PDL-Medication Categories Guide - Effective August 2014 - HealthSCOPE Benefits
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Whirlpool Corporation
PDL—Medication Categories Guide
Effective August 2014
You can make the most of your pharmacy benefit plan and control your prescription medication costs by using this
Preferred Drug List. Be sure to share this list with your doctor to select cost-effective medications that are
clinically appropriate to treat your condition or maintain your health.
This Preferred Drug List (PDL) was developed by How to Use This Guide
Whirlpool’s Formulary Review Committee, under the Whenever possible, you and your doctor should consult
direction of a committee of doctors and pharmacists. this guide for the lowest cost brand name and generic
medications available for your therapy. Some tips to
Understanding Your Tiered Copays keep in mind when using this guide:
Your pharmacy benefit plan offers five categories— Therapeutic categories are listed alphabetically in all
or tiers—of medications that determine your costs (copays): UPPERCASE letters in black boxes. Therapeutic
Tier 0: Value-Based Medications. Select value-based classes in each category are printed in all
medications for controlling cholesterol, blood pressure, UPPERCASE letters in bold.
diabetes, asthma, chronic obstructive pulmonary disease
and coronary artery disease are included in Tier 0. Generic medications are listed in lowercase letters
The co-insurance is 0%, which means they are available at below the word GENERIC. Brand-name generic
no cost to you. medications have the first letter in Uppercase.
Tier 1: Generics. Most generic medications are included Some medications treat more than one condition.
in Tier 1. Generics contain the same active ingredient as Check different categories for your medication.
their brand-name equivalents and offer the same
All medications on the PDL have been approved
effectiveness and safety. These drugs are clinically proven
by the FDA.
and typically available at a lower cost. The co-insurance is
10%.
Additional Information
Tier 2: Preferred. Clinically proven and cost-effective Not all medications are listed in this PDL. Medication
preferred-brand medications and some generic medications coverage and copays may vary from plan to plan. For
are included in Tier 2. They have higher copays than more information specific to your plan, log on to
generics but are less costly than nonpreferred medications healthscopebenefits.com and click on the Walgreens tab.
on the third tier. The co-insurance is 20%. For additional assistance, please call 877-WHIRL50
(877-944-7550).
Tier 3: Nonpreferred. Mostly non-preferred-brand
medications are included in Tier 3. These drugs are not as Please note: The PDL is subject to change without notice.
clinically or cost-effective compared to other drugs available.
Because a generic version or a second-tier alternative is
available, the co-insurance is 50%.
Tier 4: Brand and generic drugs considered to have
minimal or no clinical and cost-effective value are in Tier 4.
The co-insurance is 100%.
Drug names are the property of their respective o wners.
©2014 Catamaran Inc. All rights reserved. Catamaran is a registered trademark of C atamaran Inc.Table of Contents
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FOURTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
AMEBICIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTINEOPLASTICS, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIBIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTINEOPLASTIC ENZYMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANGIOGENESIS INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIBODIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
RADIOPHARMACEUTICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CELLULAR IMMUNOTHERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CHEMOTHERAPY ADJUNCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTINEOPLASTIC COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
PHOSPHODIESTERASE INHBTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DIRECT RENIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
CALCIUM REGULATORS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GHRH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
PROGESTERONE ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ANTACIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
HEMATOLOGICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ARTIFICIAL TEAR/LUBRICANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
LOCAL ANESTHETICS-INJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
TOXOIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
MEDICAL DEVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
DIABETIC SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Cefaclor ER
Cefotetan
Cefotetan/Dextrose
Cefuroxime/Dextrose
August 2014 TIER 03 NON PREFERRED
Cefoxitin Sodium
ANTI-INFECTIVES Ceftin
PENICILLINS Cefuroxime Sodium
GENERIC Mefoxin
TIER 01
amoxicillin Zinacef
amoxicillin/clavulanate potassium Zinacef IN Iso-osmotic Dextrose
amoxicillin/clavulanate potassium ER Zinacef IN Iso-osmotic Diluent
ampicillin THIRD GENERATION
ampicillin sodium TIER 01 GENERIC
ampicillin-sulbactam cefdinir
dicloxacillin sodium cefotaxime sodium
nafcillin sodium cefpodoxime proxetil
oxacillin sodium ceftazidime
penicillin v potassium ceftriaxone sodium
