Essential Health Benefits Formulary - 4th Quarter 2019
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Essential Health Benefits Formulary
4th Quarter 2019
HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO
products are offered through Insurance Company of Scott and White. All are Texas registered insurance
companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of
Scott and White Health Plan. These companies will be referred to collectively in this document as Scott and White Health
PlanPage |2
Table of Contents
What is my prescription drug coverage? ......................................................................3
What is the Essential Health Benefits Formulary? ........................................................3
How was the formulary created and how are new medications reviewed? ..................3
Does the formulary ever change? ................................................................................3
How am I notified of changes to the formulary? ..........................................................4
What are brand-name and generic drugs? ...................................................................4
What is generic substitution? ......................................................................................4
What are Specialty drugs? ...........................................................................................4
What are pharmaceutical management procedures? ...................................................5
Are there any restrictions on my coverage? .................................................................5
How do I request an exception to the Essential Health Benefits Formulary? ................5
What drugs are not covered by my prescription drug benefit? .....................................5
How much medication does my copayment cover and does my plan cover
maintenance medications? .........................................................................................6
How can I save money on prescriptions? .....................................................................6
Contraceptive Coverage ..............................................................................................6
Preventive Care Medications & Medications Covered Under Health Care Reform ........6
Smoking Cessation Medication Coverage ....................................................................7
Diabetic Supplies ........................................................................................................7
Oral Oncology Split Fill Program ..................................................................................7
Revised 12/27/2018Page |3
What is my prescription drug coverage?
As part of your Scott and White Health Plan (SWHP) coverage, you may have a
prescription drug benefit. This document will help you understand your prescription
drug benefit and the Essential Health Benefits Formulary.
Not every prescription drug benefit is the same. The best way to figure out your
prescription drug coverage is to review your Plan Benefit Documents or call the SWHP
Customer Service department.
What is the Essential Health Benefits Formulary?
A formulary is a list of covered drugs selected by SWHP in consultation with a team of
health care providers. The list represents the prescription drugs believed to be a
necessary part of a quality treatment program. SWHP will generally cover the drugs
listed on the formulary as long as the drug is medically necessary and plan rules are
followed. The list contains both brand-name and generic medications and is updated
regularly.
The Essential Health Benefits Formulary includes preferred drugs that are covered under
your prescription benefit. Drugs not listed on the formulary are not covered. Non-
formulary drugs require prior authorization or may be subject to clinical
edits. Formularies continually change to reflect the most recent advances in drug
therapy therefore; this list is not inclusive and does not guarantee coverage.
The formulary may change because we review new medical information regarding
current drugs listed as well as new drugs recently approved by the FDA.
How was the formulary created and how are new medications reviewed?
The Pharmacy and Therapeutics (P&T) Committee meets regularly to review new drugs
approved by the FDA and new information regarding drugs that are already on the
formulary. The Committee is primarily made up of physicians, pharmacists, and nurses.
It reviews information and scientific evidence concerning safety, effectiveness, and
current use in therapy.
Does the formulary ever change?
Since the P&T Committee meets regularly and reviews new information, the formulary
may change. Below are some possible reasons the formulary could change:
• Generic forms of the brand drug become available. The brand-name medication
may no longer be covered when a generic is available. The generic medication
may be covered at the lower copayment.
• New drugs may be added by the P&T Committee.
Revised 12/27/2018Page |4
• A drug may be withdrawn from the market by the FDA.
• A drug becomes available without a prescription (becomes over-the-counter),
then the drug may be removed from the formulary. Often, drugs available over-
the-counter are not covered under the prescription benefit.
How am I notified of changes to the formulary?
You can find the formularies on our website at swhp.org. To view the changes that have
been made to the formularies, refer to the Formulary Changes document posted on the
website. If you have any questions or wish to obtain a printed copy of the formularies
or pharmaceutical management procedures, please contact SWHP Pharmacy Help Desk
at 1-800-728-7947.
What are brand-name and generic drugs?
SWHP covers both brand-name and generic drugs. A brand-name drug is one that is
produced under the original manufacturer’s brand-name. 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 but the quality and effectiveness are the
same. Generic drugs may differ from the brand-name drug in color, shape, flavor, or
inactive ingredients. Some brand-name drugs have a generic equivalent and others do
not. If a generic form of a brand-name drug becomes available, the brand-name
medication may no longer be covered. The generic medication may be covered at the
lower copayment.
What is generic substitution?
Generic substitution occurs when a pharmacist dispenses an FDA approved generic drug
in place of a brand-name drug. Generic substitution will automatically occur at SWHP
Provider Pharmacies. Prescribers may choose to use a brand-name product and not
allow generic substitution by indicating on the prescription “brand necessary” or "brand
medically necessary. "Per state law, these statements must be handwritten by the
prescriber.
What are Specialty drugs?
Specialty drugs are those drugs used to treat complex or chronic conditions, and which
usually require close monitoring, such as multiple sclerosis, hepatitis, rheumatoid
arthritis, cancer, and other conditions that are difficult to treat with traditional
therapies. Specialty drugs may be self-administered in the home by injection (under the
skin or into a muscle), by inhalation, by mouth, or on the skin. These drugs may also
require special handling, special manufacturing processes, and may have limited
prescribing or limited pharmacy availability.
Revised 12/27/2018Page |5 What are pharmaceutical management procedures? Pharmaceutical management procedures are processes that help manage the drug formulary in order to provide the most cost-effective therapy options. As part of such processes, restrictions (described in the following section) may be applied to certain drugs on the formulary. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include; quantity limits, prior authorization, step therapy, age limits, and others. Please refer to the legend for a complete listing of requirements. How do I request an exception to the Essential Health Benefits Formulary? You, a representative, or a prescriber can submit a request to SWHP to make an exception to the formulary. For example, if there are clinically significant reasons why you cannot take a drug in accordance with the coverage requirements (e.g. step therapy, age limits, quantity limits), an exception request can be submitted for review. Additionally, if you 1) have tried the formulary alternatives, or there are clinically significant reasons why the alternatives would not be appropriate for your specific condition, and 2) the requested drug is medically necessary, and 3) the drug is not excluded from coverage, an exception request to cover a drug not listed on formulary can be submitted for review. To request an exception, you, a representative, or a prescriber can submit a coverage exception request to SWHP via swhp.org, fax, mail, or phone. You and your prescriber will be notified of the determination in writing. If approved, the drug will be covered at the applicable copayment. If the request is denied, you may still purchase the medication for the full price. For questions regarding this process, contact SWHP pharmacy customer service at 1-800-728-7947. What drugs are not covered by my prescription drug benefit? Please refer to your Plan Documents for complete plan coverage, limitations, and exclusions specific to your prescription drug benefit. Often, over-the-counter medications and herbal products are not covered under SWHP benefit plans. Revised 12/27/2018
Page |6
How much medication does my copayment cover and does my plan cover
maintenance medications?
You can get up to a 30-day supply of medication for a single copayment. Note that
medications with a quantity limit restrict the amount of drug you can get per
prescription or per copayment. Drug categories that are used for a short amount of
time, for example antibiotics, antivirals, and most topical medications are available in
30-day supplies.
Maintenance medications are used to treat chronic medical conditions. Most
medications that are usually taken chronically or long term are allowed a three-month
supply with exception of some drug categories such as opioids, testosterone, sleep
agents, benzodiazepines, specialty drugs, and drugs with quantity limits. The
prescription for the drug must be written for a three-month supply of medication.
How can I save money on prescriptions?
Medications on the SWHP formulary generally cost less than medications not listed. A
generic medication will usually be the lowest copayment option. Ask your provider or
pharmacist whether generic medications are appropriate.
Be sure to take this formulary with you to each visit so that your provider knows which
medications are covered.
