2018 Comprehensive Formulary - KDHE Comprehensive Formulary ... When this drug list (formulary) ... pharmacies to use your prescription drug benefit. Benefits, formulary,

2018 Comprehensive

Formulary

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

This formulary was updated on 10/01/2017. For more recent information or other questions, please contact Aetna Medicare Member Services at 1-800-594-9390 or for TTY users: 711, 8 a.m. to 6 p.m. local time, Monday through Friday, or visit

http://www.AetnaRetireePlans.com, choose Manage your prescription drugs.

Formulary ID Number: 18066 Version 7

Aetna Medicare(List of Covered Drugs)

GRP B2 5 Tier

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Table of contents

Mail-order Pharmacy 3

What is the Aetna Medicare Comprehensive Formulary? 4

Can the Formulary (drug list) change? 4

How do I use the Formulary? 4

What are generic drugs? 5

Are there any restrictions on my coverage? 5

What if my drug is not on the Formulary? 6

How do I request an exception to the Aetna Medicare Formulary? 6

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? 6

For more information 7

Aetna Medicare Formulary 8Drug tier copay levels 9

Formulary key 10

Drug list 10Index of Drugs 120Enhanced Drug List 147

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Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.

You must continue to pay your Medicare Part B premium.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Co-payments/co-insurance may change on January 1 of each year.

The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Members who get Extra Help are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

Mail-order PharmacyFor mail order, you can get prescription drugs shipped to your home through our preferred mail-order delivery program, which is called Aetna Rx Home Delivery. Typically, mail-order drugs arrive within 7 to 14 days. You can call 1-800-594-9390 (TTY: 711), 8 a.m. to 6 p.m. local time, Monday through Friday, if you do not receive your mail-order drugs within this timeframe. Members may have the option to sign up for automated mail-order delivery.

ATTENTION: If you speak Spanish or Chinese, language assistance services, free of charge, are available to you. Call 1-800-594-9330 (TTY: 711).ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-800-594-9330 (TTY: 711).1-800-594-9390 711

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to we, us, or our, it means Aetna Medicare. When it refers to plan or our plan, it means Aetna.

This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

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What is the Aetna Medicare Comprehensive Formulary?A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Prescription Drug Schedule of Cost Sharing.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drugs manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/01/2017. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.

In the event of any CMS-approved, mid-year non-maintenance formulary changes, the formularies will be updated monthly and posted on our website.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins on page 10. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 10. Then look under the category name for your drug.

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Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 120. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you dont get approval, we may not cover the drug.

Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30tablets per 30 days per prescription for candesartan. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 10. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Aetna Medicare formulary? on page6 for information about how to request an exception.

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What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

You can ask us to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Aetna Medicare Formulary?You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drugs included on the plans formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.Generally, we must make our decision within 72 hours of getting your prescribers supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

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For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least 91 and up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you experience a change in your setting of care (such as being discharged or admitted to a long term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 30-day supply) for the applicable drug(s).

For more informationFor more detailed information about your plans prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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Aetna Medicare Formulary

The comprehensive formulary that begins on page 10 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page120.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,LEVEMIR) and generic drugs are listed in lower-case italics (e.g., candesartan).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. The following abbreviations are used:

QL QuantityLimits

PA Prior Authorization

ST StepTherapy

LA LimitedAccess

MO Mail-orderDelivery

B/D Part B vs. D Prior Authorization

QL: Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for candesartan.

PA: Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you dont get approval, we may not cover the drug.

ST: Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition, before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

LA: Limited Access. These prescriptions may be available only at certain pharmacies. For more Information, consult your Pharmacy Directory or call Aetna Member Services at 1-800-594-9390 (TTY: 711), 8 a.m. to 6 p.m. local time, Monday through Friday.

MO: Mail Order. For certain kinds of drugs, you can use Aetna Rx Home Delivery services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plans mail-order service are marked as mail-order drugs in our Drug List or MO. For more information, consult your Pharmacy Directory or call Aetna Member Services at 1-800-594-9390 (TTY: 711), 8 a.m. to 6 p.m. local time, Monday through Friday.

B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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Drug tier copay levels

This 2018 comprehensive formulary is a listing of brand-name and generic drugs. Aetna Medicares 2018 formulary covers most drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at which the drug resides.

The copay tiers for covered prescription medications are listed below. Copay amounts and coinsurance percentages for each tier vary by Aetna Medicare plan. Consult your plans Summary of Benefits or Evidence of Coverage for your applicable copays and coinsurance amounts.

Copay tier Type of drug

Tier 1 Preferred Generic Drugs

Tier 2 Generic Drugs

Tier 3 Preferred Brand Drugs

Tier 4 Non-Preferred Drugs

Tier 5 Specialty Drugs

Our plan, in some instances, combines higher cost generic drugs on brand tiers. Refer to the drug list to determine the tier of coverage for each drug you take.

You may have drug coverage in the Coverage Gap StageThere are four drug payment stages of a Medicare Prescription Drug Plan. How much you pay for a Part D drug depends on which drug payment stage you are in. Your plan may include supplemental coverage for some drugs during the Coverage Gap stage of the plan. Look in the 2018 Prescription Drug Benefits Chart (The Prescription Drug Schedule of Cost Sharing) that was included in your EOC packet. The Prescription Drug Benefits Chart will tell you if your plan provides coverage in the gap, and how much you will pay for covered drugs. If you need assistance finding this information, call the number on the back of your ID card.

10 * You can find information on what the symbols and abbreviations on this table mean by going to page 8.

Key*Drug nameUPPERCASE = Brand-name prescription drugs

Lowercase italics = Generic medications

Drug tier1, 2, 3, 4, 5 = Copay tier level

Requirements/LimitsQL = Quantity Limit PA = Prior Authorization ST = Step Therapy LA = Limited Access MO = Mail-order Delivery B/D = Part B vs. Part D

Drug name Drug tier Requirements/LimitsANALGESICS

Analgesics ascomp/codeine 4 QL (180 EA per 30 days) PA

MObupap tabs 300mg; 50mg 4 QL (180 EA per 30 days) PA

MObutalbital/acetaminophen/caffeine/codeine

4 QL (180 EA per 30 days) PA MO

butalbital/acetaminophen/caffeine caps


butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg


butalbital/aspirin/caffeine/codeine 4 QL (180 EA per 30 days) PA MO

butalbital/aspirin/caffeine caps 4 QL (180 EA per 30 days) PA MO

capacet 4 QL (180 EA per 30 days) PAesgic caps 4 QL (180 EA per 30 days) PA

MOFIORICET/CODEINE 4 QL (180 EA per 30 days) PA

MOFIORICET CAPS 4 QL (180 EA per 30 days) PA

MOFIORINAL 4 QL (180 EA per 30 days) PA

MOzebutal caps 325mg; 50mg; 40mg 4 QL (180 EA per 30 days) PA

MONonsteroidal Anti-inflammatory Drugs

ANAPROX DS 4 MOARTHROTEC 50 4 MOARTHROTEC 75 TBEC 4 MO

11* You can find information on what the symbols and abbreviations on this table mean by going to page 8.

Drug name Drug tier Requirements/LimitsCAMBIA 4 ST MOCELEBREX CAPS 400MG 4 QL (30 EA per 30 days) ST MOCELEBREX CAPS 100MG, 200MG, 50MG

4 QL (60 EA per 30 days) ST MO

celecoxib caps 100mg 2 QL (60 EA per 30 days) MOcelecoxib caps 400mg 3 QL (30 EA per 30 days) MOcelecoxib caps 200mg, 50mg 3 QL (60 EA per 30 days) MODAYPRO 4 MOdiclofenac potassium 2 MOdiclofenac sodium dr 2 MOdiclofenac sodium er 2 MOdiclofenac sodium/misoprostol 4 MOdiclofenac sodium transdermal soln 1.5%

4 QL (450 ML per 30 days) MO

diflunisal tabs 500mg 4 MODUEXIS 4 MOEC-NAPROSYN 4 MOetodolac er 4 MOetodolac caps 200mg 2 MOetodolac caps 300mg 3 MOetodolac immediate release tabs 3 MOFELDENE 4 MOfenoprofen calcium caps 400mg 4 MOfenoprofen calcium tabs 4 MOFLECTOR 4 QL (60 EA per 30 days) PA MOflurbiprofen tabs 2 MOibuprofen susp 2 MOibuprofen tabs 400mg, 600mg, 800mg

1 MO

INDOCIN SUSP 4 PA MOindomethacin er 4 PA MOindomethacin immediate release caps

4 PA MO

ketoprofen er cp24 200mg 4 MOketoprofen caps 50mg, 75mg 4 MOketorolac tromethamine inj 30mg/ml

4 QL (20 ML per 30 days) PA


Drug name Drug tier Requirements/Limitsketorolac tromethamine inj 15mg/ml, 30mg/ml, 60mg/2ml

4 QL (20 ML per 30 days) PA MO

ketorolac tromethamine tabs 10mg 2 QL (20 EA per 30 days) PA MOmeclofenamate sodium caps 4 MOmeloxicam tabs 1 MOMOBIC TABS 4 MOnabumetone tabs 2 MONAPRELAN 4 ST MONAPROSYN TABS 500MG 4 MOnaproxen dr 2 MOnaproxen sodium er tb24 375mg 4 MOnaproxen sodium er tb24 500mg 4 MOnaproxen sodium tabs 275mg, 550mg

2 MO

naproxen tabs 1 MOnaproxen susp 2 MOoxaprozin 4 MOPENNSAID SOLN 2% 4 QL (224 GM per 28 days) ST

MOpiroxicam caps 20mg 2 MOpiroxicam caps 10mg 3 MOsulindac tabs 2 MOTIVORBEX 4 PA MOVIMOVO 4 MOVIVLODEX 4 ST MOVOLTAREN GEL 4 QL (1000 GM per 30 days) ST

MOZIPSOR 4 ST MO

Opioid Analgesics, Long-acting buprenorphine patch weekly 10mcg/hr, 15mcg/hr, 20mcg/hr, 5mcg/hr


BUTRANS 4 QL (4 EA per 28 days) ST MOCONZIP 4 QL (30 EA per 30 days) MODOLOPHINE TABS 4 QL (180 EA per 30 days) MOEXALGO 4 QL (30 EA per 30 days) ST MOfentanyl transdermal patches 4 QL (15 EA per 30 days) MOhydromorphone hcl er t24a 32mg 4 QL (30 EA per 30 days) MO


Drug name Drug tier Requirements/Limitshydromorphone hcl er t24a 12mg, 16mg, 8mg

4 QL (30 EA per 30 days) MO

KADIAN CP24 100MG, 10MG, 200MG, 20MG, 30MG, 40MG, 50MG, 60MG, 80MG


methadone hcl oral soln 3 QL (3000 ML per 30 days) MOmethadone hcl conc 3 QL (360 ML per 30 days) MOmethadone hcl inj 5methadone hcl tabs 5mg 3 QL (180 EA per 30 days) MOmethadone hcl tabs 10mg 4 QL (180 EA per 30 days) MOmorphine sulfate er cp24 (generic Avinza) 120mg, 30mg, 45mg, 60mg, 75mg, 90mg


morphine sulfate er cp24 (generic Kadian) 100mg, 10mg, 20mg, 30mg, 50mg, 60mg, 80mg


morphine sulfate er tbcr (generic MS Contin)100mg, 200mg, 30mg, 60mg


morphine sulfate er tbcr (generic MS Contin) 15mg


MS CONTIN TBCR 100MG, 200MG, 30MG, 60MG


MS CONTIN TBCR 15MG 4 QL (90 EA per 30 days) PA MONUCYNTA ER 4 QL (60 EA per 30 days) ST MOOPANA ER (CRUSH RESISTANT) 4 QL (60 EA per 30 days) MOoxycodone hcl er t12a 80mg 4 QL (120 EA per 30 days) PA

