Rocky Mountain Health Plans 2015 Premier Medicare Formulary (List of Covered Drugs)

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Rocky Mountain Health Plans 2015 Premier Medicare Formulary

(List of Covered Drugs)

PLEASE READ:

THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on November 1, 2015. For more recent information or other questions, please contact Rocky Mountain Health Plans (RMHP) Customer Service at 888-282-1420. (TTY users should call 711 for Relay Colorado). Hours are 8:00 a.m. to 8:00 p.m., Mountain Time, October 1 - February 14, 7 days/week; February 15-September 30, Monday-Friday, or visit rmhpMedicare.org.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means RMHP. When it refers to “plan” or

“our plan,” it means RMHP.

This document includes a list of the drugs (formulary) for our plan which is current as of November 1, 2015.

For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.

RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact RMHP. Limitations, copayments, and restrictions may apply.

This information is available for free in other languages. Please call our Customer Service at 888-282-1420 (TTY dial 711). Hours are 8am - 8pm, 7 days/week, Oct.1–Feb.14, and 8am - 8pm, M-F, Feb.15–Sept.30.

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What is the Rocky Mountain Health Plans Formulary?

A formulary is a list of covered drugs selected by RMHP in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.

RMHP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an RMHP network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will

immediately remove the drug from our formulary and provide notice to members who take the drug.

The enclosed formulary is current as of November 1, 2015. To get updated information about the drugs covered by RMHP, please contact us. Our contact information appears on the front and back cover pages. The only changes made to the formulary mid-year are maintenance drug changes. This means we may add new drugs to the formulary and we may move a brand name drug to a higher tier if a bioequivalent generic becomes available and is included in the formulary. RMHP does not make non-maintenance formulary changes mid-year.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins on page number 7. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page

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What are generic drugs?

RMHP covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

 Prior Authorization: RMHP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

 Quantity Limits: For certain drugs, RMHP limits the amount of the drug that we will cover. For example, RMHP provides 12 tablets per month for Imitrex tablets. This may be in addition to a standard one month or three month supply.

 Step Therapy: In some cases, RMHP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask RMHP to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the RMHP formulary?” below for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that RMHP does not cover your drug, you have two options:

 You can ask Customer Service for a list of similar drugs that are covered by RMHP. When

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How do I request an exception to the RMHP Formulary?

You can ask RMHP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

 You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

 You can ask us to cover a formulary drug at a lower cost-sharing level, if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.

 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, RMHP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, RMHP will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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get your drugs is limited; but you are past the first 90 days of membership in our plan, we will cover a 31- day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

When you have a level of care change (e.g. you are admitted to a Long Term Care facility), you may need additional supplies of your medications. When this occurs, the pharmacy can call the RMHP Pharmacy Help Desk to receive a transition supply of each affected drug. RMHP will not limit appropriate and necessary access to Part D benefits when you are being admitted to, or discharged from a Long Term Care facility.

F

or more information

For more detailed information about your RMHP prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about RMHP, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486- 2048. Or, visit http://www.medicare.gov/.

RMHP Formulary

The formulary that begins on page 7 provides coverage information about the drugs covered by RMHP. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ALLEGRA) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the Requirements/Limits column tells you if RMHP has any special requirements for coverage of your drug.

The RMHP formulary key for the Requirements/Limits column is as follows:

Drug Tier 1 Preferred Generic Drugs (lowest cost generic drugs)

Drug Tier 2 Nonpreferred Generic Drugs (may contain certain preferred brand name drugs) Drug Tier 3 Preferred Brand Drugs

Drug Tier 4 Nonpreferred Brand Drugs Drug Tier 5 Specialty Drugs

See your Summary of Benefits or Evidence of Coverage to determine how much you will pay for

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Drugs that appear with:

italics = Generic drugs

CAPITALIZATION = Brand name drugs PA = Prior Authorization required

PA BvD (Part B vs. Part D only) = Prior Authorization required. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

PA NSO (PA for New Starts Only) = Prior Authorization required for new members or members who have not taken this drug previously

QL = Quantity Limit applies

ST = Step Therapy Refer to Medicare Prescription Drugs Requiring Step Therapy on the RMHP website at http://www.rmhp.org/members/prior-authorization/pharmacy.

LA = Limited Access Drug. This prescription may be available only at certain pharmacies. For more information, consult your Provider Directory or call Customer Service at 970-244-7912 or 888-282- 1420. (TTY users call 711.) We are available for phone calls 8:00 a.m. to 8:00 p.m., Mountain Time, (from October 1-February 14, 7 days/week and from February 15 - September 30, Monday - Friday).

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Drug Name Drug Tier Requirements/Limits

Analgesics

Analgesics, Miscellaneous

acetaminophen-codeine oral solution (Acetaminophen with Codeine)

2

acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) 2 AVINZA ORAL CAPSULE, ER

MULTIPHASE 24 HR 120 MG

4 QL (30 per 30 days)

AVINZA ORAL CAPSULE, ER MULTIPHASE 24 HR 30 MG

BUPRENEX 4

buprenorphine hcl injection (Buprenorphine HCl) 2

butalbital-acetaminop-caf-cod (Fioricet with Codeine) 2

butalbital-acetaminophen (Tencon) 2

butalbital-acetaminophen-caff oral capsule

(Esgic) 2

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

(Esgic) 2

butalbital-aspirin-caffeine oral capsule (Fiorinal) 2

butorphanol tartrate (Butorphanol Tartrate) 2

CAPITAL WITH CODEINE 3

codeine sulfate oral tablet (Codeine Sulfate) 2

codeine-butalbital-asa-caffein oral capsule 30-50-325-40 mg

(Fiorinal with Codeine

#3)

