Preferred Drug List 1Q14

Transcription

Preferred Drug
List
1Q14
What Pharmacy Benefits Do I Have?
You employer has chosen either a 2-tier;
3-tier or 4-tier Prescription Drug Plan
with an open formulary. This means
that your plan covers medications that
are on the Preferred Drug List – also
known as a formulary, as well as many
others that are not. Your plan many not
cover certain medications, even though
some may be listed on the Preferred
Drug List. Please see the plan
documents provided by your employer
for a complete description of your
pharmacy benefit, or call the Member
Services number on your ID card.
The tiers identify the number of number
or the level of your covered medications.
CoPay/Tier
Tier 1
Tier 2
Tier 3
Tier 4
Description
Covered preferred generic
(formulary) medications.
Covered preferred brand
name (formulary)
medications
Covered non-preferred
generic and brand (nonformulary) medications
Preferred and NonPreferred self-injectable
drugs covered by your
plan. Insulin is excluded
in Tier 4 and will be in
either tiers 2 or 3.
All plans have a “mandatory generic”
substitution policy that requires a
generic drug be dispensed when
available, unless otherwise specified by
the prescribing doctor. If you have a 3Tier plan, if the brand name drugs with a
generic available is dispensed you will
be responsible for your tier-3 co-pay.
Please review the plan benefits provided
by your employer to determine how and
or if any cost-sharing requirements for
brand name drugs with a generic apply
to you.
What is a Preferred Drug List (PDL)?
The PDL is a list of preferred drugs
which have been approved by the Food
and Drug Administration (FDA), and are
considered safe and cost effective. The
drug list includes brand name and
generic medications and is updated
regularly. Drug on the PDL are
generally covered as long as the drug is
medically necessary and plan rules are
followed. Coverage is not limited to
drugs on the Preferred Drug List.
The Preferred Drug List is subject to
change. We choose drugs for the PDL
based upon medical necessity, safety and
cost.
How is the Preferred Drug List
Developed and Who Decides What Is
Covered?
The 4D Pharmacy-Preferred Drug List
features FDA-approved medications that
are considered safe and cost-effective. It
includes both brand-name and generic
medications. We choose drugs for the
Preferred Drug List based on reliable
medical data, safety and cost.
A Pharmacy and Therapeutics (P&T)
Committee meets regularly to review
new drugs and new information about
drugs already on the market. This
committee reviews available information
concerning safety, effectiveness and
current use in therapy. They also review
the scientific evidence from several
databases, including relevant findings of
Federal government agencies,
A
pharmaceutical manufacturers, medical
professional associations, national
commissions and peer-reviewed
journals.
follow your doctor's advice, even if a
prescribed drug is not covered.
Why does the Preferred Drug List
Change?
Changes to the Preferred Drug List.
The Preferred Drug List is updated on an
ongoing basis. Drugs can be added to or
removed from the Preferred Drug List at
any time. We might also move a drug
from one coverage tier to another.
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As brand-name medications lose
their patents and generic versions
become available, the brandname medication may be covered
at a higher copayment while the
generic medication may be
covered at a lower copayment.
The FDA approves many new
medications throughout the year.
Medications can be withdrawn
from the market or may become
available without a prescription.
Over-the-counter (OTC) drugs
are not generally covered under a
prescription plan.
Some plans do not cover non-preferred
("formulary excluded") drugs. Other
plans may cover them, but at more cost
to you. Also, there may be some specific
drugs listed on the Preferred Drug List
that your plan does not cover, such as
contraceptives, infertility medications,
erectile dysfunction medications and
diabetic supplies.
You and your doctor are responsible for
making the final decision about what
medications you need to take. If you are
taking a drug that is not covered or nonpreferred, ask your doctor about
alternative drugs. You should always
We may add or delete drugs from the
PDL at any time. Drugs may also move
from one coverage tier to another.
Changes are made to the PDL because:

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


Brand name medications lose
their patent protections and
generic versions become
available.
New medications are approved
by the FDA. Open formularies
often cover new drugs before
they are reviewed by the P&T
Committee.
Medications are sometimes
withdrawn from the market or
becomes and over-the-counter
drug (OTC). Some plans have
chosen to cover OTC drugs –
please refer to the plan
documents provided by your
employer.
New medical evidence is
published.
Any drug not listed on the
preferred drug list is considered
their 3.
What is Prior Authorization and Why
Is It Required?
Prior Authorization is a process that
encourages appropriate and cost
effective use of medications by allowing
coverage under certain conditions.
Prior Authorization promotes:
B



Compliance with dosing
guidelines;
Assists your health care provider
avoid duplicate therapies that
may be inappropriate;
Monitors that a medication is
being used for generally accepted
medical criteria.
If a drug on your plan requires Prior
Authorization, your doctor must contact
us for approval.
If we approve the request, the
medication will then be covered at the
applicable copay tier.
If the request is denied, your doctor will
be notified. You may still purchase the
medication for the full price.
Why Do Some Medications Have
Quantity Limits?
These limits help your doctor and
pharmacist check that medications are
used appropriately and promote patient
safety. The Quantity Limits are set
based upon medical guidelines, FDA
approved recommendations from the
manufacturer. Quantity limit programs
include:


step therapy drug will be approved under
your specific plan.
Step-Therapy promotes the use of
equally effective, lower cost drugs first.
The list of medications requiring prior
authorization, quantity limits or steptherapy are subject to change.
Formulary List – Key
Generic name
Age Edit may be applicable
Gender Edit may be
applicable
Prior
Prior Authorization may be
Auth
applicable
Qty.
Quantity Limit may be
Limit
applicable
Rider
Rider may be required to
coverage
Specialty Specialty Pharmacy
dispensing may be applicable
Step Edit Step-Therapy may be
applicable
italic
Age
Gender
Once-daily dosing
Limit coverage to a specific
number of units for a defined
period of time.
Coverage in excess of the plan allowed
limits are not a covered benefit.
Step-Therapy – What is this?
Step-Therapy programs are also referred
to as prerequisite programs – meaning
that certain drug use is required before a
C
Preferred Drug List - Alphabetical
Drug Name
8-MOP
ABILIFY
ABILIFY DISC
ABSTRAL
ACANYA
acarbose
ACCOLATE
Copay
Tier
2
2
2
3
3
1
3
ACCU CHEK family of test strips
ACCUHIST
ACCUNEB
ACCUPRIL
ACCURETIC
ACCUTANE
acebutolol
ACEON
acetaminophen/codeine
acetazolamide
ACIPHEX
ACIPHEX SPRINKLE
acita
ACTEMRA
ACTIMMUNE
ACTIQ
ACTIVE FE
ACTIVE OB
ACTIVELLA
ACTIVELLA (4/1/11)
ACTONEL
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS (eff 9/11/12)
ACULAR
ACULAR LS
ACULAR PF
acyclovir
ADALAT CC
adapalene
3
3
3
3
3
3
1
3
1
1
3
3
1
3
2
3
3
3
2
3
2
2
3
3
2
2
2
1
3
1
ADCIRCA
ADDERALL
ADDERALL XR
ADEMPAS
ADOXA
ADVAIR DISKUS
ADVAIR HFA
ADVATE
3
3
3
3
3
2
2
2
Dispensing
Edits
Specialty
Qty. Limit
Qty. Limit,
Rider
Qty. Limit
Qty. Limit
Prior Auth
Qty. Limit
Specialty
Specialty
Qty. Limit
Gender
Gender
Qty. Limit
Qty. Limit
Age
Prior Auth.,
Specialty
Qty. Limit
Specialty
Prior Auth
Qty. Limit
Qty. Limit
Specialty
1 Preferred Drug List - Alphabetical
Drug Name
ADVICOR
AEROBID
AEROBID-M
afeditab
Copay
Tier
3
3
2
1
AFINITOR
AGGRENOX
AGRYLIN
AKDARA
AKINETON
AKNE-MYCIN
ak-pred
ALAMAST
ALANINE
albuterol sulfate
albuterol sulfate (GE: Accuneb®)
albuterol/ipratropium
alclometasone
3
2
2
2
2
2
1
3
3
1
3
1
1
alcohol swab
ALDACTAZIDE
ALDACTAZIDE 50/50
ALDACTONE
ALDARA
ALDURAZYME
alendronate
ALESSE
alfuzosin hcl
ALINIA
ALKERAN
ALLEFEN CDX
ALLEGRA
ALLEGRA-D
ALOCRIL
ALODOX
ALOMIDE
1
3
3
3
3
2
1
3
1
2
2
3
3
3
2
3
2
ALORA
ALPHAGAN P
ALPHANATE
ALPHANINE SD
alprazolam
alprazolam ER
alprazolam rapidis
alprostadil
ALREX
3
2
2
2
1
1
1
1
3
ALTACE
3
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Prior Auth.,
Specialty
Prior Auth
Qty. Limit,
Rider
Qty. Limit
Age, Gender
Qty. Limit
Qty. Limit
Gender, Qty.
Limit
Specialty
Specialty
Qty. Limit
Age, Qty.
Limit
Drug Name
ALTOPREV
ALUPENT
ALUVEA
ALVESCO HFA
AMALPRED Plus
amantadine
AMARYL
AMBIEN
AMBIEN CR
amcinonide
AMERGE
amiloride
amiloride/HCTZ
aminophylline
amiodarone
AMITIZA
amitriptyline
amlodipine
amlodipine/benazepril
amlodipine/valsartan
amlodipine/valsartan/hctz
amnesteem
amoxapine
amoxicillin
amoxicillin/K clavulanate
AMOXIL
amphetamine salts
amphetamine salts ER
ampicillin
AMPYRA
AMRIX
AMTURNIDE (Eff 7/1/11)
amyl nitrate
ANADROL
anagrelide
ANALPRAM ADVANCED
ANAMANTLE HC
anastrozole
ANCOBON
ANDRODERM
ANDROGEL
ANGELIQ
ANTABUSE
ANTARA
anthralin
antipyrine/benzocaine
ANZEMET
Copay
Tier
3
2
3
2
2
1
3
3
3
1
3
1
1
1
1
3
1
1
1
1
1
2
1
1
1
1
1
1
1
3
3
2
1
2
1
3
3
1
3
3
2
3
3
3
1
1
2
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Qty. Limit
Gender
Qty. Limit
Copay
Tier
3
2
1
3
2
3
1
2
3
3
3
3
3
Drug Name
APIDRA
APOKYN
apri
APRISO
APTIVUS
ARALEN
aranelle
ARANESP
ARAVA
ARCALYST
ARCAPTA NEOHALER
AREOSPAN
ARICEPT/ARICEPT ODT
ARIMIDEX
3
ARIXTRA
ARMOUR THYROID
AROMASIN
ARTHROTEC
ASACOL
ASMANEX
aspirin/codeine
ASTAGRAPH XL
ASTELIN NASAL
ASTEPRO
ATACAND
ATACAND HCT
ATELVIA
atenolol
atenolol/chlorthalidone
atorvastatin (Eff 12/1/2011)
atorvastatin/amlodipine
ATRALIN
ATRAPRO CP
ATRIPLA
ATROVENT HFA
ATROVENT NASAL
3
2
3
2
2
2
1
3
3
3
3
3
2
1
1
1
1
2
3
2
2
2
AUBAGIO
AUGMENTIN
AUGMENTIN ES
AUGMENTIN XR
AURSTAT
AURSTAT
AUVI-Q
AVALIDE
AVANDAMET
ASACOL HD
3
3
3
3
3
3
2
3
2
Dispensing
Edits
Specialty
Age, Gender
Prior Auth
Age, Gender
Specialty
Specialty
Prior Auth.,
Specialty
Qty. Limit,
Specialty
Specialty
Qty. Limit
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Prior Auth,
Specialty
Qty. Limit
Drug Name
AVANDARYL
AVANDIA
AVAPRO
AVAR E LS
AVAR GREEN
AVAR LS CLEANSER
AVAR LS, E
AVELOX
AVELOX ABC
aviane
AVINZA
AVODART
Copay
Tier
2
2
3
3
3
3
3
2
2
1
3
2
AVONEX
2
AVONEX PEN
AXERT
AXID
AXIRON
AZASAN
AZASITE
azathioprine
azelastine (08/01/10)
AZELEX
AZILECT
azithromycin
AZMACORT
AZOPT
AZOR
AZOR (8/1/11)
AZULFIDINE ENTAB
AZULFIDINE+A191
B NEXA
bacitracin
bacitracin/neomycin/polymyxin
bacitracin/polymyxin
bacitracine/polymyxin/neomycin/hydrocortisone
baclofen
BACTROBAN CR, OINT
BACTROBAN NASAL
BAL-CARE DHA ESSENTIAL
balsalazide
2
3
3
3
2
3
1
1
2
2
1
2
2
3
2
3
3
3
1
1
1
1
1
3
3
3
1
BARACLUDE
2
BD Insulin Syringes
3
BD Pen Needles
2
Dispensing
Edits
Qty. Limit
Age, Gender
Qty. Limit
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Age, Gender
Prior Auth.,
Specialty
Qty. Limit,
Rider
Qty. Limit,
Rider
Drug Name
BEBULIN VH
BECONASE AQ
benazepril
benazepril/HCTZ
BENEFIX
BENICAR
BENICAR HCT
BENZACLIN
BENZAMYCIN
BENZEFOAM ULTRA
BENZIQ
BENZIQ LS
BENZIQ WASH
benzoyl peroxide
benzoyl peroxide pads
benzoyl peroxide/urea
benztropine
BEPREVE
BESAVANCE
betamethasone valerate
BETAPACE
BETAPACE AF
Copay
Tier
2
3
1
1
3
2
2
3
3
3
2
2
2
1
1
1
1
3
3
1
3
3
BETASERON
betaxolol
betaxolol
bethamethasone diprop (augmented)
bethanechol
BETHKIS
BETIMOL
BETOPTIC-S
BEYAZ
BIAXIN
BIAXIN XL
bicalutamide
BIDIL
3
1
1
1
1
2
2
2
3
3
3
1
2
BIG-STAR
bimatoprost
BINOSTO
BIO-THROID
bisoprolol fumarate
bisoprolol/HCTZ
BLEPHAMIDE S.O.P.
B-NEXA
BONIVA
Botulinum toxin
3
1
3
3
1
1
2
3
3
3
Dispensing
Edits
Specialty
Specialty
Qty. Limit
Qty. Limit
Prior Auth.,
Specialty
Specialty
Age, Gender
Qty. Limit,
Rider
Qty. Limit
Prior Auth
Drug Name
BRAVELLE
Copay
Tier
2
BREEZE 2 Test Strips
BREO ELLIPTA
BREVICON
BRILINTA (effective 7/1/13)
brimonidine
2
3
3
2
1
BRINTELLIX
BRISDELLE
bromocriptine
BRONCAP
BROVANA
budeprion
budeprion XL
bumetanide
BUMEX
BUPHENYL
BUPIVACAINE HCL-NS
3
3
1
3
3
1
1
1
3
2
3
bupreenorphine
bupropion
bupropion SR
Buproprion ER 150mg Tab
buspirone
butalbital/APAP/caffeine/codeine
butalbital/aspirin/codeine
BUTISOL SODIUM
butorphanol
BUTRANS
BYDUREON
BYETTA
BYSTOLIC
CADUET (Eff 1/15/12)
CALAN
CALAN SR
calcipotriene
calcipotriene
CALCITONIN NASAL
CAMBIA
camila
CAMPRAL
CANASA
CAPITAL/CODEINE
CAPOTEN
CAPOZIDE
captopril
captorpril/HCTZ
1
1
1
1
1
1
1
2
1
3
3
2
3
3
3
3
1
1
1
3
1
3
2
3
3
3
1
1
Dispensing
Edits
Rider
Qty. Limit,
Rider
Age, Gender
Step
Therapy
Prior Auth.,
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Age, Gender
Drug Name
CARAC
CARAFATE
CARBAGLU
carbamazapine xl
carbamazepine
carbidopa/levodopa
carbidopa/levodopa rapidis
carbidopa/levodopa SR
carboptic
CARDENE
CARDENE SR
CARDIZEM
CARDIZEM CD
CARDIZEM LA
CARDURA
CARDURA XL
carisoprodol
carisoprodol/aspirin
carisoprodol/aspirin/codeine
CARNITOR
carteolol
cartia XL
carvidilol
CASODEX
CATAPRES
CATAPRES-TTS
CAVERJECT
CAYSTON Inh
CEDAX
CEENU
cefaclor
cefaclor ER
cefadroxil
cefdinir
cefpodoxime
cefprozil
CEFTIN
cefuroxime
CEFZIL
CELEBREX
CELESTONE
CELEXA
CELLCEPT
CELONTIN
CENESTIN
CENFOL
Copay
Tier
3
3
3
1
1
1
1
1
1
3
3
3
3
3
3
3
1
1
1
2
1
1
1
2
3
3
3
3
3
2
1
1
1
1
1
1
3
1
3
2
3
3
3
2
3
3
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Qty. Limit
Prior Auth.,
Specialty
Specialty
Specialty
Gender
Drug Name
CENHIST
CENTANY
cephalexin
CEREFOLIN NAC
CESAMET
cesia
CETACAINE KIT, SPRAY, OINT
CETACAINE LIQ
CETROTIDE
CHANTIX
chloral hydrate
chlordiazepodide/amitriptyline
chlordiazepoxide
chloroquine
chlorpromazine
chlorpropamide
chlorthalidone
chlorthiazide
chlorzoxazone
cholestyramine
chorionic gonadotropin
CIALIS
CICLODAN
ciclopirox
ciclopirox gel, shampoo
CILODAN CLEANSER
cilostazol
cimetidine
Copay
Tier
3
3
1
3
3
1
3
3
3
2
1
1
1
1
1
1
1
1
1
1
1
2
3
1
1
3
1
1
CIMZIA
CIPRO
CIPRO HC
CIPRO XR
CIPRODEX
ciprofloxacin
ciprofloxacin
ciprofloxacin ER
citalopram
CITRANATAL 90 DHA
3
3
2
3
2
1
1
1
1
3
CITRANATAL B-CALM
CITRANATAL HARMONY
CITRANATAL HARMONY
CITRANATAL HARMONY
CITRNATAL-BA CALM
claravis
CLARIFOAM EF
3
3
3
3
3
1
2
Dispensing
Edits
Age, Gender
Rider
Prior Auth
Rider
Qty. Limit
Prior Auth.,
Specialty
Age, Qty.
Limit
Prior Auth
Drug Name
CLARINEX
CLARINEX REDITAB
CLARINEX-D
clarithromycin
clarithromycin SR
clarithromycin xl
CLEANSE & TREAT PLUS KIT
CLEANSE/TREAT PAD
CLENIA
CLEOCIN VAGINAL
CLIMARA
CLIMARA PRO WEEKLY
CLINDACIN PAC
clindamax
clindamaycin (vaginal)
clindamycin
clindamycin
clindamycin foam
CLINDESSE
clobetasol
clobevate
CLOBEX (lotion, shampoo,)
CLOBEX SPRAY
CLODERM
CLOMID
clomiphene
clomipramine
clonazepam
clonazepam - disintigrating tab
clonidine
clonidine patch
clopidogrel bisulfate
clorazepate
CLORPRES
clotrimazole/betamethasone
clozapine
CLOZARIL
COARTEM
COCET Plus
CODAR D
CODAR GF
codeine phosphate
codeine sulfate
COGENTIN
COLAZAL
COLCRYS
Copay
Tier
3
3
3
1
1
1
3
3
3
3
3
3
3
3
1
1
1
1
3
1
1
1
2
1
3
1
1
1
1
1
1
1
1
3
1
1
3
2
3
3
3
1
1
3
2
2
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Gender
Gender
Gender, Qty.
Limit
Gender
Gender
Rider
Rider
Drug Name
COLESTID
colestipol
colistimethate sodium
colocort
COLY-MYCIN M
COLY-MYCINS-S
COLYTE
COMBIGAN
COMBIPATCH
COMBIVENT
COMBIVENT RESPIMAT
COMBIVIR
COMBIVIR (4/1/12)
COMBUNOX
COMFORT PAC - MELOXICAM
COMFORT PAC - NAPROXEN
COMFORT PAC - TIZANIDINE
COMFORT PAC CYCLOBENZAPRINE
COMPLERA
compro
COMTAN
CONCERTA
Copay
Tier
3
1
1
1
2
2
3
2
2
2
2
2
3
2
3
3
3
3
2
1
2
2
CONTOUR Test Strips
CONZIP
2
3
COPAXONE
2
COPEGUS
CORDARONE
CORDRAN
COREG
COREG CR
CORGARD
CORTAMAX
CORTANE-B
CORTIFOAM
cortisone AC
cortomycin
CORVITE 150
CORVITE FE
CORVITE FE
CORZALL
CORZALL PE
CORZALL PLUS
CORZIDE
COSOPT
COUMADIN
3
3
2
3
3
3
3
3
2
1
1
3
3
3
3
3
3
3
3
3
Dispensing
Edits
Gender
Qty. Limit
Qty. Limit,
Rider
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Qty. Limit
Drug Name
COVERA-HS
COZAAR
CREON
CRESTOR
CRINONE
CRIXIVAN
cromolyn sodium ophth
cromolyn soduim nebulizer
cryselle
CUVPOSA
cyanocobalmin
CYCLESSA
cyclobenzaprine ER
cyclobenzaprine hcl
CYCLOPHENE
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
CYMBALTA
CYSRARAN
CYSTADANE
CYSTAGON
CYTADREN
CYTOSE
DALIRESP
DANTRIUM
dapsone
DARAPRIM
DAYPRO
Copay
Tier
3
3
2
2
3
2
1
1
1
3
1
3
1
1
3
1
3
1
1
3
3
2
2
3
3
3
1
2
3
DAYTRANA
DAZIDOX
DDAVP
DECLOMYCIN
DELOS
DELZICOL
3
3
3
3
3
2
DELZICOL 3
3
1
3
3
3
3
3
3
3
DEMADEX
demeclocycline
DEMEROL
DEMSER
DEMULEN
DENAVIR
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Age, Rider
Age, Gender
Age, Gender
Prior Auth
Qty. Limit
Prior Auth.,
Qty. Limit
Age
Age, Gender
Drug Name
DEPLIN
DEPLIN-ALGAL
DEPO-PROVERA
DEPO-PROVERA
DERASORB XM
DERMASORB AF
DERMASORB HC
DERMASROB TA
DERMATOP
desipramine
desmopressin
DESOGEN
DESONATE
desonide
DESONIL + PLUS
DESOWEN KIT
desoximetasone
DESOXYN
DETROL
DETROL LA
dexacidin
dexamethasone
dexamethasone phosphate
dexamethasone/neomycin/ polymyxin
dexasol
dexasporin
DEXEDRINE
DEXILANT
dexmethylphenidate
dextroamphetamine
dextroamphetamine CR
dextrostat
DIAMOX
DIASTAT
diazepam
DIBENZYLINE
DICLEGIS
diclofenac
diclofenac ophth
diclofenac potassium
diclofenac sodium XR
dicloxacillin sodium
didanosine delayed release
DIDRONEL
DIFFERIN
DIFLUCAN (all other strengths)
Copay
Tier
3
3
2
3
3
3
3
3
3
1
1
3
3
1
3
3
1
3
2
2
1
1
1
1
1
1
3
2
1
1
1
2
3
2
1
2
3
1
1
1
1
1
1
2
3
3
Dispensing
Edits
Age, Qty.
