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of New York

2014

Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on August 2013. For more recent information or
other questions, please contact Today’s Options of New York
at 1-800-223-7242 8:00 a.m. to 8:00 p.m. Eastern Time, Monday to Friday,
9:00 a.m. to 1:00 p.m. Eastern Time, Saturday,
or visit www.TodaysOptionsNY.com.
®

Drug Name

Drug Tier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Amphetamines
amphetamine-dextroamphetamine cap sr
24hr 5 mg
amphetamine-dextroamphetamine cap sr
24hr 10 mg
amphetamine-dextroamphetamine cap sr
24hr 15 mg
amphetamine-dextroamphetamine cap sr
24hr 20 mg
amphetamine-dextroamphetamine cap sr
24hr 25 mg
amphetamine-dextroamphetamine cap sr
24hr 30 mg
amphetamine-dextroamphetamine tab 5
mg
amphetamine-dextroamphetamine tab 7.5
mg
amphetamine-dextroamphetamine tab 10
mg
amphetamine-dextroamphetamine tab
12.5 mg
amphetamine-dextroamphetamine tab 15
mg
amphetamine-dextroamphetamine tab 20
mg
amphetamine-dextroamphetamine tab 30
mg
dextroamphetamine sulfate cap sr 24hr 5
mg
dextroamphetamine sulfate cap sr 24hr 10
mg
dextroamphetamine sulfate cap sr 24hr 15
mg
dextroamphetamine sulfate tab 5 mg
dextroamphetamine sulfate tab 10 mg
methamphetamine hcl tab 5 mg
VYVANSE CAP 20MG
VYVANSE CAP 30MG
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG

1

QL (90 caps / 25 days)

1

QL (90 caps / 25 days)

1

QL (30 caps / 25 days)

1

QL (30 caps / 25 days)

1

QL (30 caps / 25 days)

1

QL (30 caps / 25 days)

1

QL (90 tabs / 25 days)

1

QL (90 tabs / 25 days)

1

QL (90 tabs / 25 days)

1

QL (90 tabs / 25 days)

1

QL (60 tabs / 25 days)

1

QL (60 tabs / 25 days)

1

QL (30 tabs / 25 days)

1

QL (120 caps / 25 days)

1

QL (120 caps / 25 days)

1

QL (60 tabs / 25 days)

1
1
1
3
3
3
3
3
3

QL (120 tabs / 25 days)
QL (120 tabs / 25 days)
QL (150 tabs / 25 days)
PA
PA
PA
PA
PA
PA

Attention-Deficit/Hyperactivity Disorder (ADHD) Agents
INTUNIV TAB 1MG
INTUNIV TAB 2MG
INTUNIV TAB 3MG

3
3
3

ST
ST
ST

1

Drug Name
INTUNIV TAB 4MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRATTERA CAP 100MG

Drug Tier Requirements/Limits
3
ST
2
QL (120 caps / 25 days)
2
QL (120 caps / 25 days)
2
QL (120 caps / 25 days)
2
QL (60 caps / 25 days)
2
QL (30 caps / 25 days)
2
QL (30 caps / 25 days)
2
QL (30 caps / 25 days)

Stimulants - Misc.
dexmethylphenidate hcl tab 2.5 mg
dexmethylphenidate hcl tab 5 mg
dexmethylphenidate hcl tab 10 mg
metadate tab 20mg er
methylin tab 5mg
methylin tab 10mg
methylin tab 10mg er
methylin tab 20mg
methylin tab 20mg er
methylphenidate hcl cap sr 24hr 20 mg
methylphenidate hcl cap sr 24hr 30 mg
methylphenidate hcl cap sr 24hr 40 mg
methylphenidate hcl soln 5 mg/5ml
methylphenidate hcl soln 10 mg/5ml
methylphenidate hcl tab 5 mg
methylphenidate hcl tab 10 mg
methylphenidate hcl tab 20 mg
methylphenidate hcl tab cr 10 mg
methylphenidate hcl tab cr 20 mg
methylphenidate hcl tab sa osm 18 mg
methylphenidate hcl tab sa osm 27 mg
methylphenidate hcl tab sa osm 36 mg
methylphenidate hcl tab sa osm 54 mg
modafinil tab 100 mg
modafinil tab 200 mg
NUVIGIL TAB 50MG
NUVIGIL TAB 150MG
NUVIGIL TAB 250MG
RITALIN LA CAP 10MG

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2

QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
PA
PA
PA
PA
QL

1
3

PA

(120 tabs / 25 days)
(120 tabs / 25 days)
(60 tabs / 25 days)
(90 tabs / 25 days)
(180 tabs / 25 days)
(180 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(60 caps / 25 days)
(60 caps / 25 days)
(30 caps / 25 days)
(1800 ml / 25 days)
(900 ml / 25 days)
(180 tabs / 25 days)
(180 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(60 tabs / 25 days)
(30 tabs / 25 days)

(60 caps / 25 days)

AMINOGLYCOSIDES
Aminoglycosides
streptomycin sulfate for inj 1 gm
TOBI NEB 300/5ML

ANALGESICS - ANTI-INFLAMMATORY
Anti-TNF-alpha - Monoclonoal Antibodies
2

Drug Name
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEN KIT CROHNS

Drug Tier Requirements/Limits
3
PA
3
PA
3
PA

Interleukin-1 Receptor Antagonist (IL-1Ra)
KINERET INJ

3

PA

3
3
3

PA
PA
PA

Interleukin-6 Receptor Inhibitors
ACTEMRA INJ 80MG/4ML
ACTEMRA INJ 200/10ML
ACTEMRA INJ 400/20ML

Nonsteroidal Anti-inflammatory Agents (NSAIDs)
CELEBREX CAP 50MG
CELEBREX CAP 100MG
CELEBREX CAP 200MG
CELEBREX CAP 400MG
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 25
mg
diclofenac sodium tab delayed release 50
mg
diclofenac sodium tab delayed release 75
mg
diclofenac sodium tab sr 24hr 100 mg
diclofenac w/ misoprostol tab delayed
release 50-0.2 mg
diclofenac w/ misoprostol tab delayed
release 75-0.2 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
fenoprofen calcium tab 600 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen susp 100 mg/5ml
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
INDOCIN SUS 25MG/5ML
indomethacin cap 25 mg
indomethacin cap 50 mg
indomethacin cap cr 75 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketoprofen cap sr 24hr 200 mg
ketorolac tromethamine im inj 30 mg/ml
ketorolac tromethamine im inj 60 mg/2ml
(30 mg/ml)

3
3
3
3
1
1

ST
ST
ST
ST

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1

3

Drug Name
ketorolac tromethamine
ketorolac tromethamine
ketorolac tromethamine
mg/ml)
ketorolac tromethamine
(30 mg/ml)
ketorolac tromethamine

Drug Tier Requirements/Limits
inj 15 mg/ml
1
inj 30 mg/ml
1
inj 60 mg/2ml (30 1
inj 300 mg/10ml

1

tab 10 mg

1

meclofenamate sodium cap 50 mg
meclofenamate sodium cap 100 mg
mefenamic acid cap 250 mg
meloxicam susp 7.5 mg/5ml
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
NALFON CAP 200MG
NALFON CAP 400MG
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
oxaprozin tab 600 mg
piroxicam cap 10 mg
piroxicam cap 20 mg
sulindac tab 150 mg
sulindac tab 200 mg
tolmetin sodium cap 400 mg
tolmetin sodium tab 200 mg
tolmetin sodium tab 600 mg

1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

QL (20 tabs per 25
days)

ST
ST

Pyrimidine Synthesis Inhibitors
leflunomide tab 10 mg
leflunomide tab 20 mg

1
1

Selective Costimulation Modulators
ORENCIA INJ 250MG

3

PA

Soluble Tumor Necrosis Factor Receptor Agents
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML

3
3
3

PA
PA
PA

ANALGESICS - NonNarcotic
Salicylates
4

Drug Name
ADULT ASA TAB 81MG QM
aspirin chew tab 81 mg
aspirin low tab 81mg ec
aspirin tab 81 mg
aspirin tab 325 mg
aspirin tab delayed release 325 mg
bayer low chw 81mg
diflunisal tab 500 mg
ECOTRIN TAB 325MG EC
HALFPRIN TAB 162MG EC
ST JOSEPH CHW 75MG ADU

Drug Tier Requirements/Limits
0
0
0
0
0
0
0
1
0
0
0

ANALGESICS - OPIOID
Opioid Agonists
AVINZA CAP 30MG
AVINZA CAP 45MG
AVINZA CAP 60MG
AVINZA CAP 75MG
AVINZA CAP 90MG
AVINZA CAP 120MG
CODEINE SULF SOL 30MG/5ML
codeine sulfate tab 15 mg
codeine sulfate tab 30 mg
codeine sulfate tab 60 mg
EMBEDA CAP 30-1.2MG

3
3
3
3
3
3
2
1
1
1
3

EXALGO
EXALGO
EXALGO
EXALGO
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl

TAB 8MG
TAB 12MG
TAB 16MG
TAB 32MG
citrate lollipop 200 mcg
citrate lollipop 400 mcg
citrate lollipop 600 mcg
citrate lollipop 800 mcg
citrate lollipop 1200 mcg
citrate lollipop 1600 mcg
td patch 72hr 12 mcg/hr

