morphine sulfate er oral tablet extended release T1 PA

morphine sulfate oral T1

oxycodone hcl oral concentrate 100 mg/5ml T1

oxycodone hcl oral solution T1

oxycodone hcl oral tablet 10 mg T1 QL (270 EA per 30 days)

oxycodone hcl oral tablet 15 mg, 20 mg T1 QL (210 EA per 30 days)

oxycodone hcl oral tablet 30 mg T1

oxycodone hcl oral tablet 5 mg T1 QL (60 EA per 30 days)

oxycodone-acetaminophen oral tablet 5-325 mg T1


promethazine-codeine oral syrup T1 QL (120 ML per 30 days)

tramadol hcl oral T1 Min 18 Years


Opiate Antagonists

naltrexone hcl oral T1 QL (1 EA per 1 day)

NARCAN T1 QL (4 EA per 30 days)

VIVITROL T1 QL (1 EA per 30 days)

Opiate Partial Agonists

BUNAVAIL BUCCAL FILM 2.1-0.3 MG T1 QL (6 EA per 1 day)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG T1 QL (3 EA per 1 day)

BUNAVAIL BUCCAL FILM 6.3-1 MG T1 QL (2 EA per 1 day)

buprenorphine hcl sublingual tablet sublingual 2

mg


buprenorphine hcl sublingual tablet sublingual 8

mg


buprenorphine hcl-naloxone hcl sublingual film

12-3 mg


buprenorphine hcl-naloxone hcl sublingual film 2-

0.5 mg



1 mg



2 mg



39

Drug Tier Notes

buprenorphine hcl-naloxone hcl sublingual tablet

sublingual 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual tablet

sublingual 8-2 mg


butorphanol tartrate nasal T1 PA

nalbuphine hcl injection T1

SUBLOCADE SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 100 MG/0.5ML


SUBLOCADE SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 300 MG/1.5ML


SUBOXONE SUBLINGUAL FILM 12-3 MG T1 QL (2 EA per 1 day)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG T1 QL (12 EA per 1 day)



ZUBSOLV SUBLINGUAL TABLET

SUBLINGUAL 0.7-0.18 MG






SUBLINGUAL 11.4-2.9 MG, 8.6-2.1 MG








Other Nonsteroidal Anti-Inflam. Agents

cvs ibuprofen jr T1

diclofenac potassium T1

diclofenac sodium er T1

diclofenac sodium oral T1

diclofenac sodium transdermal gel 1 % T1 ST

fenoprofen calcium oral tablet T1

flurbiprofen oral tablet 100 mg T1

goodsense ibuprofen childrens T1

goodsense ibuprofen infants T1

goodsense ibuprofen oral tablet T1


40

Drug Tier Notes

goodsense naproxen sodium T1

hydrocodone-ibuprofen oral tablet 7.5-200 mg T3 PA

ibuprofen junior strength oral tablet chewable T1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1

indomethacin oral T1

ketoprofen oral capsule 50 mg, 75 mg T1

meloxicam oral tablet T1

naproxen dr T1

naproxen oral T1

naproxen sodium oral capsule T1

naproxen sodium oral tablet 275 mg, 550 mg T1

piroxicam oral T1

sulindac oral T1

Phenothiazines

chlorpromazine hcl oral T1

fluphenazine decanoate injection T1

fluphenazine hcl injection T1

fluphenazine hcl oral tablet T1

perphenazine oral T1

perphenazine-amitriptyline T1

prochlorperazine T1

prochlorperazine edisylate injection solution 5

mg/ml

T1

prochlorperazine maleate oral T1

thioridazine hcl oral T1 PA

trifluoperazine hcl oral T1

Respiratory And Cns Stimulants


30 mg

T1 Min 18 Years



caffeine citrate oral solution 60 mg/3ml T1

dexmethylphenidate hcl T1


41

Drug Tier Notes

dexmethylphenidate hcl er oral capsule extended

release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30

mg, 40 mg, 5 mg

T1

FOCALIN XR ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 35 MG

T1

methylphenidate hcl er (cd) T1

methylphenidate hcl er oral tablet extended

release 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

T1

methylphenidate hcl oral solution 10 mg/5ml T1

methylphenidate hcl oral tablet T1

Salicylates





choline-mag trisalicylate T1



salsalate oral T1

Sel.Serotonin,Norepi Reuptake Inhibitor

duloxetine hcl oral capsule delayed release

particles 20 mg, 30 mg, 60 mg

T1

SAVELLA T1

SAVELLA TITRATION PACK T1

venlafaxine hcl T1

venlafaxine hcl er oral capsule extended release

24 hour

T1

venlafaxine hcl er oral tablet extended release 24

hour 225 mg, 37.5 mg

T1

Selective Serotonin Agonists

eletriptan hydrobromide T3 PA; QL (12 EA per 30 DYs)

FROVA T3 PA; QL (12 QY per 30 DYs)

naratriptan hcl oral tablet 1 mg T3 PA; QL (12 EA per 30 days)

rizatriptan benzoate T1 QL (12 QY per 30 DYs)


42

Drug Tier Notes

sumatriptan nasal T1 QL (6 QY per 30 DYs)

sumatriptan succinate oral T1 QL (12 QY per 30 DYs)

sumatriptan succinate refill subcutaneous solution

cartridge

T1 QL (2 QY per 30 DYs)

sumatriptan succinate subcutaneous solution 6

mg/0.5ml


sumatriptan succinate subcutaneous solution auto-

injector 4 mg/0.5ml, 6 mg/0.5ml


zolmitriptan oral T3 PA; QL (12 EA per 30 days)

ZOMIG NASAL SOLUTION 5 MG T3 PA; QL (1 QY per 30 DYs)

Selective-Serotonin Reuptake Inhibitors

citalopram hydrobromide oral tablet T1

escitalopram oxalate oral tablet T1

fluoxetine hcl (pmdd) oral capsule T1

fluoxetine hcl oral capsule 40 mg T1

fluoxetine hcl oral solution T1

fluvoxamine maleate T1

paroxetine hcl oral tablet T1

sertraline hcl oral concentrate T1

sertraline hcl oral tablet 100 mg T1

sertraline hcl oral tablet 25 mg, 50 mg T1 QL (45 EA per 30 days)

Serotonin Modulators

nefazodone hcl T1

trazodone hcl oral T1

Succinimides

ethosuximide oral T1

Thioxanthenes

thiothixene oral T1

Tricyclics, Other Norepi-Ru Inhibitors

amitriptyline hcl oral T1

amoxapine T1

chlordiazepoxide-amitriptyline T1

clomipramine hcl oral T1


43

Drug Tier Notes

desipramine hcl oral T1

doxepin hcl oral capsule 10 mg, 100 mg, 25 mg,

50 mg, 75 mg

T1

doxepin hcl oral concentrate T1

imipramine hcl oral T1

maprotiline hcl T1

nortriptyline hcl oral capsule T1

perphenazine-amitriptyline T1

Wakefulness-Promoting Agents

modafinil T3 PA

Devices

Devices

ACCU-CHEK AVIVA IN VITRO SOLUTION T1 QL (1 QY per 365 DYs)

