Transcript
Your 2017
Prescription Drug List Effective January 1, 2017 Oxford Connecticut Four-Tier Please read: This document contains information about commonly prescribed medications. This Prescription Drug List (PDL) is accurate as of July 1, 2016 and is subject to change after this date. The next anticipated update will be in January 2017. Your estimated coverage and copay/co-insurance may vary based on the benefit plan you choose and the effective date of the plan. For more information: Call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages. Visit oxfordhealth.com, click on the Pharmacies & Prescriptions tab and then
“Online Pharmacy” to log in to the OptumRx1 website and: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.
OptumRx is the administrator of your Oxford pharmacy benefit plan. Note: Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Specialized non-standard infant formulas and nutritional supplements may be subject to prior authorization. Please see your Summary of Benefits and Coverage (SBC) for specifics. 1
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Your Prescription Drug List This Prescription Drug List (PDL) outlines covered medications and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you.
Go to oxfordhealth.com for drug information. Since the PDL may change, we encourage you to visit our website, oxfordhealth.com. This website is the best source for accessing up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons.
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We want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List (PDL) below.
What is a Prescription Drug List (PDL)? This document is a list of covered medications. They are placed into cost levels known as tiers. The PDL includes both brand-name and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this PDL and your health plan documents, the health plan documents will rule. Please look at your health plan documents to see what medications are covered under your health plan. You may also log on to oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more information.
How do I use my PDL? Bring your PDL with you when you see your doctor. When choosing a medication, you and your doctor should consult this guide. It will help you and your doctor choose the most cost-effective prescription drugs. This guide will also help you know if a medication has special programs that apply to it. If your medication is not listed in this guide, please visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages.
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What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2, 3 or 4, look to see if there is a Tier 1 option available. You should discuss these options with your doctor. Check your health plan documents to find your specific pharmacy plan costs.
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Drug Tier
Includes
Helpful Tips
Tier 1 Lowest Cost
Lower-cost drugs. Some brand names and generics are also included.
Use Tier 1 drugs for the lowest out‑of-pocket costs.
Tier 2 Mid-range Cost
Preferred brands.
Use Tier 2 drugs instead of Tier 4 drugs to help reduce your out-of-pocket costs.
Tier 3 Mid-range Cost
Preferred specialty and non-preferred brands.
Use Tier 3 drugs instead of Tier 4 drugs to help reduce your out-of-pocket costs.
Tier 4 Highest Cost
Higher cost brands and generics. Non-preferred specialty and non-preferred brands.
Many Tier 4 drugs have lower‑cost options in Tier 1, 2 or 3. Ask your doctor if they could work for you.
Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible health plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on oxfordhealth.com, or call us at the toll-free phone number on your health plan ID card for more information about your health plan. Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics.
When does the PDL change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available. • Medications may move to a higher tier or be excluded from coverage most often on January 1 or July 1. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call us at the toll-free phone number on your health plan ID card.
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Programs and Limits Some medications are in one or more of our pharmacy benefit programs. Your health plan determines how these medications are covered and may differ than what is noted in the PDL. Health Care Reform (HCR) Preventive – This medication is part of a Health Care Reform preventive benefit and may be available at no additional cost to you. Notification or Precertification (sometimes referred to as Prior Authorization) required1 – Your doctor is required to provide additional information to us to determine coverage. Supply Limit – Amount of medication covered per copayment or in a specific time period. Step Therapy – Trial of a lower-cost medication is required before a higher-cost medication is covered. 1
Depending on your benefit, you may have notification or precertification requirements for select medications.
To learn more about a pharmacy program or to find out if it applies to you, please visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages.
Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to an over-the-counter (OTC) medication.2 There may be other medication options available.
Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options.
What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.
This is not applicable for Connecticut Public Sector plans. For Connecticut commercial business, a prescription drug product that is therapeutically equivalent to an over-the counter drug may be covered if it is determined to be medically necessary
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What if my doctor writes a prescription for a brand-name medication? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some health plans, if a brand-name medication is prescribed and a generic equivalent is available, your share of the cost may be the copayment PLUS the cost difference between the brand-name medication and its generic equivalent. Visit oxfordhealth.com to make sure.
Are you taking a specialty medication? Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more. If you’re taking a specialty medication that is on Tier 4, call us at the toll-free phone number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.
What is Mail Service Member Select? Your plan may include a home delivery program called Mail Service Member Select, which encourages you to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home delivery can help you better manage the medication you take on a regular basis, and may save you time and money. You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a decision about whether or not to enroll in Mail Service Member Select. If you do nothing and continue to fill your medications at a retail pharmacy, you may pay more for your medication until you make a decision and take action. You must confirm your decision every year. To learn more, you may log on to myuhc.com or call the toll-free member phone number on your health plan ID card for more information.
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How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more current information.
For more information Call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID card for help in English and other languages. Or, visit oxfordhealth.com.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage. All branded medications are trademarks or registered trademarks of their respective owners. Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. ©2016 Oxford Health Plans LLC. All rights reserved. Created August 1, 2016. January 1, 2017 Prescription Drug List – Oxford Connecticut Advantage Four-Tier CT-16-354 MT993780.1
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Therapeutic Class Product Name 1st Generation/Typical - Mood Disorder Drugs ADASUVE INH 10MG
Tier Value Tier 3
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ POW HCL
Tier 3
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 100MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 200MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 50MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs COMPRO
Tier 1
SUP 25MG
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE CON 5MG/ML
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE ELX 2.5/5ML
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 2.5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL CON 2MG/ML
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 0.5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 20MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 50MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs ORAP
TAB 1MG
Tier 4
1st Generation/Typical - Mood Disorder Drugs ORAP
TAB 2MG
Tier 4
1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 16MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 2MG
Tier 1
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Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Product Name 1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 4MG
Tier Value Tier 1
1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 8MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PIMOZIDE
TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PIMOZIDE
TAB 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PROCHLORPER SUP 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PROCHLORPER TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PROCHLORPER TAB 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 100MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 50MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 5MG
Tier 1
2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs
Prior Authorization
Supply Limit
Step Therapy
ABILIFY
SOL 1MG/ML
Tier 4
ABILIFY
TAB 10MG
Tier 4
X
X
X
ABILIFY
TAB 15MG
Tier 4
X
X
X
ABILIFY
TAB 20MG
Tier 4
X
X
X
ABILIFY
TAB 2MG
Tier 4
X
X
X
ABILIFY
TAB 30MG
Tier 4
X
X
X
ABILIFY
TAB 5MG
Tier 4
X
X
X
ABILIFY DISC TAB 10MG
Tier 4
X
ABILIFY DISC TAB 15MG
Tier 4
X
ARIPIPRAZOLE SOL 1MG/ML
Tier 1
Page 2 of 279
Specialty
Therapeutic Class 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs
Product Name ARIPIPRAZOLE TAB 10MG
Tier Value Tier 1
Prior Authorization
Supply Limit X
ARIPIPRAZOLE TAB 10MG ODT
Tier 1
X
ARIPIPRAZOLE TAB 15MG
Tier 1
X
ARIPIPRAZOLE TAB 15MG ODT
Tier 1
X
ARIPIPRAZOLE TAB 20MG
Tier 1
X
ARIPIPRAZOLE TAB 2MG
Tier 1
X
ARIPIPRAZOLE TAB 30MG
Tier 1
X
ARIPIPRAZOLE TAB 5MG
Tier 1
X
FANAPT
PAK
Tier 3
X
FANAPT
TAB 10MG
Tier 4
X
FANAPT
TAB 12MG
Tier 4
X
FANAPT
TAB 1MG
Tier 4
X
FANAPT
TAB 2MG
Tier 4
X
FANAPT
TAB 4MG
Tier 4
X
FANAPT
TAB 6MG
Tier 4
X
FANAPT
TAB 8MG
Tier 4
X
Step Therapy
GEODON
CAP 20MG
Tier 4
X
X
GEODON
CAP 40MG
Tier 4
X
X
GEODON
CAP 60MG
Tier 4
X
X
GEODON
CAP 80MG
Tier 4
X
X
INVEGA
TAB 1.5MG
Tier 4
X
X
INVEGA
TAB 3MG
Tier 4
X
X
INVEGA
TAB 6MG
Tier 4
X
X
INVEGA
TAB 9MG
Tier 4
X
X
LATUDA
TAB 120MG
Tier 4
X
LATUDA
TAB 20MG
Tier 4
X
LATUDA
TAB 40MG
Tier 4
X
LATUDA
TAB 60MG
Tier 4
X
LATUDA
TAB 80MG
Tier 4
X
Page 3 of 279
Specialty
Therapeutic Class 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs
Product Name OLANZAPINE TAB 10MG
Tier Value Tier 1
Prior Authorization
Supply Limit X
Step Therapy
OLANZAPINE TAB 10MG ODT
Tier 1
X
OLANZAPINE TAB 15MG
Tier 1
X
OLANZAPINE TAB 15MG ODT
Tier 1
X
OLANZAPINE TAB 2.5MG
Tier 1
X
OLANZAPINE TAB 20MG
Tier 1
X
OLANZAPINE TAB 20MG ODT
Tier 1
X
OLANZAPINE TAB 5MG
Tier 1
X
OLANZAPINE TAB 5MG ODT
Tier 1
X
OLANZAPINE TAB 7.5MG
Tier 1
X
PALIPERIDONE TAB ER 1.5MG
Tier 1
X
PALIPERIDONE TAB ER 3MG
Tier 1
X
PALIPERIDONE TAB ER 6MG
Tier 1
X
PALIPERIDONE TAB ER 9MG
Tier 1
X
QUETIAPINE TAB 100MG
Tier 1
QUETIAPINE TAB 200MG
Tier 1
QUETIAPINE TAB 25MG
Tier 1
QUETIAPINE TAB 300MG
Tier 1
QUETIAPINE TAB 400MG
Tier 1
QUETIAPINE TAB 50MG
Tier 1
RISPERDAL SOL 1MG/ML
Tier 4
X
RISPERDAL TAB 0.25MG
Tier 4
X
RISPERDAL TAB 0.5MG
Tier 4
X
RISPERDAL TAB 1MG
Tier 4
X
RISPERDAL TAB 2MG
Tier 4
X
RISPERDAL TAB 3MG
Tier 4
X
RISPERDAL TAB 4MG
Tier 4
X
RISPERDAL M TAB 0.5MG
Tier 4
X
RISPERDAL M TAB 1MG
Tier 4
X
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Specialty
Therapeutic Class 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs
Prior Authorization
Supply Limit
Step Therapy X
Product Name RISPERDAL M TAB 2MG
Tier Value Tier 4
RISPERDAL M TAB 3MG
Tier 4
X
RISPERDAL M TAB 4MG
Tier 3
X
RISPERIDONE SOL 1MG/ML
Tier 1
RISPERIDONE TAB 0.25 ODT
Tier 1
RISPERIDONE TAB 0.25MG
Tier 1
RISPERIDONE TAB 0.5MG
Tier 1
RISPERIDONE TAB 0.5MG OD
Tier 1
RISPERIDONE TAB 1MG
Tier 1
RISPERIDONE TAB 1MG ODT
Tier 1
RISPERIDONE TAB 2MG
Tier 1
RISPERIDONE TAB 2MG ODT
Tier 1
RISPERIDONE TAB 3MG
Tier 1
RISPERIDONE TAB 3MG ODT
Tier 1
RISPERIDONE TAB 4MG
Tier 1
RISPERIDONE TAB 4MG ODT
Tier 1
SAPHRIS
SUB 10MG
Tier 3
SAPHRIS
SUB 2.5MG
Tier 3
SAPHRIS
SUB 5MG
Tier 3
X
X
SEROQUEL
TAB 100MG
Tier 4
X
SEROQUEL
TAB 200MG
Tier 4
X
SEROQUEL
TAB 25MG
Tier 4
X
SEROQUEL
TAB 300MG
Tier 4
X
SEROQUEL
TAB 400MG
Tier 4
X
SEROQUEL
TAB 50MG
Tier 4
X
SEROQUEL XR TAB 150MG
Tier 4
X
SEROQUEL XR TAB 200MG
Tier 4
X
SEROQUEL XR TAB 300MG
Tier 4
X
SEROQUEL XR TAB 400MG
Tier 4
X
Page 5 of 279
Specialty
Prior Authorization
Supply Limit X
Step Therapy
Therapeutic Class 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants Alkylating Agents - Chemotherapy Agents
Product Name SEROQUEL XR TAB 50MG
Tier Value Tier 4
ZIPRASIDONE CAP 20MG
Tier 1
X
ZIPRASIDONE CAP 40MG
Tier 1
X
ZIPRASIDONE CAP 60MG
Tier 1
X
ZIPRASIDONE CAP 80MG
Tier 1
X
ZYPREXA
TAB 10MG
Tier 4
X
X
ZYPREXA
TAB 15MG
Tier 4
X
X
ZYPREXA
TAB 2.5MG
Tier 4
X
X
ZYPREXA
TAB 20MG
Tier 4
X
X
ZYPREXA
TAB 5MG
Tier 4
X
X
ZYPREXA
TAB 7.5MG
Tier 4
X
X
ZYPREXA ZYDI TAB 10MG
Tier 4
X
X
ZYPREXA ZYDI TAB 15MG
Tier 4
X
X
ZYPREXA ZYDI TAB 20MG
Tier 4
X
X
ZYPREXA ZYDI TAB 5MG
Tier 4
X
X
ACAMPRO CAL TAB 333MG
Tier 1
ANTABUSE
TAB 250MG
Tier 4
ANTABUSE
TAB 500MG
Tier 4
DISULFIRAM TAB 250MG
Tier 1
DISULFIRAM TAB 500MG
Tier 1
NALTREXONE TAB 50MG
Tier 1
REVIA
Tier 4
Alkylating Agents - Chemotherapy Agents
ALKERAN
TAB 50MG TAB 2MG
Specialty
Tier 3
X
CYCLOPHOSPH CAP 25MG
Tier 3
X
Alkylating Agents - Chemotherapy Agents
CYCLOPHOSPH CAP 50MG
Tier 3
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 100MG
Tier 4
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 10MG
Tier 4
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 40MG
Tier 4
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 5MG
Tier 4
X
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Therapeutic Class Alkylating Agents - Chemotherapy Agents
Product Name HEXALEN CAP 50MG
Alkylating Agents - Chemotherapy Agents
LEUKERAN
Alkylating Agents - Chemotherapy Agents
TAB 2MG
Tier Value Tier 3
Prior Authorization
Supply Limit
Step Therapy
Specialty X
Tier 3
X
LOMUSTINE CAP 100MG
Tier 1
X
Alkylating Agents - Chemotherapy Agents
LOMUSTINE CAP 10MG
Tier 1
X
Alkylating Agents - Chemotherapy Agents
LOMUSTINE CAP 40MG
Tier 1
X
Alkylating Agents - Chemotherapy Agents
MATULANE
Tier 3
X
Alkylating Agents - Chemotherapy Agents
MYLERAN
TAB 2MG
Tier 3
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 100MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 140MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 180MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 20MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 250MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 5MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 100MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 140MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 180MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 20MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 250MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 5MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
VALCHLOR
GEL 0.016%
Tier 3
X
Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs
CATAPRES
TAB 0.1MG
Tier 4
CATAPRES
TAB 0.2MG
Tier 4
CATAPRES
TAB 0.3MG
Tier 4
CAP 50MG
CATAPRES-TTS DIS 0.1/24HR
Tier 4
CATAPRES-TTS DIS 0.2/24HR
Tier 4
CATAPRES-TTS DIS 0.3/24HR
Tier 4
CLONIDINE DIS 0.1/24HR
Tier 1
CLONIDINE DIS 0.2/24HR
Tier 1
CLONIDINE DIS 0.3/24HR
Tier 1
Page 7 of 279
X
X
Therapeutic Class Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs
Product Name CLONIDINE TAB 0.1MG
Tier Value Tier 1
CLONIDINE TAB 0.2MG
Tier 1
CLONIDINE TAB 0.3MG
Tier 1
CLORPRES
TAB 0.1-15MG
Tier 2
CLORPRES
TAB 0.2-15MG
Tier 2
CLORPRES
TAB 0.3-15MG
Tier 2
GUANFACINE TAB 1MG
Tier 1
GUANFACINE TAB 2MG
Tier 1
METHYLD/HCTZ TAB 250/15
Tier 1
METHYLD/HCTZ TAB 250/25
Tier 1
METHYLDOPA TAB 250MG
Tier 1
METHYLDOPA TAB 500MG
Tier 1
MIDODRINE TAB 10MG
Tier 1
MIDODRINE TAB 2.5MG
Tier 1
MIDODRINE TAB 5MG
Tier 1
TENEX
TAB 1MG
Tier 3
TENEX
TAB 2MG
Tier 3
CARDURA XL TAB 4MG
Tier 3
CARDURA XL TAB 8MG
Tier 3
DIBENZYLINE CAP 10MG
Tier 4
MINIPRESS CAP 1MG
Tier 4
MINIPRESS CAP 2MG
Tier 4
MINIPRESS CAP 5MG
Tier 4
PHENOXYBENZA CAP 10MG
Tier 1
PRAZOSIN HCL CAP 1MG
Tier 1
PRAZOSIN HCL CAP 2MG
Tier 1
PRAZOSIN HCL CAP 5MG
Tier 1
RESERPINE TAB 0.1MG
Tier 1
RESERPINE TAB 0.25MG
Tier 1
Page 8 of 279
Prior Authorization
Supply Limit
Step Therapy
X
Specialty
Prior Authorization X
Supply Limit X
Step Therapy
X
X
X
X
X X X
X X X
X
X X X
Therapeutic Class Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics
Product Name BETHKIS NEB 300/4ML GARAMYCIN SOL 0.3% OP GENTAK OIN 0.3% OP GENTAMICIN CRE 0.1% GENTAMICIN OIN 0.1% GENTAMICIN OIN 0.3% OP GENTAMICIN SOL 0.3% OP KITABIS PAK NEB 300/5ML NEOMYCIN TAB 500MG PAROMOMYCIN CAP 250MG
Tier Value Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1
Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics
TOBI NEB 300/5ML TOBI PODHALR CAP 28MG TOBRAMYCIN NEB 300/5ML
Tier 4 Tier 4 Tier 1
Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Aminosalicylates - Inflammatory Bowel Disease Drugs Anabolic Steroids - Hormone Replacement/Modifying Drugs Anabolic Steroids - Hormone Replacement/Modifying Drugs Anabolic Steroids - Hormone Replacement/Modifying Drugs Anabolic Steroids - Hormone Replacement/Modifying Drugs
TOBRAMYCIN SOL 0.3% OP TOBREX OIN 0.3% OP TOBREX SOL 0.3% OP APRISO CAP 0.375GM
Tier 1 Tier 3 Tier 4 Tier 2
ASACOL HD TAB 800MG
Tier 4
BALSALAZIDE CAP 750MG
Tier 1
CANASA
SUP 1000MG
Tier 2
COLAZAL
CAP 750MG
Tier 4
X
DELZICOL
CAP 400MG
Tier 4
X
DIPENTUM
CAP 250MG
X
X
Tier 3
GIAZO
TAB 1.1GM
Tier 4
LIALDA
TAB 1.2GM
Tier 2
X
MESALAMINE ENE 4GM
Tier 1
MESALAMINE KIT 4GM
Tier 1
MESALAMINE TAB 800MG DR
Tier 4
X
PENTASA
CAP 250MG CR
Tier 4
X
PENTASA
CAP 500MG CR
Tier 4
X
ROWASA
KIT 4GM
Tier 4
SFROWASA
ENE 4GM
Tier 4
ANADROL-50 TAB 50MG
Tier 3
OXANDRIN
TAB 10MG
Tier 4
OXANDRIN
TAB 2.5MG
Tier 3
OXANDROLONE TAB 10MG
Page 9 of 279
Tier 1
X
X
Specialty X
Supply Limit
Step Therapy
Tier 1 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X X
X
CAPACET CAP ESGIC CAP ESGIC TAB FIORICET CAP FIORINAL CAP GRALISE TAB 300MG GRALISE TAB 600MG GRALISE STAR MIS 300/600 MARGESIC CAP MARTEN-TAB TAB 50-325MG
Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 1
X X X X
TENCON TAB 50-325MG VANATOL LQ SOL ZEBUTAL CAP ANDRODERM DIS 2MG/24HR
Tier 1 Tier 1 Tier 1 Tier 2
X
X X X
ANDRODERM DIS 4MG/24HR
Tier 2
X
X
ANDROGEL
GEL 1%(25MG)
Tier 4
X
X
X
ANDROGEL
GEL 1%(50MG)
Tier 4
X
X
X
ANDROGEL
GEL 1.62%
Tier 4
X
X
X
ANDROGEL
GEL 1.62%
Tier 4
X
X
X
ANDROGEL
GEL 1.62%
Tier 4
X
X
X
ANDROGEL
GEL PUMP 1%
Tier 4
X
X
X
X
X
X
Therapeutic Class Anabolic Steroids - Hormone Replacement/Modifying Drugs Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics
Product Name OXANDROLONE TAB 2.5MG ALAGESIC LQ SOL ALLZITAL TAB 25-325MG BUPAP TAB 50-300MG BUT/APAP/CAF CAP BUT/APAP/CAF CAP BUT/APAP/CAF TAB BUT/ASA/CAFF CAP BUTAL/APAP TAB 50-325MG
Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Analgesics - Miscellaneous Analgesics Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs
Tier Value Tier 1
ANDROID
CAP 10MG
Tier 4
ANDROXY
TAB 10MG
Tier 1
AXIRON
SOL 30MG/ACT
Tier 4
DANAZOL
CAP 100MG
Tier 1
DANAZOL
CAP 200MG
Tier 1
DANAZOL
CAP 50MG
Tier 1
DEPO-TESTOST INJ 100MG/ML
Tier 3
DEPO-TESTOST INJ 200MG/ML
Tier 4
Page 10 of 279
Prior Authorization
X X X
X X X X
X X X
Specialty
Therapeutic Class Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Androgens - Hormone Replacement/Modifying Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs
Tier Value Tier 3
Prior Authorization X
FIRST-TESTOS OIN 2%
Tier 3
X
FORTESTA
Tier 4
Product Name FIRST-TESTOS CRE MC 2%
GEL 10MG/ACT
Supply Limit
Step Therapy
X
X
X
X
METHITEST TAB 10MG
Tier 2
METHYLTESTOS CAP 10MG
Tier 1
NATESTO
Tier 4
X
X
GEL 5.5MG
STRIANT
MIS 30MG
Tier 3
X
X
TESTIM
GEL 1%(50MG)
Tier 2
X
X
TESTOST CYP INJ 100MG/ML
Tier 1
TESTOST CYP INJ 200MG/ML
Tier 1
TESTOST ENAN INJ 200MG/ML
Tier 1
TESTOSTERONE GEL 1%(25MG)
Tier 1
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 4
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 4
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 1
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 3
X
X
X
TESTOSTERONE GEL 10MG/ACT TESTOSTERONE GEL PUMP 1%
Tier 4
X
X
X
Tier 4
X
X
X
TESTOSTERONE GEL PUMP 1%
Tier 3
X
X
X
TESTOSTERONE GEL PUMP 1%
Tier 1
X
X
X
TESTOSTERONE GEL PUMP 1%
Tier 4
X
X
X
TESTOSTERONE INJ 250MG/ML
Tier 3
TESTRED
Tier 4
CAP 10MG
VOGELXO
GEL 1%(50MG)
Tier 4
X
X
X
VOGELXO
GEL PUMP 1%
Tier 4
X
X
X
ATACAND
TAB 16MG
Tier 4
X
ATACAND
TAB 32MG
Tier 4
X
ATACAND
TAB 4MG
Tier 4
X
ATACAND
TAB 8MG
Tier 4
X
Page 11 of 279
Specialty
Therapeutic Class Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs
Prior Authorization
Supply Limit X
Step Therapy
Product Name ATACAND HCT TAB 16-12.5
Tier Value Tier 4
ATACAND HCT TAB 32-12.5
Tier 4
X
ATACAND HCT TAB 32-25MG
Tier 4
X
AVALIDE
TAB 150-12.5
Tier 4
X
AVALIDE
TAB 300-12.5
Tier 4
X
AVAPRO
TAB 150MG
Tier 4
X
AVAPRO
TAB 300MG
Tier 4
X
AVAPRO
TAB 75MG
Tier 4
X
BENICAR
TAB 20MG
Tier 2
X
BENICAR
TAB 40MG
Tier 2
X
BENICAR
TAB 5MG
Tier 2
X
BENICAR HCT TAB 20-12.5
Tier 2
X
BENICAR HCT TAB 40-12.5
Tier 2
X
BENICAR HCT TAB 40-25MG
Tier 2
X
CANDESA/HCTZ TAB 16-12.5
Tier 1
X
CANDESA/HCTZ TAB 32-12.5
Tier 1
X
CANDESA/HCTZ TAB 32-25MG
Tier 1
X
CANDESARTAN TAB 16MG
Tier 1
X
CANDESARTAN TAB 32MG
Tier 1
X
CANDESARTAN TAB 4MG
Tier 1
X
CANDESARTAN TAB 8MG
Tier 1
X
COZAAR
TAB 100MG
Tier 4
COZAAR
TAB 25MG
Tier 4
COZAAR
TAB 50MG
Tier 4
DIOVAN
TAB 160MG
Tier 3
X
X
DIOVAN
TAB 320MG
Tier 3
X
X
DIOVAN
TAB 40MG
Tier 3
X
X
DIOVAN
TAB 80MG
Tier 3
X
X
Tier 4
X
X
DIOVAN HCT TAB 160-12.5
Page 12 of 279
Specialty
Therapeutic Class Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs
Product Name DIOVAN HCT TAB 160-25MG
Tier Value Tier 4
Prior Authorization
Supply Limit X
Step Therapy X
DIOVAN HCT TAB 320-12.5
Tier 4
X
X
DIOVAN HCT TAB 320-25MG
Tier 4
X
X
DIOVAN HCT TAB 80/12.5
Tier 4
X
X
EDARBI
TAB 40MG
Tier 3
X
EDARBI
TAB 80MG
Tier 3
X
EDARBYCLOR TAB 40-12.5
Tier 3
X
EDARBYCLOR TAB 40-25MG
Tier 3
X
EPROSART MES TAB 600MG
Tier 1
X
HYZAAR
TAB 100-12.5
Tier 4
HYZAAR
TAB 100-25
Tier 4
HYZAAR
TAB 50-12.5
Tier 4
IRBESAR/HCTZ TAB 150-12.5
Tier 1
X
IRBESAR/HCTZ TAB 300-12.5
Tier 1
X
IRBESARTAN TAB 150MG
Tier 1
X
IRBESARTAN TAB 300MG
Tier 1
X
IRBESARTAN TAB 75MG
Tier 1
X
LOSARTAN POT TAB 100MG
Tier 1
LOSARTAN POT TAB 25MG
Tier 1
LOSARTAN POT TAB 50MG
Tier 1
LOSARTAN/HCT TAB 100-12.5
Tier 1
LOSARTAN/HCT TAB 100-25
Tier 1
LOSARTAN/HCT TAB 50-12.5
Tier 1
MICARDIS
TAB 20MG
Tier 4
X
X
MICARDIS
TAB 40MG
Tier 4
X
X
MICARDIS
TAB 80MG
Tier 4
X
X
MICARDIS HCT TAB 40/12.5
Tier 4
X
X
MICARDIS HCT TAB 80/12.5
Tier 4
X
X
MICARDIS HCT TAB 80-25MG
Tier 4
X
X
Page 13 of 279
Specialty
Therapeutic Class Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin II Receptor Antagonists - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs
Prior Authorization
Supply Limit X
Product Name TELMISA/HCTZ TAB 40-12.5
Tier Value Tier 1
TELMISA/HCTZ TAB 80-12.5
Tier 1
X
TELMISA/HCTZ TAB 80-25MG
Tier 1
X
TELMISARTAN TAB 20MG
Tier 1
X
TELMISARTAN TAB 40MG
Tier 1
X
TELMISARTAN TAB 80MG
Tier 1
X
TEVETEN HCT TAB 600-25MG
Tier 3
X
VALSART/HCTZ TAB 160-12.5
Tier 1
X
VALSART/HCTZ TAB 160-25MG
Tier 1
X
VALSART/HCTZ TAB 320-12.5
Tier 1
X
VALSART/HCTZ TAB 320-25MG
Tier 1
X
VALSART/HCTZ TAB 80-12.5
Tier 1
X
VALSARTAN TAB 160MG
Tier 1
X
VALSARTAN TAB 320MG
Tier 1
X
VALSARTAN TAB 40MG
Tier 1
X
VALSARTAN TAB 80MG
Tier 1
X
ACCUPRIL
TAB 10MG
Tier 4
ACCUPRIL
TAB 20MG
Tier 4
ACCUPRIL
TAB 40MG
Tier 4
ACCUPRIL
TAB 5MG
Tier 4
ACCURETIC TAB 10-12.5
Tier 4
ACCURETIC TAB 20-12.5
Tier 4
ACCURETIC TAB 20-25MG
Tier 4
ACEON
TAB 4MG
Tier 4
ACEON
TAB 8MG
Tier 4
ALTACE
CAP 1.25MG
Tier 4
ALTACE
CAP 10MG
Tier 4
ALTACE
CAP 2.5MG
Tier 4
ALTACE
CAP 5MG
Tier 4
Page 14 of 279
Step Therapy
Specialty
Therapeutic Class Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs
Product Name BENAZEP/HCTZ TAB 10-12.5
Tier Value Tier 1
BENAZEP/HCTZ TAB 20-12.5
Tier 1
BENAZEP/HCTZ TAB 20-25MG
Tier 1
BENAZEP/HCTZ TAB 5-6.25
Tier 1
BENAZEPRIL TAB 10MG
Tier 1
BENAZEPRIL TAB 20MG
Tier 1
BENAZEPRIL TAB 40MG
Tier 1
BENAZEPRIL TAB 5MG
Tier 1
CAPTOPR/HCTZ TAB 25-15MG
Tier 1
CAPTOPR/HCTZ TAB 25-25MG
Tier 1
CAPTOPR/HCTZ TAB 50-15MG
Tier 1
CAPTOPR/HCTZ TAB 50-25MG
Tier 1
CAPTOPRIL TAB 100MG
Tier 1
CAPTOPRIL TAB 12.5MG
Tier 1
CAPTOPRIL TAB 25MG
Tier 1
CAPTOPRIL TAB 50MG
Tier 1
ENALAPR/HCTZ TAB 10-25MG
Tier 1
ENALAPR/HCTZ TAB 5-12.5MG
Tier 1
ENALAPRIL TAB 10MG
Tier 1
ENALAPRIL TAB 2.5MG
Tier 1
ENALAPRIL TAB 20MG
Tier 1
ENALAPRIL TAB 5MG
Tier 1
EPANED
Tier 4
SOL 1MG/ML
FOSINOP/HCTZ TAB 10/12.5
Tier 1
FOSINOP/HCTZ TAB 20/12.5
Tier 1
FOSINOPRIL TAB 10MG
Tier 1
FOSINOPRIL TAB 20MG
Tier 1
FOSINOPRIL TAB 40MG
Tier 1
LISINOP/HCTZ TAB 10-12.5
Tier 1
Page 15 of 279
Prior Authorization
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs
Product Name LISINOP/HCTZ TAB 20-12.5
Tier Value Tier 1
LISINOP/HCTZ TAB 20-25MG
Tier 1
LISINOPRIL TAB 10MG
Tier 1
LISINOPRIL TAB 2.5MG
Tier 1
LISINOPRIL TAB 20MG
Tier 1
LISINOPRIL TAB 30MG
Tier 1
LISINOPRIL TAB 40MG
Tier 1
LISINOPRIL TAB 5MG
Tier 1
LOTENSIN
TAB 10MG
Tier 4
LOTENSIN
TAB 20MG
Tier 4
LOTENSIN
TAB 40MG
Tier 4
LOTENSIN HCT TAB 10-12.5
Tier 4
LOTENSIN HCT TAB 20-12.5
Tier 4
LOTENSIN HCT TAB 20-25MG
Tier 4
MAVIK
TAB 1MG
Tier 4
MAVIK
TAB 2MG
Tier 4
MAVIK
TAB 4MG
Tier 4
MOEXIPR/HCTZ TAB 15-12.5
Tier 1
MOEXIPR/HCTZ TAB 15-25MG
Tier 1
MOEXIPR/HCTZ TAB 7.5-12.5
Tier 1
MOEXIPRIL TAB 15MG
Tier 1
MOEXIPRIL TAB 7.5MG
Tier 1
PERINDOPRIL TAB 2MG
Tier 1
PERINDOPRIL TAB 4MG
Tier 1
PERINDOPRIL TAB 8MG
Tier 1
PRINIVIL
TAB 10MG
Tier 4
PRINIVIL
TAB 20MG
Tier 4
PRINIVIL
TAB 5MG
Tier 4
QBRELIS
SOL 1MG/ML
Tier 4
Page 16 of 279
Prior Authorization
Supply Limit
Step Therapy
X
Specialty
Therapeutic Class Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs
Product Name QNAPRIL/HCTZ TAB 10-12.5
Tier Value Tier 1
QNAPRIL/HCTZ TAB 20-12.5
Tier 1
QNAPRIL/HCTZ TAB 20-25MG
Tier 1
QUINAPRIL TAB 10MG
Tier 1
QUINAPRIL TAB 20MG
Tier 1
QUINAPRIL TAB 40MG
Tier 1
QUINAPRIL TAB 5MG
Tier 1
RAMIPRIL
CAP 1.25MG
Tier 1
RAMIPRIL
CAP 10MG
Tier 1
RAMIPRIL
CAP 2.5MG
Tier 1
RAMIPRIL
CAP 5MG
Tier 1
TARKA
TAB 1-240 CR
Tier 4
TARKA
TAB 2-180 CR
Tier 4
TARKA
TAB 2-240 CR
Tier 4
TARKA
TAB 4-240 CR
Tier 4
Prior Authorization
Supply Limit
Step Therapy
TRANDO/VERAP TAB 1-240 CR
Tier 1
TRANDO/VERAP TAB 1-240 ER
Tier 1
TRANDO/VERAP TAB 2-180 CR
Tier 1
TRANDO/VERAP TAB 2-180 ER
Tier 1
TRANDO/VERAP TAB 2-240 CR
Tier 1
TRANDO/VERAP TAB 2-240 ER
Tier 1
TRANDO/VERAP TAB 4-240 CR
Tier 1
TRANDO/VERAP TAB 4-240 ER
Tier 1
TRANDOLAPRIL TAB 1MG
Tier 1
TRANDOLAPRIL TAB 2MG
Tier 1
TRANDOLAPRIL TAB 4MG
Tier 1
VASERETIC TAB 10-25MG
Tier 4
X
VASOTEC
TAB 10MG
Tier 4
X
VASOTEC
TAB 2.5MG
Tier 4
X
Page 17 of 279
Specialty
Therapeutic Class Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs Anthelmintics - Worm Infection Drugs Anthelmintics - Worm Infection Drugs Anthelmintics - Worm Infection Drugs Anthelmintics - Worm Infection Drugs Antiandrogens - Hormone Suppressants Antiandrogens - Hormone Suppressants Antiandrogens - Hormone Suppressants Antiandrogens - Hormone Suppressants Antiandrogens - Hormone Suppressants Antiandrogens - Hormone Suppressants Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiangiogenic Agents - Chemotherapy Agents Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs
Product Name VASOTEC TAB 20MG VASOTEC
TAB 5MG
Tier Value Tier 4
Prior Authorization
Supply Limit
Step Therapy X
Tier 4
X
ZESTORETIC TAB 10-12.5
Tier 4
X
ZESTORETIC TAB 20-12.5
Tier 4
X
ZESTORETIC TAB 20-25MG
Tier 4
X
ZESTRIL
TAB 10MG
Tier 4
X
ZESTRIL
TAB 2.5MG
Tier 4
X
ZESTRIL
TAB 20MG
Tier 4
X
ZESTRIL
TAB 30MG
Tier 4
X
ZESTRIL
TAB 40MG
Tier 4
X
ZESTRIL
TAB 5MG
Tier 4
X
Specialty
ALBENZA TAB 200MG BILTRICIDE TAB 600MG EMVERM CHW 100MG IVERMECTIN TAB 3MG BICALUTAMIDE TAB 50MG CASODEX TAB 50MG FLUTAMIDE CAP 125MG NILANDRON TAB 150MG NILUTAMIDE TAB 150MG XTANDI CAP 40MG CAPRELSA TAB 100MG
Tier 2 Tier 2 Tier 4 Tier 1 Tier 1 Tier 4 Tier 1 Tier 4 Tier 1 Tier 4 Tier 3
X X
X X
CAPRELSA
TAB 300MG
Tier 3
X
X
X
REVLIMID
CAP 10MG
Tier 3
X
X
X
REVLIMID
CAP 15MG
Tier 3
X
X
X
REVLIMID
CAP 2.5MG
Tier 3
X
X
X
REVLIMID
CAP 20MG
Tier 3
X
X
X
REVLIMID
CAP 25MG
Tier 3
X
X
X
REVLIMID
CAP 5MG
Tier 3
X
X
X
X
X
X X X X X X X
THALOMID
CAP 100MG
Tier 3
X
X
X
THALOMID
CAP 150MG
Tier 3
X
X
X
THALOMID
CAP 200MG
Tier 3
X
X
X
THALOMID
CAP 50MG
Tier 3
X
X
X
AMIODARONE TAB 100MG AMIODARONE TAB 200MG
Page 18 of 279
Tier 1 Tier 1
Therapeutic Class Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs
Tier Value Tier 1 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 2 Tier 4 Tier 2 Tier 3 Tier 1 Tier 3 Tier 1
Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs
Product Name AMIODARONE TAB 400MG BETAPACE TAB 120MG BETAPACE TAB 160MG BETAPACE TAB 80MG BETAPACE AF TAB 120MG BETAPACE AF TAB 160MG BETAPACE AF TAB 80MG CORDARONE TAB 200MG DISOPYRAMIDE CAP 100MG DISOPYRAMIDE CAP 150MG DOFETILIDE CAP 125MCG DOFETILIDE CAP 250MCG DOFETILIDE CAP 500MCG FLECAINIDE TAB 100MG FLECAINIDE TAB 150MG FLECAINIDE TAB 50MG MEXILETINE CAP 150MG MEXILETINE CAP 200MG MEXILETINE CAP 250MG MULTAQ TAB 400MG NORPACE CAP 100MG NORPACE CAP 100MG CR NORPACE CAP 150MG NORPACE CAP 150MG CR PACERONE TAB 100MG PACERONE TAB 200MG PACERONE TAB 400MG PROPAFENONE CAP 225MG ER PROPAFENONE CAP 325MG ER PROPAFENONE CAP 425MG SR PROPAFENONE TAB 150MG PROPAFENONE TAB 225MG PROPAFENONE TAB 300MG QUINIDINE GL TAB 324MG CR
Antiarrhythmics - Heart Regulation Drugs
QUINIDINE GL TAB 324MG ER
Tier 1
Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs
QUINIDINE SU TAB 200MG QUINIDINE SU TAB 300MG QUINIDINE SU TAB 300MG ER
Tier 1 Tier 1 Tier 1
Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs
RYTHMOL TAB 150MG RYTHMOL TAB 225MG RYTHMOL SR CAP 225MG RYTHMOL SR CAP 325MG RYTHMOL SR CAP 425MG SOTALOL AF TAB 120MG SOTALOL AF TAB 160MG SOTALOL AF TAB 80MG SOTALOL HCL TAB 120MG SOTALOL HCL TAB 160MG SOTALOL HCL TAB 240MG SOTALOL HCL TAB 80MG SOTYLIZE SOL 5MG/ML TIKOSYN CAP 125MCG
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4
Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs
Page 19 of 279
Prior Authorization
Supply Limit
Step Therapy X X X
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X
Specialty
Therapeutic Class Antiarrhythmics - Heart Regulation Drugs Antiarrhythmics - Heart Regulation Drugs Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
Prior Authorization
Supply Limit
Tier Value Tier 4 Tier 4 Tier 1 Tier 3
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
Product Name TIKOSYN CAP 250MCG TIKOSYN CAP 500MCG AK-POLY-BAC OIN OP ALCOH-GLOVE PAD CONTOURE ALCOHOL PREP PAD ALCOHOL PREP PAD 70% ALCOHOL PREP PAD 70% ALCOHOL PREP PAD 70% ALCOHOL PREP PAD 70% ALCOHOL PREP PAD MED 70%
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
ALCOHOL SWAB PAD ALCOH-WIPE PAD 12"X12" ALTABAX OIN 1% AZUPHEN MB CAP 120MG BACIT/POLYMY OIN OP BACITRACIN OIN OP BACTROBAN CRE 2% BACTROBAN OIN 2% BACTROBAN OIN NASAL 2%
Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 4 Tier 2
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
CENTANY OIN 2% CENTANY AT KIT 2% CLEOCIN CAP 150MG CLEOCIN CAP 300MG CLEOCIN CAP 75MG CLEOCIN CRE 2% VAG CLEOCIN SUP 100MG CLEOCIN PED SOL 75MG/5ML
Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 4 Tier 2 Tier 4
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
CLINDAMYCIN CLINDAMYCIN CLINDAMYCIN CLINDAMYCIN CLINDAMYCIN
CAP 150MG CAP 300MG CAP 75MG CRE 2% VAG SOL 75MG/5ML
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
CLINDESSE CRE 2% COLISTIMETH INJ 150MG COLY-MYCIN M INJ 150MG CORTISPORIN CRE 0.5% CORTISPORIN OIN 1% FLAGYL CAP 375MG FLAGYL TAB 250MG FLAGYL TAB 500MG FLAGYL ER TAB 750MG FURADANTIN SUS 25MG/5ML
Tier 2 Tier 1 Tier 4 Tier 2 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
GNP ALCOHOL PAD SWABS HIPREX TAB 1GM HYOLEV MB TAB 81MG HYOPHEN TAB INDIOMIN MB CAP 120MG IODINE TIN 2% LANSOPR/AMOX MIS /CLARITH
Tier 3 Tier 4 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1
X
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
LINEZOLID SUS 100/5ML LINEZOLID TAB 600MG
Tier 1 Tier 1
X X
Page 20 of 279
Step Therapy
Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3
X
X
X
X
Specialty
Therapeutic Class Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
Product Name LUGOLS SOL STRONG MACROBID CAP 100MG MACRODANTIN CAP 100MG
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
Tier 4 Tier 4 Tier 1 Tier 1 Tier 1
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
MACRODANTIN CAP 25MG MACRODANTIN CAP 50MG ME/NAPHOS/MB TAB HYO 1 METHENAM HIP TAB 1GM METHENAM MAN TAB 1000MG METHENAM MAN TAB 1GM METHENAM MAN TAB 500MG
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
METROCREAM CRE 0.75% METROGEL GEL 1% METROGEL-VAG GEL 0.75% METROLOTION LOT 0.75% METRONIDAZOL CAP 375MG
Tier 4 Tier 4 Tier 4 Tier 4 Tier 1
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
Tier 1 Tier 1 Tier 1
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
METRONIDAZOL CRE 0.75% METRONIDAZOL GEL 0.75% METRONIDAZOL GEL 0.75%VAG METRONIDAZOL GEL 1% METRONIDAZOL LOT 0.75% METRONIDAZOL TAB 250MG METRONIDAZOL TAB 500MG MITOSOL KIT 0.2MG MONUROL PAK GRANULES
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
MUPIROCIN CRE 2% MUPIROCIN OIN 2% MUPIROCIN CA CRE 2% NEO/BAC/POLY OIN OP NEO/POLY/GRA SOL OP NEO-POLYCIN OIN OP NEOSPORIN SOL OP NITROFUR MAC CAP 100MG NITROFUR MAC CAP 25MG NITROFUR MAC CAP 50MG NITROFURANTN CAP 100MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
Antibacterials, Other - Antibiotics
Tier 1
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
NITROFURANTN SUS 25MG/5ML NORITATE CRE 1% NUVESSA GEL 1.3% OMECLAMOX- MIS PAK PHOSPHASAL TAB POLYCIN OIN OP POLYCIN B OIN OP POLYMYXIN B/ SOL TRIMETHP
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
POLYTRIM SOL OP PREP PADS PAD PREVPAC MIS PRIMSOL SOL 50MG/5ML QC ALCOHOL PAD SWABS RA ALCOHOL PAD SWABS
Tier 4 Tier 3 Tier 4 Tier 3 Tier 3 Tier 3
Page 21 of 279
Tier Value Tier 1 Tier 4 Tier 4
Prior Authorization
Supply Limit
Step Therapy
Tier 1 Tier 1
X X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
X
X X
X X X
X
X
Specialty
Prior Authorization
Therapeutic Class Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
Product Name ROSADAN CRE 0.75% ROSADAN GEL 0.75% SILVADENE CRE 1% SILVER SULFA CRE 1% SIVEXTRO TAB 200MG SM ALCOHOL PAD PREP SSD CRE 1% SULFAMYLON CRE 85MG/GM
Tier Value Tier 1 Tier 1 Tier 4 Tier 1 Tier 3 Tier 3 Tier 1 Tier 3
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
SULFAMYLON PAK 5% TRIMETHOPRIM SOL POLYMYXN TRIMETHOPRIM TAB 100MG ULTILET ALCH PAD SWAB UR N-C TAB URAMIT MB CAP 118MG URELLE TAB URETRON D/S TAB URIBEL CAP 118MG URIMAR-T TAB URIN D/S TAB URO-458 TAB UROAV-81 TAB UROAV-B CAP URO-BLUE TAB 81.6MG UROGESIC- TAB BLUE URO-L TAB 81MG UROLET MB TAB URO-MP CAP 118MG UROPHEN MB TAB 81.6MG URYL TAB USTELL CAP UTA CAP 120MG UTICAP CAP UTIRA-C TAB UTRONA-C TAB VANCOCIN HCL CAP 250MG VANCOMYCIN CAP 125MG VANCOMYCIN CAP 250MG VANCOMYCIN SUS +SYRSPEN
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1 Tier 3
X
Tier 3
X
Tier 3
X
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Anticholinergics - Parkinson's Disease Drugs
VANCOMYCN 25 SOL 25MG/ML VANCOMYCN 50 SOL 50MG/ML VANDAZOLE GEL 0.75% V-R ALC PREP PAD SWABS XIFAXAN TAB 200MG XIFAXAN TAB 550MG ZYVOX SUS 100MG/5M ZYVOX TAB 600MG BENZTROPINE TAB 0.5MG
Anticholinergics - Parkinson's Disease Drugs
BENZTROPINE TAB 1MG
Tier 1
Anticholinergics - Parkinson's Disease Drugs
BENZTROPINE TAB 2MG
Tier 1
Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics
Page 22 of 279
Tier 1 Tier 1 Tier 3 Tier 3 Tier 4 Tier 4 Tier 1
Supply Limit
Step Therapy
X
X X X
X X
X X X X
X
Specialty
Prior Authorization
Supply Limit
Therapeutic Class Anticholinergics - Parkinson's Disease Drugs
Product Name TRIHEXYPHEN ELX 0.4MG/ML
Anticholinergics - Parkinson's Disease Drugs
TRIHEXYPHEN TAB 2MG
Tier 1
Anticholinergics - Parkinson's Disease Drugs
TRIHEXYPHEN TAB 5MG
Tier 1
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
ARIXTRA INJ 10/0.8ML ARIXTRA INJ 2.5/0.5 ARIXTRA INJ 5/0.4ML ARIXTRA INJ 7.5/0.6 COUMADIN TAB 10MG COUMADIN TAB 1MG COUMADIN TAB 2.5MG COUMADIN TAB 2MG COUMADIN TAB 3MG COUMADIN TAB 4MG COUMADIN TAB 5MG COUMADIN TAB 6MG COUMADIN TAB 7.5MG ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG ENOXAPARIN INJ 100MG/ML
Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 1
X X X X
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
ENOXAPARIN INJ 120/0.8 ENOXAPARIN INJ 150MG/ML
Tier 1 Tier 1
X X
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
ENOXAPARIN INJ 30/0.3ML ENOXAPARIN INJ 300/3ML ENOXAPARIN INJ 40/0.4ML ENOXAPARIN INJ 60/0.6ML ENOXAPARIN INJ 80/0.8ML FONDAPARINUX INJ 10/0.8ML
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X X X X X X
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
FONDAPARINUX INJ 2.5/0.5 FONDAPARINUX INJ 5/0.4ML
Tier 1 Tier 1
X X
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
FONDAPARINUX INJ 7.5/0.6 FRAGMIN INJ 10000/ML FRAGMIN INJ 12500UNT FRAGMIN INJ 15000UNT FRAGMIN INJ 18000UNT FRAGMIN INJ 2500/0.2 FRAGMIN INJ 5000/0.2 FRAGMIN INJ 7500/0.3 FRAGMIN INJ 95000UNT HEPARIN LOCK INJ 100/ML HEPARIN LOCK INJ 10UNT/ML
Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1
X X X X X X X X
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
HEPARIN SOD INJ 1000/ML HEPARIN SOD INJ 10000/ML HEPARIN SOD INJ 10000/ML HEPARIN SOD INJ 2000/ML HEPARIN SOD INJ 20000/ML HEPARIN SOD INJ 2500/ML HEPARIN SOD INJ 5000/0.5 HEPARIN SOD INJ 5000/ML HEPARIN SOD INJ 5000U JANTOVEN TAB 10MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Page 23 of 279
Tier Value Tier 1
X X X
Step Therapy
Specialty
Therapeutic Class Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
Product Name JANTOVEN TAB 1MG JANTOVEN TAB 2.5MG JANTOVEN TAB 2MG JANTOVEN TAB 3MG JANTOVEN TAB 4MG JANTOVEN TAB 5MG JANTOVEN TAB 6MG JANTOVEN TAB 7.5MG LOVENOX INJ 100MG/ML LOVENOX INJ 120/0.8 LOVENOX INJ 150MG/ML LOVENOX INJ 30/0.3ML LOVENOX INJ 300/3ML LOVENOX INJ 40/0.4ML LOVENOX INJ 60/0.6ML LOVENOX INJ 80/0.8ML PRADAXA CAP 110MG PRADAXA CAP 150MG PRADAXA CAP 75MG WARFARIN TAB 10MG WARFARIN TAB 1MG WARFARIN TAB 2.5MG WARFARIN TAB 2MG WARFARIN TAB 3MG WARFARIN TAB 4MG WARFARIN TAB 5MG WARFARIN TAB 6MG WARFARIN TAB 7.5MG WARFARIN SOD TAB 10MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG XARELTO STAR TAB 15/20MG
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
Prior Authorization
Supply Limit
Step Therapy
X X X X X X X X X X X
X X X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 200MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 400MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 600MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 800MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
SOL 100MG/ML
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 1000MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 250MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 500MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 750MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA XR TAB 500MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA XR TAB 750MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA SOL 100MG/ML
Tier 1
Page 24 of 279
Specialty
Prior Authorization
Therapeutic Class Product Name Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA SOL 500/5ML
Tier Value Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 1000MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 250MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 500MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 500MG ER
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 750MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 750MG ER
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB ELX 20/5ML
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB ELX 20MG/5ML
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB SOL 20MG/5ML
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 100MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 15MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 16.2MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 30MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 32.4MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 60MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 64.8MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 97.2MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 200MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 300MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 400MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 50MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs ROWEEPRA
Supply Limit
Step Therapy
TAB 500MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 1000MG
Tier 4
X
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 250MG
Tier 4
X
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 500MG
Tier 4
X
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 750MG
Tier 4
X
Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs
VALCYTE
SOL 50MG/ML
Tier 3
VALCYTE
TAB 450MG
Tier 4
Page 25 of 279
X
X
Specialty
Therapeutic Class Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs Antidementia Agents, Other
Product Name VALGANCICLOV TAB 450MG ZIRGAN
GEL 0.15%
Tier Value Tier 1
Prior Authorization
Tier 3
Supply Limit X
Step Therapy
X
Tier 1
Antidepressants, Other - Antidepressants
ERGOLOID MES TAB 1MG ORAL APLENZIN TAB 174MG
Tier 4
X
X
X
Antidepressants, Other - Antidepressants
APLENZIN
TAB 348MG
Tier 4
X
X
X
Antidepressants, Other - Antidepressants
APLENZIN
TAB 522MG
Tier 4
X
X
X
Antidepressants, Other - Antidepressants
BRINTELLIX TAB 10MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
BRINTELLIX TAB 20MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
BRINTELLIX TAB 5MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
BUPROPION TAB 100MG
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 100MG ER
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 100MG SR
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 150MG ER
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 150MG SR
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 200MG ER
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 200MG SR
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 75MG
Tier 1
Antidepressants, Other - Antidepressants
BUPROPN HCL TAB 150MG XL
Tier 1
Antidepressants, Other - Antidepressants
BUPROPN HCL TAB 300MG XL
Tier 1
Antidepressants, Other - Antidepressants
FORFIVO XL TAB 450MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
MAPROTILINE TAB 25MG
Tier 1
Antidepressants, Other - Antidepressants
MAPROTILINE TAB 50MG
Tier 1
Antidepressants, Other - Antidepressants
MAPROTILINE TAB 75MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 15MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 15MG ODT
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 30MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 30MG ODT
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 45MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 45MG ODT
Tier 1
Page 26 of 279
X
Specialty
Supply Limit
Step Therapy
Tier 4
X
X
TAB 24HR300
Tier 4
X
X
REMERON
TAB 15MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON
TAB 30MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON
TAB 45MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON SLTB TAB 15MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON SLTB TAB 30MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON SLTB TAB 45MG
Tier 4
Antidepressants, Other - Antidepressants
TRAZODONE TAB 100MG
Tier 1
Antidepressants, Other - Antidepressants
TRAZODONE TAB 150MG
Tier 1
Antidepressants, Other - Antidepressants
TRAZODONE TAB 300MG
Tier 1
Antidepressants, Other - Antidepressants
TRAZODONE TAB 50MG
Tier 1
Antidepressants, Other - Antidepressants
TRINTELLIX TAB 10MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
TRINTELLIX TAB 20MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
TRINTELLIX TAB 5MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 100MG
Tier 4
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 100MG SR
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 150MG SR
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 200MG SR
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 75MG
Tier 4
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB XL 150MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB XL 300MG
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
ACARBOSE ACARBOSE
Tier 1 Tier 1
Therapeutic Class Antidepressants, Other - Antidepressants
Product Name MIRTAZAPINE TAB 7.5MG
Tier Value Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 100MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 150MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 200MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 250MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 50MG
Tier 1
Antidepressants, Other - Antidepressants
OLEPTRO
TAB 24HR150
Antidepressants, Other - Antidepressants
OLEPTRO
Antidepressants, Other - Antidepressants
TAB 100MG TAB 25MG
Page 27 of 279
Prior Authorization
X
X
Specialty
Therapeutic Class Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
Tier Value Tier 1 Tier 4
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
Product Name ACARBOSE TAB 50MG ACTOPLUS MET TAB 15500MG ACTOPLUS MET TAB 15850MG ACTOPLUS MET TAB XR ACTOPLUS MET TAB XR ACTOS TAB 15MG ACTOS TAB 30MG ACTOS TAB 45MG ALOG/PIOGLIP TAB 12.5-15 ALOG/PIOGLIP TAB 12.5-30 ALOG/PIOGLIT TAB 12.5-45 ALOG/PIOGLIT TAB 25-15MG
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Prior Authorization
Supply Limit
Step Therapy
X
Tier 4
X
Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
X X X X X X X X X
X X X X X X X
ALOG/PIOGLIT TAB 25-30MG
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs
ALOG/PIOGLIT TAB 25-45MG
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
ALOGLIPTIN ALOGLIPTIN ALOGLIPTIN ALOGLIPTIN/
TAB 12.5MG TAB 25MG TAB 6.25MG TAB METFORM
Tier 4 Tier 4 Tier 4 Tier 4
X X X X
X X X X
Antidiabetic Agents - Diabetic Drugs
ALOGLIPTIN/ TAB METFORM
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
AMARYL TAB 1MG AMARYL TAB 2MG AMARYL TAB 4MG AVANDAMET TAB 2-1000MG
Tier 4 Tier 4 Tier 4 Tier 3
X
Antidiabetic Agents - Diabetic Drugs
AVANDAMET TAB 4-500MG
Tier 3
X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
AVANDARYL TAB 4-1MG AVANDARYL TAB 4-2MG AVANDARYL TAB 8-4MG AVANDIA TAB 2MG AVANDIA TAB 4MG AVANDIA TAB 8MG BYDUREON INJ BYDUREON INJ BYETTA INJ 10MCG BYETTA INJ 5MCG CHLORPROPAM TAB 100MG CHLORPROPAM TAB 250MG CYCLOSET TAB 0.8MG DIABETA TAB 1.25MG DIABETA TAB 2.5MG DIABETA TAB 5MG DUETACT TAB 30-2MG DUETACT TAB 30-4MG FARXIGA TAB 10MG FARXIGA TAB 5MG FORTAMET TAB 1000MG FORTAMET TAB 500MG GLIMEPIRIDE TAB 1MG GLIMEPIRIDE TAB 2MG GLIMEPIRIDE TAB 4MG
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 3 Tier 3 Tier 4 Tier 4 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1
X X X X X X X X X X
Page 28 of 279
X X X X
X X X X X X
Specialty
Prior Authorization
Therapeutic Class Antidiabetic Agents - Diabetic Drugs
Product Name GLIP/METFORM TAB 2.5-250M
Tier Value Tier 1
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
