California Small Group
2017 California 4 Tier Prescription Drug List Please note: This Prescription Drug List (PDL) is accurate as of June 15, 2017 and is subject to change after this date. Your estimated coverage and copay/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.
Updated June 15, 2017
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At UnitedHealthcare, 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.
What is a Prescription Drug List (PDL)? This document is a list of covered medications. Medications are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the Food and Drug Administration (FDA). Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. You may also log in to myuhc.com or call the toll-free member phone number on your health plan ID card for more information.
How do I use my PDL? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if special programs apply. Bring this list with you when you see your doctor. It is organized by common medication categories and class. Medications are then listed alphabetically. If your medication is not listed in this document, please visit myuhc.com or call the toll-free member phone number on your health plan ID card.
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. Discuss these options with your doctor. Check your benefit plan documents to find out your specific pharmacy plan costs.
$
Drug tier
Includes
Helpful tips
Tier 1 Your lowest cost
Some brands and generics are also included.
Use Tier 1 drugs for the lowest out-of-pocket costs.
Tier 2 and 3 Your mid-range cost
Mix of brands and generics.
Use Tier 2 or Tier 3 drugs instead of Tier 4 to help reduce your out-of-pocket costs.
Tier 4 Your highest cost
Mostly brand as well as select generic drugs.
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: If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more information about your benefit plan.
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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 become non-formulary 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 customer service at the number on your ID card.
Programs and limits Call the number for Member Services listed on your ID card if you have any questions about your prescription drug coverage. Designated specialty program — Specialty medications need to be filled at a designated specialty pharmacy for network coverage. Call the number on your ID card or call 1-888-739-5820 for more information. Health care reform preventive — This medication is part of a health care reform preventive benefit and may be available at no cost to you. Prior authorization required* — 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 different medication is required before another medication may be covered. *Depending on your benefit, you may have notification or medical necessity requirements for select medications.
To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call the toll-free member phone number on your health plan ID card.
Your Right to Request Access to a Non-formulary Drug When a Prescription Drug Product is not on our formulary, you or your representative may request an exception to gain access to that Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Urgent Requests If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours. External Review If you are not satisfied with our determination of your exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of our determination within 72 hours. Expedited External Review If your are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours.
Should I talk to my doctor about over-the-counter (OTC) medications? An OTC medication may be the right treatment for some conditions. Talk to your doctor about available options.
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What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name 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.
What if my doctor writes a brand-name prescription? 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 benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent. Visit myuhc.com to make sure.
Are you taking a specialty medication? Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the Specialty Pharmacy Program. 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 3 or Tier 4, call the toll-free number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.
How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on your health plan ID card for more current information. Log in to myuhc.com for the following pharmacy information and tools: • Pharmacy benefit and coverage information • Possible lower-cost medication options • Medication interactions and side effects • Participating retail pharmacies by ZIP code • Your prescription history And, if home delivery services are included in your pharmacy benefit, you can also: • Refill prescriptions • Check the status of your order • Set up reminders for refills • Manage your account
Call the toll-free member phone number on your health plan ID card, or visit myuhc.com® for more information.
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. Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines coverage for these medications.
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Nondiscrimination notice and access to communication services UnitedHealthcare® does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online:
[email protected] Mail:
Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130
You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail:
U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.
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Therapeutic Class 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs
Label Name
Generic Name
Tier Value
ADASUVE INH 10MG
LOXAPINE AEROSOL POWDER BREATH ACTIVATED 10 MG
Tier 3
CHLORPROMAZ POW HCL
CHLORPROMAZINE HCL POWDER
Tier 3
CHLORPROMAZ TAB 100MG CHLORPROMAZINE HCL TAB 100 MG
Tier 1
CHLORPROMAZ TAB 10MG
Tier 1
CHLORPROMAZINE HCL TAB 10 MG
CHLORPROMAZ TAB 200MG CHLORPROMAZINE HCL TAB 200 MG
Tier 1
CHLORPROMAZ TAB 25MG
CHLORPROMAZINE HCL TAB 25 MG
Tier 1
CHLORPROMAZ TAB 50MG
CHLORPROMAZINE HCL TAB 50 MG
Tier 1
COMPRO SUP 25MG
PROCHLORPERAZINE SUPPOS 25 MG
Tier 1
FLUPHENAZINE CON 5MG/ ML
FLUPHENAZINE HCL ORAL CONC 5 MG/ ML
Tier 1
FLUPHENAZINE ELX 2.5/5ML FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML
Tier 1
FLUPHENAZINE TAB 10MG
FLUPHENAZINE HCL TAB 10 MG
Tier 1
FLUPHENAZINE TAB 1MG
FLUPHENAZINE HCL TAB 1 MG
Tier 1
FLUPHENAZINE TAB 2.5MG
FLUPHENAZINE HCL TAB 2.5 MG
Tier 1
FLUPHENAZINE TAB 5MG
FLUPHENAZINE HCL TAB 5 MG
Tier 1
HALOPERIDOL CON 2MG/ ML
HALOPERIDOL LACTATE ORAL CONC 2 MG/ML
Tier 1
HALOPERIDOL TAB 0.5MG
HALOPERIDOL TAB 0.5 MG
Tier 1
HALOPERIDOL TAB 10MG
HALOPERIDOL TAB 10 MG
Tier 1
HALOPERIDOL TAB 1MG
HALOPERIDOL TAB 1 MG
Tier 1
HALOPERIDOL TAB 20MG
HALOPERIDOL TAB 20 MG
Tier 1
HALOPERIDOL TAB 2MG
HALOPERIDOL TAB 2 MG
Tier 1
HALOPERIDOL TAB 5MG
HALOPERIDOL TAB 5 MG
Tier 1
LOXAPINE CAP 10MG
LOXAPINE SUCCINATE CAP 10 MG
Tier 1
LOXAPINE CAP 25MG
LOXAPINE SUCCINATE CAP 25 MG
Tier 1
LOXAPINE CAP 50MG
LOXAPINE SUCCINATE CAP 50 MG
Tier 1
LOXAPINE CAP 5MG
LOXAPINE SUCCINATE CAP 5 MG
Tier 1
ORAP TAB 1MG
PIMOZIDE TAB 1 MG
Tier 3
ORAP TAB 2MG
PIMOZIDE TAB 2 MG
Tier 3
PERPHENAZINE TAB 16MG
PERPHENAZINE TAB 16 MG
Tier 1
PERPHENAZINE TAB 2MG
PERPHENAZINE TAB 2 MG
Tier 1
PERPHENAZINE TAB 4MG
PERPHENAZINE TAB 4 MG
Tier 1
PERPHENAZINE TAB 8MG
PERPHENAZINE TAB 8 MG
Tier 1
PIMOZIDE TAB 1MG
PIMOZIDE TAB 1 MG
Tier 2
PIMOZIDE TAB 2MG
PIMOZIDE TAB 2 MG
Tier 2
PROCHLORPER SUP 25MG
PROCHLORPERAZINE SUPPOS 25 MG
Tier 1
PROCHLORPER TAB 10MG PROCHLORPER TAB 5MG
PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT) PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT)
Tier 1 Tier 1
THIORIDAZINE TAB 100MG
THIORIDAZINE HCL TAB 100 MG
Tier 1
THIORIDAZINE TAB 10MG
THIORIDAZINE HCL TAB 10 MG
Tier 1
THIORIDAZINE TAB 25MG
THIORIDAZINE HCL TAB 25 MG
Tier 1
7
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - Mood Disorder Drugs 1st Generation/Typical - 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 2nd Generation/Atypical - Mood Disorder Drugs 2nd Generation/Atypical - Mood Disorder Drugs
Label Name
Generic Name
Tier Value
THIORIDAZINE TAB 50MG
THIORIDAZINE HCL TAB 50 MG
Tier 1
THIOTHIXENE CAP 10MG
THIOTHIXENE CAP 10 MG
Tier 1
THIOTHIXENE CAP 1MG
THIOTHIXENE CAP 1 MG
Tier 1
THIOTHIXENE CAP 2MG
THIOTHIXENE CAP 2 MG
Tier 1
THIOTHIXENE CAP 5MG
THIOTHIXENE CAP 5 MG
Tier 1
TRIFLUOPERAZ TAB 10MG
TRIFLUOPERAZINE HCL TAB 10 MG
Tier 1
TRIFLUOPERAZ TAB 1MG
TRIFLUOPERAZINE HCL TAB 1 MG
Tier 1
TRIFLUOPERAZ TAB 2MG
TRIFLUOPERAZINE HCL TAB 2 MG
Tier 1
TRIFLUOPERAZ TAB 5MG
TRIFLUOPERAZINE HCL TAB 5 MG
Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
ARIPIPRAZOLE SOL 1MG/ML ARIPIPRAZOLE ORAL SOLUTION 1 MG/ML
Tier 3
ARIPIPRAZOLE TAB 10MG
ARIPIPRAZOLE TAB 10 MG
Tier 2
X
ARIPIPRAZOLE TAB 10MG ODT
ARIPIPRAZOLE ORALLY DISINTEGRATING TAB 10 MG
Tier 2
X
ARIPIPRAZOLE TAB 15MG
ARIPIPRAZOLE TAB 15 MG
Tier 2
X
ARIPIPRAZOLE TAB 15MG ODT
ARIPIPRAZOLE ORALLY DISINTEGRATING TAB 15 MG
Tier 2
X
ARIPIPRAZOLE TAB 20MG
ARIPIPRAZOLE TAB 20 MG
Tier 2
X
ARIPIPRAZOLE TAB 2MG
ARIPIPRAZOLE TAB 2 MG
Tier 2
X
ARIPIPRAZOLE TAB 30MG
ARIPIPRAZOLE TAB 30 MG
Tier 2
X
ARIPIPRAZOLE TAB 5MG
ARIPIPRAZOLE TAB 5 MG
Tier 2
X
FANAPT PAK
ILOPERIDONE TAB 1 MG & 2 MG & 4 MG & 6 MG TITRATION PAK
Tier 3
X
FANAPT TAB 10MG
ILOPERIDONE TAB 10 MG
Tier 3
X
FANAPT TAB 12MG
ILOPERIDONE TAB 12 MG
Tier 3
X
FANAPT TAB 1MG
ILOPERIDONE TAB 1 MG
Tier 3
X
FANAPT TAB 2MG
ILOPERIDONE TAB 2 MG
Tier 3
X
FANAPT TAB 4MG
ILOPERIDONE TAB 4 MG
Tier 3
X
FANAPT TAB 6MG
ILOPERIDONE TAB 6 MG
Tier 3
X
FANAPT TAB 8MG
ILOPERIDONE TAB 8 MG
Tier 3
X
LATUDA TAB 120MG
LURASIDONE HCL TAB 120 MG
Tier 3
X
LATUDA TAB 20MG
LURASIDONE HCL TAB 20 MG
Tier 3
X
LATUDA TAB 40MG
LURASIDONE HCL TAB 40 MG
Tier 3
X
LATUDA TAB 60MG
LURASIDONE HCL TAB 60 MG
Tier 3
X
LATUDA TAB 80MG
LURASIDONE HCL TAB 80 MG
Tier 3
X
OLANZAPINE TAB 10MG
OLANZAPINE TAB 10 MG
Tier 1
X
OLANZAPINE TAB 10MG ODT
OLANZAPINE ORALLY DISINTEGRATING TAB 10 MG
Tier 3
X
OLANZAPINE TAB 15MG
OLANZAPINE TAB 15 MG
Tier 1
X
OLANZAPINE TAB 15MG ODT
OLANZAPINE ORALLY DISINTEGRATING TAB 15 MG
Tier 3
X
OLANZAPINE TAB 2.5MG
OLANZAPINE TAB 2.5 MG
Tier 1
X
OLANZAPINE TAB 20MG
OLANZAPINE TAB 20 MG
Tier 1
X
OLANZAPINE TAB 20MG ODT
OLANZAPINE ORALLY DISINTEGRATING TAB 20 MG
Tier 3
X
OLANZAPINE TAB 5MG
OLANZAPINE TAB 5 MG
Tier 1
X
8
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 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
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Generic Name
OLANZAPINE TAB 5MG ODT
OLANZAPINE ORALLY DISINTEGRATING TAB 5 MG
Tier 3
X
OLANZAPINE TAB 7.5MG
OLANZAPINE TAB 7.5 MG
Tier 1
X
PALIPERIDONE TAB ER 1.5MG
PALIPERIDONE TAB SR 24HR 1.5 MG
Tier 3
X
PALIPERIDONE TAB ER 3MG PALIPERIDONE TAB SR 24HR 3 MG
Tier 3
X
PALIPERIDONE TAB ER 6MG PALIPERIDONE TAB SR 24HR 6 MG
Tier 3
X
PALIPERIDONE TAB ER 9MG PALIPERIDONE TAB SR 24HR 9 MG
Tier 3
X
QUETIAPINE TAB 100MG
QUETIAPINE FUMARATE TAB 100 MG
Tier 1
QUETIAPINE TAB 150MG ER
QUETIAPINE FUMARATE TAB SR 24HR 150 MG
Tier 3
QUETIAPINE TAB 200MG
QUETIAPINE FUMARATE TAB 200 MG
Tier 1
QUETIAPINE FUMARATE TAB SR 24HR QUETIAPINE TAB 200MG ER 200 MG
Tier 3
QUETIAPINE TAB 25MG
QUETIAPINE FUMARATE TAB 25 MG
Tier 1
QUETIAPINE TAB 300MG
QUETIAPINE FUMARATE TAB 300 MG
Tier 1
QUETIAPINE FUMARATE TAB SR 24HR QUETIAPINE TAB 300MG ER 300 MG
Tier 3
QUETIAPINE TAB 400MG
Tier 1
QUETIAPINE FUMARATE TAB 400 MG
QUETIAPINE FUMARATE TAB SR 24HR QUETIAPINE TAB 400MG ER 400 MG
Tier 3
QUETIAPINE TAB 50MG
QUETIAPINE FUMARATE TAB 50 MG
Tier 1
QUETIAPINE TAB 50MG ER
QUETIAPINE FUMARATE TAB SR 24HR 50 MG
Tier 3
RISPERIDONE SOL 1MG/ML
RISPERIDONE SOLN 1 MG/ML
Tier 1
RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 0.25 ODT TAB 0.25 MG
Tier 1
RISPERIDONE TAB 0.25MG
RISPERIDONE TAB 0.25 MG
Tier 1
RISPERIDONE TAB 0.5MG
RISPERIDONE TAB 0.5 MG
Tier 1
RISPERIDONE TAB 0.5MG OD
RISPERIDONE ORALLY DISINTEGRATING TAB 0.5 MG
Tier 1
RISPERIDONE TAB 1MG
RISPERIDONE TAB 1 MG
Tier 1
RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 1MG ODT TAB 1 MG
Tier 1
RISPERIDONE TAB 2MG
RISPERIDONE TAB 2 MG
Tier 1
RISPERIDONE TAB 2MG ODT
RISPERIDONE ORALLY DISINTEGRATING TAB 2 MG
Tier 1
RISPERIDONE TAB 3MG
RISPERIDONE TAB 3 MG
Tier 1
RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 3MG ODT TAB 3 MG
Tier 1
RISPERIDONE TAB 4MG
Tier 1
RISPERIDONE TAB 4 MG
RISPERIDONE ORALLY DISINTEGRATING RISPERIDONE TAB 4MG ODT TAB 4 MG ASENAPINE MALEATE SL TAB 10 MG SAPHRIS SUB 10MG (BASE EQUIV) ASENAPINE MALEATE SL TAB 2.5 MG SAPHRIS SUB 2.5MG (BASE EQUIV) ASENAPINE MALEATE SL TAB 5 MG (BASE SAPHRIS SUB 5MG EQUIV) QUETIAPINE FUMARATE TAB SR 24HR SEROQUEL XR TAB 150MG 150 MG QUETIAPINE FUMARATE TAB SR 24HR SEROQUEL XR TAB 200MG 200 MG QUETIAPINE FUMARATE TAB SR 24HR SEROQUEL XR TAB 300MG 300 MG QUETIAPINE FUMARATE TAB SR 24HR SEROQUEL XR TAB 400MG 400 MG QUETIAPINE FUMARATE TAB SR 24HR SEROQUEL XR TAB 50MG 50 MG ZIPRASIDONE CAP 20MG
ZIPRASIDONE HCL CAP 20 MG
9
X
X
X
X
X
Tier 1 Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 2
X
Therapeutic Class 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 Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alkylating Agents - Chemotherapy Agents Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs Alpha-Adrenergic Agonists - Blood Pressure Drugs
Generic Name
ZIPRASIDONE CAP 40MG
ZIPRASIDONE HCL CAP 40 MG
Tier 2
X
ZIPRASIDONE CAP 60MG
ZIPRASIDONE HCL CAP 60 MG
Tier 2
X
ZIPRASIDONE CAP 80MG
ZIPRASIDONE HCL CAP 80 MG
Tier 2
X
ACAMPRO CAL TAB 333MG
ACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG
Tier 1
ANTABUSE TAB 250MG
DISULFIRAM TAB 250 MG
Tier 3
ANTABUSE TAB 500MG
DISULFIRAM TAB 500 MG
Tier 3
DISULFIRAM TAB 250MG
DISULFIRAM TAB 250 MG
Tier 1
DISULFIRAM TAB 500MG
DISULFIRAM TAB 500 MG
Tier 1
NALTREXONE TAB 50MG
NALTREXONE HCL TAB 50 MG
Tier 1
ALKERAN TAB 2MG
MELPHALAN TAB 2 MG
Tier 2
X
CYCLOPHOSPH CAP 25MG
CYCLOPHOSPHAMIDE CAP 25 MG
Tier 2
X
CYCLOPHOSPH CAP 50MG
CYCLOPHOSPHAMIDE CAP 50 MG
Tier 2
X
GLEOSTINE CAP 100MG
LOMUSTINE CAP 100 MG
Tier 2
X
GLEOSTINE CAP 10MG
LOMUSTINE CAP 10 MG
Tier 2
X
GLEOSTINE CAP 40MG
LOMUSTINE CAP 40 MG
Tier 2
X
HEXALEN CAP 50MG
ALTRETAMINE CAP 50 MG
Tier 2
X
LEUKERAN TAB 2MG
CHLORAMBUCIL TAB 2 MG
Tier 2
X
LOMUSTINE CAP 100MG
LOMUSTINE CAP 100 MG
Tier 1
X
LOMUSTINE CAP 10MG
LOMUSTINE CAP 10 MG
Tier 1
X
LOMUSTINE CAP 40MG
LOMUSTINE CAP 40 MG
Tier 1
X
MATULANE CAP 50MG
PROCARBAZINE HCL CAP 50 MG
Tier 2
X
MYLERAN TAB 2MG
BUSULFAN TAB 2 MG
Tier 2
X
TEMODAR CAP 100MG
TEMOZOLOMIDE CAP 100 MG
Tier 3
X
X
TEMODAR CAP 140MG
TEMOZOLOMIDE CAP 140 MG
Tier 3
X
X
TEMODAR CAP 180MG
TEMOZOLOMIDE CAP 180 MG
Tier 3
X
X
TEMODAR CAP 20MG
TEMOZOLOMIDE CAP 20 MG
Tier 3
X
X
TEMODAR CAP 250MG
TEMOZOLOMIDE CAP 250 MG
Tier 3
X
X
TEMODAR CAP 5MG
TEMOZOLOMIDE CAP 5 MG
Tier 3
X
X
TEMOZOLOMIDE CAP 100 MG
Tier 1
X
X
TEMOZOLOMIDE CAP 140 MG
Tier 1
X
X
TEMOZOLOMIDE CAP 180 MG
Tier 1
X
X
TEMOZOLOMIDE CAP 20MG TEMOZOLOMIDE CAP 20 MG
Tier 1
X
X
TEMOZOLOMIDE CAP 250MG
TEMOZOLOMIDE CAP 250 MG
Tier 1
X
X
TEMOZOLOMIDE CAP 5MG
TEMOZOLOMIDE CAP 5 MG
Tier 1
X
X
VALCHLOR GEL 0.016%
MECHLORETHAMINE HCL GEL 0.016% (BASE EQUIVALENT)
Tier 2
X
CATAPRES TAB 0.1MG
CLONIDINE HCL TAB 0.1 MG
Tier 3
CATAPRES TAB 0.2MG
CLONIDINE HCL TAB 0.2 MG
Tier 3
CATAPRES TAB 0.3MG
CLONIDINE HCL TAB 0.3 MG
Tier 3
TEMOZOLOMIDE CAP 100MG TEMOZOLOMIDE CAP 140MG TEMOZOLOMIDE CAP 180MG
CLONIDINE HCL TD PATCH WEEKLY 0.1 CATAPRES-TTS DIS 0.1/24HR MG/24HR
10
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Tier 3
X
X
Therapeutic Class
Label Name
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 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 Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics Aminoglycosides - Antibiotics
CATAPRES-TTS DIS 0.2/24HR
Generic Name
CLONIDINE HCL TD PATCH WEEKLY 0.2 MG/24HR CLONIDINE HCL TD PATCH WEEKLY 0.3 CATAPRES-TTS DIS 0.3/24HR MG/24HR CLONIDINE HCL TD PATCH WEEKLY 0.1 CLONIDINE DIS 0.1/24HR MG/24HR CLONIDINE HCL TD PATCH WEEKLY 0.2 CLONIDINE DIS 0.2/24HR MG/24HR CLONIDINE HCL TD PATCH WEEKLY 0.3 CLONIDINE DIS 0.3/24HR MG/24HR
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
CLONIDINE TAB 0.1MG
CLONIDINE HCL TAB 0.1 MG
Tier 1
CLONIDINE TAB 0.2MG
CLONIDINE HCL TAB 0.2 MG
Tier 1
CLONIDINE TAB 0.3MG
CLONIDINE HCL TAB 0.3 MG
Tier 1
CLORPRES TAB 0.1-15MG CLORPRES TAB 0.2-15MG CLORPRES TAB 0.3-15MG
CLONIDINE & CHLORTHALIDONE TAB 0.1-15 MG CLONIDINE & CHLORTHALIDONE TAB 0.2-15 MG CLONIDINE & CHLORTHALIDONE TAB 0.3-15 MG
Tier 2 Tier 2 Tier 2
GUANFACINE TAB 1MG
GUANFACINE HCL TAB 1 MG
Tier 1
GUANFACINE TAB 2MG
GUANFACINE HCL TAB 2 MG
Tier 1
METHYLDOPA & HYDROCHLOROTHIAZIDE TAB 250-15 MG METHYLDOPA & METHYLD/HCTZ TAB 250/25 HYDROCHLOROTHIAZIDE TAB 250-25 MG METHYLD/HCTZ TAB 250/15
Tier 1 Tier 1
METHYLDOPA TAB 250MG
METHYLDOPA TAB 250 MG
Tier 1
METHYLDOPA TAB 500MG
METHYLDOPA TAB 500 MG
Tier 1
MIDODRINE TAB 10MG
MIDODRINE HCL TAB 10 MG
Tier 1
MIDODRINE TAB 2.5MG
MIDODRINE HCL TAB 2.5 MG
Tier 1
MIDODRINE TAB 5MG
MIDODRINE HCL TAB 5 MG
Tier 1
TENEX TAB 1MG
GUANFACINE HCL TAB 1 MG
Tier 3
TENEX TAB 2MG
GUANFACINE HCL TAB 2 MG
Tier 3
CARDURA XL TAB 4MG CARDURA XL TAB 8MG
DOXAZOSIN MESYLATE TAB SR 24 HR 4 MG (BASE EQUIV) DOXAZOSIN MESYLATE TAB SR 24 HR 8 MG (BASE EQUIV)
Tier 3 Tier 3
MINIPRESS CAP 1MG
PRAZOSIN HCL CAP 1 MG
Tier 3
MINIPRESS CAP 2MG
PRAZOSIN HCL CAP 2 MG
Tier 3
MINIPRESS CAP 5MG
PRAZOSIN HCL CAP 5 MG
Tier 3
PHENOXYBENZA CAP 10MG PHENOXYBENZAMINE HCL CAP 10 MG
Tier 2
PRAZOSIN HCL CAP 1MG
PRAZOSIN HCL CAP 1 MG
Tier 1
PRAZOSIN HCL CAP 2MG
PRAZOSIN HCL CAP 2 MG
Tier 1
PRAZOSIN HCL CAP 5MG
PRAZOSIN HCL CAP 5 MG
Tier 1
RESERPINE TAB 0.1MG
RESERPINE TAB 0.1 MG
Tier 1
RESERPINE TAB 0.25MG
RESERPINE TAB 0.25 MG
Tier 1
BETHKIS NEB 300/4ML GENTAK OIN 0.3% OP GENTAMICIN CRE 0.1% GENTAMICIN OIN 0.1% GENTAMICIN OIN 0.3% OP GENTAMICIN SOL 0.3% OP NEOMYCIN TAB 500MG PAROMOMYCIN CAP 250MG TOBI PODHALR CAP 28MG TOBRAMYCIN SOL 0.3% OP TOBREX OIN 0.3% OP
TOBRAMYCIN NEBU SOLN 300 MG/4ML GENTAMICIN SULFATE OPHTH OINT 0.3% GENTAMICIN SULFATE CREAM 0.1% GENTAMICIN SULFATE OINT 0.1% GENTAMICIN SULFATE OPHTH OINT 0.3% GENTAMICIN SULFATE OPHTH SOLN 0.3% NEOMYCIN SULFATE TAB 500 MG PAROMOMYCIN SULFATE CAP 250 MG TOBRAMYCIN INHAL CAP 28 MG TOBRAMYCIN OPHTH SOLN 0.3% TOBRAMYCIN OPHTH OINT 0.3%
Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3
11
Prior Supply Step Specialty Authorization Limit Therapy
X
X
X
X
X
X
Therapeutic Class
Label Name
Generic Name
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 Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Amphetamines - Anorexigenics, Respiratory, Cerebral Stimulant Anabolic Steroids - Hormone Replacement/Modifying 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
TOBREX SOL 0.3% OP
TOBRAMYCIN OPHTH SOLN 0.3%
Tier 3
APRISO CAP 0.375GM
MESALAMINE CAP SR 24HR 0.375 GM
Tier 2
BALSALAZIDE CAP 750MG
BALSALAZIDE DISODIUM CAP 750 MG
Tier 1
CANASA SUP 1000MG
MESALAMINE SUPPOS 1000 MG
Tier 2
DIPENTUM CAP 250MG
OLSALAZINE SODIUM CAP 250 MG
Tier 3
LIALDA TAB 1.2GM
MESALAMINE TAB DELAYED RELEASE 1.2 GM
Tier 2
MESALAMINE ENE 4GM
MESALAMINE ENEMA 4 GM
Tier 1
MESALAMINE KIT 4GM ROWASA KIT 4GM SFROWASA ENE 4GM
*MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT** *MESALAMINE RECTAL ENEMA 4 GM & CLEANSER WIPE KIT** MESALAMINE SULFITE-FREE (SF) ENEMA 4 GM/60ML
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1
X
Tier 3
X
Tier 3
ADIPEX-P CAP 37.5MG
PHENTERMINE HCL CAP 37.5 MG
Tier 3
X
ADIPEX-P TAB 37.5MG
PHENTERMINE HCL TAB 37.5 MG
Tier 3
X
BENZPHETAMIN TAB 50MG
BENZPHETAMINE HCL TAB 50 MG
Tier 1
X
BONTRIL PDM TAB 35MG
PHENDIMETRAZINE TARTRATE TAB 35 MG
Tier 3
X
DIETHYLPROP TAB 25MG
DIETHYLPROPION HCL TAB 25 MG
Tier 1
X
DIETHYLPROPION HCL TAB SR 24HR 75 DIETHYLPROP TAB 75MG ER MG
Tier 1
X
LOMAIRA TAB 8MG
PHENTERMINE HCL TAB 8 MG
Tier 3
X
PHENDIMETRAZ CAP 105MG ER
PHENDIMETRAZINE TARTRATE CAP SR 24HR 105 MG PHENDIMETRAZINE TARTRATE TAB 35 MG
Tier 1
X
Tier 1
X
PHENDIMETRAZ TAB 35MG PHENTERMINE CAP 15MG
PHENTERMINE HCL CAP 15 MG
Tier 1
X
PHENTERMINE CAP 30MG
PHENTERMINE HCL CAP 30 MG
Tier 1
X
PHENTERMINE CAP 37.5MG
PHENTERMINE HCL CAP 37.5 MG
Tier 1
X
PHENTERMINE TAB 37.5MG
PHENTERMINE HCL TAB 37.5 MG
Tier 1
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
QSYMIA CAP 11.25-69 QSYMIA CAP 15-92MG QSYMIA CAP 3.75-23 QSYMIA CAP 7.5-46MG SUPRENZA TAB 15MG SUPRENZA TAB 30MG SUPRENZA TAB 37.5MG
PHENTERMINE HCL-TOPIRAMATE CAP SR 24HR 11.25-69 MG PHENTERMINE HCL-TOPIRAMATE CAP SR 24HR 15-92 MG PHENTERMINE HCL-TOPIRAMATE CAP SR 24HR 3.75-23 MG PHENTERMINE HCL-TOPIRAMATE CAP SR 24HR 7.5-46 MG PHENTERMINE HCL ORALLY DISINTEGRATING TAB 15 MG PHENTERMINE HCL ORALLY DISINTEGRATING TAB 30 MG PHENTERMINE HCL ORALLY DISINTEGRATING TAB 37.5 MG
Tier 3
ANADROL-50 TAB 50MG
OXYMETHOLONE TAB 50 MG
Tier 3
OXANDRIN TAB 10MG
OXANDROLONE TAB 10 MG
Tier 3
OXANDRIN TAB 2.5MG
OXANDROLONE TAB 2.5 MG
Tier 3
OXANDROLONE TAB 10MG
OXANDROLONE TAB 10 MG
Tier 2
OXANDROLONE TAB 2.5 MG
Tier 2
OXANDROLONE TAB 2.5MG
Analgesics - Miscellaneous Analgesics
BUPAP TAB 50-300MG
Analgesics - Miscellaneous Analgesics
BUT/APAP/CAF CAP
Analgesics - Miscellaneous Analgesics
BUT/APAP/CAF CAP
Analgesics - Miscellaneous Analgesics
BUT/APAP/CAF TAB
BUTALBITAL-ACETAMINOPHEN TAB 50300 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-300-40 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG
12
Tier 3 Tier 1
X
Tier 3
X
Tier 1
X
Therapeutic Class 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 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 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
Label Name
Generic Name
BUTALBITAL-ASPIRIN-CAFFEINE CAP 50325-40 MG BUTALBITAL-ACETAMINOPHEN TAB 50BUTAL/APAP TAB 50-325MG 325 MG BUTALB/ACETA TAB 50BUTALBITAL-ACETAMINOPHEN TAB 50300MG 300 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAPACET CAP CAP 50-325-40 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE ESGIC CAP CAP 50-325-40 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE ESGIC TAB TAB 50-325-40 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE FIORICET CAP CAP 50-300-40 MG BUTALBITAL-ASPIRIN-CAFFEINE CAP 50FIORINAL CAP 325-40 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE MARGESIC CAP CAP 50-325-40 MG BUTALBITAL-ACETAMINOPHEN TAB 50MARTEN-TAB TAB 50-325MG 325 MG BUTALBITAL-ACETAMINOPHEN TAB 50TENCON TAB 50-325MG 325 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE VANATOL LQ SOL SOLN 50-325-40 MG/15ML BUTALBITAL-ACETAMINOPHEN-CAFFEINE ZEBUTAL CAP CAP 50-325-40 MG ANDRODERM DIS TESTOSTERONE TD PATCH 24HR 2 2MG/24HR MG/24HR ANDRODERM DIS TESTOSTERONE TD PATCH 24HR 4 4MG/24HR MG/24HR BUT/ASA/CAFF CAP
Tier Value Tier 1 Tier 1 Tier 3 Tier 1
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 1
X
Tier 1 Tier 1 Tier 1
X
Tier 1
X X
Tier 2
X
X
Tier 2
X
X
ANDROID CAP 10MG
METHYLTESTOSTERONE CAP 10 MG
Tier 3
ANDROXY TAB 10MG
FLUOXYMESTERONE TAB 10 MG
Tier 1
DANAZOL CAP 100MG
DANAZOL CAP 100 MG
Tier 1
DANAZOL CAP 200MG
DANAZOL CAP 200 MG
Tier 1
DANAZOL CAP 50MG
DANAZOL CAP 50 MG
Tier 1
DEPO-TESTOST INJ 100MG/ ML DEPO-TESTOST INJ 200MG/ ML
TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML METHYLTESTOSTERONE ORAL TAB 10 MG
METHITEST TAB 10MG
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 2
METHYLTESTOS CAP 10MG
METHYLTESTOSTERONE CAP 10 MG
Tier 2
STRIANT MIS 30MG
TESTOSTERONE BUCCAL MUCOADHESIVE SYSTEM 30 MG
Tier 3
X
X
TESTIM GEL 1%(50MG)
TESTOSTERONE TD GEL 50 MG/5GM (1%)
Tier 2
X
X
TESTOST CYP INJ 100MG/ ML TESTOST CYP INJ 200MG/ ML TESTOST ENAN INJ 200MG/ ML
TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML TESTOSTERONE ENANTHATE IM INJ IN OIL 200 MG/ML
TESTRED CAP 10MG
METHYLTESTOSTERONE CAP 10 MG
Tier 3
ATACAND TAB 16MG
CANDESARTAN CILEXETIL TAB 16 MG
Tier 3
ATACAND TAB 32MG
CANDESARTAN CILEXETIL TAB 32 MG
Tier 3
ATACAND TAB 4MG
CANDESARTAN CILEXETIL TAB 4 MG
Tier 3
ATACAND TAB 8MG
CANDESARTAN CILEXETIL TAB 8 MG
Tier 3
CANDESARTAN CILEXETILHYDROCHLOROTHIAZIDE TAB 16-12.5 MG CANDESARTAN CILEXETILATACAND HCT TAB 32-12.5 HYDROCHLOROTHIAZIDE TAB 32-12.5 MG CANDESARTAN CILEXETILATACAND HCT TAB 32-25MG HYDROCHLOROTHIAZIDE TAB 32-25 MG IRBESARTAN-HYDROCHLOROTHIAZIDE AVALIDE TAB 150-12.5 TAB 150-12.5 MG IRBESARTAN-HYDROCHLOROTHIAZIDE AVALIDE TAB 300-12.5 TAB 300-12.5 MG ATACAND HCT TAB 16-12.5
13
Tier 1 Tier 1 Tier 1
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
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 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
Label Name
Generic Name
AVAPRO TAB 150MG
IRBESARTAN TAB 150 MG
Tier 3
AVAPRO TAB 300MG
IRBESARTAN TAB 300 MG
Tier 3
AVAPRO TAB 75MG
IRBESARTAN TAB 75 MG
Tier 3
CANDESARTAN CILEXETILCANDESA/HCTZ TAB 16-12.5 HYDROCHLOROTHIAZIDE TAB 16-12.5 MG CANDESARTAN CILEXETILCANDESA/HCTZ TAB 32-12.5 HYDROCHLOROTHIAZIDE TAB 32-12.5 MG CANDESA/HCTZ TAB 32CANDESARTAN CILEXETIL25MG HYDROCHLOROTHIAZIDE TAB 32-25 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 3
CANDESARTAN TAB 16MG
CANDESARTAN CILEXETIL TAB 16 MG
Tier 3
CANDESARTAN TAB 32MG
CANDESARTAN CILEXETIL TAB 32 MG
Tier 3
CANDESARTAN TAB 4MG
CANDESARTAN CILEXETIL TAB 4 MG
Tier 3
CANDESARTAN TAB 8MG
CANDESARTAN CILEXETIL TAB 8 MG
Tier 3
COZAAR TAB 100MG
LOSARTAN POTASSIUM TAB 100 MG
Tier 3
COZAAR TAB 25MG
LOSARTAN POTASSIUM TAB 25 MG
Tier 3
COZAAR TAB 50MG
LOSARTAN POTASSIUM TAB 50 MG
Tier 3
EDARBI TAB 40MG
AZILSARTAN MEDOXOMIL TAB 40 MG
Tier 3
X
EDARBI TAB 80MG
AZILSARTAN MEDOXOMIL TAB 80 MG
Tier 3
X
Tier 3
X
Tier 3
X
AZILSARTAN MEDOXOMILEDARBYCLOR TAB 40-12.5 CHLORTHALIDONE TAB 40-12.5 MG AZILSARTAN MEDOXOMILEDARBYCLOR TAB 40-25MG CHLORTHALIDONE TAB 40-25 MG EPROSART MES TAB 600MG EPROSARTAN MESYLATE TAB 600 MG LOSARTAN POTASSIUM & HYZAAR TAB 100-12.5 HYDROCHLOROTHIAZIDE TAB 100-12.5 MG LOSARTAN POTASSIUM & HYZAAR TAB 100-25 HYDROCHLOROTHIAZIDE TAB 100-25 MG LOSARTAN POTASSIUM & HYZAAR TAB 50-12.5 HYDROCHLOROTHIAZIDE TAB 50-12.5 MG IRBESARTAN-HYDROCHLOROTHIAZIDE IRBESAR/HCTZ TAB 150-12.5 TAB 150-12.5 MG IRBESAR/HCTZ TAB 300IRBESARTAN-HYDROCHLOROTHIAZIDE 12.5 TAB 300-12.5 MG
Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
IRBESARTAN TAB 150MG
IRBESARTAN TAB 150 MG
Tier 1
IRBESARTAN TAB 300MG
IRBESARTAN TAB 300 MG
Tier 1
IRBESARTAN TAB 75MG
IRBESARTAN TAB 75 MG
Tier 1
LOSARTAN POT TAB 100MG LOSARTAN POTASSIUM TAB 100 MG
Tier 1
LOSARTAN POT TAB 25MG
LOSARTAN POTASSIUM TAB 25 MG
Tier 1
LOSARTAN POT TAB 25MG
LOSARTAN POTASSIUM TAB 25 MG
Tier 1
LOSARTAN POTASSIUM TAB 50 MG
Tier 1
LOSARTAN POT TAB 50MG
OLM MED/HCTZ TAB 4025MG
LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG OLMESARTAN MEDOXOMILHYDROCHLOROTHIAZIDE TAB 20-12.5 MG OLMESARTAN MEDOXOMILHYDROCHLOROTHIAZIDE TAB 40-12.5 MG OLMESARTAN MEDOXOMILHYDROCHLOROTHIAZIDE TAB 40-25 MG
OLMESA MEDOX TAB 20MG
OLMESARTAN MEDOXOMIL TAB 20 MG
Tier 2
X
OLMESA MEDOX TAB 40MG
OLMESARTAN MEDOXOMIL TAB 40 MG
Tier 2
X
LOSARTAN/HCT TAB 10012.5 LOSARTAN/HCT TAB 100-25 LOSARTAN/HCT TAB 50-12.5 OLM MED/HCTZ TAB 20-12.5 OLM MED/HCTZ TAB 40-12.5
14
Tier 1 Tier 1 Tier 1 Tier 2
X
Tier 2
X
Tier 2
X
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 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
Label Name
Generic Name
OLMESA MEDOX TAB 5MG
OLMESARTAN MEDOXOMIL TAB 5 MG
Tier Value Tier 2
TELMISA/HCTZ TAB 8025MG
TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-25 MG
TELMISARTAN TAB 20MG
TELMISARTAN TAB 20 MG
Tier 2
TELMISARTAN TAB 40MG
TELMISARTAN TAB 40 MG
Tier 2
TELMISARTAN TAB 80MG
TELMISARTAN TAB 80 MG
Tier 2
TELMISA/HCTZ TAB 40-12.5 TELMISA/HCTZ TAB 80-12.5
VALSART/HCTZ TAB 16012.5 VALSART/HCTZ TAB 16025MG VALSART/HCTZ TAB 32012.5 VALSART/HCTZ TAB 32025MG
VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG VALSARTAN-HYDROCHLOROTHIAZIDE VALSART/HCTZ TAB 80-12.5 TAB 80-12.5 MG
Tier 2 Tier 2 Tier 2
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
VALSARTAN TAB 160MG
VALSARTAN TAB 160 MG
Tier 2
VALSARTAN TAB 320MG
VALSARTAN TAB 320 MG
Tier 2
VALSARTAN TAB 40MG
VALSARTAN TAB 40 MG
Tier 2
VALSARTAN TAB 80MG
VALSARTAN TAB 80 MG
Tier 2
ACCUPRIL TAB 10MG
QUINAPRIL HCL TAB 10 MG
Tier 3
ACCUPRIL TAB 20MG
QUINAPRIL HCL TAB 20 MG
Tier 3
ACCUPRIL TAB 40MG
QUINAPRIL HCL TAB 40 MG
Tier 3
QUINAPRIL HCL TAB 5 MG
Tier 3
ACCUPRIL TAB 5MG ACCURETIC TAB 10-12.5 ACCURETIC TAB 20-12.5 ACCURETIC TAB 20-25MG
QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-25 MG
Tier 3 Tier 3 Tier 3
ACEON TAB 4MG
PERINDOPRIL ERBUMINE TAB 4 MG
Tier 3
ACEON TAB 8MG
PERINDOPRIL ERBUMINE TAB 8 MG
Tier 3
ALTACE CAP 1.25MG
RAMIPRIL CAP 1.25 MG
Tier 3
ALTACE CAP 10MG
RAMIPRIL CAP 10 MG
Tier 3
ALTACE CAP 2.5MG
RAMIPRIL CAP 2.5 MG
Tier 3
ALTACE CAP 5MG
RAMIPRIL CAP 5 MG
Tier 3
BENAZEPRIL & HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 10-12.5 TAB 10-12.5 MG BENAZEPRIL & HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 20-12.5 TAB 20-12.5 MG BENAZEP/HCTZ TAB 20BENAZEPRIL & HYDROCHLOROTHIAZIDE 25MG TAB 20-25 MG BENAZEPRIL & HYDROCHLOROTHIAZIDE BENAZEP/HCTZ TAB 5-6.25 TAB 5-6.25 MG
Tier 1 Tier 1 Tier 1 Tier 1
BENAZEPRIL TAB 10MG
BENAZEPRIL HCL TAB 10 MG
Tier 1
BENAZEPRIL TAB 20MG
BENAZEPRIL HCL TAB 20 MG
Tier 1
BENAZEPRIL TAB 40MG
BENAZEPRIL HCL TAB 40 MG
Tier 1
BENAZEPRIL TAB 5MG
BENAZEPRIL HCL TAB 5 MG
Tier 1
CAPTOPR/HCTZ TAB 2515MG CAPTOPR/HCTZ TAB 2525MG
CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15 MG CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-25 MG
15
Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy X
Therapeutic Class
Label Name
Generic Name
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 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
CAPTOPR/HCTZ TAB 5015MG CAPTOPR/HCTZ TAB 5025MG
CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-15 MG CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-25 MG
CAPTOPRIL TAB 100MG
CAPTOPRIL TAB 100 MG
Tier 1
CAPTOPRIL TAB 12.5MG
CAPTOPRIL TAB 12.5 MG
Tier 1
CAPTOPRIL TAB 25MG
CAPTOPRIL TAB 25 MG
Tier 1
CAPTOPRIL TAB 50MG
CAPTOPRIL TAB 50 MG
Tier 1
ENALAPR/HCTZ TAB 1025MG ENALAPR/HCTZ TAB 5-12.5MG
ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG
ENALAPRIL TAB 10MG
ENALAPRIL MALEATE TAB 10 MG
Tier 1
ENALAPRIL TAB 2.5MG
ENALAPRIL MALEATE TAB 2.5 MG
Tier 1
ENALAPRIL TAB 20MG
ENALAPRIL MALEATE TAB 20 MG
Tier 1
ENALAPRIL TAB 5MG
ENALAPRIL MALEATE TAB 5 MG
Tier 1
ENALAPRIL MALEATE FOR ORAL SOLN 1 EPANED SOL 1MG/ML MG/ML ENALAPRIL MALEATE ORAL SOLN 1 MG/ EPANED SOL 1MG/ML ML FOSINOPRIL SODIUM & FOSINOP/HCTZ TAB 10/12.5 HYDROCHLOROTHIAZIDE TAB 10-12.5 MG FOSINOPRIL SODIUM & FOSINOP/HCTZ TAB 20/12.5 HYDROCHLOROTHIAZIDE TAB 20-12.5 MG
Tier Value Tier 1 Tier 1
Tier 1 Tier 1
Tier 3
X
Tier 3
X
Tier 1 Tier 1
FOSINOPRIL TAB 10MG
FOSINOPRIL SODIUM TAB 10 MG
Tier 1
FOSINOPRIL TAB 20MG
FOSINOPRIL SODIUM TAB 20 MG
Tier 1
FOSINOPRIL TAB 40MG
FOSINOPRIL SODIUM TAB 40 MG
Tier 1
LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG LISINOPRIL & HYDROCHLOROTHIAZIDE LISINOP/HCTZ TAB 20-12.5 TAB 20-12.5 MG LISINOPRIL & HYDROCHLOROTHIAZIDE LISINOP/HCTZ TAB 20-25MG TAB 20-25 MG
LISINOP/HCTZ TAB 10-12.5
Tier 1 Tier 1 Tier 1
LISINOPRIL TAB 10MG
LISINOPRIL TAB 10 MG
Tier 1
LISINOPRIL TAB 2.5MG
LISINOPRIL TAB 2.5 MG
Tier 1
LISINOPRIL TAB 20MG
LISINOPRIL TAB 20 MG
Tier 1
LISINOPRIL TAB 30MG
LISINOPRIL TAB 30 MG
Tier 1
LISINOPRIL TAB 30MG
LISINOPRIL TAB 30 MG
Tier 1
LISINOPRIL TAB 40MG
LISINOPRIL TAB 40 MG
Tier 1
LISINOPRIL TAB 5MG
LISINOPRIL TAB 5 MG
Tier 1
LOTENSIN TAB 20MG
BENAZEPRIL HCL TAB 20 MG
Tier 3
LOTENSIN TAB 40MG
BENAZEPRIL HCL TAB 40 MG
Tier 3
LOTENSIN HCT TAB 2025MG
BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG
MAVIK TAB 1MG
TRANDOLAPRIL TAB 1 MG
Tier 3
MAVIK TAB 2MG
TRANDOLAPRIL TAB 2 MG
Tier 3
MAVIK TAB 4MG
TRANDOLAPRIL TAB 4 MG
Tier 3
LOTENSIN HCT TAB 10-12.5 LOTENSIN HCT TAB 20-12.5
MOEXIPR/HCTZ TAB 15-12.5 MOEXIPR/HCTZ TAB 1525MG
MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-12.5 MG MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 15-25 MG
16
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 3
Tier 1 Tier 1
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 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 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
Label Name
Generic Name
MOEXIPR/HCTZ TAB 7.5-12.5
MOEXIPRIL-HYDROCHLOROTHIAZIDE TAB 7.5-12.5 MG
Tier 1
MOEXIPRIL TAB 15MG
MOEXIPRIL HCL TAB 15 MG
Tier 1
MOEXIPRIL TAB 7.5MG
MOEXIPRIL HCL TAB 7.5 MG
Tier 1
PERINDOPRIL TAB 2MG
PERINDOPRIL ERBUMINE TAB 2 MG
Tier 2
PERINDOPRIL TAB 4MG
PERINDOPRIL ERBUMINE TAB 4 MG
Tier 2
PERINDOPRIL TAB 8MG
PERINDOPRIL ERBUMINE TAB 8 MG
Tier 2
PRINIVIL TAB 10MG
LISINOPRIL TAB 10 MG
Tier 3
PRINIVIL TAB 20MG
LISINOPRIL TAB 20 MG
Tier 3
PRINIVIL TAB 5MG
LISINOPRIL TAB 5 MG
Tier 3
QBRELIS SOL 1MG/ML
LISINOPRIL ORAL SOLN 1 MG/ML
Tier 3
QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG QUINAPRIL-HYDROCHLOROTHIAZIDE TAB QNAPRIL/HCTZ TAB 20-12.5 20-12.5 MG QNAPRIL/HCTZ TAB 20QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 25MG 20-25 MG
QNAPRIL/HCTZ TAB 10-12.5
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 2 Tier 2 Tier 2
QUINAPRIL TAB 10MG
QUINAPRIL HCL TAB 10 MG
Tier 1
QUINAPRIL TAB 20MG
QUINAPRIL HCL TAB 20 MG
Tier 1
QUINAPRIL TAB 40MG
QUINAPRIL HCL TAB 40 MG
Tier 1
QUINAPRIL TAB 5MG
QUINAPRIL HCL TAB 5 MG
Tier 1
RAMIPRIL CAP 1.25MG
RAMIPRIL CAP 1.25 MG
Tier 1
RAMIPRIL CAP 10MG
RAMIPRIL CAP 10 MG
Tier 1
RAMIPRIL CAP 2.5MG
RAMIPRIL CAP 2.5 MG
Tier 1
RAMIPRIL CAP 5MG
RAMIPRIL CAP 5 MG
Tier 1
TRANDO/VERAP TAB 1-240 ER TRANDO/VERAP TAB 2-180 ER TRANDO/VERAP TAB 2-240 ER TRANDO/VERAP TAB 4-240 ER
TRANDOLAPRIL-VERAPAMIL HCL TAB CR 1-240 MG TRANDOLAPRIL-VERAPAMIL HCL TAB CR 2-180 MG TRANDOLAPRIL-VERAPAMIL HCL TAB CR 2-240 MG TRANDOLAPRIL-VERAPAMIL HCL TAB CR 4-240 MG TRANDOLAPRIL-VERAPAMIL HCL TAB CR 1-240 MG TRANDOLAPRIL-VERAPAMIL HCL TAB CR 2-180 MG TRANDOLAPRIL-VERAPAMIL HCL TAB CR 2-240 MG TRANDOLAPRIL-VERAPAMIL HCL TAB CR 4-240 MG
TRANDOLAPRIL TAB 1MG
TRANDOLAPRIL TAB 1 MG
Tier 1
TRANDOLAPRIL TAB 2MG
TRANDOLAPRIL TAB 2 MG
Tier 1
TRANDOLAPRIL TAB 4MG
TRANDOLAPRIL TAB 4 MG
Tier 1
ALBENZA TAB 200MG BILTRICIDE TAB 600MG EMVERM CHW 100MG IVERMECTIN TAB 3MG STROMECTOL TAB 3MG BICALUTAMIDE TAB 50MG CASODEX TAB 50MG FLUTAMIDE CAP 125MG NILANDRON TAB 150MG NILUTAMIDE TAB 150MG XTANDI CAP 40MG
ALBENDAZOLE TAB 200 MG PRAZIQUANTEL TAB 600 MG MEBENDAZOLE CHEW TAB 100 MG IVERMECTIN TAB 3 MG IVERMECTIN TAB 3 MG BICALUTAMIDE TAB 50 MG BICALUTAMIDE TAB 50 MG FLUTAMIDE CAP 125 MG NILUTAMIDE TAB 150 MG NILUTAMIDE TAB 150 MG ENZALUTAMIDE CAP 40 MG
Tier 3 Tier 2 Tier 3 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3
X
X
X
X
X
X
CAPRELSA TAB 100MG
VANDETANIB TAB 100 MG
Tier 2
X
X
TARKA TAB 1-240 CR TARKA TAB 2-180 CR TARKA TAB 2-240 CR TARKA TAB 4-240 CR
17
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
X
X X X X X X X
Therapeutic Class 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 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
Generic Name
CAPRELSA TAB 300MG
VANDETANIB TAB 300 MG
Tier 2
X
X
X
REVLIMID CAP 10MG
LENALIDOMIDE CAP 10 MG
Tier 2
X
X
X
REVLIMID CAP 15MG
LENALIDOMIDE CAP 15 MG
Tier 2
X
X
X
REVLIMID CAP 2.5MG
LENALIDOMIDE CAPS 2.5 MG
Tier 2
X
X
X
REVLIMID CAP 20MG
LENALIDOMIDE CAP 20 MG
Tier 2
X
X
X
REVLIMID CAP 25MG
LENALIDOMIDE CAP 25 MG
Tier 2
X
X
X
REVLIMID CAP 5MG
LENALIDOMIDE CAP 5 MG
Tier 2
X
X
X
THALOMID CAP 100MG
THALIDOMIDE CAP 100 MG
Tier 2
X
X
X
THALOMID CAP 150MG
THALIDOMIDE CAP 150 MG
Tier 2
X
X
X
THALOMID CAP 200MG
THALIDOMIDE CAP 200 MG
Tier 2
X
X
X
THALOMID CAP 50MG
THALIDOMIDE CAP 50 MG
Tier 2
X
X
X
AMIODARONE TAB 100MG AMIODARONE TAB 200MG AMIODARONE TAB 400MG 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
AMIODARONE HCL TAB 100 MG AMIODARONE HCL TAB 200 MG AMIODARONE HCL TAB 400 MG SOTALOL HCL (AFIB/AFL) TAB 120 MG SOTALOL HCL (AFIB/AFL) TAB 160 MG SOTALOL HCL (AFIB/AFL) TAB 80 MG AMIODARONE HCL TAB 200 MG DISOPYRAMIDE PHOSPHATE CAP 100 MG DISOPYRAMIDE PHOSPHATE CAP 150 MG DOFETILIDE CAP 125 MCG (0.125 MG) DOFETILIDE CAP 250 MCG (0.25 MG) DOFETILIDE CAP 500 MCG (0.5 MG) FLECAINIDE ACETATE TAB 100 MG FLECAINIDE ACETATE TAB 150 MG FLECAINIDE ACETATE TAB 50 MG MEXILETINE HCL CAP 150 MG MEXILETINE HCL CAP 200 MG MEXILETINE HCL CAP 250 MG DRONEDARONE HCL TAB 400 MG (BASE EQUIVALENT) DISOPYRAMIDE PHOSPHATE CAP 100 MG DISOPYRAMIDE PHOSPHATE CAP SR 12HR 100 MG DISOPYRAMIDE PHOSPHATE CAP 150 MG DISOPYRAMIDE PHOSPHATE CAP SR 12HR 150 MG AMIODARONE HCL TAB 100 MG AMIODARONE HCL TAB 200 MG AMIODARONE HCL TAB 400 MG PROPAFENONE HCL CAP SR 12HR 225 MG PROPAFENONE HCL CAP SR 12HR 325 MG PROPAFENONE HCL CAP SR 12HR 425 MG PROPAFENONE HCL TAB 150 MG PROPAFENONE HCL TAB 225 MG PROPAFENONE HCL TAB 300 MG
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
QUINIDINE GLUCONATE TAB CR 324 MG
Tier 1
Antiarrhythmics - Heart Regulation Drugs MULTAQ TAB 400MG Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 100MG Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 100MG CR Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 150MG Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 150MG CR Antiarrhythmics - Heart Regulation Drugs PACERONE TAB 100MG Antiarrhythmics - Heart Regulation Drugs PACERONE TAB 200MG Antiarrhythmics - Heart Regulation Drugs PACERONE TAB 400MG PROPAFENONE CAP 225MG Antiarrhythmics - Heart Regulation Drugs ER PROPAFENONE CAP 325MG Antiarrhythmics - Heart Regulation Drugs ER PROPAFENONE CAP 425MG Antiarrhythmics - Heart Regulation Drugs SR Antiarrhythmics - Heart Regulation Drugs PROPAFENONE TAB 150MG Antiarrhythmics - Heart Regulation Drugs PROPAFENONE TAB 225MG Antiarrhythmics - Heart Regulation Drugs PROPAFENONE TAB 300MG QUINIDINE GL TAB 324MG Antiarrhythmics - Heart Regulation Drugs CR QUINIDINE GL TAB 324MG Antiarrhythmics - Heart Regulation Drugs ER Antiarrhythmics - Heart Regulation Drugs QUINIDINE SU TAB 200MG Antiarrhythmics - Heart Regulation Drugs QUINIDINE SU TAB 300MG QUINIDINE SU TAB 300MG Antiarrhythmics - Heart Regulation Drugs ER Antiarrhythmics - Heart Regulation Drugs RYTHMOL TAB 150MG Antiarrhythmics - Heart Regulation Drugs RYTHMOL TAB 225MG Antiarrhythmics - Heart Regulation Drugs RYTHMOL SR CAP 225MG Antiarrhythmics - Heart Regulation Drugs RYTHMOL SR CAP 325MG Antiarrhythmics - Heart Regulation Drugs RYTHMOL SR CAP 425MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Tier 3 Tier 3 Tier 2 Tier 3 Tier 2 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1
QUINIDINE GLUCONATE TAB CR 324 MG
Tier 1
QUINIDINE SULFATE TAB 200 MG QUINIDINE SULFATE TAB 300 MG
Tier 1 Tier 1
QUINIDINE SULFATE TAB CR 300 MG
Tier 1
PROPAFENONE HCL TAB 150 MG PROPAFENONE HCL TAB 225 MG PROPAFENONE HCL CAP SR 12HR 225 MG PROPAFENONE HCL CAP SR 12HR 325 MG PROPAFENONE HCL CAP SR 12HR 425 MG
Tier 3 Tier 3
18
Tier 3 Tier 3 Tier 3
X
Therapeutic Class
Label Name
Generic Name
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 Antibacterials, Other - Antibiotics
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 TIKOSYN CAP 250MCG TIKOSYN CAP 500MCG AK-POLY-BAC OIN OP ALCOH-GLOVE PAD CONTOURE ALCOHOL PAD 70% ALCOHOL PREP PAD ALCOHOL PREP PAD 70% ALCOHOL PREP PAD 70% ALCOHOL PREP PAD MED 70% ALCOHOL SWAB PAD ALCOHOL SWAB PAD 70% ALCOH-WIPE PAD 12"X12" ALTABAX OIN 1%
SOTALOL HCL (AFIB/AFL) TAB 120 MG SOTALOL HCL (AFIB/AFL) TAB 160 MG SOTALOL HCL (AFIB/AFL) TAB 80 MG SOTALOL HCL TAB 120 MG SOTALOL HCL TAB 160 MG SOTALOL HCL TAB 240 MG SOTALOL HCL TAB 80 MG SOTALOL HCL ORAL SOLUTION 5 MG/ML DOFETILIDE CAP 125 MCG (0.125 MG) DOFETILIDE CAP 250 MCG (0.25 MG) DOFETILIDE CAP 500 MCG (0.5 MG) BACITRACIN-POLYMYXIN B OPHTH OINT
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
*ALCOHOL SWABS***
Tier 3
*ALCOHOL SWABS*** *ALCOHOL SWABS*** *ALCOHOL SWABS*** *ALCOHOL SWABS***
Tier 3 Tier 3 Tier 1 Tier 3
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 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
*ALCOHOL SWABS***
*ALCOHOL SWABS*** *ALCOHOL SWABS*** *ALCOHOL SWABS*** RETAPAMULIN OINT 1% *METHENAMINE-HYOSC-METH BLUE-SOD AZUPHEN MB CAP 120MG PHOS-PHEN SAL CAP 120 MG*** BACIT/POLYMY OIN OP BACITRACIN-POLYMYXIN B OPHTH OINT BACITRACIN OIN OP BACITRACIN OPHTH OINT 500 UNIT/GM BACTROBAN CRE 2% MUPIROCIN CALCIUM CREAM 2% BACTROBAN OIN 2% MUPIROCIN OINT 2% BACTROBAN OIN NASAL 2% MUPIROCIN CALCIUM NASAL OINT 2% CARETOUCH PAD ALCOHOL *ALCOHOL SWABS*** CENTANY OIN 2% MUPIROCIN OINT 2% CLEOCIN CAP 150MG CLINDAMYCIN HCL CAP 150 MG CLEOCIN CAP 300MG CLINDAMYCIN HCL CAP 300 MG CLEOCIN CAP 75MG CLINDAMYCIN HCL CAP 75 MG CLINDAMYCIN PHOSPHATE VAGINAL CLEOCIN CRE 2% VAG CREAM 2% CLINDAMYCIN PHOSPHATE VAGINAL CLEOCIN SUP 100MG SUPPOS 100 MG CLEOCIN PED SOL CLINDAMYCIN PALMITATE HCL FOR SOLN 75MG/5ML 75 MG/5ML (BASE EQUIV) CLINDAMYCIN CAP 150MG CLINDAMYCIN HCL CAP 150 MG CLINDAMYCIN CAP 300MG CLINDAMYCIN HCL CAP 300 MG CLINDAMYCIN CAP 75MG CLINDAMYCIN HCL CAP 75 MG CLINDAMYCIN PHOSPHATE VAGINAL CLINDAMYCIN CRE 2% VAG CREAM 2% CLINDAMYCIN SOL CLINDAMYCIN PALMITATE HCL FOR SOLN 75MG/5ML 75 MG/5ML (BASE EQUIV) CLINDAMYCIN PHOSPHATE (ONE DOSE) CLINDESSE CRE 2% VAGINAL CREAM 2% COLISTIMETHATE SODIUM FOR INJ 150 COLISTIMETH INJ 150MG MG COLISTIMETHATE SODIUM FOR INJ 150 COLY-MYCIN M INJ 150MG MG NEOMYCIN-POLYMYXIN-HC CRM 3.5 MG/ CORTISPORIN CRE 0.5% GM-10000 UNT/GM-0.5% BACITRACIN-POLYMYXIN-NEOMYCIN HC CORTISPORIN OIN 1% OINT 1% FLAGYL CAP 375MG METRONIDAZOLE CAP 375 MG FLAGYL TAB 250MG METRONIDAZOLE TAB 250 MG FLAGYL TAB 500MG METRONIDAZOLE TAB 500 MG FURADANTIN SUS NITROFURANTOIN SUSP 25 MG/5ML 25MG/5ML GNP ALCOHOL PAD SWABS *ALCOHOL SWABS*** HIPREX TAB 1GM METHENAMINE HIPPURATE TAB 1 GM *METHENAMINE-HYOSC-METH BLUE-SOD HYOLEV MB TAB 81MG PHOS-PHEN SAL TAB 81 MG*** METHENAMINE-HYOSC-METH BLUE-BENZ HYOPHEN TAB ACID-PHENYL SAL TAB 81.6MG *METHENAMINE-HYOSCAMINE-METH INDIOMIN MB CAP 120MG BLUE-SOD PHOS CAP 120 MG*** IODINE TIN 2% *IODINE TINCTURE** LINEZOLID SUS 100/5ML LINEZOLID FOR SUSP 100 MG/5ML LINEZOLID TAB 600MG LINEZOLID TAB 600 MG
19
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
X X
X
Tier 3 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 1 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 2 Tier 2
X X
Therapeutic Class
Label Name
Antibacterials, Other - Antibiotics
LUGOLS SOL STRONG
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 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
Generic Name
*IODINE SOLUTION** NITROFURANTOIN MONOHYDRATE MACROBID CAP 100MG MACROCRYSTALLINE CAP 100 MG NITROFURANTOIN MACROCRYSTALLINE MACRODANTIN CAP 100MG CAP 100 MG NITROFURANTOIN MACROCRYSTALLINE MACRODANTIN CAP 25MG CAP 25 MG NITROFURANTOIN MACROCRYSTALLINE MACRODANTIN CAP 50MG CAP 50 MG *METHENAMINE-HYOSCAMINE-METH ME/NAPHOS/MB TAB HYO 1 BLUE-SOD PHOS TAB 81.6 MG*** METHENAM HIP TAB 1GM METHENAMINE HIPPURATE TAB 1 GM METHENAM MAN TAB METHENAMINE MANDELATE TAB 1 GM 1000MG METHENAM MAN TAB 1GM METHENAMINE MANDELATE TAB 1 GM METHENAM MAN TAB METHENAMINE MANDELATE TAB 0.5 GM 500MG METROCREAM CRE 0.75% METRONIDAZOLE CREAM 0.75% METROLOTION LOT 0.75% METRONIDAZOLE LOTION 0.75% METRONIDAZOL CAP METRONIDAZOLE CAP 375 MG 375MG METRONIDAZOL CRE 0.75% METRONIDAZOLE CREAM 0.75% METRONIDAZOL GEL 0.75% METRONIDAZOLE GEL 0.75% METRONIDAZOL GEL METRONIDAZOLE VAGINAL GEL 0.75% 0.75%VAG METRONIDAZOL LOT 0.75% METRONIDAZOLE LOTION 0.75% METRONIDAZOL TAB METRONIDAZOLE TAB 250 MG 250MG METRONIDAZOL TAB METRONIDAZOLE TAB 500 MG 500MG MITOSOL KIT 0.2MG MITOMYCIN FOR OPHTH SOLN KIT 0.2 MG FOSFOMYCIN TROMETHAMINE POWD MONUROL PAK GRANULES PACK 3 GM (BASE EQUIVALENT) MUPIROCIN CRE 2% MUPIROCIN CALCIUM CREAM 2% MUPIROCIN OIN 2% MUPIROCIN OINT 2% MUPIROCIN CA CRE 2% MUPIROCIN CALCIUM CREAM 2% NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5) NEO/BAC/POLY OIN OP MG-400UNT-10000UNT OP OIN NEOMYCIN-POLYMY-GRAMICID OP SOL NEO/POLY/GRA SOL OP 1.75-10000-0.025MG-UNT-MG/ML NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5) NEO-POLYCIN OIN OP MG-400UNT-10000UNT OP OIN NEOMYCIN-POLYMY-GRAMICID OP SOL NEOSPORIN SOL OP 1.75-10000-0.025MG-UNT-MG/ML NITROFURANTOIN MACROCRYSTALLINE NITROFUR MAC CAP 100MG CAP 100 MG NITROFURANTOIN MACROCRYSTALLINE NITROFUR MAC CAP 25MG CAP 25 MG NITROFURANTOIN MACROCRYSTALLINE NITROFUR MAC CAP 50MG CAP 50 MG NITROFURANTN CAP NITROFURANTOIN MONOHYDRATE 100MG MACROCRYSTALLINE CAP 100 MG NITROFURANTN SUS NITROFURANTOIN SUSP 25 MG/5ML 25MG/5ML AMOXICILLIN CAP-CLARITHRO TAB W/ OMECLAMOX- MIS PAK OMEPRAZ CAP DR THERAPY PACK *METHENAMINE-HYOS-METH BLUE-SOD PHOSPHASAL TAB PHOS-PHEN SAL TAB 81.6 MG*** POLYCIN OIN OP BACITRACIN-POLYMYXIN B OPHTH OINT POLYMYXIN B/ SOL POLYMYXIN B-TRIMETHOPRIM OPHTH TRIMETHP SOLN 10000 UNIT/ML-0.1% POLYMYXIN B-TRIMETHOPRIM OPHTH POLYTRIM SOL OP SOLN 10000 UNIT/ML-0.1% PREP PADS PAD *ALCOHOL SWABS*** TRIMETHOPRIM HCL ORAL SOLN 50 PRIMSOL SOL 50MG/5ML MG/5ML (BASE EQUIV) QC ALCOHOL PAD SWABS *ALCOHOL SWABS*** RA ALCOHOL PAD SWABS *ALCOHOL SWABS*** ROSADAN CRE 0.75% METRONIDAZOLE CREAM 0.75% ROSADAN GEL 0.75% METRONIDAZOLE GEL 0.75% SILVADENE CRE 1% SILVER SULFADIAZINE CREAM 1% SILVER SULFA CRE 1% SILVER SULFADIAZINE CREAM 1% SIVEXTRO TAB 200MG TEDIZOLID PHOSPHATE TAB 200 MG SM ALCOHOL PAD PREP *ALCOHOL SWABS*** SSD CRE 1% SILVER SULFADIAZINE CREAM 1%
20
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3
X X X
Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
X
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 1
X
Therapeutic Class
Label Name
Generic Name
Antibacterials, Other - Antibiotics
SULFAMYLON CRE 85MG/ GM
MAFENIDE ACETATE CREAM 85 MG/GM
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 Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Antibacterials, Other - Antibiotics Anticholinergics - Parkinson's Disease Drugs Anticholinergics - Parkinson's Disease Drugs Anticholinergics - Parkinson's Disease Drugs Anticholinergics - Parkinson's Disease Drugs Anticholinergics - Parkinson's Disease Drugs Anticholinergics - Parkinson's Disease Drugs
MAFENIDE ACETATE PACKET FOR TOPICAL SOLN 5% (50 GM) TRIMETHOPRIM SOL POLYMYXIN B-TRIMETHOPRIM OPHTH POLYMYXN SOLN 10000 UNIT/ML-0.1% TRIMETHOPRIM TAB 100MG TRIMETHOPRIM TAB 100 MG ULTILET ALCH PAD SWAB *ALCOHOL SWABS*** *METHENAMINE-HYOS-METH BLUE-SOD UR N-C TAB PHOS-PHEN SAL TAB 81.6 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD URAMIT MB CAP 118MG PHOS-PHEN SAL CAP 118 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD URELLE TAB PHOS-PHEN SAL TAB 81 MG*** *METHENAMINE-HYOS-METH BLUE-SOD URETRON D/S TAB PHOS-PHEN SAL TAB 81.6 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD URIBEL CAP 118MG PHOS-PHEN SAL CAP 118 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD URIMAR-T TAB PHOS-PHEN SAL TAB 120 MG*** *METHENAMINE-HYOS-METH BLUE-SOD URIN D/S TAB PHOS-PHEN SAL TAB 81.6 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD URO-458 TAB PHOS-PHEN SAL TAB 81 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD UROAV-81 TAB PHOS-PHEN SAL TAB 81 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD UROAV-B CAP PHOS-PHEN SAL CAP 118 MG*** *METHENAMINE-HYOSCAMINE-METH URO-BLUE TAB 81.6MG BLUE-SOD PHOS TAB 81.6 MG*** *METHENAMINE-HYOSCAMINE-METH UROGESIC- TAB BLUE BLUE-SOD PHOS TAB 81.6 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD URO-L TAB 81MG PHOS-PHEN SAL TAB 81 MG*** *METHENAMINE-HYOSCAMINE-METH UROLET MB TAB BLUE-SOD PHOS TAB 81.6 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD URO-MP CAP 118MG PHOS-PHEN SAL CAP 118 MG*** METHENAMINE-HYOSC-METH BLUE-BENZ UROPHEN MB TAB 81.6MG ACID-PHENYL SAL TAB 81.6MG *METHENAMINE-HYOSCAMINE-METH URYL TAB BLUE-SOD PHOS TAB 81.6 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD USTELL CAP PHOS-PHEN SAL CAP 120 MG*** *METHENAMINE-HYOSCAMINE-METH UTA CAP 120MG BLUE-SOD PHOS CAP 120 MG*** *METHENAMINE-HYOSC-METH BLUE-SOD UTICAP CAP PHOS-PHEN SAL CAP 120 MG*** *METHENAMINE-HYOS-METH BLUE-SOD UTIRA-C TAB PHOS-PHEN SAL TAB 81.6 MG*** *METHENAMINE-HYOS-METH BLUE-SOD UTRONA-C TAB PHOS-PHEN SAL TAB 81.6 MG*** VANCOCIN HCL CAP 250MG VANCOMYCIN HCL CAP 250 MG VANCOMYCIN CAP 125MG VANCOMYCIN HCL CAP 125 MG VANCOMYCIN CAP 250MG VANCOMYCIN HCL CAP 250 MG VANDAZOLE GEL 0.75% METRONIDAZOLE VAGINAL GEL 0.75% XIFAXAN TAB 200MG RIFAXIMIN TAB 200 MG XIFAXAN TAB 550MG RIFAXIMIN TAB 550 MG ZYVOX SUS 100MG/5M LINEZOLID FOR SUSP 100 MG/5ML SULFAMYLON PAK 5%
Tier Value Tier 3 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 3 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3
BENZTROPINE TAB 0.5MG
BENZTROPINE MESYLATE TAB 0.5 MG
Tier 1
BENZTROPINE TAB 1MG
BENZTROPINE MESYLATE TAB 1 MG
Tier 1
BENZTROPINE TAB 2MG
BENZTROPINE MESYLATE TAB 2 MG
Tier 1
TRIHEXYPHEN ELX 0.4MG/ ML
TRIHEXYPHENIDYL HCL ELIXIR 0.4 MG/ML
Tier 1
TRIHEXYPHEN TAB 2MG
TRIHEXYPHENIDYL HCL TAB 2 MG
Tier 1
TRIHEXYPHEN TAB 5MG
TRIHEXYPHENIDYL HCL TAB 5 MG
Tier 1
Anticoagulants - Blood Thinners
ARIXTRA INJ 10/0.8ML
Anticoagulants - Blood Thinners
ARIXTRA INJ 2.5/0.5
Anticoagulants - Blood Thinners
ARIXTRA INJ 5/0.4ML
FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML
21
Prior Supply Step Specialty Authorization Limit Therapy
X X X X X
X X X
Tier 3
X
Tier 3
X
Tier 3
X
Therapeutic Class
Label Name
Anticoagulants - Blood Thinners
ARIXTRA INJ 7.5/0.6
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
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 ENOXAPARIN INJ 120/0.8 ENOXAPARIN INJ 150MG/ML 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
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
FONDAPARINUX INJ 2.5/0.5
Anticoagulants - Blood Thinners
FONDAPARINUX INJ 5/0.4ML
Anticoagulants - Blood Thinners
FONDAPARINUX INJ 7.5/0.6
Anticoagulants - Blood Thinners
FRAGMIN INJ 10000/ML
Anticoagulants - Blood Thinners
FRAGMIN INJ 12500UNT
Anticoagulants - Blood Thinners
FRAGMIN INJ 15000UNT
Anticoagulants - Blood Thinners
FRAGMIN INJ 18000UNT
Anticoagulants - Blood Thinners
FRAGMIN INJ 2500/0.2
Anticoagulants - Blood Thinners
FRAGMIN INJ 5000/0.2
Anticoagulants - Blood Thinners
FRAGMIN INJ 7500/0.3
Anticoagulants - Blood Thinners
FRAGMIN INJ 95000UNT
Anticoagulants - Blood Thinners
HEPARIN LOCK INJ 100/ML
Anticoagulants - Blood Thinners
HEPARIN LOCK INJ 10UNT/ ML
Anticoagulants - Blood Thinners
HEPARIN SOD INJ 1000/ML
Anticoagulants - Blood Thinners
HEPARIN SOD INJ 10000/ML
Anticoagulants - Blood Thinners
HEPARIN SOD INJ 10000/ML
Anticoagulants - Blood Thinners
HEPARIN SOD INJ 20000/ML
Anticoagulants - Blood Thinners
HEPARIN SOD INJ 5000/0.5
Anticoagulants - Blood Thinners
HEPARIN SOD INJ 5000/ML
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
JANTOVEN TAB 10MG 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
Generic Name FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML WARFARIN SODIUM TAB 10 MG WARFARIN SODIUM TAB 1 MG WARFARIN SODIUM TAB 2.5 MG WARFARIN SODIUM TAB 2 MG WARFARIN SODIUM TAB 3 MG WARFARIN SODIUM TAB 4 MG WARFARIN SODIUM TAB 5 MG WARFARIN SODIUM TAB 6 MG WARFARIN SODIUM TAB 7.5 MG APIXABAN TAB 2.5 MG APIXABAN TAB 5 MG ENOXAPARIN SODIUM INJ 100 MG/ML ENOXAPARIN SODIUM INJ 120 MG/0.8ML ENOXAPARIN SODIUM INJ 150 MG/ML ENOXAPARIN SODIUM INJ 30 MG/0.3ML ENOXAPARIN SODIUM INJ 300 MG/3ML ENOXAPARIN SODIUM INJ 40 MG/0.4ML ENOXAPARIN SODIUM INJ 60 MG/0.6ML ENOXAPARIN SODIUM INJ 80 MG/0.8ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 10 MG/0.8ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 2.5 MG/0.5ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 5 MG/0.4ML FONDAPARINUX SODIUM SUBCUTANEOUS INJ 7.5 MG/0.6ML DALTEPARIN SODIUM INJ 10000 UNIT/ML DALTEPARIN SODIUM INJ 12500 UNIT/0.5ML DALTEPARIN SODIUM INJ 15000 UNIT/0.6ML DALTEPARIN SODIUM INJ 18000 UNIT/0.72ML DALTEPARIN SODIUM INJ 2500 UNIT/0.2ML DALTEPARIN SODIUM INJ 5000 UNIT/0.2ML DALTEPARIN SODIUM INJ 7500 UNIT/0.3ML DALTEPARIN SODIUM INJ 95000 UNIT/3.8ML HEPARIN SODIUM (PORCINE) LOCK FLUSH IV SOLN 100 UNIT/ML HEPARIN SODIUM (PORCINE) LOCK FLUSH IV SOLN 10 UNIT/ML HEPARIN SODIUM (PORCINE) INJ 1000 UNIT/ML HEPARIN SODIUM (PORCINE) INJ 10000 UNIT/ML HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML HEPARIN SODIUM (PORCINE) INJ 20000 UNIT/ML HEPARIN SODIUM (PORCINE) PF INJ 5000 UNIT/0.5ML HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML WARFARIN SODIUM TAB 10 MG WARFARIN SODIUM TAB 1 MG WARFARIN SODIUM TAB 2.5 MG WARFARIN SODIUM TAB 2 MG WARFARIN SODIUM TAB 3 MG WARFARIN SODIUM TAB 4 MG WARFARIN SODIUM TAB 5 MG WARFARIN SODIUM TAB 6 MG WARFARIN SODIUM TAB 7.5 MG ENOXAPARIN SODIUM INJ 100 MG/ML ENOXAPARIN SODIUM INJ 120 MG/0.8ML ENOXAPARIN SODIUM INJ 150 MG/ML ENOXAPARIN SODIUM INJ 30 MG/0.3ML ENOXAPARIN SODIUM INJ 300 MG/3ML ENOXAPARIN SODIUM INJ 40 MG/0.4ML
22
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
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
X X X X X X X X X X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
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 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X X X
Therapeutic Class
Label Name
Generic Name
Tier Value
Anticoagulants - Blood Thinners Anticoagulants - Blood Thinners
LOVENOX INJ 60/0.6ML LOVENOX INJ 80/0.8ML
Tier 3 Tier 3
Anticoagulants - Blood Thinners
PRADAXA CAP 110MG
Anticoagulants - Blood Thinners
PRADAXA CAP 150MG
Prior Supply Step Specialty Authorization Limit Therapy X X
Anticoagulants - Blood Thinners
PRADAXA CAP 75MG
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
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 XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG XARELTO STAR TAB 15/20MG
ENOXAPARIN SODIUM INJ 60 MG/0.6ML ENOXAPARIN SODIUM INJ 80 MG/0.8ML DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILATE BASE EQ) DABIGATRAN ETEXILATE MESYLATE CAP 150 MG (ETEXILATE BASE EQ) DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE BASE EQ) WARFARIN SODIUM TAB 10 MG WARFARIN SODIUM TAB 1 MG WARFARIN SODIUM TAB 2.5 MG WARFARIN SODIUM TAB 2 MG WARFARIN SODIUM TAB 3 MG WARFARIN SODIUM TAB 4 MG WARFARIN SODIUM TAB 5 MG WARFARIN SODIUM TAB 6 MG WARFARIN SODIUM TAB 7.5 MG RIVAROXABAN TAB 10 MG RIVAROXABAN TAB 15 MG RIVAROXABAN TAB 20 MG RIVAROXABAN TAB STARTER THERAPY PACK 15 MG & 20 MG
APTIOM TAB 200MG
ESLICARBAZEPINE ACETATE TAB 200 MG
Tier 3
X
APTIOM TAB 400MG
ESLICARBAZEPINE ACETATE TAB 400 MG
Tier 3
X
APTIOM TAB 600MG
ESLICARBAZEPINE ACETATE TAB 600 MG
Tier 3
X
APTIOM TAB 800MG
ESLICARBAZEPINE ACETATE TAB 800 MG
Tier 3
X
KEPPRA SOL 100MG/ML
LEVETIRACETAM ORAL SOLN 100 MG/ML
Tier 3
X
X
KEPPRA TAB 1000MG
LEVETIRACETAM TAB 1000 MG
Tier 3
X
X
KEPPRA TAB 250MG
LEVETIRACETAM TAB 250 MG
Tier 3
X
X
KEPPRA TAB 500MG
LEVETIRACETAM TAB 500 MG
Tier 3
X
X
KEPPRA TAB 750MG
LEVETIRACETAM TAB 750 MG
Tier 3
X
X
KEPPRA XR TAB 500MG
LEVETIRACETAM TAB SR 24HR 500 MG
Tier 3
X
X
KEPPRA XR TAB 750MG
LEVETIRACETAM TAB SR 24HR 750 MG
Tier 3
X
X
Anticoagulants - Blood Thinners Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs
LEVETIRACETA SOL 100MG/ LEVETIRACETAM ORAL SOLN 100 MG/ML ML LEVETIRACETA SOL LEVETIRACETAM ORAL SOLN 100 MG/ML 500/5ML LEVETIRACETA TAB LEVETIRACETAM TAB 1000 MG 1000MG
Tier 2
X
Tier 2
X
Tier 2
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2
X X X
Tier 2
Tier 1 Tier 1 Tier 1
LEVETIRACETA TAB 250MG
LEVETIRACETAM TAB 250 MG
Tier 1
LEVETIRACETA TAB 500MG
LEVETIRACETAM TAB 500 MG
Tier 1
LEVETIRACETA TAB 500MG ER
LEVETIRACETAM TAB SR 24HR 500 MG
Tier 2
LEVETIRACETA TAB 750MG
LEVETIRACETAM TAB 750 MG
Tier 1
LEVETIRACETA TAB 750MG ER
LEVETIRACETAM TAB SR 24HR 750 MG
Tier 2
PHENOBARB ELX 20/5ML
PHENOBARBITAL ELIXIR 20 MG/5ML
Tier 1
PHENOBARBITAL ELIXIR 20 MG/5ML
Tier 1
PHENOBARBITAL ELIXIR 20 MG/5ML
Tier 1
PHENOBARB TAB 100MG
PHENOBARBITAL TAB 100 MG
Tier 1
PHENOBARB TAB 15MG
PHENOBARBITAL TAB 15 MG
Tier 1
PHENOBARB TAB 16.2MG
PHENOBARBITAL TAB 16.2 MG
Tier 1
PHENOBARB TAB 30MG
PHENOBARBITAL TAB 30 MG
Tier 1
PHENOBARB TAB 32.4MG
PHENOBARBITAL TAB 32.4 MG
Tier 1
PHENOBARB ELX 20MG/5ML PHENOBARB SOL 20MG/5ML
23
Therapeutic Class Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anticonvulsants, Other - Seizure Control Drugs Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral Drugs Antidementia Agents, Other
Generic Name
PHENOBARB TAB 60MG
PHENOBARBITAL TAB 60 MG
Tier 1
PHENOBARB TAB 64.8MG
PHENOBARBITAL TAB 64.8 MG
Tier 1
PHENOBARB TAB 97.2MG
PHENOBARBITAL TAB 97.2 MG
Tier 1
POTIGA TAB 200MG
EZOGABINE TAB 200 MG
Tier 3
X
POTIGA TAB 300MG
EZOGABINE TAB 300 MG
Tier 3
X
POTIGA TAB 400MG
EZOGABINE TAB 400 MG
Tier 3
X
POTIGA TAB 50MG
EZOGABINE TAB 50 MG
Tier 3
X
ROWEEPRA TAB 1000MG
LEVETIRACETAM TAB 1000 MG
Tier 1
ROWEEPRA TAB 500MG
LEVETIRACETAM TAB 500 MG
Tier 1
ROWEEPRA TAB 750MG
LEVETIRACETAM TAB 750 MG
Tier 1
VALGANCICLOVIR HCL FOR SOLN 50 MG/ ML (BASE EQUIV) VALGANCICLOV SOL 50MG/ VALGANCICLOVIR HCL FOR SOLN 50 MG/ ML ML (BASE EQUIV) VALGANCICLOVIR HCL TAB 450 MG (BASE VALGANCICLOV TAB 450MG EQUIVALENT) VALCYTE SOL 50MG/ML
Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants
Tier 1
X X
GANCICLOVIR OPHTH GEL 0.15%
Tier 3
ERGOLOID MESYLATES TAB 1 MG
Tier 1
Antidepressants, Other - Antidepressants BRINTELLIX TAB 5MG
Antidepressants, Other - Antidepressants
Tier 1
ERGOLOID MES TAB 1MG ORAL
Antidepressants, Other - Antidepressants BRINTELLIX TAB 20MG
Antidepressants, Other - Antidepressants
Tier 3
ZIRGAN GEL 0.15%
Antidepressants, Other - Antidepressants BRINTELLIX TAB 10MG
Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants Antidepressants, Other - Antidepressants
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
BUPROPION TAB 100MG BUPROPION TAB 100MG ER BUPROPION TAB 100MG SR BUPROPION TAB 150MG ER BUPROPION TAB 150MG SR BUPROPION TAB 200MG ER BUPROPION TAB 200MG SR BUPROPION TAB 75MG BUPROPN HCL TAB 150MG XL BUPROPN HCL TAB 300MG XL MAPROTILINE TAB 25MG MAPROTILINE TAB 50MG MAPROTILINE TAB 75MG MIRTAZAPINE TAB 15MG MIRTAZAPINE TAB 15MG ODT MIRTAZAPINE TAB 30MG MIRTAZAPINE TAB 30MG ODT MIRTAZAPINE TAB 45MG MIRTAZAPINE TAB 45MG ODT MIRTAZAPINE TAB 7.5MG NEFAZODONE TAB 100MG NEFAZODONE TAB 150MG NEFAZODONE TAB 200MG NEFAZODONE TAB 250MG NEFAZODONE TAB 50MG REMERON TAB 15MG REMERON TAB 30MG REMERON TAB 45MG
Antidepressants, Other - Antidepressants REMERON SLTB TAB 15MG Antidepressants, Other - Antidepressants REMERON SLTB TAB 30MG Antidepressants, Other - Antidepressants REMERON SLTB TAB 45MG Antidepressants, Other - Antidepressants TRAZODONE TAB 100MG
VORTIOXETINE HBR TAB 10 MG (BASE EQUIV) VORTIOXETINE HBR TAB 20 MG (BASE EQUIV) VORTIOXETINE HBR TAB 5 MG (BASE EQUIV) BUPROPION HCL TAB 100 MG BUPROPION HCL TAB SR 12HR 100 MG BUPROPION HCL TAB SR 12HR 100 MG BUPROPION HCL TAB SR 12HR 150 MG BUPROPION HCL TAB SR 12HR 150 MG BUPROPION HCL TAB SR 12HR 200 MG BUPROPION HCL TAB SR 12HR 200 MG BUPROPION HCL TAB 75 MG
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
BUPROPION HCL TAB SR 24HR 150 MG
Tier 1
BUPROPION HCL TAB SR 24HR 300 MG
Tier 1
MAPROTILINE HCL TAB 25 MG MAPROTILINE HCL TAB 50 MG MAPROTILINE HCL TAB 75 MG MIRTAZAPINE TAB 15 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG MIRTAZAPINE TAB 30 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 30 MG MIRTAZAPINE TAB 45 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 45 MG MIRTAZAPINE TAB 7.5 MG NEFAZODONE HCL TAB 100 MG NEFAZODONE HCL TAB 150 MG NEFAZODONE HCL TAB 200 MG NEFAZODONE HCL TAB 250 MG NEFAZODONE HCL TAB 50 MG MIRTAZAPINE TAB 15 MG MIRTAZAPINE TAB 30 MG MIRTAZAPINE TAB 45 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 30 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 45 MG TRAZODONE HCL TAB 100 MG
Tier 1 Tier 1 Tier 1 Tier 1
24
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 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
Therapeutic Class
Label Name
Generic Name
Antidepressants, Other - Antidepressants TRAZODONE TAB 150MG Antidepressants, Other - Antidepressants TRAZODONE TAB 300MG Antidepressants, Other - Antidepressants TRAZODONE TAB 50MG
TRAZODONE HCL TAB 150 MG TRAZODONE HCL TAB 300 MG TRAZODONE HCL TAB 50 MG VORTIOXETINE HBR TAB 10 MG (BASE Antidepressants, Other - Antidepressants TRINTELLIX TAB 10MG EQUIV) VORTIOXETINE HBR TAB 20 MG (BASE Antidepressants, Other - Antidepressants TRINTELLIX TAB 20MG EQUIV) VORTIOXETINE HBR TAB 5 MG (BASE Antidepressants, Other - Antidepressants TRINTELLIX TAB 5MG EQUIV) Antidiabetic Agents - Diabetic Drugs ACARBOSE TAB 100MG ACARBOSE TAB 100 MG Antidiabetic Agents - Diabetic Drugs ACARBOSE TAB 25MG ACARBOSE TAB 25 MG Antidiabetic Agents - Diabetic Drugs ACARBOSE TAB 50MG ACARBOSE TAB 50 MG ACTOPLUS MET TAB 15PIOGLITAZONE HCL-METFORMIN HCL TAB Antidiabetic Agents - Diabetic Drugs 500MG 15-500 MG ACTOPLUS MET TAB 15PIOGLITAZONE HCL-METFORMIN HCL TAB Antidiabetic Agents - Diabetic Drugs 850MG 15-850 MG PIOGLITAZONE HCL-METFORMIN HCL TAB Antidiabetic Agents - Diabetic Drugs ACTOPLUS MET TAB XR SR 24HR 30-1000 MG PIOGLITAZONE HCL-METFORMIN HCL TAB Antidiabetic Agents - Diabetic Drugs ACTOPLUS MET TAB XR SR 24HR 15-1000 MG Antidiabetic Agents - Diabetic Drugs AMARYL TAB 1MG GLIMEPIRIDE TAB 1 MG Antidiabetic Agents - Diabetic Drugs AMARYL TAB 2MG GLIMEPIRIDE TAB 2 MG Antidiabetic Agents - Diabetic Drugs AMARYL TAB 4MG GLIMEPIRIDE TAB 4 MG ROSIGLITAZONE MALEATE TAB 2 MG Antidiabetic Agents - Diabetic Drugs AVANDIA TAB 2MG (BASE EQUIV) ROSIGLITAZONE MALEATE TAB 4 MG Antidiabetic Agents - Diabetic Drugs AVANDIA TAB 4MG (BASE EQUIV) ROSIGLITAZONE MALEATE TAB 8 MG Antidiabetic Agents - Diabetic Drugs AVANDIA TAB 8MG (BASE EQUIV) EXENATIDE FOR INJ EXTENDED RELEASE Antidiabetic Agents - Diabetic Drugs BYDUREON INJ 2MG SUSP 2 MG EXENATIDE EXTENDED RELEASE FOR Antidiabetic Agents - Diabetic Drugs BYDUREON PEN INJ 2MG SUSP PEN-INJECTOR 2 MG EXENATIDE SOLN PEN-INJECTOR 10 Antidiabetic Agents - Diabetic Drugs BYETTA INJ 10MCG MCG/0.04ML EXENATIDE SOLN PEN-INJECTOR 5 Antidiabetic Agents - Diabetic Drugs BYETTA INJ 5MCG MCG/0.02ML Antidiabetic Agents - Diabetic Drugs CHLORPROPAM TAB 100MG CHLORPROPAMIDE TAB 100 MG Antidiabetic Agents - Diabetic Drugs CHLORPROPAM TAB 250MG CHLORPROPAMIDE TAB 250 MG BROMOCRIPTINE MESYLATE TAB 0.8 MG Antidiabetic Agents - Diabetic Drugs CYCLOSET TAB 0.8MG (BASE EQUIVALENT) Antidiabetic Agents - Diabetic Drugs DIABETA TAB 1.25MG GLYBURIDE TAB 1.25 MG Antidiabetic Agents - Diabetic Drugs DIABETA TAB 2.5MG GLYBURIDE TAB 2.5 MG Antidiabetic Agents - Diabetic Drugs DIABETA TAB 5MG GLYBURIDE TAB 5 MG PIOGLITAZONE HCL-GLIMEPIRIDE TAB Antidiabetic Agents - Diabetic Drugs DUETACT TAB 30-2MG 30-2 MG PIOGLITAZONE HCL-GLIMEPIRIDE TAB Antidiabetic Agents - Diabetic Drugs DUETACT TAB 30-4MG 30-4 MG DAPAGLIFLOZIN PROPANEDIOL TAB 10 Antidiabetic Agents - Diabetic Drugs FARXIGA TAB 10MG MG (BASE EQUIVALENT) DAPAGLIFLOZIN PROPANEDIOL TAB 5 MG Antidiabetic Agents - Diabetic Drugs FARXIGA TAB 5MG (BASE EQUIVALENT) Antidiabetic Agents - Diabetic Drugs GLIMEPIRIDE TAB 1MG GLIMEPIRIDE TAB 1 MG Antidiabetic Agents - Diabetic Drugs GLIMEPIRIDE TAB 2MG GLIMEPIRIDE TAB 2 MG Antidiabetic Agents - Diabetic Drugs GLIMEPIRIDE TAB 4MG GLIMEPIRIDE TAB 4 MG Antidiabetic Agents - Diabetic Drugs GLIMEPIRIDE TAB 4MG GLIMEPIRIDE TAB 4 MG GLIP/METFORM TAB 2.5GLIPIZIDE-METFORMIN HCL TAB 2.5-250 Antidiabetic Agents - Diabetic Drugs 250M MG GLIP/METFORM TAB 2.5GLIPIZIDE-METFORMIN HCL TAB 2.5-500 Antidiabetic Agents - Diabetic Drugs 500M MG GLIP/METFORM TAB GLIPIZIDE-METFORMIN HCL TAB 5-500 Antidiabetic Agents - Diabetic Drugs 5-500MG MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE POW GLIPIZIDE POWDER Antidiabetic Agents - Diabetic Drugs GLIPIZIDE TAB 10MG GLIPIZIDE TAB 10 MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE TAB 5MG GLIPIZIDE TAB 5 MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE ER TAB 10MG GLIPIZIDE TAB SR 24HR 10 MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE ER TAB 2.5MG GLIPIZIDE TAB SR 24HR 2.5 MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE ER TAB 5MG GLIPIZIDE TAB SR 24HR 5 MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE XL TAB 10MG GLIPIZIDE TAB SR 24HR 10 MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE XL TAB 2.5MG GLIPIZIDE TAB SR 24HR 2.5 MG Antidiabetic Agents - Diabetic Drugs GLIPIZIDE XL TAB 5MG GLIPIZIDE TAB SR 24HR 5 MG Antidiabetic Agents - Diabetic Drugs GLUCOPHAGE TAB 1000MG METFORMIN HCL TAB 1000 MG Antidiabetic Agents - Diabetic Drugs GLUCOPHAGE TAB 500MG METFORMIN HCL TAB 500 MG GLUCOPHAGE TAB 500MG Antidiabetic Agents - Diabetic Drugs METFORMIN HCL TAB SR 24HR 500 MG XR
25
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 1 Tier 1 Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 1 Tier 1 Tier 1 Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 3
X
Tier 3
X
Tier 3
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
Tier 3
X
Tier 3
X
X
Tier 3
X
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3
X
Therapeutic Class 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 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
Label Name GLUCOPHAGE TAB 750MG XR GLUCOPHAGE TAB 850MG GLUCOTROL TAB 10MG GLUCOTROL TAB 5MG GLUCOTROL XL TAB 10MG GLUCOTROL XL TAB 2.5MG GLUCOTROL XL TAB 5MG GLUCOVANCE TAB 2.5-500 GLUCOVANCE TAB 5-500MG GLYB/METFORM TAB 1.25250 GLYB/METFORM TAB 2.5500 GLYB/METFORM TAB 5-500MG 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
Generic Name
Tier Value
METFORMIN HCL TAB SR 24HR 750 MG
Tier 3
METFORMIN HCL TAB 850 MG GLIPIZIDE TAB 10 MG GLIPIZIDE TAB 5 MG GLIPIZIDE TAB SR 24HR 10 MG GLIPIZIDE TAB SR 24HR 2.5 MG GLIPIZIDE TAB SR 24HR 5 MG GLYBURIDE-METFORMIN TAB 2.5-500 MG GLYBURIDE-METFORMIN TAB 5-500 MG GLYBURIDE-METFORMIN TAB 1.25-250 MG
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
GLYBURIDE-METFORMIN TAB 2.5-500 MG
Tier 1
GLYBURIDE-METFORMIN TAB 5-500 MG
Tier 1
