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2. drugs

Vital Traditions (HMO)
2015 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
Insurance Company of Scott & White is an HMO with a Medicare contract. Enrollment in Vital
Traditions depends on contract renewal.
This formulary was updated on 7/01/2015. For more recent information or other questions, please
contact Vital Traditions (HMO) Customer Service, at 1-888-423-7633 or, for TTY users, 1-800-735-2989,
Monday through Sunday, 8 a.m. to 8 p.m., or visit www.swhp.org.
This information is available for free in other languages.
Please contact our Customer Service at
1-888-423-7633, Monday – Sunday, 8 a.m. – 8 p.m., TTY users call 1-800-735-2989 for additional
information.
Esta información está disponible de forma gratuita en otros idiomas. Póngase en contacto con nuestro
Servicio de Atención al Cliente en 1-888 -423-7633, por el domingo, 8 de la mañana a 8 de la tarde, los
usuarios de TTY 1-800 -735-2989 llamada para obtener más información.
H8237_RXFORM2015
Formulary ID:
1
15308, Version:
13
Note to existing members: This formulary has changed since last year.
to make sure that it still contains the drugs you take.
Please review this document
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Insurance Company of Scott and
White. When it refers to “plan” or “our plan,” it means Vital Traditions.
This document includes a list of the drugs (formulary) for our plan which is current as of July 1, 2015.
For an updated formulary, please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2015, and
from time to time during the year.
What is the Vital Traditions (HMO) Formulary?
A formulary is a list of covered drugs selected by Vital Traditions in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. Vital Traditions will generally cover the drugs listed in our formulary as long as
the drug is medically necessary, the prescription is filled at a Vital Traditions network pharmacy, and
other plan rules are followed. For more information on how to fill your prescriptions, please review
your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug
from our formulary, will not affect members who are currently taking the drug. It will remain
available at the same cost-sharing for those members taking it for the remainder of the coverage year.
We feel it is important that you have continued access for the remainder of the coverage year to the
formulary drugs that were available when you chose our plan, except for cases in which you can save
additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of July 1, 2015. To get updated
information about the drugs covered by Vital Traditions, please contact us. Our contact information
appears on the front and back cover pages. Any changes made to the 2015 formulary will be inserted
into the formulary. This insert will appear toward the beginning of the formulary and will be titled
“2015 Formulary Changes”.
2
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used to
treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what
your drug is used for, look for the category name in the list that begins on page 8. Then look
under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 59. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first
column of the list.
What are generic drugs?
Vital Traditions covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost
less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:

Prior Authorization: Vital Traditions requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from Vital Traditions
before you fill your prescriptions. If you don’t get approval, Vital Traditions may not cover
the drug.

Quantity Limits: For certain drugs, Vital Traditions limits the amount of the drug that Vital
Traditions will cover. For example, Vital Traditions provides 90 tablets per prescription for
Oxycontin. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Vital Traditions requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For example,
if Drug A and Drug B both treat your medical condition, Vital Traditions may not cover Drug
B unless you try Drug A first. If Drug A does not work for you, Vital Traditions will then
cover Drug B.
3
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 8. You can also get more information about the restrictions applied to specific
covered drugs by visiting our Web site. We have posted on line documents that explain our prior
authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact
information, along with the date we last updated the formulary, appears on the front and back cover
pages.
You can ask Vital Traditions to make an exception to these restrictions or limits or for a list of other,
similar drugs that may treat your health condition. See the section, “How do I request an exception to
the Vital Traditions formulary?” on page 4 for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Customer
Service and ask if your drug is covered.
If you learn that Vital Traditions does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by Vital Traditions.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar
drug that is covered by Vital Traditions.

You can ask Vital Traditions to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the Vital Traditions (HMO) Formulary?
You can ask Vital Traditions to make an exception to our coverage rules.
exceptions that you can ask us to make.
There are several types of

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on
the specialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, Vital Traditions limits the amount of the drug that we will cover. If your drug
has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Vital Traditions will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would
not be as effective in treating your condition and/or would cause you to have adverse medical effects.
4
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally,
we must make our decision within 72 hours of getting your prescriber’s supporting statement. You
can request an expedited (fast) exception if you or your doctor believe that your health could be
seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we
must give you a decision no later than 24 hours after we get a supporting statement from your doctor
or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor to determine the
right course of action for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go
to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you
have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we
have provided you with 98-day transition supply, consistent with dispensing increment, (unless you
have a prescription written for fewer days). We will cover more than one refill of these drugs for the
first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will
cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
For members who experience a level of care change such as changing from one treatment setting to
another (e.g. discharge from a hospital to a long-term care facility), an exception for a one-time 31-day
supply will be allowed (unless the prescription is written for fewer days).
For more information
For more detailed information about your Vital Traditions prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Vital Traditions, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call
1-877-486-2048. Or, visit http://www.medicare.gov.
5
Vital Traditions’ Formulary
The formulary below provides coverage information about the drugs covered by Vital Traditions.
you have trouble finding your drug in the list, turn to the Index that begins on page 59.
If
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and
generic drugs are listed in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Vital Traditions has any special
requirements for coverage of your drug.
Column Abbreviations:
B/D
This prescription drug has a Part B versus D administrative prior authorization
requirement. This drug may be covered under Medicare Part B or D depending
upon the circumstances. Information may need to be submitted describing the
use and setting of the drug to make the determination.
Gap Coverage. We provide additional coverage of this prescription drug in the
coverage gap. Please refer to our Evidence of Coverage for more information
about this coverage.
Limited Availability. This prescription may be available only at certain pharmacies.
For more information consult your Pharmacy Directory or call Customer Service at
1-888-423-7633, Monday through Sunday, 8 a.m. to 8 p.m. TTY/TDD users should
call 1-800-735-2989.
Maintenance Medication
Prior Authorization Required
Quantity Limit
Step Therapy
GC
LA
M
PA
QL
ST
Drug Tiers and Drug Payment Stages:
The amount you pay for a covered drug will depend on:


Your drug payment stage. Your plan has different stages of drug coverage. When you fill a
prescription, the amount you pay depends on the stage you are in.
The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a
different copay or coinsurance amount. The chart below shows the different drug tiers.
For more information about drug payment stages and copay or coinsurance amounts for each tier,
please review your Evidence of Coverage.
Drug Tier
Tier 1: Preferred Generic
Tier 2: Non-Preferred Generic
Tier 3: Preferred Brand
Tier 4:
Tier 5:
Non-Preferred Brand
Specialty
Includes
Lower cost, commonly used generic drugs
Most generic drugs
Common brand name drugs that are considered preferred
brands
Non-preferred generic and non-preferred brand name drugs
Unique and/or very high-cost drugs
6
This formulary was updated on 7/01/2015. For more recent information or other questions, please
contact Vital Traditions Customer Service, at 1-888-423-7633 or, for TTY users, 1-800-735-2989,
Monday through Sunday, 8 a.m. to 8 p.m., or visit www.swhp.org.
Insurance Company of Scott & White is an HMO with a Medicare contract. Enrollment in Vital
Traditions depends on contract renewal.
H8237_RXFORM2015
7
DRUG NAME
ANALGESICS
acetaminophen/codeine #3