GLIP/METFORM TAB 2.5-500 GLIP/METFORM TAB 2.5-500M
Tier 1 Tier 1
Antidiabetic Agents - Diabetic Drugs
GLIP/METFORM TAB 5-500MG
Tier 1
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
GLIPIZIDE POW GLIPIZIDE TAB 10MG GLIPIZIDE TAB 5MG GLIPIZIDE ER TAB 10MG GLIPIZIDE ER TAB 2.5MG GLIPIZIDE ER TAB 5MG GLIPIZIDE XL TAB 10MG GLIPIZIDE XL TAB 2.5MG GLIPIZIDE XL TAB 5MG GLUCOPHAGE TAB 1000MG GLUCOPHAGE TAB 500MG GLUCOPHAGE TAB 500MG XR
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4
X
Antidiabetic Agents - Diabetic Drugs
GLUCOPHAGE TAB 750MG XR
Tier 4
X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
GLUCOPHAGE TAB 850MG GLUCOTROL TAB 10MG GLUCOTROL TAB 5MG GLUCOTROL XL TAB 10MG GLUCOTROL XL TAB 2.5MG GLUCOTROL XL TAB 5MG GLUCOVANCE TAB 1.25-250
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
GLUCOVANCE TAB 2.5-500 GLUCOVANCE TAB 5-500MG
Tier 4 Tier 4
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
GLUMETZA TAB 1000MG GLUMETZA TAB 500MG GLYB/METFORM TAB 1.25-250
Tier 4 Tier 4 Tier 1
Antidiabetic Agents - Diabetic Drugs
GLYB/METFORM TAB 2.5-500
Tier 1
Antidiabetic Agents - Diabetic Drugs
GLYB/METFORM TAB 5-500MG
Tier 1
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
GLYBURID MCR TAB 1.5MG GLYBURID MCR TAB 3MG GLYBURID MCR TAB 6MG GLYBURIDE POW GLYBURIDE TAB 1.25MG GLYBURIDE TAB 2.5MG GLYBURIDE TAB 5MG GLYNASE TAB 1.5MG GLYNASE TAB 3MG GLYNASE TAB 6MG GLYSET TAB 100MG GLYSET TAB 25MG GLYSET TAB 50MG INVOKAMET TAB 150-1000 INVOKAMET TAB 150-500 INVOKAMET TAB 50-1000
Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 2 Tier 2
Page 29 of 279
Supply Limit
X X
Step Therapy
X X
X X X
Specialty
Prior Authorization
Supply Limit X
Step Therapy
Therapeutic Class Antidiabetic Agents - Diabetic Drugs
Product Name INVOKAMET TAB 50-500MG
Tier Value Tier 2
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
INVOKANA TAB 100MG INVOKANA TAB 300MG JANUMET TAB 50-1000 JANUMET TAB 50-500MG JANUMET XR TAB 100-1000 JANUMET XR TAB 50-1000 JANUMET XR TAB 50-500MG
Tier 2 Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
JANUVIA TAB 100MG JANUVIA TAB 25MG JANUVIA TAB 50MG JARDIANCE TAB 10MG JARDIANCE TAB 25MG JENTADUETO TAB 2.5-1000 JENTADUETO TAB 2.5-500 JENTADUETO TAB 2.5-850 JENTADUETO TAB XR JENTADUETO TAB XR KAZANO 12.5- TAB 1000MG KAZANO 12.5- TAB 500MG KOMBIGLYZE TAB 2.5-1000 KOMBIGLYZE TAB 5-1000MG
Tier 4 Tier 4 Tier 4 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 4 Tier 4 Tier 2 Tier 2 Tier 2 Tier 2
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
KOMBIGLYZE METFORMIN METFORMIN METFORMIN METFORMIN
TAB 5-500MG TAB 1000MG TAB 1000MG TAB 500MG TAB 500MG ER
Tier 2 Tier 1 Tier 1 Tier 1 Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 500MG ER
Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 500MG ER
Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 750MG ER
Tier 1
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 850MG METFORMIN ER TAB 1000MG
Tier 1 Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
MIGLITOL TAB 100MG MIGLITOL TAB 25MG MIGLITOL TAB 50MG NATEGLINIDE TAB 120MG NATEGLINIDE TAB 60MG NESINA TAB 12.5MG NESINA TAB 25MG NESINA TAB 6.25MG ONGLYZA TAB 2.5MG ONGLYZA TAB 5MG OSENI TAB 12.5-15 OSENI TAB 12.5-30 OSENI TAB 12.5-45 OSENI TAB 25-15MG OSENI TAB 25-30MG OSENI TAB 25-45MG PIOGLIT/GLIM TAB 30-2MG PIOGLIT/GLIM TAB 30-4MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1
Page 30 of 279
X X X X X X X X X X
X X X X X X X X X X X X X X X
X X
X X X X X X X
X X X X X X X X X X X X X X X
Specialty
Prior Authorization
Supply Limit X
Therapeutic Class Antidiabetic Agents - Diabetic Drugs
Product Name PIOGLITA/MET TAB 15-500MG
Tier Value Tier 1
Antidiabetic Agents - Diabetic Drugs
PIOGLITA/MET TAB 15-850MG
Tier 1
X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
PIOGLITAZONE TAB 15MG PIOGLITAZONE TAB 30MG PIOGLITAZONE TAB 45MG PRANDIMET TAB 1-500MG PRANDIMET TAB 2-500MG PRANDIN TAB 0.5MG PRANDIN TAB 1MG PRANDIN TAB 2MG PRECOSE TAB 100MG PRECOSE TAB 25MG PRECOSE TAB 50MG REPAGLINIDE TAB 0.5MG REPAGLINIDE TAB 1-500MG REPAGLINIDE TAB 1MG REPAGLINIDE TAB 2-500MG REPAGLINIDE TAB 2MG RIOMET SOL RIOMET SOL 500/5ML STARLIX TAB 120MG STARLIX TAB 60MG SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG
Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 4 Tier 4 Tier 3 Tier 3
X X X
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidotes - Antidotes/Protectants Antidotes - Antidotes/Protectants Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs Antiemetics, Other - Nausea and Vomiting Drugs Antiemetics, Other - Nausea and Vomiting Drugs Antiestrogens/Modifiers - Chemotherapy Agents Antiestrogens/Modifiers - Chemotherapy Agents Antiestrogens/Modifiers - Chemotherapy Agents Antiestrogens/Modifiers - Chemotherapy Agents Antiestrogens/Modifiers - Chemotherapy Agents Antifungals - Fungal Infection Drugs
TANZEUM INJ 30MG TANZEUM INJ 50MG TOLAZAMIDE TAB 250MG TOLAZAMIDE TAB 500MG TOLBUTAMIDE TAB 500MG TRADJENTA TAB 5MG VICTOZA INJ 18MG/3ML VICTOZA INJ 18MG/3ML VICTOZA INJ 18MG/3ML VICTOZA INJ 18MG/3ML CETYLEV TAB 2.5GM CETYLEV TAB 500MG DICLEGIS TAB 10-10MG
Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 2 Tier 2 Tier 4 Tier 4 Tier 3
X X
TIGAN
Tier 4
CAP 300MG
Step Therapy
Specialty
X X X
X X X
X X X
X X X X X X X X
TRANSDERM-SC DIS 1MG
Tier 3
TRIMETHOBENZ CAP 300MG
Tier 1
EMCYT
CAP 140MG
Tier 3
X
TAB 60MG
Tier 3
X
FARESTON SOLTAMOX
SOL 10MG/5ML
Tier 4
TAMOXIFEN TAB 10MG
Tier 1
TAMOXIFEN TAB 20MG
HCR Preventative
ANCOBON
CAP 250MG
Page 31 of 279
Tier 4
X
Therapeutic Class Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs
Product Name ANCOBON CAP 500MG AVC CRE 15% BIO-STATIN CAP 1000000 BIO-STATIN CAP 500000 BIO-STATIN POW CICLODAN CRE 0.77% CICLODAN SOL 8% CICLODAN CRE KIT 0.77% CICLODAN SOL KIT 8% CICLOPIROX CRE 0.77% CICLOPIROX GEL 0.77% CICLOPIROX KIT 8% CICLOPIROX SHA 1% CICLOPIROX SOL 8% CICLOPIROX SUS 0.77% CLOTRIM/BETA CRE 1-0.05% CLOTRIM/BETA CRE DIPROP CLOTRIM/BETA LOT DIPROP CLOTRIMAZOLE LOZ 10MG CLOTRIMAZOLE TRO 10MG CNL8 NAIL KIT DIFLUCAN SUS 10MG/ML DIFLUCAN SUS 40MG/ML DIFLUCAN TAB 100MG DIFLUCAN TAB 150MG DIFLUCAN TAB 200MG DIFLUCAN TAB 50MG ECONAZOLE CRE 1% ECOZA AER 1% ERTACZO CRE 2% EXELDERM CRE 1% EXELDERM SOL 1% EXTINA AER 2% FLUCONAZOLE SUS 10MG/ML
Tier Value Tier 3 Tier 2 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 4 Tier 4 Tier 3 Tier 3 Tier 4 Tier 1
Antifungals - Fungal Infection Drugs
FLUCONAZOLE SUS 40MG/ML
Tier 1
Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs
FLUCONAZOLE TAB 100MG FLUCONAZOLE TAB 150MG FLUCONAZOLE TAB 200MG FLUCONAZOLE TAB 50MG FLUCYTOSINE CAP 250MG FLUCYTOSINE CAP 500MG GRIFULVIN V TAB 500MG GRISEOFULVIN SUS 125/5ML GRISEOFULVIN TAB MICR 500
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1
Antifungals - Fungal Infection Drugs
GRISEOFULVIN TAB ULTR 125
Tier 1
Antifungals - Fungal Infection Drugs
GRISEOFULVIN TAB ULTR 250
Tier 1
Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs
GRIS-PEG TAB 125MG GRIS-PEG TAB 250MG GYNAZOLE-1 CRE 2% ITRACONAZOLE CAP 100MG JUBLIA SOL 10% KETOCONAZOLE AER 2% KETOCONAZOLE CRE 2%
Tier 4 Tier 4 Tier 3 Tier 1 Tier 4 Tier 1 Tier 1
Page 32 of 279
Prior Authorization
Supply Limit
Step Therapy
X X
X
X X
X X
X X
X
X
X X X
X
Specialty
Therapeutic Class Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs
Product Name KETOCONAZOLE SHA 2% KETOCONAZOLE TAB 200MG KETODAN AER 2% KETODAN KIT 2% LAMISIL GRA 125MG LAMISIL GRA 187.5MG LAMISIL SPR 1% LAMISIL TAB 250MG LOPROX CRE 0.77% LOPROX KIT 0.77% LOPROX SHA 1% LOTRISONE CRE LUZU CRE 1% MENTAX CRE 1% MICONAZOLE 3 SUP 200MG NAFTIFINE CRE HCL 1% NAFTIFINE CRE HCL 2% NAFTIN CRE 1% NAFTIN CRE 2% NAFTIN GEL 1% NAFTIN GEL 2% NATACYN SUS 5% OP NIZORAL SHA 2% NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG NYAMYC POW 100000 NYSTAT/TRIAM CRE NYSTAT/TRIAM OIN NYSTATIN CRE 100000 NYSTATIN OIN 100000 NYSTATIN POW NYSTATIN POW 100000 NYSTATIN SUS 100000 NYSTATIN TAB 500000 NYSTOP POW 100000 ONMEL TAB 200MG ORAVIG TAB 50MG OXICONAZOLE CRE NITR 1% OXICONAZOLE CRE NITRATE
Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs
OXISTAT CRE 1% OXISTAT LOT 1% PEDIADERM AF KIT COMPLETE
Tier 4 Tier 4 Tier 4
Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs
PENLAC SOL 8% SPORANOX CAP 100MG SPORANOX CAP PULSEPAK
Tier 4 Tier 4 Tier 4
Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs
SPORANOX SOL 10MG/ML TERAZOL 3 CRE 0.8% TERAZOL 7 CRE 0.4% TERBINAFINE TAB 250MG TERCONAZOLE CRE 0.4% TERCONAZOLE CRE 0.8% TERCONAZOLE SUP 80MG VFEND SUS 40MG/ML VFEND TAB 200MG VFEND TAB 50MG
Tier 2 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 3
Page 33 of 279
Tier Value Tier 1 Tier 1 Tier 1 Tier 4 Tier 3 Tier 3 Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 3 Tier 1 Tier 1
Prior Authorization
Supply Limit
Step Therapy
X X X X X X X X X X
X
X X X X X X
X X
X
X
X X
X X
X X
X
X
X X X X
X X X
X
X X
Specialty
Therapeutic Class Antifungals - Fungal Infection Drugs
Product Name VORICONAZOLE SUS 40MG/ML
Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antifungals - Fungal Infection Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs
VORICONAZOLE TAB 200MG VORICONAZOLE TAB 50MG XOLEGEL GEL 2% ZAZOLE CRE 0.8% ZAZOLE SUP 80MG ALLOPURINOL TAB 100MG ALLOPURINOL TAB 300MG COLCHICINE CAP 0.6MG COLCHICINE TAB 0.6MG COLCRYS TAB 0.6MG MITIGARE CAP 0.6MG PROBEN/COLCH TAB 500-0.5
Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 2 Tier 1
Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antigout Agents - Gout Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs
PROBENECID TAB 500MG ULORIC TAB 40MG ULORIC TAB 80MG ZYLOPRIM TAB 100MG ZYLOPRIM TAB 300MG ADEFOV DIPIV TAB 10MG BARACLUDE SOL .05MG/ML
Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 3
Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs
BARACLUDE TAB 0.5MG BARACLUDE TAB 1MG COPEGUS TAB 200MG ENTECAVIR TAB 0.5MG ENTECAVIR TAB 1MG HEPSERA TAB 10MG INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU MODERIBA PAK 1000/DAY MODERIBA PAK 1200/DAY MODERIBA PAK 600/DAY MODERIBA PAK 800/DAY MODERIBA TAB 200MG OLYSIO CAP 150MG PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEGASYS INJ PROCLICK PEGINTRON KIT 120MCG PEGINTRON KIT 150MCG PEGINTRON KIT 50MCG PEGINTRON KIT 80MCG PEG-INTRON KIT 120 RP PEG-INTRON KIT 120MCG PEG-INTRON KIT 150 RP PEG-INTRON KIT 150MCG PEG-INTRON KIT 50MCG PEG-INTRON KIT 50MCG RP PEG-INTRON KIT 80MCG PEG-INTRON KIT 80MCG RP REBETOL CAP 200MG REBETOL SOL 40MG/ML
Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3
Page 34 of 279
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Specialty
X X
X X X
X X
X X
X X
X X X X X
X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Therapeutic Class Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antiherpetic Agents - Herpes Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
Product Name RIBAPAK PAK 1000/DAY RIBAPAK PAK 1200/DAY RIBAPAK PAK 600/DAY RIBAPAK PAK 800/DAY RIBASPHERE CAP 200MG RIBASPHERE TAB 200MG RIBASPHERE TAB 400MG RIBASPHERE TAB 600MG RIBATAB PAK 1000/DAY RIBATAB TAB 1200/DAY RIBATAB TAB 800/DAY RIBAVIRIN CAP 200MG RIBAVIRIN TAB 200MG SOVALDI TAB 400MG TYZEKA TAB 600MG VICTRELIS CAP 200MG VIRAZOLE INH 6GM ACYCLOVIR CAP 200MG ACYCLOVIR OIN 5% ACYCLOVIR SUS 200/5ML ACYCLOVIR TAB 400MG ACYCLOVIR TAB 800MG DENAVIR CRE 1% FAMCICLOVIR TAB 125MG FAMCICLOVIR TAB 250MG FAMCICLOVIR TAB 500MG FAMVIR TAB 125MG FAMVIR TAB 250MG FAMVIR TAB 500MG LIDOVIR OIN 4-4% SITAVIG TAB 50MG TRIFLURIDINE SOL 1% OP VALACYCLOVIR TAB 1GM VALACYCLOVIR TAB 500MG VALTREX TAB 1GM VALTREX TAB 500MG VIROPTIC SOL 1% OP XERESE CRE 5-1% ZOVIRAX CAP 200MG ZOVIRAX CRE 5% ZOVIRAX OIN 5% ZOVIRAX SUS 200/5ML ZOVIRAX TAB 400MG ZOVIRAX TAB 800MG ANDEHIST SYP 4-60MG/5 ARBINOXA SOL 4MG/5ML ARBINOXA TAB 4MG ASTEPRO SPR 0.15% AZELASTINE SPR 0.1% AZELASTINE SPR 0.15% BROM/PSE/DM SYP BROMFED DM SYP BROMPHENIRAM CHW 12MG
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
CARBAPHEN 12 LIQ CARBAPHEN 12 SUS PED CARBINOXAMIN SOL 4MG/5ML
Page 35 of 279
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 4 Tier 4 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 2 Tier 1 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
Prior Authorization
Supply Limit
Step Therapy X X X X
X
X
X
X
X
X
X
X
X X X X X X X X X
X
X X X X
X X X
X
X X
X X
X X X
Specialty X X X X X X X X X X X X X X X X
Supply Limit
Step Therapy
X X
X X X
Tier 1 Tier 3 Tier 2 Tier 1
X
X
DESLORATADIN TAB 5MG DESLORATADIN TAB 5MG ODT
Tier 1 Tier 1
X X
X X
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
DICOPANOL SUS 5MG/ML DICOPANOL SUS RAPIDPAQ
Tier 3 Tier 3
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
DM/CPM/PE DRO DYMISTA SPR 137-50 GNP ALLERGY ELX CHILDREN
Tier 1 Tier 4 Tier 1
X
X
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
GNP DIPHEDRY CAP 25MG GNP SUPHEDRI TAB PLUS HYD POL/CPM SUS 10-8/5ML
Tier 1 Tier 1 Tier 1
X
Antihistamines - Allergy Drugs
HYDR/CPM/PSE LIQ 5-4-60MG
Tier 1
X
Antihistamines - Allergy Drugs
HYDRO/CHLOR/ LIQ 5-4-60MG
Tier 1
X
Antihistamines - Allergy Drugs
HYDROXYZ HCL SOL 10MG/5ML HYDROXYZ HCL SYP 10MG/5ML HYDROXYZ HCL TAB 10MG HYDROXYZ HCL TAB 25MG HYDROXYZ HCL TAB 50MG HYDROXYZ PAM CAP 100MG HYDROXYZ PAM CAP 25MG HYDROXYZ PAM CAP 50MG KARBINAL ER SUS 4MG/5ML LEVOCETIRIZI SOL 2.5/5ML LEVOCETIRIZI TAB 5MG LEXUSS 210 LIQ 2-10/5ML MDL ANTIHIST ELX 12.5/5ML MED 12HR REL TAB 6-120 CR NEOTUSS PLUS LIQ OLOPATADINE SPR 0.6% PATANASE SPR 0.6% PHENADOZ SUP 12.5MG PHENADOZ SUP 25MG PHENERGAN SUP 12.5MG PHENERGAN SUP 25MG PHENERGAN SUP 50MG PROMETH VC SYP PLAIN
Tier 1
Therapeutic Class Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
Product Name CARBINOXAMIN TAB 4MG CLARINEX SYP 0.5MG/ML CLARINEX TAB 5MG CLARINEX-D TAB 2.5-120 CLEMASTINE SYP 0.5/5ML CLEMASTINE TAB 2.68MG CODAR AR LIQ 2-8/5ML CPB WC LIQ CYPROHEPTAD SYP 2MG/5ML
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
CYPROHEPTAD TAB 4MG DECON-A ELX 2-5MG/5M DECON-G DRO 2-1-40MG DESLORATADIN TAB 2.5 ODT
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
Page 36 of 279
Tier Value Tier 1 Tier 3 Tier 4 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
Prior Authorization
X X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X X
X X
Specialty
Prior Authorization
Supply Limit
Step Therapy
Therapeutic Class Antihistamines - Allergy Drugs
Product Name PROMETH VC/ SYP CODEINE
Tier Value Tier 1
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
PROMETH/COD SYP 6.25-10 PROMETH/PE SYP 6.25-5/5 PROMETH/PE SYP 6.25-5/5 PROMETH/PE SYP 6.25-5/5 PROMETH/PE SYP 6.25-5/5 PROMETH/PE/ SYP CODEINE
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
Antihistamines - Allergy Drugs
PROMETHAZINE SOL 6.25/5ML
Tier 1
Antihistamines - Allergy Drugs
PROMETHAZINE SUP 12.5MG
Tier 1
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
PROMETHAZINE SUP 25MG PROMETHAZINE SUP 50MG PROMETHAZINE SYP 6.25/5ML
Tier 1 Tier 1 Tier 1
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
PROMETHAZINE SYP DM PROMETHAZINE TAB 12.5MG
Tier 1 Tier 1
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
PROMETHAZINE TAB 25MG PROMETHAZINE TAB 50MG PROMETHEGAN SUP 12.5MG
Tier 1 Tier 1 Tier 1
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
PROMETHEGAN SUP 25MG PROMETHEGAN SUP 50MG RELHIST CHW RESPA-BR TAB 11MG SEMPREX-D CAP 8-60MG TGQ 15DM/5PE SYP H/2CPM TGQ 30/PSE/3 SYP BRM/15DM
Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 1 Tier 1
Antihistamines - Allergy Drugs
TGQ 50PSE/3 SYP BRM/30DM
Tier 1
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
TUSNEL CAP TUSSICAPS CAP 10-8MG TUSSICAPS CAP 5-4MG TUSSIONEX SUS 10-8/5ML VISTARIL CAP 25MG VISTARIL CAP 50MG VITUZ SOL 5-4MG XYZAL SOL XYZAL SOL 2.5/5ML XYZAL TAB 5MG ZUTRIPRO LIQ 60-4-5MG ATRIPLA TAB
Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
COMPLERA
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
EDURANT
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
INTELENCE TAB 100MG
Tier 3
X
TAB
TAB 25MG
Page 37 of 279
Specialty
X
X
X
X X
X X
Prior Authorization
Supply Limit
Step Therapy
Therapeutic Class Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
Product Name INTELENCE TAB 200MG
Tier Value Tier 3
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
INTELENCE TAB 25MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE SUS 50MG/5ML
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE TAB 100MG
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE TAB 200MG
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE TAB 400MG ER
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
RESCRIPTOR TAB 100 MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
RESCRIPTOR TAB 200MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
STRIBILD
TAB
Tier 4
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
SUSTIVA
CAP 200MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
SUSTIVA
CAP 50MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
SUSTIVA
TAB 600MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
VIRAMUNE
SUS 50MG/5ML
Tier 4
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
VIRAMUNE
TAB 200MG
Tier 4
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
VIRAMUNE XR TAB 100MG
Tier 4
X
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
VIRAMUNE XR TAB 400MG
Tier 4
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ABACAV/LAMIV TAB /ZIDOVUD
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ABACAVIR
TAB 300MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
COMBIVIR
TAB 150-300
Tier 4
X
Page 38 of 279
X
X
Specialty X
X
X
Prior Authorization
Supply Limit
Step Therapy
Therapeutic Class Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
Product Name DIDANOSINE CAP 125MG
Tier Value Tier 1
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
DIDANOSINE CAP 200MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
DIDANOSINE CAP 250MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
DIDANOSINE CAP 400MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
EMTRIVA
CAP 200MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
EMTRIVA
SOL 10MG/ML
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
EPIVIR
SOL 10MG/ML
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
EPIVIR
TAB 150MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
EPIVIR
TAB 300MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
EPZICOM
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUD/ZIDO TAB 150-300
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUDINE SOL 10MG/ML
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUDINE TAB 150MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUDINE TAB 300MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
RETROVIR
CAP 100MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
RETROVIR
SYP 50MG/5ML
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE CAP 15MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE CAP 20MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE CAP 30MG
Tier 1
X
TAB 600-300
Page 39 of 279
Specialty X
Prior Authorization
Supply Limit
Step Therapy
Therapeutic Class Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
Product Name STAVUDINE CAP 40MG
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE SOL 1MG/ML
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
TRIZIVIR
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 100-150
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 133-200
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 167-250
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 200-300
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX
SOL 2GM
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX
SOL 4GM
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 125MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 200MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 250MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 400MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
POW 40MG/GM
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 150MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 200MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 250MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 300MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
Tier 4
X
TAB
CAP 15MG
Page 40 of 279
Tier Value Tier 1
Specialty X
Prior Authorization
Supply Limit
Step Therapy
Therapeutic Class Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
Product Name ZERIT CAP 20MG
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
CAP 30MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
CAP 40MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
SOL 1MG/ML
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZIAGEN
SOL 20MG/ML
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZIAGEN
TAB 300MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZIDOVUDINE CAP 100MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZIDOVUDINE SYP 50MG/5ML
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
ZIDOVUDINE TAB 300MG
Tier 1
X
Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs
FUZEON INJ 90MG ISENTRESS CHW 100MG ISENTRESS CHW 25MG ISENTRESS POW 100MG ISENTRESS TAB 400MG SELZENTRY TAB 150MG SELZENTRY TAB 300MG TIVICAY TAB 10MG TIVICAY TAB 25MG TIVICAY TAB 50MG APTIVUS CAP 250MG
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3
X X X X X X X X X X X
APTIVUS
SOL
Tier 4
X
CRIXIVAN
CAP 200MG
Tier 3
X
CRIXIVAN
CAP 400MG
Tier 3
X
INVIRASE
CAP 200MG
Tier 3
X
INVIRASE
TAB 500MG
Tier 3
X
KALETRA
SOL
Tier 3
X
KALETRA
TAB 100-25MG
Tier 3
X
KALETRA
TAB 200-50MG
Tier 3
X
Tier 3
X
LEXIVA
SUS 50MG/ML
Page 41 of 279
Tier Value Tier 4
X X
Specialty X
Therapeutic Class Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-HIV Agents, Protease Inhibitors - HIV Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Product Name LEXIVA TAB 700MG
Tier Value Tier 3
Prior Authorization
Supply Limit
Step Therapy
Specialty X
NORVIR
CAP 100MG
Tier 3
X
NORVIR
SOL 80MG/ML
Tier 3
X
NORVIR
TAB 100MG
Tier 3
X
PREZISTA
SUS 100MG/ML
Tier 3
X
PREZISTA
TAB 150MG
Tier 3
X
PREZISTA
TAB 600MG
Tier 3
X
PREZISTA
TAB 75MG
Tier 3
X
PREZISTA
TAB 800MG
Tier 3
X
REYATAZ
CAP 150MG
Tier 3
X
REYATAZ
CAP 200MG
Tier 3
X
REYATAZ
CAP 300MG
Tier 3
X
REYATAZ
POW 50MG
Tier 3
X
VIRACEPT
TAB 250MG
Tier 3
X
VIRACEPT
TAB 625MG
Tier 3
X
ADVAIR DISKU AER 100/50
Tier 3
X
ADVAIR DISKU AER 250/50
Tier 3
X
ADVAIR DISKU AER 500/50
Tier 3
X
ADVAIR HFA AER 115/21
Tier 3
X
ADVAIR HFA AER 230/21
Tier 3
X
ADVAIR HFA AER 45/21
Tier 3
X
AEROSPAN
AER 80MCG
Tier 3
X
ALVESCO
AER 160MCG
Tier 1
X
ALVESCO
AER 80MCG
Tier 1
X
ASMANEX 120 AER 220MCG
Tier 1
X
ASMANEX 14 AER 220MCG
Tier 1
X
ASMANEX 30 AER 110MCG
Tier 1
X
ASMANEX 30 AER 220MCG
Tier 1
X
ASMANEX 60 AER 220MCG
Tier 1
X
Page 42 of 279
Therapeutic Class Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Product Name ASMANEX 7 AER 110MCG
Tier Value Tier 1
Prior Authorization
Supply Limit X
Step Therapy
X
ASMANEX HFA AER 100 MCG
Tier 1
ASMANEX HFA AER 200 MCG
Tier 1
BECONASE AQ SUS 0.042%
Tier 4
X
BREO ELLIPTA INH 100-25
Tier 3
X
BREO ELLIPTA INH 200-25
Tier 3
X
BUDESONIDE SUS 0.25MG/2
Tier 1
X
BUDESONIDE SUS 0.5MG/2
Tier 1
X
BUDESONIDE SUS 1MG/2ML
Tier 1
X
BUDESONIDE SUS 32MCG
Tier 1
X
X
DULERA
AER 100-5MCG
Tier 4
X
X
DULERA
AER 200-5MCG
Tier 4
X
X
FLOVENT DISK AER 100MCG
Tier 3
X
FLOVENT DISK AER 250MCG
Tier 3
X
FLOVENT DISK AER 50MCG
Tier 3
X
FLOVENT HFA AER 110MCG
Tier 3
X
FLOVENT HFA AER 220MCG
Tier 3
X
FLOVENT HFA AER 44MCG
Tier 3
X
FLUNISOLIDE SPR 0.025%
Tier 1
FLUTICASONE SPR 50MCG
Tier 1
X
MOMETASONE SPR 50MCG
Tier 1
X
X
NASONEX
SPR 50MCG/AC
Tier 4
X
X
OMNARIS
SPR
Tier 4
X
X
PULMICORT INH 180MCG
Tier 4
X
PULMICORT INH 90MCG
Tier 4
X
PULMICORT SUS 0.25MG/2
Tier 4
X
PULMICORT SUS 0.5MG/2
Tier 4
X
PULMICORT SUS 1MG/2ML
Tier 4
X
QNASL
Tier 4
X
AER 80MCG
Page 43 of 279
X
Specialty
Therapeutic Class Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Anti-Influenza Agents - Flu Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antileukotrienes - Asthma/Lung Drugs Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimycobacterials, Other - Miscellaneous Anti-Infectives Antimycobacterials, Other - Miscellaneous Anti-Infectives
Product Name QNASL CHILD SPR 40MCG
Tier Value Tier 4
Prior Authorization
Supply Limit
QVAR
AER 40MCG
Tier 1
X
QVAR
AER 80MCG
Tier 1
X
RHINOCORT SUS AQUA
Tier 4
X
SYMBICORT AER 160-4.5
Tier 3
X
SYMBICORT AER 80-4.5
Tier 3
X
VERAMYST
SPR 27.5MCG
Tier 4
X
ZETONNA
AER 37MCG
Tier 3
X
AMANTADINE CAP 100MG AMANTADINE SYP 50MG/5ML AMANTADINE TAB 100MG FLUMADINE TAB 100MG RELENZA MIS DISKHALE RIMANTADINE TAB 100MG TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML ACCOLATE TAB 10MG ACCOLATE TAB 20MG MONTELUKAST CHW 4MG MONTELUKAST CHW 5MG MONTELUKAST GRA 4MG MONTELUKAST TAB 10MG SINGULAIR CHW 4MG SINGULAIR CHW 5MG SINGULAIR GRA 4MG SINGULAIR TAB 10MG ZAFIRLUKAST TAB 10MG ZAFIRLUKAST TAB 20MG ZYFLO TAB 600MG ZYFLO CR TAB 600MG CAPECITABINE TAB 150MG CAPECITABINE TAB 500MG DROXIA CAP 200MG DROXIA CAP 300MG DROXIA CAP 400MG HYDREA CAP 500MG HYDROXYUREA CAP 500MG MERCAPTOPUR TAB 50MG PURINETHOL TAB 50MG PURIXAN SUS 20MG/ML TABLOID TAB 40MG XELODA TAB 150MG XELODA TAB 500MG DAPSONE TAB 100MG
Tier 1 Tier 1
DAPSONE
Tier 1
TAB 25MG
Page 44 of 279
Tier 1 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 3 Tier 4 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 4 Tier 1 Tier 1 Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 1
Step Therapy X
Specialty
X
X
X X X X X X X
X X X X X X X X
X X X
X X X X
X X X X X X X X X X X X X
Therapeutic Class Antimycobacterials, Other - Miscellaneous Anti-Infectives Antimycobacterials, Other - Miscellaneous Anti-Infectives Antineoplastics - Chemotherapy Agents Antineoplastics - Chemotherapy Agents Antineoplastics - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents
Product Name MYCOBUTIN CAP 150MG
Tier Value Tier 4
Prior Authorization
Supply Limit
X X X
Step Therapy
Specialty
RIFABUTIN CAP 150MG
Tier 1
TAFINLAR CAP 50MG TAFINLAR CAP 75MG ZYKADIA CAP 150MG CABOMETYX TAB 20MG
Tier 3 Tier 3 Tier 4 Tier 4
X X X X
CABOMETYX TAB 40MG
Tier 4
X
X
CABOMETYX TAB 60MG
Tier 4
X
X
COMETRIQ
KIT 100MG
Tier 3
X
X
X
COMETRIQ
KIT 140MG
Tier 3
X
X
X
COMETRIQ
KIT 60MG
Tier 3
X
X
X
ERIVEDGE
CAP 150MG
Tier 3
X
X
X
X X X X
GILOTRIF
TAB 20MG
Tier 4
X
X
X
GILOTRIF
TAB 30MG
Tier 4
X
X
X
GILOTRIF
TAB 40MG
Tier 4
X
X
X
ICLUSIG
TAB 15MG
Tier 4
X
X
X
ICLUSIG
TAB 45MG
Tier 4
X
X
X
JAKAFI
TAB 10MG
Tier 3
X
X
X
JAKAFI
TAB 15MG
Tier 3
X
X
X
JAKAFI
TAB 20MG
Tier 3
X
X
X
JAKAFI
TAB 25MG
Tier 3
X
X
X
JAKAFI
TAB 5MG
Tier 3
X
X
X
LEUCOVOR CA TAB 10MG
Tier 1
LEUCOVOR CA TAB 15MG
Tier 1
LEUCOVOR CA TAB 25MG
Tier 1
LEUCOVOR CA TAB 5MG
Tier 1
MEKINIST
TAB 0.5MG
Tier 3
X
X
X
MEKINIST
TAB 2MG
Tier 3
X
X
X
MENEST
TAB 0.3MG
Tier 3
MENEST
TAB 0.625MG
Tier 3
Page 45 of 279
Therapeutic Class Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiparkinson Agents, Other - Parkinson's Disease Drugs Antiprotozoals - Protozoal Infection Drugs
Product Name MENEST TAB 1.25MG
Tier Value Tier 3
MENEST
TAB 2.5MG
Tier 3
MESNEX
TAB 400MG
Tier 4
Prior Authorization
Supply Limit
Step Therapy
Specialty
X
PICATO
GEL 0.015%
Tier 3
X
PICATO
GEL 0.05%
Tier 3
X
POMALYST
CAP 1MG
Tier 4
X
X
X
POMALYST
CAP 2MG
Tier 4
X
X
X
POMALYST
CAP 3MG
Tier 4
X
X
X
POMALYST
CAP 4MG
Tier 4
X
X
X
SYLATRON
KIT 200MCG
Tier 3
X
X
X
SYLATRON
KIT 300MCG
Tier 3
X
X
X
SYLATRON
KIT 300MCG
Tier 3
X
X
X
SYLATRON
KIT 600MCG
Tier 3
X
X
X
X
X
X
X
ZOLINZA ZYTIGA COMTAN
CAP 100MG TAB 250MG TAB 200MG
Tier 3 Tier 3
X
Tier 4
ENTACAPONE TAB 200MG
Tier 1
NEUPRO
DIS 1MG/24HR
Tier 3
NEUPRO
DIS 2MG/24HR
Tier 3
NEUPRO
DIS 3MG/24HR
Tier 3
NEUPRO
DIS 4MG/24HR
Tier 3
NEUPRO
DIS 6MG/24HR
Tier 3
NEUPRO
DIS 8MG/24HR
Tier 3
TASMAR
TAB 100MG
Tier 4
X
TOLCAPONE TAB 100MG
Tier 1
ALINIA
SUS 100/5ML
Tier 2
X
Antiprotozoals - Protozoal Infection Drugs
ALINIA
TAB 500MG
Tier 2
X
Antiprotozoals - Protozoal Infection Drugs
ARALEN
Antiprotozoals - Protozoal Infection Drugs
ATOVAQ/PROGU TAB 250-100
TAB 500MG
Page 46 of 279
Tier 3 Tier 1
Prior Authorization
Supply Limit
Therapeutic Class Antiprotozoals - Protozoal Infection Drugs
Product Name ATOVAQ/PROGU TAB 62.5-25
Tier Value Tier 1
Antiprotozoals - Protozoal Infection Drugs
ATOVAQUONE SUS 750/5ML
Tier 1
Antiprotozoals - Protozoal Infection Drugs
CHLOROQUINE TAB 250MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
CHLOROQUINE TAB 500MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
COARTEM
TAB 20-120MG
Tier 2
Antiprotozoals - Protozoal Infection Drugs
DARAPRIM
TAB 25MG
Tier 3
Antiprotozoals - Protozoal Infection Drugs
HYDROXYCHLOR TAB 200MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
MALARONE
TAB 250-100
Tier 4
Antiprotozoals - Protozoal Infection Drugs
MALARONE
TAB 62.5-25
Tier 4
Antiprotozoals - Protozoal Infection Drugs
MEFLOQUINE TAB 250MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
MEPRON
SUS
Tier 4
Antiprotozoals - Protozoal Infection Drugs
NEBUPENT
INH 300MG
Tier 2
Antiprotozoals - Protozoal Infection Drugs
PLAQUENIL TAB 200MG
Tier 4
Antiprotozoals - Protozoal Infection Drugs
PRIMAQUINE TAB 26.3MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
QUALAQUIN CAP 324MG
Tier 4
X
Antiprotozoals - Protozoal Infection Drugs
QUININE SULF CAP 324MG
Tier 1
X
Antiprotozoals - Protozoal Infection Drugs
TINDAMAX
TAB 250MG
Tier 4
Antiprotozoals - Protozoal Infection Drugs
TINDAMAX
TAB 500MG
Tier 4
Antiprotozoals - Protozoal Infection Drugs
TINIDAZOLE TAB 250MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
TINIDAZOLE TAB 500MG
Tier 1
Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs
ANASPAZ
TAB 0.125MG
Tier 2
ATROPINE
POW SULFATE
Tier 3
BELLA/OPIUM SUP 16.2-30
Tier 1
BELLA/OPIUM SUP 16.2-60
Tier 2
BENTYL
CAP 10MG
Tier 4
BENTYL
TAB 20MG
Tier 4
CANTIL
TAB 25MG
Tier 3
CHLORD/CLIDI CAP 5-2.5MG
Tier 1
CUVPOSA
Tier 3
SOL 1MG/5ML
Page 47 of 279
Step Therapy
X
Specialty
X
X
Therapeutic Class Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs
Product Name DICYCLOMINE CAP 10MG
Tier Value Tier 1
DICYCLOMINE SOL 10MG/5ML
Tier 1
DICYCLOMINE TAB 20MG
Tier 1
ED-SPAZ
Tier 1
TAB 0.125MG
GASTRINEX NF CAP
Tier 3
GLYCOPYRROL TAB 1MG
Tier 1
GLYCOPYRROL TAB 2MG
Tier 1
HYOSCYAMINE DRO 0.125/ML
Tier 1
HYOSCYAMINE ELX 0.125/5
Tier 1
HYOSCYAMINE SUB 0.125MG
Tier 1
HYOSCYAMINE TAB 0.125MG
Tier 1
HYOSCYAMINE TAB 0.125MG
Tier 1
HYOSCYAMINE TAB 0.375 ER
Tier 1
HYOSCYAMINE TAB 0.375 SR
Tier 1
HYOSYNE
DRO 0.125/ML
Tier 1
HYOSYNE
ELX 0.125/5
Tier 1
LEVBID
TAB 0.375 ER
Tier 4
LEVSIN
TAB 0.125MG
Tier 4
LEVSIN/SL SUB 0.125MG
Tier 4
LIBRAX
Tier 4
CAP 5-2.5MG
METHSCOPOLAM TAB 2.5MG
Tier 1
METHSCOPOLAM TAB 5MG
Tier 1
NULEV
Tier 4
TAB 0.125MG
OSCIMIN
SUB 0.125MG
Tier 1
OSCIMIN
TAB 0.125MG
Tier 1
OSCIMIN
TAB 0.125MG
Tier 1
OSCIMIN SR TAB 0.375MG
Tier 1
PAMINE
Tier 4
TAB 2.5MG
PAMINE FQ KIT
Tier 3
Page 48 of 279
Prior Authorization
Supply Limit
Step Therapy
X
Specialty
Therapeutic Class Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Gastrointestinal - Bowel Treatment Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs
Product Name PROPANTHELIN TAB 15MG ROBINUL
TAB 1MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Tier 4
ROBINUL FORT TAB 2MG
Tier 4
SYMAX DUOTAB TAB
Tier 3
SYMAX-SL
SUB 0.125MG
Tier 1
SYMAX-SR
TAB 0.375MG
Tier 1
DARIFENACIN TAB 7.5MG ER
Tier 1
X
DARIFENACIN TAB HBR ER
Tier 1
X
DARIFENACIN TAB HBR ER
Tier 1
X
DETROL
TAB 1MG
Tier 4
X
DETROL
TAB 2MG
Tier 4
X
DETROL LA CAP 2MG
Tier 4
X
DETROL LA CAP 4MG
Tier 4
X
DITROPAN XL TAB 10MG
Tier 3
DITROPAN XL TAB 15MG
Tier 3
DITROPAN XL TAB 5MG
Tier 3
ENABLEX
TAB 15MG
Tier 4
X
ENABLEX
TAB 7.5MG
Tier 4
X
FLAVOXATE TAB 100MG
Tier 1
GELNIQUE
GEL 10%
Tier 4
X
GELNIQUE
GEL 3%
Tier 4
X
MYRBETRIQ TAB 25MG
Tier 4
X
MYRBETRIQ TAB 50MG
Tier 4
X
OXYBUTYNIN SYP 5MG/5ML
Tier 1
OXYBUTYNIN TAB 10MG ER
Tier 1
OXYBUTYNIN TAB 15MG ER
Tier 1
OXYBUTYNIN TAB 5MG
Tier 1
OXYBUTYNIN TAB 5MG ER
Tier 1
OXYTROL
Tier 4
DIS 3.9MG/24
Page 49 of 279
X
Specialty
Prior Authorization
Supply Limit
Step Therapy X
Therapeutic Class Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs Antispasticity Agents Antispasticity Agents - Muscle Spasm Drugs
Product Name OXYTROL DIS 3.9MG/24
Tier Value Tier 4
TOLTERODINE CAP 2MG ER
Tier 1
X
TOLTERODINE CAP 4MG ER
Tier 1
X
TOLTERODINE TAB 1MG
Tier 1
X
TOLTERODINE TAB 2MG
Tier 1
X
TOVIAZ
TAB 4MG
Tier 3
TOVIAZ
TAB 8MG
Tier 3
TROSPIUM CHL CAP 60MG ER
Tier 1
X
TROSPIUM CL TAB 20MG
Tier 1
X
VESICARE
TAB 10MG
Tier 4
X
VESICARE
TAB 5MG
Tier 4
X
GINSENG ROOT POW BACLOFEN POW
Tier 3 Tier 3
Antispasticity Agents - Muscle Spasm Drugs
BACLOFEN
TAB 10MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
BACLOFEN
TAB 20MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
DANTRIUM
CAP 25MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
DANTRIUM
CAP 50MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
DANTROLENE CAP 100MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
DANTROLENE CAP 25MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
DANTROLENE CAP 50MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE CAP 2MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE CAP 4MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE CAP 6MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE TAB 2MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE TAB 4MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
CAP 2MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
CAP 4MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
CAP 6MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
TAB 4MG
Tier 4
Page 50 of 279
X X
Specialty
Therapeutic Class Antithyroid Agents - Thyroid Suppressing Drugs Antithyroid Agents - Thyroid Suppressing Drugs Antithyroid Agents - Thyroid Suppressing Drugs Antithyroid Agents - Thyroid Suppressing Drugs Antithyroid Agents - Thyroid Suppressing Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Antituberculars - Tuberculosis Drugs Anxiolytics, Other - Anxiety Drugs
Product Name METHIMAZOLE TAB 10MG
Tier Value Tier 1
METHIMAZOLE TAB 5MG
Tier 1
PROPYLTHIOUR TAB 50MG
Tier 1
TAPAZOLE
TAB 10MG
Tier 4
TAPAZOLE
TAB 5MG
Tier 4
CYCLOSERINE CAP 250MG ETHAMBUTOL TAB 100MG ETHAMBUTOL TAB 400MG ISONIAZID SYP 50MG/5ML ISONIAZID TAB 100MG ISONIAZID TAB 300MG MYAMBUTOL TAB 100MG MYAMBUTOL TAB 400MG PASER GRA 4GM PRIFTIN TAB 150MG PYRAZINAMIDE TAB 500MG RIFADIN CAP 150MG RIFADIN CAP 300MG RIFAMATE CAP RIFAMPIN CAP 150MG RIFAMPIN CAP 300MG RIFATER TAB SIRTURO TAB 100MG TRECATOR TAB 250MG ALPRAZOLAM CON 1 MG/ML
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 4 Tier 3 Tier 2 Tier 1 Tier 3 Tier 4 Tier 3 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 1
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.25 ODT
Tier 1
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.25MG ALPRAZOLAM TAB 0.5MG ALPRAZOLAM TAB 0.5MG ER
Tier 1 Tier 1 Tier 1
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.5MG OD
Tier 1
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.5MG XR
Tier 1
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 1MG ALPRAZOLAM TAB 1MG ER ALPRAZOLAM TAB 1MG ODT
Tier 1 Tier 1 Tier 1
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM
Tier 1 Tier 1 Tier 1 Tier 1
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 2MG XR ALPRAZOLAM TAB 3MG ER ALPRAZOLAM TAB 3MG XR ATIVAN TAB 0.5MG ATIVAN TAB 1MG ATIVAN TAB 2MG BUSPIRONE TAB 10MG BUSPIRONE TAB 15MG
TAB 1MG XR TAB 2MG TAB 2MG ER TAB 2MG ODT
Page 51 of 279
Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1
Prior Authorization
Supply Limit
Step Therapy
X
X X X
Specialty
Therapeutic Class Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
Product Name BUSPIRONE TAB 30MG BUSPIRONE TAB 5MG BUSPIRONE TAB 7.5MG CDP/AMITRIP TAB 10-25MG CDP/AMITRIP TAB 5-12.5MG
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
CHLORDIAZEP CAP 10MG CHLORDIAZEP CAP 25MG CHLORDIAZEP CAP 5MG DIAZEPAM CON 5MG/ML DIAZEPAM SOL 1MG/ML DIAZEPAM TAB 10MG DIAZEPAM TAB 2MG DIAZEPAM TAB 5MG ESTAZOLAM TAB 1MG ESTAZOLAM TAB 2MG LORAZEPAM CON 2MG/ML LORAZEPAM TAB 0.5MG LORAZEPAM TAB 1MG LORAZEPAM TAB 2MG MEPROBAMATE TAB 200MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Anxiolytics, Other - Anxiety Drugs
MEPROBAMATE TAB 400MG
Tier 1
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs Anxiolytics, Sedatives and Hypnotics Benzodiazepines Anxiolytics, Sedatives and Hypnotics Benzodiazepines Anxiolytics, Sedatives and Hypnotics Benzodiazepines Aromatase Inhibitors, 3rd Generation Chemotherapy Agents Aromatase Inhibitors, 3rd Generation Chemotherapy Agents Aromatase Inhibitors, 3rd Generation Chemotherapy Agents Aromatase Inhibitors, 3rd Generation Chemotherapy Agents Aromatase Inhibitors, 3rd Generation Chemotherapy Agents Aromatase Inhibitors, 3rd Generation Chemotherapy Agents Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs
OXAZEPAM CAP 10MG OXAZEPAM CAP 15MG OXAZEPAM CAP 30MG VALIUM TAB 10MG VALIUM TAB 2MG VALIUM TAB 5MG XANAX TAB 0.25MG XANAX TAB 0.5MG XANAX TAB 1MG XANAX TAB 2MG XANAX XR TAB 0.5MG XANAX XR TAB 1MG XANAX XR TAB 2MG XANAX XR TAB 3MG DORAL TAB 15MG
Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3
MIDAZOLAM SYP 2MG/ML
Tier 1
QUAZEPAM
TAB 15MG
Tier 1
ANASTROZOLE TAB 1MG
Tier 1
ARIMIDEX
Tier 4
AROMASIN
TAB 1MG TAB 25MG
Tier 1
FEMARA
Tier 4
LETROZOLE TAB 2.5MG
Tier 1
CLONIDINE TAB 0.1MG ER
Tier 1
Page 52 of 279
Supply Limit
Step Therapy
X X X X X X X X X X X
X
Tier 4
EXEMESTANE TAB 25MG TAB 2.5MG
Prior Authorization
X
X
Specialty
Therapeutic Class Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs
Prior Authorization
Supply Limit X
Step Therapy
Product Name GUANFACINE TAB 1MG ER
Tier Value Tier 1
GUANFACINE TAB 2MG ER
Tier 1
X
GUANFACINE TAB 3MG ER
Tier 1
X
GUANFACINE TAB 4MG ER
Tier 1
X
INTUNIV
TAB 1MG
Tier 4
X
X
INTUNIV
TAB 2MG
Tier 4
X
X
INTUNIV
TAB 3MG
Tier 4
X
X
INTUNIV
TAB 4MG
Tier 4
X
X
KAPVAY
TAB 0.1 MG
Tier 4
X
STRATTERA CAP 100MG
Tier 4
X
STRATTERA CAP 10MG
Tier 4
X
STRATTERA CAP 18MG
Tier 4
X
STRATTERA CAP 25MG
Tier 4
X
STRATTERA CAP 40MG
Tier 4
X
STRATTERA CAP 60MG
Tier 4
X
STRATTERA CAP 80MG
Tier 4
X
ADDERALL
TAB 10MG
Tier 4
X
X
ADDERALL
TAB 12.5MG
Tier 4
X
X
ADDERALL
TAB 15MG
Tier 4
X
X
ADDERALL
TAB 20MG
Tier 4
X
X
ADDERALL
TAB 30MG
Tier 4
X
X
ADDERALL
TAB 5MG
Tier 4
X
X
ADDERALL
TAB 7.5MG
Tier 4
X
X
ADDERALL XR CAP 10MG
Tier 1
X
ADDERALL XR CAP 15MG
Tier 1
X
ADDERALL XR CAP 20MG
Tier 1
X
ADDERALL XR CAP 25MG
Tier 1
X
ADDERALL XR CAP 30MG
Tier 1
X
ADDERALL XR CAP 5MG
Tier 1
X
Page 53 of 279
Specialty
Therapeutic Class Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs
Supply Limit X
Step Therapy X
Tier 4
X
X
AMPHET/DEXTR CAP 20MG ER
Tier 4
X
X
AMPHET/DEXTR CAP 25MG ER
Tier 4
X
X
AMPHET/DEXTR CAP 30MG ER
Tier 4
X
X
AMPHET/DEXTR CAP 5MG ER
Tier 4
X
X
AMPHET/DEXTR TAB 10MG
Tier 1
X
AMPHET/DEXTR TAB 12.5MG
Tier 1
X
AMPHET/DEXTR TAB 15MG
Tier 1
X
AMPHET/DEXTR TAB 20MG
Tier 1
X
AMPHET/DEXTR TAB 30MG
Tier 1
X
AMPHET/DEXTR TAB 5MG
Tier 1
X
AMPHET/DEXTR TAB 7.5MG
Tier 1
X
AMPHETAMINE CAP 10MG ER
Tier 4
X
X
AMPHETAMINE CAP 15MG ER
Tier 4
X
X
AMPHETAMINE CAP 20MG ER
Tier 4
X
X
AMPHETAMINE CAP 25MG ER
Tier 4
X
X
AMPHETAMINE CAP 30MG ER
Tier 4
X
X
AMPHETAMINE CAP 5MG ER
Tier 4
X
X
APTENSIO XR CAP 10MG
Tier 4
X
X
X
APTENSIO XR CAP 15MG
Tier 4
X
X
X
APTENSIO XR CAP 20MG
Tier 4
X
X
X
APTENSIO XR CAP 30MG
Tier 4
X
X
X
APTENSIO XR CAP 40MG
Tier 4
X
X
X
APTENSIO XR CAP 50MG
Tier 4
X
X
X
APTENSIO XR CAP 60MG
Tier 4
X
X
X
CONCERTA
TAB 18MG
Tier 1
X
X
CONCERTA
TAB 27MG
Tier 1
X
X
CONCERTA
TAB 36MG
Tier 1
X
X
Product Name AMPHET/DEXTR CAP 10MG ER
Tier Value Tier 4
AMPHET/DEXTR CAP 15MG ER
Page 54 of 279
Prior Authorization
Specialty
Therapeutic Class Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs
Product Name CONCERTA TAB 54MG
Tier Value Tier 1
Prior Authorization X
Supply Limit X
Step Therapy
DAYTRANA
DIS 10MG/9HR
Tier 4
X
X
X
DAYTRANA
DIS 15MG/9HR
Tier 4
X
X
X
DAYTRANA
DIS 20MG/9HR
Tier 4
X
X
X
DAYTRANA
DIS 30MG/9HR
Tier 4
X
X
X
Tier 4
X
DEXEDRINE CAP 10MG CR
Tier 4
X
DEXEDRINE CAP 15MG CR
Tier 4
X
DEXEDRINE CAP 5MG CR
Tier 4
X
DEXEDRINE TAB 10MG
Tier 1
X
DEXEDRINE TAB 5MG
Tier 1
X
DEXMETHYLPH CAP 15MG ER
Tier 1
X
X
X
DEXMETHYLPH CAP 30MG ER
Tier 1
X
X
X
DEXMETHYLPH CAP 40MG ER
Tier 1
X
X
X
DEXMETHYLPH TAB 10MG
Tier 1
X
DEXMETHYLPH TAB 2.5MG
Tier 1
X
DEXMETHYLPH TAB 5MG
Tier 1
X
DEXMETHYLPHE CAP 10MG ER
Tier 1
X
X
X
DEXMETHYLPHE CAP 20MG ER
Tier 1
X
X
X
DEXMETHYLPHE CAP 5MG ER
Tier 1
X
X
X
DEXTROAMPHET CAP 10MG ER DEXTROAMPHET CAP 15MG ER DEXTROAMPHET CAP 5MG ER
Tier 1
X
Tier 1
X
Tier 1
X
DEXTROAMPHET SOL 5MG/5ML DEXTROAMPHET TAB 10MG
Tier 1
X
Tier 1
X
DEXTROAMPHET TAB 5MG
Tier 1
X
FOCALIN
TAB 10MG
Tier 4
X
FOCALIN
TAB 2.5MG
Tier 4
X
FOCALIN
TAB 5MG
Tier 4
X
DESOXYN
TAB 5MG
Page 55 of 279
Specialty
Therapeutic Class Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs
Product Name FOCALIN XR CAP 10MG
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
FOCALIN XR CAP 15MG
Tier 4
X
X
X
FOCALIN XR CAP 20MG
Tier 4
X
X
X
FOCALIN XR CAP 25MG
Tier 4
X
X
X
FOCALIN XR CAP 30MG
Tier 4
X
X
X
FOCALIN XR CAP 35MG
Tier 4
X
X
X
FOCALIN XR CAP 40MG
Tier 4
X
X
X
FOCALIN XR CAP 5MG
Tier 4
X
X
X
METADATE
Tier 1
X
METADATE CD CAP 10MG
Tier 1
X
X
METADATE CD CAP 20MG
Tier 1
X
X
METADATE CD CAP 30MG
Tier 1
X
X
METADATE CD CAP 40MG
Tier 1
X
X
METADATE CD CAP 50MG
Tier 1
X
X
METADATE CD CAP 60MG
Tier 1
X
X
METHAMPHETAM TAB 5MG
Tier 1
X
METHLPHENIDA CHW 2.5MG
Tier 1
X
METHYLIN
CHW 10MG
Tier 4
X
METHYLIN
CHW 2.5MG
Tier 4
X
METHYLIN
CHW 5MG
Tier 4
X
METHYLIN
SOL 10MG/5ML
Tier 4
X
METHYLIN
SOL 5MG/5ML
Tier 4
X
METHYLPHENID CAP 10MG
Tier 4
X
X
X
METHYLPHENID CAP 20MG
Tier 4
X
X
X
METHYLPHENID CAP 20MG ER
Tier 1
X
X
X
METHYLPHENID CAP 30MG
Tier 4
X
X
X
METHYLPHENID CAP 30MG ER
Tier 1
X
X
X
METHYLPHENID CAP 40MG
Tier 4
X
X
X
METHYLPHENID CAP 40MG ER
Tier 1
X
X
X
TAB 20MG ER
Page 56 of 279
Specialty
Therapeutic Class Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs
Product Name METHYLPHENID CAP 50MG
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
METHYLPHENID CAP 60MG
Tier 4
X
X
X
METHYLPHENID CHW 10MG
Tier 1
X
METHYLPHENID CHW 5MG
Tier 1
X
METHYLPHENID SOL 10MG/5ML METHYLPHENID SOL 5MG/5ML
Tier 1
X
Tier 1
X
METHYLPHENID TAB 10MG
Tier 1
X
METHYLPHENID TAB 10MG ER
Tier 1
X
METHYLPHENID TAB 18MG ER
Tier 4
X
X
X
METHYLPHENID TAB 18MG ER
Tier 1
X
X
X
METHYLPHENID TAB 20MG
Tier 1
X
METHYLPHENID TAB 20MG ER
Tier 1
X
METHYLPHENID TAB 20MG SR
Tier 1
X
METHYLPHENID TAB 27MG ER
Tier 4
X
X
X
METHYLPHENID TAB 27MG ER
Tier 1
X
X
X
METHYLPHENID TAB 36MG ER
Tier 4
X
X
X
METHYLPHENID TAB 36MG ER
Tier 1
X
X
X
METHYLPHENID TAB 54MG ER
Tier 4
X
X
X
METHYLPHENID TAB 54MG ER
Tier 1
X
X
X
METHYLPHENID TAB 5MG
Tier 1
X
PROCENTRA SOL 5MG/5ML
Tier 3
X
QUILLICHEW CHW 20MG ER
Tier 4
X
X
X
QUILLICHEW CHW 30MG ER
Tier 4
X
X
X
QUILLICHEW CHW 40MG ER
Tier 4
X
X
X
QUILLIVANT SUS 25MG/5ML
Tier 4
X
X
X
RITALIN
TAB 10MG
Tier 4
X
RITALIN
TAB 20MG
Tier 4
X
RITALIN
TAB 5MG
Tier 4
X
Tier 4
X
X
X
RITALIN LA CAP 10MG
Page 57 of 279
Specialty
Therapeutic Class Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AUTONOMIC DRUGS - CENTRALLY ACTING SKELETAL MUSCLE RELAXNT Benign Prostatic Hypertrophy Agents Benign Prostatic Hypertrophy Agents Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Product Name RITALIN LA CAP 20MG
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
RITALIN LA CAP 30MG
Tier 4
X
X
X
RITALIN LA CAP 40MG
Tier 4
X
X
X
RITALIN LA CAP 60MG
Tier 4
X
X
X
VYVANSE
CAP 10MG
Tier 2
X
VYVANSE
CAP 20MG
Tier 2
X
X
VYVANSE
CAP 30MG
Tier 2
X
X
VYVANSE
CAP 40MG
Tier 2
X
X
VYVANSE
CAP 50MG
Tier 2
X
X
VYVANSE
CAP 60MG
Tier 2
X
X
VYVANSE
CAP 70MG
Tier 2
X
X
ZENZEDI
TAB 10MG
Tier 4
X
X
ZENZEDI
TAB 15MG
Tier 4
X
X
ZENZEDI
TAB 2.5MG
Tier 4
X
X
ZENZEDI
TAB 20MG
Tier 4
X
X
ZENZEDI
TAB 30MG
Tier 4
X
X
ZENZEDI
TAB 5MG
Tier 4
X
X
ZENZEDI
TAB 7.5MG
Tier 4
X
X
TIZANIDINE KIT COMFORT
Tier 4
CIALIS TAB 2.5MG CIALIS TAB 5MG ALFUZOSIN TAB 10MG
Tier 4 Tier 4 Tier 1
X X
AVODART
CAP 0.5MG
Tier 4
X
CARDURA
TAB 1MG
Tier 4
CARDURA
TAB 2MG
Tier 4
CARDURA
TAB 4MG
Tier 4
CARDURA
TAB 8MG
Tier 4
DOXAZOSIN TAB 1MG
Tier 1
DOXAZOSIN TAB 2MG
Tier 1
DOXAZOSIN TAB 4MG
Tier 1
Page 58 of 279
X X X
X X
X
Specialty
Therapeutic Class Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs
Product Name DOXAZOSIN TAB 8MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
DUTAST/TAMSU CAP 0.5-0.4
Tier 1
DUTASTERIDE CAP 0.5MG
Tier 1
FINASTERIDE TAB 5MG
Tier 1
FLOMAX
Tier 4
X
Tier 4
X
JALYN
CAP 0.4MG CAP
PROSCAR
TAB 5MG
Tier 4
RAPAFLO
CAP 4MG
Tier 4
RAPAFLO
CAP 8MG
Tier 4
TAMSULOSIN CAP 0.4MG
Tier 1
TERAZOSIN CAP 10MG
Tier 1
TERAZOSIN CAP 1MG
Tier 1
TERAZOSIN CAP 2MG
Tier 1
TERAZOSIN CAP 5MG
Tier 1
UROXATRAL TAB 10MG
Tier 4
ACEBUTOLOL CAP 200MG
Tier 1
ACEBUTOLOL CAP 400MG
Tier 1
ATENOL/CHLOR TAB 10025MG ATENOL/CHLOR TAB 50-25MG
Tier 1
ATENOLOL
TAB 100MG
Tier 1
ATENOLOL
TAB 25MG
Tier 1
ATENOLOL
TAB 50MG
Tier 1
BETAXOLOL TAB 10MG
Tier 1
BETAXOLOL TAB 20MG
Tier 1
BISOPRL/HCTZ TAB 10/6.25
Tier 1
BISOPRL/HCTZ TAB 2.5/6.25
Tier 1
BISOPRL/HCTZ TAB 5-6.25MG
Tier 1
BISOPROL FUM TAB 10MG
Tier 1
BISOPROL FUM TAB 5MG
Tier 1
Page 59 of 279
Tier 1
X X
Specialty
Therapeutic Class Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs
Product Name BYSTOLIC TAB 10MG
Tier Value Tier 2
BYSTOLIC
TAB 2.5MG
Tier 2
BYSTOLIC
TAB 20MG
Tier 2
BYSTOLIC
TAB 5MG
Tier 2
Prior Authorization
Supply Limit
Step Therapy
CARVEDILOL TAB 12.5MG
Tier 1
CARVEDILOL TAB 25MG
Tier 1
CARVEDILOL TAB 3.125MG
Tier 1
CARVEDILOL TAB 6.25MG
Tier 1
COREG
TAB 12.5MG
Tier 4
COREG
TAB 25MG
Tier 4
COREG
TAB 3.125MG
Tier 4
COREG
TAB 6.25MG
Tier 4
COREG CR
CAP 10MG
Tier 4
X
X
COREG CR
CAP 20MG
Tier 4
X
X
COREG CR
CAP 40MG
Tier 4
X
X
COREG CR
CAP 80MG
Tier 4
X
X
CORGARD
TAB 20MG
Tier 4
CORGARD
TAB 40MG
Tier 4
CORGARD
TAB 80MG
Tier 4
CORZIDE
TAB 40-5MG
Tier 4
CORZIDE
TAB 80-5MG
Tier 3
DUTOPROL
TAB 100-12.5
Tier 2
X
DUTOPROL
TAB 25-12.5
Tier 2
X
DUTOPROL
TAB 50-12.5
Tier 2
X
HEMANGEOL SOL 4.28/ML
Tier 4
INDERAL LA CAP 120MG
Tier 4
INDERAL LA CAP 160MG
Tier 4
INDERAL LA CAP 60MG
Tier 4
INDERAL LA CAP 80MG
Tier 4
Page 60 of 279
X
Specialty
Therapeutic Class Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs
Product Name INDERAL XL CAP 120MG
Tier Value Tier 3
INDERAL XL CAP 80MG
Tier 3
INNOPRAN XL CAP 120MG
Tier 3
INNOPRAN XL CAP 80MG
Tier 3
KERLONE
TAB 10MG
Tier 3
KERLONE
TAB 20MG
Tier 3
LABETALOL TAB 100MG
Tier 1
LABETALOL TAB 200MG
Tier 1
LABETALOL TAB 300MG
Tier 1
LEVATOL
Tier 3
TAB 20MG
LOPRESS HCT TAB 100-25MG
Tier 3
LOPRESS HCT TAB 50-25MG
Tier 4
LOPRESSOR TAB 100MG
Tier 4
LOPRESSOR TAB 50MG
Tier 4
METOPRL/HCTZ TAB 10025MG METOPRL/HCTZ TAB 10050MG METOPRL/HCTZ TAB 50-25MG
Tier 1
METOPROL TAR TAB 100MG
Tier 1
METOPROL TAR TAB 25MG
Tier 1
METOPROL TAR TAB 50MG
Tier 1
METOPROLOL TAB 100MG ER
Tier 1
METOPROLOL TAB 200MG ER
Tier 1
METOPROLOL TAB 25MG ER
Tier 1
METOPROLOL TAB 37.5MG
Tier 1
METOPROLOL TAB 50MG ER
Tier 1
METOPROLOL TAB 75MG
Tier 1
NADOLOL
TAB 20MG
Tier 1
NADOLOL
TAB 40MG
Tier 1
NADOLOL
TAB 80MG
Tier 1
Page 61 of 279
Prior Authorization
Supply Limit
Step Therapy
Tier 1 Tier 1
X
X
Specialty
Therapeutic Class Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs
Product Name NADOLOL/BEND TAB 40-5MG
Tier Value Tier 1
NADOLOL/BEND TAB 80-5MG
Tier 1
PINDOLOL
TAB 10MG
Tier 1
PINDOLOL
TAB 5MG
Tier 1
PROPRAN/HCTZ TAB 40/25
Tier 1
PROPRAN/HCTZ TAB 80/25
Tier 1
PROPRANOLOL CAP 120MG ER PROPRANOLOL CAP 160MG ER PROPRANOLOL CAP 60MG ER
Tier 1
PROPRANOLOL CAP 80MG ER
Tier 1
PROPRANOLOL SOL 20MG/5ML PROPRANOLOL SOL 40MG/5ML PROPRANOLOL TAB 10MG
Tier 1
PROPRANOLOL TAB 20MG
Tier 1
PROPRANOLOL TAB 40MG
Tier 1
PROPRANOLOL TAB 60MG
Tier 1
PROPRANOLOL TAB 80MG
Tier 1
SECTRAL
CAP 200MG
Tier 4
SECTRAL
CAP 400MG
Tier 4
Prior Authorization
Supply Limit
Step Therapy
Tier 1 Tier 1
Tier 1 Tier 1
TENORETIC TAB 100
Tier 4
X
TENORETIC TAB 50
Tier 4
X
TENORMIN
TAB 100MG
Tier 4
X
TENORMIN
TAB 25MG
Tier 4
X
TENORMIN
TAB 50MG
Tier 4
X
TIMOLOL MAL TAB 10MG
Tier 1
TIMOLOL MAL TAB 20MG
Tier 1
TIMOLOL MAL TAB 5MG
Tier 1
TOPROL XL TAB 100MG
Tier 4
TOPROL XL TAB 200MG
Tier 4
Page 62 of 279
Specialty
Therapeutic Class Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Lactam, Cephalosporins - Antibiotics
Product Name TOPROL XL TAB 25MG
Tier Value Tier 4
TOPROL XL TAB 50MG
Tier 4
ZEBETA
TAB 10MG
Tier 3
ZEBETA
TAB 5MG
Tier 3
ZIAC
TAB 10/6.25
Tier 3
ZIAC
TAB 2.5/6.25
Tier 3
ZIAC
