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This booklet lists all of your

covered medicines
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Colorado Access Advantage
2014 Formulary (list of covered drugs)

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COLORADO ACCESS ADVANTAGE
2014 Formulary
(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on November 1, 2013.
For more recent information or other questions, please contact us, Access Advantage Customer Services, at
(303) 751-2657 or 1-877-441-6032 (Toll Free), or, for TTY users, 1-888-803-4494, 8:00 a.m. to 8:00 p.m.,
Mountain Time, 7 days a week, or visit www.aa.coaccess.com.

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 Colorado Access Advantage. When it
refers to “plan” or “our plan,” it means Access Advantage.
This document includes the list of the drugs (formulary) for our plan which is current as of August 1, 2013.
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, premium and/or copayments/coinsurance may change on J anuary 1, 2014.

Colorado Access Advantage is an HMO Plan with a Medicare contract. Enrollment in Colorado Access
Advantage depends on contract renewal.

This information is available for free in other languages. Please contact our Customer Service number at
(303) 751-2657 or toll free at 1-877-441-6032 for additional information. (TTY users should call 1-888-
803-4494). Hours are 8:00 a.m. to 8:00 p.m., Mountain Time, 7 days a week. Customer Service also has
free language interpreter services available for non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor, póngase en contacto con los
servicios para miembros en el (303) 751-2657 para obtener más información. (Los usuarios de TTY deben
llamar al 1-888-803-4494). Las horas de negocios son de 8:00 am a 8:00 pm, Hora de la montaña, 7 días a
la semana. Los servicios para miembros también tienen disponibles servicios gratuitos de un intérprete de
idiomas para ellos que no hablan inglés (números de teléfono están impresos en la contraportada de este
folleto).
This information may also be available in a different format, including large print and audio tapes. Please
call Customer Service at the number listed above if you need plan information in another format.

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What is the Colorado Access Advantage Formulary?
A formulary is a list of covered drugs selected by Colorado Access Advantage 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. Colorado Access Advantage will generally cover the drugs listed in our formulary as
long as the drug is medically necessary, the prescription is filled at a Colorado Access Advantage network
pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.

Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2014 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 formulary 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 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 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 August 1, 2013. In the event of mid-year non-
maintenance changes to the Formulary, we will send out an errata sheet to members. To get updated
information about the drugs covered by Colorado Access Advantage, please contact us. Our contact
information appears on the front and back cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:

Medical Condition
The formulary begins on page 7. 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”. If you know what your drug is used for, look
for the category name in the list that begins on page 7. Then look under the category name for your drug.

Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page 69. 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

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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?
Colorado Access Advantage 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.

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 (abbreviated as PA in Formulary table): Colorado Access Advantage
requires you [or your physician] to get prior authorization for certain drugs. This means that you will
need to get approval from Colorado Access Advantage before you fill your prescriptions. If you
don’t get approval, Colorado Access Advantage may not cover the drug.

• Quantity Limits (abbreviated as QL in Formulary table): For certain drugs, Colorado Access
Advantage limits the amount of the drug that Colorado Access Advantage will cover. For example,
Colorado Access Advantage provides 30 tabs per 30 days per prescription for ZYPREXA. This may
be in addition to a standard one-month or three-month supply.

• Step Therapy (abbreviated as ST in Formulary table): In some cases, Colorado Access
Advantage requires you to first try certain drugs to treat your medical condition before we will cover
another drug for that condition. For example, if Drug A and Drug B both treat your medical
condition, Colorado Access Advantage may not cover Drug B unless you try Drug A first. If Drug A
does not work for you, Colorado Access Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 7. You can also get more information about the restrictions applied to specific covered drugs
by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears
on the front and back cover pages.

You can ask Colorado Access Advantage 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 Colorado Access Advantage formulary?” on page 4 for information about how to request an exception.

What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Customer
Services and ask if your drug is covered.

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If you learn that Colorado Access Advantage does not cover your drug, you have two options:
• You can ask Customer Services for a list of similar drugs that are covered by Colorado Access
Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by Colorado Access Advantage.

• You can ask Colorado Access Advantage to make an exception and cover your drug. See below for
information about how to request an exception.

How do I request an exception to the Colorado Access Advantage Formulary?
You can ask Colorado Access Advantage to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.
• 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 pre-determined cost-sharing level, and you would not be able to ask us to provide the
drug at a lower cost-sharing level.

• 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 us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Colorado Access Advantage 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, Colorado Access Advantage will only approve your request for an exception if the alternative
drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions
would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed 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 do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
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

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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.

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.

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 91-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.
Colorado Access Advantage also provides for other circumstances that result in unplanned transitions for
current members where prescribed drug regimens may not be on the plan’s formulary. These circumstances
usually involve the level of care changes for a member that is changing from one treatment setting to
another. Colorado Access Advantage seeks to ensure appropriate medication reconciliation. The current
standard of care promotes caregivers and enrollees receiving outpatient Part D prescriptions in advance of
discharge from a Part A stay. Members, through no fault of their own, may not have access to the remainder
of the previously dispensed prescription. Colorado Access Advantage allows the member to access a refill
upon admission to or discharge from a long term care facility.
For more information
For more detailed information about your Colorado Access Advantage prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about Colorado Access Advantage, 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 www.medicare.gov.
Colorado Access Advantage Formulary
The formulary below provides coverage information about all of the drugs covered by Colorado Access
Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 69.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR) and
generic drugs are listed in lower-case italics (e.g., gemfibrozil).
The information in the Requirements/Limits column tells you if Colorado Access Advantage has any special
requirements for coverage of your drug. These requirements are discussed below.
Limited Distribution (abbreviated as LD): This prescription may be available only at certain
pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at (303)

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751-2657 or 1-877-441-6032, Monday through Sunday, 8 a.m. to 8 p.m., Mountain Time. TTY users
should call 1-888-803-4494.



