HealthNow New York Medication Guide
HealthNow New York Medication Guide
HealthNow New York Medication Guide
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>HealthNow</strong> <strong>New</strong> <strong>York</strong><br />
<strong>Medication</strong> <strong>Guide</strong><br />
Please bring this guide<br />
with you the next time<br />
you visit your doctor.<br />
© 2006 Medco Health Solutions, Inc. All rights reserved.<br />
Medco is a registered trademark of Medco Health Solutions, Inc.<br />
If you have questions about your prescription drug benefit,<br />
visit the Medco Pharmacy section of the <strong>HealthNow</strong> web site at<br />
www.healthnowny.com.<br />
MG914573<br />
(Ed. 6/06)
The <strong>HealthNow</strong> <strong>New</strong> <strong>York</strong> <strong>Medication</strong> <strong>Guide</strong> is a list of drugs to help guide physicians and pharmacists<br />
to select the medication that provides the appropriate treatment for the best price.<br />
Save Money on Your Prescription Drugs<br />
Here’s what you can do to save money:<br />
1. Bring this member guide to your doctor and review the cost-saving information below.<br />
2. Ask your doctor whether a generic or plan-preferred brand-name drug listed in this guide is<br />
right for you.*<br />
Tier 1<br />
Generic<br />
drugs<br />
Lowest cost to you<br />
Tier 2<br />
Lower-cost categories –<br />
Plan-preferred<br />
brand-name drugs<br />
Tier 3<br />
Higher-cost categories –<br />
Non-preferred<br />
brand-name<br />
drugs<br />
Highest cost to you<br />
The amount you pay for a drug is determined by which medication you purchase and where it appears<br />
on the guide. Your specific drug plan may cover medications on all three tiers of the guide, or you may<br />
have coverage for medications on Tier 1 and Tier 2 only. Some drug plans also exclude certain drugs<br />
or classes of drugs from coverage. Please check your contract or other plan documents if you have a<br />
question about your specific drug coverage.<br />
Finding <strong>Medication</strong>s on the <strong>Guide</strong><br />
This guide lists medications two different ways:<br />
Section 1: Alphabetically by Drug Category (such as Diabetes, Heart or Pain/Arthritis)<br />
Locate a category and drug on the guide and you will see the tier and copayment for that<br />
drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. Most generic medications<br />
are Tier 1; preferred brand-name medications are Tier 2; nonpreferred generic and<br />
brand-name drugs are Tier 3. To determine if a drug is a generic or brand-name medication,<br />
look at the name of the drug. Generic medications are lower case (e.g., amoxicillin), and<br />
brand-name medications are capitalized (e.g., Zithromax).<br />
Section 2: Alphabetically by drug name. Use this list to find your drug and its tier.<br />
Questions? Please call Medco Member Services at 1-800-939-3751 if you have any questions about the<br />
Three-Tier <strong>Medication</strong> <strong>Guide</strong>. For the most up-to-date version of the <strong>Guide</strong>, visit the Medco Pharmacy<br />
section of our web site at www.healthnowny.com.<br />
* Some plan designs require that you use a Tier 1 generic drug if a generic is available.<br />
Disclaimer: This list is effective only for the dates shown on the <strong>Guide</strong>. The Three Tier <strong>Medication</strong> <strong>Guide</strong> is subject to change,<br />
as we regularly review medications and existing therapies for inclusion in the <strong>HealthNow</strong> <strong>New</strong> <strong>York</strong> Formulary. The tier that a<br />
medication is currently in may change during the effective dates of the guides due to generic availability.<br />
2
Allergy/Cough & Cold<br />
Antihistamines & Decongestants<br />
brompheniramine/phenylephrine 1<br />
brompheniramine/ 1<br />
pseudoephedrine<br />
brompheniramine/pseudoephedrine<br />
carbinoxamine 1<br />
carbinoxamine/pseudoephedrine 1<br />
chlorpheniramine/ 1<br />
phenylephrine/pyrilamine/chlorpheniramine<br />
pseudoephedrine<br />
clemastine-OTC<br />
chlorpheniramine/pseudoephedrine<br />
1<br />
cyproheptadine 1<br />
dexchlorpheniramine 1<br />
diphenhydramine-OTC 1<br />
extrendryl SR 1<br />
hydroxyzine HCL 1<br />
hydroxyzine pamoate 1<br />
loratadine - OTC ONLY 1<br />
loratadine-D - OTC ONLY 1<br />
phenylephrine/pyrilamine/ 1<br />
chlorpheniramine<br />
carbinoxamine/DM/pseudoephedrine<br />
promethazine 1<br />
promethazine/phenylephrine 1<br />
promethazine/pyrilamine 1<br />
pseudoephedrine 30/60mg-OTC 1<br />
pseudoephedrine syr - OTC 1<br />
Histex IE 2<br />
Semprex-D 2<br />
❚ Allegra 3<br />
Allegra-D 3<br />
Bromfed 3<br />
Clarinex/D 3<br />
Durahist/PE 3<br />
fexofenadine 3<br />
Phenergan 3<br />
Rondec 3<br />
Rynatan/Ped. Susp 3<br />
Vistaril 3<br />
❚ Zyrtec tab/syrup 3<br />
❚ Zyrtec-D 3<br />
Expectorant & Cough Products<br />
benzonatate 1<br />
brompheniramine/pseud/DM 1<br />
carbinoxamine/DM/ 1<br />
pseudoephedrine<br />
cardec/DM 1<br />
chlorphen/hydrocodone/ 1<br />
phenylephrine<br />
chlorphen/hydrocodone/phenylephrine<br />
chlorphen/hydrocodone/ 1<br />
pseudoephedrine<br />
chlorphen/hydrocodone/pseudoephedrine<br />
chlorphen/pseudo/codeine 1<br />
guaifenesin 1200/DM 1<br />
guaifenesin/codeine 1<br />
guaifenesin/codeine/ 1<br />
pseudoephedrine<br />
guaifenesin/codeine/pseudoephedrine<br />
promethazine/phenylephrine/codeine<br />
guaifenesin/hydrocodone 1<br />
guaifenesin/pseudoephedrine 1<br />
guaifenesin/pseudoephedrine/DM 1<br />
hydrocodone/homatropine 1<br />
promethazine/codeine 1<br />
promethazine/codeine/DM 1<br />
promethazine/DM 1<br />
promethazine/phenylephrine/ 1<br />
codeine<br />
pseudoephedrine/codeine 1<br />
Tussionex susp 2<br />
Duratuss 3<br />
Entex LA 3<br />
Humibid DM/LA 3<br />
Hycodan 3<br />
Rondec DM/TR 3<br />
Tessalon Perles 3<br />
Mucolytic Agents<br />
acetylcysteine inh soln. 1<br />
Mucomyst inh soln. 3<br />
Nasal <strong>Medication</strong>s<br />
flunisolide spray 1<br />
fluticasone nasal spray 1<br />
ipratropium nasal spray 1<br />
Astelin 2<br />
❚ Flonase 2<br />
❚ Nasacort AQ 2<br />
SECTION I — THERAPEUTIC DRUG CATEGORIES<br />
TIER TIER TIER TIER<br />
Nasonex 2<br />
❚ Rhinocort AQ 2<br />
Atrovent Nasal Spray 3<br />
Beconase AQ 3<br />
Nasarel 3<br />
Alzheimer Agents<br />
ergoloid mesylates 1<br />
Aricept/ODT 2<br />
Namenda 2<br />
Cognex 3<br />
Exelon 3<br />
Razadyne/ER 3<br />
Reminyl sol. 3<br />
Bladder/Kidney<br />
Acidifiers<br />
K-Phos Original 2<br />
Alkalinizers<br />
citric acid/sod citrate 1<br />
generic Polycitra/LC/K 1<br />
Bicitra 3<br />
Oracit 3<br />
Polycitra ALL 3<br />
Urocit-K 3<br />
Analgesics<br />
phenazopyridine 1<br />
Pyridium 3<br />
Anticholinergics<br />
oxybutynin 1<br />
❚ Detrol 2<br />
❚ Detrol LA 2<br />
❚ Ditropan XL 2<br />
❚ Ditropan 3<br />
❚ Enablex 3<br />
❚ Oxytrol 3<br />
❚ Sanctura 3<br />
❚ Vesicare 3<br />
Cholinergic Agents<br />
bethanecol 1<br />
Urecholine 3<br />
Other urinary agents<br />
Elmiron 2<br />
Blood<br />
Anticoagulants/antithrombotics<br />
dipyridamole 1<br />
heparin 1<br />
ticlopidine 1<br />
warfarin 1<br />
Aggrenox 2<br />
Coumadin 2<br />
Fragmin 2<br />
Lovenox 2<br />
Plavix 2<br />
Arixtra 3<br />
Innohep 3<br />
Persantine 3<br />
Ticlid 3<br />
Antiheparin Agents (hemostatic)<br />
aminocaproic acid 1<br />
Amicar 3<br />
Other Blood Modifiers<br />
cilostazol 1<br />
pentoxifylline 1<br />
+ Actimmune 2<br />
+ Aranesp 2<br />
+ Leukine 2<br />
Miacalcin inj. 2<br />
+ Neulasta 2<br />
+ Neupogen 2<br />
+ Procrit 2<br />
Revlimid 2<br />
+Epogen 3<br />
Pletal 3<br />
Trental 3<br />
KEY: = A step edit applies to this drug.<br />
Note: 1.<br />
❚ = Specific Quantity Limits Apply.<br />
= Prior Authorization Required.<br />
◆ = Included in Tablet-Splitting Program<br />
ˆ = Approved for Males only.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.<br />
3<br />
Cancer Drugs<br />
Alkylating Agents<br />
cyclophosphamide 1<br />
Alkeran 2<br />
CeeNu 2<br />
Emcyt 2<br />
Hexalen 2<br />
Leukeran 2<br />
Myleran 2<br />
Cytoxan 3<br />
Antimetabolites<br />
mercaptopurine 1<br />
methotrexate 1<br />
+<br />
Thioguanine 2<br />
Xeloda 2<br />
Purinethol 3<br />
Trexall 3<br />
Hormones<br />
flutamide 1<br />
megestrol 1<br />
tamoxifen 1<br />
Arimidex 2<br />
Aromasin 2<br />
Casodex 2<br />
Fareston 2<br />
Femara 2<br />
Eulexin 3<br />
Megace sol. 3<br />
Nolvadex 3<br />
Miscellaneous<br />
etoposide 1<br />
hydroxyurea 1<br />
+ Gleevec 2<br />
+ Intron A 2<br />
+ Iressa 2<br />
Lysodren 2<br />
Matulane 2<br />
Mesnex 2<br />
+ Tarceva 2<br />
+ Temodar 2<br />
Thalomid 2<br />
Vesanoid 2<br />
Hydrea 3<br />
Vepesid 3<br />
Rexinoids<br />
Targretin 2<br />
Diabetes<br />
Antidiabetic Agents, Injectable<br />
Apidra 2<br />
Humalog insulin 2<br />
Humulin (all types) 2<br />
Iletin 2<br />
Lantus 2<br />
Levemir 2<br />
Novolin 2<br />
Novolog 2<br />
Byetta 3<br />
Symlin 3<br />
Antidiabetic Agents, Oral & Glucose<br />
Elevating agents<br />
chlorpropamide 1<br />
glimepiride 1<br />
glipizide 1<br />
glipizide ER 1<br />
glipizide/metformin 1<br />
glyburide 1<br />
glyburide micronized 1<br />
metformin 1<br />
metformin ER 1<br />
metformin/glyburide 1<br />
tolazamide 1<br />
tolbutamide 1<br />
ActoPLUS Met 2<br />
Actos 2<br />
Amaryl 2<br />
Avandamet 2<br />
Avandia 2<br />
Glucagon 2<br />
Metaglip 2<br />
Prandin 2<br />
2.<br />
3.<br />
Precose 2<br />
Avandaryl 3<br />
Diabeta 3<br />
Diabinese 3<br />
Fortamet 3<br />
Glucophage/XR 3<br />
Glucotrol/XL 3<br />
Glucovance 3<br />
Glynase 3<br />
Glyset 3<br />
Micronase 3<br />
Riomet solution 3<br />
Starlix 3<br />
Diabetic Supplies (Diabetic Benefit Applies)<br />
Accu-Check Compact<br />
Accu-Chek Active<br />
Accu-Chek Advantage<br />
ChemStrip BG<br />
FastTake<br />
One Touch Ultra<br />
One Touch UltraSmart<br />
SoftClix Device<br />
Surestep<br />
Ear<br />
Anti-infective Agents<br />
acetic acid otic 1<br />
acetic acid/aluminum acetate 1<br />
Floxin otic 2<br />
Domeboro 3<br />
Anti-infective/Anti-inflammatory<br />
combinations<br />
acetic acid HC otic 1<br />
generic Zoto HC 1<br />
neomycin/polymyxin/HC otic 1<br />
Ciprodex 2<br />
Cipro HC 3<br />
Cortisporin otic 3<br />
VoSol HC otic 3<br />
Zoto HC 3<br />
Local Anesthetic & Analgesic<br />
antipyrine/benzocaine/glycerin 1<br />
Wax Emulsifiers<br />
Cerumenex 2<br />
Eye<br />
Anesthetics<br />
proparacaine 1<br />
tetracaine 1<br />
Alcaine 3<br />
Pontocaine 3<br />
Antiallergy Agents (Eye)<br />
cromolyn ophth 1<br />
Alomide 2<br />
Optivar 2<br />
Patanol 2<br />
Zaditor 2<br />
Anti-infective Agents<br />
bacitracin ophth 1<br />
bacitracin/polymyxin 1<br />
ciprofloxacin ophth 1<br />
erythromycin ophth 1<br />
gentamicin ophth 1<br />
neomycin/bacitracin/poly B 1<br />
ofloxacin ophth 1<br />
polymyxin B/TMP 1<br />
sulfacetamide 10% 1<br />
tobramycin soln 1<br />
Tobrex ointment 2<br />
Vigamox 2<br />
Chloroptic 3<br />
Ciloxan 3<br />
Ocuflox 3<br />
Polytrim 3<br />
Tobrex solution 3<br />
Zymar 3<br />
Anti-inflammatory<br />
dexamethasone ophth 1<br />
eflone 1<br />
* Please note that medications listed in the 3rd tier are considered<br />
non-formulary and are not all-inclusive.<br />
* All branded self-injectables are subject to prior authorization &<br />
if approved, would be placed in the 2nd tier.<br />
* Some drugs are limited to 1 unit of use package per dispensing.
