2021-2022 Drug Formulary - Effective November 2021 - Kaiser Permanente
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Effective November 2021 2021-2022 Drug Formulary For members covered through large employer groups with a 1-tier or 2-tier in-network pharmacy benefit and no out-of-network pharmacy benefit Alliance Core All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc. XB0001338-50-17
Drug Formulary INTRODUCTION What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost. How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers. How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs. Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet. How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage. Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions. Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/ formulary. Non- formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug. Prior authorization, step therapy and nonformulary requests are considered based on
coverage criteria requirements approved by the P&T Committee. To request review of an exception to Kaiser Permanente requirements for coverage of prescription drugs, you or your prescriber may contact Kaiser Permanente Member Services at 1-888-630-4636 and request an exception. If the evidence your prescriber provides meets medical necessity, an exception may be approved. Exceptions to required therapy that may be approved include: contraindications, clinical factors associated with adverse reactions, clinical factors reducing effect, other risks of clinical harm, and barriers to compliance with clinical care. Your prescriber may also request temporary coverage while the exception request is being processed. Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share. The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 60 days prior to the effective date. What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs? Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name. Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name. Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name. High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy. Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor.
Members with an out-of-network benefit may use other pharmacies; however, they may pay
a higher cost share.
Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to
select pharmacies are listed on the www.kp.org/wa/formulary webpage.
Covered Diabetic Supplies
Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a
prescription. These items are:
Preferred blood glucose strips:
o One Touch Verio
o One Touch Ultra
o Prodigy – prior authorization required
o Contour Next – prior authorization required
o Freestyle – prior authorization required
Disposable insulin syringes and needles
Lancing devices and lancets
Preferred blood glucose meters are covered only when filled through mail order pharmacy.
Mail Order Pharmacy Service
Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service
works best for drugs that must be taken on regular basis, such as birth control pills and
drugs for high blood pressure, high cholesterol, or other chronic conditions.
To begin using mail order, ask your prescriber to send your prescription directly to the
Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy,
contact the Mail Order Pharmacy.
Address: Kaiser Permanente Mail Order Pharmacy
PO Box 34383
Seattle, WA 98124-1383
Phone: 800-245-RXRX (1-800-245-7979)
Fax: 206-630-7950, or toll-free 1-800-350-1683
Over-the-Counter (OTC) Drugs
A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC
drugs can be found in Appendix A. You may contact Member Service at 1-888-630-
4636 to find if you have OTC drug coverage.
Preventative Medications and Preferred Contraceptives
In accordance with the Affordable Care Act (ACA) requirements for preventive services,
most plans cover preventative care medicines and contraceptives in full. If your plan offers
ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser
Permanente formulary list will be covered in full when obtained in-network. For plans with
out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The
list of the preventative medications covered in full is available on thewww.kp.org/wa/formulary webpage. Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs. If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be covered in full. Excluded Prescription Products for Medications that have Over-The- Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), triamcinolone nasal spray (Nasacort), and fluticasone propionate nasal spray (Flonase). Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage. How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document. The most current drug formulary is available at www.kp.org/wa/formulary.
Kaiser Foundation Health Plan of Washington
Table of Contents
Analgesics - Drugs for Pain and Inflammation ........................................................................ 11
Analgesics - Drugs for Pain .......................................................................................................... 11
Anesthetics ....................................................................................................................................... 12
Anti-Addiction / Substance Abuse Treatment Agents........................................................... 12
Antibacterials .................................................................................................................................... 12
Anticoagulants ................................................................................................................................. 14
Anticonvulsants - Drugs for Seizures ........................................................................................ 14
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................. 14
Antidepressants ............................................................................................................................... 15
Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 15
Antifungals ........................................................................................................................................ 15