3
3
3
3
1
1
1
1
1
1
1

fentanyl td patch 72hr 25 mcg/hr

1

fentanyl td patch 72hr 50 mcg/hr

1

fentanyl td patch 72hr 75 mcg/hr

1

fentanyl td patch 72hr 100 mcg/hr

1

QL
QL
QL
QL
QL
QL

(60
(60
(60
(60
(60
(60

QL (45
QL (45
QL (45
QL (60
days)
QL (60
QL (60
QL (60
QL (60
PA
PA
PA
PA
PA
PA
QL (10
days)
QL (10
days)
QL (10
days)
QL (10
days)
QL (10
days)

ea
ea
ea
ea
ea
ea

/
/
/
/
/
/

25
25
25
25
25
25

days)
days)
days)
days)
days)
days)

tabs / 25 days)
tabs / 25 days)
tabs / 25 days)
caps per 25
tabs
tabs
tabs
tabs

/
/
/
/

25
25
25
25

days)
days)
days)
days)

patches / 25
patches / 25
patches / 25
patches / 25
patches / 25

5

Drug Name
Drug Tier Requirements/Limits
HYDROMORPHON SUP 3MG
3
hydromorphone hcl liqd 1 mg/ml
1
QL (180 ml / 25 days)
hydromorphone hcl tab 2 mg
1
QL (180 tabs / 25 days)
hydromorphone hcl tab 4 mg
1
QL (180 tabs / 25 days)
hydromorphone hcl tab 8 mg
1
QL (180 tabs / 25 days)
levorphanol tartrate tab 2 mg
1
QL (180 tabs / 25 days)
methadone hcl conc 10 mg/ml
1
methadone hcl soln 5 mg/5ml
1
methadone hcl soln 10 mg/5ml
1
methadone hcl tab 5 mg
1
QL (120 tabs / 25 days)
methadone hcl tab 10 mg
1
QL (120 tabs / 25 days)
methadone hcl tab for oral susp 40 mg
1
QL (30 tabs / 25 days)
methadose con 10mg/ml
1
methadose tab 5mg
1
QL (120 tabs / 25 days)
methadose tab 10mg
1
QL (120 tabs / 25 days)
methadose tab 40mg
1
QL (30 tabs / 25 days)
MORPHINE SUL SUP 30MG
2
QL (180 / 25 days)
morphine sulfate (concentrate) oral soln 20 1
QL (180 ml / 25 days)
mg/ml
morphine sulfate oral soln 10 mg/5ml
1
QL (900 ml / 25 days)
morphine sulfate oral soln 20 mg/5ml
1
QL (900 ml / 25 days)
morphine sulfate suppos 5 mg
1
QL (180 / 25 days)
morphine sulfate suppos 10 mg
1
QL (180 / 25 days)
morphine sulfate suppos 20 mg
1
QL (180 / 25 days)
morphine sulfate tab 15 mg
1
QL (180 tabs / 25 days)
morphine sulfate tab 30 mg
1
QL (180 tabs / 25 days)
morphine sulfate tab cr 15 mg
1
QL (90 tabs / 25 days)
morphine sulfate tab cr 30 mg
1
QL (90 tabs / 25 days)
morphine sulfate tab cr 100 mg
1
QL (90 tabs / 25 days)
morphine sulfate tab cr 200 mg
1
QL (60 tabs / 25 days)
morphine sulfate tab sr 12hr 60 mg
1
QL (90 tabs / 25 days)
NUCYNTA ER TAB 50MG
3
QL (120 tabs / 25 days)
NUCYNTA ER TAB 100MG
3
QL (120 tabs / 25 days)
NUCYNTA ER TAB 150MG
3
QL (60 tabs / 25 days)
NUCYNTA ER TAB 200MG
3
QL (60 tabs / 25 days)
NUCYNTA ER TAB 250MG
3
QL (60 tabs / 25 days)
NUCYNTA TAB 50MG
3
QL (360 tabs / 25 days)
NUCYNTA TAB 75MG
3
QL (240 tabs / 25 days)
NUCYNTA TAB 100MG
3
QL (180 tabs / 25 days)
OPANA ER TAB 5MG
3
QL (120 ea / 25 days)
OPANA ER TAB 7.5MG
3
QL (120 ea / 25 days)
OPANA ER TAB 10MG
3
QL (120 ea / 25 days)
OPANA ER TAB 15MG
3
QL (120 ea / 25 days)
OPANA ER TAB 20MG
3
QL (120 ea / 25 days)
OPANA ER TAB 30MG
3
QL (120 ea / 25 days)
OPANA ER TAB 40MG
3
QL (120 ea / 25 days)

6

Drug Name
oxycodone hcl cap 5 mg
oxycodone hcl conc 20 mg/ml
oxycodone hcl soln 5 mg/5ml
oxycodone hcl tab 5 mg
oxycodone hcl tab 10 mg
oxycodone hcl tab 15 mg
oxycodone hcl tab 20 mg
oxycodone hcl tab 30 mg
OXYCONTIN TAB 10MG CR
OXYCONTIN TAB 15MG CR
OXYCONTIN TAB 20MG CR
OXYCONTIN TAB 30MG CR
OXYCONTIN TAB 40MG CR
OXYCONTIN TAB 60MG CR
OXYCONTIN TAB 80MG CR
oxymorphone hcl tab 5 mg
oxymorphone hcl tab 10 mg
oxymorphone hcl tab sr 12hr 5 mg
oxymorphone hcl tab sr 12hr 7.5 mg
oxymorphone hcl tab sr 12hr 10 mg
oxymorphone hcl tab sr 12hr 15 mg
oxymorphone hcl tab sr 12hr 20 mg
oxymorphone hcl tab sr 12hr 30 mg
oxymorphone hcl tab sr 12hr 40 mg
tramadol hcl tab 50 mg
tramadol hcl tab sr 24hr 100 mg
tramadol hcl tab sr 24hr 200 mg
tramadol hcl tab sr 24hr 300 mg

Drug Tier Requirements/Limits
1
QL (180 caps / 25 days)
1
QL (180 ml / 25 days)
1
QL (180 ml / 25 days)
1
QL (180 tabs / 25 days)
1
QL (180 tabs / 25 days)
1
QL (180 tabs / 25 days)
1
QL (180 tabs / 25 days)
1
QL (180 tabs / 25 days)
2
QL (120 ea / 25 days)
2
QL (120 ea / 25 days)
2
QL (120 ea / 25 days)
2
QL (120 ea / 25 days)
2
QL (120 ea / 25 days)
2
QL (120 ea / 25 days)
2
QL (120 ea / 25 days)
1
QL (180 tabs / 25 days)
1
QL (180 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (240 tabs / 25 days)
1
QL (30 tabs / 25 days)
1
QL (30 tabs / 25 days)
1
QL (30 tabs / 25 days)

Opioid Combinations
acetaminophen w/ codeine soln 120-12
mg/5ml
acetaminophen w/ codeine tab 300-15 mg
acetaminophen w/ codeine tab 300-30 mg
acetaminophen w/ codeine tab 300-60 mg
CAPITAL/COD SUS 120-12/5
co-gesic tab 5-500mg
COCET PLUS TAB 650-60MG
COCET TAB 650-30MG
endocet tab 5-325mg
endocet tab 7.5-325
endocet tab 7.5-500m
endocet tab 10-325mg
endocet tab 10-650mg
HYDROCO/APAP SOL 10-325MG
hydrocodone-acetaminophen soln 7.5-325
mg/15ml

1

QL (3750 ml / 25 days)

1
1
1
2
1
2
2
1
1
1
1
1
2
1

QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL

(300 tabs / 25 days)
(300 tabs / 25 days)
(300 tabs / 25 days)
(3750 ml / 25 days)
(180 tabs / 25 days)
(120 tabs / 25 days)
(120 tabs / 25 days)
(300 tabs / 25 days)
(300 tabs / 25 days)
(180 tabs / 25 days)
(300 tabs / 25 days)
(120 tabs / 25 days)
(3750 ml / 25 days)
(3750 ml / 25 days)

7

Drug Name
Drug Tier Requirements/Limits
hydrocodone-acetaminophen soln 7.5-500 1
QL (2250 ml / 25 days)
mg/15ml
hydrocodone-acetaminophen tab 2.5-500 1
QL (180 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 5-300 mg 1
QL (300 tabs / 25 days)
hydrocodone-acetaminophen tab 5-325 mg 1
QL (300 tabs / 25 days)
hydrocodone-acetaminophen tab 5-500 mg 1
QL (180 tabs / 25 days)
hydrocodone-acetaminophen tab 7.5-300 1
QL (300 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 7.5-325 1
QL (300 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 7.5-500 1
QL (180 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 7.5-650 1
QL (120 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 7.5-750 1
QL (120 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 10-300 1
QL (300 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 10-325 1
QL (300 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 10-500 1
QL (180 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 10-650 1
QL (120 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 10-660 1
QL (120 tabs / 25 days)
mg
hydrocodone-acetaminophen tab 10-750 1
QL (120 tabs / 25 days)
mg
hydrogesic cap 5-500mg
1
QL (180 caps / 25 days)
MAGNACET TAB 7.5-400
2
QL (240 tabs / 25 days)
margesic-h cap 5-500mg
1
QL (180 caps / 25 days)
oxycodone w/ acetaminophen cap 5-500
1
QL (180 caps / 25 days)
mg
oxycodone w/ acetaminophen tab 2.5-325 1
QL (300 tabs / 25 days)
mg
oxycodone w/ acetaminophen tab 5-325
1
QL (300 tabs / 25 days)
mg
oxycodone w/ acetaminophen tab 7.5-325 1
QL (300 tabs / 25 days)
mg
oxycodone w/ acetaminophen tab 7.5-500 1
QL (180 tabs / 25 days)
mg
oxycodone w/ acetaminophen tab 10-325 1
QL (300 tabs / 25 days)
mg
oxycodone w/ acetaminophen tab 10-650 1
QL (120 tabs / 25 days)
mg
oxycodone-ibuprofen tab 5-400 mg
1
polygesic cap 5-500mg
1
QL (180 caps / 25 days)
PRIMLEV TAB 5-300MG
2
QL (300 tabs / 25 days)
PRIMLEV TAB 7.5-300
2
QL (300 tabs / 25 days)
PRIMLEV TAB 10-300MG
2
QL (300 tabs / 25 days)

8

Drug Name
ROXICET SOL 5-325/5
roxicet tab 5-325mg
ROXICET TAB 5-500MG
stagesic cap 5-500mg
vicodin es tab 7.5-300
vicodin hp tab 10-300mg
vicodin hp tab 10-660mg
vicodin tab 5-300mg
XOLOX TAB 10-500MG
ZAMICET SOL 10-325MG

Drug Tier Requirements/Limits
2
QL (1385 ml / 25 days)
1
QL (300 tabs / 25 days)
2
QL (180 tabs / 25 days)
1
QL (180 caps / 25 days)
1
QL (300 tabs / 25 days)
1
QL (300 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (300 tabs / 25 days)
2
QL (180 tabs / 25 days)
2
QL (3750 ml / 25 days)

Opioid Partial Agonists
buprenorphine hcl sl tab 2 mg (base equiv) 1
buprenorphine hcl sl tab 8 mg (base equiv) 1
butorphanol tartrate nasal soln 10 mg/ml 1
nalbuphine hcl inj 10 mg/ml
1
nalbuphine hcl inj 20 mg/ml
1
SUBOXONE MIS 2-0.5MG
2
SUBOXONE MIS 4-1MG
2
SUBOXONE MIS 8-2MG
2
SUBOXONE MIS 12-3MG
2

