Covered Drugs
Transcrição
Covered Drugs
Anthem MediBlue Plus (HMO) 2016 Formulary (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on August 1, 2016. For more recent information or other questions, please contact Anthem MediBlue Plus (HMO) Customer Service at 1-888-346-0095 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30, or visit www.anthem.com. Y0114_16_24724_U_112 CMS Accepted 6/18/2016 54169MUSENMUB _112 H1394_003 Core_16293_CG6_v15_1609_1 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us” or “our,” it means Anthem Blue Cross and Blue Shield. When it refers to “plan” or “our plan,” it means Anthem MediBlue Plus (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of September 1, 2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January 1, 2017 and from time to time during the year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Effective Date September 1, 2016 2 Core_16293_CG6_v15_1609_1 What is the Anthem MediBlue Plus (HMO) formulary? How do I use the formulary? There are two ways to find your drug within the formulary: A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Medications.” If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Can the formulary (drug list) change? Alphabetical Listing Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the forumulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If you are not sure what category to look under, you should look for your drug in the Index that begins on page 60. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step-therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of September 1, 2016. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (nonmaintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. Effective Date September 1, 2016 Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 30 tablets per prescription for irbesartan 75mg tablets. This may be in addition to a standard one-month or three-month supply. 3 Core_16293_CG6_v15_1609_1 Step Therapy: In some cases, our plan requires you to first How do I request an exception to the try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Anthem MediBlue Plus (HMO)'s Drug A and Drug B both treat your medical condition, our formulary? plan may not cover Drug B unless you try Drug A first. If You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask Drug A does not work for you, our plan will then cover us to make: Drug B. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Anthem MediBlue Plus (HMO)'s formulary?” on page 4 for information about how to request an exception. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan’s If your drug is not included in this formulary (list of covered formulary, the lower cost-sharing drug or additional drugs), you should first contact Customer Service and ask utilization restrictions would not be as effective in treating if your drug is covered. your condition and/or would cause you to have adverse medical effects. If you learn that our plan does not cover your drug, you have two options: You should contact us to ask us for an initial coverage You can ask Customer Service for a list of similar drugs that decision for a formulary, tiering or utilization restriction are covered by our plan. When you receive the list, show it exception. When you request a formulary, tiering or to your doctor and ask him or her to prescribe a similar drug utilization restriction exception, you should submit a statement from your prescriber or physician supporting that is covered by our plan. your request. Generally, we must make our decision within You can ask our plan to make an exception and cover your 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your drug. See below for information about how to request an doctor believe that your health could be seriously harmed exception. by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What if my drug is not on the formulary? Effective Date September 1, 2016 4 Core_16293_CG6_v15_1609_1 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. Our plan’s formulary For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. The formulary on page 8 provides coverage information about some of the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 60. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lowercase italics (e.g., atenolol). If you are a resident of a long-term-care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will During the time when you are getting a temporary supply need to request prior authorization before you fill the of a drug, you should talk to your prescriber or prescribing prescription. physician to decide what to do when your supply runs out. ST - Step Therapy: The process of first trying a certain You can call Customer Service to ask for a list of covered drug or drugs to determine if that drug or those drugs will drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for treat your medical condition before your plan will cover you while you pursue a formulary exception. Please refer to another drug for that condition. the Evidence of Coverage for more information about B/D - Part B vs. Part D: This drug may be covered under exceptions. either your Part D prescripton drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. Effective Date September 1, 2016 5 Core_16293_CG6_v15_1609_1 LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-888-346-0095, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. TTY/TDD users should call 711. INJ - Injectable: The drug is available in injectable form. MO - Mail Orders: Prescription drugs available through mail order. CG – Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Effective Date September 1, 2016 6 Core_16293_CG6_v15_1609_1 Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing Tier 1: Preferred Generic Network Pharmacy with preferred cost-sharing (30-day supply) or Mail-Order Pharmacy** (30-day supply) $4.00 Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply) $9.00 Cost-Sharing Tier 2: Generic Network Pharmacy with preferred cost-sharing (30-day supply) or Mail-Order Pharmacy** (30-day supply) $8.00 Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply) $13.00 Cost-Sharing Tier 3: Preferred Brand Network Pharmacy with preferred cost-sharing (30-day supply) or Mail-Order Pharmacy** (30-day supply) $42.00 Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply) $47.00 Cost-Sharing Tier 4: Nonpreferred Brand Network Pharmacy with preferred cost-sharing (30-day supply) or Mail-Order Pharmacy** (30-day supply) $95.00 Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply) $100.00 Cost-Sharing Tier 5: Specialty Tier* Network Pharmacy with preferred cost-sharing (30-day supply) or Mail-Order Pharmacy** (30-day supply) 33% Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply) 33% Cost-Sharing Tier 6: Select Care Drugs Network Pharmacy with preferred cost-sharing (30-day supply) or Mail-Order Pharmacy** (30-day supply) $0.00 Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply) $0.00 Please refer to our Evidence of Coverage for more information for cost sharing. Network Pharmacy with preferred cost-sharing – A network pharmacy that offers covered drugs to members of our plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing. * A long-term supply is not available for drugs in the Tier 5: Specialty Tier ** Mail-Order Pharmacy – Mail-order service allows you to order a 30–90-day supply of drugs. The drugs available through our plan’s mail-order service are marked as “mail-order” drugs in our drug list. Effective Date September 1, 2016 7 Core_16293_CG6_v15_1609_1 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lower-case italics (e.g. atenolol) Brand-name drugs are shown in capital letters (e.g. CRESTOR) QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service 1-888-346-0095, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30 TTY/TDD users should call 711. INJ - Injectable: The drug is available in injectable form. MO - Mail Order: Prescription drugs available through mail order. CG – Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Drug Name Anti - Infectives abacavir abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution 1, 000 mg/4 ml, 500 mg/2 ml amoxicillin oral capsule Drug Requirements/ Tier Limits 4 5 2 4 MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) B/D PAR; MO MO MO 2 4 MO B/D PAR; MO 5 4 4 MO MO MO; QLL (180 per 3 days) 4 3 3 5 4 MO MO MO B/D PAR; MO MO 1 MO 5 Drug Name amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution 250-62.5 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-125 mg amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable amphotericin b ampicillin oral capsule Drug Requirements/ Tier Limits 1 MO 1 2 MO MO 3 MO 4 MO 3 MO 2 MO 4 MO 3 MO 4 1 B/D PAR; MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 8 Effective Date September 1, 2016 Drug Name ampicillin oral suspension for reconstitution ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram APTIVUS ORAL CAPSULE Drug Requirements/ Tier Limits 2 MO 4 4 4 MO MO 4 4 4 MO 5 MO; QLL (120 per 30 days) QLL (390 per 30 days) PAR; MO MO MO; QLL (30 per 30 days) MO APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil ATRIPLA 5 azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral packet azithromycin oral suspension for reconstitution 100 mg/5 ml azithromycin oral suspension for reconstitution 200 mg/5 ml azithromycin oral tablet aztreonam BARACLUDE ORAL SOLUTION BICILLIN C-R BICILLIN L-A CANCIDAS CAPASTAT CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 4 5 4 5 4 2 4 2 2 4 5 4 4 5 4 5 3 2 2 3 MO MO MO MO MO PAR; MO MO MO B/D PAR; MO PAR; MO; LA MO MO MO Drug Name cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/ 50 ml, 2 gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin intravenous cefdinir oral capsule cefdinir oral suspension for reconstitution cefepime cefepime in dextrose,iso-osm intravenous piggyback 1 gram/ 50 ml cefepime in dextrose,iso-osm intravenous piggyback 2 gram/ 100 ml cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefotaxime injection recon soln 10 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet 100 mg cefpodoxime oral tablet 200 mg cefprozil oral suspension for reconstitution cefprozil oral tablet 250 mg cefprozil oral tablet 500 mg CEFTAZIDIME IN D5W ceftazidime injection recon soln 1 gram, 2 gram Drug Requirements/ Tier Limits 2 3 MO MO 4 4 MO MO 4 MO 4 4 2 4 MO MO 4 4 MO 4 MO 4 4 MO 4 4 4 MO 4 4 MO 3 4 3 MO MO MO 2 3 4 4 MO MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 9 Effective Date September 1, 2016 Drug Name ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram, 100 gram ceftriaxone intravenous cefuroxime axetil oral tablet 250 mg cefuroxime axetil oral tablet 500 mg cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate oral tablet 250 mg chloroquine phosphate oral tablet 500 mg cidofovir ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1, 000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg ciprofloxacin hcl oral tablet ciprofloxacin in 5 % dextrose ciprofloxacin lactate intravenous solution 200 mg/ 20 ml ciprofloxacin lactate intravenous solution 400 mg/ 40 ml ciprofloxacin oral suspension clarithromycin oral suspension for reconstitution 125 mg/5 ml Drug Requirements/ Tier Limits 4 4 4 MO MO 4 4 1 MO MO 2 MO 4 MO 4 1 MO 2 MO 1 4 4 MO 3 MO MO 5 3 B/D PAR; MO MO; QLL (14 per 2 days) 2 MO; QLL (3 per 2 days) 2 4 4 MO MO MO 4 4 2 MO Drug Name Drug Requirements/ Tier Limits clarithromycin oral suspension for reconstitution 250 mg/5 ml clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr clindamycin hcl oral capsule clindamycin in 5 % dextrose clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA 4 MO 3 3 MO MO; QLL (28 per 2 days) MO MO MO CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG CUBICIN DAKLINZA ORAL TABLET 30 MG, 60 MG DAKLINZA ORAL TABLET 90 MG DAPSONE DARAPRIM demeclocycline DESCOVY 4 dicloxacillin didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg didanosine oral capsule,delayed release(dr/ec) 400 mg DIFICID DORIBAX DOXY-100 doxycycline hyclate intravenous 2 3 2 4 4 4 4 MO 3 4 4 5 MO MO MO MO; QLL (30 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO PAR; MO; QLL (30 per 30 days) PAR; QLL (30 per 30 days) MO MO MO QLL (30 per 30 days) MO MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) PAR; MO 4 5 5 5 3 3 4 5 4 3 4 5 4 4 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 10 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral tablet 100 mg doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg e.e.s. 400 oral tablet EDURANT 4 4 EMTRIVA ORAL CAPSULE 4 EMTRIVA ORAL SOLUTION entecavir EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION 4 EPZICOM 5 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule, delayed release(dr/ec) erythromycin oral tablet ethambutol EVOTAZ 3 MO; QLL (960 per 30 days) MO; QLL (30 per 30 days) MO 3 MO famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg 3 fluconazole in dextrose(iso-o) FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS 4 4 MO MO 3 MO 2 MO 4 MO 3 5 5 3 4 MO MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (870 per 30 days) PAR; MO MO 4 3 MO 2 MO 4 4 5 MO MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (21 per 7 days) 4 Drug Name PIGGYBACK 100 MG/50 ML fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/ 100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/ 200 ml fluconazole oral suspension for reconstitution 10 mg/ml fluconazole oral suspension for reconstitution 40 mg/ml fluconazole oral tablet 100 mg fluconazole oral tablet 150 mg, 50 mg fluconazole oral tablet 200 mg flucytosine foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/ 100 ml, 60 mg/50 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/ 50 ml, 80 mg/100 ml, 80 mg/ 50 ml, 90 mg/100 ml gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/ 10 ml gentamicin sulfate (pf) intravenous solution 60 mg/6 ml, 80 mg/8 ml GENVOYA Drug Requirements/ Tier Limits 4 MO 4 3 MO 4 MO 3 2 MO MO 4 5 3 5 MO MO B/D PAR MO; QLL (60 per 30 days) 4 4 MO MO 4 4 4 4 4 MO MO MO 4 5 MO; QLL (30 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 11 Effective Date September 1, 2016 Drug Name GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 250 MG griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI Drug Requirements/ Tier Limits 4 4 4 5 MO hydroxychloroquine oral imipenem-cilastatin intravenous recon soln 250 mg imipenem-cilastatin intravenous recon soln 500 mg INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVANZ 1 GM ADDVANTAGE VIAL INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET 2 3 4 MO ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG isoniazid injection isoniazid oral solution isoniazid oral tablet 100 mg isoniazid oral tablet 300 mg itraconazole ivermectin oral KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100-25 MG 4 5 4 MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (480 per 30 days) 4 5 5 5 5 3 4 4 1 2 4 3 4 5 Drug Requirements/ Tier Limits KALETRA ORAL TABLET 200-50 MG KETEK 5 ketoconazole oral LAMISIL ORAL TABLET 3 4 lamivudine oral solution 4 lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg 4 4 lamivudine oral tablet 300 mg 4 lamivudine-zidovudine 5 levofloxacin in d5w intravenous piggyback 250 mg/50 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin oral tablet 4 LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET 4 LINCOCIN lincomycin injection linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet 4 4 5 5 linezolid-0.9% sodium chloride MALARONE mefloquine meropenem methenamine hippurate methenamine mandelate metro i.v. metronidazole in nacl (iso-os) metronidazole oral capsule metronidazole oral tablet minocycline oral capsule 100 mg, 50 mg 5 4 3 4 4 2 4 4 4 2 2 3 MO MO PAR; MO; QLL (28 per 28 days) MO MO 5 Drug Name MO; QLL (300 per 30 days) MO; QLL (120 per 30 days) MO MO; QLL (120 per 30 days) MO; QLL (180 per 30 days) MO; QLL (720 per 30 days) MO MO MO PAR; MO MO MO; QLL (480 per 30 days) MO; QLL (300 per 30 days) MO; QLL (120 per 30 days) MO; QLL (20 per 2 days) MO MO; QLL (30 per 30 days) MO; QLL (900 per 30 days) MO MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) 4 MO 2 MO; QLL (14 per 2 days) MO; QLL (1800 per 30 days) MO; QLL (120 per 30 days) MO 5 5 PAR; MO; QLL (1800 per 2 days) PAR; MO; QLL (28 per 2 days) MO MO MO MO MO MO MO MO MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 12 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits minocycline oral capsule 75 mg minocycline oral tablet moxifloxacin 3 4 3 MYCAMINE nafcillin in dextrose iso-osm intravenous piggyback 1 gram/ 50 ml nafcillin in dextrose iso-osm intravenous piggyback 2 gram/ 100 ml nafcillin injection nafcillin intravenous recon soln 1 gram NAFCILLIN INTRAVENOUS RECON SOLN 2 GRAM NEBUPENT neomycin nevirapine oral suspension 5 4 nevirapine oral tablet 3 nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/mcryst NORVIR ORAL CAPSULE 4 4 5 5 5 3 2 4 4 4 4 4 NORVIR ORAL SOLUTION NORVIR ORAL TABLET 4 NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet ODEFSEY 5 ofloxacin oral tablet 400 mg OLYSIO 3 5 3 2 2 5 Drug Name oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/ 50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/ 50 ml oxacillin injection oxacillin intravenous paromomycin MO PASER PENICILLIN G POT IN MO DEXTROSE penicillin g potassium MO penicillin g procaine intramuscular syringe 1.2 MO million unit/2 ml penicillin g procaine intramuscular syringe 600,000 B/D PAR; MO unit/ml MO MO; QLL (1200 per penicillin g sodium penicillin v potassium oral 30 days) recon soln MO; QLL (60 per penicillin v potassium oral 30 days) tablet 250 mg MO penicillin v potassium oral tablet 500 mg MO; QLL (30 per 30 days) PENTAM pfizerpen-g PAR; MO piperacillin-tazobactam PAR; MO polymyxin b sulfate PREZCOBIX MO; QLL (360 per 30 days) PREZISTA ORAL MO; QLL (480 per SUSPENSION 30 days) PREZISTA ORAL TABLET MO; QLL (360 per 150 MG 30 days) PREZISTA ORAL TABLET PAR; MO; QLL 600 MG, 800 MG (630 per 30 days) PREZISTA ORAL TABLET MO 75 MG MO PRIFTIN QLL (30 per 30 PRIMAQUINE days) pyrazinamide MO RELENZA DISKHALER PAR; MO MO MO MO; QLL (21 per 2 days) MO Drug Requirements/ Tier Limits 4 5 MO 5 5 4 4 4 MO 5 4 MO MO MO MO 4 4 1 MO MO 1 MO 2 MO 4 4 4 4 5 MO 5 4 5 4 4 3 4 3 MO MO MO; QLL (30 per 30 days) MO; QLL (420 per 30 days) MO; QLL (180 per 30 days) MO; QLL (60 per 30 days) MO; QLL (300 per 30 days) MO MO MO MO; QLL (60 per 180 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 13 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rifabutin rifampin RIFATER rimantadine SELZENTRY 4 SIRTURO SOVALDI stavudine oral capsule 15 mg 5 5 3 stavudine oral capsule 20 mg 4 stavudine oral capsule 30 mg 3 4 4 5 5 4 4 4 4 3 4 4 4 4 5 stavudine oral capsule 40 mg 4 stavudine oral recon soln 3 STREPTOMYCIN INTRAMUSCULAR STRIBILD STROMECTOL sulfadiazine oral sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet 4 5 Drug Name Drug Requirements/ Tier Limits MO; QLL (180 per 30 days) MO; QLL (360 per 30 days) MO SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET 4 MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (240 per 30 days) MO MO MO MO MO MO MO MO MO; QLL (120 per 30 days) PAR; MO; LA PAR; MO MO; QLL (120 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (2400 per 30 days) MO SYNAGIS SYNERCID TAMIFLU TECHNIVIE 5 5 3 5 TEFLARO INTRAVENOUS RECON SOLN 400 MG TEFLARO INTRAVENOUS RECON SOLN 600 MG terbinafine hcl oral 4 MO PAR; MO; QLL (56 per 28 days) MO 5 MO 2 tetracycline tinidazole oral tablet 250 mg tinidazole oral tablet 500 mg TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG TIVICAY ORAL TABLET 50 MG tobramycin in 0.225 % nacl 4 2 4 4 MO; QLL (30 per 30 days) MO MO MO QLL (60 per 30 days) QLL (60 per 30 days) MO; QLL (60 per 30 days) B/D PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ 4 TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG TRUVADA ORAL TABLET 200-300 MG TYBOST 5 TYGACIL TYZEKA 5 5 3 4 4 MO; QLL (30 per 30 days) MO MO MO 2 MO 1 MO 4 5 5 5 5 MO; QLL (120 per 30 days) MO; QLL (360 per 30 days) MO; QLL (30 per 30 days) PAR; MO; LA 4 MO 4 2 5 MO MO MO; QLL (30 per 30 days) QLL (30 per 30 days) 5 3 MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO PAR; MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 14 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits valacyclovir 3 valganciclovir VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin intravenous vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER 5 4 VIREAD ORAL TABLET 150 MG, 250 MG, 300 MG VIREAD ORAL TABLET 200 MG VITEKTA 5 voriconazole intravenous 4 4 MO; QLL (30 per 2 days) MO MO Drug Name Drug Requirements/ Tier Limits voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg 5 voriconazole oral tablet 50 mg 5 ZEPATIER 5 ZIAGEN ORAL SOLUTION zidovudine oral capsule 4 zidovudine oral syrup 3 zidovudine oral tablet 3 5 4 4 4 5 5 4 4 5 5 5 4 5 5 4 5 PAR; MO; QLL (300 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (30 per 30 days) MO; QLL (960 per 30 days) MO; QLL (180 per 30 days) MO; QLL (1920 per 30 days) MO; QLL (60 per 30 days) MO ZITHROMAX ORAL 4 PACKET MO ZITHROMAX ORAL 4 MO PAR; MO; QLL (40 TABLET 250 MG per 2 days) ZITHROMAX Z-PAK 4 MO PAR; MO; QLL (80 ZMAX 3 MO per 2 days) ZYVOX INTRAVENOUS 5 MO; QLL (1200 per PARENTERAL SOLUTION 30 days) 200 MG/100 ML MO; QLL (1200 per ZYVOX INTRAVENOUS 5 MO 30 days) PARENTERAL SOLUTION PAR; MO 600 MG/300 ML MO; QLL (300 per ZYVOX ORAL 5 PAR; MO; QLL 30 days) SUSPENSION FOR (1800 per 2 days) MO; QLL (120 per RECONSTITUTION 30 days) Antineoplastic / Immunosuppressant Drugs MO ABRAXANE 5 MO adrucil intravenous solution 2.5 4 gram/50 ml PAR; MO adrucil intravenous solution 5 4 MO MO; QLL (240 per gram/100 ml, 500 mg/10 ml 30 days) AFINITOR 5 PAR; MO MO; QLL (30 per AFINITOR DISPERZ 5 PAR; MO 30 days) ALECENSA 5 MO MO; QLL (30 per ALIMTA 5 PAR; MO 30 days) ALKERAN ORAL 4 B/D PAR; MO MO; QLL (30 per amifostine crystalline 5 PAR; MO 30 days) anastrozole 3 MO; QLL (30 per MO 30 days) ARRANON 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 15 Effective Date September 1, 2016 Drug Name ARZERRA AVASTIN azacitidine azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide BICNU bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COSMEGEN COTELLIC cyclophosphamide oral capsule cyclosporine intravenous Drug Requirements/ Tier Limits 5 5 5 2 4 5 5 5 3 4 4 5 5 5 4 5 5 5 5 4 4 4 5 5 5 5 5 5 5 4 4 Drug Name cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ ml), 2 gram/20 ml (100 mg/ ml) cytarabine (pf) injection solution 20 mg/ml dacarbazine DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 250 mg PAR; LA; QLL (90 dexrazoxane hcl intravenous recon soln 500 mg per 30 days) PAR; LA; QLL (30 DOCEFREZ INTRAVENOUS RECON per 30 days) PAR; MO; LA; QLL SOLN 20 MG DOCETAXEL (90 per 30 days) PAR; MO; LA; QLL INTRAVENOUS SOLUTION 10 MG/ML (30 per 30 days) docetaxel intravenous solution MO 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 B/D PAR; MO ml (10 mg/ml) docetaxel intravenous solution MO 20 mg/ml (1 ml), 80 mg/4 ml MO (20 mg/ml), 80 mg/8 ml (10 MO PAR; MO; QLL (56 mg/ml) doxorubicin intravenous recon per 28 days) soln doxorubicin intravenous PAR; MO; QLL solution (112 per 28 days) ELITEK PAR; MO; QLL (84 EMCYT EMPLICITI per 28 days) ENVARSUS XR epirubicin intravenous solution MO PAR; MO; LA; QLL 200 mg/100 ml epirubicin intravenous solution (90 per 30 days) 50 mg/25 ml B/D PAR; MO ERBITUX B/D PAR PAR; MO PAR; MO PAR; MO B/D PAR; MO B/D PAR PAR; MO MO PAR; MO MO MO MO PAR; MO PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (30 per 30 days) Drug Requirements/ Tier Limits 4 4 5 4 4 B/D PAR; MO B/D PAR; MO PAR; MO MO MO 4 4 5 4 MO MO; LA 5 5 MO 5 MO 5 5 5 5 MO 4 4 MO 5 5 5 4 4 PAR; MO MO B/D PAR; MO B/D PAR; MO 4 MO 5 PAR; MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 16 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits ERIVEDGE 5 ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane 5 5 3 5 4 FARESTON 5 FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg 5 5 5 5 PAR; MO; QLL (30 per 30 days) PAR; MO MO MO MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) PAR; MO PAR; MO 4 PAR; MO 4 MO 4 4 4 5 5 5 5 MO MO MO MO PAR; MO MO 5 5 MO 5 4 B/D PAR; MO 4 B/D PAR Drug Name Drug Requirements/ Tier Limits gengraf oral solution GILOTRIF 4 5 GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE 5 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin IFEX ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg 5 imatinib oral tablet 400 mg 5 IMBRUVICA 5 INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG 5 5 4 5 5 5 2 5 5 5 4 4 4 5 5 5 4 B/D PAR; MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (60 per 30 days) MO PAR; MO PAR; MO MO MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO MO PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (120 per 30 days) MO MO 4 5 5 5 5 5 PAR; MO MO PAR; MO; QLL (150 per 30 days) PAR; MO; QLL (100 per 30 days) PAR; MO; QLL (75 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 17 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/ DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) letrozole 5 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral tablet 10 mg, 25 mg leucovorin calcium oral tablet 15 mg, 5 mg LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG 4 5 5 5 5 5 5 5 5 5 3 PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (300 per 30 days) MO PAR; MO PAR; MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; QLL (90 per 30 days) PAR; MO; QLL (90 per 30 days) PAR; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO 4 4 MO 2 MO 4 4 5 5 MO PAR; MO PAR; MO PAR; MO; QLL (1 per 28 days) 5 Drug Name Drug Requirements/ Tier Limits LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) LYNPARZA 5 PAR; MO; QLL (1 per 28 days) 5 LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet NEXAVAR 3 5 4 PAR; MO; QLL (480 per 30 days) MO MO PAR 4 PAR; MO 3 5 PAR; MO PAR; QLL (90 per 30 days) PAR; QLL (30 per 30 days) NILANDRON 5 NINLARO 5 NIPENT NULOJIX 5 5 5 3 3 4 5 4 MO MO MO 4 MO 4 2 5 3 4 3 MO MO MO MO MO B/D PAR; MO 5 B/D PAR; MO 3 B/D PAR; MO 5 PAR; MO; LA; QLL (120 per 30 days) MO; QLL (30 per 30 days) PAR; MO; QLL (3 per 28 days) MO PAR; MO PAR; MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 18 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) ODOMZO 5 ONCASPAR OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG RITUXAN SANDOSTATIN LAR DEPOT INTRAMUSCULAR 5 5 5 4 4 5 5 5 5 4 5 5 5 5 5 4 5 5 5 5 5 5 5 Drug Name SUSPENSION,EXTENDED REL RECON SIGNIFOR PAR; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG PAR; MO SIMULECT INTRAVENOUS RECON SOLN 20 MG PAR; MO sirolimus SOLTAMOX PAR; MO; LA; QLL SOMATULINE DEPOT (30 per 30 days) SPRYCEL PAR; MO PAR; MO STIVARGA MO SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE MO 25 MG, 37.5 MG, 50 MG MO SYNRIBO PAR; MO TABLOID PAR; MO; QLL tacrolimus oral capsule 0.5 mg, (120 per 30 days) 1 mg PAR; MO; QLL (60 tacrolimus oral capsule 5 mg per 30 days) TAFINLAR PAR; MO; QLL (30 per 30 days) TAGRISSO ORAL TABLET MO 40 MG B/D PAR; MO TAGRISSO ORAL TABLET 80 MG PAR; MO tamoxifen B/D PAR; MO TARCEVA ORAL TABLET 100 MG, 150 MG PAR; MO; LA; QLL TARCEVA ORAL TABLET (60 per 30 days) 25 MG PAR; MO; LA; QLL TARGRETIN (30 per 30 days) TASIGNA Drug Requirements/ Tier Limits PAR; MO PAR; MO; LA; QLL (150 per 30 days) PAR; MO PAR; MO TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ ML) TECENTRIQ 5 5 MO B/D PAR 5 B/D PAR; MO 4 4 5 5 B/D PAR; MO MO PAR; MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (90 per 30 days) PAR; MO; QLL (30 per 30 days) PAR; MO MO B/D PAR; MO 5 5 5 5 4 4 5 5 5 5 2 5 5 5 5 5 5 B/D PAR; MO PAR; QLL (120 per 30 days) PAR; MO; LA; QLL (60 per 30 days) PAR; MO; LA; QLL (30 per 30 days) MO PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (90 per 30 days) PAR; MO PAR; MO; QLL (120 per 30 days) MO LA; QLL (20 per 21 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 19 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML tretinoin (chemotherapy) oral capsule TRISENOX TYKERB 5 UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML vincasar pfs intravenous solution 2 mg/2 ml 5 5 5 4 5 4 4 5 PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days) MO MO 5 5 5 MO MO MO 5 MO; QLL (1 per 168 days) 5 5 5 5 5 5 4 5 4 4 4 Drug Name Drug Requirements/ Tier Limits vincristine vinorelbine VOTRIENT 4 4 5 XALKORI 5 XGEVA 5 XTANDI 5 YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF 5 5 5 4 5 ZOLINZA 5 ZORTRESS ORAL TABLET 0.25 MG ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG ZYDELIG 4 MO MO PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (1.7 per 28 days) PAR; MO; QLL (120 per 30 days) PAR; MO MO PAR; MO MO PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (120 per 30 days) B/D PAR; MO 5 B/D PAR; MO MO MO; QLL (1 per 168 days) 5 PAR; MO; QLL (60 per 30 days) MO ZYKADIA 5 PAR; MO; QLL (150 per 30 days) MO ZYTIGA 5 PAR; MO; QLL PAR; MO; LA; QLL (120 per 30 days) (180 per 30 days) Autonomic / Cns Drugs, Neurology / Psych MO ABILIFY MAINTENA 5 MO; QLL (1 per 28 PAR; MO days) PAR; MO acetaminophen-codeine oral 3 QLL (4500 per 30 PAR; LA; QLL (60 solution 120 mg-12 mg /5 ml days) per 30 days) (5 ml), 240 mg-24 mg /10 ml PAR; LA; QLL (120 (10 ml), 300 mg-30 mg /12.5 per 30 days) ml PAR; LA; QLL (30 acetaminophen-codeine oral 3 MO; QLL (4500 per per 30 days) solution 120-12 mg/5 ml 30 days) PAR; LA; QLL (42 acetaminophen-codeine oral 3 MO; QLL (390 per per 365 days) tablet 300-15 mg 30 days) MO acetaminophen-codeine oral 3 MO; QLL (360 per tablet 300-30 mg 30 days) acetaminophen-codeine oral 3 MO; QLL (180 per tablet 300-60 mg 30 days) MO ADASUVE 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 20 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits alprazolam oral tablet 3 amitriptyline amoxapine oral tablet 100 mg, 50 mg amoxapine oral tablet 150 mg, 25 mg AMPYRA 4 3 APOKYN APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG APTIOM ORAL TABLET 800 MG aripiprazole oral solution 5 5 2 5 4 5 aripiprazole oral tablet 10 mg 5 aripiprazole oral tablet 15 mg 5 aripiprazole oral tablet 2 mg 5 aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg 5 aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML AZILECT 5 5 5 5 5 5 3 Drug Name Drug Requirements/ Tier Limits baclofen BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG MO BANZEL ORAL TABLET 400 MG PAR; MO; LA; QLL benztropine injection (60 per 30 days) benztropine oral PAR; MO; LA BRIVIACT ST; MO INTRAVENOUS BRIVIACT ORAL ST; MO SOLUTION BRIVIACT ORAL TABLET MO; QLL (900 per 10 MG 30 days) BRIVIACT ORAL TABLET MO; QLL (90 per 100 MG, 75 MG 30 days) BRIVIACT ORAL TABLET MO; QLL (60 per 25 MG 30 days) BRIVIACT ORAL TABLET MO; QLL (450 per 50 MG 30 days) bromocriptine MO; QLL (30 per buprenorphine hcl injection 30 days) solution MO; QLL (180 per buprenorphine hcl injection 30 days) syringe MO; QLL (90 per buprenorphine hcl sublingual 30 days) tablet 2 mg MO; QLL (60 per buprenorphine hcl sublingual 30 days) tablet 8 mg PAR; MO; QLL (1.6 buprenorphine-naloxone per 30 days) sublingual tablet 2-0.5 mg buprenorphine-naloxone sublingual tablet 8-2 mg bupropion hcl oral tablet 100 PAR; MO; QLL (2.4 mg per 30 days) bupropion hcl oral tablet 75 mg 2 5 bupropion hcl oral tablet extended release 100 mg PAR; MO; QLL (3.2 bupropion hcl oral tablet per 30 days) extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg MO 3 MO; QLL (90 per 30 days) PAR; MO MO 4 5 4 3 4 5 5 5 5 5 4 4 4 4 4 4 4 4 3 3 3 MO PAR; MO; QLL (2400 per 30 days) PAR; MO; QLL (480 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO PAR; MO PAR PAR; QLL (600 per 30 days) PAR; QLL (600 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (240 per 30 days) PAR; QLL (120 per 30 days) MO MO; QLL (150 per 30 days) QLL (150 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (360 per 30 days) PAR; MO; QLL (90 per 30 days) MO; QLL (135 per 30 days) MO; QLL (180 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (90 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 21 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits bupropion hcl oral tablet extended release 24 hr 300 mg buspirone oral tablet 10 mg, 15 mg, 5 mg buspirone oral tablet 30 mg, 7.5 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal 3 carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral suspension 200 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet, chewable carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release 25-100 mg carbidopa-levodopa oral tablet extended release 50-200 mg carbidopa-levodopa oral tablet, disintegrating CELONTIN ORAL CAPSULE 300 MG chlorpromazine citalopram oral solution citalopram oral tablet 10 mg 2 Drug Name Drug Requirements/ Tier Limits clonazepam oral tablet 0.5 mg 2 2 MO; QLL (45 per 30 days) MO clonazepam oral tablet 1 mg 2 4 MO clonazepam oral tablet 2 mg 3 4 4 MO clonazepam oral tablet, disintegrating 0.125 mg clonazepam oral tablet, disintegrating 0.25 mg clonazepam oral tablet, disintegrating 0.5 mg clonazepam oral tablet, disintegrating 1 mg clonazepam oral tablet, disintegrating 2 mg clorazepate dipotassium 4 4 MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (5 per 28 days) MO clozapine oral tablet 100 mg 3 clozapine oral tablet 200 mg 3 clozapine oral tablet 25 mg 2 4 4 4 2 4 4 MO 4 4 4 4 3 MO 2 MO clozapine oral tablet 50 mg 2 3 3 MO MO clozapine oral tablet, disintegrating 100 mg clozapine oral tablet, disintegrating 12.5 mg clozapine oral tablet, disintegrating 150 mg clozapine oral tablet, disintegrating 200 mg clozapine oral tablet, disintegrating 25 mg COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML cyclobenzaprine oral tablet dantrolene desipramine oral 4 4 MO 4 MO 4 4 4 citalopram oral tablet 20 mg 1 citalopram oral tablet 40 mg 1 clomipramine 4 MO PAR; MO MO; QLL (600 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) PAR; MO 4 4 4 4 5 PAR; MO; QLL (1200 per 30 days) PAR; MO; QLL (600 per 30 days) PAR; MO; QLL (300 per 30 days) PAR; MO; QLL (4800 per 30 days) PAR; MO; QLL (2400 per 30 days) PAR; MO; QLL (1200 per 30 days) PAR; MO; QLL (600 per 30 days) PAR; MO; QLL (300 per 30 days) MO; QLL (120 per 30 days) MO; QLL (270 per 30 days) MO; QLL (135 per 30 days) MO; QLL (1080 per 30 days) MO; QLL (540 per 30 days) QLL (270 per 30 days) QLL (2160 per 30 days) QLL (180 per 30 days) QLL (135 per 30 days) QLL (1080 per 30 days) PAR; MO; QLL (30 per 30 days) 5 PAR; MO; QLL (12 per 28 days) 4 4 4 PAR; MO MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 22 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits desvenlafaxine fumarate oral tablet extended release 24hr 100 mg desvenlafaxine fumarate oral tablet extended release 24hr 50 mg DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG desvenlafaxine oral tablet extended release 24hr 100 mg desvenlafaxine oral tablet extended release 24hr 50 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamineamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamineamphetamine oral tablet 30 mg diazepam intensol 4 diazepam oral concentrate 4 diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml) diazepam oral tablet 10 mg 3 diazepam oral tablet 2 mg 3 diazepam oral tablet 5 mg 3 diazepam rectal kit 12.5-1517.5-20 mg diazepam rectal kit 2.5 mg, 57.5-10 mg diclofenac potassium 4 4 4 2 MO 3 MO 2 MO 3 QLL (1000 per 30 days) MO MO MO MO 4 4 2 MO 3 MO 1 PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (1200 per 30 days) PAR; QLL (1200 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (600 per 30 days) PAR; MO; QLL (240 per 30 days) MO divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg divalproex oral tablet,delayed release (dr/ec) 500 mg donepezil oral tablet 10 mg, 5 mg donepezil oral tablet, disintegrating doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml EMSAM QLL (30 per 30 days) MO MO MO; QLL (2 per 2 days) MO endocet oral tablet 10-325 mg, 7.5-325 mg endocet oral tablet 5-325 mg 4 MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) PAR; MO MO; QLL (180 per 30 days) MO; QLL (120 per 30 days) MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (180 per 30 days) QLL (180 per 30 days) PAR; MO; QLL (30 per 30 days) MO; QLL (360 per 30 days) MO; QLL (360 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (240 per 30 days) 4 QLL (120 per 30 days) QLL (240 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) PAR; MO; QLL (90 per 30 days) 4 4 3 3 4 3 3 4 2 Drug Requirements/ Tier Limits diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg diclofenac sodium oral tablet, delayed release (dr/ec) 50 mg, 75 mg diclofenac sodium topical gel 1 % diflunisal dihydroergotamine injection DILANTIN INFATABS DILANTIN ORAL CAPSULE 30 MG diskets MO; QLL (120 per 30 days) 4 4 Drug Name 3 5 3 3 3 1 4 4 4 3 4 4 4 5 3 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 23 Effective Date September 1, 2016 Drug Name entacapone epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ethosuximide oral capsule ethosuximide oral solution etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr EXELON ORAL CAPSULE 1.5 MG, 4.5 MG FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG Drug Requirements/ Tier Limits 4 1 4 MO MO MO; QLL (480 per 30 days) 4 MO; QLL (240 per 30 days) 4 MO; QLL (180 per 30 days) 4 4 PAR; MO MO; QLL (600 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) MO MO MO MO MO 3 3 3 4 3 3 2 3 4 4 5 4 4 4 4 4 MO; QLL (60 per 30 days) ST; MO; QLL (720 per 30 days) ST; QLL (72 per 30 days) ST; MO; QLL (60 per 30 days) ST; MO; QLL (360 per 30 days) ST; MO; QLL (180 per 30 days) ST; MO; QLL (120 per 30 days) ST; MO; QLL (90 per 30 days) Drug Name Drug Requirements/ Tier Limits FANAPT ORAL TABLETS, DOSE PACK felbamate oral suspension felbamate oral tablet 400 mg felbamate oral tablet 600 mg FELBATOL ORAL TABLET 400 MG fenoprofen oral tablet fentanyl citrate 4 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG fluoxetine oral capsule 10 mg 4 fluoxetine oral capsule 20 mg 2 fluoxetine oral capsule 40 mg 2 fluoxetine oral solution 2 fluoxetine oral tablet 10 mg 2 fluoxetine oral tablet 20 mg 3 fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral flurbiprofen fluvoxamine oral tablet 100 mg 4 4 2 2 3 5 4 5 4 4 5 ST; MO; QLL (16 per 365 days) MO MO MO MO MO PAR; MO; QLL (120 per 30 days) ST; MO; QLL (15 per 30 days) 4 PAR; MO; QLL (56 per 365 days) 4 PAR; MO; QLL (30 per 30 days) 4 PAR; MO; QLL (180 per 30 days) 4 PAR; MO; QLL (90 per 30 days) 2 MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (600 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO MO MO MO MO; QLL (90 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 24 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits fluvoxamine oral tablet 25 mg 3 fluvoxamine oral tablet 50 mg 3 fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg 4 4 4 4 4 4 4 2 gabapentin oral capsule 300 mg 2 gabapentin oral capsule 400 mg 3 gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg 4 4 GABITRIL ORAL TABLET 12 MG GABITRIL ORAL TABLET 16 MG galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution 4 MO; QLL (180 per 30 days) MO; QLL (135 per 30 days) MO 5 MO galantamine oral tablet 4 GEODON INTRAMUSCULAR GILENYA 4 gabapentin oral tablet 800 mg 4 MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO QLL (720 per 30 days) MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (45 per 30 days) MO; QLL (1080 per 30 days) MO; QLL (360 per 30 days) MO; QLL (270 per 30 days) MO; QLL (2160 per 30 days) QLL (2160 per 30 days) 4 4 3 5 MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (60 per 30 days) MO PAR; MO; QLL (30 per 30 days) Drug Name Drug Requirements/ Tier Limits GLATOPA 5 guanfacine oral tablet extended release 24 hr guanidine haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral HETLIOZ 4 hydrocodone-acetaminophen oral solution 2.5-167 mg/5 ml hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg hydromorphone (pf) injection solution 1 mg/ml hydromorphone (pf) injection solution 10 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution hydromorphone injection syringe 1 mg/ml hydromorphone injection syringe 2 mg/ml hydromorphone injection syringe 4 mg/ml hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ibuprofen-oxycodone 3 imipramine hcl 4 4 2 4 4 2 5 4 3 3 PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (30 per 30 days) MO MO MO MO MO PAR; MO; QLL (30 per 30 days) QLL (2700 per 30 days) MO; QLL (2700 per 30 days) MO; QLL (360 per 30 days) MO; QLL (480 per 30 days) 4 4 4 4 MO; QLL (120 per 30 days) MO MO; QLL (180 per 30 days) 4 4 4 3 4 1 1 4 QLL (180 per 30 days) MO MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO MO MO; QLL (28 per 2 days) PAR; MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 25 Effective Date September 1, 2016 Drug Name INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/ 1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg lamotrigine oral tablet 25 mg lamotrigine oral tablet, chewable dispersible Drug Requirements/ Tier Limits 5 5 MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) 5 MO; QLL (60 per 30 days) 5 MO; QLL (30 per 30 days) 5 MO; QLL (2 per 28 days) 4 MO; QLL (2 per 28 days) 5 MO; QLL (0.875 per 90 days) 5 5 5 4 MO; QLL (1.315 per 90 days) MO; QLL (1.75 per 90 days) MO; QLL (2.625 per 90 days) MO; QLL (120 per 30 days) 4 MO; QLL (240 per 30 days) 3 MO 2 3 MO MO Drug Name Drug Requirements/ Tier Limits LATUDA ORAL TABLET 120 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG LATUDA ORAL TABLET 80 MG levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/ 100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet 1,000 mg levetiracetam oral tablet 250 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg lithium carbonate oral capsule 150 mg, 300 mg lithium carbonate oral capsule 600 mg lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml lorazepam oral tablet 5 loxapine succinate oral capsule 10 mg, 5 mg loxapine succinate oral capsule 25 mg, 50 mg LYRICA ORAL CAPSULE 100 MG 4 4 4 5 PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (75 per 30 days) PAR; MO; QLL (60 per 30 days) 4 4 MO 4 4 MO MO 4 4 MO 3 MO 4 1 MO; QLL (180 per 30 days) MO; QLL (120 per 30 days) MO 2 MO 2 2 MO MO 2 MO 3 3 MO; QLL (90 per 30 days) MO 4 MO 4 PAR; MO; QLL (180 per 30 days) 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 26 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION 4 maprotiline oral tablet 25 mg 4 maprotiline oral tablet 50 mg 4 maprotiline oral tablet 75 mg MARPLAN meclofenamate oral meloxicam oral suspension 4 4 4 3 meloxicam oral tablet 1 memantine oral solution memantine oral tablet 10 mg 4 4 4 4 4 4 3 3 memantine oral tablet 5 mg 3 MESTINON ORAL SYRUP MESTINON TIMESPAN methadone intensol 4 4 3 methadone oral concentrate 3 methadone oral solution 10 mg/ 5 ml methadone oral solution 5 mg/ 5 ml methadone oral tablet 10 mg 3 methadone oral tablet 5 mg 3 4 3 PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (90 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (720 per 30 days) PAR; MO; QLL (360 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (900 per 30 days) MO; QLL (270 per 30 days) MO; QLL (135 per 30 days) MO MO MO MO; QLL (300 per 30 days) MO; QLL (30 per 30 days) MO; QLL (300 per 30 days) MO; QLL (60 per 30 days) MO; QLL (90 per 30 days) MO MO MO; QLL (180 per 30 days) MO; QLL (180 per 30 days) MO; QLL (900 per 30 days) MO; QLL (1800 per 30 days) MO; QLL (180 per 30 days) MO; QLL (360 per 30 days) Drug Name Drug Requirements/ Tier Limits methadone oral tablet,soluble 3 methadose oral concentrate 3 methadose oral tablet,soluble 3 methylphenidate oral tablet 3 MIRAPEX ORAL TABLET 0.25 MG, 0.75 MG mirtazapine oral tablet 15 mg 4 mirtazapine oral tablet 30 mg 2 mirtazapine oral tablet 45 mg 2 mirtazapine oral tablet 7.5 mg 3 mirtazapine oral tablet, disintegrating 15 mg mirtazapine oral tablet, disintegrating 30 mg mirtazapine oral tablet, disintegrating 45 mg modafinil oral tablet 100 mg 4 modafinil oral tablet 200 mg 5 molindone morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine intravenous cartridge 4 4 morphine intravenous solution 10 mg/ml, 50 mg/ml 4 2 3 3 4 4 4 QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (30 per 30 days) MO; QLL (90 per 30 days) MO MO; QLL (90 per 30 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days) MO; QLL (180 per 30 days) MO; QLL (120 per 30 days) 4 QLL (180 per 30 days) 3 MO; QLL (270 per 30 days) QLL (120 per 30 days) MO; QLL (120 per 30 days) 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 27 Effective Date September 1, 2016 Drug Name morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml morphine intravenous solution 4 mg/ml, 8 mg/ml morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral solution 10 mg/ 5 ml morphine oral solution 20 mg/ 5 ml (4 mg/ml) morphine oral tablet 15 mg Drug Requirements/ Tier Limits 4 4 QLL (120 per 30 days) 4 4 MO; QLL (180 per 30 days) QLL (120 per 30 days) MO; QLL (2700 per 30 days) MO; QLL (1350 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (180 per 30 days) MO MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO MO 2 MO 4 3 3 3 morphine oral tablet 30 mg 3 morphine oral tablet extended release 100 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg morphine oral tablet extended release 200 mg morphine rectal 4 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection solution naloxone injection syringe 0.4 mg/ml naloxone injection syringe 1 mg/ ml naltrexone NAMENDA ORAL SOLUTION NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC naproxen oral suspension naproxen oral tablet 2 4 3 4 3 4 2 3 3 3 3 2 1 MO MO; QLL (300 per 30 days) MO; QLL (56 per 365 days) MO; QLL (30 per 30 days) MO MO MO Drug Name Drug Requirements/ Tier Limits naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg naratriptan 1 MO 1 MO 4 nefazodone oral tablet 100 mg 3 nefazodone oral tablet 150 mg 4 nefazodone oral tablet 200 mg 3 nefazodone oral tablet 250 mg 3 nefazodone oral tablet 50 mg 4 NEUPRO 3 nortriptyline oral capsule nortriptyline oral solution NUEDEXTA 2 4 3 NUPLAZID 5 olanzapine intramuscular 4 olanzapine oral tablet 10 mg 3 olanzapine oral tablet 15 mg 3 olanzapine oral tablet 2.5 mg 3 olanzapine oral tablet 20 mg 3 olanzapine oral tablet 5 mg 3 olanzapine oral tablet 7.5 mg 3 olanzapine oral tablet, disintegrating 10 mg olanzapine oral tablet, disintegrating 15 mg olanzapine oral tablet, disintegrating 20 mg olanzapine oral tablet, disintegrating 5 mg 4 MO; QLL (9 per 30 days) MO; QLL (180 per 30 days) MO; QLL (120 per 30 days) MO; QLL (90 per 30 days) MO; QLL (72 per 30 days) MO; QLL (360 per 30 days) MO; QLL (30 per 30 days) MO MO MO; QLL (60 per 30 days) PAR; LA; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (40 per 30 days) MO; QLL (240 per 30 days) MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) MO; QLL (80 per 30 days) MO; QLL (60 per 30 days) MO; QLL (40 per 30 days) MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) 4 5 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 28 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits ONFI ORAL SUSPENSION 4 ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG ORAP oxaprozin oxazepam 4 oxcarbazepine oral suspension oxcarbazepine oral tablet 150 mg, 300 mg oxcarbazepine oral tablet 600 mg oxycodone oral capsule 4 3 oxycodone oral concentrate 4 oxycodone oral solution 4 oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg 3 oxycodone oral tablet 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 5-325 mg oxycodone-aspirin 4 paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg 5 4 4 4 PAR; MO; QLL (480 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (60 per 30 days) MO MO PAR; MO; QLL (120 per 30 days) MO MO 4 MO 4 MO; QLL (360 per 30 days) MO; QLL (360 per 30 days) MO; QLL (1800 per 30 days) MO; QLL (360 per 30 days) MO; QLL (540 per 30 days) MO; QLL (180 per 30 days) QLL (1800 per 30 days) MO; QLL (360 per 30 days) 4 3 4 3 4 4 4 4 4 2 MO; QLL (360 per 30 days) MO; QLL (360 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) Drug Name Drug Requirements/ Tier Limits paroxetine hcl oral tablet 20 mg 2 paroxetine hcl oral tablet 30 mg 2 paroxetine hcl oral tablet 40 mg 2 paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION PEGANONE perphenazine phenelzine phenobarbital oral elixir 4 phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg 4 phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg 4 phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg 4 phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg PHENYTEK phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution phenytoin sodium intravenous syringe 4 4 4 4 4 4 3 4 4 4 4 4 4 3 MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (45 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (60 per 30 days) MO; QLL (900 per 30 days) MO MO MO PAR; MO; QLL (3000 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (800 per 30 days) PAR; MO; QLL (741 per 30 days) PAR; MO; QLL (400 per 30 days) PAR; MO; QLL (370 per 30 days) PAR; MO; QLL (200 per 30 days) PAR; MO; QLL (185 per 30 days) PAR; MO; QLL (123 per 30 days) MO 3 MO 3 3 4 MO MO MO 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 29 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits pimozide piroxicam POTIGA ORAL TABLET 200 MG POTIGA ORAL TABLET 300 MG, 400 MG POTIGA ORAL TABLET 50 MG pramipexole oral tablet primidone PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline pyridostigmine bromide oral tablet quetiapine oral tablet 100 mg 3 3 4 quetiapine oral tablet 200 mg 3 quetiapine oral tablet 25 mg 3 quetiapine oral tablet 300 mg 3 quetiapine oral tablet 400 mg 3 quetiapine oral tablet 50 mg 3 RAZADYNE ORAL TABLET 4 MG regonol REQUIP ORAL TABLET 1 MG, 4 MG, 5 MG REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR 4 5 4 2 3 4 4 4 MO MO MO; QLL (90 per 30 days) MO; QLL (90 per 30 days) MO; QLL (270 per 30 days) MO MO MO; QLL (120 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) Drug Name SYRINGE 12.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution Drug Requirements/ Tier Limits 5 MO; QLL (2 per 28 days) 5 MO 3 MO; QLL (480 per 30 days) MO; QLL (1920 per 30 days) MO; QLL (960 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) MO; QLL (150 per 30 days) MO; QLL (120 per 30 days) MO; QLL (1920 per 30 days) MO; QLL (960 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) MO; QLL (150 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) MO MO risperidone oral tablet 0.25 mg 2 risperidone oral tablet 0.5 mg 2 risperidone oral tablet 1 mg 2 risperidone oral tablet 2 mg 2 risperidone oral tablet 3 mg 2 4 3 MO MO risperidone oral tablet 4 mg 2 3 MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (960 per 30 days) MO; QLL (80 per 30 days) MO; QLL (60 per 30 days) MO; QLL (480 per 30 days) MO risperidone oral tablet, disintegrating 0.25 mg risperidone oral tablet, disintegrating 0.5 mg risperidone oral tablet, disintegrating 1 mg risperidone oral tablet, disintegrating 2 mg risperidone oral tablet, disintegrating 3 mg risperidone oral tablet, disintegrating 4 mg rivastigmine tartrate 4 ropinirole oral tablet ropinirole oral tablet extended release 24 hr roweepra ROZEREM 2 4 SABRIL ORAL POWDER IN PACKET SABRIL ORAL TABLET 4 4 4 5 5 4 MO PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO; QLL (2 per 28 days) 4 4 4 4 4 4 3 3 5 MO; QLL (30 per 30 days) PAR; MO; LA; QLL (180 per 30 days) PAR; MO; LA; QLL (180 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 30 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG selegiline hcl SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate 4 MO; QLL (60 per 30 days) 4 MO; QLL (240 per 30 days) 4 MO; QLL (120 per 30 days) 3 4 MO PAR; MO; QLL (150 per 30 days) sertraline oral tablet 100 mg 2 sertraline oral tablet 25 mg 2 sertraline oral tablet 50 mg 2 SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG 4 4 PAR; MO; QLL (120 per 30 days) 4 PAR; MO; QLL (80 per 30 days) 5 PAR; MO; QLL (60 per 30 days) 4 PAR; MO; QLL (480 per 30 days) 4 MO; QLL (300 per 30 days) MO; QLL (60 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO 4 PAR; QLL (60 per 30 days) 4 PAR; QLL (120 per 30 days) 4 PAR; MO; QLL (60 per 30 days) Drug Name Drug Requirements/ Tier Limits STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM 2-0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG SUBOXONE SUBLINGUAL FILM 8-2 MG sulindac oral tablet 150 mg sulindac oral tablet 200 mg sumatriptan 4 PAR; MO; QLL (30 per 30 days) 4 PAR; MO; QLL (60 per 30 days) 4 PAR; MO; QLL (360 per 30 days) 4 PAR; MO; QLL (180 per 30 days) 4 PAR; MO; QLL (90 per 30 days) 1 2 4 sumatriptan succinate oral 2 sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SURMONTIL SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 6-50 MG SYMBYAX ORAL CAPSULE 3-25 MG TECFIDERA tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg 4 MO MO MO; QLL (12 per 30 days) MO; QLL (9 per 30 days) MO; QLL (4 per 30 days) MO; QLL (4 per 30 days) MO; QLL (4 per 30 days) QLL (4 per 30 days) thioridazine thiothixene tiagabine tizanidine oral tablet tolcapone 4 2 4 2 5 4 4 4 4 4 PAR; MO MO; QLL (30 per 30 days) 4 MO; QLL (90 per 30 days) PAR; MO PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO MO MO MO MO 5 5 5 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 31 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits Drug Name Drug Requirements/ Tier Limits topiramate oral capsule, sprinkle topiramate oral tablet 100 mg 4 PAR; MO venlafaxine oral tablet 25 mg 3 2 venlafaxine oral tablet 37.5 mg 3 topiramate oral tablet 200 mg 3 venlafaxine oral tablet 50 mg 4 topiramate oral tablet 25 mg 2 venlafaxine oral tablet 75 mg 3 topiramate oral tablet 50 mg 2 3 tramadol-acetaminophen 4 4 2 4 1 3 MO MO MO venlafaxine oral tablet extended release 24hr 150 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VERSACLOZ 4 tramadol oral tablet PAR; MO; QLL (480 per 30 days) PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (1920 per 30 days) PAR; MO; QLL (960 per 30 days) MO; QLL (240 per 30 days) MO; QLL (240 per 30 days) MO MO 4 4 MO 4 ST; QLL (60 per 30 days) ST; QLL (30 per 30 days) ST; QLL (120 per 30 days) PAR; MO; LA MO MO MO VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS, DOSE PACK 10 MG (7)- 20 MG (23) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG VOLTAREN TOPICAL GEL 1 % VRAYLAR ORAL CAPSULE 1.5 MG VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 MG 4 tranylcypromine trazodone oral tablet 100 mg, 150 mg trazodone oral tablet 300 mg trazodone oral tablet 50 mg trifluoperazine oral tablet 1 mg, 2 mg trifluoperazine oral tablet 10 mg, 5 mg TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 20 MG TRINTELLIX ORAL TABLET 5 MG TYSABRI valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) venlafaxine oral capsule, extended release 24hr 150 mg venlafaxine oral capsule, extended release 24hr 37.5 mg venlafaxine oral capsule, extended release 24hr 75 mg venlafaxine oral tablet 100 mg 4 4 5 4 3 2 2 3 2 3 4 MO; QLL (60 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) MO; QLL (113 per 30 days) 4 4 4 5 4 4 4 4 4 4 4 4 3 4 5 MO; QLL (450 per 30 days) MO; QLL (300 per 30 days) MO; QLL (225 per 30 days) MO; QLL (150 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (180 per 30 days) MO; QLL (90 per 30 days) QLL (600 per 30 days) ST; MO; QLL (120 per 30 days) ST; MO; QLL (60 per 30 days) ST; MO; QLL (30 per 30 days) ST; MO; QLL (30 per 30 days) QLL (1200 per 30 days) MO; QLL (1200 per 30 days) MO; QLL (120 per 30 days) MO; QLL (80 per 30 days) MO; QLL (60 per 30 days) MO; QLL (240 per 30 days) MO; QLL (1000 per 30 days) PAR; QLL (30 per 30 days) PAR; QLL (30 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 32 Effective Date September 1, 2016 Drug Name VRAYLAR ORAL CAPSULE,DOSE PACK XENAZINE ORAL TABLET 12.5 MG XENAZINE ORAL TABLET 25 MG XYREM zaleplon oral capsule 10 mg Drug Requirements/ Tier Limits 4 5 5 5 3 zaleplon oral capsule 5 mg 3 ZARONTIN ORAL CAPSULE zenzedi oral tablet 10 mg 4 zenzedi oral tablet 5 mg 4 ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg zolpidem oral 4 4 4 4 4 PAR; QLL (7 per 365 days) PAR; MO; LA; QLL (240 per 30 days) PAR; MO; LA; QLL (120 per 30 days) PAR; MO; LA; QLL (540 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO PAR; MO; QLL (180 per 30 days) PAR; MO; QLL (90 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO zonisamide oral capsule 100 3 mg, 50 mg zonisamide oral capsule 25 mg 2 MO ZYPREXA RELPREVV 5 PAR; QLL (2 per 28 INTRAMUSCULAR days) SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV 5 PAR; MO; QLL (2 INTRAMUSCULAR per 28 days) SUSPENSION FOR RECONSTITUTION 300 MG Cardiovascular, Hypertension / Lipids ACCUPRIL 4 MO ACCURETIC ORAL 4 MO TABLET 20-12.5 MG, 20-25 MG acebutolol 2 MO ADALAT CC 4 MO Drug Name Drug Requirements/ Tier Limits afeditab cr AGGRENOX 2 4 ALDACTAZIDE ORAL TABLET 25-25 MG ALTACE ORAL CAPSULE 10 MG, 2.5 MG, 5 MG ALTOPREV 4 MO ST; MO; QLL (60 per 30 days) MO 4 MO 4 amiloride amiloride-hydrochlorothiazide amiodarone intravenous solution amiodarone intravenous syringe amiodarone oral tablet 100 mg, 200 mg amiodarone oral tablet 400 mg amlodipine besylate oral tablet 10 mg, 2.5 mg amlodipine besylate oral tablet 5 mg amlodipine-atorvastatin 3 2 4 PAR; MO; QLL (30 per 30 days) MO MO B/D PAR; MO 4 2 B/D PAR MO 4 1 amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-20 mg, 5-40 mg amlodipine-benazepril oral capsule 5-10 mg amlodipine-valsartan 3 MO MO; QLL (30 per 30 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) MO 2 MO 4 amlodipine-valsartan-hcthiazid 4 aspirin-dipyridamole 3 ATACAND HCT ORAL TABLET 16-12.5 MG ATACAND HCT ORAL TABLET 32-12.5 MG, 32-25 MG ATACAND ORAL TABLET 16 MG, 4 MG, 8 MG ATACAND ORAL TABLET 32 MG atenolol atenolol-chlorthalidone 4 MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) ST; MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) 1 3 4 4 4 1 1 MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 33 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits atorvastatin 6 AVALIDE ORAL TABLET 150-12.5 MG AVALIDE ORAL TABLET 300-12.5 MG AVAPRO 4 AZOR 3 benazepril benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 2012.5 mg, 5-6.25 mg benazepril-hydrochlorothiazide oral tablet 20-25 mg BENICAR HCT 6 2 MO; CG; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; CG MO 1 MO BENICAR ORAL TABLET 20 MG, 40 MG BENICAR ORAL TABLET 5 MG betaxolol oral BIDIL 3 4 4 3 bisoprolol fumarate bisoprolol-hydrochlorothiazide BRILINTA 2 1 3 bumetanide injection bumetanide oral tablet 0.5 mg, 1 mg bumetanide oral tablet 2 mg BYSTOLIC CALAN ORAL TABLET 120 MG CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg 4 2 MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO MO; QLL (180 per 30 days) MO MO MO; QLL (60 per 30 days) MO MO 3 3 4 MO MO MO 4 MO candesartan-hydrochlorothiazid oral tablet 16-12.5 mg 3 3 2 3 3 4 MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) Drug Name Drug Requirements/ Tier Limits candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg captopril oral tablet 100 mg, 25 mg, 50 mg captopril oral tablet 12.5 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 50-15 mg, 50-25 mg captopril-hydrochlorothiazide oral tablet 25-25 mg CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 420 MG cartia xt carvedilol chlorothiazide oral tablet 250 mg chlorothiazide oral tablet 500 mg chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg cholestyramine (with sugar) cholestyramine light cilostazol clonidine hcl oral tablet clonidine transdermal patch 3 MO; QLL (30 per 30 days) 2 MO 1 2 MO MO 1 MO 4 MO 2 1 1 MO MO MO 2 MO 4 2 MO MO 2 2 2 2 4 clopidogrel oral tablet 300 mg 4 clopidogrel oral tablet 75 mg 2 colestipol COREG CR CORZIDE ORAL TABLET 40-5 MG COUMADIN ORAL COZAAR ORAL TABLET 100 MG COZAAR ORAL TABLET 25 MG, 50 MG CRESTOR 2 4 4 MO MO MO MO MO; QLL (4 per 28 days) MO; QLL (1 per 30 days) MO; QLL (30 per 30 days) MO ST; MO MO DEMSER 4 4 4 4 3 MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 34 Effective Date September 1, 2016 Drug Name DIGITEK ORAL TABLET 125 MCG DIGOX ORAL TABLET 125 MCG digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg dilt-xr diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral capsule, extended release 360 mg diltiazem hcl oral capsule, extended release 420 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule, extended release 12 hr diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral capsule, extended release 24hr 360 mg diltiazem hcl oral tablet DIOVAN HCT Drug Requirements/ Tier Limits 3 MO 3 MO 3 3 2 4 2 MO MO MO Drug Name Drug Requirements/ Tier Limits enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml eplerenone eprosartan 4 EXFORGE 4 4 MO EXFORGE HCT 4 3 MO 3 2 MO 2 MO 3 MO 4 MO 2 MO 3 MO; QLL (30 per 30 days) 4 MO 3 MO 1 4 MO MO; QLL (30 per 30 days) felodipine oral tablet extended release 24 hr 10 mg felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg fenofibrate micronized oral capsule 130 mg fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate micronized oral capsule 43 mg fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg MO; QLL (8.4 per 30 days) MO; QLL (11.2 per 30 days) MO; QLL (16.8 per 30 days) MO MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO 3 MO 3 fenofibrate oral tablet 54 mg 2 fenofibric acid (choline) dr capsules flecainide oral tablet 100 mg, 50 mg flecainide oral tablet 150 mg fluvastatin oral capsule 20 mg 3 MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO 3 MO 4 3 fluvastatin oral capsule 40 mg 4 fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml 5 MO MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (24 per 30 days) MO; QLL (15 per 30 days) MO; QLL (12 per 30 days) dofetilide doxazosin DYAZIDE EFFIENT 4 2 4 3 ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG enalapril maleate enalapril-hydrochlorothiazide enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/ 0.8 ml 3 3 6 6 5 5 5 4 4 4 3 MO MO MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (74 per 30 days) MO; CG MO; CG MO; QLL (84 per 30 days) MO; QLL (28 per 30 days) MO; QLL (22.4 per 30 days) 4 5 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 35 Effective Date September 1, 2016 Drug Name fondaparinux subcutaneous syringe 7.5 mg/0.6 ml fosinopril fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg fosinopril-hydrochlorothiazide oral tablet 20-12.5 mg furosemide injection furosemide oral solution 10 mg/ ml furosemide oral solution 40 mg/ 5 ml (8 mg/ml) furosemide oral tablet gemfibrozil oral heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection solution heparin(porcine) in 0.45% nacl intravenous parenteral solution 12,500 unit/250 ml heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/500 ml heparin, porcine (pf) injection solution hydralazine injection Drug Requirements/ Tier Limits 5 1 3 MO; QLL (18 per 30 days) MO MO 2 MO 4 2 MO MO 1 MO 1 2 4 MO MO B/D PAR 4 4 4 MO B/D PAR 4 B/D PAR; MO 4 B/D PAR; MO 4 B/D PAR 4 4 Drug Name Drug Requirements/ Tier Limits hydralazine oral hydrochlorothiazide HYZAAR 2 1 4 indapamide irbesartan 1 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 5 mg isosorbide dinitrate oral tablet 30 mg isosorbide dinitrate oral tablet extended release isosorbide mononitrate isradipine jantoven oral tablet 1 mg, 10 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg jantoven oral tablet 2 mg JUXTAPID labetalol intravenous solution labetalol oral tablet 100 mg, 200 mg labetalol oral tablet 300 mg LANOXIN ORAL TABLET 125 MCG, 62.5 MCG LESCOL 2 LIPITOR ORAL TABLET 10 MG lisinopril lisinopril-hydrochlorothiazide LOFIBRA ORAL CAPSULE 200 MG LOPID losartan oral tablet 100 mg 4 losartan oral tablet 25 mg, 50 mg losartan-hydrochlorothiazide 6 4 MO MO MO; QLL (30 per 30 days) MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO 3 MO 4 MO 2 3 1 MO MO MO 2 5 4 2 MO PAR; MO; LA MO MO 3 3 MO MO 4 MO; QLL (60 per 30 days) MO 3 6 6 4 4 6 B/D PAR; MO 4 MO 4 MO 6 MO; CG MO; CG MO; QLL (30 per 30 days) MO MO; CG; QLL (30 per 30 days) MO; CG; QLL (60 per 30 days) MO; CG; QLL (30 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 36 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits LOTENSIN ORAL TABLET 20 MG, 40 MG lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg 4 MO 6 MAVIK ORAL TABLET 1 MG, 2 MG MAXZIDE MAXZIDE-25MG methyclothiazide metolazone oral tablet 10 mg, 5 mg metolazone oral tablet 2.5 mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg metoprolol succinate oral tablet extended release 24 hr 200 mg metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg metoprolol ta-hydrochlorothiaz oral tablet 50-25 mg metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 37.5 mg, 75 mg mexiletine oral capsule 150 mg, 250 mg mexiletine oral capsule 200 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-25 MG MICARDIS HCT ORAL TABLET 80-12.5 MG MICARDIS ORAL TABLET 20 MG, 40 MG MICARDIS ORAL TABLET 80 MG MICROZIDE 4 MO; CG; QLL (30 per 30 days) MO; CG; QLL (60 per 30 days) MO 6 4 4 3 3 MO MO MO MO 2 2 MO MO 3 MO 3 MO 2 MO 4 MO 4 1 MO 1 3 MO 4 4 MO MO; QLL (30 per 30 days) 4 4 4 4 MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO Drug Name Drug Requirements/ Tier Limits MINIPRESS ORAL CAPSULE 2 MG minoxidil oral moexipril moexipril-hydrochlorothiazide MULTAQ 4 MO 2 2 2 3 nadolol oral tablet 20 mg, 40 mg nadolol oral tablet 80 mg nadolol-bendroflumethiazide niacin oral tablet extended release 24 hr 1,000 mg, 750 mg niacin oral tablet extended release 24 hr 500 mg NIACOR nicardipine intravenous solution nicardipine oral nifedical xl nifedipine oral tablet extended release 24hr 30 mg, 60 mg nifedipine oral tablet extended release 24hr 90 mg nifedipine oral tablet extended release 30 mg, 60 mg nifedipine oral tablet extended release 90 mg nimodipine nitroglycerin intravenous nitroglycerin transdermal patch 24 hour NITROSTAT NORPACE NORVASC ORAL TABLET 10 MG, 2.5 MG NORVASC ORAL TABLET 5 MG omega-3 acid ethyl esters pacerone oral tablet 100 mg, 400 mg pacerone oral tablet 200 mg pentoxifylline perindopril erbumine pindolol oral tablet 10 mg 3 MO MO MO MO; QLL (60 per 30 days) MO 4 3 4 MO MO MO; QLL (60 per 30 days) 4 3 4 MO; QLL (30 per 30 days) MO MO 2 2 2 MO MO MO 3 MO 2 MO 3 MO 4 4 2 MO B/D PAR MO 3 4 4 3 4 MO PAR; MO MO; QLL (30 per 30 days) MO; QLL (45 per 30 days) PAR; MO MO 2 2 2 3 MO MO MO MO 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 37 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits pindolol oral tablet 5 mg PRADAXA 2 4 PRALUENT PEN 5 PRALUENT SYRINGE 5 PRAVACHOL ORAL TABLET 20 MG pravastatin oral tablet 10 mg, 20 mg, 40 mg pravastatin oral tablet 80 mg 4 prazosin oral capsule 1 mg, 2 mg prazosin oral capsule 5 mg prevalite PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml PROCARDIA PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PROMACTA ORAL TABLET 50 MG propafenone oral tablet 150 mg, 225 mg propafenone oral tablet 300 mg propranolol intravenous propranolol oral capsule, extended release 24 hr 120 mg, 160 mg propranolol oral capsule, extended release 24 hr 60 mg, 80 mg propranolol oral solution propranolol oral tablet 10 mg, 20 mg, 40 mg, 80 mg propranolol oral tablet 60 mg 2 MO; CG; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO 3 2 4 MO MO MO 6 1 MO MO; QLL (60 per 30 days) PAR; MO; QLL (2 per 28 days) PAR; MO; QLL (2 per 28 days) MO Drug Name propranolol-hydrochlorothiazid quinapril oral tablet 10 mg, 5 mg quinapril oral tablet 20 mg, 40 mg quinapril-hydrochlorothiazide quinidine sulfate oral tablet ramipril RANEXA REPATHA SURECLICK 2 1 MO MO 2 MO 2 2 1 3 5 REPATHA SYRINGE 5 reserpine oral tablet 0.1 mg rosuvastatin 1 3 simvastatin 6 2 MO MO MO MO PAR; MO; QLL (3 per 28 days) PAR; MO; QLL (3 per 28 days) PAR; MO QLL (30 per 30 days) MO; CG; QLL (30 per 30 days) MO 2 1 2 MO MO 1 2 MO MO 1 3 3 MO MO MO 2 MO 4 MO 2 MO 3 MO 4 MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) 2 1 sorine oral tablet 120 mg, 160 MO mg sorine oral tablet 240 mg sorine oral tablet 80 mg sotalol af oral tablet 120 mg, PAR; MO 160 mg MO sotalol af oral tablet 80 mg sotalol oral tablet 120 mg, 160 mg, 240 mg PAR; MO; LA; QLL sotalol oral tablet 80 mg (30 per 30 days) spironolacton-hydrochlorothiaz spironolactone oral tablet 100 PAR; MO; LA; QLL mg (60 per 30 days) spironolactone oral tablet 25 MO mg, 50 mg SULAR ORAL TABLET MO EXTENDED RELEASE 24 HR 17 MG MO taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 360 mg MO taztia xt oral capsule, extended release 300 mg TEKTURNA MO MO TEKTURNA HCT 2 MO 4 4 4 4 5 5 3 4 4 3 2 Drug Requirements/ Tier Limits 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 38 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg 4 telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg TENORETIC 100 TENORETIC 50 terazosin TIAZAC TIKOSYN timolol maleate oral tablet 10 mg, 5 mg timolol maleate oral tablet 20 mg torsemide oral tablet 10 mg, 5 mg torsemide oral tablet 100 mg, 20 mg trandolapril tranexamic acid intravenous triamterene-hydrochlorothiazid oral capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet TRIBENZOR 4 TRICOR ORAL TABLET 48 MG TRILIPIX ORAL CAPSULE, DELAYED RELEASE(DR/ EC) 45 MG TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-5 MG valsartan oral tablet 160 mg valsartan oral tablet 320 mg 4 valsartan oral tablet 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- 4 Drug Name Drug Requirements/ Tier Limits 4 4 1 4 4 2 MO; QLL (60 per 30 days) MO MO MO MO MO MO 3 MO 2 MO 3 MO 1 3 1 MO MO MO 1 MO 3 4 MO; QLL (30 per 30 days) MO 4 MO 4 MO; QLL (30 per 30 days) 25 mg, 320-12.5 mg, 80-12.5 mg valsartan-hydrochlorothiazide oral tablet 320-25 mg VASCEPA VASERETIC VASOTEC ORAL TABLET 2.5 MG VECAMYL verapamil intravenous solution verapamil intravenous syringe verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 mg verapamil oral tablet verapamil oral tablet extended release 120 mg, 120 mg (24 hours) verapamil oral tablet extended release 180 mg, 240 mg warfarin WELCHOL XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLETS,DOSE PACK ZESTORETIC ZESTRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG ZETIA MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (90 per 30 days) MO; QLL (30 per 30 days) ZIAC ORAL TABLET 104 6.25 MG, 5-6.25 MG ZOCOR ORAL TABLET 10 4 MO MG, 5 MG Dermatologicals/Topical Therapy acitretin 5 MO acyclovir topical 4 MO; QLL (30 per 30 days) 4 4 4 2 MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) 3 4 4 4 4 4 4 3 MO; QLL (30 per 30 days) MO MO MO MO MO 2 MO 3 MO 1 2 MO MO 1 MO 1 3 3 MO MO MO; QLL (30 per 30 days) MO; QLL (42 per 30 days) MO; QLL (102 per 365 days) MO MO 3 3 4 4 4 MO; QLL (30 per 30 days) MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 39 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits adapalene topical gel 0.1 % alclometasone topical cream alclometasone topical ointment amcinonide ammonium lactate betamethasone dipropionate topical cream betamethasone dipropionate topical lotion betamethasone dipropionate topical ointment betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment calcipotriene scalp 4 4 3 4 2 4 MO MO MO MO MO MO 3 MO 4 MO 2 MO 4 MO 3 MO 3 MO 4 MO 4 MO 4 MO calcipotriene topical 4 ciclodan topical cream ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension claravis oral capsule 10 mg, 20 mg, 40 mg claravis oral capsule 30 mg clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution 3 3 3 4 4 2 3 4 MO; QLL (60 per 30 days) MO; QLL (120 per 30 days) MO PAR; MO MO MO MO PAR; MO MO MO 5 3 MO MO 3 MO 3 MO 4 Drug Name Drug Requirements/ Tier Limits clindamycin phosphate topical swab clindamycin-benzoyl peroxide topical gel clobetasol scalp clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol-emollient topical cream clobetasol-emollient topical foam CLOBEX TOPICAL LOTION clotrimazole topical cream clotrimazole topical solution clotrimazole-betamethasone topical cream clotrimazole-betamethasone topical lotion cormax scalp DENAVIR 2 MO 4 MO 2 2 4 2 4 3 4 3 MO MO MO MO MO MO MO MO 4 MO 4 MO 3 2 3 MO MO MO 4 MO DERMATOP TOPICAL OINTMENT desonide desoximetasone topical cream desoximetasone topical gel desoximetasone topical ointment 0.25 % diflorasone DIPROLENE AF econazole topical ELIDEL 4 MO; QLL (5 per 2 days) MO 4 4 4 4 MO MO MO MO 4 4 2 4 ELOCON TOPICAL SOLUTION ery pads erythromycin with ethanol erythromycin-benzoyl peroxide fluocinolone topical cream fluocinolone topical ointment 4 MO MO MO PAR; MO; QLL (100 per 90 days) MO 3 2 3 4 4 MO MO MO MO MO 2 3 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 40 Effective Date September 1, 2016 Drug Name fluocinolone topical solution fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluorouracil topical cream 5 % fluorouracil topical solution fluticasone topical cream fluticasone topical lotion fluticasone topical ointment gentamicin topical halobetasol propionate hydrocortisone butyrate topical cream hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone topical cream 1 % hydrocortisone topical cream 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1% hydrocortisone topical ointment 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet imiquimod ketoconazole topical cream ketoconazole topical shampoo lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch, medicated lidocaine topical ointment lidocaine viscous lidocaine-prilocaine topical cream lindane topical shampoo Drug Requirements/ Tier Limits 4 2 MO MO 3 3 4 3 4 4 3 4 3 3 4 2 MO MO MO MO MO MO MO MO MO MO MO MO 4 MO 2 MO 1 MO 2 MO 3 MO 1 MO 2 MO 4 2 4 3 2 2 2 2 4 4 2 4 MO MO MO MO MO MO MO MO PAR; MO; QLL (90 per 30 days) MO MO MO 4 MO Drug Name Drug Requirements/ Tier Limits malathion methoxsalen rapid metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion mometasone topical mupirocin calcium mupirocin topical ointment myorisan oral capsule 10 mg, 20 mg, 40 mg nyamyc nystatin topical cream nystatin topical ointment nystatin topical powder nystatin-triamcinolone nystop PANRETIN permethrin topical cream PICATO podofilox prednicarbate rosadan topical cream rosadan topical gel SANTYL 4 5 4 3 MO PAR; MO MO MO 4 2 4 2 4 MO MO MO MO MO 3 2 3 3 4 3 5 3 4 4 4 2 2 4 selenium sulfide topical lotion SILVADENE silver sulfadiazine ssd sulfacetamide sodium (acne) TAZORAC TEMOVATE TOPICAL CREAM TEMOVATE TOPICAL OINTMENT tretinoin topical cream 2 3 2 2 4 4 4 MO MO MO MO MO MO MO MO MO MO MO MO MO MO; QLL (30 per 30 days) MO MO MO MO MO PAR; MO MO 4 MO 3 tretinoin topical gel 0.01 %, 0.025 % triamcinolone acetonide topical cream 0.025 % triamcinolone acetonide topical cream 0.1 %, 0.5 % 3 1 MO; QLL (45 per 30 days) MO; QLL (45 per 30 days) MO 2 MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 41 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits triamcinolone acetonide topical 3 MO lotion 0.025 % triamcinolone acetonide topical 4 MO lotion 0.1 % triamcinolone acetonide topical 2 MO ointment 0.025 %, 0.1 %, 0.5 % trianex 2 MO triderm topical cream 1 MO UVADEX 4 VALCHLOR 5 MO zenatane oral capsule 10 mg, 4 MO 20 mg, 40 mg ZENATANE ORAL 3 MO CAPSULE 30 MG Diagnostics / Miscellaneous Agents acamprosate 4 MO acetic acid irrigation 2 MO acetylcysteine intravenous 2 MO ADAGEN 5 MO alendronate oral tablet 40 mg 6 MO; CG; QLL (30 per 30 days) anagrelide 3 MO ARALAST NP 5 PAR; MO; LA BUPHENYL ORAL 5 PAR; MO TABLET buproban 2 QLL (60 per 30 days) CARBAGLU 5 PAR; MO; LA CHANTIX 4 PAR; MO; QLL (60 per 30 days) CHANTIX CONTINUING 4 PAR; MO; QLL (56 MONTH BOX per 28 days) CHANTIX STARTING 4 PAR; MO; QLL MONTH BOX (106 per 365 days) CLINIMIX 4.25%/D5W 4 B/D PAR SULFIT FREE CLINIMIX E 2.75%/D10W 4 B/D PAR SUL FREE CLINIMIX E 2.75%/D5W 4 B/D PAR SULF FREE d10 %-0.45 % sodium 4 chloride d2.5 %-0.45 % sodium 4 chloride Drug Name Drug Requirements/ Tier Limits d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) dextrose with sodium chloride disulfiram etidronate disodium oral tablet 200 mg etidronate disodium oral tablet 400 mg EXJADE INCRELEX kionex lactated ringers irrigation levocarnitine (with sugar) levocarnitine intravenous levocarnitine oral tablet midodrine neomycin-polymyxin b gu NICOTROL NS 4 MO 4 4 4 4 4 4 4 4 4 4 4 MO ORFADIN ORAL CAPSULE PHYSIOLYTE PHYSIOSOL IRRIGATION pilocarpine hcl oral PROLASTIN-C RAVICTI 5 RENVELA ORAL POWDER IN PACKET 0.8 GRAM 5 MO MO MO MO 4 4 4 4 3 MO 2 MO 5 5 3 4 3 4 3 4 4 3 PAR; MO; LA PAR; MO; LA MO MO B/D PAR; MO B/D PAR; MO MO MO MO MO; QLL (120 per 30 days) LA 4 4 4 5 5 MO MO MO PAR; LA PAR; MO; QLL (525 per 30 days) MO; QLL (180 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 42 Effective Date September 1, 2016 Drug Name RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET riluzole ringers irrigation risedronate oral tablet 30 mg Drug Requirements/ Tier Limits 5 MO; QLL (90 per 30 days) 3 MO; QLL (270 per 30 days) MO MO ST; MO; QLL (30 per 30 days) MO 4 4 4 sodium chloride 0.9 % 4 intravenous sodium chloride irrigation 4 sodium phenylbutyrate 5 sodium polystyrene (sorb free) 4 sodium polystyrene sulfonate 4 oral powder sodium polystyrene sulfonate 4 oral suspension sodium polystyrene sulfonate 4 rectal sps oral 4 sps rectal 4 SYPRINE 5 THIOLA 5 water for irrigation, sterile 4 Ear, Nose / Throat Medications acetasol hc 4 acetic acid otic 3 acetic acid-aluminum acetate 2 azelastine nasal 4 chlorhexidine gluconate mucous membrane CIPRODEX denta 5000 plus dentagel fluocinolone acetonide oil otic hydrocortisone-acetic acid ipratropium bromide nasal 1 neomycin-polymyxin-hc otic ofloxacin otic paroex oral rinse periogard sf 5000 plus 2 2 1 1 2 3 2 2 4 4 2 MO PAR; MO MO MO MO MO MO MO MO MO MO MO; QLL (30 per 25 days) MO MO MO MO MO MO MO; QLL (30 per 30 days) MO MO MO MO MO Drug Name Drug Requirements/ Tier Limits triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % Endocrine/Diabetes acarbose oral tablet 100 mg 4 4 MO MO 3 acarbose oral tablet 25 mg 3 acarbose oral tablet 50 mg 3 ACTHAR H.P. ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1, 000 MG ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1, 000 MG alcohol pads ALDURAZYME AMARYL ORAL TABLET 1 MG AMARYL ORAL TABLET 2 MG AMARYL ORAL TABLET 4 MG ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/ 2.5 GRAM) androxy BYDUREON 5 4 MO; QLL (90 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) PAR; MO MO; QLL (60 per 30 days) BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/ 3 4 MO; QLL (45 per 30 days) 1 5 4 MO PAR; MO MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) PAR; MO; QLL (150 per 30 days) 4 4 3 3 PAR; MO; QLL (112.5 per 30 days) 3 PAR; MO; QLL (150 per 30 days) 4 3 PAR; MO MO; QLL (4 per 28 days) MO; QLL (2.4 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 43 Effective Date September 1, 2016 Drug Name DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML cabergoline calcitonin (salmon) calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule calcitriol oral solution CEREZYME INTRAVENOUS RECON SOLN 400 UNIT cortisone CYCLOSET CYTOMEL danazol oral desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal solution desmopressin nasal spray,nonaerosol desmopressin oral dexamethasone oral elixir 0.5mg/ml dexamethasone oral solution 0.5mg/ml dexamethasone oral tablet 0.5 mg, 1.5 mg dexamethasone oral tablet 0.75 mg, 1 mg, 4 mg, 6 mg dexamethasone oral tablet 2 mg dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection doxercalciferol intravenous DUETACT ORAL TABLET 30-4 MG ELAPRASE FABRAZYME fludrocortisone Drug Requirements/ Tier Limits 3 3 3 4 2 3 5 4 4 MO; QLL (1.2 per 30 days) MO MO; QLL (4 per 30 days) MO B/D PAR; MO B/D PAR; MO PAR; MO 4 3 5 4 3 4 MO ST; MO; QLL (180 per 30 days) MO MO MO MO MO MO 4 4 MO MO 4 1 2 MO MO MO 3 4 4 MO MO MO 4 4 B/D PAR MO; QLL (30 per 30 days) PAR; MO PAR; MO MO 5 5 3 Drug Name Drug Requirements/ Tier Limits fortical 3 gauze pads 2 x 2 1 glimepiride oral tablet 1 mg 6 glimepiride oral tablet 2 mg 6 glimepiride oral tablet 4 mg 6 glipizide oral tablet 10 mg 6 glipizide oral tablet 5 mg 6 glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet 2.5-250 mg glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCOPHAGE ORAL TABLET 1,000 MG GLUCOPHAGE ORAL TABLET 500 MG GLUCOPHAGE ORAL TABLET 850 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG GLUCOTROL ORAL TABLET 10 MG GLUCOTROL ORAL TABLET 5 MG 1 6 6 2 3 3 4 4 4 4 4 MO; QLL (4 per 30 days) MO; QLL (200 per 30 days) MO; CG; QLL (240 per 30 days) MO; CG; QLL (120 per 30 days) MO; CG; QLL (60 per 30 days) MO; CG; QLL (120 per 30 days) MO; CG; QLL (240 per 30 days) MO; QLL (60 per 30 days) MO; CG; QLL (240 per 30 days) MO; CG; QLL (120 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO MO MO; QLL (76 per 30 days) MO; QLL (153 per 30 days) MO; QLL (90 per 30 days) MO; QLL (120 per 30 days) 4 MO; QLL (80 per 30 days) 4 MO; QLL (120 per 30 days) MO; QLL (240 per 30 days) 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 44 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG GLUCOVANCE 4 MO; QLL (60 per 30 days) 4 MO; QLL (240 per 30 days) GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 MG HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50-50 HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 75-25 HUMALOG MIX 75-25 KWIKPEN HUMAPEN LUXURA HD 4 HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydrocortisone oral tablet 10 mg, 5 mg hydrocortisone oral tablet 20 mg insulin pen needle 3 3 4 MO; QLL (120 per 30 days) 4 PAR; MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) 4 3 3 3 3 3 3 3 3 3 3 3 MO; QLL (120 per 30 days) MO MO MO MO MO MO MO; QLL (200 per 30 days) MO MO MO MO MO 3 MO 3 MO 2 MO 3 MO; QLL (200 per 30 days) Drug Name Drug Requirements/ Tier Limits INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML JANUMET 3 MO; QLL (200 per 30 days) 3 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 1001,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1, 000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE 3 MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) JENTADUETO 3 KORLYM KUVAN ORAL TABLET, SOLUBLE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous liothyronine oral tablet 25 mcg, 5 mcg liothyronine oral tablet 50 mcg metformin oral tablet 1,000 mg metformin oral tablet 500 mg 6 metformin oral tablet 850 mg 6 3 MO; QLL (60 per 30 days) 3 5 5 MO; QLL (30 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) PAR; MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) PAR; MO PAR; MO 3 3 3 3 1 2 MO MO MO MO MO MO 5 3 MO MO 4 6 MO MO; CG; QLL (76 per 30 days) MO; CG; QLL (153 per 30 days) MO; CG; QLL (90 per 30 days) 3 3 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 45 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg metformin oral tablet extended release 24hr 500 mg metformin oral tablet,er gast.retention 24 hr 1,000 mg metformin oral tablet,er gast.retention 24 hr 500 mg methimazole oral tablet 10 mg methimazole oral tablet 5 mg methylprednisolone acetate methylprednisolone oral tablet 16 mg, 4 mg, 8 mg methylprednisolone oral tablet 32 mg methylprednisolone oral tablets, dose pack methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous MIACALCIN INJECTION MIACALCIN NASAL 6 MYOZYME NAGLAZYME nateglinide oral tablet 120 mg 5 5 4 Drug Requirements/ Tier Limits pamidronate intravenous recon soln pamidronate intravenous solution 30 mg/10 ml (3 mg/ ml), 90 mg/10 ml (9 mg/ml) pamidronate intravenous solution 60 mg/10 ml (6 mg/ ml) paricalcitol oral capsule 1 mcg, 2 mcg paricalcitol oral capsule 4 mcg pioglitazone oral tablet 15 mg 4 MO 4 MO 4 B/D PAR; MO 4 B/D PAR; MO 5 2 3 2 4 4 MO; CG; QLL (120 per 30 days) MO; CG; QLL (80 per 30 days) MO; QLL (75 per 30 days) MO; CG; QLL (150 per 30 days) MO; QLL (60 per 30 days) MO; QLL (120 per 30 days) MO MO MO MO pioglitazone oral tablet 30 mg 2 pioglitazone oral tablet 45 mg 2 3 MO pioglitazone-glimepiride 4 3 MO pioglitazone-metformin 4 4 MO 3 B/D PAR; MO MO; QLL (90 per 30 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (90 per 30 days) MO; QLL (90 per 30 days) MO; QLL (360 per 30 days) MO; QLL (180 per 30 days) MO 3 MO 4 MO 4 MO 4 3 2 1 MO MO MO MO 1 MO 5 3 MO MO 6 4 6 4 4 4 4 4 nateglinide oral tablet 60 mg 4 NATPARA 5 needles, insulin disp.,safety 3 NOVOPEN ECHO 3 oxandrolone oral tablet 10 mg 5 oxandrolone oral tablet 2.5 mg Drug Name 3 PRECOSE ORAL TABLET 100 MG PRECOSE ORAL TABLET 25 MG MO PRECOSE ORAL TABLET 50 MG B/D PAR; MO MO; QLL (4 per 30 prednisolone oral solution 15 mg/5 ml days) prednisolone sodium phosphate PAR; MO oral solution 15 mg/5 ml (3 PAR; MO; LA mg/ml) MO; QLL (90 per prednisolone sodium phosphate 30 days) MO; QLL (180 per oral solution 5 mg base/5 ml (6.7 mg/5 ml) 30 days) PAR; MO; LA; QLL prednisolone sodium phosphate oral tablet,disintegrating (2 per 28 days) MO; QLL (200 per prednisone intensol prednisone oral solution 30 days) MO; QLL (200 per prednisone oral tablet 1 mg prednisone oral tablet 10 mg, 30 days) PAR; MO; QLL (60 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablets,dose per 30 days) pack PAR; MO; QLL PROGLYCEM (120 per 30 days) propylthiouracil 4 4 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 46 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits repaglinide oral tablet 0.5 mg 4 repaglinide oral tablet 1 mg 4 repaglinide oral tablet 2 mg 4 SAMSCA ORAL TABLET 15 MG SAMSCA ORAL TABLET 30 MG SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG SENSIPAR ORAL TABLET 90 MG SOMAVERT STIMATE SYMLINPEN 120 5 SYMLINPEN 60 4 SYNAREL SYNJARDY 5 4 SYNTHROID TANZEUM 5 3 5 5 5 4 5 4 4 TAPAZOLE testosterone cypionate testosterone enanthate testosterone transdermal gel 4 4 4 3 testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation testosterone transdermal gel in packet 1 % (25 mg/2.5gram) testosterone transdermal gel in packet 1 % (50 mg/5 gram) tolazamide oral tablet 250 mg 3 3 3 3 2 MO; QLL (960 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) PAR; MO; QLL (30 per 30 days) PAR; MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (60 per 30 days) MO; QLL (120 per 30 days) PAR; MO MO PAR; MO; QLL (11 per 30 days) PAR; MO; QLL (6 per 30 days) PAR; MO PAR; MO; QLL (60 per 30 days) MO MO; QLL (4 per 28 days) MO MO MO PAR; MO; QLL (300 per 30 days) PAR; MO; QLL (300 per 30 days) PAR; MO; QLL (120 per 30 days) PAR; MO; QLL (225 per 30 days) PAR; MO; QLL (300 per 30 days) MO; QLL (120 per 30 days) Drug Name Drug Requirements/ Tier Limits tolazamide oral tablet 500 mg 2 tolbutamide 3 TOUJEO SOLOSTAR TRADJENTA 3 3 triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml TRULICITY 4 unithroid VICTOZA 2-PAK 1 3 VICTOZA 3-PAK 3 VPRIV ZAVESCA zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Gastroenterology alosetron 5 5 5 MO; QLL (2 per 28 days) MO MO; QLL (9 per 30 days) MO; QLL (9 per 30 days) PAR; MO PAR; MO; LA PAR 5 PAR; MO 5 PAR; MO 5 APRISO ASACOL HD atropine injection syringe 0.05 mg/ml, 0.1 mg/ml balsalazide budesonide oral CIMZIA 3 3 4 PAR; MO; QLL (60 per 30 days) MO MO CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT 5 compro constulose CREON ORAL CAPSULE, DELAYED RELEASE(DR/ EC) 12,000-38,000 -60,000 4 3 3 MO; QLL (60 per 30 days) MO; QLL (180 per 30 days) MO MO; QLL (30 per 30 days) MO 4 4 4 5 5 5 MO MO PAR; MO; QLL (6 per 28 days) PAR; MO; QLL (6 per 28 days) PAR; MO; QLL (6 per 28 days) PAR; MO MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 47 Effective Date September 1, 2016 Drug Name UNIT, 24,000-76,000 -120, 000 UNIT, 3,000-9,500- 15, 000 UNIT, 6,000-19,000 30,000 UNIT CREON ORAL CAPSULE, DELAYED RELEASE(DR/ EC) 36,000-114,000- 180, 000 UNIT cromolyn oral CYSTADANE DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) DEXILANT Drug Requirements/ Tier Limits 5 MO 4 5 3 MO MO MO 4 dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet DIPENTUM diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet dronabinol oral capsule 10 mg 2 4 2 5 1 ST; MO; QLL (30 per 30 days) MO MO MO MO MO 3 MO 5 dronabinol oral capsule 2.5 mg, 5 mg 4 EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG 3 EMEND ORAL CAPSULE, DOSE PACK 3 enulose esomeprazole sodium intravenous famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral suspension 2 4 B/D PAR; MO; QLL (120 per 30 days) B/D PAR; MO; QLL (120 per 30 days) B/D PAR; MO; QLL (5 per 30 days) B/D PAR; MO; QLL (1 per 2 days) B/D PAR; MO; QLL (10 per 30 days) B/D PAR; MO; QLL (15 per 30 days) MO 3 3 4 4 4 4 MO MO MO Drug Name famotidine oral tablet 20 mg, 40 mg GATTEX 30-VIAL GATTEX ONE-VIAL gavilyte-c gavilyte-g gavilyte-n generlac glycopyrrolate injection glycopyrrolate oral tablet hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema lactulose lansoprazole oral capsule, delayed release(dr/ec) LIALDA LINZESS loperamide oral capsule meclizine oral tablet 12.5 mg, 25 mg mesalamine rectal mesalamine with cleansing wipe methscopolamine oral metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet misoprostol oral tablet 100 mcg misoprostol oral tablet 200 mcg MOVIPREP nizatidine oral capsule 150 mg nizatidine oral capsule 300 mg omeprazole oral capsule,delayed release(dr/ec) 10 mg, 40 mg omeprazole oral capsule,delayed release(dr/ec) 20 mg ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl intravenous Drug Requirements/ Tier Limits 2 MO 5 5 2 2 2 3 4 4 1 MO MO MO MO MO MO MO MO 4 2 4 3 3 3 2 MO MO MO; QLL (30 per 30 days) MO MO MO MO 3 4 4 4 MO MO MO MO 4 2 MO 2 3 4 4 3 4 2 MO MO MO MO MO MO MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO 3 4 4 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 48 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits ondansetron hcl oral tablet 4 mg, 8 mg 3 ondansetron oral tablet, disintegrating 4 mg 4 ondansetron oral tablet, disintegrating 8 mg 3 opium tincture OSMOPREP pantoprazole intravenous pantoprazole oral 2 4 4 2 paregoric peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram peg-electrolyte soln PENTASA polyethylene glycol 3350 oral prochlorperazine prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral procto-pak proctosol hc proctozone-hc propantheline ranitidine hcl injection ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE SUCRAID sucralfate oral tablet 2 2 B/D PAR; MO; QLL (90 per 30 days) B/D PAR; MO; QLL (90 per 30 days) B/D PAR; MO; QLL (90 per 30 days) MO MO MO MO; QLL (30 per 30 days) MO MO 2 2 3 2 4 4 MO MO PAR; MO PAR; MO 2 2 2 1 4 4 4 2 PAR; MO MO MO MO MO MO MO MO 4 PAR; MO 5 PAR; MO 5 5 2 PAR; MO MO MO Drug Name Drug Requirements/ Tier Limits sulfasalazine 2 MO SUPREP BOWEL PREP KIT 3 MO trilyte with flavor packets 2 MO UCERIS ORAL 5 MO ursodiol 4 MO Immunology, Vaccines / Biotechnology ACTHIB (PF) 3 MO ACTIMMUNE 5 PAR; MO ADACEL(TDAP 3 MO ADOLESN/ADULT)(PF) ARANESP (IN 5 PAR; MO POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ ML, 300 MCG/ML ARANESP (IN 4 PAR; MO POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN 4 PAR; MO POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/ 0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML ARANESP (IN 5 PAR; MO POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/ 0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML ARCALYST 5 PAR; MO AVONEX (WITH 5 PAR; MO; QLL (4 ALBUMIN) per 28 days) AVONEX 5 PAR; MO; QLL (4 INTRAMUSCULAR PEN per 28 days) INJECTOR KIT AVONEX 5 PAR; MO; QLL (4 INTRAMUSCULAR per 28 days) SYRINGE AVONEX 5 PAR; MO; QLL (4 INTRAMUSCULAR per 28 days) SYRINGE KIT BCG VACCINE, LIVE (PF) 4 MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 49 Effective Date September 1, 2016 Drug Name BETASERON SUBCUTANEOUS KIT BEXSERO (PF) BIVIGAM BOOSTRIX TDAP BOTOX CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) DYSPORT ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) EXTAVIA SUBCUTANEOUS KIT EXTAVIA SUBCUTANEOUS RECON SOLN fomepizole GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMUNEX-C GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) ILARIS (PF) IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) Drug Requirements/ Tier Limits 5 PAR; MO 3 5 3 4 5 MO PAR; MO MO PAR; MO PAR; MO 3 3 MO MO 4 3 3 PAR; MO B/D PAR; MO B/D PAR; MO 5 PAR; MO 5 PAR 5 3 5 5 MO PAR; MO PAR; MO PAR; MO 5 3 3 3 PAR; MO MO MO MO 3 MO 3 3 5 3 PAR; MO; LA MO 3 MO Drug Name Drug Requirements/ Tier Limits INTRON A INJECTION IPOL INJECTION SUSPENSION IXIARO (PF) M-M-R II (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W135 MENOMUNE - A/C/Y/W135 (PF) MENVEO A-C-Y-W-135DIP (PF) NEUPOGEN NORDITROPIN FLEXPRO OCTAGAM OMNITROPE PEDVAX HIB (PF) PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PLEGRIDY 5 3 PAR; MO MO 3 3 3 MO MO MO PRIVIGEN PROCRIT INJECTION SOLUTION 10,000 UNIT/ ML, 2,000 UNIT/ML, 20, 000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ ML, 40,000 UNIT/ML PROLEUKIN PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 4 3 3 MO 3 MO 5 5 5 5 3 5 PAR; MO PAR; MO PAR; MO PAR; MO MO PAR; MO 5 PAR; MO; QLL (1 per 28 days) PAR; MO PAR; MO; QLL (12 per 28 days) 5 PAR; MO; QLL (12 per 28 days) 5 3 3 4 5 5 5 3 MO MO MO PAR; MO PAR; MO PAR; MO B/D PAR; MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 50 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits RECOMBIVAX HB (PF) 3 INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) 3 INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX 3 ROTATEQ VACCINE 3 SYLATRON 5 tetanus,diphtheria tox ped(pf) 3 TETANUS-DIPHTHERIA 3 TOXOIDS-TD THYMOGLOBULIN 5 TICE BCG 4 TRUMENBA 3 TWINRIX (PF) 3 TYPHIM VI 3 INTRAMUSCULAR SOLUTION TYPHIM VI 3 INTRAMUSCULAR SYRINGE VAQTA (PF) 3 INTRAMUSCULAR SUSPENSION VAQTA (PF) 3 INTRAMUSCULAR SYRINGE VARIVAX (PF) 3 VARIZIG 3 XEOMIN 4 INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT XEOMIN 5 INTRAMUSCULAR RECON SOLN 200 UNIT YF-VAX (PF) 3 ZOSTAVAX (PF) 3 Musculoskeletal / Rheumatology ACTEMRA 5 INTRAVENOUS VIAL alendronate oral solution 3 alendronate oral tablet 10 mg, 5 mg 6 MO MO PAR; MO MO MO B/D PAR MO MO MO MO MO MO PAR; MO PAR; MO MO MO PAR; MO MO; QLL (300 per 28 days) MO; CG; QLL (30 per 30 days) Drug Name Drug Requirements/ Tier Limits alendronate oral tablet 35 mg, 70 mg allopurinol aloprim BENLYSTA BONIVA INTRAVENOUS colchicine-probenecid COLCRYS DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK 6 FORTEO 5 FOSAMAX ORAL TABLET 70 MG FOSAMAX PLUS D 4 HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN 5 HUMIRA PEN CROHN'SUC-HS START HUMIRA PEN PSORIASIS STARTER HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML ibandronate intravenous solution 5 1 4 5 4 3 3 5 5 MO; CG; QLL (4 per 28 days) MO PAR; MO B/D PAR; MO MO MO MO PAR; MO; QLL (8 per 28 days) 5 PAR; MO; QLL (4.08 per 28 days) 5 PAR; MO; QLL (8 per 28 days) 5 PAR; MO; QLL (8 per 28 days) PAR; MO; QLL (3 per 28 days) ST; MO; QLL (4 per 28 days) ST; MO; QLL (4 per 28 days) PAR; MO; QLL (4.8 per 365 days) PAR; MO; QLL (3.2 per 28 days) PAR; MO; QLL (9.6 per 365 days) PAR; MO; QLL (3.2 per 28 days) PAR; MO; QLL (2 per 28 days) 4 5 5 5 5 PAR; MO; QLL (3.2 per 28 days) 4 B/D PAR; MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 51 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits ibandronate intravenous syringe ibandronate oral 4 4 KINERET 5 leflunomide oral tablet 10 mg leflunomide oral tablet 20 mg ORENCIA 4 3 5 ORENCIA (WITH MALTOSE) probenecid PROLIA 5 raloxifene 3 RIDAURA risedronate oral tablet 150 mg 4 4 risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) risedronate oral tablet 5 mg 4 risedronate oral tablet,delayed release (dr/ec) SAVELLA ORAL TABLET 100 MG SAVELLA ORAL TABLET 12.5 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLET 50 MG SAVELLA ORAL TABLETS, DOSE PACK SIMPONI 4 ULORIC Obstetrics / Gynecology altavera (28) ALYACEN 1/35 (28) ALYACEN 7/7/7 (28) amethia 0.15 mg-30 mcg (84)/ 10 mcg (7) amethyst 3 ST; MO; QLL (30 per 30 days) MO; QLL (4 per 28 days) MO; QLL (60 per 30 days) MO; QLL (480 per 30 days) MO; QLL (240 per 30 days) MO; QLL (120 per 30 days) MO; QLL (110 per 365 days) PAR; MO; QLL (1 per 28 days) ST; MO 4 4 4 4 MO MO MO MO 4 MO 3 4 4 3 3 3 3 3 5 MO MO; QLL (1 per 28 days) PAR; MO; QLL (28 per 28 days) MO MO PAR; MO; QLL (4 per 28 days) PAR; MO MO PAR; MO; QLL (2 per 365 days) MO; QLL (30 per 30 days) MO ST; MO; QLL (1 per 28 days) ST; MO; QLL (4 per 28 days) Drug Name Drug Requirements/ Tier Limits apri aranelle (28) aviane azurette (28) balziva (28) blisovi fe 1.5/30 (28) briellyn camila CAZIANT (28) clindamycin phosphate vaginal cryselle (28) cyclafem 1/35 (28) cyclafem 7/7/7 (28) dasetta 1/35 (28) dasetta 7/7/7 (28) delestrogen depo-estradiol drospirenone-ethinyl estradiol elinest ELLA emoquette enpresse errin estarylla ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml ESTRING 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 3 4 4 4 4 4 1 4 falmina (28) FEMRING 4 4 gildagia gildess 1.5/30 (21) gildess 1/20 (21) GILDESS FE 1.5/30 (28) GILDESS FE 1/20 (28) heather introvale jolessa 4 4 4 4 4 4 4 4 4 4 4 MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO PAR; MO PAR; MO; QLL (8 per 28 days) PAR; MO; QLL (4 per 28 days) MO MO; QLL (1 per 90 days) MO MO; QLL (1 per 90 days) MO MO MO MO MO MO MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 52 Effective Date September 1, 2016 Drug Name jolivette junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) kariva (28) kelnor 1/35 (28) LARIN 1/20 (21) LARIN FE 1.5/30 (28) LARIN FE 1/20 (28) leena 28 lessina levonest (28) levonorg-eth estrad triphasic levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.150.03 mg levonorgestrel-ethinyl estrad oral tablet 90-20 mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month levora-28 loryna (28) low-ogestrel (28) lutera (28) lyza marlissa medroxyprogesterone intramuscular medroxyprogesterone oral MENEST methylergonovine oral metronidazole vaginal miconazole-3 vaginal suppository MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) mono-linyah mononessa (28) MYZILRA necon 0.5/35 (28) Drug Requirements/ Tier Limits 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MO MO MO MO MO MO MO MO MO MO MO MO MO MO 4 4 MO 4 4 4 4 4 4 4 MO MO MO MO MO MO MO 1 4 4 2 4 4 4 4 MO PAR; MO MO MO MO; QLL (6 per 30 days) MO MO MO 4 MO 4 4 4 4 MO MO MO MO Drug Name necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) NOR-QD nora-be norethindrone (contraceptive) norethindrone acetate norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mgmcg nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) orsythia ORTHO MICRONOR philith PIMTREA (28) pirmella oral tablet 1-35 mgmcg portia PREMARIN ORAL PREMARIN VAGINAL PREMPRO previfem progesterone micronized quasense reclipsen (28) sprintec (28) sronyx syeda terconazole vaginal cream terconazole vaginal suppository TILIA FE tranexamic acid oral tri-estarylla tri-legest fe tri-linyah tri-previfem (28) tri-sprintec (28) trinessa (28) Drug Requirements/ Tier Limits 4 4 4 4 4 4 4 4 4 MO MO MO MO MO MO MO MO MO 4 4 4 4 4 4 4 4 4 4 4 MO MO MO MO MO MO MO MO MO MO MO 4 3 3 4 4 3 4 4 4 4 4 3 4 4 4 4 4 4 4 4 4 MO PAR; MO MO PAR; MO MO ST; MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 53 Effective Date September 1, 2016 Drug Name trivora (28) vandazole velivet triphasic regimen (28) vestura (28) viorele (28) VYFEMLA (28) XULANE ZARAH zenchent (28) ZENCHENT FE zovia 1/35e (28) zovia 1/50e (28) Ophthalmology acetazolamide oral capsule, extended release acetazolamide oral tablet 125 mg acetazolamide oral tablet 250 mg acetazolamide sodium ALPHAGAN P OPHTHALMIC DROPS 0.1 % ALPHAGAN P OPHTHALMIC DROPS 0.15 % apraclonidine atropine ophthalmic drops azelastine ophthalmic AZOPT bacitracin ophthalmic bacitracin-polymyxin b ophthalmic BESIVANCE BETAGAN OPHTHALMIC DROPS 0.5 % betaxolol ophthalmic BETIMOL BETOPTIC S bimatoprost BLEPHAMIDE S.O.P. brimonidine ophthalmic drops 0.15 % brimonidine ophthalmic drops 0.2 % Drug Requirements/ Tier Limits 4 2 4 4 4 4 4 4 4 4 4 4 MO MO MO MO MO MO MO MO MO MO MO MO 4 MO 2 MO 3 MO 4 3 MO MO 4 MO 3 2 3 4 4 3 MO MO MO MO MO MO 4 4 MO MO 4 4 4 3 4 3 MO MO MO MO MO MO 2 MO Drug Name carteolol ciprofloxacin hcl ophthalmic COMBIGAN COSOPT cromolyn ophthalmic dexamethasone sodium phosphate ophthalmic diclofenac sodium ophthalmic dorzolamide dorzolamide-timolol DUREZOL erythromycin ophthalmic fluorometholone flurbiprofen sodium gentak ophthalmic ointment gentamicin ophthalmic ILEVRO IOPIDINE OPHTHALMIC DROPS ISOPTO CARPINE ketorolac ophthalmic LACRISERT latanoprost levobunolol ophthalmic drops 0.5 % levofloxacin ophthalmic LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral metipranolol MOXEZA naphazoline neo-polycin neo-polycin hc neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin bdexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc ophthalmic NEVANAC ofloxacin ophthalmic PATADAY Drug Requirements/ Tier Limits 2 2 3 4 2 2 MO MO MO MO MO MO 2 3 2 3 2 2 1 2 2 3 4 MO MO MO MO MO MO MO MO MO MO MO 4 2 3 2 2 MO MO MO MO MO 4 3 MO MO 4 3 3 1 2 2 3 3 2 MO 3 MO 3 MO 3 2 3 MO MO MO MO MO MO MO MO MO You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 54 Effective Date September 1, 2016 Drug Name PAZEO PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 % pilocarpine hcl ophthalmic drops 4 % polycin polymyxin b sulf-trimethoprim prednisolone acetate prednisolone sodium phosphate ophthalmic RESTASIS SIMBRINZA sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment sulfacetamide-prednisolone timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming solution TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE 0.25 % TIMOPTIC OPHTHALMIC DROPS 0.25 % TIMOPTIC-XE TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST tobramycin tobramycin-dexamethasone TRAVATAN Z trifluridine VIGAMOX XALATAN ZIRGAN Respiratory And Allergy acetylcysteine solution 100 mg/ ml (10 %) acetylcysteine solution 200 mg/ ml (20 %) ADEMPAS Drug Requirements/ Tier Limits Drug Name Drug Requirements/ Tier Limits 3 4 3 MO MO MO ADVAIR DISKUS 3 ADVAIR HFA 3 4 MO AEROSPAN 4 2 1 2 2 3 4 2 MO MO MO 3 MO 2 1 MO MO albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 12 hr 4 mg albuterol sulfate oral tablet extended release 12 hr 8 mg aminophylline intravenous ANORO ELLIPTA 3 MO MO MO ARNUITY ELLIPTA 3 ASMANEX HFA 3 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) 3 3 4 4 MO MO 2 4 3 MO; QLL (60 per 30 days) MO; QLL (12 per 30 days) QLL (18 per 30 days) B/D PAR; MO; QLL (360 per 30 days) B/D PAR; MO; QLL (360 per 30 days) B/D PAR; MO; QLL (60 per 30 days) MO MO MO 4 MO 2 2 4 3 MO 4 3 MO MO 3 2 3 3 4 3 4 4 MO MO MO MO MO MO MO MO 2 B/D PAR; MO 3 B/D PAR; MO 5 PAR; MO; LA MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) MO; QLL (13 per 30 days) MO; QLL (0.14 per 30 days) 3 3 MO; QLL (0.24 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 55 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits ATROVENT HFA 4 BREO ELLIPTA 3 cetirizine oral solution 1 mg/ml 2 CINRYZE clemastine oral tablet 2.68 mg COMBIVENT RESPIMAT 5 4 4 cromolyn inhalation 2 DALIRESP 4 desloratadine oral tablet 3 desloratadine oral tablet, disintegrating diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe DULERA 2 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML epinephrine injection autoinjector epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK 3 EPIPEN JR 2-PAK 4 ESBRIET 5 FIRAZYR FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ 4 4 3 4 4 4 5 3 3 MO; QLL (26 per 30 days) MO; QLL (60 per 30 days) MO; QLL (300 per 30 days) PAR; MO PAR; MO MO; QLL (8 per 30 days) B/D PAR; MO; QLL (240 per 30 days) PAR; MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) PAR; MO PAR; MO MO; QLL (13 per 30 days) MO MO; QLL (2 per 2 days) MO MO; QLL (2 per 2 days) MO; QLL (2 per 2 days) PAR; QLL (270 per 30 days) PAR; MO MO; QLL (60 per 30 days) MO; QLL (240 per 30 days) Drug Name ACTUATION, 50 MCG/ ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,nonaerosol 25 mcg (0.025 %) fluticasone nasal Drug Requirements/ Tier Limits 3 MO; QLL (12 per 30 days) 3 MO; QLL (24 per 30 days) 3 MO; QLL (11 per 30 days) 2 MO; QLL (75 per 30 days) MO; QLL (16 per 30 days) MO; QLL (60 per 30 days) B/D PAR; MO 1 FORADIL AEROLIZER 3 ipratropium bromide inhalation ipratropium-albuterol 3 KALYDECO ORAL TABLET LETAIRIS 5 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml levocetirizine oral tablet 4 mometasone nasal 3 montelukast oral granules in packet montelukast oral tablet 4 montelukast oral tablet, chewable 4 2 5 4 3 3 B/D PAR; MO; QLL (540 per 30 days) PAR; MO; QLL (60 per 30 days) PAR; MO; LA; QLL (30 per 30 days) B/D PAR; MO; QLL (270 per 30 days) B/D PAR; MO; QLL (540 per 30 days) MO; QLL (30 per 30 days) QLL (17 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 56 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits NASONEX 3 OFEV ORAL CAPSULE 150 MG PERFOROMIST 5 PROAIR HFA 3 PROAIR RESPICLICK 3 promethazine injection solution promethazine oral tablet 12.5 mg, 25 mg PULMOZYME QVAR INHALATION AEROSOL 40 MCG/ ACTUATION QVAR INHALATION AEROSOL 80 MCG/ ACTUATION SEREVENT DISKUS 4 4 sildenafil oral 5 SPIRIVA RESPIMAT 3 SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT 3 SYMBICORT 4 4 MO; QLL (17 per 30 days) PAR; MO; QLL (60 per 30 days) B/D PAR; MO; QLL (120 per 30 days) MO; QLL (18 per 30 days) MO; QLL (2 per 30 days) PAR; MO PAR; MO 5 3 B/D PAR; MO MO; QLL (9 per 30 days) 3 MO; QLL (18 per 30 days) 3 MO; QLL (60 per 30 days) PAR; MO; QLL (90 per 30 days) MO; QLL (4 per 30 days) MO; QLL (30 per 30 days) MO; QLL (4 per 30 days) PAR; MO; QLL (11 per 30 days) MO 3 terbutaline oral theophylline oral elixir theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 12 hr TRACLEER 3 2 2 2 VENTAVIS VENTOLIN HFA 5 3 2 5 Drug Name Drug Requirements/ Tier Limits XOLAIR 5 XOPENEX HFA 4 XYZAL ORAL TABLET 4 zafirlukast 4 Urologicals alfuzosin AMMONIUM CHLORIDE bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg bethanechol chloride oral tablet 50 mg CIALIS ORAL TABLET 2.5 MG, 5 MG CYSTAGON cytra k crystals finasteride oral tablet 5 mg flavoxate MYRBETRIQ PAR; MO; LA; QLL (6 per 28 days) MO; QLL (45 per 30 days) MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) 2 4 3 MO 4 MO 4 PAR; MO; QLL (30 per 30 days) MO; LA MO MO MO MO; QLL (30 per 30 days) MO; QLL (600 per 30 days) MO; QLL (120 per 30 days) MO; QLL (60 per 30 days) 3 2 2 4 4 oxybutynin chloride oral syrup 2 oxybutynin chloride oral tablet 2 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg potassium citrate oral tablet extended release 10 meq (1,080 mg) potassium citrate oral tablet MO extended release 5 meq (540 mg) MO sodium citrate-citric acid tamsulosin PAR; MO; LA; QLL tolterodine oral capsule, (60 per 30 days) extended release 24hr PAR; MO tolterodine oral tablet MO; QLL (36 per 30 days) TOVIAZ 3 3 MO 4 MO; QLL (30 per 30 days) MO 3 MO 2 2 4 MO MO MO; QLL (30 per 30 days) MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) 4 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 57 Effective Date September 1, 2016 Drug Name Drug Requirements/ Tier Limits trospium oral tablet 4 VESICARE 4 MO; QLL (60 per 30 days) MO; QLL (30 per 30 days) Vitamins, Hematinics / Electrolytes AMINOSYN 10 % 4 B/D PAR AMINOSYN 7 % WITH 4 B/D PAR ELECTROLYTES AMINOSYN 8.5 % 4 B/D PAR AMINOSYN 8.5 %4 B/D PAR ELECTROLYTES AMINOSYN II 10 % 4 B/D PAR AMINOSYN II 15 % 4 B/D PAR AMINOSYN II 7 % 4 B/D PAR AMINOSYN II 8.5 % 4 B/D PAR AMINOSYN II 8.5 %4 B/D PAR ELECTROLYTES AMINOSYN M 3.5 % 4 B/D PAR AMINOSYN-HBC 7% 4 B/D PAR AMINOSYN-PF 10 % 4 B/D PAR AMINOSYN-PF 7 % 4 B/D PAR (SULFITE-FREE) AMINOSYN-RF 5.2 % 4 B/D PAR calcium acetate oral capsule 2 MO CLINIMIX 5%/D15W 4 B/D PAR SULFITE FREE CLINIMIX 5%/D25W 4 B/D PAR SULFITE-FREE CLINIMIX 2.75%/D5W 4 B/D PAR SULFIT FREE CLINIMIX 4.25%-D20W 4 B/D PAR SULF-FREE CLINIMIX 4.25%-D25W 4 B/D PAR SULF-FREE CLINIMIX 4.25%/D10W 4 B/D PAR SULF FREE CLINIMIX 5%4 B/D PAR D20W(SULFITE-FREE) CLINIMIX E 4.25%/D10W 4 B/D PAR SUL FREE CLINIMIX E 4.25%/D25W 4 B/D PAR SUL FREE CLINIMIX E 4.25%/D5W 4 B/D PAR SULF FREE CLINIMIX E 5%/D15W 4 B/D PAR SULFIT FREE Drug Name CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE dextrose-kcl-nacl fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg) freamine iii 10 % HEPATAMINE 8% intralipid intravenous emulsion 20 % INTRALIPID INTRAVENOUS EMULSION 30 % IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE S PH 7.4 ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S k-effervescent k-tab oral tablet extended release 8 meq klor-con 10 klor-con 8 klor-con m10 klor-con m15 klor-con m20 klor-con/ef lactated ringers intravenous ludent fluoride magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/ 50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/ 100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe NEPHRAMINE 5.4 % Drug Requirements/ Tier Limits 4 B/D PAR 4 B/D PAR 4 2 MO MO 4 4 4 B/D PAR B/D PAR B/D PAR; MO 4 B/D PAR 4 4 4 4 4 1 2 2 2 2 2 2 1 4 2 4 MO MO MO MO MO MO MO MO MO 4 4 MO 4 MO 4 4 B/D PAR You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 58 Effective Date September 1, 2016 Drug Name NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH 7.4 phospha 250 neutral PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium bicarb and chloride potassium bicarb-citric acid potassium chlorid-d50.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d50.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release potassium chloride oral tablet, er particles/crystals potassium chloride-0.45 % nacl Drug Requirements/ Tier Limits 4 4 4 4 2 4 4 4 2 1 4 4 MO MO MO MO 4 4 4 MO 4 4 4 MO 2 MO 1 2 MO MO 2 MO Drug Name potassium chloride-d50.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d50.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d50.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d50.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d50.9%nacl intravenous parenteral solution 40 meq/l premasol 10 % PREMASOL 6 % prenatal vitamin oral tablet PROCALAMINE 3% PROSOL 20 % ringers intravenous sodium bicarbonate intravenous solution sodium bicarbonate intravenous syringe 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml) SODIUM BICARBONATE INTRAVENOUS SYRINGE 8.4 % (1 MEQ/ML) sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback sodium chloride 3 % sodium chloride 5 % sodium chloride intravenous sodium fluoride oral tablet sodium fluoride oral tablet, chewable sodium lactate intravenous travasol 10 % TROPHAMINE 10 % TROPHAMINE 6% Drug Requirements/ Tier Limits 4 MO 4 4 4 MO 4 4 4 2 4 4 4 4 B/D PAR; MO B/D PAR MO B/D PAR B/D PAR; MO MO 4 4 4 MO 4 4 4 4 2 2 4 4 4 4 MO MO MO MO B/D PAR; MO B/D PAR; MO B/D PAR 4 You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8. Core_16293_CG6_v15_1609_1 59 Effective Date September 1, 2016 Index of Drugs: Legend Generic drugs are shown in lowercase italic (e.g., atenolol). Brand-name drugs are shown in capital letters (e.g., CRESTOR). The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed. Find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. Drug Name Page ACTIMMUNE......................................................49 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG.................43 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 MG.................43 acyclovir oral capsule...................................................8 acyclovir oral suspension 200 mg/5 ml..........................8 acyclovir oral tablet.....................................................8 acyclovir sodium intravenous solution...........................8 acyclovir topical........................................................39 ADACEL(TDAP ADOLESN/ADULT)(PF)..........49 ADAGEN...............................................................42 ADALAT CC.........................................................33 adapalene topical gel 0.1 %.......................................40 ADASUVE.............................................................20 adefovir......................................................................8 ADEMPAS.............................................................55 adrucil intravenous solution 2.5 gram/50 ml..............15 adrucil intravenous solution 5 gram/100 ml, 500 mg/ 10 ml....................................................................15 ADVAIR DISKUS..................................................55 ADVAIR HFA........................................................55 AEROSPAN...........................................................55 afeditab cr................................................................33 AFINITOR.............................................................15 AFINITOR DISPERZ............................................15 AGGRENOX.........................................................33 ALBENZA................................................................8 albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml..................................55 albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %)........................................55 albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml.........................................55 albuterol sulfate oral syrup.........................................55 albuterol sulfate oral tablet........................................55 abacavir.....................................................................8 abacavir-lamivudine-zidovudine.................................8 ABELCET................................................................8 ABILIFY MAINTENA...........................................20 ABRAXANE...........................................................15 acamprosate..............................................................42 acarbose oral tablet 100 mg.......................................43 acarbose oral tablet 25 mg.........................................43 acarbose oral tablet 50 mg.........................................43 ACCUPRIL............................................................33 ACCURETIC ORAL TABLET 20-12.5 MG, 2025 MG.................................................................33 acebutolol.................................................................33 acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml...............................................20 acetaminophen-codeine oral solution 120-12 mg/5 ml.........................................................................20 acetaminophen-codeine oral tablet 300-15 mg............20 acetaminophen-codeine oral tablet 300-30 mg............20 acetaminophen-codeine oral tablet 300-60 mg............20 acetasol hc................................................................43 acetazolamide oral capsule, extended release................54 acetazolamide oral tablet 125 mg..............................54 acetazolamide oral tablet 250 mg..............................54 acetazolamide sodium...............................................54 acetic acid irrigation.................................................42 acetic acid otic..........................................................43 acetic acid-aluminum acetate....................................43 acetylcysteine intravenous..........................................42 acetylcysteine solution 100 mg/ml (10 %)...................55 acetylcysteine solution 200 mg/ml (20 %)...................55 acitretin...................................................................39 ACTEMRA INTRAVENOUS VIAL.....................51 ACTHAR H.P........................................................43 ACTHIB (PF).........................................................49 Core_16293_CG6_v15_1609_1 60 Effective Date September 1, 2016 albuterol sulfate oral tablet extended release 12 hr 4 mg........................................................................55 albuterol sulfate oral tablet extended release 12 hr 8 mg........................................................................55 alclometasone topical cream.......................................40 alclometasone topical ointment..................................40 alcohol pads..............................................................43 ALDACTAZIDE ORAL TABLET 25-25 MG.......33 