TAB 5-6.25MG
Tier 4
CEDAX
CAP 400MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEDAX
SUS 180/5ML
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
CAP 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
CAP 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
SUS 125/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
SUS 375/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR ER TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL CAP 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL SUS 500/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL TAB 1GM
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDINIR
CAP 300MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDINIR
SUS 125/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDINIR
SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDITOREN TAB 200MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDITOREN TAB 400MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFIXIME
SUS 100/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFIXIME
SUS 200/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPODO PROX SUS 100/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPODO PROX SUS 50MG/5ML CEFPODOXIME TAB 100MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
Page 63 of 279
Tier 1
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Beta-Lactam, Cephalosporins - Antibiotics
Product Name CEFPODOXIME TAB 200MG
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL SUS 125/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL TAB 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIBUTEN CAP 400MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIBUTEN SUS 180/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
SUS 125/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
SUS 250/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
TAB 250MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
TAB 500MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEFUROXIME TAB 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFUROXIME TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN CAP 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN CAP 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN CAP 750MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN SUS 125/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN TAB 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
KEFLEX
CAP 250MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
KEFLEX
CAP 500MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
KEFLEX
CAP 750MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SPECTRACEF TAB 200MG
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
SPECTRACEF TAB 400MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
CAP 400MG
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
CHW 100MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
CHW 200MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
SUS 100/5ML
Tier 4
Page 64 of 279
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Specialty
Prior Authorization
Supply Limit
X
X
Therapeutic Class Beta-Lactam, Cephalosporins - Antibiotics
Product Name SUPRAX SUS 200/5ML
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
Beta-Lactam, Other - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics
CAYSTON INH 75MG AMOX/K CLAV CHW 200MG AMOX/K CLAV CHW 400MG AMOX/K CLAV SUS 200/5ML
Tier 3 Tier 1 Tier 1 Tier 1
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 250/5ML
Tier 1
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 400/5ML
Tier 1
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 600/5ML
Tier 1
Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV TAB 250-125 AMOX/K CLAV TAB 500-125 AMOX/K CLAV TAB 875MG AMOXICILLIN CAP 250MG AMOXICILLIN CAP 500MG AMOXICILLIN CHW 125MG AMOXICILLIN CHW 250MG AMOXICILLIN SUS 125/5ML AMOXICILLIN SUS 200/5ML AMOXICILLIN SUS 250/5ML AMOXICILLIN SUS 250MG/5M
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics Bipolar Agents, Other - Mood Disorder Drugs
AMOXICILLIN SUS 400/5ML AMOXICILLIN TAB 500MG AMOXICILLIN TAB 775MG AMOXICILLIN TAB 875MG AMOX-POT CLA TAB ER AMPICILLIN CAP 250MG AMPICILLIN CAP 500MG AMPICILLIN SUS 125/5ML AMPICILLIN SUS 250/5ML AUGMENTIN SUS 125/5ML AUGMENTIN SUS 250/5ML AUGMENTIN SUS ES-600 AUGMENTIN TAB 500MG AUGMENTIN TAB 875MG AUGMENTIN XR TAB 12HR DICLOXACILL CAP 250MG DICLOXACILL CAP 500MG MOXATAG TAB 775MG MOXATAG TAB 775MG PENICILLN VK SOL 125/5ML PENICILLN VK SOL 250/5ML PENICILLN VK TAB 250MG PENICILLN VK TAB 500MG OLANZA/FLUOX CAP 12-25MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 2 Tier 2 Tier 4 Tier 1 Tier 1 Tier 3 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X
Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 12-50MG
Tier 1
X
Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 3-25MG
Tier 1
X
Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 6-25MG
Tier 1
X
SUS 500/5ML
Page 65 of 279
Tier Value Tier 4
Step Therapy
Specialty
Tier 4 X
X
X X X X X X
Therapeutic Class Product Name Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 6-50MG
Tier Value Tier 1
Prior Authorization
Supply Limit X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 12-25MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 12-50MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 3-25MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 6-25MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 6-50MG
Tier 4
X
Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs
AGRYLIN
CAP 0.5MG
Step Therapy
Specialty
Tier 4
ANAGRELIDE CAP 0.5MG
Tier 1
ANAGRELIDE CAP 1MG
Tier 1
EPOGEN
INJ 10000/ML
Tier 3
X
X
EPOGEN
INJ 2000/ML
Tier 3
X
X
EPOGEN
INJ 20000/ML
Tier 3
X
X
EPOGEN
INJ 3000/ML
Tier 3
X
X
EPOGEN
INJ 4000/ML
Tier 3
X
X
GRANIX
INJ 300/0.5
Tier 4
X
X
GRANIX
INJ 480/0.8
Tier 4
X
X
LEUKINE
INJ 250MCG
Tier 3
X
MOZOBIL
INJ
Tier 3
X
NEULASTA
INJ 6MG/0.6M
Tier 4
X
NEULASTA
KIT 6MG/0.6M
Tier 4
X
NEUMEGA
INJ 5MG
Tier 3
X
NEUPOGEN
INJ 300/0.5
Tier 3
X
NEUPOGEN
INJ 300MCG
Tier 3
X
NEUPOGEN
INJ 480/0.8
Tier 3
X
NEUPOGEN
INJ 480MCG
Tier 3
X
PROCRIT
INJ 10000/ML
Tier 3
X
X
PROCRIT
INJ 2000/ML
Tier 3
X
X
PROCRIT
INJ 20000/ML
Tier 3
X
X
PROCRIT
INJ 3000/ML
Tier 3
X
X
Page 66 of 279
Therapeutic Class Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs Blood Formation Modifiers - Blood Formation Drugs BLOOD FORMATION,COAGULATION & THROMBOSIS - ANTICOAGULANTS BLOOD FORMATION,COAGULATION & THROMBOSIS - ANTICOAGULANTS BLOOD FORMATION,COAGULATION & THROMBOSIS - ANTICOAGULANTS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS
Product Name PROCRIT INJ 4000/ML PROCRIT
INJ 40000/ML
Tier Value Tier 3
Prior Authorization
Tier 3
Supply Limit X X
Step Therapy
Specialty X X
PROMACTA
TAB 12.5MG
Tier 4
X
X
PROMACTA
TAB 25MG
Tier 4
X
X
PROMACTA
TAB 50MG
Tier 4
X
X
PROMACTA
TAB 75MG
Tier 4
X
X
ANTICOAG CIT SOL DEX SOL
Tier 1
NOCLOT-50 SOL ACD-A
Tier 3
TRICITRASOL CON
Tier 3
ADVATE
INJ 1000UNIT
Tier 3
X
ADVATE
INJ 1500UNIT
Tier 3
X
ADVATE
INJ 2000UNIT
Tier 3
X
ADVATE
INJ 250UNIT
Tier 3
X
ADVATE
INJ 3000UNIT
Tier 3
X
ADVATE
INJ 4000UNIT
Tier 3
X
ADVATE
INJ 500UNIT
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANINE SD INJ 1000UNIT
Tier 3
X
ALPHANINE SD INJ 1500UNIT
Tier 3
X
ALPHANINE SD INJ 500UNIT
Tier 3
X
AMICAR
SOL 0.25/ML
Tier 3
AMICAR
TAB 1000MG
Tier 3
AMICAR
TAB 500MG
Tier 3
AMINOCAPR AC SYP 25%
Tier 1
AMINOCAPR AC TAB 1000MG
Tier 1
Page 67 of 279
Therapeutic Class BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS
Product Name AMINOCAPR AC TAB 500MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Specialty
ARTISS
SOL 10ML
Tier 3
ARTISS
SOL 2ML
Tier 3
ARTISS
SOL 4ML
Tier 3
ASTRINGYN SOL 259MG/GM
Tier 3
BEBULIN
INJ 200-1200
Tier 3
X
BENEFIX
INJ 1000UNIT
Tier 3
X
BENEFIX
INJ 2000UNIT
Tier 3
X
BENEFIX
INJ 250UNIT
Tier 3
X
BENEFIX
INJ 3000UNIT
Tier 3
X
BENEFIX
INJ 500UNIT
Tier 3
X
KIT
Tier 3
X
EVICEL
KIT 2ML
Tier 3
EVICEL
KIT 5ML
Tier 3
CORIFACT
EVITHROM FEIBA
SOL 800-1200
Tier 3
X
INJ
Tier 3
X
HELIXATE FS INJ 1000UNIT
Tier 3
X
HELIXATE FS INJ 2000UNIT
Tier 3
X
HELIXATE FS INJ 250UNIT
Tier 3
X
HELIXATE FS INJ 3000UNIT
Tier 3
X
HELIXATE FS INJ 500UNIT
Tier 3
X
HEMOFIL M INJ 1000UNIT
Tier 3
X
HEMOFIL M INJ 1700UNIT
Tier 3
X
HEMOFIL M INJ 220-400
Tier 3
X
HEMOFIL M INJ 250UNIT
Tier 3
X
HEMOFIL M INJ 500UNIT
Tier 3
X
HEMOFIL M SOL
Tier 3
X
HEMOFIL M SOL 801-1500
Tier 3
X
FEIBA NF
INJ
Tier 3
Page 68 of 279
Therapeutic Class BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS
Product Name HUMATE-P SOL 2400UNIT
Tier Value Tier 3
Prior Authorization
Supply Limit
Step Therapy
Specialty X
HUMATE-P
SOL 250-600
Tier 3
X
HUMATE-P
SOL 500-1200
Tier 3
X
IXINITY
INJ 1000UNIT
Tier 4
X
X
IXINITY
INJ 1500UNIT
Tier 4
X
X
IXINITY
INJ 500UNIT
Tier 4
X
X
KOATE-DVI INJ 1000UNIT
Tier 3
X
KOATE-DVI INJ 250UNIT
Tier 3
X
KOATE-DVI INJ 500UNIT
Tier 3
X
KOGENATE FS INJ 1000/BS
Tier 3
X
KOGENATE FS INJ 1000UNIT
Tier 3
X
KOGENATE FS INJ 2000/BS
Tier 3
X
KOGENATE FS INJ 2000UNIT
Tier 3
X
KOGENATE FS INJ 250/BS
Tier 3
X
KOGENATE FS INJ 250UNIT
Tier 3
X
KOGENATE FS INJ 3000/BS
Tier 3
X
KOGENATE FS INJ 3000UNIT
Tier 3
X
KOGENATE FS INJ 500/BS
Tier 3
X
KOGENATE FS INJ 500UNIT
Tier 3
X
KOVALTRY
INJ 1000UNIT
Tier 4
X
X
KOVALTRY
INJ 2000UNIT
Tier 4
X
X
KOVALTRY
INJ 250UNIT
Tier 4
X
X
KOVALTRY
INJ 3000UNIT
Tier 4
X
X
KOVALTRY
INJ 500UNIT
Tier 4
X
X
MONOCLATE-P INJ 1000UNIT
Tier 3
X
MONOCLATE-P INJ 1500UNIT
Tier 3
X
MONOCLATE-P INJ 250UNIT
Tier 3
X
MONONINE
INJ 1000UNIT
Tier 3
X
MONONINE
INJ 500UNIT
Tier 3
X
Page 69 of 279
Therapeutic Class BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS
Step Therapy
Specialty
Tier 4
X
X
NOVOEIGHT INJ 1500UNIT
Tier 4
X
X
NOVOEIGHT INJ 2000UNIT
Tier 4
X
X
NOVOEIGHT INJ 250UNIT
Tier 4
X
X
NOVOEIGHT INJ 3000UNIT
Tier 4
X
X
NOVOEIGHT INJ 500UNIT
Tier 4
X
X
NOVOSEVEN RT INJ 1MG
Tier 3
X
NOVOSEVEN RT INJ 2MG
Tier 3
X
NOVOSEVEN RT INJ 5MG
Tier 3
X
NOVOSEVEN RT INJ 8MG
Tier 3
X
NUWIQ
INJ 1000UNIT
Tier 4
X
X
NUWIQ
INJ 2000UNIT
Tier 4
X
X
NUWIQ
INJ 250UNIT
Tier 4
X
X
NUWIQ
INJ 500UNIT
Tier 4
X
X
NUWIQ
KIT 1000UNIT
Tier 4
X
X
NUWIQ
KIT 2000UNIT
Tier 4
X
X
NUWIQ
KIT 250UNIT
Tier 4
X
X
NUWIQ
KIT 500UNIT
Tier 4
X
X
Product Name MONSELS FERR SOL SUBSULF
Tier Value Tier 1
NOVOEIGHT INJ 1000UNIT
Prior Authorization
Supply Limit
PROFILNINE INJ 1000UNIT
Tier 3
X
PROFILNINE INJ 1500UNIT
Tier 3
X
PROFILNINE INJ 500UNIT
Tier 3
X
RECOMBINATE INJ
Tier 3
X
RECOMBINATE INJ
Tier 3
X
RECOMBINATE INJ 220-400
Tier 3
X
RECOMBINATE INJ 401-800
Tier 3
X
RECOMBINATE INJ 801-1240
Tier 3
X
RECOTHROM SOL 20000UNT
Tier 3
RECOTHROM SOL 5000UNIT
Tier 3
Page 70 of 279
Therapeutic Class BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS
Product Name RIASTAP SOL 1GM
Tier Value Tier 4
Prior Authorization
Supply Limit
Step Therapy
Specialty X
RIXUBIS
INJ 1000UNIT
Tier 3
X
RIXUBIS
INJ 2000UNIT
Tier 3
X
RIXUBIS
INJ 250 UNIT
Tier 3
X
RIXUBIS
INJ 3000UNIT
Tier 3
X
RIXUBIS
INJ 500UNIT
Tier 3
X
THROMBIN
KIT 5000UNIT
Tier 3
THROMBIN-JMI KIT 20000UNT
Tier 3
THROMBIN-JMI KIT 5000UNIT
Tier 3
THROMBOGEN KIT 10000UNT
Tier 3
THROMBOGEN SOL 10000UNT THROMBOGEN SOL 1000UNIT
Tier 3
TISSEEL
KIT
Tier 3
TISSEEL
KIT
Tier 3
TISSEEL
KIT
Tier 3
TISSEEL
SOL
Tier 3
Tier 3
TISSEEL VH KIT 10ML
Tier 3
TISSEEL VH KIT 2ML
Tier 3
TISSEEL VH KIT 4ML
Tier 3
WILATE
INJ
Tier 3
X
WILATE
INJ
Tier 2
X
WILATE
INJ
Tier 3
X
WILATE
INJ
Tier 2
X
XYNTHA
INJ 1000UNIT
Tier 3
X
XYNTHA
INJ 2000UNIT
Tier 3
X
XYNTHA
INJ 250UNIT
Tier 3
X
XYNTHA
INJ 500UNIT
Tier 3
X
XYNTHA SOLOF INJ 1000UNIT
Tier 3
X
XYNTHA SOLOF INJ 2000UNIT
Tier 3
X
Page 71 of 279
Therapeutic Class BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS Blood Products/Modifiers/Volume Expanders
Supply Limit
Step Therapy
Tier Value Tier 3
XYNTHA SOLOF INJ 500UNIT
Tier 3
X
XYNTHA SOLOF KIT 250UNIT
Tier 3
X
ED CYTE F TAB
Tier 3
FER-IN-SOL DRO 15MG/ML
HCR Preventative
FER-IRON
DRO 15MG/ML
HCR Preventative
FEROSUL
ELX 220/5ML
HCR Preventative
FERROUS
DRO 15MG/ML
HCR Preventative
Specialty X
FERROUS SULF DRO 15MG/ML HCR Preventative FERROUS SULF ELX 220/5ML
HCR Preventative
FERROUS SULF SYP 300/5ML
HCR Preventative
HEMATINIC/FA TAB
Tier 1
HEMOCYTE-F TAB
Tier 1
IRON SUPPLMT DRO 15MG/ML HCR Preventative PEDIA IRON DRO 15MG/ML
HCR Preventative
PROFERRIN- TAB FORTE
Tier 3
TANDEM F
Tier 3
BERINERT
Blood Products/Modifiers/Volume Expanders CINRYZE Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs
Prior Authorization
Product Name XYNTHA SOLOF INJ 3000UNIT
CAP INJ 500UNIT
Tier 3
X
SOL 500 UNIT
Tier 4
X
ATROVENT HFA AER 17MCG
Tier 3
ATROVENT NAS SOL 0.03%
Tier 4
ATROVENT NAS SOL 0.06%
Tier 4
COMBIVENT AER 20-100
Tier 3
IPRATROPIUM SOL 0.02%INH
Tier 1
IPRATROPIUM SPR 0.03%
Tier 1
IPRATROPIUM SPR 0.06%
Tier 1
IPRATROPIUM/ SOL ALBUTER
Tier 1
IPRATROPIUM/ SOL SULFATE
Tier 1
SPIRIVA
Tier 4
AER 1.25MCG
Page 72 of 279
X
X X
X
X
X
X
Therapeutic Class Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Anticholinergic Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs
Product Name SPIRIVA CAP HANDIHLR SPIRIVA
SPR 2.5MCG
Tier Value Tier 4
Prior Authorization
Supply Limit X
Tier 4
X
TUDORZA PRES AER 400/ACT
Tier 2
X
DIFIL-G FORT LIQ 100-100
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors ELIXOPHYLLIN ELX 80/15ML (Xanthines) - Asthma/Lung Drugs
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors LUFYLLIN (Xanthines) - Asthma/Lung Drugs
TAB 200MG
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors LUFYLLIN (Xanthines) - Asthma/Lung Drugs
TAB 400MG
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24 (Xanthines) - Asthma/Lung Drugs
CAP 100MG CR
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24 (Xanthines) - Asthma/Lung Drugs
CAP 200MG CR
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24 (Xanthines) - Asthma/Lung Drugs
CAP 300MG CR
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24 (Xanthines) - Asthma/Lung Drugs
CAP 400MG ER
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEOCHRON TAB 100MG CR (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOCHRON TAB 200MG CR (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOCHRON TAB 300MG CR (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE SOL 80/15ML (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 100MG CR (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 100MG ER (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 200MG CR (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 200MG ER (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 300MG ER (Xanthines) - Asthma/Lung Drugs
Tier 1
Page 73 of 279
Step Therapy
Specialty
Supply Limit
Step Therapy
Tier 4
X
X
ADRENACLICK INJ 0.3MG
Tier 4
X
X
ADRENALIN SOL 1:1000
Tier 2
ALBUTEROL NEB 0.083%
Tier 1
ALBUTEROL NEB 0.5%
Tier 1
ALBUTEROL NEB 0.63MG/3
Tier 1
ALBUTEROL NEB 1.25MG/3
Tier 1
ALBUTEROL SYP 2MG/5ML
Tier 1
ALBUTEROL TAB 2MG
Tier 1
ALBUTEROL TAB 4MG
Tier 1
ALBUTEROL TAB 4MG ER
Tier 1
ALBUTEROL TAB 8MG ER
Tier 1
ANORO ELLIPT AER 62.5-25
Tier 3
X
ARCAPTA
Tier 3
X
Therapeutic Class Product Name Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 400MG ER (Xanthines) - Asthma/Lung Drugs
Tier Value Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 450MG ER (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 600MG ER (Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs
ADRENACLICK INJ 0.15MG
CAP 75MCG
Prior Authorization
AUVI-Q
INJ 0.15MG
Tier 4
X
X
AUVI-Q
INJ 0.3MG
Tier 4
X
X
BL DIXAPHEDR TAB 60MG
Tier 1
BROVANA
NEB 15MCG
Tier 3
X
EPINEPHRINE INJ 0.15MG
Tier 4
X
X
EPINEPHRINE INJ 0.3MG
Tier 4
X
X
EPIPEN 2-PAK INJ 0.3MG
Tier 2
X
EPIPEN-JR INJ 2-PAK
Tier 2
X
FORADIL
CAP AEROLIZE
Tier 3
X
GNP DIPHEDRY TAB 60MG
Tier 1
Page 74 of 279
Specialty
Therapeutic Class Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Bronchodilators, Sympathomimetic Asthma/Lung Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Product Name GNP DIXAPHED TAB 12 HR
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
LEVALBUTEROL NEB 0.31MG
Tier 1
X
X
LEVALBUTEROL NEB 0.63MG
Tier 1
X
X
LEVALBUTEROL NEB 1.25/0.5
Tier 1
X
X
LEVALBUTEROL NEB 1.25MG
Tier 1
X
X
METAPROTEREN SYP 10MG/5ML METAPROTEREN TAB 10MG
Tier 1
METAPROTEREN TAB 20MG
Tier 1
PERFOROMIST NEB 20MCG
Tier 3
X
PROAIR HFA AER
Tier 3
X
PROAIR RESPI AER
Tier 3
X
PROVENTIL AER HFA
Tier 3
X
SEREVENT DIS AER 50MCG
Tier 3
X
STRIVERDI AER 2.5MCG
Tier 2
X
TERBUTALINE POW SULFATE
Tier 3
TERBUTALINE TAB 2.5MG
Tier 1
TERBUTALINE TAB 5MG
Tier 1
VENTOLIN HFA AER
Tier 2
VOSPIRE ER TAB 4MG
Tier 1
VOSPIRE ER TAB 8MG
Tier 1
XOPENEX
NEB 0.31MG
Tier 4
X
X
XOPENEX
NEB 0.63MG
Tier 4
X
X
XOPENEX
NEB 1.25/3ML
Tier 4
X
X
XOPENEX CONC NEB 1.25/0.5
Tier 4
X
X
XOPENEX HFA AER
Tier 3
X
ADALAT CC TAB 30MG ER
Tier 4
ADALAT CC TAB 60MG ER
Tier 4
ADALAT CC TAB 90MG ER
Tier 4
AFEDITAB
Tier 1
TAB 30MG CR
Page 75 of 279
Tier 1
X
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Product Name AFEDITAB TAB 60MG CR
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
AMLOD/ATORVA TAB 1010MG AMLOD/ATORVA TAB 1020MG AMLOD/ATORVA TAB 1040MG AMLOD/ATORVA TAB 1080MG AMLOD/ATORVA TAB 2.510MG AMLOD/ATORVA TAB 2.520MG AMLOD/ATORVA TAB 2.540MG AMLOD/ATORVA TAB 5-10MG
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
AMLOD/ATORVA TAB 5-20MG
Tier 1
X
X
AMLOD/ATORVA TAB 5-40MG
Tier 1
X
X
AMLOD/ATORVA TAB 5-80MG
Tier 1
X
X
AMLOD/BENAZP CAP 10-20MG
Tier 1
X
AMLOD/BENAZP CAP 10-40MG
Tier 1
X
AMLOD/BENAZP CAP 2.510MG AMLOD/BENAZP CAP 5-10MG
Tier 1
X
Tier 1
X
AMLOD/BENAZP CAP 5-20MG
Tier 1
X
AMLOD/BENAZP CAP 5-40MG
Tier 1
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB 10160MG AMLOD/VALSAR TAB 10320MG AMLOD/VALSAR TAB 5-160MG
Tier 1
X
Tier 1
X
Tier 1
X
AMLOD/VALSAR TAB 5-320MG
Tier 1
X
AMLODIPINE TAB 10MG
Tier 1
AMLODIPINE TAB 2.5MG
Tier 1
Page 76 of 279
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Product Name AMLODIPINE TAB 5MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
AZOR
TAB 10-20MG
Tier 4
X
X
AZOR
TAB 10-40MG
Tier 4
X
X
AZOR
TAB 5-20MG
Tier 4
X
X
AZOR
TAB 5-40MG
Tier 4
X
X
CADUET
TAB 10-10MG
Tier 4
X
X
CADUET
TAB 10-20MG
Tier 4
X
X
CADUET
TAB 10-40MG
Tier 4
X
X
CADUET
TAB 10-80MG
Tier 4
X
X
CADUET
TAB 2.5-10MG
Tier 4
X
X
CADUET
TAB 2.5-20MG
Tier 4
X
X
CADUET
TAB 2.5-40MG
Tier 4
X
X
CADUET
TAB 5-10MG
Tier 4
X
X
CADUET
TAB 5-20MG
Tier 4
X
X
CADUET
TAB 5-40MG
Tier 4
X
X
CADUET
TAB 5-80MG
Tier 4
X
X
CALAN
TAB 120MG
Tier 4
CALAN
TAB 80MG
Tier 4
CALAN SR
TAB 120MG
Tier 4
CALAN SR
TAB 180MG
Tier 4
CALAN SR
TAB 240MG
Tier 4
CARDIZEM
TAB 120MG
Tier 3
X
CARDIZEM
TAB 30MG
Tier 4
X
CARDIZEM
TAB 60MG
Tier 4
X
CARDIZEM CD CAP 120MG/24
Tier 4
X
CARDIZEM CD CAP 180MG/24
Tier 4
X
CARDIZEM CD CAP 240MG/24
Tier 4
X
CARDIZEM CD CAP 300MG/24
Tier 4
X
CARDIZEM CD CAP 360MG/24
Tier 4
X
Page 77 of 279
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Prior Authorization
Supply Limit
Step Therapy X
Product Name CARDIZEM LA TAB 120MG
Tier Value Tier 2
CARDIZEM LA TAB 180MG
Tier 4
X
CARDIZEM LA TAB 240MG
Tier 4
X
CARDIZEM LA TAB 300MG/24
Tier 4
X
CARDIZEM LA TAB 360MG
Tier 4
X
CARDIZEM LA TAB 420MG/24
Tier 4
X
CARTIA XT CAP 120/24HR
Tier 1
CARTIA XT CAP 180/24HR
Tier 1
CARTIA XT CAP 240/24HR
Tier 1
CARTIA XT CAP 300/24HR
Tier 1
DILTIAZEM CAP 120MG CD
Tier 1
DILTIAZEM CAP 120MG ER
Tier 1
DILTIAZEM CAP 120MG ER
Tier 1
DILTIAZEM CAP 120MG ER
Tier 1
DILTIAZEM CAP 120MG/24
Tier 1
DILTIAZEM CAP 180MG CD
Tier 1
DILTIAZEM CAP 180MG ER
Tier 1
DILTIAZEM CAP 180MG ER
Tier 1
DILTIAZEM CAP 180MG/24
Tier 1
DILTIAZEM CAP 240MG CD
Tier 1
DILTIAZEM CAP 240MG ER
Tier 1
DILTIAZEM CAP 240MG ER
Tier 1
DILTIAZEM CAP 240MG/24
Tier 1
DILTIAZEM CAP 300MG CD
Tier 1
DILTIAZEM CAP 300MG ER
Tier 1
DILTIAZEM CAP 300MG/24
Tier 1
DILTIAZEM CAP 360MG CD
Tier 1
DILTIAZEM CAP 360MG ER
Tier 1
DILTIAZEM CAP 360MG ER
Tier 1
Page 78 of 279
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Product Name DILTIAZEM CAP 360MG/24
Tier Value Tier 1
DILTIAZEM CAP 420MG/24
Tier 1
DILTIAZEM CAP 60MG ER
Tier 1
DILTIAZEM CAP 90MG ER
Tier 1
DILTIAZEM TAB 120MG
Tier 1
DILTIAZEM TAB 30MG
Tier 1
DILTIAZEM TAB 60MG
Tier 1
DILTIAZEM TAB 90MG
Tier 1
DILTIAZEM ER TAB 180MG
Tier 1
DILTIAZEM ER TAB 240MG
Tier 1
DILTIAZEM ER TAB 300MG
Tier 1
DILTIAZEM ER TAB 360MG
Tier 1
DILTIAZEM ER TAB 420MG
Tier 1
DILT-XR
CAP 120MG
Tier 1
DILT-XR
CAP 180MG
Tier 1
DILT-XR
CAP 240MG
Tier 1
Prior Authorization
Supply Limit
Step Therapy
EXFORGE
TAB 10-160MG
Tier 4
X
X
EXFORGE
TAB 10-320MG
Tier 4
X
X
EXFORGE
TAB 5-160MG
Tier 4
X
X
EXFORGE
TAB 5-320MG
Tier 4
X
X
EXFORGEH/10- TAB 160-12.5
Tier 4
X
X
EXFORGEH/10- TAB 160-25
Tier 4
X
X
EXFORGEH/10- TAB 320-25
Tier 4
X
X
EXFORGEH/5- TAB 160-12.5
Tier 4
X
X
EXFORGEH/5- TAB 160-25
Tier 4
X
X
FELODIPINE TAB 10MG ER
Tier 1
FELODIPINE TAB 2.5MG ER
Tier 1
FELODIPINE TAB 5MG ER
Tier 1
ISRADIPINE CAP 2.5MG
Tier 1
Page 79 of 279
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Product Name ISRADIPINE CAP 5MG
Tier Value Tier 1
Prior Authorization
Supply Limit
LOTREL
CAP 10-20MG
Tier 4
X
LOTREL
CAP 10-40MG
Tier 4
X
LOTREL
CAP 2.5-10MG
Tier 4
X
LOTREL
CAP 5-10MG
Tier 4
X
LOTREL
CAP 5-20MG
Tier 4
X
LOTREL
CAP 5-40MG
Tier 4
X
MATZIM LA TAB 180MG/24
Tier 1
MATZIM LA TAB 240MG/24
Tier 1
MATZIM LA TAB 300MG/24
Tier 1
MATZIM LA TAB 360MG/24
Tier 1
MATZIM LA TAB 420MG/24
Tier 1
NICARDIPINE CAP 20MG
Tier 1
NICARDIPINE CAP 30MG
Tier 1
NIFEDICAL XL TAB 30MG
Tier 1
NIFEDICAL XL TAB 60MG
Tier 1
NIFEDIPINE CAP 10MG
Tier 1
NIFEDIPINE CAP 20MG
Tier 1
NIFEDIPINE TAB 30MG ER
Tier 1
NIFEDIPINE TAB 30MG ER
Tier 1
NIFEDIPINE TAB 60MG ER
Tier 1
NIFEDIPINE TAB 60MG ER
Tier 1
NIFEDIPINE TAB 90MG ER
Tier 1
NIFEDIPINE TAB 90MG ER
Tier 1
NIMODIPINE CAP 30MG
Tier 1
NISOLDIPINE TAB 17MG ER
Tier 1
NISOLDIPINE TAB 20MG
Tier 1
NISOLDIPINE TAB 25.5MG
Tier 1
NISOLDIPINE TAB 30MG
Tier 1
Page 80 of 279
Step Therapy
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Product Name NISOLDIPINE TAB 34MG ER
Tier Value Tier 1
NISOLDIPINE TAB 40MG
Tier 1
NISOLDIPINE TAB 8.5MG ER
Tier 1
NORVASC
TAB 10MG
Tier 4
NORVASC
TAB 2.5MG
Tier 4
NORVASC
TAB 5MG
Tier 4
NYMALIZE
SOL 60/20ML
Tier 2
PROCARDIA CAP 10MG
Tier 4
PROCARDIA XL TAB 30MG CR
Tier 4
PROCARDIA XL TAB 60MG CR
Tier 4
PROCARDIA XL TAB 90MG CR
Tier 4
SULAR
TAB 17MG
Tier 4
SULAR
TAB 34MG
Tier 4
SULAR
TAB 8.5MG
Tier 4
Prior Authorization
Supply Limit
Step Therapy
TAZTIA XT CAP 120MG/24
Tier 1
TAZTIA XT CAP 180MG/24
Tier 1
TAZTIA XT CAP 240MG/24
Tier 1
TAZTIA XT CAP 300MG/24
Tier 1
TAZTIA XT CAP 360MG/24
Tier 1
TELMIS/AMLOD TAB 40-10MG
Tier 1
X
X
TELMIS/AMLOD TAB 40-5MG
Tier 1
X
X
TELMIS/AMLOD TAB 80-10MG
Tier 1
X
X
TELMIS/AMLOD TAB 80-5MG
Tier 1
X
X
TIAZAC
CAP 120MG/24
Tier 4
TIAZAC
CAP 180MG/24
Tier 4
TIAZAC
CAP 240MG/24
Tier 4
TIAZAC
CAP 300MG/24
Tier 4
TIAZAC
CAP 360MG/24
Tier 4
TIAZAC
CAP 420MG/24
Tier 4
Page 81 of 279
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs
Product Name TRIBENZOR20- TAB 5-12.5MG
Tier Value Tier 4
Prior Authorization
Supply Limit X
Step Therapy X
TRIBENZOR40- TAB 10-12.5
Tier 4
X
X
TRIBENZOR40- TAB 10-25MG
Tier 4
X
X
TRIBENZOR40- TAB 5-12.5MG
Tier 4
X
X
TRIBENZOR40- TAB 5-25MG
Tier 4
X
X
TWYNSTA
TAB 40-10MG
Tier 4
X
X
TWYNSTA
TAB 40-5MG
Tier 4
X
X
TWYNSTA
TAB 80-10MG
Tier 4
X
X
TWYNSTA
TAB 80-5MG
Tier 4
X
X
VERAPAMIL CAP 100MG ER
Tier 1
VERAPAMIL CAP 120MG ER
Tier 1
VERAPAMIL CAP 120MG SR
Tier 1
VERAPAMIL CAP 180MG ER
Tier 1
VERAPAMIL CAP 180MG SR
Tier 1
VERAPAMIL CAP 200MG ER
Tier 1
VERAPAMIL CAP 240MG ER
Tier 1
VERAPAMIL CAP 240MG SR
Tier 1
VERAPAMIL CAP 300MG ER
Tier 1
VERAPAMIL CAP 360MG SR
Tier 1
VERAPAMIL TAB 120MG
Tier 1
VERAPAMIL TAB 120MG ER
Tier 1
VERAPAMIL TAB 180MG ER
Tier 1
VERAPAMIL TAB 240MG ER
Tier 1
VERAPAMIL TAB 40MG
Tier 1
VERAPAMIL TAB 80MG
Tier 1
VERELAN
CAP 120MG SR
Tier 4
VERELAN
CAP 180MG SR
Tier 4
VERELAN
CAP 240MG SR
Tier 4
VERELAN
CAP 360MG SR
Tier 4
Page 82 of 279
Specialty
Therapeutic Class Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Blocking Agents - Blood Pressure Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Calcium Channel Modifying Agents - Seizure Control Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs
Product Name VERELAN PM CAP 100MG ER
Tier Value Tier 4
VERELAN PM CAP 200MG ER
Tier 4
VERELAN PM CAP 300MG ER
Tier 4
CELONTIN
Tier 2
CAP 300MG
Prior Authorization
Supply Limit
Step Therapy
ETHOSUXIMIDE CAP 250MG
Tier 1
ETHOSUXIMIDE SOL 250/5ML
Tier 1
LYRICA
CAP 100MG
Tier 4
X
X
LYRICA
CAP 150MG
Tier 4
X
X
LYRICA
CAP 200MG
Tier 4
X
X
LYRICA
CAP 225MG
Tier 4
X
X
LYRICA
CAP 25MG
Tier 4
X
X
LYRICA
CAP 300MG
Tier 4
X
X
LYRICA
CAP 50MG
Tier 4
X
X
LYRICA
CAP 75MG
Tier 4
X
X
LYRICA
SOL 20MG/ML
Tier 4
X
X
ZARONTIN
CAP 250MG
Tier 4
ZARONTIN
SOL 250/5ML
Tier 4
ZONEGRAN
CAP 100MG
Tier 4
X
X
ZONEGRAN
CAP 25MG
Tier 4
X
X
ZONISAMIDE CAP 100MG
Tier 1
ZONISAMIDE CAP 25MG
Tier 1
ZONISAMIDE CAP 50MG
Tier 1
AMTURNIDE150 TAB -5-12.5
Tier 4
X
X
AMTURNIDE300 TAB -10-12.5
Tier 4
X
X
AMTURNIDE300 TAB -1025MG AMTURNIDE300 TAB -5-12.5
Tier 4
X
X
Tier 4
X
X
AMTURNIDE300 TAB -5-25MG
Tier 4
X
X
DEMSER
CAP 250MG
Tier 3
DIGITEK
TAB 0.125MG
Tier 1
Page 83 of 279
Specialty
Therapeutic Class Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs CARDIOVASCULAR DRUGS - CALCIUMCHANNEL BLOCKING AGENTS CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS
Product Name DIGITEK TAB 0.25MG
Tier Value Tier 1
DIGOX
TAB 0.125MG
Tier 1
DIGOX
TAB 0.25MG
Tier 1
DIGOXIN
SOL 50MCG/ML
Tier 1
DIGOXIN
TAB 0.125MG
Tier 1
DIGOXIN
TAB 0.25MG
Tier 1
LANOXIN
TAB 0.0625MG
Tier 3
LANOXIN
TAB 0.125MG
Tier 3
LANOXIN
TAB 0.1875MG
Tier 3
LANOXIN
TAB 0.25MG
Tier 3
PENTOXIFYLLI TAB 400MG ER
Tier 1
RANEXA
TAB 1000MG
Tier 2
RANEXA
TAB 500MG
Tier 2
Prior Authorization
Supply Limit
Step Therapy
TEKAMLO
TAB 150-10MG
Tier 4
X
X
TEKAMLO
TAB 150-5MG
Tier 4
X
X
TEKAMLO
TAB 300-10MG
Tier 4
X
X
TEKAMLO
TAB 300-5MG
Tier 4
X
X
TEKTURNA
TAB 150MG
Tier 3
X
TEKTURNA
TAB 300MG
Tier 3
X
TEKTURNA HCT TAB 150-12.5
Tier 3
X
TEKTURNA HCT TAB 150-25MG
Tier 3
X
TEKTURNA HCT TAB 300-12.5
Tier 3
X
TEKTURNA HCT TAB 300-25MG
Tier 3
X
TRENTAL
TAB 400MG
Tier 3
VECAMYL
TAB 2.5MG
Tier 4
KRISGEL 100 GEL
Tier 3
ISOMETH/APAP CAP DICHLOR
Tier 1
ISOMETH/CAFF TAB /APAP
Tier 1
Page 84 of 279
X
Specialty
X
Therapeutic Class CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC
Product Name NODOLOR CAP
TRYPTOPHAN CAP 500MG
Tier 3
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS Central Nervous System, Other Miscellaneous Central Nervous System Drugs
FORANE
Tier 2
PRODRIN
Tier Value Tier 1
TAB
Prior Authorization
Supply Limit
Tier 4
SOL
ISOFLURANE SOL
Tier 1
SEVOFLURANE SOL
Tier 1
SOJOURN
SOL
Tier 1
SUPRANE
INH
Tier 2
SUPRANE
SOL
Tier 2
TERRELL
SOL
Tier 1
ULTANE
SOL
Tier 3 Tier 1
X
Central Nervous System, Other BUT/APAP/CAF CAP CODEINE Miscellaneous Central Nervous System Drugs
Tier 1
X
Central Nervous System, Other FIORICET Miscellaneous Central Nervous System Drugs
CAP CODEINE
Tier 4
X
Central Nervous System, Other HETLIOZ Miscellaneous Central Nervous System Drugs
CAP 20MG
Tier 4
Central Nervous System, Other RILUTEK Miscellaneous Central Nervous System Drugs Central Nervous System, Other RILUZOLE Miscellaneous Central Nervous System Drugs
CAP 20-10MG
TAB 50MG
TAB 50MG
Specialty
X
BUT/APAP/CAF CAP CODEINE
Central Nervous System, Other NUEDEXTA Miscellaneous Central Nervous System Drugs
Step Therapy
X
X
X
X
X
Tier 2
Tier 4
Tier 1
Central Nervous System, Other TETRABENAZIN TAB 12.5MG Miscellaneous Central Nervous System Drugs
Tier 1
X
Central Nervous System, Other TETRABENAZIN TAB 25MG Miscellaneous Central Nervous System Drugs
Tier 1
X
Central Nervous System, Other XENAZINE Miscellaneous Central Nervous System Drugs
TAB 12.5MG
Tier 4
X
X
Central Nervous System, Other XENAZINE Miscellaneous Central Nervous System Drugs
TAB 25MG
Tier 4
X
X
Page 85 of 279
Therapeutic Class Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs
Product Name ARICEPT TAB 10MG
Tier Value Tier 3
ARICEPT
TAB 23MG
Tier 4
ARICEPT
TAB 5MG
Tier 3
Prior Authorization
Supply Limit
Step Therapy
X
DONEPEZIL TAB 10MG
Tier 1
DONEPEZIL TAB 10MG ODT
Tier 1
DONEPEZIL TAB 5MG
Tier 1
DONEPEZIL TAB 5MG ODT
Tier 1
DONEPEZIL TAB HCL 23MG
Tier 1
EXELON
CAP 1.5MG
Tier 3
EXELON
CAP 3MG
Tier 4
EXELON
CAP 4.5MG
Tier 4
EXELON
CAP 6MG
Tier 4
EXELON
DIS 13.3/24
Tier 4
X
EXELON
DIS 4.6MG/24
Tier 4
X
EXELON
DIS 9.5MG/24
Tier 4
X
GALANTAMINE CAP 16MG ER
Tier 1
GALANTAMINE CAP 24MG ER
Tier 1
GALANTAMINE CAP 8MG ER
Tier 1
GALANTAMINE SOL 4MG/ML
Tier 1
GALANTAMINE TAB 12MG
Tier 1
GALANTAMINE TAB 4MG
Tier 1
GALANTAMINE TAB 8MG
Tier 1
RAZADYNE
TAB 12MG
Tier 4
RAZADYNE
TAB 4MG
Tier 4
RAZADYNE
TAB 8MG
Tier 4
RAZADYNE ER CAP 16MG
Tier 4
RAZADYNE ER CAP 24MG
Tier 4
RAZADYNE ER CAP 8MG
Tier 4
RIVASTIGMINE CAP 1.5MG
Tier 1
Page 86 of 279
X
Specialty
Therapeutic Class Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs Coagulants - Blood Clotting Drugs Coagulants - Blood Clotting Drugs Coagulants - Blood Clotting Drugs Coagulants - Blood Clotting Drugs CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) CONTRACEPTIVES (E.G. FOAMS, DEVICES) Conventional - Mood Disorder Drugs
Product Name RIVASTIGMINE CAP 3MG
Tier Value Tier 1
RIVASTIGMINE CAP 4.5MG
Tier 1
RIVASTIGMINE CAP 6MG
Tier 1
RIVASTIGMINE DIS 13.3/24
Tier 1
RIVASTIGMINE DIS 4.6MG/24
Tier 1
RIVASTIGMINE DIS 9.5MG/24
Tier 1
BRILINTA TAB 60MG BRILINTA TAB 90MG LYSTEDA TAB 650MG TRANEX ACID TAB 650MG CAYA DPR FC FEMALE MIS CONDOM OMNIFLEX DPR WIDE-SEAL DPR KIT 60 WIDE-SEAL DPR KIT 65 WIDE-SEAL DPR KIT 70 WIDE-SEAL DPR KIT 75 WIDE-SEAL DPR KIT 80 WIDE-SEAL DPR KIT 85 WIDE-SEAL DPR KIT 90 WIDE-SEAL DPR KIT 95 MOLINDONE TAB HCL 10MG
Tier 4 Tier 4 Tier 3 Tier 1 Tier 3 HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative Tier 1
Conventional - Mood Disorder Drugs
MOLINDONE TAB HCL 25MG
Tier 1
Conventional - Mood Disorder Drugs DENTAL AGENTS Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dental and Oral Agents Dermatological Agents - Drugs to Treat Skin Conditions Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
MOLINDONE TAB HCL 5MG HURRISEAL SOL CEVIMELINE CAP 30MG CHLORHEX GLU SOL 0.12% EVOXAC CAP 30MG ORALONE PST 0.1% PAROEX SOL 0.12% PERIDEX SOL 0.12% PERIOGARD SOL 0.12% PILOCARPINE TAB 5MG PILOCARPINE TAB 7.5MG SALAGEN TAB 5MG SALAGEN TAB 7.5MG TRIAMCIN/ORA PST 0.1% TRIAMCINOLON PST 0.1% MIRVASO GEL 0.33%
Tier 1 Tier 3 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 1 Tier 1 Tier 4
8-MOP ABSORICA ABSORICA ABSORICA ABSORICA ABSORICA ABSORICA ACANYA ACITRETIN ACITRETIN
Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1
CAP 10MG CAP 10MG CAP 20MG CAP 25MG CAP 30MG CAP 35MG CAP 40MG GEL 1.2-2.5% CAP 10MG CAP 17.5MG
Page 87 of 279
Prior Authorization
Supply Limit
X X
X X X X
Step Therapy
X
X X X X X X X
X X X X X X X
Specialty
Prior Authorization
Supply Limit
Therapeutic Class Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
Product Name ACITRETIN CAP 25MG ACZONE GEL 5% ACZONE GEL 7.5% ADAPALENE CRE 0.1% ADAPALENE GEL 0.1% ADAPALENE GEL 0.3% ADAPALENE GEL PMP 0.3% ADAPALENE LOT 0.1% ALDARA CRE 5% AMNESTEEM CAP 10MG AMNESTEEM CAP 20MG AMNESTEEM CAP 40MG ATRALIN GEL 0.05% ATRAPRO DERM SPR AVITA CRE 0.025% AVITA GEL 0.025% AZELEX CRE 20% BEAU RX GEL BENZACLIN GEL 1-5% BENZACLIN GEL 1-5%PUMP
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
BENZAMYCIN GEL 5-3% BENZAMYCIN GEL PAK CALCIPOTRIEN CRE 0.005% CALCIPOTRIEN OIN 0.005% CALCIPOTRIEN OIN BETAMETH
Tier 2 Tier 3 Tier 1 Tier 1 Tier 1
X
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
CALCIPOTRIEN SOL 0.005% CALCITRENE OIN 0.005% CALCITRIOL OIN 3MCG/GM CARAC CRE 0.5% CLARAVIS CAP 10MG CLARAVIS CAP 20MG CLARAVIS CAP 30MG CLARAVIS CAP 40MG CLEOCIN-T GEL 1% CLEOCIN-T LOT 1% CLEOCIN-T PAD 1% CLEOCIN-T SOL 1% CLINDACIN KIT ETZ 1% CLINDACIN KIT PAC 1% CLINDACIN MIS ETZ 1% CLINDACIN-P PAD 1% CLINDAGEL GEL 1% CLINDAMAX GEL 1% CLINDAMY/BEN GEL 1.2-5% CLINDAMY/BEN GEL 1-5% CLINDAMYCIN AER 1% CLINDAMYCIN GEL 1% CLINDAMYCIN GEL TRETINOI
Tier 1 Tier 3 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
CLINDAMYCIN LOT 1% CLINDAMYCIN LOT 10MG/ML
Tier 1 Tier 1
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
CLINDAMYCIN PAD 1% CLINDAMYCIN SOL 1% CONDYLOX GEL 0.5% CONDYLOX SOL 0.5%
Tier 1 Tier 1 Tier 3 Tier 4
Page 88 of 279
Tier Value Tier 1 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 4 Tier 1 Tier 1 Tier 1 Tier 4 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 4 Tier 4
Step Therapy
X X X X X X X X X X X X X
X X X X X X
X
X
X X X
X X X
X X
X X
X X X X X X
X X
X
X
X X
X
X X
X
Specialty
Therapeutic Class Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
Product Name CVS SCAR GEL DERMASORB HC KIT 2% DICLOFENAC GEL 3% DIFFERIN CRE 0.1% DIFFERIN GEL 0.1% DIFFERIN GEL 0.3% DIFFERIN LOT 0.1% DOVONEX CRE 0.005% DOXEPIN HCL CRE 5% DUAC GEL 1.2-5% EFUDEX CRE 5% ELIDEL CRE 1% ENSTILAR AER EPIDUO GEL 0.1-2.5% EPIDUO FORTE GEL 0.3-2.5% EQL SCAR GEL ERYTHROMYCIN GEL /BENZOYL
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
EVOCLIN AER 1% FABIOR AER 0.1% FINACEA AER 15% FINACEA GEL 15% FLUOROPLEX CRE 1% FLUOROURACIL CRE 0.5% FLUOROURACIL CRE 5% FLUOROURACIL DRO 2% FLUOROURACIL DRO 5% FLUOROURACIL SOL 2% FLUOROURACIL SOL 5% GLYCERIN LIQ GLYCERIN LIQ GLYCERIN LIQ GLYCERIN LIQ GLYCERINE LIQ GLYCEROL LIQ FORMAL IMIQUIMOD CRE 5% KLARON LOT 10% LACTIC ACID LOT 10% LAVARE WOUND GEL WASH LEVULAN KERA SOL 20% MEDERMA CRE SPF 30 MEDERMA GEL MEDERMA FOR GEL KIDS MENCAPS PAD METHOXSALEN CAP 10MG MYORISAN CAP 10MG MYORISAN CAP 20MG MYORISAN CAP 30MG MYORISAN CAP 40MG NEO-SYNALAR CRE NEUAC GEL 1.2-5% ONEXTON GEL 1.2-3.75 OXSORALEN LOT 1% OXSORALEN-UL CAP 10MG PODOCON SOL 25% PODOFILOX SOL 0.5% PROTOPIC OIN 0.03% PROTOPIC OIN 0.1%
Page 89 of 279
Tier Value Tier 1 Tier 4 Tier 1 Tier 3 Tier 3 Tier 4 Tier 3 Tier 4 Tier 1 Tier 4 Tier 4 Tier 3 Tier 4 Tier 3 Tier 4 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 1 Tier 4 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 4 Tier 3 Tier 2 Tier 1 Tier 1 Tier 4 Tier 4
Prior Authorization X
Supply Limit
Step Therapy
Specialty
X X X X X X
X
X X X X X
X
X
X
X X X X
X X
X X
X
X
X
X X X X X
X
X X X X X X X X
X X
X X X
X
X X
X X
X
Prior Authorization
Supply Limit
Step Therapy
X X X X X X X X X X
X X X X X X X X
X X
Tier 4 Tier 4 Tier 4
X X X
X X X
X X X
RETINOIC ACD POW RETINOIC ACD POW ALL TRAN
Tier 4 Tier 4
X X
SANTYL OIN 250/GM SCAR GEL SCARCIN CRE SELENIUM SUL LOT 2.5% SKARJEL GEL SOLARAZE GEL 3% W/W SORIATANE CAP 10MG SORIATANE CAP 17.5MG SORIATANE CAP 25MG SORILUX AER 0.005% STELARA INJ 45MG/0.5 STELARA INJ 90MG/ML SULFACETAMID LOT 10% SULFACETAMID SUS 10% SYNALAR KIT 0.025% SYNALAR KIT 0.025% TACLONEX OIN TACLONEX SUS TACROLIMUS OIN 0.03% TACROLIMUS OIN 0.1% TAZORAC CRE 0.05% TAZORAC CRE 0.1% TAZORAC GEL 0.05% TAZORAC GEL 0.1% TERSI FOAM AER 2.25% TOLAK CRE 4% TRAMADOL CRE 5% TRAMADOL CRE 8% KIT TRETINOIN CRE 0.025% TRETINOIN CRE 0.05% TRETINOIN CRE 0.1% TRETINOIN GEL 0.01% TRETINOIN GEL 0.025% TRETINOIN GEL 0.04% TRETINOIN GEL 0.04%PMP TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% TRETINOIN GEL 0.1%PUMP TRETINOIN POW
Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 1 Tier 4
Therapeutic Class Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
Product Name PRUDOXIN CRE 5% RA SCAR GEL RECEDO GEL REGRANEX GEL 0.01% RETIN-A CRE 0.025% RETIN-A CRE 0.05% RETIN-A CRE 0.1% RETIN-A GEL 0.01% RETIN-A GEL 0.025% RETIN-A MICR GEL 0.04% RETIN-A MICR GEL 0.04%PMP
Tier Value Tier 1 Tier 1 Tier 3 Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
RETIN-A MICR GEL 0.08% RETIN-A MICR GEL 0.1% RETIN-A MICR GEL 0.1%PUMP
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
Page 90 of 279
Specialty
X X
X X X X
X X
X X X X X X
X X X
X X X X X X X X
X X X
X X X
X X X X X X X X X X X X X X
X X X X X X X X X X
X X X X X X
Therapeutic Class Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents DEVICES
Product Name TRETIN-X CRE 0.0375% TRETIN-X CRE 0.075% TRETIN-X CRE KIT 0.05% VECTICAL OIN 3MCG/GM VELTIN GEL VEREGEN OIN 15% ZENATANE CAP 10MG ZENATANE CAP 20MG ZENATANE CAP 30MG ZENATANE CAP 40MG ZIANA GEL ZONALON CRE 5% ZYCLARA CRE 3.75% ZYCLARA PUMP CRE 2.5% ZYCLARA PUMP CRE 3.75% AERCHMBR PLS MIS FLOW-VU
Tier Value Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2
DEVICES
AERCHMBR PLS MIS LRG MASK
Tier 2
DEVICES
AERCHMBR PLS MIS SM MASK
Tier 2
DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES
AEROCHAMBER MIS PLUS EASIVENT MIS EASIVENT MIS MASK LG EASIVENT MIS MASK SM EASIVENT MIS MASK MED E-Z SPACER MIS E-Z SPACER MIS BODY GRD FLEXICHAMBER MIS FLEXICHAMBER MIS MASK LRG
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
DEVICES
FLEXICHAMBER MIS MASK SM
Tier 2
DEVICES DEVICES
INSPIRACHAMB MIS LARGE INSPIRACHAMB MIS MEDIUM
Tier 2 Tier 2
DEVICES
Tier 2
DEVICES DEVICES DEVICES DEVICES
INSPIRACHAMB MIS MOUTHPCE INSPIRACHAMB MIS SMALL INSPIREASE MIS BAGS INSPIREASE MIS DD SYST INSPIREASE MIS MOUTHPCE
DEVICES DEVICES
INSPIREASE MIS RES BAG MASK VORTEX/ MIS BABY DUC
Tier 2 Tier 2
DEVICES DEVICES DEVICES
MASK VORTEX/ MIS DUCK MASK VORTEX/ MIS FROG MASK VORTEX/ MIS LADY BUG
Tier 2 Tier 2 Tier 2
DEVICES DEVICES
OPTIHALER MIS VORTEX VALVE MIS CHAMBER
Tier 2 Tier 2
DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES
WATCHHALER MIS AUTOJECT 2 MIS CGMS SYSTEM MIS GOLD GUARDIAN RT KIT GUARDIAN RT KIT STARTER
Tier 2 Tier 4 Tier 3 Tier 3 Tier 3
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Prior Authorization X X
Supply Limit X X X X X X
Step Therapy X X X
X
X
X X X
X X X
Specialty
X
X X X X
Tier 2 Tier 2 Tier 2 Tier 2
X X X X
X X X
Therapeutic Class DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES
Product Name GUARDIAN RT KIT SYST PED GUARDIAN RT KIT SYSTEM GUARDIAN RT MIS REPL PED
Tier Value Tier 3 Tier 3 Tier 3
DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES
Tier 3 Tier 3 Tier 4
DIABETIC DEVICES
GUARDIAN RT MIS REPLACE GUARDIAN RT MIS SYSTEM HUMATROPEN MIS FOR 12MG HUMATROPEN MIS FOR 24MG HUMATROPEN MIS FOR 6MG
DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC SUPPLIES
DIABETIC DEVICES
Prior Authorization X X X
Supply Limit X X X
X X
X X
Step Therapy
Specialty
X
Tier 4
X
Tier 4
X
NORDIPEN 5 MIS DEVICE NORDIPEN DEL MIS SYSTEM OMNITROPE 5 MIS DEVICE PCA INJECTOR MIS REAL-TIME KIT ACCU-CHEK KIT AVA CONN
Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1
X X X X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK ACCU-CHEK
KIT AVIVA PL KIT COMPACT KIT FASTCLIX KIT MLTICLIX KIT NANO KIT SOFTCLIX KIT VOICEMAT LIQ ACT/GLUC LIQ COMPACT LIQ SMART MIS ADAPTER MIS AVIVA MIS BATTERY MIS CLIP MIS MLTICLIX MIS SPRT COM
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 4 Tier 3 Tier 3 Tier 1 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
ACCU-CHEK SOL ACCU-CHEK SOL COMFORT ACCU-CHEK SOL COMPACT ACCU-CHEK IN LIQ CONTROL
Tier 1 Tier 1 Tier 1 Tier 1
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
ACCUTREND SOL GLUCOSE ADV LANCING MIS DEVICE ASCENSIA LIQ NORM CON ASSURE CMFRT MIS 28G ASSURE CMFRT MIS 30G AT LAST KIT GLUCOSE AT LAST MIS LANCETS AURORA LANCE MIS 30G AURORA LANCE MIS THIN 23G
Tier 1 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
AUTODISC LIQ LOW/HIGH AUTOLET II KIT CLINISAF AUTOLET LANC MIS DEVICE AUTOLET LITE KIT STARTER AUTOLET MINI MIS AUTOPEN MIS 1-21UNIT AUTOPEN MIS 2-42UNIT
Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
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X X
X X
X X
X
X X X X X X X
X X
X
X
X
X X X X X X X
X X X X
X X
Prior Authorization X
Supply Limit X
Therapeutic Class DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
Product Name BAYER BREEZE KIT 2 SYSTEM BAYER BREEZE LIQ HIGH CNT BAYER BREEZE LIQ LOW CNTL
Tier Value Tier 3 Tier 2 Tier 2
DIABETIC SUPPLIES
BAYER BREEZE LIQ NORM CNT
Tier 2
DIABETIC SUPPLIES
BAYER MICRLT MIS LANC DVC
Tier 3
X
DIABETIC SUPPLIES DIABETIC SUPPLIES
BAYER MICRLT MIS LANCETS BLOOD GLUC MIS MONITOR
Tier 3 Tier 3
X X
DIABETIC SUPPLIES DIABETIC SUPPLIES
BREEZE 2 MIS SYSTEM CAREONE ADV MIS LANCING
Tier 4 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES
CAREONE LANC MIS 28G CAREONE LANC MIS THIN 23G
Tier 3 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
CARTRIDGE MIS 3.15ML CARTRIDGE MIS IR 1000 CARTRIDGE MIS IR 1200 CARTRIDGE MIS PUMP CGMS MIS SOFTWARE CGMS CABLE MIS CHEMSTRIP BG MIS LOG CHOICE DM KIT RISK TST COAGUCHEK MIS LANCETS COMFORT MIS LANCETS COMFORT SET MIS 23"/17MM
Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2
DIABETIC SUPPLIES
COMFORT SET MIS 31"/17MM
Tier 2
DIABETIC SUPPLIES
COMFORT SET MIS 32"/17MM
Tier 2
DIABETIC SUPPLIES
COMFORT SET MIS 43"/17MM
Tier 2
DIABETIC SUPPLIES
Tier 2
DIABETIC SUPPLIES
COMFORT SHRT MIS 23"/13MM COMFORT SHRT MIS 31"/13MM COMFORT SHRT MIS 32"/13MM COMFORT SHRT MIS 43"/13MM COMFORTOUCH MIS LANCET
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR CONTOUR
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 4 Tier 4 Tier 2 Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
KIT LINK KIT MONITOR KIT NEXT KIT NEXT EZ KIT NEXT LNK KIT NEXT USB LIQ HIGH CNT LIQ LOW CNTL LIQ NORM CNT MIS MONITOR MIS MONITOR SOL NEXT SOL NEXT
Page 93 of 279
X
X X
Step Therapy X
X
X X
X X X X X
Tier 2 Tier 2 Tier 2 Tier 3
X X X X X X X
X X X X X X
X X X X X X
X
X X
X X
Specialty
Therapeutic Class DIABETIC SUPPLIES
Product Name CONTROL HIGH SOL UNISTRIP
Tier Value Tier 2
DIABETIC SUPPLIES
CONTROL LOW SOL UNISTRIP
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES
CONTROL SOL LIQ HI/MID/L CONTROL SOL LIQ HIGH/LOW
Tier 2 Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES
CONTROL SOL LIQ MID CVS LANCETS MIS ORIGINAL
Tier 2 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
CVS LANCETS MIS THIN 26G CVS LANCETS MIS THIN 33G DIDGET KIT EASYMAX SOL HIGH EASYMAX SOL LOW EASYMAX SOL NORMAL EASYMAX 15 SOL LEVEL 1 EASYMAX 15 SOL LEVEL 2 EASYMAX L KIT SYSTEM EASYMAX L MIS SYSTEM EASYMAX N KIT SYSTEM EASYMAX N MIS SYSTEM EASYMAX NG KIT SYSTEM EASYMAX NG MIS SYSTEM EASYMAX V KIT SYSTEM EASYMAX V MIS SYSTEM EASYMAX V2 KIT SYSTEM EASYMAX V2 MIS SYSTEM EASYPLS R13N KIT SYSTEM EASYPLUS V KIT SYSTEM EMBRACE MIS EMBRACE SOL LOW ENLITE MIS SERTER ENLITE GLUCO MIS SENSOR FASTCLIX MIS LANCETS FINGERSTIX MIS LANCETS FLEXLINK MIS PLS/10MM FLEXLINK MIS PLUS/6MM FLEXLINK MIS PLUS/8MM FORA GD50 MIS MONITOR FORA TEST N' MIS GO FORTISCARE KIT SYSTEM FORTISCARE SOL CNTL HI FORTISCARE SOL CNTL LOW
Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 1 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2
DIABETIC SUPPLIES
FORTISCARE SOL CNTL NML
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
FREESTYLE GENTLE-LET GENTLE-LET GENTLE-LET GENTLE-LET
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
GLUC CONTROL SOL LEVEL 1 GLUC CONTROL SOL LEVEL 2 GLUCOLET 2 MIS LANCING GLUCOSE CONT LIQ HIGH/LOW
MIS UNISTICK MIS 26G MIS 28G MIS LANCETS MIS PLATFORM
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Tier 2 Tier 2 Tier 3 Tier 2
Prior Authorization
Supply Limit
Step Therapy
X X X X
X X X X X X X X X X X X X
X
X X X
X X X
X X X X X
X
X
Specialty
Supply Limit
Step Therapy
Tier 3 Tier 3 Tier 4
X X X
X
GMATE SMART KIT METER GMATE SMART KIT STARTER GMATE VOICE MIS GLUC SYS
Tier 4 Tier 3 Tier 4
X X X
X X X
DIABETIC SUPPLIES
GUARDIAN
MIS TRANSMTR
Tier 3
DIABETIC SUPPLIES
GUARDIAN RT MIS CHARGER
Tier 3
X
DIABETIC SUPPLIES
GUARDIAN RT MIS SOFTWARE
Tier 3
X
DIABETIC SUPPLIES
GUARDIAN RT MIS TST PLUG
Tier 3
X
DIABETIC SUPPLIES
Tier 3
X
DIABETIC SUPPLIES
HAEMOLANCE MIS LOW FLOW HAEMOLANCE MIS RETRACT
Tier 3
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
HUMAPEN MIS LUXURA IN TOUCH MIS INFUSION SET MIS 23" INFUSION SET MIS 23" 13MM
Tier 3 Tier 3 Tier 2 Tier 2
DIABETIC SUPPLIES
INFUSION SET MIS 23" 17MM
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
INFUSION SET MIS 23" 6MM INFUSION SET MIS 23" 8MM INFUSION SET MIS 23" 9MM INFUSION SET MIS 23"/6MM INFUSION SET MIS 23"/9MM INFUSION SET MIS 24" INFUSION SET MIS 24" 6MM INFUSION SET MIS 24" 9MM INFUSION SET MIS 31" INFUSION SET MIS 31" 6MM INFUSION SET MIS 31" 9MM INFUSION SET MIS 32" 8MM INFUSION SET MIS 42" 6MM INFUSION SET MIS 42" 9MM INFUSION SET MIS 43" INFUSION SET MIS 43" 13MM
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
DIABETIC SUPPLIES
INFUSION SET MIS 43" 17MM
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
INFUSION SET MIS 43" 6MM INFUSION SET MIS 43" 8MM INFUSION SET MIS 43" 9MM INFUSION SET MIS 43"/6MM INFUSION SET MIS 43"/9MM KROGER BGM KIT LANCET ALTER MIS SITE 26G LANCET CARRY MIS CASE
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
Therapeutic Class DIABETIC SUPPLIES
Product Name GLUCOSE CONT SOL PRECISIO
Tier Value Tier 2
DIABETIC SUPPLIES
GMATE CONTRO SOL LEVEL 2
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
GMATE LANCET MIS 30G GMATE LANCIN MIS DEVICE GMATE ORIGIN MIS GLUC SYS
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
Page 95 of 279
Prior Authorization
X
X
X X X
X
Specialty
Prior Authorization
Supply Limit X
Therapeutic Class DIABETIC SUPPLIES
Product Name LANCET SUPER MIS THIN 30G
Tier Value Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES
LANCET ULTRA MIS 28G LANCET ULTRA MIS THIN 28G
Tier 3 Tier 3
X X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
LANCETS MIS 23G LANCETS MIS 28G LANCETS MICR MIS THIN 33G
Tier 3 Tier 3 Tier 3
X X X
DIABETIC SUPPLIES DIABETIC SUPPLIES
LANCETS THIN MIS LANCETS ULTR MIS THIN 28G
Tier 3 Tier 3
X X
DIABETIC SUPPLIES
LANCETS ULTR MIS THIN 30G
Tier 3
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
LANCING DEVI MIS LB LANCET MIS 28G LB LANCING MIS DEVICE LIFESCAN MIS UNISTIK2 LINK ASSIST MIS ACCU-CHK MEDISENSE LIQ GLUC/KET MEDISENSE LIQ GLUC-KET MEIJER MIS LANCETS MICROLET MIS LANCETS MINI LANCING MIS DEVICE MINILINK RT KIT REPLACE MINILINK RT KIT STARTER MINILINK RT MIS TRANSMIT
Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X
DIABETIC SUPPLIES
MINIMED PUMP MIS RES 3ML
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
MIO INF SET MIS 18"/6MM MIO INF SET MIS 23"/6MM MIO INF SET MIS 32"/6MM MIO INF SET MIS 32"/9MM NEUTEK 2TEK SOL CONTROL NOVOPEN ECHO MIS ON CALL MIS LANCETS ON CALL EXPR KIT SYSTEM ON CALL EXPR MIS METER ON CALL EXPR SOL GLUCOSE ON CALL LANC MIS DEVICE ON CALL PLUS KIT METER ON CALL PLUS KIT MONITOR ON CALL PLUS MIS LANC DEV
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
ON CALL PLUS MIS LANCETS ON CALL PLUS MIS METER ON CALL PLUS SOL CONTROL
Tier 3 Tier 3 Tier 2
X X
DIABETIC SUPPLIES DIABETIC SUPPLIES
ON CALL VIVD KIT METER ON CALL VIVD KIT MONITOR
Tier 3 Tier 3
X X
DIABETIC SUPPLIES DIABETIC SUPPLIES
ON CALL VIVD MIS METER ON CALL VIVD SOL CONTROL
Tier 3 Tier 2
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
ONETOUCH ONETOUCH ONETOUCH
Tier 1 Tier 1 Tier 1
X X X
KIT ULT MINI KIT ULTRA 2 KIT ULTRALNK
Page 96 of 279
X X X
X X X X X X X
Step Therapy
Specialty
Prior Authorization
Supply Limit X X X X X
Therapeutic Class DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
Product Name ONETOUCH KIT VERIO ONETOUCH KIT VERIO IQ ONETOUCH MIS 30G ONETOUCH MIS COMBO ONETOUCH MIS LANC DEV
DIABETIC SUPPLIES
ONETOUCH
MIS LANC DEV
Tier 1
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
ONETOUCH MIS LANCETS ONETOUCH MIS REMOTE ONETOUCH SOL ULT CONT ONETOUCH SOL VERIO ONETOUCH SOL VERIO-HI ONETOUCH FP MIS LANCETS
Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
X
DIABETIC SUPPLIES
ONETOUCH US MIS LANCETS
Tier 1
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
ONETOUCH VER KIT SYNC OPTIUM KIT BL GLUC OPTIUM MIS SYSTEM OPTUMRX KIT METER OPTUMRX KIT SYSTEM OPTUMRX CONT SOL LEVEL1/2
Tier 1 Tier 3 Tier 4 Tier 3 Tier 3 Tier 2
X X X X X
DIABETIC SUPPLIES DIABETIC SUPPLIES
PARADIGM MIS UPGRADE PARADIGM QR MIS POLY 24"
Tier 3 Tier 2
DIABETIC SUPPLIES
PARADIGM QR MIS POLY 42"
Tier 2
DIABETIC SUPPLIES
Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
PARADIGM REA MIS TRANSMIT PARADIGM RES MIS 1.8ML PARADIGM RES MIS 3ML PARADIGM SOF MIS -SET 24"
DIABETIC SUPPLIES
PARADIGM SOF MIS -SET 42"
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
PENLET II KIT BLOOD PENLET II MIS REPL CAP POLYFIN 24" MIS INFUSION POLYFIN 42" MIS INFUSION POLYFIN 42" MIS QR INFUS POLYFIN 60" MIS TUBING PREC NEO SYS KIT FREESTYL PRECISION KIT LINK PRECISION KIT XTRA PRECISION LIQ CONTROL PRECISION LIQ GLUC/KET PRECISION LIQ NRML/MID PRECISION MIS QID PRECISION MIS SOF-TACT PRECISION MIS XTRA PSS SAFE LAN MIS PSS SEL LANC MIS PSS SEL PLAT MIS PUMP REMOTE MIS PROGRAM PX LANCETS MIS ULT THIN
Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
DIABETIC SUPPLIES
Page 97 of 279
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Step Therapy
X
X X
Tier 2 Tier 2 Tier 2
Tier 3
X X
X
X X X
X X X
X X X X X X
X X X
X
Specialty
Therapeutic Class DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
Prior Authorization
Supply Limit X X X
Tier Value Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
Product Name QC LANCETS MIS 28G QC LANCETS MIS 30G QC LANCING MIS DEVICE QUICK-SERTER MIS INS DEV QUICK-SET MIS 18"/6MM QUICK-SET MIS 23"/6MM QUICK-SET MIS 23"/9MM QUICK-SET MIS 32"/6MM QUICK-SET MIS 32"/9MM QUICK-SET MIS 43"/6MM QUICK-SET MIS 43"/9MM QUINTET MIS SYSTEM QUINTET AC MIS SYSTEM QUINTET CONT SOL HGH/NORM RA E-ZJECT MIS 28G RA E-ZJECT MIS 33G RA E-ZJECT MIS THIN 26G RA E-ZJECT MIS THIN 28G RA E-ZJECT MIS ULT THIN RA GLUCOSE MIS MONITOR
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X X X
DIABETIC SUPPLIES DIABETIC SUPPLIES
RA TRUE2GO KIT RAPID-D INF MIS 24"/10MM
Tier 3 Tier 2
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
RAPID-D INF MIS 24"/6MM RAPID-D INF MIS 24"/8MM RAPID-D INF MIS 31"/10MM
Tier 2 Tier 2 Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
RAPID-D INF MIS 31"/6MM RAPID-D INF MIS 31"/8MM RAPID-D INF MIS 43"/10MM
Tier 2 Tier 2 Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
RAPID-D INF MIS 43"/6MM RAPID-D INF MIS 43"/8MM RAPID-D LINK MIS TRANSFER
Tier 2 Tier 2 Tier 2
DIABETIC SUPPLIES
RELION LANCE MIS THIN 26G
Tier 3
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
RELION ULTIM KIT SYSTEM REVEAL KIT MONITOR RIGHTSOURCE MIS METER SAFE-T-LANCE MIS 21G SAFE-T-LANCE MIS 25G SAFE-T-LANCE MIS HI FLOW SAFE-T-LANCE MIS LOW FLOW
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X X X X
DIABETIC SUPPLIES
SAFE-T-LANCE MIS NOR FLOW
Tier 3
X
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
SAFE-T-PRO MIS LANCETS SAFE-T-PRO MIS PLUS SELECT-LITE KIT DEV/LANC SEN-SERTER MIS SILHOUETTE MIS 13MM SILHOUETTE MIS 17MM SILHOUETTE MIS 18"/13MM
Tier 1 Tier 1 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2
X X X
DIABETIC SUPPLIES
SILHOUETTE MIS 23" SET
Tier 2
Page 98 of 279
X X
Step Therapy
Specialty
Therapeutic Class DIABETIC SUPPLIES
Product Name SILHOUETTE MIS 32"/13MM
Tier Value Tier 2
DIABETIC SUPPLIES
SILHOUETTE MIS 32"/17MM
Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
SILHOUETTE MIS 43" SET SILHOUETTE MIS COMBO SILHOUETTE MIS FULL SET SIL-SERTER MIS INS DEV SINGLE-LET MIS 23G SNAP PUMP MIS CONTROLL
Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
SOF-SENSOR MIS SOF-SERTER MIS INS DEV SOF-SET 24" KIT INFUSION SOF-SET 24" KIT MICRO QR SOF-SET 24" KIT ULTIM QR SOF-SET 42" KIT INFUSION SOF-SET 42" KIT MICRO QR SOF-SET 42" KIT ULTIM QR SOFT TOUCH MIS LANCETS SOFTCLIX MIS LANCETS SOFTCLIX LAN MIS DEVICE SUPER THIN MIS LANCETS SUPREME II LIQ HIGH/LOW SURESTEP SOL CONTROL SURESTEP GLU SOL SURESTEP GLU SOL HIGH/LOW
Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1
DIABETIC SUPPLIES DIABETIC SUPPLIES
SURESTEP PRO KIT LINEARIT SURESTEP PRO TES HIGH CON
Tier 1 Tier 1
DIABETIC SUPPLIES
SURESTEP PRO TES LOW CON
Tier 1
DIABETIC SUPPLIES
SURESTEP PRO TES NORM CON
Tier 1
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
SURE-T MIS 23"/6MM SURE-T MIS 23"/8MM T:30 INFUSIO MIS SET T:FLEX 4.8ML MIS CARTRDGE
Tier 2 Tier 2 Tier 2 Tier 2
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
T:SLIM 3ML MIS CARTRDGE T:SLIM G4 MIS CARTRDGE TECHLITE MIS LANCETS TEST PLUG MIS TGT LANCET MIS 23G TGT LANCET MIS 28G TGT LANCET MIS 30G TGT LANCET MIS ALTERNAT TGT LANCING MIS ADV DEV TGT LANCING MIS DEVICE THIN LANCETS MIS THINLETS GP MIS 26G TRANSMITTER MIS TAPE TRUE METRIX KIT AIR TRUE METRIX KIT METER TRUE METRIX MIS AIR TRUE METRIX SOL LEVEL 1 TRUE METRIX SOL LEVEL 2
Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2
Page 99 of 279
Prior Authorization
Supply Limit
X
X
X
X X X X
X X X X X X X X X X X X X X
Step Therapy
Specialty
Therapeutic Class DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
Product Name TRUE METRIX SOL LEVEL 3 TRUE2GO KIT TRUECONTROL LIQ LEVEL 0 TRUECONTROL LIQ LEVEL 1 TRUEDRAW MIS LANC DEV
Tier Value Tier 2 Tier 3 Tier 2 Tier 2 Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIAGNOSTIC AGENTS
TRUERESULT KIT TRUERESULT KIT MONITOR TRUETEST LIQ LEVEL 1 TRUETEST LIQ LEVEL 2 TRUETEST LIQ LEVEL 3 TRUETRACK KIT SYSTEM TRUETRACK MIS BLD GLC TRUPLUS LANC MIS 26G TRUPLUS LANC MIS 28G TRUPLUS LANC MIS 30G TRUPLUS LANC MIS 33G ULTILET OPER MIS DEVICE ULTIMA KIT MONITOR ULTRA THIN MIS LANC 26G ULTRA THIN MIS LANC 28G ULTRA THIN MIS LANC 30G ULTRA THIN MIS LANCETS ULTRAFLEX MIS 12"/6MM ULTRAFLEX MIS 24"/10MM ULTRAFLEX MIS 24"/6MM ULTRAFLEX MIS 24"/8MM ULTRAFLEX MIS 31"/10MM ULTRAFLEX MIS 31"/6MM ULTRAFLEX MIS 31"/8MM ULTRAFLEX MIS 43"/10MM ULTRAFLEX MIS 43"/8MM UNILET EX II MIS 28G UNILET EXCEL MIS 23G UNILET G.P MIS SUPR 23G UNILET G.P. MIS 21G UNILET LANCT MIS 33G UNILET SUPER MIS 23G UNISTIK 1 MIS 2.4MM UNISTIK 1 MIS 3.0MM UNISTIK 2 MIS 1.8MM UNISTIK 2 MIS 2.4MM UNISTIK 2 MIS EXTRA UNISTIK 2 MIS SUPER UNISTIK 3 MIS 1.8MM UNISTIK II MIS LANCETS VERIO FLEX KIT ONETOUCH VIVID PAL KIT METER VIVID PAL MIS METER ADVANCED DNA KIT COLLECTI
Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS
ARIDOL KIT CHEMSTRIP TES UGK CHEMSTRIP K TES CVS KETONE TES CARE DNA COLLECT KIT DNA COLLECT KIT MEDICATE
Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3
Page 100 of 279
Prior Authorization
Supply Limit
Step Therapy
X
X X X
X X X X X X X X X X X
X X X X X X X X X X X X X X X X X
X
X
Specialty
Therapeutic Class DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS
Product Name DYNAMIC KIT DYNAMIC PLUS KIT PAK FLURA-SAFE SOL KETOCARE TES KETO-DIASTIX TES KETOSTIX TES KETOSTIX TES STRIP MEDCATED DNA KIT COLLECT
Tier Value Tier 1 Tier 3 Tier 3 Tier 2 Tier 3 Tier 2 Tier 2 Tier 3
DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS - ADRENOCORTICAL INSUFFICIENCY DIAGNOSTIC AGENTS - ADRENOCORTICAL INSUFFICIENCY DIAGNOSTIC AGENTS - OCULAR DISORDERS
MULTI-DRUG KIT DIUSCREE PRECISN XTRA TES KETONE PRO DNA KIT KIT RELION KETON TES T.R.U.E. TES CORTROSYN INJ 0.25MG
Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 4
COSYNTROPIN INJ 0.25MG
Tier 1
ALTAFLUOR SOL 0.25-0.4
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
BIO GLO
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUCAINE
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUORACAINE SOL OP
Tier 3
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUORE-BENOX SOL 0.25-0.4
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUORESCEIN/ SOL PROPARAC
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUOR-I-STRI TES 1MG OP
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUROX
SOL OP
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FUL-GLO
TES 0.6MG OP
Tier 2
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FUL-GLO
TES 1MG OP
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
GREEN GLO MIS 1.5MG
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
LISSAMINE GR TES 1.5MG
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
ROSE GLO
Tier 3
DIAGNOSTIC AGENTS - PITUITARY FUNCTION
METOPIRONE CAP 250MG
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
ENTERO VU SUS 24%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-CAT DRY PAK
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-DISK
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-DOSE
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-HD
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-PAQUE SUS 60%
TES 1MG OP SOL 0.25-0.5
TES 1.5MG
TAB 700MG ENE
Tier 1
Tier 2
SUS 98%
Page 101 of 279
Tier 3 Tier 2
Prior Authorization
Supply Limit
X X X
X X
Step Therapy
Specialty
Therapeutic Class DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
Product Name E-Z-PAQUE SUS 96%
Tier Value Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-PASTE CRE 60%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
GASTROGRAFIN SOL 66-10%
Tier 4
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
MD-GASTROVIE SOL 66-10%
Tier 1
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
POLIBAR ACB KIT 96%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
POLIBAR PLUS SUS 105%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS 2.1%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS BANANA
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS BERRY
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS MOCHACCI
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
TAGITOL V SUS 40%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR HONE SUS 40%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR NECT SUS 40%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR THIN SUS HONEY
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR THIN SUS LIQUID
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VOLUMEN
Tier 2
DISINFECTANTS (FOR NON-DERMATOLOGIC USE) Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs
GLUTARALDEHY SOL 25%
Tier 3
BUMETANIDE TAB 0.5MG BUMETANIDE TAB 1MG BUMETANIDE TAB 2MG BUMEX TAB 0.5MG BUMEX TAB 1MG BUMEX TAB 2MG DEMADEX TAB 100MG DEMADEX TAB 10MG DEMADEX TAB 20MG DEMADEX TAB 5MG EDECRIN TAB 25MG ETHACRYNIC TAB ACD 25MG
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 3 Tier 4 Tier 1
Diuretics, Loop - Cardiac Drugs
FUROSEMIDE SOL 10MG/ML
Tier 1
Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs
FUROSEMIDE SOL 8MG/ML FUROSEMIDE TAB 20MG FUROSEMIDE TAB 40MG FUROSEMIDE TAB 80MG LASIX TAB 20MG LASIX TAB 40MG LASIX TAB 80MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4
PST PUDDING
SUS 0.1%
Page 102 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Loop - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs
Product Name TORSEMIDE TAB 100MG TORSEMIDE TAB 10MG TORSEMIDE TAB 20MG TORSEMIDE TAB 5MG ALDACTAZIDE TAB 25/25
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTAZIDE TAB 50/50
Tier 2
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTONE TAB 100MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTONE TAB 25MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTONE TAB 50MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
AMILOR/HCTZ TAB 5-50
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
AMILORIDE TAB 5MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
DYAZIDE
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
DYRENIUM
CAP 100MG
Tier 3
Diuretics, Potassium-sparing - Cardiac Drugs
DYRENIUM
CAP 50MG
Tier 3
Diuretics, Potassium-sparing - Cardiac Drugs
EPLERENONE TAB 25MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
EPLERENONE TAB 50MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
INSPRA
TAB 25MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
INSPRA
TAB 50MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
MAXZIDE
Diuretics, Potassium-sparing - Cardiac Drugs
MAXZIDE-25 TAB
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONO/HCTZ TAB 25/25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT POW
Tier 3
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT TAB 100MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT TAB 25MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT TAB 50MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ CAP 37.5-25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ CAP 50/25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ CAP 50-25MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ TAB 37.5-25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ TAB 75-50MG
Tier 1
Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs
CHLOROTHIAZ TAB 250MG CHLOROTHIAZ TAB 500MG
Tier 1 Tier 1
CAP 37.5-25
TAB 75-50
Page 103 of 279
Prior Authorization
Tier 4
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs
Product Name CHLORTHALID TAB 100MG CHLORTHALID TAB 25MG CHLORTHALID TAB 50MG DIURIL SUS 250/5ML EZIDE TAB 50MG HYDROCHLOROT CAP 12.5MG
Tier Value Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1
Diuretics, Thiazide - Cardiac Drugs
HYDROCHLOROT TAB 12.5MG
Tier 1
Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Diuretics, Thiazide - Cardiac Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs
HYDROCHLOROT TAB 25MG HYDROCHLOROT TAB 50MG INDAPAMIDE TAB 1.25MG INDAPAMIDE TAB 2.5MG METHYCLOTHIA TAB 5MG METOLAZONE TAB 10MG METOLAZONE TAB 2.5MG METOLAZONE TAB 5MG MICROZIDE CAP 12.5MG APOKYN INJ 10MG/ML
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 3
BROMOCRIPTIN CAP 5MG
Tier 1
BROMOCRIPTIN TAB 2.5MG
Tier 1
MIRAPEX
TAB 0.125MG
Tier 4
MIRAPEX
TAB 0.25MG
Tier 4
MIRAPEX
TAB 0.5MG
Tier 4
MIRAPEX
TAB 0.75MG
Tier 4
MIRAPEX
TAB 1.5MG
Tier 4
MIRAPEX
TAB 1MG
Tier 4
Prior Authorization
Supply Limit
Step Therapy
X
MIRAPEX ER TAB 0.375MG
Tier 4
X
MIRAPEX ER TAB 0.75MG
Tier 4
X
MIRAPEX ER TAB 1.5MG
Tier 4
X
MIRAPEX ER TAB 2.25MG
Tier 4
X
MIRAPEX ER TAB 3.75MG
Tier 4
X
MIRAPEX ER TAB 3MG
Tier 4
X
MIRAPEX ER TAB 4.5MG
Tier 4
X
PARLODEL
Tier 3
CAP 5MG
PRAMIPEXOLE TAB 0.125MG
Tier 1
PRAMIPEXOLE TAB 0.25MG
Tier 1
PRAMIPEXOLE TAB 0.375MG
Tier 1
Page 104 of 279
Specialty
X
Therapeutic Class Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs
Prior Authorization
Supply Limit
Step Therapy
Product Name PRAMIPEXOLE TAB 0.5MG
Tier Value Tier 1
PRAMIPEXOLE TAB 0.75 ER
Tier 1
PRAMIPEXOLE TAB 0.75MG
Tier 1
PRAMIPEXOLE TAB 1.5MG
Tier 1
PRAMIPEXOLE TAB 1.5MG ER
Tier 1
PRAMIPEXOLE TAB 1MG
Tier 1
PRAMIPEXOLE TAB 2.25MG
Tier 1
X
PRAMIPEXOLE TAB 3.75MG
Tier 1
X
PRAMIPEXOLE TAB 3MG
Tier 1
X
PRAMIPEXOLE TAB 4.5MG
Tier 1
X
REQUIP
TAB 0.25MG
Tier 4
REQUIP
TAB 0.5MG
Tier 4
REQUIP
TAB 1MG
Tier 4
REQUIP
TAB 2MG
Tier 4
REQUIP
TAB 3MG
Tier 4
REQUIP
TAB 4MG
Tier 4
REQUIP
TAB 5MG
Tier 4
X
X
REQUIP XL TAB 12MG
Tier 4
X
REQUIP XL TAB 2MG
Tier 4
X
REQUIP XL TAB 4MG
Tier 4
X
REQUIP XL TAB 6MG
Tier 4
X
REQUIP XL TAB 8MG
Tier 4
X
ROPINIROLE TAB 0.25MG
Tier 1
ROPINIROLE TAB 0.5MG
Tier 1
ROPINIROLE TAB 12MG ER
Tier 1
ROPINIROLE TAB 1MG
Tier 1
ROPINIROLE TAB 2MG
Tier 1
ROPINIROLE TAB 2MG ER
Tier 1
ROPINIROLE TAB 3MG
Tier 1
Page 105 of 279
X
X
Specialty
Therapeutic Class Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Agonists - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs
Product Name ROPINIROLE TAB 4MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
ROPINIROLE TAB 4MG ER
Tier 1
ROPINIROLE TAB 5MG
Tier 1
ROPINIROLE TAB 6MG ER
Tier 1
X
ROPINIROLE TAB 8MG ER
Tier 1
X
CARB/LEVO TAB 10-100MG
Tier 1
CARB/LEVO TAB 10-100MG
Tier 1
CARB/LEVO TAB 25-100MG
Tier 1
CARB/LEVO TAB 25-100MG
Tier 1
CARB/LEVO TAB 25-250MG
Tier 1
CARB/LEVO TAB 25-250MG
Tier 1
CARB/LEVO 50 TAB /ENTACAP
Tier 1
CARB/LEVO 75 TAB /ENTACAP
Tier 1
CARB/LEVO ER TAB 25-100MG
Tier 1
CARB/LEVO ER TAB 50-200MG
Tier 1
CARB/LEVO100 TAB /ENTACAP
Tier 1
CARB/LEVO125 TAB /ENTACAP
Tier 1
CARB/LEVO150 TAB /ENTACAP
Tier 1
CARB/LEVO200 TAB /ENTACAP
Tier 1
CARBIDOPA TAB 25MG
Tier 1
DUOPA
Tier 4
SUS 4.63-20
Page 106 of 279
X
X
Specialty
Therapeutic Class Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs Dyslipidemics - Cholesterol Control Drugs
Product Name LODOSYN TAB 25MG
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Tier Value Tier 4
Prior Authorization
Supply Limit
Step Therapy X
RYTARY
CAP
Tier 4
X
RYTARY
CAP
Tier 4
X
RYTARY
CAP
Tier 4
X
RYTARY
CAP 23.75-95
Tier 4
X
SINEMET
TAB 10-100MG
Tier 4
SINEMET
TAB 25-100MG
Tier 4
SINEMET
TAB 25-250MG
Tier 4
SINEMET CR TAB 25-100MG
Tier 4
SINEMET CR TAB 50-200MG
Tier 4
STALEVO 100 TAB
Tier 4
STALEVO 125 TAB
Tier 4
STALEVO 150 TAB
Tier 4
STALEVO 200 TAB
Tier 4
STALEVO 50 TAB
Tier 4
STALEVO 75 TAB
Tier 4
NIACIN
POW USP/NF
Tier 3
ANTARA
CAP 30MG
Tier 4
X
ANTARA
CAP 90MG
Tier 4
X
FENOFIBRATE CAP 130MG
Tier 1
X
FENOFIBRATE CAP 134MG
Tier 1
X
Page 107 of 279
Specialty
Therapeutic Class Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Prior Authorization
Supply Limit
Step Therapy X
Product Name FENOFIBRATE CAP 150MG
Tier Value Tier 1
FENOFIBRATE CAP 200MG
Tier 1
X
FENOFIBRATE CAP 43MG
Tier 1
X
FENOFIBRATE CAP 50MG
Tier 1
X
FENOFIBRATE CAP 67MG
Tier 1
X
FENOFIBRATE TAB 120MG
Tier 1
X
FENOFIBRATE TAB 145MG
Tier 1
X
FENOFIBRATE TAB 160MG
Tier 1
FENOFIBRATE TAB 40MG
Tier 1
X
FENOFIBRATE TAB 48MG
Tier 1
X
FENOFIBRATE TAB 54MG
Tier 1
FENOFIBRIC CAP 135MG DR
Tier 1
X
FENOFIBRIC CAP 45MG DR
Tier 1
X
FENOFIBRIC TAB 105MG
Tier 1
X
FENOFIBRIC TAB 35MG
Tier 1
X
FENOGLIDE TAB 120MG
Tier 4
X
FENOGLIDE TAB 40MG
Tier 4
X
FIBRICOR
TAB 105MG
Tier 4
X
FIBRICOR
TAB 35MG
Tier 4
X
GEMFIBROZIL TAB 600MG
Tier 1
LIPOFEN
CAP 150MG
Tier 4
X
LIPOFEN
CAP 50MG
Tier 4
X
LOFIBRA
CAP 134MG
Tier 4
X
LOFIBRA
CAP 200MG
Tier 4
X
LOFIBRA
CAP 67MG
Tier 4
X
LOFIBRA
TAB 160MG
Tier 4
X
LOFIBRA
TAB 54MG
Tier 4
X
TAB 600MG
Tier 4
LOPID TRICOR
TAB 145MG
Page 108 of 279
Tier 4
X
Specialty
Therapeutic Class Product Name Dyslipidemics, Fibric Acid Derivatives TRICOR TAB 48MG Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives TRIGLIDE TAB 160MG Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives TRILIPIX CAP 135MG Cholesterol Control Drugs Dyslipidemics, Fibric Acid Derivatives TRILIPIX CAP 45MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 1000-20 Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 1000-40 Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 500-20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 750-20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ALTOPREV TAB 20MG ER Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ALTOPREV TAB 40MG ER Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ALTOPREV TAB 60MG ER Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 10MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 80MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 10MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 5MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - FLUVASTATIN CAP 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - FLUVASTATIN CAP 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - FLUVASTATIN TAB 80MG ER Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LESCOL CAP 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LESCOL CAP 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LESCOL XL TAB 80MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 10MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 80MG Cholesterol Control Drugs
Page 109 of 279
Tier Value Tier 4
Prior Authorization
Supply Limit
Step Therapy X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 4
X
Tier 4
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
X
Specialty
Therapeutic Class Product Name Dyslipidemics, HMG CoA Reductase Inhibitors - LIVALO TAB 1MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LIVALO TAB 2MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LIVALO TAB 4MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LOVASTATIN TAB 10MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LOVASTATIN TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - LOVASTATIN TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - MEVACOR TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVACHOL TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVACHOL TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVACHOL TAB 80MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 10MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 80MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 10MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 5MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR TAB 1000-20 Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR TAB 1000-40 Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR TAB 500-20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR TAB 500-40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR TAB 750-20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 10MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 5MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 80MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR TAB 10MG Cholesterol Control Drugs
Page 110 of 279
Supply Limit X
Step Therapy X
Tier 4
X
X
Tier 4
X
X
Tier Value Tier 4
Prior Authorization
Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4
Specialty
Therapeutic Class Product Name Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR TAB 20MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR TAB 40MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR TAB 5MG Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR TAB 80MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous CHOLESTYRAM POW 4GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous CHOLESTYRAM POW 4GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous CHOLESTYRAM POW 4GM Cholesterol Control Drugs LITE Dyslipidemics, Other - Miscellaneous CHOLESTYRAM POW 4GM Cholesterol Control Drugs LITE Dyslipidemics, Other - Miscellaneous COLESTID GRA 5GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous COLESTID POW 5GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous COLESTID TAB 1GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous COLESTID FLA GRA 5/7.5GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous COLESTID FLA GRA 5GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous COLESTIPOL GRA 5GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous COLESTIPOL GRA 5GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous COLESTIPOL TAB 1GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous JUXTAPID CAP 10MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous JUXTAPID CAP 20MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous JUXTAPID CAP 30MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous JUXTAPID CAP 40MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous JUXTAPID CAP 5MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous JUXTAPID CAP 60MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous KYNAMRO INJ 200MG/ML Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous LOVAZA CAP 1GM Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous NIACIN ER TAB 1000MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous NIACIN ER TAB 500MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous NIACIN ER TAB 750MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous NIACOR TAB 500MG Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous NIASPAN TAB 1000 ER Cholesterol Control Drugs
Page 111 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
Tier Value Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 4
X
Therapeutic Class Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs
Product Name NIASPAN TAB 500MG ER NIASPAN
TAB 750MG ER
Tier Value Tier 4
Prior Authorization
Supply Limit
Tier 1
PREVALITE POW 4GM
Tier 1
PREVALITE POW 4GM PK
Tier 1
QUESTRAN
POW 4GM
Tier 4
QUESTRAN
POW 4GM
Tier 4
QUESTRAN
POW 4GM LITE
Tier 4
CAP 1GM
Tier 3
VYTORIN
TAB 10-10MG
Tier 4
X
VYTORIN
TAB 10-20MG
Tier 4
X
VYTORIN
TAB 10-40MG
Tier 4
X
VYTORIN
TAB 10-80MG
Tier 4
X
WELCHOL
PAK 3.75GM
Tier 2
WELCHOL
TAB 625MG
Tier 2
CHEMET
CAP 100MG
X
X
X
VASCEPA
TAB 10MG
Specialty
Tier 4
OMEGA-3-ACID CAP 1GM
ZETIA
Step Therapy
X
Tier 4
X
Tier 2
CUPRIMINE CAP 250MG
Tier 4
DEPEN TITRA TAB 250MG
Tier 2
EXJADE
TAB 125MG
Tier 3
X
X
EXJADE
TAB 250MG
Tier 3
X
X
EXJADE
TAB 500MG
Tier 3
X
X
JADENU
TAB 180MG
Tier 3
X
X
JADENU
TAB 360MG
Tier 3
X
X
JADENU
TAB 90MG
Tier 3
X
X
KAYEXALATE POW
Tier 4
KIONEX
POW
Tier 1
KIONEX
SUS 15GM/60
Tier 1
SAMSCA
TAB 15MG
Tier 3
Page 112 of 279
X
X
Therapeutic Class Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
Product Name SAMSCA TAB 30MG
CALC ACETATE CAP 667MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
CALC ACETATE TAB 667MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
ELIPHOS
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON 10 TAB 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON 8 TAB 8MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON M10 TAB 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON M15 TAB 15MEQ ER
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON M20 TAB 20MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON SPR CAP 10MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON SPR CAP 8MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON/25 POW 25MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
KLOR-CON-25 POW 25MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
K-SOL
Tier 1
Tier Value Tier 3
SOD POLY SUL POW
Tier 1
SOD POLY SUL SUS 15GM/60
Tier 1
SOD POLY SUL SUS 30/120ML
Tier 1
SOD POLY SUL SUS 50/200ML
Tier 1
SPS
SUS 15GM/60
Tier 1
CAP 250MG
Tier 4
SYPRINE
TAB 667MG
POW 20MEQ
SOL 10%
Page 113 of 279
Tier 1
Prior Authorization
X
Supply Limit X
Step Therapy
Specialty X
X
Therapeutic Class Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
Product Name K-SOL SOL 20%
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
K-TAB
TAB 10MEQ CR
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
K-TAB
TAB 20MEQ
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
K-TAB
TAB 8MEQ CR
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
MICRO-K
CAP 10MEQ CR
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
MICRO-K
CAP 8MEQ CR
Tier 4
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
PHOSLO
CAP 667MG
Tier 4
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
PHOSLYRA
SOL
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE CAP 10MEQ CR
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE CAP 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE CAP 8MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE POW 20MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 10%
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 10% SF
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 20%
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 20% SF
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 10MEQ CR
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 20MEQ ER
Tier 1
Tier Value Tier 1
Page 114 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
Product Name POT CHLORIDE TAB 8MEQ ER
Tier Value Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 8MEQ SR
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CITRATE TAB 1080MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CITRATE TAB 1620MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CITRATE TAB 540MG ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CL MICRO TAB 10MEQ CR
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CL MICRO TAB 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
POT CL MICRO TAB 20MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
SOD CHLORIDE GRA
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
SODIUM
Tier 3
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
UROCIT-K 10 TAB
Tier 4
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
UROCIT-K 15 TAB
Tier 4
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
UROCIT-K 5 TAB
Tier 4
Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals
CITRIC ACID/ SOL SOD CITR
Tier 1
POW CHLORIDE
CITROMA
SOL CHERRY
HCR Preventative
CITROMA
SOL LEMON
HCR Preventative
CYTRA K
GRA CRYSTALS
Tier 1
CYTRA-2
SOL
Tier 1
CYTRA-3
SYP
Tier 1
CYTRA-K
SOL
Tier 1
K CITRATE SOL CITR ACD
Tier 1
K/NA CITRATE SOL CITR ACD
Tier 1
Page 115 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
Product Name MAG CITRATE SOL CHERRY
Prior Authorization Tier Value HCR Preventative
MAG CITRATE SOL GRAPE
HCR Preventative
MAG CITRATE SOL LEMON
HCR Preventative
MED CIT MAGN SOL
Tier 1
ORACIT
SOL
Tier 2
POT CITRATE- PAK CIT ACID
Tier 1
SHOHLS
Tier 2
SOL MODIFIED
SOD CITRATE SOL CITR ACD
Tier 1
TARON
GRA CRYSTALS
Tier 1
TAURINE
CAP 500MG
Tier 1
TRICITRATES SOL
Tier 1
VIRTRATE-2 SOL
Tier 1
VIRTRATE-2 SOL 500-334
Tier 1
VIRTRATE-3 SOL
Tier 1
VIRTRATE-K SOL
Tier 1
VIRTRATE-K SOL 1100-334
Tier 1
FLUORABON DRO
HCR Preventative
FLUOR-A-DAY DRO 0.125MG
HCR Preventative
FLUORIDE
CHW 0.25MG F
HCR Preventative
FLUORIDE
CHW 0.5MG F
HCR Preventative
FLUORIDE
CHW 1MG F
HCR Preventative
FLUORITAB CHW 0.25MG F
HCR Preventative
FLUORITAB CHW 0.5MG F
HCR Preventative
FLUORITAB CHW 1MG F
HCR Preventative
FLUORITAB CHW 2.2MG
HCR Preventative
FLUORITAB DRO 0.125MG
HCR Preventative
FLURA-DROPS DRO 0.125MG HCR Preventative FLURA-DROPS DRO 0.25MG F HCR Preventative KARIDIUM
DRO 0.125MG
HCR Preventative
Page 116 of 279
Supply Limit
Step Therapy
Specialty
Therapeutic Class Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS
Product Name LOZI-FLUR LOZ 1MG F
Tier Value Tier 2
LUDENT
CHW 0.25MG F
HCR Preventative
LUDENT
CHW 0.5MG F
HCR Preventative
LUDENT
CHW 1MG F
HCR Preventative
LURIDE
CHW 0.25MG F
HCR Preventative
LURIDE
CHW 0.5MG F
HCR Preventative
LURIDE
CHW 1MG F
HCR Preventative
LURIDE
DRO 0.5MG/ML
HCR Preventative
NAFRINSE
CHW 1MG F
HCR Preventative
NAFRINSE
DRO 0.125MG
HCR Preventative
Prior Authorization
Supply Limit
Step Therapy
SOD FLUORIDE CHW 0.25MG F HCR Preventative SOD FLUORIDE CHW 0.5MG F HCR Preventative SOD FLUORIDE CHW 1.1MG
HCR Preventative
SOD FLUORIDE CHW 1MG F
HCR Preventative
SOD FLUORIDE CHW 2.2MG
HCR Preventative
SOD FLUORIDE DRO 0.5MG/ML SOD FLUORIDE TAB 0.5MG F
HCR Preventative Tier 1
SOD FLUORIDE TAB 1MG F
Tier 1
ACCU-CHEK TES ACTIVE
Tier 4
X
X
X
ACCU-CHEK TES AVIVA
Tier 4
X
X
X
ACCU-CHEK TES AVIVA PL
Tier 4
X
X
X
ACCU-CHEK TES COMFORT
Tier 4
X
X
X
ACCU-CHEK TES COMPACT
Tier 4
X
X
X
ACCU-CHEK TES DRUM
Tier 4
X
X
X
ACCU-CHEK TES SMART
Tier 4
X
X
X
ACCU-CK COMF TES CURVE
Tier 4
X
X
X
ACCUTREND TES GLUCOSE
Tier 4
X
X
X
ASCENSIA
Tier 4
X
X
X
AT LAST
MIS AUTODISC TES
Tier 3
Page 117 of 279
X
Specialty
Therapeutic Class ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS
Prior Authorization
Supply Limit X
Step Therapy X
X
X
X
Product Name BAYER BREEZE MIS 2 TEST
Tier Value Tier 4
BAYER BREEZE MIS 2 TEST
Tier 4
BLOOD GLUCOS TES PREMIUM
Tier 3
X
BLOOD GLUCOS TES STRIPS
Tier 3
X
CLINISTIX TES STRIPS
Tier 3
CONTOUR
TES BLD GLUC
Tier 4
X
X
X
CONTOUR
TES NEXT
Tier 4
X
X
X
CVS ADVANCED TES GLUCOSE
Tier 3
DIASTIX
Tier 3
EASYMAX
TES STRIPS TES
X
Tier 3
X
EASYMAX 15 TES
Tier 3
X
EASYPLUS
TES BLD GLUC
Tier 3
X
EMBRACE
TES BLD GLUC
Tier 3
X
EXACTECH
TES
Tier 4
X
X
EXACTECH
TES R-S-G
Tier 4
X
X
FORA GD50 TES
Tier 3
X
FORTISCARE TES BLD GLUC
Tier 3
X
FREESTYLE TES PREC NEO
Tier 4
X
GENSTRIP 50 TES
Tier 3
X
GLUTAMINE POW
Tier 3
X
GLUTATHIONE POW
Tier 3
X
GLUTATHIONE POW REDUCED
Tier 3
X
GMATE BLOOD TES GLUCOSE
Tier 3
X
KROGER
Tier 4
X
TES
L-GLUTAMINE POW
Tier 3
X
L-GLUTATHION CRY
Tier 3
X
LIBERTY
TES
Tier 3
X
NEUTEK 2TEK TES STRIPS
Tier 3
X
ON CALL
Tier 3
X
TES EXPRESS
Page 118 of 279
X
X
Specialty
Therapeutic Class ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS
Prior Authorization
Supply Limit X
Step Therapy
Product Name ON CALL PLUS TES BLD GLUC
Tier Value Tier 3
ON CALL VIVD TES BLD GLUC
Tier 3
X
ONETOUCH
TES ULTRA BL
Tier 1
X
ONETOUCH
TES VERIO
Tier 1
X
Tier 4
X
X X
OPTIUM
TES
OPTIUMEZ
TES
Tier 4
X
OPTUMRX
TES BLD GLUC
Tier 3
X
PRECISION TES PCX
Tier 4
X
X
PRECISION TES PCX PLUS
Tier 4
X
X
PRECISION TES QID
Tier 4
X
X
PRECISION TES SOF-TACT
Tier 4
X
X
PRECISION TES XTRA
Tier 4
X
X
PRECISION PT TES OF CARE
Tier 4
X
X
PROTEIN
TAB 975MG
Tier 3
QUINTET
TES BLD GLUC
Tier 3
X
QUINTET AC TES BLD GLUC
Tier 3
X
RA TRUETEST TES
Tier 3
X
RELION
Tier 3
X
RELION BLOOD TES GLUCOSE
Tier 4
X
REVEAL
Tier 3
X
Tier 3
X
TRUE METRIX TES
Tier 3
X
TRUE METRIX TES GLUCOSE
Tier 3
X
TRUETEST
TES
Tier 3
X
TRUETEST
TES BLD GLUC
Tier 3
X
TRUETRACK TES
Tier 3
X
TRUETRACK TES BLD GLUC
Tier 3
X
ULTIMA
Tier 3
X
Tier 4
X
SUPREME
TES ULTIMA
TES BLD GLUC TES
TES
UNISTRIP1 TES GENERIC
Page 119 of 279
X
X
X
Specialty
Therapeutic Class ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs
Product Name AV-PHOS 250 TAB NEUTRAL CALCIFOL
WAF
Tier Value Tier 1
Prior Authorization
Supply Limit
Tier 3
CALCIUM-FA WAF PLUS D
Tier 1
EFFER-K
TAB 10MEQ
Tier 2
EFFER-K
TAB 20MEQ
Tier 2
EFFER-K
TAB 25MEQ EF
Tier 1
K-EFFERVESCE TAB 25MEQ EF
Tier 1
KLOR-CON/EF TAB 25MEQ EF
Tier 1
KLOR-CON/EF TAB 25MEQ FR
Tier 1
K-PHOS
TAB
Tier 2
K-PHOS
TAB NEUTRAL
Tier 2
K-PRIME
TAB 25MEQ EF
Tier 1
K-VESCENT TAB 25MEQ EF
Tier 1
LEG-GESIC SUS
Tier 3
MAGNEBIND TAB 400
Tier 2
OSTIGEN
Tier 3
MIS 350MG
PHOSPHA 250 TAB NEUTRAL
Tier 1
POT CHLORIDE TAB 25MEQ EF
Tier 1
POT/CHLORIDE TAB 25MEQ EF
Tier 1
POTASSIUM TAB 25MEQ EF
Tier 1
VIRT-PHOS TAB 250 NEUT
Tier 1
ANZEMET
TAB 100MG
Tier 3
X
ANZEMET
TAB 50MG
Tier 3
X
CESAMET
CAP 1MG
Tier 3
DRONABINOL CAP 10MG
Tier 1
DRONABINOL CAP 2.5MG
Tier 1
DRONABINOL CAP 5MG
Tier 1
EMEND
CAP 125MG
Tier 2
X
EMEND
CAP 40MG
Tier 2
X
Page 120 of 279
Step Therapy
Specialty
Prior Authorization
Supply Limit X
Step Therapy
Therapeutic Class Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs Enzyme Inhibitors - Chemotherapy Agents
Product Name EMEND CAP 80MG
ETOPOSIDE CAP 50MG
Tier 1
Enzyme Inhibitors - Chemotherapy Agents
HYCAMTIN
CAP 0.25MG
Tier 3
X
X
X
Enzyme Inhibitors - Chemotherapy Agents
HYCAMTIN
CAP 1MG
Tier 3
X
X
X
Enzyme Inhibitors - Chemotherapy Agents
ZYDELIG
TAB 100MG
Tier 4
X
X
X
Enzyme Inhibitors - Chemotherapy Agents
ZYDELIG
TAB 150MG
Tier 4
X
X
X
Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs
BUPHENYL
POW
Tier 4
X
BUPHENYL
TAB 500MG
Tier 4
X
CARBAGLU
TAB 200MG
Tier 3
X
Tier Value Tier 2
EMEND
PAK 80 & 125
Tier 2
EMEND
SUS 125MG
Tier 2
GRANISETRON TAB 1MG
Tier 1
MARINOL
CAP 10MG
Tier 4
MARINOL
CAP 2.5MG
Tier 4
MARINOL
CAP 5MG
Tier 4
ONDANSETRON SOL 4MG/5ML ONDANSETRON TAB 24MG
Tier 1
ONDANSETRON TAB 4MG
Tier 1
ONDANSETRON TAB 4MG ODT ONDANSETRON TAB 8MG
Tier 1
ONDANSETRON TAB 8MG ODT SANCUSO DIS 3.1MG
Tier 1
ZOFRAN
SOL 4MG/5ML
Tier 4
ZOFRAN
TAB 4MG
Tier 4
ZOFRAN
TAB 4MG ODT
Tier 4
ZOFRAN
TAB 8MG
Tier 4
ZOFRAN
TAB 8MG ODT
Tier 4
ZUPLENZ
MIS 4MG
ZUPLENZ
MIS 8MG
Page 121 of 279
Specialty
X
X
Tier 1
Tier 1
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X X
Therapeutic Class Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs
Product Name CREON CAP 12000UNT
Tier Value Tier 2
CREON
CAP 24000UNT
Tier 2
CREON
CAP 3000UNIT
Tier 2
CREON
CAP 36000UNT
Tier 2
CREON
CAP 6000UNIT
Tier 2
Prior Authorization
Supply Limit
Step Therapy
Specialty
CYSTADANE POW
Tier 3
X
CYSTAGON
CAP 150MG
Tier 2
CYSTAGON
CAP 50MG
Tier 2
KUVAN
POW 100MG
Tier 3
X
X
X
KUVAN
POW 500MG
Tier 3
X
X
X
KUVAN
TAB 100MG
Tier 3
X
X
X
ORFADIN
CAP 10MG
Tier 4
X
ORFADIN
CAP 20MG
Tier 4
X
ORFADIN
CAP 2MG
Tier 4
X
X
ORFADIN
CAP 5MG
Tier 4
X
X
ORFADIN
SUS 4MG/ML
Tier 3
X
X
X X
PANCREAZE CAP 10500UNT
Tier 3
X
PANCREAZE CAP 16800UNT
Tier 3
X
PANCREAZE CAP 21000UNT
Tier 3
X
PANCREAZE CAP 4200UNIT
Tier 3
X
PANCRELIPASE CAP 5000UNIT
Tier 1
PERTZYE
CAP
Tier 4
X
PERTZYE
CAP
Tier 4
X
PHENYLBUTYRA POW SODIUM
Tier 1
PROCYSBI
CAP 25MG
Tier 4
X
X
X
PROCYSBI
CAP 75MG
Tier 4
X
X
X
RAVICTI
LIQ 1.1GM/ML
Tier 4
X
SUCRAID
SOL 8500/ML
Tier 3
ULTRESA
CAP 13800UNT
Tier 4
Page 122 of 279
X
X
X X X
Prior Authorization
Supply Limit
Therapeutic Class Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs Ergot Alkaloids - Migraine Drugs Ergot Alkaloids - Migraine Drugs Ergot Alkaloids - Migraine Drugs
Product Name ULTRESA CAP 20700UNT
CAFERGOT TAB 1-100MG D.H.E. 45 INJ 1MG/ML DIHYDROERGOT INJ 1MG/ML
Tier 3 Tier 4 Tier 1
Ergot Alkaloids - Migraine Drugs
DIHYDROERGOT POW MESYLATE DIHYDROERGOT SPR 4MG/ML
Tier 3
ERGOMAR SUB 2MG MIGERGOT SUP 2/100 MIGRANAL SPR 4MG/ML ACTIVELLA TAB 0.5-0.1
Tier 2 Tier 3 Tier 4 Tier 4
ACTIVELLA TAB 1-0.5MG
Tier 4
ALORA
DIS 0.025MG
Tier 3
X
ALORA
DIS 0.05MG
Tier 3
X
ALORA
DIS 0.075MG
Tier 3
X
ALORA
DIS 0.1MG
Tier 3
X
Ergot Alkaloids - Migraine Drugs Ergot Alkaloids - Migraine Drugs Ergot Alkaloids - Migraine Drugs Ergot Alkaloids - Migraine Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Tier Value Tier 4
Step Therapy X
ULTRESA
CAP 23000UNT
Tier 4
X
VIOKACE
TAB
Tier 4
X
VIOKACE
TAB 20880
Tier 4
X
ZAVESCA
CAP 100MG
Tier 4
ZENPEP
CAP 10000UNT
Tier 2
ZENPEP
CAP 15000UNT
Tier 2
ZENPEP
CAP 20000UNT
Tier 2
ZENPEP
CAP 25000UNT
Tier 2
ZENPEP
CAP 3000UNIT
Tier 2
ZENPEP
CAP 40000UNT
Tier 2
ZENPEP
CAP 5000UNIT
Tier 2
X
X
Tier 1
X
ALTAVERA
TAB
HCR Preventative
ALYACEN
TAB 1/35
HCR Preventative
ALYACEN
TAB 7/7/7
HCR Preventative
AMETHIA
TAB
HCR Preventative
X
HCR Preventative
X
AMETHIA LO TAB
Page 123 of 279
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name AMETHYST TAB 90-20MCG
Prior Authorization Tier Value HCR Preventative
ANGELIQ
TAB 0.25-0.5
Tier 3
ANGELIQ
TAB 0.5-1MG
Tier 3
APRI
TAB TAB
HCR Preventative
ASHLYNA
TAB
HCR Preventative
AUBRA
TAB 0.1-0.02
HCR Preventative
AVIANE
TAB
HCR Preventative
TAB 28 DAY TAB
HCR Preventative
BEKYREE
TAB
HCR Preventative
TAB
Tier 4
BLISOVI 24 TAB FE 1/20
HCR Preventative
BLISOVI FE TAB 1.5/30
HCR Preventative
BLISOVI FE TAB 1/20
HCR Preventative
BREVICON BRIELLYN CAMRESE
TAB 0.5/35 TAB
X
HCR Preventative
BALZIVA
BEYAZ
Step Therapy
HCR Preventative
ARANELLE
AZURETTE
Supply Limit
X
Tier 4 HCR Preventative
TAB
HCR Preventative
X
CAMRESE LO TAB
HCR Preventative
X
CAZIANT
PAK
HCR Preventative
CHATEAL
TAB 0.15/30
HCR Preventative
CLIMARA
DIS 0.025MG
Tier 2
X
CLIMARA
DIS 0.0375MG
Tier 2
X
CLIMARA
DIS 0.05MG
Tier 2
X
CLIMARA
DIS 0.06MG
Tier 2
X
CLIMARA
DIS 0.075MG
Tier 2
X
CLIMARA
DIS 0.1MG
Tier 2
X
CLIMARA PRO DIS WEEKLY
Tier 3
X
COMBIPATCH DIS .05/.14
Tier 3
X
Page 124 of 279
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name COMBIPATCH DIS .05/.25 COVARYX
Tier Value Tier 3
TAB 1.25-2.5
Tier 1
CRYSELLE-28 TAB 28 TABS
HCR Preventative
CYCLAFEM
TAB 1/35
HCR Preventative
CYCLAFEM
TAB 7/7/7
HCR Preventative
CYRED
PAK
Tier 4
TAB
HCR Preventative
DASETTA
TAB 1/35
HCR Preventative
DASETTA
TAB 7/7/7
HCR Preventative
DAYSEE
TAB
HCR Preventative
DELYLA
TAB 0.1-0.02
HCR Preventative
DESO/ETHINYL TAB ESTRADIO HCR Preventative DESO/ETHINYL TAB ESTRADIO HCR Preventative DESOGEN-28 TAB
Tier 4
DIVIGEL
GEL 0.25MG
Tier 3
DIVIGEL
GEL 0.5MG
Tier 3
DIVIGEL
GEL 1MG/GM
Tier 3
DROSPIR/ETHI TAB 3-0.03MG HCR Preventative DROSPIRENONE TAB ETHY EST HCR Preventative DUAVEE EEMT
TAB 0.45-20
Tier 3
TAB 1.25-2.5
Tier 1
EEMT HS
TAB
Tier 1
ELESTRIN
GEL 0.06%
Tier 3
ELINEST
Supply Limit X
Tier 1
COVARYX HS TAB
CYCLESSA
Prior Authorization
TAB
HCR Preventative
EMOQUETTE TAB
HCR Preventative
ENJUVIA
TAB 0.3MG
Tier 3
ENJUVIA
TAB 0.45MG
Tier 3
ENJUVIA
TAB 0.625MG
Tier 3
Page 125 of 279
X
Step Therapy
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name ENJUVIA TAB 0.9MG ENJUVIA
Tier Value Tier 3
TAB 1.25MG
HCR Preventative
ENSKYCE
HCR Preventative
EST ESTROGEN TAB MTEST
Tier 1
EST ESTROGEN TAB MTEST HS
Tier 1
ESTARYLLA TAB 0.25-35
Supply Limit
Step Therapy
X
Tier 3
ENPRESSE-28 TAB TAB
Prior Authorization
HCR Preventative
ESTRA/NORETH TAB 0.5-0.1
Tier 1
ESTRA/NORETH TAB 1-0.5MG
Tier 1
ESTRACE
TAB 0.5MG
Tier 4
ESTRACE
TAB 1MG
Tier 4
ESTRACE
TAB 2MG
Tier 4
ESTRACE VAG CRE 0.1MG/GM
Tier 3
ESTRADIOL DIS 0.025MG
Tier 4
X
ESTRADIOL DIS 0.025MG
Tier 1
X
ESTRADIOL DIS 0.0375MG
Tier 4
X
ESTRADIOL DIS 0.0375MG
Tier 1
X
ESTRADIOL DIS 0.05MG
Tier 4
X
ESTRADIOL DIS 0.05MG
Tier 1
X
ESTRADIOL DIS 0.06MG
Tier 1
X
ESTRADIOL DIS 0.075MG
Tier 4
X
ESTRADIOL DIS 0.075MG
Tier 1
X
ESTRADIOL DIS 0.1MG
Tier 4
X
ESTRADIOL DIS 0.1MG
Tier 1
X
ESTRADIOL TAB 0.5MG
Tier 1
ESTRADIOL TAB 1MG
Tier 1
ESTRADIOL TAB 2MG
Tier 1
ESTRING
Tier 2
MIS 2MG
ESTROG/MTEST TAB 1.25-2.5
Page 126 of 279
Tier 1
X
X
X
X
X
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name ESTROGEL GEL
Tier Value Tier 3
ESTROPIPATE TAB 0.75MG
Tier 1
ESTROPIPATE TAB 1.5MG
Tier 1
ESTROPIPATE TAB 3MG
Tier 1
ESTROSTEP FE TAB
Tier 4
EVAMIST
SPR 1.53MG
Tier 2
FALESSA
KIT
Tier 4
FALMINA
TAB
Prior Authorization
Supply Limit X
X
HCR Preventative
FEMCON FE CHW
Tier 4
FEMHRT
TAB 0.5-2.5
Tier 3
FEMRING
MIS 0.05/24H
Tier 3
X
FEMRING
MIS 0.1MG/24
Tier 3
X
FYAVOLV
TAB 0.5-2.5
Tier 1
FYAVOLV
TAB 1-5
Tier 1
GENERESS FE CHW GIANVI GILDAGIA
Step Therapy
Tier 4
TAB 3-0.02MG
HCR Preventative
TAB 0.4-35
HCR Preventative
GILDESS
TAB 1.5/30
HCR Preventative
GILDESS
TAB 1/20
HCR Preventative
GILDESS 24 TAB FE 1/20
HCR Preventative
GILDESS FE TAB 1.5/30
HCR Preventative
GILDESS FE TAB 1/20
HCR Preventative
INTROVALE TAB
HCR Preventative
JEVANTIQUE L TAB 0.5-2.5
Tier 1
JINTELI
Tier 1
TAB 1MG-5MCG
JOLESSA
TAB
HCR Preventative
JULEBER
TAB
HCR Preventative
JUNEL 1.5/30 TAB
HCR Preventative
JUNEL 1/20 TAB
HCR Preventative
Page 127 of 279
X
X
X
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name JUNEL FE TAB 1.5/30
Prior Authorization Tier Value HCR Preventative
JUNEL FE
HCR Preventative
TAB 1/20
JUNEL FE 24 TAB 1/20
HCR Preventative
KAITLIB FE CHW
HCR Preventative
KARIVA
TAB 28 DAY
HCR Preventative
KELNOR
TAB 1/35
HCR Preventative
KIMIDESS
TAB
HCR Preventative
KURVELO
TAB 0.15/30
HCR Preventative
LARIN
TAB 1.5/30
HCR Preventative
LARIN
TAB 1/20
HCR Preventative
LARIN 24
TAB FE 1/20
HCR Preventative
LARIN FE
TAB 1.5/30
HCR Preventative
LARIN FE
TAB 1/20
HCR Preventative
LARISSIA
TAB
HCR Preventative
LAYOLIS FE CHW
HCR Preventative
LEENA
TAB
HCR Preventative
LESSINA
TAB
HCR Preventative
Supply Limit
X
X
LEVO-ETH EST TAB 90-20MCG HCR Preventative LEVONEST
TAB
HCR Preventative
LEVONOR/ETHI TAB
HCR Preventative
LEVONOR/ETHI TAB 0.1-0.02
HCR Preventative
LEVONOR/ETHI TAB ESTRADIO HCR Preventative
X
LEVONOR/ETHI TAB ESTRADIO HCR Preventative LEVONOR/ETHI TAB ESTRADIO HCR Preventative
X
LEVONOR/ETHI TAB ESTRADIO HCR Preventative
X
LEVORA-28 TAB 0.15/30
HCR Preventative
LO LOESTRIN TAB
Tier 3
LOESTRIN
TAB 1/20-21
Tier 4
LOESTRIN 21 TAB 1.5/30
Tier 4
Page 128 of 279
Step Therapy
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name LOESTRIN FE TAB 1.5/30
Tier Value Tier 4
LOESTRIN FE TAB 1/20 LOMEDIA 24 TAB FE
Tier 1
LOPREEZA
TAB 1-0.5MG
Tier 1
TAB 3-0.02MG
HCR Preventative
LOSEASONIQUE TAB
Tier 4
LOW-OGESTREL TAB
HCR Preventative
LUTERA
HCR Preventative
MARLISSA MENOSTAR
TAB 0.15/30
X
HCR Preventative
DIS 14MCG
Tier 3
MICRGSTIN 24 TAB FE 1/20
HCR Preventative
MICROGESTIN TAB 1.5/30
HCR Preventative
MICROGESTIN TAB 1/20
HCR Preventative
MICROGESTIN TAB FE 1/20
HCR Preventative
MICROGESTIN TAB FE1.5/30
HCR Preventative
MIMVEY
X
TAB 1-0.5MG
Tier 1
MIMVEY LO TAB 0.5-0.1
Tier 1
MINASTRIN 24 CHW FE
Tier 4
MINIVELLE DIS 0.025 MG
Tier 3
X
MINIVELLE DIS 0.0375MG
Tier 3
X
MINIVELLE DIS 0.05MG
Tier 3
X
MINIVELLE DIS 0.075MG
Tier 3
X
MINIVELLE DIS 0.1MG
Tier 3
X
MIRCETTE
TAB 28 DAY
Tier 4
MODICON
TAB 0.5/35
Tier 4
MONO-LINYAH TAB 0.25-35
HCR Preventative
MONONESSA TAB
HCR Preventative
MYZILRA
HCR Preventative
TAB
Step Therapy
HCR Preventative
TAB 0.5-0.1
TAB
Supply Limit
Tier 4
LOPREEZA
LORYNA
Prior Authorization
Page 129 of 279
X
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name NATAZIA TAB
Prior Authorization Tier Value HCR Preventative
NECON
TAB 0.5/35
HCR Preventative
NECON
TAB 1/35
HCR Preventative
NECON
TAB 10/11-28
HCR Preventative
NECON
TAB 7/7/7
HCR Preventative
TAB 3-0.02MG
HCR Preventative
NORETH/ETHIN CHW FE
HCR Preventative
NIKKI
NORETH/ETHIN TAB 0.5-2.5 NORETH/ETHIN TAB 1/20
Supply Limit
Step Therapy
X
Tier 1 HCR Preventative
NORETH/ETHIN TAB 1MG5MCG NORETH/ETHIN TAB FE 1/20
Tier 1 HCR Preventative
NORETH/ETHIN TAB FE 1/20
HCR Preventative
NORGEST/ETHI TAB 0.25/35
HCR Preventative
NORGEST/ETHI TAB ESTRADIO HCR Preventative NORGEST/ETHI TAB ESTRADIO HCR Preventative NORINYL
TAB 1/35
NORTREL
TAB 0.5/35
HCR Preventative
NORTREL
TAB 1/35
HCR Preventative
NORTREL
TAB 7/7/7
HCR Preventative
NUVARING OCELLA
MIS
Tier 4
HCR Preventative
TAB 3-0.03MG
HCR Preventative
OGESTREL
TAB
HCR Preventative
ORSYTHIA
TAB
HCR Preventative
ORTHO EVRA DIS WEEK
Tier 4
ORTHO TRI- TAB CYCLEN
Tier 3
ORTHO TRI- TAB CYCLN LO
Tier 3
ORTHO-CEPT TAB 28
Tier 4
ORTHO-CYCLEN TAB 0.25/35
Tier 3
ORTHO-EST TAB 0.625
Tier 1
Page 130 of 279
X
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Supply Limit
Step Therapy
Tier 4
X
X
HCR Preventative
X
Product Name ORTHO-EST TAB 1.25
Tier Value Tier 1
ORTHO-NOVUM TAB 1/35
Tier 4
ORTHO-NOVUM TAB 7/7/7
Tier 3
OVCON-35
Tier 4
PHILITH
TAB TAB 0.4-35
HCR Preventative
PIMTREA
TAB
HCR Preventative
PIRMELLA
TAB 1/35
HCR Preventative
PIRMELLA
TAB 7/7/7
HCR Preventative
PORTIA-28 TAB PREFEST
HCR Preventative
TAB
Tier 2
PREMARIN
TAB 0.3MG
Tier 3
PREMARIN
TAB 0.45MG
Tier 3
PREMARIN
TAB 0.625MG
Tier 3
PREMARIN
TAB 0.9MG
Tier 3
PREMARIN
TAB 1.25MG
Tier 3
PREMARIN VAG CRE 0.625MG
Tier 3
PREMPHASE TAB
Tier 3
PREMPRO
TAB .625-2.5
Tier 3
PREMPRO
TAB 0.3-1.5
Tier 3
PREMPRO
TAB 0.45-1.5
Tier 3
PREMPRO
TAB 0.625-5
Tier 3
PREVIFEM
TAB
HCR Preventative
QUARTETTE TAB QUASENSE
TAB
RECLIPSEN TAB SAFYRAL
HCR Preventative
TAB
Tier 4
SEASONIQUE TAB SETLAKIN
Prior Authorization
TAB
SPRINTEC 28 TAB 28 DAY
X
Tier 4
X
HCR Preventative
X
HCR Preventative
Page 131 of 279
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs
Product Name SRONYX TAB
Prior Authorization Tier Value HCR Preventative
SYEDA
HCR Preventative
TAB 3-0.03MG
TARINA FE TAB 1/20
HCR Preventative
TILIA FE
HCR Preventative
TAB
TRI-ESTARYLL TAB
HCR Preventative
TRI-LEGEST TAB FE
HCR Preventative
TRI-LINYAH TAB
HCR Preventative
TRI-LO
TAB ESTARYLL
HCR Preventative
TRI-LO-
TAB MARZIA
HCR Preventative
TRI-LO-
TAB SPRINTEC
HCR Preventative
TRINESSA
TAB
HCR Preventative
TRINESSA LO TAB
HCR Preventative
TRI-NORINYL TAB 28
Tier 4
TRI-PREVIFEM TAB
HCR Preventative
TRI-SPRINTEC TAB
HCR Preventative
TRIVORA-28 TAB
HCR Preventative
VAGIFEM VELIVET VESTURA
Supply Limit
TAB 10MCG PAK
Tier 2 HCR Preventative
TAB 3-0.02MG
HCR Preventative
VIENVA
TAB 0.1-20
HCR Preventative
VIORELE
TAB
HCR Preventative
VIVELLE-DOT DIS 0.025MG
Tier 1
X
VIVELLE-DOT DIS 0.0375MG
Tier 1
X
VIVELLE-DOT DIS 0.05MG
Tier 1
X
VIVELLE-DOT DIS 0.075MG
Tier 1
X
VIVELLE-DOT DIS 0.1MG
Tier 1
X
VYFEMLA WERA
TAB 0.4-35 TAB 0.5/35
HCR Preventative HCR Preventative
WYMZYA FE CHW 0.4MG-35 HCR Preventative
Page 132 of 279
Step Therapy
Specialty
Therapeutic Class Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs Estrogens - Hormone Replacement/Modifying Drugs EYE, EAR, NOSE AND THROAT (EENT) PREPS LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS MISCELLANEOUS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS
Product Name XULANE DIS 150-35
Prior Authorization Tier Value HCR Preventative
YASMIN 28 TAB 3-0.03MG
Tier 3
YAZ
Tier 3
TAB 3-0.02MG
ZARAH ZENCHENT
TAB 3-0.03MG TAB
HCR Preventative HCR Preventative
ZENCHENT FE CHW 0.4MG-35 HCR Preventative ZOVIA 1/35E TAB
HCR Preventative
ZOVIA 1/50E TAB
HCR Preventative
BXN MOUTHWSH SUS
Tier 3
COCAINE HCL SOL 4%
Tier 1
FIRST-MOUTHW SUS BLM
Tier 3
GELFILM
Tier 2
MIS OP
CYCLOGYL
SOL 0.5% OP
Tier 4
CYCLOGYL
SOL 1% OP
Tier 4
CYCLOGYL
SOL 2% OP
Tier 4
CYCLOMYDRIL SOL OP
Tier 3
CYCLOPENTOL SOL 1% OP
Tier 1
CYCLOPENTOL SOL 2% OP
Tier 1
CYCLOPENTOLA SOL 0.5%
Tier 1
HOMATROPAIRE SOL 5% OP
Tier 1
HOMATROPINE SOL 5% OP
Tier 1
PAREMYD
Tier 3
SOL 1-0.25%
ALTAFRIN
SOL 10% OP
Tier 1
ALTAFRIN
SOL 2.5% OP
Tier 1
NEOFRIN
SOL 10% OP
Tier 1
NEOFRIN
SOL 2.5% OP
Tier 1
PHENYLEPHRIN SOL 10% OP
Tier 1
PHENYLEPHRIN SOL 2.5% OP
Tier 1
Page 133 of 279
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Product Name EYE, EAR, NOSE AND THROAT (EENT) PREPS. - BETADINE SOL 5% OP ANTI-INFECTIVES, MISCELLANEOUS EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT) Fibromyalgia Agents - Fibromyalgia Drugs Fibromyalgia Agents - Fibromyalgia Drugs Fibromyalgia Agents - Fibromyalgia Drugs Fibromyalgia Agents - Fibromyalgia Drugs Fibromyalgia Agents - Fibromyalgia Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs
Tier Value Tier 3
AERO OTIC HC SOL
Tier 1
CORTANE-B DRO AQ OTIC
Tier 2
CORTANE-B DRO OTIC
Tier 2
CORTIC-ND DRO
Tier 1
CYOTIC
Tier 1
DRO
EXOTIC-HC DRO OTIC
Tier 1
OTIC CARE DRO
Tier 1
OTICIN HC DRO
Tier 2
OTO-END 10 SOL
Tier 1
OTOMAX-HC DRO
Tier 1
AKTEN
Tier 3
GEL 3.5%
ALTACAINE SOL 0.5% OP
Tier 1
ANTIPY/BENZO SOL OTIC
Tier 1
ANTIPY/BENZO SOL OTIC
Tier 1
OTOZIN
DRO
Tier 1
PINNACAINE DRO 20% OTIC
Tier 1
TETCAINE
Tier 1
SOL 0.5% OP
Prior Authorization
Supply Limit
Step Therapy
TETRACAINE SOL 0.5% OP
Tier 1
TETRAVISC SOL 0.5% OP
Tier 1
TETRAVISC SOL FORTE
Tier 1
SAVELLA SAVELLA SAVELLA SAVELLA SAVELLA AMBIEN
MIS TITR PAK TAB 100MG TAB 12.5MG TAB 25MG TAB 50MG TAB 10MG
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
X X X X X X
X
AMBIEN
TAB 5MG
Tier 4
X
X
AMBIEN CR TAB 12.5MG
Tier 4
X
X
AMBIEN CR TAB 6.25MG
Tier 4
X
X
EDLUAR
Tier 4
X
X
SUB 10MG
Page 134 of 279
Specialty
Therapeutic Class GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs
Product Name EDLUAR SUB 5MG
Tier Value Tier 4
Prior Authorization
Supply Limit X
ESZOPICLONE TAB 1MG