penicillin G potassium Cefditoren Pivoxil
piperacillin sodium/ tazobactam sodium Ceftazidime/Dextrose
piperacillin sodium/tazobactam sodium Ceftriaxone IN Iso-osmotic Dextrose
piperacillin/tazobactam Ceftriaxone/Dextrose
Amoxicillin TIER 03 NON PREFERRED
Ampicillin Cedax
Ampicillin Sodium Ceftazidime
Penicillin G Potassium IN Iso-osmotic Dextrose Ceftibuten
Penicillin G Sodium Claforan
Pfizerpen-G Claforan/D5W
NON PREFERRED Fortaz
TIER 03
Amoxicillin ER Rocephin
Ampicillin-sulbactam Spectracef
Augmentin Suprax
Augmentin ES-600 Tazicef
Augmentin XR FOURTH GENERATION
Bactocill IN Dextrose TIER 01 GENERIC
Bicillin C-R cefepime
Bicillin L-a TIER 03 NON PREFERRED
Moxatag Cefepime
Nafcillin Sodium Maxipime
Nallpen Iso-osmotic IN Dextrose
Nallpen/Dextrose MACROLIDES
Penicillin G Procaine TIER 01 GENERIC
Timentin azithromycin
Unasyn clarithromycin
Unasyn Bulk Pack clarithromycin ER
Zosyn erythromycin
Azithromycin
CEPHALOSPORIN E.e.s. 400
FIRST GENERATION Erythrocin Stearate
GENERIC Erythromycin Base
TIER 01
cefadroxil Erythromycin Ethylsuccinate
cefazolin sodium TIER 03 NON PREFERRED
cephalexin Biaxin
Cefazolin Sodium Biaxin XL
Cephalexin Biaxin XL PAC
NON PREFERRED Dificid
TIER 03
Ancef E.e.s. Granules
Cefazolin Sodium/Dextrose Ery-TAB
Keflex Eryped 200
SECOND GENERATION Eryped 400
GENERIC Erythrocin Lactobionate
TIER 01
cefaclor PCE
cefoxitin sodium Zithromax
cefprozil Zithromax Tri-PAK
cefuroxime axetil Zithromax Z-PAK
cefuroxime sodium Zmax
Cefaclor
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 1TETRACYCLINES PREFERRED
TIER 01 GENERIC tobramycinPA
demeclocycline HCL Tobi Podhaler
doxycycline TIER 03 NON PREFERRED
doxycycline hyclate BethkisPA
doxycycline monohydrate Gentamicin Sulfate/0.9% Sodium Chloride
minocycline HCL Streptomycin Sulfate
Morgidox 1X100MG TobiPA
Morgidox 2X100MG Tobramycin Sulfate/Sodium Chloride
Tetracycline HCL
TIER 03 NON PREFERRED SULFONAMIDES
Acticlate TIER 01 GENERIC
Adoxa Sulfadiazine
Adoxa PAK 1/100
Adoxa PAK 1/150 ANTIMYCOBACTERIAL AGENTS
Adoxa PAK 2/100 TIER 01 GENERIC
Alodox Convenience Kit ethambutol HCL
Avidoxy DK isoniazid
Dynacin pyrazinamide
Minocin rifampin
Minocin Kit Cycloserine
Monodox Isoniazid
Nutridox TIER 02 PREFERRED
Ocudox rifabutin
Oraxyl TIER 03 NON PREFERRED
Vibramycin Capastat Sulfate
TIER 04 100% COPAY Myambutol
doxycycline hyclate DR Mycobutin
minocycline HCL ER Paser
Doryx Priftin
Nicazeldoxy 30 Kit Rifadin
Nicazeldoxy 60 Kit Rifamate
Solodyn Rifater
Seromycin
QUINOLONES Sirturo
TIER 01 GENERIC Trecator
ciprofloxacin
ciprofloxacin ER ANTIFUNGALS
ciprofloxacin HCL TIER 01 GENERIC
ciprofloxacin I.V.-IN D5W fluconazole
levofloxacin fluconazole IN dextrose
levofloxacin IN D5W fluconazole IN NACL
moxifloxacin HCL griseofulvin microsize
ofloxacin griseofulvin ultramicrosize
TIER 02 PREFERRED itraconazole
Noroxin ketoconazole
TIER 03 NON PREFERRED nystatin
Avelox terbinafine HCL
Avelox Abc Pack voriconazole
Cipro Amphotericin B
Cipro I.V.-IN D5W Fluconazole IN NACL
Cipro XR TIER 02 PREFERRED
Factive flucytosine
Levaquin Noxafil
Ofloxacin TIER 03 NON PREFERRED
Abelcet
AMINOGLYCOSIDES Ambisome
TIER 01 GENERIC Amphotec
amikacin sulfate Ancobon
gentamicin sulfate Cancidas
gentamicin sulfate pediatric Diflucan
gentamicin sulfate/sodium chloride Eraxis
gentamicin sulfate/0.9% sodium chloride Grifulvin V
isotonic gentamicin Gris-peg
neomycin sulfate Lamisil
paromomycin sulfate Mycamine
tobramycin sulfate Onmel
Isotonic Gentamicin Sporanox
TIER 02 Sporanox Pulsepak
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 2Terbinex Famvir
Vfend Flumadine
Vfend IV Foscavir
HepseraPA
ANTIVIRALS IncivekPA
TIER 01 GENERIC InfergenPA
abacavir Moderiba
abacavir sulfate/lamivudine/zidovudine Moderiba 1200 Dose Pack
acyclovir Moderiba 800 Dose Pack
acyclovir sodium OlysioPA
cidofovir Rebetol
didanosine Retrovir
famciclovir Retrovir IV Infusion
ganciclovir Ribatab
lamivudine/zidovudine Rimantalist
nevirapine Sitavig
nevirapine ER SovaldiPA
ribavirin Stribild
rimantadine HCL Trizivir
stavudine TyzekaPA
valacyclovir HCL Valtrex
zidovudine VictrelisPA
Acyclovir Sodium Videx EC
Foscarnet Sodium Viramune
Nevirapine Viramune XR
Ribasphere Virazole
Ribasphere Ribapak Vistide
TIER 02 PREFERRED Zerit
adefovir dipivoxilPA Ziagen
lamivudine Zovirax
Aptivus
Atripla ANTIMALARIALS
BaracludePA TIER 01 GENERIC
Complera atovaquone/proguanil HCL
Crixivan chloroquine phosphate
Emtriva hydroxychloroquine sulfate
Epzicom mefloquine HCL
FuzeonPA quinine sulfate
Intelence TIER 02 PREFERRED
Invirase Daraprim
Isentress Primaquine Phosphate
Kaletra TIER 03 NON PREFERRED
Lexiva Aralen
Norvir Coartem
Peg-intronPA Malarone
Peg-intron RedipenPA Plaquenil
Peg-intron Redipen PAK 4PA Qualaquin
PegasysPA
Pegasys ProclickPA AMEBICIDES
Prezista TIER 02 PREFERRED
Relenza Diskhaler Yodoxin
Rescriptor
Reyataz ANTHELMINTICS
SelzentryPA TIER 02 PREFERRED
Sustiva Albenza
Tamiflu Biltricide
Tivicay Stromectol
TruvadaPA
Valcyte MISC. ANTI-INFECTIVES
Videx Pediatric GENERIC
TIER 01
Viracept aztreonam
Viread bacitracin
TIER 03 NON PREFERRED clindamycin palmitate HCL
Combivir clindamycin phosphate
Copegus clindamycin phosphate add-vantage
Cytovene clindamycin phosphate pharmacy bulk package
Edurant clindamycin phosphate IN D5W
Epivir clindamycin HCL
Epivir HBV colistimethate sodium
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 3imipenem/cilastatin Cisplatin
meropenem Cyclophosphamide
metronidazole Ifosfamide
metronidazole IN NACL 0.79% TIER 02 PREFERRED