ALDURAZYME.....................................................43 ALECENSA............................................................15 alendronate oral solution...........................................51 alendronate oral tablet 10 mg, 5 mg..........................51 alendronate oral tablet 35 mg, 70 mg........................51 alendronate oral tablet 40 mg....................................42 alfuzosin..................................................................57 ALIMTA.................................................................15 ALINIA ORAL SUSPENSION FOR RECONSTITUTION...........................................8 ALINIA ORAL TABLET.........................................8 ALKERAN ORAL..................................................15 allopurinol...............................................................51 aloprim....................................................................51 alosetron...................................................................47 ALPHAGAN P OPHTHALMIC DROPS 0.1 %.........................................................................54 ALPHAGAN P OPHTHALMIC DROPS 0.15 %.........................................................................54 alprazolam oral tablet...............................................21 ALTACE ORAL CAPSULE 10 MG, 2.5 MG, 5 MG......................................................................33 altavera (28)............................................................52 ALTOPREV...........................................................33 ALYACEN 1/35 (28)..............................................52 ALYACEN 7/7/7 (28).............................................52 amantadine hcl oral capsule........................................8 amantadine hcl oral tablet..........................................8 AMARYL ORAL TABLET 1 MG..........................43 AMARYL ORAL TABLET 2 MG..........................43 AMARYL ORAL TABLET 4 MG..........................43 AMBISOME............................................................8 amcinonide..............................................................40 amethia 0.15 mg-30 mcg (84)/10 mcg (7).................52 amethyst...................................................................52 amifostine crystalline.................................................15 amikacin injection solution 1,000 mg/4 ml, 500 mg/ 2 ml........................................................................8 amiloride.................................................................33 amiloride-hydrochlorothiazide...................................33 Core_16293_CG6_v15_1609_1 aminophylline intravenous........................................55 AMINOSYN 10 %.................................................58 AMINOSYN 7 % WITH ELECTROLYTES........58 AMINOSYN 8.5 %................................................58 AMINOSYN 8.5 %-ELECTROLYTES.................58 AMINOSYN II 10 %.............................................58 AMINOSYN II 15 %.............................................58 AMINOSYN II 7 %...............................................58 AMINOSYN II 8.5 %............................................58 AMINOSYN II 8.5 %-ELECTROLYTES.............58 AMINOSYN M 3.5 %...........................................58 AMINOSYN-HBC 7%..........................................58 AMINOSYN-PF 10 %...........................................58 AMINOSYN-PF 7 % (SULFITE-FREE)...............58 AMINOSYN-RF 5.2 %..........................................58 amiodarone intravenous solution...............................33 amiodarone intravenous syringe.................................33 amiodarone oral tablet 100 mg, 200 mg....................33 amiodarone oral tablet 400 mg..................................33 amitriptyline............................................................21 amlodipine besylate oral tablet 10 mg, 2.5 mg............33 amlodipine besylate oral tablet 5 mg..........................33 amlodipine-atorvastatin............................................33 amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-20 mg, 5-40 mg.........................33 amlodipine-benazepril oral capsule 5-10 mg...............33 amlodipine-valsartan................................................33 amlodipine-valsartan-hcthiazid.................................33 AMMONIUM CHLORIDE..................................57 ammonium lactate....................................................40 amoxapine oral tablet 100 mg, 50 mg........................21 amoxapine oral tablet 150 mg, 25 mg........................21 amoxicillin oral capsule...............................................8 amoxicillin oral suspension for reconstitution................8 amoxicillin oral tablet.................................................8 amoxicillin oral tablet,chewable 125 mg, 250 mg.........8 amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml...................................................8 amoxicillin-pot clavulanate oral suspension for reconstitution 250-62.5 mg/5 ml..............................8 amoxicillin-pot clavulanate oral tablet 250-125 mg..........................................................................8 amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg............................................................8 amoxicillin-pot clavulanate oral tablet extended release 12 hr......................................................................8 amoxicillin-pot clavulanate oral tablet,chewable...........8 61 Effective Date September 1, 2016 ARCALYST............................................................49 aripiprazole oral solution...........................................21 aripiprazole oral tablet 10 mg...................................21 aripiprazole oral tablet 15 mg...................................21 aripiprazole oral tablet 2 mg.....................................21 aripiprazole oral tablet 20 mg, 30 mg........................21 aripiprazole oral tablet 5 mg.....................................21 aripiprazole oral tablet,disintegrating 10 mg..............21 aripiprazole oral tablet,disintegrating 15 mg..............21 ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 441 MG/1.6 ML.......................................................................21 ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 662 MG/2.4 ML.......................................................................21 ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 882 MG/3.2 ML.......................................................................21 ARNUITY ELLIPTA..............................................55 ARRANON............................................................15 ARZERRA..............................................................16 ASACOL HD.........................................................47 ASMANEX HFA....................................................55 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES).......................................55 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)...............................................................55 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES).......................55 aspirin-dipyridamole.................................................33 ATACAND HCT ORAL TABLET 16-12.5 MG......................................................................33 ATACAND HCT ORAL TABLET 32-12.5 MG, 32-25 MG............................................................33 ATACAND ORAL TABLET 16 MG, 4 MG, 8 MG......................................................................33 ATACAND ORAL TABLET 32 MG.....................33 atenolol....................................................................33 atenolol-chlorthalidone..............................................33 atorvastatin..............................................................34 atovaquone.................................................................9 atovaquone-proguanil.................................................9 ATRIPLA..................................................................9 amphotericin b...........................................................8 ampicillin oral capsule................................................8 ampicillin oral suspension for reconstitution..................9 ampicillin sodium injection.........................................9 ampicillin sodium intravenous.....................................9 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram.......................................................................9 ampicillin-sulbactam injection recon soln 15 gram........9 ampicillin-sulbactam intravenous recon soln 1.5 gram.......................................................................9 ampicillin-sulbactam intravenous recon soln 3 gram.......................................................................9 AMPYRA................................................................21 anagrelide................................................................42 anastrozole...............................................................15 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)..................................................43 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM)........43 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM)............43 androxy....................................................................43 ANORO ELLIPTA................................................55 APOKYN................................................................21 apraclonidine...........................................................54 apri.........................................................................52 APRISO..................................................................47 APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG......................................................................21 APTIOM ORAL TABLET 800 MG......................21 APTIVUS ORAL CAPSULE....................................9 APTIVUS ORAL SOLUTION................................9 ARALAST NP........................................................42 aranelle (28)............................................................52 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML.....................................................49 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML............................................................49 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML...................49 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML............................................................49 Core_16293_CG6_v15_1609_1 62 Effective Date September 1, 2016 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml.......47 atropine ophthalmic drops.........................................54 ATROVENT HFA.................................................56 AVALIDE ORAL TABLET 150-12.5 MG.............34 AVALIDE ORAL TABLET 300-12.5 MG.............34 AVAPRO................................................................34 AVASTIN...............................................................16 aviane......................................................................52 AVONEX (WITH ALBUMIN).............................49 AVONEX INTRAMUSCULAR PEN INJECTOR KIT......................................................................49 AVONEX INTRAMUSCULAR SYRINGE...........49 AVONEX INTRAMUSCULAR SYRINGE KIT......................................................................49 azacitidine...............................................................16 azathioprine.............................................................16 azathioprine sodium.................................................16 azelastine nasal.........................................................43 azelastine ophthalmic................................................54 AZILECT...............................................................21 azithromycin intravenous recon soln 500 mg................9 azithromycin intravenous recon soln 500 mg (2 mg/ ml).........................................................................9 azithromycin oral packet.............................................9 azithromycin oral suspension for reconstitution 100 mg/5 ml..................................................................9 azithromycin oral suspension for reconstitution 200 mg/5 ml..................................................................9 azithromycin oral tablet..............................................9 AZOPT..................................................................54 AZOR.....................................................................34 aztreonam..................................................................9 azurette (28)............................................................52 bacitracin ophthalmic...............................................54 bacitracin-polymyxin b ophthalmic............................54 baclofen...................................................................21 balsalazide...............................................................47 balziva (28).............................................................52 BANZEL ORAL SUSPENSION............................21 BANZEL ORAL TABLET 200 MG.......................21 BANZEL ORAL TABLET 400 MG.......................21 BARACLUDE ORAL SOLUTION.........................9 BCG VACCINE, LIVE (PF)..................................49 BELEODAQ..........................................................16 benazepril................................................................34 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 5-6.25 mg...................................34 Core_16293_CG6_v15_1609_1 benazepril-hydrochlorothiazide oral tablet 20-25 mg........................................................................34 BENDEKA.............................................................16 BENICAR HCT.....................................................34 BENICAR ORAL TABLET 20 MG, 40 MG.........34 BENICAR ORAL TABLET 5 MG.........................34 BENLYSTA............................................................51 benztropine injection................................................21 benztropine oral.......................................................21 BESIVANCE..........................................................54 BETAGAN OPHTHALMIC DROPS 0.5 %.........54 betamethasone dipropionate topical cream..................40 betamethasone dipropionate topical lotion..................40 betamethasone dipropionate topical ointment.............40 betamethasone valerate topical cream.........................40 betamethasone valerate topical lotion.........................40 betamethasone valerate topical ointment.....................40 betamethasone, augmented topical cream....................40 betamethasone, augmented topical gel........................40 betamethasone, augmented topical lotion....................40 betamethasone, augmented topical ointment...............40 BETASERON SUBCUTANEOUS KIT................50 betaxolol ophthalmic.................................................54 betaxolol oral............................................................34 bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg........................................................................57 bethanechol chloride oral tablet 50 mg.......................57 BETIMOL..............................................................54 BETOPTIC S.........................................................54 bexarotene................................................................16 BEXSERO (PF)......................................................50 bicalutamide............................................................16 BICILLIN C-R.........................................................9 BICILLIN L-A..........................................................9 BICNU...................................................................16 BIDIL.....................................................................34 bimatoprost..............................................................54 bisoprolol fumarate...................................................34 bisoprolol-hydrochlorothiazide...................................34 BIVIGAM...............................................................50 bleomycin.................................................................16 BLEPHAMIDE S.O.P............................................54 BLINCYTO...........................................................16 blisovi fe 1.5/30 (28)................................................52 BONIVA INTRAVENOUS...................................51 BOOSTRIX TDAP................................................50 BOSULIF ORAL TABLET 100 MG.....................16 BOSULIF ORAL TABLET 500 MG.....................16 63 Effective Date September 1, 2016 BOTOX..................................................................50 BREO ELLIPTA.....................................................56 briellyn....................................................................52 BRILINTA.............................................................34 brimonidine ophthalmic drops 0.15 %......................54 brimonidine ophthalmic drops 0.2 %........................54 BRIVIACT INTRAVENOUS................................21 BRIVIACT ORAL SOLUTION............................21 BRIVIACT ORAL TABLET 10 MG.....................21 BRIVIACT ORAL TABLET 100 MG, 75 MG......21 BRIVIACT ORAL TABLET 25 MG.....................21 BRIVIACT ORAL TABLET 50 MG.....................21 bromocriptine...........................................................21 budesonide oral.........................................................47 bumetanide injection................................................34 bumetanide oral tablet 0.5 mg, 1 mg.........................34 bumetanide oral tablet 2 mg......................................34 BUPHENYL ORAL TABLET...............................42 buprenorphine hcl injection solution..........................21 buprenorphine hcl injection syringe............................21 buprenorphine hcl sublingual tablet 2 mg...................21 buprenorphine hcl sublingual tablet 8 mg...................21 buprenorphine-naloxone sublingual tablet 2-0.5 mg........................................................................21 buprenorphine-naloxone sublingual tablet 8-2 mg......21 buproban.................................................................42 bupropion hcl oral tablet 100 mg...............................21 bupropion hcl oral tablet 75 mg.................................21 bupropion hcl oral tablet extended release 100 mg.......21 bupropion hcl oral tablet extended release 150 mg, 200 mg........................................................................21 bupropion hcl oral tablet extended release 24 hr 150 mg........................................................................21 bupropion hcl oral tablet extended release 24 hr 300 mg........................................................................22 buspirone oral tablet 10 mg, 15 mg, 5 mg..................22 buspirone oral tablet 30 mg, 7.5 mg..........................22 BUSULFEX............................................................16 butorphanol tartrate injection solution 1 mg/ml..........22 butorphanol tartrate injection solution 2 mg/ml..........22 butorphanol tartrate nasal.........................................22 BYDUREON.........................................................43 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML....43– 4 4 BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML............44 BYSTOLIC.............................................................34 Core_16293_CG6_v15_1609_1 cabergoline...............................................................44 CABOMETYX ORAL TABLET 20 MG...............16 CABOMETYX ORAL TABLET 40 MG, 60 MG......................................................................16 CALAN ORAL TABLET 120 MG.........................34 CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG..............................................34 calcipotriene scalp.....................................................40 calcipotriene topical..................................................40 calcitonin (salmon)...................................................44 calcitriol intravenous solution 1 mcg/ml.....................44 calcitriol oral capsule.................................................44 calcitriol oral solution...............................................44 calcium acetate oral capsule.......................................58 camila......................................................................52 CANCIDAS.............................................................9 candesartan oral tablet 16 mg, 4 mg, 8 mg.................34 candesartan oral tablet 32 mg....................................34 candesartan-hydrochlorothiazid oral tablet 16-12.5 mg........................................................................34 candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg.......................................................34 CAPASTAT..............................................................9 CAPRELSA ORAL TABLET 100 MG...................16 CAPRELSA ORAL TABLET 300 MG...................16 captopril oral tablet 100 mg, 25 mg, 50 mg...............34 captopril oral tablet 12.5 mg.....................................34 captopril-hydrochlorothiazide oral tablet 25-15 mg, 50-15 mg, 50-25 mg.............................................34 captopril-hydrochlorothiazide oral tablet 25-25 mg........................................................................34 CARBAGLU...........................................................42 carbamazepine oral capsule, er multiphase 12 hr........22 carbamazepine oral suspension 100 mg/5 ml..............22 carbamazepine oral suspension 200 mg/10 ml............22 carbamazepine oral tablet.........................................22 carbamazepine oral tablet extended release 12 hr 100 mg........................................................................22 carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg...........................................................22 carbamazepine oral tablet,chewable...........................22 carbidopa-levodopa oral tablet...................................22 carbidopa-levodopa oral tablet extended release 25100 mg.................................................................22 carbidopa-levodopa oral tablet extended release 50200 mg.................................................................22 carbidopa-levodopa oral tablet,disintegrating..............22 carboplatin intravenous solution................................16 64 Effective Date September 1, 2016 CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 420 MG......................................................................34 CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM..............................................................50 carteolol...................................................................54 cartia xt...................................................................34 carvedilol.................................................................34 CAYSTON...............................................................9 CAZIANT (28)......................................................52 cefaclor oral capsule.....................................................9 cefaclor oral suspension for reconstitution 125 mg/5 ml...........................................................................9 cefaclor oral suspension for reconstitution 250 mg/5 ml, 375 mg/5 ml.....................................................9 cefaclor oral tablet extended release 12 hr.....................9 cefadroxil oral capsule.................................................9 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml.....................................................9 cefadroxil oral tablet...................................................9 cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml.......................................9 cefazolin injection recon soln 1 gram, 500 mg..............9 cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g............................................................9 cefazolin intravenous..................................................9 cefdinir oral capsule....................................................9 cefdinir oral suspension for reconstitution.....................9 cefepime.....................................................................9 cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml.............................................................9 cefepime in dextrose,iso-osm intravenous piggyback 2 gram/100 ml...........................................................9 cefotaxime injection recon soln 1 gram, 2 gram, 500 mg..........................................................................9 cefotaxime injection recon soln 10 gram.......................9 cefotetan.....................................................................9 cefoxitin in dextrose, iso-osm........................................9 cefoxitin intravenous recon soln 1 gram........................9 cefoxitin intravenous recon soln 10 gram, 2 gram.........9 cefpodoxime oral suspension for reconstitution...............9 cefpodoxime oral tablet 100 mg...................................9 cefpodoxime oral tablet 200 mg...................................9 cefprozil oral suspension for reconstitution....................9 cefprozil oral tablet 250 mg.........................................9 cefprozil oral tablet 500 mg.........................................9 CEFTAZIDIME IN D5W.......................................9 Core_16293_CG6_v15_1609_1 ceftazidime injection recon soln 1 gram, 2 gram...........9 ceftazidime injection recon soln 6 gram......................10 ceftriaxone in dextrose,iso-os......................................10 ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg...........................................................10 ceftriaxone injection recon soln 10 gram, 100 gram.....................................................................10 ceftriaxone intravenous..............................................10 cefuroxime axetil oral tablet 250 mg..........................10 cefuroxime axetil oral tablet 500 mg..........................10 cefuroxime sodium injection recon soln 1.5 gram, 750 mg........................................................................10 cefuroxime sodium intravenous vial...........................10 CELLCEPT INTRAVENOUS...............................16 CELONTIN ORAL CAPSULE 300 MG...............22 cephalexin oral capsule 250 mg, 500 mg....................10 cephalexin oral suspension for reconstitution...............10 cephalexin oral tablet................................................10 CEREZYME INTRAVENOUS RECON SOLN 400 UNIT...........................................................44 CERVARIX VACCINE (PF)..................................50 cetirizine oral solution 1 mg/ml.................................56 CHANTIX.............................................................42 CHANTIX CONTINUING MONTH BOX........42 CHANTIX STARTING MONTH BOX...............42 chloramphenicol sod succinate....................................10 chlorhexidine gluconate mucous membrane.................43 chloroquine phosphate oral tablet 250 mg..................10 chloroquine phosphate oral tablet 500 mg..................10 chlorothiazide oral tablet 250 mg..............................34 chlorothiazide oral tablet 500 mg..............................34 chlorothiazide sodium...............................................34 chlorpromazine.........................................................22 chlorthalidone oral tablet 25 mg, 50 mg.....................34 cholestyramine (with sugar).......................................34 cholestyramine light..................................................34 CIALIS ORAL TABLET 2.5 MG, 5 MG...............57 ciclodan topical cream...............................................40 ciclodan topical solution............................................40 ciclopirox topical cream.............................................40 ciclopirox topical gel..................................................40 ciclopirox topical shampoo.........................................40 ciclopirox topical solution..........................................40 ciclopirox topical suspension.......................................40 cidofovir...................................................................10 cilostazol..................................................................34 CIMZIA.................................................................47 CIMZIA POWDER FOR RECONST...................47 65 Effective Date September 1, 2016 CIMZIA STARTER KIT.......................................47 CINRYZE..............................................................56 CIPRODEX...........................................................43 ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg..........................................................10 ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg.............................................................10 ciprofloxacin hcl ophthalmic......................................54 ciprofloxacin hcl oral tablet.......................................10 ciprofloxacin in 5 % dextrose.....................................10 ciprofloxacin lactate intravenous solution 200 mg/20 ml.........................................................................10 ciprofloxacin lactate intravenous solution 400 mg/40 ml.........................................................................10 ciprofloxacin oral suspension......................................10 cisplatin...................................................................16 citalopram oral solution............................................22 citalopram oral tablet 10 mg.....................................22 citalopram oral tablet 20 mg.....................................22 citalopram oral tablet 40 mg.....................................22 cladribine.................................................................16 claravis oral capsule 10 mg, 20 mg, 40 mg.................40 claravis oral capsule 30 mg........................................40 clarithromycin oral suspension for reconstitution 125 mg/5 ml................................................................10 clarithromycin oral suspension for reconstitution 250 mg/5 ml................................................................10 clarithromycin oral tablet..........................................10 clarithromycin oral tablet extended release 24 hr.........10 clemastine oral tablet 2.68 mg...................................56 clindamycin hcl oral capsule......................................10 clindamycin in 5 % dextrose.....................................10 clindamycin phosphate injection................................10 clindamycin phosphate intravenous solution 300 mg/ 2 ml, 900 mg/6 ml................................................10 clindamycin phosphate intravenous solution 600 mg/ 4 ml......................................................................10 clindamycin phosphate topical gel...............................40 clindamycin phosphate topical lotion..........................40 clindamycin phosphate topical solution.......................40 clindamycin phosphate topical swab...........................40 clindamycin phosphate vaginal..................................52 clindamycin-benzoyl peroxide topical gel....................40 CLINIMIX 2.75%/D5W SULFIT FREE...............58 CLINIMIX 4.25%-D20W SULF-FREE................58 CLINIMIX 4.25%-D25W SULF-FREE................58 CLINIMIX 4.25%/D10W SULF FREE.................58 CLINIMIX 4.25%/D5W SULFIT FREE...............42 Core_16293_CG6_v15_1609_1 CLINIMIX 5%-D20W(SULFITE-FREE)..............58 CLINIMIX 5%/D15W SULFITE FREE...............58 CLINIMIX 5%/D25W SULFITE-FREE...............58 CLINIMIX E 2.75%/D10W SUL FREE................42 CLINIMIX E 2.75%/D5W SULF FREE...............42 CLINIMIX E 4.25%/D10W SUL FREE................58 CLINIMIX E 4.25%/D25W SUL FREE................58 CLINIMIX E 4.25%/D5W SULF FREE...............58 CLINIMIX E 5%/D15W SULFIT FREE..............58 CLINIMIX E 5%/D20W SULFIT FREE..............58 CLINIMIX E 5%/D25W SULFIT FREE..............58 clobetasol scalp..........................................................40 clobetasol topical cream.............................................40 clobetasol topical foam...............................................40 clobetasol topical gel..................................................40 clobetasol topical lotion.............................................40 clobetasol topical ointment.........................................40 clobetasol topical shampoo.........................................40 clobetasol-emollient topical cream..............................40 clobetasol-emollient topical foam................................40 CLOBEX TOPICAL LOTION.............................40 CLOLAR................................................................16 clomipramine...........................................................22 clonazepam oral tablet 0.5 mg...................................22 clonazepam oral tablet 1 mg......................................22 clonazepam oral tablet 2 mg......................................22 clonazepam oral tablet,disintegrating 0.125 mg..........22 clonazepam oral tablet,disintegrating 0.25 mg............22 clonazepam oral tablet,disintegrating 0.5 mg..............22 clonazepam oral tablet,disintegrating 1 mg.................22 clonazepam oral tablet,disintegrating 2 mg.................22 clonidine hcl oral tablet.............................................34 clonidine transdermal patch......................................34 clopidogrel oral tablet 300 mg...................................34 clopidogrel oral tablet 75 mg.....................................34 clorazepate dipotassium.............................................22 clotrimazole mucous membrane.................................10 clotrimazole topical cream.........................................40 clotrimazole topical solution......................................40 clotrimazole-betamethasone topical cream..................40 clotrimazole-betamethasone topical lotion...................40 clozapine oral tablet 100 mg.....................................22 clozapine oral tablet 200 mg.....................................22 clozapine oral tablet 25 mg.......................................22 clozapine oral tablet 50 mg.......................................22 clozapine oral tablet,disintegrating 100 mg................22 clozapine oral tablet,disintegrating 12.5 mg...............22 clozapine oral tablet,disintegrating 150 mg................22 66 Effective Date September 1, 2016 clozapine oral tablet,disintegrating 200 mg................22 clozapine oral tablet,disintegrating 25 mg..................22 COARTEM............................................................10 colchicine-probenecid................................................51 COLCRYS..............................................................51 colestipol..................................................................34 colistin (colistimethate na).........................................10 COMBIGAN..........................................................54 COMBIVENT RESPIMAT...................................56 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1).............................................16 COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3).............................................16 COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY).....................................................16 COMPLERA..........................................................10 compro.....................................................................47 constulose.................................................................47 COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML...............................................................22 COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML...............................................................22 COREG CR...........................................................34 cormax scalp.............................................................40 cortisone...................................................................44 CORZIDE ORAL TABLET 40-5 MG..................34 COSMEGEN.........................................................16 COSOPT................................................................54 COTELLIC............................................................16 COUMADIN ORAL.............................................34 COZAAR ORAL TABLET 100 MG......................34 COZAAR ORAL TABLET 25 MG, 50 MG..........34 CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,0009,500- 15,000 UNIT, 6,000-19,000 -30,000 UNIT............................................................47–48 CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 36,000-114,000- 180,000 UNIT..................................................................48 CRESTOR.............................................................34 CRIXIVAN ORAL CAPSULE 200 MG................10 CRIXIVAN ORAL CAPSULE 400 MG................10 cromolyn inhalation..................................................56 cromolyn ophthalmic.................................................54 cromolyn oral...........................................................48 cryselle (28)..............................................................52 CUBICIN...............................................................10 Core_16293_CG6_v15_1609_1 cyclafem 1/35 (28)....................................................52 cyclafem 7/7/7 (28)...................................................52 cyclobenzaprine oral tablet........................................22 cyclophosphamide oral capsule....................................16 CYCLOSET...........................................................44 cyclosporine intravenous............................................16 cyclosporine modified................................................16 cyclosporine oral capsule............................................16 CYRAMZA.............................................................16 