Limit
Age
Age, Gender
Qty. Limit
Age
Drug Name
DIFLUCAN 150mg
DIGIBAR
digitek
digoxin
DILACOR XR
DILATRATE SR
diltia XT
diltiazem
diltiazem CD/ER/XT
diltiazem SR
DILUADID
DIOVAN
DIOVAN HCT
DIPENTUM
dipivefrin
DIPROLENE AF
disopyramide
DISPERMOX
disulfiram
DITROPAN
DITROPAN XL
DIURIL
divalproex sodium DR
divalproex sodium ER
divalproex sodium sprinkle
divalproex sodium SR
DIVIGEL
DNA MEDICATED COLLECTION
DONATUSS XP ORAL
donepezil hcl
DONNATAL ELIX
DORAL
DORYX
DORYX TAB
dorzolamide
dorzolamide hcl ophthalmic
dorzolamide/tilomol ophthalmic
DOVONEX
doxazosin
doxepin cr
doxepin hcl
doxy-caps
doxycycline hyclate
doxycycline monohydrate
doxycycline monohydrate 150mg
DRITHOCREME HP
DRITHO-SCALP
Copay
Tier
3
3
1
1
3
3
1
1
1
1
3
3
3
2
1
3
1
3
1
3
3
3
1
1
1
1
3
3
3
1
3
2
3
3
1
1
1
3
1
1
1
1
1
1
1
3
2
Dispensing
Edits
Qty. Limit
Qty. Limit
Gender
Qty. Limit
Qty. Limit
Prior Auth
Drug Name
DUAC
DUET DHA BALANCED
DUET DHA BALANCED
DUET DHA BALANCED
DUET DHA BALANCED <geq>
DUET DHA COMPLETE
DUET DHA COMPLETE <geq>
DUET DHC EC
DUETACT
DULERA
DUONEB
DURAGESIC
DURASAL
DURICEF
DYAZIDE
DYMISTA
DYNABAC
DYNACIN
DYNACIRC CR
dypridamole
DYRENIUM
DYSPORT
e.e.s.
EDARBI
EDECRIN
EDEX
EDURANT
EFFEXOR
EFFEXOR XR
EFFIENT
EFUDEX
EGRIFTA
ELDEPRYL
ELESTAT
ELESTRIN
ELIDEL
ELIMIRON
ELIQUIS (Eff 8/1/13)
ELOCON
EMADINE
EMCYT
EMEND
Emollient Combo #32
EMSAM
EMTRIVA
ENABLEX
enalapril
Copay
Tier
2
3
3
3
1
3
1
3
3
2
3
3
3
3
3
3
3
3
3
1
2
3
1
3
3
3
2
3
3
2
3
3
2
3
3
2
2
2
3
3
2
3
1
2
2
3
1
Dispensing
Edits
Gender
Gender
Gender
Gender
Qty. Limit
Qty. Limit
Prior Auth
Qty. Limit
Prior Auth
Gender
Specialty
Drug Name
enalapril/HCTZ
Copay
Tier
1
ENBREL
ENJUVIA
ENLYTE
enoxaparin
enpresse
ENTERAGAM
ENTOCORT EC
EPANED
EPICREAM
EPIDUO
epinastine hcl
epinephrine
EPIPEN
EPIPEN-JR
EPISIL
EPIVIR
EPIVIR (4/1/12)
2
3
3
1
1
3
2
3
3
3
1
1
2
2
3
2
3
EPIVIR HBV
EPOGEN
eprosartan mesylate
EPZICOM
EQUETRO
ergoloid mesylate
ERIVEDGE
errin
ERTACZO
erythrocin
erythromycin
erythromycin
erythromycin
erythromycin delayed relase particles
erythromycin ethylsuccinate
erythromycin/benzoyl peroxide
ESCAVITE
escitalopram oxalate
ESCLIM
estazolam
ESTRACE
ESTRACE VAGINAL
ESTRADERM
2
2
1
2
3
1
3
1
3
1
1
1
1
1
1
1
3
1
3
1
3
2
3
estradiol patch
estradiol tab
estradiol/norethidrome acetate
estradiol-noreth ac
1
1
1
1
Dispensing
Edits
Prior Auth.,
Specialty
Gender
Qty. Limit
Age, Gender
Prior Auth.,
Specialty
Specialty
Specialty
Age, Gender
Gender
Gender
Gender
Gender
Gender, Qty.
Limit
Gender
Gender
Gender
Drug Name
ESTRASORB
ESTRATEST
ESTRATEST HS
ESTRING
ESTROGEL
estropipate
ESTROSTEP FE
ethambutol
ETHINYL ESTRADIOL/DROSPIRENONE
ethosuximide
etodolac
etodolac ER
etoposide
EULEXIN
EURAX
EVAMIST
EVISTA
EVOCLIN
EVOXAC
EXALGO
EXELDERM
EXELON
exemestane
EXFORGE, EXFORGE HCT
Copay
Tier
3
3
3
2
2
1
3
1
1
1
1
1
1
2
3
3
2
3
3
3
3
3
1
3
EXTAVIA
EXTINA
EYLEA
E-Z DISK
FABIOR
FABRAZYME
FACTIVE
famciclovir
famciclovir
famciclovir
famotidine
FAMVIR
FANAPT
FANATREX
FANSIDAR
FARSETON
FASLODEX
3
3
3
3
3
2
3
1
1
1
1
3
3
3
2
2
2
FAST TAKE test strips
favciclovir
FAZACLO
FEIBA VH IMMUNO
3
1
3
2
Dispensing
Edits
Gender
Gender
Gender
Gender
Gender
Gender
Age, Gender
Age, Gender
Specialty
Specialty
Gender
Prior Auth.,
Specialty
Specialty
Prior Auth
Specialty
Specialty
Qty. Limit,
Rider
Specialty
Drug Name
felbamate
FELBATOL
FELBATOL (4/1/12)
felodipine
FEMARA
FEMCON FE
FEMHRT
FEMHRT LOW DOSE
FEMRING
FEMTRACE
fenofibrate
fenofibrate
FENOGLIDE
fenoprofen
fentanyl citrate
fentanyl citrate lozenge
fentanyl transdermal
fentanyl transmucosal lozenge
FENTORA
FERRIPROX
FERVIA
FETZIMA
FEXMID
fexofenadine
fexophenadine/Pseudoephedrine
FINACEA
FINACEA PLUS
finasteride
FIORICET W/CODEINE
FIORICET/CODEINE
FIORINAL/CODEINE
FIRAZYR
FIRMAGON
FIRST LANSOPRAZOLE
FIRST OMEPRAZOLE Susp
flacoxate
flecanide
FLECTOR
FLOMAX
FLONASE
FLO-PRED
FLOVENT DISKUS
FLOVENT HFA
FLOXIN OTIC
flubiprofen
fluconazole (all other strengths)
Copay
Tier
1
2
3
1
3
3
3
3
2
3
1
1
3
1
1
1
1
1
3
3
3
3
3
1
1
3
3
1
3
3
3
3
2
3
3
1
1
2
3
3
3
2
2
2
1
1
Dispensing
Edits
Prior Auth.,
Specialty
Age, Gender
Gender
Gender
Gender
Gender
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Specialty
Age
Qty. Limit
Qty. Limit
Drug Name
fluconazole 150mg
flucytosine
fludrocort
FLUMADINE
flunisolide
fluocinolone acetonide
fluocinonide
fluorometholone
fluor-op
FLUOROPLEX
fluorouracil
fluoxetine
fluoxymesterone
fluphenazine
flurbiprofen
flutamide
fluticasone
fluticasone propionate nasal
fluvastatin sod
fluvoxamine
FML FORTE
FML LIQUIFILM
FML S.O.P.
FOCALIN
FOCALIN XR
folic acid
FOLLISTIM AQ
FOLTX
Copay
Tier
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
3
3
2
3
2
1
3
3
fondaparinux
FORADIL
FORFIVO XL
FORTAMET
2
2
3
3
FORTEO
FORTESTA
fortical
FOSAMAX
FOSAMAX PLUS D
fosaprepitant
fosinapril
fosinapril/HCTZ
FOSRENOL
FOSTEUM PLUS
FRAGMIN
3
3
1
3
3
1
1
1
2
3
2
FREESTYLE LITE Test Strips
FROVA
3
3
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Rider
Qty. Limit,
Specialty
Prior Auth.,
Specialty
Qty. Limit
Qty. Limit,
Rider
Qty. Limit
Drug Name
frovatriptan succinate
FULYZAQ
furosemide
FUSION PLUS
Copay
Tier
1
3
1
3
FUZEON
gabapentin
GABARONE
GABITRIL
galantamine hbr
ganciclovir
GASTROCROM
GELNIQUE
GELX
gemfibrozil
GENADUR
GENADUR
GENERESS DE
gengraf
2
1
3
3
1
1
2
3
3
1
3
3
3
1
GENOTROPIN
gentamicin
gentamicin
GEODON
GESTICARE DHA
gianvi
GIAZO
2
1
1
3
3
1
3
GILENYA
GILOTRIF
GILTUSS TR
GLEEVEC
glimepiride
glipizide
glipizide ER/XL
glipizide/metformin
gluburide
GLUCAGON
GLUCOPHAGE
GLUCOPHAGE XR
3
3
3
2
1
1
1
1
1
3
3
3
Glucose Test Strips (all other brands)
GLUCOVANCE
GLUMETZA
GLUTARADE GA-1
glyburide micronized
glyburide/metformin
GLYCLATE
3
3
3
3
1
1
3
Dispensing
Edits
Qty. Limit
Prior Auth.,
Specialty
Age, Gender
Prior Auth.,
Specialty
Age, Gender
Age, Gender
Prior Auth.,
Specialty
Specialty
Specialty
Qty. Limit,
Rider
Drug Name
glycolax
glycon
GLYSET
GLYSET
GLYTACTIN
GOLYTELY
GONAL-F
GONAL-F RFF
GRALISE
GRANIRELIX
granisetron
GRANIX
GRIFULVIN V
GRIS-PEG
guanabenz
guanfacine
guinidine sulfate
GYNAZOLE-1
gynodiol
HALDOL D
HALFLYTELY
halobetasol propionate
HALOG
haloperidol
HECORIA
HECTOROL
HELIDAC
HELIXATE FS
Copay
Tier
1
1
3
2
3
3
2
2
3
3
1
3
2
2
1
1
1
3
1
3
2
1
3
1
3
2
3
3
HEMENATAL OB
3
HEMENATAL OB + DHA COMBO
HEMOFIL M
heparin
3
2
1
HEPSERA
HEXALEN
HISTEX SR
HIZENTRA
HMS
HORIZANT
HUMALOG pdts
HUMATE-P
3
2
3
3
2
3
2
2
HUMATROPE
3
HUMIRA
HUMULIN
2
2
Dispensing
Edits
Rider
Rider
Rider
Qty. Limit
Specialty
Gender
Gender
Rider
Specialty
Specialty
Age, Qty.
Limit
Age, Qty.
Limit
Specialty
Qty. Limit
Prior Auth.,
Specialty
Specialty
Specialty
Specialty
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Drug Name
hydralazine
hydralazine/HCTZ
HYDREA
hydrochlorothiazide (HTCZ)
hydrocodone bit/APAP
hydrocodone/acetaminophen
Hydrocort/Parmoxn SKN CLNSR #16
Hydrocort/Pramoxine
hydrocortison valerate
hydrocortisone
hydrocortisone
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone/clioquinol
hydrocortisone/iodoquinol
hydrocortisone/pramoxine
hydromorphone
hydroxychloroquine sulfate
hydroxyne pamoate
hydroxyurea
hydroxyzine hcl
HYLASE
HYLATOPIC P;LUS-AURSTAT
HYLATOPIC PLUS
HYLATOPIC, HYLATOPIC PLUS
HYPERTENSA
hyscyamine
HYTRIN
HYZAAR
ibandronate sodium
IBUDONE
ibuprofen
ICLUSIG
ILARIS
ILVERO
IMBRUVICA
IMDUR
imipramine hcl
imipramine pm
imiquimod
IMITREX
IMURAN
Copay
Tier
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
1
3
3
1
3
1
3
3
3
3
3
1
1
1
3
2
INCIVEK
2
INCRELEX
indapamide
3
1
Dispensing
Edits
Qty. Limit
Specialty
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Drug Name
INDERAL
INDERAL LA
INDERIDE
indomethacin
indomethacin ER
INFANATE BALANCE
Copay
Tier
3
3
3
1
1
3
INFERGEN
INLYTA
INNOHEP
INNOPRAN XL
INOVA
INSPRA
3
3
2
3
3
2
insulin syringes
INTELENCE
INTERMEZZO
1
2
3
INTRON-A
INTUNIV
INVEGA
INVEGA Syringe
INVIRASE
INVOKANA
INVOKANA
IOPIDINE
ipratropium inhaler
ipratropium nasal
IPRIVASK
IQUIX
irbesartan
irbesartan/HCTZ
IROSPAN
ISENTRESS
ISMO
ISO CARBACHOL
isoniazid
ISOPTIN SR
ISOPTO CARPINE
ISORDIL
isosorbide dinitrate
isosorbide mononitrate
isotretinoin
isoxuprine
isradipine
ISTALOL
itraconazole
JAKAFI
2
3
3
3
2
3
3
1
1
1
3
2
1
1
3
2
3
2
1
3
2
3
1
1
1
1
1
3
1
3
Dispensing
Edits
Prior Auth.,
Specialty
Specialty
Qty. Limit
Qty. Limit,
Rider
Prior Auth.,
Specialty
Specialty
Qty. Limit
Qty. Limit
Prior Auth
Drug Name
JALYN
JANUMET
JANUMET XR
JANUVIA
JAYLN (Eff. 7/1/11)
JENTADUETO
JETREA
jolessa
jolivette
junel
junel FE
JUVISYNC
KADIAN
KALBITOR
KALETRA
Copay
Tier
2
2
2
2
2
3
3
1
1
1
1
3
2
3
2
KALYDECO
KAPIDEX
KAPVAY
kariva
KAZANO
kelnor
KEPPRA
KEPPRA XR
KERALYT
KERLONE
KETEK
KETOCON + PLUS
ketoconazole
ketoconazole
KETODAN
ketopofen
ketoprofen ER
ketorolac
3
3
3
1
3
1
3
3
3
3
3
3
1
1
3
1
1
1
KINERET
KLARON
KLONOPIN
KLONOPIN WAFER
KOATE-DVI
KOGENATE FS
KOGENATE FS IV
KOMBIGLYZE XR
KOMBIGLYZE XR (8/1/11)
KORLYM
KRISTALOSE
KUVAN
3
3
3
3
3
3
3
3
2
3
3
3
Dispensing
Edits
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Qty. Limit
Specialty
Prior Auth.,
Specialty
Age, Gender
Age, Gender
Prior Auth.,
Specialty
Specialty
Specialty
Specialty
Specialty
Drug Name
Copay
Tier
KYNAMRO
KYTRIL
labatelol
lacticare/hydrocortisone
lactulose
LAMICTAL
LAMICTAL XR
LAMISIL
lamivudine
lamivudine-zidovudine
lamotrigine
lamotrigine XR
3
3
1
1
1
3
3
3
1
1
1
1
lancets
LANOXICAP
LANOXIN
lansoprazole cap
lansoprazole rap dr
LANTUS
LARIAM
LASIX
LASTACAFT
LATUDA
LAVOCLEN
leena
leflunomide
LESCOL
LESCOL XL
lessina
LETAIRIS
letrozole
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide
leuprolide
LEVAQUIN
LEVATOL
LEVELEN
LEVEMIR
levetiracetam
levetiracetam ER
LEVITRA
LEVLITE
levobunolol
2
3
3
1
1
2
2
3
3
3
3
1
1
3
3
1
2
1
1
1
2
2
1
1
3
3
3
2
1
1
3
3
1
Dispensing
Edits
Prior Auth,
Specialty
Qty. Limit
Qty. Limit,
Rider
Age, Gender
Qty. Limit
Qty. Limit
Age, Gender
Specialty
Specialty
Rider
Age, Gender
Qty. Limit
Age, Gender
Drug Name
levocetirizine dihydrochloride
levofloxacin (1/16/12) oral
levofloxacin ophth
levomefolate calcium
levora
levorphanol
LEVOTHROID
levothyroxine
LEVOXYL
LEVULAN
LEXAPRO
LEXIVA
LIALDA
LIDAMANTLE HC
lidocaine
lidocaine/hydrocortisone
lidocaine/prilocaine
LIDODERM
LIDORX
LIDOVIR
lindane
LIPITOR
LIPITOR (Eff 12/1/2011)
LIPOFEN
LIPTRUZET
LIQUADD
lisinopril
lisinopril/HCTZ
lithium carbonate
lithium carbonate CR
lithium citrate
LITHOBID
LIVALO
l-methylfolate calcium
LO LOESTRIN FE
LO/OVRAL
LODOSYN
LOESTRIN
LOESTRIN FE
LOESTRIN FE 24
LOFIBRA
loperamide
LOPID
LOPRESSOR
LOPRESSOR HCT
LOPROX (Cr., lotion, susp)
LOPROX (gel, shampoo)
Copay
Tier
1
1
1
1
1
1
3
1
3
3
3
2
3
3
1
1
1
3
3
2
3
2
3
3
3
2
1
1
1
1
1
3
3
1
3
3
2
3
3
3
3
1
3
3
3
3
3
Dispensing
Edits
Qty. Limit
Age, Gender
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Drug Name
loratadine
lorazepam
LORCET
LORCET PLUS
LORTAB
LORZONE
LORZONE
losartan
losartan
losartan/hctz
losartan/HCTZ
LOTEMAX
LOTENSIN
LOTENSIN HCT
LOTREL
LOTRISONE
LOTRONEX
LOUTREX
lovastatin
LOVAZA
LOVENOX
low-ogestrel
loxapine
LUMIGAN
LUNESTA
LUPRON
LUPRON
LUPRON DEPOT
lutera
LUVERIS
LUVOX CR
LUXIQ
LYBREL
LYCELLE
LYRICA
LYSTEDA
MACROBID
MACUGEN
MAGNACET
MAKENA
MALARONE
maldemar
MARNATAL F
MARPLAN
marprotaline
MATULANE
Copay
Tier
1
1
3
3
3
3
3
1
1
1
1
2
3
3
3
3
2
3
1
3
3
1
1
3
3
3
3
3
1
3
3
3
3
3
2
3
2
3
3
3
2
1
3
2
1
2
Dispensing
Edits
Qty. Limit
Age, Gender
Specialty
Rider
Specialty
Age, Gender
Rider
Age, Gender
Qty. Limit
Specialty
Prior Auth.,
Specialty
Drug Name
MAVIK
MAXAIR AUTOHALER
MAXALT
MAXALT MLT
MAXARON FORTE
MAXIDONE
MAXZIDE
MEBARAL
meclizine
meclofenamate sodium
MEDIHONEY
medroxyprogesterone
medroxyprogesterone
mefenamic acid
mefloquine
MEGACE
MEGACE ES
megestrol
MEKINIST
meloxicam
MENEST
MENOPUR
MENOSTAR
MENTANX
meperidine
meperidine/promethazine
mephobarbital
meprobamate
MEPRON
meprozine
mercaptopurine
mesalamine
MESNEX
MESTINON
MESTINON TIMESPAN
METADATE CD
METADATE ER
METAGLIP
metaproterenol
metaxalone
metformin
metformin ER 24 (Fortamet®)
metformin XR
methadose
methanamine hippurate
methanamine madelate
Copay
Tier
3
3
3
3
3
3
3
3
1
1
3
1
1
1
1
3
3
1
3
1
3
3
3
3
1
1
1
1
2
1
1
1
2
2
2
3
3
3
1
1
1
1
1
1
1
1
Dispensing
Edits
Qty. Limit
Qty. Limit
Age, Qty.