acetaminophen/codeine solution
acetaminophen/codeine tablet 300mg; 15mg,
300mg; 60mg
ascomp/codeine
butalbital/acetaminophen/caffeine/codeine
butalbital/acetaminophen/caffeine capsule
butalbital/acetaminophen/caffeine tablet 325mg;
50mg; 40mg
butalbital/apap/caffeine
butalbital/aspirin/caffeine capsule
butorphanol tartrate nasal solution
butorphanol tartrate injection
celecoxib capsule
codeine sulfate tablet
duramorph
endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg;
7.5mg
fentanyl citrate oral transmucosal lozenge on a
handle 200mcg
fentanyl citrate oral transmucosal lozenge on a
handle 1200mcg, 1600mcg, 400mcg, 600mcg,
800mcg
fentanyl patch 72 hour 100mcg/hr, 12mcg/hr,
25mcg/hr, 50mcg/hr, 75mcg/hr
hydrocodone bitartrate/acetaminophen solution
hydrocodone bitartrate/acetaminophen tablet
300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg, 325mg;
2.5mg
hydrocodone/acetaminophen tablet 325mg; 10mg,
325mg; 5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tablet 7.5mg; 200mg
hydromorphone hcl liquid
hydromorphone hcl tablet
DRUG TIER
NOTES
1
1
1
2
2
2
2
2
2
2
4
2
2
2
2
M
QL (180 EA per 30 days)
4
QL (120 EA per 30 days),PA
5
QL (120 EA per 30 days),PA
4
QL (20 EA per 30 days)
2
2
2
2
2
2
QL (240 EA per 30 days)
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
8
DRUG NAME
DRUG TIER
hydromorphone hcl injection 500mg/50ml
LAZANDA
levorphanol tartrate tablet
methadone hcl injection, oral solution
methadone hcl tablet
morphine sulfate er tablet extended release 100mg,
200mg, 60mg
morphine sulfate er tablet extended release 15mg,
30mg
morphine sulfate oral solution
morphine sulfate tablet
morphine sulfate injection 10mg/ml, 2mg/ml,
4mg/ml, 8mg/ml
NUCYNTA
NUCYNTA ER
oxycodone hcl er tablet er 12 hour abuse-deterrent
80mg
oxycodone hcl er tablet er 12 hour abuse-deterrent
10mg, 20mg, 40mg
oxycodone hcl concentrate, solution
oxycodone hcl capsule
oxycodone hcl tablet 10mg, 15mg, 20mg, 30mg
oxycodone hcl tablet 5mg
oxycodone/acetaminophen tablet 325mg; 10mg,
325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg
oxycodone/aspirin
OXYCONTIN TABLET ER 12 HOUR ABUSE-DETERRENT
80MG
OXYCONTIN TABLET ER 12 HOUR ABUSE-DETERRENT
10MG, 15MG, 20MG, 30MG, 40MG, 60MG
tramadol hcl tablet
tramadol hydrochloride/acetaminophen
ANESTHETICS
lidocaine hcl jelly
lidocaine hcl external solution
2
4
2
1
1
2
NOTES
QL (30 EA per 30 days),PA
QL (180 EA per 30 days)
QL (240 EA per 30 days)
QL (120 EA per 30 days)
2
QL (180 EA per 30 days)
2
2
2
QL (180 EA per 30 days)
4
4
4
QL (120 EA per 30 days)
4
QL (90 EA per 30 days)
2
2
2
2
2
QL (360 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
2
4
QL (120 EA per 30 days)
4
QL (90 EA per 30 days)
1
2
2
1
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
9
DRUG NAME
DRUG TIER
NOTES
lidocaine hcl injection 0.5%, 2%
lidocaine viscous
lidocaine/prilocaine cream
lidocaine ointment
lidocaine patch
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
acamprosate calcium dr
buprenorphine hcl/naloxone hcl
buprenorphine hcl injection, tablet sublingual
buproban
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHANTIX TABLET 0.5MG, 1MG
disulfiram tablet
naloxone hcl injection 1mg/ml
naltrexone hcl tablet
NICOTROL INHALER
NICOTROL NS
ANTI-INFLAMMATORY AGENTS
CELEBREX
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diclofenac sodium gel 3%
diflunisal tablet
etodolac er
etodolac capsule 300mg
etodolac capsule 200mg
etodolac tablet
fenoprofen calcium tablet
flurbiprofen tablet
ibuprofen suspension
ibuprofen tablet 400mg, 600mg, 800mg
1
1
2
2
2
PA
4
4
4
2
3
3
3
1
1
2
4
4
M
M
QL (60 EA per 30 days)
QL (60 EA per 30 days)
M
4
2
2
2
4
2
2
2
2
2
2
2
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
10
DRUG NAME
DRUG TIER
NOTES
ketoprofen er
ketoprofen capsule
meclofenamate sodium capsule
meloxicam tablet
meloxicam suspension
nabumetone
naproxen dr
naproxen sodium tablet 275mg, 550mg
naproxen suspension, tablet
oxaprozin
piroxicam capsule
sulindac tablet
tolmetin sodium capsule
tolmetin sodium tablet 200mg
tolmetin sodium tablet 600mg
VOLTAREN
ANTIBACTERIALS
alcohol preps
amikacin sulfate injection 500mg/2ml
amoxicillin
amoxicillin/clavulanate potassium
ampicillin
ampicillin sodium injection 10gm, 125mg, 1gm
ampicillin-sulbactam
AVELOX INJECTION
azithromycin packet, suspension reconstituted, tablet
azithromycin injection 500mg
aztreonam injection 1gm
bacitracin ointment
BACTROBAN NASAL
BICILLIN C-R
BICILLIN L-A
CEDAX CAPSULE
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
4
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
1
4
1
2
2
4
4
4
2
4
4
2
3
3
3
3
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
11
DRUG NAME
cefaclor er
cefaclor capsule
cefadroxil
cefazolin sodium injection 10gm, 1gm; 5%, 1gm,
500mg
cefdinir
cefepime injection 1gm/50ml; 5%, 1gm, 2gm/50ml;
5%, 2gm
cefixime
cefotaxime sodium injection 1gm, 2gm, 500mg
cefoxitin sodium injection 10gm, 1gm, 2gm
cefpodoxime proxetil
cefprozil
CEFTAZIDIME/DEXTROSE
ceftazidime injection 1gm, 2gm, 6gm
ceftriaxone sodium
cefuroxime axetil tablet
cefuroxime sodium injection 1.5gm, 7.5gm, 750mg
cephalexin capsule 250mg, 500mg
cephalexin suspension reconstituted, tablet
chloramphenicol sodium succinate
ciprofloxacin hcl solution, tablet
ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5%
ciprofloxacin suspension reconstituted
ciprofloxacin injection 400mg/40ml
clarithromycin er
clarithromycin suspension reconstituted, tablet
clindamycin hcl capsule
clindamycin palmitate hcl
clindamycin phosphate add-vantage
clindamycin phosphate in d5w
clindamycin phosphate cream, gel, lotion, solution,
swab
colistimethate sodium
DRUG TIER
NOTES
2
2
2
4
2
4
2
4
4
2
2
4
4
4
2
4
2
2
4
2
4
2
2
2
2
2
2
4
4
2
4
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
12
DRUG NAME
CUBICIN
demeclocycline hcl tablet
dicloxacillin sodium
doxycycline hyclate capsule, tablet
doxycycline hyclate injection
doxycycline monohydrate tablet 50mg, 75mg
doxycycline suspension reconstituted
e.e.s. 400
ery
ERY-TAB
ERYPED 200
ERYPED 400
erythrocin lactobionate injection 500mg
erythrocin stearate
erythromycin base tablet
erythromycin ethylsuccinate tablet
erythromycin gel, ointment, solution
garamycin solution
gatifloxacin
gentak
gentamicin sulfate/0.9% sodium chloride injection
0.9mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%,
1mg/ml; 0.9%
gentamicin sulfate cream, external ointment,
ophthalmic ointment, ophthalmic solution
gentamicin sulfate injection
IMIPENEM/CILASTATIN
INVANZ
isotonic gentamicin injection 0.8mg/ml; 0.9%
KETEK
LEVOFLOXACIN IN D5W INJECTION 5%;
500MG/100ML
LEVOFLOXACIN INJECTION
levofloxacin tablet
DRUG TIER
NOTES
5
4
2
2
4
2
2
2
2
3
3
3
4
2
2
2
2
1
2
1
4
1
4
4
3
4
4
4
4
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
13
DRUG NAME
levofloxacin oral solution
linezolid injection
meropenem injection 500mg
methenamine hippurate
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole capsule, cream, gel, lotion, tablet
minocycline hcl capsule, tablet
MONUROL
moxifloxacin hcl
mupirocin cream, ointment
nafcillin sodium injection 10gm, 1gm
neomycin sulfate tablet
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/hydrocortisone ophthalmic
suspension 1%; 3.5mg/ml; 10000unit/ml
nitrofurantoin macrocrystals capsule 50mg
nitrofurantoin monohydrate
nitrofurantoin suspension
ofloxacin ophthalmic solution, otic solution
ofloxacin tablet 300mg, 400mg
paromomycin sulfate
penicillin g potassium in iso-osmotic dextrose
injection 0; 40000unit/ml, 0; 60000unit/ml
penicillin g potassium injection 5000000unit
penicillin g procaine
penicillin g sodium
penicillin v potassium tablet
penicillin v potassium solution reconstituted
piperacillin sodium/tazobactam sodium injection
3gm; 0.375gm, 4gm; 0.5gm
polymyxin b sulfate injection
silver sulfadiazine cream
sodium sulfacetamide solution
DRUG TIER
NOTES
4
4
4
2
4
2
2
2
4
4
2
4
4
2
2
2
2
2
2
2
4
4
4
4
4
2
4
4
4
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
14
DRUG NAME
ssd
streptomycin sulfate injection
sulfacetamide sodium ointment, suspension
sulfadiazine tablet
sulfamethoxazole/trimethoprim ds
sulfamethoxazole/trimethoprim tablet
sulfamethoxazole/trimethoprim suspension
sulfamethoxazole/trimethoprim injection
SUPRAX CAPSULE, TABLET CHEWABLE, SUSPENSION
RECONSTITUTED
SYNERCID
tazicef injection 1gm, 2gm, 6gm
TEFLARO
tobramycin sulfate/sodium chloride injection 0.9%;
0.8mg/ml
tobramycin sulfate ophthalmic solution
tobramycin sulfate injection 10mg/ml, 80mg/2ml
trimethoprim tablet
TYGACIL
vancomycin hcl capsule
vancomycin hcl injection 1000mg, 10gm, 500mg
VIGAMOX
XIFAXAN
ZOSYN INJECTION 5%; 2GM/50ML; 0.25GM/50ML,
5%; 3GM/50ML; 0.375GM/50ML
ZYVOX
ANTICONVULSANTS
APTIOM
BANZEL
carbamazepine er
carbamazepine tablet chewable, suspension, tablet
CARBATROL
CELONTIN
clonazepam odt
DRUG TIER
NOTES
2
4
2
1
1
1
2
4
3
4
4
4
4
2
4
2
4
4
4
4
4
4
PA
5
4
4
2
2
3
3
4
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
15
DRUG NAME
DRUG TIER
NOTES
clonazepam tablet
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
diazepam gel 10mg, 2.5mg, 20mg
DILANTIN INFATABS
DILANTIN-125
DILANTIN CAPSULE 30MG
DILANTIN CAPSULE 100MG
divalproex sodium
divalproex sodium dr
divalproex sodium er
epitol
ethosuximide
felbamate
fosphenytoin sodium injection 100mg pe/2ml
FYCOMPA
gabapentin capsule, solution, tablet
GABITRIL TABLET 12MG, 16MG
lamotrigine
levetiracetam er
levetiracetam oral solution, tablet
levetiracetam injection
LYRICA
ONFI SUSPENSION
ONFI TABLET 10MG, 20MG
oxcarbazepine
PEGANONE
phenobarbital elixir, tablet
phenytoin sodium extended
phenytoin sodium injection
phenytoin tablet chewable, suspension
2
3
3
3
3
4
3
3
3
3
2
2
2
2
2
4
4
4
2
3
2
2
2
4
4
4
4
2
3
2
2
4
2
M
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
16
DRUG NAME
POTIGA
primidone tablet
SABRIL TABLET
SABRIL PACKET
TEGRETOL-XR
TEGRETOL SUSPENSION, TABLET
tiagabine hydrochloride
topiramate capsule sprinkle, tablet
TRILEPTAL
valproate sodium injection
valproic acid capsule, syrup
VIMPAT INJECTION
VIMPAT ORAL SOLUTION, TABLET
zonisamide
ANTIDEMENTIA AGENTS
donepezil hcl tablet dispersible
donepezil hcl tablet 10mg, 5mg