CYSTADANE........................................................48 CYSTAGON..........................................................57 cytarabine................................................................16 cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml).......................16 cytarabine (pf) injection solution 20 mg/ml................16 CYTOMEL............................................................44 cytra k crystals..........................................................57 d10 %-0.45 % sodium chloride................................42 d2.5 %-0.45 % sodium chloride...............................42 d5 % and 0.9 % sodium chloride..............................42 d5 %-0.45 % sodium chloride..................................42 dacarbazine..............................................................16 DAKLINZA ORAL TABLET 30 MG, 60 MG......10 DAKLINZA ORAL TABLET 90 MG....................10 DALIRESP.............................................................56 danazol oral.............................................................44 dantrolene................................................................22 DAPSONE.............................................................10 DAPTACEL (DTAP PEDIATRIC) (PF)...............50 DARAPRIM...........................................................10 DARZALEX...........................................................16 dasetta 1/35 (28)......................................................52 dasetta 7/7/7 (28).....................................................52 daunorubicin intravenous solution.............................16 decitabine................................................................16 delestrogen................................................................52 DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC)..............................................48 demeclocycline..........................................................10 DEMSER................................................................34 DENAVIR..............................................................40 denta 5000 plus.......................................................43 dentagel...................................................................43 DEPEN TITRATABS............................................51 depo-estradiol...........................................................52 DERMATOP TOPICAL OINTMENT................40 DESCOVY.............................................................10 desipramine oral.......................................................22 67 Effective Date September 1, 2016 desloratadine oral tablet............................................56 desloratadine oral tablet,disintegrating.......................56 desmopressin injection...............................................44 desmopressin nasal aerosol,spray.................................44 desmopressin nasal solution........................................44 desmopressin nasal spray,non-aerosol..........................44 desmopressin oral......................................................44 desonide...................................................................40 desoximetasone topical cream.....................................40 desoximetasone topical gel..........................................40 desoximetasone topical ointment 0.25 %....................40 desvenlafaxine fumarate oral tablet extended release 24hr 100 mg.........................................................23 desvenlafaxine fumarate oral tablet extended release 24hr 50 mg...........................................................23 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG...........23 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG.............23 desvenlafaxine oral tablet extended release 24hr 100 mg........................................................................23 desvenlafaxine oral tablet extended release 24hr 50 mg........................................................................23 dexamethasone oral elixir 0.5mg/ml...........................44 dexamethasone oral solution 0.5mg/ml.......................44 dexamethasone oral tablet 0.5 mg, 1.5 mg..................44 dexamethasone oral tablet 0.75 mg, 1 mg, 4 mg, 6 mg........................................................................44 dexamethasone oral tablet 2 mg.................................44 dexamethasone sodium phos (pf)................................44 dexamethasone sodium phosphate injection.................44 dexamethasone sodium phosphate ophthalmic.............54 DEXILANT............................................................48 dexrazoxane hcl intravenous recon soln 250 mg..........16 dexrazoxane hcl intravenous recon soln 500 mg..........16 dextroamphetamine oral tablet 10 mg........................23 dextroamphetamine oral tablet 5 mg..........................23 dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg...................23 dextroamphetamine-amphetamine oral tablet 30 mg........................................................................23 dextrose 10 % and 0.2 % nacl..................................42 dextrose 10 % in water (d10w).................................42 dextrose 25 % in water (d25w).................................42 dextrose 30 % in water (d30w).................................42 dextrose 40 % in water (d40w).................................42 dextrose 5 % in water (d5w).....................................42 dextrose 5 %-lactated ringers.....................................42 Core_16293_CG6_v15_1609_1 dextrose 5%-0.2 % sod chloride.................................42 dextrose 5%-0.3 % sod.chloride.................................42 dextrose 50 % in water (d50w) intravenous parenteral solution.................................................................42 dextrose 50 % in water (d50w) intravenous syringe...................................................................42 dextrose 70 % in water (d70w).................................42 dextrose with sodium chloride....................................42 dextrose-kcl-nacl.......................................................58 diazepam intensol.....................................................23 diazepam oral concentrate.........................................23 diazepam oral solution 5 mg/5 ml (1 mg/ml)..............23 diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml).......................................................................23 diazepam oral tablet 10 mg.......................................23 diazepam oral tablet 2 mg.........................................23 diazepam oral tablet 5 mg.........................................23 diazepam rectal kit 12.5-15-17.5-20 mg...................23 diazepam rectal kit 2.5 mg, 5-7.5-10 mg...................23 diclofenac potassium..................................................23 diclofenac sodium ophthalmic....................................54 diclofenac sodium oral tablet extended release 24 hr.........................................................................23 diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg........................................................................23 diclofenac sodium oral tablet,delayed release (dr/ec) 50 mg, 75 mg.............................................................23 diclofenac sodium topical gel 1 %..............................23 dicloxacillin..............................................................10 dicyclomine oral capsule............................................48 dicyclomine oral solution...........................................48 dicyclomine oral tablet..............................................48 didanosine oral capsule,delayed release(dr/ec) 125 mg........................................................................10 didanosine oral capsule,delayed release(dr/ec) 200 mg........................................................................10 didanosine oral capsule,delayed release(dr/ec) 250 mg........................................................................10 didanosine oral capsule,delayed release(dr/ec) 400 mg........................................................................10 DIFICID................................................................10 diflorasone................................................................40 diflunisal..................................................................23 DIGITEK ORAL TABLET 125 MCG..................35 DIGOX ORAL TABLET 125 MCG......................35 digoxin oral solution 50 mcg/ml.................................35 digoxin oral tablet 125 mcg.......................................35 dihydroergotamine injection......................................23 68 Effective Date September 1, 2016 DILANTIN INFATABS........................................23 DILANTIN ORAL CAPSULE 30 MG..................23 dilt-xr......................................................................35 diltiazem hcl intravenous..........................................35 diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg......................................35 diltiazem hcl oral capsule, extended release 360 mg........................................................................35 diltiazem hcl oral capsule, extended release 420 mg........................................................................35 diltiazem hcl oral capsule,ext release degradable..........35 diltiazem hcl oral capsule,extended release 12 hr.........35 diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg................................35 diltiazem hcl oral capsule,extended release 24hr 360 mg........................................................................35 diltiazem hcl oral tablet............................................35 DIOVAN HCT......................................................35 DIPENTUM..........................................................48 diphenhydramine hcl injection solution 50 mg/ml.......56 diphenhydramine hcl injection syringe........................56 diphenoxylate-atropine oral liquid.............................48 diphenoxylate-atropine oral tablet..............................48 DIPROLENE AF...................................................40 diskets......................................................................23 disulfiram................................................................42 divalproex oral capsule, sprinkle.................................23 divalproex oral tablet extended release 24 hr...............23 divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg.................................................................23 divalproex oral tablet,delayed release (dr/ec) 500 mg........................................................................23 DOCEFREZ INTRAVENOUS RECON SOLN 20 MG.................................................................16 DOCETAXEL INTRAVENOUS SOLUTION 10 MG/ML...............................................................16 docetaxel intravenous solution 160 mg/16 ml (10 mg/ ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ ml).......................................................................16 docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml).........16 dofetilide..................................................................35 donepezil oral tablet 10 mg, 5 mg..............................23 donepezil oral tablet,disintegrating.............................23 DORIBAX..............................................................10 dorzolamide.............................................................54 dorzolamide-timolol..................................................54 doxazosin.................................................................35 Core_16293_CG6_v15_1609_1 doxepin oral.............................................................23 doxercalciferol intravenous........................................44 doxorubicin intravenous recon soln............................16 doxorubicin intravenous solution...............................16 DOXY-100.............................................................10 doxycycline hyclate intravenous..................................10 doxycycline hyclate oral capsule..................................11 doxycycline hyclate oral tablet 100 mg, 50 mg............11 doxycycline hyclate oral tablet 20 mg..........................11 doxycycline monohydrate oral tablet 100 mg...............11 doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg...................................................................11 dronabinol oral capsule 10 mg...................................48 dronabinol oral capsule 2.5 mg, 5 mg........................48 drospirenone-ethinyl estradiol....................................52 DUETACT ORAL TABLET 30-4 MG.................44 DULERA................................................................56 duloxetine oral capsule,delayed release(dr/ec) 20 mg........................................................................23 duloxetine oral capsule,delayed release(dr/ec) 30 mg........................................................................23 duloxetine oral capsule,delayed release(dr/ec) 40 mg........................................................................23 duloxetine oral capsule,delayed release(dr/ec) 60 mg........................................................................23 duramorph (pf) injection solution 0.5 mg/ml..............23 duramorph (pf) injection solution 1 mg/ml.................23 DUREZOL.............................................................54 DYAZIDE..............................................................35 DYSPORT..............................................................50 e.e.s. 400 oral tablet..................................................11 econazole topical.......................................................40 EDURANT............................................................11 EFFIENT...............................................................35 ELAPRASE.............................................................44 ELIDEL..................................................................40 elinest......................................................................52 ELIQUIS ORAL TABLET 2.5 MG.......................35 ELIQUIS ORAL TABLET 5 MG..........................35 ELITEK..................................................................16 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML.......................................................................56 ELLA......................................................................52 ELOCON TOPICAL SOLUTION.......................40 EMCYT..................................................................16 EMEND ORAL CAPSULE 125 MG.....................48 EMEND ORAL CAPSULE 40 MG.......................48 EMEND ORAL CAPSULE 80 MG.......................48 69 Effective Date September 1, 2016 EMEND ORAL CAPSULE,DOSE PACK.............48 emoquette.................................................................52 EMPLICITI............................................................16 EMSAM.................................................................23 EMTRIVA ORAL CAPSULE................................11 EMTRIVA ORAL SOLUTION.............................11 enalapril maleate......................................................35 enalapril-hydrochlorothiazide....................................35 ENBREL SUBCUTANEOUS RECON SOLN..................................................................51 ENBREL SUBCUTANEOUS SYRINGE 25 MG/ 0.5ML (0.51).......................................................51 ENBREL SUBCUTANEOUS SYRINGE 50 MG/ ML (0.98 ML).....................................................51 ENBREL SURECLICK..........................................51 endocet oral tablet 10-325 mg, 7.5-325 mg...............23 endocet oral tablet 5-325 mg.....................................23 ENGERIX-B (PF)...................................................50 ENGERIX-B PEDIATRIC (PF).............................50 enoxaparin subcutaneous solution..............................35 enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ ml.........................................................................35 enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml.............................................................35 enoxaparin subcutaneous syringe 30 mg/0.3 ml...........35 enoxaparin subcutaneous syringe 40 mg/0.4 ml..........35 enoxaparin subcutaneous syringe 60 mg/0.6 ml...........35 enpresse....................................................................52 entacapone...............................................................24 entecavir..................................................................11 enulose.....................................................................48 ENVARSUS XR.....................................................16 epinephrine injection auto-injector.............................56 epinephrine injection syringe 0.1 mg/ml.....................56 EPIPEN 2-PAK......................................................56 EPIPEN JR 2-PAK.................................................56 epirubicin intravenous solution 200 mg/100 ml.........16 epirubicin intravenous solution 50 mg/25 ml.............16 epitol.......................................................................24 EPIVIR HBV ORAL SOLUTION.........................11 EPIVIR ORAL SOLUTION..................................11 eplerenone................................................................35 eprosartan................................................................35 EPZICOM.............................................................11 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG...................................................24 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG...................................................24 Core_16293_CG6_v15_1609_1 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG...................................................24 ERBITUX...............................................................16 ergoloid....................................................................24 ERIVEDGE............................................................17 errin........................................................................52 ERWINAZE...........................................................17 ery pads....................................................................40 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg........................................................................11 erythrocin (as stearate) oral tablet 250 mg..................11 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG...................................................11 erythromycin ethylsuccinate oral tablet.......................11 erythromycin ophthalmic...........................................54 erythromycin oral capsule,delayed release(dr/ec)...........11 erythromycin oral tablet............................................11 erythromycin with ethanol.........................................40 erythromycin-benzoyl peroxide...................................40 ESBRIET................................................................56 escitalopram oxalate oral solution...............................24 escitalopram oxalate oral tablet 10 mg.......................24 escitalopram oxalate oral tablet 20 mg.......................24 escitalopram oxalate oral tablet 5 mg.........................24 esomeprazole sodium intravenous...............................48 estarylla....................................................................52 ESTRACE VAGINAL............................................52 estradiol oral............................................................52 estradiol transdermal patch semiweekly......................52 estradiol transdermal patch weekly.............................52 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ ml.........................................................................52 ESTRING...............................................................52 ethambutol...............................................................11 ethosuximide oral capsule..........................................24 ethosuximide oral solution.........................................24 etidronate disodium oral tablet 200 mg......................42 etidronate disodium oral tablet 400 mg......................42 etodolac oral capsule..................................................24 etodolac oral tablet....................................................24 etodolac oral tablet extended release 24 hr..................24 ETOPOPHOS.......................................................17 etoposide intravenous................................................17 EVOMELA.............................................................17 EVOTAZ................................................................11 EXELON ORAL CAPSULE 1.5 MG, 4.5 MG......24 exemestane...............................................................17 EXFORGE.............................................................35 70 Effective Date September 1, 2016 EXFORGE HCT....................................................35 EXJADE.................................................................42 EXTAVIA SUBCUTANEOUS KIT......................50 EXTAVIA SUBCUTANEOUS RECON SOLN..................................................................50 FABRAZYME.........................................................44 falmina (28)............................................................52 famciclovir oral tablet 125 mg, 250 mg.....................11 famciclovir oral tablet 500 mg...................................11 famotidine (pf).........................................................48 famotidine (pf)-nacl (iso-os)......................................48 famotidine intravenous.............................................48 famotidine oral suspension.........................................48 famotidine oral tablet 20 mg, 40 mg..........................48 FANAPT ORAL TABLET 1 MG...........................24 FANAPT ORAL TABLET 10 MG.........................24 FANAPT ORAL TABLET 12 MG.........................24 FANAPT ORAL TABLET 2 MG...........................24 FANAPT ORAL TABLET 4 MG...........................24 FANAPT ORAL TABLET 6 MG...........................24 FANAPT ORAL TABLET 8 MG...........................24 FANAPT ORAL TABLETS,DOSE PACK............24 FARESTON...........................................................17 FARYDAK ORAL CAPSULE 10 MG....................17 FARYDAK ORAL CAPSULE 15 MG, 20 MG......17 FASLODEX...........................................................17 felbamate oral suspension..........................................24 felbamate oral tablet 400 mg.....................................24 felbamate oral tablet 600 mg.....................................24 FELBATOL ORAL TABLET 400 MG..................24 felodipine oral tablet extended release 24 hr 10 mg........................................................................35 felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg.....................................................................35 FEMRING.............................................................52 fenofibrate micronized oral capsule 130 mg................35 fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg...................................................................35 fenofibrate micronized oral capsule 43 mg..................35 fenofibrate nanocrystallized 48 mg, 145 mg...............35 fenofibrate oral tablet 160 mg...................................35 fenofibrate oral tablet 54 mg.....................................35 fenofibric acid (choline) dr capsules............................35 fenoprofen oral tablet................................................24 fentanyl citrate.........................................................24 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr...............24 Core_16293_CG6_v15_1609_1 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK.......................................................24 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG....................24 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG....................................24 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG....................................24 finasteride oral tablet 5 mg........................................57 FIRAZYR...............................................................56 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG......................................................................17 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG......................................................................17 flavoxate..................................................................57 flecainide oral tablet 100 mg, 50 mg..........................35 flecainide oral tablet 150 mg.....................................35 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION.......56 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ACTUATION..........................................56 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION.................56 FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION.................56 FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION...................56 fluconazole in dextrose(iso-o).....................................11 FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML.......................................................................11 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml.....................................................11 fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml.....................................................11 fluconazole oral suspension for reconstitution 10 mg/ ml.........................................................................11 fluconazole oral suspension for reconstitution 40 mg/ ml.........................................................................11 fluconazole oral tablet 100 mg...................................11 fluconazole oral tablet 150 mg, 50 mg.......................11 fluconazole oral tablet 200 mg...................................11 flucytosine................................................................11 fludarabine intravenous recon soln.............................17 fludarabine intravenous solution................................17 71 Effective Date September 1, 2016 FOSAMAX ORAL TABLET 70 MG.....................51 FOSAMAX PLUS D...............................................51 foscarnet...................................................................11 fosinopril..................................................................36 fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg........................................................................36 fosinopril-hydrochlorothiazide oral tablet 20-12.5 mg........................................................................36 fosphenytoin.............................................................25 freamine iii 10 %.....................................................58 furosemide injection..................................................36 furosemide oral solution 10 mg/ml.............................36 furosemide oral solution 40 mg/5 ml (8 mg/ml)..........36 furosemide oral tablet................................................36 FUSILEV................................................................17 FUZEON SUBCUTANEOUS RECON SOLN..................................................................11 FYCOMPA ORAL SUSPENSION........................25 FYCOMPA ORAL TABLET 10 MG, 12 MG.......25 FYCOMPA ORAL TABLET 2 MG.......................25 FYCOMPA ORAL TABLET 4 MG.......................25 FYCOMPA ORAL TABLET 6 MG.......................25 FYCOMPA ORAL TABLET 8 MG.......................25 gabapentin oral capsule 100 mg.................................25 gabapentin oral capsule 300 mg.................................25 gabapentin oral capsule 400 mg.................................25 gabapentin oral solution 250 mg/5 ml........................25 gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)......................................................25 gabapentin oral tablet 600 mg...................................25 gabapentin oral tablet 800 mg...................................25 GABITRIL ORAL TABLET 12 MG......................25 GABITRIL ORAL TABLET 16 MG......................25 galantamine oral capsule,ext rel. pellets 24 hr.............25 galantamine oral solution..........................................25 galantamine oral tablet.............................................25 GAMASTAN S/D..................................................50 GAMMAGARD LIQUID......................................50 GAMMAGARD S-D (IGA < 1 MCG/ML).......50 GAMUNEX-C.......................................................50 ganciclovir sodium....................................................11 GARDASIL (PF)....................................................50 GARDASIL 9 (PF).................................................50 GATTEX 30-VIAL.................................................48 GATTEX ONE-VIAL............................................48 gauze pads 2 x 2.......................................................44 gavilyte-c..................................................................48 gavilyte-g..................................................................48 fludrocortisone..........................................................44 flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)........................................................................56 fluocinolone acetonide oil otic....................................43 fluocinolone topical cream.........................................40 fluocinolone topical ointment.....................................40 fluocinolone topical solution......................................41 fluocinonide topical cream 0.05 %............................41 fluocinonide topical gel..............................................41 fluocinonide topical ointment....................................41 fluocinonide topical solution......................................41 fluocinonide-e...........................................................41 fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg).......................................................................58 fluorometholone........................................................54 fluorouracil intravenous............................................17 fluorouracil topical cream 5 %..................................41 fluorouracil topical solution.......................................41 fluoxetine oral capsule 10 mg.....................................24 fluoxetine oral capsule 20 mg.....................................24 fluoxetine oral capsule 40 mg.....................................24 fluoxetine oral solution..............................................24 fluoxetine oral tablet 10 mg.......................................24 fluoxetine oral tablet 20 mg.......................................24 fluphenazine decanoate.............................................24 fluphenazine hcl injection..........................................24 fluphenazine hcl oral.................................................24 flurbiprofen..............................................................24 flurbiprofen sodium..................................................54 flutamide.................................................................17 fluticasone nasal.......................................................56 fluticasone topical cream...........................................41 fluticasone topical lotion............................................41 fluticasone topical ointment.......................................41 fluvastatin oral capsule 20 mg...................................35 fluvastatin oral capsule 40 mg...................................35 fluvoxamine oral tablet 100 mg.................................24 fluvoxamine oral tablet 25 mg...................................25 fluvoxamine oral tablet 50 mg...................................25 FOLOTYN.............................................................17 fomepizole................................................................50 fondaparinux subcutaneous syringe 10 mg/0.8 ml.......35 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml......35 fondaparinux subcutaneous syringe 5 mg/0.4 ml.........35 fondaparinux subcutaneous syringe 7.5 mg/0.6 ml......36 FORADIL AEROLIZER........................................56 FORTEO...............................................................51 fortical.....................................................................44 Core_16293_CG6_v15_1609_1 72 Effective Date September 1, 2016 gavilyte-n.................................................................48 GAZYVA................................................................17 gemcitabine intravenous recon soln 1 gram, 200 mg........................................................................17 gemcitabine intravenous recon soln 2 gram.................17 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)......................17 gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml)..................................................................17 gemfibrozil oral........................................................36 generlac....................................................................48 gengraf oral capsule 100 mg, 25 mg...........................17 gengraf oral capsule 50 mg........................................17 gengraf oral solution..................................................17 gentak ophthalmic ointment......................................54 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml................................11 GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML.........................................11 gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/ 100 ml..................................................................11 gentamicin injection.................................................11 gentamicin ophthalmic..............................................54 gentamicin sulfate (ped) (pf)......................................11 gentamicin sulfate (pf) intravenous solution 100 mg/ 10 ml....................................................................11 gentamicin sulfate (pf) intravenous solution 60 mg/6 ml, 80 mg/8 ml.....................................................11 gentamicin topical....................................................41 GENVOYA............................................................11 GEODON INTRAMUSCULAR...........................25 gildagia....................................................................52 gildess 1.5/30 (21)....................................................52 gildess 1/20 (21).......................................................52 GILDESS FE 1.5/30 (28).......................................52 GILDESS FE 1/20 (28)..........................................52 GILENYA...............................................................25 GILOTRIF.............................................................17 GLATOPA.............................................................25 GLEEVEC ORAL TABLET 100 MG....................17 GLEEVEC ORAL TABLET 400 MG....................17 GLEOSTINE.........................................................17 glimepiride oral tablet 1 mg......................................44 glimepiride oral tablet 2 mg......................................44 glimepiride oral tablet 4 mg......................................44 glipizide oral tablet 10 mg........................................44 Core_16293_CG6_v15_1609_1 glipizide oral tablet 5 mg..........................................44 glipizide oral tablet extended release 24hr 10 mg........44 glipizide oral tablet extended release 24hr 2.5 mg.......44 glipizide oral tablet extended release 24hr 5 mg..........44 glipizide-metformin oral tablet 2.5-250 mg...............44 glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg........................................................................44 GLUCAGEN HYPOKIT.......................................44 GLUCAGON EMERGENCY KIT (HUMAN)..........................................................44 GLUCOPHAGE ORAL TABLET 1,000 MG.......44 GLUCOPHAGE ORAL TABLET 500 MG..........44 GLUCOPHAGE ORAL TABLET 850 MG..........44 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG...........44 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG...........44 GLUCOTROL ORAL TABLET 10 MG...............44 GLUCOTROL ORAL TABLET 5 MG.................44 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG.....................................45 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG....................................45 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG.......................................45 GLUCOVANCE....................................................45 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG.............45 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 MG................45 glycopyrrolate injection..............................................48 glycopyrrolate oral tablet............................................48 GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 250 MG...............................................12 griseofulvin microsize oral suspension.........................12 griseofulvin ultramicrosize.........................................12 guanfacine oral tablet extended release 24 hr..............25 guanidine.................................................................25 HALAVEN.............................................................17 halobetasol propionate...............................................41 haloperidol...............................................................25 haloperidol decanoate................................................25 haloperidol lactate injection.......................................25 haloperidol lactate oral..............................................25 HARVONI.............................................................12 HAVRIX (PF) INTRAMUSCULAR SUSPENSION....................................................50 73 Effective Date September 1, 2016 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1, 