polymyxin b sulfate Alkeran
sulfamethoxazole/trimethoprim Hexalen
sulfamethoxazole/trimethoprim DS Leukeran
tinidazole Lomustine
trimethoprim MyleranPA
vancomycin HCL Treanda
Chloramphenicol Sodium Succinate ValchlorPA
Dapsone TIER 03 NON PREFERRED
Metro IV Bicnu
Sulfamethoxazole/Trimethoprim Busulfex
Vancomycin HCL Ceenu
TIER 02 PREFERRED Eloxatin
atovaquone Gliadel Wafer
Alinia Ifex
Nebupent Mustargen
Zyvox TemodarPA
TIER 03 NON PREFERRED Zanosar
Azactam
Azactam IN Iso-osmotic Dextrose ANTIBIOTICS
Bacitracin TIER 01 GENERIC
Bactrim bleomycin sulfate
Bactrim DS daunorubicin HCL
CaystonPA doxorubicin HCL
Cleocin doxorubicin HCL liposome
Cleocin IN D5W epirubicin HCL
Cleocin Pediatric Granules idarubicin HCL
Cleocin Phosphate mitomycin
Clindamycin Phosphate mitoxantrone HCLPA
Coly-mycin M Adriamycin
Cubicin Epirubicin HCL
Dalvance TIER 03 NON PREFERRED
Doribax Cosmegen
First-vancomycin 25 Daunoxome
First-vancomycin 50 Doxil
Flagyl Ellence
Flagyl ER Idamycin PFS
Invanz
Ketek ANTINEOPLASTIC ENZYMES
Lincocin TIER 03 NON PREFERRED
Mepron Elspar
Merrem ErwinazePA
Neutrexin Oncaspar
Pentam 300
Primaxin IV ANTIMETABOLITES
Primaxin IV Add-vantage GENERIC
TIER 01
Primsol azacitidinePA
Sivextro cladribine
Synercid cytarabine
Tindamax cytarabine aqueous
Tygacil decitabinePA
Vancocin HCL floxuridine
Vancomycin HCL IN Dextrose fludarabine phosphate
Vibativ fluorouracil
Xifaxan gemcitabine HCL
mercaptopurine
ANTINEOPLASTICS, ETC methotrexate
ALKYLATING AGENTS methotrexate sodium
TIER 01 GENERIC Cytarabine
carboplatin Fludarabine Phosphate
cisplatin Gemcitabine
ifosfamide TIER 02 PREFERRED
melphalan hydrochloride capecitabinePA
oxaliplatin Folotyn
temozolomidePA Trexall
Carboplatin TIER 03
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 4NON PREFERRED Trelstar MixjectPA
Alimta ZytigaPA
Arranon
Clolar IMMUNOMODULATORS
DacogenPA TIER 01 GENERIC
Fludara azathioprine
Gemzar cyclosporine
Purinethol cyclosporine modified
Purixan mycophenolate mofetil
Tabloid mycophenolic acid DR
VidazaPA sirolimus
XelodaPA tacrolimus
Cyclosporine Modified
ANGIOGENESIS INHIBITORS TIER 02 PREFERRED
TIER 02 PREFERRED Atgam
Avastin Azasan
CyramzaPA Neoral
ZaltrapPA PomalystPA
Rapamune
ANTIBODIES RevlimidPA
TIER 02 PREFERRED Sandimmune
Erbitux ThalomidPA
GazyvaPA Thymoglobulin
HerceptinPA TIER 03 NON PREFERRED
KadcylaPA Astagraf XL
RituxanPA Cellcept
TIER 03 NON PREFERRED Cellcept Intravenous
AdcetrisPA Imuran
ArzerraPA Myfortic
Bexxar NulojixPA
PerjetaPA Prograf
Vectibix Simulect
YervoyPA ZortressPA
Zevalin Y-90
MITOTIC INHIBITORS
HORMONAL AGENTS TIER 01 GENERIC
TIER 01 GENERIC etoposide
anastrozole paclitaxel
bicalutamide vincristine sulfate
exemestane vinorelbine tartrate
flutamide Etoposide
letrozole Paclitaxel
leuprolide acetatePA Vinblastine Sulfate
megestrol acetate TIER 02 PREFERRED
tamoxifen citrate Ixempra Kit
TIER 02 PREFERRED JevtanaPA
Depo-provera TIER 03 NON PREFERRED
Emcyt Abraxane
FirmagonPA Docefrez
Lupron DepotPA Docetaxel
Lysodren Etopophos
VantasPA HalavenPA
XtandiPA Marqibo
ZoladexPA Navelbine
TIER 03 NON PREFERRED Taxotere
Arimidex Teniposide
Aromasin Vumon
Casodex
EligardPA ENZYME INHIBITORS
Fareston TIER 02 PREFERRED
Faslodex AfinitorPA
Femara Afinitor DisperzPA
Megace Oral BosulifPA
Nilandron GleevecPA
Soltamox JakafiPA
Trelstar DepotPA MekinistPA
Trelstar Depot MixjectPA NexavarPA
Trelstar LAPA SprycelPA
Trelstar LA MixjectPA SutentPA
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 5TafinlarPA GENERIC
TarcevaPA amifostine
TasignaPA dexrazoxane
Torisel leucovorin calcium
TykerbPA mesna
VelcadePA Calcium Folinate
VotrientPA Leucovorin Calcium
XalkoriPA TIER 03 NON PREFERRED
ZelborafPA Ethyol
TIER 03 NON PREFERRED Fusilev
Beleodaq Mesnex
CaprelsaPA Totect
CometriqPA Zinecard
GilotrifPA TIER 04 100% COPAY
IclusigPA Voraxaze
IstodaxPA
KyprolisPA CHEMOTHERAPY ADJUNCTS
StivargaPA TIER 02 PREFERRED
ZolinzaPA Kepivance
Zydelig TIER 03 NON PREFERRED
ZykadiaPA Elitek
TOPOISOMERASE I INHIBITOR ANTINEOPLASTIC COMBO
TIER 01 GENERIC TIER 01 GENERIC
irinotecan Ifosfamide/Mesna
topotecan HCL
Topotecan HCL CARDIOVASCULAR DRUGS
TIER 03 NON PREFERRED
PHOSPHODIESTERASE INHBTR
Camptosar GENERIC
TIER 01
Hycamtin milrinone lactate
Irinotecan
milrinone IN dextrose
RADIOPHARMACEUTICALS CARDIAC GLYCOSIDES
TIER 03 NON PREFERRED GENERIC
TIER 01
Bexxar 131 Iodine digoxin
Metastron
Digoxin
Quadramet NON PREFERRED
TIER 03
TIER 04 100% COPAY Lanoxin
Xofigo
Lanoxin Pediatric
CELLULAR IMMUNOTHERAPY ANTIANGINAL AGENTS
TIER 03 NON PREFERRED VALUE BASED BENEFIT
TIER 00
Provenge Nitrostat
TIER 01 GENERIC
ANTINEOPLASTICS MISC. isosorbide dinitrate
TIER 01 GENERIC isosorbide dinitrate ER
dacarbazine isosorbide mononitrate
hydroxyurea isosorbide mononitrate ER
tretinoin nitroglycerin
Dacarbazine nitroglycerin lingual
TIER 02 PREFERRED nitroglycerin transdermal
Actimmune nitroglycerin IN dextrose 5%
Intron-aPA nitroglycerin IN 5% dextrose
Intron-a W/DiluentPA Isosorbide Dinitrate
Matulane Nitroglycerin
Proleukin Nitroglycerin IN Dextrose 5%
SynriboPA Nitroglycerin Lingual
TIER 03 NON PREFERRED PREFERRED
TIER 02
Alferon N Dilatrate SR
Hydrea RanexaPA
Nipent NON PREFERRED
TIER 03
Photofrin Imdur
SylatronPA Isordil Titradose
TargretinPA Nitro-bid
Trisenox Nitro-dur
Uvadex Nitrolingual Pumpspray
Nitromist
CHEMOTHERAPY RESCUE Nitronal
TIER 01
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 6BETA BLOCKERS Calan
TIER 00 VALUE BASED BENEFIT Calan SR
carvedilol Cardene I.v.