See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
ADHD/ ANTI-NARCOLEPSY/ ANTI-OBESITY/ ANOREXIANTS
AMPHETAMINES
3
amphetamine ER cap 5mg, 10mg, 15mg, 20mg, 25mg,
30mg
QL=30 Caps/30 Days
2
amphetamine/ dextroamphetamine tab 5mg, 7.5mg,
10mg, 12.5mg, 15mg, 20mg, 30mg
PA
2
dextroamphetamine er cap 5mg, 10mg, 15mg PA
2
dextroamphetamine tab 5mg, 10mg PA
ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS
4
INTUNIV TAB 1MG
3
STRATTERA CAP 10MG, 60MG, 80MG, 100MG QL=30 Caps/30 Days
3
STRATTERA CAP 18MG, 25MG, 40MG QL=60 Caps/30 Days
STIMULANTS - MISC.
2
dexmethylphenidate tab 2.5mg, 5mg, 10mg PA
4
METHYLIN CHEW TAB 2.5MG, 5MG, 10MG PA
3
methylphenidate soln. 5mg/ 5ml, 10mg/ 5ml PA
2
methylphenidate SR tab 20mg PA
2
methylphenidate tab 5mg, 10mg, 20mg PA
3
NUVIGIL TAB 50MG, 250MG PA QL=30 Tabs/30 Days
AMINOGLYCOSIDES
AMINOGLYCOSIDES
2
amikacin inj. 50mg/ ml
2
gentamicin inj. 10mg/ ml, 40mg/ ml
2
gentamicin/ nacl inj. 0.6mg/ ml, 0.8mg/ ml, 0.9mg/ ml,
1mg/ ml, 1.2mg/ ml, 1.4mg/ ml, 1.6mg/ ml
2
neomycin tab 500mg
4
paromomycin cap 250mg
3
STREPTOMYCIN INJ. 1GM
5
TOBI NEB 300MG/ 5ML PA
5
TOBI PODHALER 28MG PA
2
tobramycin inj. 10mg/ ml, 40mg/ ml
2
tobramycin/ nacl 0.8mg/ ml, 1.2mg/ ml
ANALGESICS - ANTI-INFLAMMATORY
ANTIRHEUMATIC ANTIMETABOLITES
3
RHEUMATREX TAB 2.5MG
ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES
7
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
5
HUMIRA KIT 20MG/ 0.4ML, 40MG/ 0.8ML PA
5
SIMPONI INJ. 50MG PA
GOLD COMPOUNDS
3
RIDAURA CAP 3MG
INTERLEUKIN-1 BLOCKERS
5
ARCALYST INJ. 220MG PA
INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)
5
KINERET INJ. PA
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)
3
CELEBREX CAP 50MG, 100MG, 200MG, 400MG PA QL=60 Caps/30 Days
2
diclofenac ec tab 25mg, 50mg
1
diclofenac ec tab 75mg
2
diclofenac potassium tab 50mg
2
diclofenac XR tab 100mg
2
diclofenac/ misoprostol tab 50/ 0.2mg, 75/ 0.2mg
2
etodolac cap 200mg, 300mg
2
etodolac ER tab 400mg, 500mg, 600mg
2
etodolac tab 400mg, 500mg
2
fenoprofen tab 600mg
2
flurbiprofen tab 50mg, 100mg
2
ibuprofen susp. 100mg/ 5ml
1
ibuprofen tab 400mg, 600mg, 800mg
3
INDOCIN SUSP. 25MG/ 5ML
1
indomethacin cap 25mg PA
2
indomethacin cap 50mg PA
2
indomethacin ER cap 75mg PA
2
ketoprofen cap 50mg, 75mg
2
ketorolac tab 10mg PA QL=20 Tabs/5 Days
3
MECLOFENAMATE SODIUM CAP 50MG, 100MG
2
meloxicam susp. 7.5mg/ 5ml
1
meloxicam tab 7.5mg, 15mg
2
nabumetone tab 500mg, 750mg
2
naproxen dr tab 375mg, 500mg
2
naproxen sodium tab 275mg, 550mg
2
naproxen susp. 125mg/ 5ml
1
naproxen tab 250mg, 375mg, 500mg
2
oxaprozin tab 600mg
8
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
piroxicam cap 10mg, 20mg
2
sulindac tab 150mg, 200mg
2
tolmetin cap 400mg
2
tolmetin tab 200mg, 600mg
PYRIMIDINE SYNTHESIS INHIBITORS
3
leflunomide tab 10mg, 20mg
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS
5
ENBREL INJ. 25MG, 50MG PA
ANALGESICS - NONNARCOTIC
SALICYLATES
2
diflunisal tab 500mg
ANALGESICS - OPIOID
OPIOID AGONISTS
2
codeine sulfate tab 15mg, 30mg, 60mg
4
fentanyl lollipop 200mcg, 400mcg, 600mcg, 800mcg,
1200mcg, 1600mcg
QL=120 Lozenges/30 Days
3
fentanyl patch 12mcg/ hr, 25mcg/ hr, 50mcg/ hr,
75mcg/ hr, 100mcg/ hr
QL=10 Patches/30 Days
2
hydromorphone inj. 10mg/ ml
2
hydromorphone tab 2mg, 4mg, 8mg
4
LAZANDA SPRAY 100MCG, 400MCG PA QL=15 Bottles/30 Days
4
LAZANDA SPRAY 100MCG, 400MCG PA QL
2
methadone conc. 10mg/ ml
2
methadone soln. 5mg/ 5ml, 10mg/ 5ml
2
methadone tab 5mg, 10mg
2
morphine inj. 0.5mg/ ml, 1mg/ ml
2
morphine sulfate er tab 15mg, 30mg, 60mg, 100mg,
200mg
2
morphine sulfate soln. 10mg/ 5ml, 20mg/ ml, 20mg/ 5ml
2
morphine sulfate tab 15mg, 30mg
2
oxycodone cap 5mg
2
oxycodone soln. 20mg/ ml
2
oxycodone tab 5mg, 10mg, 15mg, 20mg, 30mg
3
OXYCONTIN TAB 10MG, 15MG, 20MG, 30MG,
40MG, 60MG, 80MG
QL=120 Tabs/30 Days
2
tramadol hcl tab 50mg QL=240 Tabs/30 Days
9
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
OPIOID COMBINATIONS
2
acetaminophen/ caffeine/ dihydrocodeine tab
712.8-60-32mg
2
acetaminophen/ codeine soln. 120-12mg/ 5ml
2
acetaminophen/ codeine tab 300-15mg, 300-30mg,
300-60mg
2
butalbital/ apap/ caffeine/ codeine cap 50-325-40-30mg
2
co-gesic tab 500-5mg
2
endocet tab 5-325mg, 7.5-325mg, 7.5-500mg, 10-325mg,
10-650mg
2
hydrocodone/ acetaminophen soln. 7.5-325mg/ ml,
7.5-500mg/ 15ml
2
hydrocodone/ acetaminophen tab (all strengths)
2
hydrocodone/ ibuprofen tab 7.5-200mg
2
oxycodone/ acetaminophen cap 5-500mg
2
oxycodone/ acetaminophen tab 2.5-325mg, 5-325mg,
7.5-325mg, 7.5-500mg, 10-325mg, 10-650mg
2
oxycodone/ aspirin tab
3
ROXICET SOLN. 5-325MG/ 5ML
2
tramadol/ apap tab 37.5-325 QL=240 Tabs/30 Days
OPIOID PARTIAL AGONISTS
4
buprenorphine inj. 0.3mg/ ml
3
buprenorphine sl tab 2mg, 8mg
2
buprenorphine/ naloxone SL tab 2-0.5mg, 8-2mg
3
butorphanol inj. 2mg/ ml
3
butorphanol soln. 10mg/ ml
3
nalbuphine inj. 10mg/ ml, 20mg/ ml
3
SUBOXONE SL FILM 2-0.5MG, 4-1MG, 8-2MG,
12-3MG
ANDROGENS-ANABOLIC
ANABOLIC STEROIDS
3
oxandrolone tab 2.5mg, 10mg PA
ANDROGENS
3
ANDRODERM PATCH 2MG/ HR, 4MG/ HR PA QL=30 Patches/30 Days
3
ANDROGEL GEL 1% PA
3
ANDROGEL PUMP 1.62% PA QL=2 Bottles/30 Days
4
ANDROXY TAB 10MG PA
10
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
danazol cap 50mg, 100mg, 200mg
3
METHITEST TAB 10MG PA
3
testosterone cypionate inj. 100mg/ ml PA
2
testosterone cypionate inj. 200mg/ ml PA
3
testosterone enanthate inj. 200mg/ ml PA
ANORECTAL AGENTS
INTRARECTAL STEROIDS
2
colocort enema 100mg/ 6ml
4
CORTIFOAM AEROSOL 90MG
2
hydrocortisone enema 100mg/ 60ml
RECTAL STEROIDS
2
procto-pak rectal cream 1%
2
proctozone hc rectal cream
ANTHELMINTICS
ANTHELMINTICS
3
ALBENZA TAB 200MG
3
STROMECTOL TAB 3MG
ANTIANGINAL AGENTS
ANTIANGINALS-OTHER
3
RANEXA TAB 500MG, 1000MG PA
NITRATES
3
ISORDIL TITRADOSE TAB 40MG
2
isosorbide dinitrate ER tab 40mg
1
isosorbide dinitrate sl tab 2.5mg
2
isosorbide dinitrate tab 5mg, 10mg, 20mg, 30mg
2
isosorbide mononitrate er tab 120mg
1
isosorbide mononitrate er tab 30mg, 60mg
2
isosorbide mononitrate tab 10mg, 20mg
2
nitroglycerin inj. 5mg/ ml
2
nitroglycerin patch 0.1mg/ hr, 0.2mg/ hr, 0.4mg/ hr,
0.6mg/ hr
3
NITROLINGUAL PUMPSPRAY
2
NITROSTAT SL TAB 0.3MG, 0.4MG, 0.6MG
ANTIANXIETY AGENTS
ANTIANXIETY AGENTS - MISC.
1
buspirone tab 5mg, 10mg
11
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
buspirone tab 7.5mg, 15mg, 30mg
2
hydroxyzine inj. 25mg/ ml, 50mg/ ml
2
hydroxyzine pamoate cap 25mg, 50mg, 100mg PA
2
hydroxyzine syrup 10mg/ 5ml PA
2
hydroxyzine tab 10mg, 25mg, 50mg PA
BENZODIAZEPINES
2
alprazolam tab 0.25mg, 0.5mg, 1mg, 2mg PA
2
chlordiazepoxide cap 5mg, 10mg, 25mg PA
2
clorazepate tab 3.75mg, 7.5mg, 15mg PA
2
diazepam oral soln. 1mg/ ml, 5mg/ ml PA
2
diazepam tab 2mg, 5mg, 10mg PA
2
lorazepam oral soln. 2mg/ ml PA
2
lorazepam tab 0.5mg, 1mg, 2mg PA
ANTIARRHYTHMICS
ANTIARRHYTHMICS TYPE I-A
2
disopyramide cap 100mg, 150mg
3
NORPACE CR CAP 100MG
2
procainamide inj. 100mg/ ml, 500mg/ ml
2
quinidine gluconate er tab
2
quinidine gluconate inj. 80mg/ ml
2
quinidine sulfate er tab 300mg
2
quinidine sulfate tab 200mg, 300mg
ANTIARRHYTHMICS TYPE I-B
2
mexiletine cap 150mg, 200mg, 250mg
ANTIARRHYTHMICS TYPE I-C
2
flecainide tab 50mg, 100mg, 150mg
2
propafenone tab 150mg, 225mg, 300mg
ANTIARRHYTHMICS TYPE III
3
amiodarone inj. 50mg/ ml
2
amiodarone tab 200mg, 400mg
4
MULTAQ TAB 400MG PA
2
NEXTERONE INJ. PA
3
PACERONE TAB 100MG
3
TIKOSYN CAP 125MCG, 250MCG, 500MCG
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
ANTIASTHMATIC - MONOCLONAL ANTIBODIES
12
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
5
XOLAIR INJ. 150MG PA
ANTI-INFLAMMATORY AGENTS
2
cromolyn neb 20mg/ 2ml PA QL=240 Vials/30 Days
BRONCHODILATORS - ANTICHOLINERGICS
3
ATROVENT HFA INHALER 17MCG QL=2 Inhalers/30 Days
1
ipratropium neb 0.02% PA
3
SPIRIVA CAP HANDIHALER QL=30 Caps/30 Days
LEUKOTRIENE MODULATORS
2
montelukast chew tab 4mg, 5mg
3
montelukast granules
2
montelukast tab 10mg
3
zafirlukast tab 10mg, 20mg
SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS
4
DALIRESP TAB 500MCG PA
STEROID INHALANTS
3
budesonide susp. 0.25mg/ 2ml, 0.5mg/ 2ml PA QL=120 Vials/30 Days
3
FLOVENT DISKUS 50MCG, 100MCG, 250MCG QL=1 Inhalers/30 Days
3
FLOVENT HFA INHALER 44MCG, 110MCG,
220MCG
QL=2 Inhalers/30 Days
3
PULMICORT FLEXHALER
3
QVAR INHALER 40MCG/ ACT, 80MCG/ ACT
SYMPATHOMIMETICS
3
ADVAIR DISKUS 100MCG, 250MCG, 500MCG QL=1 Inhalers/30 Days
3
ADVAIR HFA INHALER 45MCG, 115MCG, 230MCG QL=1 Inhalers/30 Days
1
albuterol neb 0.083%, 0.5% PA
2
albuterol neb 0.63mg/ 3ml, 1.25mg/ 3ml PA
3
albuterol sulfate ER tab 4mg, 8mg
1
albuterol syrup 2mg/ 5ml
1
albuterol tab 2mg, 4mg
3
COMBIVENT INHALER QL=2 Inhalers/30 Days
3
COMBIVENT RESPIMAT QL=2 Inhalers/30 Days
3
DULERA INHALER QL=1 Inhalers/30 Days
4
FORADIL CAP QL=60 Caps/30 Days
1
ipratropium/ albuterol soln. PA QL=180 Vials/30 Days
2
levalbuterol neb 0.31mg/ 3ml, 0.63mg/ ml PA
4
levalbuterol neb 1.25mg/ 0.5ml PA
3
SEREVENT INHALER 50MCG QL=1 Inhalers/30 Days
13
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
SYMBICORT INHALER 80, 160 QL=1 Inhalers/30 Days
2
terbutaline inj. 1mg/ ml
2
terbutaline tab 2.5mg, 5mg
3
VENTOLIN HFA INHALER QL=2 Inhalers/30 Days
XANTHINES
2
aminophylline inj. 25mg/ ml
3
ELIXOPHYLLIN SOLN.
2
theophylline ER tab 100mg, 200mg, 300mg, 400mg,
450mg, 600mg
ANTICOAGULANTS
COUMARIN ANTICOAGULANTS
3
COUMADIN TAB 1MG, 2MG, 2.5MG, 3MG, 4MG,
5MG, 6MG, 7.5MG, 10MG
2
jantoven tab 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg,
7.5mg, 10mg
1
warfarin tab 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg,
7.5mg, 10mg
DIRECT FACTOR XA INHIBITORS
3
ELIQUIS TAB 2.5MG, 5MG QL=60 Tabs/30 Days
3
XARELTO TAB 10MG, 15MG, 20MG QL=30 Tabs/30 Days
HEPARINS AND HEPARINOID-LIKE AGENTS
3
enoxaparin inj. 30mg/ 0.3ml, 40mg/ 0.4ml, 60mg/ 0.6ml,
80mg/ 0.8ml, 100mg/ 1ml, 120mg/ 0.8ml, 150mg/ ml
QL=60 Syringes/30 Days
4
fondaparinux inj. 2.5mg/ 0.5ml QL=56 Syringes/30 Days
5
fondaparinux inj. 5mg/ 0.4ml, 7.5mg/ 0.6ml, 10mg/ 0.8ml QL=56 Syringes/30 Days
4
FRAGMIN INJ. 2500U/ 0.2ML
5
FRAGMIN INJ. 7500U/ 0.3ML, 10000U/ ML, 12500U/
0.5ML, 15000U/ 0.6ML, 18000U/ 0.72ML
3
heparin inj. 1000u/ ml, 2000u/ ml, 5000u/ ml, 10000u/
ml, 20000u/ ml
PA
3
heparin/ d5w 40unit/ ml PA
3
heparin/ nacl inj. 2u/ ml, 50u/ ml, 100u/ ml PA
THROMBIN INHIBITORS
4
ARGATROBAN INJ.
4
PRADAXA CAP 75MG, 150MG PA QL=60 Caps/30 Days
ANTICONVULSANTS
14
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
ANTICONVULSANTS - BENZODIAZEPINES
2
clonazepam ODT tab 0.125mg, 0.25mg, 0.5mg, 1mg, 2mg PA
2
clonazepam tab 0.5mg, 1mg, 2mg PA
2
diazepam rectal gel 2.5mg, 10mg, 20mg PA
4
ONFI TAB 5MG, 10MG, 20MG PA
ANTICONVULSANTS - MISC.
3
BANZEL SUSP. 40MG/ ML QL=2400 ml/30 Days
3
BANZEL TAB 200MG, 400MG QL=240 Tabs/30 Days
2
carbamazepine chew tab 100mg
3
carbamazepine ER cap 100mg, 200mg, 300mg
3
carbamazepine ER tab 200mg, 400mg
2
carbamazepine susp. 100mg/ 5ml
1
carbamazepine tab 200mg
2
epitol tab 200mg
2
gabapentin cap 100mg QL=1080 Caps/30 Days
2
gabapentin cap 300mg QL=360 Caps/30 Days
2
gabapentin cap 400mg QL=270 Caps/30 Days
3
gabapentin soln. 50mg/ ml QL=2160 ml/30 Days
2
gabapentin tab 600mg QL=180 Tabs/30 Days
2
gabapentin tab 800mg QL=120 Tabs/30 Days
4
LAMICTAL STARTER KIT 35, 49, 98
4
LAMICTAL XR KIT
2
lamotrigine chew tab 5mg, 25mg
3
lamotrigine er tab 25mg, 50mg, 100mg, 200mg, 250mg,
300mg
2
lamotrigine tab 25mg, 100mg, 150mg, 200mg
2
levetiracetam ER tab 500mg, 750mg
4
levetiracetam inj 500mg/ 5ml
3
levetiracetam soln. 100mg/ ml
2
levetiracetam tab 250mg, 500mg, 750mg, 1000mg
3
LYRICA CAP 25MG, 50MG, 75MG, 100MG, 150MG,
200MG, 225MG, 300MG
PA QL=90 Caps/30 Days
3
LYRICA SOLN. 20MG/ ML PA
2
oxcarbazepine oral susp.
2
oxcarbazepine tab 150mg, 300mg, 600mg
4
POTIGA TAB 50MG, 200MG, 300MG, 400MG PA QL=90 Tabs/30 Days
2
primidone tab 50mg, 250mg
15
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
TEGRETOL-XR TAB 100MG
2
topiramate sprinkle cap 15mg, 25mg
2
topiramate tab 25mg, 50mg, 100mg, 200mg
3
VIMPAT INJ. 200MG/ 20ML
3
VIMPAT SOLN. 10MG/ ML QL=1200 ml/30 Days
3
VIMPAT TAB 50MG, 100MG, 150MG, 200MG
2
zonisamide cap 25mg, 50mg, 100mg
CARBAMATES
3
felbamate susp. 600mg/ 5ml
3
felbamate tab 400mg, 600mg
GABA MODULATORS
4
GABITRIL TAB 2MG, 4MG, 12MG, 16MG
4
SABRIL POWDER 500MG
4
SABRIL TAB 500MG
2
tigabine tab
HYDANTOINS
3
DILANTIN CAP 30MG, 100MG
3
DILANTIN INFATAB 50MG
3
DILANTIN SUSP. 125MG/ 5ML
2
fosphenytoin inj. 75mg/ ml
3
PEGANONE TAB 250MG
2
phenytoin cap 100mg, 200mg, 300mg
2
phenytoin chew tab 50mg
3
phenytoin inj. 50mg/ ml
2
phenytoin susp. 125mg/ 5ml
SUCCINIMIDES
3
CELONTIN CAP 300MG
2
ethosuximide cap 250mg
2
ethosuximide soln. 250mg/ 5ml
VALPROIC ACID
2
divalproex dr tab 125mg, 250mg, 500mg
2
divalproex ER tab 250mg, 500mg
2
divalproex sprinkle cap 125mg
2
valproate sodium inj. 100mg/ ml
2
valproic acid cap 250mg
2
valproic acid syrup 250mg/ 5ml
ANTIDEPRESSANTS
16
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
2
mirtazapine odt tab 15mg, 30mg, 45mg
2
mirtazapine tab 7.5mg, 15mg, 30mg, 45mg
ANTIDEPRESSANTS - MISC.
3
APLENZIN TAB 174MG, 348MG, 522MG
2
budeprion tab sr 100mg, 150mg
2