GLYBURIDE MICRONIZED TAB 1.5 MG GLYBURIDE MICRONIZED TAB 3 MG GLYBURIDE MICRONIZED TAB 6 MG GLYBURIDE POWDER GLYBURIDE TAB 1.25 MG GLYBURIDE TAB 2.5 MG GLYBURIDE TAB 5 MG GLYBURIDE MICRONIZED TAB 1.5 MG GLYBURIDE MICRONIZED TAB 3 MG GLYBURIDE MICRONIZED TAB 6 MG MIGLITOL TAB 100 MG MIGLITOL TAB 25 MG MIGLITOL TAB 50 MG CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 150-1000 150-1000 MG CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 150-500 150-500 MG CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 50-1000 50-1000 MG CANAGLIFLOZIN-METFORMIN HCL TAB INVOKAMET TAB 50-500MG 50-500 MG INVOKAMET XR TAB 150CANAGLIFLOZIN-METFORMIN HCL TAB SR 1000 24HR 150-1000 MG INVOKAMET XR TAB 150CANAGLIFLOZIN-METFORMIN HCL TAB SR 500 24HR 150-500 MG CANAGLIFLOZIN-METFORMIN HCL TAB SR INVOKAMET XR TAB 50-1000 24HR 50-1000 MG INVOKAMET XR TAB 50CANAGLIFLOZIN-METFORMIN HCL TAB SR 500MG 24HR 50-500 MG INVOKANA TAB 100MG CANAGLIFLOZIN TAB 100 MG INVOKANA TAB 300MG CANAGLIFLOZIN TAB 300 MG SITAGLIPTIN-METFORMIN HCL TAB 50JANUMET TAB 50-1000 1000 MG SITAGLIPTIN-METFORMIN HCL TAB 50JANUMET TAB 50-500MG 500 MG SITAGLIPTIN-METFORMIN HCL TAB SR JANUMET XR TAB 100-1000 24HR 100-1000 MG SITAGLIPTIN-METFORMIN HCL TAB SR JANUMET XR TAB 50-1000 24HR 50-1000 MG SITAGLIPTIN-METFORMIN HCL TAB SR JANUMET XR TAB 50-500MG 24HR 50-500 MG SITAGLIPTIN PHOSPHATE TAB 100 MG JANUVIA TAB 100MG (BASE EQUIV) SITAGLIPTIN PHOSPHATE TAB 25 MG JANUVIA TAB 25MG (BASE EQUIV) SITAGLIPTIN PHOSPHATE TAB 50 MG JANUVIA TAB 50MG (BASE EQUIV) JARDIANCE TAB 10MG EMPAGLIFLOZIN TAB 10 MG JARDIANCE TAB 25MG EMPAGLIFLOZIN TAB 25 MG LINAGLIPTIN-METFORMIN HCL TAB 2.5JENTADUETO TAB 2.5-1000 1000 MG LINAGLIPTIN-METFORMIN HCL TAB 2.5JENTADUETO TAB 2.5-500 500 MG LINAGLIPTIN-METFORMIN HCL TAB 2.5JENTADUETO TAB 2.5-850 850 MG LINAGLIPTIN-METFORMIN HCL TAB SR JENTADUETO TAB XR 24HR 2.5-1000 MG LINAGLIPTIN-METFORMIN HCL TAB SR JENTADUETO TAB XR 24HR 5-1000 MG
26
Prior Supply Step Specialty Authorization Limit Therapy X
Tier 1
Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2 Tier 2
X X
X X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 2 Tier 2
X X
X X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2 Tier 2
Therapeutic Class
Label Name
Antidiabetic Agents - Diabetic Drugs
KAZANO 12.5- TAB 1000MG
Antidiabetic Agents - Diabetic Drugs
KAZANO 12.5- TAB 500MG
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
KOMBIGLYZ XR TAB 2.51000 KOMBIGLYZ XR TAB 5-1000MG KOMBIGLYZ XR TAB 5-500MG METFORMIN TAB 1000MG METFORMIN TAB 500MG METFORMIN TAB 500MG ER METFORMIN TAB 750MG ER METFORMIN TAB 850MG MIGLITOL TAB 100MG MIGLITOL TAB 25MG MIGLITOL TAB 50MG NATEGLINIDE TAB 120MG NATEGLINIDE TAB 60MG
Antidiabetic Agents - Diabetic Drugs
NESINA TAB 12.5MG
Antidiabetic Agents - Diabetic Drugs
NESINA TAB 25MG
Antidiabetic Agents - Diabetic Drugs
NESINA TAB 6.25MG
Antidiabetic Agents - Diabetic Drugs
ONGLYZA TAB 2.5MG
Antidiabetic Agents - Diabetic Drugs
ONGLYZA TAB 5MG
Antidiabetic Agents - Diabetic Drugs
OSENI TAB 12.5-15
Antidiabetic Agents - Diabetic Drugs
OSENI TAB 12.5-30
Antidiabetic Agents - Diabetic Drugs
OSENI TAB 12.5-45
Antidiabetic Agents - Diabetic Drugs
OSENI TAB 25-15MG
Antidiabetic Agents - Diabetic Drugs
OSENI TAB 25-30MG
Antidiabetic Agents - Diabetic Drugs
OSENI TAB 25-45MG
Antidiabetic Agents - Diabetic Drugs
PIOGLIT/GLIM TAB 30-2MG
Antidiabetic Agents - Diabetic Drugs
PIOGLIT/GLIM TAB 30-4MG
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
PIOGLITA/MET TAB 15500MG PIOGLITA/MET TAB 15850MG
Antidiabetic Agents - Diabetic Drugs
PIOGLITAZONE TAB 15MG
Antidiabetic Agents - Diabetic Drugs
PIOGLITAZONE TAB 30MG
Antidiabetic Agents - Diabetic Drugs
PIOGLITAZONE TAB 45MG
Antidiabetic Agents - Diabetic Drugs
PRANDIMET TAB 1-500MG
Antidiabetic Agents - Diabetic Drugs
PRANDIMET TAB 2-500MG
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
PRANDIN TAB 0.5MG PRANDIN TAB 1MG PRANDIN TAB 2MG PRECOSE TAB 100MG PRECOSE TAB 25MG PRECOSE TAB 50MG REPAGLINIDE TAB 0.5MG
Antidiabetic Agents - Diabetic Drugs
REPAGLINIDE TAB 1-500MG
Antidiabetic Agents - Diabetic Drugs
REPAGLINIDE TAB 1MG
Antidiabetic Agents - Diabetic Drugs
REPAGLINIDE TAB 2-500MG
Antidiabetic Agents - Diabetic Drugs
REPAGLINIDE TAB 2MG
Antidiabetic Agents - Diabetic Drugs
RIOMET SOL
Antidiabetic Agents - Diabetic Drugs
RIOMET SOL 500/5ML
Antidiabetic Agents - Diabetic Drugs
STARLIX TAB 120MG
Generic Name ALOGLIPTIN-METFORMIN HCL TAB 12.51000 MG ALOGLIPTIN-METFORMIN HCL TAB 12.5500 MG SAXAGLIPTIN-METFORMIN HCL TAB SR 24HR 2.5-1000 MG SAXAGLIPTIN-METFORMIN HCL TAB SR 24HR 5-1000 MG SAXAGLIPTIN-METFORMIN HCL TAB SR 24HR 5-500 MG METFORMIN HCL TAB 1000 MG METFORMIN HCL TAB 500 MG METFORMIN HCL TAB SR 24HR 500 MG METFORMIN HCL TAB SR 24HR 750 MG METFORMIN HCL TAB 850 MG MIGLITOL TAB 100 MG MIGLITOL TAB 25 MG MIGLITOL TAB 50 MG NATEGLINIDE TAB 120 MG NATEGLINIDE TAB 60 MG ALOGLIPTIN BENZOATE TAB 12.5 MG (BASE EQUIV) ALOGLIPTIN BENZOATE TAB 25 MG (BASE EQUIV) ALOGLIPTIN BENZOATE TAB 6.25 MG (BASE EQUIV) SAXAGLIPTIN HCL TAB 2.5 MG (BASE EQUIV) SAXAGLIPTIN HCL TAB 5 MG (BASE EQUIV) ALOGLIPTIN-PIOGLITAZONE TAB 12.5-15 MG ALOGLIPTIN-PIOGLITAZONE TAB 12.5-30 MG ALOGLIPTIN-PIOGLITAZONE TAB 12.5-45 MG ALOGLIPTIN-PIOGLITAZONE TAB 25-15 MG ALOGLIPTIN-PIOGLITAZONE TAB 25-30 MG ALOGLIPTIN-PIOGLITAZONE TAB 25-45 MG PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-2 MG PIOGLITAZONE HCL-GLIMEPIRIDE TAB 30-4 MG PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV) PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV) REPAGLINIDE-METFORMIN HCL TAB 1-500 MG REPAGLINIDE-METFORMIN HCL TAB 2-500 MG REPAGLINIDE TAB 0.5 MG REPAGLINIDE TAB 1 MG REPAGLINIDE TAB 2 MG ACARBOSE TAB 100 MG ACARBOSE TAB 25 MG ACARBOSE TAB 50 MG REPAGLINIDE TAB 0.5 MG REPAGLINIDE-METFORMIN HCL TAB 1-500 MG REPAGLINIDE TAB 1 MG REPAGLINIDE-METFORMIN HCL TAB 2-500 MG REPAGLINIDE TAB 2 MG METFORMIN HCL ORAL SOLN 500 MG/5ML METFORMIN HCL ORAL SOLN 500 MG/5ML NATEGLINIDE TAB 120 MG
27
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
X X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 1
X
Tier 1
X
Tier 2
X
Tier 2
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
X X X
X
Tier 3 Tier 2
X
Tier 3 Tier 2
X
Tier 3 Tier 3 Tier 3
X
Therapeutic Class
Label Name
Generic Name
Antidiabetic Agents - Diabetic Drugs
STARLIX TAB 60MG SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG
NATEGLINIDE TAB 60 MG PRAMLINTIDE ACETATE PEN-INJ 1500 MCG/1.5ML (1000 MCG/ML) PRAMLINTIDE ACETATE PEN-INJ 2700 MCG/2.7ML (1000 MCG/ML) ALBIGLUTIDE FOR SOLN PEN-INJECTOR 30 MG ALBIGLUTIDE FOR SOLN PEN-INJECTOR 50 MG TOLAZAMIDE TAB 250 MG TOLAZAMIDE TAB 500 MG TOLBUTAMIDE TAB 500 MG LINAGLIPTIN TAB 5 MG LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML) LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML) ACETYLCYSTEINE EFFERVESCENT TAB 2.5 GM ACETYLCYSTEINE EFFERVESCENT TAB 500 MG DOXYLAMINE-PYRIDOXINE TAB DELAYED RELEASE 10-10 MG
Tier 3
TIGAN CAP 300MG
TRIMETHOBENZAMIDE HCL CAP 300 MG
Tier 3
TRANSDERM-SC DIS 1MG
SCOPOLAMINE TD PATCH 72HR 1 MG/3DAYS
Tier 3
TRIMETHOBENZAMIDE HCL CAP 300 MG
Tier 1
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
TANZEUM INJ 30MG
Antidiabetic Agents - Diabetic Drugs
TANZEUM INJ 50MG
Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs Antidiabetic Agents - Diabetic Drugs
TOLAZAMIDE TAB 250MG TOLAZAMIDE TAB 500MG TOLBUTAMIDE TAB 500MG TRADJENTA TAB 5MG
Antidiabetic Agents - Diabetic Drugs
VICTOZA INJ 18MG/3ML
Antidiabetic Agents - Diabetic Drugs
VICTOZA INJ 18MG/3ML
Antidotes - Antidotes/Protectants
CETYLEV TAB 2.5GM
Antidotes - Antidotes/Protectants
CETYLEV TAB 500MG
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
DICLEGIS TAB 10-10MG
TRIMETHOBENZ CAP 300MG EMCYT CAP 140MG FARESTON TAB 60MG TAMOXIFEN TAB 10MG
Antiestrogens/Modifiers - Chemotherapy TAMOXIFEN TAB 20MG Agents 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
ESTRAMUSTINE PHOSPHATE SODIUM CAP 140 MG TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT) TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT) TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)
ANCOBON CAP 250MG ANCOBON CAP 500MG AVC CRE 15% BIO-STATIN CAP 1000000 BIO-STATIN CAP 500000 BIO-STATIN POW
FLUCYTOSINE CAP 250 MG FLUCYTOSINE CAP 500 MG SULFANILAMIDE VAGINAL CREAM 15% NYSTATIN CAP 1000000 UNIT NYSTATIN CAP 500000 UNIT *NYSTATIN ORAL POWDER* CICLOPIROX OLAMINE CREAM 0.77% CICLODAN CRE 0.77% (BASE EQUIV) CICLODAN SOL 8% CICLOPIROX SOLUTION 8% CICLOPIROX OLAMINE CREAM 0.77% CICLOPIROX CRE 0.77% (BASE EQUIV) CICLOPIROX GEL 0.77% CICLOPIROX GEL 0.77% CICLOPIROX SHA 1% CICLOPIROX SHAMPOO 1% CICLOPIROX SOL 8% CICLOPIROX SOLUTION 8% CICLOPIROX OLAMINE SUSP 0.77% (BASE CICLOPIROX SUS 0.77% EQUIV) CLOTRIMAZOLE W/ BETAMETHASONE CLOTRIM/BETA CRE 1-0.05% CREAM 1-0.05% CLOTRIMAZOLE W/ BETAMETHASONE CLOTRIM/BETA CRE DIPROP CREAM 1-0.05% CLOTRIMAZOLE W/ BETAMETHASONE CLOTRIM/BETA LOT DIPROP LOTION 1-0.05% CLOTRIMAZOLE LOZ 10MG CLOTRIMAZOLE TROCHE 10 MG CLOTRIMAZOLE TRO 10MG CLOTRIMAZOLE TROCHE 10 MG *CICLOPIROX SOLN 8% & LACQUER CNL8 NAIL KIT REMOVAL PADS KIT** DIFLUCAN SUS 10MG/ML FLUCONAZOLE FOR SUSP 10 MG/ML DIFLUCAN SUS 40MG/ML FLUCONAZOLE FOR SUSP 40 MG/ML DIFLUCAN TAB 100MG FLUCONAZOLE TAB 100 MG DIFLUCAN TAB 150MG FLUCONAZOLE TAB 150 MG DIFLUCAN TAB 200MG FLUCONAZOLE TAB 200 MG DIFLUCAN TAB 50MG FLUCONAZOLE TAB 50 MG ECONAZOLE CRE 1% ECONAZOLE NITRATE CREAM 1% EXELDERM CRE 1% SULCONAZOLE NITRATE CREAM 1% EXELDERM SOL 1% SULCONAZOLE NITRATE SOLUTION 1% EXTINA AER 2% KETOCONAZOLE FOAM 2% FLUCONAZOLE SUS 10MG/ FLUCONAZOLE FOR SUSP 10 MG/ML ML
28
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy X
Tier 3
X
Tier 3
X
Tier 2
X
Tier 2
X
Tier 1 Tier 1 Tier 1 Tier 2
X
Tier 2
X
Tier 3
X
Tier 3 Tier 3 Tier 3
X
Tier 2
X
Tier 2
X
Tier 1 HCR Preventive Care Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1
X
Tier 1
X
Tier 1 Tier 1 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
X
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 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
Label Name FLUCONAZOLE SUS 40MG/ ML 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 GRISEOFULVIN TAB ULTR 125 GRISEOFULVIN TAB ULTR 250
Generic Name
Tier Value
FLUCONAZOLE FOR SUSP 40 MG/ML
Tier 1
FLUCONAZOLE TAB 100 MG FLUCONAZOLE TAB 150 MG FLUCONAZOLE TAB 200 MG FLUCONAZOLE TAB 50 MG FLUCYTOSINE CAP 250 MG FLUCYTOSINE CAP 500 MG GRISEOFULVIN MICROSIZE TAB 500 MG GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
GRISEOFULVIN MICROSIZE TAB 500 MG
Tier 1
GRISEOFULVIN ULTRAMICROSIZE TAB 125 MG GRISEOFULVIN ULTRAMICROSIZE TAB 250 MG GRISEOFULVIN ULTRAMICROSIZE TAB GRIS-PEG TAB 125MG 125 MG GRISEOFULVIN ULTRAMICROSIZE TAB GRIS-PEG TAB 250MG 250 MG BUTOCONAZOLE NITRATE (ONE DOSE) GYNAZOLE-1 CRE 2% VAGINAL CREAM 2% ITRACONAZOLE CAP 100MG ITRACONAZOLE CAP 100 MG JUBLIA SOL 10% EFINACONAZOLE SOLN 10% KETOCONAZOLE AER 2% KETOCONAZOLE FOAM 2% KETOCONAZOLE CRE 2% KETOCONAZOLE CREAM 2% KETOCONAZOLE SHA 2% KETOCONAZOLE SHAMPOO 2% KETOCONAZOLE TAB KETOCONAZOLE TAB 200 MG 200MG KETODAN AER 2% KETOCONAZOLE FOAM 2% TERBINAFINE HCL ORAL GRANULES LAMISIL GRA 125MG PACKET 125 MG TERBINAFINE HCL ORAL GRANULES LAMISIL GRA 187.5MG PACKET 187.5 MG LAMISIL TAB 250MG TERBINAFINE HCL TAB 250 MG CLOTRIMAZOLE W/ BETAMETHASONE LOTRISONE CRE CREAM 1-0.05% MENTAX CRE 1% BUTENAFINE HCL CREAM 1% MICONAZOLE NITRATE VAGINAL SUPPOS MICONAZOLE 3 SUP 200MG 200 MG NATACYN SUS 5% OP NATAMYCIN OPHTH SUSP 5% NIZORAL SHA 2% KETOCONAZOLE SHAMPOO 2% NOXAFIL SUS 40MG/ML POSACONAZOLE SUSP 40 MG/ML POSACONAZOLE TAB DELAYED RELEASE NOXAFIL TAB 100MG 100 MG NYSTATIN TOPICAL POWDER 100000 NYAMYC POW 100000 UNIT/GM NYSTATIN TOPICAL POWDER 100000 NYATA POW 100000 UNIT/GM NYSTATIN CRE 100000 NYSTATIN CREAM 100000 UNIT/GM NYSTATIN OIN 100000 NYSTATIN OINT 100000 UNIT/GM NYSTATIN POW *NYSTATIN ORAL POWDER* NYSTATIN TOPICAL POWDER 100000 NYSTATIN POW 100000 UNIT/GM NYSTATIN SUS 100000 NYSTATIN SUSP 100000 UNIT/ML NYSTATIN TAB 500000 NYSTATIN TAB 500000 UNIT NYSTATIN TOPICAL POWDER 100000 NYSTOP POW 100000 UNIT/GM MICONAZOLE BUCCAL TAB 50 MG ORAVIG TAB 50MG (MOUTH-THROAT) OXICONAZOLE CRE OXICONAZOLE NITRATE CREAM 1% NITRATE OXISTAT CRE 1% OXICONAZOLE NITRATE CREAM 1% SPORANOX CAP 100MG ITRACONAZOLE CAP 100 MG SPORANOX CAP PULSEPAK ITRACONAZOLE CAP 100 MG SPORANOX SOL 10MG/ML ITRACONAZOLE ORAL SOLN 10 MG/ML TERAZOL 3 CRE 0.8% TERCONAZOLE VAGINAL CREAM 0.8% TERAZOL 7 CRE 0.4% TERCONAZOLE VAGINAL CREAM 0.4% TERBINAFINE TAB 250MG TERBINAFINE HCL TAB 250 MG TERCONAZOLE CRE 0.4% TERCONAZOLE VAGINAL CREAM 0.4% TERCONAZOLE CRE 0.8% TERCONAZOLE VAGINAL CREAM 0.8% TERCONAZOLE SUP 80MG TERCONAZOLE VAGINAL SUPPOS 80 MG VFEND SUS 40MG/ML VORICONAZOLE FOR SUSP 40 MG/ML VFEND TAB 200MG VORICONAZOLE TAB 200 MG
29
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1
X
X X X
X
Tier 1 Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
X
X
X
Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
X
X X X X
X
X
X
Therapeutic Class
Label Name
Generic Name
Antifungals - Fungal Infection Drugs
VFEND TAB 50MG VORICONAZOLE SUS 40MG/ ML VORICONAZOLE TAB 200MG VORICONAZOLE TAB 50MG XOLEGEL GEL 2% ZAZOLE CRE 0.8% ZAZOLE SUP 80MG ALLOPURINOL TAB 100MG ALLOPURINOL TAB 300MG MITIGARE CAP 0.6MG PROBEN/COLCH TAB 5000.5 PROBENECID TAB 500MG ULORIC TAB 40MG ULORIC TAB 80MG ZYLOPRIM TAB 100MG ZYLOPRIM TAB 300MG ADEFOV DIPIV TAB 10MG BARACLUDE SOL .05MG/ML BARACLUDE TAB 0.5MG BARACLUDE TAB 1MG COPEGUS TAB 200MG ENTECAVIR TAB 0.5MG ENTECAVIR TAB 1MG HEPSERA TAB 10MG
VORICONAZOLE TAB 50 MG
Antifungals - Fungal Infection Drugs 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 Antigout Agents - Gout Drugs Antigout Agents - Gout 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 Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs Antihepatitis Agents - Hepatitis Drugs
VORICONAZOLE FOR SUSP 40 MG/ML
VORICONAZOLE TAB 200 MG VORICONAZOLE TAB 50 MG KETOCONAZOLE GEL 2% TERCONAZOLE VAGINAL CREAM 0.8% TERCONAZOLE VAGINAL SUPPOS 80 MG ALLOPURINOL TAB 100 MG ALLOPURINOL TAB 300 MG COLCHICINE CAP 0.6 MG COLCHICINE W/ PROBENECID TAB 0.5500 MG PROBENECID TAB 500 MG FEBUXOSTAT TAB 40 MG FEBUXOSTAT TAB 80 MG ALLOPURINOL TAB 100 MG ALLOPURINOL TAB 300 MG ADEFOVIR DIPIVOXIL TAB 10 MG ENTECAVIR ORAL SOLN 0.05 MG/ML ENTECAVIR TAB 0.5 MG ENTECAVIR TAB 1 MG RIBAVIRIN TAB 200 MG ENTECAVIR TAB 0.5 MG ENTECAVIR TAB 1 MG ADEFOVIR DIPIVOXIL TAB 10 MG INTERFERON ALFA-2B FOR INJ 10000000 INTRON A INJ 10MU UNIT INTERFERON ALFA-2B FOR INJ 18000000 INTRON A INJ 18MU UNIT INTERFERON ALFA-2B INJ 6000000 UNIT/ INTRON A INJ 18MU ML INTERFERON ALFA-2B INJ 10000000 INTRON A INJ 25MU UNIT/ML INTERFERON ALFA-2B FOR INJ 50000000 INTRON A INJ 50MU UNIT SIMEPREVIR SODIUM CAP 150 MG (BASE OLYSIO CAP 150MG EQUIVALENT) PEGINTERFERON ALFA-2A INJ 180 PEGASYS INJ MCG/0.5ML PEGINTERFERON ALFA-2A INJ 180 MCG/ PEGASYS INJ 180MCG/M ML PEGINTERFERON ALFA-2A INJ 135 PEGASYS INJ PROCLICK MCG/0.5ML PEGINTERFERON ALFA-2A INJ 180 PEGASYS INJ PROCLICK MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT PEGINTRON KIT 120MCG 120 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT PEGINTRON KIT 150MCG 150 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT 50 PEGINTRON KIT 50MCG MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT 80 PEGINTRON KIT 80MCG MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT PEG-INTRON KIT 120 RP 120 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT PEG-INTRON KIT 150 RP 150 MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT 50 PEG-INTRON KIT 50MCG MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT 50 PEG-INTRON KIT 50MCG RP MCG/0.5ML PEGINTERFERON ALFA-2B FOR INJ KIT 80 PEG-INTRON KIT 80MCG RP MCG/0.5ML REBETOL CAP 200MG RIBAVIRIN CAP 200 MG REBETOL SOL 40MG/ML RIBAVIRIN SOLN 40 MG/ML RIBASPHERE CAP 200MG RIBAVIRIN CAP 200 MG RIBASPHERE TAB 200MG RIBAVIRIN TAB 200 MG RIBASPHERE TAB 400MG RIBAVIRIN TAB 400 MG RIBASPHERE TAB 600MG RIBAVIRIN TAB 600 MG RIBAVIRIN TAB 400 MG & RIBAVIRIN TAB RIBATAB PAK 1000/DAY 600 MG DOSE PACK RIBATAB TAB 1200/DAY RIBAVIRIN TAB 600 MG RIBATAB TAB 800/DAY RIBAVIRIN TAB 400 MG RIBAVIRIN CAP 200MG RIBAVIRIN CAP 200 MG RIBAVIRIN INH 6GM RIBAVIRIN FOR INHAL SOLN 6 GM
30
Tier Value Tier 3
Prior Supply Step Specialty Authorization Limit Therapy X
Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
X X
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3
X X
X X
X X X X X X X X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 4
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
X
X
Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1
X X X X X X
Tier 1
X
Tier 1 Tier 1 Tier 1 Tier 3
X X X
Therapeutic Class
Label Name
Generic Name
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
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 FAMCICLOVIR TAB 125MG FAMCICLOVIR TAB 250MG FAMCICLOVIR TAB 500MG FAMVIR TAB 125MG FAMVIR TAB 250MG FAMVIR TAB 500MG TRIFLURIDINE SOL 1% OP VALACYCLOVIR TAB 1GM VALACYCLOVIR TAB 500MG VIROPTIC SOL 1% OP ZOVIRAX CAP 200MG ZOVIRAX SUS 200/5ML ZOVIRAX TAB 400MG ZOVIRAX TAB 800MG
Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Antihistamines - Allergy Drugs
ANDEHIST SYP 4-60MG/5
Antihistamines - Allergy Drugs
ARBINOXA SOL 4MG/5ML
Antihistamines - Allergy Drugs
ARBINOXA TAB 4MG
Antihistamines - Allergy Drugs
AZELASTINE SPR 0.1%
Antihistamines - Allergy Drugs
BROM/PSE/DM SYP
RIBAVIRIN TAB 200 MG SOFOSBUVIR TAB 400 MG TELBIVUDINE TAB 600 MG BOCEPREVIR CAP 200 MG RIBAVIRIN FOR INHAL SOLN 6 GM ACYCLOVIR CAP 200 MG ACYCLOVIR OINT 5% ACYCLOVIR SUSP 200 MG/5ML ACYCLOVIR TAB 400 MG ACYCLOVIR TAB 800 MG FAMCICLOVIR TAB 125 MG FAMCICLOVIR TAB 250 MG FAMCICLOVIR TAB 500 MG FAMCICLOVIR TAB 125 MG FAMCICLOVIR TAB 250 MG FAMCICLOVIR TAB 500 MG TRIFLURIDINE OPHTH SOLN 1% VALACYCLOVIR HCL TAB 1 GM VALACYCLOVIR HCL TAB 500 MG TRIFLURIDINE OPHTH SOLN 1% ACYCLOVIR CAP 200 MG ACYCLOVIR SUSP 200 MG/5ML ACYCLOVIR TAB 400 MG ACYCLOVIR TAB 800 MG BROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP 4-60 MG/5ML CARBINOXAMINE MALEATE SOLN 4 MG/5ML CARBINOXAMINE MALEATE TAB 4 MG AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY) PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML BROMPHENIRAMINE TANNATE CHEW TAB 12 MG PHENYLEPH-CHLORPHENCARBETAPENTANE LIQD 10-4-27.5 MG/5ML PHENYLEPH-CHLORPHENCARBETAPENTANE SUSP 2.5-1.25-7.5 MG/ ML CARBINOXAMINE MALEATE SOLN 4 MG/5ML CARBINOXAMINE MALEATE TAB 4 MG CLEMASTINE FUMARATE TAB 2.68 MG CHLORPHENIRAMINE W/ CODEINE LIQUID 2-8 MG/5ML CYPROHEPTADINE HCL SYRUP 2 MG/5ML
Tier 1
Antihistamines - Allergy Drugs
BROMFED DM SYP
Antihistamines - Allergy Drugs
BROMPHENIRAM CHW 12MG
Antihistamines - Allergy Drugs
CARBAPHEN 12 LIQ
Antihistamines - Allergy Drugs
CARBAPHEN 12 SUS PED
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
CARBINOXAMIN SOL 4MG/5ML CARBINOXAMIN TAB 4MG CLEMASTINE TAB 2.68MG
Antihistamines - Allergy Drugs
CODAR AR LIQ 2-8/5ML
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs
CYPROHEPTAD SYP 2MG/5ML CYPROHEPTAD TAB 4MG
Antihistamines - Allergy Drugs
DECON-A ELX 2-5MG/5M
Antihistamines - Allergy Drugs
DECON-G DRO 2-1-40MG
Antihistamines - Allergy Drugs
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
HYD POL/CPM SUS 108/5ML HYDR/CPM/PSE LIQ 5-460MG HYDRO/CHLOR/ LIQ 5-460MG 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
Antihistamines - Allergy Drugs
LEVOCETIRIZI SOL 2.5/5ML
Antihistamines - Allergy Drugs
LEVOCETIRIZI TAB 5MG
Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs Antihistamines - Allergy Drugs
CYPROHEPTADINE HCL TAB 4 MG BROMPHENIRAMINE & PHENYLEPHRINE ELIXIR 2-5 MG/5ML PHENYLEPHRINE-BROMPHENIRAMINEGUAIFENESIN LIQD 2-1-40 MG/ML HYDROCOD POLST-CHLORPHEN POLST ER SUSP 10-8 MG/5ML PSEUDOEPH-CHLORPHEN W/ HYDROCODONE SOLN 60-4-5 MG/5ML PSEUDOEPH-CHLORPHEN W/ HYDROCODONE SOLN 60-4-5 MG/5ML
Tier Value
X
X
X X X X X X X X
Tier 3 Tier 2 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3
Tier 1 Tier 3 Tier 2 Tier 3
X
Tier 2
X
Tier 2
X
HYDROXYZINE HCL SYRUP 10 MG/5ML
Tier 1
HYDROXYZINE HCL TAB 10 MG HYDROXYZINE HCL TAB 25 MG HYDROXYZINE HCL TAB 50 MG
Tier 1 Tier 1 Tier 1
HYDROXYZINE PAMOATE CAP 100 MG
Tier 1
HYDROXYZINE PAMOATE CAP 25 MG HYDROXYZINE PAMOATE CAP 50 MG LEVOCETIRIZINE DIHYDROCHLORIDE SOLN 2.5 MG/5ML (0.5 MG/ML) LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG
Tier 1 Tier 1
31
Prior Supply Step Specialty Authorization Limit Therapy X X X X X X X X X
Tier 3 Tier 1
X
Therapeutic Class
Label Name
Antihistamines - Allergy Drugs
LEXUSS 210 LIQ 2-10/5ML
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 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 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs
Generic Name
CHLORPHENIRAMINE W/ CODEINE LIQUID 2-10 MG/5ML DIPHENHYDRAMINE HCL ELIXIR 12.5 MDL ANTIHIST ELX 12.5/5ML MG/5ML PHENYLEPHRINE-CHLORPHEN-DM NEOTUSS PLUS LIQ LIQUID 7.5-4-30 MG/5ML OLOPATADINE SPR 0.6% OLOPATADINE HCL NASAL SOLN 0.6% PATANASE SPR 0.6% OLOPATADINE HCL NASAL SOLN 0.6% PHENADOZ SUP 12.5MG PROMETHAZINE HCL SUPPOS 12.5 MG PHENADOZ SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG PHENERGAN SUP 12.5MG PROMETHAZINE HCL SUPPOS 12.5 MG PHENERGAN SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG PHENERGAN SUP 50MG PROMETHAZINE HCL SUPPOS 50 MG PROMETHAZINE & PHENYLEPHRINE PROMETH VC SYP PLAIN SYRUP 6.25-5 MG/5ML PROMETH VC/ SYP PROMETHAZINE-PHENYLEPHRINECODEINE CODEINE SYRUP 6.25-5-10 MG/5ML PROMETHAZINE W/ CODEINE SYRUP PROMETH/COD SYP 6.25-10 6.25-10 MG/5ML PROMETHAZINE & PHENYLEPHRINE PROMETH/PE SYP 6.25-5/5 SYRUP 6.25-5 MG/5ML PROMETH/PE/ SYP PROMETHAZINE-PHENYLEPHRINECODEINE CODEINE SYRUP 6.25-5-10 MG/5ML PROMETHAZINE SOL PROMETHAZINE HCL SYRUP 6.25 6.25/5ML MG/5ML PROMETHAZINE SUP PROMETHAZINE HCL SUPPOS 12.5 MG 12.5MG PROMETHAZINE SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG PROMETHAZINE SUP 50MG PROMETHAZINE HCL SUPPOS 50 MG PROMETHAZINE SYP PROMETHAZINE HCL SYRUP 6.25 6.25/5ML MG/5ML PROMETHAZINE-DM SYRUP 6.25-15 PROMETHAZINE SYP DM MG/5ML PROMETHAZINE TAB PROMETHAZINE HCL TAB 12.5 MG 12.5MG PROMETHAZINE TAB 25MG PROMETHAZINE HCL TAB 25 MG PROMETHAZINE TAB 50MG PROMETHAZINE HCL TAB 50 MG PROMETHEGAN SUP PROMETHAZINE HCL SUPPOS 12.5 MG 12.5MG PROMETHEGAN SUP 25MG PROMETHAZINE HCL SUPPOS 25 MG PROMETHEGAN SUP 50MG PROMETHAZINE HCL SUPPOS 50 MG BROMPHEN TAN-PHENYLEPH TAN CHEW RELHIST CHW TAB 6-15 MG BROMPHENIRAMINE MALEATE TAB SR RESPA-BR TAB 11MG 12HR 11 MG ACRIVASTINE & PSEUDOEPHEDRINE CAP SEMPREX-D CAP 8-60MG 8-60 MG PHENYLEPHRINE-CHLORPHEN-DM TGQ 15DM/5PE SYP H/2CPM SYRUP 5-2-15 MG/5ML TGQ 30/PSE/3 SYP PSEUDOEPHED-BROMPHEN-DM SYRUP BRM/15DM 30-3-15 MG/5ML BROMPHENIRAMINE W/ DM-GG CAP 2-15TUSNEL CAP 200 MG HYDROCOD POLST-CHLORPHEN POLST TUSSICAPS CAP 10-8MG CAP SR 12HR 10-8 MG HYDROCOD POLST-CHLORPHEN POLST TUSSICAPS CAP 5-4MG CAP SR 12HR 5-4 MG HYDROCOD POLST-CHLORPHEN POLST TUSSIONEX SUS 10-8/5ML ER SUSP 10-8 MG/5ML VISTARIL CAP 25MG HYDROXYZINE PAMOATE CAP 25 MG VISTARIL CAP 50MG HYDROXYZINE PAMOATE CAP 50 MG LEVOCETIRIZINE DIHYDROCHLORIDE XYZAL SOL SOLN 2.5 MG/5ML (0.5 MG/ML) LEVOCETIRIZINE DIHYDROCHLORIDE XYZAL SOL 2.5/5ML SOLN 2.5 MG/5ML (0.5 MG/ML) LEVOCETIRIZINE DIHYDROCHLORIDE TAB XYZAL TAB 5MG 5 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X X
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 Tier 1 Tier 2 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
ATRIPLA TAB
EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG
Tier 2
X
COMPLERA TAB
EMTRICITABINE-RILPIVIRINE-TENOFOVIR DF TAB 200-25-300 MG
Tier 3
X
EDURANT TAB 25MG
RILPIVIRINE HCL TAB 25 MG (BASE EQUIVALENT)
Tier 2
X
32
Therapeutic Class Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
Generic Name
INTELENCE TAB 100MG
ETRAVIRINE TAB 100 MG
Tier 2
X
INTELENCE TAB 200MG
ETRAVIRINE TAB 200 MG
Tier 2
X
INTELENCE TAB 25MG
ETRAVIRINE TAB 25 MG
Tier 2
X
NEVIRAPINE SUS 50MG/5ML NEVIRAPINE SUSP 50 MG/5ML
Tier 1
X
NEVIRAPINE TAB 200MG
NEVIRAPINE TAB 200 MG
Tier 1
X
RESCRIPTOR TAB 100 MG
DELAVIRDINE MESYLATE TAB 100 MG
Tier 2
X
RESCRIPTOR TAB 200MG
DELAVIRDINE MESYLATE TAB 200 MG
Tier 2
X
STRIBILD TAB
ELVITEGRAV-COBIC-EMTRICITABTENOFOVDF TAB 150-150-200-300 MG
Tier 3
X
SUSTIVA CAP 200MG
EFAVIRENZ CAP 200 MG
Tier 2
X
SUSTIVA CAP 50MG
EFAVIRENZ CAP 50 MG
Tier 2
X
SUSTIVA TAB 600MG
EFAVIRENZ TAB 600 MG
Tier 2
X
VIRAMUNE SUS 50MG/5ML
NEVIRAPINE SUSP 50 MG/5ML
Tier 3
X
ABACA/LAMIVU TAB 600300
ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG
Tier 2
X
ABACAV/LAMIV TAB / ZIDOVUD
ABACAVIR SULFATE-LAMIVUDINEZIDOVUDINE TAB 300-150-300 MG
Tier 1
X
ABACAVIR TAB 300MG
ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)
Tier 1
X
COMBIVIR TAB 150-300
LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG
Tier 3
X
DIDANOSINE CAP 125MG
DIDANOSINE DELAYED RELEASE CAPSULE 125 MG
Tier 1
X
DIDANOSINE CAP 200MG
DIDANOSINE DELAYED RELEASE CAPSULE 200 MG
Tier 1
X
DIDANOSINE CAP 250MG
DIDANOSINE DELAYED RELEASE CAPSULE 250 MG
Tier 1
X
DIDANOSINE CAP 400MG
DIDANOSINE DELAYED RELEASE CAPSULE 400 MG
Tier 1
X
EMTRIVA CAP 200MG
EMTRICITABINE CAPS 200 MG
Tier 2
X
EMTRIVA SOL 10MG/ML
EMTRICITABINE SOLN 10 MG/ML
Tier 2
X
EPIVIR SOL 10MG/ML
LAMIVUDINE ORAL SOLN 10 MG/ML
Tier 3
X
EPIVIR TAB 150MG
LAMIVUDINE TAB 150 MG
Tier 3
X
EPIVIR TAB 300MG
LAMIVUDINE TAB 300 MG
Tier 3
X
LAMIVUD/ZIDO TAB 150-300
LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG
Tier 1
X
33
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Therapeutic Class Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs
Label Name
Generic Name
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
LAMIVUDINE SOL 10MG/ML LAMIVUDINE ORAL SOLN 10 MG/ML
Tier 1
X
LAMIVUDINE TAB 150MG
LAMIVUDINE TAB 150 MG
Tier 1
X
LAMIVUDINE TAB 300MG
LAMIVUDINE TAB 300 MG
Tier 1
X
RETROVIR CAP 100MG
ZIDOVUDINE CAP 100 MG
Tier 3
X
RETROVIR SYP 50MG/5ML
ZIDOVUDINE SYRUP 10 MG/ML
Tier 3
X
STAVUDINE CAP 15MG
STAVUDINE CAP 15 MG
Tier 1
X
STAVUDINE CAP 20MG
STAVUDINE CAP 20 MG
Tier 1
X
STAVUDINE CAP 30MG
STAVUDINE CAP 30 MG
Tier 1
X
STAVUDINE CAP 40MG
STAVUDINE CAP 40 MG
Tier 1
X
STAVUDINE SOL 1MG/ML
STAVUDINE FOR ORAL SOLN 1 MG/ML
Tier 1
X
TRIZIVIR TAB
ABACAVIR SULFATE-LAMIVUDINEZIDOVUDINE TAB 300-150-300 MG
Tier 3
X
TRUVADA TAB 100-150
EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 100-150 MG
Tier 3
X
X
TRUVADA TAB 133-200
EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 133-200 MG
Tier 3
X
X
TRUVADA TAB 167-250
EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 167-250 MG
Tier 3
X
X
TRUVADA TAB 200-300
EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG
Tier 3
X
X
VIDEX SOL 2GM
DIDANOSINE FOR SOLN 2 GM
Tier 2
X
VIDEX SOL 4GM
DIDANOSINE FOR SOLN 4 GM
Tier 2
X
VIDEX EC CAP 125MG
DIDANOSINE DELAYED RELEASE CAPSULE 125 MG
Tier 3
X
VIDEX EC CAP 200MG
DIDANOSINE DELAYED RELEASE CAPSULE 200 MG
Tier 3
X
VIDEX EC CAP 250MG
DIDANOSINE DELAYED RELEASE CAPSULE 250 MG
Tier 3
X
VIDEX EC CAP 400MG
DIDANOSINE DELAYED RELEASE CAPSULE 400 MG
Tier 3
X
VIREAD POW 40MG/GM
TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER 40 MG/GM
Tier 3
X
VIREAD TAB 150MG
TENOFOVIR DISOPROXIL FUMARATE TAB 150 MG
Tier 2
X
VIREAD TAB 200MG
TENOFOVIR DISOPROXIL FUMARATE TAB 200 MG
Tier 2
X
VIREAD TAB 250MG
TENOFOVIR DISOPROXIL FUMARATE TAB 250 MG
Tier 2
X
VIREAD TAB 300MG
TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG
Tier 2
X
34
Therapeutic Class Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs Anti-HIV Agents, Other - HIV Drugs
Generic Name
ZERIT CAP 15MG
STAVUDINE CAP 15 MG
Tier 3
X
ZERIT CAP 20MG
STAVUDINE CAP 20 MG
Tier 3
X
ZERIT CAP 30MG
STAVUDINE CAP 30 MG
Tier 3
X
ZERIT CAP 40MG
STAVUDINE CAP 40 MG
Tier 3
X
ZERIT SOL 1MG/ML
STAVUDINE FOR ORAL SOLN 1 MG/ML
Tier 3
X
ZIAGEN SOL 20MG/ML
ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV)
Tier 2
X
ZIAGEN TAB 300MG
ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)
Tier 3
X
ZIDOVUDINE CAP 100MG
ZIDOVUDINE CAP 100 MG
Tier 1
X
ZIDOVUDINE SYP 50MG/5ML ZIDOVUDINE SYRUP 10 MG/ML
Tier 1
X
ZIDOVUDINE TAB 300MG
ZIDOVUDINE TAB 300 MG
Tier 1
X
FUZEON INJ 90MG
ENFUVIRTIDE FOR INJ 90 MG RALTEGRAVIR POTASSIUM CHEW TAB 100 MG (BASE EQUIV) RALTEGRAVIR POTASSIUM CHEW TAB 25 MG (BASE EQUIV) RALTEGRAVIR POTASSIUM PACKET FOR SUSP 100 MG (BASE EQUIV) RALTEGRAVIR POTASSIUM TAB 400 MG (BASE EQUIV) MARAVIROC TAB 150 MG MARAVIROC TAB 25 MG MARAVIROC TAB 300 MG MARAVIROC TAB 75 MG DOLUTEGRAVIR SODIUM TAB 10 MG (BASE EQUIV) DOLUTEGRAVIR SODIUM TAB 25 MG (BASE EQUIV) DOLUTEGRAVIR SODIUM TAB 50 MG (BASE EQUIV)
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
APTIVUS CAP 250MG
Anti-HIV Agents, Other - HIV Drugs
ISENTRESS CHW 100MG
Anti-HIV Agents, Other - HIV Drugs
ISENTRESS CHW 25MG
Anti-HIV Agents, Other - HIV Drugs
ISENTRESS POW 100MG
Anti-HIV Agents, Other - HIV Drugs
ISENTRESS TAB 400MG
Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs Anti-HIV Agents, Other - HIV Drugs
SELZENTRY TAB 150MG SELZENTRY TAB 25MG SELZENTRY TAB 300MG SELZENTRY TAB 75MG
Anti-HIV Agents, Other - HIV Drugs
TIVICAY TAB 10MG
Anti-HIV Agents, Other - HIV Drugs
TIVICAY TAB 25MG
Anti-HIV Agents, Other - HIV Drugs
TIVICAY TAB 50MG
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
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
X X X X X
X X X X
Tier 3
X
Tier 3
X
Tier 3
X
TIPRANAVIR CAP 250 MG
Tier 2
X
APTIVUS SOL
TIPRANAVIR ORAL SOLN 100 MG/ML
Tier 3
X
CRIXIVAN CAP 200MG
INDINAVIR SULFATE CAP 200 MG
Tier 2
X
CRIXIVAN CAP 400MG
INDINAVIR SULFATE CAP 400 MG
Tier 2
X
INVIRASE CAP 200MG
SAQUINAVIR MESYLATE CAP 200 MG
Tier 2
X
INVIRASE TAB 500MG
SAQUINAVIR MESYLATE TAB 500 MG
Tier 2
X
KALETRA SOL
LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML)
Tier 3
X
KALETRA TAB 100-25MG
LOPINAVIR-RITONAVIR TAB 100-25 MG
Tier 2
X
KALETRA TAB 200-50MG
LOPINAVIR-RITONAVIR TAB 200-50 MG
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
FOSAMPRENAVIR CALCIUM SUSP 50 MG/ ML (BASE EQUIV) FOSAMPRENAVIR CALCIUM TAB 700 MG LEXIVA TAB 700MG (BASE EQUIV) LOPINAVIR-RITONAVIR SOLN 400-100 LOPIN/RITON SOL 80-20/ML MG/5ML (80-20 MG/ML)
LEXIVA SUS 50MG/ML
NORVIR CAP 100MG
RITONAVIR CAP 100 MG
Tier 2
X
NORVIR SOL 80MG/ML
RITONAVIR ORAL SOLN 80 MG/ML
Tier 2
X
NORVIR TAB 100MG
RITONAVIR TAB 100 MG
Tier 2
X
35
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-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
Label Name PREZISTA SUS 100MG/ML PREZISTA TAB 150MG PREZISTA TAB 600MG PREZISTA TAB 75MG PREZISTA TAB 800MG REYATAZ CAP 150MG REYATAZ CAP 200MG REYATAZ CAP 300MG REYATAZ POW 50MG
Generic Name DARUNAVIR ETHANOLATE SUSP 100 MG/ ML (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 150 MG (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 600 MG (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 75 MG (BASE EQUIV) DARUNAVIR ETHANOLATE TAB 800 MG (BASE EQUIV) ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV) ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV) ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV) ATAZANAVIR SULFATE ORAL POWDER PACKET 50 MG (BASE EQUIV)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
VIRACEPT TAB 250MG
NELFINAVIR MESYLATE TAB 250 MG
Tier 2
X
VIRACEPT TAB 625MG
NELFINAVIR MESYLATE TAB 625 MG
Tier 2
X
ADVAIR DISKU AER 100/50 ADVAIR DISKU AER 250/50 ADVAIR DISKU AER 500/50 ADVAIR HFA AER 115/21 ADVAIR HFA AER 230/21 ADVAIR HFA AER 45/21 AEROSPAN AER 80MCG ALVESCO AER 160MCG ALVESCO AER 80MCG ASMANEX 120 AER 220MCG ASMANEX 14 AER 220MCG ASMANEX 30 AER 110MCG ASMANEX 30 AER 220MCG ASMANEX 60 AER 220MCG ASMANEX 7 AER 110MCG ASMANEX HFA AER 100 MCG ASMANEX HFA AER 200 MCG BREO ELLIPTA INH 100-25 BREO ELLIPTA INH 200-25 BUDESONIDE SUS 0.25MG/2 BUDESONIDE SUS 0.5MG/2 BUDESONIDE SUS 1MG/2ML DULERA AER 100-5MCG DULERA AER 200-5MCG FLOVENT DISK AER 100MCG FLOVENT DISK AER 250MCG FLOVENT DISK AER 50MCG FLOVENT HFA AER 110MCG
FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/DOSE FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/DOSE FLUTICASONE-SALMETEROL INHAL AEROSOL 115-21 MCG/ACT FLUTICASONE-SALMETEROL INHAL AEROSOL 230-21 MCG/ACT FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 MCG/ACT FLUNISOLIDE HFA INHAL AEROSOL 80 MCG/ACT CICLESONIDE INHAL AEROSOL 160 MCG/ ACT CICLESONIDE INHAL AEROSOL 80 MCG/ ACT MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED) MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED) MOMETASONE FUROATE INHAL POWD 110 MCG/INH (BREATH ACTIVATED) MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED) MOMETASONE FUROATE INHAL POWD 220 MCG/INH (BREATH ACTIVATED) MOMETASONE FUROATE INHAL POWD 110 MCG/INH (BREATH ACTIVATED) MOMETASONE FUROATE INHAL AEROSOL SUSPENSION 100 MCG/ACT MOMETASONE FUROATE INHAL AEROSOL SUSPENSION 200 MCG/ACT FLUTICASONE FUROATE-VILANTEROL AERO POWD BA 100-25 MCG/INH FLUTICASONE FUROATE-VILANTEROL AERO POWD BA 200-25 MCG/INH BUDESONIDE INHALATION SUSP 0.25 MG/2ML BUDESONIDE INHALATION SUSP 0.5 MG/2ML BUDESONIDE INHALATION SUSP 1 MG/2ML MOMETASONE FUROATE-FORMOTEROL FUMARATE AEROSOL 100-5 MCG/ACT MOMETASONE FUROATE-FORMOTEROL FUMARATE AEROSOL 200-5 MCG/ACT FLUTICASONE PROPIONATE AER POW BA 100 MCG/BLISTER FLUTICASONE PROPIONATE AER POW BA 250 MCG/BLISTER FLUTICASONE PROPIONATE AER POW BA 50 MCG/BLISTER FLUTICASONE PROPIONATE HFA INHAL AER 110 MCG/ACT (125/VALVE)
36
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
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 Tier 1 Tier 3
X
Tier 3
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
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-Influenza Agents - Flu Drugs
Label Name FLOVENT HFA AER 220MCG FLOVENT HFA AER 44MCG FLUNISOLIDE SPR 0.025% FLUTICASONE SPR 50MCG PULMICORT INH 180MCG PULMICORT INH 90MCG PULMICORT SUS 0.25MG/2 PULMICORT SUS 0.5MG/2 PULMICORT SUS 1MG/2ML QVAR AER 40MCG QVAR AER 80MCG SYMBICORT AER 160-4.5 SYMBICORT AER 80-4.5 ZETONNA AER 37MCG
Anti-Influenza Agents - Flu Drugs
AMANTADINE CAP 100MG AMANTADINE SYP 50MG/5ML AMANTADINE TAB 100MG
Anti-Influenza Agents - Flu Drugs
FLUMADINE TAB 100MG
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 Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents
Generic Name FLUTICASONE PROPIONATE HFA INHAL AER 220 MCG/ACT (250/VALVE) FLUTICASONE PROPIONATE HFA INHAL AERO 44 MCG/ACT (50/VALVE) FLUNISOLIDE NASAL SOLN 25 MCG/ACT (0.025%) FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT BUDESONIDE INHAL AERO POWD 180 MCG/ACT (BREATH ACTIVATED) BUDESONIDE INHAL AERO POWD 90 MCG/ACT (BREATH ACTIVATED) BUDESONIDE INHALATION SUSP 0.25 MG/2ML BUDESONIDE INHALATION SUSP 0.5 MG/2ML BUDESONIDE INHALATION SUSP 1 MG/2ML BECLOMETHASONE DIPROP INHAL AERO SOLN 40 MCG/ACT (50/VALVE) BECLOMETHASONE DIPROP INHAL AERO SOLN 80 MCG/ACT (100/VALVE) BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 160-4.5 MCG/ACT BUDESONIDE-FORMOTEROL FUMARATE DIHYD AEROSOL 80-4.5 MCG/ACT CICLESONIDE NASAL AEROSOL SOLN 37 MCG/ACT (50 MCG/VALVE) AMANTADINE HCL CAP 100 MG AMANTADINE HCL SYRUP 50 MG/5ML
AMANTADINE HCL TAB 100 MG RIMANTADINE HYDROCHLORIDE TAB 100 MG OSELTAMIVIR PHOSPHATE CAP 30 MG OSELTAMIVIR CAP 30MG (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 45 MG OSELTAMIVIR CAP 45MG (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 75 MG OSELTAMIVIR CAP 75MG (BASE EQUIV) ZANAMIVIR AERO POWDER BREATH RELENZA MIS DISKHALE ACTIVATED 5 MG/BLISTER RIMANTADINE HYDROCHLORIDE TAB RIMANTADINE TAB 100MG 100 MG OSELTAMIVIR PHOSPHATE CAP 30 MG TAMIFLU CAP 30MG (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 45 MG TAMIFLU CAP 45MG (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 75 MG TAMIFLU CAP 75MG (BASE EQUIV) OSELTAMIVIR PHOSPHATE FOR SUSP 6 TAMIFLU SUS 6MG/ML MG/ML (BASE EQUIV) ACCOLATE TAB 10MG ZAFIRLUKAST TAB 10 MG ACCOLATE TAB 20MG ZAFIRLUKAST TAB 20 MG MONTELUKAST SODIUM CHEW TAB 4 MG MONTELUKAST CHW 4MG (BASE EQUIV) MONTELUKAST SODIUM CHEW TAB 5 MG MONTELUKAST CHW 5MG (BASE EQUIV) MONTELUKAST SODIUM ORAL MONTELUKAST GRA 4MG GRANULES PACKET 4 MG (BASE EQUIV) MONTELUKAST SODIUM TAB 10 MG MONTELUKAST TAB 10MG (BASE EQUIV) MONTELUKAST SODIUM ORAL SINGULAIR GRA 4MG GRANULES PACKET 4 MG (BASE EQUIV) ZAFIRLUKAST TAB 10MG ZAFIRLUKAST TAB 10 MG ZAFIRLUKAST TAB 20MG ZAFIRLUKAST TAB 20 MG ZILEUTON ER TAB 600MG ZILEUTON TAB SR 12HR 600 MG ZYFLO TAB 600MG ZILEUTON TAB 600 MG ZYFLO CR TAB 600MG ZILEUTON TAB SR 12HR 600 MG DROXIA CAP 200MG HYDROXYUREA CAP 200 MG DROXIA CAP 300MG HYDROXYUREA CAP 300 MG DROXIA CAP 400MG HYDROXYUREA CAP 400 MG HYDREA CAP 500MG HYDROXYUREA CAP 500 MG HYDROXYUREA CAP 500MG HYDROXYUREA CAP 500 MG MERCAPTOPUR TAB 50MG MERCAPTOPURINE TAB 50 MG MERCAPTOPURINE SUSP 2000 PURIXAN SUS 20MG/ML MG/100ML (20 MG/ML)
37
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
Tier 3
X
Tier 3 Tier 2
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1
X
Tier 1
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1 Tier 1 Tier 1 Tier 3 Tier 2
X
Tier 2
X
Tier 2
X
Tier 3
X
Tier 1 Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 3 Tier 1 Tier 1 Tier 2 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 1 Tier 1 Tier 3
X X X X X X X X X X
X
Therapeutic Class
Label Name
Generic Name
Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimetabolites - Chemotherapy Agents Antimycobacterials, Other Miscellaneous Anti-Infectives Antimycobacterials, Other Miscellaneous Anti-Infectives Antimycobacterials, Other Miscellaneous Anti-Infectives Antimycobacterials, Other Miscellaneous Anti-Infectives
TABLOID TAB 40MG XELODA TAB 150MG XELODA TAB 500MG
THIOGUANINE TAB 40 MG CAPECITABINE TAB 150 MG CAPECITABINE TAB 500 MG
Tier 2 Tier 1 Tier 1
DAPSONE TAB 100MG
DAPSONE TAB 100 MG
Tier 2
DAPSONE TAB 25MG
DAPSONE TAB 25 MG
Tier 2
MYCOBUTIN CAP 150MG
RIFABUTIN CAP 150 MG
Tier 3
RIFABUTIN CAP 150MG
RIFABUTIN CAP 150 MG
Tier 1
Antineoplastics - Chemotherapy Agents
TAFINLAR CAP 50MG
Antineoplastics - Chemotherapy Agents
TAFINLAR CAP 75MG
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 Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents Antineoplastics, Other - Chemotherapy Agents
ZYKADIA CAP 150MG CABOMETYX TAB 20MG CABOMETYX TAB 40MG CABOMETYX TAB 60MG COMETRIQ KIT 100MG COMETRIQ KIT 140MG COMETRIQ KIT 60MG ERIVEDGE CAP 150MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG
DABRAFENIB MESYLATE CAP 50 MG (BASE EQUIVALENT) DABRAFENIB MESYLATE CAP 75 MG (BASE EQUIVALENT) CERITINIB CAP 150 MG CABOZANTINIB S-MALATE TAB 20 MG (BASE EQUIVALENT) CABOZANTINIB S-MALATE TAB 40 MG (BASE EQUIVALENT) CABOZANTINIB S-MALATE TAB 60 MG (BASE EQUIVALENT) CABOZANTINIB S-MAL CAP 1 X 80 MG & 1 X 20 MG (100 DOSE) KIT CABOZANTINIB S-MAL CAP 1 X 80 MG & 3 X 20 MG (140 DOSE) KIT CABOZANTINIB S-MALATE CAP 3 X 20 MG (60 MG DOSE) KIT VISMODEGIB CAP 150 MG AFATINIB DIMALEATE TAB 20 MG (BASE EQUIVALENT) AFATINIB DIMALEATE TAB 30 MG (BASE EQUIVALENT) AFATINIB DIMALEATE TAB 40 MG (BASE EQUIVALENT)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy X X X X X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 3
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
ICLUSIG TAB 15MG
PONATINIB HCL TAB 15 MG (BASE EQUIV)
Tier 3
X
X
X
ICLUSIG TAB 45MG
PONATINIB HCL TAB 45 MG (BASE EQUIV)
Tier 3
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JAKAFI TAB 5MG
RUXOLITINIB PHOSPHATE TAB 10 MG (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 15 MG (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 20 MG (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 25 MG (BASE EQUIVALENT) RUXOLITINIB PHOSPHATE TAB 5 MG (BASE EQUIVALENT)
LEUCOVOR CA TAB 10MG
LEUCOVORIN CALCIUM TAB 10 MG
Tier 1
LEUCOVOR CA TAB 15MG
LEUCOVORIN CALCIUM TAB 15 MG
Tier 1
LEUCOVOR CA TAB 25MG
LEUCOVORIN CALCIUM TAB 25 MG
Tier 1
LEUCOVOR CA TAB 5MG
LEUCOVORIN CALCIUM TAB 5 MG
Tier 1
MEKINIST TAB 0.5MG MEKINIST TAB 2MG
TRAMETINIB DIMETHYL SULFOXIDE TAB 0.5 MG (BASE EQUIVALENT) TRAMETINIB DIMETHYL SULFOXIDE TAB 2 MG (BASE EQUIVALENT)
MENEST TAB 0.3MG
ESTERIFIED ESTROGENS TAB 0.3 MG
Tier 3
MENEST TAB 0.625MG
ESTERIFIED ESTROGENS TAB 0.625 MG
Tier 3
MENEST TAB 1.25MG
ESTERIFIED ESTROGENS TAB 1.25 MG
Tier 3
MENEST TAB 2.5MG
ESTERIFIED ESTROGENS TAB 2.5 MG
Tier 3
MESNEX TAB 400MG
MESNA TAB 400 MG
Tier 3
PICATO GEL 0.015%
INGENOL MEBUTATE GEL 0.015%
Tier 3
X
PICATO GEL 0.05%
INGENOL MEBUTATE GEL 0.05%
Tier 3
X
POMALYST CAP 1MG
POMALIDOMIDE CAP 1 MG
Tier 3
38
X
X
X
X
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 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 Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs
Generic Name
POMALYST CAP 2MG
POMALIDOMIDE CAP 2 MG
Tier 3
X
X
X
POMALYST CAP 3MG
POMALIDOMIDE CAP 3 MG
Tier 3
X
X
X
POMALYST CAP 4MG
POMALIDOMIDE CAP 4 MG
Tier 3
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
X
X
X
X
SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG ZOLINZA CAP 100MG
VORINOSTAT CAP 100 MG
Tier 2
ZYTIGA TAB 250MG
ABIRATERONE ACETATE TAB 250 MG
Tier 2
X
ZYTIGA TAB 500MG
ABIRATERONE ACETATE TAB 500 MG
Tier 2
X
COMTAN TAB 200MG
ENTACAPONE TAB 200 MG
Tier 3
ENTACAPONE TAB 200MG
ENTACAPONE TAB 200 MG
Tier 1
NEUPRO DIS 1MG/24HR
ROTIGOTINE TD PATCH 24HR 1 MG/24HR
Tier 3
NEUPRO DIS 2MG/24HR
ROTIGOTINE TD PATCH 24HR 2 MG/24HR
Tier 3
NEUPRO DIS 3MG/24HR
ROTIGOTINE TD PATCH 24HR 3 MG/24HR
Tier 3
NEUPRO DIS 4MG/24HR
ROTIGOTINE TD PATCH 24HR 4 MG/24HR
Tier 3
NEUPRO DIS 6MG/24HR
ROTIGOTINE TD PATCH 24HR 6 MG/24HR
Tier 3
NEUPRO DIS 8MG/24HR
ROTIGOTINE TD PATCH 24HR 8 MG/24HR
Tier 3
TOLCAPONE TAB 100MG
TOLCAPONE TAB 100 MG
Tier 2
ALINIA SUS 100/5ML ALINIA TAB 500MG ATOVAQ/PROGU TAB 250100 ATOVAQ/PROGU TAB 62.525 ATOVAQUONE SUS 750/5ML CHLOROQUINE TAB 250MG CHLOROQUINE TAB 500MG
NITAZOXANIDE FOR SUSP 100 MG/5ML NITAZOXANIDE TAB 500 MG ATOVAQUONE-PROGUANIL HCL TAB 250100 MG ATOVAQUONE-PROGUANIL HCL TAB 62.525 MG ATOVAQUONE SUSP 750 MG/5ML CHLOROQUINE PHOSPHATE TAB 250 MG CHLOROQUINE PHOSPHATE TAB 500 MG ARTEMETHER-LUMEFANTRINE TAB 20120 MG PYRIMETHAMINE TAB 25 MG HYDROXYCHLOROQUINE SULFATE TAB 200 MG ATOVAQUONE-PROGUANIL HCL TAB 250100 MG ATOVAQUONE-PROGUANIL HCL TAB 62.525 MG MEFLOQUINE HCL TAB 250 MG PENTAMIDINE ISETHIONATE FOR NEBULIZATION SOLN 300 MG HYDROXYCHLOROQUINE SULFATE TAB 200 MG PRIMAQUINE PHOSPHATE TAB 26.3 MG (15 MG BASE) QUININE SULFATE CAP 324 MG QUININE SULFATE CAP 324 MG TINIDAZOLE TAB 250 MG TINIDAZOLE TAB 500 MG TINIDAZOLE TAB 250 MG TINIDAZOLE TAB 500 MG HYOSCYAMINE SULFATE TAB DISP 0.125 MG
Tier 2 Tier 2
ATROPINE SULFATE POWDER
Tier 3
Antiprotozoals - Protozoal Infection Drugs COARTEM TAB 20-120MG Antiprotozoals - Protozoal Infection Drugs DARAPRIM TAB 25MG HYDROXYCHLOR TAB Antiprotozoals - Protozoal Infection Drugs 200MG Antiprotozoals - Protozoal Infection Drugs MALARONE TAB 250-100 Antiprotozoals - Protozoal Infection Drugs MALARONE TAB 62.5-25 Antiprotozoals - Protozoal Infection Drugs MEFLOQUINE TAB 250MG Antiprotozoals - Protozoal Infection Drugs NEBUPENT INH 300MG Antiprotozoals - Protozoal Infection Drugs PLAQUENIL TAB 200MG Antiprotozoals - Protozoal Infection Drugs PRIMAQUINE TAB 26.3MG Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection Drugs Antiprotozoals - Protozoal Infection 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
PEGINTERFERON ALFA-2B FOR INJ KIT 200 MCG PEGINTERFERON ALFA-2B FOR INJ KIT 300 MCG PEGINTERFERON ALFA-2B FOR INJ KIT 600 MCG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
QUALAQUIN CAP 324MG QUININE SULF CAP 324MG TINDAMAX TAB 250MG TINDAMAX TAB 500MG TINIDAZOLE TAB 250MG TINIDAZOLE TAB 500MG ANASPAZ TAB 0.125MG ATROPINE POW SULFATE BELLA/OPIUM SUP 16.2-30 BELLA/OPIUM SUP 16.2-60 BENTYL CAP 10MG
BELLADONNA ALKALOIDS & OPIUM SUPPOS 16.2-30 MG BELLADONNA ALKALOIDS & OPIUM SUPPOS 16.2-60 MG DICYCLOMINE HCL CAP 10 MG
39
X
X X
Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 2 Tier 2
X
X
Tier 1 Tier 3 Tier 3 Tier 1 Tier 2 Tier 3 Tier 1 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
Tier 1 Tier 2 Tier 3
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 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, Urinary - Bladder Control Drugs Antispasmodics, Urinary - Bladder Control Drugs
Label Name
Generic Name
BENTYL TAB 20MG
DICYCLOMINE HCL TAB 20 MG
Tier 3
CANTIL TAB 25MG
MEPENZOLATE BROMIDE TAB 25 MG
Tier 3
CHLORDIAZEPOXIDE HCL-CLIDINIUM CHLORD/CLIDI CAP 5-2.5MG BROMIDE CAP 5-2.5 MG GLYCOPYRROLATE ORAL SOLN 1 CUVPOSA SOL 1MG/5ML MG/5ML
Tier Value
Tier 3 Tier 3
DICYCLOMINE CAP 10MG
DICYCLOMINE HCL CAP 10 MG
Tier 1
DICYCLOMINE SOL 10MG/5ML
DICYCLOMINE HCL ORAL SOLN 10 MG/5ML
Tier 1
DICYCLOMINE TAB 20MG
DICYCLOMINE HCL TAB 20 MG
Tier 1
ED-SPAZ TAB 0.125MG
HYOSCYAMINE SULFATE TAB DISP 0.125 MG
Tier 1
GLYCOPYRROL TAB 1MG
GLYCOPYRROLATE TAB 1 MG
Tier 1
GLYCOPYRROL TAB 2MG
GLYCOPYRROLATE TAB 2 MG
Tier 1
HYOSCYAMINE DRO 0.125/ ML
HYOSCYAMINE SULFATE SOLN 0.125 MG/ ML HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML
HYOSCYAMINE ELX 0.125/5
Tier 1 Tier 1
HYOSCYAMINE SUB 0.125MG
HYOSCYAMINE SULFATE TAB SL 0.125 MG
Tier 1
HYOSCYAMINE TAB 0.125MG
HYOSCYAMINE SULFATE TAB DISP 0.125 MG
Tier 1
HYOSCYAMINE TAB 0.125MG HYOSCYAMINE SULFATE TAB 0.125 MG HYOSCYAMINE SULFATE TAB SR 12HR HYOSCYAMINE TAB 0.375 ER 0.375 MG HYOSCYAMINE SULFATE TAB SR 12HR HYOSCYAMINE TAB 0.375 SR 0.375 MG HYOSCYAMINE SULFATE SOLN 0.125 MG/ HYOSYNE DRO 0.125/ML ML HYOSCYAMINE SULFATE ELIXIR 0.125 HYOSYNE ELX 0.125/5 MG/5ML HYOSCYAMINE SULFATE TAB SR 12HR LEVBID TAB 0.375 ER 0.375 MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
LEVSIN TAB 0.125MG
HYOSCYAMINE SULFATE TAB 0.125 MG
Tier 3
LEVSIN/SL SUB 0.125MG
HYOSCYAMINE SULFATE TAB SL 0.125 MG
Tier 3
METHSCOPOLAM TAB 2.5MG
METHSCOPOLAMINE BROMIDE TAB 2.5 MG
Tier 1
METHSCOPOLAM TAB 5MG METHSCOPOLAMINE BROMIDE TAB 5 MG
Tier 1
NULEV TAB 0.125MG
HYOSCYAMINE SULFATE TAB DISP 0.125 MG
Tier 3
OSCIMIN SUB 0.125MG
HYOSCYAMINE SULFATE TAB SL 0.125 MG
Tier 1
OSCIMIN TAB 0.125MG
HYOSCYAMINE SULFATE TAB 0.125 MG
Tier 1
OSCIMIN TAB 0.125MG OSCIMIN SR TAB 0.375MG PAMINE TAB 2.5MG PAMINE FQ KIT
HYOSCYAMINE SULFATE TAB DISP 0.125 MG HYOSCYAMINE SULFATE TAB SR 12HR 0.375 MG METHSCOPOLAMINE BROMIDE TAB 2.5 MG *METHSCOPOLAMINE TAB 5 MG & MISC INTESTINAL FLORA REG CAP***
Tier 1 Tier 1 Tier 3 Tier 3
PROPANTHELIN TAB 15MG
PROPANTHELINE BROMIDE TAB 15 MG
Tier 1
ROBINUL TAB 1MG
GLYCOPYRROLATE TAB 1 MG
Tier 3
ROBINUL FORT TAB 2MG
GLYCOPYRROLATE TAB 2 MG
Tier 3
SYMAX DUOTAB TAB
HYOSCYAMINE SULFATE TAB CR 0.375 MG (0.125 MG IR/0.25 MG CR)
Tier 3
SYMAX-SL SUB 0.125MG
HYOSCYAMINE SULFATE TAB SL 0.125 MG
Tier 1
SYMAX-SR TAB 0.375MG DITROPAN XL TAB 10MG DITROPAN XL TAB 15MG
HYOSCYAMINE SULFATE TAB SR 12HR 0.375 MG OXYBUTYNIN CHLORIDE TAB SR 24HR 10 MG OXYBUTYNIN CHLORIDE TAB SR 24HR 15 MG
40
Tier 1 Tier 3 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
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 Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs Antispasticity Agents - Muscle Spasm Drugs 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
Label Name
Generic Name
DITROPAN XL TAB 5MG
OXYBUTYNIN CHLORIDE TAB SR 24HR 5 MG
Tier 3
FLAVOXATE TAB 100MG
FLAVOXATE HCL TAB 100 MG
Tier 1
OXYBUTYNIN CHLORIDE SYRUP 5 OXYBUTYNIN SYP 5MG/5ML MG/5ML OXYBUTYNIN CHLORIDE TAB SR 24HR OXYBUTYNIN TAB 10MG ER 10 MG OXYBUTYNIN CHLORIDE TAB SR 24HR OXYBUTYNIN TAB 15MG ER 15 MG OXYBUTYNIN TAB 5MG OXYBUTYNIN TAB 5MG ER TOVIAZ TAB 4MG TOVIAZ TAB 8MG
OXYBUTYNIN CHLORIDE TAB 5 MG OXYBUTYNIN CHLORIDE TAB SR 24HR 5 MG FESOTERODINE FUMARATE TAB SR 24HR 4 MG FESOTERODINE FUMARATE TAB SR 24HR 8 MG
Tier Value
Tier 1 Tier 2 Tier 2 Tier 1 Tier 2 Tier 3 Tier 3
BACLOFEN TAB 10MG
BACLOFEN TAB 10 MG
Tier 1
BACLOFEN TAB 20MG
BACLOFEN TAB 20 MG
Tier 1
DANTRIUM CAP 25MG
DANTROLENE SODIUM CAP 25 MG
Tier 3
DANTRIUM CAP 50MG
DANTROLENE SODIUM CAP 50 MG
Tier 3
DANTROLENE CAP 100MG
DANTROLENE SODIUM CAP 100 MG
Tier 1
DANTROLENE CAP 25MG
DANTROLENE SODIUM CAP 25 MG
Tier 1
DANTROLENE CAP 50MG
DANTROLENE SODIUM CAP 50 MG
Tier 1
TIZANIDINE CAP 2MG TIZANIDINE CAP 4MG TIZANIDINE CAP 6MG TIZANIDINE TAB 2MG TIZANIDINE TAB 4MG ZANAFLEX CAP 2MG ZANAFLEX CAP 4MG ZANAFLEX CAP 6MG ZANAFLEX TAB 4MG
TIZANIDINE HCL CAP 2 MG (BASE EQUIVALENT) TIZANIDINE HCL CAP 4 MG (BASE EQUIVALENT) TIZANIDINE HCL CAP 6 MG (BASE EQUIVALENT) TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT) TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT) TIZANIDINE HCL CAP 2 MG (BASE EQUIVALENT) TIZANIDINE HCL CAP 4 MG (BASE EQUIVALENT) TIZANIDINE HCL CAP 6 MG (BASE EQUIVALENT) TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT)
Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3
METHIMAZOLE TAB 10MG
METHIMAZOLE TAB 10 MG
Tier 1
METHIMAZOLE TAB 5MG
METHIMAZOLE TAB 5 MG
Tier 1
PROPYLTHIOUR TAB 50MG
PROPYLTHIOURACIL TAB 50 MG
Tier 1
TAPAZOLE TAB 10MG
METHIMAZOLE TAB 10 MG
Tier 3
TAPAZOLE TAB 5MG
METHIMAZOLE TAB 5 MG
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
CYCLOSERINE CAP 250 MG ETHAMBUTOL HCL TAB 100 MG ETHAMBUTOL HCL TAB 400 MG ISONIAZID SYRUP 50 MG/5ML ISONIAZID TAB 100 MG ISONIAZID TAB 300 MG ETHAMBUTOL HCL TAB 100 MG ETHAMBUTOL HCL TAB 400 MG AMINOSALICYLIC ACID CR GRANULES PASER GRA 4GM PACKET 4 GM PRIFTIN TAB 150MG RIFAPENTINE TAB 150 MG PYRAZINAMIDE TAB 500MG PYRAZINAMIDE TAB 500 MG RIFADIN CAP 150MG RIFAMPIN CAP 150 MG RIFADIN CAP 300MG RIFAMPIN CAP 300 MG RIFAMATE CAP ISONIAZID & RIFAMPIN CAP 150-300 MG RIFAMPIN CAP 150MG RIFAMPIN CAP 150 MG RIFAMPIN CAP 300MG RIFAMPIN CAP 300 MG
41
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Antituberculars - Tuberculosis Drugs
RIFATER TAB
Antituberculars - Tuberculosis Drugs
SIRTURO TAB 100MG
Antituberculars - Tuberculosis Drugs
TRECATOR TAB 250MG ALPRAZOLAM CON 1 MG/ ML
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.25 ODT
Anxiolytics, Other - Anxiety Drugs Anxiolytics, Other - Anxiety Drugs
ALPRAZOLAM TAB 0.25MG ALPRAZOLAM TAB 0.5MG ALPRAZOLAM TAB 0.5MG ER ALPRAZOLAM TAB 0.5MG OD ALPRAZOLAM TAB 0.5MG XR ALPRAZOLAM TAB 1MG ALPRAZOLAM TAB 1MG ER ALPRAZOLAM TAB 1MG ODT ALPRAZOLAM TAB 1MG XR ALPRAZOLAM TAB 2MG ALPRAZOLAM TAB 2MG ER ALPRAZOLAM TAB 2MG ODT ALPRAZOLAM TAB 2MG XR ALPRAZOLAM TAB 3MG ER ALPRAZOLAM TAB 3MG XR BUSPIRONE TAB 10MG BUSPIRONE TAB 15MG BUSPIRONE TAB 30MG BUSPIRONE TAB 5MG BUSPIRONE TAB 7.5MG
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 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 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 Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs
Generic Name
Tier Value
ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE TAB 50-120-300 MG BEDAQUILINE FUMARATE TAB 100 MG (BASE EQUIV) ETHIONAMIDE TAB 250 MG
Tier 2
ALPRAZOLAM CONC 1 MG/ML
Tier 1
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG ALPRAZOLAM TAB 0.25 MG ALPRAZOLAM TAB 0.5 MG
Tier 1 Tier 1
Tier 2 Tier 2
Tier 1
ALPRAZOLAM TAB SR 24HR 0.5 MG
Tier 1
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG
Tier 1
ALPRAZOLAM TAB SR 24HR 0.5 MG
Tier 1
ALPRAZOLAM TAB 1 MG ALPRAZOLAM TAB SR 24HR 1 MG ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG ALPRAZOLAM TAB SR 24HR 1 MG ALPRAZOLAM TAB 2 MG ALPRAZOLAM TAB SR 24HR 2 MG ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG ALPRAZOLAM TAB SR 24HR 2 MG ALPRAZOLAM TAB SR 24HR 3 MG ALPRAZOLAM TAB SR 24HR 3 MG BUSPIRONE HCL TAB 10 MG BUSPIRONE HCL TAB 15 MG BUSPIRONE HCL TAB 30 MG BUSPIRONE HCL TAB 5 MG BUSPIRONE HCL TAB 7.5 MG CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB CDP/AMITRIP TAB 10-25MG 10-25 MG CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB CDP/AMITRIP TAB 5-12.5MG 5-12.5 MG CHLORDIAZEP CAP 10MG CHLORDIAZEPOXIDE HCL CAP 10 MG CHLORDIAZEP CAP 25MG CHLORDIAZEPOXIDE HCL CAP 25 MG CHLORDIAZEP CAP 5MG CHLORDIAZEPOXIDE HCL CAP 5 MG DIAZEPAM CON 5MG/ML DIAZEPAM CONC 5 MG/ML DIAZEPAM SOL 1MG/ML DIAZEPAM ORAL SOLN 1 MG/ML DIAZEPAM TAB 10MG DIAZEPAM TAB 10 MG DIAZEPAM TAB 2MG DIAZEPAM TAB 2 MG DIAZEPAM TAB 5MG DIAZEPAM TAB 5 MG ESTAZOLAM TAB 1MG ESTAZOLAM TAB 1 MG ESTAZOLAM TAB 2MG ESTAZOLAM TAB 2 MG LORAZEPAM CON 2MG/ML LORAZEPAM CONC 2 MG/ML LORAZEPAM TAB 0.5MG LORAZEPAM TAB 0.5 MG LORAZEPAM TAB 1MG LORAZEPAM TAB 1 MG LORAZEPAM TAB 2MG LORAZEPAM TAB 2 MG MEPROBAMATE TAB 200MG MEPROBAMATE TAB 200 MG MEPROBAMATE TAB 400MG MEPROBAMATE TAB 400 MG OXAZEPAM CAP 10MG OXAZEPAM CAP 10 MG OXAZEPAM CAP 15MG OXAZEPAM CAP 15 MG OXAZEPAM CAP 30MG OXAZEPAM CAP 30 MG
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 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 Tier 1 Tier 1 Tier 1 Tier 1
DORAL TAB 15MG
QUAZEPAM TAB 15 MG
Tier 3
MIDAZOLAM SYP 2MG/ML
MIDAZOLAM HCL SYRUP 2 MG/ML (BASE EQUIVALENT)
Tier 1
QUAZEPAM TAB 15MG
QUAZEPAM TAB 15 MG
Tier 1
ANASTROZOLE TAB 1MG
ANASTROZOLE TAB 1 MG
Tier 1
AROMASIN TAB 25MG
EXEMESTANE TAB 25 MG
Tier 3
EXEMESTANE TAB 25MG
EXEMESTANE TAB 25 MG
Tier 2
LETROZOLE TAB 2.5 MG
Tier 1
LETROZOLE TAB 2.5MG ATOMOXETINE CAP 100MG ATOMOXETINE CAP 10MG
ATOMOXETINE HCL CAP 100 MG (BASE EQUIV) ATOMOXETINE HCL CAP 10 MG (BASE EQUIV)
42
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1
X
Tier 1
X
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 Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs
Label Name
Generic Name
ATOMOXETINE HCL CAP 18 MG (BASE EQUIV) ATOMOXETINE HCL CAP 25 MG (BASE ATOMOXETINE CAP 25MG EQUIV) ATOMOXETINE HCL CAP 40 MG (BASE ATOMOXETINE CAP 40MG EQUIV) ATOMOXETINE HCL CAP 60 MG (BASE ATOMOXETINE CAP 60MG EQUIV) ATOMOXETINE HCL CAP 80 MG (BASE ATOMOXETINE CAP 80MG EQUIV) GUANFACINE HCL TAB SR 24HR 1 MG GUANFACINE TAB 1MG ER (BASE EQUIV) GUANFACINE HCL TAB SR 24HR 2 MG GUANFACINE TAB 2MG ER (BASE EQUIV) GUANFACINE HCL TAB SR 24HR 3 MG GUANFACINE TAB 3MG ER (BASE EQUIV) GUANFACINE HCL TAB SR 24HR 4 MG GUANFACINE TAB 4MG ER (BASE EQUIV) ATOMOXETINE HCL CAP 100 MG (BASE STRATTERA CAP 100MG EQUIV) ATOMOXETINE HCL CAP 10 MG (BASE STRATTERA CAP 10MG EQUIV) ATOMOXETINE HCL CAP 18 MG (BASE STRATTERA CAP 18MG EQUIV) ATOMOXETINE HCL CAP 25 MG (BASE STRATTERA CAP 25MG EQUIV) ATOMOXETINE HCL CAP 40 MG (BASE STRATTERA CAP 40MG EQUIV) ATOMOXETINE HCL CAP 60 MG (BASE STRATTERA CAP 60MG EQUIV) ATOMOXETINE HCL CAP 80 MG (BASE STRATTERA CAP 80MG EQUIV) AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 10MG CAP SR 24HR 10 MG AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 15MG CAP SR 24HR 15 MG AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 20MG CAP SR 24HR 20 MG AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 25MG CAP SR 24HR 25 MG AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 30MG CAP SR 24HR 30 MG AMPHETAMINE-DEXTROAMPHETAMINE ADDERALL XR CAP 5MG CAP SR 24HR 5 MG AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 10MG TAB 10 MG AMPHET/DEXTR TAB AMPHETAMINE-DEXTROAMPHETAMINE 12.5MG TAB 12.5 MG AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 15MG TAB 15 MG AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 20MG TAB 20 MG AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 30MG TAB 30 MG AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 5MG TAB 5 MG AMPHETAMINE-DEXTROAMPHETAMINE AMPHET/DEXTR TAB 7.5MG TAB 7.5 MG METHYLPHENIDATE HCL TAB SA OSM CONCERTA TAB 18MG 18 MG METHYLPHENIDATE HCL TAB SA OSM CONCERTA TAB 27MG 27 MG METHYLPHENIDATE HCL TAB SA OSM CONCERTA TAB 36MG 36 MG METHYLPHENIDATE HCL TAB SA OSM CONCERTA TAB 54MG 54 MG
ATOMOXETINE CAP 18MG
DESOXYN TAB 5MG DEXEDRINE CAP 10MG CR DEXEDRINE CAP 15MG CR DEXEDRINE CAP 5MG CR DEXEDRINE TAB 10MG DEXEDRINE TAB 5MG
METHAMPHETAMINE HCL TAB 5 MG DEXTROAMPHETAMINE SULFATE CAP SR 24HR 10 MG DEXTROAMPHETAMINE SULFATE CAP SR 24HR 15 MG DEXTROAMPHETAMINE SULFATE CAP SR 24HR 5 MG DEXTROAMPHETAMINE SULFATE TAB 10 MG DEXTROAMPHETAMINE SULFATE TAB 5 MG
43
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
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 Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs
Generic Name
DEXMETHYLPH TAB 10MG
DEXMETHYLPHENIDATE HCL TAB 10 MG
Tier 1
X
DEXMETHYLPH TAB 2.5MG
DEXMETHYLPHENIDATE HCL TAB 2.5 MG
Tier 1
X
DEXMETHYLPH TAB 5MG
DEXMETHYLPHENIDATE HCL TAB 5 MG
Tier 1
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1
X
Tier 3
X
Tier 3
X
DEXTROAMPHET CAP 10MG ER DEXTROAMPHET CAP 15MG ER DEXTROAMPHET CAP 5MG ER DEXTROAMPHET SOL 5MG/5ML
DEXTROAMPHETAMINE SULFATE CAP SR 24HR 10 MG DEXTROAMPHETAMINE SULFATE CAP SR 24HR 15 MG DEXTROAMPHETAMINE SULFATE CAP SR 24HR 5 MG DEXTROAMPHETAMINE SULFATE ORAL SOLUTION 5 MG/5ML DEXTROAMPHETAMINE SULFATE TAB 10 DEXTROAMPHET TAB 10MG MG DEXTROAMPHETAMINE SULFATE TAB 5 DEXTROAMPHET TAB 5MG MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
FOCALIN TAB 10MG
DEXMETHYLPHENIDATE HCL TAB 10 MG
Tier 3
X
FOCALIN TAB 2.5MG
DEXMETHYLPHENIDATE HCL TAB 2.5 MG
Tier 3
X
FOCALIN TAB 5MG
DEXMETHYLPHENIDATE HCL TAB 5 MG
Tier 3
X
METADATE TAB 20MG ER
METHYLPHENIDATE HCL TAB CR 20 MG
Tier 3
X
METHAMPHETAM TAB 5MG
METHAMPHETAMINE HCL TAB 5 MG
Tier 1
X
METHLPHENIDA CHW 2.5MG
METHYLPHENIDATE HCL CHEW TAB 2.5 MG METHYLPHENIDATE HCL CHEW TAB 10 MG METHYLPHENIDATE HCL CHEW TAB 2.5 MG
Tier 3
X
Tier 3
X
Tier 3
X
METHYLIN CHW 10MG METHYLIN CHW 2.5MG
X
METHYLIN CHW 5MG
METHYLPHENIDATE HCL CHEW TAB 5 MG
Tier 3
X
METHYLIN SOL 10MG/5ML
METHYLPHENIDATE HCL SOLN 10 MG/5ML
Tier 3
X
METHYLIN SOL 5MG/5ML
METHYLPHENIDATE HCL SOLN 5 MG/5ML
Tier 3
X
Tier 2
X
X
Tier 2
X
X
X
X
X
X
Tier 2
X
X
Tier 2
X
X
METHYLPHENIDATE HCL CAP CR 10 MG METHYLPHENID CAP 10MG (CD) METHYLPHENIDATE HCL CAP CR 20 MG METHYLPHENID CAP 20MG (CD) METHYLPHENID CAP 20MG METHYLPHENIDATE HCL CAP SR 24HR ER 20 MG (LA) METHYLPHENIDATE HCL CAP CR 30 MG METHYLPHENID CAP 30MG (CD) METHYLPHENID CAP 30MG METHYLPHENIDATE HCL CAP SR 24HR ER 30 MG (LA) METHYLPHENIDATE HCL CAP CR 40 MG METHYLPHENID CAP 40MG (CD) METHYLPHENID CAP 40MG METHYLPHENIDATE HCL CAP SR 24HR ER 40 MG (LA) METHYLPHENIDATE HCL CAP CR 50 MG METHYLPHENID CAP 50MG (CD) METHYLPHENIDATE HCL CAP CR 60 MG METHYLPHENID CAP 60MG (CD) METHYLPHENID CAP 60MG METHYLPHENIDATE HCL CAP SR 24HR LA 60 MG (LA) METHYLPHENIDATE HCL CHEW TAB 10 METHYLPHENID CHW 10MG MG
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Tier 2 Tier 3
X
METHYLPHENID CHW 5MG
METHYLPHENIDATE HCL CHEW TAB 5 MG
Tier 3
X
METHYLPHENID SOL 10MG/5ML METHYLPHENID SOL 5MG/5ML
METHYLPHENIDATE HCL SOLN 10 MG/5ML
Tier 1
X
METHYLPHENIDATE HCL SOLN 5 MG/5ML
Tier 1
X
METHYLPHENID TAB 10MG
METHYLPHENIDATE HCL TAB 10 MG
Tier 1
X
METHYLPHENID TAB 10MG ER
METHYLPHENIDATE HCL TAB CR 10 MG
Tier 3
X
METHYLPHENID TAB 20MG
METHYLPHENIDATE HCL TAB 20 MG
Tier 1
X
METHYLPHENIDATE HCL TAB CR 20 MG
Tier 3
X
X
METHYLPHENIDATE HCL TAB CR 20 MG
Tier 3
X
X
METHYLPHENID TAB 20MG ER METHYLPHENID TAB 20MG SR
44
X
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 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 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
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Generic Name
METHYLPHENID TAB 5MG
METHYLPHENIDATE HCL TAB 5 MG
Tier 1
X
PROCENTRA SOL 5MG/5ML
DEXTROAMPHETAMINE SULFATE ORAL SOLUTION 5 MG/5ML
Tier 3
X
RITALIN TAB 10MG
METHYLPHENIDATE HCL TAB 10 MG
Tier 3
X
RITALIN TAB 20MG
METHYLPHENIDATE HCL TAB 20 MG
Tier 3
X
RITALIN TAB 5MG
METHYLPHENIDATE HCL TAB 5 MG
Tier 3
X
Tier 2
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
CIALIS TAB 2.5MG CIALIS TAB 5MG
LISDEXAMFETAMINE DIMESYLATE CAP 10 MG LISDEXAMFETAMINE DIMESYLATE CAP 20 MG LISDEXAMFETAMINE DIMESYLATE CAP 30 MG LISDEXAMFETAMINE DIMESYLATE CAP 40 MG LISDEXAMFETAMINE DIMESYLATE CAP 50 MG LISDEXAMFETAMINE DIMESYLATE CAP 60 MG LISDEXAMFETAMINE DIMESYLATE CAP 70 MG LISDEXAMFETAMINE DIMESYLATE CHEW TAB 10 MG LISDEXAMFETAMINE DIMESYLATE CHEW TAB 20 MG LISDEXAMFETAMINE DIMESYLATE CHEW TAB 30 MG LISDEXAMFETAMINE DIMESYLATE CHEW TAB 40 MG LISDEXAMFETAMINE DIMESYLATE CHEW TAB 50 MG LISDEXAMFETAMINE DIMESYLATE CHEW TAB 60 MG TADALAFIL TAB 2.5 MG TADALAFIL TAB 5 MG
ALFUZOSIN TAB 10MG ER
ALFUZOSIN HCL TAB SR 24HR 10 MG
Tier 1
CARDURA TAB 1MG
DOXAZOSIN MESYLATE TAB 1 MG
Tier 3
CARDURA TAB 2MG
DOXAZOSIN MESYLATE TAB 2 MG
Tier 3
CARDURA TAB 4MG
DOXAZOSIN MESYLATE TAB 4 MG
Tier 3
CARDURA TAB 8MG
DOXAZOSIN MESYLATE TAB 8 MG
Tier 3
DOXAZOSIN TAB 1MG
DOXAZOSIN MESYLATE TAB 1 MG
Tier 1
DOXAZOSIN TAB 2MG
DOXAZOSIN MESYLATE TAB 2 MG
Tier 1
DOXAZOSIN TAB 4MG
DOXAZOSIN MESYLATE TAB 4 MG
Tier 1
DOXAZOSIN TAB 8MG
DOXAZOSIN MESYLATE TAB 8 MG
Tier 1
DUTASTERIDE CAP 0.5MG
DUTASTERIDE CAP 0.5 MG
Tier 3
FINASTERIDE TAB 5MG
FINASTERIDE TAB 5 MG
Tier 1
PROSCAR TAB 5MG
FINASTERIDE TAB 5 MG
Tier 3
RAPAFLO CAP 4MG
SILODOSIN CAP 4 MG
Tier 3
RAPAFLO CAP 8MG
SILODOSIN CAP 8 MG
Tier 3
TAMSULOSIN CAP 0.4MG
TAMSULOSIN HCL CAP 0.4 MG
Tier 1
TERAZOSIN CAP 10MG
TERAZOSIN HCL CAP 10 MG
Tier 1
TERAZOSIN CAP 1MG
TERAZOSIN HCL CAP 1 MG
Tier 1
TERAZOSIN CAP 2MG
TERAZOSIN HCL CAP 2 MG
Tier 1
TERAZOSIN CAP 5MG
TERAZOSIN HCL CAP 5 MG
Tier 1
UROXATRAL TAB 10MG
ALFUZOSIN HCL TAB SR 24HR 10 MG
Tier 3
VYVANSE CAP 10MG VYVANSE CAP 20MG VYVANSE CAP 30MG VYVANSE CAP 40MG VYVANSE CAP 50MG VYVANSE CAP 60MG VYVANSE CAP 70MG VYVANSE CHW 10MG VYVANSE CHW 20MG VYVANSE CHW 30MG VYVANSE CHW 40MG VYVANSE CHW 50MG VYVANSE CHW 60MG
45
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
X X
X
X X
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 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs Beta-Adrenergic Blocking Agents - Blood Pressure Drugs
Label Name
Generic Name
ACEBUTOLOL CAP 200MG
ACEBUTOLOL HCL CAP 200 MG
Tier 1
ACEBUTOLOL CAP 400MG
ACEBUTOLOL HCL CAP 400 MG
Tier 1
ATENOL/CHLOR TAB 10025MG ATENOL/CHLOR TAB 5025MG
ATENOLOL & CHLORTHALIDONE TAB 100-25 MG ATENOLOL & CHLORTHALIDONE TAB 5025 MG
ATENOLOL TAB 100MG
ATENOLOL TAB 100 MG
Tier 1
ATENOLOL TAB 25MG
ATENOLOL TAB 25 MG
Tier 1
ATENOLOL TAB 50MG
ATENOLOL TAB 50 MG
Tier 1
BETAXOLOL TAB 10MG
BETAXOLOL HCL TAB 10 MG
Tier 1
BETAXOLOL TAB 20MG
BETAXOLOL HCL TAB 20 MG
Tier 1
BISOPROLOL & HYDROCHLOROTHIAZIDE BISOPRL/HCTZ TAB 10/6.25 TAB 10-6.25 MG BISOPROLOL & HYDROCHLOROTHIAZIDE BISOPRL/HCTZ TAB 2.5/6.25 TAB 2.5-6.25 MG BISOPRL/HCTZ TAB BISOPROLOL & HYDROCHLOROTHIAZIDE 5-6.25MG TAB 5-6.25 MG BISOPROL FUM TAB 10MG BISOPROL FUM TAB 5MG BYSTOLIC TAB 10MG BYSTOLIC TAB 2.5MG BYSTOLIC TAB 20MG BYSTOLIC TAB 5MG
Tier Value
Tier 1 Tier 1
Tier 1 Tier 1 Tier 1
BISOPROLOL FUMARATE TAB 10 MG
Tier 1
BISOPROLOL FUMARATE TAB 5 MG
Tier 1
NEBIVOLOL HCL TAB 10 MG (BASE EQUIVALENT) NEBIVOLOL HCL TAB 2.5 MG (BASE EQUIVALENT) NEBIVOLOL HCL TAB 20 MG (BASE EQUIVALENT) NEBIVOLOL HCL TAB 5 MG (BASE EQUIVALENT)
Tier 2 Tier 2 Tier 2 Tier 2
CARVEDILOL TAB 12.5MG
CARVEDILOL TAB 12.5 MG
Tier 1
CARVEDILOL TAB 25MG
CARVEDILOL TAB 25 MG
Tier 1
CARVEDILOL TAB 3.125MG
CARVEDILOL TAB 3.125 MG
Tier 1
CARVEDILOL TAB 6.25MG
CARVEDILOL TAB 6.25 MG
Tier 1
COREG TAB 12.5MG
CARVEDILOL TAB 12.5 MG
Tier 3
COREG TAB 25MG
CARVEDILOL TAB 25 MG
Tier 3
COREG TAB 3.125MG
CARVEDILOL TAB 3.125 MG
Tier 3
COREG TAB 6.25MG
CARVEDILOL TAB 6.25 MG
Tier 3
CORGARD TAB 20MG
NADOLOL TAB 20 MG
Tier 3
CORGARD TAB 40MG
NADOLOL TAB 40 MG
Tier 3
CORGARD TAB 80MG
NADOLOL TAB 80 MG
Tier 3
CORZIDE TAB 40-5MG CORZIDE TAB 80-5MG
Beta-Adrenergic Blocking Agents - Blood DUTOPROL TAB 100-12.5 Pressure Drugs Beta-Adrenergic Blocking Agents - Blood DUTOPROL TAB 25-12.5 Pressure Drugs Beta-Adrenergic Blocking Agents - Blood DUTOPROL TAB 50-12.5 Pressure Drugs Beta-Adrenergic Blocking Agents - Blood INDERAL LA CAP 120MG Pressure Drugs Beta-Adrenergic Blocking Agents - Blood INDERAL LA CAP 160MG Pressure Drugs Beta-Adrenergic Blocking Agents - Blood INDERAL LA CAP 60MG Pressure Drugs
NADOLOL & BENDROFLUMETHIAZIDE TAB 40-5 MG NADOLOL & BENDROFLUMETHIAZIDE TAB 80-5 MG METOPROLOL & HYDROCHLOROTHIAZIDE TAB SR 24HR 100-12.5 MG METOPROLOL & HYDROCHLOROTHIAZIDE TAB SR 24HR 25-12.5 MG METOPROLOL & HYDROCHLOROTHIAZIDE TAB SR 24HR 50-12.5 MG PROPRANOLOL HCL CAP SR 24HR 120 MG PROPRANOLOL HCL CAP SR 24HR 160 MG PROPRANOLOL HCL CAP SR 24HR 60 MG
46
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 2
X
Tier 2
X
Tier 2
X
Tier 3 Tier 3 Tier 3
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 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
Label Name
Generic Name
INDERAL LA CAP 80MG
PROPRANOLOL HCL CAP SR 24HR 80 MG
INDERAL XL CAP 120MG INDERAL XL CAP 80MG INNOPRAN XL CAP 120MG INNOPRAN XL CAP 80MG
PROPRANOLOL HCL SUSTAINEDRELEASE BEADS CAP SR 24HR 120 MG PROPRANOLOL HCL SUSTAINEDRELEASE BEADS CAP SR 24HR 80 MG PROPRANOLOL HCL SUSTAINEDRELEASE BEADS CAP SR 24HR 120 MG PROPRANOLOL HCL SUSTAINEDRELEASE BEADS CAP SR 24HR 80 MG
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
LABETALOL TAB 100MG
LABETALOL HCL TAB 100 MG
Tier 1
LABETALOL TAB 200MG
LABETALOL HCL TAB 200 MG
Tier 1
LABETALOL TAB 300MG
LABETALOL HCL TAB 300 MG
Tier 1
METOPROLOL & LOPRESS HCT TAB 50-25MG HYDROCHLOROTHIAZIDE TAB 50-25 MG
Tier 3
LOPRESSOR TAB 100MG
METOPROLOL TARTRATE TAB 100 MG
Tier 3
LOPRESSOR TAB 50MG
METOPROLOL TARTRATE TAB 50 MG
Tier 3
METOPRL/HCTZ TAB 10025MG METOPRL/HCTZ TAB 10050MG METOPRL/HCTZ TAB 5025MG
METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-50 MG METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG
Tier 1 Tier 1 Tier 1
METOPROL TAR TAB 100MG METOPROLOL TARTRATE TAB 100 MG
Tier 1
METOPROL TAR TAB 25MG
METOPROLOL TARTRATE TAB 25 MG
Tier 1
METOPROL TAR TAB 50MG
METOPROLOL TARTRATE TAB 50 MG
Tier 1
METOPROLOL TAB 100MG ER METOPROLOL TAB 200MG ER
METOPROLOL SUCCINATE TAB SR 24HR 100 MG (TARTRATE EQUIV) METOPROLOL SUCCINATE TAB SR 24HR 200 MG (TARTRATE EQUIV) METOPROLOL SUCCINATE TAB SR 24HR METOPROLOL TAB 25MG ER 25 MG (TARTRATE EQUIV) METOPROLOL SUCCINATE TAB SR 24HR METOPROLOL TAB 50MG ER 50 MG (TARTRATE EQUIV)
Tier 2 Tier 2 Tier 1 Tier 2
NADOLOL TAB 20MG
NADOLOL TAB 20 MG
Tier 1
NADOLOL TAB 40MG
NADOLOL TAB 40 MG
Tier 1
NADOLOL TAB 80MG
NADOLOL TAB 80 MG
Tier 1
NADOLOL/BEND TAB 405MG NADOLOL/BEND TAB 805MG
NADOLOL & BENDROFLUMETHIAZIDE TAB 40-5 MG NADOLOL & BENDROFLUMETHIAZIDE TAB 80-5 MG
PINDOLOL TAB 10MG
PINDOLOL TAB 10 MG
Tier 1
PINDOLOL TAB 5MG
PINDOLOL TAB 5 MG
Tier 1
PROPRANOLOL & HYDROCHLOROTHIAZIDE TAB 40-25 MG PROPRANOLOL & PROPRAN/HCTZ TAB 80/25 HYDROCHLOROTHIAZIDE TAB 80-25 MG PROPRANOLOL CAP 120MG PROPRANOLOL HCL CAP SR 24HR 120 ER MG PROPRANOLOL CAP 160MG PROPRANOLOL HCL CAP SR 24HR 160 ER MG PROPRANOLOL CAP 60MG PROPRANOLOL HCL CAP SR 24HR 60 MG ER PROPRANOLOL CAP 80MG PROPRANOLOL HCL CAP SR 24HR 80 MG ER PROPRANOLOL SOL PROPRANOLOL HCL ORAL SOLN 20 20MG/5ML MG/5ML PROPRANOLOL SOL PROPRANOLOL HCL ORAL SOLN 40 40MG/5ML MG/5ML
PROPRAN/HCTZ TAB 40/25
Tier 1 Tier 1
Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1
PROPRANOLOL TAB 10MG
PROPRANOLOL HCL TAB 10 MG
Tier 1
PROPRANOLOL TAB 20MG
PROPRANOLOL HCL TAB 20 MG
Tier 1
PROPRANOLOL TAB 40MG
PROPRANOLOL HCL TAB 40 MG
Tier 1
47
Prior Supply Step Specialty Authorization Limit Therapy
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-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics
Label Name
Generic Name
PROPRANOLOL TAB 60MG
PROPRANOLOL HCL TAB 60 MG
Tier 1
PROPRANOLOL TAB 80MG
PROPRANOLOL HCL TAB 80 MG
Tier 1
SECTRAL CAP 200MG
ACEBUTOLOL HCL CAP 200 MG
Tier 3
SECTRAL CAP 400MG
ACEBUTOLOL HCL CAP 400 MG
Tier 3
TIMOLOL MAL TAB 10MG
TIMOLOL MALEATE TAB 10 MG
Tier 1
TIMOLOL MAL TAB 20MG
TIMOLOL MALEATE TAB 20 MG
Tier 1
TIMOLOL MAL TAB 5MG
TIMOLOL MALEATE TAB 5 MG
Tier 1
TOPROL XL TAB 100MG TOPROL XL TAB 200MG TOPROL XL TAB 25MG TOPROL XL TAB 50MG
METOPROLOL SUCCINATE TAB SR 24HR 100 MG (TARTRATE EQUIV) METOPROLOL SUCCINATE TAB SR 24HR 200 MG (TARTRATE EQUIV) METOPROLOL SUCCINATE TAB SR 24HR 25 MG (TARTRATE EQUIV) METOPROLOL SUCCINATE TAB SR 24HR 50 MG (TARTRATE EQUIV)
Tier Value
Tier 3 Tier 3 Tier 3 Tier 3
ZEBETA TAB 10MG
BISOPROLOL FUMARATE TAB 10 MG
Tier 3
ZEBETA TAB 5MG
BISOPROLOL FUMARATE TAB 5 MG
Tier 3
ZIAC TAB 10/6.25 ZIAC TAB 2.5/6.25 ZIAC TAB 5-6.25MG
BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG
Tier 3 Tier 3 Tier 3
CEDAX CAP 400MG
CEFTIBUTEN CAP 400 MG
Tier 3
CEDAX SUS 180/5ML
CEFTIBUTEN FOR SUSP 180 MG/5ML
Tier 3
CEFACLOR CAP 250MG
CEFACLOR CAP 250 MG
Tier 1
CEFACLOR CAP 500MG
CEFACLOR CAP 500 MG
Tier 1
CEFACLOR SUS 125/5ML
CEFACLOR FOR SUSP 125 MG/5ML
Tier 3
CEFACLOR SUS 250/5ML
CEFACLOR FOR SUSP 250 MG/5ML
Tier 1
CEFACLOR SUS 375/5ML
CEFACLOR FOR SUSP 375 MG/5ML
Tier 3
CEFACLOR ER TAB 500MG
CEFACLOR MONOHYDRATE TAB SR 12HR 500 MG
Tier 1
CEFADROXIL CAP 500MG
CEFADROXIL CAP 500 MG
Tier 1
CEFADROXIL SUS 250/5ML
CEFADROXIL FOR SUSP 250 MG/5ML
Tier 1
CEFADROXIL SUS 500/5ML
CEFADROXIL FOR SUSP 500 MG/5ML
Tier 1
CEFADROXIL TAB 1GM
CEFADROXIL TAB 1 GM
Tier 1
CEFDINIR CAP 300MG
CEFDINIR CAP 300 MG
Tier 1
CEFDINIR SUS 125/5ML
CEFDINIR FOR SUSP 125 MG/5ML
Tier 2
CEFDINIR SUS 250/5ML
CEFDINIR FOR SUSP 250 MG/5ML
Tier 2
CEFDITOREN TAB 200MG CEFDITOREN TAB 400MG CEFIXIME SUS 100/5ML
CEFDITOREN PIVOXIL TAB 200 MG (BASE EQUIVALENT) CEFDITOREN PIVOXIL TAB 400 MG (BASE EQUIVALENT)
Tier 1 Tier 1
CEFIXIME FOR SUSP 100 MG/5ML
Tier 3
CEFIXIME SUS 200/5ML
CEFIXIME FOR SUSP 200 MG/5ML
Tier 3
CEFPODO PROX SUS 100/5ML CEFPODO PROX SUS 50MG/5ML
CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML
CEFPODOXIME TAB 100MG
CEFPODOXIME PROXETIL TAB 100 MG
Tier 1
CEFPODOXIME TAB 200MG
CEFPODOXIME PROXETIL TAB 200 MG
Tier 1
48
Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics Beta-Lactam, Cephalosporins Antibiotics
Label Name
Generic Name
CEFPROZIL SUS 125/5ML
CEFPROZIL FOR SUSP 125 MG/5ML
Tier 1
CEFPROZIL SUS 250/5ML
CEFPROZIL FOR SUSP 250 MG/5ML
Tier 1
CEFPROZIL TAB 250MG
CEFPROZIL TAB 250 MG
Tier 1
CEFPROZIL TAB 500MG
CEFPROZIL TAB 500 MG
Tier 1
CEFTIBUTEN CAP 400MG
CEFTIBUTEN CAP 400 MG
Tier 1
CEFTIBUTEN SUS 180/5ML
CEFTIBUTEN FOR SUSP 180 MG/5ML
Tier 1
CEFTIN SUS 125/5ML CEFTIN SUS 250/5ML
CEFUROXIME AXETIL FOR SUSP 125 MG/5ML CEFUROXIME AXETIL FOR SUSP 250 MG/5ML
Tier Value
Tier 3 Tier 3
CEFTIN TAB 250MG
CEFUROXIME AXETIL TAB 250 MG
Tier 3
CEFTIN TAB 500MG
CEFUROXIME AXETIL TAB 500 MG
Tier 3
CEFUROXIME TAB 250MG
CEFUROXIME AXETIL TAB 250 MG
Tier 1
CEFUROXIME TAB 500MG
CEFUROXIME AXETIL TAB 500 MG
Tier 1
CEPHALEXIN CAP 250MG
CEPHALEXIN CAP 250 MG
Tier 1
CEPHALEXIN CAP 500MG
CEPHALEXIN CAP 500 MG
Tier 1
CEPHALEXIN CAP 750MG
CEPHALEXIN CAP 750 MG
Tier 1
CEPHALEXIN SUS 125/5ML
CEPHALEXIN FOR SUSP 125 MG/5ML
Tier 1
CEPHALEXIN SUS 250/5ML
CEPHALEXIN FOR SUSP 250 MG/5ML
Tier 1
CEPHALEXIN TAB 250MG
CEPHALEXIN TAB 250 MG
Tier 1
CEPHALEXIN TAB 500MG
CEPHALEXIN TAB 500 MG
Tier 1
KEFLEX CAP 250MG
CEPHALEXIN CAP 250 MG
Tier 3
KEFLEX CAP 500MG
CEPHALEXIN CAP 500 MG
Tier 3
KEFLEX CAP 750MG
CEPHALEXIN CAP 750 MG
Tier 3
SPECTRACEF TAB 400MG
CEFDITOREN PIVOXIL TAB 400 MG (BASE EQUIVALENT)
Tier 3
SUPRAX CAP 400MG
CEFIXIME CAP 400 MG
Tier 3
SUPRAX CHW 100MG
CEFIXIME CHEW TAB 100 MG
Tier 3
SUPRAX CHW 200MG
CEFIXIME CHEW TAB 200 MG
Tier 3
SUPRAX SUS 100/5ML
CEFIXIME FOR SUSP 100 MG/5ML
Tier 3
SUPRAX SUS 200/5ML
CEFIXIME FOR SUSP 200 MG/5ML
Tier 3
CEFIXIME FOR SUSP 500 MG/5ML
Tier 3
SUPRAX SUS 500/5ML
Beta-Lactam, Other - Antibiotics
CAYSTON INH 75MG
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV CHW 200MG
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV CHW 400MG
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 200/5ML
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 250/5ML
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 400/5ML
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV SUS 600/5ML
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV TAB 250-125
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV TAB 500-125
Beta-Lactam, Penicillins - Antibiotics
AMOX/K CLAV TAB 875-125
AZTREONAM LYSINE FOR INHAL SOLN 75 MG (BASE EQUIVALENT) AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MG AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML AMOXICILLIN & K CLAVULANATE TAB 250125 MG AMOXICILLIN & K CLAVULANATE TAB 500125 MG AMOXICILLIN & K CLAVULANATE TAB 875125 MG
49
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
X
X
X
Therapeutic Class
Label Name
Beta-Lactam, Penicillins - Antibiotics Beta-Lactam, Penicillins - Antibiotics
AMOXICILLIN CAP 250MG AMOXICILLIN CAP 500MG
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 Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder Drugs Bipolar Agents, Other - Mood Disorder 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
Generic Name
AMOXICILLIN (TRIHYDRATE) CAP 250 MG AMOXICILLIN (TRIHYDRATE) CAP 500 MG AMOXICILLIN (TRIHYDRATE) CHEW TAB AMOXICILLIN CHW 125MG 125 MG AMOXICILLIN (TRIHYDRATE) CHEW TAB AMOXICILLIN CHW 250MG 250 MG AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 125/5ML 125 MG/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 200/5ML 200 MG/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 250/5ML 250 MG/5ML AMOXICILLIN SUS AMOXICILLIN (TRIHYDRATE) FOR SUSP 250MG/5M 250 MG/5ML AMOXICILLIN (TRIHYDRATE) FOR SUSP AMOXICILLIN SUS 400/5ML 400 MG/5ML AMOXICILLIN TAB 500MG AMOXICILLIN (TRIHYDRATE) TAB 500 MG AMOXICILLIN (TRIHYDRATE) TAB SR 24HR AMOXICILLIN TAB 775MG 775 MG AMOXICILLIN TAB 875MG AMOXICILLIN (TRIHYDRATE) TAB 875 MG AMPICILLIN CAP 250MG AMPICILLIN CAP 250 MG AMPICILLIN CAP 500MG AMPICILLIN CAP 500 MG AMPICILLIN SUS 125/5ML AMPICILLIN FOR SUSP 125 MG/5ML AMPICILLIN SUS 250/5ML AMPICILLIN FOR SUSP 250 MG/5ML DICLOXACILL CAP 250MG DICLOXACILLIN SODIUM CAP 250 MG DICLOXACILL CAP 500MG DICLOXACILLIN SODIUM CAP 500 MG AMOXICILLIN (TRIHYDRATE) TAB SR 24HR MOXATAG TAB 775MG 775 MG PENICILLIN V POTASSIUM FOR SOLN 125 PENICILLN VK SOL 125/5ML MG/5ML PENICILLIN V POTASSIUM FOR SOLN 250 PENICILLN VK SOL 250/5ML MG/5ML PENICILLN VK TAB 250MG PENICILLIN V POTASSIUM TAB 250 MG PENICILLN VK TAB 500MG PENICILLIN V POTASSIUM TAB 500 MG OLANZA/FLUOX CAP 12OLANZAPINE-FLUOXETINE HCL CAP 1225MG 25 MG OLANZA/FLUOX CAP 12OLANZAPINE-FLUOXETINE HCL CAP 1250MG 50 MG OLANZA/FLUOX CAP OLANZAPINE-FLUOXETINE HCL CAP 3-25 3-25MG MG OLANZA/FLUOX CAP OLANZAPINE-FLUOXETINE HCL CAP 6-25 6-25MG MG OLANZA/FLUOX CAP OLANZAPINE-FLUOXETINE HCL CAP 6-50 6-50MG MG OLANZAPINE-FLUOXETINE HCL CAP 12SYMBYAX CAP 12-25MG 25 MG OLANZAPINE-FLUOXETINE HCL CAP 12SYMBYAX CAP 12-50MG 50 MG OLANZAPINE-FLUOXETINE HCL CAP 3-25 SYMBYAX CAP 3-25MG MG OLANZAPINE-FLUOXETINE HCL CAP 6-25 SYMBYAX CAP 6-25MG MG OLANZAPINE-FLUOXETINE HCL CAP 6-50 SYMBYAX CAP 6-50MG MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
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 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
AGRYLIN CAP 0.5MG
ANAGRELIDE HCL CAP 0.5 MG
Tier 3
ANAGRELIDE CAP 0.5MG
ANAGRELIDE HCL CAP 0.5 MG
Tier 1
ANAGRELIDE CAP 1MG
ANAGRELIDE HCL CAP 1 MG
Tier 1
EPOGEN INJ 10000/ML
EPOETIN ALFA INJ 10000 UNIT/ML
Tier 2
X
X
EPOGEN INJ 2000/ML
EPOETIN ALFA INJ 2000 UNIT/ML
Tier 2
X
X
EPOGEN INJ 20000/ML
EPOETIN ALFA INJ 20000 UNIT/ML
Tier 2
X
X
EPOGEN INJ 3000/ML
EPOETIN ALFA INJ 3000 UNIT/ML
Tier 2
X
X
EPOGEN INJ 4000/ML
EPOETIN ALFA INJ 4000 UNIT/ML
Tier 2
X
X
LEUKINE INJ 250MCG MOZOBIL INJ NEULASTA INJ 6MG/0.6M
SARGRAMOSTIM LYOPHILIZED FOR INJ 250 MCG PLERIXAFOR SUBCUTANEOUS INJ 24 MG/1.2ML (20 MG/ML) PEGFILGRASTIM SOLN PREFILLED SYRINGE 6 MG/0.6ML
50
Tier 2
X
Tier 2
X
Tier 4
X
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 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 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
Generic Name
PROCRIT INJ 10000/ML
EPOETIN ALFA INJ 10000 UNIT/ML
Tier 2
X
X
PROCRIT INJ 2000/ML
EPOETIN ALFA INJ 2000 UNIT/ML
Tier 2
X
X
PROCRIT INJ 20000/ML
EPOETIN ALFA INJ 20000 UNIT/ML
Tier 2
X
X
PROCRIT INJ 3000/ML
EPOETIN ALFA INJ 3000 UNIT/ML
Tier 2
X
X
PROCRIT INJ 4000/ML
EPOETIN ALFA INJ 4000 UNIT/ML
Tier 2
X
X
PROCRIT INJ 40000/ML
EPOETIN ALFA INJ 40000 UNIT/ML
Tier 2
X
X
ELTROMBOPAG OLAMINE TAB 12.5 MG PROMACTA TAB 12.5MG (BASE EQUIV) ELTROMBOPAG OLAMINE TAB 25 MG PROMACTA TAB 25MG (BASE EQUIV) ELTROMBOPAG OLAMINE TAB 50 MG PROMACTA TAB 50MG (BASE EQUIV) ELTROMBOPAG OLAMINE TAB 75 MG PROMACTA TAB 75MG (BASE EQUIV) *ANTICOAGULANT CITRATE DEXTROSE ANTICOAG CIT SOL DEX SOL SOLUTION A** *ANTICOAGULANT CITRATE DEXTROSE NOCLOT-50 SOL ACD-A SOLUTION A** ANTICOAGULANT SODIUM CITRATE TRICITRASOL CON CONCENTRATE 46.7% ANTIHEMOPHILIC FACTOR RAHF-PFM ADVATE INJ 1000UNIT FOR INJ 1000 UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM ADVATE INJ 1500UNIT FOR INJ 1500 UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM ADVATE INJ 2000UNIT FOR INJ 2000 UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM ADVATE INJ 250UNIT FOR INJ 250 UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM ADVATE INJ 3000UNIT FOR INJ 3000 UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM ADVATE INJ 4000UNIT FOR INJ 4000 UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM ADVATE INJ 500UNIT FOR INJ 500 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) ALPHANATE INJ VWF/HUM FOR INJ 250 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) ALPHANATE INJ VWF/HUM FOR INJ 500 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) ALPHANATE INJ VWF/HUM FOR INJ 1000 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) ALPHANATE INJ VWF/HUM FOR INJ 1500 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) ALPHANATE INJ VWF/HUM FOR INJ 2000 UNIT ALPHANINE SD INJ COAGULATION FACTOR IX FOR INJ 1000 1000UNIT UNIT ALPHANINE SD INJ COAGULATION FACTOR IX FOR INJ 1500 1500UNIT UNIT COAGULATION FACTOR IX FOR INJ 500 ALPHANINE SD INJ 500UNIT UNIT AMINOCAPROIC ACID ORAL SOLN 0.25 AMICAR SOL 0.25/ML GM/ML
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 1 Tier 3 Tier 3 Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 3
AMICAR TAB 1000MG
AMINOCAPROIC ACID TAB 1000 MG
Tier 3
AMICAR TAB 500MG
AMINOCAPROIC ACID TAB 500 MG
Tier 3
ARTISS SOL 10ML ARTISS SOL 2ML ARTISS SOL 4ML
*FIBRIN SEALANT COMPONENT SOLUTION*** *FIBRIN SEALANT COMPONENT SOLUTION*** *FIBRIN SEALANT COMPONENT SOLUTION***
ASTRINGYN SOL 259MG/GM FERRIC SUBSULFATE SOLN 259 MG/GM BEBULIN INJ 200-1200 BENEFIX INJ 1000UNIT BENEFIX INJ 2000UNIT BENEFIX INJ 250UNIT
FACTOR IX COMPLEX FOR INJ 200-1200 UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 1000 UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 2000 UNIT COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 250 UNIT
51
Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
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 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
Label Name
Generic Name
COAGULATION FACTOR IX (RECOMBINANT) FOR INJ KIT 3000 UNIT COAGULATION FACTOR IX BENEFIX INJ 500UNIT (RECOMBINANT) FOR INJ KIT 500 UNIT FACTOR XIII CONCENTRATE (HUMAN) FOR CORIFACT KIT INJ KIT 1000-1600 UNIT *FIBRIN SEALANT COMPONENT KIT 2 EVICEL KIT 2ML ML*** *FIBRIN SEALANT COMPONENT KIT 5 EVICEL KIT 5ML ML*** THROMBIN (HUMAN) TOPICAL SOLN 800EVITHROM SOL 800-1200 1200 UNIT/ML *ANTIINHIBITOR COAGULANT COMPLEX FEIBA INJ FOR INJ** *ANTIINHIBITOR COAGULANT COMPLEX FEIBA NF INJ FOR INJ** ANTIHEMOPHILIC FACTOR (HUMAN) FOR HEMOFIL M INJ 1000UNIT INJ 1000 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR HEMOFIL M INJ 1700UNIT INJ 1700 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR HEMOFIL M INJ 250UNIT INJ 250 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR HEMOFIL M INJ 500UNIT INJ 500 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR HEMOFIL M SOL INJ 1501-2000 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR HEMOFIL M SOL 801-1500 INJ 801-1500 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) HUMATE-P SOL 2400UNIT FOR INJ 1000-2400 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) HUMATE-P SOL 250-600 FOR INJ 250-600 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) HUMATE-P SOL 500-1200 FOR INJ 500-1200 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR KOATE INJ 1000UNIT INJ 1000 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR KOATE INJ 250UNIT INJ 250 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR KOATE INJ 500 UNIT INJ 500 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR KOATE-DVI INJ 1000UNIT INJ 1000 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR KOATE-DVI INJ 250UNIT INJ 250 UNIT ANTIHEMOPHILIC FACTOR (HUMAN) FOR KOATE-DVI INJ 500UNIT INJ 500 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 1000/BS (RECOMBINANT) FOR INJ KIT 1000 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 1000UNIT (RECOMBINANT) FOR INJ KIT 1000 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 2000/BS (RECOMBINANT) FOR INJ KIT 2000 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 2000UNIT (RECOMBINANT) FOR INJ KIT 2000 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 250/BS (RECOMBINANT) FOR INJ KIT 250 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 250UNIT (RECOMBINANT) FOR INJ KIT 250 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 3000/BS (RECOMBINANT) FOR INJ KIT 3000 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 3000UNIT (RECOMBINANT) FOR INJ KIT 3000 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 500/BS (RECOMBINANT) FOR INJ KIT 500 UNIT ANTIHEMOPHILIC FACTOR KOGENATE FS INJ 500UNIT (RECOMBINANT) FOR INJ KIT 500 UNIT ANTIHEMOPHILIC FACTOR KOVALTRY INJ 1000UNIT (RECOMBINANT) FOR INJ 1000 UNIT ANTIHEMOPHILIC FACTOR KOVALTRY INJ 2000UNIT (RECOMBINANT) FOR INJ 2000 UNIT ANTIHEMOPHILIC FACTOR KOVALTRY INJ 250UNIT (RECOMBINANT) FOR INJ 250 UNIT ANTIHEMOPHILIC FACTOR KOVALTRY INJ 3000UNIT (RECOMBINANT) FOR INJ 3000 UNIT ANTIHEMOPHILIC FACTOR KOVALTRY INJ 500UNIT (RECOMBINANT) FOR INJ 500 UNIT MONOCLATE-P INJ ANTIHEMOPHILIC FACTOR (HUMAN) FOR 1000UNIT INJ KIT 1000 UNIT
BENEFIX INJ 3000UNIT
52
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
Tier 2
X
Tier 2
X
Tier 3 Tier 3 Tier 3 Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Therapeutic Class
Label Name
Generic Name
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 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
MONOCLATE-P INJ 1500UNIT
ANTIHEMOPHILIC FACTOR (HUMAN) FOR INJ KIT 1500 UNIT COAGULATION FACTOR IX FOR INJ 1000 UNIT
MONONINE INJ 1000UNIT MONSELS FERR SOL SUBSULF NOVOEIGHT INJ 1000UNIT NOVOEIGHT INJ 1500UNIT NOVOEIGHT INJ 2000UNIT NOVOEIGHT INJ 250UNIT NOVOEIGHT INJ 3000UNIT NOVOEIGHT INJ 500UNIT NOVOSEVEN RT INJ 1MG NOVOSEVEN RT INJ 2MG NOVOSEVEN RT INJ 5MG NOVOSEVEN RT INJ 8MG
*FERRIC SUBSULFATE SOLN** ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 1000 UNIT ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 1500 UNIT ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 2000 UNIT ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 250 UNIT ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 3000 UNIT ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 500 UNIT COAGULATION FACTOR VIIA (RECOMB) FOR INJ 1 MG (1000 MCG) COAGULATION FACTOR VIIA (RECOMB) FOR INJ 2 MG (2000 MCG) COAGULATION FACTOR VIIA (RECOMB) FOR INJ 5 MG (5000 MCG) COAGULATION FACTOR VIIA (RECOMB) FOR INJ 8 MG (8000 MCG)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
Tier 2
X
Tier 1 Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
PROFILNINE INJ 1000UNIT
FACTOR IX COMPLEX FOR INJ 1000 UNIT
Tier 2
X
PROFILNINE INJ 1500UNIT
FACTOR IX COMPLEX FOR INJ 1500 UNIT
Tier 2
X
PROFILNINE INJ 500UNIT
FACTOR IX COMPLEX FOR INJ 500 UNIT
Tier 2
X
ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 1241-1800 UNIT ANTIHEMOPHILIC FACTOR RECOMBINATE INJ (RECOMBINANT) FOR INJ 1801-2400 UNIT ANTIHEMOPHILIC FACTOR RECOMBINATE INJ 220-400 (RECOMBINANT) FOR INJ 220-400 UNIT ANTIHEMOPHILIC FACTOR RECOMBINATE INJ 401-800 (RECOMBINANT) FOR INJ 401-800 UNIT ANTIHEMOPHILIC FACTOR RECOMBINATE INJ 801-1240 (RECOMBINANT) FOR INJ 801-1240 UNIT RECOTHROM SOL THROMBIN (RECOMBINANT) FOR SOLN 20000UNT 20000 UNIT RECOTHROM SOL THROMBIN (RECOMBINANT) FOR SOLN 5000UNIT 5000 UNIT FIBRINOGEN CONC (HUMAN) INJ RIASTAP SOL 1GM APPROXIMATELY 1 GM (900-1300 MG) COAGULATION FACTOR IX RIXUBIS INJ 1000UNIT (RECOMBINANT) FOR INJ 1000 UNIT COAGULATION FACTOR IX RIXUBIS INJ 2000UNIT (RECOMBINANT) FOR INJ 2000 UNIT COAGULATION FACTOR IX RIXUBIS INJ 250 UNIT (RECOMBINANT) FOR INJ 250 UNIT COAGULATION FACTOR IX RIXUBIS INJ 3000UNIT (RECOMBINANT) FOR INJ 3000 UNIT COAGULATION FACTOR IX RIXUBIS INJ 500UNIT (RECOMBINANT) FOR INJ 500 UNIT
RECOMBINATE INJ
THROMBIN KIT 5000UNIT THROMBIN-JMI KIT 20000UNT THROMBIN-JMI KIT 5000UNIT THROMBOGEN KIT 10000UNT THROMBOGEN SOL 10000UNT THROMBOGEN SOL 1000UNIT TISSEEL SOL TISSEEL VH KIT 10ML TISSEEL VH KIT 2ML TISSEEL VH KIT 4ML
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 3 Tier 3 Tier 3
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
THROMBIN FOR SOLN KIT 5000 UNIT
Tier 3
THROMBIN FOR SOLN KIT 20000 UNIT
Tier 3
THROMBIN FOR SOLN KIT 5000 UNIT
Tier 3
THROMBIN FOR SOLN KIT 10000 UNIT
Tier 3
THROMBIN FOR SOLN 10000 UNIT
Tier 3
THROMBIN FOR SOLN 1000 UNIT
Tier 3
*FIBRIN SEALANT COMPONENT SOLUTION*** *FIBRIN SEALANT COMPONENT KIT 10 ML*** *FIBRIN SEALANT COMPONENT KIT 2 ML*** *FIBRIN SEALANT COMPONENT KIT 4 ML***
53
Tier 3 Tier 3 Tier 3 Tier 3
Therapeutic Class BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS
Label Name
Generic Name
ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500-500 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) WILATE INJ FOR INJ 1000-1000 UNIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) WILATE INJ FOR INJ 500-500 UNIT KIT ANTIHEMOPHILIC FACTOR/VWF (HUMAN) WILATE INJ FOR INJ 1000-1000 UNIT KIT ANTIHEMOPHILIC FACTOR BLOOD FORMATION,COAGULATION & XYNTHA INJ 1000UNIT RECOMBINANT PAF FOR INJ KIT 1000 THROMBOSIS - HEMOSTATICS UNIT ANTIHEMOPHILIC FACTOR BLOOD FORMATION,COAGULATION & XYNTHA INJ 2000UNIT RECOMBINANT PAF FOR INJ KIT 2000 THROMBOSIS - HEMOSTATICS UNIT BLOOD FORMATION,COAGULATION & ANTIHEMOPHILIC FACTOR XYNTHA INJ 250UNIT THROMBOSIS - HEMOSTATICS RECOMBINANT PAF FOR INJ KIT 250 UNIT BLOOD FORMATION,COAGULATION & ANTIHEMOPHILIC FACTOR XYNTHA INJ 500UNIT THROMBOSIS - HEMOSTATICS RECOMBINANT PAF FOR INJ KIT 500 UNIT ANTIHEMOPHILIC FACTOR BLOOD FORMATION,COAGULATION & XYNTHA SOLOF INJ RECOMBINANT PAF FOR INJ KIT 1000 THROMBOSIS - HEMOSTATICS 1000UNIT UNIT ANTIHEMOPHILIC FACTOR BLOOD FORMATION,COAGULATION & XYNTHA SOLOF INJ RECOMBINANT PAF FOR INJ KIT 2000 THROMBOSIS - HEMOSTATICS 2000UNIT UNIT ANTIHEMOPHILIC FACTOR BLOOD FORMATION,COAGULATION & XYNTHA SOLOF INJ RECOMBINANT PAF FOR INJ KIT 3000 THROMBOSIS - HEMOSTATICS 3000UNIT UNIT BLOOD FORMATION,COAGULATION & ANTIHEMOPHILIC FACTOR XYNTHA SOLOF INJ 500UNIT THROMBOSIS - HEMOSTATICS RECOMBINANT PAF FOR INJ KIT 500 UNIT BLOOD FORMATION,COAGULATION & ANTIHEMOPHILIC FACTOR XYNTHA SOLOF KIT 250UNIT THROMBOSIS - HEMOSTATICS RECOMBINANT PAF FOR INJ KIT 250 UNIT BLOOD FORMATION,COAGULATION & FERROUS FUMARATE-FOLIC ACID TAB HEMATINIC/FA TAB THROMBOSIS - IRON PREPARATIONS 324-1 MG BLOOD FORMATION,COAGULATION & FERROUS FUMARATE-FOLIC ACID TAB HEMOCYTE-F TAB THROMBOSIS - IRON PREPARATIONS 324-1 MG BLOOD FORMATION,COAGULATION & IRON HEME POLYPEPTIDE-FOLIC ACID PROFERRIN- TAB FORTE THROMBOSIS - IRON PREPARATIONS TAB 12-1 MG (FE EQUIV) BLOOD FORMATION,COAGULATION & FERROUS FUM-IRON POLYSACCH-FA CAP TANDEM F CAP THROMBOSIS - IRON PREPARATIONS 162-115.2-1 MG (106 MG FE) Blood Products/Modifiers/Volume C1 ESTERASE INHIBITOR (HUMAN) FOR IV BERINERT INJ 500UNIT Expanders INJ KIT 500 UNIT Blood Products/Modifiers/Volume C1 ESTERASE INHIBITOR (HUMAN) FOR IV CINRYZE SOL 500 UNIT Expanders INJ 500 UNIT Bronchodilators, Anticholinergic IPRATROPIUM BROMIDE HFA INHAL ATROVENT HFA AER 17MCG Asthma/Lung Drugs AEROSOL 17 MCG/ACT Bronchodilators, Anticholinergic IPRATROPIUM BROMIDE NASAL SOLN ATROVENT NAS SOL 0.03% Asthma/Lung Drugs 0.03% (21 MCG/SPRAY) Bronchodilators, Anticholinergic IPRATROPIUM BROMIDE NASAL SOLN ATROVENT NAS SOL 0.06% Asthma/Lung Drugs 0.06% (42 MCG/SPRAY) Bronchodilators, Anticholinergic IPRATROPIUM-ALBUTEROL INHAL COMBIVENT AER 20-100 Asthma/Lung Drugs AEROSOL SOLN 20-100 MCG/ACT Bronchodilators, Anticholinergic IPRATROPIUM SOL IPRATROPIUM BROMIDE INHAL SOLN Asthma/Lung Drugs 0.02%INH 0.02% Bronchodilators, Anticholinergic IPRATROPIUM BROMIDE NASAL SOLN IPRATROPIUM SPR 0.03% Asthma/Lung Drugs 0.03% (21 MCG/SPRAY) Bronchodilators, Anticholinergic IPRATROPIUM BROMIDE NASAL SOLN IPRATROPIUM SPR 0.06% Asthma/Lung Drugs 0.06% (42 MCG/SPRAY) Bronchodilators, Anticholinergic IPRATROPIUM/ SOL IPRATROPIUM-ALBUTEROL NEBU SOLN Asthma/Lung Drugs ALBUTER 0.5-2.5(3) MG/3ML Bronchodilators, Anticholinergic TIOTROPIUM BROMIDE MONOHYDRATE SPIRIVA AER 1.25MCG Asthma/Lung Drugs INHAL AEROSOL 1.25 MCG/ACT Bronchodilators, Anticholinergic TIOTROPIUM BROMIDE MONOHYDRATE SPIRIVA CAP HANDIHLR Asthma/Lung Drugs INHAL CAP 18 MCG (BASE EQUIV) Bronchodilators, Anticholinergic TIOTROPIUM BROMIDE MONOHYDRATE SPIRIVA SPR 2.5MCG Asthma/Lung Drugs INHAL AEROSOL 2.5 MCG/ACT Bronchodilators, Anticholinergic TUDORZA PRES AER 400/ ACLIDINIUM BROMIDE AEROSOL POWD Asthma/Lung Drugs ACT BREATH ACTIVATED 400 MCG/ACT Bronchodilators, Phosphodiesterase DYPHYLLINE-GUAIFENESIN LIQD 100-100 Inhibitors (Xanthines) - Asthma/Lung DIFIL-G FORT LIQ 100-100 MG/5ML Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung ELIXOPHYLLIN ELX 80/15ML THEOPHYLLINE ELIXIR 80 MG/15ML Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung THEO-24 CAP 100MG CR THEOPHYLLINE CAP SR 24HR 100 MG Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung THEO-24 CAP 200MG CR THEOPHYLLINE CAP SR 24HR 200 MG Drugs WILATE INJ
54
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 1 Tier 1 Tier 3 Tier 3 Tier 2
X
X
X
Tier 3
X
X
X
Tier 3
X
Tier 3 Tier 3 Tier 3
X
Tier 1 Tier 1 Tier 1 Tier 2 Tier 3
X
Tier 3
X
Tier 3
X
Tier 2
X
Tier 1 Tier 3 Tier 3 Tier 3
Therapeutic Class Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - 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
Label Name
Generic Name
Tier Value
THEO-24 CAP 300MG CR
THEOPHYLLINE CAP SR 24HR 300 MG
Tier 3
THEO-24 CAP 400MG ER
THEOPHYLLINE CAP SR 24HR 400 MG
Tier 3
THEOCHRON TAB 100MG CR
THEOPHYLLINE TAB SR 12HR 100 MG
Tier 1
THEOCHRON TAB 200MG CR
THEOPHYLLINE TAB SR 12HR 200 MG
Tier 1
THEOCHRON TAB 300MG CR
THEOPHYLLINE TAB SR 12HR 300 MG
Tier 1
THEOPHYLLINE SOL 80/15ML
THEOPHYLLINE SOLN 80 MG/15ML
Tier 1
THEOPHYLLINE TAB 100MG THEOPHYLLINE TAB SR 12HR 100 MG CR
Tier 1
THEOPHYLLINE TAB 100MG THEOPHYLLINE TAB SR 12HR 100 MG ER
Tier 1
THEOPHYLLINE TAB 200MG THEOPHYLLINE TAB SR 12HR 200 MG CR
Tier 1
THEOPHYLLINE TAB 200MG THEOPHYLLINE TAB SR 12HR 200 MG ER
Tier 1
THEOPHYLLINE TAB 300MG THEOPHYLLINE TAB SR 12HR 300 MG ER
Tier 1
THEOPHYLLINE TAB 400MG THEOPHYLLINE TAB SR 24HR 400 MG ER
Tier 1
THEOPHYLLINE TAB 450MG THEOPHYLLINE TAB SR 12HR 450 MG ER
Tier 1
THEOPHYLLINE TAB 600MG THEOPHYLLINE TAB SR 24HR 600 MG ER
Tier 1
ADRENALIN SOL 1:1000
Tier 2
ALBUTEROL NEB 0.083% ALBUTEROL NEB 0.5% ALBUTEROL NEB 0.63MG/3 ALBUTEROL NEB 1.25MG/3
EPINEPHRINE HCL NASAL SOLN 0.1% ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML) ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML) ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV) ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)
Tier 1 Tier 1 Tier 1 Tier 1
ALBUTEROL SYP 2MG/5ML
ALBUTEROL SULFATE SYRUP 2 MG/5ML
Tier 1
ALBUTEROL TAB 2MG
ALBUTEROL SULFATE TAB 2 MG
Tier 1
ALBUTEROL TAB 4MG
ALBUTEROL SULFATE TAB 4 MG
Tier 1
ALBUTEROL TAB 4MG ER
ALBUTEROL SULFATE TAB SR 12HR 4 MG
Tier 1
ALBUTEROL SULFATE TAB SR 12HR 8 MG
Tier 1
ALBUTEROL TAB 8MG ER ANORO ELLIPT AER 62.5-25 ARCAPTA CAP 75MCG BROVANA NEB 15MCG EPINEPHRINE INJ 0.15MG EPINEPHRINE INJ 0.3MG EPINEPHRINE INJ 0.3MG FORADIL CAP AEROLIZE LEVALBUTEROL AER 45/ ACT
UMECLIDINIUM-VILANTEROL AERO POWD BA 62.5-25 MCG/INH INDACATEROL MALEATE INHAL POWDER CAP 75 MCG (BASE EQUIV) ARFORMOTEROL TARTRATE SOLN NEBU 15 MCG/2ML (BASE EQUIV) EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML (1:2000) EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000) EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML (1:1000) FORMOTEROL FUMARATE INHAL CAP 12 MCG LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV)
55
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
Tier 3
X
Tier 3
X
Tier 2
X
Tier 2
X
Tier 3
X
Tier 3
X
Tier 3
X
Therapeutic Class
Label Name
Generic Name
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 Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs
METAPROTEREN SYP 10MG/5ML
METAPROTERENOL SULFATE SYRUP 10 MG/5ML
Tier Value Tier 1
METAPROTEREN TAB 10MG METAPROTERENOL SULFATE TAB 10 MG
Tier 1
METAPROTEREN TAB 20MG METAPROTERENOL SULFATE TAB 20 MG
Tier 1
FORMOTEROL FUMARATE SOLN NEBU 20 PERFOROMIST NEB 20MCG MCG/2ML ALBUTEROL SULFATE INHAL AERO 108 PROAIR HFA AER MCG/ACT (90MCG BASE EQUIV) ALBUTEROL SULFATE AER POW BA 108 PROAIR RESPI AER MCG/ACT (90 MCG BASE EQUIV) ALBUTEROL SULFATE INHAL AERO 108 PROVENTIL AER HFA MCG/ACT (90MCG BASE EQUIV) SALMETEROL XINAFOATE AER POW BA SEREVENT DIS AER 50MCG 50 MCG/DOSE (BASE EQUIV) OLODATEROL HCL INHAL AEROSOL SOLN STRIVERDI AER 2.5MCG 2.5 MCG/ACT (BASE EQUIV) TERBUTALINE POW TERBUTALINE SULFATE POWDER SULFATE TERBUTALINE TAB 2.5MG
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 2
X
Tier 3
TERBUTALINE SULFATE TAB 2.5 MG
Tier 1
TERBUTALINE TAB 5MG
TERBUTALINE SULFATE TAB 5 MG
Tier 1
VENTOLIN HFA AER
ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)
Tier 2
VOSPIRE ER TAB 4MG
ALBUTEROL SULFATE TAB SR 12HR 4 MG
Tier 3
VOSPIRE ER TAB 8MG
ALBUTEROL SULFATE TAB SR 12HR 8 MG
Tier 3
XOPENEX HFA AER
LEVALBUTEROL TARTRATE INHAL AEROSOL 45 MCG/ACT (BASE EQUIV)
Tier 3
ADALAT CC TAB 30MG ER
NIFEDIPINE TAB SR 24HR 30 MG
Tier 3
ADALAT CC TAB 60MG ER
NIFEDIPINE TAB SR 24HR 60 MG
Tier 3
ADALAT CC TAB 90MG ER
NIFEDIPINE TAB SR 24HR 90 MG
Tier 3
AFEDITAB TAB 30MG CR
NIFEDIPINE TAB SR 24HR 30 MG
Tier 1
AFEDITAB TAB 60MG CR
NIFEDIPINE TAB SR 24HR 60 MG
Tier 1
AMLOD/BENAZP CAP 1020MG AMLOD/BENAZP CAP 1040MG AMLOD/BENAZP CAP 2.510MG AMLOD/BENAZP CAP 5-10MG AMLOD/BENAZP CAP 5-20MG AMLOD/BENAZP CAP 5-40MG AMLOD/VALSAR TAB 10160MG AMLOD/VALSAR TAB 10320MG AMLOD/VALSAR TAB 5-160MG AMLOD/VALSAR TAB 5-320MG
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG AMLODIPINE BESYLATE-VALSARTAN TAB 10-160 MG AMLODIPINE BESYLATE-VALSARTAN TAB 10-320 MG AMLODIPINE BESYLATE-VALSARTAN TAB 5-160 MG AMLODIPINE BESYLATE-VALSARTAN TAB 5-320 MG
AMLODIPINE TAB 10MG
AMLODIPINE BESYLATE TAB 10 MG
Tier 1
AMLODIPINE TAB 2.5MG
AMLODIPINE BESYLATE TAB 2.5 MG
Tier 1
AMLODIPINE TAB 5MG
AMLODIPINE BESYLATE TAB 5 MG
Tier 1
CALAN TAB 120MG
VERAPAMIL HCL TAB 120 MG
Tier 3
CALAN TAB 80MG
VERAPAMIL HCL TAB 80 MG
Tier 3
CALAN SR TAB 120MG
VERAPAMIL HCL TAB CR 120 MG
Tier 3
CALAN SR TAB 180MG
VERAPAMIL HCL TAB CR 180 MG
Tier 3
CALAN SR TAB 240MG
VERAPAMIL HCL TAB CR 240 MG
Tier 3
56
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
X
X
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 Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs
Label Name CARTIA XT CAP 120/24HR CARTIA XT CAP 180/24HR CARTIA XT CAP 240/24HR CARTIA XT CAP 300/24HR DILTIAZEM CAP 120MG CD
Generic Name DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 240 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG
Tier Value Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
DILTIAZEM CAP 120MG ER
DILTIAZEM HCL CAP SR 24HR 120 MG
Tier 1
DILTIAZEM CAP 120MG ER
DILTIAZEM HCL CAP SR 12HR 120 MG
Tier 1
DILTIAZEM CAP 120MG ER DILTIAZEM CAP 120MG ER DILTIAZEM CAP 120MG/24 DILTIAZEM CAP 180MG CD DILTIAZEM CAP 180MG ER DILTIAZEM CAP 180MG ER DILTIAZEM CAP 180MG/24 DILTIAZEM CAP 240MG CD DILTIAZEM CAP 240MG ER DILTIAZEM CAP 240MG ER DILTIAZEM CAP 240MG/24 DILTIAZEM CAP 300MG CD DILTIAZEM CAP 300MG ER DILTIAZEM CAP 300MG/24 DILTIAZEM CAP 360MG CD DILTIAZEM CAP 360MG ER DILTIAZEM CAP 360MG ER DILTIAZEM CAP 360MG/24 DILTIAZEM CAP 360MG/24 DILTIAZEM CAP 420MG/24
DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG DILTIAZEM HCL CAP SR 24HR 180 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 180 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 240 MG DILTIAZEM HCL CAP SR 24HR 240 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 240 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 240 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 300 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 360 MG DILTIAZEM HCL COATED BEADS CAP SR 24HR 360 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 420 MG
Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 2 Tier 2 Tier 2 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
DILTIAZEM CAP 60MG ER
DILTIAZEM HCL CAP SR 12HR 60 MG
Tier 1
DILTIAZEM CAP 90MG ER
DILTIAZEM HCL CAP SR 12HR 90 MG
Tier 1
DILTIAZEM TAB 120MG
DILTIAZEM HCL TAB 120 MG
Tier 1
DILTIAZEM TAB 30MG
DILTIAZEM HCL TAB 30 MG
Tier 1
DILTIAZEM TAB 60MG
DILTIAZEM HCL TAB 60 MG
Tier 1
DILTIAZEM HCL TAB 90 MG
Tier 1
DILTIAZEM TAB 90MG DILTIAZEM ER TAB 180MG DILTIAZEM ER TAB 240MG DILTIAZEM ER TAB 300MG DILTIAZEM ER TAB 360MG DILTIAZEM ER TAB 420MG DILT-XR CAP 120MG
DILTIAZEM HCL COATED BEADS TAB SR 24HR 180 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 240 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 300 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 360 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 420 MG DILTIAZEM HCL CAP SR 24HR 120 MG
57
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
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 Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs
Label Name
Generic Name
DILT-XR CAP 180MG
DILTIAZEM HCL CAP SR 24HR 180 MG
Tier 1
DILT-XR CAP 240MG
DILTIAZEM HCL CAP SR 24HR 240 MG
Tier 1
FELODIPINE TAB 10MG ER
FELODIPINE TAB SR 24HR 10 MG
Tier 1
FELODIPINE TAB 2.5MG ER
FELODIPINE TAB SR 24HR 2.5 MG
Tier 1
FELODIPINE TAB 5MG ER
FELODIPINE TAB SR 24HR 5 MG
Tier 1
ISRADIPINE CAP 2.5MG
ISRADIPINE CAP 2.5 MG
Tier 1
ISRADIPINE CAP 5MG
ISRADIPINE CAP 5 MG
Tier 1
LOTREL CAP 10-20MG LOTREL CAP 10-40MG LOTREL CAP 2.5-10MG LOTREL CAP 5-10MG LOTREL CAP 5-20MG MATZIM LA TAB 180MG/24 MATZIM LA TAB 240MG/24 MATZIM LA TAB 300MG/24 MATZIM LA TAB 360MG/24 MATZIM LA TAB 420MG/24
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 180 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 240 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 300 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 360 MG DILTIAZEM HCL COATED BEADS TAB SR 24HR 420 MG
Tier Value
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
NICARDIPINE CAP 20MG
NICARDIPINE HCL CAP 20 MG
Tier 1
NICARDIPINE CAP 30MG
NICARDIPINE HCL CAP 30 MG
Tier 1
NIFEDICAL XL TAB 30MG NIFEDICAL XL TAB 60MG
NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 30 MG NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 60 MG
Tier 1 Tier 1
NIFEDIPINE CAP 10MG
NIFEDIPINE CAP 10 MG
Tier 1
NIFEDIPINE CAP 20MG
NIFEDIPINE CAP 20 MG
Tier 1
NIFEDIPINE TAB 30MG ER
NIFEDIPINE TAB SR 24HR 30 MG
Tier 1
NIFEDIPINE TAB 30MG ER
NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 30 MG
Tier 1
NIFEDIPINE TAB 60MG ER
NIFEDIPINE TAB SR 24HR 60 MG
Tier 1
NIFEDIPINE TAB 60MG ER
NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 60 MG
Tier 1
NIFEDIPINE TAB 90MG ER
NIFEDIPINE TAB SR 24HR 90 MG
Tier 1
NIFEDIPINE TAB 90MG ER
NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 90 MG
Tier 1
NIMODIPINE CAP 30MG
NIMODIPINE CAP 30 MG
Tier 1
NISOLDIPINE TAB 17MG ER
NISOLDIPINE TAB SR 24HR 17 MG
Tier 2
NISOLDIPINE TAB 20MG ER
NISOLDIPINE TAB SR 24HR 20 MG
Tier 2
NISOLDIPINE TAB 25.5MG
NISOLDIPINE TAB SR 24HR 25.5 MG
Tier 2
NISOLDIPINE TAB 30MG ER
NISOLDIPINE TAB SR 24HR 30 MG
Tier 2
NISOLDIPINE TAB 34MG ER
NISOLDIPINE TAB SR 24HR 34 MG
Tier 2
NISOLDIPINE TAB 40MG ER
NISOLDIPINE TAB SR 24HR 40 MG
Tier 2
NISOLDIPINE TAB 8.5MG ER
NISOLDIPINE TAB SR 24HR 8.5 MG
Tier 2
NORVASC TAB 10MG
AMLODIPINE BESYLATE TAB 10 MG
Tier 3
NORVASC TAB 2.5MG
AMLODIPINE BESYLATE TAB 2.5 MG
Tier 3
58
Prior Supply Step Specialty Authorization Limit Therapy
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 Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs Calcium Channel Blocking Agents Blood Pressure Drugs
Label Name
Generic Name
NORVASC TAB 5MG
AMLODIPINE BESYLATE TAB 5 MG
Tier 3
NYMALIZE SOL 60/20ML
NIMODIPINE ORAL SOLN 60 MG/20ML
Tier 2
PROCARDIA CAP 10MG
NIFEDIPINE CAP 10 MG
Tier 3
PROCARDIA XL TAB 30MG CR PROCARDIA XL TAB 60MG CR PROCARDIA XL TAB 90MG CR
NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 30 MG NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 60 MG NIFEDIPINE TAB SR 24HR OSMOTIC RELEASE 90 MG
SULAR TAB 17MG
NISOLDIPINE TAB SR 24HR 17 MG
Tier 3
SULAR TAB 34MG
NISOLDIPINE TAB SR 24HR 34 MG
Tier 3
NISOLDIPINE TAB SR 24HR 8.5 MG
Tier 3
SULAR TAB 8.5MG
Tier Value
Tier 3 Tier 3 Tier 3
DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 180 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 240 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 300 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 180 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 240 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 300 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 420 MG
Tier 3
VERAPAMIL CAP 100MG ER
VERAPAMIL HCL CAP SR 24HR 100 MG
Tier 3
VERAPAMIL CAP 120MG ER
VERAPAMIL HCL CAP SR 24HR 120 MG
Tier 1
VERAPAMIL CAP 120MG SR
VERAPAMIL HCL CAP SR 24HR 120 MG
Tier 1
VERAPAMIL CAP 180MG ER
VERAPAMIL HCL CAP SR 24HR 180 MG
Tier 1
VERAPAMIL CAP 180MG SR
VERAPAMIL HCL CAP SR 24HR 180 MG
Tier 1
VERAPAMIL CAP 200MG ER
VERAPAMIL HCL CAP SR 24HR 200 MG
Tier 3
VERAPAMIL CAP 240MG ER
VERAPAMIL HCL CAP SR 24HR 240 MG
Tier 1
VERAPAMIL CAP 240MG SR
VERAPAMIL HCL CAP SR 24HR 240 MG
Tier 1
VERAPAMIL CAP 300MG ER
VERAPAMIL HCL CAP SR 24HR 300 MG
Tier 3
VERAPAMIL CAP 360MG SR
VERAPAMIL HCL CAP SR 24HR 360 MG
Tier 1
VERAPAMIL TAB 120MG
VERAPAMIL HCL TAB 120 MG
Tier 1
VERAPAMIL TAB 120MG ER
VERAPAMIL HCL TAB CR 120 MG
Tier 1
VERAPAMIL TAB 180MG ER
VERAPAMIL HCL TAB CR 180 MG
Tier 1
VERAPAMIL TAB 240MG ER
VERAPAMIL HCL TAB CR 240 MG
Tier 1
VERAPAMIL TAB 40MG
VERAPAMIL HCL TAB 40 MG
Tier 1
VERAPAMIL TAB 80MG
VERAPAMIL HCL TAB 80 MG
Tier 1
VERELAN CAP 120MG SR
VERAPAMIL HCL CAP SR 24HR 120 MG
Tier 3
VERELAN CAP 180MG SR
VERAPAMIL HCL CAP SR 24HR 180 MG
Tier 3
VERELAN CAP 240MG SR
VERAPAMIL HCL CAP SR 24HR 240 MG
Tier 3
TAZTIA XT CAP 120MG/24 TAZTIA XT CAP 180MG/24 TAZTIA XT CAP 240MG/24 TAZTIA XT CAP 300MG/24 TAZTIA XT CAP 360MG/24 TIAZAC CAP 120MG/24 TIAZAC CAP 180MG/24 TIAZAC CAP 240MG/24 TIAZAC CAP 300MG/24 TIAZAC CAP 360MG/24 TIAZAC CAP 420MG/24
59
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
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 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 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
Label Name
Generic Name
Tier Value
VERELAN CAP 360MG SR
VERAPAMIL HCL CAP SR 24HR 360 MG
Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
VERELAN PM CAP 100MG ER VERELAN PM CAP 200MG ER VERELAN PM CAP 300MG ER
VERAPAMIL HCL CAP SR 24HR 100 MG
Tier 3
VERAPAMIL HCL CAP SR 24HR 200 MG
Tier 3
VERAPAMIL HCL CAP SR 24HR 300 MG
Tier 3
CELONTIN CAP 300MG
METHSUXIMIDE CAP 300 MG
Tier 2
ETHOSUXIMIDE CAP 250MG ETHOSUXIMIDE CAP 250 MG
Tier 1
ETHOSUXIMIDE SOL 250/5ML
ETHOSUXIMIDE SOLN 250 MG/5ML
Tier 1
LYRICA CAP 100MG
PREGABALIN CAP 100 MG
Tier 3
X
X
LYRICA CAP 150MG
PREGABALIN CAP 150 MG
Tier 3
X
X
LYRICA CAP 200MG
PREGABALIN CAP 200 MG
Tier 3
X
X
LYRICA CAP 225MG
PREGABALIN CAP 225 MG
Tier 3
X
X
LYRICA CAP 25MG
PREGABALIN CAP 25 MG
Tier 3
X
X
LYRICA CAP 300MG
PREGABALIN CAP 300 MG
Tier 3
X
X
LYRICA CAP 50MG
PREGABALIN CAP 50 MG
Tier 3
X
X
LYRICA CAP 75MG
PREGABALIN CAP 75 MG
Tier 3
X
X
LYRICA SOL 20MG/ML
PREGABALIN SOLN 20 MG/ML
Tier 3
X
X
ZARONTIN CAP 250MG
ETHOSUXIMIDE CAP 250 MG
Tier 3
ZARONTIN SOL 250/5ML
ETHOSUXIMIDE SOLN 250 MG/5ML
Tier 3
ZONEGRAN CAP 100MG
ZONISAMIDE CAP 100 MG
Tier 3
X
X
ZONEGRAN CAP 25MG
ZONISAMIDE CAP 25 MG
Tier 3
X
X
ZONISAMIDE CAP 100MG
ZONISAMIDE CAP 100 MG
Tier 1
ZONISAMIDE CAP 25MG
ZONISAMIDE CAP 25 MG
Tier 1
ZONISAMIDE CAP 50MG
ZONISAMIDE CAP 50 MG
Tier 1
DEMSER CAP 250MG
METYROSINE CAP 250 MG
Tier 3
DIGITEK TAB 0.125MG
DIGOXIN TAB 125 MCG (0.125 MG)
Tier 1
DIGITEK TAB 0.25MG
DIGOXIN TAB 250 MCG (0.25 MG)
Tier 1
DIGOX TAB 0.125MG
DIGOXIN TAB 125 MCG (0.125 MG)
Tier 1
DIGOX TAB 0.25MG
DIGOXIN TAB 250 MCG (0.25 MG)
Tier 1
DIGOX TAB 0.25MG
DIGOXIN TAB 250 MCG (0.25 MG)
Tier 1
DIGOXIN SOL 50MCG/ML
DIGOXIN ORAL SOLN 0.05 MG/ML
Tier 1
DIGOXIN TAB 0.125MG
DIGOXIN TAB 125 MCG (0.125 MG)
Tier 1
DIGOXIN TAB 0.25MG
DIGOXIN TAB 250 MCG (0.25 MG)
Tier 1
DIGOXIN TAB 0.25MG
DIGOXIN TAB 250 MCG (0.25 MG)
Tier 1
LANOXIN TAB 0.0625MG
DIGOXIN TAB 62.5 MCG (0.0625 MG)
Tier 3
LANOXIN TAB 0.125MG
DIGOXIN TAB 125 MCG (0.125 MG)
Tier 3
LANOXIN TAB 0.1875MG
DIGOXIN TAB 187.5 MCG (0.1875 MG)
Tier 3
LANOXIN TAB 0.25MG
DIGOXIN TAB 250 MCG (0.25 MG)
Tier 3
PENTOXIFYLLI TAB 400MG ER
PENTOXIFYLLINE TAB CR 400 MG
Tier 1
RANEXA TAB 1000MG
RANOLAZINE TAB SR 12HR 1000 MG
Tier 2
60
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 DRUGS CALCIUM-CHANNEL BLOCKING AGENTS CENTRAL NERVOUS SYSTEM AGENTS - ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS - ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS - ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS - ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC 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 Central Nervous System, Other Miscellaneous Central Nervous System Drugs Central Nervous System, Other Miscellaneous Central Nervous System Drugs Central Nervous System, Other Miscellaneous Central Nervous System Drugs Central Nervous System, Other Miscellaneous Central Nervous System Drugs Central Nervous System, Other Miscellaneous Central Nervous System Drugs Central Nervous System, Other Miscellaneous Central Nervous System 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
Label Name
Generic Name
RANEXA TAB 500MG
RANOLAZINE TAB SR 12HR 500 MG
Tier Value Tier 2
TEKTURNA HCT TAB 15012.5 TEKTURNA HCT TAB 15025MG TEKTURNA HCT TAB 30012.5 TEKTURNA HCT TAB 30025MG
ALISKIREN FUMARATE TAB 150 MG (BASE EQUIVALENT) ALISKIREN FUMARATE TAB 300 MG (BASE EQUIVALENT) ALISKIREN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG ALISKIREN-HYDROCHLOROTHIAZIDE TAB 150-25 MG ALISKIREN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG ALISKIREN-HYDROCHLOROTHIAZIDE TAB 300-25 MG
TRENTAL TAB 400MG
PENTOXIFYLLINE TAB 400MG
Tier 3
VECAMYL TAB 2.5MG
MECAMYLAMINE HCL TAB 2.5 MG
Tier 3
KRISGEL 100 GEL
KRISGEL 100 GEL
Tier 3
ISOMETH/APAP CAP DICHLOR
ISOMETHEPTENE-DICHLORALACETAMINOPHEN CAP 65-100-325 MG
Tier 1
ISOMETH/CAFF TAB /APAP
ISOMETHEPTENE-CAFFEINEACETAMINOPHEN TAB 65-20-325 MG
Tier 1
NODOLOR CAP
ISOMETHEPTENE-DICHLORALACETAMINOPHEN CAP 65-100-325 MG
Tier 1
TRYPTOPHAN CAP 500MG
TRYPTOPHAN CAP 500 MG
Tier 3
FORANE SOL
ISOFLURANE INHAL SOLN
Tier 2
ISOFLURANE SOL
ISOFLURANE INHAL SOLN
Tier 1
SEVOFLURANE SOL
SEVOFLURANE INHAL SOLN
Tier 1
SOJOURN SOL
SEVOFLURANE INHAL SOLN
Tier 1
SUPRANE INH
DESFLURANE INHAL SOLN
Tier 2
SUPRANE SOL
DESFLURANE INHAL SOLN
Tier 2
TERRELL SOL
ISOFLURANE INHAL SOLN
Tier 1
ULTANE SOL
SEVOFLURANE INHAL SOLN
Tier 3
BUT/APAP/CAF CAP CODEINE
BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-325-40-30 MG
Tier 1
HETLIOZ CAP 20MG
TASIMELTEON CAPSULE 20 MG
Tier 3
NUEDEXTA CAP 20-10MG
DEXTROMETHORPHAN HBR-QUINIDINE SULFATE CAP 20-10 MG
Tier 2
RILUTEK TAB 50MG
RILUZOLE TAB 50 MG
Tier 3
RILUZOLE TAB 50MG
RILUZOLE TAB 50 MG
Tier 1
TEKTURNA TAB 150MG TEKTURNA TAB 300MG
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
X
X
X X
X
X
TETRABENAZIN TAB 12.5MG TETRABENAZINE TAB 12.5 MG
Tier 1
X
TETRABENAZIN TAB 25MG
TETRABENAZINE TAB 25 MG
Tier 1
X
ARICEPT TAB 10MG
DONEPEZIL HYDROCHLORIDE TAB 10 MG
Tier 3
ARICEPT TAB 5MG
DONEPEZIL HYDROCHLORIDE TAB 5 MG
Tier 3
DONEPEZIL TAB 10MG
DONEPEZIL HYDROCHLORIDE TAB 10 MG
Tier 1
DONEPEZIL TAB 10MG ODT
DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 10 MG
Tier 1
61
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 Coagulants - Blood Clotting Drugs Coagulants - Blood Clotting Drugs Coagulants - Blood Clotting Drugs Coagulants - Blood Clotting Drugs CONTRACEPTIVES (E.G. FOAMS, DEVICES)
Label Name
Generic Name
DONEPEZIL TAB 5MG
DONEPEZIL HYDROCHLORIDE TAB 5 MG
Tier 1
DONEPEZIL TAB 5MG ODT
DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TAB 5 MG
Tier 1
EXELON CAP 1.5MG
RIVASTIGMINE TARTRATE CAP 1.5 MG
Tier 3
EXELON CAP 3MG
RIVASTIGMINE TARTRATE CAP 3 MG
Tier 3
EXELON CAP 4.5MG
RIVASTIGMINE TARTRATE CAP 4.5 MG
Tier 3
EXELON CAP 6MG
RIVASTIGMINE TARTRATE CAP 6 MG
Tier 3
GALANTAMINE CAP 16MG ER GALANTAMINE CAP 24MG ER
GALANTAMINE HYDROBROMIDE CAP SR 24HR 16 MG GALANTAMINE HYDROBROMIDE CAP SR 24HR 24 MG GALANTAMINE HYDROBROMIDE CAP SR GALANTAMINE CAP 8MG ER 24HR 8 MG GALANTAMINE SOL 4MG/ GALANTAMINE HYDROBROMIDE ORAL ML SOLN 4 MG/ML GALANTAMINE HYDROBROMIDE TAB 12 GALANTAMINE TAB 12MG MG GALANTAMINE HYDROBROMIDE TAB 4 GALANTAMINE TAB 4MG MG GALANTAMINE HYDROBROMIDE TAB 8 GALANTAMINE TAB 8MG MG GALANTAMINE HYDROBROMIDE TAB 12 RAZADYNE TAB 12MG MG GALANTAMINE HYDROBROMIDE TAB 4 RAZADYNE TAB 4MG MG GALANTAMINE HYDROBROMIDE TAB 8 RAZADYNE TAB 8MG MG GALANTAMINE HYDROBROMIDE CAP SR RAZADYNE ER CAP 16MG 24HR 16 MG GALANTAMINE HYDROBROMIDE CAP SR RAZADYNE ER CAP 24MG 24HR 24 MG GALANTAMINE HYDROBROMIDE CAP SR RAZADYNE ER CAP 8MG 24HR 8 MG
Tier Value
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
RIVASTIGMINE CAP 1.5MG
RIVASTIGMINE TARTRATE CAP 1.5 MG
Tier 1
RIVASTIGMINE CAP 3MG
RIVASTIGMINE TARTRATE CAP 3 MG
Tier 1
RIVASTIGMINE CAP 4.5MG
RIVASTIGMINE TARTRATE CAP 4.5 MG
Tier 1
RIVASTIGMINE CAP 6MG
RIVASTIGMINE TARTRATE CAP 6 MG
Tier 1
RIVASTIGMINE TD PATCH 24HR 13.3 RIVASTIGMINE DIS 13.3/24 MG/24HR RIVASTIGMINE TD PATCH 24HR 4.6 RIVASTIGMINE DIS 4.6MG/24 MG/24HR RIVASTIGMINE TD PATCH 24HR 9.5 RIVASTIGMINE DIS 9.5MG/24 MG/24HR BRILINTA TAB 60MG TICAGRELOR TAB 60 MG BRILINTA TAB 90MG TICAGRELOR TAB 90 MG LYSTEDA TAB 650MG TRANEXAMIC ACID TAB 650 MG TRANEX ACID TAB 650MG TRANEXAMIC ACID TAB 650 MG CAYA DPR
*DIAPHRAGM ARC-SPRING***
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
FC FEMALE MIS CONDOM
*CONDOMS - FEMALE***
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
OMNIFLEX DPR
*DIAPHRAGMS***
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 60
DIAPHRAGM WIDE SEAL 60 MM
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 65
DIAPHRAGM WIDE SEAL 65 MM
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 70
DIAPHRAGM WIDE SEAL 70 MM
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 75
DIAPHRAGM WIDE SEAL 75 MM
62
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
X X X X
Therapeutic Class
Label Name
Generic Name
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 80
DIAPHRAGM WIDE SEAL 80 MM
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 85
DIAPHRAGM WIDE SEAL 85 MM
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 90
DIAPHRAGM WIDE SEAL 90 MM
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
WIDE-SEAL DPR KIT 95
DIAPHRAGM WIDE SEAL 95 MM
Conventional - Mood Disorder Drugs Conventional - Mood Disorder Drugs 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 Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents 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 10MG MOLINDONE HCL TAB 10 MG MOLINDONE TAB HCL 25MG MOLINDONE HCL TAB 25 MG MOLINDONE TAB HCL 5MG MOLINDONE HCL TAB 5 MG *DENTAL DESENSITIZING PRODUCT HURRISEAL SOL SOLUTION*** CEVIMELINE CAP 30MG CEVIMELINE HCL CAP 30 MG CHLORHEXIDINE GLUCONATE SOLN CHLORHEX GLU SOL 0.12% 0.12% EVOXAC CAP 30MG CEVIMELINE HCL CAP 30 MG TRIAMCINOLONE ACETONIDE DENTAL ORALONE PST 0.1% PASTE 0.1% CHLORHEXIDINE GLUCONATE SOLN PAROEX SOL 0.12% 0.12% CHLORHEXIDINE GLUCONATE SOLN PERIDEX SOL 0.12% 0.12% CHLORHEXIDINE GLUCONATE SOLN PERIOGARD SOL 0.12% 0.12% PILOCARPINE TAB 5MG PILOCARPINE HCL TAB 5 MG PILOCARPINE TAB 7.5MG PILOCARPINE HCL TAB 7.5 MG SALAGEN TAB 5MG PILOCARPINE HCL TAB 5 MG SALAGEN TAB 7.5MG PILOCARPINE HCL TAB 7.5 MG TRIAMCINOLONE ACETONIDE DENTAL TRIAMCIN/ORA PST 0.1% PASTE 0.1% TRIAMCINOLONE ACETONIDE DENTAL TRIAMCINOLON PST 0.1% PASTE 0.1% BRIMONIDINE TARTRATE GEL 0.33% MIRVASO GEL 0.33% (BASE EQUIVALENT) 8-MOP CAP 10MG METHOXSALEN CAP 10 MG ACITRETIN CAP 10MG ACITRETIN CAP 10 MG ACITRETIN CAP 17.5MG ACITRETIN CAP 17.5 MG ACITRETIN CAP 25MG ACITRETIN CAP 25 MG ACZONE GEL 5% DAPSONE GEL 5% ACZONE GEL 7.5% DAPSONE GEL 7.5% ALDARA CRE 5% IMIQUIMOD CREAM 5% AMELUZ GEL 10% AMINOLEVULINIC ACID HCL GEL 10% AMNESTEEM CAP 10MG ISOTRETINOIN CAP 10 MG AMNESTEEM CAP 20MG ISOTRETINOIN CAP 20 MG AMNESTEEM CAP 40MG ISOTRETINOIN CAP 40 MG AZELEX CRE 20% AZELAIC ACID CREAM 20% BENZOYL PEROXIDE-ERYTHROMYCIN BENZAMYCIN GEL 5-3% GEL 5-3% CALCIPOTRIEN CRE 0.005% CALCIPOTRIENE CREAM 0.005% CALCIPOTRIEN OIN 0.005% CALCIPOTRIENE OINT 0.005% CALCIPOTRIEN OIN CALCIPOTRIENE-BETAMETHASONE BETAMETH DIPROPIONATE OINT 0.005-0.064% CALCIPOTRIENE SOLN 0.005% (50 MCG/ CALCIPOTRIEN SOL 0.005% ML) CALCITRENE OIN 0.005% CALCIPOTRIENE OINT 0.005% CALCITRIOL OIN 3MCG/GM CALCITRIOL OINT 3 MCG/GM CARAC CRE 0.5% FLUOROURACIL CREAM 0.5% CLARAVIS CAP 10MG ISOTRETINOIN CAP 10 MG CLARAVIS CAP 20MG ISOTRETINOIN CAP 20 MG CLARAVIS CAP 30MG ISOTRETINOIN CAP 30 MG CLARAVIS CAP 40MG ISOTRETINOIN CAP 40 MG CLEOCIN-T GEL 1% CLINDAMYCIN PHOSPHATE GEL 1% CLEOCIN-T LOT 1% CLINDAMYCIN PHOSPHATE LOTION 1% CLEOCIN-T PAD 1% CLINDAMYCIN PHOSPHATE SWAB 1% CLEOCIN-T SOL 1% CLINDAMYCIN PHOSPHATE SOLN 1% CLINDACIN MIS ETZ 1% CLINDAMYCIN PHOSPHATE SWAB 1% CLINDACIN-P PAD 1% CLINDAMYCIN PHOSPHATE SWAB 1% CLINDAMYCIN PHOSPH-BENZOYL CLINDAMY/BEN GEL 1.2-5% PEROXIDE (REFRIG) GEL 1.2 (1)-5% CLINDAMYCIN AER 1% CLINDAMYCIN PHOSPHATE FOAM 1% CLINDAMYCIN GEL 1% CLINDAMYCIN PHOSPHATE GEL 1%
63
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3
X
X X X X X X X
Tier 2
X
Tier 2 Tier 2
X
Tier 3
X
Tier 1
X
Tier 3 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
X X X X X X
Tier 3
X
Tier 3 Tier 3
X
Therapeutic Class
Label Name
Generic Name
Dermatological Agents - Skin Agents
CLINDAMYCIN LOT 1% CLINDAMYCIN LOT 10MG/ ML CLINDAMYCIN MIS 1% CLINDAMYCIN PAD 1% CLINDAMYCIN SOL 1% CONDYLOX GEL 0.5% CONDYLOX SOL 0.5%
CLINDAMYCIN PHOSPHATE LOTION 1%
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
Tier Value Tier 3
CLINDAMYCIN PHOSPHATE LOTION 1%
Tier 3
CLINDAMYCIN PHOSPHATE SWAB 1% CLINDAMYCIN PHOSPHATE SWAB 1% CLINDAMYCIN PHOSPHATE SOLN 1% PODOFILOX GEL 0.5% PODOFILOX SOLN 0.5% DICLOFENAC SODIUM (ACTINIC DICLOFENAC GEL 3% KERATOSES) GEL 3% DOVONEX CRE 0.005% CALCIPOTRIENE CREAM 0.005% DOXEPIN HCL CRE 5% DOXEPIN HCL CREAM 5% EFUDEX CRE 5% FLUOROURACIL CREAM 5% ELIDEL CRE 1% PIMECROLIMUS CREAM 1% CALCIPOTRIENE-BETAMETHASONE ENSTILAR AER DIPROPIONATE FOAM 0.005-0.064% BENZOYL PEROXIDE-ERYTHROMYCIN ERY/BENZOYL GEL 5-3% GEL 5-3% EVOCLIN AER 1% CLINDAMYCIN PHOSPHATE FOAM 1% FINACEA AER 15% AZELAIC ACID FOAM 15% FINACEA GEL 15% AZELAIC ACID GEL 15% FLUOROPLEX CRE 1% FLUOROURACIL CREAM 1% FLUOROURACIL CRE 5% FLUOROURACIL CREAM 5% FLUOROURACIL DRO 2% FLUOROURACIL SOLN 2% FLUOROURACIL DRO 5% FLUOROURACIL SOLN 5% FLUOROURACIL SOL 2% FLUOROURACIL SOLN 2% FLUOROURACIL SOL 5% FLUOROURACIL SOLN 5% GLYCERIN LIQ GLYCERIN LIQUID GLYCERIN LIQ GLYCERIN LIQUID GLYCERINE LIQ GLYCERIN LIQUID GLYCEROL LIQ FORMAL GLYCERIN LIQUID IMIQUIMOD CRE 5% IMIQUIMOD CREAM 5% SULFACETAMIDE SODIUM LOTION 10% KLARON LOT 10% (ACNE) LAVARE WOUND GEL WASH *WOUND CLEANSERS - GEL** AMINOLEVULINIC ACID HCL FOR SOLN LEVULAN KERA SOL 20% 20% (STICK APPLICATOR) METHOXSALEN CAP 10MG METHOXSALEN RAPID CAP 10 MG MYORISAN CAP 10MG ISOTRETINOIN CAP 10 MG MYORISAN CAP 20MG ISOTRETINOIN CAP 20 MG MYORISAN CAP 30MG ISOTRETINOIN CAP 30 MG MYORISAN CAP 40MG ISOTRETINOIN CAP 40 MG CLINDAMYCIN PHOSPH-BENZOYL NEUAC GEL 1.2-5% PEROXIDE (REFRIG) GEL 1.2 (1)-5% OXSORALEN LOT 1% METHOXSALEN LOTION 1% OXSORALEN-UL CAP 10MG METHOXSALEN RAPID CAP 10 MG PODOCON SOL 25% PODOPHYLLUM RESIN SOLN 25% PODOFILOX SOL 0.5% PODOFILOX SOLN 0.5% PRUDOXIN CRE 5% DOXEPIN HCL CREAM 5% REGRANEX GEL 0.01% BECAPLERMIN GEL 0.01% SANTYL OIN 250/GM COLLAGENASE OINT 250 UNIT/GM SELENIUM SUL LOT 2.5% SELENIUM SULFIDE LOTION 2.5% DICLOFENAC SODIUM (ACTINIC SOLARAZE GEL 3% W/W KERATOSES) GEL 3% SORIATANE CAP 10MG ACITRETIN CAP 10 MG SORIATANE CAP 17.5MG ACITRETIN CAP 17.5 MG SORIATANE CAP 25MG ACITRETIN CAP 25 MG STELARA INJ 45MG/0.5 USTEKINUMAB INJ 45 MG/0.5ML USTEKINUMAB SOLN PREFILLED STELARA INJ 45MG/0.5 SYRINGE 45 MG/0.5ML USTEKINUMAB SOLN PREFILLED STELARA INJ 90MG/ML SYRINGE 90 MG/ML SULFACETAMIDE SODIUM LOTION 10% SULFACETAMID LOT 10% (ACNE) SULFACETAMIDE SODIUM LOTION 10% SULFACETAMID SUS 10% (ACNE) CALCIPOTRIENE-BETAMETHASONE TACLONEX SUS DIPROPIONATE SUSP 0.005-0.064% TACROLIMUS OIN 0.03% TACROLIMUS OINT 0.03% TACROLIMUS OIN 0.1% TACROLIMUS OINT 0.1% TAZORAC CRE 0.05% TAZAROTENE CREAM 0.05% TAZORAC CRE 0.1% TAZAROTENE CREAM 0.1% TAZORAC GEL 0.05% TAZAROTENE GEL 0.05% TAZORAC GEL 0.1% TAZAROTENE GEL 0.1%
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
64
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 1 Tier 3 Tier 3
X X
X X
X
X
Tier 3
X
Tier 1
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1
X X X X
X
Tier 3 Tier 1 Tier 3 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2
X X X X
Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 1
X
X X
X X X
Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 2
X
Tier 2
X
X
X
Tier 2
X
X
X
X X X X X X
X X X X X X
X
Tier 1 Tier 1 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
X
Therapeutic Class
Label Name
Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents Dermatological Agents - Skin Agents
TERSI FOAM AER 2.25% TRETINOIN CRE 0.025% TRETINOIN CRE 0.05% TRETINOIN CRE 0.1% VECTICAL OIN 3MCG/GM VEREGEN OIN 15% ZENATANE CAP 10MG ZENATANE CAP 20MG ZENATANE CAP 30MG ZENATANE CAP 40MG ZONALON CRE 5% AERCHMBR PLS MIS FLOWVU AERCHMBR PLS MIS LRG MASK AERCHMBR PLS MIS SM MASK
DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES DIABETIC DEVICES
Generic Name
SELENIUM SULFIDE FOAM 2.25% TRETINOIN CREAM 0.025% TRETINOIN CREAM 0.05% TRETINOIN CREAM 0.1% CALCITRIOL OINT 3 MCG/GM SINECATECHINS OINT 15% ISOTRETINOIN CAP 10 MG ISOTRETINOIN CAP 20 MG ISOTRETINOIN CAP 30 MG ISOTRETINOIN CAP 40 MG DOXEPIN HCL CREAM 5% *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING AEROCHAMBER MIS PLUS CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING EASIVENT MIS CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING EASIVENT MIS MASK LG CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING EASIVENT MIS MASK SM CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING EASIVENT MIS MASK MED CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING E-Z SPACER MIS CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING E-Z SPACER MIS BODY GRD CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING FLEXICHAMBER MIS CHAMBERS - DEVICE*** FLEXICHAMBER MIS MASK *SPACER/AEROSOL-HOLDING CHAMBER LRG SUPPLIES - MASKS*** FLEXICHAMBER MIS MASK *SPACER/AEROSOL-HOLDING CHAMBER SM SUPPLIES - MASKS*** *SPACER/AEROSOL-HOLDING INSPIRACHAMB MIS LARGE CHAMBERS - DEVICE*** INSPIRACHAMB MIS *SPACER/AEROSOL-HOLDING MEDIUM CHAMBERS - DEVICE*** INSPIRACHAMB MIS *SPACER/AEROSOL-HOLDING MOUTHPCE CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING INSPIRACHAMB MIS SMALL CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING INSPIREASE MIS DD SYST CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING CHAMBER INSPIREASE MIS RES BAG SUPPLIES - BAGS*** MASK VORTEX/ MIS BABY *SPACER/AEROSOL-HOLDING CHAMBER DUC SUPPLIES - MASKS*** *SPACER/AEROSOL-HOLDING CHAMBER MASK VORTEX/ MIS DUCK SUPPLIES - MASKS*** *SPACER/AEROSOL-HOLDING CHAMBER MASK VORTEX/ MIS FROG SUPPLIES - MASKS*** MASK VORTEX/ MIS LADY *SPACER/AEROSOL-HOLDING CHAMBER BUG SUPPLIES - MASKS*** *SPACER/AEROSOL-HOLDING OPTIHALER MIS CHAMBERS - DEVICE*** VORTEX VALVE MIS *SPACER/AEROSOL-HOLDING CHAMBER CHAMBERS - DEVICE*** *SPACER/AEROSOL-HOLDING WATCHHALER MIS CHAMBERS - DEVICE*** AUTOJECT 2 MIS *INJECTION DEVICE - MISC*** *CONTINUOUS BLOOD GLUCOSE GUARDIAN RT KIT MONITOR/COMPONENTS KIT*** *CONTINUOUS BLOOD GLUCOSE GUARDIAN RT KIT STARTER MONITOR/COMPONENTS KIT*** *CONTINUOUS BLOOD GLUCOSE GUARDIAN RT KIT SYST PED MONITOR/COMPONENTS KIT*** *CONTINUOUS BLOOD GLUCOSE GUARDIAN RT KIT SYSTEM MONITOR/COMPONENTS KIT*** *CONTINUOUS BLOOD GLUCOSE GUARDIAN RT KIT SYSTEM MONITOR/COMPONENTS KIT*** *CONTINUOUS BLOOD GLUCOSE REAL-TIME KIT MONITOR/COMPONENTS KIT***
65
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy X X X
X X X X X
X X X X X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
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 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 2 Tier 3 Tier 3
X
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 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
Label Name
Generic Name
*BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ ACCU-CHEK KIT AVIVA PL DEVICE*** ACCU-CHEK KIT COMPACT *BLOOD GLUCOSE MONITORING KIT*** ACCU-CHEK KIT FASTCLIX *LANCETS KIT*** *BLOOD GLUCOSE MONITORING KIT W/ ACCU-CHEK KIT GUIDE DEVICE*** ACCU-CHEK KIT MLTICLIX *LANCETS KIT*** *BLOOD GLUCOSE MONITORING KIT W/ ACCU-CHEK KIT NANO DEVICE*** ACCU-CHEK KIT SOFTCLIX *LANCETS KIT*** *BLOOD GLUCOSE CALIBRATION ACCU-CHEK LIQ ACT/GLUC LIQUID*** *BLOOD GLUCOSE CALIBRATION ACCU-CHEK LIQ GUIDE LIQUID*** *BLOOD GLUCOSE CALIBRATION ACCU-CHEK LIQ SMART LIQUID*** *INSULIN INFUSION PUMP ACCU-CHEK MIS ADAPTER ACCESSORIES*** *BLOOD GLUCOSE MONITORING ACCU-CHEK MIS AVIVA DEVICES*** *INSULIN INFUSION PUMP ACCU-CHEK MIS BATTERY ACCESSORIES*** *INSULIN INFUSION PUMP ACCU-CHEK MIS CLIP ACCESSORIES*** ACCU-CHEK MIS MLTICLIX *LANCETS*** *INSULIN INFUSION PUMP ACCU-CHEK MIS SPRT COM ACCESSORIES*** *BLOOD GLUCOSE CALIBRATION ACCU-CHEK SOL LIQUID*** *BLOOD GLUCOSE CALIBRATION ACCU-CHEK SOL COMPACT LIQUID*** *BLOOD GLUCOSE CALIBRATION ACCUTREND SOL GLUCOSE LIQUID*** ADV LANCING MIS DEVICE *LANCET DEVICES*** ASSURE CMFRT MIS 28G *LANCETS*** ASSURE CMFRT MIS 30G *LANCETS*** AT LAST KIT GLUCOSE *BLOOD GLUCOSE MONITORING KIT*** AT LAST MIS LANCETS *LANCETS*** AURORA LANCE MIS 30G *LANCETS*** AURORA LANCE MIS THIN *LANCETS*** 23G AUTOLET II KIT CLINISAF *LANCETS KIT*** AUTOLET LANC MIS DEVICE *LANCET DEVICES*** AUTOLET LITE KIT STARTER *LANCETS KIT*** AUTOLET MINI MIS *LANCET DEVICES*** AUTOPEN MIS 1-21UNIT INJECTION DEVICE FOR INSULIN AUTOPEN MIS 2-42UNIT INJECTION DEVICE FOR INSULIN BAYER BREEZE KIT 2 *BLOOD GLUCOSE MONITORING KIT W/ SYSTEM DEVICE*** BAYER BREEZE LIQ HIGH *BLOOD GLUCOSE CALIBRATION - LIQUID CNT - HIGH*** BAYER BREEZE LIQ LOW *BLOOD GLUCOSE CALIBRATION - LIQUID CNTL - LOW*** BAYER BREEZE LIQ NORM *BLOOD GLUCOSE CALIBRATION - LIQUID CNT - NORMAL*** BAYER MICRLT MIS LANC *LANCET DEVICES*** DVC BAYER MICRLT MIS *LANCETS*** LANCETS *BLOOD GLUCOSE MONITORING BLOOD GLUC MIS MONITOR DEVICES*** *BLOOD GLUCOSE MONITORING BREEZE 2 MIS SYSTEM DEVICES*** CAREONE ADV MIS *LANCET DEVICES*** LANCING CAREONE LANC MIS 28G *LANCETS*** CAREONE LANC MIS THIN *LANCETS*** 23G CARETOUCH MIS EJECTOR *LANCET DEVICES*** CARETOUCH MIS TWIST 30 *LANCETS*** CARTRIDGE MIS 3.15ML *INSULIN INFUSION PUMP SUPPLIES*** CARTRIDGE MIS IR 1000 *INSULIN INFUSION PUMP SUPPLIES*** CARTRIDGE MIS IR 1200 *INSULIN INFUSION PUMP SUPPLIES*** CARTRIDGE MIS PUMP *INSULIN INFUSION PUMP SUPPLIES*** ACCU-CHEK KIT AVA CONN
66
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 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 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 2 Tier 2 Tier 2 Tier 2
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
DIABETIC SUPPLIES
CGMS MIS SOFTWARE
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
Generic Name
*CONTINUOUS BLOOD GLUCOSE MONITOR SUPPLIES*** *CONTINUOUS BLOOD GLUCOSE CGMS CABLE MIS MONITOR SUPPLIES*** *BLOOD GLUCOSE MONITORING CHEMSTRIP BG MIS LOG MISC.*** CHOICE DM KIT RISK TST *BLOOD GLUCOSE MONITORING KIT*** COAGUCHEK MIS LANCETS *LANCETS*** COMFORT MIS LANCETS *LANCETS*** COMFORT SET MIS *INSULIN INFUSION PUMP SUPPLIES*** 23"/17MM COMFORT SET MIS *INSULIN INFUSION PUMP SUPPLIES*** 31"/17MM COMFORT SET MIS *INSULIN INFUSION PUMP SUPPLIES*** 32"/17MM COMFORT SET MIS *INSULIN INFUSION PUMP SUPPLIES*** 43"/17MM COMFORT SHRT MIS *INSULIN INFUSION PUMP SUPPLIES*** 23"/13MM COMFORT SHRT MIS *INSULIN INFUSION PUMP SUPPLIES*** 31"/13MM COMFORT SHRT MIS *INSULIN INFUSION PUMP SUPPLIES*** 32"/13MM COMFORT SHRT MIS *INSULIN INFUSION PUMP SUPPLIES*** 43"/13MM COMFORTOUCH MIS *LANCETS*** LANCET *BLOOD GLUCOSE MONITORING KIT W/ CONTOUR KIT LINK DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ CONTOUR KIT MONITOR DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ CONTOUR KIT NEXT DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ CONTOUR KIT NEXT EZ DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ CONTOUR KIT NEXT LNK DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ CONTOUR KIT NEXT USB DEVICE*** *BLOOD GLUCOSE CALIBRATION - LIQUID CONTOUR LIQ HIGH CNT - HIGH*** *BLOOD GLUCOSE CALIBRATION - LIQUID CONTOUR LIQ LOW CNTL - LOW*** *BLOOD GLUCOSE CALIBRATION - LIQUID CONTOUR LIQ NORM CNT - NORMAL*** *BLOOD GLUCOSE MONITORING CONTOUR MIS MONITOR DEVICES*** *BLOOD GLUCOSE CALIBRATION - LIQUID CONTOUR SOL NEXT - NORMAL*** *BLOOD GLUCOSE CALIBRATION - LIQUID CONTOUR SOL NEXT - LOW*** CONTOUR NEXT KIT ONE *BLOOD GLUCOSE MONITORING KIT*** CONTROL HIGH SOL *BLOOD GLUCOSE CALIBRATION - LIQUID UNISTRIP - HIGH*** CONTROL LOW SOL *BLOOD GLUCOSE CALIBRATION - LIQUID UNISTRIP - LOW*** *BLOOD GLUCOSE CALIBRATION CONTROL SOL LIQ HI/MID/L LIQUID*** CONTROL SOL LIQ HIGH/ *BLOOD GLUCOSE CALIBRATION LOW LIQUID*** *BLOOD GLUCOSE CALIBRATION CONTROL SOL LIQ MID LIQUID*** CVS LANCETS MIS *LANCETS*** ORIGINAL CVS LANCETS MIS THIN 26G *LANCETS*** CVS LANCETS MIS THIN 33G *LANCETS*** CVS LANCING MIS DEVICE *LANCET DEVICES*** D-CARE GLUCO KIT TEST *BLOOD GLUCOSE MONITORING KIT W/ STR DEVICE*** *BLOOD GLUCOSE CALIBRATION - LIQUID EASYMAX SOL HIGH - HIGH*** *BLOOD GLUCOSE CALIBRATION - LIQUID EASYMAX SOL LOW - LOW*** *BLOOD GLUCOSE CALIBRATION EASYMAX SOL NORM/LOW LIQUID*** *BLOOD GLUCOSE CALIBRATION - LIQUID EASYMAX SOL NORMAL - NORMAL***
67
Tier Value Tier 3 Tier 3 Tier 1 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 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 2 Tier 2 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
DIABETIC SUPPLIES
EASYMAX 15 SOL LEVEL 1
DIABETIC SUPPLIES
EASYMAX 15 SOL LEVEL 2
DIABETIC SUPPLIES
EASYMAX 15 SOL LEVEL1-2
DIABETIC SUPPLIES
EASYMAX L KIT SYSTEM
DIABETIC SUPPLIES
EASYMAX L MIS SYSTEM
DIABETIC SUPPLIES
EASYMAX N KIT SYSTEM
DIABETIC SUPPLIES
EASYMAX N MIS SYSTEM
DIABETIC SUPPLIES
EASYMAX NG KIT SYSTEM
DIABETIC SUPPLIES
EASYMAX NG MIS SYSTEM
DIABETIC SUPPLIES
EASYMAX V KIT SYSTEM
DIABETIC SUPPLIES
EASYMAX V MIS SYSTEM
DIABETIC SUPPLIES
EASYMAX V2 KIT SYSTEM
DIABETIC SUPPLIES
EASYMAX V2 MIS SYSTEM
DIABETIC SUPPLIES
EASYPLS R13N KIT SYSTEM
DIABETIC SUPPLIES
EASYPLUS V KIT SYSTEM
DIABETIC SUPPLIES
EMBRACE MIS
DIABETIC SUPPLIES
EMBRACE SOL LOW
DIABETIC SUPPLIES
ENLITE MIS SERTER
DIABETIC SUPPLIES
ENLITE GLUCO MIS SENSOR
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
FASTCLIX MIS LANCETS FINGERSTIX MIS LANCETS FLEXLINK MIS PLS/10MM FLEXLINK MIS PLUS/6MM FLEXLINK MIS PLUS/8MM
DIABETIC SUPPLIES
FORA GD50 MIS MONITOR
DIABETIC SUPPLIES
FORA TEST N' MIS GO
DIABETIC SUPPLIES
FORTISCARE KIT SYSTEM
DIABETIC SUPPLIES
FORTISCARE SOL CNTL HI
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
FORTISCARE SOL CNTL LOW FORTISCARE SOL CNTL NML FREESTYLE MIS UNISTICK GENTLE-LET MIS 26G GENTLE-LET MIS 28G GENTLE-LET MIS LANCETS GENTLE-LET MIS PLATFORM GLUC CONTROL SOL LEVEL 1 GLUC CONTROL SOL LEVEL 2 GLUCOLET 2 MIS LANCING GLUCOSE CONT LIQ HIGH/ LOW GLUCOSE CONT SOL PRECISIO GMATE CONTRO SOL LEVEL 2 GMATE LANCET MIS 30G GMATE LANCIN MIS DEVICE GMATE ORIGIN MIS GLUC SYS GMATE SMART KIT METER
Generic Name *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE CALIBRATION - LIQUID - LOW*** *INSULIN INFUSION PUMP SUPPLIES*** *CONTINUOUS BLOOD GLUCOSE MONITOR SUPPLIES*** *LANCETS*** *LANCETS*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE CALIBRATION - LIQUID - HIGH*** *BLOOD GLUCOSE CALIBRATION - LIQUID - LOW*** *BLOOD GLUCOSE CALIBRATION - LIQUID - NORMAL*** *LANCETS*** *LANCETS*** *LANCETS*** *LANCETS*** *LANCETS MISC.*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *LANCET DEVICES*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *LANCETS*** *LANCET DEVICES*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING DEVICES***
68
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
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 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
X
X
Therapeutic Class
Label Name
DIABETIC SUPPLIES
GMATE SMART KIT STARTER
DIABETIC SUPPLIES
GMATE VOICE MIS GLUC SYS
DIABETIC SUPPLIES
GUARDIAN MIS TRANSMTR
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 DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
GUARDIAN RT MIS CHARGER GUARDIAN RT MIS SOFTWARE GUARDIAN RT MIS TST PLUG HAEMOLANCE MIS LOW FLOW HAEMOLANCE MIS RETRACT HUMAPEN MIS LUXURA
Generic Name *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *CONTINUOUS BLOOD GLUCOSE MONITOR SUPPLIES*** *CONTINUOUS BLOOD GLUCOSE MONITOR SUPPLIES*** *CONTINUOUS BLOOD GLUCOSE MONITOR SUPPLIES*** *CONTINUOUS BLOOD GLUCOSE MONITOR SUPPLIES*** *LANCETS*** *LANCETS***
INJECTION DEVICE FOR INSULIN *BLOOD GLUCOSE MONITORING IN TOUCH MIS MISC.*** INFUSION SET MIS 23" *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 23" 6MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 23" 8MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 23" 9MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 23"/6MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 23"/9MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 24" *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 24" 6MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 24" 9MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 31" *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 31" 6MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 31" 9MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 32" 8MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 42" 6MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 42" 9MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 43" *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 43" 6MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 43" 8MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 43" 9MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 43"/6MM *INSULIN INFUSION PUMP SUPPLIES*** INFUSION SET MIS 43"/9MM *INSULIN INFUSION PUMP SUPPLIES*** *BLOOD GLUCOSE MONITORING KIT W/ KROGER BGM KIT DEVICE*** LANCET ALTER MIS SITE *LANCETS*** 26G LANCET CARRY MIS CASE *LANCETS MISC.*** LANCET SUPER MIS THIN *LANCETS*** 30G LANCET ULTRA MIS 28G *LANCETS*** LANCET ULTRA MIS THIN *LANCETS*** 28G LANCETS MIS 23G *LANCETS*** LANCETS MIS 28G *LANCETS*** LANCETS MICR MIS THIN *LANCETS*** 33G LANCETS THIN MIS *LANCETS*** LANCETS ULTR MIS THIN *LANCETS*** 28G LANCETS ULTR MIS THIN *LANCETS*** 30G LANCING DEVI MIS *LANCET DEVICES*** LB LANCET MIS 28G *LANCETS*** LB LANCING MIS DEVICE *LANCET DEVICES*** LIFESCAN MIS UNISTIK2 *LANCETS*** *INSULIN INFUSION PUMP LINK ASSIST MIS ACCU-CHK ACCESSORIES*** *BLOOD GLUCOSE CALIBRATION MEDISENSE LIQ GLUC/KET LIQUID*** *BLOOD GLUCOSE CALIBRATION MEDISENSE LIQ GLUC-KET LIQUID*** MEIJER MIS LANCETS *LANCETS*** MICROLET MIS LANCETS *LANCETS*** MICROLET MIS NEXT *LANCET DEVICES*** MINI LANCING MIS DEVICE *LANCET DEVICES*** *INSULIN INFUSION PUMP MINILINK RT KIT REPLACE ACCESSORIES***
69
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 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 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 3 Tier 3 Tier 1 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
X
Therapeutic Class
Label Name
DIABETIC SUPPLIES
MINILINK RT KIT STARTER
DIABETIC SUPPLIES
MINILINK RT MIS TRANSMIT
DIABETIC SUPPLIES DIABETIC SUPPLIES
MINIMED PUMP MIS RES 3ML 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
DIABETIC SUPPLIES
ON CALL EXPR KIT SYSTEM
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
DIABETIC SUPPLIES
ON CALL EXPR MIS METER
DIABETIC SUPPLIES
ON CALL EXPR SOL GLUCOSE ON CALL LANC MIS DEVICE
DIABETIC SUPPLIES
ON CALL PLUS KIT METER
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
ON CALL PLUS KIT MONITOR ON CALL PLUS MIS LANC DEV ON CALL PLUS MIS LANCETS