ergoloid mesylates tablet
EXELON PATCH 24 HOUR
NAMENDA
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION PACK
rivastigmine tartrate
ANTIDEPRESSANTS
amitriptyline hcl tablet
amoxapine
BRINTELLIX
BRISDELLE
bupropion hcl sr
bupropion hcl xl
bupropion hcl tablet
citalopram hydrobromide
DRUG TIER
NOTES
4
2
5
5
3
3
4
2
4
4
2
4
4
2
M
M
LA
LA,M
M
M
M
M
M
2
2
2
3
3
3
3
3
2
2
2
4
4
2
2
2
1
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
17
DRUG NAME
clomipramine hcl capsule
desipramine hcl tablet
duloxetine hcl capsule delayed release particles
EMSAM
escitalopram oxalate
FETZIMA
FETZIMA TITRATION PACK
fluoxetine hcl capsule, solution, tablet
fluvoxamine maleate
imipramine hcl tablet
maprotiline hcl
MARPLAN
mirtazapine odt
mirtazapine tablet
nefazodone hcl
nortriptyline hcl capsule, solution
paroxetine hcl
paroxetine hcl er
PAXIL SUSPENSION
phenelzine sulfate tablet
PRISTIQ
protriptyline hcl
sertraline hcl concentrate, tablet
SURMONTIL
tranylcypromine sulfate
trazodone hcl tablet
venlafaxine hcl
venlafaxine hcl er capsule extended release 24 hour
VIIBRYD KIT
VIIBRYD TABLET
ANTIEMETICS
dronabinol
EMEND CAPSULE 125MG, 40MG, 80MG
DRUG TIER
NOTES
2
2
2
4
2
4
4
1
2
2
2
3
2
2
2
1
2
4
4
2
4
2
1
4
2
1
2
2
4
4
M
M
M
4
4
M
M
M
M
M
M
M
M
M
M
,M
M
M
M
M
M
M
,M
M
M
M
M
M
QL (12 EA per 30 days),B/D
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
18
DRUG NAME
EMEND TRI PACK CAPSULE
granisetron hcl tablet
granisetron hcl injection 0.1mg/ml, 1mg/ml
meclizine hcl tablet
ondansetron hcl oral solution
ondansetron hcl injection 4mg/2ml
ondansetron hcl tablet 4mg, 8mg
ondansetron hcl tablet 24mg
ondansetron odt
phenadoz suppository 12.5mg
phenergan suppository
promethazine hcl injection, suppository, syrup, tablet
promethegan suppository 25mg, 50mg
TRANSDERM-SCOP
ANTIFUNGALS
AMBISOME
amphotericin b
CANCIDAS
ciclopirox
ciclopirox olamine cream
clotrimazole solution, troche
econazole nitrate cream
EXELDERM
fluconazole in dextrose injection 56mg/ml;
400mg/200ml
fluconazole suspension reconstituted, tablet
flucytosine
GRIS-PEG
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole capsule
ketoconazole cream, shampoo, tablet
DRUG TIER
NOTES
4
2
2
2
2
QL (6 EA per 30 days),B/D
QL (60 EA per 30 days),B/D
2
1
2
2
2
2
2
2
3
QL (900 ML per 30
days),B/D
QL (90 EA per 30 days),B/D
QL (20 EA per 30 days),B/D
QL (90 EA per 30 days),B/D
5
4
5
2
2
2
2
3
4
B/D
2
4
4
4
4
4
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
19
DRUG NAME
DRUG TIER
NATACYN
NOXAFIL SUSPENSION, TABLET DELAYED RELEASE
nyamyc
nystatin/triamcinolone
nystatin cream, ointment, powder, suspension, tablet
nystop
OXISTAT
terbinafine hcl tablet
terconazole
VORICONAZOLE INJECTION
VORICONAZOLE TABLET
voriconazole suspension reconstituted
ANTIGOUT AGENTS
allopurinol tablet
colchicine capsule, tablet
COLCRYS
probenecid/colchicine
probenecid tablet
ULORIC
ANTIMIGRAINE AGENTS
dihydroergotamine mesylate solution
ERGOMAR
MIGRANAL
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan
sumatriptan succinate tablet
sumatriptan succinate injection 6mg/0.5ml
ANTIMYASTHENIC AGENTS
guanidine hcl
pyridostigmine bromide tablet
ANTIMYCOBACTERIALS
CAPASTAT SULFATE
3
3
2
2
2
2
3
2
2
4
5
5
NOTES
PA
1
4
4
2
2
4
M
M
M
M
ST; M
2
4
3
4
4
2
1
4
QL (6 EA per 30 days)
QL (18 EA per 30 days)
QL (5 ML per 30 days)
1
1
M
4
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
20
DRUG NAME
dapsone tablet
ethambutol hcl tablet
isoniazid syrup, tablet
PASER
pyrazinamide tablet
rifabutin
rifampin capsule
rifampin injection
RIFATER
TRECATOR
ANTINEOPLASTICS
AFINITOR
AFINITOR DISPERZ
ALIMTA INJECTION 500MG
amifostine
anastrozole tablet
AVASTIN INJECTION 100MG/4ML
azacitidine
bicalutamide
bleomycin sulfate injection 30unit
BOSULIF
CAPRELSA
COMETRIQ
cyclophosphamide capsule
ELITEK INJECTION 1.5MG
EMCYT
ERIVEDGE
etoposide injection 500mg/25ml
exemestane
FARESTON
FARYDAK
FASLODEX
flutamide
DRUG TIER
NOTES
1
2
1
4
2
4
2
4
4
4
M
M
M
M
5
5
5
5
1
5
4
1
4
5
5
5
4
5
3
5
1
2
4
5
5
4
M
M
B/D
B/D
M
B/D
B/D
M
B/D
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
B/D
LA,M
B/D
M
M
B/D,M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
21
DRUG NAME
GILOTRIF
GLEEVEC
HEXALEN
hydroxyurea capsule
IBRANCE
ICLUSIG
IMBRUVICA
INLYTA
JAKAFI
LENVIMA 10MG DAILY DOSE
LENVIMA 14MG DAILY DOSE
LENVIMA 20MG DAILY DOSE
LENVIMA 24MG DAILY DOSE
letrozole
leucovorin calcium injection 100mg, 350mg
leucovorin calcium tablet 25mg
leucovorin calcium tablet 10mg, 15mg, 5mg
LEUKERAN
lomustine
LYNPARZA
MATULANE
MEKINIST
mercaptopurine tablet
MESNEX TABLET
mitoxantrone hcl
NEXAVAR
NILANDRON
PANRETIN
POMALYST
PROLEUKIN
PURIXAN
REVLIMID
RITUXAN
DRUG TIER
NOTES
5
5
5
1
5
5
5
5
5
5
5
5
5
2
4
1
4
3
2
5
5
5
2
4
1
5
4
5
5
5
5
5
5
PA,M
PA,M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
PA
LA
M
M
B/D
PA,M
B/D,M
LA
M
M
B/D
LA,M
B/D
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
22
DRUG NAME
SOLTAMOX
SPRYCEL
STIVARGA
SUTENT
SYLATRON
SYLVANT INJECTION 100MG
TABLOID
TAFINLAR
tamoxifen citrate tablet
TARCEVA
TARGRETIN CAPSULE
TASIGNA
THALOMID
topotecan hcl injection 4mg
tretinoin capsule 10mg
TRISENOX
TYKERB
VALCHLOR
VELCADE
VOTRIENT
XALKORI
XTANDI
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
ZYTIGA
ANTIPARASITICS
ALBENZA
ALINIA
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate tablet
DRUG TIER
NOTES
4
5
5
5
5
5
4
5
2
5
5
5
5
4
5
4
5
5
5
5
5
5
5
5
5
5
5
M
PA,M
LA
3
4
4
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
PA
M
PA,M
M
M
M
B/D
B/D
LA,M
M
B/D
PA,M
M
PA,M
PA
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
23
DRUG NAME
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
ivermectin tablet
lindane lotion, shampoo
mefloquine hcl
NEBUPENT
PENTAM 300
permethrin cream
primaquine phosphate tablet
quinine sulfate
STROMECTOL
ANTIPARKINSON AGENTS
amantadine hcl capsule, syrup, tablet
APOKYN
AZILECT
benztropine mesylate tablet
bromocriptine mesylate capsule, tablet
carbidopa/levodopa
carbidopa/levodopa er
entacapone
NEUPRO
pramipexole dihydrochloride tablet 0.75mg
pramipexole dihydrochloride tablet 0.125mg,
0.25mg, 0.5mg, 1.5mg, 1mg
ropinirole hcl
selegiline hcl capsule, tablet
trihexyphenidyl hcl
ANTIPSYCHOTICS
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY INJECTION
ABILIFY TABLET
DRUG TIER
4
3
2
2
2
2
4
4
1
2
4
3
NOTES
M
M
B/D
M
2
4
4
1
2
1
1
2
4
1
1
M
LA,M
M
M
M
M
M
M
M
2
1
2
M
M
M
4
5
4
4
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
24
DRUG NAME
chlorpromazine hcl injection
chlorpromazine hcl tablet
clozapine
clozapine odt tablet dispersible 100mg, 12.5mg,
25mg
FANAPT
FANAPT TITRATION PACK
FAZACLO
fluphenazine decanoate injection
fluphenazine hcl concentrate, injection
fluphenazine hcl elixir, tablet
GEODON INJECTION
haloperidol decanoate
haloperidol lactate
haloperidol concentrate, tablet
INVEGA
INVEGA SUSTENNA INJECTION 39MG/0.25ML,
78MG/0.5ML
INVEGA SUSTENNA INJECTION 117MG/0.75ML,
156MG/ML, 234MG/1.5ML
LATUDA
loxapine succinate capsule
olanzapine odt
olanzapine tablet
olanzapine injection
ORAP
perphenazine tablet
prochlorperazine
prochlorperazine edisylate injection
prochlorperazine maleate tablet
quetiapine fumarate
RISPERDAL CONSTA
risperidone
risperidone odt
DRUG TIER
NOTES
2
2
1
4
M
M
M
4
4
4
2
2
2
4
2
2
2
4
4
M
5
M
4
2
2
2
4
3
2
2
2
2
2
4
2
2
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
25
DRUG NAME
SAPHRIS TABLET SUBLINGUAL 10MG, 5MG
SEROQUEL XR
thioridazine hcl tablet
thiothixene capsule
trifluoperazine hcl tablet
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV INJECTION 210MG
ANTISPASTICITY AGENTS
baclofen tablet
tizanidine hcl tablet
ANTIVIRALS
abacavir
abacavir sulfate/lamivudine/zidovudine
acyclovir sodium injection 50mg/ml
acyclovir ointment
acyclovir capsule, suspension, tablet
adefovir dipivoxil
APTIVUS
ATRIPLA
BARACLUDE SOLUTION
BARACLUDE TABLET
COMPLERA
CRIXIVAN
DENAVIR
didanosine
EDURANT
EMTRIVA
entecavir
EPIVIR HBV SOLUTION
EPIVIR SOLUTION
EPZICOM
EVOTAZ
DRUG TIER
NOTES
4
3
2
2
2
4
2
4
M
M
M
M
M
M
M
M
1
1
M
M
2
2
4
2
2
4
3
4
4
5
5
3
3
2
5
3
4
3
3
4
5
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
26
DRUG NAME
famciclovir tablet
FOSCARNET SODIUM
FUZEON
ganciclovir injection
HARVONI
INTELENCE
INTRON A W/DILUENT INJECTION 10MU
INTRON A INJECTION 18MU, 50MU,
6000000UNIT/ML
INVIRASE
ISENTRESS PACKET
ISENTRESS TABLET CHEWABLE, TABLET
KALETRA
lamivudine
lamivudine/zidovudine
LEXIVA
nevirapine suspension
nevirapine tablet
NORVIR
OLYSIO
PEG-INTRON REDIPEN
PEG-INTRON INJECTION 120MCG/0.5ML,
50MCG/0.5ML
PEGASYS
PEGASYS PROCLICK INJECTION 135MCG/0.5ML
PEGINTRON INJECTION 150MCG/0.5ML,
80MCG/0.5ML
PREZCOBIX
PREZISTA SUSPENSION
PREZISTA TABLET 150MG, 600MG, 75MG, 800MG
RELENZA DISKHALER
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ PACKET
DRUG TIER
2
4
3
1
5
4
4
4
3
3
3
4
2
2
3
2
2
3
5
5
5
NOTES
B/D
M
PA
M
M
M
M
M
M
M
M
M
PA
5
5
5
5
3
3
4
3
4
3
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
27
DRUG NAME
REYATAZ CAPSULE 150MG, 200MG, 300MG
ribavirin
rimantadine hcl
SELZENTRY
SOVALDI
stavudine
STRIBILD
SUSTIVA
TAMIFLU SUSPENSION RECONSTITUTED
TAMIFLU CAPSULE 30MG
TAMIFLU CAPSULE 45MG, 75MG
TIVICAY
trifluridine solution
TRIUMEQ
TRUVADA
TYBOST
TYZEKA
valacyclovir hcl
VALCYTE
VALGANCICLOVIR
VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM
VIRACEPT
VIRAZOLE
VIREAD
VITEKTA
ZIAGEN SOLUTION
zidovudine
ANXIOLYTICS
alprazolam
alprazolam intensol
buspirone hcl tablet
chlordiazepoxide hcl
clorazepate dipotassium
DRUG TIER
NOTES
3
1
2
4
5
2
5
3
3
3
3
5
2
5
4
4
4
2
5
5
3
3
5
3
5
3
2
M
M
PA
M
M
M
QL (112 EA per 365 days)
QL (56 EA per 365 days)
M
2
2
1
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
B/D
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
28
DRUG NAME
diazepam intensol
diazepam solution 1mg/ml
diazepam tablet 10mg, 2mg, 5mg
doxepin hcl capsule 150mg
doxepin hcl capsule 100mg, 10mg, 25mg, 50mg,
75mg
doxepin hcl concentrate
estazolam
lorazepam intensol
lorazepam tablet
oxazepam
triazolam
BIPOLAR AGENTS
lithium
lithium carbonate er
lithium carbonate capsule, tablet
BLOOD,GLUCOSE REGULATORS
acarbose
APIDRA
APIDRA SOLOSTAR
BYDUREON
BYETTA
CYCLOSET
glimepiride
glipizide er
glipizide/metformin hcl