PA
PA
QL (2 bottles / 25 days)

PA
PA
PA
PA

ANDROGENS-ANABOLIC
Anabolic Steroids
ANADROL-50 TAB 50MG
oxandrolone tab 2.5 mg
oxandrolone tab 10 mg

3
1
1

PA
PA
PA

ANDRODERM DIS 2.5MG/24
2
ANDRODERM DIS 2MG/24HR
2
ANDRODERM DIS 4MG/24HR
2
ANDRODERM DIS 5MG/24HR
2
android cap 10mg
1
ANDROXY TAB 10MG
3
AXIRON SOL 30MG/ACT
2
danazol cap 50 mg
1
danazol cap 100 mg
1
danazol cap 200 mg
1
FORTESTA GEL 10MG/ACT
2
testosterone cypionate im in oil 100 mg/ml 1
testosterone cypionate im in oil 200 mg/ml 1
testosterone enanthate im in oil 200 mg/ml1

PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA

Androgens

ANORECTAL AGENTS
Intrarectal Steroids
hydrocortisone enema 100 mg/60ml

1

Rectal Steroids
9

Drug Name
anucort-hc sup 25mg
hemril-30 sup 30mg
hydrocortisone acetate suppos 25 mg
hydrocortisone acetate suppos 30 mg
proctocream cre -hc 2.5%
proctosol hc cre 2.5%
proctozone cre -hc 2.5%

Drug Tier Requirements/Limits
1
1
1
1
1
1
1

Vasodilating Agents
RECTIV OIN 0.4%

3

ANTHELMINTICS
Anthelmintics
ALBENZA TAB 200MG
BILTRICIDE TAB 600MG
mebendazole chew tab 100 mg
STROMECTOL TAB 3MG

2
3
1
3

ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.
aztreonam for inj 1 gm
aztreonam for inj 2 gm
metronidazole cap 375 mg
metronidazole tab 250 mg
metronidazole tab 500 mg
NEBUPENT INH 300MG
PENTAM 300 INJ 300MG
PRIMSOL SOL 50MG/5ML
tinidazole tab 250 mg
tinidazole tab 500 mg
trimethoprim tab 100 mg
vancomycin hcl cap 125 mg
vancomycin hcl cap 250 mg
VIBATIV INJ 250MG
XIFAXAN TAB 200MG
XIFAXAN TAB 550MG

1
1
1
1
1
3
3
2
1
1
1
1
1
3
2
2

ST
ST

PA

Anti-infective Misc. - Combinations
erythromycin-sulfisoxazole for susp 200- 1
600 mg/5ml
sulfamethoxazole-trimethoprim susp 200- 1
40 mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 1
mg
sulfamethoxazole-trimethoprim tab 800- 1
160 mg

Antiprotozoal Agents
ALINIA SUS 100MG/5M
ALINIA TAB 500MG

2
2

10

Drug Name

Drug Tier Requirements/Limits

Carbapenems
DORIBAX INJ 250MG
DORIBAX INJ 500MG

3
3

Cyclic Lipopeptides
CUBICIN SOL 500MG

3

Ketolides
KETEK TAB 300MG
KETEK TAB 400MG

3
3

Leprostatics
dapsone tab 25 mg
dapsone tab 100 mg

1
1

Lincosamides
clindamycin hcl cap 75 mg
clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg

1
1
1

Oxazolidinones
ZYVOX SUS 100MG/5M
ZYVOX TAB 600MG

2
2

ANTIANGINAL AGENTS
Antianginals-Other
RANEXA TAB 500MG
RANEXA TAB 1000MG

2
2

ST
ST

Nitrates
ISORDIL TAB 40MG
2
isosorbide dinitrate sl tab 5 mg
1
isosorbide dinitrate tab 5 mg
1
isosorbide dinitrate tab 10 mg
1
isosorbide dinitrate tab 20 mg
1
isosorbide dinitrate tab 30 mg
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide mononitrate tab 10 mg
1
isosorbide mononitrate tab 20 mg
1
isosorbide mononitrate tab sr 24hr 30 mg 1
isosorbide mononitrate tab sr 24hr 60 mg 1
isosorbide mononitrate tab sr 24hr 120 mg 1
minitran dis 0.2mg/hr
1
minitran dis 0.4mg/hr
1
minitran dis 0.6mg/hr
1
NITRO-DUR DIS 0.3MG/HR
2
NITRO-DUR DIS 0.8MG/HR
2
nitroglycerin td patch 24hr 0.1 mg/hr
1
nitroglycerin td patch 24hr 0.2 mg/hr
1
nitroglycerin td patch 24hr 0.4 mg/hr
1
nitroglycerin td patch 24hr 0.6 mg/hr
1
NITROSTAT SUB 0.3MG
2

11

Drug Name
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG

Drug Tier Requirements/Limits
2
2

ANTIANXIETY AGENTS
Antianxiety Agents - Misc.
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
hydroxyzine hcl syrup 10 mg/5ml

1
1
1
1
1
1

hydroxyzine hcl tab 10 mg

1

hydroxyzine hcl tab 25 mg

1

hydroxyzine hcl tab 50 mg

1

meprobamate tab 200 mg
meprobamate tab 400 mg

1
1

PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older

Benzodiazepines
ALPRAZOLAM CON 1 MG/ML
2
alprazolam orally disintegrating tab 0.5 mg 1
alprazolam orally disintegrating tab 0.25
1
mg
alprazolam orally disintegrating tab 1 mg 1
alprazolam orally disintegrating tab 2 mg 1
alprazolam tab 0.5 mg
1
alprazolam tab 0.25 mg
1
alprazolam tab 1 mg
1
alprazolam tab 2 mg
1
clorazepate dipotassium tab 3.75 mg
1
clorazepate dipotassium tab 7.5 mg
1
clorazepate dipotassium tab 15 mg
1
DIAZEPAM CON 5MG/ML
2
diazepam soln 1 mg/ml
1
diazepam tab 2 mg
1

QL (120 ml / 25 days)
QL (90 tabs / 25 days)
QL (90 tabs / 25 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL

(90 tabs / 25 days)
(60 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(90 tabs / 25 days)
(60 tabs / 25 days)
(120 tabs / 25 days)
(120 tabs / 25 days)
(120 tabs / 25 days)
(240 ml / 25 days)
(1200 ml / 25 days)
(120 tabs / 25 days)

12

Drug Name
diazepam tab 5 mg
diazepam tab 10 mg
lorazepam conc 2 mg/ml
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg

Drug Tier Requirements/Limits
1
QL (120 tabs / 25 days)
1
QL (120 tabs / 25 days)
1
QL (90 ml / 25 days)
1
QL (150 tabs / 25 days)
1
QL (150 tabs / 25 days)
1
QL (150 tabs / 25 days)
1
QL (120 caps / 25 days)
1
QL (120 caps / 25 days)
1
QL (120 caps / 25 days)

ANTIARRHYTHMICS
Antiarrhythmics Type I-A
disopyramide phosphate cap 100 mg
disopyramide phosphate cap 150 mg
NORPACE CAP 100MG CR
NORPACE CAP 150MG CR
procainamide hcl inj 100 mg/ml
PROCAINAMIDE INJ 500MG/ML

1
1
2
2
1
3

Antiarrhythmics Type I-B
mexiletine hcl cap 150 mg
mexiletine hcl cap 200 mg
mexiletine hcl cap 250 mg

1
1
1

Antiarrhythmics Type I-C
flecainide acetate tab 50 mg
flecainide acetate tab 100 mg
flecainide acetate tab 150 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

1
1
1
1
1
1
1
1
1

Antiarrhythmics Type III
amiodarone hcl tab 200 mg
amiodarone hcl tab 400 mg
MULTAQ TAB 400MG
PACERONE TAB 100MG
pacerone tab 200mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG

1
1
3
2
1
3
3
3

PA

PA
PA
PA

ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Anti-Inflammatory Agents
cromolyn sodium soln nebu 20 mg/2ml

1

QL (240 mL / 25 days)

Bronchodilators - Anticholinergics
13

Drug Name
ATROVENT HFA AER 17MCG
ipratropium bromide inhal soln 0.02%
SPIRIVA CAP HANDIHLR

Drug Tier Requirements/Limits
2
QL (2 inhalers per 25
days)
1
QL (2 containers / 25
days)
2
QL (30 caps / 25 days)

Leukotriene Modulators
montelukast sodium chew tab 4 mg (base 1
equiv)
montelukast sodium chew tab 5 mg (base 1
equiv)
montelukast sodium oral granules packet 4 1
mg (base equiv)
montelukast sodium tab 10 mg (base
1
equiv)
zafirlukast tab 10 mg
1
zafirlukast tab 20 mg
1
ZYFLO CR TAB 600MG
3

ST
ST
ST
ST

Selective Phosphodiesterase 4 (PDE4) Inhibitors
DALIRESP TAB 500MCG

3

PA

ALVESCO AER 80MCG
ALVESCO AER 160MCG
ASMANEX 7 AER 110MCG

3
3
2

ASMANEX 14 AER 220MCG
ASMANEX 30 AER 110MCG

2
2

ASMANEX 30 AER 220MCG
ASMANEX 60 AER 220MCG
ASMANEX 120 AER 220MCG
budesonide inhalation susp 0.5 mg/2ml
budesonide inhalation susp 0.25 mg/2ml
PULMICORT INH 90MCG

2
2
2
1
1
2

PULMICORT INH 180MCG
PULMICORT SUS 1MG/2ML
QVAR AER 40MCG

2
2
3

QVAR AER 80MCG

3

QL (2 / 25 days)
QL (2 / 25 days)
QL (2 inhalers per 25
days)
QL (1 inhaler / 25 days)
QL (2 inhalers / 25
days)
QL (1 inhaler / 25 days)
QL (1 inhaler / 25 days)
QL (1 inhaler / 25 days)
QL (60 / 25 days)
QL (60 / 25 days)
QL (2 inhalers per 25
days)
QL (2 / 25 days)
QL (30 ea / 25 days)
QL (2 inhalers per 25
days)
QL (2 inhalers per 25
days)