bupropion sr tab 100mg, 150mg, 200mg
2
bupropion tab 75mg, 100mg
2
bupropion xl 150mg, 300mg
3
FORFIVO XL TAB 450MG QL=30 Tabs/30 Days
2
maprotiline tab 25mg, 50mg, 75mg
MODIFIED CYCLICS
2
NEFAZODONE TAB 50MG, 100MG, 150MG, 200MG,
250MG
3
OLEPTRO ER TAB 150MG, 300MG ST
2
trazodone tab 300mg
1
trazodone tab 50mg, 100mg, 150mg
3
VIIBRYD PACK PA
3
VIIBRYD TAB 10MG, 20MG, 40MG PA
MONOAMINE OXIDASE INHIBITORS (MAOIS)
3
EMSAM PATCH 6MG/ 24HR, 9MG/ 24HR, 12MG/
24HR
QL=30 Patches/30 Days
3
MARPLAN TAB 10MG
3
phenelzine tab 15mg
2
tranylcypromine tab 10mg
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
2
citalopram soln. 10mg/ 5ml
1
citalopram tab 10mg, 20mg, 40mg
3
escitalopram oral soln. 1mg/ ml QL=600 ml/30 Days
3
escitalopram tab 5mg, 10mg, 20mg QL=30 Tabs/30 Days
1
fluoxetine cap 10mg, 20mg, 40mg
2
fluoxetine soln. 20mg/ 5ml
1
fluoxetine tab 10mg
2
fluoxetine tab 20mg
2
FLUOXETINE TAB 60MG
1
fluvoxamine tab 25mg
2
fluvoxamine tab 50mg, 100mg
17
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
paroxetine er tab 12.5mg, 25mg, 37.5mg
1
paroxetine tab 10mg, 20mg
2
paroxetine tab 30mg, 40mg
3
PAXIL SUSP. 10MG/ 5ML
2
sertraline conc. 20mg/ ml
2
sertraline tab 25mg, 50mg, 100mg
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
3
CYMBALTA CAP 20MG, 30MG, 60MG QL=60 Caps/30 Days
3
PRISTIQ TAB 50MG, 100MG QL=30 Tabs/30 Days
2
venlafaxine ER cap 37.5mg, 75mg, 150mg
2
venlafaxine tab 25mg, 37.5mg, 50mg, 75mg, 100mg
TRICYCLIC AGENTS
1
amitriptyline tab 10mg, 25mg, 50mg, 75mg, 100mg PA
2
amitriptyline tab 150mg PA
3
amoxapine tab 25mg, 50mg, 100mg, 150mg
2
clomipramine cap 25mg, 50mg, 75mg PA
2
desipramine tab 10mg, 25mg, 50mg, 75mg, 100mg,
150mg
2
doxepin cap 10mg, 25mg, 50mg, 75mg, 100mg, 150mg PA
2
doxepin conc. 10mg/ ml PA
2
imipramine pamoate 75mg, 100mg, 125mg, 150mg
2
imipramine tab 10mg, 25mg, 50mg
1
nortriptyline cap 10mg, 25mg
2
nortriptyline cap 50mg, 75mg
2
protriptyline tab 5mg, 10mg
2
trimipramine cap 25mg, 50mg, 100mg PA
ANTIDIABETICS
ALPHA-GLUCOSIDASE INHIBITORS
1
acarbose tab 25mg, 50mg, 100mg
4
GLYSET TAB 25MG, 50MG, 100MG
ANTIDIABETIC - AMYLIN ANALOGS
4
SYMLINPEN 60, 120
ANTIDIABETIC COMBINATIONS
3
AVANDAMET TAB 2/ 500MG, 2/ 1000MG, 4/ 500MG,
4/ 1000MG
QL=60 Tabs/30 Days
3
AVANDARYL TAB 4/ 1MG, 4/ 2MG, 4/ 4MG, 8/ 2MG,
8/ 4MG
QL=30 Tabs/30 Days
18
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
1
glimepiride/ pioglitazone tab 2mg/ 30mg, 4mg/ 30mg QL=30 Tabs/30 Days
1
glipizide/ metformin tab 2.5/ 250mg, 2.5/ 500mg, 5/
500mg
QL=120 Tabs/30 Days
1
glyburide/ metformin tab 1.25/ 250mg, 2.5/ 500mg, 5/
500mg
PA QL=120 Tabs/30 Days
3
JANUMET TAB 50/ 500MG, 50/ 1000MG QL=60 Tabs/30 Days
3
JANUMET XR TAB 500-50MG, 1000-50MG,
1000-100MG
QL=60 Tabs/30 Days
3
JUVISYNC TAB 10-50MG, 20-50MG, 40-50MG,
10-100MG, 20-100MG, 40-100MG
4
KOMBIGLYZE ER TAB 5-500MG, 2.5-1000MG,
5-1000MG
ST
1
metformin/ pioglitazone tab 500/ 15mg, 850/ 15mg QL=90 Tabs/30 Days
3
PRANDIMET TAB 1/ 500MG, 2/ 500MG QL=150 Tabs/30 Days
BIGUANIDES
1
metformin er tab 500mg, 750mg, 1000mg QL=60 Tabs/30 Days
1
metformin tab 500mg, 1000mg QL=60 Tabs/30 Days
1
metformin tab 850mg QL=90 Tabs/30 Days
DIABETIC OTHER
3
GLUCAGEN HYPOKIT
3
GLUCAGON KIT
3
PROGLYCEM SUSP. 50MG/ ML
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
3
JANUVIA TAB 25MG, 50MG, 100MG
4
ONGLYZA TAB 2.5MG, 5MG ST
DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC
4
CYCLOSET TAB 0.8MG PA
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)
3
BYDUREON INJ.
3
BYETTA INJ. 5MCG, 10MCG
3
VICTOZA INJ. 18MG/ 3ML
INSULIN
3
HUMALOG INJ. 100UNIT/ ML
3
HUMALOG MIX INJ. 75/ 25, 50/ 50
3
HUMALOG MIX KWIKPEN 75/ 25, 50/ 50
2
HUMULIN 70/ 30
2
HUMULIN 70/ 30 PEN
19
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
HUMULIN N PEN
2
HUMULIN N U-100
2
HUMULIN R U-100
2
HUMULIN R U-500
3
LANTUS INJ.
3
LANTUS SOLOSTAR
3
LEVEMIR FLEXPEN
3
LEVEMIR INJ.
2
NOVOLIN 70/ 30
2
NOVOLIN N U-100
2
NOVOLIN R U-100
3
NOVOLOG FLEXPEN
3
NOVOLOG INJ.
3
NOVOLOG MIX 70/ 30
3
NOVOLOG MIX 70/ 30 PEN
INSULIN SENSITIZING AGENTS
3
AVANDIA TAB 2MG, 4MG, 8MG
1
pioglitazone tab 15mg, 30mg, 45mg
MEGLITINIDE ANALOGUES
1
nateglinide tab 60mg, 120mg
3
PRANDIN TAB 0.5MG, 1MG, 2MG
SULFONYLUREAS
1
glimepiride tab 1mg, 2mg, 4mg QL=60 Tabs/30 Days
1
glipizide ER tab 2.5mg, 5mg, 10mg QL=60 Tabs/30 Days
1
glipizide tab 5mg, 10mg QL=120 Tabs/30 Days
1
glyburide micronized tab 1.5mg, 3mg, 6mg PA QL=60 Tabs/30 Days
1
glyburide tab 1.25mg, 2.5mg, 5mg PA QL=120 Tabs/30 Days
2
tolazamide tab 250mg, 500mg QL=60 Tabs/30 Days
2
tolbutamide tab 500mg QL=180 Tabs/30 Days
ANTIDIARRHEALS
ANTIPERISTALTIC AGENTS
2
diphenoxylate/ atropine liquid 2.5-0.025mg/ 5ml PA
2
diphenoxylate/ atropine tab 2.5/ 0.025mg PA
2
loperamide cap 2mg
ANTIDOTES
ANTIDOTES
20
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
fomepizole inj. 1gm/ ml
ANTIDOTES - CHELATING AGENTS
4
CHEMET CAP 100MG
4
EXJADE TAB 125MG PA
5
EXJADE TAB 250MG, 500MG PA
OPIOID ANTAGONISTS
2
naloxone inj. 0.4mg/ ml, 1mg/ ml
2
naltrexone tab 50mg
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
4
granisetron inj. 0.1mg/ ml, 1mg/ ml PA
4
granisetron tab 1mg PA
4
GRANISOL SOLN. 2MG/ 10ML PA
4
ondansetron inj. 4mg/ 2ml PA
2
ondansetron odt tab 4mg, 8mg PA
3
ondansetron soln. 4mg/ 5ml PA
3
ondansetron tab 24mg PA
2
ondansetron tab 4mg, 8mg PA
ANTIEMETICS - ANTICHOLINERGIC
3
ANTIVERT TAB 50MG
2
meclizine tab 12.5mg, 25mg
4
TRANSDERM-SCOP PATCH 1.5MG PA
ANTIEMETICS - MISCELLANEOUS
4
CESAMET CAP 1MG
4
dronabinol cap 2.5mg, 5mg, 10mg PA
SUBSTANCE P/ NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
4
EMEND CAP 125MG PA QL=2 Caps/30 Days
4
EMEND CAP 40MG PA QL=8 Caps/30 Days
4
EMEND CAP 80-125MG PA QL=6 Caps/30 Days
4
EMEND CAP 80MG PA QL=4 Caps/30 Days
ANTIFUNGALS
ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)
5
CANCIDAS INJ. 50MG, 70MG
4
MYCAMINE INJ. 50MG, 100MG
ANTIFUNGALS
5
AMBISOME INJ. 50MG PA
21
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
AMPHOTERICIN B INJ. 50MG
4
flucytosine cap 250mg, 500mg
2
griseofulvin microsize susp. 125mg/ ml
3
griseofulvin microsize tab 500mg
3
griseofulvin ultramicrosize tab 125mg, 250mg
2
nystatin tab 500000unit
3
terbinafine tab 250mg QL=60 Tabs/30 Days
IMIDAZOLE-RELATED ANTIFUNGALS
2
fluconazole susp. 10mg/ ml, 40mg/ ml
2
fluconazole tab 50mg, 100mg, 150mg, 200mg
3
fluconazole/ dextrose inj. 400mg/ 200ml
3
itraconazole cap 100mg PA
2
ketoconazole tab 200mg
5
NOXAFIL SUSP 40MG/ ML PA
4
SPORANOX SOLN. 10MG/ ML PA
5
VFEND SUSP. 40MG/ ML
4
voriconazole inj. 10mg/ ml
5
voriconazole tab 50mg, 200mg
ANTIHISTAMINES
ANTIHISTAMINES - ETHANOLAMINES
2
carbinoxamine liquid 4mg/ 5ml
2
carbinoxamine tab 4mg
2
clemastine tab 2.68mg
2
diphenhydramine cap 50mg PA
2
diphenhydramine inj. 50mg/ ml PA
ANTIHISTAMINES - NON-SEDATING
2
cetirizine syrup 1mg/ ml
2
desloratadine tab 5mg
2
levocetirizine oral soln. 0.5mg/ ml QL=300 ml/30 Days
2
levocetirizine tab 5mg
ANTIHISTAMINES - PHENOTHIAZINES
2
phenadoz supp. 12.5mg PA
2
promethazine inj. 25mg/ ml, 50mg/ ml PA
2
promethazine supp. 12.5mg, 25mg PA
2
promethazine syrup 6.25mg/ 5ml PA
2
promethazine tab 12.5mg, 50mg PA
1
promethazine tab 25mg PA
22
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
promethazine VC syrup 6.25-5mg/ 5ml PA
2
promethegan supp. 25mg, 50mg PA
ANTIHISTAMINES - PIPERIDINES
2
cyproheptadine syrup 2mg/ 5ml PA
2
cyproheptadine tab 4mg PA
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS - MISC.
3
LOVAZA CAP 1GM
4
VASCEPA CAP 1GM PA
BILE ACID SEQUESTRANTS
2
cholestyramine lite powder packet 4gm
2
colestipol granule 5gm
2
colestipol tab 1gm
3
WELCHOL TAB 625MG
FIBRIC ACID DERIVATIVES
3
fenofibrate cap 67mg, 134mg, 200mg
3
fenofibrate tab 45mg, 54mg, 145mg, 160mg
2
gemfibrozil tab 600mg
3
TRILIPIX CAP 45MG, 135MG QL=30 Caps/30 Days
HMG COA REDUCTASE INHIBITORS
1
atorvastatin tab 10mg, 20mg, 40mg, 80mg QL=30 Tabs/30 Days
3
CRESTOR TAB 5MG, 10MG, 20MG, 40MG ST QL=30 Tabs/30 Days
1
lovastatin tab 10mg, 20mg
2
lovastatin tab 40mg
1
pravastatin tab 10mg, 20mg, 40mg
2
pravastatin tab 80mg
3
SIMCOR TAB 500-40MG, 1000-20MG, 1000-40MG
1
simvastatin tab 5mg, 10mg, 20mg, 40mg, 80mg
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS
3
ZETIA TAB 10MG
NICOTINIC ACID DERIVATIVES
3
NIASPAN ER TAB 500MG, 750MG, 1000MG
ANTIHYPERTENSIVES
ACE INHIBITORS
1
benazepril tab 5mg, 10mg, 20mg, 40mg
1
captopril tab 12.5mg, 25mg, 50mg, 100mg
23
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
1
enalapril tab 2.5mg, 5mg, 10mg, 20mg
1
fosinopril tab 10mg, 20mg, 40mg
1
lisinopril tab 2.5mg, 5mg, 10mg, 20mg
2
lisinopril tab 30mg, 40mg
1
moexipril tab 7.5mg, 15mg
1
perindopril tab 2mg, 4mg, 8mg
1
quinapril tab 5mg, 10mg, 20mg, 40mg
1
ramipril cap 1.25mg, 2.5mg, 5mg, 10mg
1
trandolapril tab 1mg, 2mg, 4mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS
3
BENICAR TAB 5MG, 20MG, 40MG
1
eprosartan tab 600mg
1
irbesartan tab 75mg, 150mg, 300mg
1
losartan tab 25mg, 50mg, 100mg
ANTIADRENERGIC ANTIHYPERTENSIVES
1
clonidine tab 0.1mg, 0.2mg PA
2
clonidine tab 0.3mg PA
1
doxazosin tab 1mg, 2mg, 4mg, 8mg PA
1
guanfacine tab 1mg
2
guanfacine tab 2mg
1
methyldopa tab 250mg
2
methyldopa tab 500mg
1
prazosin cap 1mg PA
2
prazosin cap 2mg, 5mg PA
2
reserpine tab 0.1mg, 0.25mg
1
terazosin cap 1mg, 2mg, 5mg, 10mg PA
ANTIHYPERTENSIVE COMBINATIONS
1
amlodipine/ benazepril cap 2.5-10mg, 5-10mg, 5-20mg,
10-20mg, 5-40mg, 10-40mg
1
atenolol/ chlorthalidone tab 100/ 25mg
2
atenolol/ chlorthalidone tab 50/ 25mg
1
benazepril/ hctz tab 5/ 6.25mg, 10/ 12.5mg, 20/ 12.5mg,
20/ 25mg
3
BENICAR HCT TAB 20/ 12.5MG, 40/ 12.5MG, 40/
25MG
1
bisoprolol/ hctz tab 2.5/ 6.25mg, 5/ 6.25mg, 10/ 6.25mg
1
candesartan/ hctz tab 16/ 12.5mg, 32/ 12.5mg, 32/ 25mg
24
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
captopril/ hctz tab 25/ 15mg, 25/ 25mg, 50/ 15mg, 50/
25mg
2
DUTOPROL TAB
1
enalapril/ hctz tab 5/ 12.5mg, 10/ 25mg
1
fosinopril/ hctz tab 10/ 12.5mg, 20-12.5mg
1
irbesartan/ hctz tab 12.5-150mg, 12.5-300mg
1
lisinopril/ hctz tab 10/ 12.5mg, 20/ 12.5mg, 20/ 25mg
1
losartan/ hctz tab 50/ 12.5mg, 100/ 12.5mg, 100/ 25mg
2
methyldopa/ hctz tab 250/ 15mg, 250/ 25mg, 250/ 50mg
2
metoprolol/ hctz tab 50/ 25mg, 100/ 25mg, 100/ 50mg
1
moexipril/ hctz tab 7.5/ 12.5mg, 15/ 12.5mg, 15/ 25mg
2
propranolol/ hctz tab 40/ 25mg, 80/ 25mg
1
quinapril/ hctz tab 10-12.5mg, 20-12.5mg, 20-25mg
1
valsartan/ hydrochlorothiazide tab
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)
2
eplerenone tab 25mg, 50mg
VASODILATORS
1
hydralazine tab 10mg, 25mg
2
hydralazine tab 50mg, 100mg
2
minoxidil tab 2.5mg, 10mg
ANTI-INFECTIVE AGENTS - MISC.
ANTI-INFECTIVE AGENTS - MISC.
4
AZACTAM/ DEXTROSE INJ. 1GM/ 50ML, 2GM/
50ML
3
aztreonam inj. 1gm
5
CAYSTON 28 DAY
4
colistimethate inj. 150mg PA
2
metronidazole tab 250mg, 500mg
3
metronidazole/ nacl inj. 500mg/ 100ml
4
NEBUPENT NEB PA
4
PENTAM 300 PA
2
tinidazole tab 250mg, 500mg
2
trimethoprim tab 100mg
3
vancomycin cap 125mg, 250mg ST
3
vancomycin inj. 1000mg PA
4
vancomycin inj. 500mg PA
ANTI-INFECTIVE MISC. - COMBINATIONS
25
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
sulfamethoxazole/ trimethoprim inj 400-80mg
1
sulfamethoxazole/ trimethoprim susp. 200-40mg/ 5ml
1
sulfamethoxazole/ trimethoprim tab 400-80mg,
800-160mg
ANTIPROTOZOAL AGENTS
3
ALINIA SUSP. 100MG/ 5ML QL=180 ml/30 Days
3
ALINIA TAB 500MG QL=6 Tabs/30 Days
4
MEPRON SUSP. 750MG/ 5ML
CARBAPENEMS
3
imipenem/ cilastatin inj.
3
INVANZ INJ. 1GM
3
meropenem inj. 500mg
CHLORAMPHENICOLS
2
chloramphenicol inj. 1gm
CYCLIC LIPOPEPTIDES
5
CUBICIN INJ. 500MG PA
GLYCYLCYCLINES
4
TYGACIL INJ. 50MG
LEPROSTATICS
3
DAPSONE TAB 25MG, 100MG
LINCOSAMIDES
2
clindamycin cap 75mg, 150mg, 300mg
3
clindamycin inj. 150mg/ ml
2
clindamycin inj. 6mg/ ml, 12mg/ ml, 18mg/ ml
4
LINCOCIN INJ. 300MG/ ML PA
OXAZOLIDINONES
5
ZYVOX INJ. 2MG/ ML PA
5
ZYVOX SUSP. 100MG/ 5ML PA
5
ZYVOX TAB 600MG PA
POLYMYXINS
4
polymyxin B inj. 500000unit
ANTIMALARIALS
ANTIMALARIAL COMBINATIONS
2
atovaquone/ proguanil tab
3
COARTEM TAB 20-120MG
3
MALARONE TAB 62.5-25MG, 250-100MG
26
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
ANTIMALARIALS
2
chloroquine tab 250mg, 500mg
3
DARAPRIM TAB 25MG
2
hydroxychloroquine tab 200mg
2
mefloquine tab 250mg
3
PRIMAQUINE TAB 26.3MG
ANTIMYASTHENIC AGENTS
ANTIMYASTHENIC AGENTS
3
GUANIDINE TAB
3
MESTINON SYRUP 60MG/ 5ML
3
MESTINON TIMESPAN TAB 180MG
2
pyridostigmine tab 60mg
ANTIMYCOBACTERIAL AGENTS
ANTI TB COMBINATIONS
4
RIFAMATE CAP
4
RIFATER TAB
ANTIMYCOBACTERIAL AGENTS
4
CAPASTAT INJ. 1GM
2
ethambutol tab 100mg, 400mg
2
isoniazid inj. 100mg/ ml
2
isoniazid syrup 50mg/ 5ml
2
isoniazid tab 100mg
1
isoniazid tab 300mg
3
MYCOBUTIN CAP 150MG
3
PASER GRANULE 4GM
4
PRIFTIN TAB 150MG
2
pyrazinamide tab
2
rifampin cap 150mg, 300mg
3
rifampin inj. 600mg
4
SEROMYCIN CAP 250MG
4
TRECATOR TAB 250MG
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
ALKYLATING AGENTS
3
BICNU INJ. 100MG
3
BUSULFEX INJ.
3
carboplatin inj. 150mg/ 15ml
27
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
CEENU CAP 10MG, 40MG
3
cisplatin inj. 1mg/ ml
2
cyclophosphamide tab 25mg, 50mg PA
5
HEXALEN CAP 50MG