Contraceptive Coverage
As specified by health care reform, women must have access to a full range of FDA-
approved contraceptive methods and plans must cover without cost sharing at least one
form of contraception in each of the FDA identified methods. However, plans can use
reasonable medical management within each category to determine what birth control
products are available at $0 cost-share.
• Please refer to the formulary to determine which contraceptives are available at
a $0 cost-share. These are noted as preventive drugs (PV).
• Certain over-the-counter (OTC) contraceptives for women may also be covered
at a $0 cost-share. These must be filled at a network pharmacy with a
prescription prescribed by a health care professional.
Coverage may vary according to your plan. Please refer to applicable plan documents.
Preventive Care Medications & Medications Covered Under Health Care Reform
Preventive care medications as well as other medications covered under Health Care
Reform are covered according to your plan benefits. These medications are noted as
preventive drugs (PV). Please note this list is subject to change.
Revised 12/27/2018Page |7 In order to obtain this benefit, you must fill at a network pharmacy with a prescription prescribed by a health care professional (includes prescription and over-the-counter medications). Smoking Cessation Medication Coverage All FDA approved tobacco cessation medications, including prescription and over-the- counter medications, are allowed at $0 cost-share per the Patient Protection and Affordable Care Act (PPACA). You are limited to two smoking cessation attempts per year, up to 180 days total. These medications are noted as preventive drugs (PV). Please note some drugs maybe subject to step therapy. In order to obtain this benefit, you must fill at a network pharmacy with a prescription prescribed by a health care professional (includes prescription and over-the-counter medications). Diabetic Supplies The preferred diabetic testing supplies include all OneTouch® (LifeScan) products. Oral Oncology Split Fill Program Prescriptions for drugs included in the oral oncology program will be restricted to a 2- week supply for the first 2 months of therapy. Revised 12/27/2018
Reading your formulary
The formulary gives you choices so you and your doctor can determine your best course of
treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example,
CLOBEX) and generic medications in lowercase (for example, clobetasol).
Tier information
Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your
plan may have multiple or no tiers.
Drug Tier Includes Helpful Tips
Tier CM Oral Chemotherapy Oral chemotherapy drugs may have a designated
copayment or coinsurance based on state laws or
client preference.
Tier 1 $ Generic Use Tier 1 generic drugs, instead of brand name drugs, to
help reduce your out-of-pocket costs.
Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower
copayments than non-preferred brand-name drugs.
Tier 3 $$$ Non-Preferred Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
Ask your doctor if they could work for you.
Tier 4 $$$$ Specialty Tier 4 is generally highest in copayment and cost.
These drugs are sometimes used to treat complex and
chronic conditions and may require special monitoring
and handling.
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones
may have coverage requirements or limits. Your benefit plan determines how these medications
may be covered for you.
M Authorized generic or co-branded product
PA Prior Authorization – Your doctor is required to provide additional information to
determine coverage.
PV
Preventive drugs – May have coverage and no copayments when health care
reform requirements are met.
PV* Preventive drugs – Available at $0 if prior authorization is approved.
QL Quantity Limit – Medication may be limited to a certain quantity.
ST tep Therapy – Trial of lower-cost medication(s) is required before a higher-cost
S
medication can be covered.
8Table of Contents
Analgesics.....................................................12 Antimycobacterials...................................... 26
Nonsteroidal Anti-inflammatory Drugs....... 12 Antimycobacterials, Other.......................... 26
Opioid Analgesics, Long-acting................. 14 Antituberculars........................................... 26
Opioid Analgesics, Short-acting................. 15 Antineoplastics.............................................26
Anesthetics................................................... 16 Alkylating Agents....................................... 26
Local Anesthetics....................................... 16 Antiandrogens............................................ 26
Anti-Addiction/Substance Abuse Antiangiogenic Agents............................... 27
Treatment Agents.......................................17 Antiestrogens/Modifiers............................. 27
Alcohol Deterrents/Anti-craving................. 17 Antimetabolites.......................................... 27
Opioid Dependence Treatments................ 17 Antineoplastics, Other................................ 27
Opioid Reversal Agents............................. 17 Aromatase Inhibitors, 3rd Generation........ 28
Smoking Cessation Agents........................ 17 Enzyme Inhibitors...................................... 28
Antibacterials................................................18 Molecular Target Inhibitors........................ 28
Aminoglycosides........................................ 18 Monoclonal Antibody/Antibody-Drug
Antibacterials, Other.................................. 18 Conjugate................................................ 29
Beta-lactam, Cephalosporins..................... 19 Retinoids.................................................... 30
Beta-lactam, Other..................................... 20 Antiparasitics................................................30
Beta-lactam, Penicillins.............................. 20 Anthelmintics..............................................30
Macrolides..................................................21 Antiprotozoals............................................ 30
Quinolones................................................. 21 Pediculicides/Scabicides............................30
Sulfonamides............................................. 21 Antiparkinson Agents.................................. 30
Tetracyclines.............................................. 21 Anticholinergics.......................................... 30