Antigout Agents ............................................................................................................................... 16
Antimigraine Agents ....................................................................................................................... 16
Antimyasthenic Agents .................................................................................................................. 16
Antimycobacterials ......................................................................................................................... 16
Antineoplastics - Drugs for Cancer ............................................................................................ 16
Antiparasitics .................................................................................................................................... 17
Antiparkinson Agents..................................................................................................................... 17
Antiplatelets ...................................................................................................................................... 18
Antipsychotics - Drugs for Mood Disorders ............................................................................ 18
Antivirals ............................................................................................................................................ 18
Anxiolytics - Drugs for Anxiety .................................................................................................... 20
Bipolar Agents - Drugs for Mood Disorders............................................................................. 20
Blood Products and Modifiers - Drugs for Blood Disorders ............................................... 20
Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 20
Central Nervous System Agents - Drugs for Attention Deficit Disorder .......................... 23
Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 23
Central Nervous System Agents - Miscellaneous .................................................................. 23
Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 23
Dermatological Agents - Drugs for Skin Conditions ............................................................. 23
Diabetes - Antidiabetic Agents .................................................................................................... 26
Diabetes - Glucose Monitoring .................................................................................................... 26
Diabetes - Glycemic Agents ......................................................................................................... 27
Diabetes - Insulins ........................................................................................................................... 27
Electrolytes / Minerals / Metals / Vitamins ................................................................................ 28
9Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 29
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 29
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 30
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 30
Genitourinary Agents - Drugs for Prostate Conditions......................................................... 30
Hormonal Agents - Adrenal .......................................................................................................... 30
Hormonal Agents - Men's Health ................................................................................................. 31
Hormonal Agents - Pituitary ......................................................................................................... 31
Hormonal Agents - Selective Estrogen Receptor Modifying Agents ................................ 31
Hormonal Agents - Sex Hormones and Birth Control ........................................................... 31
Hormonal Agents - Thyroid........................................................................................................... 34
Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 34
Immunological Agents - Drugs for Vaccination ...................................................................... 35
Inflammatory Bowel Disease Agents ......................................................................................... 36
Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 36
Metabolic Bone Disease Agents - Other ................................................................................... 36
Miscellaneous Therapeutic Agents ............................................................................................ 36
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 37
Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 38
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 38
Otic Agents - Drugs for Ear Conditions..................................................................................... 39
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 39
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
.............................................................................................................................................................. 40
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 40
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 41
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 41
Sleep Disorder Agents ................................................................................................................... 41
Index of Drugs .................................................................................................................................. 43
10Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Analgesics - Drugs for Pain and acetaminophen-codeine
1 QL
Inflammation #4
celecoxib oral 1 bac 1
diclofenac potassium oral butalbital-apap-caffeine
1 1
tablet 50 mg oral tablet
diclofenac sodium er 1 butalbital-aspirin-caffeine 1
diclofenac sodium oral 1 butalbital-aspirin-caffeine
1
oral tablet 50-325-40 mg
diflunisal oral 1
codeine sulfate 1 QL
etodolac 1
endocet 1 QL
flurbiprofen oral 1
fentanyl transdermal
ibuprofen oral tablet 400 patch 72 hour 100
1
mg, 600 mg, 800 mg mcg/hr, 12 mcg/hr, 25 1 PA; QL
indomethacin er 1 mcg/hr, 50 mcg/hr, 75
mcg/hr
indomethacin oral capsule