3
IFEX INJ. 3GM
3
ifosfamide inj. 1gm
3
LEUKERAN TAB 2MG
3
melphalan inj. 50mg PA
3
MUSTARGEN INJ. 10MG
2
oxaliplatin inj. 100mg PA
3
THIOTEPA INJ. 15MG
ANTIMETABOLITES
3
ALIMTA INJ. 500MG
3
cladribine inj. 1mg/ ml
3
CYTARABINE INJ. 20MG/ ML, 100MG/ ML
3
cytarabine inj. 500mg
5
DACOGEN INJ. 50MG PA
2
fludarabine inj. 50mg PA
3
fluorouracil inj. 50mg/ ml
5
FOLOTYN INJ. 20MG/ ML PA
3
gemcitabine inj. 38mg/ ml
2
mercaptopurine tab 50mg
3
methotrexate inj. 1gm
3
methotrexate inj. 25mg/ ml
2
methotrexate tab 2.5mg
3
TABLOID TAB 40MG
5
VIDAZA INJ. 100MG
ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS
5
AVASTIN INJ. 25MG/ ML
5
ZALTRAP INJ. PA
ANTINEOPLASTIC - ANTIBODIES
5
HERCEPTIN INJ. 440MG
5
KADCYLA INJ. 20MG/ ML PA
5
PERJETA INJ. PA
5
RITUXAN INJ. 10MG/ ML
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS
5
ERIVEDGE CAP 150MG PA
28
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS
2
anastrozole tab 1mg
2
bicalutamide tab 50mg
3
EMCYT CAP 140MG
3
exemestane tab 25mg
3
FARESTON TAB 60MG
5
FASLODEX INJ. 50MG/ ML
3
flutamide cap 125
3
letrozole tab 2.5mg
3
leuprolide inj. 5mg/ ml
3
LUPRON DEPOT INJ. 3.75MG, 11.25MG PA
5
LUPRON DEPOT INJ. 7.5MG, 22.5MG, 30MG PA
5
LUPRON DEPOT KIT 45MG PA
3
LYSODREN TAB 500MG
2
megestrol acetate susp 40mg/ ml PA
2
megestrol acetate tab 20mg, 40mg PA
3
NILANDRON TAB 150MG
1
SOLTAMOX SUSP. 10MG/ 5ML
1
tamoxifen citrate tab 10mg, 20mg
4
TRELSTAR DEPOT MIXJECT INJ.
4
TRELSTAR LA MIXJECT INJ.
4
TRELSTAR MIXJECT INJ.
5
XTANDI CAP PA
5
ZYTIGA TAB 250MG PA
ANTINEOPLASTIC ANTIBIOTICS
3
adriamycin inj. 2mg/ ml
3
bleomycin sulfate inj. 30unit
3
COSMEGEN INJ. 0.5MG
3
daunorubicin inj. 20mg
5
DOXIL INJ. 2MG/ ML
3
doxorubicin inj. 2mg/ ml
3
epirubicin inj. 2mg/ ml
3
idarubicin inj. 1mg/ ml
3
mitomycin inj. 20mg
3
mitoxantrone inj. 2mg/ ml
ANTINEOPLASTIC ENZYME INHIBITORS
5
AFINITOR TAB 2.5MG, 5MG, 7.5MG, 10MG PA
29
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
5
BOSULIF TAB 100MG, 500MG PA
5
CAPRELSA TAB 100MG, 300MG PA QL=60 Tabs/30 Days
5
COMETRIQ PACK PA
3
ELSPAR INJ. 10000UNIT
5
GLEEVEC TAB 100MG, 400MG PA
5
ICLUSIG TAB 15MG, 45MG PA
5
INLYTA TAB 1MG, 4MG PA
5
JAKAFI TAB 5MG, 10MG, 15MG, 20MG, 25MG PA QL=60 Tabs/30 Days
5
MEKINIST TAB PA
5
NEXAVAR TAB 200MG LD PA
5
SPRYCEL TAB 20MG, 50MG, 70MG, 80MG, 100MG,
140MG
PA
5
STIVARGA TAB 40MG PA
5
SUTENT CAP 12.5MG, 25MG, 50MG PA
5
TAFINLAR CAP 50MG, 75MG PA
5
TARCEVA TAB 25MG, 100MG, 150MG
5
TASIGNA CAP 150MG, 200MG
5
TYKERB TAB 250MG LD PA
5
VELCADE INJ. 3.5MG
5
VOTRIENT TAB 200MG PA
5
XALKORI CAP 200MG, 250MG PA
5
ZELBORAF TAB 240MG PA
5
ZOLINZA CAP 100MG
ANTINEOPLASTICS MISC.
5
ACTIMMUNE INJ. 2MU/ 0.5ML LD PA
3
dacarbazine inj. 200mg
2
hydroxyurea cap 500mg
4
INTRON-A INJ. 10MU, 18MU
3
MATULANE CAP 50MG
3
ONTAK INJ. 150MCG/ ML
3
pentostatin inj. 10mg
5
POMALYST CAP 1MG, 2MG, 3MG, 4MG PA
5
PROLEUKINE IV SOLN.
5
SYLATRON INJ. 296MCG, 444MCG, 888MCG PA
5
SYNRIBO INJ. PA
5
TARGRETIN CAP 75MG
2
tretinoin cap 10mg
30
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
TRISENOX INJ. 10MG/ 10ML
CHEMOTHERAPY ADJUNCTS
5
ELITEK INJ. 1.5MG PA
5
KEPIVANCE INJ 6.25MG PA
CHEMOTHERAPY RESCUE/ ANTIDOTE AGENTS
3
amifostine inj. 500mg PA
3
dexrazoxane inj. 500mg
4
FUSILEV INJ. 50MG
3
leucovorin inj. 100mg, 350mg
2
leucovorin tab 5mg, 10mg, 15mg, 25mg
3
mesna inj. 100mg/ ml
3
MESNEX TAB 400MG
MITOTIC INHIBITORS
3
DOCEFREZ INJ. 20MG, 80MG PA
5
DOCETAXEL INJ. 20MG/ ML PA
3
DOCETAXEL INJ. 80MG/ 8ML PA
3
etoposide inj. 20mg/ ml
5
HALAVEN INJ. 0.5MG/ ML PA
5
JEVTANA INJ. 60/ 1.5ML PA
3
paclitaxel inj. 6mg/ ml
5
TAXOTERE INJ. 20MG/ 0.5ML, 20MG/ ML PA
3
toposar inj. 20mg/ ml
3
VINBLASTINE SULFATE INJ. 10MG
3
vincasar pfs inj. 1mg/ ml
3
vincristine inj. 1mg/ ml
3
vinorelbine inj. 10mg/ ml
TOPOISOMERASE I INHIBITORS
4
irinotecan inj. 20mg/ ml
3
topotecan inj. 1mg/ ml
ANTIPARKINSON AGENTS
ANTIPARKINSON ANTICHOLINERGICS
2
benztropine inj.
2
benztropine tab 0.5mg, 1mg
1
benztropine tab 2mg
2
trihexypenidyl elixir 0.4mg/ ml
1
trihexyphenidyl tab 2mg
2
trihexyphenidyl tab 5mg
31
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
ANTIPARKINSON COMT INHIBITORS
3
COMTAN TAB 200MG
3
entacapone tab 200mg
4
TASMAR TAB 100MG
ANTIPARKINSON DOPAMINERGICS
2
amantadine cap 100mg
2
amantadine syrup 50mg/ 5ml
2
AMANTADINE TAB 100MG
5
APOKYN INJ. 10MG/ ML
2
bromocriptine cap 5mg
2
bromocriptine tab 2.5mg
2
carbidopa/ levodopa er tab 25/ 100mg, 50/ 200mg
2
carbidopa/ levodopa ODT tab 10/ 100mg, 25/ 100mg, 25/
250mg
2
carbidopa/ levodopa tab 10/ 100mg, 25/ 100mg, 25/
250mg
2
pramipexole tab 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg,
1.5mg
3
ropinirole ER tab 2mg, 4mg, 6mg, 8mg, 12mg
2
ropinirole tab 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg
3
STALEVO TAB 50MG, 75MG, 100MG, 125MG,
150MG, 200MG
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS
4
AZILECT TAB 0.5MG, 1MG
2
selegiline cap 5mg
2
selegiline tab 5mg
ANTIPSYCHOTICS/ ANTIMANIC AGENTS
ANTIMANIC AGENTS
2
lithium carbonate cap 150mg, 600mg
1
lithium carbonate cap 300mg
2
lithium carbonate ER tab 300mg, 450mg
2
lithium carbonate tab 300mg
2
lithium citrate soln. 8meq/ 5ml
ANTIPSYCHOTICS - MISC.
3
EQUETRO CAP 100MG, 200MG, 300MG
3
GEODON INJ. 20MG
4
LATUDA TAB 20MG, 40MG, 80MG, 120MG PA QL=30 Tabs/30 Days
32
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
ziprasidone cap 20mg, 40mg, 60mg, 80mg QL=60 Caps/30 Days
BENZISOXAZOLES
4
FANAPT TAB 1MG, 2MG, 4MG, 6MG, 8MG, 10MG,
12MG
PA QL=60 Tabs/30 Days
4
FANAPT TITRATION PACK PA QL=60 Tabs/30 Days
4
INVEGA SUSTENNA INJ. 39MG/ 0.25ML, 78MG/
0.5ML, 117MG/ 0.75ML, 156MG/ ML, 234MG/ 1.5ML
PA
3
INVEGA TAB 1.5MG, 3MG, 9MG PA QL=30 Tabs/30 Days
3
INVEGA TAB 6MG PA QL=60 Tabs/30 Days
4
RISPERDAL INJ. 12.5MG, 25MG, 37.5MG, 50MG PA
3
risperidone odt 0.25mg, 0.5mg, 1mg, 2mg, 3mg QL=60 Tabs/30 Days
3
risperidone odt 4mg QL=120 Tabs/30 Days
2
risperidone soln. 1mg/ ml QL=480 ml/30 Days
2
risperidone tab 0.25mg, 0.5mg, 1mg, 2mg, 3mg QL=60 Tabs/30 Days
2
risperidone tab 4mg QL=120 Tabs/30 Days
BUTYROPHENONES
3
haloperidol decanoate inj. 5mg/ ml, 100mg/ ml
3
haloperidol inj. 5mg/ ml
3
haloperidol oral conc. 2mg/ ml
1
haloperidol tab 0.5mg, 1mg, 2mg, 5mg
2
haloperidol tab 10mg, 20mg
DIBENZAPINES
2
clozapine tab 100mg QL=270 Tabs/30 Days
2
clozapine tab 200mg QL=120 Tabs/30 Days
2
clozapine tab 25mg, 50mg QL=60 Tabs/30 Days
4
FAZACLO TAB 12.5MG, 100MG QL=60 Tabs/30 Days
4
FAZACLO TAB 150MG QL=240 Tabs/30 Days
4
FAZACLO TAB 200MG QL=120 Tabs/30 Days
4
FAZACLO TAB 25MG QL=90 Tabs/30 Days
2
loxapine cap 5mg, 10mg, 25mg, 50mg
4
olanzapine inj. 5mg/ ml
2
olanzapine ODT tab 5mg, 10mg, 15mg, 20mg QL=30 Tabs/30 Days
2
olanzapine tab 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg QL=30 Tabs/30 Days
2
quetiapine tab 25mg, 50mg, 100mg, 200mg, 300mg,
400mg
QL=90 Tabs/30 Days
4
SAPHRIS SL TAB 5MG, 10MG PA QL=60 Tabs/30 Days
3
SEROQUEL XR TAB 300MG, 400MG QL=60 Tabs/30 Days
33
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
SEROQUEL XR TAB 50MG, 150MG, 200MG QL=30 Tabs/30 Days
PHENOTHIAZINES
2
chlorpromazine inj. 25mg/ ml
2
chlorpromazine tab 10mg, 25mg, 50mg, 100mg, 200mg
2
compro suppository 25mg
2
fluphenazine decanoate inj. 25mg/ ml
2
fluphenazine elixir 2.5mg/ 5ml
2
fluphenazine inj. 2.5mg/ ml
2
fluphenazine oral conc. 5mg/ ml
1
fluphenazine tab 1mg
2
fluphenazine tab 2.5mg, 5mg, 10mg
2
perphenazine tab 2mg, 4mg, 8mg, 16mg
3
prochlorperazine edisylate inj. 5mg/ ml
2
prochlorperazine suppository 25mg
1
prochlorperazine tab 5mg, 10mg
1
thioridazine tab 10mg, 100mg PA
2
thioridazine tab 25mg, 50mg PA
2
trifluoperazine tab 1mg, 2mg, 5mg, 10mg
QUINOLINONE DERIVATIVES
3
ABILIFY DISC TAB 10MG QL=90 Tabs/30 Days
3
ABILIFY DISC TAB 15MG QL=60 Tabs/30 Days
3
ABILIFY INJ. 9.75MG/ 1.3ML
5
ABILIFY MAINTENANCE INJ. PA
3
ABILIFY SOLN. 1MG/ ML QL=900 ml/30 Days
3
ABILIFY TAB 2MG, 5MG, 10MG, 15MG, 20MG,
30MG
QL=30 Tabs/30 Days
THIOXANTHENES
2
thiothixene cap 1mg, 2mg, 5mg, 10mg
ANTIVIRALS
ANTIRETROVIRALS
3
abacavir tab 300mg
5
APTIVUS CAP 250MG
5
APTIVUS SOLN. 100MG/ ML
5
ATRIPLA TAB
5
COMPLERA TAB
3
CRIXIVAN CAP 100MG, 200MG, 400MG
3
didanosine cap 125mg, 200mg, 250mg, 400mg
34
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
5
EDURANT TAB 25MG
3
EMTRIVA CAP 200MG
3
EMTRIVA SOLN. 10MG/ ML
3
EPIVIR HBV SOLN. 5MG/ ML
3
EPIVIR HBV TAB 100MG
3
EPIVIR SOLN. 10MG/ ML
3
EPZICOM TAB 600-300MG
5
FUZEON INJ. 90MG
5
INTELENCE TAB 100MG, 200MG
3
INVIRASE CAP 200MG
3
INVIRASE TAB 500MG
5
ISENTRESS TAB 25MG, 100MG
5
ISENTRESS TAB 400MG
5
KALETRA SOLN. 400-100MG/ 5ML
4
KALETRA TAB 100-25MG
5
KALETRA TAB 200-50MG
3
lamivudine tab 150mg, 300mg
5
lamivudine/ zidovudine tab 150/ 300mg
4
LEXIVA SUSP. 50MG/ ML
5
LEXIVA TAB 700MG
2
nevirapine tab 200mg
3
NORVIR CAP 100MG
3
NORVIR SOLN. 80MG/ ML
3
NORVIR TAB 100MG
4
PREZISTA SUSP. 100MG/ ML
4
PREZISTA TAB 75MG, 150MG, 400MG, 600MG,
800MG
3
RESCRIPTOR TAB 100MG, 200MG
3
RETROVIR INJ. 10MG/ ML
4
REYATAZ CAP 100MG
5
REYATAZ CAP 150MG, 200MG, 300MG
5
SELZENTRY TAB 150MG, 300MG
2
stavudine cap 15mg, 20mg, 30mg, 40mg
3
stavudine oral solution
5
STRIBILD TAB QL=30 Tabs/30 Days
3
SUSTIVA CAP 50MG, 200MG
3
SUSTIVA TAB 600MG
35
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
TRIZIVIR TAB
3
TRUVADA TAB
3
VIDEX SOLN. 2GM
5
VIRACEPT TAB 250MG, 625MG
3
VIRAMUNE SUSP. 50MG/ 5ML
4
VIRAMUNE XR TAB 100MG, 400MG
3
VIREAD POWDER 40MG/ GM
3
VIREAD TAB 150MG, 200MG, 250MG, 300MG
3
ZIAGEN SOLN. 20MG/ ML
3
zidovudine cap 100mg
3
zidovudine syrup 10mg/ ml
3
zidovudine tab 300mg
CMV AGENTS
2
FOSCARNET INJ. 24MG/ ML
3
ganciclovir inj. 50mg/ ml
5
VALCYTE SOLN. 50MG/ ML
5
VALCYTE TAB 450MG
HEPATITIS AGENTS
4
BARACLUDE SOLN. 0.05MG/ ML
3
BARACLUDE TAB 0.5MG, 1MG
3
HEPSERA TAB 10MG
5
INCIVEK TAB 375MG PA
5
INFERGEN INJ. 9MCG PA
5
PEG-INTRON KIT 50MCG, 50MCG RP, 80MCG RP,
120 RP, 150 RP
5
PEGASYS INJ. 135MCG/ 0.5ML, 180MCG/ ML,
PEGASYS KIT
4
REBETOL SOLN. 40MG/ ML
4
ribasphere cap 200mg
4
ribasphere tab 200mg
4
ribavirin cap 200mg
4
ribavirin tab 200mg
3
TYZEKA TAB 600MG PA
5
VICTRELIS CAP 200MG PA
HERPES AGENTS
1
acyclovir cap 200mg
3
acyclovir inj. 500mg
36
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
acyclovir susp. 200mg/ 5ml
2
acyclovir tab 400mg, 800mg
2
famciclovir tab 125mg, 250mg, 500mg
3
valacyclovir tab 500mg, 1000mg
INFLUENZA AGENTS
2
rimantadine tab 100mg
3
TAMIFLU CAP 30MG QL=84 Caps/180 Days
3
TAMIFLU CAP 45MG, 75MG QL=85 Caps/365 Days
3
TAMIFLU SUSP. 6MG/ ML QL=20 Bottles/365 Days
ASSORTED CLASSES
CHELATING AGENTS
4
DEPEN TITRATAB 250MG
3
SYPRINE CAP 250MG
IMMUNOMODULATORS
5
REVLIMID CAP 5MG, 10MG, 15MG, 25MG LD
5
THALOMID CAP 50MG, 100MG, 150MG, 200MG
IMMUNOSUPPRESSIVE AGENTS
5
ATGAM INJ. 50MG/ ML PA
3
AZASAN TAB 75 MG, 100MG PA
2
azathioprine inj. 100mg PA
2
azathioprine tab 50mg PA
4
CELLCEPT CAP 250MG PA
4
CELLCEPT SUSP. 200MG/ ML PA
4
CELLCEPT TAB 500MG PA
2
cyclosporine cap 25mg, 100mg PA
3
cyclosporine inj. 50mg/ ml PA
2
cyclosporine modified cap 25mg, 50mg, 100mg PA
2
cyclosporine modified soln. 100mg/ ml PA
2
gengraf cap 25mg, 100mg PA
2
gengraf soln. 100mg/ ml PA
2
mycophenolate cap 250mg PA
2
mycophenolate tab 500mg PA
4
MYFORTIC TAB 180MG, 360MG PA
4
NEORAL CAP 25MG, 100MG PA
4
NEORAL SOLN. 100MG/ ML PA
4
PROGRAF CAP 0.5MG, 1MG, 5MG PA
4
RAPAMUNE SOLN. 1MG/ ML PA
37
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
4
RAPAMUNE TAB 0.5MG, 1MG, 2MG PA
4
SANDIMMUNE CAP 25MG, 100MG PA
4
SANDIMMUNE INJ. 50MG/ ML PA
4
SANDIMMUNE ORAL SOLN. 100MG/ ML PA
3
tacrolimus cap 0.5mg, 1mg, 5mg PA
4
ZORTRESS TAB 0.25MG PA
IRRIGATION SOLUTIONS
3
lactated ringers irrigation
2
physiolyte irrigation soln.
2
physiosol irrigation soln.
2
ringers irrigation soln.
POTASSIUM REMOVING RESINS
2
kionex powder
2
sodium polystyrene sulfonate powder
BETA BLOCKERS
ALPHA-BETA BLOCKERS
1
carvedilol tab 3.125mg, 6.25mg, 12.5mg, 25mg
3
COREG CR CAP 10MG, 20MG, 40MG, 80MG
2
labetalol inj. 5mg/ ml
2
labetalol tab 100mg, 200mg, 300mg
BETA BLOCKERS CARDIO-SELECTIVE
2
acebutolol cap 200mg, 400mg
1
atenolol tab 25mg, 50mg, 100mg
2
betaxolol tab 10mg, 20mg
2
bisoprolol tab 5mg, 10mg
2
metoprolol ER tab 25mg, 50mg, 100mg, 200mg
2
metoprolol inj. 1mg/ ml
1
metoprolol tab 25mg, 50mg, 100mg
BETA BLOCKERS NON-SELECTIVE
1
nadolol tab 20mg, 40mg
2
nadolol tab 80mg
2
pindolol tab 5mg, 10mg
2
propranolol er cap 60mg, 80mg, 120mg, 160mg
2
propranolol inj. 1mg/ ml
2
propranolol oral soln. 20mg/ 5ml, 40mg/ 5ml
1
propranolol tab 10mg, 20mg, 40mg, 80mg
2
propranolol tab 60mg
38
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
sorine tab 80mg, 120mg, 160mg, 240mg
2
sotalol tab 120mg, 160mg, 240mg
1
sotalol tab 80mg
2
timolol maleate tab 5mg, 10mg, 20mg
BIOLOGICALS MISC
BIOLOGICALS MISC
5
ADAGEN INJ. 250MG/ ML PA
CALCIUM CHANNEL BLOCKERS
CALCIUM CHANNEL BLOCKERS
2
afeditab CR tab 30mg, 60mg
2
amlodipine tab 2.5mg, 5mg, 10mg
3
CARDIZEM CD CAP 360MG
2
cartia xt cap 120mg, 180mg, 240mg, 300mg
2
dilt-cd cap 120mg, 300mg
2
dilt-xr cap 180mg, 240mg
2
diltiazem CD cap 120mg, 240mg, 300mg
2
diltiazem ER cap 60mg, 90mg, 120mg, 180mg, 360mg,
420mg
2
DILTIAZEM INJ. 100MG
2
diltiazem inj. 5mg/ ml
1