440 ELISA UNIT/ML.........................................50 HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML...................................50 heather.....................................................................52 heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml..................................36 heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml)..............36 heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml).......................................36 heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml.........................................................................36 heparin (porcine) injection cartridge..........................36 heparin (porcine) injection solution............................36 heparin(porcine) in 0.45% nacl intravenous parenteral solution 12,500 unit/250 ml..................................36 heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml..................................36 heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/500 ml..................................36 heparin, porcine (pf) injection solution.......................36 HEPATAMINE 8%...............................................58 HERCEPTIN.........................................................17 HETLIOZ..............................................................25 HEXALEN.............................................................17 HIBERIX (PF)........................................................50 HUMALOG...........................................................45 HUMALOG KWIKPEN........................................45 HUMALOG MIX 50-50........................................45 HUMALOG MIX 50-50 KWIKPEN.....................45 HUMALOG MIX 75-25........................................45 HUMALOG MIX 75-25 KWIKPEN.....................45 HUMAPEN LUXURA HD...................................45 HUMIRA PEDIATRIC CROHN'S START.........51 HUMIRA PEN.......................................................51 HUMIRA PEN CROHN'S-UC-HS START.........51 HUMIRA PEN PSORIASIS STARTER................51 HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML..............................51 HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML.........................................................51 HUMULIN 70/30..................................................45 HUMULIN 70/30 KWIKPEN..............................45 HUMULIN N........................................................45 HUMULIN N KWIKPEN.....................................45 Core_16293_CG6_v15_1609_1 HUMULIN R........................................................45 HUMULIN R U-500 (CONC) KWIKPEN..........45 HUMULIN R U-500 (CONCENTRATED)........45 hydralazine injection................................................36 hydralazine oral.......................................................36 hydrochlorothiazide..................................................36 hydrocodone-acetaminophen oral solution 2.5-167 mg/ 5 ml......................................................................25 hydrocodone-acetaminophen oral solution 7.5-325 mg/ 15 ml....................................................................25 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg..........................................25 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg....................................................25 hydrocortisone butyrate topical cream.........................41 hydrocortisone butyrate topical ointment....................41 hydrocortisone butyrate topical solution......................41 hydrocortisone oral tablet 10 mg, 5 mg.......................45 hydrocortisone oral tablet 20 mg................................45 hydrocortisone rectal cream 2.5 %.............................48 hydrocortisone rectal enema.......................................48 hydrocortisone topical cream 1 %...............................41 hydrocortisone topical cream 2.5 %............................41 hydrocortisone topical lotion 2.5 %............................41 hydrocortisone topical ointment 1 %..........................41 hydrocortisone topical ointment 2.5 %.......................41 hydrocortisone valerate..............................................41 hydrocortisone-acetic acid..........................................43 hydrocortisone-min oil-wht pet..................................41 hydromorphone (pf) injection solution 1 mg/ml...........25 hydromorphone (pf) injection solution 10 mg/ml.........25 hydromorphone (pf) injection solution 4 mg/ml...........25 hydromorphone injection solution..............................25 hydromorphone injection syringe 1 mg/ml...................25 hydromorphone injection syringe 2 mg/ml...................25 hydromorphone injection syringe 4 mg/ml...................25 hydromorphone oral tablet 2 mg, 4 mg.......................25 hydromorphone oral tablet 8 mg................................25 hydroxychloroquine oral............................................12 hydroxyurea..............................................................17 HYZAAR................................................................36 ibandronate intravenous solution...............................51 ibandronate intravenous syringe.................................52 ibandronate oral.......................................................52 IBRANCE..............................................................17 ibuprofen oral suspension...........................................25 ibuprofen oral tablet 400 mg, 600 mg, 800 mg..........25 ibuprofen-oxycodone.................................................25 74 Effective Date September 1, 2016 ICLUSIG ORAL TABLET 15 MG........................17 ICLUSIG ORAL TABLET 45 MG........................17 idarubicin................................................................17 IFEX.......................................................................17 ifosfamide intravenous recon soln...............................17 ifosfamide intravenous solution..................................17 ILARIS (PF)............................................................50 ILEVRO.................................................................54 imatinib oral tablet 100 mg......................................17 imatinib oral tablet 400 mg......................................17 IMBRUVICA.........................................................17 imipenem-cilastatin intravenous recon soln 250 mg........................................................................12 imipenem-cilastatin intravenous recon soln 500 mg........................................................................12 imipramine hcl.........................................................25 imiquimod...............................................................41 IMOVAX RABIES VACCINE (PF).......................50 INCRELEX............................................................42 indapamide..............................................................36 INFANRIX (DTAP) (PF).......................................50 INLYTA ORAL TABLET 1 MG............................17 INLYTA ORAL TABLET 5 MG............................17 insulin pen needle.....................................................45 INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML........................................................45 INTELENCE ORAL TABLET 100 MG...............12 INTELENCE ORAL TABLET 200 MG...............12 INTELENCE ORAL TABLET 25 MG.................12 intralipid intravenous emulsion 20 %........................58 INTRALIPID INTRAVENOUS EMULSION 30 %.........................................................................58 INTRON A INJECTION......................................50 introvale..................................................................52 INVANZ 1 GM ADD-VANTAGE VIAL..............12 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG....................................26 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG.......................................26 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG.......................................26 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG.......................................26 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML..............................26 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML................................26 Core_16293_CG6_v15_1609_1 INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML............................26 INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML............................26 INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML..............................26 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML............................26 INVIRASE ORAL CAPSULE................................12 INVIRASE ORAL TABLET..................................12 IONOSOL-B IN D5W..........................................58 IONOSOL-MB IN D5W.......................................58 IOPIDINE OPHTHALMIC DROPS...................54 IPOL INJECTION SUSPENSION.......................50 ipratropium bromide inhalation................................56 ipratropium bromide nasal........................................43 ipratropium-albuterol...............................................56 irbesartan.................................................................36 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg........................................................................36 irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg........................................................................36 IRESSA...................................................................17 irinotecan intravenous solution 100 mg/5 ml, 40 mg/ 2 ml......................................................................17 irinotecan intravenous solution 500 mg/25 ml............17 ISENTRESS ORAL POWDER IN PACKET........12 ISENTRESS ORAL TABLET................................12 ISENTRESS ORAL TABLET,CHEWABLE 100 MG......................................................................12 ISENTRESS ORAL TABLET,CHEWABLE 25 MG......................................................................12 ISOLYTE S PH 7.4................................................58 ISOLYTE-P IN 5 % DEXTROSE.........................58 ISOLYTE-S............................................................58 isoniazid injection....................................................12 isoniazid oral solution...............................................12 isoniazid oral tablet 100 mg......................................12 isoniazid oral tablet 300 mg......................................12 ISOPTO CARPINE...............................................54 isosorbide dinitrate oral tablet 10 mg, 20 mg, 5 mg........................................................................36 isosorbide dinitrate oral tablet 30 mg.........................36 isosorbide dinitrate oral tablet extended release...........36 isosorbide mononitrate..............................................36 isradipine.................................................................36 ISTODAX..............................................................17 itraconazole..............................................................12 75 Effective Date September 1, 2016 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG.....................................26 KINERET..............................................................52 kionex......................................................................42 klor-con 10..............................................................58 klor-con 8................................................................58 klor-con m10............................................................58 klor-con m15............................................................58 klor-con m20............................................................58 klor-con/ef................................................................58 KORLYM...............................................................45 KUVAN ORAL TABLET,SOLUBLE....................45 labetalol intravenous solution....................................36 labetalol oral tablet 100 mg, 200 mg.........................36 labetalol oral tablet 300 mg.......................................36 LACRISERT...........................................................54 lactated ringers intravenous.......................................58 lactated ringers irrigation..........................................42 lactulose...................................................................48 LAMISIL ORAL TABLET.....................................12 lamivudine oral solution...........................................12 lamivudine oral tablet 100 mg..................................12 lamivudine oral tablet 150 mg..................................12 lamivudine oral tablet 300 mg..................................12 lamivudine-zidovudine.............................................12 lamotrigine oral tablet 100 mg, 150 mg, 200 mg.......26 lamotrigine oral tablet 25 mg....................................26 lamotrigine oral tablet, chewable dispersible...............26 LANOXIN ORAL TABLET 125 MCG, 62.5 MCG...................................................................36 lansoprazole oral capsule,delayed release(dr/ec)............48 LANTUS................................................................45 LANTUS SOLOSTAR...........................................45 LARIN 1/20 (21)....................................................53 LARIN FE 1.5/30 (28)...........................................53 LARIN FE 1/20 (28)..............................................53 latanoprost...............................................................54 LATUDA ORAL TABLET 120 MG......................26 LATUDA ORAL TABLET 20 MG........................26 LATUDA ORAL TABLET 40 MG........................26 LATUDA ORAL TABLET 60 MG........................26 LATUDA ORAL TABLET 80 MG........................26 leena 28...................................................................53 leflunomide oral tablet 10 mg....................................52 leflunomide oral tablet 20 mg....................................52 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY).....................................................18 ivermectin oral.........................................................12 IXEMPRA..............................................................17 IXIARO (PF)..........................................................50 JAKAFI ORAL TABLET 10 MG...........................17 JAKAFI ORAL TABLET 15 MG...........................17 JAKAFI ORAL TABLET 20 MG...........................17 JAKAFI ORAL TABLET 25 MG...........................18 JAKAFI ORAL TABLET 5 MG.............................18 jantoven oral tablet 1 mg, 10 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg.........................................36 jantoven oral tablet 2 mg..........................................36 JANUMET.............................................................45 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG...............45 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG......................................................................45 JANUVIA ORAL TABLET 100 MG.....................45 JANUVIA ORAL TABLET 25 MG.......................45 JANUVIA ORAL TABLET 50 MG.......................45 JARDIANCE..........................................................45 JENTADUETO.....................................................45 JEVTANA..............................................................18 jolessa.......................................................................52 jolivette....................................................................53 junel 1.5/30 (21)......................................................53 junel 1/20 (21).........................................................53 junel fe 1.5/30 (28)..................................................53 junel fe 1/20 (28).....................................................53 JUXTAPID.............................................................36 k-effervescent............................................................58 k-tab oral tablet extended release 8 meq.....................58 KADCYLA.............................................................18 KALETRA ORAL SOLUTION.............................12 KALETRA ORAL TABLET 100-25 MG...............12 KALETRA ORAL TABLET 200-50 MG...............12 KALYDECO ORAL TABLET...............................56 kariva (28)..............................................................53 kelnor 1/35 (28).......................................................53 KETEK...................................................................12 ketoconazole oral......................................................12 ketoconazole topical cream.........................................41 ketoconazole topical shampoo.....................................41 ketorolac ophthalmic.................................................54 KEYTRUDA..........................................................18 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG...................................26 Core_16293_CG6_v15_1609_1 76 Effective Date September 1, 2016 LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2).........................................................................18 LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2)..............................................18 LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1).............................................18 LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK)..........18 LESCOL.................................................................36 lessina......................................................................53 LETAIRIS...............................................................56 letrozole...................................................................18 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg...............................................18 leucovorin calcium injection recon soln 500 mg..........18 leucovorin calcium oral tablet 10 mg, 25 mg..............18 leucovorin calcium oral tablet 15 mg, 5 mg................18 LEUKERAN...........................................................18 leuprolide subcutaneous kit........................................18 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml........56 levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml........................................................56 LEVEMIR..............................................................45 LEVEMIR FLEXTOUCH.....................................45 levetiracetam in nacl (iso-os) intravenous piggyback 1, 000 mg/100 ml, 1,500 mg/100 ml.........................26 levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml.....................................................26 levetiracetam intravenous..........................................26 levetiracetam oral solution 100 mg/ml.......................26 levetiracetam oral solution 500 mg/5 ml (5 ml)..........26 levetiracetam oral tablet 1,000 mg.............................26 levetiracetam oral tablet 250 mg, 500 mg, 750 mg........................................................................26 levetiracetam oral tablet extended release 24 hr 500 mg........................................................................26 levetiracetam oral tablet extended release 24 hr 750 mg........................................................................26 levobunolol ophthalmic drops 0.5 %..........................54 levocarnitine (with sugar)..........................................42 levocarnitine intravenous..........................................42 levocarnitine oral tablet.............................................42 levocetirizine oral tablet............................................56 levofloxacin in d5w intravenous piggyback 250 mg/50 ml.........................................................................12 Core_16293_CG6_v15_1609_1 levofloxacin in d5w intravenous piggyback 500 mg/ 100 ml, 750 mg/150 ml........................................12 levofloxacin ophthalmic.............................................54 levofloxacin oral tablet..............................................12 levonest (28).............................................................53 levonorg-eth estrad triphasic......................................53 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg........................................................53 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg......53 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month...................................................................53 levora-28.................................................................53 levothyroxine oral.....................................................45 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg.....................................................45 LEXIVA ORAL SUSPENSION.............................12 LEXIVA ORAL TABLET.......................................12 LIALDA..................................................................48 lidocaine hcl laryngotracheal......................................41 lidocaine hcl mucous membrane.................................41 lidocaine hcl urethral................................................41 lidocaine topical adhesive patch,medicated.................41 lidocaine topical ointment.........................................41 lidocaine viscous.......................................................41 lidocaine-prilocaine topical cream..............................41 LINCOCIN............................................................12 lincomycin injection..................................................12 lindane topical shampoo............................................41 linezolid intravenous.................................................12 linezolid oral suspension for reconstitution..................12 linezolid oral tablet...................................................12 linezolid-0.9% sodium chloride.................................12 LINZESS................................................................48 liothyronine intravenous............................................45 liothyronine oral tablet 25 mcg, 5 mcg.......................45 liothyronine oral tablet 50 mcg..................................45 LIPITOR ORAL TABLET 10 MG........................36 lisinopril..................................................................36 lisinopril-hydrochlorothiazide....................................36 lithium carbonate oral capsule 150 mg, 300 mg.........26 lithium carbonate oral capsule 600 mg.......................26 lithium carbonate oral tablet.....................................26 lithium carbonate oral tablet extended release.............26 lithium citrate oral solution 8 meq/5 ml.....................26 LOFIBRA ORAL CAPSULE 200 MG...................36 LONSURF.............................................................18 loperamide oral capsule.............................................48 77 Effective Date September 1, 2016 LOPID...................................................................36 lorazepam oral tablet................................................26 loryna (28)...............................................................53 losartan oral tablet 100 mg.......................................36 losartan oral tablet 25 mg, 50 mg..............................36 losartan-hydrochlorothiazide.....................................36 LOTENSIN ORAL TABLET 20 MG, 40 MG......37 lovastatin oral tablet 10 mg, 20 mg...........................37 lovastatin oral tablet 40 mg.......................................37 low-ogestrel (28).......................................................53 loxapine succinate oral capsule 10 mg, 5 mg...............26 loxapine succinate oral capsule 25 mg, 50 mg.............26 ludent fluoride..........................................................58 LUMIGAN OPHTHALMIC DROPS 0.01 %......54 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG.....................................18 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG.......................................18 LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED).............................................18 lutera (28)...............................................................53 LYNPARZA............................................................18 LYRICA ORAL CAPSULE 100 MG......................26 LYRICA ORAL CAPSULE 150 MG......................27 LYRICA ORAL CAPSULE 200 MG......................27 LYRICA ORAL CAPSULE 225 MG, 300 MG......27 LYRICA ORAL CAPSULE 25 MG........................27 LYRICA ORAL CAPSULE 50 MG........................27 LYRICA ORAL CAPSULE 75 MG........................27 LYRICA ORAL SOLUTION.................................27 LYSODREN...........................................................18 lyza..........................................................................53 M-M-R II (PF).......................................................50 magnesium sulfate in water intravenous parenteral solution.................................................................58 magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %)................58 magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %)...............................................58 magnesium sulfate injection solution..........................58 magnesium sulfate injection syringe............................58 MALARONE.........................................................12 malathion................................................................41 maprotiline oral tablet 25 mg....................................27 maprotiline oral tablet 50 mg....................................27 maprotiline oral tablet 75 mg....................................27 marlissa...................................................................53 MARPLAN.............................................................27 Core_16293_CG6_v15_1609_1 MATULANE..........................................................18 MAVIK ORAL TABLET 1 MG, 2 MG.................37 MAXZIDE.............................................................37 MAXZIDE-25MG..................................................37 meclizine oral tablet 12.5 mg, 25 mg.........................48 meclofenamate oral...................................................27 medroxyprogesterone intramuscular............................53 medroxyprogesterone oral...........................................53 mefloquine...............................................................12 megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml)..................................................18 megestrol oral suspension 400 mg/10 ml (40 mg/ ml).......................................................................18 megestrol oral tablet..................................................18 MEKINIST ORAL TABLET 0.5 MG....................18 MEKINIST ORAL TABLET 2 MG.......................18 meloxicam oral suspension.........................................27 meloxicam oral tablet................................................27 melphalan hcl...........................................................18 memantine oral solution............................................27 memantine oral tablet 10 mg....................................27 memantine oral tablet 5 mg......................................27 MENACTRA (PF) INTRAMUSCULAR SOLUTION........................................................50 MENEST...............................................................53 MENOMUNE - A/C/Y/W-135.............................50 MENOMUNE - A/C/Y/W-135 (PF).....................50 MENVEO A-C-Y-W-135-DIP (PF).......................50 mercaptopurine.........................................................18 meropenem...............................................................12 mesalamine rectal.....................................................48 mesalamine with cleansing wipe................................48 mesna......................................................................18 MESNEX ORAL....................................................18 MESTINON ORAL SYRUP..................................27 MESTINON TIMESPAN.....................................27 metformin oral tablet 1,000 mg.................................45 metformin oral tablet 500 mg....................................45 metformin oral tablet 850 mg....................................45 metformin oral tablet extended release 24 hr 500 mg........................................................................46 metformin oral tablet extended release 24 hr 750 mg........................................................................46 metformin oral tablet extended release 24hr 1,000 mg........................................................................46 metformin oral tablet extended release 24hr 500 mg........................................................................46 78 Effective Date September 1, 2016 metformin oral tablet,er gast.retention 24 hr 1,000 mg........................................................................46 metformin oral tablet,er gast.retention 24 hr 500 mg........................................................................46 methadone intensol...................................................27 methadone oral concentrate.......................................27 methadone oral solution 10 mg/5 ml..........................27 methadone oral solution 5 mg/5 ml............................27 methadone oral tablet 10 mg.....................................27 methadone oral tablet 5 mg.......................................27 methadone oral tablet,soluble.....................................27 methadose oral concentrate........................................27 methadose oral tablet,soluble......................................27 methazolamide oral..................................................54 methenamine hippurate............................................12 methenamine mandelate...........................................12 methimazole oral tablet 10 mg..................................46 methimazole oral tablet 5 mg....................................46 methotrexate sodium (pf) injection recon soln..............18 methotrexate sodium (pf) injection solution................18 methotrexate sodium injection...................................18 methotrexate sodium oral..........................................18 methoxsalen rapid.....................................................41 methscopolamine oral................................................48 methyclothiazide.......................................................37 methylergonovine oral...............................................53 methylphenidate oral tablet.......................................27 methylprednisolone acetate.........................................46 methylprednisolone oral tablet 16 mg, 4 mg, 8 mg......46 methylprednisolone oral tablet 32 mg.........................46 methylprednisolone oral tablets,dose pack....................46 methylprednisolone sodium succ injection recon soln 125 mg, 40 mg......................................................46 methylprednisolone sodium succ intravenous...............46 metipranolol.............................................................54 metoclopramide hcl injection solution.........................48 metoclopramide hcl injection syringe..........................48 metoclopramide hcl oral solution................................48 metoclopramide hcl oral tablet...................................48 metolazone oral tablet 10 mg, 5 mg...........................37 metolazone oral tablet 2.5 mg....................................37 metoprolol succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg..........................................37 metoprolol succinate oral tablet extended release 24 hr 200 mg.................................................................37 metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg............................................................37 Core_16293_CG6_v15_1609_1 metoprolol ta-hydrochlorothiaz oral tablet 50-25 mg........................................................................37 metoprolol tartrate intravenous solution.....................37 metoprolol tartrate intravenous syringe.......................37 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg........................................................................37 metoprolol tartrate oral tablet 37.5 mg, 75 mg...........37 metro i.v..................................................................12 metronidazole in nacl (iso-os)....................................12 metronidazole oral capsule.........................................12 metronidazole oral tablet...........................................12 metronidazole topical cream......................................41 metronidazole topical gel 0.75 %...............................41 metronidazole topical lotion......................................41 metronidazole vaginal...............................................53 mexiletine oral capsule 150 mg, 250 mg....................37 mexiletine oral capsule 200 mg..................................37 MIACALCIN INJECTION...................................46 MIACALCIN NASAL............................................46 MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-25 MG............................................................37 MICARDIS HCT ORAL TABLET 80-12.5 MG......................................................................37 MICARDIS ORAL TABLET 20 MG, 40 MG.......37 MICARDIS ORAL TABLET 80 MG....................37 miconazole-3 vaginal suppository...............................53 MICROGESTIN 1.5/30 (21).................................53 MICROGESTIN 1/20 (21)....................................53 MICROGESTIN FE 1.5/30 (28)...........................53 MICROGESTIN FE 1/20 (28)..............................53 MICROZIDE.........................................................37 midodrine................................................................42 MINIPRESS ORAL CAPSULE 2 MG...................37 minocycline oral capsule 100 mg, 50 mg....................12 minocycline oral capsule 75 mg..................................13 minocycline oral tablet..............................................13 minoxidil oral..........................................................37 MIRAPEX ORAL TABLET 0.25 MG, 0.75 MG......................................................................27 mirtazapine oral tablet 15 mg...................................27 mirtazapine oral tablet 30 mg...................................27 mirtazapine oral tablet 45 mg...................................27 mirtazapine oral tablet 7.5 mg..................................27 mirtazapine oral tablet,disintegrating 15 mg..............27 mirtazapine oral tablet,disintegrating 30 mg..............27 mirtazapine oral tablet,disintegrating 45 mg..............27 misoprostol oral tablet 100 mcg.................................48 misoprostol oral tablet 200 mcg.................................48 79 Effective Date September 1, 2016 mitomycin................................................................18 mitoxantrone............................................................18 modafinil oral tablet 100 mg.....................................27 modafinil oral tablet 200 mg.....................................27 moexipril..................................................................37 moexipril-hydrochlorothiazide...................................37 molindone................................................................27 mometasone nasal.....................................................56 mometasone topical...................................................41 mono-linyah.............................................................53 mononessa (28).........................................................53 montelukast oral granules in packet............................56 montelukast oral tablet..............................................56 montelukast oral tablet,chewable...............................56 morphine (pf) injection solution 0.5 mg/ml................27 morphine (pf) injection solution 1 mg/ml...................27 morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml................................................27 morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml..................................................27 morphine concentrate oral solution.............................27 morphine intravenous cartridge.................................27 morphine intravenous solution 10 mg/ml, 50 mg/ ml.........................................................................27 morphine intravenous solution 100 mg/4 ml, 25 mg/ ml, 250 mg/10 ml.................................................28 morphine intravenous solution 4 mg/ml, 8 mg/ml.......28 morphine intravenous syringe 2 mg/ml, 4 mg/ml.........28 morphine oral solution 10 mg/5 ml............................28 morphine oral solution 20 mg/5 ml (4 mg/ml)............28 morphine oral tablet 15 mg.......................................28 morphine oral tablet 30 mg.......................................28 morphine oral tablet extended release 100 mg, 30 mg, 60 mg...................................................................28 morphine oral tablet extended release 15 mg...............28 morphine oral tablet extended release 200 mg.............28 morphine rectal........................................................28 MOVIPREP...........................................................48 MOXEZA...............................................................54 moxifloxacin.............................................................13 MULTAQ..............................................................37 mupirocin calcium....................................................41 mupirocin topical ointment.......................................41 MUSTARGEN.......................................................18 MYCAMINE..........................................................13 mycophenolate mofetil oral capsule.............................18 mycophenolate mofetil oral suspension for reconstitution........................................................18 