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BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide Please bring this guide with you the next time you visit your doctor. If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueCross BlueShield web site at www.bcbswny.com. MG45831E (Revise Date 3/2015) A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are registered trademarks of the BlueCross BlueShield Association. TABLE OF CONTENTS INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS . . iv Save Money on Your Prescription Drugs . . . . . . . . . . . . . . . . . iv Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . iv SECTION 1 — THERAPEUTIC DRUG CATEGORIES . . . . . . . . . . .1 SECTION II — MEDICAID OVER-THE-COUNTER (OTC) MEDICATION LIST . . . . . . . . . . . . . . . . . . . . . . . . .5 SECTION III — INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 ii The BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide is a list of drugs to help guide physicians and pharmacists to select the medication that provides the appropriate treatment for the best price. INTRODUCTION BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories. Formularies In order to serve the diverse needs of patients and their plan sponsors, BlueCross BlueShield of Western New York makes available this formulary design: Closed Formulary — Features the requirement that prescribed drugs must be on the formulary in order for the member to receive coverage. If a prescription is written for a medication that is not on the formulary, the patient will be responsible for the full cost. If special circumstances necessitate that the patient take the nonpreferred drug, prescribers may request a coverage review. If coverage is approved, the medication will be covered. If coverage is not approved, the patient will be responsible for the full cost of the medication. UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows: Key ❚ = ! = ◆ = + = Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication. Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately. Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay. Access restricted to network specialty pharmacies. Medications must be obtained through a network specialty pharmacy. iii USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS We realize that the formulary may not include every drug from every manufacturer. However, using a generic or preferred drug can help you stay healthy at a more affordable cost. Save Money on Your Prescription Drugs Here’s what you can do to save money: 1. Bring this member guide to your doctor and review the cost-saving information below. 2. Ask your doctor whether a generic or formulary brand-name drug listed in this guide is right for you. Formulary generic drugs Formulary brand-name drugs Lowest cost to you Non-formulary drugs Highest cost to you The amount you pay for a drug is determined by which medication you purchase and where it appears on the guide. Some drug plans also exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage. Finding Medications in the Guide This guide lists medications two different ways: Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis) Locate a category on the guide to see what drugs are on the formulary. Generic drugs are listed as G and brand drugs are listed with a B. Section 2: Alphabetically by drug name. Use this list to find your drug. Questions? Please call Member Services at 1-866-544-7948 if you have any questions about the BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com/NYSdrug. Disclaimer: The BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability. iv SECTION I — THERAPEUTIC DRUG CATEGORIES TIER TIER Allergy/Cough & Cold Antihistamines & Decongestants ❚ !❚ !❚ !❚ brompheniramine/ phenylephrine brompheniramine/ pseudoephedrine cetirizine chlorpheniramine/ pseudoephedrine clemastine cyproheptadine dexchlorpheniramine diphenhydramine hydroxyzine HCL hydroxyzine pamoate loratadine loratadine-D promethazine pseudoephedrine Grastek Histex IE Oralair Ragwitek Semprex-D Expectorant & Cough Products benzonatate cardec/DM guaifenesin 1200/DM guaifenesin/codeine hydrocodone/chlorpheniramine hydrocodone/homatropine promethazine/codeine pseudoephedrine/codeine Mucolytic Agents acetylcysteine inh soln. Nasal Medications ❚ ❚ ❚ azelastine 0.1% nasal spray fluticasone nasal spray ipratropium nasal spray Nasacort OTC G + ❚ G !❚ G G Other Blood Modifiers G G G G G G G G G G B B B B B +! + + + +! G G G G G G G G ❚ ❚ ❚ ❚ donepezil ergoloid mesylates galantamine rivastigamine Exelon Patch Namenda G G G B G G G G B B Bladder/Kidney Alkalinizers citric acid/sod citrate potassium citrate Analgesics phenazopyridine Anticholinergics ❚ ❚ ❚ ❚ ❚ BPH !❚ G G G oxybutynin oxybutynin ER tolterodine tolterodine ER trospium G G G G G finasteride tamsulosin G G Cholinergic Agents bethanecol ! +! +! +!❚ + +!❚ G Alkylating Agents cyclophosphamide melphalan CeeNu Emcyt Hexalen Leukeran Myleran Antimetabolites capecitabine mercaptopurine methotrexate Purixan Hormones ! +! +!❚ anagrelide clopidogrel dipyridamole enoxaparin fondaparinux heparin jantoven ticlopidine warfarin Aggrenox Brilinta Effient KEY: ❚ ! ◆ + = = = = G G G G G G G G G B B B bicalutamide exemestane flutamide letrozole leuprolide megestrol tamoxifen anastrozole Fareston Xtandi Zytiga Miscellaneous +! +!❚ +! +! +!❚ +!❚ +!❚ +!❚ +!❚ + +!❚ !❚ +!❚ +! ! +!❚ Blood Anticoagulants/antithrombotics cilostazol pentoxifylline Actimmune Aranesp Epogen Exjade Leukine Miacalcin inj. Neulasta Neumega Neupogen Promacta Procrit Revlimid TIER B B B B B B +!❚ +!❚ +!❚ +!❚ +!❚ +! +!❚ +!❚ +!❚ +! +!❚ + etoposide hydroxyurea mesna temozolomide topotecan Afinitor Arcalyst Bosulif Caprelsa Cometriq Erivedge Gilotrif Gleevec Hycamptin Iclusig Imbruvica Inlyta Intron A Iressa Jakafi Lysodren Matulane Mekinist Nexavar Nilandron Pomalyst Signifor Sprycel Stivarga Sutent Sylatron Tafinlar Tarceva Tasigna Thalomid Tykerb Valchlor Votrient Xalkori Zelboraf Zolinza Zydelig Zykadia +! +!❚ ! +!❚ +!❚ ! !