diltiazem tab 30mg, 60mg, 90mg, 120mg
2
felodipine tab 2.5mg, 5mg, 10mg
2
isradipine cap 2.5mg, 5mg
3
matzim la tab 180mg, 240mg, 300mg, 360mg, 420mg
2
nicardipine cap 20mg, 30mg
2
nifediac cc tab 90mg
2
nifedical XL tab 30mg, 60mg
2
nifedipine cap 10mg, 20mg PA
2
nifedipine ER tab 30mg, 60mg, 90mg
2
nimodipine cap 30mg
3
nisoldipine er tab 8.5mg, 17mg, 20mg, 25.5mg, 30mg,
34mg, 40mg
2
taztia-xt cap 120mg, 180mg, 240mg, 300mg, 360mg
3
verapamil ER cap 100mg, 200mg, 300mg
2
verapamil ER cap 120mg, 180mg, 240mg, 360mg
2
verapamil ER tab 120mg, 180mg, 240mg
2
verapamil inj. 2.5mg/ ml
39
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
verapamil tab 40mg
1
verapamil tab 80mg, 120mg
CARDIOTONICS
CARDIAC GLYCOSIDES
2
digoxin inj. 0.25mg/ ml
2
digoxin oral soln 0.05mg/ ml PA
1
digoxin tab 0.125mg QL=30 Tabs/30 Days
1
digoxin tab 0.25mg PA
CARDIOVASCULAR AGENTS - MISC.
PROSTAGLANDIN VASODILATORS
5
REMODULIN INJ. 1MG/ ML, 2.5MG/ ML, 5MG/ ML,
10MG/ ML
PA
5
VENTAVIS INH. 10MCG/ ML, 20MCG/ ML PA
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS
5
LETAIRIS TAB 5MG, 10MG PA
5
TRACLEER TAB 62.5MG, 125MG LD PA
PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS
5
ADCIRCA TAB 20MG PA
5
REVATIO INJ. 0.8MG/ ML PA
2
sildenafil tab 20mg PA
CEPHALOSPORINS
CEPHALOSPORINS - 1ST GENERATION
2
cefadroxil cap 500mg
2
cefadroxil susp. 250mg/ 5ml, 500mg/ 5ml
2
cefadroxil tab 1gm
2
cefazolin inj. 200mg/ ml
3
cefazolin inj. 500mg, 1gm, 20gm
3
cefazolin/ d5w inj. 1gm/ 50ml
1
cephalexin cap 250mg, 500mg
1
cephalexin susp 125mg/ 5ml, 250mg/ 5ml
1
cephalexin tab 250mg, 500mg
CEPHALOSPORINS - 2ND GENERATION
2
cefaclor cap 250mg, 500mg
2
cefaclor ER tab 500mg
3
CEFOTETAN INJ. 1GM, 2GM, 10GM
4
cefoxitin inj. 1gm, 2gm, 10gm
40
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
4
cefoxitin/ dextrose inj. 1gm, 2gm
2
cefprozil susp. 125mg/ 5ml, 250mg/ 5ml
2
cefprozil tab 250mg, 500mg
2
cefuroxime inj. 7.5gm
3
cefuroxime inj. 750mg, 1.5gm
2
cefuroxime tab 250mg, 500mg
CEPHALOSPORINS - 3RD GENERATION
2
cefdinir cap 300mg
2
cefdinir susp. 125mg/ 5ml, 250mg/ 5ml
2
cefotaxime inj. 10gm
2
cefpodoxime susp. 50mg/ 5ml, 100mg/ 5ml
2
cefpodoxime tab 100mg, 200mg
3
ceftazidime inj. 1gm, 2gm, 6gm
3
ceftazidime/ dextrose inj.
2
ceftriaxone inj. 1gm, 2gm
3
ceftriaxone inj. 250mg, 500mg, 10gm
4
SUPRAX CAP
4
SUPRAX CHEW TAB 100MG, 200MG
4
SUPRAX SUSP. 100MG/ 5ML, 200MG/ 5ML, 500MG/
5ML
4
SUPRAX TAB 400MG
CEPHALOSPORINS - 4TH GENERATION
2
cefepime inj. 1gm, 2gm
CEPHALOSPORINS - 5TH GENERATION
4
TEFLARO INJ. 400MG, 600MG
CONTRACEPTIVES
COMBINATION CONTRACEPTIVES - ORAL
2
amethia tab
2
apri tab
2
aranelle tab
2
aviane tab
2
balziva tab
2
briellyn tab
2
cryselle-28 tab
2
cyclafem tab 1/ 35, 7/ 7/ 7
2
emoquette tab
2
enpresse-28 tab
41
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
GENERESS FE 28
2
gildagia tab
2
introvale tab
2
junel fe tab 1-20, 1.5-30
2
junel tab 1-20, 1.5-30
2
kariva tab
2
kelnor tab 1-35
2
leena tab
2
lessina-28 tab
2
levonest tab
2
levonorgestrel/ ethinyl estradiol tab
2
levora-28 tab
2
low-ogestrel tab
2
lutera tab
2
marlissa 28 day tab
2
microgestin tab 1-20, 1.5-30
2
mononessa tab
2
necon tab 0.5-35, 1-35, 7-7-7
3
necon tab 10-11
2
nortrel tab 0.5-35, 1-35, 7-7-7
2
orsythia tab
2
portia-28 tab
2
previfem tab
2
quasense tab
1
sprintec-28 tab
2
sronyx tab
2
tri-previfem tab
2
tri-sprintec tab
1
trinessa tab
2
trivora-28 tab
2
velivet tab
2
YASMIN TAB
3
YAZ TAB
2
zenchent fe
2
zovia tab 1-35e, 1-50e
COMBINATION CONTRACEPTIVES - TRANSDERMAL
3
ORTHO EVRA PATCH
42
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
COMBINATION CONTRACEPTIVES - VAGINAL
4
NUVARING
EMERGENCY CONTRACEPTIVES
3
ELLA TAB 30MG QL=1 Tabs/28 Days
PROGESTIN CONTRACEPTIVES - INJECTABLE
2
medroxyprogesterone acetate inj. 150mg/ ml
PROGESTIN CONTRACEPTIVES - ORAL
2
camila tab
2
errin tab
2
jolivette tab
2
nora-be tab
CORTICOSTEROIDS
GLUCOCORTICOSTEROIDS
2
a-hydrocort inj. 100mg
2
budesonide EC cap 3mg
2
CORTEF TAB 5MG, 10MG
2
cortisone tab 25mg
2
dexamethasone conc. 1mg/ ml
2
dexamethasone elixir 0.5mg/ 5ml
2
dexamethasone inj. 4mg/ ml
1
dexamethasone tab 0.5mg, 0.75mg, 4mg
2
dexamethasone tab 1mg, 1.5mg, 2mg, 6mg
2
hydrocortisone tab 5mg, 10mg, 20mg
3
methylprednisolone acetate inj. 40mg/ ml, 80mg/ ml
2
methylprednisolone dose pak 4mg
2
methylprednisolone inj. 125mg
3
methylprednisolone inj. 40mg/ ml
2
methylprednisolone tab 4mg, 8mg, 16mg, 32mg
2
prednisolone sodium phosphate soln. 5mg/ 5ml, 15mg/
5ml, 25mg/ 5ml
3
PREDNISONE INTENSOL 5MG/ ML
3
prednisone soln. 5mg/ 5ml
2
prednisone tab 1mg, 50mg
1
prednisone tab 2.5mg, 5mg, 10mg, 20mg
3
SOLU-CORTEF INJ 250MG
MINERALOCORTICOIDS
43
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
fludrocortisone tab 0.1mg
COUGH/ COLD/ ALLERGY
MUCOLYTICS
2
acetylcysteine soln. 10%, 20% PA
DERMATOLOGICALS
ACNE PRODUCTS
3
adapalene cream 0.1%
3
adapalene gel 0.1%
2
clindamycin phosphate gel 1%
2
clindamycin phosphate lotion 1%
2
clindamycin phosphate soln. 1%
2
clindamycin phosphate swab 1%
2
clindamycin/ benzoyl peroxide gel 1-5%
2
erythromycin gel 2%
2
erythromycin soln. 2%
2
erythromycin/ benzoyl peroxide gel 5-3%
4
RETIN-A MICRO GEL 0.04%, 0.1%
2
sulfacetamide sodium topical lotion
2
tretinoin cream 0.025%, 0.05%, 0.1%
2
tretinoin gel 0.01%, 0.025%
ANTIBIOTICS - TOPICAL
2
gentamicin sulfate cream 0.1%
2
gentamicin sulfate oint. 0.1%
3
mupirocin cream
2
mupirocin oint. 2%
ANTIFUNGALS - TOPICAL
2
ciclopirox cream 0.77%
2
ciclopirox gel 0.77%
2
ciclopirox nail lacquer 8%
3
ciclopirox shampoo 1%
2
ciclopirox topical soln.
2
clotrimazole cream 1%
2
clotrimazole soln. 1%
2
clotrimazole/ betamethasone lotion 1-0.05%
2
clotrimazole/ betamethazone cream
2
econazole nitrate cream 1%
44
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
ketoconazole cream 2%
2
ketoconazole shampoo 2%
1
nystatin cream 100000unit/ gm
2
nystatin oint. 100000unit/ gm
2
nystatin topical powder
2
nystatin/ triamcinolone cream
2
nystatin/ triamcinolone oint.
2
nystop topical powder
4
OXISTAT CREAM 1%
4
OXISTAT LOTION 1%
2
pedi-dri topical powder
ANTI-INFLAMMATORY AGENTS - TOPICAL
3
VOLTAREN GEL 1% QL=5 Tubes/1 Fills
ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL
2
fluorouracil cream 5%
2
fluorouracil soln. 2%, 5%
5
PANRETIN GEL 0.1%
3
SOLARAZE GEL 3%
5
TARGRETIN GEL 1%
ANTIPRURITICS - TOPICAL
3
doxepin hcl cream 5%
3
ZONALON CREAM 5%
ANTIPSORIATICS
2
calcipotriene cream 0.005%
3
calcipotriene oint. 0.005%
3
calcipotriene soln. 0.005%
3
OXSORALEN ULTRA CAP 10MG
5
SORIATANE CAP 10MG, 17.5MG, 25MG PA
4
TAZORAC CREAM 0.05%, 0.1%
4
TAZORAC GEL 0.05%, 0.1%
3
VECTICAL OINT. 3MCG/ GM
ANTISEBORRHEIC PRODUCTS
2
selenium sulfide lotion 2.5%
ANTIVIRALS - TOPICAL
3
DENAVIR CREAM 1%
3
ZOVIRAX CREAM
3
ZOVIRAX OINT.
45
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
BURN PRODUCTS
3
mafenide acetate topical soln 5% (50 GM)
2
silver sulfadiazine cream 1%
3
SULFAMYLON CREAM 85MG/ GM
2
thermazene cream 1%
CORTICOSTEROIDS - TOPICAL
2
alclometasone cream 0.05%
2
alclometasone oint. 0.05%
3
amcinonide cream 0.1%
3
amcinonide lotion 0.1%
3
amcinonide oint. 0.1%
2
augmented betamethasone cream 0.05%
2
augmented betamethasone gel 0.05%
3
augmented betamethasone lotion 0.05%
2
augmented betamethasone oint 0.05%
2
betamethasone dipropionate cream 0.05%
2
betamethasone dipropionate oint. 0.05%
2
betamethasone lotion
2
betamethasone valerate cream 0.1%
2
betamethasone valerate lotion 0.1%
2
betamethasone valerate oint 0.1%
2
clobetasol e cream 0.05%
2
clobetasol gel 0.05%
2
clobetasol lotion 0.05%
2
clobetasol oint 0.05%
2
clobetasol shampoo 0.05%
2
clobetasol soln. 0.05%
4
clobetasol topical foam
4
CORDRAN TAPE 4MCG/ CM
2
desonide cream 0.05%
2
desonide lotion 0.05%
2
desonide oint. 0.05%
2
desoximetasone cream 0.25%, 0.05%
2
desoximetasone gel 0.05%
2
desoximetasone oint 0.25%
2
DESOXIMETASONE OINT. 0.05%
2
diflorasone cream 0.05%
46
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
diflorasone oint 0.05%
2
fluocinolone acetonide cream 0.01%, 0.025%
2
fluocinolone acetonide oil
2
fluocinolone acetonide oint. 0.025%
2
fluocinolone acetonide soln. 0.01%
2
fluocinonide cream 0.05%
2
fluocinonide gel 0.05%
2
fluocinonide oint 0.05%
2
fluocinonide soln. 0.05%
2
fluticasone cream 0.05%
2
fluticasone oint. 0.005%
3
fluticasone propionate lotion 0.05%
2
halobetasol cream 0.05%
2
halobetasol oint 0.05%
2
hc butyrate cream 0.1%
2
hc butyrate oint. 0.1%
2
hc butyrate soln. 0.1%
2
hydrocortisone cream 1%, 2.5%
2
hydrocortisone lotion 2.5%
2
hydrocortisone oint. 1%, 2.5%
2
hydrocortisone valerate cream 0.2%
2
hydrocortisone valerate oint 0.2%
3
KENALOG AEROSOL SPRAY
2
mometasone cream 0.1%
2
mometasone oint 0.1%
2
mometasone topical soln.
2
prednicarbate cream 0.1%
2
prednicarbate oint. 0.1%
1
triamcinolone cream 0.025%, 0.1%, 0.5%
2
triamcinolone lotion 0.025%, 0.1%
2
triamcinolone oint 0.025%, 0.5%
1
triamcinolone oint 0.1%
2
triderm cream 0.1%
EMOLLIENTS
2
ammonium lactate cream 12%
2
ammonium lactate lotion 12%
ENZYMES - TOPICAL
47
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
4
SANTYL OINT. 250UNIT/ GM
IMMUNOMODULATING AGENTS - TOPICAL
3
imiquimod cream 5%
IMMUNOSUPPRESSIVE AGENTS - TOPICAL
4
ELIDEL CREAM 1%
4
PROTOPIC OINT 0.03%, 0.1%
KERATOLYTIC/ ANTIMITOTIC AGENTS
4
CONDYLOX GEL 0.5%
2
podofilox soln. 0.5%
LOCAL ANESTHETICS - TOPICAL
2
lidocaine gel 2%
2
lidocaine oint. 5%
2
lidocaine soln. 4%
2
lidocaine/ prilocaine cream 2.5-2.5%
4
LIDODERM PATCH 5% PA QL=90 Patches/30 Days
ROSACEA AGENTS
4
FINACEA GEL 15%
3
METROGEL 1%
2
metronidazole cream 0.75%
2
metronidazole gel 0.75%
2
metronidazole lotion 0.75%
SCABICIDES & PEDICULICIDES
3
EURAX CREAM 10%
3
EURAX LOTION 10%
3
lindane lotion 1%
3
lindane shampoo 1%
3
malathion lotion 0.5%
2
permethrin cream 5%
DIGESTIVE AIDS
DIGESTIVE ENZYMES
3
CREON CAP 3000UNIT, 6000UNIT, 12000UNIT,
24000UNIT, 36000UNIT
3
PANCREAZE CAP 4200UNIT, 10500UNIT,
16800UNIT, 21000UNIT
5
SUCRAID SUSP.
DIURETICS
48
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
CARBONIC ANHYDRASE INHIBITORS
3
acetazolamide inj. 500mg
2
acetazolamide SR cap 500mg
2
acetazolamide tab 125mg, 250mg
2
methazolamide tab 25mg, 50mg
DIURETIC COMBINATIONS
3
ALDACTAZIDE TAB 50-50MG
1
amiloride/ hctz tab 5/ 50mg
2
spironolactone/ hctz tab 25/ 25mg
2
triamterene/ hctz cap 37.5/ 25mg
2
triamterene/ hctz tab 37.5/ 25mg
1
triamterene/ hctz tab 75/ 50mg
LOOP DIURETICS
2
bumetanide inj. 0.25mg/ ml
1
bumetanide tab 0.5mg, 1mg
2
bumetanide tab 2mg
3
EDECRIN TAB 25MG
2
furosemide soln. 8mg/ ml, 10mg/ ml
1
furosemide tab 20mg, 40mg, 80mg
2
TORSEMIDE INJ. 10MG/ ML
2
torsemide tab 5mg, 10mg, 20mg, 100mg
POTASSIUM SPARING DIURETICS
2
amiloride tab 5mg
1
spironolactone tab 25mg
2
spironolactone tab 50mg, 100mg
THIAZIDES AND THIAZIDE-LIKE DIURETICS
4
chlorothiazide inj. 500mg
1
chlorothiazide tab 250mg, 500mg
2
chlorthalidone tab 25mg, 50mg
1
hydrochlorothiazide cap 12.5mg
1
hydrochlorothiazide tab 25mg, 50mg
1
indapamide tab 1.25mg, 2.5mg
2
metolazone tab 2.5mg, 5mg, 10mg
ENDOCRINE AND METABOLIC AGENTS - MISC.
BONE DENSITY REGULATORS
3
ACTONEL TAB 5MG, 30MG, 35MG, 150MG
49
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
1
alendronate tab 35mg, 70mg
2
alendronate tab 5mg, 10mg, 40mg
4
BONIVA INJ. 3MG/ 3ML ST
3
ibandronic acid tab 150mg
4
PROLIA SOLN 60MG/ ML PA
5
XGEVA INJ. PA
4
zoledronic acid inj. 4mg/ 5ml, 5mg/ 100ml
CALCIUM REGULATORS - MISC.
3
calcitonin nasal spray 200unit/ act
2
etidronate disodium tab 200mg, 400mg
5
FORTEO SOLN. 600MCG/ 2.4ML PA
3
FORTICAL NASAL SPRAY 200UNIT/ ACT
3
FOSAMAX-D TAB 70-2800MG, 70-5600MG
4
MIACALCIN INJ. 200UNIT/ ML PA
5
ZOMETA INJ. 4MG/ 5ML
FERTILITY REGULATORS
4
chorionic gonadotropin inj. 10000unit PA
4
NOVAREL INJ. 10000UNIT/ ML PA
GROWTH HORMONE RECEPTOR ANTAGONISTS
5
SOMAVERT INJ. 10MG, 15MG, 20MG PA
GROWTH HORMONES
5
NORDITROPIN INJ. 5MG/ 1.5ML, 10MG/ 1.5ML,
15MG/ 1.5ML
PA
5
NORDITROPIN NORDIFLEX PEN 10MG/ ML PA
HORMONE RECEPTOR MODULATORS
3
EVISTA TAB 60MG
INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)
5
INCRELEX INJ. 40MG/ 4ML LD PA
LHRH/ GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS
3
LUPRON DEPOT INJ. 3.75MG, 11.25MG PA
5
LUPRON DEPOT PEDIATRIC INJ. 11.25, 15MG PA
5
SYNAREL SOLN. 2MG/ ML PA
METABOLIC MODIFIERS
5
ALDURAZYME INJ. 2.9MG/ 5ML LD
5
BUPHENYL TAB 500MG
2
calcitriol cap 0.25mcg, 0.5mcg PA
50
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
calcitriol inj. 1mcg/ ml PA
3
calcitriol soln. 1mcg/ ml PA
3
CYSTADANE POWDER
5
ELAPRASE INJ. 6MG/ 3ML
5
FABRAZYME INJ. 35MG LD PA
4
HECTOROL CAP 0.5MCG, 1MCG, 2.5MCG PA
4
HECTOROL INJ. 4MCG/ 2ML PA
5
KUVAN TAB 100MG PA
2
levocarnitine inj. 200mg/ ml PA
2
levocarnitine soln. 1gm/ 10ml PA
2
levocarnitine tab 330mg PA
5
LUMIZYME INJ. 50MG
5
MYOZYME INJ. 50MG
5
NAGLAZYME INJ. 1MG/ ML PA
5
ORFADIN CAP 2MG, 5MG, 10MG PA
3
SENSIPAR TAB 30MG, 60MG, 90MG PA
3
ZEMPLAR CAP 1MCG, 2MCG, 4MCG PA
3
ZEMPLAR INJ. 2MCG/ ML, 5MCG/ ML PA
POSTERIOR PITUITARY HORMONES
3
desmopressin inj. 4mcg/ ml
3
desmopressin nasal spray 0.01%
3
desmopressin tab 0.1mg, 0.2mg
PROLACTIN INHIBITORS
4
cabergoline tab 0.5mg
SOMATOSTATIC AGENTS