Anticonvulsants............................................21 Antiparkinson Agents, Other...................... 30
Anticonvulsants, Other............................... 21 Dopamine Agonists.................................... 30
Calcium Channel Modifying Agents........... 22 Dopamine Precursors/L- Amino Acid
Gamma-aminobutyric Acid (GABA) Decarboxylase Inhibitors......................... 30
Augmenting Agents................................. 22 Monoamine Oxidase B (MAO-B) Inhibitors 31
Glutamate Reducing Agents...................... 22 Antipsychotics..............................................31
Sodium Channel Agents............................ 22 1st Generation/Typical............................... 31
Antidementia Agents....................................22 2nd Generation/Atypical.............................31
Antidementia Agents, Other....................... 22 Treatment-Resistant.................................. 31
Cholinesterase Inhibitors........................... 23 Antispasticity Agents...................................31
N-methyl-D-aspartate (NMDA) Receptor Antivirals....................................................... 31
Antagonist................................................23 Anti-cytomegalovirus (CMV) Agents.......... 31
Antidepressants........................................... 23 Anti-hepatitis B (HBV) Agents.................... 31
Antidepressants, Other.............................. 23 Anti-hepatitis C (HBV) Agents....................32
Monoamine Oxidase Inhibitors.................. 23 Antiherpetic Agents.................................... 32
SSRI/SNRI (Selective Serotonin Reuptake Anti-HIV Agents, Integrase Inhibitors
Inhibitors/Serotonin and Norepinephrine (INSTI)..................................................... 32
Reuptake Inhibitors).................................23 Anti-HIV Agents, Non-nucleoside Reverse
Tricyclics.................................................... 23 Transcriptase Inhibitors (NNRTI)............. 32
Antiemetics................................................... 24 Anti-HIV Agents, Nucleoside and
Antiemetics, Other..................................... 24 Nucleotide Reverse Transcriptase
Emetogenic Therapy Adjuncts................... 24 Inhibitors (NRTI)...................................... 32
Antifungals....................................................24 Anti-HIV Agents, Other.............................. 33
Antigout Agents............................................25 Anti-HIV Agents, Protease Inhibitors......... 33
Antimigraine Agents.................................... 25 Anti-influenza Agents................................. 33
Ergot Alkaloids........................................... 25 Anxiolytics.................................................... 33
Serotonin (5-HT) 1b/1d Receptor Agonists 25 Anxiolytics, Other....................................... 33
Antimyasthenic Agents................................26 Benzodiazepines........................................33
Parasympathomimetics..............................26 Bipolar Agents.............................................. 34
9Mood Stabilizers........................................ 34 Genetic or Enzyme Disorder:
Blood Glucose Monitoring...........................34 Replacement, Modifiers, Treatment..........53
Blood Glucose Regulators.......................... 35 Genitourinary Agents...................................54
Antidiabetic Agents.................................... 35 Antispasmodics, Urinary............................ 54
Glycemic Agents........................................ 35 Benign Prostatic Hypertrophy Agents........ 54
Insulins....................................................... 35 Genitourinary Agents, Other...................... 54
Blood Products/Modifiers/Volume Phosphate Binders.....................................54
Expanders................................................... 36 Hormonal Agents,
Anticoagulants........................................... 36 Stimulant/Replacement/Modifying
Blood Formation Modifiers......................... 37 (Adrenal)......................................................54
Hemostasis Agents.................................... 37 Hormonal Agents,
Platelet Modifying Agents.......................... 38 Stimulant/Replacement/Modifying
Cardiovascular Agents................................ 38 (Pituitary).....................................................56
Alpha-adrenergic Agonists......................... 38 Hormonal Agents, Suppressant (Pituitary).56
Alpha-adrenergic Blocking Agents............. 39 Hormonal Agents,
Angiotensin II Receptor Antagonists.......... 39 Stimulant/Replacement/Modifying
Angiotensin-converting Enzyme (ACE) (Prostaglandins)......................................... 56
Inhibitors.................................................. 39 Hormonal Agents,
Antiarrhythmics.......................................... 39 Stimulant/Replacement/Modifying (Sex
Beta-adrenergic Blocking Agents...............40 Hormones/Modifiers)................................. 56
Calcium Channel Blocking Agents............. 40 Anabolic Steroids....................................... 56
Cardiovascular Agents, Other.................... 41 Androgens..................................................56
Diuretics, Loop........................................... 41 Estrogens................................................... 57
Diuretics, Potassium-sparing..................... 41 Progesterone Agonists/Antagonists........... 59
Diuretics, Thiazide..................................... 41 Progestins.................................................. 59
Dyslipidemics, Fibric Acid Derivatives........42 Selective Estrogen Receptor Modifying
Dyslipidemics, HMG CoA Reductase Agents......................................................60
Inhibitors.................................................. 42 Hormonal Agents,
Dyslipidemics, Other.................................. 42 Stimulant/Replacement/Modifying
Vasodilators, Direct-acting Arterial.............42 (Thyroid)......................................................60
Vasodilators, Direct-acting Arterial/Venous42 Hormonal Agents, Suppressant (Adrenal). 60
Central Nervous System Agents.................42 Hormonal Agents, Suppressant (Pituitary) 60
Attention Deficit Hyperactivity Disorder Hormonal Agents, Suppressant (Thyroid). 61
Agents, Amphetamines............................42 Antithyroid Agents...................................... 61