Tier 1
X
ESZOPICLONE TAB 2MG
Tier 1
X
ESZOPICLONE TAB 3MG
Tier 1
X
FLURAZEPAM CAP 15MG
Tier 1
FLURAZEPAM CAP 30MG
Tier 1
HALCION
Tier 4
TAB 0.25MG
Step Therapy X
INTERMEZZO SUB 1.75MG
Tier 4
X
X
INTERMEZZO SUB 3.5MG
Tier 4
X
X
LUNESTA
TAB 1MG
Tier 4
X
X
LUNESTA
TAB 2MG
Tier 4
X
X
LUNESTA
TAB 3MG
Tier 4
X
X
RESTORIL
CAP 15MG
Tier 4
RESTORIL
CAP 22.5MG
Tier 4
RESTORIL
CAP 30MG
Tier 4
RESTORIL
CAP 7.5MG
Tier 4
SONATA
CAP 10MG
Tier 4
X
SONATA
CAP 5MG
Tier 4
X
TEMAZEPAM CAP 15MG
Tier 1
TEMAZEPAM CAP 22.5MG
Tier 1
TEMAZEPAM CAP 30MG
Tier 1
TEMAZEPAM CAP 7.5MG
Tier 1
TRIAZOLAM TAB 0.125MG
Tier 1
TRIAZOLAM TAB 0.25MG
Tier 1
ZALEPLON
CAP 10MG
Tier 1
X
ZALEPLON
CAP 5MG
Tier 1
X
ZOLPIDEM
TAB 10MG
Tier 1
X
ZOLPIDEM
TAB 5MG
Tier 1
X
Tier 1
X
ZOLPIDEM ER TAB 12.5MG
Page 135 of 279
X
Specialty
Supply Limit X
Step Therapy X
Tier 1
X
X
ZOLPIDEM TAR SUB 3.5MG
Tier 1
X
X
ZOLPIMIST SPR 5MG
Tier 4
X
X
CLONAZEP ODT TAB 0.125MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 0.25MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 0.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 1MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 2MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLONAZEPAM TAB 0.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLONAZEPAM TAB 1MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLONAZEPAM TAB 2MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLORAZ DIPOT TAB 15MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLORAZ DIPOT TAB 3.75MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
CLORAZ DIPOT TAB 7.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DEPAKENE
CAP 250MG
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DEPAKENE
SYP 250/5ML
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DEPAKOTE
TAB 125MG DR
Tier 4
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DEPAKOTE
TAB 250MG DR
Tier 4
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DEPAKOTE
TAB 500MG DR
Tier 4
X
Therapeutic Class GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs GABA Receptor Modulators - Sedation and Sleep Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Product Name ZOLPIDEM ER TAB 6.25MG
Tier Value Tier 1
ZOLPIDEM TAR SUB 1.75MG
Page 136 of 279
Prior Authorization
Specialty
Therapeutic Class Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Product Name DEPAKOTE ER TAB 250MG
Tier Value Tier 4
Prior Authorization X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DEPAKOTE ER TAB 500MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DEPAKOTE SPR CAP 125MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIASTAT ACDL GEL 12.5-20
Tier 4
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIASTAT ACDL GEL 5-10MG
Tier 4
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIASTAT PED GEL 2.5M GEL
Tier 2
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIAZEPAM
GEL 10MG
Tier 1
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIAZEPAM
GEL 2.5MG
Tier 1
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIAZEPAM
GEL 20MG
Tier 1
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIVALPROEX CAP 125MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 125MG DR
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 250MG DR
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 250MG ER
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 500MG DR
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 500MG ER
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
FANATREX
SUS 25MG/ML
Tier 3
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
FYCOMPA
SUS 0.5MG/ML
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
FYCOMPA
TAB 10MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
FYCOMPA
TAB 12MG
Tier 3
X
Page 137 of 279
Supply Limit
Step Therapy X
Specialty
Tier Value Tier 3
Prior Authorization X
TAB 4MG
Tier 3
X
FYCOMPA
TAB 6MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
FYCOMPA
TAB 8MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABAPENTIN CAP 100MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABAPENTIN CAP 300MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABAPENTIN CAP 400MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABAPENTIN SOL 250/5ML
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABAPENTIN TAB 600MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABAPENTIN TAB 800MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 12MG
Tier 2
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 16MG
Tier 2
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 2MG
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 4MG
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GENE-XENE TAB 15MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GENE-XENE TAB 3.75MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
GENE-XENE TAB 7.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
HORIZANT
TAB 300MG
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
HORIZANT
TAB 600MG
Therapeutic Class Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Product Name FYCOMPA TAB 2MG
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
FYCOMPA
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Page 138 of 279
Supply Limit
Step Therapy
Tier 4
X
X
Tier 4
X
X
Specialty
Prior Authorization
Supply Limit
Step Therapy
Therapeutic Class Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Product Name KLONOPIN TAB 0.5MG
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
KLONOPIN
TAB 1MG
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
KLONOPIN
TAB 2MG
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
MYSOLINE
TAB 250MG
Tier 2
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
MYSOLINE
TAB 50MG
Tier 2
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
NEURONTIN CAP 100MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
NEURONTIN CAP 300MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
NEURONTIN CAP 400MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
NEURONTIN SOL 250/5ML
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
NEURONTIN TAB 600MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
NEURONTIN TAB 800MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
ONFI
SUS 2.5MG/ML
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
ONFI
TAB 10MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
ONFI
TAB 20MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
PRIMIDONE TAB 250MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
PRIMIDONE TAB 50MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
SABRIL
POW 500MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
SABRIL
TAB 500MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
STAVZOR
CAP 125MG
Page 139 of 279
Tier Value Tier 4
Tier 3
X
X
Specialty
Tier Value Tier 3
Prior Authorization X
Tier 3
X
Therapeutic Class Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Product Name STAVZOR CAP 250MG
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
STAVZOR
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
TIAGABINE TAB 2MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
TIAGABINE TAB 4MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
TRANXENE T TAB 3.75MG
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
TRANXENE T TAB 7.5MG
Tier 4
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
VALPROIC ACD CAP 250MG
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
VALPROIC ACD SOL 250/5ML
Tier 1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
VALPROIC ACD SYP 250/5ML
Tier 1
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
ACTIGALL
Tier 4
CAP 500MG
CAP 300MG
BISACODYL TAB 5MG EC CASCARA CHENODAL CORRECT
Tier 1
TAB 250MG
Tier 4
Tier 1
DIPHEN/ATROP TAB 2.5MG
Tier 1
TAB 5MG EC
ENTEREG
CAP 12MG
X
X
Tier 1
HCR Preventative Tier 3
EQL LAXATIVE TAB 5MG EC
HCR Preventative
EX-LAX ULTRA TAB 5MG EC
HCR Preventative
FEMININE LAX TAB 5MG EC
HCR Preventative
FLEET LAXATI TAB 5MG EC
HCR Preventative
FULYZAQ
Specialty
HCR Preventative
CROMOLYN SOD CON 100/5ML DIPHEN/ATROP LIQ 2.5/5
DUCODYL
Step Therapy X
HCR Preventative
EXT SAGRADA
TAB 5MG EC
Supply Limit
TAB 125MG
Page 140 of 279
Tier 4
X
X
X
Therapeutic Class Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Product Name GASTROCROM CON 100/5ML GATTEX
Tier Value Tier 4
KIT 5MG
Tier 3
GAVILYTE-H KIT
Supply Limit
X
X
Step Therapy
HCR Preventative
GNP BISA-LAX TAB 5MG EC
HCR Preventative
GNP LAXATIVE TAB 5MG EC
HCR Preventative
HM LAXATIVE TAB 5MG
HCR Preventative
HM LAXATIVE TAB 5MG EC
HCR Preventative
KP BISACODYL TAB 5MG EC
HCR Preventative
LAXATIVE
TAB 5MG EC
HCR Preventative
LOFENE
TAB 2.5MG
Tier 1
TAB 2.5MG
Tier 4
METOCLOPRAM SOL 5MG/5ML METOCLOPRAM TAB 10MG
Tier 1
METOCLOPRAM TAB 5MG
Tier 1
METOCLOPRAM TAB 5MG ODT METOCLOPRAMI TAB 10MG ODT METOZOLV ODT TAB 5MG
Tier 1
X
Tier 1
X
Tier 4
X
MINERAL
Tier 1
Tier 1
OIL HEAVY
MOTOFEN
TAB 1-0.025
Tier 3
NICOTINAMIDE POW ADENINE
Tier 3
OSMOPREP
Tier 3
TAB 1.5GM
PAREGORIC TIN 2MG/5ML
Tier 1
PEG-PREP
KIT
Tier 1
CAP
Tier 3
QC LAXATIVE TAB 5MG EC
HCR Preventative
RA LAXATIVE TAB 5MG EC
HCR Preventative
PYLERA
REGLAN
TAB 10MG
Tier 4
REGLAN
TAB 5MG
Tier 4
Page 141 of 279
X
X
Specialty
X
Tier 1
GENTLE LAXAT TAB 5MG EC
LOMOTIL
Prior Authorization
Therapeutic Class Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs GASTROINTESTINAL DRUGS - LIPOTROPIC AGENTS Genitourinary Agents, Other Genitourinary Agents, Other Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents
Product Name RELISTOR INJ 12/0.6ML RELISTOR
INJ 8/0.4ML
REZYST IM CHW
Tier Value Tier 4
Prior Authorization X
Tier 4
X
Tier 3
SM GENTLE TAB LAXATIVE
HCR Preventative
SM LAXATIVE TAB 5MG EC
HCR Preventative
SODIUM
Supply Limit
POW BICARBON
STIM LAXAT TAB 5MG EC
Tier 3 HCR Preventative
SUCLEAR
KIT
Tier 3
URSO 250
TAB 250MG
Tier 4
URSO FORTE TAB 500MG
Tier 4
URSODIOL
CAP 300MG
Tier 1
URSODIOL
TAB 250MG
Tier 1
URSODIOL
TAB 500MG
Tier 1
VERCOLATE TAB 5MG EC
HCR Preventative
WOMANS LAXAT TAB 5MG EC HCR Preventative WOMENS LAXAT TAB 5MG EC HCR Preventative LECITHIN
GRA
Tier 1
CIALIS TAB 10MG CIALIS TAB 20MG CAVERJECT INJ 20MCG
Tier 4 Tier 4 Tier 3
X X X
X X X
CAVERJECT INJ 40MCG
Tier 3
X
X
CAVERJECT KIT 10MCG
Tier 3
X
X
CAVERJECT KIT 20MCG
Tier 3
X
X
EDEX
KIT 10MCG
Tier 3
X
X
EDEX
KIT 20MCG
Tier 3
X
X
EDEX
KIT 40MCG
Tier 3
X
X
LEVITRA
TAB 10MG
Tier 4
X
X
LEVITRA
TAB 2.5MG
Tier 4
X
X
LEVITRA
TAB 20MG
Tier 4
X
X
LEVITRA
TAB 5MG
Tier 4
X
X
Page 142 of 279
Step Therapy
Specialty
Therapeutic Class Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Erectile Dysfunction Agents Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs
Product Name MUSE SUP 1000MCG
Tier Value Tier 3
Prior Authorization X
Supply Limit X
MUSE
SUP 125MCG
Tier 3
X
X
MUSE
SUP 250MCG
Tier 3
X
X
MUSE
SUP 500MCG
Tier 3
X
X
STAXYN
TAB 10MG
Tier 4
X
X
STENDRA
TAB 100MG
Tier 4
X
X
STENDRA
TAB 200MG
Tier 4
X
X
STENDRA
TAB 50MG
Tier 4
X
X
VIAGRA
TAB 100MG
Tier 4
X
X
VIAGRA
TAB 25MG
Tier 4
X
X
VIAGRA
TAB 50MG
Tier 4
X
X
BETHANECHOL TAB 10MG
Tier 1
Genitourinary Agents, Other - Miscellaneous BETHANECHOL TAB 25MG Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous BETHANECHOL TAB 50MG Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous BETHANECHOL TAB 5MG Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous ELMIRON Bladder, Genital, and Kidney Conditions Drugs
CAP 100MG
Tier 2
Genitourinary Agents, Other - Miscellaneous LITHOSTAT TAB 250MG Bladder, Genital, and Kidney Conditions Drugs
Tier 3
Genitourinary Agents, Other - Miscellaneous PHENAZO Bladder, Genital, and Kidney Conditions Drugs
Tier 1
TAB 200MG
Genitourinary Agents, Other - Miscellaneous PHENAZOPYRID TAB 100MG Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous PHENAZOPYRID TAB 200MG Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous PYRIDIUM Bladder, Genital, and Kidney Conditions Drugs
TAB 100MG
Tier 3
Genitourinary Agents, Other - Miscellaneous PYRIDIUM Bladder, Genital, and Kidney Conditions Drugs
TAB 200MG
Tier 3
Genitourinary Agents, Other - Miscellaneous THIOLA Bladder, Genital, and Kidney Conditions Drugs
TAB 100MG
Page 143 of 279
Tier 4
Step Therapy
Specialty
X
X
Therapeutic Class Product Name Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 10MG Bladder, Genital, and Kidney Conditions Drugs
Tier Value Tier 3
Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 25MG Bladder, Genital, and Kidney Conditions Drugs
Tier 4
Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 50MG Bladder, Genital, and Kidney Conditions Drugs
Tier 3
Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 5MG Bladder, Genital, and Kidney Conditions Drugs
Tier 3
Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Tier 1
COLOCORT
ENE 100MG
CORTENEMA ENE 100MG
Tier 4
HYDROCORT ENE 100MG
Tier 1
MILLIPRED TAB 5MG
Tier 2
MILLIPRED DP PAK 5MG
Tier 2
MILLIPRED DP PAK 5MG
Tier 2
PREDNISOLONE SOL 15MG/5ML PREDNISOLONE SYP 15MG/5ML UCERIS TAB 9MG
Tier 1
ACLOVATE
Tier 3
CRE 0.05%
Supply Limit
Tier 1 Tier 3
ALA SCALP LOT 2%
Tier 4
ALCLOMETASON CRE 0.05%
Tier 1
ALCLOMETASON OIN 0.05%
Tier 1
ALPHATREX GEL 0.05%
Tier 1
AMCINONIDE CRE 0.1%
Tier 1
AMCINONIDE LOT 0.1%
Tier 1
AMCINONIDE OIN 0.1%
Tier 1
ANUSOL-HC CRE 2.5%
Tier 4
APEXICON E CRE 0.05%
Tier 2
AUG BETAMET CRE 0.05%
Tier 1
AUG BETAMET GEL 0.05%
Tier 1
AUG BETAMET LOT 0.05%
Tier 1
AUG BETAMET OIN 0.05%
Tier 1
Page 144 of 279
Prior Authorization
X
Step Therapy
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Prior Authorization
Supply Limit
Step Therapy
X
X
Tier 1
X
X
CLOBETASOL AER 0.05%
Tier 1
X
X
CLOBETASOL CRE 0.05%
Tier 1
X
CLOBETASOL GEL 0.05%
Tier 1
X
CLOBETASOL LOT 0.05%
Tier 1
X
CLOBETASOL OIN 0.05%
Tier 1
X
CLOBETASOL POW PROPIONA
Tier 3
CLOBETASOL SHA 0.05%
Tier 1
X
CLOBETASOL SOL 0.05%
Tier 1
X
CLOBETASOL SPR 0.05%
Tier 1
X
CLOBETASOL E CRE 0.05%
Tier 1
X
CLOBEX
LOT 0.05%
Tier 4
X
X
CLOBEX
SHA 0.05%
Tier 4
X
X
CLOBEX
SPR 0.05%
Tier 3
X
CLOCORTOLONE CRE PIV 0.1%
Tier 1
X
X
CLODAN
SHA 0.05%
Tier 1
X
X
CRE 0.1%
Tier 4
X
X
Product Name BETAMETH DIP CRE 0.05%
Tier Value Tier 1
BETAMETH DIP LOT 0.05%
Tier 1
BETAMETH DIP OIN 0.05%
Tier 1
BETAMETH DIP POW
Tier 3
X
BETAMETH DIP POW MICRONIZ BETAMETH DIP POW USP NF
Tier 3
X
Tier 3
X
BETAMETH VAL AER 0.12%
Tier 1
BETAMETH VAL CRE 0.1%
Tier 1
BETAMETH VAL LOT 0.1%
Tier 1
BETAMETH VAL OIN 0.1%
Tier 1
BETAMETHASON POW VALERATE CAPEX SHA 0.01%
Tier 3
CLOBETASOL AER 0.05%
CLODERM
Page 145 of 279
X
Tier 2
X
X X
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name CLODERM CRE 0.1% PMP
Tier Value Tier 4
Prior Authorization
Supply Limit X
Step Therapy X
CORDRAN
CRE 0.05%
Tier 4
X
X
CORDRAN
LOT 0.05%
Tier 4
X
X
CORDRAN
OIN 0.05%
Tier 4
CORDRAN 24X3 TAP 4MCG/CM CORDRAN 24X3 TAP SML 24IN
Tier 3
CORDRAN 80X3 TAP 4MCG/CM CORMAX SCALP SOL 0.05%
Tier 3
CORTEF
TAB 10MG
Tier 4
CORTEF
TAB 20MG
Tier 4
CORTEF
TAB 5MG
Tier 4
Tier 3
Tier 1
CORTIFOAM AER 90MG
Tier 2
CORTISONE AC TAB 25MG
Tier 1
CUTIVATE
CRE 0.05%
Tier 4
CUTIVATE
LOT 0.05%
Tier 3
X
X
DELTASONE TAB 20MG
Tier 1
DERMA-SMOOTH OIL /FS BODY DERMA-SMOOTH OIL /FS SCLP
Tier 4
DERMATOP
CRE 0.1%
Tier 4
DERMATOP
OIN 0.1%
Tier 4
DESONATE
GEL 0.05%
Tier 3
X
DESONIDE
CRE 0.05%
Tier 1
X
DESONIDE
LOT 0.05%
Tier 1
X
DESONIDE
OIN 0.05%
Tier 1
X
DESOWEN
CRE 0.05%
Tier 3
X
DESOWEN
LOT 0.05%
Tier 4
X
DESOXIMETAS CRE 0.05%
Tier 1
X
DESOXIMETAS CRE 0.25%
Tier 1
X
DESOXIMETAS GEL 0.05%
Tier 1
X
Page 146 of 279
X
X
Tier 4
X
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Prior Authorization
Product Name DESOXIMETAS OIN 0.05%
Tier Value Tier 1
DESOXIMETAS OIN 0.25%
Tier 1
DEXAMETH SOD POW PHOSPHAT DEXAMETHASON CON 1MG/ML DEXAMETHASON ELX 0.5/5ML
Tier 3
DEXAMETHASON POW
Tier 3
X
DEXAMETHASON POW MICRONIZ DEXAMETHASON SOL 0.5/5ML
Tier 3
X
DEXAMETHASON TAB 0.5MG
Tier 1
DEXAMETHASON TAB 0.75MG
Tier 1
DEXAMETHASON TAB 1.5MG
Tier 1
DEXAMETHASON TAB 1MG
Tier 1
DEXAMETHASON TAB 2MG
Tier 1
DEXAMETHASON TAB 4MG
Tier 1
DEXAMETHASON TAB 6MG
Tier 1
DEXPAK
PAK 10 DAY
Tier 3
DEXPAK
PAK 13 DAY
Tier 3
DEXPAK
PAK 6 DAY
Tier 3
Supply Limit X X
X
Tier 1 Tier 1
Tier 1
DIFLORASONE CRE 0.05%
Tier 1
DIFLORASONE OIN 0.05%
Tier 1
DIPROLENE LOT 0.05%
Tier 4
DIPROLENE OIN 0.05%
Tier 4
DIPROLENE AF CRE 0.05%
Tier 4
ELOCON
CRE 0.1%
Tier 4
ELOCON
LOT 0.1%
Tier 4
ELOCON
OIN 0.1%
Tier 4
FLUDROCORT TAB 0.1MG
Tier 1
FLUOCIN ACET CRE 0.01%
Tier 1
X
FLUOCIN ACET CRE 0.025%
Tier 1
X
Page 147 of 279
Step Therapy
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Prior Authorization
Supply Limit
Step Therapy
Product Name FLUOCIN ACET OIL 0.01% SC
Tier Value Tier 1
FLUOCIN ACET OIL 0.01%BDY
Tier 1
X
FLUOCIN ACET OIL BODY
Tier 1
X
FLUOCIN ACET OIL SCALP
Tier 1
FLUOCIN ACET OIN 0.025%
Tier 1
X
FLUOCIN ACET SOL 0.01%
Tier 1
X
FLUOCINONIDE CRE 0.05%
Tier 1
FLUOCINONIDE CRE 0.1%
Tier 1
FLUOCINONIDE CRE -E 0.05%
Tier 1
FLUOCINONIDE GEL 0.05%
Tier 1
FLUOCINONIDE OIN 0.05%
Tier 1
FLUOCINONIDE SOL 0.05%
Tier 1
FLURANDRENOL CRE 0.05%
Tier 1
FLUTICASONE CRE 0.05%
Tier 1
FLUTICASONE LOT 0.05%
Tier 1
FLUTICASONE OIN 0.005%
Tier 1
FRST-HYDRCRT GEL 10%
Tier 2
GNP HYDROCOR OIN 1% W/ALO HALOBETASOL CRE 0.05%
Tier 1 Tier 1
X
HALOBETASOL OIN 0.05%
Tier 1
X
HALOG
CRE 0.1%
Tier 3
X
X
HALOG
OIN 0.1%
Tier 3
X
X
X
X
X
X
X
X
X
X
X
HC BUTYRATE CRE 0.1%
Tier 1
HC BUTYRATE CRE 0.1%
Tier 1
HC BUTYRATE OIN 0.1%
Tier 1
HC BUTYRATE SOL 0.1%
Tier 1
HC VALERATE CRE 0.2%
Tier 1
X
HC VALERATE OIN 0.2%
Tier 1
X
HYDROCORT CRE 1%
Tier 1
Page 148 of 279
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name HYDROCORT CRE 2.5%
Tier Value Tier 1
HYDROCORT LOT 2.5%
Tier 1
HYDROCORT OIN 1%
Tier 1
HYDROCORT OIN 2.5%
Tier 1
HYDROCORT TAB 10MG
Tier 1
HYDROCORT TAB 20MG
Tier 1
HYDROCORT TAB 5MG
Tier 1
HYDROCORT/AB OIN 1%
Tier 1
HYDROCORTISO CRE 2.5%
Tier 1
KENALOG
Tier 4
AER SPRAY
LOCOID
CRE 0.1%
Tier 4
LOCOID
LOT 0.1%
Tier 4
LOCOID
OIN 0.1%
Tier 4
LOCOID
SOL 0.1%
Tier 4
Prior Authorization
Supply Limit
X
X
X
X
LOCOID LIPO CRE 0.1%
Tier 4
X
LOKARA
Tier 1
X
Tier 4
X
LUXIQ
LOT 0.05% AER 0.12%
MEDROL
TAB 16MG
Tier 4
MEDROL
TAB 2MG
Tier 2
MEDROL
TAB 32MG
Tier 3
MEDROL
TAB 4MG
Tier 4
MEDROL
TAB 4MG
Tier 4
MEDROL
TAB 8MG
Tier 4
METHYLPRED POW ACETATE
Tier 3
METHYLPRED TAB 16MG
Tier 1
METHYLPRED TAB 32MG
Tier 1
METHYLPRED TAB 4MG
Tier 1
METHYLPRED TAB 4MG
Tier 1
METHYLPRED TAB 8MG
Tier 1
Page 149 of 279
Step Therapy
X
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name MILLIPRED SOL 10MG/5ML
Tier Value Tier 3
Prior Authorization
Supply Limit
Step Therapy
MOMETASONE CRE 0.1%
Tier 1
MOMETASONE OIN 0.1%
Tier 1
MOMETASONE POW
Tier 3
MOMETASONE SOL 0.1%
Tier 1
OLUX
Tier 4
X
X
Tier 4
X
X
OLUX-E
AER 0.05% AER 0.05%
ORAPRED ODT TAB 10MG
Tier 4
ORAPRED ODT TAB 15MG
Tier 4
ORAPRED ODT TAB 30MG
Tier 4
PANDEL
Tier 3
CRE 0.1%
PEDIAPRED SOL 6.7/5ML
Tier 2
PRED SOD PHO SOL 5MG/5ML
Tier 1
PREDNICARBAT CRE 0.1%
Tier 1
PREDNICARBAT OIN 0.1%
Tier 1
PREDNISOLONE SOL 15MG/5ML PREDNISOLONE SOL 25MG/5ML PREDNISOLONE TAB 10MG ODT PREDNISOLONE TAB 15MG ODT PREDNISOLONE TAB 30MG ODT PREDNISONE CON 5MG/ML
Tier 1
PREDNISONE PAK 10MG
Tier 1
PREDNISONE PAK 10MG
Tier 1
PREDNISONE PAK 5MG
Tier 1
PREDNISONE PAK 5MG
Tier 1
PREDNISONE SOL 5MG/5ML
Tier 1
PREDNISONE TAB 10MG
Tier 1
PREDNISONE TAB 1MG
Tier 1
PREDNISONE TAB 2.5MG
Tier 1
Page 150 of 279
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X
X
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name PREDNISONE TAB 20MG
Tier Value Tier 1
PREDNISONE TAB 50MG
Tier 1
PREDNISONE TAB 5MG
Tier 1
PROCTOCORT CRE 1%
Tier 4
PROCTO-MED CRE HC 2.5%
Tier 1
PROCTO-PAK CRE 1%
Tier 1
PROCTOSOL HC CRE 2.5%
Tier 1
PROCTOZONE CRE -HC 2.5%
Tier 1
PSORCON
Tier 1
CRE 0.05%
Prior Authorization
Supply Limit
Step Therapy
X
RAYOS
TAB 1MG
Tier 4
X
RAYOS
TAB 2MG
Tier 4
X
RAYOS
TAB 5MG
Tier 4
X
SCALACORT LOT 2%
Tier 1
SERNIVO
SPR
Tier 4
SYNALAR
CRE 0.025%
Tier 4
X
X
SYNALAR
OIN 0.025%
Tier 4
X
X
SYNALAR
SOL 0.01%
Tier 4
X
X
X
TEMOVATE
CRE 0.05%
Tier 4
X
TEMOVATE
GEL 0.05%
Tier 3
X
TEMOVATE
OIN 0.05%
Tier 4
X
TEMOVATE
SOL 0.05%
Tier 4
X
TEMOVATE E CRE 0.05%EML
Tier 4
X
TEXACORT
SOL 2.5%
Tier 2
TOPICORT
CRE 0.05%
Tier 4
X
TOPICORT
CRE 0.25%
Tier 4
X
TOPICORT
GEL 0.05%
Tier 4
X
TOPICORT
OIN 0.05%
Tier 4
X
TOPICORT
OIN 0.25%
Tier 4
X
TOPICORT
SPR 0.25%
Tier 4
Page 151 of 279
X
Specialty
Therapeutic Class Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs
Product Name TRIAMCINOLON AER SPRAY
Tier Value Tier 1
TRIAMCINOLON CRE 0.025%
Tier 1
TRIAMCINOLON CRE 0.1%
Tier 1
TRIAMCINOLON CRE 0.5%
Tier 1
TRIAMCINOLON LOT 0.025%
Tier 1
TRIAMCINOLON LOT 0.1%
Tier 1
TRIAMCINOLON OIN 0.025%
Tier 1
TRIAMCINOLON OIN 0.1%
Tier 1
TRIAMCINOLON OIN 0.5%
Tier 1
TRIAMCINOLON POW ACETONID TRIANEX OIN 0.05%
Tier 3
TRIDERM
Tier 1
CRE 0.1%
Prior Authorization
Supply Limit
Step Therapy
X
Tier 4
X
ULTRAVATE CRE 0.05%
Tier 4
ULTRAVATE LOT 0.05%
Tier 4
ULTRAVATE OIN 0.05%
Tier 4
X
VANOS
Tier 4
X
X
Tier 4
X
X
VERDESO
CRE 0.1% AER 0.05%
VERIPRED 20 SOL 20MG/5ML
Tier 3
WESTCORT
Tier 4
OIN 0.2%
X X
X
FELBAMATE SUS 600/5ML
Tier 1
FELBAMATE TAB 400MG
Tier 1
FELBAMATE TAB 600MG
Tier 1
FELBATOL
SUS 600/5ML
Tier 4
X
X
FELBATOL
TAB 400MG
Tier 4
X
X
FELBATOL
TAB 600MG
Tier 4
X
X
LAMICTAL
CHW 25MG
Tier 4
X
X
LAMICTAL
CHW 5MG
Tier 4
X
X
LAMICTAL
KIT START 35
Tier 3
X
X
LAMICTAL
KIT START 49
Tier 3
X
X
Page 152 of 279
Specialty
Therapeutic Class Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs
Product Name LAMICTAL KIT START 98
Tier Value Tier 3
Prior Authorization X
Supply Limit
Step Therapy X
LAMICTAL
TAB 100MG
Tier 4
X
X
LAMICTAL
TAB 150MG
Tier 4
X
X
LAMICTAL
TAB 200MG
Tier 4
X
X
LAMICTAL
TAB 25MG
Tier 4
X
X
LAMICTAL ODT KIT
Tier 4
X
X
LAMICTAL ODT KIT
Tier 4
X
X
LAMICTAL ODT KIT
Tier 4
X
X
LAMICTAL ODT TAB 100MG
Tier 4
X
X
LAMICTAL ODT TAB 200MG
Tier 4
X
X
LAMICTAL ODT TAB 25MG
Tier 4
X
X
LAMICTAL ODT TAB 50MG
Tier 4
X
X
LAMICTAL XR KIT
Tier 3
X
X
LAMICTAL XR KIT
Tier 3
X
X
LAMICTAL XR KIT
Tier 3
X
X
LAMICTAL XR TAB 100MG
Tier 3
X
X
LAMICTAL XR TAB 200MG
Tier 3
X
X
LAMICTAL XR TAB 250MG
Tier 3
X
X
LAMICTAL XR TAB 25MG
Tier 3
X
X
LAMICTAL XR TAB 300MG
Tier 3
X
X
LAMICTAL XR TAB 50MG
Tier 3
X
X
LAMOTRIG ODT KIT 25/50MG
Tier 1
X
X
LAMOTRIG ODT KIT 50/100MG
Tier 1
X
X
LAMOTRIGINE CHW 25MG
Tier 1
LAMOTRIGINE CHW 5MG
Tier 1
LAMOTRIGINE KIT ODT
Tier 1
X
X
LAMOTRIGINE TAB 100MG
Tier 1
LAMOTRIGINE TAB 100MG
Tier 1
LAMOTRIGINE TAB 100MG ER
Tier 1
Page 153 of 279
X
X
X
Specialty
Therapeutic Class Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs
Prior Authorization
Supply Limit
Step Therapy
Product Name LAMOTRIGINE TAB 150MG
Tier Value Tier 1
LAMOTRIGINE TAB 200MG
Tier 1
LAMOTRIGINE TAB 200MG
Tier 1
LAMOTRIGINE TAB 200MG ER
Tier 1
X
X
LAMOTRIGINE TAB 250MG ER
Tier 1
X
X
LAMOTRIGINE TAB 25MG
Tier 1
LAMOTRIGINE TAB 25MG ER
Tier 1
X
X
LAMOTRIGINE TAB 25MG ODT
Tier 1
LAMOTRIGINE TAB 300MG ER
Tier 1
X
X
LAMOTRIGINE TAB 50MG ER
Tier 1
X
X
LAMOTRIGINE TAB 50MG ODT
Tier 1
QUDEXY XR CAP 100/24HR
Tier 4
X
X
QUDEXY XR CAP 150/24HR
Tier 4
X
X
QUDEXY XR CAP 200/24HR
Tier 4
X
X
QUDEXY XR CAP 25/24HR
Tier 4
X
X
QUDEXY XR CAP 50/24HR
Tier 4
X
X
TOPAMAX
TAB 100MG
Tier 4
X
X
TOPAMAX
TAB 200MG
Tier 4
X
X
TOPAMAX
TAB 25MG
Tier 4
X
X
TOPAMAX
TAB 50MG
Tier 4
X
X
TOPAMAX SPR CAP 15MG
Tier 4
X
X
TOPAMAX SPR CAP 25MG
Tier 4
X
X
TOPIRAGEN TAB 100MG
Tier 1
TOPIRAGEN TAB 200MG
Tier 1
TOPIRAGEN TAB 25MG
Tier 1
TOPIRAGEN TAB 50MG
Tier 1
TOPIRAMATE CAP 15MG
Tier 1
TOPIRAMATE CAP 25MG
Tier 1
TOPIRAMATE CAP ER 100MG
Tier 4
X
X
Page 154 of 279
X
X
X
Specialty
Therapeutic Class Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glutamate Reducing Agents - Seizure Control Drugs Glycemic Agents - Diabetic Drugs Glycemic Agents - Diabetic Drugs Glycemic Agents - Diabetic Drugs
Product Name TOPIRAMATE CAP ER 150MG
Tier Value Tier 4
Prior Authorization X
TOPIRAMATE CAP ER 200MG
Tier 4
X
X
TOPIRAMATE CAP ER 25MG
Tier 4
X
X
TOPIRAMATE CAP ER 50MG
Tier 4
X
X
TOPIRAMATE TAB 100MG
Tier 1
TOPIRAMATE TAB 200MG
Tier 1
TOPIRAMATE TAB 25MG
Tier 1
TOPIRAMATE TAB 50MG
Tier 1
TROKENDI XR CAP 100MG
Tier 4
X
X
TROKENDI XR CAP 200MG
Tier 4
X
X
TROKENDI XR CAP 25MG
Tier 4
X
X
TROKENDI XR CAP 50MG
Tier 4
X
X
GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG PROGLYCEM SUS 50MG/ML
Tier 2 Tier 2 Tier 3
HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs
GALZIN GALZIN AXID
Tier 3 Tier 3 Tier 4
CAP 25MG CAP 50MG SOL 15MG/ML
X X
CIMETIDINE SOL 300/5ML
Tier 1
CIMETIDINE TAB 200MG
Tier 1
CIMETIDINE TAB 300MG
Tier 1
CIMETIDINE TAB 400MG
Tier 1
CIMETIDINE TAB 800MG
Tier 1
CIMETIDINE TAB 400MG
Tier 1
DEPRIZINE SUS 22.4/ML
Tier 3
X
DEPRIZINE SUS RAPIDPAQ
Tier 3
X
FAMOTIDINE SUS 40MG/5ML
Tier 1
NIZATIDINE SOL 15MG/ML
Tier 4
NIZATIDINE SOL 15MG/ML
Tier 4
NIZATIDINE SOL 15MG/ML
Tier 1
NIZATIDINE SOL 15MG/ML
Tier 3
Page 155 of 279
Supply Limit
Step Therapy X
Specialty
Therapeutic Class Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs
Product Name PEPCID SUS 40MG/5ML
Tier Value Tier 4
RANITIDINE SYP 150/10ML
Tier 1
RANITIDINE SYP 15MG/ML
Tier 1
RANITIDINE SYP 75MG/5ML
Tier 1
CERVIDIL VAG MIS 10MG INS
Tier 3
Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs
PREPIDIL
Tier 3
Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs
PROSTIN E2 SUP 20MG
Hormonal Agents, BRAVELLE Stimulant/Replacement/Modifying (Pituitary)
GEL 0.5MG/3G
INJ 75UNIT
Prior Authorization
Supply Limit
Step Therapy
Specialty
X
X
X
Tier 3
Tier 4
Hormonal Agents, CLOMIPHENE TAB 50MG Stimulant/Replacement/Modifying (Pituitary)
Tier 1
Hormonal Agents, FOLLISTIM AQ INJ 150UNIT Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents, FOLLISTIM AQ INJ 300UNIT Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents, FOLLISTIM AQ INJ 600UNIT Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents, FOLLISTIM AQ INJ 75UNIT Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents, FOLLISTIM AQ INJ 900UNIT Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents, GONAL-F Stimulant/Replacement/Modifying (Pituitary)
INJ 1050UNIT
Tier 3
X
X
Hormonal Agents, GONAL-F Stimulant/Replacement/Modifying (Pituitary)
INJ 450UNIT
Tier 3
X
X
Hormonal Agents, GONAL-F RFF INJ 300/0.5 Stimulant/Replacement/Modifying (Pituitary)
Tier 3
X
X
Hormonal Agents, GONAL-F RFF INJ 450/0.75 Stimulant/Replacement/Modifying (Pituitary)
Tier 3
X
X
Hormonal Agents, GONAL-F RFF INJ 75UNIT Stimulant/Replacement/Modifying (Pituitary)
Tier 3
X
X
Page 156 of 279
Therapeutic Class Product Name Hormonal Agents, GONAL-F RFF INJ 900/1.5 Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, MENOPUR Stimulant/Replacement/Modifying (Pituitary)
INJ 75UNIT
Tier Value Tier 3
Prior Authorization X
Tier 4
X
Hormonal Agents, CHOR GONADOT INJ Stimulant/Replacement/Modifying (Pituitary) - 10000UNT Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents, DDAVP Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 4MCG/ML
Tier 4
Hormonal Agents, DDAVP Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
SOL 0.01%
Tier 3
Hormonal Agents, DDAVP Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
SPR 0.01%
Tier 4
Hormonal Agents, DDAVP Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
TAB 0.1MG
Tier 4
Hormonal Agents, DDAVP Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
TAB 0.2MG
Tier 4
Hormonal Agents, DESMOPRESSIN INJ 4MCG/ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents, DESMOPRESSIN SOL 0.01% Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents, DESMOPRESSIN SPR 0.01% Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents, DESMOPRESSIN SPR 0.01% Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents, DESMOPRESSIN TAB 0.1MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents, DESMOPRESSIN TAB 0.2MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents, EGRIFTA Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
SOL 1MG
Page 157 of 279
Supply Limit
Step Therapy
Specialty X
X
X
X
X
Therapeutic Class Product Name Hormonal Agents, EGRIFTA SOL 2MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier Value Tier 4
Prior Authorization
Supply Limit
Step Therapy
Specialty X
Hormonal Agents, GENOTROPIN INJ 0.2MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 0.4MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 0.6MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 0.8MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 1.2MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 1.4MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 1.6MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 1.8MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 12MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 1MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 2MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, GENOTROPIN INJ 5MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, H.P. ACTHAR INJ 80UNIT Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Page 158 of 279
Therapeutic Class Product Name Hormonal Agents, HUMATROPE INJ 12MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
Specialty X
Hormonal Agents, HUMATROPE INJ 24MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, HUMATROPE INJ 5MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, HUMATROPE INJ 6MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, INCRELEX Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
Hormonal Agents, NORDITROPIN INJ 10/1.5ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, NORDITROPIN INJ 15/1.5ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, NORDITROPIN INJ 30/3ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, NORDITROPIN INJ 5/1.5ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, NOVAREL Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
INJ 40MG/4ML
INJ 10000UNT
X
X
Hormonal Agents, NUTROPIN AQ INJ 10MG/2ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
X
X
Hormonal Agents, NUTROPIN AQ INJ 20MG/2ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
X
X
Hormonal Agents, NUTROPIN AQ INJ NUSPIN 5 Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
X
X
Hormonal Agents, OMNITROPE INJ 10/1.5ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
Page 159 of 279
X
X
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
Specialty X
Hormonal Agents, OMNITROPE INJ 5/1.5ML Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, OVIDREL Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ
Tier 4
X
Hormonal Agents, PREGNYL Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 10000UNT
Tier 1
X
Therapeutic Class Product Name Hormonal Agents, OMNITROPE INJ 5.8MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Hormonal Agents, SAIZEN Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 5MG
Tier 4
X
X
X
X
Hormonal Agents, SAIZEN Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 8.8MG
Tier 4
X
X
X
X
Hormonal Agents, SEROSTIM Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 4MG
Tier 4
X
X
X
Hormonal Agents, SEROSTIM Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 5MG
Tier 4
X
X
X
Hormonal Agents, SEROSTIM Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 6MG
Tier 4
X
X
X
Hormonal Agents, STIMATE Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
SOL 1.5MG/ML
Tier 3
Hormonal Agents, TEV-TROPIN INJ 5MG Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents, ZOMACTON Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 10MG
Tier 4
X
X
X
X
Hormonal Agents, ZOMACTON Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 5MG
Tier 4
X
X
X
X
INJ 8.8MG
Tier 4
X
X
Hormonal Agents, ZORBTIVE Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Page 160 of 279
X
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name KORLYM TAB 300MG
Tier Value Tier 4
ARMOUR THYRO TAB 120MG
Tier 3
ARMOUR THYRO TAB 15MG
Tier 3
ARMOUR THYRO TAB 180MG
Tier 3
ARMOUR THYRO TAB 240MG
Tier 3
ARMOUR THYRO TAB 300MG
Tier 3
ARMOUR THYRO TAB 30MG
Tier 3
ARMOUR THYRO TAB 60MG
Tier 3
ARMOUR THYRO TAB 90MG
Tier 3
CYTOMEL
TAB 25MCG
Tier 4
CYTOMEL
TAB 50MCG
Tier 4
CYTOMEL
TAB 5MCG
Tier 4
LEVO-T
TAB 100MCG
Tier 1
LEVO-T
TAB 112MCG
Tier 1
LEVO-T
TAB 125MCG
Tier 1
LEVO-T
TAB 137MCG
Tier 1
LEVO-T
TAB 150MCG
Tier 1
LEVO-T
TAB 175MCG
Tier 1
LEVO-T
TAB 200 MCG
Tier 1
Page 161 of 279
Prior Authorization X
Supply Limit
Step Therapy
Specialty X
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name LEVO-T TAB 25MCG
Tier Value Tier 1
LEVO-T
TAB 300 MCG
Tier 1
LEVO-T
TAB 50MCG
Tier 1
LEVO-T
TAB 75MCG
Tier 1
LEVO-T
TAB 88MCG
Tier 1
LEVOTHYROXIN TAB 100MCG
Tier 1
LEVOTHYROXIN TAB 112MCG
Tier 1
LEVOTHYROXIN TAB 125MCG
Tier 1
LEVOTHYROXIN TAB 137MCG
Tier 1
LEVOTHYROXIN TAB 150MCG
Tier 1
LEVOTHYROXIN TAB 175MCG
Tier 1
LEVOTHYROXIN TAB 200MCG
Tier 1
LEVOTHYROXIN TAB 25MCG
Tier 1
LEVOTHYROXIN TAB 300MCG
Tier 1
LEVOTHYROXIN TAB 50MCG
Tier 1
LEVOTHYROXIN TAB 75MCG
Tier 1
LEVOTHYROXIN TAB 88MCG
Tier 1
LEVOXYL
TAB 100MCG
Tier 1
LEVOXYL
TAB 112MCG
Tier 1
Page 162 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name LEVOXYL TAB 125MCG
Tier Value Tier 1
LEVOXYL
TAB 137MCG
Tier 1
LEVOXYL
TAB 150MCG
Tier 1
LEVOXYL
TAB 175MCG
Tier 1
LEVOXYL
TAB 200MCG
Tier 1
LEVOXYL
TAB 25MCG
Tier 1
LEVOXYL
TAB 50MCG
Tier 1
LEVOXYL
TAB 75MCG
Tier 1
LEVOXYL
TAB 88MCG
Tier 1
LIOTHYRONINE TAB 25MCG
Tier 1
LIOTHYRONINE TAB 50MCG
Tier 1
LIOTHYRONINE TAB 5MCG
Tier 1
NATURE THROI TAB 162.5MG
Tier 3
NATURE-THROI TAB 113.75MG
Tier 3
NATURE-THROI TAB 130MG
Tier 3
NATURE-THROI TAB 146.25MG
Tier 3
NATURE-THROI TAB 16.25MG
Tier 3
NATURE-THROI TAB 195MG
Tier 3
NATURE-THROI TAB 260MG
Tier 3
Page 163 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name NATURE-THROI TAB 32.5MG
Tier Value Tier 3
NATURE-THROI TAB 325MG
Tier 3
NATURE-THROI TAB 48.75MG
Tier 3
NATURE-THROI TAB 65MG
Tier 3
NATURE-THROI TAB 81.25MG
Tier 3
NATURE-THROI TAB 97.5MG
Tier 3
NP THYROID TAB 30MG
Tier 1
NP THYROID TAB 60MG
Tier 1
NP THYROID TAB 90MG
Tier 1
SYNTHROID TAB 100MCG
Tier 2
SYNTHROID TAB 112MCG
Tier 2
SYNTHROID TAB 125MCG
Tier 2
SYNTHROID TAB 137MCG
Tier 2
SYNTHROID TAB 150MCG
Tier 2
SYNTHROID TAB 175MCG
Tier 2
SYNTHROID TAB 200MCG
Tier 2
SYNTHROID TAB 25MCG
Tier 2
SYNTHROID TAB 300MCG
Tier 2
SYNTHROID TAB 50MCG
Tier 2
Page 164 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Prior Authorization
Supply Limit
Step Therapy
Product Name SYNTHROID TAB 75MCG
Tier Value Tier 2
SYNTHROID TAB 88MCG
Tier 2
THYROLAR-1 TAB 60MG
Tier 3
THYROLAR-1/2 TAB 30MG
Tier 3
THYROLAR-1/4 TAB 15MG
Tier 3
THYROLAR-2 TAB 120MG
Tier 3
THYROLAR-3 TAB 180MG
Tier 3
TIROSINT
CAP 100MCG
Tier 4
X
TIROSINT
CAP 112MCG
Tier 4
X
TIROSINT
CAP 125MCG
Tier 4
X
TIROSINT
CAP 137MCG
Tier 4
X
TIROSINT
CAP 13MCG
Tier 4
X
TIROSINT
CAP 150MCG
Tier 4
X
TIROSINT
CAP 25MCG
Tier 4
X
TIROSINT
CAP 50MCG
Tier 4
X
TIROSINT
CAP 75MCG
Tier 4
X
TIROSINT
CAP 88MCG
Tier 4
X
UNITH DIRECT TAB 100MCG
Tier 1
UNITH DIRECT TAB 112MCG
Tier 1
Page 165 of 279
Specialty
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name UNITH DIRECT TAB 125MCG
Tier Value Tier 1
UNITH DIRECT TAB 150MCG
Tier 1
UNITH DIRECT TAB 175MCG
Tier 1
UNITH DIRECT TAB 200MCG
Tier 1
UNITH DIRECT TAB 25MCG
Tier 1
UNITH DIRECT TAB 300MCG
Tier 1
UNITH DIRECT TAB 50MCG
Tier 1
UNITH DIRECT TAB 75MCG
Tier 1
UNITH DIRECT TAB 88MCG
Tier 1
UNITHROID TAB 100MCG
Tier 1
UNITHROID TAB 112MCG
Tier 1
UNITHROID TAB 125MCG
Tier 1
UNITHROID TAB 137MCG
Tier 1
UNITHROID TAB 150MCG
Tier 1
UNITHROID TAB 175MCG
Tier 1
UNITHROID TAB 200MCG
Tier 1
UNITHROID TAB 25MCG
Tier 1
UNITHROID TAB 300MCG
Tier 1
UNITHROID TAB 50MCG
Tier 1
Page 166 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name UNITHROID TAB 75MCG
Tier Value Tier 1
UNITHROID TAB 88MCG
Tier 1
WESTHROID TAB 113.75MG
Tier 3
WESTHROID TAB 130MG
Tier 3
WESTHROID TAB 146.25MG
Tier 3
WESTHROID TAB 16.25MG
Tier 3
WESTHROID TAB 162.50MG
Tier 3
WESTHROID TAB 195MG
Tier 3
WESTHROID TAB 260MG
Tier 3
WESTHROID TAB 32.5MG
Tier 3
WESTHROID TAB 325MG
Tier 3
WESTHROID TAB 48.75MG
Tier 3
WESTHROID TAB 65MG
Tier 3
WESTHROID TAB 81.25MG
Tier 3
WESTHROID TAB 97.5MG
Tier 3
WP THYROID TAB 113.75MG
Tier 3
WP THYROID TAB 130MG
Tier 3
WP THYROID TAB 16.25MG
Tier 3
WP THYROID TAB 32.5MG
Tier 3
Page 167 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Prior Authorization
Supply Limit
Step Therapy
Therapeutic Class Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Suppressant (Adrenal) Hormone Suppressants Hormonal Agents, Suppressant (Parathyroid) Hormone Suppressants Hormonal Agents, Suppressant (Parathyroid) Hormone Suppressants Hormonal Agents, Suppressant (Parathyroid) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary)
Product Name WP THYROID TAB 48.75MG
CETROTIDE KIT 0.25MG
Tier 3
X
Hormonal Agents, Suppressant (Pituitary)
GANIRELIX AC INJ
Tier 4
X
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
CABERGOLINE TAB 0.5MG
Tier 1
ELIGARD
INJ 22.5MG
Tier 4
X
X
ELIGARD
INJ 30MG
Tier 4
X
X
ELIGARD
INJ 45MG
Tier 4
X
X
ELIGARD
INJ 7.5MG
Tier 4
X
X
Tier Value Tier 3
WP THYROID TAB 65MG
Tier 3
WP THYROID TAB 81.25MG
Tier 3
WP THYROID TAB 97.5MG
Tier 3
LYSODREN
Tier 3
TAB 500MG
SENSIPAR
TAB 30MG
Tier 4
SENSIPAR
TAB 60MG
Tier 4
SENSIPAR
TAB 90MG
Tier 4
Specialty
X
FIRMAGON
INJ 120MG
Tier 4
X
FIRMAGON
INJ 80MG
Tier 4
X
LEUPROLIDE INJ 1MG/0.2
Tier 1
X
X
OCTREOTIDE INJ 1000MCG
Tier 1
X
X
OCTREOTIDE INJ 100MCG
Tier 1
X
X
OCTREOTIDE INJ 200MCG
Tier 1
X
X
OCTREOTIDE INJ 500MCG
Tier 1
X
X
OCTREOTIDE INJ 50MCG/ML
Tier 1
X
X
SANDOSTATIN INJ 1000MCG
Tier 4
X
X
SANDOSTATIN INJ 100MCG
Tier 4
X
X
SANDOSTATIN INJ 200MCG
Tier 4
X
X
SANDOSTATIN INJ 500MCG
Tier 4
X
X
Page 168 of 279
Therapeutic Class Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants HORMONES AND SYNTHETIC SUBSTITUTES ANTITHYROID AGENTS HORMONES AND SYNTHETIC SUBSTITUTES ANTITHYROID AGENTS Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs
Product Name SANDOSTATIN INJ 50MCG/ML
Tier Value Tier 4
Prior Authorization X
Supply Limit
Step Therapy
Specialty X
SIGNIFOR
INJ 0.3MG/ML
Tier 3
X
X
X
SIGNIFOR
INJ 0.6MG/ML
Tier 3
X
X
X
SIGNIFOR
INJ 0.9MG/ML
Tier 3
X
X
X
SOMATULINE INJ 120/.5ML
Tier 4
X
SOMATULINE INJ 60/0.2ML
Tier 4
X
SOMATULINE INJ 90/0.3ML
Tier 4
X
SOMAVERT
INJ 10MG
Tier 4
X
SOMAVERT
INJ 15MG
Tier 4
X
SOMAVERT
INJ 20MG
Tier 4
X
SOMAVERT
INJ 25MG
Tier 4
X
SOMAVERT
INJ 30MG
Tier 4
X
SOL 2MG/ML
Tier 2
SYNAREL IODINE SSKI
SOL STRONG SOL 1GM/ML
Tier 2 Tier 3
ASTAGRAF XL CAP 0.5MG
Tier 4
X
X
ASTAGRAF XL CAP 1MG
Tier 4
X
X
ASTAGRAF XL CAP 5MG
Tier 4
X
X
AZASAN
TAB 100MG
Tier 3
AZASAN
TAB 75 MG
Tier 3
AZATHIOPRINE TAB 50MG
Tier 1
CELLCEPT
CAP 250MG
Tier 4
X
CELLCEPT
SUS 200MG/ML
Tier 4
X
CELLCEPT
TAB 500MG
Tier 4
X
CIMZIA
KIT
Tier 3
X
X
X
CIMZIA
KIT STARTER
Tier 3
X
X
X
CIMZIA PREFL KIT 200MG/ML
Tier 3
X
X
X
CYCLOSPORINE CAP 100MG
Tier 1
X
CYCLOSPORINE CAP 100MG MD
Tier 1
X
Page 169 of 279
Therapeutic Class Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs
Product Name CYCLOSPORINE CAP 25MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Specialty X
CYCLOSPORINE CAP 25MG MOD CYCLOSPORINE CAP 50MG MOD CYCLOSPORINE SOL MODIFIED
Tier 1
X
Tier 1
X
Tier 1
X
ENBREL
INJ 25/0.5ML
Tier 4
X
X
X
ENBREL
INJ 25MG
Tier 4
X
X
X
ENBREL
INJ 50MG/ML
Tier 4
X
X
X
ENBREL SRCLK INJ 50MG/ML
Tier 4
X
X
X
ENVARSUS XR TAB 0.75MG
Tier 4
X
X
ENVARSUS XR TAB 1MG
Tier 4
X
X
ENVARSUS XR TAB 4MG
Tier 4
X
X
GENGRAF
CAP 100MG
Tier 1
X
GENGRAF
CAP 25MG
Tier 1
X
GENGRAF
CAP 50MG
Tier 1
X
GENGRAF
SOL 100MG/ML
Tier 1
X
HUMIRA
INJ 10MG/0.2
Tier 3
X
X
X
HUMIRA
KIT 20MG/0.4
Tier 3
X
X
X
HUMIRA
KIT 40MG/0.8
Tier 3
X
X
X
HUMIRA PEDIA INJ CROHNS
Tier 3
X
X
X
HUMIRA PEN INJ 40MG/0.8
Tier 3
X
X
X
HUMIRA PEN INJ CROHNS
Tier 3
X
X
X
HUMIRA PEN INJ PSORIASI
Tier 3
X
X
X
IMURAN
Tier 4 X
X
X
KINERET
TAB 50MG INJ
Tier 4
METHOTREXATE TAB 2.5MG
Tier 1
MYCOPHENOLAT CAP 250MG
Tier 1
X
MYCOPHENOLAT SUS 200MG/ML MYCOPHENOLAT TAB 500MG
Tier 1
X
Tier 1
X
MYCOPHENOLIC TAB 180MG DR
Tier 1
X
Page 170 of 279
Therapeutic Class Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs
Product Name MYCOPHENOLIC TAB 360MG DR MYFORTIC TAB 180MG MYFORTIC
TAB 360MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Specialty X
Tier 4
X
Tier 4
X
NEORAL
CAP 100MG
Tier 4
X
NEORAL
CAP 25MG
Tier 4
X
NEORAL
SOL 100MG/ML
Tier 4
X
ORENCIA
INJ 125MG/ML
Tier 4
X
ORENCIA CLCK INJ 125MG/ML
Tier 4
X
OTREXUP
INJ 10MG
Tier 4
X
X
OTREXUP
INJ 12.5/0.4
Tier 4
X
X
OTREXUP
INJ 15MG
Tier 4
X
X
OTREXUP
INJ 17.5/0.4
Tier 4
OTREXUP
INJ 20MG
Tier 4
OTREXUP
INJ 22.5/0.4
Tier 4
OTREXUP
INJ 25MG
Tier 4
X
X
OTREXUP
INJ 7.5/0.4
Tier 4
X
X
PROGRAF
CAP 0.5MG
Tier 4
X
PROGRAF
CAP 1MG
Tier 4
X
PROGRAF
CAP 5MG
Tier 4
X
X
X
X X
X X
RAPAMUNE
SOL 1MG/ML
Tier 3
X
RAPAMUNE
TAB 0.5MG
Tier 4
X
RAPAMUNE
TAB 1MG
Tier 4
X
RAPAMUNE
TAB 2MG
Tier 4
X
RASUVO
INJ 10MG
Tier 4
X
X
RASUVO
INJ 12.5MG
Tier 4
X
X
RASUVO
INJ 15MG
Tier 4
X
X
RASUVO
INJ 17.5MG
Tier 4
X
X
RASUVO
INJ 20MG
Tier 4
X
X
RASUVO
INJ 22.5MG
Tier 4
X
X
Page 171 of 279
Therapeutic Class Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immune Suppressants - Immune System Drugs Immunomodulators - Immune System Drugs
Product Name RASUVO INJ 25MG
Immunomodulators - Immune System Drugs
Tier Value Tier 4
Prior Authorization
Supply Limit X
Step Therapy X
RASUVO
INJ 27.5MG
Tier 4
X
X
RASUVO
INJ 30MG
Tier 4
X
X
RASUVO
INJ 7.5MG
Tier 4
X
X
Specialty
RHEUMATREX TAB 2.5MG
Tier 2
SANDIMMUNE CAP 100MG
Tier 4
X
SANDIMMUNE CAP 25MG
Tier 4
X
SANDIMMUNE SOL 100MG/ML SIMPONI INJ 100MG/ML
Tier 4
X
Tier 3
X
X
X
SIMPONI
INJ 100MG/ML
Tier 3
X
X
X
SIMPONI
INJ 50/0.5ML
Tier 3
X
X
X
SIMPONI
INJ 50/0.5ML
Tier 3
X
X
X
SIROLIMUS TAB 0.5MG
Tier 1
X
SIROLIMUS TAB 1MG
Tier 1
X
SIROLIMUS TAB 2MG
Tier 1
X
TACROLIMUS CAP 0.5MG
Tier 1
X
TACROLIMUS CAP 1MG
Tier 1
X
TACROLIMUS CAP 5MG
Tier 1
X
TREXALL
TAB 10MG
Tier 2
TREXALL
TAB 15MG
Tier 2
TREXALL
TAB 5MG
Tier 2
TREXALL
TAB 7.5MG
Tier 2
ZORTRESS
TAB 0.25MG
Tier 4
X
ZORTRESS
TAB 0.5MG
Tier 4
X
ZORTRESS
TAB 0.75MG
Tier 4
X
ACTEMRA
INJ 162/0.9
Tier 4
X
X
X
ACTIMMUNE INJ 2MU/0.5
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
ALFERON N INJ 5MU/ML
Tier 3
Immunomodulators - Immune System Drugs
ARAVA
Tier 4
TAB 10MG
Page 172 of 279
X
Prior Authorization
Supply Limit
Tier 3
X
X
X
Tier 3
X
X
X
AVONEX PEN KIT 30MCG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
AVONEX PREFL KIT 30MCG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
BETASERON INJ 0.3MG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
EXTAVIA
Tier 4
X
X
Immunomodulators - Immune System Drugs
LEFLUNOMIDE TAB 10MG
Tier 1
Immunomodulators - Immune System Drugs
LEFLUNOMIDE TAB 20MG
Tier 1
Immunomodulators - Immune System Drugs
OTEZLA
TAB 10/20/30
Tier 4
X
X
X
Immunomodulators - Immune System Drugs
OTEZLA
TAB 30MG
Tier 4
X
X
X
Immunomodulators - Immune System Drugs
REBIF
INJ 22/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF
INJ 44/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF REBIDO INJ 22/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF REBIDO INJ 44/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF REBIDO INJ TITRATN
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF TITRTN INJ PACK
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
RIDAURA
Tier 3
Immunomodulators - Immune System Drugs
TECFIDERA CAP 120MG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
TECFIDERA CAP 240MG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
TECFIDERA MIS STARTER
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
XELJANZ
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
XELJANZ XR TAB 11MG
Tier 4
X
X
X
X
Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs
AFREZZA POW AFREZZA POW 4& 8UNIT AFREZZA POW 4& 8UNIT AFREZZA POW 4UNIT AFREZZA POW 8&12UNIT APIDRA INJ SOLOSTAR APIDRA INJ U-100 HUMALOG INJ 100/ML HUMALOG INJ 100/ML HUMALOG KWIK INJ 100/ML HUMALOG KWIK INJ 200/ML HUMALOG MIX INJ 50/50
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 2 Tier 2 Tier 2 Tier 1
X X X X X X X
Therapeutic Class Immunomodulators - Immune System Drugs
Product Name ARAVA TAB 20MG
Immunomodulators - Immune System Drugs
ARCALYST
INJ 220MG
Immunomodulators - Immune System Drugs
AVONEX
KIT 30MCG
Immunomodulators - Immune System Drugs
INJ 0.3MG
CAP 3MG
TAB 5MG
Page 173 of 279
Tier Value Tier 4
X X X X X X X X X
Step Therapy
X
X X X X X
Specialty
X
Prior Authorization
Supply Limit X
Step Therapy
Therapeutic Class Insulins - Diabetic Drugs
Product Name HUMALOG MIX INJ 50/50KWP
Tier Value Tier 2
Insulins - Diabetic Drugs
HUMALOG MIX INJ 75/25KWP
Tier 2
X
Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs Insulins - Diabetic Drugs
HUMALOG MIX SUS 75/25 HUMULIN INJ 70/30 HUMULIN INJ 70/30KWP HUMULIN N INJ U-100 HUMULIN N INJ U-100KWP HUMULIN R INJ U-100 HUMULIN R INJ U-500 HUMULIN R INJ U-500 LANTUS INJ 100/ML LANTUS INJ SOLOSTAR LEVEMIR INJ LEVEMIR INJ FLEXTOUC NOVOLIN INJ 70/30 NOVOLIN N INJ RELION NOVOLIN N INJ U-100 NOVOLIN R INJ RELION NOVOLIN R INJ U-100 NOVOLIN70/30 INJ RELION NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN
Tier 1 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
X X X X X X X
X X X X X X X X X X X
X X X X X X X X X X X X X X X
Insulins - Diabetic Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Irritable Bowel Syndrome Agents - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs
TOUJEO SOLO INJ 300IU/ML ALOSETRON TAB 0.5MG
Tier 4 Tier 1
X
X X
ALOSETRON TAB 1MG
Tier 1
X
X
AMITIZA
CAP 24MCG
Tier 4
X
X
X
AMITIZA
CAP 8MCG
Tier 4
X
X
X
LINZESS
CAP 145MCG
Tier 2
X
X
LINZESS
CAP 290MCG
Tier 2
X
X
LOTRONEX
TAB 0.5MG
Tier 4
X
X
X
LOTRONEX
TAB 1MG
Tier 4
X
X
X
CHOLAC SYP 10GM/15 CLEARLAX POW COLYTE/FLAVR SOL PACKS COLYTE/FLAVR SOL PACKS CONSTULOSE SOL 10GM/15 CVS PURELAX POW ENULOSE SOL 10GM/15 EQ CLEARLAX POW EQL CLEARLAX POW GAVILAX POW GAVILYTE-C SOL GAVILYTE-G SOL GAVILYTE-N SOL FLAV PK
Tier 1 HCR Preventative Tier 4 Tier 2 Tier 1 HCR Preventative Tier 1 HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative
Page 174 of 279
X
Specialty
Prior Authorization Tier Value Tier 1 HCR Preventative Tier 3 HCR Preventative HCR Preventative Tier 4 Tier 2 Tier 4 HCR Preventative Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 HCR Preventative HCR Preventative Tier 3 HCR Preventative Tier 4 HCR Preventative Tier 3 Tier 3 Tier 1 Tier 1 HCR Preventative HCR Preventative HCR Preventative HCR Preventative Tier 1 Tier 1
Therapeutic Class Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs
Product Name GENERLAC SOL 10GM/15 GENTLELAX POW GIALAX KIT GLYCOLAX POW 3350 NF GNP CLEARLAX POW GOLYTELY SOL GOLYTELY SOL GOLYTELY SOL PINEAPPL HM CLEARLAX POW KRISTALOSE PAK 10GM KRISTALOSE PAK 20GM LACTULOSE SOL 10GM/15 LACTULOSE SOL 10GM/15 LACTULOSE SOL 20GM/30 LACTULOSE SYP 10GM/15 LAXACLEAR POW LAXATIVE POL POW GLYCOL MOVIPREP SOL NATURA-LAX POW 3350 NF NULYTELY SOL FLAV PKS PEG 3350 POW PEG 3350 POW PEG 3350 POW PEG 3350 POW PEG 3350 POW PEG 3350 SOL ELECTROL PEG3350 POW PEG-3350 SOL ELECTROL PEG-3350/KCL SOL /SODIUM PEGYLAX POW POLYETH GLYC POW 3350 NF
Laxatives - Bowel Treatment Drugs
POLYETH GLYC POW 3350 NF
Tier 1
Laxatives - Bowel Treatment Drugs
POLYETH GLYC POW 3350 NF
HCR Preventative
Laxatives - Bowel Treatment Drugs
POLYETH GLYC POW 3350-GRX HCR Preventative
Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs Local Anesthetics Local Anesthetics Local Anesthetics
POWDERLAX POW PREPOPIK PAK RA LAXATIVE POW SM CLEARLAX POW SMOOTH LAX POW SUPREP BOWEL SOL PREP SW CLEARLAX POW TRILYTE SOL ATENDIA PAD 4-3% BUPIVACAINE POW HCL DERMACINRX KIT PRIZOPAK
HCR Preventative Tier 3 HCR Preventative HCR Preventative HCR Preventative Tier 3 HCR Preventative HCR Preventative Tier 4 Tier 3 Tier 1
Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics
EMLA CRE 2.5-2.5% LETS KIT LEVA SET KIT LIDO/PRILOCN CRE 2.5-2.5% LIDO/PRILOCN KIT 2.5-2.5% LIDOCAINE CRE 10% LIDOCAINE CRE 5% LIDOCAINE CRE TETRACAI
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
Page 175 of 279
Supply Limit
X
X
X
X X X X X
Step Therapy
Specialty
Therapeutic Class Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics
Product Name LIDOCAINE GEL 2% JELLY LIDOCAINE OIN 5% LIDOCAINE OIN PAK 5% LIDOCAINE PAD 5% LIDOCAINE SOL 2% VISC LIDOCAINE SOL 4% LIDOCAINE SOL 4% LIDOCAINE-PR CRE LIDODERM DIS 5% LIDOPIN CRE 3.25% LIDOPRIL KIT 2.5-2.5% LIDOVEX CRE 3.75% LP LITE PAK KIT 2.5-2.5% PAIN RELIEF PAD PATCH PLIAGLIS CRE 7-7% PROZENA PAD 4% RELADOR PAK KIT 2.5-2.5% RELADOR PAK KIT PLUS SYNERA DIS 70-70MG SYNVEXIA TC CRE 4-1% TOPEX TOPCAL SPR ANESTHET
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 1 Tier 4 Tier 1 Tier 4 Tier 3 Tier 4 Tier 1 Tier 1 Tier 3 Tier 4 Tier 3
Local Anesthetics Local Anesthetics Macrolides - Antibiotics Macrolides - Antibiotics
Tier 4 Tier 3 Tier 3 Tier 1