glipizide tablet
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
DRUG TIER
NOTES
2
2
2
2
2
M
2
2
2
2
2
2
M
1
1
1
M
M
M
2
4
4
4
4
4
1
1
1
1
3
3
3
3
3
3
M
M
M
PA,M
PA,M
M
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
29
DRUG NAME
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMULIN 70/30
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
INVOKANA
JANUMET
JANUVIA
JENTADUETO
KOMBIGLYZE XR
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
metformin hcl er tablet extended release 24 hour
500mg, 750mg
metformin hcl tablet
nateglinide
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
ONGLYZA
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
PROGLYCEM
DRUG TIER
NOTES
3
3
3
3
3
3
3
3
4
4
4
3
4
3
3
3
3
1
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
1
2
3
3
3
3
3
3
3
4
2
2
2
3
M
M
M
M
M
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
30
DRUG NAME
DRUG TIER
NOTES
SYMLINPEN 120
SYMLINPEN 60
tolazamide
tolbutamide
TRADJENTA
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
AGGRENOX
anagrelide hydrochloride capsule 1mg
anagrelide hydrochloride capsule 0.5mg
ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML,
100MCG/ML, 10MCG/0.4ML, 25MCG/0.42ML,
25MCG/ML, 40MCG/0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/ML
ARANESP ALBUMIN FREE INJECTION 150MCG/0.3ML,
200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML,
300MCG/ML, 500MCG/ML
ARGATROBAN INJECTION 100MG/ML,
125MG/125ML; 0.9%
BRILINTA
cilostazol
clopidogrel tablet 75mg
COUMADIN TABLET
CYKLOKAPRON
EFFIENT
ELIQUIS
enoxaparin sodium injection 40mg/0.4ml
enoxaparin sodium injection 60mg/0.6ml
enoxaparin sodium injection 120mg/0.8ml,
80mg/0.8ml
enoxaparin sodium injection 100mg/ml, 150mg/ml
enoxaparin sodium injection 30mg/0.3ml
fondaparinux sodium injection 2.5mg/0.5ml
fondaparinux sodium injection 5mg/0.4ml
fondaparinux sodium injection 7.5mg/0.6ml
4
4
2
2
3
M
M
M
M
M
4
2
2
4
M
M
B/D,M
5
B/D,M
4
3
2
1
3
3
4
3
4
4
4
M
M
M
M
M
PA,M
QL (12 ML per 30 days)
QL (36 ML per 30 days)
QL (48 ML per 30 days)
4
4
4
4
4
QL (60 ML per 30 days)
QL (9 ML per 30 days)
QL (15 ML per 30 days)
QL (12 ML per 30 days)
QL (18 ML per 30 days)
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
31
DRUG NAME
DRUG TIER
NOTES
fondaparinux sodium injection 10mg/0.8ml
FRAGMIN INJECTION 12500UNIT/0.5ML
FRAGMIN INJECTION 15000UNIT/0.6ML
FRAGMIN INJECTION 18000UNT/0.72ML
FRAGMIN INJECTION 10000UNIT/ML
FRAGMIN INJECTION 2500UNIT/0.2ML,
5000UNIT/0.2ML
FRAGMIN INJECTION 7500UNIT/0.3ML
heparin sodium/d5w
heparin sodium injection 10000unit/ml, 1000unit/ml,
20000unit/ml, 5000unit/ml
jantoven
LEUKINE INJECTION 250MCG
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN INJECTION 300MCG/0.5ML,
480MCG/0.8ML, 480MCG/1.6ML
PRADAXA
PROCRIT INJECTION 2000UNIT/ML, 3000UNIT/ML,
4000UNIT/ML
PROCRIT INJECTION 10000UNIT/ML, 20000UNIT/ML,
40000UNIT/ML
PROMACTA
TRANEXAMIC ACID TABLET
tranexamic acid injection
warfarin sodium tablet
XARELTO STARTER PACK
XARELTO TABLET 15MG, 20MG
XARELTO TABLET 10MG
CARDIOVASCULAR AGENTS
acebutolol hcl capsule
acetazolamide tablet
ADVICOR
4
4
4
4
4
4
QL (24 ML per 30 days)
QL (15 ML per 30 days)
QL (18 ML per 30 days)
QL (21.6 ML per 30 days)
QL (30 ML per 30 days)
QL (6 ML per 30 days)
4
2
2
QL (9 ML per 30 days)
2
5
5
5
5
5
M
B/D
QL (9.6 ML per 30 days),PA
B/D
B/D
B/D
3
3
PA,M
B/D,M
4
B/D,M
5
4
4
1
3
3
3
LA,M
M
M
PA
PA,M
QL (35 EA per 35 days)
2
1
3
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
32
DRUG NAME
DRUG TIER
NOTES
afeditab cr
ALDACTAZIDE TABLET 50MG; 50MG
amiloride hcl tablet
amiloride/hydrochlorothiazide
amiodarone hcl injection 50mg/ml
amiodarone hcl tablet 200mg, 400mg
amlodipine besylate/benazepril hcl
amlodipine besylate/benazepril hydrochloride
amlodipine besylate/valsartan
amlodipine besylate tablet
amlodipine/valsartan/hctz
atenolol/chlorthalidone
atenolol tablet
atorvastatin calcium
AZOR
benazepril hcl/hydrochlorothiazide
benazepril hcl tablet
BENICAR
BENICAR HCT
betaxolol hcl tablet 10mg, 20mg
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
bumetanide injection
bumetanide tablet
BYSTOLIC
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
captopril/hydrochlorothiazide
captopril tablet
cartia xt
carvedilol
chlorothiazide
chlorthalidone tablet 25mg, 50mg
2
3
2
2
2
2
2
2
2
1
2
1
1
1
3
1
1
3
3
2
2
2
2
2
4
2
2
2
2
2
1
2
2
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
33
DRUG NAME
cholestyramine light packet
clonidine hcl tablet
clonidine hcl patch weekly
colestipol hcl
CRESTOR
DEMSER
DIBENZYLINE
digitek tablet 0.125mg
digitek tablet 0.25mg
digoxin injection
digoxin oral solution
digoxin tablet 125mcg
digoxin tablet 250mcg
dilt-xr
diltiazem cd capsule extended release 24 hour 240mg
diltiazem hcl er capsule extended release 24 hour
120mg, 180mg, 300mg, 360mg, 420mg
diltiazem hcl er capsule extended release 12 hour
diltiazem hcl tablet
diltiazem hcl injection 100mg, 50mg/10ml
DIOVAN
disopyramide phosphate capsule
enalapril maleate/hydrochlorothiazide
enalapril maleate tablet
EXFORGE
EXFORGE HCT
felodipine er
fenofibrate micronized
fenofibrate tablet 145mg, 160mg, 48mg, 54mg
fenofibric acid dr
flecainide acetate
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
DRUG TIER
NOTES
2
1
2
2
3
4
3
1
2
2
2
1
2
2
2
2
M
M
M
M
M
QL (30 EA per 30 days),M
M
M
QL (30 EA per 30 days),M
M
M
M
M
2
2
2
4
2
1
1
4
4
2
2
2
2
2
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
34
DRUG NAME
furosemide injection
furosemide oral solution, tablet
gemfibrozil tablet
hydralazine hcl injection
hydralazine hcl tablet
hydrochlorothiazide capsule, tablet
indapamide tablet
irbesartan
irbesartan/hydrochlorothiazide
isosorbide dinitrate er
isosorbide dinitrate tablet
isosorbide mononitrate
isosorbide mononitrate er
labetalol hcl injection
labetalol hcl tablet
LANOXIN TABLET 250MCG
LANOXIN TABLET 125MCG
lisinopril
lisinopril/hydrochlorothiazide
losartan potassium
losartan potassium/hydrochlorothiazide
lovastatin
methyclothiazide tablet
metolazone
metoprolol succinate er
metoprolol tartrate tablet
metoprolol tartrate injection
metoprolol/hydrochlorothiazide
mexiletine hcl
midodrine hcl
minoxidil tablet
MULTAQ
nadolol/bendroflumethiazide
DRUG TIER
1
1
1
2
2
1
2
2
2
2
2
2
2
2
2
3
3
1
1
1
1
2
2
2
2
1
2
2
2
4
2
3
2
NOTES
M
M
M
M
M
M
M
M
M
M
M
M
M
QL (30 EA per 30 days),M
M
M
M
M
M
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
35
DRUG NAME
nadolol tablet
niacin er
nifedical xl
nifedipine er
nimodipine capsule
NITRO-BID
NITRO-DUR PATCH 24 HOUR 0.3MG/HR, 0.8MG/HR
nitroglycerin lingual solution
nitroglycerin transdermal patch 24 hour 0.1mg/hr
nitroglycerin injection
nitroglycerin patch 24 hour 0.2mg/hr, 0.4mg/hr,
0.6mg/hr
NITROLINGUAL PUMPSPRAY
NITROSTAT
NORPACE CR CAPSULE EXTENDED RELEASE 12 HOUR
150MG
omega-3-acid ethyl esters
pacerone
pentoxifylline er
pindolol
pravastatin sodium
prazosin hcl
prevalite powder
procainamide hcl injection
propafenone hcl
propranolol hcl er
propranolol hcl injection
propranolol hcl oral solution, tablet
propranolol/hydrochlorothiazide
quinapril hcl
quinapril/hydrochlorothiazide
quinidine gluconate cr
quinidine sulfate
DRUG TIER
NOTES
2
2
2
2
4
3
3
2
2
2
2
M
M
M
M
M
M
M
M
3
2
3
M
M
M
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
36
DRUG NAME
quinidine sulfate er
ramipril
RANEXA
reserpine tablet
SIMCOR TABLET EXTENDED RELEASE 24 HOUR
1000MG; 40MG, 500MG; 40MG
SIMCOR TABLET EXTENDED RELEASE 24 HOUR
1000MG; 20MG, 500MG; 20MG, 750MG; 20MG
simvastatin
sotalol hcL,(af) tablet 120mg
sotalol hcl tablet 160mg, 240mg, 80mg
spironolactone/hydrochlorothiazide
spironolactone tablet
taztia xt
TEKTURNA
TEKTURNA HCT
TIKOSYN
torsemide tablet
torsemide injection 20mg/2ml
triamterene/hydrochlorothiazide
TRIBENZOR
valsartan
valsartan/hydrochlorothiazide
VASCEPA
verapamil hcl er
verapamil hcl sr capsule extended release 24 hour
360mg
verapamil hcl injection
verapamil hcl tablet
VYTORIN
WELCHOL
ZETIA
CENTRAL NERVOUS SYSTEM AGENTS
amphetamine/dextroamphetamine
DRUG TIER
NOTES
2
2
4
2
3
M
M
M
M
3
M
1
2
2
2
2
2
4
4
4
2
2
1
3
2
2
4
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
2
2
3
4
3
M
M
M
M
2
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
37
DRUG NAME
DRUG TIER
NOTES
AUBAGIO
AVONEX
COPAXONE INJECTION 20MG/ML
dextroamphetamine sulfate er
dextroamphetamine sulfate tablet
EXTAVIA
GILENYA
guanfacine er
INTUNIV
methylphenidate hcl cd capsule extended release
10mg
methylphenidate hcl er capsule extended release 24
hour
methylphenidate hcl er tablet extended release 20mg
methylphenidate hcl tablet
methylphenidate hydrochloride
NUEDEXTA
riluzole
SAVELLA
SAVELLA TITRATION PACK
STRATTERA
TECFIDERA
TECFIDERA STARTER PACK
TYSABRI
VYVANSE
XENAZINE
DENTAL AND ORAL AGENTS
chlorhexidine gluconate oral rinse
pilocarpine hcl tablet 7.5mg
pilocarpine hydrochloride
triamcinolone in orabase
DERMATOLOGICAL AGENTS
acitretin
5
5
5
2
2
5
5
4
4
2
PA,M
M
QL (30 ML per 30 days),M
M
M
QL (15 EA per 30 days),M
PA,M
M
M
M
2
M
2
2
2
4
2
3
3
3
5
5
5
3
5
M
M
M
M
M
PA,M
PA,M
B/D
M
LA,M
1
2
2
2
4
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
38
DRUG NAME
amnesteem
calcipotriene
calcipotriene/betamethasone dipropionate
calcitriol ointment 3mcg/gm
CARAC
claravis
clotrimazole/betamethasone dipropionate
CORTISPORIN
ELIDEL
fluorouracil
imiquimod cream
methoxsalen capsule
myorisan
PICATO
podofilox solution
PROTOPIC
REGRANEX
RETIN-A MICRO PUMP GEL 0.08%, 0.1%
RETIN-A MICRO GEL 0.04%
SANTYL
selenium sulfide lotion
STELARA
TACLONEX SUSPENSION
tacrolimus ointment 0.03%, 0.1%
TAZORAC
tretinoin microsphere
tretinoin cream 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%
zenatane capsule 10mg, 20mg, 40mg
ZYCLARA
ZYCLARA PUMP CREAM 2.5%
ENZYME REPLACEMENT/MODIFIERS
ADAGEN
DRUG TIER
4
2
4
4
3
4
2
3
4
2
4
2
4
4
2
4
4
3
3
3
1
5
4
4
4
2
2
2
4
4
4
NOTES
PA
PA
PA,M
PA
PA
PA
PA
5
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
39
DRUG NAME
ALDURAZYME
CEREZYME INJECTION 400UNIT
CREON
CYSTADANE
CYSTAGON
ELAPRASE
FABRAZYME INJECTION 35MG
KUVAN TABLET SOLUBLE
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
ZAVESCA
ZENPEP
GASTROINTESTINAL AGENTS
AMITIZA
CARAFATE SUSPENSION
cimetidine hcl solution