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)<br />
TIER TIER TIER TIER<br />
fluorometholone ophth 1 phenylephrine ophth 1<br />
prednisolone acetate 1 Neo-Synephrine 3<br />
prednisolone sod acetate 1<br />
FML Forte 2 Gout<br />
allopurinol 1<br />
colchicine 1<br />
Decadron 3<br />
colchicine/probenecid 1<br />
Flarex 3<br />
indomethacin 1<br />
FML/S 3<br />
probenecid 1<br />
Inflamase Forte 3<br />
sulfinpyrazone 1<br />
Inflamase Mild 3<br />
Indocin 3<br />
Maxidex 3<br />
Zyloprim 3<br />
Pred Forte 3<br />
FML S.O.P.<br />
Pred Mild<br />
2<br />
2<br />
Anti-inflammatory/Anti-infective Heart<br />
combinations<br />
Angiotensin Converting Enzyme Inhibitors<br />
dexameth/neomycin 1<br />
benazepril 1<br />
dexameth/neomycin/poly B 1<br />
captopril 1<br />
neomycin/bacitracin/poly B/HC 1<br />
enalapril 1<br />
sulfacetamide/prednisolone ophth 1<br />
fosinopril 1<br />
Tobradex 2<br />
lisinopril 1<br />
Cortisporin oint ophth 3<br />
quinapril 1<br />
Maxitrol ophth 3<br />
Altace 2<br />
Pred-G 3<br />
Accupril 3<br />
Vasocidin 3<br />
Zylet 3<br />
Aceon 3<br />
Capoten 3<br />
Antiviral<br />
Lotensin 3<br />
trifluridine 1 Mavik 3<br />
Viroptic 3 Monopril 3<br />
Beta-Blockers (Eye)<br />
Prinivil 3<br />
betaxolol HCL eye drops 1 Univasc 3<br />
carteolol 1 Vasotec 3<br />
levobunolol 1 Zestril 3<br />
metipranolol 1 Angiotensin II Antagonists<br />
timolol 1 Avapro 2<br />
timolol XE 1 Diovan 2<br />
Betoptic-S 2 Atacand 3<br />
Betagan 3 Benicar 3<br />
Istalol 3<br />
Cozaar 3<br />
Optipranolol 3<br />
Micardis 3<br />
Timoptic/XE 3<br />
Teveten 3<br />
Carbonic Anhydrase Inhibitors<br />
Anti-Adrenergic Blockers Centrally acting<br />
Azopt 2<br />
clonidine 1<br />
Cosopt 2<br />
guanabenz 1<br />
Trusopt 2<br />
guanfacine 1<br />
Miotics<br />
methyldopa 1<br />
carboptic 1 midodrine 1<br />
pilocarpine 1 Catapres TTS patch 2<br />
Isopto Carbachol 1.5% 2 Dibenzyline 2<br />
Phospholine Iodide 2 Aldomet 3<br />
Isopto Carbachol 3% 3 Catapres oral 3<br />
Isopto Carpine 3<br />
Anti-Adrenergic Blockers Peripheral<br />
Miscellaneous<br />
doxazosin 1<br />
Restasis 2 prazosin 1<br />
Mydriatics<br />
terazosin 1<br />
atropine sulfate ophth 1 Flomax 2<br />
homatropine 1 Cardura 3<br />
tropicamide 1 Hytrin 3<br />
Isopto Atropine 3 Minipress 3<br />
Mydriacyl 3 Antiarrhythmics<br />
NSAIDs<br />
amiodarone 1<br />
flurbiprofen ophth 1 digoxin 1<br />
Acular 2 disopyramide 1<br />
Acular LS 2 disopyramide CR 1<br />
Acular PF 3 flecainide 1<br />
Ocufen 3 mexiletine 1<br />
Voltaren 3 procainamide 1<br />
Prostaglandin Analogues/Prostamines procainamide SR 1<br />
Lumigan 2 propafenone 1<br />
Travatan 2 quinidine gluconate 1<br />
Xalatan 2 quinidine sulfate SR 1<br />
sotalol 1<br />
Sympathomimetics<br />
Ethmozine 2<br />
brimonidine 1 Lanoxin 2<br />
dipivefrin 1 Rythmol SR 2<br />
Alphagan P 2 Betapace/AF 3<br />
Alphagan 3<br />
Cordarone 3<br />
Propine 3<br />
Norpace/CR 3<br />
Vasoconstrictors<br />
Procanbid 3<br />
naphazoline 1 Pronestyl 3<br />
KEY: = A step edit applies to this drug.<br />
Note: 1.<br />
❚ = Specific Quantity Limits Apply.<br />
= Prior Authorization Required.<br />
◆ = Included in Tablet-Splitting Program<br />
ˆ = Approved for Males only.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.<br />
4<br />
Rythmol 3<br />
Tambocor 3<br />
Tikosyn 3<br />
Antilipemics<br />
cholestyramine 1<br />
gemfibrozil 1<br />
◆ lovastatin 1<br />
Advicor 2<br />
Colestid 2<br />
◆ Crestor 2<br />
◆ Lipitor 2<br />
Niaspan 2<br />
Tricor 2<br />
Zetia 2<br />
❚ Altoprev 3<br />
Antara 3<br />
Lescol/XL 3<br />
Lofibra 3<br />
Lopid 3<br />
◆❚ Mevacor 3<br />
◆❚ Pravachol 3<br />
Questran 3<br />
Vytorin 3<br />
Welchol 3<br />
◆ Zocor 3<br />
Beta Blockers<br />
acebutolol 1<br />
atenolol 1<br />
betaxolol 1<br />
bisoprolol 1<br />
labetalol 1<br />
metoprolol 1<br />
nadolol 1<br />
pindolol 1<br />
propranolol 1<br />
timolol 1<br />
Coreg 2<br />
Inderal LA 2<br />
Innopran XL 2<br />
Toprol XL 2<br />
Blocadren 3<br />
Corgard 3<br />
Inderal 3<br />
Kerlone 3<br />
Lopressor 3<br />
Tenormin 3<br />
Trandate 3<br />
Calcium Channel Blockers<br />
cartia XT 1<br />
diltia XT 1<br />
diltiazem 1<br />
diltiazem CD/SR/ER/XR 1<br />
felodipine 1<br />
nicardipine 1<br />
nifediac CC 1<br />
nifedical XL 1<br />
nifedipine 1<br />
nifedipine SR 1<br />
verapamil 1<br />
verapamil SR 1<br />
verapamil SR pellet 1<br />
Nimotop 2<br />
Norvasc 2<br />
Adalat CC 3<br />
Calan/SR 3<br />
Cardene/SR 3<br />
Cardizem/CD/SR/LA 3<br />
Covera HS 3<br />
Dilacor XR 3<br />
Dynacirc/CR 3<br />
isradipine 3<br />
Plendil 3<br />
Procardia/XL 3<br />
Sular 3<br />
Tiazac 3<br />
Verelan/PM 3<br />
Combination Anti-Hypertensive<br />
atenolol/chlorthalidone 1<br />
benazepril/HCTZ 1<br />
bisoprolol/HCTZ 1<br />
captopril/HCTZ 1<br />
2.<br />
3.<br />
nitroglycerin transdermal<br />
enalapril/HCTZ 1<br />
hydralazine/reserpine/HCTZ 1<br />
lisinopril/HCTZ 1<br />
methyldopa/HCTZ 1<br />
metoprolol/HCTZ 1<br />
propranolol/HCTZ 1<br />
quinapril/HCTZ 1<br />
Avalide 2<br />
Clorpres 2<br />
Diovan HCT 2<br />
Hydra-zide 2<br />
Lotrel 2<br />
Accuretic 3<br />
Aldoril 3<br />
Atacand HCT 3<br />
Benicar HCT 3<br />
Caduet 3<br />
Capozide 3<br />
fosinopril/HCTZ 3<br />
Hyzaar 3<br />
Inderide 3<br />
Lopressor HCT 3<br />
Lotensin HCT 3<br />
Micardis HCT 3<br />
Monopril HCT 3<br />
Prinzide 3<br />
Tarka 3<br />
Tenoretic 3<br />
Teveten HCT 3<br />
Vaseretic 3<br />
Zestoretic 3<br />
Ziac 3<br />
Diuretics<br />
acetazolamide 1<br />
amiloride 1<br />
amiloride/HCTZ 1<br />
bumetanide 1<br />
chlorothiazide 1<br />
chlorthalidone 1<br />
furosemide 1<br />
hydrochlorothiazide 1<br />
indapamide 1<br />
methazolamide 1<br />
methyclothiazide 1<br />
metolazone 1<br />
spironolactone 1<br />
spironolactone/HCTZ 1<br />
torsemide 1<br />
triamterene/HCTZ 1<br />
Diamox Sequels 2<br />
Aldactazide 3<br />
Aldactone 3<br />
Bumex 3<br />
Demadex 3<br />
Dyazide 3<br />
Lasix 3<br />
Lozol 3<br />
Maxzide 3<br />
Moduretic 3<br />
Zaroxolyn 3<br />
Miscellaneous Anti-hypertensives<br />
midodrine 1<br />
❚ Inspra 3<br />
ProAmatine 3<br />
Vasodilators<br />
hydralazine 1<br />
isosorbide dinitrate 1<br />
isosorbide mononitrate 1<br />
isosorbide mononitrate SA 1<br />
isoxsuprine 1<br />
minoxidil oral 1<br />
Nitrek nitroglycerin patch 1<br />
nitroglycerin oint 1<br />
nitroglycerin SR 1<br />
nitroglycerin sublingual 1<br />
nitroglycerin transdermal 1<br />
patch<br />
Dilatrate SR<br />
patch<br />
2<br />
Nitrolingual pump 2<br />
Nitrolingual spray 2<br />
Imdur 3<br />
Isordil 3<br />
* Please note that medications listed in the 3rd tier are considered<br />
non-formulary and are not all-inclusive.<br />
* All branded self-injectables are subject to prior authorization &<br />
if approved, would be placed in the 2nd tier.<br />
* Some drugs are limited to 1 unit of use package per dispensing.
Minitran 3<br />
NitroDur patches 3<br />
Nitrostat SL tabs 3<br />
+ Revatio 3<br />
HIV - Antivirals<br />
Non-Nucleoside Reverse Transcriptase<br />
Inhibitor<br />
Rescriptor 2<br />
Sustiva 2<br />
Viramune 2<br />
Nucleoside Analog Reverse Transcriptase<br />
Inhibitor Combination<br />
Combivir 2<br />
Trizivir 2<br />
Truvada 2<br />
Viread 2<br />
Nucleoside Reverse Transcriptase<br />
Inhibitors<br />
didanosine 1<br />
Emtriva 2<br />
Epivir 2<br />
Epzicom 2<br />
Hivid 2<br />
Retrovir 2<br />
Videx 2<br />
Zerit 2<br />
Ziagen 2<br />
Videx EC 3<br />
Protease Inhibitors<br />
Agenerase 2<br />
Crixivan 2<br />
Fortovase 2<br />
Invirase 2<br />
Lexiva 2<br />
Norvir 2<br />
Reyataz 2<br />
Viracept 2<br />
Protease Inhibitors Combinations<br />
Kaletra 2<br />
Immunosuppressants<br />
azathioprine 1<br />
cyclosporine 1<br />
ganciclovir 1<br />
gengraf 1<br />
Cellcept 2<br />
Neoral 2<br />
Prograf 2<br />
Rapamune 2<br />
Sandimmune 2<br />
Cytovene 3<br />
Imuran 3<br />
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)<br />
TIER TIER TIER TIER<br />
ethylsuccinate<br />
erythromycin ethylsuccinate 1<br />
(E.E.S.)<br />
erythromycin<br />
erythromycin stearate<br />
(E.E.S.)<br />
1<br />
erythromycin/sulfisoxazole 1<br />
minocycline 1<br />
penicillin VK 1<br />
sulfamethoxazole/trimethoprim 1<br />
sulfisoxazole tabs 1<br />
tetracycline 1<br />
Augmentin XR 2<br />
Biaxin suspension 2<br />
Biaxin tabs 2<br />
Biaxin XL 2<br />
Ceftin Susp 2<br />
Cefzil 2<br />
Ery-Tab 2<br />
Levaquin 2<br />
Lorabid Caps 2<br />
Lorabid Susp 2<br />
Omnicef 2<br />
Vantin susp 2<br />
Zithromax susp. 2<br />
Zmax 2<br />
Augmentin/ES 3<br />
Avelox 3<br />
Bactrim/DS 3<br />
Biaxin suspension 3<br />
Biaxin tab 3<br />
Ceclor 3<br />
cefadroxil 3<br />
Ceftin 3<br />
Cipro/XR 3<br />
Cleocin 3<br />
Dispermox 3<br />
Doryx 3<br />
doxycycline 20mg tab 3<br />
Duricef 3<br />
Dynacin 3<br />
Eryc 3<br />
Factive 3<br />
Floxin oral 3<br />
Furadantin 3<br />
Gantrisin Susp 3<br />
Ketek 3<br />
Maxaquin 3<br />
Minocin 3<br />
Myrac 3<br />
Noroxin 3<br />
ofloxacin 3<br />
PCE 3<br />
Pediazole 3<br />
Periostat 3<br />
Septra/DS 3<br />
Spectracef 3<br />
Suprax 3<br />
Tequin 3<br />
Vantin 3<br />
Vibramycin 3<br />
Zithromax tablets 3<br />
Antifungals<br />
fluconazole 1<br />
❚ fluconazole 150 mg tab 1<br />
❚ itraconazole 1<br />
ketoconazole 1<br />
nystatin 1<br />
Ancobon 2<br />
Grifulvin V susp 2<br />
Grispeg 2<br />
❚ Lamisil Oral 2<br />
❚ Vfend 2<br />
Diflucan 3<br />
❚ Diflucan 150mg 3<br />
Nizoral tablets 3<br />
❚ Sporanox 3<br />
Antimalarials<br />
chloroquine phosphate 1<br />
hydroxychloroquine 1<br />
mefloquine 1<br />
quinine sulfate 1<br />
Daraprim 2<br />
Malarone 2<br />
Primaquine 2<br />
Infection<br />
Amebicides<br />
metronidazole 1<br />
Yodoxin 2<br />
Flagyl/ER 3<br />
Tindamax 3<br />
Anthelmintics<br />
mebendazole chew tab 1<br />
Vermox chew tab 3<br />
Antibacterial agents/Antibiotics<br />
amoxicillin 1<br />
amoxicillin/clavulanate 1<br />
ampicillin 1<br />
azithromycin tablets 1<br />
cefaclor 1<br />
cefpodoxime 1<br />
cefprozil 1<br />
cefuroxime 1<br />
cephalexin 1<br />
cephradine 1<br />
ciprofloxacin 1<br />
clindamycin HCL 1<br />
dicloxacillin 1<br />
doxycycline 1<br />
erythromycin base 1<br />
erythromycin estolate 1<br />
KEY: = A step edit applies to this drug.<br />
Note: 1.<br />
❚ = Specific Quantity Limits Apply.<br />
= Prior Authorization Required.<br />
◆ = Included in Tablet-Splitting Program<br />
ˆ = Approved for Males only.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.<br />
5<br />
Aralen 3<br />
Lariam 3<br />
Plaquenil 3<br />