ACCU-CHEK FASTCLIX LANCET T1

ACCU-CHEK GUIDE T1

ACCU-CHEK GUIDE CONTROL T1

ACCU-CHEK GUIDE ME T1

ACCU-CHEK MULTICLIX LANCET DEV T1

ACCU-CHEK MULTICLIX LANCETS T1

ACCU-CHEK SMARTVIEW CONTROL T1

ACCU-CHEK SOFT TOUCH LANCETS T1

ACCU-CHEK SOFTCLIX LANCET DEV T1

ACCU-CHEK SOFTCLIX LANCETS T1

ACTIVA MICROFIBER DRESS SOCKS T1

adult mask large T1 QL (2 EA per 365 days)

BD AUTOSHIELD DUO T1

BD INSULIN SYRINGE U/F T1

BD INSULIN SYRINGE U/F 1/2UNIT T1

BD INSULIN SYRINGE U-500 T1

BD PEN NEEDLE MICRO U/F T1 QL (300 EA per 34 days)

BD PEN NEEDLE MINI U/F T1 QL (200 EA per 34 days)

BD PEN NEEDLE NANO 2ND GEN T1 QL (200 EA per 34 days)


44

Drug Tier Notes

BD PEN NEEDLE NANO U/F T1 QL (200 EA per 34 days)

BD PEN NEEDLE ORIGINAL U/F T1 QL (200 EA per 34 days)

BD PEN NEEDLE SHORT U/F T1 QL (200 EA per 34 days)

BD VEO INSULIN SYRINGE U/F 31G X

15/64" 0.3 ML


BD VEO INSULIN SYRINGE U/F 31G X

15/64" 0.5 ML, 31G X 15/64" 1 ML

T1

cvs eye patch T1 QL (40 EA per 30 days)

JOBST ANTI-EM KNEE HIGH MED T1

JOBST FOR MEN 20-30MMHG LG NC

NEBUSAL INHALATION NEBULIZATION

SOLUTION 3 %

T1

PULMOSAL T1

SCD SOFT SLEEVES/KNEE LENGTH T1

T.E.D. KNEE LENGTH/M-LONG T1

T.E.D. KNEE LENGTH/S-REGULAR T1

T.E.D. THIGH LENGTH/S-REGULAR T1

TRUFORM STOCKINGS 20-30MMHG T1

Diagnostic Agents

Diabetes Mellitus

ACCU-CHEK AVIVA PLUS IN VITRO T1

ACCU-CHEK GUIDE IN VITRO T1

ACCU-CHEK SMARTVIEW T1

Roentgenography And Other Imaging Agents

MAGNEVIST T1

Electrolytic, Caloric, And Water Balance

Alkalinizing Agents

potassium citrate er oral tablet extended release

10 meq (1080 mg), 5 meq (540 mg)

T1

Ammonia Detoxicants

enulose T1

Carbonic Anhydrase Inhibitors

acetazolamide er T1


45

Drug Tier Notes


Diuretics, Miscellaneous

THEO-24 T1


hour 200 mg, 300 mg

T1

Loop Diuretics

bumetanide oral T1

furosemide oral solution 10 mg/ml, 8 mg/ml T1

furosemide oral tablet T1

torsemide oral T1

Phosphate-Removing Agents

calcium acetate (phos binder) oral capsule T1

FOSRENOL ORAL TABLET CHEWABLE

750 MG

T1

lanthanum carbonate T1

sevelamer carbonate oral tablet T1

Potassium-Removing Agents

LOKELMA T3 PA

sodium polystyrene sulfonate oral suspension T1

sodium polystyrene sulfonate rectal suspension 30

gm/120ml

T1

VELTASSA T3 PA

Potassium-Sparing Diuretics

amiloride hcl oral T1





Replacement Preparations

antacid extra strength oral tablet chewable 750

mg

T1

calcium + d3 oral tablet 600-200 mg-unit T1

calcium 1000 + d T1


46

Drug Tier Notes

calcium 500 + d3 oral tablet 500-600 mg-unit T1

calcium 500/d oral tablet T1

calcium 500/vitamin d T1

calcium 500+d high potency T1

calcium 600+d3 plus minerals oral tablet T1

calcium antacid ultra strength T1

calcium carbonate antacid oral tablet chewable

500 mg

T1

calcium carbonate oral tablet 1250 (500 ca) mg,

600 mg

T1

calcium carbonate-vitamin d oral tablet 600-200

mg-unit, 600-400 mg-unit

T1

calcium citrate oral tablet 250 mg T1

calcium citrate-vitamin d oral tablet 200-125 mg-

unit

T1

citrus calcium/vitamin d oral tablet 200-250 mg-

unit

T1


KLOR-CON M10 T1

KLOR-CON M20 T1

KLOR-CON ORAL PACKET 20 MEQ T1

liquid calcium/vitamin d T1

magnesium chloride-calcium T1

MYNATAL ADVANCE T1

mynatal plus T1

mynatal-z T1

NEBUSAL INHALATION NEBULIZATION

SOLUTION 3 %

T1



oyster shell calcium oral tablet 500 mg T1

potassium chloride crys er T1

potassium chloride er oral capsule extended

release 10 meq

T1


47

Drug Tier Notes

potassium chloride er oral tablet extended release

10 meq, 8 meq

T1

potassium chloride oral solution 20 meq/15ml

(10%), 40 meq/15ml (20%)

T1

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1





PULMOSAL T1

ra one daily T1

ra oyster shell calcium/d oral tablet 250-125 mg-

unit

T1


sm calcium citrate+d3 petite T1

sm calcium/vitamin d oral tablet 500-200 mg-unit T1

TRIVEEN-DUO DHA T1

VINATE II T1

VINATE ONE T1

vinate ultra T1

vol-nate T1

vol-tab rx T1

Thiazide Diuretics





chlorothiazide oral T1

DIURIL T1




48

Drug Tier Notes

hydrochlorothiazide oral T1






mg, 50-25 mg

T1




mg, 40-12.5 mg

T1 ST

propranolol-hctz T1





Thiazide-Like Diuretics

chlorthalidone oral tablet 25 mg, 50 mg T1

CLORPRES T1

indapamide oral T1

metolazone T1

Uricosuric Agents

colchicine-probenecid T1

probenecid oral T1

Enzymes

Enzymes

PALYNZIQ T3 PA

Eye, Ear, Nose And Throat (Eent) Preps.