cimetidine tablet 300mg, 400mg, 800mg
constulose
cromolyn sodium concentrate 100mg/5ml
dicyclomine hcl
diphenoxylate/atropine
enulose
famotidine tablet 20mg, 40mg
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
glycopyrrolate tablet
GOLYTELY
lactulose solution
lansoprazole capsule delayed release
DRUG TIER
5
5
3
4
4
5
5
5
5
5
5
5
5
4
4
3
2
2
2
2
2
2
2
1
2
2
2
2
2
3
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
NOTES
M
M
LA,M
LA,M
LA,M
PA
PA
LA,M
M
LA,M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
40
DRUG NAME
loperamide hcl capsule
LOTRONEX
metoclopramide hcl injection, oral solution, tablet
misoprostol
nizatidine capsule
omeprazole capsule delayed release 20mg
omeprazole capsule delayed release 10mg, 40mg
pantoprazole sodium tablet delayed release
polyethylene glycol 3350 powder
propantheline bromide
rabeprazole sodium
ranitidine hcl capsule, syrup
ranitidine hcl injection 150mg/6ml
ranitidine hcl tablet 150mg, 300mg
RELISTOR
sucralfate tablet
trilyte
ursodiol capsule, tablet
GENITOURINARY AGENTS
alfuzosin hcl er
AVODART
bethanechol chloride tablet
calcium acetate capsule
doxazosin mesylate tablet 2mg, 8mg
doxazosin mesylate tablet 1mg, 4mg
ELMIRON
ENABLEX
finasteride tablet 5mg
flavoxate hcl
MYRBETRIQ
oxybutynin chloride er
oxybutynin chloride tablet
oxybutynin chloride syrup
DRUG TIER
NOTES
1
3
2
2
2
2
2
2
2
2
2
1
1
1
4
1
2
2
M
M
2
4
2
1
1
1
3
4
2
2
3
2
1
2
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
41
DRUG NAME
DRUG TIER
NOTES
RENAGEL
RENVELA
tamsulosin hcl
terazosin hcl
tolterodine tartrate
tolterodine tartrate er
VESICARE
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
alclometasone dipropionate
amcinonide
augmented betamethasone dipropionate
betamethasone dipropionate cream, lotion, ointment
betamethasone valerate cream, lotion, ointment
budesonide capsule extended release 24 hour
clobetasol propionate e
clobetasol propionate gel, ointment, solution
CORTIFOAM
desonide cream, lotion, ointment
desoximetasone cream, gel, ointment
dexamethasone sodium phosphate injection
10mg/ml, 120mg/30ml
dexamethasone elixir, tablet
diflorasone diacetate cream, ointment
fludrocortisone acetate tablet
fluocinolone acetonide body
fluocinolone acetonide cream, oil, ointment, solution
fluocinonide-e
fluocinonide gel, ointment, solution
fluticasone propionate cream 0.05%
fluticasone propionate lotion 0.05%
fluticasone propionate ointment 0.005%
halobetasol propionate
4
4
2
1
2
2
4
M
M
M
M
M
M
2
2
2
2
2
4
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
42
DRUG NAME
DRUG TIER
NOTES
hydrocortisone butyrate (lipophilic)
hydrocortisone butyrate ointment, solution
hydrocortisone valerate
hydrocortisone cream 2.5%
hydrocortisone enema
hydrocortisone tablet
hydrocortisone lotion 2.5%
hydrocortisone ointment 2.5%
methylprednisolone acetate injection
methylprednisolone dose pack
methylprednisolone sodiumsuccinate injection
125mg, 40mg
methylprednisolone tablet
millipred tablet
mometasone furoate cream, ointment, solution
prednisolone sodium phosphate oral solution
15mg/5ml, 25mg/5ml, 5mg/5ml
prednisone solution, tablet
proctosol hc
proctozone-hc
SOLU-CORTEF INJECTION 100MG, 250MG
triamcinolone acetonide cream 0.025%, 0.1%, 0.5%
triamcinolone acetonide injection 10mg/ml, 40mg/ml
triamcinolone acetonide lotion 0.025%, 0.1%
triamcinolone acetonide ointment 0.025%, 0.1%,
0.5%
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin acetate tablet
desmopressin acetate injection
desmopressin acetate nasal solution
INCRELEX
NORDITROPIN FLEXPRO INJECTION 10MG/1.5ML,
15MG/1.5ML, 5MG/1.5ML
2
2
2
2
1
2
2
2
2
2
2
M
2
2
2
2
1
2
2
4
2
2
2
2
2
4
4
4
5
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
LA
PA,M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
43
DRUG NAME
NORDITROPIN NORDIFLEX PEN
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYING (SEX
HORMONES/MODIFIERS)
amethia
amethyst
ANDRODERM
ANDROGEL
ANDROGEL PUMP
apri
aubra
aviane
balziva
briellyn
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
CYCLESSA
danazol capsule
deblitane
delyla
DEPO-TESTOSTERONE
desogestrel/ethinyl estradiol tablet 0; 0
drospirenone/ethinyl estradiol
ELLA
emoquette
enpresse-28
ESTRACE CREAM
estradiol valerate injection 20mg/ml, 40mg/ml
estradiol/norethindrone acetate
estradiol patch weekly, tablet
estradiol patch twice weekly
estropipate tablet
DRUG TIER
NOTES
5
PA,M
2
2
4
4
4
2
2
2
2
2
2
2
2
3
4
2
2
3
2
2
3
2
2
3
2
2
2
4
2
M
M
M
M
M
M
M
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
44
DRUG NAME
DRUG TIER
falmina
2
gildess 1.5/30
2
gildess 24 fe
2
introvale
2
kariva
2
larin 1.5/30
2
larin 1/20
2
larin fe 1.5/30
2
larin fe 1/20
2
lessina
2
levonorgestrel and ethinyl estradiol tablet 20mcg;
2
90mcg
levonorgestrel/ethinyl estradiol tablet 0.03mg;
2
0.15mg, 20mcg; 0.1mg
levora 0.15/30-28
2
low-ogestrel
2
lutera
2
marlissa
2
medroxyprogesterone acetate injection, tablet
2
megestrol acetate tablet
2
megestrol acetate suspension
2
menest
4
microgestin 1.5/30
2
microgestin 1/20
2
microgestin fe
2
microgestin fe 1.5/30
2
necon 0.5/35-28
2
necon 1/35
2
necon 10/11-28
2
necon 7/7/7
2
nikki
2
norethindrone & ethinyl estradiol ferrous fumarate
2
norethindrone acetate/ethinyl estradiol/ferrous
2
fumarate
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
NOTES
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
PA,M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
45
DRUG NAME
norethindrone acetate tablet
norlyroc
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
ogestrel
orsythia
oxandrolone tablet
portia-28
PREMARIN CREAM
PREMARIN INJECTION
PREMARIN TABLET
PREMPHASE
PREMPRO
quasense
raloxifene hydrochloride
reclipsen
sharobel
sronyx
tarina fe 1/20
TESTIM
testosterone cypionate injection 200mg/ml
testosterone enanthate injection
testosterone pump
testosterone gel 1%, 25mg/2.5gm
tri-legest fe
trivora-28
velivet
VIVELLE-DOT
vyfemla
wymzya fe
zenchent
DRUG TIER
NOTES
2
2
2
2
2
2
2
2
2
2
3
4
4
3
4
2
2
2
2
2
2
4
2
2
4
4
2
2
2
4
2
2
2
M
M
M
M
M
M
M
M
M
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
46
DRUG NAME
DRUG TIER
NOTES
zenchent fe
zovia 1/35e
zovia 1/50e
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYING (SEX
HORMONES/MODIFIERS)
levothyroxine sodium tablet
LEVOXYL
liothyronine sodium tablet
SYNTHROID
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
HORMONAL AGENTS, SUPPRESSANT (ADRENAL
LYSODREN
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline
leuprolide acetate injection
LUPRON DEPOT
LUPRON DEPOT-PED INJECTION 11.25MG, 15MG
octreotide acetate injection 100mcg/ml, 200mcg/ml,
50mcg/ml
octreotide acetate injection 1000mcg/ml, 500mcg/ml
SANDOSTATIN INJECTION 500MCG/ML, 50MCG/ML
SANDOSTATIN INJECTION 1000MCG/ML,
100MCG/ML, 200MCG/ML
SOMATULINE DEPOT
SOMAVERT INJECTION 20MG, 25MG, 30MG
SOMAVERT INJECTION 10MG, 15MG
SYNAREL
2
2
2
M
M
M
1
3
2
3
3
3
3
3
3
M
M
M
M
M
M
M
M
M
3
3
M
1
4
5
5
4
M
B/D
B/D
5
4
5
5
5
5
5
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
B/D,M
LA,M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
47
DRUG NAME
HORMONAL AGENTS, SUPPRESSANT (THYROID)
methimazole tablet
propylthiouracil tablet
IMMUNOLOGICAL AGENTS
ACTEMRA INJECTION 162MG/0.9ML
ACTHIB
ACTIMMUNE
ADACEL
ARCALYST
ATGAM
azathioprine tablet
BEXSERO
BOOSTRIX
CARIMUNE NANOFILTERED INJECTION 6GM
CELLCEPT
CERVARIX
CIMZIA
CINRYZE
COMVAX
cyclosporine modified capsule 50mg
cyclosporine modified capsule 100mg, 25mg
cyclosporine modified solution
cyclosporine capsule
DAPTACEL
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC
ENBREL
ENGERIX-B
FIRAZYR
GAMMAGARD LIQUID
GAMUNEX-C INJECTION 1GM/10ML
GARDASIL
GARDASIL 9
DRUG TIER
NOTES
1
1
M
M
5
3
5
3
5
5
2
3
3
5
4
3
5
5
3
2
2
2
2
3
3
PA,M
5
3
5
5
3
3
3
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
LA,M
B/D
B/D,M
B/D
B/D,M
PA,M
PA
B/D
B/D,M
B/D,M
B/D,M
PA,M
B/D
PA
B/D
B/D
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
48
DRUG NAME
DRUG TIER
NOTES
gengraf
HAVRIX
HUMIRA
HUMIRA PEN-CROHNS DISEASESTARTER
ILARIS
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINERET
leflunomide
M-M-R II W/DILUENT 10 DOSE
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
methotrexate sodium injection 1gm/40ml, 1gm
methotrexate tablet
mycophenolate mofetil
mycophenolic acid dr
MYFORTIC
NEORAL
NULOJIX
ORENCIA INJECTION 250MG
ORENCIA INJECTION 125MG/ML
PEDVAX HIB
PRIVIGEN INJECTION 20GM/200ML
PROGRAF INJECTION
PROGRAF CAPSULE
PROQUAD
QUADRACEL
RABAVERT
RAPAMUNE SOLUTION
RAPAMUNE TABLET 0.5MG
2
3
5
5
5
3
3
3
4
5
1
3
3
3
3
2
2
2
2
4
3
5
5
5
3
5
4
4
3
3
3
4
4
B/D,M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
PA,M
PA,M
PA
PA,M
M
M
B/D,M
B/D,M
B/D,M
B/D,M
B/D,M
B/D,M
PA,M
B/D
B/D
B/D,M
B/D,M
B/D
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
49
DRUG NAME
RAPAMUNE TABLET 1MG, 2MG
RECOMBIVAX HB
REMICADE
RIDAURA
ROTARIX
ROTATEQ
SIMPONI INJECTION 100MG/ML
SIMPONI INJECTION 50MG/0.5ML
sirolimus tablet
SYNAGIS INJECTION 50MG/0.5ML
tacrolimus capsule 0.5mg, 1mg, 5mg
TENIVAC
tetanus toxoid adsorbed
tetanus/diphtheria toxoids-adsorbed adult
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZORTRESS TABLET 0.25MG
ZORTRESS TABLET 0.5MG, 0.75MG
ZOSTAVAX
INFLAMMATORY BOWEL DISEASE AGENTS
ASACOL HD
AZULFIDINE EN-TABS
balsalazide disodium
CANASA
DELZICOL
DIPENTUM
LIALDA
mesalamine kit
PENTASA
DRUG TIER
NOTES
4
3
5
4
3
3
5
5
2
5
2
3
2
2
3
3
3
3
3
3
4
5
3
B/D,M
B/D
B/D,M
M
3
3
2
4
3
3
4
2
3
M
M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
PA
PA,M
B/D,M
PA
B/D,M
B/D
B/D
B/D
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
50
DRUG NAME
SFROWASA
sulfasalazine tablet
sulfazine ec
METABOLIC BONE DISEASE AGENTS
ACTONEL TABLET 30MG
ACTONEL TABLET 35MG, 5MG
alendronate sodium tablet
alendronate sodium solution
calcitonin-salmon
calcitriol capsule 0.25mcg, 0.5mcg
calcitriol injection 1mcg/ml
calcitriol oral solution 1mcg/ml
doxercalciferol
etidronate disodium
FORTEO
FORTICAL
ibandronate sodium tablet
MIACALCIN INJECTION
pamidronate disodium injection 30mg/10ml,
6mg/ml, 90mg/10ml
paricalcitol
PROLIA
risedronate sodium tablet 150mg
XGEVA
ZEMPLAR INJECTION
ZOLEDRONIC ACID INJECTION 4MG/5ML
ZOLEDRONIC ACID INJECTION 5MG/100ML