Antituberculosis<br />
ethambutol 1<br />
isoniazid 1<br />
pyrazinamide 1<br />
rifampin 1<br />
Mycobutin 2<br />
Rifamate 2<br />
Rifater 2<br />
Myambutol 3<br />
Rifadin 3<br />
Antivirals<br />
acyclovir oral 1<br />
amantadine 1<br />
ganciclovir 1<br />
+ ribapak 1<br />
+ ribasphere 1<br />
+ ribatab 1<br />
+ ribavirin 1<br />
rimantadine 1<br />
Epivir-HBV 2<br />
Famvir 2<br />
Hepsera 2<br />
+ Pegasys 2<br />
+PegIntron 2<br />
+Rebetron 2<br />
❚ Relenza 2<br />
❚ Tamiflu 2<br />
Valcyte 2<br />
Valtrex 2<br />
Baraclude 3<br />
+ Copegus 3<br />
Cytovene 3<br />
Flumadine 3<br />
+ Rebetol 3<br />
Symmetrel 3<br />
Zovirax 3<br />
Other Anti-Infectives<br />
methenamine combination 1<br />
metronidazole 1<br />
neomycin 1<br />
nitrofurantoin 1<br />
paromomycin 1<br />
trimethoprim 1<br />
Dapsone 2<br />
Mepron 2<br />
Nebupent 2<br />
Tobi 2<br />
Vancocin 2<br />
Zyvox 2<br />
Flagyl/ER 3<br />
Humatin 3<br />
Macrobid 3<br />
Macrodantin 3<br />
Trimpex 3<br />
Urised 3<br />
Xifaxan 3<br />
Men's Health<br />
Impotence^ - possible contract exclusion;<br />
refer to individual contract<br />
^ yohimbine 1<br />
❚^ Caverject 2<br />
❚^ MUSE 2<br />
❚^ Viagra 2<br />
❚^ Cialis 3<br />
❚^ Edex 3<br />
❚^ Levitra 3<br />
Male Hormones<br />
Androderm patch 2<br />
❚ Androgel 2<br />
Testosterone 2<br />
Android 3<br />
fluoxymesterone 3<br />
Striant 3<br />
Testim 3<br />
2.<br />
3.<br />
Prostate Health<br />
❚^ Avodart 2<br />
❚^ Proscar 2<br />
^ Uroxatral 2<br />
Mental Health<br />
Antidepressants<br />
amitriptyline 1<br />
amitriptyline/chlordiazepoxide 1<br />
amitriptyline/perphenazine 1<br />
amoxapine 1<br />
bupropion 1<br />
bupropion ER 1<br />
◆ citalopram 1<br />
clomipramine 1<br />
desipramine 1<br />
doxepin 1<br />
◆ fluoxetine 10mg tablet 1<br />
fluoxetine capsule 1<br />
◆ fluvoxamine 25mg, 50mg 1<br />
fluvoxamine 100mg 1<br />
imipramine 1<br />
maprotiline 1<br />
◆ mirtazapine 15mg 1<br />
mirtazapine 30mg, 45mg 1<br />
nefazodone 1<br />
nortriptyline 1<br />
◆ paroxetine HCL 1<br />
trazodone 1<br />
❚ Cymbalta 2<br />
◆❚ Effexor tabs 2<br />
❚ Effexor XR 2<br />
◆❚ Lexapro 2<br />
Nardil 2<br />
Parnate 2<br />
Wellbutrin XL 2<br />
◆❚ Zoloft 2<br />
❚ Zoloft Elixir 2<br />
Anafranil 3<br />
◆ Celexa 3<br />
Desyrel 3<br />
Elavil 3<br />
mirtazapine sol tab/7.5mg 3<br />
Norpramin 3<br />
Pamelor 3<br />
◆ Paxil 3<br />
Paxil CR 3<br />
Prozac capsule 3<br />
❚ Prozac Weekly 3<br />
◆ Remeron 3<br />
Remeron Sol Tab 3<br />
Sarafem 3<br />
Sinequan 3<br />
❚ Symbyax 3<br />
Tofranil/PM 3<br />
Vivactil 3<br />
❚ Wellbutrin/SR 3<br />
Antimanic Agents<br />
lithium carbonate 1<br />
Eskalith/CR 3<br />
Lithobid 3<br />
Antipsychotic Agents<br />
chlorpromazine 1<br />
+ clozapine 1<br />
fluphenazine 1<br />
haloperidol 1<br />
loxapine 1<br />
perphenazine 1<br />
thioridazine 1<br />
thiothixene 1<br />
trifluoperazine 1<br />
Abilify 2<br />
Clozaril 2<br />
❚ Risperdal 2<br />
❚ Risperdal-M 2<br />
❚ Zyprexa 2<br />
❚ Zyprexa Zydis 2<br />
Fazaclo 3<br />
Geodon 3<br />
Loxitane 3<br />
Navane 3<br />
Prolixin 3<br />
* Please note that medications listed in the 3rd tier are considered<br />
non-formulary and are not all-inclusive.<br />
* All branded self-injectables are subject to prior authorization &<br />
if approved, would be placed in the 2nd tier.<br />
* Some drugs are limited to 1 unit of use package per dispensing.
Risperdal lingual 3<br />
Seroquel 3<br />
Anxiolytics, Sedatives, and Hypnotics<br />
alprazolam/ER 1<br />
buspirone 1<br />
chloral hydrate 1<br />
chlordiazepoxide 1<br />
clorazepate 1<br />
diazepam 1<br />
estazolam 1<br />
flurazepam 1<br />
lorazepam 1<br />
meprobamate 1<br />
oxazepam 1<br />
temazepam 1<br />
triazolam 1<br />
❚ Ambien 2<br />
Restoril 7.5mg 2<br />
Somnote 2<br />
❚ Ambien CR 3<br />
Ativan 3<br />
Buspar 3<br />
Dalmane 3<br />
Halcion 3<br />
Librium 3<br />
❚ Lunesta 3<br />
Miltown 3<br />
Restoril 3<br />
Serax 3<br />
❚ Sonata 3<br />
Tranxene SD/T 3<br />
Valium 3<br />
Xanax/XR 3<br />
Cerebral Stimulants<br />
dextroamphetamine tabs 1<br />
generic Adderall 1<br />
generic Dexedrine spansules 1<br />
metadate ER 1<br />
methylphenidate/SR 1<br />
pemoline 1<br />
Adderall XR 2<br />
Concerta 2<br />
Metadate CD 2<br />
❚ Provigil 2<br />
Ritalin LA 2<br />
❚ Strattera 2<br />
Adderall 3<br />
Dexedrine tab/spansules 3<br />
Focalin/XR 3<br />
Ritalin/SR 3<br />
Muscle Stimulants<br />
pyridostigmine bromide 1<br />
Mestinon 3<br />
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)<br />
TIER TIER TIER TIER<br />
+Zorbtive 3<br />
Sialogogues<br />
pilocarpine 1<br />
Evoxac 2<br />
Salagen 3<br />
Multiple Sclerosis Agents<br />
+ Avonex 2<br />
+ Copaxone 2<br />
+ Rebif 2<br />
+ Betaseron 3<br />
Muscle Relaxants<br />
baclofen 1<br />
carisoprodol 1<br />
carisoprodol/ASA 1<br />
cyclobenzaprine 1<br />
diazepam 1<br />
methocarbamol 1<br />
methocarbamol/ASA 1<br />
orphenadrine 1<br />
tizanidine 1<br />
chlorzoxazone 3<br />
Dantrium 3<br />
Flexeril 3<br />
Parafon Forte 3<br />
Robaxin 3<br />
Skelaxin 3<br />
Soma/Compound 3<br />
Valium 3<br />
Zanaflex 3<br />
Osteoporosis<br />
❚ fortical NS 1<br />
❚ Actonel 2<br />
❚ Evista 2<br />
+ Forteo 2<br />
❚ Fosamax 2<br />
❚ Fosamax D 2<br />
❚ Miacalcin NS 2<br />
Boniva 3<br />
Pain/Arthritis<br />
Analgesics, Narcotic<br />
acetaminophen w/codeine 1<br />
aspirin w/codeine 1<br />
belladonna & opium supp 1<br />
butalbital/APAP/codeine 1<br />
butalbital/aspirin/codeine 1<br />
+❚ butorphanol NS 1<br />
endocet 1<br />
fentanyl patch (25,50,75,100 mg) 1<br />
Miscellaneous<br />
hydrocodone/APAP 1<br />
hydromorphone 1<br />
Antidiuretic Agents<br />
desmopressin solution 1<br />
meperidine<br />
meperidine/promethazine<br />
1<br />
1<br />
desmopressin tabs 1 methadone 1<br />
DDAVP nasal spray 2 morphine SR 1<br />
Stimate 2 morphine tab, soln, supp 1<br />
DDAVP sol, tab 3 MSIR tabs, sol 1<br />
oxycodone (10, 20, 40, 80mg) 1<br />
Other CNS<br />
oxycodone SA 1<br />
naltrexone 1<br />
oxycodone/acetaminophen 1<br />
Antabuse 2<br />
Rilutek 2<br />
oxycodone/aspirin 1<br />
Suboxone 2<br />
pentazocine/naloxone 1<br />
Subutex 2<br />
propoxyphene HCL 1<br />
Campral 3<br />
propoxyphene HCL/APAP 1<br />
propoxyphene HCL/ASA/caffeine 1<br />
Other Endocrine<br />
propoxyphene napsylate/APAP 1<br />
danazol 1 Darvon-N 2<br />
fludrocortisone 1 Duragesic patch 12mg 2<br />
Cortrosyn 2 Kadian 2<br />
+ Norditropin 2 Lorabid 2<br />
+ Nutropin/AQ 2 Oxycontin 160 mg 2<br />
Sensipar 2 Roxicet 2<br />
Synarel 2 Subutex 2<br />
Zavesca 2 Avinza 3<br />
Florinef 3 B&O supprettes 3<br />
+Humatrope 3 Codeine 3<br />
+Saizen 3<br />
Combunox 3<br />
KEY: = A step edit applies to this drug.<br />
Note: 1.<br />
❚ = Specific Quantity Limits Apply.<br />
= Prior Authorization Required.<br />
◆ = Included in Tablet-Splitting Program<br />
ˆ = Approved for Males only.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.<br />
6<br />
Duragesic patch (25,50,75,100mg)<br />
Darvocet-N 3<br />
Darvon Comp-65 3<br />
Darvon/Darvon-65 3<br />
Demerol 3<br />
Dilaudid 3<br />
Duragesic patch (25,50,75, 3<br />
100mg)<br />
Fioricet/codeine 3<br />
Fiorinal/codeine 3<br />
hydrocodone/ibuprofen 3<br />
Lortab 3<br />
MS Contin 3<br />
Oxycontin (10, 20, 40, 80mg) 3<br />
Palladone 3<br />
Percocet 3<br />
Percodan 3<br />
Talwin NX 3<br />
Tylenol/codeine 3<br />
Vicodin/ES 3<br />
Vicoprofen 3<br />
Vopac 3<br />
Analgesics, Salicylates<br />
aspirin SR 1<br />
choline mag. trisalicylate 1<br />
diflunisal 1<br />
salsalate 1<br />
Dolobid 3<br />
Easprin 3<br />
Anti-Rheumatic<br />
hydroxychloroquine 1<br />
methotrexate 1<br />
Arava 2<br />
Cuprimine 2<br />
+ Enbrel 2<br />
+ Humira 2<br />
+ Kineret 2<br />
Ridaura 2<br />
Depen 3<br />
Plaquenil 3<br />
Cox-2s<br />
❚ Celebrex 3<br />
Migraine (Analgesics, Non-narcotic)<br />
bellamine 1<br />
bellamine-S 1<br />
Bellaspas 1<br />
butalbital/APAP 1<br />
butalbital/APAP/caffeine 1<br />
butalbital/aspirin/caffeine 1<br />
ergotamine/caffeine 1<br />
isometh/dichloralphen/APAP 1<br />
tramadol 1<br />
❚ Amerge 2<br />
Ergomar 2<br />
❚ Frova 2<br />
❚ Imitrex tab, nasal, injection 2<br />
❚ Maxalt 2<br />
❚ Maxalt MLT 2<br />
❚ Migranal 2<br />
❚ Relpax 2<br />
❚ Zomig 2<br />
Zomig Nasal 2<br />
❚ Zomig ZMT 2<br />
❚ Axert 3<br />
Cafergot 3<br />
Fioricet/Fiorinal 3<br />
Midrin 3<br />
Ultracet 3<br />
Ultram/ER 3<br />
Nonsteroidal Anti-Inflammatory/<br />
Combination Products<br />
diclofenac potassium 1<br />
diclofenac sodium 1<br />
etodolac 1<br />
etodolac SA 1<br />
fenoprofen 1<br />
flurbiprofen 1<br />
ibuprofen 1<br />
indomethacin 1<br />
ketoprofen 1<br />
❚ ketorolac inj. 1<br />
meclofenamate 1<br />
2.<br />
3.<br />
nabumetone 1<br />
naproxen 1<br />
naproxen EC 1<br />
oxaprozin 1<br />
piroxicam 1<br />
sulindac 1<br />
tolmetin 1<br />
Anaprox 3<br />
Ansaid 3<br />
Arthrotec 3<br />
Cataflam 3<br />
Clinoril 3<br />
Daypro 3<br />
diclofenac sodium SA 3<br />
Feldene 3<br />
Indocin 3<br />
❚ ketorolac tab 3<br />
Lodine/XL 3<br />
❚ Mobic 3<br />
Motrin 3<br />
Naprosyn 3<br />
Oruvail 3<br />
Prevacid Naprapac 3<br />
Relafen 3<br />
❚ Toradol inj/tabs 3<br />
Voltaren/XR 3<br />
Parkinson's Disease<br />
amantadine 1<br />
benztropine 1<br />
bromocriptine 1<br />
carbidopa/levodopa 1<br />
carbidopa/levodopa SA 1<br />
selegiline 1<br />
trihexyphenidyl 1<br />
+ Apokyn 2<br />
Comtan 2<br />
Mirapex 2<br />
Requip 2<br />
Stalevo 2<br />
Dostinex 3<br />
Eldepryl 3<br />
Parcopa 3<br />
Parlodel 3<br />
pergolide 3<br />
Permax 3<br />
Sinemet/CR 3<br />
Symmetrel 3<br />
Tasmar 3<br />
potassium bicarb/potassium chloride<br />
Potassium<br />
Potassium agents<br />
generic K-Dur 1<br />
potassium bicarb/potassium 1<br />
chloride<br />
potassium bicarbonate 1<br />
potassium chloride 1<br />
K-Dur 3<br />
K-lor powder 3<br />
K-Lyte/DS 3<br />
Micro-K 3<br />
Potassium Removing agent<br />
sod. polystyrene sulfonate 1<br />
Kayexalate 3<br />
Respiratory/Asthma<br />
Adrenergic<br />
epinephrine inj. 1<br />
Epi EZ Jr. 2<br />
Epipen/Jr. 2<br />
Twinject 2<br />
Corticosteroids<br />
❚ Azmacort 2<br />
❚ Flovent/HFA 2<br />
❚ Flovent Rotadisk 2<br />
❚ Pulmicort 2<br />
Pulmicort respules 2<br />
❚ Qvar 2<br />
❚ Aerobid/M 3<br />
* Please note that medications listed in the 3rd tier are considered<br />
non-formulary and are not all-inclusive.<br />
* All branded self-injectables are subject to prior authorization &<br />
if approved, would be placed in the 2nd tier.<br />
* Some drugs are limited to 1 unit of use package per dispensing.