Attention Deficit Hyperactivity Disorder Immunological Agents................................. 61
Agents, Non-amphetamines.................... 43 Angioedema Agents...................................61
Central Nervous System, Other................. 43 Immune Suppressants............................... 61
Fibromyalgia Agents.................................. 43 Immunizing Agents, Passive...................... 62
Multiple Sclerosis Agents........................... 43 Immunomodulators.................................... 63
Dental and Oral Agents................................43 Vaccines.................................................... 63
Dermatological Agents................................ 44 Inflammatory Bowel Disease Agents..........64
Electrolytes/Minerals/Metals/Vitamins....... 45 Aminosalicylates........................................ 64
Electrolyte/Mineral Replacement............... 45 Glucocorticoids.......................................... 65
Electrolyte/Mineral/Metal Modifiers............ 47 Sulfonamides............................................. 65
Vitamins..................................................... 47 Metabolic Bone Disease Agents................. 65
Gastrointestinal Agents............................... 50 Miscellaneous Therapeutic Agents............ 65
Antispasmodics, Gastrointestinal............... 50 Ophthalmic Agents.......................................69
Gastrointestinal Agents, Other................... 51 Aminoglycosides........................................ 69
Histamine2 (H2) Receptor Antagonists......51 Antibacterials, Other.................................. 69
Irritable Bowel Syndrome Agents...............51 Anti-cytomegalovirus (CMV) Agents.......... 70
Laxatives.................................................... 51 Antifungals................................................. 70
Protectants................................................. 53 Antiherpetic Agents.................................... 70
Proton Pump Inhibitors.............................. 53 Macrolides..................................................70
10Ophthalmic Prostaglandin and
Prostamide Analogs.................................70
Ophthalmic Agents, Other..........................70
Ophthalmic Anti-allergy Agents..................70
Ophthalmic Antiglaucoma Agents.............. 70
Ophthalmic Anti-inflammatories................. 71
Quinolones................................................. 71
Sulfonamides............................................. 71
Otic Agents................................................... 71
Respiratory Tract/Pulmonary Agents......... 72
Antihistamines............................................72
Anti-inflammatories, Inhaled
Corticosteroids.........................................72
Antileukotrienes......................................... 72
Bronchodilators, Anticholinergic.................72
Bronchodilators, Sympathomimetic........... 73
Cystic Fibrosis Agents............................... 73
Mast Cell Stabilizers.................................. 73
Phosphodiesterase Inhibitors, Airways
Disease....................................................73
Pulmonary Antihypertensives.................... 73
Pulmonary Fibrosis Agents........................ 74
Respiratory Tract Agents, Other................ 74
Skeletal Muscle Relaxants...........................74
Sleep Disorder Agents................................. 75
GABA Receptor Modulators.......................75
Sleep Disorders, Other.............................. 75
Index of Drugs................................................ 76
11Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Analgesics aspirtab 1
butalbital-acetaminophen 1 bayer advanced aspirin 1
oral tablet reg st
butalbital-apap 1 bayer aspirin ec low dose 1
butalbital-apap-caffeine bayer aspirin oral tablet 1
1
oral capsule bayer aspirin oral tablet 1
butalbital-apap-caffeine 1 delayed release
oral tablet 50-325-40 mg bayer low dose 1
butalbital-aspirin-caffeine 1 1
careall aspirin
duraxin 1 1 QL
celecoxib oral
esgic oral capsule 1 1
childrens aspirin
phrenilin forte oral childrens aspirin low
1 1
capsule 50-300-40 mg strength
tencon oral tablet 50-325 cvs aspirin adult low
1 1
mg dose
zebutal oral capsule 50- cvs aspirin adult low
1 1
325-40 mg strength
Nonsteroidal Anti-inflammatory Drugs 1
cvs aspirin ec
adult aspirin regimen 1 1
cvs aspirin low dose
aspirin 81 1
cvs aspirin low strength
aspirin adult 1 oral tablet delayed 1
aspirin adult low dose 1 release
aspirin adult low strength 1 cvs aspirin oral tablet 325 1
mg
aspirin childrens 1
cvs aspirin oral tablet 1
aspirin ec 1
delayed release 325 mg
aspirin ec adult low 1 diclofenac potassium 1
strength
diclofenac sodium er 1
aspirin ec low dose 1
diclofenac sodium oral 1
aspirin ec low strength 1
diclofenac sodium
aspirin low dose oral 1 solution 1.5 % 1 PA
tablet chewable transdermal
aspirin low dose oral diclofenac sodium
1 1 QL
tablet delayed release transdermal gel 1 %
aspirin low strength 1
diclofenac-misoprostol
aspirin oral tablet 325 mg 1 oral tablet delayed 1
aspirin oral tablet release
1
chewable diclofex dc combination
aspirin oral tablet therapy pack 1.5-0.025 1
delayed release 325 mg, 1 %
81 mg DICLOFONO GEL 1.6 %
2
aspir-low 1 TRANSDERMAL
12Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
diflunisal oral 1 hm aspirin 1
ec-naproxen 1 hm aspirin ec 1
ecotrin low strength 1 hm aspirin ec low dose 1
ecotrin tablet delayed ibu 1
1
release 325 mg oral ibuprofen lysine 1
ecpirin 1 ibuprofen oral 1
eq adult aspirin low 1 suspension
strength ibuprofen oral tablet 400 1
eq aspirin adult low dose 1 mg, 600 mg, 800 mg
eq aspirin low dose oral indomethacin er 1
1
tablet chewable indomethacin oral 1
eq aspirin low dose oral indomethacin sodium 1
1
tablet delayed release
ketoprofen er 1
eq aspirin oral tablet 1
ketoprofen oral capsule 1
eq aspirin oral tablet 25 mg
1
delayed release 325 mg
ketorolac tromethamine
eq childrens aspirin 1 injection solution 15 1
eql aspirin 1 mg/ml, 30 mg/ml
eql aspirin ec oral tablet ketorolac tromethamine
1 1 QL
delayed release 325 mg oral
eql aspirin low dose 1 ketorolac tromethamine
etodolac er 1 solution 60 mg/2ml 1
intramuscular
etodolac oral 1
kls aspirin ec 1
fenoprofen calcium oral 1
kls aspirin low dose 1
fenortho oral capsule 200 1
mg kp aspirin 1
flurbiprofen oral 1 meclofenamate sodium 1
oral
gnp adult aspirin low
strength oral tablet 1 medique aspirin 1
chewable meijer aspirin ec 1
gnp aspirin low dose 1 meloxicam oral tablet 1