Limit
Gender
Gender
Rider
Gender
Specialty
Qty. Limit
Qty. Limit
Drug Name
methazolamide
methimazole
METHITEST
methocarbamol
methotrexate
methychlorthiazide
methyldopa
methyldopa/HCTZ
methylin
METHYLIN (Chew. Soln)
methylin ER
methylphenidate
methylphenidate CD
methylphenidate ER
methylphenidate LA
methylphenidate SR
methylprednisolone
methyltestesterone
metipranolol
metoclopramide
metolazone
metoprolol succinate SR
metoprolol tartrate
metoprolol/HCTZ
METOZZOLV ODT
METROCREAM
METROGEL 1% ONLY
METROGEL VAG
METROLOTION
metronidazole
metronidazole
metronidazole SR
METVIXIA
MEVACOR
mexiletine
MIACALCIN injection
MIACALCIN NASAL
MICARDIS
MICARDIS HCT
microgestin
microgestin FE
micronefrin
MICROZIDE
midazolam
MIGRANAL
MILLIPRED
MINASTRIN 24 FE CHEW
Copay
Tier
1
1
2
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
1
1
1
3
3
1
2
3
3
3
1
1
1
3
1
2
3
3
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Gender
Specialty
Age, Gender
Age, Gender
Qty. Limit
Gender
Drug Name
MINIPRESS
MINIRIN
MINOCIN
minocycline
minocycline ER
minoxidyl
MIRAPEX
MIRCETTE
mirtazapine
mirtazapine ODT
misoprostol
MISTOSOL
MOBIC
modafinil
MODICON 0.5/35
moexipril
moexipril/HCTZ
mometasone
monessa
MONOCLATE-P
MONODOX
MONOKET
MONONINE
MONSEL'S
montelukast sod (10mg tab, 4mg, 5mg chew)
MONUROL
MORGIDOX
morphine sulfate
morphine sulfate CR
morphine sulfate ER Pel
MS CONTIN
MUGARD
mupirocin
MYAMBUTOL
MYFORTIC
MYLERAN
MYOZYME
myrac
MYRBETRIQ
nabumetone
nadolol
nadolol/bendroflumethiazide
NAFTIN
NALFON
naltrexone
NAMENDA
nandrolone deconate
Copay
Tier
3
2
3
1
1
1
3
3
1
3
1
3
3
1
3
1
1
1
1
2
3
3
3
3
1
3
3
1
1
3
3
2
1
2
2
2
2
1
3
1
1
1
3
3
1
2
1
Dispensing
Edits
Age
Age, Gender
Age, Gender
Age, Gender
Specialty
Specialty
Specialty
Specialty
Drug Name
NAPRELAN
naproxen
NAPROXEN COMFORT PAC
naproxen sodium
naratriptan
NARDIL
NASACORT AQ
NASAREL
NASONEX
NASOTUSS
NATA KOMPLETE
NATAZIA
nateglinide
NATROBA
NATURE_THYROID
NATURETIN
NEBUPENT
necon
NEEVO COMBO PK
NEEVO, NEEVO DHA
nefazodone
nemoycin/polymyxin/gramicidin
NEOBENZ MICRO
neomycin
neomycin/polymyxin/ hydrocortisone
NEORAL
NESINA
NESTABS
NESTABS ABC
NESTABS DHA
NEULASTA
NEUPOGEN
NEUPRO (Transdermal)
NEURONTIN
NEVANAC
NEXA PLUS
NEXA SELECT
NEXAVAR
NEXICLON XR
NEXIUM
NIASPAN
nicardipine
NICAZEL
NICAZEL FORTE
NICOMIDE
Nicotine Gum
Copay
Tier
3
1
3
1
1
3
3
3
3
3
3
3
1
2
2
3
3
1
3
3
1
1
3
1
1
1
3
3
3
3
3
2
2
3
3
2
3
3
2
3
3
2
1
3
3
3
1
Dispensing
Edits
Qty. Limit
Age, Gender
Age
Specialty
Specialty
Specialty
Age, Gender
Age, Gender
Specialty
Drug Name
Nicotine Lozenge
Nicotine Patches
NICOTROL (Cartridge, Spray)
nifedical CC
nifedical XL
nifedipine
nifedipine CR/ER/SR
NILANDRON
nimodipine
NIMOTOP
NIRAVAM
NIRON KOMPLETE
nisolpidine er
NITROBID
NITRO-DUR
nitrofurantoin
nitrofurantoin macrocrystal
nitroglycerin
nitroglycerin SL
nitroglycerin SR
NITROLINGUAL
NITROSTAT
nitro-transdermal
nizatidine
nora-be
NORCO
NORDETTE
Copay
Tier
1
1
3
1
1
1
1
2
1
3
3
3
1
3
3
1
1
1
1
1
2
2
1
1
1
3
3
NORDITROPIN
3
NORDITROPIN AQ
norethindrone acetate
NORINYL
NORITATE
NORMELGEL AG
NOROXIN
NORPACE
NOR-QD
nortrel
nortriptyline
NORVASC
NORVIR
NOTUSS NXD
NOTUSS NXD
novarel
3
1
3
2
3
3
3
3
1
1
3
2
3
3
1
Novofine Pen Needles
NOVOLIN
2
2
Dispensing
Edits
Age, Gender
Age, Gender
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Gender
Age, Gender
Age, Gender
Age, Gender
Rider
Qty. Limit,
Rider
Drug Name
NOVOLOG
NOVOSEVEN
Copay
Tier
2
2
Novotwist Needles
NOXAFIL
NUCORT
NUCYNTA, NUCYNTA ER
NUEDEXTA
NULYTELY
NUOX
2
3
3
3
3
3
3
NUTROPIN
NUVAIL
NUVARING
NUVIGIL
NUZON
NYMALIZE
NYMALIZE
nystatin
nystatin
nystatin vag
nystatin/triamcinolone
OB COMPLETE W/DHA
ocella
octreotide acetate
ofloxacin
ofloxacin
ofloxacin otic
2
3
3
2
3
3
3
1
1
1
1
3
1
1
1
1
1
OFORTA
OGEN
ogestrel
olanzapine
olanzapine zydis
OLEPTRO ER
OLUX
OLUX-E
3
3
1
1
1
3
3
3
OLYSIO
OMACOR
OMECLAMOX-PAK
omeprazole
omeprazole/sodium bicarf
OMNARIS
OMNICEF
3
3
3
1
1
3
3
OMNITROPE
ondesetron
3
1
Dispensing
Edits
Specialty
Qty. Limit,
Rider
Prior Auth.,
Specialty
Age, Gender
Gender
Age, Gender
Specialty
Prior Auth.,
Specialty
Gender
Age, Gender
Prior Auth,
Specialty
Prior Auth.,
Specialty
Qty. Limit
Drug Name
Copay
Tier
ONE TOUCH family of test strips
ONFI
ONGLYZA
ONGLYZA (8/1/11)
ONMEL
ONSOLIS
OPANA
OPANA ER
3
3
3
2
3
3
3
3
OPSUMIT
OPTIPRANOLOL
OPTIVAR
ORACEA
ORAMORPH SR
ORAP
ORAPRED
ORAXYL
ORBIVAN
ORENCIA
ORFADIN
orphenadrine cpd
orphenadrine ER
orphenadrine/aspirin/caffeine
ORTHO EVRA
ORTHO MICRONOR
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ORTHO-CYCELN
ORTHO-NESIC
ORTHO-NOVUM
OSCION
OSENI
OSMOPREP
OSPHENA
OVACE
OVCON
OVIDREL
oxaprozin
oxazepam
oxcarbazepine
OXECTA
OXISTAT
OXSORALEN-UL
OXTELLAR XR
oxybutynin
3
2
2
3
3
2
3
3
3
3
2
1
1
1
2
3
3
2
3
3
3
3
3
3
2
3
3
3
3
1
1
1
3
3
2
3
1
Dispensing
Edits
Qty. Limit,
Rider
Prior Auth.,
Specialty
Specialty
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Rider
Specialty
Drug Name
oxybutynin SR
oxycodone
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
OXYCONTIN CR
OXYCONTIN CR (Eff 4/1/12)
oxyfast
OXYIR
OXYTROL
PACERONE
PACNEX LP
pamidronate
PANCREAZE
PANRETIN
pantoprazole
papaverine ER
PARCOPA
PARLODEL
PARNATE
paromomycin
paroxetine
paroxetine CR/ER
PATADAY
PATANASE
PATANOL
PAXIL
PAXIL CR
PCE
PEDIADERM AF, HC, TA
PEDIATEX TDM
peg 3350
Copay
Tier
1
3
1
1
1
3
2
1
2
3
3
3
1
2
3
1
1
2
3
3
1
1
1
2
3
2
3
3
1
3
3
1
PEGASYS
PEGASYS
PEGASYS PROCLICK
2
2
2
PEG-INTRON
penicillin VK
PENLAC
PENNSAID
PENTASA
pentazocine/acetaminophen
pentazocine/naltrexone
pentoxifylline
PEPCID
PERCOCET
2
1
3
3
2
1
1
1
3
3
Dispensing
Edits
Qty. Limit
Qty. Limit
Prior Auth.,
Specialty
Specialty
Specialty
Prior Auth.,
Specialty
Drug Name
PERCODAN
PERCURA
PERFORMIST
pergnyl
perindopril erbumine
PERIOSTAT
permethrin
perphenazine
perphenazine/amitriptyline
PERSANTINE
PERTZYE
PEXEVA
phenelzine sulfate
phenobarbital
phenytoin extended
phenytoin sodium
PHOSLO
PHOSLYRA
PHOSPHOLINE
phrenilin/caffeine/codeine
pilocar
pilocarpine
pilocarpine
PILOPINE HS
piloptic
pindolol
pioglitazone/glimepiride
piroxicam
PLAVIX
PLAVIX (Eff 6/1/2012)
PLENDIL
PLETAL
PLEXION (cloth, emulsion)
PLEXION SCT
PLEXION TS
PLIAGLIS
plioglitazone
PNV FOLIC ACID + IRON
PNV-DHA PLUS
PNV-IRON
POLIBAR ORAL SUSP
POLY VI FLOR W/IRON
poly-dex
polyethylene glycol
POLYHIST forte
polymyxin B/trimethoprim
Copay
Tier
3
3
3
1
1
1
3
1
1
1
3
2
3
1
1
1
1
2
3
2
1
1
1
1
2
1
1
1
1
2
3
3
2
2
2
2
3
1
3
3
3
3
3
1
1
3
1
Dispensing
Edits
Rider
Drug Name
POLY-PRED
POLY-VI-FLOR
PONSTEL
PONTOCAINE
portia
potassium chloride
POTIGA
PRADAXA
PRAM-HCA
pramipexole di-hcl
PRANDIN
PRAVACHOL
pravastatin
prazosin
PRECEDEX
PRECISION family of test strips
PRECOSE
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone
prednisolone ophthalmic
prednisone
PREFERA OB
PREFEST
PREFLIN
PREMARIN
PREMARIN VAGINAL
PREMPHASE
PREMPRO
PRENAISSANCE NEXT B
PRENATA
PRENATAL 19
PRENATAL 19 CHEW TAB
PRENATAL PLUS
prenatal vitamins (oral)
PRENATE AM
PRENATE DHA
PRENATE ELITE
PRENATE ENHANCE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PLUS
PRENATE RESTORE
PRENEXA
PREPOIK
Copay
Tier
3
3
3
3
1
1
3
2
3
1
2
3
1
1
3
3
3
2
2
1
1
1
1
3
3
3
2
2
2
2
3
3
3
3
3
1
3
3
3
3
3
3
3
3
3
3
Dispensing
Edits
Age, Gender
Qty. Limit,
Rider
Gender
Prior Auth
Gender
Gender
Gender
Gender
Age, Gender
Age, Gender
Drug Name
PREQUE 10
PRESERA
PREVACID
PREVACID NAPRAPAC
prevalite
previfem
PREVPAC
PREZISTA
PREZISTA SUSP
PRILOSEC
PRILOSEC OTC
PRIMALEV
primaquine
primidone
principen
PRINIVIL
PRINZIDE
PRISTIQ
PROAIR HFA
procainamide
procainamide ER
PROCARDIA
PROCARDIA XL
PROCHIEVE
prochlorperazine
PROCLEAR CAP
PROCLYCEM
PROCRIT
PROCYSBI
PROFILNINE
PROGESTERONE VAGINAL
PROGRAF
PROHIST CD
PROHIST CF
PROHIST LQ
PROLEX DM
promethazine
PROMETIUM
PROMISEB COMPLETE
PRONESTYL
PRONESTYL SR
propafenone
propafernone hcl
propafernone hcl er
PROPINE
propoxyphene
propranolol
Copay
Tier
3
3
3
2
1
1
2
2
2
3
1
3
1
1
1
3
3
2
2
1
1
3
3
3
1
3
2
2
3
2
2
3
3
3
3
3
1
2
2
3
3
1
1
1
1
1
1
Dispensing
Edits
Qty. Limit
Age, Gender
Rider
Age, Rider
Specialty
Specialty
Age, Rider
Specialty
Gender
Drug Name
propranolol SR
propranolol/HCTZ
propylthiouracil
PROSCAR
PROTECT BONE
PROTECT IRON
PROTECT NATAL
PROTONIX
PROTOPIC
Copay
Tier
1
1
1
3
3
3
3
3
3
PROTROPIN
PROVENTIL HFA
PROVIGIL
PROZAC
PROZAC WEEKLY
prudoxin
PULMICORT FLEXHALER
PULMICORT RESPULES
3
3
2
3
3
1
2
2
PULMOZYNE
PUREFE OB PLUS
PUREFE PLUS
PURINETHOL
PYLERA
pyrazinamide
pyridostigmine
QNASL
QUARETTE
quasense
QUESTRAN
quetiaprine fumarate
quinapril
quinaretic
quinerva
quinidine gluconate
quinine sulfate
QUIXIN
QVAR
ramipril
RANEXA
ranitidine
RAPAFLO
RAPAMUNE
RAPIFLUX
rauwolfia/bendroflumethazide
2
3
3
2
3
1
1
3
3
1
3
1
1
1
1
1
1
3
2
1
3
1
3
3
3
1
RAVICTI 3
3
RAZADYNE/RAZADYNE ER
Dispensing
Edits
Prior Auth.,
Specialty
Qty. Limit
Qty. Limit
Prior Auth.,
Specialty
Age, Gender
Age, Gender
Gender
Age, Gender
Qty. Limit
Age
Specialty
Drug Name
Copay
Tier
REBETOL
3
REBIF
2
REBIF REBIDOSE 2
1
3
3
3
reclipsen
RECOMBINATE
RECTIV
RELENZA
RELION - NOT COVERED
RELISTOR
RELPAX
REMERON
REMERON ODT
REMESENSE
Dispensing
Edits
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Age, Gender
Specialty
X
3
2
3
3
3
REMICADE
RENAGEL
RENVELA
REPREXAIN
REPRONEX
REQUIP
REQUIP XL
RESCON JR
RESCRIPTOR
reserpine
RESPA C&C IR
RESTASIS
RESTORIL (7.5MG, 22.5MG)
RETIN-A
RETIN-A MICRO
RETROVIR
3
2
3
3
3
2
3
3
2
1
3
2
3
3
3
3
REVATIO
REV-EYES
REVLIMID
REYATAZ
REZYST
RHEUMATREX
RHINOCORT AQ
RIAX
ribasphere
ribavirin
RIDAURA
RIFAMATE
rifampin
RIFATER
3
2
2
2
3
2
3
3
1
1
2
3
1
3
Qty. Limit
Prior Auth.,
Specialty
Rider
Age
Age
Prior Auth.,
Specialty
Specialty
Specialty
Specialty
Drug Name
RILUTEK
riluzole
rimantadine
RIMSO
RIOMET
RISPERDAL
RISPERDAL M
risperidone
RITALIN
RITALIN LA
RITALIN SR
rivastigmine tartrate
rizatriptan benzoate
rizatriptan benzoate rapidis
ropinirole hcl
ROSADAN
ROSULA
ROSULA CLK
ROSULA NS
ROSULA/ROSULA CLK/ROSULA NS
ROVIDA OB
ROWASA enema
ROXICET
ROZEREM
RYTHMOL
RYTHMOL SR
RYZOLT
SAFYRAL
SAIZEN
SALAGEN
SALICYLIC ACID
salsalate
SALVAX DUO PLUS FOAM
SANCTURA
SANCTURA XR
SANDIMMUNE
SANDOSTATIN
SAPHRIS
SARAFEM
SAVELLA
SE BPO CLEANSER
SE BPO WASH
SEASONALE
SEASONIQUE
SECONAL
SECTRAL
Copay
Tier
3
1
1
2
3
3
2
1
3
3
3
1
1
1
1
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
2
1
3
3
3
3
3
3
3
3
3
3
3
3
2
3
Dispensing
Edits
Specialty
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Prior Auth.,
Specialty
Specialty
Specialty
Age, Gender
Age, Gender
Drug Name
selegiline
selenium sulfide
selfemra
SELRX
SELZENTRY
SEMPREX-D
SENSIPAR
SENTRA PM
SEREVENT DISKUS
SEROQUEL
SEROQUEL XR
Copay
Tier
1
1
1
3
2
3
2
3
2
3
2
SEROSTIM
sertraline
3
1
SIGNIFOR
SILENOR
silver sulfadiazine
SILVRSTAT
SIMBRINZA
SIMCOR
3
3
1
3
3
3
SIMPONI
simvastatin
SINEMET
SINEMET CR
SINGULAIR
SINGULAIR (10mg tab, 4mg, 5mg chew)
SIRTURO
SKELAXIN
SKELID
SKLICE
SMZ/TMP
sod. Sulfacetamide/sulfur
SODIUM SULFACETAMIDE-SULFUR GEL
SOLARAZE
solia
SOLODYN
SOMATULINE
2
1
3
3
2
3
3
3
2
3
1
1
3
3
1
3
3
SOMAVERT
SONATA
SORIATANE
SORILUX
sorine
sotalol
sotalol AF
SOVALDI
3
3
3
3
1
1
1
3
Dispensing
Edits
Prior Auth.,
Specialty
Prior Auth,
Specialty
Prior Auth.,
Specialty
Qty. Limit
Qty. Limit
Age, Gender
Specialty
Prior Auth.,
Specialty
Prior Auth
Prior Auth,
Drug Name
Copay
Tier
SPECTRACEF
SPIRIVA
spironolactone
spironolactone/HCTZ
SPORANOX
sprintec
SPRIX
2
2
1
1
3
1
3
SPRYCEL
sronyx
STAFLEX
STAGESIC
STALEVO
STARLIX
STATUSS GREEN
STAXYN
STELARA
STIMATE
2
1
3
3
2
3
3
3
3
2
STIVARGA
STRATTERA
STRIANT
3
3
2
STRIBILID
3
SUBOXONE
3
SUBOXONE Film
SUBSYS
2
3
SUBUTEX
SUCLEAR
SUCRAID
sucralafate
SULAR
sulfacetamide sod
sulfacetamide sod
sulfacetamide sod./sulfur susp
sulfacetamide sod/sulfar/urea
sulfacetamide sodium
sulfacetamide sodium/prednisolone
SULFACETAMIDE SODIUM-SULFUR
SULFACET-R
sulfacet-sulf in urea emul & Sunscreen Cr kit
sulfadiazine
sulfasalazine
sulfasalazine ER
sulfazine
3
3
2
1
3
1
1
1
1
1
1
1
3
1
1
1
1
1
Dispensing
Edits
Specialty
Age, Gender
Qty. Limit,
Specialty
Age, Gender
Qty. Limit
Specialty
Age
Prior Auth,
Specialty
Preclusive
Edit
Prior Auth.,
Qty. Limit
Prior Auth.,
Qty. Limit
Prior Auth.,
Qty. Limit
Drug Name
sulfazine EC
sulfisoxazole
sulindac
SUMADAN
SUMADAN XLT
SUMADIN, SUMADIN CO
sumatriptan inj
sumatriptan nasal spray
sumatriptan tab
SUMAVEL
SUMAXIN
SUPRAX
SUPRENZA ODT
SURPREP
SUSTIVA
Copay
Tier
1
1
1
3
3
3
1
1
1
3
3
3
3
2
2
SUTENT
SYLATRON
2
3
SYLATRON PK
SYMBICORT
SYMBYAX
SYMETREL
SYMLIN
2
2
3
3
3
SYNAGIS
SYNALAR
SYNALGOS DC
SYNERA
SYNTEST DS/HS
SYNTHROID
2
3
3
3
3
3
TACHOSIL
TAFINLAR
TAGAMET
TAGRETIN
TALACEN
3
3
3
3
2
TALCONEX
TALWIN NX
TAMBOCOR
TAMIFLU
tamoxifen
tamsulosin hcl
TAPAZOLE
TARCEVA
TARGRETIN
TARKA
3
2
2
3
1
1
2
2
2
3
Dispensing
Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit,
Specialty
Specialty
Prior Auth.,
Specialty
Prior Auth
Prior Auth.,
Specialty
Gender
Prior Auth.,
Specialty
Step
Therapy
Specialty
Specialty
Drug Name
Copay
Tier
TASIGNA
TASMAR
TAZORAC
taztia XT
tebamide
2
2
2
1
1
TECFIDERA
TEGRETOL
TEGRETOL XL
TEKAMLO
TEKEURNA/TEKTURNA HCT
temazepam
temazepam (7.5MG, 22.5MG)
TEMODAR
temozolomide
TENEX
tenitoin 10mg
TENORETIC
TENORMIN
TERAZOL
terazosin
terbinafine
terbutaline
terconazole
TESTIM
TESTOPEL
testosterone enanthate
testoterone propionate
tetracycline
TEVETEN
TEVETEN HCT
3
3
3
2
2
1
3
2
1
3
1
3
3
3
1
1
1
1
3
3
1
1
1
1
3
3
TEV-TROPIN
THALITONE
THALOMID
THEO-24
theocap
theochron
theophylline ER
THERAMINE
thioridazine
thiothixene
THYROLAR
TIAZAC
ticlopidine
TIKOSYN
3
3
2
3
1
1
1
3
1
1
3
3
1
3
Dispensing
Edits
Qty. Limit,
Specialty
Prior Auth,
Specialty
Specialty
Gender
Gender
Prior Auth.,
Specialty
Specialty
Drug Name
TIMOLIDE
timolol
timolol maleate
timolol maleate ophth
TINDAMAX
tioconazole
tizanidine cap
tizanidine tab
TL TRISEB
TL-ICARE
TL-SELECT DHA
TOBI
TOBI PODHALER
TOBRADEX
TOBRADEX ST
tobramycin
TOFRANIL PM
tolazamide
tolbutabamide
tolmetin sodium
TOPAMAX
TOPICORT
topiramate
TOPROL XL
torsemide
TOVIAZ
TOZAL
Copay
Tier
3
1
1
1
3
1
3
1
3
3
3
1
3
2
2
1
3
1
1
1
3
3
1
3
1
2
3
TRACER BG test strips
3
TRACLEER
3
TRACLEER (Eff 12.11.2012)
TRADJENTA
tramadol
tramadol 24 HR TBMP
tramadol er
tramadol/acetaminophen
TRANDATE
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVATAN
TRAVATAN Z
trazadone
TRELSTAR
TRETIN-X
2
3
1
3
1
1
3
1
1
2
1
2
2
1
3
3
Dispensing
Edits
Gender
Gender
Specialty
Specialty
Qty. Limit,
Rider
Prior Auth.,
Specialty
Prior Auth.,
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Drug Name
TREXALL
TREXIMET
triamcinolone
triamcinolone acetate nasal spray
triamterene/HCTZ
TRIAZ
triazolam
TRIBENZOR
TRICODE AR
TRICOR
tri-estarylla
trifluoperazine
trifluridine
TRIGLIDE
triheyphenidyl
TRILEPTAL
TRI-LEVLEN
trilyte
trimethobenzamide
trimethoprim
trimox
trinessa
TRI-NORINYL
TRIPHASIL
triple antibotic
TRIPLIX
tri-previfem
tri-sprintec
TRIVEEN-U
TRI-VITAMIN W/FL
trivora
TRIZIVIR
TROKENDI XR
TROPAZONE
Copay
Tier
2
3
1
1
1
3
1
2
3
3
1
1
1
3
1
3
3
1
1
1
1
1
3
3
1
3
1
1
3
3
1
2
3
3
TRUE TRACK test strips
TRUSOPT
TRUVADA
TUDORZA
TUSSIONEX
TWINJECT
TYKERB
TYLENOL/CODEINE
TYLOX
TYVASO
3
3
2
3
3
2
2
3
3
3
TYZEKA
3
Dispensing
Edits
Specialty
Qty. Limit
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Qty. Limit,
Rider
Qty. Limit
Qty. Limit
Specialty
Prior Auth.,
Specialty
Drug Name
UCERIS
ULESFIA
ULORIC
ULTRACET
ULTRAM
ULTRAM ER
ULTRASE
ULTRAVATE
ULTRAVATE X
UNIPHYL
UNIRETIC
UNITHROID
UNIVASC
URAMAXIN
URAMAXIN GT
URECHOLINE
URELLE
UREX
URISPAS
UROCIT-K
UROCIT-K
UROGESIC-BLUE
UROXATRAL
URSO
URSO FORTE
ursodiol
ursodiol
UTA
UTAC
UTOPIC
VAGIFEM
VAGIFEM Tab
valacyclovir
VALCYTE
valsartan
valsartan/HCTZ
VALTREX
VALTURNA
vanatrip
vandazole
VANDETANIB
VANOS
VANTIN
VASCEPA
VASCULERA
VASERETIC
VASODILAN
Copay
Tier
2
2
3
3
3
2
3
3
3
3
3
3
3
3
3
3
2
3
2
3
2
3
3
3
1
1
3
3
3
2
2
1
3
1
1
3
2
1
1
3
3
3
3
3
3
3
Dispensing
Edits
Qty. Limit
Qty. Limit
Gender
Gender
Gender
Specialty
Drug Name
VASOTEC
VAYACOG
VAYARIN
VAYAROL
V-COF
veetids
velivet
VELTIN
VENATAL - FA
VENELEX OIN
venlafaxine
venlafaxine ER caps
venlafaxine OSM 24H
VENTAVIS
VENTOLIN HFA
VERAMYST
verapamil
verapamil 24 HR Pel
verapamil SR/ER/CE/XR
VERCACLOZ
VERDESO
VEREGEN
VERELAN
VERELAN PM
VESICARE
VEXOL
VFEND
V-HIST
VIAGRA
VIBRAMYCIN
VIBRATAB
VICODIN
VICODIN ES
VICODIN HP
VICOPROFEN
VICTOZA
VICTRELIS
VIDEX
VIDEX EC
VIGAMOX
VIIBRYD
VIMOVO
VIOKASE
VIRACEPT
VIRAMUNE
VIRAMUNE XR
Copay
Tier
3
3
3
3
3
1
1
3
3
3
1
1
3
3
2
3
1
1
1
3
3
3
3
3
3
2
3
3
2
3
3
3
3
3
3
3
3
3
3
2
3
3
2
2
2
3
Dispensing
Edits
Age, Gender
Prior Auth
Qty. Limit
Prior Auth.,
Specialty
Drug Name
VIRASAL
Copay
Tier
3
VIRAZOLE
VIREAD
VIRT-VITE
VISICOL
VITAFOL ULTRA
VITAFOL-ONE
VITAFOL PLUS
2
2
3
3
3
VITAMEDMD ONE RX
VIVA CT
3
3
VIVELLE/VIVELLE DOT
VOL-NATE
VOL-PLUS
VOL-TAB RX
VOLTAREN
VOLTAREN
VOLTAREN GEL
VOLTAREN XR
VOPAC
VOSPIRE ER
VOTRIENT
2
3
3
2
3
2
3
3
3
3
3
VPRIV
VUSION
VYTONE
VYTORIN
VYVANSE
warfarin
WELCHOL
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
WESTHROID
XALATAN
XANAX XR
XARELTO (Eff 12/1/11)
3
2
3
3
2
1
2
3
3
3
2
2
3
2
XELODA
XERESE
XIAFLEX
XIBROM
XIFAXAN
XODOL
2
3
3
3
3
3
XOLAIR
XOLEGEL
3
2
Dispensing
Edits
Prior Auth.,
Specialty
Age, Gender
3
Age, Qty.
