1. No category

2015 Formulary
Priority Health Medicare
List of covered drugs
Please read:
This
document contains information about the drugs we cover in this plan.
Y0056_1000_1085_10 CMS-accepted 08042014
ID 15216, Version 11
This formulary was updated on 10/31/2014. For more recent information or other
questions, please contact Priority Health Medicare at toll-free 888.389.6648 or, for TTY
users, 711, 8 a.m. – 8 p.m., 7 days a week, or visit www.prioritymedicare.com.
Note to existing members:
This formulary has changed since last year. Please review this document to make sure that
it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Priority Health. When it
refers to “plan” or “our plan,” it means Priority Health Medicare.
This document includes a list of the drugs (formulary) for our plan which is current as of
January 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, 2016, and from time to time during the year.
Introduction
What is the Priority Health Medicare Formulary?
A formulary is a list of covered drugs selected by Priority Health Medicare 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. Priority Health Medicare will
generally cover the drugs listed in our formulary as long as the drug is medically necessary,
the prescription is filled at a Priority Health Medicare 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 January 1, 2015.
To get updated information about the drugs covered by Priority Health Medicare, please
contact us. Our contact information appears on the front and back cover pages. If there
are significant changes to the formulary, you may receive a letter in the mail outlining those
changes.
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How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical condition
The formulary begins on page 10. The drugs in this formulary are grouped into
categories depending on the type of medical conditions that they are used to treat.
For example, drugs used to treat a heart condition are listed under the category,
“Cardiovascular Agents”. If you know what your drug is used for, look for the category
name in the list that begins on page 10. Then look under the category name for your
drug.
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 73. 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?
Priority Health Medicare 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: Priority Health Medicare requires you or your physician to
get prior authorization for certain drugs. This means that you will need to get
approval from Priority Health Medicare before you fill your prescriptions. If you
don’t get approval, Priority Health Medicare may not cover the drug.
•
Quantity Limits: For certain drugs, Priority Health Medicare limits the amount
of the drug that Priority Health Medicare will cover. For example, Priority Health
Medicare provides 30 tablets per 30 days for JANUVIA. This may be in addition to
a standard one-month or three-month supply.
•
Step Therapy: In some cases, Priority Health Medicare 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, Priority Health Medicare may not cover Drug B unless you try Drug A first.
If Drug A does not work for you, Priority Health Medicare will then cover Drug B.
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You can find out if your drug has any additional requirements or limits by looking
in the formulary that begins on page 10. You can also get more information about
the restrictions applied to specific covered drugs by visiting our website. We have
posted 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 Priority Health Medicare 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 Priority Health Medicare
formulary?” on this page 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 Priority Health Medicare does not cover your drug, you have two options:
•
You can ask Customer Service for a list of similar drugs that are covered by
Priority Health Medicare. When you receive the list, show it to your doctor and ask
him or her to prescribe a similar drug that is covered by Priority Health Medicare.
•
You can ask Priority Health Medicare 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 Priority Health Medicare Formulary?
You can ask Priority Health Medicare to make an exception to our coverage rules. There
are several types of exceptions that you can ask us to make.
•
You can ask us to cover your 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, Priority Health Medicare 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.
5
Generally, Priority Health Medicare 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.
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 a 91-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 30 day
emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
Priority Health Medicare provides members experiencing a level of care change with a
transition supply of at least 30 days of medication unless the prescription is written for
fewer days.
6
Priority Health Medicare realizes that a 30 day transition may not be sufficient time to talk
to your doctor and review alternatives. Therefore, we may grant up to a maximum of
two 30 day supply authorizations per non-formulary medication or formulary medication
requiring step therapy or prior authorization during a single transition event.
For more information
For more detailed information about your prescription drug coverage, please review your
Evidence of Coverage and other Priority Health Medicare plan materials.
If you have questions about Priority Health Medicare 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 www.medicare.gov.
7
Priority Health
Medicare Formulary
The formulary that begins on page 10 provides coverage information about the drugs covered by
Priority Health Medicare. If you have trouble finding your drug in the list, turn to the Index that begins
on page 73.
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 Priority Health Medicare has any special
requirements for coverage of your drug.
List of abbreviations
B/D: Part B vs. Part D. This drug requires prior authorization and may be covered differently
under Medicare Part B (medical services) or D (prescription drug coverage) depending upon your
circumstances. Information may need to be submitted by your doctor describing the use and setting
of the drug to make the determination.
EA: Each.
FF: Free First Fill. This prescription drug will be provided at zero cost-sharing the first time you fill it.
HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more
information, call Customer Service at toll-free 888.389.6648, 8 a.m. to 8 p.m., 7 days a week. TTY
users should call 711.
QL: Quantity Limit. For certain drugs, Priority Health Medicare limits the amount of the drug that
Priority Health Medicare will cover. For example, Priority Health Medicare provides 30 tablets per
30 days for JANUVIA. This may be in addition to a standard one month or three month supply.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, consult your Pharmacy Directory or call Customer Service at toll-free 888.389.6648,
8 a.m. to 8 p.m., 7 days a week. TTY users should call 711.
PA: Prior Authorization. Priority Health Medicare requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Priority Health
Medicare before you fill your prescriptions. If you don’t get approval, Priority Health Medicare may not
cover the drug.
ST: Step Therapy. In some cases, Priority Health Medicare 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, Priority Health Medicare may not cover Drug B
unless you try Drug A first. If Drug A does not work for you, Priority Health Medicare will then cover
Drug B.
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Understanding your copayments/coinsurance
The table below lists the Priority Health Medicare drug tiers and the copayment and coinsurance amount
associated with each tier during the initial coverage stage.
Drug Tiers
PriorityMedicare
IdealSM (PPO)
PriorityMedicare
PriorityMedicare
ValueSM (HMO-POS) MeritSM (PPO)
PriorityMedicareSM
(HMO-POS)
PriorityMedicare
SelectSM (PPO)
Retail: one-month (30 day) supply
Mail Order: three-month (90-day) supply*
Tier 1
Preferred
generic
After deductible of
$320 is met:
After deductible of
$75 is met:
25% coinsurance
$5 copayment
$12.50 copayment
Tier 2
Nonpreferred
generic
After deductible of
$320 is met:
After deductible of
$75 is met:
25% coinsurance
$12 copayment
$30 copayment
Tier 3
Preferred
brand
After deductible of
$320 is met:
After deductible of
$75 is met:
25% coinsurance
$45 copayment
$112.50 copayment
After deductible of
$320 is met:
After deductible of
$75 is met:
25% coinsurance
$95 copayment
$237.50 copayment
Tier 4
4 Nonpreferred
brand
Tier 5
After deductible of
Specialty
$320 is met:
(30 day
supply only) 25% coinsurance
$4 copayment
$10 copayment
$4 copayment
$10 copayment
$4 copayment
$10 copayment
$12 copayment
$30 copayment
$10 copayment
$25 copayment
$9 copayment
$22.50 copayment
$45 copayment
$112.50 copayment
$40 copayment
$100 copayment
$40 copayment
$100 copayment
$95 copayment
$237.50 copayment
$85 copayment
$85 copayment
$212.50 copayment $212.50 copayment
After deductible of
$75 is met:
33% coinsurance
31% coinsurance
* All drugs listed on our formulary are available via mail order.
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Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
Analgesics
Analgesics
GRALISE
GRALISE STARTER
4
4
QL (90 EA per 30 days) ST
QL (90 EA per 30 days) ST
CAMBIA
4
2
2
2
1
3
2
1
2
2
4
4
ST
Nonsteroidal Anti-inflammatory Drugs
diclofenac sodium/misoprostol
etodolac capsule 300mg
mefenamic acid capsule
meloxicam tablet 7.5mg
NALFON CAPSULE 400MG
naproxen sodium tablet 275mg, 550mg
naproxen tablet 500mg
oxycodone/ibuprofen
salsalate
SPRIX
ZIPSOR
Opioid Analgesics Long-acting
astramorph
fentanyl
hydromorphone hcl er tablet er 24 hour abusedeterrent 12mg
hydromorphone hcl er tablet er 24 hour abusedeterrent 8mg
hydromorphone hcl er tablet er 24 hour abusedeterrent 16mg, 32mg
INFUMORPH 200
INFUMORPH 500
levorphanol tartrate tablet
methadone hcl tablet soluble
methadone hcl injection
methadone hcl concentrate
methadone hcl oral solution 5mg/5ml
methadone hcl oral solution 10mg/5ml
methadone hcl tablet 5mg
methadone hcl tablet 10mg
methadose tablet 10mg
morphine sulfate er capsule extended release 24
hour 100mg, 120mg, 30mg, 45mg, 60mg,
75mg, 80mg, 90mg
morphine sulfate er capsule extended release 24
hour 10mg, 20mg, 30mg, 50mg, 60mg (generic
Kadian)
QL (240 EA per 30 days)
QL (8.5 EA per 30 days)
ST
2
2
4
QL (15 EA per 30 days)
QL (60 EA per 30 days)
4
QL (90 EA per 30 days)
5
QL (30 EA per 30 days)
3
3
2
2
2
2
2
2
2
2
2
4
QL (360 ML per 30 days)
QL (20 ML per 30 days)
4
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (300 ML per 30 days)
QL (60 ML per 30 days)
QL (1200 ML per 30 days)
QL (600 ML per 30 days)
QL (120 EA per 30 days)
QL (300 EA per 30 days)
QL (30 EA per 30 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
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Drug Name
morphine sulfate er tablet extended release
30mg
morphine sulfate er tablet extended release
15mg
morphine sulfate er tablet extended release
100mg, 200mg
morphine sulfate er tablet extended release
60mg
morphine sulfate injection 10mg/0.7ml
morphine sulfate suppository 30mg
morphine sulfate suppository 20mg
morphine sulfate suppository 10mg
morphine sulfate suppository 5mg
OPANA ER (CRUSH RESISTANT)
OXYCONTIN TABLET ER 12 HOUR ABUSEDETERRENT 10MG, 15MG, 20MG, 30MG
OXYCONTIN TABLET ER 12 HOUR ABUSEDETERRENT 40MG
OXYCONTIN TABLET ER 12 HOUR ABUSEDETERRENT 60MG, 80MG
oxymorphone hydrochloride er
tramadol hcl er tablet extended release 24 hour
ZOHYDRO ER
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
QL (120 EA per 30 days)
2
QL (240 EA per 30 days)
2
QL (30 EA per 30 days)
2
QL (60 EA per 30 days)
2
2
2
2
2
3
3
QL (83 ML per 30 days)
QL (120 EA per 30 days)
QL (180 EA per 30 days)
QL (360 EA per 30 days)
QL (720 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
4
QL (90 EA per 30 days)
5
QL (60 EA per 30 days)
2
2
4
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days) PA
5
2
PA
QL (150 EA per 30 days)
2
2
2
QL (390 EA per 30 days)
QL (4980 ML per 30 days)
QL (390 EA per 30 days)
2
3
2
2
2
2
2
2
QL (3990 ML per 30 days)
QL (1590 EA per 30 days)
QL (390 EA per 30 days)
QL (780 EA per 30 days)
5
2
5
PA
QL (240 ML per 30 days) HI
PA
Opioid Analgesics Short-acting
ABSTRAL
acetaminophen/caffeine/dihydrocodeine
bitartrate
acetaminophen/codeine #3
acetaminophen/codeine solution
acetaminophen/codeine tablet 300mg; 15mg,
300mg; 60mg
butorphanol tartrate
CAPITAL/CODEINE
codeine sulfate solution
codeine sulfate tablet 15mg
codeine sulfate tablet 60mg
codeine sulfate tablet 30mg
duramorph
endocet tablet 325mg; 10mg, 325mg; 5mg,
325mg; 7.5mg
fentanyl citrate oral transmucosal
fentanyl citrate injection
FENTORA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
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Drug Name
hydrocodone bitartrate/acetaminophen solution
hydrocodone bitartrate/acetaminophen tablet
750mg; 10mg
hydrocodone bitartrate/acetaminophen tablet
300mg; 10mg, 325mg; 2.5mg
hydrocodone bitartrate/acetaminophen tablet
300mg; 5mg, 300mg; 7.5mg
hydrocodone/acetaminophen solution
500mg/15ml; 7.5mg/15ml
hydrocodone/acetaminophen tablet 650mg;
10mg, 650mg; 7.5mg, 660mg; 10mg
hydrocodone/acetaminophen tablet 500mg;
10mg, 500mg; 5mg, 500mg; 7.5mg
hydrocodone/acetaminophen tablet 325mg;
10mg, 325mg; 5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tablet 10mg; 200mg
hydrocodone/ibuprofen tablet 2.5mg; 200mg,
5mg; 200mg, 7.5mg; 200mg
hydromorphone hcl suppository
hydromorphone hcl liquid
HYDROMORPHONE HCL INJECTION 1MG/ML
hydromorphone hcl injection 500mg/50ml
hydromorphone hcl injection 1mg/ml
hydromorphone hcl injection 4mg/ml
hydromorphone hcl injection 2mg/ml
hydromorphone hcl tablet 4mg
hydromorphone hcl tablet 2mg
hydromorphone hcl tablet 8mg
LAZANDA
morphine sulfate injection 10mg/ml
morphine sulfate injection 1mg/ml
morphine sulfate injection 8mg/ml
morphine sulfate injection 150mg/30ml
morphine sulfate injection 5mg/ml
morphine sulfate injection 0.5mg/ml
morphine sulfate injection 1mg/ml
morphine sulfate injection 4mg/ml
morphine sulfate injection 25mg/ml
morphine sulfate injection 15mg/ml
morphine sulfate injection 2mg/ml
morphine sulfate injection 0.5mg/ml
morphine sulfate oral solution 20mg/ml
morphine sulfate oral solution 10mg/5ml
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
QL (5714 ML per 30 days)
QL (150 EA per 30 days)
2
QL (360 EA per 30 days)
2
QL (390 EA per 30 days)
2
QL (3630 ML per 30 days)
2
QL (180 EA per 30 days)
2
QL (240 EA per 30 days)
2
QL (360 EA per 30 days)
2
2
QL (360 EA per 30 days)
QL (480 EA per 30 days)
2
2
4
2
2
2
2
2
2
2
5
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL (300 EA per 30 days)
QL (900 ML per 30 days)
QL (180 ML per 30 days)
QL (180 ML per 30 days)
QL (45 ML per 30 days)
QL (90 ML per 30 days)
QL (210 EA per 30 days)
QL (450 EA per 30 days)
QL (90 EA per 30 days)
PA
QL (120 ML per 30 days)
QL (1200 ML per 30 days)
QL (150 ML per 30 days)
QL (210 ML per 30 days)
QL (240 ML per 30 days)
QL (2400 ML per 30 days)
QL (30 ML per 30 days)
QL (300 ML per 30 days)
QL (48 ML per 30 days)
QL (60 ML per 30 days)
QL (600 ML per 30 days)
QL (7200 ML per 30 days)
QL (180 ML per 30 days)
QL (1800 ML per 30 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
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Drug Name
morphine sulfate oral solution 20mg/5ml
morphine sulfate tablet 30mg
morphine sulfate tablet 15mg
nalbuphine hcl injection
OPIUM TINCTURE
oxycodone hcl solution
oxycodone hcl concentrate
oxycodone hcl capsule
oxycodone hcl tablet 30mg
oxycodone hcl tablet 20mg
oxycodone hcl tablet 15mg
oxycodone hcl tablet 10mg
oxycodone hcl tablet 5mg
oxycodone/acetaminophen tablet 650mg; 10mg
oxycodone/acetaminophen tablet 500mg;
7.5mg
oxycodone/acetaminophen tablet 325mg;
10mg, 325mg; 2.5mg, 325mg; 5mg
oxycodone/acetaminophen tablet 325mg;
7.5mg
oxycodone/aspirin tablet 325mg; 4.835mg
oxymorphone hydrochloride tablet 10mg
oxymorphone hydrochloride tablet 5mg
primlev tablet 300mg; 10mg
primlev tablet 300mg; 5mg, 300mg; 7.5mg
reprexain tablet 10mg; 200mg
ROXICET SOLUTION
roxicet tablet 325mg; 5mg
stagesic
SUBSYS LIQUID 100MCG, 1600MCG,
200MCG, 400MCG, 600MCG, 800MCG
tramadol hcl tablet
tramadol hydrochloride/acetaminophen
trezix
xolox
zamicet
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
QL (900 ML per 30 days)
QL (120 EA per 30 days)
QL (240 EA per 30 days)
HI
QL (118 ML per 30 days)
QL (150 ML per 30 days)
QL (180 ML per 30 days)
QL (720 EA per 30 days)
QL (120 EA per 30 days)
QL (180 EA per 30 days)
QL (240 EA per 30 days)
QL (360 EA per 30 days)
QL (720 EA per 30 days)
QL (180 EA per 30 days)
QL (240 EA per 30 days)
2
QL (360 EA per 30 days)
2
QL (480 EA per 30 days)
2
2
2
2
2
2
3
2
2
5
QL (720 EA per 30 days)
QL (120 EA per 30 days)
QL (240 EA per 30 days)
QL (360 EA per 30 days)
QL (390 EA per 30 days)
2
2
2
2
2
QL (1830 ML per 30 days)
QL (360 EA per 30 days)
QL (240 EA per 30 days)
PA
QL (330 EA per 30 days)
QL (240 EA per 30 days)
Anesthetics
Local Anesthetics
lidocaine hcl jelly
lidocaine hcl external solution
lidocaine hcl injection 1%, 2%
lidocaine viscous
lidocaine/prilocaine
2
2
2
2
2
B/D
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
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Drug Name
LIDOCAINE PATCH
lidocaine ointment
SYNERA
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr
disulfiram tablet
Opioid Dependence Treatments
buprenorphine hcl/naloxone hcl
buprenorphine hcl injection
buprenorphine hcl tablet sublingual 2mg
buprenorphine hcl tablet sublingual 8mg
BUTRANS
naltrexone hcl tablet
SUBOXONE FILM 12MG; 3MG
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG,
8MG; 2MG
ZUBSOLV
Opioid Reversal Agents
naloxone hcl injection
Smoking Cessation Agents
buproban
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CHANTIX TABLET 0.5MG, 1MG
NICOTROL INHALER
NICOTROL NS
Anti-inflammatory Agents
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
4
2
4
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
PA
B/D
B/D
2
2
2
2
2
2
4
2
4
4
QL (90 EA per 30 days) PA
HI
QL (120 EA per 30 days)
QL (60 EA per 30 days)
QL (4 EA per 28 days)
4
QL (90 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (90 EA per 30 days) PA
2
2
4
4
4
3
3
Glucocorticoids
EPIFOAM
3
Nonsteroidal Anti-inflammatory Drugs
CELEBREX
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diclofenac sodium gel 3%