TIER 01 GENERIC Cardene IV
acebutolol HCL Cardene SR
atenolol Cardizem
betaxolol HCL Cardizem CD
bisoprolol fumarate Cleviprex
esmolol HCL Dilacor XR
labetalol HCL Hypertenipine-2.5
metoprolol succinate ER Isoptin SR
metoprolol tartrate Norvasc
nadolol Nymalize
pindolol Procardia
propranolol HCL Procardia XL
propranolol HCL ER Sular
sotalol HCL Tiazac
sotalol HCL (AF) Verelan
Propranolol HCL Verelan PM
Timolol Maleate
TIER 02 PREFERRED ANTIARRHYTHMICS
Coreg CR TIER 01 GENERIC
TIER 03 NON PREFERRED adenosine
Betapace amiodarone HCL
Betapace AF disopyramide phosphate
Brevibloc flecainide acetate
Bystolic ibutilide fumarate
Coreg lidocaine HCL
Corgard lidocaine HCL IN D5W
Hemangeol lidocaine HCL/dextrose
Hypertenevide-12.5 mexiletine HCL
Inderal LA propafenone HCL
Inderal XL propafenone HCL ER
Innopran XL quinidine gluconate CR
Kerlone quinidine gluconate ER
Levatol quinidine sulfate
Lopressor Amiodarone HCL
Sectral Lidocaine HCL
Sotalol Hydrochloride Procainamide HCL
Tenormin Quinidine Sulfate ER
Toprol XL TIER 02 PREFERRED
Trandate Tikosyn
Zebeta TIER 03 NON PREFERRED
Adenocard
CALCIUM CHANNEL BLOCKERS Cordarone
TIER 00 VALUE BASED BENEFIT Corvert
amlodipine besylate Multaq
diltiazem HCL Nexterone
verapamil HCL Norpace
TIER 01 GENERIC Norpace CR
diltiazem CD Quinidine Gluconate
diltiazem HCL ER Quinidine Sulfate
felodipine ER Rythmol
nicardipine HCL Rythmol SR
nifedipine Tambocor
nifedipine ER Xylocaine
nimodipine
nisoldipine ACE INHIBITORS
verapamil HCL ER TIER 00 VALUE BASED BENEFIT
verapamil HCL SR benazepril HCL
Diltiazem HCL captopril
Isradipine enalapril maleate
Nisoldipine fosinopril sodium
Nisoldipine ER lisinopril
Verapamil HCL moexipril HCL
TIER 02 PREFERRED perindopril erbumine
Cardizem LA quinapril HCL
TIER 03 NON PREFERRED ramipril
Adalat CC trandolapril
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 7TIER 01 GENERIC ANTIHYPERTENSIVE COMBO
enalaprilat TIER 00 VALUE BASED BENEFIT
TIER 03 NON PREFERRED benazepril HCL/hydrochlorothiazide
Accupril enalapril maleate/hydrochlorothiazide
Aceon lisinopril/hydrochlorothiazide
Altace losartan potassium/hydrochlorothiazide
Epaned Captopril/Hydrochlorothiazide
Lotensin TIER 01 GENERIC
Mavik amlodipine besylate/benazepril hydrochloride
Prinivil amlodipine besylate/benazepril HCL
Univasc atenolol/chlorthalidone
Vasotec bisoprolol fumarate/hydrochlorothiazide
Zestril candesartan cilexetil/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
ANGIOTENSIN RCPTR BLOCKER irbesartan/hydrochlorothiazide
TIER 00 VALUE BASED BENEFIT metoprolol/hydrochlorothiazide
losartan potassium moexipril/hydrochlorothiazide
TIER 01 GENERIC nadolol/bendroflumethiazide
candesartan cilexetil quinapril/hydrochlorothiazide
eprosartan mesylate telmisartan/amlodipine
irbesartan telmisartan/hydrochloroth
telmisartan telmisartan/hydrochlorothiazide
valsartan valsartan/hydrochlorothiazide
TIER 03 NON PREFERRED Clorpres
AtacandST Methyldopa/Hydrochlorothiazide
AvaproST Propranolol/Hydrochlorothiazide
BenicarST TIER 03 NON PREFERRED
CozaarST Accuretic
DiovanST Atacand HCTST
Edarbi AvalideST
MicardisST AzorST
TevetenST Benicar HCTST
Corzide
DIRECT RENIN INHIBITORS Diovan HCTST
TIER 03 NON PREFERRED Dutoprol
TekturnaST ExforgeST
Exforge HCTST
ANTIHYPERTENSIVES MISC. Hypertensolol
TIER 01 GENERIC HyzaarST
clonidine HCL Lopressor HCT
doxazosin mesylate Lotensin HCT
eplerenone Lotrel
fenoldopam mesylate Lytensopril Kit
guanfacine HCL Lytensopril-90
hydralazine HCL Lytensopril-90 Kit
methyldopa Micardis HCTST
minoxidil Tarka
prazosin HCL Tekturna HCTST
terazosin HCL Tenoretic 100
Methyldopate HCL Tenoretic 50
Nitropress Teveten HCTST
Phentolamine Mesylate Twynsta
Reserpine Uniretic
TIER 02 PREFERRED Vaseretic
Demser Zestoretic
Dibenzyline Ziac
TIER 03 NON PREFERRED TIER 04 100% COPAY
Cardura Amturnide
Catapres Edarbyclor
Catapres-tts-1 Tekamlo
Catapres-tts-2 Tribenzor
Catapres-tts-3
Corlopam DIURETICS
Inspra TIER 00 VALUE BASED BENEFIT
Minipress hydrochlorothiazide
Tenex Chlorthalidone
Vecamyl TIER 01 GENERIC
acetazolamide
acetazolamide sodium
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 8acetazolamide ER VALUE BASED BENEFIT
amiloride HCL atorvastatin calcium
amiloride/hydrochlorothiazide lovastatin
bumetanide pravastatin sodium
chlorothiazide simvastatin
chlorothiazide sodium TIER 01 GENERIC
furosemide cholestyramine
indapamide cholestyramine light
mannitol colestipol HCL
methazolamide colestipol HCL for oral suspension
metolazone fenofibrate
spironolactone fenofibrate micronized
spironolactone/hydrochlorothiazide fluvastatin
torsemide gemfibrozil
triamterene/hydrochlorothiazide niacin ER
Acetazolamide Fenofibric AcidST
Furosemide TIER 02 PREFERRED
Methyclothiazide omega-3-acid ethyl esters
Torsemide JuxtapidPA
TIER 03 NON PREFERRED KynamroPA
Aldactazide Welchol
Aldactone Zetia
Chlorothiazide TIER 03 NON PREFERRED
Demadex Advicor
Diamox AltoprevST
Diuril Colestid
Dyazide Colestid Flavored
Dyrenium CrestorST
Edecrin Fenofibrate
Introl FibricorST
Lasix Lescol
Maxzide Lescol XLST
Maxzide-25 Lipitor
Microzide LivaloST
Neptazane Lopid
Sodium Diuril Lovaza
Sodium Edecrin Mevacor
Triamterene/Hydrochlorothiazide Niacor
Zaroxolyn Niaspan
Pravachol
VASOPRESSORS Questran
TIER 01 GENERIC Questran Light
dobutamine HCL Simcor
dobutamine HCL/D5W Zocor
dobutamine/dextrose 5% TIER 04 100% COPAY
dopamine HCL fenofibric acid DR
dopamine HCL-dextrose 5% AntaraST
dopamine HCL/dextrose 5% FenoglideST
dopamine/D5W Lipofen
ephedrine sulfate Lofibra
midodrine HCL Tricor
norepinephrine bitartrate TriglideST
phenylephrine HCL Trilipix
Adrenaclick Vytorin
Auvi-q
Dopamine HCL CARDIOVASCULAR - MISC.