Generic Name *INSULIN INFUSION PUMP ACCESSORIES*** *INSULIN INFUSION PUMP ACCESSORIES***
Tier Value Tier 3 Tier 3
*INSULIN INFUSION PUMP SUPPLIES***
Tier 2
*INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *BLOOD GLUCOSE CALIBRATION LIQUID*** INJECTION DEVICE FOR INSULIN *LANCETS*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *LANCET DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE***
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
*LANCET DEVICES***
Tier 3
*LANCETS***
Tier 3
*BLOOD GLUCOSE MONITORING ON CALL PLUS MIS METER DEVICES*** ON CALL PLUS SOL *BLOOD GLUCOSE CALIBRATION CONTROL LIQUID*** *BLOOD GLUCOSE MONITORING KIT W/ ON CALL VIVD KIT METER DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ ON CALL VIVD KIT MONITOR DEVICE*** *BLOOD GLUCOSE MONITORING ON CALL VIVD MIS METER DEVICES*** ON CALL VIVD SOL *BLOOD GLUCOSE CALIBRATION CONTROL LIQUID*** *BLOOD GLUCOSE MONITORING KIT W/ ONETOUCH KIT ULT MINI DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ ONETOUCH KIT ULTRA 2 DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ ONETOUCH KIT ULTRALNK DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ ONETOUCH KIT VERIO DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ ONETOUCH KIT VERIO IQ DEVICE*** ONETOUCH MIS 30G *LANCETS*** ONETOUCH MIS COMBO *LANCETS*** ONETOUCH MIS LANC DEV *LANCETS MISC.*** ONETOUCH MIS LANC DEV *LANCET DEVICES*** ONETOUCH MIS LANCETS *LANCETS*** *BLOOD GLUCOSE MONITORING ONETOUCH MIS REMOTE SUPPLIES*** *BLOOD GLUCOSE CALIBRATION ONETOUCH SOL ULT CONT LIQUID*** *BLOOD GLUCOSE CALIBRATION ONETOUCH SOL VERIO LIQUID*** *BLOOD GLUCOSE CALIBRATION - LIQUID ONETOUCH SOL VERIO-HI - HIGH*** ONETOUCH FP MIS *LANCETS*** LANCETS ONETOUCH US MIS *LANCETS*** LANCETS *BLOOD GLUCOSE MONITORING KIT W/ ONETOUCH VER KIT SYNC DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ OPTIUM KIT BL GLUC DEVICE*** *BLOOD GLUCOSE MONITORING OPTIUM MIS SYSTEM DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ OPTUMRX KIT METER DEVICE***
70
Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
DIABETIC SUPPLIES
OPTUMRX KIT SYSTEM
DIABETIC SUPPLIES
OPTUMRX CONT SOL LEVEL1/2
DIABETIC SUPPLIES
PARADIGM MIS UPGRADE
DIABETIC SUPPLIES DIABETIC SUPPLIES
PARADIGM QR MIS POLY 24" PARADIGM QR MIS POLY 42" PARADIGM REA MIS TRANSMIT PARADIGM RES MIS 1.8ML PARADIGM RES MIS 3ML PARADIGM SOF MIS -SET 24" PARADIGM SOF MIS -SET 42" 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
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
PRECISION KIT LINK
DIABETIC SUPPLIES
PRECISION KIT XTRA
DIABETIC SUPPLIES
PRECISION KIT XTRA
DIABETIC SUPPLIES
PRECISION LIQ CONTROL
DIABETIC SUPPLIES
PRECISION LIQ GLUC/KET
DIABETIC SUPPLIES
PRECISION LIQ NRML/MID
DIABETIC SUPPLIES
PRECISION MIS QID
DIABETIC SUPPLIES
PRECISION MIS SOF-TACT
DIABETIC SUPPLIES
PRECISION MIS XTRA
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
PSS SAFE LAN MIS PSS SEL LANC MIS PSS SEL PLAT MIS PUMP REMOTE MIS PROGRAM PX LANCETS MIS ULT THIN 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
DIABETIC SUPPLIES
QUINTET MIS SYSTEM
DIABETIC SUPPLIES
DIABETIC SUPPLIES
QUINTET AC MIS SYSTEM
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
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
DIABETIC SUPPLIES
RA GLUCOSE MIS MONITOR
DIABETIC SUPPLIES
RA TRUE2GO KIT
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
RAPID-D INF MIS 24"/10MM RAPID-D INF MIS 24"/6MM RAPID-D INF MIS 24"/8MM RAPID-D INF MIS 31"/10MM
DIABETIC SUPPLIES
Generic Name *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *INSULIN INFUSION PUMP ACCESSORIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP ACCESSORIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *LANCETS KIT*** *LANCETS MISC.*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING KIT*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING DEVICES*** *LANCETS*** *LANCETS*** *LANCETS MISC.*** *INSULIN INFUSION PUMP ACCESSORIES*** *LANCETS*** *LANCETS*** *LANCETS*** *LANCET DEVICES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE CALIBRATION LIQUID*** *LANCETS*** *LANCETS*** *LANCETS*** *LANCETS*** *LANCETS*** *BLOOD GLUCOSE MONITORING DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES***
71
Tier Value Tier 3 Tier 2 Tier 3 Tier 2 Tier 2 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 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 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
RAPID-D INF MIS 31"/6MM RAPID-D INF MIS 31"/8MM RAPID-D INF MIS 43"/10MM RAPID-D INF MIS 43"/6MM RAPID-D INF MIS 43"/8MM RAPID-D LINK MIS TRANSFER RELION LANCE MIS THIN 26G RELION LANCE MIS THIN 30G
*INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES***
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2
*INSULIN INFUSION PUMP SUPPLIES***
Tier 2
*LANCETS***
Tier 3
*LANCETS***
Tier 3
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
RELION ULTIM KIT SYSTEM
DIABETIC SUPPLIES
REVEAL KIT MONITOR
DIABETIC SUPPLIES
RIGHTSOURCE MIS METER
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
SAFE-T-LANCE MIS 21G SAFE-T-LANCE MIS 25G SAFE-T-LANCE MIS HI FLOW SAFE-T-LANCE MIS LOW FLOW SAFE-T-LANCE MIS NOR FLOW 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 SILHOUETTE MIS 23" SET SILHOUETTE MIS 32"/13MM SILHOUETTE MIS 32"/17MM SILHOUETTE MIS 43" SET SILHOUETTE MIS COMBO SILHOUETTE MIS FULL SET SIL-SERTER MIS INS DEV SINGLE-LET MIS 23G
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
Tier Value
*BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** *BLOOD GLUCOSE MONITORING DEVICES*** *LANCETS*** *LANCETS*** *LANCETS***
Tier 3 Tier 3 Tier 3
*LANCETS***
Tier 3
*LANCETS***
Tier 3
*LANCETS*** *LANCETS*** *LANCETS KIT*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *INSULIN INFUSION PUMP SUPPLIES*** *LANCETS*** *CONTINUOUS BLOOD GLUCOSE SOF-SENSOR MIS MONITOR SUPPLIES*** SOF-SERTER MIS INS DEV *INSULIN INFUSION PUMP SUPPLIES*** SOF-SET 24" KIT INFUSION *INSULIN INFUSION PUMP SUPPLIES*** SOF-SET 24" KIT MICRO QR *INSULIN INFUSION PUMP SUPPLIES*** SOF-SET 24" KIT ULTIM QR *INSULIN INFUSION PUMP SUPPLIES*** SOF-SET 42" KIT INFUSION *INSULIN INFUSION PUMP SUPPLIES*** SOF-SET 42" KIT MICRO QR *INSULIN INFUSION PUMP SUPPLIES*** SOF-SET 42" KIT ULTIM QR *INSULIN INFUSION PUMP SUPPLIES*** SOFT TOUCH MIS LANCETS *LANCETS*** SOFTCLIX MIS LANCETS *LANCETS*** SUPER THIN MIS LANCETS *LANCETS*** *BLOOD GLUCOSE CALIBRATION SUPREME II LIQ HIGH/LOW LIQUID*** *BLOOD GLUCOSE CALIBRATION SURESTEP SOL CONTROL LIQUID*** *BLOOD GLUCOSE CALIBRATION SURESTEP GLU SOL LIQUID*** SURESTEP GLU SOL HIGH/ *BLOOD GLUCOSE CALIBRATION LOW LIQUID*** SURESTEP PRO KIT *BLOOD GLUCOSE MONITORING LINEARIT MISC.*** SURESTEP PRO TES HIGH *BLOOD GLUCOSE CALIBRATION - LIQUID CON - HIGH*** SURESTEP PRO TES LOW *BLOOD GLUCOSE CALIBRATION - LIQUID CON - LOW*** SURESTEP PRO TES NORM *BLOOD GLUCOSE CALIBRATION - LIQUID CON - NORMAL*** SURE-T MIS 23"/6MM *INSULIN INFUSION PUMP SUPPLIES*** SURE-T MIS 23"/8MM *INSULIN INFUSION PUMP SUPPLIES*** T:30 INFUSIO MIS SET *INSULIN INFUSION PUMP SUPPLIES*** T:FLEX 4.8ML MIS *INSULIN INFUSION PUMP SUPPLIES*** CARTRDGE T:SLIM 3ML MIS CARTRDGE *INSULIN INFUSION PUMP SUPPLIES*** T:SLIM G4 MIS CARTRDGE *INSULIN INFUSION PUMP SUPPLIES*** TECHLITE MIS LANCETS *LANCETS***
72
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 3
Tier 1 Tier 1 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 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
X
X
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 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
Label Name
Generic Name
*CONTINUOUS BLOOD GLUCOSE MONITOR SUPPLIES*** TGT LANCET MIS 23G *LANCETS*** TGT LANCET MIS 28G *LANCETS*** TGT LANCET MIS 30G *LANCETS*** TGT LANCET MIS ALTERNAT *LANCETS*** TGT LANCING MIS ADV DEV *LANCET DEVICES*** TGT LANCING MIS DEVICE *LANCET DEVICES*** THIN LANCETS MIS *LANCETS*** THINLETS GP MIS 26G *LANCETS*** *CONTINUOUS BLOOD GLUCOSE TRANSMITTER MIS TAPE MONITOR SUPPLIES*** *BLOOD GLUCOSE MONITORING KIT W/ TRUE METRIX KIT AIR DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ TRUE METRIX KIT METER DEVICE*** *BLOOD GLUCOSE MONITORING TRUE METRIX MIS AIR DEVICES*** *BLOOD GLUCOSE CALIBRATION - LIQUID TRUE METRIX SOL LEVEL 1 - LOW*** *BLOOD GLUCOSE CALIBRATION - LIQUID TRUE METRIX SOL LEVEL 2 - NORMAL*** *BLOOD GLUCOSE CALIBRATION - LIQUID TRUE METRIX SOL LEVEL 3 - HIGH*** *BLOOD GLUCOSE MONITORING KIT W/ TRUE2GO KIT DEVICE*** *BLOOD GLUCOSE CALIBRATION TRUECONTROL LIQ LEVEL 0 LIQUID*** *BLOOD GLUCOSE CALIBRATION TRUECONTROL LIQ LEVEL 1 LIQUID*** TRUEDRAW MIS LANC DEV *LANCET DEVICES*** *BLOOD GLUCOSE MONITORING KIT W/ TRUERESULT KIT DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ TRUERESULT KIT MONITOR DEVICE*** *BLOOD GLUCOSE CALIBRATION TRUETEST LIQ LEVEL 1 LIQUID*** *BLOOD GLUCOSE CALIBRATION TRUETEST LIQ LEVEL 2 LIQUID*** *BLOOD GLUCOSE CALIBRATION TRUETEST LIQ LEVEL 3 LIQUID*** *BLOOD GLUCOSE MONITORING KIT W/ TRUETRACK KIT SYSTEM DEVICE*** *BLOOD GLUCOSE MONITORING TRUETRACK MIS BLD GLC DEVICES*** TRUPLUS LANC MIS 26G *LANCETS*** TRUPLUS LANC MIS 28G *LANCETS*** TRUPLUS LANC MIS 30G *LANCETS*** TRUPLUS LANC MIS 33G *LANCETS*** *BLOOD GLUCOSE MONITORING ULTILET OPER MIS DEVICE DEVICES**** ULTIMA KIT MONITOR *BLOOD GLUCOSE MONITORING KIT*** ULTRA THIN MIS LANC 26G *LANCETS*** ULTRA THIN MIS LANC 28G *LANCETS*** ULTRA THIN MIS LANC 30G *LANCETS*** ULTRA THIN MIS LANCETS *LANCETS*** ULTRAFLEX MIS 12"/6MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 24"/10MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 24"/6MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 24"/8MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 31"/10MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 31"/6MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 31"/8MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 43"/10MM *INSULIN INFUSION PUMP SUPPLIES*** ULTRAFLEX MIS 43"/8MM *INSULIN INFUSION PUMP SUPPLIES*** UNILET EX II MIS 28G *LANCETS*** UNILET EXCEL MIS 23G *LANCETS*** UNILET G.P MIS SUPR 23G *LANCETS*** UNILET G.P. MIS 21G *LANCETS*** UNILET LANCT MIS 30G *LANCETS*** UNILET LANCT MIS 33G *LANCETS*** UNILET SUPER MIS 23G *LANCETS*** UNISTIK 1 MIS 2.4MM *LANCETS MISC.*** UNISTIK 1 MIS 3.0MM *LANCETS MISC.*** UNISTIK 2 MIS 1.8MM *LANCETS MISC.*** TEST PLUG MIS
73
Tier Value 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 2 Tier 3 Tier 2 Tier 2 Tier 3 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
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES
UNISTIK 2 MIS 2.4MM UNISTIK 2 MIS EXTRA UNISTIK 2 MIS SUPER UNISTIK 3 MIS 1.8MM UNISTIK II MIS LANCETS
DIABETIC SUPPLIES DIABETIC SUPPLIES DIABETIC SUPPLIES DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS ADRENOCORTICAL INSUFFICIENCY DIAGNOSTIC AGENTS ADRENOCORTICAL INSUFFICIENCY DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - OCULAR DISORDERS DIAGNOSTIC AGENTS - PITUITARY FUNCTION DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY
Generic Name
Tier Value
*LANCETS MISC.*** *LANCETS MISC.*** *LANCETS MISC.*** *LANCETS MISC.*** *LANCETS*** *BLOOD GLUCOSE MONITORING KIT W/ VERIO FLEX KIT ONETOUCH DEVICE*** *BLOOD GLUCOSE MONITORING KIT W/ VIVID PAL KIT METER DEVICE*** *BLOOD GLUCOSE MONITORING VIVID PAL MIS METER DEVICES*** 12-PANEL POC KIT *DRUG ASSAY (URINE) TEST KIT** TOXICOLO ADVANCED DNA KIT *DNA COLLECTION PRODUCT KIT** COLLECTI *URINE GLUCOSE-KETONES TEST CHEMSTRIP TES UGK STRIPS*** CHEMSTRIP K TES ACETONE (URINE) TEST STRIP *URINE GLUCOSE-KETONES TEST CVS KETONE TES CARE STRIPS*** DNA COLLECT KIT *DNA COLLECTION PRODUCT KIT** DNA COLLECT KIT *DNA COLLECTION PRODUCT KIT** MEDICATE DYNAMIC KIT *DNA COLLECTION PRODUCT KIT** DYNAMIC PLUS KIT PAK *DNA COLLECTION PRODUCT KIT** FLUOREXON-BENOXINATE OPHTH SOLN FLURA-SAFE SOL 0.35-0.4% KETOCARE TES ACETONE (URINE) TEST STRIP *URINE GLUCOSE-KETONES TEST KETO-DIASTIX TES STRIPS*** KETOSTIX TES STRIP ACETONE (URINE) TEST STRIP MEDCATED DNA KIT *DNA COLLECTION PRODUCT KIT** COLLECT MULTI-DRUG KIT DIUSCREE *DRUG ASSAY (URINE) TEST KIT** ORAGENOMIC KIT *DNA COLLECTION PRODUCT KIT** MEDICATE PRECISN XTRA TES KETONE KETONE BLOOD TEST STRIP PRO DNA KIT KIT *DNA COLLECTION PRODUCT KIT** RELION KETON TES ACETONE (URINE) TEST STRIP T.R.U.E. TES DERMATITIS ANTIGENS TEST TOXICOLOGY KIT MEDICATE *DRUG ASSAY (URINE) TEST KIT**
Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
CORTROSYN INJ 0.25MG
COSYNTROPIN FOR INJ 0.25 MG
Tier 3
COSYNTROPIN INJ 0.25MG
COSYNTROPIN FOR INJ 0.25 MG
Tier 1
ALTAFLUOR SOL 0.25-0.4 BIO GLO TES 1MG OP FLUCAINE SOL 0.25-0.5 FLUORE-BENOX SOL 0.250.4 FLUORESCEIN/ SOL PROPARAC FLUOR-I-STRI TES 1MG OP FLUROX SOL OP FUL-GLO TES 0.6MG OP FUL-GLO TES 1MG OP
FLUORESCEIN W/ BENOXINATE OPHTH SOLN 0.25-0.4% FLUORESCEIN SODIUM OPHTH STRIPS 1 MG FLUORESCEIN W/ PROPARACAINE OPHTH SOLN 0.25-0.5% FLUORESCEIN W/ BENOXINATE OPHTH SOLN 0.25-0.4% FLUORESCEIN W/ PROPARACAINE OPHTH SOLN 0.25-0.5% FLUORESCEIN SODIUM OPHTH STRIPS 1 MG FLUORESCEIN W/ BENOXINATE OPHTH SOLN 0.25-0.4% FLUORESCEIN SODIUM OPHTH STRIPS 0.6 MG FLUORESCEIN SODIUM OPHTH STRIPS 1 MG
Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 2 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1
GREEN GLO MIS 1.5MG
LISSAMINE GREEN STRIPS 1.5 MG
Tier 1
LISSAMINE GR TES 1.5MG
LISSAMINE GREEN STRIPS 1.5 MG
Tier 1
ROSE GLO TES 1.5MG
ROSE BENGAL STRIPS 1.5 MG
Tier 3
METOPIRONE CAP 250MG
METYRAPONE CAP 250 MG
Tier 2
ENTERO VU SUS 24%
BARIUM SULFATE SUSP 24%
Tier 3
E-Z-CAT DRY PAK
BARIUM SULFATE FOR SUSP PACKET 2%
Tier 3
E-Z-DISK TAB 700MG
BARIUM SULFATE TAB 700 MG
Tier 3
74
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DIAGNOSTIC AGENTS ROENTGENOGRAPHY DISINFECTANTS (FOR NONDERMATOLOGIC 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 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 Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs
Label Name
Generic Name
E-Z-DOSE ENE
BARIUM SULFATE ENEMA 105%
Tier 2
E-Z-HD SUS 98%
BARIUM SULFATE FOR SUSP 98%
Tier 3
E-Z-PAQUE SUS 60%
BARIUM SULFATE SUSP 60%
Tier 2
E-Z-PAQUE SUS 96%
BARIUM SULFATE FOR SUSP 96%
Tier 2
E-Z-PASTE CRE 60%
BARIUM SULFATE ORAL CREAM 60%
Tier 2
GASTROGRAFIN SOL 6610%
DIATRIZOATE MEGLUMINE & SODIUM ORAL SOLN 66-10% DIATRIZOATE MEGLUMINE & SODIUM MD-GASTROVIE SOL 66-10% ORAL SOLN 66-10% BARIUM SULFATE ORAL/RECTAL SUSP POLIBAR PLUS SUS 105% 105% BARIUM SULFATE ORAL/RECTAL SUSP READI-CAT 2 SUS 2.1% 2.1%
Tier Value
Tier 3 Tier 1 Tier 2 Tier 2
READI-CAT 2 SUS BANANA
BARIUM SULFATE SUSP 2%
Tier 2
READI-CAT 2 SUS BERRY
BARIUM SULFATE SUSP 2.1%
Tier 2
READI-CAT 2 SUS MOCHACCI
BARIUM SULFATE SUSP 2.1%
Tier 2
TAGITOL V SUS 40%
BARIUM SULFATE SUSP 40%
Tier 2
VARIBAR PST PUDDING
BARIUM SULFATE ORAL PASTE 40%
Tier 3
VARIBAR HONE SUS 40%
BARIUM SULFATE SUSP 40%
Tier 3
VARIBAR NECT SUS 40%
BARIUM SULFATE SUSP 40%
Tier 3
VARIBAR THIN SUS HONEY
BARIUM SULFATE SUSP 40%
Tier 3
VARIBAR THIN SUS LIQUID
BARIUM SULFATE FOR SUSP 40%
Tier 3
VOLUMEN SUS 0.1%
BARIUM SULFATE SUSP 0.1%
Tier 2
GLUTARALDEHY SOL 25%
GLUTARAL SOLN 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 10MG DEMADEX TAB 20MG DEMADEX TAB 5MG EDECRIN TAB 25MG ETHACRYNIC TAB ACD 25MG ETHACRYNIC TAB ACID 25 FUROSEMIDE SOL 10MG/ML FUROSEMIDE SOL 8MG/ML FUROSEMIDE TAB 20MG FUROSEMIDE TAB 40MG FUROSEMIDE TAB 80MG LASIX TAB 20MG LASIX TAB 40MG LASIX TAB 80MG TORSEMIDE TAB 100MG TORSEMIDE TAB 10MG TORSEMIDE TAB 20MG TORSEMIDE TAB 5MG
BUMETANIDE TAB 0.5 MG BUMETANIDE TAB 1 MG BUMETANIDE TAB 2 MG BUMETANIDE TAB 0.5 MG BUMETANIDE TAB 1 MG BUMETANIDE TAB 2 MG TORSEMIDE TAB 10 MG TORSEMIDE TAB 20 MG TORSEMIDE TAB 5 MG ETHACRYNIC ACID TAB 25 MG
Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
ETHACRYNIC ACID TAB 25 MG
Tier 3
ETHACRYNIC ACID TAB 25 MG FUROSEMIDE ORAL SOLN 10 MG/ML FUROSEMIDE ORAL SOLN 8 MG/ML FUROSEMIDE TAB 20 MG FUROSEMIDE TAB 40 MG FUROSEMIDE TAB 80 MG FUROSEMIDE TAB 20 MG FUROSEMIDE TAB 40 MG FUROSEMIDE TAB 80 MG TORSEMIDE TAB 100 MG TORSEMIDE TAB 10 MG TORSEMIDE TAB 20 MG TORSEMIDE TAB 5 MG SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 50-50 MG
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
ALDACTONE TAB 100MG
SPIRONOLACTONE TAB 100 MG
Tier 3
ALDACTONE TAB 25MG
SPIRONOLACTONE TAB 25 MG
Tier 3
ALDACTONE TAB 50MG
SPIRONOLACTONE TAB 50 MG
Tier 3
ALDACTAZIDE TAB 25/25 ALDACTAZIDE TAB 50/50
75
Tier 3 Tier 2
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - Cardiac Drugs Diuretics, Potassium-sparing - 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 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
Label Name
Generic Name
AMILOR/HCTZ TAB 5-50
AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG
Tier 1
AMILORIDE TAB 5MG
AMILORIDE HCL TAB 5 MG
Tier 1
DYAZIDE CAP 37.5-25
TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG
Tier 3
DYRENIUM CAP 100MG
TRIAMTERENE CAP 100 MG
Tier 3
DYRENIUM CAP 50MG
TRIAMTERENE CAP 50 MG
Tier 3
EPLERENONE TAB 25MG
EPLERENONE TAB 25 MG
Tier 2
EPLERENONE TAB 50MG
EPLERENONE TAB 50 MG
Tier 2
INSPRA TAB 25MG
EPLERENONE TAB 25 MG
Tier 3
EPLERENONE TAB 50 MG
Tier 3
INSPRA TAB 50MG MAXZIDE TAB 75-50 MAXZIDE-25 TAB SPIRONO/HCTZ TAB 25/25
TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG
Tier Value
Tier 3 Tier 3 Tier 1
SPIRONOLACT TAB 100MG
SPIRONOLACTONE TAB 100 MG
Tier 1
SPIRONOLACT TAB 25MG
SPIRONOLACTONE TAB 25 MG
Tier 1
SPIRONOLACT TAB 50MG
SPIRONOLACTONE TAB 50 MG
Tier 1
TRIAMTERENE & TRIAMT/HCTZ CAP 37.5-25 HYDROCHLOROTHIAZIDE CAP 37.5-25 MG TRIAMTERENE & TRIAMT/HCTZ CAP 50-25MG HYDROCHLOROTHIAZIDE CAP 50-25 MG TRIAMTERENE & TRIAMT/HCTZ TAB 37.5-25 HYDROCHLOROTHIAZIDE TAB 37.5-25 MG TRIAMTERENE & TRIAMT/HCTZ TAB 75-50MG HYDROCHLOROTHIAZIDE TAB 75-50 MG CHLOROTHIAZ TAB 250MG CHLOROTHIAZIDE TAB 250 MG CHLOROTHIAZ TAB 500MG CHLOROTHIAZIDE TAB 500 MG CHLORTHALID TAB 25MG CHLORTHALIDONE TAB 25 MG CHLORTHALID TAB 50MG CHLORTHALIDONE TAB 50 MG DIURIL SUS 250/5ML CHLOROTHIAZIDE SUSP 250 MG/5ML EZIDE TAB 50MG HYDROCHLOROTHIAZIDE TAB 50 MG HYDROCHLOROT CAP HYDROCHLOROTHIAZIDE CAP 12.5 MG 12.5MG HYDROCHLOROT TAB HYDROCHLOROTHIAZIDE TAB 12.5 MG 12.5MG HYDROCHLOROT TAB 25MG HYDROCHLOROTHIAZIDE TAB 25 MG HYDROCHLOROT TAB 50MG HYDROCHLOROTHIAZIDE TAB 50 MG INDAPAMIDE TAB 1.25MG INDAPAMIDE TAB 1.25 MG INDAPAMIDE TAB 2.5MG INDAPAMIDE TAB 2.5 MG METHYCLOTHIA TAB 5MG METHYCLOTHIAZIDE TAB 5 MG METOLAZONE TAB 10MG METOLAZONE TAB 10 MG METOLAZONE TAB 2.5MG METOLAZONE TAB 2.5 MG METOLAZONE TAB 5MG METOLAZONE TAB 5 MG MICROZIDE CAP 12.5MG HYDROCHLOROTHIAZIDE CAP 12.5 MG APOMORPHINE HCL SOLN CARTRIDGE APOKYN INJ 10MG/ML 30 MG/3ML BROMOCRIPTINE MESYLATE CAP 5 MG BROMOCRIPTIN CAP 5MG (BASE EQUIVALENT) BROMOCRIPTINE MESYLATE TAB 2.5 MG BROMOCRIPTIN TAB 2.5MG (BASE EQUIVALENT) PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.125MG 0.125 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.25MG 0.25 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.5MG 0.5 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 0.75MG 0.75 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 1.5MG 1.5 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB MIRAPEX TAB 1MG 1 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB PRAMIPEXOLE TAB 0.125MG 0.125 MG
76
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 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 2 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
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 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
Label Name PRAMIPEXOLE TAB 0.25MG PRAMIPEXOLE TAB 0.5MG PRAMIPEXOLE TAB 0.75MG PRAMIPEXOLE TAB 1.5MG PRAMIPEXOLE TAB 1MG REQUIP TAB 0.25MG REQUIP TAB 0.5MG
Generic Name PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG ROPINIROLE HYDROCHLORIDE TAB 0.25 MG ROPINIROLE HYDROCHLORIDE TAB 0.5 MG
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3
REQUIP TAB 1MG
ROPINIROLE HYDROCHLORIDE TAB 1 MG
Tier 3
REQUIP TAB 2MG
ROPINIROLE HYDROCHLORIDE TAB 2 MG
Tier 3
REQUIP TAB 3MG
ROPINIROLE HYDROCHLORIDE TAB 3 MG
Tier 3
REQUIP TAB 4MG
ROPINIROLE HYDROCHLORIDE TAB 4 MG
Tier 3
ROPINIROLE HYDROCHLORIDE TAB 5 MG
Tier 3
REQUIP TAB 5MG ROPINIROLE TAB 0.25MG ROPINIROLE TAB 0.5MG
ROPINIROLE HYDROCHLORIDE TAB 0.25 MG ROPINIROLE HYDROCHLORIDE TAB 0.5 MG
Tier 1 Tier 1
ROPINIROLE TAB 1MG
ROPINIROLE HYDROCHLORIDE TAB 1 MG
Tier 1
ROPINIROLE TAB 2MG
ROPINIROLE HYDROCHLORIDE TAB 2 MG
Tier 1
ROPINIROLE TAB 3MG
ROPINIROLE HYDROCHLORIDE TAB 3 MG
Tier 1
ROPINIROLE TAB 4MG
ROPINIROLE HYDROCHLORIDE TAB 4 MG
Tier 1
ROPINIROLE TAB 5MG
ROPINIROLE HYDROCHLORIDE TAB 5 MG
Tier 1
CARB/LEVO TAB 10-100MG
CARBIDOPA & LEVODOPA TAB 10-100 MG
Tier 1
CARB/LEVO TAB 10-100MG
CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 10-100 MG
Tier 1
CARB/LEVO TAB 25-100MG
CARBIDOPA & LEVODOPA TAB 25-100 MG
Tier 1
CARB/LEVO TAB 25-100MG
CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-100 MG
Tier 1
CARB/LEVO TAB 25-250MG
CARBIDOPA & LEVODOPA TAB 25-250 MG
Tier 1
CARB/LEVO TAB 25-250MG
CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-250 MG
Tier 1
CARB/LEVO 50 TAB / ENTACAP
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG
Tier 1
CARB/LEVO 75 TAB / ENTACAP
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG
Tier 1
CARB/LEVO ER TAB 25100MG
CARBIDOPA & LEVODOPA TAB CR 25-100 MG
Tier 1
CARB/LEVO ER TAB 50200MG
CARBIDOPA & LEVODOPA TAB CR 50-200 MG
Tier 1
CARB/LEVO100 TAB / ENTACAP
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG
Tier 1
CARB/LEVO125 TAB / ENTACAP
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG
Tier 1
CARB/LEVO150 TAB / ENTACAP
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG
Tier 1
77
Prior Supply Step Specialty Authorization Limit Therapy
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 Dyslipidemics - 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, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs
Label Name
Generic Name
CARB/LEVO200 TAB / ENTACAP
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG
Tier 1
CARBIDOPA TAB 25MG
CARBIDOPA TAB 25 MG
Tier 1
DUOPA SUS 4.63-20
CARBIDOPA-LEVODOPA ENTERAL SUSP 4.63-20 MG/ML
Tier 3
SINEMET TAB 10-100MG
CARBIDOPA & LEVODOPA TAB 10-100 MG
Tier 3
SINEMET TAB 25-100MG
CARBIDOPA & LEVODOPA TAB 25-100 MG
Tier 3
SINEMET TAB 25-250MG
CARBIDOPA & LEVODOPA TAB 25-250 MG
Tier 3
SINEMET CR TAB 25-100MG
CARBIDOPA & LEVODOPA TAB CR 25-100 MG
Tier 3
SINEMET CR TAB 50-200MG
CARBIDOPA & LEVODOPA TAB CR 50-200 MG
Tier 3
STALEVO 100 TAB
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG
Tier 3
STALEVO 125 TAB
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG
Tier 3
STALEVO 150 TAB
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG
Tier 3
STALEVO 200 TAB
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG
Tier 3
STALEVO 50 TAB
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG
Tier 3
STALEVO 75 TAB
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG
Tier 3
NIACIN POW USP/NF
*NIACIN ORAL POWDER***
Tier 3
FENOFIBRATE TAB 160MG
FENOFIBRATE TAB 160 MG
Tier 2
FENOFIBRATE TAB 54MG
FENOFIBRATE TAB 54 MG
Tier 2
GEMFIBROZIL TAB 600MG
GEMFIBROZIL TAB 600 MG
Tier 1
LOPID TAB 600MG
GEMFIBROZIL TAB 600 MG
Tier 3
ADVICOR TAB 1000-20 ADVICOR TAB 1000-40 ADVICOR TAB 500-20MG ADVICOR TAB 750-20MG ATORVASTATIN TAB 10MG ATORVASTATIN TAB 20MG ATORVASTATIN TAB 40MG ATORVASTATIN TAB 80MG
NIACIN-LOVASTATIN TAB SR 24HR 100020 MG NIACIN-LOVASTATIN TAB SR 24HR 100040 MG NIACIN-LOVASTATIN TAB SR 24HR 500-20 MG NIACIN-LOVASTATIN TAB SR 24HR 750-20 MG ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT) ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT) ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
FLUVASTATIN CAP 20MG
FLUVASTATIN SODIUM CAP 20 MG
Tier 1
X
FLUVASTATIN CAP 40MG
FLUVASTATIN SODIUM CAP 40 MG
Tier 1
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
FLUVASTATIN TAB 80MG ER LIVALO TAB 1MG LIVALO TAB 2MG
FLUVASTATIN SODIUM TAB SR 24 HR 80 MG PITAVASTATIN CALCIUM TAB 1 MG (BASE EQUIV) PITAVASTATIN CALCIUM TAB 2 MG (BASE EQUIV)
78
Therapeutic Class Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs Dyslipidemics, HMG CoA Reductase Inhibitors - 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
Generic Name
LIVALO TAB 4MG
PITAVASTATIN CALCIUM TAB 4 MG (BASE EQUIV)
Tier 3
LOVASTATIN TAB 10MG
LOVASTATIN TAB 10 MG
Tier 1
LOVASTATIN TAB 20MG
LOVASTATIN TAB 20 MG
Tier 1
LOVASTATIN TAB 40MG
LOVASTATIN TAB 40 MG
Tier 1
LOVASTATIN TAB 40MG
LOVASTATIN TAB 40 MG
Tier 1
MEVACOR TAB 40MG
LOVASTATIN TAB 40 MG
Tier 3
PRAVACHOL TAB 20MG
PRAVASTATIN SODIUM TAB 20 MG
Tier 3
PRAVACHOL TAB 40MG
PRAVASTATIN SODIUM TAB 40 MG
Tier 3
PRAVACHOL TAB 80MG
PRAVASTATIN SODIUM TAB 80 MG
Tier 3
PRAVASTATIN TAB 10MG
PRAVASTATIN SODIUM TAB 10 MG
Tier 1
PRAVASTATIN TAB 20MG
PRAVASTATIN SODIUM TAB 20 MG
Tier 1
PRAVASTATIN TAB 40MG
PRAVASTATIN SODIUM TAB 40 MG
Tier 1
PRAVASTATIN TAB 80MG
PRAVASTATIN SODIUM TAB 80 MG
Tier 1
ROSUVASTATIN TAB 10MG
ROSUVASTATIN CALCIUM TAB 10 MG
Tier 2
X
ROSUVASTATIN TAB 20MG
ROSUVASTATIN CALCIUM TAB 20 MG
Tier 2
X
ROSUVASTATIN TAB 40MG
ROSUVASTATIN CALCIUM TAB 40 MG
Tier 2
X
ROSUVASTATIN TAB 5MG
ROSUVASTATIN CALCIUM TAB 5 MG
Tier 2
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
SIMCOR TAB 1000-20 SIMCOR TAB 1000-40 SIMCOR TAB 500-20MG SIMCOR TAB 500-40MG SIMCOR TAB 750-20MG
NIACIN-SIMVASTATIN TAB SR 24HR 100020 MG NIACIN-SIMVASTATIN TAB SR 24HR 100040 MG NIACIN-SIMVASTATIN TAB SR 24HR 50020 MG NIACIN-SIMVASTATIN TAB SR 24HR 50040 MG NIACIN-SIMVASTATIN TAB SR 24HR 75020 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
SIMVASTATIN TAB 10MG
SIMVASTATIN TAB 10 MG
Tier 1
SIMVASTATIN TAB 20MG
SIMVASTATIN TAB 20 MG
Tier 1
SIMVASTATIN TAB 40MG
SIMVASTATIN TAB 40 MG
Tier 1
SIMVASTATIN TAB 5MG
SIMVASTATIN TAB 5 MG
Tier 1
SIMVASTATIN TAB 80MG
SIMVASTATIN TAB 80 MG
Tier 1
SIMVASTATIN TAB 80MG
SIMVASTATIN TAB 80 MG
Tier 1
ZOCOR TAB 10MG
SIMVASTATIN TAB 10 MG
Tier 3
ZOCOR TAB 20MG
SIMVASTATIN TAB 20 MG
Tier 3
ZOCOR TAB 40MG
SIMVASTATIN TAB 40 MG
Tier 3
ZOCOR TAB 5MG
SIMVASTATIN TAB 5 MG
Tier 3
ZOCOR TAB 80MG
SIMVASTATIN TAB 80 MG
Tier 3
ZOCOR TAB 80MG
SIMVASTATIN TAB 80 MG
Tier 3
CHOLESTYRAMINE POWDER 4 GM/DOSE
Tier 1
CHOLESTYRAM POW 4GM
CHOLESTYRAM POW 4GM LITE CHOLESTYRAM POW 4GM LITE
CHOLESTYRAMINE POWDER PACKETS 4 GM CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM
COLESTID GRA 5GM
COLESTIPOL HCL GRANULES 5 GM
CHOLESTYRAM POW 4GM
79
Tier 1 Tier 1 Tier 1 Tier 3
X
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 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 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
Label Name
Generic Name
Tier Value
COLESTID POW 5GM
COLESTIPOL HCL GRANULE PACKETS 5 GM
Tier 3
COLESTID TAB 1GM
COLESTIPOL HCL TAB 1 GM
Tier 3
COLESTIPOL HCL GRANULE PACKETS COLESTID FLA GRA 5/7.5GM 5 GM
Tier 3
COLESTID FLA GRA 5GM
COLESTIPOL HCL GRANULES 5 GM
Tier 3
COLESTIPOL GRA 5GM
COLESTIPOL HCL GRANULE PACKETS 5 GM
Tier 1
COLESTIPOL GRA 5GM
COLESTIPOL HCL GRANULES 5 GM
Tier 1
COLESTIPOL TAB 1GM
COLESTIPOL HCL TAB 1 GM
Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
EZETIM/SIMVA TAB 10-10MG EZETIMIBE-SIMVASTATIN TAB 10-10 MG
Tier 3
X
EZETIM/SIMVA TAB 10-20MG EZETIMIBE-SIMVASTATIN TAB 10-20 MG
Tier 3
X
EZETIMIBE-SIMVASTATIN TAB 10-40 MG
Tier 3
X
EZETIMIBE-SIMVASTATIN TAB 10-80 MG
Tier 3
X
EZETIMIBE TAB 10 MG
Tier 3
X
EZETIM/SIMVA TAB 1040MG EZETIM/SIMVA TAB 1080MG EZETIMIBE TAB 10MG JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 30MG JUXTAPID CAP 40MG JUXTAPID CAP 5MG JUXTAPID CAP 60MG KYNAMRO INJ 200MG/ML NIACIN ER TAB 1000MG NIACIN ER TAB 500MG NIACIN ER TAB 750MG NIACOR TAB 500MG NIASPAN TAB 1000 ER NIASPAN TAB 500MG ER NIASPAN TAB 750MG ER OMEGA-3-ACID CAP 1GM PREVALITE POW 4GM PREVALITE POW 4GM PK QUESTRAN POW 4GM
LOMITAPIDE MESYLATE CAP 10 MG (BASE EQUIV) LOMITAPIDE MESYLATE CAP 20 MG (BASE EQUIV) LOMITAPIDE MESYLATE CAP 30 MG (BASE EQUIV) LOMITAPIDE MESYLATE CAP 40 MG (BASE EQUIV) LOMITAPIDE MESYLATE CAP 5 MG (BASE EQUIV) LOMITAPIDE MESYLATE CAP 60 MG (BASE EQUIV) MIPOMERSEN SODIUM SOLN PREFILLED SYRINGE 200 MG/ML NIACIN TAB CR 1000 MG (ANTIHYPERLIPIDEMIC) NIACIN TAB CR 500 MG (ANTIHYPERLIPIDEMIC) NIACIN TAB CR 750 MG (ANTIHYPERLIPIDEMIC) NIACIN (ANTIHYPERLIPIDEMIC) TAB 500 MG NIACIN TAB CR 1000 MG (ANTIHYPERLIPIDEMIC) NIACIN TAB CR 500 MG (ANTIHYPERLIPIDEMIC) NIACIN TAB CR 750 MG (ANTIHYPERLIPIDEMIC) OMEGA-3-ACID ETHYL ESTERS CAP 1 GM CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM CHOLESTYRAMINE POWDER PACKETS 4 GM
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 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
X
Tier 1 Tier 1 Tier 3
QUESTRAN POW 4GM
CHOLESTYRAMINE POWDER 4 GM/DOSE
Tier 3
QUESTRAN POW 4GM LITE
CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE
Tier 3
VASCEPA CAP 0.5GM
ICOSAPENT ETHYL CAP 0.5 GM
Tier 3
X
VASCEPA CAP 1GM
ICOSAPENT ETHYL CAP 1 GM
Tier 3
X
VYTORIN TAB 10-10MG
EZETIMIBE-SIMVASTATIN TAB 10-10 MG
Tier 3
X
VYTORIN TAB 10-20MG
EZETIMIBE-SIMVASTATIN TAB 10-20 MG
Tier 3
X
VYTORIN TAB 10-40MG
EZETIMIBE-SIMVASTATIN TAB 10-40 MG
Tier 3
X
VYTORIN TAB 10-80MG
EZETIMIBE-SIMVASTATIN TAB 10-80 MG
Tier 3
X
WELCHOL PAK 3.75GM
COLESEVELAM HCL PACKET FOR SUSP 3.75 GM
Tier 2
80
Therapeutic Class 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 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 Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
Label Name
Generic Name
WELCHOL TAB 625MG
COLESEVELAM HCL TAB 625 MG
Tier 2
CHEMET CAP 100MG
SUCCIMER CAP 100 MG
Tier 2
DEPEN TITRA TAB 250MG
PENICILLAMINE TAB 250 MG
Tier 2
EXJADE TAB 125MG EXJADE TAB 250MG EXJADE TAB 500MG
DEFERASIROX TAB FOR ORAL SUSP 125 MG DEFERASIROX TAB FOR ORAL SUSP 250 MG DEFERASIROX TAB FOR ORAL SUSP 500 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
JADENU TAB 180MG
DEFERASIROX TAB 180 MG
Tier 2
X
X
JADENU TAB 360MG
DEFERASIROX TAB 360 MG
Tier 2
X
X
JADENU TAB 90MG
DEFERASIROX TAB 90 MG
Tier 2
X
X
KAYEXALATE POW KIONEX POW KIONEX SUS 15GM/60
*SODIUM POLYSTYRENE SULFONATE POWDER** *SODIUM POLYSTYRENE SULFONATE POWDER** SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML
Tier 3 Tier 1 Tier 1
SAMSCA TAB 15MG
TOLVAPTAN TAB 15 MG
Tier 2
X
X
SAMSCA TAB 30MG
TOLVAPTAN TAB 30 MG
Tier 2
X
X
SOD POLY SUL POW SOD POLY SUL SUS 15GM/60 SOD POLY SUL SUS 30/120ML SOD POLY SUL SUS 50/200ML SPS SUS 15GM/60
*SODIUM POLYSTYRENE SULFONATE POWDER** SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML SODIUM POLYSTYRENE SULFONATE RECTAL SUSP 30 GM/120ML SODIUM POLYSTYRENE SULFONATE RECTAL SUSP 30 GM/120ML SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
SYPRINE CAP 250MG
TRIENTINE HCL CAP 250 MG
Tier 3
CALC ACETATE CAP 667MG
CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)
Tier 1
CALC ACETATE TAB 667MG
CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG
Tier 1
ELIPHOS TAB 667MG
CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG
Tier 1
KLOR-CON POW 20MEQ
POTASSIUM CHLORIDE POWDER PACKET 20 MEQ
Tier 1
KLOR-CON 10 TAB 10MEQ ER
POTASSIUM CHLORIDE TAB CR 10 MEQ
Tier 1
KLOR-CON 8 TAB 8MEQ ER
POTASSIUM CHLORIDE TAB CR 8 MEQ (600 MG)
Tier 1
POTASSIUM CHLORIDE KLOR-CON M10 TAB 10MEQ MICROENCAPSULATED CRYS CR TAB 10 ER MEQ POTASSIUM CHLORIDE KLOR-CON M15 TAB 15MEQ MICROENCAPSULATED CRYS CR TAB 15 ER MEQ POTASSIUM CHLORIDE KLOR-CON M20 TAB 20MEQ MICROENCAPSULATED CRYS CR TAB 20 ER MEQ
Tier 1 Tier 3 Tier 1
KLOR-CON SPR CAP 10MEQ POTASSIUM CHLORIDE CAP CR 10 MEQ
Tier 1
KLOR-CON SPR CAP 8MEQ
POTASSIUM CHLORIDE CAP CR 8 MEQ
Tier 1
KLOR-CON/25 POW 25MEQ
POTASSIUM CHLORIDE POWDER PACKET 25 MEQ
Tier 1
K-SOL SOL 10%
POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)
Tier 1
81
X
X
Therapeutic Class Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
Label Name
Generic Name
Tier Value
K-SOL SOL 20%
POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)
Tier 1
K-TAB TAB 10MEQ CR
POTASSIUM CHLORIDE TAB CR 10 MEQ
Tier 3
K-TAB TAB 20MEQ
POTASSIUM CHLORIDE TAB CR 20 MEQ (1500 MG)
Tier 3
K-TAB TAB 8MEQ CR
POTASSIUM CHLORIDE TAB CR 8 MEQ (600 MG)
Tier 3
MICRO-K CAP 10MEQ CR
POTASSIUM CHLORIDE CAP CR 10 MEQ
Tier 3
MICRO-K CAP 8MEQ CR
POTASSIUM CHLORIDE CAP CR 8 MEQ
Tier 3
PHOSLYRA SOL
CALCIUM ACETATE (PHOSPHATE BINDER) ORAL SOLN 667 MG/5ML
Tier 3
POT CHLORIDE CAP 10MEQ POTASSIUM CHLORIDE CAP CR 10 MEQ ER
Tier 1
POT CHLORIDE CAP 8MEQ ER
POTASSIUM CHLORIDE CAP CR 8 MEQ
Tier 1
POT CHLORIDE POW 20MEQ
POTASSIUM CHLORIDE POWDER PACKET 20 MEQ
Tier 1
POT CHLORIDE SOL 10%
POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)
Tier 1
POT CHLORIDE SOL 10% SF
POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML)
Tier 1
POT CHLORIDE SOL 20%
POTASSIUM CHLORIDE ORAL SOLN 20% (40 MEQ/15ML)
Tier 1
POT CHLORIDE TAB 10MEQ CR
POTASSIUM CHLORIDE TAB CR 10 MEQ
Tier 1
POT CHLORIDE TAB 10MEQ ER
POTASSIUM CHLORIDE TAB CR 10 MEQ
Tier 1
POT CHLORIDE TAB 10MEQ ER
POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 10 MEQ
Tier 1
POT CHLORIDE TAB 20MEQ ER
POTASSIUM CHLORIDE TAB CR 20 MEQ (1500 MG)
Tier 1
POT CHLORIDE TAB 8MEQ ER
POTASSIUM CHLORIDE TAB CR 8 MEQ (600 MG)
Tier 1
POT CHLORIDE TAB 8MEQ SR
POTASSIUM CHLORIDE TAB CR 8 MEQ (600 MG)
Tier 1
POT CITRATE TAB 1080MG
POTASSIUM CITRATE TAB CR 10 MEQ (1080 MG)
Tier 1
POT CITRATE TAB 1620MG
POTASSIUM CITRATE TAB CR 15 MEQ (1620 MG)
Tier 1
POT CITRATE TAB 540MG ER
POTASSIUM CITRATE TAB CR 5 MEQ (540 MG)
Tier 1
POT CL MICRO TAB 10MEQ CR POT CL MICRO TAB 10MEQ ER POT CL MICRO TAB 20MEQ ER SOD CHLORIDE GRA
POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 10 MEQ POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 10 MEQ POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 20 MEQ SODIUM CHLORIDE GRANULES
82
Tier 1 Tier 1 Tier 1 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
SODIUM POW CHLORIDE
SODIUM CHLORIDE POWDER
Tier 3
UROCIT-K 10 TAB
POTASSIUM CITRATE TAB CR 10 MEQ (1080 MG)
Tier 3
UROCIT-K 15 TAB
POTASSIUM CITRATE TAB CR 15 MEQ (1620 MG)
Tier 3
UROCIT-K 5 TAB
POTASSIUM CITRATE TAB CR 5 MEQ (540 MG)
Tier 3
Electrolytes/Minerals - Electrolytes and Minerals
CITROMA SOL CHERRY
MAGNESIUM CITRATE SOLN
Electrolytes/Minerals - Electrolytes and Minerals
CITROMA SOL LEMON
MAGNESIUM CITRATE SOLN
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs
Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals Electrolytes/Minerals - Electrolytes and Minerals
K/NA CITRATE SOL CITR ACD
POTASSIUM CITRATE & CITRIC ACID POWDER PACK 3300-1002 MG POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML POT & SOD CITRATES W/ CIT AC SOLN 550-500-334 MG/5ML
Electrolytes/Minerals - Electrolytes and Minerals
MAG CITRATE SOL
MAGNESIUM CITRATE SOLN
Electrolytes/Minerals - Electrolytes and Minerals
MAG CITRATE SOL CHERRY MAGNESIUM CITRATE SOLN
Electrolytes/Minerals - Electrolytes and Minerals
MAG CITRATE SOL GRAPE
MAGNESIUM CITRATE SOLN
Electrolytes/Minerals - Electrolytes and Minerals
MAG CITRATE SOL LEMON
MAGNESIUM CITRATE SOLN
N-ACETYL-L- CAP CYSTEINE
ACETYLCYSTEINE CAP 600 MG
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
CYTRA K GRA CRYSTALS K CITRATE SOL CITR ACD
SODIUM CITRATE & CITRIC ACID SOLN ORACIT SOL 490-640 MG/5ML POTASSIUM CITRATE & CITRIC ACID POT CITRATE- PAK CIT ACID POWDER PACK 3300-1002 MG SODIUM CITRATE & CITRIC ACID SOLN SHOHLS SOL MODIFIED 500-334 MG/5ML SODIUM CITRATE & CITRIC ACID SOLN SOD CITRATE SOL CITR ACD 500-334 MG/5ML POTASSIUM CITRATE & CITRIC ACID TARON GRA CRYSTALS POWDER PACK 3300-1002 MG POT & SOD CITRATES W/ CIT AC SOLN TRICITRATES SOL 550-500-334 MG/5ML SODIUM CITRATE & CITRIC ACID SOLN VIRTRATE-2 SOL 500-334 MG/5ML SODIUM CITRATE & CITRIC ACID SOLN VIRTRATE-2 SOL 500-334 500-334 MG/5ML POT & SOD CITRATES W/ CIT AC SOLN VIRTRATE-3 SOL 550-500-334 MG/5ML POTASSIUM CITRATE & CITRIC ACID SOLN VIRTRATE-K SOL 1100-334 MG/5ML POTASSIUM CITRATE & CITRIC ACID SOLN VIRTRATE-K SOL 1100-334 1100-334 MG/5ML SODIUM FLUORIDE SOLN 0.25 MG/0.6ML FLUORABON DRO (FROM 0.55 MG/0.6ML NAF) SODIUM FLUORIDE SOLN 0.125 MG/DROP FLUOR-A-DAY DRO 0.125MG F (0.275 MG/DROP NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
FLUORIDE CHW 0.25MG F
SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
FLUORIDE CHW 0.5MG F
SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
FLUORIDE CHW 1MG F
SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
FLUORITAB CHW 0.25MG F
SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
FLUORITAB CHW 0.5MG F
SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)
83
Tier Value
HCR Preventive Care HCR Preventive Care Tier 1 Tier 1 Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
FLUORITAB CHW 1MG F
SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
FLUORITAB CHW 2.2MG
SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)
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
SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF) FLURA-DROPS DRO SODIUM FLUORIDE SOLN 0.125 MG/DROP 0.125MG F (0.275 MG/DROP NAF) FLURA-DROPS DRO 0.25MG SODIUM FLUORIDE SOLN 0.25 MG/DROP F F (FROM 0.55 MG/DROP NAF) SODIUM FLUORIDE SOLN 0.125 MG/DROP KARIDIUM DRO 0.125MG F (0.275 MG/DROP NAF) SODIUM FLUORIDE LOZENGE 1 MG F LOZI-FLUR LOZ 1MG F (FROM 2.2 MG NAF) FLUORITAB DRO 0.125MG
Tier Value HCR Preventive Care HCR Preventive Care Tier 1 Tier 1 Tier 3 Tier 1 Tier 2 HCR Preventive Care HCR Preventive Care HCR Preventive Care
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
LUDENT CHW 0.25MG F
SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
LUDENT CHW 0.5MG F
SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
LUDENT CHW 1MG F
SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
LURIDE DRO 0.5MG/ML
SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF)
Tier 3 HCR Preventive Care
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
NAFRINSE CHW 1MG F
SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
NAFRINSE DRO 0.125MG
SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
SOD FLUORIDE CHW 0.25MG F
SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
SOD FLUORIDE CHW 0.5MG SODIUM FLUORIDE CHEW TAB 0.5 MG F F (FROM 1.1 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
SOD FLUORIDE CHW 1.1MG
SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
SOD FLUORIDE CHW 1MG F
SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)
Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs
SOD FLUORIDE CHW 2.2MG
SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)
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 ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS
SOD FLUORIDE DRO 0.5MG/ SODIUM FLUORIDE SOLN 0.5 MG/ML F ML (FROM 1.1 MG/ML NAF) SODIUM FLUORIDE TAB 0.5 MG F (FROM SOD FLUORIDE TAB 0.5MG F 1.1 MG NAF) SODIUM FLUORIDE TAB 1 MG F (FROM 2.2 SOD FLUORIDE TAB 1MG F MG NAF)
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 1 Tier 1 Tier 1
ACCU-CHEK MIS GUIDE
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCU-CHEK TES ACTIVE
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCU-CHEK TES AVIVA
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCU-CHEK TES AVIVA PL
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCU-CHEK TES COMPACT
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCU-CHEK TES DRUM
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCU-CHEK TES SMART
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCU-CK COMF TES CURVE GLUCOSE BLOOD TEST STRIP
Tier 3
X
ACCUTREND TES GLUCOSE GLUCOSE BLOOD TEST STRIP
Tier 3
X
AT LAST TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
BAYER BREEZE MIS 2 TEST
GLUCOSE BLOOD TEST DISK
Tier 3
X
GLUCOSE BLOOD TEST STRIP
Tier 3
X
GLUCOSE BLOOD TEST STRIP
Tier 3
X
BLOOD GLUCOS TES PREMIUM BLOOD GLUCOS TES STRIPS
84
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 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
Generic Name
CONTOUR TES BLD GLUC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
CONTOUR TES NEXT
GLUCOSE BLOOD TEST STRIP
Tier 3
X
GLUCOSE BLOOD TEST STRIP
Tier 3
X
GLUCOSE BLOOD TEST STRIP
Tier 3
X
DIASTIX TES STRIPS
GLUCOSE URINE TEST-(GLUCOSE OXIDASE) STRIP
Tier 3
EASYMAX TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
EASYMAX 15 TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
EASYPLUS TES BLD GLUC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
EMBRACE TES BLD GLUC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
EXACTECH TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
EXACTECH TES R-S-G
GLUCOSE BLOOD TEST STRIP
Tier 3
X
FORA GD50 TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
FORTISCARE TES BLD GLUC GLUCOSE BLOOD TEST STRIP
Tier 3
X
FREESTYLE TES PREC NEO
GLUCOSE BLOOD TEST STRIP
Tier 3
X
GENSTRIP 50 TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
GMATE BLOOD TES GLUCOSE
GLUCOSE BLOOD TEST STRIP
Tier 3
X
KROGER TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
LIBERTY TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
NEUTEK 2TEK TES STRIPS
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ON CALL TES EXPRESS
GLUCOSE BLOOD TEST STRIP
Tier 3
X
GLUCOSE BLOOD TEST STRIP
Tier 3
X
GLUCOSE BLOOD TEST STRIP
Tier 3
X
ONETOUCH TES ULTRA BL
GLUCOSE BLOOD TEST STRIP
Tier 1
X
ONETOUCH TES VERIO
GLUCOSE BLOOD TEST STRIP
Tier 1
X
OPTIUM TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
OPTIUMEZ TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
OPTUMRX TES BLD GLUC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
PRECISION TES PCX
GLUCOSE BLOOD TEST STRIP
Tier 3
X
PRECISION TES PCX PLUS
GLUCOSE BLOOD TEST STRIP
Tier 3
X
PRECISION TES QID
GLUCOSE BLOOD TEST STRIP
Tier 3
X
PRECISION TES SOF-TACT
GLUCOSE BLOOD TEST STRIP
Tier 3
X
PRECISION TES XTRA
GLUCOSE BLOOD TEST STRIP
Tier 3
X
PRECISION PT TES OF CARE GLUCOSE BLOOD TEST STRIP
Tier 3
X
QUINTET TES BLD GLUC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
QUINTET AC TES BLD GLUC GLUCOSE BLOOD TEST STRIP
Tier 3
X
RA TRUETEST TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
RELION TES ULTIMA
GLUCOSE BLOOD TEST STRIP
Tier 3
X
RELION BLOOD TES GLUCOSE
GLUCOSE BLOOD TEST STRIP
Tier 3
X
REVEAL TES BLD GLUC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
CVS ADVANCED TES GLUCOSE D-CARE BLOOD TES GLUCOSE
ON CALL PLUS TES BLD GLUC ON CALL VIVD TES BLD GLUC
85
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
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 - 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
Generic Name
SUPREME TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
TRUE METRIX TES GLUCOSE
GLUCOSE BLOOD TEST STRIP
Tier 3
X
TRUETEST TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
TRUETEST TES BLD GLUC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
TRUETRACK TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
TRUETRACK TES BLD GLUC GLUCOSE BLOOD TEST STRIP
Tier 3
X
ULTIMA TES
GLUCOSE BLOOD TEST STRIP
Tier 3
X
UNISTRIP1 TES GENERIC
GLUCOSE BLOOD TEST STRIP
Tier 3
X
AV-PHOS 250 TAB NEUTRAL
POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG
Tier 1
CALCIFOL WAF
CA CARB-FOLIC ACID-VIT D-B6-B12BORON-MAG WAFER 1342-1.6 MG
Tier 3
CALCIUM-FA WAF PLUS D
CA CARB-FOLIC ACID-VIT D-B6-B12BORON-MAG WAFER 1342-1 MG
Tier 1
EFFER-K TAB 10MEQ
POTASSIUM BICARBONATE-CITRIC ACID EFFER TAB 10 MEQ
Tier 2
EFFER-K TAB 20MEQ
POTASSIUM BICARBONATE-CITRIC ACID EFFER TAB 20 MEQ
Tier 2
EFFER-K TAB 25MEQ EF
POTASSIUM BICARBONATE EFFER TAB 25 MEQ
Tier 1
K-EFFERVESCE TAB 25MEQ EF
POTASSIUM BICARBONATE EFFER TAB 25 MEQ
Tier 1
KLOR-CON/EF TAB 25MEQ FR
POTASSIUM BICARBONATE EFFER TAB 25 MEQ
Tier 1
K-PHOS TAB
POTASSIUM PHOSPHATE MONOBASIC TAB 500 MG
Tier 2
K-PHOS TAB NEUTRAL
POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG
Tier 3
K-PRIME TAB 25MEQ EF
POTASSIUM BICARBONATE EFFER TAB 25 MEQ
Tier 1
K-VESCENT TAB 25MEQ EF
POTASSIUM BICARBONATE EFFER TAB 25 MEQ
Tier 1
MAGNEBIND TAB 400
MAGNESIUM-CALCIUM-FOLIC ACID TAB 400-200-1 MG
Tier 2
PHOSPHA 250 TAB NEUTRAL
POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG
Tier 1
PHOSPHO-TRIN TAB 250 NEUT
POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG
Tier 1
POT CHLORIDE TAB 25MEQ EF
POT BICARBONATE & CHLORIDE EFFER TAB 25 MEQ
Tier 1
POT/CHLORIDE TAB 25MEQ EF
POT BICARBONATE & CHLORIDE EFFER TAB 25 MEQ
Tier 1
POTASSIUM TAB 25MEQ EF
POTASSIUM BICARBONATE EFFER TAB 25 MEQ
Tier 1
VIRT-PHOS TAB 250 NEUT
POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MG
Tier 1
ANZEMET TAB 100MG
DOLASETRON MESYLATE TAB 100 MG
Tier 3
X
ANZEMET TAB 50MG
DOLASETRON MESYLATE TAB 50 MG
Tier 3
X
APREPITANT CAP 125MG
APREPITANT CAPSULE 125 MG
Tier 2
X
86
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
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 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 Enzyme Inhibitors - Chemotherapy Agents Enzyme Inhibitors - Chemotherapy Agents Enzyme Inhibitors - Chemotherapy Agents Enzyme Inhibitors - Chemotherapy Agents 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
Generic Name
APREPITANT CAP 40MG
APREPITANT CAPSULE 40 MG
Tier 2
X
APREPITANT CAP 80MG
APREPITANT CAPSULE 80 MG
Tier 2
X
APREPITANT PAK 80 & 125
APREPITANT CAPSULE THERAPY PACK 80 & 125 MG
Tier 2
X
CESAMET CAP 1MG
NABILONE CAP 1 MG
Tier 3
DRONABINOL CAP 10MG
DRONABINOL CAP 10 MG
Tier 1
DRONABINOL CAP 2.5MG
DRONABINOL CAP 2.5 MG
Tier 1
DRONABINOL CAP 5MG
DRONABINOL CAP 5 MG
Tier 1
EMEND CAP 125MG
APREPITANT CAPSULE 125 MG
Tier 3
X
EMEND CAP 40MG
APREPITANT CAPSULE 40 MG
Tier 3
X
EMEND CAP 80MG
APREPITANT CAPSULE 80 MG
Tier 3
X
Tier 3
X
Tier 2
X
EMEND PAK 80 & 125 EMEND SUS 125MG
APREPITANT CAPSULE THERAPY PACK 80 & 125 MG APREPITANT FOR ORAL SUSP 125 MG (125 MG/5ML)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
GRANISETRON TAB 1MG
GRANISETRON HCL TAB 1 MG
Tier 2
MARINOL CAP 10MG
DRONABINOL CAP 10 MG
Tier 3
MARINOL CAP 2.5MG
DRONABINOL CAP 2.5 MG
Tier 3
MARINOL CAP 5MG
DRONABINOL CAP 5 MG
Tier 3
ONDANSETRON SOL 4MG/5ML
ONDANSETRON HCL ORAL SOLN 4 MG/5ML
Tier 1
ONDANSETRON TAB 24MG
ONDANSETRON HCL TAB 24 MG
Tier 1
ONDANSETRON TAB 4MG
ONDANSETRON HCL TAB 4 MG
Tier 1
ONDANSETRON TAB 4MG ODT
ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG
Tier 1
ONDANSETRON TAB 8MG
ONDANSETRON HCL TAB 8 MG
Tier 1
ONDANSETRON TAB 8MG ODT
ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG ONDANSETRON HCL ORAL SOLN 4 MG/5ML
ZOFRAN SOL 4MG/5ML
Tier 1 Tier 3
ZOFRAN TAB 4MG
ONDANSETRON HCL TAB 4 MG
Tier 3
ZOFRAN TAB 4MG ODT
ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG
Tier 3
ZOFRAN TAB 8MG
ONDANSETRON HCL TAB 8 MG
Tier 3
ZOFRAN TAB 8MG ODT
ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG
Tier 3
ETOPOSIDE CAP 50MG
ETOPOSIDE CAP 50 MG
Tier 1
HYCAMTIN CAP 0.25MG
TOPOTECAN HCL CAP 0.25 MG (BASE EQUIV)
Tier 2
X
X
X
HYCAMTIN CAP 1MG
TOPOTECAN HCL CAP 1 MG (BASE EQUIV)
Tier 2
X
X
X
ZYDELIG TAB 100MG
IDELALISIB TAB 100 MG
Tier 3
X
X
X
ZYDELIG TAB 150MG
IDELALISIB TAB 150 MG
Tier 3
X
X
X
BUPHENYL POW
SODIUM PHENYLBUTYRATE ORAL POWDER 3 GM/TEASPOONFUL
Tier 3
X
BUPHENYL TAB 500MG
SODIUM PHENYLBUTYRATE TAB 500 MG
Tier 3
X
CARGLUMIC ACID TAB 200 MG
Tier 2
X
CARBAGLU TAB 200MG CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 36000UNT
PANCRELIPASE (LIP-PROT-AMYL) DR CAP 12000-38000-60000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 24000-76000-120000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-9500-15000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 36000-114000-180000 UNIT
87
Tier 2 Tier 2 Tier 2 Tier 2
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 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
Label Name CREON CAP 6000UNIT CYSTADANE POW
Generic Name PANCRELIPASE (LIP-PROT-AMYL) DR CAP 6000-19000-30000 UNIT *BETAINE POWDER FOR ORAL SOLUTION***
Tier Value Tier 2 Tier 2
CYSTAGON CAP 150MG
CYSTEAMINE BITARTRATE CAP 150 MG
Tier 2
CYSTAGON CAP 50MG
CYSTEAMINE BITARTRATE CAP 50 MG
Tier 2
KUVAN POW 100MG KUVAN POW 500MG KUVAN TAB 100MG
SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 500 MG SAPROPTERIN DIHYDROCHLORIDE SOLUBLE TAB 100 MG
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
ORFADIN CAP 10MG
NITISINONE CAP 10 MG
Tier 3
X
X
ORFADIN CAP 20MG
NITISINONE CAP 20 MG
Tier 3
X
X
ORFADIN CAP 2MG
NITISINONE CAP 2 MG
Tier 3
X
X
ORFADIN CAP 5MG
NITISINONE CAP 5 MG
Tier 3
X
X
ORFADIN SUS 4MG/ML
NITISINONE SUSP 4 MG/ML
Tier 3
X
X
PANCREAZE CAP PANCREAZE CAP 10500UNT PANCREAZE CAP 16800UNT PANCREAZE CAP 21000UNT PANCREAZE CAP 4200UNIT PERTZYE CAP PERTZYE CAP PERTZYE CAP PHENYLBUTYRA POW SODIUM PROCYSBI CAP 25MG PROCYSBI CAP 75MG RAVICTI LIQ 1.1GM/ML SUCRAID SOL 8500/ML ULTRESA CAP 13800UNT ULTRESA CAP 20700UNT ULTRESA CAP 23000UNT VIOKACE TAB VIOKACE TAB 20880 ZAVESCA CAP 100MG ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 3000UNIT ZENPEP CAP 40000UNT ZENPEP CAP 5000UNIT CAFERGOT TAB 1-100MG
PANCRELIPASE (LIP-PROT-AMYL) DR CAP 2600-6200-10850 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 10500-35500-61500 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 16800-56800-98400 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 21000-54700-83900 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 4200-14200-24600 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 4000-14375-15125 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 8000-28750-30250 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 16000-57500-60500 UNIT SODIUM PHENYLBUTYRATE ORAL POWDER 3 GM/TEASPOONFUL CYSTEAMINE BITARTRATE CAP DELAYED RELEASE 25 MG (BASE EQUIV) CYSTEAMINE BITARTRATE CAP DELAYED RELEASE 75 MG (BASE EQUIV) GLYCEROL PHENYLBUTYRATE LIQUID 1.1 GM/ML SACROSIDASE SOLN 8500 UNIT/ML PANCRELIPASE (LIP-PROT-AMYL) DR CAP 13800-27600-27600 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 20700-41400-41400 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 23000-46000-46000 UNIT PANCRELIPASE (LIP-PROT-AMYL) TAB 10440-39150-39150 UNIT PANCRELIPASE (LIP-PROT-AMYL) TAB 20880-78300-78300 UNIT MIGLUSTAT CAP 100 MG PANCRELIPASE (LIP-PROT-AMYL) DR CAP 10000-34000-55000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 15000-51000-82000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 20000-68000-109000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 25000-85000-136000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 3000-10000-16000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 40000-136000-218000 UNIT PANCRELIPASE (LIP-PROT-AMYL) DR CAP 5000-17000-27000 UNIT ERGOTAMINE W/ CAFFEINE TAB 1-100 MG
88
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 2
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
X
Therapeutic Class Ergot Alkaloids - Migraine Drugs 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
Label Name
Generic Name
DIHYDROERGOT INJ 1MG/ ML DIHYDROERGOT POW MESYLATE DIHYDROERGOT SPR 4MG/ ML ERGOT/CAFFEN TAB 1-100MG
DIHYDROERGOTAMINE MESYLATE INJ 1 MG/ML DIHYDROERGOTAMINE MESYLATE POWDER DIHYDROERGOTAMINE MESYLATE NASAL SPRAY 4 MG/ML
MIGERGOT SUP 2/100 ACTIVELLA TAB 0.5-0.1 ACTIVELLA TAB 1-0.5MG ALORA DIS 0.025MG ALORA DIS 0.05MG ALORA DIS 0.075MG ALORA DIS 0.1MG
ERGOTAMINE W/ CAFFEINE TAB 1-100 MG ERGOTAMINE W/ CAFFEINE SUPPOS 2-100 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR
Estrogens - Hormone Replacement/ Modifying Drugs
ALTAVERA TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ALYACEN TAB 1/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ALYACEN TAB 7/7/7
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
AMABELZ TAB 0.5-0.1 AMABELZ TAB 1-0.5MG
ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG
Estrogens - Hormone Replacement/ Modifying Drugs
AMETHIA TAB
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
AMETHIA LO TAB
LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
AMETHYST TAB 90-20MCG
LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
ANGELIQ TAB 0.25-0.5 ANGELIQ TAB 0.5-1MG
DROSPIRENONE-ESTRADIOL TAB 0.250.5 MG DROSPIRENONE-ESTRADIOL TAB 0.5-1 MG
Estrogens - Hormone Replacement/ Modifying Drugs
APRI TAB
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ARANELLE TAB
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ASHLYNA TAB
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
AUBRA TAB 0.1-0.02
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
AVIANE TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
AZURETTE TAB 28 DAY
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)
Estrogens - Hormone Replacement/ Modifying Drugs
BALZIVA TAB
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
BEKYREE TAB
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)
Estrogens - Hormone Replacement/ Modifying Drugs
BLISOVI 24 TAB FE 1/20
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
BLISOVI FE TAB 1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG
89
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 3 Tier 1
X
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 2 Tier 2 HCR Preventive Care HCR Preventive Care HCR Preventive Care
X X
Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
X
Therapeutic Class
Label Name
Generic Name
Tier Value
Estrogens - Hormone Replacement/ Modifying Drugs
BLISOVI FE TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG
HCR Preventive Care
Estrogens - Hormone Replacement/ Modifying Drugs
BREVICON TAB 0.5/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
BRIELLYN TAB
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
CAMRESE TAB
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
CAMRESE LO TAB
LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
CAZIANT PAK
DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG
Estrogens - Hormone Replacement/ Modifying Drugs
CHATEAL TAB 0.15/30
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
CLIMARA DIS 0.025MG CLIMARA DIS 0.0375MG CLIMARA DIS 0.05MG CLIMARA DIS 0.06MG CLIMARA DIS 0.075MG CLIMARA DIS 0.1MG CLIMARA PRO DIS WEEKLY COMBIPATCH DIS .05/.14 COMBIPATCH DIS .05/.25 COVARYX TAB 1.25-2.5
ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR) ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR ESTRADIOL-LEVONORGESTREL TD PATCH WEEKLY 0.045-0.015 MG/DAY ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.14 MG/DAY ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.25 MG/DAY ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG
Estrogens - Hormone Replacement/ Modifying Drugs
COVARYX HS TAB
Estrogens - Hormone Replacement/ Modifying Drugs
CRYSELLE-28 TAB 28 TABS
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
CYCLAFEM TAB 1/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
CYCLAFEM TAB 7/7/7
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
CYCLESSA PAK
DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG
Estrogens - Hormone Replacement/ Modifying Drugs
CYRED TAB
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
DASETTA TAB 1/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
DASETTA TAB 7/7/7
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
DAYSEE TAB
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
DELYLA TAB 0.1-0.02
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
DESO/ETHINYL TAB ESTRADIO
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
DESO/ETHINYL TAB ESTRADIO
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
DESOGEN-28 TAB DIVIGEL GEL 0.25MG
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG ESTRADIOL TD GEL 0.25 MG/0.25GM (0.1%)
90
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
X X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1 Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 Tier 3
X
Therapeutic Class
Label Name
Generic Name
DIVIGEL GEL 0.5MG
ESTRADIOL TD GEL 0.5 MG/0.5GM (0.1%)
Tier 3
DIVIGEL GEL 1MG/GM
ESTRADIOL TD GEL 1 MG/GM (0.1%)
Tier 3
DROSPIR/ETHI TAB 3-0.03MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
Tier 3
Estrogens - Hormone Replacement/ Modifying Drugs
DROSPIRE/ETH TAB ESTR/ LEV
DROSPIRENONE-ETHINYL ESTRADLEVOMEFOLATE TAB 3-0.02-0.451 MG
HCR Preventive Care
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
DROSPIRENONE TAB ETHY EST
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG CONJUGATED ESTROGENSBAZEDOXIFENE TAB 0.45-20 MG ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG ESTRADIOL GEL 0.06% (0.52 MG/0.87 GM METERED-DOSE PUMP)
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
DUAVEE TAB 0.45-20 EEMT TAB 1.25-2.5
Estrogens - Hormone Replacement/ Modifying Drugs
EEMT HS TAB
Estrogens - Hormone Replacement/ Modifying Drugs
ELESTRIN GEL 0.06%
Estrogens - Hormone Replacement/ Modifying Drugs
ELINEST TAB
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
EMOQUETTE TAB
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
ENJUVIA TAB 0.3MG ENJUVIA TAB 0.45MG ENJUVIA TAB 0.625MG ENJUVIA TAB 0.9MG
ESTROGENS, CONJUGATED SYNTHETIC B TAB 0.3 MG ESTROGENS, CONJUGATED SYNTHETIC B TAB 0.45 MG ESTROGENS, CONJUGATED SYNTHETIC B TAB 0.625 MG ESTROGENS, CONJUGATED SYNTHETIC B TAB 0.9 MG
Estrogens - Hormone Replacement/ Modifying Drugs
ENPRESSE-28 TAB
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ENSKYCE TAB
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
EST ESTROGEN TAB MTEST
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG ESTERIFIED ESTROGENS & EST ESTROGEN TAB MTEST METHYLTESTOSTERONE TAB 0.625-1.25 HS MG ESTARYLLA TAB 0.25-35
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG
Tier Value
Tier 3 Tier 1 Tier 1 Tier 3 HCR Preventive Care HCR Preventive Care Tier 3 Tier 3 Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care Tier 1 Tier 1 HCR Preventive Care
ESTRA/NORETH TAB 1-0.5MG ESTRACE TAB 0.5MG
ESTRADIOL TAB 0.5 MG
Tier 3
ESTRACE TAB 1MG
ESTRADIOL TAB 1 MG
Tier 3
ESTRACE TAB 2MG
ESTRADIOL TAB 2 MG
Tier 3
ESTRADIOL VAGINAL CREAM 0.1 MG/GM
Tier 3
ESTRACE VAG CRE 0.1MG/ GM ESTRADIOL DIS 0.025MG ESTRADIOL DIS 0.0375MG ESTRADIOL DIS 0.05MG ESTRADIOL DIS 0.06MG ESTRADIOL DIS 0.075MG ESTRADIOL DIS 0.1MG
ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR) ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR
Tier 2 Tier 2
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
ESTRADIOL TAB 0.5MG
ESTRADIOL TAB 0.5 MG
Tier 1
ESTRADIOL TAB 1MG
ESTRADIOL TAB 1 MG
Tier 1
ESTRADIOL TAB 2MG
ESTRADIOL TAB 2 MG
Tier 1
91
X
Tier 3
ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG
ESTRA/NORETH TAB 0.5-0.1
Prior Supply Step Specialty Authorization Limit Therapy
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
Label Name
Generic Name
Tier Value
ESTRADIOL VAGINAL RING 2 MG (7.5 MCG/24HRS) ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG ESTRADIOL GEL 0.06% (0.75 MG/1.25 GM METERED-DOSE PUMP)
Tier 1
ESTROPIPATE TAB 0.75MG
ESTROPIPATE TAB 0.75 MG
Tier 1
ESTROPIPATE TAB 1.5MG
ESTROPIPATE TAB 1.5 MG
Tier 1
ESTROPIPATE TAB 3MG
ESTROPIPATE TAB 3 MG
Tier 1
ESTROSTEP FE TAB
NORETHINDRONE AC-ETHINYL ESTRADFE TAB 1-20/1-30/1-35 MG-MCG
Tier 3
Estrogens - Hormone Replacement/ Modifying Drugs
ETHYNODIOL TAB 1-50
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
EVAMIST SPR 1.53MG
ESTRADIOL TRANSDERMAL SPRAY 1.53 MG/SPRAY
Estrogens - Hormone Replacement/ Modifying Drugs
FALESSA KIT
*LEVONORGEST-ETH ESTRAD TAB 0.1 MG-20 MCG & FA TAB 1 MG KIT*
Estrogens - Hormone Replacement/ Modifying Drugs
FALMINA TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
FAYOSIM TAB
LEVONOR-ETH EST TAB 0.150.02/0.025/0.03 MG Ð EST 0.01 MG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
ESTRING MIS 2MG ESTROG/MTEST TAB 1.252.5 ESTROGEL GEL
FEMCON FE CHW FEMHRT TAB 0.5-2.5 FEMRING MIS 0.05/24H FEMRING MIS 0.1MG/24 FEMYNOR TAB 0.25-35 FYAVOLV TAB 0.5-2.5 FYAVOLV TAB 1-5 GIANVI TAB 3-0.02MG
NORETHINDRONE & ETHINYL ESTRADIOLFE CHEW TAB 0.4 MG-35 MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG ESTRADIOL ACETATE VAGINAL RING 0.05 MG/24HR ESTRADIOL ACETATE VAGINAL RING 0.1 MG/24HR NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG
Estrogens - Hormone Replacement/ Modifying Drugs
GILDAGIA TAB 0.4-35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
GILDESS TAB 1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
GILDESS TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
GILDESS 24 TAB FE 1/20
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
GILDESS FE TAB 1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
GILDESS FE TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
INTROVALE TAB
LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
JEVANTIQUE L TAB 0.5-2.5 JINTELI TAB 1MG-5MCG
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
JOLESSA TAB
LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG
Estrogens - Hormone Replacement/ Modifying Drugs
JULEBER TAB
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
JUNEL 1.5/30 TAB
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG
92
Tier 2
Tier 3
Prior Supply Step Specialty Authorization Limit Therapy X
X
HCR Preventive Care Tier 2 HCR Preventive Care HCR Preventive Care HCR Preventive Care
X
X
Tier 3 Tier 3 Tier 3
X
Tier 3
X
HCR Preventive Care Tier 3 Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
X
Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care
X
Therapeutic Class
Label Name
Generic Name
Estrogens - Hormone Replacement/ Modifying Drugs
JUNEL 1/20 TAB
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
JUNEL FE TAB 1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
JUNEL FE TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
JUNEL FE 24 TAB 1/20
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
KAITLIB FE CHW
NORETHINDRONE & ETHINYL ESTRADIOLFE CHEW TAB 0.8 MG-25 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
KARIVA TAB 28 DAY
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)
Estrogens - Hormone Replacement/ Modifying Drugs
KELNOR TAB 1/35
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
KIMIDESS TAB
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)
Estrogens - Hormone Replacement/ Modifying Drugs
KURVELO TAB 0.15/30
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LARIN TAB 1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LARIN TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LARIN 24 TAB FE 1/20
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
LARIN FE TAB 1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LARIN FE TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LARISSIA TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LAYOLIS FE CHW
NORETHINDRONE & ETHINYL ESTRADIOLFE CHEW TAB 0.8 MG-25 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LEENA TAB
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LESSINA TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LEVO-ETH EST TAB 9020MCG
LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LEVONEST TAB
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LEVONOR/ETHI TAB
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LEVONOR/ETHI TAB 0.1-0.02
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LEVONOR/ETHI TAB ESTRADIO
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LEVONOR/ETHI TAB ESTRADIO
LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG
Estrogens - Hormone Replacement/ Modifying Drugs
LEVONOR/ETHI TAB ESTRADIO
LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
LEVONOR/ETHI TAB ESTRADIO
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)
93
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
X X X
Therapeutic Class
Label Name
Generic Name
Estrogens - Hormone Replacement/ Modifying Drugs
LEVORA-28 TAB 0.15/30
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LO LOESTRIN TAB
NORETHIN-ETH ESTRADIOL-FE TAB 1 MG10 MCG (24)/10 MCG (2)
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
LOESTRIN TAB 1/20-21 LOESTRIN 21 TAB 1.5/30 LOESTRIN FE TAB 1.5/30 LOESTRIN FE TAB 1/20 LOMEDIA 24 TAB FE LOPREEZA TAB 0.5-0.1 LOPREEZA TAB 1-0.5MG LORYNA TAB 3-0.02MG LOSEASONIQUE TAB
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
LOW-OGESTREL TAB
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
LUTERA TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
MARLISSA TAB 0.15/30
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
MENOSTAR DIS 14MCG
ESTRADIOL TD PATCH WEEKLY 14 MCG/24HR
Estrogens - Hormone Replacement/ Modifying Drugs
MIBELAS 24 CHW FE
NORETHINDRONE ACE-ETH ESTRADIOLFE CHEW TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
MICRGSTIN 24 TAB FE 1/20
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
MICROGESTIN TAB 1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
MICROGESTIN TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
MICROGESTIN TAB FE 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
MICROGESTIN TAB FE1.5/30
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
MIMVEY TAB 1-0.5MG MIMVEY LO TAB 0.5-0.1 MINASTRIN 24 CHW FE MINIVELLE DIS 0.025MG MINIVELLE DIS 0.0375MG MINIVELLE DIS 0.05MG MINIVELLE DIS 0.075MG MINIVELLE DIS 0.1MG MIRCETTE TAB 28 DAY MODICON TAB 0.5/35 MONO-LINYAH TAB 0.25-35
ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG NORETHINDRONE ACE-ETH ESTRADIOLFE CHEW TAB 1 MG-20 MCG (24) ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5) NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG
94
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
HCR Preventive Care HCR Preventive Care Tier 3 Tier 3 Tier 3 Tier 3 HCR Preventive Care Tier 2 Tier 2 Tier 3 Tier 3
X
HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3
X
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
X
Tier 2 Tier 2 HCR Preventive Care
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 3 HCR Preventive Care
Therapeutic Class
Label Name
Generic Name
Estrogens - Hormone Replacement/ Modifying Drugs
MONONESSA TAB
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
MYZILRA TAB
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NATAZIA TAB
ESTRADIOL VALERATE-DIENOGEST TAB 3 MG /2-2 MG/2-3 MG/1 MG
Estrogens - Hormone Replacement/ Modifying Drugs
NECON TAB 0.5/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NECON TAB 1/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NECON TAB 10/11-28
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35 MG-MCG (10/11)
Estrogens - Hormone Replacement/ Modifying Drugs
NECON TAB 7/7/7