diflunisal tablet
etodolac er
etodolac capsule 200mg
etodolac tablet 400mg, 500mg
fenoprofen calcium tablet
FLECTOR
flurbiprofen tablet
4
2
2
2
5
2
2
2
2
2
4
2
PA
ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
14
Drug Name
ibuprofen suspension
ibuprofen tablet 400mg, 600mg, 800mg
ketoprofen er
ketoprofen capsule
meloxicam suspension 7.5mg/5ml
meloxicam tablet 15mg
nabumetone
naproxen dr
naproxen suspension 125mg/5ml
naproxen tablet 250mg, 375mg
oxaprozin
piroxicam capsule
sulindac tablet
tolmetin sodium
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
1
1
2
2
2
1
2
2
1
1
2
2
2
2
Antibacterials
Aminoglycosides
amikacin sulfate injection 1gm/4ml, 500mg/2ml
BETHKIS
gentak
gentamicin sulfate/0.9% sodium chloride
injection 1.2mg/ml; 0.9%, 1.6mg/ml; 0.9%,
1mg/ml; 0.9%
gentamicin sulfate cream, ointment, ophthalmic
solution
gentamicin sulfate injection 40mg/ml
neomycin sulfate
paromomycin sulfate
streptomycin sulfate injection
TOBI
TOBI PODHALER
tobramycin sulfate/sodium chloride
tobramycin sulfate ophthalmic solution
tobramycin sulfate injection 10mg/ml, 80mg/2ml
tobramycin nebulization solution
TOBREX OINTMENT
Antibacterials, Other
alcohol preps pad
bacitracin ointment
BACTROBAN NASAL
chloramphenicol sodium succinate
CLEOCIN PEDIATRIC GRANULES
CLEOCIN SUPPOSITORY
clindamycin hcl capsule 150mg, 300mg
2
5
2
2
HI
B/D
HI
2
2
2
2
2
5
5
2
2
2
5
3
B/D
QL (224 EA per 28 days)
HI
HI
B/D
2
2
3
2
3
3
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
15
Drug Name
clindamycin palmitate hcl
clindamycin phosphate add-vantage
clindamycin phosphate cream, foam, gel, lotion,
solution, swab
colistimethate sodium
CORTISPORIN OINTMENT 400UNIT/GM; 1%;
0.5%; 5000UNIT/GM
CUBICIN
FLAGYL ER
LANSOPRAZOLE/AMOXICILLIN/CLARITHROM
YCIN
LINCOCIN
mafenide acetate packet
methenamine hippurate
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole cream, gel, lotion, tablet
MIRVASO
MONUROL
mupirocin cream, ointment
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hydrocortisone ophthalmic
suspension 1%; 3.5mg/ml; 10000unit/ml
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
NORITATE
polycin b
polymyxin b sulfate/trimethoprim sulfate
PRIMSOL
silver sulfadiazine cream
SULFAMYLON CREAM
SYNERCID
trimethoprim tablet
TYGACIL
vancomycin hcl capsule
vancomycin hcl injection 1000mg, 10gm,
5000mg, 500mg
VIBATIV INJECTION 750MG
XIFAXAN TABLET 200MG
XIFAXAN TABLET 550MG
ZYVOX
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
2
2
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D
2
4
HI
5
3
4
B/D HI
4
2
2
2
2
2
4
3
2
2
2
2
2
HI
2
2
3
2
2
3
2
4
5
2
3
5
2
QL (90 EA per 365 days)
QL (90 EA per 365 days)
3
4
5
5
HI
QL (30 GM per 30 days)
HI
B/D HI
B/D
QL (30 EA per 30 days)
QL (60 EA per 30 days)
PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
16
Drug Name
Beta-lactam, Cephalosporins
cefaclor
cefadroxil
cefazolin sodium injection 10gm, 1gm; 5%,
1gm, 500mg
cefdinir
cefditoren pivoxil
cefepime injection 1gm, 2gm
cefotaxime sodium injection 10gm, 1gm, 2gm
cefoxitin sodium injection 10gm, 1gm, 2gm
cefpodoxime proxetil
cefprozil
ceftazidime injection 1gm, 2gm, 6gm
ceftibuten
CEFTIN SUSPENSION RECONSTITUTED
250MG/5ML
ceftriaxone in iso-osmotic dextrose injection
40mg/ml; 0
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium injection 1.5gm, 7.5gm,
750mg
cefuroxime/dextrose
cephalexin capsule 250mg, 500mg
cephalexin suspension reconstituted, tablet
SUPRAX
tazicef injection 1gm, 2gm, 6gm
TEFLARO
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
2
2
2
2
2
2
2
2
2
2
2
3
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
HI
HI
HI
HI
HI
2
HI
2
2
2
HI
2
2
2
3
2
4
HI
HI
B/D
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE
CAYSTON
imipenem/cilastatin
INVANZ
MERREM INJECTION 500MG
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amoxicillin capsule, suspension reconstituted,
tablet
amoxicillin tablet chewable 125mg, 250mg
ampicillin
ampicillin sodium injection
ampicillin-sulbactam
3
5
2
4
4
HI
LA
2
2
2
2
2
2
2
HI
HI
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
17
Drug Name
bactocill in dextrose injection 0; 1gm/50ml
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium
oxacillin sodium
penicillin g potassium in iso-osmotic dextrose
penicillin g potassium injection 20000000unit,
5mu
penicillin g procaine
penicillin g sodium
penicillin v potassium
ZOSYN INJECTION 2GM; 0.25GM, 36GM;
4.5GM, 3GM; 0.375GM, 4GM; 0.5GM, 5%;
2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML;
0.375GM/50ML
Macrolides
azithromycin packet, suspension reconstituted,
tablet
azithromycin injection 500mg
clarithromycin er
clarithromycin suspension reconstituted, tablet
DIFICID
E.E.S. 400
E.E.S. GRANULES
ery
ERY-TAB
ERYTHROCIN LACTOBIONATE
ERYTHROCIN STEARATE
erythromycin base tablet
erythromycin ethylsuccinate tablet
erythromycin/sulfisoxazole
erythromycin capsule delayed release particles,
gel, ointment, solution
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
3
3
2
2
2
2
2
2
2
2
4
2
2
2
5
3
3
2
3
3
3
2
2
2
2
3
2
CILOXAN OINTMENT
3
2
2
2
2
2
ciprofloxacin er
ciprofloxacin hcl solution, tablet
ciprofloxacin suspension reconstituted
ciprofloxacin injection 400mg/40ml
gatifloxacin
HI
HI
HI
HI
HI
2
PCE
romycin
Quinolones
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D HI
QL (20 EA per 30 days) ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
18
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
levofloxacin in d5w injection 5%; 500mg/100ml
levofloxacin ophthalmic solution, oral solution,
tablet
levofloxacin injection
moxifloxacin hcl
ofloxacin
VIGAMOX
Sulfonamides
sodium sulfacetamide solution
sulfacetamide sodium ointment 10%
sulfadiazine tablet
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim ds
Tetracyclines
DEMECLOCYCLINE HCL TABLET
doxycycline hyclate dr
doxycycline hyclate capsule, injection, tablet
doxycycline monohydrate
doxycycline capsule 75mg
doxycycline suspension reconstituted
minocycline hcl capsule, tablet
SOLODYN TABLET EXTENDED RELEASE 24
HOUR 105MG, 115MG, 55MG, 65MG, 80MG
tetracycline hcl capsule
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
2
2
3
HI
2
2
2
2
2
4
2
2
2
2
2
2
5
2
Anticonvulsants
Anticonvulsants, Other
APTIOM TABLET 200MG, 400MG, 800MG
APTIOM TABLET 600MG
FYCOMPA
levetiracetam er
levetiracetam oral solution, tablet
levetiracetam injection 500mg/5ml
magnesium sulfate in d5w injection 5%;
10mg/ml
POTIGA TABLET 50MG
POTIGA TABLET 200MG, 300MG, 400MG
4
4
4
2
2
2
2
QL (30 EA per 30 days) ST
QL (60 EA per 30 days) ST
QL (30 EA per 30 days) ST
4
4
QL (180 EA per 30 days)
QL (90 EA per 30 days)
B/D HI
Calcium Channel Modifying Agents
CELONTIN
ethosuximide
LYRICA
zonisamide
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt
3
2
4
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
19
Drug Name
clonazepam tablet
clorazepate dipotassium
DIAZEPAM GEL 10MG, 2.5MG, 20MG
divalproex sodium
divalproex sodium dr
gabapentin capsule, solution, tablet
GABITRIL TABLET 12MG, 16MG
ONFI TABLET
ONFI SUSPENSION
phenobarbital tablet 100mg, 15mg, 60mg
primidone tablet
SABRIL
STAVZOR
tiagabine hydrochloride
valproate sodium injection
valproic acid capsule, syrup
Glutamate Reducing Agents
FELBAMATE
LAMICTAL ODT TABLET DISPERSIBLE
lamotrigine
lamotrigine er
QUDEXY XR CAPSULE ER 24 HOUR
SPRINKLE 100MG, 150MG, 25MG, 50MG
QUDEXY XR CAPSULE ER 24 HOUR
SPRINKLE 200MG
TROKENDI XR CAPSULE EXTENDED RELEASE
24 HOUR 200MG
TROKENDI XR CAPSULE EXTENDED RELEASE
24 HOUR 100MG, 25MG, 50MG
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
1
2
4
2
2
2
3
3
4
2
2
5
4
2
2
2
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
QL (60 EA per 30 days) ST
ST
PA
LA
4
4
2
2
4
QL (30 EA per 30 days) ST
4
QL (60 EA per 30 days) ST
4
QL (60 EA per 30 days) ST
4
QL (90 EA per 30 days) ST
4
4
5
2
2
PA
PA
PA
Sodium Channel Agents
BANZEL SUSPENSION
BANZEL TABLET 200MG
BANZEL TABLET 400MG
carbamazepine er
carbamazepine tablet chewable, suspension,
tablet
CARBATROL
DILANTIN INFATABS
DILANTIN CAPSULE 30MG
epitol
EQUETRO
fosphenytoin sodium injection 100mg pe/2ml
oxcarbazepine
4
3
3
1
4
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
20
Drug Name
OXTELLAR XR
PEGANONE
phenytoin infatabs
phenytoin sodium extended
phenytoin sodium injection
phenytoin tablet chewable, suspension
TEGRETOL-XR
VIMPAT
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates tablet
Cholinesterase Inhibitors
donepezil hcl
EXELON PATCH 24 HOUR, SOLUTION
galantamine hydrobromide
rivastigmine tartrate
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION PACK
NAMENDA TABLET
Antidepressants
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
4
4
2
2
2
2
3
4
2
2
3
2
2
3
3
3
3
QL (30 EA per 30 days)
QL (30 EA per 30 days)
4
4
2
QL (30 EA per 30 days) ST
Antidepressants, Other
APLENZIN
BRINTELLIX
budeprion sr tablet extended release 12 hour
150mg
bupropion hcl sr
bupropion hcl xl
bupropion hcl tablet
FORFIVO XL
maprotiline hcl
mirtazapine
mirtazapine odt tablet dispersible 30mg, 45mg
nefazodone hcl
trazodone hcl tablet 100mg, 150mg, 50mg
trazodone hcl tablet 300mg
Monoamine Oxidase Inhibitors
EMSAM
MARPLAN
phenelzine sulfate tablet
tranylcypromine sulfate
ZELAPAR
2
2
2
4
2
2
2
2
1
2
3
3
2
2
4
QL (30 EA per 30 days) ST
ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
21
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor
BRISDELLE
citalopram hydrobromide solution
citalopram hydrobromide tablet 40mg
citalopram hydrobromide tablet 10mg, 20mg
DESVENLAFAXINE ER
duloxetine hcl capsule delayed release particles
30mg
duloxetine hcl capsule delayed release particles
20mg
duloxetine hcl capsule delayed release particles
60mg
escitalopram oxalate
FETZIMA
FETZIMA TITRATION PACK
fluoxetine dr
fluoxetine hcl
fluvoxamine maleate
fluvoxamine maleate er
KHEDEZLA
OLANZAPINE/FLUOXETINE CAPSULE 25MG;
3MG
paroxetine hcl
paroxetine hcl er
PAXIL
PRISTIQ
sertraline hcl
venlafaxine hcl
venlafaxine hcl er capsule extended release 24
hour
3
1
1
1
4
2
QL (30 EA per 30 days)
QL (600 ML per 30 days)
QL (30 EA per 30 days)
QL (45 EA per 30 days)
QL (30 EA per 30 days) ST
QL (120 EA per 30 days)
2
QL (180 EA per 30 days)
2
QL (60 EA per 30 days)
2
4
4
2
1
2
2
4
4
2
2
4
4
1
2
2
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST
VENLAFAXINE HCL ER TABLET EXTENDED
RELEASE 24 HOUR 225MG
3
venlafaxine hcl er tablet extended release 24
hour 150mg, 37.5mg, 75mg
2
VIIBRYD
4
QL (30 EA per 30 days) ST
2
2
2
2
2
2
2
PA
Tricyclics
amitriptyline hcl tablet
amoxapine
clomipramine hcl capsule
desipramine hcl tablet
doxepin hcl capsule, concentrate
imipramine hcl tablet
imipramine pamoate
PA
PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
22
Drug Name
nortriptyline hcl capsule, solution
protriptyline hcl
SURMONTIL
Antiemetics
Antiemetics, Other
meclizine hcl tablet
phenadoz
promethazine hcl injection 25mg/ml
promethazine hcl suppository 12.5mg, 25mg
promethegan suppository 25mg, 50mg
TRANSDERM-SCOP
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
2
4
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
PA
2
2
2
2
2
3
Emetogenic Therapy Adjuncts
ANZEMET TABLET
DRONABINOL
EMEND CAPSULE
granisetron hcl tablet
granisetron hcl injection 0.1mg/ml, 1mg/ml
granisol
ondansetron hcl oral solution, tablet
ondansetron hcl injection 4mg/2ml
ondansetron odt
SANCUSO
ZUPLENZ
Antifungals
3
4
4
2
2
2
2
2
2
5
4
QL (20 EA per 30 days) B/D
B/D
QL (6 EA per 30 days) B/D
B/D
HI
B/D
B/D
HI
B/D
QL (4 EA per 28 days) PA
QL (90 EA per 30 days) B/D
5
5
2
3
5
2
2
2
2
2
2
4
3
2
HI
Antifungals
ABELCET
AMBISOME
amphotericin b
ANCOBON
CANCIDAS
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine cream
clotrimazole/betamethasone dipropionate
clotrimazole cream, solution, troche
econazole nitrate cream
ERAXIS
EXELDERM CREAM
fluconazole in dextrose injection 56mg/ml;
400mg/200ml
fluconazole suspension reconstituted, tablet
GRIFULVIN V
griseofulvin microsize tablet
2
3
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
23
Drug Name
griseofulvin ultramicrosize
ITRACONAZOLE CAPSULE
ketoconazole cream, shampoo, tablet
miconazole 3 suppository
MYCAMINE INJECTION 50MG
MYCAMINE INJECTION 100MG
NOXAFIL SUSPENSION, TABLET DELAYED
RELEASE
nyamyc
nystatin/triamcinolone
nystatin cream, ointment, powder, suspension,
tablet
nystop
OXISTAT
pedi-dri
terbinafine hcl tablet
terconazole
VFEND TABLET
VORICONAZOLE INJECTION
voriconazole suspension reconstituted, tablet
ZAZOLE CREAM 0.8%
zazole cream 0.4%
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
4
2
2
4
5
5
2
2
2
2
3
2
2
2
5
4
5
4
2
Antigout Agents
Antigout Agents
allopurinol sodium
allopurinol tablet
COLCRYS
KRYSTEXXA
probenecid/colchicine
probenecid tablet
ULORIC
Antimigraine Agents
1
1
3
5
2
2
4
B/D LA
4
QL (18 EA per 30 days) ST
ST
Antimigraine Agents
TREXIMET
Ergot Alkaloids
dihydroergotamine mesylate injection
dihydroergotamine mesylate nasal solution
ERGOMAR
migergot
Prophylactic
divalproex sodium er
topiramate capsule sprinkle, tablet
Serotonin (5-HT) 1b/1d Receptor Agonists
2
2
3
2
QL (12 ML per 30 days)
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
24
Drug Name
AXERT
FROVA
naratriptan hcl
RELPAX
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan
sumatriptan succinate refill
sumatriptan succinate tablet
sumatriptan succinate injection 6mg/0.5ml
SUMAVEL DOSEPRO
zolmitriptan odt
zolmitriptan tablet
ZOMIG NASAL SPRAY
Antimyasthenic Agents
Parasympathomimetics
guanidine hcl
MESTINON TIMESPAN
pyridostigmine bromide tablet
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
4
4
2
4
2
2
2
2
2
2
4
2
2
4
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
QL (12 EA per 30 days) ST
QL (18 EA per 30 days) ST
QL (12 EA per 30 days) ST
QL (18 EA per 30 days)
QL (18 EA per 30 days)
QL (3 ML per 30 days)
ST
QL (12 EA per 30 days)
QL (12 EA per 30 days)
QL (12 EA per 30 days) ST
2
3
2
Antimycobacterials
Antimycobacterials, Other
dapsone tablet
rifabutin
Antituberculars
CAPASTAT SULFATE
cycloserine
ethambutol hcl tablet
isoniazid syrup, tablet
PASER
PRIFTIN
pyrazinamide tablet
RIFAMATE
rifampin capsule, injection
RIFATER
SIRTURO
TRECATOR
Antineoplastics
2
4
3
2
2
1
3
4
2
4
2
4
5
4
Alkylating Agents
BICNU
BUSULFEX
cyclophosphamide injection, tablet
cyclophosphamide capsule
dacarbazine injection 200mg
4
4
2
4
2
B/D
B/D
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
25
Drug Name
HEXALEN
IFEX
ifosfamide/mesna injection 1gm; 1gm
ifosfamide injection 1gm
LEUKERAN
LOMUSTINE
MATULANE
melphalan hydrochloride
MUSTARGEN
thiotepa
TREANDA INJECTION 100MG
VALCHLOR
ZANOSAR
Antiandrogens
bicalutamide
flutamide
NILANDRON
XTANDI
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
5
4
2
2
3
3
5
2
4
2
5
5
4
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D
PA
QL (60 GM per 30 days) PA LA
2
2
5
5
PA LA
5
5
QL (30 EA per 30 days) PA LA
PA
Antiangiogenic Agents
REVLIMID
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX
SOLTAMOX
tamoxifen citrate tablet
Antimetabolites
ALIMTA INJECTION 500MG
ARRANON
cladribine
CLOLAR
cytarabine aqueous
DROXIA
ELITEK INJECTION 1.5MG
fluorouracil injection 2.5gm/50ml
FOLOTYN
gemcitabine
gemcitabine hcl
hydroxyurea capsule
mercaptopurine tablet
pentostatin
tabloid
4
5
5
3
2
5
5
2
4
2
4
4
2
5
5
5
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
26
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
Antineoplastics, Other
ABRAXANE
adriamycin injection 2mg/ml
amifostine
azacitidine
bleomycin sulfate injection 30unit
carboplatin injection 150mg/15ml
cisplatin injection 100mg/100ml
COMETRIQ KIT 140MG/DAY
COMETRIQ KIT 100MG/DAY
COMETRIQ KIT 60MG/DAY
COSMEGEN
DACOGEN
daunorubicin hcl injection 5mg/ml
DAUNOXOME
decitabine
dexrazoxane injection 250mg
DOCEFREZ
docetaxel injection 80mg/4ml, 80mg/8ml
doxorubicin hcl injection 2mg/ml, 50mg
ELSPAR
epirubicin hcl injection 50mg/25ml
ERIVEDGE
ERWINAZE
fludarabine phosphate injection 50mg
FUSILEV
GILOTRIF
HALAVEN
idarubicin hcl injection 10mg/10ml
irinotecan injection 100mg/5ml
ISTODAX
IXEMPRA KIT INJECTION 45MG
JAKAFI
JEVTANA
leucovorin calcium tablet
leucovorin calcium injection
lipodox
MARQIBO
MEKINIST TABLET 2MG
MEKINIST TABLET 0.5MG
MENEST
mesna
MESNEX TABLET
5
2
5
5
2
2
2
5
5
5
5
5
2
4
5
2
5
5
2
4
2
5
5
2
5
5
5
2
2
5
5
5
5
2
2
5
5
5
5
4
2
5
QL (112 EA per 28 days) PA
QL (56 EA per 28 days) PA
QL (84 EA per 28 days) PA
B/D
PA LA
ST
QL (30 EA per 30 days) PA
PA LA
PA
B/D
B/D
QL (30 EA per 30 days) PA
QL (90 EA per 30 days) PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
27
Drug Name
mitomycin injection 20mg
mitoxantrone hcl
ONCASPAR
oxaliplatin injection 100mg/20ml
paclitaxel injection 300mg/50ml
PICATO
POMALYST
PROLEUKIN
SYLATRON
SYNRIBO
TRISENOX
VELCADE
VIDAZA
vinblastine sulfate injection 1mg/ml
vincasar pfs
vincristine sulfate
vinorelbine tartrate injection 50mg/5ml
ZOLINZA
ZYTIGA
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
2
5
2
2
5
5
5
5
5
4
3
5
2
2
2
2
5
5
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
ST
QL (21 EA per 28 days) PA LA
PA
PA
PA
PA LA
Antineoplastics
ZALTRAP INJECTION 100MG/4ML
ZYKADIA
Aromatase Inhibitors, 3rd Generation
anastrozole tablet
exemestane
letrozole
Enzyme Inhibitors
ETOPOSIDE CAPSULE
etoposide injection 500mg/25ml
toposar injection 1gm/50ml
topotecan hcl injection 4mg
Molecular Target Inhibitors
AFINITOR
AFINITOR DISPERZ
BOSULIF TABLET 100MG
BOSULIF TABLET 500MG
CAPRELSA
GLEEVEC
IMBRUVICA
INLYTA
NEXAVAR
SPRYCEL
STIVARGA
5
5
B/D
PA
2
2
2
4
2
2
5
5
5
5
5
5
5
5
5
5
5
5
PA
PA
QL (120 EA per 30 days) PA
QL (30 EA per 30 days) PA
PA LA
PA
QL (120 EA per 30 days) PA
PA LA
PA LA
PA
QL (84 EA per 28 days) PA LA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
28
Drug Name
SUTENT
TAFINLAR
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
5
5
5
5
5
5
5
5
PA
QL (120 EA per 30 days) PA
PA
PA
PA LA
PA
QL (60 EA per 30 days) PA LA
QL (240 EA per 30 days) PA LA
5
5
5
5
5
5
5
5
5
5
5
5
PA
Monoclonal Antibodies
ARZERRA INJECTION 100MG/5ML
AVASTIN INJECTION 100MG/4ML
ERBITUX INJECTION 100MG/50ML
GAZYVA
HERCEPTIN
KADCYLA
PERJETA
RITUXAN
SYLVANT
VECTIBIX INJECTION 100MG/5ML
YERVOY
ZALTRAP INJECTION 200MG/8ML
PA
PA
PA
PA
PA
PA
PA
B/D
Retinoids
PANRETIN
TARGRETIN
tretinoin capsule 10mg
5
5
5
PA
PA
Antiparasitics
Anthelmintics
ALBENZA
BILTRICIDE
STROMECTOL
3
3
3
ALINIA
3
5
4
2
3
3
2
2
5
3
4
2
Antiprotozoals
atovaquone
ATOVAQUONE/PROGUANIL HCL
chloroquine phosphate tablet
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
mefloquine hcl
MEPRON
NEBUPENT
PENTAM 300
primaquine phosphate tablet
QL (24 EA per 30 days)
PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
29
Drug Name
quinine sulfate
Pediculicides/Scabicides
acticin
EURAX
lindane lotion, shampoo
malathion lotion
permethrin cream
SKLICE
ULESFIA
Antiparkinson Agents