1 hydrocodone-
25 mg, 50 mg
acetaminophen oral
ketorolac tromethamine
1 solution 2.5-108 mg/5ml, 1 QL
injection
5-217 mg/10ml, 7.5-325
ketorolac tromethamine mg/15ml
1
intramuscular
hydrocodone-
meclofenamate sodium acetaminophen oral tablet
1 1 QL
oral 10-325 mg, 5-325 mg,
meloxicam oral tablet 1 7.5-325 mg
nabumetone oral 1 hydromorphone hcl oral 1 QL
hydromorphone hcl rectal 1 QL
naproxen oral suspension 1
levorphanol tartrate oral 1 PA; QL
naproxen oral tablet 1
lorcet hd oral tablet 10-
naproxen sodium oral 1 QL
1 325 mg
tablet 275 mg, 550 mg
lorcet oral tablet 5-325 mg 1 QL
piroxicam oral 1
lorcet plus oral tablet 7.5-
salsalate oral 1 1 QL
325 mg
sulindac oral 1 methadone hcl oral
1 ST; QL
tolmetin sodium oral solution
1
capsule 400 mg methadone hcl oral tablet 1 ST; QL
tolmetin sodium oral methadone hcl oral tablet
1 1 ST; QL
tablet 200 mg soluble
Analgesics - Drugs for Pain methadose oral tablet
1 ST; QL
acetaminophen-codeine 1 QL soluble
acetaminophen-codeine morphine sulfate
1 QL (concentrate) oral solution 1 QL
#2
100 mg/5ml, 20 mg/ml
acetaminophen-codeine
1 QL morphine sulfate er oral
#3 1 ST; QL
tablet extended release
Effective Date: 11/01/2021
11Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
morphine sulfate oral 1 QL CHANTIX CONTINUING
morphine sulfate rectal 1 QL MONTH PAK ORAL 2
TABLET 1 MG
OXYCODONE HCL ER 2 ST; QL
CHANTIX ORAL TABLET
oxycodone hcl oral 2
1 QL 0.5 MG, 1 MG
concentrate 100 mg/5ml
CHANTIX STARTING
oxycodone hcl oral MONTH PAK ORAL
1 QL 2
solution TABLET 0.5 MG X 11 & 1
oxycodone hcl oral tablet 1 QL MG X 42
oxycodone- disulfiram oral 1
acetaminophen oral tablet goodsense nicotine
1 QL
10-325 mg, 2.5-325 mg, mouth/throat lozenge 4 2
5-325 mg, 7.5-325 mg mg
oxycodone-aspirin oral 1
1 QL habitrol
tablet 4.8355-325 mg
naloxone hcl injection 1
OXYCONTIN 2 ST; QL
tramadol hcl ir 1 QL naltrexone hcl oral 1
tramadol-acetaminophen 1 QL NARCAN 1
Anesthetics NICORETTE
MOUTH/THROAT GUM 2 2
glydo 1 MG
lidocaine external patch 5 NICORETTE
1
% MOUTH/THROAT 2
lidocaine hcl (pf) injection LOZENGE 4 MG
1
solution 1 %, 2 % nicotine polacrilex mini 2
lidocaine hcl injection nicotine polacrilex
1 2
solution mouth/throat
lidocaine hcl nicotine step 1 1
1
urethral/mucosal
nicotine step 2 1
lidocaine-prilocaine 1
nicotine step 3 1
prilovix ultralite 1
nicotine transdermal kit 1
prilovix ultralite plus 1
varenicline tartrate 2
Anti-Addiction / Substance Abuse
Treatment Agents VIVITROL 2 QL
acamprosate calcium 1 Antibacterials
APO-VARENICLINE 2 amoxicillin 1
buprenorphine hcl amoxicillin-potassium
1 QL 1
sublingual clavulanate
buprenorphine hcl- ampicillin 1
naloxone hcl sublingual 1 QL ampicillin sodium injection
tablet sublingual solution reconstituted 1
1
bupropion hcl er (smoking gm, 125 mg, 250 mg, 500
1 mg
det)
avidoxy 1
Effective Date: 11/01/2021
12Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
azithromycin oral 1 doxycycline monohydrate
1
oral capsule
BICILLIN L-A 2
doxycycline monohydrate
cefadroxil 1 1
oral tablet
cefazolin sodium injection 2
FIRVANQ
solution reconstituted 1 1
gm gentamicin sulfate
1
external
cefdinir 1
gentamicin sulfate
cefixime 1 injection solution 40 1
cefprozil 1 mg/ml
ceftazidime injection levofloxacin oral 1
solution reconstituted 1 1 linezolid oral suspension
gm 1 QL
reconstituted
ceftriaxone sodium linezolid oral tablet 1
injection solution
1 methenamine hippurate 1
reconstituted 1 gm, 2 gm,
250 mg, 500 mg metronidazole oral tablet 1
cefuroxime axetil 1 metronidazole vaginal 1
cephalexin oral capsule minocycline hcl oral
1 1
250 mg, 500 mg capsule
cephalexin oral mondoxyne nl 1
1
suspension reconstituted
morgidox oral 1
CIPRO ORAL
SUSPENSION moxifloxacin hcl oral 1
2
RECONSTITUTED 250 mupirocin calcium 1
MG/5ML (5%)
mupirocin external 1
ciprofloxacin hcl oral 1
neomycin sulfate oral 1
ciprofloxacin oral
suspension reconstituted 1 nitrofurantoin 1
500 mg/5ml (10%) nitrofurantoin
1
clarithromycin oral 1 macrocrystal
clindamycin hcl oral 1 nitrofurantoin
monohydrate 1
clindamycin palmitate hcl 1 macrocrystals
clindamycin phosphate okebo oral capsule 75 mg 1
injection solution 300 1
mg/2ml penicillin v potassium 1
clindamycin phosphate PRIMSOL 2
1
vaginal silver sulfadiazine
1
dicloxacillin sodium 1 external
doxycycline hyclate oral SIVEXTRO ORAL 2 QL
1
capsule ssd 1
doxycycline hyclate oral sulfamethoxazole-
tablet 100 mg, 150 mg, 50 1 1
trimethoprim oral
mg, 75 mg
Effective Date: 11/01/2021
13Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
sulfatrim pediatric 1 gabapentin oral 1
SUPRAX ORAL lamotrigine oral tablet 1
SUSPENSION
2 lamotrigine oral tablet
RECONSTITUTED 500 1
chewable
MG/5ML
levetiracetam er 1
tazicef injection 1
levetiracetam oral 1
trimethoprim oral 1
NAYZILAM 2 PA; QL
vancomycin hcl oral
1 QL oxcarbazepine 1
capsule
vancomycin hcl oral phenobarbital oral 1
1
solution reconstituted phenobarbital oral
1
vandazole 1 solution 20 mg/5ml
Anticoagulants phenobarbital sodium
injection solution 130 1
enoxaparin sodium 1 QL
mg/ml
fondaparinux sodium 1 QL
phenytoin infatabs 1
heparin sodium (porcine)
injection solution 1000 phenytoin oral 1
1
unit/ml, 10000 unit/ml, phenytoin sodium
5000 unit/ml extended oral capsule 1
heparin sodium (porcine) 100 mg
1
pf phenytoin sodium
1
1 injection
jantoven
primidone oral 1 QL
LOVENOX 1 QL
roweepra 1
PRADAXA 2
roweepra xr oral tablet
warfarin sodium oral 1
extended release 24 hour 1
XARELTO 2 PA 500 mg, 750 mg
XARELTO STARTER subvenite 1
2 PA
PACK
topiramate oral 1
Anticonvulsants - Drugs for Seizures
valproic acid oral 1
carbamazepine er 1
VALTOCO 2 PA; QL
carbamazepine oral 1
zonisamide oral 1
CELONTIN 2
Antidementia Agents - Drugs for
DIASTAT PEDIATRIC 1 QL Alzheimer's Disease and Dementia
diazepam rectal 1 QL donepezil hcl oral tablet
1
DILANTIN ORAL 10 mg, 5 mg
2
CAPSULE 30 MG galantamine
1
divalproex sodium er 1 hydrobromide
1 galantamine
divalproex sodium oral 1
hydrobromide er
epitol 1
memantine hcl oral tablet
1
ethosuximide oral 1 10 mg, 5 mg
Effective Date: 11/01/2021
14Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
rivastigmine tartrate 1 venlafaxine hcl 1
Antidepressants venlafaxine hcl er oral
capsule extended release 1
amitriptyline hcl oral 1
24 hour
amoxapine 1 Antiemetics - Drugs for Nausea and
bupropion hcl er (sr) 1 Vomiting
bupropion hcl er (xl) oral aprepitant oral 1