Leukotrienes<br />
❚ Accolate 2<br />
Singulair 2<br />
Other Agents<br />
cromolyn inh. soln. 1<br />
ipratropium inh. soln. 1<br />
Advair diskus 2<br />
❚ Atrovent inhaler/HFA 2<br />
Combivent 2<br />
Duoneb 2<br />
❚ Intal Inhaler 2<br />
Pulmozyme 2<br />
Tracleer 2<br />
❚ Spiriva 2<br />
❚ Tilade 2<br />
Ventavis 3<br />
Sympathomimetics<br />
❚ albuterol HFA inhaler 1<br />
albuterol tab,syr,inhaler 1<br />
metaproterenol syr 1<br />
terbutaline tab 1<br />
❚ Alupent inhaler 2<br />
❚ Maxair Autohaler 2<br />
❚ Proventil HFA 2<br />
❚ Serevent 2<br />
❚ Serevent Diskus 2<br />
Vospire ER 2<br />
Accuneb 3<br />
Brethine tabs 3<br />
❚ Foradil 3<br />
Proventil Inh/Sol 3<br />
❚ Ventolin HFA 3<br />
❚ Xopenex/HFA 3<br />
Xanthine Derivatives<br />
aminophylline 1<br />
theochron 1<br />
theophylline/SR tabs, liquid 1<br />
Theo-24 2<br />
Elixophyllin 3<br />
Uniphyl 3<br />
Seizures<br />
Barbiturates<br />
phenobarbital 1<br />
Mebaral 2<br />
Hydantoins<br />
phenytoin 1<br />
Dilantin 2<br />
Phenytek 2<br />
Peganone 3<br />
Miscellaneous<br />
carbamazepine 1<br />
clonazepam 1<br />
gabapentin 1<br />
primidone 1<br />
valproic acid 1<br />
Carbatrol 2<br />
Depakote 2<br />
Depakote ER 2<br />
Diastat 2<br />
Gabitril 2<br />
Felbatol 2<br />
Keppra 2<br />
Lamictal 2<br />
Tegretol 2<br />
Tegretol XR 2<br />
Topamax 2<br />
Trileptal 2<br />
Zonegran 2<br />
Depakene 3<br />
Klonopin 3<br />
Lyrica 3<br />
Mysoline 3<br />
Neurontin 3<br />
Succinimides<br />
ethosuximide 1<br />
Celontin 2<br />
Zarontin 2<br />
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)<br />
TIER TIER TIER TIER<br />
emulsion<br />
Skin<br />
Acne<br />
amnesteem 1<br />
avita 1<br />
benzoyl peroxide 1<br />
claravis 1<br />
prascion RA 1<br />
sod.sulfacetamide/sulfur 1<br />
emulsion cleanser<br />
sod.sulfacetamide/sulfur<br />
sod.sulfacetamide/sulfur lot<br />
cleanser<br />
1<br />
sortret 1<br />
tretinoin cr/oint/gel 1<br />
Benzaclin 2<br />
Differin 2<br />
Klaron lotion 2<br />
Tazorac cream 2<br />
Tazorac cream 2<br />
Accutane 3<br />
Benzamycin gel/pckts 3<br />
Duac 3<br />
erythromycin/benz peroxide 3<br />
Evoclin 3<br />
Retin A cr/oint 3<br />
Retin A gel 3<br />
Retin A liquid 3<br />
Retin A micro 3<br />
Rosac 3<br />
Antibiotics (Topical)<br />
clindamax 1<br />
clindamycin sol/swabs/gel/ 1<br />
lotion<br />
clindamycin<br />
erythromycin sol/swabs/gel<br />
sol/swabs/gel/lotion<br />
1<br />
gentamicin cr/oint 1<br />
metronidazole cream 1<br />
mupirocin 1<br />
Bactroban cream 2<br />
Finacea 2<br />
Metrogel topical 2<br />
Metrolotion 2<br />
Noritate 2<br />
Bactroban oint. 3<br />
Cleocin-T sol/swabs/gel/lotion 3<br />
MetroCream 3<br />
Antipsoriatics<br />
Dovonex 2<br />
Dritho-Scalp 2<br />
Elidel 2<br />
Protopic 2<br />
+ Raptiva 2<br />
Tazorac gel 2<br />
Burn preparation<br />
silver sulfadiazine 1<br />
Silvadene cream 3<br />
Depigmenting agent<br />
hydroquinone 1<br />
Claripel 3<br />
Eldoquin/forte 3<br />
Lustra/AF 3<br />
Solaquin/forte 3<br />
Fungicides<br />
ciclopirox cream/lotion 1<br />
econazole 1<br />
ketoconazole 1<br />
nystatin 1<br />
nystatin/triamcinolone 1<br />
nystop 1<br />
Exelderm 2<br />
Oxistat 2<br />
Loprox cr/gel/lot/shampoo 3<br />
Lotrisone 3<br />
Mycostatin 3<br />
Naftin 3<br />
Nizoral 2% shampoo 3<br />
Penlac 3<br />
Spectazole 3<br />
Other Topicals<br />
aluminum chloride 20% 1<br />
fluorouracil 1<br />
podofilox 1<br />
sodium chloride irrigating soln 1<br />
7<br />
Aldara 2<br />
Carac 2<br />
Efudex cr. 2<br />
Panretin 2<br />
Phisohex 2<br />
Regranex 2<br />
Condylox 3<br />
Drysol 3<br />
Efudex sol. 3<br />
Fluoroplex 3<br />
Regencare 3<br />
Psoralens<br />
8-MOP 2<br />
Oxsoralen 2<br />
Oxsoralen Ultra 2<br />
Scabicides & Pediculicides<br />
acticin 1<br />
lindane 1<br />
Elimite 3<br />
Eurax 3<br />
Topical Anti-Inflammatory Agents<br />
alclometasone 1<br />
amcinonide 1<br />
aug. betamethasone diprop 1<br />
betamethasone dipropionate 1<br />
betamethasone valerate 1<br />
clobetasol propionate 1<br />
desonide 1<br />
desoximetasone 1<br />
diflorasone 1<br />
fluocinolone acetonide 1<br />
fluocinonide 1<br />
fluticasone propionate 1<br />
halobetasol 1<br />
hydrocortisone 2.5% 1<br />
hydrocortisone valerate 1<br />
hydrocortisone/iodoquinol 1<br />
hydrocortisone/urea 1<br />
mometasone cr/oint 1<br />
triamcinolone acetonide 1<br />
Cordran tape 2<br />
Derma-Smoothe FS 2<br />
Elocon lot 2<br />
Aclovate 3<br />
Aristocort 3<br />
Capex Shampoo 3<br />
Cordran SP 3<br />
Cutivate 3<br />
Cyclocort 3<br />
Dermatop 3<br />
Desowen 3<br />
Diprolene/AF 3<br />
Diprosone 3<br />
Elocon cr/oint 3<br />
Halog 3<br />
Hytone 3<br />
Kenalog/aerosol 3<br />
Lidex 3<br />
Luxiq foam 3<br />
Olux 3<br />
Psorcon E 3<br />
Synalar 3<br />
Temovate 3<br />
Topicort 3<br />
Ultravate 3<br />
Westcort 3<br />
Topical Antipruritics/Anesthetics<br />
lidocaine 2% viscous 1<br />
lidocaine 5% oint. 1<br />
lidocaine gel, soln 1<br />
selenium sulf 2.5% shampoo 1<br />
Selsun Rx 3<br />
Xylocaine viscous, gel, soln. 3<br />
Topical Antivirals<br />
Zovirax ointment 2<br />
Denavir 3<br />
Smoking Cessation<br />
Members coverage varies by plan.<br />
Patient should be in a smoking cessation<br />
program.<br />
Steroids<br />
cortisone acetate 1<br />
dexamethasone oral 1<br />
hydrocortisone oral 1<br />
methylprednisolone 4mg, 8mg 1<br />
prednisolone oral 1<br />
prednisone oral 1<br />
Cortef 5mg, 10mg 2<br />
Medrol (all except 4mg,8mg) 2<br />
Cortef 20mg 3<br />
Decadron oral 3<br />
Medrol 4mg, 8mg 3<br />
Orapred 3<br />
Pediapred 3<br />
Prelone syrup 3<br />
hydrocortisone rectal cr. &<br />
Stomach/Ulcer<br />
Anorectal<br />
hydrocortisone rectal cr. & 1<br />
supp.<br />
hydrocortisone rectal enema<br />
supp.<br />
1<br />
pramoxine/HC acetate 2.5% 1<br />
Analpram-HC 1-1% 2<br />
Cortifoam 2<br />
Proctofoam-HC 2<br />
Analpram-HC 2.5% cr/lot 3<br />
Proctocort rectal 3<br />
Anticholinergics/Antispasmodic/GI<br />
Motility<br />
belladonna/phenobarbital 1<br />
chlordiazepoxide/clindinium 1<br />
dicyclomine 1<br />
glycopyrrolate 1<br />
hyoscyamine/CR 1<br />
metoclopramide 1<br />
Bentyl oral 3<br />
Bentyl syrup 3<br />
Donnatal 3<br />
Levsin/Levsinex 3<br />
Librax 3<br />
Reglan 3<br />
Robinul 3<br />
Antidiarrheal<br />
diphenoxylate/atropine 1<br />
paregoric 1<br />
❚ Alinia 3<br />
Lomotil 3<br />
Antiemetic/Antivertigo<br />
meclizine 1<br />
prochlorperazine 1<br />
promethazine 1<br />
trimethobenzamide 1<br />
trimethobenzamide supp. 1<br />
Antivert 50mg 2<br />
❚ Anzemet 2<br />
❚ Emend 2<br />
Transderm Scop 2<br />
❚ Zofran 2<br />
❚ Zofran ODT 2<br />
Compazine syr. 3<br />
❚ Kytril 3<br />
Phenergan 3<br />
Tigan cap/supp 3<br />
Bowel Evacuants<br />
glycolax 1<br />
peg 3350/electrolyte 1<br />
Halflytely 2<br />
CoLyte 3<br />
Miralax 3<br />
Nulytely 3<br />
Trilyte 3<br />
Digestants<br />
dygase 1<br />
enzycap 1<br />
lipram (all) 1<br />
palipase 1<br />
pancrelipase 1<br />
pangestyme (all) 1<br />
panokase 1<br />
plaretase 8000 1<br />
KEY: = A step edit applies to this drug.<br />
Note: 1. * Please note that medications listed in the 3rd tier are considered<br />
❚ = Specific Quantity Limits Apply.<br />
non-formulary and are not all-inclusive.<br />
= Prior Authorization Required.<br />
2. * All branded self-injectables are subject to prior authorization &<br />
◆ = Included in Tablet-Splitting Program<br />
if approved, would be placed in the 2nd tier.<br />
ˆ = Approved for Males only.<br />
3. * Some drugs are limited to 1 unit of use package per dispensing.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.