Anticholinergics
diphenhydramine hcl capsule 50mg
diphenhydramine hcl injection
trihexyphenidyl hcl
Antiparkinson Agents, Other
entacapone
TASMAR
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
3
2
2
2
4
3
QL (117 GM per 14 days)
2
2
2
2
4
Dopamine Agonists
APOKYN
bromocriptine mesylate capsule, tablet
MIRAPEX ER
NEUPRO
3
2
4
4
2
2
2
LA
ST
ST
pramipexole dihydrochloride
ropinirole er
ropinirole hcl
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa
2
carbidopa/levodopa er tablet extended release
2
50mg; 200mg
carbidopa/levodopa odt
2
CARBIDOPA/LEVODOPA/ENTACAPONE
carbidopa tablet
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
selegiline hcl capsule, tablet
4
2
3
2
Antipsychotics
1st Generation/Typical
chlorpromazine hcl injection, tablet
compro
fluphenazine decanoate injection
fluphenazine hcl concentrate, elixir, injection,
tablet
haloperidol decanoate
2
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
30
Drug Name
haloperidol lactate
haloperidol tablet
haloperidol concentrate
loxapine succinate capsule
ORAP
perphenazine tablet
prochlorperazine
prochlorperazine edisylate injection
prochlorperazine maleate tablet
thioridazine hcl tablet
thiothixene capsule
trifluoperazine hcl tablet
2nd Generation/Atypical
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY INJECTION
ABILIFY ORAL SOLUTION
ABILIFY TABLET 10MG, 15MG, 2MG, 5MG
ABILIFY TABLET 20MG, 30MG
FANAPT
FANAPT TITRATION PACK
INVEGA SUSTENNA INJECTION
39MG/0.25ML, 78MG/0.5ML
INVEGA SUSTENNA INJECTION
117MG/0.75ML, 156MG/ML, 234MG/1.5ML
INVEGA TABLET EXTENDED RELEASE 24
HOUR 1.5MG, 3MG
INVEGA TABLET EXTENDED RELEASE 24
HOUR 9MG
INVEGA TABLET EXTENDED RELEASE 24
HOUR 6MG
LATUDA
olanzapine
olanzapine odt
quetiapine fumarate
RISPERDAL CONSTA INJECTION 12.5MG,
25MG
RISPERDAL CONSTA INJECTION 37.5MG,
50MG
risperidone
risperidone odt
SAPHRIS
SEROQUEL XR TABLET EXTENDED RELEASE
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
1
2
2
3
2
2
2
2
2
2
2
5
5
3
5
4
5
4
4
4
QL (30 EA per 30 days) PA
PA
PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) ST
ST
5
4
QL (30 EA per 30 days) ST
5
QL (30 EA per 30 days) ST
5
QL (60 EA per 30 days) ST
4
2
2
2
4
QL (30 EA per 30 days) ST
QL (30 EA per 30 days)
QL (30 EA per 30 days)
5
2
2
5
3
QL (60 EA per 30 days) ST
QL (30 EA per 30 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
31
Drug Name
24 HOUR 150MG, 200MG, 50MG
SEROQUEL XR TABLET EXTENDED RELEASE
24 HOUR 300MG
SEROQUEL XR TABLET EXTENDED RELEASE
24 HOUR 400MG
ziprasidone hcl
ZYPREXA RELPREVV
ZYPREXA INJECTION
Treatment-Resistant
clozapine
clozapine odt
FAZACLO
VERSACLOZ
Antispasticity Agents
Antispasticity Agents
baclofen tablet
dantrolene sodium capsule
tizanidine hcl capsule, tablet
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
3
QL (60 EA per 30 days)
5
QL (60 EA per 30 days)
2
5
4
QL (60 EA per 30 days)
2
2
4
5
ST
ST
2
2
2
Antivirals
Anti-cytomegalovirus (CMV) Agents
foscarnet sodium
GANCICLOVIR INJECTION
VALCYTE TABLET
ZIRGAN
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
BARACLUDE TABLET
BARACLUDE SOLUTION
EPIVIR HBV SOLUTION
HEPSERA
INTRON-A
INTRON-A W/DILUENT
lamivudine tablet 100mg
TYZEKA
2
4
5
4
5
4
4
3
5
5
5
2
5
QL (30 EA per 30 days)
QL (600 ML per 30 days)
Anti-hepatitis C (HCV) Agents
INCIVEK
INFERGEN INJECTION 15MCG/0.5ML
moderiba
moderiba 1200 dose pack
moderiba 800 dose pack
OLYSIO
PEG-INTRON REDIPEN
PEG-INTRON INJECTION 120MCG/0.5ML,
5
5
2
2
2
5
5
5
QL (180 EA per 30 days) PA
QL (30 EA per 30 days) PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
32
Drug Name
50MCG/0.5ML
PEGASYS PROCLICK
PEGASYS INJECTION 180MCG/0.5ML,
180MCG/ML
ribasphere
ribavirin
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
5
5
SOVALDI
VICTRELIS
VIRAZOLE
2
2
5
5
5
ISENTRESS PACKET 100MG
3
Anti-HIV Agents, Integrase Inhibitors (INSTI)
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
QL (30 EA per 30 days) PA
PA
B/D
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA
EDURANT
INTELENCE TABLET 25MG
INTELENCE TABLET 100MG, 200MG
nevirapine er
nevirapine tablet
nevirapine suspension
RESCRIPTOR
STRIBILD
SUSTIVA
VIRAMUNE XR TABLET EXTENDED RELEASE
24 HOUR 100MG
VIRAMUNE XR TABLET EXTENDED RELEASE
24 HOUR 400MG
VIRAMUNE SUSPENSION
VIRAMUNE TABLET
5
3
3
5
4
4
5
3
5
3
4
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (120 EA per 30 days)
5
QL (30 EA per 30 days)
4
5
QL (1200 ML per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir
2
abacavir sulfate/lamivudine/zidovudine
5
didanosine
2
EMTRIVA
EPIVIR SOLUTION
EPZICOM
LAMIVUDINE/ZIDOVUDINE
lamivudine tablet 150mg, 300mg
RETROVIR IV INFUSION
stavudine
TRIZIVIR
TRUVADA
VIDEX PEDIATRIC
VIREAD
3
3
5
4
2
3
2
5
5
3
5
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
33
Drug Name
ZIAGEN SOLUTION
zidovudine
Anti-HIV Agents, Other
FUZEON INJECTION 90MG
ISENTRESS TABLET CHEWABLE 25MG
ISENTRESS TABLET CHEWABLE 100MG
ISENTRESS TABLET 400MG
SELZENTRY
TIVICAY
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
3
2
5
3
5
5
5
5
QL (60 EA per 30 days)
Anti-HIV Agents, Protease Inhibitors
APTIVUS SOLUTION
APTIVUS CAPSULE
CRIXIVAN CAPSULE 200MG, 400MG
INVIRASE CAPSULE
INVIRASE TABLET
KALETRA SOLUTION
KALETRA TABLET 100MG; 25MG
KALETRA TABLET 200MG; 50MG
LEXIVA SUSPENSION
LEXIVA TABLET
NORVIR
PREZISTA SUSPENSION
PREZISTA TABLET 150MG, 75MG
PREZISTA TABLET 400MG, 600MG, 800MG
REYATAZ CAPSULE 150MG, 200MG, 300MG
VIRACEPT TABLET
Anti-influenza Agents
amantadine hcl capsule, syrup, tablet
RELENZA DISKHALER
rimantadine hcl
TAMIFLU CAPSULE 30MG
TAMIFLU CAPSULE 45MG, 75MG
TAMIFLU SUSPENSION RECONSTITUTED
6MG/ML
Antiherpetic Agents
acyclovir sodium injection 50mg/ml
acyclovir capsule, suspension, tablet
acyclovir ointment
DENAVIR
famciclovir tablet
trifluridine solution
valacyclovir hcl
XERESE
4
5
3
4
5
5
4
5
4
5
4
5
3
5
5
3
2
3
2
4
4
4
2
2
2
3
2
2
2
4
QL (112 EA per 365 days)
QL (56 EA per 365 days)
B/D
QL (30 GM per 30 days)
ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
34
Drug Name
ZOVIRAX CREAM
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
3
Antivirals
ATRIPLA
Anxiolytics
Anxiolytics, Other
alprazolam
alprazolam er tablet extended release 24 hour
0.5mg
alprazolam intensol
alprazolam odt
alprazolam xr tablet extended release 24 hour
1mg, 2mg, 3mg
buspirone hcl tablet
chlordiazepoxide hcl
diazepam intensol
diazepam solution 1mg/ml
diazepam tablet 10mg, 2mg, 5mg
estazolam
lorazepam intensol
lorazepam tablet
oxazepam
Benzodiazepines
alprazolam xr tablet extended release 24 hour
0.5mg
5
1
2
2
2
2
2
1
2
1
1
2
2
1
2
2
Bipolar Agents
Bipolar Agents, Other
GEODON INJECTION
OLANZAPINE/FLUOXETINE CAPSULE 25MG;
12MG, 25MG; 6MG, 50MG; 12MG, 50MG;
6MG
Mood Stabilizers
lithium carbonate er
lithium carbonate capsule, tablet
lithium citrate
3
4
2
1
2
Blood Glucose Regulators
Antidiabetic Agents
acarbose
ACTOPLUS MET XR
AVANDAMET
AVANDARYL
AVANDIA
BYDUREON
BYETTA
2
3
3
3
3
3
3
LA
QL (4 EA per 28 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
35
Drug Name
chlorpropamide
CYCLOSET
FARXIGA
glimepiride
glipizide er
glipizide xl tablet extended release 24 hour
2.5mg
glipizide/metformin hcl
glipizide tablet
GLUMETZA
GLYSET
INVOKANA
JANUMET
JANUMET XR TABLET EXTENDED RELEASE
24 HOUR 1000MG; 100MG, 500MG; 50MG
JANUMET XR TABLET EXTENDED RELEASE
24 HOUR 1000MG; 50MG
JANUVIA
JENTADUETO
KOMBIGLYZE XR TABLET EXTENDED
RELEASE 24 HOUR 1000MG; 5MG, 500MG;
5MG
KOMBIGLYZE XR TABLET EXTENDED
RELEASE 24 HOUR 1000MG; 2.5MG
metformin hcl er
metformin hcl tablet
nateglinide
ONGLYZA
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
PRANDIMET
repaglinide
SYMLINPEN 120
SYMLINPEN 60
tolazamide
tolbutamide
TRADJENTA
VICTOZA
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
4
4
1
2
2
2
1
4
3
3
3
3
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
QL (30 EA per 30 days)
ST
QL (30 EA per 30 days)
QL (30 EA per 30 days)
3
QL (60 EA per 30 days)
3
4
4
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
4
QL (60 EA per 30 days)
2
1
2
4
2
2
2
4
2
5
3
2
2
4
3
ST
QL (6 ML per 30 days) ST
QL (30 EA per 30 days)
Glycemic Agents
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
3
3
3
B/D
B/D
B/D
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
36
Drug Name
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 25%
dextrose 10%/nacl 0.45%
dextrose 10% flex container
dextrose 10%/nacl 0.2%
dextrose 2.5%/nacl 0.45%
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%
dextrose 5%/sodium chloride 0.2%
dextrose 5%/sodium chloride 0.33%
dextrose 5%/sodium chloride 0.9%
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
kcl 0.15%/d5w/ nacl 0.3%
kcl 0.15%/d5w/lr
kcl 0.15%/d5w/nacl 0.45%
potassium chloride packet 20meq
PROGLYCEM
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
2
2
2
2
3
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Insulins
APIDRA
APIDRA SOLOSTAR
humalog
humalog kwikpen
humalog mix 50/50
humalog mix 50/50 kwikpen
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)
LANTUS
4
4
2
2
2
2
2
2
2
2
2
2
2
2
3
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
37
Drug Name
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
NOVOLOG PENFILL
Blood Products/Modifiers/Volume Expanders
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
3
3
3
4
4
4
4
4
4
4
4
Anticoagulants
COUMADIN
ELIQUIS
ENOXAPARIN SODIUM INJECTION
30MG/0.3ML
ENOXAPARIN SODIUM INJECTION
120MG/0.8ML
ENOXAPARIN SODIUM INJECTION 100MG/ML,
150MG/ML
3
3
4
QL (60 EA per 30 days)
QL (18 ML per 30 days)
5
QL (48 ML per 30 days)
5
QL (60 ML per 30 days)
enoxaparin sodium injection 300mg/3ml
enoxaparin sodium injection 40mg/0.4ml
enoxaparin sodium injection 60mg/0.6ml
enoxaparin sodium injection 80mg/0.8ml
2
4
4
4
4
QL (24 ML per 30 days)
QL (36 ML per 30 days)
QL (48 ML per 30 days)
QL (15 ML per 30 days)
FONDAPARINUX SODIUM INJECTION
2.5MG/0.5ML
fondaparinux sodium injection 5mg/0.4ml
fondaparinux sodium injection 7.5mg/0.6ml
fondaparinux sodium injection 10mg/0.8ml
FRAGMIN INJECTION 25000UNIT/ML,
2500UNIT/0.2ML, 5000UNIT/0.2ML
FRAGMIN INJECTION 10000UNIT/ML,
7500UNIT/0.3ML
heparin sodium/d5w
heparin sodium/nacl 0.45%
heparin sodium/nacl 0.9%
heparin sodium/sodium chloride 0.9% premix
heparin sodium injection 10000unit/ml,
1000unit/ml, 20000unit/ml, 2000unit/ml,
2500unit/ml, 5000unit/ml
jantoven
PRADAXA
5
5
5
4
QL (12 ML per 30 days)
QL (18 ML per 30 days)
QL (24 ML per 30 days)
5
2
2
2
2
2
B/D HI
2
3
QL (60 EA per 30 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
38
Drug Name
warfarin sodium tablet
XARELTO TABLET 10MG, 20MG
XARELTO TABLET 15MG
Blood Formation Modifiers
anagrelide hydrochloride
ARANESP ALBUMIN FREE INJECTION
100MCG/ML, 25MCG/0.42ML, 25MCG/ML,
40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML,
60MCG/ML
ARANESP ALBUMIN FREE INJECTION
100MCG/0.5ML, 150MCG/0.3ML,
200MCG/0.4ML, 200MCG/ML,
300MCG/0.6ML, 300MCG/ML, 500MCG/ML
EPOGEN
GRANIX
LEUKINE
NEULASTA
NEUMEGA
NEUPOGEN INJECTION 300MCG/0.5ML,
480MCG/0.8ML, 480MCG/1.6ML
PROCRIT INJECTION 2000UNIT/ML,
3000UNIT/ML
PROCRIT INJECTION 4000UNIT/ML
PROCRIT INJECTION 10000UNIT/ML,
20000UNIT/ML, 40000UNIT/ML
PROMACTA
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
1
3
3
QL (30 EA per 30 days)
QL (60 EA per 30 days)
2
4
B/D
5
B/D
4
5
5
5
5
5
B/D
B/D
3
B/D
4
5
B/D
B/D
5
PA LA
5
PA LA
PA
Blood Products/Modifiers/Volume Expanders
SOLIRIS
Coagulants
aminocaproic acid syrup
aminocaproic acid tablet 500mg
BRILINTA
tranexamic acid injection, tablet
Platelet Modifying Agents
AGGRENOX
cilostazol
clopidogrel
EFFIENT
ZONTIVITY
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl er
clonidine hcl tablet
2
2
3
2
3
2
2
3
4
QL (60 EA per 30 days)
QL (30 EA per 30 days) ST
2
1
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
39
Drug Name
clonidine hcl patch weekly
clorpres
midodrine hcl
Alpha-adrenergic Blocking Agents
doxazosin mesylate
prazosin hcl
Angiotensin II Receptor Antagonists
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
DIOVAN
EDARBYCLOR
eprosartan mesylate
irbesartan
irbesartan/hydrochlorothiazide
losartan potassium
losartan potassium/hydrochlorothiazide
telmisartan
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
TEVETEN HCT
valsartan/hydrochlorothiazide
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide
benazepril hcl tablet
captopril/hydrochlorothiazide
captopril tablet
enalapril maleate/hydrochlorothiazide
enalapril maleate tablet
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
moexipril hcl
smoexipril/hydrochlorothiazide
perindopril erbumine
quinapril hcl
quinapril/hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmics
amiodarone hcl tablet
amiodarone hcl injection 50mg/ml
disopyramide phosphate capsule
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
2
2
2
2
3
4
2
2
2
1
2
2
2
2
4
2
FF
FF
ST
QL (30 EA per 30 days) ST
FF
FF
FF
FF
FF
FF
FF
FF
ST
FF
2
1
2
1
2
1
2
2
1
1
2
2
2
2
2
2
2
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
FF
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
40
Drug Name
flecainide acetate
mexiletine hcl
MULTAQ
pacerone tablet 200mg
propafenone hcl
propafenone hcl er
quinidine gluconate cr
quinidine sulfate
RYTHMOL SR
sorine
sotalol hcl (af)
sotalol hcl tablet 160mg, 240mg, 80mg
TIKOSYN
Beta-adrenergic Blocking Agents
acebutolol hcl capsule
atenolol/chlorthalidone
atenolol tablet
betaxolol hcl tablet 10mg, 20mg
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
BYSTOLIC
carvedilol
COREG CR
INNOPRAN XL
labetalol hcl injection, tablet
metoprolol succinate er
metoprolol tartrate injection, tablet
metoprolol/hydrochlorothiazide
nadolol/bendroflumethiazide
nadolol tablet 20mg, 40mg, 80mg
pindolol
propranolol hcl er
propranolol hcl injection, oral solution, tablet
propranolol/hydrochlorothiazide
timolol maleate tablet 10mg, 20mg, 5mg
Calcium Channel Blocking Agents
afeditab cr
amlodipine besylate/atorvastatin calcium
amlodipine besylate/benazepril hydrochloride
amlodipine besylate tablet
AZOR
CARDIZEM LA TABLET EXTENDED RELEASE
24 HOUR 120MG
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
3
2
2
2
2
2
4
2
2
2
3
2
1
1
2
2
2
4
2
4
4
2
2
1
2
2
2
2
2
1
2
2
2
2
2
1
4
3
ST
FF
ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
41
Drug Name
cartia xt
dilt-cd capsule extended release 24 hour
120mg, 300mg
dilt-xr capsule extended release 24 hour 180mg,
240mg
diltiazem cd capsule extended release 24 hour
120mg, 240mg, 300mg
diltiazem hcl er capsule extended release 12
hour, capsule extended release 24 hour
diltiazem hcl tablet
diltiazem hcl injection 100mg, 50mg/10ml
diltzac
EXFORGE
EXFORGE HCT
felodipine er
isradipine
matzim la
nicardipine hcl capsule
nifediac cc tablet extended release 24 hour
90mg
nifedical xl
nifedipine er
NIMODIPINE CAPSULE
nisoldipine
nisoldipine er
taztia xt
TRIBENZOR
verapamil hcl er
verapamil hcl sr capsule extended release 24
hour 360mg
verapamil hcl tablet
Cardiovascular Agents, Other
AMTURNIDE
DEMSER
digoxin injection, oral solution
digoxin tablet 250mcg
digoxin tablet 125mcg
pentoxifylline er
RANEXA
TEKAMLO
TEKTURNA
TEKTURNA HCT
vecamyl
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
2
2
2
2
2
3
3
2
2
2
2
2
2
2
4
2
2
2
4
2
2
ST
ST
ST
2
3
4
2
2
2
2
3
3
3
3
5
QL (30 EA per 30 days) ST
PA
PA
QL (30 EA per 30 days)
ST
ST
ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
42
Drug Name
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide sodium
acetazolamide tablet
methazolamide
Diuretics, Loop
bumetanide tablet
EDECRIN
furosemide tablet
furosemide injection
furosemide oral solution 10mg/ml
torsemide tablet
Diuretics, Potassium-sparing
amiloride hcl tablet
amiloride/hydrochlorothiazide
DYRENIUM
eplerenone
spironolactone/hydrochlorothiazide
spironolactone tablet
triamterene/hydrochlorothiazide capsule 25mg;
37.5mg
triamterene/hydrochlorothiazide tablet
Diuretics, Thiazide
chlorothiazide
chlorthalidone tablet 25mg, 50mg
hydrochlorothiazide capsule, tablet
indapamide tablet
methyclothiazide tablet
metolazone
Dyslipidemics, Fibric Acid Derivatives
fenofibrate
fenofibrate micronized
fenofibric acid
fenofibric acid dr
gemfibrozil tablet
Dyslipidemics, HMG CoA Reductase Inhibitors
ADVICOR
ALTOPREV
atorvastatin calcium
CRESTOR
fluvastatin
LESCOL XL
LIPTRUZET
LIVALO
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
1
3
1
1
1
2
HI
2
2
3
2
2
2
2
2
2
2
1
1
2
2
2
2
2
2
2
3
4
2
3
2
4
4
4
QL (30 EA per 30 days) ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
43
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
lovastatin
pravastatin sodium
SIMCOR
simvastatin
Dyslipidemics, Other
cholestyramine light
cholestyramine packet, powder
COLESTID FLAVORED PACKET 5GM/7.5GM
colestipol hcl
JUXTAPID
KYNAMRO
omega-3-acid ethyl esters
prevalite powder
VASCEPA
VYTORIN
WELCHOL
ZETIA
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
3
1
2
2
3
2
5
5
2
2
4
4
3
4
PA
PA
PA
PA
Vasodilators, Direct-acting Arterial/Venous
BIDIL
isoditrate er
isosorbide dinitrate er
isosorbide dinitrate tablet
isosorbide mononitrate
isosorbide mononitrate er
NITRO-BID
NITRO-DUR PATCH 24 HOUR 0.3MG/HR,
0.8MG/HR
3
2
2
2
2
2
3
3
nitroglycerin lingual
nitroglycerin transdermal patch 24 hour
0.1mg/hr
nitroglycerin patch 24 hour 0.2mg/hr, 0.4mg/hr,
0.6mg/hr
2
2
NITROLINGUAL PUMPSPRAY
NITROSTAT
RECTIV
3
3
4
Vasodilators, Direct-acting Arterial
hydralazine hcl injection, tablet
minoxidil tablet
2
2
2
QL (30 GM per 30 days)
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
AMPHETAMINE/DEXTROAMPHETAMINE
CAPSULE EXTENDED RELEASE 24 HOUR
AMPHETAMINE/DEXTROAMPHETAMINE
4
QL (30 EA per 30 days)
4
QL (120 EA per 30 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
44
Drug Name
TABLET 5MG, 7.5MG, 10MG, 12.5MG, 15MG
AMPHETAMINE/DEXTROAMPHETAMINE
TABLET 30MG
AMPHETAMINE/DEXTROAMPHETAMINE
TABLET 20MG
dextroamphetamine sulfate er
dextroamphetamine sulfate tablet
VYVANSE
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
4
QL (60 EA per 30 days)
4
QL (90 EA per 30 days)
2
2
4
QL (30 EA per 30 days)
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
DAYTRANA
dexmethylphenidate hcl
dexmethylphenidate hcl er
FOCALIN XR CAPSULE EXTENDED RELEASE
24 HOUR 10MG, 20MG, 25MG, 35MG, 5MG
INTUNIV
metadate er
METHYLIN TABLET CHEWABLE
methylphenidate hcl cd
methylphenidate hcl er capsule extended
release 24 hour
METHYLPHENIDATE HCL ER TABLET
EXTENDED RELEASE 18MG, 54MG
METHYLPHENIDATE HCL ER TABLET
EXTENDED RELEASE 27MG, 36MG
methylphenidate hcl er tablet extended release
10mg, 20mg
methylphenidate hcl tablet
methylphenidate hydrochloride
STRATTERA
Central Nervous System, Other
HORIZANT TABLET EXTENDED RELEASE 24
HOUR 300MG
HORIZANT TABLET EXTENDED RELEASE 24
HOUR 600MG
NUEDEXTA
RILUTEK
riluzole
XENAZINE
4
2
2
4
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
4
2
3
2
2
QL (30 EA per 30 days)
QL (30 EA per 30 days)