MOoxycodone hcl er t12a 15mg, 30mg, 60mg

4 QL (60 EA per 30 days) PA

oxycodone hcl er t12a 10mg, 20mg, 40mg


oxymorphone hydrochloride er tb12 40mg


oxymorphone hydrochloride er tb12 10mg, 15mg, 20mg, 30mg, 5mg, 7.5mg


tramadol hcl er cp24 100mg, 200mg, 300mg



Drug name Drug tier Requirements/Limitstramadol hcl er tb24 100mg, 200mg, 300mg


Opioid Analgesics, Short-acting acetaminophen/codeine tabs 2 QL (180 EA per 30 days) MOacetaminophen/codeine soln 2 QL (4500 ML per 30 days) MObutorphanol tartrate nasal soln 4 QL (5 ML per 30 days) MObutorphanol tartrate inj 1mg/ml 4butorphanol tartrate inj 2mg/ml 4 MOcodeine sulfate tabs 4 QL (180 EA per 30 days) MODEMEROL INJ 100MG/2ML, 25MG/0.5ML, 25MG/ML, 75MG/1.5ML, 75MG/ML

4 PA

DEMEROL INJ 100MG/ML, 50MG/ML

4 PA MO

DEMEROL TABS 100MG 4 QL (120 EA per 30 days) PA MO

DILAUDID ORAL IQD 4 QL (2400 ML per 30 days) MODILAUDID TABS 2MG, 4MG, 8MG 4 QL (180 EA per 30 days) MODURAMORPH 3 B/Dendocet tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 7.5mg

3 QL (180 EA per 30 days)

endocet tabs 325mg; 5mg 4 QL (180 EA per 30 days)fentanyl citrate oral transmucosal 5 QL (120 EA per 30 days) PA

MOFENTORA TABS 100MCG, 200MCG, 400MCG, 600MCG, 800MCG


hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml


hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg, 325mg; 2.5mg


hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg


hydrocodone/ibuprofen tabs 5mg; 200mg, 7.5mg; 200mg



Drug name Drug tier Requirements/Limitshydrocodone/ibuprofen tabs 10mg; 200mg


hydromorphone hcl immediate release tabs


hydromorphone hcl liqd 4 QL (2400 ML per 30 days) MOhydromorphone hcl inj 10mg/ml, 50mg/5ml

4 B/D

hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml

4 B/D MO

ibudone tabs 5mg; 200mg 3 QL (150 EA per 30 days)lorcet 4 QL (180 EA per 30 days)lorcet hd 4 QL (180 EA per 30 days)lorcet plus tabs 325mg; 7.5mg 4 QL (180 EA per 30 days)meperidine hcl tabs 4 QL (120 EA per 30 days) PA

MOmeperidine hcl oral soln 4 QL (3600 ML per 30 days) PA

MOmeperidine hcl inj 10mg/ml, 25mg/ml

4 PA

meperidine hcl inj 100mg/ml, 50mg/ml

4 PA MO

morphine sulfate inj 0.5mg/ml, 10mg/ml, 150mg/30ml, 1mg/ml iv, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 8mg/ml

3 B/D

morphine sulfate inj 15mg/ml 3 B/D MOmorphine sulfate oral soln 10mg/5ml


morphine sulfate oral soln 20mg/5ml


morphine sulfate oral soln 100mg/5ml


morphine sulfate tabs 30mg 3 QL (180 EA per 30 days) MOmorphine sulfate tabs 15mg 3 QL (60 EA per 30 days) MOnalbuphine hcl inj 10mg/ml, 20mg/ml

3 MO

NORCO 4 QL (180 EA per 30 days) MONUCYNTA 4 QL (180 EA per 30 days) ST MOOPANA TABS 4 QL (180 EA per 30 days) MO


Drug name Drug tier Requirements/Limitsoxycodone hcl caps 3 QL (180 EA per 30 days) MOoxycodone hcl soln 3 QL (5400 ML per 30 days) MOoxycodone hcl conc 4 QL (180 ML per 30 days) MOoxycodone hcl tabs 30mg 3 QL (120 EA per 30 days) MOoxycodone hcl tabs 10mg, 15mg, 20mg, 5mg


oxycodone/acetaminophen soln 4 QL (1800 ML per 30 days)oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 7.5mg


oxycodone/acetaminophen tabs 325mg; 5mg


oxycodone/aspirin tabs 325mg; 4.835mg


oxycodone/ibuprofen 3 QL (120 EA per 30 days) MOoxymorphone hydrochloride 4 QL (180 EA per 30 days) MOpentazocine/naloxone hcl 4 QL (360 EA per 30 days) PA

MOPERCOCET TABS 325MG; 10MG, 325MG; 2.5MG, 325MG; 5MG, 325MG; 7.5MG


reprexain tabs 10mg; 200mg 4 QL (150 EA per 30 days) MOROXICODONE TABS 30MG 4 QL (120 EA per 30 days) MOROXICODONE TABS 15MG, 5MG 4 QL (180 EA per 30 days) MOtramadol hcl immediate release tabs 50mg


tramadol hydrochloride/acetaminophen


TYLENOL/CODEINE #3 4 QL (180 EA per 30 days) MOULTRACET 4 QL (240 EA per 30 days) MOULTRAM 4 QL (240 EA per 30 days) MOvicodin es tabs 300mg; 7.5mg 4 QL (180 EA per 30 days)vicodin hp tabs 300mg; 10mg 4 QL (180 EA per 30 days)vicodin tabs 300mg; 5mg 4 QL (180 EA per 30 days)XODOL TABS 300MG; 10MG 4 QL (180 EA per 30 days) MOxylon 4 QL (150 EA per 30 days)zamicet 4 QL (5550 ML per 30 days) MO


Drug name Drug tier Requirements/LimitsANESTHETICS

Local Anesthetics lidocaine hcl inj 2% 3lidocaine hcl inj 0.5% 4lidocaine hcl external soln 4% 4 MOlidocaine viscous 4 MOlidocaine/prilocaine crea 4 QL (30 GM per 30 days) PA MOlidocaine ptch 3 QL (90 EA per 30 days) PA MOlidocaine oint 4 QL (36 GM per 30 days) PA MOLIDODERM 4 QL (90 EA per 30 days) PA MOXYLOCAINE INJ 2% 4 MO

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTSAlcohol Deterrents/Anti-craving

acamprosate calcium dr 4 MOANTABUSE 4 MOdisulfiram tabs 4 MOnaltrexone hcl tabs 3 MO

Opioid Dependence Treatments buprenorphine hcl/naloxone hcl 3 QL (90 EA per 30 days) PA MObuprenorphine hcl subl 3 QL (90 EA per 30 days) PA MOSUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG


SUBOXONE FILM 12MG; 3MG 4 QL (60 EA per 30 days) PA MOOpioid Reversal Agents

naloxone hcl inj 0.4mg/ml, 2mg/2ml, 4mg/10ml

3 MO

Smoking Cessation Agents bupropion hcl sr tb12 150mg 3 QL (60 EA per 30 days) MOCHANTIX CONTINUING MONTH PAK

4 PA MO

CHANTIX STARTING MONTH PAK 4 PA MOCHANTIX TABS 0.5MG, 1MG 4 PA MONICOTROL INHALER 4 MONICOTROL NS 4 MOZYBAN 4 QL (60 EA per 30 days) ST MO


Drug name Drug tier Requirements/LimitsANTIBACTERIALS

Aminoglycosides amikacin sulfate inj 1gm/4ml, 500mg/2ml

4 MO

gentamicin sulfate pediatric 4 MOgentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml, 1.2mg/ml, 1.4mg/ml, 1.6mg/ml, 1mg/ml, 2mg/ml

4

gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml

4 MO

gentamicin sulfate inj 10mg/ml 4gentamicin sulfate inj 40mg/ml 4 MOisotonic gentamicin inj 0.8mg/ml; 0.9%

4 MO

neomycin sulfate 2 MOparomomycin sulfate 4 MOstreptomycin sulfate inj 1gm 4 MOtobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml

4

tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml

4 MO

Antibacterials, Other baciim 4bacitracin inj 50000unit 4 MOBACTROBAN NASAL 4 MOchloramphenicol sodium succinate 4CLEOCIN CAPS, 2% VAGINAL CREAM AND 100MG SUPPOSITORY

4 MO

CLEOCIN PHOSPHATE INJ 300MG/2ML, 600MG/4ML IV, 900MG/6ML IV

4

CLEOCIN PHOSPHATE INJ 600MG/4ML, 900MG/6ML

4 MO

clindamycin hcl caps 2 MOclindamycin inj 900mg/60ml 4clindamycin palmitate hcl 75mg/5ml

4 MO


Drug name Drug tier Requirements/Limitsclindamycin phosphate in d5w 4clindamycin phosphate vaginal crea 2%

4 MO

clindamycin phosphate inj 150mg/ml, 300mg/2ml, 9000mg/60ml

4

clindamycin phosphate inj 600mg/4ml, 900mg/6ml

4 MO

CLINDESSE 4 MOcolistimethate sodium 4 PA MOCUBICIN 5CUBICIN RF 5daptomycin 5FLAGYL 4 MOFURADANTIN 4 MOHIPREX 4 MOISOPROPYL ALCOHOL WIPES 3lansoprazole/amoxicillin/clarithromycin


linezolid inj 5 PAlinezolid susr 5 QL (1800 ML per 28 days) PA

MOlinezolid tabs 5 QL (56 EA per 28 days) PA MOMACROBID 4 MOMACRODANTIN 4 MOmethenamine hippurate 4 MOMETROGEL-VAGINAL 4 MOmetronidazole in nacl 0.79% 4metronidazole vaginal 4 MOmetronidazole caps 375mg 3 MOmetronidazole tabs 250mg, 500mg 3 MOMONUROL 4 MOnitrofurantoin macrocrystals 3 MOnitrofurantoin monohydrate 3 MOnitrofurantoin susp 4 MONUVESSA 4 MOPREVPAC 4 QL (224 EA per 365 days) MOSIVEXTRO INJ 5SIVEXTRO TABS 5 MO


Drug name Drug tier Requirements/LimitsSYNERCID INJ 350MG; 150MG 5tigecycline 5tinidazole 4 MOtrimethoprim tabs 1 MOTYGACIL 5VANCOCIN HCL CAPS 125MG 4 QL (120 EA per 30 days) MOVANCOCIN HCL CAPS 250MG 5 MOVANCOMYCIN HCL IN DEXTROSE 4vancomycin hcl caps 125mg 4 QL (120 EA per 30 days) MOvancomycin hcl caps 250mg 5 MOVANCOMYCIN HCL INJ 0.9%; 1GM/200ML

4

vancomycin hcl inj 1000mg, 10gm, 5000mg, 750mg

2

vancomycin hcl inj 500mg 4 MOVANCOMYCIN INJ 0.9%; 500MG/100ML

3

VANCOMYCIN INJ 0.9%; 750MG/150ML

4

VANDAZOLE 4 MOXIFAXAN TABS 200MG 4 QL (9 EA per 3 days) PA MOXIFAXAN TABS 550MG 5 PA MOZYVOX SUSR 5 QL (1800 ML per 28 days) PA

MOZYVOX TABS 5 QL (56 EA per 28 days) PA MOZYVOX INJ 600MG/300ML 5 PA

Beta-lactam, Cephalosporins cefaclor er tb12 500mg 4 MOcefaclor caps 3 MOcefaclor susr 125mg/5ml, 250mg/5ml, 375mg/5ml

3 MO

cefadroxil 2 MOCEFAZOLIN SODIUM/DEXTROSE INJ 1GM; 4%, 2GM; 3%

4

cefazolin sodium inj 100gm, 1gm, 1gm; 5%, 20gm, 300gm

4

cefazolin sodium inj 10gm, 500mg 4 MOCEFAZOLIN INJ 2GM/100ML; 4% 4


Drug name Drug tier Requirements/Limitscefdinir caps 2 MOcefdinir susr 3 MOCEFEPIME/DEXTROSE 4CEFEPIME INJ 1GM/50ML, 2GM/100ML