Creon 2<br />
Ku-Zyme 2<br />
Ku-Zyme HP 2<br />
Kutrase 2<br />
Pancrease (all) 2<br />
Ultrase (all) 2<br />
Viokase 2<br />
Gallstone Solubilizing Agents<br />
ursodiol 1<br />
Urso 2<br />
Urso Forte 2<br />
Actigall 3<br />
H 2 Antagonists<br />
cimetidine 1<br />
famotidine 1<br />
ranitidine 1<br />
Zantac liquid 2<br />
Axid 3<br />
nizatidine 3<br />
Pepcid 3<br />
Tagamet 3<br />
Zantac 3<br />
Other Antiulcer<br />
misoprostol 1<br />
propantheline 1<br />
sucralfate 1<br />
Prevpac 2<br />
Carafate 3<br />
Cytotec 3<br />
Helidac 3<br />
Other GI Products<br />
lactulose 1<br />
mesalamine enema 1<br />
sulfasalazine 1<br />
sulfasalazine EC 1<br />
Asacol 2<br />
Canasa supp. 2<br />
Colazal 2<br />
Dipentum 2<br />
Entocort EC 2<br />
Gastrocrom 2<br />
Pentasa 2<br />
Zelnorm 2<br />
Azulfidine 3<br />
Enulose 3<br />
u Lotronex 3<br />
Rowasa 3<br />
Proton Pump Inhibitors<br />
❚ omeprazole 1<br />
❚ prilosec-OTC 1<br />
❚ Prevacid/susp 2<br />
❚ Protonix 2<br />
❚ Aciphex 3<br />
❚ Nexium 3<br />
❚ Prilosec 3<br />
❚ Zegerid 3<br />
Thyroid<br />
Antithyroid<br />
methimazole 1<br />
propylthiouracil 1<br />
Tapazole 3<br />
Thyroid<br />
levothroid 1<br />
levothyroxine 1<br />
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)<br />
TIER TIER TIER TIER<br />
thyroid 1<br />
unithroid 1<br />
Cytomel 2<br />
Levoxyl 2<br />
Synthroid 2<br />
Thyroid (Armour) 2<br />
Thyrolar 2<br />
sodium fluoride chewable tab &<br />
Vitamins<br />
calcitriol 1<br />
calcitriol inj 1<br />
cyanocobalamin inj. 1<br />
ergocalciferol cap 1<br />
folic acid 1<br />
leucovorin 1<br />
multivitamin + fluoride 1<br />
phytonadione 1<br />
potassium aminobenzoate 1<br />
pre-natal vitamins 1<br />
sodium fluoride chewable tab & 1<br />
drops<br />
vit A,D,C + fluoride<br />
drops<br />
1<br />
vit A,D,C + fluoride and iron 1<br />
Carnitor 2<br />
DHT Intensol drops 2<br />
DHT tablets 2<br />
Didronel 2<br />
Fo Hx 2<br />
Galzin 2<br />
Nascobal 2<br />
Phoslo 2<br />
Prenate Elite 2<br />
Renagel 2<br />
Calcijex 3<br />
Drisdol caps 3<br />
Fosrenol 3<br />
Mephyton 3<br />
Poly-Vi-Flor 3<br />
Poly-Vi-Flor + Iron 3<br />
Potaba 3<br />
Rocaltrol 3<br />
Tri-Vi-Flor 3<br />
Tri-Vi-Flor + Iron 3<br />
Weight Loss - possible contract<br />
exclusion; refer to individual<br />
contract<br />
Adipex 3<br />
diethylpropion 3<br />
Meridia 3<br />
phentermine 3<br />
Tenuate 3<br />
Xenical 3<br />
Women's Health<br />
Contraceptives - Other<br />
NuvaRing 2<br />
❚ Ortho Evra 2<br />
Depo-SubQ Provera 3<br />
Fertility Induction Agents - possible<br />
contract exclusion; refer to individual<br />
contract<br />
chorionic gonadotropin 1<br />
clomiphene 1<br />
novarel 1<br />
serophene 1<br />
+ Bravelle 2<br />
+ Cetrotide 2<br />
+ Fertinex 2<br />
+ Follistim AQ 2<br />
+ Gonal F 2<br />
+ Profasi 2<br />
+ Repronex 2<br />
+ Antagon 3<br />
Clomid 3<br />
+ Luveris 3<br />
+ Ovidrel 3<br />
+ Pregnyl 3<br />
Hormones<br />
❚ esclim 1<br />
estradiol oral 1<br />
❚ estradiol patches 1<br />
estropipate 1<br />
generic Estratest/HS 1<br />
medroxyprogesterone 1<br />
norethindrone 1<br />
Activella 2<br />
❚ Alora 2<br />
Cenestin 2<br />
Climara 0.0375,0.06 2<br />
Combipatch 2<br />
Estrace vag. Cream 2<br />
❚ Estraderm 2<br />
Estratest/HS 2<br />
Estring 2<br />
Femhrt 2<br />
Menest 2<br />
Premarin 2<br />
Premphase 2<br />
Prempro 2<br />
Progesterone 2<br />
Prometrium 2<br />
Syntest D.S./H.S. 2<br />
Vagifem 2<br />
❚ Vivelle 2<br />
❚ Vivelle-DOT 2<br />
Aygestin 3<br />
❚ Climara 0.025,0.05mg, 3<br />
0.075mg0.1mg<br />
Climara 0.025,0.05mg, 0.075mg0.1mg<br />
Crinone 8% 3<br />
Estrace tab 3<br />
Estrasorb packet 3<br />
Estrogel 3<br />
Femring 3<br />
Menostar 3<br />
Ogen 3<br />
Ortho-Est 3<br />
Prefest 3<br />
Provera 3<br />
Oral Contraceptives<br />
apri 1<br />
aranelle 1<br />
aviane 1<br />
camila 1<br />
cesia 1<br />
cryselle 1<br />
enpresse 1<br />
errin 1<br />
jolivette 1<br />
junel/FE 1<br />
kariva 1<br />
lessina 1<br />
levora 1<br />
low-ogestrel 1<br />
lutera 1<br />
microgestin/FE 1<br />
mononessa 1<br />
N.E.E. 1<br />
necon 1<br />
nelova 1<br />
nora-BE 1<br />
nortrel 1<br />
ogestrel 1<br />
portia 1<br />
previfem 1<br />
solia 1<br />
sprintec 1<br />
tri-sprintec 1<br />
trinessa 1<br />
triprevifem 1<br />
trivora 1<br />
velivet 1<br />
zovia 1<br />
Estrostep FE 2<br />
Modicon 2<br />
Ortho Micronor 2<br />
Ortho Tri-Cyclen/Lo 2<br />
Ortho-Cept 2<br />
Ortho-Cyclen 2<br />
Ortho-Novum 2<br />
Ovcon-35 2<br />
Ovcon-50 2<br />
Seasonale 2<br />
Yasmin 2<br />
Yaz 2<br />
Alesse 3<br />
Brevicon 3<br />
Cyclessa 3<br />
Demulen 3<br />
Desogen 3<br />
Levlen 3<br />
Levlite 3<br />
Lo/Ovral 3<br />
Loestrin/Loestrin FE 3<br />
Mircette 3<br />
Nor Q-D 3<br />
Nordette 3<br />
Norinyl 3<br />
Ovral 3<br />
Tri-Norinyl 3<br />
Tri-Levlen 3<br />
Triphasil 3<br />
Oxytocic Agents<br />
Methergine 2<br />
Vaginal Preparations<br />
miconazole vag supp 1<br />
nystatin vag tab 1<br />
terconazole 1<br />
vandazole vag 1<br />
Premarin vag cream 2<br />
Cleocin Vag/Ovules 3<br />
Clindamax 3<br />
Clindesse 3<br />
Gynazole-1 3<br />
MetroGel vag 3<br />
Monistat supp 3<br />
Terazol 3<br />
KEY: = A step edit applies to this drug.<br />
Note: 1. * Please note that medications listed in the 3rd tier are considered<br />
❚ = Specific Quantity Limits Apply.<br />
non-formulary and are not all-inclusive.<br />
= Prior Authorization Required.<br />
2. * All branded self-injectables are subject to prior authorization &<br />
◆ = Included in Tablet-Splitting Program<br />
if approved, would be placed in the 2nd tier.<br />
ˆ = Approved for Males only.<br />
3. * Some drugs are limited to 1 unit of use package per dispensing.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.<br />
8
A<br />
Abilify 2<br />
❚ Accolate 2<br />
Accu-Check Compact<br />
Accu-Chek Active<br />
Accu-Chek Advantage<br />
Accuneb 3<br />
Accupril 3<br />
Accuretic 3<br />
Accutane 3<br />
acebutolol 1<br />
Aceon 3<br />
acetaminophen w/codeine 1<br />
acetazolamide 1<br />
acetic acid HC otic 1<br />
acetic acid otic 1<br />
acetic acid/aluminum acetate 1<br />
acetylcysteine inh soln. 1<br />
❚ Aciphex 3<br />
Aclovate 3<br />
acticin 1<br />
Actigall 3<br />
+Actimmune 2<br />
Activella 2<br />
❚ Actonel 2<br />
ActoPLUS Met 2<br />
Actos 2<br />
Acular 2<br />
Acular LS 2<br />
Acular PF 3<br />
acyclovir oral 1<br />
Adalat CC 3<br />
Adderall 3<br />
Adderall XR 2<br />
Adipex 3<br />
Advair diskus 2<br />
Advicor 2<br />
❚ Aerobid/M 3<br />
Agenerase 2<br />
Aggrenox 2<br />
❚ albuterol HFA inhaler 1<br />
albuterol tab,syr,inhaler 1<br />
Alcaine 3<br />
alclometasone 1<br />
Aldactazide 3<br />
Aldactone 3<br />
Aldara 2<br />
Aldomet 3<br />
Aldoril 3<br />
Alesse 3<br />
❚ Alinia 3<br />
Alkeran 2<br />
❚ Allegra 3<br />
Allegra-D 3<br />
allopurinol 1<br />
Alomide 2<br />
❚ Alora 2<br />
Alphagan 3<br />
Alphagan P 2<br />
alprazolam/ ER 1<br />
Altace 2<br />
❚ Altoprev 3<br />
aluminum chloride 20% 1<br />
❚ Alupent inhaler 2<br />
amantadine 1<br />
Amaryl 2<br />
❚ Ambien 2<br />
❚ Ambien CR 3<br />
amcinonide 1<br />
❚ Amerge 2<br />
Amicar 3<br />
amiloride 1<br />
amiloride/HCTZ 1<br />
aminocaproic acid 1<br />
aminophylline 1<br />
amiodarone 1<br />
amitriptyline 1<br />
amitriptyline/ 1<br />
chlordiazepoxide<br />
amitriptyline/perphenazine 1<br />
amnesteem 1<br />
amoxapine 1<br />
amoxicillin 1<br />
amoxicillin/clavulanate 1<br />
ampicillin 1<br />
Anafranil 3<br />
Analpram-HC 1-1% 2<br />
Analpram-HC 2.5% cr/lot 3<br />
Anaprox 3<br />
Ancobon 2<br />
Androderm patch 2<br />
Androgel 2<br />
Android 3<br />
Ansaid 3<br />
Antabuse 2<br />
+Antagon 3<br />
Antara 3<br />
antipyrine/benzocaine/ 1<br />
glycerin<br />
Antivert 50mg 2<br />
❚Anzemet 2<br />
Apidra 2<br />
+Apokyn 2<br />
apri 1<br />
Aralen 3<br />
aranelle 1<br />
+Aranesp 2<br />
Arava 2<br />
Aricept/ODT 2<br />
Arimidex 2<br />
Aristocort 3<br />
Arixtra 3<br />
Aromasin 2<br />
Arthrotec 3<br />
Asacol 2<br />
aspirin SR 1<br />
aspirin w/ codeine 1<br />
Astelin 2<br />
Atacand 3<br />
Atacand HCT 3<br />
atenolol 1<br />
atenolol/chlorthalidone 1<br />
Ativan 3<br />
atropine sulfate ophth 1<br />
❚ Atrovent inhaler/HFA 2<br />
Atrovent Nasal Spray 3<br />
aug. betamethasone diprop 1<br />
Augmentin XR 2<br />
Augmentin/ES 3<br />
Avalide 2<br />
Avandamet 2<br />
Avandaryl 3<br />
Avandia 2<br />
Avapro 2<br />
Avelox 3<br />
aviane 1<br />
Avinza 3<br />
avita 1<br />
❚^ Avodart 2<br />
+Avonex 2<br />
❚ Axert 3<br />
Axid 3<br />
Aygestin 3<br />
azathioprine 1<br />
azithromycin tablets 1<br />
❚ Azmacort 2<br />
Azopt 2<br />
Azulfidine 3<br />
B<br />
B&O supprettes 3<br />
bacitracin ophth 1<br />
bacitracin/polymyxin 1<br />
baclofen 1<br />
Bactrim/DS 3<br />
Bactroban cream 2<br />
Bactroban oint. 3<br />
Baraclude 3<br />
Beconase AQ 3<br />
belladonna & opium supp 1<br />
belladonna/phenobarbital 1<br />
bellamine 1<br />
bellamine-S 1<br />
Bellaspas 1<br />
benazepril 1<br />
benazepril/HCTZ 1<br />
Benicar 3<br />
Benicar HCT 3<br />
Bentyl oral 3<br />
Bentyl syrup 3<br />
Benzaclin 2<br />
Benzamycin gel/ pckts 3<br />
benzonatate 1<br />
benzoyl peroxide 1<br />
benztropine 1<br />
Betagan 3<br />
betamethasone dipropionate 1<br />
betamethasone valerate 1<br />
Betapace/AF 3<br />
+Betaseron 3<br />
betaxolol 1<br />
betaxolol HCL eye drops 1<br />
bethanecol 1<br />
Betoptic-S 2<br />
Biaxin suspension 3<br />
Biaxin tab 3<br />
Biaxin tabs 2<br />
SECTION II — INDEX<br />
DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER<br />
Biaxin XL 2<br />
Bicitra 3<br />
bisoprolol 1<br />
bisoprolol/HCTZ 1<br />
Blocadren 3<br />
Boniva 3<br />
+Bravelle 2<br />
Brethine tabs 3<br />
Brevicon 3<br />
brimonidine 1<br />
Bromfed 3<br />
bromocriptine 1<br />
brompheniramine/phenylephrine 1<br />
