Connecticut 4 Tier Prescription Drug List, effective

Your 2017
Prescription Drug List
Effective January 1, 2017
Oxford Connecticut Four-Tier
Please read: This document contains information about commonly prescribed medications.
This Prescription Drug List (PDL) is accurate as of July 1, 2016 and is subject to change after
this date. The next anticipated update will be in January 2017. Your estimated coverage and
copay/co-insurance may vary based on the benefit plan you choose and the effective date of
the plan. For more information:
Call us at the toll-free phone number on your health plan ID card. TTY users can
dial 711. Si usted necesita ayuda en español llame al número de teléfono en su
tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on
your ID card for help in English and other languages.
Visit oxfordhealth.com, click on the Pharmacies & Prescriptions tab and then
“Online Pharmacy” to log in to the OptumRx1 website and:
• Locate a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
OptumRx is the administrator of your Oxford pharmacy benefit plan.
Note: Diabetic supplies and prescription medications may be subject to different cost-share arrangements.
Specialized non-standard infant formulas and nutritional supplements may be subject to prior authorization.
Please see your Summary of Benefits and Coverage (SBC) for specifics.
1
1
Your Prescription Drug List
This Prescription Drug List (PDL) outlines covered medications and organizes them into cost levels,
also known as tiers. An important part of the PDL is giving you choices so you and your doctor can
choose the best course of treatment for you.
Go to oxfordhealth.com for drug information.
Since the PDL may change, we encourage you to visit our website, oxfordhealth.com. This website is
the best source for accessing up-to-date information about the medications your pharmacy benefit covers,
possible lower-cost options, and cost comparisons.
2
We want to help you better understand your medication
options.
Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To
help you get the most out of your pharmacy benefit, we’ve included some of the most commonly
asked questions about the Prescription Drug List (PDL) below.
What is a Prescription Drug List (PDL)?
This document is a list of covered medications. They are placed into cost levels known as tiers. The PDL
includes both brand-name and generic prescription medications approved by the U.S. Food and Drug
Administration (FDA).
Please note: Where differences are noted between this PDL and your health plan documents, the health
plan documents will rule. Please look at your health plan documents to see what medications are covered
under your health plan. You may also log on to oxfordhealth.com or call us at the toll-free phone
number on your health plan ID card for more information.
How do I use my PDL?
Bring your PDL with you when you see your doctor. When choosing a medication, you and your doctor
should consult this guide. It will help you and your doctor choose the most cost-effective prescription
drugs. This guide will also help you know if a medication has special programs that apply to it.
If your medication is not listed in this guide, please visit oxfordhealth.com or call us at the toll-free
phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español
llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719, 1-888-201-4746, or the
phone number on your ID card for help in English and other languages.
3
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is
determined by your employer or health plan. This is how much you will pay when you fill a prescription.
Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2, 3 or 4, look to see
if there is a Tier 1 option available. You should discuss these options with your doctor.
Check your health plan documents to find your specific pharmacy plan costs.
$
Drug Tier
Includes
Helpful Tips
Tier 1
Lowest Cost
Lower-cost drugs.
Some brand names and
generics are also included.
Use Tier 1 drugs for the lowest
out‑of-pocket costs.
Tier 2
Mid-range Cost
Preferred brands.
Use Tier 2 drugs instead of
Tier 4 drugs to help reduce your
out-of-pocket costs.
Tier 3
Mid-range Cost
Preferred specialty and
non-preferred brands.
Use Tier 3 drugs instead of
Tier 4 drugs to help reduce your
out-of-pocket costs.
Tier 4
Highest Cost
Higher cost brands and
generics.
Non-preferred specialty
and non-preferred brands.
Many Tier 4 drugs have lower‑cost
options in Tier 1, 2 or 3. Ask your
doctor if they could work for you.
Please note: Some plans may have two or four tiers, while others may not have any. If you have a
high deductible health plan, the tier cost levels may apply once you hit your deductible. Refer to your
enrollment and plan materials on oxfordhealth.com, or call us at the toll-free phone number on your
health plan ID card for more information about your health plan.
Diabetic supplies and prescription medications may be subject to different cost-share arrangements.
Please see your Summary of Benefits and Coverage (SBC) for specifics.
When does the PDL change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when a generic becomes available.
• Medications may move to a higher tier or be excluded from coverage most often on
January 1 or July 1.
When a medication changes tiers, you may have to pay a different amount for that medication.
For the most up-to-date list, call us at the toll-free phone number on your health plan ID card.
4
Programs and Limits
Some medications are in one or more of our pharmacy benefit programs. Your health plan determines
how these medications are covered and may differ than what is noted in the PDL.
Health Care Reform (HCR) Preventive – This medication is part of a Health Care Reform
preventive benefit and may be available at no additional cost to you.
Notification or Precertification (sometimes referred to as Prior Authorization) required1 –
Your doctor is required to provide additional information to us to determine coverage.
Supply Limit – Amount of medication covered per copayment or in a specific time period.
Step Therapy – Trial of a lower-cost medication is required before a higher-cost medication is
covered.
1
Depending on your benefit, you may have notification or precertification requirements for select medications.
To learn more about a pharmacy program or to find out if it applies to you, please visit oxfordhealth.com
or call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted
necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1-800-303-6719,
1-888-201-4746, or the phone number on your ID card for help in English and other languages.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same as or
similar to an over-the-counter (OTC) medication.2 There may be other medication options available.
Should I talk to my doctor about over-the-counter (OTC)
medications?
An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your
doctor about available OTC options.
What is the difference between brand-name and generic
medications?
Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA
can approve a generic version with the same active ingredients. These types of medications are known
as generic medications. Sometimes, the same company that makes a brand-name medication also makes
the generic version.
This is not applicable for Connecticut Public Sector plans. For Connecticut commercial business, a prescription drug product that is therapeutically equivalent to an over-the counter
drug may be covered if it is determined to be medically necessary
2
5
What if my doctor writes a prescription for a brand-name
medication?
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic
equivalent or lower-cost option is available and if it might be right for you. Generic medications are
usually your lowest-cost option, but not always. For some health plans, if a brand-name medication is
prescribed and a generic equivalent is available, your share of the cost may be the copayment PLUS the
cost difference between the brand-name medication and its generic equivalent. Visit oxfordhealth.com
to make sure.
Are you taking a specialty medication?
Take advantage of personalized support designed to help you get the most out of your treatment plan.
Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn
more. If you’re taking a specialty medication that is on Tier 4, call us at the toll-free phone number
on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial
assistance program.
What is Mail Service Member Select?
Your plan may include a home delivery program called Mail Service Member Select, which encourages
you to use the OptumRx® Mail Service Pharmacy for medication you take regularly. Choosing home
delivery can help you better manage the medication you take on a regular basis, and may save you time
and money.
You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll from
mail service and continue to fill your maintenance medications at a retail pharmacy. You can get up to
two fills at a retail pharmacy before you have to decide. However, please be aware that you must make a
decision about whether or not to enroll in Mail Service Member Select. If you do nothing and continue
to fill your medications at a retail pharmacy, you may pay more for your medication until you make a
decision and take action. You must confirm your decision every year.
To learn more, you may log on to myuhc.com or call the toll-free member phone number on your health
plan ID card for more information.
6
How do I get updated information about my pharmacy
benefit?
Since the PDL may change during your plan year, we encourage you to visit oxfordhealth.com or call us
at the toll-free phone number on your health plan ID card for more current information.
For more information
Call us at the toll-free phone number on your health plan ID card. TTY users can dial
711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de
identificación, 1-800-303-6719, 1-888-201-4746, or the phone number on your ID
card for help in English and other languages.
Or, visit oxfordhealth.com.
In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.
All branded medications are trademarks or registered trademarks of their respective owners.
Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.
©2016 Oxford Health Plans LLC. All rights reserved.
Created August 1, 2016. January 1, 2017 Prescription Drug List – Oxford Connecticut Advantage Four-Tier
CT-16-354
MT993780.1
7
Therapeutic Class
Product Name
1st Generation/Typical - Mood Disorder Drugs ADASUVE INH 10MG
Tier Value
Tier 3
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ POW HCL
Tier 3
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 100MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 200MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 50MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs COMPRO
Tier 1
SUP 25MG
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE CON 5MG/ML
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE ELX 2.5/5ML
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 2.5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL CON 2MG/ML
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 0.5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 20MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 50MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs LOXAPINE
CAP 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs ORAP
TAB 1MG
Tier 4
1st Generation/Typical - Mood Disorder Drugs ORAP
TAB 2MG
Tier 4
1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 16MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 2MG
Tier 1
Page 1 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Product Name
1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 4MG
Tier Value
Tier 1
1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 8MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PIMOZIDE
TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PIMOZIDE
TAB 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PROCHLORPER SUP 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PROCHLORPER TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs PROCHLORPER TAB 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 100MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 25MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 50MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 5MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 10MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 1MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 2MG
Tier 1
1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 5MG
Tier 1
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
ABILIFY
SOL 1MG/ML
Tier 4
ABILIFY
TAB 10MG
Tier 4
X
X
X
ABILIFY
TAB 15MG
Tier 4
X
X
X
ABILIFY
TAB 20MG
Tier 4
X
X
X
ABILIFY
TAB 2MG
Tier 4
X
X
X
ABILIFY
TAB 30MG
Tier 4
X
X
X
ABILIFY
TAB 5MG
Tier 4
X
X
X
ABILIFY DISC TAB 10MG
Tier 4
X
ABILIFY DISC TAB 15MG
Tier 4
X
ARIPIPRAZOLE SOL 1MG/ML
Tier 1
Page 2 of 279
Specialty
Therapeutic Class
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
Product Name
ARIPIPRAZOLE TAB 10MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
ARIPIPRAZOLE TAB 10MG ODT
Tier 1
X
ARIPIPRAZOLE TAB 15MG
Tier 1
X
ARIPIPRAZOLE TAB 15MG ODT
Tier 1
X
ARIPIPRAZOLE TAB 20MG
Tier 1
X
ARIPIPRAZOLE TAB 2MG
Tier 1
X
ARIPIPRAZOLE TAB 30MG
Tier 1
X
ARIPIPRAZOLE TAB 5MG
Tier 1
X
FANAPT
PAK
Tier 3
X
FANAPT
TAB 10MG
Tier 4
X
FANAPT
TAB 12MG
Tier 4
X
FANAPT
TAB 1MG
Tier 4
X
FANAPT
TAB 2MG
Tier 4
X
FANAPT
TAB 4MG
Tier 4
X
FANAPT
TAB 6MG
Tier 4
X
FANAPT
TAB 8MG
Tier 4
X
Step
Therapy
GEODON
CAP 20MG
Tier 4
X
X
GEODON
CAP 40MG
Tier 4
X
X
GEODON
CAP 60MG
Tier 4
X
X
GEODON
CAP 80MG
Tier 4
X
X
INVEGA
TAB 1.5MG
Tier 4
X
X
INVEGA
TAB 3MG
Tier 4
X
X
INVEGA
TAB 6MG
Tier 4
X
X
INVEGA
TAB 9MG
Tier 4
X
X
LATUDA
TAB 120MG
Tier 4
X
LATUDA
TAB 20MG
Tier 4
X
LATUDA
TAB 40MG
Tier 4
X
LATUDA
TAB 60MG
Tier 4
X
LATUDA
TAB 80MG
Tier 4
X
Page 3 of 279
Specialty
Therapeutic Class
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
Product Name
OLANZAPINE TAB 10MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
Step
Therapy
OLANZAPINE TAB 10MG ODT
Tier 1
X
OLANZAPINE TAB 15MG
Tier 1
X
OLANZAPINE TAB 15MG ODT
Tier 1
X
OLANZAPINE TAB 2.5MG
Tier 1
X
OLANZAPINE TAB 20MG
Tier 1
X
OLANZAPINE TAB 20MG ODT
Tier 1
X
OLANZAPINE TAB 5MG
Tier 1
X
OLANZAPINE TAB 5MG ODT
Tier 1
X
OLANZAPINE TAB 7.5MG
Tier 1
X
PALIPERIDONE TAB ER 1.5MG
Tier 1
X
PALIPERIDONE TAB ER 3MG
Tier 1
X
PALIPERIDONE TAB ER 6MG
Tier 1
X
PALIPERIDONE TAB ER 9MG
Tier 1
X
QUETIAPINE TAB 100MG
Tier 1
QUETIAPINE TAB 200MG
Tier 1
QUETIAPINE TAB 25MG
Tier 1
QUETIAPINE TAB 300MG
Tier 1
QUETIAPINE TAB 400MG
Tier 1
QUETIAPINE TAB 50MG
Tier 1
RISPERDAL SOL 1MG/ML
Tier 4
X
RISPERDAL TAB 0.25MG
Tier 4
X
RISPERDAL TAB 0.5MG
Tier 4
X
RISPERDAL TAB 1MG
Tier 4
X
RISPERDAL TAB 2MG
Tier 4
X
RISPERDAL TAB 3MG
Tier 4
X
RISPERDAL TAB 4MG
Tier 4
X
RISPERDAL M TAB 0.5MG
Tier 4
X
RISPERDAL M TAB 1MG
Tier 4
X
Page 4 of 279
Specialty
Therapeutic Class
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
X
Product Name
RISPERDAL M TAB 2MG
Tier Value
Tier 4
RISPERDAL M TAB 3MG
Tier 4
X
RISPERDAL M TAB 4MG
Tier 3
X
RISPERIDONE SOL 1MG/ML
Tier 1
RISPERIDONE TAB 0.25 ODT
Tier 1
RISPERIDONE TAB 0.25MG
Tier 1
RISPERIDONE TAB 0.5MG
Tier 1
RISPERIDONE TAB 0.5MG OD
Tier 1
RISPERIDONE TAB 1MG
Tier 1
RISPERIDONE TAB 1MG ODT
Tier 1
RISPERIDONE TAB 2MG
Tier 1
RISPERIDONE TAB 2MG ODT
Tier 1
RISPERIDONE TAB 3MG
Tier 1
RISPERIDONE TAB 3MG ODT
Tier 1
RISPERIDONE TAB 4MG
Tier 1
RISPERIDONE TAB 4MG ODT
Tier 1
SAPHRIS
SUB 10MG
Tier 3
SAPHRIS
SUB 2.5MG
Tier 3
SAPHRIS
SUB 5MG
Tier 3
X
X
SEROQUEL
TAB 100MG
Tier 4
X
SEROQUEL
TAB 200MG
Tier 4
X
SEROQUEL
TAB 25MG
Tier 4
X
SEROQUEL
TAB 300MG
Tier 4
X
SEROQUEL
TAB 400MG
Tier 4
X
SEROQUEL
TAB 50MG
Tier 4
X
SEROQUEL XR TAB 150MG
Tier 4
X
SEROQUEL XR TAB 200MG
Tier 4
X
SEROQUEL XR TAB 300MG
Tier 4
X
SEROQUEL XR TAB 400MG
Tier 4
X
Page 5 of 279
Specialty
Prior
Authorization
Supply
Limit
X
Step
Therapy
Therapeutic Class
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
2nd Generation/Atypical - Mood Disorder
Drugs
Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants
Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants
Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants
Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants
Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants
Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants
Alcohol Deterrents/Anti-craving Antidotes/Deterrents/Protectants
Alkylating Agents - Chemotherapy Agents
Product Name
SEROQUEL XR TAB 50MG
Tier Value
Tier 4
ZIPRASIDONE CAP 20MG
Tier 1
X
ZIPRASIDONE CAP 40MG
Tier 1
X
ZIPRASIDONE CAP 60MG
Tier 1
X
ZIPRASIDONE CAP 80MG
Tier 1
X
ZYPREXA
TAB 10MG
Tier 4
X
X
ZYPREXA
TAB 15MG
Tier 4
X
X
ZYPREXA
TAB 2.5MG
Tier 4
X
X
ZYPREXA
TAB 20MG
Tier 4
X
X
ZYPREXA
TAB 5MG
Tier 4
X
X
ZYPREXA
TAB 7.5MG
Tier 4
X
X
ZYPREXA ZYDI TAB 10MG
Tier 4
X
X
ZYPREXA ZYDI TAB 15MG
Tier 4
X
X
ZYPREXA ZYDI TAB 20MG
Tier 4
X
X
ZYPREXA ZYDI TAB 5MG
Tier 4
X
X
ACAMPRO CAL TAB 333MG
Tier 1
ANTABUSE
TAB 250MG
Tier 4
ANTABUSE
TAB 500MG
Tier 4
DISULFIRAM TAB 250MG
Tier 1
DISULFIRAM TAB 500MG
Tier 1
NALTREXONE TAB 50MG
Tier 1
REVIA
Tier 4
Alkylating Agents - Chemotherapy Agents
ALKERAN
TAB 50MG
TAB 2MG
Specialty
Tier 3
X
CYCLOPHOSPH CAP 25MG
Tier 3
X
Alkylating Agents - Chemotherapy Agents
CYCLOPHOSPH CAP 50MG
Tier 3
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 100MG
Tier 4
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 10MG
Tier 4
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 40MG
Tier 4
X
Alkylating Agents - Chemotherapy Agents
GLEOSTINE CAP 5MG
Tier 4
X
Page 6 of 279
Therapeutic Class
Alkylating Agents - Chemotherapy Agents
Product Name
HEXALEN CAP 50MG
Alkylating Agents - Chemotherapy Agents
LEUKERAN
Alkylating Agents - Chemotherapy Agents
TAB 2MG
Tier Value
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
Tier 3
X
LOMUSTINE CAP 100MG
Tier 1
X
Alkylating Agents - Chemotherapy Agents
LOMUSTINE CAP 10MG
Tier 1
X
Alkylating Agents - Chemotherapy Agents
LOMUSTINE CAP 40MG
Tier 1
X
Alkylating Agents - Chemotherapy Agents
MATULANE
Tier 3
X
Alkylating Agents - Chemotherapy Agents
MYLERAN
TAB 2MG
Tier 3
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 100MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 140MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 180MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 20MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 250MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMODAR
CAP 5MG
Tier 4
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 100MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 140MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 180MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 20MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 250MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
TEMOZOLOMIDE CAP 5MG
Tier 1
X
X
Alkylating Agents - Chemotherapy Agents
VALCHLOR
GEL 0.016%
Tier 3
X
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
CATAPRES
TAB 0.1MG
Tier 4
CATAPRES
TAB 0.2MG
Tier 4
CATAPRES
TAB 0.3MG
Tier 4
CAP 50MG
CATAPRES-TTS DIS 0.1/24HR
Tier 4
CATAPRES-TTS DIS 0.2/24HR
Tier 4
CATAPRES-TTS DIS 0.3/24HR
Tier 4
CLONIDINE DIS 0.1/24HR
Tier 1
CLONIDINE DIS 0.2/24HR
Tier 1
CLONIDINE DIS 0.3/24HR
Tier 1
Page 7 of 279
X
X
Therapeutic Class
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Agonists - Blood Pressure
Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Alpha-Adrenergic Blocking Agents - Blood
Pressure Drugs
Product Name
CLONIDINE TAB 0.1MG
Tier Value
Tier 1
CLONIDINE TAB 0.2MG
Tier 1
CLONIDINE TAB 0.3MG
Tier 1
CLORPRES
TAB 0.1-15MG
Tier 2
CLORPRES
TAB 0.2-15MG
Tier 2
CLORPRES
TAB 0.3-15MG
Tier 2
GUANFACINE TAB 1MG
Tier 1
GUANFACINE TAB 2MG
Tier 1
METHYLD/HCTZ TAB 250/15
Tier 1
METHYLD/HCTZ TAB 250/25
Tier 1
METHYLDOPA TAB 250MG
Tier 1
METHYLDOPA TAB 500MG
Tier 1
MIDODRINE TAB 10MG
Tier 1
MIDODRINE TAB 2.5MG
Tier 1
MIDODRINE TAB 5MG
Tier 1
TENEX
TAB 1MG
Tier 3
TENEX
TAB 2MG
Tier 3
CARDURA XL TAB 4MG
Tier 3
CARDURA XL TAB 8MG
Tier 3
DIBENZYLINE CAP 10MG
Tier 4
MINIPRESS CAP 1MG
Tier 4
MINIPRESS CAP 2MG
Tier 4
MINIPRESS CAP 5MG
Tier 4
PHENOXYBENZA CAP 10MG
Tier 1
PRAZOSIN HCL CAP 1MG
Tier 1
PRAZOSIN HCL CAP 2MG
Tier 1
PRAZOSIN HCL CAP 5MG
Tier 1
RESERPINE TAB 0.1MG
Tier 1
RESERPINE TAB 0.25MG
Tier 1
Page 8 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
Specialty
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Product Name
BETHKIS NEB 300/4ML
GARAMYCIN SOL 0.3% OP
GENTAK
OIN 0.3% OP
GENTAMICIN CRE 0.1%
GENTAMICIN OIN 0.1%
GENTAMICIN OIN 0.3% OP
GENTAMICIN SOL 0.3% OP
KITABIS PAK NEB 300/5ML
NEOMYCIN TAB 500MG
PAROMOMYCIN CAP 250MG
Tier Value
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
TOBI
NEB 300/5ML
TOBI PODHALR CAP 28MG
TOBRAMYCIN NEB 300/5ML
Tier 4
Tier 4
Tier 1
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminoglycosides - Antibiotics
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Aminosalicylates - Inflammatory Bowel
Disease Drugs
Anabolic Steroids - Hormone
Replacement/Modifying Drugs
Anabolic Steroids - Hormone
Replacement/Modifying Drugs
Anabolic Steroids - Hormone
Replacement/Modifying Drugs
Anabolic Steroids - Hormone
Replacement/Modifying Drugs
TOBRAMYCIN SOL 0.3% OP
TOBREX
OIN 0.3% OP
TOBREX
SOL 0.3% OP
APRISO
CAP 0.375GM
Tier 1
Tier 3
Tier 4
Tier 2
ASACOL HD TAB 800MG
Tier 4
BALSALAZIDE CAP 750MG
Tier 1
CANASA
SUP 1000MG
Tier 2
COLAZAL
CAP 750MG
Tier 4
X
DELZICOL
CAP 400MG
Tier 4
X
DIPENTUM
CAP 250MG
X
X
Tier 3
GIAZO
TAB 1.1GM
Tier 4
LIALDA
TAB 1.2GM
Tier 2
X
MESALAMINE ENE 4GM
Tier 1
MESALAMINE KIT 4GM
Tier 1
MESALAMINE TAB 800MG DR
Tier 4
X
PENTASA
CAP 250MG CR
Tier 4
X
PENTASA
CAP 500MG CR
Tier 4
X
ROWASA
KIT 4GM
Tier 4
SFROWASA
ENE 4GM
Tier 4
ANADROL-50 TAB 50MG
Tier 3
OXANDRIN
TAB 10MG
Tier 4
OXANDRIN
TAB 2.5MG
Tier 3
OXANDROLONE TAB 10MG
Page 9 of 279
Tier 1
X
X
Specialty
X
Supply
Limit
Step
Therapy
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
X
X
X
CAPACET CAP
ESGIC
CAP
ESGIC
TAB
FIORICET CAP
FIORINAL CAP
GRALISE TAB 300MG
GRALISE TAB 600MG
GRALISE STAR MIS 300/600
MARGESIC CAP
MARTEN-TAB TAB 50-325MG
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
X
X
X
X
TENCON
TAB 50-325MG
VANATOL LQ SOL
ZEBUTAL CAP
ANDRODERM DIS 2MG/24HR
Tier 1
Tier 1
Tier 1
Tier 2
X
X
X
X
ANDRODERM DIS 4MG/24HR
Tier 2
X
X
ANDROGEL
GEL 1%(25MG)
Tier 4
X
X
X
ANDROGEL
GEL 1%(50MG)
Tier 4
X
X
X
ANDROGEL
GEL 1.62%
Tier 4
X
X
X
ANDROGEL
GEL 1.62%
Tier 4
X
X
X
ANDROGEL
GEL 1.62%
Tier 4
X
X
X
ANDROGEL
GEL PUMP 1%
Tier 4
X
X
X
X
X
X
Therapeutic Class
Anabolic Steroids - Hormone
Replacement/Modifying Drugs
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Product Name
OXANDROLONE TAB 2.5MG
ALAGESIC LQ SOL
ALLZITAL TAB 25-325MG
BUPAP
TAB 50-300MG
BUT/APAP/CAF CAP
BUT/APAP/CAF CAP
BUT/APAP/CAF TAB
BUT/ASA/CAFF CAP
BUTAL/APAP TAB 50-325MG
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Analgesics - Miscellaneous Analgesics
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Tier Value
Tier 1
ANDROID
CAP 10MG
Tier 4
ANDROXY
TAB 10MG
Tier 1
AXIRON
SOL 30MG/ACT
Tier 4
DANAZOL
CAP 100MG
Tier 1
DANAZOL
CAP 200MG
Tier 1
DANAZOL
CAP 50MG
Tier 1
DEPO-TESTOST INJ 100MG/ML
Tier 3
DEPO-TESTOST INJ 200MG/ML
Tier 4
Page 10 of 279
Prior
Authorization
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Androgens - Hormone
Replacement/Modifying Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Tier Value
Tier 3
Prior
Authorization
X
FIRST-TESTOS OIN 2%
Tier 3
X
FORTESTA
Tier 4
Product Name
FIRST-TESTOS CRE MC 2%
GEL 10MG/ACT
Supply
Limit
Step
Therapy
X
X
X
X
METHITEST TAB 10MG
Tier 2
METHYLTESTOS CAP 10MG
Tier 1
NATESTO
Tier 4
X
X
GEL 5.5MG
STRIANT
MIS 30MG
Tier 3
X
X
TESTIM
GEL 1%(50MG)
Tier 2
X
X
TESTOST CYP INJ 100MG/ML
Tier 1
TESTOST CYP INJ 200MG/ML
Tier 1
TESTOST ENAN INJ 200MG/ML
Tier 1
TESTOSTERONE GEL 1%(25MG)
Tier 1
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 4
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 4
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 1
X
X
X
TESTOSTERONE GEL 1%(50MG)
Tier 3
X
X
X
TESTOSTERONE GEL
10MG/ACT
TESTOSTERONE GEL PUMP 1%
Tier 4
X
X
X
Tier 4
X
X
X
TESTOSTERONE GEL PUMP 1%
Tier 3
X
X
X
TESTOSTERONE GEL PUMP 1%
Tier 1
X
X
X
TESTOSTERONE GEL PUMP 1%
Tier 4
X
X
X
TESTOSTERONE INJ 250MG/ML
Tier 3
TESTRED
Tier 4
CAP 10MG
VOGELXO
GEL 1%(50MG)
Tier 4
X
X
X
VOGELXO
GEL PUMP 1%
Tier 4
X
X
X
ATACAND
TAB 16MG
Tier 4
X
ATACAND
TAB 32MG
Tier 4
X
ATACAND
TAB 4MG
Tier 4
X
ATACAND
TAB 8MG
Tier 4
X
Page 11 of 279
Specialty
Therapeutic Class
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Prior
Authorization
Supply
Limit
X
Step
Therapy
Product Name
ATACAND HCT TAB 16-12.5
Tier Value
Tier 4
ATACAND HCT TAB 32-12.5
Tier 4
X
ATACAND HCT TAB 32-25MG
Tier 4
X
AVALIDE
TAB 150-12.5
Tier 4
X
AVALIDE
TAB 300-12.5
Tier 4
X
AVAPRO
TAB 150MG
Tier 4
X
AVAPRO
TAB 300MG
Tier 4
X
AVAPRO
TAB 75MG
Tier 4
X
BENICAR
TAB 20MG
Tier 2
X
BENICAR
TAB 40MG
Tier 2
X
BENICAR
TAB 5MG
Tier 2
X
BENICAR HCT TAB 20-12.5
Tier 2
X
BENICAR HCT TAB 40-12.5
Tier 2
X
BENICAR HCT TAB 40-25MG
Tier 2
X
CANDESA/HCTZ TAB 16-12.5
Tier 1
X
CANDESA/HCTZ TAB 32-12.5
Tier 1
X
CANDESA/HCTZ TAB 32-25MG
Tier 1
X
CANDESARTAN TAB 16MG
Tier 1
X
CANDESARTAN TAB 32MG
Tier 1
X
CANDESARTAN TAB 4MG
Tier 1
X
CANDESARTAN TAB 8MG
Tier 1
X
COZAAR
TAB 100MG
Tier 4
COZAAR
TAB 25MG
Tier 4
COZAAR
TAB 50MG
Tier 4
DIOVAN
TAB 160MG
Tier 3
X
X
DIOVAN
TAB 320MG
Tier 3
X
X
DIOVAN
TAB 40MG
Tier 3
X
X
DIOVAN
TAB 80MG
Tier 3
X
X
Tier 4
X
X
DIOVAN HCT TAB 160-12.5
Page 12 of 279
Specialty
Therapeutic Class
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Product Name
DIOVAN HCT TAB 160-25MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
DIOVAN HCT TAB 320-12.5
Tier 4
X
X
DIOVAN HCT TAB 320-25MG
Tier 4
X
X
DIOVAN HCT TAB 80/12.5
Tier 4
X
X
EDARBI
TAB 40MG
Tier 3
X
EDARBI
TAB 80MG
Tier 3
X
EDARBYCLOR TAB 40-12.5
Tier 3
X
EDARBYCLOR TAB 40-25MG
Tier 3
X
EPROSART MES TAB 600MG
Tier 1
X
HYZAAR
TAB 100-12.5
Tier 4
HYZAAR
TAB 100-25
Tier 4
HYZAAR
TAB 50-12.5
Tier 4
IRBESAR/HCTZ TAB 150-12.5
Tier 1
X
IRBESAR/HCTZ TAB 300-12.5
Tier 1
X
IRBESARTAN TAB 150MG
Tier 1
X
IRBESARTAN TAB 300MG
Tier 1
X
IRBESARTAN TAB 75MG
Tier 1
X
LOSARTAN POT TAB 100MG
Tier 1
LOSARTAN POT TAB 25MG
Tier 1
LOSARTAN POT TAB 50MG
Tier 1
LOSARTAN/HCT TAB 100-12.5
Tier 1
LOSARTAN/HCT TAB 100-25
Tier 1
LOSARTAN/HCT TAB 50-12.5
Tier 1
MICARDIS
TAB 20MG
Tier 4
X
X
MICARDIS
TAB 40MG
Tier 4
X
X
MICARDIS
TAB 80MG
Tier 4
X
X
MICARDIS HCT TAB 40/12.5
Tier 4
X
X
MICARDIS HCT TAB 80/12.5
Tier 4
X
X
MICARDIS HCT TAB 80-25MG
Tier 4
X
X
Page 13 of 279
Specialty
Therapeutic Class
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin II Receptor Antagonists - Blood
Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Prior
Authorization
Supply
Limit
X
Product Name
TELMISA/HCTZ TAB 40-12.5
Tier Value
Tier 1
TELMISA/HCTZ TAB 80-12.5
Tier 1
X
TELMISA/HCTZ TAB 80-25MG
Tier 1
X
TELMISARTAN TAB 20MG
Tier 1
X
TELMISARTAN TAB 40MG
Tier 1
X
TELMISARTAN TAB 80MG
Tier 1
X
TEVETEN HCT TAB 600-25MG
Tier 3
X
VALSART/HCTZ TAB 160-12.5
Tier 1
X
VALSART/HCTZ TAB 160-25MG
Tier 1
X
VALSART/HCTZ TAB 320-12.5
Tier 1
X
VALSART/HCTZ TAB 320-25MG
Tier 1
X
VALSART/HCTZ TAB 80-12.5
Tier 1
X
VALSARTAN TAB 160MG
Tier 1
X
VALSARTAN TAB 320MG
Tier 1
X
VALSARTAN TAB 40MG
Tier 1
X
VALSARTAN TAB 80MG
Tier 1
X
ACCUPRIL
TAB 10MG
Tier 4
ACCUPRIL
TAB 20MG
Tier 4
ACCUPRIL
TAB 40MG
Tier 4
ACCUPRIL
TAB 5MG
Tier 4
ACCURETIC TAB 10-12.5
Tier 4
ACCURETIC TAB 20-12.5
Tier 4
ACCURETIC TAB 20-25MG
Tier 4
ACEON
TAB 4MG
Tier 4
ACEON
TAB 8MG
Tier 4
ALTACE
CAP 1.25MG
Tier 4
ALTACE
CAP 10MG
Tier 4
ALTACE
CAP 2.5MG
Tier 4
ALTACE
CAP 5MG
Tier 4
Page 14 of 279
Step
Therapy
Specialty
Therapeutic Class
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Product Name
BENAZEP/HCTZ TAB 10-12.5
Tier Value
Tier 1
BENAZEP/HCTZ TAB 20-12.5
Tier 1
BENAZEP/HCTZ TAB 20-25MG
Tier 1
BENAZEP/HCTZ TAB 5-6.25
Tier 1
BENAZEPRIL TAB 10MG
Tier 1
BENAZEPRIL TAB 20MG
Tier 1
BENAZEPRIL TAB 40MG
Tier 1
BENAZEPRIL TAB 5MG
Tier 1
CAPTOPR/HCTZ TAB 25-15MG
Tier 1
CAPTOPR/HCTZ TAB 25-25MG
Tier 1
CAPTOPR/HCTZ TAB 50-15MG
Tier 1
CAPTOPR/HCTZ TAB 50-25MG
Tier 1
CAPTOPRIL TAB 100MG
Tier 1
CAPTOPRIL TAB 12.5MG
Tier 1
CAPTOPRIL TAB 25MG
Tier 1
CAPTOPRIL TAB 50MG
Tier 1
ENALAPR/HCTZ TAB 10-25MG
Tier 1
ENALAPR/HCTZ TAB 5-12.5MG
Tier 1
ENALAPRIL TAB 10MG
Tier 1
ENALAPRIL TAB 2.5MG
Tier 1
ENALAPRIL TAB 20MG
Tier 1
ENALAPRIL TAB 5MG
Tier 1
EPANED
Tier 4
SOL 1MG/ML
FOSINOP/HCTZ TAB 10/12.5
Tier 1
FOSINOP/HCTZ TAB 20/12.5
Tier 1
FOSINOPRIL TAB 10MG
Tier 1
FOSINOPRIL TAB 20MG
Tier 1
FOSINOPRIL TAB 40MG
Tier 1
LISINOP/HCTZ TAB 10-12.5
Tier 1
Page 15 of 279
Prior
Authorization
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Product Name
LISINOP/HCTZ TAB 20-12.5
Tier Value
Tier 1
LISINOP/HCTZ TAB 20-25MG
Tier 1
LISINOPRIL TAB 10MG
Tier 1
LISINOPRIL TAB 2.5MG
Tier 1
LISINOPRIL TAB 20MG
Tier 1
LISINOPRIL TAB 30MG
Tier 1
LISINOPRIL TAB 40MG
Tier 1
LISINOPRIL TAB 5MG
Tier 1
LOTENSIN
TAB 10MG
Tier 4
LOTENSIN
TAB 20MG
Tier 4
LOTENSIN
TAB 40MG
Tier 4
LOTENSIN HCT TAB 10-12.5
Tier 4
LOTENSIN HCT TAB 20-12.5
Tier 4
LOTENSIN HCT TAB 20-25MG
Tier 4
MAVIK
TAB 1MG
Tier 4
MAVIK
TAB 2MG
Tier 4
MAVIK
TAB 4MG
Tier 4
MOEXIPR/HCTZ TAB 15-12.5
Tier 1
MOEXIPR/HCTZ TAB 15-25MG
Tier 1
MOEXIPR/HCTZ TAB 7.5-12.5
Tier 1
MOEXIPRIL TAB 15MG
Tier 1
MOEXIPRIL TAB 7.5MG
Tier 1
PERINDOPRIL TAB 2MG
Tier 1
PERINDOPRIL TAB 4MG
Tier 1
PERINDOPRIL TAB 8MG
Tier 1
PRINIVIL
TAB 10MG
Tier 4
PRINIVIL
TAB 20MG
Tier 4
PRINIVIL
TAB 5MG
Tier 4
QBRELIS
SOL 1MG/ML
Tier 4
Page 16 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
Specialty
Therapeutic Class
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Product Name
QNAPRIL/HCTZ TAB 10-12.5
Tier Value
Tier 1
QNAPRIL/HCTZ TAB 20-12.5
Tier 1
QNAPRIL/HCTZ TAB 20-25MG
Tier 1
QUINAPRIL TAB 10MG
Tier 1
QUINAPRIL TAB 20MG
Tier 1
QUINAPRIL TAB 40MG
Tier 1
QUINAPRIL TAB 5MG
Tier 1
RAMIPRIL
CAP 1.25MG
Tier 1
RAMIPRIL
CAP 10MG
Tier 1
RAMIPRIL
CAP 2.5MG
Tier 1
RAMIPRIL
CAP 5MG
Tier 1
TARKA
TAB 1-240 CR
Tier 4
TARKA
TAB 2-180 CR
Tier 4
TARKA
TAB 2-240 CR
Tier 4
TARKA
TAB 4-240 CR
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
TRANDO/VERAP TAB 1-240 CR
Tier 1
TRANDO/VERAP TAB 1-240 ER
Tier 1
TRANDO/VERAP TAB 2-180 CR
Tier 1
TRANDO/VERAP TAB 2-180 ER
Tier 1
TRANDO/VERAP TAB 2-240 CR
Tier 1
TRANDO/VERAP TAB 2-240 ER
Tier 1
TRANDO/VERAP TAB 4-240 CR
Tier 1
TRANDO/VERAP TAB 4-240 ER
Tier 1
TRANDOLAPRIL TAB 1MG
Tier 1
TRANDOLAPRIL TAB 2MG
Tier 1
TRANDOLAPRIL TAB 4MG
Tier 1
VASERETIC TAB 10-25MG
Tier 4
X
VASOTEC
TAB 10MG
Tier 4
X
VASOTEC
TAB 2.5MG
Tier 4
X
Page 17 of 279
Specialty
Therapeutic Class
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Angiotensin-converting Enzyme (ACE)
Inhibitors - Blood Pressure Drugs
Anthelmintics - Worm Infection Drugs
Anthelmintics - Worm Infection Drugs
Anthelmintics - Worm Infection Drugs
Anthelmintics - Worm Infection Drugs
Antiandrogens - Hormone Suppressants
Antiandrogens - Hormone Suppressants
Antiandrogens - Hormone Suppressants
Antiandrogens - Hormone Suppressants
Antiandrogens - Hormone Suppressants
Antiandrogens - Hormone Suppressants
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiangiogenic Agents - Chemotherapy
Agents
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Product Name
VASOTEC TAB 20MG
VASOTEC
TAB 5MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
X
Tier 4
X
ZESTORETIC TAB 10-12.5
Tier 4
X
ZESTORETIC TAB 20-12.5
Tier 4
X
ZESTORETIC TAB 20-25MG
Tier 4
X
ZESTRIL
TAB 10MG
Tier 4
X
ZESTRIL
TAB 2.5MG
Tier 4
X
ZESTRIL
TAB 20MG
Tier 4
X
ZESTRIL
TAB 30MG
Tier 4
X
ZESTRIL
TAB 40MG
Tier 4
X
ZESTRIL
TAB 5MG
Tier 4
X
Specialty
ALBENZA TAB 200MG
BILTRICIDE TAB 600MG
EMVERM
CHW 100MG
IVERMECTIN TAB 3MG
BICALUTAMIDE TAB 50MG
CASODEX TAB 50MG
FLUTAMIDE CAP 125MG
NILANDRON TAB 150MG
NILUTAMIDE TAB 150MG
XTANDI
CAP 40MG
CAPRELSA TAB 100MG
Tier 2
Tier 2
Tier 4
Tier 1
Tier 1
Tier 4
Tier 1
Tier 4
Tier 1
Tier 4
Tier 3
X
X
X
X
CAPRELSA
TAB 300MG
Tier 3
X
X
X
REVLIMID
CAP 10MG
Tier 3
X
X
X
REVLIMID
CAP 15MG
Tier 3
X
X
X
REVLIMID
CAP 2.5MG
Tier 3
X
X
X
REVLIMID
CAP 20MG
Tier 3
X
X
X
REVLIMID
CAP 25MG
Tier 3
X
X
X
REVLIMID
CAP 5MG
Tier 3
X
X
X
X
X
X
X
X
X
X
X
X
THALOMID
CAP 100MG
Tier 3
X
X
X
THALOMID
CAP 150MG
Tier 3
X
X
X
THALOMID
CAP 200MG
Tier 3
X
X
X
THALOMID
CAP 50MG
Tier 3
X
X
X
AMIODARONE TAB 100MG
AMIODARONE TAB 200MG
Page 18 of 279
Tier 1
Tier 1
Therapeutic Class
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Tier Value
Tier 1
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 2
Tier 4
Tier 2
Tier 3
Tier 1
Tier 3
Tier 1
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Product Name
AMIODARONE TAB 400MG
BETAPACE TAB 120MG
BETAPACE TAB 160MG
BETAPACE TAB 80MG
BETAPACE AF TAB 120MG
BETAPACE AF TAB 160MG
BETAPACE AF TAB 80MG
CORDARONE TAB 200MG
DISOPYRAMIDE CAP 100MG
DISOPYRAMIDE CAP 150MG
DOFETILIDE CAP 125MCG
DOFETILIDE CAP 250MCG
DOFETILIDE CAP 500MCG
FLECAINIDE TAB 100MG
FLECAINIDE TAB 150MG
FLECAINIDE TAB 50MG
MEXILETINE CAP 150MG
MEXILETINE CAP 200MG
MEXILETINE CAP 250MG
MULTAQ
TAB 400MG
NORPACE CAP 100MG
NORPACE CAP 100MG CR
NORPACE CAP 150MG
NORPACE CAP 150MG CR
PACERONE TAB 100MG
PACERONE TAB 200MG
PACERONE TAB 400MG
PROPAFENONE CAP 225MG
ER
PROPAFENONE CAP 325MG
ER
PROPAFENONE CAP 425MG
SR
PROPAFENONE TAB 150MG
PROPAFENONE TAB 225MG
PROPAFENONE TAB 300MG
QUINIDINE GL TAB 324MG CR
Antiarrhythmics - Heart Regulation Drugs
QUINIDINE GL TAB 324MG ER
Tier 1
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
QUINIDINE SU TAB 200MG
QUINIDINE SU TAB 300MG
QUINIDINE SU TAB 300MG ER
Tier 1
Tier 1
Tier 1
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
RYTHMOL TAB 150MG
RYTHMOL TAB 225MG
RYTHMOL SR CAP 225MG
RYTHMOL SR CAP 325MG
RYTHMOL SR CAP 425MG
SOTALOL AF TAB 120MG
SOTALOL AF TAB 160MG
SOTALOL AF TAB 80MG
SOTALOL HCL TAB 120MG
SOTALOL HCL TAB 160MG
SOTALOL HCL TAB 240MG
SOTALOL HCL TAB 80MG
SOTYLIZE SOL 5MG/ML
TIKOSYN CAP 125MCG
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Page 19 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
X
Specialty
Therapeutic Class
Antiarrhythmics - Heart Regulation Drugs
Antiarrhythmics - Heart Regulation Drugs
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Prior
Authorization
Supply
Limit
Tier Value
Tier 4
Tier 4
Tier 1
Tier 3
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Product Name
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
AK-POLY-BAC OIN OP
ALCOH-GLOVE PAD
CONTOURE
ALCOHOL PREP PAD
ALCOHOL PREP PAD 70%
ALCOHOL PREP PAD 70%
ALCOHOL PREP PAD 70%
ALCOHOL PREP PAD 70%
ALCOHOL PREP PAD MED 70%
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
ALCOHOL SWAB PAD
ALCOH-WIPE PAD 12"X12"
ALTABAX OIN 1%
AZUPHEN MB CAP 120MG
BACIT/POLYMY OIN OP
BACITRACIN OIN OP
BACTROBAN CRE 2%
BACTROBAN OIN 2%
BACTROBAN OIN NASAL 2%
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 3
Tier 4
Tier 2
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
CENTANY OIN 2%
CENTANY AT KIT 2%
CLEOCIN CAP 150MG
CLEOCIN CAP 300MG
CLEOCIN CAP 75MG
CLEOCIN CRE 2% VAG
CLEOCIN SUP 100MG
CLEOCIN PED SOL 75MG/5ML
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 4
Tier 2
Tier 4
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
CAP 150MG
CAP 300MG
CAP 75MG
CRE 2% VAG
SOL 75MG/5ML
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
CLINDESSE CRE 2%
COLISTIMETH INJ 150MG
COLY-MYCIN M INJ 150MG
CORTISPORIN CRE 0.5%
CORTISPORIN OIN 1%
FLAGYL
CAP 375MG
FLAGYL
TAB 250MG
FLAGYL
TAB 500MG
FLAGYL ER TAB 750MG
FURADANTIN SUS 25MG/5ML
Tier 2
Tier 1
Tier 4
Tier 2
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
GNP ALCOHOL PAD SWABS
HIPREX
TAB 1GM
HYOLEV MB TAB 81MG
HYOPHEN TAB
INDIOMIN MB CAP 120MG
IODINE
TIN 2%
LANSOPR/AMOX MIS /CLARITH
Tier 3
Tier 4
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
X
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
LINEZOLID SUS 100/5ML
LINEZOLID TAB 600MG
Tier 1
Tier 1
X
X
Page 20 of 279
Step
Therapy
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 3
X
X
X
X
Specialty
Therapeutic Class
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Product Name
LUGOLS
SOL STRONG
MACROBID CAP 100MG
MACRODANTIN CAP 100MG
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
MACRODANTIN CAP 25MG
MACRODANTIN CAP 50MG
ME/NAPHOS/MB TAB HYO 1
METHENAM HIP TAB 1GM
METHENAM MAN TAB
1000MG
METHENAM MAN TAB 1GM
METHENAM MAN TAB 500MG
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
METROCREAM CRE 0.75%
METROGEL GEL 1%
METROGEL-VAG GEL 0.75%
METROLOTION LOT 0.75%
METRONIDAZOL CAP 375MG
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Tier 1
Tier 1
Tier 1
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
METRONIDAZOL CRE 0.75%
METRONIDAZOL GEL 0.75%
METRONIDAZOL GEL
0.75%VAG
METRONIDAZOL GEL 1%
METRONIDAZOL LOT 0.75%
METRONIDAZOL TAB 250MG
METRONIDAZOL TAB 500MG
MITOSOL KIT 0.2MG
MONUROL PAK GRANULES
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
MUPIROCIN CRE 2%
MUPIROCIN OIN 2%
MUPIROCIN CA CRE 2%
NEO/BAC/POLY OIN OP
NEO/POLY/GRA SOL OP
NEO-POLYCIN OIN OP
NEOSPORIN SOL OP
NITROFUR MAC CAP 100MG
NITROFUR MAC CAP 25MG
NITROFUR MAC CAP 50MG
NITROFURANTN CAP 100MG
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Antibacterials, Other - Antibiotics
Tier 1
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
NITROFURANTN SUS
25MG/5ML
NORITATE CRE 1%
NUVESSA GEL 1.3%
OMECLAMOX- MIS PAK
PHOSPHASAL TAB
POLYCIN OIN OP
POLYCIN B OIN OP
POLYMYXIN B/ SOL TRIMETHP
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
POLYTRIM SOL OP
PREP PADS PAD
PREVPAC MIS
PRIMSOL SOL 50MG/5ML
QC ALCOHOL PAD SWABS
RA ALCOHOL PAD SWABS
Tier 4
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Page 21 of 279
Tier Value
Tier 1
Tier 4
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 1
Tier 1
X
X
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
X
X
X
X
X
X
X
X
Specialty
Prior
Authorization
Therapeutic Class
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Product Name
ROSADAN CRE 0.75%
ROSADAN GEL 0.75%
SILVADENE CRE 1%
SILVER SULFA CRE 1%
SIVEXTRO TAB 200MG
SM ALCOHOL PAD PREP
SSD
CRE 1%
SULFAMYLON CRE 85MG/GM
Tier Value
Tier 1
Tier 1
Tier 4
Tier 1
Tier 3
Tier 3
Tier 1
Tier 3
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
SULFAMYLON PAK 5%
TRIMETHOPRIM SOL
POLYMYXN
TRIMETHOPRIM TAB 100MG
ULTILET ALCH PAD SWAB
UR N-C
TAB
URAMIT MB CAP 118MG
URELLE
TAB
URETRON D/S TAB
URIBEL
CAP 118MG
URIMAR-T TAB
URIN D/S TAB
URO-458 TAB
UROAV-81 TAB
UROAV-B CAP
URO-BLUE TAB 81.6MG
UROGESIC- TAB BLUE
URO-L
TAB 81MG
UROLET MB TAB
URO-MP
CAP 118MG
UROPHEN MB TAB 81.6MG
URYL
TAB
USTELL
CAP
UTA
CAP 120MG
UTICAP
CAP
UTIRA-C TAB
UTRONA-C TAB
VANCOCIN HCL CAP 250MG
VANCOMYCIN CAP 125MG
VANCOMYCIN CAP 250MG
VANCOMYCIN SUS +SYRSPEN
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Tier 3
X
Tier 3
X
Tier 3
X
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Anticholinergics - Parkinson's Disease Drugs
VANCOMYCN 25 SOL
25MG/ML
VANCOMYCN 50 SOL
50MG/ML
VANDAZOLE GEL 0.75%
V-R ALC PREP PAD SWABS
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG
ZYVOX
SUS 100MG/5M
ZYVOX
TAB 600MG
BENZTROPINE TAB 0.5MG
Anticholinergics - Parkinson's Disease Drugs
BENZTROPINE TAB 1MG
Tier 1
Anticholinergics - Parkinson's Disease Drugs
BENZTROPINE TAB 2MG
Tier 1
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Antibacterials, Other - Antibiotics
Page 22 of 279
Tier 1
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Tier 1
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
Specialty
Prior
Authorization
Supply
Limit
Therapeutic Class
Anticholinergics - Parkinson's Disease Drugs
Product Name
TRIHEXYPHEN ELX 0.4MG/ML
Anticholinergics - Parkinson's Disease Drugs
TRIHEXYPHEN TAB 2MG
Tier 1
Anticholinergics - Parkinson's Disease Drugs
TRIHEXYPHEN TAB 5MG
Tier 1
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
ARIXTRA INJ 10/0.8ML
ARIXTRA INJ 2.5/0.5
ARIXTRA INJ 5/0.4ML
ARIXTRA INJ 7.5/0.6
COUMADIN TAB 10MG
COUMADIN TAB 1MG
COUMADIN TAB 2.5MG
COUMADIN TAB 2MG
COUMADIN TAB 3MG
COUMADIN TAB 4MG
COUMADIN TAB 5MG
COUMADIN TAB 6MG
COUMADIN TAB 7.5MG
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
ENOXAPARIN INJ 100MG/ML
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 1
X
X
X
X
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
ENOXAPARIN INJ 120/0.8
ENOXAPARIN INJ 150MG/ML
Tier 1
Tier 1
X
X
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
ENOXAPARIN INJ 30/0.3ML
ENOXAPARIN INJ 300/3ML
ENOXAPARIN INJ 40/0.4ML
ENOXAPARIN INJ 60/0.6ML
ENOXAPARIN INJ 80/0.8ML
FONDAPARINUX INJ 10/0.8ML
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
X
X
X
X
X
X
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
FONDAPARINUX INJ 2.5/0.5
FONDAPARINUX INJ 5/0.4ML
Tier 1
Tier 1
X
X
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
FONDAPARINUX INJ 7.5/0.6
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
FRAGMIN INJ 15000UNT
FRAGMIN INJ 18000UNT
FRAGMIN INJ 2500/0.2
FRAGMIN INJ 5000/0.2
FRAGMIN INJ 7500/0.3
FRAGMIN INJ 95000UNT
HEPARIN LOCK INJ 100/ML
HEPARIN LOCK INJ 10UNT/ML
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
X
X
X
X
X
X
X
X
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
HEPARIN SOD INJ 1000/ML
HEPARIN SOD INJ 10000/ML
HEPARIN SOD INJ 10000/ML
HEPARIN SOD INJ 2000/ML
HEPARIN SOD INJ 20000/ML
HEPARIN SOD INJ 2500/ML
HEPARIN SOD INJ 5000/0.5
HEPARIN SOD INJ 5000/ML
HEPARIN SOD INJ 5000U
JANTOVEN TAB 10MG
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Page 23 of 279
Tier Value
Tier 1
X
X
X
Step
Therapy
Specialty
Therapeutic Class
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Anticoagulants - Blood Thinners
Product Name
JANTOVEN TAB 1MG
JANTOVEN TAB 2.5MG
JANTOVEN TAB 2MG
JANTOVEN TAB 3MG
JANTOVEN TAB 4MG
JANTOVEN TAB 5MG
JANTOVEN TAB 6MG
JANTOVEN TAB 7.5MG
LOVENOX INJ 100MG/ML
LOVENOX INJ 120/0.8
LOVENOX INJ 150MG/ML
LOVENOX INJ 30/0.3ML
LOVENOX INJ 300/3ML
LOVENOX INJ 40/0.4ML
LOVENOX INJ 60/0.6ML
LOVENOX INJ 80/0.8ML
PRADAXA CAP 110MG
PRADAXA CAP 150MG
PRADAXA CAP 75MG
WARFARIN TAB 10MG
WARFARIN TAB 1MG
WARFARIN TAB 2.5MG
WARFARIN TAB 2MG
WARFARIN TAB 3MG
WARFARIN TAB 4MG
WARFARIN TAB 5MG
WARFARIN TAB 6MG
WARFARIN TAB 7.5MG
WARFARIN SOD TAB 10MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
XARELTO STAR TAB 15/20MG
Tier Value
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 200MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 400MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 600MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs APTIOM
TAB 800MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
SOL 100MG/ML
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 1000MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 250MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 500MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA
TAB 750MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA XR TAB 500MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs KEPPRA XR TAB 750MG
Tier 4
X
X
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA SOL 100MG/ML
Tier 1
Page 24 of 279
Specialty
Prior
Authorization
Therapeutic Class
Product Name
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA SOL 500/5ML
Tier Value
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 1000MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 250MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 500MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 500MG ER
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 750MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 750MG ER
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB ELX 20/5ML
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB ELX 20MG/5ML
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB SOL 20MG/5ML
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 100MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 15MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 16.2MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 30MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 32.4MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 60MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 64.8MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 97.2MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 200MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 300MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 400MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs POTIGA
TAB 50MG
Tier 3
X
Anticonvulsants, Other - Seizure Control Drugs ROWEEPRA
Supply
Limit
Step
Therapy
TAB 500MG
Tier 1
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 1000MG
Tier 4
X
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 250MG
Tier 4
X
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 500MG
Tier 4
X
Anticonvulsants, Other - Seizure Control Drugs SPRITAM
TAB 750MG
Tier 4
X
Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs
Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs
VALCYTE
SOL 50MG/ML
Tier 3
VALCYTE
TAB 450MG
Tier 4
Page 25 of 279
X
X
Specialty
Therapeutic Class
Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs
Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs
Antidementia Agents, Other
Product Name
VALGANCICLOV TAB 450MG
ZIRGAN
GEL 0.15%
Tier Value
Tier 1
Prior
Authorization
Tier 3
Supply
Limit
X
Step
Therapy
X
Tier 1
Antidepressants, Other - Antidepressants
ERGOLOID MES TAB 1MG
ORAL
APLENZIN TAB 174MG
Tier 4
X
X
X
Antidepressants, Other - Antidepressants
APLENZIN
TAB 348MG
Tier 4
X
X
X
Antidepressants, Other - Antidepressants
APLENZIN
TAB 522MG
Tier 4
X
X
X
Antidepressants, Other - Antidepressants
BRINTELLIX TAB 10MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
BRINTELLIX TAB 20MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
BRINTELLIX TAB 5MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
BUPROPION TAB 100MG
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 100MG ER
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 100MG SR
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 150MG ER
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 150MG SR
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 200MG ER
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 200MG SR
Tier 1
Antidepressants, Other - Antidepressants
BUPROPION TAB 75MG
Tier 1
Antidepressants, Other - Antidepressants
BUPROPN HCL TAB 150MG XL
Tier 1
Antidepressants, Other - Antidepressants
BUPROPN HCL TAB 300MG XL
Tier 1
Antidepressants, Other - Antidepressants
FORFIVO XL TAB 450MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
MAPROTILINE TAB 25MG
Tier 1
Antidepressants, Other - Antidepressants
MAPROTILINE TAB 50MG
Tier 1
Antidepressants, Other - Antidepressants
MAPROTILINE TAB 75MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 15MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 15MG ODT
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 30MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 30MG ODT
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 45MG
Tier 1
Antidepressants, Other - Antidepressants
MIRTAZAPINE TAB 45MG ODT
Tier 1
Page 26 of 279
X
Specialty
Supply
Limit
Step
Therapy
Tier 4
X
X
TAB 24HR300
Tier 4
X
X
REMERON
TAB 15MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON
TAB 30MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON
TAB 45MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON SLTB TAB 15MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON SLTB TAB 30MG
Tier 4
Antidepressants, Other - Antidepressants
REMERON SLTB TAB 45MG
Tier 4
Antidepressants, Other - Antidepressants
TRAZODONE TAB 100MG
Tier 1
Antidepressants, Other - Antidepressants
TRAZODONE TAB 150MG
Tier 1
Antidepressants, Other - Antidepressants
TRAZODONE TAB 300MG
Tier 1
Antidepressants, Other - Antidepressants
TRAZODONE TAB 50MG
Tier 1
Antidepressants, Other - Antidepressants
TRINTELLIX TAB 10MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
TRINTELLIX TAB 20MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
TRINTELLIX TAB 5MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 100MG
Tier 4
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 100MG SR
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 150MG SR
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 200MG SR
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB 75MG
Tier 4
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB XL 150MG
Tier 4
X
X
Antidepressants, Other - Antidepressants
WELLBUTRIN TAB XL 300MG
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
ACARBOSE
ACARBOSE
Tier 1
Tier 1
Therapeutic Class
Antidepressants, Other - Antidepressants
Product Name
MIRTAZAPINE TAB 7.5MG
Tier Value
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 100MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 150MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 200MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 250MG
Tier 1
Antidepressants, Other - Antidepressants
NEFAZODONE TAB 50MG
Tier 1
Antidepressants, Other - Antidepressants
OLEPTRO
TAB 24HR150
Antidepressants, Other - Antidepressants
OLEPTRO
Antidepressants, Other - Antidepressants
TAB 100MG
TAB 25MG
Page 27 of 279
Prior
Authorization
X
X
Specialty
Therapeutic Class
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Tier Value
Tier 1
Tier 4
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Product Name
ACARBOSE TAB 50MG
ACTOPLUS MET TAB 15500MG
ACTOPLUS MET TAB 15850MG
ACTOPLUS MET TAB XR
ACTOPLUS MET TAB XR
ACTOS
TAB 15MG
ACTOS
TAB 30MG
ACTOS
TAB 45MG
ALOG/PIOGLIP TAB 12.5-15
ALOG/PIOGLIP TAB 12.5-30
ALOG/PIOGLIT TAB 12.5-45
ALOG/PIOGLIT TAB 25-15MG
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
X
Tier 4
X
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
ALOG/PIOGLIT TAB 25-30MG
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs
ALOG/PIOGLIT TAB 25-45MG
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
ALOGLIPTIN
ALOGLIPTIN
ALOGLIPTIN
ALOGLIPTIN/
TAB 12.5MG
TAB 25MG
TAB 6.25MG
TAB METFORM
Tier 4
Tier 4
Tier 4
Tier 4
X
X
X
X
X
X
X
X
Antidiabetic Agents - Diabetic Drugs
ALOGLIPTIN/ TAB METFORM
Tier 4
X
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
AMARYL
TAB 1MG
AMARYL
TAB 2MG
AMARYL
TAB 4MG
AVANDAMET TAB 2-1000MG
Tier 4
Tier 4
Tier 4
Tier 3
X
Antidiabetic Agents - Diabetic Drugs
AVANDAMET TAB 4-500MG
Tier 3
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
AVANDARYL TAB 4-1MG
AVANDARYL TAB 4-2MG
AVANDARYL TAB 8-4MG
AVANDIA TAB 2MG
AVANDIA TAB 4MG
AVANDIA TAB 8MG
BYDUREON INJ
BYDUREON INJ