4

cefepime inj 1gm, 2gm 4 MOcefixime 4 MOcefotaxime sodium inj 10gm, 2gm, 500mg

4

cefotaxime sodium inj 1gm 4 MOcefotetan 4CEFOTETAN/DEXTROSE 4CEFOXITIN SODIUM IN DEXTROSE INJ 1GM, 2GM

4

cefoxitin sodium inj 10gm, 2gm 4cefoxitin sodium inj 1gm 4 MOcefpodoxime proxetil 4 MOcefprozil 3 MOCEFTAZIDIME/DEXTROSE 3ceftazidime inj 6gm 4ceftazidime inj 1gm, 2gm 4 MOCEFTIN SUSR 4 MOceftriaxone in iso-osmotic dextrose 4ceftriaxone sodium inj 100gm, 1gm 4ceftriaxone sodium inj 10gm, 250mg, 2gm, 500mg

4 MO

CEFTRIAXONE/DEXTROSE 4cefuroxime axetil tabs 3 MOcefuroxime sodium inj 1.5gm, 7.5gm

4

cefuroxime sodium inj 750mg 4 MOcephalexin 2 MOFORTAZ INJ 1GM IV, 2GM IV, 500MG, 6GM

4

FORTAZ INJ 1GM, 2GM 4 MOMAXIPIME INJ 1GM, 2GM 4SUPRAX CAPS 3 MOSUPRAX CHEW 100MG 4


Drug name Drug tier Requirements/LimitsSUPRAX CHEW 200MG 4 MOSUPRAX SUSR 500MG/5ML 3SUPRAX SUSR 100MG/5ML, 200MG/5ML

4 MO

tazicef inj 1gm, 2gm, 6gm 4TEFLARO 5

Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE

4

aztreonam inj 1gm 4 MOaztreonam inj 2gm 5 MOimipenem/cilastatin 4 MOINVANZ INJ 1GM 4INVANZ INJ 1GM 4 MOmeropenem vial 4 MOMEROPENEM/SODIUM CHLORIDE

4

Beta-lactam, Penicillins amoxicillin/clavulanate potassium 2 MOamoxicillin/clavulanate potassium er

4 MO

amoxicillin chew 125mg, 250mg 1 MOamoxicillin caps, susr, tabs 1 MOampicillin sodium inj 10gm, 125mg, 1gm iv, 250mg, 2gm iv

4

ampicillin sodium inj 1gm, 2gm, 500mg

4 MO

ampicillin-sulbactam 4ampicillin caps 1 MOampicillin susr 125mg/5ml 2ampicillin susr 250mg/5ml 2 MOAUGMENTIN ES-600 4 MOAUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML, 250MG/5ML; 62.5MG/5ML

4 MO

BICILLIN L-A INJ 1200000UNIT/2ML, 2400000UNIT/4ML, 600000UNIT/ML

4 MO


Drug name Drug tier Requirements/Limitsdicloxacillin sodium 2 MOnafcillin sodium inj 10gm, 1gm, 2gm iv

4

nafcillin sodium inj 2gm 4 MOoxacillin sodium inj 10gm, 1gm 4oxacillin sodium inj 2gm 4 MOpenicillin g potassium inj 20000000unit, 5000000unit

4 MO

penicillin g procaine 4 MOpenicillin g sodium 4penicillin v potassium 1 MOpiperacillin sodium/tazobactam sodium inj 2gm-0.25gm, 3gm-0.375gm, 36gm-4.5gm

4

piperacillin sodium/tazobactam inj 12gm; 1.5gm, 4gm; 0.5gm

4

Macrolides AZITHROMYCIN PACK 3 MOazithromycin susr, tabs 2 MOazithromycin inj 500mg 4 MOBIAXIN TABS 4 MOclarithromycin er 4 MOclarithromycin susr, tabs 3 MODIFICID 5 MOE.E.S. 400 TABS 4 MOE.E.S. GRANULES 4 MOERY-TAB 4 MOERYPED 200 4 MOERYPED 400 4 MOERYTHROCIN LACTOBIONATE INJ 500MG

4

ERYTHROCIN STEARATE TABS 250MG

4 MO

erythromycin base 3 MOerythromycin ethylsuccinate tabs 3 MOerythromycin ethylsuccinate susr 4 MOerythromycin stearate tabs 250mg 3 MOerythromycin caps dr 250mg 3 MO


Drug name Drug tier Requirements/LimitsPCE 4 MOZITHROMAX TRI-PAK 4 MOZITHROMAX Z-PAK 4 MOZITHROMAX INJ, SUSR, TABS 4 MOZMAX 4 MO

Quinolones AVELOX 4 MOAVELOX ABC PACK 4 MOCIPRO I.V.-IN D5W INJ 400MG/200ML; 5%

4

CIPRO SUSR 4 MOciprofloxacin er tb24 1000mg 1 MOciprofloxacin er tb24 500mg 3 MOciprofloxacin hcl tabs 100mg, 250mg, 500mg, 750mg

1 MO

ciprofloxacin i.v.-in d5w inj 200mg/100ml ( 5%)

4

ciprofloxacin i.v.-in d5w inj 400mg/200ml (5%)

4 MO

CIPROFLOXACIN OTIC SOLN 3 MOciprofloxacin susr 3 MOciprofloxacin inj 4 MOCIPRO TABS 250MG, 500MG 4 MOLEVAQUIN TABS 4 MOlevofloxacin in d5w 4levofloxacin inj 25mg/ml 4levofloxacin oral soln 25mg/ml 3 MOlevofloxacin tabs 250mg, 500mg, 750mg

3 MO

moxifloxacin hcl tabs 4 MOofloxacin tabs 400mg 2 MOofloxacin tabs 300mg 4 MO

Sulfonamides BACTRIM DS 4 MOBACTRIM TABS 4 MOsulfadiazine tabs 4 MOsulfamethoxazole/trimethoprim ds 1 MO


Drug name Drug tier Requirements/Limitssulfamethoxazole/trimethoprim tabs

1 MO

sulfamethoxazole/trimethoprim inj, susp

4 MO

SULFATRIM PEDIATRIC 4Tetracyclines

doxy 100 4 MOdoxycycline hyclate dr 4 MOdoxycycline hyclate caps 3 MOdoxycycline hyclate inj 4 MOdoxycycline hyclate tabs 100mg, 20mg

3 MO

doxycycline monohydrate caps 100mg, 50mg

2 MO

doxycycline monohydrate caps 150mg, 75mg

4 MO

doxycycline monohydrate tabs 2 MOdoxycycline susr 25mg/5ml 3 MOMINOCIN CAPS 4 ST MOminocycline hcl er 4 ST MOminocycline hcl caps 2 MOminocycline hcl tabs 4 ST MOmorgidox 1x100mg caps 4morgidox 1x50mg caps 4morgidox 2x100mg caps 4SOLODYN TB24 105MG, 115MG, 55MG, 65MG, 80MG

4 ST MO

tetracycline hydrochloride 4 MOVIBRAMYCIN SUSR 25MG/5ML 4 ST MOVIBRAMYCIN CAPS 100MG 4 ST MO

ANTICONVULSANTSAnticonvulsants, Other

APTIOM TABS 200MG 4 QL (180 EA per 30 days) MOAPTIOM TABS 600MG, 800MG 5 QL (60 EA per 30 days) MOAPTIOM TABS 400MG 5 QL (90 EA per 30 days) MOBRIVIACT INJ 4 PABRIVIACT ORAL SOLN, TABS 5 PA MO


Drug name Drug tier Requirements/LimitsFYCOMPA SUSP 4 QL (720 ML per 30 days) PA

MOFYCOMPA TABS 2MG 4 QL (180 EA per 30 days) PA

MOFYCOMPA TABS 10MG, 12MG, 8MG


FYCOMPA TABS 6MG 4 QL (60 EA per 30 days) PA MOFYCOMPA TABS 4MG 4 QL (90 EA per 30 days) PA MOKEPPRA XR 4 ST MOKEPPRA SOLN, TABS 4 ST MOlevetiracetam er 4 MOlevetiracetam oral soln, tabs 2 MOlevetiracetam inj 10mg/ml, 15mg/ml, 5mg/ml

4

levetiracetam inj 500mg/5ml 4 MOPOTIGA TABS 50MG 4 QL (270 EA per 30 days) MOPOTIGA TABS 200MG 5 QL (180 EA per 30 days) MOPOTIGA TABS 300MG, 400MG 5 QL (90 EA per 30 days) MOroweepra 2SPRITAM 4 MO

Calcium Channel Modifying Agents CELONTIN CAPS 300MG 4 MOethosuximide 4 MOLYRICA SOLN 3 QL (946 ML per 30 days) MOLYRICA CAPS 100MG, 150MG, 25MG, 50MG, 75MG


LYRICA CAPS 225MG, 300MG 3 QL (60 EA per 30 days) MOLYRICA CAPS 200MG 3 QL (90 EA per 30 days) MOZARONTIN 4 MOZONEGRAN CAPS 100MG, 25MG 4 ST MOzonisamide 2 MO

Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 1mg 3 QL (120 EA per 30 days) MOclonazepam odt tbdp 2mg 3 QL (300 EA per 30 days) MOclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg


clonazepam tabs 1mg 1 QL (120 EA per 30 days) MOclonazepam tabs 2mg 1 QL (300 EA per 30 days) MO


Drug name Drug tier Requirements/Limitsclonazepam tabs 0.5mg 1 QL (90 EA per 30 days) MODEPAKENE CAPS 4 MODEPAKOTE 4 MODEPAKOTE ER 4 MODEPAKOTE SPRINKLES 4 MODIASTAT ACUDIAL 4 MODIASTAT PEDIATRIC GEL 2.5MG 4 MOdiazepam gel 10mg, 2.5mg, 20mg 4 MOdivalproex sodium dr 3 MOdivalproex sodium er 4 MOdivalproex sodium sprinkle caps 3 MOgabapentin caps 100mg, 300mg 3 QL (180 EA per 30 days) MOgabapentin caps 400mg 3 QL (270 EA per 30 days) MOgabapentin soln 3 QL (2160 ML per 30 days) MOgabapentin tabs 800mg 3 QL (120 EA per 30 days) MOgabapentin tabs 600mg 3 QL (180 EA per 30 days) MOGABITRIL TABS 12MG, 16MG, 2MG, 4MG

4 MO

KLONOPIN TABS 1MG 4 QL (120 EA per 30 days) MOKLONOPIN TABS 2MG 4 QL (300 EA per 30 days) MOKLONOPIN TABS 0.5MG 4 QL (90 EA per 30 days) MOMYSOLINE TABS 4 MONEURONTIN SOLN 4 QL (2160 ML per 30 days) MONEURONTIN CAPS 100MG, 300MG


NEURONTIN CAPS 400MG 4 QL (270 EA per 30 days) MONEURONTIN TABS 800MG 4 QL (120 EA per 30 days) MONEURONTIN TABS 600MG 4 QL (180 EA per 30 days) MOONFI SUSP 5 PA MOONFI TABS 10MG 4 PA MOONFI TABS 20MG 5 PA MOphenobarbital elix 4 QL (1500 ML per 30 days) PA

MOphenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 64.8mg, 97.2mg


primidone tabs 2 MOSABRIL 5 QL (180 EA per 30 days) PA LA


Drug name Drug tier Requirements/Limitstiagabine hydrochloride 4 MOvalproate sodium inj 3valproic acid caps, soln 2 MO

Glutamate Reducing Agents felbamate 4 MOFELBATOL 5 MOLAMICTAL CHEWABLE DISPERSIBLE

4 ST MO

LAMICTAL ODT TABS 4 ST MOLAMICTAL STARTER BLUE (35) 4 ST MOLAMICTAL STARTER GREEN (98) 4 ST MOLAMICTAL STARTER ORANGE (49) 4 ST MOLAMICTAL XR KIT 4 ST MOLAMICTAL XR TB24 100MG, 200MG, 250MG, 25MG, 50MG