Core_16293_CG6_v15_1609_1 mycophenolate mofetil oral tablet...............................18 myorisan oral capsule 10 mg, 20 mg, 40 mg...............41 MYOZYME............................................................46 MYRBETRIQ........................................................57 MYZILRA..............................................................53 nabumetone.............................................................28 nadolol oral tablet 20 mg, 40 mg...............................37 nadolol oral tablet 80 mg..........................................37 nadolol-bendroflumethiazide.....................................37 nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml...........................................................13 nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml.........................................................13 nafcillin injection.....................................................13 nafcillin intravenous recon soln 1 gram......................13 NAFCILLIN INTRAVENOUS RECON SOLN 2 GRAM..............................................................13 NAGLAZYME.......................................................46 nalbuphine injection solution 10 mg/ml.....................28 nalbuphine injection solution 20 mg/ml.....................28 naloxone injection solution........................................28 naloxone injection syringe 0.4 mg/ml.........................28 naloxone injection syringe 1 mg/ml............................28 naltrexone................................................................28 NAMENDA ORAL SOLUTION..........................28 NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK............................................28 NAMENDA XR ORAL CAPSULE,SPRINKLE, ER 24HR.............................................................28 NAMZARIC..........................................................28 naphazoline..............................................................54 naproxen oral suspension...........................................28 naproxen oral tablet..................................................28 naproxen oral tablet,delayed release (dr/ec).................28 naproxen sodium oral tablet 275 mg, 550 mg............28 naratriptan..............................................................28 NASONEX.............................................................57 nateglinide oral tablet 120 mg...................................46 nateglinide oral tablet 60 mg.....................................46 NATPARA.............................................................46 NEBUPENT..........................................................13 necon 0.5/35 (28).....................................................53 necon 1/35 (28)........................................................53 necon 1/50 (28)........................................................53 necon 10/11 (28)......................................................53 necon 7/7/7 (28).......................................................53 needles, insulin disp.,safety........................................46 nefazodone oral tablet 100 mg...................................28 80 Effective Date September 1, 2016 NITROSTAT.........................................................37 nizatidine oral capsule 150 mg..................................48 nizatidine oral capsule 300 mg..................................48 NOR-QD...............................................................53 nora-be....................................................................53 NORDITROPIN FLEXPRO.................................50 norethindrone (contraceptive)....................................53 norethindrone acetate................................................53 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/ 0.25 mg-35 mcg (28), 0.25-35 mg-mcg..................53 NORMOSOL-M IN 5 % DEXTROSE.................59 NORMOSOL-R.....................................................59 NORMOSOL-R IN 5 % DEXTROSE..................59 NORMOSOL-R PH 7.4........................................59 NORPACE.............................................................37 nortrel 0.5/35 (28)...................................................53 nortrel 1/35 (21)......................................................53 nortrel 1/35 (28)......................................................53 nortrel 7/7/7 (28).....................................................53 nortriptyline oral capsule...........................................28 nortriptyline oral solution..........................................28 NORVASC ORAL TABLET 10 MG, 2.5 MG......37 NORVASC ORAL TABLET 5 MG.......................37 NORVIR ORAL CAPSULE...................................13 NORVIR ORAL SOLUTION...............................13 NORVIR ORAL TABLET.....................................13 NOVOPEN ECHO...............................................46 NOXAFIL ORAL SUSPENSION..........................13 NUEDEXTA..........................................................28 NULOJIX...............................................................18 NUPLAZID...........................................................28 nyamyc.....................................................................41 nystatin oral suspension.............................................13 nystatin oral tablet....................................................13 nystatin topical cream...............................................41 nystatin topical ointment...........................................41 nystatin topical powder.............................................41 nystatin-triamcinolone..............................................41 nystop......................................................................41 ocella.......................................................................53 OCTAGAM...........................................................50 octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml..................................................................19 octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml................................................19 octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml)..................................................19 nefazodone oral tablet 150 mg...................................28 nefazodone oral tablet 200 mg...................................28 nefazodone oral tablet 250 mg...................................28 nefazodone oral tablet 50 mg.....................................28 neo-polycin...............................................................54 neo-polycin hc...........................................................54 neomycin..................................................................13 neomycin-bacitracin-poly-hc......................................54 neomycin-bacitracin-polymyxin.................................54 neomycin-polymyxin b gu..........................................42 neomycin-polymyxin b-dexameth...............................54 neomycin-polymyxin-gramicidin................................54 neomycin-polymyxin-hc ophthalmic...........................54 neomycin-polymyxin-hc otic.......................................43 NEPHRAMINE 5.4 %...........................................58 NEUPOGEN.........................................................50 NEUPRO...............................................................28 NEVANAC............................................................54 nevirapine oral suspension.........................................13 nevirapine oral tablet................................................13 nevirapine oral tablet extended release 24 hr 100 mg........................................................................13 nevirapine oral tablet extended release 24 hr 400 mg........................................................................13 NEXAVAR.............................................................18 niacin oral tablet extended release 24 hr 1,000 mg, 750 mg.................................................................37 niacin oral tablet extended release 24 hr 500 mg........37 NIACOR................................................................37 nicardipine intravenous solution................................37 nicardipine oral........................................................37 NICOTROL NS....................................................42 nifedical xl...............................................................37 nifedipine oral tablet extended release 24hr 30 mg, 60 mg........................................................................37 nifedipine oral tablet extended release 24hr 90 mg......37 nifedipine oral tablet extended release 30 mg, 60 mg........................................................................37 nifedipine oral tablet extended release 90 mg..............37 NILANDRON.......................................................18 nimodipine...............................................................37 NINLARO.............................................................18 NIPENT.................................................................18 nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg........................................................................13 nitrofurantoin monohyd/m-cryst................................13 nitroglycerin intravenous...........................................37 nitroglycerin transdermal patch 24 hour.....................37 Core_16293_CG6_v15_1609_1 81 Effective Date September 1, 2016 octreotide acetate injection syringe 500 mcg/ml (1 ml).......................................................................19 ODEFSEY..............................................................13 ODOMZO.............................................................19 OFEV ORAL CAPSULE 150 MG.........................57 ofloxacin ophthalmic.................................................54 ofloxacin oral tablet 400 mg......................................13 ofloxacin otic............................................................43 ogestrel (28).............................................................53 olanzapine intramuscular..........................................28 olanzapine oral tablet 10 mg.....................................28 olanzapine oral tablet 15 mg.....................................28 olanzapine oral tablet 2.5 mg....................................28 olanzapine oral tablet 20 mg.....................................28 olanzapine oral tablet 5 mg.......................................28 olanzapine oral tablet 7.5 mg....................................28 olanzapine oral tablet,disintegrating 10 mg................28 olanzapine oral tablet,disintegrating 15 mg................28 olanzapine oral tablet,disintegrating 20 mg................28 olanzapine oral tablet,disintegrating 5 mg..................28 OLYSIO.................................................................13 omega-3 acid ethyl esters............................................37 omeprazole oral capsule,delayed release(dr/ec) 10 mg, 40 mg...................................................................48 omeprazole oral capsule,delayed release(dr/ec) 20 mg........................................................................48 OMNITROPE.......................................................50 ONCASPAR...........................................................19 ondansetron hcl (pf) injection solution........................48 ondansetron hcl (pf) injection syringe.........................48 ondansetron hcl intravenous......................................48 ondansetron hcl oral tablet 4 mg, 8 mg......................49 ondansetron oral tablet,disintegrating 4 mg................49 ondansetron oral tablet,disintegrating 8 mg................49 ONFI ORAL SUSPENSION.................................29 ONFI ORAL TABLET 10 MG..............................29 ONFI ORAL TABLET 20 MG..............................29 OPDIVO................................................................19 opium tincture..........................................................49 ORAP.....................................................................29 ORENCIA..............................................................52 ORENCIA (WITH MALTOSE)............................52 ORFADIN ORAL CAPSULE................................42 orsythia....................................................................53 ORTHO MICRONOR.........................................53 OSMOPREP..........................................................49 oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml...........................................................13 Core_16293_CG6_v15_1609_1 oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml...........................................................13 oxacillin injection.....................................................13 oxacillin intravenous.................................................13 oxaliplatin intravenous recon soln 100 mg..................19 oxaliplatin intravenous recon soln 50 mg....................19 oxaliplatin intravenous solution.................................19 oxandrolone oral tablet 10 mg...................................46 oxandrolone oral tablet 2.5 mg..................................46 oxaprozin.................................................................29 oxazepam.................................................................29 oxcarbazepine oral suspension....................................29 oxcarbazepine oral tablet 150 mg, 300 mg.................29 oxcarbazepine oral tablet 600 mg..............................29 oxybutynin chloride oral syrup...................................57 oxybutynin chloride oral tablet...................................57 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg........................................................57 oxybutynin chloride oral tablet extended release 24hr 5 mg.....................................................................57 oxycodone oral capsule...............................................29 oxycodone oral concentrate.........................................29 oxycodone oral solution..............................................29 oxycodone oral tablet 10 mg, 5 mg.............................29 oxycodone oral tablet 15 mg......................................29 oxycodone oral tablet 20 mg, 30 mg...........................29 oxycodone-acetaminophen oral solution......................29 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5325 mg, 7.5-325 mg.............................................29 oxycodone-acetaminophen oral tablet 5-325 mg..........29 oxycodone-aspirin.....................................................29 pacerone oral tablet 100 mg, 400 mg.........................37 pacerone oral tablet 200 mg......................................37 paclitaxel..................................................................19 paliperidone oral tablet extended release 24hr 1.5 mg........................................................................29 paliperidone oral tablet extended release 24hr 3 mg........................................................................29 paliperidone oral tablet extended release 24hr 6 mg........................................................................29 paliperidone oral tablet extended release 24hr 9 mg........................................................................29 pamidronate intravenous recon soln...........................46 pamidronate intravenous solution 30 mg/10 ml (3 mg/ ml), 90 mg/10 ml (9 mg/ml)..................................46 pamidronate intravenous solution 60 mg/10 ml (6 mg/ ml).......................................................................46 PANRETIN............................................................41 82 Effective Date September 1, 2016 pantoprazole intravenous..........................................49 pantoprazole oral......................................................49 paregoric..................................................................49 paricalcitol oral capsule 1 mcg, 2 mcg........................46 paricalcitol oral capsule 4 mcg...................................46 paroex oral rinse.......................................................43 paromomycin............................................................13 paroxetine hcl oral tablet 10 mg.................................29 paroxetine hcl oral tablet 20 mg.................................29 paroxetine hcl oral tablet 30 mg.................................29 paroxetine hcl oral tablet 40 mg................................29 paroxetine hcl oral tablet extended release 24 hr 12.5 mg........................................................................29 paroxetine hcl oral tablet extended release 24 hr 25 mg........................................................................29 paroxetine hcl oral tablet extended release 24 hr 37.5 mg........................................................................29 PASER....................................................................13 PATADAY..............................................................54 PAXIL ORAL SUSPENSION................................29 PAZEO...................................................................55 PEDVAX HIB (PF)................................................50 peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram............................................................49 peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram............................................................49 peg-electrolyte soln.....................................................49 PEGANONE..........................................................29 PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML.......................................................................50 PENICILLIN G POT IN DEXTROSE.................13 penicillin g potassium................................................13 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml..............................................................13 penicillin g procaine intramuscular syringe 600,000 unit/ml.................................................................13 penicillin g sodium....................................................13 penicillin v potassium oral recon soln.........................13 penicillin v potassium oral tablet 250 mg...................13 penicillin v potassium oral tablet 500 mg...................13 PENTAM...............................................................13 PENTASA..............................................................49 pentoxifylline............................................................37 PERFOROMIST....................................................57 perindopril erbumine................................................37 periogard..................................................................43 PERJETA................................................................19 Core_16293_CG6_v15_1609_1 permethrin topical cream...........................................41 perphenazine............................................................29 pfizerpen-g...............................................................13 phenelzine................................................................29 phenobarbital oral elixir............................................29 phenobarbital oral tablet 100 mg..............................29 phenobarbital oral tablet 15 mg................................29 phenobarbital oral tablet 16.2 mg.............................29 phenobarbital oral tablet 30 mg................................29 phenobarbital oral tablet 32.4 mg.............................29 phenobarbital oral tablet 60 mg................................29 phenobarbital oral tablet 64.8 mg.............................29 phenobarbital oral tablet 97.2 mg.............................29 PHENYTEK...........................................................29 phenytoin oral suspension 100 mg/4 ml......................29 phenytoin oral suspension 125 mg/5 ml......................29 phenytoin oral tablet,chewable...................................29 phenytoin sodium extended........................................29 phenytoin sodium intravenous solution.......................29 phenytoin sodium intravenous syringe........................29 philith......................................................................53 phospha 250 neutral.................................................59 PHOSPHOLINE IODIDE....................................55 PHYSIOLYTE........................................................42 PHYSIOSOL IRRIGATION.................................42 PICATO.................................................................41 pilocarpine hcl ophthalmic drops 1 %, 2 %................55 pilocarpine hcl ophthalmic drops 4 %........................55 pilocarpine hcl oral...................................................42 pimozide..................................................................30 PIMTREA (28).......................................................53 pindolol oral tablet 10 mg.........................................37 pindolol oral tablet 5 mg...........................................38 pioglitazone oral tablet 15 mg...................................46 pioglitazone oral tablet 30 mg...................................46 pioglitazone oral tablet 45 mg...................................46 pioglitazone-glimepiride............................................46 pioglitazone-metformin.............................................46 piperacillin-tazobactam............................................13 pirmella oral tablet 1-35 mg-mcg..............................53 piroxicam.................................................................30 PLASMA-LYTE 148...............................................59 PLASMA-LYTE A..................................................59 PLASMA-LYTE-56 IN 5 % DEXTROSE..............59 PLEGRIDY............................................................50 podofilox..................................................................41 polycin.....................................................................55 polyethylene glycol 3350 oral.....................................49 83 Effective Date September 1, 2016 PRADAXA..............................................................38 PRALUENT PEN..................................................38 PRALUENT SYRINGE.........................................38 pramipexole oral tablet..............................................30 PRAVACHOL ORAL TABLET 20 MG................38 pravastatin oral tablet 10 mg, 20 mg, 40 mg.............38 pravastatin oral tablet 80 mg....................................38 prazosin oral capsule 1 mg, 2 mg...............................38 prazosin oral capsule 5 mg.........................................38 PRECOSE ORAL TABLET 100 MG....................46 PRECOSE ORAL TABLET 25 MG......................46 PRECOSE ORAL TABLET 50 MG......................46 prednicarbate...........................................................41 prednisolone acetate..................................................55 prednisolone oral solution 15 mg/5 ml........................46 prednisolone sodium phosphate ophthalmic.................55 prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml).........................................................46 prednisolone sodium phosphate oral solution 5 mg base/ 5 ml (6.7 mg/5 ml)................................................46 prednisolone sodium phosphate oral tablet, disintegrating........................................................46 prednisone intensol....................................................46 prednisone oral solution.............................................46 prednisone oral tablet 1 mg.......................................46 prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg...................................................................46 prednisone oral tablets,dose pack................................46 PREMARIN ORAL................................................53 PREMARIN VAGINAL.........................................53 premasol 10 %.........................................................59 PREMASOL 6 %....................................................59 PREMPRO.............................................................53 prenatal vitamin oral tablet......................................59 prevalite...................................................................38 previfem...................................................................53 PREZCOBIX..........................................................13 PREZISTA ORAL SUSPENSION.........................13 PREZISTA ORAL TABLET 150 MG....................13 PREZISTA ORAL TABLET 600 MG, 800 MG......................................................................13 PREZISTA ORAL TABLET 75 MG......................13 PRIFTIN................................................................13 PRIMAQUINE......................................................13 primidone................................................................30 PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG......................................................................38 polymyxin b sulf-trimethoprim...................................55 polymyxin b sulfate...................................................13 POMALYST ORAL CAPSULE 1 MG...................19 POMALYST ORAL CAPSULE 2 MG...................19 POMALYST ORAL CAPSULE 3 MG, 4 MG.......19 portia.......................................................................53 PORTRAZZA........................................................19 potassium bicarb and chloride...................................59 potassium bicarb-citric acid.......................................59 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/ l............................................................................59 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l...................................59 potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l....................................59 potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l.....................59 potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l...................................................59 potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l...................................................59 potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml......................59 potassium chloride intravenous piggyback 10 meq/50 ml.........................................................................59 potassium chloride oral capsule, extended release.........59 potassium chloride oral liquid....................................59 potassium chloride oral tablet extended release............59 potassium chloride oral tablet,er particles/crystals.........59 potassium chloride-0.45 % nacl.................................59 potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l...................................59 potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l....................59 potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l...................................59 potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l...................................59 potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l...................................59 potassium citrate oral tablet extended release 10 meq (1,080 mg)...........................................................57 potassium citrate oral tablet extended release 5 meq (540 mg)..............................................................57 POTIGA ORAL TABLET 200 MG.......................30 POTIGA ORAL TABLET 300 MG, 400 MG.......30 POTIGA ORAL TABLET 50 MG.........................30 Core_16293_CG6_v15_1609_1 84 Effective Date September 1, 2016 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG..................................30 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG....................................30 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG....................................30 PRIVIGEN.............................................................50 PROAIR HFA........................................................57 PROAIR RESPICLICK..........................................57 probenecid................................................................52 procainamide injection solution 100 mg/ml................38 procainamide injection solution 500 mg/ml................38 PROCALAMINE 3%.............................................59 PROCARDIA.........................................................38 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG.....................................38 prochlorperazine.......................................................49 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml).........................................................49 prochlorperazine maleate oral....................................49 PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML............50 PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML............................50 procto-pak................................................................49 proctosol hc...............................................................49 proctozone-hc...........................................................49 progesterone micronized............................................53 PROGLYCEM.......................................................46 PROGRAF INTRAVENOUS................................19 PROLASTIN-C......................................................42 PROLEUKIN.........................................................50 PROLIA.................................................................52 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG.................................................................38 PROMACTA ORAL TABLET 50 MG..................38 promethazine injection solution.................................57 promethazine oral tablet 12.5 mg, 25 mg...................57 propafenone oral tablet 150 mg, 225 mg....................38 propafenone oral tablet 300 mg.................................38 propantheline...........................................................49 propranolol intravenous............................................38 propranolol oral capsule,extended release 24 hr 120 mg, 160 mg...........................................................38 propranolol oral capsule,extended release 24 hr 60 mg, 80 mg...................................................................38 propranolol oral solution...........................................38 Core_16293_CG6_v15_1609_1 propranolol oral tablet 10 mg, 20 mg, 40 mg, 80 mg........................................................................38 propranolol oral tablet 60 mg....................................38 propranolol-hydrochlorothiazid..................................38 propylthiouracil........................................................46 PROQUAD (PF)....................................................50 PROSOL 20 %.......................................................59 protriptyline.............................................................30 PULMOZYME......................................................57 PURIXAN..............................................................19 pyrazinamide...........................................................13 pyridostigmine bromide oral tablet.............................30 QUADRACEL (PF)...............................................50 quasense...................................................................53 quetiapine oral tablet 100 mg...................................30 quetiapine oral tablet 200 mg...................................30 quetiapine oral tablet 25 mg.....................................30 quetiapine oral tablet 300 mg...................................30 quetiapine oral tablet 400 mg...................................30 quetiapine oral tablet 50 mg.....................................30 quinapril oral tablet 10 mg, 5 mg..............................38 quinapril oral tablet 20 mg, 40 mg............................38 quinapril-hydrochlorothiazide...................................38 quinidine sulfate oral tablet.......................................38 QVAR INHALATION AEROSOL 40 MCG/ ACTUATION.....................................................57 QVAR INHALATION AEROSOL 80 MCG/ ACTUATION.....................................................57 RABAVERT (PF)...................................................50 raloxifene.................................................................52 ramipril...................................................................38 RANEXA................................................................38 ranitidine hcl injection..............................................49 ranitidine hcl oral syrup............................................49 ranitidine hcl oral tablet 150 mg, 300 mg.................49 RAPAMUNE ORAL SOLUTION.........................19 RAVICTI................................................................42 RAZADYNE ORAL TABLET 4 MG.....................30 REBIF (WITH ALBUMIN)...................................50 REBIF REBIDOSE................................................50 REBIF TITRATION PACK..................................50 reclipsen (28)............................................................53 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION....................................................50 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML.....................................51 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML.................................51 85 Effective Date September 1, 2016 regonol.....................................................................30 RELENZA DISKHALER.......................................13 RELISTOR SUBCUTANEOUS SOLUTION......49 RELISTOR SUBCUTANEOUS SYRINGE..........49 REMICADE...........................................................49 RENVELA ORAL POWDER IN PACKET 0.8 GRAM.................................................................42 RENVELA ORAL POWDER IN PACKET 2.4 GRAM.................................................................43 RENVELA ORAL TABLET...................................43 repaglinide oral tablet 0.5 mg....................................47 repaglinide oral tablet 1 mg.......................................47 repaglinide oral tablet 2 mg.......................................47 REPATHA SURECLICK.......................................38 REPATHA SYRINGE............................................38 REQUIP ORAL TABLET 1 MG, 4 MG, 5 MG......................................................................30 RESCRIPTOR ORAL TABLET............................14 RESCRIPTOR ORAL TABLET, DISPERSIBLE.....................................................14 reserpine oral tablet 0.1 mg.......................................38 RESTASIS..............................................................55 RETROVIR INTRAVENOUS..............................14 REVLIMID ORAL CAPSULE 10 MG..................19 REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG...................................................19 REVLIMID ORAL CAPSULE 5 MG....................19 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG..........................................................30 REXULTI ORAL TABLET 3 MG, 4 MG.............30 REYATAZ ORAL CAPSULE 150 MG, 200 MG......................................................................14 REYATAZ ORAL CAPSULE 300 MG..................14 REYATAZ ORAL POWDER IN PACKET...........14 ribasphere oral capsule..............................................14 ribasphere oral tablet 200 mg....................................14 ribavirin oral capsule................................................14 ribavirin oral tablet 200 mg......................................14 RIDAURA..............................................................52 rifabutin..................................................................14 rifampin..................................................................14 RIFATER...............................................................14 riluzole....................................................................43 rimantadine.............................................................14 ringers intravenous....................................................59 ringers irrigation.......................................................43 risedronate oral tablet 150 mg...................................52 risedronate oral tablet 30 mg.....................................43 Core_16293_CG6_v15_1609_1 risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)...........................................................52 risedronate oral tablet 5 mg.......................................52 risedronate oral tablet,delayed release (dr/ec)...............52 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML..........30 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML..................................30 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML.....................................30 risperidone oral solution............................................30 risperidone oral tablet 0.25 mg..................................30 risperidone oral tablet 0.5 mg....................................30 risperidone oral tablet 1 mg.......................................30 risperidone oral tablet 2 mg.......................................30 risperidone oral tablet 3 mg.......................................30 risperidone oral tablet 4 mg.......................................30 risperidone oral tablet,disintegrating 0.25 mg.............30 risperidone oral tablet,disintegrating 0.5 mg...............30 risperidone oral tablet,disintegrating 1 mg..................30 risperidone oral tablet,disintegrating 2 mg..................30 risperidone oral tablet,disintegrating 3 mg..................30 risperidone oral tablet,disintegrating 4 mg..................30 RITUXAN..............................................................19 rivastigmine tartrate.................................................30 ropinirole oral tablet.................................................30 ropinirole oral tablet extended release 24 hr................30 rosadan topical cream...............................................41 rosadan topical gel....................................................41 