BYETTA
INJ 10MCG
BYETTA
INJ 5MCG
CHLORPROPAM TAB 100MG
CHLORPROPAM TAB 250MG
CYCLOSET TAB 0.8MG
DIABETA TAB 1.25MG
DIABETA TAB 2.5MG
DIABETA TAB 5MG
DUETACT TAB 30-2MG
DUETACT TAB 30-4MG
FARXIGA TAB 10MG
FARXIGA TAB 5MG
FORTAMET TAB 1000MG
FORTAMET TAB 500MG
GLIMEPIRIDE TAB 1MG
GLIMEPIRIDE TAB 2MG
GLIMEPIRIDE TAB 4MG
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
X
X
X
X
X
X
X
X
X
X
Page 28 of 279
X
X
X
X
X
X
X
X
X
X
Specialty
Prior
Authorization
Therapeutic Class
Antidiabetic Agents - Diabetic Drugs
Product Name
GLIP/METFORM TAB 2.5-250M
Tier Value
Tier 1
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
GLIP/METFORM TAB 2.5-500
GLIP/METFORM TAB 2.5-500M
Tier 1
Tier 1
Antidiabetic Agents - Diabetic Drugs
GLIP/METFORM TAB 5-500MG
Tier 1
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
GLIPIZIDE POW
GLIPIZIDE TAB 10MG
GLIPIZIDE TAB 5MG
GLIPIZIDE ER TAB 10MG
GLIPIZIDE ER TAB 2.5MG
GLIPIZIDE ER TAB 5MG
GLIPIZIDE XL TAB 10MG
GLIPIZIDE XL TAB 2.5MG
GLIPIZIDE XL TAB 5MG
GLUCOPHAGE TAB 1000MG
GLUCOPHAGE TAB 500MG
GLUCOPHAGE TAB 500MG XR
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
X
Antidiabetic Agents - Diabetic Drugs
GLUCOPHAGE TAB 750MG XR
Tier 4
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
GLUCOPHAGE TAB 850MG
GLUCOTROL TAB 10MG
GLUCOTROL TAB 5MG
GLUCOTROL XL TAB 10MG
GLUCOTROL XL TAB 2.5MG
GLUCOTROL XL TAB 5MG
GLUCOVANCE TAB 1.25-250
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
GLUCOVANCE TAB 2.5-500
GLUCOVANCE TAB 5-500MG
Tier 4
Tier 4
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
GLUMETZA TAB 1000MG
GLUMETZA TAB 500MG
GLYB/METFORM TAB 1.25-250
Tier 4
Tier 4
Tier 1
Antidiabetic Agents - Diabetic Drugs
GLYB/METFORM TAB 2.5-500
Tier 1
Antidiabetic Agents - Diabetic Drugs
GLYB/METFORM TAB 5-500MG
Tier 1
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
GLYBURID MCR TAB 1.5MG
GLYBURID MCR TAB 3MG
GLYBURID MCR TAB 6MG
GLYBURIDE POW
GLYBURIDE TAB 1.25MG
GLYBURIDE TAB 2.5MG
GLYBURIDE TAB 5MG
GLYNASE TAB 1.5MG
GLYNASE TAB 3MG
GLYNASE TAB 6MG
GLYSET
TAB 100MG
GLYSET
TAB 25MG
GLYSET
TAB 50MG
INVOKAMET TAB 150-1000
INVOKAMET TAB 150-500
INVOKAMET TAB 50-1000
Tier 1
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Page 29 of 279
Supply
Limit
X
X
Step
Therapy
X
X
X
X
X
Specialty
Prior
Authorization
Supply
Limit
X
Step
Therapy
Therapeutic Class
Antidiabetic Agents - Diabetic Drugs
Product Name
INVOKAMET TAB 50-500MG
Tier Value
Tier 2
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
INVOKANA TAB 100MG
INVOKANA TAB 300MG
JANUMET TAB 50-1000
JANUMET TAB 50-500MG
JANUMET XR TAB 100-1000
JANUMET XR TAB 50-1000
JANUMET XR TAB 50-500MG
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
JANUVIA TAB 100MG
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JARDIANCE TAB 10MG
JARDIANCE TAB 25MG
JENTADUETO TAB 2.5-1000
JENTADUETO TAB 2.5-500
JENTADUETO TAB 2.5-850
JENTADUETO TAB XR
JENTADUETO TAB XR
KAZANO 12.5- TAB 1000MG
KAZANO 12.5- TAB 500MG
KOMBIGLYZE TAB 2.5-1000
KOMBIGLYZE TAB 5-1000MG
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
KOMBIGLYZE
METFORMIN
METFORMIN
METFORMIN
METFORMIN
TAB 5-500MG
TAB 1000MG
TAB 1000MG
TAB 500MG
TAB 500MG ER
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 500MG ER
Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 500MG ER
Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 750MG ER
Tier 1
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
METFORMIN TAB 850MG
METFORMIN ER TAB 1000MG
Tier 1
Tier 1
X
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
MIGLITOL TAB 100MG
MIGLITOL TAB 25MG
MIGLITOL TAB 50MG
NATEGLINIDE TAB 120MG
NATEGLINIDE TAB 60MG
NESINA
TAB 12.5MG
NESINA
TAB 25MG
NESINA
TAB 6.25MG
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
OSENI
TAB 12.5-15
OSENI
TAB 12.5-30
OSENI
TAB 12.5-45
OSENI
TAB 25-15MG
OSENI
TAB 25-30MG
OSENI
TAB 25-45MG
PIOGLIT/GLIM TAB 30-2MG
PIOGLIT/GLIM TAB 30-4MG
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Page 30 of 279
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Prior
Authorization
Supply
Limit
X
Therapeutic Class
Antidiabetic Agents - Diabetic Drugs
Product Name
PIOGLITA/MET TAB 15-500MG
Tier Value
Tier 1
Antidiabetic Agents - Diabetic Drugs
PIOGLITA/MET TAB 15-850MG
Tier 1
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
PIOGLITAZONE TAB 15MG
PIOGLITAZONE TAB 30MG
PIOGLITAZONE TAB 45MG
PRANDIMET TAB 1-500MG
PRANDIMET TAB 2-500MG
PRANDIN TAB 0.5MG
PRANDIN TAB 1MG
PRANDIN TAB 2MG
PRECOSE TAB 100MG
PRECOSE TAB 25MG
PRECOSE TAB 50MG
REPAGLINIDE TAB 0.5MG
REPAGLINIDE TAB 1-500MG
REPAGLINIDE TAB 1MG
REPAGLINIDE TAB 2-500MG
REPAGLINIDE TAB 2MG
RIOMET
SOL
RIOMET
SOL 500/5ML
STARLIX TAB 120MG
STARLIX TAB 60MG
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Tier 3
Tier 3
X
X
X
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs
Antidotes - Antidotes/Protectants
Antidotes - Antidotes/Protectants
Antiemetics - Drugs to Treat Nausea and
Vomiting
Antiemetics, Other - Nausea and Vomiting
Drugs
Antiemetics, Other - Nausea and Vomiting
Drugs
Antiemetics, Other - Nausea and Vomiting
Drugs
Antiestrogens/Modifiers - Chemotherapy
Agents
Antiestrogens/Modifiers - Chemotherapy
Agents
Antiestrogens/Modifiers - Chemotherapy
Agents
Antiestrogens/Modifiers - Chemotherapy
Agents
Antiestrogens/Modifiers - Chemotherapy
Agents
Antifungals - Fungal Infection Drugs
TANZEUM INJ 30MG
TANZEUM INJ 50MG
TOLAZAMIDE TAB 250MG
TOLAZAMIDE TAB 500MG
TOLBUTAMIDE TAB 500MG
TRADJENTA TAB 5MG
VICTOZA INJ 18MG/3ML
VICTOZA INJ 18MG/3ML
VICTOZA INJ 18MG/3ML
VICTOZA INJ 18MG/3ML
CETYLEV TAB 2.5GM
CETYLEV TAB 500MG
DICLEGIS TAB 10-10MG
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 3
Tier 3
Tier 2
Tier 2
Tier 4
Tier 4
Tier 3
X
X
TIGAN
Tier 4
CAP 300MG
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
TRANSDERM-SC DIS 1MG
Tier 3
TRIMETHOBENZ CAP 300MG
Tier 1
EMCYT
CAP 140MG
Tier 3
X
TAB 60MG
Tier 3
X
FARESTON
SOLTAMOX
SOL 10MG/5ML
Tier 4
TAMOXIFEN TAB 10MG
Tier 1
TAMOXIFEN TAB 20MG
HCR Preventative
ANCOBON
CAP 250MG
Page 31 of 279
Tier 4
X
Therapeutic Class
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Product Name
ANCOBON CAP 500MG
AVC
CRE 15%
BIO-STATIN CAP 1000000
BIO-STATIN CAP 500000
BIO-STATIN POW
CICLODAN CRE 0.77%
CICLODAN SOL 8%
CICLODAN CRE KIT 0.77%
CICLODAN SOL KIT 8%
CICLOPIROX CRE 0.77%
CICLOPIROX GEL 0.77%
CICLOPIROX KIT 8%
CICLOPIROX SHA 1%
CICLOPIROX SOL 8%
CICLOPIROX SUS 0.77%
CLOTRIM/BETA CRE 1-0.05%
CLOTRIM/BETA CRE DIPROP
CLOTRIM/BETA LOT DIPROP
CLOTRIMAZOLE LOZ 10MG
CLOTRIMAZOLE TRO 10MG
CNL8 NAIL KIT
DIFLUCAN SUS 10MG/ML
DIFLUCAN SUS 40MG/ML
DIFLUCAN TAB 100MG
DIFLUCAN TAB 150MG
DIFLUCAN TAB 200MG
DIFLUCAN TAB 50MG
ECONAZOLE CRE 1%
ECOZA
AER 1%
ERTACZO CRE 2%
EXELDERM CRE 1%
EXELDERM SOL 1%
EXTINA
AER 2%
FLUCONAZOLE SUS 10MG/ML
Tier Value
Tier 3
Tier 2
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 1
Antifungals - Fungal Infection Drugs
FLUCONAZOLE SUS 40MG/ML
Tier 1
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
FLUCONAZOLE TAB 100MG
FLUCONAZOLE TAB 150MG
FLUCONAZOLE TAB 200MG
FLUCONAZOLE TAB 50MG
FLUCYTOSINE CAP 250MG
FLUCYTOSINE CAP 500MG
GRIFULVIN V TAB 500MG
GRISEOFULVIN SUS 125/5ML
GRISEOFULVIN TAB MICR 500
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Antifungals - Fungal Infection Drugs
GRISEOFULVIN TAB ULTR 125
Tier 1
Antifungals - Fungal Infection Drugs
GRISEOFULVIN TAB ULTR 250
Tier 1
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
GRIS-PEG TAB 125MG
GRIS-PEG TAB 250MG
GYNAZOLE-1 CRE 2%
ITRACONAZOLE CAP 100MG
JUBLIA
SOL 10%
KETOCONAZOLE AER 2%
KETOCONAZOLE CRE 2%
Tier 4
Tier 4
Tier 3
Tier 1
Tier 4
Tier 1
Tier 1
Page 32 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Product Name
KETOCONAZOLE SHA 2%
KETOCONAZOLE TAB 200MG
KETODAN AER 2%
KETODAN KIT 2%
LAMISIL GRA 125MG
LAMISIL GRA 187.5MG
LAMISIL SPR 1%
LAMISIL TAB 250MG
LOPROX
CRE 0.77%
LOPROX
KIT 0.77%
LOPROX
SHA 1%
LOTRISONE CRE
LUZU
CRE 1%
MENTAX
CRE 1%
MICONAZOLE 3 SUP 200MG
NAFTIFINE CRE HCL 1%
NAFTIFINE CRE HCL 2%
NAFTIN
CRE 1%
NAFTIN
CRE 2%
NAFTIN
GEL 1%
NAFTIN
GEL 2%
NATACYN SUS 5% OP
NIZORAL SHA 2%
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
NYAMYC
POW 100000
NYSTAT/TRIAM CRE
NYSTAT/TRIAM OIN
NYSTATIN CRE 100000
NYSTATIN OIN 100000
NYSTATIN POW
NYSTATIN POW 100000
NYSTATIN SUS 100000
NYSTATIN TAB 500000
NYSTOP
POW 100000
ONMEL
TAB 200MG
ORAVIG
TAB 50MG
OXICONAZOLE CRE NITR 1%
OXICONAZOLE CRE NITRATE
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
OXISTAT CRE 1%
OXISTAT LOT 1%
PEDIADERM AF KIT COMPLETE
Tier 4
Tier 4
Tier 4
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
PENLAC
SOL 8%
SPORANOX CAP 100MG
SPORANOX CAP PULSEPAK
Tier 4
Tier 4
Tier 4
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
SPORANOX SOL 10MG/ML
TERAZOL 3 CRE 0.8%
TERAZOL 7 CRE 0.4%
TERBINAFINE TAB 250MG
TERCONAZOLE CRE 0.4%
TERCONAZOLE CRE 0.8%
TERCONAZOLE SUP 80MG
VFEND
SUS 40MG/ML
VFEND
TAB 200MG
VFEND
TAB 50MG
Tier 2
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 3
Page 33 of 279
Tier Value
Tier 1
Tier 1
Tier 1
Tier 4
Tier 3
Tier 3
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 3
Tier 1
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Antifungals - Fungal Infection Drugs
Product Name
VORICONAZOLE SUS 40MG/ML
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antifungals - Fungal Infection Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
VORICONAZOLE TAB 200MG
VORICONAZOLE TAB 50MG
XOLEGEL GEL 2%
ZAZOLE
CRE 0.8%
ZAZOLE
SUP 80MG
ALLOPURINOL TAB 100MG
ALLOPURINOL TAB 300MG
COLCHICINE CAP 0.6MG
COLCHICINE TAB 0.6MG
COLCRYS TAB 0.6MG
MITIGARE CAP 0.6MG
PROBEN/COLCH TAB 500-0.5
Tier 1
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 2
Tier 1
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antigout Agents - Gout Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
PROBENECID TAB 500MG
ULORIC
TAB 40MG
ULORIC
TAB 80MG
ZYLOPRIM TAB 100MG
ZYLOPRIM TAB 300MG
ADEFOV DIPIV TAB 10MG
BARACLUDE SOL .05MG/ML
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 3
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
BARACLUDE TAB 0.5MG
BARACLUDE TAB 1MG
COPEGUS TAB 200MG
ENTECAVIR TAB 0.5MG
ENTECAVIR TAB 1MG
HEPSERA TAB 10MG
INTRON A INJ 10MU
INTRON A INJ 18MU
INTRON A INJ 18MU
INTRON A INJ 25MU
INTRON A INJ 50MU
MODERIBA PAK 1000/DAY
MODERIBA PAK 1200/DAY
MODERIBA PAK 600/DAY
MODERIBA PAK 800/DAY
MODERIBA TAB 200MG
OLYSIO
CAP 150MG
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGASYS INJ PROCLICK
PEGINTRON KIT 120MCG
PEGINTRON KIT 150MCG
PEGINTRON KIT 50MCG
PEGINTRON KIT 80MCG
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 120MCG
PEG-INTRON KIT 150 RP
PEG-INTRON KIT 150MCG
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG
PEG-INTRON KIT 80MCG RP
REBETOL CAP 200MG
REBETOL SOL 40MG/ML
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Page 34 of 279
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antihepatitis Agents - Hepatitis Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antiherpetic Agents - Herpes Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Product Name
RIBAPAK PAK 1000/DAY
RIBAPAK PAK 1200/DAY
RIBAPAK PAK 600/DAY
RIBAPAK PAK 800/DAY
RIBASPHERE CAP 200MG
RIBASPHERE TAB 200MG
RIBASPHERE TAB 400MG
RIBASPHERE TAB 600MG
RIBATAB PAK 1000/DAY
RIBATAB TAB 1200/DAY
RIBATAB TAB 800/DAY
RIBAVIRIN CAP 200MG
RIBAVIRIN TAB 200MG
SOVALDI TAB 400MG
TYZEKA
TAB 600MG
VICTRELIS CAP 200MG
VIRAZOLE INH 6GM
ACYCLOVIR CAP 200MG
ACYCLOVIR OIN 5%
ACYCLOVIR SUS 200/5ML
ACYCLOVIR TAB 400MG
ACYCLOVIR TAB 800MG
DENAVIR CRE 1%
FAMCICLOVIR TAB 125MG
FAMCICLOVIR TAB 250MG
FAMCICLOVIR TAB 500MG
FAMVIR
TAB 125MG
FAMVIR
TAB 250MG
FAMVIR
TAB 500MG
LIDOVIR OIN 4-4%
SITAVIG TAB 50MG
TRIFLURIDINE SOL 1% OP
VALACYCLOVIR TAB 1GM
VALACYCLOVIR TAB 500MG
VALTREX TAB 1GM
VALTREX TAB 500MG
VIROPTIC SOL 1% OP
XERESE
CRE 5-1%
ZOVIRAX CAP 200MG
ZOVIRAX CRE 5%
ZOVIRAX OIN 5%
ZOVIRAX SUS 200/5ML
ZOVIRAX TAB 400MG
ZOVIRAX TAB 800MG
ANDEHIST SYP 4-60MG/5
ARBINOXA SOL 4MG/5ML
ARBINOXA TAB 4MG
ASTEPRO SPR 0.15%
AZELASTINE SPR 0.1%
AZELASTINE SPR 0.15%
BROM/PSE/DM SYP
BROMFED DM SYP
BROMPHENIRAM CHW 12MG
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
CARBAPHEN 12 LIQ
CARBAPHEN 12 SUS PED
CARBINOXAMIN SOL
4MG/5ML
Page 35 of 279
Tier Value
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 4
Tier 4
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 2
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Supply
Limit
Step
Therapy
X
X
X
X
X
Tier 1
Tier 3
Tier 2
Tier 1
X
X
DESLORATADIN TAB 5MG
DESLORATADIN TAB 5MG ODT
Tier 1
Tier 1
X
X
X
X
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
DICOPANOL SUS 5MG/ML
DICOPANOL SUS RAPIDPAQ
Tier 3
Tier 3
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
DM/CPM/PE DRO
DYMISTA SPR 137-50
GNP ALLERGY ELX CHILDREN
Tier 1
Tier 4
Tier 1
X
X
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
GNP DIPHEDRY CAP 25MG
GNP SUPHEDRI TAB PLUS
HYD POL/CPM SUS 10-8/5ML
Tier 1
Tier 1
Tier 1
X
Antihistamines - Allergy Drugs
HYDR/CPM/PSE LIQ 5-4-60MG
Tier 1
X
Antihistamines - Allergy Drugs
HYDRO/CHLOR/ LIQ 5-4-60MG
Tier 1
X
Antihistamines - Allergy Drugs
HYDROXYZ HCL SOL
10MG/5ML
HYDROXYZ HCL SYP
10MG/5ML
HYDROXYZ HCL TAB 10MG
HYDROXYZ HCL TAB 25MG
HYDROXYZ HCL TAB 50MG
HYDROXYZ PAM CAP 100MG
HYDROXYZ PAM CAP 25MG
HYDROXYZ PAM CAP 50MG
KARBINAL ER SUS 4MG/5ML
LEVOCETIRIZI SOL 2.5/5ML
LEVOCETIRIZI TAB 5MG
LEXUSS 210 LIQ 2-10/5ML
MDL ANTIHIST ELX 12.5/5ML
MED 12HR REL TAB 6-120 CR
NEOTUSS PLUS LIQ
OLOPATADINE SPR 0.6%
PATANASE SPR 0.6%
PHENADOZ SUP 12.5MG
PHENADOZ SUP 25MG
PHENERGAN SUP 12.5MG
PHENERGAN SUP 25MG
PHENERGAN SUP 50MG
PROMETH VC SYP PLAIN
Tier 1
Therapeutic Class
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Product Name
CARBINOXAMIN TAB 4MG
CLARINEX SYP 0.5MG/ML
CLARINEX TAB 5MG
CLARINEX-D TAB 2.5-120
CLEMASTINE SYP 0.5/5ML
CLEMASTINE TAB 2.68MG
CODAR AR LIQ 2-8/5ML
CPB WC
LIQ
CYPROHEPTAD SYP 2MG/5ML
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
CYPROHEPTAD TAB 4MG
DECON-A ELX 2-5MG/5M
DECON-G DRO 2-1-40MG
DESLORATADIN TAB 2.5 ODT
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Page 36 of 279
Tier Value
Tier 1
Tier 3
Tier 4
Tier 3
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
Prior
Authorization
X
X
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
X
X
X
X
Specialty
Prior
Authorization
Supply
Limit
Step
Therapy
Therapeutic Class
Antihistamines - Allergy Drugs
Product Name
PROMETH VC/ SYP CODEINE
Tier Value
Tier 1
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
PROMETH/COD SYP 6.25-10
PROMETH/PE SYP 6.25-5/5
PROMETH/PE SYP 6.25-5/5
PROMETH/PE SYP 6.25-5/5
PROMETH/PE SYP 6.25-5/5
PROMETH/PE/ SYP CODEINE
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
Antihistamines - Allergy Drugs
PROMETHAZINE SOL 6.25/5ML
Tier 1
Antihistamines - Allergy Drugs
PROMETHAZINE SUP 12.5MG
Tier 1
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
PROMETHAZINE SUP 25MG
PROMETHAZINE SUP 50MG
PROMETHAZINE SYP 6.25/5ML
Tier 1
Tier 1
Tier 1
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
PROMETHAZINE SYP DM
PROMETHAZINE TAB 12.5MG
Tier 1
Tier 1
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
PROMETHAZINE TAB 25MG
PROMETHAZINE TAB 50MG
PROMETHEGAN SUP 12.5MG
Tier 1
Tier 1
Tier 1
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
PROMETHEGAN SUP 25MG
PROMETHEGAN SUP 50MG
RELHIST CHW
RESPA-BR TAB 11MG
SEMPREX-D CAP 8-60MG
TGQ 15DM/5PE SYP H/2CPM
TGQ 30/PSE/3 SYP BRM/15DM
Tier 1
Tier 1
Tier 2
Tier 3
Tier 3
Tier 1
Tier 1
Antihistamines - Allergy Drugs
TGQ 50PSE/3 SYP BRM/30DM
Tier 1
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
TUSNEL
CAP
TUSSICAPS CAP 10-8MG
TUSSICAPS CAP 5-4MG
TUSSIONEX SUS 10-8/5ML
VISTARIL CAP 25MG
VISTARIL CAP 50MG
VITUZ
SOL 5-4MG
XYZAL
SOL
XYZAL
SOL 2.5/5ML
XYZAL
TAB 5MG
ZUTRIPRO LIQ 60-4-5MG
ATRIPLA TAB
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
COMPLERA
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
EDURANT
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
INTELENCE TAB 100MG
Tier 3
X
TAB
TAB 25MG
Page 37 of 279
Specialty
X
X
X
X
X
X
X
Prior
Authorization
Supply
Limit
Step
Therapy
Therapeutic Class
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
Product Name
INTELENCE TAB 200MG
Tier Value
Tier 3
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
INTELENCE TAB 25MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE SUS 50MG/5ML
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE TAB 100MG
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE TAB 200MG
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
NEVIRAPINE TAB 400MG ER
Tier 1
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
RESCRIPTOR TAB 100 MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
RESCRIPTOR TAB 200MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
STRIBILD
TAB
Tier 4
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
SUSTIVA
CAP 200MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
SUSTIVA
CAP 50MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
SUSTIVA
TAB 600MG
Tier 3
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
VIRAMUNE
SUS 50MG/5ML
Tier 4
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
VIRAMUNE
TAB 200MG
Tier 4
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
VIRAMUNE XR TAB 100MG
Tier 4
X
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors - HIV Drugs
VIRAMUNE XR TAB 400MG
Tier 4
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ABACAV/LAMIV TAB
/ZIDOVUD
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ABACAVIR
TAB 300MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
COMBIVIR
TAB 150-300
Tier 4
X
Page 38 of 279
X
X
Specialty
X
X
X
Prior
Authorization
Supply
Limit
Step
Therapy
Therapeutic Class
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
Product Name
DIDANOSINE CAP 125MG
Tier Value
Tier 1
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
DIDANOSINE CAP 200MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
DIDANOSINE CAP 250MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
DIDANOSINE CAP 400MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
EMTRIVA
CAP 200MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
EMTRIVA
SOL 10MG/ML
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
EPIVIR
SOL 10MG/ML
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
EPIVIR
TAB 150MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
EPIVIR
TAB 300MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
EPZICOM
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUD/ZIDO TAB 150-300
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUDINE SOL 10MG/ML
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUDINE TAB 150MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
LAMIVUDINE TAB 300MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
RETROVIR
CAP 100MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
RETROVIR
SYP 50MG/5ML
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE CAP 15MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE CAP 20MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE CAP 30MG
Tier 1
X
TAB 600-300
Page 39 of 279
Specialty
X
Prior
Authorization
Supply
Limit
Step
Therapy
Therapeutic Class
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
Product Name
STAVUDINE CAP 40MG
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
STAVUDINE SOL 1MG/ML
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
TRIZIVIR
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 100-150
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 133-200
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 167-250
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
TRUVADA
TAB 200-300
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX
SOL 2GM
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX
SOL 4GM
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 125MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 200MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 250MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIDEX EC
CAP 400MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
POW 40MG/GM
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 150MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 200MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 250MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
VIREAD
TAB 300MG
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
Tier 4
X
TAB
CAP 15MG
Page 40 of 279
Tier Value
Tier 1
Specialty
X
Prior
Authorization
Supply
Limit
Step
Therapy
Therapeutic Class
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
Product Name
ZERIT
CAP 20MG
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
CAP 30MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
CAP 40MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZERIT
SOL 1MG/ML
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZIAGEN
SOL 20MG/ML
Tier 3
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZIAGEN
TAB 300MG
Tier 4
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZIDOVUDINE CAP 100MG
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZIDOVUDINE SYP 50MG/5ML
Tier 1
X
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors - HIV Drugs
ZIDOVUDINE TAB 300MG
Tier 1
X
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Other - HIV Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
FUZEON
INJ 90MG
ISENTRESS CHW 100MG
ISENTRESS CHW 25MG
ISENTRESS POW 100MG
ISENTRESS TAB 400MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
TIVICAY TAB 10MG
TIVICAY TAB 25MG
TIVICAY TAB 50MG
APTIVUS CAP 250MG
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
X
X
X
X
X
X
X
X
X
X
X
APTIVUS
SOL
Tier 4
X
CRIXIVAN
CAP 200MG
Tier 3
X
CRIXIVAN
CAP 400MG
Tier 3
X
INVIRASE
CAP 200MG
Tier 3
X
INVIRASE
TAB 500MG
Tier 3
X
KALETRA
SOL
Tier 3
X
KALETRA
TAB 100-25MG
Tier 3
X
KALETRA
TAB 200-50MG
Tier 3
X
Tier 3
X
LEXIVA
SUS 50MG/ML
Page 41 of 279
Tier Value
Tier 4
X
X
Specialty
X
Therapeutic Class
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-HIV Agents, Protease Inhibitors - HIV
Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Product Name
LEXIVA
TAB 700MG
Tier Value
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
NORVIR
CAP 100MG
Tier 3
X
NORVIR
SOL 80MG/ML
Tier 3
X
NORVIR
TAB 100MG
Tier 3
X
PREZISTA
SUS 100MG/ML
Tier 3
X
PREZISTA
TAB 150MG
Tier 3
X
PREZISTA
TAB 600MG
Tier 3
X
PREZISTA
TAB 75MG
Tier 3
X
PREZISTA
TAB 800MG
Tier 3
X
REYATAZ
CAP 150MG
Tier 3
X
REYATAZ
CAP 200MG
Tier 3
X
REYATAZ
CAP 300MG
Tier 3
X
REYATAZ
POW 50MG
Tier 3
X
VIRACEPT
TAB 250MG
Tier 3
X
VIRACEPT
TAB 625MG
Tier 3
X
ADVAIR DISKU AER 100/50
Tier 3
X
ADVAIR DISKU AER 250/50
Tier 3
X
ADVAIR DISKU AER 500/50
Tier 3
X
ADVAIR HFA AER 115/21
Tier 3
X
ADVAIR HFA AER 230/21
Tier 3
X
ADVAIR HFA AER 45/21
Tier 3
X
AEROSPAN
AER 80MCG
Tier 3
X
ALVESCO
AER 160MCG
Tier 1
X
ALVESCO
AER 80MCG
Tier 1
X
ASMANEX 120 AER 220MCG
Tier 1
X
ASMANEX 14 AER 220MCG
Tier 1
X
ASMANEX 30 AER 110MCG
Tier 1
X
ASMANEX 30 AER 220MCG
Tier 1
X
ASMANEX 60 AER 220MCG
Tier 1
X
Page 42 of 279
Therapeutic Class
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Product Name
ASMANEX 7 AER 110MCG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
ASMANEX HFA AER 100 MCG
Tier 1
ASMANEX HFA AER 200 MCG
Tier 1
BECONASE AQ SUS 0.042%
Tier 4
X
BREO ELLIPTA INH 100-25
Tier 3
X
BREO ELLIPTA INH 200-25
Tier 3
X
BUDESONIDE SUS 0.25MG/2
Tier 1
X
BUDESONIDE SUS 0.5MG/2
Tier 1
X
BUDESONIDE SUS 1MG/2ML
Tier 1
X
BUDESONIDE SUS 32MCG
Tier 1
X
X
DULERA
AER 100-5MCG
Tier 4
X
X
DULERA
AER 200-5MCG
Tier 4
X
X
FLOVENT DISK AER 100MCG
Tier 3
X
FLOVENT DISK AER 250MCG
Tier 3
X
FLOVENT DISK AER 50MCG
Tier 3
X
FLOVENT HFA AER 110MCG
Tier 3
X
FLOVENT HFA AER 220MCG
Tier 3
X
FLOVENT HFA AER 44MCG
Tier 3
X
FLUNISOLIDE SPR 0.025%
Tier 1
FLUTICASONE SPR 50MCG
Tier 1
X
MOMETASONE SPR 50MCG
Tier 1
X
X
NASONEX
SPR 50MCG/AC
Tier 4
X
X
OMNARIS
SPR
Tier 4
X
X
PULMICORT INH 180MCG
Tier 4
X
PULMICORT INH 90MCG
Tier 4
X
PULMICORT SUS 0.25MG/2
Tier 4
X
PULMICORT SUS 0.5MG/2
Tier 4
X
PULMICORT SUS 1MG/2ML
Tier 4
X
QNASL
Tier 4
X
AER 80MCG
Page 43 of 279
X
Specialty
Therapeutic Class
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Inflammatories, Inhaled Corticosteroids Asthma/Lung Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Anti-Influenza Agents - Flu Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antileukotrienes - Asthma/Lung Drugs
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimetabolites - Chemotherapy Agents
Antimycobacterials, Other - Miscellaneous
Anti-Infectives
Antimycobacterials, Other - Miscellaneous
Anti-Infectives
Product Name
QNASL CHILD SPR 40MCG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
QVAR
AER 40MCG
Tier 1
X
QVAR
AER 80MCG
Tier 1
X
RHINOCORT SUS AQUA
Tier 4
X
SYMBICORT AER 160-4.5
Tier 3
X
SYMBICORT AER 80-4.5
Tier 3
X
VERAMYST
SPR 27.5MCG
Tier 4
X
ZETONNA
AER 37MCG
Tier 3
X
AMANTADINE CAP 100MG
AMANTADINE SYP
50MG/5ML
AMANTADINE TAB 100MG
FLUMADINE TAB 100MG
RELENZA MIS DISKHALE
RIMANTADINE TAB 100MG
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
ACCOLATE TAB 10MG
ACCOLATE TAB 20MG
MONTELUKAST CHW 4MG
MONTELUKAST CHW 5MG
MONTELUKAST GRA 4MG
MONTELUKAST TAB 10MG
SINGULAIR CHW 4MG
SINGULAIR CHW 5MG
SINGULAIR GRA 4MG
SINGULAIR TAB 10MG
ZAFIRLUKAST TAB 10MG
ZAFIRLUKAST TAB 20MG
ZYFLO
TAB 600MG
ZYFLO CR TAB 600MG
CAPECITABINE TAB 150MG
CAPECITABINE TAB 500MG
DROXIA
CAP 200MG
DROXIA
CAP 300MG
DROXIA
CAP 400MG
HYDREA
CAP 500MG
HYDROXYUREA CAP 500MG
MERCAPTOPUR TAB 50MG
PURINETHOL TAB 50MG
PURIXAN SUS 20MG/ML
TABLOID TAB 40MG
XELODA
TAB 150MG
XELODA
TAB 500MG
DAPSONE TAB 100MG
Tier 1
Tier 1
DAPSONE
Tier 1
TAB 25MG
Page 44 of 279
Tier 1
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 3
Tier 4
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 4
Tier 1
Tier 1
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 1
Step
Therapy
X
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Antimycobacterials, Other - Miscellaneous
Anti-Infectives
Antimycobacterials, Other - Miscellaneous
Anti-Infectives
Antineoplastics - Chemotherapy Agents
Antineoplastics - Chemotherapy Agents
Antineoplastics - Chemotherapy Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Product Name
MYCOBUTIN CAP 150MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
X
X
Step
Therapy
Specialty
RIFABUTIN CAP 150MG
Tier 1
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
ZYKADIA CAP 150MG
CABOMETYX TAB 20MG
Tier 3
Tier 3
Tier 4
Tier 4
X
X
X
X
CABOMETYX TAB 40MG
Tier 4
X
X
CABOMETYX TAB 60MG
Tier 4
X
X
COMETRIQ
KIT 100MG
Tier 3
X
X
X
COMETRIQ
KIT 140MG
Tier 3
X
X
X
COMETRIQ
KIT 60MG
Tier 3
X
X
X
ERIVEDGE
CAP 150MG
Tier 3
X
X
X
X
X
X
X
GILOTRIF
TAB 20MG
Tier 4
X
X
X
GILOTRIF
TAB 30MG
Tier 4
X
X
X
GILOTRIF
TAB 40MG
Tier 4
X
X
X
ICLUSIG
TAB 15MG
Tier 4
X
X
X
ICLUSIG
TAB 45MG
Tier 4
X
X
X
JAKAFI
TAB 10MG
Tier 3
X
X
X
JAKAFI
TAB 15MG
Tier 3
X
X
X
JAKAFI
TAB 20MG
Tier 3
X
X
X
JAKAFI
TAB 25MG
Tier 3
X
X
X
JAKAFI
TAB 5MG
Tier 3
X
X
X
LEUCOVOR CA TAB 10MG
Tier 1
LEUCOVOR CA TAB 15MG
Tier 1
LEUCOVOR CA TAB 25MG
Tier 1
LEUCOVOR CA TAB 5MG
Tier 1
MEKINIST
TAB 0.5MG
Tier 3
X
X
X
MEKINIST
TAB 2MG
Tier 3
X
X
X
MENEST
TAB 0.3MG
Tier 3
MENEST
TAB 0.625MG
Tier 3
Page 45 of 279
Therapeutic Class
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antineoplastics, Other - Chemotherapy
Agents
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiparkinson Agents, Other - Parkinson's
Disease Drugs
Antiprotozoals - Protozoal Infection Drugs
Product Name
MENEST
TAB 1.25MG
Tier Value
Tier 3
MENEST
TAB 2.5MG
Tier 3
MESNEX
TAB 400MG
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
PICATO
GEL 0.015%
Tier 3
X
PICATO
GEL 0.05%
Tier 3
X
POMALYST
CAP 1MG
Tier 4
X
X
X
POMALYST
CAP 2MG
Tier 4
X
X
X
POMALYST
CAP 3MG
Tier 4
X
X
X
POMALYST
CAP 4MG
Tier 4
X
X
X
SYLATRON
KIT 200MCG
Tier 3
X
X
X
SYLATRON
KIT 300MCG
Tier 3
X
X
X
SYLATRON
KIT 300MCG
Tier 3
X
X
X
SYLATRON
KIT 600MCG
Tier 3
X
X
X
X
X
X
X
ZOLINZA
ZYTIGA
COMTAN
CAP 100MG
TAB 250MG
TAB 200MG
Tier 3
Tier 3
X
Tier 4
ENTACAPONE TAB 200MG
Tier 1
NEUPRO
DIS 1MG/24HR
Tier 3
NEUPRO
DIS 2MG/24HR
Tier 3
NEUPRO
DIS 3MG/24HR
Tier 3
NEUPRO
DIS 4MG/24HR
Tier 3
NEUPRO
DIS 6MG/24HR
Tier 3
NEUPRO
DIS 8MG/24HR
Tier 3
TASMAR
TAB 100MG
Tier 4
X
TOLCAPONE TAB 100MG
Tier 1
ALINIA
SUS 100/5ML
Tier 2
X
Antiprotozoals - Protozoal Infection Drugs
ALINIA
TAB 500MG
Tier 2
X
Antiprotozoals - Protozoal Infection Drugs
ARALEN
Antiprotozoals - Protozoal Infection Drugs
ATOVAQ/PROGU TAB 250-100
TAB 500MG
Page 46 of 279
Tier 3
Tier 1
Prior
Authorization
Supply
Limit
Therapeutic Class
Antiprotozoals - Protozoal Infection Drugs
Product Name
ATOVAQ/PROGU TAB 62.5-25
Tier Value
Tier 1
Antiprotozoals - Protozoal Infection Drugs
ATOVAQUONE SUS 750/5ML
Tier 1
Antiprotozoals - Protozoal Infection Drugs
CHLOROQUINE TAB 250MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
CHLOROQUINE TAB 500MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
COARTEM
TAB 20-120MG
Tier 2
Antiprotozoals - Protozoal Infection Drugs
DARAPRIM
TAB 25MG
Tier 3
Antiprotozoals - Protozoal Infection Drugs
HYDROXYCHLOR TAB 200MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
MALARONE
TAB 250-100
Tier 4
Antiprotozoals - Protozoal Infection Drugs
MALARONE
TAB 62.5-25
Tier 4
Antiprotozoals - Protozoal Infection Drugs
MEFLOQUINE TAB 250MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
MEPRON
SUS
Tier 4
Antiprotozoals - Protozoal Infection Drugs
NEBUPENT
INH 300MG
Tier 2
Antiprotozoals - Protozoal Infection Drugs
PLAQUENIL TAB 200MG
Tier 4
Antiprotozoals - Protozoal Infection Drugs
PRIMAQUINE TAB 26.3MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
QUALAQUIN CAP 324MG
Tier 4
X
Antiprotozoals - Protozoal Infection Drugs
QUININE SULF CAP 324MG
Tier 1
X
Antiprotozoals - Protozoal Infection Drugs
TINDAMAX
TAB 250MG
Tier 4
Antiprotozoals - Protozoal Infection Drugs
TINDAMAX
TAB 500MG
Tier 4
Antiprotozoals - Protozoal Infection Drugs
TINIDAZOLE TAB 250MG
Tier 1
Antiprotozoals - Protozoal Infection Drugs
TINIDAZOLE TAB 500MG
Tier 1
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
ANASPAZ
TAB 0.125MG
Tier 2
ATROPINE
POW SULFATE
Tier 3
BELLA/OPIUM SUP 16.2-30
Tier 1
BELLA/OPIUM SUP 16.2-60
Tier 2
BENTYL
CAP 10MG
Tier 4
BENTYL
TAB 20MG
Tier 4
CANTIL
TAB 25MG
Tier 3
CHLORD/CLIDI CAP 5-2.5MG
Tier 1
CUVPOSA
Tier 3
SOL 1MG/5ML
Page 47 of 279
Step
Therapy
X
Specialty
X
X
Therapeutic Class
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Product Name
DICYCLOMINE CAP 10MG
Tier Value
Tier 1
DICYCLOMINE SOL 10MG/5ML
Tier 1
DICYCLOMINE TAB 20MG
Tier 1
ED-SPAZ
Tier 1
TAB 0.125MG
GASTRINEX NF CAP
Tier 3
GLYCOPYRROL TAB 1MG
Tier 1
GLYCOPYRROL TAB 2MG
Tier 1
HYOSCYAMINE DRO 0.125/ML
Tier 1
HYOSCYAMINE ELX 0.125/5
Tier 1
HYOSCYAMINE SUB 0.125MG
Tier 1
HYOSCYAMINE TAB 0.125MG
Tier 1
HYOSCYAMINE TAB 0.125MG
Tier 1
HYOSCYAMINE TAB 0.375 ER
Tier 1
HYOSCYAMINE TAB 0.375 SR
Tier 1
HYOSYNE
DRO 0.125/ML
Tier 1
HYOSYNE
ELX 0.125/5
Tier 1
LEVBID
TAB 0.375 ER
Tier 4
LEVSIN
TAB 0.125MG
Tier 4
LEVSIN/SL SUB 0.125MG
Tier 4
LIBRAX
Tier 4
CAP 5-2.5MG
METHSCOPOLAM TAB 2.5MG
Tier 1
METHSCOPOLAM TAB 5MG
Tier 1
NULEV
Tier 4
TAB 0.125MG
OSCIMIN
SUB 0.125MG
Tier 1
OSCIMIN
TAB 0.125MG
Tier 1
OSCIMIN
TAB 0.125MG
Tier 1
OSCIMIN SR TAB 0.375MG
Tier 1
PAMINE
Tier 4
TAB 2.5MG
PAMINE FQ KIT
Tier 3
Page 48 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
Specialty
Therapeutic Class
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Gastrointestinal - Bowel
Treatment Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Product Name
PROPANTHELIN TAB 15MG
ROBINUL
TAB 1MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 4
ROBINUL FORT TAB 2MG
Tier 4
SYMAX DUOTAB TAB
Tier 3
SYMAX-SL
SUB 0.125MG
Tier 1
SYMAX-SR
TAB 0.375MG
Tier 1
DARIFENACIN TAB 7.5MG ER
Tier 1
X
DARIFENACIN TAB HBR ER
Tier 1
X
DARIFENACIN TAB HBR ER
Tier 1
X
DETROL
TAB 1MG
Tier 4
X
DETROL
TAB 2MG
Tier 4
X
DETROL LA CAP 2MG
Tier 4
X
DETROL LA CAP 4MG
Tier 4
X
DITROPAN XL TAB 10MG
Tier 3
DITROPAN XL TAB 15MG
Tier 3
DITROPAN XL TAB 5MG
Tier 3
ENABLEX
TAB 15MG
Tier 4
X
ENABLEX
TAB 7.5MG
Tier 4
X
FLAVOXATE TAB 100MG
Tier 1
GELNIQUE
GEL 10%
Tier 4
X
GELNIQUE
GEL 3%
Tier 4
X
MYRBETRIQ TAB 25MG
Tier 4
X
MYRBETRIQ TAB 50MG
Tier 4
X
OXYBUTYNIN SYP 5MG/5ML
Tier 1
OXYBUTYNIN TAB 10MG ER
Tier 1
OXYBUTYNIN TAB 15MG ER
Tier 1
OXYBUTYNIN TAB 5MG
Tier 1
OXYBUTYNIN TAB 5MG ER
Tier 1
OXYTROL
Tier 4
DIS 3.9MG/24
Page 49 of 279
X
Specialty
Prior
Authorization
Supply
Limit
Step
Therapy
X
Therapeutic Class
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasmodics, Urinary - Bladder Control
Drugs
Antispasticity Agents
Antispasticity Agents - Muscle Spasm Drugs
Product Name
OXYTROL DIS 3.9MG/24
Tier Value
Tier 4
TOLTERODINE CAP 2MG ER
Tier 1
X
TOLTERODINE CAP 4MG ER
Tier 1
X
TOLTERODINE TAB 1MG
Tier 1
X
TOLTERODINE TAB 2MG
Tier 1
X
TOVIAZ
TAB 4MG
Tier 3
TOVIAZ
TAB 8MG
Tier 3
TROSPIUM CHL CAP 60MG ER
Tier 1
X
TROSPIUM CL TAB 20MG
Tier 1
X
VESICARE
TAB 10MG
Tier 4
X
VESICARE
TAB 5MG
Tier 4
X
GINSENG ROOT POW
BACLOFEN POW
Tier 3
Tier 3
Antispasticity Agents - Muscle Spasm Drugs
BACLOFEN
TAB 10MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
BACLOFEN
TAB 20MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
DANTRIUM
CAP 25MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
DANTRIUM
CAP 50MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
DANTROLENE CAP 100MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
DANTROLENE CAP 25MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
DANTROLENE CAP 50MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE CAP 2MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE CAP 4MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE CAP 6MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE TAB 2MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
TIZANIDINE TAB 4MG
Tier 1
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
CAP 2MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
CAP 4MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
CAP 6MG
Tier 4
Antispasticity Agents - Muscle Spasm Drugs
ZANAFLEX
TAB 4MG
Tier 4
Page 50 of 279
X
X
Specialty
Therapeutic Class
Antithyroid Agents - Thyroid Suppressing
Drugs
Antithyroid Agents - Thyroid Suppressing
Drugs
Antithyroid Agents - Thyroid Suppressing
Drugs
Antithyroid Agents - Thyroid Suppressing
Drugs
Antithyroid Agents - Thyroid Suppressing
Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Antituberculars - Tuberculosis Drugs
Anxiolytics, Other - Anxiety Drugs
Product Name
METHIMAZOLE TAB 10MG
Tier Value
Tier 1
METHIMAZOLE TAB 5MG
Tier 1
PROPYLTHIOUR TAB 50MG
Tier 1
TAPAZOLE
TAB 10MG
Tier 4
TAPAZOLE
TAB 5MG
Tier 4
CYCLOSERINE CAP 250MG
ETHAMBUTOL TAB 100MG
ETHAMBUTOL TAB 400MG
ISONIAZID SYP 50MG/5ML
ISONIAZID TAB 100MG
ISONIAZID TAB 300MG
MYAMBUTOL TAB 100MG
MYAMBUTOL TAB 400MG
PASER
GRA 4GM
PRIFTIN TAB 150MG
PYRAZINAMIDE TAB 500MG
RIFADIN CAP 150MG
RIFADIN CAP 300MG
RIFAMATE CAP
RIFAMPIN CAP 150MG
RIFAMPIN CAP 300MG
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
ALPRAZOLAM CON 1 MG/ML
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 4
Tier 3
Tier 2
Tier 1
Tier 3
Tier 4
Tier 3
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.25 ODT
Tier 1
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.25MG
ALPRAZOLAM TAB 0.5MG
ALPRAZOLAM TAB 0.5MG ER
Tier 1
Tier 1
Tier 1
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.5MG OD
Tier 1
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.5MG XR
Tier 1
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 1MG
ALPRAZOLAM TAB 1MG ER
ALPRAZOLAM TAB 1MG ODT
Tier 1
Tier 1
Tier 1
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM
ALPRAZOLAM
ALPRAZOLAM
ALPRAZOLAM
Tier 1
Tier 1
Tier 1
Tier 1
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 2MG XR
ALPRAZOLAM TAB 3MG ER
ALPRAZOLAM TAB 3MG XR
ATIVAN
TAB 0.5MG
ATIVAN
TAB 1MG
ATIVAN
TAB 2MG
BUSPIRONE TAB 10MG
BUSPIRONE TAB 15MG
TAB 1MG XR
TAB 2MG
TAB 2MG ER
TAB 2MG ODT
Page 51 of 279
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
Specialty
Therapeutic Class
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Product Name
BUSPIRONE TAB 30MG
BUSPIRONE TAB 5MG
BUSPIRONE TAB 7.5MG
CDP/AMITRIP TAB 10-25MG
CDP/AMITRIP TAB 5-12.5MG
Tier Value
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
CHLORDIAZEP CAP 10MG
CHLORDIAZEP CAP 25MG
CHLORDIAZEP CAP 5MG
DIAZEPAM CON 5MG/ML
DIAZEPAM SOL 1MG/ML
DIAZEPAM TAB 10MG
DIAZEPAM TAB 2MG
DIAZEPAM TAB 5MG
ESTAZOLAM TAB 1MG
ESTAZOLAM TAB 2MG
LORAZEPAM CON 2MG/ML
LORAZEPAM TAB 0.5MG
LORAZEPAM TAB 1MG
LORAZEPAM TAB 2MG
MEPROBAMATE TAB 200MG
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Anxiolytics, Other - Anxiety Drugs
MEPROBAMATE TAB 400MG
Tier 1
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Other - Anxiety Drugs
Anxiolytics, Sedatives and Hypnotics Benzodiazepines
Anxiolytics, Sedatives and Hypnotics Benzodiazepines
Anxiolytics, Sedatives and Hypnotics Benzodiazepines
Aromatase Inhibitors, 3rd Generation Chemotherapy Agents
Aromatase Inhibitors, 3rd Generation Chemotherapy Agents
Aromatase Inhibitors, 3rd Generation Chemotherapy Agents
Aromatase Inhibitors, 3rd Generation Chemotherapy Agents
Aromatase Inhibitors, 3rd Generation Chemotherapy Agents
Aromatase Inhibitors, 3rd Generation Chemotherapy Agents
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
OXAZEPAM CAP 10MG
OXAZEPAM CAP 15MG
OXAZEPAM CAP 30MG
VALIUM
TAB 10MG
VALIUM
TAB 2MG
VALIUM
TAB 5MG
XANAX
TAB 0.25MG
XANAX
TAB 0.5MG
XANAX
TAB 1MG
XANAX
TAB 2MG
XANAX XR TAB 0.5MG
XANAX XR TAB 1MG
XANAX XR TAB 2MG
XANAX XR TAB 3MG
DORAL
TAB 15MG
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
MIDAZOLAM SYP 2MG/ML
Tier 1
QUAZEPAM
TAB 15MG
Tier 1
ANASTROZOLE TAB 1MG
Tier 1
ARIMIDEX
Tier 4
AROMASIN
TAB 1MG
TAB 25MG
Tier 1
FEMARA
Tier 4
LETROZOLE TAB 2.5MG
Tier 1
CLONIDINE TAB 0.1MG ER
Tier 1
Page 52 of 279
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
Tier 4
EXEMESTANE TAB 25MG
TAB 2.5MG
Prior
Authorization
X
X
Specialty
Therapeutic Class
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Non-Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Prior
Authorization
Supply
Limit
X
Step
Therapy
Product Name
GUANFACINE TAB 1MG ER
Tier Value
Tier 1
GUANFACINE TAB 2MG ER
Tier 1
X
GUANFACINE TAB 3MG ER
Tier 1
X
GUANFACINE TAB 4MG ER
Tier 1
X
INTUNIV
TAB 1MG
Tier 4
X
X
INTUNIV
TAB 2MG
Tier 4
X
X
INTUNIV
TAB 3MG
Tier 4
X
X
INTUNIV
TAB 4MG
Tier 4
X
X
KAPVAY
TAB 0.1 MG
Tier 4
X
STRATTERA CAP 100MG
Tier 4
X
STRATTERA CAP 10MG
Tier 4
X
STRATTERA CAP 18MG
Tier 4
X
STRATTERA CAP 25MG
Tier 4
X
STRATTERA CAP 40MG
Tier 4
X
STRATTERA CAP 60MG
Tier 4
X
STRATTERA CAP 80MG
Tier 4
X
ADDERALL
TAB 10MG
Tier 4
X
X
ADDERALL
TAB 12.5MG
Tier 4
X
X
ADDERALL
TAB 15MG
Tier 4
X
X
ADDERALL
TAB 20MG
Tier 4
X
X
ADDERALL
TAB 30MG
Tier 4
X
X
ADDERALL
TAB 5MG
Tier 4
X
X
ADDERALL
TAB 7.5MG
Tier 4
X
X
ADDERALL XR CAP 10MG
Tier 1
X
ADDERALL XR CAP 15MG
Tier 1
X
ADDERALL XR CAP 20MG
Tier 1
X
ADDERALL XR CAP 25MG
Tier 1
X
ADDERALL XR CAP 30MG
Tier 1
X
ADDERALL XR CAP 5MG
Tier 1
X
Page 53 of 279
Specialty
Therapeutic Class
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Supply
Limit
X
Step
Therapy
X
Tier 4
X
X
AMPHET/DEXTR CAP 20MG ER
Tier 4
X
X
AMPHET/DEXTR CAP 25MG ER
Tier 4
X
X
AMPHET/DEXTR CAP 30MG ER
Tier 4
X
X
AMPHET/DEXTR CAP 5MG ER
Tier 4
X
X
AMPHET/DEXTR TAB 10MG
Tier 1
X
AMPHET/DEXTR TAB 12.5MG
Tier 1
X
AMPHET/DEXTR TAB 15MG
Tier 1
X
AMPHET/DEXTR TAB 20MG
Tier 1
X
AMPHET/DEXTR TAB 30MG
Tier 1
X
AMPHET/DEXTR TAB 5MG
Tier 1
X
AMPHET/DEXTR TAB 7.5MG
Tier 1
X
AMPHETAMINE CAP 10MG ER
Tier 4
X
X
AMPHETAMINE CAP 15MG ER
Tier 4
X
X
AMPHETAMINE CAP 20MG ER
Tier 4
X
X
AMPHETAMINE CAP 25MG ER
Tier 4
X
X
AMPHETAMINE CAP 30MG ER
Tier 4
X
X
AMPHETAMINE CAP 5MG ER
Tier 4
X
X
APTENSIO XR CAP 10MG
Tier 4
X
X
X
APTENSIO XR CAP 15MG
Tier 4
X
X
X
APTENSIO XR CAP 20MG
Tier 4
X
X
X
APTENSIO XR CAP 30MG
Tier 4
X
X
X
APTENSIO XR CAP 40MG
Tier 4
X
X
X
APTENSIO XR CAP 50MG
Tier 4
X
X
X
APTENSIO XR CAP 60MG
Tier 4
X
X
X
CONCERTA
TAB 18MG
Tier 1
X
X
CONCERTA
TAB 27MG
Tier 1
X
X
CONCERTA
TAB 36MG
Tier 1
X
X
Product Name
AMPHET/DEXTR CAP 10MG ER
Tier Value
Tier 4
AMPHET/DEXTR CAP 15MG ER
Page 54 of 279
Prior
Authorization
Specialty
Therapeutic Class
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Product Name
CONCERTA TAB 54MG
Tier Value
Tier 1
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
DAYTRANA
DIS 10MG/9HR
Tier 4
X
X
X
DAYTRANA
DIS 15MG/9HR
Tier 4
X
X
X
DAYTRANA
DIS 20MG/9HR
Tier 4
X
X
X
DAYTRANA
DIS 30MG/9HR
Tier 4
X
X
X
Tier 4
X
DEXEDRINE CAP 10MG CR
Tier 4
X
DEXEDRINE CAP 15MG CR
Tier 4
X
DEXEDRINE CAP 5MG CR
Tier 4
X
DEXEDRINE TAB 10MG
Tier 1
X
DEXEDRINE TAB 5MG
Tier 1
X
DEXMETHYLPH CAP 15MG ER
Tier 1
X
X
X
DEXMETHYLPH CAP 30MG ER
Tier 1
X
X
X
DEXMETHYLPH CAP 40MG ER
Tier 1
X
X
X
DEXMETHYLPH TAB 10MG
Tier 1
X
DEXMETHYLPH TAB 2.5MG
Tier 1
X
DEXMETHYLPH TAB 5MG
Tier 1
X
DEXMETHYLPHE CAP 10MG ER
Tier 1
X
X
X
DEXMETHYLPHE CAP 20MG ER
Tier 1
X
X
X
DEXMETHYLPHE CAP 5MG ER
Tier 1
X
X
X
DEXTROAMPHET CAP 10MG
ER
DEXTROAMPHET CAP 15MG
ER
DEXTROAMPHET CAP 5MG ER
Tier 1
X
Tier 1
X
Tier 1
X
DEXTROAMPHET SOL
5MG/5ML
DEXTROAMPHET TAB 10MG
Tier 1
X
Tier 1
X
DEXTROAMPHET TAB 5MG
Tier 1
X
FOCALIN
TAB 10MG
Tier 4
X
FOCALIN
TAB 2.5MG
Tier 4
X
FOCALIN
TAB 5MG
Tier 4
X
DESOXYN
TAB 5MG
Page 55 of 279
Specialty
Therapeutic Class
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Product Name
FOCALIN XR CAP 10MG
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
FOCALIN XR CAP 15MG
Tier 4
X
X
X
FOCALIN XR CAP 20MG
Tier 4
X
X
X
FOCALIN XR CAP 25MG
Tier 4
X
X
X
FOCALIN XR CAP 30MG
Tier 4
X
X
X
FOCALIN XR CAP 35MG
Tier 4
X
X
X
FOCALIN XR CAP 40MG
Tier 4
X
X
X
FOCALIN XR CAP 5MG
Tier 4
X
X
X
METADATE
Tier 1
X
METADATE CD CAP 10MG
Tier 1
X
X
METADATE CD CAP 20MG
Tier 1
X
X
METADATE CD CAP 30MG
Tier 1
X
X
METADATE CD CAP 40MG
Tier 1
X
X
METADATE CD CAP 50MG
Tier 1
X
X
METADATE CD CAP 60MG
Tier 1
X
X
METHAMPHETAM TAB 5MG
Tier 1
X
METHLPHENIDA CHW 2.5MG
Tier 1
X
METHYLIN
CHW 10MG
Tier 4
X
METHYLIN
CHW 2.5MG
Tier 4
X
METHYLIN
CHW 5MG
Tier 4
X
METHYLIN
SOL 10MG/5ML
Tier 4
X
METHYLIN
SOL 5MG/5ML
Tier 4
X
METHYLPHENID CAP 10MG
Tier 4
X
X
X
METHYLPHENID CAP 20MG
Tier 4
X
X
X
METHYLPHENID CAP 20MG ER
Tier 1
X
X
X
METHYLPHENID CAP 30MG
Tier 4
X
X
X
METHYLPHENID CAP 30MG ER
Tier 1
X
X
X
METHYLPHENID CAP 40MG
Tier 4
X
X
X
METHYLPHENID CAP 40MG ER
Tier 1
X
X
X
TAB 20MG ER
Page 56 of 279
Specialty
Therapeutic Class
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Product Name
METHYLPHENID CAP 50MG
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
METHYLPHENID CAP 60MG
Tier 4
X
X
X
METHYLPHENID CHW 10MG
Tier 1
X
METHYLPHENID CHW 5MG
Tier 1
X
METHYLPHENID SOL
10MG/5ML
METHYLPHENID SOL 5MG/5ML
Tier 1
X
Tier 1
X
METHYLPHENID TAB 10MG
Tier 1
X
METHYLPHENID TAB 10MG ER
Tier 1
X
METHYLPHENID TAB 18MG ER
Tier 4
X
X
X
METHYLPHENID TAB 18MG ER
Tier 1
X
X
X
METHYLPHENID TAB 20MG
Tier 1
X
METHYLPHENID TAB 20MG ER
Tier 1
X
METHYLPHENID TAB 20MG SR
Tier 1
X
METHYLPHENID TAB 27MG ER
Tier 4
X
X
X
METHYLPHENID TAB 27MG ER
Tier 1
X
X
X
METHYLPHENID TAB 36MG ER
Tier 4
X
X
X
METHYLPHENID TAB 36MG ER
Tier 1
X
X
X
METHYLPHENID TAB 54MG ER
Tier 4
X
X
X
METHYLPHENID TAB 54MG ER
Tier 1
X
X
X
METHYLPHENID TAB 5MG
Tier 1
X
PROCENTRA SOL 5MG/5ML
Tier 3
X
QUILLICHEW CHW 20MG ER
Tier 4
X
X
X
QUILLICHEW CHW 30MG ER
Tier 4
X
X
X
QUILLICHEW CHW 40MG ER
Tier 4
X
X
X
QUILLIVANT SUS 25MG/5ML
Tier 4
X
X
X
RITALIN
TAB 10MG
Tier 4
X
RITALIN
TAB 20MG
Tier 4
X
RITALIN
TAB 5MG
Tier 4
X
Tier 4
X
X
X
RITALIN LA CAP 10MG
Page 57 of 279
Specialty
Therapeutic Class
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
Attention Deficit Hyperactivity Disorder
Agents, Stimulants - ADHD Drugs
AUTONOMIC DRUGS - CENTRALLY ACTING
SKELETAL MUSCLE RELAXNT
Benign Prostatic Hypertrophy Agents
Benign Prostatic Hypertrophy Agents
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Product Name
RITALIN LA CAP 20MG
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
RITALIN LA CAP 30MG
Tier 4
X
X
X
RITALIN LA CAP 40MG
Tier 4
X
X
X
RITALIN LA CAP 60MG
Tier 4
X
X
X
VYVANSE
CAP 10MG
Tier 2
X
VYVANSE
CAP 20MG
Tier 2
X
X
VYVANSE
CAP 30MG
Tier 2
X
X
VYVANSE
CAP 40MG
Tier 2
X
X
VYVANSE
CAP 50MG
Tier 2
X
X
VYVANSE
CAP 60MG
Tier 2
X
X
VYVANSE
CAP 70MG
Tier 2
X
X
ZENZEDI
TAB 10MG
Tier 4
X
X
ZENZEDI
TAB 15MG
Tier 4
X
X
ZENZEDI
TAB 2.5MG
Tier 4
X
X
ZENZEDI
TAB 20MG
Tier 4
X
X
ZENZEDI
TAB 30MG
Tier 4
X
X
ZENZEDI
TAB 5MG
Tier 4
X
X
ZENZEDI
TAB 7.5MG
Tier 4
X
X
TIZANIDINE KIT COMFORT
Tier 4
CIALIS
TAB 2.5MG
CIALIS
TAB 5MG
ALFUZOSIN TAB 10MG
Tier 4
Tier 4
Tier 1
X
X
AVODART
CAP 0.5MG
Tier 4
X
CARDURA
TAB 1MG
Tier 4
CARDURA
TAB 2MG
Tier 4
CARDURA
TAB 4MG
Tier 4
CARDURA
TAB 8MG
Tier 4
DOXAZOSIN TAB 1MG
Tier 1
DOXAZOSIN TAB 2MG
Tier 1
DOXAZOSIN TAB 4MG
Tier 1
Page 58 of 279
X
X
X
X
X
X
Specialty
Therapeutic Class
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Benign Prostatic Hypertrophy Agents Prostate Enlargement Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Product Name
DOXAZOSIN TAB 8MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
DUTAST/TAMSU CAP 0.5-0.4
Tier 1
DUTASTERIDE CAP 0.5MG
Tier 1
FINASTERIDE TAB 5MG
Tier 1
FLOMAX
Tier 4
X
Tier 4
X
JALYN
CAP 0.4MG
CAP
PROSCAR
TAB 5MG
Tier 4
RAPAFLO
CAP 4MG
Tier 4
RAPAFLO
CAP 8MG
Tier 4
TAMSULOSIN CAP 0.4MG
Tier 1
TERAZOSIN CAP 10MG
Tier 1
TERAZOSIN CAP 1MG
Tier 1
TERAZOSIN CAP 2MG
Tier 1
TERAZOSIN CAP 5MG
Tier 1
UROXATRAL TAB 10MG
Tier 4
ACEBUTOLOL CAP 200MG
Tier 1
ACEBUTOLOL CAP 400MG
Tier 1
ATENOL/CHLOR TAB 10025MG
ATENOL/CHLOR TAB 50-25MG
Tier 1
ATENOLOL
TAB 100MG
Tier 1
ATENOLOL
TAB 25MG
Tier 1
ATENOLOL
TAB 50MG
Tier 1
BETAXOLOL TAB 10MG
Tier 1
BETAXOLOL TAB 20MG
Tier 1
BISOPRL/HCTZ TAB 10/6.25
Tier 1
BISOPRL/HCTZ TAB 2.5/6.25
Tier 1
BISOPRL/HCTZ TAB 5-6.25MG
Tier 1
BISOPROL FUM TAB 10MG
Tier 1
BISOPROL FUM TAB 5MG
Tier 1
Page 59 of 279
Tier 1
X
X
Specialty
Therapeutic Class
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Product Name
BYSTOLIC TAB 10MG
Tier Value
Tier 2
BYSTOLIC
TAB 2.5MG
Tier 2
BYSTOLIC
TAB 20MG
Tier 2
BYSTOLIC
TAB 5MG
Tier 2
Prior
Authorization
Supply
Limit
Step
Therapy
CARVEDILOL TAB 12.5MG
Tier 1
CARVEDILOL TAB 25MG
Tier 1
CARVEDILOL TAB 3.125MG
Tier 1
CARVEDILOL TAB 6.25MG
Tier 1
COREG
TAB 12.5MG
Tier 4
COREG
TAB 25MG
Tier 4
COREG
TAB 3.125MG
Tier 4
COREG
TAB 6.25MG
Tier 4
COREG CR
CAP 10MG
Tier 4
X
X
COREG CR
CAP 20MG
Tier 4
X
X
COREG CR
CAP 40MG
Tier 4
X
X
COREG CR
CAP 80MG
Tier 4
X
X
CORGARD
TAB 20MG
Tier 4
CORGARD
TAB 40MG
Tier 4
CORGARD
TAB 80MG
Tier 4
CORZIDE
TAB 40-5MG
Tier 4
CORZIDE
TAB 80-5MG
Tier 3
DUTOPROL
TAB 100-12.5
Tier 2
X
DUTOPROL
TAB 25-12.5
Tier 2
X
DUTOPROL
TAB 50-12.5
Tier 2
X
HEMANGEOL SOL 4.28/ML
Tier 4
INDERAL LA CAP 120MG
Tier 4
INDERAL LA CAP 160MG
Tier 4
INDERAL LA CAP 60MG
Tier 4
INDERAL LA CAP 80MG
Tier 4
Page 60 of 279
X
Specialty
Therapeutic Class
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Product Name
INDERAL XL CAP 120MG
Tier Value
Tier 3
INDERAL XL CAP 80MG
Tier 3
INNOPRAN XL CAP 120MG
Tier 3
INNOPRAN XL CAP 80MG
Tier 3
KERLONE
TAB 10MG
Tier 3
KERLONE
TAB 20MG
Tier 3
LABETALOL TAB 100MG
Tier 1
LABETALOL TAB 200MG
Tier 1
LABETALOL TAB 300MG
Tier 1
LEVATOL
Tier 3
TAB 20MG
LOPRESS HCT TAB 100-25MG
Tier 3
LOPRESS HCT TAB 50-25MG
Tier 4
LOPRESSOR TAB 100MG
Tier 4
LOPRESSOR TAB 50MG
Tier 4
METOPRL/HCTZ TAB 10025MG
METOPRL/HCTZ TAB 10050MG
METOPRL/HCTZ TAB 50-25MG
Tier 1
METOPROL TAR TAB 100MG
Tier 1
METOPROL TAR TAB 25MG
Tier 1
METOPROL TAR TAB 50MG
Tier 1
METOPROLOL TAB 100MG ER
Tier 1
METOPROLOL TAB 200MG ER
Tier 1
METOPROLOL TAB 25MG ER
Tier 1
METOPROLOL TAB 37.5MG
Tier 1
METOPROLOL TAB 50MG ER
Tier 1
METOPROLOL TAB 75MG
Tier 1
NADOLOL
TAB 20MG
Tier 1
NADOLOL
TAB 40MG
Tier 1
NADOLOL
TAB 80MG
Tier 1
Page 61 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 1
Tier 1
X
X
Specialty
Therapeutic Class
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Product Name
NADOLOL/BEND TAB 40-5MG
Tier Value
Tier 1
NADOLOL/BEND TAB 80-5MG
Tier 1
PINDOLOL
TAB 10MG
Tier 1
PINDOLOL
TAB 5MG
Tier 1
PROPRAN/HCTZ TAB 40/25
Tier 1
PROPRAN/HCTZ TAB 80/25
Tier 1
PROPRANOLOL CAP 120MG
ER
PROPRANOLOL CAP 160MG
ER
PROPRANOLOL CAP 60MG ER
Tier 1
PROPRANOLOL CAP 80MG ER
Tier 1
PROPRANOLOL SOL
20MG/5ML
PROPRANOLOL SOL
40MG/5ML
PROPRANOLOL TAB 10MG
Tier 1
PROPRANOLOL TAB 20MG
Tier 1
PROPRANOLOL TAB 40MG
Tier 1
PROPRANOLOL TAB 60MG
Tier 1
PROPRANOLOL TAB 80MG
Tier 1
SECTRAL
CAP 200MG
Tier 4
SECTRAL
CAP 400MG
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 1
Tier 1
Tier 1
Tier 1
TENORETIC TAB 100
Tier 4
X
TENORETIC TAB 50
Tier 4
X
TENORMIN
TAB 100MG
Tier 4
X
TENORMIN
TAB 25MG
Tier 4
X
TENORMIN
TAB 50MG
Tier 4
X
TIMOLOL MAL TAB 10MG
Tier 1
TIMOLOL MAL TAB 20MG
Tier 1
TIMOLOL MAL TAB 5MG
Tier 1
TOPROL XL TAB 100MG
Tier 4
TOPROL XL TAB 200MG
Tier 4
Page 62 of 279
Specialty
Therapeutic Class
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Adrenergic Blocking Agents - Blood
Pressure Drugs
Beta-Lactam, Cephalosporins - Antibiotics
Product Name
TOPROL XL TAB 25MG
Tier Value
Tier 4
TOPROL XL TAB 50MG
Tier 4
ZEBETA
TAB 10MG
Tier 3
ZEBETA
TAB 5MG
Tier 3
ZIAC
TAB 10/6.25
Tier 3
ZIAC
TAB 2.5/6.25
Tier 3
ZIAC
TAB 5-6.25MG
Tier 4
CEDAX
CAP 400MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEDAX
SUS 180/5ML
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
CAP 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
CAP 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
SUS 125/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR
SUS 375/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFACLOR ER TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL CAP 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL SUS 500/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFADROXIL TAB 1GM
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDINIR
CAP 300MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDINIR
SUS 125/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDINIR
SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDITOREN TAB 200MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFDITOREN TAB 400MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFIXIME
SUS 100/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFIXIME
SUS 200/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPODO PROX SUS 100/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPODO PROX SUS
50MG/5ML
CEFPODOXIME TAB 100MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
Page 63 of 279
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Beta-Lactam, Cephalosporins - Antibiotics
Product Name
CEFPODOXIME TAB 200MG
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL SUS 125/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL TAB 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFPROZIL TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIBUTEN CAP 400MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIBUTEN SUS 180/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