Epinephrine TIER 01 GENERIC
Epipen 2-PAK amlodipine besylate/atorvastatin calcium
Epipen-JR 2-PAK epoprostenol sodium
TIER 03 NON PREFERRED papaverine HCL
Adrenalin VeletriPA
Dobutamine/Dextrose 5% TIER 02 PREFERRED
Levophed sildenafilPA
Neo-synephrine sildenafil citratePA
Northera AdempasPA
Phenylephrine HCL Bidil
Cialis
ANTIHYPERLIPIDEMICS FlolanPA
TIER 00 LetairisPA
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 9Muse Nuox
RemodulinPA Plexion
RevatioPA Plexion Cleanser
TracleerPA Plexion Cleansing Cloths
VentavisPA Retin-aPA
Viagra Retin-a MicroPA
TIER 03 NON PREFERRED Retin-a Micro P.M.PA
AdcircaPA Rosanil
Caduet Sulfoam
Levitra Sumadan Wash
Natrecor Sumadan XLT
OrenitramPA Sumaxin
Staxyn Sumaxin CP Kit
Stendra Sumaxin Ts
TyvasoPA Sumaxin Wash
Tyvaso RefillPA Tretin-xPA
Tyvaso StarterPA VeltinPA
TIER 04 100% COPAY ZianaPA
OpsumitPA TIER 04 100% COPAY
Benzaclin With P.M.
DERMATOLOGICALS EpiduoPA
ACNE PRODUCTS Sumadan Kit
TIER 01 GENERIC
adapalenePA ROSACEA AGENTS
clindamycin phosphate TIER 01 GENERIC
clindamycin/benzoyl peroxide metronidazole
erythromycin TIER 02 PREFERRED
erythromycin/benzoyl peroxide Finacea
sodium sulfacetamide Oracea
sodium sulfacetamide/sulfur TIER 03 NON PREFERRED
sodium sulfacetamide/sulfur cleanser Metrocream
sodium sulfacetamide/sulfur cleansing cloths Metrogel
sodium sulfacetamide/sulfur green Metrolotion
sodium sulfacetamide/sulfur wash Noritate
sulfacetamide sodium Rosadan Kit
sulfacetamide sodium/sulfur cleanser
tretinoinPA ANTIBIOTICS - TOPICAL
tretinoin microspherePA TIER 01 GENERIC
tretinoin microsphere P.M.PA mupirocin
Claravis mupirocin calcium
Clindacin PAC Gentamicin Sulfate
Sodium Sulfacetamide/Sulfur TIER 03 NON PREFERRED
Sodium Sulfacetamide/Sulfur Cleanser IN Urea Altabax
Sodium Sulfacetamide/Sulfur IN Urea Bactroban
TIER 03 NON PREFERRED Centany
Absorica Centany AT
Acanya Cortisporin
Aczone Neo-synalar
Akne-mycin Neo-synalar Kit
AtralinPA
Avar ANTIFUNGALS - TOPICAL
Avar LS TIER 01 GENERIC
Avar LS Cleanser ciclopirox
Avar-e LS ciclopirox nail lacquer
Azelex ciclopirox olamine
Benzaclin clotrimazole
Benzamycin clotrimazole/betamethasone dipropionate
Benzamycinpak econazole nitrate
Clarifoam EF ketoconazole
Cleocin-t nystatin
Clindacin Etz nystatin/triamcinolone
Clindagel Ciclodan Solution Kit
DifferinPA Ciclopirox Topical Solution Kit
Duac TIER 02 PREFERRED
Erygel Ertaczo
Evoclin Mentax
Fabior TIER 03 NON PREFERRED
Klaron Cnl8 Nail Kit
Neuac Kit Exelderm
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 10Extina 8-mop
Halotin TIER 04 100% COPAY
Jublia Sorilux
Lamisil Spray
Loprox ANTISEBORRHEIC AGENTS
Loprox Shampoo TIER 01 GENERIC
Lotrisone selenium sulfide
Luzu sodium sulfacetamide
Naftin sodium sulfacetamide wash
Nizoral Seb-prev
Oxistat Selenium Sulfide
Pediaderm AF Complete Kit Sodium Sulfacetamide/Urea
Pedipirox-4 Nail TIER 03 NON PREFERRED
Penlac Nail Lacquer Glycolic Acid
Vusion Glycolic Acid 70% High Purity
Xolegel Ovace Plus
Xolegel Corepak Ovace Plus Wash
Xolegel Duo/Head & Shoulders Ovace Wash
Xolegel Duo/Xolex Promiseb
TIER 04 100% COPAY Selrx
Ciclodan Cream Kit Selsun Shampoo
Ecoza Tersi Foam
Ketodan Kit TL Triseb
TIER 04 100% COPAY
ANTIVIRALS - TOPICAL Promiseb Complete
TIER 02 PREFERRED
acyclovir CORTICOSTEROIDS - TOPICAL
TIER 03 NON PREFERRED TIER 01 GENERIC
Denavir alclometasone dipropionate
Xerese amcinonide
Zovirax augmented betamethasone dipropionate
TIER 04 100% COPAY betamethasone dipropionate
Lidovir betamethasone valerate
clobetasol propionate
ANTI-INFLAMMATORY AGENTS clobetasol propionate emollient
TIER 01 GENERIC desonide
diclofenac sodium desoximetasone
TIER 03 NON PREFERRED diflorasone diacetate
Flector fluocinolone acetonide
Lidoprofen fluocinonide
Pennsaid fluocinonide emollient base
Voltaren fluocinonide-e
Vopac fluticasone propionate
Vopac GB halobetasol propionate
Vopac Kt hydrocortisone
hydrocortisone acetate/aloe
ANTIPRURITICS hydrocortisone butyrate
TIER 01 GENERIC hydrocortisone valerate
Prudoxin hydrocortisone IN absorbase
TIER 03 NON PREFERRED mometasone furoate
Zonalon prednicarbate
triamcinolone acetonide
ANTIPSORIATICS Amcinonide
TIER 01 GENERIC Apexicon E
calcipotriene Desoximetasone
Calcitriol Diflorasone Diacetate
TIER 02 PREFERRED Triamcinolone Acetonide
acitretin Trianex
methoxsalen U-cort
StelaraPA TIER 02 PREFERRED
TIER 03 NON PREFERRED hydrocortisone butyrate (lipid)
Dovonex hydrocortisone butyrate (lipophilic)
Dritho-creme HP Capex
Oxsoralen Ultra Cordran Tape
Soriatane TIER 03 NON PREFERRED
Tazorac Aclovate
Vectical Ala Scalp
Zithranol Carmol-HC
Zithranol-rr Clobex
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 11Clodan Kit lactic acid e