4
QL (30 EA per 30 days)
4
QL (60 EA per 30 days)
2
2
2
3
4
QL (30 EA per 30 days) ST
4
QL (60 EA per 30 days) ST
3
5
2
5
QL (60 EA per 30 days)
LA
Fibromyalgia Agents
SAVELLA
SAVELLA TITRATION PACK
4
4
Multiple Sclerosis Agents
AMPYRA
5
PA LA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
45
Drug Name
AUBAGIO
AVONEX PEN
COPAXONE
GILENYA
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK
TYSABRI
Dental and Oral Agents
Dental and Oral Agents
cevimeline hcl
chlorhexidine gluconate oral rinse
chlorhexidine gluconate solution
KEPIVANCE
pilocarpine hcl tablet 7.5mg
pilocarpine hydrochloride
triamcinolone in orabase
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
5
5
5
5
5
5
5
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
PA LA
PA
PA
2
2
2
5
2
2
2
Dermatological Agents
Dermatological Agents
ACITRETIN
adapalene
ammonium lactate cream, lotion
amnesteem
ATRALIN
AZELEX
calcipotriene
calcitrene
calcitriol ointment 3mcg/gm
CARAC
claravis
clindamycin/benzoyl peroxide gel 5%; 1%
CONDYLOX GEL
CORTISPORIN CREAM 0.5%; 0.5%;
10000UNIT/GM
CURITY GAUZE PADS 2"X2"
ELIDEL
erythromycin/benzoyl peroxide
FABIOR
FINACEA
FLUOROPLEX
fluorouracil cream 5%
fluorouracil external solution 2%, 5%
imiquimod cream
laclotion
4
2
2
2
4
3
2
2
2
4
2
2
4
4
3
3
2
4
3
4
2
2
2
2
QL (100 GM per 30 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
46
Drug Name
methoxsalen capsule
OXSORALEN
OXSORALEN ULTRA
podofilox solution
PROCTOFOAM HC
PROTOPIC
REGRANEX
salicylic acid lotion
SANTYL
selenium sulfide
SOLARAZE
SORIATANE
STELARA
sulfacetamide sodium suspension 10%
TAZORAC
TRETIN-X CREAM 0.075%
tretinoin microsphere
tretinoin cream 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%
urea 40% nail film
urea nail stick
urea cream 40%, 50%
urea gel
urea lotion 40%
UVADEX
VEREGEN
VOLTAREN
ZONALON
ZYCLARA
ZYCLARA PUMP CREAM 3.75%
Enzyme Replacement/Modifiers
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
5
3
5
2
3
3
5
2
3
2
5
5
5
2
4
4
2
2
2
2
2
2
2
2
3
4
4
4
4
4
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
PA
ST
ST
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABLET
CEREZYME
CREON
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME
KUVAN TABLET SOLUBLE
5
5
5
3
4
3
3
5
5
5
5
LA
LA
LA
LA
LA
B/D LA
LA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
47
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
LUMIZYME
NAGLAZYME
ORFADIN
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 17500UNIT; 4200UNIT;
10000UNIT, 43750UNIT; 10500UNIT;
25000UNIT
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 61000UNIT; 21000UNIT;
37000UNIT, 70000UNIT; 16800UNIT;
40000UNIT
5
5
5
4
pancrelipase
2
5
5
5
4
RAVICTI
sodium phenylbutyrate powder
SUCRAID
ULTRESA CAPSULE DELAYED RELEASE
PARTICLES 27600UNIT; 13800UNIT;
27600UNIT
ULTRESA CAPSULE DELAYED RELEASE
PARTICLES 41400UNIT; 20700UNIT;
41400UNIT, 46000UNIT; 23000UNIT;
46000UNIT
VIOKACE
ZAVESCA
ZENPEP
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
belladonna & opium
belladonna alkaloids & opium
CANTIL
CUVPOSA
dicyclomine hcl capsule, solution, tablet
glycopyrrolate tablet
hyoscyamine sulfate
methscopolamine bromide
propantheline bromide
Gastrointestinal Agents, Other
diphenoxylate/atropine
FULYZAQ
GASTROCROM
GATTEX
loperamide hcl capsule
metoclopramide hcl oral solution, tablet
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D LA
LA
LA
5
PA
LA
5
4
5
4
LA
2
2
3
4
1
2
2
2
2
2
4
5
5
2
1
QL (60 EA per 30 days) PA
PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
48
Drug Name
metoclopramide hcl injection
METOZOLV ODT TABLET DISPERSIBLE 5MG
RELISTOR INJECTION 12MG/0.6ML
SUCLEAR
ursodiol capsule, tablet
Histamine2 (H2) receptor Antagonists
cimetidine hcl solution
cimetidine tablet
famotidine injection 20mg/2ml
famotidine tablet 20mg, 40mg
nizatidine capsule
ranitidine hcl capsule, syrup
ranitidine hcl tablet 150mg, 300mg
Irritable Bowel Syndrome Agents
AMITIZA
LINZESS
LOTRONEX
Laxatives
constulose
enulose
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
KRISTALOSE
lactulose solution
peg 3350/electrolytes
polyethylene glycol 3350 powder
PREPOPIK
RELISTOR INJECTION 12MG/0.6ML,
8MG/0.4ML
SUPREP BOWEL PREP
trilyte
Protectants
CARAFATE SUSPENSION
misoprostol tablet
sucralfate tablet
Proton Pump Inhibitors
DEXILANT
ESOMEPRAZOLE SODIUM
ESOMEPRAZOLE STRONTIUM
lansoprazole capsule delayed release
omeprazole/sodium bicarbonate
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
1
4
4
4
2
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D
ST
PA
2
2
2
1
2
2
1
4
3
5
2
2
2
2
2
2
3
2
2
2
4
4
QL (30 EA per 30 days)
PA
4
2
3
2
2
4
4
3
2
2
ST
ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
49
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
omeprazole capsule delayed release
pantoprazole sodium
rabeprazole sodium
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
Genitourinary Agents
Antispasmodics, Urinary
ENABLEX
flavoxate hcl
GELNIQUE
oxybutynin chloride er
oxybutynin chloride syrup, tablet
tolterodine tartrate
tolterodine tartrate er
TOVIAZ
trospium chloride
trospium chloride er
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
AVODART
finasteride tablet 5mg
JALYN
RAPAFLO
tamsulosin hcl
terazosin hcl
Genitourinary Agents, Other
bethanechol chloride
CIALIS TABLET 2.5MG, 5MG
ELMIRON
phenazopyridine hcl tablet 100mg, 200mg
Phosphate Binders
calcium acetate capsule
FOSRENOL
RENVELA TABLET
RENVELA PACKET
SEVELAMER CARBONATE
VELPHORO
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
3
2
4
2
2
2
2
4
2
2
2
3
2
4
3
2
2
2
4
4
2
2
5
4
5
4
5
ST
ST
QL (30 EA per 30 days) PA
ST
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
ala cort
2
ALA SCALP
alclometasone dipropionate
amcinonide
augmented betamethasone dipropionate cream,
gel, ointment
3
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
50
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
betamethasone dipropionate cream, lotion,
ointment
betamethasone valerate cream, foam, lotion,
ointment
2
BUDESONIDE CAPSULE EXTENDED RELEASE
24 HOUR 3MG
CALCIPOTRIENE/BETAMETHASONE
DIPROPIONATE
CAPEX
CELESTONE
4
clobetasol propionate e
clobetasol propionate emollient cream
CLOBETASOL PROPIONATE SHAMPOO
clobetasol propionate cream, foam, gel, lotion,
ointment, solution
clocortolone pivalate
CORDRAN TAPE
CORTIFOAM
cortisone acetate tablet
desonide cream, lotion, ointment
desoximetasone cream, gel, ointment
dexamethasone intensol
dexamethasone sodium phosphate injection
120mg/30ml
dexamethasone elixir, solution, tablet
diflorasone diacetate cream, ointment
fludrocortisone acetate tablet
fluocinolone acetonide body
fluocinolone acetonide scalp
fluocinolone acetonide cream, oil, ointment,
solution
fluocinonide-e
fluocinonide cream, gel, ointment, solution
fluticasone propionate cream 0.05%
fluticasone propionate lotion 0.05%
fluticasone propionate ointment 0.005%
halobetasol propionate
HALOG CREAM
hydrocortisone butyrate cream, ointment,
solution
hydrocortisone in absorbase
hydrocortisone valerate
hydrocortisone cream 1%, 2.5%
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
4
4
3
2
2
4
2
2
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
51
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
hydrocortisone lotion 2.5%
hydrocortisone ointment 1%, 2.5%
hydrocortisone tablet 10mg, 20mg, 5mg
KENALOG
lidocaine hcl/hydrocortisone acetate cream
lokara
MEDROL TABLET 2MG
methylprednisolone acetate injection
methylprednisolone dose pack
methylprednisolone sodium succinate injection
125mg, 40mg
methylprednisolone tablet 32mg, 8mg
millipred tablet
mometasone furoate cream, ointment, solution
prednicarbate
prednisolone sodium phosphate oral solution
15mg/5ml, 5mg/5ml
prednisone intensol
prednisone tablet
prednisone solution
procto-pak
proctosol hc
proctozone-hc
RAYOS
triamcinolone acetonide cream 0.025%, 0.1%,
0.5%
triamcinolone acetonide lotion 0.025%, 0.1%
triamcinolone acetonide ointment 0.025%,
0.1%, 0.5%
triderm cream
u-cort
UCERIS
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
2
2
2
3
2
2
3
2
2
2
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
HI
2
2
2
2
2
2
1
2
2
2
2
4
2
ST
2
2
2
2
5
QL (30 EA per 30 days)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
ACTHAR HP
chorionic gonadotropin
desmopressin acetate injection, nasal solution,
tablet
GENOTROPIN
GENOTROPIN MINIQUICK INJECTION 0.2MG
GENOTROPIN MINIQUICK INJECTION 0.4MG,
0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG,
1MG, 2MG
5
2
2
PA
5
4
5
PA
PA
PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
52
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
HUMATROPE COMBO PACK
5
HUMATROPE INJECTION 6MG
4
HUMATROPE INJECTION 12MG, 24MG
5
INCRELEX
5
NORDITROPIN FLEXPRO
5
NORDITROPIN NORDIFLEX PEN INJECTION
5
30MG/3ML
NUTROPIN AQ PEN
5
SEROSTIM
5
ZORBTIVE
5
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
PA
PA
PA
LA
PA
PA
PA
PA LA
PA LA
Anabolic Steroids
ANADROL-50
oxandrolone tablet
Androgens
ANDRODERM PATCH 24 HOUR 2MG/24HR,
4MG/24HR
ANDROGEL PUMP
ANDROGEL GEL 20.25MG/1.25GM,
40.5MG/2.5GM, 50MG/5GM
ANDROGEL GEL 25MG/2.5GM
androxy
AVEED
AXIRON
danazol capsule
FORTESTA
STRIANT
TESTIM
TESTOPEL
testosterone cypionate injection
testosterone enanthate injection
Estrogens
ALORA
altavera
alyacen 1/35
alyacen 7/7/7
amethia
amethia lo
amethyst
apri
aranelle
aviane
balziva
3
2
3
QL (30 EA per 30 days) PA
3
3
PA
PA
3
2
4
4
2
4
4
4
4
2
2
QL (75 GM per 30 days) PA
QL (3 ML per 70 days) PA
PA
PA
PA
QL (300 GM per 30 days) PA
PA
3
2
2
2
2
2
2
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
53
Drug Name
BEYAZ
camrese
camrese lo
chateal
CLIMARA PRO
COMBIPATCH
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
dasetta 1/35
dasetta 7/7/7
DEPO-ESTRADIOL
DIVIGEL
ELESTRIN
emoquette
enskyce
ESTRACE CREAM
estradiol valerate injection
estradiol/norethindrone acetate
estradiol patch weekly, tablet
ESTRASORB
ESTRING
EVAMIST
falmina
FEMCON FE
FEMHRT LOW DOSE
FEMRING
GENERESS FE
gianvi
gildess fe 1.5/30
gildess fe 1/20
jinteli
jolessa
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
kurvelo
larin fe 1.5/30
larin fe 1/20
leena
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
4
2
2
2
3
3
2
2
2
2
2
3
3
3
2
2
3
2
2
2
3
3
3
2
4
3
3
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
54
Drug Name
lessina
levonorgestrel/ethinyl estradiol tablet 0.03mg;
0.15mg
levora 0.15/30-28
LO MINASTRIN FE
lomedia 24 fe
loryna
low-ogestrel
lutera
MAKENA
marlissa
MENOSTAR
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mimvey
MINASTRIN 24 FE
MINIVELLE
mononessa
NATAZIA
necon 0.5/35-28
necon 1/35
necon 1/50-28
necon 10/11-28
necon 7/7/7
norgestimate/ethinyl estradiol tablet 0; 0
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
NUVARING
ocella
ogestrel
orsythia
pirmella 1/35
pirmella 7/7/7
portia-28
PREMARIN CREAM
previfem
QUARTETTE
quasense
reclipsen
SAFYRAL
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
4
2
2
2
2
5
2
3
2
2
2
2
2
4
4
2
4
2
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
3
2
4
2
2
4
B/D LA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
55
Drug Name
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
sprintec 28
sronyx
tri-estarylla
tri-legest fe
tri-linyah
tri-previfem
tri-sprintec
trinessa
trivora-28
VAGIFEM
velivet
VIVELLE-DOT
xulane
zovia 1/35e
zovia 1/50e
Progesterone Agonists/Antagonists
ELLA
Progestins
camila
CRINONE GEL 8%
DEPO-SUBQ PROVERA 104
errin
jolivette
medroxyprogesterone acetate tablet
medroxyprogesterone acetate injection
megestrol acetate suspension, tablet
nora-be
norethindrone acetate tablet
progesterone capsule
Selective Estrogen Receptor Modifying Agents
raloxifene hydrochloride
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
2
2
2
2
2
2
3
2
3
2
2
2
3
2
4
4
2
2
1
2
2
2
2
2
2
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium tablet
1
levoxyl
2
liothyronine sodium tablet
2
SYNTHROID
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
TIROSINT
4
4
4
4
4
4
4
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
56
Drug Name
unithroid tablet 100mcg, 112mcg, 125mcg,
150mcg, 175mcg, 200mcg, 25mcg, 300mcg,
50mcg, 75mcg, 88mcg
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
3
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABLET 30MG
SENSIPAR TABLET 90MG
SENSIPAR TABLET 60MG
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
ELIGARD
FIRMAGON INJECTION 80MG
FIRMAGON INJECTION 120MG
leuprolide acetate injection
LUPANETA PACK KIT 3.75MG; 5MG
LUPANETA PACK KIT 11.25MG; 5MG
LUPRON DEPOT
LUPRON DEPOT-PED INJECTION 11.25MG,
15MG, 7.5MG
OCTREOTIDE ACETATE INJECTION
100MCG/ML, 200MCG/ML, 50MCG/ML
octreotide acetate injection 1000mcg/ml,
500mcg/ml
SANDOSTATIN LAR DEPOT
SIGNIFOR
SOMATULINE DEPOT
SOMAVERT
SYNAREL
TRELSTAR DEPOT
TRELSTAR DEPOT MIXJECT
TRELSTAR LA
TRELSTAR LA MIXJECT
TRELSTAR MIXJECT
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole tablet
propylthiouracil tablet
3
5
5
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (60 EA per 30 days)
2
4
4
5
2
4
4
5
5
QL (1 EA per 30 days)
QL (1 EA per 90 days)
B/D
B/D
4
5
5
5
5
5
5
5
3
5
5
5
PA
B/D
LA
2
2
Immunological Agents
Angioedema (HAE) Agents
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
57
Drug Name
CINRYZE
FIRAZYR
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
5
5
B/D LA
LA
4
4
2
2
5
4
3
5
5
2
2
4
5
5
2
2
5
5
5
5
5
2
2
2
4
B/D
B/D
B/D
B/D
mycophenolic acid dr tablet delayed release
360mg
5
B/D
MYFORTIC TABLET DELAYED RELEASE
180MG
MYFORTIC TABLET DELAYED RELEASE
360MG
NULOJIX
ORENCIA INJECTION 250MG
ORENCIA INJECTION 125MG/ML
OTREXUP
PROGRAF INJECTION
RAPAMUNE SOLUTION
RAPAMUNE TABLET 0.5MG
RAPAMUNE TABLET 1MG, 2MG
4
B/D
5
B/D
5
5
5
4
4
5
3
5
PA
Immune Suppressants
ASTAGRAF XL
AZASAN
azathioprine sodium
azathioprine tablet
BENLYSTA
CELLCEPT INTRAVENOUS
CELLCEPT SUSPENSION RECONSTITUTED
CELLCEPT CAPSULE, TABLET
CIMZIA
cyclosporine modified
cyclosporine capsule, injection
DEPEN TITRATABS
ENBREL
ENBREL SURECLICK
gengraf
hecoria
HUMIRA PEN
HUMIRA PEN-CROHNS DISEASESTARTER
HUMIRA INJECTION 20MG/0.4ML
HUMIRA INJECTION 40MG/0.8ML
KINERET
methotrexate sodium injection 1gm/40ml, 1gm
methotrexate tablet
mycophenolate mofetil
MYCOPHENOLIC ACID DR TABLET DELAYED
RELEASE 180MG
B/D
B/D
B/D
PA
B/D
B/D
PA
PA
B/D
B/D
PA
PA
PA
QL (6 EA per 28 days) PA
PA
B/D
B/D
PA
ST
B/D
B/D
B/D
B/D
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
58
Drug Name
REMICADE
RHEUMATREX
SANDIMMUNE SOLUTION
SIMPONI
SIMPONI ARIA
sirolimus tablet
tacrolimus capsule
TORISEL
TREXALL
ZORTRESS TABLET 0.25MG
ZORTRESS TABLET 0.5MG, 0.75MG
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
5
4
3
5
5
2
2
5
4
4
5
PA
B/D
B/D
PA
PA
B/D
B/D
PA
B/D
B/D
B/D
5
5
3
5
4
5
5
PA
PA
PA
PA
PA
PA LA
PA
5
5
5
5
5
5
5
5
2
5
5
5
3
4
5
5
5
PA
QL (3.6 ML per 28 days) PA
PA LA
LA
Immunizing Agents, Passive
ATGAM
CARIMUNE NANOFILTERED INJECTION 3GM
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C INJECTION 1GM/10ML
HIZENTRA
THYMOGLOBULIN
Immunomodulators
ACTEMRA INJECTION 200MG/10ML
ACTEMRA INJECTION 162MG/0.9ML
ACTIMMUNE
ARCALYST
AVONEX
BETASERON
EXTAVIA
ILARIS
leflunomide
OTEZLA
REBIF
REBIF TITRATION PACK
RIDAURA
SIMULECT INJECTION 20MG
TECFIDERA
TECFIDERA STARTER PACK
XELJANZ
ST
ST
PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days)
QL (60 EA per 30 days)
PA
Vaccines
ACTHIB
ADACEL
BOOSTRIX
CERVARIX
COMVAX
3
3
3
3
3
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
59
Drug Name
DAPTACEL
diphtheria/tetanus toxoids adsorbed pediatric
ENGERIX-B INJECTION 10MCG/0.5ML,
20MCG/ML
GARDASIL
HAVRIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II W/DILUENT 10 DOSE
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TENIVAC
tetanus toxoid adsorbed
tetanus/diphtheria toxoids-adsorbed adult
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
Inflammatory Bowel Disease Agents
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
3
3
3
3
3
3
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D
B/D
B/D
B/D
B/D
B/D
Aminosalicylates
APRISO
ASACOL HD
balsalazide disodium
CANASA
DELZICOL
DIPENTUM
GIAZO
LIALDA
4
3
2
4
3
4
5
3
QL (180 EA per 30 days)
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
60
Drug Name
mesalamine kit
PENTASA
Glucocorticoids
colocort
hydrocortisone enema 100mg/60ml
methylprednisolone tablet 16mg, 4mg
Sulfonamides
sulfasalazine tablet, tablet delayed release
sulfazine
sulfazine ec
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
3
2
2
2
2
2
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL TABLET 30MG, 5MG
ACTONEL TABLET 35MG
alendronate sodium
ATELVIA
BINOSTO
BONIVA INJECTION
calcitonin-salmon
calcitriol capsule 0.25mcg, 0.5mcg
calcitriol injection 1mcg/ml
calcitriol oral solution 1mcg/ml
doxercalciferol
etidronate disodium
FORTEO
fortical
FOSAMAX PLUS D
ibandronate sodium tablet
MIACALCIN NASAL SOLUTION
MIACALCIN INJECTION
pamidronate disodium injection 30mg/10ml,
6mg/ml, 90mg/10ml
PARICALCITOL CAPSULE 2MCG, 4MCG
paricalcitol capsule 1mcg
PROLIA
risedronate sodium tablet 150mg
XGEVA
ZEMPLAR INJECTION
ZOLEDRONIC ACID INJECTION 4MG/100ML,
4MG/5ML, 5MG/100ML
ZOMETA INJECTION 4MG/100ML
Miscellaneous Therapeutic Agents
3
3
1
4
4
4
2
2
2
2
2
2
5
2
3
2
3
3
2
QL (30 EA per 30 days)
QL (4 EA per 28 days)
QL (4 EA per 28 days) ST
B/D
B/D
B/D
B/D
B/D
B/D
PA
QL (4 EA per 28 days)
B/D
B/D
4
2
4
2
5
3
4
B/D
B/D
PA
QL (1 EA per 28 days)
B/D
B/D
B/D
5
B/D
Miscellaneous Therapeutic Agents
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
61
Drug Name
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G
X 1/2"
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G
X 5/16"
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G
X 1/2"
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X
5/16"
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
FERRIPROX
INTRALIPID
KALBITOR
lactated ringers irrigation
levocarnitine injection, oral solution, tablet
methylergonovine maleate tablet
MYALEPT
sodium chloride 0.9%
V-GO 20
V-GO 30
V-GO 40
VORAXAZE
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost
LUMIGAN SOLUTION 0.01%
TRAVATAN Z
travoprost
ZIOPTAN
Ophthalmic Agents, Other
atropine sulfate solution
atropine-care
bacitracin/polymyxin b
cyclopentolate hcl
CYSTARAN
homatropaire
LACRISERT
mydral solution 0.5%
naphazoline hcl
proparacaine hcl
RESTASIS
tropicamide
Ophthalmic Anti-allergy Agents
ALOCRIL
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
3
3
3
3
3
5
3
5
2
2
2
5
2
3
3
3
5
2
3
3
2
3
2
2
2
2
5
2
3
2
2
2
4
2
LA
B/D
B/D LA
B/D
PA
ST
QL (30 EA per 30 days) ST
QL (60 ML per 28 days)
4
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
62
Drug Name
azelastine hcl ophthalmic solution 0.05%
cromolyn sodium solution 4%
EMADINE
epinastine hcl
LASTACAFT
Ophthalmic Anti-inflammatories
ALOMIDE
BLEPHAMIDE
BLEPHAMIDE S.O.P.