❚ +!❚ G G B B B B B B B B B B B B Rexinoids Targretin TIER B B B B B B B B Eye Antiallergy Agents (Eye) azelastine ophth cromolyn ophth ketotifen opthalmic solution Patanol Anti-infective Agents bacitracin ophth bacitracin/polymyxin ciprofloxacin ophth erythromycin ophth gentamicin ophth neomycin/bacitracin/poly B ofloxacin ophth polymyxin B/TMP sulfacetamide 10% tobramycin soln B Diabetes Antidiabetic Agents, Injectable Apidra Bydureon Byetta Humalog insulin Humulin (all types) Lantus Levemir Novolin Novolog Symlin Tanzeum Trulicity Victoza ! ! Cancer Drugs G Alzheimer Agents ❚ Eliquis Fragmin Innohep Pradaxa Xarelto Zontivity !❚ !❚ !❚ !❚ G G B B B B B Antidiabetic Agents, Oral & Glucose Elevating agents acarbose chlorpropamide glimepiride glipizide glipizide ER glipizide/metformin glyburide glyburide micronized metformin metformin ER metformin/glyburide nateglinide pioglitazone repaglanide tolazamide tolbutamide Avandamet Avandaryl Avandia Farxiga Glucagon Invokamet Invokana Janumet Januvia Jardiance Jentadueto Juvisync Kazano Kombiglyze Nesina Onglyza Oseni Tradjenta Xigduo XR ❚ G G G B ❚ ❚ G G G G G G G G B B B ❚ ❚ ❚ ❚ ❚ G G G G G B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ Diabetic Test Strips ! ! ! ! Accu-Chek Ascensia Breeze Contour FreeStyle OneTouch Precision TRUEtest TRUEtrack ! ! ! B B B B B B B B B B B B B G G G G G G G G G G G G G G G G B B B B B B B B B B B B B B B B B B B B B B B B B B B Anti-inflammatory dexamethasone ophth fluorometholone ophth prednisolone acetate prednisolone sod acetate FML Forte FML S.O.P. Lotemax Pred Mild Anti-inflammatory/Anti-infective combinations dexameth/neomycin/poly B neomycin/bacitracin/poly B/HC sulfacetamide/prednisolone ophth tobramycin/dexameth Antiviral ❚ famciclovir trifluridine Beta-Blockers (Eye) betaxolol HCl carteolol levobunolol metipranolol timolol Betoptic-S Carbonic Anhydrase Inhibitors Miotics Anti-infective Agents acetic acid otic acetic acid/aluminum acetate ofloxacin otic Anti-infective/Anti-inflammatory combinations acetic acid HC otic neomycin/polymyxin/HC otic Ciprodex G G G G G B G G G G G G G G B G B B Cystaran Mydriatics B atropine sulfate ophth homatropine tropicamide G G G bromfenac flurbiprofen ophth ketorolac tromethamine Nevanac G G G B Prostaglandin Analogues/Prostamines latanoprost travoprost Lumigan Sympathomimetics brimonidine G G B G naphazoline phenylephrine ophth G G allopurinol colchicine colchicine/probenecid indomethacin probenecid Colcrys G G G G G B Gout 1. * All branded self-injectables are subject to prior authorization. 2. * Some drugs are limited to 1 unit of use package per dispensing. 1 G G G pilocarpine Isopto Carbachol 1.5% Phospholine Iodide Note: Specific Quantity Limits Apply. Prior Authorization Required. Included in Tablet-Splitting Program Access restricted to network specialty phamacies. G G G G B B B B G G B Vasoconstrictors Ear G G G G G G G G G G dorzolamide 2% eye drops dorzolamide/timolol eye drops Azopt Miscellaneous NSAIDs G G G B SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D) TIER TIER Heart Combination Anti-Hypertensive Angiotensin Converting Enzyme Inhibitors benazepril captopril enalapril fosinopril lisinopril quinapril ramipril Angiotensin II Antagonists ❚ ❚ ❚ ❚ ❚ ❚ candesartan eprosartan irbesartan losartan telmisartan valsartan G G G G G G G G G G G G G Anti-Adrenergic Blockers Centrally acting +!❚ clonidine, oral, patch guanabenz guanfacine methyldopa midodrine Dibenzyline Northera Anti-Adrenergic Blockers Peripheral doxazosin prazosin terazosin Antiarrhythmics amiodarone digoxin disopyramide disopyramide CR flecainide mexiletine propafenone quinidine gluconate quinidine sulfate SR sotalol Antilipidemics ❚◆ ❚◆ ❚◆ +! ❚ atorvastatin calcium cholestyramine colestipol fenofibrate fenofibric acid, tab fluvastatin gemfibrozil lovastatin niacin ER pravastatin simvastatin Kynamro Zetia Beta Blockers acebutolol atenolol betaxolol bisoprolol carvedilol labetalol metoprolol metoprolol ER nadolol pindolol propranolol timolol Calcium Channel Blockers amlodipine cartia XT diltia XT diltiazem diltiazem CD/SR/ER/XR felodipine ER isradipine nicardipine nifediac CC nifedical XL nifedipine nifedipine SR nimodipine nisoldipine verapamil verapamil SR KEY: ❚ ! ◆ + = = = = G G G G G B B ❚ ❚ ❚ ❚ ❚ Diuretics acetazolamide acetazolamide ER amiloride amiloride/HCTZ bumetanide chlorothiazide chlorthalidone furosemide hydrochlorothiazide indapamide methazolamide metolazone spironolactone spironolactone/HCTZ torsemide triamterene/HCTZ G G G G G G G G G G G G G G G G G G G G G G G G B B G G G G G G G G G G G G G G G G G G G G G G G G G G G G amlodipine/benazepril atenolol/chlorthalidone benazepril/HCTZ bisoprolol/HCTZ candesartan/HCTZ captopril/HCTZ enalapril/HCTZ irbesartan/HCTZ lisinopril/HCTZ losartan HCT methyldopa/HCTZ metoprolol/HCTZ propranolol/HCTZ quinapril/HCTZ telmisartan/HCTZ valsartan/HCTZ Miscellaneous Cardiovascular Agents +!❚ !❚ !❚ !❚ eplerenone midodrine Berinert Cinryze Firazyr Ranexa Ruconest Samsca Tekturna Tekturna HCT +!❚ +!❚ +! +!❚ +!❚ +!❚ +!❚ +! Adcirca Adempas Flolan Letairis Opsumit Orenitram Tracleer Veletri +! ! +! Pulmonary Arterial Hypertension Vasodilators hydralazine isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate SA isoxsuprine minoxidil oral nitroglycerin oint nitroglycerin pumpspray nitroglycerin SR nitroglycerin transdermal patch Dilatrate SR Nitrostat TIER Stribild Triumeq Truvada Viread G G G G G G G G G G G G G G G G Nucleoside Reverse Transcriptase Inhibitors Other G G G G G G G G G G G G G G G G + nevirapine Atripla Intelence Rescriptor Sustiva Viramune XR Complera Edurant Fuzeon Isentress Selzentry Tivicay Tybost Vitekta B B B B B B B B Protease Inhibitors Combinations Kaletra B B B B B B B B B B B Xenazine +!❚ azathioprine cyclosporine gengraf mycophenolate mofetil sirolimus tacrolimus Astagraf XL Sandimmune Antifungals ! ❚ ❚ !❚ G G G G G G B B chloroquine phosphate hydroxychloroquine mefloquine Daraprim Malarone Primaquine Antituberculosis ethambutol isoniazid pyrazinamide rifabutin rifampin Coartem Rifater Antivirals ❚ ❚ +! +! +! +!