Cordran lactic acid w/vitamin e
Cutivate lidocaine
Derma-smoothe/FS Body lidocaine HCL
Derma-smoothe/FS Body Oil lidocaine HCL jelly
Derma-smoothe/FS Scalp lidocaine/prilocaine
Derma-smoothe/FS Scalp Oil lindane
Dermasorb HC malathion
Dermasorb Ta permethrin
Dermatop podofilox
Desonate salicylic acid
Desowen sodium hyaluronate
Desowen Cream/Cetaphil Lotion urea
Desowen Lotion/Cetaphil Cream urea topical
Desowen Ointment/Cetaphil Lotion urea IN zinc undecylenate/lactic acid vehicle
Diprolene urea 40% nail film
Diprolene AF Aluminum Acetate
Elocon Benzoin Compound Tincture
Epifoam Cocaine HCL
First-hydrocortisone Ethyl Chloride/Fine Pinpoint
Halog Ethyl Chloride/Fine Stream
Halonate Ethyl Chloride/Medium Jet Stream
Kenalog Ethyl Chloride/Medium Stream
Locoid Ethyl Chloride/Mist
Locoid Lipocream Hylira
Luxiq Latrix XM
Nucort Lidocaine HCL
Nuzon Lidocaine/Prilocaine
Olux Mb Hydrogel
Olux-e Pr Cream
Pandel Pruclair
Pediaderm HC Prumyx
Pediaderm Ta Salicylic Acid
Pramosone Salicylic Acid IN Ammonium Lactate Vehicle
Scalacort DK TL-cermide
Synalar TIER 02 PREFERRED
Temovate Condylox
Temovate E Eurax
Texacort Oxsoralen
Topicort TIER 03 NON PREFERRED
Ultravate Aluvea
Ultravate PAC Anacaine
Vanos Arnica Flower
Verdeso Atopiclair
Westcort Aurstat
TIER 04 100% COPAY Aurstat Anti-itch Hydrogel
calcipotriene/betamethasone dipropionate Aurstat Anti-itch Hydrogel Kit
Synalar Cream Kit Benzoin Tincture
Synalar Ointment Kit Boric Acid
Synalar Ts Cem-urea
Taclonex Coal TAR
Ultravate X Dermasorb XM
Drysol
IMMUNOMODULATING AGENTS Elenzapatch
TIER 01 GENERIC Eletone
imiquimod Eletone Twinpack
TIER 02 PREFERRED Elimite
ElidelPA Emla
ProtopicPA Emulsion SB
TIER 03 NON PREFERRED Epiceram
Aldara Ethyl Chloride
Zyclara Gebauers Pain Ease
Zyclara P.M. Gebauers Spray And Stretch
Genadur
DERMATOLOGICALS - MISC. Gordofilm
TIER 01 GENERIC Gordons Urea
ammonium lactate Hydro 35
episone CRE Hydro 40 Foam
lactic acid Kerafoam
Kerafoam 42
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 12Keralac TIER 03 NON PREFERRED
Lac-hydrin A-hydrocort
Lidoderm Aristospan Intra-articular
Lycelle Aristospan Intralesional
Natroba Celestone
Neosalus Celestone-soluspan
Neosalus CP Cortef
Nivatopic Plus Depo-medrol
Ovide Dexamethasone Sodium Phosphate
Pliaglis Dexpak 10 Day
Presera Dexpak 13 Day
Pyrogallic Acid Dexpak 6 Day
Qutenza Entocort EC
Radigel FLO-pred
Salkera Interarticular Joint Kit
Salvax Duo Plus Kenalog-10
Sklice Kenalog-40
Spinosad Medrol
Sulfurated Lime Medrol Dosepak
Synera Millipred
Tetrix Millipred DP
Tropazone Orapred
Ulesfia Orapred Odt
Umecta Pediapred
Umecta Nail Film Prelone
Umecta PD Rayos
Uramaxin Solu-cortef
Uramaxin GT Solu-medrol
Uramaxin GT Kit Uceris
Utopic Veripred 20
Veregen
Vexa ANDROGENS-ANABOLIC
Witch Hazel TIER 01 GENERIC
Xclair danazol
Xerac Ac oxandrolonePA
Xylocaine testosterone cypionatePA
TIER 04 100% COPAY testosterone enanthatePA
Hylatopic AndroxyPA
Hylatopic Plus TIER 02 PREFERRED
HPR AndrodermPA
HPR Plus AndrogelPA
HPR Plus/Mb Hydrogel Androgel P.M.PA
Nuvail TIER 03 NON PREFERRED
Ultrasal-ER Anadrol-50PA
Virasal AndroidPA
Aveed
ENDOCRINE AND METABOLIC AxironPA
CORTICOSTEROIDS Depo-testosteronePA
TIER 01 GENERIC First-testosterone
betamethasone sodium phosphate/betamethasone First-testosterone Mc Compounding KitPA
acetate FortestaPA
budesonide OxandrinPA
dexamethasone StriantPA
dexamethasone sodium phosphate TestimPA
fludrocortisone acetate Testopel
hydrocortisone TestosteronePA
methylprednisolone Testosterone P.M.PA
methylprednisolone acetate TestredPA
methylprednisolone dose pack VogelxoPA
methylprednisolone sodiumsuccinate Vogelxo P.M.PA
prednisolone
prednisolone sodium phosphate ESTROGENS
prednisone TIER 01 GENERIC
Cortisone Acetate estradiol
Dexamethasone estradiol valerate
Dexamethasone Intensol estradiol/norethindrone acetate
Prednisolone Sodium Phosphate estropipate
Prednisone Estropipate
Prednisone Intensol Jinteli
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 13TIER 02 PREFERRED Nordette-28
Cenestin Norinyl 1+50
Climara Ortho Micronor
Combipatch Ortho Tri-cyclen
Divigel Ortho-cept
Enjuvia Ortho-cyclen
Evamist Ortho-novum 1/35
Premphase Ovcon-35
Prempro Plan B
Vivelle-dot Plan B One-step
TIER 03 NON PREFERRED Quartette
Activella Tri-norinyl 28
Alora Yasmin 28
Angeliq Yaz
Climara Pro TIER 04 100% COPAY
Delestrogen Cyclessa
Depo-estradiol Femcon FE
Duavee Loestrin FE 1.5/30
Elestrin Loestrin FE 1/20
Estrace Loestrin 24 FE
Estrasorb Minastrin 24 FE
Estrogel Seasonique
Femhrt Low Dose
Menest PROGESTINS
Menostar TIER 00 GENERIC
Minivelle medroxyprogesterone acetate
Prefest TIER 01 GENERIC
Premarin norethindrone acetate
progesterone