brompheniramine/pseud/DM 1<br />
brompheniramine/ 1<br />
pseudoephedrine<br />
bumetanide 1<br />
Bumex 3<br />
bupropion 1<br />
bupropion ER 1<br />
Buspar 3<br />
buspirone 1<br />
butalbital/APAP 1<br />
butalbital/APAP/caffeine 1<br />
butalbital/APAP/codeine 1<br />
butalbital/aspirin/caffeine 1<br />
butalbital/aspirin/codeine 1<br />
+❚ butorphanol NS 1<br />
Byetta 3<br />
C<br />
Caduet 3<br />
Cafergot 3<br />
Calan/SR 3<br />
Calcijex 3<br />
calcitriol 1<br />
calcitriol inj 1<br />
camila 1<br />
Campral 3<br />
Canasa supp. 2<br />
Capex Shampoo 3<br />
Capoten 3<br />
Capozide 3<br />
captopril 1<br />
captopril/HCTZ 1<br />
Carac 2<br />
Carafate 3<br />
carbamazepine 1<br />
Carbatrol 2<br />
carbidopa/levodopa 1<br />
carbidopa/levodopa SA 1<br />
carbinoxamine 1<br />
carbinoxamine/DM/ 1<br />
pseudoephedrine<br />
carbinoxamine/pseudoephedrine 1<br />
carboptic 1<br />
cardec/DM 1<br />
Cardene/SR 3<br />
Cardizem/CD/SR/LA 3<br />
Cardura 3<br />
carisoprodol 1<br />
carisoprodol/ASA 1<br />
Carnitor 2<br />
carteolol 1<br />
cartia XT 1<br />
Casodex 2<br />
Cataflam 3<br />
Catapres oral 3<br />
Catapres TTS patch 2<br />
❚^Caverject 2<br />
Ceclor 3<br />
CeeNu 2<br />
cefaclor 1<br />
cefadroxil 3<br />
cefpodoxime 1<br />
cefprozil 1<br />
Ceftin 3<br />
Ceftin Susp 2<br />
cefuroxime 1<br />
Cefzil 2<br />
❚ Celebrex 3<br />
◆Celexa 3<br />
Cellcept 2<br />
Celontin 2<br />
Cenestin 2<br />
cephalexin 1<br />
cephradine 1<br />
Cerumenex 2<br />
cesia 1<br />
+Cetrotide 2<br />
ChemStrip BG<br />
chloral hydrate 1<br />
chlordiazepoxide 1<br />
chlordiazepoxide/clindinium 1<br />
Chloroptic 3<br />
chloroquine phosphate 1<br />
chlorothiazide 1<br />
chlorphen/hydrocodone/ 1<br />
phenylephrine<br />
chlorphen/hydrocodone/ 1<br />
pseudoephedrine<br />
chlorphen/pseudo/codeine 1<br />
chlorpheniramine/ 1<br />
pseudoephedrine<br />
chlorpromazine 1<br />
chlorpropamide 1<br />
chlorthalidone 1<br />
chlorzoxazone 3<br />
cholestyramine 1<br />
choline mag. trisalicylate 1<br />
chorionic gonadotropin 1<br />
❚^Cialis 3<br />
ciclopirox cream/lotion 1<br />
cilostazol 1<br />
Ciloxan 3<br />
cimetidine 1<br />
Cipro HC 3<br />
Cipro/XR 3<br />
Ciprodex 2<br />
ciprofloxacin 1<br />
ciprofloxacin ophth 1<br />
◆citalopram 1<br />
citric acid/sod citrate 1<br />
claravis 1<br />
Clarinex/D 3<br />
Claripel 3<br />
clemastine-OTC 1<br />
Cleocin 3<br />
Cleocin Vag/Ovules 3<br />
Cleocin-T sol/swabs/gel/ 3<br />
lotion<br />
❚ Climara 0.025,0.05mg, 3<br />
0.075mg0.1mg<br />
Climara 0.0375,0.06 2<br />
clindamax 1<br />
Clindamax 3<br />
clindamycin HCL 1<br />
clindamycin sol/swabs/gel/ 1<br />
lotion<br />
Clindesse 3<br />
Clinoril 3<br />
clobetasol propionate 1<br />
Clomid 3<br />
clomiphene 1<br />
clomipramine 1<br />
clonazepam 1<br />
clonidine 1<br />
clorazepate 1<br />
Clorpres 2<br />
+clozapine 1<br />
Clozaril 2<br />
Codeine 3<br />
Cognex 3<br />
Colazal 2<br />
colchicine 1<br />
colchicine/probenecid 1<br />
Colestid 2<br />
CoLyte 3<br />
Combipatch 2<br />
Combivent 2<br />
Combivir 2<br />
Combunox 3<br />
Compazine syr. 3<br />
Comtan 2<br />
Concerta 2<br />
Condylox 3<br />
+Copaxone 2<br />
+Copegus 3<br />
Cordarone 3<br />
Cordran SP 3<br />
Cordran tape 2<br />
Coreg 2<br />
Corgard 3<br />
Cortef 20mg 3<br />
Cortef 5mg, 10mg 2<br />
Cortifoam 2<br />
cortisone acetate 1<br />
Cortisporin oint ophth 3<br />
Cortisporin otic 3<br />
Cortrosyn 2<br />
Cosopt 2<br />
Coumadin 2<br />
Covera HS 3<br />
Cozaar 3<br />
Creon 2<br />
◆ Crestor 2<br />
Crinone 8% 3<br />
9<br />
Crixivan 2<br />
cromolyn inh. soln. 1<br />
cromolyn ophth 1<br />
cryselle 1<br />
Cuprimine 2<br />
Cutivate 3<br />
cyanocobalamin inj. 1<br />
Cyclessa 3<br />
cyclobenzaprine 1<br />
Cyclocort 3<br />
cyclophosphamide 1<br />
cyclosporine 1<br />
❚ Cymbalta 2<br />
cyproheptadine 1<br />
Cytomel 2<br />
Cytotec 3<br />
Cytovene 3<br />
Cytoxan 3<br />
D<br />
Dalmane 3<br />
danazol 1<br />
Dantrium 3<br />
Dapsone 2<br />
Daraprim 2<br />
Darvocet-N 3<br />
Darvon Comp-65 3<br />
Darvon-N 2<br />
Darvon/Darvon-65 3<br />
Daypro 3<br />
DDAVP nasal spray 2<br />
DDAVP sol, tab 3<br />
Decadron 3<br />
Decadron oral 3<br />
Demadex 3<br />
Demerol 3<br />
Demulen 3<br />
Denavir 3<br />
Depakene 3<br />
Depakote 2<br />
Depakote ER 2<br />
Depen 3<br />
Depo-SubQ Provera 3<br />
Derma-Smoothe FS 2<br />
Dermatop 3<br />
desipramine 1<br />
desmopressin solution 1<br />
desmopressin tabs 1<br />
Desogen 3<br />
desonide 1<br />
Desowen 3<br />
desoximetasone 1<br />
Desyrel 3<br />
❚ Detrol 2<br />
❚ Detrol LA 2<br />
dexameth/neomycin 1<br />
dexameth/neomycin/poly B 1<br />
dexamethasone ophth 1<br />
dexamethasone oral 1<br />
dexchlorpheniramine 1<br />
Dexedrine tab/spansules 3<br />
dextroamphetamine tabs 1<br />
DHT Intensol drops 2<br />
DHT tablets 2<br />
Diabeta 3<br />
Diabetic Benefit Applies<br />
Diabinese 3<br />
Diamox Sequels 2<br />
Diastat 2<br />
diazepam 1<br />
Dibenzyline 2<br />
diclofenac potassium 1<br />
diclofenac sodium 1<br />
diclofenac sodium SA 3<br />
dicloxacillin 1<br />
dicyclomine 1<br />
didanosine 1<br />
Didronel 2<br />
diethylpropion 3<br />
Differin 2<br />
diflorasone 1<br />
Diflucan 3<br />
❚ Diflucan 150mg 3<br />
diflunisal 1<br />
digoxin 1<br />
Dilacor XR 3<br />
Dilantin 2<br />
Dilatrate SR 2<br />
Dilaudid 3<br />
diltia XT 1<br />
diltiazem 1<br />
diltiazem CD/SR/ER/XR 1<br />
Diovan 2<br />
Diovan HCT 2<br />
Dipentum 2<br />
diphenhydramine-OTC 1<br />
diphenoxylate/atropine 1<br />
dipivefrin 1<br />
Diprolene/AF 3<br />
Diprosone 3<br />
dipyridamole 1<br />
disopyramide 1<br />
disopyramide CR 1<br />
Dispermox 3<br />
❚ Ditropan 3<br />
❚ Ditropan XL 2<br />
Dolobid 3<br />
Domeboro 3<br />
Donnatal 3<br />
Doryx 3<br />
Dostinex 3<br />
Dovonex 2<br />
doxazosin 1<br />
doxepin 1<br />
doxycycline 1<br />
doxycycline 20mg tab 3<br />
Drisdol caps 3<br />
Dritho-Scalp 2<br />
Drysol 3<br />
Duac 3<br />
Duoneb 2<br />
Duragesic patch (25,50,75, 3<br />
100mg)<br />
Duragesic patch 12mg 2<br />
Durahist/PE 3<br />
Duratuss 3<br />
Duricef 3<br />
Dyazide 3<br />
dygase 1<br />
Dynacin 3<br />
Dynacirc/CR 3<br />
E<br />
Easprin 3<br />
econazole 1<br />
❚^Edex 3<br />
◆❚ Effexor tabs 2<br />
❚ Effexor XR 2<br />
eflone 1<br />
Efudex cr. 2<br />
Efudex sol. 3<br />
8-MOP 2<br />
Elavil 3<br />
Eldepryl 3<br />
Eldoquin/forte 3<br />
Elidel 2<br />
Elimite 3<br />
Elixophyllin 3<br />
Elmiron 2<br />
Elocon cr/oint 3<br />
Elocon lot 2<br />
Emcyt 2<br />
❚Emend 2<br />
Emtriva 2<br />
❚ Enablex 3<br />
enalapril 1<br />
enalapril/HCTZ 1<br />
+Enbrel 2<br />
endocet 1<br />
enpresse 1<br />
Entex LA 3<br />
Entocort EC 2<br />
Enulose 3<br />
enzycap 1<br />
Epi EZ Jr. 2<br />
epinephrine inj. 1<br />
Epipen/Jr. 2<br />
Epivir 2<br />
Epivir-HBV 2<br />
+Epogen 3<br />
Epzicom 2<br />
ergocalciferol cap 1<br />
ergoloid mesylates 1<br />
Ergomar 2<br />
ergotamine/caffeine 1<br />
errin 1<br />
Ery-Tab 2<br />
Eryc 3<br />
erythromycin base 1<br />
erythromycin estolate 1<br />
erythromycin ethylsuccinate 1<br />
(E.E.S.)<br />
erythromycin ophth 1<br />
erythromycin sol/swabs/gel 1<br />
erythromycin stearate 1<br />
erythromycin/benz peroxide 3<br />
erythromycin/sulfisoxazole 1<br />
❚ esclim 1<br />
KEY: = A step edit applies to this drug.<br />
Note: 1. * Please note that medications listed in the 3rd tier are considered<br />
❚ = Specific Quantity Limits Apply.<br />
non-formulary and are not all-inclusive.<br />
= Prior Authorization Required.<br />
2. * All branded self-injectables are subject to prior authorization &<br />
◆ = Included in Tablet-Splitting Program<br />
if approved, would be placed in the 2nd tier.<br />
ˆ = Approved for Males only.<br />
3. * Some drugs are limited to 1 unit of use package per dispensing.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.
Eskalith/CR 3<br />
estazolam 1<br />
Estrace tab 3<br />
Estrace vag. Cream 2<br />
❚ Estraderm 2<br />
estradiol oral 1<br />
❚ estradiol patches 1<br />
Estrasorb packet 3<br />
Estratest/HS 2<br />
Estring 2<br />
Estrogel 3<br />
estropipate 1<br />
Estrostep FE 2<br />
ethambutol 1<br />
Ethmozine 2<br />
ethosuximide 1<br />
etodolac 1<br />
etodolac SA 1<br />
etoposide 1<br />
Eulexin 3<br />
Eurax 3<br />
❚ Evista 2<br />
Evoclin 3<br />
Evoxac 2<br />
Exelderm 2<br />
Exelon 3<br />
extrendryl SR 1<br />
F<br />
Factive 3<br />
famotidine 1<br />
Famvir 2<br />
Fareston 2<br />
FastTake<br />
Fazaclo 3<br />
Felbatol 2<br />
Feldene 3<br />
felodipine 1<br />
Femara 2<br />
Femhrt 2<br />
Femring 3<br />
fenoprofen 1<br />
fentanyl patch (25,50,75,100 1<br />
mg)<br />
+Fertinex 2<br />
fexofenadine 3<br />
Finacea 2<br />
Fioricet/codeine 3<br />
Fioricet/Fiorinal 3<br />
Fiorinal/codeine 3<br />
Flagyl /ER 3<br />
Flagyl/ER 3<br />
Flarex 3<br />
flecainide 1<br />
Flexeril 3<br />
Flomax 2<br />
❚ Flonase 2<br />
Florinef 3<br />
❚ Flovent/HFA 2<br />
❚ Flovent Rotadisk 2<br />
Floxin oral 3<br />
Floxin otic 2<br />
fluconazole 1<br />
❚ fluconazole 150 mg tab 1<br />
fludrocortisone 1<br />
Flumadine 3<br />
flunisolide spray 1<br />
fluocinolone acetonide 1<br />
fluocinonide 1<br />
fluorometholone ophth 1<br />
Fluoroplex 3<br />
fluorouracil 1<br />
◆fluoxetine 10mg tablet 1<br />
fluoxetine capsule 1<br />
fluoxymesterone 3<br />
fluphenazine 1<br />
flurazepam 1<br />
flurbiprofen 1<br />
flurbiprofen ophth 1<br />
flutamide 1<br />
fluticasone nasal spray 1<br />
fluticasone propionate 1<br />
fluvoxamine 100mg 1<br />
◆fluvoxamine 25mg, 50mg 1<br />
FML Forte 2<br />
FML S.O.P. 2<br />
FML/S 3<br />
Focalin/ XR 3<br />
Fo Hx 2<br />
folic acid 1<br />
+Follistim AQ 2<br />
❚ Foradil 3<br />
Fortamet 3<br />
+Forteo 2<br />
❚ fortical NS 1<br />
Fortovase 2<br />
❚ Fosamax 2<br />
❚ Fosamax D 2<br />
fosinopril 1<br />
fosinopril/HCTZ 3<br />
Fosrenol 3<br />