gnp aspirin oral tablet miniprin low dose 1
1
325 mg mm aspirin 1
gnp aspirin oral tablet nabumetone oral 1
1
delayed release
naproxen dr 1
goodsense aspirin 1
naproxen oral tablet 1
goodsense aspirin adult 1
low st naproxen sodium oral
1
tablet 275 mg, 550 mg
goodsense aspirin low 1
dose norwich aspirin oral tablet 1
325 mg
h-e-b aspirin 1
oxaprozin 1
13Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
piroxicam oral 1 tgt aspirin low dose oral
1
px aspirin 1 tablet delayed release
px enteric aspirin 1 tgt childrens aspirin 1
qc aspirin 1 tolmetin sodium 1
1 Opioid Analgesics, Long-acting
qc aspirin low dose
qc childrens aspirin 1 buprenorphine hcl
injection solution 0.3 1
qc enteric aspirin 1 mg/ml
ra aspirin adult low dose 1 buprenorphine
ra aspirin adult low transdermal patch weekly
1 1 PA; QL
strength 10 mcg/hr, 15 mcg/hr, 20
ra aspirin childrens 1 mcg/hr, 5 mcg/hr
ra aspirin ec 1 BUPRENORPHINE
TRANSDERMAL PATCH 3 PA; QL
ra aspirin ec adult low st 1 WEEKLY 7.5 MCG/HR
ra aspirin oral tablet 325 1 BUTRANS
mg TRANSDERMAL PATCH 3 PA; QL
ra childrens aspirin 1 WEEKLY 7.5 MCG/HR
ra pain relief aspirin 1 EMBEDA 2 PA; QL
sb aspirin 1 fentanyl 1 PA; QL
sb aspirin adult low hydromorphone hcl er 1 PA; QL
1
strength HYSINGLA ER 2 PA; QL
sb aspirin ec 1 methadone hcl injection 1
sb childrens aspirin 1 methadone hcl intensol 1
sb low dose asa ec 1 methadone hcl oral
1
sm aspirin 1 concentrate
sm aspirin adult low methadone hcl oral
1 1
strength solution
sm aspirin ec 1 methadone hcl oral tablet 1 PA
sm aspirin ec low methadone hcl oral tablet
1 1
strength soluble
sm aspirin low dose oral methadose oral 1
1
tablet chewable concentrate 10 mg/ml
sm childrens aspirin 1 methadose oral tablet 1
SPRIX 3 PA; QL soluble
methadose sugar-free 1
st joseph aspirin oral 1
tablet delayed release mitigo 1
st joseph low dose 1 morphine sulfate er 1 PA; QL
sulindac oral 1 beads
tgt aspirin 1 morphine sulfate er oral
capsule extended 1 PA; QL
tgt aspirin ec 1 release 24 hour
14Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
morphine sulfate er oral fentanyl citrate buccal
1 PA; QL 1 PA; QL
tablet extended release lozenge on a handle
morphine sulfate 1 hydrocodone-
intramuscular acetaminophen oral
OXYCODONE HCL ER solution 10-325 mg/15ml, 1 QL
ORAL TABLET ER 12 2.5-108 mg/5ml, 5-217
3 PA; QL mg/10ml, 7.5-325
HOUR ABUSE-
DETERRENT mg/15ml
OXYCONTIN ORAL hydrocodone-
TABLET ER 12 HOUR 2 PA; QL acetaminophen oral
ABUSE-DETERRENT tablet 10-300 mg, 10-325 1 QL
mg, 5-300 mg, 5-325 mg,
oxymorphone hcl er 1 PA; QL 7.5-300 mg, 7.5-325 mg
tramadol hcl er (biphasic) hydrocodone-ibuprofen
oral tablet extended 1 QL oral tablet 10-200 mg, 5- 1 QL
release 24 hour 100 mg, 200 mg, 7.5-200 mg
200 mg, 300 mg
hydromorphone hcl
tramadol hcl er oral 1
injection solution 4 mg/ml
capsule extended 1 PA; QL
release 24 hour 150 mg hydromorphone hcl oral 1 QL
tramadol hcl er oral tablet hydromorphone hcl pf 1
1 QL
extended release 24 hour hydromorphone hcl
1
Opioid Analgesics, Short-acting solution 1 mg/ml injection
acetaminophen-codeine 1 QL hydromorphone hcl
1
solution 2 mg/ml injection
acetaminophen-codeine
1 QL levorphanol tartrate oral
#2 1 QL
tablet 2 mg
acetaminophen-codeine 1 QL
#3 lorcet 1 QL
acetaminophen-codeine lorcet hd 1 QL
1 QL
#4 lorcet plus oral tablet 7.5- 1 QL
alfentanil hcl intravenous 1 325 mg
ascomp-codeine 1 meperidine hcl injection
solution 100 mg/ml, 25 1
butalbital-apap-caff-cod 1
mg/ml, 50 mg/ml
butalbital-asa-caff- 1 meperidine hcl oral 1 QL
codeine
morphine sulfate
butorphanol tartrate (concentrate) oral
1 1 QL
injection solution 100 mg/5ml, 20
butorphanol tartrate mg/ml
1 QL
nasal morphine sulfate (pf) 1
codeine sulfate oral injection
1 QL
tablet 30 mg, 60 mg morphine sulfate (pf)
duramorph 1 intravenous solution 10 1
endocet oral tablet 10- mg/ml, 2 mg/ml, 4 mg/ml,
325 mg, 2.5-325 mg, 5- 1 QL 8 mg/ml
325 mg, 7.5-325 mg
15Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
morphine sulfate bupivacaine spinal 1
intravenous solution 150 1 bupivacaine-epinephrine
mg/30ml (pf) injection solution 1
morphine sulfate oral 1 QL 0.25% -1:200000, 0.5% -
morphine sulfate solution 1:200000
1
1 mg/ml intravenous bupivacaine-epinephrine
nalbuphine hcl injection 1 injection solution 0.25% - 1
1:200000, 0.5% -
oxycodone hcl oral 1 QL 1:200000
capsule
chloroprocaine hcl (pf) 1
oxycodone hcl oral
1 QL ethyl chloride 1
concentrate 100 mg/5ml
oxycodone hcl oral glydo 1
1 QL
solution lidocaine external patch 5
1
oxycodone hcl oral tablet 1 QL %
oxycodone- lidocaine hcl (pf) injection 1
acetaminophen oral solution
tablet 10-325 mg, 2.5- 1 QL lidocaine hcl external 1
325 mg, 5-325 mg, 7.5- solution
325 mg lidocaine hcl injection 1
oxycodone-aspirin oral 1 QL solution 0.5 %, 1 %, 2 %
tablet 4.8355-325 mg lidocaine hcl 1
oxycodone-ibuprofen 1 QL mouth/throat
oxymorphone hcl 1 QL lidocaine hcl
1
pentazocine-naloxone hcl 1 QL urethral/mucosal
remifentanil hcl 1 lidocaine ointment 5 %
1
external
tramadol hcl ir 1 QL
lidocaine viscous 1
tramadol-acetaminophen 1 QL
lidocaine-epinephrine
vicodin es oral tablet 7.5- injection solution 0.5 %-
1 QL
300 mg 1:200000, 1 %-1:100000, 1
vicodin hp oral tablet 10- 1.5 %-1:200000, 2 %-
1 QL
300 mg 1:100000, 2 %-1:200000,
vicodin oral tablet 5-300 2 %-1:50000
1 QL
mg lidocaine-prilocaine
1
Anesthetics external cream
Local Anesthetics polocaine 1
bd pudendal/local polocaine-mpf 1
1
tray/1% lido ropivacaine hcl injection
bupivacaine fisiopharma 1 solution 10 mg/ml, 2
1
mg/ml, 5 mg/ml, 7.5
bupivacaine hcl (pf) 1
mg/ml
bupivacaine hcl injection 1 sensorcaine 1
solution 0.25 %, 0.5 %
sensorcaine/epinephrine 1
bupivacaine in dextrose
1 sensorcaine-mpf 1
intrathecal
16Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
sensorcaine- eq nicotine step 3 1 QL
mpf/epinephrine injection eq nicotine transdermal 1 QL
solution 0.25% - 1
1:200000, 0.5% - eql nicotine polacrilex 1 QL
1:200000 folding paddle walker 1 QL
xylocaine dental 1 gnp nicotine 1 QL
Anti-Addiction/Substance Abuse Treatment gnp nicotine mini 1 QL
Agents 1 QL
gnp nicotine polacrilex
Alcohol Deterrents/Anti-craving 1 QL
goodsense nicotine
acamprosate calcium 1 1 QL
hm nicotine
disulfiram oral 1 1 QL
hm nicotine polacrilex
VIVITROL 4 1 QL
kls quit2
Opioid Dependence Treatments 1 QL
kls quit4
buprenorphine hcl nicorelief mouth/throat
1 QL 1 QL
sublingual gum 2 mg
buprenorphine hcl- nicotine 1 QL
1 QL
naloxone hcl
nicotine mini 1 QL
naltrexone hcl oral 1
nicotine polacrilex 1 QL
Opioid Reversal Agents
mouth/throat