ZOMETA INJECTION 4MG/100ML
MISCELLANEOUS THERAPEUTIC AGENTS
insulin needles
Insulin pen needles
insulin syringes
gauze pads 2"x2"
DRUG TIER
NOTES
3
2
2
M
M
M
3
3
1
2
2
2
2
2
2
4
5
3
2
3
4
2
4
2
5
4
4
4
4
1
1
1
1
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
,M
M
M
M
M
M
M
PA,M
M
M
B/D
M
B/D
B/D
B/D
B/D,M
B/D
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
51
DRUG NAME
INTRALIPID
LIPOSYN III INJECTION 1.2GM/100ML;
2.5GM/100ML; 10GM/100ML, 1.2GM/100ML;
2.5GM/100ML; 20GM/100ML
sterile water irrigation
OPHTHALMIC AGENTS
acetazolamide er
ALOCRIL
ALOMIDE
ALPHAGAN P SOLUTION 0.1%
atropine sulfate solution
AZOPT
bacitracin/polymyxin b
betaxolol hcl solution 0.5%
BETOPTIC-S
bimatoprost
brimonidine tartrate
carteolol hcl
COMBIGAN
cromolyn sodium solution 4%
dexamethasone sodium phosphate ophthalmic
solution 0.1%
diclofenac sodium solution 0.1%
dorzolamide hcl
dorzolamide hcl/timolol maleate
fluorometholone
flurbiprofen sodium
FML
FML FORTE
FML LIQUIFILM
IOPIDINE
ISOPTO CARPINE
ISTALOL
DRUG TIER
NOTES
4
4
B/D
B/D
4
2
3
3
3
2
3
2
2
3
2
2
2
3
2
2
1
2
2
2
2
3
3
3
3
3
3
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
52
DRUG NAME
DRUG TIER
ketorolac tromethamine
LACRISERT
latanoprost
levobunolol hcl solution 0.5%
LOTEMAX
LUMIGAN SOLUTION 0.01%
methazolamide tablet
metipranolol
neomycin/bacitracin/polymyxin
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
PATANOL
PHOSPHOLINE IODIDE
pilocarpine hcl solution 1%, 2%, 4%
polymyxin b sulfate/trimethoprim sulfate
prednisolone acetate
prednisolone sodium phosphate ophthalmic solution
1%
RESTASIS
sulfacetamide sodium/prednisolone sodium
phosphate
timolol maleate ophthalmic gel forming
timolol maleate solution
TOBRADEX OINTMENT
tobramycin/dexamethasone
VEXOL
OTIC AGENTS
acetasol hc
acetic acid
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
2
3
2
2
3
3
2
2
2
2
2
3
3
2
2
2
2
NOTES
M
M
M
M
M
4
2
M
2
1
3
2
3
M
M
2
2
3
3
3
3
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
53
DRUG NAME
DRUG TIER
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone otic suspension
1%; 3.5mg/ml; 10000unit/ml
RESPIRATORY TRACT/PULMONARY AGENTS
ADVAIR DISKUS
ADVAIR HFA
albuterol sulfate nebulization solution
albuterol sulfate syrup, tablet
aminophylline
ARALAST NP INJECTION 400MG
ARCAPTA NEOHALER
ASMANEX HFA
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
ASMANEX TWISTHALER 60 METERED DOSES
ATROVENT HFA
AUVI-Q
azelastine hcl solution 0.1%
BECONASE AQ
COMBIVENT RESPIMAT
cromolyn sodium nebulization solution 20mg/2ml
cyproheptadine hcl syrup, tablet
DALIRESP
diphenhydramine hcl elixir
diphenhydramine hcl injection
epinephrine injection 0.15mg/0.15ml
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
FLOVENT DISKUS
FLOVENT HFA
flunisolide solution 0.025%
fluticasone propionate suspension 50mcg/act
2
2
2
3
3
2
2
2
3
3
3
3
3
3
3
3
2
3
3
1
2
4
1
1
2
3
3
3
3
2
2
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
NOTES
M
M
B/D,M
M
LA,M
M
M
M
M
M
M
M
M
M
B/D,M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
54
DRUG NAME
FORADIL AEROLIZER
ipratropium bromide inhalation solution
ipratropium bromide nasal solution
LETAIRIS
levocetirizine dihydrochloride tablet
montelukast sodium
OPSUMIT
PROLASTIN-C
PULMOZYME
QVAR
REVATIO INJECTION, SUSPENSION RECONSTITUTED
SEREVENT DISKUS
sildenafil tablet
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
SYMBICORT
terbutaline sulfate tablet
theophylline cr tablet extended release 12 hour
100mg, 200mg
theophylline er tablet extended release 24 hour
theophylline er tablet extended release 12 hour
300mg, 450mg
TOBI
TOBI PODHALER
TRACLEER
triamcinolone acetonide aerosol 55mcg/act
VENTAVIS
VENTOLIN HFA
XOLAIR
zafirlukast
ZYFLO
ZYFLO CR
SKELETAL MUSCLE RELAXANTS
DRUG TIER
NOTES
3
2
2
5
2
2
5
3
5
3
5
3
2
3
3
3
2
1
M
B/D,M
M
LA,M
M
M
M
LA,M
B/D,M
M
1
1
M
M
5
5
5
2
5
3
5
2
3
3
B/D,M
B/D,M
LA,M
M
B/D,M
M
PA,LA,M
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
M
PA,M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
55
DRUG NAME
carisoprodol tablet 350mg
chlorzoxazone tablet
cyclobenzaprine hcl tablet 10mg, 5mg
metaxalone tablet 800mg
methocarbamol tablet
orphenadrine citrate er
SLEEP DISORDER AGENTS
eszopiclone
flurazepam hcl
modafinil
NUVIGIL
ROZEREM
SILENOR
temazepam
XYREM
zaleplon
zolpidem tartrate
zolpidem tartrate er
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
AMINOSYN 7%/ELECTROLYTES
AMINOSYN 8.5%/ELECTROLYTES
AMINOSYN II
AMINOSYN II 8.5%/ELECTROLYTES
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
DEPEN TITRATABS
dextrose 10%/nacl 0.45%
dextrose 10% flex container
dextrose 10%/nacl 0.2%
dextrose 2.5%/sodium chloride 0.45%
DRUG TIER
NOTES
2
2
2
2
2
1
PA
2
1
4
3
3
4
1
4
2
2
2
PA
PA,M
PA,M
QL (30 EA per 30 days)
QL (30 EA per 30 days)
LA
QL (90 EA per 365 days),PA
QL (90 EA per 365 days),PA
QL (90 EA per 365 days),PA
4
4
4
4
4
4
4
4
4
4
4
4
4
4
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
56
DRUG NAME
dextrose 5%
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
EXJADE TABLET SOLUBLE 125MG
EXJADE TABLET SOLUBLE 250MG, 500MG
FREAMINE HBC 6.9%
HEPATAMINE
K-TAB TABLET EXTENDED RELEASE 10MEQ, 20MEQ
kionex powder
klor-con 10
klor-con 8
klor-con m15
klor-con m20
lactated ringers dextrose 5% viaflex
lactated ringers irrigation
lactated ringers viaflex
potassium chloride 0.15% /nacl 0.45% viaflex
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.15%/nacl 0.9%
potassium chloride 0.22% d5w/nacl 0.45%
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
potassium chloride er
potassium chloride liquid
potassium chloride injection 10meq/100ml,
20meq/100ml, 2meq/ml, 40meq/100ml
potassium citrate er
prenatal vitamins
sodium chloride 0.45% viaflex
DRUG TIER
4
4
4
4
4
4
4
5
4
4
3
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
2
2
4
2
1
4
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
NOTES
PA,LA,M
PA,LA,M
B/D
B/D
M
M
M
M
M
M
M
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
57
DRUG NAME
sodium chloride 0.9%
sodium chloride injection 0.9%, 2.5meq/ml, 3%, 5%
sodium fluoride tablet 1mg
sodium polystyrene sulfonate suspension
SYPRINE
tpn electrolytes
DRUG TIER
4
4
1
2
3
4
GC – We provide additional coverage of this prescription drug in the coverage gap.
Evidence of Coverage for more information about this coverage.
NOTES
M
Please refer to our
LA – This prescription may be available only at certain pharmacies. For more information consult your
Pharmacy Directory or call Customer Services at 1-888-423-7633, Monday – Friday, 8:00 AM – 8:00 PM
CST. TTY/TTD users should call 800-735-2989.
B/D – Part B versus D Prior Authorization; M – Maintenance Medication; PA – Prior Authorization;
QL – Quantity Limit; ST – Step Therapy.
58
INDEX
abacavir
abacavir
sulfate/lamivudine/zidovudine
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
acamprosate calcium dr
acarbose
acebutolol hcl
acetaminophen/codeine
acetaminophen/codeine #3
acetasol hc
acetazolamide
acetazolamide er
acetic acid
acitretin
ACTEMRA
ACTHIB
ACTIMMUNE
ACTONEL
acyclovir
acyclovir sodium
ADACEL
ADAGEN
adefovir dipivoxil
ADVAIR DISKUS
ADVAIR HFA
ADVICOR
afeditab cr
AFINITOR
AFINITOR DISPERZ
AGGRENOX
ALBENZA
albuterol sulfate
alclometasone dipropionate
alcohol preps
ALDACTAZIDE
ALDURAZYME
alendronate sodium
alfuzosin hcl er
ALIMTA
26
26
ALINIA
allopurinol
ALOCRIL
ALOMIDE
ALPHAGAN P
alprazolam
alprazolam intensol
amantadine hcl
AMBISOME
amcinonide
amethia
amethyst
amifostine
amikacin sulfate
amiloride hcl
amiloride/hydrochlorothiazide
aminophylline
AMINOSYN 7%/ELECTROLYTES
AMINOSYN 8.5%/ELECTROLYTES
AMINOSYN II
AMINOSYN II 8.5%/ELECTROLYTES
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlodipine besylate
amlodipine besylate/benazepril hcl
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
amnesteem
amoxapine
amoxicillin
amoxicillin/clavulanate potassium
amphetamine/dextroamphetamine
amphotericin b
ampicillin
ampicillin sodium
ampicillin-sulbactam
24
24
24
10
29
32
8
8
53
32
52
53
38
48
48
48
51
26
26
48
39
26
54
54
32
33
21
21
31
23
54
42
11
33
40
51
41
21
59
23
20
52
52
52
28
28
24
19
42
44
44
21
11
33
33
54
56
56
56
56
56
56
56
56
56
33
40
17
33
33
33
33
33
39
17
11
11
37
19
11
11
11
anagrelide hydrochloride
anastrozole
ANDRODERM
ANDROGEL
ANDROGEL PUMP
APIDRA
APIDRA SOLOSTAR
APOKYN
apri
APTIOM
APTIVUS
ARALAST NP
ARANESP ALBUMIN FREE
ARCALYST
ARCAPTA NEOHALER
ARGATROBAN
ASACOL HD
ascomp/codeine
ASMANEX HFA
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 30
METERED DOSES
ASMANEX TWISTHALER 60
METERED DOSES
atenolol
atenolol/chlorthalidone
ATGAM
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
atropine sulfate
ATROVENT HFA
AUBAGIO
aubra
augmented betamethasone
dipropionate
AUVI-Q
AVASTIN
AVELOX
aviane
AVODART
AVONEX
azacitidine
azathioprine
31
21
44
44
44
29
29
24
44
15
26
54
31
48
54
31
50
8
54
54
azelastine hcl
AZILECT
azithromycin
AZOPT
AZOR
aztreonam
AZULFIDINE EN-TABS
bacitracin
bacitracin/polymyxin b
baclofen
BACTROBAN NASAL
balsalazide disodium
balziva
BANZEL
BARACLUDE
BECONASE AQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
BENICAR
BENICAR HCT
benztropine mesylate
betamethasone dipropionate
betamethasone valerate
betaxolol hcl
betaxolol hcl
bethanechol chloride
BETOPTIC-S
BEXSERO
bicalutamide
BICILLIN C-R
BICILLIN L-A
bimatoprost
bisoprolol fumarate
bisoprolol
fumarate/hydrochlorothiazide
bleomycin sulfate
BOOSTRIX
BOSULIF
briellyn
BRILINTA
brimonidine tartrate
BRINTELLIX
BRISDELLE
bromocriptine mesylate
budesonide
bumetanide
54
54
33
33
48
33
23
23
26
52
54
38
44
42
54
21
11
44
41
38
21
48
60
54
24
11
52
33
11
50
11
52
26
11
50
44
15
26
54
33
33
33
33
24
42
42
33
52
41
52
48
21
11
11
52
33
33
21
48
21
44
31
52
17
17
24
42
33
buprenorphine hcl
buprenorphine hcl/naloxone hcl
buproban
bupropion hcl
bupropion hcl sr
bupropion hcl xl
buspirone hcl
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine
/codeine
butalbital/apap/caffeine
butalbital/aspirin/caffeine
butorphanol tartrate
BYDUREON
BYETTA
BYSTOLIC
cabergoline
calcipotriene
calcipotriene/betamethasone
dipropionate
calcitonin-salmon
calcitriol
calcitriol
calcium acetate
CANASA
CANCIDAS
candesartan cilexetil