4 ST MO

LAMICTAL XR TB24 300MG 5 ST MOLAMICTAL TABS 4 ST MOlamotrigine er 4 MOlamotrigine odt 4 MOlamotrigine titration 4 MOlamotrigine chew, tabs 2 MOQUDEXY XR 4 ST MOTOPAMAX 4 ST MOTOPAMAX SPRINKLE 4 ST MOtopiramate er 4 MOtopiramate sprinkle caps, tabs 2 MOTROKENDI XR 4 MO

Sodium Channel Agents BANZEL 5 PA MOcarbamazepine er 4 MOcarbamazepine chew, susp, tabs 2 MOCARBATROL 4 MODILANTIN INFATABS 3 MODILANTIN-125 3 MODILANTIN CAPS 3 MOepitol 4fosphenytoin sodium inj 100mg pe/2ml

4


Drug name Drug tier Requirements/Limitsfosphenytoin sodium inj 500mg pe/10ml

4 MO

oxcarbazepine tabs 3 MOoxcarbazepine susp 4 MOOXTELLAR XR 4 ST MOPEGANONE TABS 250MG 4 MOPHENYTEK 3 MOphenytoin sodium extended 3 MOphenytoin sodium inj 4phenytoin chew, susp 3 MOTEGRETOL-XR 4 ST MOTEGRETOL SUSP, TABS 4 ST MOTRILEPTAL 4 ST MOVIMPAT INJ 4VIMPAT ORAL SOLN 4 QL (1200 ML per 30 days) MOVIMPAT TABS 50MG 4 QL (180 EA per 30 days) MOVIMPAT TABS 100MG, 150MG, 200MG


ANTIDEMENTIA AGENTSAntidementia Agents, Other

ergoloid mesylates tabs 3 PA MONAMZARIC 4 PA MO

Cholinesterase Inhibitors ARICEPT TABS 23MG, 5MG 4 QL (30 EA per 30 days) ST MOARICEPT TABS 10MG 4 QL (60 EA per 30 days) ST MOdonepezil hcl odt 2 QL (30 EA per 30 days) MOdonepezil hcl tabs 23mg, 5mg 2 QL (30 EA per 30 days) MOdonepezil hcl tabs 10mg 2 QL (60 EA per 30 days) MOEXELON PT24 4 QL (30 EA per 30 days) ST MOgalantamine hydrobromide er 4 QL (30 EA per 30 days) MOgalantamine hydrobromide soln 4 QL (200 ML per 30 days) MOgalantamine hydrobromide tabs 4 QL (60 EA per 30 days) MORAZADYNE ER 4 QL (30 EA per 30 days) ST MORAZADYNE TABS 4 QL (60 EA per 30 days) ST MOrivastigmine tartrate caps 4 QL (60 EA per 30 days) MOrivastigmine transdermal system 4 QL (30 EA per 30 days) MO


Drug name Drug tier Requirements/LimitsN-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl 3 QL (60 EA per 30 days) PA MOmemantine hcl titration pak 3 QL (98 EA per 365 days) PA

MOmemantine hydrochloride soln 3 QL (360 ML per 30 days) PA

MONAMENDA TITRATION PAK 4 QL (98 EA per 365 days) PA

MONAMENDA XR 4 PA MONAMENDA XR TITRATION PACK 4 PA MONAMENDA SOLN 4 QL (360 ML per 30 days) PA

MONAMENDA TABS 4 QL (60 EA per 30 days) PA MO

ANTIDEPRESSANTSAntidepressants, Other

bupropion hcl sr tb12 100mg, 150mg, 200mg


bupropion hcl xl 3 QL (30 EA per 30 days) MObupropion hcl tabs 3 QL (180 EA per 30 days) MOFORFIVO XL 4 QL (30 EA per 30 days) ST MOmirtazapine odt 3 QL (30 EA per 30 days) MOmirtazapine tabs 7.5mg 2 MOmirtazapine tabs 15mg, 30mg, 45mg


REMERON 4 QL (30 EA per 30 days) MOREMERON SOLTAB 4 QL (30 EA per 30 days) MOTRINTELLIX TABS 5MG 4 QL (120 EA per 30 days) ST MOTRINTELLIX TABS 20MG 4 QL (30 EA per 30 days) ST MOTRINTELLIX TABS 10MG 4 QL (60 EA per 30 days) ST MOWELLBUTRIN SR 4 QL (60 EA per 30 days) ST MOWELLBUTRIN XL 4 QL (30 EA per 30 days) ST MO

Monoamine Oxidase Inhibitors EMSAM 5 QL (30 EA per 30 days) PA MOMARPLAN 4 QL (180 EA per 30 days) MOphenelzine sulfate 3 MOtranylcypromine sulfate 4 MO


Drug name Drug tier Requirements/LimitsSSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor

CELEXA TABS 10MG 4 QL (120 EA per 30 days) ST MOCELEXA TABS 40MG 4 QL (30 EA per 30 days) ST MOCELEXA TABS 20MG 4 QL (60 EA per 30 days) ST MOcitalopram hydrobromide soln 3 QL (600 ML per 30 days) MOcitalopram hydrobromide tabs 10mg


citalopram hydrobromide tabs 40mg


citalopram hydrobromide tabs 20mg


CYMBALTA CPEP 20MG, 60MG 4 QL (60 EA per 30 days) ST MOCYMBALTA CPEP 30MG 4 QL (90 EA per 30 days) ST MODESVENLAFAXINE ER TB24 (GENERIC KHEDEZLA) 100MG, 50MG


desvenlafaxine er tb24 (generic Pristiq) 25mg


duloxetine hcl cpep 20mg, 40mg, 60mg


duloxetine hcl cpep 30mg 3 QL (90 EA per 30 days) MOEFFEXOR XR CP24 37.5MG, 75MG 4 QL (30 EA per 30 days) ST MOEFFEXOR XR CP24 150MG 4 QL (60 EA per 30 days) ST MOescitalopram oxalate soln 3 QL (600 ML per 30 days) MOescitalopram oxalate tabs 20mg 3 QL (30 EA per 30 days) MOescitalopram oxalate tabs 10mg, 5mg


FETZIMA TITRATION PACK 4 ST MOFETZIMA CP24 20MG 4 QL (180 EA per 30 days) ST MOFETZIMA CP24 120MG, 80MG 4 QL (30 EA per 30 days) ST MOFETZIMA CP24 40MG 4 QL (90 EA per 30 days) ST MOfluoxetine dr caps 90mg 4 QL (4 EA per 28 days) MOfluoxetine hcl caps 20mg 2 QL (120 EA per 30 days) MOfluoxetine hcl caps 10mg 2 QL (30 EA per 30 days) MOfluoxetine hcl caps 40mg 2 QL (60 EA per 30 days) MOfluoxetine hcl soln 2 MOFLUOXETINE HCL TABS 60MG 3 MO


Drug name Drug tier Requirements/Limitsfluoxetine hcl tabs (generic Prozac) 10mg, 20mg

2 MO

fluvoxamine maleate er caps 4 QL (60 EA per 30 days) MOfluvoxamine maleate tabs 2 MOLEXAPRO SOLN 4 QL (600 ML per 30 days) ST

MOLEXAPRO TABS 20MG 4 QL (30 EA per 30 days) ST MOLEXAPRO TABS 10MG, 5MG 4 QL (45 EA per 30 days) ST MOmaprotiline hcl 4 MOnefazodone hcl 4 MOolanzapine/fluoxetine 4 QL (30 EA per 30 days) MOparoxetine hcl er tb24 37.5mg 4 QL (60 EA per 30 days) MOparoxetine hcl er tb24 12.5mg, 25mg


paroxetine hcl tabs 10mg, 20mg 2 QL (30 EA per 30 days) MOparoxetine hcl tabs 30mg, 40mg 2 QL (60 EA per 30 days) MOPAXIL CR TB24 37.5MG 4 QL (60 EA per 30 days) ST MOPAXIL CR TB24 12.5MG, 25MG 4 QL (90 EA per 30 days) ST MOPAXIL SUSP 4 QL (900 ML per 30 days) MOPAXIL TABS 10MG, 20MG 4 QL (30 EA per 30 days) ST MOPAXIL TABS 30MG, 40MG 4 QL (60 EA per 30 days) ST MOPRISTIQ TB24 100MG, 50MG 3 QL (30 EA per 30 days) MOPRISTIQ TB24 25MG 3 QL (30 EA per 30 days) ST MOPROZAC WEEKLY 4 QL (4 EA per 28 days) ST MOPROZAC CAPS 20MG 4 QL (120 EA per 30 days) ST MOPROZAC CAPS 10MG 4 QL (30 EA per 30 days) ST MOPROZAC CAPS 40MG 4 QL (60 EA per 30 days) ST MOsertraline hcl conc 3 QL (300 ML per 30 days) MOsertraline hcl tabs 25mg 1 QL (30 EA per 30 days) MOsertraline hcl tabs 100mg, 50mg 1 QL (60 EA per 30 days) MOSYMBYAX 4 QL (30 EA per 30 days) ST MOtrazodone hcl tabs 2 MOvenlafaxine hcl er cp24 37.5mg, 75mg


venlafaxine hcl er cp24 150mg 3 QL (60 EA per 30 days) MOvenlafaxine hcl er tb24 225mg, 37.5mg, 75mg


venlafaxine hcl er tb24 150mg 3 QL (60 EA per 30 days) MO


Drug name Drug tier Requirements/Limitsvenlafaxine hcl tabs 3 MOVIIBRYD STARTER PACK 4 MOVIIBRYD TABS 4 QL (30 EA per 30 days) MOZOLOFT CONC 4 QL (300 ML per 30 days) ST

MOZOLOFT TABS 25MG 4 QL (30 EA per 30 days) ST MOZOLOFT TABS 100MG, 50MG 4 QL (60 EA per 30 days) ST MO

Tricyclics amitriptyline hcl tabs 3 PA MOamoxapine 3 MOANAFRANIL 4 PA MOchlordiazepoxide/amitriptyline 4 PA MOclomipramine hcl caps 4 PA MOdesipramine hcl tabs 4 MOdoxepin hcl caps, conc 3 PA MOELAVIL TABS 25MG 4 PA MOimipramine hcl tabs 2 PA MOimipramine pamoate caps 4 PA MONORPRAMIN TABS 10MG, 25MG 4 MOnortriptyline hcl caps, soln 2 MOPAMELOR CAPS 4 MOperphenazine/amitriptyline 4 PA MOprotriptyline hcl 4 MOTOFRANIL TABS 4 PA MOtrimipramine maleate caps 4 PA MO

ANTIEMETICSAntiemetics, Other

meclizine hcl tabs 2 MOphenadoz supp 25mg 4 PAphenadoz supp 12.5mg 4 PA MOphenergan supp 12.5mg, 25mg, 50mg

4 PA

promethazine hcl supp 12.5mg, 25mg, 50mg

4 PA MO

promethegan supp 12.5mg, 25mg 4 PApromethegan supp 50mg 4 PA MOTIGAN INJ 4 PA MOTIGAN CAPS 300MG 4 PA MO


Drug name Drug tier Requirements/LimitsTRANSDERM-SCOP 4 QL (10 EA per 30 days) PA MOtrimethobenzamide hcl caps 300mg

4 PA MO

Emetogenic Therapy Adjuncts aprepitant 4 B/D MOdronabinol 4 QL (60 EA per 30 days) PA MOEMEND TRIPACK 4 B/D MOEMEND SUSR 4 B/DEMEND CAPS 4 B/D MOEMEND INJ 4 MOgranisetron hcl tabs 3 QL (60 EA per 30 days) B/D MOMARINOL CAPS 2.5MG 4 QL (60 EA per 30 days) PA MOMARINOL CAPS 10MG, 5MG 5 QL (60 EA per 30 days) PA MOondansetron hcl tabs 2 B/D MOondansetron hcl oral soln 3 QL (900 ML per 30 days) B/D

