Medicare-Medicaid Plan 2015 List of Covered Drugs (Formulary)

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This is a list of drugs that members can get in Health Alliance Connect.

 Health Alliance Medical Plans is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees.

 Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year.

 You can always check Health Alliance Connect’s up-to-date List of Covered Drugs online at HealthAllianceConnect.org.

 You can ask for this information in other formats, such as Braille or large print. Call 1-866-951-0264. The call is free.

 Limitations, copayments, and restrictions may apply. For more information, call Health Alliance Connect Client Services or read the Health Alliance Connect Medicare-

Medicaid Member Handbook.

 Copayments for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

 You can get this document in Spanish, or speak with someone about this information in other languages for free. Call 1-866-951-0264. The call is free.

 Puede obtener este documento en inglés o hablar con alguien sobre esta información en otro idioma de manera gratuita. Llame al 1-877-933-8480. La llamada es gratuita.

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1. What prescription drugs are on the List of Covered Drugs?

(We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Health Alliance Connect. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

Health Alliance Connect will cover all medically necessary drugs on the Drug List if:

• your doctor or other prescriber says you need them to get better or stay healthy, and

• you fill the prescription at a Health Alliance Connect network pharmacy.

• Health Alliance Connect may have additional steps to access certain drugs (see question #5 below).

You can also see an up-to-date list of drugs that we cover on our website at HealthAllianceConnect.org or call Client Services at 1-866-951-0264.

2. Does the Drug List ever change?

Yes. Health Alliance Connect may add or remove drugs on the Drug List during the year.

Generally, the Drug List will only change if:

• a cheaper drug comes along that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Health Alliance Connect before you can get a drug.)

• Add or change the amount of a drug you can get (called “quantity limits”).

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You can always check Health Alliance Connect’s up to date Drug List online at HealthAllianceConnect.org. You can also call Client Services to check the current Drug List at 1-866-951-0264.

3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?

If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will send you a letter to tell you how we can work with you and your doctor or other prescriber to find a drug on the list that would be similar. This letter will also tell you how you can request an exception.

4. What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you receive this letter, contact your provider to discuss next steps.

5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor must get approval from Health Alliance Connect before you fill your prescription. If you don’t get approval, Health Alliance Connect may not cover the drug.

• Quantity limits: Sometimes Health Alliance Connect limits the amount of a drug

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You can find out if your drug has any additional requirements or limits by looking in the tables that start on page 1. You can also get more information by visiting our web site at HealthAllianceConnect.org.

You can also ask for an “exception” from these limits. Please see question 10 for more information on exceptions.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a

prescription for fewer days), whether or not you are a new Health Alliance Connect member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 10 for more information about exceptions.

6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?

The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor about what to do next.

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• You can search by medical condition.

To search alphabetically, go to the Alphabetical Listing section. You can find it by searching the name.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.

9. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Client Services at 1-866-951-0264 and ask about it. If you learn that Health Alliance Connect will not cover the drug, you can do one of these things:

• Ask Client Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see question 10 for more information about exceptions.

10. What if you are a new Health Alliance Connect member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Health Alliance Connect. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We will cover a 30-day supply of your drug if:

• you are taking a drug that is not on our Drug List, or

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prescription for as long as 91 days. You may refill the drug multiple times during the 91 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.

You may also receive a one-time emergency supply of drugs if you have a level of service change such as a discharge from a long-term care facility.

11. Can you ask for an exception to cover your drug?

Yes. You can ask Health Alliance Connect to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, Health Alliance Connect may limit the amount of a drug we will cover.

If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

12. How long does it take to get an exception?

First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

13. How can you ask for an exception?

To ask for an exception, call Health Alliance Client Services. A Client Services

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drugs are approved by the Food and Drug Administration (FDA).

Health Alliance Connect covers both brand name drugs and generic drugs.

15. What are OTC drugs?

OTC stands for “over-the-counter.” You can buy OTC drugs without a prescription.

Health Alliance Connect covers some OTC drugs.

You can read the Health Alliance Connect Drug List to see what OTC drugs are covered.

16. Does Health Alliance Connect cover OTC non-drug products?

Health Alliance Connect covers some OTC non-drug products.

You can read the Health Alliance Connect Drug List to see what OTC non-drug products are covered.

17. What is your copayment?

You can read the Health Alliance Connect Drug List to learn about the copayment for each drug.

Health Alliance Connect members living in nursing homes or other long-term care facilities will have no copayments. Some members getting long-term care in the community will also have no copayments.

Tier 1/$0- Part D Generic Drugs—These drugs are the lowest prescription cost drugs on our formulary.

Tier 2/$0-$6.35 (depending on your level of Extra Help)- Part D Brand Drugs—These are drugs typically cost more than Tier 1 and some many have special rules, like preauthorization, before you can take them

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Tier 6/$0-Brand Over-the-Counter Drugs—These are brand name OTC drugs, and cost more than Tier 5

List of Covered Drugs

The list of covered drugs, that begins on page 1, gives you information about the drugs covered by Health Alliance Connect. 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 name of the drug. Brand name drugs are capitalized (e.g., CHANTIX) and generic drugs are listed in lower-case italics (e.g., acetaminophen).

The information in the necessary actions, restrictions, or limits on use column tells you if Health Alliance Connect has any rules for covering your drug.

EX = Excluded Part D drug, this drug is not covered under a Part D plan, it may be covered under Part B

LA = Limited Access drug, this drug may only be available from some places NM = Non Mail-order drug, only available from a walk-in/drive-thru pharmacy

PA = Preauthorization required, must get approval from Health Alliance Connect before the drug is covered

PA BvD = Preauthorization required to decide if the drug will be covered by Part D or Part B PA NSO = Preauthorization required for the first time it is prescribed

QL = Quantity Limit applies, you may only be able to get a certain amount of this drug

ST = Step-Therapy required, you may have to take a lower-tier drug first before Health Alliance Connect will cover a drug at a higher tier

Note, when you see an * next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic

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appeal, call Client Services at 1-866-951-0264. You can also read the Member Handbook to learn how to appeal a decision.

Name of drug

What the drug will cost you (tier level)

Necessary actions,

restrictions, or limits on use

Analgesics

Analgesics, Miscellaneous

acetaminophen * (Acetaminophen) $0 (Tier 5) PA; QL 480 in 1 day; solution acetaminophen * (Acetaminophen) $0 (Tier 5) PA; drops: 80mg/0.8ml acetaminophen with codeine (Vopac) $0 (Tier 1) QL 180 in 30 days; tablet:

300mg-60mg

Here are the meanings of the codes used in the “Necessary actions, restrictions or limits on use” column:

EX = Excluded Part D drug, this drug is not covered under a Part D plan, it may be covered under Part B

LA = Limited Access drug, this drug may only be available from some places NM = Non Mail-order drug, only available from a walk-in/drive-thru pharmacy

PA = Preauthorization required, must get approval from Health Alliance Connect before the drug is covered

PA BvD = Preauthorization required to decide if the drug will be covered by Part D or Part B PA NSO = Preauthorization required for the first time it is prescribed

QL = Quantity Limit applies, you may only be able to get a certain amount of this drug

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Analgesics

Analgesics, Miscellaneous

acetaminophen-codeine oral solution (Acetaminophen with Codeine)

$0 (Tier 1) QL (4500 per 30 days) acetaminophen-codeine oral tablet 300-15

mg, 300-30 mg

(Tylenol-Codeine No.3)

$0 (Tier 1) QL (360 per 30 days) acetaminophen-codeine oral tablet 300-60

mg

(Tylenol-Codeine No.3)