Macrolides - Antibiotics
VELTRIX CRE 4-1% XYLOCAINE SOL 4% AZASITE SOL 1% AZITHROMYCIN POW 1GM PAK AZITHROMYCIN SUS 100/5ML
Macrolides - Antibiotics
AZITHROMYCIN SUS 200/5ML
Tier 1
Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics
AZITHROMYCIN TAB 250MG AZITHROMYCIN TAB 500MG AZITHROMYCIN TAB 600MG BIAXIN SUS 250/5ML BIAXIN TAB 250MG BIAXIN TAB 500MG CLARITHROMYC SUS 125/5ML
Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 1
Macrolides - Antibiotics
CLARITHROMYC SUS 250/5ML
Tier 1
Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics
CLARITHROMYC TAB 250MG CLARITHROMYC TAB 500MG CLARITHROMYC TAB 500MG ER DIFICID TAB 200MG E.E.S. 400 TAB 400MG E.E.S. GRAN SUS 200/5ML ERY PAD 2% ERYGEL GEL 2% ERYPED SUS 200/5ML ERYPED SUS 400/5ML ERY-TAB TAB 250MG EC ERY-TAB TAB 333MG EC ERY-TAB TAB 500MG EC ERYTHROCIN TAB 250MG ERYTHROM ETH TAB 400MG
Tier 1 Tier 1 Tier 1
Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics
Page 176 of 279
Prior Authorization
Supply Limit
Step Therapy
X X X
X X
X
X X
X X
X
Tier 1
Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1
X X
Specialty
Therapeutic Class Macrolides - Antibiotics
Product Name ERYTHROMYCIN CAP 250MG EC ERYTHROMYCIN GEL 2% ERYTHROMYCIN OIN 5MG/GM
Tier Value Tier 1
ERYTHROMYCIN OIN OP ERYTHROMYCIN PAD 2% ERYTHROMYCIN SOL 2% ERYTHROMYCIN TAB 250MG BS ERYTHROMYCIN TAB 500MG BS ILOTYCIN OIN OP KETEK TAB 300MG KETEK TAB 400MG PCE TAB 333MG EC PCE TAB 500MG EC ROMYCIN OIN OP ZITHROMAX POW 1GM PAK
Tier 1 Tier 1 Tier 1 Tier 1
ZITHROMAX SUS 100/5ML ZITHROMAX SUS 200/5ML ZITHROMAX TAB 250MG ZITHROMAX TAB 500MG ZITHROMAX TAB 600MG ZITHROMAX TAB TRI-PAK ZITHROMAX TAB Z-PAK ZMAX SUS 2GM CROMOLYN SOD NEB 20MG/2ML Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 150MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 30MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 35MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 5MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE SOL 70/75ML (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 10MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 35MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 40MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 5MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 70MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis ATELVIA TAB (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis BINOSTO TAB 70MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis BONIVA TAB 150MG (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis CALCITONIN SPR 200/ACT (Bone Loss) Drugs
Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 4 Tier 3 Tier 1
Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Mast Cell Stabilizers - Asthma/Lung Drugs
Page 177 of 279
Prior Authorization
Supply Limit
Step Therapy
Tier 1 Tier 1
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 4
Tier 4
X
Tier 4 Tier 4
X
Tier 4 Tier 1 Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
Tier 1
Specialty
Therapeutic Class Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs
Prior Authorization
Supply Limit
Product Name CALCITRIOL CAP 0.25MCG
Tier Value Tier 1
CALCITRIOL CAP 0.5MCG
Tier 1
CALCITRIOL SOL 1MCG/ML
Tier 1
DOXERCALCIF CAP 0.5MCG
Tier 1
DOXERCALCIF CAP 1MCG
Tier 1
DOXERCALCIF CAP 2.5MCG
Tier 1
ETIDRON DISD TAB 200MG
Tier 1
ETIDRON DISD TAB 400MG
Tier 1
FORTEO
SOL 600/2.4
Tier 3
FORTICAL
SPR 200/ACT
Tier 4
FOSAMAX
TAB 70MG
Tier 4
X
FOSAMAX + D TAB 70-2800
Tier 3
X
FOSAMAX + D TAB 70-5600
Tier 3
X
HECTOROL
CAP 0.5MCG
Tier 4
HECTOROL
CAP 1MCG
Tier 4
HECTOROL
CAP 2.5MCG
Tier 4
X
Specialty
X
IBANDRONATE TAB 150MG
Tier 1
MIACALCIN INJ 200/ML
Tier 3
MIACALCIN SPR 200/ACT
Tier 4
PARICALCITOL CAP 1 MCG
Tier 1
PARICALCITOL CAP 2 MCG
Tier 1
PARICALCITOL CAP 4 MCG
Tier 1
RISEDRON SOD TAB 35MG DR
Tier 1
X
RISEDRONATE TAB 150MG
Tier 1
X
RISEDRONATE TAB 30MG
Tier 1
RISEDRONATE TAB 35MG
Tier 1
RISEDRONATE TAB 5MG
Tier 1
ROCALTROL CAP 0.25MCG
Tier 4
ROCALTROL CAP 0.5MCG
Tier 4
Page 178 of 279
Step Therapy
X
X
X
Therapeutic Class Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents
Product Name ROCALTROL SOL 1MCG/ML
A/G PRO TAB ACTIVE MEDIC KIT SPECIMEN
Tier 3 Tier 1
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
ACUNOL TAB 600MG ADVERA LIQ CHOCOLAT ADVERA LIQ VANILLA AMINOBEZ POT POW APPTRIM CAP APPTRIM CAP APPTRIM-D CAP ASILNASAL CAP RMS AURUM LIQ 12X BCAD 1 POW BCAD 2 POW B-D UF SYRG MIS .3CC/30G BHI URI- TAB CONTROL BIO-IMMUNEX CAP BISMUTH SUBC POW BOOST LIQ BUT PECN BOOST LIQ CHOC/MLT BOOST LIQ CHOCOLAT BOOST LIQ MOCHA BOOST LIQ STRWBRRY BOOST LIQ VANILLA BOOST HIGH LIQ PROTEIN BOOST PLUS LIQ CHOCOLAT
Tier 3 Tier 3 Tier 3 Tier 1 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
BOOST PLUS LIQ STRAWBER
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
BOOST PLUS LIQ VANILLA BOOST PUDDIN MIS BUTTSCTH
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
BOOST PUDDIN MIS CHOCOLAT BOOST PUDDIN MIS VANILLA
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
CARDIOVID CAP PLUS CAREFINE MIS 31GX8MM CAREFINE MIS 32GX4MM CAREFINE MIS 32GX5MM CAREFINE MIS 32GX6MM CARNITOR SOL 1GM/10ML CARNITOR TAB 330MG CARNITOR SF SOL 1GM/10ML
Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 4 Tier 4 Tier 4
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
CATALYTIC TAB FORMULA CAVAREST GEL 1.1% CAVIRINSE SOL 0.2% CHELIDONIUM LIQ COMPOUND CHOICE DM LIQ VANILLA
Tier 3 Tier 1 Tier 1 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Tier Value Tier 4
ZEMPLAR
CAP 1MCG
Tier 4
ZEMPLAR
CAP 2MCG
Tier 4
Page 179 of 279
Tier 3
Tier 3
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS
Product Name CHOICE DM TF LIQ UNSWEET
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS
CHOLECALCIF POW Tier 3 CHOLECALCIFE CRY USP/NF Tier 3 CLINPRO 5000 PST 1.1% Tier 1 COENZYME Q10 CHW 60MG Tier 3 COENZYME Q10 TAB 200MG Tier 3 COLCIGEL GEL Tier 3 COMPLEAT LIQ CLS SYS Tier 3 COMPLEAT PED LIQ Tier 3 CONCEPTROL GEL 4% HCR Preventative CONTROLRX CRE 1.1% Tier 1 CRITICARE HN LIQ Tier 3 CRUCIAL LIQ ULTRAPAK Tier 3 CRUCIAL LIQ UNFLAVOR Tier 3 CRYOSERV SOL Tier 3 CVS NUTRITIO LIQ CHOCOLAT Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
CVS NUTRITIO LIQ STRABERY
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents
CVS NUTRITIO LIQ VANILLA DENTA 5000 CRE PLUS DENTA 5000 CRE PLUS 2PK DENTAGEL GEL 1.1% DERMATODORON LIQ DIABETIC TF LIQ DIABETISOURC LIQ DIABETISOURC LIQ AC DIGESTODORON LIQ DIMETHYL SOL SULFOXID DISCUS LIQ COMPOSIT DIUSCREEN ME KIT COLLECTI
Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
DIVISTA CAP EASYGEL GEL 0.4% EASYGEL GEL 0.4%CHRY EASYGEL GEL 0.4%CITR EASYGEL GEL 0.4%MINT ECZEMOL TAB ERYSIDORON LIQ #1 ESTRO VITAL TAB NUTRIENT
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
F.A.A. LIQ FEM PH GEL FERRIPROX SOL 100MG/ML
Tier 3 Tier 4 Tier 3
Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS
FERRIPROX TAB 500MG FIBERSOUR HN LIQ CLS SYS FIBERSOUR HN LIQ VANILLA FIBERSOURCE LIQ CLS SYS FIRAZYR INJ 30MG/3ML FIRST DUKES SUS MOUTHWSH
MISCELLANEOUS THERAPEUTIC AGENTS
FIRST-MARYS SUS MOUTHWSH FLUOR-A-DAY CHW 0.25MG F
MISCELLANEOUS THERAPEUTIC AGENTS
Page 180 of 279
Tier Value Tier 3
Prior Authorization
Supply Limit
Step Therapy
Specialty
X X
X
X
Tier 4 Tier 3 Tier 3 Tier 3 Tier 4 Tier 3
X
X
Tier 3
X
Tier 3
X X
X
X
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS
Product Name FLUOR-A-DAY CHW 0.5MG F
Tier Value Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
FLUOR-A-DAY CHW 1MG F FLUORIDEX GEL 1.1% FLUORIDEX GEL SENSITIV FLUORIDEX GEL WHITENIN FLUORIDEX DD PST SENSITIV
Tier 3 Tier 1 Tier 3 Tier 1 Tier 1
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
GA POW GA DIET POW GEL-KAM CON 0.63% GLONOIN DRO HOMACCOR
Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
GLYTROL LIQ ULTRAPAK GRASTEK SUB 2800BAU GYNOL II GEL 3% H2Q POW 200MG/GM HCU COOLER LIQ HCY 1 DIET POW HCY 2 POW HEXAPEPTIDE POW ACETYL HEXAPEPTIDE SOL ACETYL IMPACT LIQ IMPACT LIQ CHOCOLAT IMPACT 1.5 LIQ IMPACT GLUTA LIQ IMPACT/FIBER LIQ INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/31G INSULIN SYRG MIS 0.5/28G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/31G INSULIN SYRG MIS 1ML/28G INSULIN SYRG MIS 1ML/29G INSULIN SYRG MIS 1ML/30G INSULIN SYRG MIS 1ML/30G INSULIN SYRG MIS 1ML/31G ISOCAL LIQ ISOCAL HN LIQ ISOCAL HN LIQ PLUS ISOSOURCE LIQ ISOSOURCE LIQ 1.5 CAL ISOSOURCE LIQ CLS SYS ISOSOURCE LIQ VHN VANL ISOSOURCE HN LIQ KARIGEL GEL 0.5% KARIGEL-N GEL 1.1% K-PHOS TAB NO 2 LEVOCARNITIN SOL 1GM/10ML LEVOCARNITIN TAB 330MG L-GLUT/CHOL/ TAB INOSITOL
Tier 3 Tier 4 HCR Preventative Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 2 Tier 1
Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS
Page 181 of 279
Tier 1 Tier 3
Prior Authorization
Supply Limit
X
X
X
X X
Step Therapy
Specialty
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Product Name LITHATE CAP LMD POW LMD DIET POW MCT PROCAL POW MERITENE POW CHOCOLAT
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
MERITENE POW VANILLA METHERGINE TAB 0.2MG METHIONINE CAP 200MG METHYLERGON TAB 0.2MG MODULEN IBD POW MORCIN CRE MSUD COOLER LIQ MSUD COOLER LIQ 20 MYALEPT INJ 11.3MG NAFRINSE SOL DAILY NAFRINSE DLY SOL /NEUTRAL
Tier 3 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 2 Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Tier 4 Tier 3 Tier 1 Tier 3 Tier 3
Miscellaneous Therapeutic Agents
NAFRINSE WK SOL 0.2% NESTLE FLAVO PAK EX-STR NEUTRAGARD GEL 1.1% NITRIC ACID LIQ NOVASOURCE LIQ PULMONAR NOVOFINE MIS 30GX8MM NOVOFINE MIS 32GX6MM NOVOFINE AUT MIS 30GX8MM NOVOFINE PLS MIS 32GX4MM
Miscellaneous Therapeutic Agents
NOVOTWIST MIS 30GX8MM
Tier 2
Miscellaneous Therapeutic Agents
NOVOTWIST MIS 32GX5MM
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
NUTREN LIQ JR/FIBER NUTREN LIQ JUNIOR NUTREN LIQ PULMONAR NUTREN 1.0 LIQ /FIB UNF NUTREN 1.0 LIQ /FIBER NUTREN 1.0 LIQ ULTRAPAK NUTREN 1.0 LIQ UNFLAVOR
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
NUTREN 1.5 LIQ ULTRAPAK NUTRI DRINK LIQ CHOCOLAT
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
NUTRI DRINK NUTRI DRINK NUTRI DRINK NUTRI-DRINK
Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
NUTRI-DRINK LIQ + VANILA NUTRI-DRINK LIQ CHOCOLAT
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
NUTRI-DRINK LIQ VANILLA NUTRIHEAL LIQ VANILLA NUTRIRENAL LIQ NUTRITIONAL LIQ SUPPLEME
Tier 3 Tier 3 Tier 3 Tier 3
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
LIQ PLUS LIQ STRWBER LIQ VANILLA LIQ + CHOCOL
Page 182 of 279
Tier 2 Tier 2 Tier 2 Tier 2
Prior Authorization
Supply Limit
X
X
X
Step Therapy
Specialty
X
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
Product Name NUTRIVENT LIQ NUTRIVENT LIQ 1.5 VAN OA 1 POW OA 1 DIET POW OA 2 POW OA 2 DIET POW ORALAIR SUB 300 IR ORALAIR ADLT SUB 300 IR ORALAIR CHLD PAK SAMPLE ORALAIR CHLD SUB 100 IR PEN NEEDLE MIS 29GX1/2" PEN NEEDLES MIS 29GX1/2" PEN NEEDLES MIS 29GX12MM
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
PEN NEEDLES PEN NEEDLES PEN NEEDLES PEN NEEDLES PEN NEEDLES
MIS 30GX5/16 MIS 31GX1/4" MIS 31GX3/16 MIS 31GX5/16 MIS 31GX6MM
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Miscellaneous Therapeutic Agents
PEN NEEDLES MIS 31GX8MM
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN PEPTAMEN
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN 1.5 LIQ PEPTAMEN AF LIQ UNFLAVOR
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN JR LIQ CHOCOLAT
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN JR LIQ UNFLAVRD
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN JUN POW VANILLA
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN OS LIQ 1.5/VAN PEPTAMEN OS LIQ CHOCOLAT
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN OS LIQ VANILLA PEPTAMEN VHP LIQ ULTRAPAK
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN VHP LIQ UNFLAVOR PEPTAMEN VHP LIQ VANILLA
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
PEPTINEX 1.5 LIQ VANILLA PEPTINEX DT LIQ PEPTINEX DT LIQ /FIBER PEPTINEX DT LIQ PREBIOTC PEPTINEX DT LIQ VANILLA PFD 1 POW PFD 2 POW PHOS-FLUR GEL 1.1% PNEUMODORON LIQ POLYOX POW WSR-301 PORTAGEN POW POTABA CAP 500MG PREVDNT 5000 PST 1.1% PREVIDENT CRE 5000 PLS
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 4 Tier 3 Tier 4 Tier 3 Tier 4
LIQ PREBIO1 LIQ UNFLAVOR
Page 183 of 279
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 3 Tier 4 Tier 2 Tier 2 Tier 2
Prior Authorization
Supply Limit
X X
X X
X
X
Step Therapy
Specialty
Tier 3
X
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Product Name PREVIDENT GEL 1.1% PREVIDENT GEL 1.1% BER PREVIDENT GEL 1.1% CHR PREVIDENT GEL 1.1% MIN PREVIDENT PST 5000 BST PREVIDENT PST 5000 SEN PREVIDENT SOL 0.2% PREVIDENT SOL RINSE PROBALANCE LIQ ULTRAPAK
Tier Value Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
PROBALANCE LIQ VANILLA PRO-CAL POW PRODUCT3232A POW PROS-TECH CAP PLUS PROT COOKIE MIS OATRAISN
Tier 3 Tier 3 Tier 3 Tier 1 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PROTEOLYTIC TAB FORMULA
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PRVDNT 5000 PST ENAML PR
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
PSORIZIDE TAB FORTE PSORIZIDE TAB ULTRA Q2 ORAL CLEA KIT SYSTEM Q4 ORAL CLEA KIT SYSTEM QUINZYME TAB 90MG RA NUTRITION LIQ CHOCOLAT
Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents
RA NUTRITION LIQ VANILLA RA PEN NEEDL MIS 31GX3/16
Tier 3 Tier 2
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
RADIOGARDASE CAP 0.5GM RAGWITEK SUB RAPID GEL RX GEL RELAGARD GEL RENASTART POW REPLETE LIQ /FIBER REPLETE LIQ ULTRAPAK RESOURCE KID LIQ CR STRAW
Tier 3 Tier 4 Tier 3 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE KID LIQ FR VAN RESOURCE KID LIQ SW CHOC
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE KID LIQ W/FIBER RESOURCE SUP LIQ CHOCOLAT
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE SUP LIQ STRAWBER
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE SUP LIQ VANILLA RESPALOR LIQ RHEUMADORON LIQ 102A RX-SPECIMEN KIT COLLECTI SCANDICAL POW SCANDISHAKE POW VANILLA
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
SF GEL 1.1% SF 5000 PLUS CRE 1.1% SHUR-SEAL GEL 2% SM INSULIN SYRINGE
Tier 1 Tier 1 HCR Preventative Tier 2
Page 184 of 279
Prior Authorization
Supply Limit
X
X
Step Therapy
Specialty
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Product Name SOD FLUORIDE SOL 0.2% SOD FLUORIDE SOL 0.2%MINT
Tier Value Tier 1 Tier 1
Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
SPECIMEN KIT COLLECTI SPEEDGEL RX GEL STERYMINE GEL SUBDUE LIQ CHOC/ALM SUBDUE LIQ ORNG/VAN SUBDUE LIQ REDI-FED SUBDUE LIQ UNFLAVRD SUBDUE PLUS LIQ UNFLAVRD
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
SULFZIX POW THALAMUS SUB COMPOSIT
Tier 3 Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents
THERA-FLUR-N DRO 1.1% Tier 4 TODAY SPONGE MIS HCR Preventative TRANZGEL GEL Tier 3 TYR COOLER LIQ 20 Tier 3 TYR COOLER LIQ RED Tier 3 TYROS 1 POW Tier 3 TYROS 2 POW Tier 3 UBIQUINOL POW Tier 3 UBIQUINOL POW 30% Tier 3 UCD TRIO POW Tier 3 ULTRA ENERGY TAB Tier 3 ULTRACAL LIQ Tier 3 ULTRACAL HN LIQ PLUS Tier 3 UNFINE PNTP MIS 32GX4MM Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 29GX1/2"
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 29GX12MM
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX3/16
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX5/16
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX5MM
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX6MM
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX8MM
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents
URI-CONTROL TAB RX URINX MEDIC KIT SPECIMEN
Tier 3 Tier 3
Miscellaneous Therapeutic Agents
VCF VAGINAL AER CONTRACP HCR Preventative
Miscellaneous Therapeutic Agents
VCF VAGINAL GEL CONTRACE HCR Preventative
Miscellaneous Therapeutic Agents
VCF VAGINAL MIS CONTRACP HCR Preventative
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
VERTIGOHEEL SUB VITAJOULE POW VITAMIN D3 LIQ VITAMIN D3 POW VITAMIN D3 POW
Page 185 of 279
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Prior Authorization
X X
X X X
Supply Limit
Step Therapy
Specialty
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents
Product Name VITAMIN E LIQ ACETATE VITAPRO POW VIVONEX RTF LIQ WELLMIND TAB VERTIGO WND POW WND 1 POW WND 2 POW XIZFLUS POW AFINITOR TAB 10MG
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Prior Authorization X
Supply Limit
Step Therapy
X
X
X
Specialty
AFINITOR
TAB 2.5MG
Tier 3
X
X
X
AFINITOR
TAB 5MG
Tier 3
X
X
X
AFINITOR
TAB 7.5MG
Tier 3
X
X
X
AFINITOR DIS TAB 2MG
Tier 3
X
X
X
AFINITOR DIS TAB 3MG
Tier 3
X
X
X
AFINITOR DIS TAB 5MG
Tier 3
X
X
X
BOSULIF
TAB 100MG
Tier 3
X
X
X
X
BOSULIF
TAB 500MG
Tier 3
X
X
X
X
GLEEVEC
TAB 100MG
Tier 1
X
X
X
GLEEVEC
TAB 400MG
Tier 1
X
X
X
IMATINIB MES TAB 100MG
Tier 4
X
X
X
X
IMATINIB MES TAB 400MG
Tier 4
X
X
X
X
IMBRUVICA CAP 140MG
Tier 3
X
X
X
INLYTA
TAB 1MG
Tier 4
X
X
X
INLYTA
TAB 5MG
Tier 4
X
X
X
IRESSA
TAB 250MG
Tier 4
X
Tier 3
X
X
NEXAVAR
TAB 200MG
X X
SPRYCEL
TAB 100MG
Tier 4
X
X
X
X
SPRYCEL
TAB 140MG
Tier 4
X
X
X
X
SPRYCEL
TAB 20MG
Tier 4
X
X
X
X
SPRYCEL
TAB 50MG
Tier 4
X
X
X
X
SPRYCEL
TAB 70MG
Tier 4
X
X
X
X
SPRYCEL
TAB 80MG
Tier 4
X
X
X
X
Tier 3
X
X
STIVARGA
TAB 40MG
Page 186 of 279
X
Therapeutic Class Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Molecular Target Inhibitors - Chemotherapy Agents Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs Monoamine Oxidase Inhibitors Antidepressants Monoamine Oxidase Inhibitors Antidepressants Monoamine Oxidase Inhibitors Antidepressants Monoamine Oxidase Inhibitors Antidepressants Monoamine Oxidase Inhibitors Antidepressants Monoamine Oxidase Inhibitors Antidepressants Monoamine Oxidase Inhibitors Antidepressants Monoamine Oxidase Inhibitors Antidepressants Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs
Product Name SUTENT CAP 12.5MG
Tier Value Tier 3
Prior Authorization X
Supply Limit X
Step Therapy
Specialty X
SUTENT
CAP 25MG
Tier 3
X
X
X
SUTENT
CAP 37.5MG
Tier 3
X
X
X
SUTENT
CAP 50MG
Tier 3
X
X
X
TARCEVA
TAB 100MG
Tier 3
X
X
X
TARCEVA
TAB 150MG
Tier 3
X
X
X
TARCEVA
TAB 25MG
Tier 3
X
X
X
TASIGNA
CAP 150MG
Tier 3
X
X
X
TASIGNA
CAP 200MG
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
TYKERB VOTRIENT
TAB 250MG TAB 200MG
XALKORI
CAP 200MG
Tier 3
X
X
X
XALKORI
CAP 250MG
Tier 3
X
X
X
Tier 3
X
X
X
ZELBORAF
TAB 240MG
AZILECT
TAB 0.5MG
Tier 3
AZILECT
TAB 1MG
Tier 3
ELDEPRYL
CAP 5MG
Tier 4
SELEGILINE CAP 5MG
Tier 1
SELEGILINE TAB 5MG
Tier 1
ZELAPAR
TAB 1.25MG
Tier 3
EMSAM
DIS 12MG/24H
Tier 3
EMSAM
DIS 6MG/24HR
Tier 3
EMSAM
DIS 9MG/24HR
Tier 3
MARPLAN NARDIL PARNATE
TAB 10MG TAB 15MG TAB 10MG
Tier 3 Tier 4 Tier 4
PHENELZINE TAB 15MG
Tier 1
TRANYLCYPROM TAB 10MG
Tier 1
LITHIUM SOL 8MEQ/5ML LITHIUM CARB CAP 150MG
Tier 1 Tier 1
Page 187 of 279
Prior Authorization
Supply Limit
Tier 4 Tier 3
X
X
TAB 14MG
Tier 4
X
X
X
X
TAB 7MG
Tier 4
X
X
X
X
Therapeutic Class Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs
Product Name LITHIUM CARB CAP 300MG LITHIUM CARB CAP 600MG LITHIUM CARB TAB 300MG LITHIUM CARB TAB 300MG ER
Tier Value Tier 1 Tier 1 Tier 1 Tier 1
Mood Stabilizers - Mood Disorder Drugs
LITHIUM CARB TAB 450MG ER
Tier 1
Mood Stabilizers - Mood Disorder Drugs Multiple Sclerosis Agents - Multiple Sclerosis Drugs Multiple Sclerosis Agents - Multiple Sclerosis Drugs Multiple Sclerosis Agents - Multiple Sclerosis Drugs Multiple Sclerosis Agents - Multiple Sclerosis Drugs Multiple Sclerosis Agents - Multiple Sclerosis Drugs Multiple Sclerosis Agents - Multiple Sclerosis Drugs Multiple Sclerosis Agents - Multiple Sclerosis Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs
LITHOBID AMPYRA
TAB 300MG CR TAB 10MG
AUBAGIO AUBAGIO
Step Therapy
Specialty
X
COPAXONE
INJ 20MG/ML
Tier 3
X
X
X
COPAXONE
INJ 40MG/ML
Tier 3
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
GILENYA GLATOPA
CAP 0.5MG INJ 20MG/ML
MEMANT TITRA PAK 5-10MG
Tier 1
MEMANTINE TAB HCL 10MG
Tier 1
MEMANTINE TAB HCL 5MG
Tier 1
MEMANTINE HC SOL 2MG/ML
Tier 1
NAMENDA
SOL 10MG/5ML
Tier 4
NAMENDA
TAB 10MG
Tier 4
NAMENDA
TAB 5-10MG
Tier 4
NAMENDA
TAB 5MG
Tier 4
NAMENDA XR CAP 14MG
Tier 4
X
NAMENDA XR CAP 21MG
Tier 4
X
NAMENDA XR CAP 28MG
Tier 4
X
NAMENDA XR CAP 7MG
Tier 4
X
Page 188 of 279
Therapeutic Class N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs Non-Amphetamines, Other - Miscellaneous Nervous System Drugs Non-Amphetamines, Other - Miscellaneous Nervous System Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name NAMENDA XR CAP TITRATIO
Tier Value Tier 4
CAFFEINE CIT SOL 20MG/ML
Tier 1
CAFFEINE CIT SOL 60MG/3ML
Tier 1
ACTIVE-PREP CRE KIT III
Tier 3
Prior Authorization
X
ADLT ASA LOW TAB 81MG EC HCR Preventative AIF #2 DRUG CRE PREP KIT
Tier 1
ANAPROX DS TAB 550MG
Tier 4
ARTHROTEC 50 TAB
Tier 3
ARTHROTEC 75 TAB
Tier 3
ASPIR-81
TAB 81MG EC
HCR Preventative
ASPIRIN
CHW 81MG
HCR Preventative
ASPIRIN
TAB 325MG
HCR Preventative
ASPIRIN
TAB 325MG
HCR Preventative
ASPIRIN
TAB 325MG EC
HCR Preventative
ASPIRIN
TAB 81MG
HCR Preventative
ASPIRIN
TAB 81MG EC
HCR Preventative
ASPIRIN 81 TAB 81MG EC
HCR Preventative
ASPIRIN CHIL CHW 81MG
HCR Preventative
ASPIRIN CHLD CHW 81MG
HCR Preventative
ASPIRIN LOW CHW 81MG
HCR Preventative
ASPIRIN LOW TAB 81MG EC
HCR Preventative
ASPIRIN-81 CHW 81MG
HCR Preventative
ASPIR-LOW TAB 81MG EC
HCR Preventative
ASPIRTAB
HCR Preventative
TAB 324MG EC
BAYER ASA TAB 325MG
HCR Preventative
BL ASPIRIN TAB 300MG
HCR Preventative
BL ASPIRIN TAB 325MG
HCR Preventative
BL ASPIRIN TAB 325MG EC
HCR Preventative
Page 189 of 279
X
Supply Limit
Step Therapy X
Specialty
Therapeutic Class Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name CAMBIA POW 50MG
Tier Value Tier 4
Prior Authorization
Supply Limit X
Step Therapy X
CELEBREX
CAP 100MG
Tier 4
X
X
CELEBREX
CAP 200MG
Tier 4
X
X
CELEBREX
CAP 400MG
Tier 4
X
X
CELEBREX
CAP 50MG
Tier 4
X
X
CELECOXIB CAP 100MG
Tier 1
X
CELECOXIB CAP 200MG
Tier 1
X
CELECOXIB CAP 400MG
Tier 1
X
CELECOXIB CAP 50MG
Tier 1
X
CHILD ASA CHW 81MG
HCR Preventative
CHILD ASA LS CHW 81MG
HCR Preventative
CHO MAG TRIS LIQ 500/5ML
Tier 1
CHO MAG TRIS TAB 1000MG
Tier 1
CVS ASPIRIN TAB 325MG
HCR Preventative
CVS ASPIRIN TAB 325MG EC
HCR Preventative
CVS ASPIRIN TAB 81MG EC
HCR Preventative
CVS CHLD ASA CHW 81MG
HCR Preventative
DAYPRO
TAB 600MG
Tier 4
DICLO/MISOPR TAB 50-0.2MG
Tier 1
DICLO/MISOPR TAB 75-0.2MG
Tier 1
DICLOFEN POT TAB 50MG
Tier 1
DICLOFENAC GEL 1%
Tier 4
X
DICLOFENAC SOL 1.5%
Tier 1
X
DICLOFENAC TAB 100MG ER
Tier 1
DICLOFENAC TAB 25MG DR
Tier 1
DICLOFENAC TAB 50MG DR
Tier 1
DICLOFENAC TAB 75MG DR
Tier 1
DIFLUNISAL TAB 500MG
Tier 1
DISALCID
Tier 4
TAB 500MG
Page 190 of 279
X
Specialty
Therapeutic Class Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name DISALCID TAB 750MG DURAXIN
Tier Value Tier 4
CAP
Tier 1
EC-NAPROSYN TAB 375MG
Tier 3
EC-NAPROSYN TAB 500MG
Tier 4
ECOTRIN
TAB 325MG EC
HCR Preventative
ECOTRIN LOW TAB 81MG EC
HCR Preventative
ECPIRIN
TAB 325MG EC
HCR Preventative
ED-FLEX
CAP
Tier 1
EQ ASPIRIN TAB 325MG
HCR Preventative
EQ ASPIRIN TAB 325MG EC
HCR Preventative
EQ CHILD ASA CHW 81MG
HCR Preventative
EQL ASPIRIN TAB 325MG
HCR Preventative
EQL ASPIRIN TAB 325MG EC
HCR Preventative
EQL ASPIRIN TAB 81MG EC
HCR Preventative
EQL CHLD ASA CHW 81MG
HCR Preventative
ETODOLAC
CAP 200MG
Tier 1
ETODOLAC
CAP 300MG
Tier 1
ETODOLAC
TAB 400MG
Tier 1
ETODOLAC
TAB 500MG
Tier 1
ETODOLAC ER TAB 400MG
Tier 1
ETODOLAC ER TAB 500MG
Tier 1
ETODOLAC ER TAB 600MG
Tier 1
FELDENE
CAP 10MG
Tier 4
FELDENE
CAP 20MG
Tier 4
FENOPROFEN CAP 200MG
Tier 1
FENOPROFEN CAP 400MG
Tier 1
FENOPROFEN TAB 600MG
Tier 1
FENORTHO
CAP 200MG
Tier 1
FENORTHO
CAP 400MG
Tier 1
Page 191 of 279
Prior Authorization
Supply Limit
Step Therapy X
Specialty
Therapeutic Class Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name FLECTOR DIS 1.3%
Tier Value Tier 4
FLURBIPROFEN POW
Tier 3
FLURBIPROFEN TAB 100MG
Tier 1
FLURBIPROFEN TAB 50MG
Tier 1
GNP ASPIRIN CHW 81MG
HCR Preventative
GNP ASPIRIN TAB 325MG
HCR Preventative
GNP ASPIRIN TAB 325MG EC
HCR Preventative
GNP ASPIRIN TAB 81MG EC
HCR Preventative
GNP ASPIRIN TAB LT.COAT
HCR Preventative
HM ASPIRIN CHW 81MG
HCR Preventative
HM ASPIRIN TAB 325MG
HCR Preventative
Prior Authorization
X
IBUPROFEN CRE 10%
Tier 1
IBUPROFEN KIT COMFORT
Tier 3
IBUPROFEN POW
Tier 3
IBUPROFEN TAB 400MG
Tier 1
IBUPROFEN TAB 600MG
Tier 1
IBUPROFEN TAB 800MG
Tier 1
INDOCIN
SUP 50MG
Tier 3
INDOCIN
SUS 25MG/5ML
Tier 3
INDOMETHACIN CAP 25MG
Tier 1
INDOMETHACIN CAP 50MG
Tier 1
INDOMETHACIN CAP 75MG ER
Tier 1
KETOPHENE CRE RAPIDPAQ
Tier 3
KETOPROFEN CAP 200MG ER
Tier 1
KETOPROFEN CAP 50MG
Tier 1
KETOPROFEN CAP 75MG
Tier 1
KETOPROFEN CRE 5% KIT
Tier 3
X
KETOPROFEN POW
Tier 3
X
KETOPROFEN POW MICRONIZ
Tier 3
X
Page 192 of 279
X
X
X
Supply Limit
Step Therapy X
Specialty
Therapeutic Class Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name KETOPROFEN POW ULT MICR
Tier Value Tier 3
KETOROLAC TAB 10MG
Tier 1
KLOFENSAID SOL II
Tier 1
KLS ASPIRIN TAB 325MG EC
HCR Preventative
KLS ASPIRIN TAB 81MG EC
HCR Preventative
KP ASPIRIN TAB 81MG EC
HCR Preventative
LEVACET
TAB
Prior Authorization X
Supply Limit
Step Therapy
X
Tier 3
LIDOPROFEN CRE 5-5-2%
Tier 3
LO-DOSE ASA TAB 81MG EC
HCR Preventative
MECLOFEN SOD CAP 100MG
Tier 1
MECLOFEN SOD CAP 50MG
Tier 1
MEFENAM ACID CAP 250MG
Tier 1
MEFENAMIC POW ACID
Tier 3
MELOXICAM KIT COMFORT
Tier 3
MELOXICAM SUS 7.5/5ML
Tier 1
MELOXICAM TAB 15MG
Tier 1
MELOXICAM TAB 7.5MG
Tier 1
X
X
MINIPRIN LOW TAB 81MG EC HCR Preventative MOBIC
SUS 7.5/5ML
Tier 4
MOBIC
TAB 15MG
Tier 4
MOBIC
TAB 7.5MG
Tier 4
NABUMETONE TAB 500MG
Tier 1
NABUMETONE TAB 750MG
Tier 1
NALFON
Tier 3
CAP 400MG
NAPRELAN
TAB 375MG CR
Tier 4
X
NAPRELAN
TAB 500MG CR
Tier 4
X
NAPRELAN
TAB 750MG CR
Tier 4
X
NAPROSYN
SUS 125/5ML
Tier 4
NAPROSYN
TAB 500MG
Tier 4
Page 193 of 279
Specialty
Therapeutic Class Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name NAPROXEN CRE
Tier Value Tier 3
Prior Authorization X X
NAPROXEN
CRE 10%
Tier 1
NAPROXEN
SUS 125/5ML
Tier 1
NAPROXEN
TAB 250MG
Tier 1
NAPROXEN
TAB 375MG
Tier 1
NAPROXEN
TAB 500MG
Tier 1
Supply Limit
Step Therapy
NAPROXEN DR TAB 375MG
Tier 1
NAPROXEN DR TAB 500MG
Tier 1
NAPROXEN SOD TAB 275MG
Tier 1
NAPROXEN SOD TAB 375MG
Tier 1
X
NAPROXEN SOD TAB 375MG CR NAPROXEN SOD TAB 500MG CR NAPROXEN SOD TAB 550MG
Tier 1
X
Tier 1
X
OXAPROZIN TAB 600MG
Tier 1
OXYCOD/IBU TAB 5-400MG
Tier 1
PENNSAID
SOL 1.5%
Tier 4
X
PENNSAID
SOL 2%
Tier 4
X
Tier 1
PIROXICAM CAP 10MG
Tier 1
PIROXICAM CAP 20MG
Tier 1
PIROXICAM POW
Tier 3
PONSTEL
Tier 4
CAP 250MG
PX ASPIRIN TAB 325MG
HCR Preventative
PX ASPIRIN TAB 325MG EC
HCR Preventative
QC ASPIRIN TAB 325MG
HCR Preventative
QC ASPIRIN TAB 325MG EC
HCR Preventative
QC CHILD ASA CHW 81MG
HCR Preventative
RA ASPIRIN CHW 81MG
HCR Preventative
RA ASPIRIN TAB 325MG
HCR Preventative
RA ASPIRIN TAB 325MG EC
HCR Preventative
Page 194 of 279
X
Specialty
Therapeutic Class Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name RA ASPIRIN TAB 81MG EC
Prior Authorization Tier Value HCR Preventative
RA CHILD ASA CHW 81MG
HCR Preventative
SALSALATE TAB 500MG
Tier 1
SALSALATE TAB 750MG
Tier 1
SM ASPIRIN CHW 81MG
HCR Preventative
SM ASPIRIN TAB 325MG
HCR Preventative
SM ASPIRIN TAB 325MG EC
HCR Preventative
SM ASPIRIN TAB 81MG EC
HCR Preventative
SM CHILD ASA CHW 81MG
HCR Preventative
SPRIX
SPR 15.75MG
Supply Limit
Step Therapy
Tier 3
ST JOSEPH CHW LOW 81MG HCR Preventative ST JOSEPH AS CHW 81MG
HCR Preventative
SULINDAC
TAB 150MG
Tier 1
SULINDAC
TAB 200MG
Tier 1
TGT ASPIRIN CHW 81MG
HCR Preventative
TGT ASPIRIN CHW CHILD
HCR Preventative
TGT ASPIRIN TAB 325MG
HCR Preventative
TGT ASPIRIN TAB 81MG
HCR Preventative
TGT ASPIRIN TAB 81MG EC
HCR Preventative
TIVORBEX
CAP 20MG
Tier 4
X
TIVORBEX
CAP 40MG
Tier 4
X
TOLMETIN SOD CAP 400MG
Tier 1
TOLMETIN SOD TAB 200MG
Tier 1
TOLMETIN SOD TAB 600MG
Tier 1
TREXIMET
TAB 85-500MG
Tier 4
VIVLODEX
CAP 10MG
VIVLODEX VOLTAREN
X
X
Tier 4
X
X
CAP 5MG
Tier 4
X
X
GEL 1%
Tier 1
VOLTAREN-XR TAB 100MG
Page 195 of 279
Tier 4
X
Specialty
Tier Value Tier 3
Prior Authorization X
Tier 3
X
Therapeutic Class Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Not Specified
Product Name VOPAC CRE 10-2%
2-DEOXY-D POW -GLUCOSE
Tier 3
Not Specified Not Specified
5-METHYLTETR POW 5-METHYLTETR POW CALCIUM
Tier 3 Tier 3
X X
Not Specified Not Specified
A.A.G.C KIT CRE TERODERM ACIDO LACTOB POW 10BU/GM
Tier 3 Tier 3
X X
Not Specified
ACIDO LACTOB POW 1BU/GM
Tier 3
X
Not Specified
ACIDOPHILUS POW LACTOBAC
Tier 3
X
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
ACTIVE-PREP CRE KIT I ACTIVE-PREP CRE KIT II ACTIVE-PREP CRE KIT IV ACTIVE-PREP CRE KIT V ADAPTADERM GEL ADDYI TAB 100MG ADEMETIONINE POW DISULFAT ADENOSINE POW ADYNOVATE INJ 1000UNIT ADYNOVATE INJ 2000UNIT ADYNOVATE INJ 250UNIT ADYNOVATE INJ 500UNIT ADZENYS XR TAB 12.5MG ADZENYS XR TAB 15.7 MG ADZENYS XR TAB 18.8MG ADZENYS XR TAB 3.1MG ADZENYS XR TAB 6.3MG ADZENYS XR TAB 9.4MG AFSTYLA KIT 1000UNIT AFSTYLA KIT 2000UNIT AFSTYLA KIT 250UNIT AFSTYLA KIT 3000UNIT AFSTYLA KIT 500UNIT AIF #3 DRUG CRE PREP KIT AKYNZEO CAP ALASKAN RED POW ALGAE ALECENSA CAP 150MG A-LIPOIC POW ACID ALLO-PAX CRE 5-5% ALOE VERA OIL ALOE VERA POW
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 3
X X X X
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
VOPAC 5
CRE 5%
VOPAC GB
CRE 5-2-5%
Tier 3
X
VOPAC KT
CRE 5-5-2%
Tier 3
X
ZIPSOR
CAP 25MG
Supply Limit
Step Therapy
Tier 4
X
ZORVOLEX
CAP 18MG
Tier 4
X
ZORVOLEX
CAP 35MG
Tier 4
X
Page 196 of 279
Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 3 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
X X
Specialty
X
X
X X X X X X
X X X X X X X X X X X X X X X
X X X X
X X X X X
X X X X X X X X
X
Prior Authorization X X
Therapeutic Class Not Specified Not Specified
Product Name ALOE VERA POW 200:1 ALOE VERA POW FRZE DRD
Tier Value Tier 3 Tier 3
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
ALOE VERA POW LEAF ALPHA LIPOIC POW ACID ALPROLIX INJ 1000UNIT ALPROLIX INJ 2000UNIT ALPROLIX INJ 250UNIT ALPROLIX INJ 3000UNIT ALPROLIX INJ 500UNIT ALPROSTADIL POW AMITRIPTYLIN CRE ANASTROZOLE POW ANHYDROUS GEL BASE APOMORPHINE POW HCL ARANESP INJ 100MCG ARANESP INJ 100MCG ARANESP INJ 10MCG ARANESP INJ 150MCG ARANESP INJ 200MCG ARANESP INJ 200MCG ARANESP INJ 25MCG ARANESP INJ 25MCG ARANESP INJ 300MCG ARANESP INJ 300MCG ARANESP INJ 40MCG ARANESP INJ 40MCG ARANESP INJ 500MCG ARANESP INJ 60MCG ARANESP INJ 60MCG ARNUITY ELPT INH 100MCG ARNUITY ELPT INH 200MCG ASCORBIC ACD GRA ASCORBIC ACD POW ASCORBIC ACD POW CASSAVE
Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
ASCORBIC ACD POW FINE ATROHIST LA TAB CR ATROHIST SR CAP SPRINKLE AURYXIA TAB 210MG AVIPTADIL POW ACETATE BASE FOR GEL SALTS BASE FOR GEL WOUNDS BEE POLLEN CAP 580MG BELSOMRA TAB 10MG BELSOMRA TAB 15MG BELSOMRA TAB 20MG BELSOMRA TAB 5MG BETA GLUCAN POW BETAMETH ACE POW BETAMETH ACE POW MICRONIZ BETAMETHASON POW SOD PHOS BEVESPI AER BHT POW BIEST/PROGES CRE BL DECONGEST TAB CR
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3
X
X X X
Tier 3
X
Not Specified Not Specified Not Specified Not Specified Not Specified
Page 197 of 279
Tier 4 Tier 3 Tier 3 Tier 1
Supply Limit
Step Therapy
Specialty
X X X X X X X
X X X
X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X
X
X X X X
X X X X
X X X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Product Name BORAGE CAP BRIVIACT INJ 50MG/5ML BRIVIACT SOL 10MG/ML BRIVIACT TAB 100MG BRIVIACT TAB 10MG BRIVIACT TAB 25MG BRIVIACT TAB 50MG BRIVIACT TAB 75MG BROMFENAC POW SOD 98+%
Not Specified Not Specified Not Specified Not Specified Not Specified
BUPRENORPHIN POW HCL BYVALSON TAB 5-80MG CALCIUM POW FOLINATE CALCIUM AA GRA CHELATE CAPSAICIN POW PALMITAT
Tier 3 Tier 4 Tier 3 Tier 3 Tier 3
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
CARBIN/PSE/ SYP DM CENOVIA CRE CERDELGA CAP 84MG CHEMSIL K-51 GEL CHLOROFORM SOL CHOLBAM CAP 250MG CHOLBAM CAP 50MG CHOLESTYRAMI POW CHOLESTYRAMI POW RESIN CHRYSIN POW CLARYS CRE CLINDAP-T CRE CLINOIN CRE CLODAN KIT 0.05% CLOMIPRAMINE POW HCL CLOVAGEL GEL COAGADEX INJ 250UNIT COAGADEX INJ 500UNIT COENZYME Q10 POW COLLIGINIX MIS CONGESTANT TAB CORLANOR TAB 5MG CORLANOR TAB 7.5MG COSENTYX INJ 150MG/ML COSENTYX PEN INJ 150MG/ML
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 1 Tier 3 Tier 3 Tier 4 Tier 4
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
COTELLIC TAB 20MG CRESEMBA CAP 186 MG CUST LIPOTHN GEL 110 CUST LIPOTHN GEL 133 CYCLACILLIN TAB 500MG CYCLOBENZAPR POW CYCLOBENZAPR POW HCL CYCLOPHOSPHA POW CYCLOSERINE POW CYCLOSPORINE POW CYCLOSPORINE POW A DAKLINZA TAB 30MG DAKLINZA TAB 60MG DAKLINZA TAB 90MG DEHYDROEPIAN POW MICRO
Tier 4 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 4 Tier 3 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
Page 198 of 279
Tier Value Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3
Prior Authorization
Supply Limit
Step Therapy
Specialty
X X X X X X X X X X X X
X X X X X X X X X X X
X
X X
X X
X X X X X
X X X X
X X X X
X
X
X X
X X X
X X X X
X X X X
X X
X X X
X X X X X
Therapeutic Class Not Specified Not Specified
Tier Value Tier 3 Tier 3
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Product Name DERMACINRX PAK DERMACINRX PAK DUOPATCH DERMACINRX SOL BASE DESCOVY TAB 200/25 DEXAMETHASON POW ACETATE DEXCOM G4 PLATINUM DEXCOM SENSOR DEXCOM TRANSMITTER DEXTROMETH POW DHEA POW DIMERCAPT-1- POW SULF NA
Not Specified Not Specified Not Specified
Not Specified Not Specified Not Specified
Prior Authorization
Tier 3 Tier 4 Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X X X
DIMERCAPTOSU POW ACID DIPENTOCAINE CRE 5-5-2% DL-3-HYDROXY POW ACID NA
Tier 3 Tier 3 Tier 3
X X X
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
DMPS POW DMR ANTIGEN THERAPY DOUBLE PM SOL DURACHOL CAP 1-3775IU DURLAZA CAP 162.5MG D-VITAMIN E POW SUCCINAT
Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 3
X
Not Specified
DYANAVEL XR SUS 2.5MG/ML
Tier 4
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
ELOCTATE INJ 1000UNIT ELOCTATE INJ 1500UNIT ELOCTATE INJ 2000UNIT ELOCTATE INJ 250UNIT ELOCTATE INJ 3000UNIT ELOCTATE INJ 500UNIT ELOCTATE INJ 750UNIT EMVOREN CRE ENBRACE HR CAP ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB 97-103MG EPCLUSA TAB 400-100 EPINEPHR HCL SOL 2% OP EPIVIR HBV SOL 5MG/ML EPIVIR HBV TAB 100MG ESBRIET CAP 267MG ESTRIOL POW ESTRIOL POW MICRONIZ ESTRIOL ULT POW MICRONIZ
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 3 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
ETHOSUXIMIDE POW ETOPOSIDE POW EVEKEO TAB 10MG EVEKEO TAB 5MG EVOTAZ TAB 300-150 EXTARDOL CRE FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FBL KIT CRE 15-4-5%
Tier 3 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3
Page 199 of 279
Supply Limit
Step Therapy
Specialty
X
X X X
X X
X
X
X
X
X X X X X X X X X X X X
X
X X X X X X X
X X X X
X X X X
X
X X X
X X X
X X X X X
X X X
X X X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Prior Product Name Authorization Tier Value FEMCAP MIS 22MM HCR Preventative FLORIVA DRO 0.25MG Tier 3 FLOWTUSS SOL 2.5-200 Tier 4 FLUOROURACIL POW Tier 4 FLUOROURACIL POW USP/NF Tier 4 FLUTICASONE POW PROPIONA FOLET DHA PAK FOLET ONE CAP 38-1-225 FORTIGAN CAP FP CEPA GEL FP DERM GEL FP SILO GEL FREEDOM GEL CEPAPRO FREEDOM GEL SET FREEDOM GEL SILOMAC GABAPENTIN POW GAPEAUM CRE BUDIBAC GENVOYA TAB GINSENG POW AMERICAN
Tier 3
X
Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 1
Not Specified Not Specified Not Specified Not Specified Not Specified
GLUCOCARD 01 TES SENSOR GLUCOCARD 01 TEST STRIPS GLUCOCARD TES VITAL GLYXAMBI TAB 10-5 MG GLYXAMBI TAB 25-5 MG GNP DECONGES TAB ADV.FORM H20 GEL BASE GEL HARVONI TAB 90-400MG HYALUCIL-0.5 CRE HYALUCIL-4 CRE HYALURONATE POW SODIUM
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X
Not Specified
HYALURONIC POW SODIUM
Tier 3
X
Not Specified Not Specified Not Specified
HYALURONIDAS POW HYCOFENIX SOL HYDROCODONE CRY BITARTRA HYDROCODONE POW BITARTRA HYDROPHEN SYP HYDROXYUREA POW IBRANCE CAP 100MG IBRANCE CAP 125MG IBRANCE CAP 75MG IDELVION SOL 1000UNIT IDELVION SOL 2000UNIT IDELVION SOL 250UNIT IDELVION SOL 500UNIT IMPAVIDO CAP 50MG INCRUSE ELPT INH 62.5MCG INNOPRAX-5 CRE K.B.G.L IN CRE TERODERM KERYDIN SOL 5% KETAMINE HCL POW
Tier 3 Tier 4 Tier 3
X
Tier 3
X
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Page 200 of 279
Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 3 Tier 3 Tier 4 Tier 3
Supply Limit
Step Therapy
X
X
Specialty
X X X
X X X
X
X
X X
X X X X X
X X
X
X X X
X
X
X
X X X
X X X X
X X X X X X X X
X X X X X X
X
X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Prior Authorization X X X
Supply Limit
Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3
X X
X
LEUPROLIDE POW ACETATE LEVOMEFOLATE POW GLUCOSAM LIDOCAINE-PR CRE LIDOCAINE-PR CRE LIPODERM HMW GEL PCCA LIPOGEL CR GEL BASE LIPOIC ACID POW L-ISOLEUCINE POW LONSURF TAB 15-6.14 LONSURF TAB 20-8.19 LUBRAJEL NP GEL LYNPARZA CAP 50MG MAGNESIUM POW GLYCINAT
Tier 4 Tier 3
X X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 3 Tier 4 Tier 3
X X
MAGNESIUM AA POW CHELATE MELATONIN POW MELOXICAM POW MEPER/PROMET CAP 5025MG MERCAPTOPURI POW MERCAPTOPURI POW MERCAPTOPURI POW MONOHYDR METHOTREXATE POW METHYL POW FOLATE METHYLCOBALA POW METHYLCOBALA POW PREMIUM MIDAZOLAM POW MINOXIDIL POW MITOMYCIN POW MITOMYCIN C POW MONOBENZONE POW MORCOMINE SYP MOUTH WASH LIQ GP MOUTHWASH LIQ AF MOUTHWASH LIQ OM MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG
Tier 3
X
Tier 3 Tier 3 Tier 3
X X
Product Name KETOPROFEN CRE 10% KETOROLAC GEL 2% KETOROLAC POW TROMETHA KEVEYIS TAB 50MG KUDZU ROOT POW LAMIVUDINE TAB 100MG L-CARNITINE TAB 250MG L-CYSTINE POW LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG LENVIMA CAP 8 MG LEUCOVORIN POW CALCIUM
Tier Value Tier 3 Tier 3 Tier 3
Page 201 of 279
Tier 3 Tier 3 Tier 4 Tier 4 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2
Specialty
X X
X X X X X X
X X X X
X X X X X X
X
X X X X
X X
X X
X
X
X
Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
Step Therapy
X X X
X X
X X X X
X X
X X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Product Name NABUMETONE POW NAMZARIC CAP 14-10MG NAMZARIC CAP 28-10MG NATPARA INJ 100MCG NATPARA INJ 25MCG NATPARA INJ 50MCG NATPARA INJ 75MCG NAZIREX CRE NEO-SYNALAR KIT NEUAC KIT 1.2-5% NICOMIDE TAB NINLARO CAP 2.3MG NINLARO CAP 3MG NINLARO CAP 4MG NITEBITE BAR CHOCFUDG NITEBITE BAR PBUTTER NITROFURANZO OIN 0.2% NORTHERA CAP 100MG NORTHERA CAP 200MG NORTHERA CAP 300MG NOVOCLAIR CRE NP #2 DRUG CRE PREP KIT NUPLAZID TAB 17MG NUVYA CRE OBIZUR INJ 500 UNIT OBREDON SOL 2.5-200 OCALIVA TAB 10MG OCALIVA TAB 5MG OCCLUSADERM GEL PCCA ODEFSEY TAB ODOMZO CAP 200MG OFEV CAP 100MG OFEV CAP 150MG ORKAMBI TAB 200-125 OTOVEL DRO PCP 100 KIT PEDIPAK PAK PEMOLINE POW PENTOXIFYL POW PERGOLIDE POW MESYLATE
Tier Value Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 4 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 1 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 4 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
PETN TAB 80MG PHENYLPROPAN POW HCL PHOSPHATIDYL POW 20% PINE BARK EX POW 95% PLEGRIDY INJ PLEGRIDY INJ PEN PLEGRIDY INJ STARTER PLEGRIDY PEN INJ STARTER POLYSORBATE LIQ 80 POLYSORBATE LIQ 80 POLYSORBATE LIQ 80 POLYSORBATE LIQ 80 POT PHOSPHAT GRA DIBASIC
Tier 1 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3
Not Specified Not Specified Not Specified
PRALUENT PRALUENT PRALUENT
Tier 3 Tier 3 Tier 3
INJ 150MG/ML INJ 150MG/ML INJ 75MG/ML
Page 202 of 279
Prior Authorization X
Supply Limit
Step Therapy
Specialty
X X X X X X X
X X X X
X X X X X X
X X X
X X X
X X X
X X X X X X X
X X X
X X X
X X
X X
X X X X
X X X
X X X
X X X X X X X
X X X X X X
X X X
X X X X X X X
X X X X
X X X X
X X X X
X X X
X X X
X X X
X X X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Product Name PRALUENT INJ 75MG/ML PREGNENOLONE POW PREGNENOLONE POW MICRONIZ PRENA 1 TRUE MIS PRENATE CAP ESSENT PRENATE CAP PIXIE PRENATE TAB ELITE PRENATE DHA CAP PRENATE MINI CAP PRENATE STAR TAB 20-1MG PRESTALIA TAB 14-10MG PRESTALIA TAB 3.5-2.5 PRESTALIA TAB 7-5MG PREZCOBIX TAB 800-150 PROMETHAZINE CRY HCL PROMETHAZINE POW HCL PROSTAGLAND POW E1 PROVIDA DHA CAP RA BEE POLLE CHW 500MG REGENECARE GEL REMAXAZON PAD REPATHA INJ 140MG/ML REPATHA PUSH INJ 420/3.5 REPATHA SURE INJ 140MG/ML
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
RESTORA RX CAP 60-1.25 RESVERATROL POW RESVERATROL POW +98% RESVERATROL POW 98% RETINALDEHYD POW REXULTI TAB 0.25MG REXULTI TAB 0.5MG REXULTI TAB 1MG REXULTI TAB 2MG REXULTI TAB 3MG REXULTI TAB 4MG RIBAVIRIN POW RUCONEST INJ 2100UNIT SAVAYSA TAB 15MG SAVAYSA TAB 30MG SAVAYSA TAB 60MG SEEBRI NEOHA CAP 15.6MCG
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2
Not Specified Not Specified
SERAQUA LIQ SERMORELIN POW ACETATE
Tier 3 Tier 3
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
SEROTONIN POW HCL SILOMAC GEL ULTRA SIMPLGEL 30 GEL SIROLIMUS POW SODIUM BUTYR POW SOLU-K GEL SOLUPAK PAK SOOLANTRA CRE 1% SPIRA-WASH GEL BASE STIOLTO AER 2.5-2.5 STRENSIQ INJ 18/0.45
Tier 3 Tier 3 Tier 3 Tier 4 Tier 3 Tier 3 Tier 3 Tier 4 Tier 3 Tier 4 Tier 3
Page 203 of 279
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4
Prior Authorization X X X
Supply Limit X
Step Therapy X
X X X
X X X
Specialty X
X X X X
X X X
X X
X X X
X X X X X X
X X X X X X
X X X
X X X X
X
X X
X X X X X
X X
X X
X
X X
X X
X X
X X
Prior Authorization X X X X X X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Product Name STRENSIQ INJ 28/0.7ML STRENSIQ INJ 40MG/ML STRENSIQ INJ 80/0.8ML SUCCIMER DMS POW SULFADIMETHO POW SUPRACIL CRE SYNJARDY TAB SYNJARDY TAB 12.5-500 SYNJARDY TAB 5-1000MG SYNJARDY TAB 5-500MG TABRADOL SUS 1MG/ML TABRADOL SUS RAPIDPAQ
Not Specified Not Specified
TACROLIMUS POW TACROLIMUS POW MONOHYD TAGRISSO TAB 40MG TAGRISSO TAB 80MG TALTZ INJ 80MG/ML TALTZ INJ 80MG/ML TAMOXIFEN POW CITRATE TDM SOLUTION SOL TECHNIVIE TAB TESTOSTERONE CRY YAM TESTOSTERONE POW TESTOSTERONE POW CYPIONAT TESTOSTERONE POW ENANTHAT TESTOSTERONE POW SOY TETRAMEX SPR 2-1-3% THERATEARS CAP NUTR THIOGUANINE POW THIOTEPA POW TIZANIDINE POW HCL TOCOPHEROL LIQ ALPHA TOCOPHEROLS POW 30% TOCOPHERYL POW SUCCINAT
Tier 4 Tier 4
TOMMY GEL GEL TOXICOL SALV KIT COLLECT TRAMADOL HCL POW TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT TRETTEN INJ TRIAMCINOLON POW TRIAMCINOLON POW DIACETAT TRIAMCINOLON POW HEXACETO TRICARE PAK PRENATAL TRIDERMA CRE FORTE TRIFERIC SOL TRIPLE PMB SOL TRIPLE PMK SOL TRISEON CRE TRIUMEQ TAB TRULICITY INJ 0.75/0.5
Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3
X X
Tier 3
X
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Page 204 of 279
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 3 Tier 4 Tier 3 Tier 3 Tier 3
Supply Limit X X X
Step Therapy
Specialty X X X
X X X X X X X X X X X X X
X X X X
X X
X
X X X X
X
Tier 3 Tier 3 Tier 4 Tier 3 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 4
X X X X X X
X X X X
X X X X X X
X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Product Name TRULICITY INJ 1.5/0.5 TUZISTRA XR SUS TYBOST TAB 150MG UBIDECARENON POW UCERIS AER 2MG/ACT UPTRAVI TAB 1000MCG UPTRAVI TAB 1200MCG UPTRAVI TAB 1400MCG UPTRAVI TAB 1600MCG UPTRAVI TAB 200/800 UPTRAVI TAB 200MCG UPTRAVI TAB 400MCG UPTRAVI TAB 600MCG UPTRAVI TAB 800MCG UREA POW UTIBRON CAP NEOHALER VALIDERM CRE VANACHOL CAP VARUBI TAB 90MG VELTASSA POW 16.8GM VELTASSA POW 25.2GM VELTASSA POW 8.4GM VENCLEXTA TAB 100MG VENCLEXTA TAB 10MG VENCLEXTA TAB 50MG VENCLEXTA TAB START PK VERRUNEX CRE VERSAPRO GEL VIBERZI TAB 100MG VIBERZI TAB 75MG VIEKIRA PAK TAB VIEKIRA XR TAB VISTOGARD PAK 10GM VITAFOL CHW GUMMIES VITAFOL FE+ CAP VITAMIN E LIQ VITAMIN E POW SUCCINAT
Tier Value Tier 4 Tier 4 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 2 Tier 3 Tier 3 Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
VITAMIN K2 POW 0.2% VITATRUE MIS VITEKTA TAB 150MG VITEKTA TAB 85MG VONVENDI INJ 1300UNIT VONVENDI INJ 650UNIT VRAYLAR CAP 1.5-3MG VRAYLAR CAP 1.5MG VRAYLAR CAP 3MG VRAYLAR CAP 4.5MG VRAYLAR CAP 6MG WOUND WASH GEL BASE XIGDUO XR TAB 10-1000 XIGDUO XR TAB 10-500MG XIGDUO XR TAB 5-1000MG XIGDUO XR TAB 5-500MG XIIDRA DRO 5% XTAMPZA ER CAP 13.5MG XTAMPZA ER CAP 18MG XTAMPZA ER CAP 27MG
Tier 3 Tier 3 Tier 2 Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4
Page 205 of 279
Prior Authorization X
Supply Limit X X
Step Therapy
Specialty
X X
X X X X X X X X X X X
X X X X X X X X X
X X X X X X X X X
X X
X X X X X X X X X X
X X X X X X X
X X X
X
X X X
X X
X X X X
X
X
X X X X X
X X X X X X X X X X
X X X X
X X X X X X X X X X X X X X X
Therapeutic Class Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Agents, Other - Miscellaneous Eye Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs
Product Name XTAMPZA ER CAP 36MG XTAMPZA ER CAP 9MG XURIDEN POW 2GM ZARXIO INJ 300/0.5 ZARXIO INJ 480/0.8 ZEPATIER TAB 50-100MG ZINBRYTA INJ 150MG/ML ZOLATE CAP ZYVODOL CRE ALCAINE SOL 0.5% OP
Tier Value Tier 4 Tier 4 Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3
ATROPINE SUL OIN 1% OP
Tier 1
ATROPINE SUL SOL 1% OP
Tier 1
CYSTARAN
Tier 3
SOL 0.44%
ISO ATROPINE SOL 1% OP
Tier 3
LACRISERT MIS 5MG OP
Tier 2
MYDRAL
SOL 0.5% OP
Tier 1
MYDRAL
SOL 1% OP
Tier 1
MYDRIACYL SOL 1% OP
Tier 3
NAPHAZOLINE SOL 0.1% OP
Tier 1
PARCAINE
Tier 1
SOL 0.5% OP
PROPARACAINE SOL 0.5% OP
Tier 1
RESTASIS
Tier 4
EMU 0.05%
TROPICAMIDE SOL 0.5% OP
Tier 1
TROPICAMIDE SOL 1% OP
Tier 1
ALOCRIL
Tier 3
ALOMIDE
SOL 2% SOL 0.1% OP
Prior Authorization
Supply Limit
X
X
X X
X
Step Therapy X X X X X X
X
X
X
X
X
Tier 3 Tier 1
X
BEPREVE
Tier 4
X
X
X
X
CROMOLYN SOD SOL 4% OP
Tier 1
ELESTAT
Tier 4
EMADINE
DRO 0.05% SOL 0.05% OP
Tier 4
X
EPINASTINE DRO 0.05%
Tier 1
X
LASTACAFT SOL 0.25%
Tier 3
X
Page 206 of 279
X X X X
X
AZELASTINE DRO 0.05% DRO 1.5%
Specialty
X
Therapeutic Class Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs
Product Name OLOPATADINE DRO 0.1%
Tier Value Tier 1
Prior Authorization
Supply Limit X
Step Therapy
OPTIVAR
DRO 0.05%
Tier 4
X
X
PATADAY
SOL 0.2%
Tier 4
X
X
PATANOL
SOL 0.1% OP
Tier 4
X
X
Tier 4
X
X
PAZEO
DRO 0.7%
ACETAZOLAMID CAP 500MG ER ACETAZOLAMID TAB 125MG
Tier 1
ACETAZOLAMID TAB 250MG
Tier 1
ALPHAGAN P SOL 0.1%
Tier 2
X
ALPHAGAN P SOL 0.15%
Tier 4
X
APRACLONIDIN SOL 0.5% OP
Tier 1
AZOPT
Tier 2
SUS 1% OP
BETAGAN
SOL 0.5% OP
Tier 1
X
Tier 4
BETAXOLOL SOL 0.5% OP
Tier 1
BETIMOL
SOL 0.25%
Tier 2
X
BETIMOL
SOL 0.5%
Tier 2
X
BETOPTIC-S SUS 0.25% OP
Tier 3
BRIMONIDINE SOL 0.15%
Tier 1
BRIMONIDINE SOL 0.2% OP
Tier 1
CARTEOLOL SOL 1% OP
Tier 1
COMBIGAN
Tier 2
COSOPT
SOL 0.2/0.5% SOL 22.3-6.8
Tier 4
DIAMOX SEQUE CAP 500MG CR DORZOL/TIMOL SOL 22.3-6.8
Tier 4
DORZOLAMIDE SOL 2% OP
Tier 1
IOPIDINE
SOL 0.5% OP
Tier 4
IOPIDINE
SOL 1% OP
Tier 3
Page 207 of 279
X
Tier 4
COSOPT PF SOL
ISOPTO CARP SOL 1% OP
X
Tier 1
Tier 4
X
X
Specialty
Therapeutic Class Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs Ophthalmic Antiglaucoma Agents - Glaucoma Drugs
Product Name ISOPTO CARP SOL 2% OP
Tier Value Tier 4
ISOPTO CARP SOL 4% OP
Tier 3
ISTALOL
Tier 3
SOL 0.5% OP
LEVOBUNOLOL SOL 0.5% OP
Tier 1
METHAZOLAMID TAB 25MG
Tier 1
METHAZOLAMID TAB 50MG
Tier 1
METIPRANOLOL SOL 0.3% OPH
Tier 1
NEPTAZANE TAB 25MG
Tier 4
NEPTAZANE TAB 50MG
Tier 4
PHOSPHOLINE SOL 0.125%OP
Tier 2
PILOCARPINE SOL 1% OP
Tier 1
PILOCARPINE SOL 2% OP
Tier 1
PILOCARPINE SOL 4% OP
Tier 1
SIMBRINZA SUS 1-0.2%
Tier 4
TIMOLOL GEL SOL 0.25% OP
Tier 1
TIMOLOL GEL SOL 0.5% OP
Tier 1
TIMOLOL MAL SOL 0.25% OP
Tier 1
TIMOLOL MAL SOL 0.5% OP
Tier 1
TIMOPTIC
SOL 0.25% OP
Tier 4
TIMOPTIC
SOL 0.5% OP
Tier 4
TIMOPTIC OCU SOL 0.25% OP
Tier 3
TIMOPTIC OCU SOL 0.25% OP
Tier 3
TIMOPTIC OCU SOL 0.25% OP
Tier 2
TIMOPTIC OCU SOL 0.25% OP
Tier 2
TIMOPTIC OCU SOL 0.5% OP
Tier 2
TIMOPTIC-XE SOL 0.25% OP
Tier 4
TIMOPTIC-XE SOL 0.5% OP
Tier 4
TRUSOPT
Tier 4
SOL 2% OP
Page 208 of 279
Prior Authorization
Supply Limit
Step Therapy
X
X
Specialty
Prior Authorization
Supply Limit
Step Therapy
Tier 4
X
X
Tier 4
X
Therapeutic Class Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
Product Name ACULAR SOL 0.5% OP
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
ACULAR LS SOL 0.4%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
ACUVAIL
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
ALREX
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
BLEPHAMIDE OIN S.O.P.