naloxone hcl injection nicotine step 1 1 QL
solution 0.4 mg/ml, 4 1
mg/10ml nicotine step 2 1 QL
naloxone hcl injection nicotine step 3 1 QL
1
solution cartridge NICOTROL 3 ST; QL
naloxone hcl injection NICOTROL NS 3 ST; QL
1
solution prefilled syringe px stop smoking aid 1 QL
NARCAN 2 1 QL
ra mini nicotine
Smoking Cessation Agents
ra nicotine 1 QL
bupropion hcl er
1 QL ra nicotine gum
(smoking det) 1 QL
mouth/throat gum 2 mg,
CHANTIX 3 ST; QL 4 mg
CHANTIX CONTINUING 3 ST; QL ra nicotine polacrilex 1 QL
MONTH PAK 1 QL
sm nicotine
CHANTIX STARTING 3 ST; QL 1 QL
sm nicotine polacrilex
MONTH PAK
sr nicotine 1 QL
cvs nicotine 1 QL
tgt nicotine 1 QL
cvs nicotine polacrilex 1 QL
tgt nicotine polacrilex 1 QL
eq nicotine mouth/throat 1 QL
gum 4 mg tgt nicotine step one 1 QL
eq nicotine mouth/throat tgt nicotine step three 1 QL
1 QL
lozenge tgt nicotine step two 1 QL
eq nicotine polacrilex 1 QL
17Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
thrive mouth/throat gum CORTISPORIN
1 QL 3
2 mg EXTERNAL
Antibacterials daptomycin 1
Aminoglycosides IMPAVIDO 3
amikacin sulfate injection iodine tincture tincture 2 1
solution 1 gm/4ml, 500 1 % external (rx)
mg/2ml iv prep wipes external 3
gentamicin in saline pad 70 %
intravenous solution 0.8- lincomycin hcl injection 1
0.9 mg/ml-%, 1-0.9
1 linezolid in sodium
mg/ml-%, 1.2-0.9 mg/ml- 1
%, 1.6-0.9 mg/ml-%, 2- chloride
0.9 mg/ml-% linezolid intravenous
1
gentamicin sulfate solution 600 mg/300ml
1
external linezolid oral 1 QL
gentamicin sulfate 1 mafenide acetate
1
injection external
neomycin sulfate oral 1 methenamine hippurate 1
paromomycin sulfate oral 1 metronidazole in nacl
streptomycin sulfate intravenous solution 5- 1
1 0.79 mg/ml-%, 500-0.79
intramuscular
mg/100ml-%
tobramycin sulfate
1 metronidazole oral 1
injection
Antibacterials, Other metronidazole vaginal 1
ALTABAX 3 MICROCLENS WIPES 3
baciim 1 MONUROL 3
bacitracin intramuscular 1 mupirocin calcium 1
chloramphenicol sod mupirocin external 1
1
succinate NEO-SYNALAR
3
clindamycin hcl oral 1 EXTERNAL CREAM
clindamycin palmitate hcl 1 nitrofurantoin
1
macrocrystal oral
clindamycin phosphate in 1
d5w nitrofurantoin
monohydrate 1
clindamycin phosphate 1 macrocrystals
injection
nitrofurantoin oral 1
clindamycin phosphate suspension
intravenous solution 300 1
mg/2ml, 600 mg/4ml, 900 polymyxin b sulfate 1
mg/6ml injection
clindamycin phosphate PRIMSOL 3
1
vaginal silver sulfadiazine 1
colistimethate sodium external
1
(cba) ssd 1
18Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
SULFAMYLON cefazolin sodium
3
EXTERNAL CREAM injection solution
trimethoprim oral 1 reconstituted 1 gm, 10 1
gm, 100 gm, 300 gm,
UNI-SOLVE 3 500 mg
vancomycin hcl in cefazolin sodium
dextrose intravenous 1 intravenous solution 1
solution 1-5 gm/200ml-%, reconstituted
500-5 mg/100ml-%
cefazolin sodium-
vancomycin hcl in dextrose intravenous
dextrose solution 750-5 1 1
solution 1-4 gm/50ml-%,
mg/150ml-% intravenous 2-4 gm/100ml-%
vancomycin hcl in nacl cefazolin sodium-
intravenous solution 1- dextrose intravenous
1
0.9 gm/200ml-%, 500-0.9 solution reconstituted 1-4 1
mg/100ml-% gm-%(50ml), 2-3 gm-
VANCOMYCIN HCL IN %(50ml)
NACL SOLUTION 750- 3 cefdinir 1
0.9 MG/150ML-%
INTRAVENOUS cefditoren pivoxil 1
vancomycin hcl in nacl cefepime hcl 1
solution 750-0.9 1 cefepime-dextrose
mg/150ml-% intravenous intravenous solution
vancomycin hcl reconstituted 1-5 gm- 1
intravenous solution %(50ml), 2-5 gm-
1000 mg/200ml, 1500 1 %(50ml)
mg/300ml, 2000 cefixime 1
mg/400ml cefotaxime sodium
vancomycin hcl injection solution 1
intravenous solution reconstituted 1 gm, 500
reconstituted 1 gm, 1.25 mg
1
gm, 10 gm, 100 gm, cefotetan disodium
1000 mg, 250 mg, 5 gm, injection solution 1
500 mg, 750 mg reconstituted 1 gm, 2 gm
vancomycin hcl oral 1 cefotetan disodium-
vandazole 1 dextrose intravenous
XIFAXAN 3 PA solution reconstituted 1- 1
3.58 gm-%(50ml), 2-2.08
ZYVOX INTRAVENOUS gm-%(50ml)
SOLUTION 200 3
cefoxitin sodium 1
MG/100ML
Beta-lactam, Cephalosporins cefoxitin sodium-dextrose
intravenous solution
cefaclor 1 1
reconstituted 1-4 gm-
cefaclor er 1 %(50ml), 2-2.2 gm-
cefadroxil 1 %(50ml)
cefpodoxime proxetil 1
cefprozil 1
19Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
ceftazidime and dextrose Beta-lactam, Penicillins
intravenous solution amoxicillin oral capsule 1
reconstituted 1-5 gm- 1
%(50ml), 2-5 gm- amoxicillin oral 1
%(50ml) suspension reconstituted
amoxicillin oral tablet 1
ceftazidime injection
solution reconstituted 1 1 amoxicillin oral tablet
gm, 2 gm, 6 gm chewable 125 mg, 250 1
ceftriaxone sodium in mg
1
dextrose amoxicillin-potassium 1
ceftriaxone sodium clavulanate er
1
injection amoxicillin-potassium
1
ceftriaxone sodium clavulanate oral
1
intravenous ampicillin oral capsule
1
ceftriaxone sodium- 500 mg
dextrose intravenous ampicillin sodium
1
solution reconstituted 1- 1 injection
3.74 gm-%(50ml), 2-2.22 ampicillin sodium
gm-%(50ml) 1
intravenous
cefuroxime axetil oral ampicillin-sulbactam
1 1
tablet sodium
cefuroxime sodium AUGMENTIN ORAL
injection solution 1 SUSPENSION
reconstituted 7.5 gm, 750 3
RECONSTITUTED 125-
mg 31.25 MG/5ML
cefuroxime sodium BICILLIN L-A 3
intravenous solution 1
dicloxacillin sodium 1
reconstituted 1.5 gm
cephalexin 1 nafcillin sodium injection
solution reconstituted 1 1
MAXIPIME gm, 2 gm
INTRAVENOUS
3 nafcillin sodium
SOLUTION 1
RECONSTITUTED 2 GM intravenous
1 oxacillin sodium 1
tazicef injection
penicillin g potassium 1
tazicef solution
reconstituted 1 gm 1 penicillin g procaine 1
intravenous penicillin g sodium 1
tazicef solution penicillin v potassium 1
reconstituted 2 gm 1
intravenous pfizerpen solution
reconstituted 5000000 1
Beta-lactam, Other unit injection
aztreonam 1
piperacillin sod-
1
ertapenem sodium 1 tazobactam so
imipenem-cilastatin 1
meropenem 1
20Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Macrolides sulfamethoxazole-
1
azithromycin intravenous trimethoprim intravenous
solution reconstituted 1 sulfamethoxazole-
500 mg trimethoprim oral 1
azithromycin oral packet 1 suspension 200-40
mg/5ml
azithromycin oral 1
suspension reconstituted sulfamethoxazole- 1
trimethoprim oral tablet
azithromycin oral tablet 1
250 mg, 500 mg, 600 mg sulfatrim pediatric 1
clarithromycin er 1 Tetracyclines
clarithromycin oral 1 avidoxy 1
DIFICID 3 coremino 1
e.e.s. 400 oral tablet 1 demeclocycline hcl oral 1
erythrocin lactobionate doxy 100 1
solution reconstituted 1 doxycycline hyclate
1
500 mg intravenous intravenous
erythromycin base oral 1 doxycycline hyclate oral 1