$0 (Tier 1) QL (180 per 30 days) buprenorphine hcl injection (Buprenorphine HCl) $0 (Tier 1)  

butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg

(Fioricet with Codeine)

$0 (Tier 1)   butalbital-acetaminophen-caff oral capsule (Esgic) $0 (Tier 1)   butalbital-acetaminophen-caff oral tablet

50-325-40 mg

(Esgic) $0 (Tier 1)   butalbital-aspirin-caffeine oral capsule (Fiorinal) $0 (Tier 1)   butorphanol tartrate injection (Butorphanol

Tartrate) $0 (Tier 1)  

butorphanol tartrate nasal (Butorphanol

Tartrate)

$0 (Tier 1) QL (5 per 28 days)

CAPITAL WITH CODEINE $0 - $6.60

(Tier 2)  

codeine sulfate oral tablet (Codeine Sulfate) $0 (Tier 1) QL (180 per 30 days) codeine-butalbital-asa-caffein oral capsule

30-50-325-40 mg

(Fiorinal with Codeine #3)

$0 (Tier 1)  

dihydrocodeine-aspirin-caff (Synalgos-Dc) $0 (Tier 1) QL (300 per 30 days)

DISKETS $0 (Tier 1) QL (90 per 30 days)

DURAMORPH (PF) $0 - $6.60

(Tier 2)  

fentanyl citrate (Actiq) $0 - $6.60

(Tier 2)

PA; QL (120 per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr

(Duragesic) $0 (Tier 1) QL (20 per 30 days)

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fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour

(Duragesic) $0 (Tier 1) QL (10 per 30 days)

hydrocodone-acetaminophen oral solution (Hycet) $0 (Tier 1) QL (2700 per 30 days) 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) $0 (Tier 1) QL (240 per 30 days)

hydrocodone-ibuprofen (Ibudone) $0 (Tier 1) QL (150 per 30 days)

hydromorphone (pf) injection solution 10 mg/ml

(Hydromorphone HCl/PF)

$0 (Tier 1)   hydromorphone (pf) injection solution 4

mg/ml

(Dilaudid) $0 (Tier 1)   hydromorphone injection solution (Hydromorphone

HCl)

$0 (Tier 1)   hydromorphone injection syringe 2 mg/ml (Hydromorphone

HCl) $0 (Tier 1)  

hydromorphone oral liquid (Dilaudid) $0 (Tier 1) QL (1200 per 30 days)

hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) $0 (Tier 1) QL (180 per 30 days) hydromorphone oral tablet 8 mg (Dilaudid) $0 (Tier 1) QL (120 per 30 days)

ibuprofen-oxycodone (Ibuprofen/Oxycodon

e HCl) $0 (Tier 1) QL (28 per 30 days) INFUMORPH P/F INJECTION

SOLUTION 25 MG/ML

$0 - $6.60 (Tier 2)  

LAZANDA $0 - $6.60

(Tier 2)

PA NSO

levorphanol tartrate (Levorphanol

Tartrate)

$0 (Tier 1) QL (180 per 30 days)

methadone hcl oral concentrate 10 mg/ml (Methadose) $0 (Tier 1) QL (1800 per 30 days) methadone hcl oral tablet,soluble 40 mg (Diskets) $0 (Tier 1) QL (90 per 30 days)

methadone injection (Methadone HCl) $0 (Tier 1)  

methadone oral (Methadone HCl) $0 (Tier 1) QL (1800 per 30 days)

methadone oral (Diskets) $0 (Tier 1) QL (360 per 30 days)

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morphine (pf) injection solution (Morphine Sulfate/PF)

$0 (Tier 1)  

morphine (pf) intravenous (Morphine

Sulfate/PF)

$0 (Tier 1)  

morphine concentrate oral solution (Msir) $0 (Tier 1) QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) $0 (Tier 1) QL (200 per 30 days) morphine injection solution 15 mg/ml, 8

mg/ml (Morphine Sulfate) $0 (Tier 1)  

morphine injection syringe 10 mg/ml, 2 mg/ml

(Morphine Sulfate) $0 (Tier 1)  

morphine intramuscular (Morphine Sulfate) $0 (Tier 1)  

morphine intravenous (Morphine Sulfate) $0 (Tier 1)  

morphine intravenous solution 25 mg/ml, 50 mg/ml

(Morphine Sulfate) $0 (Tier 1)  

morphine intravenous (Morphine Sulfate) $0 (Tier 1)  

morphine oral capsule,extend.release pellets 100 mg, 20 mg, 50 mg, 60 mg, 80 mg

(Kadian) $0 (Tier 1) QL (60 per 30 days)

morphine oral capsule,extend.release

pellets 30 mg (Kadian) $0 (Tier 1) QL (120 per 30 days)

morphine oral solution 10 mg/5 ml (Msir) $0 (Tier 1) QL (700 per 30 days) morphine oral solution 20 mg/5 ml (Msir) $0 (Tier 1) QL (300 per 30 days)

MORPHINE ORAL TABLET $0 (Tier 1) QL (180 per 30 days)

morphine oral tablet extended release 100

mg, 60 mg (MS Contin) $0 (Tier 1) QL (120 per 30 days)

morphine oral tablet extended release 15 mg, 200 mg

(MS Contin) $0 (Tier 1) QL (180 per 30 days) morphine oral tablet extended release 30

mg

(MS Contin) $0 (Tier 1) QL (60 per 30 days)

morphine rectal (Morphine Sulfate) $0 (Tier 1)  

morphine sulfate-pf injection solution 0.5

mg/ml (Morphine

Sulfate/PF) $0 - $6.60 (Tier 2)   morphine sulfate-pf injection solution 1

mg/ml

(Morphine Sulfate/PF)

$0 (Tier 1)  

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nalbuphine injection (Nalbuphine HCl) $0 (Tier 1)  

nortemp oral (Acetaminophen) $0 (Tier 4) PA

OFIRMEV $0 - $6.60

(Tier 2)   oxycodone hcl-acetaminophen oral

solution 5-325 mg/5 ml

(Oxycodone

HCl/Acetaminophen)

$0 (Tier 1) QL (1800 per 30 days) oxycodone hcl-acetaminophen oral tablet

10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

(Xolox) $0 (Tier 1) QL (240 per 30 days)

oxycodone hcl-aspirin (Percodan) $0 (Tier 1) QL (240 per 30 days)

oxycodone oral capsule (Oxycodone HCl) $0 (Tier 1) QL (180 per 30 days)

oxycodone oral concentrate (Oxycodone HCl) $0 (Tier 1) QL (180 per 30 days)

oxycodone oral solution (Oxycodone HCl) $0 (Tier 1) QL (1300 per 30 days)

oxycodone oral tablet (Percolone) $0 (Tier 1) QL (180 per 30 days)

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

(Oxycodone HCl) $0 (Tier 1) QL (60 per 30 days) oxycodone-acetaminophen oral tablet

10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg, 7.5-500 mg

(Xolox) $0 (Tier 1) QL (240 per 30 days)

oxycodone-acetaminophen oral tablet 10-650 mg

(Xolox) $0 (Tier 1) QL (180 per 30 days)

oxycodone-aspirin (Percodan) $0 (Tier 1) QL (240 per 30 days)

oxymorphone oral tablet (Opana) $0 (Tier 1) QL (180 per 30 days)

oxymorphone oral tablet extended release

12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) $0 (Tier 1) QL (60 per 30 days) oxymorphone oral tablet extended release

