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Empire BlueCross BlueShield HealthPlus – New York Essential Plan – Drug List
Table of Contents
NOTE: Not all medications and not all plans are subject to prior authorization and quantity limits. For
more information regarding prior authorization or quantity limits, contact Member Services at the
telephone number listed on your identification card.
Tier 1: Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions.
Tier 2: Tier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they’re newer to the market.
Tier 3: Tier 3 drugs have the highest cost share. They often include non-preferred brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA or specialty drugs that are used to treat serious, long-term health conditions and that may need special handling.
Brand name drugs are in UPPER CASE, bold type.
Generic drugs are in lower case, plain type.
$0: preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.
DO: dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once a day at a higher strength.
LD: limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on what the manufacturer decides.
PA: prior authorization. You may need to get benefits approved before certain prescriptions can be filled.
QL: quantity limits. There are limits on the amount of medicine covered within a certain amount of time.
SP: specialty drugs. Specialty drugs are used to treat difficult, long-term conditions. You may need to get this drug through a specialty pharmacy.
ST: step therapy. You may need to use another recommended drug first before a prescribed drug is covered. www.empireblue.com/nyessentialplan Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
2019 New York Essential Plan Drug List
Table of Contents
ANALGESICS ...........................................................................................................................................................................4ANESTHETICS .........................................................................................................................................................................5ANTIARTHRITICS .................................................................................................................................................................... 5ANTIASTHMATICS .................................................................................................................................................................. 6ANTIBIOTICS ........................................................................................................................................................................... 7ANTICOAGULANTS .............................................................................................................................................................. 11ANTIDOTES ........................................................................................................................................................................... 12ANTIFUNGALS ...................................................................................................................................................................... 12ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 13ANTIHISTAMINES ..................................................................................................................................................................13ANTIHYPERGLYCEMICS ...................................................................................................................................................... 13ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................15ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ....................................................................................16ANTINEOPLASTICS .............................................................................................................................................................. 16ANTIPARASITICS .................................................................................................................................................................. 18ANTIPARKINSON DRUGS .................................................................................................................................................... 18ANTIPLATELET DRUGS ....................................................................................................................................................... 19ANTIVIRALS ...........................................................................................................................................................................19AUTONOMIC DRUGS ............................................................................................................................................................ 20BIOLOGICALS ....................................................................................................................................................................... 21BLOOD ................................................................................................................................................................................... 23CARDIAC DRUGS ..................................................................................................................................................................23CARDIOVASCULAR .............................................................................................................................................................. 25CNS DRUGS ...........................................................................................................................................................................27COLONY STIMULATING FACTORS .....................................................................................................................................29CONTRACEPTIVES ............................................................................................................................................................... 29COUGH/COLD PREPARATIONS .......................................................................................................................................... 32DIAGNOSTIC ..........................................................................................................................................................................33DIURETICS .............................................................................................................................................................................33EENT PREPS ......................................................................................................................................................................... 34ELECT/CALORIC/H2O ...........................................................................................................................................................35GASTROINTESTINAL ............................................................................................................................................................36HORMONES ........................................................................................................................................................................... 38IMMUNOSUPPRESSANTS ....................................................................................................................................................39MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 40MUSCLE RELAXANTS .......................................................................................................................................................... 41PRE-NATAL VITAMINS ......................................................................................................................................................... 41PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................42SEDATIVE/HYPNOTICS ........................................................................................................................................................ 44SKIN PREPS .......................................................................................................................................................................... 45SMOKING DETERRENTS ......................................................................................................................................................48THYROID PREPS ...................................................................................................................................................................48UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................48VITAMINS ............................................................................................................................................................................... 50
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2019 New York Essential Plan Drug List
CURRENT AS OF 10/1/2019
Drug Name Tier Notes
ANALGESICS
acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml
Tier 1 PA; QL
acetaminophen-codeine oral tablet
Tier 1 PA; QL
almotriptan malate oral tablet
Tier 1 QL
ascomp with codeine oral capsule
Tier 1 PA; QL
butalbital compound w/codeine oral capsule
Tier 1 PA; QL
butalbital-acetaminop-caf-cod oral capsule
Tier 1 PA; QL
butalbital-acetaminophen oral tablet
Tier 1
butalbital-acetaminophen-caff oral capsule
Tier 1
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Tier 1
butalbital-aspirin-caffeine oral capsule
Tier 1
butalbital-aspirin-caffeine oral tablet
Tier 1
butorphanol tartrate nasal spray,non-aerosol
Tier 1 QL
codeine sulfate oral tablet Tier 2 PA; QL
codeine-butalbital-asa-caff oral capsule
Tier 1 PA; QL
diclofenac potassium oral tablet
Tier 1
diflunisal oral tablet Tier 1
dihydroergotamine nasal spray,non-aerosol
Tier 2 QL
diskets oral tablet,soluble Tier 1 PA; QL
eletriptan oral tablet Tier 2 QL
ELMIRON ORAL CAPSULE
Tier 3
EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL
Tier 3 PA; QL
Drug Name Tier Notes
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 2 QL
ergotamine-caffeine oral tablet
Tier 1
fentanyl transdermal patch 72 hour
Tier 2 PA; QL
frovatriptan oral tablet Tier 2 QL
hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 7.5-325 mg/15 ml
Tier 1 QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
Tier 1 QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
Tier 1 QL
hydromorphone oral liquid Tier 1 QL
hydromorphone oral tablet Tier 1 QL
hydromorphone rectal suppository
Tier 2 QL
ibuprofen-oxycodone oral tablet
Tier 1 QL
ketorolac oral tablet Tier 1 QL
levorphanol tartrate oral tablet 2 mg
Tier 2 PA; QL
LEVORPHANOL TARTRATE ORAL TABLET 3 MG
Tier 2 PA
mefenamic acid oral capsule
Tier 1 QL
meperidine injection cartridge
Tier 1 QL
meperidine oral solution Tier 1 QL
meperidine oral tablet Tier 1 QL
methadone intensol oral concentrate
Tier 1 PA; QL
methadone oral concentrate
Tier 1 PA; QL
methadone oral solution Tier 1 PA; QL
methadone oral tablet Tier 1 PA; QL
methadone oral tablet,soluble
Tier 1 PA; QL
Effective 10/1/20194
Drug Name Tier Notes
methadose oral concentrate
Tier 1 PA; QL
methadose oral tablet,soluble
Tier 1 PA; QL
migergot rectal suppository
Tier 1
morphine concentrate oral solution
Tier 1 QL
morphine oral capsule,extend.release pellets
Tier 2 PA; QL
morphine oral solution Tier 1 QL
morphine oral tablet Tier 1 QL
morphine oral tablet extended release
Tier 2 PA; QL
morphine rectal suppository
Tier 1 QL
naratriptan oral tablet Tier 1 QL
NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 PA; QL
oxycodone oral capsule Tier 2 QL
oxycodone oral concentrate
Tier 2 QL
oxycodone oral solution Tier 2 QL
oxycodone oral syringe Tier 2 QL
oxycodone oral tablet Tier 2 QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1 QL
oxycodone-aspirin oral tablet
Tier 1 QL
oxymorphone oral tablet Tier 2 QL
oxymorphone oral tablet extended release 12 hr
Tier 2 PA; QL
pentazocine-naloxone oral tablet
Tier 1 QL
rizatriptan oral tablet Tier 1 QL
rizatriptan oral tablet,disintegrating
Tier 1 QL
sumatriptan nasal spray,non-aerosol
Tier 1 QL
sumatriptan succinate oral tablet
Tier 1 QL
sumatriptan succinate subcutaneous cartridge
Tier 2 QL
Drug Name Tier Notes
sumatriptan succinate subcutaneous pen injector
Tier 2 QL
sumatriptan succinate subcutaneous solution
Tier 2 QL
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml
Tier 2 QL
tencon oral tablet 50-325 mg
Tier 1
tramadol oral tablet Tier 1 QL
tramadol oral tablet extended release 24 hr
Tier 2 PA; QL
tramadol oral tablet, er multiphase 24 hr
Tier 2 PA; QL
vicodin es oral tablet Tier 2 QL
vicodin hp oral tablet Tier 2 QL