SUS 125/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
SUS 250/5ML
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
TAB 250MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEFTIN
TAB 500MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
CEFUROXIME TAB 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEFUROXIME TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN CAP 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN CAP 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN CAP 750MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN SUS 125/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN SUS 250/5ML
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN TAB 250MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
CEPHALEXIN TAB 500MG
Tier 1
Beta-Lactam, Cephalosporins - Antibiotics
KEFLEX
CAP 250MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
KEFLEX
CAP 500MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
KEFLEX
CAP 750MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SPECTRACEF TAB 200MG
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
SPECTRACEF TAB 400MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
CAP 400MG
Tier 3
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
CHW 100MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
CHW 200MG
Tier 4
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
SUS 100/5ML
Tier 4
Page 64 of 279
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Prior
Authorization
Supply
Limit
X
X
Therapeutic Class
Beta-Lactam, Cephalosporins - Antibiotics
Product Name
SUPRAX
SUS 200/5ML
Beta-Lactam, Cephalosporins - Antibiotics
SUPRAX
Beta-Lactam, Other - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
CAYSTON INH 75MG
AMOX/K CLAV CHW 200MG
AMOX/K CLAV CHW 400MG
AMOX/K CLAV SUS 200/5ML
Tier 3
Tier 1
Tier 1
Tier 1
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 250/5ML
Tier 1
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 400/5ML
Tier 1
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 600/5ML
Tier 1
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV TAB 250-125
AMOX/K CLAV TAB 500-125
AMOX/K CLAV TAB 875MG
AMOXICILLIN CAP 250MG
AMOXICILLIN CAP 500MG
AMOXICILLIN CHW 125MG
AMOXICILLIN CHW 250MG
AMOXICILLIN SUS 125/5ML
AMOXICILLIN SUS 200/5ML
AMOXICILLIN SUS 250/5ML
AMOXICILLIN SUS 250MG/5M
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Beta-Lactam, Penicillins - Antibiotics
Bipolar Agents, Other - Mood Disorder Drugs
AMOXICILLIN SUS 400/5ML
AMOXICILLIN TAB 500MG
AMOXICILLIN TAB 775MG
AMOXICILLIN TAB 875MG
AMOX-POT CLA TAB ER
AMPICILLIN CAP 250MG
AMPICILLIN CAP 500MG
AMPICILLIN SUS 125/5ML
AMPICILLIN SUS 250/5ML
AUGMENTIN SUS 125/5ML
AUGMENTIN SUS 250/5ML
AUGMENTIN SUS ES-600
AUGMENTIN TAB 500MG
AUGMENTIN TAB 875MG
AUGMENTIN XR TAB 12HR
DICLOXACILL CAP 250MG
DICLOXACILL CAP 500MG
MOXATAG TAB 775MG
MOXATAG TAB 775MG
PENICILLN VK SOL 125/5ML
PENICILLN VK SOL 250/5ML
PENICILLN VK TAB 250MG
PENICILLN VK TAB 500MG
OLANZA/FLUOX CAP 12-25MG
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 1
Tier 1
Tier 3
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
X
Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 12-50MG
Tier 1
X
Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 3-25MG
Tier 1
X
Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 6-25MG
Tier 1
X
SUS 500/5ML
Page 65 of 279
Tier Value
Tier 4
Step
Therapy
Specialty
Tier 4
X
X
X
X
X
X
X
X
Therapeutic Class
Product Name
Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 6-50MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 12-25MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 12-50MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 3-25MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 6-25MG
Tier 4
X
Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX
CAP 6-50MG
Tier 4
X
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
AGRYLIN
CAP 0.5MG
Step
Therapy
Specialty
Tier 4
ANAGRELIDE CAP 0.5MG
Tier 1
ANAGRELIDE CAP 1MG
Tier 1
EPOGEN
INJ 10000/ML
Tier 3
X
X
EPOGEN
INJ 2000/ML
Tier 3
X
X
EPOGEN
INJ 20000/ML
Tier 3
X
X
EPOGEN
INJ 3000/ML
Tier 3
X
X
EPOGEN
INJ 4000/ML
Tier 3
X
X
GRANIX
INJ 300/0.5
Tier 4
X
X
GRANIX
INJ 480/0.8
Tier 4
X
X
LEUKINE
INJ 250MCG
Tier 3
X
MOZOBIL
INJ
Tier 3
X
NEULASTA
INJ 6MG/0.6M
Tier 4
X
NEULASTA
KIT 6MG/0.6M
Tier 4
X
NEUMEGA
INJ 5MG
Tier 3
X
NEUPOGEN
INJ 300/0.5
Tier 3
X
NEUPOGEN
INJ 300MCG
Tier 3
X
NEUPOGEN
INJ 480/0.8
Tier 3
X
NEUPOGEN
INJ 480MCG
Tier 3
X
PROCRIT
INJ 10000/ML
Tier 3
X
X
PROCRIT
INJ 2000/ML
Tier 3
X
X
PROCRIT
INJ 20000/ML
Tier 3
X
X
PROCRIT
INJ 3000/ML
Tier 3
X
X
Page 66 of 279
Therapeutic Class
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
Blood Formation Modifiers - Blood Formation
Drugs
BLOOD FORMATION,COAGULATION &
THROMBOSIS - ANTICOAGULANTS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - ANTICOAGULANTS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - ANTICOAGULANTS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
Product Name
PROCRIT INJ 4000/ML
PROCRIT
INJ 40000/ML
Tier Value
Tier 3
Prior
Authorization
Tier 3
Supply
Limit
X
X
Step
Therapy
Specialty
X
X
PROMACTA
TAB 12.5MG
Tier 4
X
X
PROMACTA
TAB 25MG
Tier 4
X
X
PROMACTA
TAB 50MG
Tier 4
X
X
PROMACTA
TAB 75MG
Tier 4
X
X
ANTICOAG CIT SOL DEX SOL
Tier 1
NOCLOT-50 SOL ACD-A
Tier 3
TRICITRASOL CON
Tier 3
ADVATE
INJ 1000UNIT
Tier 3
X
ADVATE
INJ 1500UNIT
Tier 3
X
ADVATE
INJ 2000UNIT
Tier 3
X
ADVATE
INJ 250UNIT
Tier 3
X
ADVATE
INJ 3000UNIT
Tier 3
X
ADVATE
INJ 4000UNIT
Tier 3
X
ADVATE
INJ 500UNIT
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANATE INJ VWF/HUM
Tier 3
X
ALPHANINE SD INJ 1000UNIT
Tier 3
X
ALPHANINE SD INJ 1500UNIT
Tier 3
X
ALPHANINE SD INJ 500UNIT
Tier 3
X
AMICAR
SOL 0.25/ML
Tier 3
AMICAR
TAB 1000MG
Tier 3
AMICAR
TAB 500MG
Tier 3
AMINOCAPR AC SYP 25%
Tier 1
AMINOCAPR AC TAB 1000MG
Tier 1
Page 67 of 279
Therapeutic Class
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
Product Name
AMINOCAPR AC TAB 500MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
ARTISS
SOL 10ML
Tier 3
ARTISS
SOL 2ML
Tier 3
ARTISS
SOL 4ML
Tier 3
ASTRINGYN SOL 259MG/GM
Tier 3
BEBULIN
INJ 200-1200
Tier 3
X
BENEFIX
INJ 1000UNIT
Tier 3
X
BENEFIX
INJ 2000UNIT
Tier 3
X
BENEFIX
INJ 250UNIT
Tier 3
X
BENEFIX
INJ 3000UNIT
Tier 3
X
BENEFIX
INJ 500UNIT
Tier 3
X
KIT
Tier 3
X
EVICEL
KIT 2ML
Tier 3
EVICEL
KIT 5ML
Tier 3
CORIFACT
EVITHROM
FEIBA
SOL 800-1200
Tier 3
X
INJ
Tier 3
X
HELIXATE FS INJ 1000UNIT
Tier 3
X
HELIXATE FS INJ 2000UNIT
Tier 3
X
HELIXATE FS INJ 250UNIT
Tier 3
X
HELIXATE FS INJ 3000UNIT
Tier 3
X
HELIXATE FS INJ 500UNIT
Tier 3
X
HEMOFIL M INJ 1000UNIT
Tier 3
X
HEMOFIL M INJ 1700UNIT
Tier 3
X
HEMOFIL M INJ 220-400
Tier 3
X
HEMOFIL M INJ 250UNIT
Tier 3
X
HEMOFIL M INJ 500UNIT
Tier 3
X
HEMOFIL M SOL
Tier 3
X
HEMOFIL M SOL 801-1500
Tier 3
X
FEIBA NF
INJ
Tier 3
Page 68 of 279
Therapeutic Class
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
Product Name
HUMATE-P SOL 2400UNIT
Tier Value
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
HUMATE-P
SOL 250-600
Tier 3
X
HUMATE-P
SOL 500-1200
Tier 3
X
IXINITY
INJ 1000UNIT
Tier 4
X
X
IXINITY
INJ 1500UNIT
Tier 4
X
X
IXINITY
INJ 500UNIT
Tier 4
X
X
KOATE-DVI INJ 1000UNIT
Tier 3
X
KOATE-DVI INJ 250UNIT
Tier 3
X
KOATE-DVI INJ 500UNIT
Tier 3
X
KOGENATE FS INJ 1000/BS
Tier 3
X
KOGENATE FS INJ 1000UNIT
Tier 3
X
KOGENATE FS INJ 2000/BS
Tier 3
X
KOGENATE FS INJ 2000UNIT
Tier 3
X
KOGENATE FS INJ 250/BS
Tier 3
X
KOGENATE FS INJ 250UNIT
Tier 3
X
KOGENATE FS INJ 3000/BS
Tier 3
X
KOGENATE FS INJ 3000UNIT
Tier 3
X
KOGENATE FS INJ 500/BS
Tier 3
X
KOGENATE FS INJ 500UNIT
Tier 3
X
KOVALTRY
INJ 1000UNIT
Tier 4
X
X
KOVALTRY
INJ 2000UNIT
Tier 4
X
X
KOVALTRY
INJ 250UNIT
Tier 4
X
X
KOVALTRY
INJ 3000UNIT
Tier 4
X
X
KOVALTRY
INJ 500UNIT
Tier 4
X
X
MONOCLATE-P INJ 1000UNIT
Tier 3
X
MONOCLATE-P INJ 1500UNIT
Tier 3
X
MONOCLATE-P INJ 250UNIT
Tier 3
X
MONONINE
INJ 1000UNIT
Tier 3
X
MONONINE
INJ 500UNIT
Tier 3
X
Page 69 of 279
Therapeutic Class
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
Step
Therapy
Specialty
Tier 4
X
X
NOVOEIGHT INJ 1500UNIT
Tier 4
X
X
NOVOEIGHT INJ 2000UNIT
Tier 4
X
X
NOVOEIGHT INJ 250UNIT
Tier 4
X
X
NOVOEIGHT INJ 3000UNIT
Tier 4
X
X
NOVOEIGHT INJ 500UNIT
Tier 4
X
X
NOVOSEVEN RT INJ 1MG
Tier 3
X
NOVOSEVEN RT INJ 2MG
Tier 3
X
NOVOSEVEN RT INJ 5MG
Tier 3
X
NOVOSEVEN RT INJ 8MG
Tier 3
X
NUWIQ
INJ 1000UNIT
Tier 4
X
X
NUWIQ
INJ 2000UNIT
Tier 4
X
X
NUWIQ
INJ 250UNIT
Tier 4
X
X
NUWIQ
INJ 500UNIT
Tier 4
X
X
NUWIQ
KIT 1000UNIT
Tier 4
X
X
NUWIQ
KIT 2000UNIT
Tier 4
X
X
NUWIQ
KIT 250UNIT
Tier 4
X
X
NUWIQ
KIT 500UNIT
Tier 4
X
X
Product Name
MONSELS FERR SOL SUBSULF
Tier Value
Tier 1
NOVOEIGHT INJ 1000UNIT
Prior
Authorization
Supply
Limit
PROFILNINE INJ 1000UNIT
Tier 3
X
PROFILNINE INJ 1500UNIT
Tier 3
X
PROFILNINE INJ 500UNIT
Tier 3
X
RECOMBINATE INJ
Tier 3
X
RECOMBINATE INJ
Tier 3
X
RECOMBINATE INJ 220-400
Tier 3
X
RECOMBINATE INJ 401-800
Tier 3
X
RECOMBINATE INJ 801-1240
Tier 3
X
RECOTHROM SOL 20000UNT
Tier 3
RECOTHROM SOL 5000UNIT
Tier 3
Page 70 of 279
Therapeutic Class
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
Product Name
RIASTAP SOL 1GM
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
RIXUBIS
INJ 1000UNIT
Tier 3
X
RIXUBIS
INJ 2000UNIT
Tier 3
X
RIXUBIS
INJ 250 UNIT
Tier 3
X
RIXUBIS
INJ 3000UNIT
Tier 3
X
RIXUBIS
INJ 500UNIT
Tier 3
X
THROMBIN
KIT 5000UNIT
Tier 3
THROMBIN-JMI KIT 20000UNT
Tier 3
THROMBIN-JMI KIT 5000UNIT
Tier 3
THROMBOGEN KIT 10000UNT
Tier 3
THROMBOGEN SOL
10000UNT
THROMBOGEN SOL 1000UNIT
Tier 3
TISSEEL
KIT
Tier 3
TISSEEL
KIT
Tier 3
TISSEEL
KIT
Tier 3
TISSEEL
SOL
Tier 3
Tier 3
TISSEEL VH KIT 10ML
Tier 3
TISSEEL VH KIT 2ML
Tier 3
TISSEEL VH KIT 4ML
Tier 3
WILATE
INJ
Tier 3
X
WILATE
INJ
Tier 2
X
WILATE
INJ
Tier 3
X
WILATE
INJ
Tier 2
X
XYNTHA
INJ 1000UNIT
Tier 3
X
XYNTHA
INJ 2000UNIT
Tier 3
X
XYNTHA
INJ 250UNIT
Tier 3
X
XYNTHA
INJ 500UNIT
Tier 3
X
XYNTHA SOLOF INJ 1000UNIT
Tier 3
X
XYNTHA SOLOF INJ 2000UNIT
Tier 3
X
Page 71 of 279
Therapeutic Class
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - HEMOSTATICS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
BLOOD FORMATION,COAGULATION &
THROMBOSIS - IRON PREPARATIONS
Blood Products/Modifiers/Volume Expanders
Supply
Limit
Step
Therapy
Tier Value
Tier 3
XYNTHA SOLOF INJ 500UNIT
Tier 3
X
XYNTHA SOLOF KIT 250UNIT
Tier 3
X
ED CYTE F TAB
Tier 3
FER-IN-SOL DRO 15MG/ML
HCR Preventative
FER-IRON
DRO 15MG/ML
HCR Preventative
FEROSUL
ELX 220/5ML
HCR Preventative
FERROUS
DRO 15MG/ML
HCR Preventative
Specialty
X
FERROUS SULF DRO 15MG/ML HCR Preventative
FERROUS SULF ELX 220/5ML
HCR Preventative
FERROUS SULF SYP 300/5ML
HCR Preventative
HEMATINIC/FA TAB
Tier 1
HEMOCYTE-F TAB
Tier 1
IRON SUPPLMT DRO 15MG/ML HCR Preventative
PEDIA IRON DRO 15MG/ML
HCR Preventative
PROFERRIN- TAB FORTE
Tier 3
TANDEM F
Tier 3
BERINERT
Blood Products/Modifiers/Volume Expanders CINRYZE
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Prior
Authorization
Product Name
XYNTHA SOLOF INJ 3000UNIT
CAP
INJ 500UNIT
Tier 3
X
SOL 500 UNIT
Tier 4
X
ATROVENT HFA AER 17MCG
Tier 3
ATROVENT NAS SOL 0.03%
Tier 4
ATROVENT NAS SOL 0.06%
Tier 4
COMBIVENT AER 20-100
Tier 3
IPRATROPIUM SOL 0.02%INH
Tier 1
IPRATROPIUM SPR 0.03%
Tier 1
IPRATROPIUM SPR 0.06%
Tier 1
IPRATROPIUM/ SOL ALBUTER
Tier 1
IPRATROPIUM/ SOL SULFATE
Tier 1
SPIRIVA
Tier 4
AER 1.25MCG
Page 72 of 279
X
X
X
X
X
X
X
Therapeutic Class
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Anticholinergic Asthma/Lung Drugs
Bronchodilators, Phosphodiesterase Inhibitors
(Xanthines) - Asthma/Lung Drugs
Product Name
SPIRIVA CAP HANDIHLR
SPIRIVA
SPR 2.5MCG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
Tier 4
X
TUDORZA PRES AER 400/ACT
Tier 2
X
DIFIL-G FORT LIQ 100-100
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors ELIXOPHYLLIN ELX 80/15ML
(Xanthines) - Asthma/Lung Drugs
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors LUFYLLIN
(Xanthines) - Asthma/Lung Drugs
TAB 200MG
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors LUFYLLIN
(Xanthines) - Asthma/Lung Drugs
TAB 400MG
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24
(Xanthines) - Asthma/Lung Drugs
CAP 100MG CR
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24
(Xanthines) - Asthma/Lung Drugs
CAP 200MG CR
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24
(Xanthines) - Asthma/Lung Drugs
CAP 300MG CR
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEO-24
(Xanthines) - Asthma/Lung Drugs
CAP 400MG ER
Tier 3
Bronchodilators, Phosphodiesterase Inhibitors THEOCHRON TAB 100MG CR
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOCHRON TAB 200MG CR
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOCHRON TAB 300MG CR
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE SOL 80/15ML
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 100MG CR
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 100MG ER
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 200MG CR
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 200MG ER
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 300MG ER
(Xanthines) - Asthma/Lung Drugs
Tier 1
Page 73 of 279
Step
Therapy
Specialty
Supply
Limit
Step
Therapy
Tier 4
X
X
ADRENACLICK INJ 0.3MG
Tier 4
X
X
ADRENALIN SOL 1:1000
Tier 2
ALBUTEROL NEB 0.083%
Tier 1
ALBUTEROL NEB 0.5%
Tier 1
ALBUTEROL NEB 0.63MG/3
Tier 1
ALBUTEROL NEB 1.25MG/3
Tier 1
ALBUTEROL SYP 2MG/5ML
Tier 1
ALBUTEROL TAB 2MG
Tier 1
ALBUTEROL TAB 4MG
Tier 1
ALBUTEROL TAB 4MG ER
Tier 1
ALBUTEROL TAB 8MG ER
Tier 1
ANORO ELLIPT AER 62.5-25
Tier 3
X
ARCAPTA
Tier 3
X
Therapeutic Class
Product Name
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 400MG ER
(Xanthines) - Asthma/Lung Drugs
Tier Value
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 450MG ER
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE TAB 600MG ER
(Xanthines) - Asthma/Lung Drugs
Tier 1
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
ADRENACLICK INJ 0.15MG
CAP 75MCG
Prior
Authorization
AUVI-Q
INJ 0.15MG
Tier 4
X
X
AUVI-Q
INJ 0.3MG
Tier 4
X
X
BL DIXAPHEDR TAB 60MG
Tier 1
BROVANA
NEB 15MCG
Tier 3
X
EPINEPHRINE INJ 0.15MG
Tier 4
X
X
EPINEPHRINE INJ 0.3MG
Tier 4
X
X
EPIPEN 2-PAK INJ 0.3MG
Tier 2
X
EPIPEN-JR INJ 2-PAK
Tier 2
X
FORADIL
CAP AEROLIZE
Tier 3
X
GNP DIPHEDRY TAB 60MG
Tier 1
Page 74 of 279
Specialty
Therapeutic Class
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Bronchodilators, Sympathomimetic Asthma/Lung Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Product Name
GNP DIXAPHED TAB 12 HR
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
LEVALBUTEROL NEB 0.31MG
Tier 1
X
X
LEVALBUTEROL NEB 0.63MG
Tier 1
X
X
LEVALBUTEROL NEB 1.25/0.5
Tier 1
X
X
LEVALBUTEROL NEB 1.25MG
Tier 1
X
X
METAPROTEREN SYP
10MG/5ML
METAPROTEREN TAB 10MG
Tier 1
METAPROTEREN TAB 20MG
Tier 1
PERFOROMIST NEB 20MCG
Tier 3
X
PROAIR HFA AER
Tier 3
X
PROAIR RESPI AER
Tier 3
X
PROVENTIL AER HFA
Tier 3
X
SEREVENT DIS AER 50MCG
Tier 3
X
STRIVERDI AER 2.5MCG
Tier 2
X
TERBUTALINE POW SULFATE
Tier 3
TERBUTALINE TAB 2.5MG
Tier 1
TERBUTALINE TAB 5MG
Tier 1
VENTOLIN HFA AER
Tier 2
VOSPIRE ER TAB 4MG
Tier 1
VOSPIRE ER TAB 8MG
Tier 1
XOPENEX
NEB 0.31MG
Tier 4
X
X
XOPENEX
NEB 0.63MG
Tier 4
X
X
XOPENEX
NEB 1.25/3ML
Tier 4
X
X
XOPENEX CONC NEB 1.25/0.5
Tier 4
X
X
XOPENEX HFA AER
Tier 3
X
ADALAT CC TAB 30MG ER
Tier 4
ADALAT CC TAB 60MG ER
Tier 4
ADALAT CC TAB 90MG ER
Tier 4
AFEDITAB
Tier 1
TAB 30MG CR
Page 75 of 279
Tier 1
X
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Product Name
AFEDITAB TAB 60MG CR
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
AMLOD/ATORVA TAB 1010MG
AMLOD/ATORVA TAB 1020MG
AMLOD/ATORVA TAB 1040MG
AMLOD/ATORVA TAB 1080MG
AMLOD/ATORVA TAB 2.510MG
AMLOD/ATORVA TAB 2.520MG
AMLOD/ATORVA TAB 2.540MG
AMLOD/ATORVA TAB 5-10MG
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
Tier 1
X
X
AMLOD/ATORVA TAB 5-20MG
Tier 1
X
X
AMLOD/ATORVA TAB 5-40MG
Tier 1
X
X
AMLOD/ATORVA TAB 5-80MG
Tier 1
X
X
AMLOD/BENAZP CAP 10-20MG
Tier 1
X
AMLOD/BENAZP CAP 10-40MG
Tier 1
X
AMLOD/BENAZP CAP 2.510MG
AMLOD/BENAZP CAP 5-10MG
Tier 1
X
Tier 1
X
AMLOD/BENAZP CAP 5-20MG
Tier 1
X
AMLOD/BENAZP CAP 5-40MG
Tier 1
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB /HCTZ
Tier 1
X
X
AMLOD/VALSAR TAB 10160MG
AMLOD/VALSAR TAB 10320MG
AMLOD/VALSAR TAB 5-160MG
Tier 1
X
Tier 1
X
Tier 1
X
AMLOD/VALSAR TAB 5-320MG
Tier 1
X
AMLODIPINE TAB 10MG
Tier 1
AMLODIPINE TAB 2.5MG
Tier 1
Page 76 of 279
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Product Name
AMLODIPINE TAB 5MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
AZOR
TAB 10-20MG
Tier 4
X
X
AZOR
TAB 10-40MG
Tier 4
X
X
AZOR
TAB 5-20MG
Tier 4
X
X
AZOR
TAB 5-40MG
Tier 4
X
X
CADUET
TAB 10-10MG
Tier 4
X
X
CADUET
TAB 10-20MG
Tier 4
X
X
CADUET
TAB 10-40MG
Tier 4
X
X
CADUET
TAB 10-80MG
Tier 4
X
X
CADUET
TAB 2.5-10MG
Tier 4
X
X
CADUET
TAB 2.5-20MG
Tier 4
X
X
CADUET
TAB 2.5-40MG
Tier 4
X
X
CADUET
TAB 5-10MG
Tier 4
X
X
CADUET
TAB 5-20MG
Tier 4
X
X
CADUET
TAB 5-40MG
Tier 4
X
X
CADUET
TAB 5-80MG
Tier 4
X
X
CALAN
TAB 120MG
Tier 4
CALAN
TAB 80MG
Tier 4
CALAN SR
TAB 120MG
Tier 4
CALAN SR
TAB 180MG
Tier 4
CALAN SR
TAB 240MG
Tier 4
CARDIZEM
TAB 120MG
Tier 3
X
CARDIZEM
TAB 30MG
Tier 4
X
CARDIZEM
TAB 60MG
Tier 4
X
CARDIZEM CD CAP 120MG/24
Tier 4
X
CARDIZEM CD CAP 180MG/24
Tier 4
X
CARDIZEM CD CAP 240MG/24
Tier 4
X
CARDIZEM CD CAP 300MG/24
Tier 4
X
CARDIZEM CD CAP 360MG/24
Tier 4
X
Page 77 of 279
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
X
Product Name
CARDIZEM LA TAB 120MG
Tier Value
Tier 2
CARDIZEM LA TAB 180MG
Tier 4
X
CARDIZEM LA TAB 240MG
Tier 4
X
CARDIZEM LA TAB 300MG/24
Tier 4
X
CARDIZEM LA TAB 360MG
Tier 4
X
CARDIZEM LA TAB 420MG/24
Tier 4
X
CARTIA XT CAP 120/24HR
Tier 1
CARTIA XT CAP 180/24HR
Tier 1
CARTIA XT CAP 240/24HR
Tier 1
CARTIA XT CAP 300/24HR
Tier 1
DILTIAZEM CAP 120MG CD
Tier 1
DILTIAZEM CAP 120MG ER
Tier 1
DILTIAZEM CAP 120MG ER
Tier 1
DILTIAZEM CAP 120MG ER
Tier 1
DILTIAZEM CAP 120MG/24
Tier 1
DILTIAZEM CAP 180MG CD
Tier 1
DILTIAZEM CAP 180MG ER
Tier 1
DILTIAZEM CAP 180MG ER
Tier 1
DILTIAZEM CAP 180MG/24
Tier 1
DILTIAZEM CAP 240MG CD
Tier 1
DILTIAZEM CAP 240MG ER
Tier 1
DILTIAZEM CAP 240MG ER
Tier 1
DILTIAZEM CAP 240MG/24
Tier 1
DILTIAZEM CAP 300MG CD
Tier 1
DILTIAZEM CAP 300MG ER
Tier 1
DILTIAZEM CAP 300MG/24
Tier 1
DILTIAZEM CAP 360MG CD
Tier 1
DILTIAZEM CAP 360MG ER
Tier 1
DILTIAZEM CAP 360MG ER
Tier 1
Page 78 of 279
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Product Name
DILTIAZEM CAP 360MG/24
Tier Value
Tier 1
DILTIAZEM CAP 420MG/24
Tier 1
DILTIAZEM CAP 60MG ER
Tier 1
DILTIAZEM CAP 90MG ER
Tier 1
DILTIAZEM TAB 120MG
Tier 1
DILTIAZEM TAB 30MG
Tier 1
DILTIAZEM TAB 60MG
Tier 1
DILTIAZEM TAB 90MG
Tier 1
DILTIAZEM ER TAB 180MG
Tier 1
DILTIAZEM ER TAB 240MG
Tier 1
DILTIAZEM ER TAB 300MG
Tier 1
DILTIAZEM ER TAB 360MG
Tier 1
DILTIAZEM ER TAB 420MG
Tier 1
DILT-XR
CAP 120MG
Tier 1
DILT-XR
CAP 180MG
Tier 1
DILT-XR
CAP 240MG
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
EXFORGE
TAB 10-160MG
Tier 4
X
X
EXFORGE
TAB 10-320MG
Tier 4
X
X
EXFORGE
TAB 5-160MG
Tier 4
X
X
EXFORGE
TAB 5-320MG
Tier 4
X
X
EXFORGEH/10- TAB 160-12.5
Tier 4
X
X
EXFORGEH/10- TAB 160-25
Tier 4
X
X
EXFORGEH/10- TAB 320-25
Tier 4
X
X
EXFORGEH/5- TAB 160-12.5
Tier 4
X
X
EXFORGEH/5- TAB 160-25
Tier 4
X
X
FELODIPINE TAB 10MG ER
Tier 1
FELODIPINE TAB 2.5MG ER
Tier 1
FELODIPINE TAB 5MG ER
Tier 1
ISRADIPINE CAP 2.5MG
Tier 1
Page 79 of 279
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Product Name
ISRADIPINE CAP 5MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
LOTREL
CAP 10-20MG
Tier 4
X
LOTREL
CAP 10-40MG
Tier 4
X
LOTREL
CAP 2.5-10MG
Tier 4
X
LOTREL
CAP 5-10MG
Tier 4
X
LOTREL
CAP 5-20MG
Tier 4
X
LOTREL
CAP 5-40MG
Tier 4
X
MATZIM LA TAB 180MG/24
Tier 1
MATZIM LA TAB 240MG/24
Tier 1
MATZIM LA TAB 300MG/24
Tier 1
MATZIM LA TAB 360MG/24
Tier 1
MATZIM LA TAB 420MG/24
Tier 1
NICARDIPINE CAP 20MG
Tier 1
NICARDIPINE CAP 30MG
Tier 1
NIFEDICAL XL TAB 30MG
Tier 1
NIFEDICAL XL TAB 60MG
Tier 1
NIFEDIPINE CAP 10MG
Tier 1
NIFEDIPINE CAP 20MG
Tier 1
NIFEDIPINE TAB 30MG ER
Tier 1
NIFEDIPINE TAB 30MG ER
Tier 1
NIFEDIPINE TAB 60MG ER
Tier 1
NIFEDIPINE TAB 60MG ER
Tier 1
NIFEDIPINE TAB 90MG ER
Tier 1
NIFEDIPINE TAB 90MG ER
Tier 1
NIMODIPINE CAP 30MG
Tier 1
NISOLDIPINE TAB 17MG ER
Tier 1
NISOLDIPINE TAB 20MG
Tier 1
NISOLDIPINE TAB 25.5MG
Tier 1
NISOLDIPINE TAB 30MG
Tier 1
Page 80 of 279
Step
Therapy
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Product Name
NISOLDIPINE TAB 34MG ER
Tier Value
Tier 1
NISOLDIPINE TAB 40MG
Tier 1
NISOLDIPINE TAB 8.5MG ER
Tier 1
NORVASC
TAB 10MG
Tier 4
NORVASC
TAB 2.5MG
Tier 4
NORVASC
TAB 5MG
Tier 4
NYMALIZE
SOL 60/20ML
Tier 2
PROCARDIA CAP 10MG
Tier 4
PROCARDIA XL TAB 30MG CR
Tier 4
PROCARDIA XL TAB 60MG CR
Tier 4
PROCARDIA XL TAB 90MG CR
Tier 4
SULAR
TAB 17MG
Tier 4
SULAR
TAB 34MG
Tier 4
SULAR
TAB 8.5MG
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
TAZTIA XT CAP 120MG/24
Tier 1
TAZTIA XT CAP 180MG/24
Tier 1
TAZTIA XT CAP 240MG/24
Tier 1
TAZTIA XT CAP 300MG/24
Tier 1
TAZTIA XT CAP 360MG/24
Tier 1
TELMIS/AMLOD TAB 40-10MG
Tier 1
X
X
TELMIS/AMLOD TAB 40-5MG
Tier 1
X
X
TELMIS/AMLOD TAB 80-10MG
Tier 1
X
X
TELMIS/AMLOD TAB 80-5MG
Tier 1
X
X
TIAZAC
CAP 120MG/24
Tier 4
TIAZAC
CAP 180MG/24
Tier 4
TIAZAC
CAP 240MG/24
Tier 4
TIAZAC
CAP 300MG/24
Tier 4
TIAZAC
CAP 360MG/24
Tier 4
TIAZAC
CAP 420MG/24
Tier 4
Page 81 of 279
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Product Name
TRIBENZOR20- TAB 5-12.5MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
TRIBENZOR40- TAB 10-12.5
Tier 4
X
X
TRIBENZOR40- TAB 10-25MG
Tier 4
X
X
TRIBENZOR40- TAB 5-12.5MG
Tier 4
X
X
TRIBENZOR40- TAB 5-25MG
Tier 4
X
X
TWYNSTA
TAB 40-10MG
Tier 4
X
X
TWYNSTA
TAB 40-5MG
Tier 4
X
X
TWYNSTA
TAB 80-10MG
Tier 4
X
X
TWYNSTA
TAB 80-5MG
Tier 4
X
X
VERAPAMIL CAP 100MG ER
Tier 1
VERAPAMIL CAP 120MG ER
Tier 1
VERAPAMIL CAP 120MG SR
Tier 1
VERAPAMIL CAP 180MG ER
Tier 1
VERAPAMIL CAP 180MG SR
Tier 1
VERAPAMIL CAP 200MG ER
Tier 1
VERAPAMIL CAP 240MG ER
Tier 1
VERAPAMIL CAP 240MG SR
Tier 1
VERAPAMIL CAP 300MG ER
Tier 1
VERAPAMIL CAP 360MG SR
Tier 1
VERAPAMIL TAB 120MG
Tier 1
VERAPAMIL TAB 120MG ER
Tier 1
VERAPAMIL TAB 180MG ER
Tier 1
VERAPAMIL TAB 240MG ER
Tier 1
VERAPAMIL TAB 40MG
Tier 1
VERAPAMIL TAB 80MG
Tier 1
VERELAN
CAP 120MG SR
Tier 4
VERELAN
CAP 180MG SR
Tier 4
VERELAN
CAP 240MG SR
Tier 4
VERELAN
CAP 360MG SR
Tier 4
Page 82 of 279
Specialty
Therapeutic Class
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Blocking Agents - Blood
Pressure Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Calcium Channel Modifying Agents - Seizure
Control Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Product Name
VERELAN PM CAP 100MG ER
Tier Value
Tier 4
VERELAN PM CAP 200MG ER
Tier 4
VERELAN PM CAP 300MG ER
Tier 4
CELONTIN
Tier 2
CAP 300MG
Prior
Authorization
Supply
Limit
Step
Therapy
ETHOSUXIMIDE CAP 250MG
Tier 1
ETHOSUXIMIDE SOL 250/5ML
Tier 1
LYRICA
CAP 100MG
Tier 4
X
X
LYRICA
CAP 150MG
Tier 4
X
X
LYRICA
CAP 200MG
Tier 4
X
X
LYRICA
CAP 225MG
Tier 4
X
X
LYRICA
CAP 25MG
Tier 4
X
X
LYRICA
CAP 300MG
Tier 4
X
X
LYRICA
CAP 50MG
Tier 4
X
X
LYRICA
CAP 75MG
Tier 4
X
X
LYRICA
SOL 20MG/ML
Tier 4
X
X
ZARONTIN
CAP 250MG
Tier 4
ZARONTIN
SOL 250/5ML
Tier 4
ZONEGRAN
CAP 100MG
Tier 4
X
X
ZONEGRAN
CAP 25MG
Tier 4
X
X
ZONISAMIDE CAP 100MG
Tier 1
ZONISAMIDE CAP 25MG
Tier 1
ZONISAMIDE CAP 50MG
Tier 1
AMTURNIDE150 TAB -5-12.5
Tier 4
X
X
AMTURNIDE300 TAB -10-12.5
Tier 4
X
X
AMTURNIDE300 TAB -1025MG
AMTURNIDE300 TAB -5-12.5
Tier 4
X
X
Tier 4
X
X
AMTURNIDE300 TAB -5-25MG
Tier 4
X
X
DEMSER
CAP 250MG
Tier 3
DIGITEK
TAB 0.125MG
Tier 1
Page 83 of 279
Specialty
Therapeutic Class
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
Cardiovascular Agents, Other - Miscellaneous
Cardiac Drugs
CARDIOVASCULAR DRUGS - CALCIUMCHANNEL BLOCKING AGENTS
CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS,
MISCELLANEOUS
CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS,
MISCELLANEOUS
Product Name
DIGITEK TAB 0.25MG
Tier Value
Tier 1
DIGOX
TAB 0.125MG
Tier 1
DIGOX
TAB 0.25MG
Tier 1
DIGOXIN
SOL 50MCG/ML
Tier 1
DIGOXIN
TAB 0.125MG
Tier 1
DIGOXIN
TAB 0.25MG
Tier 1
LANOXIN
TAB 0.0625MG
Tier 3
LANOXIN
TAB 0.125MG
Tier 3
LANOXIN
TAB 0.1875MG
Tier 3
LANOXIN
TAB 0.25MG
Tier 3
PENTOXIFYLLI TAB 400MG ER
Tier 1
RANEXA
TAB 1000MG
Tier 2
RANEXA
TAB 500MG
Tier 2
Prior
Authorization
Supply
Limit
Step
Therapy
TEKAMLO
TAB 150-10MG
Tier 4
X
X
TEKAMLO
TAB 150-5MG
Tier 4
X
X
TEKAMLO
TAB 300-10MG
Tier 4
X
X
TEKAMLO
TAB 300-5MG
Tier 4
X
X
TEKTURNA
TAB 150MG
Tier 3
X
TEKTURNA
TAB 300MG
Tier 3
X
TEKTURNA HCT TAB 150-12.5
Tier 3
X
TEKTURNA HCT TAB 150-25MG
Tier 3
X
TEKTURNA HCT TAB 300-12.5
Tier 3
X
TEKTURNA HCT TAB 300-25MG
Tier 3
X
TRENTAL
TAB 400MG
Tier 3
VECAMYL
TAB 2.5MG
Tier 4
KRISGEL 100 GEL
Tier 3
ISOMETH/APAP CAP DICHLOR
Tier 1
ISOMETH/CAFF TAB /APAP
Tier 1
Page 84 of 279
X
Specialty
X
Therapeutic Class
CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS,
MISCELLANEOUS
CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS,
MISCELLANEOUS
CENTRAL NERVOUS SYSTEM AGENTS ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC
Product Name
NODOLOR CAP
TRYPTOPHAN CAP 500MG
Tier 3
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
CENTRAL NERVOUS SYSTEM AGENTS INHALATION ANESTHETICS
Central Nervous System, Other Miscellaneous Central Nervous System Drugs
FORANE
Tier 2
PRODRIN
Tier Value
Tier 1
TAB
Prior
Authorization
Supply
Limit
Tier 4
SOL
ISOFLURANE SOL
Tier 1
SEVOFLURANE SOL
Tier 1
SOJOURN
SOL
Tier 1
SUPRANE
INH
Tier 2
SUPRANE
SOL
Tier 2
TERRELL
SOL
Tier 1
ULTANE
SOL
Tier 3
Tier 1
X
Central Nervous System, Other BUT/APAP/CAF CAP CODEINE
Miscellaneous Central Nervous System Drugs
Tier 1
X
Central Nervous System, Other FIORICET
Miscellaneous Central Nervous System Drugs
CAP CODEINE
Tier 4
X
Central Nervous System, Other HETLIOZ
Miscellaneous Central Nervous System Drugs
CAP 20MG
Tier 4
Central Nervous System, Other RILUTEK
Miscellaneous Central Nervous System Drugs
Central Nervous System, Other RILUZOLE
Miscellaneous Central Nervous System Drugs
CAP 20-10MG
TAB 50MG
TAB 50MG
Specialty
X
BUT/APAP/CAF CAP CODEINE
Central Nervous System, Other NUEDEXTA
Miscellaneous Central Nervous System Drugs
Step
Therapy
X
X
X
X
X
Tier 2
Tier 4
Tier 1
Central Nervous System, Other TETRABENAZIN TAB 12.5MG
Miscellaneous Central Nervous System Drugs
Tier 1
X
Central Nervous System, Other TETRABENAZIN TAB 25MG
Miscellaneous Central Nervous System Drugs
Tier 1
X
Central Nervous System, Other XENAZINE
Miscellaneous Central Nervous System Drugs
TAB 12.5MG
Tier 4
X
X
Central Nervous System, Other XENAZINE
Miscellaneous Central Nervous System Drugs
TAB 25MG
Tier 4
X
X
Page 85 of 279
Therapeutic Class
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Product Name
ARICEPT TAB 10MG
Tier Value
Tier 3
ARICEPT
TAB 23MG
Tier 4
ARICEPT
TAB 5MG
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
X
DONEPEZIL TAB 10MG
Tier 1
DONEPEZIL TAB 10MG ODT
Tier 1
DONEPEZIL TAB 5MG
Tier 1
DONEPEZIL TAB 5MG ODT
Tier 1
DONEPEZIL TAB HCL 23MG
Tier 1
EXELON
CAP 1.5MG
Tier 3
EXELON
CAP 3MG
Tier 4
EXELON
CAP 4.5MG
Tier 4
EXELON
CAP 6MG
Tier 4
EXELON
DIS 13.3/24
Tier 4
X
EXELON
DIS 4.6MG/24
Tier 4
X
EXELON
DIS 9.5MG/24
Tier 4
X
GALANTAMINE CAP 16MG ER
Tier 1
GALANTAMINE CAP 24MG ER
Tier 1
GALANTAMINE CAP 8MG ER
Tier 1
GALANTAMINE SOL 4MG/ML
Tier 1
GALANTAMINE TAB 12MG
Tier 1
GALANTAMINE TAB 4MG
Tier 1
GALANTAMINE TAB 8MG
Tier 1
RAZADYNE
TAB 12MG
Tier 4
RAZADYNE
TAB 4MG
Tier 4
RAZADYNE
TAB 8MG
Tier 4
RAZADYNE ER CAP 16MG
Tier 4
RAZADYNE ER CAP 24MG
Tier 4
RAZADYNE ER CAP 8MG
Tier 4
RIVASTIGMINE CAP 1.5MG
Tier 1
Page 86 of 279
X
Specialty
Therapeutic Class
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Cholinesterase Inhibitors - Alzheimer's
Disease and Dementia Drugs
Coagulants - Blood Clotting Drugs
Coagulants - Blood Clotting Drugs
Coagulants - Blood Clotting Drugs
Coagulants - Blood Clotting Drugs
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
Conventional - Mood Disorder Drugs
Product Name
RIVASTIGMINE CAP 3MG
Tier Value
Tier 1
RIVASTIGMINE CAP 4.5MG
Tier 1
RIVASTIGMINE CAP 6MG
Tier 1
RIVASTIGMINE DIS 13.3/24
Tier 1
RIVASTIGMINE DIS 4.6MG/24
Tier 1
RIVASTIGMINE DIS 9.5MG/24
Tier 1
BRILINTA TAB 60MG
BRILINTA TAB 90MG
LYSTEDA TAB 650MG
TRANEX ACID TAB 650MG
CAYA
DPR
FC FEMALE MIS CONDOM
OMNIFLEX DPR
WIDE-SEAL DPR KIT 60
WIDE-SEAL DPR KIT 65
WIDE-SEAL DPR KIT 70
WIDE-SEAL DPR KIT 75
WIDE-SEAL DPR KIT 80
WIDE-SEAL DPR KIT 85
WIDE-SEAL DPR KIT 90
WIDE-SEAL DPR KIT 95
MOLINDONE TAB HCL 10MG
Tier 4
Tier 4
Tier 3
Tier 1
Tier 3
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
Tier 1
Conventional - Mood Disorder Drugs
MOLINDONE TAB HCL 25MG
Tier 1
Conventional - Mood Disorder Drugs
DENTAL AGENTS
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dental and Oral Agents
Dermatological Agents - Drugs to Treat Skin
Conditions
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
MOLINDONE TAB HCL 5MG
HURRISEAL SOL
CEVIMELINE CAP 30MG
CHLORHEX GLU SOL 0.12%
EVOXAC
CAP 30MG
ORALONE PST 0.1%
PAROEX
SOL 0.12%
PERIDEX SOL 0.12%
PERIOGARD SOL 0.12%
PILOCARPINE TAB 5MG
PILOCARPINE TAB 7.5MG
SALAGEN TAB 5MG
SALAGEN TAB 7.5MG
TRIAMCIN/ORA PST 0.1%
TRIAMCINOLON PST 0.1%
MIRVASO GEL 0.33%
Tier 1
Tier 3
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 4
8-MOP
ABSORICA
ABSORICA
ABSORICA
ABSORICA
ABSORICA
ABSORICA
ACANYA
ACITRETIN
ACITRETIN
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
CAP 10MG
CAP 10MG
CAP 20MG
CAP 25MG
CAP 30MG
CAP 35MG
CAP 40MG
GEL 1.2-2.5%
CAP 10MG
CAP 17.5MG
Page 87 of 279
Prior
Authorization
Supply
Limit
X
X
X
X
X
X
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Prior
Authorization
Supply
Limit
Therapeutic Class
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Product Name
ACITRETIN CAP 25MG
ACZONE
GEL 5%
ACZONE
GEL 7.5%
ADAPALENE CRE 0.1%
ADAPALENE GEL 0.1%
ADAPALENE GEL 0.3%
ADAPALENE GEL PMP 0.3%
ADAPALENE LOT 0.1%
ALDARA
CRE 5%
AMNESTEEM CAP 10MG
AMNESTEEM CAP 20MG
AMNESTEEM CAP 40MG
ATRALIN GEL 0.05%
ATRAPRO DERM SPR
AVITA
CRE 0.025%
AVITA
GEL 0.025%
AZELEX
CRE 20%
BEAU RX GEL
BENZACLIN GEL 1-5%
BENZACLIN GEL 1-5%PUMP
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
BENZAMYCIN GEL 5-3%
BENZAMYCIN GEL PAK
CALCIPOTRIEN CRE 0.005%
CALCIPOTRIEN OIN 0.005%
CALCIPOTRIEN OIN BETAMETH
Tier 2
Tier 3
Tier 1
Tier 1
Tier 1
X
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
CALCIPOTRIEN SOL 0.005%
CALCITRENE OIN 0.005%
CALCITRIOL OIN 3MCG/GM
CARAC
CRE 0.5%
CLARAVIS CAP 10MG
CLARAVIS CAP 20MG
CLARAVIS CAP 30MG
CLARAVIS CAP 40MG
CLEOCIN-T GEL 1%
CLEOCIN-T LOT 1%
CLEOCIN-T PAD 1%
CLEOCIN-T SOL 1%
CLINDACIN KIT ETZ 1%
CLINDACIN KIT PAC 1%
CLINDACIN MIS ETZ 1%
CLINDACIN-P PAD 1%
CLINDAGEL GEL 1%
CLINDAMAX GEL 1%
CLINDAMY/BEN GEL 1.2-5%
CLINDAMY/BEN GEL 1-5%
CLINDAMYCIN AER 1%
CLINDAMYCIN GEL 1%
CLINDAMYCIN GEL TRETINOI
Tier 1
Tier 3
Tier 1
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
X
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
CLINDAMYCIN LOT 1%
CLINDAMYCIN LOT 10MG/ML
Tier 1
Tier 1
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
CLINDAMYCIN PAD 1%
CLINDAMYCIN SOL 1%
CONDYLOX GEL 0.5%
CONDYLOX SOL 0.5%
Tier 1
Tier 1
Tier 3
Tier 4
Page 88 of 279
Tier Value
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 4
Tier 1
Tier 1
Tier 1
Tier 4
Tier 3
Tier 1
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Product Name
CVS SCAR GEL
DERMASORB HC KIT 2%
DICLOFENAC GEL 3%
DIFFERIN CRE 0.1%
DIFFERIN GEL 0.1%
DIFFERIN GEL 0.3%
DIFFERIN LOT 0.1%
DOVONEX CRE 0.005%
DOXEPIN HCL CRE 5%
DUAC
GEL 1.2-5%
EFUDEX
CRE 5%
ELIDEL
CRE 1%
ENSTILAR AER
EPIDUO
GEL 0.1-2.5%
EPIDUO FORTE GEL 0.3-2.5%
EQL SCAR GEL
ERYTHROMYCIN GEL /BENZOYL
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
EVOCLIN AER 1%
FABIOR
AER 0.1%
FINACEA AER 15%
FINACEA GEL 15%
FLUOROPLEX CRE 1%
FLUOROURACIL CRE 0.5%
FLUOROURACIL CRE 5%
FLUOROURACIL DRO 2%
FLUOROURACIL DRO 5%
FLUOROURACIL SOL 2%
FLUOROURACIL SOL 5%
GLYCERIN LIQ
GLYCERIN LIQ
GLYCERIN LIQ
GLYCERIN LIQ
GLYCERINE LIQ
GLYCEROL LIQ FORMAL
IMIQUIMOD CRE 5%
KLARON
LOT 10%
LACTIC ACID LOT 10%
LAVARE WOUND GEL WASH
LEVULAN KERA SOL 20%
MEDERMA CRE SPF 30
MEDERMA GEL
MEDERMA FOR GEL KIDS
MENCAPS PAD
METHOXSALEN CAP 10MG
MYORISAN CAP 10MG
MYORISAN CAP 20MG
MYORISAN CAP 30MG
MYORISAN CAP 40MG
NEO-SYNALAR CRE
NEUAC
GEL 1.2-5%
ONEXTON GEL 1.2-3.75
OXSORALEN LOT 1%
OXSORALEN-UL CAP 10MG
PODOCON SOL 25%
PODOFILOX SOL 0.5%
PROTOPIC OIN 0.03%
PROTOPIC OIN 0.1%
Page 89 of 279
Tier Value
Tier 1
Tier 4
Tier 1
Tier 3
Tier 3
Tier 4
Tier 3
Tier 4
Tier 1
Tier 4
Tier 4
Tier 3
Tier 4
Tier 3
Tier 4
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Tier 3
Tier 1
Tier 4
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 4
Tier 3
Tier 2
Tier 1
Tier 1
Tier 4
Tier 4
Prior
Authorization
X
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Tier 4
Tier 4
Tier 4
X
X
X
X
X
X
X
X
X
RETINOIC ACD POW
RETINOIC ACD POW ALL TRAN
Tier 4
Tier 4
X
X
SANTYL
OIN 250/GM
SCAR
GEL
SCARCIN CRE
SELENIUM SUL LOT 2.5%
SKARJEL GEL
SOLARAZE GEL 3% W/W
SORIATANE CAP 10MG
SORIATANE CAP 17.5MG
SORIATANE CAP 25MG
SORILUX AER 0.005%
STELARA INJ 45MG/0.5
STELARA INJ 90MG/ML
SULFACETAMID LOT 10%
SULFACETAMID SUS 10%
SYNALAR KIT 0.025%
SYNALAR KIT 0.025%
TACLONEX OIN
TACLONEX SUS
TACROLIMUS OIN 0.03%
TACROLIMUS OIN 0.1%
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
TERSI FOAM AER 2.25%
TOLAK
CRE 4%
TRAMADOL CRE 5%
TRAMADOL CRE 8% KIT
TRETINOIN CRE 0.025%
TRETINOIN CRE 0.05%
TRETINOIN CRE 0.1%
TRETINOIN GEL 0.01%
TRETINOIN GEL 0.025%
TRETINOIN GEL 0.04%
TRETINOIN GEL 0.04%PMP
TRETINOIN GEL 0.05%
TRETINOIN GEL 0.1%
TRETINOIN GEL 0.1%PUMP
TRETINOIN POW
Tier 3
Tier 1
Tier 3
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 1
Tier 4
Therapeutic Class
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Product Name
PRUDOXIN CRE 5%
RA SCAR GEL
RECEDO
GEL
REGRANEX GEL 0.01%
RETIN-A CRE 0.025%
RETIN-A CRE 0.05%
RETIN-A CRE 0.1%
RETIN-A GEL 0.01%
RETIN-A GEL 0.025%
RETIN-A MICR GEL 0.04%
RETIN-A MICR GEL 0.04%PMP
Tier Value
Tier 1
Tier 1
Tier 3
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
RETIN-A MICR GEL 0.08%
RETIN-A MICR GEL 0.1%
RETIN-A MICR GEL 0.1%PUMP
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Page 90 of 279
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
Dermatological Agents - Skin Agents
DEVICES
Product Name
TRETIN-X CRE 0.0375%
TRETIN-X CRE 0.075%
TRETIN-X CRE KIT 0.05%
VECTICAL OIN 3MCG/GM
VELTIN
GEL
VEREGEN OIN 15%
ZENATANE CAP 10MG
ZENATANE CAP 20MG
ZENATANE CAP 30MG
ZENATANE CAP 40MG
ZIANA
GEL
ZONALON CRE 5%
ZYCLARA CRE 3.75%
ZYCLARA PUMP CRE 2.5%
ZYCLARA PUMP CRE 3.75%
AERCHMBR PLS MIS FLOW-VU
Tier Value
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
DEVICES
AERCHMBR PLS MIS LRG MASK
Tier 2
DEVICES
AERCHMBR PLS MIS SM MASK
Tier 2
DEVICES
DEVICES
DEVICES
DEVICES
DEVICES
DEVICES
DEVICES
DEVICES
DEVICES
AEROCHAMBER MIS PLUS
EASIVENT MIS
EASIVENT MIS MASK LG
EASIVENT MIS MASK SM
EASIVENT MIS MASK MED
E-Z SPACER MIS
E-Z SPACER MIS BODY GRD
FLEXICHAMBER MIS
FLEXICHAMBER MIS MASK LRG
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
DEVICES
FLEXICHAMBER MIS MASK SM
Tier 2
DEVICES
DEVICES
INSPIRACHAMB MIS LARGE
INSPIRACHAMB MIS MEDIUM
Tier 2
Tier 2
DEVICES
Tier 2
DEVICES
DEVICES
DEVICES
DEVICES
INSPIRACHAMB MIS
MOUTHPCE
INSPIRACHAMB MIS SMALL
INSPIREASE MIS BAGS
INSPIREASE MIS DD SYST
INSPIREASE MIS MOUTHPCE
DEVICES
DEVICES
INSPIREASE MIS RES BAG
MASK VORTEX/ MIS BABY DUC
Tier 2
Tier 2
DEVICES
DEVICES
DEVICES
MASK VORTEX/ MIS DUCK
MASK VORTEX/ MIS FROG
MASK VORTEX/ MIS LADY BUG
Tier 2
Tier 2
Tier 2
DEVICES
DEVICES
OPTIHALER MIS
VORTEX VALVE MIS CHAMBER
Tier 2
Tier 2
DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
WATCHHALER MIS
AUTOJECT 2 MIS
CGMS SYSTEM MIS GOLD
GUARDIAN RT KIT
GUARDIAN RT KIT STARTER
Tier 2
Tier 4
Tier 3
Tier 3
Tier 3
Page 91 of 279
Prior
Authorization
X
X
Supply
Limit
X
X
X
X
X
X
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
Specialty
X
X
X
X
X
Tier 2
Tier 2
Tier 2
Tier 2
X
X
X
X
X
X
X
Therapeutic Class
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
Product Name
GUARDIAN RT KIT SYST PED
GUARDIAN RT KIT SYSTEM
GUARDIAN RT MIS REPL PED
Tier Value
Tier 3
Tier 3
Tier 3
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
Tier 3
Tier 3
Tier 4
DIABETIC DEVICES
GUARDIAN RT MIS REPLACE
GUARDIAN RT MIS SYSTEM
HUMATROPEN MIS FOR
12MG
HUMATROPEN MIS FOR
24MG
HUMATROPEN MIS FOR 6MG
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC DEVICES
DIABETIC SUPPLIES
DIABETIC DEVICES
Prior
Authorization
X
X
X
Supply
Limit
X
X
X
X
X
X
X
Step
Therapy
Specialty
X
Tier 4
X
Tier 4
X
NORDIPEN 5 MIS DEVICE
NORDIPEN DEL MIS SYSTEM
OMNITROPE 5 MIS DEVICE
PCA INJECTOR MIS
REAL-TIME KIT
ACCU-CHEK KIT AVA CONN
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
X
X
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
ACCU-CHEK
KIT AVIVA PL
KIT COMPACT
KIT FASTCLIX
KIT MLTICLIX
KIT NANO
KIT SOFTCLIX
KIT VOICEMAT
LIQ ACT/GLUC
LIQ COMPACT
LIQ SMART
MIS ADAPTER
MIS AVIVA
MIS BATTERY
MIS CLIP
MIS MLTICLIX
MIS SPRT COM
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 4
Tier 3
Tier 3
Tier 1
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ACCU-CHEK SOL
ACCU-CHEK SOL COMFORT
ACCU-CHEK SOL COMPACT
ACCU-CHEK IN LIQ CONTROL
Tier 1
Tier 1
Tier 1
Tier 1
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ACCUTREND SOL GLUCOSE
ADV LANCING MIS DEVICE
ASCENSIA LIQ NORM CON
ASSURE CMFRT MIS 28G
ASSURE CMFRT MIS 30G
AT LAST KIT GLUCOSE
AT LAST MIS LANCETS
AURORA LANCE MIS 30G
AURORA LANCE MIS THIN 23G
Tier 1
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
AUTODISC LIQ LOW/HIGH
AUTOLET II KIT CLINISAF
AUTOLET LANC MIS DEVICE
AUTOLET LITE KIT STARTER
AUTOLET MINI MIS
AUTOPEN MIS 1-21UNIT
AUTOPEN MIS 2-42UNIT
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Page 92 of 279
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Prior
Authorization
X
Supply
Limit
X
Therapeutic Class
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
Product Name
BAYER BREEZE KIT 2 SYSTEM
BAYER BREEZE LIQ HIGH CNT
BAYER BREEZE LIQ LOW CNTL
Tier Value
Tier 3
Tier 2
Tier 2
DIABETIC SUPPLIES
BAYER BREEZE LIQ NORM CNT
Tier 2
DIABETIC SUPPLIES
BAYER MICRLT MIS LANC DVC
Tier 3
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
BAYER MICRLT MIS LANCETS
BLOOD GLUC MIS MONITOR
Tier 3
Tier 3
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
BREEZE 2 MIS SYSTEM
CAREONE ADV MIS LANCING
Tier 4
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
CAREONE LANC MIS 28G
CAREONE LANC MIS THIN 23G
Tier 3
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
CARTRIDGE MIS 3.15ML
CARTRIDGE MIS IR 1000
CARTRIDGE MIS IR 1200
CARTRIDGE MIS PUMP
CGMS
MIS SOFTWARE
CGMS CABLE MIS
CHEMSTRIP BG MIS LOG
CHOICE DM KIT RISK TST
COAGUCHEK MIS LANCETS
COMFORT MIS LANCETS
COMFORT SET MIS 23"/17MM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 2
DIABETIC SUPPLIES
COMFORT SET MIS 31"/17MM
Tier 2
DIABETIC SUPPLIES
COMFORT SET MIS 32"/17MM
Tier 2
DIABETIC SUPPLIES
COMFORT SET MIS 43"/17MM
Tier 2
DIABETIC SUPPLIES
Tier 2
DIABETIC SUPPLIES
COMFORT SHRT MIS
23"/13MM
COMFORT SHRT MIS
31"/13MM
COMFORT SHRT MIS
32"/13MM
COMFORT SHRT MIS
43"/13MM
COMFORTOUCH MIS LANCET
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
CONTOUR
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
KIT LINK
KIT MONITOR
KIT NEXT
KIT NEXT EZ
KIT NEXT LNK
KIT NEXT USB
LIQ HIGH CNT
LIQ LOW CNTL
LIQ NORM CNT
MIS MONITOR
MIS MONITOR
SOL NEXT
SOL NEXT
Page 93 of 279
X
X
X
Step
Therapy
X
X
X
X
X
X
X
X
X
Tier 2
Tier 2
Tier 2
Tier 3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
DIABETIC SUPPLIES
Product Name
CONTROL HIGH SOL UNISTRIP
Tier Value
Tier 2
DIABETIC SUPPLIES
CONTROL LOW SOL UNISTRIP
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
CONTROL SOL LIQ HI/MID/L
CONTROL SOL LIQ HIGH/LOW
Tier 2
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
CONTROL SOL LIQ MID
CVS LANCETS MIS ORIGINAL
Tier 2
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
CVS LANCETS MIS THIN 26G
CVS LANCETS MIS THIN 33G
DIDGET
KIT
EASYMAX SOL HIGH
EASYMAX SOL LOW
EASYMAX SOL NORMAL
EASYMAX 15 SOL LEVEL 1
EASYMAX 15 SOL LEVEL 2
EASYMAX L KIT SYSTEM
EASYMAX L MIS SYSTEM
EASYMAX N KIT SYSTEM
EASYMAX N MIS SYSTEM
EASYMAX NG KIT SYSTEM
EASYMAX NG MIS SYSTEM
EASYMAX V KIT SYSTEM
EASYMAX V MIS SYSTEM
EASYMAX V2 KIT SYSTEM
EASYMAX V2 MIS SYSTEM
EASYPLS R13N KIT SYSTEM
EASYPLUS V KIT SYSTEM
EMBRACE MIS
EMBRACE SOL LOW
ENLITE
MIS SERTER
ENLITE GLUCO MIS SENSOR
FASTCLIX MIS LANCETS
FINGERSTIX MIS LANCETS
FLEXLINK MIS PLS/10MM
FLEXLINK MIS PLUS/6MM
FLEXLINK MIS PLUS/8MM
FORA GD50 MIS MONITOR
FORA TEST N' MIS GO
FORTISCARE KIT SYSTEM
FORTISCARE SOL CNTL HI
FORTISCARE SOL CNTL LOW
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Tier 1
Tier 3
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
DIABETIC SUPPLIES
FORTISCARE SOL CNTL NML
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
FREESTYLE
GENTLE-LET
GENTLE-LET
GENTLE-LET
GENTLE-LET
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
GLUC CONTROL SOL LEVEL 1
GLUC CONTROL SOL LEVEL 2
GLUCOLET 2 MIS LANCING
GLUCOSE CONT LIQ HIGH/LOW
MIS UNISTICK
MIS 26G
MIS 28G
MIS LANCETS
MIS PLATFORM
Page 94 of 279
Tier 2
Tier 2
Tier 3
Tier 2
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Supply
Limit
Step
Therapy
Tier 3
Tier 3
Tier 4
X
X
X
X
GMATE SMART KIT METER
GMATE SMART KIT STARTER
GMATE VOICE MIS GLUC SYS
Tier 4
Tier 3
Tier 4
X
X
X
X
X
X
DIABETIC SUPPLIES
GUARDIAN
MIS TRANSMTR
Tier 3
DIABETIC SUPPLIES
GUARDIAN RT MIS CHARGER
Tier 3
X
DIABETIC SUPPLIES
GUARDIAN RT MIS SOFTWARE
Tier 3
X
DIABETIC SUPPLIES
GUARDIAN RT MIS TST PLUG
Tier 3
X
DIABETIC SUPPLIES
Tier 3
X
DIABETIC SUPPLIES
HAEMOLANCE MIS LOW
FLOW
HAEMOLANCE MIS RETRACT
Tier 3
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
HUMAPEN MIS LUXURA
IN TOUCH MIS
INFUSION SET MIS 23"
INFUSION SET MIS 23" 13MM
Tier 3
Tier 3
Tier 2
Tier 2
DIABETIC SUPPLIES
INFUSION SET MIS 23" 17MM
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
INFUSION SET MIS 23" 6MM
INFUSION SET MIS 23" 8MM
INFUSION SET MIS 23" 9MM
INFUSION SET MIS 23"/6MM
INFUSION SET MIS 23"/9MM
INFUSION SET MIS 24"
INFUSION SET MIS 24" 6MM
INFUSION SET MIS 24" 9MM
INFUSION SET MIS 31"
INFUSION SET MIS 31" 6MM
INFUSION SET MIS 31" 9MM
INFUSION SET MIS 32" 8MM
INFUSION SET MIS 42" 6MM
INFUSION SET MIS 42" 9MM
INFUSION SET MIS 43"
INFUSION SET MIS 43" 13MM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
DIABETIC SUPPLIES
INFUSION SET MIS 43" 17MM
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
INFUSION SET MIS 43" 6MM
INFUSION SET MIS 43" 8MM
INFUSION SET MIS 43" 9MM
INFUSION SET MIS 43"/6MM
INFUSION SET MIS 43"/9MM
KROGER BGM KIT
LANCET ALTER MIS SITE 26G
LANCET CARRY MIS CASE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Therapeutic Class
DIABETIC SUPPLIES
Product Name
GLUCOSE CONT SOL PRECISIO
Tier Value
Tier 2
DIABETIC SUPPLIES
GMATE CONTRO SOL LEVEL 2
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
GMATE LANCET MIS 30G
GMATE LANCIN MIS DEVICE
GMATE ORIGIN MIS GLUC SYS
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
Page 95 of 279
Prior
Authorization
X
X
X
X
X
X
Specialty
Prior
Authorization
Supply
Limit
X
Therapeutic Class
DIABETIC SUPPLIES
Product Name
LANCET SUPER MIS THIN 30G
Tier Value
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
LANCET ULTRA MIS 28G
LANCET ULTRA MIS THIN 28G
Tier 3
Tier 3
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
LANCETS MIS 23G
LANCETS MIS 28G
LANCETS MICR MIS THIN 33G
Tier 3
Tier 3
Tier 3
X
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
LANCETS THIN MIS
LANCETS ULTR MIS THIN 28G
Tier 3
Tier 3
X
X
DIABETIC SUPPLIES
LANCETS ULTR MIS THIN 30G
Tier 3
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
LANCING DEVI MIS
LB LANCET MIS 28G
LB LANCING MIS DEVICE
LIFESCAN MIS UNISTIK2
LINK ASSIST MIS ACCU-CHK
MEDISENSE LIQ GLUC/KET
MEDISENSE LIQ GLUC-KET
MEIJER
MIS LANCETS
MICROLET MIS LANCETS
MINI LANCING MIS DEVICE
MINILINK RT KIT REPLACE
MINILINK RT KIT STARTER
MINILINK RT MIS TRANSMIT
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
X
X
X
DIABETIC SUPPLIES
MINIMED PUMP MIS RES 3ML
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
MIO INF SET MIS 18"/6MM
MIO INF SET MIS 23"/6MM
MIO INF SET MIS 32"/6MM
MIO INF SET MIS 32"/9MM
NEUTEK 2TEK SOL CONTROL
NOVOPEN ECHO MIS
ON CALL MIS LANCETS
ON CALL EXPR KIT SYSTEM
ON CALL EXPR MIS METER
ON CALL EXPR SOL GLUCOSE
ON CALL LANC MIS DEVICE
ON CALL PLUS KIT METER
ON CALL PLUS KIT MONITOR
ON CALL PLUS MIS LANC DEV
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ON CALL PLUS MIS LANCETS
ON CALL PLUS MIS METER
ON CALL PLUS SOL CONTROL
Tier 3
Tier 3
Tier 2
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ON CALL VIVD KIT METER
ON CALL VIVD KIT MONITOR
Tier 3
Tier 3
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ON CALL VIVD MIS METER
ON CALL VIVD SOL CONTROL
Tier 3
Tier 2
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ONETOUCH
ONETOUCH
ONETOUCH
Tier 1
Tier 1
Tier 1
X
X
X
KIT ULT MINI
KIT ULTRA 2
KIT ULTRALNK
Page 96 of 279
X
X
X
X
X
X
X
X
X
X
Step
Therapy
Specialty
Prior
Authorization
Supply
Limit
X
X
X
X
X
Therapeutic Class
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
Product Name
ONETOUCH KIT VERIO
ONETOUCH KIT VERIO IQ
ONETOUCH MIS 30G
ONETOUCH MIS COMBO
ONETOUCH MIS LANC DEV
DIABETIC SUPPLIES
ONETOUCH
MIS LANC DEV
Tier 1
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ONETOUCH MIS LANCETS
ONETOUCH MIS REMOTE
ONETOUCH SOL ULT CONT
ONETOUCH SOL VERIO
ONETOUCH SOL VERIO-HI
ONETOUCH FP MIS LANCETS
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
X
DIABETIC SUPPLIES
ONETOUCH US MIS LANCETS
Tier 1
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ONETOUCH VER KIT SYNC
OPTIUM
KIT BL GLUC
OPTIUM
MIS SYSTEM
OPTUMRX KIT METER
OPTUMRX KIT SYSTEM
OPTUMRX CONT SOL LEVEL1/2
Tier 1
Tier 3
Tier 4
Tier 3
Tier 3
Tier 2
X
X
X
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
PARADIGM MIS UPGRADE
PARADIGM QR MIS POLY 24"
Tier 3
Tier 2
DIABETIC SUPPLIES
PARADIGM QR MIS POLY 42"
Tier 2
DIABETIC SUPPLIES
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
PARADIGM REA MIS
TRANSMIT
PARADIGM RES MIS 1.8ML
PARADIGM RES MIS 3ML
PARADIGM SOF MIS -SET 24"
DIABETIC SUPPLIES
PARADIGM SOF MIS -SET 42"
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
PENLET II KIT BLOOD
PENLET II MIS REPL CAP
POLYFIN 24" MIS INFUSION
POLYFIN 42" MIS INFUSION
POLYFIN 42" MIS QR INFUS
POLYFIN 60" MIS TUBING
PREC NEO SYS KIT FREESTYL
PRECISION KIT LINK
PRECISION KIT XTRA
PRECISION LIQ CONTROL
PRECISION LIQ GLUC/KET
PRECISION LIQ NRML/MID
PRECISION MIS QID
PRECISION MIS SOF-TACT
PRECISION MIS XTRA
PSS SAFE LAN MIS
PSS SEL LANC MIS
PSS SEL PLAT MIS
PUMP REMOTE MIS
PROGRAM
PX LANCETS MIS ULT THIN
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
DIABETIC SUPPLIES
Page 97 of 279
Tier Value
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Step
Therapy
X
X
X
Tier 2
Tier 2
Tier 2
Tier 3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
Prior
Authorization
Supply
Limit
X
X
X
Tier Value
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
Product Name
QC LANCETS MIS 28G
QC LANCETS MIS 30G
QC LANCING MIS DEVICE
QUICK-SERTER MIS INS DEV
QUICK-SET MIS 18"/6MM
QUICK-SET MIS 23"/6MM
QUICK-SET MIS 23"/9MM
QUICK-SET MIS 32"/6MM
QUICK-SET MIS 32"/9MM
QUICK-SET MIS 43"/6MM
QUICK-SET MIS 43"/9MM
QUINTET MIS SYSTEM
QUINTET AC MIS SYSTEM
QUINTET CONT SOL
HGH/NORM
RA E-ZJECT MIS 28G
RA E-ZJECT MIS 33G
RA E-ZJECT MIS THIN 26G
RA E-ZJECT MIS THIN 28G
RA E-ZJECT MIS ULT THIN
RA GLUCOSE MIS MONITOR
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
X
X
X
X
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
RA TRUE2GO KIT
RAPID-D INF MIS 24"/10MM
Tier 3
Tier 2
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
RAPID-D INF MIS 24"/6MM
RAPID-D INF MIS 24"/8MM
RAPID-D INF MIS 31"/10MM
Tier 2
Tier 2
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
RAPID-D INF MIS 31"/6MM
RAPID-D INF MIS 31"/8MM
RAPID-D INF MIS 43"/10MM
Tier 2
Tier 2
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
RAPID-D INF MIS 43"/6MM
RAPID-D INF MIS 43"/8MM
RAPID-D LINK MIS TRANSFER
Tier 2
Tier 2
Tier 2
DIABETIC SUPPLIES
RELION LANCE MIS THIN 26G
Tier 3
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
RELION ULTIM KIT SYSTEM
REVEAL
KIT MONITOR
RIGHTSOURCE MIS METER
SAFE-T-LANCE MIS 21G
SAFE-T-LANCE MIS 25G
SAFE-T-LANCE MIS HI FLOW
SAFE-T-LANCE MIS LOW FLOW
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
X
X
X
X
X
X
DIABETIC SUPPLIES
SAFE-T-LANCE MIS NOR FLOW
Tier 3
X
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
SAFE-T-PRO MIS LANCETS
SAFE-T-PRO MIS PLUS
SELECT-LITE KIT DEV/LANC
SEN-SERTER MIS
SILHOUETTE MIS 13MM
SILHOUETTE MIS 17MM
SILHOUETTE MIS 18"/13MM
Tier 1
Tier 1
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
X
X
X
DIABETIC SUPPLIES
SILHOUETTE MIS 23" SET
Tier 2
Page 98 of 279
X
X
Step
Therapy
Specialty
Therapeutic Class
DIABETIC SUPPLIES
Product Name
SILHOUETTE MIS 32"/13MM
Tier Value
Tier 2
DIABETIC SUPPLIES
SILHOUETTE MIS 32"/17MM
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
SILHOUETTE MIS 43" SET
SILHOUETTE MIS COMBO
SILHOUETTE MIS FULL SET
SIL-SERTER MIS INS DEV
SINGLE-LET MIS 23G
SNAP PUMP MIS CONTROLL
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
SOF-SENSOR MIS
SOF-SERTER MIS INS DEV
SOF-SET 24" KIT INFUSION
SOF-SET 24" KIT MICRO QR
SOF-SET 24" KIT ULTIM QR
SOF-SET 42" KIT INFUSION
SOF-SET 42" KIT MICRO QR
SOF-SET 42" KIT ULTIM QR
SOFT TOUCH MIS LANCETS
SOFTCLIX MIS LANCETS
SOFTCLIX LAN MIS DEVICE
SUPER THIN MIS LANCETS
SUPREME II LIQ HIGH/LOW
SURESTEP SOL CONTROL
SURESTEP GLU SOL
SURESTEP GLU SOL HIGH/LOW
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 3
Tier 2
Tier 1
Tier 1
Tier 1
DIABETIC SUPPLIES
DIABETIC SUPPLIES
SURESTEP PRO KIT LINEARIT
SURESTEP PRO TES HIGH CON
Tier 1
Tier 1
DIABETIC SUPPLIES
SURESTEP PRO TES LOW CON
Tier 1
DIABETIC SUPPLIES
SURESTEP PRO TES NORM CON
Tier 1
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
SURE-T
MIS 23"/6MM
SURE-T
MIS 23"/8MM
T:30 INFUSIO MIS SET
T:FLEX 4.8ML MIS CARTRDGE
Tier 2
Tier 2
Tier 2
Tier 2
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
T:SLIM 3ML MIS CARTRDGE
T:SLIM G4 MIS CARTRDGE
TECHLITE MIS LANCETS
TEST PLUG MIS
TGT LANCET MIS 23G
TGT LANCET MIS 28G
TGT LANCET MIS 30G
TGT LANCET MIS ALTERNAT
TGT LANCING MIS ADV DEV
TGT LANCING MIS DEVICE
THIN LANCETS MIS
THINLETS GP MIS 26G
TRANSMITTER MIS TAPE
TRUE METRIX KIT AIR
TRUE METRIX KIT METER
TRUE METRIX MIS AIR
TRUE METRIX SOL LEVEL 1
TRUE METRIX SOL LEVEL 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Page 99 of 279
Prior
Authorization
Supply
Limit
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Step