Limit
Gender, Qty.
Limit
Specialty
Prior Auth.,
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Prior Auth.,
Specialty
Specialty
Prior Auth.,
Specialty
Drug Name
Copay
Tier
XOPENEX
3
XOPENEX HFA
XYNTHA
XYREM
XYZAL
YASMIN
YAZ
yohimbine
ZACARE
ZACLIR
zafirlukast
zalepon
ZANAFLEX
ZANTAC
ZANTAC (syrup)
ZARONTIN
ZAROXOLYN
ZAVESCA
zazole
Z-COF I
ZEBETA
ZEGERID
ZEMPLAR
ZEN PEP
ZENDEDI
ZERIT
ZESTORETIC
ZESTRIL
ZETIA
ZETONNA
ZIAC
ZIAGEN
ZIANA
zidovudine
ZINOTIC/ZINOTIC ES
ziprasidone
ZIRGAN
ZITHROMAX
ZMAX
ZOCOR
ZODERM
ZOFRAN
ZOFRAN ODT
ZOLINZA
ZOLOFT
3
2
3
3
3
3
1
3
3
1
1
3
3
3
3
3
3
1
3
3
3
2
2
3
2
3
3
2
3
3
2
3
1
3
1
3
3
3
3
3
3
3
2
3
Dispensing
Edits
Age, Prior
Auth
Age, Prior
Auth
Qty. Limit
Age, Gender
Age, Gender
Qty. Limit
Specialty
Gender
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Copay
Tier
1
1
3
2
Drug Name
zolpidem
zolpidem tartrate cr
ZOLPIMIST
ZOLVIT
ZOMETA
ZOMIG
ZOMIG INH
ZOMIG ZMT
ZONALON
ZONATUSS
ZONEGRAN
zonisamide
3
3
3
3
3
3
3
1
ZORBTIVE
ZORTRESS
ZORVOLEX
3
3
3
3
3
1
3
2
3
2
3
3
3
3
3
3
2
3
3
3
2
3
3
ZORVOLEX ZOTEX-PE, EX, D
zovia
ZOVIRAX
ZOVIRAX (topical)
Z-PRAM
ZPREXA
ZUBSOLV
ZULPLENZ
ZUTRIPRO
ZYDONE
ZYFLO/ZYFLO CR
ZYLET
ZYMAR
ZYPRAM
ZYPREXA
ZYPREXA ZYDIS
ZYTAZE
ZYTIGA
ZYVOX
Dispensing
Edits
Prior Auth.,
Specialty
Qty. Limit
Qty. Limit
Prior Auth.,
Specialty
Specialty
Age, Gender
Qty. Limit
Specialty
Prior Auth
52 Therapeutic Preferred Drug List Therapeutic
Class
Antineoplastic
Agents
Copay
Tier
Therapeutic Class II
Drug Name
Dispensing Edits
Adrenal Steroid Inhibitors
CYTADREN
3
Alkylating Agents
ALKERAN
2
(blank)
CEENU
2
Specialty
cyclophosphamide
1
(blank)
HEXALEN
2
Specialty
LEUKERAN
2
(blank)
MYLERAN
2
Specialty
(blank)
TEMODAR
2
Specialty
temozolomide
1
(blank)
Anti-Androgenic Agent
ZYTIGA
3
Specialty
Antimetabolites
mercaptopurine
1
Specialty
methotrexate
1
(blank)
Antineoplastic Enzyme Inhibitor
Antineoplastic Hormonal Agents
OFORTA
3
Prior Auth., Specialty
PURINETHOL
2
(blank)
TREXALL
2
Specialty
XELODA
2
GLEEVEC
2
Specialty
NEXAVAR
2
Specialty
SPRYCEL
2
Qty. Limit, Specialty
SUTENT
2
TARCEVA
2
Specialty
TASIGNA
2
VANDETANIB
3
Specialty
anastrozole
1
(blank)
ARIMIDEX
3
AROMASIN
3
Specialty
bicalutamide
1
(blank)
CASODEX
2
Specialty
DEPO-PROVERA
2
(blank)
EMCYT
2
Specialty
EULEXIN
2
Specialty
exemestane
1
FARSETON
2
Specialty
FEMARA
3
flutamide
1
(blank)
letrozole
1
Specialty
leuprolide
1
(blank)
LUPRON
3
Specialty
LUPRON DEPOT
3
Specialty
MEGACE
3
(blank)
MEGACE ES
3
(blank)
megestrol
1
(blank)
NILANDRON
2
(blank)
tamoxifen
1
(blank)
(blank)
Class
Drug Name
Antineoplastic, System Enzyme Inh
ICLUSIG
Hedgehog Pathway Inh
Immunomodulators
THALOMID
2
Specialty
JAK Inh
JAKAFI
3
(blank)
LHRH(GNRH) Agonist
FIRMAGON
2
Specialty
TRELSTAR
3
Specialty
Miotic Inhibitors
etoposide
1
Specialty
Miscellaneous
ACTIMMUNE
2
Specialty
HYDREA
3
(blank)
hydroxyurea
1
(blank)
Mtor Kinase Inhibitor
Blood Products
Copay
Tier
Dispensing Edits
3
Specialty
ERIVEDGE
3
Specialty
REVLIMID
2
Specialty
INTRON-A
2
leucovorin calcium
1
(blank)
MATULANE
2
(blank)
MESNEX
2
(blank)
TARGRETIN
2
Specialty
tenitoin 10mg
1
(blank)
TYKERB
2
Specialty
ZOLINZA
2
Specialty
AFINITOR
3
SERM
FASLODEX
2
Specialty
Skin and Mucous Membrane
METVIXIA
3
Specialty
Systemic Enzyme Inh
GILOTRIF
3
Specialty
IMBRUVICA
3
(blank)
INLYTA
3
Specialty
MEKINIST
3
(blank)
STIVARGA
3
Prior Auth, Specialty
TAFINLAR
3
(blank)
VOTRIENT
3
Specialty
Anticoagulant
ARIXTRA
3
COUMADIN
3
(blank)
enoxaparin
1
Qty. Limit
fondaparinux
2
FRAGMIN
2
Qty. Limit
heparin
1
Qty. Limit
INNOHEP
2
Qty. Limit
LOVENOX
3
Qty. Limit
warfarin
1
(blank)
Antiinhibitor Coagulant Cplx
FEIBA VH IMMUNO
2
Specialty
Blood Plasma
TACHOSIL
3
FACTOR
XYNTHA
2
(blank)
Factor IX Complex
BEBULIN VH
2
Specialty
Factor IX Non Recombinant
ALPHANINE SD
2
Specialty
MONONINE
3
Specialty
PROFILNINE
2
Specialty
Class
Drug Name
Factor IX Recombinant
BENEFIX
3
Factor VIIa
NOVOSEVEN
2
Specialty
Factor VIII Human
ALPHANATE
2
Specialty
HEMOFIL M
2
Specialty
HUMATE-P
2
Specialty
KOATE-DVI
3
Specialty
Factor VIII Recombinant
Dispensing Edits
Specialty
MONOCLATE-P
2
Specialty
ADVATE
2
Specialty
HELIXATE FS
3
Specialty
KOGENATE FS
3
Specialty
KOGENATE FS IV
3
Specialty
RECOMBINATE
3
Specialty
Gauchers Disease
ZAVESCA
3
Specialty
Hematopoetic Growth Factor
ARANESP
2
Specialty
EPOGEN
2
Specialty
Platlet Aggregation Inhibitor
Cardiovascular
System
Copay
Tier
ACE Inhibitors and Combos
GRANIX
3
Specialty
LEUKINE
2
Specialty
NEULASTA
2
Specialty
NEUPOGEN
2
Specialty
PROCRIT
2
Specialty
AGGRENOX
2
(blank)
AGRYLIN
2
(blank)
anagrelide
1
(blank)
cilostazol
1
(blank)
clopidogrel bisulfate
1
(blank)
dypridamole
1
(blank)
PERSANTINE
3
(blank)
PLAVIX
2
(blank)
PLAVIX (Eff 6/1/2012)
3
(blank)
PLETAL
2
(blank)
ticlopidine
1
(blank)
ACCUPRIL
3
Qty. Limit
ACCURETIC
3
Qty. Limit
ACEON
3
(blank)
ALTACE
3
Age, Qty. Limit
benazepril
1
(blank)
benazepril/HCTZ
1
(blank)
CAPOTEN
3
(blank)
CAPOZIDE
3
(blank)
captopril
1
(blank)
captorpril/HCTZ
1
(blank)
enalapril
1
(blank)
enalapril/HCTZ
1
(blank)
EPANED
3
(blank)
fosinapril
1
(blank)
Class
Drug Name
fosinapril/HCTZ
Copay
Tier
Dispensing Edits
1
(blank)
lisinopril
1
(blank)
lisinopril/HCTZ
1
(blank)
LOTENSIN
3
(blank)
LOTENSIN HCT
3
(blank)
MAVIK
3
(blank)
moexipril
1
(blank)
moexipril/HCTZ
1
(blank)
1
(blank)
PRINIVIL
3
(blank)
PRINZIDE
3
(blank)
quinapril
1
(blank)
quinaretic
1
(blank)
ramipril
1
Age
trandolapril
1
(blank)
UNIRETIC
3
(blank)
UNIVASC
3
(blank)
VASERETIC
3
(blank)
VASOTEC
3
(blank)
ZESTORETIC
3
(blank)
ZESTRIL
3
(blank)
Agiotensin Recep Antag
losartan
1
(blank)
losartan/hctz
1
(blank)
Alpha-Beta Blockers
carvidilol
1
(blank)
COREG
3
(blank)
COREG CR
3
(blank)
labatelol
1
(blank)
TRANDATE
3
(blank)
AUVI-Q
2
(blank)
epinephrine
1
(blank)
EPIPEN
2
(blank)
EPIPEN-JR
2
(blank)
Anaphalaxis Therapy Agents
TWINJECT
2
Qty. Limit
Anthyperlipidemic
KYNAMRO
3
Antiadrenergic Antihypertensives
CARDURA
3
(blank)
CARDURA XL
3
Qty. Limit
CATAPRES
3
(blank)
CATAPRES-TTS
3
(blank)
clonidine
1
(blank)
clonidine patch
1
(blank)
doxazosin
1
(blank)
guanabenz
1
(blank)
guanfacine
1
(blank)
HYTRIN
3
(blank)
methyldopa
1
(blank)
Class
Antianginal - Nitrates
Drug Name
Copay
Tier
Dispensing Edits
MINIPRESS
3
(blank)
prazosin
1
(blank)
reserpine
1
(blank)
TENEX
3
(blank)
terazosin
1
(blank)
amyl nitrate
1
(blank)
DILATRATE SR
3
(blank)
IMDUR
3
(blank)
ISMO
3
(blank)
ISORDIL
3
(blank)
isosorbide dinitrate
1
(blank)
isosorbide mononitrate
1
(blank)
MONOKET
3
(blank)
NITROBID
3
(blank)
NITRO-DUR
3
(blank)
nitroglycerin
1
(blank)
nitroglycerin SL
1
(blank)
nitroglycerin SR
1
(blank)
NITROLINGUAL
2
(blank)
NITROSTAT
2
(blank)
nitro-transdermal
1
(blank)
Antianginal - Other
RANEXA
3
(blank)
Antiarrhythmic Type 1-A
disopyramide
1
(blank)
guinidine sulfate
1
(blank)
NORPACE
3
(blank)
procainamide
1
(blank)
procainamide ER
1
(blank)
PRONESTYL
3
(blank)
PRONESTYL SR
3
(blank)
quinidine gluconate
1
(blank)
Antiarrhythmic Type 1-B
mexiletine
1
(blank)
Antiarrhythmic Type 1-C
flecanide
1
(blank)
propafenone
1
(blank)
propafernone hcl
1
(blank)
propafernone hcl er
1
(blank)
RYTHMOL
3
(blank)
RYTHMOL SR
3
(blank)
TAMBOCOR
2
(blank)
amiodarone
1
(blank)
CORDARONE
3
(blank)
PACERONE
3
(blank)
TIKOSYN
3
(blank)
EFFIENT
2
(blank)
ELIQUIS (Eff 8/1/13)
2
(blank)
PRADAXA
2
(blank)
Antiarrhythmic Type III
Anticoagulant
Class
Antihyperlipidemic - Bile Sequestrants
Antihyperlipidemic - Fibric Acid
Derivative
Antihyperlipidemic - HMG CoA
Reductase Inh
Drug Name
Copay
Tier
Dispensing Edits
XARELTO (Eff 12/1/11)
2
(blank)
cholestyramine
1
(blank)
COLESTID
3
(blank)
colestipol
1
(blank)
prevalite
1
(blank)
QUESTRAN
3
(blank)
WELCHOL
2
(blank)
ANTARA
3
(blank)
fenofibrate
1
(blank)
FENOGLIDE
3
(blank)
gemfibrozil
1
(blank)
LIPOFEN
3
(blank)
LOFIBRA
3
(blank)
LOPID
3
(blank)
TRICOR
3
(blank)
TRIGLIDE
3
(blank)
TRIPLIX
3
(blank)
ADVICOR
3
Qty. Limit
ALTOPREV
3
Qty. Limit
atorvastatin (Eff 12/1/2011)
1
Qty. Limit
CADUET (Eff 1/15/12)
3
(blank)
CRESTOR
2
Qty. Limit
fluvastatin sod
1
(blank)
LESCOL
3
Qty. Limit
LESCOL XL
3
Qty. Limit
LIPITOR
2
Qty. Limit
LIPITOR (Eff 12/1/2011)
3
Qty. Limit
LIPTRUZET
3
(blank)
LIVOLO
3
Qty. Limit
lovastatin
1
(blank)
MEVACOR
3
(blank)
PRAVACHOL
3
(blank)
pravastatin
1
(blank)
SIMCOR
3
(blank)
simvastatin
1
(blank)
VYTORIN
3
Qty. Limit
ZOCOR
3
(blank)
Antihyperlipidemic - HMG CoA
Reductase Inh combo
atorvastatin/amlodipine
1
Qty. Limit
Antihyperlipidemic - Intestinal
Cholesterol Absorp. Inh
ZETIA
2
(blank)
Antihyperlipidemic - Other
LOVAZA
3
(blank)
NIASPAN
2
(blank)
amlodipine/valsartan
1
(blank)
ARB and Combos
Class
Beta Blocker Cardioselective & Combos
Drug Name
Copay
Tier
Dispensing Edits
amlodipine/valsartan/hctz
1
(blank)
ATACAND
3
Qty. Limit
ATACAND HCT
3
Qty. Limit
AVALIDE
3
Qty. Limit
AVAPRO
3
Qty. Limit
AZOR
3
(blank)
AZOR (8/1/11)
2
(blank)
BENICAR
2
Qty. Limit
BENICAR HCT
2
Qty. Limit
COZAAR
3
Qty. Limit
DIOVAN
3
(blank)
DIOVAN HCT
3
Qty. Limit
EDARBI
3
(blank)
eprosartan mesylate
1
(blank)
EXFORGE, EXFORGE HCT
3
(blank)
HYZAAR
3
(blank)
irbesartan
1
Qty. Limit
irbesartan/HCTZ
1
Qty. Limit
losartan
1
(blank)
losartan/hctz
1
(blank)
MICARDIS
3
(blank)
MICARDIS HCT
3
(blank)
TEVETEN
3
(blank)
TEVETEN HCT
3
(blank)
valsartan
1
(blank)
valsartan/HCTZ
1
(blank)
VALTURNA
2
(blank)
acebutolol
1
(blank)
atenolol
1
(blank)
atenolol/chlorthalidone
1
(blank)
BETAPACE
3
(blank)
BETAPACE AF
3
(blank)
betaxolol
1
(blank)
bisoprolol fumarate
1
(blank)
bisoprolol/HCTZ
1
(blank)
BYSTOLIC
3
Qty. Limit
CORGARD
3
(blank)
KERLONE
3
(blank)
LOPRESSOR
3
(blank)
LOPRESSOR HCT
3
(blank)
metoprolol succinate SR
1
(blank)
metoprolol tartrate
1
(blank)
SECTRAL
3
(blank)
TENORETIC
3
(blank)
Class
Beta Blocker Non-Selective & Combos
Calcium Channel Blocker
Drug Name
Copay
Tier
Dispensing Edits
TENORMIN
3
(blank)
TOPROL XL
3
(blank)
ZEBETA
3
(blank)
ZIAC
3
(blank)
CORZIDE
3
(blank)
INDERAL
3
(blank)
INDERAL LA
3
(blank)
INDERIDE
3
(blank)
INNOPRAN XL
3
(blank)
LEVATOL
3
(blank)
metoprolol/HCTZ
1
(blank)
nadolol
1
(blank)
nadolol/bendroflumethiazide
1
(blank)
pindolol
1
(blank)
propranolol
1
(blank)
propranolol SR
1
(blank)
propranolol/HCTZ
1
(blank)
sorine
1
(blank)
sotalol
1
(blank)
sotalol AF
1
(blank)
TIMOLIDE
3
(blank)
timolol maleate
1
(blank)
ADALAT CC
3
Qty. Limit
afeditab
1
Qty. Limit
amlodipine
1
Qty. Limit
CALAN
3
Qty. Limit
CALAN SR
3
Qty. Limit
CARDENE
3
(blank)
CARDENE SR
3
(blank)
CARDIZEM
3
(blank)
CARDIZEM CD
3
Qty. Limit
CARDIZEM LA
3
Qty. Limit
cartia XL
1
Qty. Limit
COVERA-HS
3
Qty. Limit
DILACOR XR
3
(blank)
diltia XT
1
(blank)
diltiazem
1
(blank)
diltiazem CD/ER/XT
1
(blank)
diltiazem SR
1
(blank)
DYNACIRC CR
3
(blank)
felodipine
1
(blank)
ISOPTIN SR
3
(blank)
isradipine
1
(blank)
nicardipine
1
(blank)
Class
Drug Name
nifedical CC
Copay
Tier
Dispensing Edits
1
(blank)
nifedical XL
1
(blank)
nifedipine
1
(blank)
nifedipine CR/ER/SR
1
(blank)
nimodipine
1
(blank)
NIMOTOP
3
(blank)
nisolpidine er
1
(blank)
NORVASC
3
(blank)
NYMALIZE
3
(blank)
PLENDIL
3
(blank)
PROCARDIA
3
(blank)
PROCARDIA XL
3
(blank)
SULAR
3
(blank)
taztia XT
1
(blank)
TIAZAC
3
(blank)
verapamil
1
(blank)
verapamil 24 HR Pel
1
(blank)
verapamil SR/ER/CE/XR
1
(blank)
VERELAN
3
(blank)
VERELAN PM
3
(blank)
digitek
1
(blank)
digoxin
1
(blank)
LANOXICAP
3
(blank)
LANOXIN
3
(blank)
CCB Combo
AMTURNIDE (Eff 7/1/11)
2
Qty. Limit
TEKAMLO
2
(blank)
Combinations-Misc
amlodipine/benazepril
1
Qty. Limit
BIDIL
2
(blank)
CLORPRES
3
(blank)
hydralazine/HCTZ
1
(blank)
LOTREL
3
(blank)
methyldopa/HCTZ
1
(blank)
rauwolfia/bendroflumethazide
1
(blank)
TARKA
3
(blank)
Cardiac Glycoside
Direct Renin Inhibitor
TEKEURNA/TEKTURNA HCT
2
(blank)
Diuretic - Carbonic Anhydrase Inh
acetazolamide
1
(blank)
DIAMOX
3
(blank)
methazolamide
1
(blank)
bumetanide
1
(blank)
BUMEX
3
(blank)
DEMADEX
3
(blank)
EDECRIN
3
(blank)
furosemide
1
(blank)
LASIX
3
(blank)
torsemide
1
(blank)
Diuretic - Loop
Class
Drug Name
Diuretic - Potassium Sparing & Combos
ALDACTAZIDE
Copay
Tier
Dispensing Edits
3
(blank)
ALDACTAZIDE 50/50
3
(blank)
ALDACTONE
3
(blank)
amiloride
1
(blank)
amiloride/HCTZ
1
(blank)
DYAZIDE
3
(blank)
DYRENIUM
2
(blank)
MAXZIDE
3
(blank)
spironolactone
1
(blank)
spironolactone/HCTZ
1
(blank)
triamterene/HCTZ
1
(blank)
Diuretic - SARAs
INSPRA
2
(blank)
Diuretic - Thiazide/Thiazide Like
chlorthalidone
1
(blank)
chlorthiazide
1
(blank)
DIURIL
3
(blank)
hydrochlorothiazide (HTCZ)
1
(blank)
indapamide
1
(blank)
methychlorthiazide
1
(blank)
metolazone
1
(blank)
MICROZIDE
3
(blank)
NATURETIN
3
(blank)
THALITONE
3
(blank)
ZAROXOLYN
3
(blank)
DPP4 Combo
JUVISYNC
3
(blank)
Hemorreologic Agents
pentoxifylline
1
(blank)
Lipotropic
OMACOR
3
(blank)
VASCEPA
3
(blank)
PAH
ADCIRCA
3
OPSUMIT
3
DEMSER
3
(blank)
DIBENZYLINE
2
(blank)
Platlet Aggregation Inhibitor
BRILINTA (effective 7/1/13)
2
(blank)
Potassium Replacement