Steroid Inhalants

Sympathomimetics
ADVAIR DISKU AER 100/50
2
albuterol sulfate soln nebu 0.5% (5 mg/ml)1
albuterol sulfate soln nebu 0.63 mg/3ml
1
(base equiv)

ST
QL (60 / 25 days)
QL (125 / 25 days)

14

Drug Name
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml)
albuterol sulfate soln nebu 1.25 mg/3ml
(base equiv)
BROVANA NEB 15MCG
COMBIVENT AER RESPIMAT

Drug Tier Requirements/Limits
1
QL (125 / 25 days)
1

QL (125 / 25 days)

3
2

QL (60 / 25 days)
QL (2 inhalers / 25
days)
ST
ST

DULERA AER 100-5MCG
DULERA AER 200-5MCG
epinephrine hcl inj 0.1 mg/ml
epinephrine hcl inj 1 mg/ml
FORADIL CAP AEROLIZE
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml
levalbuterol hcl soln nebu 0.31 mg/3ml
(base equiv)
levalbuterol hcl soln nebu 0.63 mg/3ml
(base equiv)
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
MAXAIR AUTOH AER 200MCG
metaproterenol sulfate syrup 10 mg/5ml
metaproterenol sulfate tab 10 mg
metaproterenol sulfate tab 20 mg
PERFOROMIST NEB 20MCG
PROAIR HFA AER

2
2
1
1
2
1

PROVENTIL AER HFA
SEREVENT DIS AER 50MCG

3
3

SYMBICORT AER 80-4.5
SYMBICORT AER 160-4.5
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
VENTOLIN HFA AER

2
2
1
1
3

QL (60 caps / 25 days)
QL (180 / 25 days)

1

QL (4 boxes / 25 days)

1

QL (4 boxes / 25 days)

1

QL (3 boxes / 25 days)

3
1
1
1
2
2

ST

QL (60 ea / 25 days)
QL (2 inhalers per 25
days)
ST
QL (1 inhaler per 25
days)
ST
ST

ST

Xanthines
theophylline
theophylline
theophylline
theophylline
theophylline
theophylline

tab
tab
tab
tab
tab
tab

450mg er
sr 12hr 100
sr 12hr 200
sr 12hr 300
sr 24hr 400
sr 24hr 600

mg
mg
mg
mg
mg

1
1
1
1
1
1

ANTICOAGULANTS
Coumarin Anticoagulants
jantoven tab 1mg
jantoven tab 2.5mg

1
1

15

Drug Name
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
jantoven tab 10mg
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab
warfarin sodium tab

1 mg
2 mg
2.5 mg
3 mg
4 mg
5 mg
6 mg
7.5 mg
10 mg

Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Direct Factor Xa Inhibitors
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG

3
3
2
2
2

PA
PA
QL (35 tabs / 90 days)
QL (42 tabs / 90 days)
PA

Heparins And Heparinoid-Like Agents
enoxaparin sodium inj 30 mg/0.3ml
1
enoxaparin sodium inj 40 mg/0.4ml
1
enoxaparin sodium inj 60 mg/0.6ml
1
enoxaparin sodium inj 80 mg/0.8ml
1
enoxaparin sodium inj 100 mg/ml
1
enoxaparin sodium inj 120 mg/0.8ml
1
enoxaparin sodium inj 150 mg/ml
1
enoxaparin sodium inj 300 mg/3ml
1
fondaparinux sodium inj 2.5 mg/0.5ml
1
fondaparinux sodium inj 5 mg/0.4ml
1
fondaparinux sodium inj 7.5 mg/0.6ml
1
fondaparinux sodium inj 10 mg/0.8ml
1
FRAGMIN INJ 10000/ML
3
FRAGMIN INJ 12500UNT
3
FRAGMIN INJ 15000UNT
3
heparin sodium (porcine) inj 1000 unit/ml 1
heparin sodium (porcine) inj 10000 unit/ml 1

QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL

(60
(60
(60
(60
(60
(60
(60
(20
(30
(30
(30
(30
(30
(30
(30

ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml
ml

/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
/ 180 days)
per 180 days)
per 180 days)
per 180 days)

Thrombin Inhibitors
argatroban inj 100 mg/ml (concentrate for 1
iv infusion)
ARGATROBAN INJ 125/125
3
PRADAXA CAP 75MG
2
PRADAXA CAP 150MG
2

16

Drug Name

Drug Tier Requirements/Limits

ANTICONVULSANTS
Anticonvulsants - Benzodiazepines
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
ONFI TAB 5MG
ONFI TAB 10MG
ONFI TAB 20MG

1
1
1
2
2
2

Anticonvulsants - Misc.
BANZEL SUS 40MG/ML
2
BANZEL TAB 200MG
2
BANZEL TAB 400MG
2
carbamazepine chew tab 100 mg
1
carbamazepine susp 100 mg/5ml
1
carbamazepine tab 200 mg
1
carbamazepine tab sr 12hr 200 mg
1
carbamazepine tab sr 12hr 400 mg
1
epitol tab 200mg
1
gabapentin cap 100 mg
1
gabapentin cap 300 mg
1
gabapentin cap 400 mg
1
gabapentin tab 600 mg
1
gabapentin tab 800 mg
1
LAMICTAL CHW 2MG
2
lamotrigine tab 25 mg
1
lamotrigine tab 100 mg
1
lamotrigine tab 150 mg
1
lamotrigine tab 200 mg
1
lamotrigine tab chewable dispersible 5 mg 1
lamotrigine tab chewable dispersible 25 mg1
lamotrigine tab sr 24hr 25 mg
1
lamotrigine tab sr 24hr 50 mg
1
lamotrigine tab sr 24hr 100 mg
1
lamotrigine tab sr 24hr 200 mg
1
lamotrigine tab sr 24hr 250 mg
1
lamotrigine tab sr 24hr 300 mg
1
levetiracetam oral soln 100 mg/ml
1
levetiracetam tab 250 mg
1
levetiracetam tab 500 mg
1
levetiracetam tab 750 mg
1
levetiracetam tab 1000 mg
1
levetiracetam tab sr 24hr 500 mg
1
levetiracetam tab sr 24hr 750 mg
1
LYRICA CAP 25MG
2
LYRICA CAP 50MG
2

ST
ST

17

Drug Name
LYRICA CAP 75MG
LYRICA CAP 100MG
LYRICA CAP 150MG
LYRICA CAP 200MG
LYRICA CAP 225MG
LYRICA CAP 300MG
LYRICA SOL 20MG/ML
oxcarbazepine susp 300 mg/5ml (60
mg/ml)
oxcarbazepine tab 150 mg
oxcarbazepine tab 300 mg
oxcarbazepine tab 600 mg
POTIGA TAB 50MG
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
primidone tab 50 mg
primidone tab 250 mg
TEGRETOL XR TAB 100MG
topiragen tab 25mg
topiragen tab 50mg
topiragen tab 100mg
topiragen tab 200mg
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg
topiramate tab 50 mg
topiramate tab 100 mg
topiramate tab 200 mg
VIMPAT SOL 10MG/ML
VIMPAT TAB 50MG
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
zonisamide cap 25 mg
zonisamide cap 50 mg
zonisamide cap 100 mg

Drug Tier Requirements/Limits
2
ST
2
ST
2
ST
2
ST
2
ST
2
ST
2
ST
1
1
1
1
2
2
2
2
1
1
2
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
1
1
1

Carbamates
felbamate susp 600 mg/5ml
felbamate tab 400 mg
felbamate tab 600 mg

1
1
1

GABA Modulators
GABITRIL TAB 12MG
GABITRIL TAB 16MG
SABRIL POW 500MG
SABRIL TAB 500MG

2
2
3
3

PA
PA

18

Drug Name
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg

Drug Tier Requirements/Limits
1
1

Hydantoins
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin susp 125 mg/5ml

1
1
1

Succinimides
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml

1
1

Valproic Acid
divalproex sodium cap sprinkle 125 mg
divalproex sodium tab delayed release 125
mg
divalproex sodium tab delayed release 250
mg
divalproex sodium tab delayed release 500
mg
divalproex sodium tab sr 24 hr 250 mg
divalproex sodium tab sr 24 hr 500 mg
valproate sodium syrup 250 mg/5ml (base
equiv)
valproic acid cap 250 mg

1
1
1
1
1
1
1
1

ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine
mirtazapine

orally disintegrating tab 15 mg 1
orally disintegrating tab 30 mg 1
orally disintegrating tab 45 mg 1
tab 7.5 mg
1
tab 15 mg
1
tab 30 mg
1
tab 45 mg
1

Antidepressants - Misc.
APLENZIN
APLENZIN
APLENZIN
budeprion
budeprion
budeprion
budeprion
bupropion
bupropion
bupropion
bupropion
bupropion
bupropion
bupropion

TAB 174MG
TAB 348MG
TAB 522MG
tab 100mg sr
tab 150mg sr
xl tab 150mg
xl tab 300mg
hcl tab 75 mg
hcl tab 100 mg
hcl tab sr 12hr 100
hcl tab sr 12hr 150
hcl tab sr 12hr 200
hcl tab sr 24hr 150
hcl tab sr 24hr 300

mg
mg
mg
mg
mg

3
3
3
1
1
1
1
1
1
1
1
1
1
1

19

Drug Name
maprotiline hcl tab 25 mg
maprotiline hcl tab 50 mg
maprotiline hcl tab 75 mg

Drug Tier Requirements/Limits
1
1
1

Modified Cyclics
nefazodone hcl tab 100 mg
nefazodone hcl tab 200 mg
nefazodone hcl tab 250 mg
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG

1
1
1
1
1
1
1
3
3
3
3

ST
ST
ST
ST

Monoamine Oxidase Inhibitors (MAOIs)
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMSAM DIS 12MG/24H
MARPLAN TAB 10MG
phenelzine sulfate tab 15 mg
tranylcypromine sulfate tab 10 mg

3
3
3
3
1
1

Selective Serotonin Reuptake Inhibitors (SSRIs)
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)
escitalopram oxalate soln 5 mg/5ml (base
equiv)
escitalopram oxalate tab 5 mg (base
equiv)
escitalopram oxalate tab 10 mg (base
equiv)
escitalopram oxalate tab 20 mg (base
equiv)
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 mg