erythromycin capsule
1
ethylsuccinate oral doxycycline hyclate oral
ZITHROMAX ORAL tablet 100 mg, 150 mg, 1
2 20 mg, 50 mg, 75 mg
PACKET
Quinolones doxycycline hyclate oral
tablet delayed release
AVELOX 1
3 100 mg, 150 mg, 200
INTRAVENOUS mg, 50 mg, 75 mg
CIPRO ORAL doxycycline monohydrate
SUSPENSION 1
3 oral
RECONSTITUTED 250
MG/5ML (5%) MINOCIN
3
INTRAVENOUS
ciprofloxacin hcl oral 1
minocycline hcl er 1
ciprofloxacin in d5w 1
minocycline hcl oral 1
ciprofloxacin oral
suspension reconstituted 1 mondoxyne nl oral 1
500 mg/5ml (10%) capsule 100 mg, 75 mg
levofloxacin in d5w 1 morgidox oral 1
levofloxacin intravenous 1 okebo oral capsule 75 1
mg
levofloxacin oral 1
tetracycline hcl oral 1
moxifloxacin hcl in nacl 1
tigecycline solution
moxifloxacin hcl oral 1 1
reconstituted 50 mg
ofloxacin oral tablet 300 1 intravenous
mg, 400 mg Anticonvulsants
Sulfonamides Anticonvulsants, Other
sulfadiazine oral 1 BRIVIACT ORAL 3
21Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
FYCOMPA 3 lamotrigine oral tablet
1
levetiracetam er 1 chewable
levetiracetam in nacl 1 lamotrigine oral tablet 1
dispersible
levetiracetam 1
intravenous lamotrigine starter kit- 1
blue
levetiracetam oral 1
lamotrigine starter kit- 1
roweepra 1 green
roweepra xr 1 lamotrigine starter kit-
1
Calcium Channel Modifying Agents orange
CELONTIN 3 subvenite 1
ethosuximide oral 1 subvenite starter kit-blue 1
pregabalin oral 1 QL subvenite starter kit-
1
zonisamide oral 1 green
Gamma-aminobutyric Acid (GABA) subvenite starter kit-
1
Augmenting Agents orange
clobazam 1 PA topiramate er 1
clonazepam oral 1 QL topiramate oral 1
diazepam rectal 1 QL Sodium Channel Agents
divalproex sodium er oral BANZEL 3
tablet extended release 1 carbamazepine er 1
24 hour carbamazepine oral 1
divalproex sodium oral DILANTIN ORAL
capsule delayed release 1 3
CAPSULE 30 MG
sprinkle
epitol 1
divalproex sodium oral 1
tablet delayed release fosphenytoin sodium 1
gabapentin oral 1 oxcarbazepine 1
phenobarbital oral 1 PEGANONE 3
primidone oral 1 phenytoin infatabs 1
tiagabine hcl 1 phenytoin oral
1
suspension 125 mg/5ml
valproate sodium 1
intravenous phenytoin oral tablet
1
chewable
valproic acid oral capsule 1
phenytoin sodium
valproic acid oral solution 1 1
extended
vigabatrin 4 PA
phenytoin sodium 1
vigadrone 4 PA injection
Glutamate Reducing Agents VIMPAT ORAL 3
felbamate 1 Antidementia Agents
lamotrigine er 1 Antidementia Agents, Other
lamotrigine oral tablet 1 ergoloid mesylates oral 1
22Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Cholinesterase Inhibitors fluoxetine hcl (pmdd) 1
donepezil hcl 1 fluoxetine hcl oral 1
galantamine capsule
1
hydrobromide fluoxetine hcl oral 1 QL
galantamine capsule delayed release
1
hydrobromide er fluoxetine hcl oral 1
rivastigmine 1 solution
rivastigmine tartrate 1 fluoxetine hcl oral tablet 1
N-methyl-D-aspartate (NMDA) Receptor fluvoxamine maleate 1
Antagonist fluvoxamine maleate er 1 QL
memantine hcl er 1 QL maprotiline hcl 1
memantine hcl oral 1 nefazodone hcl 1
NAMENDA XR olanzapine-fluoxetine hcl 1 QL
2 QL
TITRATION PACK paroxetine hcl er 1
NAMZARIC ORAL paroxetine hcl oral tablet 1
CAPSULE EXTENDED 2 QL
RELEASE 24 HOUR paroxetine mesylate 1 QL
Antidepressants PAXIL ORAL
2
SUSPENSION
Antidepressants, Other
sertraline hcl oral 1
APLENZIN 3 ST; QL
trazodone hcl oral 1
bupropion hcl er (sr) 1 QL
TRINTELLIX 3 ST; QL
bupropion hcl er (xl) oral
tablet extended release 1 QL venlafaxine hcl 1
24 hour 150 mg, 300 mg venlafaxine hcl er oral
bupropion hcl oral 1 capsule extended 1
release 24 hour
mirtazapine oral 1
venlafaxine hcl er oral
Monoamine Oxidase Inhibitors
tablet extended release 1
EMSAM 3 QL 24 hour 225 mg
MARPLAN 3 VIIBRYD ORAL TABLET 3 QL
phenelzine sulfate oral 1 VIIBRYD STARTER
3 QL
tranylcypromine sulfate 1 PACK
SSRI/SNRI (Selective Serotonin Reuptake Tricyclics
Inhibitors/Serotonin and Norepinephrine amitriptyline hcl oral 1
Reuptake Inhibitors) 1
amoxapine
citalopram hydrobromide 1
chlordiazepoxide-
1
desvenlafaxine succinate amitriptyline
1 QL
er 1
clomipramine hcl oral
duloxetine hcl oral 1 QL
desipramine hcl oral 1
escitalopram oxalate 1
doxepin hcl oral 1
FETZIMA 3 ST; QL
imipramine hcl oral 1
FETZIMA TITRATION 3 ST; QL
imipramine pamoate 1
23Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
nortriptyline hcl oral 1 dronabinol 1 PA; QL
perphenazine- 1 fosaprepitant 1
amitriptyline dimeglumine
protriptyline hcl 1 granisetron hcl
trimipramine maleate oral 1 intravenous solution 1 1
mg/ml, 4 mg/4ml
Antiemetics
granisetron hcl oral 1 QL
Antiemetics, Other
ondansetron hcl injection 1
AKYNZEO ORAL 3 QL
solution 40 mg/20ml
compro 1
ondansetron hcl oral
1 QL
dimenhydrinate injection 1 solution
doxylamine-pyridoxine 1 PA; QL ondansetron hcl oral
1 QL
droperidol injection 1 tablet 24 mg
meclizine hcl oral tablet ondansetron hcl oral
1 1
25 mg tablet 4 mg, 8 mg
meclizine hcl tablet 12.5 ondansetron hcl solution 1
1 4 mg/2ml injection
mg oral (rx)
phenadoz 1 ondansetron odt 1
prochlorperazine 1 palonosetron hcl 1
prochlorperazine Antifungals
edisylate injection ABELCET 3
1
solution 10 mg/2ml, 50 AMBISOME 3
mg/10ml
amphotericin b 1
prochlorperazine maleate 1 intravenous
oral
caspofungin acetate 1
promethazine hcl 1
injection ciclodan external solution 1
promethazine hcl oral ciclopirox 1
1
syrup ciclopirox olamine
1
promethazine hcl oral external
1
tablet clotrimazole cream 1 %
1
promethazine hcl rectal 1 external (rx)
promethegan 1 clotrimazole mouth/throat 1
scopolamine 1 clotrimazole solution 1 %
1
external (rx)
TIGAN
3 clotrimazole-
INTRAMUSCULAR 1
betamethasone
trimethobenzamide hcl 1
oral CRESEMBA 3
Emetogenic Therapy Adjuncts econazole nitrate 1
external
ANZEMET ORAL 3 QL
ERAXIS INTRAVENOUS
aprepitant 1 QL
SOLUTION 3
CESAMET 3 PA; QL RECONSTITUTED 50
MG
24Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
exoderm external lotion 1 Antigout Agents
fluconazole in sodium allopurinol oral 1
chloride intravenous allopurinol sodium 1
solution 200-0.9 1
mg/100ml-%, 400-0.9 COLCHICINE ORAL 3
mg/200ml-% TABLET
1 colchicine-probenecid 1
fluconazole oral
1 COLCRYS 2
flucytosine oral
febuxostat 1 ST
griseofulvin microsize
1
oral probenecid oral 1
griseofulvin Antimigraine Agents
1
ultramicrosize Ergot Alkaloids
GYNAZOLE-1 3 dihydroergotamine 1
itraconazole oral 1 PA mesylate injection
JUBLIA 3 PA dihydroergotamine 1 QL
KERYDIN 3 PA mesylate nasal
ergotamine-caffeine 1
ketoconazole external 1
cream Serotonin (5-HT) 1b/1d Receptor Agonists
ketoconazole external almotriptan malate 1 QL
1