bromfenac
dexamethasone sodium phosphate ophthalmic
solution 0.1%
diclofenac sodium solution 0.1%
FLAREX
fluorometholone
flurbiprofen sodium
FML
FML FORTE
ketorolac tromethamine
LOTEMAX
MAXIDEX
neomycin/polymyxin/dexamethasone
NEVANAC
poly-dex ointment
PRED MILD
PRED-G
PRED-G S.O.P.
prednisolone acetate
prednisolone sodium phosphate ophthalmic
solution 1%
PROLENSA
sulfacetamide sodium/prednisolone sodium
phosphate
TOBRADEX OINTMENT
tobramycin/dexamethasone
VEXOL
Ophthalmic Antiglaucoma Agents
acetazolamide er
ALPHAGAN P SOLUTION 0.1%
apraclonidine
AZOPT
betaxolol hcl solution 0.5%
BETIMOL
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
3
2
3
4
4
3
2
2
2
3
2
2
3
3
2
4
3
2
4
2
3
4
3
2
2
3
2
4
2
3
1
3
2
3
2
3
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
63
Drug Name
BETOPTIC-S
brimonidine tartrate
carteolol hcl
COMBIGAN
dorzolamide hcl
dorzolamide hcl/timolol maleate
IOPIDINE SOLUTION 1%
levobunolol hcl
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl solution 1%, 2%, 4%
PILOPINE HS
SIMBRINZA
timolol maleate ophthalmic gel forming
timolol maleate solution 0.25%, 0.5%
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
3
2
2
3
2
2
4
2
2
4
2
3
3
2
1
Otic Agents
Otic Agents
acetic acid
acetic acid/aluminum acetate
antipyrine/benzocaine solution 5.4%; 1.4%
aurodex
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone otic
suspension 1%; 3.5mg/ml; 10000unit/ml
2
2
2
2
4
3
3
4
2
2
2
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
ALVESCO
ASMANEX 120 METERED DOSES
ASMANEX 14 METERED DOSES
ASMANEX 30 METERED DOSES
ASMANEX 60 METERED DOSES
ASMANEX 7 METERED DOSES
BECONASE AQ
BREO ELLIPTA
budesonide inhalation suspension 0.25mg/2ml,
0.5mg/2ml
3
3
4
4
4
4
4
4
4
4
2
QL (60 EA per 30 days)
B/D
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
64
Drug Name
budesonide nasal suspension 32mcg/act
DULERA
FLOVENT DISKUS
FLOVENT HFA
flunisolide solution 0.025%
fluticasone propionate suspension 50mcg/act
NASONEX
OMNARIS
PULMICORT FLEXHALER
PULMICORT SUSPENSION 1MG/2ML
QNASL
QVAR
SYMBICORT
triamcinolone acetonide inhaler 55mcg/act
VERAMYST
Antihistamines
azelastine hcl nasal solution 0.15%,
137mcg/spray
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
CLARINEX SYRUP
cyproheptadine hcl syrup, tablet
desloratadine
desloratadine odt
levocetirizine dihydrochloride solution, tablet
SEMPREX-D
Antileukotrienes
montelukast sodium
zafirlukast
ZYFLO CR
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
4
4
4
2
2
3
4
3
3
4
3
3
2
4
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D
QL (8.7 GM per 30 days)
2
4
4
4
2
2
2
2
4
2
2
5
ST
ST
ST
QL (120 EA per 30 days)
Bronchodilators, Anticholinergic
ATROVENT HFA
COMBIVENT RESPIMAT
ipratropium bromide/albuterol sulfate
ipratropium bromide nasal solution
ipratropium bromide inhalation solution
SPIRIVA HANDIHALER
TUDORZA PRESSAIR
Bronchodilators, Sympathomimetic
albuterol sulfate er
albuterol sulfate syrup, tablet
albuterol sulfate nebulization solution
ANORO ELLIPTA
3
3
2
2
2
3
3
QL (1 EA per 30 days)
2
2
2
4
B/D
QL (60 EA per 30 days)
B/D
B/D
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
65
Drug Name
ARCAPTA NEOHALER
AUVI-Q
BROVANA
epinephrine
epinephrine hcl injection 0.1mg/ml
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
FORADIL AEROLIZER
levalbuterol hcl nebulization solution
levalbuterol nebulization solution
metaproterenol sulfate syrup, tablet
PERFOROMIST
PROAIR HFA
SEREVENT DISKUS
terbutaline sulfate injection, tablet
VENTOLIN HFA
XOPENEX HFA
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
4
4
3
2
2
3
3
4
2
2
2
3
3
4
2
4
4
QL (30 EA per 30 days)
QL (4 EA per 30 days)
B/D
5
5
QL (60 EA per 30 days) PA
B/D
2
B/D
QL (3 EA per 30 days)
B/D
B/D
B/D
Cystic Fibrosis Agents
KALYDECO
PULMOZYME
Mast Cell Stabilizers
cromolyn sodium nebulization solution
20mg/2ml
Phosphodiesterase Inhibitors, Airways Disease
aminophylline injection
DALIRESP
ELIXOPHYLLIN
theochron
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
Pulmonary Antihypertensives
2
4
4
2
2
QL (30 EA per 30 days) PA
2
2
ADCIRCA
ADEMPAS
LETAIRIS
OPSUMIT
ORENITRAM TABLET EXTENDED RELEASE
0.125MG
ORENITRAM TABLET EXTENDED RELEASE
0.25MG, 1MG, 2.5MG
5
5
5
5
4
PA
QL (90 EA per 30 days) PA LA
LA
QL (30 EA per 30 days) PA LA
PA
5
PA
sildenafil
2
PA
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
66
Drug Name
TRACLEER
TYVASO
TYVASO REFILL
TYVASO STARTER
VENTAVIS
Respiratory Tract Agents, Other
acetylcysteine solution
ARALAST NP INJECTION 400MG
GLASSIA
PROLASTIN-C
TYZINE
TYZINE PEDIATRIC NASAL DROPS
XOLAIR
ZEMAIRA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone tablet
orphenadrine citrate er
orphenadrine citrate injection
orphenadrine/asa/caffeine tablet 385mg; 30mg;
25mg
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
5
5
5
5
5
LA
PA LA
PA LA
PA LA
PA
2
5
5
5
4
4
5
5
B/D
PA LA
PA LA
PA LA
PA LA
PA LA
2
2
2
2
Sleep Disorder Agents
GABA Receptor Modulators
eszopiclone
flurazepam hcl
temazepam capsule 15mg, 30mg
temazepam capsule 22.5mg, 7.5mg
triazolam
zaleplon
zolpidem tartrate
zolpidem tartrate er
Sleep Disorders, Other
modafinil tablet 100mg
modafinil tablet 200mg
NUVIGIL
phenobarbital elixir 20mg/5ml
phenobarbital tablet 16.2mg, 30mg, 32.4mg,
64.8mg, 97.2mg
ROZEREM
XYREM
Therapeutic Nutrients/Minerals/Electrolytes
2
1
1
2
2
2
2
2
PA
4
5
4
2
2
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (30 EA per 30 days) PA
PA
PA
3
5
QL (540 ML per 30 days) PA LA
QL (10 EA per 30 days)
QL (90 EA per 365 days)
QL (90 EA per 365 days)
QL (90 EA per 365 days)
Electrolyte/Mineral Modifiers
CUPRIMINE
4
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
67
Drug Name
EXJADE TABLET SOLUBLE 125MG
EXJADE TABLET SOLUBLE 250MG, 500MG
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
4
5
2
5
2
3
LA
LA
AMINOSYN 7%/ELECTROLYTES
AMINOSYN II 8.5%/ELECTROLYTES
AMINOSYN II INJECTION 61.1MEQ/L;
844MG/100ML; 865MG/100ML;
595MG/100ML; 627MG/100ML;
425MG/100ML; 255MG/100ML;
561MG/100ML; 850MG/100ML;
893MG/100ML; 146MG/100ML;
253MG/100ML; 614MG/100ML;
450MG/100ML; 33.3MEQ/L; 340MG/100ML;
170MG/100ML; 230MG/100ML;
425MG/100ML
3
3
3
B/D
B/D
B/D
aminosyn ii injection 107.6meq/l;
1490mg/100ml; 1527mg/100ml;
1050mg/100ml; 1107mg/100ml; 750mg/100ml;
450mg/100ml; 990mg/100ml; 1500mg/100ml;
1575mg/100ml; 258mg/100ml; 447mg/100ml;
1083mg/100ml; 795mg/100ml; 50meq/l;
600mg/100ml; 300mg/100ml; 405mg/100ml;
750mg/100ml
2
B/D
AMINOSYN-HF
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN INJECTION 50.3MEQ/L;
695MG/100ML; 713MG/100ML;
490MG/100ML; 517MG/100ML;
350MG/100ML; 210MG/100ML;
462MG/100ML; 700MG/100ML;
735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML;
371MG/100ML; 31.3MEQ/L; 280MG/100ML;
140MG/100ML; 189MG/100ML;
350MG/100ML, 90MEQ/L; 1100MG/100ML;
850MG/100ML; 35MEQ/L; 1100MG/100ML;
260MG/100ML; 620MG/100ML;
810MG/100ML; 624MG/100ML;
340MG/100ML; 380MG/100ML; 5.4MEQ/L;
3
3
3
3
B/D
B/D
B/D
B/D
kionex powder
SAMSCA
sodium polystyrene sulfonate suspension
SYPRINE
PA
Electrolyte/Mineral Replacement
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
68
Drug Name
750MG/100ML; 370MG/100ML;
460MG/100ML; 150MG/100ML; 44MG/100ML;
680MG/100ML
CARBAGLU
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 5%/DEXTROSE 20%
cytra k crystals
cytra-k
denta 5000 plus
dextrose 5% /electrolyte #48 viaflex
dextrose 5%/lactated ringers
dextrose 5%/potassium chloride 0.15%
effer-k tablet effervescent 25meq
eliphos
FREAMINE III INJECTION 72MEQ/L;
600MG/100ML; 810MG/100ML; 3MEQ/L;
14MG/100ML; 1190MG/100ML;
240MG/100ML; 590MG/100ML;
770MG/100ML; 620MG/100ML;
450MG/100ML; 480MG/100ML; 10MMOLE/L;
115MG/100ML; 950MG/100ML;
500MG/100ML; 10MEQ/L; 340MG/100ML;
130MG/100ML; 560MG/100ML
k-effervescent
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
klor-con/ef
lactated ringers viaflex
magnesium sulfate injection 50%
magnesium sulfate injection 40mg/ml, 80mg/ml
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
5
3
3
3
3
3
3
2
2
2
2
2
2
2
2
3
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
PA LA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
2
2
2
2
2
2
2
2
B/D
2
B/D
2
B/D HI
MOZOBIL
5
NEPHRAMINE
3
B/D
NORMOSOL -R
3
B/D
normosol-m in d5w
2
B/D
PHOSLYRA
4
ST
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
69
Drug Name
phospha 250 neutral
potassium chloride 0.15% /nacl 0.45% viaflex
potassium chloride 0.15%/nacl 0.9%
potassium chloride 0.3%/ nacl 0.9%
potassium chloride 0.3%/d5w
potassium chloride 0.3%/nacl 0.9%/viaflex
potassium chloride er capsule extended release
potassium chloride er tablet extended release
10meq, 20meq
potassium chloride sr tablet extended release
8meq
potassium chloride injection 10meq/100ml,
20meq/100ml, 2meq/ml, 30meq/100ml,
40meq/100ml
potassium chloride liquid 20%
potassium chloride oral solution 10%
potassium citrate er tablet extended release
15meq
potassium citrate tablet extended release
PREMASOL
PROCALAMINE
sf
sf 5000 plus
sodium chloride 0.45% viaflex
taron-crystals
TROPHAMINE
Therapeutic Nutrients/Minerals/Electrolytes
pnv-first
Vitamins
c-nate dha
cavan-ec sod dha
choice-ob+dha
complete natal dha
completenate
elite ob with dha
elite-ob
elite-ob 400
extra-virt plus dha
focalgin-b
folbecal
folivane-ob
folivane-prx dha nf
hemenatal ob
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
2
2
2
2
2
2
2
2
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
B/D
B/D
B/D
B/D
B/D
2
2
B/D HI
2
2
2
2
3
3
2
2
2
2
3
B/D
B/D
B/D HI
B/D
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
70
Drug Name
hemenatal ob + dha
mynatal
mynatal-z
mynate 90 plus
niacin er tablet extended release
niacor
obstetrix dha
paire ob
pnv folic acid + iron multivitamin
pnv-dha
pnv-ob/dha
pr natal 400 ec
pr natal 430
pr natal 430 ec
prena1 chew/quatrefolic
prena1 plus/quatrefolic
prena1/quatrefolic
prenaissance 90 dha
prenaissance balance
prenaissance dha
prenaissance harmony dha
prenaissance next
prenaissance plus
prenaissance promise
prenatabs obn
prenatal 19 tablet chewable 100mg; 1000unit;
200mg; 7mg; 400unit; 12mcg; 29mg; 1mg;
15mg; 20mg; 3mg; 3mg; 30unit; 20mg
prenatal 19 tablet 100mg; 1000unit; 200mg;
7mg; 400unit; 12mcg; 25mg; 29mg; 1mg;
15mg; 20mg; 3mg; 3mg; 30unit; 20mg
prenatal ad
prenatal low iron tablet 120mg; 0; 200mg;
400unit; 2mg; 12mcg; 27mg; 1mg; 20mg;
10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg
prenatal plus
prenatal plus iron tablet 120mg; 0; 200mg;
400unit; 2mg; 12mcg; 1mg; 29mg; 20mg;
10mg; 3mg; 1.84mg; 22mg; 4000unit; 25mg
r-natal ob
se-natal 19 tablet chewable
se-tan dha
taron-bc
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
71
Drug Name
taron-c dha
taron-prex
tl-care dha
tl-select
tri-tabs dha
TRICARE PRENATAL COMPLEAT
triveen-duo dha
triveen-one
triveen-prx rnf
triveen-u
ultimatecare one
ultimatecare one nf
vemavite-prx 2
vena-bal dha
venatal complete dha
venatal-fa
vinacal
vinate az
vinate calcium
vinate dha
vinate gt
vinate ic
vinate ii
vinate m
vinate one
vinate pn care
vinate ultra
vitaspire
vol-nate
vol-plus
vol-tab rx
vp-ch plus
vp-era ob plus
vp-heme ob
zatean-ch
zatean-pn
zatean-pn plus
Drug tiers:
T1-Preferred generic
T2-Non-preferred
generic
T3- Preferred brand
T4-Non-preferred brand
T5-Specialty
Notes:
B/D-Part B vs. Part D
EA-Each
FF-Free First Fill
HI-Home Infusion
LA-Limited Availability
PA-Prior Authorization
QL-Quantity Limits
ST-Step Therapy
2
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
Note: All drugs listed on the formulary are available via mail order. Tier 5 drugs are 30-day supply only.