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NIKKI TAB 3-0.02MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG
Estrogens - Hormone Replacement/ Modifying Drugs
NORE/ETH/FER CHW 0.4MG-35
NORETHINDRONE & ETHINYL ESTRADIOLFE CHEW TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORETH/ETHIN CHW FE
NORETHINDRONE & ETHINYL ESTRADIOLFE CHEW TAB 0.8 MG-25 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORETH/ETHIN CHW FE 1/20
NORETHINDRONE ACE-ETH ESTRADIOLFE CHEW TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
NORETH/ETHIN TAB 0.5-2.5
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORETH/ETHIN TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORETH/ETHIN TAB 1MG5MCG
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORETH/ETHIN TAB FE 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORETH/ETHIN TAB FE 1/20
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
NORGEST/ETHI TAB 0.25/35
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORGEST/ETHI TAB ESTRADIO
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORGEST/ETHI TAB ESTRADIO
NORGESTIMATE-ETH ESTRAD TAB 0.1825/0.215-25/0.25-25 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORINYL TAB 1/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORTREL TAB 0.5/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORTREL TAB 1/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NORTREL TAB 7/7/7
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
NUVARING MIS
ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR
Estrogens - Hormone Replacement/ Modifying Drugs
OCELLA TAB 3-0.03MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
Estrogens - Hormone Replacement/ Modifying Drugs
OGESTREL TAB
NORGESTREL & ETHINYL ESTRADIOL TAB 0.5 MG-50 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ORSYTHIA TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
ORTHO TRI- TAB CYCLEN ORTHO-CYCLEN TAB 0.25/35
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG
95
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
HCR Preventive Care HCR Preventive Care Tier 2 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care Tier 3 Tier 3
X
Therapeutic Class Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
Label Name ORTHO-NOVUM TAB 1/35 ORTHO-NOVUM TAB 7/7/7 OVCON-35 TAB
Generic Name NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG
Tier Value Tier 3 Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Estrogens - Hormone Replacement/ Modifying Drugs
PHILITH TAB 0.4-35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
PIMTREA TAB
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)
Estrogens - Hormone Replacement/ Modifying Drugs
PIRMELLA TAB 1/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
PIRMELLA TAB 7/7/7
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
PORTIA-28 TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
PREFEST TAB
ESTRADIOL TAB 1 MG(15)/ESTRADNORGESTIMATE TAB 1-0.09MG(15)
Tier 2
PREMARIN TAB 0.3MG
ESTROGENS, CONJUGATED TAB 0.3 MG
Tier 3
PREMARIN TAB 0.45MG
ESTROGENS, CONJUGATED TAB 0.45 MG
Tier 3
PREMARIN TAB 0.625MG
ESTROGENS, CONJUGATED TAB 0.625 MG
Tier 3
PREMARIN TAB 0.9MG
ESTROGENS, CONJUGATED TAB 0.9 MG
Tier 3
PREMARIN TAB 1.25MG
ESTROGENS, CONJUGATED TAB 1.25 MG
Tier 3
PREMARIN VAG CRE 0.625MG
ESTROGENS, CONJUGATED VAGINAL CREAM 0.625 MG/GM CONJ EST 0.625(14)/CONJ ESTMEDROXYPRO AC TAB 0.625-5MG(14) CONJUGATED ESTROGENMEDROXYPROGEST ACETATE TAB 0.6252.5 MG CONJUGATED ESTROGENMEDROXYPROGEST ACETATE TAB 0.3-1.5 MG CONJUGATED ESTROGENMEDROXYPROGEST ACETATE TAB 0.451.5 MG CONJUGATED ESTROGENMEDROXYPROGEST ACETATE TAB 0.6255 MG
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
PREMPHASE TAB
Estrogens - Hormone Replacement/ Modifying Drugs
PREMPRO TAB .625-2.5
Estrogens - Hormone Replacement/ Modifying Drugs
PREMPRO TAB 0.3-1.5
Estrogens - Hormone Replacement/ Modifying Drugs
PREMPRO TAB 0.45-1.5
Estrogens - Hormone Replacement/ Modifying Drugs
PREMPRO TAB 0.625-5
Estrogens - Hormone Replacement/ Modifying Drugs
PREVIFEM TAB
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
QUARTETTE TAB
LEVONOR-ETH EST TAB 0.150.02/0.025/0.03 MG Ð EST 0.01 MG
Estrogens - Hormone Replacement/ Modifying Drugs
QUASENSE TAB
LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG
Estrogens - Hormone Replacement/ Modifying Drugs
RAJANI TAB
DROSPIRENONE-ETHINYL ESTRADLEVOMEFOLATE TAB 3-0.02-0.451 MG
Estrogens - Hormone Replacement/ Modifying Drugs
RECLIPSEN TAB
DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
RIVELSA TAB
LEVONOR-ETH EST TAB 0.150.02/0.025/0.03 MG Ð EST 0.01 MG
Estrogens - Hormone Replacement/ Modifying Drugs
SAFYRAL TAB
DROSPIRENONE-ETHINYL ESTRADLEVOMEFOLATE TAB 3-0.03-0.451 MG
Estrogens - Hormone Replacement/ Modifying Drugs
SEASONIQUE TAB
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)
Estrogens - Hormone Replacement/ Modifying Drugs
SETLAKIN TAB
LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG
Estrogens - Hormone Replacement/ Modifying Drugs
SPRINTEC 28 TAB 28 DAY
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG
96
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care
X X X
X X X X
Therapeutic Class
Label Name
Generic Name
Estrogens - Hormone Replacement/ Modifying Drugs
SRONYX TAB
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
SYEDA TAB 3-0.03MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
Estrogens - Hormone Replacement/ Modifying Drugs
TARINA FE TAB 1/20
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TAYTULLA CAP
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE CAP 1 MG-20 MCG (24)
Estrogens - Hormone Replacement/ Modifying Drugs
TILIA FE TAB
NORETHINDRONE AC-ETHINYL ESTRADFE TAB 1-20/1-30/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI FEMYNOR TAB
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-ESTARYLL TAB
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-LEGEST TAB FE
NORETHINDRONE AC-ETHINYL ESTRADFE TAB 1-20/1-30/1-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-LINYAH TAB
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-LO TAB ESTARYLL
NORGESTIMATE-ETH ESTRAD TAB 0.1825/0.215-25/0.25-25 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-LO- TAB MARZIA
NORGESTIMATE-ETH ESTRAD TAB 0.1825/0.215-25/0.25-25 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-LO- TAB SPRINTEC
NORGESTIMATE-ETH ESTRAD TAB 0.1825/0.215-25/0.25-25 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRINESSA TAB
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRINESSA LO TAB
NORGESTIMATE-ETH ESTRAD TAB 0.1825/0.215-25/0.25-25 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-NORINYL TAB 28
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-PREVIFEM TAB
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRI-SPRINTEC TAB
NORGESTIMATE-ETH ESTRAD TAB 0.1835/0.215-35/0.25-35 MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
TRIVORA-28 TAB
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG
Estrogens - Hormone Replacement/ Modifying Drugs
VELIVET PAK
DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG
Estrogens - Hormone Replacement/ Modifying Drugs
VESTURA TAB 3-0.02MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG
Estrogens - Hormone Replacement/ Modifying Drugs
VIENVA TAB 0.1-20
LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
VIORELE TAB
DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
VIVELLE-DOT DIS 0.025MG VIVELLE-DOT DIS 0.0375MG VIVELLE-DOT DIS 0.05MG VIVELLE-DOT DIS 0.075MG VIVELLE-DOT DIS 0.1MG
ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.1 MG/24HR
Estrogens - Hormone Replacement/ Modifying Drugs
VYFEMLA TAB 0.4-35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
WERA TAB 0.5/35
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG
97
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
X
Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
HCR Preventive Care HCR Preventive Care
Therapeutic Class
Label Name
Generic Name
Estrogens - Hormone Replacement/ Modifying Drugs
WYMZYA FE CHW 0.4MG-35
NORETHINDRONE & ETHINYL ESTRADIOLFE CHEW TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
XULANE DIS 150-35
NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR
Estrogens - Hormone Replacement/ Modifying Drugs
YASMIN 28 TAB 3-0.03MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
Tier 2
YAZ TAB 3-0.02MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG
HCR Preventive Care
YUVAFEM TAB 10MCG
ESTRADIOL VAGINAL TAB 10 MCG
Tier 2
ZARAH TAB 3-0.03MG
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
Tier 3
Estrogens - Hormone Replacement/ Modifying Drugs
ZENCHENT TAB
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ZENCHENT FE CHW 0.4MG35
NORETHINDRONE & ETHINYL ESTRADIOLFE CHEW TAB 0.4 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ZOVIA 1/35E TAB
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG
Estrogens - Hormone Replacement/ Modifying Drugs
ZOVIA 1/50E TAB
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG
GELFILM MIS OP
GELATIN ADSORBABLE OPHTH FILM
Tier 2
CYCLOGYL SOL 0.5% OP
CYCLOPENTOLATE HCL OPHTH SOLN 0.5%
Tier 3
CYCLOGYL SOL 1% OP
CYCLOPENTOLATE HCL OPHTH SOLN 1%
Tier 3
CYCLOGYL SOL 2% OP
CYCLOPENTOLATE HCL OPHTH SOLN 2%
Tier 3
CYCLOMYDRIL SOL OP
CYCLOPENTOLATE W/ PHENYLEPHRINE OPHTH SOLN 0.2-1%
Tier 3
CYCLOPENTOL SOL 1% OP
CYCLOPENTOLATE HCL OPHTH SOLN 1%
Tier 1
CYCLOPENTOL SOL 2% OP
CYCLOPENTOLATE HCL OPHTH SOLN 2%
Tier 1
CYCLOPENTOLA SOL 0.5%
CYCLOPENTOLATE HCL OPHTH SOLN 0.5%
Tier 1
HOMATROPAIRE SOL 5% OP HOMATROPINE HBR OPHTH SOLN 5%
Tier 1
HOMATROPINE SOL 5% OP
HOMATROPINE HBR OPHTH SOLN 5%
Tier 1
PAREMYD SOL 1-0.25%
HYDROXYAMPHETAMINE-TROPICAMIDE OPHTH SOLN 1-0.25%
Tier 3
ALTAFRIN SOL 10% OP
PHENYLEPHRINE HCL OPHTH SOLN 10%
Tier 1
ALTAFRIN SOL 2.5% OP
PHENYLEPHRINE HCL OPHTH SOLN 2.5%
Tier 1
PHENYLEPHRINE HCL OPHTH SOLN 10%
Tier 1
PHENYLEPHRINE HCL OPHTH SOLN 2.5%
Tier 1
POVIDONE-IODINE OPHTH SOLN 5%
Tier 3
Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs Estrogens - Hormone Replacement/ Modifying Drugs
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. - 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. - LOCAL ANESTHETICS (EENT) EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT)
PHENYLEPHRIN SOL 10% OP PHENYLEPHRIN SOL 2.5% OP BETADINE SOL 5% OP CORTANE-B DRO AQ OTIC CORTANE-B DRO OTIC CORTIC-ND DRO CYOTIC DRO EXOTIC-HC DRO OTIC OTICIN HC DRO OTOMAX-HC DRO
PRAMOXINE-HC-CHLOROXYLENOL AQUEOUS OTIC SOLN 10-10-1 MG/ML PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLN 10-10-1 MG/ML PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLN 10-10-1 MG/ML PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLN 10-10-1 MG/ML PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLN 10-10-1 MG/ML PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLN 10-10-1 MG/ML PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLN 10-10-1 MG/ML
Tier Value HCR Preventive Care HCR Preventive Care
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 2 Tier 1
AKTEN GEL 3.5%
LIDOCAINE HCL OPHTH GEL 3.5%
Tier 3
ALTACAINE SOL 0.5% OP
TETRACAINE HCL OPHTH SOLN 0.5%
Tier 1
98
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class 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 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 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Generic Name
TETCAINE SOL 0.5% OP
TETRACAINE HCL OPHTH SOLN 0.5%
Tier 1
TETRACAINE SOL 0.5% OP
TETRACAINE HCL OPHTH SOLN 0.5%
Tier 1
TETRAVISC SOL 0.5% OP
TETRACAINE HCL OPHTH SOLN 0.5%
Tier 1
TETRAVISC SOL FORTE
TETRACAINE HCL OPHTH SOLN 0.5%
Tier 1
SAVELLA MIS TITR PAK
MILNACIPRAN HCL TAB 12.5 MG (5) & 25 MG (8) & 50 MG (42) PAK
Tier 3
X
SAVELLA TAB 100MG
MILNACIPRAN HCL TAB 100 MG
Tier 3
X
SAVELLA TAB 12.5MG
MILNACIPRAN HCL TAB 12.5 MG
Tier 3
X
SAVELLA TAB 25MG
MILNACIPRAN HCL TAB 25 MG
Tier 3
X
SAVELLA TAB 50MG
MILNACIPRAN HCL TAB 50 MG
Tier 3
X
ESZOPICLONE TAB 1MG
ESZOPICLONE TAB 1 MG
Tier 2
X
ESZOPICLONE TAB 2MG
ESZOPICLONE TAB 2 MG
Tier 2
X
ESZOPICLONE TAB 3MG
ESZOPICLONE TAB 3 MG
Tier 2
X
FLURAZEPAM CAP 15MG
FLURAZEPAM HCL CAP 15 MG
Tier 1
FLURAZEPAM CAP 30MG
FLURAZEPAM HCL CAP 30 MG
Tier 1
HALCION TAB 0.25MG
TRIAZOLAM TAB 0.25 MG
Tier 3
RESTORIL CAP 15MG
TEMAZEPAM CAP 15 MG
Tier 3
RESTORIL CAP 22.5MG
TEMAZEPAM CAP 22.5 MG
Tier 3
RESTORIL CAP 30MG
TEMAZEPAM CAP 30 MG
Tier 3
RESTORIL CAP 7.5MG
TEMAZEPAM CAP 7.5 MG
Tier 3
SONATA CAP 10MG
ZALEPLON CAP 10 MG
Tier 3
X
SONATA CAP 5MG
ZALEPLON CAP 5 MG
Tier 3
X
TEMAZEPAM CAP 15MG
TEMAZEPAM CAP 15 MG
Tier 1
TEMAZEPAM CAP 22.5MG
TEMAZEPAM CAP 22.5 MG
Tier 1
TEMAZEPAM CAP 30MG
TEMAZEPAM CAP 30 MG
Tier 1
TEMAZEPAM CAP 7.5MG
TEMAZEPAM CAP 7.5 MG
Tier 1
TRIAZOLAM TAB 0.125MG
TRIAZOLAM TAB 0.125 MG
Tier 1
TRIAZOLAM TAB 0.25MG
TRIAZOLAM TAB 0.25 MG
Tier 1
ZALEPLON CAP 10MG
ZALEPLON CAP 10 MG
Tier 1
X
ZALEPLON CAP 5MG
ZALEPLON CAP 5 MG
Tier 1
X
ZOLPIDEM TAB 10MG
ZOLPIDEM TARTRATE TAB 10 MG
Tier 1
X
ZOLPIDEM TAB 5MG
ZOLPIDEM TARTRATE TAB 5 MG
Tier 1
X
ZOLPIMIST SPR 5MG
ZOLPIDEM TARTRATE ORAL SPRAY 5 MG/ ACT
Tier 3
X
CLONAZEP ODT TAB 0.125MG
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG
Tier 1
CLONAZEP ODT TAB 0.25MG
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG
Tier 1
CLONAZEP ODT TAB 0.5MG
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG
Tier 1
CLONAZEP ODT TAB 1MG
CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG
Tier 1
CLONAZEP ODT TAB 2MG
CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG
Tier 1
99
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
X
Therapeutic Class Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Generic Name
CLONAZEPAM TAB 0.5MG
CLONAZEPAM TAB 0.5 MG
Tier 1
CLONAZEPAM TAB 1MG
CLONAZEPAM TAB 1 MG
Tier 1
CLONAZEPAM TAB 2MG
CLONAZEPAM TAB 2 MG
Tier 1
CLORAZ DIPOT TAB 15MG
CLORAZEPATE DIPOTASSIUM TAB 15 MG
Tier 1
CLORAZ DIPOT TAB 3.75MG
CLORAZEPATE DIPOTASSIUM TAB 3.75 MG
Tier 1
CLORAZ DIPOT TAB 7.5MG
CLORAZEPATE DIPOTASSIUM TAB 7.5 MG
Tier 1
DEPAKENE CAP 250MG
VALPROIC ACID CAP 250 MG
Tier 3
DEPAKENE SOL 250/5ML
VALPROATE SODIUM ORAL SOLN 250 MG/5ML (BASE EQUIV)
Tier 3
DEPAKOTE TAB 125MG DR
DIVALPROEX SODIUM TAB DELAYED RELEASE 125 MG
Tier 3
X
DEPAKOTE TAB 250MG DR
DIVALPROEX SODIUM TAB DELAYED RELEASE 250 MG
Tier 3
X
DEPAKOTE TAB 500MG DR
DIVALPROEX SODIUM TAB DELAYED RELEASE 500 MG
Tier 3
X
DEPAKOTE ER TAB 250MG
DIVALPROEX SODIUM TAB SR 24 HR 250 MG
Tier 3
X
X
DEPAKOTE ER TAB 500MG
DIVALPROEX SODIUM TAB SR 24 HR 500 MG
Tier 3
X
X
DEPAKOTE SPR CAP 125MG
DIVALPROEX SODIUM CAP DELAYED RELEASE SPRINKLE 125 MG
Tier 3
X
X
DIASTAT ACDL GEL 12.5-20
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG
Tier 3
X
DIASTAT ACDL GEL 5-10MG
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG
Tier 3
X
DIASTAT PED GEL 2.5M GEL
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG
Tier 2
X
DIAZEPAM GEL 10MG
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG
Tier 1
X
DIAZEPAM GEL 2.5MG
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG
Tier 1
X
DIAZEPAM GEL 20MG
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG
Tier 1
X
DIVALPROEX CAP 125MG
DIVALPROEX SODIUM CAP DELAYED RELEASE SPRINKLE 125 MG
Tier 2
DIVALPROEX TAB 125MG DR
DIVALPROEX SODIUM TAB DELAYED RELEASE 125 MG
Tier 1
DIVALPROEX TAB 250MG DR
DIVALPROEX SODIUM TAB DELAYED RELEASE 250 MG
Tier 1
DIVALPROEX TAB 250MG ER
DIVALPROEX SODIUM TAB SR 24 HR 250 MG
Tier 2
DIVALPROEX TAB 500MG DR
DIVALPROEX SODIUM TAB DELAYED RELEASE 500 MG
Tier 1
DIVALPROEX TAB 500MG ER
DIVALPROEX SODIUM TAB SR 24 HR 500 MG
Tier 2
100
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Therapeutic Class Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs
Generic Name
FYCOMPA SUS 0.5MG/ML
PERAMPANEL SUSP 0.5 MG/ML
Tier 3
X
FYCOMPA TAB 10MG
PERAMPANEL TAB 10 MG
Tier 3
X
FYCOMPA TAB 12MG
PERAMPANEL TAB 12 MG
Tier 3
X
FYCOMPA TAB 2MG
PERAMPANEL TAB 2 MG
Tier 3
X
FYCOMPA TAB 4MG
PERAMPANEL TAB 4 MG
Tier 3
X
FYCOMPA TAB 6MG
PERAMPANEL TAB 6 MG
Tier 3
X
FYCOMPA TAB 8MG
PERAMPANEL TAB 8 MG
Tier 3
X
GABAPENTIN CAP 100MG
GABAPENTIN CAP 100 MG
Tier 1
GABAPENTIN CAP 300MG
GABAPENTIN CAP 300 MG
Tier 1
GABAPENTIN CAP 400MG
GABAPENTIN CAP 400 MG
Tier 1
GABAPENTIN SOL 250/5ML
GABAPENTIN ORAL SOLN 250 MG/5ML
Tier 1
GABAPENTIN TAB 600MG
GABAPENTIN TAB 600 MG
Tier 1
GABAPENTIN TAB 800MG
GABAPENTIN TAB 800 MG
Tier 1
GABITRIL TAB 12MG
TIAGABINE HCL TAB 12 MG
Tier 2
GABITRIL TAB 16MG
TIAGABINE HCL TAB 16 MG
Tier 2
GABITRIL TAB 2MG
TIAGABINE HCL TAB 2 MG
Tier 3
GABITRIL TAB 4MG
TIAGABINE HCL TAB 4 MG
Tier 3
GENE-XENE TAB 15MG
CLORAZEPATE DIPOTASSIUM TAB 15 MG
Tier 1
GENE-XENE TAB 3.75MG
CLORAZEPATE DIPOTASSIUM TAB 3.75 MG
Tier 1
GENE-XENE TAB 7.5MG
CLORAZEPATE DIPOTASSIUM TAB 7.5 MG
Tier 1
KLONOPIN TAB 0.5MG
CLONAZEPAM TAB 0.5 MG
Tier 3
KLONOPIN TAB 1MG
CLONAZEPAM TAB 1 MG
Tier 3
KLONOPIN TAB 2MG
CLONAZEPAM TAB 2 MG
Tier 3
MYSOLINE TAB 250MG
PRIMIDONE TAB 250 MG
Tier 2
X
X
MYSOLINE TAB 50MG
PRIMIDONE TAB 50 MG
Tier 2
X
X
NEURONTIN CAP 100MG
GABAPENTIN CAP 100 MG
Tier 3
X
X
101
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Therapeutic Class Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control 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
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Generic Name
NEURONTIN CAP 300MG
GABAPENTIN CAP 300 MG
Tier 3
X
X
NEURONTIN CAP 400MG
GABAPENTIN CAP 400 MG
Tier 3
X
X
NEURONTIN SOL 250/5ML
GABAPENTIN ORAL SOLN 250 MG/5ML
Tier 3
X
X
NEURONTIN TAB 600MG
GABAPENTIN TAB 600 MG
Tier 3
X
X
NEURONTIN TAB 800MG
GABAPENTIN TAB 800 MG
Tier 3
X
X
ONFI SUS 2.5MG/ML
CLOBAZAM SUSPENSION 2.5 MG/ML
Tier 3
X
ONFI TAB 10MG
CLOBAZAM TAB 10 MG
Tier 3
X
ONFI TAB 20MG
CLOBAZAM TAB 20 MG
Tier 3
X
PRIMIDONE TAB 250MG
PRIMIDONE TAB 250 MG
Tier 1
PRIMIDONE TAB 50MG
PRIMIDONE TAB 50 MG
Tier 1
SABRIL POW 500MG
VIGABATRIN POWD PACK 500 MG
Tier 2
X
SABRIL TAB 500MG
VIGABATRIN TAB 500 MG
Tier 2
X
TIAGABINE TAB 2MG
TIAGABINE HCL TAB 2 MG
Tier 1
TIAGABINE TAB 4MG
TIAGABINE HCL TAB 4 MG
Tier 1
TRANXENE T TAB 3.75MG
CLORAZEPATE DIPOTASSIUM TAB 3.75 MG
Tier 3
TRANXENE T TAB 7.5MG
CLORAZEPATE DIPOTASSIUM TAB 7.5 MG
Tier 3
VALPROIC ACD CAP 250MG VALPROIC ACID CAP 250 MG
Tier 1
VALPROIC ACD SOL 250/5ML
VALPROATE SODIUM ORAL SOLN 250 MG/5ML (BASE EQUIV)
Tier 1
ACTIGALL CAP 300MG
URSODIOL CAP 300 MG
Tier 3
BISACODYL TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
CASCARA EXT SAGRADA
CASCARA SAGRADA FL EXT 1 GM/ML
Tier 1
CHENODAL TAB 250MG
CHENODIOL TAB 250 MG
Tier 3
CORRECT TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
CROMOLYN SOD CON 100/5ML
CROMOLYN SODIUM ORAL CONC 100 MG/5ML DIPHENOXYLATE W/ ATROPINE LIQ 2.50.025 MG/5ML DIPHENOXYLATE W/ ATROPINE TAB 2.50.025 MG
DIPHEN/ATROP LIQ 2.5/5 DIPHEN/ATROP TAB 2.5MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
DUCODYL TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
ENTEREG CAP 12MG
ALVIMOPAN CAP 12 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
EQL GENTLE TAB LAXATIVE
BISACODYL TAB DELAYED RELEASE 5 MG
102
HCR Preventive Care
HCR Preventive Care Tier 1 Tier 1 Tier 1 HCR Preventive Care Tier 3 HCR Preventive Care
X
Therapeutic Class
Label Name
Generic Name
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
EQL LAXATIVE TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
EX-LAX ULTRA TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
FEMININE LAX TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
FLEET LAXATI TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
GASTROCROM CON 100/5ML GATTEX KIT 5MG
TEDUGLUTIDE (RDNA) FOR INJ KIT 5 MG
Tier 2
GAVILYTE-H KIT
BISACODYL TAB & PEG 3350-KCL-SOD BICARB-NACL FOR SOLN KIT
Tier 1
GENTLE LAXAT TAB 5MG EC BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
GNP BISA-LAX TAB 5MG EC
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
GNP LAXATIVE TAB 5MG EC BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
HM LAXATIVE TAB 5MG
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
HM LAXATIVE TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
KP BISACODYL TAB 5MG EC BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
LAXATIVE TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
BISACODYL TAB DELAYED RELEASE 5 MG
Tier 3
METOCLOPRAM TAB 10MG
METOCLOPRAMIDE HCL TAB 10 MG
Tier 1
METOCLOPRAM TAB 5MG
METOCLOPRAMIDE HCL TAB 5 MG
Tier 1
MINERAL OIL
Tier 1
MINERAL OIL HEAVY MYTESI TAB 125MG OSMOPREP TAB 1.5GM PAREGORIC TIN 2MG/5ML PEG-PREP KIT PYLERA CAP
CROFELEMER TAB DELAYED RELEASE 125 MG SOD PHOS MONO-SOD PHOS DI TABS 1.102-0.398 GM(1.5GM NA PHOS) PAREGORIC TINCTURE 2 MG/5ML (MORPHINE EQUIVALENT) BISACODYL TAB & PEG 3350-KCL-SOD BICARB-NACL FOR SOLN KIT BISMUTH SUBCIT-METRONIDAZOLETETRACYCLINE CAP 140-125-125 MG
Tier 3
X
X
Tier 1 Tier 3
X
HCR Preventive Care HCR Preventive Care
BISACODYL TAB DELAYED RELEASE 5 MG
REGLAN TAB 10MG
METOCLOPRAMIDE HCL TAB 10 MG
Tier 3
METOCLOPRAMIDE HCL TAB 5 MG
Tier 3
103
X
Tier 1
RA LAXATIVE TAB 5MG EC
RELISTOR INJ 8/0.4ML
X
Tier 3
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
RELISTOR INJ 12/0.6ML
X
Tier 1
BISACODYL TAB DELAYED RELEASE 5 MG
METHYLNALTREXONE BROMIDE INJ 12 MG/0.6ML (20 MG/ML) METHYLNALTREXONE BROMIDE INJ 8 MG/0.4ML (20 MG/ML)
X
Tier 3
QC LAXATIVE TAB 5MG EC
REGLAN TAB 5MG
X
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
X
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
METOCLOPRAM SOL 5MG/5ML
LOMOTIL TAB 2.5MG
X
Tier 3
DIPHENOXYLATE W/ ATROPINE TAB 2.50.025 MG DIPHENOXYLATE W/ ATROPINE TAB 2.50.025 MG METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML)
LOFENE TAB 2.5MG
Prior Supply Step Specialty Authorization Limit Therapy
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
CROFELEMER TAB DELAYED RELEASE 125 MG CROMOLYN SODIUM ORAL CONC 100 MG/5ML
FULYZAQ TAB 125MG
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
Tier Value
Tier 3
X
Tier 3
X
Therapeutic Class
Label Name
Generic Name
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
SM GENTLE TAB LAXATIVE
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
SM LAXATIVE TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
SODIUM POW BICARBON
*SODIUM BICARBONATE POWDER**
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
STIM LAXAT TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
URSO 250 TAB 250MG
URSODIOL TAB 250 MG
Tier 3
URSO FORTE TAB 500MG
URSODIOL TAB 500 MG
Tier 3
URSODIOL CAP 300MG
URSODIOL CAP 300 MG
Tier 1
URSODIOL TAB 250MG
URSODIOL TAB 250 MG
Tier 1
URSODIOL TAB 500MG
URSODIOL TAB 500 MG
Tier 1
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
VERCOLATE TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
WOMANS LAXAT TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
Gastrointestinal Agents, Other Miscellaneous Gastrointestinal Drugs
WOMENS LAXAT TAB 5MG EC
BISACODYL TAB DELAYED RELEASE 5 MG
XENICAL CAP 120MG
ORLISTAT CAP 120 MG
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 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
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care
HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3
X
LECITHIN GRA
LECITHIN GRANULES
Tier 1
CIALIS TAB 10MG CIALIS TAB 20MG
TADALAFIL TAB 10 MG TADALAFIL TAB 20 MG
Tier 3 Tier 3
X X
CAVERJECT INJ 20MCG
ALPROSTADIL FOR INJ 20 MCG
Tier 3
X
CAVERJECT INJ 40MCG
ALPROSTADIL FOR INJ 40 MCG
Tier 3
X
CAVERJECT KIT 10MCG
ALPROSTADIL FOR INJ KIT 10 MCG
Tier 3
X
CAVERJECT KIT 20MCG
ALPROSTADIL FOR INJ KIT 20 MCG
Tier 3
X
EDEX KIT 10MCG
ALPROSTADIL FOR INJ KIT 10 MCG
Tier 3
X
EDEX KIT 20MCG
ALPROSTADIL FOR INJ KIT 20 MCG
Tier 3
X
EDEX KIT 40MCG
ALPROSTADIL FOR INJ KIT 40 MCG
Tier 3
X
LEVITRA TAB 10MG
VARDENAFIL HCL TAB 10 MG
Tier 3
X
LEVITRA TAB 2.5MG
VARDENAFIL HCL TAB 2.5 MG
Tier 3
X
LEVITRA TAB 20MG
VARDENAFIL HCL TAB 20 MG
Tier 3
X
LEVITRA TAB 5MG
VARDENAFIL HCL TAB 5 MG
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
MUSE SUP 1000MCG MUSE SUP 125MCG MUSE SUP 250MCG MUSE SUP 500MCG
ALPROSTADIL URETHRAL PELLET 1000 MCG ALPROSTADIL URETHRAL PELLET 125 MCG ALPROSTADIL URETHRAL PELLET 250 MCG ALPROSTADIL URETHRAL PELLET 500 MCG
STENDRA TAB 100MG
AVANAFIL TAB 100 MG
Tier 3
X
X
STENDRA TAB 200MG
AVANAFIL TAB 200 MG
Tier 3
X
X
STENDRA TAB 50MG
AVANAFIL TAB 50 MG
Tier 3
X
X
VIAGRA TAB 100MG
SILDENAFIL CITRATE TAB 100 MG
Tier 3
X
VIAGRA TAB 25MG
SILDENAFIL CITRATE TAB 25 MG
Tier 3
X
VIAGRA TAB 50MG
SILDENAFIL CITRATE TAB 50 MG
Tier 3
X
104
Therapeutic Class Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions Drugs Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions 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 - Inflammatory Bowel Disease Drugs Glucocorticoids - Inflammatory Bowel Disease Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs
Label Name
Generic Name
BETHANECHOL TAB 10MG
BETHANECHOL CHLORIDE TAB 10 MG
Tier 1
BETHANECHOL TAB 25MG
BETHANECHOL CHLORIDE TAB 25 MG
Tier 1
BETHANECHOL TAB 50MG
BETHANECHOL CHLORIDE TAB 50 MG
Tier 1
BETHANECHOL TAB 5MG
BETHANECHOL CHLORIDE TAB 5 MG
Tier 1
ELMIRON CAP 100MG
PENTOSAN POLYSULFATE SODIUM CAPS 100 MG
Tier 2
LITHOSTAT TAB 250MG
ACETOHYDROXAMIC ACID TAB 250 MG
Tier 3
PHENAZO TAB 200MG
PHENAZOPYRIDINE HCL TAB 200 MG
Tier 1
PHENAZOPYRID TAB 100MG PHENAZOPYRIDINE HCL TAB 100 MG
Tier 1
PHENAZOPYRID TAB 200MG PHENAZOPYRIDINE HCL TAB 200 MG
Tier 1
PYRIDIUM TAB 100MG
PHENAZOPYRIDINE HCL TAB 100 MG
Tier 3
PYRIDIUM TAB 200MG
PHENAZOPYRIDINE HCL TAB 200 MG
Tier 3
THIOLA TAB 100MG
TIOPRONIN TAB 100 MG
Tier 3
URECHOLINE TAB 10MG
BETHANECHOL CHLORIDE TAB 10 MG
Tier 3
URECHOLINE TAB 25MG
BETHANECHOL CHLORIDE TAB 25 MG
Tier 3
URECHOLINE TAB 50MG
BETHANECHOL CHLORIDE TAB 50 MG
Tier 3
URECHOLINE TAB 5MG
BETHANECHOL CHLORIDE TAB 5 MG
Tier 3
BUDESONIDE CAP 3MG DR
BUDESONIDE DELAYED RELEASE PARTICLES CAP 3 MG
Tier 2
COLOCORT ENE 100MG
HYDROCORTISONE ENEMA 100 MG/60ML
Tier 1
CORTENEMA ENE 100MG
HYDROCORTISONE ENEMA 100 MG/60ML
Tier 3
HYDROCORT ENE 100MG
HYDROCORTISONE ENEMA 100 MG/60ML
Tier 1
PREDNISOLONE TAB 5 MG
Tier 2
MILLIPRED TAB 5MG MILLIPRED DP PAK 5MG MILLIPRED DP PAK 5MG PREDNISOLONE SOL 15MG/5ML PREDNISOLONE SYP 15MG/5ML
PREDNISOLONE TAB THERAPY PACK 5 MG (48) PREDNISOLONE TAB THERAPY PACK 5 MG (21) PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT) PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT)
Tier Value
Tier 2 Tier 2 Tier 1 Tier 1
UCERIS TAB 9MG
BUDESONIDE TAB SR 24HR 9 MG
Tier 2
ACLOVATE CRE 0.05%
ALCLOMETASONE DIPROPIONATE CREAM 0.05%
Tier 3
ALA SCALP LOT 2%
HYDROCORTISONE LOTION 2%
Tier 3
ALA-CORT CRE 2.5%
HYDROCORTISONE CREAM 2.5%
Tier 1
ALCLOMETASONE DIPROPIONATE ALCLOMETASON CRE 0.05% CREAM 0.05% ALCLOMETASONE DIPROPIONATE OINT ALCLOMETASON OIN 0.05% 0.05%
105
Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
X
Therapeutic Class Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs
Label Name
Generic Name
ALPHATREX GEL 0.05%
BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05%
Tier 1
AMCINONIDE CRE 0.1%
AMCINONIDE CREAM 0.1%
Tier 3
AMCINONIDE LOT 0.1%
AMCINONIDE LOTION 0.1%
Tier 3
AMCINONIDE OIN 0.1%
AMCINONIDE OINT 0.1%
Tier 1
ANUSOL-HC CRE 2.5%
HYDROCORTISONE RECTAL CREAM 2.5%
Tier 3
APEXICON E CRE 0.05% AUG BETAMET CRE 0.05% AUG BETAMET GEL 0.05% AUG BETAMET LOT 0.05% AUG BETAMET OIN 0.05% BETAMETH DIP CRE 0.05% BETAMETH DIP LOT 0.05% BETAMETH DIP OIN 0.05% BETAMETH VAL CRE 0.1% BETAMETH VAL LOT 0.1%
DIFLORASONE DIACETATE EMOLLIENT BASE CREAM 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED LOTION 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% BETAMETHASONE DIPROPIONATE CREAM 0.05% BETAMETHASONE DIPROPIONATE LOTION 0.05% BETAMETHASONE DIPROPIONATE OINT 0.05% BETAMETHASONE VALERATE CREAM 0.1% BETAMETHASONE VALERATE LOTION 0.1%
Tier Value
Tier 2
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 1 Tier 2 Tier 1 Tier 1
BETAMETH VAL OIN 0.1%
BETAMETHASONE VALERATE OINT 0.1%
Tier 1
CAPEX SHA 0.01%
FLUOCINOLONE ACETONIDE SHAMPOO 0.01%
Tier 2
CLOBETASOL CRE 0.05%
CLOBETASOL PROPIONATE CREAM 0.05%
Tier 2
X
CLOBETASOL GEL 0.05%
CLOBETASOL PROPIONATE GEL 0.05%
Tier 2
X
CLOBETASOL OIN 0.05%
CLOBETASOL PROPIONATE OINT 0.05%
Tier 2
X
CLOBETASOL SOL 0.05%
CLOBETASOL PROPIONATE SOLN 0.05%
Tier 1
X
CLOBETASOL SPR 0.05%
CLOBETASOL PROPIONATE SPRAY 0.05%
Tier 1
X
CLOBETASOL E CRE 0.05%
CLOBETASOL PROPIONATE EMOLLIENT BASE CREAM 0.05%
Tier 2
X
CLOBEX SPR 0.05%
CLOBETASOL PROPIONATE SPRAY 0.05%
Tier 3
X
CLOCORTOLONE CRE PIV 0.1%
CLOCORTOLONE PIVALATE CREAM 0.1%
Tier 3
X
X
CORDRAN CRE 0.05%
FLURANDRENOLIDE CREAM 0.05%
Tier 3
X
X
CORDRAN CRE 0.05%
FLURANDRENOLIDE CREAM 0.05%
Tier 3
X
X
CORDRAN LOT 0.05%
FLURANDRENOLIDE LOTION 0.05%
Tier 3
X
X
CORDRAN LOT 0.05%
FLURANDRENOLIDE LOTION 0.05%
Tier 3
X
X
CORDRAN OIN 0.05%
FLURANDRENOLIDE OINT 0.05%
Tier 3
CORDRAN 24X3 TAP 4MCG/ FLURANDRENOLIDE TAPE 4 MCG/SQCM CM CORDRAN 24X3 TAP SML FLURANDRENOLIDE TAPE 4 MCG/SQCM 24IN CORDRAN 80X3 TAP 4MCG/ FLURANDRENOLIDE TAPE 4 MCG/SQCM CM
Tier 3
X
Tier 3
X
Tier 3
X X
CORMAX SCALP SOL 0.05%
CLOBETASOL PROPIONATE SOLN 0.05%
Tier 1
CORTEF TAB 10MG
HYDROCORTISONE TAB 10 MG
Tier 3
CORTEF TAB 20MG
HYDROCORTISONE TAB 20 MG
Tier 3
CORTEF TAB 5MG
HYDROCORTISONE TAB 5 MG
Tier 3
CORTIFOAM AER 90MG
HYDROCORTISONE ACETATE RECTAL FOAM 10% (90 MG/DOSE)
Tier 2
CORTISONE AC TAB 25MG
CORTISONE ACETATE TAB 25 MG
Tier 1
106
X
Therapeutic Class Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs
Label Name CUTIVATE CRE 0.05% CUTIVATE LOT 0.05%
Generic Name FLUTICASONE PROPIONATE CREAM 0.05% FLUTICASONE PROPIONATE LOTION 0.05%
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3
X
DELTASONE TAB 20MG
PREDNISONE TAB 20 MG
DERMA-SMOOTH OIL /FS BODY DERMA-SMOOTH OIL /FS SCLP
FLUOCINOLONE ACETONIDE OIL 0.01% (BODY OIL) FLUOCINOLONE ACETONIDE OIL 0.01% (SCALP OIL)
DERMATOP CRE 0.1%
PREDNICARBATE CREAM 0.1%
Tier 3
DERMATOP OIN 0.1%
PREDNICARBATE OINT 0.1%
Tier 3
DESONATE GEL 0.05%
DESONIDE GEL 0.05%
Tier 3
X
DESONIDE CRE 0.05%
DESONIDE CREAM 0.05%
Tier 3
X
DESONIDE LOT 0.05%
DESONIDE LOTION 0.05%
Tier 3
X
DESONIDE OIN 0.05%
DESONIDE OINT 0.05%
Tier 3
X
DESOWEN CRE 0.05%
DESONIDE CREAM 0.05%
Tier 3
X
DESOWEN LOT 0.05%
DESONIDE LOTION 0.05%
Tier 3
X
DESOXIMETAS CRE 0.05%
DESOXIMETASONE CREAM 0.05%
Tier 1
X
DESOXIMETAS CRE 0.25%
DESOXIMETASONE CREAM 0.25%
Tier 1
X
DESOXIMETAS GEL 0.05%
DESOXIMETASONE GEL 0.05%
Tier 3
X
DESOXIMETAS OIN 0.05%
DESOXIMETASONE OINT 0.05%
Tier 3
X
DESOXIMETAS OIN 0.25%
DESOXIMETASONE OINT 0.25%
Tier 3
X
DEXAMETHASONE CONC 1 MG/ML
Tier 1
DEXAMETHASONE ELIXIR 0.5 MG/5ML
Tier 1
DEXAMETHASONE SOLN 0.5 MG/5ML
Tier 1
DEXAMETHASONE TAB 0.5 MG
Tier 1
DEXAMETHASONE TAB 0.75 MG
Tier 1
DEXAMETHASONE TAB 1.5 MG
Tier 1
DEXAMETHASON TAB 1MG
DEXAMETHASONE TAB 1 MG
Tier 1
DEXAMETHASON TAB 2MG
DEXAMETHASONE TAB 2 MG
Tier 1
DEXAMETHASON TAB 4MG
DEXAMETHASONE TAB 4 MG
Tier 1
DEXAMETHASON TAB 6MG
DEXAMETHASONE TAB 6 MG
Tier 1
DEXAMETHASON CON 1MG/ML DEXAMETHASON ELX 0.5/5ML DEXAMETHASON SOL 0.5/5ML DEXAMETHASON TAB 0.5MG DEXAMETHASON TAB 0.75MG DEXAMETHASON TAB 1.5MG
DEXPAK PAK 10 DAY DEXPAK PAK 13 DAY DEXPAK PAK 6 DAY
DEXAMETHASONE TAB THERAPY PACK 1.5 MG (35) DEXAMETHASONE TAB THERAPY PACK 1.5 MG (51) DEXAMETHASONE TAB THERAPY PACK 1.5 MG (21)
Tier 1 Tier 3
Tier 3 Tier 3 Tier 3
DIFLORASONE DIACETATE CREAM 0.05%
Tier 3
DIFLORASONE OIN 0.05%
DIFLORASONE DIACETATE OINT 0.05%
Tier 3
DIPROLENE LOT 0.05% DIPROLENE OIN 0.05% DIPROLENE AF CRE 0.05%
Tier 3 Tier 3 Tier 3
ELOCON CRE 0.1%
MOMETASONE FUROATE CREAM 0.1%
Tier 3
ELOCON LOT 0.1%
MOMETASONE FUROATE SOLUTION 0.1% (LOTION)
Tier 3
ELOCON OIN 0.1%
MOMETASONE FUROATE OINT 0.1%
Tier 3
107
X
Tier 3
DIFLORASONE CRE 0.05%
BETAMETHASONE DIPROPIONATE AUGMENTED LOTION 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05%
X
X
Therapeutic Class Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs
Label Name
Generic Name
FLUDROCORT TAB 0.1MG
FLUDROCORTISONE ACETATE TAB 0.1 MG
FLUOCINOLONE ACETONIDE CREAM 0.01% FLUOCINOLONE ACETONIDE CREAM FLUOCIN ACET CRE 0.025% 0.025% FLUOCINOLONE ACETONIDE OIL 0.01% FLUOCIN ACET OIL 0.01% SC (SCALP OIL) FLUOCIN ACET OIL FLUOCINOLONE ACETONIDE OIL 0.01% 0.01%BDY (BODY OIL) FLUOCINOLONE ACETONIDE OIL 0.01% FLUOCIN ACET OIL BODY (BODY OIL) FLUOCINOLONE ACETONIDE OIL 0.01% FLUOCIN ACET OIL SCALP (SCALP OIL)
FLUOCIN ACET CRE 0.01%
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 3
X
Tier 3
X
Tier 3 Tier 3
X
Tier 3
X
Tier 3
FLUOCIN ACET OIN 0.025%
FLUOCINOLONE ACETONIDE OINT 0.025%
Tier 2
X
FLUOCIN ACET SOL 0.01%
FLUOCINOLONE ACETONIDE SOLN 0.01%
Tier 3
X
FLUOCINONIDE CRE 0.05%
FLUOCINONIDE CREAM 0.05%
Tier 1
FLUOCINONIDE CRE -E 0.05%
FLUOCINONIDE EMULSIFIED BASE CREAM 0.05% FLUOCINONIDE EMULSIFIED BASE CREAM 0.05%
FLUOCINONIDE GEL 0.05%
FLUOCINONIDE GEL 0.05%
Tier 1
FLUOCINONIDE OIN 0.05%
FLUOCINONIDE OINT 0.05%
Tier 1
FLUOCINONIDE SOL 0.05%
FLUOCINONIDE SOLN 0.05%
Tier 1
FLUOCINONIDE CRE E 0.05%
Tier 1 Tier 1
FLURANDRENOL CRE 0.05% FLURANDRENOLIDE CREAM 0.05%
Tier 3
X
X
FLURANDRENOL CRE 0.05% FLURANDRENOLIDE CREAM 0.05%
Tier 3
X
X
FLURANDRENOL LOT 0.05% FLURANDRENOLIDE LOTION 0.05%
Tier 3
X
X
FLURANDRENOL OIN 0.05%
Tier 3
FLUTICASONE CRE 0.05% FLUTICASONE LOT 0.05%
FLURANDRENOLIDE OINT 0.05% FLUTICASONE PROPIONATE CREAM 0.05% FLUTICASONE PROPIONATE LOTION 0.05%
X
Tier 1 Tier 3
X
X
FLUTICASONE OIN 0.005%
FLUTICASONE PROPIONATE OINT 0.005%
Tier 1
HALOBETASOL CRE 0.05%
HALOBETASOL PROPIONATE CREAM 0.05%
Tier 2
X
HALOBETASOL OIN 0.05%
HALOBETASOL PROPIONATE OINT 0.05%
Tier 2
X
HALOG CRE 0.1%
HALCINONIDE CREAM 0.1%
Tier 3
X
X
HALOG OIN 0.1%
HALCINONIDE OINT 0.1%
Tier 3
X
X
HC BUTYRATE CRE 0.1%
HYDROCORTISONE BUTYRATE CREAM 0.1%
Tier 1
HC BUTYRATE OIN 0.1%
HYDROCORTISONE BUTYRATE OINT 0.1%
Tier 1
HC BUTYRATE SOL 0.1% HC VALERATE CRE 0.2%
HYDROCORTISONE BUTYRATE SOLN 0.1% HYDROCORTISONE VALERATE CREAM 0.2%
Tier 1 Tier 3
X X
HC VALERATE OIN 0.2%
HYDROCORTISONE VALERATE OINT 0.2%
Tier 3
HYDROCORT CRE 1%
HYDROCORTISONE RECTAL CREAM 1%
Tier 1
HYDROCORT CRE 2.5%
HYDROCORTISONE CREAM 2.5%
Tier 1
HYDROCORT LOT 2.5%
HYDROCORTISONE LOTION 2.5%
Tier 1
HYDROCORT OIN 1%
HYDROCORTISONE OINT 1%
Tier 1
HYDROCORT OIN 2.5%
HYDROCORTISONE OINT 2.5%
Tier 1
HYDROCORT TAB 10MG
HYDROCORTISONE TAB 10 MG
Tier 1
HYDROCORT TAB 20MG
HYDROCORTISONE TAB 20 MG
Tier 1
HYDROCORT TAB 5MG
HYDROCORTISONE TAB 5 MG
Tier 1
108
Therapeutic Class Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs
Label Name
Generic Name
Tier Value
HYDROCORT/AB OIN 1%
HYDROCORTISONE OINT 1%
Tier 1
HYDROCORTISO CRE 2.5%
HYDROCORTISONE RECTAL CREAM 2.5%
Tier 1
LOCOID CRE 0.1%
HYDROCORTISONE BUTYRATE CREAM 0.1%
Tier 3
LOCOID OIN 0.1%
HYDROCORTISONE BUTYRATE OINT 0.1%
Tier 3
LOCOID SOL 0.1%
HYDROCORTISONE BUTYRATE SOLN 0.1%
Tier 3
LOKARA LOT 0.05%
DESONIDE LOTION 0.05%
Tier 3
MEDROL TAB 16MG
METHYLPREDNISOLONE TAB 16 MG
Tier 3
MEDROL TAB 2MG
METHYLPREDNISOLONE TAB 2 MG
Tier 2
MEDROL TAB 32MG
METHYLPREDNISOLONE TAB 32 MG
Tier 3
MEDROL TAB 4MG
METHYLPREDNISOLONE TAB 4 MG
Tier 3
MEDROL TAB 4MG
METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)
Tier 3
MEDROL TAB 8MG
METHYLPREDNISOLONE TAB 8 MG
Tier 3
METHYLPRED POW ACETATE
METHYLPREDNISOLONE ACETATE POWDER
Tier 3
METHYLPRED TAB 16MG
METHYLPREDNISOLONE TAB 16 MG
Tier 1
METHYLPRED TAB 32MG
METHYLPREDNISOLONE TAB 32 MG
Tier 1
METHYLPRED TAB 4MG
METHYLPREDNISOLONE TAB 4 MG
Tier 1
METHYLPRED TAB 4MG
METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)
Tier 1
METHYLPRED TAB 8MG
METHYLPREDNISOLONE TAB 8 MG
Tier 1
MILLIPRED SOL 10MG/5ML
PREDNISOLONE SOD PHOSPHATE ORAL SOLN 10 MG/5ML (BASE EQUIV)
Tier 1
MOMETASONE CRE 0.1%
MOMETASONE FUROATE CREAM 0.1%
Tier 1
MOMETASONE OIN 0.1%
MOMETASONE FUROATE OINT 0.1%
Tier 1
MOMETASONE SOL 0.1%
MOMETASONE FUROATE SOLUTION 0.1% (LOTION)
Tier 1
NOLIX LOT 0.05%
FLURANDRENOLIDE LOTION 0.05%
Tier 3
PRED SOD PHO SOL 5MG/5ML
PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 10 MG (BASE EQ) PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 15 MG (BASE EQ) PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 30 MG (BASE EQ) HYDROCORTISONE PROBUTATE CREAM 0.1% PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE) PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE)
PREDNICARBAT CRE 0.1%
PREDNICARBATE CREAM 0.1%
Tier 1
PREDNICARBAT OIN 0.1%
PREDNICARBATE OINT 0.1%
Tier 1
PREDNISOLONE SOL 10MG/5ML PREDNISOLONE SOL 15MG/5ML PREDNISOLONE SOL 20MG/5ML PREDNISOLONE SOL 25MG/5ML PREDNISOLONE TAB 10MG ODT PREDNISOLONE TAB 15MG ODT PREDNISOLONE TAB 30MG ODT
PREDNISOLONE SOD PHOSPHATE ORAL SOLN 10 MG/5ML (BASE EQUIV) PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV) PREDNISOLONE SOD PHOSPHATE ORAL SOLN 20 MG/5ML (BASE EQUIV) PREDNISOLONE SODIUM PHOSPHATE ORAL SOLN 25 MG/5ML (BASE EQ) PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 10 MG (BASE EQ) PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 15 MG (BASE EQ) PREDNISOLONE SOD PHOS ORALLY DISINTEGR TAB 30 MG (BASE EQ)
ORAPRED ODT TAB 10MG ORAPRED ODT TAB 15MG ORAPRED ODT TAB 30MG PANDEL CRE 0.1% PEDIAPRED SOL 6.7/5ML
PREDNISONE CON 5MG/ML PREDNISONE CONC 5 MG/ML
109
Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 1
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
X
X
X
Therapeutic Class Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs
Label Name PREDNISONE PAK 10MG PREDNISONE PAK 10MG PREDNISONE PAK 5MG PREDNISONE PAK 5MG
Generic Name PREDNISONE TAB THERAPY PACK 10 MG (21) PREDNISONE TAB THERAPY PACK 10 MG (48) PREDNISONE TAB THERAPY PACK 5 MG (21) PREDNISONE TAB THERAPY PACK 5 MG (48)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 1 Tier 1 Tier 1
PREDNISONE SOL 5MG/5ML PREDNISONE ORAL SOLN 5 MG/5ML
Tier 1
PREDNISONE TAB 10MG
PREDNISONE TAB 10 MG
Tier 1
PREDNISONE TAB 1MG
PREDNISONE TAB 1 MG
Tier 1
PREDNISONE TAB 2.5MG
PREDNISONE TAB 2.5 MG
Tier 1
PREDNISONE TAB 20MG
PREDNISONE TAB 20 MG
Tier 1
PREDNISONE TAB 50MG
PREDNISONE TAB 50 MG
Tier 1
PREDNISONE TAB 5MG
PREDNISONE TAB 5 MG
Tier 1
PROCTO-MED CRE HC 2.5%
HYDROCORTISONE RECTAL CREAM 2.5%
Tier 1
PROCTO-PAK CRE 1%
HYDROCORTISONE RECTAL CREAM 1%
Tier 1
PROCTOSOL HC CRE 2.5%
HYDROCORTISONE RECTAL CREAM 2.5%
Tier 1
PROCTOZONE CRE -HC 2.5% HYDROCORTISONE RECTAL CREAM 2.5%
Tier 1
PSORCON CRE 0.05%
DIFLORASONE DIACETATE CREAM 0.05%
Tier 3
SCALACORT LOT 2%
HYDROCORTISONE LOTION 2%
Tier 1
TEMOVATE CRE 0.05%
CLOBETASOL PROPIONATE CREAM 0.05%
Tier 3
X
TEMOVATE GEL 0.05%
CLOBETASOL PROPIONATE GEL 0.05%
Tier 3
X
TEMOVATE OIN 0.05%
CLOBETASOL PROPIONATE OINT 0.05%
Tier 3
X
TEMOVATE SOL 0.05%
CLOBETASOL PROPIONATE SOLN 0.05%
Tier 3
X
CLOBETASOL PROPIONATE EMOLLIENT TEMOVATE E CRE 0.05%EML BASE CREAM 0.05%
Tier 3
X
TEXACORT SOL 2.5%
HYDROCORTISONE SOLN 2.5%
Tier 2
TOPICORT CRE 0.05%
DESOXIMETASONE CREAM 0.05%
Tier 3
X
TOPICORT CRE 0.25%
DESOXIMETASONE CREAM 0.25%
Tier 3
X
TOPICORT GEL 0.05%
DESOXIMETASONE GEL 0.05%
Tier 3
X
TOPICORT OIN 0.05%
DESOXIMETASONE OINT 0.05%
Tier 3
X
TOPICORT OIN 0.25%
DESOXIMETASONE OINT 0.25%
Tier 3
X
TRIAMCINOLONE ACETONIDE AEROSOL SOLN 0.147 MG/GM TRIAMCINOLONE ACETONIDE CREAM TRIAMCINOLON CRE 0.025% 0.025% TRIAMCINOLONE ACETONIDE CREAM TRIAMCINOLON CRE 0.1% 0.1% TRIAMCINOLONE ACETONIDE CREAM TRIAMCINOLON CRE 0.5% 0.5% TRIAMCINOLONE ACETONIDE LOTION TRIAMCINOLON LOT 0.025% 0.025% TRIAMCINOLONE ACETONIDE LOTION TRIAMCINOLON LOT 0.1% 0.1% TRIAMCINOLONE ACETONIDE OINT TRIAMCINOLON OIN 0.025% 0.025%
TRIAMCINOLON AER SPRAY
Tier 2 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
TRIAMCINOLON OIN 0.1%
TRIAMCINOLONE ACETONIDE OINT 0.1%
Tier 1
TRIAMCINOLON OIN 0.5%
TRIAMCINOLONE ACETONIDE OINT 0.5%
Tier 1
TRIDERM CRE 0.1%
TRIAMCINOLONE ACETONIDE CREAM 0.1%
Tier 1
TRIDESILON CRE 0.05%
DESONIDE CREAM 0.05%
Tier 3
110
X
Therapeutic Class Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory Drugs Glucocorticoids/Mineralocorticoids Anti-Inflammatory 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 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
Label Name ULTRAVATE CRE 0.05% ULTRAVATE LOT 0.05%
Generic Name HALOBETASOL PROPIONATE CREAM 0.05% HALOBETASOL PROPIONATE LOTION 0.05%
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3
X X
X
X
ULTRAVATE OIN 0.05%
HALOBETASOL PROPIONATE OINT 0.05%
Tier 3
VERIPRED 20 SOL 20MG/5ML
PREDNISOLONE SOD PHOSPHATE ORAL SOLN 20 MG/5ML (BASE EQUIV)
Tier 1
WESTCORT OIN 0.2%
HYDROCORTISONE VALERATE OINT 0.2%
Tier 3
FELBAMATE SUS 600/5ML
FELBAMATE SUSP 600 MG/5ML
Tier 1
FELBAMATE TAB 400MG
FELBAMATE TAB 400 MG
Tier 1
FELBAMATE TAB 600MG
FELBAMATE TAB 600 MG
Tier 1
FELBATOL SUS 600/5ML
FELBAMATE SUSP 600 MG/5ML
Tier 3
X
X
FELBATOL TAB 400MG
FELBAMATE TAB 400 MG
Tier 3
X
X
FELBATOL TAB 600MG
FELBAMATE TAB 600 MG
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
LAMICTAL CHW 25MG LAMICTAL CHW 5MG LAMICTAL KIT START 35 LAMICTAL KIT START 49 LAMICTAL KIT START 98
LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 25 MG LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 5 MG LAMOTRIGINE TAB 25 MG (35) STARTER KIT LAMOTRIGINE TAB 25 MG (42) & 100 MG (7) STARTER KIT LAMOTRIGINE TAB 25 MG (84) & 100 MG (14) STARTER KIT
X
X
LAMICTAL TAB 100MG
LAMOTRIGINE TAB 100 MG
Tier 3
X
X
LAMICTAL TAB 150MG
LAMOTRIGINE TAB 150 MG
Tier 3
X
X
LAMICTAL TAB 200MG
LAMOTRIGINE TAB 200 MG
Tier 3
X
X
LAMICTAL TAB 25MG
LAMOTRIGINE TAB 25 MG
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
LAMICTAL ODT KIT LAMICTAL ODT KIT LAMICTAL ODT KIT LAMICTAL ODT TAB 100MG LAMICTAL ODT TAB 200MG LAMICTAL ODT TAB 25MG LAMICTAL ODT TAB 50MG LAMICTAL XR KIT LAMICTAL XR KIT LAMICTAL XR KIT
LAMOTRIGINE TAB DISP 25 (14) & 50 MG (14) & 100 MG (7) KIT LAMOTRIGINE TAB DISP 25 MG (21) & 50 MG (7) TITRATION KIT LAMOTRIGINE TAB DISP 50 MG (42) & 100 MG (14) TITRATION KIT LAMOTRIGINE ORALLY DISINTEGRATING TAB 100 MG LAMOTRIGINE ORALLY DISINTEGRATING TAB 200 MG LAMOTRIGINE ORALLY DISINTEGRATING TAB 25 MG LAMOTRIGINE ORALLY DISINTEGRATING TAB 50 MG LAMOTRIGINE TAB SR 24HR 25 MG (21) & 50 MG (7) TITRATION KIT LAMOTRIGINE TAB SR 24HR 50 (14) & 100 MG(14) & 200 MG(7) KIT LAMOTRIGINE TAB SR 24HR 25 (14) & 50 MG (14) & 100 MG(7) KIT
LAMICTAL XR TAB 100MG
LAMOTRIGINE TAB SR 24HR 100 MG
Tier 3
X
X
LAMICTAL XR TAB 200MG
LAMOTRIGINE TAB SR 24HR 200 MG
Tier 3
X
X
LAMICTAL XR TAB 250MG
LAMOTRIGINE TAB SR 24HR 250 MG
Tier 3
X
X
LAMICTAL XR TAB 25MG
LAMOTRIGINE TAB SR 24HR 25 MG
Tier 3
X
X
LAMICTAL XR TAB 300MG
LAMOTRIGINE TAB SR 24HR 300 MG
Tier 3
X
X
LAMICTAL XR TAB 50MG
LAMOTRIGINE TAB SR 24HR 50 MG
Tier 3
X
X
LAMOTRIG ODT KIT 25/50MG LAMOTRIG ODT KIT 50/100MG
LAMOTRIGINE TAB DISP 25 MG (21) & 50 MG (7) TITRATION KIT LAMOTRIGINE TAB DISP 50 MG (42) & 100 MG (14) TITRATION KIT LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 25 MG
Tier 3
X
X
Tier 3
X
X
LAMOTRIGINE CHW 25MG
111
Tier 1
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 Glycemic Agents - Diabetic Drugs Glycemic Agents - Diabetic Drugs Glycemic Agents - Diabetic Drugs 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
Label Name LAMOTRIGINE CHW 5MG LAMOTRIGINE KIT ODT
Generic Name LAMOTRIGINE TAB CHEWABLE DISPERSIBLE 5 MG LAMOTRIGINE TAB DISP 25 (14) & 50 MG (14) & 100 MG (7) KIT
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 3
X
X
LAMOTRIGINE TAB 100MG
LAMOTRIGINE TAB 100 MG
Tier 1
LAMOTRIGINE TAB 100MG
LAMOTRIGINE ORALLY DISINTEGRATING TAB 100 MG
Tier 3
LAMOTRIGINE TAB 100MG ER
LAMOTRIGINE TAB SR 24HR 100 MG
Tier 3
LAMOTRIGINE TAB 150MG
LAMOTRIGINE TAB 150 MG
Tier 1
LAMOTRIGINE TAB 200MG
LAMOTRIGINE TAB 200 MG
Tier 1
LAMOTRIGINE TAB 200MG
LAMOTRIGINE ORALLY DISINTEGRATING TAB 200 MG
Tier 3
LAMOTRIGINE TAB SR 24HR 200 MG
Tier 3
X
X
LAMOTRIGINE TAB SR 24HR 250 MG
Tier 3
X
X
LAMOTRIGINE TAB 25 MG
Tier 1 X
X
LAMOTRIGINE TAB 200MG ER LAMOTRIGINE TAB 250MG ER LAMOTRIGINE TAB 25MG
LAMOTRIGINE TAB 25MG ER LAMOTRIGINE TAB SR 24HR 25 MG LAMOTRIGINE TAB 25MG ODT LAMOTRIGINE TAB 300MG ER
Tier 3
X X
X
X
LAMOTRIGINE ORALLY DISINTEGRATING TAB 25 MG
Tier 3
LAMOTRIGINE TAB SR 24HR 300 MG
Tier 3
X
X
LAMOTRIGINE TAB 50MG ER LAMOTRIGINE TAB SR 24HR 50 MG
Tier 3
X
X
LAMOTRIGINE TAB 50MG ODT
LAMOTRIGINE ORALLY DISINTEGRATING TAB 50 MG
Tier 3
TOPAMAX TAB 100MG
TOPIRAMATE TAB 100 MG
Tier 3
X
X
TOPAMAX TAB 200MG
TOPIRAMATE TAB 200 MG
Tier 3
X
X
TOPAMAX TAB 25MG
TOPIRAMATE TAB 25 MG
Tier 3
X
X
TOPAMAX TAB 50MG
TOPIRAMATE TAB 50 MG
Tier 3
X
X
TOPAMAX SPR CAP 15MG
TOPIRAMATE SPRINKLE CAP 15 MG
Tier 3
X
X
TOPAMAX SPR CAP 25MG
TOPIRAMATE SPRINKLE CAP 25 MG
Tier 3
X
X
TOPIRAMATE CAP 15MG
TOPIRAMATE SPRINKLE CAP 15 MG
Tier 1
TOPIRAMATE CAP 25MG
TOPIRAMATE SPRINKLE CAP 25 MG
Tier 1
TOPIRAMATE TAB 100MG
TOPIRAMATE TAB 100 MG
Tier 1
TOPIRAMATE TAB 200MG
TOPIRAMATE TAB 200 MG
Tier 1
TOPIRAMATE TAB 25MG
TOPIRAMATE TAB 25 MG
Tier 1
TOPIRAMATE TAB 50MG
TOPIRAMATE TAB 50 MG
Tier 1
GLUCAGON HCL (RDNA) FOR INJ 1 MG (BASE EQUIV) GLUCAGON KIT 1MG GLUCAGON (RDNA) FOR INJ KIT 1 MG PROGLYCEM SUS 50MG/ML DIAZOXIDE SUSP 50 MG/ML ZINC ACETATE CAP 25 MG (ELEMENTAL GALZIN CAP 25MG ZINC) ZINC ACETATE CAP 50 MG (ELEMENTAL GALZIN CAP 50MG ZINC)
GLUCAGEN INJ HYPOKIT
X
Tier 2
X
Tier 2 Tier 3
X
Tier 3 Tier 3
AXID SOL 15MG/ML
NIZATIDINE ORAL SOLN 15 MG/ML
Tier 3
CIMETIDINE SOL 300/5ML
CIMETIDINE HCL SOLN 300 MG/5ML
Tier 1
CIMETIDINE TAB 200MG
CIMETIDINE TAB 200 MG
Tier 1
CIMETIDINE TAB 300MG
CIMETIDINE TAB 300 MG
Tier 1
CIMETIDINE TAB 400MG
CIMETIDINE TAB 400 MG
Tier 1
CIMETIDINE TAB 800MG
CIMETIDINE TAB 800 MG
Tier 1
CIMETIDINE TAB 400MG
CIMETIDINE TAB 400 MG
Tier 1
112
X
Therapeutic Class
Label Name
Generic Name
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 Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs
FAMOTIDINE SUS 40MG/5ML
FAMOTIDINE FOR SUSP 40 MG/5ML
Tier 1
NIZATIDINE SOL 15MG/ML
NIZATIDINE ORAL SOLN 15 MG/ML
Tier 2
PEPCID SUS 40MG/5ML
FAMOTIDINE FOR SUSP 40 MG/5ML
Tier 3
RANITIDINE SYP 150/10ML RANITIDINE SYP 15MG/ML RANITIDINE SYP 75MG/5ML
RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML) RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML) RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML)
CERVIDIL VAG MIS 10MG INS DINOPROSTONE VAGINAL INSERTS 10 MG
Tier Value
Tier 1 Tier 1 Tier 1 Tier 3
PREPIDIL GEL 0.5MG/3G
DINOPROSTONE CERVICAL GEL 0.5 MG/3GM
Tier 3
PROSTIN E2 SUP 20MG
DINOPROSTONE VAGINAL SUPPOS 20 MG
Tier 3
DDAVP INJ 4MCG/ML
DESMOPRESSIN ACETATE INJ 4 MCG/ML
Tier 3
DDAVP SOL 0.01%
DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED)
Tier 3
DDAVP SPR 0.01%
DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01%
Tier 3
DDAVP TAB 0.1MG
DESMOPRESSIN ACETATE TAB 0.1 MG
Tier 3
DDAVP TAB 0.2MG
DESMOPRESSIN ACETATE TAB 0.2 MG
Tier 3
DESMOPRESSIN INJ 4MCG/ DESMOPRESSIN ACETATE INJ 4 MCG/ML ML
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1
DESMOPRESSIN SOL 0.01%
DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED)
Tier 1
DESMOPRESSIN SPR 0.01%
DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% (REFRIGERATED)
Tier 1
DESMOPRESSIN SPR 0.01%
DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01%
Tier 1
DESMOPRESSIN TAB 0.1MG
DESMOPRESSIN ACETATE TAB 0.1 MG
Tier 1
DESMOPRESSIN TAB 0.2MG DESMOPRESSIN ACETATE TAB 0.2 MG
Tier 1
EGRIFTA SOL 1MG
TESAMORELIN ACETATE FOR INJ 1 MG (BASE EQUIV)
Tier 4
EGRIFTA SOL 2MG
TESAMORELIN ACETATE FOR INJ 2 MG (BASE EQUIV)
Tier 4
H.P. ACTHAR INJ 80UNIT
CORTICOTROPIN INJ GEL 80 UNIT/ML
Tier 4
X
X
INCRELEX INJ 40MG/4ML
MECASERMIN INJ 40 MG/4ML (10 MG/ML)
Tier 2
X
X
X
NUTROPIN AQ INJ 10MG/2ML
SOMATROPIN INJ 10 MG/2ML
Tier 2
X
X
X
NUTROPIN AQ INJ 20MG/2ML
SOMATROPIN INJ 20 MG/2ML
Tier 2
X
X
X
Tier 2
X
X
X
NUTROPIN AQ INJ NUSPIN 5 SOMATROPIN INJ 5 MG/2ML
113
X
X X X
X
Therapeutic Class Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Pituitary) Hormone Replacement/Modifying Drugs 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 Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) Thyroid Replacement Drugs Hormonal Agents, Stimulant/ Replacement/Modifying (Thyroid) Thyroid Replacement Drugs
Generic Name
SEROSTIM INJ 4MG
SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 4 MG
Tier 4
X
X
X
SEROSTIM INJ 5MG
SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 5 MG
Tier 4
X
X
X
SEROSTIM INJ 6MG
SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 6 MG
Tier 4
X
X
X
STIMATE SOL 1.5MG/ML
DESMOPRESSIN ACETATE NASAL SOLN 1.5 MG/ML
Tier 3
ZORBTIVE INJ 8.8MG
SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 8.8 MG
Tier 3
X
X
X
KORLYM TAB 300MG
MIFEPRISTONE TAB 300 MG
Tier 3
X
ARMOUR THYRO TAB 120MG
THYROID TAB 120 MG (2 GRAIN)
Tier 3
ARMOUR THYRO TAB 15MG THYROID TAB 15 MG (1/4 GRAIN)
Tier 3
ARMOUR THYRO TAB 180MG
THYROID TAB 180 MG (3 GRAIN)
Tier 3
ARMOUR THYRO TAB 240MG
THYROID TAB 240 MG (4 GRAIN)
Tier 3
ARMOUR THYRO TAB 300MG
THYROID TAB 300 MG (5 GRAIN)
Tier 3
ARMOUR THYRO TAB 30MG THYROID TAB 30 MG (1/2 GRAIN)
Tier 3
ARMOUR THYRO TAB 60MG THYROID TAB 60 MG (1 GRAIN)
Tier 3
ARMOUR THYRO TAB 90MG THYROID TAB 90 MG (1 1/2 GRAIN)
Tier 3
CYTOMEL TAB 25MCG
LIOTHYRONINE SODIUM TAB 25 MCG
Tier 3
CYTOMEL TAB 50MCG
LIOTHYRONINE SODIUM TAB 50 MCG
Tier 3
CYTOMEL TAB 5MCG
LIOTHYRONINE SODIUM TAB 5 MCG
Tier 3
LEVO-T TAB 100MCG
LEVOTHYROXINE SODIUM TAB 100 MCG
Tier 1
LEVO-T TAB 112MCG
LEVOTHYROXINE SODIUM TAB 112 MCG
Tier 1
LEVO-T TAB 125MCG
LEVOTHYROXINE SODIUM TAB 125 MCG
Tier 1
LEVO-T TAB 137MCG
LEVOTHYROXINE SODIUM TAB 137 MCG
Tier 1
LEVO-T TAB 150MCG
LEVOTHYROXINE SODIUM TAB 150 MCG
Tier 1
LEVO-T TAB 175MCG
LEVOTHYROXINE SODIUM TAB 175 MCG
Tier 1
LEVO-T TAB 200 MCG
LEVOTHYROXINE SODIUM TAB 200 MCG
Tier 1
LEVO-T TAB 25MCG
LEVOTHYROXINE SODIUM TAB 25 MCG
Tier 1
LEVO-T TAB 300 MCG
LEVOTHYROXINE SODIUM TAB 300 MCG
Tier 1
114
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
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 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
Label Name
Generic Name
Tier Value
LEVO-T TAB 50MCG
LEVOTHYROXINE SODIUM TAB 50 MCG
Tier 1
LEVO-T TAB 75MCG
LEVOTHYROXINE SODIUM TAB 75 MCG
Tier 1
LEVO-T TAB 88MCG
LEVOTHYROXINE SODIUM TAB 88 MCG
Tier 1
LEVOTHYROXIN TAB 100MCG
LEVOTHYROXINE SODIUM TAB 100 MCG
Tier 1
LEVOTHYROXIN TAB 112MCG
LEVOTHYROXINE SODIUM TAB 112 MCG
Tier 1
LEVOTHYROXIN TAB 125MCG
LEVOTHYROXINE SODIUM TAB 125 MCG
Tier 1
LEVOTHYROXIN TAB 137MCG
LEVOTHYROXINE SODIUM TAB 137 MCG
Tier 1
LEVOTHYROXIN TAB 150MCG
LEVOTHYROXINE SODIUM TAB 150 MCG
Tier 1
LEVOTHYROXIN TAB 175MCG
LEVOTHYROXINE SODIUM TAB 175 MCG
Tier 1
LEVOTHYROXIN TAB 200MCG
LEVOTHYROXINE SODIUM TAB 200 MCG
Tier 1
LEVOTHYROXIN TAB 25MCG LEVOTHYROXINE SODIUM TAB 25 MCG
Tier 1
LEVOTHYROXIN TAB 300MCG
Tier 1
LEVOTHYROXINE SODIUM TAB 300 MCG
LEVOTHYROXIN TAB 50MCG LEVOTHYROXINE SODIUM TAB 50 MCG
Tier 1
LEVOTHYROXIN TAB 75MCG LEVOTHYROXINE SODIUM TAB 75 MCG
Tier 1
LEVOTHYROXIN TAB 88MCG LEVOTHYROXINE SODIUM TAB 88 MCG
Tier 1
LEVOXYL TAB 100MCG
LEVOTHYROXINE SODIUM TAB 100 MCG
Tier 2
LEVOXYL TAB 112MCG
LEVOTHYROXINE SODIUM TAB 112 MCG
Tier 2
LEVOXYL TAB 125MCG
LEVOTHYROXINE SODIUM TAB 125 MCG
Tier 2
LEVOXYL TAB 137MCG
LEVOTHYROXINE SODIUM TAB 137 MCG
Tier 2
LEVOXYL TAB 150MCG
LEVOTHYROXINE SODIUM TAB 150 MCG
Tier 2
LEVOXYL TAB 175MCG
LEVOTHYROXINE SODIUM TAB 175 MCG
Tier 2
LEVOXYL TAB 200MCG
LEVOTHYROXINE SODIUM TAB 200 MCG
Tier 2
LEVOXYL TAB 25MCG
LEVOTHYROXINE SODIUM TAB 25 MCG
Tier 2
LEVOXYL TAB 50MCG
LEVOTHYROXINE SODIUM TAB 50 MCG
Tier 2
LEVOXYL TAB 75MCG
LEVOTHYROXINE SODIUM TAB 75 MCG
Tier 2
LEVOXYL TAB 88MCG
LEVOTHYROXINE SODIUM TAB 88 MCG
Tier 2
115
Prior Supply Step Specialty Authorization Limit 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, 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 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
Label Name
Generic Name
Tier Value
LIOTHYRONINE TAB 25MCG LIOTHYRONINE SODIUM TAB 25 MCG
Tier 2
LIOTHYRONINE TAB 50MCG LIOTHYRONINE SODIUM TAB 50 MCG
Tier 2
LIOTHYRONINE TAB 5MCG
LIOTHYRONINE SODIUM TAB 5 MCG
Tier 2
NATURE THROI TAB 162.5MG
THYROID TAB 162.5 MG (2 1/2 GRAIN)
Tier 3
NATURE-THROI TAB 113.75MG
THYROID TAB 113.75 MG
Tier 3
NATURE-THROI TAB 130MG
THYROID TAB 130 MG
Tier 3
NATURE-THROI TAB 146.25MG
THYROID TAB 146.25 MG
Tier 3
NATURE-THROI TAB 16.25MG
THYROID TAB 16.25 MG
Tier 3
NATURE-THROI TAB 195MG
THYROID TAB 195 MG
Tier 3
NATURE-THROI TAB 260MG
THYROID TAB 260 MG
Tier 3
NATURE-THROI TAB 32.5MG THYROID TAB 32.5 MG
Tier 3
NATURE-THROI TAB 325MG
THYROID TAB 325 MG (5 GRAIN)
Tier 3
NATURE-THROI TAB 48.75MG
THYROID TAB 48.75 MG (3/4 GRAIN)
Tier 3
NATURE-THROI TAB 65MG
THYROID TAB 65 MG
Tier 3
NATURE-THROI TAB 81.25MG
THYROID TAB 81.25 MG
Tier 3
NATURE-THROI TAB 97.5MG
THYROID TAB 97.5 MG
Tier 3
NP THYROID TAB 120MG
THYROID TAB 120 MG (2 GRAIN)
Tier 1
NP THYROID TAB 15MG
THYROID TAB 15 MG (1/4 GRAIN)
Tier 1
NP THYROID TAB 30MG
THYROID TAB 30 MG (1/2 GRAIN)
Tier 1
NP THYROID TAB 60MG
THYROID TAB 60 MG (1 GRAIN)
Tier 1
NP THYROID TAB 90MG
THYROID TAB 90 MG (1 1/2 GRAIN)
Tier 1
SYNTHROID TAB 100MCG
LEVOTHYROXINE SODIUM TAB 100 MCG
Tier 2
SYNTHROID TAB 112MCG
LEVOTHYROXINE SODIUM TAB 112 MCG
Tier 2
SYNTHROID TAB 125MCG
LEVOTHYROXINE SODIUM TAB 125 MCG
Tier 2
SYNTHROID TAB 137MCG
LEVOTHYROXINE SODIUM TAB 137 MCG
Tier 2
SYNTHROID TAB 150MCG
LEVOTHYROXINE SODIUM TAB 150 MCG
Tier 2
116
Prior Supply Step Specialty Authorization Limit 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, 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 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
Label Name
Generic Name
Tier Value
SYNTHROID TAB 175MCG
LEVOTHYROXINE SODIUM TAB 175 MCG
Tier 2
SYNTHROID TAB 200MCG
LEVOTHYROXINE SODIUM TAB 200 MCG
Tier 2
SYNTHROID TAB 25MCG
LEVOTHYROXINE SODIUM TAB 25 MCG
Tier 2
SYNTHROID TAB 300MCG
LEVOTHYROXINE SODIUM TAB 300 MCG
Tier 2
SYNTHROID TAB 50MCG
LEVOTHYROXINE SODIUM TAB 50 MCG
Tier 2
SYNTHROID TAB 75MCG
LEVOTHYROXINE SODIUM TAB 75 MCG
Tier 2
SYNTHROID TAB 88MCG
LEVOTHYROXINE SODIUM TAB 88 MCG
Tier 2
THYROLAR-1 TAB 60MG
LIOTRIX (T3-T4) TAB 60 MG (12.5-50 MCG)
Tier 3
THYROLAR-1/2 TAB 30MG
LIOTRIX (T3-T4) TAB 30 MG (6.25-25 MCG)
Tier 3
THYROLAR-1/4 TAB 15MG
LIOTRIX (T3-T4) TAB 15 MG (3.1-12.5 MCG)
Tier 3
THYROLAR-2 TAB 120MG
LIOTRIX (T3-T4) TAB 120 MG (25-100 MCG)
Tier 3
THYROLAR-3 TAB 180MG
LIOTRIX (T3-T4) TAB 180 MG (37.5-150 MCG)
Tier 3
UNITH DIRECT TAB 100MCG LEVOTHYROXINE SODIUM TAB 100 MCG
Tier 1
UNITH DIRECT TAB 112MCG LEVOTHYROXINE SODIUM TAB 112 MCG
Tier 1
UNITH DIRECT TAB 125MCG LEVOTHYROXINE SODIUM TAB 125 MCG
Tier 1
UNITH DIRECT TAB 150MCG LEVOTHYROXINE SODIUM TAB 150 MCG
Tier 1
UNITH DIRECT TAB 175MCG LEVOTHYROXINE SODIUM TAB 175 MCG
Tier 1
UNITH DIRECT TAB 200MCG LEVOTHYROXINE SODIUM TAB 200 MCG
Tier 1
UNITH DIRECT TAB 25MCG
Tier 1
LEVOTHYROXINE SODIUM TAB 25 MCG
UNITH DIRECT TAB 300MCG LEVOTHYROXINE SODIUM TAB 300 MCG
Tier 1
UNITH DIRECT TAB 50MCG
LEVOTHYROXINE SODIUM TAB 50 MCG
Tier 1
UNITH DIRECT TAB 75MCG
LEVOTHYROXINE SODIUM TAB 75 MCG
Tier 1
UNITH DIRECT TAB 88MCG
LEVOTHYROXINE SODIUM TAB 88 MCG
Tier 1
UNITHROID TAB 100MCG
LEVOTHYROXINE SODIUM TAB 100 MCG
Tier 1
UNITHROID TAB 112MCG
LEVOTHYROXINE SODIUM TAB 112 MCG
Tier 1
UNITHROID TAB 125MCG
LEVOTHYROXINE SODIUM TAB 125 MCG
Tier 1
117
Prior Supply Step Specialty Authorization Limit 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, 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, Suppressant (Parathyroid) - Hormone Suppressants Hormonal Agents, Suppressant (Parathyroid) - Hormone Suppressants Hormonal Agents, Suppressant (Parathyroid) - 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
Label Name
Generic Name
Tier Value
UNITHROID TAB 137MCG
LEVOTHYROXINE SODIUM TAB 137 MCG
Tier 1
UNITHROID TAB 150MCG
LEVOTHYROXINE SODIUM TAB 150 MCG
Tier 1
UNITHROID TAB 175MCG
LEVOTHYROXINE SODIUM TAB 175 MCG
Tier 1
UNITHROID TAB 200MCG
LEVOTHYROXINE SODIUM TAB 200 MCG
Tier 1
UNITHROID TAB 25MCG
LEVOTHYROXINE SODIUM TAB 25 MCG
Tier 1
UNITHROID TAB 300MCG
LEVOTHYROXINE SODIUM TAB 300 MCG
Tier 1
UNITHROID TAB 50MCG
LEVOTHYROXINE SODIUM TAB 50 MCG
Tier 1
UNITHROID TAB 75MCG
LEVOTHYROXINE SODIUM TAB 75 MCG
Tier 1
UNITHROID TAB 88MCG
LEVOTHYROXINE SODIUM TAB 88 MCG
Tier 1
WESTHROID TAB 130MG
THYROID TAB 130 MG
Tier 3
WESTHROID TAB 195MG
THYROID TAB 195 MG
Tier 3
WESTHROID TAB 32.5MG
THYROID TAB 32.5 MG
Tier 3
WESTHROID TAB 65MG
THYROID TAB 65 MG
Tier 3
WESTHROID TAB 97.5MG
THYROID TAB 97.5 MG
Tier 3
WP THYROID TAB 113.75MG THYROID TAB 113.75 MG
Tier 3
WP THYROID TAB 130MG
THYROID TAB 130 MG
Tier 3
WP THYROID TAB 16.25MG
THYROID TAB 16.25 MG
Tier 3
WP THYROID TAB 32.5MG
THYROID TAB 32.5 MG
Tier 3
WP THYROID TAB 48.75MG
THYROID TAB 48.75 MG (3/4 GRAIN)
Tier 3
WP THYROID TAB 65MG
THYROID TAB 65 MG
Tier 3
WP THYROID TAB 81.25MG
THYROID TAB 81.25 MG
Tier 3
WP THYROID TAB 97.5MG
THYROID TAB 97.5 MG
Tier 3
SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG CABERGOLINE TAB 0.5MG ELIGARD INJ 22.5MG ELIGARD INJ 30MG ELIGARD INJ 45MG
CINACALCET HCL TAB 30 MG (BASE EQUIV) CINACALCET HCL TAB 60 MG (BASE EQUIV) CINACALCET HCL TAB 90 MG (BASE EQUIV) CABERGOLINE TAB 0.5 MG LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG LEUPROLIDE ACETATE (4 MONTH) FOR SUBCUTANEOUS INJ KIT 30 MG LEUPROLIDE ACETATE (6 MONTH) FOR SUBCUTANEOUS INJ KIT 45 MG
118
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
Tier 3
X
Tier 3
X
Tier 2 Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
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 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
Label Name ELIGARD INJ 7.5MG FIRMAGON INJ 120MG FIRMAGON INJ 80MG LEUPROLIDE INJ 1MG/0.2
Generic Name LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG DEGARELIX ACETATE FOR INJ 120 MG (BASE EQUIV) DEGARELIX ACETATE FOR INJ 80 MG (BASE EQUIV) LEUPROLIDE ACETATE INJ KIT 5 MG/ML
OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML) OCTREOTIDE ACETATE INJ 100 MCG/ML OCTREOTIDE INJ 100MCG (0.1 MG/ML) OCTREOTIDE ACETATE INJ 200 MCG/ML OCTREOTIDE INJ 200MCG (0.2 MG/ML) OCTREOTIDE ACETATE INJ 500 MCG/ML OCTREOTIDE INJ 500MCG (0.5 MG/ML) OCTREOTIDE INJ 50MCG/ OCTREOTIDE ACETATE INJ 50 MCG/ML ML (0.05 MG/ML) OCTREOTIDE ACETATE INJ 1000 MCG/ML SANDOSTATIN INJ 1000MCG (1 MG/ML) OCTREOTIDE ACETATE INJ 100 MCG/ML SANDOSTATIN INJ 100MCG (0.1 MG/ML) OCTREOTIDE ACETATE INJ 200 MCG/ML SANDOSTATIN INJ 200MCG (0.2 MG/ML) OCTREOTIDE ACETATE INJ 500 MCG/ML SANDOSTATIN INJ 500MCG (0.5 MG/ML) SANDOSTATIN INJ 50MCG/ OCTREOTIDE ACETATE INJ 50 MCG/ML ML (0.05 MG/ML) PASIREOTIDE DIASPARTATE INJ 0.3 MG/ SIGNIFOR INJ 0.3MG/ML ML (BASE EQUIV) PASIREOTIDE DIASPARTATE INJ 0.6 MG/ SIGNIFOR INJ 0.6MG/ML ML (BASE EQUIV) PASIREOTIDE DIASPARTATE INJ 0.9 MG/ SIGNIFOR INJ 0.9MG/ML ML (BASE EQUIV) LANREOTIDE ACETATE EXTENDED SOMATULINE INJ 120/.5ML RELEASE INJ 120 MG/0.5ML LANREOTIDE ACETATE EXTENDED SOMATULINE INJ 60/0.2ML RELEASE INJ 60 MG/0.2ML LANREOTIDE ACETATE EXTENDED SOMATULINE INJ 90/0.3ML RELEASE INJ 90 MG/0.3ML PEGVISOMANT FOR INJ 10 MG (AS SOMAVERT INJ 10MG PROTEIN) PEGVISOMANT FOR INJ 15 MG (AS SOMAVERT INJ 15MG PROTEIN) PEGVISOMANT FOR INJ 20 MG (AS SOMAVERT INJ 20MG PROTEIN) PEGVISOMANT FOR INJ 25 MG (AS SOMAVERT INJ 25MG PROTEIN) PEGVISOMANT FOR INJ 30 MG (AS SOMAVERT INJ 30MG PROTEIN) NAFARELIN ACETATE NASAL SOLN 2 MG/ SYNAREL SOL 2MG/ML ML (200 MCG/ACT) (BASE EQ)
OCTREOTIDE INJ 1000MCG
Tier Value Tier 3
Tier 3
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 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 4
X
Tier 4
X
Tier 4
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2 Tier 2
SSKI SOL 1GM/ML
POTASSIUM IODIDE SOLN 1 GM/ML
Tier 3
AZASAN TAB 100MG
AZATHIOPRINE TAB 100 MG
Tier 3
AZASAN TAB 75 MG
AZATHIOPRINE TAB 75 MG
Tier 3
AZATHIOPRINE TAB 50MG
AZATHIOPRINE TAB 50 MG
Tier 1
CIMZIA KIT STARTER CIMZIA PREFL KIT 200MG/ ML
X X
IODINE SOLUTION STRONG 5% (LUGOL'S)
CERTOLIZUMAB PEGOL FOR INJ KIT 2 X 200 MG CERTOLIZUMAB PEGOL INJ KIT 6 X 200 MG/ML CERTOLIZUMAB PEGOL INJ KIT 2 X 200 MG/ML
X
Tier 3
IODINE SOL STRONG
CIMZIA KIT
Prior Supply Step Specialty Authorization Limit Therapy
CYCLOSPORINE CAP 100MG CYCLOSPORINE CAP 100 MG
Tier 1
X
CYCLOSPORINE CAP 100MG MD
CYCLOSPORINE MODIFIED CAP 100 MG
Tier 1
X
CYCLOSPORINE CAP 25MG
CYCLOSPORINE CAP 25 MG
Tier 1
X
CYCLOSPORINE CAP 25MG MOD
CYCLOSPORINE MODIFIED CAP 25 MG
Tier 1
X
119
Therapeutic Class
Label Name
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 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
CYCLOSPORINE CAP 50MG MOD CYCLOSPORINE SOL MODIFIED
Generic Name CYCLOSPORINE MODIFIED CAP 50 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1
X
Tier 1
X
ENBREL SRCLK INJ 50MG/ ML
CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 25 MG/0.5ML ETANERCEPT FOR SUBCUTANEOUS INJ 25 MG ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/ML ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML
GENGRAF CAP 100MG
CYCLOSPORINE MODIFIED CAP 100 MG
Tier 1
X
GENGRAF CAP 25MG
CYCLOSPORINE MODIFIED CAP 25 MG
Tier 1
X
GENGRAF CAP 50MG
CYCLOSPORINE MODIFIED CAP 50 MG
Tier 1
X
Tier 1
X
ENBREL INJ 25/0.5ML ENBREL INJ 25MG ENBREL INJ 50MG/ML
CYCLOSPORINE MODIFIED ORAL SOLN GENGRAF SOL 100MG/ML 100 MG/ML ADALIMUMAB PREFILLED SYRINGE KIT 10 HUMIRA INJ 10MG/0.2 MG/0.2ML ADALIMUMAB PREFILLED SYRINGE KIT 20 HUMIRA KIT 20MG/0.4 MG/0.4ML ADALIMUMAB PREFILLED SYRINGE KIT 40 HUMIRA KIT 40MG/0.8 MG/0.8ML ADALIMUMAB PREFILLED SYRINGE KIT 40 HUMIRA PEDIA INJ CROHNS MG/0.8ML ADALIMUMAB PEN-INJECTOR KIT 40 HUMIRA PEN INJ 40MG/0.8 MG/0.8ML ADALIMUMAB PEN-INJECTOR KIT 40 HUMIRA PEN INJ CROHNS MG/0.8ML ADALIMUMAB PEN-INJECTOR KIT 40 HUMIRA PEN INJ PSORIASI MG/0.8ML ANAKINRA SUBCUTANEOUS SOLN KINERET INJ PREFILLED SYRINGE 100 MG/0.67ML METHOTREXATE SODIUM TAB 2.5 MG METHOTREXATE TAB 2.5MG (BASE EQUIV) MYCOPHENOLAT CAP MYCOPHENOLATE MOFETIL CAP 250 MG 250MG MYCOPHENOLAT SUS MYCOPHENOLATE MOFETIL FOR ORAL 200MG/ML SUSP 200 MG/ML MYCOPHENOLAT TAB MYCOPHENOLATE MOFETIL TAB 500 MG 500MG MYCOPHENOLIC TAB MYCOPHENOLATE SODIUM TAB DR 180 180MG DR MG (MYCOPHENOLIC ACID EQUIV) MYCOPHENOLIC TAB MYCOPHENOLATE SODIUM TAB DR 360 360MG DR MG (MYCOPHENOLIC ACID EQUIV) ABATACEPT SUBCUTANEOUS SOLN ORENCIA INJ 125MG/ML PREFILLED SYRINGE 125 MG/ML ABATACEPT SUBCUTANEOUS SOLN ORENCIA INJ 50/0.4 PREFILLED SYRINGE 50 MG/0.4ML ABATACEPT SUBCUTANEOUS SOLN ORENCIA INJ 87.5/0.7 PREFILLED SYRINGE 87.5 MG/0.7ML ORENCIA CLCK INJ 125MG/ ABATACEPT SUBCUTANEOUS SOLN ML AUTO-INJECTOR 125 MG/ML RAPAMUNE SOL 1MG/ML RASUVO INJ 10MG RASUVO INJ 12.5MG RASUVO INJ 15MG RASUVO INJ 17.5MG RASUVO INJ 20MG RASUVO INJ 22.5MG RASUVO INJ 25MG RASUVO INJ 27.5MG RASUVO INJ 30MG RASUVO INJ 7.5MG
SIROLIMUS ORAL SOLN 1 MG/ML METHOTREXATE SOLN PF AUTOINJECTOR 10 MG/0.2ML METHOTREXATE SOLN PF AUTOINJECTOR 12.5 MG/0.25ML METHOTREXATE SOLN PF AUTOINJECTOR 15 MG/0.3ML METHOTREXATE SOLN PF AUTOINJECTOR 17.5 MG/0.35ML METHOTREXATE SOLN PF AUTOINJECTOR 20 MG/0.4ML METHOTREXATE SOLN PF AUTOINJECTOR 22.5 MG/0.45ML METHOTREXATE SOLN PF AUTOINJECTOR 25 MG/0.5ML METHOTREXATE SOLN PF AUTOINJECTOR 27.5 MG/0.55ML METHOTREXATE SOLN PF AUTOINJECTOR 30 MG/0.6ML METHOTREXATE SOLN PF AUTOINJECTOR 7.5 MG/0.15ML
120
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 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 3
X
X
X
Tier 1 Tier 1
X
Tier 1
X
Tier 1
X
Tier 2
X
Tier 2
X
Tier 4
X
Tier 4
X
X
X
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
X
Tier 2
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
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 Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs
Label Name
Generic Name
RHEUMATREX TAB 2.5MG
METHOTREXATE SODIUM TAB 2.5 MG (ANTIRHEUMATIC)
Tier 2
SANDIMMUNE SOL 100MG/ ML
CYCLOSPORINE ORAL SOLN 100 MG/ML
Tier 3
SIMPONI INJ 100MG/ML SIMPONI INJ 100MG/ML SIMPONI INJ 50/0.5ML SIMPONI INJ 50/0.5ML
GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/ML GOLIMUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 100 MG/ML GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/0.5ML GOLIMUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 50 MG/0.5ML
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
SIROLIMUS TAB 0.5MG
SIROLIMUS TAB 0.5 MG
Tier 1
X
SIROLIMUS TAB 1MG
SIROLIMUS TAB 1 MG
Tier 1
X
SIROLIMUS TAB 2MG
SIROLIMUS TAB 2 MG
Tier 1
X
TACROLIMUS CAP 0.5MG
TACROLIMUS CAP 0.5 MG
Tier 1
X
TACROLIMUS CAP 1MG
TACROLIMUS CAP 1 MG
Tier 1
X
TACROLIMUS CAP 5MG
TACROLIMUS CAP 5 MG
Tier 1
X
TREXALL TAB 10MG TREXALL TAB 15MG TREXALL TAB 5MG TREXALL TAB 7.5MG
METHOTREXATE SODIUM TAB 10 MG (BASE EQUIV) METHOTREXATE SODIUM TAB 15 MG (BASE EQUIV) METHOTREXATE SODIUM TAB 5 MG (BASE EQUIV) METHOTREXATE SODIUM TAB 7.5 MG (BASE EQUIV)
Tier 2 Tier 2 Tier 2 Tier 2
ZORTRESS TAB 0.25MG
EVEROLIMUS TAB 0.25 MG
Tier 3
X
ZORTRESS TAB 0.5MG
EVEROLIMUS TAB 0.5 MG
Tier 3
X
ZORTRESS TAB 0.75MG
EVEROLIMUS TAB 0.75 MG
Tier 3
X
ACTEMRA INJ 162/0.9 ACTIMMUNE INJ 2MU/0.5 ALFERON N INJ 5MU/ML
TOCILIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 162 MG/0.9ML INTERFERON GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML) INTERFERON ALFA-N3 INJ 5000000 UNIT/ ML
Tier 4
X
X
Tier 2
X
X
X
X X
Tier 2
X
ARAVA TAB 10MG
LEFLUNOMIDE TAB 10 MG
Tier 3
ARAVA TAB 20MG
LEFLUNOMIDE TAB 20 MG
Tier 3
ARCALYST INJ 220MG
RILONACEPT FOR INJ 220 MG
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
X
X
X
AVONEX KIT 30MCG AVONEX PEN KIT 30MCG AVONEX PREFL KIT 30MCG
INTERFERON BETA-1A FOR IM INJ KIT 30MCG (33MCG(6.6 MU)/VIAL) INTERFERON BETA-1A IM AUTO-INJECTOR KIT 30 MCG/0.5ML INTERFERON BETA-1A IM PREFILLED SYRINGE KIT 30 MCG/0.5ML
BETASERON INJ 0.3MG
INTERFERON BETA-1B FOR INJ KIT 0.3 MG
Tier 2
LEFLUNOMIDE TAB 10MG
LEFLUNOMIDE TAB 10 MG
Tier 1
LEFLUNOMIDE TAB 20MG
LEFLUNOMIDE TAB 20 MG
Tier 1
OTEZLA TAB 10/20/30
APREMILAST TAB STARTER THERAPY PACK 10 MG & 20 MG & 30 MG
Tier 4
X
X
X
X
OTEZLA TAB 30MG
APREMILAST TAB 30 MG
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
REBIF INJ 22/0.5 REBIF INJ 44/0.5 REBIF REBIDO INJ 22/0.5 REBIF REBIDO INJ 44/0.5 REBIF REBIDO INJ TITRATN REBIF TITRTN INJ PACK
INTERFERON BETA-1A SOLN PREF SYR 22 MCG/0.5ML (12MU/ML) INTERFERON BETA-1A SOLN PREF SYR 44 MCG/0.5ML (24MU/ML) INTERFERON BETA-1A SOLN AUTO-INJ 22 MCG/0.5ML (12MU/ML) INTERFERON BETA-1A SOLN AUTO-INJ 44 MCG/0.5ML (24MU/ML) INTERFERON BETA-1A AUTO-INJ 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML INTERFERON BETA-1A PREF SYR 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML
121
Therapeutic Class Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs Immunomodulators - Immune System Drugs
Label Name
Generic Name
RIDAURA CAP 3MG
AURANOFIN CAP 3 MG
DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG DIMETHYL FUMARATE CAPSULE TECFIDERA CAP 240MG DELAYED RELEASE 240 MG DIMETHYL FUMARATE CAPSULE DR TECFIDERA MIS STARTER STARTER PACK 120 MG & 240 MG TOFACITINIB CITRATE TAB 5 MG (BASE XELJANZ TAB 5MG EQUIVALENT) TOFACITINIB CITRATE TAB SR 24HR 11 MG XELJANZ XR TAB 11MG (BASE EQUIVALENT) INSULIN GLULISINE SOLN PEN-INJECTOR Insulins - Diabetic Drugs APIDRA INJ SOLOSTAR INJ 100 UNIT/ML Insulins - Diabetic Drugs APIDRA INJ U-100 INSULIN GLULISINE INJ 100 UNIT/ML INSULIN GLARGINE SOLN PEN-INJECTOR Insulins - Diabetic Drugs BASAGLAR INJ 100UNIT 100 UNIT/ML Insulins - Diabetic Drugs HUMALOG INJ 100/ML INSULIN LISPRO INJ 100 UNIT/ML INSULIN LISPRO SOLN CARTRIDGE 100 Insulins - Diabetic Drugs HUMALOG INJ 100/ML UNIT/ML INSULIN LISPRO SOLN PEN-INJECTOR 100 Insulins - Diabetic Drugs HUMALOG KWIK INJ 100/ML UNIT/ML INSULIN LISPRO SOLN PEN-INJECTOR 200 Insulins - Diabetic Drugs HUMALOG KWIK INJ 200/ML UNIT/ML INSULIN LISPRO PROTAMINE & LISPRO INJ Insulins - Diabetic Drugs HUMALOG MIX INJ 50/50 100 UNIT/ML (50-50) HUMALOG MIX INJ INSULIN LISPRO PROT & LISPRO SUS PENInsulins - Diabetic Drugs 50/50KWP INJ 100 UNIT/ML (50-50) HUMALOG MIX INJ INSULIN LISPRO PROT & LISPRO SUS PENInsulins - Diabetic Drugs 75/25KWP INJ 100 UNIT/ML (75-25) INSULIN LISPRO PROT & LISPRO INJ 100 Insulins - Diabetic Drugs HUMALOG MIX SUS 75/25 UNIT/ML (75-25) INSULIN NPH ISOPHANE & REGULAR Insulins - Diabetic Drugs HUMULIN INJ 70/30 HUMAN INJ 100 UNIT/ML (70-30) INSULIN NPH & REGULAR SUSP PEN-INJ Insulins - Diabetic Drugs HUMULIN INJ 70/30KWP 100 UNIT/ML (70-30) INSULIN NPH (HUMAN) (ISOPHANE) INJ Insulins - Diabetic Drugs HUMULIN N INJ U-100 100 UNIT/ML INSULIN NPH (HUMAN) (ISOPHANE) SUSP Insulins - Diabetic Drugs HUMULIN N INJ U-100KWP PEN-INJECTOR 100 UNIT/ML INSULIN REGULAR (HUMAN) INJ 100 UNIT/ Insulins - Diabetic Drugs HUMULIN R INJ U-100 ML INSULIN REGULAR (HUMAN) INJ 500 UNIT/ Insulins - Diabetic Drugs HUMULIN R INJ U-500 ML INSULIN REGULAR (HUMAN) SOLN PENInsulins - Diabetic Drugs HUMULIN R INJ U-500 INJECTOR 500 UNIT/ML Insulins - Diabetic Drugs LEVEMIR INJ INSULIN DETEMIR INJ 100 UNIT/ML INSULIN DETEMIR SOLN PEN-INJECTOR Insulins - Diabetic Drugs LEVEMIR INJ FLEXTOUC 100 UNIT/ML INSULIN NPH ISOPHANE & REGULAR Insulins - Diabetic Drugs NOVOLIN INJ 70/30 HUMAN INJ 100 UNIT/ML (70-30) INSULIN NPH (HUMAN) (ISOPHANE) INJ Insulins - Diabetic Drugs NOVOLIN N INJ RELION 100 UNIT/ML INSULIN NPH (HUMAN) (ISOPHANE) INJ Insulins - Diabetic Drugs NOVOLIN N INJ U-100 100 UNIT/ML INSULIN REGULAR (HUMAN) INJ 100 UNIT/ Insulins - Diabetic Drugs NOVOLIN R INJ RELION ML INSULIN REGULAR (HUMAN) INJ 100 UNIT/ Insulins - Diabetic Drugs NOVOLIN R INJ U-100 ML INSULIN NPH ISOPHANE & REGULAR Insulins - Diabetic Drugs NOVOLIN70/30 INJ RELION HUMAN INJ 100 UNIT/ML (70-30) Insulins - Diabetic Drugs NOVOLOG INJ 100/ML INSULIN ASPART INJ 100 UNIT/ML INSULIN ASPART SOLN PEN-INJECTOR Insulins - Diabetic Drugs NOVOLOG INJ FLEXPEN 100 UNIT/ML INSULIN ASPART SOLN CARTRIDGE 100 Insulins - Diabetic Drugs NOVOLOG INJ PENFILL UNIT/ML INSULIN ASPART PROT & ASPART Insulins - Diabetic Drugs NOVOLOG MIX INJ 70/30 (HUMAN) INJ 100 UNIT/ML (70-30) INSULIN ASPART PROT & ASPART SUS Insulins - Diabetic Drugs NOVOLOG MIX INJ FLEXPEN PEN-INJ 100 UNIT/ML (70-30) Irritable Bowel Syndrome Agents - Bowel ALOSETRON HCL TAB 0.5 MG (BASE ALOSETRON TAB 0.5MG Treatment Drugs EQUIV) Irritable Bowel Syndrome Agents - Bowel ALOSETRON TAB 1MG ALOSETRON HCL TAB 1 MG (BASE EQUIV) Treatment Drugs Irritable Bowel Syndrome Agents - Bowel AMITIZA CAP 24MCG LUBIPROSTONE CAP 24 MCG Treatment Drugs Irritable Bowel Syndrome Agents - Bowel AMITIZA CAP 8MCG LUBIPROSTONE CAP 8 MCG Treatment Drugs TECFIDERA CAP 120MG
122
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 4
X
X
Tier 4
X
X
X
X X
Tier 3
X
X
Tier 3
X
X
Tier 1
X
Tier 1
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 1
X
Tier 2
X
Tier 2
X
Tier 1
X
Tier 1
X
Tier 2
X
Tier 1
X
Tier 2
X
Tier 1
X
Tier 1
X
Tier 2 Tier 2
X
Tier 2
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 2
X
X
Tier 2
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Therapeutic Class
Label Name
Irritable Bowel Syndrome Agents - Bowel LINZESS CAP 145MCG Treatment Drugs Irritable Bowel Syndrome Agents - Bowel LINZESS CAP 290MCG Treatment Drugs Irritable Bowel Syndrome Agents - Bowel LINZESS CAP 72MCG Treatment Drugs
Generic Name
Tier 2
X
X
LINACLOTIDE CAP 290 MCG
Tier 2
X
X
LINACLOTIDE CAP 72 MCG
Tier 2
X
X
Tier 1
Laxatives - Bowel Treatment Drugs
CHOLAC SYP 10GM/15
Laxatives - Bowel Treatment Drugs
CLEARLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM CONSTULOSE SOL 10GM/15 LACTULOSE SOLUTION 10 GM/15ML
Laxatives - Bowel Treatment Drugs
CVS PURELAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
CVS PURELAX POW 3350
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
ENULOSE SOL 10GM/15
LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML
Laxatives - Bowel Treatment Drugs
EQ CLEARLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
EQL CLEARLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
GAVILAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
GAVILYTE-C SOL
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM
Laxatives - Bowel Treatment Drugs
GAVILYTE-G SOL
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM
Laxatives - Bowel Treatment Drugs
GAVILYTE-N SOL FLAV PK
PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM
Laxatives - Bowel Treatment Drugs
GENERLAC SOL 10GM/15
LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML
Laxatives - Bowel Treatment Drugs
GENTLELAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
GLYCOLAX POW 3350 NF
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
GNP CLEARLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
GOLYTELY SOL
Laxatives - Bowel Treatment Drugs
GOLYTELY SOL
Laxatives - Bowel Treatment Drugs
GOLYTELY SOL PINEAPPL
Laxatives - Bowel Treatment Drugs
HM CLEARLAX POW
Laxatives - Bowel Treatment Drugs
KRISTALOSE PAK 10GM
COLYTE/FLAVR SOL PACKS
Laxatives - Bowel Treatment Drugs
KRISTALOSE PAK 20GM
Laxatives - Bowel Treatment Drugs
LACTULOSE SOL 10GM/15
Laxatives - Bowel Treatment Drugs
LACTULOSE SOL 10GM/15
Laxatives - Bowel Treatment Drugs
LACTULOSE SOL 20GM/30
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE PACKET 227.1 GM PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM POLYETHYLENE GLYCOL 3350 ORAL POWDER LACTULOSE ORAL CRYSTAL PACKET 10 GM LACTULOSE ORAL CRYSTAL PACKET 20 GM LACTULOSE SOLUTION 10 GM/15ML LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML LACTULOSE SOLUTION 10 GM/15ML
HCR Preventive Care Tier 3 Tier 1 HCR Preventive Care HCR Preventive Care Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 2 Tier 3 Tier 3 HCR Preventive Care Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 HCR Preventive Care HCR Preventive Care
Laxatives - Bowel Treatment Drugs
LAXACLEAR POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
LAXATIVE POL POW GLYCOL
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
MOVIPREP SOL
PEG 3350-KCL-NACL-NA SULFATE-NA ASCORBATE-C FOR SOLN 100 GM
Tier 3
POLYETHYLENE GLYCOL 3350 ORAL POWDER
HCR Preventive Care
Laxatives - Bowel Treatment Drugs
NATURA-LAX POW 3350 NF
Prior Supply Step Specialty Authorization Limit Therapy
LINACLOTIDE CAP 145 MCG
LACTULOSE (ENCEPHALOPATHY) SYRUP 10 GM/15ML
Laxatives - Bowel Treatment Drugs
Tier Value
123
X
Therapeutic Class
Label Name
Generic Name
Laxatives - Bowel Treatment Drugs
NULYTELY SOL FLAV PKS
PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM
Laxatives - Bowel Treatment Drugs
PEG 3350 POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
PEG 3350 POW
POLYETHYLENE GLYCOL 3350 POWDER
Laxatives - Bowel Treatment Drugs
PEG 3350 SOL ELECTROL
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM
Laxatives - Bowel Treatment Drugs
PEG3350 POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
PEG-3350 SOL ELECTROL
PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM
Laxatives - Bowel Treatment Drugs
PEG-3350/KCL SOL / SODIUM
PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM
Laxatives - Bowel Treatment Drugs
PEGYLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Tier 2
Laxatives - Bowel Treatment Drugs
POLYETH GLYC POW 3350 NF
POLYETHYLENE GLYCOL 3350 ORAL POWDER
HCR Preventive Care
POLYETH GLYC POW 3350 NF POLYETH GLYC POW 3350 NF
POLYETHYLENE GLYCOL 3350 ORAL POWDER POLYETHYLENE GLYCOL 3350 ORAL PACKET
Laxatives - Bowel Treatment Drugs
POWDERLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
HCR Preventive Care
Laxatives - Bowel Treatment Drugs
PREPOPIK PAK
SOD PICOSULFATE-MG OXIDE-CITRIC ACID PACK 10 MG-3.5 GM-12 GM
Tier 3
Laxatives - Bowel Treatment Drugs
RA LAXATIVE POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
SM CLEARLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
SMOOTH LAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
SUPREP BOWEL SOL PREP KIT
SODIUM SULFATE-POTASSIUM SULFATEMAGNESIUM SULFATE ORAL SOLN
Laxatives - Bowel Treatment Drugs
SW CLEARLAX POW
POLYETHYLENE GLYCOL 3350 ORAL POWDER
Laxatives - Bowel Treatment Drugs
TRILYTE SOL
PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM
Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics Local Anesthetics
BUPIVACAINE POW HCL EMLA CRE 2.5-2.5% LIDO/PRILOCN CRE 2.5-2.5% LIDOCAINE CRE TETRACAI LIDOCAINE GEL 2% JELLY LIDOCAINE OIN 5% LIDOCAINE OIN PAK 5% LIDOCAINE PAD 5% LIDOCAINE SOL 2% VISC LIDOCAINE SOL 4%
Laxatives - Bowel Treatment Drugs Laxatives - Bowel Treatment Drugs
Local Anesthetics
LIDOCAINE SOL 4%
Local Anesthetics
PLIAGLIS CRE 7-7%
Local Anesthetics
SYNERA DIS 70-70MG
Local Anesthetics Local Anesthetics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics
TOPEX TOPCAL AER ANESTHET XYLOCAINE SOL 4% AZASITE SOL 1% AZITHROMYCIN POW 1GM PAK AZITHROMYCIN SUS 100/5ML AZITHROMYCIN SUS 200/5ML AZITHROMYCIN TAB 250MG AZITHROMYCIN TAB 500MG AZITHROMYCIN TAB 600MG
BUPIVACAINE HCL POWDER LIDOCAINE-PRILOCAINE CREAM 2.5-2.5% LIDOCAINE-PRILOCAINE CREAM 2.5-2.5% LIDOCAINE-TETRACAINE CREAM 7-7% LIDOCAINE HCL GEL 2% LIDOCAINE OINT 5% LIDOCAINE OINT 5% LIDOCAINE PATCH 5% LIDOCAINE HCL VISCOUS SOLN 2% LIDOCAINE HCL SOLN 4% LIDOCAINE HCL LARYNGOTRACHEAL SOLN 4% LIDOCAINE-TETRACAINE CREAM 7-7% LIDOCAINE-TETRACAINE TOPICAL PATCH 70-70 MG BENZOCAINE MOUTH/THROAT AEROSOL 20% LIDOCAINE HCL SOLN 4% AZITHROMYCIN OPHTH SOLN 1% AZITHROMYCIN POWD PACK FOR SUSP 1 GM
Tier Value Tier 3 HCR Preventive Care Tier 2 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Tier 2 Tier 2
HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care Tier 3 Tier 3 Tier 1 Tier 3 Tier 1 Tier 2 Tier 2 Tier 3 Tier 1 Tier 1
X
X
X X X
Tier 1 Tier 3
X
Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 1
AZITHROMYCIN FOR SUSP 100 MG/5ML
Tier 1
AZITHROMYCIN FOR SUSP 200 MG/5ML
Tier 1
AZITHROMYCIN TAB 250 MG AZITHROMYCIN TAB 500 MG AZITHROMYCIN TAB 600 MG
Tier 1 Tier 1 Tier 1
124
Prior Supply Step Specialty Authorization Limit Therapy
X
Therapeutic Class
Label Name
Macrolides - Antibiotics
BIAXIN SUS 250/5ML
Macrolides - Antibiotics Macrolides - Antibiotics
Macrolides - Antibiotics
BIAXIN TAB 250MG BIAXIN TAB 500MG CLARITHROMYC SUS 125/5ML CLARITHROMYC SUS 250/5ML CLARITHROMYC TAB 250MG CLARITHROMYC TAB 500MG CLARITHROMYC TAB 500MG ER DIFICID TAB 200MG
Macrolides - Antibiotics
E.E.S. GRAN SUS 200/5ML
Macrolides - Antibiotics Macrolides - Antibiotics
ERY PAD 2% ERYGEL GEL 2%
Macrolides - Antibiotics
ERYPED SUS 200/5ML
Macrolides - Antibiotics
ERYPED SUS 400/5ML
Macrolides - Antibiotics
ERY-TAB TAB 250MG EC
Macrolides - Antibiotics
ERY-TAB TAB 333MG EC
Macrolides - Antibiotics
ERY-TAB TAB 500MG EC
Macrolides - Antibiotics
Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics
ERYTHROCIN TAB 250MG ERYTHROM ETH SUS 200/5ML ERYTHROM ETH TAB 400MG ERYTHROMYCIN CAP 250MG EC ERYTHROMYCIN GEL 2% ERYTHROMYCIN OIN 5MG/ GM 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
Macrolides - Antibiotics
PCE TAB 333MG EC
Macrolides - Antibiotics
PCE TAB 500MG EC
Macrolides - Antibiotics
ZITHROMAX POW 1GM PAK
Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics Macrolides - Antibiotics
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
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
Generic Name CLARITHROMYCIN FOR SUSP 250 MG/5ML CLARITHROMYCIN TAB 250 MG CLARITHROMYCIN TAB 500 MG CLARITHROMYCIN FOR SUSP 125 MG/5ML CLARITHROMYCIN FOR SUSP 250 MG/5ML
Tier Value Tier 3 Tier 3 Tier 3 Tier 2 Tier 2
CLARITHROMYCIN TAB 250 MG
Tier 1
CLARITHROMYCIN TAB 500 MG
Tier 1
CLARITHROMYCIN TAB SR 24HR 500 MG
Tier 2
FIDAXOMICIN TAB 200 MG ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML ERYTHROMYCIN PADS 2% ERYTHROMYCIN GEL 2% ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 400 MG/5ML ERYTHROMYCIN TAB DELAYED RELEASE 250 MG ERYTHROMYCIN TAB DELAYED RELEASE 333 MG ERYTHROMYCIN TAB DELAYED RELEASE 500 MG ERYTHROMYCIN STEARATE TAB 250 MG ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG ERYTHROMYCIN W/ DELAYED RELEASE PARTICLES CAP 250 MG ERYTHROMYCIN GEL 2%
Tier 3
ERYTHROMYCIN OPHTH OINT 5 MG/GM
Tier 1
ERYTHROMYCIN OPHTH OINT 5 MG/GM ERYTHROMYCIN PADS 2% ERYTHROMYCIN SOLN 2%
Tier 1 Tier 1 Tier 1
ERYTHROMYCIN TAB 250 MG
Tier 1
ERYTHROMYCIN TAB 500 MG
Tier 1 Tier 1 Tier 3 Tier 3
X
Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2 Tier 2 Tier 2 Tier 1 Tier 1 Tier 1 Tier 1
Macrolides - Antibiotics
ZMAX SUS 2GM
Mast Cell Stabilizers - Asthma/Lung 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
CROMOLYN SOD NEB 20MG/2ML
ERYTHROMYCIN OPHTH OINT 5 MG/GM TELITHROMYCIN TAB 300 MG TELITHROMYCIN TAB 400 MG ERYTHROMYCIN W/ ENTERIC COATED PARTICLES TAB 333 MG ERYTHROMYCIN W/ ENTERIC COATED PARTICLES TAB 500 MG AZITHROMYCIN POWD PACK FOR SUSP 1 GM AZITHROMYCIN FOR SUSP 100 MG/5ML AZITHROMYCIN FOR SUSP 200 MG/5ML AZITHROMYCIN TAB 250 MG AZITHROMYCIN TAB 500 MG AZITHROMYCIN TAB 600 MG AZITHROMYCIN TAB 500 MG AZITHROMYCIN TAB 250 MG AZITHROMYCIN EXTENDED RELEASE FOR ORAL SUSP 2 GM CROMOLYN SODIUM SOLN NEBU 20 MG/2ML
ACTONEL TAB 150MG
RISEDRONATE SODIUM TAB 150 MG
Tier 3
ACTONEL TAB 30MG
RISEDRONATE SODIUM TAB 30 MG
Tier 3
ACTONEL TAB 35MG
RISEDRONATE SODIUM TAB 35 MG
Tier 3
ACTONEL TAB 5MG
RISEDRONATE SODIUM TAB 5 MG
Tier 3
ALENDRONATE SOL 70/75ML
ALENDRONATE SODIUM ORAL SOLN 70 MG/75ML
Tier 1
125
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 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 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
Label Name
Generic Name
ALENDRONATE TAB 10MG
ALENDRONATE SODIUM TAB 10 MG
Tier 1
ALENDRONATE TAB 35MG
ALENDRONATE SODIUM TAB 35 MG
Tier 1
ALENDRONATE TAB 40MG
ALENDRONATE SODIUM TAB 40 MG
Tier 1
ALENDRONATE TAB 5MG
ALENDRONATE SODIUM TAB 5 MG
Tier 1
ALENDRONATE SODIUM TAB 70 MG
Tier 1
ALENDRONATE TAB 70MG BONIVA TAB 150MG CALCITONIN SPR 200/ACT
Tier 1
CALCITRIOL CAP 0.5MCG
CALCITRIOL CAP 0.5 MCG
Tier 1
CALCITRIOL SOL 1MCG/ML
CALCITRIOL ORAL SOLN 1 MCG/ML
Tier 1
DOXERCALCIF CAP 0.5MCG
DOXERCALCIFEROL CAP 0.5 MCG
Tier 1
DOXERCALCIF CAP 1MCG
DOXERCALCIFEROL CAP 1 MCG
Tier 1
DOXERCALCIF CAP 2.5MCG
DOXERCALCIFEROL CAP 2.5 MCG
Tier 1
ETIDRON DISD TAB 200MG
ETIDRONATE DISODIUM TAB 200 MG
Tier 1
ETIDRON DISD TAB 400MG
ETIDRONATE DISODIUM TAB 400 MG
Tier 1
FORTEO SOL 600/2.4 FORTICAL SPR 200/ACT FOSAMAX TAB 70MG FOSAMAX + D TAB 70-2800
Metabolic Bone Disease Agents Osteoporosis (Bone Loss) Drugs
FOSAMAX + D TAB 70-5600
ALENDRONATE SODIUM TAB 70 MG ALENDRONATE SODIUMCHOLECALCIFEROL TAB 70-2800 MGUNIT ALENDRONATE SODIUMCHOLECALCIFEROL TAB 70-5600 MGUNIT
Tier 2
X
X
Tier 3 Tier 3 Tier 3 Tier 3
HECTOROL CAP 0.5MCG
DOXERCALCIFEROL CAP 0.5 MCG
Tier 3
HECTOROL CAP 1MCG
DOXERCALCIFEROL CAP 1 MCG
Tier 3
HECTOROL CAP 2.5MCG
DOXERCALCIFEROL CAP 2.5 MCG
Tier 3
IBANDRONATE TAB 150MG
IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT)
Tier 2
MIACALCIN INJ 200/ML
CALCITONIN (SALMON) INJ 200 UNIT/ML
Tier 3
MIACALCIN SPR 200/ACT
CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT
Tier 3
PARICALCITOL CAP 1 MCG
PARICALCITOL CAP 1 MCG
Tier 1
PARICALCITOL CAP 2 MCG
PARICALCITOL CAP 2 MCG
Tier 1
PARICALCITOL CAP 4 MCG
PARICALCITOL CAP 4 MCG
Tier 1
RISEDRONATE TAB 150MG
RISEDRONATE SODIUM TAB 150 MG
Tier 3
RISEDRONATE TAB 30MG
RISEDRONATE SODIUM TAB 30 MG
Tier 3
RISEDRONATE TAB 35MG
RISEDRONATE SODIUM TAB 35 MG
Tier 3
RISEDRONATE TAB 5MG
RISEDRONATE SODIUM TAB 5 MG
Tier 3
ROCALTROL CAP 0.25MCG
CALCITRIOL CAP 0.25 MCG
Tier 3
ROCALTROL CAP 0.5MCG
CALCITRIOL CAP 0.5 MCG
Tier 3
ROCALTROL SOL 1MCG/ML CALCITRIOL ORAL SOLN 1 MCG/ML
Tier 3
ZEMPLAR CAP 1MCG
PARICALCITOL CAP 1 MCG
Tier 3
ZEMPLAR CAP 2MCG
PARICALCITOL CAP 2 MCG
Tier 3
126
X
Tier 2
CALCITRIOL CAP 0.25 MCG
TERIPARATIDE (RECOMBINANT) INJ 600 MCG/2.4ML CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
CALCITRIOL CAP 0.25MCG
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
IBANDRONATE SODIUM TAB 150 MG (BASE EQUIVALENT) CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT
Tier Value
X
X
X
Therapeutic Class
Label Name
Generic Name
Miscellaneous Therapeutic Agents
ACTIVE MEDIC KIT SPECIMEN
*URINE SPECIMEN COLLECTION KIT**
MISCELLANEOUS THERAPEUTIC AGENTS
AMINOBEZ POT POW
Miscellaneous Therapeutic Agents
B-D UF SYRG MIS .3CC/30G
Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS
BISMUTH SUBC POW
Tier Value Tier 1
Miscellaneous Therapeutic Agents
CARETOUCH MIS 31GX8MM
Miscellaneous Therapeutic Agents
CARETOUCH MIS 32GX4MM
Miscellaneous Therapeutic Agents
CARETOUCH MIS 32GX5MM
Miscellaneous Therapeutic Agents
CARNITOR SOL 1GM/10ML
Miscellaneous Therapeutic Agents
CARNITOR SF SOL 1GM/10ML
POTASSIUM AMINOBENZOATE PACKET 2 GM INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2" BISMUTH SUBCARBONATE POWDER DHA-EPA-VIT B6-B12-FOLIC ACID CAP 240360-20-0.5-0.8 MG INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 32 G X 4 MM (5/32") INSULIN PEN NEEDLE 32 G X 5 MM (1/5" OR 3/16") INSULIN PEN NEEDLE 32 G X 6 MM (1/4") INSULIN PEN NEEDLE 31 G X 5 MM (3/16") INSULIN PEN NEEDLE 31 G X 6 MM (1/4") INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 32 G X 4 MM (5/32") INSULIN PEN NEEDLE 32 G X 5 MM (1/5" OR 3/16") LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%) LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)
CAVAREST GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
CAVIRINSE SOL 0.2%
SODIUM FLUORIDE RINSE 0.2%
Tier 1
CLINPRO 5000 PST 1.1%
SODIUM FLUORIDE PASTE 1.1%
Tier 1
COLCIGEL GEL
*HOMEOPATHIC PRODUCTS - GEL**
Tier 3
CONCEPTROL GEL 4%
NONOXYNOL-9 GEL 4%
CONTROLRX CRE 1.1%
SODIUM FLUORIDE CREAM 1.1%
Tier 1
CRYOSERV SOL
*DIMETHYL SULFOXIDE - SOLUTION***
Tier 3
DENTA 5000 CRE PLUS
SODIUM FLUORIDE CREAM 1.1%
Tier 1
DENTA 5000 CRE PLUS 2PK
SODIUM FLUORIDE CREAM 1.1%
Tier 1
DENTAGEL GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
DERMATODORON LIQ
*HOMEOPATHIC PRODUCTS - LIQUID**
Tier 3
DIGESTODORON LIQ
*HOMEOPATHIC PRODUCTS - LIQUID**
Tier 3
CARDIOVID CAP PLUS
Miscellaneous Therapeutic Agents
CAREFINE MIS 31GX8MM
Miscellaneous Therapeutic Agents
CAREFINE MIS 32GX4MM
Miscellaneous Therapeutic Agents
CAREFINE MIS 32GX5MM
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
CAREFINE MIS 32GX6MM CARETOUCH MIS 31GX5MM CARETOUCH MIS 31GX6MM
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
Tier 1 Tier 2 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
HCR Preventive Care
DIMETHYL SOL SULFOXID
*DIMETHYL SULFOXIDE - SOLUTION***
Tier 3
DISCUS LIQ COMPOSIT
*HOMEOPATHIC PRODUCTS - LIQUID**
Tier 3
DIUSCREEN ME KIT COLLECTI
*URINE SPECIMEN COLLECTION KIT**
Tier 3
EASYGEL GEL 0.4%
STANNOUS FLUORIDE GEL 0.4%
Tier 1
EASYGEL GEL 0.4%CHRY
STANNOUS FLUORIDE GEL 0.4%
Tier 1
EASYGEL GEL 0.4%CITR
STANNOUS FLUORIDE GEL 0.4%
Tier 1
EASYGEL GEL 0.4%MINT
STANNOUS FLUORIDE GEL 0.4%
Tier 1
ERYSIDORON LIQ #1
*HOMEOPATHIC PRODUCTS - LIQUID**
Tier 3
FE PYROPHOSP POW
*BULK CHEMICALS - POWDER**
Tier 3
ACETIC ACID-OXYQUINOLINE VAGINAL GEL 0.9-0.025% FERRIPROX SOL 100MG/ML DEFERIPRONE ORAL SOLN 100 MG/ML FERRIPROX TAB 500MG DEFERIPRONE TAB 500 MG ICATIBANT ACETATE INJ 30 MG/3ML FIRAZYR INJ 30MG/3ML (BASE EQUIVALENT) FLUOR-A-DAY CHW 0.25MG SODIUM FLUORIDE-XYLITOL CHEW TAB F 0.55 (0.25 MG F)-236.79 MG SODIUM FLUORIDE-XYLITOL CHEW TAB FLUOR-A-DAY CHW 0.5MG F 1.1 (0.5 MG F)-236.79 MG
FEM PH GEL
127
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 3 Tier 2 Tier 3
X X
Tier 4
X
Tier 3 Tier 3
X X X
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
Label Name FLUOR-A-DAY CHW 1MG F FLUORID SENS PST 1.1-5%
SODIUM FLUORIDE-XYLITOL CHEW TAB 2.2 (1 MG F)-236.79 MG SODIUM FLUORIDE-POTASSIUM NITRATE PASTE 1.1-5%
Tier Value
Tier 1
STANNOUS FLUORIDE CONC 0.63%
Tier 1
FLUORIDEX GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
FLUORIDEX GEL SENSITIV
SODIUM FLUORIDE-POTASSIUM NITRATE GEL 1.1-5%
Tier 3
FLUORIDEX GEL WHITENIN
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
FLUORIDEX PST 1.1%
SODIUM FLUORIDE PASTE 1.1%
Tier 1
FLUORIDEX DD PST SENSITIV
SODIUM FLUORIDE-POTASSIUM NITRATE PASTE 1.1-5%
Tier 1
GEL-KAM CON 0.63%
STANNOUS FLUORIDE CONC 0.63%
Tier 3
GLONOIN DRO HOMACCOR *HOMEOPATHIC PRODUCTS - LIQUID** GRASTEK SUB 2800BAU GYNOL II GEL 3%
Miscellaneous Therapeutic Agents
INSULIN SYR MIS 0.3/31G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.3/29G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.3/30G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.3/30G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.3/31G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.5/28G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.5/29G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.5/30G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.5/30G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.5/30G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.5/31G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 0.5/31G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 1ML/28G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 1ML/29G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 1ML/30G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 1ML/30G
Miscellaneous Therapeutic Agents
INSULIN SYRG MIS 1ML/31G
TIMOTHY GRASS POLLEN ALLERGEN EXT TAB SL 2800 BAU NONOXYNOL-9 GEL 3% INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 15/64" INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2" INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 1/2" INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 3/8" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64" INSULIN SYRINGE/NEEDLE U-100 1 ML 28 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1 ML 29 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 5/16"
Tier 3 Tier 3
X
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 Tier 2
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
KARIGEL-N GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
Miscellaneous Therapeutic Agents
K-PHOS TAB NO 2
POTASSIUM & SODIUM ACID PHOSPHATES TAB 305-700 MG
Tier 2
MISCELLANEOUS THERAPEUTIC AGENTS
L-ASPARAGINE POW MONOHYDR LEVOCARNITIN SOL 1GM/10ML
*BULK CHEMICALS - POWDER**
Tier 3
LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%) METHYLERGONOVINE MALEATE TAB 0.2 MG METHYLERGONOVINE MALEATE TAB 0.2 MG
Tier 1
X
Tier 1
Miscellaneous Therapeutic Agents
METHERGINE TAB 0.2MG
Miscellaneous Therapeutic Agents
METHYLERGON TAB 0.2MG
MISCELLANEOUS THERAPEUTIC AGENTS
MORCIN CRE
*HOMEOPATHIC PRODUCTS - CREAM**
Tier 3
Miscellaneous Therapeutic Agents
MYALEPT INJ 11.3MG
METRELEPTIN FOR SUBCUTANEOUS INJ 11.3 MG
Tier 3
128
X
HCR Preventive Care
KARIGEL GEL 0.5%
Miscellaneous Therapeutic Agents
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
FLUORIDEX CON DLY REN
Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Generic Name
Tier 1
X
X
X
Therapeutic Class MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Label Name
NAFRINSE DLY SOL / NEUTRAL NAFRINSE WK SOL 0.2%
SODIUM FLUORIDE FOR SOLN RINSE 0.2%
Tier 3
NEUTRAGARD GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
NOVOFINE MIS 30GX8MM
Miscellaneous Therapeutic Agents
NOVOFINE MIS 32GX6MM NOVOFINE AUT MIS 30GX8MM NOVOFINE PLS MIS 32GX4MM
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
Tier Value
SODIUM FLUORIDE-PHOSPHORIC ACID FOR SOLN 1 MG/5ML (F EQUIV) SODIUM FLUORIDE FOR SOLN RINSE 0.05%
NAFRINSE SOL DAILY
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
Generic Name
INSULIN PEN NEEDLE 30 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 32 G X 6 MM (1/4") INSULIN PEN NEEDLE 30 G X 8 MM (1/3" OR 5/16") INSULIN PEN NEEDLE 32 G X 4 MM (5/32")
INSULIN PEN NEEDLE 30 G X 8 MM (1/3" NOVOTWIST MIS 30GX8MM OR 5/16") INSULIN PEN NEEDLE 32 G X 5 MM (1/5" NOVOTWIST MIS 32GX5MM OR 3/16") *GRASS MIXED POLLEN EXT TAB SL 300 ORALAIR SUB 300 IR IR (INDEX OF REACTIVITY)* *GRASS MIXED POLLEN EXT TAB SL 300 ORALAIR ADLT SUB 300 IR IR (INDEX OF REACTIVITY)* ORALAIR CHLD PAK *GRASS MIXED POLLEN TAB SL THERPAK SAMPLE 100 (3) IR & 300 (6) IR* *GRASS MIXED POLLEN EXT TAB SL 100 ORALAIR CHLD SUB 100 IR IR (INDEX OF REACTIVITY)* PEN NEEDLE MIS 29GX1/2" INSULIN PEN NEEDLE 29 G X 12.7 MM PEN NEEDLES MIS 29GX1/2" INSULIN PEN NEEDLE 29 G X 12 MM (1/2") PEN NEEDLES MIS INSULIN PEN NEEDLE 29 G X 12 MM (1/2") 29GX12MM INSULIN PEN NEEDLE 30 G X 8 MM (1/3" PEN NEEDLES MIS 30GX5/16 OR 5/16") PEN NEEDLES MIS 31GX1/4" INSULIN PEN NEEDLE 31 G X 6 MM (1/4") PEN NEEDLES MIS 31GX3/16 INSULIN PEN NEEDLE 31 G X 5 MM (3/16") INSULIN PEN NEEDLE 31 G X 8 MM (1/3" PEN NEEDLES MIS 31GX5/16 OR 5/16") PEN NEEDLES MIS INSULIN PEN NEEDLE 31 G X 5 MM (3/16") 31GX5MM PEN NEEDLES MIS INSULIN PEN NEEDLE 31 G X 6 MM (1/4") 31GX6MM PEN NEEDLES MIS INSULIN PEN NEEDLE 31 G X 8 MM (1/3" 31GX8MM OR 5/16") PEN NEEDLES MIS INSULIN PEN NEEDLE 32 G X 4 MM (5/32") 32GX4MM
Tier 2 Tier 2
Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 Tier 3
X
X
Tier 3
X
X
X
X
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
PHOS-FLUR GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
PNEUMODORON LIQ
*HOMEOPATHIC PRODUCTS - LIQUID**
Tier 3
POLYOX POW WSR-301
*BULK CHEMICALS - POWDER**
Tier 3
POTABA CAP 500MG
POTASSIUM AMINOBENZOATE CAP 500 MG
Tier 3
PREVDNT 5000 PST 1.1%
SODIUM FLUORIDE PASTE 1.1%
Tier 3
PREVDNT 5000 PST 1.1-5%
SODIUM FLUORIDE-POTASSIUM NITRATE PASTE 1.1-5%
Tier 3
PREVIDENT CRE 5000 PLS
SODIUM FLUORIDE CREAM 1.1%
Tier 3
PREVIDENT GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 3
PREVIDENT GEL 1.1% BER
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 3
PREVIDENT GEL 1.1% CHR
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 3
PREVIDENT GEL 1.1% MIN
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 3
PREVIDENT PST 5000 BST
SODIUM FLUORIDE PASTE 1.1%
Tier 3
PREVIDENT SOL 0.2%
SODIUM FLUORIDE RINSE 0.2%
Tier 3
PREVIDENT SOL RINSE
SODIUM FLUORIDE RINSE 0.2%
Tier 3
Q2 ORAL CLEA KIT SYSTEM
*ORAL HYGIENE PRODUCTS - KIT**
Tier 3
Q4 ORAL CLEA KIT SYSTEM
*ORAL HYGIENE PRODUCTS - KIT**
Tier 3
129
Prior Supply Step Specialty Authorization Limit Therapy
X
Therapeutic Class
Label Name
Generic Name
Tier Value
RA PEN NEEDL MIS INSULIN PEN NEEDLE 31 G X 5 MM (3/16") 31GX3/16 RADIOGARDASE CAP 0.5GM PRUSSIAN BLUE INSOLUBLE CAP 0.5 GM SHORT RAGWEED POLLEN ALLERGEN RAGWITEK SUB EXTRACT TAB SL 12 AMB A 1-U
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS
RAPID GEL RX GEL
*HOMEOPATHIC PRODUCTS - GEL**
Tier 3
Miscellaneous Therapeutic Agents
RELAGARD GEL
ACETIC ACID-OXYQUINOLINE VAGINAL GEL 0.9-0.025%
Tier 3
RHEUMADORON LIQ 102A
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Tier 2
Tier 3
*HOMEOPATHIC PRODUCTS - LIQUID**
Tier 3
RX-SPECIMEN KIT COLLECTI *URINE SPECIMEN COLLECTION KIT**
Tier 3
SF GEL 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 1
SF 5000 PLUS CRE 1.1%
SODIUM FLUORIDE CREAM 1.1%
Tier 1
Miscellaneous Therapeutic Agents
SHUR-SEAL GEL 2%
NONOXYNOL-9 GEL 2%
Miscellaneous Therapeutic Agents
SM INSULIN SYRINGE
INSULIN SYRINGE/NEEDLE U-100 0.3 ML 29 X 1/2"
Tier 2
SOD FLUORIDE SOL 0.2%
SODIUM FLUORIDE RINSE 0.2%
Tier 1
SPECIMEN KIT COLLECTI
*URINE SPECIMEN COLLECTION KIT**
Tier 3
SPEEDGEL RX GEL
*HOMEOPATHIC PRODUCTS - GEL**
Tier 3
STERYMINE GEL
*HOMEOPATHIC PRODUCTS - GEL**
Tier 3
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS
Tier 3
THERA-FLUR-N DRO 1.1%
SODIUM FLUORIDE GEL 1.1% (0.5% F)
Tier 3
TODAY SPONGE MIS
NONOXYNOL-9 VAGINAL SPONGE 1000 MG
TRANZGEL GEL
*HOMEOPATHIC PRODUCTS - GEL**
Tier 3
INSULIN PEN NEEDLE 32 G X 4 MM (5/32") INSULIN PEN NEEDLE 29 G X 12 MM (1/2")
Tier 2 Tier 2
INSULIN PEN NEEDLE 29 G X 12 MM (1/2")
Tier 2
Miscellaneous Therapeutic Agents
UNFINE PNTP MIS 32GX4MM UNIFINE PNTP MIS 29GX1/2" UNIFINE PNTP MIS 29GX12MM UNIFINE PNTP MIS 31GX3/16
Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX5/16
MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
UNIFINE PNTP MIS 31GX5MM UNIFINE PNTP MIS 31GX6MM UNIFINE PNTP MIS 31GX8MM URINX MEDIC KIT SPECIMEN
INSULIN PEN NEEDLE 31 G X 5 MM (3/16") INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16")
X
HCR Preventive Care
Tier 2 Tier 2
INSULIN PEN NEEDLE 31 G X 5 MM (3/16")
Tier 2
INSULIN PEN NEEDLE 31 G X 6 MM (1/4")
Tier 2
INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") *URINE SPECIMEN COLLECTION KIT**
X
HCR Preventive Care
THALAMUS SUB COMPOSIT *HOMEOPATHIC PRODUCTS - SL TAB**
Miscellaneous Therapeutic Agents
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care
Miscellaneous Therapeutic Agents
VCF VAGINAL AER CONTRACP
NONOXYNOL-9 FOAM 12.5%
Miscellaneous Therapeutic Agents
VCF VAGINAL GEL CONTRACE
NONOXYNOL-9 GEL 4%
Miscellaneous Therapeutic Agents
VCF VAGINAL MIS CONTRACP
NONOXYNOL-9 FILM 28%
AFINITOR TAB 10MG
EVEROLIMUS TAB 10 MG
Tier 2
X
X
X
AFINITOR TAB 2.5MG
EVEROLIMUS TAB 2.5 MG
Tier 2
X
X
X
AFINITOR TAB 5MG
EVEROLIMUS TAB 5 MG
Tier 2
X
X
X
AFINITOR TAB 7.5MG
EVEROLIMUS TAB 7.5 MG
Tier 2
X
X
X
AFINITOR DIS TAB 2MG
EVEROLIMUS TAB FOR ORAL SUSP 2 MG
Tier 2
X
X
X
AFINITOR DIS TAB 3MG
EVEROLIMUS TAB FOR ORAL SUSP 3 MG
Tier 2
X
X
X
AFINITOR DIS TAB 5MG
EVEROLIMUS TAB FOR ORAL SUSP 5 MG
Tier 2
X
X
X
BOSULIF TAB 100MG
BOSUTINIB TAB 100 MG
Tier 2
X
X
X
X
BOSULIF TAB 500MG
BOSUTINIB TAB 500 MG
Tier 2
X
X
X
X
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
130
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 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 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
Label Name IMATINIB MES TAB 100MG IMATINIB MES TAB 400MG
Generic Name IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT) IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1
X
X
X
Tier 1
X
X
X
IMBRUVICA CAP 140MG
IBRUTINIB CAP 140 MG
Tier 2
X
X
X
INLYTA TAB 1MG
AXITINIB TAB 1 MG
Tier 3
X
X
X
INLYTA TAB 5MG
AXITINIB TAB 5 MG
Tier 3
X
X
X
IRESSA TAB 250MG
GEFITINIB TAB 250 MG
Tier 3
X
X
X
NEXAVAR TAB 200MG
SORAFENIB TOSYLATE TAB 200 MG (BASE EQUIVALENT)
Tier 2
X
X
X
SPRYCEL TAB 100MG
DASATINIB TAB 100 MG
Tier 3
X
X
X
X
SPRYCEL TAB 140MG
DASATINIB TAB 140 MG
Tier 3
X
X
X
X
SPRYCEL TAB 20MG
DASATINIB TAB 20 MG
Tier 3
X
X
X
X
SPRYCEL TAB 50MG
DASATINIB TAB 50 MG
Tier 3
X
X
X
X
SPRYCEL TAB 70MG
DASATINIB TAB 70 MG
Tier 3
X
X
X
X
SPRYCEL TAB 80MG
DASATINIB TAB 80 MG
Tier 3
X
X
X
X
STIVARGA TAB 40MG
REGORAFENIB TAB 40 MG
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
X
Tier 2
X
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG TARCEVA TAB 100MG TARCEVA TAB 150MG TARCEVA TAB 25MG TASIGNA CAP 150MG TASIGNA CAP 200MG TYKERB TAB 250MG VOTRIENT TAB 200MG
SUNITINIB MALATE CAP 12.5 MG (BASE EQUIVALENT) SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT) SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT) SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT) ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT) ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT) ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT) NILOTINIB HCL CAP 150 MG (BASE EQUIVALENT) NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT) LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV) PAZOPANIB HCL TAB 200 MG (BASE EQUIV)
XALKORI CAP 200MG
CRIZOTINIB CAP 200 MG
Tier 2
X
X
X
XALKORI CAP 250MG
CRIZOTINIB CAP 250 MG
Tier 2
X
X
X
ZELBORAF TAB 240MG
VEMURAFENIB TAB 240 MG
Tier 2
X
X
X
AZILECT TAB 0.5MG AZILECT TAB 1MG ELDEPRYL CAP 5MG RASAGILINE TAB 0.5MG RASAGILINE TAB 1MG SELEGILINE CAP 5MG
RASAGILINE MESYLATE TAB 0.5 MG (BASE EQUIV) RASAGILINE MESYLATE TAB 1 MG (BASE EQUIV) SELEGILINE HCL CAP 5 MG RASAGILINE MESYLATE TAB 0.5 MG (BASE EQUIV) RASAGILINE MESYLATE TAB 1 MG (BASE EQUIV)
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
SELEGILINE HCL CAP 5 MG
Tier 1
SELEGILINE TAB 5MG
SELEGILINE HCL TAB 5 MG
Tier 1
ZELAPAR TAB 1.25MG
SELEGILINE HCL ORALLY DISINTEGRATING TAB 1.25 MG
Tier 3
EMSAM DIS 12MG/24H
SELEGILINE TD PATCH 24HR 12 MG/24HR
Tier 3
EMSAM DIS 6MG/24HR
SELEGILINE TD PATCH 24HR 6 MG/24HR
Tier 3
EMSAM DIS 9MG/24HR
SELEGILINE TD PATCH 24HR 9 MG/24HR
Tier 3
131
Therapeutic Class 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 Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs Mood Stabilizers - Mood Disorder Drugs 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 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 Non-Amphetamines- Anorexigenics Non-Amphetamines- Anorexigenics 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
Label Name
Generic Name
Tier Value
MARPLAN TAB 10MG
ISOCARBOXAZID TAB 10 MG
Tier 3
NARDIL TAB 15MG
PHENELZINE SULFATE TAB 15 MG
Tier 3
PARNATE TAB 10MG
TRANYLCYPROMINE SULFATE TAB 10 MG
Tier 3
PHENELZINE TAB 15MG
PHENELZINE SULFATE TAB 15 MG
Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
TRANYLCYPROM TAB 10MG TRANYLCYPROMINE SULFATE TAB 10 MG
Tier 1
LITHIUM SOL 8MEQ/5ML LITHIUM CARB CAP 150MG LITHIUM CARB CAP 300MG LITHIUM CARB CAP 600MG LITHIUM CARB TAB 300MG LITHIUM CARB TAB 300MG ER LITHIUM CARB TAB 450MG ER LITHOBID TAB 300MG CR
LITHIUM ORAL SOLUTION 8 MEQ/5ML LITHIUM CARBONATE CAP 150 MG LITHIUM CARBONATE CAP 300 MG LITHIUM CARBONATE CAP 600 MG LITHIUM CARBONATE TAB 300 MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
LITHIUM CARBONATE TAB CR 300 MG
Tier 1
LITHIUM CARBONATE TAB CR 450 MG
Tier 1
LITHIUM CARBONATE TAB CR 300 MG
Tier 3
AMPYRA TAB 10MG
DALFAMPRIDINE TAB SR 12HR 10 MG
Tier 2
X
X
X
AUBAGIO TAB 14MG
TERIFLUNOMIDE TAB 14 MG
Tier 3
X
X
X
AUBAGIO TAB 7MG
TERIFLUNOMIDE TAB 7 MG
Tier 3
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 3
X
X
X
COPAXONE INJ 20MG/ML COPAXONE INJ 40MG/ML GILENYA CAP 0.5MG MEMANT TITRA PAK 5-10MG
GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 40 MG/ML FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV) MEMANTINE HCL TAB 5 MG (28) & 10 MG (21) TITRATION PAK
Tier 2
MEMANTINE TAB HCL 10MG MEMANTINE HCL TAB 10 MG
Tier 2
MEMANTINE TAB HCL 5MG
MEMANTINE HCL TAB 5 MG
Tier 2
MEMANTINE HC SOL 2MG/ ML
MEMANTINE HCL ORAL SOLUTION 2 MG/ ML
Tier 3
NAMENDA SOL 10MG/5ML
MEMANTINE HCL ORAL SOLUTION 2 MG/ ML
Tier 3
NAMENDA TAB 10MG
MEMANTINE HCL TAB 10 MG
Tier 3
NAMENDA TAB 5-10MG
MEMANTINE HCL TAB 5 MG (28) & 10 MG (21) TITRATION PAK
Tier 3
NAMENDA TAB 5MG
MEMANTINE HCL TAB 5 MG
Tier 3
BELVIQ TAB 10MG BELVIQ XR TAB 20MG CAFFEINE CIT SOL 20MG/ ML CAFFEINE CIT SOL 60MG/3ML
LORCASERIN HCL TAB 10 MG LORCASERIN HCL TAB SR 24HR 20 MG CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV) CAFFEINE CITRATE ORAL SOLN 60 MG/3ML (10 MG/ML BASE EQUIV)
Tier 3 Tier 3
ADLT ASA LOW TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
ANAPROX DS TAB 550MG
NAPROXEN SODIUM TAB 550 MG
ARTHROTEC 50 TAB ARTHROTEC 75 TAB
DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 50-0.2 MG DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 75-0.2 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIR-81 TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN CHW 81MG
ASPIRIN CHEW TAB 81 MG
132
Tier 1 Tier 1 HCR Preventive Care Tier 3 Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care
X X
Label Name
Generic Name
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN TAB 325MG
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN TAB 325MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN TAB 81MG
ASPIRIN TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN 81 TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN ADLT TAB 81MG
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN CHIL CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN CHLD CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN LOW CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN LOW TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRIN-81 CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIR-LOW TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ASPIRTAB TAB 324MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
BAYER ASA TAB 325MG
ASPIRIN TAB 325 MG
CELECOXIB CAP 100MG
CELECOXIB CAP 100 MG
Tier 2
X
CELECOXIB CAP 200MG
CELECOXIB CAP 200 MG
Tier 2
X
CELECOXIB CAP 400MG
CELECOXIB CAP 400 MG
Tier 2
X
CELECOXIB CAP 50MG
CELECOXIB CAP 50 MG
Tier 2
X
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
CHILD ASA CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
CHILD ASA LS CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
CHO MAG TRIS LIQ 500/5ML
CHOLINE & MAGNESIUM SALICYLATES LIQ 500 MG/5ML
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
CVS ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
CVS ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
CVS ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
CVS CHLD ASA CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
DAYPRO TAB 600MG
OXAPROZIN TAB 600 MG
DICLO/MISOPR TAB 500.2MG DICLO/MISOPR TAB 750.2MG
DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 50-0.2 MG DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 75-0.2 MG
133
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
HCR Preventive Care HCR Preventive Care Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 Tier 3 Tier 3
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
Label Name
Generic Name
DICLOFEN POT TAB 50MG
DICLOFENAC POTASSIUM TAB 50 MG
DICLOFENAC TAB 100MG ER DICLOFENAC TAB 25MG DR DICLOFENAC TAB 50MG DR DICLOFENAC TAB 75MG DR
DICLOFENAC SODIUM TAB SR 24HR 100 MG DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
DIFLUNISAL TAB 500MG
DIFLUNISAL TAB 500 MG
Tier 1
DURAXIN CAP
ACETAMINOPHEN-SALICYLAMIDEPHENYLTOLOXAMINE CAP 300-200-20MG
Tier 1
EC-NAPROSYN TAB 375MG
NAPROXEN TAB EC 375 MG
Tier 3
EC-NAPROSYN TAB 500MG
NAPROXEN TAB EC 500 MG
Tier 3
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ECPIRIN TAB 325MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ENTERIC ASA TAB 325MG
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQ ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQ ASPIRIN TAB 325MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQ CHILD ASA CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQL ASPIRIN CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQL ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQL ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQL ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
EQL CHLD ASA CHW 81MG
ASPIRIN CHEW TAB 81 MG
ETODOLAC CAP 200MG
ETODOLAC CAP 200 MG
Tier 1
ETODOLAC CAP 300MG
ETODOLAC CAP 300 MG
Tier 1
ETODOLAC TAB 400MG
ETODOLAC TAB 400 MG
Tier 1
ETODOLAC TAB 500MG
ETODOLAC TAB 500 MG
Tier 1
ETODOLAC ER TAB 400MG
ETODOLAC TAB SR 24HR 400 MG
Tier 1
ETODOLAC ER TAB 500MG
ETODOLAC TAB SR 24HR 500 MG
Tier 1
ETODOLAC ER TAB 600MG
ETODOLAC TAB SR 24HR 600 MG
Tier 1
FELDENE CAP 10MG
PIROXICAM CAP 10 MG
Tier 3
FELDENE CAP 20MG
PIROXICAM CAP 20 MG
Tier 3
FENOPROFEN CAP 200MG
FENOPROFEN CALCIUM CAP 200 MG
Tier 1
FENOPROFEN CAP 400MG
FENOPROFEN CALCIUM CAP 400 MG
Tier 1
FENOPROFEN TAB 600MG
FENOPROFEN CALCIUM TAB 600 MG
Tier 1
FENORTHO CAP 200MG
FENOPROFEN CALCIUM CAP 200 MG
Tier 1
FENORTHO CAP 400MG
FENOPROFEN CALCIUM CAP 400 MG
Tier 1
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
FLURBIPROFEN TAB 100MG FLURBIPROFEN TAB 100 MG
134
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
FLURBIPROFEN TAB 50MG
FLURBIPROFEN TAB 50 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
GNP ASPIRIN CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
GNP ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
GNP ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
GNP ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
HM ASPIRIN CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
HM ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
IBUPROFEN TAB 400MG
IBUPROFEN TAB 400 MG
Tier 1
IBUPROFEN TAB 600MG
IBUPROFEN TAB 600 MG
Tier 1
IBUPROFEN TAB 800MG
IBUPROFEN TAB 800 MG
Tier 1
INDOCIN SUP 50MG
INDOMETHACIN SUPPOS 50 MG
Tier 3
INDOCIN SUS 25MG/5ML
INDOMETHACIN SUSP 25 MG/5ML
Tier 3
INDOMETHACIN CAP 25MG
INDOMETHACIN CAP 25 MG
Tier 1
INDOMETHACIN CAP 50MG
INDOMETHACIN CAP 50 MG
Tier 1
INDOMETHACIN CAP CR 75 MG
Tier 1
KETOPROFEN CAP SR 24HR 200 MG
Tier 1
KETOPROFEN CAP 50MG
KETOPROFEN CAP 50 MG
Tier 1
KETOPROFEN CAP 75MG
KETOPROFEN CAP 75 MG
Tier 1
KETOROLAC TAB 10MG
KETOROLAC TROMETHAMINE TAB 10 MG
Tier 1
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
INDOMETHACIN CAP 75MG ER KETOPROFEN CAP 200MG ER
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
KLS ASPIRIN TAB 325MG EC ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
KLS ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
KP ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
LEVACET TAB
ASPIRIN-APAP-SALICYLAMIDE-CAFFEINE TAB 500-250-150-32.5 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
LO-DOSE ASA TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Tier Value Tier 1 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care
MECLOFEN SOD CAP 100MG
MECLOFENAMATE SODIUM CAP 100 MG
Tier 1
MECLOFEN SOD CAP 50MG
MECLOFENAMATE SODIUM CAP 50 MG
Tier 1
MEFENAM ACID CAP 250MG MEFENAMIC ACID CAP 250 MG
Tier 3
MELOXICAM SUS 7.5/5ML
MELOXICAM SUSP 7.5 MG/5ML
Tier 1
MELOXICAM TAB 15MG
MELOXICAM TAB 15 MG
Tier 1
MELOXICAM TAB 7.5MG
MELOXICAM TAB 7.5 MG
Tier 1
MINIPRIN LOW TAB 81MG EC ASPIRIN TAB DELAYED RELEASE 81 MG
HCR Preventive Care
MOBIC SUS 7.5/5ML
MELOXICAM SUSP 7.5 MG/5ML
Tier 3
MOBIC TAB 15MG
MELOXICAM TAB 15 MG
Tier 3
MOBIC TAB 7.5MG
MELOXICAM TAB 7.5 MG
Tier 3
135
Prior Supply Step Specialty Authorization Limit Therapy
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
Label Name
Generic Name
Tier Value
NABUMETONE TAB 500MG
NABUMETONE TAB 500 MG
Tier 1
NABUMETONE TAB 750MG
NABUMETONE TAB 750 MG
Tier 1
NALFON CAP 400MG
FENOPROFEN CALCIUM CAP 400 MG
Tier 3
NAPROSYN SUS 125/5ML
NAPROXEN SUSP 125 MG/5ML
Tier 3
NAPROSYN TAB 500MG
NAPROXEN TAB 500 MG
Tier 3
NAPROXEN SUS 125/5ML
NAPROXEN SUSP 125 MG/5ML
Tier 1
NAPROXEN TAB 250MG
NAPROXEN TAB 250 MG
Tier 1
NAPROXEN TAB 375MG
NAPROXEN TAB 375 MG
Tier 1
NAPROXEN TAB 500MG
NAPROXEN TAB 500 MG
Tier 1
NAPROXEN DR TAB 375MG
NAPROXEN TAB EC 375 MG
Tier 1
NAPROXEN DR TAB 500MG
NAPROXEN TAB EC 500 MG
Tier 1
NAPROXEN SOD TAB 275MG NAPROXEN SODIUM TAB 275 MG
Tier 1
NAPROXEN SOD TAB 550MG NAPROXEN SODIUM TAB 550 MG
Tier 1
OXAPROZIN TAB 600MG
OXAPROZIN TAB 600 MG
Tier 1
OXYCOD/IBU TAB 5-400MG
OXYCODONE-IBUPROFEN TAB 5-400 MG
Tier 1
PIROXICAM CAP 10MG
PIROXICAM CAP 10 MG
Tier 1
PIROXICAM CAP 20MG
PIROXICAM CAP 20 MG
Tier 1
PONSTEL CAP 250MG
MEFENAMIC ACID CAP 250 MG
Tier 3
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
PX ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
PX ASPIRIN TAB 325MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
QC ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
QC ASPIRIN TAB 325MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
QC CHILD ASA CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
RA ASPIRIN CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
RA ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
RA ASPIRIN TAB 325MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
RA ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
RA CHILD ASA CHW 81MG
ASPIRIN CHEW TAB 81 MG
SALSALATE TAB 500MG
SALSALATE TAB 500 MG
Tier 1
SALSALATE TAB 750MG
SALSALATE TAB 750 MG
Tier 1
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
SM ASPIRIN CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
SM ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
SM ASPIRIN TAB 325MG EC
ASPIRIN TAB DELAYED RELEASE 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
136
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
SM ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
SM CHILD ASA CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
SPRIX SPR 15.75MG
KETOROLAC TROMETHAMINE NASAL SPRAY 15.75 MG/SPRAY
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
ST JOSEPH CHW LOW 81MG ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
Tier Value HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care
SULINDAC TAB 150MG
SULINDAC TAB 150 MG
Tier 1
SULINDAC TAB 200MG
SULINDAC TAB 200 MG
Tier 1
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
TGT ASPIRIN CHW 81MG
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
TGT ASPIRIN CHW CHILD
ASPIRIN CHEW TAB 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
TGT ASPIRIN TAB 325MG
ASPIRIN TAB 325 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
TGT ASPIRIN TAB 81MG
ASPIRIN TAB DELAYED RELEASE 81 MG
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs
TGT ASPIRIN TAB 81MG EC
ASPIRIN TAB DELAYED RELEASE 81 MG
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory Drugs 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 Not Specified Not Specified
VOLTAREN GEL 1%
DICLOFENAC SODIUM GEL 1%
Tier 2
2-DEOXY-D POW -GLUCOSE ADAPTADERM GEL ADDYI TAB 100MG
Tier 3 Tier 3 Tier 3
Not Specified
ADLYXIN INJ 10/20MCG
Not Specified
ADLYXIN INJ 20MCG
Not Specified
AFSTYLA KIT 1000UNIT
Not Specified
AFSTYLA KIT 2000UNIT
Not Specified
AFSTYLA KIT 250UNIT
Not Specified
AFSTYLA KIT 3000UNIT
Not Specified
AFSTYLA KIT 500UNIT
Not Specified
AKYNZEO CAP
Not Specified
AKYNZEO CAP 300-0.5
Not Specified
ALECENSA CAP 150MG
Not Specified
ALPROLIX INJ 1000UNIT
Not Specified
ALPROLIX INJ 2000UNIT
Not Specified
ALPROLIX INJ 250UNIT
Not Specified
ALPROLIX INJ 3000UNIT
Not Specified
ALPROLIX INJ 4000UNIT
Not Specified
ALPROLIX INJ 500UNIT
Not Specified Not Specified Not Specified Not Specified Not Specified
ALUNBRIG TAB 30MG AMINOAM CAP RMS AMINORELIEF CAP RMS ANASTROZOLE POW ANHYDROUS GEL BASE
2-DEOXY-D-GLUCOSE POWDER *GEL BASE - GEL** FLIBANSERIN TAB 100 MG LIXISENATIDE PEN-INJ STARTER KIT 10 MCG/0.2ML & 20 MCG/0.2ML LIXISENATIDE SOLN PEN-INJECTOR 20 MCG/0.2ML (100 MCG/ML) ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 1000 UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 2000 UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 250 UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 3000 UNIT ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN FOR INJ KIT 500 UNIT NETUPITANT-PALONOSETRON CAP 3000.5 MG NETUPITANT-PALONOSETRON CAP 3000.5 MG ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT) COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 1000 UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 2000 UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 250 UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 3000 UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 4000 UNIT COAGULATION FACTOR IX (RECOMB) (RFIXFC) FOR INJ 500 UNIT BRIGATINIB TAB 30 MG *AMINO ACIDS CAP*** *AMINO ACIDS CAP*** ANASTROZOLE (BULK) POWDER *GEL BASE - GEL**
TOLMETIN SOD CAP 400MG TOLMETIN SODIUM CAP 400 MG
Tier 2
TOLMETIN SOD TAB 200MG TOLMETIN SODIUM TAB 200 MG
Tier 2
TOLMETIN SOD TAB 600MG TOLMETIN SODIUM TAB 600 MG
Tier 2
137
Prior Supply Step Specialty Authorization Limit Therapy
X
X
Tier 3
X
Tier 3
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
Tier 3
X
Tier 2
X
X
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 3 Tier 3
X X
X
Therapeutic Class
Label Name
Not Specified
ARANESP INJ 100MCG
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Generic Name
DARBEPOETIN ALFA SOLN INJ 100 MCG/ ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 100MCG SYRINGE 100 MCG/0.5ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 10MCG SYRINGE 10 MCG/0.4ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 150MCG SYRINGE 150 MCG/0.3ML DARBEPOETIN ALFA SOLN INJ 200 MCG/ ARANESP INJ 200MCG ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 200MCG SYRINGE 200 MCG/0.4ML DARBEPOETIN ALFA SOLN INJ 25 MCG/ ARANESP INJ 25MCG ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 25MCG SYRINGE 25 MCG/0.42ML DARBEPOETIN ALFA SOLN INJ 300 MCG/ ARANESP INJ 300MCG ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 300MCG SYRINGE 300 MCG/0.6ML DARBEPOETIN ALFA SOLN INJ 40 MCG/ ARANESP INJ 40MCG ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 40MCG SYRINGE 40 MCG/0.4ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 500MCG SYRINGE 500 MCG/ML DARBEPOETIN ALFA SOLN INJ 60 MCG/ ARANESP INJ 60MCG ML DARBEPOETIN ALFA SOLN PREFILLED ARANESP INJ 60MCG SYRINGE 60 MCG/0.3ML FLUTICASONE FUROATE AEROSOL ARNUITY ELPT INH 100MCG POWDER BREATH ACTIV 100 MCG/ACT FLUTICASONE FUROATE AEROSOL ARNUITY ELPT INH 200MCG POWDER BREATH ACTIV 200 MCG/ACT FERRIC CITRATE TAB 1 GM (210 MG AURYXIA TAB 210MG FERRIC IRON) BASE FOR GEL SALTS *GEL BASE - GEL** BASE FOR GEL WOUNDS *GEL BASE - GEL** BELSOMRA TAB 10MG SUVOREXANT TAB 10 MG BELSOMRA TAB 15MG SUVOREXANT TAB 15 MG BELSOMRA TAB 20MG SUVOREXANT TAB 20 MG BELSOMRA TAB 5MG SUVOREXANT TAB 5 MG GLYCOPYRROLATE-FORMOTEROL BEVESPI AER 9-4.8MCG FUMARATE AEROSOL 9-4.8 MCG/ACT BUTYLATED HYDROXYTOLUENE BHT POW POWDER BRIVIACT SOL 10MG/ML BRIVARACETAM ORAL SOLN 10 MG/ML BRIVIACT TAB 100MG BRIVARACETAM TAB 100 MG BRIVIACT TAB 10MG BRIVARACETAM TAB 10 MG BRIVIACT TAB 25MG BRIVARACETAM TAB 25 MG BRIVIACT TAB 50MG BRIVARACETAM TAB 50 MG BRIVIACT TAB 75MG BRIVARACETAM TAB 75 MG BYVALSON TAB 5-80MG NEBIVOLOL-VALSARTAN TAB 5-80 MG CALCIUM POW FOLINATE LEUCOVORIN CALCIUM POWDER ELIGLUSTAT TARTRATE CAP 84 MG (BASE CERDELGA CAP 84MG EQUIVALENT) CHEMSIL K-51 GEL *GEL BASE - GEL** CHOLBAM CAP 250MG CHOLIC ACID CAP 250 MG CHOLBAM CAP 50MG CHOLIC ACID CAP 50 MG CHOLESTYRAMI POW CHOLESTYRAMINE (BULK) POWDER CHOLESTYRAMI POW RESIN CHOLESTYRAMINE (BULK) POWDER CLOPIDOGREL POW CLOPIDOGREL BISULFATE (BULK) BISULFAT POWDER CLOVAGEL GEL *GEL BASE - GEL** COAGULATION FACTOR X (HUMAN) FOR COAGADEX INJ 250UNIT INJ 250 UNIT COAGULATION FACTOR X (HUMAN) FOR COAGADEX INJ 500UNIT INJ 500 UNIT DIMETHICONE-ALLANTOIN BANDAGE COLLIGINIX MIS 5-2% NALTREXONE HCL-BUPROPION HCL TAB CONTRAVE TAB 8-90MG SR 12HR 8-90 MG CORLANOR TAB 5MG IVABRADINE HCL TAB 5 MG (BASE EQUIV) IVABRADINE HCL TAB 7.5 MG (BASE CORLANOR TAB 7.5MG EQUIV) CORN SYP CORN SYRUP
138
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 3
X
Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X
Tier 2
X
X X X X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3
X X X X X X
Tier 2
X
Tier 3 Tier 2 Tier 2 Tier 3 Tier 3
X X X X
X X X X
X X
Tier 3 Tier 3 Tier 4
X
Tier 4
X
Tier 3 Tier 3
X
Tier 3
X
X
Tier 3
X
X
Tier 3
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
Label Name
Generic Name
SECUKINUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML SECUKINUMAB SUBCUTANEOUS SOLN COSENTYX INJ 300DOSE PREFILLED SYRINGE 150 MG/ML COSENTYX PEN INJ 150MG/ SECUKINUMAB SUBCUTANEOUS SOLN ML AUTO-INJECTOR 150 MG/ML COSENTYX PEN INJ SECUKINUMAB SUBCUTANEOUS SOLN 300DOSE AUTO-INJECTOR 150 MG/ML ISAVUCONAZONIUM SULFATE CAP 186 CRESEMBA CAP 186 MG MG *DEXAMETHASONE TAB 2 X 0.5 MG CUSHING SYND KIT DIAG DIAGNOSTIC TEST KIT** CUST LIPOTHN GEL 110 *GEL BASE - GEL** CUST LIPOTHN GEL 133 *GEL BASE - GEL** CYCLACILLIN TAB 500MG CYCLACILLIN TAB 500 MG CYCLOPHOSPHA POW CYCLOPHOSPHAMIDE (BULK) POWDER CYCLOSPORINE POW CYCLOSPORINE (BULK) POWDER CYCLOSPORINE POW A CYCLOSPORINE (BULK) POWDER DACLATASVIR DIHYDROCHLORIDE TAB 30 DAKLINZA TAB 30MG MG (BASE EQUIVALENT) DACLATASVIR DIHYDROCHLORIDE TAB 60 DAKLINZA TAB 60MG MG (BASE EQUIVALENT) DACLATASVIR DIHYDROCHLORIDE TAB 90 DAKLINZA TAB 90MG MG (BASE EQUIVALENT) DERMACINRX SOL BASE *EXTERNAL VEHICLES - SOLUTION*** EMTRICITABINE-TENOFOVIR DESCOVY TAB 200/25 ALAFENAMIDE FUMARATE TAB 200-25 MG *CONTINUOUS BLOOD GLUCOSE DEXCOM G4 PLATINUM MONITOR/COMPONENTS* *CONTINUOUS BLOOD GLUCOSE DEXCOM SENSOR MONITOR/COMPONENTS* *CONTINUOUS BLOOD GLUCOSE DEXCOM TRANSMITTER MONITOR/COMPONENTS* ANTIGEN SERUM (MIXED) {DMR USE DMR ANTIGEN THERAPY ONLY} ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 1000UNIT RFVIIIFC FOR INJ 1000 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 1500UNIT RFVIIIFC FOR INJ 1500 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 2000UNIT RFVIIIFC FOR INJ 2000 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 250UNIT RFVIIIFC FOR INJ 250 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 3000UNIT RFVIIIFC FOR INJ 3000 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 4000UNIT RFVIIIFC FOR INJ 4000 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 5000UNIT RFVIIIFC FOR INJ 5000 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 500UNIT RFVIIIFC FOR INJ 500 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 6000UNIT RFVIIIFC FOR INJ 6000 UNIT ANTIHEMOPHILIC FACTOR (RECOMB) ELOCTATE INJ 750UNIT RFVIIIFC FOR INJ 750 UNIT *PRENATAL VIT W/ FE GLY CYS-FA-OMEGA ENBRACE HR CAP 3 FATTY ACIDS CAP*** ENTRESTO TAB 24-26MG SACUBITRIL-VALSARTAN TAB 24-26 MG ENTRESTO TAB 49-51MG SACUBITRIL-VALSARTAN TAB 49-51 MG ENTRESTO TAB 97-103MG SACUBITRIL-VALSARTAN TAB 97-103 MG SOFOSBUVIR-VELPATASVIR TAB 400-100 EPCLUSA TAB 400-100 MG EPINEPHR HCL SOL 2% OP EPINEPHRINE HCL OPHTH SOLN 2% EPIVIR HBV SOL 5MG/ML LAMIVUDINE ORAL SOLN 5 MG/ML (HBV) EPIVIR HBV TAB 100MG LAMIVUDINE TAB 100 MG (HBV) ESBRIET CAP 267MG PIRFENIDONE CAP 267 MG ESBRIET TAB 267MG PIRFENIDONE TAB 267 MG ESBRIET TAB 801MG PIRFENIDONE TAB 801 MG ESTRIOL POW ESTRIOL MICRONIZED (BULK) POWDER ESTRIOL POW MICRONIZ ESTRIOL MICRONIZED (BULK) POWDER ESTRIOL ULT POW ESTRIOL MICRONIZED (BULK) POWDER MICRONIZ ETHOSUXIMIDE POW ETHOSUXIMIDE (BULK) POWDER ETOPOSIDE POW ETOPOSIDE (BULK) POWDER ATAZANAVIR SULFATE-COBICISTAT TAB EVOTAZ TAB 300-150 300-150 MG (BASE EQUIV) COSENTYX INJ 150MG/ML
139
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
X
X
X
Tier 3
X
X
X
X
Tier 3
X
X
X
X
Tier 3
X
X
X
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3
X X X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
Tier 3 Tier 3
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3 Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 4
X
X
Tier 3 Tier 3 Tier 3 Tier 3
X X X
X X X
Tier 2
X
X
X
X X X
X X X X X
Tier 1 Tier 2 Tier 3 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3
X X X
Tier 3 Tier 3 Tier 3
X
Tier 2
X
Therapeutic Class
Label Name
Not Specified
FARYDAK CAP 10MG
Not Specified
FARYDAK CAP 15MG
Not Specified
FARYDAK CAP 20MG
Not Specified
FEMCAP MIS 22MM
Not Specified
FLORIVA DRO 0.25MG
Not Specified
FLUOROURACIL POW FLUOROURACIL POW USP/ NF
Not Specified Not Specified
FOLET DHA PAK
Not Specified
FOLET ONE CAP 38-1-225
Not Specified
FORTIGAN CAP
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
FP CEPA GEL FP DERM GEL FP SILO GEL FREEDOM GEL CEPAPRO FREEDOM GEL SET FREEDOM GEL SILOMAC
Not Specified
GELFOAM-JMI KIT POWDER
Not Specified
GELFOAM-JMI KIT SPONGE
Not Specified
GENVOYA TAB
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
GLUCOCARD 01 TES SENSOR GLUCOCARD 01 TEST STRIPS GLUCOCARD TES VITAL GUARDIAN RT MIS REPL PED
Generic Name PANOBINOSTAT LACTATE CAP 10 MG (BASE EQUIVALENT) PANOBINOSTAT LACTATE CAP 15 MG (BASE EQUIVALENT) PANOBINOSTAT LACTATE CAP 20 MG (BASE EQUIVALENT) PLACEHOLDER DNU SODIUM FLUORIDE-VITAMIN D LIQD DROPS 0.25 MG/ML-400 UNIT/ML FLUOROURACIL (BULK) POWDER FLUOROURACIL (BULK) POWDER *PRENAT W/FECBN-BISG-METHYLF-DSS TAB DR & DHA CAP PAK*** *PRENAT W/O A W/FECBN-BISGMETHYLF-DSS-DHA CAP 38-1-225 MG** MEPERIDINE W/ PROMETHAZINE CAP 50-25 MG *GEL BASE - GEL** *GEL BASE - GEL** *GEL BASE - GEL** *GEL BASE - GEL** *GEL BASE - GEL** *GEL BASE - GEL** *GELATIN ABSORBABLE POWDER & THROMBIN FOR SOLN KIT*** *GELATIN ABSORBABLE SPONGE & THROMBIN FOR SOLN KIT*** ELVITEGRAV-COBIC-EMTRICITABTENOFOV AF TAB 150-150-200-10 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
HCR Preventive Care Tier 3 Tier 3
X
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 3
X
GLUCOSE BLOOD TEST STRIPS
Tier 3
X
GLUCOSE BLOOD TEST STRIPS
Tier 3
X
Tier 3
X
GLUCOSE BLOOD TEST STRIPS *CONTINUOUS BLOOD GLUCOSE SYSTEM RECEIVER*** *CONTINUOUS BLOOD GLUCOSE GUARDIAN RT MIS REPLACE SYSTEM RECEIVER*** H20 GEL BASE GEL *GEL BASE - GEL** HARVONI TAB 90-400MG LEDIPASVIR-SOFOSBUVIR TAB 90-400 MG HYDROXYUREA POW HYDROXYUREA (BULK) POWDER IBRANCE CAP 100MG PALBOCICLIB CAP 100 MG IBRANCE CAP 125MG PALBOCICLIB CAP 125 MG IBRANCE CAP 75MG PALBOCICLIB CAP 75 MG COAGULATION FACTOR IX (RECOMB) (RIXIDELVION SOL 1000UNIT FP) FOR INJ 1000 UNIT COAGULATION FACTOR IX (RECOMB) (RIXIDELVION SOL 2000UNIT FP) FOR INJ 2000 UNIT COAGULATION FACTOR IX (RECOMB) (RIXIDELVION SOL 250UNIT FP) FOR INJ 250 UNIT COAGULATION FACTOR IX (RECOMB) (RIXIDELVION SOL 500UNIT FP) FOR INJ 500 UNIT IMPAVIDO CAP 50MG MILTEFOSINE CAP 50 MG UMECLIDINIUM BR AERO POWD BREATH INCRUSE ELPT INH 62.5MCG ACT 62.5 MCG/INH (BASE EQ) KERYDIN SOL 5% TAVABOROLE SOLN 5% KEVEYIS TAB 50MG DICHLORPHENAMIDE TAB 50 MG RIBOCICLIB SUCCINATE TAB 200 MG KISQALI TAB 200DOSE (BASE EQUIV) RIBOCICLIB SUCCINATE TAB 200 MG KISQALI TAB 400DOSE (BASE EQUIV) RIBOCICLIB SUCCINATE TAB 200 MG KISQALI TAB 600DOSE (BASE EQUIV) LAMIVUDINE TAB 100MG LAMIVUDINE TAB 100 MG (HBV) L-CYSTINE POW CYSTINE POWDER LENVATINIB CAP THERAPY PACK 10 MG LENVIMA CAP 10 MG (10 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 10 & 4 LENVIMA CAP 14 MG MG (14 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 10 & 4 (2) LENVIMA CAP 18 MG MG (18 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 10 (2) LENVIMA CAP 20 MG MG (20 MG DAILY DOSE)
140
Tier 3
X
X
Tier 3
X
X
X
X
X X X
X X X
Tier 3 Tier 2 Tier 3 Tier 2 Tier 2 Tier 2
X X X X X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 2
X
Tier 2
X X
Tier 3 Tier 2
X X
X X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 1 Tier 3
X X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Therapeutic Class
Label Name
Not Specified
LENVIMA CAP 24 MG
Not Specified
LENVIMA CAP 8 MG
Not Specified
LEUCOVORIN POW CALCIUM LIPODERM HMW GEL PCCA LIPOGEL CR GEL BASE LONSURF TAB 15-6.14 LONSURF TAB 20-8.19 LUBRAJEL NP GEL LYNPARZA CAP 50MG LYSODREN TAB 500MG MAGNESIUM POW BISGLYCI MAGNESIUM POW GLYCINAT MEPER/PROMET CAP 5025MG MERCAPTOPURI POW
Not Specified
MERCAPTOPURI POW
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Not Specified Not Specified Not Specified Not Specified
MERCAPTOPURI POW MONOHYDR METHOTREXATE POW MIDAZOLAM POW MITOMYCIN POW MITOMYCIN C POW
Not Specified
MOUTH WASH LIQ GP
Not Specified
MOUTHWASH LIQ AF
Not Specified
MOUTHWASH LIQ OM
Not Specified
MOVANTIK TAB 12.5MG
Not Specified
MOVANTIK TAB 25MG
Not Specified
NATPARA INJ 100MCG
Not Specified
NATPARA INJ 25MCG
Not Specified
NATPARA INJ 50MCG
Not Specified
NATPARA INJ 75MCG
Not Specified
NICOMIDE TAB
Not Specified
NINLARO CAP 2.3MG
Not Specified
NINLARO CAP 3MG
Not Specified
NINLARO CAP 4MG
Not Specified Not Specified Not Specified
NORTHERA CAP 100MG NORTHERA CAP 200MG NORTHERA CAP 300MG
Not Specified
NUPLAZID TAB 17MG
Not Specified
NUWIQ INJ 1000UNIT
Not Specified
NUWIQ INJ 2000UNIT
Not Specified
NUWIQ INJ 250UNIT
Not Specified
NUWIQ INJ 500UNIT
Not Specified
NUWIQ KIT 1000UNIT
Not Specified
NUWIQ KIT 2000UNIT
Not Specified
NUWIQ KIT 250UNIT
Not Specified
Generic Name LENVATINIB CAP THERAPY PACK 10 (2) & 4 MG (24 MG DAILY DOSE) LENVATINIB CAP THERAPY PACK 4 (2) MG (8 MG DAILY DOSE)
Tier Value Tier 3
X
X
X
Tier 3
X
X
X
X X
X X
X X
X
X
X X
LEUCOVORIN CALCIUM POWDER
Tier 3
*GEL BASE - GEL** *GEL BASE - GEL** TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG TRIFLURIDINE-TIPIRACIL TAB 20-8.19 MG *GEL BASE - GEL** OLAPARIB CAP 50 MG MITOTANE TAB 500 MG MAGNESIUM GLYCINATE (BULK) POWDER
Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 2 Tier 3
MAGNESIUM GLYCINATE (BULK) POWDER
Tier 3
MEPERIDINE W/ PROMETHAZINE CAP 50-25 MG MERCAPTOPURINE (BULK) POWDER MERCAPTOPURINE MONOHYDRATE (BULK) POWDER MERCAPTOPURINE MONOHYDRATE (BULK) POWDER METHOTREXATE POWDER MIDAZOLAM (BULK) POWDER MITOMYCIN (BULK) POWDER MITOMYCIN (BULK) POWDER *MOUTHWASH COMPOUNDING BASE LIQUID*** *MOUTHWASH COMPOUNDING BASE LIQUID*** *MOUTHWASH COMPOUNDING BASE LIQUID*** NALOXEGOL OXALATE TAB 12.5 MG (BASE EQUIVALENT) NALOXEGOL OXALATE TAB 25 MG (BASE EQUIVALENT) PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 100 MCG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 25 MCG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 50 MCG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 75 MCG *NIACINAMIDE W/ ZN-CU-METHYLFOL-SECR TAB 750-27-2-0.5 MG*** IXAZOMIB CITRATE CAP 2.3 MG (BASE EQUIVALENT) IXAZOMIB CITRATE CAP 3 MG (BASE EQUIVALENT) IXAZOMIB CITRATE CAP 4 MG (BASE EQUIVALENT) DROXIDOPA CAP 100 MG DROXIDOPA CAP 200 MG DROXIDOPA CAP 300 MG PIMAVANSERIN TARTRATE TAB 17 MG (BASE EQUIVALENT) ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ 1000 UNIT ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ 2000 UNIT ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ 250 UNIT ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ 500 UNIT ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ KIT 1000 UNIT ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ KIT 2000 UNIT ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ KIT 250 UNIT
141
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 3 Tier 3 Tier 3
X X
Tier 3 Tier 3 Tier 3 Tier 2
X
X
Tier 2
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 3 Tier 3 Tier 3
X X X
X X X
X X X
Tier 3
X
X
Tier 3
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Therapeutic Class
Label Name
Not Specified
NUWIQ KIT 500UNIT
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
Generic Name
ANTIHEMOPHILIC FACTOR (BDD-RFVIII) FOR INJ KIT 500 UNIT ANTIHEMOPHILIC FACTOR (RECOMB OBIZUR INJ 500 UNIT PORC) RPFVIII FOR INJ 500 UNIT HYDROCODONE-GUAIFENESIN SOLN 2.5OBREDON SOL 2.5-200 200 MG/5ML OBSTETRX ONE CAP 38*PRENAT W/O A W/FECBN-BISG1-225 METHYLF-DSS-DHA CAP 38-1-225 MG** OCALIVA TAB 10MG OBETICHOLIC ACID TAB 10 MG OCALIVA TAB 5MG OBETICHOLIC ACID TAB 5 MG OCCLUSADERM GEL PCCA *GEL BASE - GEL** EMTRICITABINE-RILPIVIRINE-TENOFOVIR ODEFSEY TAB AF TAB 200-25-25 MG SONIDEGIB PHOSPHATE CAP 200 MG ODOMZO CAP 200MG (BASE EQUIVALENT) NINTEDANIB ESYLATE CAP 100 MG (BASE OFEV CAP 100MG EQUIVALENT) NINTEDANIB ESYLATE CAP 150 MG (BASE OFEV CAP 150MG EQUIVALENT) LUMACAFTOR-IVACAFTOR TAB 100-125 ORKAMBI TAB 100-125 MG LUMACAFTOR-IVACAFTOR TAB 200-125 ORKAMBI TAB 200-125 MG PENTAERYTHRITOL TETRANITRATE TAB PETN TAB 80MG 80 MG PEGINTERFERON BETA-1A SOLN PLEGRIDY INJ PREFILLED SYRINGE 125 MCG/0.5ML PEGINTERFERON BETA-1A SOLN PENPLEGRIDY INJ PEN INJECTOR 125 MCG/0.5ML PEGINTERFERON BETA-1A SOLN PREF PLEGRIDY INJ STARTER SYR 63 & 94 MCG/0.5ML PACK PEGINTERFERON BETA-1A SOLN PEN-INJ PLEGRIDY PEN INJ STARTER 63 & 94 MCG/0.5ML PACK POLY GLYCOL LIQ 1450 POLYETHYLENE GLYCOL 1450 LIQUID POLYSORBATE LIQ 80 POLYSORBATE 80 LIQ POLYSORBATE LIQ 80 POLYSORBATE 80 LIQ POT PHOSPHAT GRA POTASSIUM PHOSPHATE DIBASIC DIBASIC GRANULES ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 150MG/ML PEN-INJECTOR 150 MG/ML ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 150MG/ML PREFILLED SYRINGE 150 MG/ML ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 75MG/ML PEN-INJECTOR 75 MG/ML ALIROCUMAB SUBCUTANEOUS SOLN PRALUENT INJ 75MG/ML PREFILLED SYRINGE 75 MG/ML *PRENAT W/O A W/FE CHEL-FA TAB 30-1.4 PRENA 1 TRUE MIS MG & DHA CAP 300MG PK* *PRENAT W/O A W/FEASPG-METHFOL-FAPRENATE CAP ESSENT DHA CAP 18-0.6-0.4-300 MG* *PRENAT W/O A W/FEASPG-METHFOL-FAPRENATE CAP PIXIE DHA CAP 10-0.6-0.4-200 MG* *PRENATAL W/ FE ASP GLY-L METHYLFOLPRENATE TAB ELITE FA TAB 20-0.6-0.4 MG*** *PRENAT W/O A W/FEASPG-METHFOL-FAPRENATE DHA CAP DHA CAP 18-0.6-0.4-300 MG* *PRENAT W/OA W/FECB-FEASP-METH-FAPRENATE MINI CAP DHA CAP 18-0.6-0.4-350 MG* *PRENATAL VIT W/ FE ASPARTO PRENATE STAR TAB 20-1MG GLYCINATE-FA TAB 20-1 MG*** PREZCOBIX TAB 800-150 DARUNAVIR-COBICISTAT TAB 800-150 MG PROGESTERONE POW PROGESTERONE MICRONIZED (BULK) MICRONIZ POWDER *PRENAT W/O A W/FE FUM-FE POLY-FAPROVIDA DHA CAP DHA CAP 16-16-1.25-110 MG* EVOLOCUMAB SUBCUTANEOUS SOLN REPATHA INJ 140MG/ML PREFILLED SYRINGE 140 MG/ML REPATHA SURE INJ 140MG/ EVOLOCUMAB SUBCUTANEOUS SOLN ML AUTO-INJECTOR 140 MG/ML LACTOBACILLUS CASEI-FOLIC ACID CAP RESTORA RX CAP 60-1.25 60-1.25 MG REXULTI TAB 0.25MG BREXPIPRAZOLE TAB 0.25 MG REXULTI TAB 0.5MG BREXPIPRAZOLE TAB 0.5 MG REXULTI TAB 1MG BREXPIPRAZOLE TAB 1 MG REXULTI TAB 2MG BREXPIPRAZOLE TAB 2 MG REXULTI TAB 3MG BREXPIPRAZOLE TAB 3 MG REXULTI TAB 4MG BREXPIPRAZOLE TAB 4 MG
142
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2
X
Tier 3
X
Tier 3
X
X
X X
X X
Tier 3 Tier 3 Tier 3 Tier 3
X X
Tier 3
X X X
Tier 2
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 2
X
X
X
Tier 2
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 2
X
X
X
X
Tier 2
X
X
X
X
Tier 2
X
X
X
X
Tier 2
X
X
X
X
Tier 1
Tier 3 Tier 2 Tier 3 Tier 3
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
X
Tier 3 Tier 3 Tier 4
X
X
X
X
Tier 4
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 3 Tier 3 Tier 3 Tier 3 Tier 3
Therapeutic Class
Label Name
Generic Name
Not Specified
RIBAVIRIN POW
Not Specified
RUBRACA TAB 200MG
Not Specified
RUBRACA TAB 250MG
Not Specified
RUBRACA TAB 300MG
Not Specified
RUCONEST INJ 2100UNIT
Not Specified