potassium chloride
1
(blank)
Pulmonary Hypertension
LETAIRIS
2
(blank)
Pheochromocytoma
REVATIO
3
TRACLEER
3
TRACLEER (Eff 12.11.2012)
2
TYVASO
3
(blank)
VENTAVIS
3
(blank)
Sympatholytic
NEXICLON XR
3
(blank)
Thrombin Inh
IPRIVASK
3
Specialty
Vasodilators
ADEMPAS
3
Specialty
hydralazine
1
(blank)
isoxuprine
1
(blank)
Class
Central Nervous
System
ADD/ADHD
ALS Agent
Drug Name
Copay
Tier
Dispensing Edits
minoxidyl
1
(blank)
papaverine ER
1
(blank)
VASODILAN
3
(blank)
INTUNIV
3
(blank)
KAPVAY
3
(blank)
RILUTEK
3
Specialty
riluzole
1
Specialty
Analgesic
RELISTOR
3
(blank)
Analgesic - Narcotic
BUTRANS
3
(blank)
COCET Plus
3
(blank)
CONZIP
3
(blank)
EXALGO
3
(blank)
FIORICET W/CODEINE
3
(blank)
hydrocodone bit/APAP
1
(blank)
NUCYNTA, NUCYNTA ER
3
(blank)
ONSOLIS
3
(blank)
ZOLVIT
2
(blank)
Analgesic/Antypyretic
SALAGEN
3
(blank)
Anorexiant
SUPRENZA ODT
3
(blank)
Antianxiety - Benzodiazepines
Antianxiety - Misc
Anticonvulsant
Anticonvulsants - Benzodiapines
Anticonvulsants - Carbamates
alprazolam
1
(blank)
alprazolam ER
1
(blank)
alprazolam rapidis
1
(blank)
chlordiazepoxide
1
(blank)
clorazepate
1
(blank)
diazepam
1
(blank)
lorazepam
1
(blank)
NIRAVAM
3
(blank)
oxazepam
1
(blank)
XANAX XR
3
(blank)
buspirone
1
(blank)
hydroxyne pamoate
1
(blank)
hydroxyzine hcl
1
(blank)
meprobamate
1
(blank)
FANATREX
3
(blank)
ONFI
3
(blank)
OXTELLAR XR
3
(blank)
POTIGA
3
(blank)
TROKENDI XR
3
(blank)
clonazepam
1
(blank)
clonazepam - disintigrating tab
1
(blank)
DIASTAT
2
(blank)
KLONOPIN
3
(blank)
KLONOPIN WAFER
3
(blank)
felbamate
1
(blank)
FELBATOL
2
(blank)
Class
Drug Name
FELBATOL (4/1/12)
Copay
Tier
Dispensing Edits
3
(blank)
Anticonvulsants - GABA Modulator
GABITRIL
3
(blank)
Anticonvulsants - Hydantoin
phenytoin extended
1
(blank)
phenytoin sodium
1
(blank)
Anticonvulsants - Misc
carbamazapine xl
1
(blank)
carbamazepine
1
(blank)
gabapentin
1
(blank)
GABARONE
3
(blank)
KEPPRA
3
(blank)
KEPPRA XR
3
(blank)
LAMICTAL
3
(blank)
LAMICTAL XR
3
(blank)
lamotrigine
1
(blank)
lamotrigine XR
1
(blank)
levetiracetam
1
(blank)
levetiracetam ER
1
(blank)
LYRICA
2
(blank)
NEURONTIN
3
(blank)
oxcarbazepine
1
(blank)
primidone
1
(blank)
TEGRETOL
3
(blank)
TEGRETOL XL
3
(blank)
TOPAMAX
3
(blank)
topiramate
1
(blank)
TRILEPTAL
3
(blank)
ZONEGRAN
3
(blank)
zonisamide
1
(blank)
CELONTIN
2
(blank)
ethosuximide
1
(blank)
Anticonvulsants - Succinamide
Anticonvulsants - Valpric Acid
Antidementia - Alzheimers Dx
ZARONTIN
3
(blank)
DEPAKOTE
3
(blank)
DEPAKOTE ER
3
(blank)
DEPAKOTE SPRINKLE
3
(blank)
divalproex sodium DR
1
(blank)
divalproex sodium ER
1
(blank)
divalproex sodium sprinkle
1
(blank)
divalproex sodium SR
1
(blank)
ARICEPT/ARICEPT ODT
3
(blank)
donepezil hcl
1
(blank)
EXELON
3
(blank)
galantamine hbr
1
(blank)
NAMENDA
2
(blank)
RAZADYNE/RAZADYNE ER
3
(blank)
rivastigmine tartrate
1
(blank)
Class
Copay
Tier
Drug Name
Antidepressant - Alpha 2 Receptor
Agonist
mirtazapine
1
(blank)
mirtazapine ODT
3
(blank)
REMERON
3
(blank)
REMERON ODT
3
(blank)
EMSAM
2
(blank)
MARPLAN
2
(blank)
NARDIL
3
(blank)
PARNATE
3
(blank)
phenelzine sulfate
1
(blank)
tranylcypromine sulfate
1
(blank)
budeprion
1
(blank)
budeprion XL
1
(blank)
bupropion
1
(blank)
bupropion SR
1
(blank)
marprotaline
1
(blank)
nefazodone
1
(blank)
trazadone
1
(blank)
WELLBUTRIN
3
(blank)
WELLBUTRIN SR
3
(blank)
WELLBUTRIN XL
3
(blank)
CYMBALTA
3
(blank)
EFFEXOR
3
(blank)
EFFEXOR XR
3
(blank)
FETZIMA
3
(blank)
PRISTIQ
2
(blank)
venlafaxine
1
(blank)
venlafaxine ER caps
1
(blank)
venlafaxine OSM 24H
3
(blank)
BRISDELLE
3
(blank)
CELEXA
3
(blank)
citalopram
1
(blank)
escitalopram oxalate
1
(blank)
fluoxetine
1
(blank)
fluvoxamine
1
(blank)
LEXAPRO
3
(blank)
LUVOX CR
3
(blank)
paroxetine
1
(blank)
paroxetine CR/ER
1
(blank)
PAXIL
3
(blank)
PAXIL CR
3
(blank)
PEXEVA
3
(blank)
PROZAC
3
(blank)
PROZAC WEEKLY
3
(blank)
RAPIFLUX
3
(blank)
Antidepressant - MAO Inhibitor
Antidepressant - Misc
Antidepressant - SNRI
Antidepressant - SSRI
Dispensing Edits
Class
Drug Name
sertraline
Antidepressant - Tricyclic Agent
Antiemetic
Antiparkinson
Antiparkinson - Anticholinergic
Copay
Tier
Dispensing Edits
1
(blank)
ZOLOFT
3
amitriptyline
1
(blank)
amoxapine
1
(blank)
clomipramine
1
(blank)
desipramine
1
(blank)
doxepin hcl
1
(blank)
imipramine hcl
1
(blank)
imipramine pm
1
(blank)
nortriptyline
1
(blank)
OLEPTRO ER
3
(blank)
TOFRANIL PM
3
(blank)
vanatrip
1
(blank)
DICLEGIS
3
(blank)
promethazine
1
(blank)
NEUPRO (Transdermal)
3
(blank)
REQUIP XL
3
(blank)
AKINETON
2
(blank)
benztropine
1
(blank)
COGENTIN
3
(blank)
triheyphenidyl
1
(blank)
Antiparkinson - COMT Inh
COMTAN
2
(blank)
TASMAR
2
(blank)
Antiparkinson - Dopaminergic
amantadine
1
(blank)
APOKYN
2
Specialty
bromocriptine
1
(blank)
carbidopa/levodopa
1
(blank)
carbidopa/levodopa rapidis
1
(blank)
carbidopa/levodopa SR
1
(blank)
MIRAPEX
3
(blank)
PARCOPA
2
(blank)
PARLODEL
3
(blank)
pramipexole di-hcl
1
(blank)
REQUIP
2
(blank)
ropinirole hcl
1
(blank)
SINEMET
3
(blank)
SINEMET CR
3
(blank)
STALEVO
2
(blank)
SYMETREL
3
(blank)
AZILECT
2
(blank)
ELDEPRYL
2
(blank)
Antiparkinson - Monoamine Oxidase Inh
selegiline
1
(blank)
Antiparkison Adjuncts
LODOSYN
2
(blank)
Antipsychotic
chlorpromazine
1
(blank)
Class
Drug Name
compro
Antipsychotic - Atyptical
Antipsychotic - Combo
Copay
Tier
Dispensing Edits
1
(blank)
EQUETRO
3
(blank)
fluphenazine
1
(blank)
HALDOL D
3
Rider
haloperidol
1
(blank)
INVEGA Syringe
3
(blank)
loxapine
1
(blank)
perphenazine
1
(blank)
prochlorperazine
1
(blank)
thioridazine
1
(blank)
thiothixene
1
(blank)
trifluoperazine
1
(blank)
ABILIFY
2
(blank)
ABILIFY DISC
2
(blank)
clozapine
1
(blank)
CLOZARIL
3
(blank)
FANAPT
3
Prior Auth
FAZACLO
3
(blank)
GEODON
3
(blank)
INVEGA
3
(blank)
olanzapine
1
(blank)
olanzapine zydis
1
(blank)
quetiaprine fumarate
1
(blank)
RISPERDAL
3
(blank)
RISPERDAL M
2
(blank)
risperidone
1
(blank)
SAPHRIS
3
(blank)
SEROQUEL
3
(blank)
SEROQUEL XR
2
(blank)
VERCACLOZ
3
(blank)
ziprasidone
1
(blank)
ZPREXA
2
(blank)
ZYPREXA
3
(blank)
ZYPREXA ZYDIS
3
(blank)
chlordiazepodide/amitriptyline
1
(blank)
perphenazine/amitriptyline
1
(blank)
SYMBYAX
3
(blank)
Atypical Antispychotic
LATUDA
3
(blank)
Chemical Dependency
ANTABUSE
3
(blank)
CAMPRAL
3
(blank)
disulfiram
1
(blank)
naltrexone
1
(blank)
Fibromyalgia
SAVELLA
3
(blank)
Lithium
lithium carbonate
1
(blank)
lithium carbonate CR
1
(blank)
Class
Drug Name
lithium citrate
Migraine Agents
Copay
Tier
Dispensing Edits
1
(blank)
LITHOBID
3
(blank)
AMERGE
3
Qty. Limit
AXERT
3
Qty. Limit
FROVA
3
Qty. Limit
frovatriptan succinate
1
Qty. Limit
IMITREX
3
(blank)
MAXALT
3
Qty. Limit
MAXALT MLT
3
Qty. Limit
MIGRANAL
2
Qty. Limit
naratriptan
1
Qty. Limit
RELPAX
2
Qty. Limit
rizatriptan benzoate
1
Qty. Limit
rizatriptan benzoate rapidis
1
Qty. Limit
sumatriptan inj
1
Qty. Limit
sumatriptan nasal spray
1
Qty. Limit
sumatriptan tab
1
Qty. Limit
SUMAVEL
3
Qty. Limit
TREXIMET
3
Qty. Limit
ZOMIG
3
Qty. Limit
ZOMIG INH
3
(blank)
ZOMIG ZMT
3
Qty. Limit
Movement Disorder
HORIZANT
3
(blank)
Multiple Sclerosis
AUBAGIO
3
AVONEX
2
AVONEX PEN
2
BETASERON
3
COPAXONE
2
EXTAVIA
3
GILENYA
3
REBIF
2
REBIF REBIDOSE
2
TECFIDERA
3
Muscle Relaxants and Combinations
LORZONE
3
(blank)
metaxalone
1
(blank)
Narcotic - Combo
acetaminophen/codeine
1
(blank)
aspirin/codeine
1
(blank)
butalbital/APAP/caffeine/codeine
1
(blank)
butalbital/aspirin/codeine
1
(blank)
CAPITAL/CODEINE
3
(blank)
COMBUNOX
2
(blank)
FIORICET/CODEINE
3
(blank)
FIORINAL/CODEINE
3
(blank)
hydrocodone/acetaminophen
1
(blank)
IBUDONE
3
(blank)
Class
Drug Name
LORCET
Narcotic - Partial Agonist
Narcotic Agonists
Copay
Tier
Dispensing Edits
3
(blank)
LORCET PLUS
3
(blank)
LORTAB
3
(blank)
MAGNACET
3
(blank)
MAXIDONE
3
(blank)
meperidine/promethazine
1
(blank)
meprozine
1
(blank)
NORCO
3
(blank)
ORBIVAN
3
(blank)
oxycodone/acetaminophen
1
(blank)
oxycodone/aspirin
1
(blank)
oxycodone/ibuprofen
1
(blank)
pentazocine/acetaminophen
1
(blank)
PERCOCET
3
(blank)
PERCODAN
3
(blank)
phrenilin/caffeine/codeine
1
(blank)
PRIMALEV
3
(blank)
REPREXAIN
3
(blank)
ROXICET
3
(blank)
STAFLEX
3
(blank)
STAGESIC
3
(blank)
SYNALGOS DC
3
(blank)
TALACEN
2
(blank)
tramadol/acetaminophen
1
(blank)
TYLENOL/CODEINE
3
(blank)
TYLOX
3
(blank)
ULTRACET
3
(blank)
VICODIN
3
(blank)
VICODIN ES
3
(blank)
VICODIN HP
3
(blank)
VICOPROFEN
3
(blank)
VOPAC
3
(blank)
XODOL
3
(blank)
ZYDONE
3
(blank)
bupreenorphine
1
Prior Auth., Qty. Limit
butorphanol
1
(blank)
pentazocine/naltrexone
1
(blank)
SUBOXONE
3
SUBOXONE Film
2
SUBUTEX
3
TALWIN NX
2
(blank)
ACTIQ
3
Qty. Limit
AVINZA
3
Qty. Limit
codeine phosphate
1
(blank)
codeine sulfate
1
(blank)
Class
Drug Name
DAZIDOX
Copay
Tier
Dispensing Edits
3
(blank)
DEMEROL
3
(blank)
DILUADID
3
(blank)
DURAGESIC
3
Qty. Limit
fentanyl citrate
1
(blank)
fentanyl citrate lozenge
1
Qty. Limit
fentanyl transdermal
1
Qty. Limit
fentanyl transmucosal lozenge
1
Qty. Limit
FENTORA
3
(blank)
hydromorphone
1
(blank)
KADIAN
2
Qty. Limit
levorphanol
1
(blank)
meperidine
1
(blank)
methadose
1
(blank)
morphine sulfate
1
(blank)
morphine sulfate CR
1
(blank)
morphine sulfate ER Pel
3
(blank)
MS CONTIN
3
(blank)
OPANA
3
(blank)
OPANA ER
3
(blank)
ORAMORPH SR
3
(blank)
oxycodone
3
(blank)
OXYCONTIN CR
3
Qty. Limit
OXYCONTIN CR (Eff 4/1/12)
2
Qty. Limit
oxyfast
1
(blank)
OXYIR
2
(blank)
propoxyphene
1
(blank)
RYZOLT
3
Qty. Limit
tramadol
1
Qty. Limit
tramadol 24 HR TBMP
3
Qty. Limit
tramadol er
1
Qty. Limit
ULTRAM
3
Qty. Limit
ULTRAM ER
3
Qty. Limit
ABSTRAL
3
(blank)
OXECTA
3
(blank)
SUBSYS
3
(blank)
Narcotic Withdrawl Therapy
ZUBSOLV
3
(blank)
NDRIS
FORFIVO XL
3
(blank)
PMS
SARAFEM
3
(blank)
selfemra
1
(blank)
Postherpetic Neuralgia Agent
GRALISE
3
(blank)
Pseudobulbar Affect Agent
NUEDEXTA
3
(blank)
Psychotherapeutic & Neurological
Agents
ergoloid mesylate
1
(blank)
modafinil
1
(blank)
Narcotic Analgesic
Class
Drug Name
NUVIGIL
Sedative/Hypnotic - Barbiturate
Sedative/Hypnotic - Non-Barbiturate
Smoking Cessation
Copay
Tier
Dispensing Edits
2
(blank)
ORAP
2
(blank)
PROVIGIL
2
(blank)
STRATTERA
3
(blank)
XYREM
3
(blank)
BUTISOL SODIUM
2
(blank)
MEBARAL
3
(blank)
mephobarbital
1
(blank)
phenobarbital
1
(blank)
RESTORIL (7.5MG, 22.5MG)
3
(blank)
SECONAL
2
(blank)
temazepam (7.5MG, 22.5MG)
3
(blank)
AMBIEN
3
(blank)
AMBIEN CR
3
(blank)
chloral hydrate
1
(blank)
DORAL
2
(blank)
estazolam
1
(blank)
INTERMEZZO
3
(blank)
LUNESTA
3
(blank)
midazolam
1
(blank)
PRECEDEX
3
(blank)
ROZEREM
3
(blank)
SILENOR
3
(blank)
SONATA
3
(blank)
temazepam
1
(blank)
triazolam
1
(blank)
zalepon
1
(blank)
zolpidem
1
(blank)
zolpidem tartrate cr
1
(blank)
Buproprion ER 150mg Tab
1
(blank)
CHANTIX
2
(blank)
Nicotine Gum
1
(blank)
Nicotine Lozenge
1
(blank)
Nicotine Patches
1
(blank)
NICOTROL (Cartridge, Spray)
3
(blank)
SSRI, 5HT1A Partial Agonist
VIIBRYD
3
(blank)
SSRI/SRM Antidepressant
BRINTELLIX
3
Step Therapy
Stimulants - Amphetamines
ADDERALL
3
(blank)
ADDERALL XR
3
Qty. Limit
amphetamine salts
1
(blank)
amphetamine salts ER
1
Qty. Limit
DESOXYN
3
(blank)
DEXEDRINE
3
(blank)
dextroamphetamine
1
(blank)
dextroamphetamine CR
1
Qty. Limit
Class
Stimulants - Methylphenidate
Dermatology
Acne Agents
Drug Name
Copay
Tier
Dispensing Edits
dextrostat
2
(blank)
VYVANSE
2
Qty. Limit
ZENDEDI
3
(blank)
CONCERTA
2
Qty. Limit
DAYTRANA
3
dexmethylphenidate
1
(blank)
FOCALIN
3
Qty. Limit
FOCALIN XR
2
Qty. Limit
LIQUADD
2
Qty. Limit
METADATE CD
3
Qty. Limit
METADATE ER
3
Qty. Limit
methylin
1
(blank)
METHYLIN (Chew. Soln)
3
Qty. Limit
methylin ER
1
Qty. Limit
methylphenidate
1
(blank)
methylphenidate CD
1
Qty. Limit
methylphenidate ER
1
Qty. Limit
methylphenidate LA
1
Qty. Limit
methylphenidate SR
1
(blank)
RITALIN
3
Qty. Limit
RITALIN LA
3
Qty. Limit
RITALIN SR
3
(blank)
(blank)
ACANYA
3
ACCUTANE
3
Prior Auth
acita
1
(blank)
adapalene
1
Age
AKNE-MYCIN
2
(blank)
amnesteem
2
(blank)
ATRALIN
2
(blank)
AVAR GREEN
3
(blank)
AVAR LS, E
3
(blank)
AZELEX
2
(blank)
BENZACLIN
3
(blank)
BENZAMYCIN
3
(blank)
BENZEFOAM ULTRA
3
(blank)
BENZIQ
2
(blank)
BENZIQ LS
2
(blank)
BENZIQ WASH
2
(blank)
benzoyl peroxide
1
(blank)
benzoyl peroxide pads
1
(blank)
benzoyl peroxide/urea
1
(blank)
claravis
1
Prior Auth
CLARIFOAM EF
2
(blank)
CLEANSE/TREAT PAD
3
(blank)
clindamax
3
(blank)
Class
Anesthetic
Drug Name
Copay
Tier
Dispensing Edits
clindamycin
1
(blank)
clindamycin foam
1
(blank)
DELOS
3
(blank)
DIFFERIN
3
Age
DUAC
2
(blank)
EPIDUO
3
(blank)
erythromycin
1
(blank)
erythromycin/benzoyl peroxide
1
(blank)
EVOCLIN
3
(blank)
FABIOR
3
(blank)
INOVA
3
(blank)
isotretinoin
1
Prior Auth
KLARON
3
(blank)
LAVOCLEN
3
(blank)
METROCREAM
3
(blank)
METROGEL 1% ONLY
3
(blank)
METROLOTION
3
(blank)
metronidazole
1
(blank)
NEOBENZ MICRO
3
Age
NORITATE
2
(blank)
NUOX
3
(blank)
OSCION
3
(blank)
PLEXION (cloth, emulsion)
2
(blank)
PLEXION SCT
2
(blank)
PLEXION TS
2
(blank)
RETIN-A
3
Age
RETIN-A MICRO
3