2

DEMEROL (PF) INJECTION SOLUTION

4

DEMEROL (PF) INJECTION SYRINGE 4

DEMEROL INJECTION SOLUTION 4

DEMEROL ORAL 4

DILAUDID 4

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Drug Name Drug Tier Requirements/Limits

DILAUDID (PF) 4

DILAUDID-HP (PF) INJECTION 4

DOLOPHINE ORAL 4

DURAGESIC 4 QL (15 per 30 days)

DURAMORPH (PF) 3

fentanyl citrate (Actiq) 2 PA; QL (120 per 30

days); AGE (Min 16 Years)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

(Duragesic) 2 QL (15 per 30 days)

FENTORA 4 PA; QL (120 per 30

FIORINAL-CODEINE #3 4

HYCET 4

hydrocodone-acetaminophen oral solution (Hycet) 2

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

(Norco) 2

hydrocodone-ibuprofen oral tablet 7.5-200 mg

(Vicoprofen) 2

hydromorphone (pf) injection solution 10 mg/ml

(Hydromorphone HCl/PF)

2

hydromorphone oral liquid (Dilaudid) 2

hydromorphone oral tablet (Dilaudid) 2

hydromorphone oral tablet extended release 24 hr

(Exalgo) 3

ibuprofen-oxycodone (Ibuprofen/Oxycodone

HCl)

2

KADIAN ORAL

CAPSULE,EXTEND.RELEASE PELLETS 10 MG

KADIAN ORAL

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Drug Name Drug Tier Requirements/Limits

KADIAN ORAL

CAPSULE,EXTEND.RELEASE PELLETS 130 MG, 150 MG, 200 MG

KADIAN ORAL

LAZANDA 5 PA; QL (120 per 30

levorphanol tartrate (Levorphanol Tartrate) 2

LORTAB 10-325 2

LORTAB 5-325 2

LORTAB 7.5-325 2

meperidine (Demerol) 2

meperidine (pf) (Meperidine HCl/PF) 2

meperidine oral solution (Meperidine HCl) 3

meperidine oral tablet (Demerol) 2

methadone hcl oral concentrate 10 mg/ml (Methadose) 2

methadone injection (Methadone HCl) 3

methadone oral (Methadone HCl) 2

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Drug Name Drug Tier Requirements/Limits

methadone oral (Dolophine HCl) 2

morphine concentrate oral solution (Msir) 2

morphine intravenous cartridge 10 mg/ml, 8 mg/ml

(Morphine Sulfate) 2

morphine intravenous cartridge 2 mg/ml, 4 mg/ml

morphine intravenous syringe 10 mg/ml, 8 mg/ml

morphine intravenous syringe 2 mg/ml, 4 mg/ml

morphine oral capsule, er multiphase 24 hr 120 mg

(Avinza) 2 QL (30 per 30 days)

morphine oral capsule,extend.release pellets 10 mg

(Kadian) 2 QL (360 per 30 days)

morphine oral solution (Msir) 2

MORPHINE ORAL TABLET 3

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Drug Name Drug Tier Requirements/Limits

morphine oral tablet extended release 100

mg

(MS Contin) 2 QL (36 per 30 days)

morphine oral tablet extended release 15 mg

MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG

nalbuphine injection (Nalbuphine HCl) 2

NORCO 4

NUCYNTA 3

NUCYNTA ER 4 QL (60 per 30 days)

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 7.5 MG

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Drug Name Drug Tier Requirements/Limits

OPANA ORAL 4

oxycodone hcl-acetaminophen oral solution 5-325 mg/5 ml

(Oxycodone

HCl/Acetaminophen)

2

oxycodone hcl-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

(Percocet) 2

oxycodone hcl-aspirin (Percodan) 2

oxycodone oral capsule (Oxycodone HCl) 2

oxycodone oral concentrate (Oxycodone HCl) 2

oxycodone oral solution (Oxycodone HCl) 2

oxycodone oral tablet (Roxicodone) 2

oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg

(Oxycodone HCl) 3 QL (240 per 30 days)

oxycodone oral tablet,oral only,ext.rel.12 hr 20 mg, 80 mg

oxycodone oral tablet,oral only,ext.rel.12 hr 40 mg

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

(Percocet) 2

oxycodone-aspirin (Percodan) 2

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 20 MG, 80 MG

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG

oxymorphone oral tablet (Opana) 2

oxymorphone oral tablet extended release 12 hr 10 mg

(Opana ER) 3 QL (120 per 30 days)

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Drug Name Drug Tier Requirements/Limits

oxymorphone oral tablet extended release

12 hr 30 mg

oxymorphone oral tablet extended release 12 hr 7.5 mg

pentazocine-naloxone (Pentazocine

HCl/Naloxone HCl)

2

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG

4

PERCODAN 4

ROXICODONE 4

SYNALGOS-DC 4

TALWIN 3

tramadol oral tablet (Ultram) 2

tramadol oral tablet extended release 24 hr 100 mg, 200 mg

(Ultram ER) 2

tramadol-acetaminophen (Ultracet) 2

TYLENOL-CODEINE #3 4

TYLENOL-CODEINE #4 4

ULTRACET 4

ULTRAM 4

ULTRAM ER 4

VICOPROFEN 4

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR

Nonsteroidal Anti-Inflammatory Agents

ANAPROX 4

ANAPROX DS 4

ARTHROTEC 50 4

ARTHROTEC 75 4

CAMBIA 4 QL (9 per 30 days)

CATAFLAM 4

CELEBREX 4

celecoxib (Celebrex) 2

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Drug Name Drug Tier Requirements/Limits