vicodin oral tablet Tier 2 QL
zebutal oral capsule 50-325-40 mg
Tier 2
ZIPSOR ORAL CAPSULE Tier 3 ST; QL
ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR
Tier 3 PA; QL
zolmitriptan oral tablet Tier 1 QL
zolmitriptan oral tablet,disintegrating
Tier 1 QL
ANESTHETICS
lidocaine viscous mucous membrane solution
Tier 1 QL
lidocaine-prilocaine topical cream
Tier 1 QL
lidocaine-prilocaine topical kit
Tier 1
phenazopyridine oral tablet 100 mg, 200 mg
Tier 1
SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING
Tier 3
ANTIARTHRITICS
allopurinol oral tablet Tier 1
celecoxib oral capsule Tier 2 ST; QL
COLCHICINE ORAL TABLET
Tier 3 PA; QL
COLCRYS ORAL TABLET
Tier 3 PA; QL
Effective 10/1/20195
Drug Name Tier Notes
diclofenac sodium oral tablet extended release 24 hr
Tier 1
diclofenac sodium oral tablet,delayed release (dr/ec)
Tier 1
ec-naproxen oral tablet,delayed release (dr/ec)
Tier 1
etodolac oral capsule Tier 1
etodolac oral tablet Tier 1
etodolac oral tablet extended release 24 hr
Tier 1
febuxostat oral tablet Tier 2 ST; QL
fenoprofen oral tablet Tier 1 QL
flurbiprofen oral tablet Tier 1
ibu oral tablet Tier 1
ibuprofen oral suspension Tier 1 QL
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
indomethacin oral capsule Tier 1 QL
indomethacin oral capsule, extended release
Tier 1 QL
ketoprofen oral capsule Tier 1
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
Tier 1 QL
meclofenamate oral capsule
Tier 1
meloxicam oral suspension
Tier 1 QL
meloxicam oral tablet Tier 1 QL
nabumetone oral tablet Tier 1
naproxen oral suspension Tier 1
naproxen oral tablet Tier 1
naproxen oral tablet,delayed release (dr/ec)
Tier 1
naproxen sodium oral tablet 275 mg, 550 mg
Tier 1
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN
Tier 3 PA; SP; QL
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR
Tier 3 PA; SP; QL
Drug Name Tier Notes
ORENCIA SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
oxaprozin oral tablet Tier 1
penicillamine oral capsule Tier 2
piroxicam oral capsule Tier 1
probenecid oral tablet Tier 1
probenecid-colchicine oral tablet
Tier 1
RIDAURA ORAL CAPSULE
Tier 3
sulindac oral tablet Tier 1
tolmetin oral capsule Tier 2
tolmetin oral tablet Tier 2
ANTIASTHMATICS
acetylcysteine solution Tier 2
ADVAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
albuterol sulfate inhalation solution for nebulization
Tier 1
albuterol sulfate oral syrup Tier 1
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)
Tier 2 QL
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (14)
Tier 2
BREO ELLIPTA INHALATION BLISTER WITH DEVICE
Tier 3 QL
BROVANA INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
Effective 10/1/20196
Drug Name Tier Notes
budesonide inhalation suspension for nebulization
Tier 1 QL
cromolyn inhalation solution for nebulization
Tier 2
DALIRESP ORAL TABLET
Tier 3 QL
DULERA INHALATION HFA AEROSOL INHALER
Tier 2 QL
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
FLOVENT HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
fluticasone propion-salmeterol inhalation blister with device
Tier 1 QL
ipratropium bromide inhalation solution
Tier 1 QL
ipratropium-albuterol inhalation solution for nebulization
Tier 2
levalbuterol hcl inhalation solution for nebulization
Tier 2
metaproterenol oral syrup Tier 1
montelukast oral granules in packet
Tier 1 QL
montelukast oral tablet Tier 1 QL
montelukast oral tablet,chewable
Tier 1 QL
PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION
Tier 3 QL
PROAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
PROVENTIL HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
Drug Name Tier Notes
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
SPIRIVA RESPIMAT INHALATION MIST
Tier 3 QL
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
STRIVERDI RESPIMAT INHALATION MIST
Tier 3 QL
SYMBICORT INHALATION HFA AEROSOL INHALER
Tier 2 QL
terbutaline oral tablet Tier 2
theochron oral tablet extended release 12 hr
Tier 1
theophylline oral elixir Tier 1
theophylline oral solution Tier 1
theophylline oral tablet extended release 12 hr
Tier 1
theophylline oral tablet extended release 24 hr
Tier 1
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
VENTOLIN HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
wixela inhub inhalation blister with device
Tier 1 QL
XOPENEX HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
zafirlukast oral tablet Tier 1
zileuton oral tablet, er multiphase 12 hr
Tier 2
ANTIBIOTICS
ak-poly-bac ophthalmic (eye) ointment
Tier 1
amoxicillin oral capsule Tier 1
Effective 10/1/20197
Drug Name Tier Notes
amoxicillin oral suspension for reconstitution
Tier 1
amoxicillin oral tablet Tier 1
amoxicillin oral tablet,chewable 125 mg, 250 mg
Tier 1
amoxicillin-pot clavulanate oral suspension for reconstitution
Tier 1
amoxicillin-pot clavulanate oral tablet
Tier 1
amoxicillin-pot clavulanate oral tablet extended release 12 hr
Tier 1
amoxicillin-pot clavulanate oral tablet,chewable
Tier 1
ampicillin oral capsule Tier 1
avidoxy oral tablet Tier 1
AZASITE OPHTHALMIC (EYE) DROPS
Tier 3
azithromycin oral packet Tier 1 QL
azithromycin oral suspension for reconstitution
Tier 1 QL
azithromycin oral tablet Tier 1 QL
bacitracin ophthalmic (eye) ointment
Tier 1
bacitracin-polymyxin b ophthalmic (eye) ointment
Tier 1
BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
bp 10-1 topical cleanser Tier 1
CAYSTON INHALATION SOLUTION FOR NEBULIZATION
Tier 3 SP; LD
cefaclor oral capsule Tier 1
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Tier 1
cefaclor oral tablet extended release 12 hr
Tier 2
cefadroxil oral capsule Tier 1
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
Tier 1
Drug Name Tier Notes
cefadroxil oral tablet Tier 1
cefdinir oral capsule Tier 1
cefdinir oral suspension for reconstitution
Tier 1
cefditoren pivoxil oral tablet
Tier 2
cefixime oral capsule Tier 2
cefpodoxime oral suspension for reconstitution
Tier 2
cefpodoxime oral tablet Tier 2
cefprozil oral suspension for reconstitution
Tier 1
cefprozil oral tablet Tier 1
cefuroxime axetil oral tablet
Tier 1
cephalexin oral capsule Tier 1
cephalexin oral suspension for reconstitution
Tier 1
cephalexin oral tablet Tier 1
CIPRO HC OTIC (EAR) DROPS,SUSPENSION
Tier 3
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
Tier 3
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr
Tier 1 QL
ciprofloxacin hcl ophthalmic (eye) drops
Tier 1
ciprofloxacin hcl oral tablet Tier 1 QL
ciprofloxacin hcl otic (ear) dropperette
Tier 1
clarithromycin oral suspension for reconstitution
Tier 1
clarithromycin oral tablet Tier 1
clarithromycin oral tablet extended release 24 hr
Tier 1
cleansing wash topical cleanser
Tier 1
clindamycin hcl oral capsule
Tier 1
clindamycin palmitate hcl oral recon soln
Tier 1
clindamycin pediatric oral recon soln
Tier 1
Effective 10/1/20198
Drug Name Tier Notes
clindamycin phosphate topical foam
Tier 1
clindamycin phosphate topical gel
Tier 1
clindamycin phosphate topical lotion
Tier 1
clindamycin phosphate topical solution
Tier 1
clindamycin phosphate topical swab
Tier 1
clindamycin phosphate vaginal cream
Tier 1
COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION
Tier 3
CORTISPORIN TOPICAL CREAM
Tier 3
CORTISPORIN TOPICAL OINTMENT
Tier 3
CYCLOSERINE ORAL CAPSULE
Tier 3
DAPSONE ORAL TABLET
Tier 2
demeclocycline oral tablet Tier 2
dicloxacillin oral capsule Tier 1
DIFICID ORAL TABLET Tier 3 PA
doxycycline hyclate oral capsule
Tier 1
doxycycline hyclate oral tablet 100 mg, 50 mg
Tier 1
doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg
Tier 1 PA
doxycycline monohydrate oral capsule
Tier 1
doxycycline monohydrate oral suspension for reconstitution
Tier 1
doxycycline monohydrate oral tablet
Tier 1
e.e.s. 400 oral tablet Tier 2
ertapenem injection recon soln
Tier 2
ery pads topical swab Tier 1
erygel topical gel Tier 1
Drug Name Tier Notes
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
Tier 1
erythrocin (as stearate) oral tablet 250 mg
Tier 1
erythromycin ethylsuccinate oral tablet
Tier 2
erythromycin ophthalmic (eye) ointment
Tier 1
erythromycin oral capsule,delayed release(dr/ec)
Tier 2
erythromycin oral tablet Tier 2
erythromycin oral tablet,delayed release (dr/ec)
Tier 1
erythromycin with ethanol topical gel
Tier 1
erythromycin with ethanol topical solution
Tier 1
erythromycin with ethanol topical swab
Tier 1
erythromycin-benzoyl peroxide topical gel
Tier 1
ethambutol oral tablet Tier 2
FACTIVE ORAL TABLET Tier 3 QL
gatifloxacin ophthalmic (eye) drops
Tier 1
gentak ophthalmic (eye) ointment
Tier 1
gentamicin ophthalmic (eye) drops
Tier 1
gentamicin ophthalmic (eye) ointment
Tier 1
gentamicin topical cream Tier 1
gentamicin topical ointment
Tier 1
isoniazid oral solution Tier 1
isoniazid oral tablet Tier 1
levofloxacin ophthalmic (eye) drops
Tier 1
levofloxacin oral tablet Tier 2 QL
linezolid oral suspension for reconstitution
Tier 2 PA; QL
linezolid oral tablet Tier 2 PA; QL
mafenide acetate topical packet
Tier 2
Effective 10/1/20199
Drug Name Tier Notes
methenamine hippurate oral tablet
Tier 2
methenamine mandelate oral tablet
Tier 2
metronidazole oral capsule
Tier 1
metronidazole oral tablet Tier 1
metronidazole vaginal gel Tier 1
minocycline oral capsule Tier 1
minocycline oral tablet Tier 1
minocycline oral tablet extended release 24 hr 115 mg, 135 mg, 45 mg, 65 mg, 90 mg
Tier 1 PA
MONUROL ORAL PACKET
Tier 3
morgidox oral capsule 100 mg
Tier 1
MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR
Tier 3
moxifloxacin ophthalmic (eye) drops
Tier 1
moxifloxacin oral tablet Tier 2 QL
mupirocin topical ointment Tier 1
neomycin oral tablet Tier 1
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment
Tier 1
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment
Tier 1
neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension
Tier 1
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment
Tier 1
neomycin-polymyxin-gramicidin ophthalmic (eye) drops
Tier 1
neomycin-polymyxin-hc ophthalmic (eye) drops,suspension
Tier 1
neomycin-polymyxin-hc otic (ear) drops,suspension
Tier 1
Drug Name Tier Notes
neomycin-polymyxin-hc otic (ear) solution
Tier 1
neo-polycin hc ophthalmic (eye) ointment
Tier 1
neo-polycin ophthalmic (eye) ointment
Tier 1
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
Tier 1
nitrofurantoin monohyd/m-cryst oral capsule
Tier 1
nitrofurantoin oral suspension
Tier 1
ofloxacin ophthalmic (eye) drops
Tier 1
ofloxacin oral tablet 300 mg, 400 mg
Tier 1 QL
ofloxacin otic (ear) drops Tier 1
ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE
Tier 3
penicillin v potassium oral recon soln
Tier 1
penicillin v potassium oral tablet
Tier 1
polycin ophthalmic (eye) ointment
Tier 1
polymyxin b sulf-trimethoprim ophthalmic (eye) drops
Tier 1
PRIFTIN ORAL TABLET Tier 3
PRIMSOL ORAL SOLUTION
Tier 3
pyrazinamide oral tablet Tier 2
rifabutin oral capsule Tier 2
rifampin oral capsule Tier 2
RIFATER ORAL TABLET Tier 3
silver sulfadiazine topical cream
Tier 1
SIRTURO ORAL TABLET Tier 3
SIVEXTRO ORAL TABLET
Tier 3 PA; QL
ssd topical cream Tier 1
sss 10-5 topical cream Tier 1
sss 10-5 topical foam Tier 1
Effective 10/1/201910
Drug Name Tier Notes
sulfacetamide sodium ophthalmic (eye) drops
Tier 1
sulfacetamide sodium ophthalmic (eye) ointment
Tier 1
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %
Tier 1
sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)
Tier 1
sulfacetamide sodium-sulfur topical pads, medicated 10-4 %
Tier 1
sulfacetamide sodium-sulfur topical suspension
Tier 1
sulfacetamide sod-sulfur-urea topical cleanser
Tier 1
sulfacetamide-prednisolone ophthalmic (eye) drops
Tier 1
sulfacetamide-sulfur-cleansr23 topical kit
Tier 1
sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream
Tier 1
sulfadiazine oral tablet Tier 2
sulfamethoxazole-trimethoprim oral suspension
Tier 1
sulfamethoxazole-trimethoprim oral tablet
Tier 1
SULFAMYLON TOPICAL CREAM
Tier 3
sulfatrim oral suspension Tier 1
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML
Tier 3
tetracycline oral capsule Tier 1
THALOMID ORAL CAPSULE
Tier 2 PA; SP; QL
tigecycline intravenous recon soln
Tier 2
TOBRADEX OPHTHALMIC (EYE) OINTMENT
Tier 3
Drug Name Tier Notes
tobramycin in 0.225 % nacl inhalation solution for nebulization
Tier 3 SP
tobramycin ophthalmic (eye) drops
Tier 1
tobramycin-dexamethasone ophthalmic (eye) drops,suspension
Tier 1
TRECATOR ORAL TABLET
Tier 3
trimethoprim oral tablet Tier 1
vancomycin oral capsule Tier 2 PA
vandazole vaginal gel Tier 1
XIFAXAN ORAL TABLET Tier 3 PA; QL
ANTICOAGULANTS
ELIQUIS ORAL TABLET Tier 3 QL
ELIQUIS ORAL TABLETS,DOSE PACK
Tier 3 QL
enoxaparin subcutaneous solution
Tier 3 QL
enoxaparin subcutaneous syringe
Tier 3 QL
fondaparinux subcutaneous syringe
Tier 3 QL
FRAGMIN SUBCUTANEOUS SOLUTION
Tier 3 QL
FRAGMIN SUBCUTANEOUS SYRINGE
Tier 3 QL
hep flush-10 (pf) intravenous solution
Tier 1
heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)
Tier 1
heparin (porcine) in nacl (pf) intravenous parenteral solution
Tier 1
heparin (porcine) injection cartridge
Tier 1
heparin (porcine) injection solution
Tier 1
Effective 10/1/201911
Drug Name Tier Notes
heparin flush(porcine)-0.9nacl intravenous kit
Tier 1
heparin lock flush (porcine) intravenous solution
Tier 1
heparin lock flush (porcine) intravenous syringe 10 unit/ml
Tier 2
heparin lock flush (porcine) intravenous syringe 100 unit/ml
Tier 1
heparin lock flush intravenous solution
Tier 1
heparin lock flush intravenous syringe
Tier 1
heparin lock intravenous solution
Tier 1
heparin lockflush(porcine)(pf) intravenous syringe
Tier 1
heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml
Tier 1
heparin, porcine (pf) injection solution
Tier 1
heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml
Tier 1
heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)
Tier 1
heparin, porcine (pf) intravenous syringe
Tier 1
jantoven oral tablet Tier 1
PRADAXA ORAL CAPSULE
Tier 3 QL
warfarin oral tablet Tier 1
XARELTO ORAL TABLET
Tier 3 QL
XARELTO ORAL TABLETS,DOSE PACK
Tier 3 QL
ANTIDOTES
naloxone injection solution Tier 2 QL
naloxone injection syringe Tier 2 QL
naltrexone oral tablet Tier 1
Drug Name Tier Notes
ANTIFUNGALS
ciclopirox topical cream Tier 1
ciclopirox topical gel Tier 1
ciclopirox topical shampoo Tier 1
ciclopirox topical solution Tier 1
ciclopirox topical suspension
Tier 1
clotrimazole mucous membrane troche
Tier 2 QL
clotrimazole topical cream Tier 1
clotrimazole topical solution
Tier 1
clotrimazole-betamethasone topical cream
Tier 1
clotrimazole-betamethasone topical lotion
Tier 1
econazole topical cream Tier 1
ERTACZO TOPICAL CREAM
Tier 3
EXELDERM TOPICAL CREAM
Tier 3
EXELDERM TOPICAL SOLUTION
Tier 3
fluconazole oral suspension for reconstitution
Tier 1 QL
fluconazole oral tablet Tier 1 QL
flucytosine oral capsule Tier 2
griseofulvin microsize oral suspension
Tier 1
griseofulvin microsize oral tablet
Tier 1
griseofulvin ultramicrosize oral tablet
Tier 1
GYNAZOLE-1 VAGINAL CREAM
Tier 3
itraconazole oral capsule Tier 2 PA; QL
JUBLIA TOPICAL SOLUTION WITH APPLICATOR
Tier 3
ketoconazole oral tablet Tier 1 QL
ketoconazole topical cream
Tier 1
ketoconazole topical foam Tier 1
Effective 10/1/201912
Drug Name Tier Notes
ketoconazole topical shampoo
Tier 1
MENTAX TOPICAL CREAM
Tier 3
miconazole-3 vaginal suppository
Tier 1
NAFTIFINE TOPICAL CREAM 1 %
Tier 2
naftifine topical cream 2 % Tier 2
NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
NOXAFIL ORAL SUSPENSION
Tier 3 QL
nyamyc topical powder Tier 1
nystatin oral suspension Tier 1
nystatin oral tablet Tier 1
nystatin topical cream Tier 1
nystatin topical ointment Tier 1
nystatin topical powder Tier 1
nystatin-triamcinolone topical cream
Tier 1
nystatin-triamcinolone topical ointment
Tier 1
nystop topical powder Tier 1
oxiconazole topical cream Tier 2
OXISTAT TOPICAL LOTION
Tier 3
terbinafine hcl oral tablet Tier 1 QL
terconazole vaginal cream Tier 1
terconazole vaginal suppository
Tier 1
voriconazole oral suspension for reconstitution
Tier 2 PA; QL
voriconazole oral tablet Tier 2 PA; QL
ANTIHISTAMINE AND DECONGESTANT COMBINATION
promethazine vc oral syrup
Tier 1
promethazine-phenylephrine oral syrup
Tier 1
ANTIHISTAMINES
azelastine ophthalmic (eye) drops
Tier 1 QL
Drug Name Tier Notes
BEPREVE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
carbinoxamine maleate oral liquid
Tier 1
carbinoxamine maleate oral tablet
Tier 1
cetirizine oral solution 1 mg/ml
Tier 1
clemastine oral tablet 2.68 mg
Tier 1
cyproheptadine oral syrup Tier 1
cyproheptadine oral tablet Tier 1
desloratadine oral tablet Tier 1
desloratadine oral tablet,disintegrating
Tier 1
diphenhydramine hcl injection solution 50 mg/ml
Tier 2
diphenhydramine hcl injection syringe
Tier 2
diphenhydramine hcl oral capsule 50 mg
Tier 1
epinastine ophthalmic (eye) drops
Tier 1 QL
fexofenadine oral tablet 180 mg
Tier 1
hydroxyzine hcl oral solution 10 mg/5 ml
Tier 1
hydroxyzine hcl oral tablet Tier 1
hydroxyzine pamoate oral capsule
Tier 1
LASTACAFT OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
levocetirizine oral solution Tier 1
levocetirizine oral tablet Tier 1
olopatadine ophthalmic (eye) drops
Tier 2 PA; QL
promethazine oral syrup Tier 1
promethazine oral tablet Tier 1
ANTIHYPERGLYCEMICS
acarbose oral tablet Tier 1
APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 3 ST
Effective 10/1/201913
Drug Name Tier Notes
APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 3 ST
AVANDIA ORAL TABLET2 MG, 4 MG
Tier 3 ST; QL
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR
Tier 3 ST; QL
BYDUREON SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
chlorpropamide oral tablet Tier 1
CYCLOSET ORAL TABLET
Tier 3
FARXIGA ORAL TABLET Tier 3 ST; QL
glimepiride oral tablet Tier 1
glipizide oral tablet Tier 1
glipizide oral tablet extended release 24hr
Tier 1
glipizide-metformin oral tablet
Tier 1
glyburide micronized oral tablet
Tier 1
glyburide oral tablet Tier 1
glyburide-metformin oral tablet
Tier 1
HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT
Tier 2
HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
Drug Name Tier Notes
HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE
Tier 2
HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION
Tier 2
HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
insulin lispro subcutaneous insulin pen
Tier 2
insulin lispro subcutaneous solution
Tier 2
INVOKAMET ORAL TABLET
Tier 3 ST; QL
JANUMET ORAL TABLET
Tier 2 ST; QL
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR
Tier 2 ST; QL
Effective 10/1/201914
Drug Name Tier Notes
JANUVIA ORAL TABLET Tier 2 ST; QL
JARDIANCE ORAL TABLET
Tier 2 ST; QL
JENTADUETO ORAL TABLET
Tier 2 ST; QL
LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN
Tier 2
LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION
Tier 2
metformin oral tablet Tier 1
metformin oral tablet extended release 24 hr
Tier 1
miglitol oral tablet Tier 2
nateglinide oral tablet Tier 2
NESINA ORAL TABLET Tier 3 ST; QL
NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION
Tier 2
NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION
Tier 2
Drug Name Tier Notes
NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE
Tier 2
NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION
Tier 2
ONGLYZA ORAL TABLET
Tier 3 ST; QL
OZEMPIC SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
pioglitazone oral tablet Tier 1 QL
SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
SYNJARDY ORAL TABLET
Tier 2 ST; QL
tolazamide oral tablet Tier 1
tolbutamide oral tablet Tier 2
TRADJENTA ORAL TABLET
Tier 2 ST; DO
TRULICITY SUBCUTANEOUS PEN INJECTOR
Tier 3 ST; QL
VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR
Tier 2 ST; QL
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR
Tier 3 ST; QL
ANTIINFECTIVES/MISCELLANEOUS
atovaquone oral suspension
Tier 2
atovaquone-proguanil oral tablet
Tier 1
Effective 10/1/201915
Drug Name Tier Notes
chloroquine phosphate oral tablet
Tier 1
COARTEM ORAL TABLET
Tier 3
DARAPRIM ORAL TABLET
Tier 3 PA; LD; QL
hydroxychloroquine oral tablet
Tier 1
ivermectin oral tablet Tier 1
mefloquine oral tablet Tier 1
NEBUPENT INHALATION RECON SOLN
Tier 3
paromomycin oral capsule Tier 1
praziquantel oral tablet Tier 2
PRIMAQUINE ORAL TABLET
Tier 3
quinine sulfate oral capsule
Tier 2 PA; QL
ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT
Tier 3 PA; SP; LD; QL
CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT
Tier 3 PA; SP; LD; QL
CIMZIA SUBCUTANEOUS SYRINGE KIT
Tier 3 PA; SP; LD; QL
ENBREL MINI SUBCUTANEOUS CARTRIDGE
Tier 3 PA; SP; QL
ENBREL SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP; QL
ENBREL SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP; QL
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT
Tier 3 PA; SP; QL
Drug Name Tier Notes
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT
Tier 3 PA; SP; QL
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT
Tier 3 PA; SP; QL
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT
Tier 3 PA; SP; QL
HUMIRA SUBCUTANEOUS SYRINGE KIT
Tier 3 PA; SP; QL
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML
Tier 3 PA; SP; QL
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML
Tier 3 PA; SP; QL
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT
Tier 3 PA; SP; QL
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT
Tier 3 PA; SP; QL
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML
Tier 3 PA; SP; QL
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT
Tier 3 PA; SP; QL
SIMPONI ARIA INTRAVENOUS SOLUTION
Tier 3 PA; SP
SIMPONI SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP; QL
SIMPONI SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
ANTINEOPLASTICS
abiraterone oral tablet Tier 3 PA; SP; QL
Effective 10/1/201916
Drug Name Tier Notes
ACTIMMUNE SUBCUTANEOUS SOLUTION
Tier 3 PA; SP; LD
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION
Tier 3 PA; SP
AFINITOR ORAL TABLET
Tier 3 PA; SP
anastrozole oral tablet Tier 2 QL
bexarotene oral capsule Tier 3 PA; SP; QL
bicalutamide oral tablet Tier 2
BOSULIF ORAL TABLET Tier 3 PA; SP; QL
capecitabine oral tablet Tier 3 PA; SP
CAPRELSA ORAL TABLET
Tier 3 PA; QL
CARAC TOPICAL CREAM
Tier 2 QL
COMETRIQ ORAL CAPSULE
Tier 3 PA; LD; QL
CYCLOPHOSPHAMIDE ORAL CAPSULE
Tier 3 SP
diclofenac sodium topical gel 3 %
Tier 2 QL
EMCYT ORAL CAPSULE Tier 3 PA
ERBITUX INTRAVENOUS SOLUTION
Tier 3 PA; SP
ERIVEDGE ORAL CAPSULE
Tier 3 PA; SP; QL
erlotinib oral tablet Tier 3 PA; SP; QL
etoposide oral capsule Tier 3 SP
exemestane oral tablet Tier 2 QL
FARYDAK ORAL CAPSULE
Tier 3 PA; SP; QL
fluorouracil topical cream 5 %
Tier 1 QL
fluorouracil topical solution Tier 1 QL
flutamide oral capsule Tier 2
GILOTRIF ORAL TABLET
Tier 2 PA; SP; LD; QL
GLEOSTINE ORAL CAPSULE
Tier 3 PA
HYCAMTIN ORAL CAPSULE
Tier 3 SP
hydroxyurea oral capsule Tier 2
Drug Name Tier Notes
IBRANCE ORAL CAPSULE
Tier 3 PA; SP; QL
ICLUSIG ORAL TABLET Tier 3 PA; QL
imatinib oral tablet Tier 3 PA; SP; QL
IMBRUVICA ORAL CAPSULE
Tier 3 PA; LD; QL
IMBRUVICA ORAL TABLET
Tier 3 PA; LD; QL
INLYTA ORAL TABLET Tier 3 PA; SP; QL
INTRON A INJECTION RECON SOLN
Tier 3 SP
INTRON A INJECTION SOLUTION
Tier 3 SP
JAKAFI ORAL TABLET Tier 3 PA; SP; LD; QL
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)
Tier 3 PA; SP; LD; QL
LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3)
Tier 3 PA; SP; QL
LENVIMA ORAL CAPSULE 4 MG
Tier 3 PA; SP
letrozole oral tablet Tier 2 QL
LEUKERAN ORAL TABLET
Tier 3
leuprolide subcutaneous kit
Tier 3 PA; SP
LYNPARZA ORAL TABLET
Tier 3 PA; SP; LD; QL
LYSODREN ORAL TABLET
Tier 2 QL
MATULANE ORAL CAPSULE
Tier 3 LD
MEKINIST ORAL TABLET
Tier 3 PA; SP; QL
melphalan oral tablet Tier 3 SP
mercaptopurine oral tablet Tier 2
methotrexate sodium oral tablet
Tier 2
mitoxantrone intravenous concentrate
Tier 3 SP
Effective 10/1/201917
Drug Name Tier Notes
MYLERAN ORAL TABLET
Tier 3
NEXAVAR ORAL TABLET
Tier 3 PA; SP; QL
nilutamide oral tablet Tier 3 QL
ODOMZO ORAL CAPSULE
Tier 3 PA; SP; QL
PICATO TOPICAL GEL Tier 3 PA; QL
POMALYST ORAL CAPSULE
Tier 3 PA; SP; QL
REVLIMID ORAL CAPSULE
Tier 3 PA; SP; QL
SPRYCEL ORAL TABLET
Tier 3 PA; SP; QL
STIVARGA ORAL TABLET
Tier 3 PA; SP; QL
SUTENT ORAL CAPSULE
Tier 3 PA; SP; QL
TABLOID ORAL TABLET Tier 3
TAFINLAR ORAL CAPSULE
Tier 3 PA; SP; QL
tamoxifen oral tablet Tier 2 $0
TARGRETIN TOPICAL GEL
Tier 3 PA; SP
TASIGNA ORAL CAPSULE
Tier 3 PA; SP; QL
temozolomide oral capsule Tier 3 PA; SP; QL
toremifene oral tablet Tier 3 QL
tretinoin (chemotherapy) oral capsule
Tier 2
TYKERB ORAL TABLET Tier 2 PA; SP; QL
VOTRIENT ORAL TABLET
Tier 3 PA; SP; QL
XALKORI ORAL CAPSULE
Tier 3 PA; SP; QL
XTANDI ORAL CAPSULE Tier 3 PA; SP; QL
ZELBORAF ORAL TABLET
Tier 3 PA; SP; QL
ZOLINZA ORAL CAPSULE
Tier 3 PA; SP; QL
ZYDELIG ORAL TABLET Tier 3 PA; SP; LD; QL
ZYKADIA ORAL CAPSULE
Tier 3 PA; SP; QL
ZYTIGA ORAL TABLET500 MG
Tier 3 PA; SP; QL
Drug Name Tier Notes
ANTIPARASITICS
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
ALINIA ORAL TABLET Tier 3
crotan topical lotion Tier 2
EURAX TOPICAL CREAM
Tier 3
EURAX TOPICAL LOTION
Tier 3
lindane topical shampoo Tier 1
malathion topical lotion Tier 1
permethrin topical cream Tier 1
SKLICE TOPICAL LOTION
Tier 3
spinosad topical suspension
Tier 1
ULESFIA TOPICAL LOTION
Tier 3
ANTIPARKINSON DRUGS
amantadine hcl oral capsule
Tier 2 QL
amantadine hcl oral solution
Tier 2
amantadine hcl oral tablet Tier 2 QL
APOKYN SUBCUTANEOUS CARTRIDGE
Tier 3 SP; LD; QL
benztropine oral tablet Tier 1
bromocriptine oral capsule Tier 1
bromocriptine oral tablet Tier 1
carbidopa oral tablet Tier 2
carbidopa-levodopa oral tablet
Tier 1
carbidopa-levodopa oral tablet extended release
Tier 2
carbidopa-levodopa oral tablet,disintegrating
Tier 2
entacapone oral tablet Tier 2 QL