RYDAPT CAP 25MG
Not Specified
SAVAYSA TAB 15MG
Not Specified
SAVAYSA TAB 30MG
Not Specified
SAVAYSA TAB 60MG
Not Specified
SAXENDA INJ 6MG/ML
Not Specified Not Specified Not Specified Not Specified
SERAQUA LIQ SILOMAC GEL ULTRA SIMPLGEL 30 GEL SIROLIMUS POW
Not Specified
SOLIQUA INJ 100/33
Not Specified Not Specified
SOLU-K GEL SOOLANTRA CRE 1%
Not Specified
STRENSIQ INJ 18/0.45
Not Specified
STRENSIQ INJ 28/0.7ML
Not Specified
STRENSIQ INJ 40MG/ML
Not Specified
STRENSIQ INJ 80/0.8ML
Not Specified
SYNJARDY TAB
Not Specified
SYNJARDY TAB 12.5-500
Not Specified
SYNJARDY TAB 5-1000MG
Not Specified
SYNJARDY TAB 5-500MG
Not Specified
SYNJARDY XR TAB
Not Specified
SYNJARDY XR TAB 10-1000
Not Specified
SYNJARDY XR TAB 25-1000
RIBAVIRIN (BULK) POWDER RUCAPARIB CAMSYLATE TAB 200 MG (BASE EQUIVALENT) RUCAPARIB CAMSYLATE TAB 250 MG (BASE EQUIVALENT) RUCAPARIB CAMSYLATE TAB 300 MG (BASE EQUIVALENT) C1 ESTERASE INHIBITOR (RECOMBINANT) FOR IV INJ 2100 UNIT MIDOSTAURIN CAP 25 MG EDOXABAN TOSYLATE TAB 15 MG (BASE EQUIVALENT) EDOXABAN TOSYLATE TAB 30 MG (BASE EQUIVALENT) EDOXABAN TOSYLATE TAB 60 MG (BASE EQUIVALENT) LIRAGLUTIDE (WEIGHT MANAGEMENT) SOLN PEN-INJECTOR 18 MG/3ML *SERUM BASE - LIQUID*** *GEL BASE - GEL** *GEL BASE - GEL** SIROLIMUS (BULK) POWDER INSULIN GLARGINE-LIXISENATIDE SOL PEN-INJ 100-33 UNIT-MCG/ML *GEL BASE - GEL** IVERMECTIN CREAM 1% ASFOTASE ALFA SUBCUTANEOUS INJ 18 MG/0.45ML ASFOTASE ALFA SUBCUTANEOUS INJ 28 MG/0.7ML ASFOTASE ALFA SUBCUTANEOUS INJ 40 MG/ML ASFOTASE ALFA SUBCUTANEOUS INJ 80 MG/0.8ML EMPAGLIFLOZIN-METFORMIN HCL TAB 12.5-1000 MG EMPAGLIFLOZIN-METFORMIN HCL TAB 12.5-500 MG EMPAGLIFLOZIN-METFORMIN HCL TAB 5-1000 MG EMPAGLIFLOZIN-METFORMIN HCL TAB 5-500 MG EMPAGLIFLOZIN-METFORMIN HCL TAB SR 24HR 12.5-1000 MG EMPAGLIFLOZIN-METFORMIN HCL TAB SR 24HR 10-1000 MG EMPAGLIFLOZIN-METFORMIN HCL TAB SR 24HR 25-1000 MG EMPAGLIFLOZIN-METFORMIN HCL TAB SR 24HR 5-1000 MG
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
SYNJARDY XR TAB 5-1000MG T TACROLIMUS POW TACROLIMUS POW MONOHYD
Tier Value Tier 3
Prior Supply Step Specialty Authorization Limit Therapy X
Tier 3
X
X
Tier 3
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 2
X X
Tier 3 Tier 3
X X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 4
X
X
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2
X
Tier 2 Tier 2 Tier 2 Tier 2
TACROLIMUS (BULK) POWDER
Tier 1 Tier 3
X
TACROLIMUS (BULK) POWDER
Tier 3
X
OSIMERTINIB MESYLATE TAB 40 MG TAGRISSO TAB 40MG (BASE EQUIVALENT) OSIMERTINIB MESYLATE TAB 80 MG TAGRISSO TAB 80MG (BASE EQUIVALENT) IXEKIZUMAB SUBCUTANEOUS SOLN TALTZ INJ 80MG/ML AUTO-INJECTOR 80 MG/ML IXEKIZUMAB SUBCUTANEOUS SOLN TALTZ INJ 80MG/ML PREFILLED SYRINGE 80 MG/ML TDM SOLUTION SOL *EXTERNAL VEHICLES - SOLUTION*** OMBITASVIR-PARITAPREVIR-RITONAVIR TECHNIVIE TAB TAB 12.5-75-50 MG TESTOSTERONE MICRONIZED (BULK) TESTOSTERONE CRY YAM CRYSTALS TESTOSTERONE POW TESTOSTERONE (BULK) POWDER TESTOSTERONE POW TESTOSTERONE CYPIONATE (BULK) CYPIONAT POWDER TESTOSTERONE POW TESTOSTERONE ENANTHATE (BULK) ENANTHAT POWDER TESTOSTERONE POW SOY TESTOSTERONE (BULK) POWDER THIOGUANINE POW THIOGUANINE (BULK) POWDER THIOTEPA POW THIOTEPA (BULK) POWDER TOMMY GEL GEL *GEL BASE - GEL** TOXICOL SALV KIT COLLECT *TOXICOLOGY SALIVA COLLECTION KIT**
143
Tier 3
X
X
X
Tier 3
X
X
X
Tier 4
X
X
X
X
Tier 4
X
X
X
X
X
X
Tier 3 Tier 4
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X
Therapeutic Class
Label Name
Not Specified
TRETTEN INJ
Not Specified
TRICARE CHW PRENATAL
Not Specified
TRICARE PAK PRENATAL
Not Specified
TRIUMEQ TAB
Not Specified
TRULICITY INJ 0.75/0.5
Not Specified
TRULICITY INJ 1.5/0.5
Not Specified Not Specified Not Specified Not Specified Not Specified Not Specified
TYBOST TAB 150MG UCERIS AER 2MG/ACT UPTRAVI TAB 1000MCG UPTRAVI TAB 1200MCG UPTRAVI TAB 1400MCG UPTRAVI TAB 1600MCG
Not Specified
UPTRAVI TAB 200/800
Not Specified Not Specified Not Specified Not Specified Not Specified
UPTRAVI TAB 200MCG UPTRAVI TAB 400MCG UPTRAVI TAB 600MCG UPTRAVI TAB 800MCG UREA POW
Not Specified
VELTASSA POW 16.8GM
Not Specified
VELTASSA POW 25.2GM
Not Specified
VELTASSA POW 8.4GM
Not Specified Not Specified Not Specified
VENCLEXTA TAB 100MG VENCLEXTA TAB 10MG VENCLEXTA TAB 50MG
Not Specified
VENCLEXTA TAB START PK
Not Specified Not Specified Not Specified
VERSAPRO GEL VIBERZI TAB 100MG VIBERZI TAB 75MG
Not Specified
VIEKIRA PAK TAB
Not Specified
VISTOGARD PAK 10GM
Not Specified
VITAFOL CHW GUMMIES
Not Specified
VITAFOL FE+ CAP
Not Specified
VITATRUE MIS
Not Specified Not Specified
VITEKTA TAB 150MG VITEKTA TAB 85MG
Not Specified
VONVENDI INJ 1300UNIT
Not Specified
VONVENDI INJ 650UNIT
Not Specified
VRAYLAR CAP 1.5-3MG
Not Specified
VRAYLAR CAP 1.5MG
Not Specified
VRAYLAR CAP 3MG
Not Specified
VRAYLAR CAP 4.5MG
Not Specified
VRAYLAR CAP 6MG
Not Specified Not Specified
WOUND WASH GEL BASE XIIDRA DRO 5%
Not Specified
XTAMPZA ER CAP 13.5MG
Not Specified
XTAMPZA ER CAP 18MG
Not Specified
XTAMPZA ER CAP 27MG
Not Specified
XTAMPZA ER CAP 36MG
Not Specified
XTAMPZA ER CAP 9MG
Generic Name COAGULATION FACTOR XIII A-SUBUNIT FOR INJ 2000-3125 UNIT *PRENAT W/O VIT A W/ FE PYROPHOSMETHYLF CHEW TAB 4.5-1 MG* *PRENAT W/O A W/FEPYRO-MFOL CHW 4.5-1 MG & DHA CAP 150 THPK* ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TAB 600-50-300 MG DULAGLUTIDE SOLN PEN-INJECTOR 0.75 MG/0.5ML DULAGLUTIDE SOLN PEN-INJECTOR 1.5 MG/0.5ML COBICISTAT TAB 150 MG BUDESONIDE RECTAL FOAM 2 MG/ACT SELEXIPAG TAB 1000 MCG SELEXIPAG TAB 1200 MCG SELEXIPAG TAB 1400 MCG SELEXIPAG TAB 1600 MCG SELEXIPAG TAB THERAPY PACK 200 MCG (140) & 800 MCG (60) SELEXIPAG TAB 200 MCG SELEXIPAG TAB 400 MCG SELEXIPAG TAB 600 MCG SELEXIPAG TAB 800 MCG UREA POWDER PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 16.8 GM (BASE EQ) PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 25.2 GM (BASE EQ) PATIROMER SORBITEX CALCIUM FOR SUSP PACKET 8.4 GM (BASE EQ) VENETOCLAX TAB 100 MG VENETOCLAX TAB 10 MG VENETOCLAX TAB 50 MG VENETOCLAX TAB THERAPY STARTER PACK 10 & 50 & 100 MG *GEL BASE - GEL** ELUXADOLINE TAB 100 MG ELUXADOLINE TAB 75 MG OMBITAS-PARITAPRE-RITON & DASAB TAB PAK 12.5-75-50 & 250 MG URIDINE TRIACETATE ORAL GRANULES PACKET 10 GM *PRENAT VIT W/ FE PHOS-FA-OMEGA CHEW TAB 3.33-0.333-34.8 MG* *PRENAT-FEPOLY-METHOL-FA-DHA CAP 90-1-200 MG & DSS 50MG CAP* *PRENAT W/O A W/FE CHEL-FA TAB 30-1.4 MG & DHA CAP 300MG PK* ELVITEGRAVIR TAB 150 MG ELVITEGRAVIR TAB 85 MG VON WILLEBRAND FACTOR (RECOMBINANT) FOR INJ 1300 UNIT VON WILLEBRAND FACTOR (RECOMBINANT) FOR INJ 650 UNIT CARIPRAZINE HCL CAP THERAPY PACK 1.5 MG (1) & 3 MG (6) CARIPRAZINE HCL CAP 1.5 MG (BASE EQUIVALENT) CARIPRAZINE HCL CAP 3 MG (BASE EQUIVALENT) CARIPRAZINE HCL CAP 4.5 MG (BASE EQUIVALENT) CARIPRAZINE HCL CAP 6 MG (BASE EQUIVALENT) *GEL BASE - GEL** LIFITEGRAST OPHTH SOLN 5% OXYCODONE CAP ER 12HR ABUSEDETERRENT 13.5 MG OXYCODONE CAP ER 12HR ABUSEDETERRENT 18 MG OXYCODONE CAP ER 12HR ABUSEDETERRENT 27 MG OXYCODONE CAP ER 12HR ABUSEDETERRENT 36 MG OXYCODONE CAP ER 12HR ABUSEDETERRENT 9 MG
144
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
Tier 3 Tier 3 Tier 2
X
Tier 3
X
Tier 3
X
Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3
X X X X X
X X X X
X X X X
Tier 3
X
X
X
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X X X X
X X X X
X X X X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 2 Tier 2 Tier 2
X X X
X X X
X X X
Tier 2
X
X
X
Tier 3 Tier 3 Tier 3
X X
X X
Tier 4
X
X
Tier 2
X
X
X
X
Tier 3 Tier 3 Tier 3 Tier 2 Tier 2
X X
Tier 2
X
Tier 2
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3 Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Therapeutic Class
Label Name
Generic Name
Tier Value
Not Specified
XURIDEN POW 2GM
Not Specified
ZARXIO INJ 300/0.5
Not Specified
ZARXIO INJ 480/0.8
Not Specified
ZEJULA CAP 100MG
Not Specified
ZEPATIER TAB 50-100MG
Not Specified
ZINBRYTA INJ 150MG/ML
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 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
ZURAMPIC TAB 200MG
URIDINE TRIACETATE ORAL GRANULES PACKET 2 GM FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 300 MCG/0.5ML FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 480 MCG/0.8ML NIRAPARIB TOSYLATE CAP 100 MG (BASE EQUIVALENT) ELBASVIR-GRAZOPREVIR TAB 50-100 MG DACLIZUMAB SOLN PREFILLED SYRINGE 150 MG/ML LESINURAD TAB 200 MG
ALCAINE SOL 0.5% OP
PROPARACAINE HCL OPHTH SOLN 0.5%
Tier 3
ATROPINE SUL OIN 1% OP
ATROPINE SULFATE OPHTH OINT 1%
Tier 1
ATROPINE SUL SOL 1% OP
ATROPINE SULFATE OPHTH SOLN 1%
Tier 1
CYSTARAN SOL 0.44%
CYSTEAMINE HCL OPHTH SOLN 0.44% (BASE EQUIVALENT)
Tier 2
LACRISERT MIS 5MG OP
*ARTIFICIAL TEAR OPHTH INSERT***
Tier 2
MYDRIACYL SOL 1% OP
TROPICAMIDE OPHTH SOLN 1%
Tier 3
Tier 2
Prior Supply Step Specialty Authorization Limit Therapy X
X
Tier 2
X
Tier 2
X
Tier 3
X
Tier 4
X
X
Tier 3
X
X
Tier 3
X
X
X
X
X
X
NAPHAZOLINE SOL 0.1% OP NAPHAZOLINE HCL OPHTH SOLN 0.1%
Tier 1
PROPARACAINE SOL 0.5% OP
PROPARACAINE HCL OPHTH SOLN 0.5%
Tier 1
RESTASIS EMU 0.05%
CYCLOSPORINE (OPHTH) EMULSION 0.05%
Tier 3
TROPICAMIDE SOL 0.5% OP
TROPICAMIDE OPHTH SOLN 0.5%
Tier 1
TROPICAMIDE SOL 1% OP
TROPICAMIDE OPHTH SOLN 1%
Tier 1
ALOCRIL SOL 2%
NEDOCROMIL SODIUM OPHTH SOLN 2%
Tier 3
ALOMIDE SOL 0.1% OP
LODOXAMIDE TROMETHAMINE OPHTH SOLN 0.1%
Tier 3
AZELASTINE DRO 0.05%
AZELASTINE HCL OPHTH SOLN 0.05%
Tier 1
CROMOLYN SOD SOL 4% OP CROMOLYN SODIUM OPHTH SOLN 4%
Tier 1
LASTACAFT SOL 0.25%
ALCAFTADINE OPHTH SOLN 0.25%
Tier 3
ACETAZOLAMID CAP 500MG ER
ACETAZOLAMIDE CAP SR 12HR 500 MG
Tier 1
ACETAZOLAMID TAB 125MG ACETAZOLAMIDE TAB 125 MG
Tier 1
ACETAZOLAMID TAB 250MG ACETAZOLAMIDE TAB 250 MG
Tier 1
X
X
X
APRACLONIDIN SOL 0.5% OP
BRIMONIDINE TARTRATE OPHTH SOLN 0.1% BRIMONIDINE TARTRATE OPHTH SOLN 0.15% APRACLONIDINE HCL OPHTH SOLN 0.5% (BASE EQUIVALENT)
AZOPT SUS 1% OP
BRINZOLAMIDE OPHTH SUSP 1%
Tier 2
BETAGAN SOL 0.5% OP
LEVOBUNOLOL HCL OPHTH SOLN 0.5%
Tier 3
BETAXOLOL SOL 0.5% OP
BETAXOLOL HCL OPHTH SOLN 0.5%
Tier 1
BETIMOL SOL 0.25%
TIMOLOL OPHTH SOLN 0.25%
Tier 2
X
BETIMOL SOL 0.5%
TIMOLOL OPHTH SOLN 0.5%
Tier 2
X
BETOPTIC-S SUS 0.25% OP
BETAXOLOL HCL OPHTH SUSP 0.25%
Tier 3
ALPHAGAN P SOL 0.1% ALPHAGAN P SOL 0.15%
BRIMONIDINE SOL 0.15% BRIMONIDINE SOL 0.2% OP CARTEOLOL SOL 1% OP COMBIGAN SOL 0.2/0.5% COSOPT SOL 22.3-6.8
BRIMONIDINE TARTRATE OPHTH SOLN 0.15% BRIMONIDINE TARTRATE OPHTH SOLN 0.2% CARTEOLOL HCL OPHTH SOLN 1% BRIMONIDINE TARTRATE-TIMOLOL MALEATE OPHTH SOLN 0.2-0.5% DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML
145
X
Tier 2
X
Tier 3
X
Tier 1
Tier 2
X
X
Tier 1 Tier 1 Tier 2 Tier 3
X
X
X X
X
Therapeutic Class
Label Name
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 Ophthalmic Antiglaucoma Agents Glaucoma Drugs Ophthalmic Antiglaucoma Agents Glaucoma Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs
DIAMOX SEQUE CAP 500MG ACETAZOLAMIDE CAP SR 12HR 500 MG CR DORZOL/TIMOL SOL 22.3DORZOLAMIDE HCL-TIMOLOL MALEATE 6.8 OPHTH SOLN 22.3-6.8 MG/ML DORZOLAMIDE SOL 2% OP IOPIDINE SOL 0.5% OP IOPIDINE SOL 1% OP
Generic Name
DORZOLAMIDE HCL OPHTH SOLN 2% APRACLONIDINE HCL OPHTH SOLN 0.5% (BASE EQUIVALENT) APRACLONIDINE HCL OPHTH SOLN 1% (BASE EQUIVALENT)
Tier Value Tier 3 Tier 2 Tier 1 Tier 3 Tier 3
ISOPTO CARP SOL 1% OP
PILOCARPINE HCL OPHTH SOLN 1%
Tier 3
ISOPTO CARP SOL 2% OP
PILOCARPINE HCL OPHTH SOLN 2%
Tier 3
ISOPTO CARP SOL 4% OP
PILOCARPINE HCL OPHTH SOLN 4%
Tier 3
ISTALOL SOL 0.5% OP
TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE-DAILY)
Tier 3
LEVOBUNOLOL SOL 0.5% OP
LEVOBUNOLOL HCL OPHTH SOLN 0.5%
Tier 1
METHAZOLAMID TAB 25MG METHAZOLAMIDE TAB 25 MG
Tier 1
METHAZOLAMID TAB 50MG METHAZOLAMIDE TAB 50 MG
Tier 1
METIPRANOLOL SOL 0.3% OPH
METIPRANOLOL OPHTH SOLN 0.3%
Tier 1
NEPTAZANE TAB 25MG
METHAZOLAMIDE TAB 25 MG
Tier 3
NEPTAZANE TAB 50MG
METHAZOLAMIDE TAB 50 MG
Tier 3
PHOSPHOLINE SOL 0.125%OP
ECHOTHIOPHATE IODIDE OPHTH FOR SOLN 0.125%
Tier 2
PILOCARPINE SOL 1% OP
PILOCARPINE HCL OPHTH SOLN 1%
Tier 1
PILOCARPINE SOL 2% OP
PILOCARPINE HCL OPHTH SOLN 2%
Tier 1
PILOCARPINE SOL 4% OP
PILOCARPINE HCL OPHTH SOLN 4%
Tier 1
TIMOLOL GEL SOL 0.25% OP TIMOLOL GEL SOL 0.5% OP
TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5%
Tier 1 Tier 1
TIMOLOL MAL SOL 0.25% OP TIMOLOL MALEATE OPHTH SOLN 0.25%
Tier 1
TIMOLOL MAL SOL 0.5% OP
TIMOLOL MALEATE OPHTH SOLN 0.5%
Tier 1
TIMOPTIC SOL 0.25% OP
TIMOLOL MALEATE OPHTH SOLN 0.25%
Tier 3
TIMOPTIC SOL 0.5% OP
TIMOLOL MALEATE OPHTH SOLN 0.5%
Tier 3
TIMOPTIC OCU SOL 0.25% OP
TIMOLOL MALEATE PRESERVATIVE FREE OPHTH SOLN 0.25% TIMOLOL MALEATE PRESERVATIVE FREE TIMOPTIC OCU SOL 0.5% OP OPHTH SOLN 0.5% TIMOLOL MALEATE OPHTH GEL FORMING TIMOPTIC-XE SOL 0.25% OP SOLN 0.25% TIMOLOL MALEATE OPHTH GEL FORMING TIMOPTIC-XE SOL 0.5% OP SOLN 0.5% TRUSOPT SOL 2% OP
DORZOLAMIDE HCL OPHTH SOLN 2%
KETOROLAC TROMETHAMINE OPHTH ACULAR SOL 0.5% OP SOLN 0.5% KETOROLAC TROMETHAMINE OPHTH ACULAR LS SOL 0.4% SOLN 0.4% LOTEPREDNOL ETABONATE OPHTH SUSP ALREX SUS 0.2% 0.2% SULFACETAMIDE SODIUMBLEPHAMIDE OIN S.O.P. PREDNISOLONE OPHTH OINT 10-0.2% SULFACETAMIDE SODIUMBLEPHAMIDE SUS OP PREDNISOLONE OPHTH SUSP 10-0.2% BROMFENAC SODIUM OPHTH SOLN BROMFENAC SOL 0.09% OP 0.09% (BASE EQUIVALENT) DEXAMETH PHO SOL 0.1% DEXAMETHASONE SODIUM PHOSPHATE OP OPHTH SOLN 0.1%
Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
Tier 2 Tier 3 Tier 3 Tier 1
DICLOFENAC SOL 0.1% OP
DICLOFENAC SODIUM OPHTH SOLN 0.1%
Tier 1
DUREZOL EMU 0.05%
DIFLUPREDNATE OPHTH EMULSION 0.05%
Tier 3
146
Prior Supply Step Specialty Authorization Limit Therapy
X
Therapeutic Class Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation 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
Label Name
Generic Name
Tier Value
FLAREX SUS 0.1% OP
FLUOROMETHOLONE ACETATE OPHTH SUSP 0.1%
Tier 2
FLUOROMETHOL SUS 0.1% OP FLURBIPROFEN SOL 0.03% OP
FLUOROMETHOLONE OPHTH SUSP 0.1%
Tier 1
FLURBIPROFEN SODIUM OPHTH SOLN 0.03%
Tier 1
FML OIN 0.1% OP
FLUOROMETHOLONE OPHTH OINT 0.1%
Tier 2
FML FORTE SUS 0.25% OP
FLUOROMETHOLONE OPHTH SUSP 0.25%
Tier 2
FML LIQUIFLM SUS 0.1% OP
FLUOROMETHOLONE OPHTH SUSP 0.1%
Tier 3
KETOROLAC SOL 0.4% KETOROLAC SOL 0.5% LOTEMAX OIN 0.5% LOTEMAX SUS 0.5% MAXIDEX SUS 0.1% OP
KETOROLAC TROMETHAMINE OPHTH SOLN 0.4% KETOROLAC TROMETHAMINE OPHTH SOLN 0.5% LOTEPREDNOL ETABONATE OPHTH OINT 0.5% LOTEPREDNOL ETABONATE OPHTH SUSP 0.5% DEXAMETHASONE OPHTH SUSP 0.1%
NEOMYCIN-POLYMYXINMAXITROL OIN 0.1% OP DEXAMETHASONE OPHTH OINT 0.1% NEOMYCIN-POLYMYXINMAXITROL SUS 0.1% OP DEXAMETHASONE OPHTH SUSP 0.1% NEO/POLY/BAC OIN /HC BACITRACIN-POLYMYXIN-NEOMYCIN-HC 1%OP OPHTH OINT 1% NEOMYCIN-POLYMYXINNEO/POLY/DEX OIN 0.1% OP DEXAMETHASONE OPHTH OINT 0.1% NEOMYCIN-POLYMYXINNEO/POLY/DEX SUS 0.1% OP DEXAMETHASONE OPHTH SUSP 0.1% BACITRACIN-POLYMYXIN-NEOMYCIN-HC NEO-POLYCIN OIN HC 1%OP OPHTH OINT 1% NEVANAC SUS 0.1%
NEPAFENAC OPHTH SUSP 0.1%
FLURBIPROFEN SODIUM OPHTH SOLN OCUFEN SOL 0.03% OP 0.03% PREDNISOLONE ACETATE OPHTH SUSP OMNIPRED SUS 1% OP 1% PREDNISOLONE ACETATE OPHTH SUSP PRED FORTE SUS 1% OP 1% PREDNISOLONE ACETATE OPHTH SUSP PRED MILD SUS 0.12% OP 0.12% PREDNISOLONE SODIUM PHOSPHATE PRED SOD PHO SOL 1% OP OPHTH SOLN 1% GENTAMICIN-PREDNISOLONE ACE PRED-G SUS OP OPHTH SUSP 0.3-1% GENTAMICIN-PREDNISOLONE ACE PRED-G S.O.P OIN OP OPHTH OINT 0.3-0.6% PREDNISOLONE ACETATE OPHTH SUSP PREDNISOLONE SUS 1% OP 1% SULFACETAMIDE SODIUMSULF/PRED NA SOL OP PREDNISOLONE OPHTH SOLN 100.23(0.25)% TOBRA/DEXAME SUS 0.3TOBRAMYCIN-DEXAMETHASONE OPHTH 0.1% SUSP 0.3-0.1% TOBRAMYCIN-DEXAMETHASONE OPHTH TOBRADEX OIN 0.3-0.1% OINT 0.3-0.1% TOBRAMYCIN-DEXAMETHASONE OPHTH TOBRADEX SUS 0.3-0.1% SUSP 0.3-0.1%
Tier 1 Tier 1 Tier 3 Tier 3
Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
Tier 3 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 2
ZYLET SUS 0.5-0.3%
LOTEPREDNOL ETABONATETOBRAMYCIN OPHTH SUSP 0.5-0.3%
Tier 3
LATANOPROST SOL 0.005%
LATANOPROST OPHTH SOLN 0.005%
Tier 1
LUMIGAN SOL 0.01%
BIMATOPROST OPHTH SOLN 0.01%
Tier 2
TRAVATAN Z DRO 0.004%
Tier 3
X
Tier 2
X
TRAVOPROST DRO 0.004%
TRAVOPROST OPHTH SOLN 0.004%
Tier 3
XALATAN SOL 0.005%
LATANOPROST OPHTH SOLN 0.005%
Tier 3
147
X
Tier 3
RIMEXOLONE OPHTH SUSP 1%
UNOPROSTONE ISOPROPYL OPHTH SOLN 0.15% TRAVOPROST OPHTH SOLN 0.004% (BENZALKONIUM FREE) (BAK FREE)
X
Tier 2
VEXOL SUS 1% OP
RESCULA SOL 0.15%
Prior Supply Step Specialty Authorization Limit Therapy
X
X
Label Name
Generic Name
Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs
ZIOPTAN DRO 0.0015%
TAFLUPROST OPHTH SOLN 0.0015%
Tier 3
OPIUM TINCTURE 1% (10 MG/ML) (MORPHINE EQUIV)
Tier 1
DOLOPHINE TAB 10MG
METHADONE HCL TAB 10 MG
Tier 3
X
DOLOPHINE TAB 5MG
METHADONE HCL TAB 5 MG
Tier 3
X
FENTANYL DIS 100MCG/H
FENTANYL TD PATCH 72HR 100 MCG/HR
Tier 2
X
FENTANYL DIS 12MCG/HR
FENTANYL TD PATCH 72HR 12 MCG/HR
Tier 2
X
FENTANYL DIS 25MCG/HR
FENTANYL TD PATCH 72HR 25 MCG/HR
Tier 2
X
FENTANYL DIS 50MCG/HR
FENTANYL TD PATCH 72HR 50 MCG/HR
Tier 2
X
FENTANYL DIS 75MCG/HR
FENTANYL TD PATCH 72HR 75 MCG/HR
Tier 2
X
LEVORPHANOL TAB 2MG
LEVORPHANOL TARTRATE TAB 2 MG
Tier 1
METHADONE HCL CONC 10 MG/ML
Tier 1
X
METHADONE HCL SOLN 10 MG/5ML
Tier 1
X
METHADONE SOL 5MG/5ML METHADONE HCL SOLN 5 MG/5ML
Tier 1
X
METHADONE TAB 10MG
METHADONE HCL TAB 10 MG
Tier 1
X
METHADONE TAB 40MG
METHADONE HCL TAB FOR ORAL SUSP 40 MG
Tier 1
X
METHADONE TAB 5MG
METHADONE HCL TAB 5 MG
Tier 1
X
METHADOSE CON 10MG/ ML
METHADONE HCL CONC 10 MG/ML
Tier 1
X
METHADOSE TAB 40MG
METHADONE HCL TAB FOR ORAL SUSP 40 MG
Tier 1
X
METHADONE HCL CONC 10 MG/ML
Tier 1
X
Opioid Analgesics - Opioid Pain Relievers OPIUM TIN 10MG/ML Opioid Analgesics, Long-acting - 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 Opioid Analgesics, Long-acting - 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
METHADONE CON 10MG/ ML METHADONE SOL 10MG/5ML
METHADOSE SF CON 10MG/ML MORPHINE SUL CAP 120MG ER MORPHINE SUL CAP 30MG ER MORPHINE SUL CAP 45MG ER MORPHINE SUL CAP 60MG ER MORPHINE SUL CAP 75MG ER MORPHINE SUL CAP 90MG ER MORPHINE SUL SOL 100/5ML MORPHINE SUL SOL 10MG/5ML MORPHINE SUL SOL 20MG/5ML MORPHINE SUL SOL 20MG/ ML
MORPHINE SULFATE BEADS CAP SR 24HR 120 MG MORPHINE SULFATE BEADS CAP SR 24HR 30 MG MORPHINE SULFATE BEADS CAP SR 24HR 45 MG MORPHINE SULFATE BEADS CAP SR 24HR 60 MG MORPHINE SULFATE BEADS CAP SR 24HR 75 MG MORPHINE SULFATE BEADS CAP SR 24HR 90 MG MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) MORPHINE SULFATE ORAL SOLN 10 MG/5ML MORPHINE SULFATE ORAL SOLN 20 MG/5ML MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML)
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 1 Tier 1 Tier 1 Tier 1
MORPHINE SULFATE SUPPOS 10 MG
Tier 3
MORPHINE SUL SUP 20MG
MORPHINE SULFATE SUPPOS 20 MG
Tier 1
MORPHINE SUL SUP 30MG
MORPHINE SULFATE SUPPOS 30 MG
Tier 1
MORPHINE SUL SUP 5MG
MORPHINE SULFATE SUPPOS 5 MG
Tier 1
MORPHINE SUL TAB 100MG MORPHINE SULFATE TAB CR 100 MG ER
Tier 1
MORPHINE SUL TAB 15MG
Tier 1
MORPHINE SULFATE TAB 15 MG
X
Tier 1
X
Tier 1
X
MORPHINE SUL TAB 30MG
MORPHINE SULFATE TAB 30 MG
Tier 1
MORPHINE SUL TAB 30MG ER
MORPHINE SULFATE TAB CR 30 MG
Tier 1
148
X
Tier 3
MORPHINE SUL SUP 10MG
MORPHINE SUL TAB 15MG MORPHINE SULFATE TAB CR 15 MG ER MORPHINE SUL TAB 200MG MORPHINE SULFATE TAB CR 200 MG ER
X
X
Label Name
Generic Name
Opioid Analgesics, Long-acting - 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 Opioid Analgesics, Long-acting - 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
MORPHINE SUL TAB 60MG ER
MORPHINE SULFATE TAB CR 60 MG
Tier 1
MS CONTIN TAB 100MG CR
MORPHINE SULFATE TAB CR 100 MG
Tier 3
X
X
X
MS CONTIN TAB 100MG ER
MORPHINE SULFATE TAB CR 100 MG
Tier 3
X
X
X
MS CONTIN TAB 15MG CR
MORPHINE SULFATE TAB CR 15 MG
Tier 3
X
X
X
MS CONTIN TAB 15MG ER
MORPHINE SULFATE TAB CR 15 MG
Tier 3
X
X
X
MS CONTIN TAB 200MG CR
MORPHINE SULFATE TAB CR 200 MG
Tier 3
X
X
X
MS CONTIN TAB 200MG ER
MORPHINE SULFATE TAB CR 200 MG
Tier 3
X
X
X
MS CONTIN TAB 30MG CR
MORPHINE SULFATE TAB CR 30 MG
Tier 3
X
X
X
MS CONTIN TAB 30MG ER
MORPHINE SULFATE TAB CR 30 MG
Tier 3
X
X
X
MS CONTIN TAB 60MG CR
MORPHINE SULFATE TAB CR 60 MG
Tier 3
X
X
X
MS CONTIN TAB 60MG ER
MORPHINE SULFATE TAB CR 60 MG
Tier 3
X
X
X
NUCYNTA TAB 100MG
TAPENTADOL HCL TAB 100 MG
Tier 3
X
NUCYNTA TAB 50MG
TAPENTADOL HCL TAB 50 MG
Tier 3
X
NUCYNTA TAB 75MG
TAPENTADOL HCL TAB 75 MG
Tier 3
X
NUCYNTA ER TAB 100MG
TAPENTADOL HCL TAB SR 12HR 100 MG
Tier 3
X
X
NUCYNTA ER TAB 150MG
TAPENTADOL HCL TAB SR 12HR 150 MG
Tier 3
X
X
NUCYNTA ER TAB 200MG
TAPENTADOL HCL TAB SR 12HR 200 MG
Tier 3
X
X
NUCYNTA ER TAB 250MG
TAPENTADOL HCL TAB SR 12HR 250 MG
Tier 3
X
X
NUCYNTA ER TAB 50MG
TAPENTADOL HCL TAB SR 12HR 50 MG
Tier 3
X
X
OPANA TAB 10MG
OXYMORPHONE HCL TAB 10 MG
Tier 3
X
OPANA TAB 5MG
OXYMORPHONE HCL TAB 5 MG
Tier 3
X
OPANA ER TAB 10MG OPANA ER TAB 15MG OPANA ER TAB 20MG OPANA ER TAB 30MG OPANA ER TAB 40MG OPANA ER TAB 5MG OPANA ER TAB 7.5MG OXYMORPHONE TAB 10MG ER OXYMORPHONE TAB 15MG ER OXYMORPHONE TAB 20MG ER OXYMORPHONE TAB 30MG ER OXYMORPHONE TAB 40MG ER OXYMORPHONE TAB 5MG ER OXYMORPHONE TAB 7.5MG ER OXYMORPHONE TAB HCL 10MG OXYMORPHONE TAB HCL 5MG TRAMADOL HCL CAP 150MG ER TRAMADOL HCL TAB 100MG ER
OXYMORPHONE HCL TAB ER 12HR DETER 10 MG OXYMORPHONE HCL TAB ER 12HR DETER 15 MG OXYMORPHONE HCL TAB ER 12HR DETER 20 MG OXYMORPHONE HCL TAB ER 12HR DETER 30 MG OXYMORPHONE HCL TAB ER 12HR DETER 40 MG OXYMORPHONE HCL TAB ER 12HR DETER 5 MG OXYMORPHONE HCL TAB ER 12HR DETER 7.5 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
OXYMORPHONE HCL TAB SR 12HR 10 MG
Tier 3
X
X
X
OXYMORPHONE HCL TAB SR 12HR 15 MG
Tier 3
X
X
X
OXYMORPHONE HCL TAB SR 12HR 20 MG
Tier 3
X
X
X
OXYMORPHONE HCL TAB SR 12HR 30 MG
Tier 3
X
X
X
OXYMORPHONE HCL TAB SR 12HR 40 MG
Tier 3
X
X
X
OXYMORPHONE HCL TAB SR 12HR 5 MG
Tier 3
X
X
X
OXYMORPHONE HCL TAB SR 12HR 7.5 MG
Tier 3
X
X
X
OXYMORPHONE HCL TAB 10 MG
Tier 2
X
OXYMORPHONE HCL TAB 5 MG
Tier 2
X
TRAMADOL HCL CAP SR 24HR BIPHASIC RELEASE 150 MG
Tier 1
X
TRAMADOL HCL TAB SR 24HR 100 MG
Tier 2
X
149
Therapeutic Class
Label Name
Opioid Analgesics, Long-acting - 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, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers
TRAMADOL HCL TAB 200MG ER TRAMADOL HCL TAB 300MG ER
Generic Name
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
TRAMADOL HCL TAB SR 24HR 200 MG
Tier 2
X
TRAMADOL HCL TAB SR 24HR 300 MG
Tier 2
X
TRAMADOL HCL TAB 50MG
TRAMADOL HCL TAB 50 MG
Tier 1
ULTRAM TAB 50MG
TRAMADOL HCL TAB 50 MG
Tier 3
ULTRAM ER TAB 100MG
TRAMADOL HCL TAB SR 24HR 100 MG
Tier 3
X
ULTRAM ER TAB 200MG
TRAMADOL HCL TAB SR 24HR 200 MG
Tier 3
X
ULTRAM ER TAB 300MG
TRAMADOL HCL TAB SR 24HR 300 MG
Tier 3
X
HYDROCODONE BITARTRATE CAP SR 12HR ABUSE-DETERRENT 10 MG HYDROCODONE BITARTRATE CAP SR ZOHYDRO ER CAP 15MG 12HR ABUSE-DETERRENT 15 MG HYDROCODONE BITARTRATE CAP SR ZOHYDRO ER CAP 20MG 12HR ABUSE-DETERRENT 20 MG HYDROCODONE BITARTRATE CAP SR ZOHYDRO ER CAP 30MG 12HR ABUSE-DETERRENT 30 MG HYDROCODONE BITARTRATE CAP SR ZOHYDRO ER CAP 40MG 12HR ABUSE-DETERRENT 40 MG HYDROCODONE BITARTRATE CAP SR ZOHYDRO ER CAP 50MG 12HR ABUSE-DETERRENT 50 MG APAP/CODEINE SOL 120ACETAMINOPHEN W/ CODEINE SOLN 12012/5 12 MG/5ML APAP/CODEINE TAB 300ACETAMINOPHEN W/ CODEINE TAB 30015MG 15 MG APAP/CODEINE TAB 300ACETAMINOPHEN W/ CODEINE TAB 30030MG 30 MG APAP/CODEINE TAB 300ACETAMINOPHEN W/ CODEINE TAB 30060MG 60 MG APAP-CAFFEIN CAP ACETAMINOPHEN-CAFFEINEDIHYDROC DIHYDROCODEINE CAP 320.5-30-16 MG BUTALBITAL-ASPIRIN-CAFF W/ CODEINE ASCOMP/COD CAP 30MG CAP 50-325-40-30 MG BUT/ASA/CAF/ CAP COD BUTALBITAL-ASPIRIN-CAFF W/ CODEINE 30MG CAP 50-325-40-30 MG BUTORPHANOL SOL 10MG/ BUTORPHANOL TARTRATE NASAL SOLN ML 10 MG/ML ACETAMINOPHEN W/ CODEINE SUSP 120CAPITAL/COD SUS 120-12/5 12 MG/5ML CARISOPRODOL TAB ASA/ CARISOPRODOL W/ ASPIRIN & CODEINE COD TAB 200-325-16 MG ZOHYDRO ER CAP 10MG
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 3
X
Tier 1 Tier 1 Tier 2
X
Tier 2
X
Tier 1
CODEINE SULF TAB 15MG
CODEINE SULFATE TAB 15 MG
Tier 1
CODEINE SULF TAB 30MG
CODEINE SULFATE TAB 30 MG
Tier 1
CODEINE SULF TAB 60MG
CODEINE SULFATE TAB 60 MG
Tier 1
DEMEROL TAB 100MG
MEPERIDINE HCL TAB 100 MG
Tier 3
DEMEROL TAB 50MG
MEPERIDINE HCL TAB 50 MG
Tier 3
DIHYDROCOD/ CAP ASA/ CAFF
ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG
Tier 1
DILAUDID LIQ 1MG/ML
HYDROMORPHONE HCL LIQD 1 MG/ML
Tier 3
DILAUDID TAB 2MG
HYDROMORPHONE HCL TAB 2 MG
Tier 3
DILAUDID TAB 4MG
HYDROMORPHONE HCL TAB 4 MG
Tier 3
DILAUDID TAB 8MG
HYDROMORPHONE HCL TAB 8 MG
Tier 3
ENDOCET TAB 10-325MG ENDOCET TAB 2.5-325 ENDOCET TAB 5-325MG ENDOCET TAB 7.5-325 FENTANYL OT LOZ 1200MCG FENTANYL OT LOZ 1600MCG
OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG FENTANYL CITRATE LOZENGE ON A HANDLE 1200 MCG FENTANYL CITRATE LOZENGE ON A HANDLE 1600 MCG
150
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 2
X
X
Tier 2
X
X
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 Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers
Label Name FENTANYL OT LOZ 200MCG FENTANYL OT LOZ 400MCG FENTANYL OT LOZ 600MCG FENTANYL OT LOZ 800MCG FIORINAL/COD CAP 30MG HYCET SOL 7.5-325 HYDROCO/APAP SOL 7.5325 HYDROCO/APAP TAB 10325MG HYDROCO/APAP TAB 2.5325 HYDROCO/APAP TAB 5-325MG HYDROCO/APAP TAB 7.5325 HYDROCOD/IBU TAB 10200MG HYDROCOD/IBU TAB 5-200MG HYDROCOD/IBU TAB 7.5-200
Generic Name FENTANYL CITRATE LOZENGE ON A HANDLE 200 MCG FENTANYL CITRATE LOZENGE ON A HANDLE 400 MCG FENTANYL CITRATE LOZENGE ON A HANDLE 600 MCG FENTANYL CITRATE LOZENGE ON A HANDLE 800 MCG BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG HYDROCODONE-ACETAMINOPHEN TAB 2.5-325 MG HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG HYDROCODONE-IBUPROFEN TAB 10-200 MG HYDROCODONE-IBUPROFEN TAB 5-200 MG HYDROCODONE-IBUPROFEN TAB 7.5-200 MG HYDROCODONE-ACETAMINOPHEN SOLN 10-325 MG/15ML
HYDROCODONE SOL 10325MG HYDROMORPHON LIQ 1MG/ HYDROMORPHONE HCL LIQD 1 MG/ML ML HYDROMORPHON SUP 3MG HYDROMORPHONE HCL SUPPOS 3 MG HYDROMORPHON TAB 12MG ER HYDROMORPHON TAB 16MG ER
HYDROMORPHONE HCL TAB ER 24HR DETER 12 MG HYDROMORPHONE HCL TAB ER 24HR DETER 16 MG
Tier Value Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 3 Tier 3
X
Tier 2
X
Tier 1
X
Tier 1 Tier 1
X
Tier 1
X
Tier 1 Tier 1 Tier 1 Tier 1
Tier 1 Tier 3
X
X
X
Tier 3
X
X
X
X
X
X
X
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
HYDROMORPHON TAB 2MG HYDROMORPHONE HCL TAB 2 MG
Tier 1 Tier 3
HYDROMORPHON TAB 4MG HYDROMORPHONE HCL TAB 4 MG
Tier 1
HYDROMORPHON TAB 8MG HYDROMORPHONE HCL TAB 8 MG
Tier 1
HYDROMORPHON TAB 8MG ER
Tier 3
IBUDONE TAB 10-200MG IBUDONE TAB 5-200MG LAZANDA SPR 100MCG LAZANDA SPR 300MCG LAZANDA SPR 400MCG LORCET TAB 5-325MG LORCET HD TAB 10-325MG LORCET PLUS TAB 7.5-325 LORTAB ELX 10-300MG LORTAB TAB 10-325MG LORTAB TAB 5-325MG LORTAB TAB 7.5-325
HYDROMORPHONE HCL TAB ER 24HR DETER 8 MG HYDROCODONE-IBUPROFEN TAB 10-200 MG HYDROCODONE-IBUPROFEN TAB 5-200 MG FENTANYL CITRATE NASAL SPRAY 100 MCG/ACT (BASE EQUIV) FENTANYL CITRATE NASAL SPRAY 300 MCG/ACT (BASE EQUIV) FENTANYL CITRATE NASAL SPRAY 400 MCG/ACT (BASE EQUIV) HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG HYDROCODONE-ACETAMINOPHEN SOLN 10-300 MG/15ML HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG
Tier 1 Tier 1
Tier 1
X
Tier 1
X
Tier 1
X
Tier 3 Tier 1
X
Tier 1
X
Tier 1
X
MEPERIDINE SOL 50MG/5ML
MEPERIDINE HCL ORAL SOLN 50 MG/5ML
Tier 1
MEPERIDINE TAB 100MG
MEPERIDINE HCL TAB 100 MG
Tier 1
MEPERIDINE TAB 50MG
MEPERIDINE HCL TAB 50 MG
Tier 1
151
X
Tier 1
HYDROMORPHON TAB 32MG ER
HYDROMORPHONE HCL TAB ER 24HR DETER 32 MG
Prior Supply Step Specialty Authorization Limit Therapy
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 Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid Pain Relievers Opioid Analgesics, Short-acting - Opioid 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
Label Name NORCO TAB 10-325MG NORCO TAB 5-325MG NORCO TAB 7.5-325 OXYCOD/APAP TAB 10325MG OXYCOD/APAP TAB 2.5-325 OXYCOD/APAP TAB 5-325MG OXYCOD/APAP TAB 7.5-325
Generic Name HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG OXYCODONE W/ ACETAMINOPHEN TAB 10-325 MG OXYCODONE W/ ACETAMINOPHEN TAB 2.5-325 MG OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG
Tier Value Tier 3
X
Tier 3
X
Tier 3
X
Tier 1
X
Tier 1
X
Tier 1
X
Tier 1
X
OXYCOD/ASA TAB
OXYCODONE-ASPIRIN TAB 4.8355-325 MG
Tier 1
OXYCODONE CAP 5MG
OXYCODONE HCL CAP 5 MG
Tier 1
OXYCODONE HCL CONC 100 MG/5ML (20 OXYCODONE CON 100/5ML MG/ML) OXYCODONE CON 20MG/ OXYCODONE HCL CONC 100 MG/5ML (20 ML MG/ML)
Tier 1 Tier 1
OXYCODONE SOL 5MG/5ML OXYCODONE HCL SOLN 5 MG/5ML
Tier 1
OXYCODONE TAB 10MG
OXYCODONE HCL TAB 10 MG
Tier 1
OXYCODONE TAB 15MG
OXYCODONE HCL TAB 15 MG
Tier 1
OXYCODONE TAB 20MG
OXYCODONE HCL TAB 20 MG
Tier 1
OXYCODONE TAB 30MG
OXYCODONE HCL TAB 30 MG
Tier 1
OXYCODONE HCL TAB 5 MG
Tier 1
OXYCODONE TAB 5MG OXYCODONE/ SOL APAP PENTAZ/NALOX TAB 500.5MG PRIMLEV TAB 10-300MG PRIMLEV TAB 5-300MG PRIMLEV TAB 7.5-300 REPREXAIN TAB 10-200MG REPREXAIN TAB 5-200MG
OXYCODONE W/ ACETAMINOPHEN SOLN 5-325 MG/5ML PENTAZOCINE W/ NALOXONE TAB 50-0.5 MG OXYCODONE W/ ACETAMINOPHEN TAB 10-300 MG OXYCODONE W/ ACETAMINOPHEN TAB 5-300 MG OXYCODONE W/ ACETAMINOPHEN TAB 7.5-300 MG HYDROCODONE-IBUPROFEN TAB 10-200 MG HYDROCODONE-IBUPROFEN TAB 5-200 MG
Tier 2
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1 Tier 1
OXYCODONE HCL TAB 15 MG
Tier 3
ROXICODONE TAB 30MG
OXYCODONE HCL TAB 30 MG
Tier 3
OXYCODONE HCL TAB 5 MG
Tier 3
SYNALGOS-DC CAP TRAMADL/APAP TAB 37.5325 TREZIX CAP TYLENOL/COD TAB #3 TYLENOL/COD TAB #4 ULTRACET TAB 37.5-325 VERDROCET TAB 2.5-325 VICOPROFEN TAB 7.5-200 XYLON TAB 10-200MG ZAMICET SOL 10-325MG BELBUCA MIS 150MCG BELBUCA MIS 300MCG
ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG TRAMADOL-ACETAMINOPHEN TAB 37.5325 MG ACETAMINOPHEN-CAFFEINEDIHYDROCODEINE CAP 320.5-30-16 MG ACETAMINOPHEN W/ CODEINE TAB 30030 MG ACETAMINOPHEN W/ CODEINE TAB 30060 MG TRAMADOL-ACETAMINOPHEN TAB 37.5325 MG HYDROCODONE-ACETAMINOPHEN TAB 2.5-325 MG HYDROCODONE-IBUPROFEN TAB 7.5-200 MG HYDROCODONE-IBUPROFEN TAB 10-200 MG HYDROCODONE-ACETAMINOPHEN SOLN 10-325 MG/15ML BUPRENORPHINE HCL BUCCAL FILM 150 MCG (BASE EQUIVALENT) BUPRENORPHINE HCL BUCCAL FILM 300 MCG (BASE EQUIVALENT)
152
X
Tier 1
ROXICODONE TAB 15MG
ROXICODONE TAB 5MG
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 Tier 1
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 1 Tier 3 Tier 1 Tier 1
X
Tier 3
X
X
X
Tier 3
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 Opioid Antagonists - Antidotes/ Deterrents/Protectants 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 Otic Agents - Ear Drugs 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 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
Label Name BELBUCA MIS 450MCG BELBUCA MIS 600MCG BELBUCA MIS 750MCG BELBUCA MIS 75MCG BELBUCA MIS 900MCG BUPRENORPHIN SUB 2MG BUPRENORPHIN SUB 8MG
Generic Name BUPRENORPHINE HCL BUCCAL FILM 450 MCG (BASE EQUIVALENT) BUPRENORPHINE HCL BUCCAL FILM 600 MCG (BASE EQUIVALENT) BUPRENORPHINE HCL BUCCAL FILM 750 MCG (BASE EQUIVALENT) BUPRENORPHINE HCL BUCCAL FILM 75 MCG (BASE EQUIVALENT) BUPRENORPHINE HCL BUCCAL FILM 900 MCG (BASE EQUIVALENT) BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV) BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)
Tier Value Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 1
X
Tier 1
X
NALOXONE INJ 0.4MG/ML
NALOXONE HCL INJ 0.4 MG/ML
Tier 1
NALOXONE INJ 0.4MG/ML
NALOXONE HCL INJ 4 MG/10ML
Tier 1
NALOXONE HCL SOLN CARTRIDGE 0.4 NALOXONE INJ 0.4MG/ML MG/ML NALOXONE HCL SOLN PREFILLED NALOXONE INJ 1MG/ML SYRINGE 2 MG/2ML NALOXONE HCL NASAL SPRAY 4 NARCAN SPR MG/0.1ML BUPRENORPHINE HCL-NALOXONE HCL ZUBSOLV SUB 0.7-0.18 SL TAB 0.7-0.18 MG (BASE EQ) BUPRENORPHINE HCL-NALOXONE HCL ZUBSOLV SUB 1.4-0.36 SL TAB 1.4-0.36 MG (BASE EQ) BUPRENORPHINE HCL-NALOXONE HCL ZUBSOLV SUB 11.4-2.9 SL TAB 11.4-2.9 MG (BASE EQ) BUPRENORPHINE HCL-NALOXONE HCL ZUBSOLV SUB 2.9-0.71 SL TAB 2.9-0.71 MG (BASE EQ) BUPRENORPHINE HCL-NALOXONE HCL ZUBSOLV SUB 5.7-1.4 SL TAB 5.7-1.4 MG (BASE EQ) BUPRENORPHINE HCL-NALOXONE HCL ZUBSOLV SUB 8.6-2.1 SL TAB 8.6-2.1 MG (BASE EQ) ACE ACD/ALUM SOL 2% ACETIC ACID 2% IN ALUMINUM ACETATE OTIC OTIC SOLN HYDROCORTISONE W/ ACETIC ACID OTIC ACETASOL HC SOL OTIC SOLN 1-2% ACETIC ACID SOL 2% OTIC ACETIC ACID OTIC SOLN 2% NEOMYCIN-COLISTIN-HC-THONZONIUM COLY-MYCIN S SUS OTIC OTIC SUSP 3.3-3-10-0.5 MG/ML NEOMYCIN-COLISTIN-HC-THONZONIUM CORTISPORIN SUS -TC OTIC OTIC SUSP 3.3-3-10-0.5 MG/ML FLUOCINOLONE ACETONIDE (OTIC) OIL DERMOTIC OIL 0.01% 0.01% FLUOCINOLONE ACETONIDE (OTIC) OIL FLUOCIN ACET OIL 0.01% 0.01% FLUOCIN ACET OIL FLUOCINOLONE ACETONIDE (OTIC) OIL EAR0.01% 0.01% HYDROCORTISONE W/ ACETIC ACID OTIC HC/ACET ACID SOL OTIC SOLN 1-2% NEOMYCIN-POLYMYXIN-HC OTIC SOLN NEO/POLY/HC SOL 1% OTIC 1% NEOMYCIN-POLYMYXIN-HC OTIC SUSP NEO/POLY/HC SUS 1% OTIC 3.5 MG/ML-10000 UNIT/ML-1% NEO/POLY/HC SUS OP NEOMYCIN-POLYMYXIN-HC OPHTH SUSP PRAMOXINE-CHLOROXYLENOL OTIC PRAMOTIC DRO 1-0.1% LIQUID 1-0.1%
Tier 1 Tier 1 Tier 2
X
Tier 2
X
Tier 2
X
Tier 2 Tier 2 Tier 2
X
Tier 2
X
Tier 1 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
GUANIDINE TAB 125MG
GUANIDINE HCL TAB 125 MG
Tier 3
MESTINON SYP 60MG/5ML
PYRIDOSTIGMINE BROMIDE SYRUP 60 MG/5ML
Tier 2
MESTINON TAB 60MG
PYRIDOSTIGMINE BROMIDE TAB 60 MG
Tier 3
MESTINON TAB TIMESPAN
PYRIDOSTIGMINE BROMIDE TAB CR 180 MG
Tier 3
PYRIDOSTIGM TAB 60MG
PYRIDOSTIGMINE BROMIDE TAB 60 MG
Tier 1
PYRIDOSTIGMI TAB ER 180MG
PYRIDOSTIGMINE BROMIDE TAB CR 180 MG
Tier 1
ELIMITE CRE 5%
PERMETHRIN CREAM 5%
Tier 3
EURAX CRE 10%
CROTAMITON CREAM 10%
Tier 2
EURAX LOT 10%
CROTAMITON LOTION 10%
Tier 3
153
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class 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 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
Label Name
Generic Name
LINDANE LOT 1%
LINDANE LOTION 1%
Tier 1
LINDANE SHA 1%
LINDANE SHAMPOO 1%
Tier 1
LYCELLE GEL
*NIT REMOVER - GEL***
Tier 3
MALATHION LOT 0.5%
MALATHION LOTION 0.5%
Tier 1
OVIDE LOT 0.5%
MALATHION LOTION 0.5%
Tier 3
PERMETHRIN CRE 5%
PERMETHRIN CREAM 5%
Tier 1
SKLICE LOT 0.5%
IVERMECTIN LOTION 0.5%
Tier 3
SPINOSAD SUS 0.9%
SPINOSAD SUSP 0.9%
Tier 3
ULESFIA LOT 5%
BENZYL ALCOHOL LOTION 5%
Tier 3
ACE AERO CLD MIS ENHANCER
*RESPIRATORY THERAPY SUPPLIES MISC** *RESPIRATORY THERAPY SUPPLIES ADULT MASK MIS MISC** *RESPIRATORY THERAPY SUPPLIES AEROSOL MASK MIS ADULT MISC** ALPAWASH OIN POLYETHYLENE GLYCOL OINTMENT *RESPIRATORY THERAPY SUPPLIES ALTERA NEB MIS HANDSET MISC** APOTHEDERM CRE *TRANSDERMAL BASE CREAM** APOTHESAR CRE *TRANSDERMAL BASE CREAM** TRANSDER AQUORAL AER *ARTIFICIAL SALIVA - AERO SOLN*** AQUORAL SPR *ARTIFICIAL SALIVA - SOLUTION*** *PHARMACEUTICAL EXCIPIENTS (BULK) BACOCALMINE LIQ LIQUID** BASE CRE LIPOSOME *CREAM BASE LIPOSOMIC** *RESPIRATORY THERAPY SUPPLIES BUBBLES PEDI MIS MASK MISC** CARBOGEL GEL 940 *CARBOMER GEL BASE** CARBOHOL GEL 940 *CARBOMER GEL BASE** CARBOMER GEL AQUEOUS *CARBOMER GEL BASE** CARBOMER GEL *CARBOMER GEL BASE** HYDROALC CHERRY SYP CHERRY SYRUP COLLODION LIQ FLEXIBLE COLLODION FLEXIBLE *RESPIRATORY THERAPY SUPPLIES CONE MASK MIS MISC** *RESPIRATORY THERAPY SUPPLIES CONVERSION MIS BABY SZ1 MISC** *RESPIRATORY THERAPY SUPPLIES CONVERSION MIS BABY SZ2 MISC** *RESPIRATORY THERAPY SUPPLIES CONVERSION MIS BABY SZ3 MISC** DELIVRA CRE SR *TRANSDERMAL BASE CREAM** *RESPIRATORY THERAPY SUPPLIES EARLOOP MASK MIS MISC** *RESPIRATORY THERAPY SUPPLIES EBASE CONTRO MIS KIT MISC** *RESPIRATORY THERAPY SUPPLIES EFLOW SCF MIS AEROSOL MISC** *RESPIRATORY THERAPY SUPPLIES ERAPID NEB MIS HANDSET MISC** *RESPIRATORY THERAPY SUPPLIES FILTER AIR MIS PP MISC** FLAVOR BLEND SUS *ORAL VEHICLES - SUSP*** FLAVOR PLUS LIQ *ORAL VEHICLES*** FLAVOR SWEET SYP *ORAL VEHICLES - SYRUP*** FLAVOR SWEET SYP S/F *ORAL VEHICLES - SYRUP*** FLOW-EZE MIS VENTED HYPODERMIC NEEDLES (DISPOSABLE) DYE FDC BLUE 1 (BRILLIANT BLUE FCF) FOOD COLOR LIQ BLUE - LIQUID HYDROGEL GEL *CARBOMER GEL BASE** HYPO NEEDLE MIS 18GX1" NEEDLE (DISP) 18 X 1" KERAGELT GEL *WOUND DRESSINGS - GEL*** KERAMATRIX PAD 10X10CM *WOUND DRESSINGS - PADS*** KERAMATRIX PAD 5X5CM *WOUND DRESSINGS - PADS*** LANOLIN OIN LANOLIN
154
Tier Value
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 3 Tier 3 Tier 3 Tier 2 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 1 Tier 3 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
X
X
Therapeutic Class
Label Name
Generic Name
PHARMACEUTICAL AIDS
LANOLIN ANHY OIN
PHARMACEUTICAL AIDS
LECITHIN GEL
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
LIPOZYME CRE LUXAMEND CRE
LANOLIN ANHYDROUS PREMIUM LECITHIN ORGANOGEL BASE GEL *CREAM BASE LIPOSOMIC** *WOUND DRESSINGS - CREAM*** *PHARMACEUTICAL EXCIPIENTS (BULK) LIQUID** NEEDLE (DISP) 22 X 1-1/2" *ARTIFICIAL SALIVA - PACKET*** *RESPIRATORY THERAPY SUPPLIES MISC** *RESPIRATORY THERAPY SUPPLIES MISC** *RESPIRATORY THERAPY SUPPLIES MISC** *ORAL VEHICLES - SUSP*** *ORAL VEHICLES - SUSP*** *ORAL VEHICLES*** *ORAL VEHICLES - SYRUP*** *ORAL VEHICLES - SYRUP*** ACACIA SYRUP COBASE #1 OINTMENT BASE
PHARMACEUTICAL AIDS
MUCOLOX LIQ
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
NEEDLES 22G X 1 1/2" NEUTRASAL POW
PHARMACEUTICAL AIDS
OPTICHAMBER MIS
PHARMACEUTICAL AIDS
OPTICHAMBER/ MIS MASK
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 PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
OPTICHAMBER/ MIS MASK SM ORA-BLEND SUS ORA-BLEND SF SUS ORA-PLUS LIQ ORA-SWEET SYP ORA-SWEET SF SYP PCCA ACACIA SYP BASE PCCA COBASE OIN #1 PCCA CUSTOM CRE LIPOMAX PCCA LIPOSOM CRE DRY PCCA LIPOSOM CRE NORMAL PCCA LIPOSOM CRE OILY PCCA LIPOSOM CRE SENSITIV PCCA SWEET SYP -SF PCCA SYRUP SYP VEHICLE PCCA-PLUS SUS PETROLATUM OIN YELLOW PLACEBO #00 CAP
Tier Value 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 3 Tier 3 Tier 3
*CREAM BASE LIPOSOMIC**
Tier 3
*CREAM BASE LIPOSOMIC**
Tier 3
*CREAM BASE LIPOSOMIC**
Tier 3
*CREAM BASE LIPOSOMIC**
Tier 3
*CREAM BASE LIPOSOMIC**
Tier 3
*ORAL VEHICLES - SYRUP*** *ORAL VEHICLES - SYRUP*** *ORAL VEHICLES - SUSP*** PETROLATUM OINTMENT *PLACEBO - CAP** PREMIUM LECITHIN ORGANOGEL BASE PLO GEL MEDIFLO GEL PREMIUM LECITHIN ORGANOGEL BASE PLO MEDIFLO KIT KIT KIT PLO TRANSDER CRE *TRANSDERMAL BASE CREAM** PREMIUM LECITHIN ORGANOGEL BASE PLO20 BASE GEL GEL POLYETH GLYC OIN 8000 POLYETHYLENE GLYCOL 8000 OINT POLYPEG OIN BASE POLYETHYLENE GLYCOL OINTMENT PROPYLENE GL SOL PROPYLENE GLYCOL PURIFIED LIQ WATER *DISTILLED WATER*** RASPBERRY SYP RASPBERRY SYRUP *RESPIRATORY THERAPY SUPPLIES REPLACEMENT MIS FILTERS MISC** SAFTY NEEDLE MIS 18GX1" NEEDLE (DISP) 18 X 1" SAFTY NEEDLE MIS 18GX1.5" NEEDLE (DISP) 18 X 1-1/2" SAFTY NEEDLE MIS 19GX1" NEEDLE (DISP) 19 X 1" SAFTY NEEDLE MIS 19GX1.5" NEEDLE (DISP) 19 X 1-1/2" SAFTY NEEDLE MIS 20GX1" NEEDLE (DISP) 20 X 1" SAFTY NEEDLE MIS NEEDLE (DISP) 20 X 1-1/2" 20GX1.5" SAFTY NEEDLE MIS 21GX1" NEEDLE (DISP) 21 X 1" SAFTY NEEDLE MIS 21GX1.5" NEEDLE (DISP) 21 X 1-1/2" SAFTY NEEDLE MIS 22GX1" NEEDLE (DISP) 22 X 1" SAFTY NEEDLE MIS NEEDLE (DISP) 22 X 1-1/2" 22GX1.5" SAFTY NEEDLE MIS 23GX1" NEEDLE (DISP) 23 X 1" SAFTY NEEDLE MIS 25GX1" NEEDLE (DISP) 25 X 1" SAFTY NEEDLE MIS NEEDLE (DISP) 25 X 5/8" 25GX5/8" SALIVAMAX POW *ARTIFICIAL SALIVA - PACKET*** SALIVATE RX POW *ARTIFICIAL SALIVA - PACKET*** SHARP CONTAI MIS *SHARPS CONTAINER - MISC*** SILOSOME CRE TRANSDER *TRANSDERMAL BASE CREAM** SIMPLE SYP SIMPLE - SYRUP SOLVATECH SUS PLUS *ORAL VEHICLES - SUSP*** SOLVATECH SYP SWEET SF *ORAL VEHICLES - SYRUP*** SOLYDRA LIQ *OIL BASE - LIQUID*** SUSPENSION SUS VEHICLE *ORAL VEHICLES - SUSP*** SYRPALTA SYP SIMPLE - SYRUP
155
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 1 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 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
*ORAL VEHICLES - SYRUP*** SIMPLE - SYRUP *ORAL VEHICLES*** *ORAL VEHICLES FOR SUSP*** *ORAL VEHICLES - SYRUP*** *ORAL VEHICLES - SYRUP*** *TRANSDERMAL BASE CREAM** *WOUND DRESSINGS - PADS*** *WOUND DRESSINGS - PADS*** *WOUND DRESSINGS - PADS*** *WOUND DRESSINGS - PADS***
Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
*TRANSDERMAL BASE CREAM**
Tier 3
PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS
SYRPALTA SYP 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" TRANSDERMAL CRE PAIN BAS TRANS-PEN CRE VERSAFREE SYP VERSAPLUS SYP
Tier 3 Tier 3 Tier 3
PHARMACEUTICAL AIDS
WING TIP MIS TUBING
*TRANSDERMAL BASE CREAM** *ORAL VEHICLES - SYRUP*** *ORAL VEHICLES - SYRUP*** *RESPIRATORY THERAPY SUPPLIES MISC** LANTHANUM CARBONATE CHEW TAB 1000 MG (ELEMENTAL) LANTHANUM CARBONATE CHEW TAB 500 MG (ELEMENTAL) LANTHANUM CARBONATE CHEW TAB 750 MG (ELEMENTAL) LANTHANUM CARBONATE ORAL POWDER PACK 1000 MG (ELEMENTAL) LANTHANUM CARBONATE ORAL POWDER PACK 750 MG (ELEMENTAL)
PHARMACEUTICAL AIDS
Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents Phosphate Binders - PhosphateRemoving Agents 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
FOSRENOL CHW 1000MG FOSRENOL CHW 500MG FOSRENOL CHW 750MG FOSRENOL POW 1000MG FOSRENOL POW 750MG
Tier Value
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
RENAGEL TAB 400MG
SEVELAMER HCL TAB 400 MG
Tier 3
RENAGEL TAB 800MG
SEVELAMER HCL TAB 800 MG
Tier 3
RENVELA PAK 0.8GM
SEVELAMER CARBONATE PACKET 0.8 GM
Tier 2
RENVELA PAK 2.4GM
SEVELAMER CARBONATE PACKET 2.4 GM
Tier 2
RENVELA TAB 800MG
SEVELAMER CARBONATE TAB 800 MG
Tier 2
ASA/DIPYRIDA CAP 25200MG
SUCROFERRIC OXYHYDROXIDE CHEW TAB 500 MG ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25-200 MG ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25-200 MG
CILOSTAZOL TAB 100MG
CILOSTAZOL TAB 100 MG
Tier 1
CILOSTAZOL TAB 50MG
CILOSTAZOL TAB 50 MG
Tier 1
VELPHORO CHW 500MG AGGRENOX CAP 25-200MG
CLOPIDOGREL TAB 300MG CLOPIDOGREL TAB 75MG
CLOPIDOGREL BISULFATE TAB 300 MG (BASE EQUIV) CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)
Prior Supply Step Specialty Authorization Limit Therapy
Tier 2 Tier 3 Tier 3
Tier 1 Tier 1
DIPYRIDAMOLE TAB 25MG
DIPYRIDAMOLE TAB 25 MG
Tier 1
DIPYRIDAMOLE TAB 50MG
DIPYRIDAMOLE TAB 50 MG
Tier 1
DIPYRIDAMOLE TAB 75MG
DIPYRIDAMOLE TAB 75 MG
Tier 1
EFFIENT TAB 10MG
PRASUGREL HCL TAB 10 MG (BASE EQUIV)
Tier 3
X
EFFIENT TAB 5MG
PRASUGREL HCL TAB 5 MG (BASE EQUIV)
Tier 3
X
PERSANTINE TAB 25MG
DIPYRIDAMOLE TAB 25 MG
Tier 3
PERSANTINE TAB 50MG
DIPYRIDAMOLE TAB 50 MG
Tier 3
PERSANTINE TAB 75MG
DIPYRIDAMOLE TAB 75 MG
Tier 3
PLETAL TAB 100MG
CILOSTAZOL TAB 100 MG
Tier 3
PLETAL TAB 50MG
CILOSTAZOL TAB 50 MG
Tier 3
ZONTIVITY TAB 2.08MG
VORAPAXAR SULFATE TAB 2.08 MG (BASE EQUIVALENT)
Tier 3
X
HCR Preventive Care
X
Progesterone Agonists/Antagonists ELLA TAB 30MG Hormone Replacement/Modifying Drugs
ULIPRISTAL ACETATE TAB 30 MG
156
Therapeutic Class
Label Name
Generic Name
Tier Value
Progestins - Hormone Replacement/ Modifying Drugs
AFTERA TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
HCR Preventive Care
Progestins - Hormone Replacement/ Modifying Drugs
AYGESTIN TAB 5MG
NORETHINDRONE ACETATE TAB 5 MG
Progestins - Hormone Replacement/ Modifying Drugs
CAMILA TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
CRINONE GEL 4% VAG
PROGESTERONE VAGINAL GEL 4%
Tier 2
CRINONE GEL 8% VAG
PROGESTERONE VAGINAL GEL 8%
Tier 2
Progestins - Hormone Replacement/ Modifying Drugs Progestins - Hormone Replacement/ Modifying Drugs Progestins - Hormone Replacement/ Modifying Drugs
DEBLITANE TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs Progestins - Hormone Replacement/ Modifying Drugs
DEPO-PROVERA INJ 150MG/ ML DEPO-PROVERA INJ 150MG/ ML
MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML
Progestins - Hormone Replacement/ Modifying Drugs
DEPO-SQ PROV INJ 104
MEDROXYPROGESTERONE ACETATE SUSP PREF SYR 104 MG/0.65ML
Progestins - Hormone Replacement/ Modifying Drugs
ECONTRA EZ TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
ENDOMETRIN SUP 100MG
PROGESTERONE VAGINAL INSERT 100 MG
Progestins - Hormone Replacement/ Modifying Drugs
ERRIN TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
FALLBACK TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
HEATHER TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
JENCYCLA TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
JOLIVETTE TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
LEVONORGESTR TAB 1.5MG LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
LYZA TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
MEDROXYPR AC INJ 150MG/ML
MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML
Progestins - Hormone Replacement/ Modifying Drugs
MEDROXYPR AC INJ 150MG/ML
MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML
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
MEDROXYPROGESTERONE ACETATE TAB 10 MG MEDROXYPROGESTERONE ACETATE TAB MEDROXYPR AC TAB 2.5MG 2.5 MG MEDROXYPROGESTERONE ACETATE TAB MEDROXYPR AC TAB 5MG 5 MG
MEDROXYPR AC TAB 10MG
MEGACE ES SUS 625/5ML
MEGESTROL ACETATE SUSP 625 MG/5ML
Tier 3 HCR Preventive Care
X
HCR Preventive Care Tier 3
X
Tier 3
X
HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 1 Tier 1 Tier 1 Tier 3
MEGACE ORAL SUS 40MG/ MEGESTROL ACETATE SUSP 40 MG/ML ML MEGESTROL SUS MEGESTROL ACETATE SUSP 625 MG/5ML 625MG/5M MEGESTROL AC SUS 40MG/ MEGESTROL ACETATE SUSP 40 MG/ML ML
Tier 3
MEGESTROL AC TAB 20MG
MEGESTROL ACETATE TAB 20 MG
Tier 1
MEGESTROL AC TAB 40MG
MEGESTROL ACETATE TAB 40 MG
Tier 1
Progestins - Hormone Replacement/ Modifying Drugs
MY WAY TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
NECON TAB 1/50-28
NORETHINDRONE & MESTRANOL TAB 1 MG-50 MCG
157
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
Tier 1
HCR Preventive Care HCR Preventive Care
X
X
X X
Therapeutic Class
Label Name
Generic Name
Progestins - Hormone Replacement/ Modifying Drugs
NEXT CHOICE TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
NORA-BE TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
NORETHIN ACE TAB 5MG
NORETHINDRONE ACETATE TAB 5 MG
Progestins - Hormone Replacement/ Modifying Drugs
NORETHINDRON TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
NORINYL TAB 1+50-28
NORETHINDRONE & MESTRANOL TAB 1 MG-50 MCG
Progestins - Hormone Replacement/ Modifying Drugs
NORLYDA TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
NORLYROC TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
NOR-QD TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
OPCICON TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
OPTION 2 TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
ORTHO MICRON TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Tier 3
Progestins - Hormone Replacement/ Modifying Drugs
PLAN B TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
HCR Preventive Care
PROGESTERONE CAP 100MG PROGESTERONE CAP 200MG PROGESTERONE INJ 50MG/ ML
PROGESTERONE MICRONIZED CAP 100 MG PROGESTERONE MICRONIZED CAP 200 MG
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
PROMETRIUM CAP 100MG PROMETRIUM CAP 200MG PROVERA TAB 10MG PROVERA TAB 2.5MG PROVERA TAB 5MG
PROGESTERONE IM IN OIL 50 MG/ML PROGESTERONE MICRONIZED CAP 100 MG PROGESTERONE MICRONIZED CAP 200 MG MEDROXYPROGESTERONE ACETATE TAB 10 MG MEDROXYPROGESTERONE ACETATE TAB 2.5 MG MEDROXYPROGESTERONE ACETATE TAB 5 MG
Tier Value HCR Preventive Care HCR Preventive Care Tier 1 HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care
Tier 2 Tier 2 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care
Progestins - Hormone Replacement/ Modifying Drugs
REACT TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
Progestins - Hormone Replacement/ Modifying Drugs
SHAROBEL TAB 0.35MG
NORETHINDRONE TAB 0.35 MG
Progestins - Hormone Replacement/ Modifying Drugs
TAKE ACTION TAB 1.5MG
LEVONORGESTREL TAB 1.5 MG
CARAFATE SUS 1GM/10ML
SUCRALFATE SUSP 1 GM/10ML
Tier 3
CARAFATE TAB 1GM
SUCRALFATE TAB 1 GM
Tier 3
CYTOTEC TAB 100MCG
MISOPROSTOL TAB 100 MCG
Tier 3
CYTOTEC TAB 200MCG
MISOPROSTOL TAB 200 MCG
Tier 3
MISOPROSTOL TAB 100 MCG
Tier 1
MISOPROSTOL TAB 200 MCG
Tier 1
SUCRALFATE TAB 1 GM
Tier 1
Protectants - Ulcer and Stomach Acid Drugs Protectants - Ulcer and Stomach Acid Drugs Protectants - Ulcer and Stomach Acid Drugs Protectants - Ulcer and Stomach Acid Drugs Protectants - Ulcer and Stomach Acid Drugs Protectants - Ulcer and Stomach Acid Drugs Protectants - 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
MISOPROSTOL TAB 100MCG MISOPROSTOL TAB 200MCG SUCRALFATE TAB 1GM DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR NEXIUM GRA 10MG DR NEXIUM GRA 2.5MG DR
DEXLANSOPRAZOLE CAP DELAYED RELEASE 30 MG DEXLANSOPRAZOLE CAP DELAYED RELEASE 60 MG ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACKET 10 MG ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACK 2.5 MG
158
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
Tier 3
X
Tier 3
X
X
X
Tier 3
X
X
X
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 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
Label Name
Generic Name
ESOMEPRAZOLE MAGNESIUM FOR DELAYED RELEASE SUSP PACKET 20 MG ESOMEPRAZOLE MAGNESIUM FOR NEXIUM GRA 40MG DR DELAYED RELEASE SUSP PACKET 40 MG ESOMEPRAZOLE MAGNESIUM FOR NEXIUM GRA 5MG DR DELAYED RELEASE SUSP PACKET 5 MG OMEPRAZOLE CAP DELAYED RELEASE OMEPRAZOLE CAP 10MG 10 MG OMEPRAZOLE CAP DELAYED RELEASE OMEPRAZOLE CAP 20MG 20 MG OMEPRAZOLE CAP DELAYED RELEASE OMEPRAZOLE CAP 40MG 40 MG PANTOPRAZOLE SODIUM EC TAB 20 MG PANTOPRAZOLE TAB 20MG (BASE EQUIV) PANTOPRAZOLE SODIUM EC TAB 40 MG PANTOPRAZOLE TAB 40MG (BASE EQUIV) LANSOPRAZOLE TAB DELAYED RELEASE PREVACID TAB 15MG STB ORALLY DISINTEGRATING 15 MG LANSOPRAZOLE TAB DELAYED RELEASE PREVACID TAB 30MG STB ORALLY DISINTEGRATING 30 MG
NEXIUM GRA 20MG DR
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
X
X
X
Tier 3
X
X
X
RABEPRAZOLE TAB 20MG
RABEPRAZOLE SODIUM EC TAB 20 MG
Tier 3
ADCIRCA TAB 20MG
TADALAFIL TAB 20 MG (PAH)
Tier 3
X
X
X
ADEMPAS TAB 0.5MG
RIOCIGUAT TAB 0.5 MG
Tier 2
X
X
X
ADEMPAS TAB 1.5MG
RIOCIGUAT TAB 1.5 MG
Tier 2
X
X
X
ADEMPAS TAB 1MG
RIOCIGUAT TAB 1 MG
Tier 2
X
X
X
ADEMPAS TAB 2.5MG
RIOCIGUAT TAB 2.5 MG
Tier 2
X
X
X
ADEMPAS TAB 2MG
RIOCIGUAT TAB 2 MG
Tier 2
X
X
X
LETAIRIS TAB 10MG
AMBRISENTAN TAB 10 MG
Tier 2
X
X
X
LETAIRIS TAB 5MG
AMBRISENTAN TAB 5 MG
Tier 2
X
X
X
OPSUMIT TAB 10MG
MACITENTAN TAB 10 MG
Tier 2
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
Tier 3
X
X
X
ORENITRAM TAB 0.125MG ORENITRAM TAB 0.25MG ORENITRAM TAB 1MG ORENITRAM TAB 2.5MG REVATIO SUS 10MG/ML
TREPROSTINIL DIOLAMINE TAB CR 0.125 MG (BASE EQUIV) TREPROSTINIL DIOLAMINE TAB CR 0.25 MG (BASE EQUIV) TREPROSTINIL DIOLAMINE TAB CR 1 MG (BASE EQUIV) TREPROSTINIL DIOLAMINE TAB CR 2.5 MG (BASE EQUIV) SILDENAFIL CITRATE FOR SUSPENSION 10 MG/ML
X
SILDENAFIL TAB 20MG
SILDENAFIL CITRATE TAB 20 MG
Tier 1
X
X
X
TRACLEER TAB 125MG
BOSENTAN TAB 125 MG
Tier 2
X
X
X
TRACLEER TAB 62.5MG
BOSENTAN TAB 62.5 MG
Tier 2
X
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
Tier 2
X
X
TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML TYVASO REFIL SOL 0.6MG/ TREPROSTINIL INHALATION SOLUTION ML 0.6 MG/ML TYVASO START SOL 0.6MG/ TREPROSTINIL INHALATION SOLUTION ML 0.6 MG/ML ILOPROST INHALATION SOLUTION 10 VENTAVIS SOL 10MCG/ML MCG/ML ILOPROST INHALATION SOLUTION 20 VENTAVIS SOL 20MCG/ML MCG/ML BESIFLOXACIN HCL OPHTH SUSP 0.6% BESIVANCE SUS 0.6% (BASE EQUIV) CIPROFLOXACIN HCL OTIC SOLN 0.2% CETRAXAL SOL 0.2% (BASE EQUIVALENT) CILOXAN OIN 0.3% OP CIPROFLOXACIN HCL OPHTH OINT 0.3% CILOXAN SOL 0.3% OP CIPROFLOXACIN HCL OPHTH SOLN 0.3% CIPROFLOXACIN HCL TAB 250 MG (BASE CIPRO TAB 250MG EQUIV) CIPROFLOXACIN HCL TAB 500 MG (BASE CIPRO TAB 500MG EQUIV) CIPROFLOXACIN FOR ORAL SUSP 500 CIPRO (10%) SUS 500MG/5 MG/5ML (10%) (10 GM/100ML)
TYVASO SOL 0.6MG/ML
159
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Therapeutic Class
Label Name
Quinolones - Antibiotics
CIPRO (5%) SUS 250MG/5
Quinolones - Antibiotics
CIPRO HC SUS OTIC
Quinolones - Antibiotics
CIPRO XR TAB 1000MG
Quinolones - Antibiotics
CIPRO XR TAB 500MG
Quinolones - Antibiotics
CIPRODEX SUS 0.3-0.1%
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
CIPROFLOXACN SOL 0.2% CIPROFLOXACN SOL 0.3% OP CIPROFLOXACN SUS 250MG/5 CIPROFLOXACN SUS 500MG/5 CIPROFLOXACN TAB 1000MG
Quinolones - Antibiotics
CIPROFLOXACN TAB 100MG
Quinolones - Antibiotics
CIPROFLOXACN TAB 250MG
Quinolones - Antibiotics
CIPROFLOXACN TAB 500MG
Quinolones - Antibiotics
CIPROFLOXACN TAB 500MG ER
Quinolones - Antibiotics
CIPROFLOXACN TAB 750MG
Quinolones - Antibiotics
FACTIVE TAB 320MG
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
GATIFLOXACIN SOL 0.5% LEVAQUIN TAB 250MG LEVAQUIN TAB 500MG LEVAQUIN TAB 750MG LEVOFLOXACIN SOL 0.5% LEVOFLOXACIN SOL 25MG/ ML LEVOFLOXACIN TAB 250MG LEVOFLOXACIN TAB 500MG LEVOFLOXACIN TAB 750MG
Quinolones - Antibiotics
MOXEZA SOL 0.5%
Quinolones - Antibiotics
Generic Name CIPROFLOXACIN FOR ORAL SUSP 250 MG/5ML (5%) (5 GM/100ML) CIPROFLOXACIN-HYDROCORTISONE OTIC SUSP 0.2-1% CIPROFLOXACIN-CIPROFLOXACIN HCL TAB SR 24HR 1000 MG(BASE EQ) CIPROFLOXACIN-CIPROFLOXACIN HCL TAB SR 24HR 500 MG (BASE EQ) CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1% CIPROFLOXACIN HCL OTIC SOLN 0.2% (BASE EQUIVALENT) CIPROFLOXACIN HCL OPHTH SOLN 0.3%
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
CIPROFLOXACIN FOR ORAL SUSP 250 MG/5ML (5%) (5 GM/100ML) CIPROFLOXACIN FOR ORAL SUSP 500 MG/5ML (10%) (10 GM/100ML) CIPROFLOXACIN-CIPROFLOXACIN HCL TAB SR 24HR 1000 MG(BASE EQ) CIPROFLOXACIN HCL TAB 100 MG (BASE EQUIV) CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) CIPROFLOXACIN-CIPROFLOXACIN HCL TAB SR 24HR 500 MG (BASE EQ) CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV) GEMIFLOXACIN MESYLATE TAB 320 MG (BASE EQUIV) GATIFLOXACIN OPHTH SOLN 0.5% LEVOFLOXACIN TAB 250 MG LEVOFLOXACIN TAB 500 MG LEVOFLOXACIN TAB 750 MG LEVOFLOXACIN OPHTH SOLN 0.5%
Tier 3 Tier 3 Tier 3 Tier 3 Tier 1
LEVOFLOXACIN ORAL SOLN 25 MG/ML
Tier 1 Tier 1 Tier 1 Tier 1
Tier 2 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3
Quinolones - Antibiotics
MOXIFLOXACIN TAB 400MG
Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics Quinolones - Antibiotics
OCUFLOX DRO 0.3% OP OFLOXACIN DRO 0.3% OP OFLOXACIN DRO 0.3%OTIC OFLOXACIN TAB 300MG OFLOXACIN TAB 400MG
Quinolones - Antibiotics
VIGAMOX DRO 0.5%
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 Respiratory Tract Agents, Other Asthma/Lung Drugs
ZYMAXID SOL 0.5%
LEVOFLOXACIN TAB 250 MG LEVOFLOXACIN TAB 500 MG LEVOFLOXACIN TAB 750 MG MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQ) (2 TIMES DAILY) MOXIFLOXACIN HCL TAB 400 MG (BASE EQUIV) OFLOXACIN OPHTH SOLN 0.3% OFLOXACIN OPHTH SOLN 0.3% OFLOXACIN OTIC SOLN 0.3% OFLOXACIN TAB 300 MG OFLOXACIN TAB 400 MG MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV) GATIFLOXACIN OPHTH SOLN 0.5%
ACETYLCYST SOL 10%
ACETYLCYSTEINE INHAL SOLN 10%
Tier 1
ACETYLCYST SOL 20%
ACETYLCYSTEINE INHAL SOLN 20%
Tier 1
BENZONATATE CAP 100MG
BENZONATATE CAP 100 MG
Tier 1
BENZONATATE CAP 200MG
BENZONATATE CAP 200 MG
Tier 1
PHENYLEPHRINE W/ DM-GG LIQD 10-15BIOTUSS LIQ 300 MG/5ML PHENYLEPHRINE W/ DM-GG LIQD 2.5-5BIOTUSS LIQ PEDIATRC 50 MG/ML GUAIFENESIN-CODEINE SOLN 100-10 CHERATUSSIN SYP 100-10/5 MG/5ML GUAIFENESIN-CODEINE SOLN 100-10 CODEINE/GG SOL 10-100/5 MG/5ML DALIRESP TAB 500MCG EXACTUSS LIQ G TUSSIN AC LIQ 100-10/5
ROFLUMILAST TAB 500 MCG PHENYLEPHRINE W/ DM-GG LIQD 10-28388 MG/5ML GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML
160
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 3 Tier 3 Tier 3 Tier 1 Tier 2 Tier 1 Tier 1 Tier 3 Tier 3
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 1
X
X
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 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 Selective Estrogen Receptor Modifying Agents - Hormone Replacement/ Modifying Drugs
Label Name GG/CODEINE SOL 100-10/5 GILPHEX TR TAB 10-388MG GILTUSS LIQ GILTUSS PED LIQ GILTUSS TR TAB GUAIATUSSIN SYP 100-10/5 GUAIFENESIN SYP 100-10/5 HYDROC/HOMAT TAB 5-1.5MG HYDROCOD/HOM SYP 5-1.5/5 HYDROMET SYP 5-1.5/5
Generic Name GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML PHENYLEPHRINE-GUAIFENESIN TAB 10388 MG PHENYLEPHRINE W/ DM-GG LIQD 10-28388 MG/5ML PHENYLEPHRINE W/ DM-GG LIQD 2.5-7.588 MG/ML PHENYLEPHRINE W/ DM-GG TAB 10-28388 MG GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
HYPERSAL NEB 3.5%
SODIUM CHLORIDE SOLN NEBU 3.5%
Tier 2
HYPERSAL NEB 7%
SODIUM CHLORIDE SOLN NEBU 7%
Tier 2
HYPER-SAL NEB 7%
SODIUM CHLORIDE SOLN NEBU 7%
Tier 2
IOPHEN C-NR LIQ 100-10/5
GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML
Tier 1
KALYDECO PAK 50MG
IVACAFTOR PACKET 50 MG
Tier 2
X
X
X
KALYDECO PAK 75MG
IVACAFTOR PACKET 75 MG
Tier 2
X
X
X
KALYDECO TAB 150MG
IVACAFTOR TAB 150 MG
Tier 2
X
X
X
NEBUSAL NEB 3%
SODIUM CHLORIDE SOLN NEBU 3%
Tier 1
NEBUSAL NEB 6%
SODIUM CHLORIDE SOLN NEBU 6%
Tier 3
X
X
X
X X
X X X
PE/GUAIFENES DRO 1.520MG
PHENYLEPHRINE W/ DM-GG LIQD 2.5-550 MG/ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-200 MG/5ML PHENYLEPHRINE-GUAIFENESIN LIQD 7.5100 MG/5ML (1.5-20 MG/ML)
PULMOSAL NEB 7%
SODIUM CHLORIDE SOLN NEBU 7%
Tier 1
PULMOZYME SOL 1MG/ML
DORNASE ALFA INHAL SOLN 1 MG/ML
Tier 2
Q-BID-LA TAB 600MG
GUAIFENESIN TAB SR 12HR 600 MG
Tier 1
REZIRA SOL 60-5/5ML
PSEUDOEPHEDRINE W/ HYDROCODONE SOLN 60-5 MG/5ML
Tier 3
SOD CHLORIDE NEB 0.9%
SODIUM CHLORIDE SOLN NEBU 0.9%
Tier 1
SODIUM CHLOR NEB 10%
SODIUM CHLORIDE SOLN NEBU 10%
Tier 1
SODIUM CHLOR NEB 3%
SODIUM CHLORIDE SOLN NEBU 3%
Tier 1
SODIUM CHLOR NEB 7%
SODIUM CHLORIDE SOLN NEBU 7%
Tier 1
NORTUSS-DE DRO NORTUSS-EX LIQ 200-20/5
TESSALON PER CAP 100MG BENZONATATE CAP 100 MG PSEUDOEPHEDRINE W/ DM-GG SYRUP 30-15-150 MG/5ML HYDROCODONE W/ HOMATROPINE TAB TUSSIGON TAB 5-1.5MG 5-1.5 MG TETRAHYDROZOLINE HCL NASAL SOLN TYZINE PED DRO 0.05% 0.05% GUAIFENESIN-CODEINE SOLN 100-10 VIRTUSSIN AC SOL 100-10/5 MG/5ML PANRETIN GEL 0.1% ALITRETINOIN GEL 0.1% TARGRETIN CAP 75MG BEXAROTENE CAP 75 MG TARGRETIN GEL 1% BEXAROTENE GEL 1% TRETINOIN CAP 10MG TRETINOIN CAP 10 MG
TGQ 30/ SYP 150/15
EVISTA TAB 60MG
RALOXIFENE HCL TAB 60 MG
161
Tier 1 Tier 1 Tier 1
Tier 3 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 2 Tier 3 Tier 2 HCR Preventive Care
Therapeutic Class Selective Estrogen Receptor Modifying Agents - Hormone Replacement/ Modifying Drugs Selective Estrogen Receptor Modifying Agents - Hormone Replacement/ Modifying 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 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
Label Name
Generic Name
OSPHENA TAB 60MG
OSPEMIFENE TAB 60 MG
RALOXIFENE TAB 60MG
RALOXIFENE HCL TAB 60 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Tier 3 HCR Preventive Care
ALMOTRIP MAL TAB 12.5MG ALMOTRIPTAN MALATE TAB 12.5 MG
Tier 3
X
ALMOTRIP MAL TAB 6.25MG ALMOTRIPTAN MALATE TAB 6.25 MG
Tier 3
X
ALMOTRIPTAN TAB 12.5MG
ALMOTRIPTAN MALATE TAB 12.5 MG
Tier 3
X
ALMOTRIPTAN TAB 6.25MG
ALMOTRIPTAN MALATE TAB 6.25 MG
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
AMERGE TAB 1MG AMERGE TAB 2.5MG FROVA TAB 2.5MG FROVATRIPTAN TAB 2.5MG
NARATRIPTAN HCL TAB 1 MG (BASE EQUIV) NARATRIPTAN HCL TAB 2.5 MG (BASE EQUIV) FROVATRIPTAN SUCCINATE TAB 2.5 MG (BASE EQUIVALENT) FROVATRIPTAN SUCCINATE TAB 2.5 MG (BASE EQUIVALENT)
IMITREX SPR 20MG/ACT
SUMATRIPTAN NASAL SPRAY 20 MG/ACT
Tier 3
X
IMITREX SPR 5MG/ACT
SUMATRIPTAN NASAL SPRAY 5 MG/ACT
Tier 3
X
Tier 1
X
Tier 1
X
Tier 2
X
Tier 2
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 2
X
Tier 2
X
NARATRIPTAN HCL TAB 1 MG (BASE NARATRIPTAN TAB 1MG EQUIV) NARATRIPTAN HCL TAB 2.5 MG (BASE NARATRIPTAN TAB 2.5MG EQUIV) ELETRIPTAN HYDROBROMIDE TAB 20 MG RELPAX TAB 20MG (BASE EQUIVALENT) ELETRIPTAN HYDROBROMIDE TAB 40 MG RELPAX TAB 40MG (BASE EQUIVALENT) RIZATRIPTAN BENZOATE TAB 10 MG RIZATRIPTAN TAB 10MG (BASE EQUIVALENT) RIZATRIPTAN TAB 10MG RIZATRIPTAN BENZOATE ORAL ODT DISINTEGRATING TAB 10 MG (BASE EQ) RIZATRIPTAN BENZOATE TAB 5 MG (BASE RIZATRIPTAN TAB 5MG EQUIVALENT) RIZATRIPTAN BENZOATE ORAL RIZATRIPTAN TAB 5MG ODT DISINTEGRATING TAB 5 MG (BASE EQ) SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 4MG/0.5 AUTO-INJECTOR 4 MG/0.5ML SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 4MG/0.5 CARTRIDGE 4 MG/0.5ML SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 6MG/0.5 AUTO-INJECTOR 6 MG/0.5ML SUMATRIPTAN SUCCINATE INJ 6 SUMATRIPTAN INJ 6MG/0.5 MG/0.5ML SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 6MG/0.5 CARTRIDGE 6 MG/0.5ML SUMATRIPTAN SUCCINATE SOLUTION SUMATRIPTAN INJ 6MG/0.5 PREFILLED SYRINGE 6 MG/0.5ML SUMATRIPTAN SPR 20MG/ SUMATRIPTAN NASAL SPRAY 20 MG/ACT ACT SUMATRIPTAN SPR 5MG/ SUMATRIPTAN NASAL SPRAY 5 MG/ACT ACT SUMATRIPTAN TAB 100MG
SUMATRIPTAN SUCCINATE TAB 100 MG
Tier 1
X
SUMATRIPTAN TAB 25MG
SUMATRIPTAN SUCCINATE TAB 25 MG
Tier 1
X
SUMATRIPTAN TAB 50MG
SUMATRIPTAN SUCCINATE TAB 50 MG
Tier 1
X
ZOLMITRIPTAN TAB 2.5 MG
ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 2.5 MG
Tier 3
X
ZOLMITRIPTAN TAB 2.5MG
ZOLMITRIPTAN TAB 2.5 MG
Tier 3
X
ZOLMITRIPTAN TAB 5MG
ZOLMITRIPTAN TAB 5 MG
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
ZOLMITRIPTAN TAB 5MG ZOMIG SPR 2.5MG ZOMIG SPR 5MG ZOMIG TAB 2.5MG
ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 5 MG ZOLMITRIPTAN NASAL SPRAY 2.5 MG/ SPRAY UNIT ZOLMITRIPTAN NASAL SPRAY 5 MG/ SPRAY UNIT ZOLMITRIPTAN TAB 2.5 MG
162
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/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 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
Label Name
Generic Name
ZOMIG TAB 5MG
ZOLMITRIPTAN TAB 5 MG
ZOMIG ZMT TAB 2.5 MG ZOMIG ZMT TAB 5MG CITALOPRAM SOL 10MG/5ML CITALOPRAM TAB 10MG CITALOPRAM TAB 20MG CITALOPRAM TAB 40MG DESVENLAFAX TAB 100MG ER DESVENLAFAX TAB 25MG ER DESVENLAFAX TAB 50MG ER DESVENLAFAXI TAB 100MG DULOXETINE CAP 20MG DULOXETINE CAP 30MG DULOXETINE CAP 60MG ESCITALOPRAM SOL 5MG/5ML ESCITALOPRAM TAB 10MG ESCITALOPRAM TAB 20MG ESCITALOPRAM TAB 5MG FETZIMA CAP 120MG FETZIMA CAP 20MG FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP TITRATIO
ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 2.5 MG ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 5 MG CITALOPRAM HYDROBROMIDE ORAL SOLN 10 MG/5ML CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE TAB 20 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV) DESVENLAFAXINE SUCCINATE TAB SR 24HR 100 MG (BASE EQUIV) DESVENLAFAXINE SUCCINATE TAB SR 24HR 25 MG (BASE EQUIV) DESVENLAFAXINE SUCCINATE TAB SR 24HR 50 MG (BASE EQUIV) DESVENLAFAXINE SUCCINATE TAB SR 24HR 100 MG (BASE EQUIV) DULOXETINE HCL ENTERIC COATED PELLETS CAP 20 MG DULOXETINE HCL ENTERIC COATED PELLETS CAP 30 MG DULOXETINE HCL ENTERIC COATED PELLETS CAP 60 MG ESCITALOPRAM OXALATE SOLN 5 MG/5ML (BASE EQUIV) ESCITALOPRAM OXALATE TAB 10 MG (BASE EQUIV) ESCITALOPRAM OXALATE TAB 20 MG (BASE EQUIV) ESCITALOPRAM OXALATE TAB 5 MG (BASE EQUIV) LEVOMILNACIPRAN HCL CAP SR 24HR 120 MG (BASE EQUIVALENT) LEVOMILNACIPRAN HCL CAP SR 24HR 20 MG (BASE EQUIVALENT) LEVOMILNACIPRAN HCL CAP SR 24HR 40 MG (BASE EQUIVALENT) LEVOMILNACIPRAN HCL CAP SR 24HR 80 MG (BASE EQUIVALENT) LEVOMILNACIPRAN HCL CAP SR 24HR 20 & 40 MG THERAPY PACK
Tier Value Tier 3
X
Tier 3
X
Tier 3
X
Tier 1 Tier 1 Tier 1 Tier 1 Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3 Tier 1 Tier 1 Tier 1 Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
Tier 3
X
X
FLUOXETINE CAP 10MG
FLUOXETINE HCL (PMDD) CAP 10 MG
Tier 1
FLUOXETINE CAP 10MG
FLUOXETINE HCL CAP 10 MG
Tier 1
FLUOXETINE CAP 20MG
FLUOXETINE HCL (PMDD) CAP 20 MG
Tier 1
FLUOXETINE CAP 20MG
FLUOXETINE HCL CAP 20 MG
Tier 1
FLUOXETINE CAP 40MG
FLUOXETINE HCL CAP 40 MG
Tier 1
FLUOXETINE CAP 90MG DR
FLUOXETINE HCL CAP DELAYED RELEASE 90 MG
Tier 1
FLUOXETINE SOL 20MG/5ML
FLUOXETINE HCL SOLUTION 20 MG/5ML
Tier 1
FLUOXETINE TAB 10MG
FLUOXETINE HCL TAB 10 MG
Tier 1
FLUOXETINE TAB 10MG
FLUOXETINE HCL (PMDD) TAB 10 MG
Tier 3
FLUOXETINE TAB 20MG
FLUOXETINE HCL TAB 20 MG
Tier 1
FLUOXETINE TAB 20MG
FLUOXETINE HCL (PMDD) TAB 20 MG
Tier 3
FLUOXETINE TAB 60MG
FLUOXETINE HCL TAB 60 MG
Tier 2
FLUVOXAMINE CAP 100MG ER FLUVOXAMINE CAP 150MG ER
FLUVOXAMINE MALEATE CAP SR 24HR 100 MG FLUVOXAMINE MALEATE CAP SR 24HR 150 MG
FLUVOXAMINE TAB 100MG
FLUVOXAMINE MALEATE TAB 100 MG
Tier 1
FLUVOXAMINE TAB 25MG
FLUVOXAMINE MALEATE TAB 25 MG
Tier 1
163
Prior Supply Step Specialty Authorization Limit Therapy
X
Tier 3
X
Tier 3
X
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 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
Generic Name
FLUVOXAMINE TAB 50MG
FLUVOXAMINE MALEATE TAB 50 MG
Tier 1
LEXAPRO SOL 5MG/5ML
ESCITALOPRAM OXALATE SOLN 5 MG/5ML (BASE EQUIV)
Tier 3
PAROXETIN ER TAB 12.5MG
PAROXETINE HCL TAB SR 24HR 12.5 MG
Tier 3
X
PAROXETIN ER TAB 37.5MG
PAROXETINE HCL TAB SR 24HR 37.5 MG
Tier 3
X
PAROXETINE TAB 10MG
PAROXETINE HCL TAB 10 MG
Tier 1
PAROXETINE TAB 20MG
PAROXETINE HCL TAB 20 MG
Tier 1
PAROXETINE TAB 25MG ER
PAROXETINE HCL TAB SR 24HR 25 MG
Tier 3
PAROXETINE TAB 30MG
PAROXETINE HCL TAB 30 MG
Tier 1
PAROXETINE TAB 40MG
PAROXETINE HCL TAB 40 MG
Tier 1
PAXIL SUS 10MG/5ML
PAROXETINE HCL ORAL SUSP 10 MG/5ML (BASE EQUIV)
Tier 3
PAXIL TAB 10MG
PAROXETINE HCL TAB 10 MG
Tier 3
PAXIL TAB 20MG
PAROXETINE HCL TAB 20 MG
Tier 3
PAXIL TAB 30MG
PAROXETINE HCL TAB 30 MG
Tier 3
PAXIL TAB 40MG
PAROXETINE HCL TAB 40 MG
Tier 3
PAXIL CR TAB 12.5MG
PAROXETINE HCL TAB SR 24HR 12.5 MG
Tier 3
X
PAXIL CR TAB 25MG
PAROXETINE HCL TAB SR 24HR 25 MG
Tier 3
X
PAROXETINE HCL TAB SR 24HR 37.5 MG
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
Tier 3
X
PAXIL CR TAB 37.5MG PRISTIQ TAB 100MG PRISTIQ TAB 25MG PRISTIQ TAB 50MG PROZAC WEEKL CAP 90MG
DESVENLAFAXINE SUCCINATE TAB SR 24HR 100 MG (BASE EQUIV) DESVENLAFAXINE SUCCINATE TAB SR 24HR 25 MG (BASE EQUIV) DESVENLAFAXINE SUCCINATE TAB SR 24HR 50 MG (BASE EQUIV) FLUOXETINE HCL CAP DELAYED RELEASE 90 MG
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
SARAFEM TAB 10MG
FLUOXETINE HCL (PMDD) TAB 10 MG
Tier 3
SARAFEM TAB 20MG
FLUOXETINE HCL (PMDD) TAB 20 MG
Tier 3
SERTRALINE CON 20MG/ML SERTRALINE HCL ORAL CONC 20 MG/ML
Tier 1
SERTRALINE TAB 100MG
SERTRALINE HCL TAB 100 MG
Tier 1
SERTRALINE TAB 25MG
SERTRALINE HCL TAB 25 MG
Tier 1
SERTRALINE TAB 50MG
SERTRALINE HCL TAB 50 MG
Tier 1
VENLAFAXINE CAP 150MG ER