Alpha-Adrenergic Agonists (Eent)

brimonidine tartrate ophthalmic T1

Antiallergic Agents

ALAWAY T1 QL (1 QY per 30 DYs)


49

Drug Tier Notes

ASTEPRO NASAL SOLUTION 0.15 % T1

azelastine hcl nasal solution 0.1 % T1

azelastine hcl ophthalmic T1 ST

cromolyn sodium nasal T1

cromolyn sodium ophthalmic T1

kp ketotifen fumarate T1 QL (1 QY per 30 DYs)

olopatadine hcl ophthalmic solution 0.1 % T1 ST; QL (1 EA per 30 DYs)

ZADITOR T1 QL (1 QY per 30 DYs)

Antibacterials (Eent)

bacitracin-polymyxin b ophthalmic ointment 500-

10000 unit/gm

T1

bacitra-neomycin-polymyxin-hc T1

CIPRODEX T3 PA; ST

ciprofloxacin hcl ophthalmic T1

erythromycin ophthalmic T1

GENTAK OPHTHALMIC OINTMENT T1

MOXEZA T1 ST

moxifloxacin hcl ophthalmic T1

neomycin-bacitracin zn-polymyx ophthalmic

ointment 5-400-10000

T1

neomycin-polymyxin-dexameth ophthalmic

ointment

T1


suspension 3.5-10000-0.1

T1

neomycin-polymyxin-gramicidin ophthalmic

solution 1.75-10000-.025

T1

neomycin-polymyxin-hc ophthalmic suspension

3.5-10000-1

T1

neomycin-polymyxin-hc otic solution 1 % T1

neomycin-polymyxin-hc otic suspension T1

ofloxacin ophthalmic T1

ofloxacin otic T1

polymyxin b-trimethoprim T1

sulfacetamide sodium ophthalmic solution T1


50

Drug Tier Notes

sulfacetamide-prednisolone ophthalmic solution T1

tobramycin ophthalmic T1

tobramycin-dexamethasone T1

TOBREX OPHTHALMIC OINTMENT T1

Antivirals (Eent)

trifluridine ophthalmic T1

Beta-Adrenergic Blocking Agents (Eent)

carteolol hcl T1

dorzolamide hcl-timolol mal T1 QL (10 ML per 30 days)

levobunolol hcl ophthalmic solution 0.5 % T1

timolol maleate ophthalmic gel forming solution T1

timolol maleate ophthalmic solution 0.25 %, 0.5 % T1

TIMOPTIC OCUDOSE T1

Carbonic Anhydrase Inhibitors (Eent)

acetazolamide er T1


dorzolamide hcl ophthalmic T1

dorzolamide hcl-timolol mal T1 QL (10 ML per 30 days)

Corticosteroids (Eent)

bacitra-neomycin-polymyxin-hc T1

BECONASE AQ T3 PA

CIPRODEX T3 PA; ST

dexamethasone sodium phosphate ophthalmic T1

FLAREX T1

fluorometholone ophthalmic T1

fluticasone propionate nasal T1

FML T1

FML FORTE T1

goodsense nasal allergy spray T1 ST

hydrocortisone-acetic acid T1

MAXIDEX T1

NASACORT ALLERGY 24HR T1 ST


51

Drug Tier Notes

NASACORT ALLERGY 24HR CHILDREN T1 ST


ointment

T1


suspension 3.5-10000-0.1

T1

neomycin-polymyxin-hc ophthalmic suspension

3.5-10000-1

T1

OMNARIS T3 PA

PRED MILD T1

prednisolone acetate ophthalmic T1

prednisolone sodium phosphate ophthalmic T1

tobramycin-dexamethasone T1

triamcinolone acetonide nasal aerosol T3 PA

Eent Anti-Infectives, Miscellaneous

acetic acid otic T1

chlorhexidine gluconate mouth/throat T1

hydrocortisone-acetic acid T1

Eent Anti-Inflammatory Agents, Misc.

RESTASIS T1 ST

RESTASIS MULTIDOSE OPHTHALMIC

EMULSION 0.05 %

T1 ST

XIIDRA T1 ST

Eent Drugs, Miscellaneous

apraclonidine hcl T1

artificial tears ophthalmic solution 1.4 % T1

EYLEA INTRAVITREAL T1 PA

IOPIDINE OPHTHALMIC SOLUTION 1 % T1

ipratropium bromide nasal T1

LUCENTIS INTRAVITREAL T1 PA

Eent Nonsteroidal Anti-Inflam. Agents

flurbiprofen sodium T1

ketorolac tromethamine ophthalmic T1

Local Anesthetics (Eent)


52

Drug Tier Notes

lidocaine hcl external gel 2 % T1

lidocaine hcl external solution T1

lidocaine viscous T1

Miotics

PHOSPHOLINE IODIDE T1

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % T1

Mydriatics

cyclopentolate hcl ophthalmic solution 2 % T1

Prostaglandin Analogs

latanoprost ophthalmic T1

TRAVATAN Z T1

Vasoconstrictors

ADRENALIN NASAL T1

phenylephrine hcl ophthalmic solution 10 %, 2.5

%

T1

Gastrointestinal Drugs

5-Ht3 Receptor Antagonists

granisetron hcl oral T1 ST

ondansetron hcl oral solution T1 QL (50 QY per 30 DYs)

ondansetron hcl oral tablet 4 mg T1

ondansetron hcl oral tablet 8 mg T1 QL (15 QY per 30 DYs)

ondansetron oral tablet dispersible 4 mg T1

ondansetron oral tablet dispersible 8 mg T1 QL (15 QY per 30 DYs)

Antacids And Adsorbents

aluminum hydroxide gel oral suspension 320

mg/5ml

T1

antacid extra strength oral tablet chewable 750

mg

T1

antacid plus anti-gas relief oral suspension 400-

400-40 mg/5ml

T1

calcium antacid ultra strength T1


500 mg

T1


53

Drug Tier Notes

kp mag-oxide magnesium T1

magnesium oxide oral tablet 250 mg, 420 mg, 500

mg

T1

ra pink bismuth oral tablet chewable T1

sodium bicarbonate oral tablet 650 mg T1

Antidiarrhea Agents


loperamide hcl oral capsule T1

ra pink bismuth oral tablet chewable T1

Antiemetics, Miscellaneous

doxylamine-pyridoxine T1 PA

scopolamine T3 PA

Antiflatulents

antacid plus anti-gas relief oral suspension 400-

400-40 mg/5ml

T1

Antihistamines (Gi Drugs)


meclizine hcl oral T1

prochlorperazine T1

prochlorperazine edisylate injection solution 5

mg/ml

T1

prochlorperazine maleate oral T1

Anti-Inflammatory Agents (Gi Drugs)