tablet extended release 1 aprepitant oral capsule
24 hour 150 mg, 300 mg 125 mg, 80 & 125 mg, 80 1
bupropion hcl oral 1 mg
citalopram hydrobromide 1 compro 1
clomipramine hcl oral 1 dimenhydrinate injection 1
desipramine hcl oral 1 dronabinol 1
doxepin hcl oral capsule 1 metoclopramide hcl
1
injection
doxepin hcl oral
1 metoclopramide hcl oral
concentrate 1
solution
duloxetine hcl oral
capsule delayed release metoclopramide hcl oral
1 1
particles 20 mg, 30 mg, tablet
60 mg ondansetron hcl injection 1
escitalopram oxalate 1 ondansetron hcl oral 1
fluoxetine hcl oral capsule 1 ondansetron odt 1
fluoxetine hcl oral solution 1 perphenazine oral 1
fluvoxamine maleate 1 prochlorperazine 1
imipramine hcl oral 1 prochlorperazine
1
maprotiline hcl oral tablet edisylate injection
1
25 mg, 50 mg, 75 mg prochlorperazine maleate
1
mirtazapine oral 1 oral
nortriptyline hcl oral 1 Antifungals
paroxetine hcl 1 ciclodan 1
PAXIL ORAL ciclopirox external gel 1
2
SUSPENSION ciclopirox external
1
perphenazine- solution
1
amitriptyline ciclopirox olamine
1
phenelzine sulfate oral 1 external
protriptyline hcl 1 clotrimazole mouth/throat 1
sertraline hcl oral clotrimazole-
1 1
concentrate betamethasone
sertraline hcl oral tablet 1 CRESEMBA ORAL 2 PA; QL
tranylcypromine sulfate 1 fluconazole oral 1
1 flucytosine oral 2 QL
trazodone hcl oral
Effective Date: 11/01/2021
15Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
griseofulvin microsize oral 1 sumatriptan succinate
1
subcutaneous
griseofulvin ultramicrosize 1
sumatriptan succinate
itraconazole oral 1 PA
subcutaneous solution
ketoconazole external 1
1 prefilled syringe 6
cream mg/0.5ml
ketoconazole external zolmitriptan oral 1
1
shampoo
Antimyasthenic Agents
ketoconazole oral 1
MESTINON ORAL
nyamyc 1 2
SOLUTION
nystatin external 1 pyridostigmine bromide er 1
nystatin mouth/throat 1 pyridostigmine bromide
1
nystatin oral 1 oral
1 Antimycobacterials
nystatin-triamcinolone
1 dapsone oral 1
nystop
1 ethambutol hcl oral 1
terbinafine hcl oral
voriconazole oral 1 PA isoniazid oral 1
Antigout Agents PRIFTIN 2
allopurinol oral 1 pyrazinamide oral 1
COLCHICINE ORAL rifabutin 1
1
CAPSULE rifampin oral 1
colchicine oral tablet 1 Antineoplastics - Drugs for Cancer
colchicine-probenecid 1 abiraterone acetate 1 QL
probenecid 1 AFINITOR DISPERZ 2 PA; QL
Antimigraine Agents AFINITOR ORAL
2 PA; QL
dihydroergotamine TABLET 10 MG
1 QL
mesylate injection anastrozole oral 1
dihydroergotamine bicalutamide 1
1
mesylate nasal
BRUKINSA 2 PA; QL
ERGOMAR 2 CALQUENCE 2 PA; QL
ergotamine-caffeine 1 capecitabine 1 QL
MIGERGOT 2 COTELLIC 2 PA; QL
naratriptan hcl 1 cyclophosphamide oral
1
rizatriptan benzoate 1 capsule
sumatriptan nasal 1 DROXIA 2
sumatriptan succinate erlotinib hcl 1 PA
1
oral etoposide oral 1 QL
sumatriptan succinate everolimus oral tablet 2.5
1 1 PA; QL
refill mg, 5 mg, 7.5 mg
exemestane 1
Effective Date: 11/01/2021
16Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
flutamide 1 VENCLEXTA STARTING
2 PA; QL
PACK
GILOTRIF 2 PA; QL
VOTRIENT 2 PA; QL
GLEOSTINE 2
XTANDI ORAL CAPSULE 2 PA; QL
hydroxyurea oral 1
ZELBORAF 2 PA
imatinib mesylate 1 QL
ZYDELIG 2 PA; QL
IMBRUVICA ORAL
2 PA; QL Antiparasitics
CAPSULE
IMBRUVICA ORAL albendazole oral 1
TABLET 140 MG, 420 2 PA; QL ALINIA ORAL
MG, 560 MG SUSPENSION 2
IRESSA 2 PA; QL RECONSTITUTED
lapatinib ditosylate 1 PA; QL atovaquone 1
letrozole oral 1 chloroquine phosphate
1
oral
leucovorin calcium oral 1
crotan 2
LEUKERAN 2
EURAX EXTERNAL
MATULANE 2 QL 2
CREAM 10 %
MEKINIST 2 PA; QL
EURAX EXTERNAL
melphalan 1 QL 2
LOTION 10 %
mercaptopurine oral 1 hydroxychloroquine
1
mesna 1 sulfate oral
KRINTAFEL 2
MESNEX ORAL 2
MYLERAN 2 QL nitazoxanide oral 2
NEXAVAR 2 PA permethrin external 1
REVLIMID 2 PA; QL praziquantel oral 1
ROZLYTREK 2 PA; QL primaquine phosphate 1
RYDAPT 2 PA; QL pyrimethamine oral 1 PA; QL
SPRYCEL 2 PA; QL ULESFIA EXTERNAL
2
STIVARGA 2 PA LOTION 5 %
sunitinib malate 1 PA; QL Antiparkinson Agents
SUTENT 2 PA; QL amantadine hcl oral
1
capsule
TABLOID 2
amantadine hcl oral syrup
TAFINLAR 2 PA; QL 1
50 mg/5ml
TAGRISSO 2 PA; QL amantadine hcl oral tablet 1
tamoxifen citrate oral 1 benztropine mesylate 1
temozolomide 1 QL bromocriptine mesylate
1
THALOMID 2 PA; QL oral
tretinoin oral 1 QL carbidopa oral 1
VENCLEXTA 2 PA; QL carbidopa-levodopa er 1
Effective Date: 11/01/2021
17Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
carbidopa-levodopa oral INVEGA HAFYERA 2 QL
1
tablet 2
INVEGA SUSTENNA
carbidopa-levodopa oral
INVEGA TRINZA 2 QL
tablet dispersible 10-100 1
mg, 25-100 mg loxapine succinate 1
carbidopa-levodopa- olanzapine 1
1
entacapone 2
PERSERIS
DUOPA 2 PA
pimozide 1
entacapone 1
quetiapine fumarate 1
pramipexole
1 quetiapine fumarate er 1
dihydrochloride
rasagiline mesylate oral 1 PA RISPERDAL CONSTA 2
ropinirole hcl 1 risperidone oral solution 1
selegiline hcl oral 1 risperidone oral tablet 1
trihexyphenidyl hcl 1 thiothixene 1
Antiplatelets trifluoperazine hcl 1
aspirin-dipyridamole er 1 ziprasidone hcl 1
BRILINTA 2 ZYPREXA RELPREVV 2
cilostazol 1 Antivirals
clopidogrel bisulfate oral 1 abacavir sulfate 1
dipyridamole oral 1 abacavir sulfate-
1 QL
lamivudine
prasugrel hcl 1
abacavir-lamivudine-
Antipsychotics - Drugs for Mood Disorders 1 QL
zidovudine
ABILIFY MAINTENA 2 QL acyclovir oral 1
aripiprazole oral solution 1 adefovir dipivoxil 1 QL
aripiprazole oral tablet 1 APTIVUS 2 QL
ARISTADA 2 QL atazanavir sulfate 1 QL
ARISTADA INITIO 2 QL BARACLUDE ORAL
2 QL
chlorpromazine hcl SOLUTION
1
injection BIKTARVY 2 QL
chlorpromazine hcl oral CIMDUO 2 QL
1
tablet COMPLERA 2 PA; QL
clozapine oral tablet 1 CRIXIVAN 2
fluphenazine decanoate DESCOVY 2 PA; QL
1
injection
didanosine oral capsule
fluphenazine hcl 1 delayed release 200 mg, 1
haloperidol decanoate 250 mg, 400 mg
1
intramuscular DOVATO 2 QL
haloperidol lactate 1 EDURANT 2
haloperidol oral 1
Effective Date: 11/01/2021
18Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
efavirenz 1 oseltamivir phosphate
1
oral
efavirenz-emtricitab-
1 PEGASYS PROCLICK
tenofovir
SUBCUTANEOUS
efavirenz-lamivudine- 2 QL
1 SOLUTION 180
tenofovir
MCG/0.5ML
emtricitabine 1
PEGASYS
emtricitabine-tenofovir df 1 SUBCUTANEOUS 2 QL
EMTRIVA ORAL SOLUTION
2
SOLUTION PEGINTRON
entecavir 1 QL SUBCUTANEOUS KIT 50 2 QL
MCG/0.5ML
EPCLUSA 2 PA; QL
PREVYMIS ORAL 2 PA; QL