candesartan
cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
CAPRELSA
captopril
captopril/hydrochlorothiazide
CARAC
CARAFATE
carbamazepine
carbamazepine er
CARBATROL
carbidopa/levodopa
carbidopa/levodopa er
CARIMUNE NANOFILTERED
carisoprodol
carteolol hcl
cartia xt
carvedilol
CEDAX
10
10
10
17
17
17
28
8
8
cefaclor
cefaclor er
cefadroxil
cefazolin sodium
cefdinir
cefepime
cefixime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
CEFTAZIDIME/DEXTROSE
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELEBREX
celecoxib
CELLCEPT
CELONTIN
cephalexin
CEREZYME
CERVARIX
CHANTIX
CHANTIX CONTINUING MONTH
PAK
CHANTIX STARTING MONTH PAK
chloramphenicol sodium succinate
chlordiazepoxide hcl
chlorhexidine gluconate oral rinse
chloroquine phosphate
chlorothiazide
chlorpromazine hcl
chlorthalidone
chlorzoxazone
cholestyramine light
ciclopirox
ciclopirox olamine
cilostazol
cimetidine
cimetidine hcl
CIMZIA
CINRYZE
CIPRO HC
CIPRODEX
ciprofloxacin
8
8
8
29
29
33
47
39
39
51
39
51
41
50
19
33
33
20
21
33
33
39
40
15
15
15
24
24
48
55
52
33
33
11
61
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
12
10
8
48
15
12
40
48
10
10
10
12
28
38
23
33
25
33
56
34
19
19
31
40
40
48
48
53
53
12
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
citalopram hydrobromide
claravis
clarithromycin
clarithromycin er
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phosphate
add-vantage
clindamycin phosphate in d5w
clobetasol propionate
clobetasol propionate e
clomipramine hcl
clonazepam
clonazepam odt
clonidine hcl
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole/betamethasone
dipropionate
clozapine
clozapine odt
COARTEM
codeine sulfate
colchicine
COLCRYS
colestipol hcl
colistimethate sodium
COLY-MYCIN S
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
COMPLERA
COMVAX
constulose
COPAXONE
CORTIFOAM
CORTISPORIN
CORTISPORIN-TC
COUMADIN
CREON
CRESTOR
CRIXIVAN
12
12
17
39
12
12
12
12
12
12
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
cyclafem 1/35
cyclafem 7/7/7
CYCLESSA
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
CYKLOKAPRON
cyproheptadine hcl
CYSTADANE
CYSTAGON
DALIRESP
danazol
dapsone
DAPTACEL
DARAPRIM
deblitane
delyla
DELZICOL
demeclocycline hcl
DEMSER
DENAVIR
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
DEPEN TITRATABS
DEPO-TESTOSTERONE
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
desonide
desoximetasone
dexamethasone
dexamethasone sodium phosphate
dexamethasone sodium phosphate
dextroamphetamine sulfate
dextroamphetamine sulfate er
dextrose 10%/nacl 0.45%
dextrose 10% flex container
12
42
42
18
16
15
34
31
28
19
39
25
25
24
8
20
20
34
12
53
52
54
21
26
48
40
38
42
39
53
31
40
34
26
62
40
52
54
44
13
44
44
44
56
21
29
48
48
31
54
40
40
54
44
21
48
24
44
44
50
13
34
26
16
16
16
16
56
44
18
43
44
42
42
42
42
52
38
38
56
56
dextrose 10%/nacl 0.2%
dextrose 2.5%/sodium chloride
0.45%
dextrose 5%
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
diazepam
diazepam
diazepam intensol
DIBENZYLINE
diclofenac potassium
diclofenac sodium
diclofenac sodium
diclofenac sodium dr
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflorasone diacetate
diflunisal
digitek
digoxin
dihydroergotamine mesylate
DILANTIN
DILANTIN INFATABS
DILANTIN-125
diltiazem cd
diltiazem hcl
diltiazem hcl er
dilt-xr
DIOVAN
DIPENTUM
diphenhydramine hcl
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
disopyramide phosphate
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
donepezil hcl
dorzolamide hcl
56
56
dorzolamide hcl/timolol maleate
doxazosin mesylate
doxepin hcl
doxercalciferol
doxycycline
doxycycline hyclate
doxycycline monohydrate
dronabinol
drospirenone/ethinyl estradiol
duloxetine hcl
duramorph
e.e.s. 400
econazole nitrate
EDURANT
EFFIENT
ELAPRASE
ELIDEL
ELIQUIS
ELITEK
ELLA
ELMIRON
EMCYT
EMEND
emoquette
EMSAM
EMTRIVA
ENABLEX
enalapril maleate
enalapril
maleate/hydrochlorothiazide
ENBREL
endocet
ENGERIX-B
enoxaparin sodium
enpresse-28
entacapone
entecavir
enulose
epinephrine
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epitol
EPIVIR
EPIVIR HBV
EPZICOM
ergoloid mesylates
57
57
57
57
57
57
16
29
29
34
10
10
52
10
10
13
40
26
42
10
34
34
20
16
16
16
34
34
34
34
34
50
54
40
48
34
10
16
16
16
17
52
63
52
41
29
51
13
13
13
18
44
18
8
13
19
26
31
40
39
31
21
44
41
21
18
44
18
26
41
34
34
48
8
48
31
44
24
26
40
54
54
54
16
26
26
26
17
ERGOMAR
ERIVEDGE
ery
ERYPED 200
ERYPED 400
ERY-TAB
erythrocin lactobionate
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
escitalopram oxalate
estazolam
ESTRACE
estradiol
estradiol valerate
estradiol/norethindrone acetate
estropipate
eszopiclone
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
etodolac er
etoposide
EVOTAZ
EXELDERM
EXELON
exemestane
EXFORGE
EXFORGE HCT
EXJADE
EXTAVIA
FABRAZYME
falmina
famciclovir
famotidine
FANAPT
FANAPT TITRATION PACK
FARESTON
FARYDAK
FASLODEX
FAZACLO
felbamate
felodipine er
fenofibrate
20
21
13
13
13
13
13
13
13
13
13
18
29
44
44
44
44
44
56
21
16
51
10
10
21
26
19
17
21
34
34
57
38
40
45
27
40
25
25
21
21
21
25
16
34
34
fenofibrate micronized
fenofibric acid dr
fenoprofen calcium
fentanyl
fentanyl citrate oral transmucosal
FETZIMA
FETZIMA TITRATION PACK
finasteride
FIRAZYR
flavoxate hcl
flecainide acetate
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fluconazole in dextrose
flucytosine
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinolone acetonide body
fluocinonide
fluocinonide-e
fluorometholone
fluorouracil
fluoxetine hcl
fluphenazine decanoate
fluphenazine hcl
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluticasone propionate
fluvoxamine maleate
FML
FML FORTE
FML LIQUIFILM
fondaparinux sodium
FORADIL AEROLIZER
FORTEO
FORTICAL
FOSCARNET SODIUM
fosinopril sodium
fosinopril
sodium/hydrochlorothiazide
fosphenytoin sodium
64
34
34
10
8
8
18
18
41
48
41
34
54
54
19
19
19
42
54
42
42
42
42
52
39
18
25
25
56
10
52
21
42
54
18
52
52
52
31
55
51
51
27
34
34
16
FRAGMIN
FREAMINE HBC 6.9%
furosemide
FUZEON
FYCOMPA
gabapentin
GABITRIL
GAMMAGARD LIQUID
GAMUNEX-C
ganciclovir
garamycin
GARDASIL
GARDASIL 9
gatifloxacin
gauze pad 2”x2”
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
gentamicin sulfate/0.9% sodium
chloride
GEODON
gildess 1.5/30
gildess 24 fe
GILENYA
GILOTRIF
GLEEVEC
glimepiride
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glycopyrrolate
GOLYTELY
granisetron hcl
griseofulvin microsize
griseofulvin ultramicrosize
GRIS-PEG
guanfacine er
guanidine hcl
halobetasol propionate
32
57
35
27
16
16
16
48
48
27
13
48
48
13
51
40
40
40
35
40
49
13
13
13
haloperidol
haloperidol decanoate
haloperidol lactate
HARVONI
HAVRIX
heparin sodium
heparin sodium/d5w
HEPATAMINE
HEXALEN
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMIRA
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMULIN 70/30
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500
(CONCENTRATED)
hydralazine hcl
hydrochlorothiazide
hydrocodone
bitartrate/acetaminophen
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydrocortisone
hydrocortisone butyrate
hydrocortisone butyrate (lipophilic)
hydrocortisone valerate
hydrocortisone/acetic acid
hydromorphone hcl
hydroxychloroquine sulfate
hydroxyurea
ibandronate sodium
IBRANCE
ibuprofen
ICLUSIG
ILARIS
IMBRUVICA
IMIPENEM/CILASTATIN
25
45
45
38
22
22
29
29
29
29
29
29
40
40
19
19
19
19
38
20
42
65
25
25
25
27
49
32
32
57
22
29
29
29
29
30
30
49
49
30
30
30
30
30
30
35
35
8
8
8
43
43
43
43
54
8
24
22
51
22
10
22
49
22
13
imipramine hcl
imiquimod
IMOVAX RABIES (H.D.C.V.)
INCRELEX
indapamide
INFANRIX
INLYTA
insulin needles
insulin pen needles
insulin syringes
INTELENCE
INTRALIPID
INTRON A
INTRON A W/DILUENT
introvale
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVIRASE
INVOKANA
IOPIDINE
IPOL INACTIVATED IPV
ipratropium bromide
irbesartan
irbesartan/hydrochlorothiazide
ISENTRESS
isoniazid
ISOPTO CARPINE
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin
ISTALOL
itraconazole
ivermectin
IXIARO
JAKAFI
jantoven
JANUMET
JANUVIA
JENTADUETO
KALETRA
kariva
KETEK
18
39
49
43
35
49
22
51
51
51
27
52
27
27
45
38
13
25
25
27
30
52
49
55
35
35
27
21
52
35
35
35
35
13
52
19
24
49
22
32
30
30
30
27
45
13
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
KINERET
kionex
klor-con 10
klor-con 8
klor-con m15
klor-con m20
KOMBIGLYZE XR
K-TAB
KUVAN
labetalol hcl
LACRISERT
lactated ringers dextrose 5% viaflex
lactated ringers irrigation
lactated ringers viaflex
lactulose
lamivudine
lamivudine/zidovudine
lamotrigine
LANOXIN
lansoprazole
LANTUS
LANTUS SOLOSTAR
larin 1.5/30
larin 1/20
larin fe 1.5/30
larin fe 1/20
latanoprost
LATUDA
LAZANDA
leflunomide
LENVIMA 10MG DAILY DOSE
LENVIMA 14MG DAILY DOSE
LENVIMA 20MG DAILY DOSE
LENVIMA 24MG DAILY DOSE
lessina
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
LEVEMIR
66
19
11
11
53
49
57
57
57
57
57
30
57
40
35
53
57
57
57
40
27
27
16
35
40
30
30
45
45
45
45
53
25
9
49
22
22
22
22
45
55
22
22
22
32
47
30
LEVEMIR FLEXTOUCH
levetiracetam
levetiracetam er
levobunolol hcl
levocetirizine dihydrochloride
LEVOFLOXACIN
LEVOFLOXACIN IN D5W
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
levorphanol tartrate
levothyroxine sodium
LEVOXYL
LEXIVA
LIALDA
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
lindane
linezolid
liothyronine sodium
LIPOSYN III
lisinopril
lisinopril/hydrochlorothiazide
lithium
lithium carbonate
lithium carbonate er
lomustine
loperamide hcl
lorazepam
lorazepam intensol
losartan potassium
losartan
potassium/hydrochlorothiazide
LOTEMAX
LOTRONEX
lovastatin
low-ogestrel
loxapine succinate
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
lutera
30
16
16
53
55
13
13
45
45
45
9
47
47
27
50
10
9
9
10
10
24
14
47
52
35
35
29
29
29
22
41
29
29
35
35
LYNPARZA
LYRICA
LYSODREN
maprotiline hcl
marlissa
MARPLAN
MATULANE
meclizine hcl
meclofenamate sodium
medroxyprogesterone acetate
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
MENACTRA
menest
MENOMUNE-A/C/Y/W-135
MENVEO
mercaptopurine
meropenem
mesalamine
MESNEX
metaxalone
metformin hcl
metformin hcl er
methadone hcl
methazolamide
methenamine hippurate
methimazole
methocarbamol
methotrexate
methotrexate sodium
methoxsalen
methyclothiazide