72
Index
abacavir ...................................................................... 33
abacavir sulfate/lamivudine/zidovudine ......................... 33
abelcet ........................................................................ 23
abilify ........................................................................... 31
abilify discmelt ............................................................. 31
abilify maintena ............................................................ 31
abraxane ..................................................................... 27
abstral ......................................................................... 11
acamprosate calcium dr .............................................. 14
acarbose ..................................................................... 35
acebutolol hcl .............................................................. 41
acetaminophen/caffeine/dihydrocodeine bitartrate ........ 11
acetaminophen/codeine .............................................. 11
acetaminophen/codeine #3.......................................... 11
acetazolamide ....................................................... 43, 63
acetazolamide er ......................................................... 63
acetazolamide sodium ................................................. 43
acetic acid ................................................................... 64
acetic acid/aluminum acetate ....................................... 64
acetylcysteine .............................................................. 67
acitretin ....................................................................... 46
actemra ....................................................................... 59
acthar hp ..................................................................... 52
acthib .......................................................................... 59
acticin ......................................................................... 30
actimmune .................................................................. 59
actonel ........................................................................ 61
actoplus met xr............................................................ 35
acyclovir ...................................................................... 34
acyclovir sodium .......................................................... 34
adacel ......................................................................... 59
adagen ........................................................................ 47
adapalene ................................................................... 46
adcirca ........................................................................ 66
adefovir dipivoxil .......................................................... 32
adempas ..................................................................... 66
adriamycin ................................................................... 27
advair diskus ............................................................... 64
advair hfa .................................................................... 64
advicor ........................................................................ 43
afeditab cr ................................................................... 41
afinitor ......................................................................... 28
afinitor disperz ............................................................. 28
aggrenox ..................................................................... 39
ala cort ........................................................................ 50
ala scalp ...................................................................... 50
albenza ....................................................................... 29
albuterol sulfate ........................................................... 65
albuterol sulfate er ....................................................... 65
alclometasone dipropionate ......................................... 50
alcohol preps ............................................................... 15
aldurazyme .................................................................. 47
73
alendronate sodium......................................................61
alfuzosin hcl er .............................................................50
alimta...........................................................................26
alinia ............................................................................29
allopurinol ....................................................................24
allopurinol sodium ........................................................24
alocril ...........................................................................62
alomide ........................................................................63
alora ............................................................................53
alphagan p...................................................................63
alprazolam ...................................................................35
alprazolam er ...............................................................35
alprazolam intensol ......................................................35
alprazolam odt .............................................................35
alprazolam xr ...............................................................35
altavera ........................................................................53
altoprev .......................................................................43
alvesco ........................................................................64
alyacen 1/35 ................................................................53
alyacen 7/7/7 ...............................................................53
amantadine hcl ............................................................34
ambisome ....................................................................23
amcinonide ..................................................................50
amethia........................................................................53
amethia lo ....................................................................53
amethyst ......................................................................53
amifostine ....................................................................27
amikacin sulfate ...........................................................15
amiloride hcl.................................................................43
amiloride/hydrochlorothiazide .......................................43
aminocaproic acid ........................................................39
aminophylline ...............................................................66
aminosyn .....................................................................68
aminosyn 7%/electrolytes .............................................68
aminosyn ii ...................................................................68
aminosyn ii 8.5%/electrolytes .......................................68
aminosyn-hf .................................................................68
aminosyn-pf .................................................................68
aminosyn-pf 7% ...........................................................68
amiodarone hcl ............................................................40
amitiza .........................................................................49
amitriptyline hcl ............................................................22
amlodipine besylate......................................................41
amlodipine besylate/atorvastatin calcium ......................41
amlodipine besylate/benazepril hydrochloride ...............41
ammonium lactate .......................................................46
amnesteem ..................................................................46
amoxapine ...................................................................22
amoxicillin ..............................................................16, 17
amoxicillin/clavulanate potassium .................................17
amoxicillin/clavulanate potassium er .............................17
amphetamine/dextroamphetamine ......................... 44, 45
amphotericin b .............................................................23
ampicillin ......................................................................17
ampicillin sodium..........................................................17
ampicillin-sulbactam .................................................... 17
ampyra ........................................................................ 45
amturnide .................................................................... 42
anadrol-50................................................................... 53
anagrelide hydrochloride .............................................. 39
anastrozole .................................................................. 28
ancobon ...................................................................... 23
androderm .................................................................. 53
androgel ...................................................................... 53
androgel pump ............................................................ 53
androxy ....................................................................... 53
anoro ellipta ................................................................. 65
antipyrine/benzocaine .................................................. 64
anzemet ...................................................................... 23
apidra.......................................................................... 37
apidra solostar ............................................................. 37
aplenzin ....................................................................... 21
apokyn ........................................................................ 30
apraclonidine ............................................................... 63
apri ............................................................................. 53
apriso .......................................................................... 60
aptiom......................................................................... 19
aptivus ........................................................................ 34
aralast np .................................................................... 67
aranelle ....................................................................... 53
aranesp albumin free ................................................... 39
arcalyst ....................................................................... 59
arcapta neohaler.......................................................... 66
arranon ....................................................................... 26
arzerra......................................................................... 29
asacol hd .................................................................... 60
asmanex 120 metered doses ....................................... 64
asmanex 14 metered doses ......................................... 64
asmanex 30 metered doses ......................................... 64
asmanex 60 metered doses ......................................... 64
asmanex 7 metered doses ........................................... 64
astagraf xl.................................................................... 58
astramorph.................................................................. 10
atelvia.......................................................................... 61
atenolol ....................................................................... 41
atenolol/chlorthalidone ................................................. 41
atgam ......................................................................... 59
atorvastatin calcium ............................................... 41, 43
atovaquone ................................................................. 29
atovaquone/proguanil hcl ............................................. 29
atralin .......................................................................... 46
atripla .......................................................................... 35
atropine sulfate ............................................................ 62
atropine-care ............................................................... 62
atrovent hfa ................................................................. 65
aubagio ....................................................................... 46
augmented betamethasone dipropionate ..................... 50
aurodex ....................................................................... 64
auvi-q .......................................................................... 66
avandamet .................................................................. 35
74
avandaryl .....................................................................35
avandia ........................................................................35
avastin .........................................................................29
aveed ..........................................................................53
aviane ..........................................................................53
avodart ........................................................................50
avonex ...................................................................46, 59
avonex pen ..................................................................46
axert ............................................................................25
axiron ..........................................................................53
azacitidine ....................................................................27
azactam in iso-osmotic dextrose ..................................17
azasan .........................................................................58
azathioprine .................................................................58
azathioprine sodium .....................................................58
azelastine hcl .........................................................63, 65
azelex ..........................................................................46
azilect ..........................................................................30
azithromycin ................................................................18
azopt ...........................................................................63
azor .............................................................................41
bacitracin ......................................................... 15, 16, 62
bacitracin/polymyxin b..................................................62
baclofen.......................................................................32
bactocill in dextrose .....................................................18
bactroban nasal ...........................................................15
balsalazide disodium ....................................................60
balziva .........................................................................53
banzel ..........................................................................20
baraclude.....................................................................32
bd insulin syringe safetyglide/1ml/29g x 1/2 ..................62
bd insulin syringe ultrafine/0.3ml/31g x 5/16 .................62
bd insulin syringe ultrafine/0.5ml/30g x 1/2 ...................62
bd insulin syringe ultrafine/1ml/31g x 5/16 ....................62
bd pen needle/ultrafine/29g x 12.7mm .........................62
beconase aq ................................................................64
belladonna & opium .....................................................48
belladonna alkaloids & opium .......................................48
benazepril hcl ...............................................................40
benazepril hcl/hydrochlorothiazide ................................40
benlysta .......................................................................58
betamethasone dipropionate ............................ 23, 50, 51
betamethasone valerate ...............................................51
betaseron ....................................................................59
betaxolol hcl...........................................................41, 63
bethanechol chloride ....................................................50
bethkis.........................................................................15
betimol ........................................................................63
betoptic-s ....................................................................64
beyaz...........................................................................54
bicalutamide ................................................................26
bicillin c-r .....................................................................18
bicillin l-a ......................................................................18
bicnu ...........................................................................25
bidil..............................................................................44
biltricide....................................................................... 29
binosto ........................................................................ 61
bisoprolol fumarate ...................................................... 41
bisoprolol fumarate/hydrochlorothiazide ....................... 41
bleomycin sulfate ......................................................... 27
blephamide ................................................................. 63
blephamide s.o.p. ........................................................ 63
boniva ......................................................................... 61
boostrix ....................................................................... 59
bosulif ......................................................................... 28
breo ellipta................................................................... 64
brilinta ......................................................................... 39
brimonidine tartrate...................................................... 64
brintellix ....................................................................... 21
brisdelle....................................................................... 22
bromfenac ................................................................... 63
bromocriptine mesylate................................................ 30
brovana ....................................................................... 66
budeprion sr ................................................................ 21
budesonide ..................................................... 51, 64, 65
bumetanide ................................................................. 43
buphenyl ..................................................................... 47
buprenorphine hcl........................................................ 14
buprenorphine hcl/naloxone hcl ................................... 14
buproban .................................................................... 14
bupropion hcl .............................................................. 21
bupropion hcl sr .......................................................... 21
bupropion hcl xl ........................................................... 21
buspirone hcl ............................................................... 35
busulfex ...................................................................... 25
butorphanol tartrate ..................................................... 11
butrans........................................................................ 14
bydureon ..................................................................... 35
byetta .......................................................................... 35
bystolic........................................................................ 41
cabergoline.................................................................. 57
calcipotriene .......................................................... 46, 51
calcipotriene/betamethasone dipropionate ................... 51
calcitonin-salmon......................................................... 61
calcitrene..................................................................... 46
calcitriol ................................................................. 46, 61
calcium acetate ........................................................... 50
cambia ........................................................................ 10
camila ......................................................................... 56
camrese ...................................................................... 54
camrese lo .................................................................. 54
canasa ........................................................................ 60
cancidas...................................................................... 23
candesartan cilexetil .................................................... 40
candesartan cilexetil/hydrochlorothiazide ...................... 40
cantil ........................................................................... 48
capastat sulfate ........................................................... 25
capex .......................................................................... 51
capital/codeine ............................................................ 11
caprelsa ...................................................................... 28
75
captopril ......................................................................40
captopril/hydrochlorothiazide ........................................40
carac ...........................................................................46
carafate .......................................................................49
carbaglu ......................................................................69
carbamazepine ............................................................20
carbamazepine er ........................................................20
carbatrol ......................................................................20
carbidopa ....................................................................30
carbidopa/levodopa .....................................................30
carbidopa/levodopa er .................................................30
carbidopa/levodopa odt ...............................................30
carbidopa/levodopa/entacapone ..................................30
carboplatin ...................................................................27
cardizem la ..................................................................41
carimune nanofiltered ...................................................59
carteolol hcl .................................................................64
cartia xt........................................................................42
carvedilol .....................................................................41
cavan-ec sod dha ........................................................70
cayston........................................................................17
cefaclor........................................................................17
cefadroxil .....................................................................17
cefazolin sodium ..........................................................17
cefdinir .........................................................................17
cefditoren pivoxil ..........................................................17
cefepime ......................................................................17
cefotaxime sodium .......................................................17
cefoxitin sodium ...........................................................17
cefpodoxime proxetil ....................................................17
cefprozil .......................................................................17
ceftazidime ..................................................................17
ceftibuten.....................................................................17
ceftin ...........................................................................17
ceftriaxone in iso-osmotic dextrose...............................17
ceftriaxone sodium .......................................................17
cefuroxime axetil ..........................................................17
cefuroxime sodium .......................................................17
cefuroxime/dextrose.....................................................17
celebrex .......................................................................14
celestone .....................................................................51
cellcept ........................................................................58
cellcept intravenous .....................................................58
celontin ........................................................................19
cephalexin ...................................................................17
cerezyme .....................................................................47
cervarix ........................................................................59
cevimeline hcl ..............................................................46
chantix .........................................................................14
chantix continuing month pak .......................................14
chantix starting month pak ...........................................14
chateal.........................................................................54
chloramphenicol sodium succinate ...............................15
chlordiazepoxide hcl.....................................................35
chlorhexidine gluconate ................................................46
chlorhexidine gluconate oral rinse................................. 46
chloroquine phosphate ................................................ 29
chlorothiazide .............................................................. 43
chlorpromazine hcl ...................................................... 30
chlorpropamide ........................................................... 36
chlorthalidone ........................................................ 41, 43
chlorzoxazone ............................................................. 67
choice-ob+dha ............................................................ 70
cholestyramine ............................................................ 44
cholestyramine light ..................................................... 44
chorionic gonadotropin ................................................ 52
cialis ............................................................................ 50
ciclopirox ..................................................................... 23
ciclopirox nail lacquer................................................... 23
ciclopirox olamine ........................................................ 23
cilostazol ..................................................................... 39
ciloxan......................................................................... 18
cimetidine .................................................................... 49
cimetidine hcl .............................................................. 49
cimzia.......................................................................... 58
cinryze......................................................................... 58
cipro hc ....................................................................... 64
ciprodex ...................................................................... 64
ciprofloxacin ................................................................ 18
ciprofloxacin er ............................................................ 18
ciprofloxacin hcl ........................................................... 18
cisplatin ....................................................................... 27
citalopram hydrobromide ............................................. 22
cladribine..................................................................... 26
claravis ........................................................................ 46
clarinex........................................................................ 65
clarinex-d 12 hour........................................................ 65
clarinex-d 24 hour........................................................ 65
clarithromycin ........................................................ 16, 18
clarithromycin er .......................................................... 18
cleocin ........................................................................ 15
cleocin pediatric granules............................................. 15
climara pro .................................................................. 54
clindamycin hcl ............................................................ 15
clindamycin palmitate hcl ............................................. 16
clindamycin phosphate ................................................ 16
clindamycin phosphate add-vantage ............................ 16
clindamycin/benzoyl peroxide ...................................... 46
clinimix 2.75%/dextrose 5% ......................................... 69
clinimix 4.25%/dextrose 10% ....................................... 69
clinimix 4.25%/dextrose 20% ....................................... 36
clinimix 4.25%/dextrose 25% ....................................... 69
clinimix 4.25%/dextrose 5% ......................................... 69
clinimix 5%/dextrose 15% ............................................ 36
clinimix 5%/dextrose 20% ............................................ 36
clinimix 5%/dextrose 25% ............................................ 69
clinimix e 2.75%/dextrose 10% .................................... 37
clinimix e 2.75%/dextrose 5% ...................................... 37
clinimix e 4.25%/dextrose 25% .................................... 37
clinimix e 4.25%/dextrose 5% ...................................... 37
76
clinimix e 5%/dextrose 15% .........................................37
clinimix e 5%/dextrose 20% .........................................69
clinimix e 5%/dextrose 25% .........................................37
clobetasol propionate ...................................................51
clobetasol propionate e ................................................51
clobetasol propionate emollient ....................................51
clocortolone pivalate ....................................................51
clolar............................................................................26
clomipramine hcl ..........................................................22
clonazepam ...........................................................19, 20
clonazepam odt ...........................................................19
clonidine hcl ...........................................................39, 40
clonidine hcl er .............................................................39
clopidogrel ...................................................................39
clorazepate dipotassium...............................................20
clorpres .......................................................................40
clotrimazole .................................................................23
clotrimazole/betamethasone dipropionate .....................23
clozapine .....................................................................32
clozapine odt ...............................................................32
c-nate dha ...................................................................70
coartem .......................................................................29
codeine sulfate .............................................................11
colcrys .........................................................................24
colestid flavored ...........................................................44
colestipol hcl ................................................................44
colistimethate sodium...................................................16
colocort .......................................................................61
coly-mycin s.................................................................64
combigan ....................................................................64
combipatch..................................................................54
combivent respimat ......................................................65
cometriq ......................................................................27
complera .....................................................................33
complete natal dha ......................................................70
completenate ...............................................................70
compro ........................................................................30
comvax ........................................................................59
condylox ......................................................................46
constulose ...................................................................49
copaxone.....................................................................46
cordran tape ................................................................51
coreg cr .......................................................................41
cortifoam .....................................................................51
cortisone acetate .........................................................51
cortisporin........................................................ 16, 46, 64
cortisporin-tc ...............................................................64
cosmegen....................................................................27
coumadin.....................................................................38
creon ...........................................................................47
crestor .........................................................................43
crinone ........................................................................56
crixivan ........................................................................34
cromolyn sodium ...................................................63, 66
cryselle-28 ...................................................................54
cubicin ........................................................................ 16
cuprimine .................................................................... 67
curity gauze pads 2x2 .................................................. 46
cuvposa ...................................................................... 48
cyclafem 1/35.............................................................. 54
cyclafem 7/7/7 ............................................................ 54
cyclopentolate hcl ........................................................ 62
cyclophosphamide ...................................................... 25
cycloserine .................................................................. 25
cycloset....................................................................... 36
cyclosporine ................................................................ 58
cyclosporine modified .................................................. 58
cyproheptadine hcl ...................................................... 65
cystadane ................................................................... 47
cystagon ..................................................................... 47
cystaran ...................................................................... 62
cytarabine aqueous ..................................................... 26
cytra k crystals ............................................................ 69
cytra-k......................................................................... 69
dacarbazine................................................................. 25
dacogen ...................................................................... 27
daliresp ....................................................................... 66
danazol ....................................................................... 53
dantrolene sodium ....................................................... 32
dapsone ...................................................................... 25
daptacel ...................................................................... 60
daraprim...................................................................... 29
dasetta 1/35 ................................................................ 54
dasetta 7/7/7............................................................... 54
daunorubicin hcl .......................................................... 27
daunoxome ................................................................. 27
daytrana ...................................................................... 45
decitabine ................................................................... 27
delzicol ........................................................................ 60
demeclocycline hcl ...................................................... 19
demser ........................................................................ 42
denavir ........................................................................ 34
denta 5000 plus .......................................................... 69
depen titratabs ............................................................ 58
depo-estradiol ............................................................. 54
depo-subq provera 104 ............................................... 56
desipramine hcl ........................................................... 22
desloratadine ............................................................... 65
desloratadine odt ......................................................... 65
desmopressin acetate.................................................. 52
desonide ..................................................................... 51
desoximetasone .......................................................... 51
desvenlafaxine er ......................................................... 22
dexamethasone ..................................................... 51, 63
dexamethasone intensol .............................................. 51
dexamethasone sodium phosphate ....................... 51, 63
dexilant ....................................................................... 49
dexmethylphenidate hcl ............................................... 45
dexmethylphenidate hcl er ........................................... 45
dexrazoxane ................................................................ 27
77
dextroamphetamine sulfate ..........................................45
dextroamphetamine sulfate er ......................................45
dextrose 10%/nacl 0.45% ...........................................37
dextrose 5% /electrolyte #48 viaflex .............................69
dextrose 10% flex container .........................................37
dextrose 10%/nacl 0.2% ..............................................37
dextrose 2.5%/nacl 0.45% ...........................................37
dextrose 2.5%/sodium chloride 0.45% .........................37
dextrose 5% ..........................................................37, 69
dextrose 5%/lactated ringers ........................................69
dextrose 5%/nacl 0.2% ................................................37
dextrose 5%/nacl 0.225% ............................................37
dextrose 5%/nacl 0.33% ..............................................37
dextrose 5%/nacl 0.45% ..............................................37
dextrose 5%/nacl 0.9% ................................................37
dextrose 5%/potassium chloride 0.15% .......................69
dextrose 5%/sodium chloride 0.2% ..............................37
dextrose 5%/sodium chloride 0.33% ............................37
dextrose 5%/sodium chloride 0.9% ..............................37
diazepam ...............................................................20, 35
diazepam intensol ........................................................35
diclofenac potassium ...................................................14
diclofenac sodium ............................................ 10, 14, 63
diclofenac sodium dr ....................................................14
diclofenac sodium er ....................................................14
diclofenac sodium/misoprostol .....................................10
dicloxacillin sodium ......................................................18
dicyclomine hcl ............................................................48
didanosine ...................................................................33
dificid ...........................................................................18
diflorasone diacetate ....................................................51
diflunisal .......................................................................14
digoxin .........................................................................42
dihydroergotamine mesylate .........................................24
dilantin .........................................................................20
dilantin infatabs ............................................................20
dilt-cd ..........................................................................42
diltiazem cd .................................................................42
diltiazem hcl .................................................................42
diltiazem hcl er .............................................................42
dilt-xr ...........................................................................42
diltzac ..........................................................................42
diovan..........................................................................40
dipentum .....................................................................60
diphenhydramine hcl ....................................................30
diphenoxylate/atropine .................................................48
diphtheria/tetanus toxoids adsorbed pediatric ...............60
disopyramide phosphate ..............................................40
disulfiram .....................................................................14
divalproex sodium ..................................................20, 24
divalproex sodium dr ....................................................20
divalproex sodium er ....................................................24
divigel ..........................................................................54
docefrez ......................................................................27
docetaxel .....................................................................27
donepezil hcl ............................................................... 21
dorzolamide hcl ........................................................... 64
dorzolamide hcl/timolol maleate ................................... 64
doxazosin mesylate ..................................................... 40
doxepin hcl .................................................................. 22
doxercalciferol ............................................................. 61
doxorubicin hcl ............................................................ 27
doxycycline ................................................................. 19
doxycycline hyclate ...................................................... 19
doxycycline hyclate dr .................................................. 19
doxycycline monohydrate ............................................ 19
dronabinol ................................................................... 23
droxia .......................................................................... 26
dulera .......................................................................... 65
duloxetine hcl .............................................................. 22
duramorph .................................................................. 11
dyrenium ..................................................................... 43
e.e.s. 400 .................................................................... 18
e.e.s. granules ............................................................. 18
econazole nitrate ......................................................... 23
edarbyclor ................................................................... 40
edecrin ........................................................................ 43
edurant ....................................................................... 33
effer-k ......................................................................... 69
effient .......................................................................... 39
elaprase ...................................................................... 47
elelyso ......................................................................... 47
elestrin ........................................................................ 54
elidel ........................................................................... 46
eligard ......................................................................... 57
eliphos ........................................................................ 69
eliquis .......................................................................... 38
elite ob with dha .......................................................... 70
elitek ........................................................................... 26
elite-ob ........................................................................ 70
elite-ob 400 ................................................................. 70
elixophyllin ................................................................... 66
ella .............................................................................. 56
elmiron ........................................................................ 50
elspar .......................................................................... 27
emadine ...................................................................... 63
emcyt .......................................................................... 26
emend......................................................................... 23
emoquette ................................................................... 54
emsam ........................................................................ 21
emtriva ........................................................................ 33
enablex ....................................................................... 50
enalapril maleate .......................................................... 40
enalapril maleate/hydrochlorothiazide ........................... 40
enbrel .......................................................................... 58
enbrel sureclick............................................................ 58
endocet....................................................................... 11
engerix-b ..................................................................... 60
enoxaparin sodium ...................................................... 38
enskyce....................................................................... 54
78
entacapone..................................................................30
enulose ........................................................................49
epifoam .......................................................................14
epinastine hcl ...............................................................63
epinephrine ..................................................................66
epinephrine hcl.............................................................66
epipen 2-pak ...............................................................66
epipen-jr 2-pak ............................................................66
epirubicin hcl................................................................27
epitol ...........................................................................20
epivir ......................................................................32, 33
epivir hbv .....................................................................32
eplerenone ...................................................................43
epogen ........................................................................39
eprosartan mesylate .....................................................40
epzicom .......................................................................33
equetro ........................................................................20
eraxis ...........................................................................23
erbitux .........................................................................29
ergoloid mesylates .......................................................21
ergomar .......................................................................24
erivedge .......................................................................27
errin .............................................................................56
erwinaze ......................................................................27
ery ...............................................................................18
ery-tab .........................................................................18
erythrocin lactobionate .................................................18
erythrocin stearate .......................................................18
erythromycin ..........................................................18, 46
erythromycin base ........................................................18
erythromycin ethylsuccinate .........................................18
erythromycin/benzoyl peroxide .....................................46
erythromycin/sulfisoxazole ............................................18
escitalopram oxalate ....................................................22
esomeprazole sodium ..................................................49
esomeprazole strontium ...............................................49
estazolam ....................................................................35
estrace ........................................................................54
estradiol .................................................................54, 55
estradiol valerate ..........................................................54
estradiol/norethindrone acetate ....................................54
estrasorb .....................................................................54
estring .........................................................................54
eszopiclone..................................................................67
ethambutol hcl .............................................................25
ethosuximide ...............................................................19
etidronate disodium......................................................61
etodolac ................................................................10, 14
etodolac er...................................................................14
etoposide.....................................................................28
eurax ...........................................................................30
evamist ........................................................................54
exelderm......................................................................23
exelon ..........................................................................21
exemestane .................................................................28
exforge ........................................................................ 42
exforge hct .................................................................. 42
exjade ......................................................................... 68
extavia......................................................................... 59
extra-virt plus dha ........................................................ 70
fabior........................................................................... 46