MOondansetron hcl inj 40mg/20ml, 4mg/2ml

4 MO

ondansetron odt 2 B/D MOSANCUSO 5 QL (4 EA per 28 days) MOZOFRAN ODT 4 B/D MOZOFRAN SOLN 4 QL (900 ML per 30 days) B/D

MOZOFRAN TABS 4MG, 8MG 4 B/D MO

ANTIFUNGALSAntifungals

ABELCET 5 B/DAMBISOME 4 B/Damphotericin b inj 4 B/D MOCANCIDAS INJ 50MG 5CANCIDAS INJ 70MG 5 MOciclodan 3ciclopirox nail lacquer 3 MOciclopirox olamine crea 3 MOciclopirox gel, sham, susp 3 MOclotrimazole/betamethasone dipropionate

4 MO

clotrimazole crea, lozg, soln 3 MO


Drug name Drug tier Requirements/LimitsDIFLUCAN 4 MOeconazole nitrate crea 4 MOERTACZO 4 MOEXTINA 4 MOfluconazole in dextrose inj 4fluconazole in nacl inj 4fluconazole tabs 2 MOfluconazole susr 3 MOflucytosine caps 5 MOgriseofulvin microsize 4 MOgriseofulvin ultramicrosize tabs 125mg, 250mg

4 MO

itraconazole caps 4 PA MOketoconazole sham, tabs 2 MOketoconazole crea 3 MOketoconazole foam 4 MOLAMISIL TABS 4 ST MOLOPROX SHAMPOO 4 MOLOPROX CREA 4 MOLOTRISONE 4 MOmiconazole 3 supp 4 MOMYCAMINE 5 MOnaftifine hcl 1% cream 4 MOnaftifine hcl 2% cream 4 MONAFTIN GEL 4 MONAFTIN CREA 2% 4 MONIZORAL SHAM 4 MONOXAFIL SUSP, DR TAB 5 MOnyamyc 3nyata powd 3nystatin/triamcinolone 4 MOnystatin crea 2 MOnystatin powd 3 MOnystatin oint, susp, tabs 4 MOnystop 3 MOONMEL 5 PA MOORAVIG 4 MO


Drug name Drug tier Requirements/Limitsoxiconazole nitrate 4 MOOXISTAT 4 MOSPORANOX PULSEPAK 4 PA MOSPORANOX CAPS 4 PA MOSPORANOX SOLN 5 PA MOTERAZOL 7 4 MOterbinafine hcl tabs 2 MOterconazole crea 3 MOterconazole supp 4 MOvoriconazole inj 4voriconazole susr, tabs 4 MOzazole supp 4

ANTIGOUT AGENTSAntigout Agents

allopurinol tabs 1 MOcolchicine caps 3 MOcolchicine tabs 0.6mg 3 QL (120 EA per 30 days) MOCOLCRYS 3 QL (120 EA per 30 days) MOMITIGARE 4 MOprobenecid/colchicine 3 MOprobenecid tabs 3 MOULORIC 3 ST MOZYLOPRIM 4 MO

ANTIMIGRAINE AGENTSErgot Alkaloids

CAFERGOT TABS 4 MOdihydroergotamine mesylate inj 4 MOdihydroergotamine mesylate nasal soln


ergotamine tartrate/caffeine 4 MOMIGRANAL 4 QL (8 ML per 28 days) MO

Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate 4 QL (8 EA per 30 days) MOAMERGE 4 QL (9 EA per 30 days) ST MOAXERT 4 QL (8 EA per 30 days) ST MOFROVA 5 QL (12 EA per 30 days) ST MOfrovatriptan succinate 4 QL (12 EA per 30 days) MO


Drug name Drug tier Requirements/LimitsIMITREX STATDOSE REFILL 4 QL (4 ML per 30 days) ST MOIMITREX STATDOSE SYSTEM 4 QL (4 ML per 30 days) ST MOIMITREX NASAL SOLN 4 QL (12 EA per 30 days) ST MOIMITREX INJ 4 QL (4 ML per 30 days) ST MOIMITREX TABS 4 QL (9 EA per 30 days) ST MOMAXALT 4 QL (12 EA per 30 days) ST MOMAXALT-MLT 4 QL (12 EA per 30 days) ST MOnaratriptan hcl 3 QL (9 EA per 30 days) MOONZETRA XSAIL 4 QL (16 EA per 30 days) ST MORELPAX 3 QL (12 EA per 30 days) MOrizatriptan benzoate odt 3 QL (12 EA per 30 days) MOrizatriptan benzoate tabs 3 QL (12 EA per 30 days) MOsumatriptan succinate refill inj 6mg/0.5ml

4 QL (4 ML per 30 days)

sumatriptan succinate refill inj 4mg/0.5ml


sumatriptan succinate tabs 2 QL (9 EA per 30 days) MOsumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml


sumatriptan soln 2 QL (12 EA per 30 days) MOSUMAVEL DOSEPRO 5 QL (4 ML per 30 days) ST MOTREXIMET TABS 500MG; 85MG 4 QL (9 EA per 30 days) ST MOZEMBRACE SYMTOUCH 4 QL (8 ML per 30 days) ST MOzolmitriptan odt 4 QL (6 EA per 30 days) MOzolmitriptan tabs 4 QL (6 EA per 30 days) MOZOMIG SOLN 4 QL (12 EA per 30 days) ST MOZOMIG TABS 4 QL (6 EA per 30 days) ST MO

ANTIMYASTHENIC AGENTSParasympathomimetics

GUANIDINE HCL 4MESTINON TIMESPAN 4 MOMESTINON SYRP, TABS 4 MOpyridostigmine bromide er 3 MOpyridostigmine bromide tabs 3 MO

ANTIMYCOBACTERIALSAntimycobacterials, Other

dapsone tabs 3 MOrifabutin 4 MO


Drug name Drug tier Requirements/LimitsAntituberculars

CAPASTAT SULFATE 4cycloserine 5 MOethambutol hcl tabs 4 MOisoniazid tabs 1 MOisoniazid syrp 2 MOisoniazid inj 4MYAMBUTOL 4 MOPASER 3 MOPRIFTIN 4 MOpyrazinamide tabs 4 MORIFADIN INJ 5RIFADIN CAPS 150MG 4 MOrifampin caps 3 MOrifampin inj 4 MORIFATER 4 MOSIRTURO 5 PA LATRECATOR 4 MO

ANTINEOPLASTICSAlkylating Agents

ALKERAN TABS 4 B/D MOALKERAN INJ 5 B/DBENDEKA 5busulfan 5 B/DBUSULFEX 5 B/Dcyclophosphamide inj 4cyclophosphamide caps 4 B/D MOEVOMELA 5 B/DGLEOSTINE 4HEXALEN 5 MOKISQALI 200MG FEMARA CO-PACK


KISQALI 400MG FEMARA CO-PACK


KISQALI 600MG FEMARA CO-PACK


LEUKERAN 4 MOMATULANE 5 LA


Drug name Drug tier Requirements/Limitsmelphalan hydrochloride 5 B/DMUSTARGEN 5 B/DTEMODAR INJ 5 B/Dthiotepa inj 15mg 5TREANDA INJ 100MG, 25MG 5 B/DVALCHLOR 5 PA LAYONDELIS 5 PA

Antiandrogens bicalutamide 3 MOCASODEX 4 MOflutamide 4 MOnilutamide 5 MOXTANDI 5 PA LAZYTIGA TABS 250MG 5 PA LA

Antiangiogenic Agents POMALYST 5 PA LAREVLIMID 5 PA LATHALOMID 5 PA

Antiestrogens/Modifiers EMCYT 4 MOFARESTON 5 MOSOLTAMOX 4 MOtamoxifen citrate tabs 2 MO

Antimetabolites clofarabine 5DEPOCYT 4DROXIA 3 MOfluorouracil inj 1gm/20ml, 5gm/100ml

3 B/D

HYDREA 4 MOhydroxyurea caps 2 MOmercaptopurine tabs 4 MOPURIXAN 5TABLOID 4 MO

Antineoplastics, Other ABRAXANE 5 B/Dadrucil 3 B/D


Drug name Drug tier Requirements/LimitsALIMTA 5 B/DARRANON 5AVASTIN 5 PA LABICNU 5 B/DBLEO 15K 5 B/Dbleomycin sulfate 4 B/Dcarboplatin 3cisplatin 3cladribine 4 B/DCLOLAR 5COSMEGEN 5cytarabine aqueous 4 B/Ddacarbazine 4daunorubicin hcl inj 5mg/ml 4decitabine 4dexrazoxane 4docetaxel inj 20mg/ml 4 B/Ddocetaxel liposomal inj 160mg/16ml, 20mg/2ml, 80mg/8ml

5

docetaxel inj 160mg/8ml, 80mg/4ml

5 B/D

doxorubicin hcl liposome 4doxorubicin hcl inj 10mg, 2mg/ml, 50mg

4 B/D

epirubicin hcl inj 200mg/100ml, 50mg/25ml

4

ERBITUX 5 PAERWINAZE 5 PAFASLODEX 5 B/Dfludarabine phosphate 4fluorouracil inj 2.5gm/50ml 3 B/DFOLOTYN 5FUSILEV 5 B/Dgemcitabine inj 2gm/52.6ml 4gemcitabine inj 1gm/26.3ml, 200mg/5.26ml

5

HALAVEN 5 PAHERCEPTIN 5 PA


Drug name Drug tier Requirements/Limitsidarubicin hcl 4IFOSFAMIDE INJ 3GM 4ifosfamide inj 1gm/20ml, 1gm, 3gm/60ml

4

INTRON A W/DILUENT INJ 10MU 5 B/DINTRON A INJ 10MU/ML, 18MU 5 B/Dirinotecan 4ISTODAX (OVERFILL) 5 B/DIXEMPRA KIT 5 PAKADCYLA 5 B/DKISQALI 5 PAleucovorin calcium tabs 3 MOleucovorin calcium inj 100mg, 200mg, 350mg, 500mg, 50mg

4

levoleucovorin calcium inj 175mg/17.5ml (10mg/ml)

5 B/D

LEVOLEUCOVORIN INJ 175MG 4 B/Dlevoleucovorin inj 50mg 4 B/Dlevoleucovorin inj 250mg/25ml 5 B/DLONSURF 5 PAMARQIBO 5 PAmitomycin inj 20mg, 5mg 4mitomycin inj 40mg 5mitoxantrone hcl inj 2mg/ml 3NINLARO 5 PANIPENT 5 B/DONCASPAR 5ONIVYDE 5 PAoxaliplatin 4paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml, 30mg/5ml

4

PERJETA 5 PA LAPORTRAZZA 5 PAPROLEUKIN 5 B/DRUBRACA TABS 200MG, 300MG 5 QL (120 EA per 30 days) PARYDAPT 5 PASYNRIBO 5 PA


Drug name Drug tier Requirements/LimitsTAXOTERE INJ 80MG/4ML 5 B/DTHERACYS INJ 81MG/VIAL 4TICE BCG 4TRISENOX 5 B/DUVADEX 4VALSTAR 5VECTIBIX 5 PAVELCADE 5 PAvinblastine sulfate inj 1mg/ml 4 B/Dvincasar pfs 4 B/Dvincristine sulfate 4 B/Dvinorelbine tartrate 4YERVOY 5 PAZALTRAP INJ 100MG/4ML 5 PAZALTRAP INJ 200MG/8ML 5 PA LAZANOSAR 4ZEJULA 5 QL (90 EA per 30 days) PAZOLINZA 5 PA

Aromatase Inhibitors, 3rd Generation anastrozole tabs 2 MOARIMIDEX 4 MOAROMASIN 4 MOexemestane 4 MOFEMARA 4 MOletrozole 2 MO