❚ ❚ +!❚ +! ❚ +!❚ ❚ +!❚ Antibacterial agents/Antibiotics amoxicillin amoxicillin-clavulanate ER ampicillin azithromycin suspension azithromycin tablets cefaclor cefadroxil cefdinir cefpodoxime cefprozil cefuroxime cephalexin ciprofloxacin clarithromycin susp clarithromycin tabs clindamycin HCL dicloxacillin doxycycline erythromycin base erythromycin ethylsuccinate (E.E.S.) erythromycin stearate erythromycin/sulfisoxazole minocycline ofloxacin penicillin VK sulfamethoxazole/trimethoprim tetracycline B B G B B B B B G G G G G G G G G G G G G G G G G G G G G G G G G G G G G acyclovir oral amantadine famciclovir ganciclovir lamivudine tabs ribapak ribasphere ribavirin rimantadine valacyclovir valganciclovir tablets Epivir-HBV solution Harvoni Hepsera Olysio Pegasys Relenza Sovaldi Tamiflu Viekira Pak Other Anti-Infectives Infection G G G G G G G G G G ciclodan clotrimazole lozenge fluconazole flucytosine griseofulvin itraconazole ketoconazole nystatin terbinafine voriconazole Antimalarials B Immunosuppressants B B B B B B B B Ery-Tab Ketek Zmax ❚ Huntington’s Disease Nucleoside Analog Reverse Transcriptase Inhibitor Combination abacavir/lamivudine/ zidovudine lamivudine/zidovudine G G G G G B B B B B B Aptivus Crixivan Evotaz Invirase Lexiva Norvir Prezcobix Prezista Reyataz Viracept HIV - Antivirals Non-Nucleoside Reverse Transcriptase Inhibitor abacavir sulfate didanosine lamivudine stavudine zidovudine Emtriva Epivir solution Epzicom Retrovir IV infusion vial Videx Videx pediatric solution Protease Inhibitors G G B B B B B B B B TIER B B B B !❚ + !❚ atovaquone methenamine combination metronidazole neomycin nitrofurantoin paromomycin trimethoprim vancomycin Dapsone Nebupent Sivextro Tobi Zyvox G G G B B B G G G G G B B G G G G G G G G G G G B B B B B B B B B G G G G G G G G B B B B B Impotence - possible contract exclusion; refer to individual contract yohimbine G Male Hormones ❚ ❚ ❚ ❚ ❚ ❚ Androderm patch Androgel Axiron Fortesta Testim Testosterone gel Vogelxo Prostate Health ❚ !❚ alfuzosin HCl finasteride tamsulosin 1. * All branded self-injectables are subject to prior authorization. 2. * Some drugs are limited to 1 unit of use package per dispensing. 2 G G G G G G G G G G Men’s Health Note: Specific Quantity Limits Apply. Prior Authorization Required. Included in Tablet-Splitting Program Access restricted to network specialty phamacies. B B B B B B B B B B G G G SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D) TIER TIER Mental Health Antidepressants ❚ ❚ ❚ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ amitriptyline amitriptyline/ chlordiazepoxide amitriptyline/perphenazine amoxapine bupropion bupropion ER bupropion XL citalopram clomipramine desipramine doxepin duloxetine escitalopram fluoxetine 10, 20mg tablet fluoxetine capsule fluvoxamine tab imipramine maprotiline mirtazapine nefazodone nortriptyline paroxetine HCl phenelzine sertraline tranylcypromine trazodone venlafaxine venlafaxine ER Brintellix Desvenlafaxine ER Desvenlafaxine fumarate Fetzima Khedezla Pexeva Pristiq Viibryd Antimanic Agents lithium carbonate Antipsychotic Agents ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ chlorpromazine clozapine fluphenazine decanoate fluphenazine, oral haloperidol decanoate haloperidol, oral loxapine olanzapine olanzapine/fluoxetine perphenazine quetiapine risperidone risperidone m-tab thioridazine thiothixene trifluoperazine ziprasidone caps Abilify Fanapt Invega Latuda Saphris Seroquel XR Versacloz Anxiolytics, Sedatives, and Hypnotics ❚ ❚ ❚ !❚ alprazolam/ER buspirone chloral hydrate chlordiazepoxide clorazepate diazepam estazolam flurazepam lorazepam meprobamate oxazepam temazepam triazolam zaleplon zolpidem zolpidem CR Hetlioz KEY: ❚ ! ◆ + = = = = Cerebral Stimulants G G G G G G G G G G G G G G G G G G G G G G G G G G G G B B B B B B B B G G G G G G G G G G G G G G G G G G B B B B B B B G G G G G G G G G G G G G G G G B !❚ !❚ dexmethylphenidate dexmethylphenidate ER dextroamphetamine tabs generic Adderall generic Adderall XR generic Concerta generic Dexedrine spansules metadate ER methylphenidate/SR/CD modafinil procentra Daytrana Intuniv Nuvigil Strattera TIER Osteoporosis G G G G G G G G G G G B B B B alendronate calcitonin-salmon fortical NS ibandronate raloxifene risedronate 150mg Actonel 5mg, 30mg Actonel with Calcium Atelvia Binosto Fosamax Plus D Forteo ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ +! + desmopressin solution desmopressin tabs desmopressin vial 4mcg/ml Stimate Other CNS ❚ acamprosate calcium tablet EC buprenorphine HCl disulfiram naltrexone Campral dosepack Evzio Rilutek Savella Suboxone Film Other Endocrine + +!❚ !❚ ! +! +! +!❚ +! +! +! +! + +! +! + +! danazol fludrocortisone octreotide Acthar H.P. gel Cerdelga Egrifta Genotropin Humatrope Myalept Norditropin Nutropin Omnitrope Saizen Sensipar Somavert Synarel Tev-Tropin Zavesca Zorbtive Other Miscellaneous +! +! +! ! Gamunex C Hizentra Procysbi Ravicti Analgesics, Narcotic acetaminophen w/codeine belladonna & opium supp butorphanol NS codeine sulfate endocet fentanyl lozenge fentanyl patch hydrocodone/ibuprofen hydromorphone meperidine meperidine/promethazine methadone morphine SR morphine tab, soln, supp MSIR tabs, sol oxycodone oxycodone/acetaminophen oxycodone/aspirin oxymorphone ER pentazocine/naloxone Opana ER G G G B !❚ G G G G B B B B B G G G B B B B B B B B B B B B B B B B Analgesics, Salicylates aspirin SR choline mag. trisalicylate diflunisal salsalate Anti-Rheumatic +!❚ +!❚ +!❚ +! +!❚ +!❚ +!❚ +!❚ B B B B Cox-2s !