Age
RIAX
3
(blank)
SE BPO WASH
3
(blank)
sod. Sulfacetamide/sulfur
1
(blank)
sulfacetamide sod
1
(blank)
SULFACET-R
3
(blank)
sulfacet-sulf in urea emul & Sunscreen Cr kit
1
(blank)
TRETIN-X
3
(blank)
TRIAZ
3
(blank)
VELTIN
3
(blank)
ZACARE
3
(blank)
ZACLIR
3
(blank)
ZIANA
3
(blank)
ZODERM
3
(blank)
CETACAINE KIT, SPRAY, OINT
3
(blank)
CETACAINE LIQ
3
(blank)
PLIAGLIS
3
(blank)
PONTOCAINE
3
(blank)
Class
Drug Name
Anesthetics
LIDORX
Antibacterial
Antibiotic - Topical
Antifungal
Copay
Tier
Dispensing Edits
3
(blank)
NORMELGEL AG
3
(blank)
SILVRSTAT
3
(blank)
BACTROBAN CR, OINT
3
(blank)
BACTROBAN NASAL
3
(blank)
CENTANY
3
(blank)
CLINDACIN PAC
3
(blank)
DERMASORB AF
3
(blank)
gentamicin
1
(blank)
mupirocin
1
(blank)
CICLODAN
3
(blank)
ciclopirox
1
(blank)
ciclopirox gel, shampoo
1
(blank)
CILODAN CLEANSER
3
(blank)
clotrimazole/betamethasone
1
(blank)
CORTAMAX
3
(blank)
ERTACZO
3
(blank)
EXELDERM
3
(blank)
hydrocortisone/clioquinol
1
(blank)
hydrocortisone/iodoquinol
1
(blank)
ketoconazole
1
(blank)
KETODAN
3
(blank)
LOPROX (Cr., lotion, susp)
3
(blank)
LOPROX (gel, shampoo)
3
(blank)
LOTRISONE
3
(blank)
NAFTIN
3
(blank)
nystatin
1
(blank)
nystatin/triamcinolone
1
(blank)
OXISTAT
3
(blank)
PENLAC
3
(blank)
VUSION
2
(blank)
XOLEGEL
2
(blank)
Antifungal Combo - Topical
KETOCON + PLUS
3
(blank)
Anti-infective Sulfunamide
ROSULA
3
(blank)
ROSULA CLK
3
(blank)
ROSULA NS
3
(blank)
silver sulfadiazine
1
(blank)
SULFACETAMIDE SODIUM-SULFUR
1
(blank)
SUMADIN, SUMADIN CO
3
(blank)
CARAC
3
(blank)
EFUDEX
3
(blank)
FLUOROPLEX
3
(blank)
fluorouracil
1
(blank)
LEVULAN
3
(blank)
Antineoplastic & Keratolytics - Topical
Class
Antiparasitics
Antipruritics & Anesthetics - Topical
Antipsoriatic agent
Antiseborrheic
Antiviral - Topical
Drug Name
Copay
Tier
Dispensing Edits
PANRETIN
3
(blank)
SOLARAZE
3
(blank)
TAGRETIN
3
(blank)
LYCELLE
3
(blank)
NATROBA
2
(blank)
ULESFIA
2
(blank)
doxepin cr
1
(blank)
lidocaine
1
(blank)
lidocaine/prilocaine
1
(blank)
LIDODERM
3
(blank)
prudoxin
1
(blank)
SYNERA
3
(blank)
ZONALON
3
(blank)
anthralin
1
(blank)
calcipotriene
1
(blank)
DOVONEX
3
(blank)
DRITHOCREME HP
3
(blank)
DRITHO-SCALP
2
(blank)
OXSORALEN-UL
2
Specialty
SORIATANE
3
Prior Auth
SORILUX
3
(blank)
TAZORAC
2
(blank)
CLENIA
3
(blank)
EXTINA
3
(blank)
OVACE
3
(blank)
ROSULA/ROSULA CLK/ROSULA NS
3
(blank)
selenium sulfide
1
(blank)
sulfacetamide sod
1
(blank)
sulfacetamide sod/sulfar/urea
1
(blank)
DENAVIR
3
(blank)
LIDOVIR
2
(blank)
ZOVIRAX (topical)
2
(blank)
Antiviral/Anti-inflammatory
XERESE
3
(blank)
Corticosteroids - Topical
alclometasone
1
(blank)
amcinonide
1
(blank)
ANAMANTLE HC
3
(blank)
betamethasone valerate
1
(blank)
bethamethasone diprop (augmented)
1
(blank)
clobetasol
1
(blank)
clobevate
1
(blank)
CLOBEX (lotion, shampoo,)
1
(blank)
CLOBEX SPRAY
2
(blank)
CLODERM
1
(blank)
CORDRAN
2
(blank)
Class
Emollient
Drug Name
Copay
Tier
Dispensing Edits
DERMASORB HC
3
(blank)
DERMASROB TA
3
(blank)
DERMATOP
3
(blank)
DESONATE
3
(blank)
desonide
1
(blank)
DESOWEN KIT
3
(blank)
desoximetasone
1
(blank)
DIPROLENE AF
3
(blank)
ELOCON
3
(blank)
fluocinolone acetonide
1
(blank)
fluocinonide
1
(blank)
fluticasone
1
(blank)
halobetasol propionate
1
(blank)
HALOG
3
(blank)
Hydrocort/Parmoxn SKN CLNSR #16
1
(blank)
Hydrocort/Pramoxine
1
(blank)
hydrocortison valerate
1
(blank)
hydrocortisone
1
(blank)
hydrocortisone acetate
1
(blank)
hydrocortisone butyrate
1
(blank)
hydrocortisone/pramoxine
1
(blank)
lacticare/hydrocortisone
1
(blank)
LIDAMANTLE HC
3
(blank)
lidocaine/hydrocortisone
1
(blank)
LUXIQ
3
(blank)
mometasone
1
(blank)
NUCORT
3
(blank)
NUZON
3
(blank)
OLUX
3
(blank)
OLUX-E
3
(blank)
PENNSAID
3
(blank)
prednicarbate
1
(blank)
SYNALAR
3
(blank)
TALCONEX
3
Step Therapy
triamcinolone
1
(blank)
ULTRAVATE
3
(blank)
ULTRAVATE X
3
(blank)
VANOS
3
(blank)
VERDESO
3
(blank)
VYTONE
3
(blank)
ATRAPRO CP
3
(blank)
AURSTAT
3
(blank)
Emollient Combo #32
1
(blank)
EPICREAM
3
(blank)
Class
Drug Name
Copay
Tier
Dispensing Edits
HYLATOPIC P;LUS-AURSTAT
3
(blank)
HYLATOPIC PLUS
3
(blank)
HYLATOPIC, HYLATOPIC PLUS
3
(blank)
PEDIADERM AF, HC, TA
3
(blank)
PRESERA
3
(blank)
PROMISEB COMPLETE
2
(blank)
TL TRISEB
3
(blank)
TROPAZONE
3
(blank)
Hemorrhoidal Agent
ANALPRAM ADVANCED
3
(blank)
Hemorrhoidal Prep
PRAM-HCA
3
(blank)
Hemostatic
MONSEL'S
3
(blank)
AKDARA
2
(blank)
ALDARA
3
(blank)
ELIDEL
2
(blank)
imiquimod
1
(blank)
Immunomulating Agents - Topical
PROTOPIC
3
(blank)
Irritants
ORTHO-NESIC
3
(blank)
Keratolytic
ALUVEA
3
(blank)
CLEANSE & TREAT PLUS KIT
3
(blank)
DERASORB XM
3
(blank)
DURASAL
3
(blank)
KERALYT
3
(blank)
PACNEX LP
3
(blank)
SALICYLIC ACID
2
(blank)
SALVAX DUO PLUS FOAM
3
(blank)
SE BPO CLEANSER
3
(blank)
URAMAXIN
3
(blank)
URAMAXIN GT
3
(blank)
UTOPIC
3
(blank)
Local Anesthetic
Miscellaneous
VIRASAL
3
(blank)
BUPIVACAINE HCL-NS
3
(blank)
DNA MEDICATED COLLECTION
3
(blank)
LOUTREX
3
(blank)
MEDIHONEY
3
(blank)
VEREGEN
3
(blank)
RECTIV
3
(blank)
Oral Mucositis
MUGARD
2
(blank)
Protectant
GENADUR
3
(blank)
HYLASE
3
(blank)
NUVAIL
3
(blank)
FINACEA
3
(blank)
FINACEA PLUS
3
(blank)
ORACEA
3
(blank)
ROSADAN
3
(blank)
EURAX
3
(blank)
Nitrate, Rectal
Rosacea
Scabicides &Pediculicides
Class
Drug Name
lindane
Endocrine
Copay
Tier
Dispensing Edits
3
(blank)
permethrin
1
(blank)
SELRX
3
(blank)
SKLICE
3
(blank)
Steroid Combo - Topical
DESONIL + PLUS
3
(blank)
Steroids (Glucocorticoids)
TOPICORT
3
(blank)
Sulfonamide
AVAR E LS
3
(blank)
AVAR LS CLEANSER
3
(blank)
SODIUM SULFACETAMIDE-SULFUR GEL
3
(blank)
sulfacetamide sod./sulfur susp
1
(blank)
SUMADAN
3
(blank)
SUMADAN XLT
3
(blank)
SUMAXIN
3
(blank)
Tetracycline
MORGIDOX
3
(blank)
Wound Healing
VENELEX OIN
3
(blank)
Androgen
ANADROL
2
(blank)
ANDRODERM
3
(blank)
ANDROGEL
2
(blank)
AXIRON
3
(blank)
fluoxymesterone
1
(blank)
FORTESTA
3
(blank)
METHITEST
2
(blank)
methyltestesterone
1
(blank)
nandrolone deconate
1
(blank)
STRIANT
2
(blank)
TESTIM
3
(blank)
TESTOPEL
3
(blank)
1
(blank)
testoterone propionate
1
(blank)
Antidiuretic Agent
DDAVP
3
Age
desmopressin
1
Age
MINIRIN
2
Age
STIMATE
2
Age
Antihyperglycemic-Glucocorticoid
Receptor Blk
KORLYM
3
Specialty
Antipsychotic - Atyptical
GLYSET
3
(blank)
Antithyroid
methimazole
1
(blank)
propylthiouracil
1
(blank)
TAPAZOLE
2
(blank)
Contraceptive - Oral
NATAZIA
3
(blank)
Contraceptive - Transdermal
ORTHO EVRA
2
Age, Gender
Contraceptive - Vaginal
NUVARING
3
Age, Gender
Contraceptives - Inj
DEPO-PROVERA
3
Age, Qty. Limit
medroxyprogesterone
1
Age, Qty. Limit
ALESSE
3
Age, Gender
Contraceptives - Oral
Class
Drug Name
apri
Copay
Tier
Dispensing Edits
1
Age, Gender
aranelle
1
Age, Gender
aviane
1
Age, Gender
BEYAZ
3
Age, Gender
BREVICON
3
Age, Gender
camila
1
Age, Gender
cesia
1
Age, Gender
cryselle
1
Age, Gender
CYCLESSA
3
Age, Gender
DEMULEN
3
Age, Gender
DESOGEN
3
Age, Gender
enpresse
1
Age, Gender
errin
1
Age, Gender
ESTROSTEP FE
3
Age, Gender
ETHINYL ESTRADIOL/DROSPIRENONE
1
Age, Gender
FEMCON FE
3
Age, Gender
GENERESS DE
3
Age, Gender
jolessa
1
Age, Gender
jolivette
1
Age, Gender
junel
1
Age, Gender
junel FE
1
Age, Gender
kariva
1
Age, Gender
kelnor
1
Age, Gender
leena
1
Age, Gender
lessina
1
Age, Gender
LEVELEN
3
Age, Gender
LEVLITE
3
Age, Gender
levora
1
Age, Gender
LO/OVRAL
3
Age, Gender
LOESTRIN
3
Age, Gender
LOESTRIN FE
3
Age, Gender
LOESTRIN FE 24
3
Age, Gender
low-ogestrel
1
Age, Gender
lutera
1
Age, Gender
LYBREL
3
Age, Gender
microgestin
1
Age, Gender
microgestin FE
1
Age, Gender
MINASTRIN 24 FE CHEW
3
Gender
MIRCETTE
3
Age, Gender
MODICON 0.5/35
3
Age, Gender
monessa
1
Age, Gender
necon
1
Age, Gender
nora-be
1
Age, Gender
NORDETTE
3
Age, Gender
Class
Drug Name
Copay
Tier
Dispensing Edits
NORINYL
3
Age, Gender
NOR-QD
3
Age, Gender
nortrel
1
Age, Gender
ocella
1
Age, Gender
ogestrel
1
Age, Gender
ORTHO MICRONOR
3
Age, Gender
ORTHO TRI-CYCLEN
3
Age, Gender
ORTHO TRI-CYCLEN LO
2
Age, Gender
ORTHO-CEPT
3
Age, Gender
ORTHO-CYCELN
3
Age, Gender
ORTHO-NOVUM
3
Age, Gender
OVCON
3
Age, Gender
portia
1
Age, Gender
previfem
1
Age, Gender
QUARETTE
3
Gender
quasense
1
Age, Gender
reclipsen
1
Age, Gender
SAFYRAL
3
(blank)
SEASONALE
3
Age, Gender
SEASONIQUE
3
Age, Gender
solia
1
Age, Gender
sprintec
1
Age, Gender
sronyx
1
Age, Gender
tri-estarylla
1
(blank)
TRI-LEVLEN
3
Age, Gender
trinessa
1
Age, Gender
TRI-NORINYL
3
Age, Gender
TRIPHASIL
3
Age, Gender
tri-previfem
1
Age, Gender
tri-sprintec
1
Age, Gender
trivora
1
Age, Gender
velivet
1
Age, Gender
YASMIN
3
Age, Gender
YAZ
3
Age, Gender
zovia
1
Age, Gender
CYCLOSET
3
Prior Auth
DPP4 Combo
JENTADUETO
3
(blank)
DPP4 Inhbitor
KOMBIGLYZE XR
3
(blank)
KOMBIGLYZE XR (8/1/11)
2
(blank)
ALORA
3
Gender, Qty. Limit
CENESTIN
3
Gender
CLIMARA
3
Gender
DIVIGEL
3
Gender
Dopamine Receptor Agonist
Estrogens
ELESTRIN
3
Gender
ENJUVIA
3
Gender
Class
Drug Name
ESCLIM
Estrogens Combo
Fertility Agents
Copay
Tier
Dispensing Edits
3
Gender
ESTRACE
3
Gender
ESTRADERM
3
Gender
estradiol patch
1
Gender, Qty. Limit
estradiol tab
1
Gender
ESTRASORB
3
Gender
ESTROGEL
2
Gender
estropipate
1
Gender
Gender
EVAMIST
3
gynodiol
1
Gender
MENEST
3
Gender
MENOSTAR
3
Gender
OGEN
3
Gender
PREMARIN
2
Gender
VAGIFEM Tab
2
Gender
VIVELLE/VIVELLE DOT
2
Gender, Qty. Limit
ACTIVELLA
2
Gender
ACTIVELLA (4/1/11)
3
Gender
ANGELIQ
3
Gender
CLIMARA PRO WEEKLY
3
Gender, Qty. Limit
COMBIPATCH
2
Gender
estradiol/norethidrome acetate
1
Gender
estradiol-noreth ac
1
Gender
ESTRATEST
3
Gender
ESTRATEST HS
3
Gender
FEMHRT
3
Gender
FEMHRT LOW DOSE
3
Gender
FEMTRACE
3
Gender
PREFEST
3
Gender
PREMPHASE
2
Gender
PREMPRO
2
Gender
SYNTEST DS/HS
3
Gender
BRAVELLE
2
Rider
CETROTIDE
3
Rider
chorionic gonadotropin
1
Rider
CLOMID
3
Rider
clomiphene
1
Rider
FOLLISTIM AQ
3
Rider
GONAL-F
2
Rider
GONAL-F RFF
2
Rider
GRANIRELIX
3
Rider
leuprolide
1
Rider
LUPRON
3
Rider
LUVERIS
3
Rider
MENOPUR
3
Rider
Class
Drug Name
novarel
Copay
Tier
Dispensing Edits
1
Rider
OVIDREL
3
Rider
pergnyl
1
Rider
REPRONEX
3
Rider
Glucocorticoid
UCERIS
3
(blank)
Glucose Elevating Agents
GLUCAGON
3
(blank)
PROCLYCEM
2
(blank)
EGRIFTA
3
Prior Auth
Growth Hormone Agents
Metabolic Modifiers
Oral Contraceptive
Progestins
SGLT2 INH
GENOTROPIN
2
HUMATROPE
3
INCRELEX
3
NORDITROPIN
3
NORDITROPIN AQ
3
NUTROPIN
2
OMNITROPE
3
PROTROPIN
3
SAIZEN
3
SEROSTIM
3
SOMAVERT
3
TEV-TROPIN
3
ZORBTIVE
3
ALDURAZYME
2
(blank)
BUPHENYL
2
(blank)
CARNITOR
2
(blank)
CYSTADANE
2
(blank)
FABRAZYME
2
(blank)
HECTOROL
2
(blank)
MYOZYME
2
(blank)
ORFADIN
2
(blank)
SENSIPAR
2
(blank)
SUCRAID
2
(blank)
ZEMPLAR
2
(blank)
gianvi
1
Age, Gender
LO LOESTRIN FE
3
(blank)
MAKENA
3
medroxyprogesterone
1
Gender
norethindrone acetate
1
Gender
PROMETIUM
2
Gender
INVOKANA
3
(blank)
Steroids
fludrocort
1
(blank)
Steroids (Glucocorticoids)
CELESTONE
3
(blank)
cortisone AC
1
(blank)
dexamethasone
1
(blank)
ENTOCORT EC
2
(blank)
FLO-PRED
3
(blank)
Class
Endocrine Diabetes
Drug Name
Copay
Tier
Dispensing Edits
hydrocortisone
1
(blank)
methylprednisolone
1
(blank)
MILLIPRED
3
(blank)
ORAPRED
3
(blank)
prednisolone
1
(blank)
prednisone
1
(blank)
Thyroid
WESTHROID
2
(blank)
Thyroid Hormones
ARMOUR THYROID
2
(blank)
BIO-THROID
3
(blank)
LEVOTHROID
3
(blank)
levothyroxine
1
(blank)
LEVOXYL
3
(blank)
NATURE_THYROID
2
(blank)
SYNTHROID
3
(blank)
THYROLAR
3
(blank)
UNITHROID
3
(blank)
acarbose
1
(blank)
GLYSET
2
(blank)
PRECOSE
3
(blank)
Amylin Analog
SYMLIN
3
Prior Auth
Biguanides & Combo
FORTAMET
3
(blank)
glipizide/metformin
1
(blank)
GLUCOPHAGE
3
(blank)
GLUCOPHAGE XR
3
(blank)
GLUCOVANCE
3
(blank)
GLUMETZA
3
(blank)
glyburide/metformin
1
(blank)
METAGLIP
3
(blank)
metformin
1
(blank)
metformin ER 24 (Fortamet®)
1
(blank)
metformin XR
1
(blank)
RIOMET
3
(blank)
ACCU CHEK family of test strips
3
Qty. Limit, Rider
alcohol swab
1
Qty. Limit, Rider
BD Insulin Syringes
3
Qty. Limit, Rider
BD Pen Needles
2
Qty. Limit, Rider
Alpha Glucosidase Inh
Diabetic Supplies (Requires Plan Rider)
BIG-STAR
3
Qty. Limit, Rider
BREEZE 2 Test Strips
2
Qty. Limit, Rider
Qty. Limit, Rider
CONTOUR Test Strips
2
FAST TAKE test strips
3
Qty. Limit, Rider
FREESTYLE LITE Test Strips
3
Qty. Limit, Rider
Glucose Test Strips (all other brands)
3
Qty. Limit, Rider
insulin syringes
1
Qty. Limit, Rider
Class
Drug Name
Copay
Tier
lancets
DPP4
DPP4 Combo
Dispensing Edits
2
Qty. Limit, Rider
Novofine Pen Needles
2
Qty. Limit, Rider
Novotwist Needles
2
Qty. Limit, Rider
ONE TOUCH family of test strips
3
Qty. Limit, Rider
PRECISION family of test strips
3
Qty. Limit, Rider
TRACER BG test strips
3
Qty. Limit, Rider
TRUE TRACK test strips
3
Qty. Limit, Rider
NESINA
3
(blank)
KAZANO
3
(blank)
OSENI
3
(blank)
TRIBENZOR
2
(blank)
DPP-4 Inhibitor
TRADJENTA
3
(blank)
DPP-IV Inh
ONGLYZA
3
(blank)
ONGLYZA (8/1/11)
2
(blank)
JANUMET
2
(blank)
JANUMET XR
2
(blank)
JANUVIA
2
(blank)
GLUC COTRANSPORT2(SGLT2)INHIB
INVOKANA
3
(blank)
Incretin Mimetic Agent
BYDUREON
3