Therapy
Specialty
Therapeutic Class
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
Product Name
TRUE METRIX SOL LEVEL 3
TRUE2GO KIT
TRUECONTROL LIQ LEVEL 0
TRUECONTROL LIQ LEVEL 1
TRUEDRAW MIS LANC DEV
Tier Value
Tier 2
Tier 3
Tier 2
Tier 2
Tier 3
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIABETIC SUPPLIES
DIAGNOSTIC AGENTS
TRUERESULT KIT
TRUERESULT KIT MONITOR
TRUETEST LIQ LEVEL 1
TRUETEST LIQ LEVEL 2
TRUETEST LIQ LEVEL 3
TRUETRACK KIT SYSTEM
TRUETRACK MIS BLD GLC
TRUPLUS LANC MIS 26G
TRUPLUS LANC MIS 28G
TRUPLUS LANC MIS 30G
TRUPLUS LANC MIS 33G
ULTILET OPER MIS DEVICE
ULTIMA
KIT MONITOR
ULTRA THIN MIS LANC 26G
ULTRA THIN MIS LANC 28G
ULTRA THIN MIS LANC 30G
ULTRA THIN MIS LANCETS
ULTRAFLEX MIS 12"/6MM
ULTRAFLEX MIS 24"/10MM
ULTRAFLEX MIS 24"/6MM
ULTRAFLEX MIS 24"/8MM
ULTRAFLEX MIS 31"/10MM
ULTRAFLEX MIS 31"/6MM
ULTRAFLEX MIS 31"/8MM
ULTRAFLEX MIS 43"/10MM
ULTRAFLEX MIS 43"/8MM
UNILET EX II MIS 28G
UNILET EXCEL MIS 23G
UNILET G.P MIS SUPR 23G
UNILET G.P. MIS 21G
UNILET LANCT MIS 33G
UNILET SUPER MIS 23G
UNISTIK 1 MIS 2.4MM
UNISTIK 1 MIS 3.0MM
UNISTIK 2 MIS 1.8MM
UNISTIK 2 MIS 2.4MM
UNISTIK 2 MIS EXTRA
UNISTIK 2 MIS SUPER
UNISTIK 3 MIS 1.8MM
UNISTIK II MIS LANCETS
VERIO FLEX KIT ONETOUCH
VIVID PAL KIT METER
VIVID PAL MIS METER
ADVANCED DNA KIT COLLECTI
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
ARIDOL
KIT
CHEMSTRIP TES UGK
CHEMSTRIP K TES
CVS KETONE TES CARE
DNA COLLECT KIT
DNA COLLECT KIT MEDICATE
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Tier 3
Page 100 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
Product Name
DYNAMIC KIT
DYNAMIC PLUS KIT PAK
FLURA-SAFE SOL
KETOCARE TES
KETO-DIASTIX TES
KETOSTIX TES
KETOSTIX TES STRIP
MEDCATED DNA KIT COLLECT
Tier Value
Tier 1
Tier 3
Tier 3
Tier 2
Tier 3
Tier 2
Tier 2
Tier 3
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS - ADRENOCORTICAL
INSUFFICIENCY
DIAGNOSTIC AGENTS - ADRENOCORTICAL
INSUFFICIENCY
DIAGNOSTIC AGENTS - OCULAR DISORDERS
MULTI-DRUG KIT DIUSCREE
PRECISN XTRA TES KETONE
PRO DNA KIT KIT
RELION KETON TES
T.R.U.E. TES
CORTROSYN INJ 0.25MG
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 4
COSYNTROPIN INJ 0.25MG
Tier 1
ALTAFLUOR SOL 0.25-0.4
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
BIO GLO
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUCAINE
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUORACAINE SOL OP
Tier 3
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUORE-BENOX SOL 0.25-0.4
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUORESCEIN/ SOL PROPARAC
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUOR-I-STRI TES 1MG OP
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FLUROX
SOL OP
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FUL-GLO
TES 0.6MG OP
Tier 2
DIAGNOSTIC AGENTS - OCULAR DISORDERS
FUL-GLO
TES 1MG OP
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
GREEN GLO MIS 1.5MG
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
LISSAMINE GR TES 1.5MG
Tier 1
DIAGNOSTIC AGENTS - OCULAR DISORDERS
ROSE GLO
Tier 3
DIAGNOSTIC AGENTS - PITUITARY FUNCTION
METOPIRONE CAP 250MG
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
ENTERO VU SUS 24%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-CAT DRY PAK
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-DISK
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-DOSE
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-HD
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-PAQUE SUS 60%
TES 1MG OP
SOL 0.25-0.5
TES 1.5MG
TAB 700MG
ENE
Tier 1
Tier 2
SUS 98%
Page 101 of 279
Tier 3
Tier 2
Prior
Authorization
Supply
Limit
X
X
X
X
X
Step
Therapy
Specialty
Therapeutic Class
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
Product Name
E-Z-PAQUE SUS 96%
Tier Value
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
E-Z-PASTE CRE 60%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
GASTROGRAFIN SOL 66-10%
Tier 4
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
MD-GASTROVIE SOL 66-10%
Tier 1
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
POLIBAR ACB KIT 96%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
POLIBAR PLUS SUS 105%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS 2.1%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS BANANA
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS BERRY
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
READI-CAT 2 SUS MOCHACCI
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
TAGITOL V SUS 40%
Tier 2
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR HONE SUS 40%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR NECT SUS 40%
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR THIN SUS HONEY
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VARIBAR THIN SUS LIQUID
Tier 3
DIAGNOSTIC AGENTS - ROENTGENOGRAPHY
VOLUMEN
Tier 2
DISINFECTANTS (FOR NON-DERMATOLOGIC
USE)
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
GLUTARALDEHY SOL 25%
Tier 3
BUMETANIDE TAB 0.5MG
BUMETANIDE TAB 1MG
BUMETANIDE TAB 2MG
BUMEX
TAB 0.5MG
BUMEX
TAB 1MG
BUMEX
TAB 2MG
DEMADEX TAB 100MG
DEMADEX TAB 10MG
DEMADEX TAB 20MG
DEMADEX TAB 5MG
EDECRIN TAB 25MG
ETHACRYNIC TAB ACD 25MG
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 3
Tier 4
Tier 1
Diuretics, Loop - Cardiac Drugs
FUROSEMIDE SOL 10MG/ML
Tier 1
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
FUROSEMIDE SOL 8MG/ML
FUROSEMIDE TAB 20MG
FUROSEMIDE TAB 40MG
FUROSEMIDE TAB 80MG
LASIX
TAB 20MG
LASIX
TAB 40MG
LASIX
TAB 80MG
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
PST PUDDING
SUS 0.1%
Page 102 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Loop - Cardiac Drugs
Diuretics, Potassium-sparing - Cardiac Drugs
Product Name
TORSEMIDE TAB 100MG
TORSEMIDE TAB 10MG
TORSEMIDE TAB 20MG
TORSEMIDE TAB 5MG
ALDACTAZIDE TAB 25/25
Tier Value
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTAZIDE TAB 50/50
Tier 2
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTONE TAB 100MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTONE TAB 25MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
ALDACTONE TAB 50MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
AMILOR/HCTZ TAB 5-50
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
AMILORIDE TAB 5MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
DYAZIDE
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
DYRENIUM
CAP 100MG
Tier 3
Diuretics, Potassium-sparing - Cardiac Drugs
DYRENIUM
CAP 50MG
Tier 3
Diuretics, Potassium-sparing - Cardiac Drugs
EPLERENONE TAB 25MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
EPLERENONE TAB 50MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
INSPRA
TAB 25MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
INSPRA
TAB 50MG
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
MAXZIDE
Diuretics, Potassium-sparing - Cardiac Drugs
MAXZIDE-25 TAB
Tier 4
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONO/HCTZ TAB 25/25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT POW
Tier 3
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT TAB 100MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT TAB 25MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
SPIRONOLACT TAB 50MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ CAP 37.5-25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ CAP 50/25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ CAP 50-25MG
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ TAB 37.5-25
Tier 1
Diuretics, Potassium-sparing - Cardiac Drugs
TRIAMT/HCTZ TAB 75-50MG
Tier 1
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
CHLOROTHIAZ TAB 250MG
CHLOROTHIAZ TAB 500MG
Tier 1
Tier 1
CAP 37.5-25
TAB 75-50
Page 103 of 279
Prior
Authorization
Tier 4
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Product Name
CHLORTHALID TAB 100MG
CHLORTHALID TAB 25MG
CHLORTHALID TAB 50MG
DIURIL
SUS 250/5ML
EZIDE
TAB 50MG
HYDROCHLOROT CAP 12.5MG
Tier Value
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 1
Diuretics, Thiazide - Cardiac Drugs
HYDROCHLOROT TAB 12.5MG
Tier 1
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Diuretics, Thiazide - Cardiac Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
HYDROCHLOROT TAB 25MG
HYDROCHLOROT TAB 50MG
INDAPAMIDE TAB 1.25MG
INDAPAMIDE TAB 2.5MG
METHYCLOTHIA TAB 5MG
METOLAZONE TAB 10MG
METOLAZONE TAB 2.5MG
METOLAZONE TAB 5MG
MICROZIDE CAP 12.5MG
APOKYN
INJ 10MG/ML
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 3
BROMOCRIPTIN CAP 5MG
Tier 1
BROMOCRIPTIN TAB 2.5MG
Tier 1
MIRAPEX
TAB 0.125MG
Tier 4
MIRAPEX
TAB 0.25MG
Tier 4
MIRAPEX
TAB 0.5MG
Tier 4
MIRAPEX
TAB 0.75MG
Tier 4
MIRAPEX
TAB 1.5MG
Tier 4
MIRAPEX
TAB 1MG
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
X
MIRAPEX ER TAB 0.375MG
Tier 4
X
MIRAPEX ER TAB 0.75MG
Tier 4
X
MIRAPEX ER TAB 1.5MG
Tier 4
X
MIRAPEX ER TAB 2.25MG
Tier 4
X
MIRAPEX ER TAB 3.75MG
Tier 4
X
MIRAPEX ER TAB 3MG
Tier 4
X
MIRAPEX ER TAB 4.5MG
Tier 4
X
PARLODEL
Tier 3
CAP 5MG
PRAMIPEXOLE TAB 0.125MG
Tier 1
PRAMIPEXOLE TAB 0.25MG
Tier 1
PRAMIPEXOLE TAB 0.375MG
Tier 1
Page 104 of 279
Specialty
X
Therapeutic Class
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
Product Name
PRAMIPEXOLE TAB 0.5MG
Tier Value
Tier 1
PRAMIPEXOLE TAB 0.75 ER
Tier 1
PRAMIPEXOLE TAB 0.75MG
Tier 1
PRAMIPEXOLE TAB 1.5MG
Tier 1
PRAMIPEXOLE TAB 1.5MG ER
Tier 1
PRAMIPEXOLE TAB 1MG
Tier 1
PRAMIPEXOLE TAB 2.25MG
Tier 1
X
PRAMIPEXOLE TAB 3.75MG
Tier 1
X
PRAMIPEXOLE TAB 3MG
Tier 1
X
PRAMIPEXOLE TAB 4.5MG
Tier 1
X
REQUIP
TAB 0.25MG
Tier 4
REQUIP
TAB 0.5MG
Tier 4
REQUIP
TAB 1MG
Tier 4
REQUIP
TAB 2MG
Tier 4
REQUIP
TAB 3MG
Tier 4
REQUIP
TAB 4MG
Tier 4
REQUIP
TAB 5MG
Tier 4
X
X
REQUIP XL TAB 12MG
Tier 4
X
REQUIP XL TAB 2MG
Tier 4
X
REQUIP XL TAB 4MG
Tier 4
X
REQUIP XL TAB 6MG
Tier 4
X
REQUIP XL TAB 8MG
Tier 4
X
ROPINIROLE TAB 0.25MG
Tier 1
ROPINIROLE TAB 0.5MG
Tier 1
ROPINIROLE TAB 12MG ER
Tier 1
ROPINIROLE TAB 1MG
Tier 1
ROPINIROLE TAB 2MG
Tier 1
ROPINIROLE TAB 2MG ER
Tier 1
ROPINIROLE TAB 3MG
Tier 1
Page 105 of 279
X
X
Specialty
Therapeutic Class
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Agonists - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Product Name
ROPINIROLE TAB 4MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
ROPINIROLE TAB 4MG ER
Tier 1
ROPINIROLE TAB 5MG
Tier 1
ROPINIROLE TAB 6MG ER
Tier 1
X
ROPINIROLE TAB 8MG ER
Tier 1
X
CARB/LEVO TAB 10-100MG
Tier 1
CARB/LEVO TAB 10-100MG
Tier 1
CARB/LEVO TAB 25-100MG
Tier 1
CARB/LEVO TAB 25-100MG
Tier 1
CARB/LEVO TAB 25-250MG
Tier 1
CARB/LEVO TAB 25-250MG
Tier 1
CARB/LEVO 50 TAB /ENTACAP
Tier 1
CARB/LEVO 75 TAB /ENTACAP
Tier 1
CARB/LEVO ER TAB 25-100MG
Tier 1
CARB/LEVO ER TAB 50-200MG
Tier 1
CARB/LEVO100 TAB /ENTACAP
Tier 1
CARB/LEVO125 TAB /ENTACAP
Tier 1
CARB/LEVO150 TAB /ENTACAP
Tier 1
CARB/LEVO200 TAB /ENTACAP
Tier 1
CARBIDOPA TAB 25MG
Tier 1
DUOPA
Tier 4
SUS 4.63-20
Page 106 of 279
X
X
Specialty
Therapeutic Class
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dopamine Precursors/L- Amino Acid
Decarboxylase Inhibitors - Parkinson's Disease
Drugs
Dyslipidemics - Cholesterol Control Drugs
Product Name
LODOSYN TAB 25MG
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
X
RYTARY
CAP
Tier 4
X
RYTARY
CAP
Tier 4
X
RYTARY
CAP
Tier 4
X
RYTARY
CAP 23.75-95
Tier 4
X
SINEMET
TAB 10-100MG
Tier 4
SINEMET
TAB 25-100MG
Tier 4
SINEMET
TAB 25-250MG
Tier 4
SINEMET CR TAB 25-100MG
Tier 4
SINEMET CR TAB 50-200MG
Tier 4
STALEVO 100 TAB
Tier 4
STALEVO 125 TAB
Tier 4
STALEVO 150 TAB
Tier 4
STALEVO 200 TAB
Tier 4
STALEVO 50 TAB
Tier 4
STALEVO 75 TAB
Tier 4
NIACIN
POW USP/NF
Tier 3
ANTARA
CAP 30MG
Tier 4
X
ANTARA
CAP 90MG
Tier 4
X
FENOFIBRATE CAP 130MG
Tier 1
X
FENOFIBRATE CAP 134MG
Tier 1
X
Page 107 of 279
Specialty
Therapeutic Class
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives Cholesterol Control Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
X
Product Name
FENOFIBRATE CAP 150MG
Tier Value
Tier 1
FENOFIBRATE CAP 200MG
Tier 1
X
FENOFIBRATE CAP 43MG
Tier 1
X
FENOFIBRATE CAP 50MG
Tier 1
X
FENOFIBRATE CAP 67MG
Tier 1
X
FENOFIBRATE TAB 120MG
Tier 1
X
FENOFIBRATE TAB 145MG
Tier 1
X
FENOFIBRATE TAB 160MG
Tier 1
FENOFIBRATE TAB 40MG
Tier 1
X
FENOFIBRATE TAB 48MG
Tier 1
X
FENOFIBRATE TAB 54MG
Tier 1
FENOFIBRIC CAP 135MG DR
Tier 1
X
FENOFIBRIC CAP 45MG DR
Tier 1
X
FENOFIBRIC TAB 105MG
Tier 1
X
FENOFIBRIC TAB 35MG
Tier 1
X
FENOGLIDE TAB 120MG
Tier 4
X
FENOGLIDE TAB 40MG
Tier 4
X
FIBRICOR
TAB 105MG
Tier 4
X
FIBRICOR
TAB 35MG
Tier 4
X
GEMFIBROZIL TAB 600MG
Tier 1
LIPOFEN
CAP 150MG
Tier 4
X
LIPOFEN
CAP 50MG
Tier 4
X
LOFIBRA
CAP 134MG
Tier 4
X
LOFIBRA
CAP 200MG
Tier 4
X
LOFIBRA
CAP 67MG
Tier 4
X
LOFIBRA
TAB 160MG
Tier 4
X
LOFIBRA
TAB 54MG
Tier 4
X
TAB 600MG
Tier 4
LOPID
TRICOR
TAB 145MG
Page 108 of 279
Tier 4
X
Specialty
Therapeutic Class
Product Name
Dyslipidemics, Fibric Acid Derivatives TRICOR
TAB 48MG
Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives TRIGLIDE TAB 160MG
Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives TRILIPIX CAP 135MG
Cholesterol Control Drugs
Dyslipidemics, Fibric Acid Derivatives TRILIPIX CAP 45MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 1000-20
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 1000-40
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 500-20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ADVICOR TAB 750-20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ALTOPREV TAB 20MG ER
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ALTOPREV TAB 40MG ER
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ALTOPREV TAB 60MG ER
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 10MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ATORVASTATIN TAB 80MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 10MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - CRESTOR TAB 5MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - FLUVASTATIN CAP 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - FLUVASTATIN CAP 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - FLUVASTATIN TAB 80MG ER
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LESCOL
CAP 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LESCOL
CAP 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LESCOL XL TAB 80MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 10MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LIPITOR TAB 80MG
Cholesterol Control Drugs
Page 109 of 279
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 4
X
Tier 4
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
X
Specialty
Therapeutic Class
Product Name
Dyslipidemics, HMG CoA Reductase Inhibitors - LIVALO
TAB 1MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LIVALO
TAB 2MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LIVALO
TAB 4MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LOVASTATIN TAB 10MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LOVASTATIN TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - LOVASTATIN TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - MEVACOR TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVACHOL TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVACHOL TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVACHOL TAB 80MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 10MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - PRAVASTATIN TAB 80MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 10MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ROSUVASTATIN TAB 5MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR
TAB 1000-20
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR
TAB 1000-40
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR
TAB 500-20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR
TAB 500-40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMCOR
TAB 750-20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 10MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 5MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - SIMVASTATIN TAB 80MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR
TAB 10MG
Cholesterol Control Drugs
Page 110 of 279
Supply
Limit
X
Step
Therapy
X
Tier 4
X
X
Tier 4
X
X
Tier Value
Tier 4
Prior
Authorization
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Specialty
Therapeutic Class
Product Name
Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR
TAB 20MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR
TAB 40MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR
TAB 5MG
Cholesterol Control Drugs
Dyslipidemics, HMG CoA Reductase Inhibitors - ZOCOR
TAB 80MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
CHOLESTYRAM POW 4GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
CHOLESTYRAM POW 4GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
CHOLESTYRAM POW 4GM
Cholesterol Control Drugs
LITE
Dyslipidemics, Other - Miscellaneous
CHOLESTYRAM POW 4GM
Cholesterol Control Drugs
LITE
Dyslipidemics, Other - Miscellaneous
COLESTID GRA 5GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
COLESTID POW 5GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
COLESTID TAB 1GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
COLESTID FLA GRA 5/7.5GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
COLESTID FLA GRA 5GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
COLESTIPOL GRA 5GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
COLESTIPOL GRA 5GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
COLESTIPOL TAB 1GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
JUXTAPID CAP 10MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
JUXTAPID CAP 20MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
JUXTAPID CAP 30MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
JUXTAPID CAP 40MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
JUXTAPID CAP 5MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
JUXTAPID CAP 60MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
KYNAMRO INJ 200MG/ML
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
LOVAZA
CAP 1GM
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
NIACIN ER TAB 1000MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
NIACIN ER TAB 500MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
NIACIN ER TAB 750MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
NIACOR
TAB 500MG
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
NIASPAN TAB 1000 ER
Cholesterol Control Drugs
Page 111 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
Tier Value
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
X
Therapeutic Class
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Dyslipidemics, Other - Miscellaneous
Cholesterol Control Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Product Name
NIASPAN TAB 500MG ER
NIASPAN
TAB 750MG ER
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
Tier 1
PREVALITE POW 4GM
Tier 1
PREVALITE POW 4GM PK
Tier 1
QUESTRAN
POW 4GM
Tier 4
QUESTRAN
POW 4GM
Tier 4
QUESTRAN
POW 4GM LITE
Tier 4
CAP 1GM
Tier 3
VYTORIN
TAB 10-10MG
Tier 4
X
VYTORIN
TAB 10-20MG
Tier 4
X
VYTORIN
TAB 10-40MG
Tier 4
X
VYTORIN
TAB 10-80MG
Tier 4
X
WELCHOL
PAK 3.75GM
Tier 2
WELCHOL
TAB 625MG
Tier 2
CHEMET
CAP 100MG
X
X
X
VASCEPA
TAB 10MG
Specialty
Tier 4
OMEGA-3-ACID CAP 1GM
ZETIA
Step
Therapy
X
Tier 4
X
Tier 2
CUPRIMINE CAP 250MG
Tier 4
DEPEN TITRA TAB 250MG
Tier 2
EXJADE
TAB 125MG
Tier 3
X
X
EXJADE
TAB 250MG
Tier 3
X
X
EXJADE
TAB 500MG
Tier 3
X
X
JADENU
TAB 180MG
Tier 3
X
X
JADENU
TAB 360MG
Tier 3
X
X
JADENU
TAB 90MG
Tier 3
X
X
KAYEXALATE POW
Tier 4
KIONEX
POW
Tier 1
KIONEX
SUS 15GM/60
Tier 1
SAMSCA
TAB 15MG
Tier 3
Page 112 of 279
X
X
Therapeutic Class
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Modifiers - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Product Name
SAMSCA
TAB 30MG
CALC ACETATE CAP 667MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
CALC ACETATE TAB 667MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
ELIPHOS
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON 10 TAB 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON 8 TAB 8MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON M10 TAB 10MEQ
ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON M15 TAB 15MEQ
ER
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON M20 TAB 20MEQ
ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON SPR CAP 10MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON SPR CAP 8MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON/25 POW 25MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
KLOR-CON-25 POW 25MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
K-SOL
Tier 1
Tier Value
Tier 3
SOD POLY SUL POW
Tier 1
SOD POLY SUL SUS 15GM/60
Tier 1
SOD POLY SUL SUS 30/120ML
Tier 1
SOD POLY SUL SUS 50/200ML
Tier 1
SPS
SUS 15GM/60
Tier 1
CAP 250MG
Tier 4
SYPRINE
TAB 667MG
POW 20MEQ
SOL 10%
Page 113 of 279
Tier 1
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
Specialty
X
X
Therapeutic Class
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Product Name
K-SOL
SOL 20%
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
K-TAB
TAB 10MEQ CR
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
K-TAB
TAB 20MEQ
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
K-TAB
TAB 8MEQ CR
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
MICRO-K
CAP 10MEQ CR
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
MICRO-K
CAP 8MEQ CR
Tier 4
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
PHOSLO
CAP 667MG
Tier 4
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
PHOSLYRA
SOL
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE CAP 10MEQ CR
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE CAP 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE CAP 8MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE POW 20MEQ
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 10%
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 10% SF
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 20%
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE SOL 20% SF
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 10MEQ CR
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 20MEQ ER
Tier 1
Tier Value
Tier 1
Page 114 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
Product Name
POT CHLORIDE TAB 8MEQ ER
Tier Value
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CHLORIDE TAB 8MEQ SR
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CITRATE TAB 1080MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CITRATE TAB 1620MG
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CITRATE TAB 540MG ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CL MICRO TAB 10MEQ CR
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CL MICRO TAB 10MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
POT CL MICRO TAB 20MEQ ER
Tier 1
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
SOD CHLORIDE GRA
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
SODIUM
Tier 3
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
UROCIT-K 10 TAB
Tier 4
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
UROCIT-K 15 TAB
Tier 4
Electrolyte/Mineral Replacement - Vitamin,
Mineral and Body Fluid Deficiency Drugs
UROCIT-K 5 TAB
Tier 4
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
CITRIC ACID/ SOL SOD CITR
Tier 1
POW CHLORIDE
CITROMA
SOL CHERRY
HCR Preventative
CITROMA
SOL LEMON
HCR Preventative
CYTRA K
GRA CRYSTALS
Tier 1
CYTRA-2
SOL
Tier 1
CYTRA-3
SYP
Tier 1
CYTRA-K
SOL
Tier 1
K CITRATE SOL CITR ACD
Tier 1
K/NA CITRATE SOL CITR ACD
Tier 1
Page 115 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Electrolytes and
Minerals
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Product Name
MAG CITRATE SOL CHERRY
Prior
Authorization
Tier Value
HCR Preventative
MAG CITRATE SOL GRAPE
HCR Preventative
MAG CITRATE SOL LEMON
HCR Preventative
MED CIT MAGN SOL
Tier 1
ORACIT
SOL
Tier 2
POT CITRATE- PAK CIT ACID
Tier 1
SHOHLS
Tier 2
SOL MODIFIED
SOD CITRATE SOL CITR ACD
Tier 1
TARON
GRA CRYSTALS
Tier 1
TAURINE
CAP 500MG
Tier 1
TRICITRATES SOL
Tier 1
VIRTRATE-2 SOL
Tier 1
VIRTRATE-2 SOL 500-334
Tier 1
VIRTRATE-3 SOL
Tier 1
VIRTRATE-K SOL
Tier 1
VIRTRATE-K SOL 1100-334
Tier 1
FLUORABON DRO
HCR Preventative
FLUOR-A-DAY DRO 0.125MG
HCR Preventative
FLUORIDE
CHW 0.25MG F
HCR Preventative
FLUORIDE
CHW 0.5MG F
HCR Preventative
FLUORIDE
CHW 1MG F
HCR Preventative
FLUORITAB CHW 0.25MG F
HCR Preventative
FLUORITAB CHW 0.5MG F
HCR Preventative
FLUORITAB CHW 1MG F
HCR Preventative
FLUORITAB CHW 2.2MG
HCR Preventative
FLUORITAB DRO 0.125MG
HCR Preventative
FLURA-DROPS DRO 0.125MG HCR Preventative
FLURA-DROPS DRO 0.25MG F HCR Preventative
KARIDIUM
DRO 0.125MG
HCR Preventative
Page 116 of 279
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
Electrolytes/Minerals - Vitamin, Mineral and
Body Fluid Deficiency Drugs
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
Product Name
LOZI-FLUR LOZ 1MG F
Tier Value
Tier 2
LUDENT
CHW 0.25MG F
HCR Preventative
LUDENT
CHW 0.5MG F
HCR Preventative
LUDENT
CHW 1MG F
HCR Preventative
LURIDE
CHW 0.25MG F
HCR Preventative
LURIDE
CHW 0.5MG F
HCR Preventative
LURIDE
CHW 1MG F
HCR Preventative
LURIDE
DRO 0.5MG/ML
HCR Preventative
NAFRINSE
CHW 1MG F
HCR Preventative
NAFRINSE
DRO 0.125MG
HCR Preventative
Prior
Authorization
Supply
Limit
Step
Therapy
SOD FLUORIDE CHW 0.25MG F HCR Preventative
SOD FLUORIDE CHW 0.5MG F HCR Preventative
SOD FLUORIDE CHW 1.1MG
HCR Preventative
SOD FLUORIDE CHW 1MG F
HCR Preventative
SOD FLUORIDE CHW 2.2MG
HCR Preventative
SOD FLUORIDE DRO
0.5MG/ML
SOD FLUORIDE TAB 0.5MG F
HCR Preventative
Tier 1
SOD FLUORIDE TAB 1MG F
Tier 1
ACCU-CHEK TES ACTIVE
Tier 4
X
X
X
ACCU-CHEK TES AVIVA
Tier 4
X
X
X
ACCU-CHEK TES AVIVA PL
Tier 4
X
X
X
ACCU-CHEK TES COMFORT
Tier 4
X
X
X
ACCU-CHEK TES COMPACT
Tier 4
X
X
X
ACCU-CHEK TES DRUM
Tier 4
X
X
X
ACCU-CHEK TES SMART
Tier 4
X
X
X
ACCU-CK COMF TES CURVE
Tier 4
X
X
X
ACCUTREND TES GLUCOSE
Tier 4
X
X
X
ASCENSIA
Tier 4
X
X
X
AT LAST
MIS AUTODISC
TES
Tier 3
Page 117 of 279
X
Specialty
Therapeutic Class
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
X
X
X
Product Name
BAYER BREEZE MIS 2 TEST
Tier Value
Tier 4
BAYER BREEZE MIS 2 TEST
Tier 4
BLOOD GLUCOS TES PREMIUM
Tier 3
X
BLOOD GLUCOS TES STRIPS
Tier 3
X
CLINISTIX TES STRIPS
Tier 3
CONTOUR
TES BLD GLUC
Tier 4
X
X
X
CONTOUR
TES NEXT
Tier 4
X
X
X
CVS ADVANCED TES GLUCOSE
Tier 3
DIASTIX
Tier 3
EASYMAX
TES STRIPS
TES
X
Tier 3
X
EASYMAX 15 TES
Tier 3
X
EASYPLUS
TES BLD GLUC
Tier 3
X
EMBRACE
TES BLD GLUC
Tier 3
X
EXACTECH
TES
Tier 4
X
X
EXACTECH
TES R-S-G
Tier 4
X
X
FORA GD50 TES
Tier 3
X
FORTISCARE TES BLD GLUC
Tier 3
X
FREESTYLE TES PREC NEO
Tier 4
X
GENSTRIP 50 TES
Tier 3
X
GLUTAMINE POW
Tier 3
X
GLUTATHIONE POW
Tier 3
X
GLUTATHIONE POW REDUCED
Tier 3
X
GMATE BLOOD TES GLUCOSE
Tier 3
X
KROGER
Tier 4
X
TES
L-GLUTAMINE POW
Tier 3
X
L-GLUTATHION CRY
Tier 3
X
LIBERTY
TES
Tier 3
X
NEUTEK 2TEK TES STRIPS
Tier 3
X
ON CALL
Tier 3
X
TES EXPRESS
Page 118 of 279
X
X
Specialty
Therapeutic Class
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - CALORIC AGENTS
Prior
Authorization
Supply
Limit
X
Step
Therapy
Product Name
ON CALL PLUS TES BLD GLUC
Tier Value
Tier 3
ON CALL VIVD TES BLD GLUC
Tier 3
X
ONETOUCH
TES ULTRA BL
Tier 1
X
ONETOUCH
TES VERIO
Tier 1
X
Tier 4
X
X
X
OPTIUM
TES
OPTIUMEZ
TES
Tier 4
X
OPTUMRX
TES BLD GLUC
Tier 3
X
PRECISION TES PCX
Tier 4
X
X
PRECISION TES PCX PLUS
Tier 4
X
X
PRECISION TES QID
Tier 4
X
X
PRECISION TES SOF-TACT
Tier 4
X
X
PRECISION TES XTRA
Tier 4
X
X
PRECISION PT TES OF CARE
Tier 4
X
X
PROTEIN
TAB 975MG
Tier 3
QUINTET
TES BLD GLUC
Tier 3
X
QUINTET AC TES BLD GLUC
Tier 3
X
RA TRUETEST TES
Tier 3
X
RELION
Tier 3
X
RELION BLOOD TES GLUCOSE
Tier 4
X
REVEAL
Tier 3
X
Tier 3
X
TRUE METRIX TES
Tier 3
X
TRUE METRIX TES GLUCOSE
Tier 3
X
TRUETEST
TES
Tier 3
X
TRUETEST
TES BLD GLUC
Tier 3
X
TRUETRACK TES
Tier 3
X
TRUETRACK TES BLD GLUC
Tier 3
X
ULTIMA
Tier 3
X
Tier 4
X
SUPREME
TES ULTIMA
TES BLD GLUC
TES
TES
UNISTRIP1 TES GENERIC
Page 119 of 279
X
X
X
Specialty
Therapeutic Class
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
ELECTROLYTIC, CALORIC, AND WATER
BALANCE - REPLACEMENT PREPARATIONS
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Product Name
AV-PHOS 250 TAB NEUTRAL
CALCIFOL
WAF
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Tier 3
CALCIUM-FA WAF PLUS D
Tier 1
EFFER-K
TAB 10MEQ
Tier 2
EFFER-K
TAB 20MEQ
Tier 2
EFFER-K
TAB 25MEQ EF
Tier 1
K-EFFERVESCE TAB 25MEQ EF
Tier 1
KLOR-CON/EF TAB 25MEQ EF
Tier 1
KLOR-CON/EF TAB 25MEQ FR
Tier 1
K-PHOS
TAB
Tier 2
K-PHOS
TAB NEUTRAL
Tier 2
K-PRIME
TAB 25MEQ EF
Tier 1
K-VESCENT TAB 25MEQ EF
Tier 1
LEG-GESIC SUS
Tier 3
MAGNEBIND TAB 400
Tier 2
OSTIGEN
Tier 3
MIS 350MG
PHOSPHA 250 TAB NEUTRAL
Tier 1
POT CHLORIDE TAB 25MEQ EF
Tier 1
POT/CHLORIDE TAB 25MEQ EF
Tier 1
POTASSIUM TAB 25MEQ EF
Tier 1
VIRT-PHOS TAB 250 NEUT
Tier 1
ANZEMET
TAB 100MG
Tier 3
X
ANZEMET
TAB 50MG
Tier 3
X
CESAMET
CAP 1MG
Tier 3
DRONABINOL CAP 10MG
Tier 1
DRONABINOL CAP 2.5MG
Tier 1
DRONABINOL CAP 5MG
Tier 1
EMEND
CAP 125MG
Tier 2
X
EMEND
CAP 40MG
Tier 2
X
Page 120 of 279
Step
Therapy
Specialty
Prior
Authorization
Supply
Limit
X
Step
Therapy
Therapeutic Class
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Emetogenic Therapy Adjuncts - Nausea and
Vomiting Drugs
Enzyme Inhibitors - Chemotherapy Agents
Product Name
EMEND
CAP 80MG
ETOPOSIDE CAP 50MG
Tier 1
Enzyme Inhibitors - Chemotherapy Agents
HYCAMTIN
CAP 0.25MG
Tier 3
X
X
X
Enzyme Inhibitors - Chemotherapy Agents
HYCAMTIN
CAP 1MG
Tier 3
X
X
X
Enzyme Inhibitors - Chemotherapy Agents
ZYDELIG
TAB 100MG
Tier 4
X
X
X
Enzyme Inhibitors - Chemotherapy Agents
ZYDELIG
TAB 150MG
Tier 4
X
X
X
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
BUPHENYL
POW
Tier 4
X
BUPHENYL
TAB 500MG
Tier 4
X
CARBAGLU
TAB 200MG
Tier 3
X
Tier Value
Tier 2
EMEND
PAK 80 & 125
Tier 2
EMEND
SUS 125MG
Tier 2
GRANISETRON TAB 1MG
Tier 1
MARINOL
CAP 10MG
Tier 4
MARINOL
CAP 2.5MG
Tier 4
MARINOL
CAP 5MG
Tier 4
ONDANSETRON SOL
4MG/5ML
ONDANSETRON TAB 24MG
Tier 1
ONDANSETRON TAB 4MG
Tier 1
ONDANSETRON TAB 4MG
ODT
ONDANSETRON TAB 8MG
Tier 1
ONDANSETRON TAB 8MG
ODT
SANCUSO DIS 3.1MG
Tier 1
ZOFRAN
SOL 4MG/5ML
Tier 4
ZOFRAN
TAB 4MG
Tier 4
ZOFRAN
TAB 4MG ODT
Tier 4
ZOFRAN
TAB 8MG
Tier 4
ZOFRAN
TAB 8MG ODT
Tier 4
ZUPLENZ
MIS 4MG
ZUPLENZ
MIS 8MG
Page 121 of 279
Specialty
X
X
Tier 1
Tier 1
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
X
Therapeutic Class
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Product Name
CREON
CAP 12000UNT
Tier Value
Tier 2
CREON
CAP 24000UNT
Tier 2
CREON
CAP 3000UNIT
Tier 2
CREON
CAP 36000UNT
Tier 2
CREON
CAP 6000UNIT
Tier 2
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
CYSTADANE POW
Tier 3
X
CYSTAGON
CAP 150MG
Tier 2
CYSTAGON
CAP 50MG
Tier 2
KUVAN
POW 100MG
Tier 3
X
X
X
KUVAN
POW 500MG
Tier 3
X
X
X
KUVAN
TAB 100MG
Tier 3
X
X
X
ORFADIN
CAP 10MG
Tier 4
X
ORFADIN
CAP 20MG
Tier 4
X
ORFADIN
CAP 2MG
Tier 4
X
X
ORFADIN
CAP 5MG
Tier 4
X
X
ORFADIN
SUS 4MG/ML
Tier 3
X
X
X
X
PANCREAZE CAP 10500UNT
Tier 3
X
PANCREAZE CAP 16800UNT
Tier 3
X
PANCREAZE CAP 21000UNT
Tier 3
X
PANCREAZE CAP 4200UNIT
Tier 3
X
PANCRELIPASE CAP 5000UNIT
Tier 1
PERTZYE
CAP
Tier 4
X
PERTZYE
CAP
Tier 4
X
PHENYLBUTYRA POW SODIUM
Tier 1
PROCYSBI
CAP 25MG
Tier 4
X
X
X
PROCYSBI
CAP 75MG
Tier 4
X
X
X
RAVICTI
LIQ 1.1GM/ML
Tier 4
X
SUCRAID
SOL 8500/ML
Tier 3
ULTRESA
CAP 13800UNT
Tier 4
Page 122 of 279
X
X
X
X
X
Prior
Authorization
Supply
Limit
Therapeutic Class
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Enzyme Replacement/Modifiers - Enzyme
Replacement/Modifying Drugs
Ergot Alkaloids - Migraine Drugs
Ergot Alkaloids - Migraine Drugs
Ergot Alkaloids - Migraine Drugs
Product Name
ULTRESA CAP 20700UNT
CAFERGOT TAB 1-100MG
D.H.E. 45 INJ 1MG/ML
DIHYDROERGOT INJ 1MG/ML
Tier 3
Tier 4
Tier 1
Ergot Alkaloids - Migraine Drugs
DIHYDROERGOT POW
MESYLATE
DIHYDROERGOT SPR 4MG/ML
Tier 3
ERGOMAR SUB 2MG
MIGERGOT SUP 2/100
MIGRANAL SPR 4MG/ML
ACTIVELLA TAB 0.5-0.1
Tier 2
Tier 3
Tier 4
Tier 4
ACTIVELLA TAB 1-0.5MG
Tier 4
ALORA
DIS 0.025MG
Tier 3
X
ALORA
DIS 0.05MG
Tier 3
X
ALORA
DIS 0.075MG
Tier 3
X
ALORA
DIS 0.1MG
Tier 3
X
Ergot Alkaloids - Migraine Drugs
Ergot Alkaloids - Migraine Drugs
Ergot Alkaloids - Migraine Drugs
Ergot Alkaloids - Migraine Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Tier Value
Tier 4
Step
Therapy
X
ULTRESA
CAP 23000UNT
Tier 4
X
VIOKACE
TAB
Tier 4
X
VIOKACE
TAB 20880
Tier 4
X
ZAVESCA
CAP 100MG
Tier 4
ZENPEP
CAP 10000UNT
Tier 2
ZENPEP
CAP 15000UNT
Tier 2
ZENPEP
CAP 20000UNT
Tier 2
ZENPEP
CAP 25000UNT
Tier 2
ZENPEP
CAP 3000UNIT
Tier 2
ZENPEP
CAP 40000UNT
Tier 2
ZENPEP
CAP 5000UNIT
Tier 2
X
X
Tier 1
X
ALTAVERA
TAB
HCR Preventative
ALYACEN
TAB 1/35
HCR Preventative
ALYACEN
TAB 7/7/7
HCR Preventative
AMETHIA
TAB
HCR Preventative
X
HCR Preventative
X
AMETHIA LO TAB
Page 123 of 279
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
AMETHYST TAB 90-20MCG
Prior
Authorization
Tier Value
HCR Preventative
ANGELIQ
TAB 0.25-0.5
Tier 3
ANGELIQ
TAB 0.5-1MG
Tier 3
APRI
TAB
TAB
HCR Preventative
ASHLYNA
TAB
HCR Preventative
AUBRA
TAB 0.1-0.02
HCR Preventative
AVIANE
TAB
HCR Preventative
TAB 28 DAY
TAB
HCR Preventative
BEKYREE
TAB
HCR Preventative
TAB
Tier 4
BLISOVI 24 TAB FE 1/20
HCR Preventative
BLISOVI FE TAB 1.5/30
HCR Preventative
BLISOVI FE TAB 1/20
HCR Preventative
BREVICON
BRIELLYN
CAMRESE
TAB 0.5/35
TAB
X
HCR Preventative
BALZIVA
BEYAZ
Step
Therapy
HCR Preventative
ARANELLE
AZURETTE
Supply
Limit
X
Tier 4
HCR Preventative
TAB
HCR Preventative
X
CAMRESE LO TAB
HCR Preventative
X
CAZIANT
PAK
HCR Preventative
CHATEAL
TAB 0.15/30
HCR Preventative
CLIMARA
DIS 0.025MG
Tier 2
X
CLIMARA
DIS 0.0375MG
Tier 2
X
CLIMARA
DIS 0.05MG
Tier 2
X
CLIMARA
DIS 0.06MG
Tier 2
X
CLIMARA
DIS 0.075MG
Tier 2
X
CLIMARA
DIS 0.1MG
Tier 2
X
CLIMARA PRO DIS WEEKLY
Tier 3
X
COMBIPATCH DIS .05/.14
Tier 3
X
Page 124 of 279
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
COMBIPATCH DIS .05/.25
COVARYX
Tier Value
Tier 3
TAB 1.25-2.5
Tier 1
CRYSELLE-28 TAB 28 TABS
HCR Preventative
CYCLAFEM
TAB 1/35
HCR Preventative
CYCLAFEM
TAB 7/7/7
HCR Preventative
CYRED
PAK
Tier 4
TAB
HCR Preventative
DASETTA
TAB 1/35
HCR Preventative
DASETTA
TAB 7/7/7
HCR Preventative
DAYSEE
TAB
HCR Preventative
DELYLA
TAB 0.1-0.02
HCR Preventative
DESO/ETHINYL TAB ESTRADIO HCR Preventative
DESO/ETHINYL TAB ESTRADIO HCR Preventative
DESOGEN-28 TAB
Tier 4
DIVIGEL
GEL 0.25MG
Tier 3
DIVIGEL
GEL 0.5MG
Tier 3
DIVIGEL
GEL 1MG/GM
Tier 3
DROSPIR/ETHI TAB 3-0.03MG HCR Preventative
DROSPIRENONE TAB ETHY EST HCR Preventative
DUAVEE
EEMT
TAB 0.45-20
Tier 3
TAB 1.25-2.5
Tier 1
EEMT HS
TAB
Tier 1
ELESTRIN
GEL 0.06%
Tier 3
ELINEST
Supply
Limit
X
Tier 1
COVARYX HS TAB
CYCLESSA
Prior
Authorization
TAB
HCR Preventative
EMOQUETTE TAB
HCR Preventative
ENJUVIA
TAB 0.3MG
Tier 3
ENJUVIA
TAB 0.45MG
Tier 3
ENJUVIA
TAB 0.625MG
Tier 3
Page 125 of 279
X
Step
Therapy
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
ENJUVIA TAB 0.9MG
ENJUVIA
Tier Value
Tier 3
TAB 1.25MG
HCR Preventative
ENSKYCE
HCR Preventative
EST ESTROGEN TAB MTEST
Tier 1
EST ESTROGEN TAB MTEST HS
Tier 1
ESTARYLLA TAB 0.25-35
Supply
Limit
Step
Therapy
X
Tier 3
ENPRESSE-28 TAB
TAB
Prior
Authorization
HCR Preventative
ESTRA/NORETH TAB 0.5-0.1
Tier 1
ESTRA/NORETH TAB 1-0.5MG
Tier 1
ESTRACE
TAB 0.5MG
Tier 4
ESTRACE
TAB 1MG
Tier 4
ESTRACE
TAB 2MG
Tier 4
ESTRACE VAG CRE 0.1MG/GM
Tier 3
ESTRADIOL DIS 0.025MG
Tier 4
X
ESTRADIOL DIS 0.025MG
Tier 1
X
ESTRADIOL DIS 0.0375MG
Tier 4
X
ESTRADIOL DIS 0.0375MG
Tier 1
X
ESTRADIOL DIS 0.05MG
Tier 4
X
ESTRADIOL DIS 0.05MG
Tier 1
X
ESTRADIOL DIS 0.06MG
Tier 1
X
ESTRADIOL DIS 0.075MG
Tier 4
X
ESTRADIOL DIS 0.075MG
Tier 1
X
ESTRADIOL DIS 0.1MG
Tier 4
X
ESTRADIOL DIS 0.1MG
Tier 1
X
ESTRADIOL TAB 0.5MG
Tier 1
ESTRADIOL TAB 1MG
Tier 1
ESTRADIOL TAB 2MG
Tier 1
ESTRING
Tier 2
MIS 2MG
ESTROG/MTEST TAB 1.25-2.5
Page 126 of 279
Tier 1
X
X
X
X
X
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
ESTROGEL GEL
Tier Value
Tier 3
ESTROPIPATE TAB 0.75MG
Tier 1
ESTROPIPATE TAB 1.5MG
Tier 1
ESTROPIPATE TAB 3MG
Tier 1
ESTROSTEP FE TAB
Tier 4
EVAMIST
SPR 1.53MG
Tier 2
FALESSA
KIT
Tier 4
FALMINA
TAB
Prior
Authorization
Supply
Limit
X
X
HCR Preventative
FEMCON FE CHW
Tier 4
FEMHRT
TAB 0.5-2.5
Tier 3
FEMRING
MIS 0.05/24H
Tier 3
X
FEMRING
MIS 0.1MG/24
Tier 3
X
FYAVOLV
TAB 0.5-2.5
Tier 1
FYAVOLV
TAB 1-5
Tier 1
GENERESS FE CHW
GIANVI
GILDAGIA
Step
Therapy
Tier 4
TAB 3-0.02MG
HCR Preventative
TAB 0.4-35
HCR Preventative
GILDESS
TAB 1.5/30
HCR Preventative
GILDESS
TAB 1/20
HCR Preventative
GILDESS 24 TAB FE 1/20
HCR Preventative
GILDESS FE TAB 1.5/30
HCR Preventative
GILDESS FE TAB 1/20
HCR Preventative
INTROVALE TAB
HCR Preventative
JEVANTIQUE L TAB 0.5-2.5
Tier 1
JINTELI
Tier 1
TAB 1MG-5MCG
JOLESSA
TAB
HCR Preventative
JULEBER
TAB
HCR Preventative
JUNEL 1.5/30 TAB
HCR Preventative
JUNEL 1/20 TAB
HCR Preventative
Page 127 of 279
X
X
X
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
JUNEL FE TAB 1.5/30
Prior
Authorization
Tier Value
HCR Preventative
JUNEL FE
HCR Preventative
TAB 1/20
JUNEL FE 24 TAB 1/20
HCR Preventative
KAITLIB FE CHW
HCR Preventative
KARIVA
TAB 28 DAY
HCR Preventative
KELNOR
TAB 1/35
HCR Preventative
KIMIDESS
TAB
HCR Preventative
KURVELO
TAB 0.15/30
HCR Preventative
LARIN
TAB 1.5/30
HCR Preventative
LARIN
TAB 1/20
HCR Preventative
LARIN 24
TAB FE 1/20
HCR Preventative
LARIN FE
TAB 1.5/30
HCR Preventative
LARIN FE
TAB 1/20
HCR Preventative
LARISSIA
TAB
HCR Preventative
LAYOLIS FE CHW
HCR Preventative
LEENA
TAB
HCR Preventative
LESSINA
TAB
HCR Preventative
Supply
Limit
X
X
LEVO-ETH EST TAB 90-20MCG HCR Preventative
LEVONEST
TAB
HCR Preventative
LEVONOR/ETHI TAB
HCR Preventative
LEVONOR/ETHI TAB 0.1-0.02
HCR Preventative
LEVONOR/ETHI TAB ESTRADIO HCR Preventative
X
LEVONOR/ETHI TAB ESTRADIO HCR Preventative
LEVONOR/ETHI TAB ESTRADIO HCR Preventative
X
LEVONOR/ETHI TAB ESTRADIO HCR Preventative
X
LEVORA-28 TAB 0.15/30
HCR Preventative
LO LOESTRIN TAB
Tier 3
LOESTRIN
TAB 1/20-21
Tier 4
LOESTRIN 21 TAB 1.5/30
Tier 4
Page 128 of 279
Step
Therapy
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
LOESTRIN FE TAB 1.5/30
Tier Value
Tier 4
LOESTRIN FE TAB 1/20
LOMEDIA 24 TAB FE
Tier 1
LOPREEZA
TAB 1-0.5MG
Tier 1
TAB 3-0.02MG
HCR Preventative
LOSEASONIQUE TAB
Tier 4
LOW-OGESTREL TAB
HCR Preventative
LUTERA
HCR Preventative
MARLISSA
MENOSTAR
TAB 0.15/30
X
HCR Preventative
DIS 14MCG
Tier 3
MICRGSTIN 24 TAB FE 1/20
HCR Preventative
MICROGESTIN TAB 1.5/30
HCR Preventative
MICROGESTIN TAB 1/20
HCR Preventative
MICROGESTIN TAB FE 1/20
HCR Preventative
MICROGESTIN TAB FE1.5/30
HCR Preventative
MIMVEY
X
TAB 1-0.5MG
Tier 1
MIMVEY LO TAB 0.5-0.1
Tier 1
MINASTRIN 24 CHW FE
Tier 4
MINIVELLE DIS 0.025 MG
Tier 3
X
MINIVELLE DIS 0.0375MG
Tier 3
X
MINIVELLE DIS 0.05MG
Tier 3
X
MINIVELLE DIS 0.075MG
Tier 3
X
MINIVELLE DIS 0.1MG
Tier 3
X
MIRCETTE
TAB 28 DAY
Tier 4
MODICON
TAB 0.5/35
Tier 4
MONO-LINYAH TAB 0.25-35
HCR Preventative
MONONESSA TAB
HCR Preventative
MYZILRA
HCR Preventative
TAB
Step
Therapy
HCR Preventative
TAB 0.5-0.1
TAB
Supply
Limit
Tier 4
LOPREEZA
LORYNA
Prior
Authorization
Page 129 of 279
X
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
NATAZIA TAB
Prior
Authorization
Tier Value
HCR Preventative
NECON
TAB 0.5/35
HCR Preventative
NECON
TAB 1/35
HCR Preventative
NECON
TAB 10/11-28
HCR Preventative
NECON
TAB 7/7/7
HCR Preventative
TAB 3-0.02MG
HCR Preventative
NORETH/ETHIN CHW FE
HCR Preventative
NIKKI
NORETH/ETHIN TAB 0.5-2.5
NORETH/ETHIN TAB 1/20
Supply
Limit
Step
Therapy
X
Tier 1
HCR Preventative
NORETH/ETHIN TAB 1MG5MCG
NORETH/ETHIN TAB FE 1/20
Tier 1
HCR Preventative
NORETH/ETHIN TAB FE 1/20
HCR Preventative
NORGEST/ETHI TAB 0.25/35
HCR Preventative
NORGEST/ETHI TAB ESTRADIO HCR Preventative
NORGEST/ETHI TAB ESTRADIO HCR Preventative
NORINYL
TAB 1/35
NORTREL
TAB 0.5/35
HCR Preventative
NORTREL
TAB 1/35
HCR Preventative
NORTREL
TAB 7/7/7
HCR Preventative
NUVARING
OCELLA
MIS
Tier 4
HCR Preventative
TAB 3-0.03MG
HCR Preventative
OGESTREL
TAB
HCR Preventative
ORSYTHIA
TAB
HCR Preventative
ORTHO EVRA DIS WEEK
Tier 4
ORTHO TRI- TAB CYCLEN
Tier 3
ORTHO TRI- TAB CYCLN LO
Tier 3
ORTHO-CEPT TAB 28
Tier 4
ORTHO-CYCLEN TAB 0.25/35
Tier 3
ORTHO-EST TAB 0.625
Tier 1
Page 130 of 279
X
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Supply
Limit
Step
Therapy
Tier 4
X
X
HCR Preventative
X
Product Name
ORTHO-EST TAB 1.25
Tier Value
Tier 1
ORTHO-NOVUM TAB 1/35
Tier 4
ORTHO-NOVUM TAB 7/7/7
Tier 3
OVCON-35
Tier 4
PHILITH
TAB
TAB 0.4-35
HCR Preventative
PIMTREA
TAB
HCR Preventative
PIRMELLA
TAB 1/35
HCR Preventative
PIRMELLA
TAB 7/7/7
HCR Preventative
PORTIA-28 TAB
PREFEST
HCR Preventative
TAB
Tier 2
PREMARIN
TAB 0.3MG
Tier 3
PREMARIN
TAB 0.45MG
Tier 3
PREMARIN
TAB 0.625MG
Tier 3
PREMARIN
TAB 0.9MG
Tier 3
PREMARIN
TAB 1.25MG
Tier 3
PREMARIN VAG CRE 0.625MG
Tier 3
PREMPHASE TAB
Tier 3
PREMPRO
TAB .625-2.5
Tier 3
PREMPRO
TAB 0.3-1.5
Tier 3
PREMPRO
TAB 0.45-1.5
Tier 3
PREMPRO
TAB 0.625-5
Tier 3
PREVIFEM
TAB
HCR Preventative
QUARTETTE TAB
QUASENSE
TAB
RECLIPSEN TAB
SAFYRAL
HCR Preventative
TAB
Tier 4
SEASONIQUE TAB
SETLAKIN
Prior
Authorization
TAB
SPRINTEC 28 TAB 28 DAY
X
Tier 4
X
HCR Preventative
X
HCR Preventative
Page 131 of 279
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Product Name
SRONYX
TAB
Prior
Authorization
Tier Value
HCR Preventative
SYEDA
HCR Preventative
TAB 3-0.03MG
TARINA FE TAB 1/20
HCR Preventative
TILIA FE
HCR Preventative
TAB
TRI-ESTARYLL TAB
HCR Preventative
TRI-LEGEST TAB FE
HCR Preventative
TRI-LINYAH TAB
HCR Preventative
TRI-LO
TAB ESTARYLL
HCR Preventative
TRI-LO-
TAB MARZIA
HCR Preventative
TRI-LO-
TAB SPRINTEC
HCR Preventative
TRINESSA
TAB
HCR Preventative
TRINESSA LO TAB
HCR Preventative
TRI-NORINYL TAB 28
Tier 4
TRI-PREVIFEM TAB
HCR Preventative
TRI-SPRINTEC TAB
HCR Preventative
TRIVORA-28 TAB
HCR Preventative
VAGIFEM
VELIVET
VESTURA
Supply
Limit
TAB 10MCG
PAK
Tier 2
HCR Preventative
TAB 3-0.02MG
HCR Preventative
VIENVA
TAB 0.1-20
HCR Preventative
VIORELE
TAB
HCR Preventative
VIVELLE-DOT DIS 0.025MG
Tier 1
X
VIVELLE-DOT DIS 0.0375MG
Tier 1
X
VIVELLE-DOT DIS 0.05MG
Tier 1
X
VIVELLE-DOT DIS 0.075MG
Tier 1
X
VIVELLE-DOT DIS 0.1MG
Tier 1
X
VYFEMLA
WERA
TAB 0.4-35
TAB 0.5/35
HCR Preventative
HCR Preventative
WYMZYA FE CHW 0.4MG-35 HCR Preventative
Page 132 of 279
Step
Therapy
Specialty
Therapeutic Class
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
Estrogens - Hormone Replacement/Modifying
Drugs
EYE, EAR, NOSE AND THROAT (EENT) PREPS LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS MISCELLANEOUS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS MYDRIATICS
EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS
EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS
EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS
EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS
EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS
EYE, EAR, NOSE AND THROAT (EENT) PREPS VASOCONSTRICTORS
Product Name
XULANE
DIS 150-35
Prior
Authorization
Tier Value
HCR Preventative
YASMIN 28 TAB 3-0.03MG
Tier 3
YAZ
Tier 3
TAB 3-0.02MG
ZARAH
ZENCHENT
TAB 3-0.03MG
TAB
HCR Preventative
HCR Preventative
ZENCHENT FE CHW 0.4MG-35 HCR Preventative
ZOVIA 1/35E TAB
HCR Preventative
ZOVIA 1/50E TAB
HCR Preventative
BXN MOUTHWSH SUS
Tier 3
COCAINE HCL SOL 4%
Tier 1
FIRST-MOUTHW SUS BLM
Tier 3
GELFILM
Tier 2
MIS OP
CYCLOGYL
SOL 0.5% OP
Tier 4
CYCLOGYL
SOL 1% OP
Tier 4
CYCLOGYL
SOL 2% OP
Tier 4
CYCLOMYDRIL SOL OP
Tier 3
CYCLOPENTOL SOL 1% OP
Tier 1
CYCLOPENTOL SOL 2% OP
Tier 1
CYCLOPENTOLA SOL 0.5%
Tier 1
HOMATROPAIRE SOL 5% OP
Tier 1
HOMATROPINE SOL 5% OP
Tier 1
PAREMYD
Tier 3
SOL 1-0.25%
ALTAFRIN
SOL 10% OP
Tier 1
ALTAFRIN
SOL 2.5% OP
Tier 1
NEOFRIN
SOL 10% OP
Tier 1
NEOFRIN
SOL 2.5% OP
Tier 1
PHENYLEPHRIN SOL 10% OP
Tier 1
PHENYLEPHRIN SOL 2.5% OP
Tier 1
Page 133 of 279
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Product Name
EYE, EAR, NOSE AND THROAT (EENT) PREPS. - BETADINE SOL 5% OP
ANTI-INFECTIVES, MISCELLANEOUS
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. CORTICOSTEROIDS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
EYE, EAR, NOSE AND THROAT (EENT) PREPS. LOCAL ANESTHETICS (EENT)
Fibromyalgia Agents - Fibromyalgia Drugs
Fibromyalgia Agents - Fibromyalgia Drugs
Fibromyalgia Agents - Fibromyalgia Drugs
Fibromyalgia Agents - Fibromyalgia Drugs
Fibromyalgia Agents - Fibromyalgia Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
Tier Value
Tier 3
AERO OTIC HC SOL
Tier 1
CORTANE-B DRO AQ OTIC
Tier 2
CORTANE-B DRO OTIC
Tier 2
CORTIC-ND DRO
Tier 1
CYOTIC
Tier 1
DRO
EXOTIC-HC DRO OTIC
Tier 1
OTIC CARE DRO
Tier 1
OTICIN HC DRO
Tier 2
OTO-END 10 SOL
Tier 1
OTOMAX-HC DRO
Tier 1
AKTEN
Tier 3
GEL 3.5%
ALTACAINE SOL 0.5% OP
Tier 1
ANTIPY/BENZO SOL OTIC
Tier 1
ANTIPY/BENZO SOL OTIC
Tier 1
OTOZIN
DRO
Tier 1
PINNACAINE DRO 20% OTIC
Tier 1
TETCAINE
Tier 1
SOL 0.5% OP
Prior
Authorization
Supply
Limit
Step
Therapy
TETRACAINE SOL 0.5% OP
Tier 1
TETRAVISC SOL 0.5% OP
Tier 1
TETRAVISC SOL FORTE
Tier 1
SAVELLA
SAVELLA
SAVELLA
SAVELLA
SAVELLA
AMBIEN
MIS TITR PAK
TAB 100MG
TAB 12.5MG
TAB 25MG
TAB 50MG
TAB 10MG
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
X
X
X
X
X
X
X
AMBIEN
TAB 5MG
Tier 4
X
X
AMBIEN CR TAB 12.5MG
Tier 4
X
X
AMBIEN CR TAB 6.25MG
Tier 4
X
X
EDLUAR
Tier 4
X
X
SUB 10MG
Page 134 of 279
Specialty
Therapeutic Class
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
Product Name
EDLUAR
SUB 5MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
ESZOPICLONE TAB 1MG
Tier 1
X
ESZOPICLONE TAB 2MG
Tier 1
X
ESZOPICLONE TAB 3MG
Tier 1
X
FLURAZEPAM CAP 15MG
Tier 1
FLURAZEPAM CAP 30MG
Tier 1
HALCION
Tier 4
TAB 0.25MG
Step
Therapy
X
INTERMEZZO SUB 1.75MG
Tier 4
X
X
INTERMEZZO SUB 3.5MG
Tier 4
X
X
LUNESTA
TAB 1MG
Tier 4
X
X
LUNESTA
TAB 2MG
Tier 4
X
X
LUNESTA
TAB 3MG
Tier 4
X
X
RESTORIL
CAP 15MG
Tier 4
RESTORIL
CAP 22.5MG
Tier 4
RESTORIL
CAP 30MG
Tier 4
RESTORIL
CAP 7.5MG
Tier 4
SONATA
CAP 10MG
Tier 4
X
SONATA
CAP 5MG
Tier 4
X
TEMAZEPAM CAP 15MG
Tier 1
TEMAZEPAM CAP 22.5MG
Tier 1
TEMAZEPAM CAP 30MG
Tier 1
TEMAZEPAM CAP 7.5MG
Tier 1
TRIAZOLAM TAB 0.125MG
Tier 1
TRIAZOLAM TAB 0.25MG
Tier 1
ZALEPLON
CAP 10MG
Tier 1
X
ZALEPLON
CAP 5MG
Tier 1
X
ZOLPIDEM
TAB 10MG
Tier 1
X
ZOLPIDEM
TAB 5MG
Tier 1
X
Tier 1
X
ZOLPIDEM ER TAB 12.5MG
Page 135 of 279
X
Specialty
Supply
Limit
X
Step
Therapy
X
Tier 1
X
X
ZOLPIDEM TAR SUB 3.5MG
Tier 1
X
X
ZOLPIMIST SPR 5MG
Tier 4
X
X
CLONAZEP ODT TAB 0.125MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 0.25MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 0.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 1MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLONAZEP ODT TAB 2MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLONAZEPAM TAB 0.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLONAZEPAM TAB 1MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLONAZEPAM TAB 2MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLORAZ DIPOT TAB 15MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLORAZ DIPOT TAB 3.75MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
CLORAZ DIPOT TAB 7.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DEPAKENE
CAP 250MG
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DEPAKENE
SYP 250/5ML
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DEPAKOTE
TAB 125MG DR
Tier 4
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DEPAKOTE
TAB 250MG DR
Tier 4
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DEPAKOTE
TAB 500MG DR
Tier 4
X
Therapeutic Class
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
GABA Receptor Modulators - Sedation and
Sleep Drugs
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
Product Name
ZOLPIDEM ER TAB 6.25MG
Tier Value
Tier 1
ZOLPIDEM TAR SUB 1.75MG
Page 136 of 279
Prior
Authorization
Specialty
Therapeutic Class
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
Product Name
DEPAKOTE ER TAB 250MG
Tier Value
Tier 4
Prior
Authorization
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DEPAKOTE ER TAB 500MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DEPAKOTE SPR CAP 125MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIASTAT ACDL GEL 12.5-20
Tier 4
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIASTAT ACDL GEL 5-10MG
Tier 4
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIASTAT PED GEL 2.5M GEL
Tier 2
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIAZEPAM
GEL 10MG
Tier 1
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIAZEPAM
GEL 2.5MG
Tier 1
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIAZEPAM
GEL 20MG
Tier 1
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIVALPROEX CAP 125MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 125MG DR
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 250MG DR
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 250MG ER
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 500MG DR
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
DIVALPROEX TAB 500MG ER
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
FANATREX
SUS 25MG/ML
Tier 3
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
FYCOMPA
SUS 0.5MG/ML
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
FYCOMPA
TAB 10MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
FYCOMPA
TAB 12MG
Tier 3
X
Page 137 of 279
Supply
Limit
Step
Therapy
X
Specialty
Tier Value
Tier 3
Prior
Authorization
X
TAB 4MG
Tier 3
X
FYCOMPA
TAB 6MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
FYCOMPA
TAB 8MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABAPENTIN CAP 100MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABAPENTIN CAP 300MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABAPENTIN CAP 400MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABAPENTIN SOL 250/5ML
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABAPENTIN TAB 600MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABAPENTIN TAB 800MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 12MG
Tier 2
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 16MG
Tier 2
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 2MG
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GABITRIL
TAB 4MG
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GENE-XENE TAB 15MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GENE-XENE TAB 3.75MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
GENE-XENE TAB 7.5MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
HORIZANT
TAB 300MG
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
HORIZANT
TAB 600MG
Therapeutic Class
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
Product Name
FYCOMPA TAB 2MG
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
FYCOMPA
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
Page 138 of 279
Supply
Limit
Step
Therapy
Tier 4
X