pramipexole oral tablet Tier 2 QL
rasagiline oral tablet Tier 2
ropinirole oral tablet Tier 1
ropinirole oral tablet extended release 24 hr
Tier 2
Effective 10/1/201918
Drug Name Tier Notes
selegiline hcl oral capsule Tier 2
selegiline hcl oral tablet Tier 2
tolcapone oral tablet Tier 2 QL
trihexyphenidyl oral elixir Tier 1
trihexyphenidyl oral tablet Tier 1
ANTIPLATELET DRUGS
anagrelide oral capsule Tier 2
aspirin-dipyridamole oral capsule, er multiphase 12 hr
Tier 2 QL
BRILINTA ORAL TABLET
Tier 3 QL
cilostazol oral tablet Tier 2
clopidogrel oral tablet 300 mg
Tier 2
clopidogrel oral tablet 75 mg
Tier 2 QL
dipyridamole oral tablet Tier 2
prasugrel oral tablet 10 mg Tier 2 QL
prasugrel oral tablet 5 mg Tier 2 DO
ANTIVIRALS
abacavir oral solution Tier 2
abacavir oral tablet Tier 2
abacavir-lamivudine oral tablet
Tier 3
abacavir-lamivudine-zidovudine oral tablet
Tier 3
acyclovir oral capsule Tier 1
acyclovir oral suspension 200 mg/5 ml
Tier 1
acyclovir oral tablet Tier 1
acyclovir topical ointment Tier 3 QL
adefovir oral tablet Tier 3 SP
APTIVUS ORAL CAPSULE
Tier 3
APTIVUS ORAL SOLUTION
Tier 3
atazanavir oral capsule Tier 3
BARACLUDE ORAL SOLUTION
Tier 3 SP
BIKTARVY ORAL TABLET
Tier 3
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 3
Drug Name Tier Notes
DENAVIR TOPICAL CREAM
Tier 3 QL
didanosine oral capsule,delayed release(dr/ec)
Tier 2
EDURANT ORAL TABLET
Tier 3
efavirenz oral capsule Tier 3
efavirenz oral tablet Tier 3
EMTRIVA ORAL CAPSULE
Tier 3
EMTRIVA ORAL SOLUTION
Tier 3
entecavir oral tablet Tier 3 SP
EPIVIR HBV ORAL SOLUTION
Tier 3 SP
EVOTAZ ORAL TABLET Tier 3
famciclovir oral tablet Tier 1
GENVOYA ORAL TABLET
Tier 3
INTELENCE ORAL TABLET
Tier 3
INVIRASE ORAL TABLET
Tier 3
ISENTRESS ORAL TABLET
Tier 2
ISENTRESS ORAL TABLET,CHEWABLE
Tier 2
KALETRA ORAL TABLET
Tier 3
lamivudine oral tablet 150 mg, 300 mg
Tier 2
lamivudine-zidovudine oral tablet
Tier 3
lopinavir-ritonavir oral solution
Tier 2
MAVYRET ORAL TABLET
Tier 3 PA; SP; QL
moderiba oral tablet Tier 2 SP
nevirapine oral suspension Tier 2
nevirapine oral tablet Tier 2
NORVIR ORAL CAPSULE
Tier 2
NORVIR ORAL SOLUTION
Tier 2
oseltamivir oral capsule Tier 2 QL
Effective 10/1/201919
Drug Name Tier Notes
oseltamivir oral suspension for reconstitution
Tier 2 QL
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML
Tier 3 SP; QL
PEGASYS SUBCUTANEOUS SOLUTION
Tier 3 SP; QL
PEGASYS SUBCUTANEOUS SYRINGE
Tier 3 SP; QL
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
Tier 3 SP
PREZISTA ORAL SUSPENSION
Tier 3
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Tier 3
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE
Tier 2 QL
RESCRIPTOR ORAL TABLET
Tier 3
ribasphere oral capsule Tier 2 SP
ribasphere oral tablet 600 mg
Tier 2 SP
ribasphere ribapak oral tablets,dose pack 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7), 600-400 mg (28)-mg (28), 600-600 mg (28)-mg (28)
Tier 2 SP
ribavirin oral capsule Tier 2 SP
ribavirin oral tablet 200 mg Tier 2 SP
rimantadine oral tablet Tier 1
ritonavir oral tablet Tier 2
SELZENTRY ORAL TABLET
Tier 3
SOFOSBUVIR-VELPATASVIR ORAL TABLET
Tier 3 PA; SP; QL
stavudine oral capsule Tier 2
STRIBILD ORAL TABLET
Tier 3
tenofovir disoproxil fumarate oral tablet
Tier 3
Drug Name Tier Notes
TIVICAY ORAL TABLET Tier 3
trifluridine ophthalmic (eye) drops
Tier 1
TRIUMEQ ORAL TABLET
Tier 3
TRUVADA ORAL TABLET
Tier 2
valacyclovir oral tablet Tier 1
valganciclovir oral recon soln
Tier 2 SP
valganciclovir oral tablet Tier 2 SP
VEREGEN TOPICAL OINTMENT
Tier 3
VIRACEPT ORAL TABLET
Tier 3
VIREAD ORAL TABLET150 MG, 200 MG, 250 MG
Tier 3
VOSEVI ORAL TABLET Tier 3 PA; SP; QL
XOFLUZA ORAL TABLET
Tier 3
zidovudine oral capsule Tier 2
zidovudine oral syrup Tier 2
zidovudine oral tablet Tier 2
ZIRGAN OPHTHALMIC (EYE) GEL
Tier 3
AUTONOMIC DRUGS
bethanechol chloride oral tablet
Tier 2
cevimeline oral capsule Tier 2
dextroamphetamine oral capsule, extended release
Tier 1 PA
dextroamphetamine oral solution
Tier 1 PA
dextroamphetamine oral tablet
Tier 1 PA
dextroamphetamine-amphetamine oral capsule,extended release 24hr
Tier 1 PA
dextroamphetamine-amphetamine oral tablet
Tier 1 PA
donepezil oral tablet Tier 2
donepezil oral tablet,disintegrating
Tier 2
epinephrine injection auto-injector
Tier 1 QL
Effective 10/1/201920
Drug Name Tier Notes
galantamine oral capsule,ext rel. pellets 24 hr
Tier 2
galantamine oral solution Tier 2
galantamine oral tablet Tier 2
guanidine oral tablet Tier 1
methamphetamine oral tablet
Tier 2 PA
midodrine oral tablet Tier 2
phenoxybenzamine oral capsule
Tier 2 QL
pilocarpine hcl oral tablet Tier 2
procentra oral solution Tier 1 PA
pyridostigmine bromide oral tablet 60 mg
Tier 2
rivastigmine tartrate oral capsule
Tier 2
SYMJEPI INJECTION SYRINGE
Tier 3 QL
zenzedi oral tablet 10 mg, 5 mg
Tier 1 PA
BIOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
AFLURIA QD 2019-20(3YR UP)(PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
AFLURIA QD 2019-20(6-35MO)(PF) INTRAMUSCULAR SYRINGE
Tier 1 $0
AFLURIA QUAD 2019-20(6MO UP) INTRAMUSCULAR SUSPENSION
Tier 1 $0
BEXSERO INTRAMUSCULAR SYRINGE
Tier 2 $0
Drug Name Tier Notes
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION
Tier 3 $0
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE
Tier 3 $0
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
FLUAD 2019-2020 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUARIX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUBLOK QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUCELVAX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUCELVAX QUAD 2019-2020 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLULAVAL QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLULAVAL QUAD 2019-2020 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUMIST QUAD 2019-2020 NASAL NASAL SPRAY SYRINGE
Tier 1 $0; QL
Effective 10/1/201921
Drug Name Tier Notes
FLUZONE HIGH-DOSE 2019-20 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUZONE QUAD 2019-2020 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE QUAD PEDI 2019-20 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION
Tier 2 $0
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
GRASTEK SUBLINGUAL TABLET
Tier 3 PA; QL
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML
Tier 3 $0
HAVRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
HIBERIX (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
HYQVIA SUBCUTANEOUS SOLUTION
Tier 3 PA; SP
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN
Tier 3
Drug Name Tier Notes
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
IPOL INJECTION SUSPENSION
Tier 3 $0
IXIARO (PF) INTRAMUSCULAR SYRINGE
Tier 3
KINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
KINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
MENACTRA (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT
Tier 3 $0
M-M-R II (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
PENTACEL (PF) INTRAMUSCULAR KIT
Tier 3 $0
PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
PNEUMOVAX 23 INJECTION SOLUTION
Tier 2 $0
PNEUMOVAX 23 INJECTION SYRINGE
Tier 2 $0
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
Effective 10/1/201922
Drug Name Tier Notes
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 3
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3 $0
ROTATEQ VACCINE ORAL SOLUTION
Tier 3 $0
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 2 $0
SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 2 $0
TENIVAC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TRUMENBA INTRAMUSCULAR SYRINGE
Tier 2 $0
TWINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TYPHIM VI INTRAMUSCULAR SOLUTION
Tier 3
TYPHIM VI INTRAMUSCULAR SYRINGE
Tier 3
Drug Name Tier Notes
VAQTA (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
VAQTA (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 2 $0
BLOOD
DROXIA ORAL CAPSULE
Tier 3
pentoxifylline oral tablet extended release
Tier 1
tranexamic acid oral tablet Tier 1
CARDIAC DRUGS
afeditab cr oral tablet extended release 30 mg
Tier 2 DO
afeditab cr oral tablet extended release 60 mg
Tier 2 QL
amiodarone oral tablet Tier 1
amlodipine oral tablet 10 mg
Tier 1 QL
amlodipine oral tablet 2.5 mg, 5 mg
Tier 1 DO
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
cartia xt oral capsule,extended release 24hr 240 mg, 300 mg
Tier 1 QL
digox oral tablet Tier 1
digoxin oral solution 50 mcg/ml
Tier 1
digoxin oral tablet Tier 1
Effective 10/1/201923
Drug Name Tier Notes
diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 12 hr
Tier 2 QL
diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg
Tier 1 QL
diltiazem hcl oral tablet Tier 1 QL
diltiazem hcl oral tablet extended release 24 hr 180 mg
Tier 1 DO
diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg
Tier 1 DO
dilt-xr oral capsule,ext.rel 24h degradable 240 mg
Tier 1 QL
disopyramide phosphate oral capsule
Tier 2
dofetilide oral capsule Tier 2
felodipine oral tablet extended release 24 hr 10 mg
Tier 1 QL
felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg
Tier 1 DO
flecainide oral tablet Tier 2
isosorbide dinitrate oral tablet
Tier 1
Drug Name Tier Notes
isosorbide dinitrate oral tablet extended release
Tier 1
isosorbide mononitrate oral tablet
Tier 1
isosorbide mononitrate oral tablet extended release 24 hr
Tier 1
isradipine oral capsule Tier 1 QL
LANOXIN ORAL TABLET Tier 3
matzim la oral tablet extended release 24 hr 180 mg
Tier 1 DO
matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
mexiletine oral capsule Tier 2
MULTAQ ORAL TABLET Tier 3
nicardipine oral capsule Tier 2 QL
nifedipine oral capsule Tier 2 QL
nifedipine oral tablet extended release 24hr 30 mg
Tier 2 DO
nifedipine oral tablet extended release 24hr 60 mg, 90 mg
Tier 2 QL
nifedipine oral tablet extended release 30 mg
Tier 2 DO
nifedipine oral tablet extended release 60 mg, 90 mg
Tier 2 QL
nimodipine oral capsule Tier 2 QL
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg
Tier 1 DO
nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg
Tier 1 QL
nitro-bid transdermal ointment
Tier 1
nitroglycerin oral capsule, extended release
Tier 2
nitroglycerin sublingual tablet
Tier 1
nitroglycerin translingual spray,non-aerosol
Tier 2
Effective 10/1/201924
Drug Name Tier Notes
nitro-time oral capsule, extended release
Tier 1
pacerone oral tablet 100 mg, 200 mg, 400 mg
Tier 2
propafenone oral capsule,extended release 12 hr
Tier 2
propafenone oral tablet Tier 2
quinidine sulfate oral tablet Tier 1
ranolazine oral tablet extended release 12 hr
Tier 2
taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg
Tier 1 DO
taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg
Tier 1 QL
verapamil oral capsule, 24 hr er pellet ct 100 mg
Tier 1 DO
verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg
Tier 1 QL
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg
Tier 1 DO
verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg
Tier 1 QL
verapamil oral tablet Tier 1 QL
verapamil oral tablet extended release
Tier 1 QL
CARDIOVASCULAR
acebutolol oral capsule Tier 1
ADEMPAS ORAL TABLET
Tier 3 PA; SP; LD; QL
aliskiren oral tablet 150 mg
Tier 2 DO
aliskiren oral tablet 300 mg
Tier 2 QL
ambrisentan oral tablet Tier 3 PA; SP; LD; QL
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg
Tier 1 QL
Drug Name Tier Notes
amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg
Tier 1 DO
amlodipine-benazepril oral capsule
Tier 1
atenolol oral tablet Tier 1
atenolol-chlorthalidone oral tablet
Tier 1
atorvastatin oral tablet 10 mg, 20 mg
Tier 1 DO; $0
atorvastatin oral tablet 40 mg
Tier 1 DO
atorvastatin oral tablet 80 mg
Tier 1 QL
benazepril oral tablet Tier 1
benazepril-hydrochlorothiazide oral tablet
Tier 1
betaxolol oral tablet Tier 1
bisoprolol fumarate oral tablet
Tier 1
bisoprolol-hydrochlorothiazide oral tablet
Tier 1
bosentan oral tablet Tier 3 SP; QL
BYSTOLIC ORAL TABLET
Tier 3
candesartan oral tablet Tier 1 QL
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg
Tier 1 QL
candesartan-hydrochlorothiazid oral tablet 32-25 mg
Tier 1
captopril oral tablet Tier 2
captopril-hydrochlorothiazide oral tablet
Tier 2
carvedilol oral tablet Tier 1
cholestyramine (with sugar) oral powder
Tier 2 QL
cholestyramine (with sugar) oral powder in packet
Tier 2 QL
cholestyramine light oral powder
Tier 2 QL
Effective 10/1/201925
Drug Name Tier Notes
cholestyramine light oral powder in packet
Tier 2
clonidine hcl oral tablet Tier 1
colesevelam oral powder in packet
Tier 2
colesevelam oral tablet Tier 2
colestipol oral granules Tier 1
colestipol oral packet Tier 1
colestipol oral tablet Tier 1
doxazosin oral tablet Tier 1
EDARBI ORAL TABLET40 MG
Tier 3 DO
EDARBI ORAL TABLET80 MG
Tier 3 QL
enalapril maleate oral tablet
Tier 1
enalapril-hydrochlorothiazide oral tablet
Tier 1
eprosartan oral tablet Tier 1 QL
ergoloid oral tablet Tier 2
ezetimibe oral tablet Tier 2 PA; QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 1