VENLAFAXINE HCL CAP SR 24HR 150 MG (BASE EQUIVALENT) VENLAFAXINE HCL CAP SR 24HR 37.5 MG VENLAFAXINE CAP 37.5 ER (BASE EQUIVALENT) VENLAFAXINE HCL CAP SR 24HR 75 MG VENLAFAXINE CAP 75MG ER (BASE EQUIVALENT)
X
Tier 1 Tier 1 Tier 1
VENLAFAXINE TAB 100MG
VENLAFAXINE HCL TAB 100 MG
Tier 1
VENLAFAXINE TAB 25MG
VENLAFAXINE HCL TAB 25 MG
Tier 1
VENLAFAXINE TAB 37.5MG
VENLAFAXINE HCL TAB 37.5 MG
Tier 1
VENLAFAXINE TAB 50MG
VENLAFAXINE HCL TAB 50 MG
Tier 1
VENLAFAXINE TAB 75MG
VENLAFAXINE HCL TAB 75 MG
Tier 1
VIIBRYD KIT STARTER
VILAZODONE HCL TAB STARTER KIT 10 (7) & 20 (23) MG
Tier 3
VIIBRYD TAB 10MG
VILAZODONE HCL TAB 10 MG
Tier 3
X
VIIBRYD TAB 20MG
VILAZODONE HCL TAB 20 MG
Tier 3
X
VIIBRYD TAB 40MG
VILAZODONE HCL TAB 40 MG
Tier 3
X
164
Therapeutic Class
Label Name
Generic Name
Tier Value
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 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTIINFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTIINFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTIINFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTIINFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTIINFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTIINFECTIVES SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTIINFECTIVES 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)
CARISOPR/ASA TAB 200325 CARISOPRODOL TAB 350MG CHLORZOXAZON TAB 500MG
CARISOPRODOL W/ ASPIRIN TAB 200-325 MG
Tier 1
CARISOPRODOL TAB 350 MG
Tier 1
CHLORZOXAZONE TAB 500 MG
Tier 1
CYCLOBENZAPR TAB 10MG CYCLOBENZAPRINE HCL TAB 10 MG
Tier 1
CYCLOBENZAPR TAB 5MG
Tier 1
CYCLOBENZAPRINE HCL TAB 5 MG
CYCLOBENZAPR TAB 7.5MG CYCLOBENZAPRINE HCL TAB 7.5 MG
Tier 1
FEXMID TAB 7.5MG
CYCLOBENZAPRINE HCL TAB 7.5 MG
Tier 3
METAXALL TAB 800MG
METAXALONE TAB 800 MG
Tier 3
METAXALONE TAB 400MG
METAXALONE TAB 400 MG
Tier 3
METAXALONE TAB 800MG
METAXALONE TAB 800 MG
Tier 3
METHOCARBAMOL TAB 500 MG
Tier 1
METHOCARBAMOL TAB 750 MG
Tier 1
ORPHENADRINE CITRATE TAB SR 12HR 100 MG
Tier 2
METHOCARBAM TAB 500MG METHOCARBAM TAB 750MG ORPHENADRINE TAB 100MG ER
PARAFON FORT TAB 500MG CHLORZOXAZONE TAB 500 MG
Tier 3
ROBAXIN TAB 500MG
METHOCARBAMOL TAB 500 MG
Tier 3
ROBAXIN-750 TAB 750MG
METHOCARBAMOL TAB 750 MG
Tier 3
SOMA TAB 350MG
CARISOPRODOL TAB 350 MG
Tier 3
PETROLATUM GEL WHITE
WHITE PETROLATUM GEL
Tier 1
PETROLATUM OIN WHITE
WHITE PETROLATUM OINTMENT
Tier 3
VERSABASE GEL
VERSABASE GEL
Tier 3
EXODERM LOT 25-1%
SODIUM THIOSULFATE-SALICYLIC ACID LOTION 25-1%
Tier 1
HALOTIN CRE 1%
HALOPROGIN CREAM 1%
Tier 3
KERR TRIPLE MIS DYE SWAB TRIPLE DYE SWABS
Tier 2
MICONAZOLE POW NITRATE MICONAZOLE NITRATE POWDER
Tier 3
XOLEGEL KIT COREPAK
KETOCONAZOLE GEL 2% & HYDROCORTISONE GEL 1% KIT
Tier 3
XOLEGEL DUO/ KIT HEAD&SHD
KETOCONAZOLE GEL 2% & PYRITHIONE ZINC SHAMPOO 1% KIT
Tier 3
XOLEGEL DUO/ KIT XOLEX
KETOCONAZOLE GEL 2% & PYRITHIONE ZINC SHAMPOO 1% KIT
Tier 3
ANALPRAM E KIT
*HC-PRAMOXINE EMOL CREAM 2.5-1% & PRAMOXINE WIPE 1% KIT***
Tier 3
ANALPRAM HC CRE 2.5-1%
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 2.5-1%
Tier 3
ANALPRAM-HC CRE 1-1%
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 1-1%
Tier 3
ANALPRAM-HC LOT 2.5%
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL LOTN 2.5-1%
Tier 3
ANALPRM SNGL CRE HC 2.5-1
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 2.5-1%
Tier 3
ANUCORT-HC SUP 25MG
HYDROCORTISONE ACETATE SUPPOS 25 MG
Tier 1
165
Prior Supply Step Specialty Authorization Limit Therapy
X
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) 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
Label Name
Generic Name
CORTANE-B LOT
HYDROCORTISONE-PRAMOXINECHLOROXYLENOL LOT 10-10-1MG/ML
Tier 3
EPIFOAM AER 1%
PRAMOXINE-HC AEROSOL FOAM 1-1%
Tier 2
HALAC KIT
HALOBETASOL PROP OINT 0.05% & AMMONIUM LACTATE LOT 12% KIT
Tier 1
HC PRAMOXINE CRE 1-1%
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 1-1%
Tier 1
HC PRAMOXINE CRE 2.5-1%
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 2.5-1%
Tier 1
HC PRAMOXINE CRE 2.5-1%
PRAMOXINE-HC CREAM 1-2.5%
Tier 1
HEMMOREX-HC SUP 25MG
HYDROCORTISONE ACETATE SUPPOS 25 MG
Tier 1
HEMMOREX-HC SUP 30MG
HYDROCORTISONE ACETATE SUPPOS 30 MG
Tier 1
HEMORRHOIDAL SUP -HC 25MG
HYDROCORTISONE ACETATE SUPPOS 25 MG
Tier 1
HYDROCORT AC SUP 25MG
HYDROCORTISONE ACETATE SUPPOS 25 MG
Tier 1
HYDROCORT AC SUP 30MG
HYDROCORTISONE ACETATE SUPPOS 30 MG
Tier 1
HYDROCORT/ KIT PRAMOXIN
*HC-PRAMOXINE EMOL CREAM 2.5-1% & PRAMOXINE WIPE 1% KIT***
Tier 1
NUCORT LOT 2%
HYDROCORTISONE ACETATE LOTION 2%
Tier 3
PEDIADERM HC KIT
*HYDROCORTISONE LOT 2% & EMOLLIENT CREAM KIT**
Tier 3
PRAMCORT CRE 1-1%
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 1-1%
Tier 1
PRAMOSONE CRE 1-1%
PRAMOXINE-HC CREAM 1-1%
Tier 1
PRAMOSONE CRE 1-2.5%
PRAMOXINE-HC CREAM 1-2.5%
Tier 3
PRAMOSONE LOT 1%
PRAMOXINE-HC LOTION 1-1%
Tier 2
PRAMOSONE LOT 2.5%
PRAMOXINE-HC LOTION 1-2.5%
Tier 2
PRAMOSONE OIN 1%
PRAMOXINE-HC OINT 1-1%
Tier 2
PRAMOSONE OIN 2.5%
PRAMOXINE-HC OINT 1-2.5%
Tier 3
PRAMOX GEL 1%
PRAMOXINE HCL GEL 1%
Tier 1
PROCTOFOAM AER HC 1%
HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL FOAM 1-1%
Tier 2
SCALACORT DK KIT
*HC LOT 2% & SAL ACID-SULFUR SHAMPOO 2-2% & SHAMPOO KIT***
Tier 3
VANOXIDE-HC LOT 5-0.5%
BENZOYL PEROXIDE-HC LOTION 5-0.5%
Tier 3
QUTENZA KIT 8% 1-PCH
CAPSAICIN PATCH 8% & CLEANSING GEL KIT
Tier 3
166
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
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 - 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 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS
Label Name
Generic Name
QUTENZA KIT 8% 2-PCH
CAPSAICIN PATCH 8% & CLEANSING GEL KIT
Tier 3
VENELEX OIN
*BALSAM PERU-CASTOR OIL OINT***
Tier 3
XERAC-AC SOL 6.25%
ALUMINUM CHLORIDE IN ALCOHOL SOLUTION 6.25%
Tier 2
HYALURONATE GEL 0.2%
HYALURONATE SODIUM (EMOLLIENT) GEL 0.2%
Tier 1
HYLIRA GEL 0.2%
HYALURONATE SODIUM (EMOLLIENT) GEL 0.2%
Tier 2
HYLIRA LOT 0.1%
HYALURONATE SODIUM (EMOLLIENT) LOTION 0.1%
Tier 3
ALUVEA CRE 39%
UREA CREAM 39%
Tier 3
BENSAL HP OIN
SALICYLIC ACID & BENZOIC ACID OINT 3-6%
Tier 2
CEM-UREA SOL 45%
UREA SOLN 45%
Tier 3
CEROVEL GEL 40%
UREA GEL 40%
Tier 1
CEROVEL LOT 40%
UREA LOTION 40%
Tier 1
GORDOFILM SOL
SALICYLIC & LACTIC ACIDS SOLN 16.716.7%
Tier 2
GORDONS UREA OIN 40%
UREA OINTMENT 40%
Tier 3
HYDRO 35 AER
UREA IN LACTIC ACID VEHICLE FOAM 35%
Tier 3
HYDRO 40 AER FOAM
UREA FOAM 40%
Tier 3
KERALYT GEL 6%
SALICYLIC ACID GEL 6%
Tier 3
LATRIX SUS 50% LATRIX XM EMU 45%
UREA IN LACTIC ACID-SALICYLIC ACID VEHICLE SUSP 50% UREA IN ZINC UNDECYLENATE-LACTIC ACID VEHICLE EMULSION 45%
Tier Value
Tier 2 Tier 2
NA HYDROXIDE SOL 10%
SODIUM HYDROXIDE SOLUTION 10%
Tier 1
POT HYDROXID SOL 5%
POTASSIUM HYDROXIDE SOLUTION 5%
Tier 2
REA LO 39 CRE 39%
UREA CREAM 39%
Tier 1
REA LO 40 CRE 40%
UREA CREAM 40%
Tier 1
REA LO 40 LOT 40%
UREA LOTION 40%
Tier 1
REMEVEN CRE 50%
UREA CREAM 50%
Tier 2
SALACYN CRE 6%
SALICYLIC ACID CREAM 6%
Tier 1
SALACYN LOT 6%
SALICYLIC ACID LOTION 6%
Tier 1
SALICYLIC AER 6%
SALICYLIC ACID FOAM 6%
Tier 1
SALICYLIC AC CRE 6%
SALICYLIC ACID CREAM 6%
Tier 1
SALICYLIC AC GEL 6%
SALICYLIC ACID GEL 6%
Tier 1
SALICYLIC AC LIQ 26%
SALICYLIC ACID SOLN 26%
Tier 1
SALICYLIC AC LOT 6%
SALICYLIC ACID LOTION 6%
Tier 1
SALVAX AER 6%
SALICYLIC ACID FOAM 6%
Tier 3
URAMAXIN AER 20%
*UREA IN AMMONIUM LACTATE VEHICLE FOAM 20%***
Tier 3
URAMAXIN CRE 45%
UREA CREAM 45%
Tier 3
URAMAXIN LOT 45%
UREA LOTION 45%
Tier 3
UREA CRE 39%
UREA CREAM 39%
Tier 1
UREA CRE 40%
UREA CREAM 40%
Tier 1
167
Prior Supply Step Specialty Authorization Limit Therapy 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 - 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
Label Name
Generic Name
UREA CRE 45%
UREA CREAM 45%
Tier 1
UREA CRE 50%
UREA CREAM 50%
Tier 1
UREA EMU 50%
UREA IN ZINC UNDECYLENATE-LACTIC ACID VEHICLE EMULSION 50%
Tier 1
UREA GEL 40%
UREA GEL 40%
Tier 1
UREA LOT 40%
UREA LOTION 40%
Tier 1
UREA LOT 45%
UREA LOTION 45%
Tier 1
UREA SUS 50%
UREA IN LACTIC ACID-SALICYLIC ACID VEHICLE SUSP 50%
Tier 1
UREA 40% SUS NAIL
UREA SUSPENSION 40%
Tier 1
UREA HYDRATI AER 35%
UREA IN LACTIC ACID VEHICLE FOAM 35%
Tier 1
UREA NAIL GEL 45%
UREA GEL 45%
Tier 1
UREA NAIL KIT UREA NAIL MIS 50%
UREA SUSP 40% & HYALURONATE SODIUM GEL 0.2% KIT UREA IN ZINC UNDECYLENATE-LACTIC ACID VEHICLE STICK 50%
Tier Value
Tier 1 Tier 1
UREA TOPICAL SUS 40%
UREA SUSPENSION 40%
Tier 1
UREA-C40 LOT 40%
UREA LOTION 40%
Tier 1
UREA CREAM 50%
Tier 1
URE-K CRE 50% AVAR CLEANSE EMU 10-5% AVAR-E EMOLL CRE 10-5% AVAR-E GREEN CRE 10-5% AVAR-E LS CRE 10-2%
SULFACETAMIDE SODIUM W/ SULFUR EMULSION 10-5% SULFACETAMIDE SODIUM W/ SULFUR CREAM 10-5% SULFACETAMIDE SODIUM W/ SULFUR CREAM 10-5% SULFACETAMIDE SODIUM W/ SULFUR CREAM 10-2%
Tier 1 Tier 3 Tier 3 Tier 3
BENZIQ GEL 5.25%
BENZOYL PEROXIDE GEL 5.25 %
Tier 3
BENZIQ LS GEL 2.75%
BENZOYL PEROXIDE GEL 2.75%
Tier 3
BENZIQ WASH LIQ 5.25%
BENZOYL PEROXIDE LIQ 5.25%
Tier 3
BP 10-1 EMU BP CLEANSING EMU 10-4% CERISA WASH EMU 10-1% COAL TAR SOL 20%
SULFACETAMIDE SODIUM W/ SULFUR EMULSION 10-1% SULFACETAMIDE SODIUM-SULFUR IN UREA EMULSION 10-4% SULFACETAMIDE SODIUM W/ SULFUR EMULSION 10-1% COAL TAR SOLN 20%
DRITHO-CREME CRE HP 1% ANTHRALIN CREAM 1% INOVA KIT 4% INOVA KIT 8% INOVA 4/1 KIT ACNE CON INOVA 8/2 KIT ACNE CON OSCION CLNSR LOT 6% ROSANIL EMU CLEANSER SOD SUL/SULF CRE 10-2% SOD SUL/SULF CRE 10-5% SOD SUL/SULF EMU 10-5% SOD SUL/SULF EMU 10-5% SOD SUL/SULF GEL 10-5% SOD SUL/SULF LIQ 9-4.5%
*BENZOYL PEROXIDE PAD 4% & VITAMIN E TOPICAL 5% KIT*** *BENZOYL PEROXIDE PAD 8% & VITAMIN E TOPICAL 5% KIT*** *BENZOYL PEROX PAD 4% & SALICYLIC AC PAD 1% & VIT E 5% KIT* *BENZOYL PEROX PAD 8% & SALICYLIC AC PAD 2% & VIT E 5% KIT* BENZOYL PEROXIDE LOTION 6% SULFACETAMIDE SODIUM W/ SULFUR EMULSION 10-5% SULFACETAMIDE SODIUM W/ SULFUR CREAM 10-2% SULFACETAMIDE SODIUM W/ SULFUR CREAM 10-5% SULFACETAMIDE SODIUM-SULFUR IN UREA EMULSION 10-5% SULFACETAMIDE SODIUM W/ SULFUR EMULSION 10-5% SULFACETAMIDE SODIUM-SULFUR IN UREA GEL 10-5% SULFACETAMIDE SODIUM W/ SULFUR WASH 9-4.5%
168
Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
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 - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS)
Label Name SOD SUL/SULF LIQ WASH SOD SUL/SULF LOT 10-5% SOD SUL/SULF PAD 10-4% SOD SUL/SULF SUS 10-5% SOD SUL/SULF SUS 8-4% SSS CRE 10%-5% SSS 10-5 AER 10-5% SUL SOD/SULF PAD 10-4% SULFACLEANSE SUS 8-4% SUMAXIN PAD 10-4% SUMAXIN WASH LIQ 9-4% ZACARE KIT KIT 4% ZACARE KIT KIT 8%
Generic Name SULFACETAMIDE SODIUM W/ SULFUR WASH 9-4% SULFACETAMIDE SODIUM W/ SULFUR LOTION 10-5% SULFACETAMIDE SODIUM W/ SULFUR CLEANSING PAD 10-4% SULFACETAMIDE SODIUM W/ SULFUR SUSP 10-5% SULFACETAMIDE SODIUM W/ SULFUR SUSP 8-4% SULFACETAMIDE SODIUM W/ SULFUR CREAM 10-5% SULFACETAMIDE SODIUM W/ SULFUR FOAM 10-5% SULFACETAMIDE SODIUM W/ SULFUR CLEANSING PAD 10-4% SULFACETAMIDE SODIUM W/ SULFUR SUSP 8-4% SULFACETAMIDE SODIUM W/ SULFUR CLEANSING PAD 10-4% SULFACETAMIDE SODIUM W/ SULFUR WASH 9-4% BENZOYL PEROXIDE LOTION 4% & HYALURONATE SODIUM GEL 0.2% KIT BENZOYL PEROXIDE LOTION 8% & HYALURONATE SODIUM GEL 0.2% KIT
Tier Value Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3
ZACLIR LOT 8%
BENZOYL PEROXIDE LOTION 8%
Tier 1
ZENCIA LIQ 9-4%
SULFACETAMIDE SODIUM W/ SULFUR WASH 9-4%
Tier 1
ZITHRANOL SHA 1%
ANTHRALIN SHAMPOO 1%
Tier 3
ZITHRANOL-RR CRE 1.2%
ANTHRALIN CREAM 1.2%
Tier 3
ARZOL SILVER MIS NITR APP
SILVER NITRATE-POTASSIUM NITRATE APPLICATOR 75-25%
Tier 3
DERMAZENE CRE 1%
IODOQUINOL-HC CREAM 1%
Tier 1
HYDROCORT/ CRE IODOQUIN
IODOQUINOL-HC CREAM 1%
Tier 1
LOUTREX CRE
*ANTISEBORRHEIC PRODUCTS MISC CREAM***
Tier 3
OVACE PLUS CRE 10%
SULFACETAMIDE SODIUM CREAM 10%
Tier 3
OVACE PLUS GEL 10% WASH
SULFACETAMIDE SODIUM CLEANSING GEL 10%
Tier 3
OVACE PLUS LIQ 10% WASH SULFACETAMIDE SODIUM LIQUID 10%
Tier 3
OVACE PLUS SHA 10%
SULFACETAMIDE SODIUM SHAMPOO 10%
Tier 3
OVACE WASH LIQ 10%
SULFACETAMIDE SODIUM LIQUID 10%
Tier 3
PROMISEB CRE
*ANTISEBORRHEIC PRODUCTS MISC CREAM***
Tier 3
SEB-PREV LIQ WASH
SULFACETAMIDE SODIUM LIQUID 10%
Tier 1
SELENIUM SUL SHA 2.25%
SELENIUM SULFIDE-PYRITHIONE ZINC IN UREA SHAMPOO 2.25%
Tier 3
SILVER NITRA OIN 10%
SILVER NITRATE OINT 10%
Tier 1
SILVER NITRA SOL 0.5%
SILVER NITRATE SOLN 0.5%
Tier 1
SILVER NITRA SOL 10%
SILVER NITRATE SOLN 10%
Tier 1
169
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, 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 - SCABICIDES
Label Name
Generic Name
SILVER NITRA SOL 25%
SILVER NITRATE SOLN 25%
Tier 1
SILVER NITRA SOL 50%
SILVER NITRATE SOLN 50%
Tier 1
SOD SULFACET GEL 10%
SULFACETAMIDE SODIUM CLEANSING GEL 10%
Tier 1
SOD SULFACET SHA 10%
SULFACETAMIDE SODIUM SHAMPOO 10%
Tier 1
SODIUM SULFA LIQ 10% WASH
SULFACETAMIDE SODIUM LIQUID 10%
Tier 1
SODIUM SULFA LIQ 10% WASH
SULFACETAMIDE SODIUM IN BAKUCHIOL VEHICLE WASH 10%
Tier 1
ANASEPT SPR
SODIUM HYPOCHLORITE LIQUID 0.057%
Tier 3
BENZALKONIUM SOL 50%
BENZALKONIUM CHLORIDE SOLN 50%
Tier 1
BENZALKONIUM SOL NF
BENZALKONIUM CHLORIDE SOLN
Tier 2
BORIC ACID GRA
BORIC ACID GRANULES
Tier 3
BUCALSEP SOL
*ANTISEPTIC PRODUCTS MISC SOLUTION**
Tier 3
BUCALSEP SPR
*ANTISEPTIC PRODUCTS MISC - LIQUID**
Tier 3
BENZOIN TIN NF
BENZOIN TINCTURE
Tier 3
BENZOIN CMPD TIN
BENZOIN COMPOUND TINCTURE
Tier 1
DEBACTEROL SOL 30-50%
SULFURIC ACID-SULFONATED PHENOLICS SOLN 30-50%
Tier 2
DRYSOL SOL 20%
ALUMINUM CHLORIDE SOLN 20%
Tier 3
EPISONE CRE
*DERMATOLOGICAL PRODUCTS MISC CREAM**
Tier 1
ESSENTRA MIS 9X9"
ISOPROPYL ALCOHOL WIPES 70%
Tier 3
FORMADON SOL
FORMALDEHYDE SOLUTION 10%
Tier 3
FORMALDEHYDE SOL 10%
FORMALDEHYDE SOLUTION 10%
Tier 1
FORMALDEHYDE SOL 37%
FORMALDEHYDE SOLUTION 37%
Tier 3
FORMA-RAY SOL 20%
FORMALDEHYDE SOLUTION 20%
Tier 2
GRANULEX AER MEDI-DERM CRE -RX MEDROX-RX OIN METHYL SALIC LIQ NUVAIL SOL 16% PYROGALL ACD OIN SALVAX DUO KIT PLUS TBC AER
TRYPSIN W/ CASTOR OIL & PERUVIAN BALSAM SPRAY CAPSAICIN-MENTHOL-METHYL SALICYLATE CREAM 0.035-5-20% CAPSAICIN-MENTHOL-METHYL SALICYLATE OINT 0.05-7-20% *METHYL SALICYLATE LIQUID** *DERMATOLOGICAL PRODUCTS MISC SOLUTION** PYROGALLOL-CHLOROBUTANOL OINT 25-2% SALICYLIC ACID FOAM 6% & UREA IN LACTIC ACID FOAM 35% KIT TRYPSIN W/ CASTOR OIL & PERUVIAN BALSAM SPRAY
Tier Value
Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 2 Tier 3 Tier 1
TRI-CHLOR LIQ 80%
TRICHLOROACETIC ACID LIQD 80%
Tier 2
TURPENTINE SOL SPIRITS
TURPENTINE SPIRIT
Tier 3
SULF LIME SOL
SULFURATED LIME SOLUTION
Tier 3
170
Prior Supply Step Specialty Authorization Limit Therapy
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 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
Generic Name
ARMODAFINIL TAB 150MG
ARMODAFINIL TAB 150 MG
Tier 3
X
X
ARMODAFINIL TAB 200MG
ARMODAFINIL TAB 200 MG
Tier 3
X
X
ARMODAFINIL TAB 250MG
ARMODAFINIL TAB 250 MG
Tier 3
X
X
ARMODAFINIL TAB 50MG
ARMODAFINIL TAB 50 MG
Tier 3
X
X
BUTISOL SOD TAB 30MG
BUTABARBITAL SODIUM TAB 30 MG
Tier 3
MODAFINIL TAB 100MG
MODAFINIL TAB 100 MG
Tier 3
X
X
MODAFINIL TAB 200MG
MODAFINIL TAB 200 MG
Tier 3
X
X
ROZEREM TAB 8MG
RAMELTEON TAB 8 MG
Tier 3
SECONAL CAP 100MG
SECOBARBITAL SODIUM CAP 100 MG
Tier 3
SECONAL SOD CAP 100MG
SECOBARBITAL SODIUM CAP 100 MG
Tier 3
XYREM SOL 500MG/ML
SODIUM OXYBATE ORAL SOLUTION 500 MG/ML
Tier 4
Smoking Cessation Agents - Deterrents
BUPROBAN TAB 150MG
BUPROPION HCL (SMOKING DETERRENT) TAB SR 12HR 150 MG
Smoking Cessation Agents - Deterrents
BUPROPION TAB 150MG
BUPROPION HCL (SMOKING DETERRENT) TAB SR 12HR 150 MG
Smoking Cessation Agents - Deterrents
CHANTIX PAK 0.5& 1MG
VARENICLINE TARTRATE TAB 0.5 MG X 11 & TAB 1 MG X 42 PACK
Smoking Cessation Agents - Deterrents
CHANTIX PAK 1MG
VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)
Smoking Cessation Agents - Deterrents
CHANTIX TAB 0.5MG
VARENICLINE TARTRATE TAB 0.5 MG (BASE EQUIV)
Smoking Cessation Agents - Deterrents
CHANTIX TAB 1MG
VARENICLINE TARTRATE TAB 1 MG (BASE EQUIV)
Smoking Cessation Agents - Deterrents
CVS NICOTINE DIS 14MG/24H
NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
CVS NICOTINE DIS 7MG/24HR
NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MG CINN
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MG ORIG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 2MGFRUIT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 4MG CINN
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 4MG ORIG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE GUM 4MGFRUIT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE LOZ 2MG
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
CVS NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
171
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
X
X
X X X X
X
X
X
Therapeutic Class
Label Name
Generic Name
Smoking Cessation Agents - Deterrents
CVS NTS DIS STEP 1
NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
EQ NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
EQ NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
EQ NICOTINE DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG CINN
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MG ORIG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 2MGFRUIT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG CINN
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG ORIG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG REF NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MG STRT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE GUM 4MGFRUIT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 2MG CHER
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 2MG CINN NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 2MG MINT NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 4MG CHRY
Smoking Cessation Agents - Deterrents
EQ NICOTINE LOZ 4MG MINT NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 2MG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 2MG REF
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 2MG STRT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 4MG REF
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE GUM 4MG STRT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 2MG
NICOTINE POLACRILEX LOZENGE 2 MG
NICOTINE POLACRILEX LOZENGE 4 MG
172
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 4MG CHRY
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
EQL NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
GNP NICOTINE DIS 21MG/24H
NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
GNP NICOTINE DIS 7MG/24HR
NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
GNP NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
GNP NICOTINE GUM 2MG ORIG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
GNP NICOTINE GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
GNP NICOTINE GUM 4MG ORIG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
GNP NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
GNP NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
GNP NICOTINE LOZ MINI 2MG
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
HM NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
HM NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
HM NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
HM NICOTINE GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
HM NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
HM NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
KLS QUIT2 GUM 2MG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
KLS QUIT2 LOZ 2MG
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
KLS QUIT4 GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
KLS QUIT4 LOZ 4MG
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICODERM CQ DIS 14MG/24H
NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
NICODERM CQ DIS 21MG/24H
NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
NICODERM CQ DIS 7MG/24HR
NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 2MG MINT NICOTINE POLACRILEX GUM 2 MG
173
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 2MG ORIG NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 4MG MINT NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICORELIEF GUM 4MG ORIG NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG CINN NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG MINT NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MG ORIG NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 2MGFRUIT NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG CINN NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG MINT NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MG ORIG NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE GUM 4MGFRUIT NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 2MG CHRY NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 2MG ORIG
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 4MG CHRY NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE LOZ 4MG ORIG
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICORETTE ST GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE ST GUM 2MG ORIG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICORETTE ST GUM 4MG ORIG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE DIS 14MG/24H
NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
NICOTINE DIS 21MG/24H
NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
NICOTINE DIS 7MG/24HR
NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
NICOTINE GUM 2MG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE GUM 2MGFRUIT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
174
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Smoking Cessation Agents - Deterrents
NICOTINE LOZ 2MG CHRY
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE LOZ 4MG CHRY
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE LOZ 4MG CINN
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE LOZ MINI 2MG
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG CINN
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG ORIG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG REF
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MG STRT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 2MGFRUIT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG CINN
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG ORIG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG REF
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MG STRT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL GUM 4MGFRUIT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 2MG CHRY
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 2MG CINN
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG CHRY
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG CINN
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
NICOTINE POL LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
175
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Smoking Cessation Agents - Deterrents
NICOTINE SYS KIT TRANSDER
NICOTINE TD PATCH 24 HR KIT 21-14-7 MG/24HR
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
NICOTINE TD DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
NICOTROL INH
NICOTINE INHALER SYSTEM 10 MG (4 MG DELIVERED)
Smoking Cessation Agents - Deterrents
NICOTROL NS SPR 10MG/ ML
NICOTINE NASAL SPRAY 10 MG/ML (0.5 MG/SPRAY)
Smoking Cessation Agents - Deterrents
QC NICOTINE GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
RA NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
RA NICOTINE DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MG CINN
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 2MGFRUIT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 4MG FRUT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE LOZ 2MG MINT NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
RA NICOTINE LOZ 4MG MINT NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 14MG/24H NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 21MG
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 21MG/24H NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
SM NICOTINE DIS 7MG/24HR NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
SM NICOTINE GUM 2MG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
SM NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
SM NICOTINE GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
NICOTINE TD PATCH 24HR 21 MG/24HR
176
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
X X
Therapeutic Class
Label Name
Generic Name
Smoking Cessation Agents - Deterrents
SM NICOTINE GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
SM NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
SM NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
STOP SMOKING GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
STOP SMOKING GUM 2MG ORIG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
STOP SMOKING GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
STOP SMOKING LOZ 2MG
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
STOP SMOKING LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
STOP SMOKING LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
SW NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
SW NICOTINE GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
SW NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
SW NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 14MG/24H
NICOTINE TD PATCH 24HR 14 MG/24HR
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 21MG/24H
NICOTINE TD PATCH 24HR 21 MG/24HR
Smoking Cessation Agents - Deterrents
TGT NICOTINE DIS 7MG/24HR
NICOTINE TD PATCH 24HR 7 MG/24HR
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 2MG ORIG
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 2MGFRUIT
NICOTINE POLACRILEX GUM 2 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 4MG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 4MG MINT
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE GUM 4MG ORIG
NICOTINE POLACRILEX GUM 4 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 2MG CHRY
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 2MG MINT
NICOTINE POLACRILEX LOZENGE 2 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 4MG CHRY
NICOTINE POLACRILEX LOZENGE 4 MG
Smoking Cessation Agents - Deterrents
TGT NICOTINE LOZ 4MG MINT
NICOTINE POLACRILEX LOZENGE 4 MG
177
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care
Prior Supply Step Specialty Authorization Limit Therapy
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Tier Value
Smoking Cessation Agents - Deterrents
THRIVE GUM 2MG MINT
NICOTINE POLACRILEX GUM 2 MG
HCR Preventive Care
BANZEL SUS 40MG/ML
RUFINAMIDE SUSP 40 MG/ML
Tier 3
BANZEL TAB 200MG
RUFINAMIDE TAB 200 MG
Tier 3
X
BANZEL TAB 400MG
RUFINAMIDE TAB 400 MG
Tier 3
X
CARBAMAZEPINE CAP SR 12HR 100 MG
Tier 2
CARBAMAZEPINE CAP SR 12HR 200 MG
Tier 2
CARBAMAZEPINE CAP SR 12HR 300 MG
Tier 2
CARBAMAZEPINE CHEW TAB 100 MG
Tier 1
CARBAMAZEPINE SUSP 100 MG/5ML
Tier 1
CARBAMAZEPINE TAB SR 12HR 100 MG
Tier 3
CARBAMAZEPINE TAB 200 MG
Tier 1
CARBAMAZEPINE TAB 200 MG
Tier 1
CARBAMAZEPINE TAB SR 12HR 200 MG
Tier 3
CARBAMAZEPINE TAB SR 12HR 400 MG
Tier 3
CARBATROL CAP 100MG
CARBAMAZEPINE CAP SR 12HR 100 MG
Tier 3
CARBATROL CAP 200MG
CARBAMAZEPINE CAP SR 12HR 200 MG
Tier 3
CARBAMAZEPINE CAP SR 12HR 300 MG
Tier 3
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 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
CARBAMAZEPIN CAP 100MG ER CARBAMAZEPIN CAP 200MG ER CARBAMAZEPIN CAP 300MG ER CARBAMAZEPIN CHW 100MG CARBAMAZEPIN SUS 100/5ML CARBAMAZEPIN TAB 100MGER CARBAMAZEPIN TAB 200MG CARBAMAZEPIN TAB 200MG CARBAMAZEPIN TAB 200MG ER CARBAMAZEPIN TAB 400MG ER
CARBATROL CAP 300MG DILANTIN CAP 100MG DILANTIN CAP 30MG
PHENYTOIN SODIUM EXTENDED CAP 100 MG PHENYTOIN SODIUM EXTENDED CAP 30 MG
Tier 3 Tier 3
DILANTIN CHW 50MG
PHENYTOIN CHEW TAB 50 MG
Tier 3
DILANTIN-125 SUS 125/5ML
PHENYTOIN SUSP 125 MG/5ML
Tier 3
EPITOL TAB 200MG
CARBAMAZEPINE TAB 200 MG
Tier 1
EQUETRO CAP 100MG EQUETRO CAP 200MG EQUETRO CAP 300MG OXCARBAZEPIN SUS 300MG/5M
CARBAMAZEPINE (ANTIPSYCHOTIC) CAP SR 12HR 100 MG CARBAMAZEPINE (ANTIPSYCHOTIC) CAP SR 12HR 200 MG CARBAMAZEPINE (ANTIPSYCHOTIC) CAP SR 12HR 300 MG OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)
Tier 3 Tier 3 Tier 3 Tier 1
OXCARBAZEPIN TAB 150MG OXCARBAZEPINE TAB 150 MG
Tier 1
OXCARBAZEPIN TAB 300MG OXCARBAZEPINE TAB 300 MG
Tier 1
OXCARBAZEPIN TAB 600MG OXCARBAZEPINE TAB 600 MG
Tier 1
PEGANONE TAB 250MG
Tier 2
PHENYTEK CAP 200MG PHENYTEK CAP 300MG
ETHOTOIN TAB 250 MG PHENYTOIN SODIUM EXTENDED CAP 200 MG PHENYTOIN SODIUM EXTENDED CAP 300 MG
Tier 3 Tier 3
PHENYTOIN CHW 50MG
PHENYTOIN CHEW TAB 50 MG
Tier 3
PHENYTOIN SUS 125/5ML
PHENYTOIN SUSP 125 MG/5ML
Tier 1
PHENYTOIN SODIUM EXTENDED CAP 100 MG PHENYTOIN SODIUM EXTENDED CAP PHENYTOIN EX CAP 200MG 200 MG PHENYTOIN SODIUM EXTENDED CAP PHENYTOIN EX CAP 300MG 300 MG PHENYTOIN EX CAP 100MG
TEGRETOL SUS 100/5ML
CARBAMAZEPINE SUSP 100 MG/5ML
178
Tier 1 Tier 1 Tier 1 Tier 3
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 Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics Sulfonamides - Antibiotics
Generic Name
TEGRETOL TAB 200MG
CARBAMAZEPINE TAB 200 MG
Tier 3
TEGRETOL-XR TAB 100MG
CARBAMAZEPINE TAB SR 12HR 100 MG
Tier 3
TEGRETOL-XR TAB 200MG
CARBAMAZEPINE TAB SR 12HR 200 MG
Tier 3
TEGRETOL-XR TAB 400MG
CARBAMAZEPINE TAB SR 12HR 400 MG
Tier 3
TRILEPTAL SUS 300MG/5M
OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)
Tier 3
X
X
TRILEPTAL TAB 150MG
OXCARBAZEPINE TAB 150 MG
Tier 3
X
X
TRILEPTAL TAB 300MG
OXCARBAZEPINE TAB 300 MG
Tier 3
X
X
TRILEPTAL TAB 600MG
OXCARBAZEPINE TAB 600 MG
Tier 3
X
X
VIMPAT SOL 10MG/ML
LACOSAMIDE ORAL SOLUTION 10 MG/ML
Tier 3
X
VIMPAT TAB 100MG
LACOSAMIDE TAB 100 MG
Tier 3
X
VIMPAT TAB 150MG
LACOSAMIDE TAB 150 MG
Tier 3
X
VIMPAT TAB 200MG
LACOSAMIDE TAB 200 MG
Tier 3
X
VIMPAT TAB 50MG
LACOSAMIDE TAB 50 MG
Tier 3
X
SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG SULFAMETHOXAZOLE-TRIMETHOPRIM BACTRIM DS TAB 800-160 TAB 800-160 MG SULFACETAMIDE SODIUM OPHTH SOLN BLEPH-10 SOL 10% OP 10% SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ/TMP DS TAB 800-160 TAB 800-160 MG SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ-TMP SUS 200-40/5 SUSP 200-40 MG/5ML SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ-TMP TAB 400-80MG TAB 400-80 MG SULFAMETHOXAZOLE-TRIMETHOPRIM SMZ-TMP DS TAB 800-160 TAB 800-160 MG SULFACETAMIDE SODIUM OPHTH SOLN SOD SULFACET SOL 10% OP 10% SULFACETAMIDE SODIUM OPHTH OINT SULFACET SOD OIN 10% OP 10% SULFACETAMIDE SODIUM OPHTH SOLN SULFACET SOD SOL 10% OP 10% SULFADIAZINE TAB 500MG SULFADIAZINE TAB 500 MG SULFATRIM PD SUS 200SULFAMETHOXAZOLE-TRIMETHOPRIM 40/5 SUSP 200-40 MG/5ML BACTRIM TAB 400-80MG
Sulfonamides - Inflammatory Bowel Disease Drugs Sulfonamides - Inflammatory Bowel Disease Drugs Sulfonamides - Inflammatory Bowel Disease Drugs Sulfonamides - Inflammatory Bowel Disease Drugs Tetracyclines - Antibiotics
AVIDOXY TAB 100MG
Tetracyclines - Antibiotics
AVIDOXY DK KIT
Tetracyclines - Antibiotics Tetracyclines - Antibiotics
DEMECLOCYCL TAB 150MG DEMECLOCYCL TAB 300MG DOXYCYC MONO CAP 100MG
Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
Tier Value
Prior Supply Step Specialty Authorization Limit Therapy
Label Name
Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
AZULFIDINE TAB 500MG
SULFASALAZINE TAB 500 MG
Tier 3
AZULFIDINE TAB 500MG EN
SULFASALAZINE TAB DELAYED RELEASE 500 MG
Tier 3
SULFASALAZIN TAB 500MG
SULFASALAZINE TAB 500 MG
Tier 1
SULFASALAZIN TAB 500MG DR
SULFASALAZINE TAB DELAYED RELEASE 500 MG DOXYCYCLINE MONOHYDRATE TAB 100 MG *DOXYCYCLINE TAB 100 MG & SUNCREEN & SAL ACID WASH 2% KIT** DEMECLOCYCLINE HCL TAB 150 MG DEMECLOCYCLINE HCL TAB 300 MG DOXYCYCLINE MONOHYDRATE CAP 100 MG DOXYCYCLINE MONOHYDRATE CAP 50 MG DOXYCYCLINE MONOHYDRATE TAB 100 MG DOXYCYCLINE MONOHYDRATE TAB 150 MG DOXYCYCLINE MONOHYDRATE TAB 50 MG DOXYCYCLINE MONOHYDRATE TAB 75 MG DOXYCYCLINE HYCLATE CAP 100 MG DOXYCYCLINE HYCLATE CAP 50 MG DOXYCYCLINE HYCLATE TAB 100 MG
DOXYCYC MONO CAP 50MG DOXYCYC MONO TAB 100MG DOXYCYC MONO TAB 150MG DOXYCYC MONO TAB 50MG
Tetracyclines - Antibiotics
DOXYCYC MONO TAB 75MG
Tetracyclines - Antibiotics Tetracyclines - Antibiotics Tetracyclines - Antibiotics
DOXYCYCL HYC CAP 100MG DOXYCYCL HYC CAP 50MG DOXYCYCL HYC TAB 100MG
179
Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2
Therapeutic Class 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 Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs Treatment-Resistant - Mood Disorder Drugs 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
Label Name DOXYCYCLINE POW HYCLATE DOXYCYCLINE SUS 25MG/5ML DOXYCYCLINE TAB 20MG
Generic Name DOXYCYCLINE HYCLATE POWDER
DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML DOXYCYCLINE HYCLATE TAB 20 MG *MINOCYCLINE HCL CAP 100 MG W/ MINOCIN KIT 100MG ACNE CARE PRODUCTS KIT* *MINOCYCLINE HCL CAP 50 MG W/ ACNE MINOCIN KIT 50MG CARE PRODUCTS KIT* MINOCYCLINE CAP 100MG MINOCYCLINE HCL CAP 100 MG MINOCYCLINE CAP 50MG MINOCYCLINE HCL CAP 50 MG MINOCYCLINE CAP 75MG MINOCYCLINE HCL CAP 75 MG MONDOXYNE NL CAP DOXYCYCLINE MONOHYDRATE CAP 100 100MG MG DOXYCYCLINE MONOHYDRATE CAP 50 MONDOXYNE NL CAP 50MG MG MORGIDOX CAP 1X100MG DOXYCYCLINE HYCLATE CAP 100 MG MORGIDOX CAP 1X50MG DOXYCYCLINE HYCLATE CAP 50 MG MORGIDOX CAP 2X100MG DOXYCYCLINE HYCLATE CAP 100 MG *DOXYCYCLINE MONOHYD CAP 75 MG W/ NUTRIDOX KIT OMEGA 3-VIT E CAP KIT* DOXYCYCLINE (ROSACEA) CAP DELAYED ORACEA CAP 40MG RELEASE 40 MG TETRACYCLINE CAP 250MG TETRACYCLINE HCL CAP 250 MG TETRACYCLINE CAP 500MG TETRACYCLINE HCL CAP 500 MG VIBRAMYCIN CAP 100MG DOXYCYCLINE HYCLATE CAP 100 MG VIBRAMYCIN SUS DOXYCYCLINE MONOHYDRATE FOR SUSP 25MG/5ML 25 MG/5ML VIBRAMYCIN SYP DOXYCYCLINE CALCIUM SYRUP 50 50MG/5ML MG/5ML CLOZAPINE ORALLY DISINTEGRATING CLOZAPINE TAB 100/ODT TAB 100 MG CLOZAPINE TAB 100MG CLOZAPINE TAB 12.5/ODT CLOZAPINE TAB 150/ODT CLOZAPINE TAB 200/ODT CLOZAPINE TAB 200MG
CLOZAPINE TAB 100 MG CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG CLOZAPINE ORALLY DISINTEGRATING TAB 150 MG CLOZAPINE ORALLY DISINTEGRATING TAB 200 MG
Tier Value Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
CLOZAPINE TAB 200 MG
Tier 1
CLOZAPINE TAB 25MG
CLOZAPINE TAB 25 MG
Tier 1
CLOZAPINE TAB 25MG ODT
CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG
Tier 1
CLOZAPINE TAB 50MG
CLOZAPINE TAB 50 MG
Tier 1
CLOZARIL TAB 100MG
CLOZAPINE TAB 100 MG
Tier 3
CLOZARIL TAB 25MG
CLOZAPINE TAB 25 MG
Tier 3
FAZACLO TAB 100 ODT FAZACLO TAB 12.5 ODT FAZACLO TAB 150 ODT FAZACLO TAB 200 ODT FAZACLO TAB 25MG ODT 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 CITRULLINE POW (L) CLOMIPRAMINE CAP 25MG CLOMIPRAMINE CAP 50MG CLOMIPRAMINE CAP 75MG
CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG CLOZAPINE ORALLY DISINTEGRATING TAB 150 MG CLOZAPINE ORALLY DISINTEGRATING TAB 200 MG CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG AMITRIPTYLINE HCL TAB 100 MG AMITRIPTYLINE HCL TAB 10 MG AMITRIPTYLINE HCL TAB 150 MG AMITRIPTYLINE HCL TAB 25 MG AMITRIPTYLINE HCL TAB 50 MG AMITRIPTYLINE HCL TAB 75 MG AMOXAPINE TAB 100 MG AMOXAPINE TAB 150 MG AMOXAPINE TAB 25 MG AMOXAPINE TAB 50 MG CITRULLINE (BULK) POWDER CLOMIPRAMINE HCL CAP 25 MG CLOMIPRAMINE HCL CAP 50 MG CLOMIPRAMINE HCL CAP 75 MG
180
Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
DESIPRAMINE HCL TAB 100 MG DESIPRAMINE HCL TAB 10 MG DESIPRAMINE HCL TAB 150 MG DESIPRAMINE HCL TAB 25 MG DESIPRAMINE HCL TAB 50 MG DESIPRAMINE HCL TAB 75 MG DOXEPIN HCL CAP 100 MG DOXEPIN HCL CAP 10 MG DOXEPIN HCL CAP 150 MG DOXEPIN HCL CAP 25 MG DOXEPIN HCL CAP 50 MG DOXEPIN HCL CAP 75 MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1
DOXEPIN HCL CONC 10 MG/ML
Tier 1
AMITRIPTYLINE HCL TAB 25 MG IMIPRAMINE HCL TAB 10 MG IMIPRAMINE HCL TAB 25 MG IMIPRAMINE HCL TAB 50 MG IMIPRAMINE PAMOATE CAP 100 MG IMIPRAMINE PAMOATE CAP 125 MG IMIPRAMINE PAMOATE CAP 150 MG IMIPRAMINE PAMOATE CAP 75 MG CITRULLINE (BULK) POWDER DESIPRAMINE HCL TAB 100 MG DESIPRAMINE HCL TAB 10 MG DESIPRAMINE HCL TAB 150 MG DESIPRAMINE HCL TAB 25 MG DESIPRAMINE HCL TAB 50 MG DESIPRAMINE HCL TAB 75 MG NORTRIPTYLINE HCL CAP 10 MG NORTRIPTYLINE HCL CAP 25 MG NORTRIPTYLINE HCL CAP 50 MG NORTRIPTYLINE HCL CAP 75 MG
Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1
Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
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 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 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 PAMELOR CAP 10MG PAMELOR CAP 25MG PAMELOR CAP 50MG PAMELOR CAP 75MG
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 2-10MG
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 2-25MG
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-10MG
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-25MG
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
NORTRIPTYLINE HCL SOLN 10 MG/5ML
Tier 1
NORTRIPTYLINE HCL CAP 10 MG NORTRIPTYLINE HCL CAP 25 MG NORTRIPTYLINE HCL CAP 50 MG NORTRIPTYLINE HCL CAP 75 MG PERPHENAZINE-AMITRIPTYLINE TAB 2-10 MG PERPHENAZINE-AMITRIPTYLINE TAB 2-25 MG PERPHENAZINE-AMITRIPTYLINE TAB 4-10 MG PERPHENAZINE-AMITRIPTYLINE TAB 4-25 MG PERPHENAZINE-AMITRIPTYLINE TAB 4-50 MG PROTRIPTYLINE HCL TAB 10 MG PROTRIPTYLINE HCL TAB 5 MG TRIMIPRAMINE MALEATE CAP 100 MG TRIMIPRAMINE MALEATE CAP 25 MG TRIMIPRAMINE MALEATE CAP 50 MG IMIPRAMINE HCL TAB 10 MG IMIPRAMINE HCL TAB 25 MG IMIPRAMINE HCL TAB 50 MG TRIMIPRAMINE MALEATE CAP 100 MG TRIMIPRAMINE MALEATE CAP 25 MG TRIMIPRAMINE MALEATE CAP 50 MG ISOPROTERENOL HCL INHAL AEROSOL SOLN 131 MCG/ACT (2.5 MG/ML) ISOXSUPRINE HCL TAB 10 MG
Tier 3 Tier 3 Tier 3 Tier 3
ISOXSUPRINE HCL TAB 20 MG
Tier 1
HYDRALAZINE TAB 100MG
HYDRALAZINE HCL TAB 100 MG
Tier 1
HYDRALAZINE TAB 10MG
HYDRALAZINE HCL TAB 10 MG
Tier 1
HYDRALAZINE TAB 25MG
HYDRALAZINE HCL TAB 25 MG
Tier 1
HYDRALAZINE TAB 50MG
HYDRALAZINE HCL TAB 50 MG
Tier 1
MINOXIDIL TAB 10MG
MINOXIDIL TAB 10 MG
Tier 1
Tricyclics - Antidepressants
PERPHEN/AMIT TAB 4-50MG
Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants Tricyclics - Antidepressants
PROTRIPTYLIN TAB 10MG PROTRIPTYLIN TAB 5MG SURMONTIL CAP 100MG SURMONTIL CAP 25MG SURMONTIL CAP 50MG TOFRANIL TAB 10MG TOFRANIL TAB 25MG TOFRANIL TAB 50MG TRIMIPRAMINE CAP 100MG TRIMIPRAMINE CAP 25MG TRIMIPRAMINE CAP 50MG
Vasodilators - Chest Pain Drugs
ISOPROTEREN AER 131MCG
Vasodilators - Chest Pain Drugs
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
Tier Value
181
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class 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 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
Label Name
Generic Name
Tier Value
MINOXIDIL TAB 2.5MG
MINOXIDIL TAB 2.5 MG
Tier 1
BIDIL TAB
ISOSORBIDE DINITRATE-HYDRALAZINE HCL TAB 20-37.5 MG
Tier 2
DILATRATE SR CAP 40MG
ISOSORBIDE DINITRATE CAP CR 40 MG
Tier 3
ISORDIL TAB 40MG
ISOSORBIDE DINITRATE TAB 40 MG
Tier 2
ISORDIL TAB 5MG
ISOSORBIDE DINITRATE TAB 5 MG
Tier 3
ISOSORB DIN TAB 10MG
ISOSORBIDE DINITRATE TAB 10 MG
Tier 1
ISOSORB DIN TAB 20MG
ISOSORBIDE DINITRATE TAB 20 MG
Tier 1
ISOSORB DIN TAB 30MG
ISOSORBIDE DINITRATE TAB 30 MG
Tier 1
ISOSORB DIN TAB 40MG ER
ISOSORBIDE DINITRATE TAB CR 40 MG
Tier 1
ISOSORB DIN TAB 5MG
ISOSORBIDE DINITRATE TAB 5 MG
Tier 1
ISOSORB MONO TAB 10MG
ISOSORBIDE MONONITRATE TAB 10 MG
Tier 1
ISOSORB MONO TAB 120MG ISOSORBIDE MONONITRATE TAB SR 24HR ER 120 MG
Tier 1
ISOSORB MONO TAB 20MG
ISOSORBIDE MONONITRATE TAB 20 MG
Tier 1
ISOSORB MONO TAB 30MG ER ISOSORB MONO TAB 60MG ER
ISOSORBIDE MONONITRATE TAB SR 24HR 30 MG ISOSORBIDE MONONITRATE TAB SR 24HR 60 MG NITROGLYCERIN TD PATCH 24HR 0.1 MG/ HR NITROGLYCERIN TD PATCH 24HR 0.2 MG/ HR NITROGLYCERIN TD PATCH 24HR 0.4 MG/ HR NITROGLYCERIN TD PATCH 24HR 0.6 MG/ HR
MINITRAN DIS 0.1MG/HR MINITRAN DIS 0.2MG/HR MINITRAN DIS 0.4MG/HR MINITRAN DIS 0.6MG/HR NITRO-BID OIN 2%
NITROGLYCERIN OINT 2%
NITROGLYCERIN TD PATCH 24HR 0.1 MG/ NITRO-DUR DIS 0.1MG/HR HR NITROGLYCERIN TD PATCH 24HR 0.2 MG/ NITRO-DUR DIS 0.2MG/HR HR NITROGLYCERIN TD PATCH 24HR 0.3 MG/ NITRO-DUR DIS 0.3MG/HR HR NITROGLYCERIN TD PATCH 24HR 0.4 MG/ NITRO-DUR DIS 0.4MG/HR HR NITROGLYCERIN TD PATCH 24HR 0.6 MG/ NITRO-DUR DIS 0.6MG/HR HR NITROGLYCERIN TD PATCH 24HR 0.8 MG/ NITRO-DUR DIS 0.8MG/HR HR NITROGLYCERIN LINGUAL AEROSOL 400 NITROGLYCER AER 400MCG MCG/SPRAY NITROGLYCER CAP 2.5MG NITROGLYCERIN CAP CR 2.5 MG ER NITROGLYCER CAP 6.5MG NITROGLYCERIN CAP CR 6.5 MG ER NITROGLYCER CAP 9MG ER NITROGLYCERIN CAP CR 9 MG
Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
X
Tier 1 Tier 1 Tier 1
NITROGLYCER DIS 0.1MG/ HR NITROGLYCER DIS 0.2MG/ HR NITROGLYCER DIS 0.4MG/ HR NITROGLYCER DIS 0.6MG/ HR
NITROGLYCERIN TD PATCH 24HR 0.1 MG/ HR NITROGLYCERIN TD PATCH 24HR 0.2 MG/ HR NITROGLYCERIN TD PATCH 24HR 0.4 MG/ HR NITROGLYCERIN TD PATCH 24HR 0.6 MG/ HR
NITROGLYCERI SUB 0.6MG
NITROGLYCERIN SL TAB 0.6 MG
Tier 1
NITROGLYCERN SUB 0.3MG NITROGLYCERIN SL TAB 0.3 MG
Tier 1
NITROGLYCERN SUB 0.4MG NITROGLYCERIN SL TAB 0.4 MG
Tier 1
Tier 1 Tier 1 Tier 1 Tier 1
NITROMIST AER 400MCG
NITROGLYCERIN LINGUAL AEROSOL 400 MCG/SPRAY
Tier 3
NITROSTAT SUB 0.3MG
NITROGLYCERIN SL TAB 0.3 MG
Tier 3
182
Prior Supply Step Specialty Authorization Limit Therapy
X
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 VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS
Label Name
Generic Name
NITROSTAT SUB 0.4MG
NITROGLYCERIN SL TAB 0.4 MG
Tier 3
NITROSTAT SUB 0.6MG
NITROGLYCERIN SL TAB 0.6 MG
Tier 3
NITRO-TIME CAP 2.5MG CR
NITROGLYCERIN CAP CR 2.5 MG
Tier 1
NITRO-TIME CAP 6.5MG CR
NITROGLYCERIN CAP CR 6.5 MG
Tier 1
NITRO-TIME CAP 9MG CR
NITROGLYCERIN CAP CR 9 MG
Tier 1
RECTIV OIN 0.4%
NITROGLYCERIN OINT 0.4%
Tier 3
*PRENATAL W/O A W/FE CBN-FA-DHA CAP ACTIVE OB CAP 20-1-320 MG*** *PRENAT W/FE POLY-NA FERED-FA TAB BAL-CARE MIS DHA 27-1 & OMEGA CAP DR 430MG* *PRENATAL W/ CALCIUM CARBONATEBP FOLINATAL TAB PLUS B B6-B12-FA TAB 1 MG*** *PRENATAL W/O A VIT W/ FE FUM-FA TAB BP MULTINATL CHW PLUS CHEW 40-1 MG*** *PRENATAL W/O A VIT W/ FE FUMARATEBP MULTINATL TAB PLUS FA TAB 30-1 MG*** *PRENATAL W/O VIT A W/ FE FUM-FACALCIUM PNV CAP OMEGA 3 CAP 28-1-250 MG*** *PRENAT W/O A W/FECBN-FEGL-DSS-FA CITRANATAL MIS 90 DHA TAB 90 &DHA CAP 300MG PAK* *PRENAT W/O A W/FECBN-FEGLU-FA TAB CITRANATAL MIS B-CALM 20-1 MG & VIT B6 TAB PAK* *PRENAT W/O A W/FECBN-FEGL-DSS-FA CITRANATAL PAK ASSURE TAB & DHA CAP 300 MG PACK* *PRENAT W/O A W/FECBN-FEGL-DSS-FA CITRANATAL PAK DHA TAB & DHA CAP 250 MG PACK* *PRENATAL W/O A W/ FE CARBONYL-FE CITRANATAL TAB RX GLUC-DSS-FA TAB 27-1MG*** *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 C-NATE DHA CAP 28-1-200 CAP 28-1-200 MG*** *PRENAT-FE BIS-FE PROT SUCC-FA-CA COMPLETE NAT PAK DHA TAB & OMEGA 3 CAP 250 PK** *PRENATAL VIT W/ FE FUMARATE-FA COMPLETENATE CHW CHEW TAB 29-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB CO-NATAL FA TAB 29-1MG 29-1 MG*** *PRENATAL W/FE FUM-FE POLY -FACONCEPT DHA CAP OMEGA 3 CAP 53.5-38-1 MG*** *PRENATAL W/O A W/FE FUM-FE POLY-FA CONCEPT OB CAP CAP 130-92.4-1 MG*** *PRENATAL W/FE FUM-FE POLY -FADOTHELLE DHA CAP OMEGA 3 CAP 53.5-38-1 MG*** *PRENAT W/FE POLY-NA FERED-FA TAB DUET DHA MIS BALANCED 25-1 & OMEGA CAP 267 MG*** *PRENAT W/FE POLY-NA FERED-FA TAB DUET DHA 400 MIS 25-1-400 25-1 & OMEGA CAP 400 MG*** *PRENATAL VIT W/ IRON CARBONYL-FA ELITE-OB TAB TAB 50-1.25 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE ESCAVITE CHW CHEW TAB 0.25-7.5 MG** *PRENATAL W/O VIT A W/ FE FUM-DOCEXTRA-VIRT CAP PLUS DHA FA-DHA CAP 29-1.25-350 MG* *PEDIATRIC MULTIPLE VITAMINS W/ FLORIVA DRO PLUS FLUORIDE SOLN 0.25 MG/ML*** *PRENAT W/O A W/FECBN-FEGL-DSS-FA FOCALGIN 90 MIS DHA TAB 90 &DHA CAP 300MG PAK* *PRENAT W/O A W/FECBN-FEGL-DSS-FA FOCALGIN CA MIS TAB & DHA CAP 300 MG PACK* *PRENATAL W/O VIT A W/ FE FUM-DSS-FAFOLCAL DHA CAP DHA CAP 27-1.25-300 MG* *PRENATAL VIT W/ FE CBN-FE ASP GLYCFOLCAPS CAP OMEGA 3 FA-OMEGA 3 CAP 27-1MG*** *PRENATAL W/O A W/FE FUM-FE POLY-FA FOLIVANE-OB CAP CAP 130-92.4-1 MG*** *PRENAT-FE POLY CMPLX-FE HEME POLYHEMENATAL OB MIS + DHA FA TAB & OMEGA 3 CAP PCK* HEMENATAL OB TAB 28-6*PRENAT VIT-FE POLY CMPLX-FE HEME 1MG POLY-FA TAB 28-6-1 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLINATAL ADV TAB FA TAB 90-1 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLINATAL ADV TAB FA TAB 90-1 MG***
183
Tier Value
Tier 3 Tier 2 Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 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 2 Tier 2 Tier 1 Tier 2
Prior Supply Step Specialty Authorization Limit Therapy
X
Therapeutic Class
Label Name
Generic Name
VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS
*PRENATAL VIT W/ DSS-IRON CARBONYLFA TAB 90-1 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLINATAL ULTRA TAB FA TAB 90-1 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLINATAL ULTRA TAB FA TAB 90-1 MG*** *PRENATAL W/O A W/FE CBN-DSS-FA-DHA INFANATE CAP BALANCE CAP 29-1-265 MG*** *PRENATAL VIT W/ IRON CARBONYL-FA KOSHR PRENAT TAB 30-1MG TAB 30-1 MG*** *PRENAT W/FE FUM-L METHYLFOLATELEVOMEFOLATE CAP DHA FA-DHA CAP 27-1.13-0.4 MG*** *PRENATAL W/O A W/FE CBN-DSS-FA-DHA MACNATAL CN CAP DHA CAP 28-1-250 MG*** *PRENATAL W/O VIT A W/ FE POLYSAC MARNATAL-F CAP CMPLX-FA CAP 60-1 MG*** MULTI VIT/FL DRO 0.5MG/ *PEDIATRIC MULTIPLE VITAMINS W/ ML FLUORIDE SOLN 0.5 MG/ML*** *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE MULTI-VIT/FE DRO /FL 0.25 DROPS 0.25-10 MG/ML** *PEDIATRIC MULTIPLE VITAMINS W/ MULTIVIT/FL CHW 0.25MG FLUORIDE CHEW TAB 0.25 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MULTIVIT/FL CHW 0.25MG FLUORIDE CHEW TAB 0.25 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MULTIVIT/FL CHW 0.5MG FLUORIDE CHEW TAB 0.5 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MULTIVIT/FL CHW 0.5MG FLUORIDE CHEW TAB 0.5 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MULTIVIT/FL CHW 1MG FLUORIDE CHEW TAB 1 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MULTIVIT/FL CHW 1MG FLUORIDE CHEW TAB 1 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MULTIVIT/FL DRO 0.25MG FLUORIDE SOLN 0.25 MG/ML*** *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE MULTI-VIT/FL DRO /FE 0.25 DROPS 0.25-10 MG/ML** *PEDIATRIC MULTIPLE VITAMINS W/ MULTI-VIT/FL DRO 0.25MG FLUORIDE SOLN 0.25 MG/ML*** MULTI-VIT/FL DRO 0.5MG/ *PEDIATRIC MULTIPLE VITAMINS W/ ML FLUORIDE SOLN 0.5 MG/ML*** *PEDIATRIC MULTIPLE VITAMINS W/ MULT-VIT/FL CHW 0.5MG FLUORIDE CHEW TAB 0.5 MG*** MVC-FLUORIDE CHW *PEDIATRIC MULTIPLE VITAMINS W/ 0.25MG FLUORIDE CHEW TAB 0.25 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MVC-FLUORIDE CHW 0.5MG FLUORIDE CHEW TAB 0.5 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ MVC-FLUORIDE CHW 1MG FLUORIDE CHEW TAB 1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB M-VIT TAB 27-1MG 27-1 MG*** *PEDIATRIC VITAMINS ACD FLUORIDE & MYKIDZ IRON SUS FL FE SUSP 0.25-10 MG/2ML*** *PRENATAL MULTIVITAMINS & MINERALS MYNATAL CAP W/ IRON & FA CAP 1 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLMYNATAL TAB FA TAB 90-1 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLMYNATAL TAB ADVANCE FA TAB 90-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB MYNATAL PLUS TAB 65-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB MYNATAL-Z TAB 65-1 MG*** *PRENATAL VIT W/ DSS-FE FUMARATE-FA MYNATE 90 TAB PLUS TAB CR 90-1 MG*** *PRENATAL VIT W/ FE FUM-FE BISGLYCINNATACHEW CHW FA CHEW TAB 28-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB NATALVIT TAB 75-1MG 75-1 MG*** *PRENATAL W/O VIT A W/ FE FUM-FANATELLE ONE CAP OMEGA 3 CAP 28-1-250 MG*** *PRENAT W/O A W/FEFUM-METHYLFOLNEEVO DHA CAP 27-1.13 OMEGAS CAP 27-1.13 MG*** *PRENATAL VIT W/O VIT A W/ FE NESTABS TAB BISGLYCINATE-FA TAB 32-1 MG*** *PRENATAL W/O VIT A W/FE POLYSAC-FANESTABS ABC MIS CA TAB & OMEGA 3 CAP*** *PRENAT W/O A W/ FE BISGLYC-FA TAB NESTABS DHA PAK 32-1 MG & OMEGA CAP PACK* INATAL GT TAB
184
Tier Value Tier 2 Tier 1 Tier 2 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 1 Tier 1 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 2 Tier 2 Tier 1 Tier 2 Tier 1 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS
Label Name NEWGEN TAB 32-1MG NEXA PLUS CAP NIVA-PLUS TAB OB COMPLETE CAP GOLD OB COMPLETE CAP ONE OB COMPLETE CAP PETITE OB COMPLETE TAB OB COMPLETE TAB PREMIER OB COMPLETE/ CAP DHA OBSTETRIX PAK DHA OBSTETRIX EC TAB O-CAL TAB PRENATAL O-CAL FA TAB PNV FE FUM TAB DOC/FA PNV FOLIC AC TAB + IRON PNV OB+DHA PAK PNV PRENATAL TAB PLUS PNV TABS TAB 29-1MG PNV-DHA CAP PNV-DHA CAP DOCUSATE PNV-OMEGA CAP PNV-SELECT TAB PNV-TOTAL CAP PNV-VP-U CAP 106.5-1 POLY-VI-FLOR CHW 0.25MG POLY-VI-FLOR CHW 0.5MG POLY-VI-FLOR CHW 1MG POLY-VI-FLOR CHW W/IRON POLY-VI-FLOR SUS /IRON POLY-VI-FLOR SUS 0.25/ML PR NATAL 400 PAK PR NATAL 400 PAK EC PR NATAL 430 PAK PR NATAL 430 PAK EC PREFERA OB TAB PREFERAOB CAP ONE PREFERAOB MIS +DHA PRENAISSANCE CAP PRENAISSANCE CAP BALANCE
Generic Name *PRENATAL VIT W/O VIT A W/ FE BISGLYCINATE-FA TAB 32-1 MG*** *PRENATAL W/O VIT A W/ FE FUM-DOCFA-DHA CAP 29-1.25-350 MG* *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG*** *PRENAT W/O A W/FECBN-METHFOL-FADHA CAP 27.5-1-200 MG*** *PRENATAL W/O A W/FECBN-FE ASP GLYC-FA-FISH CAP 50-1-476 MG* *PRENAT W/O A W/FECBN-FEASPGLYCFA-OMEGA CAP 35-5-1-200 MG** *PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1.25 MG*** *PRENATAL VIT W/ FE CBN-FE ASP GLYCFA TAB 30-20-1 MG*** *PRENAT W/ IRON CBN-FE ASP GLYC-FAOMEGA CAP 30-10-1-200 MG* *PRENAT W/FECBN-FA-DSS TAB 29-1 MG & OMEGA 3 CAP 387 MG PAK* *PRENATAL VIT W/ DSS-IRON CARBONYLFA TAB 29-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 15-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG*** *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB 29-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG*** *PRENAT W/O A W/FECBN-FEGL-DSS-FA TAB & DHA CAP 250 MG PACK* *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG*** *PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG*** *PRENAT W/O A W/FEFUM-METHFOL-FADHA CAP 27-0.6-0.4-300 MG** *PRENATAL W/O VIT A W/ FE FUM-DSS-FADHA CAP 27-1.25-300 MG* *PRENAT W/O A W/ FE FUMERATEMETHYLFOLATE-FA-OMEGA 3 CAP*** *PRENATAL VIT W/ FE FUMMETHYLFOLATE-FA TAB 27-0.6-0.4 MG*** *PRENAT W/ FE CBN-FE BISGLYC-FA-FISH OIL CAP 35-5-1.2 MG** *PRENATAL W/O A VIT W/ FE FUMARATEFA CAP 106.5-1 MG*** *PED MULTIPLE VIT W/ FLUORIDE BIPHASIC CHEW TAB 0.25 MG*** *PED MULTIPLE VIT W/ FLUORIDE BIPHASIC CHEW TAB 0.5 MG*** *PED MULTIPLE VIT W/ FLUORIDE BIPHASIC CHEW TAB 1 MG*** *PED MULTIPLE VIT W/ FL-FE BIPHASIC CHEW TAB 0.5-10 MG** *PED MULTIPLE VITAMIN W/ FL-FE BIPHASIC SUSP 0.25-7 MG/ML** *PED MULTIPLE VIT W/ FLUORIDE BIPHASIC SUSP 0.25 MG/ML*** *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 400 PK** *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 400 PK* *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 430 PK** *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 430 PK* *PRENAT VIT-FE POLY CMPLX-FE HEME POLY-FA TAB 34-1 MG*** *PRENAT-FE POLY CMPLX-FE HEME POLYFA-DHA CAP 22-6-1-200 MG* *PRENAT-FE POLY CMPLX 28MG-FE HEME POLY-FA TAB&DHA CAP PACK* *PRENATAL W/O VIT A W/ FE FUM-DSS-FADHA CAP 29-1.25-325 MG* *PRENATAL W/O VIT A W/ FE CBN-DSS-FADHA CAP 30-1-260 MG***
185
Tier Value Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 2 Tier 2 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 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 2 Tier 2
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS
*PRENATAL W/O A W/FE CBN-DSS-FA-DHA CAP 28-1-250 MG*** PRENAISSANCE MIS *PRENAT W/FE POLY-NA FERED-FA TAB HARMONY 27-1 & OMEGA CAP DR 380MG* *PRENATAL W/ CALCIUM-VIT B6-FAPRENAISSANCE TAB NEXT GINGER TAB 1.2 MG** *PRENATAL W/ CALCIUM-VIT B6-FAPRENAISSANCE TAB NEXT-B GINGER TAB 1.22 MG** *PRENATAL VIT W/ FE FUMARATE-FA TAB PRENAT PLUS TAB 27-1MG 27-1 MG*** *PRENATAL W/O A VIT W/ FE FUM-FA TAB PRENATA CHW 29-1MG CHEW 29-1 MG*** *PRENATAL VIT W/ IRON CARBONYL-FA PRENATABS RX TAB TAB 29-1 MG*** *PRENAT W/O A FEFUM-FA TAB 27-1 MG & PRENATAL MIS COMPLEAT FISH OIL CHEW CAP PAK** *PRENATAL VIT W/ FE FUMARATE-FA TAB PRENATAL TAB 27-1MG 27-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB PRENATAL TAB PLUS 27-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA PRENATAL 19 CHW 29-1MG CHEW TAB 29-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA PRENATAL 19 CHW TAB CHEW TAB 29-1 MG*** *PRENATAL VIT W/ DSS-FE FUMARATE-FA PRENATAL 19 TAB TAB 29-1 MG*** *PRENATAL VIT W/ DSS-FE FUMARATE-FA PRENATAL 19 TAB 29-1MG TAB 29-1 MG*** PRENATAL PLS MIS MV + *PRENAT W/ FE FUM-FA TAB 27-1 MG & DHA OMEGA 3 CAP 312 MG PAK* PRENATAL VIT TAB LOW *PRENATAL VIT W/ FE FUMARATE-FA TAB IRON 27-1 MG*** *PRENATAL VIT W/ IRON CARBONYL-FA PRENATAL+FE TAB 29-1MG TAB 29-1 MG*** *PRENATAL W/O A VIT W/ FE FUMARATEPRENATAL-U CAP 106.5-1 FA CAP 106.5-1 MG*** *PRENAT W/O A W/FEFUM-METHFOL-FAPRENATE CAP ENHANCE DHA CAP 28-0.6-0.4-400 MG** *PRENAT W/O A W/FEFUM-METHFOL-FAPRENATE CAP RESTORE DHA CAP 27-0.6-0.4-400 MG** *PRENAT MV & MIN W/ L-METHYLFOLATEPRENATE CHW 0.6-0.4 FA CHEW TAB 0.6-0.4 MG*** *PRENATAL VIT W/ FE FUMPRENATE TAB ELITE METHYLFOLATE-FA TAB 26-0.6-0.4 MG*** *PRENATAL W/ CALCIUM-VIT B6-VIT B12PRENATE AM TAB 1MG FA-GINGER TAB 1 MG*** *PRENAT W/O A W/FEFUM-METHFOL-FAPRENATE DHA CAP DHA CAP 28-0.6-0.4-300 MG** *PRENAT W/O A W/FECBN-METHYLF-FAPRENATE MINI CAP DHA CAP 29-0.6-0.4-350 MG** *PRENATAL VIT W/ FE FUMARATE-FA TAB PREPLUS TAB 27-1MG 27-1 MG*** *PRENATAL MV W/FE CARBONYL-DSS-FAPREQUE 10 TAB DHA TAB 15-25-0.5-50 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB PRETAB TAB 29-1MG 29-1 MG*** *PRENATAL W/O A W/FE FUM-FE POLY-FA PROVIDA OB CAP CAP 20-20-1.25 MG*** *PRENATAL W/O A W/FE FUM-FE POLY-FA PUREFE OB CAP PLUS CAP 162.115.2-1 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ QUFLORA PED CHW 0.25MG FLUORIDE CHEW TAB 0.25 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ QUFLORA PED CHW 0.5MG FLUORIDE CHEW TAB 0.5 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ QUFLORA PED CHW 1MG FLUORIDE CHEW TAB 1 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ QUFLORA PED DRO 0.25MG FLUORIDE SOLN 0.25 MG/ML*** QUFLORA PED DRO 0.5MG/ *PEDIATRIC MULTIPLE VITAMINS W/ ML FLUORIDE SOLN 0.5 MG/ML*** *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 RELNATE DHA CAP CAP 28-1-200 MG*** *PRENATAL W/O A W/FE CBN-FA-DHA CAP R-NATAL OB CAP 20-1-320 20-1-320 MG*** *PRENAT W/O A W/FEFUM-METHFOL-FARULAVITE DHA CAP DHA CAP 27-0.6-0.4-300 MG** *PRENATAL VIT W/ FE POLYSAC CMPLXSELECT-OB CHW FA CHEW TAB 29-1 MG*** PRENAISSANCE CAP PLUS
186
Tier Value Tier 2 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 1 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 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 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS
*PRENAT W/ FEPOLYCMPLX-METHYLFOLFA CHEW TAB 29-0.6-0.4 MG** *PRENATAL MV W/FE POLY-FA CHW 29-1 SELECT-OB+ PAK DHA MG & DHA CAP 250 MG PAK * *PRENATAL VIT W/ FE FUMARATE-FA SE-NATAL 19 CHW CHEW TAB 29-1 MG*** *PRENATAL VIT W/ DSS-FE FUMARATE-FA SE-NATAL 19 TAB TAB 29-1 MG*** *PRENATAL W/FE FUM-FE POLY -FASE-TAN DHA CAP OMEGA 3 CAP 15-15-1 MG*** *PRENAT W/O A W/ FE CBNYL-FA TAB 20-1 TARON-BC MIS MG & VIT B6 TAB PAK* *PRENATAL W/FE FUM-FE POLY -FATARON-C DHA CAP OMEGA 3 CAP 53.5-38-1 MG*** *PRENATAL W/O VIT A W/ FE FUM-DSS-FATARON-PREX CAP DHA CAP 30-1.2-265 MG** *PRENATAL VIT W/ DSS-FE FUMARATE-FA THRIVITE 19 TAB TAB 29-1 MG*** *PRENATAL VIT W/ IRON CARBONYL-FA THRIVITE RX TAB 29-1MG TAB 29-1 MG*** *PRENATAL VIT W/ FE FUMTL FOLATE TAB METHYLFOLATE-FA TAB 27-0.5-0.5 MG*** *PRENATAL W/FE FUMARATE-FA-DSSTL-CARE DHA CAP 27-1-500 FISH OIL CAP 27-1-500 MG*** *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE TL-FLUORIVIT CHW CHEW TAB 0.25-7.5 MG** *PRENATAL W/O VIT A W/ FE FUM-DSS-FATL-SELECT CAP DHA CAP 29-1.25-325 MG* *PRENATAL VIT W/ DSS-IRON CARBONYLTRIADVANCE TAB FA TAB 90-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB TRICARE TAB PRENATAL 27-1 MG*** *PRENATAL W/FE FUMARATE-FA-DSSTRICARE PRE CAP 27-1-500 FISH OIL CAP 27-1-500 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLTRINATAL GT TAB FA TAB 90-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB TRINATAL RX TAB 1 60-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB TRINATE TAB 28-1 MG*** *PRENAT W/O A W/FECBN-METHYLF-FATRISTART DHA CAP DHA CAP 31-0.6-0.4-200 MG** *PRENAT W/O A W/ FE BISGLYC-FA TAB TRI-TABS DHA MIS 32-1 MG & OMEGA CAP PACK* *PRENAT-FE BIS-FE PROT SUCC-FA-CA TRIVEEN-DUO PAK DHA TAB & OMEGA 3 CAP 400 PK** *PRENATAL W/O VIT A W/ FE FUM-DSS-FATRIVEEN-PRX CAP RNF DHA CAP 26-1.2-300 MG** *PED VIT ACD & L-METHYLFOL W/ FL TRI-VI-FLOR SUS 0.25/ML BIPHASIC SUSP 0.25 MG/ML*** *PED VIT ACD & L-METHYLFOL W/ FL TRI-VI-FLOR SUS 0.5MG/ML BIPHASIC SUSP 0.5 MG/ML*** *PED VIT ACD & L-METHYLFOL W/ FL TRI-VI-FLORO SUS 0.25/ML BIPHASIC SUSP 0.25 MG/ML*** TRI-VI-FLORO SUS 0.5MG/ *PED VIT ACD & L-METHYLFOL W/ FL ML BIPHASIC SUSP 0.5 MG/ML*** *PEDIATRIC VITAMINS ACD FLUORIDE & TRI-VIT/FE DRO /FL 0.25 FE DROPS 0.25-10 MG/ML*** *PEDIATRIC VITAMINS ACD W/ FLUORIDE TRI-VIT/FL DRO 0.25MG SOLN 0.25 MG/ML*** *PEDIATRIC VITAMINS ACD W/ FLUORIDE TRI-VIT/FL DRO 0.5MG SOLN 0.5 MG/ML*** *PEDIATRIC VITAMINS ACD W/ FLUORIDE TRI-VIT/FLUO DRO 0.25MG SOLN 0.25 MG/ML*** *PEDIATRIC VITAMINS ACD W/ FLUORIDE TRI-VIT/FLUO DRO 0.5MG SOLN 0.5 MG/ML*** *PEDIATRIC VITAMINS ACD W/ FLUORIDE TRI-VITA/FL DRO 0.25MG SOLN 0.25 MG/ML*** *PRENATAL VIT W/ FE CBN-FE ASP GLYCULTIMATECARE CAP ONE FA-OMEGA 3 CAP 27-1MG*** *PRENATAL W/FE CBNYL-FE ASP GLYC-FAULTIMATECARE CAP ONE NF DSS-OMEGA CAP 20-7-1 MG* *PRENATAL W/O VIT A W/ FE FUM-DSS-FAVEMAVITE- CAP PRX 2 DHA CAP 27-1.25-300 MG* *PRENAT W/FE POLY-NA FERED-FA TAB VENA-BAL MIS DHA 27-1 & OMEGA CAP DR 430MG* *PRENAT W/O A W/FEFUM-METHYLFOLVINATE DHA CAP 27-1.13 OMEGAS CAP 27-1.13 MG*** SELECT-OB CHW
187
Tier Value Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 1 Tier 3 Tier 3 Tier 2 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 1 Tier 3 Tier 2 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS VITAMINS - MULTIVITAMIN PREPARATIONS
Label Name VINATE II TAB VINATE M TAB VINATE ONE TAB VIRT NATE TAB VIRT NATE TAB 28-1MG VIRT-ADVANCE TAB 90-1MG VIRT-C DHA CAP VIRT-CARE CAP ONE VIRT-NATE CAP DHA VIRT-PN TAB VIRT-PN DHA CAP VIRT-PN PLUS CAP VIRTPREX CAP VIRT-SELECT CAP VIRT-VITE GT TAB 90-1MG VIT A/C/D/FL DRO 0.25MG VITAFOL CAP ULTRA VITAFOL-OB PAK +DHA VITAFOL-OB TAB 65-1MG VITAFOL-ONE CAP VITAMEDMD CAP ONE RX VITAMEDMD MIS PLUS RX VITA-PREN TAB VIVA DHA CAP VOL-NATE TAB VOL-PLUS TAB VOL-TAB RX TAB VP-CH PLUS CAP VP-CH-PNV CAP VP-CH-PNV CAP VP-GGR-B6 TAB PRENATAL VP-HEME OB MIS + DHA VP-HEME OB TAB VP-HEME ONE CAP VP-HEME-OB TAB 28-6-1MG VP-PNV-DHA CAP ZATEAN-CH CAP ZATEAN-PN CAP DHA ZATEAN-PN CAP PLUS
Generic Name *PRENATAL VIT W/ FE BISGLYCINATE CHELATE-FA TAB 29-1 MG*** *PRENATAL VIT W/ SEL-FE FUMARATE-FA TAB 27-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 28-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 28-1 MG*** *PRENATAL VIT W/ DSS-IRON CARBONYLFA TAB 90-1 MG*** *PRENATAL W/FE FUM-FE POLY -FAOMEGA 3 CAP 53.5-38-1 MG*** *PRENATAL VIT W/ FE CBN-FE ASP GLYCFA-OMEGA 3 CAP 27-1MG*** *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-1-200 MG*** *PRENATAL VIT W/ FE FUMMETHYLFOLATE-FA TAB 27-0.6-0.4 MG*** *PRENAT W/O A W/FEFUM-METHFOL-FADHA CAP 27-0.6-0.4-300 MG** *PRENAT W/O A W/ FE FUMERATEMETHYLFOLATE-FA-OMEGA 3 CAP*** *PRENATAL W/O VIT A W/ FE FUM-DSS-FADHA CAP 26-1.2-300 MG** *PRENATAL W/O VIT A W/ FE FUM-DSS-FADHA CAP 29-1.25-325 MG* *PRENATAL VIT W/ DSS-IRON CARBONYLFA TAB 90-1 MG*** *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML*** *PRENAT W/FE POLY-METHYLFOL-FA-DHA CAP 29-0.6-0.4-200 MG*** *PRENATAL MV W/FE FUM-FA TAB 65-1 MG & DHA CAP 250 MG PACK * *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG*** *PRENATAL MV W/ FE POLYSAC CMPLXFA-DHA CAP 29-1-200 MG*** *PRENAT W/O A W/FEFUM-METHFOL-FADHA CAP 30-0.6-0.4-200 MG** *PRENAT W/O A W/ FE CHELATE-L METHYLFOL-FA TAB & DHA CAP PK* *PRENATAL VIT W/ DOCUSATE-IRON-FA TAB 65-1 MG*** *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-1-200 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 28-1 MG*** *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG*** *PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG*** *PRENATAL W/O A W/FE CBN-DSS-FA-DHA CAP 29-1-265 MG*** *PRENATAL W/O VIT A W/ FE CBN-DSS-FADHA CAP 30-1-260 MG*** *PRENATAL W/O VIT A W/ FE CBN-DSS-FADHA CAP 30-1-260 MG*** *PRENATAL W/ CALCIUM-VIT B6-FAGINGER TAB 1.2 MG** *PRENAT-FE POLY CMPLX-FE HEME POLYFA TAB & OMEGA 3 CAP PCK* *PRENAT VIT-FE POLY CMPLX-FE HEME POLY-FA TAB 28-6-1 MG*** *PRENAT-FE POLY CMPLX-FE HEME POLYFA-DHA CAP 22-6-1-200 MG* *PRENAT VIT-FE POLY CMPLX-FE HEME POLY-FA TAB 28-6-1 MG*** *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-1-215.8 MG*** *PRENATAL W/O A W/FE CBN-DSS-FA-DHA CAP 27-1-250 MG*** *PRENAT W/O A W/FEFUM-METHFOL-FADHA CAP 27-0.6-0.4-300 MG** *PRENAT W/O A W/ FE FUMERATEMETHYLFOLATE-FA-OMEGA 3 CAP***
188
Tier Value Tier 1 Tier 1 Tier 1 Tier 3 Tier 3 Tier 2 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 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 2 Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 2 Tier 3 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
VITAMINS - VITAMIN B COMPLEX
CYANOCOBAL POW
VITAMINS - VITAMIN B COMPLEX
CYANOCOBALAM CRY
CYANOCOBALAMIN POWDER (FOR COMPOUNDING) CYANOCOBALAMIN CRYSTALS
VITAMINS - VITAMIN B COMPLEX
FA-8 CAP 800MCG
FOLIC ACID CAP 0.8 MG
VITAMINS - VITAMIN B COMPLEX
FA-8 TAB 0.8MG
FOLIC ACID TAB 800 MCG
VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX VITAMINS - VITAMIN B COMPLEX
FOLIC ACID POW FOLIC ACID TAB 1000MCG FOLIC ACID TAB 1MG
FOLIC ACID POWDER FOLIC ACID TAB 1 MG FOLIC ACID TAB 1 MG
VITAMINS - VITAMIN B COMPLEX
FOLIC ACID TAB 400MCG
FOLIC ACID TAB 400 MCG
VITAMINS - VITAMIN B COMPLEX
FOLIC ACID TAB 800MCG
FOLIC ACID TAB 800 MCG
VITAMINS - VITAMIN B COMPLEX
NASCOBAL SPR 500MCG
CYANOCOBALAMIN NASAL SPRAY 500 MCG/0.1ML
VITAMINS - VITAMIN B COMPLEX
SM FOLIC ACD TAB 400MCG FOLIC ACID TAB 400 MCG
VITAMINS - VITAMIN D
CVD D3 CHW 1000UNIT
CHOLECALCIFEROL CHEW TAB 1000 UNIT
VITAMINS - VITAMIN D
CVS D3 CAP 1000UNIT
CHOLECALCIFEROL CAP 1000 UNIT
VITAMINS - VITAMIN D
CVS D3 CAP 400UNIT
CHOLECALCIFEROL CAP 400 UNIT
VITAMINS - VITAMIN D
CVS D3 CHW 1000 UNT
CHOLECALCIFEROL CHEW TAB 1000 UNIT
VITAMINS - VITAMIN D
D 1000 CHW 1000UNIT
CHOLECALCIFEROL CHEW TAB 1000 UNIT
VITAMINS - VITAMIN D
D 400 CHW 400UNIT
CHOLECALCIFEROL CHEW TAB 400 UNIT
VITAMINS - VITAMIN D
D 400 TAB 400UNIT
CHOLECALCIFEROL TAB 400 UNIT
VITAMINS - VITAMIN D
D3 CAP 1000UNIT
CHOLECALCIFEROL CAP 1000 UNIT
VITAMINS - VITAMIN D
D-3 GUMMY CHW 400UNIT
CHOLECALCIFEROL CHEW TAB 400 UNIT
VITAMINS - VITAMIN D
D-400 TAB 400UNIT
CHOLECALCIFEROL TAB 400 UNIT
VITAMINS - VITAMIN D
DELTA D3 TAB 400UNIT
CHOLECALCIFEROL TAB 400 UNIT
VITAMINS - VITAMIN D
DRISDOL CAP 50000UNT
ERGOCALCIFEROL CAP 50000 UNIT
VITAMINS - VITAMIN D
D-VI-SOL LIQ 400UNIT
CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML
VITAMINS - VITAMIN D
D-VITA LIQ 400UNIT
CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML
VITAMINS - VITAMIN D
GNP VIT D TAB 1000UNIT
CHOLECALCIFEROL TAB 1000 UNIT
VITAMINS - VITAMIN D
PEDIA D-VITE DRO 400UNIT
CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML
VITAMINS - VITAMIN D
VIT D CHILD CHW 1000UNIT CHOLECALCIFEROL CHEW TAB 1000 UNIT
VITAMINS - VITAMIN D
VITAMIN D CAP 1000UNIT
CHOLECALCIFEROL CAP 1000 UNIT
VITAMINS - VITAMIN D
VITAMIN D CAP 400UNIT
CHOLECALCIFEROL CAP 400 UNIT
VITAMINS - VITAMIN D
VITAMIN D CAP 50000UNT
ERGOCALCIFEROL CAP 50000 UNIT
189
Tier Value Tier 3 Tier 3 HCR Preventive Care HCR Preventive Care Tier 3 Tier 1 Tier 1 HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 1
Prior Supply Step Specialty Authorization Limit Therapy
Therapeutic Class
Label Name
Generic Name
VITAMINS - VITAMIN D
VITAMIN D CHW 400UNIT
CHOLECALCIFEROL CHEW TAB 400 UNIT
VITAMINS - VITAMIN D
VITAMIN D DRO 400UNIT
CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML
VITAMINS - VITAMIN D
VITAMIN D TAB 1000UNIT
CHOLECALCIFEROL TAB 1000 UNIT
VITAMINS - VITAMIN D
VITAMIN D TAB 400UNIT
CHOLECALCIFEROL TAB 400 UNIT
VITAMINS - VITAMIN D
VITAMIN D2 TAB 400UNIT
ERGOCALCIFEROL TAB 400 UNIT
VITAMINS - VITAMIN D
VITAMIN D3 CAP 1000UNIT
CHOLECALCIFEROL CAP 1000 UNIT
VITAMINS - VITAMIN D
VITAMIN D3 CAP 400UNIT
CHOLECALCIFEROL CAP 400 UNIT
VITAMINS - VITAMIN D
VITAMIN D3 CHW 1000UNIT
CHOLECALCIFEROL CHEW TAB 1000 UNIT
VITAMINS - VITAMIN D
VITAMIN D3 CHW 400UNIT
CHOLECALCIFEROL CHEW TAB 400 UNIT
VITAMINS - VITAMIN D
VITAMIN D3 DRO 400UNIT
CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML
VITAMINS - VITAMIN D
VITAMIN D3 TAB 1000UNIT
CHOLECALCIFEROL TAB 1000 UNIT
VITAMINS - VITAMIN D
VITAMIN D3 TAB 400UNIT
CHOLECALCIFEROL TAB 400 UNIT
VITAMINS - VITAMIN D
VITAMIN D-3 TAB 1000UNIT
CHOLECALCIFEROL TAB 1000 UNIT
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
WHEAT GERM OIL MEPHYTON TAB 5MG CITRANATAL CAP HARMONY
*WHEAT GERM - OIL*** PHYTONADIONE TAB 5 MG *PRENAT W/O A W/FE FUM-FE CBN-DSSFA-DHA CAP 27-1-260 MG*** *PRENAT W/ B2-B6-B12-D3-FOLIC ACID CHEW TAB 1.4 MG** *PRENAT W/OA W/FEFUM-NA FERED-FADHA CAP CR 30-1.4-200 MG*** *PRENAT W/O A W/FEASP-METHYLF-FAOMEG CAP 29-0.6-0.4-340 MG*
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
PRENA1 CHW PRENA1 PEARL CAP PRENATE CAP ESSENTIA PRIMACARE CAP REDICHEW RX CHW VITAFOL-NANO TAB VITAPEARL CAP
*PRENAT W/O A W/FEASP-METHLF-FAOMEG CAP 30-0.75-0.25-470MG* *PRENAT W/ B2-B6-B12-D3-FOLIC ACID CHEW TAB 1.4 MG** *PRENATAL W/O A W/ FEFUM-L METHYLFOL-FA TAB 18-0.6-0.4 MG*** *PRENAT W/OA W/FEFUM-NA FERED-FADHA CAP CR 30-1.4-200 MG***
190
Tier Value HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care HCR Preventive Care Tier 3 Tier 2 Tier 3 Tier 3 Tier 3 Tier 3 HCR Preventive Care Tier 3 Tier 3 Tier 3
Prior Supply Step Specialty Authorization Limit Therapy
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66064-062017 M56821 6/17 ©2017 United HealthCare Services, Inc.