balsalazide disodium T1

CANASA T1

mesalamine oral tablet delayed release 1.2 gm T1

mesalamine rectal enema T1

PENTASA T1


Cathartics And Laxatives

AMITIZA T1

docusate calcium T1


54

Drug Tier Notes

docusate sodium oral capsule 100 mg T1

docusate sodium oral syrup T1

gentle laxative oral T1

milk of magnesia oral suspension 1200 mg/15ml T1

mineral oil oral oil T1

natural fiber therapy oral powder 48.57 % T1

natural senna laxative oral tablet 8.6 mg T1

peg 3350 oral powder T1

peg 3350/electrolytes T1

senna s T1

vinate ultra T1

Cholelitholytic Agents

ursodiol oral T1

Digestants

CREON T1

ZENPEP ORAL CAPSULE DELAYED

RELEASE PARTICLES 10000-32000 UNIT,

15000-47000 UNIT, 20000-63000 UNIT, 25000-

79000 UNIT, 3000-14000 UNIT, 40000-126000

UNIT, 5000-24000 UNIT

T1

Gi Drugs, Miscellaneous

HUMIRA PEDIATRIC CROHNS START

SUBCUTANEOUS PREFILLED SYRINGE

KIT 40 MG/0.8ML, 80 MG/0.8ML, 80

MG/0.8ML & 40MG/0.4ML

T1 PA

HUMIRA PEN SUBCUTANEOUS PEN-

INJECTOR KIT

T1 PA

HUMIRA PEN-CD/UC/HS STARTER T1 PA

HUMIRA PEN-PS/UV/ADOL HS START T1 PA

HUMIRA SUBCUTANEOUS PREFILLED

SYRINGE KIT

T1 PA

LINZESS T1

Histamine H2-Antagonists

cimetidine 200 T1

cimetidine hcl oral T1


55

Drug Tier Notes

cimetidine oral tablet 300 mg, 400 mg, 800 mg T1

famotidine oral tablet T1

nizatidine oral capsule T1

ranitidine hcl oral syrup 75 mg/5ml T1

ranitidine hcl oral tablet T1

Lipotropic Agents

choline sr T1

Neurokinin-1 Receptor Antagonists

EMEND ORAL CAPSULE 125 MG, 80 MG T1

EMEND ORAL CAPSULE 40 MG T1 QL (1 QY per 30 DYs)

EMEND TRI-PACK T1

Prokinetic Agents

metoclopramide hcl oral solution 5 mg/5ml T1

metoclopramide hcl oral tablet T1

Prostaglandins

misoprostol oral T1

Protectants

CARAFATE ORAL SUSPENSION T1

sucralfate oral tablet T1

Proton-Pump Inhibitors

ACIPHEX T1 ST

esomeprazole magnesium oral capsule delayed

release

T1 ST

lansoprazole oral capsule delayed release T1 ST; QL (2 EA per 1 day)

NEXIUM 24HR ORAL TABLET DELAYED

RELEASE

T1 ST; QL (2 EA per 1 DY)

NEXIUM ORAL PACKET T3 PA

omeprazole oral capsule delayed release T1 QL (2 EA per 1 day)

omeprazole-sodium bicarbonate oral capsule 40-

1100 mg

T3 PA

omeprazole-sodium bicarbonate oral packet 40-

1680 mg

T3 PA

pantoprazole sodium oral T1 QL (2 EA per 1 day)


56

Drug Tier Notes

PREVACID ORAL CAPSULE DELAYED

RELEASE 15 MG

T3 PA

PREVACID SOLUTAB ORAL TABLET

DISPERSIBLE 30 MG

T3 PA

PRILOSEC ORAL PACKET T1 QL (2 EA per 1 day); Max 7 Years

PRILOSEC OTC T3 PA

PROTONIX ORAL PACKET T3 PA

rabeprazole sodium oral tablet delayed release T3 PA

ZEGERID ORAL PACKET 20-1680 MG T3 PA

Gold Compounds

Gold Compounds

RIDAURA T1

Heavy Metal Antagonists

Heavy Metal Antagonists

CHEMET T1

EXJADE T3 PA

JADENU T3 PA

Hormones And Synthetic Substitutes

Adrenals

ARMONAIR RESPICLICK 113 T1



ARNUITY ELLIPTA T1 QL (1 EA per 30 days)

ASMANEX 120 METERED DOSES T1 QL (1 QY per 30 DYs)





ASMANEX HFA T1

budesonide inhalation suspension 0.25 mg/2ml T1 QL (60 QY per 30 DYs); Max 8 Years

budesonide inhalation suspension 0.5 mg/2ml T1 QL (120 QY per 30 DYs); Max 8

Years


57

Drug Tier Notes

budesonide inhalation suspension 1 mg/2ml T1 QL (60 ML per 30 days); Max 8

Years

cortisone acetate oral T1

DEXAMETHASONE INTENSOL T1

dexamethasone oral elixir T1

dexamethasone oral solution T1

dexamethasone oral tablet T1

dexamethasone sod phosphate pf T1

ENTOCORT EC ORAL CAPSULE

DELAYED RELEASE PARTICLES

T3 PA

FLOVENT DISKUS INHALATION

AEROSOL POWDER BREATH ACTIVATED

100 MCG/BLIST




250 MCG/BLIST




50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL

110 MCG/ACT



220 MCG/ACT


FLOVENT HFA INHALATION AEROSOL 44

MCG/ACT

T1 QL (10.6 QY per 30 DYs)

fludrocortisone acetate oral T1


hydrocortisone oral T1

INTRAROSA T1

MEDROL ORAL TABLET 2 MG T1

methylprednisolone oral T1

prednisolone oral solution T1

prednisolone sodium phosphate oral solution 15

mg/5ml, 6.7 (5 base) mg/5ml

T1

PREDNISONE INTENSOL T1

prednisone oral solution T1


58

Drug Tier Notes

prednisone oral tablet T1

prednisone oral tablet therapy pack 10 mg (21), 5

mg (21)

T1

QVAR INHALATION AEROSOL SOLUTION

40 MCG/ACT



80 MCG/ACT


QVAR REDIHALER INHALATION

AEROSOL BREATH ACTIVATED 40

MCG/ACT

T1 QL (10.6 GM per 30 days)



MCG/ACT



Androgens

danazol oral T1 PA

TESTIM T3 PA

testosterone cypionate intramuscular solution 100

mg/ml


testosterone cypionate intramuscular solution 200

mg/ml


testosterone enanthate intramuscular solution T1 QL (5 ML per 28 DYs)

testosterone transdermal gel 10 mg/act (2%), 12.5

mg/act (1%), 25 mg/2.5gm (1%)

T1 PA

testosterone transdermal solution T1 PA

Antiestrogens

letrozole oral T1 QL (1 QY per 1 DY)