Tier 2
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
BLEPHAMIDE SUS OP
Tier 3
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
BROMFENAC SOL 0.09% OP
Tier 1
X
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
BROMFENAC SOL 0.09% OP
Tier 1
X
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
DEXAMETH PHO SOL 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
DICLOFENAC SOL 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
DUREZOL
EMU 0.05%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
FLAREX
SUS 0.1% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
FLUOROMETHOL SUS 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
FLURBIPROFEN SOL 0.03% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
FML
Tier 2
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
FML FORTE SUS 0.25% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
FML LIQUIFLM SUS 0.1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
ILEVRO
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
KETOROLAC SOL 0.4%
SOL 0.45%
SUS 0.2%
OIN 0.1% OP
DRO 0.3% OP
Page 209 of 279
Tier Value Tier 4
Tier 1
X
X
Specialty
Therapeutic Class Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
Product Name KETOROLAC SOL 0.5%
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
LOTEMAX
GEL 0.5%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
LOTEMAX
OIN 0.5%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
LOTEMAX
SUS 0.5%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
MAXIDEX
SUS 0.1% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
MAXITROL
OIN 0.1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
MAXITROL
SUS 0.1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
NEO/POLY/BAC OIN /HC 1%OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
NEO/POLY/DEX OIN 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
NEO/POLY/DEX SUS 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
NEO-POLYCIN OIN HC 1%OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
NEVANAC
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
OCUFEN
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
SUS 0.1%
Tier Value Tier 1
SOL 0.03% OP
Tier 3
OMNIPRED
SUS 1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
POLY-DEX
OIN 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
PRED FORTE SUS 1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
PRED MILD SUS 0.12% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
PRED SOD PHO SOL 1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
PRED-G
Tier 3
SUS OP
Page 210 of 279
Prior Authorization
Supply Limit
Step Therapy
X
X
X
Specialty
Supply Limit
Step Therapy
X
X
X
X
X
X
Tier 3
X
X
TRAVATAN Z DRO 0.004%
Tier 2
X
TRAVOPROST DRO 0.004%
Tier 1
XALATAN
SOL 0.005%
Tier 4
ZIOPTAN
DRO 0.0015%
Tier 3
EMBEDA EMBEDA EMBEDA EMBEDA EMBEDA EMBEDA OPIUM AVINZA
CAP 100-4MG CAP 20-0.8MG CAP 30-1.2MG CAP 50-2MG CAP 60-2.4MG CAP 80-3.2MG TIN 1% CAP 120MG
Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 4
AVINZA
CAP 30MG
Tier 4
Therapeutic Class Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
Product Name PRED-G S.O.P OIN OP
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
PREDNISOLONE SUS 1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
PROLENSA
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
SULF/PRED NA SOL OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
TOBRA/DEXAME SUS 0.3-0.1%
Tier 1
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
TOBRADEX
OIN 0.3-0.1%
Tier 3
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
TOBRADEX
SUS 0.3-0.1%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
TOBRADEX ST SUS 0.3-0.05
Tier 4
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
VEXOL
SUS 1% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
ZYLET
SUS 0.5-0.3%
Tier 3
Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs Opioid Analgesics - Opioid Pain Relievers Opioid Analgesics - Opioid Pain Relievers Opioid Analgesics - Opioid Pain Relievers Opioid Analgesics - Opioid Pain Relievers Opioid Analgesics - Opioid Pain Relievers Opioid Analgesics - Opioid Pain Relievers Opioid Analgesics - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers
BIMATOPROST SOL 0.03%
Tier 1
LATANOPROST SOL 0.005%
Tier 1
LUMIGAN
Tier 2
RESCULA
SOL 0.07%
SOL 0.01% SOL 0.15%
Page 211 of 279
Tier Value Tier 3
Prior Authorization
X
X
X
X X X X X X
X X X X X X
X X X X X X
X
X
X
X
X
X
Specialty
Therapeutic Class Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers
Product Name AVINZA CAP 45MG
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
AVINZA
CAP 60MG
Tier 4
X
X
X
AVINZA
CAP 75MG
Tier 4
X
X
X
AVINZA
CAP 90MG
Tier 4
X
X
X
BUTRANS
DIS 10MCG/HR
Tier 4
X
BUTRANS
DIS 15MCG/HR
Tier 4
X
BUTRANS
DIS 20MCG/HR
Tier 4
X
BUTRANS
DIS 5MCG/HR
Tier 4
X
BUTRANS
DIS 7.5/HR
Tier 4
X
CONZIP
CAP 100MG
Tier 4
X
X
CONZIP
CAP 200MG
Tier 4
X
X
CONZIP
CAP 300MG
Tier 4
X
X
DOLOPHINE TAB 10MG
Tier 3
X
DOLOPHINE TAB 5MG
Tier 3
X
DURAGESIC DIS 100MCG/H
Tier 4
X
X
DURAGESIC DIS 12MCG/HR
Tier 4
X
X
DURAGESIC DIS 25MCG/HR
Tier 4
X
X
DURAGESIC DIS 50MCG/HR
Tier 4
X
X
DURAGESIC DIS 75MCG/HR
Tier 4
X
X
FENTANYL
DIS 100MCG/H
Tier 1
X
FENTANYL
DIS 12MCG/HR
Tier 1
X
FENTANYL
DIS 25MCG/HR
Tier 1
X
FENTANYL
DIS 37.5MCG
Tier 1
X
FENTANYL
DIS 50MCG/HR
Tier 1
X
FENTANYL
DIS 62.5MCG
Tier 1
X
FENTANYL
DIS 75MCG/HR
Tier 1
X
FENTANYL
DIS 87.5MCG
Tier 1
X
X
HYSINGLA ER TAB 100 MG
Tier 4
X
X
X
HYSINGLA ER TAB 120 MG
Tier 4
X
X
X
Page 212 of 279
X
X
Specialty
Therapeutic Class Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers
Product Name HYSINGLA ER TAB 20 MG
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
HYSINGLA ER TAB 30 MG
Tier 4
X
X
X
HYSINGLA ER TAB 40 MG
Tier 4
X
X
X
HYSINGLA ER TAB 60 MG
Tier 4
X
X
X
HYSINGLA ER TAB 80 MG
Tier 4
X
X
X
KADIAN
CAP 100MG ER
Tier 4
X
X
X
KADIAN
CAP 10MG ER
Tier 4
X
X
X
KADIAN
CAP 200MG ER
Tier 4
X
X
X
KADIAN
CAP 20MG ER
Tier 4
X
X
X
KADIAN
CAP 30MG ER
Tier 4
X
X
X
KADIAN
CAP 40MG ER
Tier 4
X
X
X
KADIAN
CAP 50MG ER
Tier 4
X
X
X
KADIAN
CAP 60MG ER
Tier 4
X
X
X
KADIAN
CAP 80MG ER
Tier 4
X
X
X
LEVORPHANOL TAB 2MG
Tier 1
METHADONE CON 10MG/ML
Tier 1
METHADONE POW
Tier 3
METHADONE SOL 10MG/5ML METHADONE SOL 5MG/5ML
Tier 1
X
Tier 1
X
METHADONE TAB 10MG
Tier 1
X
METHADONE TAB 40MG
Tier 1
X
METHADONE TAB 5MG
Tier 1
X
METHADOSE CON 10MG/ML
Tier 1
X
METHADOSE TAB 40MG
Tier 1
X
METHADOSE SF CON 10MG/ML MORPHINE POW SULFATE
Tier 1
X
Tier 3
X
MORPHINE SUL CAP 100MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 10MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 120MG ER
Tier 1
X
X
X
Page 213 of 279
X X
Specialty
Therapeutic Class Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers
Product Name MORPHINE SUL CAP 20MG ER
Tier Value Tier 1
Prior Authorization X
Supply Limit X
Step Therapy X
MORPHINE SUL CAP 30MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 30MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 45MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 50MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 60MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 60MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 75MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 80MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 90MG ER
Tier 1
X
X
X
MORPHINE SUL SOL 100/5ML
Tier 1
MORPHINE SUL SOL 10MG/5ML MORPHINE SUL SOL 20MG/5ML MORPHINE SUL SUP 10MG
Tier 1
MORPHINE SUL SUP 20MG
Tier 1
MORPHINE SUL SUP 30MG
Tier 1
MORPHINE SUL SUP 5MG
Tier 1
MORPHINE SUL TAB 100MG ER
Tier 1
MORPHINE SUL TAB 15MG
Tier 1
MORPHINE SUL TAB 15MG ER
Tier 1
X
MORPHINE SUL TAB 200MG ER
Tier 1
X
MORPHINE SUL TAB 30MG
Tier 1
MORPHINE SUL TAB 30MG ER
Tier 1
X
MORPHINE SUL TAB 60MG ER
Tier 1
X
MS CONTIN TAB 100MG CR
Tier 3
X
X
X
MS CONTIN TAB 15MG CR
Tier 3
X
X
X
MS CONTIN TAB 200MG CR
Tier 3
X
X
X
MS CONTIN TAB 30MG CR
Tier 3
X
X
X
MS CONTIN TAB 60MG CR
Tier 3
X
X
X
Page 214 of 279
Tier 1 Tier 3
X
Specialty
Therapeutic Class Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers
Product Name NUCYNTA TAB 100MG
Tier Value Tier 4
Prior Authorization
Supply Limit X
NUCYNTA
TAB 50MG
Tier 4
X
NUCYNTA
TAB 75MG
Tier 4
X
NUCYNTA ER TAB 100MG
Tier 3
X
X
NUCYNTA ER TAB 150MG
Tier 3
X
X
NUCYNTA ER TAB 200MG
Tier 3
X
X
NUCYNTA ER TAB 250MG
Tier 3
X
X
NUCYNTA ER TAB 50MG
Tier 3
X
X
OPANA
TAB 10MG
Tier 4
X
OPANA
TAB 5MG
Tier 4
X
Step Therapy
OPANA ER
TAB 10MG
Tier 2
X
X
OPANA ER
TAB 15MG
Tier 2
X
X
OPANA ER
TAB 20MG
Tier 2
X
X
OPANA ER
TAB 30MG
Tier 2
X
X
OPANA ER
TAB 40MG
Tier 2
X
X
OPANA ER
TAB 5MG
Tier 2
X
X
OPANA ER
TAB 7.5MG
Tier 2
X
X
TAB 10MG
Tier 1
X
X
X
TAB 15MG
Tier 1
X
X
X
TAB 20MG
Tier 1
X
X
X
TAB 30MG
Tier 1
X
X
X
TAB 40MG
Tier 1
X
X
X
TAB 5MG ER
Tier 1
X
X
X
OXYMORPHONE TAB 7.5MG ER OXYMORPHONE TAB HCL 10MG OXYMORPHONE TAB HCL 5MG SUBSYS SPR 100MCG
Tier 1
X
X
X
Tier 4
X
X
X
SUBSYS
SPR 1200MCG
Tier 4
X
X
X
SUBSYS
SPR 1600MCG
Tier 4
X
X
X
OXYMORPHONE ER OXYMORPHONE ER OXYMORPHONE ER OXYMORPHONE ER OXYMORPHONE ER OXYMORPHONE
Page 215 of 279
Tier 1
X
Tier 1
X
Specialty
Therapeutic Class Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers
Product Name SUBSYS SPR 200MCG
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
SUBSYS
SPR 400MCG
Tier 4
X
X
X
SUBSYS
SPR 600MCG
Tier 4
X
X
X
SUBSYS
SPR 800MCG
Tier 4
X
X
X
SUS 10MG/ML
Tier 3
X
TRAMADOL HCL CAP 150MG ER TRAMADOL HCL CAP ER 100MG TRAMADOL HCL CAP ER 200MG TRAMADOL HCL CAP ER 300MG TRAMADOL HCL TAB 100MG ER TRAMADOL HCL TAB 100MG ER TRAMADOL HCL TAB 200MG ER TRAMADOL HCL TAB 200MG ER TRAMADOL HCL TAB 300MG ER TRAMADOL HCL TAB 300MG ER TRAMADOL HCL TAB 50MG
Tier 1 Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
ULTRAM
Tier 4
SYNAPRYN
TAB 50MG
X
X
X
Tier 1
ULTRAM ER TAB 100MG
Tier 4
X
ULTRAM ER TAB 200MG
Tier 4
X
ULTRAM ER TAB 300MG
Tier 4
X
ZOHYDRO ER CAP 10MG
Tier 4
X
X
X
ZOHYDRO ER CAP 10MG
Tier 4
X
X
X
ZOHYDRO ER CAP 15MG
Tier 4
X
X
X
ZOHYDRO ER CAP 15MG
Tier 4
X
X
X
ZOHYDRO ER CAP 20MG
Tier 4
X
X
X
ZOHYDRO ER CAP 20MG
Tier 4
X
X
X
ZOHYDRO ER CAP 30MG
Tier 4
X
X
X
ZOHYDRO ER CAP 30MG
Tier 4
X
X
X
ZOHYDRO ER CAP 40MG
Tier 4
X
X
X
Page 216 of 279
Specialty
Therapeutic Class Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Long-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers
Product Name ZOHYDRO ER CAP 40MG
Tier Value Tier 4
Prior Authorization X
Supply Limit X
Step Therapy X
ZOHYDRO ER CAP 50MG
Tier 4
X
X
X
ZOHYDRO ER CAP 50MG
Tier 4
X
X
X
ABSTRAL
SUB 100MCG
Tier 4
X
X
X
ABSTRAL
SUB 200MCG
Tier 4
X
X
X
ABSTRAL
SUB 300MCG
Tier 4
X
X
X
ABSTRAL
SUB 400MCG
Tier 4
X
X
X
ABSTRAL
SUB 600MCG
Tier 4
X
X
X
ABSTRAL
SUB 800MCG
Tier 4
X
X
X
ACTIQ
LOZ 1200MCG
Tier 4
X
X
X
ACTIQ
LOZ 1600MCG
Tier 4
X
X
X
ACTIQ
LOZ 200MCG
Tier 4
X
X
X
ACTIQ
LOZ 400MCG
Tier 4
X
X
X
ACTIQ
LOZ 600MCG
Tier 4
X
X
X
ACTIQ
LOZ 800MCG
Tier 4
X
X
X
APAP/CODEINE SOL 120-12/5
Tier 1
X
APAP/CODEINE TAB 300-15MG
Tier 1
X
APAP/CODEINE TAB 300-30MG
Tier 1
X
APAP/CODEINE TAB 300-60MG
Tier 1
X
APAP-CAFFEIN CAP DIHYDROC
Tier 1
X
ASCOMP/COD CAP 30MG
Tier 1
BUT/ASA/CAF/ CAP COD 30MG
Tier 1
BUTORPHANOL SOL 10MG/ML
Tier 1
X
CAPITAL/COD SUS 120-12/5
Tier 2
X
CARISOPRODOL TAB ASA/COD
Tier 1
CODEINE SULF SOL 30MG/5ML
Tier 1
CODEINE SULF TAB 15MG
Tier 1
CODEINE SULF TAB 30MG
Tier 1
CODEINE SULF TAB 60MG
Tier 1
Page 217 of 279
Specialty
Therapeutic Class Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers
Product Name DEMEROL TAB 100MG DEMEROL
TAB 50MG
Tier Value Tier 4
Prior Authorization
Supply Limit
Tier 4
DIHYDROCOD/ CAP ASA/CAFF
Tier 1
DILAUDID
LIQ 1MG/ML
Tier 4
DILAUDID
TAB 2MG
Tier 4
DILAUDID
TAB 4MG
Tier 4
DILAUDID
TAB 8MG
Tier 4
ENDOCET
TAB 10-325MG
Tier 1
X
ENDOCET
TAB 2.5-325
Tier 1
X
ENDOCET
TAB 5-325MG
Tier 1
X
ENDOCET
TAB 7.5-325
Tier 1
X
ENDODAN
TAB
Step Therapy
Tier 1
EXALGO
TAB 12MG
Tier 4
X
X
X
EXALGO
TAB 16MG
Tier 4
X
X
X
EXALGO
TAB 32MG
Tier 4
X
X
X
EXALGO
TAB 8MG
Tier 4
X
X
X
Tier 3
X
FENTANYL OT LOZ 1200MCG
Tier 1
X
X
FENTANYL OT LOZ 1600MCG
Tier 1
X
X
FENTANYL OT LOZ 200MCG
Tier 1
X
X
FENTANYL OT LOZ 400MCG
Tier 1
X
X
FENTANYL OT LOZ 600MCG
Tier 1
X
X
FENTANYL OT LOZ 800MCG
Tier 1
X
X
FENTORA
TAB 100MCG
Tier 3
X
X
X
FENTORA
TAB 200MCG
Tier 3
X
X
X
FENTORA
TAB 400MCG
Tier 3
X
X
X
FENTORA
TAB 600MCG
Tier 3
X
X
X
FENTORA
TAB 800MCG
Tier 3
X
X
X
FIORINAL/COD CAP 30MG
Tier 4
FENTANYL
POW CITRATE
Page 218 of 279
Specialty
Therapeutic Class Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers
Product Name HYCET SOL 7.5-325
Tier Value Tier 4
Prior Authorization
Supply Limit X
Step Therapy
HYDROCO/APAP SOL 7.5-325
Tier 1
X
HYDROCO/APAP TAB 10300MG HYDROCO/APAP TAB 10325MG HYDROCO/APAP TAB 2.5-325
Tier 1
X
Tier 1
X
HYDROCO/APAP TAB 5-300MG
Tier 1
X
HYDROCO/APAP TAB 5-325MG
Tier 1
X
HYDROCO/APAP TAB 7.5-300
Tier 1
X
HYDROCO/APAP TAB 7.5-325
Tier 1
X
HYDROCOD/IBU TAB 10200MG HYDROCOD/IBU TAB 2.5-200
Tier 1
HYDROCOD/IBU TAB 5-200MG
Tier 1
HYDROCOD/IBU TAB 7.5-200
Tier 1
HYDROCODONE SOL 10325MG HYDROMORPHON LIQ 1MG/ML HYDROMORPHON POW HCL
Tier 1
HYDROMORPHON SUP 3MG
Tier 1
HYDROMORPHON TAB 12MG ER HYDROMORPHON TAB 16MG ER HYDROMORPHON TAB 2MG
Tier 1
X
X
X
Tier 1
X
X
X
HYDROMORPHON TAB 32MG ER HYDROMORPHON TAB 4MG
Tier 1
X
X
X
HYDROMORPHON TAB 8MG
Tier 1
HYDROMORPHON TAB 8MG ER IBUDONE TAB 10-200MG
Tier 1
X
X
X
IBUDONE
TAB 5-200MG
Tier 1
LAZANDA
SPR 100MCG
Tier 4
X
X
LAZANDA
SPR 300MCG
Tier 4
X
LAZANDA
SPR 400MCG
Tier 4
X
Page 219 of 279
X
Tier 1 X
X
Tier 1
X
Tier 1 Tier 3
X
Tier 1
Tier 1
Tier 1
X
Specialty
Therapeutic Class Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers
Product Name LORCET TAB 5-325MG
Tier Value Tier 1
Prior Authorization
Supply Limit X
LORCET HD TAB 10-325MG
Tier 1
X
LORCET PLUS TAB 7.5-325
Tier 1
X
LORTAB
ELX 10-300MG
Tier 4
LORTAB
TAB 10-325MG
Tier 1
X
LORTAB
TAB 5-325MG
Tier 1
X
LORTAB
TAB 7.5-325
Tier 1
X
Step Therapy
MEPERIDINE SOL 50MG/5ML
Tier 1
MEPERIDINE TAB 100MG
Tier 1
MEPERIDINE TAB 50MG
Tier 1
NORCO
TAB 10-325MG
Tier 4
X
NORCO
TAB 5-325MG
Tier 4
X
NORCO
TAB 7.5-325
Tier 4
X
OXAYDO
TAB 5MG
Tier 4
X
X
OXAYDO
TAB 7.5MG
Tier 4
X
X
OXYCOD/APAP TAB 10-325MG
Tier 1
X
OXYCOD/APAP TAB 2.5-325
Tier 1
X
OXYCOD/APAP TAB 5-325MG
Tier 1
X
OXYCOD/APAP TAB 7.5-325
Tier 1
X
OXYCOD/ASA TAB
Tier 1
OXYCODONE CAP 5MG
Tier 1
OXYCODONE CON 100/5ML
Tier 1
OXYCODONE CON 20MG/ML
Tier 1
OXYCODONE POW HCL
Tier 3
OXYCODONE SOL 5MG/5ML
Tier 1
OXYCODONE TAB 10MG
Tier 1
OXYCODONE TAB 10MG ER
Tier 4
OXYCODONE TAB 15MG
Tier 1
OXYCODONE TAB 15MG ER
Tier 4
Page 220 of 279
X
X
X
X
X
X
X
Specialty
Therapeutic Class Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers
Product Name OXYCODONE TAB 20MG
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
X
X
X
OXYCODONE TAB 20MG ER
Tier 4
OXYCODONE TAB 30MG
Tier 1
OXYCODONE TAB 30MG ER
Tier 4
X
X
X
OXYCODONE TAB 40MG ER
Tier 4
X
X
X
OXYCODONE TAB 5MG
Tier 1
OXYCODONE TAB 60MG ER
Tier 4
X
X
X
OXYCODONE TAB 80MG ER
Tier 4
X
X
X
OXYCODONE/ SOL APAP
Tier 1
OXYCONTIN TAB 10MG CR
Tier 4
X
X
X
OXYCONTIN TAB 15MG CR
Tier 4
X
X
X
OXYCONTIN TAB 20MG CR
Tier 4
X
X
X
OXYCONTIN TAB 30MG CR
Tier 4
X
X
X
OXYCONTIN TAB 40MG CR
Tier 4
X
X
X
OXYCONTIN TAB 60MG CR
Tier 4
X
X
X
OXYCONTIN TAB 80MG CR
Tier 4
X
X
X
PENTAZ/NALOX TAB 50-0.5MG
Tier 1
PERCOCET
TAB 10-325MG
Tier 4
X
X
PERCOCET
TAB 2.5-325
Tier 4
X
X
PERCOCET
TAB 5-325MG
Tier 4
X
X
PERCOCET
TAB 7.5-325
Tier 4
X
X
PRIMLEV
TAB 10-300MG
Tier 3
X
PRIMLEV
TAB 5-300MG
Tier 3
X
PRIMLEV
TAB 7.5-300
Tier 3
X
X
REPREXAIN TAB 10-200MG
Tier 1
REPREXAIN TAB 5-200MG
Tier 1
ROXICET
SOL 5-325/5
Tier 1
X
ROXICET
TAB 5-325MG
Tier 1
X
ROXICODONE TAB 15MG
Tier 4
Page 221 of 279
Specialty
Therapeutic Class Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants
Prior Authorization
Supply Limit
Step Therapy
Product Name ROXICODONE TAB 30MG
Tier Value Tier 4
ROXICODONE TAB 5MG
Tier 3
SYNALGOS-DC CAP
Tier 4
TRAMADL/APAP TAB 37.5-325
Tier 1
X
TREZIX
Tier 1
X
TYLENOL/COD TAB #3
Tier 4
X
TYLENOL/COD TAB #4
Tier 4
X
ULTRACET
TAB 37.5-325
Tier 4
X
VERDROCET TAB 2.5-325
Tier 1
VICODIN
TAB 5-300MG
Tier 1
X
X
VICODIN ES TAB 7.5-300
Tier 1
X
X
VICODIN HP TAB 10-300MG
Tier 1
X
X
VICOPROFEN TAB 7.5-200
Tier 4
XARTEMIS XR TAB 7.5-325
Tier 4
X
X
XODOL
TAB 10-300MG
Tier 4
X
X
XODOL
TAB 5-300MG
Tier 4
X
X
XODOL
TAB 7.5-300
Tier 4
X
X
XYLON
TAB 10-200MG
Tier 1
CAP
ZAMICET
SOL 10-325MG
Tier 1
X
BELBUCA
MIS 150MCG
Tier 4
X
X
BELBUCA
MIS 300MCG
Tier 4
X
X
BELBUCA
MIS 450MCG
Tier 4
X
X
BELBUCA
MIS 600MCG
Tier 4
X
X
BELBUCA
MIS 750MCG
Tier 4
X
X
BELBUCA
MIS 75MCG
Tier 4
X
X
BELBUCA
MIS 900MCG
Tier 4
X
X
BUNAVAIL
MIS 2.1-0.3
Tier 4
X
X
X
BUNAVAIL
MIS 4.2-0.7
Tier 4
X
X
X
BUNAVAIL
MIS 6.3-1MG
Tier 4
X
X
X
Page 222 of 279
Specialty
Tier Value Tier 1
Prior Authorization X
Supply Limit X
Step Therapy X
BUPREN/NALOX SUB 8-2MG
Tier 1
X
X
X
BUPRENORPHIN SUB 2MG
Tier 1
X
X
BUPRENORPHIN SUB 8MG
Tier 1
X
X
EVZIO
Tier 4
X
X
X
X
X
Therapeutic Class Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Opioid Antagonists Antidotes/Deterrents/Protectants Otic Agents - Ear Drugs
Product Name BUPREN/NALOX SUB 2-0.5MG
ACE ACD/ALUM SOL 2% OTIC
Tier 1
Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs
ACETASOL HC SOL OTIC ACETIC ACID SOL 2% OTIC COLY-MYCIN S SUS OTIC CORTISPORIN SUS -TC OTIC DERMOTIC OIL 0.01% FLUOCIN ACET OIL 0.01% FLUOCIN ACET OIL EAR0.01%
Tier 2 Tier 1 Tier 3 Tier 3 Tier 4 Tier 1 Tier 1
Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs Otic Agents - Ear Drugs Parasympathomimetics - Myasthenia Gravis Drugs Parasympathomimetics - Myasthenia Gravis Drugs Parasympathomimetics - Myasthenia Gravis Drugs Parasympathomimetics - Myasthenia Gravis Drugs
HC/ACET ACID SOL OTIC NEO/POLY/HC SOL 1% OTIC NEO/POLY/HC SUS 1% OTIC NEO/POLY/HC SUS OP PRAMOTIC DRO 1-0.1% GUANIDINE TAB 125MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
MESTINON
SYP 60MG/5ML
Tier 2
MESTINON
TAB 60MG
Tier 4
MESTINON
TAB TIMESPAN
Tier 3
INJ
NALOXONE
INJ 0.4MG/ML
Tier 1
NALOXONE
INJ 1MG/ML
Tier 1
NARCAN
SPR
Tier 4
SUBOXONE
MIS 12-3MG
Tier 4
X
X
X
SUBOXONE
MIS 2-0.5MG
Tier 4
X
X
X
SUBOXONE
MIS 4-1MG
Tier 4
X
X
X
SUBOXONE
MIS 8-2MG
Tier 4
X
X
X
ZUBSOLV
SUB 1.4-0.36
Tier 1
X
X
ZUBSOLV
SUB 11.4-2.9
Tier 1
X
ZUBSOLV
SUB 2.9-0.71
Tier 1
X
ZUBSOLV
SUB 5.7-1.4
Tier 1
X
X
ZUBSOLV
SUB 8.6-2.1
Tier 1
X
X
Page 223 of 279
Specialty
Therapeutic Class Parasympathomimetics - Myasthenia Gravis Drugs Parasympathomimetics - Myasthenia Gravis Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs Pediculicides/Scabicides - Scabies and Lice Drugs PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
Prior Authorization
Supply Limit
Product Name PYRIDOSTIGM TAB 60MG
Tier Value Tier 1
PYRIDOSTIGMI TAB 180MG
Tier 1
ELIMITE
CRE 5%
Tier 4
EURAX
CRE 10%
Tier 2
EURAX
LOT 10%
Tier 3
LINDANE
LOT 1%
Tier 1
X
LINDANE
SHA 1%
Tier 1
X
LYCELLE
GEL
Tier 3
MALATHION LOT 0.5%
Tier 1
NATROBA
Tier 4
OVIDE
SUS 0.9% LOT 0.5%
Tier 1
SKLICE
Tier 4
ULESFIA
LOT 0.5% SUS 0.9%
X
Tier 4
PERMETHRIN CRE 5%
SPINOSAD
Step Therapy
X
Tier 1
LOT 5%
Tier 3 Tier 3 Tier 3 Tier 3
X X X
PHARMACEUTICAL AIDS
1ST BASE CRE ADAPTADERM CRE ADENOSINE-5 POW MONOPHOS ADENOSINE-5 POW TRIPHOSP
Tier 3
X
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
ADVANCED BAS CRE PLUS ALBA-DERM CRE ALMONDERM CRE ALPAWASH OIN ALTADERM CRE BASE APOTHEDERM CRE APOTHESAR CRE TRANSDER
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
APOTHESIL CRE AQUORAL AER ATRAPRO GEL HYDROGEL ATRAPRO CP KIT AUXIPRO CRE EMOLLIEN AUXIPRO CRE VANISHIN AZ CREAM CRE BACOCALMINE LIQ BASE CRE LIPOSOME BASE FOR CRE SCARS BASE W301 CRE B-CREAM CRE BIOPEPTIDE CRE BASE CARBOGEL GEL 940
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
Page 224 of 279
X
X X X
X X X X
Specialty
Therapeutic Class PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
Product Name CARBOHOL GEL 940 CARBOMER GEL AQUEOUS CARBOMER GEL HYDROALC
Tier Value Tier 2 Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
CELA BASE CRE CHERRY SYP CHRYSADERM CRE DAY CHRYSADERM CRE NIGHT COLLODION LIQ FLEXIBLE CONCENTRATE CRE CREAM BASE CRE CUTIS PLUS CRE DELBASE OIN COMPOUND
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
DELIVRA CRE SR DERMA SERUM CRE FREEDOM
Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
DIAB GEL DIAB F.D.G. GEL EMOLIVAN CRE EMOLLIENT CRE EMOLLIENT CRE BASE FAGRON LS CRE PLUS FAGRON LS CRE ULTRA FITALITE CRE BASE FLAVOR BLEND SUS FLAVOR PLUS LIQ FLAVOR SWEET LIQ S/F FLAVOR SWEET SYP FLOW-EZE MIS VENTED FOOD COLOR LIQ BLUE FP DERM CRE FP ENHANCING CRE FP NATURAL CRE FP PLUS CRE FP SUPREME CRE FP ULTRA CRE FREEDOM CRE DERMA-D FREEDOM CRE DERMA-N FREEDOM CRE ULTRAPEN FREEDOM HRT CRE ULTRA HYDROGEL GEL HYDROPHILIC OIN HYDROUS CRE EMULSIFI HYPO NEEDLE MIS 18GX1" LANOLIN OIN LANOLIN ANHY OIN LECITHIN GEL LIPO CREAM CRE BASE LIPOBASE CRE HEAVY LIPOBASE CRE REGULAR LIPOPEN CRE LIPOPEN CRE ANHYDRO LIPOPEN CRE PLUS LIPOPEN CRE ULTRA LIPOZYME CRE LUXAMEND CRE MEDIDERM CRE
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Page 225 of 279
Prior Authorization
X X X X X X X
X
X X X X X X
X X X X X X X X X X X X
X X X X X X X
X
Supply Limit
Step Therapy
Specialty
Prior Authorization X
Therapeutic Class PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
Product Name MICRODERM CRE BASE MUCOLOX LIQ MULTIUSE CRE BASE NATACREAM CRE NATURAL CRE NEEDLES 22G X 1 1/2" NEUTRASAL POW NOURILITE CRE NOURIVAN CRE ANTIOX NOXI-K CRE OCCLUVAN OIN ORA-BLEND SUS ORA-BLEND SF SUS ORAL MIX LIQ SUSPENDI ORAL MIX SF LIQ ORAL SUSPEND LIQ ORAL SYRUP LIQ FLAVORED
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
ORAL SYRUP LIQ SF ORA-PLUS LIQ ORA-SWEET SYP ORA-SWEET SF SYP PCCA ACACIA SYP BASE PCCA ALADERM CRE BASE PCCA BASE CRE 7542 PCCA COBASE OIN #1 PCCA COSMETI CRE HRT BASE
Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
PHARMACEUTICAL AIDS
PCCA CUSTOM CRE LIPO-MAX
Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
PCCA EMOLLIE CRE BASE PCCA LIPODER CRE BASE PCCA LIPODER CRE BASE PCCA LIPODER CRE BASE PCCA LIPODER CRE BASE PCCA LIPOSOM CRE DRY PCCA LIPOSOM CRE NORMAL
Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
PCCA LIPOSOM CRE OILY PCCA LIPOSOM CRE SENSITIV
Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
PCCA MVC CRE BASE PCCA SWEET SYP -SF PCCA SYRUP SYP VEHICLE PCCA VANISH CRE BASE PCCA VANISHI CRE LIGHT PCCA VANPEN CRE BASE PCCA-PLUS SUS PENCREAM CRE PENDERM CRE PENTAPHENE CRE PETROLATUM OIN YELLOW PFCB CRE PHARMABASE CRE ANTIOXID
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
PHARMACEUTICAL AIDS
PHARMABASE CRE COSMETIC
Tier 3
X
PHARMACEUTICAL AIDS
PHARMABASE CRE HEAVY
Tier 3
X
Page 226 of 279
X X X
X X X X
X X X
X X X X X
X X X X X X X X
Supply Limit
Step Therapy
Specialty
Therapeutic Class PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
Product Name PHARMABASE CRE LIGHT PHARMABASE CRE VAGINAL
Tier Value Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
PHYTOBASE CRE PHYTOBASE CRE PHYTOBASE CRE PHYTOBASE CRE PICODERM CRE PLACEBO #00 CAP PLO GEL MEDIFLO PLO MEDIFLO KIT KIT PLO TRANSDER CRE PLO20 BASE GEL PNA-HRT BASE CRE POLYETH GLYC OIN 8000 POLYPEG OIN BASE PRACASIL TM- CRE PLUS PROPYLENE GL SOL P-SILOXAN DS CRE PURIFIED LIQ WATER Q-DERM CRE RADIAGEL GEL RADIAPLEXRX GEL RASPBERRY SYP SAFTY NEEDLE MIS 18GX1" SAFTY NEEDLE MIS 18GX1.5" SAFTY NEEDLE MIS 19GX1" SAFTY NEEDLE MIS 19GX1.5" SAFTY NEEDLE MIS 20GX1" SAFTY NEEDLE MIS 20GX1.5" SAFTY NEEDLE MIS 21GX1" SAFTY NEEDLE MIS 21GX1.5" SAFTY NEEDLE MIS 22GX1" SAFTY NEEDLE MIS 22GX1.5" SAFTY NEEDLE MIS 23GX1" SAFTY NEEDLE MIS 25GX1" SAFTY NEEDLE MIS 25GX5/8"
Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
SALIVAMAX POW SALIVATE RX POW SALT DURABLE CRE SALT STABLE CRE SALT STABLE CRE LS ADV SANARE CRE ADVANCED SANARE SCAR CRE THERAPY
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
SCAR CARE CRE SEDANARE CRE SILOSOME CRE TRANSDER SILPROTEX CRE PLUS SIMPLE SYP SKYY DERM CRE SOLYDRA LIQ STERA BASE CRE SUPREME CRE SUSPENSION SUS VEHICLE SYRPALTA SYP SYRPALTA SYP
Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
Page 227 of 279
Prior Authorization X X X X X X X
X
X X X
X X X X X X X X X X X
Supply Limit
Step Therapy
Specialty
Therapeutic Class PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
Product Name SYRPALTA SYP CLEAR SYRSPEND SF LIQ SYRSPEND SF SUS PH4 SYRUP SYP VEHICLE SYRUP SF SYP VEHICLE TDC MAX CRE TEGADERM AG PAD 2"X2" TEGADERM AG PAD 4"X5" TEGADERM AG PAD 4"X8" TEGADERM AG PAD 8"X8" TERODERM CRE TIGHTENING CRE BASE TRANSDERMAL CRE PAIN BAS
Tier Value Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
TRANS-PEN CRE U-BASE CRE ULTRADERM CRE VANIBASE CRE VANISHING CRE VANISHING CRE BOTANCAL
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
VANISH-PEN CRE VASCUDERM GEL HYDROGEL
Tier 3 Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents Phosphate Binders - Phosphate-Removing Agents
VASCUDERM KIT STASIS VERSAFREE SYP VERSAPLUS SYP VERSAPRO CRE VERSATILE CRE BASE VERSATILE CRE RICH BSE VERSIGEL CRE V-MAX CRE WOUND CARE CRE XCEL 100 CRE XEMATOP CRE BASE ZOE SCRIPTS CRE IDEALBAS FOSRENOL CHW 1000MG
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
FOSRENOL
CHW 500MG
Tier 3
FOSRENOL
CHW 750MG
Tier 3
FOSRENOL
POW 1000MG
Tier 3
FOSRENOL
POW 750MG
Tier 3
RENAGEL
TAB 400MG
Tier 3
RENAGEL
TAB 800MG
Tier 3
RENVELA
PAK 0.8GM
Tier 2
RENVELA
PAK 2.4GM
Tier 2
RENVELA
TAB 800MG
Tier 2
VELPHORO
CHW 500MG
Page 228 of 279
Tier 2
Prior Authorization
X X
X X X X X X
X X X X X X X X X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Platelet Modifying Agents - Platelet Modifying Drugs Progesterone Agonists/Antagonists Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs
Prior Authorization
Supply Limit
Product Name AGGRENOX CAP 25-200MG
Tier Value Tier 3
ASA/DIPYRIDA CAP 25-200MG
Tier 3
CILOSTAZOL TAB 100MG
Tier 1
CILOSTAZOL TAB 50MG
Tier 1
CLOPIDOGREL TAB 300MG
Tier 1
CLOPIDOGREL TAB 75MG
Tier 1
DIPYRIDAMOLE TAB 25MG
Tier 1
DIPYRIDAMOLE TAB 50MG
Tier 1
DIPYRIDAMOLE TAB 75MG
Tier 1
EFFIENT
TAB 10MG
Tier 4
X
EFFIENT
TAB 5MG
Tier 4
X
Step Therapy
PERSANTINE TAB 25MG
Tier 3
PERSANTINE TAB 50MG
Tier 4
PERSANTINE TAB 75MG
Tier 3
PLAVIX
TAB 300MG
Tier 4
X
PLAVIX
TAB 75MG
Tier 4
X
PLETAL
TAB 100MG
Tier 4
PLETAL
TAB 50MG
Tier 4
TICLOPIDINE TAB 250MG
Tier 1
ZONTIVITY TAB 2.08MG
Tier 4
ELLA
TAB 30MG
AFTERA
HCR Preventative
TAB 1.5MG
HCR Preventative
TAB 5MG
Tier 4
CAMILA
TAB 0.35MG
HCR Preventative
CRINONE
GEL 4% VAG
Tier 2
CRINONE
GEL 8% VAG
Tier 2
AYGESTIN
DEBLITANE TAB 0.35MG
X
X X
HCR Preventative
DEPO-PROVERA INJ 150MG/ML DEPO-SQ PROV INJ 104
Page 229 of 279
Tier 4
X
Tier 2
X
Specialty
Therapeutic Class Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs
Product Name ECONTRA EZ TAB 1.5MG
Prior Authorization Tier Value HCR Preventative
ENDOMETRIN SUP 100MG ERRIN
TAB 0.35MG
Tier 3 HCR Preventative
FALLBACK
TAB 1.5MG
HCR Preventative
HEATHER
TAB 0.35MG
HCR Preventative
JENCYCLA
TAB 0.35MG
HCR Preventative
JOLIVETTE TAB 0.35MG
HCR Preventative
LEVONORGESTR TAB 1.5MG
HCR Preventative
LYZA
HCR Preventative
TAB 0.35MG
MEDROXYPR AC INJ 150MG/ML MEDROXYPR AC TAB 10MG
HCR Preventative
MEDROXYPR AC TAB 2.5MG
Tier 1
MEDROXYPR AC TAB 5MG
Tier 1
MEGACE ES SUS 625/5ML
Tier 4
MEGACE ORAL SUS 40MG/ML
Tier 4
MEGESTROL SUS 625MG/5M
Tier 1
MEGESTROL AC SUS 40MG/ML
Tier 1
MEGESTROL AC TAB 20MG
Tier 1
MEGESTROL AC TAB 40MG
Tier 1
Tier 1
MY WAY
TAB 1.5MG
HCR Preventative
NECON
TAB 1/50-28
HCR Preventative
NEXT CHOICE TAB 1.5MG
HCR Preventative
NORA-BE
HCR Preventative
TAB 0.35MG
NORETHIN ACE TAB 5MG
Tier 1
NORETHINDRON TAB 0.35MG HCR Preventative NORINYL NORLYROC
TAB 1+50-28 TAB 0.35MG
Supply Limit
Tier 4 HCR Preventative
NOR-QD
TAB 0.35MG
Tier 4
OPCICON
TAB 1.5MG
HCR Preventative
Page 230 of 279
X
Step Therapy
Specialty
Supply Limit
Step Therapy
Tier 4
X
X
Tier 4
X
X
Therapeutic Class Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Progestins - Hormone Replacement/Modifying Drugs Protectants - Ulcer and Stomach Acid Drugs
Product Name ORTHO MICRON TAB 0.35MG
CARAFATE
SUS 1GM/10ML
Tier 3
Protectants - Ulcer and Stomach Acid Drugs
CARAFATE
TAB 1GM
Tier 4
Protectants - Ulcer and Stomach Acid Drugs
CYTOTEC
TAB 100MCG
Tier 4
Protectants - Ulcer and Stomach Acid Drugs
CYTOTEC
TAB 200MCG
Tier 4
Protectants - Ulcer and Stomach Acid Drugs
MISOPROSTOL TAB 100MCG
Tier 1
Protectants - Ulcer and Stomach Acid Drugs
MISOPROSTOL TAB 200MCG
Tier 1
Protectants - Ulcer and Stomach Acid Drugs
SUCRALFATE TAB 1GM
Tier 1
Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs
ACIPHEX
PLAN B
TAB 1.5MG
Tier Value Tier 3
Prior Authorization
HCR Preventative
PROGESTERONE CAP 100MG
Tier 1
PROGESTERONE CAP 200MG
Tier 1
PROGESTERONE CRE 10% KIT
Tier 3
PROGESTERONE INJ 50MG/ML
Tier 1
PROGESTERONE POW MICRONIZ PROGESTERONE SUP VGS 100
Tier 3 Tier 3
X
PROGESTERONE SUP VGS 200
Tier 3
X
PROGESTERONE SUP VGS 25
Tier 3
X
PROGESTERONE SUP VGS 400
Tier 3
X
PROGESTERONE SUP VGS 50
Tier 3
X
PROMETRIUM CAP 100MG
Tier 4
PROMETRIUM CAP 200MG
Tier 4
PROVERA
TAB 10MG
Tier 4
PROVERA
TAB 2.5MG
Tier 4
PROVERA
TAB 5MG
Tier 4
REACT SHAROBEL
TAB 1.5MG
X
HCR Preventative
TAB 0.35MG
HCR Preventative
TAKE ACTION TAB 1.5MG
HCR Preventative
TAB 20MG
ACIPHEX SPR CAP 10MG
Page 231 of 279
Specialty
Therapeutic Class Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs
Product Name ACIPHEX SPR CAP 5MG
Tier Value Tier 4
Prior Authorization
Supply Limit X
DEXILANT
CAP 30MG DR
Tier 3
X
DEXILANT
CAP 60MG DR
Tier 3
X
Step Therapy X
FIRST-OMEPRA SUS 2MG/ML
Tier 3
X
LANSOPRAZOLE SUS 3MG/ML
Tier 3
X
NEXIUM
GRA 10MG DR
Tier 3
X
X
X
NEXIUM
GRA 2.5MG DR
Tier 3
X
X
X
NEXIUM
GRA 20MG DR
Tier 3
X
X
X
NEXIUM
GRA 40MG DR
Tier 3
X
X
X
NEXIUM
GRA 5MG DR
Tier 3
X
OMEPRA/BICAR POW 20-1680
Tier 1
X
X
X
OMEPRA/BICAR POW 40-1680
Tier 1
X
X
X
OMEPRAZOLE CAP 10MG
Tier 1
OMEPRAZOLE CAP 20MG
Tier 1
OMEPRAZOLE CAP 40MG
Tier 1
OMEPRAZOLE + SUS SYRSPEND
Tier 3
PANTOPRAZOLE TAB 20MG
Tier 1
PANTOPRAZOLE TAB 40MG
Tier 1
PREVACID
TAB 15MG STB
Tier 3
X
X
X
PREVACID
TAB 30MG STB
Tier 3
X
X
X
PRILOSEC
POW 10MG
Tier 4
X
PRILOSEC
POW 2.5MG
Tier 4
X
X
X
PROTONIX
PAK
Tier 4
PROTONIX
TAB 20MG
Tier 4
X
PROTONIX
TAB 40MG
Tier 4
X
X
X
RABEPRAZOLE TAB 20MG
Tier 1
ZEGERID
POW 20-1680
Tier 3
X
X
X
ZEGERID
POW 40-1680
Tier 3
X
X
X
ADCIRCA
TAB 20MG
Tier 4
X
X
Page 232 of 279
Specialty
X
X
Therapeutic Class Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Pulmonary Antihypertensives - Asthma/Lung Drugs Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
Product Name ADEMPAS TAB 0.5MG
Tier Value Tier 3
Prior Authorization X
Supply Limit X
Step Therapy
Specialty X
ADEMPAS
TAB 1.5MG
Tier 3
X
X
X
ADEMPAS
TAB 1MG
Tier 3
X
X
X
ADEMPAS
TAB 2.5MG
Tier 3
X
X
X
ADEMPAS
TAB 2MG
Tier 3
X
X
X
LETAIRIS
TAB 10MG
Tier 3
X
X
X
LETAIRIS
TAB 5MG
Tier 3
X
X
X
Tier 3
X
X
X
ORENITRAM TAB 0.125MG
Tier 4
X
X
X
ORENITRAM TAB 0.25MG
Tier 4
X
X
X
ORENITRAM TAB 1MG
Tier 4
X
X
X
ORENITRAM TAB 2.5MG
Tier 4
X
X
X
REVATIO
SUS 10MG/ML
Tier 4
X
X
X
REVATIO
TAB 20MG
Tier 4
X
X
SILDENAFIL TAB 20MG
Tier 1
X
X
X
TRACLEER
TAB 125MG
Tier 3
X
X
X
TRACLEER
TAB 62.5MG
Tier 3
X
X
X
SOL 0.6MG/ML
Tier 3
X
X
TYVASO REFIL SOL 0.6MG/ML
Tier 3
X
X
TYVASO START SOL 0.6MG/ML
Tier 3
X
X
VENTAVIS
SOL 10MCG/ML
Tier 3
X
X
VENTAVIS
SOL 20MCG/ML
Tier 3
X
X
OPSUMIT
TYVASO
TAB 10MG
AVELOX TAB 400MG AVELOX ABC TAB 400MG BESIVANCE SUS 0.6% CETRAXAL SOL 0.2% CILOXAN OIN 0.3% OP CILOXAN SOL 0.3% OP CIPRO TAB 250MG CIPRO TAB 500MG CIPRO (10%) SUS 500MG/5 CIPRO (5%) SUS 250MG/5 CIPRO HC SUS OTIC CIPRO XR TAB 1000MG CIPRO XR TAB 500MG CIPRODEX SUS 0.3-0.1%
Page 233 of 279
Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
X
X X
X
Therapeutic Class Quinolones - Antibiotics Quinolones - Antibiotics
Product Name CIPROFLOXACN SOL 0.2% CIPROFLOXACN SOL 0.3% OP
Tier Value Tier 1 Tier 1
Quinolones - Antibiotics
CIPROFLOXACN SUS 250MG/5
Tier 1
Quinolones - Antibiotics
CIPROFLOXACN SUS 500MG/5
Tier 1
Quinolones - Antibiotics
CIPROFLOXACN TAB 1000MG
Tier 1
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
CIPROFLOXACN TAB 100MG CIPROFLOXACN TAB 250MG CIPROFLOXACN TAB 500MG CIPROFLOXACN TAB 500MG ER
Tier 1 Tier 1 Tier 1 Tier 1
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
CIPROFLOXACN TAB 750MG FACTIVE TAB 320MG FLOXIN SOL 0.3% GATIFLOXACIN SOL 0.5% LEVAQUIN SOL 25MG/ML LEVAQUIN TAB 250MG LEVAQUIN TAB 500MG LEVAQUIN TAB 750MG LEVOFLOXACIN SOL 0.5% LEVOFLOXACIN SOL 25MG/ML
Tier 1 Tier 3 Tier 4 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
LEVOFLOXACIN TAB 250MG LEVOFLOXACIN TAB 500MG LEVOFLOXACIN TAB 750MG MOXEZA SOL 0.5% MOXIFLOXACIN TAB 400MG OCUFLOX DRO 0.3% OP OFLOXACIN DRO 0.3% OP OFLOXACIN DRO 0.3%OTIC
Tier 1 Tier 1 Tier 1 Tier 4 Tier 1 Tier 4 Tier 1 Tier 1
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs
OFLOXACIN TAB 400MG VIGAMOX DRO 0.5% ZYMAXID SOL 0.5% ACETYLCYST SOL 10%
Tier 1 Tier 4 Tier 4 Tier 1
ACETYLCYST SOL 20%
Tier 1
AMBITUSSIN SOL 100-10/5
Tier 1
BENZONATATE CAP 100MG
Tier 1
BENZONATATE CAP 150MG
Tier 1
BENZONATATE CAP 200MG
Tier 1
BIOTUSS
LIQ
Tier 1
BIOTUSS
LIQ PEDIATRC
Tier 1
CHERATUSSIN SYP 100-10/5
Tier 1
CODEINE/GG SOL 10-100/5
Tier 1
Page 234 of 279
Prior Authorization
Supply Limit
Step Therapy
X X
X
X
Specialty
Therapeutic Class Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs
Product Name DALIRESP TAB 500MCG DECONSAL
TAB L.A.