COMFORT PAC-IBUPROFEN 2

COMFORT PAC-MELOXICAM 2

COMFORT PAC-NAPROXEN 2

DAYPRO 4

diclofenac potassium (Cataflam) 2

diclofenac sodium oral tablet extended release 24 hr

(Voltaren-XR) 2

diclofenac sodium oral tablet,delayed release (dr/ec)

(Diclofenac Sodium) 2

diclofenac sodium topical gel (Solaraze) 2

diclofenac-misoprostol (Arthrotec 75) 2

diflunisal (Diflunisal) 2

EC-NAPROSYN 4

etodolac (Etodolac) 2

FELDENE 4

FENOPROFEN ORAL CAPSULE 3

fenoprofen oral tablet (Fenoprofen Calcium) 2

flurbiprofen (Ansaid) 2

ibuprofen oral (Ibuprofen) 2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

(Ibuprofen) 2

INDOCIN ORAL 3

indomethacin oral (Indomethacin) 2

ketoprofen oral capsule (Ketoprofen) 2

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

(Ketoprofen) 3

ketorolac injection solution 15 mg/ml, 30 mg/ml (1 ml)

(Ketorolac Tromethamine)

2

ketorolac intramuscular solution (Ketorolac Tromethamine)

2

ketorolac oral (Ketorolac

Tromethamine)

2

meclofenamate oral (Meclofenamate

Sodium)

3

mefenamic acid (Ponstel) 2

meloxicam oral suspension (Mobic) 3

meloxicam oral tablet (Mobic) 2

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Drug Name Drug Tier Requirements/Limits

MOBIC 4

nabumetone (Nabumetone) 2

NAPROSYN 4

naproxen oral suspension (Naprosyn) 2

naproxen oral tablet (Naprosyn) 2

naproxen oral tablet,delayed release (dr/ec)

(Ec-Naprosyn) 2

naproxen sodium oral tablet 275 mg, 550 mg

(Anaprox Ds) 2

naproxen sodium oral tablet, er multiphase 24 hr

(Naprelan) 2

oxaprozin (Daypro) 2

piroxicam (Feldene) 2

PONSTEL 4

SOLARAZE 4

sulindac oral (Sulindac) 2

tolmetin oral capsule (Tolmetin Sodium) 2

tolmetin oral tablet 200 mg (Tolmetin Sodium) 2

tolmetin oral tablet 600 mg (Tolmetin Sodium) 3

VOLTAREN TOPICAL 4

VOLTAREN-XR 4

Anesthetics

Local Anesthetics

EMLA 4 PA BvD

lidocaine (pf) injection solution 5 mg/ml (0.5 %)

(Xylocaine-MPF) 2 PA BvD

lidocaine hcl injection solution 10 mg/ml (1 %)

(Xylocaine) 2 PA BvD

lidocaine hcl injection solution 20 mg/ml (2 %)

(Xylocaine) 2

lidocaine hcl mucous membrane gel (Lidocaine HCl) 2

lidocaine hcl mucous membrane jelly in applicator

(Lidocaine HCl) 2

lidocaine hcl mucous membrane solution (Xylocaine) 2

lidocaine hcl urethral (Lidocaine HCl) 2

lidocaine topical adhesive patch,medicated

(Lidoderm) 2 PA

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Drug Name Drug Tier Requirements/Limits

lidocaine topical ointment (Lidocaine) 2 PA BvD

lidocaine-prilocaine topical (EMLA) 2 PA BvD

lidocaine-prilocaine topical kit (Relador Pak) 2 PA BvD

lidocaine-tetracaine (Pliaglis) 2 PA BvD

LIDODERM 4 PA

SYNERA 3 PA BvD

XYLOCAINE MUCOUS MEMBRANE SOLUTION

4

Anti-Addiction/Substance Abuse Treatment Agents

Anti-Addiction/Substance Abuse Treatment Agents

acamprosate (Campral) 2

ANTABUSE 4

buprenorphine hcl sublingual (Subutex) 2

buprenorphine-naloxone (Buprenorphine

HCl/Naloxone HCl)

2

bupropion hcl sr 150 mg tablet f/c (Zyban) 2

CAMPRAL 4

CHANTIX 3 QL (336 per 365 days)

CHANTIX STARTING MONTH BOX 3 QL (106 per 365 days)

disulfiram (Antabuse) 2

EVZIO 4 QL (0.8 per 365 days)

naloxone injection syringe 1 mg/ml (Naloxone HCl) 2

naltrexone (Revia) 2

NICOTROL 3

NICOTROL NS 3

REVIA 4

SUBOXONE SUBLINGUAL FILM 3

ZYBAN 4

Antianxiety Agents

Benzodiazepines

clonazepam oral tablet (Klonopin) 2

clonazepam oral tablet,disintegrating (Clonazepam) 2

clorazepate dipotassium (Tranxene T-Tab) 2

DIASTAT 4

DIASTAT ACUDIAL 4

diazepam intensol (Diazepam) 3

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Drug Name Drug Tier Requirements/Limits

diazepam oral solution (Diazepam) 3

diazepam oral tablet (Valium) 2

diazepam rectal (Diastat Acudial) 2

lorazepam injection solution (Ativan) 2

lorazepam injection syringe 4 mg/ml (Ativan) 2

lorazepam oral tablet (Ativan) 2

ONFI ORAL SUSPENSION 3

ONFI ORAL TABLET 10 MG, 20 MG 3 QL (60 per 30 days)

oxazepam (Oxazepam) 2

temazepam oral capsule 15 mg, 30 mg, 7.5 mg

(Restoril) 2

Antibacterials

Aminoglycosides

amikacin (Amikacin Sulfate) 2

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

(Gentamicin In Nacl, Iso-Osm)