5
octreotide inj. 500mcg/ ml, 1000mcg/ ml PA
4
octreotide inj. 50mcg/ ml, 100mcg/ ml, 200mcg/ ml PA
5
SANDOSTATIN KIT LAR 10MG, 20MG, 30MG PA
5
SOMATULINE INJ. 60/ 0.2ML, 90/ 0.3ML, 120/ .5ML PA
ESTROGENS
ESTROGEN COMBINATIONS
3
COMBIPATCH 0.05/ 0.14MG, 0.05/ 0.25MG PA
2
estradiol/ norethindrone tab 1/ 0.5mg PA
2
jinteli tab PA
3
PREMPHASE TAB 0.625/ 5MG PA
3
PREMPRO TAB 0.625-2.5MG, 0.625-5MG, 0.3-1.5MG,
0.45-1.5MG
PA
51
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
ESTROGENS
1
estradiol tab 0.5mg, 1mg, 2mg PA
2
estropipate tab 0.75mg, 1.5mg, 3mg PA
4
MENEST TAB PA
3
MINIVELLE PATCH 0.0375MG, 0.05MG, 0.075MG,
0.1MG
PA
4
PREMARIN INJ. 25MG PA
3
PREMARIN TAB 0.3MG, 0.45MG, 0.9MG, 1.25MG PA
3
VIVELLE-DOT PATCH 0.025MG, 0.0375MG, 0.05MG,
0.075MG, 0.1MG
PA
FLUOROQUINOLONES
FLUOROQUINOLONES
3
CIPRO SUSP. 250MG/ 5ML, 500MG/ 5ML
3
ciprofloxacin IV soln. 1%
1
ciprofloxacin tab 100mg, 250mg, 500mg, 750mg
3
LEVAQUIN/ D5W INJ. 5MG/ ML
3
levofloxacin inj. 25mg/ ml
2
levofloxacin soln. 25mg/ ml
2
levofloxacin tab 250mg, 500mg, 750mg
3
levofloxacin/ D5W inj.
2
ofloxacin tab 200mg, 300mg, 400mg
GASTROINTESTINAL AGENTS - MISC.
GALLSTONE SOLUBILIZING AGENTS
5
CHENODAL TAB 250MG PA
2
ursodiol cap 300mg
3
ursodiol tab 250mg, 500mg
GASTROINTESTINAL ANTIALLERGY AGENTS
3
cromoyln sodium oral solution
GASTROINTESTINAL STIMULANTS
2
metoclopramide inj. 5mg/ ml
1
metoclopramide soln. 5mg/ 5ml PA
1
metoclopramide tab 10mg PA
2
metoclopramide tab 5mg PA
INFLAMMATORY BOWEL AGENTS
4
APRISO CAP 0.375GM
4
ASACOL TAB 400MG
52
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
balsalazide cap 750mg
3
CANASA SUPPOSITORY 1000MG
5
CIMZIA KIT PA
4
DELZICOL CAP
3
DIPENTUM CAP 250MG
3
mesalamine enema 4gm
4
PENTASA CAP 250MG, 500MG
5
REMICADE INJ. 100MG PA
2
sulfasalazine tab 500mg
2
sulfazine EC tab 500mg
INTESTINAL ACIDIFIERS
2
generlac soln. 10gm/ 15ml
IRRITABLE BOWEL SYNDROME (IBS) AGENTS
3
LINZESS CAP 145MCG, 290MCG QL=30 Caps/30 Days
3
LOTRONEX TAB 0.5MG, 1MG
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS
4
RELISTOR INJ. 12MG/ 0.6ML PA
PHOSPHATE BINDER AGENTS
2
calcium acetate cap 667mg
2
PHOSLYRA SOLN. 667MG/ 5ML
3
RENAGEL TAB 400MG, 800MG
3
RENVELA PACKET 0.8GM, 2.4GM
3
RENVELA TAB 800MG
GENITOURINARY AGENTS - MISCELLANEOUS
ALKALINIZERS
2
potassium citrate ER tab 5meq, 10meq
CYSTINOSIS AGENTS
4
CYSTAGON CAP 50MG, 150MG
GENITOURINARY IRRIGANTS
2
neomycin/ polymyxin B GU irrigation soln.
2
sodium chloride irrigation soln. 0.9%
PROSTATIC HYPERTROPHY AGENTS
3
alfuzosin ER tab 10mg
3
AVODART CAP 0.5MG
2
finasteride tab 5mg
3
JALYN CAP 0.5-0.4MG
53
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
4
RAPAFLO CAP 4MG, 8MG
2
tamsulosin cap 0.4mg
GOUT AGENTS
GOUT AGENT COMBINATIONS
2
colchicine/ probenecid tab 0.5/ 500mg
GOUT AGENTS
2
allopurinol inj. 500mg
1
allopurinol tab 100mg, 300mg
3
COLCRYS TAB 0.6MG
4
ULORIC TAB 40MG, 80MG ST QL=30 Tabs/30 Days
URICOSURICS
2
probenecid tab 500mg
HEMATOLOGICAL AGENTS - MISC.
HEMATORHEOLOGIC AGENTS
2
pentoxifylline ER tab 400mg
PLATELET AGGREGATION INHIBITORS
3
AGGRENOX CAP 25-200MG
2
anagrelide cap 0.5mg, 1mg
4
BRILINTA TAB 90MG
2
cilostazol tab 50mg, 100mg
2
clopidogrel tab 75mg QL=30 Tabs/30 Days
2
dipyridamole tab 25mg, 50mg, 75mg PA
2
ticlopidine tab 250mg
HEMATOPOIETIC AGENTS
AGENTS FOR GAUCHER DISEASE
5
CEREZYME INJ. 200UNIT LD PA
5
ZAVESCA CAP 100MG PA
AGENTS FOR SICKLE CELL ANEMIA
3
DROXIA CAP 200MG, 300MG, 400MG
HEMATOPOIETIC GROWTH FACTORS
3
ARANESP INJ 25MCG, 40MCG PA
5
ARANESP INJ. 300MCG, 500MCG PA
4
ARANESP INJ. 60MCG, 100MCG, 150MCG, 200MCG PA
3
EPOGEN INJ. 2000U/ ML, 3000U/ ML, 4000U/ ML,
10000U/ ML, 20000U/ ML, 40000U/ ML
PA
5
LEUKINE INJ. 250MCG/ ML, 500MCG/ ML PA
54
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
5
NEULASTA INJ. 6MG/ 0.6ML PA
5
NEUMEGA INJ. 5MG PA
5
NEUPOGEN INJ. 300MCG/ ML, 600MCG/ ML PA
4
PROCRIT INJ. 2000/ ML, 3000/ ML, 4000/ ML, 10000/
ML
PA
5
PROCRIT INJ. 20000/ ML, 40000/ ML PA
5
PROMACTA TAB 12.5MG, 25MG, 50MG, 75MG QL=30 Tabs/30 Days
STEM CELL MOBILIZERS
5
MOZOBIL INJ. 20MG/ ML PA
HEMOSTATICS
HEMOSTATICS - SYSTEMIC
2
tranexamic acid inj. 100mg/ ml
3
tranexamic acid tab
HYPNOTICS
BARBITURATE HYPNOTICS
4
BUTISOL TAB 50MG PA QL=60 Tabs/30 Days
2
phenobarbital oral soln. 4mg/ ml PA
2
phenobarbital tab 15mg, 16.2mg, 30mg, 32.4mg, 60mg,
64.8mg, 97.2mg, 100mg
PA
NON-BARBITURATE HYPNOTICS
4
LUNESTA TAB 1MG, 2MG, 3MG PA ST QL=30 Tabs/30 Days
2
zaleplon cap 5mg, 10mg PA
2
zolpidem tab 5mg, 10mg PA QL=30 Tabs/30 Days
LAXATIVES
LAXATIVE COMBINATIONS
2
gavilyte-c powder 240gm
2
gavilyte-n powder 420gm
2
GOLYTELY POWDER PACKET
2
PREPOPIK PACK
4
SUPREP BOWEL SOLN.
2
trilyte powder 420gm
LAXATIVES - MISCELLANEOUS
2
constulose soln. 10gm/ 15ml
2
KRISTALOSE PACKET
2
KRISTALOSE PACKET 10GM
1
lactulose soln. 10gm/ 15ml
55
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
polyethylene glycol powder 3350
LOCAL ANESTHETICS-PARENTERAL
LOCAL ANESTHETICS - AMIDES
2
lidocaine inj. 0.5%, 1%
MACROLIDES
AZITHROMYCIN
3
azithromycin inj. 500mg
2
azithromycin susp. 100mg/ 5ml, 200mg/ 5ml
2
azithromycin tab 250mg, 500mg, 600mg
CLARITHROMYCIN
2
clarithromycin ER tab 500mg
2
clarithromycin susp. 125mg/ 5ml, 250mg/ 5ml
2
clarithromycin tab 250mg, 500mg
ERYTHROMYCINS
2
e.e.s tab 400mg
2
ERY-TAB 333MG
3
ERYPED SUSP. 200MG/ 5ML, 400MG/ 5ML
3
ERYTHROCIN LACTOBIONATE INJ. 500MG
2
ERYTHROCIN STEARATE TAB 250MG
2
erythromycin tab 250mg, 500mg
2
erythromycin tab 400mg
FIDAXOMICIN
5
DIFICID TAB 200MG ST QL=20 Tabs/1 Fills
MEDICAL DEVICES
BANDAGES-DRESSINGS-TAPE
2
GAUZE PAD
MISC. DEVICES
2
ALCOHOL SWAB
PARENTERAL THERAPY SUPPLIES
2
B-D INSULIN SYRINGE
2
FREESTYLE INSULIN SYRINGE
2
INSULIN SYRINGE
2
PEN NEEDLE
2
PRECISION INSULIN SYRINGE
MIGRAINE PRODUCTS
56
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
MIGRAINE PRODUCTS
2
dihydroergotamine inj. 1mg/ ml
4
ERGOMAR SL TAB PA
4
MIGERGOT SUPPOSITORY
4
MIGRANAL NASAL SPRAY 4MG/ ML
SEROTONIN AGONISTS
2
naratriptan tab 1mg, 2.5mg QL=18 Tabs/30 Days
2
rizatriptan ODT tab 5mg, 10mg QL=24 Tabs/30 Days
2
rizatriptan tab 5mg, 10mg QL=24 Tabs/30 Days
3
sumatriptan inj. 6mg/ 0.5ml
2
sumatriptan tab 25mg, 50mg, 100mg QL=9 Tabs/30 Days
MINERALS & ELECTROLYTES
BICARBONATES
2
sodium lactate inj. 5meq/ ml
2
sodium lactate IV soln.
CHLORIDE
3
AMMONIUM CHLORIDE INJ. 5MEQ/ ML
ELECTROLYTE MIXTURES
3
dextrose/ sodium chloride inj.
3
ISOLYTE-S INJ.
3
ISOLYTE/ DEXTROSE INJ.
3
kcl/ d5w/ lactated ringers inj.
3
kcl/ d5w/ nacl inj. (all strengths)
3
NORMOSOL-R INJ.
3
NORMOSOL/ DEXTROSE INJ.
3
PLASMA-LYTE INJ.
3
PLASMA-LYTE/ D5W INJ.
3
potassium chloride/ dextrose inj.
3
potassium chloride/ nacl inj.
2
ringers inj.
2
tpn electrolytes inj.
FLUORIDE
2
sodium fluoride tab 1mg
MAGNESIUM
3
magnesium sulfate inj. 4%, 8%, 50%
POTASSIUM
57
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
KLOR-CON 8MEQ, 10MEQ
2
KLOR-CON M15, M20
2
potassium chloride ER cap 8meq, 10meq
2
potassium chloride er tab 10meq, 20meq
2
potassium chloride inj.
2
potassium chloride inj. 2meq/ ml, 10meq/ 50ml, 10meq/
100ml
SODIUM
3
sodium chloride inj. 0.45%, 0.9%, 3%, 5%
2
sodium chloride inj. 2.5meq/ ml
MOUTH/ THROAT/ DENTAL AGENTS
ANESTHETICS TOPICAL ORAL
1
lidocaine viscous 2%
ANTI-INFECTIVES - THROAT
2
clotrimazole troche 10mg
2
nystatin susp. 100000unit/ ml
ANTISEPTICS - MOUTH/ THROAT
2
chlorhexidine gluconate soln. 0.12%
STEROIDS - MOUTH/ THROAT
2
triamcinolone in orabase paste 0.1%
THROAT PRODUCTS - MISC.
3
cevimeline cap 30mg
2
pilocarpine tab 5mg, 7.5mg
MULTIVITAMINS
PRENATAL VITAMINS
3
PRENATAL VITAMIN
MUSCULOSKELETAL THERAPY AGENTS
CENTRAL MUSCLE RELAXANTS
1
baclofen tab 10mg
2
baclofen tab 20mg
2
carisoprodol tab 350mg PA
2
chlorzoxazone tab 500mg PA
1
cyclobenzaprine tab 5mg, 10mg PA
2
methocarbamol tab 500mg, 750mg PA
3
tizanidine cap 2mg, 4mg, 6mg
3
tizanidine tab 2mg, 4mg
58
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
DIRECT MUSCLE RELAXANTS
2
dantrolene cap 25mg, 50mg, 100mg
MUSCLE RELAXANT COMBINATIONS
2
carisoprodol/ aspirin tab 200/ 325mg PA
2
carisoprodol/ aspirin/ codeine tab PA
2
orphenadrine/ aspirin/ caffeine 25/ 385/ 30mg PA
NASAL AGENTS - SYSTEMIC AND TOPICAL
NASAL ANTIALLERGY
3
ASTEPRO NASAL SPRAY 0.15% QL=2 Bottles/30 Days
3
PATANASE NASAL SPRAY 0.6% QL=1 Bottles/30 Days
NASAL ANTICHOLINERGICS
2
ipratropium nasal spray 0.03%, 0.06%
NASAL STEROIDS
3
FLUNISOLIDE NASAL SPRAY
2
flunisolide nasal spray 0.025% QL=2 Bottles/30 Days
2
fluticasone nasal spray 50mcg QL=1 Bottles/30 Days
3
NASONEX NASAL SPRAY 50MCG/ ACT QL=2 Bottles/30 Days
3
triamcinolone nasal spray 55mcg/ act QL=1 Bottles/30 Days
SYMPATHOMIMETIC DECONGESTANTS
3
TYZINE NASAL SOLN. 0.1%
NEUROMUSCULAR AGENTS
ALS AGENTS
5
RILUTEK TAB 50MG
4
riluzole tab
NUTRIENTS
CARBOHYDRATES
3
dextrose inj. 5%, 10%
LIPIDS
3
intralipid inj. 20%, 30% PA
3
LIPOSYN III INJ. 10%, 20%, 30% PA
PROTEINS
3
AMINOSYN II INJ. 7%, 8.5%, 10%, 15% PA
3
AMINOSYN II INJ. 8.5%/ LYTE PA
3
AMINOSYN M INJ. 3.5% PA
3
AMINOSYN-HBC INJ. 7%, 8% PA
59
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
AMINOSYN-PF INJ. 7%, 10% PA
3
CLINIMIX E INJ. 2.75%, 4.25%, 5% PA
3
CLINIMIX INJ. 2.75%, 4.25%, 5% PA
3
clinisol sf inj. 15% PA
3
NEPHRAMINE INJ. 5.4% PA
3
premasol soln. 6% PA
3
PROCALAMINE INJ. 3% PA
3
PROSOL INJ. 20% PA
3
TRAVASOL INJ. 10% PA
OPHTHALMIC AGENTS
BETA-BLOCKERS - OPHTHALMIC
2
betaxolol ophth soln. 0.5%
4
BETIMOL OPHTH SOLN. 0.25%, 0.5%
3
BETOPTIC-S OPHTH SOLN. 0.25%
2
carteolol ophth soln. 1%
2
dorzolamide/ timolol ophth soln.
1
levobunolol ophth soln. 0.5%
2
metipranolol ophth soln. 0.3%
2
timolol maleate ophth gel 0.25%, 0.5%
1
timolol maleate ophth soln. 0.25%, 0.5%
MIOTICS
4
PHOSPHOLINE IODIDE OPHTH SOLN. 0.125%
3
PILOPINE HS OPHTH GEL 4%
OPHTHALMIC ADRENERGIC AGENTS
3
ALPHAGAN P OPHTH SOLN. 0.1%, 0.15%
2
apraclonidine ophth soln. 0.5%
2
brimonidine ophth soln. 0.15%, 0.2%
OPHTHALMIC ANTI-INFECTIVES
2
bacitracin ophth oint. 500unit/ gm
2
bacitracin/ polymyxin B ophth oint.
3
CILOXAN OPHTH OINT. 0.3%
2
ciprofloxacin ophth soln. 0.3%
2
erythromycin ophth oint. 5mg/ gm
2
gentamicin ophth soln. 0.3%
2
levofloxacin ophth soln. 5mg/ ml
3
NATACYN OPHTH SUSP. 5%
2
neomycin/ bacitracin/ polymyxin ophth oint.
60
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
neomycin/ polymyxin/ gramicidin ophth soln.
2
ofloxacin ophth soln. 0.3%
2
polymyxin B/ trimethoprim ophth soln.
2
sodium sulfacetamide ophth soln. 10%
2
sulfacetamide sodium ophth oint. 10%
1
tobramycin ophth soln. 0.3%
3
TOBREX OPHTH OINT. 0.3%
2
trifluridine ophth soln. 1%
3
VIGAMOX OPHTH SOLN. 0.5%
3
ZIRGAN OPHTH GEL 0.15%
3
ZYMAXID OPHTH SOLN. 0.5%
OPHTHALMIC IMMUNOMODULATORS
3
RESTASIS EMULSION 0.05%
OPHTHALMIC STEROIDS
3
BLEPHAMIDE S.O.P. OPHTH OINT. 10-2%
2
dexamethasone sodium phosphate ophth soln 0.1%
3
FML FORTE OPHTH SUSP 0.25%
3
FML OPHTH OINT. 0.1%
3
LOTEMAX OPHTH GEL
3
LOTEMAX OPHTH OINT.
2
neomycin/ polymyxin/ bacitracin/ hc ophth oint. 1%
2
neomycin/ polymyxin/ dexamethasone ophth oint. 0.1%
2
neomycin/ polymyxin/ dexamethasone ophth soln. 0.1%
2
neomycin/ polymyxin/ hc ophth susp.
4
PRED MILD OPHTH SUSP. 0.12%
2
prednisolone ophth susp. 1%
2
prednisolone sodium phosphate ophth soln. 1%
2
sulfacetamide sodium/ prednisolone ophth soln.
4
TOBRADEX OPHTH OINT. 0.3-0.1%
4
tobramycin/ dexamethasone ophth soln. 0.3-0.1%
OPHTHALMICS - MISC.
4
ALOCRIL OPHTH SOLN. 2%
4
ALOMIDE OPHTH SOLN. 0.1%
3
azelastine ophth soln. 0.05%
2
bromfenac ophth soln. 0.09%
2
cromolyn sodium ophth soln. 4%
2
diclofenac ophth soln. 0.1%
61
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
dorzolamide ophth soln. 2%
2
flurbiprofen ophth soln. 0.03%
4
ketorolac ophth soln. 0.4%, 0.5%
3
PATADAY OPHTH SOLN. 0.2%
PROSTAGLANDINS - OPHTHALMIC
3
latanoprost ophth soln. 0.005%
4
LUMIGAN SOLN. 0.01%
OTIC AGENTS
OTIC AGENTS - MISCELLANEOUS
3
acetic acid otic soln. 2%
OTIC ANTI-INFECTIVES
2
ofloxacin otic soln. 0.3%
OTIC COMBINATIONS
3
CIPRODEX OTIC SUSP. 0.3-0.1%
2
neomycin/ polymyxin/ hc otic soln. 1%
2
neomycin/ polymyxin/ hc otic susp. 1%
OTIC STEROIDS
2
fluocinolone acetonide otic oil 0.01%
2
hydrocortisone/ acetic acid otic soln. 1-2%
PASSIVE IMMUNIZING AGENTS
IMMUNE SERUMS
5
CARIMUNE NF INJ. 3GM PA
3
GAMASTAN S/ D INJ. PA
5
GAMMAGARD INJ. 2.5GM/ 25ML PA
5
GAMMAPLEX INJ. 50MG/ ML PA
4
GAMUNEX INJ. 10% PA
5
PRIVIGEN INJ. 20GRAMS PA
PENICILLINS
AMINOPENICILLINS
1
amoxicillin cap 250mg, 500mg
1
amoxicillin chew tab 125mg, 200mg, 250mg
1
amoxicillin susp. 125mg/ 5ml, 200mg/ 5ml, 250mg/ 5ml,
400mg/ 5ml
1
amoxicillin tab 500mg, 875mg
2
ampicillin cap 250mg, 500mg
3
ampicillin inj. 125mg, 1gm, 10gm
62
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
ampicillin susp. 125mg/ 5ml, 250mg/ 5ml
NATURAL PENICILLINS
3
BICILLIN L-A INJ. 600000UNIT/ ML
2
penicillin g potassium inj. 5mu
3
PENICILLIN G PROCAINE INJ. 600000UNIT/ ML
2
penicillin g sodium inj. 5mu
2
penicillin g/ dextrose 40000unit/ ml, 60000unit/ ml
1
penicillin v potassium soln. 125mg/ 5ml, 250mg/ 5ml
1
penicillin v potassium tab 250mg, 500mg
PENICILLIN COMBINATIONS
2
amoxicillin/ clavulanate chew tab 200mg, 400mg
3
amoxicillin/ clavulanate ER tab 1000-62.5mg