Tier Value Tier 3
Prior Authorization X
Tier 1
DECONSAL-II TAB
Tier 3
DEXTROMETHOR CRY MONOHYDR DEXTROMETHOR POW HBR
Tier 3
X
Tier 3
X
DEXTROMETHOR POW HBR MONO EXACTUSS LIQ
Tier 3
X
GG/CODEINE SOL 100-10/5
Tier 1
GILPHEX TR TAB 10-388MG
Tier 3
GILTUSS
Tier 3
Specialty
Tier 3
GILTUSS PED LIQ
Tier 3
GILTUSS TR TAB
Tier 3
GUAIATUSSIN SYP 100-10/5
Tier 1
GUAIFENESIN SYP 100-10/5
Tier 1
HUMIBID L.A. TAB 600MG
Tier 3
HUMIBID SPRI CAP 300MG
Tier 3
HUMIBID-DM TAB
Tier 3
HYDROC/HOMAT TAB 5-1.5MG
Tier 1
HYDROCOD/HOM SYP 5-1.5/5
Tier 1
HYDROMET
Tier 1
SYP 5-1.5/5
Step Therapy
Tier 1
DECONSAL SR CAP SPRINKLE
LIQ
Supply Limit X
HYPERSAL
NEB 3.5%
Tier 2
HYPERSAL
NEB 7%
Tier 2
HYPER-SAL NEB 7%
Tier 2
IOPHEN C-NR LIQ 100-10/5
Tier 1
KALYDECO
PAK 50MG
Tier 3
X
X
X
KALYDECO
PAK 75MG
Tier 3
X
X
X
KALYDECO
TAB 150MG
Tier 3
X
X
X
NEBUSAL
NEB 3%
Tier 1
Page 235 of 279
Therapeutic Class Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Respiratory Tract Agents, Other Asthma/Lung Drugs Retinoids - Chemotherapy Agents Retinoids - Chemotherapy Agents Retinoids - Chemotherapy Agents Retinoids - Chemotherapy Agents Retinoids - Chemotherapy Agents Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs
Product Name NEBUSAL NEB 6%
Tier Value Tier 3
NORTUSS-DE DRO
Tier 1
NORTUSS-EX LIQ 200-20/5
Tier 1
PE/GUAIFENES DRO 1.5-20MG
Tier 1
PULMOSAL
Tier 1
NEB 7%
PULMOZYME SOL 1MG/ML
Tier 3
Q-BID-LA
TAB 600MG
Tier 1
SOL 60-5/5ML
Tier 3
SOD CHLORIDE NEB 0.9%
Tier 1
SODIUM CHLOR NEB 10%
Tier 1
SODIUM CHLOR NEB 3%
Tier 1
SODIUM CHLOR NEB 7%
Tier 1
SURVANTA
Tier 3
REZIRA
INH
TESSALON PER CAP 100MG
Tier 4
TGQ 30/
Tier 1
TUSSIGON TYZINE
SYP 150/15 TAB 5-1.5MG
Supply Limit
X
X
Step Therapy
Tier 1
SOL 0.1%
Tier 3 Tier 3
VIRTUSSIN AC SOL 100-10/5
Tier 1
ZONATUSS
Tier 1
X
Tier 4 Tier 3 Tier 1 Tier 4 Tier 1 HCR Preventative
X
CAP 150MG
BEXAROTENE CAP 75MG PANRETIN GEL 0.1% TARGRETIN CAP 75MG TARGRETIN GEL 1% TRETINOIN CAP 10MG EVISTA TAB 60MG
TAB 60MG
Selective Estrogen Receptor Modifying Agents RALOXIFENE TAB 60MG - Hormone Replacement/Modifying Drugs
Specialty
X
TYZINE PED DRO 0.05%
Selective Estrogen Receptor Modifying Agents OSPHENA - Hormone Replacement/Modifying Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Prior Authorization
X
HCR Preventative
ALMOTRIP MAL TAB 12.5MG
Tier 1
X
ALMOTRIP MAL TAB 6.25MG
Tier 1
X
Page 236 of 279
X X X
X X
Tier 3
X
Therapeutic Class Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Product Name ALMOTRIPTAN TAB 12.5MG
Tier Value Tier 1
Prior Authorization
Supply Limit X
Step Therapy
X
ALSUMA
INJ 6MG/0.5
Tier 4
X
AMERGE
TAB 1MG
Tier 4
X
AMERGE
TAB 2.5MG
Tier 4
X
AXERT
TAB 12.5MG
Tier 4
X
X
AXERT
TAB 6.25MG
Tier 4
X
X
FROVA
TAB 2.5MG
Tier 4
X
FROVATRIPTAN TAB 2.5MG
Tier 1
X
IMITREX
INJ 4MG/0.5
Tier 4
X
X
IMITREX
INJ 4MG/0.5
Tier 4
X
X
IMITREX
INJ 6MG/0.5
Tier 4
X
X
IMITREX
INJ 6MG/0.5
Tier 4
X
X
IMITREX
INJ 6MG/0.5
Tier 4
X
X
IMITREX
SPR 20MG/ACT
Tier 4
X
IMITREX
SPR 5MG/ACT
Tier 4
X
IMITREX
TAB 100MG
Tier 4
X
X
IMITREX
TAB 25MG
Tier 4
X
X
IMITREX
TAB 50MG
Tier 4
X
X
MAXALT
TAB 10MG
Tier 4
X
X
MAXALT
TAB 5MG
Tier 4
X
X
MAXALT-MLT TAB 10MG
Tier 4
X
X
MAXALT-MLT TAB 5MG
Tier 4
X
X
NARATRIPTAN TAB 1MG
Tier 1
X
NARATRIPTAN TAB 2.5MG
Tier 1
X
ONZETRA XSAI MIS 11MG
Tier 4
RELPAX
TAB 20MG
Tier 2
X
RELPAX
TAB 40MG
Tier 2
X
RIZATRIPTAN TAB 10MG
Tier 1
X
RIZATRIPTAN TAB 10MG ODT
Tier 1
X
Page 237 of 279
X
Specialty
Therapeutic Class Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants
Product Name RIZATRIPTAN TAB 5MG
Tier Value Tier 1
Prior Authorization
Supply Limit X
Step Therapy
RIZATRIPTAN TAB 5MG ODT
Tier 1
X
SUMATRIPTAN INJ 4MG/0.5
Tier 1
X
SUMATRIPTAN INJ 4MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN SPR 20MG/ACT SUMATRIPTAN SPR 5MG/ACT
Tier 1
X
Tier 1
X
SUMATRIPTAN TAB 100MG
Tier 1
X
SUMATRIPTAN TAB 25MG
Tier 1
X
SUMATRIPTAN TAB 50MG
Tier 1
X
SUMAVEL DOSE INJ 4MG/0.5
Tier 3
X
SUMAVEL DOSE INJ 6MG/0.5
Tier 3
X
ZECUITY
Tier 4
X
X
ZEMBRACE SYM INJ 3/0.5ML
Tier 4
X
X
ZOLMITRIPTAN TAB 2.5 MG
Tier 1
X
ZOLMITRIPTAN TAB 2.5MG
Tier 1
X
ZOLMITRIPTAN TAB 5MG
Tier 1
X
ZOLMITRIPTAN TAB 5MG
Tier 1
X
ZOMIG
SPR 2.5MG
Tier 3
X
ZOMIG
TAB 2.5MG
Tier 4
X
ZOMIG
TAB 5MG
Tier 4
X
ZOMIG NASAL SPR 5MG
Tier 4
X
ZOMIG ZMT TAB 2.5 MG
Tier 4
X
ZOMIG ZMT TAB 5MG
Tier 4
X
BRISDELLE CAP 7.5MG
Tier 4
X
CELEXA
Tier 4
PAD 6.5MG/4H
TAB 10MG
Page 238 of 279
X
X X
Specialty
Therapeutic Class Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants
Product Name CELEXA TAB 20MG CELEXA
TAB 40MG
Tier Value Tier 4
Prior Authorization X
Tier 4
X
Supply Limit
Step Therapy X X
CITALOPRAM SOL 10MG/5ML
Tier 1
CITALOPRAM TAB 10MG
Tier 1
CITALOPRAM TAB 20MG
Tier 1
CITALOPRAM TAB 40MG
Tier 1
CYMBALTA
CAP 20MG
Tier 4
X
X
X
CYMBALTA
CAP 30MG
Tier 4
X
X
X
CYMBALTA
CAP 60MG
Tier 4
X
X
X
X
X
DESVENLAFAX TAB 100MG ER
Tier 4
DESVENLAFAX TAB 100MG ER
Tier 4
DESVENLAFAX TAB 50MG ER
Tier 4
X
X
DESVENLAFAX TAB 50MG ER
Tier 4
X
X
DULOXETINE CAP 20MG
Tier 1
X
DULOXETINE CAP 30MG
Tier 1
X
DULOXETINE CAP 40MG
Tier 4
X
DULOXETINE CAP 60MG
Tier 1
X
EFFEXOR XR CAP 150MG
Tier 4
X
X
EFFEXOR XR CAP 37.5MG
Tier 4
X
X
EFFEXOR XR CAP 75MG
Tier 4
X
X
ESCITALOPRAM SOL 5MG/5ML
Tier 1
ESCITALOPRAM TAB 10MG
Tier 1
ESCITALOPRAM TAB 20MG
Tier 1
ESCITALOPRAM TAB 5MG
Tier 1
FETZIMA
CAP 120MG
Tier 4
X
X
FETZIMA
CAP 20MG
Tier 4
X
X
FETZIMA
CAP 40MG
Tier 4
X
X
FETZIMA
CAP 80MG
Tier 4
X
X
FETZIMA
CAP TITRATIO
Tier 4
X
X
Page 239 of 279
X
X
Specialty
Therapeutic Class Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants
Prior Authorization
Supply Limit
Product Name FLUOXETINE CAP 10MG
Tier Value Tier 1
FLUOXETINE CAP 10MG
Tier 1
FLUOXETINE CAP 20MG
Tier 1
FLUOXETINE CAP 20MG
Tier 1
FLUOXETINE CAP 40MG
Tier 1
FLUOXETINE CAP 90MG DR
Tier 1
FLUOXETINE SOL 20MG/5ML
Tier 1
FLUOXETINE TAB 10MG
Tier 1
FLUOXETINE TAB 20MG
Tier 1
FLUOXETINE TAB 60MG
Tier 1
FLUVOXAMINE CAP 100MG ER
Tier 1
X
FLUVOXAMINE CAP 150MG ER
Tier 1
X
FLUVOXAMINE TAB 100MG
Tier 1
FLUVOXAMINE TAB 25MG
Tier 1
FLUVOXAMINE TAB 50MG
Tier 1
IRENKA
Tier 4
CAP 40MG
Step Therapy
X
X
X
KHEDEZLA
TAB 100MG ER
Tier 4
X
KHEDEZLA
TAB 50MG ER
Tier 4
LEXAPRO
SOL 5MG/5ML
Tier 4
X
X
LEXAPRO
TAB 10MG
Tier 4
X
X
LEXAPRO
TAB 20MG
Tier 4
X
X
LEXAPRO
TAB 5MG
Tier 4
X
X
X
PAROXETIN ER TAB 12.5MG
Tier 1
X
PAROXETIN ER TAB 37.5MG
Tier 1
X
PAROXETINE TAB 10MG
Tier 1
PAROXETINE TAB 20MG
Tier 1
PAROXETINE TAB 25MG ER
Tier 1
PAROXETINE TAB 30MG
Tier 1
PAROXETINE TAB 40MG
Tier 1
Page 240 of 279
X
X
Specialty
Therapeutic Class Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants
Product Name PAXIL SUS 10MG/5ML
Tier Value Tier 3
PAXIL
TAB 10MG
Tier 4
PAXIL
TAB 20MG
Tier 4
PAXIL
TAB 30MG
Tier 4
PAXIL
TAB 40MG
Tier 4
Prior Authorization
Supply Limit
Step Therapy
PAXIL CR
TAB 12.5MG
Tier 4
X
PAXIL CR
TAB 25MG
Tier 4
X
PAXIL CR
TAB 37.5MG
Tier 4
X
PEXEVA
TAB 10MG
Tier 4
X
X
X
PEXEVA
TAB 20MG
Tier 4
X
X
X
PEXEVA
TAB 30MG
Tier 4
X
X
X
PEXEVA
TAB 40MG
Tier 4
X
X
X
PRISTIQ
TAB 100MG
Tier 3
X
PRISTIQ
TAB 25MG
Tier 3
X
PRISTIQ
TAB 50MG
Tier 3
X
PROZAC
CAP 10MG
Tier 4
X
X
PROZAC
CAP 20MG
Tier 4
X
X
PROZAC
CAP 40MG
Tier 4
X
X
PROZAC WEEKL CAP 90MG
Tier 4
X
SARAFEM
TAB 10MG
Tier 3
SARAFEM
TAB 20MG
Tier 3
SERTRALINE CON 20MG/ML
Tier 1
SERTRALINE TAB 100MG
Tier 1
SERTRALINE TAB 25MG
Tier 1
SERTRALINE TAB 50MG
Tier 1
VENLAFAXINE CAP 150MG ER
Tier 1
VENLAFAXINE CAP 37.5 ER
Tier 1
VENLAFAXINE CAP 75MG ER
Tier 1
VENLAFAXINE TAB 100MG
Tier 1
Page 241 of 279
X
Specialty
Therapeutic Class Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs
Supply Limit X
Step Therapy X
X
X
X
X
Tier 4
X
X
KIT
Tier 4
X
VIIBRYD
KIT STARTER
Tier 4
VIIBRYD
TAB 10MG
Tier 4
X
VIIBRYD
TAB 20MG
Tier 4
X
VIIBRYD
TAB 40MG
Tier 4
X
ZOLOFT
CON 20MG/ML
Tier 4
X
X
ZOLOFT
TAB 100MG
Tier 4
X
X
ZOLOFT
TAB 25MG
Tier 4
X
X
ZOLOFT
TAB 50MG
Tier 4
X
X
AMRIX
CAP 15MG
Tier 4
X
AMRIX
CAP 30MG
Tier 4
X
Product Name VENLAFAXINE TAB 150MG ER
Tier Value Tier 4
VENLAFAXINE TAB 225MG ER
Tier 4
VENLAFAXINE TAB 25MG
Tier 1
VENLAFAXINE TAB 37.5 ER
Tier 4
VENLAFAXINE TAB 37.5MG
Tier 1
VENLAFAXINE TAB 50MG
Tier 1
VENLAFAXINE TAB 75MG
Tier 1
VENLAFAXINE TAB 75MG ER VIIBRYD
Prior Authorization
BACLOFEN
CRE
Tier 3
X
BACLOFEN
CRE 1%
Tier 1
X
BACLOFEN
CRE 2%
Tier 3
X
CARISOPR/ASA TAB 200-325
Tier 1
CARISOPRODOL TAB 250MG
Tier 1
CARISOPRODOL TAB 350MG
Tier 1
CHLORZOXAZON TAB 250MG
Tier 1
CHLORZOXAZON TAB 500MG
Tier 1
CYCLOBENZAPR CRE 20MG/GM CYCLOBENZAPR CRE 5% KIT
Tier 1
X
Tier 1
X
Page 242 of 279
X
Specialty
Therapeutic Class Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs Skeletal Muscle Relaxants - Pain/Swelling Management Drugs SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS ANTIBACTERIALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIBACTERIALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIBACTERIALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
Product Name CYCLOBENZAPR KIT COMFORT
Tier Value Tier 3
CYCLOBENZAPR TAB 10MG
Tier 1
CYCLOBENZAPR TAB 5MG
Tier 1
CYCLOBENZAPR TAB 7.5MG
Tier 1
CYCLOPHENE CRE RAPIDPAQ
Tier 3
FEXMID
Tier 4
TAB 7.5MG
Prior Authorization
Supply Limit
Step Therapy
X
LORZONE
TAB 375MG
Tier 4
X
X
LORZONE
TAB 750MG
Tier 4
X
X
METAXALL
TAB 800MG
Tier 1
METAXALONE TAB 400MG
Tier 1
METAXALONE TAB 800MG
Tier 1
METHOCARBAM TAB 500MG
Tier 1
METHOCARBAM TAB 750MG
Tier 1
ORPHENADRINE POW CITRATE
Tier 3
ORPHENADRINE TAB 100MG ER PARAFON FORT TAB 500MG
Tier 1
ROBAXIN
Tier 4
TAB 500MG
X
Tier 4
ROBAXIN-750 TAB 750MG
Tier 4
SKELAXIN
Tier 4
X X
TAB 800MG
SOMA
TAB 250MG
Tier 4
SOMA
TAB 350MG
Tier 3
PETROLATUM OIN WHITE VERSABASE GEL BL TRIP ANTI OIN W/LID 4%
Tier 3 Tier 3 Tier 1
ROSADAN
KIT 0.75%
Tier 4
X
ROSADAN
KIT 0.75%
Tier 4
X
EXODERM
LOT 25-1%
Tier 1
HALOTIN
CRE 1%
Tier 3
KERR TRIPLE MIS DYE SWAB
Tier 2
MICONAZOLE POW NITRATE
Tier 3
Page 243 of 279
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
Product Name VUSION OIN XOLEGEL
Tier Value Tier 4
KIT COREPAK
Tier 3
XOLEGEL DUO/ KIT XOLEX
Tier 3
ANALPRAM
Tier 4
ANALPRAM E KIT
Tier 4
ANALPRAM HC CRE 2.5-1%
Tier 4
ANALPRAM-HC CRE 1-1%
Tier 4
ANALPRAM-HC CRE 1-2.5%
Tier 4
ANALPRAM-HC CRE SINGLES
Tier 4
ANALPRAM-HC CRE SINGLES
Tier 4
ANALPRAM-HC LOT 2.5%
Tier 3
ANALPRM SNGL CRE HC 2.5-1
Tier 4
ANUCORT-HC SUP 25MG
Tier 1
ANUSOL-HC SUP 25MG
Tier 4
CORTANE-B LOT
Tier 4
EPIFOAM
Tier 2
AER 1%
GRX HICORT SUP 25MG
Tier 1
HALAC
KIT
Tier 1
HC PRAMOXINE CRE 1-1%
Tier 1
Page 244 of 279
Supply Limit
Step Therapy X
Tier 3
XOLEGEL DUO/ KIT HEAD&SHD
KIT ADVANCED
Prior Authorization
X
X
X
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
Product Name HC PRAMOXINE CRE 2.5-1%
Tier Value Tier 1
HC PRAMOXINE CRE 2.5-1%
Tier 1
HEMMOREX-HC SUP 25MG
Tier 1
HEMMOREX-HC SUP 30MG
Tier 1
HEMORRHOIDAL SUP -HC 25MG
Tier 1
HYDROCORT AC SUP 25MG
Tier 1
HYDROCORT AC SUP 30MG
Tier 1
HYDROCORT/ KIT PRAMOXIN
Tier 1
NUCORT
LOT 2%
Tier 3
PEDIADERM HC KIT
Tier 3
PRAMCORT
Tier 1
CRE 1-1%
PRAMOSONE CRE 1%
Tier 1
PRAMOSONE CRE 1-1%
Tier 1
PRAMOSONE CRE 1-2.5%
Tier 3
PRAMOSONE LOT 1%
Tier 2
PRAMOSONE LOT 2.5%
Tier 2
PRAMOSONE OIN 1%
Tier 2
PRAMOSONE OIN 2.5%
Tier 4
PRAMOSONE E CRE 1-2.5%
Tier 4
Page 245 of 279
Prior Authorization
Supply Limit
Step Therapy
X
X
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
Product Name PRAMOX GEL 1%
PROCORT
CRE
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Tier 4
X
PROCTOCORT SUP 30MG
Tier 4
X
PROCTOFOAM AER HC 1%
Tier 2
RECTACORT-HC SUP 25MG
Tier 1
SCALACORT DK KIT
Tier 3
SYNALAR TS KIT 0.01%
Tier 4
X
ULTRAVATE X KIT 0.05-10%
Tier 4
X
ULTRAVATE X KIT 0.05-10%
Tier 4
X
VANOXIDE-HC LOT 5-0.5%
Tier 4
ANACAINE
OIN
Tier 2
CETACAINE AER
Tier 3
DERMASORB TA KIT 0.1%
Tier 4
ETHYL CHLOR AER FINE PIN
Tier 1
ETHYL CHLOR AER FN STRM
Tier 1
ETHYL CHLOR AER MED JET
Tier 1
ETHYL CHLOR AER MED STRM
Tier 1
ETHYL CHLOR AER MIST
Tier 1
ETHYL CHLOR AER SPRAY
Tier 1
GEBAUERS SPR AER /STRETCH
Tier 3
PAIN EASE AER MD STRM
Tier 3
PAIN EASE AER MIST
Tier 3
PEDIADERM TA KIT
Tier 4
QUTENZA
Tier 4
KIT 8% 1-PCH
Page 246 of 279
Specialty
X
X X
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS SKIN AND MUCOUS MEMBRANE AGENTS ASTRINGENTS SKIN AND MUCOUS MEMBRANE AGENTS ASTRINGENTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS SKIN AND MUCOUS MEMBRANE AGENTS DEPIGMENTING AND PIGMENTING AGENTS
Product Name QUTENZA KIT 8% 2-PCH
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
Tier Value Tier 4
VENELEX
OIN
Tier 3
XERAC-AC
SOL 6.25%
Tier 2
COPASIL
GEL
Prior Authorization
Supply Limit
Step Therapy
Tier 3
HPR PLUS MB KIT HYDROGEL
Tier 3
HYALURONATE GEL 0.2%
Tier 1
HYLIRA
GEL 0.2%
Tier 2
HYLIRA
LOT 0.1%
Tier 3
LACTIC ACID CRE /VIT E
Tier 1
LACTIC ACID CRE E
Tier 1
NEOSALUS
Tier 3
LOT
TROPAZONE LOT
Tier 3
HYDROQUINONE POW
Tier 3
ALUVEA
Tier 3
CRE 39%
BENSAL HP OIN
Tier 2
CARB-O-PHILC CRE /40
Tier 1
CARB-O-PHILC GEL 40%
Tier 1
CEM-UREA
Tier 4
SOL 45%
CEROVEL
GEL 40%
Tier 1
CEROVEL
LOT 40%
Tier 1
DERMASORB XM KIT 39%
Tier 4
GORDOFILM SOL
Tier 2
GORDONS UREA OIN 40%
Tier 3
HYDRO 35
AER
Tier 3
HYDRO 40
AER FOAM
Tier 3
KERALAC
CRE 47%
Tier 4
KERALYT
GEL 6%
Tier 4
KERALYT
KIT SCALP 6%
Tier 4
Page 247 of 279
X
X
X
X
Specialty X
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
Product Name LATRIX SUS 50%
Tier Value Tier 2
LATRIX XM EMU 45%
Tier 2
NA HYDROXIDE SOL 10%
Tier 1
POT HYDROXID SOL 5%
Tier 2
REA LO 39 CRE 39%
Tier 1
REA LO 40 CRE 40%
Tier 1
REA LO 40 LOT 40%
Tier 1
REMEVEN
Tier 2
CRE 50%
Prior Authorization
Supply Limit
Step Therapy
SALACYN
CRE 6%
Tier 1
SALACYN
LOT 6%
Tier 1
SALICYLIC AER 6%
Tier 1
SALICYLIC AC CRE 6%
Tier 1
SALICYLIC AC GEL 6%
Tier 1
SALICYLIC AC LIQ 26%
Tier 1
SALICYLIC AC LOT 6%
Tier 1
SALVAX
AER 6%
Tier 3
UMECTA
EMU
Tier 3
X
UMECTA MOUSS AER 40%
Tier 3
X
UMECTA NAIL SUS FILM
Tier 4
X
UMECTA PD EMU 40-0.3%
Tier 4
X
UMECTA PD SUS 40-0.3%
Tier 4
X
URAMAXIN
AER 20%
Tier 3
URAMAXIN
CRE 45%
Tier 4
URAMAXIN
GEL 45%
Tier 4
URAMAXIN
LOT 45%
Tier 3
URAMAXIN GT GEL 45%
Tier 4
X
URAMAXIN GT KIT 45%
Tier 4
X
UREA
CRE 39%
Tier 1
UREA
CRE 40%
Tier 1
Page 248 of 279
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
Product Name UREA CRE 45%
Tier Value Tier 1
UREA
CRE 47%
Tier 1
UREA
CRE 50%
Tier 1
UREA
EMU 50%
Tier 1
UREA
GEL 40%
Tier 1
UREA
LOT 40%
Tier 1
UREA
LOT 45%
Tier 1
UREA
SUS 50%
Tier 1
UREA 40%
SUS NAIL
Tier 1
UREA NAIL GEL 45%
Tier 1
UREA NAIL KIT
Tier 1
UREA NAIL MIS 50%
Tier 1
UREA TOPICAL SUS 40%
Tier 1
UREA-C40
Tier 1
URE-K
CRE 50% CRE 41%
Tier 4
X-VIATE
CRE 40%
Tier 1
X-VIATE
GEL 40%
Tier 4
X-VIATE
LOT 40%
Tier 1
AVAR
PAD 9.5-5%
Tier 4
AVAR CLEANSE EMU 10-5%
Tier 1
AVAR LS
LIQ 10-2%
Tier 3
AVAR LS
PAD 10-2%
Tier 4
AVAR-E EMOLL CRE 10-5%
Tier 3
AVAR-E GREEN CRE 10-5%
Tier 3
AVAR-E LS CRE 10-2%
Tier 3
BENZIQ
Tier 3
BENZIQ LS GEL 2.75%
Page 249 of 279
Step Therapy
X
Tier 1
UTOPIC
GEL 5.25%
Supply Limit
Tier 1
UREA HYDRATI AER 35%
LOT 40%
Prior Authorization
Tier 3
X
X
X
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
Product Name BENZIQ WASH LIQ 5.25% BP 10-1
Tier Value Tier 4
EMU
Tier 1
BP CLEANSING EMU 10-4%
Tier 1
CERISA WASH EMU 10-1%
Tier 1
CLARIFOAM EF AER 10-5%
Tier 3
CLARIS WASH EMU 10-4%
Tier 1
COAL TAR
Tier 3
SOL 20%
DRITHO-CREME CRE HP 1%
Tier 2
INOVA
KIT 4%
Tier 3
INOVA
KIT 8%
Tier 3
INOVA 4/1 KIT ACNE CON
Tier 3
INOVA 8/2 KIT ACNE CON
Tier 3
NUOX
Tier 3
GEL 6-3%
Prior Authorization
Supply Limit
Step Therapy
X
OSCION CLNSR LOT 6%
Tier 3
PLEXION
CRE 9.8-4.8%
Tier 4
X
PLEXION
LIQ 9.8-4.8%
Tier 4
X
PLEXION
LOT 9.8-4.8%
Tier 4
X
PLEXION CLTH PAD 9.8-4.8%
Tier 4
X
PRASCION
Tier 1
EMU
PRASCION RA CRE 10-5%
Tier 1
ROSANIL
Tier 1
EMU CLEANSER
SOD SUL/SULF CRE 10-2%
Tier 1
SOD SUL/SULF CRE 10-5%
Tier 1
SOD SUL/SULF CRE 9.8-4.8%
Tier 1
SOD SUL/SULF EMU 10-5%
Tier 1
SOD SUL/SULF EMU 10-5%
Tier 1
SOD SUL/SULF GEL 10-5%
Tier 1
SOD SUL/SULF KIT
Tier 1
SOD SUL/SULF LIQ 10-2%
Tier 1
Page 250 of 279
X
X
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
Product Name SOD SUL/SULF LIQ 9.8-4.8%
Tier Value Tier 1
SOD SUL/SULF LIQ 9-4.5%
Tier 1
SOD SUL/SULF LIQ WASH
Tier 1
SOD SUL/SULF LOT 10-5%
Tier 1
SOD SUL/SULF LOT 9.8-4.8%
Tier 1
SOD SUL/SULF PAD 10-4%
Tier 1
SOD SUL/SULF SUS 10-5%
Tier 1
SOD SUL/SULF SUS 8-4%
Tier 1
SS 10-2
SOL 10-2%
Tier 1
CRE 10%-5%
Tier 1
AER 10-5%
Tier 1
SSS SSS 10-5
SUL SOD/SULF LIQ 10-2%
Tier 1
SUL SOD/SULF PAD 10-4%
Tier 1
SULF/SUNSCRN KIT 9-4.5%
Tier 1
SULFACLEANSE SUS 8-4%
Tier 1
SULFOAM
Tier 3
SUMADAN
SHA 2% KIT
Prior Authorization
Supply Limit
Step Therapy X
X
X
Tier 4
X
SUMADAN WASH LIQ 9-4.5%
Tier 4
X
SUMADAN XLT KIT 9-4.5%
Tier 4
X
SUMAXIN
Tier 4
PAD 10-4%
SUMAXIN CP KIT
Tier 4
X
SUMAXIN TS SUS 8-4%
Tier 4
X
SUMAXIN WASH LIQ 9-4%
Tier 3
VIRTI-SULF CRE 10-5%
Tier 1
ZACARE KIT KIT 4%
Tier 3
ZACARE KIT KIT 8%
Tier 3
ZACLIR
LOT 8%
Tier 1
ZENCIA
LIQ 9-4%
Tier 1
ZITHRANOL SHA 1%
Page 251 of 279
Tier 3
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
Product Name ZITHRANOL-RR CRE 1.2% ARZOL SILVER MIS NITR APP
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
DERMAZENE CRE 1%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
GRAFCO SILVR MIS NIT APPL
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
HYDROCORT/ CRE IODOQUIN
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
LOUTREX
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS CRE 10%
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS GEL 10% WASH
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS LIQ 10% WASH
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS LOT 9.8%
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS SHA 10%
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE WASH LIQ 10%
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
PROMISEB
CRE
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
PROMISEB
KIT COMPLETE
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SEB-PREV
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SELENIUM SUL SHA 2.25%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA OIN 10%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA SOL 0.5%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA SOL 10%
Tier 1
CRE
LIQ WASH
Page 252 of 279
Tier Value Tier 3
Tier 1
Prior Authorization
Supply Limit
Step Therapy
X
X
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
Product Name SILVER NITRA SOL 25%
Tier Value Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA SOL 50%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SOD SULFACET GEL 10%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SOD SULFACET SHA 10%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SODIUM SULFA LIQ 10% WASH
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
TL TRISEB CRE
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
SODIUM SULFA LIQ 10% WASH
Tier 1
ANASEPT
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BENZALKONIUM SOL 50%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BENZALKONIUM SOL NF
Tier 2
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BORIC ACID GRA
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BUCALSEP
SOL
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BUCALSEP
SPR
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
ATOPICLAIR CRE
Tier 3
AURSTAT
Tier 3
SPR
KIT HYDROGEL
AURSTAT ANTI GEL -ITCH
Tier 3
BENZOIN
TIN NF
Tier 3
BENZOIN CMPD TIN
Tier 3
CERACADE
Tier 3
EMU
DEBACTEROL SOL 30-50%
Tier 2
DRYSOL
SOL 20%
Tier 4
ELETONE
CRE
Tier 3
Page 253 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
Product Name ELETONE CRE TWINPACK
Tier Value Tier 3
EMULSION SB EMU
Tier 3
EPICERAM
Tier 3
EPISONE
EMU CRE
ESSENTRA
Tier 3
SOL
Tier 3
FORMALDEHYDE SOL 10%
Tier 1
FORMALDEHYDE SOL 37%
Tier 3
FORMA-RAY SOL 20%
Tier 2
GENADUR
KIT
Tier 4
GENADUR
LIQ
Tier 3
GRANULEX
AER
Tier 4
HPR
Supply Limit
Step Therapy
Tier 1
MIS 9X9"
FORMADON
Prior Authorization
AER
Tier 4
HPR PLUS
AER
Tier 4
HPR PLUS
CRE
Tier 4
HPR PLUS
KIT
Tier 3
HYLATOPIC AER
Tier 3
HYLATOPIC AER PLUS
Tier 3
HYLATOPIC CRE PLUS
Tier 3
HYPERCARE SOL 20%
Tier 1
MB HYDROGEL KIT
Tier 3
MEDI-DERM CRE -RX
Tier 3
MEDROX-RX OIN
Tier 3
METHYL SALIC LIQ
Tier 1
NEOSALUS
AER
Tier 3
NEOSALUS
CRE
Tier 3
NEOSALUS CP CRE
Tier 3
NIVATOPIC CRE PLUS
Tier 3
NUVAIL
Tier 3
SOL 16%
Page 254 of 279
X
Specialty
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS SCABICIDES Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs
Product Name PR CREAM KIT
Tier Value Tier 2
PRESERA
AER
Tier 3
PRUCLAIR
CRE
Tier 2
PRUMYX
CRE
Tier 2
PYROGALL ACD OIN
Tier 2
SALICYLIC AC AER 6%
Tier 1
SALVAX DUO KIT PLUS
Tier 3
TBC
Tier 1
AER
Prior Authorization
Supply Limit
Step Therapy
TRI-CHLOR LIQ 80%
Tier 2
TURPENTINE SOL SPIRITS
Tier 3
VASOLEX
OIN
Tier 1
XERALUX
CRE
Tier 3
SULF LIME SOL
Tier 3
ARMODAFINIL TAB 150MG
Tier 1
X
X
X
ARMODAFINIL TAB 200MG
Tier 1
X
X
X
ARMODAFINIL TAB 250MG
Tier 1
X
X
X
ARMODAFINIL TAB 50MG
Tier 1
X
X
X
BUTISOL SOD TAB 30MG
Tier 3
BUTISOL SOD TAB 50MG
Tier 3
MODAFINIL TAB 100MG
Tier 1
X
X
MODAFINIL TAB 200MG
Tier 1
X
X
NUVIGIL
TAB 150MG
Tier 4
X
X
X
NUVIGIL
TAB 200MG
Tier 4
X
X
X
NUVIGIL
TAB 250MG
Tier 4
X
X
X
NUVIGIL
TAB 50MG
Tier 4
X
X
X
PROVIGIL
TAB 100MG
Tier 4
X
X
X
PROVIGIL
TAB 200MG
Tier 4
X
X
X
ROZEREM
TAB 8MG
Tier 3
X
X
SECONAL
CAP 100MG
Tier 3
Page 255 of 279
Specialty
Therapeutic Class Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Product Name SECONAL SOD CAP 100MG
Tier Value Tier 3
Prior Authorization
Supply Limit
Step Therapy
SILENOR
TAB 3MG
Tier 4
X
X
SILENOR
TAB 6MG
Tier 4
X
X
XYREM
SOL 500MG/ML
Tier 4
X
HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative
X X X X X X X
Smoking Cessation Agents - Deterrents
CVS NICOTINE DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MG HCR Preventative MINT CVS NICOTINE GUM 2MG ORIG HCR Preventative
X
CVS NICOTINE GUM HCR Preventative 2MGFRUIT CVS NICOTINE GUM 4MG CINN HCR Preventative
X
CVS NICOTINE GUM 4MG HCR Preventative MINT CVS NICOTINE GUM 4MG ORIG HCR Preventative
X
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM HCR Preventative 4MGFRUIT CVS NICOTINE LOZ 2MG HCR Preventative CVS NICOTINE LOZ 2MG MINT HCR Preventative
Smoking Cessation Agents - Deterrents
CVS NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
CVS NTS DIS STEP 1 EQ NICOTINE DIS 14MG/24H
HCR Preventative HCR Preventative
X X
Smoking Cessation Agents - Deterrents
EQ NICOTINE DIS 21MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE DIS 7MG/24HR
HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
BUPROBAN TAB 150MG BUPROPION TAB 150MG CHANTIX PAK 0.5& 1MG CHANTIX PAK 1MG CHANTIX TAB 0.5MG CHANTIX TAB 1MG CVS NICOTINE DIS 14MG/24H
Page 256 of 279
X
X
X
X X
X
Specialty
X
Therapeutic Class Smoking Cessation Agents - Deterrents
Prior Product Name Authorization Tier Value EQ NICOTINE GUM 4MG ORIG HCR Preventative X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG REF
HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 2MG CHER HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 4MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 2MG HCR Preventative EQL NICOTINE GUM 2MG REF HCR Preventative
X X
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 2MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 4MG HCR Preventative EQL NICOTINE GUM 4MG REF HCR Preventative
X X
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 4MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
HCR Preventative
X
HCR Preventative
X
HCR Preventative
X
HCR Preventative
X
Smoking Cessation Agents - Deterrents
GNP NICOTINE GUM 2MG MINT GNP NICOTINE GUM 2MG ORIG GNP NICOTINE GUM 4MG MINT GNP NICOTINE GUM 4MG ORIG GNP NICOTINE LOZ 2MG MINT
HCR Preventative
X
Smoking Cessation Agents - Deterrents
GNP NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
GNP NICOTINE LOZ MINI 2MG HCR Preventative
X
Smoking Cessation Agents - Deterrents
HM NICOTINE DIS 14MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
HM NICOTINE DIS 21MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
X
Smoking Cessation Agents - Deterrents
HM NICOTINE GUM 2MG HCR Preventative MINT HM NICOTINE GUM 4MG HCR Preventative MINT HM NICOTINE LOZ 2MG MINT HCR Preventative
Smoking Cessation Agents - Deterrents
HM NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
KLS QUIT2 GUM 2MG KLS QUIT2 LOZ 2MG
X X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
HCR Preventative HCR Preventative
Page 257 of 279
X X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Prior Product Name Authorization Tier Value KLS QUIT4 GUM 4MG HCR Preventative X KLS QUIT4 LOZ 4MG HCR Preventative X NICODERM CQ DIS 14MG/24H HCR Preventative X
Smoking Cessation Agents - Deterrents
NICODERM CQ DIS 21MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICODERM CQ DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 2MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
X X X X X X X
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 2MG CHRY HCR Preventative NICORETTE LOZ 2MG MINT HCR Preventative NICORETTE LOZ 2MG ORIG HCR Preventative NICORETTE LOZ 4MG CHRY HCR Preventative NICORETTE LOZ 4MG MINT HCR Preventative NICORETTE LOZ 4MG ORIG HCR Preventative NICORETTE ST GUM 2MG HCR Preventative MINT NICORETTE ST GUM 2MG ORIG HCR Preventative
Smoking Cessation Agents - Deterrents
NICORETTE ST GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
NICOTINE DIS 14MG/24H HCR Preventative NICOTINE DIS 21MG/24H HCR Preventative NICOTINE DIS 7MG/24HR HCR Preventative NICOTINE GUM 2MGFRUIT HCR Preventative NICOTINE GUM 4MG HCR Preventative NICOTINE LOZ 2MG CHRY HCR Preventative NICOTINE LOZ 2MG MINT HCR Preventative NICOTINE LOZ 4MG CHRY HCR Preventative NICOTINE LOZ 4MG CINN HCR Preventative NICOTINE LOZ 4MG MINT HCR Preventative NICOTINE LOZ MINI 2MG HCR Preventative NICOTINE POL GUM 2MG HCR Preventative NICOTINE POL GUM 2MG CINN HCR Preventative
X X X X X X X X X X X X X
Page 258 of 279
X
Supply Limit
Step Therapy
Specialty
Smoking Cessation Agents - Deterrents
Prior Product Name Authorization Tier Value NICOTINE POL GUM 2MG HCR Preventative X MINT NICOTINE POL GUM 2MG ORIG HCR Preventative X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG REF HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM HCR Preventative 2MGFRUIT NICOTINE POL GUM 4MG HCR Preventative NICOTINE POL GUM 4MG CINN HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG HCR Preventative MINT NICOTINE POL GUM 4MG ORIG HCR Preventative
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG REF HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM HCR Preventative 4MGFRUIT NICOTINE POL LOZ 2MG CHRY HCR Preventative
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE SYS KIT TRANSDER
HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 14MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 21MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 7MG/24HR
HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
NICOTROL INH NICOTROL NS SPR 10MG/ML
HCR Preventative HCR Preventative
X X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
QC NICOTINE GUM 4MG RA NICOTINE DIS 14MG/24H
HCR Preventative HCR Preventative
X X
Smoking Cessation Agents - Deterrents
RA NICOTINE DIS 21MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
RA NICOTINE DIS 7MG/24HR
HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MG HCR Preventative RA NICOTINE GUM 2MG CINN HCR Preventative
X X
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MG MINT HCR Preventative
X
Therapeutic Class Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Page 259 of 279
X X
X
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Smoking Cessation Agents - Deterrents
Prior Product Name Authorization Tier Value RA NICOTINE GUM 2MGFRUIT HCR Preventative X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 4MG HCR Preventative RA NICOTINE GUM 4MG FRUT HCR Preventative
X X
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
RA NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
RA NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 14MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 21MG HCR Preventative SM NICOTINE DIS 21MG/24H HCR Preventative
X X
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
SM NICOTINE SM NICOTINE MINT SM NICOTINE SM NICOTINE MINT SM NICOTINE
GUM 2MG GUM 2MG
HCR Preventative HCR Preventative
X X
GUM 4MG GUM 4MG
HCR Preventative HCR Preventative
X X
LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
SM NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
HCR Preventative
X
HCR Preventative
X
HCR Preventative HCR Preventative HCR Preventative
X X X
HCR Preventative
X
HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
STOP SMOKING GUM 2MG MINT STOP SMOKING GUM 2MG ORIG STOP SMOKING GUM 4MG STOP SMOKING LOZ 2MG STOP SMOKING LOZ 2MG MINT STOP SMOKING LOZ 4MG MINT SW NICOTINE GUM 2MG MINT SW NICOTINE GUM 4MG SW NICOTINE LOZ 2MG MINT
HCR Preventative HCR Preventative
X X
Smoking Cessation Agents - Deterrents
SW NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 14MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 21MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 2MG HCR Preventative MINT TGT NICOTINE GUM 2MG ORIG HCR Preventative
X
TGT NICOTINE GUM 2MGFRUIT TGT NICOTINE GUM 4MG
HCR Preventative
X
HCR Preventative
X
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents Smoking Cessation Agents - Deterrents
Page 260 of 279
X
Supply Limit
Step Therapy
Specialty
Smoking Cessation Agents - Deterrents
Prior Product Name Authorization Tier Value TGT NICOTINE GUM 4MG HCR Preventative X MINT TGT NICOTINE GUM 4MG ORIG HCR Preventative X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 2MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 4MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs
THRIVE BANZEL
GUM 2MG MINT SUS 40MG/ML
HCR Preventative Tier 3
X
BANZEL
TAB 200MG
Tier 3
X
BANZEL
TAB 400MG
Tier 3
X
Therapeutic Class Smoking Cessation Agents - Deterrents
CARBAMAZEPIN CAP 100MG ER CARBAMAZEPIN CAP 200MG ER CARBAMAZEPIN CAP 300MG ER CARBAMAZEPIN CHW 100MG
Tier 1
CARBAMAZEPIN POW
Tier 3
CARBAMAZEPIN SUS 100/5ML
Tier 1
CARBAMAZEPIN TAB 100MGER CARBAMAZEPIN TAB 200MG
Tier 1
CARBAMAZEPIN TAB 200MG ER CARBAMAZEPIN TAB 400MG ER CARBATROL CAP 100MG
Tier 1
CARBATROL CAP 200MG
Tier 4
CARBATROL CAP 300MG
Tier 4
DILANTIN
CAP 100MG
Tier 3
DILANTIN
CAP 30MG
Tier 3
DILANTIN
CHW 50MG
Tier 3
Tier 1 Tier 1 Tier 1
Tier 1
Tier 1 Tier 4
DILANTIN-125 SUS 125/5ML
Tier 3
EPITOL
Tier 1
EQUETRO
TAB 200MG CAP 100MG
Page 261 of 279
Tier 3
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs
Product Name EQUETRO CAP 200MG EQUETRO
CAP 300MG
Tier Value Tier 3
Prior Authorization
Supply Limit
Step Therapy
Tier 3
OXCARBAZEPIN SUS 300MG/5M OXCARBAZEPIN TAB 150MG
Tier 1
OXCARBAZEPIN TAB 300MG
Tier 1
OXCARBAZEPIN TAB 600MG
Tier 1
OXTELLAR XR TAB 150MG
Tier 4
X
X
OXTELLAR XR TAB 300MG
Tier 4
X
X
OXTELLAR XR TAB 600MG
Tier 4
X
X
PEGANONE
Tier 2
TAB 250MG
Tier 1
PHENYTEK
CAP 200MG
Tier 4
PHENYTEK
CAP 300MG
Tier 4
PHENYTOIN CHW 50MG
Tier 1
PHENYTOIN SUS 125/5ML
Tier 1
PHENYTOIN EX CAP 100MG
Tier 1
PHENYTOIN EX CAP 200MG
Tier 1
PHENYTOIN EX CAP 300MG
Tier 1
TEGRETOL
SUS 100/5ML
Tier 3
TEGRETOL
TAB 200MG
Tier 3
TEGRETOL-XR TAB 100MG
Tier 4
TEGRETOL-XR TAB 200MG
Tier 4
TEGRETOL-XR TAB 400MG
Tier 4
TRILEPTAL SUS 300MG/5M
Tier 4
X
X
TRILEPTAL TAB 150MG
Tier 4
X
X
TRILEPTAL TAB 300MG
Tier 4
X
X
TRILEPTAL TAB 600MG
Tier 4
X
X
VIMPAT
SOL 10MG/ML
Tier 3
X
VIMPAT
TAB 100MG
Tier 3
X
VIMPAT
TAB 150MG
Tier 3
X
Page 262 of 279
Specialty
Therapeutic Class Sodium Channel Agents - Seizure Control Drugs Sodium Channel Agents - Seizure Control Drugs Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Inflammatory Bowel Disease Drugs Sulfonamides - Inflammatory Bowel Disease Drugs Sulfonamides - Inflammatory Bowel Disease Drugs Sulfonamides - Inflammatory Bowel Disease Drugs Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
Product Name VIMPAT TAB 200MG VIMPAT
TAB 50MG
Tier Value Tier 3
Prior Authorization X
Tier 3
X
BACTRIM TAB 400-80MG BACTRIM DS TAB 800-160 BLEPH-10 SOL 10% OP SMZ/TMP DS TAB 800-160 SMZ-TMP SUS 200-40/5 SMZ-TMP TAB 400-80MG SMZ-TMP DS TAB 800-160 SOD SULFACET SOL 10% OP SULFACET SOD OIN 10% OP SULFACET SOD SOL 10% OP SULFADIAZINE TAB 500MG SULFATRIM PD SUS 200-40/5 AZULFIDINE TAB 500MG
Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4
AZULFIDINE TAB 500MG EN
Tier 4
SULFASALAZIN TAB 500MG
Tier 1
SULFASALAZIN TAB 500MG DR
Tier 1
ACTICLATE TAB 150MG ACTICLATE TAB 75MG ADOXA CAP 150MG ADOXA TAB 100MG ADOXA TAB 50MG ADOXA TAB 75MG ADOXA PAK 1/ TAB 100MG ADOXA PAK 1/ TAB 150MG ADOXA PAK 2/ TAB 100MG ALODOX KIT 20MG AVIDOXY TAB 100MG AVIDOXY DK KIT DEMECLOCYCL TAB 150MG DEMECLOCYCL TAB 300MG DORYX TAB 200MG DORYX TAB 50MG DORYX MPC TAB 120MG DOXYCYC CAP 100MG DOXYCYC CAP 50MG DOXYCYC MONO CAP 100MG
Tier 4 Tier 4 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1
Tetracyclines - Antibiotics Tetracyclines - Antibiotics
DOXYCYC MONO CAP 50MG DOXYCYC MONO TAB 100MG
Tier 1 Tier 1
Tetracyclines - Antibiotics
DOXYCYC MONO TAB 150MG
Tier 1
Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
DOXYCYC MONO TAB 50MG DOXYCYC MONO TAB 75MG DOXYCYCL HYC CAP 100MG DOXYCYCL HYC CAP 50MG DOXYCYCL HYC TAB 100MG DOXYCYCL HYC TAB 100MG DR
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Page 263 of 279
Supply Limit
Step Therapy
X X X X X X X X X
X X X
X
Specialty
Prior Authorization
Supply Limit
Step Therapy X
Therapeutic Class Tetracyclines - Antibiotics
Product Name DOXYCYCL HYC TAB 150MG DR
Tier Value Tier 1
Tetracyclines - Antibiotics
DOXYCYCL HYC TAB 200MG DR
Tier 1
X
Tetracyclines - Antibiotics
DOXYCYCL HYC TAB 50MG DR
Tier 1
X
Tetracyclines - Antibiotics
DOXYCYCL HYC TAB 75MG DR
Tier 1
X
Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
DOXYCYCLINE DOXYCYCLINE DOXYCYCLINE DOXYCYCLINE
Tier 1 Tier 4 Tier 1 Tier 3
X X X
Tetracyclines - Antibiotics
DOXYCYCLINE SUS 25MG/5ML
Tier 1
Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
DOXYCYCLINE TAB 20MG MINOCIN CAP 100MG MINOCIN CAP 50MG MINOCIN CAP 75MG MINOCIN KIT 100MG MINOCIN KIT 50MG MINOCYCLINE CAP 100MG MINOCYCLINE CAP 50MG MINOCYCLINE CAP 75MG MINOCYCLINE TAB 100MG MINOCYCLINE TAB 135MG ER
Tier 1 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tetracyclines - Antibiotics
MINOCYCLINE TAB 45MG ER
Tier 1
Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
MINOCYCLINE TAB 50MG MINOCYCLINE TAB 75MG MINOCYCLINE TAB 90MG ER
Tier 1 Tier 1 Tier 1
Tetracyclines - Antibiotics
MONDOXYNE NL CAP 100MG
Tier 1
Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
MONDOXYNE NL CAP 50MG MONDOXYNE NL CAP 75MG MONODOX CAP 100MG MONODOX CAP 75MG MORGIDOX CAP 1X100MG MORGIDOX CAP 1X50MG MORGIDOX CAP 2X100MG MORGIDOX KIT 1X100MG MORGIDOX KIT 1X50MG MORGIDOX KIT 2X100MG NICAZELDOXY KIT 30 NICAZELDOXY KIT 60 NUTRIDOX KIT OCUDOX KIT ORACEA CAP 40MG SOLODYN TAB 105MG SOLODYN TAB 115MG SOLODYN TAB 55MG SOLODYN TAB 65MG SOLODYN TAB 80MG TETRACYCLINE CAP 250MG TETRACYCLINE CAP 500MG VIBRAMYCIN CAP 100MG
Tier 1 Tier 1 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 2 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 4
CAP 150MG CAP 40MG CAP 75MG POW HYCLATE
Page 264 of 279
X X X X X
X X X
X X X X X
Specialty
Therapeutic Class Tetracyclines - Antibiotics
Product Name VIBRAMYCIN SUS 25MG/5ML
Tier Value Tier 4
Tetracyclines - Antibiotics
VIBRAMYCIN SYP 50MG/5ML
Tier 3
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 100/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 100MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 12.5/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 150/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 200/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 200MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 25MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 25MG ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 50MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZARIL
TAB 100MG
Tier 4
Treatment-Resistant - Mood Disorder Drugs
CLOZARIL
TAB 25MG
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 100 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 12.5 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 150 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 200 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 25MG ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
VERSACLOZ SUS 50MG/ML
Tier 4
Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
AMITRIPTYLIN KIT 2% AMITRIPTYLIN POW HCL AMITRIPTYLIN TAB 100MG AMITRIPTYLIN TAB 10MG AMITRIPTYLIN TAB 150MG AMITRIPTYLIN TAB 25MG AMITRIPTYLIN TAB 50MG AMITRIPTYLIN TAB 75MG AMOXAPINE TAB 100MG AMOXAPINE TAB 150MG AMOXAPINE TAB 25MG AMOXAPINE TAB 50MG ANAFRANIL CAP 25MG ANAFRANIL CAP 50MG ANAFRANIL CAP 75MG CETYL MYRIST MIS OLEATE CETYL MYRIST OIL OLEATE CETYL MYRIST POW 20% CETYL MYRIST POW OLEATE CETYL MYRIST POW OLEATE
Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 4 Tier 4 Tier 4 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Page 265 of 279
Prior Authorization
Supply Limit
Step Therapy
X X X
X X X X X X X X
Specialty
Therapeutic Class Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
Product Name CITRULLINE POW (L) CLOMIPRAMINE CAP 25MG CLOMIPRAMINE CAP 50MG CLOMIPRAMINE CAP 75MG DESIPRAMINE TAB 100MG DESIPRAMINE TAB 10MG DESIPRAMINE TAB 150MG DESIPRAMINE TAB 25MG DESIPRAMINE TAB 50MG DESIPRAMINE TAB 75MG DOXEPIN HCL CAP 100MG DOXEPIN HCL CAP 10MG DOXEPIN HCL CAP 150MG DOXEPIN HCL CAP 25MG DOXEPIN HCL CAP 50MG DOXEPIN HCL CAP 75MG DOXEPIN HCL CON 10MG/ML
Tier Value Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
ELAVIL TAB 25MG IMIPRAM HCL TAB 10MG IMIPRAM HCL TAB 25MG IMIPRAM HCL TAB 50MG IMIPRAM PAM CAP 100MG IMIPRAM PAM CAP 125MG IMIPRAM PAM CAP 150MG IMIPRAM PAM CAP 75MG IMIPRAMINE POW HCL L-CITRULLINE POW NORPRAMIN TAB 100MG NORPRAMIN TAB 10MG NORPRAMIN TAB 150MG NORPRAMIN TAB 25MG NORPRAMIN TAB 50MG NORPRAMIN TAB 75MG NORTRIPTYLIN CAP 10MG NORTRIPTYLIN CAP 25MG NORTRIPTYLIN CAP 50MG NORTRIPTYLIN CAP 75MG NORTRIPTYLIN SOL 10MG/5ML
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
PAMELOR CAP 10MG PAMELOR CAP 25MG PAMELOR CAP 50MG PAMELOR CAP 75MG PERPHEN/AMIT TAB 2-10MG
Tier 4 Tier 4 Tier 4 Tier 4 Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 2-25MG
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-10MG
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-25MG
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-50MG
Tier 1
Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
PROTRIPTYLIN TAB 10MG PROTRIPTYLIN TAB 5MG SURMONTIL CAP 100MG SURMONTIL CAP 25MG
Tier 1 Tier 1 Tier 4 Tier 4
Page 266 of 279
Prior Authorization
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Vasodilators - Chest Pain Drugs Vasodilators - Chest Pain Drugs Vasodilators - Chest Pain Drugs
Product Name SURMONTIL CAP 50MG TOFRANIL TAB 10MG TOFRANIL TAB 25MG TOFRANIL TAB 50MG TOFRANIL-PM CAP 100MG TOFRANIL-PM CAP 125MG TOFRANIL-PM CAP 150MG TOFRANIL-PM CAP 75MG TRIMIPRAMINE CAP 100MG TRIMIPRAMINE CAP 25MG TRIMIPRAMINE CAP 50MG ISOPROTEREN AER 131MCG ISOXSUPRINE TAB 10MG ISOXSUPRINE TAB HCL 20MG
Vasodilators - Chest Pain Drugs Vasodilators, Direct-acting Arterial - Chest Pain Drugs Vasodilators, Direct-acting Arterial - Chest Pain Drugs Vasodilators, Direct-acting Arterial - Chest Pain Drugs Vasodilators, Direct-acting Arterial - Chest Pain Drugs Vasodilators, Direct-acting Arterial - Chest Pain Drugs Vasodilators, Direct-acting Arterial - Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
PAPAVERINE POW HCL HYDRALAZINE TAB 100MG
Tier 3 Tier 1
HYDRALAZINE TAB 10MG
Tier 1
HYDRALAZINE TAB 25MG
Tier 1
HYDRALAZINE TAB 50MG
Tier 1
MINOXIDIL TAB 10MG
Tier 1
MINOXIDIL TAB 2.5MG
Tier 1
BIDIL
Tier 2
TAB
Tier Value Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
DILATRATE SR CAP 40MG
Tier 3
ISORDIL
TAB 40MG
Tier 2
ISORDIL
TAB 5MG
Tier 4
ISOSORB DIN TAB 10MG
Tier 1
ISOSORB DIN TAB 20MG
Tier 1
ISOSORB DIN TAB 30MG
Tier 1
ISOSORB DIN TAB 40MG ER
Tier 1
ISOSORB DIN TAB 5MG
Tier 1
ISOSORB MONO TAB 10MG
Tier 1
ISOSORB MONO TAB 120MG ER ISOSORB MONO TAB 20MG
Tier 1
ISOSORB MONO TAB 30MG ER
Tier 1
ISOSORB MONO TAB 60MG ER
Tier 1
MINITRAN
Tier 1
DIS 0.1MG/HR
Page 267 of 279
Tier 1
Prior Authorization
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Product Name MINITRAN DIS 0.2MG/HR
Tier Value Tier 1
MINITRAN
DIS 0.4MG/HR
Tier 1
MINITRAN
DIS 0.6MG/HR
Tier 1
Prior Authorization
Supply Limit
Step Therapy
NITRO-BID OIN 2%
Tier 2
NITRO-DUR DIS 0.1MG/HR
Tier 3
NITRO-DUR DIS 0.2MG/HR
Tier 3
NITRO-DUR DIS 0.3MG/HR
Tier 3
NITRO-DUR DIS 0.4MG/HR
Tier 3
NITRO-DUR DIS 0.6MG/HR
Tier 3
NITRO-DUR DIS 0.8MG/HR
Tier 3
NITROGLYCER AER 400MCG
Tier 1
NITROGLYCER CAP 2.5MG ER
Tier 1
NITROGLYCER CAP 6.5MG ER
Tier 1
NITROGLYCER CAP 9MG ER
Tier 1
NITROGLYCER DIS 0.1MG/HR
Tier 1
NITROGLYCER DIS 0.2MG/HR
Tier 1
NITROGLYCER DIS 0.4MG/HR
Tier 1
NITROGLYCER DIS 0.4MG/HR
Tier 1
NITROGLYCER DIS 0.6MG/HR
Tier 1
NITROGLYCRN SPR 0.4MG
Tier 1
X
X
NITROGLYCRN SPR LINGUAL
Tier 1
X
X
NITROLINGUAL SPR PUMPSPRA NITROMIST AER 400MCG
Tier 3
X
X
Tier 4
X
NITROSTAT SUB 0.3MG
Tier 2
NITROSTAT SUB 0.4MG
Tier 2
NITROSTAT SUB 0.6MG
Tier 2
NITRO-TIME CAP 2.5MG CR
Tier 1
NITRO-TIME CAP 6.5MG CR
Tier 1
NITRO-TIME CAP 9MG CR
Tier 1
Page 268 of 279
X
Specialty
Therapeutic Class Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name RECTIV OIN 0.4% ACTIVE OB CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
AIRSHIELD TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
AP-ZEL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
ATABEX EC TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
BAL-CARE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
BP FOLINATAL TAB PLUS B
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
BP MULTINATL CHW PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
BP MULTINATL TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
CALCIUM PNV CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CHLORELLA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL MIS 90 DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL MIS B-CALM
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL PAK ASSURE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL PAK DHA
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL TAB RX
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
C-NATE DHA CAP 28-1-200
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
COMPLETE NAT PAK DHA
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
COMPLETENATE CHW
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
CO-NATAL FA TAB 29-1MG
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
CONCEPT DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
CONCEPT OB CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
DOTHELLE DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
DUET DHA
MIS BALANCED
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
DUET DHA 400 MIS 25-1-400
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
ELITE-OB
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
ESCAVITE
CHW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
EXTRA-VIRT CAP PLUS DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
FLORIVA
Tier 1
TAB
MIS DHA
DRO PLUS
Page 269 of 279
Tier Value Tier 3
Prior Authorization X
Supply Limit X
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name FOCALGIN 90 MIS DHA
VITAMINS - MULTIVITAMIN PREPARATIONS
FOCALGIN CA MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLCAL DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLCAPS
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLIVANE-OB CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLIVANE-PRX CAP DHA NF
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
GERM DEFENSE TAB LEM-LIME
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
GERM DEFENSE TAB ORANGE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
GERM DEFENSE TAB PM
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
GESTICARE PAK DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
HEMENATAL OB MIS + DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
HEMENATAL OB TAB 28-61MG INATAL ADV TAB
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ADV TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ADV TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ADV TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL GT TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INFANATE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
LEVOMEFOLATE CAP DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
LYSIPLEX
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MACNATAL CN CAP DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MARNATAL-F CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
MILTAB #1 TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FE DRO /FL 0.25
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTIVIT/FL CHW 0.25MG
Tier 1
CAP OMEGA 3
CAP BALANCE
TAB PLUS
Page 270 of 279
Tier Value Tier 3
Tier 2
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name MULTIVIT/FL CHW 0.5MG
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTIVIT/FL CHW 1MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FL DRO /FE 0.25
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FL DRO 0.5MG/ML
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULT-VIT/FL CHW 0.5MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MVC-FLUORIDE CHW 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MVC-FLUORIDE CHW 0.5MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MVC-FLUORIDE CHW 1MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
M-VIT
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MYKIDZ IRON SUS FL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL
CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL
TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL
TAB ADVANCE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL PLUS TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL-Z TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATE 90 TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
NATACHEW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NATALVIT
VITAMINS - MULTIVITAMIN PREPARATIONS
NATELLE ONE CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NEEVO DHA CAP 27-1.13
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NESTABS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NESTABS ABC MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NESTABS DHA PAK
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NEWGEN
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NEXA PLUS CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NICAZEL
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NICAZEL
TAB FORTE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NIVA-PLUS TAB
TAB 27-1MG
CHW TAB 75-1MG
TAB
TAB 32-1MG
Tier Value Tier 1
Tier 2
Tier 3
Page 271 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name OB COMPLETE CAP GOLD
Tier Value Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE CAP ONE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE CAP PETITE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE TAB PREMIER
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE/ CAP DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OBSTETRIX PAK DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
OBSTETRIX EC TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
O-CAL
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
O-CAL FA
TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PAIRE OB
MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV FE FUM TAB DOC/FA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV FOLIC AC TAB + IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV OB+DHA PAK
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV PRENATAL TAB PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV TABS
TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-DHA
CAP
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-DHA
CAP DOCUSATE
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-OMEGA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-SELECT TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-TOTAL CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-VP-U
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW 0.25MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW 0.5MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW 1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW W/IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR SUS /IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR SUS 0.25/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PR NATAL 400 PAK
Tier 1
TAB PRENATAL
CAP 106.5-1
Page 272 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name PR NATAL 400 PAK EC
VITAMINS - MULTIVITAMIN PREPARATIONS
PR NATAL 430 PAK
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PR NATAL 430 PAK EC
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERA OB MIS + DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERA OB TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERA OB TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERAOB CAP ONE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERAOB MIS +DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE CAP BALANCE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE CAP PLUS
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE MIS HARMONY
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE PAK 90 DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE PAK DHA
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE PAK PROMISE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE TAB NEXT
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE TAB NEXT-B
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAT PLUS TAB 27-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATABS FA TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATABS RX TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
MIS COMPLEAT
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB 27-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL 19 CHW 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL 19 CHW TAB
Tier 1
CHW 29-1MG
Page 273 of 279
Tier Value Tier 1
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name PRENATAL 19 TAB
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL 19 TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL VIT TAB LOW IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL+FE TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL-U CAP 106.5-1
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
CAP ENHANCE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
CAP RESTORE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
CHW 0.6-0.4
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
TAB ELITE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE AM TAB 1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE DHA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE MINI CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREPLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREQUE 10 TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRETAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PROVIDA OB CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PUREFE OB CAP PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED CHW 0.25MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED CHW 0.5MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED CHW 1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED DRO 0.25MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED DRO 0.5MG/ML RA EFFERVESC TAB FORMULA
VITAMINS - MULTIVITAMIN PREPARATIONS
RELNATE DHA CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
R-NATAL OB CAP 20-1-320
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
RULAVITE DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
SELECT-OB CHW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
SELECT-OB CHW
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
SELECT-OB+ PAK DHA
Tier 3
Tier Value Tier 1
TAB 27-1MG
TAB 29-1MG
Page 274 of 279
Tier 3
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name SE-NATAL 19 CHW
Tier Value Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
SE-NATAL 19 TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
SE-TAN DHA CAP
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TARON-BC
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TARON-C DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
TARON-PREX CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
THRIVITE 19 TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
THRIVITE RX TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL FOLATE TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL-CARE DHA CAP 27-1-500
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL-FLUORIVIT CHW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL-SELECT CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRIADVANCE TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRICARE
TAB PRENATAL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRICARE PRE CAP 27-1-500
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRINATAL GT TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRINATAL RX TAB 1
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRINATE
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRISTART DHA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-TABS DHA MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRIVEEN-DUO PAK DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRIVEEN-PRX CAP RNF
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLOR SUS 0.25/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLOR SUS 0.5MG/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLORO SUS 0.25/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLORO SUS 0.5MG/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FE DRO /FL 0.25
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FL DRO 0.5MG
Tier 1
MIS
TAB
Page 275 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name TRI-VIT/FLUO DRO 0.25MG
Tier Value Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FLUO DRO 0.5MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VITA/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
ULTIMATECARE CAP ONE
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
ULTIMATECARE CAP ONE NF
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VEMAVITE- CAP PRX 2
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VENA-BAL
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VENATAL-FA TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VINACAL B MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE AZ EX TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE C
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE CAL TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE CARE CHW
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE DHA CAP 27-1.13
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE IC CAP
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE II TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE M
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE ONE TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT NATE TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT NATE TAB 28-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-ADVANCE TAB 90-1MG
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-C DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-CARE CAP ONE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-NATE CAP DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-PN
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-PN DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-PN PLUS CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRTPREX
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-SELECT CAP
MIS DHA
TAB
TAB
TAB
CAP
Tier 3
Page 276 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name VIRT-VITE GT TAB 90-1MG
Tier Value Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VIT A/C/D/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL-OB PAK +DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL-OB TAB 65-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL-ONE CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAMEDMD CAP ONE RX
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAMEDMD MIS PLUS RX
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITA-PREN TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIVA DHA
CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VOL-NATE
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VOL-PLUS
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VOL-TAB RX TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH PLUS CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-GGR-B6 TAB PRENATAL
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME OB MIS + DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME OB TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME ONE CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME-OB TAB 28-6-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-PNV-DHA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-ZEL
TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-ZEL
TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
ZATEAN-CH CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
ZATEAN-PN CAP DHA
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
ZATEAN-PN CAP PLUS
Tier 4
CAP ULTRA
Page 277 of 279
Prior Authorization
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name ZATEAN-PN TAB
VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN C VITAMINS - VITAMIN C VITAMINS - VITAMIN C VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D
BIOTIN POW BIOTIN-D POW BL FOLIC ACD TAB 400MCG CYANOCOBAL POW CYANOCOBALAM CRY FA-8 CAP 800MCG FA-8 TAB 0.8MG FOLIC ACID INJ 5MG/ML FOLIC ACID POW FOLIC ACID TAB 1000MCG FOLIC ACID TAB 1MG FOLIC ACID TAB 400MCG FOLIC ACID TAB 800MCG NASCOBAL SPR 500MCG NIACINAMIDE POW NICOTINAMIDE POW SM FOLIC ACD TAB 400MCG ASCOCID POW ASCORBIC ACD POW VITAMIN C POW CVD D3 CHW 1000UNIT CVS D3 CAP 1000UNIT CVS D3 CAP 400UNIT D 1000 CHW 1000UNIT D 400 CHW 400UNIT D 400 TAB 400UNIT D3 CAP 1000UNIT D-3 GUMMY CHW 400UNIT D-400 TAB 400UNIT DELTA D3 TAB 400UNIT DRISDOL CAP 50000UNT D-VI-SOL LIQ 400UNIT D-VITA LIQ 400UNIT ERGOCALCIFER CAP 50000UNT
Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 HCR Preventative HCR Preventative Tier 1 Tier 3 Tier 1 Tier 1 HCR Preventative HCR Preventative Tier 3 Tier 3 Tier 3 HCR Preventative Tier 3 Tier 3 Tier 3 HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative Tier 4 HCR Preventative HCR Preventative Tier 1
VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D
GNP VIT D TAB 1000UNIT PEDIA D-VITE DRO 400UNIT VIT D CHILD CHW 1000UNIT VITAMIN D CAP 1000UNIT VITAMIN D CAP 400UNIT VITAMIN D CAP 50000UNT VITAMIN D CHW 400UNIT VITAMIN D DRO 400UNIT VITAMIN D TAB 1000UNIT VITAMIN D TAB 400UNIT VITAMIN D2 TAB 400UNIT VITAMIN D3 CAP 1000UNIT VITAMIN D3 CAP 400UNIT VITAMIN D3 CHW 1000UNIT
HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative Tier 1 HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative
VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN D VITAMINS - VITAMIN E
VITAMIN D3 CHW 400UNIT VITAMIN D3 DRO 400UNIT VITAMIN D3 TAB 1000UNIT VITAMIN D3 TAB 400UNIT VITAMIN D-3 TAB 1000UNIT VITAMIN E POW ACETATE
HCR Preventative HCR Preventative HCR Preventative HCR Preventative HCR Preventative Tier 3
Tier Value Tier 4
Page 278 of 279
Prior Authorization
X X
X X X X X
X
Supply Limit
Step Therapy
Specialty
Therapeutic Class VITAMINS - VITAMIN E VITAMINS - VITAMIN K ACTIVITY Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs
Product Name WHEAT GERM OIL MEPHYTON TAB 5MG CITRANATAL CAP HARMONY INFANATE PRENA1
CAP PLUS CHW
Tier Value Tier 3 Tier 2 Tier 3 Tier 3 Tier 3
PRENA1 PEARL CAP
Tier 3
PRENATE
Tier 3
CAP ESSENTIA
REDICHEW RX CHW
Tier 3
VITAFOL-NANO TAB
Tier 3
VITAPEARL CAP
Tier 3
VP CH ULTRA CAP
Tier 3
Page 279 of 279
Prior Authorization
Supply Limit X
Step Therapy
Specialty