2

gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 90 mg/100 ml

(Gentamicin In Nacl, Iso-Osm)

3

gentamicin injection solution (Garamycin) 2

gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) 2

gentamicin sulfate (pf) intravenous solution

(Gentamicin Sulfate/PF) 2

neomycin (Neomycin Sulfate) 2

streptomycin intramuscular (Streptomycin Sulfate) 3

TOBI 5

TOBI PODHALER INHALATION 5

tobramycin in 0.225 % nacl (Tobi) 4

tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml

(Tobramycin/Sodium Chloride)

3

tobramycin sulfate injection solution (Nebcin) 2

Antibacterials, Miscellaneous

bacitracin (Bacitracin) 2

bacitracin intramuscular (Bacitracin) 4

chloramphenicol sod succinate (Chloramphenicol Sod Succ)

3

CLEOCIN IN 5 % DEXTROSE 4

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Drug Name Drug Tier Requirements/Limits

clindamycin hcl (Cleocin HCl) 2

clindamycin in 5 % dextrose (Cleocin Phosphate In D5w)

2

clindamycin palmitate hcl (Cleocin Palmitate) 2

clindamycin phosphate injection (Cleocin Phosphate) 2

CLINDAMYCIN PHOSPHATE INJECTION SOLUTION 150 MG/ML

4

clindamycin phosphate intravenous solution

(Cleocin Phosphate) 2

CLINDAMYCIN PHOSPHATE ORAL CAPSULE 150 MG, 300 MG, 75 MG

4

CLINDAMYCIN PHOSPHATE ORAL RECON SOLN 75 MG/5 ML

4

colistin (colistimethate na) (Coly-Mycin M Parenteral)

2

COLY-MYCIN M PARENTERAL 4

CUBICIN 3

FURADANTIN 4

HIPREX 4

LINCOCIN 4

linezolid intravenous (Zyvox) 3

linezolid oral (Zyvox) 4

MACROBID 4

MACRODANTIN 4

methenamine hippurate (Hiprex) 2

methenamine mandelate oral tablet 1 gram

(Methenamine Mandelate)

2

MONUROL 3

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

(Macrodantin) 2

nitrofurantoin monohyd/m-cryst (Macrobid) 2

nitrofurantoin oral (Furadantin) 2

polymyxin b sulfate (Polymyxin B Sulfate) 2

PRIMSOL 3

SYNERCID 3

trimethoprim (Trimethoprim) 2

VANCOCIN 4

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Drug Name Drug Tier Requirements/Limits

vancomycin in d5w intravenous piggyback (Vancomycin

HCl/D5W)

2

vancomycin intravenous recon soln 1,000 mg, 10 gram

(Vancomycin HCl) 2

vancomycin intravenous recon soln 500 mg

(Vancomycin HCl/D5W)

2

vancomycin oral capsule (Vancocin HCl) 2

XIFAXAN ORAL TABLET 200 MG 3

XIFAXAN ORAL TABLET 550 MG 5

ZYVOX INTRAVENOUS PARENTERAL SOLUTION

3

ZYVOX ORAL 5

Cephalosporins

CEDAX 4

cefaclor oral capsule (Cefaclor) 2

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

(Cefaclor) 3

cefaclor oral tablet extended release 12 hr (Cefaclor) 3

cefadroxil oral capsule (Cefadroxil) 2

cefadroxil oral suspension for

reconstitution 250 mg/5 ml, 500 mg/5 ml

(Cefadroxil) 2

cefadroxil oral tablet (Cefadroxil) 2

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml

(Cefazolin Sodium) 3

cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml

(Cefazolin

Sodium/Dextrose, Iso)

2

cefazolin injection recon soln (Ancef) 2

cefazolin injection recon soln 100 gram, 300 g

(Cefazolin Sodium) 2

cefazolin intravenous (Cefazolin Sodium) 3

cefdinir (Cefdinir) 2

cefditoren pivoxil (Spectracef) 2

cefepime (Maxipime) 2

CEFEPIME IN DEXTROSE 5 % 2

CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK

2

cefixime (Suprax) 3

(20)

Drug Name Drug Tier Requirements/Limits

cefotaxime (Claforan) 2

cefotetan (Cefotetan Disodium) 3

cefoxitin (Mefoxin) 2

cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml

(Cefoxitin

3

cefpodoxime (Cefpodoxime Proxetil) 2

cefprozil (Cefprozil) 2

ceftazidime (Fortaz) 2

CEFTAZIDIME IN D5W 3

ceftazidime injection recon soln 2 gram, 6 gram

(Fortaz) 2

ceftibuten (Cedax) 2

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

4

CEFTIN ORAL TABLET 250 MG, 500 MG

4

ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml

(Ceftriaxone Na/Dextrose, Iso)

2

CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2

GRAM/50 ML

2

ceftriaxone injection recon soln (Rocephin) 2

ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso)

2

CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM

2

cefuroxime axetil oral tablet (Ceftin) 2

cefuroxime sodium injection recon soln 1.5 gram, 750 mg

(Zinacef) 2

cefuroxime sodium intravenous (Zinacef) 2

cephalexin oral capsule 250 mg, 500 mg (Keflex) 2

cephalexin oral suspension for reconstitution

(Cephalexin) 2

cephalexin oral tablet (Cephalexin) 3

CLAFORAN INJECTION 4

CLAFORAN INTRAVENOUS RECON SOLN 2 GRAM

4

FORTAZ INJECTION RECON SOLN 4

(21)