Antigonadtropins

ORILISSA T1 PA

Antiparathyroid Agents

calcitonin (salmon) T1

Antithyroid Agents

methimazole oral T1

propylthiouracil oral T1

SSKI T1


59

Drug Tier Notes

Biguanides

alogliptin-metformin hcl T1 ST

glipizide-metformin hcl T1

glyburide-metformin oral tablet 1.25-250 mg T1

JANUMET T1 ST

JANUMET XR T1 ST

metformin hcl er T1

metformin hcl oral tablet T1

pioglitazone hcl-metformin hcl T1 ST

SEGLUROMET T1 ST

Contraceptives

APRI T1

ARANELLE T1

AVIANE T1

BALZIVA T1

CAMILA T1

CAMRESE T1

CRYSELLE-28 T1

ELLA T1

ENPRESSE-28 T1

ERRIN T1

JOLESSA T1

JOLIVETTE T1

JUNEL 1.5/30 T1

JUNEL 1/20 T1

JUNEL FE 1.5/30 T1

JUNEL FE 1/20 T1

KARIVA T1

KELNOR 1/35 T1

LEENA T1

LESSINA T1

LEVORA 0.15/30 (28) T1


60

Drug Tier Notes

LOW-OGESTREL T1

LUTERA T1

MICROGESTIN 1.5/30 T1

MICROGESTIN 1/20 T1

MICROGESTIN FE 1.5/30 T1

MICROGESTIN FE 1/20 T1

MONONESSA T1

NECON 1/50 (28) T1

NECON 7/7/7 T1

NEXT CHOICE ONE DOSE T1

NORA-BE T1

norethindrone oral T1

norgestim-eth estrad triphasic oral tablet

0.18/0.215/0.25 mg-25 mcg

T1

NORTREL 0.5/35 (28) T1

NORTREL 1/35 (21) T1

NORTREL 1/35 (28) T1

NORTREL 7/7/7 T1

NUVARING T1

OCELLA T1

OGESTREL T1

PORTIA-28 T1

QUASENSE T1

RECLIPSEN T1

SPRINTEC 28 T1

SRONYX T1

TILIA FE T1

TRINESSA (28) T1

TRI-SPRINTEC T1

TRIVORA (28) T1

VELIVET T1

XULANE T1

ZOVIA 1/35E (28) T1


61

Drug Tier Notes

ZOVIA 1/50E (28) T1

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors

alogliptin benzoate T1 ST

alogliptin-metformin hcl T1 ST

alogliptin-pioglitazone T1 ST

JANUMET T1 ST

JANUMET XR T1 ST

JANUVIA T1 ST

Estrogen Agonist-Antagonists

FARESTON T1 PA

raloxifene hcl T1

tamoxifen citrate oral T1

Estrogens

estradiol oral T1

estradiol transdermal T1

estropipate oral T1

JINTELI T1

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG

T1

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-

mcg

T1

PREMARIN ORAL T1

PREMARIN VAGINAL T1

PREMPHASE T1

PREMPRO T1

Glycogenolytic Agents

GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)

GLUCAGON EMERGENCY T1 QL (2 QY per 30 DYs)

Incretin Mimetics

OZEMPIC T1 ST

TRULICITY T1 ST


62

Drug Tier Notes

VICTOZA SUBCUTANEOUS SOLUTION

PEN-INJECTOR

T1 ST

Insulins

ADMELOG T1 QL (30 ML per 30 DYs)

ADMELOG SOLOSTAR T1 QL (30 ML per 30 DYs)

BASAGLAR KWIKPEN T1 QL (30 ML per 30 days)

HUMALOG JUNIOR KWIKPEN T1 QL (30 ML per 30 days)

HUMALOG MIX 50/50 T1 QL (30 QY per 30 DYs)

HUMALOG MIX 50/50 KWIKPEN

SUBCUTANEOUS SUSPENSION PEN-

INJECTOR





INJECTOR


HUMULIN 70/30 T1 QL (30 QY per 30 DYs)

HUMULIN N T1 QL (30 QY per 30 DYs)

HUMULIN R T1 QL (30 QY per 30 DYs)

HUMULIN R U-500 (CONCENTRATED) T1 QL (30 QY per 30 DYs)

NOVOLIN 70/30 RELION T1 QL (30 ML per 30 days)

Intermediate-Acting Insulins




INJECTOR





INJECTOR



HUMULIN N T1 QL (30 QY per 30 DYs)


Long-Acting Insulins

BASAGLAR KWIKPEN T1 QL (30 ML per 30 days)

Parathyroid And Antiparathyroid Agents


63

Drug Tier Notes


Pituitary

DDAVP RHINAL TUBE T1 QL (15 ML per 30 days)

desmopressin ace rhinal tube T1 PA

desmopressin ace spray refrig T1 PA

desmopressin acetate oral tablet 0.1 mg T1 QL (90 EA per 30 days); Min 4 Years

desmopressin acetate oral tablet 0.2 mg T1 QL (180 EA per 30 days); Min 4

Years

desmopressin acetate spray T1 QL (15 ML per 30 days)

Progestins

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/ML

T1

hydroxyprogesterone caproate intramuscular T1

JINTELI T1

MAKENA T3 PA

medroxyprogesterone acetate intramuscular T1

medroxyprogesterone acetate oral T1

megestrol acetate oral suspension 40 mg/ml T1

megestrol acetate oral suspension 625 mg/5ml T1 QL (150 ML per 30 days)

megestrol acetate oral tablet T1

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-

mcg

T1

Rapid-Acting Insulins

ADMELOG T1 QL (30 ML per 30 DYs)

ADMELOG SOLOSTAR T1 QL (30 ML per 30 DYs)

HUMALOG JUNIOR KWIKPEN T1 QL (30 ML per 30 days)




INJECTOR





INJECTOR



64

Drug Tier Notes

Short-Acting Insulins


HUMULIN R T1 QL (30 QY per 30 DYs)

HUMULIN R U-500 (CONCENTRATED) T1 QL (30 QY per 30 DYs)


Sodium-Gluc Cotransport 2 (Sglt2) Inhib

SEGLUROMET T1 ST

STEGLATRO T1 ST

Sulfonylureas

glimepiride T1

glipizide er T1

glipizide oral T1

glipizide-metformin hcl T1

glyburide micronized T1

glyburide oral T1

glyburide-metformin oral tablet 1.25-250 mg T1

Thiazolidinediones

alogliptin-pioglitazone T1 ST

pioglitazone hcl T1 ST

pioglitazone hcl-metformin hcl T1 ST

Thyroid Agents

ARMOUR THYROID T1

levothyroxine sodium oral T1

liothyronine sodium oral T1

NATURE-THROID ORAL TABLET 195 MG T1

THYROLAR-1 ORAL TABLET 60 (12.5-50)

MG (MCG)

T1

THYROLAR-1/2 ORAL TABLET 30 (6.25-25)

MG (MCG)

T1

THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5)

MG (MCG)

T1

THYROLAR-2 ORAL TABLET 120 (25-100)

MG (MCG)

T1


65

Drug Tier Notes

THYROLAR-3 ORAL TABLET 180 (37.5-150)

MG (MCG)

T1

Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors

finasteride oral tablet 5 mg T1

Alcohol Deterrents

disulfiram oral T1

naltrexone hcl oral T1 QL (1 EA per 1 day)

VIVITROL T1 QL (1 EA per 30 days)