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1 QL
fenofibrate nanocrystallized oral tablet 145 mg, 48 mg
Tier 1 QL
fenofibrate oral tablet 160 mg, 54 mg
Tier 1 QL
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
Tier 1 QL
fenofibric acid oral tablet Tier 1 QL
fluvastatin oral capsule Tier 1 DO; $0
fluvastatin oral tablet extended release 24 hr
Tier 1 $0
fosinopril oral tablet Tier 1
fosinopril-hydrochlorothiazide oral tablet
Tier 1
gemfibrozil oral tablet Tier 1
guanfacine oral tablet Tier 1
hydralazine oral tablet Tier 1
Drug Name Tier Notes
irbesartan oral tablet 150 mg, 75 mg
Tier 1 DO
irbesartan oral tablet 300 mg
Tier 1 QL
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg
Tier 1 QL
irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg
Tier 1
labetalol oral tablet Tier 1
LEVATOL ORAL TABLET
Tier 3
lisinopril oral tablet Tier 1
lisinopril-hydrochlorothiazide oral tablet
Tier 1
LIVALO ORAL TABLET 1 MG, 2 MG
Tier 3 ST; DO
LIVALO ORAL TABLET 4 MG
Tier 3 ST; QL
losartan oral tablet Tier 1 QL
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg
Tier 1 QL
losartan-hydrochlorothiazide oral tablet 50-12.5 mg
Tier 1 DO
lovastatin oral tablet 10 mg, 20 mg
Tier 1 DO; $0
lovastatin oral tablet 40 mg
Tier 1 $0; QL
methyldopa oral tablet Tier 1
methyldopa-hydrochlorothiazide oral tablet
Tier 1
metoprolol succinate oral tablet extended release 24 hr
Tier 1
metoprolol ta-hydrochlorothiaz oral tablet
Tier 1
metoprolol tartrate oral tablet
Tier 1
minoxidil oral tablet Tier 1
moexipril oral tablet Tier 1
nadolol oral tablet Tier 2
Effective 10/1/201926
Drug Name Tier Notes
nadolol-bendroflumethiazide oral tablet 80-5 mg
Tier 1
niacin oral tablet extended release 24 hr
Tier 1 QL
olmesartan oral tablet 20 mg
Tier 2 DO
olmesartan oral tablet 40 mg, 5 mg
Tier 2 QL
perindopril erbumine oral tablet
Tier 1
pindolol oral tablet Tier 2
pravastatin oral tablet 10 mg, 20 mg
Tier 1 DO; $0
pravastatin oral tablet 40 mg
Tier 1 $0
pravastatin oral tablet 80 mg
Tier 1 $0; QL
prazosin oral capsule Tier 1
prevalite oral powder Tier 2 QL
prevalite oral powder in packet
Tier 2
propranolol oral capsule,extended release 24 hr
Tier 1
propranolol oral solution Tier 1
propranolol oral tablet Tier 1
propranolol-hydrochlorothiazid oral tablet
Tier 1
quinapril oral tablet Tier 1
quinapril-hydrochlorothiazide oral tablet
Tier 1
ramipril oral capsule Tier 1
rosuvastatin oral tablet 10 mg, 5 mg
Tier 2 DO; $0
rosuvastatin oral tablet 20 mg
Tier 2 DO
rosuvastatin oral tablet 40 mg
Tier 2 QL
sildenafil (antihypertensive) oral tablet
Tier 2 PA; SP; QL
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1 DO; $0
Drug Name Tier Notes
simvastatin oral tablet 80 mg
Tier 1 PA; QL
sorine oral tablet Tier 2
sotalol af oral tablet Tier 2
sotalol oral tablet Tier 2
tadalafil (antihypertensive) oral tablet
Tier 3 PA; SP; QL
telmisartan oral tablet 20 mg, 40 mg
Tier 1 DO
telmisartan oral tablet 80 mg
Tier 1 QL
terazosin oral capsule Tier 1
timolol maleate oral tablet Tier 1
trandolapril oral tablet Tier 1
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg
Tier 1 DO
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg
Tier 1 QL
treprostinil sodium injection solution
Tier 3 SP
valsartan oral tablet Tier 1 QL
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg
Tier 1 DO
valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg
Tier 1 QL
VECAMYL ORAL TABLET
Tier 3
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
Tier 3 PA; SP; LD; QL
CNS DRUGS
APTIOM ORAL TABLET Tier 3
BANZEL ORAL SUSPENSION
Tier 3
BANZEL ORAL TABLET Tier 3
carbamazepine oral capsule, er multiphase 12 hr
Tier 1
carbamazepine oral suspension 100 mg/5 ml
Tier 1
Effective 10/1/201927
Drug Name Tier Notes
carbamazepine oral tablet Tier 1
carbamazepine oral tablet extended release 12 hr
Tier 1
carbamazepine oral tablet,chewable
Tier 1
CELONTIN ORAL CAPSULE 300 MG
Tier 3
clobazam oral suspension Tier 2
clobazam oral tablet Tier 2
clonazepam oral tablet Tier 1
clonazepam oral tablet,disintegrating
Tier 1
DIASTAT ACUDIAL RECTAL KIT
Tier 2 QL
DIASTAT RECTAL KIT Tier 2 QL
diazepam rectal kit Tier 2 QL
divalproex oral capsule, delayed rel sprinkle
Tier 2
divalproex oral tablet extended release 24 hr
Tier 2
divalproex oral tablet,delayed release (dr/ec)
Tier 2
epitol oral tablet Tier 1
ethosuximide oral capsule Tier 1
ethosuximide oral solution Tier 1
EXTAVIA SUBCUTANEOUS KIT
Tier 3 PA; SP
EXTAVIA SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP
felbamate oral suspension Tier 2
felbamate oral tablet Tier 2
FYCOMPA ORAL TABLET
Tier 3
gabapentin oral capsule Tier 2
gabapentin oral solution Tier 2
gabapentin oral tablet 600 mg, 800 mg
Tier 2
GILENYA ORAL CAPSULE 0.5 MG
Tier 3 PA; SP; QL
glatiramer subcutaneous syringe
Tier 3 PA; SP
glatopa subcutaneous syringe
Tier 3 PA; SP
Drug Name Tier Notes
HORIZANT ORAL TABLET EXTENDED RELEASE
Tier 3 PA; QL
lamotrigine oral tablet Tier 1
lamotrigine oral tablet, chewable dispersible
Tier 1
levetiracetam oral solution Tier 2
levetiracetam oral tablet Tier 2
levetiracetam oral tablet extended release 24 hr
Tier 2
memantine oral solution Tier 2
memantine oral tablet Tier 2
memantine oral tablets,dose pack
Tier 2
NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK
Tier 2
oxcarbazepine oral suspension
Tier 2
oxcarbazepine oral tablet Tier 2
PEGANONE ORAL TABLET
Tier 3
phenytoin sodium extended oral capsule
Tier 1
PLEGRIDY SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP
PLEGRIDY SUBCUTANEOUS SYRINGE
Tier 3 PA; SP
pregabalin oral capsule Tier 2 PA; QL
pregabalin oral solution Tier 2 PA; QL
primidone oral tablet Tier 1
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
Tier 2 PA; SP
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
Tier 2 PA; SP
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
Tier 2 PA; SP
tetrabenazine oral tablet Tier 2 PA; SP; LD
tiagabine oral tablet Tier 2
topiramate oral capsule, sprinkle
Tier 1
topiramate oral tablet Tier 1
Effective 10/1/201928
Drug Name Tier Notes
valproic acid (as sodium salt) oral solution
Tier 1
valproic acid oral capsule Tier 1
vigabatrin oral powder in packet
Tier 2 SP; LD
vigabatrin oral tablet Tier 2 SP
VIMPAT ORAL SOLUTION
Tier 3
VIMPAT ORAL TABLET Tier 3
zonisamide oral capsule Tier 2
COLONY STIMULATING FACTORS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION
Tier 3 PA; SP
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
Tier 3 PA; SP
NEULASTA SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR
Tier 3 PA; SP; QL
NEUPOGEN INJECTION SOLUTION
Tier 3 PA; SP
NEUPOGEN INJECTION SYRINGE
Tier 3 PA; SP
PROCRIT INJECTION SOLUTION
Tier 3 PA; SP
PROMACTA ORAL TABLET
Tier 3 PA; SP
CONTRACEPTIVES
AFIRMELLE ORAL TABLET
Tier 1 $0
altavera (28) oral tablet Tier 1 $0
alyacen 1/35 (28) oral tablet
Tier 1 $0
alyacen 7/7/7 (28) oral tablet
Tier 1 $0
amethia lo oral tablets,dose pack,3 month
Tier 1 $0
amethia oral tablets,dose pack,3 month
Tier 1 $0
amethyst (28) oral tablet Tier 1 $0
apri oral tablet Tier 1 $0
Drug Name Tier Notes
aranelle (28) oral tablet Tier 1 $0
ashlyna oral tablets,dose pack,3 month
Tier 1 $0
aubra eq oral tablet Tier 1 $0
aubra oral tablet Tier 1 $0
AUROVELA 1.5/30 (21) ORAL TABLET
Tier 1 $0
AUROVELA 1/20 (21) ORAL TABLET
Tier 1 $0
AUROVELA 24 FE ORAL TABLET
Tier 1 $0
AUROVELA FE 1.5/30 (28) ORAL TABLET
Tier 1 $0
AUROVELA FE 1-20 (28) ORAL TABLET
Tier 1 $0
aviane oral tablet Tier 1 $0
AYUNA ORAL TABLET Tier 1 $0
azurette (28) oral tablet Tier 1 $0
BALCOLTRA ORAL TABLET
Tier 3 $0
balziva (28) oral tablet Tier 1 $0
BEKYREE (28) ORAL TABLET
Tier 1 $0
BLISOVI 24 FE ORAL TABLET
Tier 1 $0
BLISOVI FE 1.5/30 (28) ORAL TABLET
Tier 1 $0
BLISOVI FE 1/20 (28) ORAL TABLET
Tier 1 $0
briellyn oral tablet Tier 1 $0
camila oral tablet Tier 1 $0
camrese lo oral tablets,dose pack,3 month
Tier 1 $0
camrese oral tablets,dose pack,3 month
Tier 1 $0
CAYA CONTOURED VAGINAL DIAPHRAGM
Tier 3 $0
caziant (28) oral tablet Tier 1 $0
chateal (28) oral tablet Tier 1 $0
chateal eq (28) oral tablet Tier 1 $0
cryselle (28) oral tablet Tier 1 $0
cyclafem 1/35 (28) oral tablet
Tier 1 $0
cyclafem 7/7/7 (28) oral tablet
Tier 1 $0
Effective 10/1/201929
Drug Name Tier Notes
cyred eq oral tablet Tier 1 $0
cyred oral tablet Tier 1 $0
dasetta 1/35 (28) oral tablet
Tier 1 $0
dasetta 7/7/7 (28) oral tablet
Tier 1 $0
daysee oral tablets,dose pack,3 month
Tier 1 $0
deblitane oral tablet Tier 1 $0
delyla (28) oral tablet Tier 1 $0
desog-e.estradiol/e.estradiol oral tablet
Tier 1 $0
desogestrel-ethinyl estradiol oral tablet
Tier 1 $0
drospirenone-e.estradiol-lm.fa oral tablet
Tier 1 $0
drospirenone-ethinyl estradiol oral tablet
Tier 1 $0
econtra one-step oral tablet
Tier 1 $0; QL
elinest oral tablet Tier 1 $0
ELLA ORAL TABLET Tier 3 $0
emoquette oral tablet Tier 1 $0
enpresse oral tablet Tier 1 $0
enskyce oral tablet Tier 1 $0
errin oral tablet Tier 1 $0
estarylla oral tablet Tier 1 $0
ethynodiol diac-eth estradiol oral tablet
Tier 1 $0
falmina (28) oral tablet Tier 1 $0
FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1 $0
FEMCAP VAGINAL DEVICE
Tier 3 $0
FEMYNOR ORAL TABLET
Tier 1 $0
gianvi (28) oral tablet Tier 1 $0
hailey 24 fe oral tablet Tier 1 $0
HAILEY ORAL TABLET Tier 1 $0
heather oral tablet Tier 1 $0
incassia oral tablet Tier 1 $0
introvale oral tablets,dose pack,3 month
Tier 1 $0
Drug Name Tier Notes
isibloom oral tablet Tier 1 $0
jasmiel (28) oral tablet Tier 1 $0
jencycla oral tablet Tier 1 $0
jolessa oral tablets,dose pack,3 month
Tier 1 $0
JULEBER ORAL TABLET
Tier 1 $0
junel 1.5/30 (21) oral tablet Tier 1 $0
junel 1/20 (21) oral tablet Tier 1 $0
junel fe 1.5/30 (28) oral tablet
Tier 1 $0
junel fe 1/20 (28) oral tablet
Tier 1 $0
junel fe 24 oral tablet Tier 1 $0
KAITLIB FE ORAL TABLET,CHEWABLE
Tier 1 $0
KALLIGA ORAL TABLET Tier 1 $0
kariva (28) oral tablet Tier 1 $0
kelnor 1/35 (28) oral tablet Tier 1 $0
kelnor 1-50 oral tablet Tier 1 $0
kurvelo (28) oral tablet Tier 1 $0
l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month
Tier 1 $0
larin 1.5/30 (21) oral tablet Tier 1 $0
larin 1/20 (21) oral tablet Tier 1 $0
larin 24 fe oral tablet Tier 1 $0
larin fe 1.5/30 (28) oral tablet
Tier 1 $0
larin fe 1/20 (28) oral tablet
Tier 1 $0
LARISSIA ORAL TABLET
Tier 1 $0
layolis fe oral tablet,chewable
Tier 1 $0
leena 28 oral tablet Tier 1 $0
lessina oral tablet Tier 1 $0
levonest (28) oral tablet Tier 1 $0
levonorgestrel oral tablet 1.5 mg
Tier 1 $0; QL
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg
Tier 1 $0
Effective 10/1/201930
Drug Name Tier Notes
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (28)
Tier 1 $0
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
Tier 1 $0
levonorg-eth estrad triphasic oral tablet
Tier 1 $0
levora-28 oral tablet Tier 1 $0
lillow (28) oral tablet Tier 1 $0
LO LOESTRIN FE ORAL TABLET
Tier 3 $0
loryna (28) oral tablet Tier 1 $0
low-ogestrel (28) oral tablet
Tier 1 $0
LO-ZUMANDIMINE (28) ORAL TABLET
Tier 1 $0
lutera (28) oral tablet Tier 1 $0
lyza oral tablet Tier 1 $0
marlissa (28) oral tablet Tier 1 $0
medroxyprogesterone intramuscular suspension
Tier 1 $0
medroxyprogesterone intramuscular syringe
Tier 1 $0
MELODETTA 24 FE ORAL TABLET,CHEWABLE
Tier 1 $0
MIBELAS 24 FE ORAL TABLET,CHEWABLE
Tier 1 $0
microgestin 1.5/30 (21) oral tablet
Tier 1 $0
microgestin 1/20 (21) oral tablet
Tier 1 $0
microgestin fe 1.5/30 (28) oral tablet
Tier 1 $0
microgestin fe 1/20 (28) oral tablet
Tier 1 $0
mili oral tablet Tier 1 $0
mono-linyah oral tablet Tier 1 $0
my way oral tablet Tier 1 $0; QL
NATAZIA ORAL TABLET Tier 3 $0
necon 0.5/35 (28) oral tablet
Tier 1 $0
next choice one dose oral tablet
Tier 1 $0; QL
nikki (28) oral tablet Tier 1 $0
Drug Name Tier Notes
nora-be oral tablet Tier 1 $0
noreth-ethinyl estradiol-iron oral tablet,chewable
Tier 1 $0
norethindrone (contraceptive) oral tablet
Tier 1 $0
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg
Tier 1 $0
norethindrone-e.estradiol-iron oral tablet
Tier 1 $0
norethindrone-e.estradiol-iron oral tablet,chewable
Tier 1 $0
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)
Tier 1 $0
norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg
Tier 1 $0
norgestrel-ethinyl estradiol oral tablet
Tier 1 $0
NORLYDA ORAL TABLET
Tier 1 $0
norlyroc oral tablet Tier 1 $0
nortrel 0.5/35 (28) oral tablet
Tier 1 $0
nortrel 1/35 (21) oral tablet Tier 1 $0
nortrel 1/35 (28) oral tablet Tier 1 $0
nortrel 7/7/7 (28) oral tablet
Tier 1 $0
NUVARING VAGINAL RING
Tier 3 $0
ocella oral tablet Tier 1 $0
ogestrel (28) oral tablet Tier 1 $0
option-2 oral tablet Tier 1 $0; QL
orsythia oral tablet Tier 1 $0
philith oral tablet Tier 1 $0
pimtrea (28) oral tablet Tier 1 $0
pirmella oral tablet Tier 1 $0
PLAN B ONE-STEP ORAL TABLET
Tier 1 $0; QL
portia 28 oral tablet Tier 1 $0
previfem oral tablet Tier 1 $0
RAJANI ORAL TABLET Tier 1 $0
reclipsen (28) oral tablet Tier 1 $0