Drug Name Drug Tier Requirements/Limits

FORTAZ INTRAVENOUS 4

KEFLEX ORAL CAPSULE 250 MG, 500 MG

4

MAXIPIME INJECTION 4

ROCEPHIN INJECTION RECON SOLN 500 MG

4

SPECTRACEF ORAL TABLET 400 MG 4

SUPRAX 3

TEFLARO 3

ZINACEF INJECTION 4

ZINACEF INTRAVENOUS RECON SOLN

4

Macrolides

azithromycin (Zithromax) 2

BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML

4

BIAXIN ORAL TABLET 4

BIAXIN XL 4

clarithromycin oral suspension for reconstitution

(Biaxin) 2

clarithromycin oral tablet (Biaxin) 2

clarithromycin oral tablet extended release 24 hr

(Biaxin XL) 2

DIFICID 4 PA

ERYPED 200 4

ERYPED 400 3

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

3

erythromycin base oral tablet,delayed release (dr/ec) 250 mg, 500 mg

(Erythromycin Base) 3

ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG

3

erythromycin ethylsuccinate oral

suspension for reconstitution 200 mg/5 ml

(Eryped 200) 4

erythromycin ethylsuccinate oral tablet (Erythromycin Ethylsuccinate)

2

(22)

Drug Name Drug Tier Requirements/Limits

erythromycin ethylsuccinate oral tablet

400 mg

(Erythromycin Ethylsuccinate)

4

erythromycin oral tablet (Erythromycin Base) 3

erythromycin stearate oral tablet 250 mg (Erythromycin Stearate) 2

KETEK 4

PCE 3

ZITHROMAX INTRAVENOUS 4

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION

4

ZITHROMAX ORAL TABLET 4

ZITHROMAX TRI-PAK 4

ZITHROMAX Z-PAK 4

ZMAX 3

Miscellaneous B-Lactam Antibiotics

AZACTAM IN DEXTROSE (ISO-OSM) 3

AZACTAM INJECTION RECON SOLN 4

aztreonam (Azactam) 2

CAYSTON 5 LA

DORIBAX INTRAVENOUS RECON SOLN 500 MG

3

imipenem-cilastatin (Primaxin) 2

INVANZ INJECTION 3

meropenem (Merrem) 2

MERREM 4

PRIMAXIN IV 4

Penicillins

amoxicillin oral capsule (Amoxicillin) 2

amoxicillin oral suspension for reconstitution

(Amoxil) 2

amoxicillin oral tablet (Amoxicillin) 2

amoxicillin oral tablet, er multiphase 24 hr

(Moxatag) 3

amoxicillin oral tablet,chewable 125 mg, 250 mg

(Amoxicillin) 2

amoxicillin-pot clavulanate oral suspension for reconstitution

(Augmentin) 2

amoxicillin-pot clavulanate oral tablet (Augmentin) 2

(23)

Drug Name Drug Tier Requirements/Limits

amoxicillin-pot clavulanate oral tablet

extended release 12 hr

(Augmentin XR) 2

amoxicillin-pot clavulanate oral tablet,chewable

(Amoxicillin/Potassium Clav)

2

ampicillin oral capsule (Ampicillin Trihydrate) 2

ampicillin oral suspension for reconstitution

(Ampicillin Trihydrate) 3

ampicillin sodium injection recon soln (Totacillin-N) 2

ampicillin sodium intravenous recon soln (Totacillin-N) 2

ampicillin-sulbactam injection (Unasyn) 2

ampicillin-sulbactam intravenous recon soln

(Unasyn) 2

AUGMENTIN ES-600 4

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML, 250-62.5 MG/5 ML

4

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

4

AUGMENTIN XR 4

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin (Dicloxacillin Sodium) 2

nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm)

3

nafcillin injection (Unipen) 2

oxacillin in dextrose(iso-osm) (Oxacillin

3

oxacillin injection recon soln (Oxacillin Sodium) 2

oxacillin intravenous recon soln (Oxacillin Sodium) 2

penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml

(Pen G

Pot/Dextrose-Water)

3

penicillin g potassium injection recon soln (Penicillin G Potassium) 2 penicillin g procaine intramuscular

syringe 1.2 million unit/2 ml

(Penicillin G Procaine) 3

penicillin g sodium (Penicillin G Sodium) 3

penicillin v potassium (Penicillin V Potassium) 2

piperacillin-tazobactam (Zosyn) 2

(24)

Drug Name Drug Tier Requirements/Limits

TIMENTIN INTRAVENOUS RECON

SOLN 31 GRAM

3

UNASYN INJECTION 4

ZOSYN IN DEXTROSE (ISO-OSM) 3

ZOSYN INTRAVENOUS RECON SOLN 3.375 GRAM, 40.5 GRAM

4

Quinolones

AVELOX 4

AVELOX ABC PACK 4

AVELOX IN NACL (ISO-OSMOTIC) 4

CIPRO IN D5W INTRAVENOUS PIGGYBACK

4

CIPRO ORAL

SUSPENSION,MICROCAPSULE RECON

3

CIPRO ORAL TABLET 250 MG, 500 MG

4

ciprofloxacin (Cipro) 2

ciprofloxacin (mixture) (Cipro XR) 2

ciprofloxacin hcl oral (Cipro) 2

ciprofloxacin in 5 % dextrose (Cipro I.V.) 2

ciprofloxacin lactate intravenous solution 400 mg/40 ml

(Cipro I.V.) 2

FACTIVE 4

LEVAQUIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

4

LEVAQUIN ORAL 4

levofloxacin in d5w intravenous piggyback (Levaquin) 2

levofloxacin intravenous (Levofloxacin) 2

levofloxacin oral (Levaquin) 2

moxifloxacin (Avelox) 2

moxifloxacin-sod.ace,sul-water (Moxifloxacin/Sod.Ace, Sul/Water)