Antidotes

CHEMET T1

FOSRENOL ORAL TABLET CHEWABLE

750 MG

T1

GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)

GLUCAGON EMERGENCY T1 QL (2 QY per 30 DYs)

lanthanum carbonate T1

leucovorin calcium oral tablet 10 mg, 15 mg T1 PA

leucovorin calcium oral tablet 25 mg, 5 mg T1

NARCAN T1 QL (4 EA per 30 days)

phytonadione oral T1

sevelamer carbonate oral tablet T1

sodium polystyrene sulfonate oral suspension T1

sodium polystyrene sulfonate rectal suspension 30

gm/120ml

T1

SSKI T1

Antigout Agents

allopurinol oral T1

colchicine oral tablet T1 ST; QL (60 EA per 30 days)

colchicine-probenecid T1

goodsense naproxen sodium T1

indomethacin oral T1

naproxen dr T1


66

Drug Tier Notes

naproxen oral T1

naproxen sodium oral capsule T1

naproxen sodium oral tablet 275 mg, 550 mg T1

probenecid oral T1

Bone Resorption Inhibitors

alendronate sodium oral tablet T1


etidronate disodium T1

raloxifene hcl T1

Cariostatic Agents

CLINPRO 5000 T1 Max 20 Years

multivitamin/fluoride oral solution T1


MVC-FLUORIDE ORAL TABLET

CHEWABLE 0.5 MG, 1 MG

T1

PHOS FLUR T1

sf T1 Max 20 Years

sf 5000 plus T1 Max 20 Years

sodium fluoride oral solution T1 Max 20 Years

sodium fluoride oral tablet chewable T1 Max 20 Years


tri-vitamin/fluoride T1

Disease-Modifying Antirheumatic Agents

azathioprine oral T1

cyclosporine modified oral capsule 100 mg, 25 mg T1

cyclosporine oral capsule T1

GENGRAF ORAL CAPSULE 100 MG, 25 MG T1



KIT 40 MG/0.8ML, 80 MG/0.8ML

T1 PA


INJECTOR KIT

T1 PA




67

Drug Tier Notes


SYRINGE KIT

T1 PA


leflunomide oral T1



mg/2ml

T1 PA


RIDAURA T1

SANDIMMUNE ORAL SOLUTION T1



Immunomodulatory Agents







KIT 40 MG/0.8ML, 80 MG/0.8ML, 80

MG/0.8ML & 40MG/0.4ML

T1 PA


INJECTOR KIT

T1 PA




SYRINGE KIT

T1 PA


leflunomide oral T1

MAYZENT T3 PA

MAYZENT STARTER PACK T3 PA



mg/2ml

T1 PA


68

Drug Tier Notes


RIDAURA T1




Immunosuppressive Agents


cyclophosphamide oral capsule T1



ELIDEL T1 PA


mercaptopurine oral T1



mg/2ml

T1 PA


mycophenolate mofetil T1


tacrolimus oral T1


Other Miscellaneous Therapeutic Agents

biotin oral tablet 800 mcg T1

choline citrate T1

DEMSER T1

levocarnitine oral tablet T1

XEOMIN INTRAMUSCULAR SOLUTION

RECONSTITUTED 100 UNIT, 50 UNIT

T3 PA

Protective Agents

ELMIRON T1 QL (90 EA per 30 days)

Respiratory Tract Agents

Alpha And Beta Adrenergic Agonist(Respr)

BROMFED DM T1


69

Drug Tier Notes


epinephrine injection solution auto-injector 0.15

mg/0.3ml, 0.3 mg/0.3ml



kp pseudoephedrine hcl oral tablet 60 mg T1


MG/5ML


m-end dmx T1


mg/5ml

T1



Anticholinergic Agents (Respir.Tract)

ANORO ELLIPTA T1

ATROVENT HFA T1



ipratropium bromide inhalation T1


SPIRIVA RESPIMAT INHALATION

AEROSOL SOLUTION 1.25 MCG/ACT, 2.5

MCG/ACT

T1

Antitussives

benzonatate oral capsule 100 mg, 200 mg T1

BROMFED DM T1


Years




extended release




MG/5ML



70

Drug Tier Notes

m-end dmx T1





mg/5ml

T1


robafen dm T1


Expectorants


Years


guaifenesin oral liquid T1



MG/5ML




robafen dm T1

SSKI T1


First Generation Antihist.(Respir Tract)


BROMFED DM T1









extended release



71

Drug Tier Notes

m-end dmx T1









mg/5ml

T1


Leukotriene Modifiers

montelukast sodium oral T1 QL (1 EA per 1 day)

Mast-Cell Stabilizers

cromolyn sodium nasal T1

cromolyn sodium ophthalmic T1

Nasal Preparations (Steroids)

BECONASE AQ T3 PA

fluticasone propionate nasal T1

goodsense nasal allergy spray T1 ST

NASACORT ALLERGY 24HR T1 ST

NASACORT ALLERGY 24HR CHILDREN T1 ST

OMNARIS T3 PA

triamcinolone acetonide nasal aerosol T3 PA

Orally Inhaled Preparations (Steroids)




ARNUITY ELLIPTA T1 QL (1 EA per 30 days)





72

Drug Tier Notes



ASMANEX HFA T1

budesonide inhalation suspension 0.25 mg/2ml T1 QL (60 QY per 30 DYs); Max 8 Years

budesonide inhalation suspension 0.5 mg/2ml T1 QL (120 QY per 30 DYs); Max 8

Years

budesonide inhalation suspension 1 mg/2ml T1 QL (60 ML per 30 days); Max 8

Years



100 MCG/BLIST




250 MCG/BLIST




50 MCG/BLIST



110 MCG/ACT



220 MCG/ACT


FLOVENT HFA INHALATION AEROSOL 44

MCG/ACT




40 MCG/ACT



80 MCG/ACT




MCG/ACT




MCG/ACT



Phosphodiesterase Type 4 Inhibitors

DALIRESP ORAL TABLET 500 MCG T1 ST

Second Generation Antihist(Respir Tract)


73

Drug Tier Notes

all day allergy oral capsule T1 ST

allergy relief oral tablet dispersible T1 ST

cetirizine hcl oral solution 5 mg/5ml T1

cetirizine hcl oral tablet 10 mg T1


CLARINEX T3 PA

fexofenadine hcl childrens T1 ST

hm loratadine childrens T1 ST

kp cetirizine hcl oral tablet 5 mg T1

kp fexofenadine hcl oral tablet 180 mg T1 ST

levocetirizine dihydrochloride oral solution T3 PA

levocetirizine dihydrochloride oral tablet T1

loratadine allergy relief oral tablet dispersible T1 ST

loratadine childrens oral solution T1 ST

loratadine oral capsule T1 ST

loratadine oral tablet T1

sm loratadine oral tablet dispersible T1 ST

Select.Beta-2-Adrenergic Agonist(Respir)

albuterol sulfate hfa inhalation aerosol solution

108 (90 base) mcg/act

T1 QL (2 EA per 30 DYs)

albuterol sulfate inhalation nebulization solution

(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

T1

albuterol sulfate oral T1

ANORO ELLIPTA T1




SEREVENT DISKUS T1

terbutaline sulfate oral T1


Vasodilating Agents (Respiratory Tract)