12 hr 30 mg, 40 mg

(Opana ER) $0 (Tier 1) QL (120 per 30 days)

PRIALT $0 - $6.60

(Tier 2)

PA

q-pap oral liquid (Tylenol Sore Throat) $0 (Tier 4) PA; QL (480 per 1 day)

SYNALGOS-DC $0 - $6.60

(Tier 2)

QL (300 per 30 days) tramadol oral capsule,er biphase 24 hr (Conzip) $0 (Tier 1) ST; QL (60 per 30

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tramadol oral capsule,er biphase 24 hr 25-75

(Conzip) $0 (Tier 1) ST; QL (60 per 30 days)

tramadol oral tablet (Ultram) $0 (Tier 1) QL (240 per 30 days)

tramadol oral tablet extended release 24 hr 100 mg

(Ultram ER) $0 (Tier 1) ST; QL (90 per 30 days)

tramadol oral tablet extended release 24 hr 200 mg, 300 mg

(Ultram ER) $0 (Tier 1) ST; QL (30 per 30 days)

tramadol oral tablet, er multiphase 24 hr (Ultram ER) $0 (Tier 1) ST; QL (30 per 30 days)

tramadol-acetaminophen (Ultracet) $0 (Tier 1) ST; QL (240 per 30

days)

xylon 10 (Ibudone) $0 (Tier 1) QL (150 per 30 days)

Nonsteroidal Anti-Inflammatory Agents

aspirin oral tablet,chewable (Bayer Chewable Aspirin)

$0 (Tier 4)   aspirin oral tablet,delayed release (dr/ec)

81 mg

(Ecotrin) $0 (Tier 4) PA

aspir-low (Ecotrin) $0 (Tier 4)  

CALDOLOR INTRAVENOUS

RECON SOLN $0 - $6.60

(Tier 2)  

celecoxib (Celebrex) $0 (Tier 1)  

choline,magnesium salicylate (Choline Sal/Mag Salicylate)

$0 (Tier 1)  

COMFORT PAC-IBUPROFEN $0 (Tier 1)  

COMFORT PAC-MELOXICAM $0 (Tier 1)  

COMFORT PAC-NAPROXEN $0 (Tier 1)  

diclofenac potassium (Cataflam) $0 (Tier 1)  

diclofenac sodium oral tablet extended release 24 hr

(Voltaren-XR) $0 (Tier 1)   diclofenac sodium oral tablet,delayed

release (dr/ec)

(Diclofenac Sodium) $0 (Tier 1)  

diclofenac sodium topical gel (Solaraze) $0 (Tier 1)  

diclofenac-misoprostol (Arthrotec 50) $0 (Tier 1)  

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diflunisal (Diflunisal) $0 (Tier 1)  

ECOTRIN LOW STRENGTH $0 (Tier 4)  

etodolac (Etodolac) $0 (Tier 1)  

fenoprofen oral tablet (Fenoprofen

Calcium) $0 (Tier 1)  

flurbiprofen (Ansaid) $0 (Tier 1)  

ibuprofen oral (Ibuprofen) $0 (Tier 1)  

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

(Ibuprofen) $0 (Tier 1)  

ketoprofen oral capsule (Ketoprofen) $0 (Tier 1)  

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

(Ketoprofen) $0 (Tier 1)  

ketorolac injection (Toradol) $0 (Tier 1) QL (20 per 23 days)

meclofenamate oral (Meclofenamate

Sodium)

$0 (Tier 1)  

mefenamic acid (Ponstel) $0 (Tier 1)  

meloxicam (Mobic) $0 (Tier 1)  

nabumetone (Nabumetone) $0 (Tier 1)  

naproxen oral suspension (Naprosyn) $0 (Tier 1)  

naproxen oral tablet (Naprosyn) $0 (Tier 1)  

naproxen oral tablet,delayed release (dr/ec)

(Ec-Naprosyn) $0 (Tier 1)   naproxen sodium oral tablet 275 mg, 550

mg (Anaprox) $0 (Tier 1)  

NEOPROFEN (IBUPROFEN LYSN)(PF)

$0 - $6.60 (Tier 2)  

oxaprozin (Daypro) $0 (Tier 1)  

piroxicam (Feldene) $0 (Tier 1)  

salsalate (Salsalate) $0 (Tier 1)  

sulindac oral (Sulindac) $0 (Tier 1)  

tolmetin (Tolmetin Sodium) $0 (Tier 1)  

VOLTAREN TOPICAL $0 - $6.60

(Tier 2)  

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Anesthetics

Local Anesthetics

cocaine topical solution 4 % (Cocaine HCl) $0 (Tier 1)  

glydo (Lidocaine HCl) $0 (Tier 1)  

lidocaine (pf) injection solution (Xylocaine-MPF) $0 (Tier 1) PA BvD lidocaine (pf) intravenous syringe 100

mg/5 ml (2 %)

(Lidocaine HCl/PF) $0 (Tier 1)   lidocaine hcl injection solution 10 mg/ml

(1 %)

(Xylocaine) $0 (Tier 1) PA BvD lidocaine hcl injection solution 20 mg/ml

(2 %)

(Xylocaine) $0 (Tier 1)  

lidocaine hcl laryngotracheal (Xylocaine) $0 (Tier 1)  

lidocaine hcl mucous membrane gel (Lidocaine HCl) $0 (Tier 1)   lidocaine hcl mucous membrane jelly in

applicator

(Lidocaine HCl) $0 (Tier 1)   lidocaine hcl mucous membrane solution (Xylocaine) $0 (Tier 1)  

lidocaine hcl urethral (Lidocaine HCl) $0 (Tier 1)  

LIDOCAINE HCL-PF INJECTION

SOLUTION 15 MG/ML (1.5 %) $0 - $6.60

(Tier 2) PA BvD lidocaine topical adhesive patch,medicated (Lidoderm) $0 (Tier 1) PA NSO

lidocaine topical ointment (Lidocaine) $0 (Tier 1)  

lidocaine-prilocaine topical (EMLA) $0 (Tier 1)  

lidocaine-prilocaine topical kit (Relador Pak) $0 (Tier 1) PA BvD

lidocaine-tetracaine (Pliaglis) $0 (Tier 1) PA BvD

PLIAGLIS $0 - $6.60

(Tier 2)

PA BvD

RELADOR PAK $0 (Tier 1)  

SYNERA $0 - $6.60

(Tier 2)   Anti-Addiction/Substance Abuse Treatment Agents

Anti-Addiction/Substance Abuse Treatment Agents

acamprosate (Campral) $0 (Tier 1)  

buprenorphine hcl sublingual (Subutex) $0 (Tier 1) QL (90 per 30 days)

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buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl)

$0 - $6.60 (Tier 2)

QL (90 per 30 days) bupropion hcl sr 150 mg tablet f/c (Zyban) $0 (Tier 1)  

CAMPRAL $0 - $6.60

(Tier 2)  

CHANTIX $0 - $6.60

(Tier 2)

PA CHANTIX CONTINUING MONTH

BOX

$0 - $6.60 (Tier 2)

PA CHANTIX CONTINUING MONTH

PAK $0 - $6.60

(Tier 2) PA

CHANTIX STARTING MONTH BOX $0 - $6.60

(Tier 2)

PA

disulfiram (Antabuse) $0 (Tier 1)  

naloxone (Naloxone HCl) $0 (Tier 1)  

naltrexone hcl (Revia) $0 (Tier 1)  

naltrexone (Revia) $0 (Tier 1)  