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

20

Drug Name
Drug Tier Requirements/Limits
paroxetine hcl oral susp 10 mg/5ml (base 1
equiv)
paroxetine hcl tab 10 mg
1
paroxetine hcl tab 20 mg
1
paroxetine hcl tab 30 mg
1
paroxetine hcl tab 40 mg
1
paroxetine hcl tab sr 24hr 12.5 mg
1
paroxetine hcl tab sr 24hr 25 mg
1
paroxetine hcl tab sr 24hr 37.5 mg
1
PAXIL SUS 10MG/5ML
2
PEXEVA TAB 10MG
3
ST
PEXEVA TAB 20MG
3
ST
PEXEVA TAB 30MG
3
ST
PEXEVA TAB 40MG
3
ST
sertraline hcl oral conc 20 mg/ml
1
sertraline hcl tab 25 mg
1
sertraline hcl tab 50 mg
1
sertraline hcl tab 100 mg
1

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
CYMBALTA CAP 20MG
CYMBALTA CAP 30MG
CYMBALTA CAP 60MG
PRISTIQ TAB 50MG
PRISTIQ TAB 100MG
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
venlafaxine hcl tab sr 24hr 37.5 mg (base
equivalent)
venlafaxine hcl tab sr 24hr 75 mg (base
equivalent)
venlafaxine hcl tab sr 24hr 150 mg (base
equivalent)
venlafaxine hcl tab sr 24hr 225 mg (base
equivalent)

2
2
2
3
3
1

ST
ST
ST
ST
ST

1
1
1
1
1
1
1
1
1
1
1

Tricyclic Agents
amitriptyline hcl tab 10 mg

1

QL (90 tabs / 25 days);
QL applies to members
age 65 and older

21

Drug Name
amitriptyline hcl tab 25 mg

amitriptyline hcl tab 50 mg

amitriptyline hcl tab 75 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
AMOXAPINE TAB 25MG

AMOXAPINE TAB 50MG

AMOXAPINE TAB 100MG

AMOXAPINE TAB 150MG

clomipramine hcl cap 25 mg

clomipramine hcl cap 50 mg

clomipramine hcl cap 75 mg

desipramine hcl tab 10 mg

desipramine hcl tab 25 mg

desipramine hcl tab 50 mg

Drug Tier Requirements/Limits
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL applies to members
age 65 and older
1
QL applies to members
age 65 and older
1
QL applies to members
age 65 and older
3
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
3
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
3
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
3
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 tabs / 25 days);
QL applies to members
age 65 and older

22

Drug Name
desipramine hcl tab 75 mg

desipramine hcl tab 100 mg

desipramine hcl tab 150 mg

doxepin hcl cap 10 mg

doxepin hcl cap 25 mg

doxepin hcl cap 50 mg

doxepin hcl cap 75 mg

doxepin hcl cap 100 mg

doxepin hcl cap 150 mg

doxepin hcl conc 10 mg/ml

imipramine hcl tab 10 mg

imipramine hcl tab 25 mg

imipramine hcl tab 50 mg

imipramine pamoate cap 75 mg

Drug Tier Requirements/Limits
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (90 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL (360 ml / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older

23

Drug Name
imipramine pamoate cap 100 mg

imipramine pamoate cap 125 mg
imipramine pamoate cap 150 mg
nortriptyline hcl cap 10 mg

nortriptyline hcl cap 25 mg

nortriptyline hcl cap 50 mg

nortriptyline hcl cap 75 mg

nortriptyline hcl soln 10 mg/5ml

protriptyline hcl tab 5 mg

protriptyline hcl tab 10 mg

trimipramine maleate cap 25 mg

trimipramine maleate cap 50 mg

trimipramine maleate cap 100 mg

Drug Tier Requirements/Limits
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL applies to members
age 65 and older
1
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older
1
QL (3 bottles per 25
days); QL applies to
members age 65 and
older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 tabs / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (60 caps / 25 days);
QL applies to members
age 65 and older
1
QL (30 caps / 25 days);
QL applies to members
age 65 and older

ANTIDIABETICS
Alpha-Glucosidase Inhibitors
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg

1
1
1

24

Drug Name
GLYSET TAB 25MG
GLYSET TAB 50MG
GLYSET TAB 100MG

Drug Tier Requirements/Limits
3
3
3

Antidiabetic - Amylin Analogs
SYMLIN INJ 600MCG
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG

3
3
3

PA
PA
PA

Antidiabetic Combinations
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
glyburide-metformin tab 1.25-250 mg

1
1
1
1

glyburide-metformin tab 2.5-500 mg

1

glyburide-metformin tab 5-500 mg

1

JANUMET TAB 50-500MG
JANUMET TAB 50-1000
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JENTADUETO TAB 2.5-500
JENTADUETO TAB 2.5-850
JENTADUETO TAB 2.5-1000
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

3
3
3
3
3
3
3
3
1
1
1

PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA
PA
PA
PA
PA
PA
PA
PA
ST
ST
ST

1

ST

Biguanides
metformin
metformin
metformin
metformin
metformin

hcl
hcl
hcl
hcl
hcl

tab
tab
tab
tab
tab

500 mg
850 mg
1000 mg
sr 24hr 500 mg
sr 24hr 750 mg

1
1
1
1
1

Diabetic Other
GLUCAGEN INJ HYPOKIT

2

25

Drug Name
GLUCAGON KIT 1MG
PROGLYCEM SUS 50MG/ML

Drug Tier Requirements/Limits
2
3

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JANUVIA TAB 100MG
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
TRADJENTA TAB 5MG

2
2
2
3
3
3

ST
ST
ST
PA
PA
PA

Dopamine Receptor Agonists - Antidiabetic
CYCLOSET TAB 0.8MG

3

Incretin Mimetic Agents (GLP-1 Receptor Agonists)
BYDUREON INJ
BYETTA INJ 5MCG
BYETTA INJ 10MCG
VICTOZA INJ 18MG/3ML

2
2
2
3

ST
ST
ST
PA

Insulin
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
HUMALOG INJ 100/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN N INJ U-100
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
HUMULIN R INJ U-500
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN

2
2
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2

Insulin Sensitizing Agents
pioglitazone hcl tab 15 mg (base equiv)
pioglitazone hcl tab 30 mg (base equiv)
pioglitazone hcl tab 45 mg (base equiv)

1
1
1

ST
ST
ST

26

Drug Name

Drug Tier Requirements/Limits

Meglitinide Analogues
nateglinide tab 60 mg
nateglinide tab 120 mg
PRANDIN TAB 0.5MG
PRANDIN TAB 1MG
PRANDIN TAB 2MG

1
1
3
3
3

Sulfonylureas
chlorpropamide tab 100 mg
chlorpropamide tab 250 mg
glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab sr 24hr 2.5 mg
glipizide tab sr 24hr 5 mg
glipizide tab sr 24hr 10 mg
glyburide micronized tab 1.5 mg

1
1
1
1
1
1
1
1
1
1
1

glyburide micronized tab 3 mg

1

glyburide micronized tab 6 mg

1

glyburide tab 1.25 mg

1

glyburide tab 2.5 mg

1

glyburide tab 5 mg

1

PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older

27

Drug Name
glycron tab 1.5mg

glycron tab 3mg

GLYCRON TAB 4.5MG

glycron tab 6mg

tolbutamide tab 500 mg

Drug Tier Requirements/Limits
1
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
2
PA; High Risk
Medications require PA
for members age 65 and
older
1
PA; High Risk
Medications require PA
for members age 65 and
older
1

ANTIDIARRHEALS
Antiperistaltic Agents
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025
mg
loperamide hcl cap 2 mg
loperamide hcl tab 2 mg
MOTOFEN TAB

1
1
1
1
3

ANTIDOTES
Antidotes - Chelating Agents
CHEMET CAP 100MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX TAB 500MG

3
3
3
3
3

PA
PA
PA
PA

Opioid Antagonists
depade tab 50mg
naltrexone hcl tab 50 mg

1
1

ANTIEMETICS
5-HT3 Receptor Antagonists
ALOXI INJ
ALOXI INJ 0.25MG/5
granisetron hcl tab 1 mg
ondansetron hcl oral soln 4 mg/5ml

3
3
1
1

QL (1
QL (1
QL (6
QL (2
days)

vial / 15 days)
vial / 15 days)
tabs / 15 days)
bottles per 15

28

Drug Name
Drug Tier Requirements/Limits
ondansetron hcl tab 4 mg
1
QL (12 tabs / 15 days)
ondansetron hcl tab 8 mg
1
QL (12 tabs / 15 days)
ondansetron hcl tab 24 mg
1
QL (1 tab / 15 days)
ondansetron orally disintegrating tab 4 mg 1
QL (12 tabs / 15 days)
ondansetron orally disintegrating tab 8 mg 1
QL (12 tabs / 15 days)
SANCUSO DIS 3.1MG
3
QL (1 patch / 15 days)

Antiemetics - Anticholinergic
ANTIVERT TAB 50MG
dimenhydrinate tab 50 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
TRANSDERM-SC DIS 1.5MG
trimethobenzamide hcl cap 300 mg

2
1
1
1
3
1

PA; High Risk
Medications require PA
for members age 65 and
older

univert tab 32mg

1

Antiemetics - Miscellaneous
dronabinol cap 2.5 mg
dronabinol cap 5 mg
dronabinol cap 10 mg

1
1
1

QL (60 caps / 25 days)
QL (60 caps / 25 days)
QL (60 caps / 25 days)

Substance P/Neurokinin 1 (NK1) Receptor Antagonists
EMEND
EMEND
EMEND
EMEND

CAP
CAP
CAP
PAK

40MG
80MG
125MG
80 & 125

3
3
3
3

QL
QL
QL
QL

(3
(2
(1
(1

caps
caps
caps
caps

/
/
/
/

180 days)
15 days)
15 days)
25 days)

ANTIFUNGALS
Antifungal - Glucan Synthesis Inhibitors (Echinocandins)
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ERAXIS INJ 50MG
ERAXIS INJ 100MG

3
3
3
3

Antifungals
ABELCET INJ 5MG/ML
AMPHOTEC INJ 50MG
AMPHOTEC INJ 100MG
amphotericin b for inj 50 mg
BIO-STATIN CAP 500000
BIO-STATIN CAP 1000000
griseofulvin microsize susp 125 mg/5ml
griseofulvin microsize tab 500 mg
griseofulvin ultramicrosize tab 125 mg
griseofulvin ultramicrosize tab 250 mg
nystatin oral powder
nystatin tab 500000 unit