2

NOROXIN 4

ofloxacin oral (Ofloxacin) 2

Sulfonamides

AZULFIDINE 4

(25)

Drug Name Drug Tier Requirements/Limits

AZULFIDINE EN-TABS 4

BACTRIM 4

BACTRIM DS 4

sulfadiazine oral (Sulfadiazine) 3

sulfamethoxazole-trimethoprim intravenous

(Sulfamethoxazole/Trim ethoprim)

3

sulfamethoxazole-trimethoprim oral suspension

(Sulfamethoxazole/Trim ethoprim)

2

sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 2

sulfasalazine (Azulfidine) 2

sulfazine (Azulfidine) 2

sulfazine ec (Azulfidine) 2

Tetracyclines

demeclocycline oral (Demeclocycline HCl) 2

doxycycline hyclate oral capsule 100 mg (Vibramycin) 2

doxycycline hyclate 100 mg tab f/c (Doryx) 2

doxycycline hyclate intravenous (Doxycycline Hyclate) 2

doxycycline hyclate oral capsule 100 mg (Adoxa) 2

doxycycline hyclate oral capsule 50 mg (Vibramycin) 2

doxycycline hyclate oral tablet 100 mg, 50 mg

(Adoxa) 2

doxycycline hyclate oral tablet 20 mg (Doryx) 2

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg

(Doryx) 2

doxycycline hyclate oral tablet,delayed release (dr/ec) 75 mg

(Doryx) 3

doxycycline mono 100 mg cap (Adoxa) 2

doxycycline mono 100 mg tablet (Adoxa) 2

doxycycline monohydrate oral capsule 50 mg, 75 mg

(Adoxa) 2

doxycycline monohydrate oral capsule,ir

& delay rel,biphase

(Oracea) 3

doxycycline monohydrate oral suspension for reconstitution

(Vibramycin) 2

doxycycline monohydrate oral tablet 50 mg, 75 mg

(Adoxa) 2

minocycline oral capsule (Minocin) 2

(26)

Drug Name Drug Tier Requirements/Limits

minocycline oral tablet (Minocycline HCl) 2

ORACEA 3

SOLODYN ORAL TABLET

EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG

5

tetracycline (Ala-Tet) 3

TYGACIL 3

VIBRAMYCIN ORAL CAPSULE 100 MG

4

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

4

VIBRAMYCIN ORAL SYRUP 3

Anticancer Agents

Anticancer Agents

ABRAXANE 3

ADCETRIS 5 PA NSO

AFINITOR 5 PA NSO

AFINITOR DISPERZ 5 PA NSO

ALIMTA INTRAVENOUS RECON SOLN

3

ALKERAN INTRAVENOUS 4 PA BvD

anastrozole (Arimidex) 2

ARIMIDEX 4

AROMASIN 4

ARRANON 3

ARZERRA 5 PA NSO

AVASTIN 5 PA NSO

azacitidine (Vidaza) 3

BELEODAQ 5 PA NSO

bexarotene (Targretin) 5

bicalutamide (Casodex) 2

BICNU 3

bleomycin (Bleomycin Sulfate) 2 PA BvD

BOSULIF 5 PA NSO

BUSULFEX INTRAVENOUS 4

CAMPTOSAR INTRAVENOUS SOLUTION

4

(27)

Drug Name Drug Tier Requirements/Limits

CAPRELSA 5 PA NSO

carboplatin intravenous solution (Carboplatin) 2

CASODEX 4

cisplatin (Cisplatin) 2

cladribine (Cladribine) 2 PA BvD

CLOLAR 5 AGE (Max 21 Years)

COMETRIQ 5 PA NSO

COSMEGEN 3

CYCLOPHOSPHAMIDE ORAL CAPSULE

2 PA BvD

cyclophosphamide oral tablet (Cyclophosphamide) 2 PA BvD

CYRAMZA 5 PA NSO

cytarabine (Cytarabine) 3 PA BvD

cytarabine (pf) injection recon soln (Cytarabine/PF) 2 PA BvD

cytarabine (pf) injection solution (Cytarabine/PF) 3 PA BvD

dacarbazine intravenous recon soln (Dtic-Dome IV) 2

DACOGEN 5

dactinomycin (Dactinomycin) 3

DAUNORUBICIN HCL 4

daunorubicin intravenous (Cerubidine) 2

DAUNOXOME 4

decitabine (Dacogen) 5

DOCEFREZ 3

docetaxel intravenous solution (Taxotere) 3

DOXIL 4 PA BvD

doxorubicin hcl intravenous recon soln 10 mg

(Doxorubicin HCl) 2 PA BvD

doxorubicin hcl peg-liposomal intravenous suspension 2 mg/ml

(Doxil) 2

doxorubicin intravenous solution 2 mg/ml, 50 mg/25 ml

(Doxorubicin HCl) 2 PA BvD

doxorubicin, peg-liposomal (Doxil) 2

DROXIA 3

ELIGARD 3

ELLENCE 4

ELOXATIN INTRAVENOUS SOLUTION

4

(28)