fabrazyme ................................................................... 47
falmina ........................................................................ 54
famciclovir ................................................................... 34
famotidine ................................................................... 49
fanapt.......................................................................... 31
fanapt titration pack ..................................................... 31
fareston ....................................................................... 26
farxiga ......................................................................... 36
faslodex ...................................................................... 26
fazaclo ........................................................................ 32
felbamate .................................................................... 20
felodipine er ................................................................. 42
femcon fe .................................................................... 54
femhrt low dose ........................................................... 54
femring ........................................................................ 54
fenofibrate ................................................................... 43
fenofibrate micronized.................................................. 43
fenofibric acid .............................................................. 43
fenofibric acid dr .......................................................... 43
fenoprofen calcium ...................................................... 14
fentanyl ................................................................. 10, 11
fentanyl citrate ............................................................. 11
fentanyl citrate oral transmucosal ................................. 11
fentora......................................................................... 11
ferriprox ....................................................................... 62
fetzima ........................................................................ 22
fetzima titration pack.................................................... 22
finacea ........................................................................ 46
finasteride.................................................................... 50
firazyr .......................................................................... 58
firmagon ...................................................................... 57
flagyl er........................................................................ 16
flarex ........................................................................... 63
flavoxate hcl ................................................................ 50
flecainide acetate ......................................................... 41
flector .......................................................................... 14
flovent diskus .............................................................. 65
flovent hfa.................................................................... 65
fluconazole .................................................................. 23
fluconazole in dextrose ................................................ 23
fludarabine phosphate ................................................. 27
fludrocortisone acetate ................................................ 51
flunisolide .................................................................... 65
fluocinolone acetonide ................................................. 51
fluocinolone acetonide body......................................... 51
fluocinolone acetonide scalp ........................................ 51
fluocinonide ................................................................. 51
fluocinonide-e .............................................................. 51
fluorometholone........................................................... 63
79
fluoroplex .....................................................................46
fluorouracil .............................................................26, 46
fluoxetine dr .................................................................22
fluoxetine hcl ................................................................22
fluphenazine decanoate................................................30
fluphenazine hcl ...........................................................30
flurazepam hcl..............................................................67
flurbiprofen.............................................................14, 63
flurbiprofen sodium ......................................................63
flutamide ......................................................................26
fluticasone propionate ............................................ 51, 65
fluvastatin ....................................................................43
fluvoxamine maleate .....................................................22
fluvoxamine maleate er .................................................22
fml ...............................................................................63
fml forte .......................................................................63
focalgin-b.....................................................................70
focalin xr ......................................................................45
folbecal ........................................................................70
folivane-ob ...................................................................70
folivane-prx dha nf........................................................70
folotyn..........................................................................26
fondaparinux sodium ....................................................38
foradil aerolizer .............................................................66
forfivo xl .......................................................................21
forteo ...........................................................................61
fortesta ........................................................................53
fortical..........................................................................61
fosamax plus d ............................................................61
foscarnet sodium .........................................................32
fosinopril sodium ..........................................................40
fosinopril sodium/hydrochlorothiazide ...........................40
fosphenytoin sodium ....................................................20
fosrenol........................................................................50
fragmin ........................................................................38
freamine iii....................................................................69
frova ............................................................................25
fulyzaq .........................................................................48
furosemide ...................................................................43
fusilev ..........................................................................27
fuzeon .........................................................................34
fycompa ......................................................................19
gabapentin...................................................................20
gabitril..........................................................................20
galantamine hydrobromide ...........................................21
gamastan s/d ...............................................................59
gammagard liquid ........................................................59
gamunex-c ..................................................................59
ganciclovir....................................................................32
gardasil ........................................................................60
gastrocrom ..................................................................48
gatifloxacin...................................................................18
gattex ..........................................................................48
gavilyte-c .....................................................................49
gavilyte-g .....................................................................49
gavilyte-n/flavor pack ................................................... 49
gazyva......................................................................... 29
gelnique ...................................................................... 50
gemcitabine................................................................. 26
gemcitabine hcl ........................................................... 26
gemfibrozil ................................................................... 43
generess fe.................................................................. 54
generlac ...................................................................... 49
gengraf........................................................................ 58
genotropin ................................................................... 52
genotropin miniquick ................................................... 52
gentak ......................................................................... 15
gentamicin sulfate ........................................................ 15
gentamicin sulfate/0.9% sodium chloride ..................... 15
geodon ....................................................................... 35
gianvi .......................................................................... 54
giazo ........................................................................... 60
gildess fe 1.5/30 .......................................................... 54
gildess fe 1/20 ............................................................. 54
gilenya......................................................................... 46
gilotrif .......................................................................... 27
glassia ......................................................................... 67
gleevec........................................................................ 28
glimepiride ................................................................... 36
glipizide ....................................................................... 36
glipizide er ................................................................... 36
glipizide xl .................................................................... 36
glipizide/metformin hcl ................................................. 36
glucagen hypokit ......................................................... 37
glucagon emergency kit ............................................... 37
glumetza ..................................................................... 36
glycopyrrolate .............................................................. 48
glyset .......................................................................... 36
gralise ......................................................................... 10
gralise starter ............................................................... 10
granisetron hcl ............................................................. 23
granisol ....................................................................... 23
granix .......................................................................... 39
grifulvin v ..................................................................... 23
griseofulvin microsize ................................................... 23
griseofulvin ultramicrosize ............................................ 24
guanidine hcl ............................................................... 25
halaven........................................................................ 27
halobetasol propionate ................................................ 51
halog ........................................................................... 51
haloperidol............................................................. 30, 31
haloperidol decanoate ................................................. 30
haloperidol lactate ....................................................... 31
havrix .......................................................................... 60
hecoria ........................................................................ 58
hemenatal ob ........................................................ 70, 71
hemenatal ob + dha..................................................... 71
heparin sodium ............................................................ 38
heparin sodium/d5w .................................................... 38
heparin sodium/nacl 0.45% ......................................... 38
80
heparin sodium/nacl 0.9% ............................................38
heparin sodium/sodium chloride 0.9% premix...............38
hepsera .......................................................................32
herceptin .....................................................................29
hexalen ........................................................................26
hizentra ........................................................................59
homatropaire ...............................................................62
horizant........................................................................45
humalog ......................................................................37
humalog kwikpen .........................................................37
humalog mix 50/50 ......................................................37
humalog mix 50/50 kwikpen.........................................37
humalog mix 75/25 ......................................................37
humalog mix 75/25 kwikpen.........................................37
humatrope ...................................................................53
humatrope combo pack ...............................................53
humira .........................................................................58
humira pen...................................................................58
humira pen-crohns diseasestarter.................................58
humulin 70/30 ..............................................................37
humulin 70/30 pen .......................................................37
humulin n .....................................................................37
humulin n u-100 pen ....................................................37
humulin r ......................................................................37
humulin r u-500 (concentrated) .....................................37
hydralazine hcl .............................................................44
hydrochlorothiazide .......................................... 40, 41, 43
hydrocodone bitartrate/acetaminophen ........................12
hydrocodone/acetaminophen .......................................12
hydrocodone/ibuprofen ................................................12
hydrocortisone ..................................... 16, 51, 52, 61, 64
hydrocortisone butyrate................................................51
hydrocortisone in absorbase ........................................51
hydrocortisone valerate ................................................51
hydrocortisone/acetic acid ...........................................64
hydromorphone hcl ................................................10, 12
hydromorphone hcl er ..................................................10
hydroxychloroquine sulfate ...........................................29
hydroxyurea .................................................................26
hyoscyamine sulfate .....................................................48
ibandronate sodium .....................................................61
ibuprofen ......................................................... 10, 12, 15
idarubicin hcl................................................................27
ifex ..............................................................................26
ifosfamide ....................................................................26
ifosfamide/mesna .........................................................26
ilaris .............................................................................59
imbruvica .....................................................................28
imipenem/cilastatin.......................................................17
imipramine hcl ..............................................................22
imipramine pamoate.....................................................22
imiquimod ....................................................................46
imovax rabies (h.d.c.v.) .................................................60
incivek .........................................................................32
increlex ........................................................................53
indapamide ................................................................. 43
infanrix ........................................................................ 60
infergen ....................................................................... 32
infumorph 200 ............................................................. 10
infumorph 500 ............................................................. 10
inlyta ........................................................................... 28
innopran xl................................................................... 41
intelence...................................................................... 33
intralipid....................................................................... 62
intron-a ....................................................................... 32
intron-a w/diluent......................................................... 32
intuniv ......................................................................... 45
invanz.......................................................................... 17
invega ......................................................................... 31
invega sustenna........................................................... 31
invirase ........................................................................ 34
invokana...................................................................... 36
iopidine ....................................................................... 64
ipol inactivated ipv ....................................................... 60
ipratropium bromide .................................................... 65
ipratropium bromide/albuterol sulfate ........................... 65
irbesartan .................................................................... 40
irbesartan/hydrochlorothiazide ..................................... 40
irinotecan .................................................................... 27
isentress................................................................ 33, 34
isoditrate er ................................................................. 44
isoniazid ...................................................................... 25
isosorbide dinitrate ...................................................... 44
isosorbide dinitrate er................................................... 44
isosorbide mononitrate ................................................ 44
isosorbide mononitrate er ............................................ 44
isradipine ..................................................................... 42
istodax ........................................................................ 27
itraconazole ................................................................. 24
ixempra kit................................................................... 27
ixiaro ........................................................................... 60
jakafi ........................................................................... 27
jalyn ............................................................................ 50
jantoven ...................................................................... 38
janumet ....................................................................... 36
janumet xr ................................................................... 36
januvia ......................................................................... 36
jentadueto ................................................................... 36
jevtana ........................................................................ 27
jinteli ............................................................................ 54
jolessa ......................................................................... 54
jolivette ........................................................................ 56
junel 1.5/30 ................................................................. 54
junel 1/20 .................................................................... 54
junel fe 1.5/30 ............................................................. 54
junel fe 1/20 ................................................................ 54
juxtapid ....................................................................... 44
kadcyla........................................................................ 29
kalbitor ........................................................................ 62
kaletra ......................................................................... 34
81
kalydeco ......................................................................66
kariva ...........................................................................54
kcl 0.15%/d5w/ nacl 0.3% ...........................................37
kcl 0.15%/d5w/lr..........................................................37
kcl 0.15%/d5w/nacl 0.45% ..........................................37
k-effervescent ..............................................................69
kelnor 1/35 ..................................................................54
kenalog ........................................................................52
kepivance ....................................................................46
ketoconazole ...............................................................24
ketoprofen ...................................................................15
ketoprofen er ...............................................................15
ketorolac tromethamine................................................63
khedezla ......................................................................22
kineret .........................................................................58
kinrix ............................................................................60
kionex ..........................................................................68
klor-con 10 ..................................................................69
klor-con 8 ....................................................................69
klor-con m10 ...............................................................69
klor-con m15 ...............................................................69
klor-con m20 ...............................................................69
klor-con/ef ...................................................................69
kombiglyze xr ...............................................................36
kristalose .....................................................................49
krystexxa .....................................................................24
kurvelo .........................................................................54
kuvan...........................................................................47
kynamro ......................................................................44
labetalol hcl ..................................................................41
laclotion .......................................................................46
lacrisert ........................................................................62
lactated ringers irrigation ..............................................62
lactated ringers viaflex ..................................................69
lactulose ......................................................................49
lamictal odt ..................................................................20
lamivudine..............................................................32, 33
lamivudine/zidovudine ..................................................33
lamotrigine ...................................................................20
lamotrigine er ...............................................................20
lansoprazole ..........................................................16, 49
lansoprazole/amoxicillin/clarithromycin ..........................16
lantus.....................................................................37, 38
lantus solostar..............................................................38
larin fe 1.5/30 ...............................................................54
larin fe 1/20..................................................................54
lastacaft .......................................................................63
latanoprost...................................................................62
latuda ..........................................................................31
lazanda ........................................................................12
leena............................................................................54
leflunomide ..................................................................59
lescol xl........................................................................43
lessina .........................................................................55
letairis ..........................................................................66
letrozole ...................................................................... 28
leucovorin calcium ....................................................... 27
leukeran ...................................................................... 26
leukine......................................................................... 39
leuprolide acetate ........................................................ 57
levalbuterol .................................................................. 66
levalbuterol hcl............................................................. 66
levemir ........................................................................ 38
levemir flexpen............................................................. 38
levetiracetam ............................................................... 19
levetiracetam er ........................................................... 19
levobunolol hcl............................................................. 64
levocarnitine ................................................................ 62
levocetirizine dihydrochloride ........................................ 65
levofloxacin.................................................................. 19
levofloxacin in d5w ...................................................... 19
levonorgestrel/ethinyl estradiol ..................................... 55
levora 0.15/30-28 ........................................................ 55
levorphanol tartrate ...................................................... 10
levothyroxine sodium ................................................... 56
levoxyl ......................................................................... 56
lexiva ........................................................................... 34
lialda ........................................................................... 60
lidocaine .......................................................... 13, 14, 52
lidocaine hcl .......................................................... 13, 52
lidocaine hcl jelly .......................................................... 13
lidocaine hcl/hydrocortisone acetate ............................ 52
lidocaine viscous ......................................................... 13
lidocaine/prilocaine ...................................................... 13
lincocin ........................................................................ 16
lindane ........................................................................ 30
linzess ......................................................................... 49
liothyronine sodium ...................................................... 56
lipodox ........................................................................ 27
liptruzet ....................................................................... 43
lisinopril ....................................................................... 40
lisinopril/hydrochlorothiazide ........................................ 40
lithium carbonate ......................................................... 35
lithium carbonate er ..................................................... 35
lithium citrate ............................................................... 35
livalo ............................................................................ 43
lo minastrin fe .............................................................. 55
lokara .......................................................................... 52
lomedia 24 fe............................................................... 55
lomustine..................................................................... 26
loperamide hcl ............................................................. 48
lorazepam ................................................................... 35
lorazepam intensol ....................................................... 35
loryna .......................................................................... 55
losartan potassium ...................................................... 40
losartan potassium/hydrochlorothiazide........................ 40
lotemax ....................................................................... 63
lotronex ....................................................................... 49
lovastatin ..................................................................... 44
low-ogestrel ................................................................ 55
82
loxapine succinate........................................................31
lumigan ........................................................................62
lumizyme .....................................................................48
lupaneta pack ..............................................................57
lupron depot ................................................................57
lupron depot-ped .........................................................57
lutera ...........................................................................55
lyrica ............................................................................19
lysodren .......................................................................57
mafenide acetate .........................................................16
magnesium sulfate .................................................19, 69
magnesium sulfate in d5w ............................................19
makena .......................................................................55
malathion .....................................................................30
maprotiline hcl..............................................................21
marlissa .......................................................................55
marplan .......................................................................21
marqibo .......................................................................27
matulane......................................................................26
matzim la .....................................................................42
maxidex .......................................................................63
meclizine hcl ................................................................23
medrol .........................................................................52
medroxyprogesterone acetate ......................................56
mefenamic acid............................................................10
mefloquine hcl..............................................................29
megestrol acetate ........................................................56
mekinist .......................................................................27
meloxicam .............................................................10, 15
melphalan hydrochloride ..............................................26
menactra .....................................................................60
menest ........................................................................27
menhibrix .....................................................................60
menomune-a/c/y/w-135 ..............................................60
menostar .....................................................................55
menveo .......................................................................60
mepron ........................................................................29
mercaptopurine............................................................26
merrem ........................................................................17
mesalamine .................................................................61
mesna ...................................................................26, 27
mesnex........................................................................27
mestinon timespan .......................................................25
metadate er .................................................................45
metaproterenol sulfate ..................................................66
metformin hcl ...............................................................36
metformin hcl er ...........................................................36
methadone hcl .............................................................10
methadose...................................................................10
methazolamide.............................................................43
methenamine hippurate ................................................16
methimazole ................................................................57
methotrexate................................................................58
methotrexate sodium ...................................................58
methoxsalen ................................................................47
methscopolamine bromide........................................... 48
methyclothiazide .......................................................... 43
methylergonovine maleate ........................................... 62
methylin....................................................................... 45
methylphenidate hcl ..................................................... 45
methylphenidate hcl cd ................................................ 45
methylphenidate hcl er ................................................. 45
methylphenidate hydrochloride..................................... 45
methylprednisolone................................................ 52, 61
methylprednisolone acetate ......................................... 52
methylprednisolone dose pack..................................... 52
metipranolol................................................................. 64
metoclopramide hcl ............................................... 48, 49
metolazone.................................................................. 43
metoprolol succinate er................................................ 41
metoprolol tartrate ....................................................... 41
metoprolol/hydrochlorothiazide .................................... 41
metozolv odt ............................................................... 49
metronidazole .............................................................. 16
metronidazole in nacl 0.79% ........................................ 16
metronidazole vaginal .................................................. 16
mexiletine hcl ............................................................... 41
miacalcin ..................................................................... 61
miconazole 3 ............................................................... 24
microgestin 1.5/30....................................................... 55
microgestin 1/20 ......................................................... 55
microgestin fe .............................................................. 55
microgestin fe 1.5/30 ................................................... 55
midodrine hcl ............................................................... 40
migergot...................................................................... 24
millipred....................................................................... 52
mimvey ....................................................................... 55
minastrin 24 fe ............................................................. 55
minivelle ...................................................................... 55
minocycline hcl ............................................................ 19
minoxidil ...................................................................... 44
mirapex er ................................................................... 30
mirtazapine .................................................................. 21
mirtazapine odt............................................................ 21
mirvaso ....................................................................... 16
misoprostol ........................................................... 10, 49
mitomycin.................................................................... 28
mitoxantrone hcl .......................................................... 28
m-m-r ii w/diluent 10 dose ........................................... 60
modafinil...................................................................... 67
moderiba ..................................................................... 32
moderiba 1200 dose pack ........................................... 32
moderiba 800 dose pack ............................................. 32
moexipril hcl ................................................................ 40
mometasone furoate.................................................... 52
mononessa ................................................................. 55
montelukast sodium .................................................... 65
monurol ....................................................................... 16
morphine sulfate ........................................ 10, 11, 12, 13
morphine sulfate er ................................................ 10, 11
83
moxifloxacin hcl............................................................19
mozobil ........................................................................69
multaq .........................................................................41
mupirocin.....................................................................16
mustargen ...................................................................26
myalept........................................................................62
mycamine ....................................................................24
mycophenolate mofetil .................................................58
mycophenolic acid dr ...................................................58
mydral .........................................................................62
myfortic .......................................................................58
mynatal ........................................................................71
mynatal-z .....................................................................71
mynate 90 plus ............................................................71
nabumetone ................................................................15
nadolol.........................................................................41
nadolol/bendroflumethiazide .........................................41
nafcillin sodium ............................................................18
naglazyme ...................................................................48
nalbuphine hcl..............................................................13
nalfon ..........................................................................10
naloxone hcl ................................................................14
naltrexone hcl ..............................................................14
namenda .....................................................................21
namenda titration pak...................................................21
namenda xr..................................................................21
namenda xr titration pack .............................................21
naphazoline hcl ............................................................62
naproxen ...............................................................10, 15
naproxen dr .................................................................15
naproxen sodium .........................................................10
naratriptan hcl ..............................................................25
nasonex .......................................................................65
natazia .........................................................................55
nateglinide ...................................................................36
nebupent .....................................................................29
necon 0.5/35-28 ..........................................................55
necon 1/35 ..................................................................55
necon 1/50-28 .............................................................55
necon 10/11-28 ...........................................................55
necon 7/7/7 .................................................................55
nefazodone hcl ............................................................21
neomycin sulfate ..........................................................15
neomycin/bacitracin/polymyxin .....................................16
neomycin/polymyxin/bacitracin/hydrocortisone .............16
neomycin/polymyxin/dexamethasone ...........................63
neomycin/polymyxin/gramicidin ....................................16
neomycin/polymyxin/hc ................................................64
neomycin/polymyxin/hydrocortisone ....................... 16, 64
nephramine ..................................................................69
neulasta .......................................................................39
neumega .....................................................................39
neupogen ....................................................................39
neupro .........................................................................30
nevanac .......................................................................63
nevirapine .................................................................... 33
nevirapine er ................................................................ 33
nexavar ....................................................................... 28
niacin er ...................................................................... 71
niacor .......................................................................... 71
nicardipine hcl ............................................................. 42
nicotrol inhaler ............................................................. 14
nicotrol ns ................................................................... 14
nifediac cc ................................................................... 42
nifedical xl ................................................................... 42
nifedipine er ................................................................. 42
nilandron ..................................................................... 26
nimodipine................................................................... 42
nisoldipine ................................................................... 42
nisoldipine er ............................................................... 42
nitro-bid ...................................................................... 44
nitro-dur ...................................................................... 44
nitrofurantoin macrocrystals ......................................... 16
nitrofurantoin monohydrate .......................................... 16
nitroglycerin ................................................................. 44
nitroglycerin lingual ...................................................... 44
nitroglycerin transdermal .............................................. 44
nitrolingual pumpspray ................................................. 44
nitrostat ....................................................................... 44
nizatidine ..................................................................... 49
nora-be ....................................................................... 56
norditropin flexpro........................................................ 53
norditropin nordiflex pen .............................................. 53
norethindrone acetate ............................................ 54, 56
norgestimate/ethinyl estradiol ....................................... 55
noritate ........................................................................ 16
normosol -r.................................................................. 69
normosol-m in d5w...................................................... 69
nortrel 0.5/35 (28) ........................................................ 55
nortrel 1/35 ................................................................. 55
nortrel 7/7/7 ................................................................ 55
nortriptyline hcl ............................................................ 23
norvir ........................................................................... 34
novolin 70/30 .............................................................. 38
novolin n...................................................................... 38
novolin r ...................................................................... 38
novolog ....................................................................... 38
novolog flexpen ........................................................... 38
novolog mix 70/30 ....................................................... 38
novolog mix 70/30 prefilled flexpen .............................. 38
novolog penfill ............................................................. 38
noxafil ......................................................................... 24
nuedexta ..................................................................... 45
nulojix .......................................................................... 58
nutropin aq pen ........................................................... 53
nuvaring ...................................................................... 55
nuvigil .......................................................................... 67
nyamyc ....................................................................... 24
nystatin ....................................................................... 24
nystatin/triamcinolone .................................................. 24
84
nystop .........................................................................24
obstetrix dha ................................................................71
ocella ...........................................................................55
octreotide acetate ........................................................57
ofloxacin ......................................................................19
ogestrel .......................................................................55
olanzapine ....................................................... 22, 31, 35
olanzapine odt .............................................................31
olanzapine/fluoxetine .............................................. 22, 35
olysio ...........................................................................32
omega-3-acid ethyl esters ............................................44
omeprazole ............................................................49, 50
omeprazole/sodium bicarbonate ..................................49
omnaris .......................................................................65
oncaspar .....................................................................28
ondansetron hcl ...........................................................23
ondansetron odt ..........................................................23
onfi ..............................................................................20
onglyza ........................................................................36
opana er (crush resistant) .............................................11
opium tincture ..............................................................13
opsumit .......................................................................66
orap.............................................................................31
orencia ........................................................................58
orenitram .....................................................................66
orfadin .........................................................................48
orphenadrine citrate .....................................................67
orphenadrine citrate er .................................................67
orphenadrine/asa/caffeine ............................................67
orsythia ........................................................................55
otezla...........................................................................59
otrexup ........................................................................58
oxacillin sodium............................................................18
oxaliplatin.....................................................................28
oxandrolone .................................................................53
oxaprozin .....................................................................15
oxazepam ....................................................................35
oxcarbazepine .............................................................20
oxistat ..........................................................................24
oxsoralen .....................................................................47
oxsoralen ultra .............................................................47
oxtellar xr .....................................................................21
oxybutynin chloride ......................................................50
oxybutynin chloride er ..................................................50
oxycodone hcl .............................................................13
oxycodone/acetaminophen ..........................................13
oxycodone/aspirin ........................................................13
oxycodone/ibuprofen ...................................................10
oxycontin .....................................................................11
oxymorphone hydrochloride ................................... 11, 13
oxymorphone hydrochloride er .....................................11
pacerone .....................................................................41
paclitaxel......................................................................28
paire ob .......................................................................71
pamidronate disodium..................................................61
pancreaze ................................................................... 48
pancrelipase ................................................................ 48
panretin ....................................................................... 29
pantoprazole sodium ................................................... 50