CONTRACEPTIVES TIER 03 NON PREFERRED
TIER 00 GENERIC Aygestin
drospirenone/ethinyl estradiol MakenaPA
levonorgestrel and ethinyl estradiol Megace ES
levonorgestrel/ethinyl estradiol Prometrium
norethindrone Provera
norgestimate/ethinyl estradiol
Amethyst ANTIDIABETIC AGENTS
Beyaz INSULIN
Generess FE TIER 00 VALUE BASED BENEFIT
Loseasonique Humalog
Natazia Humalog Mix 50/50
Necon 1/50-28 Humalog Mix 75/25
Necon 10/11-28 Humulin R U-500 (concentrated)
Norinyl 1+35 Lantus
Ogestrel Levemir
Ortho Tri-cyclen LO Novolog
Ortho-novum 7/7/7 Novolog Mix 70/30
Safyral TIER 02 PREFERRED
Zovia 1/50e Apidra
TIER 01 GENERIC Apidra Solostar
desogestrel/ethinyl estradiol Humalog Kwikpen
levonorgestrel Humalog Mix 50/50 Kwikpen
norethindrone acetate/ethinyl estradiol Humalog Mix 75/25 Kwikpen
norethindrone acetate/ethinyl estradiol/ferrous fumarate Lantus Solostar
Brevicon-28 Levemir Flexpen
TIER 02 PREFERRED Novolog Flexpen
Desogen Novolog Mix 70/30 Prefilled Flexpen
TIER 03 NON PREFERRED Novolog Penfill
Ella TIER 03 NON PREFERRED
Estrostep FE Levemir Flextouch
Falessa AMYLIN ANALOGS
Loestrin 1.5/30-21 TIER 02 PREFERRED
Loestrin 1/20-21 Symlinpen 120PA
Lomedia 24 FE Symlinpen 60PA
LO Loestrin FE INCRETIN MIMETIC AGENTS
LO Minastrin FE TIER 02 PREFERRED
Mircette ByettaPA
Modicon TIER 03 NON PREFERRED
Nor-QD Bydureon
Tanzeum
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 14VictozaPA TIER 01 GENERIC
SULFONYLUREAS glipizide/metformin HCL
TIER 00 VALUE BASED BENEFIT pioglitazone HCL/metformin HCL
glimepiride TIER 02 PREFERRED
glipizide pioglitazone HCL-glimepiride
glipizide ER TIER 03 NON PREFERRED
glyburide Actoplus Met
glyburide micronized Actoplus Met XR
Glyburide Appformin
TIER 01 GENERIC Appformin-d
tolazamide Duetact
Chlorpropamide Glucovance
Tolazamide Invokamet
Tolbutamide Janumet
TIER 03 NON PREFERRED Janumet XR
Amaryl Juvisync
Diabeta Kombiglyze XR
Glucotrol Prandimet
Glucotrol XL TIER 04 100% COPAY
Glynase Avandamet
BIGUANIDES Avandaryl
TIER 00 VALUE BASED BENEFIT Kazano
metformin HCL Oseni
metformin HCL ER
TIER 03 NON PREFERRED BISPHOSPHONATES
Fortamet TIER 01 GENERIC
Glucophage alendronate sodiumQL
Glucophage XR pamidronate disodium
Glumetza risedronate sodiumQL
Riomet Alendronate SodiumQL
MEGLITINIDE ANALOGUES Etidronate Disodium
TIER 01 GENERIC TIER 02 PREFERRED
nateglinide ActonelQL,ST
TIER 02 PREFERRED Zoledronic AcidPA
repaglinide TIER 03 NON PREFERRED
TIER 03 NON PREFERRED ibandronate sodiumQL
Prandin zoledronic acidPA
Starlix Didronel
DIABETIC OTHER FosamaxQL
TIER 02 PREFERRED Pamidronate Disodium
Glucagon Emergency Kit ReclastPA
Korlym ZometaPA
TIER 03 NON PREFERRED TIER 04 100% COPAY
Farxiga BinostoQL
Glucagen BonivaQL
Glucagen Hypokit
InvokanaPA CALCITONINS
Jardiance TIER 01 GENERIC
Proglycem calcitonin salmon
ALPHA-GLUCOSIDASE INHIBIT calcitonin-salmon
TIER 01 GENERIC TIER 03 NON PREFERRED
acarbose Fortical
TIER 03 NON PREFERRED Miacalcin
Glyset
Precose PARATHYROID HORMONE
DPP-4 INHIBITORS TIER 02 PREFERRED
TIER 03 NON PREFERRED Forteo
Januvia
Nesina
RANK LIGAND INHIBITORS
Onglyza NON PREFERRED
TIER 03
Tradjenta ProliaPA
INSULIN SENSITIZING AGENT XgevaPA
TIER 01 GENERIC
pioglitazone HCL
NON PREFERRED
CALCIUM REGULATORS - MISC
TIER 03 NON PREFERRED
Actos TIER 03
Ganite
Avandia
ANTIDIABETIC COMBINATIONS
TIER 00 VALUE BASED BENEFIT HORMONE RECEPTOR MDLTR
glyburide/metformin HCL TIER 02
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 15PREFERRED TIER 02 PREFERRED
raloxifene hydrochloride Sandostatin Lar DepotPA
TIER 03 NON PREFERRED Somatuline DepotPA
Evista TIER 03 NON PREFERRED
Osphena SandostatinPA
SigniforPA
FERTILITY REGULATORS
TIER 01 GENERIC GH RECEPTOR ANTAGONISTS
chorionic gonadotropin TIER 02 PREFERRED
clomiphene citrate SomavertPA
TIER 02 PREFERRED
Bravelle POSTERIOR PITUITARY
Gonal-f TIER 01 GENERIC
Gonal-f RFF desmopressin acetate
Gonal-f RFF Pen vasopressin
Ovidrel TIER 02 PREFERRED
Repronex Stimate
TIER 03 NON PREFERRED TIER 03 NON PREFERRED
Follistim AQ Ddavp
Gonal-f RFF Rediject Pitressin Synthetic
Menopur
CORTICOTROPIN
LHRH/GNRH AGONIST TIER 03 NON PREFERRED
TIER 02 PREFERRED Acthar HPPA
Lupron Depot-PEDPA
Supprelin LAPA PROLACTIN INHIBITORS
Synarel TIER 01 GENERIC
TIER 03 NON PREFERRED cabergoline
Lupaneta PackPA
VASOPRESSIN ANTAGONISTS
GNRH/LHRH ANTAGONISTS TIER 03 NON PREFERRED
TIER 02 PREFERRED Samsca
Cetrotide Vaprisol
TIER 03 NON PREFERRED
Ganirelix Acetate PROGESTERONE ANTAGONISTS
TIER 03 NON PREFERRED
GROWTH HORMONES Mifeprex
TIER 02 PREFERRED
GenotropinPA METABOLIC MODIFIERS
Genotropin MiniquickPA GENERIC
TIER 01
HumatropePA calcitriol
Humatrope Combo PackPA levocarnitine
TIER 03 NON PREFERRED PREFERRED
TIER 02
Norditropin CartridgePA doxercalciferol