Enzyme Inhibitors etoposide inj 100mg/5ml, 1gm/50ml, 500mg/25ml

3

KYPROLIS 5 PAtoposar inj 100mg/5ml, 1gm/50ml, 500mg/25ml

3

topotecan hcl 5Molecular Target Inhibitors

AFINITOR 5 PAAFINITOR DISPERZ 5 PAALECENSA 5 PA LAALUNBRIG 5 PA


Drug name Drug tier Requirements/LimitsBELEODAQ 5 PABOSULIF 5 PACABOMETYX 5 PA LACAPRELSA 5 PA LACOMETRIQ 5 PA LACOTELLIC 5 PA LACYRAMZA 5 PAERIVEDGE 5 PA LAFARYDAK 5 PA LAGILOTRIF 5 PA LAGLEEVEC TABS 400MG 5 QL (60 EA per 30 days) PAGLEEVEC TABS 100MG 5 QL (90 EA per 30 days) PAIBRANCE 5 PA LAICLUSIG 5 PA LAimatinib mesylate tabs 400mg 5 QL (60 EA per 30 days) PAimatinib mesylate tabs 100mg 5 QL (90 EA per 30 days) PAIMBRUVICA 5 PA LAINLYTA 5 PA LAIRESSA 5 PA LA MOJAKAFI 5 PA LAJEVTANA 5 PALENVIMA 10 MG DAILY DOSE 5 PA LALENVIMA 14 MG DAILY DOSE 5 PA LALENVIMA 18 MG DAILY DOSE 5 PA LALENVIMA 20 MG DAILY DOSE 5 PA LALENVIMA 24 MG DAILY DOSE 5 PA LALENVIMA 8 MG DAILY DOSE 5 PA LALYNPARZA 5 PA LAMEKINIST 5 PA LANEXAVAR 5 PA LAODOMZO 5 PA LASPRYCEL 5 PASTIVARGA 5 PA LASUTENT 5 PATAFINLAR 5 PA LATAGRISSO 5 PA LATARCEVA 5 PA LA


Drug name Drug tier Requirements/LimitsTASIGNA 5 PATORISEL 5TYKERB 5 PA LAVENCLEXTA STARTING PACK 5 PA LAVENCLEXTA TABS 10MG, 50MG 4 PA LAVENCLEXTA TABS 100MG 5 PA LAVOTRIENT 5 PA LAXALKORI 5 PA LAZELBORAF 5 PA LAZYDELIG 5 PA LAZYKADIA 5 PA LA

Monoclonal Antibody/Antibody-Drug Conjugate ARZERRA INJ 1000MG/50ML 5 PAARZERRA INJ 100MG/5ML 5 PA LABAVENCIO 5 PABLINCYTO 5 PA LADARZALEX 5 PAEMPLICITI 5 PAGAZYVA 5 PA LAIMFINZI 5 PAKEYTRUDA 5 PALARTRUVO INJ 500MG/50ML 5 PAOPDIVO 5 PA LARITUXAN INJ 100MG/10ML 5 PARITUXAN INJ 500MG/50ML 5 PA LATECENTRIQ 5 PA LA

Retinoids bexarotene 5 PAPANRETIN 5 MOTARGRETIN GEL 5 PAtretinoin caps 10mg 5 MO

Treatment Adjuncts ELITEK 5 B/Dmesna 4MESNEX TABS 5 MO


Drug name Drug tier Requirements/LimitsANTIPARASITICS

Anthelmintics ALBENZA 5 MOBILTRICIDE 3 MOEMVERM 4 MOivermectin tabs 3 MOSTROMECTOL TABS 3MG 4 MO

Antiprotozoals ALINIA 4 MOatovaquone 4 PA MOatovaquone/proguanil hcl 4 MOchloroquine phosphate tabs 2 MOCOARTEM 4 MOhydroxychloroquine sulfate tabs 3 MOmefloquine hcl 3 MOMEPRON SUSP 5 PA MONEBUPENT 4 B/D MOPENTAM 300 4 MOPLAQUENIL 4 MOprimaquine phosphate tabs 3 MOQUALAQUIN 4 PA MOquinine sulfate caps 324mg 4 PA MO

Pediculicides/Scabicides ELIMITE 4 MOEURAX 4 MOlindane sham 3 MOmalathion 4 MOOVIDE 4 MOpermethrin crea 4 MO

ANTIPARKINSON AGENTSAnticholinergics

benztropine mesylate inj, tabs 2 PA MOCOGENTIN INJ 4 PAtrihexyphenidyl hcl 2 PA MO

Antiparkinson Agents, Other amantadine hcl tabs 3 MOamantadine hcl caps, syrp 4 MO


Drug name Drug tier Requirements/LimitsCOMTAN 4 MOentacapone 4 MO

Dopamine Agonists APOKYN INJ 5 PA LAbromocriptine mesylate caps, tabs 4 MOMIRAPEX 4 ST MOMIRAPEX ER 4 QL (30 EA per 30 days) ST MONEUPRO 4 MOpramipexole dihydrochloride er 4 QL (30 EA per 30 days) MOpramipexole dihydrochloride immediate release tabs

2 MO

REQUIP XL TB24 6MG 4 QL (120 EA per 30 days) MOREQUIP XL TB24 4MG 4 QL (150 EA per 30 days) MOREQUIP XL TB24 2MG 4 QL (30 EA per 30 days) MOREQUIP XL TB24 12MG 4 QL (60 EA per 30 days) MOREQUIP XL TB24 8MG 4 QL (90 EA per 30 days) MOREQUIP TABS 4 MOropinirole er tb24 6mg 4 QL (120 EA per 30 days) MOropinirole er tb24 4mg 4 QL (150 EA per 30 days) MOropinirole er tb24 2mg 4 QL (30 EA per 30 days) MOropinirole er tb24 12mg 4 QL (60 EA per 30 days) MOropinirole er tb24 8mg 4 QL (90 EA per 30 days) MOropinirole hcl immediate release tabs

2 MO

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa er 4 MOcarbidopa/levodopa odt 3 MOcarbidopa/levodopa tabs 2 MOcarbidopa/levodopa/entacapone 4 MOcarbidopa tabs 5 MODUOPA 5 B/DLODOSYN 5 MORYTARY 4 MOSINEMET 4 MOSINEMET CR 4 MOSTALEVO 100 5 ST MOSTALEVO 150 5 ST MO


Drug name Drug tier Requirements/LimitsSTALEVO 200 5 ST MOSTALEVO 50 4 ST MO

Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 3 MOELDEPRYL CAPS 4 MOrasagiline mesylate tabs 4 MOselegiline hcl caps, tabs 2 MOZELAPAR 4 QL (60 EA per 30 days) MO

ANTIPSYCHOTICS1st Generation/Typical

chlorpromazine hcl tabs 4 MOchlorpromazine hcl inj 50mg/2ml 4chlorpromazine hcl inj 25mg/ml 4 MOcompro 2 MOfluphenazine decanoate inj 4 MOfluphenazine hcl conc, elix, tabs 2 MOfluphenazine hcl inj 4 MOHALDOL DECANOATE 100 INJ 4 MOHALDOL DECANOATE 50 INJ 4 MOHALDOL INJ 4 MOhaloperidol decanoate inj 4 MOhaloperidol lactate inj 4 MOhaloperidol conc, tabs 3 MOloxapine succinate caps 3 MOmolindone hydrochloride tabs 25mg


molindone hydrochloride tabs 10mg


molindone hydrochloride tabs 5mg 3 QL (90 EA per 30 days) MOperphenazine tabs 4 MOpimozide 4 MOprochlorperazine edisylate inj 4 MOprochlorperazine maleate tabs 2 MOprochlorperazine supp 25mg 2 MOthioridazine hcl tabs 100mg, 10mg, 25mg, 50mg

3 PA MO

thiothixene caps 10mg, 1mg, 2mg, 5mg

4 MO


Drug name Drug tier Requirements/Limitstrifluoperazine hcl tabs 4 MO

2nd Generation/Atypical ABILIFY MAINTENA 5 QL (1 EA per 28 days) MOaripiprazole odt 5 QL (60 EA per 30 days) MOaripiprazole tabs 4 QL (30 EA per 30 days) MOaripiprazole soln 4 QL (900 ML per 30 days) MOARISTADA INJ 441MG/1.6ML 5 QL (1.6 ML per 28 days)ARISTADA INJ 662MG/2.4ML 5 QL (2.4 ML per 28 days)ARISTADA INJ 882MG/3.2ML 5 QL (3.2 ML per 28 days)ARISTADA INJ 1064MG/3.9ML 5 QL (3.9 ML per 28 days)FANAPT TITRATION PACK 4 STFANAPT TABS 1MG, 2MG, 4MG 4 QL (60 EA per 30 days) ST MOFANAPT TABS 10MG, 12MG, 6MG, 8MG


GEODON INJ 4 QL (6 EA per 3 days) MOGEODON CAPS 4 QL (60 EA per 30 days) ST MOINVEGA SUSTENNA INJ 39MG/0.25ML

4 QL (0.25 ML per 28 days) MO

INVEGA SUSTENNA INJ 78MG/0.5ML




INVEGA SUSTENNA INJ 156MG/ML




INVEGA TRINZA INJ 273MG/0.875ML

5 QL (0.88 ML per 90 days)







INVEGA TB24 1.5MG, 3MG, 9MG 4 QL (30 EA per 30 days) ST MOINVEGA TB24 6MG 4 QL (60 EA per 30 days) ST MOLATUDA TABS 20MG 4 QL (240 EA per 30 days) MOLATUDA TABS 120MG, 40MG 4 QL (30 EA per 30 days) MOLATUDA TABS 60MG, 80MG 4 QL (60 EA per 30 days) MO


Drug name Drug tier Requirements/LimitsNUPLAZID 5 QL (60 EA per 30 days) PA LAolanzapine odt 4 QL (30 EA per 30 days) MOolanzapine inj 4 MOolanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg


olanzapine tabs 2.5mg 3 QL (60 EA per 30 days) MOpaliperidone er tb24 1.5mg, 3mg, 9mg


paliperidone er tb24 6mg 5 QL (60 EA per 30 days) MOquetiapine fumarate er tb24 50mg 3 QL (180 EA per 30 days) MOquetiapine fumarate er tb24 150mg, 200mg


quetiapine fumarate er tb24 300mg, 400mg


quetiapine fumarate tabs 200mg 3 QL (120 EA per 30 days) MOquetiapine fumarate tabs 25mg 3 QL (180 EA per 30 days) MOquetiapine fumarate tabs 300mg, 400mg


quetiapine fumarate tabs 100mg, 50mg


REXULTI TABS 0.5MG 5 QL (180 EA per 30 days) MOREXULTI TABS 3MG, 4MG 5 QL (30 EA per 30 days) MOREXULTI TABS 0.25MG 5 QL (360 EA per 30 days) MOREXULTI TABS 2MG 5 QL (60 EA per 30 days) MOREXULTI TABS 1MG 5 QL (90 EA per 30 days) MORISPERDAL CONSTA INJ 12.5MG, 25MG


RISPERDAL CONSTA INJ 37.5MG, 50MG


RISPERDAL M-TAB TBDP 4MG 4 QL (120 EA per 30 days) MORISPERDAL M-TAB TBDP 1MG, 2MG


RISPERDAL M-TAB TBDP 0.5MG, 3MG


RISPERDAL SOLN 4 MORISPERDAL TABS 4MG 4 QL (120 EA per 30 days) MORISPERDAL TABS 1MG, 2MG 4 QL (60 EA per 30 days) MORISPERDAL TABS 0.25MG, 0.5MG, 3MG



Drug name Drug tier Requirements/Limitsrisperidone odt tbdp 4mg 4 QL (120 EA per 30 days) MOrisperidone odt tbdp 1mg, 2mg 4 QL (60 EA per 30 days) MOrisperidone odt tbdp 0.25mg, 0.5mg, 3mg


risperidone soln 2 MOrisperidone tabs 4mg 2 QL (120 EA per 30 days) MOrisperidone tabs 1mg, 2mg 2 QL (60 EA per 30 days) MOrisperidone tabs 0.25mg, 0.5mg, 3mg


SAPHRIS SUBL 5MG 4 QL (120 EA per 30 days) MOSAPHRIS SUBL 2.5MG 4 QL (240 EA per 30 days) MOSAPHRIS SUBL 10MG 4 QL (60 EA per 30 days) MOVRAYLAR CPPK 4 PA MOVRAYLAR CAPS 1.5MG 5 QL (120 EA per 30 days) PA