X
Tier 4
X
X
Specialty
Prior
Authorization
Supply
Limit
Step
Therapy
Therapeutic Class
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
Product Name
KLONOPIN TAB 0.5MG
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
KLONOPIN
TAB 1MG
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
KLONOPIN
TAB 2MG
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
MYSOLINE
TAB 250MG
Tier 2
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
MYSOLINE
TAB 50MG
Tier 2
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
NEURONTIN CAP 100MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
NEURONTIN CAP 300MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
NEURONTIN CAP 400MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
NEURONTIN SOL 250/5ML
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
NEURONTIN TAB 600MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
NEURONTIN TAB 800MG
Tier 4
X
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
ONFI
SUS 2.5MG/ML
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
ONFI
TAB 10MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
ONFI
TAB 20MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
PRIMIDONE TAB 250MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
PRIMIDONE TAB 50MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
SABRIL
POW 500MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
SABRIL
TAB 500MG
Tier 3
X
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
STAVZOR
CAP 125MG
Page 139 of 279
Tier Value
Tier 4
Tier 3
X
X
Specialty
Tier Value
Tier 3
Prior
Authorization
X
Tier 3
X
Therapeutic Class
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
Product Name
STAVZOR CAP 250MG
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
STAVZOR
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
TIAGABINE TAB 2MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
TIAGABINE TAB 4MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
TRANXENE T TAB 3.75MG
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
TRANXENE T TAB 7.5MG
Tier 4
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
VALPROIC ACD CAP 250MG
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
VALPROIC ACD SOL 250/5ML
Tier 1
Gamma-Aminobutyric Acid (GABA)
Augmenting Agents - Seizure Control Drugs
VALPROIC ACD SYP 250/5ML
Tier 1
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
ACTIGALL
Tier 4
CAP 500MG
CAP 300MG
BISACODYL TAB 5MG EC
CASCARA
CHENODAL
CORRECT
Tier 1
TAB 250MG
Tier 4
Tier 1
DIPHEN/ATROP TAB 2.5MG
Tier 1
TAB 5MG EC
ENTEREG
CAP 12MG
X
X
Tier 1
HCR Preventative
Tier 3
EQL LAXATIVE TAB 5MG EC
HCR Preventative
EX-LAX ULTRA TAB 5MG EC
HCR Preventative
FEMININE LAX TAB 5MG EC
HCR Preventative
FLEET LAXATI TAB 5MG EC
HCR Preventative
FULYZAQ
Specialty
HCR Preventative
CROMOLYN SOD CON
100/5ML
DIPHEN/ATROP LIQ 2.5/5
DUCODYL
Step
Therapy
X
HCR Preventative
EXT SAGRADA
TAB 5MG EC
Supply
Limit
TAB 125MG
Page 140 of 279
Tier 4
X
X
X
Therapeutic Class
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Product Name
GASTROCROM CON 100/5ML
GATTEX
Tier Value
Tier 4
KIT 5MG
Tier 3
GAVILYTE-H KIT
Supply
Limit
X
X
Step
Therapy
HCR Preventative
GNP BISA-LAX TAB 5MG EC
HCR Preventative
GNP LAXATIVE TAB 5MG EC
HCR Preventative
HM LAXATIVE TAB 5MG
HCR Preventative
HM LAXATIVE TAB 5MG EC
HCR Preventative
KP BISACODYL TAB 5MG EC
HCR Preventative
LAXATIVE
TAB 5MG EC
HCR Preventative
LOFENE
TAB 2.5MG
Tier 1
TAB 2.5MG
Tier 4
METOCLOPRAM SOL
5MG/5ML
METOCLOPRAM TAB 10MG
Tier 1
METOCLOPRAM TAB 5MG
Tier 1
METOCLOPRAM TAB 5MG
ODT
METOCLOPRAMI TAB 10MG
ODT
METOZOLV ODT TAB 5MG
Tier 1
X
Tier 1
X
Tier 4
X
MINERAL
Tier 1
Tier 1
OIL HEAVY
MOTOFEN
TAB 1-0.025
Tier 3
NICOTINAMIDE POW ADENINE
Tier 3
OSMOPREP
Tier 3
TAB 1.5GM
PAREGORIC TIN 2MG/5ML
Tier 1
PEG-PREP
KIT
Tier 1
CAP
Tier 3
QC LAXATIVE TAB 5MG EC
HCR Preventative
RA LAXATIVE TAB 5MG EC
HCR Preventative
PYLERA
REGLAN
TAB 10MG
Tier 4
REGLAN
TAB 5MG
Tier 4
Page 141 of 279
X
X
Specialty
X
Tier 1
GENTLE LAXAT TAB 5MG EC
LOMOTIL
Prior
Authorization
Therapeutic Class
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
GASTROINTESTINAL DRUGS - LIPOTROPIC
AGENTS
Genitourinary Agents, Other
Genitourinary Agents, Other
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Product Name
RELISTOR INJ 12/0.6ML
RELISTOR
INJ 8/0.4ML
REZYST IM CHW
Tier Value
Tier 4
Prior
Authorization
X
Tier 4
X
Tier 3
SM GENTLE TAB LAXATIVE
HCR Preventative
SM LAXATIVE TAB 5MG EC
HCR Preventative
SODIUM
Supply
Limit
POW BICARBON
STIM LAXAT TAB 5MG EC
Tier 3
HCR Preventative
SUCLEAR
KIT
Tier 3
URSO 250
TAB 250MG
Tier 4
URSO FORTE TAB 500MG
Tier 4
URSODIOL
CAP 300MG
Tier 1
URSODIOL
TAB 250MG
Tier 1
URSODIOL
TAB 500MG
Tier 1
VERCOLATE TAB 5MG EC
HCR Preventative
WOMANS LAXAT TAB 5MG EC HCR Preventative
WOMENS LAXAT TAB 5MG EC HCR Preventative
LECITHIN
GRA
Tier 1
CIALIS
TAB 10MG
CIALIS
TAB 20MG
CAVERJECT INJ 20MCG
Tier 4
Tier 4
Tier 3
X
X
X
X
X
X
CAVERJECT INJ 40MCG
Tier 3
X
X
CAVERJECT KIT 10MCG
Tier 3
X
X
CAVERJECT KIT 20MCG
Tier 3
X
X
EDEX
KIT 10MCG
Tier 3
X
X
EDEX
KIT 20MCG
Tier 3
X
X
EDEX
KIT 40MCG
Tier 3
X
X
LEVITRA
TAB 10MG
Tier 4
X
X
LEVITRA
TAB 2.5MG
Tier 4
X
X
LEVITRA
TAB 20MG
Tier 4
X
X
LEVITRA
TAB 5MG
Tier 4
X
X
Page 142 of 279
Step
Therapy
Specialty
Therapeutic Class
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Erectile
Dysfunction Agents
Genitourinary Agents, Other - Miscellaneous
Bladder, Genital, and Kidney Conditions Drugs
Product Name
MUSE
SUP 1000MCG
Tier Value
Tier 3
Prior
Authorization
X
Supply
Limit
X
MUSE
SUP 125MCG
Tier 3
X
X
MUSE
SUP 250MCG
Tier 3
X
X
MUSE
SUP 500MCG
Tier 3
X
X
STAXYN
TAB 10MG
Tier 4
X
X
STENDRA
TAB 100MG
Tier 4
X
X
STENDRA
TAB 200MG
Tier 4
X
X
STENDRA
TAB 50MG
Tier 4
X
X
VIAGRA
TAB 100MG
Tier 4
X
X
VIAGRA
TAB 25MG
Tier 4
X
X
VIAGRA
TAB 50MG
Tier 4
X
X
BETHANECHOL TAB 10MG
Tier 1
Genitourinary Agents, Other - Miscellaneous BETHANECHOL TAB 25MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous BETHANECHOL TAB 50MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous BETHANECHOL TAB 5MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous ELMIRON
Bladder, Genital, and Kidney Conditions Drugs
CAP 100MG
Tier 2
Genitourinary Agents, Other - Miscellaneous LITHOSTAT TAB 250MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 3
Genitourinary Agents, Other - Miscellaneous PHENAZO
Bladder, Genital, and Kidney Conditions Drugs
Tier 1
TAB 200MG
Genitourinary Agents, Other - Miscellaneous PHENAZOPYRID TAB 100MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous PHENAZOPYRID TAB 200MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 1
Genitourinary Agents, Other - Miscellaneous PYRIDIUM
Bladder, Genital, and Kidney Conditions Drugs
TAB 100MG
Tier 3
Genitourinary Agents, Other - Miscellaneous PYRIDIUM
Bladder, Genital, and Kidney Conditions Drugs
TAB 200MG
Tier 3
Genitourinary Agents, Other - Miscellaneous THIOLA
Bladder, Genital, and Kidney Conditions Drugs
TAB 100MG
Page 143 of 279
Tier 4
Step
Therapy
Specialty
X
X
Therapeutic Class
Product Name
Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 10MG
Bladder, Genital, and Kidney Conditions Drugs
Tier Value
Tier 3
Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 25MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 4
Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 50MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 3
Genitourinary Agents, Other - Miscellaneous URECHOLINE TAB 5MG
Bladder, Genital, and Kidney Conditions Drugs
Tier 3
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids - Inflammatory Bowel Disease
Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Tier 1
COLOCORT
ENE 100MG
CORTENEMA ENE 100MG
Tier 4
HYDROCORT ENE 100MG
Tier 1
MILLIPRED TAB 5MG
Tier 2
MILLIPRED DP PAK 5MG
Tier 2
MILLIPRED DP PAK 5MG
Tier 2
PREDNISOLONE SOL
15MG/5ML
PREDNISOLONE SYP
15MG/5ML
UCERIS
TAB 9MG
Tier 1
ACLOVATE
Tier 3
CRE 0.05%
Supply
Limit
Tier 1
Tier 3
ALA SCALP LOT 2%
Tier 4
ALCLOMETASON CRE 0.05%
Tier 1
ALCLOMETASON OIN 0.05%
Tier 1
ALPHATREX GEL 0.05%
Tier 1
AMCINONIDE CRE 0.1%
Tier 1
AMCINONIDE LOT 0.1%
Tier 1
AMCINONIDE OIN 0.1%
Tier 1
ANUSOL-HC CRE 2.5%
Tier 4
APEXICON E CRE 0.05%
Tier 2
AUG BETAMET CRE 0.05%
Tier 1
AUG BETAMET GEL 0.05%
Tier 1
AUG BETAMET LOT 0.05%
Tier 1
AUG BETAMET OIN 0.05%
Tier 1
Page 144 of 279
Prior
Authorization
X
Step
Therapy
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
Tier 1
X
X
CLOBETASOL AER 0.05%
Tier 1
X
X
CLOBETASOL CRE 0.05%
Tier 1
X
CLOBETASOL GEL 0.05%
Tier 1
X
CLOBETASOL LOT 0.05%
Tier 1
X
CLOBETASOL OIN 0.05%
Tier 1
X
CLOBETASOL POW PROPIONA
Tier 3
CLOBETASOL SHA 0.05%
Tier 1
X
CLOBETASOL SOL 0.05%
Tier 1
X
CLOBETASOL SPR 0.05%
Tier 1
X
CLOBETASOL E CRE 0.05%
Tier 1
X
CLOBEX
LOT 0.05%
Tier 4
X
X
CLOBEX
SHA 0.05%
Tier 4
X
X
CLOBEX
SPR 0.05%
Tier 3
X
CLOCORTOLONE CRE PIV 0.1%
Tier 1
X
X
CLODAN
SHA 0.05%
Tier 1
X
X
CRE 0.1%
Tier 4
X
X
Product Name
BETAMETH DIP CRE 0.05%
Tier Value
Tier 1
BETAMETH DIP LOT 0.05%
Tier 1
BETAMETH DIP OIN 0.05%
Tier 1
BETAMETH DIP POW
Tier 3
X
BETAMETH DIP POW
MICRONIZ
BETAMETH DIP POW USP NF
Tier 3
X
Tier 3
X
BETAMETH VAL AER 0.12%
Tier 1
BETAMETH VAL CRE 0.1%
Tier 1
BETAMETH VAL LOT 0.1%
Tier 1
BETAMETH VAL OIN 0.1%
Tier 1
BETAMETHASON POW
VALERATE
CAPEX
SHA 0.01%
Tier 3
CLOBETASOL AER 0.05%
CLODERM
Page 145 of 279
X
Tier 2
X
X
X
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name
CLODERM CRE 0.1% PMP
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
CORDRAN
CRE 0.05%
Tier 4
X
X
CORDRAN
LOT 0.05%
Tier 4
X
X
CORDRAN
OIN 0.05%
Tier 4
CORDRAN 24X3 TAP
4MCG/CM
CORDRAN 24X3 TAP SML 24IN
Tier 3
CORDRAN 80X3 TAP
4MCG/CM
CORMAX SCALP SOL 0.05%
Tier 3
CORTEF
TAB 10MG
Tier 4
CORTEF
TAB 20MG
Tier 4
CORTEF
TAB 5MG
Tier 4
Tier 3
Tier 1
CORTIFOAM AER 90MG
Tier 2
CORTISONE AC TAB 25MG
Tier 1
CUTIVATE
CRE 0.05%
Tier 4
CUTIVATE
LOT 0.05%
Tier 3
X
X
DELTASONE TAB 20MG
Tier 1
DERMA-SMOOTH OIL /FS
BODY
DERMA-SMOOTH OIL /FS SCLP
Tier 4
DERMATOP
CRE 0.1%
Tier 4
DERMATOP
OIN 0.1%
Tier 4
DESONATE
GEL 0.05%
Tier 3
X
DESONIDE
CRE 0.05%
Tier 1
X
DESONIDE
LOT 0.05%
Tier 1
X
DESONIDE
OIN 0.05%
Tier 1
X
DESOWEN
CRE 0.05%
Tier 3
X
DESOWEN
LOT 0.05%
Tier 4
X
DESOXIMETAS CRE 0.05%
Tier 1
X
DESOXIMETAS CRE 0.25%
Tier 1
X
DESOXIMETAS GEL 0.05%
Tier 1
X
Page 146 of 279
X
X
Tier 4
X
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Prior
Authorization
Product Name
DESOXIMETAS OIN 0.05%
Tier Value
Tier 1
DESOXIMETAS OIN 0.25%
Tier 1
DEXAMETH SOD POW
PHOSPHAT
DEXAMETHASON CON
1MG/ML
DEXAMETHASON ELX 0.5/5ML
Tier 3
DEXAMETHASON POW
Tier 3
X
DEXAMETHASON POW
MICRONIZ
DEXAMETHASON SOL 0.5/5ML
Tier 3
X
DEXAMETHASON TAB 0.5MG
Tier 1
DEXAMETHASON TAB 0.75MG
Tier 1
DEXAMETHASON TAB 1.5MG
Tier 1
DEXAMETHASON TAB 1MG
Tier 1
DEXAMETHASON TAB 2MG
Tier 1
DEXAMETHASON TAB 4MG
Tier 1
DEXAMETHASON TAB 6MG
Tier 1
DEXPAK
PAK 10 DAY
Tier 3
DEXPAK
PAK 13 DAY
Tier 3
DEXPAK
PAK 6 DAY
Tier 3
Supply
Limit
X
X
X
Tier 1
Tier 1
Tier 1
DIFLORASONE CRE 0.05%
Tier 1
DIFLORASONE OIN 0.05%
Tier 1
DIPROLENE LOT 0.05%
Tier 4
DIPROLENE OIN 0.05%
Tier 4
DIPROLENE AF CRE 0.05%
Tier 4
ELOCON
CRE 0.1%
Tier 4
ELOCON
LOT 0.1%
Tier 4
ELOCON
OIN 0.1%
Tier 4
FLUDROCORT TAB 0.1MG
Tier 1
FLUOCIN ACET CRE 0.01%
Tier 1
X
FLUOCIN ACET CRE 0.025%
Tier 1
X
Page 147 of 279
Step
Therapy
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
Product Name
FLUOCIN ACET OIL 0.01% SC
Tier Value
Tier 1
FLUOCIN ACET OIL 0.01%BDY
Tier 1
X
FLUOCIN ACET OIL BODY
Tier 1
X
FLUOCIN ACET OIL SCALP
Tier 1
FLUOCIN ACET OIN 0.025%
Tier 1
X
FLUOCIN ACET SOL 0.01%
Tier 1
X
FLUOCINONIDE CRE 0.05%
Tier 1
FLUOCINONIDE CRE 0.1%
Tier 1
FLUOCINONIDE CRE -E 0.05%
Tier 1
FLUOCINONIDE GEL 0.05%
Tier 1
FLUOCINONIDE OIN 0.05%
Tier 1
FLUOCINONIDE SOL 0.05%
Tier 1
FLURANDRENOL CRE 0.05%
Tier 1
FLUTICASONE CRE 0.05%
Tier 1
FLUTICASONE LOT 0.05%
Tier 1
FLUTICASONE OIN 0.005%
Tier 1
FRST-HYDRCRT GEL 10%
Tier 2
GNP HYDROCOR OIN 1%
W/ALO
HALOBETASOL CRE 0.05%
Tier 1
Tier 1
X
HALOBETASOL OIN 0.05%
Tier 1
X
HALOG
CRE 0.1%
Tier 3
X
X
HALOG
OIN 0.1%
Tier 3
X
X
X
X
X
X
X
X
X
X
X
HC BUTYRATE CRE 0.1%
Tier 1
HC BUTYRATE CRE 0.1%
Tier 1
HC BUTYRATE OIN 0.1%
Tier 1
HC BUTYRATE SOL 0.1%
Tier 1
HC VALERATE CRE 0.2%
Tier 1
X
HC VALERATE OIN 0.2%
Tier 1
X
HYDROCORT CRE 1%
Tier 1
Page 148 of 279
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name
HYDROCORT CRE 2.5%
Tier Value
Tier 1
HYDROCORT LOT 2.5%
Tier 1
HYDROCORT OIN 1%
Tier 1
HYDROCORT OIN 2.5%
Tier 1
HYDROCORT TAB 10MG
Tier 1
HYDROCORT TAB 20MG
Tier 1
HYDROCORT TAB 5MG
Tier 1
HYDROCORT/AB OIN 1%
Tier 1
HYDROCORTISO CRE 2.5%
Tier 1
KENALOG
Tier 4
AER SPRAY
LOCOID
CRE 0.1%
Tier 4
LOCOID
LOT 0.1%
Tier 4
LOCOID
OIN 0.1%
Tier 4
LOCOID
SOL 0.1%
Tier 4
Prior
Authorization
Supply
Limit
X
X
X
X
LOCOID LIPO CRE 0.1%
Tier 4
X
LOKARA
Tier 1
X
Tier 4
X
LUXIQ
LOT 0.05%
AER 0.12%
MEDROL
TAB 16MG
Tier 4
MEDROL
TAB 2MG
Tier 2
MEDROL
TAB 32MG
Tier 3
MEDROL
TAB 4MG
Tier 4
MEDROL
TAB 4MG
Tier 4
MEDROL
TAB 8MG
Tier 4
METHYLPRED POW ACETATE
Tier 3
METHYLPRED TAB 16MG
Tier 1
METHYLPRED TAB 32MG
Tier 1
METHYLPRED TAB 4MG
Tier 1
METHYLPRED TAB 4MG
Tier 1
METHYLPRED TAB 8MG
Tier 1
Page 149 of 279
Step
Therapy
X
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name
MILLIPRED SOL 10MG/5ML
Tier Value
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
MOMETASONE CRE 0.1%
Tier 1
MOMETASONE OIN 0.1%
Tier 1
MOMETASONE POW
Tier 3
MOMETASONE SOL 0.1%
Tier 1
OLUX
Tier 4
X
X
Tier 4
X
X
OLUX-E
AER 0.05%
AER 0.05%
ORAPRED ODT TAB 10MG
Tier 4
ORAPRED ODT TAB 15MG
Tier 4
ORAPRED ODT TAB 30MG
Tier 4
PANDEL
Tier 3
CRE 0.1%
PEDIAPRED SOL 6.7/5ML
Tier 2
PRED SOD PHO SOL 5MG/5ML
Tier 1
PREDNICARBAT CRE 0.1%
Tier 1
PREDNICARBAT OIN 0.1%
Tier 1
PREDNISOLONE SOL
15MG/5ML
PREDNISOLONE SOL
25MG/5ML
PREDNISOLONE TAB 10MG
ODT
PREDNISOLONE TAB 15MG
ODT
PREDNISOLONE TAB 30MG
ODT
PREDNISONE CON 5MG/ML
Tier 1
PREDNISONE PAK 10MG
Tier 1
PREDNISONE PAK 10MG
Tier 1
PREDNISONE PAK 5MG
Tier 1
PREDNISONE PAK 5MG
Tier 1
PREDNISONE SOL 5MG/5ML
Tier 1
PREDNISONE TAB 10MG
Tier 1
PREDNISONE TAB 1MG
Tier 1
PREDNISONE TAB 2.5MG
Tier 1
Page 150 of 279
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
X
X
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Product Name
PREDNISONE TAB 20MG
Tier Value
Tier 1
PREDNISONE TAB 50MG
Tier 1
PREDNISONE TAB 5MG
Tier 1
PROCTOCORT CRE 1%
Tier 4
PROCTO-MED CRE HC 2.5%
Tier 1
PROCTO-PAK CRE 1%
Tier 1
PROCTOSOL HC CRE 2.5%
Tier 1
PROCTOZONE CRE -HC 2.5%
Tier 1
PSORCON
Tier 1
CRE 0.05%
Prior
Authorization
Supply
Limit
Step
Therapy
X
RAYOS
TAB 1MG
Tier 4
X
RAYOS
TAB 2MG
Tier 4
X
RAYOS
TAB 5MG
Tier 4
X
SCALACORT LOT 2%
Tier 1
SERNIVO
SPR
Tier 4
SYNALAR
CRE 0.025%
Tier 4
X
X
SYNALAR
OIN 0.025%
Tier 4
X
X
SYNALAR
SOL 0.01%
Tier 4
X
X
X
TEMOVATE
CRE 0.05%
Tier 4
X
TEMOVATE
GEL 0.05%
Tier 3
X
TEMOVATE
OIN 0.05%
Tier 4
X
TEMOVATE
SOL 0.05%
Tier 4
X
TEMOVATE E CRE 0.05%EML
Tier 4
X
TEXACORT
SOL 2.5%
Tier 2
TOPICORT
CRE 0.05%
Tier 4
X
TOPICORT
CRE 0.25%
Tier 4
X
TOPICORT
GEL 0.05%
Tier 4
X
TOPICORT
OIN 0.05%
Tier 4
X
TOPICORT
OIN 0.25%
Tier 4
X
TOPICORT
SPR 0.25%
Tier 4
Page 151 of 279
X
Specialty
Therapeutic Class
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glucocorticoids/Mineralocorticoids - AntiInflammatory Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Product Name
TRIAMCINOLON AER SPRAY
Tier Value
Tier 1
TRIAMCINOLON CRE 0.025%
Tier 1
TRIAMCINOLON CRE 0.1%
Tier 1
TRIAMCINOLON CRE 0.5%
Tier 1
TRIAMCINOLON LOT 0.025%
Tier 1
TRIAMCINOLON LOT 0.1%
Tier 1
TRIAMCINOLON OIN 0.025%
Tier 1
TRIAMCINOLON OIN 0.1%
Tier 1
TRIAMCINOLON OIN 0.5%
Tier 1
TRIAMCINOLON POW
ACETONID
TRIANEX OIN 0.05%
Tier 3
TRIDERM
Tier 1
CRE 0.1%
Prior
Authorization
Supply
Limit
Step
Therapy
X
Tier 4
X
ULTRAVATE CRE 0.05%
Tier 4
ULTRAVATE LOT 0.05%
Tier 4
ULTRAVATE OIN 0.05%
Tier 4
X
VANOS
Tier 4
X
X
Tier 4
X
X
VERDESO
CRE 0.1%
AER 0.05%
VERIPRED 20 SOL 20MG/5ML
Tier 3
WESTCORT
Tier 4
OIN 0.2%
X
X
X
FELBAMATE SUS 600/5ML
Tier 1
FELBAMATE TAB 400MG
Tier 1
FELBAMATE TAB 600MG
Tier 1
FELBATOL
SUS 600/5ML
Tier 4
X
X
FELBATOL
TAB 400MG
Tier 4
X
X
FELBATOL
TAB 600MG
Tier 4
X
X
LAMICTAL
CHW 25MG
Tier 4
X
X
LAMICTAL
CHW 5MG
Tier 4
X
X
LAMICTAL
KIT START 35
Tier 3
X
X
LAMICTAL
KIT START 49
Tier 3
X
X
Page 152 of 279
Specialty
Therapeutic Class
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Product Name
LAMICTAL KIT START 98
Tier Value
Tier 3
Prior
Authorization
X
Supply
Limit
Step
Therapy
X
LAMICTAL
TAB 100MG
Tier 4
X
X
LAMICTAL
TAB 150MG
Tier 4
X
X
LAMICTAL
TAB 200MG
Tier 4
X
X
LAMICTAL
TAB 25MG
Tier 4
X
X
LAMICTAL ODT KIT
Tier 4
X
X
LAMICTAL ODT KIT
Tier 4
X
X
LAMICTAL ODT KIT
Tier 4
X
X
LAMICTAL ODT TAB 100MG
Tier 4
X
X
LAMICTAL ODT TAB 200MG
Tier 4
X
X
LAMICTAL ODT TAB 25MG
Tier 4
X
X
LAMICTAL ODT TAB 50MG
Tier 4
X
X
LAMICTAL XR KIT
Tier 3
X
X
LAMICTAL XR KIT
Tier 3
X
X
LAMICTAL XR KIT
Tier 3
X
X
LAMICTAL XR TAB 100MG
Tier 3
X
X
LAMICTAL XR TAB 200MG
Tier 3
X
X
LAMICTAL XR TAB 250MG
Tier 3
X
X
LAMICTAL XR TAB 25MG
Tier 3
X
X
LAMICTAL XR TAB 300MG
Tier 3
X
X
LAMICTAL XR TAB 50MG
Tier 3
X
X
LAMOTRIG ODT KIT 25/50MG
Tier 1
X
X
LAMOTRIG ODT KIT 50/100MG
Tier 1
X
X
LAMOTRIGINE CHW 25MG
Tier 1
LAMOTRIGINE CHW 5MG
Tier 1
LAMOTRIGINE KIT ODT
Tier 1
X
X
LAMOTRIGINE TAB 100MG
Tier 1
LAMOTRIGINE TAB 100MG
Tier 1
LAMOTRIGINE TAB 100MG ER
Tier 1
Page 153 of 279
X
X
X
Specialty
Therapeutic Class
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
Product Name
LAMOTRIGINE TAB 150MG
Tier Value
Tier 1
LAMOTRIGINE TAB 200MG
Tier 1
LAMOTRIGINE TAB 200MG
Tier 1
LAMOTRIGINE TAB 200MG ER
Tier 1
X
X
LAMOTRIGINE TAB 250MG ER
Tier 1
X
X
LAMOTRIGINE TAB 25MG
Tier 1
LAMOTRIGINE TAB 25MG ER
Tier 1
X
X
LAMOTRIGINE TAB 25MG ODT
Tier 1
LAMOTRIGINE TAB 300MG ER
Tier 1
X
X
LAMOTRIGINE TAB 50MG ER
Tier 1
X
X
LAMOTRIGINE TAB 50MG ODT
Tier 1
QUDEXY XR CAP 100/24HR
Tier 4
X
X
QUDEXY XR CAP 150/24HR
Tier 4
X
X
QUDEXY XR CAP 200/24HR
Tier 4
X
X
QUDEXY XR CAP 25/24HR
Tier 4
X
X
QUDEXY XR CAP 50/24HR
Tier 4
X
X
TOPAMAX
TAB 100MG
Tier 4
X
X
TOPAMAX
TAB 200MG
Tier 4
X
X
TOPAMAX
TAB 25MG
Tier 4
X
X
TOPAMAX
TAB 50MG
Tier 4
X
X
TOPAMAX SPR CAP 15MG
Tier 4
X
X
TOPAMAX SPR CAP 25MG
Tier 4
X
X
TOPIRAGEN TAB 100MG
Tier 1
TOPIRAGEN TAB 200MG
Tier 1
TOPIRAGEN TAB 25MG
Tier 1
TOPIRAGEN TAB 50MG
Tier 1
TOPIRAMATE CAP 15MG
Tier 1
TOPIRAMATE CAP 25MG
Tier 1
TOPIRAMATE CAP ER 100MG
Tier 4
X
X
Page 154 of 279
X
X
X
Specialty
Therapeutic Class
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glutamate Reducing Agents - Seizure Control
Drugs
Glycemic Agents - Diabetic Drugs
Glycemic Agents - Diabetic Drugs
Glycemic Agents - Diabetic Drugs
Product Name
TOPIRAMATE CAP ER 150MG
Tier Value
Tier 4
Prior
Authorization
X
TOPIRAMATE CAP ER 200MG
Tier 4
X
X
TOPIRAMATE CAP ER 25MG
Tier 4
X
X
TOPIRAMATE CAP ER 50MG
Tier 4
X
X
TOPIRAMATE TAB 100MG
Tier 1
TOPIRAMATE TAB 200MG
Tier 1
TOPIRAMATE TAB 25MG
Tier 1
TOPIRAMATE TAB 50MG
Tier 1
TROKENDI XR CAP 100MG
Tier 4
X
X
TROKENDI XR CAP 200MG
Tier 4
X
X
TROKENDI XR CAP 25MG
Tier 4
X
X
TROKENDI XR CAP 50MG
Tier 4
X
X
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
PROGLYCEM SUS 50MG/ML
Tier 2
Tier 2
Tier 3
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
GALZIN
GALZIN
AXID
Tier 3
Tier 3
Tier 4
CAP 25MG
CAP 50MG
SOL 15MG/ML
X
X
CIMETIDINE SOL 300/5ML
Tier 1
CIMETIDINE TAB 200MG
Tier 1
CIMETIDINE TAB 300MG
Tier 1
CIMETIDINE TAB 400MG
Tier 1
CIMETIDINE TAB 800MG
Tier 1
CIMETIDINE TAB 400MG
Tier 1
DEPRIZINE SUS 22.4/ML
Tier 3
X
DEPRIZINE SUS RAPIDPAQ
Tier 3
X
FAMOTIDINE SUS 40MG/5ML
Tier 1
NIZATIDINE SOL 15MG/ML
Tier 4
NIZATIDINE SOL 15MG/ML
Tier 4
NIZATIDINE SOL 15MG/ML
Tier 1
NIZATIDINE SOL 15MG/ML
Tier 3
Page 155 of 279
Supply
Limit
Step
Therapy
X
Specialty
Therapeutic Class
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Histamine2 (H2) receptor Antagonists - Ulcer
and Stomach Acid Drugs
Hormonal Agents, Stimulant/ Replacement/
Modifying (Prostaglandins) - Hormone
Replacement/Modifying Drugs
Product Name
PEPCID
SUS 40MG/5ML
Tier Value
Tier 4
RANITIDINE SYP 150/10ML
Tier 1
RANITIDINE SYP 15MG/ML
Tier 1
RANITIDINE SYP 75MG/5ML
Tier 1
CERVIDIL VAG MIS 10MG INS
Tier 3
Hormonal Agents, Stimulant/ Replacement/
Modifying (Prostaglandins) - Hormone
Replacement/Modifying Drugs
PREPIDIL
Tier 3
Hormonal Agents, Stimulant/ Replacement/
Modifying (Prostaglandins) - Hormone
Replacement/Modifying Drugs
PROSTIN E2 SUP 20MG
Hormonal Agents,
BRAVELLE
Stimulant/Replacement/Modifying (Pituitary)
GEL 0.5MG/3G
INJ 75UNIT
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
X
X
Tier 3
Tier 4
Hormonal Agents,
CLOMIPHENE TAB 50MG
Stimulant/Replacement/Modifying (Pituitary)
Tier 1
Hormonal Agents,
FOLLISTIM AQ INJ 150UNIT
Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents,
FOLLISTIM AQ INJ 300UNIT
Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents,
FOLLISTIM AQ INJ 600UNIT
Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents,
FOLLISTIM AQ INJ 75UNIT
Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents,
FOLLISTIM AQ INJ 900UNIT
Stimulant/Replacement/Modifying (Pituitary)
Tier 4
X
X
X
Hormonal Agents,
GONAL-F
Stimulant/Replacement/Modifying (Pituitary)
INJ 1050UNIT
Tier 3
X
X
Hormonal Agents,
GONAL-F
Stimulant/Replacement/Modifying (Pituitary)
INJ 450UNIT
Tier 3
X
X
Hormonal Agents,
GONAL-F RFF INJ 300/0.5
Stimulant/Replacement/Modifying (Pituitary)
Tier 3
X
X
Hormonal Agents,
GONAL-F RFF INJ 450/0.75
Stimulant/Replacement/Modifying (Pituitary)
Tier 3
X
X
Hormonal Agents,
GONAL-F RFF INJ 75UNIT
Stimulant/Replacement/Modifying (Pituitary)
Tier 3
X
X
Page 156 of 279
Therapeutic Class
Product Name
Hormonal Agents,
GONAL-F RFF INJ 900/1.5
Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents,
MENOPUR
Stimulant/Replacement/Modifying (Pituitary)
INJ 75UNIT
Tier Value
Tier 3
Prior
Authorization
X
Tier 4
X
Hormonal Agents,
CHOR GONADOT INJ
Stimulant/Replacement/Modifying (Pituitary) - 10000UNT
Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents,
DDAVP
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 4MCG/ML
Tier 4
Hormonal Agents,
DDAVP
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
SOL 0.01%
Tier 3
Hormonal Agents,
DDAVP
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
SPR 0.01%
Tier 4
Hormonal Agents,
DDAVP
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
TAB 0.1MG
Tier 4
Hormonal Agents,
DDAVP
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
TAB 0.2MG
Tier 4
Hormonal Agents,
DESMOPRESSIN INJ 4MCG/ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents,
DESMOPRESSIN SOL 0.01%
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents,
DESMOPRESSIN SPR 0.01%
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents,
DESMOPRESSIN SPR 0.01%
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents,
DESMOPRESSIN TAB 0.1MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents,
DESMOPRESSIN TAB 0.2MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
Hormonal Agents,
EGRIFTA
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
SOL 1MG
Page 157 of 279
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
X
Therapeutic Class
Product Name
Hormonal Agents,
EGRIFTA SOL 2MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
Hormonal Agents,
GENOTROPIN INJ 0.2MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 0.4MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 0.6MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 0.8MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 1.2MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 1.4MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 1.6MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 1.8MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 12MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 1MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 2MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
GENOTROPIN INJ 5MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
H.P. ACTHAR INJ 80UNIT
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Page 158 of 279
Therapeutic Class
Product Name
Hormonal Agents,
HUMATROPE INJ 12MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
Specialty
X
Hormonal Agents,
HUMATROPE INJ 24MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
HUMATROPE INJ 5MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
HUMATROPE INJ 6MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
INCRELEX
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
Hormonal Agents,
NORDITROPIN INJ 10/1.5ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
NORDITROPIN INJ 15/1.5ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
NORDITROPIN INJ 30/3ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
NORDITROPIN INJ 5/1.5ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
NOVAREL
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 1
INJ 40MG/4ML
INJ 10000UNT
X
X
Hormonal Agents,
NUTROPIN AQ INJ 10MG/2ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
X
X
Hormonal Agents,
NUTROPIN AQ INJ 20MG/2ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
X
X
Hormonal Agents,
NUTROPIN AQ INJ NUSPIN 5
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 3
X
X
X
Hormonal Agents,
OMNITROPE INJ 10/1.5ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
Page 159 of 279
X
X
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
Specialty
X
Hormonal Agents,
OMNITROPE INJ 5/1.5ML
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
OVIDREL
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ
Tier 4
X
Hormonal Agents,
PREGNYL
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 10000UNT
Tier 1
X
Therapeutic Class
Product Name
Hormonal Agents,
OMNITROPE INJ 5.8MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Hormonal Agents,
SAIZEN
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 5MG
Tier 4
X
X
X
X
Hormonal Agents,
SAIZEN
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 8.8MG
Tier 4
X
X
X
X
Hormonal Agents,
SEROSTIM
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 4MG
Tier 4
X
X
X
Hormonal Agents,
SEROSTIM
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 5MG
Tier 4
X
X
X
Hormonal Agents,
SEROSTIM
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 6MG
Tier 4
X
X
X
Hormonal Agents,
STIMATE
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
SOL 1.5MG/ML
Tier 3
Hormonal Agents,
TEV-TROPIN INJ 5MG
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Tier 4
X
X
X
X
Hormonal Agents,
ZOMACTON
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 10MG
Tier 4
X
X
X
X
Hormonal Agents,
ZOMACTON
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
INJ 5MG
Tier 4
X
X
X
X
INJ 8.8MG
Tier 4
X
X
Hormonal Agents,
ZORBTIVE
Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
Page 160 of 279
X
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying
(Prostaglandins) - Hormone
Replacement/Modifying Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name
KORLYM
TAB 300MG
Tier Value
Tier 4
ARMOUR THYRO TAB 120MG
Tier 3
ARMOUR THYRO TAB 15MG
Tier 3
ARMOUR THYRO TAB 180MG
Tier 3
ARMOUR THYRO TAB 240MG
Tier 3
ARMOUR THYRO TAB 300MG
Tier 3
ARMOUR THYRO TAB 30MG
Tier 3
ARMOUR THYRO TAB 60MG
Tier 3
ARMOUR THYRO TAB 90MG
Tier 3
CYTOMEL
TAB 25MCG
Tier 4
CYTOMEL
TAB 50MCG
Tier 4
CYTOMEL
TAB 5MCG
Tier 4
LEVO-T
TAB 100MCG
Tier 1
LEVO-T
TAB 112MCG
Tier 1
LEVO-T
TAB 125MCG
Tier 1
LEVO-T
TAB 137MCG
Tier 1
LEVO-T
TAB 150MCG
Tier 1
LEVO-T
TAB 175MCG
Tier 1
LEVO-T
TAB 200 MCG
Tier 1
Page 161 of 279
Prior
Authorization
X
Supply
Limit
Step
Therapy
Specialty
X
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name
LEVO-T
TAB 25MCG
Tier Value
Tier 1
LEVO-T
TAB 300 MCG
Tier 1
LEVO-T
TAB 50MCG
Tier 1
LEVO-T
TAB 75MCG
Tier 1
LEVO-T
TAB 88MCG
Tier 1
LEVOTHYROXIN TAB 100MCG
Tier 1
LEVOTHYROXIN TAB 112MCG
Tier 1
LEVOTHYROXIN TAB 125MCG
Tier 1
LEVOTHYROXIN TAB 137MCG
Tier 1
LEVOTHYROXIN TAB 150MCG
Tier 1
LEVOTHYROXIN TAB 175MCG
Tier 1
LEVOTHYROXIN TAB 200MCG
Tier 1
LEVOTHYROXIN TAB 25MCG
Tier 1
LEVOTHYROXIN TAB 300MCG
Tier 1
LEVOTHYROXIN TAB 50MCG
Tier 1
LEVOTHYROXIN TAB 75MCG
Tier 1
LEVOTHYROXIN TAB 88MCG
Tier 1
LEVOXYL
TAB 100MCG
Tier 1
LEVOXYL
TAB 112MCG
Tier 1
Page 162 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name
LEVOXYL TAB 125MCG
Tier Value
Tier 1
LEVOXYL
TAB 137MCG
Tier 1
LEVOXYL
TAB 150MCG
Tier 1
LEVOXYL
TAB 175MCG
Tier 1
LEVOXYL
TAB 200MCG
Tier 1
LEVOXYL
TAB 25MCG
Tier 1
LEVOXYL
TAB 50MCG
Tier 1
LEVOXYL
TAB 75MCG
Tier 1
LEVOXYL
TAB 88MCG
Tier 1
LIOTHYRONINE TAB 25MCG
Tier 1
LIOTHYRONINE TAB 50MCG
Tier 1
LIOTHYRONINE TAB 5MCG
Tier 1
NATURE THROI TAB 162.5MG
Tier 3
NATURE-THROI TAB 113.75MG
Tier 3
NATURE-THROI TAB 130MG
Tier 3
NATURE-THROI TAB 146.25MG
Tier 3
NATURE-THROI TAB 16.25MG
Tier 3
NATURE-THROI TAB 195MG
Tier 3
NATURE-THROI TAB 260MG
Tier 3
Page 163 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name
NATURE-THROI TAB 32.5MG
Tier Value
Tier 3
NATURE-THROI TAB 325MG
Tier 3
NATURE-THROI TAB 48.75MG
Tier 3
NATURE-THROI TAB 65MG
Tier 3
NATURE-THROI TAB 81.25MG
Tier 3
NATURE-THROI TAB 97.5MG
Tier 3
NP THYROID TAB 30MG
Tier 1
NP THYROID TAB 60MG
Tier 1
NP THYROID TAB 90MG
Tier 1
SYNTHROID TAB 100MCG
Tier 2
SYNTHROID TAB 112MCG
Tier 2
SYNTHROID TAB 125MCG
Tier 2
SYNTHROID TAB 137MCG
Tier 2
SYNTHROID TAB 150MCG
Tier 2
SYNTHROID TAB 175MCG
Tier 2
SYNTHROID TAB 200MCG
Tier 2
SYNTHROID TAB 25MCG
Tier 2
SYNTHROID TAB 300MCG
Tier 2
SYNTHROID TAB 50MCG
Tier 2
Page 164 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Prior
Authorization
Supply
Limit
Step
Therapy
Product Name
SYNTHROID TAB 75MCG
Tier Value
Tier 2
SYNTHROID TAB 88MCG
Tier 2
THYROLAR-1 TAB 60MG
Tier 3
THYROLAR-1/2 TAB 30MG
Tier 3
THYROLAR-1/4 TAB 15MG
Tier 3
THYROLAR-2 TAB 120MG
Tier 3
THYROLAR-3 TAB 180MG
Tier 3
TIROSINT
CAP 100MCG
Tier 4
X
TIROSINT
CAP 112MCG
Tier 4
X
TIROSINT
CAP 125MCG
Tier 4
X
TIROSINT
CAP 137MCG
Tier 4
X
TIROSINT
CAP 13MCG
Tier 4
X
TIROSINT
CAP 150MCG
Tier 4
X
TIROSINT
CAP 25MCG
Tier 4
X
TIROSINT
CAP 50MCG
Tier 4
X
TIROSINT
CAP 75MCG
Tier 4
X
TIROSINT
CAP 88MCG
Tier 4
X
UNITH DIRECT TAB 100MCG
Tier 1
UNITH DIRECT TAB 112MCG
Tier 1
Page 165 of 279
Specialty
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name
UNITH DIRECT TAB 125MCG
Tier Value
Tier 1
UNITH DIRECT TAB 150MCG
Tier 1
UNITH DIRECT TAB 175MCG
Tier 1
UNITH DIRECT TAB 200MCG
Tier 1
UNITH DIRECT TAB 25MCG
Tier 1
UNITH DIRECT TAB 300MCG
Tier 1
UNITH DIRECT TAB 50MCG
Tier 1
UNITH DIRECT TAB 75MCG
Tier 1
UNITH DIRECT TAB 88MCG
Tier 1
UNITHROID TAB 100MCG
Tier 1
UNITHROID TAB 112MCG
Tier 1
UNITHROID TAB 125MCG
Tier 1
UNITHROID TAB 137MCG
Tier 1
UNITHROID TAB 150MCG
Tier 1
UNITHROID TAB 175MCG
Tier 1
UNITHROID TAB 200MCG
Tier 1
UNITHROID TAB 25MCG
Tier 1
UNITHROID TAB 300MCG
Tier 1
UNITHROID TAB 50MCG
Tier 1
Page 166 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Product Name
UNITHROID TAB 75MCG
Tier Value
Tier 1
UNITHROID TAB 88MCG
Tier 1
WESTHROID TAB 113.75MG
Tier 3
WESTHROID TAB 130MG
Tier 3
WESTHROID TAB 146.25MG
Tier 3
WESTHROID TAB 16.25MG
Tier 3
WESTHROID TAB 162.50MG
Tier 3
WESTHROID TAB 195MG
Tier 3
WESTHROID TAB 260MG
Tier 3
WESTHROID TAB 32.5MG
Tier 3
WESTHROID TAB 325MG
Tier 3
WESTHROID TAB 48.75MG
Tier 3
WESTHROID TAB 65MG
Tier 3
WESTHROID TAB 81.25MG
Tier 3
WESTHROID TAB 97.5MG
Tier 3
WP THYROID TAB 113.75MG
Tier 3
WP THYROID TAB 130MG
Tier 3
WP THYROID TAB 16.25MG
Tier 3
WP THYROID TAB 32.5MG
Tier 3
Page 167 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Prior
Authorization
Supply
Limit
Step
Therapy
Therapeutic Class
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents,
Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Hormonal Agents, Suppressant (Adrenal) Hormone Suppressants
Hormonal Agents, Suppressant (Parathyroid) Hormone Suppressants
Hormonal Agents, Suppressant (Parathyroid) Hormone Suppressants
Hormonal Agents, Suppressant (Parathyroid) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary)
Product Name
WP THYROID TAB 48.75MG
CETROTIDE KIT 0.25MG
Tier 3
X
Hormonal Agents, Suppressant (Pituitary)
GANIRELIX AC INJ
Tier 4
X
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
CABERGOLINE TAB 0.5MG
Tier 1
ELIGARD
INJ 22.5MG
Tier 4
X
X
ELIGARD
INJ 30MG
Tier 4
X
X
ELIGARD
INJ 45MG
Tier 4
X
X
ELIGARD
INJ 7.5MG
Tier 4
X
X
Tier Value
Tier 3
WP THYROID TAB 65MG
Tier 3
WP THYROID TAB 81.25MG
Tier 3
WP THYROID TAB 97.5MG
Tier 3
LYSODREN
Tier 3
TAB 500MG
SENSIPAR
TAB 30MG
Tier 4
SENSIPAR
TAB 60MG
Tier 4
SENSIPAR
TAB 90MG
Tier 4
Specialty
X
FIRMAGON
INJ 120MG
Tier 4
X
FIRMAGON
INJ 80MG
Tier 4
X
LEUPROLIDE INJ 1MG/0.2
Tier 1
X
X
OCTREOTIDE INJ 1000MCG
Tier 1
X
X
OCTREOTIDE INJ 100MCG
Tier 1
X
X
OCTREOTIDE INJ 200MCG
Tier 1
X
X
OCTREOTIDE INJ 500MCG
Tier 1
X
X
OCTREOTIDE INJ 50MCG/ML
Tier 1
X
X
SANDOSTATIN INJ 1000MCG
Tier 4
X
X
SANDOSTATIN INJ 100MCG
Tier 4
X
X
SANDOSTATIN INJ 200MCG
Tier 4
X
X
SANDOSTATIN INJ 500MCG
Tier 4
X
X
Page 168 of 279
Therapeutic Class
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
Hormonal Agents, Suppressant (Pituitary) Hormone Suppressants
HORMONES AND SYNTHETIC SUBSTITUTES ANTITHYROID AGENTS
HORMONES AND SYNTHETIC SUBSTITUTES ANTITHYROID AGENTS
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Product Name
SANDOSTATIN INJ 50MCG/ML
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
Step
Therapy
Specialty
X
SIGNIFOR
INJ 0.3MG/ML
Tier 3
X
X
X
SIGNIFOR
INJ 0.6MG/ML
Tier 3
X
X
X
SIGNIFOR
INJ 0.9MG/ML
Tier 3
X
X
X
SOMATULINE INJ 120/.5ML
Tier 4
X
SOMATULINE INJ 60/0.2ML
Tier 4
X
SOMATULINE INJ 90/0.3ML
Tier 4
X
SOMAVERT
INJ 10MG
Tier 4
X
SOMAVERT
INJ 15MG
Tier 4
X
SOMAVERT
INJ 20MG
Tier 4
X
SOMAVERT
INJ 25MG
Tier 4
X
SOMAVERT
INJ 30MG
Tier 4
X
SOL 2MG/ML
Tier 2
SYNAREL
IODINE
SSKI
SOL STRONG
SOL 1GM/ML
Tier 2
Tier 3
ASTAGRAF XL CAP 0.5MG
Tier 4
X
X
ASTAGRAF XL CAP 1MG
Tier 4
X
X
ASTAGRAF XL CAP 5MG
Tier 4
X
X
AZASAN
TAB 100MG
Tier 3
AZASAN
TAB 75 MG
Tier 3
AZATHIOPRINE TAB 50MG
Tier 1
CELLCEPT
CAP 250MG
Tier 4
X
CELLCEPT
SUS 200MG/ML
Tier 4
X
CELLCEPT
TAB 500MG
Tier 4
X
CIMZIA
KIT
Tier 3
X
X
X
CIMZIA
KIT STARTER
Tier 3
X
X
X
CIMZIA PREFL KIT 200MG/ML
Tier 3
X
X
X
CYCLOSPORINE CAP 100MG
Tier 1
X
CYCLOSPORINE CAP 100MG
MD
Tier 1
X
Page 169 of 279
Therapeutic Class
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Product Name
CYCLOSPORINE CAP 25MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
CYCLOSPORINE CAP 25MG
MOD
CYCLOSPORINE CAP 50MG
MOD
CYCLOSPORINE SOL MODIFIED
Tier 1
X
Tier 1
X
Tier 1
X
ENBREL
INJ 25/0.5ML
Tier 4
X
X
X
ENBREL
INJ 25MG
Tier 4
X
X
X
ENBREL
INJ 50MG/ML
Tier 4
X
X
X
ENBREL SRCLK INJ 50MG/ML
Tier 4
X
X
X
ENVARSUS XR TAB 0.75MG
Tier 4
X
X
ENVARSUS XR TAB 1MG
Tier 4
X
X
ENVARSUS XR TAB 4MG
Tier 4
X
X
GENGRAF
CAP 100MG
Tier 1
X
GENGRAF
CAP 25MG
Tier 1
X
GENGRAF
CAP 50MG
Tier 1
X
GENGRAF
SOL 100MG/ML
Tier 1
X
HUMIRA
INJ 10MG/0.2
Tier 3
X
X
X
HUMIRA
KIT 20MG/0.4
Tier 3
X
X
X
HUMIRA
KIT 40MG/0.8
Tier 3
X
X
X
HUMIRA PEDIA INJ CROHNS
Tier 3
X
X
X
HUMIRA PEN INJ 40MG/0.8
Tier 3
X
X
X
HUMIRA PEN INJ CROHNS
Tier 3
X
X
X
HUMIRA PEN INJ PSORIASI
Tier 3
X
X
X
IMURAN
Tier 4
X
X
X
KINERET
TAB 50MG
INJ
Tier 4
METHOTREXATE TAB 2.5MG
Tier 1
MYCOPHENOLAT CAP 250MG
Tier 1
X
MYCOPHENOLAT SUS
200MG/ML
MYCOPHENOLAT TAB 500MG
Tier 1
X
Tier 1
X
MYCOPHENOLIC TAB 180MG
DR
Tier 1
X
Page 170 of 279
Therapeutic Class
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Product Name
MYCOPHENOLIC TAB 360MG
DR
MYFORTIC TAB 180MG
MYFORTIC
TAB 360MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
Tier 4
X
Tier 4
X
NEORAL
CAP 100MG
Tier 4
X
NEORAL
CAP 25MG
Tier 4
X
NEORAL
SOL 100MG/ML
Tier 4
X
ORENCIA
INJ 125MG/ML
Tier 4
X
ORENCIA CLCK INJ 125MG/ML
Tier 4
X
OTREXUP
INJ 10MG
Tier 4
X
X
OTREXUP
INJ 12.5/0.4
Tier 4
X
X
OTREXUP
INJ 15MG
Tier 4
X
X
OTREXUP
INJ 17.5/0.4
Tier 4
OTREXUP
INJ 20MG
Tier 4
OTREXUP
INJ 22.5/0.4
Tier 4
OTREXUP
INJ 25MG
Tier 4
X
X
OTREXUP
INJ 7.5/0.4
Tier 4
X
X
PROGRAF
CAP 0.5MG
Tier 4
X
PROGRAF
CAP 1MG
Tier 4
X
PROGRAF
CAP 5MG
Tier 4
X
X
X
X
X
X
X
RAPAMUNE
SOL 1MG/ML
Tier 3
X
RAPAMUNE
TAB 0.5MG
Tier 4
X
RAPAMUNE
TAB 1MG
Tier 4
X
RAPAMUNE
TAB 2MG
Tier 4
X
RASUVO
INJ 10MG
Tier 4
X
X
RASUVO
INJ 12.5MG
Tier 4
X
X
RASUVO
INJ 15MG
Tier 4
X
X
RASUVO
INJ 17.5MG
Tier 4
X
X
RASUVO
INJ 20MG
Tier 4
X
X
RASUVO
INJ 22.5MG
Tier 4
X
X
Page 171 of 279
Therapeutic Class
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immune Suppressants - Immune System
Drugs
Immunomodulators - Immune System Drugs
Product Name
RASUVO
INJ 25MG
Immunomodulators - Immune System Drugs
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
RASUVO
INJ 27.5MG
Tier 4
X
X
RASUVO
INJ 30MG
Tier 4
X
X
RASUVO
INJ 7.5MG
Tier 4
X
X
Specialty
RHEUMATREX TAB 2.5MG
Tier 2
SANDIMMUNE CAP 100MG
Tier 4
X
SANDIMMUNE CAP 25MG
Tier 4
X
SANDIMMUNE SOL
100MG/ML
SIMPONI INJ 100MG/ML
Tier 4
X
Tier 3
X
X
X
SIMPONI
INJ 100MG/ML
Tier 3
X
X
X
SIMPONI
INJ 50/0.5ML
Tier 3
X
X
X
SIMPONI
INJ 50/0.5ML
Tier 3
X
X
X
SIROLIMUS TAB 0.5MG
Tier 1
X
SIROLIMUS TAB 1MG
Tier 1
X
SIROLIMUS TAB 2MG
Tier 1
X
TACROLIMUS CAP 0.5MG
Tier 1
X
TACROLIMUS CAP 1MG
Tier 1
X
TACROLIMUS CAP 5MG
Tier 1
X
TREXALL
TAB 10MG
Tier 2
TREXALL
TAB 15MG
Tier 2
TREXALL
TAB 5MG
Tier 2
TREXALL
TAB 7.5MG
Tier 2
ZORTRESS
TAB 0.25MG
Tier 4
X
ZORTRESS
TAB 0.5MG
Tier 4
X
ZORTRESS
TAB 0.75MG
Tier 4
X
ACTEMRA
INJ 162/0.9
Tier 4
X
X
X
ACTIMMUNE INJ 2MU/0.5
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
ALFERON N INJ 5MU/ML
Tier 3
Immunomodulators - Immune System Drugs
ARAVA
Tier 4
TAB 10MG
Page 172 of 279
X
Prior
Authorization
Supply
Limit
Tier 3
X
X
X
Tier 3
X
X
X
AVONEX PEN KIT 30MCG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
AVONEX PREFL KIT 30MCG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
BETASERON INJ 0.3MG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
EXTAVIA
Tier 4
X
X
Immunomodulators - Immune System Drugs
LEFLUNOMIDE TAB 10MG
Tier 1
Immunomodulators - Immune System Drugs
LEFLUNOMIDE TAB 20MG
Tier 1
Immunomodulators - Immune System Drugs
OTEZLA
TAB 10/20/30
Tier 4
X
X
X
Immunomodulators - Immune System Drugs
OTEZLA
TAB 30MG
Tier 4
X
X
X
Immunomodulators - Immune System Drugs
REBIF
INJ 22/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF
INJ 44/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF REBIDO INJ 22/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF REBIDO INJ 44/0.5
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF REBIDO INJ TITRATN
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
REBIF TITRTN INJ PACK
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
RIDAURA
Tier 3
Immunomodulators - Immune System Drugs
TECFIDERA CAP 120MG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
TECFIDERA CAP 240MG
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
TECFIDERA MIS STARTER
Tier 3
X
X
X
Immunomodulators - Immune System Drugs
XELJANZ
Tier 4
X
X
X
X
Immunomodulators - Immune System Drugs
XELJANZ XR TAB 11MG
Tier 4
X
X
X
X
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
AFREZZA POW
AFREZZA POW 4& 8UNIT
AFREZZA POW 4& 8UNIT
AFREZZA POW 4UNIT
AFREZZA POW 8&12UNIT
APIDRA
INJ SOLOSTAR
APIDRA
INJ U-100
HUMALOG INJ 100/ML
HUMALOG INJ 100/ML
HUMALOG KWIK INJ 100/ML
HUMALOG KWIK INJ 200/ML
HUMALOG MIX INJ 50/50
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
X
X
X
X
X
X
X
Therapeutic Class
Immunomodulators - Immune System Drugs
Product Name
ARAVA
TAB 20MG
Immunomodulators - Immune System Drugs
ARCALYST
INJ 220MG
Immunomodulators - Immune System Drugs
AVONEX
KIT 30MCG
Immunomodulators - Immune System Drugs
INJ 0.3MG
CAP 3MG
TAB 5MG
Page 173 of 279
Tier Value
Tier 4
X
X
X
X
X
X
X
X
X
Step
Therapy
X
X
X
X
X
X
Specialty
X
Prior
Authorization
Supply
Limit
X
Step
Therapy
Therapeutic Class
Insulins - Diabetic Drugs
Product Name
HUMALOG MIX INJ 50/50KWP
Tier Value
Tier 2
Insulins - Diabetic Drugs
HUMALOG MIX INJ 75/25KWP
Tier 2
X
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
Insulins - Diabetic Drugs
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN INJ 70/30KWP
HUMULIN N INJ U-100
HUMULIN N INJ U-100KWP
HUMULIN R INJ U-100
HUMULIN R INJ U-500
HUMULIN R INJ U-500
LANTUS
INJ 100/ML
LANTUS
INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXTOUC
NOVOLIN INJ 70/30
NOVOLIN N INJ RELION
NOVOLIN N INJ U-100
NOVOLIN R INJ RELION
NOVOLIN R INJ U-100
NOVOLIN70/30 INJ RELION
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
Tier 1
Tier 1
Tier 2
Tier 1
Tier 2
Tier 1
Tier 1
Tier 2
Tier 3
Tier 3
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Insulins - Diabetic Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Irritable Bowel Syndrome Agents - Bowel
Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
TOUJEO SOLO INJ 300IU/ML
ALOSETRON TAB 0.5MG
Tier 4
Tier 1
X
X
X
ALOSETRON TAB 1MG
Tier 1
X
X
AMITIZA
CAP 24MCG
Tier 4
X
X
X
AMITIZA
CAP 8MCG
Tier 4
X
X
X
LINZESS
CAP 145MCG
Tier 2
X
X
LINZESS
CAP 290MCG
Tier 2
X
X
LOTRONEX
TAB 0.5MG
Tier 4
X
X
X
LOTRONEX
TAB 1MG
Tier 4
X
X
X
CHOLAC
SYP 10GM/15
CLEARLAX POW
COLYTE/FLAVR SOL PACKS
COLYTE/FLAVR SOL PACKS
CONSTULOSE SOL 10GM/15
CVS PURELAX POW
ENULOSE SOL 10GM/15
EQ CLEARLAX POW
EQL CLEARLAX POW
GAVILAX POW
GAVILYTE-C SOL
GAVILYTE-G SOL
GAVILYTE-N SOL FLAV PK
Tier 1
HCR Preventative
Tier 4
Tier 2
Tier 1
HCR Preventative
Tier 1
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
Page 174 of 279
X
Specialty
Prior
Authorization
Tier Value
Tier 1
HCR Preventative
Tier 3
HCR Preventative
HCR Preventative
Tier 4
Tier 2
Tier 4
HCR Preventative
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
HCR Preventative
HCR Preventative
Tier 3
HCR Preventative
Tier 4
HCR Preventative
Tier 3
Tier 3
Tier 1
Tier 1
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
Tier 1
Tier 1
Therapeutic Class
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Product Name
GENERLAC SOL 10GM/15
GENTLELAX POW
GIALAX
KIT
GLYCOLAX POW 3350 NF
GNP CLEARLAX POW
GOLYTELY SOL
GOLYTELY SOL
GOLYTELY SOL PINEAPPL
HM CLEARLAX POW
KRISTALOSE PAK 10GM
KRISTALOSE PAK 20GM
LACTULOSE SOL 10GM/15
LACTULOSE SOL 10GM/15
LACTULOSE SOL 20GM/30
LACTULOSE SYP 10GM/15
LAXACLEAR POW
LAXATIVE POL POW GLYCOL
MOVIPREP SOL
NATURA-LAX POW 3350 NF
NULYTELY SOL FLAV PKS
PEG 3350 POW
PEG 3350 POW
PEG 3350 POW
PEG 3350 POW
PEG 3350 POW
PEG 3350 SOL ELECTROL
PEG3350 POW
PEG-3350 SOL ELECTROL
PEG-3350/KCL SOL /SODIUM
PEGYLAX POW
POLYETH GLYC POW 3350 NF
Laxatives - Bowel Treatment Drugs
POLYETH GLYC POW 3350 NF
Tier 1
Laxatives - Bowel Treatment Drugs
POLYETH GLYC POW 3350 NF
HCR Preventative
Laxatives - Bowel Treatment Drugs
POLYETH GLYC POW 3350-GRX HCR Preventative
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Laxatives - Bowel Treatment Drugs
Local Anesthetics
Local Anesthetics
Local Anesthetics
POWDERLAX POW
PREPOPIK PAK
RA LAXATIVE POW
SM CLEARLAX POW
SMOOTH LAX POW
SUPREP BOWEL SOL PREP
SW CLEARLAX POW
TRILYTE SOL
ATENDIA PAD 4-3%
BUPIVACAINE POW HCL
DERMACINRX KIT PRIZOPAK
HCR Preventative
Tier 3
HCR Preventative
HCR Preventative
HCR Preventative
Tier 3
HCR Preventative
HCR Preventative
Tier 4
Tier 3
Tier 1
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
EMLA
CRE 2.5-2.5%
LETS
KIT
LEVA SET KIT
LIDO/PRILOCN CRE 2.5-2.5%
LIDO/PRILOCN KIT 2.5-2.5%
LIDOCAINE CRE 10%
LIDOCAINE CRE 5%
LIDOCAINE CRE TETRACAI
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Page 175 of 279
Supply
Limit
X
X
X
X
X
X
X
X
Step
Therapy
Specialty
Therapeutic Class
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Local Anesthetics
Product Name
LIDOCAINE GEL 2% JELLY
LIDOCAINE OIN 5%
LIDOCAINE OIN PAK 5%
LIDOCAINE PAD 5%
LIDOCAINE SOL 2% VISC
LIDOCAINE SOL 4%
LIDOCAINE SOL 4%
LIDOCAINE-PR CRE
LIDODERM DIS 5%
LIDOPIN CRE 3.25%
LIDOPRIL KIT 2.5-2.5%
LIDOVEX CRE 3.75%
LP LITE PAK KIT 2.5-2.5%
PAIN RELIEF PAD PATCH
PLIAGLIS CRE 7-7%
PROZENA PAD 4%
RELADOR PAK KIT 2.5-2.5%
RELADOR PAK KIT PLUS
SYNERA
DIS 70-70MG
SYNVEXIA TC CRE 4-1%
TOPEX TOPCAL SPR ANESTHET
Tier Value
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 4
Tier 1
Tier 4
Tier 3
Tier 4
Tier 1
Tier 1
Tier 3
Tier 4
Tier 3
Local Anesthetics
Local Anesthetics
Macrolides - Antibiotics
Macrolides - Antibiotics
Tier 4
Tier 3
Tier 3
Tier 1
Macrolides - Antibiotics
VELTRIX CRE 4-1%
XYLOCAINE SOL 4%
AZASITE SOL 1%
AZITHROMYCIN POW 1GM
PAK
AZITHROMYCIN SUS 100/5ML
Macrolides - Antibiotics
AZITHROMYCIN SUS 200/5ML
Tier 1
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
AZITHROMYCIN TAB 250MG
AZITHROMYCIN TAB 500MG
AZITHROMYCIN TAB 600MG
BIAXIN
SUS 250/5ML
BIAXIN
TAB 250MG
BIAXIN
TAB 500MG
CLARITHROMYC SUS 125/5ML
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 1
Macrolides - Antibiotics
CLARITHROMYC SUS 250/5ML
Tier 1
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
CLARITHROMYC TAB 250MG
CLARITHROMYC TAB 500MG
CLARITHROMYC TAB 500MG
ER
DIFICID TAB 200MG
E.E.S. 400 TAB 400MG
E.E.S. GRAN SUS 200/5ML
ERY
PAD 2%
ERYGEL
GEL 2%
ERYPED
SUS 200/5ML
ERYPED
SUS 400/5ML
ERY-TAB TAB 250MG EC
ERY-TAB TAB 333MG EC
ERY-TAB TAB 500MG EC
ERYTHROCIN TAB 250MG
ERYTHROM ETH TAB 400MG
Tier 1
Tier 1
Tier 1
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Page 176 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
Tier 1
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
X
X
Specialty
Therapeutic Class
Macrolides - Antibiotics
Product Name
ERYTHROMYCIN CAP 250MG
EC
ERYTHROMYCIN GEL 2%
ERYTHROMYCIN OIN 5MG/GM
Tier Value
Tier 1
ERYTHROMYCIN OIN OP
ERYTHROMYCIN PAD 2%
ERYTHROMYCIN SOL 2%
ERYTHROMYCIN TAB 250MG
BS
ERYTHROMYCIN TAB 500MG
BS
ILOTYCIN OIN OP
KETEK
TAB 300MG
KETEK
TAB 400MG
PCE
TAB 333MG EC
PCE
TAB 500MG EC
ROMYCIN OIN OP
ZITHROMAX POW 1GM PAK
Tier 1
Tier 1
Tier 1
Tier 1
ZITHROMAX SUS 100/5ML
ZITHROMAX SUS 200/5ML
ZITHROMAX TAB 250MG
ZITHROMAX TAB 500MG
ZITHROMAX TAB 600MG
ZITHROMAX TAB TRI-PAK
ZITHROMAX TAB Z-PAK
ZMAX
SUS 2GM
CROMOLYN SOD NEB
20MG/2ML
Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 150MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 30MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 35MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ACTONEL TAB 5MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE SOL 70/75ML
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 10MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 35MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 40MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 5MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ALENDRONATE TAB 70MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis ATELVIA TAB
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis BINOSTO TAB 70MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis BONIVA
TAB 150MG
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis CALCITONIN SPR 200/ACT
(Bone Loss) Drugs
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 4
Tier 3
Tier 1
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Macrolides - Antibiotics
Mast Cell Stabilizers - Asthma/Lung Drugs
Page 177 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 4
Tier 4
X
Tier 4
Tier 4
X
Tier 4
Tier 1
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
Tier 1
Specialty
Therapeutic Class
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Prior
Authorization
Supply
Limit
Product Name
CALCITRIOL CAP 0.25MCG
Tier Value
Tier 1
CALCITRIOL CAP 0.5MCG
Tier 1
CALCITRIOL SOL 1MCG/ML
Tier 1
DOXERCALCIF CAP 0.5MCG
Tier 1
DOXERCALCIF CAP 1MCG
Tier 1
DOXERCALCIF CAP 2.5MCG
Tier 1
ETIDRON DISD TAB 200MG
Tier 1
ETIDRON DISD TAB 400MG
Tier 1
FORTEO
SOL 600/2.4
Tier 3
FORTICAL
SPR 200/ACT
Tier 4
FOSAMAX
TAB 70MG
Tier 4
X
FOSAMAX + D TAB 70-2800
Tier 3
X
FOSAMAX + D TAB 70-5600
Tier 3
X
HECTOROL
CAP 0.5MCG
Tier 4
HECTOROL
CAP 1MCG
Tier 4
HECTOROL
CAP 2.5MCG
Tier 4
X
Specialty
X
IBANDRONATE TAB 150MG
Tier 1
MIACALCIN INJ 200/ML
Tier 3
MIACALCIN SPR 200/ACT
Tier 4
PARICALCITOL CAP 1 MCG
Tier 1
PARICALCITOL CAP 2 MCG
Tier 1
PARICALCITOL CAP 4 MCG
Tier 1
RISEDRON SOD TAB 35MG DR
Tier 1
X
RISEDRONATE TAB 150MG
Tier 1
X
RISEDRONATE TAB 30MG
Tier 1
RISEDRONATE TAB 35MG
Tier 1
RISEDRONATE TAB 5MG
Tier 1
ROCALTROL CAP 0.25MCG
Tier 4
ROCALTROL CAP 0.5MCG
Tier 4
Page 178 of 279
Step
Therapy
X
X
X
Therapeutic Class
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
Metabolic Bone Disease Agents - Osteoporosis
(Bone Loss) Drugs
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Product Name
ROCALTROL SOL 1MCG/ML
A/G PRO TAB
ACTIVE MEDIC KIT SPECIMEN
Tier 3
Tier 1
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
ACUNOL
TAB 600MG
ADVERA
LIQ CHOCOLAT
ADVERA
LIQ VANILLA
AMINOBEZ POT POW
APPTRIM CAP
APPTRIM CAP
APPTRIM-D CAP
ASILNASAL CAP RMS
AURUM
LIQ 12X
BCAD 1
POW
BCAD 2
POW
B-D UF SYRG MIS .3CC/30G
BHI URI- TAB CONTROL
BIO-IMMUNEX CAP
BISMUTH SUBC POW
BOOST
LIQ BUT PECN
BOOST
LIQ CHOC/MLT
BOOST
LIQ CHOCOLAT
BOOST
LIQ MOCHA
BOOST
LIQ STRWBRRY
BOOST
LIQ VANILLA
BOOST HIGH LIQ PROTEIN
BOOST PLUS LIQ CHOCOLAT
Tier 3
Tier 3
Tier 3
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 3
Tier 3
Tier 2
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
BOOST PLUS LIQ STRAWBER
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
BOOST PLUS LIQ VANILLA
BOOST PUDDIN MIS BUTTSCTH
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
BOOST PUDDIN MIS
CHOCOLAT
BOOST PUDDIN MIS VANILLA
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
CARDIOVID CAP PLUS
CAREFINE MIS 31GX8MM
CAREFINE MIS 32GX4MM
CAREFINE MIS 32GX5MM
CAREFINE MIS 32GX6MM
CARNITOR SOL 1GM/10ML
CARNITOR TAB 330MG
CARNITOR SF SOL 1GM/10ML
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
CATALYTIC TAB FORMULA
CAVAREST GEL 1.1%
CAVIRINSE SOL 0.2%
CHELIDONIUM LIQ
COMPOUND
CHOICE DM LIQ VANILLA
Tier 3
Tier 1
Tier 1
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Tier Value
Tier 4
ZEMPLAR
CAP 1MCG
Tier 4
ZEMPLAR
CAP 2MCG
Tier 4
Page 179 of 279
Tier 3
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
MISCELLANEOUS THERAPEUTIC AGENTS
Product Name
CHOICE DM TF LIQ UNSWEET
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
CHOLECALCIF POW
Tier 3
CHOLECALCIFE CRY USP/NF
Tier 3
CLINPRO 5000 PST 1.1%
Tier 1
COENZYME Q10 CHW 60MG
Tier 3
COENZYME Q10 TAB 200MG
Tier 3
COLCIGEL GEL
Tier 3
COMPLEAT LIQ CLS SYS
Tier 3
COMPLEAT PED LIQ
Tier 3
CONCEPTROL GEL 4%
HCR Preventative
CONTROLRX CRE 1.1%
Tier 1
CRITICARE HN LIQ
Tier 3
CRUCIAL LIQ ULTRAPAK
Tier 3
CRUCIAL LIQ UNFLAVOR
Tier 3
CRYOSERV SOL
Tier 3
CVS NUTRITIO LIQ CHOCOLAT
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
CVS NUTRITIO LIQ STRABERY
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
CVS NUTRITIO LIQ VANILLA
DENTA 5000 CRE PLUS
DENTA 5000 CRE PLUS 2PK
DENTAGEL GEL 1.1%
DERMATODORON LIQ
DIABETIC TF LIQ
DIABETISOURC LIQ
DIABETISOURC LIQ AC
DIGESTODORON LIQ
DIMETHYL SOL SULFOXID
DISCUS
LIQ COMPOSIT
DIUSCREEN ME KIT COLLECTI
Tier 3
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
DIVISTA CAP
EASYGEL GEL 0.4%
EASYGEL GEL 0.4%CHRY
EASYGEL GEL 0.4%CITR
EASYGEL GEL 0.4%MINT
ECZEMOL TAB
ERYSIDORON LIQ #1
ESTRO VITAL TAB NUTRIENT
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 1
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
F.A.A.