Effective 10/1/201931
Drug Name Tier Notes
RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1 $0
setlakin oral tablets,dose pack,3 month
Tier 1 $0
sharobel oral tablet Tier 1 $0
SIMLIYA (28) ORAL TABLET
Tier 1 $0
SIMPESSE ORAL TABLETS,DOSE PACK,3 MONTH
Tier 1 $0
SLYND ORAL TABLET Tier 3 $0
sprintec (28) oral tablet Tier 1 $0
sronyx oral tablet Tier 1 $0
syeda oral tablet Tier 1 $0
TARINA 24 FE ORAL TABLET
Tier 1 $0
tarina fe 1/20 (28) oral tablet
Tier 1 $0
tarina fe 1-20 eq (28) oral tablet
Tier 1 $0
TAYTULLA ORAL CAPSULE
Tier 3 $0
tilia fe oral tablet Tier 1 $0
TRI FEMYNOR ORAL TABLET
Tier 1 $0
tri-estarylla oral tablet Tier 1 $0
tri-legest fe oral tablet Tier 1 $0
tri-linyah oral tablet Tier 1 $0
TRI-LO-ESTARYLLA ORAL TABLET
Tier 1 $0
TRI-LO-MARZIA ORAL TABLET
Tier 1 $0
TRI-LO-MILI ORAL TABLET
Tier 1 $0
TRI-LO-SPRINTEC ORAL TABLET
Tier 1 $0
tri-mili oral tablet Tier 1 $0
tri-previfem (28) oral tablet Tier 1 $0
tri-sprintec (28) oral tablet Tier 1 $0
trivora (28) oral tablet Tier 1 $0
tri-vylibra lo oral tablet Tier 1 $0
tri-vylibra oral tablet Tier 1 $0
tulana oral tablet Tier 1 $0
tydemy oral tablet Tier 1 $0
Drug Name Tier Notes
velivet triphasic regimen (28) oral tablet
Tier 1 $0
VIENVA ORAL TABLET Tier 1 $0
viorele (28) oral tablet Tier 1 $0
vyfemla (28) oral tablet Tier 1 $0
vylibra oral tablet Tier 1 $0
wera (28) oral tablet Tier 1 $0
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM
Tier 3 $0
WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM
Tier 3 $0
wymzya fe oral tablet,chewable
Tier 1 $0
xulane transdermal patch weekly
Tier 1 $0
zarah oral tablet Tier 1 $0
zenchent (28) oral tablet Tier 1 $0
zovia 1/35e (28) oral tablet Tier 1 $0
ZUMANDIMINE (28) ORAL TABLET
Tier 1 $0
COUGH/COLD PREPARATIONS
benzonatate oral capsule 100 mg, 200 mg
Tier 1
codeine-guaifen 10-100 mg/5 ml (otc)
Tier 1 PA
Effective 10/1/201932
Drug Name Tier Notes
codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)
Tier 1 PA
g tussin ac oral liquid Tier 1 PA
guaiatussin ac oral liquid Tier 1 PA
guaifen-codeine 100-10 mg/5 ml (otc)
Tier 1 PA
guaifen-codeine 100-10 mg/5 ml inner (otc)
Tier 1 PA
guaifen-codeine 100-10 mg/5 ml outer (otc)
Tier 1 PA
guaifen-codeine 200-20 mg/10 ml inner (otc)
Tier 1 PA
guaifen-codeine 200-20 mg/10 ml outer (otc)
Tier 1 PA
guaifenesin ac oral liquid Tier 1 PA
guaifenesin-codeine syrup (otc)
Tier 1 PA
guaifenesin-codeine syrup (otc)
Tier 1 PA
hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr
Tier 1
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
Tier 1
promethazine-codeine oral syrup
Tier 1 PA
promethazine-dm oral syrup
Tier 1
promethazine-phenyleph-codeine oral syrup
Tier 1 PA
TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR
Tier 3 PA
virtussin ac oral liquid Tier 1 PA
DIAGNOSTIC
ACCU-CHEK AVIVA PLUS TEST STRP STRIP
Tier 2 QL
ACCU-CHEK COMPACT PLUS TEST STRIP
Tier 2 QL
ACCU-CHEK GUIDE STRIP
Tier 2 QL
ACCU-CHEK SMARTVIEW TEST STRIP STRIP
Tier 2 QL
ACCUTREND GLUCOSE STRIP
Tier 2 QL
Drug Name Tier Notes
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN
Tier 2
GLUCAGON HCL INJECTION RECON SOLN
Tier 2
ONETOUCH VERIO STRIP
Tier 2 QL
DIURETICS
acetazolamide oral capsule, extended release
Tier 1
acetazolamide oral tablet Tier 1
amiloride oral tablet Tier 2
AMMONIUM CHLORIDE INTRAVENOUS SOLUTION
Tier 3
bumetanide oral tablet Tier 1
chlorothiazide oral tablet Tier 1
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
DYRENIUM ORAL CAPSULE
Tier 3
eplerenone oral tablet Tier 2
ethacrynic acid oral tablet Tier 2
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
Tier 1
furosemide oral tablet Tier 1
hydrochlorothiazide oral capsule
Tier 1
hydrochlorothiazide oral tablet
Tier 1
indapamide oral tablet Tier 1
methazolamide oral tablet Tier 2
methyclothiazide oral tablet
Tier 1
metolazone oral tablet Tier 1
SAMSCA ORAL TABLET Tier 3 SP; LD
spironolactone oral tablet Tier 1
torsemide oral tablet Tier 1
triamterene oral capsule Tier 2
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg
Tier 1
Effective 10/1/201933
Drug Name Tier Notes
triamterene-hydrochlorothiazid oral tablet
Tier 1
EENT PREPS
acetic acid otic (ear) solution
Tier 1
ALOCRIL OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
ALOMIDE OPHTHALMIC (EYE) DROPS
Tier 3 PA; QL
apraclonidine ophthalmic (eye) drops
Tier 1
azelastine nasal aerosol,spray
Tier 1 QL
AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
betaxolol ophthalmic (eye) drops
Tier 1
bimatoprost ophthalmic (eye) drops
Tier 2
brimonidine ophthalmic (eye) drops
Tier 1
bromfenac ophthalmic (eye) drops
Tier 2
carteolol ophthalmic (eye) drops
Tier 1
COMBIGAN OPHTHALMIC (EYE) DROPS
Tier 3
cromolyn ophthalmic (eye) drops
Tier 1 QL
dexamethasone sodium phosphate ophthalmic (eye) drops
Tier 1
diclofenac sodium ophthalmic (eye) drops
Tier 1
dorzolamide ophthalmic (eye) drops
Tier 1
dorzolamide-timolol ophthalmic (eye) drops
Tier 1
DUREZOL OPHTHALMIC (EYE) DROPS
Tier 3 QL
DYMISTA NASAL SPRAY,NON-AEROSOL
Tier 3 QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
Tier 1 ST; QL
Drug Name Tier Notes
fluocinolone acetonide oil otic (ear) drops
Tier 1
fluorometholone ophthalmic (eye) drops,suspension
Tier 1
flurbiprofen sodium ophthalmic (eye) drops
Tier 1
fluticasone propionate nasal spray,suspension
Tier 1 QL
FML S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
hydrocortisone-acetic acid otic (ear) drops
Tier 1
ketorolac ophthalmic (eye) drops
Tier 1
LACRISERT OPHTHALMIC (EYE) INSERT
Tier 3
latanoprost ophthalmic (eye) drops
Tier 1
levobunolol ophthalmic (eye) drops 0.5 %
Tier 1
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL
Tier 3
LOTEMAX OPHTHALMIC (EYE) OINTMENT
Tier 3
loteprednol etabonate ophthalmic (eye) drops,suspension
Tier 2
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
Tier 3
metipranolol ophthalmic (eye) drops
Tier 1
NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
olopatadine nasal spray,non-aerosol
Tier 1 QL
OMNARIS NASAL SPRAY,NON-AEROSOL
Tier 3 ST; QL
PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS
Tier 3
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
Tier 1
prednisolone acetate ophthalmic (eye) drops,suspension
Tier 1
Effective 10/1/201934
Drug Name Tier Notes
prednisolone sodium phosphate ophthalmic (eye) drops
Tier 1
SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION
Tier 3
timolol maleate ophthalmic (eye) drops
Tier 1
timolol maleate ophthalmic (eye) gel forming solution
Tier 1
TRAVATAN Z OPHTHALMIC (EYE) DROPS
Tier 3
tropicamide ophthalmic (eye) drops
Tier 1
TYZINE NASAL DROPS0.05 %
Tier 3
XIIDRA OPHTHALMIC (EYE) DROPPERETTE
Tier 3 PA; QL
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE
Tier 3
ELECT/CALORIC/H2O
calcium acetate oral tablet 667 mg
Tier 2
dentagel dental gel Tier 1
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
Tier 3
effer-k oral tablet, effervescent 25 meq
Tier 1
fe c plus oral tablet Tier 1
fluoride (sodium) dental gel
Tier 1
fluoride (sodium) oral drops
Tier 1 $0
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
fluoridex daily defense dental paste
Tier 1
Drug Name Tier Notes
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
FOSRENOL ORAL POWDER IN PACKET
Tier 3 PA
GLUCAGEN HYPOKIT INJECTION RECON SOLN
Tier 2
GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN
Tier 2
klor-con 10 oral tablet extended release
Tier 1
klor-con 8 oral tablet extended release
Tier 1
klor-con m10 oral tablet,er particles/crystals
Tier 1
klor-con m15 oral tablet,er particles/crystals
Tier 1
klor-con m20 oral tablet,er particles/crystals
Tier 1
klor-con/ef oral tablet, effervescent
Tier 1
lanthanum oral tablet,chewable
Tier 2
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
Tier 1 $0
ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
NUTRAMINE ORAL POWDER
Tier 3
potassium chloride oral capsule, extended release
Tier 1
potassium chloride oral tablet extended release
Tier 1
potassium chloride oral tablet,er particles/crystals
Tier 1
potassium citrate oral tablet extended release
Tier 2
potassium citrate-citric acid oral solution
Tier 1
Effective 10/1/201935
Drug Name Tier Notes
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE
Tier 3
PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE
Tier 3
PREVIDENT DENTAL GEL
Tier 3
sevelamer carbonate oral powder in packet
Tier 1
sevelamer carbonate oral tablet
Tier 1
sf dental gel Tier 1
sodium chloride 0.45 % intravenous parenteral solution
Tier 1
sodium chloride 0.45 % intravenous piggyback
Tier 1
sodium chloride 0.9 % injection solution
Tier 1
sodium chloride 0.9 % intravenous parenteral solution
Tier 1
sodium chloride 0.9 % intravenous piggyback
Tier 1
sodium chloride 3 % intravenous parenteral solution
Tier 1
sodium chloride 5 % intravenous parenteral solution
Tier 1
sodium chloride intravenous parenteral solution 2.5 meq/ml
Tier 1
sodium polystyrene sulfonate oral powder
Tier 2
sodium polystyrene sulfonate oral suspension
Tier 2
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
Tier 1
sps (with sorbitol) oral suspension
Tier 2
sps (with sorbitol) rectal enema
Tier 1
SSKI ORAL SOLUTION Tier 3
VELPHORO ORAL TABLET,CHEWABLE
Tier 3 PA
Drug Name Tier Notes
XURIDEN ORAL GRANULES IN PACKET
Tier 3 PA; LD; QL
GASTROINTESTINAL
alosetron oral tablet Tier 2 QL
AMITIZA ORAL CAPSULE
Tier 3
anaspaz oral tablet,disintegrating
Tier 2
aprepitant oral capsule Tier 2 QL
aprepitant oral capsule,dose pack
Tier 2 QL
APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR
Tier 3 QL
balsalazide oral capsule Tier 1 QL
carafate oral suspension Tier 1
CESAMET ORAL CAPSULE
Tier 3
CHOLBAM ORAL CAPSULE
Tier 3 PA; LD; QL
cimetidine hcl oral solution Tier 1
cimetidine oral tablet Tier 1
COMPAZINE ORAL TABLET
Tier 1
constulose oral solution Tier 1
DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS
Tier 3 PA; QL
dicyclomine oral capsule Tier 1
dicyclomine oral solution Tier 1
dicyclomine oral tablet Tier 1
DIPENTUM ORAL CAPSULE
Tier 3 QL
diphenoxylate-atropine oral liquid
Tier 1
diphenoxylate-atropine oral tablet
Tier 1
dronabinol oral capsule Tier 2
enulose oral solution Tier 1
famotidine oral suspension Tier 1
famotidine oral tablet 20 mg, 40 mg
Tier 1
fish oil ec 1,000 mg softgel Tier 1
gavilyte-c oral recon soln Tier 1 $0
gavilyte-g oral recon soln Tier 1 $0
Effective 10/1/201936
Drug Name Tier Notes
gavilyte-n oral recon soln Tier 1 $0
generlac oral solution Tier 1
glycopyrrolate oral tablet Tier 1
granisetron hcl oral tablet Tier 2 QL
hydrocortisone-pramoxine rectal cream 1-1 %
Tier 1
hyoscyamine sulfate oral tablet extended release 12 hr
Tier 1
lactulose oral solution Tier 1
lansoprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
LINZESS ORAL CAPSULE
Tier 2
meclizine oral tablet 12.5 mg, 25 mg
Tier 1
mesalamine with cleansing wipe rectal enema kit
Tier 2 QL
methscopolamine oral tablet
Tier 1
metoclopramide hcl oral solution
Tier 1
metoclopramide hcl oral tablet
Tier 1
metoclopramide hcl oral tablet,disintegrating
Tier 1
misoprostol oral tablet Tier 1
MOTOFEN ORAL TABLET
Tier 3
MOVIPREP ORAL POWDER IN PACKET
Tier 3
nizatidine oral capsule Tier 1
nizatidine oral solution Tier 1
omega-3 acid ethyl esters oral capsule
Tier 1 QL
omeprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
ondansetron hcl oral solution
Tier 2 QL
ondansetron hcl oral tablet Tier 2 QL
ondansetron oral tablet,disintegrating
Tier 2 QL
OSMOPREP ORAL TABLET
Tier 3
Drug Name Tier Notes
pantoprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
peg 3350-electrolytes oral recon soln
Tier 1 $0
peg-3350 with flavor packs oral recon soln
Tier 1 $0
peg-electrolyte soln oral recon soln
Tier 1 $0
peg-prep oral kit Tier 1 $0
phenadoz rectal suppository
Tier 2
polyethylene glycol 3350 oral powder
Tier 1 $0
polyethylene glycol 3350 oral powder in packet
Tier 1 $0
PREPOPIK ORAL POWDER IN PACKET
Tier 3
prochlorperazine maleate oral tablet
Tier 1
promethazine rectal suppository
Tier 2
promethegan rectal suppository
Tier 2
rabeprazole oral tablet,delayed release (dr/ec)
Tier 2 QL
ranitidine hcl oral capsule Tier 1
ranitidine hcl oral syrup Tier 1
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1
RECTIV RECTAL OINTMENT
Tier 3
SANCUSO TRANSDERMAL PATCH WEEKLY
Tier 3 QL
scopolamine base transdermal patch 3 day
Tier 2
sodium phenylbutyrate oral tablet
Tier 2 PA; QL
sucralfate oral tablet Tier 1
sulfasalazine oral tablet Tier 1 QL
sulfasalazine oral tablet,delayed release (dr/ec)
Tier 1 QL
SUPREP BOWEL PREP KIT ORAL RECON SOLN
Tier 3
Effective 10/1/201937
Drug Name Tier Notes
trilyte with flavor packets oral recon soln
Tier 1 $0
trimethobenzamide oral capsule
Tier 1
ursodiol oral capsule Tier 2
ursodiol oral tablet Tier 2
VARUBI ORAL TABLET Tier 3 QL
VASCEPA ORAL CAPSULE
Tier 3 QL
VIBERZI ORAL TABLET Tier 3 PA; QL
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT
Tier 2
HORMONES
AMABELZ ORAL TABLET
Tier 1
ANADROL-50 ORAL TABLET