NICODERM CQ $0 (Tier 4)  

nicorelief buccal gum (Nicorette) $0 (Tier 4)  

nicorette buccal gum 2 mg (Nicorette) $0 (Tier 4)  

NICORETTE BUCCAL GUM 4 MG $0 (Tier 4)  

NICORETTE BUCCAL LOZENGE $0 (Tier 4)  

nicotine (polacrilex) buccal gum (Nicorette) $0 (Tier 4) QL (360 per 30 days) nicotine (polacrilex) buccal lozenge 4 mg (Nicorette) $0 (Tier 4)  

nicotine transdermal patch 24 hour 14 mg/24 hr, 22 mg/24 hr, 7 mg/24 hr

(Nicoderm Cq) $0 (Tier 4)   nicotine transdermal patch 24 hour 21

mg/24 hr

(Nicoderm Cq) $0 (Tier 4) QL (31 per 31 days)

NICOTROL $0 - $6.60

(Tier 2)

QL (480 per 30 days)

NICOTROL NS $0 - $6.60

(Tier 2)

QL (720 per 365 days)

(20)

VIVITROL $0 - $6.60 (Tier 2)   Antianxiety Agents

Benzodiazepines

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

(Xanax) $0 (Tier 1) QL (120 per 30 days)

alprazolam oral tablet 2 mg (Xanax) $0 (Tier 1) QL (90 per 30 days)

alprazolam oral tablet extended release 24

hr 0.5 mg, 1 mg (Xanax XR) $0 (Tier 1) QL (120 per 30 days)

alprazolam oral tablet extended release 24 hr 2 mg

(Xanax XR) $0 (Tier 1) QL (150 per 30 days) alprazolam oral tablet extended release 24

hr 3 mg

(Xanax XR) $0 (Tier 1) QL (90 per 30 days) alprazolam oral tablet,disintegrating 0.25

mg, 0.5 mg, 1 mg

(Alprazolam) $0 (Tier 1) QL (120 per 30 days)

alprazolam oral tablet,disintegrating 2 mg (Alprazolam) $0 (Tier 1) QL (90 per 30 days)

chlordiazepoxide hcl (Chlordiazepoxide

HCl)

$0 (Tier 1) QL (120 per 30 days)

clonazepam oral tablet (Klonopin) $0 (Tier 1)  

clonazepam oral tablet,disintegrating (Clonazepam) $0 (Tier 1)  

clorazepate dipotassium (Tranxene T-Tab) $0 (Tier 1) QL (90 per 30 days)

diazepam injection (Diazepam) $0 (Tier 1)  

diazepam intensol (Diazepam) $0 (Tier 1)  

diazepam oral solution (Diazepam) $0 (Tier 1)  

diazepam oral tablet (Valium) $0 (Tier 1) QL (120 per 30 days)

diazepam rectal (Diastat) $0 (Tier 1)  

estazolam (Estazolam) $0 (Tier 1) QL (30 per 30 days)

flurazepam (Flurazepam HCl) $0 (Tier 1) QL (30 per 30 days)

lorazepam injection solution (Ativan) $0 (Tier 1)  

lorazepam injection syringe (Ativan) $0 (Tier 1)  

lorazepam oral tablet 0.5 mg (Ativan) $0 (Tier 1) QL (120 per 30 days)

lorazepam oral tablet 1 mg (Ativan) $0 (Tier 1) QL (90 per 30 days)

lorazepam oral tablet 2 mg (Ativan) $0 (Tier 1) QL (60 per 30 days)

(21)

midazolam (pf) injection (Midazolam HCl/PF) $0 (Tier 1)   midazolam (pf) injection syringe 2 mg/2

ml (1 mg/ml)

(Midazolam HCl/PF) $0 (Tier 1)   midazolam oral syrup 2 mg/ml (Midazolam HCl) $0 (Tier 1)  

ONFI ORAL SUSPENSION $0 - $6.60

(Tier 2)  

ONFI ORAL TABLET 10 MG, 20 MG $0 - $6.60

(Tier 2)  

oxazepam (Oxazepam) $0 (Tier 1) QL (120 per 30 days)

quazepam (Doral) $0 - $6.60

(Tier 2)  

temazepam (Restoril) $0 (Tier 1) QL (30 per 30 days)

triazolam (Halcion) $0 (Tier 1) QL (30 per 30 days)

Antibacterials

Aminoglycosides

amikacin (Amikacin Sulfate) $0 (Tier 1)  

BETHKIS $0 - $6.60

(Tier 2)

PA gentamicin in nacl (iso-osm) intravenous

piggyback

(Gentamicin In Nacl, Iso-Osm)

$0 (Tier 1)   gentamicin injection solution (Garamycin) $0 (Tier 1)   gentamicin sulfate (ped) (pf) (Gentamicin

Sulfate/PF)

$0 (Tier 1)   gentamicin sulfate (pf) intravenous

solution

(Gentamicin Sulfate/PF)

$0 (Tier 1)  

neomycin (Neomycin Sulfate) $0 (Tier 1)  

streptomycin intramuscular (Streptomycin

Sulfate)

$0 (Tier 1)  

TOBI PODHALER INHALATION $0 - $6.60

(Tier 2) PA

tobramycin in 0.225 % nacl (Tobi) $0 - $6.60

(Tier 2)

PA

(22)

tobramycin in 0.9 % nacl (Tobramycin/Sodium Chloride)

$0 (Tier 1)   tobramycin sulfate injection solution (Nebcin) $0 (Tier 1)  

Antibacterials, Miscellaneous

bacitracin intramuscular (Bacitracin) $0 (Tier 1)  

chloramphenicol sod succinate (Chloramphenicol Sod Succ)

$0 (Tier 1)  

clindamycin hcl (Cleocin HCl) $0 (Tier 1)  

clindamycin in 5 % dextrose (Cleocin Phosphate In D5w)

$0 (Tier 1)   clindamycin palmitate hcl (Cleocin Palmitate) $0 (Tier 1)   clindamycin phosphate injection (Cleocin Phosphate) $0 (Tier 1)   clindamycin phosphate intravenous

solution

(Cleocin Phosphate) $0 (Tier 1)   CLINDAMYCIN PHOSPHATE ORAL

CAPSULE 150 MG, 300 MG, 75 MG

$0 - $6.60 (Tier 2)  

colistin (colistimethate na) (Coly-Mycin M

Parenteral)

$0 (Tier 1)  

CUBICIN $0 - $6.60

(Tier 2)  

DALVANCE $0 - $6.60

(Tier 2)  

LINCOCIN $0 - $6.60

(Tier 2)  

linezolid intravenous (Zyvox) $0 - $6.60

(Tier 2)

PA

linezolid oral (Zyvox) $0 - $6.60

(Tier 2) PA; QL (56 per 28 days)

methenamine hippurate (Hiprex) $0 (Tier 1)  

methenamine mandelate oral tablet 1 gram (Methenamine Mandelate)

$0 (Tier 1)  

MONUROL $0 - $6.60

(Tier 2)   nitrofurantoin macrocrystal oral capsule (Macrodantin) $0 (Tier 1)  

(23)

ORBACTIV $0 - $6.60 (Tier 2)  

polymyxin b sulfate (Polymyxin B Sulfate) $0 (Tier 1)  

PRIMSOL $0 - $6.60

(Tier 2)  

SIVEXTRO $0 - $6.60

(Tier 2)

QL (6 per 30 days)