MOVRAYLAR CAPS 4.5MG, 6MG 5 QL (30 EA per 30 days) PA MOVRAYLAR CAPS 3MG 5 QL (60 EA per 30 days) PA MOziprasidone hcl 3 QL (60 EA per 30 days) MOZYPREXA RELPREVV INJ 210MG 4 QL (2 EA per 28 days) PAZYPREXA RELPREVV INJ 405MG 5 QL (1 EA per 28 days) PAZYPREXA RELPREVV INJ 300MG 5 QL (2 EA per 28 days) PAZYPREXA ZYDIS 4 QL (30 EA per 30 days) ST MOZYPREXA INJ 4 MOZYPREXA TABS 10MG, 15MG, 20MG, 5MG, 7.5MG


ZYPREXA TABS 2.5MG 4 QL (60 EA per 30 days) ST MOTreatment-Resistant

clozapine odt 4clozapine tabs 100mg, 200mg, 25mg, 50mg

3

CLOZARIL 4 STFAZACLO 4 STVERSACLOZ 5 QL (600 ML per 30 days) PA

ANTISPASTICITY AGENTSAntispasticity Agents

baclofen tabs 2 MOdantrolene sodium caps 4 MO


Drug name Drug tier Requirements/LimitsGABLOFEN INJ 10000MCG/20ML, 40000MCG/20ML, 50MCG/ML

4 B/D

LIORESAL INTRATHECAL 4 B/Dtizanidine hcl tabs 2 MOtizanidine hcl caps 4 MOZANAFLEX CAPS 4 MOZANAFLEX TABS 4MG 4 MO

ANTIVIRALSAnti-cytomegalovirus (CMV) Agents

ganciclovir inj 500mg 3 B/DVALCYTE 5 MOvalganciclovir hydrochloride soln 5 MOvalganciclovir tabs 5 MO

Anti-hepatitis B (HBV) Agents adefovir dipivoxil 4 QL (30 EA per 30 days) MOBARACLUDE SOLN 5 MOentecavir 4 QL (30 EA per 30 days) MOEPIVIR HBV 4 MOlamivudine tabs 100mg 3 MO

Anti-hepatitis C (HCV) Agents, Direct Acting Agents EPCLUSA 5 QL (28 EA per 28 days) PAHARVONI 5 QL (30 EA per 30 days) PASOVALDI 5 QL (28 EA per 28 days) PA

Anti-hepatitis C (HCV) Agents, Other COPEGUS 5INTRON A INJ 50MU, 6000000UNIT/ML

5 B/D

moderiba tabs 200mg 3PEGASYS 5 PAPEGASYS PROCLICK 5 PAREBETOL SOLN 5RIBASPHERE RIBAPAK 4ribasphere caps 3RIBASPHERE TABS 400MG, 600MG

4

ribasphere tabs 200mg 3ribavirin caps 200mg 3ribavirin tabs 200mg 3


Drug name Drug tier Requirements/LimitsSYLATRON 5 PA

Anti-HIV Agents, Integrase Inhibitors (INSTI) ATRIPLA 5 MOGENVOYA 5 MOISENTRESS PACK 5ISENTRESS TABS 5 MOISENTRESS CHEW 25MG 3 MOISENTRESS CHEW 100MG 5 MOTIVICAY TABS 10MG 3 MOTIVICAY TABS 25MG, 50MG 5 MO

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA 5 MOEDURANT 5 MOINTELENCE TABS 25MG 4INTELENCE TABS 100MG, 200MG 5 MOnevirapine er 3 MOnevirapine susp 3nevirapine tabs 3 MOODEFSEY 5 MORESCRIPTOR 4 MOSTRIBILD 5 MOSUSTIVA TABS 5 MOSUSTIVA CAPS 50MG 3 MOSUSTIVA CAPS 200MG 5 MOVIRAMUNE 4 MOVIRAMUNE XR 4 MO

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir 3 MOabacavir sulfate/lamivudine/zidovudine

5 MO

abacavir/lamivudine 5 MODESCOVY 5 MOdidanosine 4 MOEMTRIVA 3 MOEPIVIR 4 MOEPZICOM 5 MOlamivudine/zidovudine 4 MO


Drug name Drug tier Requirements/Limitslamivudine soln 10mg/ml 4 MOlamivudine tabs 150mg, 300mg 4 MORETROVIR IV INFUSION 3RETROVIR CAPS, SYRP 4 MOstavudine caps 3 MOTRIUMEQ 5 MOTRUVADA TABS 133MG; 200MG, 167MG; 250MG, 200MG; 300MG


TRUVADA TABS 100MG; 150MG 5 QL (60 EA per 30 days) MOVIDEX EC 4 MOVIDEX PEDIATRIC 4 MOVIREAD 5 MOZERIT SOLR 4 MOZIAGEN SOLN 3 MOzidovudine 3 MO

Anti-HIV Agents, Other FUZEON 5ISENTRESS HD 5SELZENTRY TABS 25MG 4 QL (240 EA per 30 days)SELZENTRY TABS 150MG, 300MG 5 MOSELZENTRY TABS 75MG 5 QL (60 EA per 30 days)TYBOST 3 MO

Anti-HIV Agents, Protease Inhibitors APTIVUS SOLN 5APTIVUS CAPS 5 MOCRIXIVAN CAPS 200MG, 400MG 4 MOEVOTAZ 5 MOINVIRASE 5 MOKALETRA SOLN 5 MOKALETRA TABS 100MG; 25MG 3 MOKALETRA TABS 200MG; 50MG 5 MOLEXIVA SUSP 4 MOLEXIVA TABS 5 MOlopinavir/ritonavir 4 MONORVIR CAPS 3NORVIR SOLN, TABS 3 MOPREZCOBIX 5 MO


Drug name Drug tier Requirements/LimitsPREZISTA SUSP 5 MOPREZISTA TABS 150MG, 75MG 3 MOPREZISTA TABS 600MG, 800MG 5 MOREYATAZ 5 MOVIRACEPT 5 MO

Anti-influenza Agents oseltamivir phosphate 4 MORELENZA DISKHALER 3 MOrimantadine hcl 4 MOTAMIFLU CAPS 3 MOTAMIFLU SUSR 6MG/ML 3 MO

Antiherpetic Agents acyclovir sodium inj 50mg/ml 4 B/Dacyclovir caps, tabs 2 MOacyclovir susp 3 MOacyclovir oint 4 MODENAVIR 4 MOfamciclovir tabs 500mg 3 QL (21 EA per 30 days) MOfamciclovir tabs 125mg, 250mg 3 QL (60 EA per 30 days) MOFAMVIR TABS 500MG 4 QL (21 EA per 30 days) MOFAMVIR TABS 125MG, 250MG 4 QL (60 EA per 30 days) MOvalacyclovir hcl 3 MOVALTREX 4 MOZOVIRAX CAPS, CREA, OINT, SUSP 4 MO

ANXIOLYTICSAnxiolytics, Other

buspirone hcl tabs 2 MOmeprobamate 4 PA MO

Benzodiazepines alprazolam er tb24 0.5mg, 1mg 4 QL (30 EA per 30 days) MOalprazolam er tb24 3mg 4 QL (60 EA per 30 days) MOalprazolam er tb24 2mg 4 QL (90 EA per 30 days) MOalprazolam intensol oral soln conc 4 QL (300 ML per 30 days) MOalprazolam odt tbdp 0.5mg, 1mg 4 MOalprazolam odt tbdp 0.25mg 4 QL (120 EA per 30 days) MOalprazolam odt tbdp 2mg 4 QL (150 EA per 30 days) MO


Drug name Drug tier Requirements/Limitsalprazolam immediate release tabs 0.25mg, 0.5mg


alprazolam immediate release tabs 1mg, 2mg


chlordiazepoxide hcl 4 QL (120 EA per 30 days) MOclorazepate dipotassium tabs 15mg


clorazepate dipotassium tabs 3.75mg, 7.5mg


diazepam intensol oral soln conc 5mg/ml

3 MO

diazepam inj 5mg/ml 4 QL (240 ML per 30 days) MOdiazepam oral soln 1mg/ml 4 QL (1200 ML per 30 days) MOdiazepam tabs 10mg, 2mg, 5mg 3 QL (120 EA per 30 days) MOflurazepam hcl 4 QL (30 EA per 30 days) MOHALCION TABS 0.25MG 4 QL (60 EA per 30 days) MOlorazepam intensol oral soln conc 2 QL (150 ML per 30 days) MOlorazepam inj 4mg/ml 2 QL (120 ML per 30 days)lorazepam inj 2mg/ml 2 QL (120 ML per 30 days) MOlorazepam tabs 0.5mg 2 QL (120 EA per 30 days) MOlorazepam tabs 2mg 2 QL (150 EA per 30 days) MOlorazepam tabs 1mg 2 QL (180 EA per 30 days) MOoxazepam 4 QL (120 EA per 30 days) MORESTORIL 4 QL (30 EA per 30 days) MOtemazepam 4 QL (30 EA per 30 days) MOTRANXENE T TABS 7.5MG 4 MOtriazolam 4 QL (60 EA per 30 days) MOVALIUM TABS 4 QL (120 EA per 30 days) MOXANAX XR TB24 0.5MG, 1MG 4 QL (30 EA per 30 days) ST MOXANAX XR TB24 3MG 4 QL (60 EA per 30 days) ST MOXANAX XR TB24 2MG 4 QL (90 EA per 30 days) ST MOXANAX TABS 0.25MG, 0.5MG 4 QL (120 EA per 30 days) ST MOXANAX TABS 1MG, 2MG 4 QL (150 EA per 30 days) ST MO

BIPOLAR AGENTSMood Stabilizers

EQUETRO 4 MOlithium carbonate er tabs 4 MOlithium carbonate caps, tabs 1 MO


Drug name Drug tier Requirements/Limitslithium oral soln 3 MOLITHOBID 4 MO

BLOOD GLUCOSE REGULATORSAntidiabetic Agents

acarbose 1 QL (90 EA per 30 days) MOACTOPLUS MET IMMEDIATE RELEASE TABS


ACTOS 4 QL (30 EA per 30 days) MOAMARYL 4 MOAVANDIA TABS 2MG, 4MG 4 QL (60 EA per 30 days) MOBYDUREON 3 QL (4 EA per 28 days) MOBYDUREON PEN 3 QL (4 EA per 28 days) MOBYETTA INJ 5MCG/0.02ML 4 QL (1.2 ML per 30 days) MOBYETTA INJ 10MCG/0.04ML 4 QL (2.4 ML per 30 days) MOCYCLOSET 4 QL (180 EA per 30 days) PA

MODUETACT 4 QL (30 EA per 30 days) MOFARXIGA TABS 10MG 3 QL (30 EA per 30 days) MOFARXIGA TABS 5MG 3 QL (60 EA per 30 days) MOFORTAMET TB24 1000MG 4 PA MOglimepiride 1 MOglipizide er 1 MOglipizide xl 1 MOglipizide/metformin hcl 1 MOglipizide tabs 1 MOGLUCOPHAGE 4 MOGLUCOPHAGE XR 4 MOGLUCOTROL 4 MOGLUCOTROL XL 4 MOGLUCOVANCE TABS 2.5MG; 500MG, 5MG; 500MG

4 PA MO

glyburide micronized 2 PA MOglyburide/metformin hcl 2 PA MOglyburide tabs 2 PA MOGLYNASE 4 PA MOINVOKAMET XR TB24 50MG; 500MG



Drug name Drug tier Requirements/LimitsINVOKAMET XR TB24 150MG; 1000MG, 150MG; 500MG, 50MG; 1000MG