Fragmin 2<br />
❚ Frova 2<br />
Furadantin 3<br />
furosemide 1<br />
G<br />
gabapentin 1<br />
Gabitril 2<br />
Galzin 2<br />
ganciclovir 1<br />
Gantrisin Susp 3<br />
Gastrocrom 2<br />
gemfibrozil 1<br />
generic Adderall 1<br />
generic Dexedrine spansules 1<br />
generic Estratest/ HS 1<br />
generic K-Dur 1<br />
generic Polycitra/LC/K 1<br />
generic Zoto HC 1<br />
gengraf 1<br />
gentamicin cr/oint 1<br />
gentamicin ophth 1<br />
Geodon 3<br />
+Gleevec 2<br />
glimepiride 1<br />
glipizide 1<br />
glipizide ER 1<br />
glipizide/metformin 1<br />
Glucagon 2<br />
Glucophage/XR 3<br />
Glucotrol /XL 3<br />
Glucovance 3<br />
glyburide 1<br />
glyburide micronized 1<br />
glycolax 1<br />
glycopyrrolate 1<br />
Glynase 3<br />
Glyset 3<br />
+Gonal F 2<br />
Grifulvin V susp 2<br />
Grispeg 2<br />
guaifenesin 1200/DM 1<br />
guaifenesin/codeine 1<br />
guaifenesin/codeine/ 1<br />
pseudoephedrine<br />
guaifenesin/hydrocodone 1<br />
guaifenesin/pseudoephedrine 1<br />
guaifenesin/pseudoephedrine/ 1<br />
DM<br />
guanabenz 1<br />
guanfacine 1<br />
Gynazole-1 3<br />
H<br />
Halcion 3<br />
Halflytely 2<br />
halobetasol 1<br />
Halog 3<br />
haloperidol 1<br />
Helidac 3<br />
heparin 1<br />
Hepsera 2<br />
Hexalen 2<br />
Histex IE 2<br />
Hivid 2<br />
homatropine 1<br />
Humalog insulin 2<br />
Humatin 3<br />
+Humatrope 3<br />
Humibid DM/LA 3<br />
+Humira 2<br />
Humulin (all types) 2<br />
Hycodan 3<br />
Hydra-zide 2<br />
hydralazine 1<br />
hydralazine/reserpine/HCTZ 1<br />
Hydrea 3<br />
hydrochlorothiazide 1<br />
hydrocodone/APAP 1<br />
hydrocodone/homatropine 1<br />
hydrocodone/ibuprofen 3<br />
hydrocortisone 2.5% 1<br />
hydrocortisone oral 1<br />
hydrocortisone rectal cr. & 1<br />
supp.<br />
hydrocortisone rectal enema 1<br />
hydrocortisone valerate 1<br />
hydrocortisone/iodoquinol 1<br />
SECTION II — INDEX (CONT’D)<br />
DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER<br />
hydrocortisone/urea 1<br />
hydromorphone 1<br />
hydroquinone 1<br />
hydroxychloroquine 1<br />
hydroxyurea 1<br />
hydroxyzine HCL 1<br />
hydroxyzine pamoate 1<br />
hyoscyamine/CR 1<br />
Hytone 3<br />
Hytrin 3<br />
Hyzaar 3<br />
I<br />
ibuprofen 1<br />
Iletin 2<br />
Imdur 3<br />
imipramine 1<br />
❚ Imitrex tab, nasal, injection 2<br />
Imuran 3<br />
indapamide 1<br />
Inderal 3<br />
Inderal LA 2<br />
Inderide 3<br />
Indocin 3<br />
indomethacin 1<br />
Inflamase Forte 3<br />
Inflamase Mild 3<br />
Innohep 3<br />
Innopran XL 2<br />
❚ Inspra 3<br />
❚ Intal Inhaler 2<br />
+Intron A 2<br />
Invirase 2<br />
ipratropium inh. soln. 1<br />
ipratropium nasal spray 1<br />
+Iressa 2<br />
isometh/dichloralphen/APAP 1<br />
isoniazid 1<br />
Isopto Atropine 3<br />
Isopto Carbachol 1.5% 2<br />
Isopto Carbachol 3% 3<br />
Isopto Carpine 3<br />
Isordil 3<br />
isosorbide dinitrate 1<br />
isosorbide mononitrate 1<br />
isosorbide mononitrate SA 1<br />
isoxsuprine 1<br />
isradipine 3<br />
Istalol 3<br />
❚ itraconazole 1<br />
J<br />
jolivette 1<br />
junel/FE 1<br />
K<br />
K-Dur 3<br />
K-lor powder 3<br />
K-Lyte/DS 3<br />
K-Phos Original 2<br />
Kadian 2<br />
Kaletra 2<br />
kariva 1<br />
Kayexalate 3<br />
Kenalog/aerosol 3<br />
Keppra 2<br />
Kerlone 3<br />
Ketek 3<br />
ketoconazole 1<br />
ketoprofen 1<br />
❚ ketorolac inj. 1<br />
❚ ketorolac tab 3<br />
+Kineret 2<br />
Klaron lotion 2<br />
Klonopin 3<br />
Ku-Zyme 2<br />
Ku-Zyme HP 2<br />
Kutrase 2<br />
❚Kytril 3<br />
L<br />
labetalol 1<br />
lactulose 1<br />
Lamictal 2<br />
❚ Lamisil Oral 2<br />
Lanoxin 2<br />
Lantus 2<br />
Lariam 3<br />
Lasix 3<br />
Lescol/XL 3<br />
lessina 1<br />
leucovorin 1<br />
Leukeran 2<br />
+Leukine 2<br />
Levaquin 2<br />
Levemir 2<br />
❚^Levitra 3<br />
Levlen 3<br />
Levlite 3<br />
levobunolol 1<br />
levora 1<br />
levothroid 1<br />
levothyroxine 1<br />
Levoxyl 2<br />
Levsin/Levsinex 3<br />
◆❚ Lexapro 2<br />
Lexiva 2<br />
Librax 3<br />
Librium 3<br />
Lidex 3<br />
lidocaine 2% viscous 1<br />
lidocaine 5% oint. 1<br />
lidocaine gel, soln 1<br />
lindane 1<br />
◆Lipitor 2<br />
lipram (all) 1<br />
lisinopril 1<br />
lisinopril/HCTZ 1<br />
lithium carbonate 1<br />
Lithobid 3<br />
Lo/Ovral 3<br />
Lodine/XL 3<br />
Loestrin/Loestrin FE 3<br />
Lofibra 3<br />
Lomotil 3<br />
Lopid 3<br />
Lopressor 3<br />
Lopressor HCT 3<br />
Loprox cr/gel/lot/shampoo 3<br />
Lorabid 2<br />
Lorabid Caps 2<br />
Lorabid Susp 2<br />
loratadine - OTC ONLY 1<br />
loratadine-D - OTC ONLY 1<br />
lorazepam 1<br />
Lortab 3<br />
Lotensin 3<br />
Lotensin HCT 3<br />
Lotrel 2<br />
Lotrisone 3<br />
u Lotronex 3<br />
◆lovastatin 1<br />
Lovenox 2<br />
low-ogestrel 1<br />
loxapine 1<br />
Loxitane 3<br />
Lozol 3<br />
Lumigan 2<br />
❚ Lunesta 3<br />
Lustra/AF 3<br />
lutera 1<br />
+Luveris 3<br />
Luxiq foam 3<br />
Lyrica 3<br />
Lysodren 2<br />
M<br />
Macrobid 3<br />
Macrodantin 3<br />
Malarone 2<br />
maprotiline 1<br />
Matulane 2<br />
Mavik 3<br />
❚ Maxair Autohaler 2<br />
❚ Maxalt 2<br />
❚ Maxalt MLT 2<br />
Maxaquin 3<br />
Maxidex 3<br />
Maxitrol ophth 3<br />
Maxzide 3<br />
Mebaral 2<br />
mebendazole chew tab 1<br />
meclizine 1<br />
meclofenamate 1<br />
Medrol (all except 4mg,8mg) 2<br />
Medrol 4mg, 8mg 3<br />
medroxyprogesterone 1<br />
mefloquine 1<br />
Megace sol. 3<br />
megestrol 1<br />
Menest 2<br />
Menostar 3<br />
meperidine 1<br />
meperidine/promethazine 1<br />
Mephyton 3<br />
meprobamate 1<br />
Mepron 2<br />
mercaptopurine 1<br />
Meridia 3<br />
mesalamine enema 1<br />
10<br />
Mesnex 2<br />
Mestinon 3<br />
Metadate CD 2<br />
metadate ER 1<br />
Metaglip 2<br />
metaproterenol syr 1<br />
metformin 1<br />
metformin ER 1<br />
metformin/glyburide 1<br />
methadone 1<br />
methazolamide 1<br />
methenamine combination 1<br />
Methergine 2<br />
methimazole 1<br />
methocarbamol 1<br />
methocarbamol/ASA 1<br />
methotrexate 1<br />
methyclothiazide 1<br />
methyldopa 1<br />
methyldopa/HCTZ 1<br />
methylphenidate/SR 1<br />
methylprednisolone 4mg, 8mg 1<br />
metipranolol 1<br />
metoclopramide 1<br />
metolazone 1<br />
metoprolol 1<br />
metoprolol/HCTZ 1<br />
MetroCream 3<br />
Metrogel topical 2<br />
MetroGel vag 3<br />
Metrolotion 2<br />
metronidazole 1<br />
metronidazole cream 1<br />
◆❚ Mevacor 3<br />
mexiletine 1<br />
Miacalcin inj. 2<br />
❚ Miacalcin NS 2<br />
Micardis 3<br />
Micardis HCT 3<br />
miconazole vag supp 1<br />
Micro-K 3<br />
microgestin/FE 1<br />
Micronase 3<br />
midodrine 1<br />
Midrin 3<br />
❚ Migranal 2<br />
Miltown 3<br />
Minipress 3<br />
Minitran 3<br />
Minocin 3<br />
minocycline 1<br />
minoxidil oral 1<br />
Miralax 3<br />
Mirapex 2<br />
Mircette 3<br />
◆mirtazapine 15mg 1<br />
mirtazapine 30mg, 45mg 1<br />
mirtazapine sol tab/7.5mg 3<br />
misoprostol 1<br />
❚ Mobic 3<br />
Modicon 2<br />
Moduretic 3<br />
mometasone cr/oint 1<br />
Monistat supp 3<br />
mononessa 1<br />
Monopril 3<br />
Monopril HCT 3<br />
morphine SR 1<br />
morphine tab, soln, supp 1<br />
Motrin 3<br />
MS Contin 3<br />
MSIR tabs, sol 1<br />
Mucomyst inh soln. 3<br />
multivitamin + fluoride 1<br />
mupirocin 1<br />
❚^MUSE 2<br />
Myambutol 3<br />
Mycobutin 2<br />
Mycostatin 3<br />
Mydriacyl 3<br />
Myleran 2<br />
Myrac 3<br />
Mysoline 3<br />
N<br />
N.E.E. 1<br />
nabumetone 1<br />
nadolol 1<br />
Naftin 3<br />
naltrexone 1<br />
Namenda 2<br />
naphazoline 1<br />
Naprosyn 3<br />
naproxen 1<br />
naproxen EC 1<br />
Nardil 2<br />
❚ Nasacort AQ 3<br />
Nasarel 3<br />
Nascobal 2<br />
Nasonex 2<br />
Navane 3<br />
Nebupent 2<br />
necon 1<br />
nefazodone 1<br />
nelova 1<br />
Neo-Synephrine 3<br />
neomycin 1<br />
neomycin/bacitracin/poly B 1<br />
neomycin/bacitracin/poly B/HC 1<br />
neomycin/polymyxin/HC otic 1<br />
Neoral 2<br />
+Neulasta 2<br />
+Neupogen 2<br />
Neurontin 3<br />
❚ Nexium 3<br />
Niaspan 2<br />
nicardipine 1<br />
nifediac CC 1<br />
nifedical XL 1<br />
nifedipine 1<br />
nifedipine SR 1<br />
Nimotop 2<br />
Nitrek nitroglycerin patch 1<br />
NitroDur patches 3<br />
nitrofurantoin 1<br />
nitroglycerin oint 1<br />
nitroglycerin SR 1<br />
nitroglycerin sublingual 1<br />
nitroglycerin transdermal 1<br />
patch<br />
Nitrolingual pump 2<br />
Nitrolingual spray 2<br />
Nitrostat SL tabs 3<br />
nizatidine 3<br />
Nizoral 2% shampoo 3<br />
Nizoral tablets 3<br />
Nolvadex 3<br />
Nor Q-D 3<br />
nora-BE 1<br />
Nordette 3<br />
+Norditropin 2<br />
norethindrone 1<br />
Norinyl 3<br />
Noritate 2<br />
Noroxin 3<br />
Norpace/CR 3<br />
Norpramin 3<br />
nortriptyline 1<br />
nortrel 1<br />
Norvasc 2<br />
Norvir 2<br />
novarel 1<br />
Novolin 2<br />
Novolog 2<br />
Nulytely 3<br />
+Nutropin/AQ 2<br />
NuvaRing 2<br />
nystatin 1<br />
nystatin vag tab 1<br />
nystatin/triamcinolone 1<br />
nystop 1<br />
O<br />
Ocufen 3<br />
Ocuflox 3<br />
ofloxacin 3<br />
ofloxacin ophth 1<br />
Ogen 3<br />
ogestrel 1<br />
Olux 3<br />
❚ omeprazole 1<br />
Omnicef 2<br />
One Touch Ultra<br />
One Touch UltraSmart<br />
Optipranolol 3<br />
Optivar 2<br />
Oracit 3<br />
Orapred 3<br />
orphenadrine 1<br />
❚ Ortho Evra 2<br />
Ortho Micronor 2<br />
Ortho Tri-Cyclen/Lo 2<br />
Ortho-Cept 2<br />
Ortho-Cyclen 2<br />
Ortho-Est 3<br />
Ortho-Novum 2<br />
Oruvail 3<br />
Ovcon-35 2<br />
KEY: = A step edit applies to this drug.<br />
Note: 1. * Please note that medications listed in the 3rd tier are considered<br />
❚ = Specific Quantity Limits Apply.<br />
non-formulary and are not all-inclusive.<br />
= Prior Authorization Required.<br />
2. * All branded self-injectables are subject to prior authorization &<br />
◆ = Included in Tablet-Splitting Program<br />
if approved, would be placed in the 2nd tier.<br />
ˆ = Approved for Males only.<br />
3. * Some drugs are limited to 1 unit of use package per dispensing.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.