SYNERCID $0 - $6.60

(Tier 2)  

trimethoprim (Trimethoprim) $0 (Tier 1)  

vancomycin in d5w intravenous piggyback (Vancomycin

HCl/D5W) $0 - $6.60

(Tier 2)   vancomycin intravenous recon soln 1,000

mg, 10 gram, 750 mg

(Vancomycin HCl) $0 - $6.60 (Tier 2)   vancomycin intravenous recon soln 500 mg (Vancomycin

HCl/D5W)

$0 - $6.60 (Tier 2)  

vancomycin oral capsule (Vancocin HCl) $0 - $6.60

(Tier 2)   VIBATIV INTRAVENOUS RECON

SOLN

$0 - $6.60 (Tier 2)  

XIFAXAN ORAL TABLET 200 MG $0 - $6.60

(Tier 2)  

XIFAXAN ORAL TABLET 550 MG $0 - $6.60

(Tier 2)

PA ZYVOX INTRAVENOUS

PARENTERAL SOLUTION

$0 - $6.60 (Tier 2)

PA ZYVOX ORAL SUSPENSION FOR

RECONSTITUTION

$0 - $6.60 (Tier 2)

PA

ZYVOX ORAL TABLET $0 - $6.60

(Tier 2)

PA; QL (56 per 28 days)

Cephalosporins

AVYCAZ $0 - $6.60

(Tier 2)  

(24)

CEDAX $0 - $6.60 (Tier 2)  

cefaclor oral capsule (Cefaclor) $0 (Tier 1)  

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

(Cefaclor) $0 (Tier 1)   cefaclor oral tablet extended release 12 hr (Cefaclor) $0 (Tier 1)  

cefadroxil oral capsule (Cefadroxil) $0 (Tier 1)  

cefadroxil oral suspension for

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

(Cefadroxil) $0 (Tier 1)  

cefadroxil oral tablet (Cefadroxil) $0 (Tier 1)  

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

(Cefazolin Sodium) $0 (Tier 1)   cefazolin in dextrose (iso-os) intravenous

piggyback 2 gram/50 ml

(Cefazolin

Sodium/Dextrose, Iso)

$0 (Tier 1)  

cefazolin injection recon soln (Ancef) $0 (Tier 1)  

cefazolin injection recon soln 100 gram, 300 g

(Cefazolin Sodium) $0 (Tier 1)  

cefazolin intravenous (Cefazolin Sodium) $0 (Tier 1)  

cefdinir (Cefdinir) $0 (Tier 1)  

cefditoren pivoxil (Spectracef) $0 (Tier 1)  

cefepime (Maxipime) $0 (Tier 1)  

CEFEPIME IN DEXTROSE 5 % $0 - $6.60

(Tier 2)   CEFEPIME IN DEXTROSE,ISO-OSM

INTRAVENOUS PIGGYBACK

$0 - $6.60 (Tier 2)  

cefixime (Suprax) $0 (Tier 1)  

cefotaxime (Claforan) $0 (Tier 1)  

cefotetan (Cefotetan Disodium) $0 (Tier 1)  

cefotetan in dextrose, iso-osm (Cefotetan

Disod/Dextrose, Iso)

$0 (Tier 1)  

cefoxitin (Mefoxin) $0 (Tier 1)  

(25)

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

(Cefoxitin

Sodium/Dextrose, Iso)

$0 (Tier 1)  

cefpodoxime (Cefpodoxime

Proxetil)

$0 (Tier 1)  

cefprozil (Cefprozil) $0 (Tier 1)  

ceftazidime (Fortaz) $0 (Tier 1)  

CEFTAZIDIME IN D5W $0 - $6.60

(Tier 2)   ceftazidime injection recon soln 1 gram (Fortaz) $0 - $6.60

(Tier 2)   ceftazidime injection recon soln 2 gram, 6

gram

(Fortaz) $0 (Tier 1)  

ceftibuten (Cedax) $0 (Tier 1)  

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

$0 - $6.60 (Tier 2)   ceftriaxone in dextrose,iso-os intravenous

piggyback 1 gram/50 ml

(Ceftriaxone Na/Dextrose, Iso)

$0 - $6.60 (Tier 2)   CEFTRIAXONE IN

DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML

$0 - $6.60 (Tier 2)  

ceftriaxone injection recon soln (Rocephin) $0 - $6.60

(Tier 2)   ceftriaxone intravenous recon soln 1 gram (Ceftriaxone

Na/Dextrose, Iso)

$0 - $6.60 (Tier 2)   CEFTRIAXONE INTRAVENOUS

RECON SOLN 2 GRAM

$0 - $6.60 (Tier 2)   CEFUROXIME AXETIL ORAL

SUSPENSION FOR

RECONSTITUTION 125 MG/5 ML

$0 (Tier 1)  

cefuroxime axetil oral tablet (Ceftin) $0 (Tier 1)  

cefuroxime sodium injection recon soln 1.5

gram, 750 mg (Zinacef) $0 (Tier 1)  

cefuroxime sodium intravenous (Zinacef) $0 (Tier 1)

(26)

cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso)

$0 (Tier 1)  

cephalexin oral capsule (Keflex) $0 (Tier 1)  

cephalexin oral suspension for reconstitution

(Cephalexin) $0 (Tier 1)  

cephalexin oral tablet (Cephalexin) $0 (Tier 1)  

FORTAZ INJECTION RECON SOLN 1 GRAM

$0 - $6.60 (Tier 2)  

FORTAZ INTRAVENOUS $0 - $6.60

(Tier 2)  

KEFLEX ORAL CAPSULE 750 MG $0 - $6.60

(Tier 2)  

MAXIPIME $0 - $6.60

(Tier 2)  

SUPRAX $0 - $6.60

(Tier 2)  

TEFLARO $0 - $6.60

(Tier 2)  

ZERBAXA $0 - $6.60

(Tier 2)  

ZINACEF IN STERILE WATER $0 - $6.60

(Tier 2)   ZINACEF INTRAVENOUS RECON

SOLN

$0 - $6.60 (Tier 2)   Macrolides

azithromycin (Zithromax) $0 (Tier 1)  

clarithromycin oral suspension for

reconstitution (Biaxin) $0 (Tier 1)  

clarithromycin oral tablet (Biaxin) $0 (Tier 1)  

clarithromycin oral tablet extended release 24 hr

(Biaxin XL) $0 (Tier 1)  

DIFICID $0 - $6.60

(Tier 2)

ST

(27)

ERYPED 200 $0 - $6.60 (Tier 2)  

ERYPED 400 $0 - $6.60

(Tier 2)  

ERYTHROCIN $0 - $6.60

(Tier 2)   erythromycin base oral tablet,delayed

release (dr/ec) 250 mg, 500 mg

(Erythromycin Base) $0 (Tier 1)   ERYTHROMYCIN BASE ORAL

TABLET,DELAYED

RELEASE (DR/EC) 333 MG

$0 - $6.60 (Tier 2)   erythromycin ethylsuccinate oral

suspension for reconstitution

(Eryped 200) $0 (Tier 1)   erythromycin ethylsuccinate oral

suspension for reconstitution 200 mg/5 ml

(Eryped 200) $0 - $6.60 (Tier 2)   erythromycin ethylsuccinate oral tablet

400 mg (Erythromycin

Ethylsuccinate) $0 (Tier 1)   erythromycin oral capsule,delayed

release(dr/ec)

(Erythromycin Base) $0 (Tier 1)   erythromycin oral tablet (Erythromycin Base) $0 (Tier 1)   erythromycin stearate oral tablet 250 mg (Erythromycin

Stearate)