3
3
3
1
2
2
1
1
1
1
1
1

29

Drug Name
terbinafine hcl tab 250 mg

Drug Tier Requirements/Limits
1
PA

Imidazole-Related Antifungals
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole tab 50 mg
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
itraconazole cap 100 mg
ketoconazole tab 200 mg
NOXAFIL SUS 40MG/ML
SPORANOX SOL 10MG/ML
VFEND SUS 40MG/ML
voriconazole tab 50 mg
voriconazole tab 200 mg

1
1
1
1
1
1
1
1
2
2
2
1
1

PA

PA
PA
PA
PA

ANTIHISTAMINES
Antihistamines - Alkylamines
brompheniramine tannate chew tab 12 mg 1
dexchlorpheniramine maleate syrup 2
1
mg/5ml

Antihistamines - Ethanolamines
carbinoxamine maleate tab 4 mg
clemastine fumarate syrup 0.67 mg/5ml
(0.5 mg/5ml base eq)

1
1

clemastine fumarate tab 2.68 mg

1

diphenhydramine
diphenhydramine
diphenhydramine
diphenhydramine

1
1
1
1

hcl
hcl
hcl
hcl

cap 25 mg
cap 50 mg
elixir 12.5 mg/5ml
inj 50 mg/ml

PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older

Antihistamines - Non-Sedating
allergy relf tab 10mg
cetirizine hcl chew tab 5 mg
cetirizine hcl chew tab 10 mg
cetirizine hcl tab 5 mg
cetirizine hcl tab 10 mg
cetirizine sol 1mg/ml
CLARINEX SYP 0.5MG/ML
desloratadine tab 5 mg
desloratadine tab orally disintegrating 2.5
mg

1
1
1
1
1
1
3
1
1

OTC
OTC
OTC
OTC
OTC
OTC
ST
ST
ST

30

Drug Name
desloratadine tab orally disintegrating 5
mg
fexofenadine hcl tab 60 mg
fexofenadine hcl tab 180 mg
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
levocetirizine dihydrochloride tab 5 mg
loratadine syp 5mg/5ml
loratadine tab 10 mg

Drug Tier Requirements/Limits
1
ST
1
1
1
1
1
1

OTC
OTC

OTC
OTC

Antihistamines - Phenothiazines
promethazine hcl syrup 6.25 mg/5ml

1

promethazine hcl tab 12.5 mg

1

promethazine hcl tab 25 mg

1

promethazine hcl tab 50 mg

1

PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older
PA; High Risk
Medications require PA
for members age 65 and
older

Antihistamines - Piperidines
cyproheptadine hcl syrup 2 mg/5ml
cyproheptadine hcl tab 4 mg

1
1

ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Combinations
VYTORIN
VYTORIN
VYTORIN
VYTORIN

TAB
TAB
TAB
TAB

10-10MG
10-20MG
10-40MG
10-80MG

3
3
3
3

ST
ST
ST
ST

3

PA

Antihyperlipidemics - Misc.
LOVAZA CAP 1GM

Bile Acid Sequestrants
cholestyramine light powder 4 gm/dose
cholestyramine light powder packets 4 gm
cholestyramine powder 4 gm/dose
cholestyramine powder packets 4 gm
colestipol hcl granule packets 5 gm
colestipol hcl granules 5 gm

1
1
1
1
1
1

31

Drug Name
colestipol hcl tab 1 gm
prevalite pow 4gm
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG

Drug Tier Requirements/Limits
1
1
3
3

Fibric Acid Derivatives
fenofibrate micronized cap 67 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate tab 54 mg
fenofibrate tab 160 mg
gemfibrozil tab 600 mg

1
1
1
1
1
1

HMG CoA Reductase Inhibitors
atorvastatin calcium tab 10 mg
equivalent)
atorvastatin calcium tab 20 mg
equivalent)
atorvastatin calcium tab 40 mg
equivalent)
atorvastatin calcium tab 80 mg
equivalent)
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
fluvastatin sodium cap 20 mg
fluvastatin sodium cap 40 mg
LESCOL XL TAB 80MG
LIVALO TAB 1MG
LIVALO TAB 2MG
LIVALO TAB 4MG
lovastatin tab 10 mg
lovastatin tab 20 mg
lovastatin tab 40 mg
pravastatin sodium tab 10 mg
pravastatin sodium tab 20 mg
pravastatin sodium tab 40 mg
pravastatin sodium tab 80 mg
simvastatin tab 5 mg
simvastatin tab 10 mg
simvastatin tab 20 mg
simvastatin tab 40 mg
simvastatin tab 80 mg

(base

1

(base

1

(base

1

(base

1
3
3
3
1
1
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1

ST
ST

ST
ST
ST

ST

Intestinal Cholesterol Absorption Inhibitors
ZETIA TAB 10MG

3

ST

Nicotinic Acid Derivatives
NIASPAN TAB 500MG ER
NIASPAN TAB 750MG ER

2
2

32

Drug Name
NIASPAN TAB 1000 ER

Drug Tier Requirements/Limits
2

ANTIHYPERTENSIVES
ACE Inhibitors
benazepril hcl tab 5 mg
benazepril hcl tab 10 mg
benazepril hcl tab 20 mg
benazepril hcl tab 40 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
enalapril maleate tab 2.5 mg
enalapril maleate tab 5 mg
enalapril maleate tab 10 mg
enalapril maleate tab 20 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
lisinopril tab 2.5 mg
lisinopril tab 5 mg
lisinopril tab 10 mg
lisinopril tab 20 mg
lisinopril tab 30 mg
lisinopril tab 40 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
perindopril erbumine tab 2 mg
perindopril erbumine tab 4 mg
perindopril erbumine tab 8 mg
quinapril hcl tab 5 mg
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
ramipril cap 1.25 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
ramipril cap 10 mg
trandolapril tab 1 mg
trandolapril tab 2 mg
trandolapril tab 4 mg

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Agents for Pheochromocytoma
DIBENZYLINE CAP 10MG

3

Angiotensin II Receptor Antagonists
ATACAND TAB 4MG
ATACAND TAB 8MG

3
3

ST
ST

33

Drug Name
ATACAND TAB 16MG
ATACAND TAB 32MG
BENICAR TAB 5MG
BENICAR TAB 20MG
BENICAR TAB 40MG
DIOVAN TAB 40MG
DIOVAN TAB 80MG
DIOVAN TAB 160MG
DIOVAN TAB 320MG
EDARBI TAB 40MG
EDARBI TAB 80MG
eprosartan mesylate tab 600 mg
irbesartan tab 75 mg
irbesartan tab 150 mg
irbesartan tab 300 mg
losartan potassium tab 25 mg
losartan potassium tab 50 mg
losartan potassium tab 100 mg
MICARDIS TAB 20MG
MICARDIS TAB 40MG
MICARDIS TAB 80MG
TEVETEN TAB 400MG

Drug Tier Requirements/Limits
3
ST
3
ST
3
ST
3
ST
3
ST
2
ST
2
ST
2
ST
2
ST
3
ST
3
ST
1
1
1
1
1
1
1
3
ST
3
ST
3
ST
3
ST

Antiadrenergic Antihypertensives
clonidine hcl tab 0.1 mg
1
clonidine hcl tab 0.2 mg
1
clonidine hcl tab 0.3 mg
1
clonidine hcl td patch weekly 0.1 mg/24hr 1
clonidine hcl td patch weekly 0.2 mg/24hr 1
clonidine hcl td patch weekly 0.3 mg/24hr 1
doxazosin mesylate tab 1 mg
1
doxazosin mesylate tab 2 mg
1
doxazosin mesylate tab 4 mg
1
doxazosin mesylate tab 8 mg
1
guanfacine hcl tab 1 mg
1
guanfacine hcl tab 2 mg
1
methyldopa tab 250 mg
1
methyldopa tab 500 mg
1
prazosin hcl cap 1 mg
1
prazosin hcl cap 2 mg
1
prazosin hcl cap 5 mg
1
terazosin hcl cap 1 mg
1
terazosin hcl cap 2 mg
1
terazosin hcl cap 5 mg
1
terazosin hcl cap 10 mg
1

Antihypertensive Combinations
34

Drug Name
Drug Tier Requirements/Limits
amlodipine besylate-benazepril hcl cap 2.5- 1
10 mg
amlodipine besylate-benazepril hcl cap 5- 1
10 mg
amlodipine besylate-benazepril hcl cap 5- 1
20 mg
amlodipine besylate-benazepril hcl cap 5- 1
40 mg
amlodipine besylate-benazepril hcl cap 10- 1
20 mg
amlodipine besylate-benazepril hcl cap 10- 1
40 mg
atenolol & chlorthalidone tab 50-25 mg
1
atenolol & chlorthalidone tab 100-25 mg
1
bisoprolol & hydrochlorothiazide tab 2.5- 1
6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 1
mg
bisoprolol & hydrochlorothiazide tab 101
6.25 mg
captopril & hydrochlorothiazide tab 25-15 1
mg
captopril & hydrochlorothiazide tab 25-25 1
mg
captopril & hydrochlorothiazide tab 50-15 1
mg
captopril & hydrochlorothiazide tab 50-25 1
mg
enalapril maleate & hydrochlorothiazide tab 1
5-12.5 mg
enalapril maleate & hydrochlorothiazide tab 1
10-25 mg
lisinopril & hydrochlorothiazide tab 10-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-25 1
mg
losartan potassium & hydrochlorothiazide 1
tab 50-12.5 mg
losartan potassium & hydrochlorothiazide 1
tab 100-12.5 mg
losartan potassium & hydrochlorothiazide 1
tab 100-25 mg
metoprolol & hydrochlorothiazide tab 50-251
mg
metoprolol & hydrochlorothiazide tab 100- 1
25 mg
metoprolol & hydrochlorothiazide tab 100- 1
50 mg
nadolol & bendroflumethiazide tab 40-5 mg1
nadolol & bendroflumethiazide tab 80-5 mg1

35

Drug Name
Drug Tier Requirements/Limits
propranolol & hydrochlorothiazide tab 40- 1
25 mg
propranolol & hydrochlorothiazide tab 80- 1
25 mg
valsartan-hydrochlorothiazide tab 80-12.5 1
mg
valsartan-hydrochlorothiazide tab 160-12.5 1
mg
valsartan-hydrochlorothiazide tab 160-25 1
mg
valsartan-hydrochlorothiazide tab 320-12.5 1
mg
valsartan-hydrochlorothiazide tab 320-25 1
mg