EPIVIR HBV ORAL
2 PREZCOBIX 2 QL
SOLUTION
etravirine 1 PREZISTA 2
fosamprenavir calcium 1 QL RELENZA DISKHALER 2
GENVOYA 2 RESCRIPTOR ORAL
2
TABLET 200 MG
HARVONI 2 PA; QL
REYATAZ ORAL
INTELENCE ORAL 2
2 PACKET
TABLET 25 MG
ribavirin oral 1 QL
INTRON A 2 QL
rimantadine hcl 1
INVIRASE 2
ritonavir 1
ISENTRESS HD 2
SELZENTRY ORAL
ISENTRESS ORAL 2 QL
2 SOLUTION
TABLET
SELZENTRY ORAL
ISENTRESS ORAL TABLET 150 MG, 300 2 QL
2
TABLET CHEWABLE MG
JULUCA 2 QL SELZENTRY ORAL
2
lamivudine 1 TABLET 25 MG, 75 MG
lamivudine-zidovudine 1 SOFOSBUVIR-
2 PA; QL
VELPATASVIR
LEDIPASVIR-
2 PA; QL stavudine 1
SOFOSBUVIR
LEXIVA ORAL STRIBILD 2 PA; QL
2 QL
SUSPENSION SYMFI 1
lopinavir-ritonavir 1 SYMFI LO 1
nevirapine er 1 SYMTUZA 2 QL
nevirapine oral tablet 1 TAMIFLU 2
NORVIR ORAL PACKET 2 TEMIXYS 2 QL
NORVIR ORAL tenofovir disoproxil
2 1
SOLUTION fumarate
ODEFSEY 2 QL TIVICAY 2
Effective Date: 11/01/2021
19Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
TIVICAY PD 2 oxazepam 1 QL
TRIUMEQ 2 QL triazolam 1 QL
TYBOST 2 PA Bipolar Agents - Drugs for Mood Disorders
valacyclovir hcl oral 1 lithium carbonate er 1
valganciclovir hcl 1 QL lithium carbonate oral 1
VIDEX ORAL SOLUTION lithium oral solution 8
2 1
RECONSTITUTED 2 GM meq/5ml
VIRACEPT 2 Blood Products and Modifiers - Drugs for
2 Blood Disorders
VIREAD ORAL POWDER
VIREAD ORAL TABLET anagrelide hcl 1
150 MG, 200 MG, 250 2 EPOGEN 2 PA
MG HEMLIBRA 2 PA; QL
VOSEVI 2 PA; QL 2
LEUKINE
zidovudine 1 NEUPOGEN 2 QL
Anxiolytics - Drugs for Anxiety NIVESTYM 2 QL
alprazolam er 1 QL PROCRIT 2 PA
alprazolam oral tablet 1 QL tranexamic acid oral 1 QL
alprazolam xr 1 QL ZARXIO 2 QL
buspirone hcl oral 1 Cardiovascular Agents - Drugs for Heart
chlordiazepoxide hcl 1 QL and Circulation Conditions
clonazepam oral 1 QL acebutolol hcl oral 1
clorazepate dipotassium 1 QL ALDACTAZIDE ORAL
2
TABLET 50-50 MG
diazepam injection 1 QL
diazepam intramuscular 1 QL alprostadil injection 1
diazepam oral solution 1 QL amiloride hcl oral 1
diazepam oral tablet 1 QL amiloride-
1
hydrochlorothiazide
hydroxyzine hcl oral 1
amiodarone hcl oral tablet
hydroxyzine pamoate oral 1 1
200 mg
lorazepam injection amlodipine besylate oral 1
1 QL
solution 2 mg/ml
amlodipine besylate-
lorazepam intensol 1 QL 1
benazepril hcl
lorazepam oral amlodipine-olmesartan 1
1 QL
concentrate 2 mg/ml
atenolol oral 1
lorazepam oral tablet 1 QL
atenolol-chlorthalidone 1
midazolam hcl (pf)
injection solution 10 1 QL atorvastatin calcium oral 1
mg/2ml, 5 mg/ml 1
benazepril hcl oral
midazolam hcl injection
benazepril-
solution 10 mg/2ml, 5 1 QL 1
hydrochlorothiazide
mg/ml
betaxolol hcl oral 1
Effective Date: 11/01/2021
20Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
bisoprolol fumarate oral 1 epinephrine pf 1
bisoprolol- eplerenone 1
1
hydrochlorothiazide
ethacrynic acid 1 PA
bumetanide oral 1
ezetimibe 1
captopril oral 1
ezetimibe-simvastatin 1
captopril-
felodipine er 1
hydrochlorothiazide oral
1
tablet 25-15 mg, 25-25 fenofibrate micronized 1
mg, 50-15 mg, 50-25 mg fenofibrate oral capsule
1
cartia xt 1 134 mg, 200 mg, 67 mg
carvedilol 1 fenofibrate oral tablet 160
1
mg, 54 mg
chlorthalidone 1
fenofibric acid oral tablet 1
cholestyramine light 1
flecainide acetate 1
cholestyramine oral 1
fosinopril sodium 1
clonidine 1
fosinopril sodium-hctz 1
clonidine hcl oral 1
furosemide injection 1
colestipol hcl 1
furosemide oral 1
digitek 1
gemfibrozil oral 1
digox 1
guanfacine hcl 1
digoxin injection 1
hydralazine hcl oral 1
digoxin oral 1
hydrochlorothiazide oral 1
diltiazem hcl er 1
indapamide 1
diltiazem hcl er coated
beads oral capsule irbesartan 1
extended release 24 hour 1 irbesartan-
120 mg, 180 mg, 240 mg, 1
hydrochlorothiazide
300 mg
isosorbide dinitrate 1
diltiazem hcl oral 1
isosorbide mononitrate 1
dilt-xr 1
isosorbide mononitrate er 1
disopyramide phosphate 1
isradipine 1
DIURIL 2
labetalol hcl oral 1
doxazosin mesylate oral 1
lisinopril oral 1
enalapril maleate oral
1 lisinopril-
tablet 1
hydrochlorothiazide
enalapril-
1 losartan potassium oral 1
hydrochlorothiazide
ENTRESTO 2 PA losartan potassium-hctz 1
epinephrine injection lovastatin oral 1
solution prefilled syringe 1 1 methyldopa 1
mg/10ml
metolazone 1
Effective Date: 11/01/2021
21Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
metoprolol succinate er 1 phentolamine mesylate
1
injection
metoprolol tartrate oral 1
pindolol 1
metoprolol-
1
hydrochlorothiazide pravastatin sodium 1
mexiletine hcl oral 1 prazosin hcl oral 1
midodrine hcl 1 prevalite 1
minitran transdermal procainamide hcl injection 1
patch 24 hour 0.1 mg/hr,
1 propafenone hcl 1
0.2 mg/hr, 0.4 mg/hr, 0.6
mg/hr propranolol hcl er 1
minoxidil oral 1 propranolol hcl oral 1
moexipril hcl 1 propranolol-hctz oral
tablet 40-25 mg, 80-25 1
nadolol oral 1
mg
nicardipine hcl oral 1
quinapril hcl 1
nifedipine er 1 quinapril-
1
nifedipine er osmotic hydrochlorothiazide
1
release 1
quinidine gluconate er
nifedipine oral 1
quinidine sulfate 1
nimodipine oral 1
ramipril 1
NITRO-BID 2
RECTIV 2
NITRO-DUR
rosuvastatin calcium 1
TRANSDERMAL PATCH
2
24 HOUR 0.3 MG/HR, 0.8 simvastatin oral 1
MG/HR sorine 1
nitroglycerin sublingual 1
sotalol hcl (af) 1
nitroglycerin transdermal 1 1
sotalol hcl oral
nitro-time oral capsule
1 spironolactone oral 1
extended release 9 mg
spironolactone-hctz 1
NORPACE CR 2
olmesartan medoxomil telmisartan 1
1
oral timolol maleate oral 1
olmesartan medoxomil- torsemide 1
1
hctz
trandolapril 1
pacerone oral tablet 200
1 triamterene oral 1
mg
papaverine hcl injection 1 triamterene-hctz 1
pentoxifylline er 1 valsartan 1
perindopril erbumine 1 valsartan-
1
hydrochlorothiazide
phenoxybenzamine hcl
1
oral
Effective Date: 11/01/2021
22Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
verapamil hcl er oral glatopa 1 QL
capsule extended release REBIF 2 PA; QL
1
24 hour 120 mg, 180 mg,
240 mg, 360 mg REBIF REBIDOSE 2 PA; QL
verapamil hcl er oral REBIF REBIDOSE
1 2 PA; QL
tablet extended release TITRATION PACK
verapamil hcl oral 1 REBIF TITRATION PACK 2 PA; QL
Central Nervous System Agents - Drugs for Central Nervous System Agents -
Attention Deficit Disorder Miscellaneous
amphetamine- caffeine citrate oral 1
1
dextroamphetamine pregabalin 1 QL
amphetamine- riluzole 1 QL
1 QL
dextroamphetamine er Dental and Oral Agents - Drugs for Mouth
atomoxetine hcl 1 and Throat Conditions