❚ Ampyra Aubagio Avonex Betaseron Copaxone Extavia Gilenya Plegridy Rebif Tecfidera B B B B B B B B B B baclofen carisoprodol carisoprodol/ASA chlorzoxazone cyclobenzaprine dantrolene sodium diazepam methocarbamol orphenadrine tizanidine Celebrex B Nonsteroidal Anti-Inflammatory/ Combination Products diclofenac potassium diclofenac sodium etodolac etodolac SA fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac inj. ketorolac tab meclofenamate meloxicam Muscle Relaxants G G G G G G G G G G ❚ G G G G G G G B B B B B B B B B B butalbital/APAP butalbital/APAP/caffeine butalbital/aspirin/caffeine dihydroergotamine mesylate ergotamine/caffeine isometh/dichloralphen/APAP naratriptan sumatriptan tramadol Ergomar ❚ ❚ G G G G G G G G G G G G G G G G G G G G B hydroxychloroquine leflunomide methotrexate Actemra SC Cuprimine Enbrel Humira Kineret Orencia Otezla Ridaura Simponi Xeljanz Migraine (Analgesics, Non-narcotic) Multiple Sclerosis Agents +! +!❚ +! +! +! +! +!❚ +!❚ +! +!❚ G G G G G G B B B B B B G G G G G G G G G B G G G G G G G G G G G G G ❚ + amantadine benztropine bromocriptine carbidopa/levodopa carbidopa/levodopa SA carbidopa/levodopa/ entacapone entacapone pramipexole ropinirole selegiline trihexyphenidyl Apokyn Potassium agents potassium bicarbonate potassium chloride Potassium Removing agent sod. polystyrene sulfonate G G G G G B G G G Respiratory/Asthma Adrenergic epinephrine inj. Epipen/Jr. Corticosteroids ❚ ❚ ❚ ❚ ❚ ❚ budesonide inh. (0.25mg/2ml, 0.5mg/2ml) Alvesco Flovent Diskus Flovent HFA Pulmicort Flexhaler Qvar Symbicort Leukotrienes ❚ ❚ montelukast zafirlukast Other Agents ❚ ❚ ❚ ❚ +!❚ +! +!❚ + ❚ ❚ cromolyn inh. soln. ipratropium inh. soln. Advair diskus Atrovent/HFA Combivent Respimat Dulera Esbriet Kaldydeco Ofev Pulmozyme Spiriva Spiriva Respimat Sympathomimetics ❚ ❚ ❚ ❚ ❚ ❚ albuterol sulfate ER albuterol tab, syr metaproterenol syr terbutaline tab Maxair Autohaler ProAir HFA Serevent Diskus Ventolin HFA Xanthine Derivatives aminophylline theochron theophylline/SR tabs, liquid G B G B B B B B B G G G G B B B B B B B B B B G G G G B B B B G G G Seizures Barbiturates phenobarbital Hydantoins phenytoin Miscellaneous carbamazepine carbamazepine XR 200mg, 400mg clonazepam divalproex sodium/ER 1. * All branded self-injectables are subject to prior authorization. 2. * Some drugs are limited to 1 unit of use package per dispensing. 3 G G G G G G Potassium Note: Specific Quantity Limits Apply. Prior Authorization Required. Included in Tablet-Splitting Program Access restricted to network specialty phamacies. G G G G G B Parkinson’s Disease Pain/Arthritis Miscellaneous Antidiuretic Agents TIER nabumetone naproxen naproxen EC piroxicam sulindac Voltaren gel G G G G G G SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D) TIER felbamate gabapentin lamotrigine levetiracetam oxcarbazepine primidone tiagabine topiramate valproic acid zonisamide Aptiom Banzel Fycompa Gabitril Lyrica Onfi Potiga Qudexy XR Sabril Trokendi XR Succinimides ethosuximide Celontin TIER G G G G G G G G G G B B B B B B B B B B ! ! Topical Anti-Inflammatory Agents ❚ adapalene amnesteem avita cream benzoyl peroxide claravis erythromycin/benz peroxide prascion RA sod.sulfacetamide/sulfur emulsion cleanser sod. sulfacetamide/sulfur lot sotret sulfacetamide tretinoin cr/gel Tazorac Antibiotics (Topical) acitretin clindamycin sol/swabs/gel/ lotion erythromycin sol/swabs/gel gentamicin cr/oint metronidazole cream/lotion/gel mupirocin Centany Antipsoriatics +!❚ acticin Lindane Ulesfia G B Skin Acne Scabicides & Pediculicides calcipotriene ointment calcipotriene solution tacrolimus ointment Elidel Stelara Burn preparation silver sulfadiazine Fungicides betamethasone/clotrimazole ciclopirox cream/gel ciclopirox soln econazole ketoconazole nystatin nystatin/triamcinolone nystop Exelderm Oxistat Other Topicals aluminum chloride 20% fluorouracil imiquimod 5% cream podofilox sodium chloride irrigating soln Carac Phisohex Regranex Psoralens 8-MOP Oxsoralen Ultra KEY: ❚ ! ◆ + = = = = G G G G G G G G G G G G B G G G G G G B G G G B B Topical Antipruritics/Anesthetics !❚ G G G G G B B B B B lidocaine lidocaine patch selenium sulf 2.25% shampoo Topical Antivirals acyclovir G B B peg 3350/electrolyte Digestants G G G G Creon Pancreaze Pertzye Ultresa Viokace Zenpep G G G G G G G G G G G G G G G B Gallstone Solubilizing Agents ursodiol H2 Antagonists cimetidine famotidine nizatidine ranitidine (all) Other Antiulcer misoprostol sucralfate Other GI Products G !❚ +! +! !❚ Proton Pump Inhibitors G G G G G G Antithyroid Thyroid G G G G B B Anticholinergics/Antispasmodic/GI Motility belladonna/phenobarbital chlordiazepoxide/clindinium dicyclomine glycopyrrolate hyoscyamine/CR metoclopramide Antidiarrheal ❚ diphenoxylate/atropine paregoric Alinia Fulyzaq Antiemetic/Antivertigo !❚ ❚ granisetron meclizine ondansetron prochlorperazine promethazine trimethobenzamide TIER B B G B B B B B B G G G G G G G G G G G G G B B B B B B B B B B B B + Contraceptives - Other ❚ G G levothroid levothyroxine levoxyl liothyronine thyroid unithroid Synthroid Thyrolar G G G G G G B B Vitamins G G G G G G calcitriol calcium acetate cyanocobalamin inj. etidronate disodium folic acid leucovorin levocarnitine multivitamin + fluoride phytonadione potassium aminobenzoate pre-natal vitamins sevelamer tablets sodium fluoride chewable tab & drops vit A,D,C + fluoride vit A,D,C + fluoride and iron Galzin Mephyton G G B B G G G G G G G G G G G G G G G G G G G G G B B xulane Mirena NuvaRing Hormones ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ estradiol/noreth ac estradiol oral estradiol patches estropipate estrogen/methyltesterone medroxyprogesterone norethindrone progesterone, micronized Cenestin Climara Pro Combipatch Enjuvia Estring Evamist Menest Premarin Premarin vag cream Premphase Prempro Vagifem Miscellaneous Brisdelle Oral Contraceptives G G G G methimazole propylthiouracil Nascobal Orfadin Renvela ❚ ❚ ❚ amethia apri aranelle aviane balziva camila camrese cesia cryselle enpresse errin jolessa jolivette junel/FE kariva lessina levonorgestrel levora low-ogestrel lutera microgestin/FE mononessa necon next choice next choice one dose nora-BE norethindrone a-e estradiol/ ferrous fumarate nortrel ocella ogestrel portia previfem quasense solia sprintec tri-sprintec trinessa trivora velivet zarah zenchent zovia Vaginal Preparations miconazole vag supp nystatin vag tab terconazole vandazole vag Note: Specific Quantity Limits Apply. Prior Authorization Required. Included in Tablet-Splitting Program Access restricted to network specialty phamacies. 