Norditropin FlexproPA paricalcitol
Norditropin Nordiflex PenPA sodium phenylbutyrate
NutropinPA AldurazymePA
Nutropin AQ Nuspin 10PA Cystadane
Nutropin AQ Nuspin 20PA ElaprasePA
Nutropin AQ Nuspin 5PA FabrazymePA
Nutropin AQ PenPA KuvanPA
OmnitropePA MyaleptPA
SaizenPA NaglazymePA
Saizen Click.easyPA Orfadin
SerostimPA RavictiPA
Tev-tropinPA Sensipar
ZorbtivePA NON PREFERRED
TIER 03
Ammonul
GHRH Buphenyl
TIER 03 NON PREFERRED CarbagluPA
EgriftaPA Carnitor
Carnitor SF
SOMATOMEDINS Hectorol
TIER 03 NON PREFERRED LumizymePA
IncrelexPA MyozymePA
Rocaltrol
SOMATOSTATIC AGENTS VimizimPA
TIER 01 GENERIC Zemplar
octreotide acetatePA
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 16THYROID AGENTS ULCER DRUGS
TIER 01 GENERIC TIER 01 GENERIC
levothyroxine sodium atropine sulfate
liothyronine sodium cimetidine
methimazole cimetidine HCL
propylthiouracil dicyclomine HCL
Levothyroxine Sodium famotidine
TIER 03 NON PREFERRED glycopyrrolate
Armour Thyroid hyoscyamine sulfate
Cytomel hyoscyamine sulfate odt
Nature-throid hyoscyamine sulfate ER
Nature-throid Nt-2.5 hyoscyamine sulfate SR
Synthroid methscopolamine bromide
Tapazole misoprostol
Thyrolar-1 nizatidine
Thyrolar-1/2 ranitidine HCL
Thyrolar-1/4 sucralfate
Thyrolar-2 Anaspaz
Thyrolar-3 Belladonna & Opium
Tirosint Belladonna Alkaloids & Opium
Triostat Dicyclomine HCL
Westhroid Famotidine Premixed
Westhroid-p Propantheline Bromide
Wp Thyroid Scopolamine Hydrobromide
TIER 02 PREFERRED
GASTROINTESTINAL Pylera
LAXATIVES TIER 03 NON PREFERRED
GENERIC Atropen
TIER 01
lactulose Atropine Sulfate
peg 3350/electrolytes Axid
peg-3350/electrolytes Bentyl
peg-3350/NACL/NA bicarbonate/KCL Cantil
polyethylene glycol 3350 Carafate
NON PREFERRED Cuvposa
TIER 03
Cascara Sagrada Cytotec
Colyte-flavor Packs Digex NF
Golytely Famotidine
Halflytely Bowel Prep/Flavor Packs Gabitidine
Kristalose Gastrinex NF
Mineral Oil Heavy Glycate
Moviprep Helidac
Nulytely/Flavor Packs Levbid
Osmoprep Levsin
Prepopik Levsin/SL
Senna Leaves Pamine
Suclear Pamine Forte
Suprep Bowel Prep Pamine FQ
Pepcid
Robinul
ANTIDIARRHEALS
GENERIC Robinul Forte
TIER 01
diphenoxylate/atropine Sentradine
Symax Duotab
loperamide HCL
opium Zantac
opium tincture
Diphenoxylate/Atropine ANTIEMETICS
Opium Tincture (paregoric) TIER 01 GENERIC
PREFERRED dronabinol
TIER 02
Motofen granisetron HCLQL
NON PREFERRED meclizine HCL
TIER 03
FulyzaqPA ondansetron odtQL
Lomotil ondansetron HCLQL
Restora RX trimethobenzamide HCL
Rezyst IM Dimenhydrinate
Rezyst SB GranisolQL
Vsl#3 DS TIER 02 PREFERRED
AnzemetQL
DiclegisPA
ANTACIDS
EmendQL
TIER 03 NON PREFERRED
Transderm-scop
Sodium Bicarbonate
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 17TIER 03 NON PREFERRED Dipentum
Aloxi Entereg
Cesamet Gastrocrom
Marinol GattexPA
SancusoQL Giazo
Tigan Lialda
ZofranQL Lidocaine HCL-hydrocortisone Acetate With Aloe
Zofran OdtQL Linzess
TIER 04 100% COPAY Metozolv Odt
ZuplenzQL Phoslo
Phoslyra
DIGESTIVE AIDS Procort
TIER 02 PREFERRED Proctocort
Creon Reglan
Pancreaze Renvela
Pancrelipase Rowasa
Zenpep Sevelamer Carbonate
TIER 03 NON PREFERRED Sfrowasa
Pertzye Urso Forte
Sucraid Urso 250
Ultresa Velphoro
Viokace
GENITOURINARY
GASTROINTESTINAL - MISC. URINARY ANTI-INFECTIVES
TIER 01 GENERIC TIER 01 GENERIC
balsalazide disodium methenamine hippurate
calcium acetate methenamine mandelate
cromolyn sodium nitrofurantoin
hydrocort ene 100MG nitrofurantoin macrocrystals
hydrocortisone nitrofurantoin monohydrate
hydrocortisone acetate/lidocaine HCL nitrofurantoin monohydrate/macrocrystals
hydrocortisone acetate/pramoxine Methenamine Mandelate
lactulose Uretron D/S
lidocaine HCL/hydrocortisone acetate Urex
mesalamine Urogesic-blue
metoclopramide HCL TIER 03 NON PREFERRED
sulfasalazine Furadantin
ursodiol Hiprex
Dexpanthenol Macrobid
Eliphos Macrodantin
TIER 02 PREFERRED Monurol
Amitiza Prosed/DS
Anusol-HC Urelle
Apriso Uribel
Asacol Urimar-t
Asacol HD Uroqid #2
Canasa
CimziaPA URINARY ANTISPASMODICS
Cimzia Starter KitPA TIER 01 GENERIC
Cortifoam bethanechol chloride
Delzicol flavoxate HCL
EntyvioPA oxybutynin chloride
Fosrenol oxybutynin chloride ER
Lotronex tolterodine tartrate
Pentasa tolterodine tartrate ER
Proctofoam HC trospium chloride
RelistorPA trospium chloride ER
RemicadePA TIER 03 NON PREFERRED
Renagel Detrol
TIER 03 NON PREFERRED Detrol LA
Actigall Ditropan XL
Analpram Advanced Enablex
Analpram-HC Gelnique
Analpram-HC Singles Myrbetriq
Azulfidine Oxytrol
Azulfidine EN-TABS Sanctura
Chenodal Sanctura XR
Colazal Toviaz
Cortenema Urecholine
Effective August 2014
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits (higher quantity may require a PA) 18You can also read