Direct Renin Inhibitors
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG

3
3

ST
ST

Selective Aldosterone Receptor Antagonists (SARAs)
eplerenone tab 25 mg
eplerenone tab 50 mg

1
1

Vasodilators
hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg

1
1
1
1
1
1

ANTIMALARIALS
Antimalarial Combinations
atovaquone-proguanil hcl tab 62.5-25 mg 1
atovaquone-proguanil hcl tab 250-100 mg 1
COARTEM TAB 20-120MG
3

Antimalarials
chloroquine phosphate tab 250 mg
chloroquine phosphate tab 500 mg
DARAPRIM TAB 25MG
HALFAN TAB 250MG
hydroxychloroquine sulfate tab 200 mg
mefloquine hcl tab 250 mg
PRIMAQUINE TAB 26.3MG
quinine sulfate cap 324 mg

1
1
3
3
1
1
3
1

ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
MESTINON SYP 60MG/5ML
pyridostigmine bromide tab 60 mg

2
1

ANTIMYCOBACTERIAL AGENTS
36

Drug Name

Drug Tier Requirements/Limits

Anti TB Combinations
isonarif cap
RIFATER TAB

1
2

Antimycobacterial Agents
CAPASTAT SUL INJ 1GM
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
MYCOBUTIN CAP 150MG
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifampin cap 150 mg
rifampin cap 300 mg
TRECATOR TAB 250MG

2
1
1
1
1
1
1
3
2
1
1
1
2

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating Agents
ALKERAN TAB 2MG
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
carboplatin iv for inj 150 mg
carboplatin iv soln 50 mg/5ml
carboplatin iv soln 150 mg/15ml
carboplatin iv soln 450 mg/45ml
carboplatin iv soln 600 mg/60ml
CEENU CAP 10MG
CEENU CAP 40MG
CEENU CAP 100MG
cisplatin inj 50 mg/50ml (1 mg/ml)
cisplatin inj 100 mg/100ml (1 mg/ml)
cisplatin inj 200 mg/200ml (1 mg/ml)
CYCLOPHOSPH INJ 1GM
CYCLOPHOSPH INJ 2GM
CYCLOPHOSPH INJ 500MG
cyclophosphamide tab 25 mg
cyclophosphamide tab 50 mg
ELOXATIN INJ 200MG
GLIADEL WAF 7.7MG
HEXALEN CAP 50MG
ifosfamide for inj 1 gm
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
ifosfamide iv inj 3 gm/60ml (50 mg/ml)
LEUKERAN TAB 2MG

2
2
2
1
1
1
1
1
2
2
2
1
1
1
2
2
2
1
1
2
2
2
1
1
1
2

37

Drug Name
MYLERAN TAB 2MG
oxaliplatin for iv inj 50 mg
oxaliplatin for iv inj 100 mg
oxaliplatin iv soln 50 mg/10ml
oxaliplatin iv soln 100 mg/20ml
TEMODAR CAP 5MG
TEMODAR CAP 20MG
TEMODAR CAP 100MG
TEMODAR CAP 140MG
TEMODAR CAP 180MG
TEMODAR CAP 250MG
TEMODAR INJ 100MG
thiotepa for inj 15 mg
THIOTEPA INJ 15MG
ZANOSAR INJ 1GM

Drug Tier Requirements/Limits
2
1
1
1
1
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
1
2
2

Antimetabolites
adrucil inj 50mg/ml
ALIMTA INJ 100MG
ALIMTA INJ 500MG
ARRANON INJ 5MG/ML
cladribine inj 1 mg/ml
CLOLAR INJ 1MG/ML
cytarabine for inj 1 gm
cytarabine for inj 100 mg
cytarabine for inj 500 mg
cytarabine inj 20 mg/ml
cytarabine inj 100 mg/ml
cytarabine inj pf 20 mg/ml
DACOGEN INJ 50MG
DEPOCYT INJ 50MG/5ML
floxuridine for inj 0.5 gm
fludarabine phosphate for inj 50 mg
fludarabine phosphate inj 25 mg/ml
fluorouracil inj 1 gm/20ml (50 mg/ml)
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
fluorouracil inj 5 gm/100ml (50 mg/ml)
fluorouracil inj 500 mg/10ml (50 mg/ml)
gemcitabine hcl for inj 1 gm
gemcitabine hcl for inj 2 gm
gemcitabine hcl for inj 200 mg
mercaptopurine tab 50 mg
methotrexate sodium for inj 1 gm
methotrexate sodium inj 25 mg/ml
methotrexate sodium inj pf 25 mg/ml
methotrexate sodium tab 2.5 mg (base
equiv)

1
2
2
2
1
2
1
1
1
1
1
1
3
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

PA

38

Drug Name
TABLOID TAB 40MG
VIDAZA INJ 100MG
XELODA TAB 150MG
XELODA TAB 500MG

Drug Tier Requirements/Limits
2
3
PA
3
PA
3
PA

Antineoplastic - Antibodies
BEXXAR CON 14MG/ML
CAMPATH INJ 30MG/ML
ERBITUX INJ 100MG
ERBITUX INJ 200MG
RITUXAN INJ 100MG

2
2
3
3
3

PA
PA
PA

Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE CAP 150MG

3

PA

Antineoplastic - Hormonal and Related Agents
anastrozole tab 1 mg
bicalutamide tab 50 mg
EMCYT CAP 140MG
exemestane tab 25 mg
FARESTON TAB 60MG
FASLODEX INJ 250MG
FIRMAGON INJ 80MG
FIRMAGON INJ 120MG
flutamide cap 125 mg
letrozole tab 2.5 mg
leuprolide acetate inj kit 5 mg/ml
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 11.25MG
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 30MG
LUPRON DEPOT INJ 45MG
LYSODREN TAB 500MG
megestrol acetate susp 40 mg/ml
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
NILANDRON TAB 150MG
tamoxifen citrate tab 10 mg (base
equivalent)
tamoxifen citrate tab 20 mg (base
equivalent)
XTANDI CAP 40MG
ZYTIGA TAB 250MG

1
1
2
1
2
2
3
3
1
1
3
3
3
3
3
3
2
1
1
1
2
1

PA
PA

PA
PA
PA
PA
PA
PA

1
3
3

PA
PA

Antineoplastic Antibiotics
adriamycin inj 10mg
ADRIAMYCIN INJ 20MG
bleomycin sulfate for inj 15 unit
bleomycin sulfate for inj 30 unit
dactinomycin for inj 0.5 mg

1
2
1
1
1

39

Drug Name
Drug Tier Requirements/Limits
daunorubicin hcl for inj 20 mg
1
daunorubicin hcl inj 5 mg/ml (base equiv) 1
DAUNOXOME INJ 2MG/ML
2
doxorubicin hcl for inj 10 mg
1
doxorubicin hcl for inj 50 mg
1
doxorubicin hcl inj 2 mg/ml
1
epirubicin hcl inj 10 mg/5ml (2 mg/ml)
1
epirubicin hcl inj 50 mg/25ml (2 mg/ml)
1
epirubicin hcl inj 150 mg/75ml (2 mg/ml) 1
epirubicin hcl inj 200 mg/100ml (2 mg/ml) 1
EPIRUBICIN INJ 50MG
2
EPIRUBICIN INJ 200MG
2
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
1
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 1
idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 1
lipodox 50 inj 2mg/ml
1
lipodox inj 2mg/ml
1
mitomycin for inj 5 mg
1
mitomycin for inj 20 mg
1
mitomycin for inj 40 mg
1
mitoxantrone hcl inj conc 20 mg/10ml (2 3
PA
mg/ml)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 3
PA
mg/ml)
mitoxantrone hcl inj conc 30 mg/15ml (2 3
PA
mg/ml)

Antineoplastic Combinations
ifosfamide & mesna inj kit 1000-1000 mg

1

Antineoplastic Enzyme Inhibitors
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
INLYTA TAB 1MG
INLYTA TAB 5MG

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA

40

Drug Name
JAKAFI TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 50MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TORISEL SOL 25MG/ML
TYKERB TAB 250MG
VANDETANIB TAB 100MG
VANDETANIB TAB 300MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG
ZOLINZA CAP 100MG

Drug Tier Requirements/Limits
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA

Antineoplastic Enzymes
ELSPAR INJ 10000UNT
ONCASPAR INJ 750/ML

3
3

PA
PA

Antineoplastic Radiopharmaceuticals
BEXXAR 131 I INJ 0.61/ML
BEXXAR 131 I INJ 5.6MCI/M
QUADRAMET INJ

2
2
2

Antineoplastics Misc.
ALFERON N INJ 5MU/ML
dacarbazine for inj 100 mg
dacarbazine for inj 200 mg
hydroxyurea cap 500 mg
INTRON-A INJ 3MU PEN
INTRON-A INJ 5MU PEN
INTRON-A INJ 10MU

3
1
1
1
3
3
3

PA

PA
PA
PA

41

Drug Name
INTRON-A INJ 10MU PEN
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
MATULANE CAP 50MG
ONTAK INJ 150/ML
pentostatin for inj 10 mg
PHOTOFRIN INJ 75MG
TARGRETIN CAP 75MG
THERACYS INJ
TICE BCG INJ
tretinoin cap 10 mg
TRISENOX SOL 10MG/10M
UVADEX INJ 20MCG/ML

Drug Tier Requirements/Limits
3
PA
3
PA
3
PA
3
PA
2
2
1
2
3
PA
2
2
1
2
2

Chemotherapy Adjuncts
KEPIVANCE INJ 6.25MG

2

Chemotherapy Rescue/Antidote Agents
amifostine crystalline for inj 500 mg
dexrazoxane for inj 250 mg
dexrazoxane for inj 500 mg
leucovorin calcium for inj 50 mg
leucovorin calcium for inj 100 mg
leucovorin calcium for inj 200 mg
leucovorin calcium for inj 350 mg
leucovorin calcium inj 10 mg/ml
leucovorin calcium tab 5 mg
leucovorin calcium tab 10 mg
leucovorin calcium tab 15 mg
leucovorin calcium tab 25 mg
LEUCOVORIN INJ CALCIUM
mesna inj 100 mg/ml
MESNEX TAB 400MG