dexmethylphenidate hcl 1 chlorhexidine gluconate
1
mouth/throat
dextroamphetamine
1 QL
sulfate er lidocaine viscous hcl 1
dextroamphetamine oralone 1
sulfate oral tablet 10 mg, 1
paroex 1
5 mg
periogard 1
guanfacine hcl er 1
pilocarpine hcl oral tablet
methylphenidate hcl er 1 QL 1
5 mg
methylphenidate hcl er
1 QL triamcinolone acetonide
(cd) 1
mouth/throat
methylphenidate hcl er
Dermatological Agents - Drugs for Skin
(la) oral capsule extended
1 ST; QL Conditions
release 24 hour 20 mg,
30 mg, 40 mg, 60 mg accutane 1
methylphenidate hcl oral acitretin 1 QL
1
tablet adapalene external cream 1
relexxii 1 QL
adapalene external gel 1
zenzedi oral tablet 10 mg,
1 adapalene treatment 1
5 mg
Central Nervous System Agents - Drugs for ala-cort external cream
1
Multiple Sclerosis 2.5 %
AVONEX PEN 2 PA; QL alclometasone
1
dipropionate
AVONEX PREFILLED 2 PA; QL
AMELUZ 2 QL
dimethyl fumarate oral 1
amnesteem 1
dimethyl fumarate starter
1 avar cleanser external
pack 1
emulsion 10-5 %
EXTAVIA 1 QL
avita 1
GILENYA 2 PA; QL
azelaic acid external 1
glatiramer acetate 1 QL
Effective Date: 11/01/2021
23Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
AZELEX 2 clobetasol propionate
1
external ointment
benzoyl peroxide-
1 clobetasol propionate
erythromycin 1
external solution
betamethasone
1
dipropionate aug CONDYLOX 2
betamethasone CORDRAN EXTERNAL
1 2
dipropionate external TAPE
betamethasone valerate desonide external cream 1
1
external
desonide external lotion 1
calcipotriene external
1 desonide external
cream 1
ointment
calcipotriene external
1 desoximetasone external
ointment 1
cream
calcipotriene external
1 desoximetasone external
solution 1
gel
calcitrene 1
desoximetasone external
1
calcitriol external 1 ointment
CAPEX 2 DIFFERIN EXTERNAL
1
CREAM
CARAC 2
DIFFERIN EXTERNAL
claravis 1 2
LOTION
clindacin etz external 2
1 DRYSOL
swab
erythromycin external 1
clindacin-p 1
FINACEA EXTERNAL
clindamycin phos-benzoyl 2
FOAM
perox external gel 1-5 %, 1
1.2-5 % fluocinolone acetonide
1
body
clindamycin phosphate
1 fluocinolone acetonide
external gel 1
external
clindamycin phosphate
1 fluocinolone acetonide
external lotion 1
scalp
clindamycin phosphate
1 fluocinonide emulsified
external solution 1
base
clindamycin phosphate
1 fluocinonide external
external swab 1
cream 0.05 %
clobetasol prop emollient
1 fluocinonide external gel 1
base
clobetasol propionate e 1 fluocinonide external
1
ointment
clobetasol propionate
1 fluocinonide external
external cream 1
solution
clobetasol propionate
1 FLUOROPLEX 2
external gel
clobetasol propionate
1
external lotion
Effective Date: 11/01/2021
24Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
FLUOROURACIL mometasone furoate
1
EXTERNAL CREAM 0.5 2 external
% 1
myorisan
fluorouracil external
1 neuac external gel 1
cream 5 %
PICATO EXTERNAL GEL
fluorouracil external 2 QL
1 0.015 %, 0.05 %
solution
pimecrolimus cream 1 %
fluticasone propionate 1
1 external
external cream
PIMECROLIMUS CREAM
fluticasone propionate 1
1 1 % EXTERNAL
external ointment
halobetasol propionate podofilox external 1
1
external cream PRAMOSONE
halobetasol propionate EXTERNAL CREAM 1-1 2
1 %
external ointment
hydrocortisone ace- PRAMOSONE
2
pramoxine external cream 1 EXTERNAL LOTION
2.5-1 % RETIN-A 1
hydrocortisone butyrate RETIN-A MICRO GEL
1 1
external cream 0.04 %, 0.1 %
hydrocortisone butyrate RETIN-A MICRO PUMP
1
external ointment EXTERNAL GEL 0.04 %, 1
hydrocortisone butyrate 0.1 %
1
external solution rosadan external cream 1
hydrocortisone external rosadan external gel 1
1
cream 2.5 %
SANTYL 2
hydrocortisone external
1 selenium sulfide external
lotion 2.5 % 1
lotion
hydrocortisone external
1 sodium sulfacetamide
ointment 1 %, 2.5 % 1
external shampoo 10 %
hydrocortisone in
absorbase external 1 sulfacetamide sodium
1
ointment 1 % (acne)
hydrocortisone valerate 1 sulfacetamide sodium-
sulfur external emulsion 1
imiquimod external cream 10-5 %
1
5%
sulfacetamide sodium-
isotretinoin oral 1 sulfur external lotion 10-5 1
LEVULAN KERASTICK 2 QL %
methoxsalen rapid 1 QL sulfacetamide-sulfur in
1
urea
metronidazole external
1 synalar external cream 1
cream
metronidazole external synalar external ointment 1
1
gel 0.75 % 1
tacrolimus external
Effective Date: 11/01/2021
25Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
tazarotene external cream 1 ACCU-CHEK COMPACT
1
PLUS CONTROL
TAZORAC EXTERNAL
2 ACCU-CHEK FASTCLIX
CREAM 0.05 % 1
LANCET KIT
TAZORAC EXTERNAL
2 ACCU-CHEK GUIDE
GEL 1
CONTROL
tretinoin external cream 1
ACCU-CHEK GUIDE
tretinoin external gel 0.01 1 PA; QL
1 TEST STRIPS
%, 0.025 %
ACCU-CHEK
tretinoin microsphere 1 1
SMARTVIEW CONTROL
tretinoin microsphere ACCU-CHEK SOFTCLIX
1 1
pump LANCET DEVICE KIT
triamcinolone acetonide AGAMATRIX CONTROL
1 1
external cream LEVEL 2
triamcinolone acetonide AGAMATRIX CONTROL
1 1
external lotion LEVEL 4
triamcinolone acetonide AUTOLET LANCING
external ointment 0.025 1 1
DEVICE
%, 0.1 %, 0.5 %
BLULINK CONTROL
triderm 1 1
HIGH & LOW
urea external cream 40 % 1 CARETOUCH CONTROL
1
uremez-40 1 SOL LEVEL 2
VECTICAL 1 CARETOUCH
1
LANCING/EJECTOR
zenatane 1
CHEMSTRIP 10 MD 2
Diabetes - Antidiabetic Agents
CHEMSTRIP 10/SG 2
acarbose oral 1
CHEMSTRIP 2 GP 2
glimepiride 1
CHEMSTRIP 5 OB 2
glipizide er 1
CHEMSTRIP 7 2
glipizide ir 1
CHEMSTRIP 9 2
glipizide xl 1
CONTOUR CONTROL
glipizide-metformin hcl 1 1
SOLUTION
glyburide oral 1 CONTOUR NEXT
1
JARDIANCE 2 PA; QL CONTROL SOLUTION
metformin hcl er 1 CONTOUR NEXT TEST
1 PA; QL
STRIPS
metformin hcl ir 1
DIATHRIVE GLUCOSE
tolbutamide oral tablet 1
1 CONTROL SOLN
500 mg
DIATHRIVE LANCING
Diabetes - Glucose Monitoring 1
DEVICE
ACCU-CHEK AVIVA DROPLET GENTEEL
1 1
DEVICE LANCING DEVICE
EASY TRAK II CONTROL 1
Effective Date: 11/01/2021
26Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
EASYMAX 15 LEVEL 2-3 VIVAGUARD INO
1 1
CONTROL CONTROL SOLUTION
EASYMAX CONTROL 1 VIVAGUARD LANCING
1
DEVICE
GLUCOSE CONTROL
1
SOLUTIONS Diabetes - Glycemic Agents
EMBRACE LANCING BAQSIMI ONE PACK 2
1
DEVICE/EJECTOR
BAQSIMI TWO PACK 2
EMBRACE TALK
1 diazoxide oral 2
GLUCOSE CONTROL
FORTISCARE CONTROL 1 GLUCAGEN HYPOKIT 2
FREESTYLE TEST 1 PA; QL glucagon emergency kit 1
1
mg injection 1 mg
GENTEEL LANCING KIT
1 GLUCAGON
(BLUE)
EMERGENCY KIT 1 MG 2
GOJJI CONTROL 1 INJECTION 1 MG
GOJJI LANCING Diabetes - Insulins
1
DEVICE/CLEAR CAP
BD AUTOSHIELD DUO