LIQ
FEM PH
GEL
FERRIPROX SOL 100MG/ML
Tier 3
Tier 4
Tier 3
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
FERRIPROX TAB 500MG
FIBERSOUR HN LIQ CLS SYS
FIBERSOUR HN LIQ VANILLA
FIBERSOURCE LIQ CLS SYS
FIRAZYR INJ 30MG/3ML
FIRST DUKES SUS MOUTHWSH
MISCELLANEOUS THERAPEUTIC AGENTS
FIRST-MARYS SUS
MOUTHWSH
FLUOR-A-DAY CHW 0.25MG F
MISCELLANEOUS THERAPEUTIC AGENTS
Page 180 of 279
Tier Value
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
Tier 4
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
X
X
Tier 3
X
Tier 3
X
X
X
X
Therapeutic Class
MISCELLANEOUS THERAPEUTIC AGENTS
Product Name
FLUOR-A-DAY CHW 0.5MG F
Tier Value
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
FLUOR-A-DAY CHW 1MG F
FLUORIDEX GEL 1.1%
FLUORIDEX GEL SENSITIV
FLUORIDEX GEL WHITENIN
FLUORIDEX DD PST SENSITIV
Tier 3
Tier 1
Tier 3
Tier 1
Tier 1
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
GA
POW
GA DIET POW
GEL-KAM CON 0.63%
GLONOIN DRO HOMACCOR
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
GLYTROL LIQ ULTRAPAK
GRASTEK SUB 2800BAU
GYNOL II GEL 3%
H2Q
POW 200MG/GM
HCU COOLER LIQ
HCY 1 DIET POW
HCY 2
POW
HEXAPEPTIDE POW ACETYL
HEXAPEPTIDE SOL ACETYL
IMPACT
LIQ
IMPACT
LIQ CHOCOLAT
IMPACT 1.5 LIQ
IMPACT GLUTA LIQ
IMPACT/FIBER LIQ
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/31G
INSULIN SYRG MIS 0.5/28G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/31G
INSULIN SYRG MIS 1ML/28G
INSULIN SYRG MIS 1ML/29G
INSULIN SYRG MIS 1ML/30G
INSULIN SYRG MIS 1ML/30G
INSULIN SYRG MIS 1ML/31G
ISOCAL
LIQ
ISOCAL HN LIQ
ISOCAL HN LIQ PLUS
ISOSOURCE LIQ
ISOSOURCE LIQ 1.5 CAL
ISOSOURCE LIQ CLS SYS
ISOSOURCE LIQ VHN VANL
ISOSOURCE HN LIQ
KARIGEL GEL 0.5%
KARIGEL-N GEL 1.1%
K-PHOS
TAB NO 2
LEVOCARNITIN SOL
1GM/10ML
LEVOCARNITIN TAB 330MG
L-GLUT/CHOL/ TAB INOSITOL
Tier 3
Tier 4
HCR Preventative
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 2
Tier 1
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
Page 181 of 279
Tier 1
Tier 3
Prior
Authorization
Supply
Limit
X
X
X
X
X
Step
Therapy
Specialty
Therapeutic Class
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Product Name
LITHATE CAP
LMD
POW
LMD DIET POW
MCT PROCAL POW
MERITENE POW CHOCOLAT
Tier Value
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MERITENE POW VANILLA
METHERGINE TAB 0.2MG
METHIONINE CAP 200MG
METHYLERGON TAB 0.2MG
MODULEN IBD POW
MORCIN
CRE
MSUD COOLER LIQ
MSUD COOLER LIQ 20
MYALEPT INJ 11.3MG
NAFRINSE SOL DAILY
NAFRINSE DLY SOL /NEUTRAL
Tier 3
Tier 1
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 2
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Tier 4
Tier 3
Tier 1
Tier 3
Tier 3
Miscellaneous Therapeutic Agents
NAFRINSE WK SOL 0.2%
NESTLE FLAVO PAK EX-STR
NEUTRAGARD GEL 1.1%
NITRIC ACID LIQ
NOVASOURCE LIQ
PULMONAR
NOVOFINE MIS 30GX8MM
NOVOFINE MIS 32GX6MM
NOVOFINE AUT MIS
30GX8MM
NOVOFINE PLS MIS 32GX4MM
Miscellaneous Therapeutic Agents
NOVOTWIST MIS 30GX8MM
Tier 2
Miscellaneous Therapeutic Agents
NOVOTWIST MIS 32GX5MM
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
NUTREN
LIQ JR/FIBER
NUTREN
LIQ JUNIOR
NUTREN
LIQ PULMONAR
NUTREN 1.0 LIQ /FIB UNF
NUTREN 1.0 LIQ /FIBER
NUTREN 1.0 LIQ ULTRAPAK
NUTREN 1.0 LIQ UNFLAVOR
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
NUTREN 1.5 LIQ ULTRAPAK
NUTRI DRINK LIQ CHOCOLAT
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
NUTRI DRINK
NUTRI DRINK
NUTRI DRINK
NUTRI-DRINK
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
NUTRI-DRINK LIQ + VANILA
NUTRI-DRINK LIQ CHOCOLAT
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
NUTRI-DRINK LIQ VANILLA
NUTRIHEAL LIQ VANILLA
NUTRIRENAL LIQ
NUTRITIONAL LIQ SUPPLEME
Tier 3
Tier 3
Tier 3
Tier 3
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
LIQ PLUS
LIQ STRWBER
LIQ VANILLA
LIQ + CHOCOL
Page 182 of 279
Tier 2
Tier 2
Tier 2
Tier 2
Prior
Authorization
Supply
Limit
X
X
X
Step
Therapy
Specialty
X
Therapeutic Class
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Product Name
NUTRIVENT LIQ
NUTRIVENT LIQ 1.5 VAN
OA 1
POW
OA 1 DIET POW
OA 2
POW
OA 2 DIET POW
ORALAIR SUB 300 IR
ORALAIR ADLT SUB 300 IR
ORALAIR CHLD PAK SAMPLE
ORALAIR CHLD SUB 100 IR
PEN NEEDLE MIS 29GX1/2"
PEN NEEDLES MIS 29GX1/2"
PEN NEEDLES MIS 29GX12MM
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
PEN NEEDLES
PEN NEEDLES
PEN NEEDLES
PEN NEEDLES
PEN NEEDLES
MIS 30GX5/16
MIS 31GX1/4"
MIS 31GX3/16
MIS 31GX5/16
MIS 31GX6MM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Miscellaneous Therapeutic Agents
PEN NEEDLES MIS 31GX8MM
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN
PEPTAMEN
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN 1.5 LIQ
PEPTAMEN AF LIQ UNFLAVOR
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN JR LIQ CHOCOLAT
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN JR LIQ UNFLAVRD
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN JUN POW VANILLA
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN OS LIQ 1.5/VAN
PEPTAMEN OS LIQ CHOCOLAT
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN OS LIQ VANILLA
PEPTAMEN VHP LIQ ULTRAPAK
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTAMEN VHP LIQ
UNFLAVOR
PEPTAMEN VHP LIQ VANILLA
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
PEPTINEX 1.5 LIQ VANILLA
PEPTINEX DT LIQ
PEPTINEX DT LIQ /FIBER
PEPTINEX DT LIQ PREBIOTC
PEPTINEX DT LIQ VANILLA
PFD 1
POW
PFD 2
POW
PHOS-FLUR GEL 1.1%
PNEUMODORON LIQ
POLYOX
POW WSR-301
PORTAGEN POW
POTABA
CAP 500MG
PREVDNT 5000 PST 1.1%
PREVIDENT CRE 5000 PLS
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 4
Tier 3
Tier 4
Tier 3
Tier 4
LIQ PREBIO1
LIQ UNFLAVOR
Page 183 of 279
Tier Value
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 3
Tier 4
Tier 2
Tier 2
Tier 2
Prior
Authorization
Supply
Limit
X
X
X
X
X
X
Step
Therapy
Specialty
Tier 3
X
Therapeutic Class
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Product Name
PREVIDENT GEL 1.1%
PREVIDENT GEL 1.1% BER
PREVIDENT GEL 1.1% CHR
PREVIDENT GEL 1.1% MIN
PREVIDENT PST 5000 BST
PREVIDENT PST 5000 SEN
PREVIDENT SOL 0.2%
PREVIDENT SOL RINSE
PROBALANCE LIQ ULTRAPAK
Tier Value
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
PROBALANCE LIQ VANILLA
PRO-CAL POW
PRODUCT3232A POW
PROS-TECH CAP PLUS
PROT COOKIE MIS OATRAISN
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PROTEOLYTIC TAB FORMULA
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
PRVDNT 5000 PST ENAML PR
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
PSORIZIDE TAB FORTE
PSORIZIDE TAB ULTRA
Q2 ORAL CLEA KIT SYSTEM
Q4 ORAL CLEA KIT SYSTEM
QUINZYME TAB 90MG
RA NUTRITION LIQ CHOCOLAT
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
RA NUTRITION LIQ VANILLA
RA PEN NEEDL MIS 31GX3/16
Tier 3
Tier 2
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
RADIOGARDASE CAP 0.5GM
RAGWITEK SUB
RAPID GEL RX GEL
RELAGARD GEL
RENASTART POW
REPLETE LIQ /FIBER
REPLETE LIQ ULTRAPAK
RESOURCE KID LIQ CR STRAW
Tier 3
Tier 4
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE KID LIQ FR VAN
RESOURCE KID LIQ SW CHOC
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE KID LIQ W/FIBER
RESOURCE SUP LIQ CHOCOLAT
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE SUP LIQ STRAWBER
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
RESOURCE SUP LIQ VANILLA
RESPALOR LIQ
RHEUMADORON LIQ 102A
RX-SPECIMEN KIT COLLECTI
SCANDICAL POW
SCANDISHAKE POW VANILLA
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
SF
GEL 1.1%
SF 5000 PLUS CRE 1.1%
SHUR-SEAL GEL 2%
SM INSULIN SYRINGE
Tier 1
Tier 1
HCR Preventative
Tier 2
Page 184 of 279
Prior
Authorization
Supply
Limit
X
X
Step
Therapy
Specialty
Therapeutic Class
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Product Name
SOD FLUORIDE SOL 0.2%
SOD FLUORIDE SOL 0.2%MINT
Tier Value
Tier 1
Tier 1
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
SPECIMEN KIT COLLECTI
SPEEDGEL RX GEL
STERYMINE GEL
SUBDUE
LIQ CHOC/ALM
SUBDUE
LIQ ORNG/VAN
SUBDUE
LIQ REDI-FED
SUBDUE
LIQ UNFLAVRD
SUBDUE PLUS LIQ UNFLAVRD
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
SULFZIX POW
THALAMUS SUB COMPOSIT
Tier 3
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
THERA-FLUR-N DRO 1.1%
Tier 4
TODAY SPONGE MIS
HCR Preventative
TRANZGEL GEL
Tier 3
TYR COOLER LIQ 20
Tier 3
TYR COOLER LIQ RED
Tier 3
TYROS 1 POW
Tier 3
TYROS 2 POW
Tier 3
UBIQUINOL POW
Tier 3
UBIQUINOL POW 30%
Tier 3
UCD TRIO POW
Tier 3
ULTRA ENERGY TAB
Tier 3
ULTRACAL LIQ
Tier 3
ULTRACAL HN LIQ PLUS
Tier 3
UNFINE PNTP MIS 32GX4MM
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 29GX1/2"
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 29GX12MM
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX3/16
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX5/16
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX5MM
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX6MM
Tier 2
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX8MM
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
URI-CONTROL TAB RX
URINX MEDIC KIT SPECIMEN
Tier 3
Tier 3
Miscellaneous Therapeutic Agents
VCF VAGINAL AER CONTRACP HCR Preventative
Miscellaneous Therapeutic Agents
VCF VAGINAL GEL CONTRACE HCR Preventative
Miscellaneous Therapeutic Agents
VCF VAGINAL MIS CONTRACP HCR Preventative
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
VERTIGOHEEL SUB
VITAJOULE POW
VITAMIN D3 LIQ
VITAMIN D3 POW
VITAMIN D3 POW
Page 185 of 279
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Prior
Authorization
X
X
X
X
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Product Name
VITAMIN E LIQ ACETATE
VITAPRO POW
VIVONEX RTF LIQ
WELLMIND TAB VERTIGO
WND
POW
WND 1
POW
WND 2
POW
XIZFLUS POW
AFINITOR TAB 10MG
Tier Value
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Prior
Authorization
X
Supply
Limit
Step
Therapy
X
X
X
Specialty
AFINITOR
TAB 2.5MG
Tier 3
X
X
X
AFINITOR
TAB 5MG
Tier 3
X
X
X
AFINITOR
TAB 7.5MG
Tier 3
X
X
X
AFINITOR DIS TAB 2MG
Tier 3
X
X
X
AFINITOR DIS TAB 3MG
Tier 3
X
X
X
AFINITOR DIS TAB 5MG
Tier 3
X
X
X
BOSULIF
TAB 100MG
Tier 3
X
X
X
X
BOSULIF
TAB 500MG
Tier 3
X
X
X
X
GLEEVEC
TAB 100MG
Tier 1
X
X
X
GLEEVEC
TAB 400MG
Tier 1
X
X
X
IMATINIB MES TAB 100MG
Tier 4
X
X
X
X
IMATINIB MES TAB 400MG
Tier 4
X
X
X
X
IMBRUVICA CAP 140MG
Tier 3
X
X
X
INLYTA
TAB 1MG
Tier 4
X
X
X
INLYTA
TAB 5MG
Tier 4
X
X
X
IRESSA
TAB 250MG
Tier 4
X
Tier 3
X
X
NEXAVAR
TAB 200MG
X
X
SPRYCEL
TAB 100MG
Tier 4
X
X
X
X
SPRYCEL
TAB 140MG
Tier 4
X
X
X
X
SPRYCEL
TAB 20MG
Tier 4
X
X
X
X
SPRYCEL
TAB 50MG
Tier 4
X
X
X
X
SPRYCEL
TAB 70MG
Tier 4
X
X
X
X
SPRYCEL
TAB 80MG
Tier 4
X
X
X
X
Tier 3
X
X
STIVARGA
TAB 40MG
Page 186 of 279
X
Therapeutic Class
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Molecular Target Inhibitors - Chemotherapy
Agents
Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs
Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs
Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs
Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs
Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs
Monoamine Oxidase B (MAO-B) Inhibitors Parkinson's Disease Drugs
Monoamine Oxidase Inhibitors Antidepressants
Monoamine Oxidase Inhibitors Antidepressants
Monoamine Oxidase Inhibitors Antidepressants
Monoamine Oxidase Inhibitors Antidepressants
Monoamine Oxidase Inhibitors Antidepressants
Monoamine Oxidase Inhibitors Antidepressants
Monoamine Oxidase Inhibitors Antidepressants
Monoamine Oxidase Inhibitors Antidepressants
Mood Stabilizers - Mood Disorder Drugs
Mood Stabilizers - Mood Disorder Drugs
Product Name
SUTENT
CAP 12.5MG
Tier Value
Tier 3
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
Specialty
X
SUTENT
CAP 25MG
Tier 3
X
X
X
SUTENT
CAP 37.5MG
Tier 3
X
X
X
SUTENT
CAP 50MG
Tier 3
X
X
X
TARCEVA
TAB 100MG
Tier 3
X
X
X
TARCEVA
TAB 150MG
Tier 3
X
X
X
TARCEVA
TAB 25MG
Tier 3
X
X
X
TASIGNA
CAP 150MG
Tier 3
X
X
X
TASIGNA
CAP 200MG
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
TYKERB
VOTRIENT
TAB 250MG
TAB 200MG
XALKORI
CAP 200MG
Tier 3
X
X
X
XALKORI
CAP 250MG
Tier 3
X
X
X
Tier 3
X
X
X
ZELBORAF
TAB 240MG
AZILECT
TAB 0.5MG
Tier 3
AZILECT
TAB 1MG
Tier 3
ELDEPRYL
CAP 5MG
Tier 4
SELEGILINE CAP 5MG
Tier 1
SELEGILINE TAB 5MG
Tier 1
ZELAPAR
TAB 1.25MG
Tier 3
EMSAM
DIS 12MG/24H
Tier 3
EMSAM
DIS 6MG/24HR
Tier 3
EMSAM
DIS 9MG/24HR
Tier 3
MARPLAN
NARDIL
PARNATE
TAB 10MG
TAB 15MG
TAB 10MG
Tier 3
Tier 4
Tier 4
PHENELZINE TAB 15MG
Tier 1
TRANYLCYPROM TAB 10MG
Tier 1
LITHIUM SOL 8MEQ/5ML
LITHIUM CARB CAP 150MG
Tier 1
Tier 1
Page 187 of 279
Prior
Authorization
Supply
Limit
Tier 4
Tier 3
X
X
TAB 14MG
Tier 4
X
X
X
X
TAB 7MG
Tier 4
X
X
X
X
Therapeutic Class
Mood Stabilizers - Mood Disorder Drugs
Mood Stabilizers - Mood Disorder Drugs
Mood Stabilizers - Mood Disorder Drugs
Mood Stabilizers - Mood Disorder Drugs
Product Name
LITHIUM CARB CAP 300MG
LITHIUM CARB CAP 600MG
LITHIUM CARB TAB 300MG
LITHIUM CARB TAB 300MG ER
Tier Value
Tier 1
Tier 1
Tier 1
Tier 1
Mood Stabilizers - Mood Disorder Drugs
LITHIUM CARB TAB 450MG ER
Tier 1
Mood Stabilizers - Mood Disorder Drugs
Multiple Sclerosis Agents - Multiple Sclerosis
Drugs
Multiple Sclerosis Agents - Multiple Sclerosis
Drugs
Multiple Sclerosis Agents - Multiple Sclerosis
Drugs
Multiple Sclerosis Agents - Multiple Sclerosis
Drugs
Multiple Sclerosis Agents - Multiple Sclerosis
Drugs
Multiple Sclerosis Agents - Multiple Sclerosis
Drugs
Multiple Sclerosis Agents - Multiple Sclerosis
Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
LITHOBID
AMPYRA
TAB 300MG CR
TAB 10MG
AUBAGIO
AUBAGIO
Step
Therapy
Specialty
X
COPAXONE
INJ 20MG/ML
Tier 3
X
X
X
COPAXONE
INJ 40MG/ML
Tier 3
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
GILENYA
GLATOPA
CAP 0.5MG
INJ 20MG/ML
MEMANT TITRA PAK 5-10MG
Tier 1
MEMANTINE TAB HCL 10MG
Tier 1
MEMANTINE TAB HCL 5MG
Tier 1
MEMANTINE HC SOL 2MG/ML
Tier 1
NAMENDA
SOL 10MG/5ML
Tier 4
NAMENDA
TAB 10MG
Tier 4
NAMENDA
TAB 5-10MG
Tier 4
NAMENDA
TAB 5MG
Tier 4
NAMENDA XR CAP 14MG
Tier 4
X
NAMENDA XR CAP 21MG
Tier 4
X
NAMENDA XR CAP 28MG
Tier 4
X
NAMENDA XR CAP 7MG
Tier 4
X
Page 188 of 279
Therapeutic Class
N-methyl-D-aspartate (NMDA) Receptor
Antagonist - Alzheimer's Disease and
Dementia Drugs
Non-Amphetamines, Other - Miscellaneous
Nervous System Drugs
Non-Amphetamines, Other - Miscellaneous
Nervous System Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name
NAMENDA XR CAP TITRATIO
Tier Value
Tier 4
CAFFEINE CIT SOL 20MG/ML
Tier 1
CAFFEINE CIT SOL 60MG/3ML
Tier 1
ACTIVE-PREP CRE KIT III
Tier 3
Prior
Authorization
X
ADLT ASA LOW TAB 81MG EC HCR Preventative
AIF #2 DRUG CRE PREP KIT
Tier 1
ANAPROX DS TAB 550MG
Tier 4
ARTHROTEC 50 TAB
Tier 3
ARTHROTEC 75 TAB
Tier 3
ASPIR-81
TAB 81MG EC
HCR Preventative
ASPIRIN
CHW 81MG
HCR Preventative
ASPIRIN
TAB 325MG
HCR Preventative
ASPIRIN
TAB 325MG
HCR Preventative
ASPIRIN
TAB 325MG EC
HCR Preventative
ASPIRIN
TAB 81MG
HCR Preventative
ASPIRIN
TAB 81MG EC
HCR Preventative
ASPIRIN 81 TAB 81MG EC
HCR Preventative
ASPIRIN CHIL CHW 81MG
HCR Preventative
ASPIRIN CHLD CHW 81MG
HCR Preventative
ASPIRIN LOW CHW 81MG
HCR Preventative
ASPIRIN LOW TAB 81MG EC
HCR Preventative
ASPIRIN-81 CHW 81MG
HCR Preventative
ASPIR-LOW TAB 81MG EC
HCR Preventative
ASPIRTAB
HCR Preventative
TAB 324MG EC
BAYER ASA TAB 325MG
HCR Preventative
BL ASPIRIN TAB 300MG
HCR Preventative
BL ASPIRIN TAB 325MG
HCR Preventative
BL ASPIRIN TAB 325MG EC
HCR Preventative
Page 189 of 279
X
Supply
Limit
Step
Therapy
X
Specialty
Therapeutic Class
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name
CAMBIA
POW 50MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
CELEBREX
CAP 100MG
Tier 4
X
X
CELEBREX
CAP 200MG
Tier 4
X
X
CELEBREX
CAP 400MG
Tier 4
X
X
CELEBREX
CAP 50MG
Tier 4
X
X
CELECOXIB CAP 100MG
Tier 1
X
CELECOXIB CAP 200MG
Tier 1
X
CELECOXIB CAP 400MG
Tier 1
X
CELECOXIB CAP 50MG
Tier 1
X
CHILD ASA CHW 81MG
HCR Preventative
CHILD ASA LS CHW 81MG
HCR Preventative
CHO MAG TRIS LIQ 500/5ML
Tier 1
CHO MAG TRIS TAB 1000MG
Tier 1
CVS ASPIRIN TAB 325MG
HCR Preventative
CVS ASPIRIN TAB 325MG EC
HCR Preventative
CVS ASPIRIN TAB 81MG EC
HCR Preventative
CVS CHLD ASA CHW 81MG
HCR Preventative
DAYPRO
TAB 600MG
Tier 4
DICLO/MISOPR TAB 50-0.2MG
Tier 1
DICLO/MISOPR TAB 75-0.2MG
Tier 1
DICLOFEN POT TAB 50MG
Tier 1
DICLOFENAC GEL 1%
Tier 4
X
DICLOFENAC SOL 1.5%
Tier 1
X
DICLOFENAC TAB 100MG ER
Tier 1
DICLOFENAC TAB 25MG DR
Tier 1
DICLOFENAC TAB 50MG DR
Tier 1
DICLOFENAC TAB 75MG DR
Tier 1
DIFLUNISAL TAB 500MG
Tier 1
DISALCID
Tier 4
TAB 500MG
Page 190 of 279
X
Specialty
Therapeutic Class
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name
DISALCID TAB 750MG
DURAXIN
Tier Value
Tier 4
CAP
Tier 1
EC-NAPROSYN TAB 375MG
Tier 3
EC-NAPROSYN TAB 500MG
Tier 4
ECOTRIN
TAB 325MG EC
HCR Preventative
ECOTRIN LOW TAB 81MG EC
HCR Preventative
ECPIRIN
TAB 325MG EC
HCR Preventative
ED-FLEX
CAP
Tier 1
EQ ASPIRIN TAB 325MG
HCR Preventative
EQ ASPIRIN TAB 325MG EC
HCR Preventative
EQ CHILD ASA CHW 81MG
HCR Preventative
EQL ASPIRIN TAB 325MG
HCR Preventative
EQL ASPIRIN TAB 325MG EC
HCR Preventative
EQL ASPIRIN TAB 81MG EC
HCR Preventative
EQL CHLD ASA CHW 81MG
HCR Preventative
ETODOLAC
CAP 200MG
Tier 1
ETODOLAC
CAP 300MG
Tier 1
ETODOLAC
TAB 400MG
Tier 1
ETODOLAC
TAB 500MG
Tier 1
ETODOLAC ER TAB 400MG
Tier 1
ETODOLAC ER TAB 500MG
Tier 1
ETODOLAC ER TAB 600MG
Tier 1
FELDENE
CAP 10MG
Tier 4
FELDENE
CAP 20MG
Tier 4
FENOPROFEN CAP 200MG
Tier 1
FENOPROFEN CAP 400MG
Tier 1
FENOPROFEN TAB 600MG
Tier 1
FENORTHO
CAP 200MG
Tier 1
FENORTHO
CAP 400MG
Tier 1
Page 191 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
Specialty
Therapeutic Class
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name
FLECTOR DIS 1.3%
Tier Value
Tier 4
FLURBIPROFEN POW
Tier 3
FLURBIPROFEN TAB 100MG
Tier 1
FLURBIPROFEN TAB 50MG
Tier 1
GNP ASPIRIN CHW 81MG
HCR Preventative
GNP ASPIRIN TAB 325MG
HCR Preventative
GNP ASPIRIN TAB 325MG EC
HCR Preventative
GNP ASPIRIN TAB 81MG EC
HCR Preventative
GNP ASPIRIN TAB LT.COAT
HCR Preventative
HM ASPIRIN CHW 81MG
HCR Preventative
HM ASPIRIN TAB 325MG
HCR Preventative
Prior
Authorization
X
IBUPROFEN CRE 10%
Tier 1
IBUPROFEN KIT COMFORT
Tier 3
IBUPROFEN POW
Tier 3
IBUPROFEN TAB 400MG
Tier 1
IBUPROFEN TAB 600MG
Tier 1
IBUPROFEN TAB 800MG
Tier 1
INDOCIN
SUP 50MG
Tier 3
INDOCIN
SUS 25MG/5ML
Tier 3
INDOMETHACIN CAP 25MG
Tier 1
INDOMETHACIN CAP 50MG
Tier 1
INDOMETHACIN CAP 75MG ER
Tier 1
KETOPHENE CRE RAPIDPAQ
Tier 3
KETOPROFEN CAP 200MG ER
Tier 1
KETOPROFEN CAP 50MG
Tier 1
KETOPROFEN CAP 75MG
Tier 1
KETOPROFEN CRE 5% KIT
Tier 3
X
KETOPROFEN POW
Tier 3
X
KETOPROFEN POW MICRONIZ
Tier 3
X
Page 192 of 279
X
X
X
Supply
Limit
Step
Therapy
X
Specialty
Therapeutic Class
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name
KETOPROFEN POW ULT MICR
Tier Value
Tier 3
KETOROLAC TAB 10MG
Tier 1
KLOFENSAID SOL II
Tier 1
KLS ASPIRIN TAB 325MG EC
HCR Preventative
KLS ASPIRIN TAB 81MG EC
HCR Preventative
KP ASPIRIN TAB 81MG EC
HCR Preventative
LEVACET
TAB
Prior
Authorization
X
Supply
Limit
Step
Therapy
X
Tier 3
LIDOPROFEN CRE 5-5-2%
Tier 3
LO-DOSE ASA TAB 81MG EC
HCR Preventative
MECLOFEN SOD CAP 100MG
Tier 1
MECLOFEN SOD CAP 50MG
Tier 1
MEFENAM ACID CAP 250MG
Tier 1
MEFENAMIC POW ACID
Tier 3
MELOXICAM KIT COMFORT
Tier 3
MELOXICAM SUS 7.5/5ML
Tier 1
MELOXICAM TAB 15MG
Tier 1
MELOXICAM TAB 7.5MG
Tier 1
X
X
MINIPRIN LOW TAB 81MG EC HCR Preventative
MOBIC
SUS 7.5/5ML
Tier 4
MOBIC
TAB 15MG
Tier 4
MOBIC
TAB 7.5MG
Tier 4
NABUMETONE TAB 500MG
Tier 1
NABUMETONE TAB 750MG
Tier 1
NALFON
Tier 3
CAP 400MG
NAPRELAN
TAB 375MG CR
Tier 4
X
NAPRELAN
TAB 500MG CR
Tier 4
X
NAPRELAN
TAB 750MG CR
Tier 4
X
NAPROSYN
SUS 125/5ML
Tier 4
NAPROSYN
TAB 500MG
Tier 4
Page 193 of 279
Specialty
Therapeutic Class
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name
NAPROXEN CRE
Tier Value
Tier 3
Prior
Authorization
X
X
NAPROXEN
CRE 10%
Tier 1
NAPROXEN
SUS 125/5ML
Tier 1
NAPROXEN
TAB 250MG
Tier 1
NAPROXEN
TAB 375MG
Tier 1
NAPROXEN
TAB 500MG
Tier 1
Supply
Limit
Step
Therapy
NAPROXEN DR TAB 375MG
Tier 1
NAPROXEN DR TAB 500MG
Tier 1
NAPROXEN SOD TAB 275MG
Tier 1
NAPROXEN SOD TAB 375MG
Tier 1
X
NAPROXEN SOD TAB 375MG
CR
NAPROXEN SOD TAB 500MG
CR
NAPROXEN SOD TAB 550MG
Tier 1
X
Tier 1
X
OXAPROZIN TAB 600MG
Tier 1
OXYCOD/IBU TAB 5-400MG
Tier 1
PENNSAID
SOL 1.5%
Tier 4
X
PENNSAID
SOL 2%
Tier 4
X
Tier 1
PIROXICAM CAP 10MG
Tier 1
PIROXICAM CAP 20MG
Tier 1
PIROXICAM POW
Tier 3
PONSTEL
Tier 4
CAP 250MG
PX ASPIRIN TAB 325MG
HCR Preventative
PX ASPIRIN TAB 325MG EC
HCR Preventative
QC ASPIRIN TAB 325MG
HCR Preventative
QC ASPIRIN TAB 325MG EC
HCR Preventative
QC CHILD ASA CHW 81MG
HCR Preventative
RA ASPIRIN CHW 81MG
HCR Preventative
RA ASPIRIN TAB 325MG
HCR Preventative
RA ASPIRIN TAB 325MG EC
HCR Preventative
Page 194 of 279
X
Specialty
Therapeutic Class
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Product Name
RA ASPIRIN TAB 81MG EC
Prior
Authorization
Tier Value
HCR Preventative
RA CHILD ASA CHW 81MG
HCR Preventative
SALSALATE TAB 500MG
Tier 1
SALSALATE TAB 750MG
Tier 1
SM ASPIRIN CHW 81MG
HCR Preventative
SM ASPIRIN TAB 325MG
HCR Preventative
SM ASPIRIN TAB 325MG EC
HCR Preventative
SM ASPIRIN TAB 81MG EC
HCR Preventative
SM CHILD ASA CHW 81MG
HCR Preventative
SPRIX
SPR 15.75MG
Supply
Limit
Step
Therapy
Tier 3
ST JOSEPH CHW LOW 81MG HCR Preventative
ST JOSEPH AS CHW 81MG
HCR Preventative
SULINDAC
TAB 150MG
Tier 1
SULINDAC
TAB 200MG
Tier 1
TGT ASPIRIN CHW 81MG
HCR Preventative
TGT ASPIRIN CHW CHILD
HCR Preventative
TGT ASPIRIN TAB 325MG
HCR Preventative
TGT ASPIRIN TAB 81MG
HCR Preventative
TGT ASPIRIN TAB 81MG EC
HCR Preventative
TIVORBEX
CAP 20MG
Tier 4
X
TIVORBEX
CAP 40MG
Tier 4
X
TOLMETIN SOD CAP 400MG
Tier 1
TOLMETIN SOD TAB 200MG
Tier 1
TOLMETIN SOD TAB 600MG
Tier 1
TREXIMET
TAB 85-500MG
Tier 4
VIVLODEX
CAP 10MG
VIVLODEX
VOLTAREN
X
X
Tier 4
X
X
CAP 5MG
Tier 4
X
X
GEL 1%
Tier 1
VOLTAREN-XR TAB 100MG
Page 195 of 279
Tier 4
X
Specialty
Tier Value
Tier 3
Prior
Authorization
X
Tier 3
X
Therapeutic Class
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Not Specified
Product Name
VOPAC
CRE 10-2%
2-DEOXY-D POW -GLUCOSE
Tier 3
Not Specified
Not Specified
5-METHYLTETR POW
5-METHYLTETR POW CALCIUM
Tier 3
Tier 3
X
X
Not Specified
Not Specified
A.A.G.C KIT CRE TERODERM
ACIDO LACTOB POW 10BU/GM
Tier 3
Tier 3
X
X
Not Specified
ACIDO LACTOB POW 1BU/GM
Tier 3
X
Not Specified
ACIDOPHILUS POW LACTOBAC
Tier 3
X
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
ACTIVE-PREP CRE KIT I
ACTIVE-PREP CRE KIT II
ACTIVE-PREP CRE KIT IV
ACTIVE-PREP CRE KIT V
ADAPTADERM GEL
ADDYI
TAB 100MG
ADEMETIONINE POW
DISULFAT
ADENOSINE POW
ADYNOVATE INJ 1000UNIT
ADYNOVATE INJ 2000UNIT
ADYNOVATE INJ 250UNIT
ADYNOVATE INJ 500UNIT
ADZENYS XR TAB 12.5MG
ADZENYS XR TAB 15.7 MG
ADZENYS XR TAB 18.8MG
ADZENYS XR TAB 3.1MG
ADZENYS XR TAB 6.3MG
ADZENYS XR TAB 9.4MG
AFSTYLA KIT 1000UNIT
AFSTYLA KIT 2000UNIT
AFSTYLA KIT 250UNIT
AFSTYLA KIT 3000UNIT
AFSTYLA KIT 500UNIT
AIF #3 DRUG CRE PREP KIT
AKYNZEO CAP
ALASKAN RED POW ALGAE
ALECENSA CAP 150MG
A-LIPOIC POW ACID
ALLO-PAX CRE 5-5%
ALOE VERA OIL
ALOE VERA POW
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
X
X
X
X
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
VOPAC 5
CRE 5%
VOPAC GB
CRE 5-2-5%
Tier 3
X
VOPAC KT
CRE 5-5-2%
Tier 3
X
ZIPSOR
CAP 25MG
Supply
Limit
Step
Therapy
Tier 4
X
ZORVOLEX
CAP 18MG
Tier 4
X
ZORVOLEX
CAP 35MG
Tier 4
X
Page 196 of 279
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
X
X
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Prior
Authorization
X
X
Therapeutic Class
Not Specified
Not Specified
Product Name
ALOE VERA POW 200:1
ALOE VERA POW FRZE DRD
Tier Value
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
ALOE VERA POW LEAF
ALPHA LIPOIC POW ACID
ALPROLIX INJ 1000UNIT
ALPROLIX INJ 2000UNIT
ALPROLIX INJ 250UNIT
ALPROLIX INJ 3000UNIT
ALPROLIX INJ 500UNIT
ALPROSTADIL POW
AMITRIPTYLIN CRE
ANASTROZOLE POW
ANHYDROUS GEL BASE
APOMORPHINE POW HCL
ARANESP INJ 100MCG
ARANESP INJ 100MCG
ARANESP INJ 10MCG
ARANESP INJ 150MCG
ARANESP INJ 200MCG
ARANESP INJ 200MCG
ARANESP INJ 25MCG
ARANESP INJ 25MCG
ARANESP INJ 300MCG
ARANESP INJ 300MCG
ARANESP INJ 40MCG
ARANESP INJ 40MCG
ARANESP INJ 500MCG
ARANESP INJ 60MCG
ARANESP INJ 60MCG
ARNUITY ELPT INH 100MCG
ARNUITY ELPT INH 200MCG
ASCORBIC ACD GRA
ASCORBIC ACD POW
ASCORBIC ACD POW CASSAVE
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
X
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
ASCORBIC ACD POW FINE
ATROHIST LA TAB CR
ATROHIST SR CAP SPRINKLE
AURYXIA TAB 210MG
AVIPTADIL POW ACETATE
BASE FOR GEL SALTS
BASE FOR GEL WOUNDS
BEE POLLEN CAP 580MG
BELSOMRA TAB 10MG
BELSOMRA TAB 15MG
BELSOMRA TAB 20MG
BELSOMRA TAB 5MG
BETA GLUCAN POW
BETAMETH ACE POW
BETAMETH ACE POW
MICRONIZ
BETAMETHASON POW SOD
PHOS
BEVESPI AER
BHT
POW
BIEST/PROGES CRE
BL DECONGEST TAB CR
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
X
X
X
X
Tier 3
X
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Page 197 of 279
Tier 4
Tier 3
Tier 3
Tier 1
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Product Name
BORAGE
CAP
BRIVIACT INJ 50MG/5ML
BRIVIACT SOL 10MG/ML
BRIVIACT TAB 100MG
BRIVIACT TAB 10MG
BRIVIACT TAB 25MG
BRIVIACT TAB 50MG
BRIVIACT TAB 75MG
BROMFENAC POW SOD 98+%
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
BUPRENORPHIN POW HCL
BYVALSON TAB 5-80MG
CALCIUM POW FOLINATE
CALCIUM AA GRA CHELATE
CAPSAICIN POW PALMITAT
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
CARBIN/PSE/ SYP DM
CENOVIA CRE
CERDELGA CAP 84MG
CHEMSIL K-51 GEL
CHLOROFORM SOL
CHOLBAM CAP 250MG
CHOLBAM CAP 50MG
CHOLESTYRAMI POW
CHOLESTYRAMI POW RESIN
CHRYSIN POW
CLARYS
CRE
CLINDAP-T CRE
CLINOIN CRE
CLODAN
KIT 0.05%
CLOMIPRAMINE POW HCL
CLOVAGEL GEL
COAGADEX INJ 250UNIT
COAGADEX INJ 500UNIT
COENZYME Q10 POW
COLLIGINIX MIS
CONGESTANT TAB
CORLANOR TAB 5MG
CORLANOR TAB 7.5MG
COSENTYX INJ 150MG/ML
COSENTYX PEN INJ 150MG/ML
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
COTELLIC TAB 20MG
CRESEMBA CAP 186 MG
CUST LIPOTHN GEL 110
CUST LIPOTHN GEL 133
CYCLACILLIN TAB 500MG
CYCLOBENZAPR POW
CYCLOBENZAPR POW HCL
CYCLOPHOSPHA POW
CYCLOSERINE POW
CYCLOSPORINE POW
CYCLOSPORINE POW A
DAKLINZA TAB 30MG
DAKLINZA TAB 60MG
DAKLINZA TAB 90MG
DEHYDROEPIAN POW MICRO
Tier 4
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 4
Tier 3
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Page 198 of 279
Tier Value
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Tier Value
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Product Name
DERMACINRX PAK
DERMACINRX PAK
DUOPATCH
DERMACINRX SOL BASE
DESCOVY TAB 200/25
DEXAMETHASON POW
ACETATE
DEXCOM G4 PLATINUM
DEXCOM SENSOR
DEXCOM TRANSMITTER
DEXTROMETH POW
DHEA
POW
DIMERCAPT-1- POW SULF NA
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Prior
Authorization
Tier 3
Tier 4
Tier 3
X
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
X
X
X
X
X
DIMERCAPTOSU POW ACID
DIPENTOCAINE CRE 5-5-2%
DL-3-HYDROXY POW ACID NA
Tier 3
Tier 3
Tier 3
X
X
X
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
DMPS
POW
DMR ANTIGEN THERAPY
DOUBLE PM SOL
DURACHOL CAP 1-3775IU
DURLAZA CAP 162.5MG
D-VITAMIN E POW SUCCINAT
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
X
Not Specified
DYANAVEL XR SUS 2.5MG/ML
Tier 4
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
ELOCTATE INJ 1000UNIT
ELOCTATE INJ 1500UNIT
ELOCTATE INJ 2000UNIT
ELOCTATE INJ 250UNIT
ELOCTATE INJ 3000UNIT
ELOCTATE INJ 500UNIT
ELOCTATE INJ 750UNIT
EMVOREN CRE
ENBRACE HR CAP
ENTRESTO TAB 24-26MG
ENTRESTO TAB 49-51MG
ENTRESTO TAB 97-103MG
EPCLUSA TAB 400-100
EPINEPHR HCL SOL 2% OP
EPIVIR HBV SOL 5MG/ML
EPIVIR HBV TAB 100MG
ESBRIET CAP 267MG
ESTRIOL POW
ESTRIOL POW MICRONIZ
ESTRIOL ULT POW MICRONIZ
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
ETHOSUXIMIDE POW
ETOPOSIDE POW
EVEKEO
TAB 10MG
EVEKEO
TAB 5MG
EVOTAZ
TAB 300-150
EXTARDOL CRE
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
FBL KIT CRE 15-4-5%
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Page 199 of 279
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Prior
Product Name
Authorization
Tier Value
FEMCAP
MIS 22MM
HCR Preventative
FLORIVA DRO 0.25MG
Tier 3
FLOWTUSS SOL 2.5-200
Tier 4
FLUOROURACIL POW
Tier 4
FLUOROURACIL POW USP/NF
Tier 4
FLUTICASONE POW
PROPIONA
FOLET DHA PAK
FOLET ONE CAP 38-1-225
FORTIGAN CAP
FP CEPA GEL
FP DERM GEL
FP SILO GEL
FREEDOM GEL CEPAPRO
FREEDOM GEL SET
FREEDOM GEL SILOMAC
GABAPENTIN POW
GAPEAUM CRE BUDIBAC
GENVOYA TAB
GINSENG POW AMERICAN
Tier 3
X
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
X
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 1
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
GLUCOCARD 01 TES SENSOR
GLUCOCARD 01 TEST STRIPS
GLUCOCARD TES VITAL
GLYXAMBI TAB 10-5 MG
GLYXAMBI TAB 25-5 MG
GNP DECONGES TAB
ADV.FORM
H20 GEL BASE GEL
HARVONI TAB 90-400MG
HYALUCIL-0.5 CRE
HYALUCIL-4 CRE
HYALURONATE POW SODIUM
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
X
X
X
Not Specified
HYALURONIC POW SODIUM
Tier 3
X
Not Specified
Not Specified
Not Specified
HYALURONIDAS POW
HYCOFENIX SOL
HYDROCODONE CRY
BITARTRA
HYDROCODONE POW
BITARTRA
HYDROPHEN SYP
HYDROXYUREA POW
IBRANCE CAP 100MG
IBRANCE CAP 125MG
IBRANCE CAP 75MG
IDELVION SOL 1000UNIT
IDELVION SOL 2000UNIT
IDELVION SOL 250UNIT
IDELVION SOL 500UNIT
IMPAVIDO CAP 50MG
INCRUSE ELPT INH 62.5MCG
INNOPRAX-5 CRE
K.B.G.L IN CRE TERODERM
KERYDIN SOL 5%
KETAMINE HCL POW
Tier 3
Tier 4
Tier 3
X
Tier 3
X
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Page 200 of 279
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 3
Tier 3
Tier 4
Tier 3
Supply
Limit
Step
Therapy
X
X
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Prior
Authorization
X
X
X
Supply
Limit
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
X
X
X
LEUPROLIDE POW ACETATE
LEVOMEFOLATE POW
GLUCOSAM
LIDOCAINE-PR CRE
LIDOCAINE-PR CRE
LIPODERM HMW GEL PCCA
LIPOGEL CR GEL BASE
LIPOIC ACID POW
L-ISOLEUCINE POW
LONSURF TAB 15-6.14
LONSURF TAB 20-8.19
LUBRAJEL NP GEL
LYNPARZA CAP 50MG
MAGNESIUM POW GLYCINAT
Tier 4
Tier 3
X
X
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 3
Tier 4
Tier 3
X
X
MAGNESIUM AA POW
CHELATE
MELATONIN POW
MELOXICAM POW
MEPER/PROMET CAP 5025MG
MERCAPTOPURI POW
MERCAPTOPURI POW
MERCAPTOPURI POW
MONOHYDR
METHOTREXATE POW
METHYL
POW FOLATE
METHYLCOBALA POW
METHYLCOBALA POW
PREMIUM
MIDAZOLAM POW
MINOXIDIL POW
MITOMYCIN POW
MITOMYCIN C POW
MONOBENZONE POW
MORCOMINE SYP
MOUTH WASH LIQ GP
MOUTHWASH LIQ AF
MOUTHWASH LIQ OM
MOVANTIK TAB 12.5MG
MOVANTIK TAB 25MG
Tier 3
X
Tier 3
Tier 3
Tier 3
X
X
Product Name
KETOPROFEN CRE 10%
KETOROLAC GEL 2%
KETOROLAC POW
TROMETHA
KEVEYIS TAB 50MG
KUDZU ROOT POW
LAMIVUDINE TAB 100MG
L-CARNITINE TAB 250MG
L-CYSTINE POW
LENVIMA CAP 10 MG
LENVIMA CAP 14 MG
LENVIMA CAP 18 MG
LENVIMA CAP 20 MG
LENVIMA CAP 24 MG
LENVIMA CAP 8 MG
LEUCOVORIN POW CALCIUM
Tier Value
Tier 3
Tier 3
Tier 3
Page 201 of 279
Tier 3
Tier 3
Tier 4
Tier 4
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Product Name
NABUMETONE POW
NAMZARIC CAP 14-10MG
NAMZARIC CAP 28-10MG
NATPARA INJ 100MCG
NATPARA INJ 25MCG
NATPARA INJ 50MCG
NATPARA INJ 75MCG
NAZIREX CRE
NEO-SYNALAR KIT
NEUAC
KIT 1.2-5%
NICOMIDE TAB
NINLARO CAP 2.3MG
NINLARO CAP 3MG
NINLARO CAP 4MG
NITEBITE BAR CHOCFUDG
NITEBITE BAR PBUTTER
NITROFURANZO OIN 0.2%
NORTHERA CAP 100MG
NORTHERA CAP 200MG
NORTHERA CAP 300MG
NOVOCLAIR CRE
NP #2 DRUG CRE PREP KIT
NUPLAZID TAB 17MG
NUVYA
CRE
OBIZUR
INJ 500 UNIT
OBREDON SOL 2.5-200
OCALIVA TAB 10MG
OCALIVA TAB 5MG
OCCLUSADERM GEL PCCA
ODEFSEY TAB
ODOMZO
CAP 200MG
OFEV
CAP 100MG
OFEV
CAP 150MG
ORKAMBI TAB 200-125
OTOVEL
DRO
PCP 100 KIT
PEDIPAK PAK
PEMOLINE POW
PENTOXIFYL POW
PERGOLIDE POW MESYLATE
Tier Value
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 4
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 1
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
PETN
TAB 80MG
PHENYLPROPAN POW HCL
PHOSPHATIDYL POW 20%
PINE BARK EX POW 95%
PLEGRIDY INJ
PLEGRIDY INJ PEN
PLEGRIDY INJ STARTER
PLEGRIDY PEN INJ STARTER
POLYSORBATE LIQ 80
POLYSORBATE LIQ 80
POLYSORBATE LIQ 80
POLYSORBATE LIQ 80
POT PHOSPHAT GRA DIBASIC
Tier 1
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
PRALUENT
PRALUENT
PRALUENT
Tier 3
Tier 3
Tier 3
INJ 150MG/ML
INJ 150MG/ML
INJ 75MG/ML
Page 202 of 279
Prior
Authorization
X
Supply
Limit
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Product Name
PRALUENT INJ 75MG/ML
PREGNENOLONE POW
PREGNENOLONE POW
MICRONIZ
PRENA 1 TRUE MIS
PRENATE CAP ESSENT
PRENATE CAP PIXIE
PRENATE TAB ELITE
PRENATE DHA CAP
PRENATE MINI CAP
PRENATE STAR TAB 20-1MG
PRESTALIA TAB 14-10MG
PRESTALIA TAB 3.5-2.5
PRESTALIA TAB 7-5MG
PREZCOBIX TAB 800-150
PROMETHAZINE CRY HCL
PROMETHAZINE POW HCL
PROSTAGLAND POW E1
PROVIDA DHA CAP
RA BEE POLLE CHW 500MG
REGENECARE GEL
REMAXAZON PAD
REPATHA INJ 140MG/ML
REPATHA PUSH INJ 420/3.5
REPATHA SURE INJ 140MG/ML
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
RESTORA RX CAP 60-1.25
RESVERATROL POW
RESVERATROL POW +98%
RESVERATROL POW 98%
RETINALDEHYD POW
REXULTI TAB 0.25MG
REXULTI TAB 0.5MG
REXULTI TAB 1MG
REXULTI TAB 2MG
REXULTI TAB 3MG
REXULTI TAB 4MG
RIBAVIRIN POW
RUCONEST INJ 2100UNIT
SAVAYSA TAB 15MG
SAVAYSA TAB 30MG
SAVAYSA TAB 60MG
SEEBRI NEOHA CAP 15.6MCG
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Not Specified
Not Specified
SERAQUA LIQ
SERMORELIN POW ACETATE
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
SEROTONIN POW HCL
SILOMAC GEL ULTRA
SIMPLGEL 30 GEL
SIROLIMUS POW
SODIUM BUTYR POW
SOLU-K
GEL
SOLUPAK PAK
SOOLANTRA CRE 1%
SPIRA-WASH GEL BASE
STIOLTO AER 2.5-2.5
STRENSIQ INJ 18/0.45
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
Tier 4
Tier 3
Page 203 of 279
Tier Value
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Prior
Authorization
X
X
X
Supply
Limit
X
Step
Therapy
X
X
X
X
X
X
X
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Prior
Authorization
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Product Name
STRENSIQ INJ 28/0.7ML
STRENSIQ INJ 40MG/ML
STRENSIQ INJ 80/0.8ML
SUCCIMER DMS POW
SULFADIMETHO POW
SUPRACIL CRE
SYNJARDY TAB
SYNJARDY TAB 12.5-500
SYNJARDY TAB 5-1000MG
SYNJARDY TAB 5-500MG
TABRADOL SUS 1MG/ML
TABRADOL SUS RAPIDPAQ
Not Specified
Not Specified
TACROLIMUS POW
TACROLIMUS POW
MONOHYD
TAGRISSO TAB 40MG
TAGRISSO TAB 80MG
TALTZ
INJ 80MG/ML
TALTZ
INJ 80MG/ML
TAMOXIFEN POW CITRATE
TDM SOLUTION SOL
TECHNIVIE TAB
TESTOSTERONE CRY YAM
TESTOSTERONE POW
TESTOSTERONE POW
CYPIONAT
TESTOSTERONE POW
ENANTHAT
TESTOSTERONE POW SOY
TETRAMEX SPR 2-1-3%
THERATEARS CAP NUTR
THIOGUANINE POW
THIOTEPA POW
TIZANIDINE POW HCL
TOCOPHEROL LIQ ALPHA
TOCOPHEROLS POW 30%
TOCOPHERYL POW SUCCINAT
Tier 4
Tier 4
TOMMY GEL GEL
TOXICOL SALV KIT COLLECT
TRAMADOL HCL POW
TRESIBA FLEX INJ 100UNIT
TRESIBA FLEX INJ 200UNIT
TRETTEN INJ
TRIAMCINOLON POW
TRIAMCINOLON POW
DIACETAT
TRIAMCINOLON POW
HEXACETO
TRICARE PAK PRENATAL
TRIDERMA CRE FORTE
TRIFERIC SOL
TRIPLE PMB SOL
TRIPLE PMK SOL
TRISEON CRE
TRIUMEQ TAB
TRULICITY INJ 0.75/0.5
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
X
X
Tier 3
X
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Page 204 of 279
Tier Value
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
Supply
Limit
X
X
X
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Tier 3
Tier 3
Tier 4
Tier 3
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Product Name
TRULICITY INJ 1.5/0.5
TUZISTRA XR SUS
TYBOST
TAB 150MG
UBIDECARENON POW
UCERIS
AER 2MG/ACT
UPTRAVI TAB 1000MCG
UPTRAVI TAB 1200MCG
UPTRAVI TAB 1400MCG
UPTRAVI TAB 1600MCG
UPTRAVI TAB 200/800
UPTRAVI TAB 200MCG
UPTRAVI TAB 400MCG
UPTRAVI TAB 600MCG
UPTRAVI TAB 800MCG
UREA
POW
UTIBRON CAP NEOHALER
VALIDERM CRE
VANACHOL CAP
VARUBI
TAB 90MG
VELTASSA POW 16.8GM
VELTASSA POW 25.2GM
VELTASSA POW 8.4GM
VENCLEXTA TAB 100MG
VENCLEXTA TAB 10MG
VENCLEXTA TAB 50MG
VENCLEXTA TAB START PK
VERRUNEX CRE
VERSAPRO GEL
VIBERZI TAB 100MG
VIBERZI TAB 75MG
VIEKIRA PAK TAB
VIEKIRA XR TAB
VISTOGARD PAK 10GM
VITAFOL CHW GUMMIES
VITAFOL FE+ CAP
VITAMIN E LIQ
VITAMIN E POW SUCCINAT
Tier Value
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 2
Tier 3
Tier 3
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
VITAMIN K2 POW 0.2%
VITATRUE MIS
VITEKTA TAB 150MG
VITEKTA TAB 85MG
VONVENDI INJ 1300UNIT
VONVENDI INJ 650UNIT
VRAYLAR CAP 1.5-3MG
VRAYLAR CAP 1.5MG
VRAYLAR CAP 3MG
VRAYLAR CAP 4.5MG
VRAYLAR CAP 6MG
WOUND WASH GEL BASE
XIGDUO XR TAB 10-1000
XIGDUO XR TAB 10-500MG
XIGDUO XR TAB 5-1000MG
XIGDUO XR TAB 5-500MG
XIIDRA
DRO 5%
XTAMPZA ER CAP 13.5MG
XTAMPZA ER CAP 18MG
XTAMPZA ER CAP 27MG
Tier 3
Tier 3
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Page 205 of 279
Prior
Authorization
X
Supply
Limit
X
X
Step
Therapy
Specialty
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Therapeutic Class
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Not Specified
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Agents, Other - Miscellaneous Eye
Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Product Name
XTAMPZA ER CAP 36MG
XTAMPZA ER CAP 9MG
XURIDEN POW 2GM
ZARXIO
INJ 300/0.5
ZARXIO
INJ 480/0.8
ZEPATIER TAB 50-100MG
ZINBRYTA INJ 150MG/ML
ZOLATE
CAP
ZYVODOL CRE
ALCAINE SOL 0.5% OP
Tier Value
Tier 4
Tier 4
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
ATROPINE SUL OIN 1% OP
Tier 1
ATROPINE SUL SOL 1% OP
Tier 1
CYSTARAN
Tier 3
SOL 0.44%
ISO ATROPINE SOL 1% OP
Tier 3
LACRISERT MIS 5MG OP
Tier 2
MYDRAL
SOL 0.5% OP
Tier 1
MYDRAL
SOL 1% OP
Tier 1
MYDRIACYL SOL 1% OP
Tier 3
NAPHAZOLINE SOL 0.1% OP
Tier 1
PARCAINE
Tier 1
SOL 0.5% OP
PROPARACAINE SOL 0.5% OP
Tier 1
RESTASIS
Tier 4
EMU 0.05%
TROPICAMIDE SOL 0.5% OP
Tier 1
TROPICAMIDE SOL 1% OP
Tier 1
ALOCRIL
Tier 3
ALOMIDE
SOL 2%
SOL 0.1% OP
Prior
Authorization
Supply
Limit
X
X
X
X
X
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
Tier 3
Tier 1
X
BEPREVE
Tier 4
X
X
X
X
CROMOLYN SOD SOL 4% OP
Tier 1
ELESTAT
Tier 4
EMADINE
DRO 0.05%
SOL 0.05% OP
Tier 4
X
EPINASTINE DRO 0.05%
Tier 1
X
LASTACAFT SOL 0.25%
Tier 3
X
Page 206 of 279
X
X
X
X
X
AZELASTINE DRO 0.05%
DRO 1.5%
Specialty
X
Therapeutic Class
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Anti-Allergy Agents - Allergy,
Infection and Inflammation Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Product Name
OLOPATADINE DRO 0.1%
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
Step
Therapy
OPTIVAR
DRO 0.05%
Tier 4
X
X
PATADAY
SOL 0.2%
Tier 4
X
X
PATANOL
SOL 0.1% OP
Tier 4
X
X
Tier 4
X
X
PAZEO
DRO 0.7%
ACETAZOLAMID CAP 500MG
ER
ACETAZOLAMID TAB 125MG
Tier 1
ACETAZOLAMID TAB 250MG
Tier 1
ALPHAGAN P SOL 0.1%
Tier 2
X
ALPHAGAN P SOL 0.15%
Tier 4
X
APRACLONIDIN SOL 0.5% OP
Tier 1
AZOPT
Tier 2
SUS 1% OP
BETAGAN
SOL 0.5% OP
Tier 1
X
Tier 4
BETAXOLOL SOL 0.5% OP
Tier 1
BETIMOL
SOL 0.25%
Tier 2
X
BETIMOL
SOL 0.5%
Tier 2
X
BETOPTIC-S SUS 0.25% OP
Tier 3
BRIMONIDINE SOL 0.15%
Tier 1
BRIMONIDINE SOL 0.2% OP
Tier 1
CARTEOLOL SOL 1% OP
Tier 1
COMBIGAN
Tier 2
COSOPT
SOL 0.2/0.5%
SOL 22.3-6.8
Tier 4
DIAMOX SEQUE CAP 500MG
CR
DORZOL/TIMOL SOL 22.3-6.8
Tier 4
DORZOLAMIDE SOL 2% OP
Tier 1
IOPIDINE
SOL 0.5% OP
Tier 4
IOPIDINE
SOL 1% OP
Tier 3
Page 207 of 279
X
Tier 4
COSOPT PF SOL
ISOPTO CARP SOL 1% OP
X
Tier 1
Tier 4
X
X
Specialty
Therapeutic Class
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Ophthalmic Antiglaucoma Agents - Glaucoma
Drugs
Product Name
ISOPTO CARP SOL 2% OP
Tier Value
Tier 4
ISOPTO CARP SOL 4% OP
Tier 3
ISTALOL
Tier 3
SOL 0.5% OP
LEVOBUNOLOL SOL 0.5% OP
Tier 1
METHAZOLAMID TAB 25MG
Tier 1
METHAZOLAMID TAB 50MG
Tier 1
METIPRANOLOL SOL 0.3% OPH
Tier 1
NEPTAZANE TAB 25MG
Tier 4
NEPTAZANE TAB 50MG
Tier 4
PHOSPHOLINE SOL 0.125%OP
Tier 2
PILOCARPINE SOL 1% OP
Tier 1
PILOCARPINE SOL 2% OP
Tier 1
PILOCARPINE SOL 4% OP
Tier 1
SIMBRINZA SUS 1-0.2%
Tier 4
TIMOLOL GEL SOL 0.25% OP
Tier 1
TIMOLOL GEL SOL 0.5% OP
Tier 1
TIMOLOL MAL SOL 0.25% OP
Tier 1
TIMOLOL MAL SOL 0.5% OP
Tier 1
TIMOPTIC
SOL 0.25% OP
Tier 4
TIMOPTIC
SOL 0.5% OP
Tier 4
TIMOPTIC OCU SOL 0.25% OP
Tier 3
TIMOPTIC OCU SOL 0.25% OP
Tier 3
TIMOPTIC OCU SOL 0.25% OP
Tier 2
TIMOPTIC OCU SOL 0.25% OP
Tier 2
TIMOPTIC OCU SOL 0.5% OP
Tier 2
TIMOPTIC-XE SOL 0.25% OP
Tier 4
TIMOPTIC-XE SOL 0.5% OP
Tier 4
TRUSOPT
Tier 4
SOL 2% OP
Page 208 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
Specialty
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 4
X
X
Tier 4
X
Therapeutic Class
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
Product Name
ACULAR
SOL 0.5% OP
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
ACULAR LS SOL 0.4%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
ACUVAIL
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
ALREX
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
BLEPHAMIDE OIN S.O.P.