shampoo 2 % eletriptan hydrobromide 1 QL
ketoconazole oral 1 naratriptan hcl 1 QL
MENTAX 3 rizatriptan benzoate 1 QL
miconazole 3 vaginal 1 sumatriptan nasal 1 QL
suppository
sumatriptan succinate
MYCAMINE 3 1 QL
oral
naftifine hcl external sumatriptan succinate
1
cream refill subcutaneous 1 QL
nyamyc 1 solution cartridge
nystatin external 1 sumatriptan succinate
1 subcutaneous solution 6 1 QL
nystatin mouth/throat
mg/0.5ml
nystatin oral tablet 1
sumatriptan succinate
nystatin-triamcinolone 1 subcutaneous solution
1 QL
nystop 1 auto-injector 4 mg/0.5ml,
OXISTAT EXTERNAL 6 mg/0.5ml
3
LOTION sumatriptan succinate
posaconazole 1 subcutaneous solution 1 QL
prefilled syringe 6
terbinafine hcl oral 1 QL mg/0.5ml
terconazole 1 sumatriptan-naproxen 1 QL
voriconazole intravenous 1 sodium
voriconazole oral 1 zolmitriptan oral 1 QL
XOLEGEL 3 ZOMIG NASAL 3 QL
25Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Antimyasthenic Agents cisplatin intravenous
Parasympathomimetics solution 100 mg/100ml, 4
200 mg/200ml, 50
GUANIDINE HCL ORAL 1
mg/50ml
neostigmine cyclophosphamide
methylsulfate intravenous 4
1 injection
solution 10 mg/10ml, 5
mg/10ml cyclophosphamide oral CM
capsule
pyridostigmine bromide 1
er dacarbazine intravenous 4
pyridostigmine bromide GLEOSTINE ORAL
1 CAPSULE 10 MG, 100 CM
oral solution
MG, 40 MG
pyridostigmine bromide
1 ifosfamide 4
oral tablet
regonol solution 10 LEUKERAN CM
1
mg/2ml intravenous MATULANE CM
Antimycobacterials melphalan CM
Antimycobacterials, Other melphalan hcl 4
dapsone oral 1 MYLERAN CM
rifabutin 1 oxaliplatin 4
Antituberculars TEMODAR 4
CAPASTAT SULFATE 3 INTRAVENOUS
cycloserine oral 1 temozolomide CM PA
ethambutol hcl oral 1 TEPADINA 4
isoniazid injection 1 thiotepa injection 4
isoniazid oral 1 TREANDA
INTRAVENOUS
PASER 3 4
SOLUTION
PRIFTIN 3 RECONSTITUTED
pyrazinamide oral 1 VYXEOS
rifampin intravenous 1 INTRAVENOUS
SUSPENSION 4 PA
rifampin oral 1
RECONSTITUTED 44-
RIFATER 3 100 MG
SIRTURO 3 ZANOSAR 4
TRECATOR 3 Antiandrogens
Antineoplastics abiraterone acetate CM PA
Alkylating Agents bicalutamide CM
busulfan 4 flutamide CM
carboplatin intravenous nilutamide CM
4
solution CM PA
XTANDI
carmustine 4
ZYTIGA ORAL TABLET
CM PA
500 MG
26Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Antiangiogenic Agents adriamycin intravenous
POMALYST CM PA solution reconstituted 10 4
mg, 50 mg
REVLIMID CM PA
arsenic trioxide
THALOMID CM PA 4
intravenous solution 10
Antiestrogens/Modifiers mg/10ml
EMCYT CM azacitidine 4
fulvestrant 4 BELEODAQ 4 PA
SOLTAMOX CM bleomycin sulfate 4
tamoxifen citrate oral CM PV COTELLIC CM PA
toremifene citrate CM dactinomycin 4
Antimetabolites daunorubicin hcl
4
adrucil 4 intravenous solution
ALIMTA 4 dexrazoxane hcl 4
ARRANON 4 dexrazoxane intravenous
solution reconstituted 4
capecitabine CM PA
500 mg
cladribine intravenous 4 diclofenac sodium
solution 10 mg/10ml 1 ST; QL
transdermal gel 3 %
clofarabine 4
docetaxel intravenous
cytarabine (pf) 4 concentrate 160 mg/8ml, 4
cytarabine injection 20 mg/ml, 200 mg/10ml,
4 80 mg/4ml
solution
decitabine 4 PA docetaxel intravenous
solution 160 mg/16ml, 20 4
DROXIA 3
mg/2ml, 80 mg/8ml
ELITEK 3
doxorubicin hcl
4
floxuridine injection 4 intravenous solution
fludarabine phosphate 4 doxorubicin hcl liposomal 4
fluorouracil intravenous 4 epirubicin hcl intravenous
FOLOTYN 4 PA solution 200 mg/100ml, 4
50 mg/25ml
gemcitabine hcl 4
ERWINAZE INJECTION 4
hydroxyurea oral CM
ETHYOL 4
LONSURF CM PA
FARYDAK CM PA
mercaptopurine oral CM
FLUOROPLEX 3
NIPENT 4
FLUOROURACIL
TABLOID CM 2
EXTERNAL CREAM 0.5
Antineoplastics, Other %
ABRAXANE 4 fluorouracil external
1
adriamycin intravenous cream 5 %
4
solution fluorouracil external
4
solution
27Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
HALAVEN 4 PA TOTECT 4
IBRANCE CM PA TRISENOX
idarubicin hcl 4 INTRAVENOUS 4
SOLUTION 12 MG/6ML
ISTODAX (OVERFILL) 4 PA
VELCADE INJECTION 4 PA
IXEMPRA KIT 4
vinblastine sulfate 4
JEVTANA 4 PA intravenous solution
KYPROLIS vincristine sulfate
INTRAVENOUS 4
intravenous
SOLUTION 4 PA
vinorelbine tartrate 4
RECONSTITUTED 10
MG ZALTRAP 4 PA
leucovorin calcium ZOLINZA CM PA
1
injection Aromatase Inhibitors, 3rd Generation
leucovorin calcium oral CM anastrozole oral CM
levoleucovorin calcium exemestane CM
4
intravenous solution
letrozole oral CM
levoleucovorin calcium
4 Enzyme Inhibitors
intravenous solution
reconstituted 50 mg CAMPTOSAR
levoleucovorin calcium pf 4 INTRAVENOUS
4
SOLUTION 300
LYNPARZA ORAL CM PA MG/15ML
TABLET
etoposide intravenous
MARQIBO 4 solution 1 gm/50ml, 100 4
mesna 4 mg/5ml, 500 mg/25ml
MESNEX ORAL CM etoposide oral CM
mitomycin intravenous 4 HYCAMTIN ORAL CM
mitoxantrone hcl 4 PA irinotecan hcl 4
mutamycin 4 KYPROLIS
NINLARO CM PA INTRAVENOUS
SOLUTION 4 PA
ONCASPAR INJECTION 4 RECONSTITUTED 30
paclitaxel 4 MG, 60 MG
PICATO 3 ST ONIVYDE 4
PROLEUKIN 4 toposar intravenous
4 PA solution 1 gm/50ml, 100 4
ROMIDEPSIN
mg/5ml, 500 mg/25ml
RUBRACA CM PA
topotecan hcl 4
SYLATRON
ZYDELIG CM PA
SUBCUTANEOUS KIT 4 PA
200 MCG, 300 MCG, 600 Molecular Target Inhibitors
MCG AFINITOR CM PA; QL
SYNRIBO 4 PA AFINITOR DISPERZ CM PA
teniposide 4 BOSULIF CM PA
28Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
CABOMETYX CM PA NEXAVAR CM PA
CAPRELSA ORAL RYDAPT CM PA
CM PA; QL
TABLET 100 MG SPRYCEL CM PA
CAPRELSA ORAL CM PA STIVARGA CM PA
TABLET 300 MG
SUTENT CM PA
COMETRIQ (100 MG CM PA
DAILY DOSE) TAFINLAR CM PA
COMETRIQ (140 MG TAGRISSO ORAL CM PA; QL
CM PA TABLET 40 MG
DAILY DOSE)
COMETRIQ (60 MG TAGRISSO ORAL CM PA
CM PA TABLET 80 MG
DAILY DOSE)
ERIVEDGE CM PA TASIGNA CM PA
erlotinib hcl CM PA temsirolimus 4
GILOTRIF CM PA; QL TYKERB CM PA
ICLUSIG ORAL TABLET VENCLEXTA CM PA
CM PA; QL
15 MG VENCLEXTA STARTING
CM PA
ICLUSIG ORAL TABLET PACK
CM PA
45 MG VOTRIENT CM PA
imatinib mesylate CM PA XALKORI CM PA
IMBRUVICA CM PA ZELBORAF CM PA
INLYTA CM PA ZYKADIA CM PA
JAKAFI ORAL TABLET Monoclonal Antibody/Antibody-Drug Conjugate
CM PA; QL
10 MG ADCETRIS 4 PA
JAKAFI ORAL TABLET ARZERRA 4 PA
15 MG, 20 MG, 25 MG, 5 CM PA
AVASTIN 4
MG
BAVENCIO 4 PA
LENVIMA (10 MG DAILY
CM PA
DOSE) BLINCYTO 4 PA
LENVIMA (12 MG DAILY CYRAMZA 4 PA
CM PA
DOSE) DARZALEX 4 PA
LENVIMA (14 MG DAILY EMPLICITI 4 PA
CM PA
DOSE)
ERBITUX 4 PA
LENVIMA (18 MG DAILY CM PA GAZYVA 4 PA
DOSE)
LENVIMA (20 MG DAILY HERCEPTIN
CM PA INTRAVENOUS
DOSE)
SOLUTION 4 PA
LENVIMA (24 MG DAILY CM PA RECONSTITUTED 150
DOSE) MG
LENVIMA (4 MG DAILY KADCYLA 4 PA
CM PA
DOSE)
LARTRUVO 4 PA
LENVIMA (8 MG DAILY
CM PA OPDIVO 4 PA
DOSE)
CM PA PERJETA 4 PA
MEKINIST
29You can also read