methylphenidate hcl
methylphenidate hcl cd
methylphenidate hcl er
methylphenidate hydrochloride
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone
sodiumsuccinate
metipranolol
metoclopramide hcl
metolazone
53
41
35
45
25
53
40
47
47
45
67
22
16
47
18
45
18
22
19
11
45
24
45
22
11
49
45
49
49
22
14
50
22
56
30
30
9
53
14
48
56
49
49
39
35
38
38
38
38
43
43
43
43
53
41
35
metoprolol succinate er
metoprolol tartrate
metoprolol/hydrochlorothiazide
metronidazole
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MIACALCIN
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
MIGRANAL
millipred
minocycline hcl
minoxidil
mirtazapine
mirtazapine odt
misoprostol
mitoxantrone hcl
M-M-R II W/DILUENT 10 DOSE
modafinil
mometasone furoate
montelukast sodium
MONUROL
morphine sulfate
morphine sulfate er
moxifloxacin hcl
MOZOBIL
MULTAQ
mupirocin
mycophenolate mofetil
mycophenolic acid dr
MYFORTIC
myorisan
MYOZYME
MYRBETRIQ
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin sodium
NAGLAZYME
naloxone hcl
naltrexone hcl
NAMENDA
35
35
35
14
14
14
35
51
45
45
45
45
35
20
43
14
35
18
18
41
22
49
56
43
55
14
9
9
14
32
35
14
49
49
49
39
40
41
11
36
35
14
40
10
10
17
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION PACK
naproxen
naproxen dr
naproxen sodium
NATACYN
nateglinide
NEBUPENT
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/hy
drocortisone
neomycin/polymyxin/dexamethaso
ne
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortison
e
neomycin/polymyxin/hydrocortison
e
NEORAL
NEULASTA
NEUMEGA
NEUPOGEN
NEUPRO
nevirapine
NEXAVAR
niacin er
NICOTROL INHALER
NICOTROL NS
nifedical xl
nifedipine er
nikki
NILANDRON
nimodipine
NITRO-BID
NITRO-DUR
nitrofurantoin
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
68
17
17
17
11
11
11
20
30
24
45
45
45
45
18
14
53
14
53
53
54
14
54
49
32
32
32
24
27
22
36
10
10
36
36
45
22
36
36
36
14
14
14
nitroglycerin
nitroglycerin lingual
nitroglycerin transdermal
NITROLINGUAL PUMPSPRAY
NITROSTAT
nizatidine
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN
norethindrone & ethinyl estradiol
ferrous fumarate
norethindrone acetate
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
norlyroc
NORPACE CR
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOXAFIL
NUCYNTA
NUCYNTA ER
NUEDEXTA
NULOJIX
NUVIGIL
nyamyc
nystatin
nystatin/triamcinolone
nystop
ocella
octreotide acetate
ofloxacin
ogestrel
olanzapine
olanzapine odt
OLYSIO
omega-3-acid ethyl esters
36
36
36
36
36
41
43
44
45
omeprazole
ondansetron hcl
ondansetron odt
ONFI
ONGLYZA
OPSUMIT
ORAP
ORENCIA
ORFADIN
orphenadrine citrate er
orsythia
oxandrolone
oxaprozin
oxazepam
oxcarbazepine
OXISTAT
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone hcl er
oxycodone/acetaminophen
oxycodone/aspirin
OXYCONTIN
pacerone
pamidronate disodium
PANRETIN
pantoprazole sodium
paricalcitol
paromomycin sulfate
paroxetine hcl
paroxetine hcl er
PASER
PATANOL
PAXIL
PEDVAX HIB
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEGINTRON
PEG-INTRON
PEG-INTRON REDIPEN
penicillin g potassium
penicillin g potassium in
iso-osmotic dextrose
penicillin g procaine
penicillin g sodium
46
45
46
36
46
46
46
18
27
30
30
30
30
30
30
30
20
9
9
38
49
56
20
20
20
20
46
47
14
46
25
25
27
36
69
41
19
19
16
30
55
25
49
40
56
46
46
11
29
16
20
41
41
9
9
9
9
9
36
51
22
41
51
14
18
18
21
53
18
49
16
27
27
27
27
27
14
14
14
14
penicillin v potassium
PENTAM 300
PENTASA
pentoxifylline er
permethrin
perphenazine
phenadoz
phenelzine sulfate
phenergan
phenobarbital
phenytoin
phenytoin sodium
phenytoin sodium extended
PHOSPHOLINE IODIDE
PICATO
pilocarpine hcl
pilocarpine hcl
pilocarpine hydrochloride
pindolol
pioglitazone hcl
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
piperacillin sodium/tazobactam
sodium
piroxicam
podofilox
polyethylene glycol 3350
polymyxin b sulfate
polymyxin b sulfate/trimethoprim
sulfate
POMALYST
portia-28
potassium chloride
potassium chloride 0.15% /nacl
0.45% viaflex
potassium chloride 0.15% d5w/nacl
0.33%
potassium chloride 0.15% d5w/nacl
0.45%
potassium chloride 0.15%/nacl
0.9%
potassium chloride 0.22% d5w/nacl
0.45%
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
potassium chloride er
14
24
50
36
24
25
19
18
19
16
16
16
16
53
39
38
53
38
36
30
30
30
14
potassium citrate er
POTIGA
PRADAXA
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
PREMARIN
PREMPHASE
PREMPRO
prenatal vitamins
prevalite
PREZCOBIX
PREZISTA
primaquine phosphate
primidone
PRISTIQ
PRIVIGEN
probenecid
probenecid/colchicine
procainamide hcl
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
proctosol hc
proctozone-hc
PROGLYCEM
PROGRAF
PROLASTIN-C
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethegan
propafenone hcl
propantheline bromide
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
propylthiouracil
PROQUAD
PROTOPIC
11
39
41
14
53
22
46
57
57
57
57
57
57
57
57
57
70
57
17
32
24
36
36
53
43
53
43
46
46
46
57
36
27
27
24
17
18
49
20
20
36
25
25
25
32
43
43
30
49
55
22
51
32
19
19
36
41
36
36
36
48
49
39
protriptyline hcl
PULMOZYME
PURIXAN
pyrazinamide
pyridostigmine bromide
QUADRACEL
quasense
quetiapine fumarate
quinapril hcl
quinapril/hydrochlorothiazide
quinidine gluconate cr
quinidine sulfate
quinidine sulfate er
quinine sulfate
QVAR
RABAVERT
rabeprazole sodium
raloxifene hydrochloride
ramipril
RANEXA
ranitidine hcl
RAPAMUNE
reclipsen
RECOMBIVAX HB
REGRANEX
RELENZA DISKHALER
RELISTOR
REMICADE
RENAGEL
RENVELA
RESCRIPTOR
reserpine
RESTASIS
RETIN-A MICRO
RETIN-A MICRO PUMP
RETROVIR IV INFUSION
REVATIO
REVLIMID
REYATAZ
ribavirin
RIDAURA
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
18
55
22
21
20
49
46
25
36
36
36
36
37
24
55
49
41
46
37
37
41
49
46
50
39
27
41
50
42
42
27
37
53
39
39
27
55
22
27
28
50
21
21
21
38
28
risedronate sodium
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
rivastigmine tartrate
rizatriptan benzoate
rizatriptan benzoate odt
ropinirole hcl
ROTARIX
ROTATEQ
ROZEREM
SABRIL
SANDOSTATIN
SANTYL
SAPHRIS
SAVELLA
SAVELLA TITRATION PACK
selegiline hcl
selenium sulfide
SELZENTRY
SENSIPAR
SEREVENT DISKUS
SEROQUEL XR
sertraline hcl
SFROWASA
sharobel
sildenafil
SILENOR
silver sulfadiazine
SIMCOR
SIMPONI
simvastatin
sirolimus
sodium chloride
sodium chloride 0.45% viaflex
sodium chloride 0.9%
sodium fluoride
sodium polystyrene sulfonate
sodium sulfacetamide
SOLTAMOX
SOLU-CORTEF
SOMATULINE DEPOT
SOMAVERT
sotalol hcl
sotalol hcL,(af)
71
51
25
25
25
22
17
20
20
24
50
50
56
17
47
39
26
38
38
24
39
28
47
55
26
18
51
46
55
56
14
37
50
37
50
58
57
58
58
58
14
23
43
47
47
37
37
SOVALDI
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPRYCEL
sronyx
ssd
stavudine
STELARA
sterile water irrigation
STIVARGA
STRATTERA
streptomycin sulfate
STRIBILD
STROMECTOL
sucralfate
sulfacetamide sodium
sulfacetamide sodium/prednisolone
sodium phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
sulfasalazine
sulfazine ec
sulindac
sumatriptan
sumatriptan succinate
SUPRAX
SURMONTIL
SUSTIVA
SUTENT
SYLATRON
SYLVANT
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNTHROID
SYPRINE
TABLOID
TACLONEX
tacrolimus
tacrolimus
28
55
55
37
37
23
46
15
28
39
52
23
38
15
28
24
41
15
53
TAFINLAR
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
tarina fe 1/20
TASIGNA
tazicef
TAZORAC
taztia xt
TECFIDERA
TECFIDERA STARTER PACK
TEFLARO
TEGRETOL
TEGRETOL-XR
TEKTURNA
TEKTURNA HCT
temazepam
TENIVAC
terazosin hcl
terbinafine hcl
terbutaline sulfate
terconazole
TESTIM
testosterone
testosterone cypionate
testosterone enanthate
testosterone pump
tetanus toxoid adsorbed
tetanus/diphtheria
toxoids-adsorbed adult
THALOMID
theophylline cr
theophylline er
thioridazine hcl
thiothixene
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
tiagabine hydrochloride
TIKOSYN
timolol maleate
15
15
15
51
51
11
20
20
15
18
28
23
23
23
55
31
31
50
47
15
47
58
23
39
39
50
72
23
28
23
42
23
23
46
23
15
39
37
38
38
15
17
17
37
37
56
50
42
20
55
20
46
46
46
46
46
50
50
23
55
55
26
26
47
47
47
47
47
17
37
53
timolol maleate ophthalmic gel
forming
TIVICAY
tizanidine hcl
TOBI
TOBI PODHALER
TOBRADEX
tobramycin sulfate
tobramycin sulfate/sodium chloride
tobramycin/dexamethasone
tolazamide
tolbutamide
tolmetin sodium
tolterodine tartrate
tolterodine tartrate er
topiramate
topotecan hcl
torsemide
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol
hydrochloride/acetaminophen
TRANEXAMIC ACID
TRANSDERM-SCOP
tranylcypromine sulfate
trazodone hcl
TRECATOR
tretinoin
tretinoin
tretinoin microsphere
triamcinolone acetonide
triamcinolone acetonide
triamcinolone in orabase
triamterene/hydrochlorothiazide
triazolam
TRIBENZOR
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
tri-legest fe
TRILEPTAL
trilyte
trimethoprim
TRISENOX
53
TRIUMEQ
trivora-28
TRUMENBA
TRUVADA
TWINRIX
TYBOST
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYZEKA
ULORIC
ursodiol
valacyclovir hcl
VALCHLOR
VALCYTE
VALGANCICLOVIR
valproate sodium
valproic acid
valsartan
valsartan/hydrochlorothiazide
vancomycin hcl
VAQTA
VARIVAX
VASCEPA
VELCADE
velivet
venlafaxine hcl
venlafaxine hcl er
VENTAVIS
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VERSACLOZ
VESICARE
VEXOL
VIDEX PEDIATRIC
VIGAMOX
VIIBRYD
VIMPAT
VIRACEPT
VIRAZOLE
VIREAD
VITEKTA
VIVELLE-DOT
28
26
55
55
53
15
15
53
31
31
11
42
42
17
23
37
58
55
31
9
9
32
19
18
18
21
23
39
39
43
55
38
37
29
37
26
28
24
46
17
41
15
23
73
28
46
50
28
50
28
15
23
50
38
28
20
41
28
23
28
28
17
17
37
37
15
50
50
37
23
46
18
18
55
55
37
37
37
26
42
53
28
15
18
17
28
28
28
28
46
VOLTAREN
VORICONAZOLE
VOTRIENT
vyfemla
VYTORIN
VYVANSE
warfarin sodium
WELCHOL
wymzya fe
XALKORI
XARELTO
XARELTO STARTER PACK
XENAZINE
XGEVA
XIFAXAN
XOLAIR
XTANDI
XYREM
YF-VAX
zafirlukast
zaleplon
ZAVESCA
ZELBORAF
ZEMPLAR
zenatane
zenchent
zenchent fe
ZENPEP
ZETIA
ZIAGEN
zidovudine
ziprasidone hcl
ZOLEDRONIC ACID
ZOLINZA
zolpidem tartrate
zolpidem tartrate er
ZOMETA
zonisamide
ZORTRESS
ZOSTAVAX
ZOSYN
zovia 1/35e
zovia 1/50e
ZYCLARA
ZYCLARA PUMP
ZYDELIG
11
20
23
46
37
38
32
37
46
23
32
32
38
51
15
55
23
56
50
55
56
40
23
51
39
46
47
40
37
28
28
26
51
23
56
56
51
17
50
50
15
47
47
39
39
23
ZYFLO
ZYFLO CR
ZYKADIA
ZYPREXA RELPREVV
ZYTIGA
ZYVOX
74
55
55
23
26
23
15