Drug Name Drug Tier Requirements/Limits

EMCYT 3

epirubicin intravenous solution 50 mg/25 ml

(Ellence) 2

ERBITUX 3 PA NSO

ERIVEDGE 5 PA NSO

ERWINAZE 5

ETOPOPHOS 3

etoposide intravenous (Etoposide) 2

exemestane (Aromasin) 2

FARESTON 3

FARYDAK 5 PA NSO

FASLODEX 3 PA NSO

FEMARA 4

FIRMAGON KIT W DILUENT SYRINGE

4

floxuridine (FUDR) 2

fludarabine (Fludara) 2 PA BvD

fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml

(Fluorouracil) 2 PA BvD

flutamide (Flutamide) 2

FOLOTYN 3

GAZYVA 5 PA NSO

gemcitabine intravenous recon soln 1 gram

(Gemzar) 2

GEMZAR 5

GILOTRIF 5 PA NSO

GLEEVEC 5 PA NSO

HALAVEN 5 PA NSO

HERCEPTIN 5 PA BvD

HEXALEN 3

HYCAMTIN INTRAVENOUS 4

HYDREA 4

hydroxyurea (Hydrea) 2

IBRANCE 5 PA NSO

ICLUSIG 5 PA NSO

IDAMYCIN PFS 4

idarubicin (Idamycin Pfs) 2

(29)

Drug Name Drug Tier Requirements/Limits

IFEX INTRAVENOUS RECON SOLN 4 PA BvD

ifosfamide intravenous recon soln (Ifex) 2 PA BvD

ifosfamide intravenous solution (Ifex) 2 PA BvD

IMBRUVICA 5 PA NSO

INLYTA 5 PA NSO

irinotecan intravenous solution (Camptosar) 2

ISTODAX 5 PA NSO

IXEMPRA 5 PA NSO

JAKAFI 5 PA NSO

JEVTANA 5

KADCYLA 5 PA NSO

KEYTRUDA 5 PA NSO

LENVIMA 5 PA NSO

letrozole (Femara) 2

LEUKERAN 3

leuprolide (Leuprolide Acetate) 2

lomustine (Gleostine) 3

LUPRON DEPOT 3

LUPRON DEPOT (3 MONTH) 3

LUPRON DEPOT-PED 3

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT

3

LYNPARZA 5 PA NSO

LYSODREN 3

MATULANE 5

MEGACE 4

MEGACE ES 3

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

(Megace Es) 2

megestrol oral tablet (Megestrol Acetate) 2

MEKINIST 5 PA NSO

melphalan hcl intravenous (Alkeran) 5 PA BvD

mercaptopurine (Purinethol) 2

methotrexate sodium (pf) injection recon soln

(Methotrexate Sodium/PF)

2 PA BvD

(30)

Drug Name Drug Tier Requirements/Limits

methotrexate sodium (pf) injection

solution

(Methotrexate Sodium) 2 PA BvD

methotrexate sodium injection (Methotrexate Sodium) 2 PA BvD

methotrexate sodium oral (Methotrexate Sodium) 2

mitomycin intravenous recon soln (Mitomycin) 2 PA BvD

mitoxantrone (Mitoxantrone HCl) 2

MUSTARGEN 3

NAVELBINE INTRAVENOUS SOLUTION

4

NEXAVAR 5 PA NSO

NILANDRON 3

NIPENT 4

ONCASPAR 5

OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML

5 PA NSO

oxaliplatin intravenous solution 100 mg/20 ml

(Eloxatin) 2

paclitaxel (Paclitaxel) 2

pentostatin (Pentostatin) 2

PERJETA 5 PA NSO

PHOTOFRIN 5

POMALYST 5 PA NSO

PROLEUKIN 5

PURINETHOL 4

PURIXAN 3

REVLIMID 5 LA

RHEUMATREX 4 PA BvD

RITUXAN 5

SOLTAMOX 4

SPRYCEL 5 PA NSO

STIVARGA 5 PA NSO

SUTENT 5 PA NSO

SYLVANT 5 PA NSO

SYNRIBO 5 PA NSO

TABLOID 3

TAFINLAR 5 PA NSO

tamoxifen (Tamoxifen Citrate) 2

(31)

Drug Name Drug Tier Requirements/Limits

TARCEVA 5 PA NSO

TARGRETIN 5

TASIGNA 5 PA NSO

TAXOTERE INTRAVENOUS

SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML)

4

teniposide (Teniposide) 5

thiotepa (Thiotepa) 2

toposar intravenous (Etoposide) 2

topotecan intravenous (Hycamtin) 3

TORISEL 5 PA NSO

TREANDA INTRAVENOUS RECON SOLN

5 PA NSO

TREANDA INTRAVENOUS SOLUTION

5 PA NSO

TRELSTAR 3

tretinoin (chemotherapy) (Tretinoin) 2

TREXALL 3 PA BvD

TRISENOX 3

TYKERB 5 PA NSO

VALSTAR 5

VECTIBIX 3 PA NSO

VELCADE 5

VIDAZA 4

vinblastine intravenous (Vinblastine Sulfate) 3 PA BvD

vincristine (Vincristine Sulfate) 2 PA BvD

vincristine sulfate intravenous solution 1 mg/ml

(Vincristine Sulfate) 2 PA BvD

vinorelbine intravenous solution (Navelbine) 2

VOTRIENT 5 PA NSO

XALKORI 5 PA NSO

XTANDI 5 PA NSO

YERVOY 5

ZANOSAR 3

ZELBORAF 5 PA NSO

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG

5

(32)