LANCETS 1 1
PEN NEEDLES
MICROLET NEXT BD ULTRA-FINE
1 1
LANCING DEVICE INSULIN SYRINGES
ONETOUCH DELICA BD ULTRA-FINE PEN
1 1
LANCING DEV NEEDLES
ONETOUCH DELICA HUMALOG 2
1
PLUS LANCING
HUMALOG KWIKPEN 2
ONETOUCH DELICA
1 HUMALOG U-100
SAFETY LANCING 2
JUNIOR KWIKPEN
ONETOUCH ULTRA
1 QL HUMULIN 70/30
TEST STRIPS 1
KWIKPEN
ONETOUCH VERIO IN
1 HUMULIN 70/30 VIAL 1
VITRO SOLUTION HIGH
ONETOUCH VERIO HUMULIN N KWIKPEN 1
1 QL
TEST STRIPS HUMULIN N VIAL 1
SURESTEP PRO HIGH HUMULIN R U-500
1 1
GLUCOSE KWIKPEN
SURESTEP PRO LOW 1
1 HUMULIN R U-500 VIAL
GLUCOSE
HUMULIN R VIAL 1
SURESTEP PRO
1 2
NORMAL GLUCOSE INSULIN LISPRO
TRUE METRIX LEVEL 1 1 INSULIN LISPRO (1
2
UNIT DIAL)
TRUE METRIX LEVEL 2 1
TRUE METRIX LEVEL 3 1
UNISTRIP CONTROL IN
1
VITRO SOLUTION LOW
Effective Date: 11/01/2021
27Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
INSULIN PEN NEEDLES CARNITOR SF 1
29G X 12.7MM , 29G X
curity sterile saline 1
12MM , 29G X 5MM ,
29G X 8MM , 30G X 5 cyanocobalamin injection
1
MM , 30G X 8 MM , 31G solution 1000 mcg/ml
X 4 MM , 31G X 5 MM , cytra k crystals 1
1
31G X 6 MM , 31G X 8
MM , 32G X 4 MM , 32G ergocalciferol oral capsule 1
X 5 MM , 32G X 6 MM , FLURA-DROPS ORAL
32G X 8 MM , 33G X 4 SOLUTION 0.55 (0.25 F) 2
MM , 33G X 5 MM , 33G MG/DROP
X 6 MM
folic acid injection 1
INSULIN SYRINGES 27G
X 1/2" 0.5 ML, 27G X 1/2" folic acid oral tablet 1 mg 1
1 ML, 28G X 1/2" 0.5 ML, kionex oral suspension 15
1
28G X 1/2" 1 ML, 29G X gm/60ml
1/2" 0.3 ML, 29G X 1/2"
klor-con 1
0.5 ML, 29G X 1/2" 1 ML,
30G X 1/2" 0.3 ML, 30G X klor-con 10 1
1/2" 0.5 ML, 30G X 1/2" 1 klor-con m10 1
1
ML, 30G X 5/16" 0.3 ML,
30G X 5/16" 0.5 ML, 30G klor-con m15 2
X 5/16" 1 ML, 31G X klor-con m20 1
15/64" 0.3 ML, 31G X
15/64" 0.5 ML, 31G X klor-con sprinkle oral
15/64" 1 ML, 31G X 5/16" capsule extended release 1
0.3 ML, 31G X 5/16" 0.5 10 meq, 8 meq
ML, 31G X 5/16" 1 ML levocarnitine oral solution 1
LANTUS SOLOSTAR 2 PA levocarnitine oral tablet 1
LANTUS U-100 VIAL 2 PA levocarnitine sf 1
LEVEMIR U-100 MEPHYTON 1
2 PA
FLEXTOUCH
nafrinse 1
LEVEMIR U-100 VIAL 2 PA
ORACIT 2
NOVOFINE
AUTOCOVER PEN 1 phospha 250 neutral 1
NEEDLE phosphorous 1
NOVOFINE PEN
1 phospho-trin 250 neutral 1
NEEDLE
phytonadione injection 1
NOVOFINE PLUS PEN
1
NEEDLE phytonadione oral 1
NOVOTWIST PEN pot & sod cit-cit ac 1
1
NEEDLE
potassium chloride crys er
ULTIGUARD SAFEPACK oral tablet extended 1
1
SYR/NEEDLE release 10 meq, 20 meq
Electrolytes / Minerals / Metals / Vitamins potassium chloride crys er
argyle sterile saline 1 oral tablet extended 2
release 15 meq
CARNITOR ORAL 1
potassium chloride er 1
Effective Date: 11/01/2021
28Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
potassium chloride oral 1 rabeprazole sodium oral
1 ST
tablet delayed release
potassium citrate er 1
sucralfate oral 1
potassium citrate-citric
1 Gastrointestinal Agents - Drugs for Bowel,
acid
Intestine and Stomach Conditions
sod citrate-citric acid 1
belladonna alkaloids-
sodium chloride (pf) 1 1 QL
opium
sodium chloride irrigation 1 chlordiazepoxide-
1 QL
sodium fluoride oral clidinium
1
solution 1.1 (0.5 f) mg/ml constulose 1
sodium fluoride oral tablet 1
1 dicyclomine hcl oral
1.1 (0.5 f) mg
diphenoxylate-atropine 1
sodium fluoride oral tablet
1
chewable enulose 1
sodium polystyrene gavilyte-c 1
1
sulfonate
gavilyte-g 1
sodium polystyrene
sulfonate oral suspension 1 gavilyte-n with flavor pack 1
15 gm/60ml generlac 1
sps 1 glycopyrrolate injection
1
taron-crystals oral packet solution
1
3300-1002 mg glycopyrrolate oral 1
tricitrates 1 GOLYTELY ORAL
1 SOLUTION
virt-phos 250 neutral 2
RECONSTITUTED 227.1
vitamin d (ergocalciferol) GM
oral capsule 1.25 mg 1
(50000 ut) HELIDAC THERAPY 2
vitamin k1 injection 1 lactulose encephalopathy 1
Gastrointestinal Agents - Drugs for Acid lactulose oral solution 1
Reflux and Ulcer loperamide hcl oral
1
cimetidine hcl 1 capsule
1 opium 1 QL
cimetidine oral
peg 3350/electrolytes oral
famotidine oral
1 solution reconstituted 240 1
suspension reconstituted
gm
famotidine oral tablet 20
1 peg 3350-kcl-na bicarb-
mg, 40 mg 1
nacl
lansoprazole oral capsule
1 peg-3350/electrolytes 1
delayed release
1 propantheline bromide
misoprostol oral 1
oral tablet 15 mg
omeprazole oral capsule
1 PYLERA 2
delayed release
pantoprazole sodium oral RELISTOR
1 2 PA
tablet delayed release SUBCUTANEOUS
Effective Date: 11/01/2021
29Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
trilyte oral solution sevelamer hcl 1
1
reconstituted 420 gm
solifenacin succinate 1
ursodiol oral capsule 300
1 tolterodine tartrate 1
mg
ursodiol oral tablet 1 tolterodine tartrate er 1
Genetic or Enzyme Disorder - Drugs for trospium chloride 1
Replacement, Modification, Treatment trospium chloride er 1
CERDELGA 2 PA; QL Genitourinary Agents - Drugs for Prostate
CREON 2 Conditions
CYSTAGON 2 PA alfuzosin hcl er 1
ZENPEP 2 dutasteride oral 1
Genitourinary Agents - Drugs for Bladder, finasteride oral tablet 5
1
Genital and Kidney Conditions mg
acetic acid irrigation 1 tamsulosin hcl 1
bethanechol chloride oral 1 terazosin hcl 1
calcium acetate (phos Hormonal Agents - Adrenal
1
binder) cortisone acetate oral
1
calcium acetate oral tablet tablet 25 mg
1
667 mg DEPO-MEDROL
CERVIDIL 2 INJECTION 2
SUSPENSION 20 MG/ML
darifenacin hydrobromide
1 dexamethasone intensol 2
er
D-PENAMINE ORAL dexamethasone oral elixir 1
2 PA; QL
TABLET 125 MG dexamethasone oral
1
ELMIRON 2 solution
flavoxate hcl 1 dexamethasone oral
1
tablet
oxybutynin chloride er 1
dexamethasone sod
oxybutynin chloride oral 1 phosphate pf injection 1
penicillamine oral capsule 1 PA; QL solution
penicillamine oral tablet 2 PA; QL dexamethasone sodium
1
phosphate injection
PENTOSAN
POLYSULFATE SODIUM 2 fludrocortisone acetate
1
ORAL oral
phenazo oral tablet 200 hydrocortisone oral 1
1
mg MEDROL ORAL TABLET
2
phenazopyridine hcl oral 2 MG
1
tablet 100 mg, 200 mg 1
methylprednisolone oral
PREPIDIL 2 methylprednisolone
PROSTIN E2 VAGINAL sodium succ injection
2 1
SUPPOSITORY 20 MG solution reconstituted 125
1 mg
sevelamer carbonate
Effective Date: 11/01/2021
30Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
prednisolone oral solution 1 LUPRON DEPOT (4-
MONTH)
prednisolone sodium 2
INTRAMUSCULAR KIT
phosphate oral solution
1 30MG
15 mg/5ml, 25 mg/5ml,
6.7 (5 base) mg/5ml LUPRON DEPOT (6-
MONTH)
prednisone oral 1 2
INTRAMUSCULAR KIT