1. * All branded self-injectables are subject to prior authorization. 2. * Some drugs are limited to 1 unit of use package per dispensing. 4 B B B Women’s Health Thyroid Stomach/Ulcer hydrocortisone/pramoxine hydrocortisone rectal cr. & supp. hydrocortisone rectal enema pramoxine/HC acetate 2.5% Cortifoam Proctofoam-HC lansoprazole omeprazole pantoprazole Prilosec-OTC ❚ ❚ ❚ ❚ Steroids Anorectal cromolyn sodium enulose lactulose mesalamine enema sulfasalazine sulfasalazine EC Asacol Asacol HD Canasa supp. Cimzia Delzicol Dipentum Gattex Kuvan Linzess Pentasa Relistor Uceris ER tablet G G G Members coverage varies by plan. Patient should be in a smoking cessation program. ❚ bupropion G ❚ Nicotine Gum G ❚ Nicotine lozenges G ❚ Nicotine patches various G ❚ Chantix B ❚ Commit B ❚ Nicotrol Inhaler/NS B cortisone acetate dexamethasone oral hydrocortisone oral methylprednisolone prednisolone oral prednisone oral Emend Transderm Scop Bowel Evacuants Smoking Cessation G G G G G G G G G B B alclometasone amcinonide betamethasone dipropionate betamethasone dipropionate augmented oint betamethasone valerate clobetasol propionate desonide desoximetasone diflorasone fluocinolone acetonide fluocinonide fluticasone propionate halobetasol hydrocortisone 2.5% hydrocortisone valerate hydrocortisone/iodoquinol hydrocortisone/urea mometasone cr/oint triamcinolone acetonide Cordran tape TIER !❚ G B B G G G G G G G G B B B B B B B B B B B B B G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G SECTION II — MEDICAID OVER-THE-COUNTER (OTC) MEDICATION LIST This OTC Medication List does not apply to Family Health Plus acetaminophen hydrocortisone permethrin AFRIN hydrocortisone acetate PINX ALAVERT ibuprofen polyethylene glycol alum/mag hydroxide w/simethicone iron prenatal aluminum acetate lice treatment PRILOSEC OTC aluminum hydroxide loperamide HCl pyridoxine HCl artificial tears loratadine ranitidine HCl aspirin loratadine-D reese’s pinworm aspirin buffered lubricant eye drops ROBITUSSIN B complex w/ vitamin C MAALOX ROBITUSSIN-DM bacitracin MAALOX PLUS EXTRA STRENGTH saline nasal spray BENADRYL magnesium senna BENEFIBER magnesium gluconate sennosides benzoyl peroxide mag-oxide SENOKOT beta-carotene meclizine HCl sinus congestion & pain bisacodyl METAMUCIL sochlor bismuth subsalicylate MICONAZOLE 3 SPECTRAVITE calcium + vitamin D MICONAZOLE 7 SPECTRAVITE SENIOR calcium carbonate miconazole nitrate SUDAFED PE calcium lactate MILK OF MAGNESIA SUDAFED SINUS NIGHTTIME CENTRA-VITE mineral oil suphedrine PE CENTRUM SILVER MONISTAT 1 SYSTANE cetirizine HCl MUCINEX THERAFLU children’s vitamin with minerals MUCINEX DM THERA-M children’s acetaminophen multivitamin tolnaftate children’s cold & cough multivitamin w/iron tussin CHILDREN’S MUCINEX multivitamin w/iron tussin DM CHILDREN’S PEPTO multivitamin w/minerals TYLENOL SINUS chlorpheniramine maleate multivitamin with calcium-iron VISINE cimetidine MYLANTA vitamin A clotrimazole vaginal NASACORT OTC vitamin B-1 cold multi-symptom nighttime nasal moisturizer vitamin C daytime cold & flu niacin vitamin D diabetic tussin DM NICODERM CQ vitamin D3 DIMAPHEN NICOTINE GUM vitamins A-D-E dimenhydrinate nighttime cold & flu relief ZANTAC OTC DIMETAPP NIX DIMETAPP DM OCUTABS diphenhydramine HCl OCUVITE docusate sodium OCUVITE PRESERVISION DRAMAMINE omeprazole famotidine oxymetazoline HCl fexofenadine oyster shell calcium fiber tabs oyster shell calcium w/vit D fiber therapy pedia relief cough & cold GAVISCON pediatric electrolyte guaifenesin PEPCID COMPLETE guaifenesin DM PEPTO-BISMOL KEY: ❚ ! ◆ + = = = = Note: Specific Quantity Limits Apply. Prior Authorization Required. Included in Tablet-Splitting Program Access restricted to network specialty phamacies. 1. * All branded self-injectables are subject to prior authorization. 2. * Some drugs are limited to 1 unit of use package per dispensing. 5 SECTION III — INDEX DRUG NAME TIER PAGE DRUG NAME A abacavir sulfate abacavir/lamivudine/ zidovudine ❚Abilify acamprosate calcium tablet EC acarbose !Accu-Chek acebutolol acetaminophen w/ codeine acetazolamide acetazolamide ER acetic acid HC otic acetic acid otic acetic acid/aluminum acetate acetylcysteine inh soln. acitretin +!❚Actemra SC +!❚Acthar H.P. gel acticin +!Actimmune ❚Actonel 5mg, 30mg ❚Actonel with Calcium acyclovir ❚acyclovir oral adapalene +!❚Adcirca +!❚Adempas ❚Advair diskus +!❚Afinitor Aggrenox ❚albuterol sulfate ER ❚albuterol tab, syr alclometasone ❚alendronate ❚alfuzosin HCl ❚Alinia allopurinol alprazolam/ER aluminum chloride 20% ❚Alvesco amantadine amcinonide amethia amiloride amiloride/HCTZ aminophylline amiodarone amitriptyline amitriptyline/ chlordiazepoxide amitriptyline/perphenazine amlodipine amlodipine/benazepril amnesteem amoxapine amoxicillin amoxicillin-clavulanate ER ampicillin +!Ampyra anagrelide anastrozole Androderm patch ❚Androgel Apidra +Apokyn apri Aptiom Aptivus aranelle +Aranesp +!Arcalyst Asacol Asacol HD !Ascensia Breeze aspirin SR Astagraf XL ❚Atelvia atenolol atenolol/chlorthalidone atorvastatin calcium atovaquone Atripla atropine sulfate ophth ❚Atrovent/HFA +!❚Aubagio ❚Avandamet ❚Avandaryl ❚Avandia aviane avita cream +!Avonex ❚Axiron azathioprine ❚azelastine 0.1% nasal spray azelastine ophth KEY: ❚ ! ◆ + = = = = G G B G G B G G G G G G G G G B B G B B B G G G B B B B B G G G G G B G G G B G G G G G G G G G G G G G G G G G B G G B B B B G B B G B B B B B G B B G G G G B G B B B B B G G B B G G G TIER PAGE DRUG NAME azithromycin suspension G G 2 azithromycin tablets B 2 Azopt B 3 bacitracin ophth 3 bacitracin/polymyxin baclofen 1 balziva 1 Banzel 2 belladonna & opium 3 supp belladonna/phenobarbital 2 benazepril 2 benazepril/HCTZ 1 benzonatate 1 benzoyl peroxide 1 benztropine +!Berinert 1 betamethasone 4 dipropionate 3 betamethasone 3 dipropionate 4 augmented oint 1 betamethasone valerate 3 betamethasone/ 3 clotrimazole 4 +!Betaseron 2 betaxolol 4 betaxolol HCl 2 bethanecol 2 Betoptic-S 3 bicalutamide 1 ❚Binosto 1 bisoprolol 3 bisoprolol/HCTZ 3 +!Bosulif 4 Brilinta 3 brimonidine 2 Brintellix 4 Brisdelle 1 bromfenac 3 bromocriptine 4 brompheniramine/ 3 phenylephrine 2,3 brompheniramine/ 4 pseudoephedrine 4 budesonide inh. 2 (0.25mg/2ml, 0.5mg/ 2 2ml) 3 bumetanide 2 buprenorphine HCl 3 ❚bupropion 3 ❚bupropion ER ❚bupropion XL 3 buspirone 2 butalbital/APAP 2 butalbital/APAP/caffeine 4 butalbital/aspirin/caffeine 3 butorphanol NS 2 !Bydureon 2 !Byetta 2 C 3 1 calcipotriene ointment 1 calcipotriene solution 2 ❚calcitonin-salmon 2 calcitriol 1 calcium acetate 3 camila 4 Campral dosepack 4 camrese 2 Canasa supp. 4 ❚candesartan 1 ❚candesartan/HCTZ 1 capecitabine 4 +!