(blank)
BYETTA
2
Qty. Limit
DPP-IV Inh & Combo
Insulin
VICTOZA
3
APIDRA
3
(blank)
HUMALOG pdts
2
(blank)
HUMULIN
2
(blank)
LANTUS
2
(blank)
LEVEMIR
2
(blank)
NOVOLIN
2
(blank)
2
(blank)
NOVOLOG
RELION - NOT COVERED
Meglitinides
Sulfonylureas
TZD & Combo
X
(blank)
nateglinide
1
(blank)
PRANDIN
2
(blank)
STARLIX
3
(blank)
AMARYL
3
(blank)
chlorpropamide
1
(blank)
glimepiride
1
(blank)
glipizide
1
(blank)
glipizide ER/XL
1
(blank)
gluburide
1
(blank)
glyburide micronized
1
(blank)
glycon
1
(blank)
tolazamide
1
(blank)
tolbutabamide
1
(blank)
ACTOPLUS MET
2
(blank)
ACTOPLUS MET XR
3
(blank)
Class
Gastrointestinal
Drug Name
Copay
Tier
Dispensing Edits
ACTOS (eff 9/11/12)
3
(blank)
AVANDAMET
2
(blank)
AVANDARYL
2
(blank)
AVANDIA
2
(blank)
DUETACT
3
(blank)
pioglitazone/glimepiride
1
(blank)
plioglitazone
1
(blank)
Antidiarrheal
FULYZAQ
3
(blank)
REZYST
3
(blank)
Antiemetic
ANZEMET
2
Qty. Limit
CESAMET
3
(blank)
EMEND
3
(blank)
fosaprepitant
1
(blank)
granisetron
1
Qty. Limit
KYTRIL
3
Qty. Limit
maldemar
1
(blank)
ondesetron
1
Qty. Limit
tebamide
1
(blank)
TRANSDERM-SCOP
2
(blank)
trimethobenzamide
1
(blank)
ZOFRAN
3
Qty. Limit
ZOFRAN ODT
3
Qty. Limit
Anti-inflammatory
ZULPLENZ
3
(blank)
Z-PRAM
3
(blank)
ZYPRAM
3
(blank)
Anti-nausea
loperamide
1
(blank)
Antispasmotic/Anticholinergic
CUVPOSA
3
(blank)
DONNATAL ELIX
3
(blank)
GLYCLATE
3
(blank)
COLYTE
3
(blank)
GOLYTELY
3
(blank)
HALFLYTELY
2
(blank)
NULYTELY
3
(blank)
OSMOPREP
2
(blank)
peg 3350
1
(blank)
polyethylene glycol
1
(blank)
trilyte
1
(blank)
VISICOL
3
(blank)
Chronic Constipation Agent
AMITIZA
3
(blank)
Diagnostic
E-Z DISK
3
(blank)
Diagnostic
DIGIBAR
3
(blank)
POLIBAR ORAL SUSP
3
(blank)
VAYACOG
3
(blank)
VAYARIN
3
(blank)
VAYAROL
3
(blank)
Bowel Evacuants
Dietary Supplement
Class
Drug Name
Gallstone Solubilizing Agent
URSO
H. pylori Agent
H-2 Antagonists
Copay
Tier
Dispensing Edits
3
(blank)
URSO FORTE
3
(blank)
ursodiol
1
(blank)
HELIDAC
3
(blank)
PREVPAC
2
(blank)
PYLERA
3
(blank)
AXID
3
Qty. Limit
cimetidine
1
(blank)
famotidine
1
(blank)
nizatidine
1
(blank)
PEPCID
3
(blank)
ranitidine
1
(blank)
TAGAMET
3
(blank)
ZANTAC
3
(blank)
ZANTAC (syrup)
3
(blank)
H-Pyloria Agent
OMECLAMOX-PAK
3
(blank)
IBS
LOTRONEX
2
(blank)
Inflammatory Bowel Agents
APRISO
3
(blank)
2
(blank)
3
(blank)
AZULFIDINE+A191
3
(blank)
balsalazide
1
(blank)
CANASA
2
(blank)
COLAZAL
2
(blank)
DELZICOL
2
(blank)
DIPENTUM
2
(blank)
GIAZO
3
(blank)
LIALDA
3
(blank)
mesalamine
1
(blank)
PENTASA
2
(blank)
ROWASA enema
2
(blank)
sulfasalazine
1
(blank)
sulfasalazine ER
1
(blank)
sulfazine
1
(blank)
sulfazine EC
1
(blank)
glycolax
1
(blank)
KRISTALOSE
3
(blank)
lactulose
1
(blank)
PREPOIK
3
(blank)
SUCLEAR
3
(blank)
SURPREP
2
(blank)
CARAFATE
3
(blank)
GASTROCROM
2
(blank)
metoclopramide
1
(blank)
ASACOL
AZULFIDINE ENTAB
Laxative
Miscellaneous
ASACOL HD
Class
Dispensing Edits
misoprostol
1
(blank)
sucralafate
1
(blank)
Motility Stimulant
METOZZOLV ODT
3
(blank)
Nausea
ZOLPIMIST
3
(blank)
NSAID/PPI
VIMOVO
3
(blank)
Pancreatic Enzymes
CREON
2
(blank)
PANCREAZE
2
(blank)
PERTZYE
2
(blank)
ULTRASE
2
(blank)
VIOKASE
2
(blank)
ZEN PEP
2
(blank)
Proton Pump Inh
Genitourinary
System
Drug Name
Copay
Tier
ACIPHEX
3
Qty. Limit
ACIPHEX SPRINKLE
3
(blank)
DEXILANT
2
(blank)
FIRST LANSOPRAZOLE
3
Age
FIRST OMEPRAZOLE Susp
3
(blank)
KAPIDEX
3
(blank)
lansoprazole cap
1
(blank)
lansoprazole rap dr
1
(blank)
NEXIUM
3
(blank)
omeprazole
1
(blank)
omeprazole/sodium bicarf
1
(blank)
pantoprazole
1
(blank)
PREVACID
3
(blank)
PRILOSEC
3
(blank)
PRILOSEC OTC
1
Rider
PROTONIX
3
(blank)
ZEGERID
3
(blank)
Rectal Steroids
colocort
1
(blank)
CORTIFOAM
2
(blank)
Tx-Chronic Inflammatory Bowel
DELZICOL
3
(blank)
BPH/Micturition
RAPAFLO
3
(blank)
Cystinosis Agents
CYSTAGON
2
(blank)
Interstitial Cystitis Agnes
ELIMIRON
2
(blank)
RIMSO
2
(blank)
Overactive Bladder
MYRBETRIQ
3
(blank)
Phosphate Binders
FOSRENOL
2
(blank)
PHOSLO
2
(blank)
RENAGEL
2
(blank)
RENVELA
3
(blank)
alfuzosin hcl
1
(blank)
AVODART
2
(blank)
finasteride
1
(blank)
FLOMAX
3
(blank)
JAYLN (Eff. 7/1/11)
2
(blank)
Prostatic Hypertrophy Agents
Class
Drug Name
Copay
Tier
Dispensing Edits
PROSCAR
3
(blank)
tamsulosin hcl
1
(blank)
UROXATRAL
3
(blank)
Urinary Antibacterials
UROGESIC-BLUE
2
(blank)
Urinary Antiinfectives & Combo
MACROBID
2
(blank)
methanamine hippurate
1
(blank)
methanamine madelate
1
(blank)
MONUROL
3
(blank)
nitrofurantoin
1
(blank)
nitrofurantoin macrocrystal
1
(blank)
URELLE
3
(blank)
UREX
2
(blank)
UTA
3
(blank)
Urinary Antispasmotics
Urinary PH Modifier
Vaginal Anti-Infectives
UTAC
3
(blank)
bethanechol
1
(blank)
DETROL
2
(blank)
DETROL LA
2
(blank)
DITROPAN
3
(blank)
DITROPAN XL
3
(blank)
ENABLEX
3
(blank)
flacoxate
1
(blank)
GELNIQUE
3
(blank)
hyscyamine
1
(blank)
oxybutynin
1
(blank)
oxybutynin SR
1
(blank)
OXYTROL
3
(blank)
SANCTURA
3
(blank)
SANCTURA XR
3
(blank)
TOVIAZ
2
(blank)
URECHOLINE
3
(blank)
URISPAS
3
(blank)
VESICARE
3
(blank)
UROCIT-K
2
(blank)
3
(blank)
CLEOCIN VAGINAL
3
Gender
clindamaycin (vaginal)
1
Gender
CLINDESSE
3
Gender
GYNAZOLE-1
3
Gender
METROGEL VAG
3
Gender
nystatin vag
1
Gender
TERAZOL
3
Gender
terconazole
1
Gender
tioconazole
1
Gender
vandazole
1
Gender
zazole
1
Gender
Class
Drug Name
Vaginal Estrogens
ESTRACE VAGINAL
Vaginal Progestins
Immunological
Agents
Infections and
Infestations
Immunosuppressive Agents
Copay
Tier
Dispensing Edits
2
Gender
ESTRING
2
Gender
FEMRING
2
Gender
PREMARIN VAGINAL
2
Gender
VAGIFEM
2
Gender
CRINONE
3
Age, Rider
PROCHIEVE
3
Age, Rider
PROGESTERONE VAGINAL
2
Age, Rider
ASTAGRAPH XL
3
Specialty
AZASAN
2
(blank)
azathioprine
1
(blank)
CELLCEPT
3
Specialty
cyclosporine
1
(blank)
cyclosporine modified
1
(blank)
gengraf
1
(blank)
HECORIA
3
Specialty
IMURAN
2
(blank)
MYFORTIC
2
Specialty
NEORAL
3
Specialty
PROGRAF
3
Specialty
RAPAMUNE
3
Specialty
SANDIMMUNE
3
Specialty
ZORTRESS
3
Specialty
BETHKIS
2
Specialty
TOBI PODHALER
3
Specialty
Antibacterial - Betalactam
NICAZEL
3
(blank)
Antibacterials - Aminoglycosides
neomycin
1
(blank)
paromomycin
1
(blank)
TOBI
1
Specialty
amoxicillin
1
(blank)
amoxicillin/K clavulanate
1
(blank)
AMOXIL
1
(blank)
ampicillin
1
(blank)
AUGMENTIN
3
(blank)
AUGMENTIN ES
3
(blank)
AUGMENTIN XR
3
(blank)
DISPERMOX
3
(blank)
principen
1
(blank)
trimox
1
(blank)
cefadroxil
1
(blank)
cephalexin
1
(blank)
DURICEF
3
(blank)
cefaclor
1
(blank)
Aminiglycoside
Antibacterials - Ampicillins and
Combinations
Antibacterials - Cephalosporins, 1st
Generation
Antibacterials - Cephalosporins, 2nd
Generation
Class
Antibacterials - Cephalosporins, 3rd
Generation
Antibacterials - Fluoroquinolones
Drug Name
Copay
Tier
Dispensing Edits
cefaclor ER
1
(blank)
cefprozil
1
(blank)
CEFTIN
3
(blank)
cefuroxime
1
(blank)
CEFZIL
3
(blank)
CEDAX
3
(blank)
cefdinir
1
(blank)
cefpodoxime
1
(blank)
OMNICEF
3
(blank)
SPECTRACEF
2
(blank)
SUPRAX
3
(blank)
VANTIN
3
(blank)
AVELOX
2
(blank)
AVELOX ABC
2
(blank)
CIPRO
3
(blank)
CIPRO XR
3
(blank)
ciprofloxacin
1
(blank)
ciprofloxacin ER
1
(blank)
FACTIVE
3
(blank)
LEVAQUIN
3
(blank)
levofloxacin (1/16/12) oral
1
(blank)
NOROXIN
3
(blank)
ofloxacin
1
(blank)
Antibacterials - Ketolides
KETEK
3
(blank)
Antibacterials - Macrolides
azithromycin
1
(blank)
BIAXIN
3
(blank)
BIAXIN XL
3
(blank)
clarithromycin
1
(blank)
clarithromycin SR
1
(blank)
clarithromycin xl
1
(blank)
DYNABAC
3
(blank)
e.e.s.
1
(blank)
erythrocin
1
(blank)
erythromycin
1
(blank)
erythromycin delayed relase particles
1
(blank)
erythromycin ethylsuccinate
1
(blank)
PCE
1
(blank)
ZITHROMAX
3
(blank)
ZMAX
3
(blank)
Antibacterials - Miscellaneous
clindamycin
1
(blank)
metronidazole
1
(blank)
metronidazole SR
1
(blank)
NEBUPENT
3
(blank)
TINDAMAX
3
(blank)
Class
Antibacterials - Penicillins
Antibacterials - Sulfonamides
Antibacterials - Tetracyclines
Antifungal
Drug Name
Copay
Tier
Dispensing Edits
trimethoprim
1
(blank)
XIFAXAN
3
(blank)
ZYVOX
3
Prior Auth
dicloxacillin sodium
1
(blank)
penicillin VK
1
(blank)
veetids
1
(blank)
SMZ/TMP
1
(blank)
sulfadiazine
1
(blank)
sulfisoxazole
1
(blank)
ADOXA
3
Prior Auth
ALODOX
3
(blank)
DECLOMYCIN
3
(blank)
demeclocycline
1
(blank)
DORYX
3
(blank)
doxy-caps
1
(blank)
doxycycline hyclate
1
(blank)
doxycycline monohydrate
1
(blank)
doxycycline monohydrate 150mg
1
Prior Auth
DYNACIN
3
(blank)
MINOCIN
3
(blank)
minocycline
1
(blank)
minocycline ER
1
(blank)
MONODOX
3
(blank)
myrac
1
(blank)
ORAXYL
3
(blank)
PERIOSTAT
3
(blank)
SOLODYN
3
(blank)
tetracycline
1
(blank)
VIBRAMYCIN
3
(blank)
VIBRATAB
3
(blank)
ANCOBON
3
(blank)
DIFLUCAN (all other strengths)
3
(blank)
DIFLUCAN 150mg
3
Qty. Limit
fluconazole (all other strengths)
1
(blank)
fluconazole 150mg
1
Qty. Limit
flucytosine
1
(blank)
GRIFULVIN V
2
(blank)
GRIS-PEG
2
(blank)
itraconazole
1
(blank)
ketoconazole
1
(blank)
LAMISIL
3
(blank)
NOXAFIL
3
(blank)
nystatin
1
(blank)
ONMEL
3
(blank)
SPORANOX
3
(blank)
Class
Drug Name
terbinafine
Copay
Tier
Dispensing Edits
1
(blank)
VFEND
3
Prior Auth
Anti-Infective Agents - Miscellanous
colistimethate sodium
1
(blank)
COLY-MYCIN M
2
(blank)
Antimalarials and Combinations
ARALEN
3
Prior Auth
chloroquine
1
Prior Auth
COARTEM
2
(blank)
DARAPRIM
2
(blank)
FANSIDAR
2
(blank)
hydroxychloroquine sulfate
1
(blank)
LARIAM
2
(blank)
MALARONE
2
(blank)
mefloquine
1
(blank)
primaquine
1
(blank)
quinerva
1
(blank)
quinine sulfate
1
(blank)
dapsone
1
(blank)
ethambutol
1
(blank)
isoniazid
1
(blank)
MYAMBUTOL
2
(blank)
pyrazinamide
1
(blank)
RIFAMATE
3
(blank)
rifampin
1
(blank)
RIFATER
3
(blank)
Antiprotozal Agents
ALINIA
2
(blank)
MEPRON
2
(blank)
Antiretroviral Combo
COMPLERA
2
(blank)
Antiretrovirals - Chemokine Receptor
Antagonist
SELZENTRY
2
(blank)
Antiretrovirals - Fusion Inhibitors
FUZEON
2
Antiretrovirals - Integrase Inhibitors
ISENTRESS
2
Antiretrovirals - Non-Nucleoside Reverse
Transcriptase Inhibitors (NNRTIs)
INTELENCE
2
Antimycobacterial Agents
RESCRIPTOR
2
SUSTIVA
2
VIRAMUNE
2
VIRAMUNE XR
3
Antiretrovirals - NRTI/NNRTI
Combination
ATRIPLA
2
Antiretrovirals - Nucleoside (NRTI) and
Nucleoside (NtRI) Analogs
COMBIVIR
2
COMBIVIR (4/1/12)
3
didanosine delayed release
1
EMTRIVA
2
EPIVIR
2
EPIVIR (4/1/12)
3
(blank)
(blank)
(blank)
Class
Drug Name
EPZICOM
Antiretrovirals - Protease Inhibitors
Antiturbecular Antibiotic
Copay
Tier
Dispensing Edits
2
lamivudine
1
(blank)
lamivudine-zidovudine
1
(blank)
RETROVIR
3
TRIZIVIR
2
TRUVADA
2
VIDEX
3
VIDEX EC
3
VIREAD
2
ZERIT
2
ZIAGEN
2
zidovudine
1
APTIVUS
2
CRIXIVAN
2
INVIRASE
2
KALETRA
2
LEXIVA
2
NORVIR
2
PREZISTA
2
REYATAZ
2
VIRACEPT
2
SIRTURO
3
(blank)
Antiviral - HIV
EDURANT
2
(blank)
Antivirals - CMV Agents
ganciclovir
1
(blank)
VALCYTE
3
(blank)
BARACLUDE
2
COPEGUS
3
Antivirals - Hepatitis Agents
EPIVIR HBV
2
HEPSERA
3
INCIVEK
2
INFERGEN
3
OLYSIO
3
PEGASYS
2
Specialty
Antivirals - Herpes Agents
PEGASYS PROCLICK
2
Specialty
PEG-INTRON
2
REBETOL
3
ribasphere
1
Specialty
ribavirin
1
Specialty
SOVALDI
3
SYLATRON
3
Specialty
SYLATRON PK
2
TYZEKA
3
VICTRELIS
3
acyclovir
1
(blank)
Class
Drug Name
famciclovir
Dispensing Edits
1
(blank)
FAMVIR
3
(blank)
favciclovir
1
(blank)
valacyclovir
1
(blank)
VALTREX
3
(blank)
ZOVIRAX
3
(blank)
FLUMADINE
1
(blank)
RELENZA
3
(blank)
rimantadine
1
(blank)
TAMIFLU
3
(blank)
Antivirals - Respiratory Syncytial Virus
(RSV) Agents
VIRAZOLE
2
Betalactam
CAYSTON Inh
3
HIV/AIDS
PREZISTA SUSP
2
(blank)
STRIBILID
3
Preclusive Edit
Monoclonal antibody
SYNAGIS
2
Antivirals - Influenza Agents
Miscellaneous
Copay
Tier
Tetracycline
DORYX TAB
3
(blank)
Ammonia Inh
RAVICTI
3
(blank)
Ammonia Inhibitor
CARBAGLU
3
(blank)
Antifibinolytic
LYSTEDA
3
Qty. Limit
tranexamic acid
1
Qty. Limit
Anti-inflamatory cytokine, interleukin1beta
ILARIS
3
(blank)
Anti-inflamatory interleukin 1 receptor
antagonist
ARCALYST
3
Specialty
Antipsoriatic agent
8-MOP
2
Specialty
Antisera
HIZENTRA
3
Specialty
Bone Resportion Inh
ZOMETA
3
Botulinum Toxin - Type A
DYSPORT
3
Prior Auth
BPH, 5-Alpha-Red Inh/Alpha-1 Adr Antg
Combo
JALYN
2
(blank)
Brandykinin B2 Recept Antag
FIRAZYR
3
Specialty
Caloric Agent
ALANINE
3
Prior Auth
Carbohydrate
CYTOSE
3
(blank)
Cushing's Disease
SIGNIFOR
3
CYSTIC FIB.TRANSMEMB
CONDUCT.REG.(CFTR)POTENTIATOR
KALYDECO
3
Dental
REMESENSE
3
(blank)
Dietary Supplement
FOSTEUM PLUS
3
(blank)
HYPERTENSA
3
(blank)
NICAZEL FORTE
3
(blank)
PERCURA
3
(blank)
PREFLIN
3
Prior Auth
SENTRA PM
3
(blank)
THERAMINE
3
(blank)
TL-ICARE
3
(blank)
Class
Drug Name
Disease Modifying Anthrheumatic agent
ACTEMRA
3
Specialty
Drugs to Treat Impotency
Musculoskeletal
System
Copay
Tier
Dispensing Edits
alprostadil
1
Qty. Limit
CAVERJECT
3
Qty. Limit
CIALIS
2
Qty. Limit
EDEX
3
Qty. Limit
LEVITRA
3
Qty. Limit
STAXYN
3
Qty. Limit
VIAGRA
2
Qty. Limit
yohimbine
1
(blank)
Electrolyte Depleter
PHOSLYRA
3
(blank)
Gout
ULORIC
2
(blank)
Joint Contracture, Collagenase Enzyme
XIAFLEX
3
Specialty
Kidney Stone Agents