LETAIRIS T1 PA


74

Drug Tier Notes

sildenafil citrate oral tablet 20 mg T1 PA

Xanthine Derivatives

THEO-24 T1


hour 200 mg, 300 mg

T1

Skin And Mucous Membrane Agents

Antibacterials (Skin, Mucous Membrane)

benzoyl peroxide-erythromycin T1

clindamycin phosphate external gel T1

clindamycin phosphate external lotion T1

clindamycin phosphate external solution T1

clindamycin phosphate external swab T1

double antibiotic T1

erythromycin external T1

gentamicin sulfate external T1

metronidazole external gel T1

metronidazole vaginal T1

mupirocin external T1

Anti-Inflammatory Agents (Skin, Mucous)

amcinonide external cream T1

betamethasone dipropionate aug external cream T1

betamethasone dipropionate aug external lotion T1

betamethasone dipropionate aug external ointment T1

betamethasone dipropionate external T1

betamethasone valerate external cream T1

betamethasone valerate external lotion T1

betamethasone valerate external ointment T1

clobetasol propionate e T1

clobetasol propionate external cream T1

clobetasol propionate external gel T1

clobetasol propionate external ointment T1

clobetasol propionate external solution T1


75

Drug Tier Notes

clotrimazole-betamethasone external cream T1 QL (15 QY per 34 DYs)

desonide external ointment T1

desoximetasone external cream T1

desoximetasone external gel T1

desoximetasone external ointment 0.25 % T1

diflorasone diacetate external T1

fluocinolone acetonide external T1

fluocinonide emulsified base T1

fluocinonide external cream 0.05 % T1

fluocinonide external gel T1

fluocinonide external ointment T1

fluocinonide external solution T1

hydrocortisone external cream 1 %, 2.5 % T1

hydrocortisone external lotion 1 %, 2.5 % T1

hydrocortisone external ointment 1 %, 2.5 % T1

hydrocortisone rectal enema T1

hydrocortisone valerate T1

mometasone furoate external cream T1 QL (45 QY per 30 DYs)

mometasone furoate external ointment T1 QL (45 QY per 30 DYs)

mometasone furoate external solution T1

PROCTOFOAM HC T1

triamcinolone acetonide external cream T1

triamcinolone acetonide external lotion T1

triamcinolone acetonide external ointment T1

XERESE T3 PA

Antipruritics And Local Anesthetics

dibucaine external T1

lidocaine external patch 5 % T3 PA

lidocaine hcl external cream 3 % T1

lidocaine hcl external solution T1

lidocaine-prilocaine external cream T1 QL (30 QY per 30 DYs)

phenazopyridine hcl oral tablet 100 mg, 200 mg T1


76

Drug Tier Notes

PROCTOFOAM HC T1

Antivirals (Skin And Mucous Membrane)

ABREVA T1

DENAVIR T3 PA

XERESE T3 PA

ZOVIRAX EXTERNAL T3 PA

Azoles (Skin And Mucous Membrane)

clotrimazole external cream T1

clotrimazole external solution T1

clotrimazole mouth/throat troche T1

clotrimazole vaginal cream 1 % T1


ketoconazole external cream T1

ketoconazole external shampoo 2 % T1

kp miconazole nitrate T1

miconazole 3 vaginal suppository T1

Basic Lotions And Liniments

ammonium lactate external lotion T1

Basic Ointments And Protectants

ammonium lactate external cream T1

Cell Stimulants And Proliferants

tretinoin external cream T1 Max 20 Years

tretinoin external gel 0.01 %, 0.025 % T1 Max 20 Years

tretinoin microsphere external gel 0.04 % T3 PA

Corticosteroids (Skin, Mucous Membrane)

amcinonide external cream T1

betamethasone dipropionate aug external cream T1

betamethasone dipropionate aug external lotion T1

betamethasone dipropionate aug external ointment T1

betamethasone dipropionate external T1

betamethasone valerate external cream T1

betamethasone valerate external lotion T1


77

Drug Tier Notes

betamethasone valerate external ointment T1

clobetasol propionate e T1

clobetasol propionate external cream T1

clobetasol propionate external gel T1

clobetasol propionate external ointment T1

clobetasol propionate external solution T1


desonide external ointment T1

desoximetasone external cream T1

desoximetasone external gel T1

desoximetasone external ointment 0.25 % T1

diflorasone diacetate external T1

fluocinolone acetonide external T1

fluocinonide emulsified base T1

fluocinonide external cream 0.05 % T1

fluocinonide external gel T1

fluocinonide external ointment T1

fluocinonide external solution T1

hydrocortisone external cream 1 %, 2.5 % T1

hydrocortisone external lotion 1 %, 2.5 % T1

hydrocortisone external ointment 1 %, 2.5 % T1

hydrocortisone rectal enema T1

hydrocortisone valerate T1

mometasone furoate external cream T1 QL (45 QY per 30 DYs)

mometasone furoate external ointment T1 QL (45 QY per 30 DYs)

mometasone furoate external solution T1

PROCTOFOAM HC T1

triamcinolone acetonide external cream T1

triamcinolone acetonide external lotion T1

triamcinolone acetonide external ointment T1

XERESE T3 PA

Keratolytic Agents


78

Drug Tier Notes

kp benzoyl peroxide external gel 10 % T1

P & S EXTERNAL SHAMPOO T1

sulfacetamide sodium-sulfur external lotion 10-5

%

T1

urea external cream 40 % T1

Keratoplastic Agents

DRITHO-CREME HP T1

Local Anti-Infectives, Miscellaneous

anti-dandruff T1

selenium sulfide external lotion T1

silver sulfadiazine external T1

sulfacetamide sodium (acne) T1

sulfacetamide sodium-sulfur external lotion 10-5

%

T1

v-r alcohol prep T1

Nonsteroidal Anti-Inflammat.Agents(Skin)


Polyenes (Skin And Mucous Membrane)

nystatin external cream T1

nystatin external ointment T1

nystatin-triamcinolone T1

Scabicides And Pediculicides

bedding spray lice treatment T1 QL (142 GM per 5 days)

CUTTER BACKWOODS EXTERNAL

AEROSOL

T1 QL (170 GM per 6 days)

CUTTER SKINSATIONS EXTERNAL

LIQUID


EURAX EXTERNAL LOTION T1 QL (60 QY per 30 DYs)

OFF ACTIVE T1 QL (170 GM per 6 days)

OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)

OFF DEEP WOODS EXTERNAL AEROSOL T1 QL (170 GM per 6 days)