2
amoxicillin/ clavulanate susp. 200mg, 250mg, 400mg,
600mg
2
amoxicillin/ clavulanate tab 250mg, 500mg, 875mg
2
ampicillin/ sulbactam inj. 2-1gm, 10-5gm
3
BICILLIN C-R INJ.
3
piperacillin/ tazobactam inj. 3-0.375gm, 4-0.5gm
3
ZOSYN INJ. 2-0.25GM/ 50ML, 3-0.375GM/ 50ML
PENICILLINASE-RESISTANT PENICILLINS
2
dicloxacillin cap 250mg, 500mg
3
nafcillin inj. 1gm, 10gm
2
nafcillin/ dextrose inj. 1gm/ 50ml
3
OXACILLIN INJ. 1GM, 10GM
3
OXACILLIN/ DEXTROSE INJ. 1GM/ 50ML, 2GM/
50ML
PROGESTINS
PROGESTINS
2
medroxyprogesterone tab 2.5mg, 5mg, 10mg
3
MEGACE ES SUSP. 625MG/ 5ML PA
2
norethindrone tab 5mg
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
AGENTS FOR CHEMICAL DEPENDENCY
3
CAMPRAL TAB 333MG
3
disulfiram tab 250mg, 500mg
ANTI-CATAPLECTIC AGENTS
63
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
5
XYREM SOLN. 500MG/ ML LD PA
ANTIDEMENTIA AGENTS
4
ARICEPT TAB 23MG ST
3
donepezil odt tab 5mg, 10mg
3
donepezil tab 5mg, 10mg
3
EXELON PATCH 4.6MG/ 24HR, 9.5MG/ 24HR,
13.3MG/ 24HR
QL=30 Patches/30 Days
3
EXELON SOLN. 2MG/ ML
2
galantamine ER cap 8mg, 16mg, 24mg
2
galantamine soln. 4mg/ ml
2
galantamine tab 4mg, 8mg, 12mg
3
NAMENDA SOLN. 2MG/ ML
3
NAMENDA TAB 5MG, 10MG
3
NAMENDA TITRATION PACK
3
rivastigmine tab 1.5mg, 3mg, 4.5mg, 6mg
COMBINATION PSYCHOTHERAPEUTICS
2
chlordiazepoxide/ amitriptyline tab 5/ 12.5mg, 10/ 25mg PA
3
fluoxetine/ olanzapine cap 3/ 25mg, 6/ 25mg, 12/ 25mg,
6/ 50mg, 12/ 50mg
2
perphenazine/ amitriptyline tab 2/ 10mg, 2/ 25mg, 4/
10mg, 4/ 25mg, 4/ 50mg
PA
FIBROMYALGIA AGENTS
3
SAVELLA TAB 12.5MG, 25MG, 50MG, 100MG QL=60 Tabs/30 Days
3
SAVELLA TITRATION PACK
MOVEMENT DISORDER DRUG THERAPY
5
XENAZINE TAB 12.5MG, 25MG PA
MULTIPLE SCLEROSIS AGENTS
5
AUBAGIO TAB 7MG, 14MG PA
5
AVONEX INJ. 30MCG/ ML
5
AVONEX PREFILL KIT 30MCG
5
BETASERON INJ. 0.3MG
5
COPAXONE INJ. 20MG/ ML
5
EXTAVIA INJ. 0.3MG
5
GILENYA CAP 0.5MG QL=30 Caps/30 Days
5
REBIF INJ. 22/ 0.5, 44/ 0.5, TITRATION PAK
5
TYSABRI INJ. LD PA
PSEUDOBULBAR AFFECT (PBA) AGENTS
64
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
3
NUEDEXTA CAP 20-10MG PA QL=60 Caps/30 Days
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
3
ergoloid mesylate tab 1mg PA
3
ORAP TAB 1MG, 2MG
SMOKING DETERRENTS
2
buproban tab 150mg
3
CHANTIX PAK 0.5MG AND 1MG QL=53 Tabs/30 Days
3
CHANTIX TAB 0.5MG, 1MG QL=336 Tabs/365 Days
3
NICOTROL INHALER 10MG QL=12 Inhalers/365 Days
RESPIRATORY AGENTS - MISC.
ALPHA-PROTEINASE INHIBITOR (HUMAN)
5
PROLASTIN INJ. 500MG, 1000MG
CYSTIC FIBROSIS AGENTS
5
KALYDECO TAB 150MG PA
5
PULMOZYME SOLN. 1MG/ ML PA
SULFONAMIDES
SULFONAMIDES
3
SULFADIAZINE TAB 500MG
TETRACYCLINES
TETRACYCLINES
2
demeclocycline tab 150mg, 300mg
2
doxycycline hyclate cap 50mg, 100mg
3
doxycycline hyclate inj. 100mg
2
doxycycline hyclate tab 20mg, 100mg
2
doxycycline monohydrate tab 50mg, 75mg, 150mg
2
minocycline cap 50mg, 75mg, 100mg
2
minocycline tab 50mg, 75mg, 100mg
3
VIBRAMYCIN SYRUP 50MG/ 5ML
THYROID AGENTS
ANTITHYROID AGENTS
2
methimazole tab 5mg, 10mg
2
propylthiouracil tab 50mg
THYROID HORMONES
2
levothroid tab 25, 50, 75, 88, 100, 112, 125, 137, 150,
175, 200, 300 mcg
65
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
1
levothyroxine tab 25, 50, 75, 88, 100, 112, 125, 137, 150,
175, 200mcg
2
levothyroxine tab 300 mcg
2
levoxyl tab 25, 50, 75, 88, 100, 112, 125, 137, 150, 175,
200, 300 mcg
2
liothyronine inj. 10mcg/ ml
2
liothyronine tab 5mcg, 25mcg, 50mcg
3
SYNTHROID TAB 25, 50, 75, 88, 100, 112, 125, 137,
150, 175, 200, 300 MCG
2
unithroid tab 25, 50, 75, 88, 100, 112, 125, 137, 150, 175,
200, 300 mcg
TOXOIDS
TOXOID COMBINATIONS
3
ADACEL INJ.
3
BOOSTRIX INJ.
3
DAPTACEL INJ.
3
INFANRIX INJ.
3
TETANUS/ DIPHTHERIA TOXOID INJ. 2-2 PA
TOXOIDS
3
TETANUS TOXOID INJ. PA
ULCER DRUGS
ANTISPASMODICS
2
atropine inj. 0.05mg/ ml, 0.1mg/ ml
1
dicyclomine cap 10mg PA
2
dicyclomine soln. 10mg/ 5ml PA
1
dicyclomine tab 20mg PA
2
glycopyrrolate inj. 0.2mg/ ml
2
glycopyrrolate tab 1mg, 2mg
H-2 ANTAGONISTS
3
cimetidine inj.
2
cimetidine oral soln. 300mg/ 5ml
2
cimetidine tab 200mg, 300mg, 400mg
1
cimetidine tab 800mg
3
famotidine inj. 10mg/ ml
3
famotidine susp. 40mg/ 5ml
1
famotidine tab 20mg
66
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
2
famotidine tab 40mg
3
famotidine/ nacl inj. 20mg/ 50ml
3
nizatidine cap 150mg, 300mg
3
nizatidine soln. 15mg/ ml
2
ranitidine cap 150mg, 300mg
3
ranitidine inj. 25mg/ ml
2
ranitidine syrup 15mg/ ml
1
ranitidine tab 150mg, 300mg
MISC. ANTI-ULCER
3
CARAFATE SUSP. 1GM/ 10ML
2
sucralfate tab 1gm
PROTON PUMP INHIBITORS
3
DEXILANT CAP 30MG, 60MG ST QL=30 Caps/30 Days
3
lansoprazole cap 15mg, 30mg
4
NEXIUM IV 20MG, 40MG
2
omeprazole cap 10mg, 20mg, 40mg QL=60 Caps/30 Days
3
pantoprazole inj.
2
pantoprazole tab 20mg, 40mg QL=30 Tabs/30 Days
ULCER DRUGS - PROSTAGLANDINS
2
misoprostol tab 100mcg, 200mcg
ULCER THERAPY COMBINATIONS
4
PREVPAC
4
PYLERA CAP
URINARY ANTI-INFECTIVES
URINARY ANTI-INFECTIVES
3
MACRODANTIN CAP 25MG PA
2
methenamine hippurate tab 1gm
2
nitrofurantoin macro cap 50mg PA
2
nitrofurantoin mono cap 100mg PA
2
nitrofurantoin susp. 25mg/ 5ml PA
URINARY ANTISPASMODICS
BETA-3 ADRENERGIC AGONISTS
4
MYRBETRIQ TAB 25MG, 50MG PA
URINARY ANTISPASMODICS
2
bethanechol tab 5mg, 10mg, 25mg, 50mg
3
DETROL LA CAP 2MG, 4MG
67
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
4
ENABLEX TAB 7.5MG, 15MG
2
flavoxate tab 100mg
2
oxybutynin ER tab 5mg, 10mg, 15mg
2
oxybutynin syrup 5mg/ 5ml
1
oxybutynin tab 5mg
2
tolterodine tab 1mg, 2mg
3
TOVIAZ TAB 4MG, 8MG
3
VESICARE TAB 5MG, 10MG
VACCINES
BACTERIAL VACCINES
3
ACTHIB INJ.
3
MENACTRA INJ.
3
MENOMUNE A-C-Y-W INJ.
3
MENVEO INJ.
3
PEDVAX HIB INJ.
3
TYPHIM VI INJ.
MIXED VACCINE COMBINATIONS
3
COMVAX INJ.
VIRAL VACCINES
3
CERVARIX INJ.
3
ENGERIX-B INJ. 10MCG, 20MCG PA
3
GARDASIL INJ.
3
HAVRIX INJ. 720UNIT, 1440UNIT
3
IMOVAX RABIES INJ.
3
IPOL INACTIVATED IPV INJ.
3
IXIARO INJ. 0.012MG/ ML
3
M-M-R II WITH DILUENT
3
PROQUAD INJ.
3
RABAVERT INJ.
3
RECOMBIVAX-HB INJ. 10MCG/ ML, 40MCG/ ML PA
3
ROTATEQ ORAL SUSP.
3
TWINRIX INJ.
3
VAQTA INJ.
3
VARIVAX INJ.
3
YF-VAX INJ.
3
ZOSTAVAX INJ.
VAGINAL PRODUCTS
68
See page 3 for more information related to QL, ST and PA. If you have questions, please call
Customer Services at (303) 751-2657 or 1-877-441-6032 (toll free) Monday through Sunday 8 a.m. to 8 p.m.,
TTY users should call 1-888-803-4494 (toll free). Or visit www.aa.coaccess.com.
Vea la página 3 para más información relacionado con QL, ST y PA. Si usted tiene preguntas,
llame a Servicios al Cliente al (303) 751-2657 o 1-877-441-6032 (llamada gratuita) de lunes a domingo 8 a.m. a
8 p.m., usuarios de TTY / TDD deben llamar al 1-888-803-4494 (llamada gratuita). O visite
www.aa.coaccess.com.
DRUG NAME DRUG TIER
REQUIREMENTS/LIMITS
VAGINAL ANTI-INFECTIVES
2
clindamycin vaginal cream 2%
2
metronidazole vaginal gel 0.75%
2
terconazole vaginal cream 0.4%, 0.8%
2
terconazole vaginal suppository 80mg
2
vandazole vaginal gel 0.75%
2
zazole vaginal cream 0.4%
VAGINAL ESTROGENS
3
ESTRACE VAGINAL CREAM 0.1MG/ GM
4
ESTRING 2MG
2
PREMARIN VAGINAL CREAM
VASOPRESSORS
ANAPHYLAXIS THERAPY AGENTS
3
EPIPEN INJ.
3
EPIPEN JR INJ.
VASOPRESSORS
2
midodrine tab 2.5mg, 5mg, 10mg
69
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
A
abacavir tab 300mg 34
ABILIFY DISC TAB
10MG
34
ABILIFY DISC TAB
15MG
34
ABILIFY INJ. 9.75MG/
1.3ML
34
ABILIFY
MAINTENANCE INJ.
34
ABILIFY SOLN. 1MG/
ML
34
ABILIFY TAB 2MG,
5MG, 10MG, 15MG,
20MG, 30MG
34
acarbose tab 25mg, 50mg,
100mg
18
acebutolol cap 200mg,
400mg
38
acetaminophen/ caffeine/
dihydrocodeine tab
712.8-60-32mg
10
acetaminophen/ codeine
soln. 120-12mg/ 5ml
10
acetaminophen/ codeine
tab 300-15mg, 300-30mg,
300-60mg
10
acetazolamide inj. 500mg 49
acetazolamide SR cap
500mg
49
acetazolamide tab 125mg,
250mg
49
acetic acid otic soln. 2% 62
acetylcysteine soln. 10%,
20%
44
ACTHIB INJ. 68
ACTIMMUNE INJ. 2MU/
0.5ML
30
ACTONEL TAB 5MG,
30MG, 35MG, 150MG
49
acyclovir cap 200mg 36
acyclovir inj. 500mg 36
acyclovir susp. 200mg/ 5ml 37
acyclovir tab 400mg,
800mg
37
ADACEL INJ. 66
ADAGEN INJ. 250MG/
ML
39
adapalene cream 0.1% 44
adapalene gel 0.1% 44
ADCIRCA TAB 20MG 40
adriamycin inj. 2mg/ ml 29
ADVAIR DISKUS
100MCG, 250MCG,
500MCG
13
ADVAIR HFA INHALER
45MCG, 115MCG,
230MCG
13
afeditab CR tab 30mg,
60mg
39
AFINITOR TAB 2.5MG,
5MG, 7.5MG, 10MG
29
AGGRENOX CAP
25-200MG
54
a-hydrocort inj. 100mg 43
ALBENZA TAB 200MG 11
albuterol neb 0.083%,
0.5%
13
albuterol neb 0.63mg/ 3ml,
1.25mg/ 3ml
13
albuterol sulfate ER tab
4mg, 8mg
13
albuterol syrup 2mg/ 5ml 13
albuterol tab 2mg, 4mg 13
alclometasone cream
0.05%
46
alclometasone oint. 0.05% 46
ALCOHOL SWAB 56
ALDACTAZIDE TAB
50-50MG
49
ALDURAZYME INJ.
2.9MG/ 5ML
50
alendronate tab 35mg,
70mg
50
alendronate tab 5mg,
10mg, 40mg
50
alfuzosin ER tab 10mg 53
ALIMTA INJ. 500MG 28
ALINIA SUSP. 100MG/
5ML
26
ALINIA TAB 500MG 26
allopurinol inj. 500mg 54
allopurinol tab 100mg,
300mg
54
ALOCRIL OPHTH SOLN.
2%
61
ALOMIDE OPHTH
SOLN. 0.1%
61
ALPHAGAN P OPHTH
SOLN. 0.1%, 0.15%
60
alprazolam tab 0.25mg,
0.5mg, 1mg, 2mg
12
amantadine cap 100mg 32
amantadine syrup 50mg/
5ml
32
AMANTADINE TAB
100MG
32
AMBISOME INJ. 50MG 21
amcinonide cream 0.1% 46
amcinonide lotion 0.1% 46
amcinonide oint. 0.1% 46
amethia tab 41
amifostine inj. 500mg 31
amikacin inj. 50mg/ ml 7
amiloride tab 5mg 49
amiloride/ hctz tab 5/ 50mg 49
aminophylline inj. 25mg/
ml
14
AMINOSYN II INJ. 7%,
8.5%, 10%, 15%
59
AMINOSYN II INJ. 8.5%/
LYTE
59
AMINOSYN M INJ. 3.5% 59
AMINOSYN-HBC INJ.
7%, 8%
59
AMINOSYN-PF INJ. 7%,
10%
60
amiodarone inj. 50mg/ ml 12
amiodarone tab 200mg,
400mg
12
amitriptyline tab 10mg,
25mg, 50mg, 75mg, 100mg
18
amitriptyline tab 150mg 18
amlodipine tab 2.5mg,
5mg, 10mg
39
70
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
amlodipine/ benazepril cap
2.5-10mg, 5-10mg,
5-20mg, 10-20mg, 5-40mg,
10-40mg
24
AMMONIUM
CHLORIDE INJ. 5MEQ/
ML
57
ammonium lactate cream
12%
47
ammonium lactate lotion
12%
47
amoxapine tab 25mg,
50mg, 100mg, 150mg
18
amoxicillin cap 250mg,
500mg
62
amoxicillin chew tab
125mg, 200mg, 250mg
62
amoxicillin susp. 125mg/
5ml, 200mg/ 5ml, 250mg/
5ml, 400mg/ 5ml
62
amoxicillin tab 500mg,
875mg
62
amoxicillin/ clavulanate
chew tab 200mg, 400mg
63
amoxicillin/ clavulanate
ER tab 1000-62.5mg
63
amoxicillin/ clavulanate
susp. 200mg, 250mg,
400mg, 600mg
63
amoxicillin/ clavulanate
tab 250mg, 500mg, 875mg
63
amphetamine ER cap 5mg,
10mg, 15mg, 20mg, 25mg,
30mg
7
amphetamine/
dextroamphetamine tab
5mg, 7.5mg, 10mg,
12.5mg, 15mg, 20mg,
30mg
7
AMPHOTERICIN B INJ.
50MG
22
ampicillin cap 250mg,
500mg
62
ampicillin inj. 125mg, 1gm,
10gm
62
ampicillin susp. 125mg/
5ml, 250mg/ 5ml
63
ampicillin/ sulbactam inj.
2-1gm, 10-5gm
63
anagrelide cap 0.5mg, 1mg 54
anastrozole tab 1mg 29
ANDRODERM PATCH
2MG/ HR, 4MG/ HR
10
ANDROGEL GEL 1% 10
ANDROGEL PUMP
1.62%
10
ANDROXY TAB 10MG 10
ANTIVERT TAB 50MG 21
APLENZIN TAB 174MG,
348MG, 522MG
17
APOKYN INJ. 10MG/ ML 32
apraclonidine ophth soln.
0.5%
60
apri tab 41
APRISO CAP 0.375GM 52
APTIVUS CAP 250MG 34
APTIVUS SOLN. 100MG/
ML
34
aranelle tab 41
ARANESP INJ 25MCG,
40MCG
54
ARANESP INJ. 300MCG,
500MCG
54
ARANESP INJ. 60MCG,
100MCG, 150MCG,
200MCG
54
ARCALYST INJ. 220MG 8
ARGATROBAN INJ. 14
ARICEPT TAB 23MG 64
ASACOL TAB 400MG 52
ASTEPRO NASAL
SPRAY 0.15%
59
atenolol tab 25mg, 50mg,
100mg
38
atenolol/ chlorthalidone
tab 100/ 25mg
24
atenolol/ chlorthalidone
tab 50/ 25mg
24
ATGAM INJ. 50MG/ ML 37
atorvastatin tab 10mg,
20mg, 40mg, 80mg
23
atovaquone/ proguanil tab 26
ATRIPLA TAB 34
atropine inj. 0.05mg/ ml,
0.1mg/ ml
66
ATROVENT HFA
INHALER 17MCG
13
AUBAGIO TAB 7MG,
14MG
64
augmented betamethasone
cream 0.05%
46
augmented betamethasone
gel 0.05%
46
augmented betamethasone
lotion 0.05%
46
augmented betamethasone
oint 0.05%
46
AVANDAMET TAB 2/
500MG, 2/ 1000MG, 4/
500MG, 4/ 1000MG
18
AVANDARYL TAB 4/
1MG, 4/ 2MG, 4/ 4MG, 8/
2MG, 8/ 4MG
18
AVANDIA TAB 2MG,
4MG, 8MG
20
AVASTIN INJ. 25MG/
ML
28
aviane tab 41
AVODART CAP 0.5MG 53
AVONEX INJ. 30MCG/
ML
64
AVONEX PREFILL KIT
30MCG
64
AZACTAM/ DEXTROSE
INJ. 1GM/ 50ML, 2GM/
50ML
25
AZASAN TAB 75 MG,
100MG
37
azathioprine inj. 100mg 37
azathioprine tab 50mg 37
azelastine ophth soln.
0.05%
61
AZILECT TAB 0.5MG,
1MG
32
azithromycin inj. 500mg 56
azithromycin susp. 100mg/
5ml, 200mg/ 5ml
56
71
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
azithromycin tab 250mg,
500mg, 600mg
56
aztreonam inj. 1gm 25
B
bacitracin ophth oint.
500unit/ gm
60
bacitracin/ polymyxin B
ophth oint.
60
baclofen tab 10mg 58
baclofen tab 20mg 58
balsalazide cap 750mg 53
balziva tab 41
BANZEL SUSP. 40MG/
ML
15
BANZEL TAB 200MG,
400MG
15
BARACLUDE SOLN.
0.05MG/ ML
36
BARACLUDE TAB
0.5MG, 1MG
36
B-D INSULIN SYRINGE 56
benazepril tab 5mg, 10mg,
20mg, 40mg
23
benazepril/ hctz tab 5/
6.25mg, 10/ 12.5mg, 20/
12.5mg, 20/ 25mg
24
BENICAR HCT TAB 20/
12.5MG, 40/ 12.5MG, 40/
25MG
24
BENICAR TAB 5MG,
20MG, 40MG
24
benztropine inj. 31
benztropine tab 0.5mg,
1mg
31
benztropine tab 2mg 31
betamethasone
dipropionate cream 0.05%
46
betamethasone
dipropionate oint. 0.05%
46
betamethasone lotion 46
betamethasone valerate
cream 0.1%
46