❚Caprelsa 4 captopril 1 captopril/HCTZ 3 Carac 2 carbamazepine 3 carbamazepine XR 2 200mg, 400mg 2 carbidopa/levodopa 2 carbidopa/levodopa SA 2 carbidopa/levodopa/ 2 entacapone 1 cardec/DM 3 carisoprodol 3 carisoprodol/ASA 1 carteolol 1 cartia XT 1 carvedilol 4 CeeNu 4 cefaclor 3 cefadroxil 2 cefdinir 2 cefpodoxime 1 cefprozil cefuroxime 1 !❚Celebrex G G G G B G G G G G G G B G G G G B G G G B G B G G B B G B B G G G G G G G G G G G G G G G B B G G G G G G B G B G G G B G G B G G G G G G G G G G G B G G G G G G B 2 Celontin 2 ❚Cenestin 1 Centany cephalexin 1 !❚Cerdelga 1 cesia 3 ❚cetirizine 4 ❚Chantix 4 chloral hydrate 3 chlordiazepoxide chlordiazepoxide/ 4 clindinium 2 chloroquine phosphate 2 chlorothiazide 1 chlorpheniramine/ 4 pseudoephedrine 3 chlorpromazine 2 chlorpropamide 4 chlorthalidone chlorzoxazone 4 cholestyramine choline mag. trisalicylate !ciclodan 4 ciclopirox cream/gel 4 ciclopirox soln cilostazol cimetidine 3 !❚Cimzia 2 !Cinryze 1 Ciprodex 1 ciprofloxacin 1 ciprofloxacin ophth 1 ◆citalopram 3 citric acid/sod citrate 2 claravis 2 clarithromycin susp 1 clarithromycin tabs 1 clemastine 1 ❚Climara Pro 3 clindamycin HCL 4 clindamycin sol/ 1 swabs/gel/lotion 3 clobetasol propionate 1 clomipramine clonazepam 1 clonidine, oral, patch clopidogrel 3 clorazepate clotrimazole lozenge clozapine 2 Coartem 3 codeine sulfate 3,4 colchicine 3 colchicine/probenecid 3 Colcrys 3 colestipol 3 ❚Combipatch 3 ❚Combivent Respimat 3 +!❚Cometriq 3 ❚Commit 1 Complera 1 !Contour +!Copaxone 4 Cordran tape 4 Cortifoam 3 cortisone acetate 4 Creon 4 Crixivan 4 cromolyn inh. soln. 3 cromolyn ophth 4 cromolyn sodium 4 cryselle 2 Cuprimine 2 cyanocobalamin inj. 1 cyclobenzaprine 1 cyclophosphamide 2 cyclosporine 2 cyproheptadine 4 Cystaran 3 D 3 danazol dantrolene sodium 3 Dapsone 3 Daraprim 3 Daytrana Delzicol 1 desipramine 3 desmopressin solution 3 desmopressin tabs 1 desmopressin vial 2 4mcg/ml 2 desonide 1 desoximetasone 2 Desvenlafaxine ER 2 Desvenlafaxine fumarate 2 dexameth/neomycin/ 2 poly B 2 dexamethasone ophth 2 dexamethasone oral 3 dexchlorpheniramine TIER PAGE DRUG NAME dexmethylphenidate dexmethylphenidate ER dextroamphetamine tabs diazepam Dibenzyline diclofenac potassium diclofenac sodium dicloxacillin dicyclomine didanosine diflorasone diflunisal digoxin dihydroergotamine mesylate Dilatrate SR diltia XT diltiazem diltiazem CD/SR/ER/XR Dipentum diphenhydramine diphenoxylate/atropine dipyridamole disopyramide disopyramide CR disulfiram divalproex sodium/ER ❚donepezil dorzolamide 2% eye drops dorzolamide/timolol eye drops doxazosin doxepin doxycycline ❚Dulera duloxetine B B B G B G G B G G G 4 4 4 2 3 4 1 4 3 3 4 G G G 2 2 1 G G G G G G G G G G G B B B G G G G G G G G B G G 3 1 2 3 2 3 2 4 4 1 4 4 2 1 2 1 3 1 4 2 2 1 E 4 econazole 2 Edurant 4 Effient !Egrifta 4 8-MOP 3 Elidel 3 Eliquis 2 Emcyt 1 !❚Emend 3 Emtriva 2 enalapril 3 enalapril/HCTZ 2 +!❚Enbrel 3 endocet 1 ❚Enjuvia 1 enoxaparin 1 enpresse 2 entacapone 4 enulose 3 epinephrine inj. 1 Epipen/Jr. 4 Epivir solution 2 Epivir-HBV solution 1 eplerenone 3 +Epogen 4 ❚eprosartan 4 Epzicom 4 ergoloid mesylates 4 Ergomar 2 ergotamine/caffeine 3 +!❚Erivedge 1 errin 4 Ery-Tab 4 erythromycin base 3 erythromycin 4 ethylsuccinate (E.E.S.) 3 erythromycin ophth 1 erythromycin sol/ 2 swabs/gel 1 erythromycin stearate 1 erythromycin/benz peroxide 3 erythromycin/ 3 sulfisoxazole 2 +!❚Esbriet 2 ◆escitalopram 3 estazolam 4 ❚estradiol oral 3 ❚estradiol patches 3 ❚estradiol/noreth ac 3 ❚Estring 3 ❚estrogen/ methyltesterone 4 ❚estropipate 4 ethambutol 3 ethosuximide 3 etidronate disodium 1 etodolac etodolac SA 1 etoposide 4 ❚Evamist 1 Evotaz G G G G G G G G B G G G B G B B B B B B B B B G B B G G G G B G G G G G B G G B B B B G G G G G G B B G G G G TIER PAGE DRUG NAME G G G G B G G G G G G G G G 3 3 3 3 2 3 3 2 4 2 4 3 2 3 B G G G B G G G G G G G G G 2 2 2 2 4 1 4 1 2 2 3 3 1 1 G 1 G G G B G 2 3 2 3 3 G B B B B B B B B B G G B G B G G G G G B B B G B G B G B G B G B G G 4 2 1 3 4 4 1 1 4 2 2 2 3 3 4 1 4 3 4 3 3 2 2 2 1 2 2 1 3 3 1 4 2 2 2 G G 1 4 G G 2 4 G 2 B G G G G G B G 3 3 3 4 4 4 4 4 G G G G G G G B B 4 2 4 4 3 3 1 4 2 ❚Evzio Exelderm ❚Exelon Patch exemestane +Exjade +!Extavia TIER PAGE DRUG NAME F ❚famciclovir famotidine ❚Fanapt Fareston ❚Farxiga felbamate felodipine ER fenofibrate fenofibric acid, tab fenoprofen !❚fentanyl lozenge fentanyl patch Fetzima !❚finasteride +!Firazyr flecainide +!Flolan ❚Flovent Diskus ❚Flovent HFA fluconazole flucytosine fludrocortisone fluocinolone acetonide fluocinonide fluorometholone ophth fluorouracil ◆fluoxetine 10, 20mg tablet fluoxetine capsule fluphenazine decanoate fluphenazine, oral flurazepam flurbiprofen flurbiprofen ophth flutamide ❚fluticasone nasal spray fluticasone propionate fluvastatin ◆fluvoxamine tab FML Forte FML S.O.P. folic acid fondaparinux +!Forteo ❚Fortesta ❚fortical NS ❚Fosamax Plus D fosinopril Fragmin !FreeStyle Fulyzaq furosemide +Fuzeon Fycompa G gabapentin Gabitril ❚galantamine Galzin +!Gamunex C ganciclovir +!Gattex gemfibrozil generic Adderall generic Adderall XR generic Concerta generic Dexedrine spansules gengraf +!Genotropin gentamicin cr/oint gentamicin ophth +!❚Gilenya +!❚Gilotrif +!❚Gleevec ❚glimepiride glipizide ❚glipizide ER ❚glipizide/metformin Glucagon glyburide glyburide micronized glycopyrrolate !❚granisetron !