PROCYSBI
3
(blank)
Menopausal SERM
OSPHENA
3
(blank)
Metabolic Dx Enzyme Replacement
VPRIV
3
Metallic Poison Agent
FERRIPROX
3
(blank)
Miscellaneous
ENTERAGAM
3
(blank)
GELX
3
(blank)
Monoclonal antibody
STELARA
3
Specialty
Neuromuscular Blocking Agent
Botulinum toxin
3
Prior Auth
Nutritional Supplement
GLUTARADE GA-1
3
(blank)
GLYTACTIN
3
(blank)
ZYTAZE
2
(blank)
Oral Mucositis
EPISIL
3
(blank)
PKU
KUVAN
3
(blank)
Plasma Kallkrein Inh
KALBITOR
3
Specialty
Somatostatic
octreotide acetate
1
Specialty
SANDOSTATIN
3
Specialty
SOMATULINE
3
Specialty
Supplement
DEPLIN-ALGAL
3
(blank)
Tx Neuromusc Transmission
AMPYRA
3
Specialty
Analgesic
salsalate
1
(blank)
Antiarthritic
COLCRYS
2
(blank)
Antimyasthenic Agents
MESTINON
2
(blank)
MESTINON TIMESPAN
2
(blank)
pyridostigmine
1
(blank)
ARAVA
3
(blank)
leflunomide
1
(blank)
RHEUMATREX
2
(blank)
RIDAURA
2
(blank)
ACTONEL
2
Qty. Limit
alendronate
1
Qty. Limit
ATELVIA
2
(blank)
Antirheumatic Agents
Calcium Regulators
Class
Drug Name
BINOSTO
Copay
Tier
Dispensing Edits
3
(blank)
BONIVA
3
Qty. Limit
CALCITONIN NASAL
1
(blank)
DIDRONEL
2
(blank)
FORTEO
3
fortical
1
(blank)
FOSAMAX
3
(blank)
FOSAMAX PLUS D
3
(blank)
ibandronate sodium
1
Qty. Limit
MIACALCIN injection
2
(blank)
MIACALCIN NASAL
3
(blank)
pamidronate
1
(blank)
SKELID
2
(blank)
DMARD
ORENCIA
3
Specialty
Immunomodulators
CIMZIA
3
ENBREL
2
HUMIRA
2
KINERET
3
REMICADE
3
SIMPONI
2
AMRIX
3
(blank)
baclofen
1
(blank)
carisoprodol
1
(blank)
carisoprodol/aspirin
1
(blank)
carisoprodol/aspirin/codeine
1
(blank)
chlorzoxazone
1
(blank)
COMFORT PAC - TIZANIDINE
3
(blank)
COMFORT PAC CYCLOBENZAPRINE
3
(blank)
cyclobenzaprine ER
1
(blank)
cyclobenzaprine hcl
1
(blank)
CYCLOPHENE
3
(blank)
DANTRIUM
3
(blank)
FEXMID
3
(blank)
methocarbamol
1
(blank)
orphenadrine cpd
1
(blank)
orphenadrine ER
1
(blank)
orphenadrine/aspirin/caffeine
1
(blank)
SKELAXIN
3
(blank)
tizanidine cap
3
(blank)
tizanidine tab
1
(blank)
ZANAFLEX
3
(blank)
Muscle Relaxants and Combinations
NSAID
ARTHROTEC
2
(blank)
CAMBIA
3
Qty. Limit
CELEBREX
2
(blank)
Class
Selective Estrogen Receptor Modlator
(SERM)
Ophthalmic
Agents
Drug Name
Copay
Tier
Dispensing Edits
COMFORT PAC - MELOXICAM
3
(blank)
COMFORT PAC - NAPROXEN
3
(blank)
DAYPRO
3
(blank)
diclofenac
1
(blank)
diclofenac potassium
1
(blank)
diclofenac sodium XR
1
(blank)
etodolac
1
(blank)
etodolac ER
1
(blank)
fenoprofen
1
(blank)
FLECTOR
2
(blank)
flurbiprofen
1
(blank)
ibuprofen
1
(blank)
indomethacin
1
(blank)
indomethacin ER
1
(blank)
ketopofen
1
(blank)
ketoprofen ER
1
(blank)
ketorolac
1
(blank)
meclofenamate sodium
1
(blank)
mefenamic acid
1
(blank)
meloxicam
1
(blank)
MOBIC
3
(blank)
nabumetone
1
(blank)
NALFON
3
(blank)
NAPRELAN
3
(blank)
naproxen
1
(blank)
NAPROXEN COMFORT PAC
3
(blank)
naproxen sodium
1
(blank)
oxaprozin
1
(blank)
piroxicam
1
(blank)
PONSTEL
3
(blank)
PREVACID NAPRAPAC
2
Qty. Limit
SPRIX
3
(blank)
sulindac
1
(blank)
tolmetin sodium
1
(blank)
VOLTAREN
3
(blank)
VOLTAREN GEL
3
(blank)
VOLTAREN XR
3
(blank)
ZORVOLEX
3
(blank)
EVISTA
2
(blank)
Antibiotic - Topical
BESAVANCE
3
(blank)
Antifibroptic Agents
MISTOSOL
3
(blank)
Antihistamine
BEPREVE
3
(blank)
LASTACAFT
3
(blank)
ILVERO
3
(blank)
Anti-inflammatory
Class
Copay
Tier
Drug Name
Antiviral
ZIRGAN
3
(blank)
Cystine Depleting Agent
CYSRARAN
3
(blank)
Glaucoma - Adrenergic Agents
ALPHAGAN P
2
(blank)
brimonidine
1
(blank)
COMBIGAN
2
(blank)
dipivefrin
1
(blank)
IOPIDINE
1
(blank)
PROPINE
1
(blank)
betaxolol
1
(blank)
BETIMOL
2
(blank)
BETOPTIC-S
2
(blank)
carteolol
1
(blank)
ISTALOL
3
(blank)
levobunolol
1
(blank)
metipranolol
1
(blank)
OPTIPRANOLOL
2
(blank)
timolol
1
(blank)
timolol maleate ophth
1
(blank)
AZOPT
2
Qty. Limit
COSOPT
3
Qty. Limit
dorzolamide
1
Qty. Limit
dorzolamide hcl ophthalmic
1
(blank)
dorzolamide/tilomol ophthalmic
1
Qty. Limit
TRUSOPT
3
Qty. Limit
carboptic
1
(blank)
ISO CARBACHOL
2
(blank)
ISOPTO CARPINE
2
(blank)
PHOSPHOLINE
2
(blank)
pilocar
1
(blank)
pilocarpine
1
(blank)
PILOPINE HS
2
(blank)
piloptic
1
(blank)
Glaucoma - Beta-blockers
Glaucoma - Carbonic Anhydrase
Inhibitors
Glaucoma - Miotics
Glaucoma - Prostaglandins
Dispensing Edits
REV-EYES
2
(blank)
LUMIGAN
3
(blank)
TRAVATAN
2
Qty. Limit
TRAVATAN Z
2
Qty. Limit
XALATAN
2
Qty. Limit
Glaucoma-Prostaglandins
bimatoprost
1
(blank)
Miotic
pilocarpine
1
(blank)
SIMBRINZA
3
(blank)
ACULAR
2
(blank)
ACULAR LS
2
(blank)
ACULAR PF
2
(blank)
ALAMAST
3
(blank)
Ophthalmic Antihistamines and NSAIDs
Class
Drug Name
ALOCRIL
Ophthalmic Anti-infectives
Ophthalmic Immunomodulators
Ophthalmic Steroidal Anti-inflammatory
Drugs
Copay
Tier
Dispensing Edits
2
(blank)
ALOMIDE
2
(blank)
cromolyn sodium ophth
1
(blank)
diclofenac ophth
1
(blank)
ELESTAT
3
(blank)
EMADINE
3
(blank)
epinastine hcl
1
(blank)
flubiprofen
1
(blank)
NEVANAC
2
(blank)
OPTIVAR
2
(blank)
PATADAY
2
(blank)
PATANOL
2
(blank)
VOLTAREN
2
(blank)
XIBROM
3
(blank)
AZASITE
3
(blank)
bacitracin
1
(blank)
bacitracin/neomycin/polymyxin
1
(blank)
bacitracin/polymyxin
1
(blank)
ciprofloxacin
1
(blank)
erythromycin
1
(blank)
gentamicin
1
(blank)
IQUIX
2
(blank)
levofloxacin ophth
1
(blank)
nemoycin/polymyxin/gramicidin
1
(blank)
ofloxacin
1
(blank)
polymyxin B/trimethoprim
1
(blank)
QUIXIN
3
(blank)
sulfacetamide sodium
1
(blank)
tobramycin
1
(blank)
trifluridine
1
(blank)
triple antibotic
1
(blank)
VIGAMOX
2
(blank)
ZYMAR
2
(blank)
RESTASIS
2
(blank)
ak-pred
1
(blank)
ALREX
3
(blank)
bacitracine/polymyxin/neomycin/hydrocortisone
1
(blank)
BLEPHAMIDE S.O.P.
2
(blank)
dexacidin
1
(blank)
dexamethasone phosphate
1
(blank)
dexamethasone/neomycin/ polymyxin
1
(blank)
dexasol
1
(blank)
dexasporin
1
(blank)
Class
Otic Agents
Respiratory Tract
Agents
Drug Name
Copay
Tier
Dispensing Edits
fluorometholone
1
(blank)
fluor-op
1
(blank)
FML FORTE
3
(blank)
FML LIQUIFILM
3
(blank)
FML S.O.P.
2
(blank)
HMS
2
(blank)
LOTEMAX
2
(blank)
1
(blank)
poly-dex
1
(blank)
POLY-PRED
3
(blank)
PRED-G
2
(blank)
PRED-G S.O.P.
2
(blank)
prednisolone ophthalmic
1
(blank)
sulfacetamide sodium/prednisolone
1
(blank)
TOBRADEX
2
(blank)
TOBRADEX ST
2
(blank)
VEXOL
2
(blank)
ZYLET
3
(blank)
Proteolytic Enzyme
JETREA
3
(blank)
Vasc. Endothelial Growth Factor Antag
EYLEA
3
Specialty
MACUGEN
3
Specialty
Anti-Infective Agents - Miscellanous
CORTANE-B
3
(blank)
Otic Anti-infectives
FLOXIN OTIC
2
(blank)
ofloxacin otic
1
(blank)
Otic Combinations
antipyrine/benzocaine
1
(blank)
CIPRO HC
2
(blank)
CIPRODEX
2
(blank)
COLY-MYCINS-S
2
(blank)
cortomycin
1
(blank)
1
(blank)
ZINOTIC/ZINOTIC ES
3
(blank)
ATROVENT HFA
2
(blank)
ipratropium inhaler
1
(blank)
SPIRIVA
2
(blank)
Antiasthmatics - Anticholinergics
Antiasthmatics - Monocolonal Antibodies
XOLAIR
3
Antihistamine
meclizine
1
(blank)
Antihistamine Decongestant Combo
ACCUHIST
3
(blank)
CENHIST
3
(blank)
CORZALL
3
(blank)
CORZALL PE
3
(blank)
CORZALL PLUS
3
(blank)
RESCON JR
3
(blank)
Class
Drug Name
RESPA C&C IR
Copay
Tier
Dispensing Edits
3
(blank)
V-HIST
3
(blank)
cromolyn soduim nebulizer
1
(blank)
Antisussive Narcotic
ZUTRIPRO
3
(blank)
Antitussive Decogestant
GILTUSS TR
3
(blank)
V-COF
3
(blank)
PROLEX DM
3
(blank)
ZONATUSS
3
(blank)
ADVAIR DISKUS
2
Qty. Limit
ADVAIR HFA
2
Qty. Limit
BREO ELLIPTA
3
(blank)
DULERA
2
(blank)
SYMBICORT
2
(blank)
Anti-Inflammatory Agents (nebulizer)
Antitussive, Non Narcotic
Beta Adrenergic-Corticosteroid Combo
Bronchodilator
ARCAPTA NEOHALER
3
(blank)
Bronchodilators - Sympathomimetics
ACCUNEB
3
(blank)
albuterol sulfate
1
(blank)
albuterol sulfate (GE: Accuneb®)
3
(blank)
albuterol/ipratropium
1
(blank)
ALUPENT
2
(blank)
BROVANA
3
(blank)
COMBIVENT
2
(blank)
COMBIVENT RESPIMAT
2
(blank)
DUONEB
3
(blank)
FORADIL
2
(blank)
MAXAIR AUTOHALER
3
(blank)
metaproterenol
1
(blank)
micronefrin
1
(blank)
PERFORMIST
3
(blank)
PROAIR HFA
2
(blank)
PROVENTIL HFA
3
(blank)
SEREVENT DISKUS
2
(blank)
terbutaline
1
(blank)
TUDORZA
3
(blank)
VENTOLIN HFA
2
(blank)
VOSPIRE ER
3
(blank)
XOPENEX
3
Age, Prior Auth
XOPENEX HFA
3
Age, Prior Auth
aminophylline
1
(blank)
BRONCAP
3
(blank)
THEO-24
3
(blank)
theocap
1
(blank)
theochron
1
(blank)
theophylline ER
1
(blank)
UNIPHYL
3
(blank)
Bronchodilators - Xanthines
Class
Copay
Tier
Drug Name
COPD
DALIRESP
3
Qty. Limit
Corticosteroids
AMALPRED Plus
2
(blank)
Cough and Cold
CODAR D
3
(blank)
CODAR GF
3
(blank)
HISTEX SR
3
(blank)
NASOTUSS
3
(blank)
NOTUSS NXD
3
(blank)
PEDIATEX TDM
3
(blank)
POLYHIST forte
3
(blank)
PROCLEAR CAP
3
(blank)
PROHIST CD
3
(blank)
PROHIST CF
3
(blank)
PROHIST LQ
3
(blank)
STATUSS GREEN
3
(blank)
TRICODE AR
3
(blank)
Z-COF I
3
(blank)
ZOTEX-PE, EX, D
3
(blank)
Cystic Fibrosis Agents
PULMOZYNE
2
Inhaled Corticosteroids
AEROBID
3
(blank)
AEROBID-M
2
Qty. Limit
ALVESCO HFA
2
(blank)
AREOSPAN
3
(blank)
Leukotriene Modulators
Dispensing Edits
ASMANEX
2
Qty. Limit
AZMACORT
2
Qty. Limit
FLOVENT DISKUS
2
Qty. Limit
FLOVENT HFA
2
Qty. Limit
PULMICORT FLEXHALER
2
Qty. Limit
PULMICORT RESPULES
2
Qty. Limit
QVAR
2
Qty. Limit
ACCOLATE
3
Qty. Limit
montelukast sod (10mg tab, 4mg, 5mg chew)
1
(blank)
SINGULAIR
2
Qty. Limit
SINGULAIR (10mg tab, 4mg, 5mg chew)
3
Qty. Limit
zafirlukast
1
Qty. Limit
ZYFLO/ZYFLO CR
3
Qty. Limit
Mouth and Throat Products
EVOXAC
3
(blank)
Narcotic Antitussive Combo
ALLEFEN CDX
3
(blank)
Nasal Antiallergy
ASTELIN NASAL
3
Qty. Limit
ASTEPRO
3
Qty. Limit
azelastine (08/01/10)
1
Qty. Limit
PATANASE
3
(blank)
ATROVENT NASAL
2
(blank)
ipratropium nasal
1
(blank)
BECONASE AQ
3
(blank)
Nasal Anticholinergics
Nasal Steroid
Class
Drug Name
FLONASE
Dispensing Edits
3
(blank)
flunisolide
1
(blank)
fluticasone propionate nasal
1
(blank)
NASACORT AQ
3
(blank)
NASAREL
3
(blank)
NASONEX
3
(blank)
OMNARIS
3
(blank)
QNASL
3
(blank)
RHINOCORT AQ
3
(blank)
triamcinolone acetate nasal spray
1
(blank)
VERAMYST
3
(blank)
ZETONNA
3
Qty. Limit
Nasal steroid combo
DYMISTA
3
Qty. Limit
Non-Sedating Antihistamines and
Combinations
ALLEGRA
3
Qty. Limit
ALLEGRA-D
3
Qty. Limit
CLARINEX
3
Qty. Limit
CLARINEX REDITAB
3
Qty. Limit
CLARINEX-D
3
Qty. Limit
fexofenadine
1
(blank)
fexophenadine/Pseudoephedrine
1
(blank)
levocetirizine dihydrochloride
1
Qty. Limit
loratadine
1
(blank)
XYZAL
3
Qty. Limit
Upper Respiratory - Cough/Cold/Allergy
Combinations
Vitamin
Copay
Tier
SEMPREX-D
3
(blank)
TUSSIONEX
3
(blank)
B-12 preparation
cyanocobalmin
1
(blank)
B-Vitamin
CENFOL
3
(blank)
Folic acid
folic acid
1
(blank)
levomefolate calcium
1
(blank)
DEPLIN
3
(blank)
ENLYTE
3
(blank)
l-methylfolate calcium
1
(blank)
ACTIVE FE
3
(blank)
CORVITE 150
3
(blank)
FERVIA
3
(blank)
IROSPAN
3
(blank)
MAXARON FORTE
3
(blank)
FUSION PLUS
3
(blank)
VIRT-VITE
3
(blank)
Multivitamin
NICOMIDE
3
(blank)
Pediatric Vitamin
ESCAVITE
3
(blank)
POLY VI FLOR W/IRON
3
(blank)
POLY-VI-FLOR
3
(blank)
TRI-VITAMIN W/FL
3
(blank)
Folic Acid Prep
Iron Replacement
Miscellaneous
Class
Copay
Tier
Drug Name
Prenatal Vitamin
ACTIVE OB
3
(blank)
Dispensing Edits
B NEXA
3
Age, Gender
BAL-CARE DHA ESSENTIAL
3
(blank)
CITRANATAL 90 DHA
3
(blank)
CITRANATAL B-CALM
3
Age, Qty. Limit
CITRANATAL HARMONY
3
(blank)
CITRNATAL-BA CALM
3
(blank)
DONATUSS XP ORAL
3
(blank)
DUET DHA BALANCED
3
Gender
DUET DHA BALANCED <geq>
1
Gender
(blank)
DUET DHA COMPLETE
3
Gender
DUET DHA COMPLETE <geq>
1
Gender
DUET DHC EC
3
(blank)
GESTICARE DHA
3
Age, Gender
HEMENATAL OB
3
Age, Qty. Limit
HEMENATAL OB + DHA COMBO
3
Age, Qty. Limit
INFANATE BALANCE
3
(blank)
MARNATAL F
3
(blank)
NATA KOMPLETE
3
(blank)
NEEVO COMBO PK
3
(blank)
NEEVO, NEEVO DHA
3
(blank)
NESTABS
3
(blank)
NESTABS ABC
3
(blank)
NESTABS DHA
3
(blank)
NEXA PLUS
3
Age, Gender
NEXA SELECT
3
Age, Gender
NIRON KOMPLETE
3
(blank)
OB COMPLETE W/DHA
3
(blank)
PNV FOLIC ACID + IRON
3
(blank)
PNV-DHA PLUS
3
(blank)
PNV-IRON
3
(blank)
PREFERA OB
3
(blank)
PRENAISSANCE NEXT B
3
(blank)
PRENATA
3
(blank)
PRENATAL 19
3
(blank)
PRENATAL 19 CHEW TAB
3
(blank)
PRENATAL PLUS
3
(blank)
prenatal vitamins (oral)
1
(blank)
PRENATE AM
3
(blank)
PRENATE DHA
3
(blank)
PRENATE ELITE
3
(blank)
PRENATE ENHANCE
3
Age, Gender
PRENATE ESSENTIAL
3
(blank)
PRENATE MINI
3
(blank)
Class
Vitamin
Drug Name
Copay
Tier
Dispensing Edits
PRENATE PLUS
3
(blank)
PRENATE RESTORE
3
Age, Gender
PRENEXA
3
(blank)
PREQUE 10
3
(blank)
PROTECT NATAL
3
(blank)
PUREFE OB PLUS
3
Age, Gender
PUREFE PLUS
3
Age, Gender
ROVIDA OB
3
(blank)
TL-SELECT DHA
3
Gender
TRIVEEN-U
3
Age, Gender
VENATAL - FA
3
(blank)
VITAFOL ULTRA
3
Age, Gender
VITAFOL-ONE
VITAFOL PLUS
3
(blank)
VITAMEDMD ONE RX
3
Age, Qty. Limit
VIVA CT
3
(blank)
VOL-NATE
3
(blank)
VOL-PLUS
3
(blank)
VOL-TAB RX
2
(blank)
B-NEXA
3
(blank)
CEREFOLIN NAC
3
(blank)
CORVITE FE
3
(blank)
DUET DHA BALANCED
3
(blank)
FOLTX
3
(blank)
MENTANX
3
(blank)
PROTECT BONE
3
(blank)
PROTECT IRON
3
(blank)
TOZAL
3
(blank)
VASCULERA
3
(blank)
105

Preferred Drug List 1Q14

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