$0 (Tier 1)  

erythromycin-sulfisoxazole (Ery

E-Succ/Sulfisoxazole) $0 (Tier 1)  

KETEK $0 - $6.60

(Tier 2)  

PCE $0 - $6.60

(Tier 2)  

ZMAX $0 - $6.60

(Tier 2)   Miscellaneous B-Lactam Antibiotics

AZACTAM IN DEXTROSE

(ISO-OSM) $0 - $6.60

(Tier 2)  

aztreonam (Azactam) $0 (Tier 1)

(28)

CAYSTON $0 - $6.60 (Tier 2)

PA

DORIBAX $0 - $6.60

(Tier 2)  

imipenem-cilastatin (Primaxin) $0 (Tier 1)  

INVANZ $0 - $6.60

(Tier 2)  

meropenem (Merrem) $0 (Tier 1)  

Penicillins

amoxicillin oral capsule (Amoxicillin) $0 (Tier 1)  

amoxicillin oral suspension for reconstitution

(Amoxil) $0 (Tier 1)  

amoxicillin oral tablet (Amoxicillin) $0 (Tier 1)  

amoxicillin oral tablet, er multiphase 24 hr (Moxatag) $0 (Tier 1)   amoxicillin oral tablet,chewable 125 mg,

250 mg

(Amoxicillin) $0 (Tier 1)   amoxicillin-pot clavulanate oral

suspension for reconstitution

(Augmentin) $0 (Tier 1)   amoxicillin-pot clavulanate oral tablet (Augmentin) $0 (Tier 1)   amoxicillin-pot clavulanate oral tablet

extended release 12 hr

(Augmentin XR) $0 (Tier 1)   amoxicillin-pot clavulanate oral

tablet,chewable

(Amoxicillin/Potassiu m Clav)

$0 (Tier 1)  

ampicillin (Ampicillin

Trihydrate) $0 (Tier 1)   ampicillin sodium injection recon soln (Totacillin-N) $0 (Tier 1)   ampicillin sodium intravenous recon soln (Totacillin-N) $0 (Tier 1)  

ampicillin-sulbactam injection (Unasyn) $0 (Tier 1)  

ampicillin-sulbactam intravenous recon

soln (Unasyn) $0 (Tier 1)  

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-

31.25 MG/5 ML

$0 - $6.60 (Tier 2)  

(29)

BICILLIN C-R $0 - $6.60 (Tier 2)  

BICILLIN L-A $0 - $6.60

(Tier 2)  

dicloxacillin (Dicloxacillin

Sodium)

$0 (Tier 1)  

MOXATAG $0 - $6.60

(Tier 2)   nafcillin in dextrose iso-osm (Nafcillin In

Dextrose,Iso-Osm)

$0 - $6.60 (Tier 2)  

nafcillin injection (Unipen) $0 (Tier 1)  

nafcillin intravenous recon soln (Nallpen) $0 (Tier 1)   oxacillin in dextrose(iso-osm) (Oxacillin

Sodium/Dextrose, Iso)

$0 (Tier 1)  

oxacillin injection recon soln (Oxacillin Sodium) $0 (Tier 1)   oxacillin intravenous recon soln (Oxacillin Sodium) $0 (Tier 1)   penicillin g pot in dextrose (Pen G

Pot/Dextrose-Water) $0 (Tier 1)  

penicillin g potassium (Penicillin G

Potassium)

$0 (Tier 1)  

penicillin g procaine (Penicillin G

Procaine) $0 (Tier 1)  

penicillin v potassium (Penicillin V

Potassium)

$0 (Tier 1)  

piperacillin-tazobactam (Zosyn) $0 (Tier 1)  

TIMENTIN INTRAVENOUS RECON SOLN 31 GRAM

$0 - $6.60 (Tier 2)   Quinolones

AVELOX IN NACL (ISO-OSMOTIC) $0 - $6.60

(Tier 2)   CIPRO ORAL

SUSPENSION,MICROCAPSULE RECON

$0 - $6.60 (Tier 2)  

(30)

ciprofloxacin (Cipro) $0 (Tier 1)  

ciprofloxacin (mixture) (Cipro XR) $0 (Tier 1)  

ciprofloxacin hcl oral (Cipro) $0 (Tier 1)  

ciprofloxacin in 5 % dextrose (Cipro I.V.) $0 (Tier 1)   ciprofloxacin lactate intravenous solution

400 mg/40 ml (Cipro I.V.) $0 (Tier 1)  

FACTIVE $0 - $6.60

(Tier 2)   levofloxacin in d5w intravenous piggyback (Levaquin) $0 (Tier 1)  

levofloxacin intravenous (Levofloxacin) $0 (Tier 1)  

levofloxacin oral (Levaquin) $0 (Tier 1)  

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

$0 (Tier 1)  

NOROXIN $0 - $6.60

(Tier 2)  

ofloxacin oral (Ofloxacin) $0 (Tier 1)  

Sulfonamides

sulfadiazine oral (Sulfadiazine) $0 (Tier 1)  

sulfamethoxazole-trimethoprim intravenous

(Sulfamethoxazole/Tr imethoprim)

$0 (Tier 1)   sulfamethoxazole-trimethoprim oral

suspension

(Sulfamethoxazole/Tr imethoprim)

$0 (Tier 1)   sulfamethoxazole-trimethoprim oral tablet (Bactrim) $0 (Tier 1)  

sulfasalazine (Azulfidine) $0 (Tier 1)  

sulfatrim (Sulfamethoxazole/Tr

imethoprim)

$0 (Tier 1)  

sulfazine (Azulfidine) $0 (Tier 1)  

sulfazine ec (Azulfidine) $0 (Tier 1)  

Tetracyclines

demeclocycline oral (Demeclocycline

HCl)

$0 (Tier 1)   doxycycline hyclate oral capsule 100 mg (Morgidox) $0 (Tier 1)   doxycycline hyclate 100 mg tab f/c (Doryx) $0 (Tier 1)  

(31)

doxycycline hyclate intravenous (Doxycycline Hyclate)

$0 (Tier 1)   doxycycline hyclate oral capsule 100 mg (Adoxa) $0 (Tier 1)   doxycycline hyclate oral capsule 50 mg (Morgidox) $0 (Tier 1)   doxycycline hyclate oral tablet 100 mg, 50

mg

(Adoxa) $0 (Tier 1)   doxycycline hyclate oral tablet 20 mg (Doryx) $0 (Tier 1)   doxycycline hyclate oral tablet,delayed

release (dr/ec)

(Doryx) $0 (Tier 1)   doxycycline monohydrate oral capsule (Adoxa) $0 (Tier 1)   doxycycline monohydrate oral suspension

for reconstitution

(Vibramycin) $0 (Tier 1)   doxycycline monohydrate oral tablet (Adoxa) $0 (Tier 1)  

MINOCIN INTRAVENOUS $0 - $6.60

(Tier 2)  

minocycline oral capsule (Minocin) $0 (Tier 1)  

minocycline oral tablet (Minocycline HCl) $0 (Tier 1)   minocycline oral tablet extended release

24 hr

(Minocycline HCl) $0 (Tier 1)  

tetracycline (Ala-Tet) $0 (Tier 1)  

TYGACIL $0 - $6.60

(Tier 2)  

VIBRAMYCIN ORAL SYRUP $0 - $6.60

(Tier 2)   Anticancer Agents

Anticancer Agents

ABRAXANE $0 - $6.60

(Tier 2)  

ADCETRIS $0 - $6.60

(Tier 2)  