rosuvastatin..............................................................38 ROTARIX..............................................................51 ROTATEQ VACCINE..........................................51 roweepra..................................................................30 ROZEREM............................................................30 SABRIL ORAL POWDER IN PACKET...............30 SABRIL ORAL TABLET.......................................30 SAMSCA ORAL TABLET 15 MG........................47 SAMSCA ORAL TABLET 30 MG........................47 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION, EXTENDED REL RECON................................19 SANTYL.................................................................41 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG.................................................31 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG................................................31 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG...................................................31 86 Effective Date September 1, 2016 SAVELLA ORAL TABLET 100 MG.....................52 SAVELLA ORAL TABLET 12.5 MG....................52 SAVELLA ORAL TABLET 25 MG.......................52 SAVELLA ORAL TABLET 50 MG.......................52 SAVELLA ORAL TABLETS,DOSE PACK...........52 selegiline hcl.............................................................31 selenium sulfide topical lotion....................................41 SELZENTRY.........................................................14 SENSIPAR ORAL TABLET 30 MG......................47 SENSIPAR ORAL TABLET 60 MG......................47 SENSIPAR ORAL TABLET 90 MG......................47 SEREVENT DISKUS............................................57 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG..................................31 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG..................................31 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG..................................31 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG..................................31 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG....................................31 sertraline oral concentrate..........................................31 sertraline oral tablet 100 mg.....................................31 sertraline oral tablet 25 mg.......................................31 sertraline oral tablet 50 mg.......................................31 sf 5000 plus..............................................................43 SIGNIFOR.............................................................19 sildenafil oral...........................................................57 SILVADENE..........................................................41 silver sulfadiazine.....................................................41 SIMBRINZA..........................................................55 SIMPONI...............................................................52 SIMULECT INTRAVENOUS RECON SOLN 10 MG.................................................................19 SIMULECT INTRAVENOUS RECON SOLN 20 MG.................................................................19 simvastatin...............................................................38 SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG........................................31 sirolimus..................................................................19 SIRTURO..............................................................14 sodium bicarbonate intravenous solution....................59 sodium bicarbonate intravenous syringe 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml)................................59 SODIUM BICARBONATE INTRAVENOUS SYRINGE 8.4 % (1 MEQ/ML)...........................59 Core_16293_CG6_v15_1609_1 sodium chloride 0.45 % intravenous parenteral solution.................................................................59 sodium chloride 0.45 % intravenous piggyback..........59 sodium chloride 0.9 % intravenous............................43 sodium chloride 3 %.................................................59 sodium chloride 5 %.................................................59 sodium chloride intravenous......................................59 sodium chloride irrigation.........................................43 sodium citrate-citric acid...........................................57 sodium fluoride oral tablet.........................................59 sodium fluoride oral tablet,chewable..........................59 sodium lactate intravenous........................................59 sodium phenylbutyrate..............................................43 sodium polystyrene (sorb free).....................................43 sodium polystyrene sulfonate oral powder....................43 sodium polystyrene sulfonate oral suspension...............43 sodium polystyrene sulfonate rectal.............................43 SOLTAMOX..........................................................19 SOMATULINE DEPOT.......................................19 SOMAVERT..........................................................47 sorine oral tablet 120 mg, 160 mg.............................38 sorine oral tablet 240 mg..........................................38 sorine oral tablet 80 mg............................................38 sotalol af oral tablet 120 mg, 160 mg.........................38 sotalol af oral tablet 80 mg........................................38 sotalol oral tablet 120 mg, 160 mg, 240 mg...............38 sotalol oral tablet 80 mg............................................38 SOVALDI..............................................................14 SPIRIVA RESPIMAT.............................................57 SPIRIVA WITH HANDIHALER..........................57 spironolacton-hydrochlorothiaz..................................38 spironolactone oral tablet 100 mg..............................38 spironolactone oral tablet 25 mg, 50 mg.....................38 sprintec (28).............................................................53 SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG.............................31 SPRITAM ORAL TABLET FOR SUSPENSION 750 MG...............................................................31 SPRYCEL...............................................................19 sps oral.....................................................................43 sps rectal...................................................................43 sronyx......................................................................53 ssd............................................................................41 stavudine oral capsule 15 mg.....................................14 stavudine oral capsule 20 mg.....................................14 stavudine oral capsule 30 mg.....................................14 stavudine oral capsule 40 mg.....................................14 stavudine oral recon soln...........................................14 87 Effective Date September 1, 2016 STIMATE..............................................................47 STIOLTO RESPIMAT..........................................57 STIVARGA............................................................19 STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG...................................................31 STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG.................................................................31 STREPTOMYCIN INTRAMUSCULAR..............14 STRIBILD..............................................................14 STROMECTOL....................................................14 SUBOXONE SUBLINGUAL FILM 12-3 MG......31 SUBOXONE SUBLINGUAL FILM 2-0.5 MG......................................................................31 SUBOXONE SUBLINGUAL FILM 4-1 MG........31 SUBOXONE SUBLINGUAL FILM 8-2 MG........31 SUCRAID..............................................................49 sucralfate oral tablet..................................................49 SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG.....................................................38 sulfacetamide sodium (acne)......................................41 sulfacetamide sodium ophthalmic drops......................55 sulfacetamide sodium ophthalmic ointment................55 sulfacetamide-prednisolone........................................55 sulfadiazine oral.......................................................14 sulfamethoxazole-trimethoprim intravenous...............14 sulfamethoxazole-trimethoprim oral suspension...........14 sulfamethoxazole-trimethoprim oral tablet..................14 sulfasalazine.............................................................49 sulindac oral tablet 150 mg.......................................31 sulindac oral tablet 200 mg.......................................31 sumatriptan.............................................................31 sumatriptan succinate oral.........................................31 sumatriptan succinate subcutaneous cartridge.............31 sumatriptan succinate subcutaneous pen injector.........31 sumatriptan succinate subcutaneous solution...............31 sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml.........................................................................31 SUPREP BOWEL PREP KIT................................49 SURMONTIL........................................................31 SUSTIVA ORAL CAPSULE 200 MG...................14 SUSTIVA ORAL CAPSULE 50 MG.....................14 SUSTIVA ORAL TABLET....................................14 SUTENT ORAL CAPSULE 12.5 MG...................19 SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG.................................................................19 syeda........................................................................53 SYLATRON...........................................................51 SYMBICORT.........................................................57 Core_16293_CG6_v15_1609_1 SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 6-50 MG.....................................................31 SYMBYAX ORAL CAPSULE 3-25 MG................31 SYMLINPEN 120..................................................47 SYMLINPEN 60....................................................47 SYNAGIS...............................................................14 SYNAREL..............................................................47 SYNERCID............................................................14 SYNJARDY............................................................47 SYNRIBO...............................................................19 SYNTHROID........................................................47 SYPRINE................................................................43 TABLOID..............................................................19 tacrolimus oral capsule 0.5 mg, 1 mg.........................19 tacrolimus oral capsule 5 mg......................................19 TAFINLAR............................................................19 TAGRISSO ORAL TABLET 40 MG.....................19 TAGRISSO ORAL TABLET 80 MG.....................19 TAMIFLU..............................................................14 tamoxifen.................................................................19 tamsulosin................................................................57 TANZEUM............................................................47 TAPAZOLE...........................................................47 TARCEVA ORAL TABLET 100 MG, 150 MG......................................................................19 TARCEVA ORAL TABLET 25 MG......................19 TARGRETIN.........................................................19 TASIGNA..............................................................19 TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ ML).....................................................................19 TAZORAC.............................................................41 taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 360 mg.............................................38 taztia xt oral capsule, extended release 300 mg............38 TECENTRIQ.........................................................19 TECFIDERA..........................................................31 TECHNIVIE..........................................................14 TEFLARO INTRAVENOUS RECON SOLN 400 MG......................................................................14 TEFLARO INTRAVENOUS RECON SOLN 600 MG......................................................................14 TEKTURNA..........................................................38 TEKTURNA HCT................................................38 telmisartan oral tablet 20 mg, 40 mg.........................39 telmisartan oral tablet 80 mg....................................39 telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg.......................................................39 88 Effective Date September 1, 2016 telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg........................................................................39 TEMOVATE TOPICAL CREAM.........................41 TEMOVATE TOPICAL OINTMENT.................41 TENORETIC 100..................................................39 TENORETIC 50....................................................39 terazosin..................................................................39 terbinafine hcl oral...................................................14 terbutaline oral.........................................................57 terconazole vaginal cream..........................................53 terconazole vaginal suppository..................................53 testosterone cypionate.................................................47 testosterone enanthate................................................47 testosterone transdermal gel........................................47 testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %)...........................................47 testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation..........................................47 testosterone transdermal gel in packet 1 % (25 mg/ 2.5gram)...............................................................47 testosterone transdermal gel in packet 1 % (50 mg/5 gram)....................................................................47 tetanus,diphtheria tox ped(pf)....................................51 TETANUS-DIPHTHERIA TOXOIDS-TD.........51 tetrabenazine oral tablet 12.5 mg..............................31 tetrabenazine oral tablet 25 mg.................................31 tetracycline...............................................................14 THALOMID ORAL CAPSULE 100 MG, 50 MG......................................................................20 THALOMID ORAL CAPSULE 150 MG, 200 MG......................................................................20 theophylline oral elixir..............................................57 theophylline oral solution...........................................57 theophylline oral tablet extended release......................57 theophylline oral tablet extended release 12 hr............57 THIOLA................................................................43 thioridazine.............................................................31 thiotepa....................................................................20 thiothixene...............................................................31 THYMOGLOBULIN............................................51 tiagabine..................................................................31 TIAZAC.................................................................39 TICE BCG.............................................................51 TIKOSYN..............................................................39 TILIA FE................................................................53 timolol maleate ophthalmic drops...............................55 timolol maleate ophthalmic gel forming solution.........55 timolol maleate oral tablet 10 mg, 5 mg.....................39 Core_16293_CG6_v15_1609_1 timolol maleate oral tablet 20 mg..............................39 TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE 0.25 %....................................55 TIMOPTIC OPHTHALMIC DROPS 0.25 %.........................................................................55 TIMOPTIC-XE......................................................55 tinidazole oral tablet 250 mg....................................14 tinidazole oral tablet 500 mg....................................14 TIVICAY ORAL TABLET 10 MG........................14 TIVICAY ORAL TABLET 25 MG........................14 TIVICAY ORAL TABLET 50 MG........................14 tizanidine oral tablet................................................31 TOBRADEX OPHTHALMIC OINTMENT.......55 TOBRADEX ST.....................................................55 tobramycin...............................................................55 tobramycin in 0.225 % nacl.....................................14 tobramycin sulfate injection recon soln.......................14 tobramycin sulfate injection solution..........................14 tobramycin-dexamethasone........................................55 tolazamide oral tablet 250 mg...................................47 tolazamide oral tablet 500 mg...................................47 tolbutamide..............................................................47 tolcapone..................................................................31 tolterodine oral capsule,extended release 24hr.............57 tolterodine oral tablet................................................57 topiramate oral capsule, sprinkle................................32 topiramate oral tablet 100 mg...................................32 topiramate oral tablet 200 mg...................................32 topiramate oral tablet 25 mg.....................................32 topiramate oral tablet 50 mg.....................................32 toposar.....................................................................20 topotecan intravenous recon soln................................20 topotecan intravenous solution...................................20 TORISEL...............................................................20 torsemide oral tablet 10 mg, 5 mg..............................39 torsemide oral tablet 100 mg, 20 mg..........................39 TOUJEO SOLOSTAR...........................................47 TOVIAZ.................................................................57 TRACLEER............................................................57 TRADJENTA.........................................................47 tramadol oral tablet..................................................32 tramadol-acetaminophen...........................................32 trandolapril..............................................................39 tranexamic acid intravenous......................................39 tranexamic acid oral.................................................53 tranylcypromine........................................................32 travasol 10 %...........................................................59 TRAVATAN Z.......................................................55 89 Effective Date September 1, 2016 TRINTELLIX ORAL TABLET 20 MG.................32 TRINTELLIX ORAL TABLET 5 MG...................32 TRISENOX............................................................20 TRIUMEQ.............................................................14 trivora (28)..............................................................54 TROPHAMINE 10 %...........................................59 TROPHAMINE 6%..............................................59 trospium oral tablet..................................................58 TRULICITY...........................................................47 TRUMENBA.........................................................51 TRUVADA ORAL TABLET 100-150 MG, 133200 MG, 167-250 MG........................................14 TRUVADA ORAL TABLET 200-300 MG...........14 TWINRIX (PF)......................................................51 TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-5 MG.....................................................39 TYBOST................................................................14 TYGACIL...............................................................14 TYKERB.................................................................20 TYPHIM VI INTRAMUSCULAR SOLUTION........................................................51 TYPHIM VI INTRAMUSCULAR SYRINGE.......51 TYSABRI................................................................32 TYZEKA................................................................14 TYZINE NASAL DROPS 0.05 %.........................43 UCERIS ORAL......................................................49 ULORIC................................................................52 unithroid.................................................................47 UNITUXIN...........................................................20 ursodiol....................................................................49 UVADEX...............................................................42 valacyclovir..............................................................15 VALCHLOR..........................................................42 valganciclovir...........................................................15 valproate sodium......................................................32 valproic acid.............................................................32 valproic acid (as sodium salt) oral solution 250 mg/5 ml.........................................................................32 valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)..........................32 valsartan oral tablet 160 mg.....................................39 valsartan oral tablet 320 mg.....................................39 valsartan oral tablet 40 mg, 80 mg............................39 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 80-12.5 mg............39 valsartan-hydrochlorothiazide oral tablet 320-25 mg........................................................................39 trazodone oral tablet 100 mg, 150 mg.......................32 trazodone oral tablet 300 mg.....................................32 trazodone oral tablet 50 mg.......................................32 TREANDA INTRAVENOUS RECON SOLN..................................................................20 TRECATOR..........................................................14 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION................................20 TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML.......................20 TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML............................................................20 tretinoin (chemotherapy) oral capsule.........................20 tretinoin topical cream..............................................41 tretinoin topical gel 0.01 %, 0.025 %.......................41 tri-estarylla...............................................................53 tri-legest fe................................................................53 tri-linyah.................................................................53 tri-previfem (28)......................................................53 tri-sprintec (28)........................................................53 triamcinolone acetonide dental..................................43 triamcinolone acetonide injection suspension 10 mg/ ml.........................................................................47 triamcinolone acetonide injection suspension 40 mg/ ml.........................................................................47 triamcinolone acetonide topical cream 0.025 %.........41 triamcinolone acetonide topical cream 0.1 %, 0.5 %.........................................................................41 triamcinolone acetonide topical lotion 0.025 %..........42 triamcinolone acetonide topical lotion 0.1 %..............42 triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %........................................................42 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg........................................................................39 triamterene-hydrochlorothiazid oral tablet..................39 trianex.....................................................................42 TRIBENZOR.........................................................39 TRICOR ORAL TABLET 48 MG.........................39 triderm topical cream................................................42 trifluoperazine oral tablet 1 mg, 2 mg........................32 trifluoperazine oral tablet 10 mg, 5 mg......................32 trifluridine...............................................................55 TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC) 45 MG.................................39 trilyte with flavor packets..........................................49 trimethoprim............................................................14 trinessa (28).............................................................53 TRINTELLIX ORAL TABLET 10 MG.................32 Core_16293_CG6_v15_1609_1 90 Effective Date September 1, 2016 VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML.........................................15 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML.......................................................................15 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML.........................................15 vancomycin intravenous............................................15 vancomycin oral capsule 125 mg................................15 vancomycin oral capsule 250 mg................................15 vandazole.................................................................54 VAQTA (PF) INTRAMUSCULAR SUSPENSION....................................................51 VAQTA (PF) INTRAMUSCULAR SYRINGE......51 VARIVAX (PF).......................................................51 VARIZIG...............................................................51 VASCEPA...............................................................39 VASERETIC..........................................................39 VASOTEC ORAL TABLET 2.5 MG.....................39 VECAMYL.............................................................39 VECTIBIX.............................................................20 VELCADE..............................................................20 velivet triphasic regimen (28)....................................54 VENCLEXTA ORAL TABLET 10 MG................20 VENCLEXTA ORAL TABLET 100 MG..............20 VENCLEXTA ORAL TABLET 50 MG................20 VENCLEXTA STARTING PACK........................20 venlafaxine oral capsule,extended release 24hr 150 mg........................................................................32 venlafaxine oral capsule,extended release 24hr 37.5 mg........................................................................32 venlafaxine oral capsule,extended release 24hr 75 mg........................................................................32 venlafaxine oral tablet 100 mg..................................32 venlafaxine oral tablet 25 mg....................................32 venlafaxine oral tablet 37.5 mg.................................32 venlafaxine oral tablet 50 mg....................................32 venlafaxine oral tablet 75 mg....................................32 venlafaxine oral tablet extended release 24hr 150 mg........................................................................32 VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG...................................32 venlafaxine oral tablet extended release 24hr 37.5 mg........................................................................32 venlafaxine oral tablet extended release 24hr 75 mg........................................................................32 Core_16293_CG6_v15_1609_1 VENTAVIS............................................................57 VENTOLIN HFA..................................................57 verapamil intravenous solution..................................39 verapamil intravenous syringe....................................39 verapamil oral capsule, 24 hr er pellet ct....................39 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg....................................................39 verapamil oral capsule,ext rel. pellets 24 hr 360 mg........................................................................39 verapamil oral tablet.................................................39 verapamil oral tablet extended release 120 mg, 120 mg (24 hours)........................................................39 verapamil oral tablet extended release 180 mg, 240 mg........................................................................39 VERSACLOZ.........................................................32 VESICARE.............................................................58 vestura (28)..............................................................54 VICTOZA 2-PAK..................................................47 VICTOZA 3-PAK..................................................47 VIDEX 2 GRAM PEDIATRIC..............................15 VIDEX 4 GRAM PEDIATRIC..............................15 VIEKIRA PAK........................................................15 VIGAMOX.............................................................55 VIIBRYD ORAL TABLET 10 MG........................32 VIIBRYD ORAL TABLET 20 MG........................32 VIIBRYD ORAL TABLET 40 MG........................32 VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)..................................................32 VIMPAT INTRAVENOUS...................................32 VIMPAT ORAL SOLUTION...............................32 VIMPAT ORAL TABLET 100 MG.......................32 VIMPAT ORAL TABLET 150 MG.......................32 VIMPAT ORAL TABLET 200 MG.......................32 VIMPAT ORAL TABLET 50 MG.........................32 vinblastine intravenous solution.................................20 VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML............................................................20 vincasar pfs intravenous solution 2 mg/2 ml...............20 vincristine................................................................20 vinorelbine...............................................................20 viorele (28)..............................................................54 VIRACEPT ORAL TABLET 250 MG...................15 VIRACEPT ORAL TABLET 625 MG...................15 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG..................................15 VIRAZOLE............................................................15 VIREAD ORAL POWDER...................................15 91 Effective Date September 1, 2016 VIREAD ORAL TABLET 150 MG, 250 MG, 300 MG......................................................................15 VIREAD ORAL TABLET 200 MG.......................15 VITEKTA...............................................................15 VOLTAREN TOPICAL GEL 1 %........................32 voriconazole intravenous...........................................15 voriconazole oral suspension for reconstitution............15 voriconazole oral tablet 200 mg.................................15 voriconazole oral tablet 50 mg...................................15 VOTRIENT...........................................................20 VPRIV....................................................................47 VRAYLAR ORAL CAPSULE 1.5 MG...................32 VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 MG......................................................................32 VRAYLAR ORAL CAPSULE,DOSE PACK..........33 VYFEMLA (28)......................................................54 warfarin..................................................................39 water for irrigation, sterile.........................................43 WELCHOL............................................................39 XALATAN.............................................................55 XALKORI..............................................................20 XARELTO ORAL TABLET 10 MG, 20 MG........39 XARELTO ORAL TABLET 15 MG......................39 XARELTO ORAL TABLETS,DOSE PACK..........39 XENAZINE ORAL TABLET 12.5 MG.................33 XENAZINE ORAL TABLET 25 MG....................33 XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT..........................................51 XEOMIN INTRAMUSCULAR RECON SOLN 200 UNIT...........................................................51 XGEVA..................................................................20 XOLAIR.................................................................57 XOPENEX HFA....................................................57 XTANDI................................................................20 XULANE................................................................54 XYREM..................................................................33 XYZAL ORAL TABLET........................................57 YERVOY................................................................20 YF-VAX (PF)..........................................................51 YONDELIS............................................................20 zafirlukast................................................................57 zaleplon oral capsule 10 mg.......................................33 zaleplon oral capsule 5 mg.........................................33 ZALTRAP..............................................................20 ZANOSAR.............................................................20 ZARAH..................................................................54 ZARONTIN ORAL CAPSULE.............................33 ZAVESCA..............................................................47 Core_16293_CG6_v15_1609_1 ZELBORAF............................................................20 zenatane oral capsule 10 mg, 20 mg, 40 mg...............42 ZENATANE ORAL CAPSULE 30 MG................42 zenchent (28)...........................................................54 ZENCHENT FE....................................................54 zenzedi oral tablet 10 mg..........................................33 zenzedi oral tablet 5 mg............................................33 ZEPATIER.............................................................15 ZESTORETIC.......................................................39 ZESTRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG..........................................................39 ZETIA....................................................................39 ZIAC ORAL TABLET 10-6.25 MG, 5-6.25 MG......................................................................39 ZIAGEN ORAL SOLUTION................................15 zidovudine oral capsule.............................................15 zidovudine oral syrup................................................15 zidovudine oral tablet...............................................15 ziprasidone hcl oral capsule 20 mg.............................33 ziprasidone hcl oral capsule 40 mg.............................33 ziprasidone hcl oral capsule 60 mg, 80 mg..................33 ZIRGAN................................................................55 ZITHROMAX ORAL PACKET............................15 ZITHROMAX ORAL TABLET 250 MG.............15 ZITHROMAX Z-PAK...........................................15 ZMAX....................................................................15 ZOCOR ORAL TABLET 10 MG, 5 MG..............39 zoledronic acid intravenous recon soln 4 mg...............47 zoledronic acid intravenous solution 4 mg/5 ml..........47 ZOLINZA..............................................................20 zolpidem oral...........................................................33 ZOMETA INTRAVENOUS SOLUTION 4 MG/ 100 ML................................................................47 zonisamide oral capsule 100 mg, 50 mg.....................33 zonisamide oral capsule 25 mg..................................33 ZORTRESS ORAL TABLET 0.25 MG.................20 ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG......................................................................20 ZOSTAVAX (PF)...................................................51 zovia 1/35e (28).......................................................54 zovia 1/50e (28).......................................................54 ZYDELIG...............................................................20 ZYKADIA..............................................................20 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG......................................................33 92 Effective Date September 1, 2016 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG......................................................................33 ZYTIGA.................................................................20 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML...........................15 Core_16293_CG6_v15_1609_1 ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML...........................15 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION.........................................15 93 Effective Date September 1, 2016 Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. This information is available for free in other languages. Please contact our customer service number at 1-888-346-0095 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30 Spanish (US): Esta información está disponible sin cargo en otros idiomas. Póngase en contacto con el Servicio de Atención al Cliente llamando al número 1-888-346-0095 o, para los usuarios de TTY, 711, de 8 a. m. a 8 p. m., los 7 días de la semana (excepto en el Día de Acción de Gracias y Navidad) desde el 1° de octubre hasta el 14 de febrero, y de lunes a viernes (excepto feriados) del 15 de febrero hasta el 30 de septiembre. This formulary was updated on August 1, 2016. For more recent information or other questions, please contact Anthem MediBlue Plus (HMO) Customer Service at 1-888-346-0095 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30, or visit www.anthem.com. 54169MUSENMUB _112 H1394_003 CO
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