INVOKAMET TABS 50MG; 500MG 3 QL (120 EA per 30 days) MOINVOKAMET TABS 150MG; 1000MG, 150MG; 500MG, 50MG; 1000MG


INVOKANA TABS 300MG 3 QL (30 EA per 30 days) MOINVOKANA TABS 100MG 3 QL (90 EA per 30 days) MOJANUMET 3 QL (60 EA per 30 days) MOJANUMET XR TB24 1000MG; 100MG


JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG


JANUVIA 3 QL (30 EA per 30 days) MOJENTADUETO 3 QL (60 EA per 30 days) MOJENTADUETO XR TB24 5MG; 1000MG


JENTADUETO XR TB24 2.5MG; 1000MG


KORLYM 5 PA LAmetformin hcl er tb24 (generic Glucophage XR) 500mg, 750mg

1 MO

metformin hcl er tb24 (generic Fortamet) 500mg

4 PA MO

metformin hcl er tb24 (generic Glumetza) 500mg


metformin hcl tabs 1 MOmiglitol 4 QL (90 EA per 30 days) MOnateglinide 1 MOpioglitazone hcl 1 QL (30 EA per 30 days) MOpioglitazone hcl-glimepiride 1 QL (30 EA per 30 days) MOpioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days) MOPRANDIN TABS 0.5MG, 1MG 4 QL (120 EA per 30 days) MOPRANDIN TABS 2MG 4 QL (240 EA per 30 days) MOPRECOSE 4 QL (90 EA per 30 days) MOrepaglinide/metformin hydrochloride


repaglinide tabs 0.5mg, 1mg 1 QL (120 EA per 30 days) MO


Drug name Drug tier Requirements/Limitsrepaglinide tabs 2mg 1 QL (240 EA per 30 days) MORIOMET 4 MOSTARLIX 4 MOSYMLINPEN 120 5 QL (10.8 ML per 30 days) PA

MOSYMLINPEN 60 5 QL (12 ML per 30 days) PA MOtolazamide tabs 250mg, 500mg 1 MOtolbutamide 1 MOTRADJENTA 3 QL (30 EA per 30 days) MOTRULICITY 4 QL (4 ML per 28 days) MOVICTOZA 3 QL (9 ML per 30 days) MOXIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG


XIGDUO XR TB24 5MG; 1000MG, 5MG; 500MG


Glycemic Agents GLUCAGEN HYPOKIT 3 MOGLUCAGON EMERGENCY KIT 3 MOPROGLYCEM 4 MO

Insulins HUMULIN R U-500 (CONCENTRATED)

5 B/D MO

HUMULIN R U-500 KWIKPEN 5 MOLANTUS 3 MOLANTUS SOLOSTAR 3 MOLEVEMIR 3 MOLEVEMIR FLEXTOUCH 3 MONOVOLIN 70/30 3 MONOVOLIN N 3 MONOVOLIN R 3 MONOVOLOG 3 MONOVOLOG FLEXPEN 3 MONOVOLOG MIX 70/30 3 MONOVOLOG MIX 70/30 PREFILLED FLEXPEN

3 MO

NOVOLOG PENFILL 3 MOTOUJEO SOLOSTAR 3 MOTRESIBA FLEXTOUCH 3 MO


Drug name Drug tier Requirements/LimitsBLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

Anticoagulants COUMADIN TABS 4 MOELIQUIS 3 MOenoxaparin sodium 4 MOfondaparinux sodium 4 MOFRAGMIN INJ 4 MOHEPARIN SODIUM/D5W INJ 100UNIT/ML

4

heparin sodium/d5w inj 40unit/ml, 50unit/ml

4

HEPARIN SODIUM/NACL 0.45% 4heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

4 MO

jantoven 1 MOLOVENOX INJ 30MG/0.3ML, 40MG/0.4ML, 60MG/0.6ML, 80MG/0.8ML

4 MO

LOVENOX INJ 100MG/ML, 120MG/0.8ML, 150MG/ML, 300MG/3ML

5 MO

PRADAXA 4 MOwarfarin sodium tabs 1 MOZONTIVITY 4

Blood Formation Modifiers anagrelide hydrochloride 3 MOARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 QL (1.2 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 40MCG/0.4ML









Drug name Drug tier Requirements/LimitsARANESP ALBUMIN FREE INJ 100MCG/ML, 25MCG/ML, 40MCG/ML, 60MCG/ML


ARANESP ALBUMIN FREE INJ 500MCG/ML








ARANESP ALBUMIN FREE INJ 200MCG/ML, 300MCG/ML


azacitidine 5 PAGRANIX 5 PAMOZOBIL 5 PANEULASTA INJ 5 PANEUPOGEN 5 PAPROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

5 PA

PROMACTA TABS 25MG 5 QL (180 EA per 30 days) PA LAPROMACTA TABS 12.5MG 5 QL (360 EA per 30 days) PA LAPROMACTA TABS 75MG 5 QL (60 EA per 30 days) PA LAPROMACTA TABS 50MG 5 QL (90 EA per 30 days) PA LA

Hemostasis Agents LYSTEDA 4 QL (30 EA per 30 days) MOtranexamic acid inj 4tranexamic acid tabs 4 QL (30 EA per 30 days) MO

Platelet Modifying Agents AGGRENOX 4 QL (60 EA per 30 days) ST MOaspirin/dipyridamole 3 QL (60 EA per 30 days) MOBRILINTA 3 MOcilostazol 1 MOclopidogrel tabs 300mg 1 QL (2 EA per 365 days)clopidogrel tabs 75mg 1 QL (30 EA per 30 days) MOdipyridamole tabs 4 PA MO


Drug name Drug tier Requirements/LimitsDURLAZA 4 QL (30 EA per 30 days) MOEFFIENT 4 MOPLAVIX TABS 300MG 4 QL (2 EA per 365 days) STPLAVIX TABS 75MG 4 QL (30 EA per 30 days) ST MO

CARDIOVASCULAR AGENTSAlpha-adrenergic Agonists

CATAPRES TABS 4 MOCATAPRES-TTS-1 PATCHES 4 QL (8 EA per 28 days) MOCATAPRES-TTS-2 PATCHES 4 QL (8 EA per 28 days) MOCATAPRES-TTS-3 PATCHES 4 QL (8 EA per 28 days) MOclonidine hcl immediate release tabs

2 MO

clonidine hcl weekly patch 3 QL (8 EA per 28 days) MOguanfacine hcl 4 PA MOmethyldopa tabs 250mg, 500mg 4 PA MOmidodrine hcl 3 MONORTHERA 5 PA LATENEX 4 PA MO

Alpha-adrenergic Blocking Agents CARDURA 4 MOdoxazosin mesylate tabs 4mg 2 MOdoxazosin mesylate tabs 1mg, 2mg, 8mg

2 MO

MINIPRESS 4 MOprazosin hcl caps 3 MOterazosin hcl caps 1 MO

Angiotensin II Receptor Antagonists amlodipine besylate/valsartan 1 QL (30 EA per 30 days) MOamlodipine/olmesartan medoxomil 4 QL (30 EA per 30 days) MOamlodipine/valsartan/hctz 1 QL (30 EA per 30 days) MOATACAND 4 QL (30 EA per 30 days) ST MOATACAND HCT TABS 32MG; 12.5MG, 32MG; 25MG


ATACAND HCT TABS 16MG; 12.5MG


AVALIDE 4 QL (30 EA per 30 days) ST MOAVAPRO 4 QL (30 EA per 30 days) ST MOAZOR 4 QL (30 EA per 30 days) ST MO


Drug name Drug tier Requirements/LimitsBENICAR 4 QL (30 EA per 30 days) MOBENICAR HCT 4 QL (30 EA per 30 days) MOcandesartan cilexetil 2 QL (30 EA per 30 days) MOcandesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg


candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg


COZAAR TABS 100MG 4 QL (30 EA per 30 days) ST MOCOZAAR TABS 25MG, 50MG 4 QL (60 EA per 30 days) ST MODIOVAN HCT 4 QL (30 EA per 30 days) ST MODIOVAN TABS 320MG 4 QL (30 EA per 30 days) ST MODIOVAN TABS 160MG, 40MG, 80MG


EDARBI 4 QL (30 EA per 30 days) MOeprosartan mesylate 1 QL (30 EA per 30 days) MOEXFORGE 4 QL (30 EA per 30 days) ST MOEXFORGE HCT 4 QL (30 EA per 30 days) ST MOHYZAAR 4 QL (30 EA per 30 days) ST MOirbesartan 1 QL (30 EA per 30 days) MOirbesartan/hydrochlorothiazide 2 QL (30 EA per 30 days) MOlosartan potassium/hydrochlorothiazide


losartan potassium tabs 100mg 1 QL (30 EA per 30 days) MOlosartan potassium tabs 25mg, 50mg


MICARDIS 4 QL (30 EA per 30 days) ST MOMICARDIS HCT 4 QL (30 EA per 30 days) ST MOolmesartan medoxomil/hydrochlorothiazide


olmesartan medoxomil tabs 4 QL (30 EA per 30 days) MOtelmisartan 2 QL (30 EA per 30 days) MOtelmisartan/amlodipine 1 QL (30 EA per 30 days) MOtelmisartan/hydrochlorothiazide 2 QL (30 EA per 30 days) MOTRIBENZOR 4 QL (30 EA per 30 days) ST MOTWYNSTA 4 QL (30 EA per 30 days) ST MOvalsartan/hydrochlorothiazide 1 QL (30 EA per 30 days) MO


Drug name Drug tier Requirements/Limitsvalsartan tabs 320mg 1 QL (30 EA per 30 days) MOvalsartan tabs 160mg, 40mg, 80mg 1 QL (60 EA per 30 days) MO

Angiotensin-converting Enzyme (ACE) Inhibitors ACCUPRIL 4 MOACCURETIC 4 MOALTACE CAPS 4 MObenazepril hcl/hydrochlorothiazide 1 MObenazepril hcl tabs 1 MOcaptopril/hydrochlorothiazide 1 MOcaptopril tabs 2 MOenalapril maleate/hydrochlorothiazide

1 MO

enalapril maleate tabs 1 MOEPANED SOLN RECONSTITUTED 4 MOfosinopril sodium 1 MOfosinopril sodium/hydrochlorothiazide

1 MO

lisinopril/hydrochlorothiazide 1 MOlisinopril tabs 1 MOLOTENSIN TABS 20MG, 40MG 4 MOMAVIK TABS 1MG, 2MG 4 MOmoexipril hcl 1 MOmoexipril/hydrochlorothiazide 1 MOperindopril erbumine 2 MOPRINIVIL TABS 10MG, 20MG, 5MG 4 MOquinapril 1 MOquinapril/hydrochlorothiazide 2 MOramipril 1 MOTARKA 4 MOtrandolapril 1 MOtrandolapril/verapamil hcl er 1 MOVASOTEC 4 MOZESTORETIC 4 MOZESTRIL 4 MO

Antiarrhythmics amiodarone hcl tabs 2 MOamiodarone hcl inj 50mg/ml 4


Drug name Drug tier Requirements/Limitsdisopyramide phosphate caps 4 PA MOdofetilide 4flecainide acetate 3 MOlidocaine hcl in d5w inj 4mg/ml 4lidocaine hcl inj 20mg/ml 4lidocaine hcl inj 10mg/ml 4 MOmexiletine hcl 4 MOMULTAQ 4 MONORPACE 4 PA MONORPACE CR 4 PA MOpacerone tabs 100mg, 200mg, 400mg

2

propafenone hcl er caps 4 MOpropafenone hcl tabs 3 MOquinidine gluconate cr tabs 4 MOquinidine gluconate er tabs 4 MOquinidine sulfate tabs 2 MORYTHMOL SR 4 MOsorine 1sotalol af 2 MOsotalol hcl 1 MOTIKOSYN 4 ST

Beta-adrenergic Blocking Agents acebutolol hcl caps 2 MOatenolol/chlorthalidone 2 MOatenolol tabs 1 MObetaxolol hcl tabs

Documents

2018 Comprehensive Formulary - KDHE Comprehensive Formulary ... When this drug list (formulary) ... pharmacies to use your prescription drug benefit. Benefits, formulary,