Ovcon-50 2<br />
+Ovidrel 3<br />
Ovral 3<br />
oxaprozin 1<br />
oxazepam 1<br />
Oxistat 2<br />
Oxsoralen 2<br />
Oxsoralen Ultra 2<br />
oxybutynin 1<br />
oxycodone (10, 20, 40, 80mg) 1<br />
oxycodone SA 1<br />
oxycodone/acetaminophen 1<br />
oxycodone/aspirin 1<br />
Oxycontin (10, 20, 40, 80mg) 3<br />
Oxycontin 160 mg 2<br />
❚ Oxytrol 3<br />
P<br />
palipase 1<br />
Palladone 3<br />
Pamelor 3<br />
Pancrease (all) 2<br />
pancrelipase 1<br />
pangestyme (all) 1<br />
panokase 1<br />
Panretin 2<br />
Parafon Forte 3<br />
Parcopa 3<br />
paregoric 1<br />
Parlodel 3<br />
Parnate 2<br />
paromomycin 1<br />
◆paroxetine HCL 1<br />
Patanol 2<br />
◆Paxil 3<br />
Paxil CR 3<br />
PCE 3<br />
Pediapred 3<br />
Pediazole 3<br />
peg 3350/electrolyte 1<br />
Peganone 3<br />
+Pegasys 2<br />
+PegIntron 2<br />
pemoline 1<br />
penicillin VK 1<br />
Penlac 3<br />
Pentasa 2<br />
pentazocine/naloxone 1<br />
pentoxifylline 1<br />
Pepcid 3<br />
Percocet 3<br />
Percodan 3<br />
pergolide 3<br />
Periostat 3<br />
Permax 3<br />
perphenazine 1<br />
Persantine 3<br />
phenazopyridine 1<br />
Phenergan 3<br />
phenobarbital 1<br />
phentermine 3<br />
phenylephrine ophth 1<br />
phenylephrine/pyrilamine/ 1<br />
chlorpheniramine<br />
Phenytek 2<br />
phenytoin 1<br />
Phisohex 2<br />
Phoslo 2<br />
Phospholine Iodide 2<br />
phytonadione 1<br />
pilocarpine 1<br />
pindolol 1<br />
piroxicam 1<br />
Plaquenil 3<br />
plaretase 8000 1<br />
Plavix 2<br />
Plendil 3<br />
Pletal 3<br />
podofilox 1<br />
Poly-Vi-Flor 3<br />
Poly-Vi-Flor + Iron 3<br />
Polycitra ALL 3<br />
polymyxin B/TMP 1<br />
Polytrim 3<br />
Pontocaine 3<br />
portia 1<br />
Potaba 3<br />
potassium aminobenzoate 1<br />
potassium bicarb/potassium 1<br />
chloride<br />
potassium bicarbonate 1<br />
potassium chloride 1<br />
pramoxine/HC acetate 2.5% 1<br />
Prandin 2<br />
prascion RA 1<br />
◆❚ Pravachol 3<br />
prazosin 1<br />
pre-natal vitamins 1<br />
Precose 2<br />
Pred Forte 3<br />
Pred Mild 2<br />
Pred-G 3<br />
prednisolone acetate 1<br />
prednisolone oral 1<br />
prednisolone sod acetate 1<br />
prednisone oral 1<br />
Prefest 3<br />
+Pregnyl 3<br />
Prelone syrup 3<br />
Premarin 2<br />
Premarin vag cream 2<br />
Premphase 2<br />
Prempro 2<br />
Prenate Elite 2<br />
Prevacid Naprapac 3<br />
❚ Prevacid/susp 2<br />
previfem 1<br />
Prevpac 2<br />
❚ Prilosec 3<br />
❚ prilosec-OTC 1<br />
Primaquine 2<br />
primidone 1<br />
Prinivil 3<br />
Prinzide 3<br />
ProAmatine 3<br />
probenecid 1<br />
procainamide 1<br />
procainamide SR 1<br />
Procanbid 3<br />
Procardia/XL 3<br />
prochlorperazine 1<br />
+Procrit 2<br />
Proctocort rectal 3<br />
Proctofoam-HC 2<br />
+Profasi 2<br />
Progesterone 2<br />
Prograf 2<br />
Prolixin 3<br />
promethazine 1<br />
promethazine/codeine 1<br />
promethazine/codeine/DM 1<br />
promethazine/DM 1<br />
promethazine/phenylephrine 1<br />
promethazine/phenylephrine/ 1<br />
codeine<br />
promethazine/pyrilamine 1<br />
Prometrium 2<br />
Pronestyl 3<br />
propafenone 1<br />
propantheline 1<br />
proparacaine 1<br />
Propine 3<br />
propoxyphene HCL 1<br />
propoxyphene HCL/APAP 1<br />
propoxyphene HCL/ASA/caffeine 1<br />
propoxyphene napsylate/APAP 1<br />
propranolol 1<br />
propranolol/HCTZ 1<br />
propylthiouracil 1<br />
❚^Proscar 2<br />
❚ Protonix 2<br />
Protopic 2<br />
❚ Proventil HFA 2<br />
Proventil Inh/Sol 3<br />
Provera 3<br />
❚Provigil 2<br />
Prozac capsule 3<br />
❚ Prozac Weekly 3<br />
pseudoephedrine 30/60mg-OTC 1<br />
pseudoephedrine syr - OTC 1<br />
pseudoephedrine/codeine 1<br />
Psorcon E 3<br />
❚ Pulmicort 2<br />
Pulmicort respules 2<br />
Pulmozyme 2<br />
Purinethol 3<br />
pyrazinamide 1<br />
Pyridium 3<br />
pyridostigmine bromide 1<br />
Q<br />
Questran 3<br />
quinapril 1<br />
quinapril/HCTZ 1<br />
quinidine gluconate 1<br />
quinidine sulfate SR 1<br />
quinine sulfate 1<br />
❚ Qvar 2<br />
SECTION II — INDEX (CONT’D)<br />
DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER DRUG NAME TIER<br />
R<br />
ranitidine 1<br />
Rapamune 2<br />
+Raptiva 2<br />
Razadyne/ ER 3<br />
+Rebetol 3<br />
+Rebetron 2<br />
+Rebif 2<br />
Regencare 3<br />
Reglan 3<br />
Regranex 2<br />
Relafen 3<br />
❚ Relenza 2<br />
❚ Relpax 2<br />
◆Remeron 3<br />
Remeron Sol Tab 3<br />
Reminyl sol. 3<br />
Renagel 2<br />
+Repronex 2<br />
Requip 2<br />
Rescriptor 2<br />
Restasis 2<br />
Restoril 3<br />
Restoril 7.5mg 2<br />
Retin A cr/oint 3<br />
Retin A gel 3<br />
Retin A liquid 3<br />
Retin A micro 3<br />
Retrovir 2<br />
+Revatio 3<br />
Revlimid 2<br />
Reyataz 2<br />
❚ Rhinocort AQ 2<br />
+ribapak 1<br />
+ribasphere 1<br />
+ribatab 1<br />
+ribavirin 1<br />
Ridaura 2<br />
Rifadin 3<br />
Rifamate 2<br />
rifampin 1<br />
Rifater 2<br />
Rilutek 2<br />
rimantadine 1<br />
Riomet solution 3<br />
❚ Risperdal 2<br />
Risperdal lingual 3<br />
❚ Risperdal-M 2<br />
Ritalin LA 2<br />
Ritalin/SR 3<br />
Robaxin 3<br />
Robinul 3<br />
Rocaltrol 3<br />
Rondec 3<br />
Rondec DM/TR 3<br />
Rosac 3<br />
Rowasa 3<br />
Roxicet 2<br />
Rynatan/Ped. Susp 3<br />
Rythmol 3<br />
Rythmol SR 2<br />
S<br />
+Saizen 3<br />
Salagen 3<br />
salsalate 1<br />
❚ Sanctura 3<br />
Sandimmune 2<br />
Sarafem 3<br />
Seasonale 2<br />
selegiline 1<br />
selenium sulf 2.5% shampoo 1<br />
Selsun Rx 3<br />
Semprex-D 2<br />
Sensipar 2<br />
Septra/DS 3<br />
Serax 3<br />
❚ Serevent 2<br />
❚ Serevent Diskus 2<br />
serophene 1<br />
Seroquel 3<br />
Silvadene cream 3<br />
silver sulfadiazine 1<br />
Sinemet/CR 3<br />
Sinequan 3<br />
Singulair 2<br />
Skelaxin 3<br />
sod. polystyrene sulfonate 1<br />
sod.sulfacetamide/sulfur 1<br />
emulsion cleanser<br />
sod.sulfacetamide/sulfur lot 1<br />
sodium chloride irrigating 1<br />
soln.<br />
sodium fluoride chewable tab 1<br />
& drops<br />
SoftClix Device<br />
Solaquin/forte 3<br />
solia 1<br />
Soma/Compound 3<br />
Somnote 2<br />
❚ Sonata 3<br />
sortret 1<br />
sotalol 1<br />
Spectazole 3<br />
Spectracef 3<br />
❚ Spiriva 2<br />
spironolactone 1<br />
spironolactone/HCTZ 1<br />
❚ Sporanox 3<br />
sprintec 1<br />
Stalevo 2<br />
Starlix 3<br />
Stimate 2<br />
❚ Strattera 2<br />
Striant 3<br />
Suboxone 2<br />
Subutex 2<br />
sucralfate 1<br />
Sular 3<br />
sulfacetamide 10% 1<br />
sulfacetamide/prednisolone 1<br />
ophth<br />
sulfamethoxazole/trimethoprim 1<br />
sulfasalazine 1<br />
sulfasalazine EC 1<br />
sulfinpyrazone 1<br />
sulfisoxazole tabs 1<br />
sulindac 1<br />
Suprax 3<br />
Surestep<br />
Sustiva 2<br />
❚ Symbyax 3<br />
Symlin 3<br />
Symmetrel 3<br />
Synalar 3<br />
Synarel 2<br />
Syntest D.S./H.S. 2<br />
Synthroid 2<br />
T<br />
Tagamet 3<br />
Talwin NX 3<br />
Tambocor 3<br />
❚ Tamiflu 2<br />
tamoxifen 1<br />
Tapazole 3<br />
+Tarceva 2<br />
Targretin 2<br />
Tarka 3<br />
Tasmar 3<br />
Tazorac cream 2<br />
Tazorac gel 2<br />
Tegretol 2<br />
Tegretol XR 2<br />
temazepam 1<br />
+Temodar 2<br />
Temovate 3<br />
Tenoretic 3<br />
Tenormin 3<br />
Tenuate 3<br />
Tequin 3<br />
Terazol 3<br />
terazosin 1<br />
terbutaline tab 1<br />
terconazole 1<br />
Tessalon Perles 3<br />
Testim 3<br />
Testosterone 2<br />
tetracaine 1<br />
tetracycline 1<br />
Teveten 3<br />
Teveten HCT 3<br />
Thalomid 2<br />
Theo-24 2<br />
theochron 1<br />
theophylline/SR tabs, liquid 1<br />
Thioguanine 2<br />
thioridazine 1<br />
thiothixene 1<br />
thyroid 1<br />
Thyroid (Armour) 2<br />
Thyrolar 2<br />
Tiazac 3<br />
Ticlid 3<br />
ticlopidine 1<br />
Tigan cap/supp 3<br />
Tikosyn 3<br />
11<br />
❚ Tilade 2<br />
timolol 1<br />
timolol XE 1<br />
Timoptic/XE 3<br />
Tindamax 3<br />
tizanidine 1<br />
Tobi 2<br />
Tobradex 2<br />
tobramycin soln 1<br />
Tobrex ointment 2<br />
Tobrex solution 3<br />
Tofranil/PM 3<br />
tolazamide 1<br />
tolbutamide 1<br />
tolmetin 1<br />
Topamax 2<br />
Topicort 3<br />
Toprol XL 2<br />
❚ Toradol inj/tabs 3<br />
torsemide 1<br />
Tracleer 2<br />
tramadol 1<br />
Trandate 3<br />
Transderm Scop 2<br />
Tranxene SD/ T 3<br />
Travatan 2<br />
trazodone 1<br />
Trental 3<br />
tretinoin cr/oint/gel 1<br />
Trexall 3<br />
Tri-Norinyl 3<br />
tri-sprintec 1<br />
Tri-Vi-Flor 3<br />
Tri-Vi-Flor + Iron 3<br />
triamcinolone acetonide 1<br />
triamterene/HCTZ 1<br />
triazolam 1<br />
Tricor 2<br />
trifluoperazine 1<br />
trifluridine 1<br />
trihexyphenidyl 1<br />
Trileptal 2<br />
Tri-Levlen 3<br />
Trilyte 3<br />
trimethobenzamide 1<br />
trimethobenzamide supp. 1<br />
trimethoprim 1<br />
Trimpex 3<br />
trinessa 1<br />
Triphasil 3<br />
triprevifem 1<br />
trivora 1<br />
Trizivir 2<br />
tropicamide 1<br />
Trusopt 2<br />
Truvada 2<br />
Tussionex susp 2<br />
Twinject 2<br />
Tylenol/codeine 3<br />
U<br />
Ultracet 3<br />
Ultram/ ER 3<br />
Ultrase (all) 2<br />
Ultravate 3<br />
Uniphyl 3<br />
unithroid 1<br />
Univasc 3<br />
Urecholine 3<br />
Urised 3<br />
Urocit-K 3<br />
^Uroxatral 2<br />
Urso 2<br />
Urso Forte 2<br />
ursodiol 1<br />
V<br />
Vagifem 2<br />
Valcyte 2<br />
Valium 3<br />
valproic acid 1<br />
Valtrex 2<br />
Vancocin 2<br />
vandazole vag 1<br />
Vantin 3<br />
Vantin susp 2<br />
Vaseretic 3<br />
Vasocidin 3<br />
Vasotec 3<br />
velivet 1<br />
Ventavis 3<br />
❚ Ventolin HFA 3<br />
Vepesid 3<br />
verapamil 1<br />
verapamil SR 1<br />
verapamil SR pellet 1<br />
Verelan/PM 3<br />
Vermox chew tab 3<br />
Vesanoid 2<br />
❚ Vesicare 3<br />
❚Vfend 2<br />
❚^Viagra 2<br />
Vibramycin 3<br />
Vicodin/ES 3<br />
Vicoprofen 3<br />
Videx 2<br />
Videx EC 3<br />
Vigamox 2<br />
Viokase 2<br />
Viracept 2<br />
Viramune 2<br />
Viread 2<br />
Viroptic 3<br />
Vistaril 3<br />
vit A,D,C + fluoride 1<br />
vit A,D,C + fluoride and iron 1<br />
Vivactil 3<br />
❚ Vivelle 2<br />
❚ Vivelle-DOT 2<br />
Voltaren 3<br />
Voltaren/XR 3<br />
Vopac 3<br />
VoSol HC otic 3<br />
Vospire ER 2<br />
Vytorin 3<br />
W<br />
warfarin 1<br />
Welchol 3<br />
Wellbutrin XL 2<br />
❚ Wellbutrin/SR 3<br />
Westcort 3<br />
X<br />
Xalatan 2<br />
Xanax /XR 3<br />
+Xeloda 2<br />
Xenical 3<br />
Xifaxan 3<br />
❚ Xopenex/ HFA 3<br />
Xylocaine viscous, gel, soln. 3<br />
Y<br />
Yasmin 2<br />
Yaz 2<br />
Yodoxin 2<br />
^yohimbine 1<br />
Z<br />
Zaditor 2<br />
Zanaflex 3<br />
Zantac 3<br />
Zantac liquid 2<br />
Zarontin 2<br />
Zaroxolyn 3<br />
Zavesca 2<br />
❚ Zegerid 3<br />
Zelnorm 2<br />
Zerit 2<br />
Zestoretic 3<br />
Zestril 3<br />
Zetia 2<br />
Ziac 3<br />
Ziagen 2<br />
Zithromax susp. 2<br />
Zithromax tablets 3<br />
Zmax 2<br />
◆Zocor 3<br />
❚Zofran 2<br />
❚Zofran ODT 2<br />
◆❚ Zoloft 2<br />
❚ Zoloft Elixir 2<br />
❚ Zomig 2<br />
Zomig Nasal 2<br />
❚ Zomig ZMT 2<br />
Zonegran 2<br />
+Zorbtive 3<br />
Zoto HC 3<br />
zovia 1<br />
Zovirax 3<br />
Zovirax ointment 2<br />
Zylet 3<br />
Zyloprim 3<br />
Zymar 3<br />
❚ Zyprexa 2<br />
❚ Zyprexa Zydis 2<br />
❚ Zyrtec tab/syrup 3<br />
❚ Zyrtec-D 3<br />
Zyvox 2<br />
KEY: = A step edit applies to this drug.<br />
Note: 1. * Please note that medications listed in the 3rd tier are considered<br />
❚ = Specific Quantity Limits Apply.<br />
non-formulary and are not all-inclusive.<br />
= Prior Authorization Required.<br />
2. * All branded self-injectables are subject to prior authorization &<br />
◆ = Included in Tablet-Splitting Program<br />
if approved, would be placed in the 2nd tier.<br />
ˆ = Approved for Males only.<br />
3. * Some drugs are limited to 1 unit of use package per dispensing.<br />
u = Approved for Females only.<br />
+ = Access restricted to specialty pharmacy.
Change language