paricalcitol ................................................................... 61
paromomycin sulfate ................................................... 15
paroxetine hcl .............................................................. 22
paroxetine hcl er .......................................................... 22
paser........................................................................... 25
paxil ............................................................................ 22
pce ............................................................................. 18
pediarix ....................................................................... 60
pedi-dri ....................................................................... 24
pedvax hib................................................................... 60
peg 3350/electrolytes .................................................. 49
peganone .................................................................... 21
pegasys ...................................................................... 33
pegasys proclick.......................................................... 33
peg-intron ................................................................... 32
peg-intron redipen ....................................................... 32
penicillin g potassium ................................................... 18
penicillin g potassium in iso-osmotic dextrose .............. 18
penicillin g procaine ..................................................... 18
penicillin g sodium ....................................................... 18
penicillin v potassium ................................................... 18
pentacel ...................................................................... 60
pentam 300 ................................................................. 29
pentasa ....................................................................... 61
pentostatin .................................................................. 26
pentoxifylline er ............................................................ 42
perforomist .................................................................. 66
perindopril erbumine .................................................... 40
perjeta ......................................................................... 29
permethrin ................................................................... 30
perphenazine............................................................... 31
phenadoz .................................................................... 23
phenazopyridine hcl ..................................................... 50
phenelzine sulfate ........................................................ 21
phenobarbital ........................................................ 20, 67
phenytoin .................................................................... 21
phenytoin infatabs ....................................................... 21
phenytoin sodium ........................................................ 21
phenytoin sodium extended ......................................... 21
phoslyra ...................................................................... 69
phospha 250 neutral .................................................... 70
phospholine iodide ...................................................... 64
picato .......................................................................... 28
pilocarpine hcl ....................................................... 46, 64
pilocarpine hydrochloride ............................................. 46
pilopine hs ................................................................... 64
pindolol ....................................................................... 41
pioglitazone hcl............................................................ 36
pioglitazone hcl/metformin hcl ...................................... 36
pioglitazone hcl-glimepiride .......................................... 36
pirmella 1/35 ............................................................... 55
85
pirmella 7/7/7 ...............................................................55
piroxicam .....................................................................15
pnv folic acid + iron multivitamin ...................................71
pnv-dha .......................................................................71
pnv-first .......................................................................70
pnv-ob/dha ..................................................................71
podofilox ......................................................................47
polycin b ......................................................................16
poly-dex ......................................................................63
polyethylene glycol 3350 ..............................................49
polymyxin b sulfate/trimethoprim sulfate .......................16
pomalyst ......................................................................28
portia-28 ......................................................................55
potassium chloride ........................................... 37, 69, 70
potassium chloride 0.15% /nacl 0.45% viaflex ..............70
potassium chloride 0.15%/nacl 0.9%............................70
potassium chloride 0.3%/ nacl 0.9%.............................70
potassium chloride 0.3%/d5w ......................................70
potassium chloride 0.3%/nacl 0.9%/viaflex ...................70
potassium chloride er ...................................................70
potassium chloride sr ...................................................70
potassium citrate..........................................................70
potassium citrate er......................................................70
potiga ..........................................................................19
pr natal 400 ec .............................................................71
pr natal 430 .................................................................71
pr natal 430 ec .............................................................71
pradaxa .......................................................................38
pramipexole dihydrochloride .........................................30
prandimet ....................................................................36
pravastatin sodium .......................................................44
prazosin hcl .................................................................40
pred mild .....................................................................63
pred-g .........................................................................63
pred-g s.o.p. ................................................................63
prednicarbate...............................................................52
prednisolone acetate ....................................................63
prednisolone sodium phosphate ............................. 52, 63
prednisone...................................................................52
prednisone intensol ......................................................52
premarin ......................................................................55
premasol......................................................................70
prena1 chew/quatrefolic ...............................................71
prena1 plus/quatrefolic .................................................71
prena1/quatrefolic ........................................................71
prenaissance 90 dha ....................................................71
prenaissance balance...................................................71
prenaissance dha .........................................................71
prenaissance harmony dha ..........................................71
prenaissance next ........................................................71
prenaissance plus ........................................................71
prenaissance promise ..................................................71
prenatabs obn .............................................................71
prenatal 19 ..................................................................71
prenatal ad...................................................................71
prenatal low iron .......................................................... 71
prenatal plus................................................................ 71
prenatal plus iron ......................................................... 71
prepopik ...................................................................... 49
prevalite ...................................................................... 44
previfem ................................................................ 55, 56
prezista ....................................................................... 34
priftin ........................................................................... 25
primaquine phosphate ................................................. 29
primidone .................................................................... 20
primlev ........................................................................ 13
primsol ........................................................................ 16
pristiq .......................................................................... 22
proair hfa ..................................................................... 66
probenecid .................................................................. 24
probenecid/colchicine .................................................. 24
procalamine................................................................. 70
prochlorperazine .......................................................... 31
prochlorperazine edisylate............................................ 31
prochlorperazine maleate ............................................. 31
procrit ......................................................................... 39
proctofoam hc ............................................................. 47
procto-pak .................................................................. 52
proctosol hc ................................................................ 52
proctozone-hc ............................................................. 52
progesterone ............................................................... 56
proglycem ................................................................... 37
prograf ........................................................................ 58
prolastin-c ................................................................... 67
prolensa ...................................................................... 63
proleukin ..................................................................... 28
prolia ........................................................................... 61
promacta..................................................................... 39
promethazine hcl ......................................................... 23
promethegan ............................................................... 23
propafenone hcl .......................................................... 41
propafenone hcl er....................................................... 41
propantheline bromide ................................................. 48
proparacaine hcl .......................................................... 62
propranolol hcl............................................................. 41
propranolol hcl er......................................................... 41
propranolol/hydrochlorothiazide ................................... 41
propylthiouracil ............................................................ 57
proquad ...................................................................... 60
protopic ...................................................................... 47
protriptyline hcl ............................................................ 23
pulmicort ..................................................................... 65
pulmicort flexhaler........................................................ 65
pulmozyme.................................................................. 66
pyrazinamide ............................................................... 25
pyridostigmine bromide................................................ 25
qnasl ........................................................................... 65
quartette ..................................................................... 55
quasense .................................................................... 55
qudexy xr .................................................................... 20
86
quetiapine fumarate......................................................31
quinapril hcl .................................................................40
quinapril/hydrochlorothiazide ........................................40
quinidine gluconate cr ..................................................41
quinidine sulfate ...........................................................41
quinine sulfate ..............................................................30
qvar .............................................................................65
rabavert .......................................................................60
rabeprazole sodium......................................................50
raloxifene hydrochloride................................................56
ramipril.........................................................................40
ranexa .........................................................................42
ranitidine hcl.................................................................49
rapaflo .........................................................................50
rapamune ....................................................................58
ravicti ...........................................................................48
rayos ...........................................................................52
rebif .......................................................................46, 59
rebif rebidose ...............................................................46
rebif rebidose titration pack ..........................................46
rebif titration pack ........................................................59
reclipsen ......................................................................55
recombivax hb .............................................................60
rectiv ...........................................................................44
regranex ......................................................................47
relenza diskhaler ..........................................................34
relistor..........................................................................49
relpax ..........................................................................25
remicade......................................................................59
renvela .........................................................................50
repaglinide ...................................................................36
reprexain......................................................................13
rescriptor .....................................................................33
restasis ........................................................................62
retrovir iv infusion .........................................................33
revlimid ........................................................................26
reyataz.........................................................................34
rheumatrex ..................................................................59
ribasphere....................................................................33
ribavirin ........................................................................33
ridaura .........................................................................59
rifabutin........................................................................25
rifamate .......................................................................25
rifampin........................................................................25
rifater ...........................................................................25
rilutek...........................................................................45
riluzole .........................................................................45
rimantadine hcl.............................................................34
risedronate sodium ......................................................61
risperdal consta ...........................................................31
risperidone ...................................................................31
risperidone odt .............................................................31
rituxan .........................................................................29
rivastigmine tartrate ......................................................21
rizatriptan benzoate ......................................................25
rizatriptan benzoate odt ............................................... 25
r-natal ob .................................................................... 71
romycin ....................................................................... 18
ropinirole er ................................................................. 30
ropinirole hcl ................................................................ 30
rotarix .......................................................................... 60
rotateq ........................................................................ 60
roxicet ......................................................................... 13
rozerem ....................................................................... 67
rythmol sr .................................................................... 41
sabril ........................................................................... 20
safyral ......................................................................... 55
salicylic acid ................................................................ 47
salsalate ...................................................................... 10
samsca ....................................................................... 68
sancuso ...................................................................... 23
sandimmune................................................................ 59
sandostatin lar depot ................................................... 57
santyl .......................................................................... 47
saphris ........................................................................ 31
savella ......................................................................... 45
savella titration pack .................................................... 45
selegiline hcl ................................................................ 30
selenium sulfide ........................................................... 47
selzentry ...................................................................... 34
semprex-d................................................................... 65
se-natal 19 .................................................................. 71
sensipar ...................................................................... 57
serevent diskus............................................................ 66
seroquel xr ............................................................ 31, 32
serostim ...................................................................... 53
sertraline hcl ................................................................ 22
se-tan dha ................................................................... 71
sevelamer carbonate ................................................... 50
sf................................................................................. 70
sf 5000 plus ................................................................ 70
signifor ........................................................................ 57
sildenafil ...................................................................... 66
silver sulfadiazine ......................................................... 16
simbrinza ..................................................................... 64
simcor ......................................................................... 44
simponi ....................................................................... 59
simponi aria ................................................................. 59
simulect....................................................................... 59
simvastatin .................................................................. 44
sirolimus ...................................................................... 59
sirturo .......................................................................... 25
sklice ........................................................................... 30
sodium chloride 0.45% viaflex ...................................... 70
sodium chloride 0.9% ...................................... 37, 38, 62
sodium phenylbutyrate................................................. 48
sodium polystyrene sulfonate ....................................... 68
sodium sulfacetamide .................................................. 19
solaraze....................................................................... 47
soliris ........................................................................... 39
87
solodyn ........................................................................19
soltamox ......................................................................26
somatuline depot .........................................................57
somavert......................................................................57
soriatane ......................................................................47
sorine ..........................................................................41
sotalol hcl ....................................................................41
sotalol hcl (af) ...............................................................41
sovaldi .........................................................................33
spiriva handihaler .........................................................65
spironolactone .............................................................43
spironolactone/hydrochlorothiazide ..............................43
sprintec 28...................................................................56
sprix ............................................................................10
sprycel .........................................................................28
sronyx..........................................................................56
stagesic .......................................................................13
stavudine .....................................................................33
stavzor.........................................................................20
stelara..........................................................................47
stivarga ........................................................................28
strattera .......................................................................45
streptomycin sulfate .....................................................15
striant ..........................................................................53
stribild ..........................................................................33
stromectol ...................................................................29
suboxone.....................................................................14
subsys .........................................................................13
suclear .........................................................................49
sucraid.........................................................................48
sucralfate .....................................................................49
sulfacetamide sodium ...................................... 19, 47, 63
sulfacetamide sodium/prednisolone sodium phosphate 63
sulfadiazine ............................................................16, 19
sulfamethoxazole/trimethoprim .....................................19
sulfamethoxazole/trimethoprim ds ................................19
sulfamylon ...................................................................16
sulfasalazine.................................................................61
sulfazine.......................................................................61
sulfazine ec ..................................................................61
sulindac .......................................................................15
sumatriptan..................................................................25
sumatriptan succinate ..................................................25
sumatriptan succinate refill ...........................................25
sumavel dosepro..........................................................25
suprax .........................................................................17
suprep bowel prep .......................................................49
surmontil ......................................................................23
sustiva .........................................................................33
sutent ..........................................................................29
sylatron ........................................................................28
sylvant .........................................................................29
symbicort .....................................................................65
symlinpen 120 .............................................................36
symlinpen 60 ...............................................................36
synarel ........................................................................ 57
synera ......................................................................... 14
synercid ...................................................................... 16
synribo ........................................................................ 28
synthroid ..................................................................... 56
syprine ........................................................................ 68
tabloid ......................................................................... 26
tacrolimus ................................................................... 59
tafinlar ......................................................................... 29
tamiflu ......................................................................... 34
tamoxifen citrate .......................................................... 26
tamsulosin hcl ............................................................. 50
tarceva ........................................................................ 29
targretin....................................................................... 29
taron-bc ...................................................................... 71
taron-c dha ................................................................. 72
taron-crystals .............................................................. 70
taron-prex ................................................................... 72
tasigna ........................................................................ 29
tasmar......................................................................... 30
tazicef ......................................................................... 17
tazorac ........................................................................ 47
taztia xt ....................................................................... 42
tecfidera ...................................................................... 59
tecfidera starter pack ................................................... 59
teflaro .......................................................................... 17
tegretol-xr.................................................................... 21
tekamlo ....................................................................... 42
tekturna ....................................................................... 42
tekturna hct ................................................................. 42
telmisartan................................................................... 40
telmisartan/amlodipine ................................................. 40
telmisartan/hydrochloroth ............................................ 40
telmisartan/hydrochlorothiazide .................................... 40
temazepam ................................................................. 67
tenivac ........................................................................ 60
terazosin hcl ................................................................ 50
terbinafine hcl .............................................................. 24
terbutaline sulfate ........................................................ 66
terconazole.................................................................. 24
testim .......................................................................... 53
testopel ....................................................................... 53
testosterone cypionate ................................................ 53
testosterone enanthate ................................................ 53
tetanus toxoid adsorbed .............................................. 60
tetanus/diphtheria toxoids-adsorbed adult ................... 60
tetracycline hcl............................................................. 19
teveten hct .................................................................. 40
thalomid ...................................................................... 26
theochron .................................................................... 66
theophylline cr ............................................................. 66
theophylline er ............................................................. 66
thioridazine hcl............................................................. 31
thiotepa ....................................................................... 26
thiothixene ................................................................... 31
88
thymoglobulin ..............................................................59
thyrolar-1 .....................................................................56
thyrolar-1/2 ..................................................................56
thyrolar-1/4 ..................................................................56
thyrolar-2 .....................................................................56
thyrolar-3 .....................................................................56
tiagabine hydrochloride ................................................20
tikosyn .........................................................................41
timolol maleate .......................................................41, 64
timolol maleate ophthalmic gel forming .........................64
tirosint..........................................................................56
tivicay ..........................................................................34
tizanidine hcl ................................................................32
tl-care dha ...................................................................72
tl-select........................................................................72
tobi ..............................................................................15
tobi podhaler................................................................15
tobradex ......................................................................63
tobramycin.............................................................15, 63
tobramycin sulfate ........................................................15
tobramycin sulfate/sodium chloride...............................15
tobramycin/dexamethasone .........................................63
tobrex ..........................................................................15
tolazamide ...................................................................36
tolbutamide ..................................................................36
tolmetin sodium ...........................................................15
tolterodine tartrate ........................................................50
tolterodine tartrate er ....................................................50
topiramate ...................................................................24
toposar ........................................................................28
topotecan hcl ...............................................................28
torisel...........................................................................59
torsemide ....................................................................43
toviaz ...........................................................................50
tracleer ........................................................................67
tradjenta ......................................................................36
tramadol hcl ...........................................................11, 13
tramadol hcl er .............................................................11
tramadol hydrochloride/acetaminophen ........................13
trandolapril ...................................................................40
tranexamic acid............................................................39
transderm-scop ...........................................................23
tranylcypromine sulfate .................................................21
travatan z .....................................................................62
travoprost ....................................................................62
trazodone hcl ...............................................................21
treanda ........................................................................26
trecator ........................................................................25
trelstar depot ...............................................................57
trelstar depot mixject ....................................................57
trelstar la ......................................................................57
trelstar la mixject ..........................................................57
trelstar mixject..............................................................57
tretinoin .................................................................29, 47
tretinoin microsphere....................................................47
tretin-x......................................................................... 47
trexall .......................................................................... 59
treximet ....................................................................... 24
trezix ........................................................................... 13
triamcinolone acetonide ......................................... 52, 65
triamcinolone in orabase .............................................. 46
triamterene/hydrochlorothiazide ................................... 43
triazolam ..................................................................... 67
tribenzor ...................................................................... 42
tricare prenatal compleat ............................................. 72
triderm ........................................................................ 52
tri-estarylla ................................................................... 56
trifluoperazine hcl ......................................................... 31
trifluridine ..................................................................... 34
trihexyphenidyl hcl ....................................................... 30
tri-legest fe .................................................................. 56
tri-linyah ...................................................................... 56
trilyte ........................................................................... 49
trimethoprim .......................................................... 16, 19
trinessa ....................................................................... 56
tri-previfem .................................................................. 56
trisenox ....................................................................... 28
tri-sprintec ................................................................... 56
tri-tabs dha .................................................................. 72
triveen-duo dha ........................................................... 72
triveen-one .................................................................. 72
triveen-prx rnf .............................................................. 72
triveen-u ...................................................................... 72
trivora-28..................................................................... 56
trizivir........................................................................... 33
trokendi xr ................................................................... 20
trophamine .................................................................. 70
tropicamide ................................................................. 62
trospium chloride ......................................................... 50
trospium chloride er ..................................................... 50
truvada ........................................................................ 33
tudorza pressair ........................................................... 65
twinrix ......................................................................... 60
tygacil ......................................................................... 16
tykerb .......................................................................... 29
typhim vi...................................................................... 60
tysabri ......................................................................... 46
tyvaso ......................................................................... 67
tyvaso refill................................................................... 67
tyvaso starter ............................................................... 67
tyzeka ......................................................................... 32
tyzine .......................................................................... 67
tyzine pediatric nasal drops .......................................... 67
uceris .......................................................................... 52
u-cort .......................................................................... 52
ulesfia.......................................................................... 30
uloric ........................................................................... 24
ultimatecare one .......................................................... 72
ultimatecare one nf ...................................................... 72
ultresa ......................................................................... 48
89
unithroid ......................................................................57
urea .............................................................................47
urea 40% nail film .........................................................47
urea nail .......................................................................47
ursodiol........................................................................49
uvadex .........................................................................47
vagifem ........................................................................56
valacyclovir hcl .............................................................34
valchlor ........................................................................26
valcyte .........................................................................32
valproate sodium..........................................................20
valproic acid.................................................................20
valsartan/hydrochlorothiazide .......................................40
vancomycin hcl ............................................................16
vaqta ...........................................................................60
varivax .........................................................................60
vascepa .......................................................................44
vecamyl .......................................................................42
vectibix ........................................................................29
velcade ........................................................................28
velivet ..........................................................................56
velphoro ......................................................................50
vemavite-prx 2 .............................................................72
vena-bal dha ................................................................72
venatal complete dha ...................................................72
venatal-fa .....................................................................72
venlafaxine hcl..............................................................22
venlafaxine hcl er..........................................................22
ventavis .......................................................................67
ventolin hfa ..................................................................66
veramyst ......................................................................65
verapamil hcl ................................................................42
verapamil hcl er ............................................................42
verapamil hcl sr ............................................................42
veregen .......................................................................47
versacloz .....................................................................32
vexol ............................................................................63
vfend ...........................................................................24
v-go 20 ........................................................................62
v-go 30 ........................................................................62
v-go 40 ........................................................................62
vibativ ..........................................................................16
victoza .........................................................................36
victrelis ........................................................................33
vidaza ..........................................................................28
videx pediatric ..............................................................33
vigamox .......................................................................19
viibryd ..........................................................................22
vimpat .........................................................................21
vinacal .........................................................................72
vinate az ......................................................................72
vinate calcium ..............................................................72
vinate dha ....................................................................72
vinate gt .......................................................................72
vinate ic .......................................................................72
vinate ii ........................................................................ 72
vinate m ...................................................................... 72
vinate one.................................................................... 72
vinate pn care .............................................................. 72
vinate ultra ................................................................... 72
vinblastine sulfate ........................................................ 28
vincasar pfs ................................................................. 28
vincristine sulfate ......................................................... 28
vinorelbine tartrate ....................................................... 28
viokace........................................................................ 48
viracept ....................................................................... 34
viramune ..................................................................... 33
viramune xr.................................................................. 33
virazole ........................................................................ 33
viread .......................................................................... 33
vitaspire....................................................................... 72
vivelle-dot .................................................................... 56
vol-nate ....................................................................... 72
vol-plus ....................................................................... 72
vol-tab rx ..................................................................... 72
voltaren ....................................................................... 47
voraxaze...................................................................... 62
voriconazole ................................................................ 24
votrient ........................................................................ 29
vp-ch plus ................................................................... 72
vp-era ob plus ............................................................. 72
vp-heme ob ................................................................. 72
vytorin ......................................................................... 44
vyvanse ....................................................................... 45
warfarin sodium ........................................................... 39
welchol ........................................................................ 44
xalkori ......................................................................... 29
xarelto ......................................................................... 39
xeljanz ......................................................................... 59
xenazine ...................................................................... 45
xerese ......................................................................... 34
xgeva .......................................................................... 61
xifaxan......................................................................... 16
xolair ........................................................................... 67
xolox ........................................................................... 13
xopenex hfa................................................................. 66
xtandi .......................................................................... 26
xulane ......................................................................... 56
xyrem .......................................................................... 67
yervoy ......................................................................... 29
yf-vax .......................................................................... 60
zafirlukast .................................................................... 65
zaleplon....................................................................... 67
zaltrap ................................................................... 28, 29
zamicet ....................................................................... 13
zanosar ....................................................................... 26
zatean-ch .................................................................... 72
zatean-pn .................................................................... 72
zatean-pn plus............................................................. 72
zavesca ....................................................................... 48
90
zazole ..........................................................................24
zelapar.........................................................................21
zelboraf........................................................................29
zemaira ........................................................................67
zemplar........................................................................61
zenpep ........................................................................48
zetia.............................................................................44
ziagen ..........................................................................34
zidovudine .............................................................33, 34
zioptan.........................................................................62
ziprasidone hcl .............................................................32
zipsor ..........................................................................10
zirgan ..........................................................................32
zohydro er ...................................................................11
zoledronic acid .............................................................61
zolinza .........................................................................28
zolmitriptan ..................................................................25
zolmitriptan odt ............................................................25
zolpidem tartrate ..........................................................67
zolpidem tartrate er ......................................................67
zometa ........................................................................61
zomig nasal spray ........................................................25
zonalon ........................................................................47
zonisamide ..................................................................19
zontivity .......................................................................39
zorbtive ........................................................................53
zortress .......................................................................59
zostavax ......................................................................60
zosyn ...........................................................................18
zovia 1/35e ..................................................................56
zovia 1/50e ..................................................................56
zovirax .........................................................................35
zubsolv ........................................................................14
zuplenz ........................................................................23
zyclara .........................................................................47
zyclara pump ...............................................................47
zyflo cr .........................................................................65
zykadia ........................................................................28
zyprexa ........................................................................32
zyprexa relprevv ...........................................................32
zytiga ...........................................................................28
zyvox ...........................................................................16
This formulary was updated on 10/31/2014. For more recent information or other
questions, please contact Priority Health Medicare at toll-free 888.389.6648 or, for
TTY users, 711, 8 a.m. – 8 p.m., 7 days a week, or visit www.prioritymedicare.com.
Priority Health has HMO-POS and PPO plans with a Medicare contract. Enrollment in
Priority Health Medicare depends on contract renewal.
Y0056_1000_1085_10 File and Use 08042014
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