❚Grastek griseofulvin guaifenesin 1200/DM guaifenesin/codeine guanabenz B B B G B B 3 4 1 1 1 3 G G B B B G G G G G G G B G B G B B B G G G G 1,2 4 3 1 1 4 2 2 2 3 3 3 3 1,2 2 2 2 3 3 2 2 3 4 G G 4 1 G G 4 3 G G 3 3 G G G G G G G G G B B G G B B G B G B B B G B B 3 3 3 1 1 1 4 2 3 1 1 4 1 3 2 3 3 2 1 1 4 2 2 4 G B G B B G B G G G G G 4 4 1 4 3 2 4 2 3 3 3 3 G B G G B B B G G G G B G G G G B G G G G 2 3 4 1 3 1 1 1 1 1 1 1 1 1 4 4 1 2 1 1 2 guanfacine TIER PAGE H halobetasol haloperidol decanoate haloperidol, oral +!❚Harvoni heparin ❚Hepsera !❚Hetlioz Hexalen Histex IE +!Hizentra homatropine Humalog insulin +!Humatrope +!❚Humira Humulin (all types) +Hycamptin hydralazine hydrochlorothiazide hydrocodone/ chlorpheniramine hydrocodone/ homatropine hydrocodone/ibuprofen hydrocortisone 2.5% hydrocortisone oral hydrocortisone rectal cr. & supp. hydrocortisone rectal enema hydrocortisone valerate hydrocortisone/ iodoquinol hydrocortisone/ pramoxine hydrocortisone/urea hydromorphone hydroxychloroquine hydroxyurea hydroxyzine HCL hydroxyzine pamoate hyoscyamine/CR G 1 G G G G 3 4 4 4 G 4 G G 4 4 G 4 4 3 2,3 1 1 1 4 ❚ibandronate ibuprofen +!❚Iclusig !❚Imbruvica imipramine imiquimod 5% cream indapamide indomethacin +!❚Inlyta +Innohep Intelence +!Intron A Intuniv ❚Invega Invirase ❚Invokamet ❚Invokana ipratropium inh. soln. ipratropium nasal spray ❚irbesartan ❚irbesartan/HCTZ !Iressa Isentress isometh/ dichloralphen/APAP isoniazid Isopto Carbachol 1.5% isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate SA isoxsuprine isradipine ❚itraconazole G G B B G G G G B B B B B B B B B G G G G B B G 3 3 1 1 3 4 2 1,3 1 1 2 1 3 3 2 1 1 3 1 2 2 1 2 3 G B G G G 2 1 2 2 2 G G G 2 2 2 +!❚Jakafi jantoven ❚Janumet ❚Januvia ❚Jardiance Jentadueto jolessa jolivette junel/FE Juvisync B G B B B B G G G B 1 1 1 1 1 1 4 4 4 1 B B G B B G G G 3 2 4 1 2 2,4 3 3 I J K +!Kaldydeco Kaletra kariva Kazano Ketek ketoconazole ketoprofen ketorolac inj. 1. * All branded self-injectables are subject to prior authorization. 2. * Some drugs are limited to 1 unit of use package per dispensing. 6 2 4 3 3 2 1 2 3 1 1 3 1 1 3 3 1 1 2 2 1 G G G G G G G Note: Specific Quantity Limits Apply. Prior Authorization Required. Included in Tablet-Splitting Program Access restricted to network specialty phamacies. G G G G B G B B B B B G B B B B B G G G SECTION III — INDEX (CONT’D) DRUG NAME TIER PAGE DRUG NAME ❚ketorolac tab ketorolac tromethamine ketotifen opthalmic solution Khedezla +!Kineret Kombiglyze +!Kuvan +!Kynamro G G G labetalol lactulose lamivudine lamivudine tabs lamivudine/zidovudine lamotrigine ❚lansoprazole Lantus latanoprost ❚Latuda leflunomide lessina +!❚Letairis letrozole leucovorin Leukeran +!Leukine !leuprolide Levemir levetiracetam levobunolol levocarnitine ❚levonorgestrel levora levothroid levothyroxine levoxyl Lexiva lidocaine !❚lidocaine patch Lindane Linzess liothyronine lisinopril lisinopril/HCTZ lithium carbonate loratadine loratadine-D lorazepam ❚losartan ❚losartan HCT Lotemax ❚◆lovastatin low-ogestrel loxapine Lumigan lutera Lyrica Lysodren G G G G G G G B G B G G B G G B B G B G G G G G G G G B G G B B G G G G G G G G G B G G G B G B B Malarone maprotiline Matulane ❚Maxair Autohaler meclizine meclofenamate medroxyprogesterone mefloquine megestrol +!❚Mekinist meloxicam melphalan ❚Menest meperidine meperidine/promethazine Mephyton meprobamate mercaptopurine mesalamine enema mesna metadate ER metaproterenol syr metformin ❚metformin ER ❚metformin/glyburide methadone methazolamide methenamine combination methimazole methocarbamol methotrexate methyldopa methyldopa/HCTZ methylphenidate/SR/CD methylprednisolone metipranolol metoclopramide metolazone B G B B G G G G G B G G B G G B G G G G G G G G G G G G L M KEY: ❚ ! ◆ + = = = = B B B B B G G G G G G G G G G 3 metoprolol 1 metoprolol ER 1 metoprolol/HCTZ metronidazole 3 metronidazole cream/ 3 lotion/gel 1 mexiletine 4 Miacalcin inj. 2 miconazole vag supp microgestin/FE 2 midodrine 4 minocycline 2 minoxidil oral 2 Mirena 2 ◆mirtazapine 4 misoprostol 4 !❚modafinil 1 mometasone cr/oint 1 mononessa 3 ❚montelukast 3 morphine SR 4 morphine tab, soln, supp 2 MSIR tabs, sol 1 multivitamin + fluoride 4 mupirocin 1 +!❚Myalept 1 mycophenolate 1 mofetil 1 Myleran N 4 1 nabumetone 4 nadolol 4 naltrexone 4 ❚Namenda 4 naphazoline 4 naproxen 4 naproxen EC 2 ❚naratriptan 4 ❚Nasacort OTC 4 Nascobal 4 ❚nateglinide 4 Nebupent 4 necon 2 nefazodone 2 neomycin 3 neomycin/bacitracin/ 1 poly B 1 neomycin/bacitracin/ 3 poly B/HC 2 neomycin/polymyxin/ 2 HC otic 1 Nesina 2 !Neulasta 4 +!Neumega 3 +!Neupogen 1 Nevanac 4 nevirapine 4 +!❚Nexavar 1 ❚next choice ❚next choice one dose 2 niacin ER 3 nicardipine 1 ❚Nicotine Gum 3 ❚Nicotine lozenges 4 ❚Nicotine patches 3 various 4 ❚Nicotrol Inhaler/NS 2 nifediac CC 1 nifedical XL 1 nifedipine 3 nifedipine SR 1 Nilandron 4 nimodipine 3 nisoldipine 3 nitrofurantoin 4 nitroglycerin oint 3 nitroglycerin pumpspray 1 nitroglycerin SR 4 nitroglycerin 1 transdermal patch 3 Nitrostat 3 nizatidine 1 nora-BE 1 +!Norditropin 1 norethindrone 3 norethindrone a-e 2 estradiol/ferrous 2 fumarate +!❚Northera 4 nortrel 3 nortriptyline 1,3 Norvir 2 Novolin 2 Novolog 3 +!Nutropin 4 NuvaRing 1 !❚Nuvigil 4 nystatin 2 nystatin vag tab TIER PAGE DRUG NAME G G G G G 2 2 2 2 4 G B G G G G G B G G G G G G G G G G G B G 2 1 4 4 2 2 2 4 3 4 3 4 4 3 3 3 3 4 4 3 2 B 1 G G G B G G G G B B G B G G G G 3 2 3 1 1 3 3 3 1 4 1 2 4 3 2 1 G 1 G 1 B B B B B G B G G G G G G G 1 1 1 1 1 2 1 4 4 2 2 4 4 4 B G G G G B G G G G G G G 4 2 2 2 2 1 2 2 2 2 2 2 2 B G G B G G 2 4 4 3 4 4 B G G B B B B B B G G 2 4 3 2 1 1 3 4 3 2,4 4 TIER PAGE DRUG NAME nystatin/triamcinolone nystop G G ocella +octreotide +!❚Ofev ofloxacin ofloxacin ophth ofloxacin otic ogestrel ❚olanzapine ❚olanzapine/ fluoxetine +!❚Olysio ❚omeprazole +!Omnitrope ❚ondansetron OneTouch Onfi Onglyza Opana ER +!❚Opsumit !❚Oralair +!❚Orencia +!❚Orenitram +Orfadin orphenadrine Oseni +!