1
1
1
1
1
1
1
1
1
1
1
1
2
1
2

Mitotic Inhibitors
ABRAXANE INJ 100MG
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
docetaxel for inj conc 20 mg/ml
docetaxel for inj conc 80 mg/4ml (20
mg/ml)
DOCETAXEL INJ 20/0.5ML
DOCETAXEL INJ 20MG/2ML
DOCETAXEL INJ 80MG/2ML
DOCETAXEL INJ 80MG/8ML
DOCETAXEL INJ 160/16ML
ETOPOPHOS INJ 100MG
etoposide cap 50 mg

2
2
2
1
1
2
2
2
2
2
2
1

42

Drug Name
etoposide inj 20 mg/ml
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
paclitaxel iv conc 100 mg/16.7ml (6
mg/ml)
paclitaxel iv conc 150 mg/25ml (6 mg/ml)
paclitaxel iv conc 300 mg/50ml (6 mg/ml)
TAXOTERE INJ 20/0.5ML
TAXOTERE INJ 80MG/2ML
toposar inj 100/5ml
VINBLASTINE INJ 10MG
vinblastine sulfate inj 1 mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate iv soln 1 mg/ml
vinorelbine tartrate inj 10 mg/ml
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml)
VUMON INJ 50MG/5ML

Drug Tier Requirements/Limits
1
1
1
1
1
2
2
1
2
1
1
1
1
1
2

Topoisomerase I Inhibitors
CAMPTOSAR INJ 300/15ML
2
HYCAMTIN CAP 0.25MG
3
HYCAMTIN CAP 1MG
3
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
1
irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1
irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1
topotecan hcl for inj 4 mg
1
TOPOTECAN INJ 4MG/4ML
2

PA
PA

ANTIPARKINSON AGENTS
Antiparkinson Adjuvants
LODOSYN TAB 25MG

3

Antiparkinson Anticholinergics
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg

1
1
1
1
1
1

Antiparkinson COMT Inhibitors
entacapone tab 200 mg
TASMAR TAB 100MG

1
3

Antiparkinson Dopaminergics
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
APOKYN INJ
bromocriptine mesylate cap 5 mg

1
1
1
3
1

PA

43

Drug Name
Drug Tier Requirements/Limits
bromocriptine mesylate tab 2.5 mg
1
carbidopa & levodopa orally disintegrating 1
tab 10-100 mg
carbidopa & levodopa orally disintegrating 1
tab 25-100 mg
carbidopa & levodopa orally disintegrating 1
tab 25-250 mg
carbidopa & levodopa tab 10-100 mg
1
carbidopa & levodopa tab 25-100 mg
1
carbidopa & levodopa tab 25-250 mg
1
carbidopa & levodopa tab cr 25-100 mg
1
carbidopa & levodopa tab cr 50-200 mg
1
carbidopa-levodopa-entacapone tabs 12.5- 1
50-200 mg
carbidopa-levodopa-entacapone tabs
1
18.75-75-200 mg
carbidopa-levodopa-entacapone tabs 25- 1
100-200 mg
carbidopa-levodopa-entacapone tabs
1
31.25-125-200 mg
carbidopa-levodopa-entacapone tabs 37.5- 1
150-200 mg
carbidopa-levodopa-entacapone tabs 50- 1
200-200 mg
MIRAPEX ER TAB 0.75MG
2
MIRAPEX ER TAB 0.375MG
2
MIRAPEX ER TAB 1.5MG
2
MIRAPEX ER TAB 2.25MG
2
MIRAPEX ER TAB 3.75MG
2
MIRAPEX ER TAB 3MG
2
MIRAPEX ER TAB 4.5MG
2
pramipexole dihydrochloride tab 0.5 mg
1
pramipexole dihydrochloride tab 0.25 mg 1
pramipexole dihydrochloride tab 0.75 mg 1
pramipexole dihydrochloride tab 0.125 mg 1
pramipexole dihydrochloride tab 1 mg
1
pramipexole dihydrochloride tab 1.5 mg
1
ropinirole hydrochloride tab 0.5 mg
1
ropinirole hydrochloride tab 0.25 mg
1
ropinirole hydrochloride tab 1 mg
1
ropinirole hydrochloride tab 2 mg
1
ropinirole hydrochloride tab 3 mg
1
ropinirole hydrochloride tab 4 mg
1
ropinirole hydrochloride tab 5 mg
1

Antiparkinson Monoamine Oxidase Inhibitors
AZILECT TAB 0.5MG
AZILECT TAB 1MG
selegiline hcl cap 5 mg

2
2
1

44

Drug Name
selegiline hcl tab 5 mg

Drug Tier Requirements/Limits
1

ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic Agents
lithium carbonate cap 150 mg
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg
lithium carbonate tab 300 mg
lithium carbonate tab cr 300 mg
lithium carbonate tab cr 450 mg
LITHIUM CITR SOL 8MEQ/5ML

1
1
1
1
1
1
3

Antipsychotics - Misc.
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 80MG
LATUDA TAB 120MG
ziprasidone hcl cap 20
ziprasidone hcl cap 40
ziprasidone hcl cap 60
ziprasidone hcl cap 80

2
2
2
2
1
1
1
1

ST
ST
ST
ST

3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
tab 0.5 mg 1
tab 0.25 1

ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
PA
PA
PA
PA

mg
mg
mg
mg

Benzisoxazoles
FANAPT PAK
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FANAPT TAB 10MG
FANAPT TAB 12MG
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone orally disintegrating
risperidone orally disintegrating
mg
risperidone orally disintegrating
risperidone orally disintegrating
risperidone orally disintegrating
risperidone orally disintegrating
risperidone soln 1 mg/ml
risperidone tab 0.5 mg

tab
tab
tab
tab

1
2
3
4

mg
mg
mg
mg

1
1
1
1
1
1

45

Drug Name
risperidone tab
risperidone tab
risperidone tab
risperidone tab
risperidone tab

0.25 mg
1 mg
2 mg
3 mg
4 mg

Drug Tier Requirements/Limits
1
1
1
1
1

Butyrophenones
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol
haloperidol

decanoate im soln 50 mg/ml
decanoate im soln 100 mg/ml
lactate oral conc 2 mg/ml
tab 0.5 mg
tab 1 mg
tab 2 mg
tab 5 mg
tab 10 mg
tab 20 mg

1
1
1
1
1
1
1
1
1

Dibenzapines
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
loxapine succinate cap 5 mg
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 50 mg
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
olanzapine tab 15 mg
olanzapine tab 20 mg
quetiapine fumarate tab 25 mg
quetiapine fumarate tab 50 mg
quetiapine fumarate tab 100 mg
quetiapine fumarate tab 200 mg
quetiapine fumarate tab 300 mg
quetiapine fumarate tab 400 mg
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL XR TAB 50MG
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
2
2
2
2
2

ST
ST
ST
ST
ST
ST
ST

Phenothiazines
chlorpromazine hcl tab 10 mg

1

46

Drug Name
chlorpromazine hcl tab 25 mg
chlorpromazine hcl tab 50 mg
chlorpromazine hcl tab 100 mg
chlorpromazine hcl tab 200 mg
compro sup 25mg
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
fluphenazine hcl tab 10 mg
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
prochlorperazine maleate tab 5 mg
prochlorperazine maleate tab 10 mg
prochlorperazine suppos 25 mg
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg
trifluoperazine hcl tab 10 mg

Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Quinolinone Derivatives
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY

SOL
TAB
TAB
TAB
TAB
TAB
TAB

1MG/ML
2MG
5MG
10MG
15MG
20MG
30MG

2
2
2
2
2
2
2

ST
ST
ST
ST
ST
ST
ST

Thioxanthenes
NAVANE CAP 20MG
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg

3
1
1
1
1

ANTISEPTICS DISINFECTANTS
Chlorine Antiseptics
PHISOHEX LIQ 3%

3

ANTIVIRALS
Antiretrovirals
47

Drug Name
Drug Tier Requirements/Limits
abacavir sulfate tab 300 mg (base equiv) 1
APTIVUS CAP 250MG
2
APTIVUS SOL
2
ATRIPLA TAB
2
COMPLERA TAB
2
CRIXIVAN CAP 100MG
2
CRIXIVAN CAP 200MG
2
CRIXIVAN CAP 400MG
2
didanosine delayed release capsule 125 mg1
didanosine delayed release capsule 200 mg1
didanosine delayed release capsule 250 mg1
didanosine delayed release capsule 400 mg1
EDURANT TAB 25MG
2
EMTRIVA CAP 200MG
2
EMTRIVA SOL 10MG/ML
2
EPIVIR HBV SOL 5MG/ML
2
EPIVIR HBV TAB 100MG
2
EPIVIR SOL 10MG/ML
2
EPZICOM TAB 600-300
2
FUZEON INJ 90MG
3
PA
FUZEON KIT
3
PA
INTELENCE TAB 25MG
2
INTELENCE TAB 100MG
2
INTELENCE TAB 200MG
2
INVIRASE CAP 200MG
2
INVIRASE TAB 500MG
2
ISENTRESS CHW 25MG
2
ISENTRESS CHW 100MG
2
ISENTRESS TAB 400MG
2
KALETRA SOL
2
KALETRA TAB 100-25MG
2
KALETRA TAB 200-50MG
2
lamivudine tab 150 mg
1
lamivudine tab 300 mg
1
lamivudine-zidovudine tab 150-300 mg
1
LEXIVA SUS 50MG/ML
2
LEXIVA TAB 700MG
2
nevirapine susp 50 mg/5ml
1
nevirapine tab 200 mg
1
NORVIR CAP 100MG
2
NORVIR SOL 80MG/ML
2
NORVIR TAB 100MG
2
PREZISTA TAB 75MG
2
PREZISTA TAB 150MG
2
PREZISTA TAB 400MG
2

48

Drug Name
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
REYATAZ CAP 100MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
stavudine for oral soln 1 mg/ml
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TRIZIVIR TAB
TRUVADA TAB 200-300
VIDEX SOL 2GM
VIDEX SOL 4GM
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 400MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg

Drug Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1

CMV Agents
foscarnet sodium inj 24 mg/ml
ganciclovir cap 250 mg
ganciclovir cap 500 mg

1
1
1

Hepatitis Agents
BARACLUDE SOL .05MG/ML
BARACLUDE TAB 0.5MG
BARACLUDE TAB 1MG
HEPSERA TAB 10MG
INCIVEK TAB 375MG
INFERGEN INJ 9MCG

2
2
2
3
3
3

PA
PA
PA

49


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