Tier 3
budesonide oral capsule,delayed,extend.release
Tier 2 QL
cabergoline oral tablet Tier 1
calcitonin (salmon) nasal spray,non-aerosol
Tier 2 QL
chorionic gonadotropin, human injection recon soln
Tier 3 SP
chorionic gonadotropin, human intramuscular recon soln
Tier 3 PA; SP
cortisone oral tablet Tier 1
danazol oral capsule Tier 2
decadron oral elixir Tier 1
desmopressin nasal spray with pump
Tier 2
desmopressin nasal spray,non-aerosol
Tier 2
desmopressin oral tablet Tier 1
Drug Name Tier Notes
dexamethasone intensol oral drops
Tier 1
dexamethasone oral elixir Tier 1
dexamethasone oral solution
Tier 1
dexamethasone oral tablet Tier 1
DUAVEE ORAL TABLET Tier 3 QL
estradiol oral tablet Tier 1
estradiol transdermal patch semiweekly
Tier 1 QL
estradiol transdermal patch weekly
Tier 1
estradiol vaginal cream Tier 2
estradiol vaginal tablet Tier 2 QL
estradiol-norethindrone acet oral tablet
Tier 1
ESTRING VAGINAL RING
Tier 3 QL
fludrocortisone oral tablet Tier 1
GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP
GONAL-F RFF SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP
GONAL-F SUBCUTANEOUS RECON SOLN
Tier 3 PA; SP
hydrocortisone oral tablet Tier 1
hydrocortisone rectal enema
Tier 2
jinteli oral tablet Tier 1
LOPREEZA ORAL TABLET
Tier 1
LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET
Tier 3 PA; SP; QL
LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET
Tier 3 PA; SP; QL
medroxyprogesterone oral tablet
Tier 1 QL
MENEST ORAL TABLET Tier 3
METHITEST ORAL TABLET
Tier 3
methylergonovine oral tablet
Tier 1
Effective 10/1/201938
Drug Name Tier Notes
methylprednisolone oral tablet
Tier 1
methylprednisolone oral tablets,dose pack
Tier 1
millipred dp oral tablets,dose pack
Tier 1
millipred oral tablet Tier 1
mimvey lo oral tablet Tier 1
mimvey oral tablet Tier 1
norethindrone acetate oral tablet
Tier 1
NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP
oxandrolone oral tablet Tier 2 PA
prednisolone oral solution 15 mg/5 ml
Tier 1
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
Tier 1
prednisone intensol oral concentrate
Tier 1
prednisone oral solution Tier 1
prednisone oral tablet Tier 1
prednisone oral tablets,dose pack
Tier 1
PREMARIN ORAL TABLET
Tier 3 QL
PREMARIN VAGINAL CREAM
Tier 3 QL
PREMPHASE ORAL TABLET
Tier 3
PREMPRO ORAL TABLET
Tier 3
progesterone micronized oral capsule
Tier 1 QL
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON
Tier 3 PA; SP; QL
Drug Name Tier Notes
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG, 30 MG
Tier 3 PA; SP; QL
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 40 MG, 60 MG
Tier 3 PA; SP; LD; QL
SIGNIFOR SUBCUTANEOUS SOLUTION
Tier 3 PA; SP; LD; QL
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
SYNAREL NASAL SPRAY,NON-AEROSOL
Tier 3 PA; SP; QL
testosterone 12.5 mg/1.25 gram
Tier 2 PA; QL
testosterone 12.5 mg/1.25 gram outer
Tier 2 PA; QL
testosterone 50 mg/5 gram pkt
Tier 2 PA; QL
testosterone 50 mg/5 gram pkt inner
Tier 2 PA; QL
testosterone 50 mg/5 gram pkt outer
Tier 2 PA; QL
testosterone cypionate intramuscular oil
Tier 1
testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %)
Tier 2 PA; QL
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)
Tier 2 PA; QL
veripred 20 oral solution Tier 1
YUVAFEM VAGINAL TABLET
Tier 2 QL
IMMUNOSUPPRESSANTS
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP; QL
ACTEMRA INTRAVENOUS SOLUTION
Tier 3 PA; SP
Effective 10/1/201939
Drug Name Tier Notes
ACTEMRA SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
azathioprine oral tablet Tier 2
cyclosporine modified oral capsule
Tier 2 SP
cyclosporine modified oral solution
Tier 2 SP
cyclosporine oral capsule Tier 2 SP
gengraf oral capsule 100 mg, 25 mg
Tier 3 SP
gengraf oral solution Tier 3 SP
mycophenolate mofetil oral capsule
Tier 3 SP
mycophenolate mofetil oral tablet
Tier 3 SP
mycophenolate sodium oral tablet,delayed release (dr/ec)
Tier 3 SP
pimecrolimus topical cream
Tier 1 PA
sirolimus oral solution Tier 3 SP
STELARA INTRAVENOUS SOLUTION
Tier 3 PA; SP; QL
STELARA SUBCUTANEOUS SOLUTION
Tier 3 PA; SP; QL
STELARA SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
tacrolimus oral capsule Tier 3 SP
tacrolimus topical ointment Tier 1 PA
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG
ACCU-CHEK AVIVA CONTROL SOLN SOLUTION
Tier 2
ACCU-CHEK AVIVA PLUS METER
Tier 2
ACCU-CHEK COMP BLUE CONT, M-H SOLUTION
Tier 2
ACCU-CHEK COMPACT PLUS CARE KIT
Tier 2
Drug Name Tier Notes
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
Tier 2
ACCU-CHEK FASTCLIX LANCING DEV KIT
Tier 2
ACCU-CHEK GUIDE GLUCOSE METER
Tier 2
ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION
Tier 2
ACCU-CHEK GUIDE ME GLUCOSE MTR
Tier 2
ACCU-CHEK MULTICLIX LANCET
Tier 2
ACCU-CHEK MULTICLIX LANCET KIT
Tier 2
ACCU-CHEK NANO Tier 2
ACCU-CHEK SAFE-T-PRO PLUS
Tier 2
ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION
Tier 2
ACCU-CHEK SOFT DEV LANCETS KIT
Tier 2
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 2
ACCU-CHEK SOFTCLIX LANCETS
Tier 2
ACCU-CHEK VOICEMATE KIT
Tier 2
ACCUTREND GLUCOSE CONTROL SOLUTION
Tier 2
acti-lance lancets 17 gauge, 28 gauge
Tier 1
CHEMSTRIP BG LOG BOOK
Tier 2
e-z ject lancets Tier 1
E-Z JECT THIN LANCETS
Tier 1
insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"
Tier 1
ONETOUCH DELICA LANC DEVICE KIT
Tier 2
ONETOUCH DELICA LANCETS
Tier 2
ONETOUCH ULTRA CONTROL SOLUTION
Tier 2
Effective 10/1/201940
Drug Name Tier Notes
ONETOUCH ULTRA2 METER
Tier 2
ONETOUCH ULTRA2 METER KIT
Tier 2
ONETOUCH ULTRAMINI KIT
Tier 2
ONETOUCH ULTRASOFT LANCETS
Tier 2
ONETOUCH VERIO FLEX
Tier 2
ONETOUCH VERIO HIGH CONTROL SOLUTION
Tier 2
ONETOUCH VERIO IQ METER
Tier 2
ONETOUCH VERIO MID CONTROL SOLUTION
Tier 2
ONETOUCH VERIO SYSTEM
Tier 2
thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"
Tier 1
MUSCLE RELAXANTS
baclofen oral tablet 10 mg, 20 mg
Tier 2
carisoprodol oral tablet Tier 1
chlorzoxazone oral tablet Tier 1
cyclobenzaprine oral tablet Tier 1
dantrolene oral capsule Tier 2
metaxalone oral tablet Tier 1
methocarbamol oral tablet Tier 1
orphenadrine citrate oral tablet extended release
Tier 1
tizanidine oral capsule Tier 1
tizanidine oral tablet Tier 1
PRE-NATAL VITAMINS
bal-care dha oral combo pack,tablet and cap,dr
Tier 1
c-nate dha oral capsule Tier 1
complete natal dha oral combo pack
Tier 1
completenate oral tablet,chewable
Tier 1
elite ob with dha oral capsule
Tier 1
elite-ob 400 oral capsule Tier 1
Drug Name Tier Notes
ELITE-OB ORAL TABLET
Tier 1
folivane-ob oral capsule Tier 1
hemenatal ob + dha oral combo pack
Tier 1
hemenatal ob oral tablet Tier 1
mynatal advance oral tablet
Tier 1
mynatal oral capsule Tier 1
mynatal oral tablet Tier 1
mynatal plus oral tablet Tier 1
mynatal-z oral tablet Tier 1
mynate 90 plus oral tablet extended release
Tier 1
obstetrix dha oral combo pack,tablet and cap,dr
Tier 1
pnv ob+dha oral combo pack 27-1-50-250 mg
Tier 1
pnv-dha + docusate oral capsule
Tier 1
pnv-ferrous fumarate-docu-fa oral tablet
Tier 1
pnv-omega oral capsule Tier 1
pr natal 400 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 400 oral combo pack
Tier 1
pr natal 430 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 430 oral combo pack
Tier 1
prenaissance oral capsule Tier 1
prenaissance plus oral capsule
Tier 1
prenatabs fa oral tablet Tier 1
prenatabs rx oral tablet Tier 1
prenatal 19 (with docusate) oral tablet
Tier 1
prenatal low iron oral tablet
Tier 1
prenatal multivitamin tablet Tier 1 $0
PRENATAL ONE DAILY ORAL TABLET
Tier 1 $0
prenatal plus (calcium carb) oral tablet
Tier 1
prenatal plus oral tablet Tier 1
Effective 10/1/201941
Drug Name Tier Notes
prenatal vitamin plus low iron
Tier 1
prenatal-u oral capsule Tier 1
preplus oral tablet Tier 1
se-natal 19 (with docusate) oral tablet
Tier 1
se-natal 19 oral tablet,chewable
Tier 1
taron-c dha oral capsule Tier 1
taron-prex prenatal-dha oral capsule
Tier 1
tl-select oral capsule Tier 1
triadvance oral tablet Tier 1
trinatal rx 1 oral tablet Tier 1
trinate oral tablet Tier 1
triveen-duo dha oral combo pack
Tier 1
triveen-one oral capsule Tier 1
triveen-prx rnf oral capsule Tier 1
trust natal dha oral combo pack
Tier 1
vena-bal dha oral combo pack,tablet and cap,dr
Tier 1
vinacal oral tablet Tier 1
vinate care oral tablet,chewable
Tier 1
vinate gt oral tablet Tier 1
vinate ii oral tablet Tier 1
vinate m oral tablet Tier 1
vinate one oral tablet Tier 1
vinate pn care oral tablet Tier 1
vinate ultra oral tablet Tier 1
VIRT-NATE DHA ORAL CAPSULE
Tier 1
virt-pn dha oral capsule Tier 1
virt-pn plus oral capsule Tier 1
virt-select oral capsule Tier 1
vitafol-ob oral tablet Tier 1
vp-ch plus oral capsule Tier 1
vp-ch-pnv oral capsule Tier 1
zatean-pn dha oral capsule
Tier 1
zatean-pn plus oral capsule
Tier 1
Drug Name Tier Notes
zingiber oral tablet Tier 1
PSYCHOTHERAPEUTIC DRUGS
ADDYI ORAL TABLET Tier 3 PA; QL
alprazolam oral tablet Tier 1
amitriptyline oral tablet Tier 1
amoxapine oral tablet Tier 1
aripiprazole oral solution Tier 2
aripiprazole oral tablet Tier 2
armodafinil oral tablet 150 mg, 250 mg, 50 mg
Tier 2 PA; QL
armodafinil oral tablet 200 mg
Tier 2 PA
atomoxetine oral capsule Tier 2 PA
bupropion hcl oral tablet 100 mg
Tier 1 QL
bupropion hcl oral tablet 75 mg
Tier 1 DO
bupropion hcl oral tablet extended release 24 hr 150 mg
Tier 1 DO
bupropion hcl oral tablet extended release 24 hr 300 mg
Tier 1 QL
bupropion hcl oral tablet sustained-release 12 hr 100 mg
Tier 1 DO
bupropion hcl oral tablet sustained-release 12 hr 150 mg
Tier 1 $0
bupropion hcl oral tablet sustained-release 12 hr 200 mg
Tier 1
buspirone oral tablet Tier 1
chlorpromazine oral tablet Tier 2
citalopram oral solution Tier 1 QL
citalopram oral tablet 10 mg, 20 mg
Tier 1 DO
citalopram oral tablet 40 mg
Tier 1 QL
clomipramine oral capsule Tier 2
clonidine hcl oral tablet extended release 12 hr
Tier 1 PA
clozapine oral tablet Tier 2
Effective 10/1/201942
Drug Name Tier Notes
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
Tier 2
desipramine oral tablet Tier 2
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg
Tier 1 QL
desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg
Tier 1 DO
dexmethylphenidate oral capsule,er biphasic 50-50
Tier 1 PA
dexmethylphenidate oral tablet
Tier 1 PA
diazepam intensol oral concentrate
Tier 1
diazepam oral concentrate Tier 1
diazepam oral solution Tier 1
diazepam oral tablet Tier 1
doxepin oral capsule Tier 1
doxepin oral concentrate Tier 1
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg
Tier 2 QL
duloxetine oral capsule,delayed release(dr/ec) 30 mg
Tier 2 DO
EMSAM TRANSDERMAL PATCH 24 HOUR
Tier 3
escitalopram oxalate oral solution
Tier 1 QL
escitalopram oxalate oral tablet 10 mg, 5 mg
Tier 1 DO
escitalopram oxalate oral tablet 20 mg
Tier 1 QL
FANAPT ORAL TABLET Tier 3
FANAPT ORAL TABLETS,DOSE PACK
Tier 3
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
Tier 3 ST; QL
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR
Tier 3 ST; QL
fluoxetine oral capsule 10 mg, 20 mg
Tier 1 DO
Drug Name Tier Notes
fluoxetine oral capsule 40 mg
Tier 1 QL
fluoxetine oral capsule,delayed release(dr/ec)
Tier 1 QL
fluoxetine oral solution Tier 1 QL
fluoxetine oral tablet 10 mg
Tier 1 DO
fluoxetine oral tablet 20 mg
Tier 1
fluphenazine hcl oral concentrate
Tier 1
fluphenazine hcl oral elixir Tier 1
fluphenazine hcl oral tablet Tier 1
fluvoxamine oral tablet 100 mg
Tier 1 QL
fluvoxamine oral tablet 25 mg, 50 mg
Tier 1 DO
guanfacine oral tablet extended release 24 hr
Tier 1 PA
haloperidol oral tablet Tier 1
imipramine hcl oral tablet Tier 1
LATUDA ORAL TABLET Tier 3
lithium carbonate oral capsule
Tier 1
lithium carbonate oral tablet
Tier 1
lithium carbonate oral tablet extended release
Tier 1
lithium citrate oral solution Tier 1
loxapine succinate oral capsule
Tier 1
maprotiline oral tablet Tier 1
MARPLAN ORAL TABLET
Tier 3
meprobamate oral tablet Tier 1
metadate er oral tablet extended release
Tier 1 PA
methylphenidate hcl oral capsule, er biphasic 30-70
Tier 1 PA
methylphenidate hcl oral capsule,er biphasic 50-50
Tier 1 PA
methylphenidate hcl oral solution
Tier 1 PA
methylphenidate hcl oral tablet
Tier 1 PA
Effective 10/1/201943
Drug Name Tier Notes
methylphenidate hcl oral tablet extended release
Tier 1 PA
methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg
Tier 1 PA
mirtazapine oral tablet Tier 1
mirtazapine oral tablet,disintegrating
Tier 1
modafinil oral tablet 100 mg
Tier 2 PA; DO
modafinil oral tablet 200 mg
Tier 2 PA; QL
nefazodone oral tablet Tier 1
nortriptyline oral capsule Tier 1
nortriptyline oral solution Tier 1
olanzapine oral tablet Tier 2
olanzapine oral tablet,disintegrating
Tier 2
oxazepam oral capsule Tier 2
paliperidone oral tablet extended release 24hr
Tier 2
paroxetine hcl oral tablet 10 mg, 20 mg
Tier 1 DO
paroxetine hcl oral tablet 30 mg, 40 mg
Tier 1 QL
paroxetine hcl oral tablet extended release 24 hr 12.5 mg