AFINITOR $0 - $6.60

(Tier 2)

PA NSO

(32)

AFINITOR DISPERZ $0 - $6.60 (Tier 2)

PA NSO ALIMTA INTRAVENOUS RECON

SOLN

$0 - $6.60 (Tier 2)  

anastrozole (Arimidex) $0 (Tier 1)  

ARRANON $0 - $6.60

(Tier 2)  

ARZERRA $0 - $6.60

(Tier 2)  

AVASTIN $0 - $6.60

(Tier 2)  

azacitidine (Vidaza) $0 - $6.60

(Tier 2)  

BELEODAQ $0 - $6.60

(Tier 2) PA NSO

bexarotene (Targretin) $0 - $6.60

(Tier 2)

PA NSO

bicalutamide (Casodex) $0 (Tier 1)  

BICNU $0 - $6.60

(Tier 2)  

bleomycin (Bleomycin Sulfate) $0 (Tier 1) PA BvD

BLINCYTO $0 - $6.60

(Tier 2) PA NSO

BOSULIF $0 - $6.60

(Tier 2)

PA NSO

BUSULFEX INTRAVENOUS $0 - $6.60

(Tier 2)  

CAPRELSA $0 - $6.60

(Tier 2)

PA NSO carboplatin intravenous solution (Carboplatin) $0 (Tier 1)  

cisplatin (Cisplatin) $0 (Tier 1)  

cladribine (Cladribine) $0 (Tier 1) PA BvD

CLOLAR $0 - $6.60

(Tier 2)  

(33)

COMETRIQ $0 - $6.60 (Tier 2)

PA NSO cyclophosphamide intravenous recon soln (Cyclophosphamide) $0 (Tier 1)  

CYCLOPHOSPHAMIDE ORAL CAPSULE

$0 - $6.60 (Tier 2)  

cyclophosphamide oral tablet (Cyclophosphamide) $0 (Tier 1) PA BvD

CYRAMZA $0 - $6.60

(Tier 2) PA NSO

cytarabine (Cytarabine) $0 (Tier 1) PA BvD

cytarabine (pf) injection recon soln (Cytarabine/PF) $0 (Tier 1) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) $0 (Tier 1) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) $0 (Tier 1)  

DACOGEN $0 - $6.60

(Tier 2)  

dactinomycin (Dactinomycin) $0 (Tier 1)  

daunorubicin intravenous (Cerubidine) $0 (Tier 1)  

DAUNOXOME $0 - $6.60

(Tier 2)  

decitabine (Dacogen) $0 (Tier 1)  

DEPOCYT (PF) $0 - $6.60

(Tier 2)

PA BvD

DOCEFREZ $0 - $6.60

(Tier 2)   docetaxel intravenous solution (Taxotere) $0 (Tier 1)   doxorubicin hcl intravenous recon soln 10

mg

(Doxorubicin HCl) $0 (Tier 1) PA BvD doxorubicin hcl peg-liposomal intravenous

suspension 2 mg/ml

(Doxil) $0 (Tier 1) PA BvD

doxorubicin, peg-liposomal (Doxil) $0 (Tier 1) PA BvD

DROXIA $0 - $6.60

(Tier 2)  

ELIGARD $0 - $6.60

(Tier 2)

PA NSO

(34)

ELOXATIN INTRAVENOUS SOLUTION

$0 - $6.60 (Tier 2)  

ELSPAR $0 - $6.60

(Tier 2)  

EMCYT $0 - $6.60

(Tier 2)

PA NSO epirubicin intravenous solution 50 mg/25

ml

(Ellence) $0 (Tier 1)  

ERBITUX $0 - $6.60

(Tier 2)

PA NSO

ERIVEDGE $0 - $6.60

(Tier 2)

PA NSO

ERWINAZE $0 - $6.60

(Tier 2)  

ETOPOPHOS $0 - $6.60

(Tier 2)  

etoposide intravenous (Etoposide) $0 (Tier 1)  

exemestane (Aromasin) $0 (Tier 1)  

FARESTON $0 - $6.60

(Tier 2)

PA NSO

FARYDAK $0 - $6.60

(Tier 2)

PA NSO

FASLODEX $0 - $6.60

(Tier 2)   FIRMAGON KIT W DILUENT

SYRINGE

$0 - $6.60 (Tier 2)  

floxuridine (FUDR) $0 (Tier 1) PA BvD

fludarabine (Fludara) $0 (Tier 1)  

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

(Fluorouracil) $0 (Tier 1) PA BvD

flutamide (Flutamide) $0 (Tier 1)  

FOLOTYN $0 - $6.60

(Tier 2)  

(35)

GAZYVA $0 - $6.60 (Tier 2)

PA NSO gemcitabine intravenous recon soln 1 gram (Gemzar) $0 (Tier 1)  

GILOTRIF $0 - $6.60

(Tier 2)

PA NSO

GLEEVEC $0 - $6.60

(Tier 2)

PA NSO

HALAVEN $0 - $6.60

(Tier 2)  

HERCEPTIN $0 - $6.60

(Tier 2) PA NSO

HEXALEN $0 - $6.60

(Tier 2)

PA NSO

hydroxyurea (Hydrea) $0 (Tier 1)  

IBRANCE $0 - $6.60

(Tier 2)

PA NSO

ICLUSIG $0 - $6.60

(Tier 2)

PA NSO

idarubicin (Idamycin Pfs) $0 (Tier 1)  

ifosfamide intravenous recon soln (Ifex) $0 (Tier 1)  

ifosfamide intravenous solution (Ifex) $0 (Tier 1)  

ifosfamide-mesna (Ifosfamide/Mesna) $0 (Tier 1)  

IMBRUVICA $0 - $6.60

(Tier 2)

PA NSO

INLYTA $0 - $6.60

(Tier 2)

PA NSO

IRESSA $0 - $6.60

(Tier 2) PA NSO irinotecan intravenous solution (Camptosar) $0 (Tier 1)  

ISTODAX $0 - $6.60

(Tier 2)  

IXEMPRA $0 - $6.60

(Tier 2)  

(36)

JAKAFI $0 - $6.60 (Tier 2)

PA NSO; QL (60 per 30 days)

JEVTANA $0 - $6.60

(Tier 2)  

KADCYLA $0 - $6.60

(Tier 2)

PA BvD

KEYTRUDA $0 - $6.60

(Tier 2)

PA NSO

KYPROLIS $0 - $6.60

(Tier 2)

PA BvD

LENVIMA $0 - $6.60

(Tier 2)

PA NSO

letrozole (Femara) $0 (Tier 1)  

LEUKERAN $0 - $6.60

(Tier 2)  

leuprolide (Leuprolide Acetate) $0 (Tier 1)  

lomustine (Gleostine) $0 - $6.60

(Tier 2)  

LUPRON DEPOT $0 - $6.60

(Tier 2)  

LUPRON DEPOT (3 MONTH) $0 - $6.60

(Tier 2)  

LUPRON DEPOT (4 MONTH) $0 - $6.60

(Tier 2)  

LUPRON DEPOT (6 MONTH) $0 - $6.60

(Tier 2)  

LUPRON DEPOT-PED $0 - $6.60

(Tier 2)   LUPRON DEPOT-PED (3 MONTH)

INTRAMUSCULAR SYRINGE KIT

$0 - $6.60 (Tier 2)  

LYNPARZA $0 - $6.60

(Tier 2) PA NSO

LYSODREN $0 - $6.60

(Tier 2)  

(37)

MARQIBO $0 - $6.60 (Tier 2)