SOLU-CORTEF 2 45MG
Hormonal Agents - Men's Health LUPRON DEPOT-PED
2
(1-MONTH)
danazol oral 1
LUPRON DEPOT-PED
DEPO-TESTOSTERONE 2
(3-MONTH)
(brand testosterone 1 PA
cypionate intramuscular) NOCTIVA NASAL
EMULSION 1.66 2
TESTOSTERONE
1 PA MCG/0.1ML
CYPIONATE INJECTION
octreotide acetate
testosterone cypionate 1
1 PA injection
intramuscular
OMNITROPE
testosterone enanthate
1 PA SUBCUTANEOUS
intramuscular 2 PA; QL
SOLUTION
testosterone transdermal RECONSTITUTED
gel 1.62 %, 12.5 mg/act
SANDOSTATIN LAR
(1%), 20.25 mg/act 1 PA; QL 2 QL
DEPOT
(1.62%), 25 mg/2.5gm
(1%), 50 mg/5gm (1%) STIMATE 2
Hormonal Agents - Pituitary Hormonal Agents - Selective Estrogen
Receptor Modifying Agents
ACTHAR 2 PA; QL
raloxifene hcl 1
cabergoline 1
Hormonal Agents - Sex Hormones and Birth
desmopressin ace spray
1 Control
refrig
afirmelle 1
desmopressin acetate
1
injection AFTERPILL 1
DESMOPRESSIN altavera 1
2
ACETATE NASAL
alyacen 1/35 1
desmopressin acetate
1 alyacen 7/7/7 1
oral
desmopressin acetate pf 1 apri 1
desmopressin acetate aranelle 1
1
spray aubra 1
leuprolide acetate aubra eq 1
1
injection
aurovela 1.5/30 1
LUPRON DEPOT (1-
2 aurovela 1/20 1
MONTH)
LUPRON DEPOT (3- aurovela fe 1.5/30 1
2
MONTH) aurovela fe 1/20 1
Effective Date: 11/01/2021
31Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
aviane 1 estradiol oral 1
ayuna 1 estradiol transdermal 1
balziva 1 estradiol vaginal 1
blisovi fe 1.5/30 1 estradiol valerate
1
intramuscular
blisovi fe 1/20 1
ESTRING 2
briellyn 1
ethynodiol diac-eth
camila 1 1
estradiol
caziant 1 etonogestrel-ethinyl
1
chateal 1 estradiol
chateal eq 1 falmina 1
CLIMARA 1 FEMRING 2
cryselle-28 1 femynor 1
cyclafem 1/35 1 hailey 1.5/30 1
cyclafem 7/7/7 1 hailey fe 1.5/30 1
cyred 1 hailey fe 1/20 1
cyred eq 1 heather 1
dasetta 1/35 1 hydroxyprogesterone
1
caproate intramuscular oil
dasetta 7/7/7 1
incassia 1
deblitane 1
isibloom 1
DELESTROGEN 2
jencycla 1
delyla 1
juleber 1
DEPO-ESTRADIOL 2
junel 1.5/30 1
desogestrel-ethinyl
estradiol oral tablet 0.15- 1 junel 1/20 1
30 mg-mcg junel fe 1.5/30 1
dotti 1 junel fe 1/20 1
drospirenone-ethinyl kalliga 1
estradiol oral tablet 3-0.03 1
mg kelnor 1/35 1
elinest 1 kelnor 1/50 1
ELLA 2 kurvelo 1
eluryng 1 larin 1.5/30 1
emoquette 1 larin 1/20 1
enpresse-28 1 larin fe 1.5/30 1
enskyce 1 larin fe 1/20 1
errin 1 larissia 1
estarylla 1 leena 1
lessina 1
Effective Date: 11/01/2021
32Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
levonest 1 norethindrone acet-ethinyl
1
est
levonorgestrel 1
norethindrone oral 1
levonorgestrel-ethinyl
estrad oral tablet 0.1-20 1 norgestimate-eth estradiol 1
mg-mcg, 0.15-30 mg-mcg norgestimate-ethinyl
1
levonorg-eth estrad estradiol triphasic
1
triphasic 1
norlyda
levora 0.15/30 (28) 1
norlyroc 1
lillow 1
nortrel 0.5/35 (28) 1
low-ogestrel 1
nortrel 1/35 (21) 1
lutera 1
nortrel 1/35 (28) 1
lyleq 1
nortrel 7/7/7 1
lyllana 1
nylia 7/7/7 1
lyza 1
nymyo 1
MAKENA
2 QL ocella 1
SUBCUTANEOUS
ogestrel oral tablet 0.5-50
marlissa 1 1
mg-mcg
medroxyprogesterone
1 orsythia 1
acetate intramuscular
PARAGARD
medroxyprogesterone
1 INTRAUTERINE 2
acetate oral
COPPER
megestrol acetate oral
suspension 40 mg/ml, 1 philith 1
400 mg/10ml pirmella 1/35 1
megestrol acetate oral pirmella 7/7/7 1
1
tablet
portia-28 1
microgestin 1.5/30 1
PREMARIN VAGINAL 2
microgestin 1/20 1
preventeza 1
microgestin fe 1.5/30 1
previfem 1
microgestin fe 1/20 1
progesterone
mili 1 1
intramuscular
MIRENA (52 MG) 2 progesterone oral 1
mono-linyah 1 reclipsen 1
necon 0.5/35 (28) 1 sharobel 1
nora-be 1 SKYLA 2
norethin ace-eth estrad-fe sprintec 28 1
1
oral tablet
sronyx 1
norethindrone acetate
1 syeda 1
oral
tarina fe 1/20 1
Effective Date: 11/01/2021
33Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
tarina fe 1/20 eq 1 azathioprine oral tablet 50
1
mg
tri femynor 1
BERINERT 2 PA; QL
tri-estarylla 1
COSENTYX (300 MG
tri-linyah 1 2 PA; QL
DOSE)
tri-lo-estarylla 1 COSENTYX 150 MG/ML 2 PA; QL
tri-lo-marzia 1 COSENTYX
2 PA; QL
tri-lo-mili 1 SENSOREADY (300 MG)
1 COSENTYX
tri-lo-sprintec 2 PA; QL
SENSOREADY PEN
tri-mili 1
CUVITRU 2 PA; QL
tri-nymyo 1
cyclosporine modified 1
tri-previfem 1
cyclosporine oral 1
tri-sprintec 1 ENBREL 2 PA; QL
trivora (28) 1 ENBREL MINI 2 PA; QL
tri-vylibra 1 ENBREL SURECLICK 2 PA; QL
tri-vylibra lo 1 gengraf 1
tulana 1 HIZENTRA 2 PA; QL
tyblume 1 HUMIRA 2 PA; QL
velivet 1 HUMIRA PEDIATRIC
2 PA; QL
CROHNS START
vienva 1
HUMIRA PEN 2 PA; QL
vyfemla 1
HUMIRA PEN-CD/UC/HS
vylibra 1 2 PA; QL
STARTER
wera 1 HUMIRA PEN-
2 PA; QL
xulane 1 PEDIATRIC UC START
yuvafem 1 HUMIRA PEN-
2 PA; QL
PS/UV/ADOL HS START
zafemy 1
HUMIRA PEN-
zarah 1 2 PA; QL
PSOR/UVEIT STARTER
zovia 1/35 (28) 1 HYPERHEP B
zovia 1/35e (28) 1 INTRAMUSCULAR 2
SOLUTION
zumandimine 1
HYQVIA 2 PA; QL
Hormonal Agents - Thyroid
icatibant acetate 2 PA; QL
levothyroxine sodium oral
1 leflunomide oral 1
tablet
methotrexate oral 1
liothyronine sodium oral 1
methotrexate sodium 1
methimazole oral 1
methotrexate sodium (pf) 1
propylthiouracil oral 1
mycophenolate mofetil
Immunological Agents - Drugs for Immune 1
oral
System Stimulation or Suppression
Effective Date: 11/01/2021
34Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
mycophenolate sodium 1 FLUCELVAX
1
QUADRIVALENT
NABI-HB
INTRAMUSCULAR 2 FLULAVAL
1
SOLUTION QUADRIVALENT
ORENCIA CLICKJECT 2 PA; QL FLUMIST
1
QUADRIVALENT
ORENCIA
2 PA; QL FLUZONE HIGH-DOSE
SUBCUTANEOUS 1
QUADRIVALENT
OTEZLA 2 PA; QL
FLUZONE
RASUVO 2 1
QUADRIVALENT
RIDAURA 2 QL
GARDASIL 9 2
sajazir 2 PA; QL
HAVRIX 2
sirolimus oral 1
HEPLISAV-B 2
SKYRIZI 2 PA; QL
HIBERIX 2
SKYRIZI (150 MG DOSE) 2 PA; QL
INFANRIX 2
SKYRIZI PEN 2 PA; QL
IPOL 2
STELARA
2 PA; QL KINRIX
SUBCUTANEOUS
INTRAMUSCULAR 2
tacrolimus oral 1
SUSPENSION
TREMFYA 2 PA; QL
MENACTRA
XELJANZ 2 PA; QL INTRAMUSCULAR 2
XELJANZ XR 2 PA; QL INJECTABLE
Immunological Agents - Drugs for MENQUADFI
Vaccination INTRAMUSCULAR 2
INJECTABLE
ACTHIB 2
MENVEO 2
ADACEL 2
M-M-R II 2
AFLURIA
1 PEDIARIX 2
QUADRIVALENT
BEXSERO 2 PEDVAX HIB 2
BOOSTRIX PENTACEL 2
INTRAMUSCULAR 2 PNEUMOVAX 23 2
SUSPENSION
PREVNAR 13 2
DAPTACEL 2
PREVNAR 20 2
DIPHTHERIA-TETANUS
2 PROQUAD 2
TOXOIDS DT
ENGERIX-B QUADRACEL 2
INTRAMUSCULAR 2
2 RECOMBIVAX HB
INJECTABLE 10
MCG/0.5ML, 20 MCG/ML ROTARIX 2
FLUARIX ROTATEQ 2
1
QUADRIVALENT 2
SHINGRIX
FLUBLOK
1 TDVAX 2
QUADRIVALENT
Effective Date: 11/01/2021
35You can also read