Tier 1 DO
paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg
Tier 1 QL
perphenazine oral tablet Tier 1
phenelzine oral tablet Tier 1
pimozide oral tablet Tier 2
protriptyline oral tablet Tier 2
quetiapine oral tablet Tier 2
quetiapine oral tablet extended release 24 hr
Tier 2
risperidone oral solution Tier 1
risperidone oral tablet Tier 1
risperidone oral tablet,disintegrating
Tier 2
SAPHRIS SUBLINGUAL TABLET
Tier 3
sertraline oral concentrate Tier 1 QL
Drug Name Tier Notes
sertraline oral tablet 100 mg
Tier 1 QL
sertraline oral tablet 25 mg, 50 mg
Tier 1 DO
thioridazine oral tablet Tier 1
thiothixene oral capsule Tier 1
tranylcypromine oral tablet Tier 1
trazodone oral tablet Tier 1
trifluoperazine oral tablet Tier 1
trimipramine oral capsule Tier 1
TRINTELLIX ORAL TABLET 10 MG, 5 MG
Tier 3 ST; DO
TRINTELLIX ORAL TABLET 20 MG
Tier 3 ST; QL
venlafaxine oral capsule,extended release 24hr 150 mg
Tier 1 QL
venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
venlafaxine oral tablet Tier 1 QL
VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 150 MG, 225 MG
Tier 1 QL
venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
VIIBRYD ORAL TABLET10 MG, 20 MG
Tier 3 ST; DO
VIIBRYD ORAL TABLET40 MG
Tier 3 ST; QL
VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)
Tier 3 ST; QL
VYVANSE ORAL CAPSULE
Tier 3 PA
VYVANSE ORAL TABLET,CHEWABLE
Tier 3 PA
ziprasidone hcl oral capsule
Tier 2
SEDATIVE/HYPNOTICS
estazolam oral tablet Tier 1
eszopiclone oral tablet 1 mg, 2 mg
Tier 1 QL
eszopiclone oral tablet 3 mg
Tier 1 PA; QL
Effective 10/1/201944
Drug Name Tier Notes
HETLIOZ ORAL CAPSULE
Tier 3 PA; SP; LD; QL
phenobarbital oral elixir Tier 1
phenobarbital oral tablet Tier 1
ramelteon oral tablet Tier 2 ST; QL
SILENOR ORAL TABLET Tier 3 QL
XYREM ORAL SOLUTION
Tier 3 PA; SP; LD; QL
zaleplon oral capsule Tier 1 QL
zolpidem oral tablet Tier 1 QL
SKIN PREPS
acitretin oral capsule Tier 2
adapalene topical cream Tier 1
adapalene topical gel Tier 1
adapalene topical gel with pump
Tier 1
adapalene-benzoyl peroxide topical gel with pump
Tier 2
alclometasone topical cream
Tier 1
alclometasone topical ointment
Tier 1
ALTABAX TOPICAL OINTMENT
Tier 3
amcinonide topical cream Tier 1
amcinonide topical lotion Tier 1
amcinonide topical ointment
Tier 1
ammonium lactate topical cream
Tier 1
ammonium lactate topical lotion
Tier 1
amnesteem oral capsule Tier 2 PA
avita topical cream Tier 1 PA
azelaic acid topical gel Tier 2
AZELEX TOPICAL CREAM
Tier 3 PA
benzoyl peroxide topical cleanser 3 %, 6 %, 9 %
Tier 1
benzoyl peroxide topical foam 5.3 %
Tier 1
betamethasone dipropionate topical cream
Tier 1
Drug Name Tier Notes
betamethasone dipropionate topical lotion
Tier 1
betamethasone dipropionate topical ointment
Tier 1
betamethasone valerate topical cream
Tier 1
betamethasone valerate topical foam
Tier 1
betamethasone valerate topical lotion
Tier 1
betamethasone valerate topical ointment
Tier 1
betamethasone, augmented topical cream
Tier 1
betamethasone, augmented topical gel
Tier 1
betamethasone, augmented topical lotion
Tier 1
betamethasone, augmented topical ointment
Tier 1
bpo topical gel Tier 1
bpo topical towelette 6 % Tier 1
calcipotriene scalp solution
Tier 1
calcipotriene topical cream Tier 1
calcipotriene topical ointment
Tier 1
calcipotriene-betamethasone topical ointment
Tier 1
calcitrene topical ointment Tier 1
calcitriol topical ointment Tier 1
claravis oral capsule Tier 2 PA
clindamycin-benzoyl peroxide topical gel
Tier 1
clindamycin-benzoyl peroxide topical gel with pump 1-5 %
Tier 1
clindamycin-tretinoin topical gel
Tier 2
clobetasol scalp solution Tier 1
clobetasol topical cream Tier 1
clobetasol topical foam Tier 1
clobetasol topical gel Tier 1
Effective 10/1/201945
Drug Name Tier Notes
clobetasol topical lotion Tier 1
clobetasol topical ointment Tier 1
clobetasol topical shampoo
Tier 1
clobetasol-emollient topical cream
Tier 1
clobetasol-emollient topical foam
Tier 1
CLODERM TOPICAL CREAM
Tier 3
CORDRAN TAPE LARGE ROLL TOPICAL TAPE
Tier 3
cormax scalp solution Tier 1
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP; QL
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP; QL
COSENTYX SUBCUTANEOUS SYRINGE
Tier 3 PA; SP; QL
dapsone topical gel Tier 2
desonide topical cream Tier 1
desonide topical lotion Tier 1
desonide topical ointment Tier 1
desoximetasone topical cream
Tier 1
desoximetasone topical gel
Tier 1
desoximetasone topical ointment
Tier 1
diclofenac sodium topical gel 1 %
Tier 2 QL
diflorasone topical cream Tier 1
diflorasone topical ointment
Tier 1
FLECTOR TRANSDERMAL PATCH 12 HOUR
Tier 3 QL
fluocinolone and shower cap scalp oil
Tier 1
fluocinolone topical cream Tier 1
Drug Name Tier Notes
fluocinolone topical oil Tier 1
fluocinolone topical ointment
Tier 1
fluocinolone topical solution
Tier 1
fluocinonide topical cream Tier 1
fluocinonide topical gel Tier 1
fluocinonide topical ointment
Tier 1
fluocinonide topical solution
Tier 1
fluocinonide-e topical cream
Tier 1
fluocinonide-emollient topical cream
Tier 1
flurandrenolide topical cream
Tier 2
flurandrenolide topical lotion
Tier 2
fluticasone propionate topical cream
Tier 1
fluticasone propionate topical lotion
Tier 1
fluticasone propionate topical ointment
Tier 1
halcinonide topical cream Tier 2
halobetasol propionate topical cream
Tier 1
halobetasol propionate topical ointment
Tier 1
HALOG TOPICAL CREAM
Tier 3
HALOG TOPICAL OINTMENT
Tier 3
hydrocortisone butyrate topical cream
Tier 1
hydrocortisone butyrate topical lotion
Tier 1
hydrocortisone butyrate topical ointment
Tier 1
hydrocortisone butyrate topical solution
Tier 1
hydrocortisone butyr-emollient topical cream
Tier 1
hydrocortisone topical cream 2.5 %
Tier 1
Effective 10/1/201946
Drug Name Tier Notes
hydrocortisone topical cream with perineal applicator
Tier 1
hydrocortisone topical lotion 2.5 %
Tier 1
hydrocortisone topical ointment 2.5 %
Tier 1
hydrocortisone valerate topical cream
Tier 1
hydrocortisone valerate topical ointment
Tier 1
hydrocortisone-iodoquinol topical cream
Tier 1
imiquimod topical cream in packet
Tier 1 PA; QL
methoxsalen oral capsule,liqd-filled,rapid rel
Tier 2 SP
metronidazole topical cream
Tier 1
metronidazole topical gel Tier 1
metronidazole topical gel with pump
Tier 1
metronidazole topical lotion
Tier 1
MIRVASO TOPICAL GEL Tier 3
MIRVASO TOPICAL GEL WITH PUMP
Tier 3
mometasone topical cream
Tier 1
mometasone topical ointment
Tier 1
mometasone topical solution
Tier 1
OVACE TOPICAL CLEANSER
Tier 3
PHYSIOLYTE IRRIGATION SOLUTION
Tier 3
podofilox topical solution Tier 1
prednicarbate topical cream
Tier 1
prednicarbate topical ointment
Tier 1
proctosol hc topical cream with perineal applicator
Tier 1
proctozone-hc topical cream with perineal applicator
Tier 1
Drug Name Tier Notes
prudoxin topical cream Tier 2
REGRANEX TOPICAL GEL
Tier 3
rosadan topical cream Tier 1
ROSADAN TOPICAL GEL
Tier 1
salicylic acid topical cream Tier 1
salicylic acid topical cream,extended release
Tier 1
salicylic acid topical foam Tier 1
salicylic acid topical gel Tier 1
salicylic acid topical liquid 26 %
Tier 1
salicylic acid topical lotion Tier 1
salicylic acid topical lotion,extended release
Tier 1
salicylic acid topical shampoo
Tier 1
salvax topical foam Tier 1
SANTYL TOPICAL OINTMENT
Tier 3
selenium sulfide topical lotion
Tier 1
selenium sulfide topical shampoo 2.25 %
Tier 1
sodium chloride irrigation solution
Tier 1
sulfacetamide sodium (acne) topical suspension
Tier 1
sulfacetamide sodium topical cleanser
Tier 1
SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL
Tier 1
sulfacetamide sodium topical shampoo
Tier 1
tazarotene topical cream Tier 2
TAZORAC TOPICAL CREAM 0.05 %
Tier 3
TAZORAC TOPICAL GEL Tier 3
tretinoin (emollient) topical cream
Tier 1 PA
tretinoin topical cream Tier 1 PA
tretinoin topical gel 0.01 %, 0.025 %
Tier 1 PA
Effective 10/1/201947
Drug Name Tier Notes
triamcinolone acetonide topical cream
Tier 1
triamcinolone acetonide topical lotion
Tier 1
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
Tier 1
trianex topical ointment Tier 1
triderm topical cream 0.1 %
Tier 1
TRIDERM TOPICAL CREAM 0.5 %
Tier 1
zenatane oral capsule Tier 2 PA
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet extended release 12 hr
Tier 1 $0; QL
CHANTIX CONTINUING MONTH BOX ORAL TABLET
Tier 3 $0; QL
CHANTIX ORAL TABLET Tier 3 $0; QL
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK
Tier 3 $0; QL
NICOTROL INHALATION CARTRIDGE
Tier 3 $0
NICOTROL NS NASAL SPRAY,NON-AEROSOL
Tier 3 $0
THYROID PREPS
ARMOUR THYROID ORAL TABLET
Tier 1
levothyroxine oral tablet Tier 1
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1
liothyronine oral tablet Tier 1
methimazole oral tablet 10 mg, 5 mg
Tier 1
nature-throid oral tablet Tier 1
NP THYROID ORAL TABLET 120 MG, 15 MG
Tier 1
np thyroid oral tablet 30 mg, 60 mg, 90 mg
Tier 1
propylthiouracil oral tablet Tier 1
Drug Name Tier Notes
SYNTHROID ORAL TABLET
Tier 1
THYROLAR-1 ORAL TABLET
Tier 3
THYROLAR-1/2 ORAL TABLET
Tier 3
THYROLAR-1/4 ORAL TABLET
Tier 3
THYROLAR-2 ORAL TABLET
Tier 3
THYROLAR-3 ORAL TABLET
Tier 3
unithroid oral tablet Tier 1
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
Tier 1
WP THYROID ORAL TABLET
Tier 1
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral tablet,delayed release (dr/ec)
Tier 2 QL
alendronate oral solution Tier 1
alendronate oral tablet Tier 1 QL
alfuzosin oral tablet extended release 24 hr
Tier 1
BERINERT INTRAVENOUS KIT
Tier 3 PA; LD
BERINERT INTRAVENOUS RECON SOLN
Tier 3 PA; LD
buprenorphine hcl sublingual tablet
Tier 2 QL
buprenorphine-naloxone sublingual tablet
Tier 1 QL
CARBAGLU ORAL TABLET, DISPERSIBLE
Tier 3 LD
CHEMET ORAL CAPSULE
Tier 3
chlorhexidine gluconate mucous membrane mouthwash
Tier 1
cinacalcet oral tablet 30 mg, 60 mg
Tier 2 PA; QL
cinacalcet oral tablet 90 mg
Tier 2 PA
Effective 10/1/201948
Drug Name Tier Notes
CYSTADANE ORAL POWDER
Tier 3 LD
darifenacin oral tablet extended release 24 hr
Tier 2 ST
DEBACTEROL MUCOUS MEMBRANE SOLUTION
Tier 3
DEBACTEROL MUCOUS MEMBRANE SWAB
Tier 3
disulfiram oral tablet Tier 1
doxercalciferol oral capsule
Tier 2
doxycycline hyclate oral tablet 20 mg
Tier 1
dutasteride oral capsule Tier 2
etidronate disodium oral tablet
Tier 2
FERRIPROX ORAL TABLET 500 MG
Tier 3 PA; LD
finasteride oral tablet Tier 1
flavoxate oral tablet Tier 1
FORTEO SUBCUTANEOUS PEN INJECTOR
Tier 3 PA; SP; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT
Tier 3 ST; QL
FOSAMAX PLUS D ORAL TABLET 70 MG- 5,600 UNIT
Tier 3 ST
ibandronate oral tablet Tier 1 QL
KALYDECO ORAL GRANULES IN PACKET25 MG
Tier 3 PA; SP; QL
KALYDECO ORAL GRANULES IN PACKET50 MG, 75 MG
Tier 3 PA; SP; LD; QL
KALYDECO ORAL TABLET
Tier 3 PA; SP; LD; QL
KUVAN ORAL TABLET,SOLUBLE
Tier 3 PA; SP; LD
leucovorin calcium oral tablet
Tier 2
levocarnitine (with sugar) oral solution
Tier 1
levocarnitine oral tablet Tier 2
miglustat oral capsule Tier 3 PA; SP
Drug Name Tier Notes
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
NYSTATIN (BULK) POWDER 150 MILLION UNIT
Tier 1
OFEV ORAL CAPSULE Tier 3 PA; SP; LD; QL
oralone dental paste Tier 1
ORFADIN ORAL CAPSULE
Tier 3 PA; LD
OSPHENA ORAL TABLET
Tier 3 QL
oxybutynin chloride oral syrup
Tier 1
oxybutynin chloride oral tablet
Tier 1
oxybutynin chloride oral tablet extended release 24hr
Tier 1
paricalcitol oral capsule Tier 2
paroex oral rinse mucous membrane mouthwash
Tier 1
periogard mucous membrane mouthwash
Tier 1
raloxifene oral tablet Tier 1 $0
risedronate oral tablet Tier 1 QL
SAVELLA ORAL TABLET
Tier 2 QL
SAVELLA ORAL TABLETS,DOSE PACK
Tier 2 QL
SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION
Tier 2 $0
sildenafil oral tablet Tier 1 PA; QL
silodosin oral capsule Tier 2
solifenacin oral tablet Tier 2
tadalafil oral tablet 2.5 mg, 5 mg
Tier 1 PA; QL
tamsulosin oral capsule Tier 1
tolterodine oral tablet Tier 1
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3
triamcinolone acetonide dental paste
Tier 1
trientine oral capsule Tier 2 SP
Effective 10/1/201949
Drug Name Tier Notes
trospium oral capsule,extended release 24hr
Tier 2
VITAMINS
calcitriol oral capsule Tier 1
calcitriol oral solution Tier 2
cyanocobalamin (vitamin b-12) injection solution
Tier 1
ergocalciferol (vitamin d2) oral capsule 50,000 unit
Tier 1
folic acid oral tablet 1 mg Tier 1
multi-vitamin with fluoride oral drops
Tier 3 $0
multivitamin with fluoride oral tablet,chewable
Tier 3 $0
multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 3 $0
multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 3 $0
mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 3 $0
triple vitamin with fluoride oral drops
Tier 3 $0
tri-vitamin with fluoride oral drops
Tier 3 $0
tri-vite with fluoride oral drops
Tier 3 $0
vitamin d2 oral capsule Tier 1
vitamins a,c,d and fluoride oral drops
Tier 3 $0
Effective 10/1/201950
Effective 10/1/201951