Tier 2
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
BLEPHAMIDE SUS OP
Tier 3
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
BROMFENAC SOL 0.09% OP
Tier 1
X
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
BROMFENAC SOL 0.09% OP
Tier 1
X
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
DEXAMETH PHO SOL 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
DICLOFENAC SOL 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
DUREZOL
EMU 0.05%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
FLAREX
SUS 0.1% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
FLUOROMETHOL SUS 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
FLURBIPROFEN SOL 0.03% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
FML
Tier 2
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
FML FORTE SUS 0.25% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
FML LIQUIFLM SUS 0.1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
ILEVRO
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
KETOROLAC SOL 0.4%
SOL 0.45%
SUS 0.2%
OIN 0.1% OP
DRO 0.3% OP
Page 209 of 279
Tier Value
Tier 4
Tier 1
X
X
Specialty
Therapeutic Class
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
Product Name
KETOROLAC SOL 0.5%
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
LOTEMAX
GEL 0.5%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
LOTEMAX
OIN 0.5%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
LOTEMAX
SUS 0.5%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
MAXIDEX
SUS 0.1% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
MAXITROL
OIN 0.1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
MAXITROL
SUS 0.1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
NEO/POLY/BAC OIN /HC 1%OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
NEO/POLY/DEX OIN 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
NEO/POLY/DEX SUS 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
NEO-POLYCIN OIN HC 1%OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
NEVANAC
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
OCUFEN
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
SUS 0.1%
Tier Value
Tier 1
SOL 0.03% OP
Tier 3
OMNIPRED
SUS 1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
POLY-DEX
OIN 0.1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
PRED FORTE SUS 1% OP
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
PRED MILD SUS 0.12% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
PRED SOD PHO SOL 1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
PRED-G
Tier 3
SUS OP
Page 210 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
Specialty
Supply
Limit
Step
Therapy
X
X
X
X
X
X
Tier 3
X
X
TRAVATAN Z DRO 0.004%
Tier 2
X
TRAVOPROST DRO 0.004%
Tier 1
XALATAN
SOL 0.005%
Tier 4
ZIOPTAN
DRO 0.0015%
Tier 3
EMBEDA
EMBEDA
EMBEDA
EMBEDA
EMBEDA
EMBEDA
OPIUM
AVINZA
CAP 100-4MG
CAP 20-0.8MG
CAP 30-1.2MG
CAP 50-2MG
CAP 60-2.4MG
CAP 80-3.2MG
TIN 1%
CAP 120MG
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 4
AVINZA
CAP 30MG
Tier 4
Therapeutic Class
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
Product Name
PRED-G S.O.P OIN OP
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
PREDNISOLONE SUS 1% OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
PROLENSA
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
SULF/PRED NA SOL OP
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
TOBRA/DEXAME SUS 0.3-0.1%
Tier 1
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
TOBRADEX
OIN 0.3-0.1%
Tier 3
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
TOBRADEX
SUS 0.3-0.1%
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
TOBRADEX ST SUS 0.3-0.05
Tier 4
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
VEXOL
SUS 1% OP
Tier 2
Ophthalmic Anti-Inflammatories - Allergy,
Infection and Inflammation Drugs
ZYLET
SUS 0.5-0.3%
Tier 3
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Ophthalmic Prostaglandin and Prostamide
Analogs - Glaucoma Drugs
Opioid Analgesics - Opioid Pain Relievers
Opioid Analgesics - Opioid Pain Relievers
Opioid Analgesics - Opioid Pain Relievers
Opioid Analgesics - Opioid Pain Relievers
Opioid Analgesics - Opioid Pain Relievers
Opioid Analgesics - Opioid Pain Relievers
Opioid Analgesics - Opioid Pain Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
BIMATOPROST SOL 0.03%
Tier 1
LATANOPROST SOL 0.005%
Tier 1
LUMIGAN
Tier 2
RESCULA
SOL 0.07%
SOL 0.01%
SOL 0.15%
Page 211 of 279
Tier Value
Tier 3
Prior
Authorization
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Product Name
AVINZA
CAP 45MG
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
AVINZA
CAP 60MG
Tier 4
X
X
X
AVINZA
CAP 75MG
Tier 4
X
X
X
AVINZA
CAP 90MG
Tier 4
X
X
X
BUTRANS
DIS 10MCG/HR
Tier 4
X
BUTRANS
DIS 15MCG/HR
Tier 4
X
BUTRANS
DIS 20MCG/HR
Tier 4
X
BUTRANS
DIS 5MCG/HR
Tier 4
X
BUTRANS
DIS 7.5/HR
Tier 4
X
CONZIP
CAP 100MG
Tier 4
X
X
CONZIP
CAP 200MG
Tier 4
X
X
CONZIP
CAP 300MG
Tier 4
X
X
DOLOPHINE TAB 10MG
Tier 3
X
DOLOPHINE TAB 5MG
Tier 3
X
DURAGESIC DIS 100MCG/H
Tier 4
X
X
DURAGESIC DIS 12MCG/HR
Tier 4
X
X
DURAGESIC DIS 25MCG/HR
Tier 4
X
X
DURAGESIC DIS 50MCG/HR
Tier 4
X
X
DURAGESIC DIS 75MCG/HR
Tier 4
X
X
FENTANYL
DIS 100MCG/H
Tier 1
X
FENTANYL
DIS 12MCG/HR
Tier 1
X
FENTANYL
DIS 25MCG/HR
Tier 1
X
FENTANYL
DIS 37.5MCG
Tier 1
X
FENTANYL
DIS 50MCG/HR
Tier 1
X
FENTANYL
DIS 62.5MCG
Tier 1
X
FENTANYL
DIS 75MCG/HR
Tier 1
X
FENTANYL
DIS 87.5MCG
Tier 1
X
X
HYSINGLA ER TAB 100 MG
Tier 4
X
X
X
HYSINGLA ER TAB 120 MG
Tier 4
X
X
X
Page 212 of 279
X
X
Specialty
Therapeutic Class
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Product Name
HYSINGLA ER TAB 20 MG
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
HYSINGLA ER TAB 30 MG
Tier 4
X
X
X
HYSINGLA ER TAB 40 MG
Tier 4
X
X
X
HYSINGLA ER TAB 60 MG
Tier 4
X
X
X
HYSINGLA ER TAB 80 MG
Tier 4
X
X
X
KADIAN
CAP 100MG ER
Tier 4
X
X
X
KADIAN
CAP 10MG ER
Tier 4
X
X
X
KADIAN
CAP 200MG ER
Tier 4
X
X
X
KADIAN
CAP 20MG ER
Tier 4
X
X
X
KADIAN
CAP 30MG ER
Tier 4
X
X
X
KADIAN
CAP 40MG ER
Tier 4
X
X
X
KADIAN
CAP 50MG ER
Tier 4
X
X
X
KADIAN
CAP 60MG ER
Tier 4
X
X
X
KADIAN
CAP 80MG ER
Tier 4
X
X
X
LEVORPHANOL TAB 2MG
Tier 1
METHADONE CON 10MG/ML
Tier 1
METHADONE POW
Tier 3
METHADONE SOL
10MG/5ML
METHADONE SOL 5MG/5ML
Tier 1
X
Tier 1
X
METHADONE TAB 10MG
Tier 1
X
METHADONE TAB 40MG
Tier 1
X
METHADONE TAB 5MG
Tier 1
X
METHADOSE CON 10MG/ML
Tier 1
X
METHADOSE TAB 40MG
Tier 1
X
METHADOSE SF CON
10MG/ML
MORPHINE POW SULFATE
Tier 1
X
Tier 3
X
MORPHINE SUL CAP 100MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 10MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 120MG ER
Tier 1
X
X
X
Page 213 of 279
X
X
Specialty
Therapeutic Class
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Product Name
MORPHINE SUL CAP 20MG ER
Tier Value
Tier 1
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
MORPHINE SUL CAP 30MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 30MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 45MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 50MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 60MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 60MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 75MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 80MG ER
Tier 1
X
X
X
MORPHINE SUL CAP 90MG ER
Tier 1
X
X
X
MORPHINE SUL SOL 100/5ML
Tier 1
MORPHINE SUL SOL
10MG/5ML
MORPHINE SUL SOL
20MG/5ML
MORPHINE SUL SUP 10MG
Tier 1
MORPHINE SUL SUP 20MG
Tier 1
MORPHINE SUL SUP 30MG
Tier 1
MORPHINE SUL SUP 5MG
Tier 1
MORPHINE SUL TAB 100MG ER
Tier 1
MORPHINE SUL TAB 15MG
Tier 1
MORPHINE SUL TAB 15MG ER
Tier 1
X
MORPHINE SUL TAB 200MG ER
Tier 1
X
MORPHINE SUL TAB 30MG
Tier 1
MORPHINE SUL TAB 30MG ER
Tier 1
X
MORPHINE SUL TAB 60MG ER
Tier 1
X
MS CONTIN TAB 100MG CR
Tier 3
X
X
X
MS CONTIN TAB 15MG CR
Tier 3
X
X
X
MS CONTIN TAB 200MG CR
Tier 3
X
X
X
MS CONTIN TAB 30MG CR
Tier 3
X
X
X
MS CONTIN TAB 60MG CR
Tier 3
X
X
X
Page 214 of 279
Tier 1
Tier 3
X
Specialty
Therapeutic Class
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Product Name
NUCYNTA TAB 100MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
NUCYNTA
TAB 50MG
Tier 4
X
NUCYNTA
TAB 75MG
Tier 4
X
NUCYNTA ER TAB 100MG
Tier 3
X
X
NUCYNTA ER TAB 150MG
Tier 3
X
X
NUCYNTA ER TAB 200MG
Tier 3
X
X
NUCYNTA ER TAB 250MG
Tier 3
X
X
NUCYNTA ER TAB 50MG
Tier 3
X
X
OPANA
TAB 10MG
Tier 4
X
OPANA
TAB 5MG
Tier 4
X
Step
Therapy
OPANA ER
TAB 10MG
Tier 2
X
X
OPANA ER
TAB 15MG
Tier 2
X
X
OPANA ER
TAB 20MG
Tier 2
X
X
OPANA ER
TAB 30MG
Tier 2
X
X
OPANA ER
TAB 40MG
Tier 2
X
X
OPANA ER
TAB 5MG
Tier 2
X
X
OPANA ER
TAB 7.5MG
Tier 2
X
X
TAB 10MG
Tier 1
X
X
X
TAB 15MG
Tier 1
X
X
X
TAB 20MG
Tier 1
X
X
X
TAB 30MG
Tier 1
X
X
X
TAB 40MG
Tier 1
X
X
X
TAB 5MG ER
Tier 1
X
X
X
OXYMORPHONE TAB 7.5MG
ER
OXYMORPHONE TAB HCL
10MG
OXYMORPHONE TAB HCL
5MG
SUBSYS
SPR 100MCG
Tier 1
X
X
X
Tier 4
X
X
X
SUBSYS
SPR 1200MCG
Tier 4
X
X
X
SUBSYS
SPR 1600MCG
Tier 4
X
X
X
OXYMORPHONE
ER
OXYMORPHONE
ER
OXYMORPHONE
ER
OXYMORPHONE
ER
OXYMORPHONE
ER
OXYMORPHONE
Page 215 of 279
Tier 1
X
Tier 1
X
Specialty
Therapeutic Class
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Product Name
SUBSYS
SPR 200MCG
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
SUBSYS
SPR 400MCG
Tier 4
X
X
X
SUBSYS
SPR 600MCG
Tier 4
X
X
X
SUBSYS
SPR 800MCG
Tier 4
X
X
X
SUS 10MG/ML
Tier 3
X
TRAMADOL HCL CAP 150MG
ER
TRAMADOL HCL CAP ER
100MG
TRAMADOL HCL CAP ER
200MG
TRAMADOL HCL CAP ER
300MG
TRAMADOL HCL TAB 100MG
ER
TRAMADOL HCL TAB 100MG
ER
TRAMADOL HCL TAB 200MG
ER
TRAMADOL HCL TAB 200MG
ER
TRAMADOL HCL TAB 300MG
ER
TRAMADOL HCL TAB 300MG
ER
TRAMADOL HCL TAB 50MG
Tier 1
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
ULTRAM
Tier 4
SYNAPRYN
TAB 50MG
X
X
X
Tier 1
ULTRAM ER TAB 100MG
Tier 4
X
ULTRAM ER TAB 200MG
Tier 4
X
ULTRAM ER TAB 300MG
Tier 4
X
ZOHYDRO ER CAP 10MG
Tier 4
X
X
X
ZOHYDRO ER CAP 10MG
Tier 4
X
X
X
ZOHYDRO ER CAP 15MG
Tier 4
X
X
X
ZOHYDRO ER CAP 15MG
Tier 4
X
X
X
ZOHYDRO ER CAP 20MG
Tier 4
X
X
X
ZOHYDRO ER CAP 20MG
Tier 4
X
X
X
ZOHYDRO ER CAP 30MG
Tier 4
X
X
X
ZOHYDRO ER CAP 30MG
Tier 4
X
X
X
ZOHYDRO ER CAP 40MG
Tier 4
X
X
X
Page 216 of 279
Specialty
Therapeutic Class
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Long-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Product Name
ZOHYDRO ER CAP 40MG
Tier Value
Tier 4
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
ZOHYDRO ER CAP 50MG
Tier 4
X
X
X
ZOHYDRO ER CAP 50MG
Tier 4
X
X
X
ABSTRAL
SUB 100MCG
Tier 4
X
X
X
ABSTRAL
SUB 200MCG
Tier 4
X
X
X
ABSTRAL
SUB 300MCG
Tier 4
X
X
X
ABSTRAL
SUB 400MCG
Tier 4
X
X
X
ABSTRAL
SUB 600MCG
Tier 4
X
X
X
ABSTRAL
SUB 800MCG
Tier 4
X
X
X
ACTIQ
LOZ 1200MCG
Tier 4
X
X
X
ACTIQ
LOZ 1600MCG
Tier 4
X
X
X
ACTIQ
LOZ 200MCG
Tier 4
X
X
X
ACTIQ
LOZ 400MCG
Tier 4
X
X
X
ACTIQ
LOZ 600MCG
Tier 4
X
X
X
ACTIQ
LOZ 800MCG
Tier 4
X
X
X
APAP/CODEINE SOL 120-12/5
Tier 1
X
APAP/CODEINE TAB 300-15MG
Tier 1
X
APAP/CODEINE TAB 300-30MG
Tier 1
X
APAP/CODEINE TAB 300-60MG
Tier 1
X
APAP-CAFFEIN CAP DIHYDROC
Tier 1
X
ASCOMP/COD CAP 30MG
Tier 1
BUT/ASA/CAF/ CAP COD 30MG
Tier 1
BUTORPHANOL SOL 10MG/ML
Tier 1
X
CAPITAL/COD SUS 120-12/5
Tier 2
X
CARISOPRODOL TAB ASA/COD
Tier 1
CODEINE SULF SOL 30MG/5ML
Tier 1
CODEINE SULF TAB 15MG
Tier 1
CODEINE SULF TAB 30MG
Tier 1
CODEINE SULF TAB 60MG
Tier 1
Page 217 of 279
Specialty
Therapeutic Class
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Product Name
DEMEROL TAB 100MG
DEMEROL
TAB 50MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
Tier 4
DIHYDROCOD/ CAP ASA/CAFF
Tier 1
DILAUDID
LIQ 1MG/ML
Tier 4
DILAUDID
TAB 2MG
Tier 4
DILAUDID
TAB 4MG
Tier 4
DILAUDID
TAB 8MG
Tier 4
ENDOCET
TAB 10-325MG
Tier 1
X
ENDOCET
TAB 2.5-325
Tier 1
X
ENDOCET
TAB 5-325MG
Tier 1
X
ENDOCET
TAB 7.5-325
Tier 1
X
ENDODAN
TAB
Step
Therapy
Tier 1
EXALGO
TAB 12MG
Tier 4
X
X
X
EXALGO
TAB 16MG
Tier 4
X
X
X
EXALGO
TAB 32MG
Tier 4
X
X
X
EXALGO
TAB 8MG
Tier 4
X
X
X
Tier 3
X
FENTANYL OT LOZ 1200MCG
Tier 1
X
X
FENTANYL OT LOZ 1600MCG
Tier 1
X
X
FENTANYL OT LOZ 200MCG
Tier 1
X
X
FENTANYL OT LOZ 400MCG
Tier 1
X
X
FENTANYL OT LOZ 600MCG
Tier 1
X
X
FENTANYL OT LOZ 800MCG
Tier 1
X
X
FENTORA
TAB 100MCG
Tier 3
X
X
X
FENTORA
TAB 200MCG
Tier 3
X
X
X
FENTORA
TAB 400MCG
Tier 3
X
X
X
FENTORA
TAB 600MCG
Tier 3
X
X
X
FENTORA
TAB 800MCG
Tier 3
X
X
X
FIORINAL/COD CAP 30MG
Tier 4
FENTANYL
POW CITRATE
Page 218 of 279
Specialty
Therapeutic Class
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Product Name
HYCET
SOL 7.5-325
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
Step
Therapy
HYDROCO/APAP SOL 7.5-325
Tier 1
X
HYDROCO/APAP TAB 10300MG
HYDROCO/APAP TAB 10325MG
HYDROCO/APAP TAB 2.5-325
Tier 1
X
Tier 1
X
HYDROCO/APAP TAB 5-300MG
Tier 1
X
HYDROCO/APAP TAB 5-325MG
Tier 1
X
HYDROCO/APAP TAB 7.5-300
Tier 1
X
HYDROCO/APAP TAB 7.5-325
Tier 1
X
HYDROCOD/IBU TAB 10200MG
HYDROCOD/IBU TAB 2.5-200
Tier 1
HYDROCOD/IBU TAB 5-200MG
Tier 1
HYDROCOD/IBU TAB 7.5-200
Tier 1
HYDROCODONE SOL 10325MG
HYDROMORPHON LIQ
1MG/ML
HYDROMORPHON POW HCL
Tier 1
HYDROMORPHON SUP 3MG
Tier 1
HYDROMORPHON TAB 12MG
ER
HYDROMORPHON TAB 16MG
ER
HYDROMORPHON TAB 2MG
Tier 1
X
X
X
Tier 1
X
X
X
HYDROMORPHON TAB 32MG
ER
HYDROMORPHON TAB 4MG
Tier 1
X
X
X
HYDROMORPHON TAB 8MG
Tier 1
HYDROMORPHON TAB 8MG
ER
IBUDONE TAB 10-200MG
Tier 1
X
X
X
IBUDONE
TAB 5-200MG
Tier 1
LAZANDA
SPR 100MCG
Tier 4
X
X
LAZANDA
SPR 300MCG
Tier 4
X
LAZANDA
SPR 400MCG
Tier 4
X
Page 219 of 279
X
Tier 1
X
X
Tier 1
X
Tier 1
Tier 3
X
Tier 1
Tier 1
Tier 1
X
Specialty
Therapeutic Class
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Product Name
LORCET
TAB 5-325MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
LORCET HD TAB 10-325MG
Tier 1
X
LORCET PLUS TAB 7.5-325
Tier 1
X
LORTAB
ELX 10-300MG
Tier 4
LORTAB
TAB 10-325MG
Tier 1
X
LORTAB
TAB 5-325MG
Tier 1
X
LORTAB
TAB 7.5-325
Tier 1
X
Step
Therapy
MEPERIDINE SOL 50MG/5ML
Tier 1
MEPERIDINE TAB 100MG
Tier 1
MEPERIDINE TAB 50MG
Tier 1
NORCO
TAB 10-325MG
Tier 4
X
NORCO
TAB 5-325MG
Tier 4
X
NORCO
TAB 7.5-325
Tier 4
X
OXAYDO
TAB 5MG
Tier 4
X
X
OXAYDO
TAB 7.5MG
Tier 4
X
X
OXYCOD/APAP TAB 10-325MG
Tier 1
X
OXYCOD/APAP TAB 2.5-325
Tier 1
X
OXYCOD/APAP TAB 5-325MG
Tier 1
X
OXYCOD/APAP TAB 7.5-325
Tier 1
X
OXYCOD/ASA TAB
Tier 1
OXYCODONE CAP 5MG
Tier 1
OXYCODONE CON 100/5ML
Tier 1
OXYCODONE CON 20MG/ML
Tier 1
OXYCODONE POW HCL
Tier 3
OXYCODONE SOL 5MG/5ML
Tier 1
OXYCODONE TAB 10MG
Tier 1
OXYCODONE TAB 10MG ER
Tier 4
OXYCODONE TAB 15MG
Tier 1
OXYCODONE TAB 15MG ER
Tier 4
Page 220 of 279
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Product Name
OXYCODONE TAB 20MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
OXYCODONE TAB 20MG ER
Tier 4
OXYCODONE TAB 30MG
Tier 1
OXYCODONE TAB 30MG ER
Tier 4
X
X
X
OXYCODONE TAB 40MG ER
Tier 4
X
X
X
OXYCODONE TAB 5MG
Tier 1
OXYCODONE TAB 60MG ER
Tier 4
X
X
X
OXYCODONE TAB 80MG ER
Tier 4
X
X
X
OXYCODONE/ SOL APAP
Tier 1
OXYCONTIN TAB 10MG CR
Tier 4
X
X
X
OXYCONTIN TAB 15MG CR
Tier 4
X
X
X
OXYCONTIN TAB 20MG CR
Tier 4
X
X
X
OXYCONTIN TAB 30MG CR
Tier 4
X
X
X
OXYCONTIN TAB 40MG CR
Tier 4
X
X
X
OXYCONTIN TAB 60MG CR
Tier 4
X
X
X
OXYCONTIN TAB 80MG CR
Tier 4
X
X
X
PENTAZ/NALOX TAB 50-0.5MG
Tier 1
PERCOCET
TAB 10-325MG
Tier 4
X
X
PERCOCET
TAB 2.5-325
Tier 4
X
X
PERCOCET
TAB 5-325MG
Tier 4
X
X
PERCOCET
TAB 7.5-325
Tier 4
X
X
PRIMLEV
TAB 10-300MG
Tier 3
X
PRIMLEV
TAB 5-300MG
Tier 3
X
PRIMLEV
TAB 7.5-300
Tier 3
X
X
REPREXAIN TAB 10-200MG
Tier 1
REPREXAIN TAB 5-200MG
Tier 1
ROXICET
SOL 5-325/5
Tier 1
X
ROXICET
TAB 5-325MG
Tier 1
X
ROXICODONE TAB 15MG
Tier 4
Page 221 of 279
Specialty
Therapeutic Class
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Analgesics, Short-acting - Opioid Pain
Relievers
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Prior
Authorization
Supply
Limit
Step
Therapy
Product Name
ROXICODONE TAB 30MG
Tier Value
Tier 4
ROXICODONE TAB 5MG
Tier 3
SYNALGOS-DC CAP
Tier 4
TRAMADL/APAP TAB 37.5-325
Tier 1
X
TREZIX
Tier 1
X
TYLENOL/COD TAB #3
Tier 4
X
TYLENOL/COD TAB #4
Tier 4
X
ULTRACET
TAB 37.5-325
Tier 4
X
VERDROCET TAB 2.5-325
Tier 1
VICODIN
TAB 5-300MG
Tier 1
X
X
VICODIN ES TAB 7.5-300
Tier 1
X
X
VICODIN HP TAB 10-300MG
Tier 1
X
X
VICOPROFEN TAB 7.5-200
Tier 4
XARTEMIS XR TAB 7.5-325
Tier 4
X
X
XODOL
TAB 10-300MG
Tier 4
X
X
XODOL
TAB 5-300MG
Tier 4
X
X
XODOL
TAB 7.5-300
Tier 4
X
X
XYLON
TAB 10-200MG
Tier 1
CAP
ZAMICET
SOL 10-325MG
Tier 1
X
BELBUCA
MIS 150MCG
Tier 4
X
X
BELBUCA
MIS 300MCG
Tier 4
X
X
BELBUCA
MIS 450MCG
Tier 4
X
X
BELBUCA
MIS 600MCG
Tier 4
X
X
BELBUCA
MIS 750MCG
Tier 4
X
X
BELBUCA
MIS 75MCG
Tier 4
X
X
BELBUCA
MIS 900MCG
Tier 4
X
X
BUNAVAIL
MIS 2.1-0.3
Tier 4
X
X
X
BUNAVAIL
MIS 4.2-0.7
Tier 4
X
X
X
BUNAVAIL
MIS 6.3-1MG
Tier 4
X
X
X
Page 222 of 279
Specialty
Tier Value
Tier 1
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
X
BUPREN/NALOX SUB 8-2MG
Tier 1
X
X
X
BUPRENORPHIN SUB 2MG
Tier 1
X
X
BUPRENORPHIN SUB 8MG
Tier 1
X
X
EVZIO
Tier 4
X
X
X
X
X
Therapeutic Class
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Opioid Antagonists Antidotes/Deterrents/Protectants
Otic Agents - Ear Drugs
Product Name
BUPREN/NALOX SUB 2-0.5MG
ACE ACD/ALUM SOL 2% OTIC
Tier 1
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
ACETASOL HC SOL OTIC
ACETIC ACID SOL 2% OTIC
COLY-MYCIN S SUS OTIC
CORTISPORIN SUS -TC OTIC
DERMOTIC OIL 0.01%
FLUOCIN ACET OIL 0.01%
FLUOCIN ACET OIL EAR0.01%
Tier 2
Tier 1
Tier 3
Tier 3
Tier 4
Tier 1
Tier 1
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Otic Agents - Ear Drugs
Parasympathomimetics - Myasthenia Gravis
Drugs
Parasympathomimetics - Myasthenia Gravis
Drugs
Parasympathomimetics - Myasthenia Gravis
Drugs
Parasympathomimetics - Myasthenia Gravis
Drugs
HC/ACET ACID SOL OTIC
NEO/POLY/HC SOL 1% OTIC
NEO/POLY/HC SUS 1% OTIC
NEO/POLY/HC SUS OP
PRAMOTIC DRO 1-0.1%
GUANIDINE TAB 125MG
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
MESTINON
SYP 60MG/5ML
Tier 2
MESTINON
TAB 60MG
Tier 4
MESTINON
TAB TIMESPAN
Tier 3
INJ
NALOXONE
INJ 0.4MG/ML
Tier 1
NALOXONE
INJ 1MG/ML
Tier 1
NARCAN
SPR
Tier 4
SUBOXONE
MIS 12-3MG
Tier 4
X
X
X
SUBOXONE
MIS 2-0.5MG
Tier 4
X
X
X
SUBOXONE
MIS 4-1MG
Tier 4
X
X
X
SUBOXONE
MIS 8-2MG
Tier 4
X
X
X
ZUBSOLV
SUB 1.4-0.36
Tier 1
X
X
ZUBSOLV
SUB 11.4-2.9
Tier 1
X
ZUBSOLV
SUB 2.9-0.71
Tier 1
X
ZUBSOLV
SUB 5.7-1.4
Tier 1
X
X
ZUBSOLV
SUB 8.6-2.1
Tier 1
X
X
Page 223 of 279
Specialty
Therapeutic Class
Parasympathomimetics - Myasthenia Gravis
Drugs
Parasympathomimetics - Myasthenia Gravis
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
Pediculicides/Scabicides - Scabies and Lice
Drugs
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
Prior
Authorization
Supply
Limit
Product Name
PYRIDOSTIGM TAB 60MG
Tier Value
Tier 1
PYRIDOSTIGMI TAB 180MG
Tier 1
ELIMITE
CRE 5%
Tier 4
EURAX
CRE 10%
Tier 2
EURAX
LOT 10%
Tier 3
LINDANE
LOT 1%
Tier 1
X
LINDANE
SHA 1%
Tier 1
X
LYCELLE
GEL
Tier 3
MALATHION LOT 0.5%
Tier 1
NATROBA
Tier 4
OVIDE
SUS 0.9%
LOT 0.5%
Tier 1
SKLICE
Tier 4
ULESFIA
LOT 0.5%
SUS 0.9%
X
Tier 4
PERMETHRIN CRE 5%
SPINOSAD
Step
Therapy
X
Tier 1
LOT 5%
Tier 3
Tier 3
Tier 3
Tier 3
X
X
X
PHARMACEUTICAL AIDS
1ST BASE CRE
ADAPTADERM CRE
ADENOSINE-5 POW
MONOPHOS
ADENOSINE-5 POW TRIPHOSP
Tier 3
X
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
ADVANCED BAS CRE PLUS
ALBA-DERM CRE
ALMONDERM CRE
ALPAWASH OIN
ALTADERM CRE BASE
APOTHEDERM CRE
APOTHESAR CRE TRANSDER
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
X
X
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
APOTHESIL CRE
AQUORAL AER
ATRAPRO GEL HYDROGEL
ATRAPRO CP KIT
AUXIPRO CRE EMOLLIEN
AUXIPRO CRE VANISHIN
AZ CREAM CRE
BACOCALMINE LIQ
BASE
CRE LIPOSOME
BASE FOR CRE SCARS
BASE W301 CRE
B-CREAM CRE
BIOPEPTIDE CRE BASE
CARBOGEL GEL 940
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
Page 224 of 279
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
Product Name
CARBOHOL GEL 940
CARBOMER GEL AQUEOUS
CARBOMER GEL HYDROALC
Tier Value
Tier 2
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
CELA BASE CRE
CHERRY
SYP
CHRYSADERM CRE DAY
CHRYSADERM CRE NIGHT
COLLODION LIQ FLEXIBLE
CONCENTRATE CRE
CREAM BASE CRE
CUTIS PLUS CRE
DELBASE OIN COMPOUND
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
DELIVRA CRE SR
DERMA SERUM CRE FREEDOM
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
DIAB
GEL
DIAB F.D.G. GEL
EMOLIVAN CRE
EMOLLIENT CRE
EMOLLIENT CRE BASE
FAGRON LS CRE PLUS
FAGRON LS CRE ULTRA
FITALITE CRE BASE
FLAVOR BLEND SUS
FLAVOR PLUS LIQ
FLAVOR SWEET LIQ S/F
FLAVOR SWEET SYP
FLOW-EZE MIS VENTED
FOOD COLOR LIQ BLUE
FP DERM CRE
FP ENHANCING CRE
FP NATURAL CRE
FP PLUS CRE
FP SUPREME CRE
FP ULTRA CRE
FREEDOM CRE DERMA-D
FREEDOM CRE DERMA-N
FREEDOM CRE ULTRAPEN
FREEDOM HRT CRE ULTRA
HYDROGEL GEL
HYDROPHILIC OIN
HYDROUS CRE EMULSIFI
HYPO NEEDLE MIS 18GX1"
LANOLIN OIN
LANOLIN ANHY OIN
LECITHIN GEL
LIPO CREAM CRE BASE
LIPOBASE CRE HEAVY
LIPOBASE CRE REGULAR
LIPOPEN CRE
LIPOPEN CRE ANHYDRO
LIPOPEN CRE PLUS
LIPOPEN CRE ULTRA
LIPOZYME CRE
LUXAMEND CRE
MEDIDERM CRE
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 2
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Page 225 of 279
Prior
Authorization
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Supply
Limit
Step
Therapy
Specialty
Prior
Authorization
X
Therapeutic Class
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
Product Name
MICRODERM CRE BASE
MUCOLOX LIQ
MULTIUSE CRE BASE
NATACREAM CRE
NATURAL CRE
NEEDLES 22G X 1 1/2"
NEUTRASAL POW
NOURILITE CRE
NOURIVAN CRE ANTIOX
NOXI-K
CRE
OCCLUVAN OIN
ORA-BLEND SUS
ORA-BLEND SF SUS
ORAL MIX LIQ SUSPENDI
ORAL MIX SF LIQ
ORAL SUSPEND LIQ
ORAL SYRUP LIQ FLAVORED
Tier Value
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
ORAL SYRUP LIQ SF
ORA-PLUS LIQ
ORA-SWEET SYP
ORA-SWEET SF SYP
PCCA ACACIA SYP BASE
PCCA ALADERM CRE BASE
PCCA BASE CRE 7542
PCCA COBASE OIN #1
PCCA COSMETI CRE HRT BASE
Tier 3
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
PHARMACEUTICAL AIDS
PCCA CUSTOM CRE LIPO-MAX
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PCCA EMOLLIE CRE BASE
PCCA LIPODER CRE BASE
PCCA LIPODER CRE BASE
PCCA LIPODER CRE BASE
PCCA LIPODER CRE BASE
PCCA LIPOSOM CRE DRY
PCCA LIPOSOM CRE NORMAL
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PCCA LIPOSOM CRE OILY
PCCA LIPOSOM CRE SENSITIV
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PCCA MVC CRE BASE
PCCA SWEET SYP -SF
PCCA SYRUP SYP VEHICLE
PCCA VANISH CRE BASE
PCCA VANISHI CRE LIGHT
PCCA VANPEN CRE BASE
PCCA-PLUS SUS
PENCREAM CRE
PENDERM CRE
PENTAPHENE CRE
PETROLATUM OIN YELLOW
PFCB
CRE
PHARMABASE CRE ANTIOXID
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
X
PHARMACEUTICAL AIDS
PHARMABASE CRE COSMETIC
Tier 3
X
PHARMACEUTICAL AIDS
PHARMABASE CRE HEAVY
Tier 3
X
Page 226 of 279
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
Product Name
PHARMABASE CRE LIGHT
PHARMABASE CRE VAGINAL
Tier Value
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHYTOBASE CRE
PHYTOBASE CRE
PHYTOBASE CRE
PHYTOBASE CRE
PICODERM CRE
PLACEBO #00 CAP
PLO
GEL MEDIFLO
PLO MEDIFLO KIT KIT
PLO TRANSDER CRE
PLO20 BASE GEL
PNA-HRT BASE CRE
POLYETH GLYC OIN 8000
POLYPEG OIN BASE
PRACASIL TM- CRE PLUS
PROPYLENE GL SOL
P-SILOXAN DS CRE
PURIFIED LIQ WATER
Q-DERM
CRE
RADIAGEL GEL
RADIAPLEXRX GEL
RASPBERRY SYP
SAFTY NEEDLE MIS 18GX1"
SAFTY NEEDLE MIS 18GX1.5"
SAFTY NEEDLE MIS 19GX1"
SAFTY NEEDLE MIS 19GX1.5"
SAFTY NEEDLE MIS 20GX1"
SAFTY NEEDLE MIS 20GX1.5"
SAFTY NEEDLE MIS 21GX1"
SAFTY NEEDLE MIS 21GX1.5"
SAFTY NEEDLE MIS 22GX1"
SAFTY NEEDLE MIS 22GX1.5"
SAFTY NEEDLE MIS 23GX1"
SAFTY NEEDLE MIS 25GX1"
SAFTY NEEDLE MIS 25GX5/8"
Tier 3
Tier 3
Tier 2
Tier 2
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 3
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
SALIVAMAX POW
SALIVATE RX POW
SALT DURABLE CRE
SALT STABLE CRE
SALT STABLE CRE LS ADV
SANARE
CRE ADVANCED
SANARE SCAR CRE THERAPY
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
SCAR CARE CRE
SEDANARE CRE
SILOSOME CRE TRANSDER
SILPROTEX CRE PLUS
SIMPLE
SYP
SKYY DERM CRE
SOLYDRA LIQ
STERA BASE CRE
SUPREME CRE
SUSPENSION SUS VEHICLE
SYRPALTA SYP
SYRPALTA SYP
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Page 227 of 279
Prior
Authorization
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
Product Name
SYRPALTA SYP CLEAR
SYRSPEND SF LIQ
SYRSPEND SF SUS PH4
SYRUP
SYP VEHICLE
SYRUP SF SYP VEHICLE
TDC MAX CRE
TEGADERM AG PAD 2"X2"
TEGADERM AG PAD 4"X5"
TEGADERM AG PAD 4"X8"
TEGADERM AG PAD 8"X8"
TERODERM CRE
TIGHTENING CRE BASE
TRANSDERMAL CRE PAIN BAS
Tier Value
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
TRANS-PEN CRE
U-BASE
CRE
ULTRADERM CRE
VANIBASE CRE
VANISHING CRE
VANISHING CRE BOTANCAL
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
VANISH-PEN CRE
VASCUDERM GEL HYDROGEL
Tier 3
Tier 3
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
Phosphate Binders - Phosphate-Removing
Agents
VASCUDERM KIT STASIS
VERSAFREE SYP
VERSAPLUS SYP
VERSAPRO CRE
VERSATILE CRE BASE
VERSATILE CRE RICH BSE
VERSIGEL CRE
V-MAX
CRE
WOUND CARE CRE
XCEL 100 CRE
XEMATOP CRE BASE
ZOE SCRIPTS CRE IDEALBAS
FOSRENOL CHW 1000MG
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
FOSRENOL
CHW 500MG
Tier 3
FOSRENOL
CHW 750MG
Tier 3
FOSRENOL
POW 1000MG
Tier 3
FOSRENOL
POW 750MG
Tier 3
RENAGEL
TAB 400MG
Tier 3
RENAGEL
TAB 800MG
Tier 3
RENVELA
PAK 0.8GM
Tier 2
RENVELA
PAK 2.4GM
Tier 2
RENVELA
TAB 800MG
Tier 2
VELPHORO
CHW 500MG
Page 228 of 279
Tier 2
Prior
Authorization
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Platelet Modifying Agents - Platelet Modifying
Drugs
Progesterone Agonists/Antagonists Hormone Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Prior
Authorization
Supply
Limit
Product Name
AGGRENOX CAP 25-200MG
Tier Value
Tier 3
ASA/DIPYRIDA CAP 25-200MG
Tier 3
CILOSTAZOL TAB 100MG
Tier 1
CILOSTAZOL TAB 50MG
Tier 1
CLOPIDOGREL TAB 300MG
Tier 1
CLOPIDOGREL TAB 75MG
Tier 1
DIPYRIDAMOLE TAB 25MG
Tier 1
DIPYRIDAMOLE TAB 50MG
Tier 1
DIPYRIDAMOLE TAB 75MG
Tier 1
EFFIENT
TAB 10MG
Tier 4
X
EFFIENT
TAB 5MG
Tier 4
X
Step
Therapy
PERSANTINE TAB 25MG
Tier 3
PERSANTINE TAB 50MG
Tier 4
PERSANTINE TAB 75MG
Tier 3
PLAVIX
TAB 300MG
Tier 4
X
PLAVIX
TAB 75MG
Tier 4
X
PLETAL
TAB 100MG
Tier 4
PLETAL
TAB 50MG
Tier 4
TICLOPIDINE TAB 250MG
Tier 1
ZONTIVITY TAB 2.08MG
Tier 4
ELLA
TAB 30MG
AFTERA
HCR Preventative
TAB 1.5MG
HCR Preventative
TAB 5MG
Tier 4
CAMILA
TAB 0.35MG
HCR Preventative
CRINONE
GEL 4% VAG
Tier 2
CRINONE
GEL 8% VAG
Tier 2
AYGESTIN
DEBLITANE TAB 0.35MG
X
X
X
HCR Preventative
DEPO-PROVERA INJ
150MG/ML
DEPO-SQ PROV INJ 104
Page 229 of 279
Tier 4
X
Tier 2
X
Specialty
Therapeutic Class
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Product Name
ECONTRA EZ TAB 1.5MG
Prior
Authorization
Tier Value
HCR Preventative
ENDOMETRIN SUP 100MG
ERRIN
TAB 0.35MG
Tier 3
HCR Preventative
FALLBACK
TAB 1.5MG
HCR Preventative
HEATHER
TAB 0.35MG
HCR Preventative
JENCYCLA
TAB 0.35MG
HCR Preventative
JOLIVETTE TAB 0.35MG
HCR Preventative
LEVONORGESTR TAB 1.5MG
HCR Preventative
LYZA
HCR Preventative
TAB 0.35MG
MEDROXYPR AC INJ
150MG/ML
MEDROXYPR AC TAB 10MG
HCR Preventative
MEDROXYPR AC TAB 2.5MG
Tier 1
MEDROXYPR AC TAB 5MG
Tier 1
MEGACE ES SUS 625/5ML
Tier 4
MEGACE ORAL SUS 40MG/ML
Tier 4
MEGESTROL SUS 625MG/5M
Tier 1
MEGESTROL AC SUS 40MG/ML
Tier 1
MEGESTROL AC TAB 20MG
Tier 1
MEGESTROL AC TAB 40MG
Tier 1
Tier 1
MY WAY
TAB 1.5MG
HCR Preventative
NECON
TAB 1/50-28
HCR Preventative
NEXT CHOICE TAB 1.5MG
HCR Preventative
NORA-BE
HCR Preventative
TAB 0.35MG
NORETHIN ACE TAB 5MG
Tier 1
NORETHINDRON TAB 0.35MG HCR Preventative
NORINYL
NORLYROC
TAB 1+50-28
TAB 0.35MG
Supply
Limit
Tier 4
HCR Preventative
NOR-QD
TAB 0.35MG
Tier 4
OPCICON
TAB 1.5MG
HCR Preventative
Page 230 of 279
X
Step
Therapy
Specialty
Supply
Limit
Step
Therapy
Tier 4
X
X
Tier 4
X
X
Therapeutic Class
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Progestins - Hormone
Replacement/Modifying Drugs
Protectants - Ulcer and Stomach Acid Drugs
Product Name
ORTHO MICRON TAB 0.35MG
CARAFATE
SUS 1GM/10ML
Tier 3
Protectants - Ulcer and Stomach Acid Drugs
CARAFATE
TAB 1GM
Tier 4
Protectants - Ulcer and Stomach Acid Drugs
CYTOTEC
TAB 100MCG
Tier 4
Protectants - Ulcer and Stomach Acid Drugs
CYTOTEC
TAB 200MCG
Tier 4
Protectants - Ulcer and Stomach Acid Drugs
MISOPROSTOL TAB 100MCG
Tier 1
Protectants - Ulcer and Stomach Acid Drugs
MISOPROSTOL TAB 200MCG
Tier 1
Protectants - Ulcer and Stomach Acid Drugs
SUCRALFATE TAB 1GM
Tier 1
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
ACIPHEX
PLAN B
TAB 1.5MG
Tier Value
Tier 3
Prior
Authorization
HCR Preventative
PROGESTERONE CAP 100MG
Tier 1
PROGESTERONE CAP 200MG
Tier 1
PROGESTERONE CRE 10% KIT
Tier 3
PROGESTERONE INJ 50MG/ML
Tier 1
PROGESTERONE POW
MICRONIZ
PROGESTERONE SUP VGS 100
Tier 3
Tier 3
X
PROGESTERONE SUP VGS 200
Tier 3
X
PROGESTERONE SUP VGS 25
Tier 3
X
PROGESTERONE SUP VGS 400
Tier 3
X
PROGESTERONE SUP VGS 50
Tier 3
X
PROMETRIUM CAP 100MG
Tier 4
PROMETRIUM CAP 200MG
Tier 4
PROVERA
TAB 10MG
Tier 4
PROVERA
TAB 2.5MG
Tier 4
PROVERA
TAB 5MG
Tier 4
REACT
SHAROBEL
TAB 1.5MG
X
HCR Preventative
TAB 0.35MG
HCR Preventative
TAKE ACTION TAB 1.5MG
HCR Preventative
TAB 20MG
ACIPHEX SPR CAP 10MG
Page 231 of 279
Specialty
Therapeutic Class
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Proton Pump Inhibitors - Ulcer and Stomach
Acid Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Product Name
ACIPHEX SPR CAP 5MG
Tier Value
Tier 4
Prior
Authorization
Supply
Limit
X
DEXILANT
CAP 30MG DR
Tier 3
X
DEXILANT
CAP 60MG DR
Tier 3
X
Step
Therapy
X
FIRST-OMEPRA SUS 2MG/ML
Tier 3
X
LANSOPRAZOLE SUS 3MG/ML
Tier 3
X
NEXIUM
GRA 10MG DR
Tier 3
X
X
X
NEXIUM
GRA 2.5MG DR
Tier 3
X
X
X
NEXIUM
GRA 20MG DR
Tier 3
X
X
X
NEXIUM
GRA 40MG DR
Tier 3
X
X
X
NEXIUM
GRA 5MG DR
Tier 3
X
OMEPRA/BICAR POW 20-1680
Tier 1
X
X
X
OMEPRA/BICAR POW 40-1680
Tier 1
X
X
X
OMEPRAZOLE CAP 10MG
Tier 1
OMEPRAZOLE CAP 20MG
Tier 1
OMEPRAZOLE CAP 40MG
Tier 1
OMEPRAZOLE + SUS SYRSPEND
Tier 3
PANTOPRAZOLE TAB 20MG
Tier 1
PANTOPRAZOLE TAB 40MG
Tier 1
PREVACID
TAB 15MG STB
Tier 3
X
X
X
PREVACID
TAB 30MG STB
Tier 3
X
X
X
PRILOSEC
POW 10MG
Tier 4
X
PRILOSEC
POW 2.5MG
Tier 4
X
X
X
PROTONIX
PAK
Tier 4
PROTONIX
TAB 20MG
Tier 4
X
PROTONIX
TAB 40MG
Tier 4
X
X
X
RABEPRAZOLE TAB 20MG
Tier 1
ZEGERID
POW 20-1680
Tier 3
X
X
X
ZEGERID
POW 40-1680
Tier 3
X
X
X
ADCIRCA
TAB 20MG
Tier 4
X
X
Page 232 of 279
Specialty
X
X
Therapeutic Class
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Pulmonary Antihypertensives - Asthma/Lung
Drugs
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Product Name
ADEMPAS TAB 0.5MG
Tier Value
Tier 3
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
Specialty
X
ADEMPAS
TAB 1.5MG
Tier 3
X
X
X
ADEMPAS
TAB 1MG
Tier 3
X
X
X
ADEMPAS
TAB 2.5MG
Tier 3
X
X
X
ADEMPAS
TAB 2MG
Tier 3
X
X
X
LETAIRIS
TAB 10MG
Tier 3
X
X
X
LETAIRIS
TAB 5MG
Tier 3
X
X
X
Tier 3
X
X
X
ORENITRAM TAB 0.125MG
Tier 4
X
X
X
ORENITRAM TAB 0.25MG
Tier 4
X
X
X
ORENITRAM TAB 1MG
Tier 4
X
X
X
ORENITRAM TAB 2.5MG
Tier 4
X
X
X
REVATIO
SUS 10MG/ML
Tier 4
X
X
X
REVATIO
TAB 20MG
Tier 4
X
X
SILDENAFIL TAB 20MG
Tier 1
X
X
X
TRACLEER
TAB 125MG
Tier 3
X
X
X
TRACLEER
TAB 62.5MG
Tier 3
X
X
X
SOL 0.6MG/ML
Tier 3
X
X
TYVASO REFIL SOL 0.6MG/ML
Tier 3
X
X
TYVASO START SOL 0.6MG/ML
Tier 3
X
X
VENTAVIS
SOL 10MCG/ML
Tier 3
X
X
VENTAVIS
SOL 20MCG/ML
Tier 3
X
X
OPSUMIT
TYVASO
TAB 10MG
AVELOX
TAB 400MG
AVELOX ABC TAB 400MG
BESIVANCE SUS 0.6%
CETRAXAL SOL 0.2%
CILOXAN OIN 0.3% OP
CILOXAN SOL 0.3% OP
CIPRO
TAB 250MG
CIPRO
TAB 500MG
CIPRO (10%) SUS 500MG/5
CIPRO (5%) SUS 250MG/5
CIPRO HC SUS OTIC
CIPRO XR TAB 1000MG
CIPRO XR TAB 500MG
CIPRODEX SUS 0.3-0.1%
Page 233 of 279
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
X
X
X
X
Therapeutic Class
Quinolones - Antibiotics
Quinolones - Antibiotics
Product Name
CIPROFLOXACN SOL 0.2%
CIPROFLOXACN SOL 0.3% OP
Tier Value
Tier 1
Tier 1
Quinolones - Antibiotics
CIPROFLOXACN SUS 250MG/5
Tier 1
Quinolones - Antibiotics
CIPROFLOXACN SUS 500MG/5
Tier 1
Quinolones - Antibiotics
CIPROFLOXACN TAB 1000MG
Tier 1
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
CIPROFLOXACN TAB 100MG
CIPROFLOXACN TAB 250MG
CIPROFLOXACN TAB 500MG
CIPROFLOXACN TAB 500MG ER
Tier 1
Tier 1
Tier 1
Tier 1
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
CIPROFLOXACN TAB 750MG
FACTIVE TAB 320MG
FLOXIN
SOL 0.3%
GATIFLOXACIN SOL 0.5%
LEVAQUIN SOL 25MG/ML
LEVAQUIN TAB 250MG
LEVAQUIN TAB 500MG
LEVAQUIN TAB 750MG
LEVOFLOXACIN SOL 0.5%
LEVOFLOXACIN SOL 25MG/ML
Tier 1
Tier 3
Tier 4
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
LEVOFLOXACIN TAB 250MG
LEVOFLOXACIN TAB 500MG
LEVOFLOXACIN TAB 750MG
MOXEZA
SOL 0.5%
MOXIFLOXACIN TAB 400MG
OCUFLOX DRO 0.3% OP
OFLOXACIN DRO 0.3% OP
OFLOXACIN DRO 0.3%OTIC
Tier 1
Tier 1
Tier 1
Tier 4
Tier 1
Tier 4
Tier 1
Tier 1
Quinolones - Antibiotics
Quinolones - Antibiotics
Quinolones - Antibiotics
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
OFLOXACIN TAB 400MG
VIGAMOX DRO 0.5%
ZYMAXID SOL 0.5%
ACETYLCYST SOL 10%
Tier 1
Tier 4
Tier 4
Tier 1
ACETYLCYST SOL 20%
Tier 1
AMBITUSSIN SOL 100-10/5
Tier 1
BENZONATATE CAP 100MG
Tier 1
BENZONATATE CAP 150MG
Tier 1
BENZONATATE CAP 200MG
Tier 1
BIOTUSS
LIQ
Tier 1
BIOTUSS
LIQ PEDIATRC
Tier 1
CHERATUSSIN SYP 100-10/5
Tier 1
CODEINE/GG SOL 10-100/5
Tier 1
Page 234 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
Specialty
Therapeutic Class
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Product Name
DALIRESP TAB 500MCG
DECONSAL
TAB L.A.