❚Otezla oxazepam oxcarbazepine Oxistat Oxsoralen Ultra ❚oxybutynin ❚oxybutynin ER oxycodone oxycodone/ acetaminophen oxycodone/aspirin oxymorphone ER G G B G G G G G G O P B G B G B B B B B B B B B G B B G G B B G G G G G G Pancreaze B ❚pantoprazole G paregoric G paromomycin G ◆paroxetine HCl G Patanol B peg 3350/electrolyte G +!Pegasys B penicillin VK G Pentasa B pentazocine/naloxone G pentoxifylline G perphenazine G Pertzye B Pexeva B phenazopyridine G phenelzine G phenobarbital G phenylephrine ophth G phenytoin G Phisohex B Phospholine Iodide B phytonadione G pilocarpine G pindolol G ❚pioglitazone G piroxicam G +!❚Plegridy B podofilox G polymyxin B/TMP G +!❚Pomalyst B portia G potassium aminobenzoate G potassium bicarbonate G potassium chloride G potassium citrate G Potiga B ❚Pradaxa B pramipexole G pramoxine/HC acetate G 2.5% prascion RA G ❚◆pravastatin G prazosin G pre-natal vitamins G !Precision B Pred Mild B prednisolone acetate G prednisolone oral G prednisolone sod acetate G prednisone oral G ❚Premarin B Premarin vag cream B ❚Premphase B ❚Prempro B previfem G Prezcobix B Prezista B 4 ❚Prilosec-OTC 4 Primaquine primidone 4 Pristiq 3 ❚ProAir HFA 3 probenecid 2 procentra 1 prochlorperazine 1 +Procrit 4 Proctofoam-HC 3 +!Procysbi 3 progesterone, micronized +!❚Promacta promethazine 2 promethazine/codeine 4 propafenone 3 propranolol 4 propranolol/HCTZ 1 propylthiouracil 4 pseudoephedrine 1 pseudoephedrine/ 3 codeine 2 ❚Pulmicort Flexhaler 1 +Pulmozyme 3 Purixan 2 pyrazinamide 4 Q 3 1 quasense Qudexy XR 3 3 ❚quetiapine 4 quinapril 4 quinapril/HCTZ 4 quinidine gluconate 1 quinidine sulfate SR 1 ❚Qvar R 3 3 !❚Ragwitek ❚raloxifene 3 ramipril 3 Ranexa ranitidine (all) 4 !Ravicti 4 +!Rebif 4 Regranex 2 ❚Relenza 3 !❚Relistor 1 Renvela 4 ❚repaglanide 2 Rescriptor 2 Retrovir IV infusion vial 4 +!❚Revlimid 3 Reyataz 1 +!ribapak 3 +!ribasphere 4 +!ribavirin 3 Ridaura 1 rifabutin 3 rifampin 3 Rifater 1 Rilutek 3 rimantadine 4 ❚risedronate 150mg 1 ❚risperidone 4 ❚risperidone m-tab 1 ❚rivastigamine 2 ropinirole 1 +!❚Ruconest S 3 3 Sabril 4 +!Saizen 1 salsalate 1 !❚Samsca 4 Sandimmune 4 ❚Saphris 3 Savella 3 ❚selegiline 1 selenium sulf 2.25% 4 shampoo 1 Selzentry 3 Semprex-D 4 +Sensipar ❚Serevent Diskus 4 ❚Seroquel XR 2 ◆sertraline 2 sevelamer tablets 4 +!❚Signifor 1 silver sulfadiazine 1 +!❚Simponi 1 ❚◆simvastatin 4 sirolimus 1 !❚Sivextro 4 sod. polystyrene 4 sulfonate 4 sod. sulfacetamide/ 4 sulfur lot 4 sod.sulfacetamide/sulfur 4 emulsion cleanser 2 sodium chloride 2 irrigating soln TIER PAGE DRUG NAME G B G B B G G G B B B G B G G G G G G G G 4 2 4 3 3 1 3 4 1 4 3 4 1 1,4 1 2 2 2 4 1 1 B B B G 3 3 1 2 G B G G G G G B 4 4 3 2 2 2 2 3 B G G B G B B B B B B G B B B B G G G B G G B B G G G G G G B 1 3 2 2 4 3 3 4 2 4 4 1 2 2 1 2 2 2 2 3 2 2 2 3 2 3 3 3 1 3 2 B B G B B B B G G 4 3 3 2 2 3 3 3 4 B B B B B G G B G B G G B G 2 1 3 3 3 3 4 1 4 3 2 2 2 3 G 4 G 4 G 4 TIER PAGE DRUG NAME sodium fluoride chewable tab & drops solia +!Somavert sotalol sotret +!❚Sovaldi ❚Spiriva ❚Spiriva Respimat spironolactone spironolactone/HCTZ sprintec +!❚Sprycel stavudine +!❚Stelara +Stimate +!Stivarga Strattera Stribild Suboxone Film sucralfate sulfacetamide sulfacetamide 10% sulfacetamide/ prednisolone ophth sulfamethoxazole/ trimethoprim sulfasalazine sulfasalazine EC sulindac ❚sumatriptan Sustiva +!❚Sutent +!❚Sylatron ❚Symbicort !❚Symlin Synarel Synthroid G tacrolimus tacrolimus ointment +!❚Tafinlar ❚Tamiflu tamoxifen tamsulosin !❚Tanzeum +!Tarceva Targretin +!❚Tasigna !Tazorac +!❚Tecfidera !❚Tekturna !❚Tekturna HCT ❚telmisartan ❚telmisartan/HCTZ temazepam +!temozolomide terazosin ❚terbinafine terbutaline tab terconazole ❚Testim ❚Testosterone gel tetracycline +!Tev-Tropin +Thalomid theochron theophylline/SR tabs, liquid thioridazine thiothixene thyroid Thyrolar tiagabine ticlopidine timolol Tivicay tizanidine +Tobi tobramycin soln tobramycin/dexameth tolazamide tolbutamide ❚tolterodine ❚tolterodine ER topiramate topotecan torsemide +!❚Tracleer Tradjenta tramadol Transderm Scop tranylcypromine travoprost trazodone !tretinoin cr/gel tri-sprintec ❚triamcinolone acetonide triamterene/HCTZ triazolam T G B G G B B B G G G B G B B B B B B G G G G TIER PAGE 4 trifluoperazine trifluridine 4 trihexyphenidyl 3 trimethobenzamide 2 trimethoprim 4 trinessa 2 Triumeq 3 trivora 3 Trokendi XR 2 tropicamide 2 ❚trospium 4 1 !TRUEtest 2 !TRUEtrack 4 !❚Trulicity 3 Truvada 1 Tybost 3 +!Tykerb U 2 3 Uceris ER tablet 4 Ulesfia 4 Ultresa 1 unithroid 1 ursodiol G 2 G G G G B B B B B B B 4 4 3 3 2 1 1 3 1 3 4 G G B B G G B B B B B B B B G G G G G G G G B B G B B G G 2 4 1 2 1 1,2 1 1 1 1 4 3 2 2 2 2 3 1 2 2 3 4 2 2 2 3 1 3 3 G G G B G G G B G B G G G G G G G G G B B G B G G G G G G G G 3 3 4 4 4 1 1,2 2 3 2 1 1 1 1 1 1 4 1 2 2 1 3 4 3 1 3 4 4 4 2 3 V B B B G G 4 4 4 4 4 B G B G G G G G G B G G G B G G B B B B B B B B B B G G 4 2 1 2 4 2 2 2 4 2 4 3 3 3 2 2 3 1 2 2 2 3 4 2 2 2 4 4 B B B G B 2 2 3 2 1 warfarin G 1 B B B B B B G 1 1 3 2 1 1 4 G 2 G G G B B G B B G G B B G G G B B G B B B B 3 3 4 3 1 4 4 2 2 3 2 1 3 3 4 1 3 4 1 1 1 2 W +!❚Xalkori Xarelto +!❚Xeljanz +!❚Xenazine ❚Xigduo XR +!Xtandi ❚xulane yohimbine X Y Z ❚zafirlukast ❚zaleplon zarah +Zavesca +!❚Zelboraf zenchent Zenpep ❚Zetia zidovudine ❚ziprasidone caps Zmax !Zolinza ❚zolpidem ❚zolpidem CR zonisamide !❚Zontivity +!Zorbtive zovia !❚Zydelig +!❚Zykadia +!❚Zytiga !❚Zyvox 1. * All branded self-injectables are subject to prior authorization. 2. * Some drugs are limited to 1 unit of use package per dispensing. 7 3 1 3 4 2 4 2 4 4 1 1 1 1 1 2 2 1 Vagifem ❚valacyclovir +!❚Valchlor valganciclovir tablets valproic acid ❚valsartan ❚valsartan/HCTZ vancomycin vandazole vag +!Veletri velivet ◆venlafaxine venlafaxine ER ❚Ventolin HFA verapamil verapamil SR Versacloz !❚Victoza Videx Videx pediatric solution +!❚Viekira Pak Viibryd Viokace Viracept Viramune XR Viread vit A,D,C + fluoride vit A,D,C + fluoride and iron Vitekta ❚Vogelxo Voltaren gel !❚voriconazole !Votrient Note: Specific Quantity Limits Apply. Prior Authorization Required. Included in Tablet-Splitting Program Access restricted to network specialty phamacies. G G G G G G B G B G G B B B B B B
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