PA NSO

MATULANE $0 - $6.60

(Tier 2)

PA NSO

MEGACE ES $0 - $6.60

(Tier 2)

PA NSO megestrol oral suspension 400 mg/10 ml

(40 mg/ml), 625 mg/5 ml

(Megace Es) $0 (Tier 1) PA NSO

megestrol oral tablet (Megestrol Acetate) $0 (Tier 1) PA NSO

MEKINIST $0 - $6.60

(Tier 2) PA NSO

melphalan hcl intravenous (Alkeran) $0 (Tier 1)  

mercaptopurine (Purinethol) $0 (Tier 1)  

methotrexate sodium (pf) injection recon soln

(Methotrexate Sodium/PF)

$0 (Tier 1)   methotrexate sodium (pf) injection

solution

(Methotrexate Sodium)

$0 (Tier 1)   methotrexate sodium injection (Methotrexate

Sodium) $0 (Tier 1)  

methotrexate sodium oral (Methotrexate

Sodium)

$0 (Tier 1) PA BvD mitomycin intravenous recon soln (Mitomycin) $0 (Tier 1)  

mitoxantrone (Mitoxantrone HCl) $0 (Tier 1)  

MUSTARGEN $0 - $6.60

(Tier 2)  

NEXAVAR $0 - $6.60

(Tier 2) PA NSO

NILANDRON $0 - $6.60

(Tier 2)  

ONCASPAR $0 - $6.60

(Tier 2)   OPDIVO INTRAVENOUS

SOLUTION 40 MG/4 ML

$0 - $6.60 (Tier 2)

PA NSO

(38)

oxaliplatin intravenous solution 100 mg/20 ml

(Eloxatin) $0 (Tier 1)  

paclitaxel (Paclitaxel) $0 (Tier 1)  

pentostatin (Pentostatin) $0 (Tier 1)  

PERJETA $0 - $6.60

(Tier 2)

PA NSO

PHOTOFRIN $0 - $6.60

(Tier 2)  

POMALYST $0 - $6.60

(Tier 2)

PA NSO; QL (21 per 28 days)

PROLEUKIN $0 - $6.60

(Tier 2)  

PURIXAN $0 - $6.60

(Tier 2)   REVLIMID ORAL CAPSULE 10 MG,

20 MG, 25 MG, 5 MG

$0 - $6.60 (Tier 2)

PA NSO REVLIMID ORAL CAPSULE 15 MG,

2.5 MG

$0 - $6.60 (Tier 2)

PA NSO; LA

RITUXAN $0 - $6.60

(Tier 2)

PA NSO

SOLTAMOX $0 - $6.60

(Tier 2)  

SPRYCEL $0 - $6.60

(Tier 2)

PA NSO

STIVARGA $0 - $6.60

(Tier 2)

PA NSO

SUTENT $0 - $6.60

(Tier 2)

PA NSO

SYLVANT $0 - $6.60

(Tier 2)

PA NSO

SYNRIBO $0 - $6.60

(Tier 2) PA BvD

TABLOID $0 - $6.60

(Tier 2)

PA NSO

(39)

TAFINLAR $0 - $6.60 (Tier 2)

PA NSO

tamoxifen (Tamoxifen Citrate) $0 (Tier 1)  

TARCEVA $0 - $6.60

(Tier 2)

PA NSO

TARGRETIN ORAL $0 - $6.60

(Tier 2)

PA NSO

TARGRETIN TOPICAL $0 - $6.60

(Tier 2)  

TASIGNA $0 - $6.60

(Tier 2) PA NSO

TEMODAR INTRAVENOUS $0 - $6.60

(Tier 2)  

teniposide (Teniposide) $0 - $6.60

(Tier 2)  

thiotepa (Thiotepa) $0 (Tier 1)  

toposar intravenous (Etoposide) $0 (Tier 1)  

topotecan intravenous (Hycamtin) $0 (Tier 1)  

TORISEL $0 - $6.60

(Tier 2)   TREANDA INTRAVENOUS RECON

SOLN

$0 - $6.60 (Tier 2)   TREANDA INTRAVENOUS

SOLUTION

$0 - $6.60 (Tier 2)  

TRELSTAR $0 - $6.60

(Tier 2)

PA NSO

tretinoin (chemotherapy) (Tretinoin) $0 - $6.60

(Tier 2)  

TREXALL $0 - $6.60

(Tier 2) PA BvD

TRISENOX $0 - $6.60

(Tier 2)  

TYKERB $0 - $6.60

(Tier 2)

PA NSO

(40)

UNITUXIN $0 - $6.60 (Tier 2)

PA NSO

VALSTAR $0 - $6.60

(Tier 2)  

VECTIBIX $0 - $6.60

(Tier 2)

PA NSO

VELCADE $0 - $6.60

(Tier 2)

PA NSO

vinblastine intravenous (Vinblastine Sulfate) $0 (Tier 1) PA BvD

vincristine (Vincristine Sulfate) $0 (Tier 1) PA BvD

vincristine sulfate intravenous solution 1

mg/ml (Vincristine Sulfate) $0 (Tier 1) PA BvD

vinorelbine intravenous solution (Navelbine) $0 (Tier 1)  

VOTRIENT $0 - $6.60

(Tier 2)

PA NSO

XALKORI $0 - $6.60

(Tier 2)

PA NSO

XTANDI $0 - $6.60

(Tier 2) PA NSO

YERVOY $0 - $6.60

(Tier 2)

PA NSO ZALTRAP INTRAVENOUS

SOLUTION $0 - $6.60

(Tier 2) PA BvD

ZANOSAR $0 - $6.60

(Tier 2)  

ZELBORAF $0 - $6.60

(Tier 2)

PA NSO

ZOLADEX $0 - $6.60

(Tier 2) PA NSO

ZOLINZA $0 - $6.60

(Tier 2)

PA NSO

ZYDELIG $0 - $6.60

(Tier 2)

PA NSO

(41)

ZYKADIA $0 - $6.60 (Tier 2)

PA NSO

ZYTIGA $0 - $6.60

(Tier 2)

PA NSO

Anticholinergic Agents

Antimuscarinics/Antispasmodics ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 ML, 1 MG/0.7 ML, 2 MG/0.7 ML

$0 - $6.60 (Tier 2)   atropine 0.1 mg/ml syringe luer-jet syr (Atropine Sulfate) $0 (Tier 1)   atropine injection solution (Atropine Sulfate) $0 (Tier 1)   atropine injection syringe 0.05 mg/ml, 0.1

mg/ml

(Atropine Sulfate) $0 (Tier 1)  

edrophonium chloride-atropine (Edrophonium

Chloride/Atropine)

$0 - $6.60 (Tier 2)  

propantheline (Propantheline

Bromide)

$0 (Tier 1)   Anticonvulsants

Anticonvulsants

APTIOM $0 - $6.60

(Tier 2)

ST

BANZEL $0 - $6.60

(Tier 2)  

carbamazepine (Tegretol) $0 (Tier 1)  

carbamazepine oral capsule, er multiphase

12 hr (Carbatrol) $0 (Tier 1)  

carbamazepine oral suspension (Tegretol) $0 (Tier 1)  

carbamazepine oral tablet extended release 12 hr

(Tegretol XR) $0 (Tier 1)   carbamazepine oral tablet,chewable (Carbamazepine) $0 (Tier 1)  

CELONTIN ORAL CAPSULE 300 MG $0 - $6.60

(Tier 2)  

Figure

Updating...

References

Related subjects :