OFF SMOOTH & DRY T1 QL (71 GM per 2 days)

permethrin external cream T1 QL (60 QY per 1 PD)


79

Drug Tier Notes

REPEL SPORTSMEN T1 QL (184 GM per 6 days)

REPEL SPORTSMEN MAX EXTERNAL

AEROSOL


RID T1 QL (141.8 GM per 5 days)

spinosad T1 ST

stop lice T1 QL (142 GM per 5 days)

Skin And Mucous Membrane Agents, Misc.

capsaicin external cream 0.025 % T1

capsaicin hp T1

CAPZASIN-HP T1

CLARAVIS T1 PA

CONDYLOX EXTERNAL GEL T1

CUTTER BACKWOODS EXTERNAL

AEROSOL


CUTTER SKINSATIONS EXTERNAL

LIQUID


cvs capsaicin hp T1


ELIDEL T1 PA



KIT 40 MG/0.8ML, 80 MG/0.8ML

T1 PA


INJECTOR KIT

T1 PA




SYRINGE KIT

T1 PA

imiquimod external T1 QL (24 QY per 30 DYs)

NATRAPEL 12-HOUR TICK/INSECT T1 QL (177 ML per 6 days)

OFF ACTIVE T1 QL (170 GM per 6 days)

OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)

OFF DEEP WOODS EXTERNAL AEROSOL T1 QL (170 GM per 6 days)

OFF SMOOTH & DRY T1 QL (71 GM per 2 days)


80

Drug Tier Notes

podofilox external T1

REPEL SPORTSMEN T1 QL (184 GM per 6 days)

REPEL SPORTSMEN MAX EXTERNAL

AEROSOL


SANTYL T1

SAWYER INSECT REPELLENT EXTERNAL

LIQUID


tacrolimus external T1 PA

TALTZ T1 PA

ZOSTRIX HP T1

Thiocarbamates(Skin And Mucous Membrane)

kp tolnaftate T1

Smooth Muscle Relaxants

Antimuscarinics

flavoxate hcl T1

oxybutynin chloride er T1

oxybutynin chloride oral T1

tolterodine tartrate T1

tolterodine tartrate er T1

TOVIAZ ORAL TABLET EXTENDED

RELEASE 24 HOUR 8 MG

T1 ST

trospium chloride T1

Respiratory Smooth Muscle Relaxants

THEO-24 T1


hour 200 mg, 300 mg

T1

Vitamins

Multivitamin Preparations

cadeau dha T1

chewable vite/iron childrens T1

childrens chewable vitamins T1

complete natal dha T1

completenate T1


81

Drug Tier Notes

cvs prenatal gummy oral tablet chewable 0.4-

113.5 mg

T1


daily-vite/iron/beta-carotene T1


multivitamin/fluoride oral solution T1


MVC-FLUORIDE ORAL TABLET

CHEWABLE 0.5 MG, 1 MG

T1

MYNATAL ADVANCE T1

MYNATAL ORAL TABLET T1

mynatal plus T1

mynatal-z T1

mynate 90 plus T1

my-vitalife T1

OBSTETRIX DHA T1

OBTREX DHA T1

one daily/minerals T1



one-daily multi vitamins T1


polyvitamin/iron oral tablet chewable T1

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1




27-0.8-250 mg

T1





82

Drug Tier Notes



ra one daily T1


TAB-A-VITE MAXIMUM T1

TRICARE T1

TRIVEEN-DUO DHA T1



trust natal dha T1

VINATE GT T1

VINATE II T1

VINATE M T1

VINATE ONE T1

vinate ultra T1

VITRUM SENIOR T1

vol-nate T1

vol-tab rx T1

Vitamin A

beta carotene oral capsule 25000 unit T1


vitamin a oral capsule 10000 unit T1

Vitamin B Complex

b complex oral capsule T1

b complex-c-biotin-e-fa T1

b-1 oral tablet 250 mg T1

b-complex/b-12 oral T1

b-complex/folic acid/vitamin c T1

biotin oral tablet 1000 mcg, 300 mcg, 800 mcg T1

cadeau dha T1

calcium pantothenate oral tablet 500 mg T1

completenate T1


83

Drug Tier Notes

cvs prenatal gummy oral tablet chewable 0.4-

113.5 mg

T1



fe c tab plus T1

folic acid oral tablet 400 mcg T1


kp folic acid T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

MYNATAL ADVANCE T1

mynatal plus T1

mynatal-z T1

niacinamide oral tablet 500 mg T1

NICOMIDE ORAL TABLET 750-25-1.5-0.5

MG

T1

OBSTETRIX DHA T1

OBTREX DHA T1



PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1




27-0.8-250 mg

T1






pyridoxine hcl oral tablet 25 mg T1


84

Drug Tier Notes

ra one daily T1


sm b-complex T1

sm vitamin b12 tr oral tablet extended release

1000 mcg

T1

stress b-complex/vit c/zinc T1

super biotin oral capsule T1

TRICARE T1

TRIVEEN-DUO DHA T1

VINATE GT T1

VINATE II T1

VINATE M T1

VINATE ONE T1

vinate ultra T1

vitamin b-2 oral tablet 100 mg T1

vitamin b-6 oral tablet 50 mg T1

vol-nate T1

vol-tab rx T1

Vitamin C

b complex-c-biotin-e-fa T1

b-complex/folic acid/vitamin c T1

c-500 oral tablet chewable T1

fe c tab plus T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

stress b-complex/vit c/zinc T1


Vitamin D

calcitriol oral capsule T1

calcium + d3 oral tablet 600-200 mg-unit T1

calcium 1000 + d T1

calcium 500 + d3 oral tablet 500-600 mg-unit T1

calcium 500/d oral tablet T1


85

Drug Tier Notes

calcium 500/vitamin d T1

calcium 500+d high potency T1

calcium 600+d3 plus minerals oral tablet T1


500 mg

T1

calcium carbonate-vitamin d oral tablet 600-200

mg-unit, 600-400 mg-unit

T1

calcium citrate-vitamin d oral tablet 200-125 mg-

unit

T1

citrus calcium/vitamin d oral tablet 200-250 mg-

unit

T1

cvs vitamin d infants T1

hm vitamin d3 oral capsule 4000 unit T1

liquid calcium/vitamin d T1



ra oyster shell calcium/d oral tablet 250-125 mg-

unit

T1

sm calcium citrate+d3 petite T1

sm calcium/vitamin d oral tablet 500-200 mg-unit T1

sm vitamin d3 oral capsule 4000 unit T1


vitamin d (ergocalciferol) oral capsule 50000 unit T1

vitamin d2 T1

vitamin d-3 oral capsule T1

vitamin d3 oral capsule 10000 unit, 2000 unit, 400

unit, 5000 unit, 50000 unit

T1

Vitamin E

e-oil oral T1

vitamin e oral capsule 400 unit T1

Vitamin K Activity


phytonadione oral T1


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