Tier Value
Tier 3
Prior
Authorization
X
Tier 1
DECONSAL-II TAB
Tier 3
DEXTROMETHOR CRY
MONOHYDR
DEXTROMETHOR POW HBR
Tier 3
X
Tier 3
X
DEXTROMETHOR POW HBR
MONO
EXACTUSS LIQ
Tier 3
X
GG/CODEINE SOL 100-10/5
Tier 1
GILPHEX TR TAB 10-388MG
Tier 3
GILTUSS
Tier 3
Specialty
Tier 3
GILTUSS PED LIQ
Tier 3
GILTUSS TR TAB
Tier 3
GUAIATUSSIN SYP 100-10/5
Tier 1
GUAIFENESIN SYP 100-10/5
Tier 1
HUMIBID L.A. TAB 600MG
Tier 3
HUMIBID SPRI CAP 300MG
Tier 3
HUMIBID-DM TAB
Tier 3
HYDROC/HOMAT TAB 5-1.5MG
Tier 1
HYDROCOD/HOM SYP 5-1.5/5
Tier 1
HYDROMET
Tier 1
SYP 5-1.5/5
Step
Therapy
Tier 1
DECONSAL SR CAP SPRINKLE
LIQ
Supply
Limit
X
HYPERSAL
NEB 3.5%
Tier 2
HYPERSAL
NEB 7%
Tier 2
HYPER-SAL NEB 7%
Tier 2
IOPHEN C-NR LIQ 100-10/5
Tier 1
KALYDECO
PAK 50MG
Tier 3
X
X
X
KALYDECO
PAK 75MG
Tier 3
X
X
X
KALYDECO
TAB 150MG
Tier 3
X
X
X
NEBUSAL
NEB 3%
Tier 1
Page 235 of 279
Therapeutic Class
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Respiratory Tract Agents, Other Asthma/Lung Drugs
Retinoids - Chemotherapy Agents
Retinoids - Chemotherapy Agents
Retinoids - Chemotherapy Agents
Retinoids - Chemotherapy Agents
Retinoids - Chemotherapy Agents
Selective Estrogen Receptor Modifying Agents
- Hormone Replacement/Modifying Drugs
Product Name
NEBUSAL NEB 6%
Tier Value
Tier 3
NORTUSS-DE DRO
Tier 1
NORTUSS-EX LIQ 200-20/5
Tier 1
PE/GUAIFENES DRO 1.5-20MG
Tier 1
PULMOSAL
Tier 1
NEB 7%
PULMOZYME SOL 1MG/ML
Tier 3
Q-BID-LA
TAB 600MG
Tier 1
SOL 60-5/5ML
Tier 3
SOD CHLORIDE NEB 0.9%
Tier 1
SODIUM CHLOR NEB 10%
Tier 1
SODIUM CHLOR NEB 3%
Tier 1
SODIUM CHLOR NEB 7%
Tier 1
SURVANTA
Tier 3
REZIRA
INH
TESSALON PER CAP 100MG
Tier 4
TGQ 30/
Tier 1
TUSSIGON
TYZINE
SYP 150/15
TAB 5-1.5MG
Supply
Limit
X
X
Step
Therapy
Tier 1
SOL 0.1%
Tier 3
Tier 3
VIRTUSSIN AC SOL 100-10/5
Tier 1
ZONATUSS
Tier 1
X
Tier 4
Tier 3
Tier 1
Tier 4
Tier 1
HCR Preventative
X
CAP 150MG
BEXAROTENE CAP 75MG
PANRETIN GEL 0.1%
TARGRETIN CAP 75MG
TARGRETIN GEL 1%
TRETINOIN CAP 10MG
EVISTA
TAB 60MG
TAB 60MG
Selective Estrogen Receptor Modifying Agents RALOXIFENE TAB 60MG
- Hormone Replacement/Modifying Drugs
Specialty
X
TYZINE PED DRO 0.05%
Selective Estrogen Receptor Modifying Agents OSPHENA
- Hormone Replacement/Modifying Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Prior
Authorization
X
HCR Preventative
ALMOTRIP MAL TAB 12.5MG
Tier 1
X
ALMOTRIP MAL TAB 6.25MG
Tier 1
X
Page 236 of 279
X
X
X
X
X
Tier 3
X
Therapeutic Class
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Product Name
ALMOTRIPTAN TAB 12.5MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
Step
Therapy
X
ALSUMA
INJ 6MG/0.5
Tier 4
X
AMERGE
TAB 1MG
Tier 4
X
AMERGE
TAB 2.5MG
Tier 4
X
AXERT
TAB 12.5MG
Tier 4
X
X
AXERT
TAB 6.25MG
Tier 4
X
X
FROVA
TAB 2.5MG
Tier 4
X
FROVATRIPTAN TAB 2.5MG
Tier 1
X
IMITREX
INJ 4MG/0.5
Tier 4
X
X
IMITREX
INJ 4MG/0.5
Tier 4
X
X
IMITREX
INJ 6MG/0.5
Tier 4
X
X
IMITREX
INJ 6MG/0.5
Tier 4
X
X
IMITREX
INJ 6MG/0.5
Tier 4
X
X
IMITREX
SPR 20MG/ACT
Tier 4
X
IMITREX
SPR 5MG/ACT
Tier 4
X
IMITREX
TAB 100MG
Tier 4
X
X
IMITREX
TAB 25MG
Tier 4
X
X
IMITREX
TAB 50MG
Tier 4
X
X
MAXALT
TAB 10MG
Tier 4
X
X
MAXALT
TAB 5MG
Tier 4
X
X
MAXALT-MLT TAB 10MG
Tier 4
X
X
MAXALT-MLT TAB 5MG
Tier 4
X
X
NARATRIPTAN TAB 1MG
Tier 1
X
NARATRIPTAN TAB 2.5MG
Tier 1
X
ONZETRA XSAI MIS 11MG
Tier 4
RELPAX
TAB 20MG
Tier 2
X
RELPAX
TAB 40MG
Tier 2
X
RIZATRIPTAN TAB 10MG
Tier 1
X
RIZATRIPTAN TAB 10MG ODT
Tier 1
X
Page 237 of 279
X
Specialty
Therapeutic Class
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin (5-HT) 1b/1d Receptor Agonists Migraine Drugs
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Product Name
RIZATRIPTAN TAB 5MG
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
X
Step
Therapy
RIZATRIPTAN TAB 5MG ODT
Tier 1
X
SUMATRIPTAN INJ 4MG/0.5
Tier 1
X
SUMATRIPTAN INJ 4MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN INJ 6MG/0.5
Tier 1
X
SUMATRIPTAN SPR
20MG/ACT
SUMATRIPTAN SPR 5MG/ACT
Tier 1
X
Tier 1
X
SUMATRIPTAN TAB 100MG
Tier 1
X
SUMATRIPTAN TAB 25MG
Tier 1
X
SUMATRIPTAN TAB 50MG
Tier 1
X
SUMAVEL DOSE INJ 4MG/0.5
Tier 3
X
SUMAVEL DOSE INJ 6MG/0.5
Tier 3
X
ZECUITY
Tier 4
X
X
ZEMBRACE SYM INJ 3/0.5ML
Tier 4
X
X
ZOLMITRIPTAN TAB 2.5 MG
Tier 1
X
ZOLMITRIPTAN TAB 2.5MG
Tier 1
X
ZOLMITRIPTAN TAB 5MG
Tier 1
X
ZOLMITRIPTAN TAB 5MG
Tier 1
X
ZOMIG
SPR 2.5MG
Tier 3
X
ZOMIG
TAB 2.5MG
Tier 4
X
ZOMIG
TAB 5MG
Tier 4
X
ZOMIG NASAL SPR 5MG
Tier 4
X
ZOMIG ZMT TAB 2.5 MG
Tier 4
X
ZOMIG ZMT TAB 5MG
Tier 4
X
BRISDELLE CAP 7.5MG
Tier 4
X
CELEXA
Tier 4
PAD 6.5MG/4H
TAB 10MG
Page 238 of 279
X
X
X
Specialty
Therapeutic Class
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Product Name
CELEXA
TAB 20MG
CELEXA
TAB 40MG
Tier Value
Tier 4
Prior
Authorization
X
Tier 4
X
Supply
Limit
Step
Therapy
X
X
CITALOPRAM SOL 10MG/5ML
Tier 1
CITALOPRAM TAB 10MG
Tier 1
CITALOPRAM TAB 20MG
Tier 1
CITALOPRAM TAB 40MG
Tier 1
CYMBALTA
CAP 20MG
Tier 4
X
X
X
CYMBALTA
CAP 30MG
Tier 4
X
X
X
CYMBALTA
CAP 60MG
Tier 4
X
X
X
X
X
DESVENLAFAX TAB 100MG ER
Tier 4
DESVENLAFAX TAB 100MG ER
Tier 4
DESVENLAFAX TAB 50MG ER
Tier 4
X
X
DESVENLAFAX TAB 50MG ER
Tier 4
X
X
DULOXETINE CAP 20MG
Tier 1
X
DULOXETINE CAP 30MG
Tier 1
X
DULOXETINE CAP 40MG
Tier 4
X
DULOXETINE CAP 60MG
Tier 1
X
EFFEXOR XR CAP 150MG
Tier 4
X
X
EFFEXOR XR CAP 37.5MG
Tier 4
X
X
EFFEXOR XR CAP 75MG
Tier 4
X
X
ESCITALOPRAM SOL 5MG/5ML
Tier 1
ESCITALOPRAM TAB 10MG
Tier 1
ESCITALOPRAM TAB 20MG
Tier 1
ESCITALOPRAM TAB 5MG
Tier 1
FETZIMA
CAP 120MG
Tier 4
X
X
FETZIMA
CAP 20MG
Tier 4
X
X
FETZIMA
CAP 40MG
Tier 4
X
X
FETZIMA
CAP 80MG
Tier 4
X
X
FETZIMA
CAP TITRATIO
Tier 4
X
X
Page 239 of 279
X
X
Specialty
Therapeutic Class
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Prior
Authorization
Supply
Limit
Product Name
FLUOXETINE CAP 10MG
Tier Value
Tier 1
FLUOXETINE CAP 10MG
Tier 1
FLUOXETINE CAP 20MG
Tier 1
FLUOXETINE CAP 20MG
Tier 1
FLUOXETINE CAP 40MG
Tier 1
FLUOXETINE CAP 90MG DR
Tier 1
FLUOXETINE SOL 20MG/5ML
Tier 1
FLUOXETINE TAB 10MG
Tier 1
FLUOXETINE TAB 20MG
Tier 1
FLUOXETINE TAB 60MG
Tier 1
FLUVOXAMINE CAP 100MG ER
Tier 1
X
FLUVOXAMINE CAP 150MG ER
Tier 1
X
FLUVOXAMINE TAB 100MG
Tier 1
FLUVOXAMINE TAB 25MG
Tier 1
FLUVOXAMINE TAB 50MG
Tier 1
IRENKA
Tier 4
CAP 40MG
Step
Therapy
X
X
X
KHEDEZLA
TAB 100MG ER
Tier 4
X
KHEDEZLA
TAB 50MG ER
Tier 4
LEXAPRO
SOL 5MG/5ML
Tier 4
X
X
LEXAPRO
TAB 10MG
Tier 4
X
X
LEXAPRO
TAB 20MG
Tier 4
X
X
LEXAPRO
TAB 5MG
Tier 4
X
X
X
PAROXETIN ER TAB 12.5MG
Tier 1
X
PAROXETIN ER TAB 37.5MG
Tier 1
X
PAROXETINE TAB 10MG
Tier 1
PAROXETINE TAB 20MG
Tier 1
PAROXETINE TAB 25MG ER
Tier 1
PAROXETINE TAB 30MG
Tier 1
PAROXETINE TAB 40MG
Tier 1
Page 240 of 279
X
X
Specialty
Therapeutic Class
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Product Name
PAXIL
SUS 10MG/5ML
Tier Value
Tier 3
PAXIL
TAB 10MG
Tier 4
PAXIL
TAB 20MG
Tier 4
PAXIL
TAB 30MG
Tier 4
PAXIL
TAB 40MG
Tier 4
Prior
Authorization
Supply
Limit
Step
Therapy
PAXIL CR
TAB 12.5MG
Tier 4
X
PAXIL CR
TAB 25MG
Tier 4
X
PAXIL CR
TAB 37.5MG
Tier 4
X
PEXEVA
TAB 10MG
Tier 4
X
X
X
PEXEVA
TAB 20MG
Tier 4
X
X
X
PEXEVA
TAB 30MG
Tier 4
X
X
X
PEXEVA
TAB 40MG
Tier 4
X
X
X
PRISTIQ
TAB 100MG
Tier 3
X
PRISTIQ
TAB 25MG
Tier 3
X
PRISTIQ
TAB 50MG
Tier 3
X
PROZAC
CAP 10MG
Tier 4
X
X
PROZAC
CAP 20MG
Tier 4
X
X
PROZAC
CAP 40MG
Tier 4
X
X
PROZAC WEEKL CAP 90MG
Tier 4
X
SARAFEM
TAB 10MG
Tier 3
SARAFEM
TAB 20MG
Tier 3
SERTRALINE CON 20MG/ML
Tier 1
SERTRALINE TAB 100MG
Tier 1
SERTRALINE TAB 25MG
Tier 1
SERTRALINE TAB 50MG
Tier 1
VENLAFAXINE CAP 150MG ER
Tier 1
VENLAFAXINE CAP 37.5 ER
Tier 1
VENLAFAXINE CAP 75MG ER
Tier 1
VENLAFAXINE TAB 100MG
Tier 1
Page 241 of 279
X
Specialty
Therapeutic Class
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Serotonin/Norepinephrine Reuptake
Inhibitors - Antidepressants
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Supply
Limit
X
Step
Therapy
X
X
X
X
X
Tier 4
X
X
KIT
Tier 4
X
VIIBRYD
KIT STARTER
Tier 4
VIIBRYD
TAB 10MG
Tier 4
X
VIIBRYD
TAB 20MG
Tier 4
X
VIIBRYD
TAB 40MG
Tier 4
X
ZOLOFT
CON 20MG/ML
Tier 4
X
X
ZOLOFT
TAB 100MG
Tier 4
X
X
ZOLOFT
TAB 25MG
Tier 4
X
X
ZOLOFT
TAB 50MG
Tier 4
X
X
AMRIX
CAP 15MG
Tier 4
X
AMRIX
CAP 30MG
Tier 4
X
Product Name
VENLAFAXINE TAB 150MG ER
Tier Value
Tier 4
VENLAFAXINE TAB 225MG ER
Tier 4
VENLAFAXINE TAB 25MG
Tier 1
VENLAFAXINE TAB 37.5 ER
Tier 4
VENLAFAXINE TAB 37.5MG
Tier 1
VENLAFAXINE TAB 50MG
Tier 1
VENLAFAXINE TAB 75MG
Tier 1
VENLAFAXINE TAB 75MG ER
VIIBRYD
Prior
Authorization
BACLOFEN
CRE
Tier 3
X
BACLOFEN
CRE 1%
Tier 1
X
BACLOFEN
CRE 2%
Tier 3
X
CARISOPR/ASA TAB 200-325
Tier 1
CARISOPRODOL TAB 250MG
Tier 1
CARISOPRODOL TAB 350MG
Tier 1
CHLORZOXAZON TAB 250MG
Tier 1
CHLORZOXAZON TAB 500MG
Tier 1
CYCLOBENZAPR CRE
20MG/GM
CYCLOBENZAPR CRE 5% KIT
Tier 1
X
Tier 1
X
Page 242 of 279
X
Specialty
Therapeutic Class
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
Skeletal Muscle Relaxants - Pain/Swelling
Management Drugs
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIBACTERIALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIBACTERIALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIBACTERIALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
Product Name
CYCLOBENZAPR KIT COMFORT
Tier Value
Tier 3
CYCLOBENZAPR TAB 10MG
Tier 1
CYCLOBENZAPR TAB 5MG
Tier 1
CYCLOBENZAPR TAB 7.5MG
Tier 1
CYCLOPHENE CRE RAPIDPAQ
Tier 3
FEXMID
Tier 4
TAB 7.5MG
Prior
Authorization
Supply
Limit
Step
Therapy
X
LORZONE
TAB 375MG
Tier 4
X
X
LORZONE
TAB 750MG
Tier 4
X
X
METAXALL
TAB 800MG
Tier 1
METAXALONE TAB 400MG
Tier 1
METAXALONE TAB 800MG
Tier 1
METHOCARBAM TAB 500MG
Tier 1
METHOCARBAM TAB 750MG
Tier 1
ORPHENADRINE POW CITRATE
Tier 3
ORPHENADRINE TAB 100MG
ER
PARAFON FORT TAB 500MG
Tier 1
ROBAXIN
Tier 4
TAB 500MG
X
Tier 4
ROBAXIN-750 TAB 750MG
Tier 4
SKELAXIN
Tier 4
X
X
TAB 800MG
SOMA
TAB 250MG
Tier 4
SOMA
TAB 350MG
Tier 3
PETROLATUM OIN WHITE
VERSABASE GEL
BL TRIP ANTI OIN W/LID 4%
Tier 3
Tier 3
Tier 1
ROSADAN
KIT 0.75%
Tier 4
X
ROSADAN
KIT 0.75%
Tier 4
X
EXODERM
LOT 25-1%
Tier 1
HALOTIN
CRE 1%
Tier 3
KERR TRIPLE MIS DYE SWAB
Tier 2
MICONAZOLE POW NITRATE
Tier 3
Page 243 of 279
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTIFUNGALS ANTI-INFECTIVES
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
Product Name
VUSION
OIN
XOLEGEL
Tier Value
Tier 4
KIT COREPAK
Tier 3
XOLEGEL DUO/ KIT XOLEX
Tier 3
ANALPRAM
Tier 4
ANALPRAM E KIT
Tier 4
ANALPRAM HC CRE 2.5-1%
Tier 4
ANALPRAM-HC CRE 1-1%
Tier 4
ANALPRAM-HC CRE 1-2.5%
Tier 4
ANALPRAM-HC CRE SINGLES
Tier 4
ANALPRAM-HC CRE SINGLES
Tier 4
ANALPRAM-HC LOT 2.5%
Tier 3
ANALPRM SNGL CRE HC 2.5-1
Tier 4
ANUCORT-HC SUP 25MG
Tier 1
ANUSOL-HC SUP 25MG
Tier 4
CORTANE-B LOT
Tier 4
EPIFOAM
Tier 2
AER 1%
GRX HICORT SUP 25MG
Tier 1
HALAC
KIT
Tier 1
HC PRAMOXINE CRE 1-1%
Tier 1
Page 244 of 279
Supply
Limit
Step
Therapy
X
Tier 3
XOLEGEL DUO/ KIT HEAD&SHD
KIT ADVANCED
Prior
Authorization
X
X
X
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
Product Name
HC PRAMOXINE CRE 2.5-1%
Tier Value
Tier 1
HC PRAMOXINE CRE 2.5-1%
Tier 1
HEMMOREX-HC SUP 25MG
Tier 1
HEMMOREX-HC SUP 30MG
Tier 1
HEMORRHOIDAL SUP -HC
25MG
Tier 1
HYDROCORT AC SUP 25MG
Tier 1
HYDROCORT AC SUP 30MG
Tier 1
HYDROCORT/ KIT PRAMOXIN
Tier 1
NUCORT
LOT 2%
Tier 3
PEDIADERM HC KIT
Tier 3
PRAMCORT
Tier 1
CRE 1-1%
PRAMOSONE CRE 1%
Tier 1
PRAMOSONE CRE 1-1%
Tier 1
PRAMOSONE CRE 1-2.5%
Tier 3
PRAMOSONE LOT 1%
Tier 2
PRAMOSONE LOT 2.5%
Tier 2
PRAMOSONE OIN 1%
Tier 2
PRAMOSONE OIN 2.5%
Tier 4
PRAMOSONE E CRE 1-2.5%
Tier 4
Page 245 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
Product Name
PRAMOX
GEL 1%
PROCORT
CRE
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 4
X
PROCTOCORT SUP 30MG
Tier 4
X
PROCTOFOAM AER HC 1%
Tier 2
RECTACORT-HC SUP 25MG
Tier 1
SCALACORT DK KIT
Tier 3
SYNALAR TS KIT 0.01%
Tier 4
X
ULTRAVATE X KIT 0.05-10%
Tier 4
X
ULTRAVATE X KIT 0.05-10%
Tier 4
X
VANOXIDE-HC LOT 5-0.5%
Tier 4
ANACAINE
OIN
Tier 2
CETACAINE AER
Tier 3
DERMASORB TA KIT 0.1%
Tier 4
ETHYL CHLOR AER FINE PIN
Tier 1
ETHYL CHLOR AER FN STRM
Tier 1
ETHYL CHLOR AER MED JET
Tier 1
ETHYL CHLOR AER MED STRM
Tier 1
ETHYL CHLOR AER MIST
Tier 1
ETHYL CHLOR AER SPRAY
Tier 1
GEBAUERS SPR AER /STRETCH
Tier 3
PAIN EASE AER MD STRM
Tier 3
PAIN EASE AER MIST
Tier 3
PEDIADERM TA KIT
Tier 4
QUTENZA
Tier 4
KIT 8% 1-PCH
Page 246 of 279
Specialty
X
X
X
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS
SKIN AND MUCOUS MEMBRANE AGENTS ASTRINGENTS
SKIN AND MUCOUS MEMBRANE AGENTS ASTRINGENTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS BASIC OINTMENTS AND PROTECTANTS
SKIN AND MUCOUS MEMBRANE AGENTS DEPIGMENTING AND PIGMENTING AGENTS
Product Name
QUTENZA KIT 8% 2-PCH
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
Tier Value
Tier 4
VENELEX
OIN
Tier 3
XERAC-AC
SOL 6.25%
Tier 2
COPASIL
GEL
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 3
HPR PLUS MB KIT HYDROGEL
Tier 3
HYALURONATE GEL 0.2%
Tier 1
HYLIRA
GEL 0.2%
Tier 2
HYLIRA
LOT 0.1%
Tier 3
LACTIC ACID CRE /VIT E
Tier 1
LACTIC ACID CRE E
Tier 1
NEOSALUS
Tier 3
LOT
TROPAZONE LOT
Tier 3
HYDROQUINONE POW
Tier 3
ALUVEA
Tier 3
CRE 39%
BENSAL HP OIN
Tier 2
CARB-O-PHILC CRE /40
Tier 1
CARB-O-PHILC GEL 40%
Tier 1
CEM-UREA
Tier 4
SOL 45%
CEROVEL
GEL 40%
Tier 1
CEROVEL
LOT 40%
Tier 1
DERMASORB XM KIT 39%
Tier 4
GORDOFILM SOL
Tier 2
GORDONS UREA OIN 40%
Tier 3
HYDRO 35
AER
Tier 3
HYDRO 40
AER FOAM
Tier 3
KERALAC
CRE 47%
Tier 4
KERALYT
GEL 6%
Tier 4
KERALYT
KIT SCALP 6%
Tier 4
Page 247 of 279
X
X
X
X
Specialty
X
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
Product Name
LATRIX
SUS 50%
Tier Value
Tier 2
LATRIX XM EMU 45%
Tier 2
NA HYDROXIDE SOL 10%
Tier 1
POT HYDROXID SOL 5%
Tier 2
REA LO 39 CRE 39%
Tier 1
REA LO 40 CRE 40%
Tier 1
REA LO 40 LOT 40%
Tier 1
REMEVEN
Tier 2
CRE 50%
Prior
Authorization
Supply
Limit
Step
Therapy
SALACYN
CRE 6%
Tier 1
SALACYN
LOT 6%
Tier 1
SALICYLIC AER 6%
Tier 1
SALICYLIC AC CRE 6%
Tier 1
SALICYLIC AC GEL 6%
Tier 1
SALICYLIC AC LIQ 26%
Tier 1
SALICYLIC AC LOT 6%
Tier 1
SALVAX
AER 6%
Tier 3
UMECTA
EMU
Tier 3
X
UMECTA MOUSS AER 40%
Tier 3
X
UMECTA NAIL SUS FILM
Tier 4
X
UMECTA PD EMU 40-0.3%
Tier 4
X
UMECTA PD SUS 40-0.3%
Tier 4
X
URAMAXIN
AER 20%
Tier 3
URAMAXIN
CRE 45%
Tier 4
URAMAXIN
GEL 45%
Tier 4
URAMAXIN
LOT 45%
Tier 3
URAMAXIN GT GEL 45%
Tier 4
X
URAMAXIN GT KIT 45%
Tier 4
X
UREA
CRE 39%
Tier 1
UREA
CRE 40%
Tier 1
Page 248 of 279
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOLYTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
Product Name
UREA
CRE 45%
Tier Value
Tier 1
UREA
CRE 47%
Tier 1
UREA
CRE 50%
Tier 1
UREA
EMU 50%
Tier 1
UREA
GEL 40%
Tier 1
UREA
LOT 40%
Tier 1
UREA
LOT 45%
Tier 1
UREA
SUS 50%
Tier 1
UREA 40%
SUS NAIL
Tier 1
UREA NAIL GEL 45%
Tier 1
UREA NAIL KIT
Tier 1
UREA NAIL MIS 50%
Tier 1
UREA TOPICAL SUS 40%
Tier 1
UREA-C40
Tier 1
URE-K
CRE 50%
CRE 41%
Tier 4
X-VIATE
CRE 40%
Tier 1
X-VIATE
GEL 40%
Tier 4
X-VIATE
LOT 40%
Tier 1
AVAR
PAD 9.5-5%
Tier 4
AVAR CLEANSE EMU 10-5%
Tier 1
AVAR LS
LIQ 10-2%
Tier 3
AVAR LS
PAD 10-2%
Tier 4
AVAR-E EMOLL CRE 10-5%
Tier 3
AVAR-E GREEN CRE 10-5%
Tier 3
AVAR-E LS CRE 10-2%
Tier 3
BENZIQ
Tier 3
BENZIQ LS GEL 2.75%
Page 249 of 279
Step
Therapy
X
Tier 1
UTOPIC
GEL 5.25%
Supply
Limit
Tier 1
UREA HYDRATI AER 35%
LOT 40%
Prior
Authorization
Tier 3
X
X
X
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
Product Name
BENZIQ WASH LIQ 5.25%
BP 10-1
Tier Value
Tier 4
EMU
Tier 1
BP CLEANSING EMU 10-4%
Tier 1
CERISA WASH EMU 10-1%
Tier 1
CLARIFOAM EF AER 10-5%
Tier 3
CLARIS WASH EMU 10-4%
Tier 1
COAL TAR
Tier 3
SOL 20%
DRITHO-CREME CRE HP 1%
Tier 2
INOVA
KIT 4%
Tier 3
INOVA
KIT 8%
Tier 3
INOVA 4/1 KIT ACNE CON
Tier 3
INOVA 8/2 KIT ACNE CON
Tier 3
NUOX
Tier 3
GEL 6-3%
Prior
Authorization
Supply
Limit
Step
Therapy
X
OSCION CLNSR LOT 6%
Tier 3
PLEXION
CRE 9.8-4.8%
Tier 4
X
PLEXION
LIQ 9.8-4.8%
Tier 4
X
PLEXION
LOT 9.8-4.8%
Tier 4
X
PLEXION CLTH PAD 9.8-4.8%
Tier 4
X
PRASCION
Tier 1
EMU
PRASCION RA CRE 10-5%
Tier 1
ROSANIL
Tier 1
EMU CLEANSER
SOD SUL/SULF CRE 10-2%
Tier 1
SOD SUL/SULF CRE 10-5%
Tier 1
SOD SUL/SULF CRE 9.8-4.8%
Tier 1
SOD SUL/SULF EMU 10-5%
Tier 1
SOD SUL/SULF EMU 10-5%
Tier 1
SOD SUL/SULF GEL 10-5%
Tier 1
SOD SUL/SULF KIT
Tier 1
SOD SUL/SULF LIQ 10-2%
Tier 1
Page 250 of 279
X
X
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
Product Name
SOD SUL/SULF LIQ 9.8-4.8%
Tier Value
Tier 1
SOD SUL/SULF LIQ 9-4.5%
Tier 1
SOD SUL/SULF LIQ WASH
Tier 1
SOD SUL/SULF LOT 10-5%
Tier 1
SOD SUL/SULF LOT 9.8-4.8%
Tier 1
SOD SUL/SULF PAD 10-4%
Tier 1
SOD SUL/SULF SUS 10-5%
Tier 1
SOD SUL/SULF SUS 8-4%
Tier 1
SS 10-2
SOL 10-2%
Tier 1
CRE 10%-5%
Tier 1
AER 10-5%
Tier 1
SSS
SSS 10-5
SUL SOD/SULF LIQ 10-2%
Tier 1
SUL SOD/SULF PAD 10-4%
Tier 1
SULF/SUNSCRN KIT 9-4.5%
Tier 1
SULFACLEANSE SUS 8-4%
Tier 1
SULFOAM
Tier 3
SUMADAN
SHA 2%
KIT
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
Tier 4
X
SUMADAN WASH LIQ 9-4.5%
Tier 4
X
SUMADAN XLT KIT 9-4.5%
Tier 4
X
SUMAXIN
Tier 4
PAD 10-4%
SUMAXIN CP KIT
Tier 4
X
SUMAXIN TS SUS 8-4%
Tier 4
X
SUMAXIN WASH LIQ 9-4%
Tier 3
VIRTI-SULF CRE 10-5%
Tier 1
ZACARE KIT KIT 4%
Tier 3
ZACARE KIT KIT 8%
Tier 3
ZACLIR
LOT 8%
Tier 1
ZENCIA
LIQ 9-4%
Tier 1
ZITHRANOL SHA 1%
Page 251 of 279
Tier 3
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS KERATOPLASTIC AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
Product Name
ZITHRANOL-RR CRE 1.2%
ARZOL SILVER MIS NITR APP
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
DERMAZENE CRE 1%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
GRAFCO SILVR MIS NIT APPL
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
HYDROCORT/ CRE IODOQUIN
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
LOUTREX
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS CRE 10%
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS GEL 10% WASH
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS LIQ 10% WASH
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS LOT 9.8%
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE PLUS SHA 10%
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
OVACE WASH LIQ 10%
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
PROMISEB
CRE
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
PROMISEB
KIT COMPLETE
Tier 4
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SEB-PREV
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SELENIUM SUL SHA 2.25%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA OIN 10%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA SOL 0.5%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA SOL 10%
Tier 1
CRE
LIQ WASH
Page 252 of 279
Tier Value
Tier 3
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
Product Name
SILVER NITRA SOL 25%
Tier Value
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SILVER NITRA SOL 50%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SOD SULFACET GEL 10%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SOD SULFACET SHA 10%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
SODIUM SULFA LIQ 10% WASH
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
TL TRISEB CRE
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES (SKIN &
MUCOUS)
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
SODIUM SULFA LIQ 10% WASH
Tier 1
ANASEPT
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BENZALKONIUM SOL 50%
Tier 1
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BENZALKONIUM SOL NF
Tier 2
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BORIC ACID GRA
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BUCALSEP
SOL
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS LOCAL ANTI-INFECTIVES, MISCELLANEOUS
BUCALSEP
SPR
Tier 3
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
ATOPICLAIR CRE
Tier 3
AURSTAT
Tier 3
SPR
KIT HYDROGEL
AURSTAT ANTI GEL -ITCH
Tier 3
BENZOIN
TIN NF
Tier 3
BENZOIN CMPD TIN
Tier 3
CERACADE
Tier 3
EMU
DEBACTEROL SOL 30-50%
Tier 2
DRYSOL
SOL 20%
Tier 4
ELETONE
CRE
Tier 3
Page 253 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
Product Name
ELETONE CRE TWINPACK
Tier Value
Tier 3
EMULSION SB EMU
Tier 3
EPICERAM
Tier 3
EPISONE
EMU
CRE
ESSENTRA
Tier 3
SOL
Tier 3
FORMALDEHYDE SOL 10%
Tier 1
FORMALDEHYDE SOL 37%
Tier 3
FORMA-RAY SOL 20%
Tier 2
GENADUR
KIT
Tier 4
GENADUR
LIQ
Tier 3
GRANULEX
AER
Tier 4
HPR
Supply
Limit
Step
Therapy
Tier 1
MIS 9X9"
FORMADON
Prior
Authorization
AER
Tier 4
HPR PLUS
AER
Tier 4
HPR PLUS
CRE
Tier 4
HPR PLUS
KIT
Tier 3
HYLATOPIC AER
Tier 3
HYLATOPIC AER PLUS
Tier 3
HYLATOPIC CRE PLUS
Tier 3
HYPERCARE SOL 20%
Tier 1
MB HYDROGEL KIT
Tier 3
MEDI-DERM CRE -RX
Tier 3
MEDROX-RX OIN
Tier 3
METHYL SALIC LIQ
Tier 1
NEOSALUS
AER
Tier 3
NEOSALUS
CRE
Tier 3
NEOSALUS CP CRE
Tier 3
NIVATOPIC CRE PLUS
Tier 3
NUVAIL
Tier 3
SOL 16%
Page 254 of 279
X
Specialty
Therapeutic Class
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS
SKIN AND MUCOUS MEMBRANE AGENTS SCABICIDES
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Product Name
PR CREAM KIT
Tier Value
Tier 2
PRESERA
AER
Tier 3
PRUCLAIR
CRE
Tier 2
PRUMYX
CRE
Tier 2
PYROGALL ACD OIN
Tier 2
SALICYLIC AC AER 6%
Tier 1
SALVAX DUO KIT PLUS
Tier 3
TBC
Tier 1
AER
Prior
Authorization
Supply
Limit
Step
Therapy
TRI-CHLOR LIQ 80%
Tier 2
TURPENTINE SOL SPIRITS
Tier 3
VASOLEX
OIN
Tier 1
XERALUX
CRE
Tier 3
SULF LIME SOL
Tier 3
ARMODAFINIL TAB 150MG
Tier 1
X
X
X
ARMODAFINIL TAB 200MG
Tier 1
X
X
X
ARMODAFINIL TAB 250MG
Tier 1
X
X
X
ARMODAFINIL TAB 50MG
Tier 1
X
X
X
BUTISOL SOD TAB 30MG
Tier 3
BUTISOL SOD TAB 50MG
Tier 3
MODAFINIL TAB 100MG
Tier 1
X
X
MODAFINIL TAB 200MG
Tier 1
X
X
NUVIGIL
TAB 150MG
Tier 4
X
X
X
NUVIGIL
TAB 200MG
Tier 4
X
X
X
NUVIGIL
TAB 250MG
Tier 4
X
X
X
NUVIGIL
TAB 50MG
Tier 4
X
X
X
PROVIGIL
TAB 100MG
Tier 4
X
X
X
PROVIGIL
TAB 200MG
Tier 4
X
X
X
ROZEREM
TAB 8MG
Tier 3
X
X
SECONAL
CAP 100MG
Tier 3
Page 255 of 279
Specialty
Therapeutic Class
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Sleep Disorders, Other - Miscellaneous
Sedation and Sleep Drugs
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Product Name
SECONAL SOD CAP 100MG
Tier Value
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
SILENOR
TAB 3MG
Tier 4
X
X
SILENOR
TAB 6MG
Tier 4
X
X
XYREM
SOL 500MG/ML
Tier 4
X
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
X
X
X
X
X
X
X
Smoking Cessation Agents - Deterrents
CVS NICOTINE DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MG
HCR Preventative
MINT
CVS NICOTINE GUM 2MG ORIG HCR Preventative
X
CVS NICOTINE GUM
HCR Preventative
2MGFRUIT
CVS NICOTINE GUM 4MG CINN HCR Preventative
X
CVS NICOTINE GUM 4MG
HCR Preventative
MINT
CVS NICOTINE GUM 4MG ORIG HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM
HCR Preventative
4MGFRUIT
CVS NICOTINE LOZ 2MG
HCR Preventative
CVS NICOTINE LOZ 2MG MINT HCR Preventative
Smoking Cessation Agents - Deterrents
CVS NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
CVS NTS DIS STEP 1
EQ NICOTINE DIS 14MG/24H
HCR Preventative
HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE DIS 21MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE DIS 7MG/24HR
HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
BUPROBAN TAB 150MG
BUPROPION TAB 150MG
CHANTIX PAK 0.5& 1MG
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
CVS NICOTINE DIS 14MG/24H
Page 256 of 279
X
X
X
X
X
X
Specialty
X
Therapeutic Class
Smoking Cessation Agents - Deterrents
Prior
Product Name
Authorization
Tier Value
EQ NICOTINE GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG REF
HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 2MG CHER HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 4MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 2MG
HCR Preventative
EQL NICOTINE GUM 2MG REF HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 2MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 4MG
HCR Preventative
EQL NICOTINE GUM 4MG REF HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 4MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
HCR Preventative
X
HCR Preventative
X
HCR Preventative
X
HCR Preventative
X
Smoking Cessation Agents - Deterrents
GNP NICOTINE GUM 2MG
MINT
GNP NICOTINE GUM 2MG
ORIG
GNP NICOTINE GUM 4MG
MINT
GNP NICOTINE GUM 4MG
ORIG
GNP NICOTINE LOZ 2MG MINT
HCR Preventative
X
Smoking Cessation Agents - Deterrents
GNP NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
GNP NICOTINE LOZ MINI 2MG HCR Preventative
X
Smoking Cessation Agents - Deterrents
HM NICOTINE DIS 14MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
HM NICOTINE DIS 21MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
X
Smoking Cessation Agents - Deterrents
HM NICOTINE GUM 2MG
HCR Preventative
MINT
HM NICOTINE GUM 4MG
HCR Preventative
MINT
HM NICOTINE LOZ 2MG MINT HCR Preventative
Smoking Cessation Agents - Deterrents
HM NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
KLS QUIT2 GUM 2MG
KLS QUIT2 LOZ 2MG
X
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
HCR Preventative
HCR Preventative
Page 257 of 279
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Step
Therapy
Specialty
Therapeutic Class
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Prior
Product Name
Authorization
Tier Value
KLS QUIT4 GUM 4MG
HCR Preventative
X
KLS QUIT4 LOZ 4MG
HCR Preventative
X
NICODERM CQ DIS 14MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICODERM CQ DIS 21MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICODERM CQ DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 2MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
X
X
X
X
X
X
X
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 2MG CHRY HCR Preventative
NICORETTE LOZ 2MG MINT HCR Preventative
NICORETTE LOZ 2MG ORIG HCR Preventative
NICORETTE LOZ 4MG CHRY HCR Preventative
NICORETTE LOZ 4MG MINT HCR Preventative
NICORETTE LOZ 4MG ORIG HCR Preventative
NICORETTE ST GUM 2MG
HCR Preventative
MINT
NICORETTE ST GUM 2MG ORIG HCR Preventative
Smoking Cessation Agents - Deterrents
NICORETTE ST GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
NICOTINE DIS 14MG/24H
HCR Preventative
NICOTINE DIS 21MG/24H
HCR Preventative
NICOTINE DIS 7MG/24HR
HCR Preventative
NICOTINE GUM 2MGFRUIT HCR Preventative
NICOTINE GUM 4MG
HCR Preventative
NICOTINE LOZ 2MG CHRY
HCR Preventative
NICOTINE LOZ 2MG MINT
HCR Preventative
NICOTINE LOZ 4MG CHRY
HCR Preventative
NICOTINE LOZ 4MG CINN
HCR Preventative
NICOTINE LOZ 4MG MINT
HCR Preventative
NICOTINE LOZ MINI 2MG
HCR Preventative
NICOTINE POL GUM 2MG
HCR Preventative
NICOTINE POL GUM 2MG CINN HCR Preventative
X
X
X
X
X
X
X
X
X
X
X
X
X
Page 258 of 279
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Therapy
Specialty
Smoking Cessation Agents - Deterrents
Prior
Product Name
Authorization
Tier Value
NICOTINE POL GUM 2MG
HCR Preventative
X
MINT
NICOTINE POL GUM 2MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG REF HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM
HCR Preventative
2MGFRUIT
NICOTINE POL GUM 4MG
HCR Preventative
NICOTINE POL GUM 4MG CINN HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG
HCR Preventative
MINT
NICOTINE POL GUM 4MG ORIG HCR Preventative
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG REF HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG STRT HCR Preventative
X
Smoking Cessation Agents - Deterrents
X
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM
HCR Preventative
4MGFRUIT
NICOTINE POL LOZ 2MG CHRY HCR Preventative
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 2MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG CINN HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE SYS KIT TRANSDER
HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 14MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 21MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 7MG/24HR
HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
NICOTROL INH
NICOTROL NS SPR 10MG/ML
HCR Preventative
HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
QC NICOTINE GUM 4MG
RA NICOTINE DIS 14MG/24H
HCR Preventative
HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
RA NICOTINE DIS 21MG/24H
HCR Preventative
X
Smoking Cessation Agents - Deterrents
RA NICOTINE DIS 7MG/24HR
HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MG
HCR Preventative
RA NICOTINE GUM 2MG CINN HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MG MINT HCR Preventative
X
Therapeutic Class
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Page 259 of 279
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X
X
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Step
Therapy
Specialty
Therapeutic Class
Smoking Cessation Agents - Deterrents
Prior
Product Name
Authorization
Tier Value
RA NICOTINE GUM 2MGFRUIT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 4MG
HCR Preventative
RA NICOTINE GUM 4MG FRUT HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
RA NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
RA NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 14MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 21MG
HCR Preventative
SM NICOTINE DIS 21MG/24H HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
SM NICOTINE
SM NICOTINE
MINT
SM NICOTINE
SM NICOTINE
MINT
SM NICOTINE
GUM 2MG
GUM 2MG
HCR Preventative
HCR Preventative
X
X
GUM 4MG
GUM 4MG
HCR Preventative
HCR Preventative
X
X
LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
SM NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
HCR Preventative
X
HCR Preventative
X
HCR Preventative
HCR Preventative
HCR Preventative
X
X
X
HCR Preventative
X
HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
STOP SMOKING GUM 2MG
MINT
STOP SMOKING GUM 2MG
ORIG
STOP SMOKING GUM 4MG
STOP SMOKING LOZ 2MG
STOP SMOKING LOZ 2MG
MINT
STOP SMOKING LOZ 4MG
MINT
SW NICOTINE GUM 2MG
MINT
SW NICOTINE GUM 4MG
SW NICOTINE LOZ 2MG MINT
HCR Preventative
HCR Preventative
X
X
Smoking Cessation Agents - Deterrents
SW NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 14MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 21MG/24H HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 7MG/24HR HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 2MG
HCR Preventative
MINT
TGT NICOTINE GUM 2MG ORIG HCR Preventative
X
TGT NICOTINE GUM
2MGFRUIT
TGT NICOTINE GUM 4MG
HCR Preventative
X
HCR Preventative
X
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Smoking Cessation Agents - Deterrents
Page 260 of 279
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Therapy
Specialty
Smoking Cessation Agents - Deterrents
Prior
Product Name
Authorization
Tier Value
TGT NICOTINE GUM 4MG
HCR Preventative
X
MINT
TGT NICOTINE GUM 4MG ORIG HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 2MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 2MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 4MG CHRY HCR Preventative
X
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 4MG MINT HCR Preventative
X
Smoking Cessation Agents - Deterrents
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
THRIVE
BANZEL
GUM 2MG MINT
SUS 40MG/ML
HCR Preventative
Tier 3
X
BANZEL
TAB 200MG
Tier 3
X
BANZEL
TAB 400MG
Tier 3
X
Therapeutic Class
Smoking Cessation Agents - Deterrents
CARBAMAZEPIN CAP 100MG
ER
CARBAMAZEPIN CAP 200MG
ER
CARBAMAZEPIN CAP 300MG
ER
CARBAMAZEPIN CHW 100MG
Tier 1
CARBAMAZEPIN POW
Tier 3
CARBAMAZEPIN SUS 100/5ML
Tier 1
CARBAMAZEPIN TAB
100MGER
CARBAMAZEPIN TAB 200MG
Tier 1
CARBAMAZEPIN TAB 200MG
ER
CARBAMAZEPIN TAB 400MG
ER
CARBATROL CAP 100MG
Tier 1
CARBATROL CAP 200MG
Tier 4
CARBATROL CAP 300MG
Tier 4
DILANTIN
CAP 100MG
Tier 3
DILANTIN
CAP 30MG
Tier 3
DILANTIN
CHW 50MG
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
DILANTIN-125 SUS 125/5ML
Tier 3
EPITOL
Tier 1
EQUETRO
TAB 200MG
CAP 100MG
Page 261 of 279
Tier 3
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Product Name
EQUETRO CAP 200MG
EQUETRO
CAP 300MG
Tier Value
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Tier 3
OXCARBAZEPIN SUS
300MG/5M
OXCARBAZEPIN TAB 150MG
Tier 1
OXCARBAZEPIN TAB 300MG
Tier 1
OXCARBAZEPIN TAB 600MG
Tier 1
OXTELLAR XR TAB 150MG
Tier 4
X
X
OXTELLAR XR TAB 300MG
Tier 4
X
X
OXTELLAR XR TAB 600MG
Tier 4
X
X
PEGANONE
Tier 2
TAB 250MG
Tier 1
PHENYTEK
CAP 200MG
Tier 4
PHENYTEK
CAP 300MG
Tier 4
PHENYTOIN CHW 50MG
Tier 1
PHENYTOIN SUS 125/5ML
Tier 1
PHENYTOIN EX CAP 100MG
Tier 1
PHENYTOIN EX CAP 200MG
Tier 1
PHENYTOIN EX CAP 300MG
Tier 1
TEGRETOL
SUS 100/5ML
Tier 3
TEGRETOL
TAB 200MG
Tier 3
TEGRETOL-XR TAB 100MG
Tier 4
TEGRETOL-XR TAB 200MG
Tier 4
TEGRETOL-XR TAB 400MG
Tier 4
TRILEPTAL SUS 300MG/5M
Tier 4
X
X
TRILEPTAL TAB 150MG
Tier 4
X
X
TRILEPTAL TAB 300MG
Tier 4
X
X
TRILEPTAL TAB 600MG
Tier 4
X
X
VIMPAT
SOL 10MG/ML
Tier 3
X
VIMPAT
TAB 100MG
Tier 3
X
VIMPAT
TAB 150MG
Tier 3
X
Page 262 of 279
Specialty
Therapeutic Class
Sodium Channel Agents - Seizure Control
Drugs
Sodium Channel Agents - Seizure Control
Drugs
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Antibiotics
Sulfonamides - Inflammatory Bowel Disease
Drugs
Sulfonamides - Inflammatory Bowel Disease
Drugs
Sulfonamides - Inflammatory Bowel Disease
Drugs
Sulfonamides - Inflammatory Bowel Disease
Drugs
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Product Name
VIMPAT
TAB 200MG
VIMPAT
TAB 50MG
Tier Value
Tier 3
Prior
Authorization
X
Tier 3
X
BACTRIM TAB 400-80MG
BACTRIM DS TAB 800-160
BLEPH-10 SOL 10% OP
SMZ/TMP DS TAB 800-160
SMZ-TMP SUS 200-40/5
SMZ-TMP TAB 400-80MG
SMZ-TMP DS TAB 800-160
SOD SULFACET SOL 10% OP
SULFACET SOD OIN 10% OP
SULFACET SOD SOL 10% OP
SULFADIAZINE TAB 500MG
SULFATRIM PD SUS 200-40/5
AZULFIDINE TAB 500MG
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
AZULFIDINE TAB 500MG EN
Tier 4
SULFASALAZIN TAB 500MG
Tier 1
SULFASALAZIN TAB 500MG DR
Tier 1
ACTICLATE TAB 150MG
ACTICLATE TAB 75MG
ADOXA
CAP 150MG
ADOXA
TAB 100MG
ADOXA
TAB 50MG
ADOXA
TAB 75MG
ADOXA PAK 1/ TAB 100MG
ADOXA PAK 1/ TAB 150MG
ADOXA PAK 2/ TAB 100MG
ALODOX
KIT 20MG
AVIDOXY TAB 100MG
AVIDOXY DK KIT
DEMECLOCYCL TAB 150MG
DEMECLOCYCL TAB 300MG
DORYX
TAB 200MG
DORYX
TAB 50MG
DORYX MPC TAB 120MG
DOXYCYC CAP 100MG
DOXYCYC CAP 50MG
DOXYCYC MONO CAP 100MG
Tier 4
Tier 4
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 3
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
DOXYCYC MONO CAP 50MG
DOXYCYC MONO TAB 100MG
Tier 1
Tier 1
Tetracyclines - Antibiotics
DOXYCYC MONO TAB 150MG
Tier 1
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
DOXYCYC MONO TAB 50MG
DOXYCYC MONO TAB 75MG
DOXYCYCL HYC CAP 100MG
DOXYCYCL HYC CAP 50MG
DOXYCYCL HYC TAB 100MG
DOXYCYCL HYC TAB 100MG DR
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Page 263 of 279
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Prior
Authorization
Supply
Limit
Step
Therapy
X
Therapeutic Class
Tetracyclines - Antibiotics
Product Name
DOXYCYCL HYC TAB 150MG DR
Tier Value
Tier 1
Tetracyclines - Antibiotics
DOXYCYCL HYC TAB 200MG DR
Tier 1
X
Tetracyclines - Antibiotics
DOXYCYCL HYC TAB 50MG DR
Tier 1
X
Tetracyclines - Antibiotics
DOXYCYCL HYC TAB 75MG DR
Tier 1
X
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
Tier 1
Tier 4
Tier 1
Tier 3
X
X
X
Tetracyclines - Antibiotics
DOXYCYCLINE SUS 25MG/5ML
Tier 1
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
DOXYCYCLINE TAB 20MG
MINOCIN CAP 100MG
MINOCIN CAP 50MG
MINOCIN CAP 75MG
MINOCIN KIT 100MG
MINOCIN KIT 50MG
MINOCYCLINE CAP 100MG
MINOCYCLINE CAP 50MG
MINOCYCLINE CAP 75MG
MINOCYCLINE TAB 100MG
MINOCYCLINE TAB 135MG ER
Tier 1
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tetracyclines - Antibiotics
MINOCYCLINE TAB 45MG ER
Tier 1
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
MINOCYCLINE TAB 50MG
MINOCYCLINE TAB 75MG
MINOCYCLINE TAB 90MG ER
Tier 1
Tier 1
Tier 1
Tetracyclines - Antibiotics
MONDOXYNE NL CAP 100MG
Tier 1
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
Tetracyclines - Antibiotics
MONDOXYNE NL CAP 50MG
MONDOXYNE NL CAP 75MG
MONODOX CAP 100MG
MONODOX CAP 75MG
MORGIDOX CAP 1X100MG
MORGIDOX CAP 1X50MG
MORGIDOX CAP 2X100MG
MORGIDOX KIT 1X100MG
MORGIDOX KIT 1X50MG
MORGIDOX KIT 2X100MG
NICAZELDOXY KIT 30
NICAZELDOXY KIT 60
NUTRIDOX KIT
OCUDOX
KIT
ORACEA
CAP 40MG
SOLODYN TAB 105MG
SOLODYN TAB 115MG
SOLODYN TAB 55MG
SOLODYN TAB 65MG
SOLODYN TAB 80MG
TETRACYCLINE CAP 250MG
TETRACYCLINE CAP 500MG
VIBRAMYCIN CAP 100MG
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 4
CAP 150MG
CAP 40MG
CAP 75MG
POW HYCLATE
Page 264 of 279
X
X
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Tetracyclines - Antibiotics
Product Name
VIBRAMYCIN SUS 25MG/5ML
Tier Value
Tier 4
Tetracyclines - Antibiotics
VIBRAMYCIN SYP 50MG/5ML
Tier 3
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 100/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 100MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 12.5/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 150/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 200/ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 200MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 25MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 25MG ODT
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZAPINE TAB 50MG
Tier 1
Treatment-Resistant - Mood Disorder Drugs
CLOZARIL
TAB 100MG
Tier 4
Treatment-Resistant - Mood Disorder Drugs
CLOZARIL
TAB 25MG
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 100 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 12.5 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 150 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 200 ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
FAZACLO
TAB 25MG ODT
Tier 4
Treatment-Resistant - Mood Disorder Drugs
VERSACLOZ SUS 50MG/ML
Tier 4
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
AMITRIPTYLIN KIT 2%
AMITRIPTYLIN POW HCL
AMITRIPTYLIN TAB 100MG
AMITRIPTYLIN TAB 10MG
AMITRIPTYLIN TAB 150MG
AMITRIPTYLIN TAB 25MG
AMITRIPTYLIN TAB 50MG
AMITRIPTYLIN TAB 75MG
AMOXAPINE TAB 100MG
AMOXAPINE TAB 150MG
AMOXAPINE TAB 25MG
AMOXAPINE TAB 50MG
ANAFRANIL CAP 25MG
ANAFRANIL CAP 50MG
ANAFRANIL CAP 75MG
CETYL MYRIST MIS OLEATE
CETYL MYRIST OIL OLEATE
CETYL MYRIST POW 20%
CETYL MYRIST POW OLEATE
CETYL MYRIST POW OLEATE
Tier 1
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Page 265 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
X
X
X
X
X
X
X
X
X
X
X
Specialty
Therapeutic Class
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Product Name
CITRULLINE POW (L)
CLOMIPRAMINE CAP 25MG
CLOMIPRAMINE CAP 50MG
CLOMIPRAMINE CAP 75MG
DESIPRAMINE TAB 100MG
DESIPRAMINE TAB 10MG
DESIPRAMINE TAB 150MG
DESIPRAMINE TAB 25MG
DESIPRAMINE TAB 50MG
DESIPRAMINE TAB 75MG
DOXEPIN HCL CAP 100MG
DOXEPIN HCL CAP 10MG
DOXEPIN HCL CAP 150MG
DOXEPIN HCL CAP 25MG
DOXEPIN HCL CAP 50MG
DOXEPIN HCL CAP 75MG
DOXEPIN HCL CON 10MG/ML
Tier Value
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
ELAVIL
TAB 25MG
IMIPRAM HCL TAB 10MG
IMIPRAM HCL TAB 25MG
IMIPRAM HCL TAB 50MG
IMIPRAM PAM CAP 100MG
IMIPRAM PAM CAP 125MG
IMIPRAM PAM CAP 150MG
IMIPRAM PAM CAP 75MG
IMIPRAMINE POW HCL
L-CITRULLINE POW
NORPRAMIN TAB 100MG
NORPRAMIN TAB 10MG
NORPRAMIN TAB 150MG
NORPRAMIN TAB 25MG
NORPRAMIN TAB 50MG
NORPRAMIN TAB 75MG
NORTRIPTYLIN CAP 10MG
NORTRIPTYLIN CAP 25MG
NORTRIPTYLIN CAP 50MG
NORTRIPTYLIN CAP 75MG
NORTRIPTYLIN SOL 10MG/5ML
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
PAMELOR CAP 10MG
PAMELOR CAP 25MG
PAMELOR CAP 50MG
PAMELOR CAP 75MG
PERPHEN/AMIT TAB 2-10MG
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 2-25MG
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-10MG
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-25MG
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-50MG
Tier 1
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
PROTRIPTYLIN TAB 10MG
PROTRIPTYLIN TAB 5MG
SURMONTIL CAP 100MG
SURMONTIL CAP 25MG
Tier 1
Tier 1
Tier 4
Tier 4
Page 266 of 279
Prior
Authorization
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Tricyclics - Antidepressants
Vasodilators - Chest Pain Drugs
Vasodilators - Chest Pain Drugs
Vasodilators - Chest Pain Drugs
Product Name
SURMONTIL CAP 50MG
TOFRANIL TAB 10MG
TOFRANIL TAB 25MG
TOFRANIL TAB 50MG
TOFRANIL-PM CAP 100MG
TOFRANIL-PM CAP 125MG
TOFRANIL-PM CAP 150MG
TOFRANIL-PM CAP 75MG
TRIMIPRAMINE CAP 100MG
TRIMIPRAMINE CAP 25MG
TRIMIPRAMINE CAP 50MG
ISOPROTEREN AER 131MCG
ISOXSUPRINE TAB 10MG
ISOXSUPRINE TAB HCL 20MG
Vasodilators - Chest Pain Drugs
Vasodilators, Direct-acting Arterial - Chest
Pain Drugs
Vasodilators, Direct-acting Arterial - Chest
Pain Drugs
Vasodilators, Direct-acting Arterial - Chest
Pain Drugs
Vasodilators, Direct-acting Arterial - Chest
Pain Drugs
Vasodilators, Direct-acting Arterial - Chest
Pain Drugs
Vasodilators, Direct-acting Arterial - Chest
Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
PAPAVERINE POW HCL
HYDRALAZINE TAB 100MG
Tier 3
Tier 1
HYDRALAZINE TAB 10MG
Tier 1
HYDRALAZINE TAB 25MG
Tier 1
HYDRALAZINE TAB 50MG
Tier 1
MINOXIDIL TAB 10MG
Tier 1
MINOXIDIL TAB 2.5MG
Tier 1
BIDIL
Tier 2
TAB
Tier Value
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
DILATRATE SR CAP 40MG
Tier 3
ISORDIL
TAB 40MG
Tier 2
ISORDIL
TAB 5MG
Tier 4
ISOSORB DIN TAB 10MG
Tier 1
ISOSORB DIN TAB 20MG
Tier 1
ISOSORB DIN TAB 30MG
Tier 1
ISOSORB DIN TAB 40MG ER
Tier 1
ISOSORB DIN TAB 5MG
Tier 1
ISOSORB MONO TAB 10MG
Tier 1
ISOSORB MONO TAB 120MG
ER
ISOSORB MONO TAB 20MG
Tier 1
ISOSORB MONO TAB 30MG ER
Tier 1
ISOSORB MONO TAB 60MG ER
Tier 1
MINITRAN
Tier 1
DIS 0.1MG/HR
Page 267 of 279
Tier 1
Prior
Authorization
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
Product Name
MINITRAN DIS 0.2MG/HR
Tier Value
Tier 1
MINITRAN
DIS 0.4MG/HR
Tier 1
MINITRAN
DIS 0.6MG/HR
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
NITRO-BID OIN 2%
Tier 2
NITRO-DUR DIS 0.1MG/HR
Tier 3
NITRO-DUR DIS 0.2MG/HR
Tier 3
NITRO-DUR DIS 0.3MG/HR
Tier 3
NITRO-DUR DIS 0.4MG/HR
Tier 3
NITRO-DUR DIS 0.6MG/HR
Tier 3
NITRO-DUR DIS 0.8MG/HR
Tier 3
NITROGLYCER AER 400MCG
Tier 1
NITROGLYCER CAP 2.5MG ER
Tier 1
NITROGLYCER CAP 6.5MG ER
Tier 1
NITROGLYCER CAP 9MG ER
Tier 1
NITROGLYCER DIS 0.1MG/HR
Tier 1
NITROGLYCER DIS 0.2MG/HR
Tier 1
NITROGLYCER DIS 0.4MG/HR
Tier 1
NITROGLYCER DIS 0.4MG/HR
Tier 1
NITROGLYCER DIS 0.6MG/HR
Tier 1
NITROGLYCRN SPR 0.4MG
Tier 1
X
X
NITROGLYCRN SPR LINGUAL
Tier 1
X
X
NITROLINGUAL SPR
PUMPSPRA
NITROMIST AER 400MCG
Tier 3
X
X
Tier 4
X
NITROSTAT SUB 0.3MG
Tier 2
NITROSTAT SUB 0.4MG
Tier 2
NITROSTAT SUB 0.6MG
Tier 2
NITRO-TIME CAP 2.5MG CR
Tier 1
NITRO-TIME CAP 6.5MG CR
Tier 1
NITRO-TIME CAP 9MG CR
Tier 1
Page 268 of 279
X
Specialty
Therapeutic Class
Vasodilators, Direct-acting Arterial/Venous Chest Pain Drugs
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
RECTIV
OIN 0.4%
ACTIVE OB CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
AIRSHIELD TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
AP-ZEL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
ATABEX EC TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
BAL-CARE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
BP FOLINATAL TAB PLUS B
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
BP MULTINATL CHW PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
BP MULTINATL TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
CALCIUM PNV CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CHLORELLA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL MIS 90 DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL MIS B-CALM
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL PAK ASSURE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL PAK DHA
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
CITRANATAL TAB RX
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
C-NATE DHA CAP 28-1-200
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
COMPLETE NAT PAK DHA
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
COMPLETENATE CHW
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
CO-NATAL FA TAB 29-1MG
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
CONCEPT DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
CONCEPT OB CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
DOTHELLE DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
DUET DHA
MIS BALANCED
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
DUET DHA 400 MIS 25-1-400
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
ELITE-OB
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
ESCAVITE
CHW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
EXTRA-VIRT CAP PLUS DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
FLORIVA
Tier 1
TAB
MIS DHA
DRO PLUS
Page 269 of 279
Tier Value
Tier 3
Prior
Authorization
X
Supply
Limit
X
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
FOCALGIN 90 MIS DHA
VITAMINS - MULTIVITAMIN PREPARATIONS
FOCALGIN CA MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLCAL DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLCAPS
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLIVANE-OB CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
FOLIVANE-PRX CAP DHA NF
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
GERM DEFENSE TAB LEM-LIME
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
GERM DEFENSE TAB ORANGE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
GERM DEFENSE TAB PM
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
GESTICARE PAK DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
HEMENATAL OB MIS + DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
HEMENATAL OB TAB 28-61MG
INATAL ADV TAB
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ADV TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ADV TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ADV TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL GT TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INATAL ULTRA TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
INFANATE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
LEVOMEFOLATE CAP DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
LYSIPLEX
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MACNATAL CN CAP DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MARNATAL-F CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
MILTAB #1 TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FE DRO /FL 0.25
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTIVIT/FL CHW 0.25MG
Tier 1
CAP OMEGA 3
CAP BALANCE
TAB PLUS
Page 270 of 279
Tier Value
Tier 3
Tier 2
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
MULTIVIT/FL CHW 0.5MG
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTIVIT/FL CHW 1MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FL DRO /FE 0.25
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULTI-VIT/FL DRO 0.5MG/ML
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MULT-VIT/FL CHW 0.5MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MVC-FLUORIDE CHW 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MVC-FLUORIDE CHW 0.5MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MVC-FLUORIDE CHW 1MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
M-VIT
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MYKIDZ IRON SUS FL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL
CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL
TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL
TAB ADVANCE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL PLUS TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATAL-Z TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
MYNATE 90 TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
NATACHEW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NATALVIT
VITAMINS - MULTIVITAMIN PREPARATIONS
NATELLE ONE CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NEEVO DHA CAP 27-1.13
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NESTABS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NESTABS ABC MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NESTABS DHA PAK
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NEWGEN
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NEXA PLUS CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NICAZEL
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NICAZEL
TAB FORTE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
NIVA-PLUS TAB
TAB 27-1MG
CHW
TAB 75-1MG
TAB
TAB 32-1MG
Tier Value
Tier 1
Tier 2
Tier 3
Page 271 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
OB COMPLETE CAP GOLD
Tier Value
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE CAP ONE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE CAP PETITE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE TAB PREMIER
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OB COMPLETE/ CAP DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
OBSTETRIX PAK DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
OBSTETRIX EC TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
O-CAL
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
O-CAL FA
TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PAIRE OB
MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV FE FUM TAB DOC/FA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV FOLIC AC TAB + IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV OB+DHA PAK
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV PRENATAL TAB PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV TABS
TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-DHA
CAP
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-DHA
CAP DOCUSATE
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-OMEGA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-SELECT TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-TOTAL CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PNV-VP-U
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW 0.25MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW 0.5MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW 1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR CHW W/IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR SUS /IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
POLY-VI-FLOR SUS 0.25/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PR NATAL 400 PAK
Tier 1
TAB PRENATAL
CAP 106.5-1
Page 272 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
PR NATAL 400 PAK EC
VITAMINS - MULTIVITAMIN PREPARATIONS
PR NATAL 430 PAK
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PR NATAL 430 PAK EC
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERA OB MIS + DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERA OB TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERA OB TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERAOB CAP ONE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREFERAOB MIS +DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE CAP BALANCE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE CAP PLUS
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE MIS HARMONY
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE PAK 90 DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE PAK DHA
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE PAK PROMISE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE TAB NEXT
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAISSANCE TAB NEXT-B
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENAT PLUS TAB 27-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATABS FA TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATABS RX TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
MIS COMPLEAT
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB 27-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL
TAB PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL 19 CHW 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL 19 CHW TAB
Tier 1
CHW 29-1MG
Page 273 of 279
Tier Value
Tier 1
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
PRENATAL 19 TAB
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL 19 TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL VIT TAB LOW IRON
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL+FE TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATAL-U CAP 106.5-1
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
CAP ENHANCE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
CAP RESTORE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
CHW 0.6-0.4
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE
TAB ELITE
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE AM TAB 1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE DHA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRENATE MINI CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREPLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PREQUE 10 TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PRETAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PROVIDA OB CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
PUREFE OB CAP PLUS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED CHW 0.25MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED CHW 0.5MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED CHW 1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED DRO 0.25MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
QUFLORA PED DRO
0.5MG/ML
RA EFFERVESC TAB FORMULA
VITAMINS - MULTIVITAMIN PREPARATIONS
RELNATE DHA CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
R-NATAL OB CAP 20-1-320
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
RULAVITE DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
SELECT-OB CHW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
SELECT-OB CHW
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
SELECT-OB+ PAK DHA
Tier 3
Tier Value
Tier 1
TAB 27-1MG
TAB 29-1MG
Page 274 of 279
Tier 3
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
SE-NATAL 19 CHW
Tier Value
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
SE-NATAL 19 TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
SE-TAN DHA CAP
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TARON-BC
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TARON-C DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
TARON-PREX CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
THRIVITE 19 TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
THRIVITE RX TAB 29-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL FOLATE TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL-CARE DHA CAP 27-1-500
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL-FLUORIVIT CHW
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TL-SELECT CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRIADVANCE TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRICARE
TAB PRENATAL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRICARE PRE CAP 27-1-500
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRINATAL GT TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRINATAL RX TAB 1
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRINATE
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRISTART DHA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-TABS DHA MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRIVEEN-DUO PAK DHA
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRIVEEN-PRX CAP RNF
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLOR SUS 0.25/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLOR SUS 0.5MG/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLORO SUS 0.25/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VI-FLORO SUS 0.5MG/ML
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FE DRO /FL 0.25
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FL DRO 0.5MG
Tier 1
MIS
TAB
Page 275 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
TRI-VIT/FLUO DRO 0.25MG
Tier Value
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VIT/FLUO DRO 0.5MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
TRI-VITA/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
ULTIMATECARE CAP ONE
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
ULTIMATECARE CAP ONE NF
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VEMAVITE- CAP PRX 2
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VENA-BAL
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VENATAL-FA TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VINACAL B MIS
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE AZ EX TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE C
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE CAL TAB
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE CARE CHW
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE DHA CAP 27-1.13
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE IC CAP
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE II TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE M
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VINATE ONE TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT NATE TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT NATE TAB 28-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-ADVANCE TAB 90-1MG
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-C DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-CARE CAP ONE
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-NATE CAP DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-PN
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-PN DHA CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-PN PLUS CAP
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRTPREX
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIRT-SELECT CAP
MIS DHA
TAB
TAB
TAB
CAP
Tier 3
Page 276 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
VIRT-VITE GT TAB 90-1MG
Tier Value
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VIT A/C/D/FL DRO 0.25MG
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL-OB PAK +DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL-OB TAB 65-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAFOL-ONE CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAMEDMD CAP ONE RX
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITAMEDMD MIS PLUS RX
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VITA-PREN TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VIVA DHA
CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VOL-NATE
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VOL-PLUS
TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VOL-TAB RX TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH PLUS CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-CH-PNV CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-GGR-B6 TAB PRENATAL
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME OB MIS + DHA
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME OB TAB
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME ONE CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-HEME-OB TAB 28-6-1MG
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-PNV-DHA CAP
Tier 3
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-ZEL
TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
VP-ZEL
TAB
Tier 1
VITAMINS - MULTIVITAMIN PREPARATIONS
ZATEAN-CH CAP
Tier 2
VITAMINS - MULTIVITAMIN PREPARATIONS
ZATEAN-PN CAP DHA
Tier 4
VITAMINS - MULTIVITAMIN PREPARATIONS
ZATEAN-PN CAP PLUS
Tier 4
CAP ULTRA
Page 277 of 279
Prior
Authorization
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - MULTIVITAMIN PREPARATIONS
Product Name
ZATEAN-PN TAB
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN B COMPLEX
VITAMINS - VITAMIN C
VITAMINS - VITAMIN C
VITAMINS - VITAMIN C
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
BIOTIN
POW
BIOTIN-D POW
BL FOLIC ACD TAB 400MCG
CYANOCOBAL POW
CYANOCOBALAM CRY
FA-8
CAP 800MCG
FA-8
TAB 0.8MG
FOLIC ACID INJ 5MG/ML
FOLIC ACID POW
FOLIC ACID TAB 1000MCG
FOLIC ACID TAB 1MG
FOLIC ACID TAB 400MCG
FOLIC ACID TAB 800MCG
NASCOBAL SPR 500MCG
NIACINAMIDE POW
NICOTINAMIDE POW
SM FOLIC ACD TAB 400MCG
ASCOCID POW
ASCORBIC ACD POW
VITAMIN C POW
CVD D3
CHW 1000UNIT
CVS D3
CAP 1000UNIT
CVS D3
CAP 400UNIT
D 1000
CHW 1000UNIT
D 400
CHW 400UNIT
D 400
TAB 400UNIT
D3
CAP 1000UNIT
D-3 GUMMY CHW 400UNIT
D-400
TAB 400UNIT
DELTA D3 TAB 400UNIT
DRISDOL CAP 50000UNT
D-VI-SOL LIQ 400UNIT
D-VITA
LIQ 400UNIT
ERGOCALCIFER CAP 50000UNT
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
HCR Preventative
HCR Preventative
Tier 1
Tier 3
Tier 1
Tier 1
HCR Preventative
HCR Preventative
Tier 3
Tier 3
Tier 3
HCR Preventative
Tier 3
Tier 3
Tier 3
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
Tier 4
HCR Preventative
HCR Preventative
Tier 1
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
GNP VIT D TAB 1000UNIT
PEDIA D-VITE DRO 400UNIT
VIT D CHILD CHW 1000UNIT
VITAMIN D CAP 1000UNIT
VITAMIN D CAP 400UNIT
VITAMIN D CAP 50000UNT
VITAMIN D CHW 400UNIT
VITAMIN D DRO 400UNIT
VITAMIN D TAB 1000UNIT
VITAMIN D TAB 400UNIT
VITAMIN D2 TAB 400UNIT
VITAMIN D3 CAP 1000UNIT
VITAMIN D3 CAP 400UNIT
VITAMIN D3 CHW 1000UNIT
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
Tier 1
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN D
VITAMINS - VITAMIN E
VITAMIN D3 CHW 400UNIT
VITAMIN D3 DRO 400UNIT
VITAMIN D3 TAB 1000UNIT
VITAMIN D3 TAB 400UNIT
VITAMIN D-3 TAB 1000UNIT
VITAMIN E POW ACETATE
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
HCR Preventative
Tier 3
Tier Value
Tier 4
Page 278 of 279
Prior
Authorization
X
X
X
X
X
X
X
X
Supply
Limit
Step
Therapy
Specialty
Therapeutic Class
VITAMINS - VITAMIN E
VITAMINS - VITAMIN K ACTIVITY
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Vitamins - Vitamin, Mineral and Body Fluid
Deficiency Drugs
Product Name
WHEAT GERM OIL
MEPHYTON TAB 5MG
CITRANATAL CAP HARMONY
INFANATE
PRENA1
CAP PLUS
CHW
Tier Value
Tier 3
Tier 2
Tier 3
Tier 3
Tier 3
PRENA1 PEARL CAP
Tier 3
PRENATE
Tier 3
CAP ESSENTIA
REDICHEW RX CHW
Tier 3
VITAFOL-NANO TAB
Tier 3
VITAPEARL CAP
Tier 3
VP CH ULTRA CAP
Tier 3
Page 279 of 279
Prior
Authorization
Supply
Limit
X
Step
Therapy
Specialty