Drug Name Drug Tier Requirements/Limits

ZOLADEX SUBCUTANEOUS

IMPLANT 3.6 MG

4

ZOLINZA 5 PA NSO

ZYDELIG 5 PA NSO

ZYKADIA 5 PA NSO

ZYTIGA 5 PA NSO

Anticholinergic Agents

Antimuscarinics/Antispasmodics

atropine injection syringe 0.05 mg/ml (Atropine Sulfate) 3 atropine injection syringe 0.1 mg/ml (Atropine Sulfate) 2

propantheline (Propantheline Bromide) 3

Anticonvulsants

Anticonvulsants

APTIOM 3

BANZEL 3

carbamazepine (Tegretol) 2

carbamazepine oral capsule, er multiphase 12 hr

(Carbatrol) 2

carbamazepine oral suspension (Tegretol) 2

carbamazepine oral tablet extended release 12 hr

(Tegretol XR) 2

carbamazepine oral tablet,chewable (Carbamazepine) 2

CARBATROL 4

CELONTIN ORAL CAPSULE 300 MG 3

CEREBYX 4

DEPACON 4

DEPAKENE 4

DEPAKOTE 4

DEPAKOTE ER 4

DEPAKOTE SPRINKLES 4

DILANTIN CAPSULE 30 MG 4

DILANTIN EXTENDED 4

DILANTIN INFATABS 4

DILANTIN-125 4

divalproex oral capsule, sprinkle (Depakote Sprinkle) 2

(33)

Drug Name Drug Tier Requirements/Limits

divalproex oral tablet extended release 24

hr

(Depakote ER) 2

divalproex oral tablet,delayed release (dr/ec)

(Depakote) 2

EQUETRO 3

ethosuximide (Zarontin) 2

felbamate (Felbatol) 2

FELBATOL 4

fosphenytoin (Cerebyx) 2

FYCOMPA ORAL TABLET 3 AGE (Min 12 Years)

gabapentin oral capsule (Neurontin) 2

gabapentin oral solution (Neurontin) 2

gabapentin oral tablet 600 mg, 800 mg (Neurontin) 2

GABITRIL 4

HORIZANT 4

KEPPRA ORAL 4

KEPPRA XR 4

LAMICTAL 4

LAMICTAL ODT 3

LAMICTAL ODT STARTER (BLUE) 4

LAMICTAL ODT STARTER (GREEN) 4

LAMICTAL ODT STARTER (ORANGE) 4

LAMICTAL STARTER (BLUE) KIT 4

LAMICTAL STARTER (GREEN) KIT 4

LAMICTAL STARTER (ORANGE) KIT 4

LAMICTAL XR 4

LAMICTAL XR STARTER (BLUE) 4

LAMICTAL XR STARTER (GREEN) 4

LAMICTAL XR STARTER (ORANGE) 4

lamotrigine oral tablet (Lamictal) 2

lamotrigine oral tablet extended release 24hr

(Lamictal XR) 2

lamotrigine oral tablet, chewable dispersible

(Lamictal) 2

lamotrigine oral tablet,disintegrating (Lamictal Odt) 2

lamotrigine oral tablets,dose pack 25 mg (35)

(Lamictal (Blue)) 2

(34)

Drug Name Drug Tier Requirements/Limits

levetiracetam in nacl (iso-os) (Levetiracetam In Nacl

(Iso-Os))

2

levetiracetam intravenous (Keppra) 2

levetiracetam oral solution (Keppra) 2

levetiracetam oral tablet (Keppra) 2

levetiracetam oral tablet extended release 24 hr

(Keppra XR) 2

LYRICA 4

MYSOLINE 4

NEURONTIN 4

oxcarbazepine (Trileptal) 2

OXTELLAR XR 4

PEGANONE 3

phenobarbital (Phenobarbital) 2

PHENYTEK 4

phenytoin oral suspension 125 mg/5 ml (Dilantin-125) 2

phenytoin oral (Dilantin) 2

phenytoin sodium (Phenytoin Sodium) 2

phenytoin sodium extended (Dilantin) 2

POTIGA 3 QL (90 per 30 days);

AGE (Min 18 Years)

primidone (Mysoline) 2

QUDEXY XR 4

SABRIL 4

TEGRETOL ORAL SUSPENSION 4

TEGRETOL ORAL TABLET 4

TEGRETOL XR 4

tiagabine (Gabitril) 2

TOPAMAX 4

topiramate oral capsule, sprinkle (Topamax) 2

topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 3

topiramate oral tablet (Topamax) 2

TRILEPTAL 4

valproate sodium (Depacon) 2

valproic acid (Depakene) 2

valproic acid (as sodium salt) oral solution 250 mg/5 ml

(Depakene) 2

(35)

Drug Name Drug Tier Requirements/Limits

VIMPAT INTRAVENOUS 3

VIMPAT ORAL SOLUTION 3

VIMPAT ORAL TABLET 3

ZARONTIN 4

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

4

zonisamide (Zonegran) 2

Antidementia Agents

Antidementia Agents

ARICEPT ODT 4

ARICEPT ORAL TABLET 10 MG, 5 MG 4

donepezil oral tablet 10 mg, 5 mg (Aricept) 2

donepezil oral tablet,disintegrating (Aricept Odt) 2

EXELON ORAL CAPSULE 4

EXELON ORAL SOLUTION 3

EXELON TRANSDERMAL 3 QL (30 per 30 days)

galantamine oral capsule,ext rel. pellets 24 hr

(Razadyne ER) 2

galantamine oral solution (Razadyne) 2

galantamine oral tablet (Razadyne) 2

memantine (Namenda) 2 PA; AGE (Min 27

Years)

NAMENDA 3 PA; AGE (Min 27

Years)

NAMENDA TITRATION PAK 3 PA; AGE (Min 27

Years)

NAMENDA XR 4 PA; AGE (Min 27

Years)

RAZADYNE 4

RAZADYNE ER 4

rivastigmine (Exelon) 3

rivastigmine tartrate (Exelon) 2

Antidepressants

Antidepressants

amitriptyline (Amitriptyline HCl) 2