betamethasone valerate
lotion 0.1%
46
betamethasone valerate
oint 0.1%
46
BETASERON INJ. 0.3MG 64
betaxolol ophth soln. 0.5% 60
betaxolol tab 10mg, 20mg 38
bethanechol tab 5mg,
10mg, 25mg, 50mg
67
BETIMOL OPHTH
SOLN. 0.25%, 0.5%
60
BETOPTIC-S OPHTH
SOLN. 0.25%
60
bicalutamide tab 50mg 29
BICILLIN C-R INJ. 63
BICILLIN L-A INJ.
600000UNIT/ ML
63
BICNU INJ. 100MG 27
bisoprolol tab 5mg, 10mg 38
bisoprolol/ hctz tab 2.5/
6.25mg, 5/ 6.25mg, 10/
6.25mg
24
bleomycin sulfate inj.
30unit
29
BLEPHAMIDE S.O.P.
OPHTH OINT. 10-2%
61
BONIVA INJ. 3MG/ 3ML 50
BOOSTRIX INJ. 66
BOSULIF TAB 100MG,
500MG
30
briellyn tab 41
BRILINTA TAB 90MG 54
brimonidine ophth soln.
0.15%, 0.2%
60
bromfenac ophth soln.
0.09%
61
bromocriptine cap 5mg 32
bromocriptine tab 2.5mg 32
budeprion tab sr 100mg,
150mg
17
budesonide EC cap 3mg 43
budesonide susp. 0.25mg/
2ml, 0.5mg/ 2ml
13
bumetanide inj. 0.25mg/ ml 49
bumetanide tab 0.5mg,
1mg
49
bumetanide tab 2mg 49
BUPHENYL TAB 500MG 50
buprenorphine inj. 0.3mg/
ml
10
buprenorphine sl tab 2mg,
8mg
10
buprenorphine/ naloxone
SL tab 2-0.5mg, 8-2mg
10
buproban tab 150mg 65
bupropion sr tab 100mg,
150mg, 200mg
17
bupropion tab 75mg,
100mg
17
bupropion xl 150mg,
300mg
17
buspirone tab 5mg, 10mg 11
buspirone tab 7.5mg,
15mg, 30mg
12
BUSULFEX INJ. 27
butalbital/ apap/ caffeine/
codeine cap
50-325-40-30mg
10
BUTISOL TAB 50MG 55
butorphanol inj. 2mg/ ml 10
butorphanol soln. 10mg/
ml
10
BYDUREON INJ. 19
BYETTA INJ. 5MCG,
10MCG
19
C
cabergoline tab 0.5mg 51
calcipotriene cream
0.005%
45
calcipotriene oint. 0.005% 45
calcipotriene soln. 0.005% 45
calcitonin nasal spray
200unit/ act
50
calcitriol cap 0.25mcg,
0.5mcg
50
calcitriol inj. 1mcg/ ml 51
calcitriol soln. 1mcg/ ml 51
calcium acetate cap 667mg 53
camila tab 43
CAMPRAL TAB 333MG 63
CANASA SUPPOSITORY
1000MG
53
CANCIDAS INJ. 50MG,
70MG
21
72
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
candesartan/ hctz tab 16/
12.5mg, 32/ 12.5mg, 32/
25mg
24
CAPASTAT INJ. 1GM 27
CAPRELSA TAB 100MG,
300MG
30
captopril tab 12.5mg,
25mg, 50mg, 100mg
23
captopril/ hctz tab 25/
15mg, 25/ 25mg, 50/ 15mg,
50/ 25mg
25
CARAFATE SUSP. 1GM/
10ML
67
carbamazepine chew tab
100mg
15
carbamazepine ER cap
100mg, 200mg, 300mg
15
carbamazepine ER tab
200mg, 400mg
15
carbamazepine susp.
100mg/ 5ml
15
carbamazepine tab 200mg 15
carbidopa/ levodopa er tab
25/ 100mg, 50/ 200mg
32
carbidopa/ levodopa ODT
tab 10/ 100mg, 25/ 100mg,
25/ 250mg
32
carbidopa/ levodopa tab
10/ 100mg, 25/ 100mg, 25/
250mg
32
carbinoxamine liquid 4mg/
5ml
22
carbinoxamine tab 4mg 22
carboplatin inj. 150mg/
15ml
27
CARDIZEM CD CAP
360MG
39
CARIMUNE NF INJ.
3GM
62
carisoprodol tab 350mg 58
carisoprodol/ aspirin tab
200/ 325mg
59
carisoprodol/ aspirin/
codeine tab
59
carteolol ophth soln. 1% 60
cartia xt cap 120mg,
180mg, 240mg, 300mg
39
carvedilol tab 3.125mg,
6.25mg, 12.5mg, 25mg
38
CAYSTON 28 DAY 25
CEENU CAP 10MG,
40MG
28
cefaclor cap 250mg,
500mg
40
cefaclor ER tab 500mg 40
cefadroxil cap 500mg 40
cefadroxil susp. 250mg/
5ml, 500mg/ 5ml
40
cefadroxil tab 1gm 40
cefazolin inj. 200mg/ ml 40
cefazolin inj. 500mg, 1gm,
20gm
40
cefazolin/ d5w inj. 1gm/
50ml
40
cefdinir cap 300mg 41
cefdinir susp. 125mg/ 5ml,
250mg/ 5ml
41
cefepime inj. 1gm, 2gm 41
cefotaxime inj. 10gm 41
CEFOTETAN INJ. 1GM,
2GM, 10GM
40
cefoxitin inj. 1gm, 2gm,
10gm
40
cefoxitin/ dextrose inj. 1gm,
2gm
41
cefpodoxime susp. 50mg/
5ml, 100mg/ 5ml
41
cefpodoxime tab 100mg,
200mg
41
cefprozil susp. 125mg/ 5ml,
250mg/ 5ml
41
cefprozil tab 250mg,
500mg
41
ceftazidime inj. 1gm, 2gm,
6gm
41
ceftazidime/ dextrose inj. 41
ceftriaxone inj. 1gm, 2gm 41
ceftriaxone inj. 250mg,
500mg, 10gm
41
cefuroxime inj. 7.5gm 41
cefuroxime inj. 750mg,
1.5gm
41
cefuroxime tab 250mg,
500mg
41
CELEBREX CAP 50MG,
100MG, 200MG, 400MG
8
CELLCEPT CAP 250MG 37
CELLCEPT SUSP.
200MG/ ML
37
CELLCEPT TAB 500MG 37
CELONTIN CAP 300MG 16
cephalexin cap 250mg,
500mg
40
cephalexin susp 125mg/
5ml, 250mg/ 5ml
40
cephalexin tab 250mg,
500mg
40
CEREZYME INJ.
200UNIT
54
CERVARIX INJ. 68
CESAMET CAP 1MG 21
cetirizine syrup 1mg/ ml 22
cevimeline cap 30mg 58
CHANTIX PAK 0.5MG
AND 1MG
65
CHANTIX TAB 0.5MG,
1MG
65
CHEMET CAP 100MG 21
CHENODAL TAB 250MG 52
chloramphenicol inj. 1gm 26
chlordiazepoxide cap 5mg,
10mg, 25mg
12
chlordiazepoxide/
amitriptyline tab 5/
12.5mg, 10/ 25mg
64
chlorhexidine gluconate
soln. 0.12%
58
chloroquine tab 250mg,
500mg
27
chlorothiazide inj. 500mg 49
chlorothiazide tab 250mg,
500mg
49
chlorpromazine inj. 25mg/
ml
34
73
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
chlorpromazine tab 10mg,
25mg, 50mg, 100mg,
200mg
34
chlorthalidone tab 25mg,
50mg
49
chlorzoxazone tab 500mg 58
cholestyramine lite powder
packet 4gm
23
chorionic gonadotropin inj.
10000unit
50
ciclopirox cream 0.77% 44
ciclopirox gel 0.77% 44
ciclopirox nail lacquer 8% 44
ciclopirox shampoo 1% 44
ciclopirox topical soln. 44
cilostazol tab 50mg, 100mg 54
CILOXAN OPHTH OINT.
0.3%
60
cimetidine inj. 66
cimetidine oral soln.
300mg/ 5ml
66
cimetidine tab 200mg,
300mg, 400mg
66
cimetidine tab 800mg 66
CIMZIA KIT 53
CIPRO SUSP. 250MG/
5ML, 500MG/ 5ML
52
CIPRODEX OTIC SUSP.
0.3-0.1%
62
ciprofloxacin IV soln. 1% 52
ciprofloxacin ophth soln.
0.3%
60
ciprofloxacin tab 100mg,
250mg, 500mg, 750mg
52
cisplatin inj. 1mg/ ml 28
citalopram soln. 10mg/
5ml
17
citalopram tab 10mg,
20mg, 40mg
17
cladribine inj. 1mg/ ml 28
clarithromycin ER tab
500mg
56
clarithromycin susp.
125mg/ 5ml, 250mg/ 5ml
56
clarithromycin tab 250mg,
500mg
56
clemastine tab 2.68mg 22
clindamycin cap 75mg,
150mg, 300mg
26
clindamycin inj. 150mg/ ml 26
clindamycin inj. 6mg/ ml,
12mg/ ml, 18mg/ ml
26
clindamycin phosphate gel
1%
44
clindamycin phosphate
lotion 1%
44
clindamycin phosphate
soln. 1%
44
clindamycin phosphate
swab 1%
44
clindamycin vaginal cream
2%
69
clindamycin/ benzoyl
peroxide gel 1-5%
44
CLINIMIX E INJ. 2.75%,
4.25%, 5%
60
CLINIMIX INJ. 2.75%,
4.25%, 5%
60
clinisol sf inj. 15% 60
clobetasol e cream 0.05% 46
clobetasol gel 0.05% 46
clobetasol lotion 0.05% 46
clobetasol oint 0.05% 46
clobetasol shampoo 0.05% 46
clobetasol soln. 0.05% 46
clobetasol topical foam 46
clomipramine cap 25mg,
50mg, 75mg
18
clonazepam ODT tab
0.125mg, 0.25mg, 0.5mg,
1mg, 2mg
15
clonazepam tab 0.5mg,
1mg, 2mg
15
clonidine tab 0.1mg, 0.2mg 24
clonidine tab 0.3mg 24
clopidogrel tab 75mg 54
clorazepate tab 3.75mg,
7.5mg, 15mg
12
clotrimazole cream 1% 44
clotrimazole soln. 1% 44
clotrimazole troche 10mg 58
clotrimazole/
betamethasone lotion
1-0.05%
44
clotrimazole/
betamethazone cream
44
clozapine tab 100mg 33
clozapine tab 200mg 33
clozapine tab 25mg, 50mg 33
COARTEM TAB
20-120MG
26
codeine sulfate tab 15mg,
30mg, 60mg
9
co-gesic tab 500-5mg 10
colchicine/ probenecid tab
0.5/ 500mg
54
COLCRYS TAB 0.6MG 54
colestipol granule 5gm 23
colestipol tab 1gm 23
colistimethate inj. 150mg 25
colocort enema 100mg/
6ml
11
COMBIPATCH 0.05/
0.14MG, 0.05/ 0.25MG
51
COMBIVENT INHALER 13
COMBIVENT
RESPIMAT
13
COMETRIQ PACK 30
COMPLERA TAB 34
compro suppository 25mg 34
COMTAN TAB 200MG 32
COMVAX INJ. 68
CONDYLOX GEL 0.5% 48
constulose soln. 10gm/
15ml
55
COPAXONE INJ. 20MG/
ML
64
CORDRAN TAPE 4MCG/
CM
46
COREG CR CAP 10MG,
20MG, 40MG, 80MG
38
CORTEF TAB 5MG,
10MG
43
CORTIFOAM AEROSOL
90MG
11
cortisone tab 25mg 43
COSMEGEN INJ. 0.5MG 29
74
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
COUMADIN TAB 1MG,
2MG, 2.5MG, 3MG, 4MG,
5MG, 6MG, 7.5MG,
10MG
14
CREON CAP 3000UNIT,
6000UNIT, 12000UNIT,
24000UNIT, 36000UNIT
48
CRESTOR TAB 5MG,
10MG, 20MG, 40MG
23
CRIXIVAN CAP 100MG,
200MG, 400MG
34
cromolyn neb 20mg/ 2ml 13
cromolyn sodium ophth
soln. 4%
61
cromoyln sodium oral
solution
52
cryselle-28 tab 41
CUBICIN INJ. 500MG 26
cyclafem tab 1/ 35, 7/ 7/ 7 41
cyclobenzaprine tab 5mg,
10mg
58
cyclophosphamide tab
25mg, 50mg
28
CYCLOSET TAB 0.8MG 19
cyclosporine cap 25mg,
100mg
37
cyclosporine inj. 50mg/ ml 37
cyclosporine modified cap
25mg, 50mg, 100mg
37
cyclosporine modified soln.
100mg/ ml
37
CYMBALTA CAP 20MG,
30MG, 60MG
18
cyproheptadine syrup 2mg/
5ml
23
cyproheptadine tab 4mg 23
CYSTADANE POWDER 51
CYSTAGON CAP 50MG,
150MG
53
CYTARABINE INJ.
20MG/ ML, 100MG/ ML
28
cytarabine inj. 500mg 28
D
dacarbazine inj. 200mg 30
DACOGEN INJ. 50MG 28
DALIRESP TAB 500MCG 13
danazol cap 50mg, 100mg,
200mg
11
dantrolene cap 25mg,
50mg, 100mg
59
DAPSONE TAB 25MG,
100MG
26
DAPTACEL INJ. 66
DARAPRIM TAB 25MG 27
daunorubicin inj. 20mg 29
DELZICOL CAP 53
demeclocycline tab 150mg,
300mg
65
DENAVIR CREAM 1% 45
DEPEN TITRATAB
250MG
37
desipramine tab 10mg,
25mg, 50mg, 75mg,
100mg, 150mg
18
desloratadine tab 5mg 22
desmopressin inj. 4mcg/ ml 51
desmopressin nasal spray
0.01%
51
desmopressin tab 0.1mg,
0.2mg
51
desonide cream 0.05% 46
desonide lotion 0.05% 46
desonide oint. 0.05% 46
desoximetasone cream
0.25%, 0.05%
46
desoximetasone gel 0.05% 46
desoximetasone oint 0.25% 46
DESOXIMETASONE
OINT. 0.05%
46
DETROL LA CAP 2MG,
4MG
67
dexamethasone conc. 1mg/
ml
43
dexamethasone elixir
0.5mg/ 5ml
43
dexamethasone inj. 4mg/
ml
43
dexamethasone sodium
phosphate ophth soln 0.1%
61
dexamethasone tab 0.5mg,
0.75mg, 4mg
43
dexamethasone tab 1mg,
1.5mg, 2mg, 6mg
43
DEXILANT CAP 30MG,
60MG
67
dexmethylphenidate tab
2.5mg, 5mg, 10mg
7
dexrazoxane inj. 500mg 31
dextroamphetamine er cap
5mg, 10mg, 15mg
7
dextroamphetamine tab
5mg, 10mg
7
dextrose inj. 5%, 10% 59
dextrose/ sodium chloride
inj.
57
diazepam oral soln. 1mg/
ml, 5mg/ ml
12
diazepam rectal gel 2.5mg,
10mg, 20mg
15
diazepam tab 2mg, 5mg,
10mg
12
diclofenac ec tab 25mg,
50mg
8
diclofenac ec tab 75mg 8
diclofenac ophth soln.
0.1%
61
diclofenac potassium tab
50mg
8
diclofenac XR tab 100mg 8
diclofenac/ misoprostol tab
50/ 0.2mg, 75/ 0.2mg
8
dicloxacillin cap 250mg,
500mg
63
dicyclomine cap 10mg 66
dicyclomine soln. 10mg/
5ml
66
dicyclomine tab 20mg 66
didanosine cap 125mg,
200mg, 250mg, 400mg
34
DIFICID TAB 200MG 56
diflorasone cream 0.05% 46
diflorasone oint 0.05% 47
diflunisal tab 500mg 9
digoxin inj. 0.25mg/ ml 40
digoxin oral soln 0.05mg/
ml
40
digoxin tab 0.125mg 40
75
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
digoxin tab 0.25mg 40
dihydroergotamine inj.
1mg/ ml
57
DILANTIN CAP 30MG,
100MG
16
DILANTIN INFATAB
50MG
16
DILANTIN SUSP.
125MG/ 5ML
16
dilt-cd cap 120mg, 300mg 39
diltiazem CD cap 120mg,
240mg, 300mg
39
diltiazem ER cap 60mg,
90mg, 120mg, 180mg,
360mg, 420mg
39
DILTIAZEM INJ. 100MG 39
diltiazem inj. 5mg/ ml 39
diltiazem tab 30mg, 60mg,
90mg, 120mg
39
dilt-xr cap 180mg, 240mg 39
DIPENTUM CAP 250MG 53
diphenhydramine cap
50mg
22
diphenhydramine inj.
50mg/ ml
22
diphenoxylate/ atropine
liquid 2.5-0.025mg/ 5ml
20
diphenoxylate/ atropine tab
2.5/ 0.025mg
20
dipyridamole tab 25mg,
50mg, 75mg
54
disopyramide cap 100mg,
150mg
12
disulfiram tab 250mg,
500mg
63
divalproex dr tab 125mg,
250mg, 500mg
16
divalproex ER tab 250mg,
500mg
16
divalproex sprinkle cap
125mg
16
DOCEFREZ INJ. 20MG,
80MG
31
DOCETAXEL INJ. 20MG/
ML
31
DOCETAXEL INJ. 80MG/
8ML
31
donepezil odt tab 5mg,
10mg
64
donepezil tab 5mg, 10mg 64
dorzolamide ophth soln.
2%
62
dorzolamide/ timolol ophth
soln.
60
doxazosin tab 1mg, 2mg,
4mg, 8mg
24
doxepin cap 10mg, 25mg,
50mg, 75mg, 100mg,
150mg
18
doxepin conc. 10mg/ ml 18
doxepin hcl cream 5% 45
DOXIL INJ. 2MG/ ML 29
doxorubicin inj. 2mg/ ml 29
doxycycline hyclate cap
50mg, 100mg
65
doxycycline hyclate inj.
100mg
65
doxycycline hyclate tab
20mg, 100mg
65
doxycycline monohydrate
tab 50mg, 75mg, 150mg
65
dronabinol cap 2.5mg,
5mg, 10mg
21
DROXIA CAP 200MG,
300MG, 400MG
54
DULERA INHALER 13
DUTOPROL TAB 25
E
e.e.s tab 400mg 56
econazole nitrate cream
1%
44
EDECRIN TAB 25MG 49
EDURANT TAB 25MG 35
ELAPRASE INJ. 6MG/
3ML
51
ELIDEL CREAM 1% 48
ELIQUIS TAB 2.5MG,
5MG
14
ELITEK INJ. 1.5MG 31
ELIXOPHYLLIN SOLN. 14
ELLA TAB 30MG 43
ELSPAR INJ. 10000UNIT 30
EMCYT CAP 140MG 29
EMEND CAP 125MG 21
EMEND CAP 40MG 21
EMEND CAP 80-125MG 21
EMEND CAP 80MG 21
emoquette tab 41
EMSAM PATCH 6MG/
24HR, 9MG/ 24HR,
12MG/ 24HR
17
EMTRIVA CAP 200MG 35
EMTRIVA SOLN. 10MG/
ML
35
ENABLEX TAB 7.5MG,
15MG
68
enalapril tab 2.5mg, 5mg,
10mg, 20mg
24
enalapril/ hctz tab 5/
12.5mg, 10/ 25mg
25
ENBREL INJ. 25MG,
50MG
9
endocet tab 5-325mg,
7.5-325mg, 7.5-500mg,
10-325mg, 10-650mg
10
ENGERIX-B INJ. 10MCG,
20MCG
68
enoxaparin inj. 30mg/
0.3ml, 40mg/ 0.4ml, 60mg/
0.6ml, 80mg/ 0.8ml,
100mg/ 1ml, 120mg/ 0.8ml,
150mg/ ml
14
enpresse-28 tab 41
entacapone tab 200mg 32
EPIPEN INJ. 69
EPIPEN JR INJ. 69
epirubicin inj. 2mg/ ml 29
epitol tab 200mg 15
EPIVIR HBV SOLN.
5MG/ ML
35
EPIVIR HBV TAB
100MG
35
EPIVIR SOLN. 10MG/
ML
35
eplerenone tab 25mg,
50mg
25
76
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
EPOGEN INJ. 2000U/
ML, 3000U/ ML, 4000U/
ML, 10000U/ ML,
20000U/ ML, 40000U/ ML
54
eprosartan tab 600mg 24
EPZICOM TAB
600-300MG
35
EQUETRO CAP 100MG,
200MG, 300MG
32
ergoloid mesylate tab 1mg 65
ERGOMAR SL TAB 57
ERIVEDGE CAP 150MG 28
errin tab 43
ERYPED SUSP. 200MG/
5ML, 400MG/ 5ML
56
ERY-TAB 333MG 56
ERYTHROCIN
LACTOBIONATE INJ.
500MG
56
ERYTHROCIN
STEARATE TAB 250MG
56
erythromycin gel 2% 44
erythromycin ophth oint.
5mg/ gm
60
erythromycin soln. 2% 44
erythromycin tab 250mg,
500mg
56
erythromycin tab 400mg 56
erythromycin/ benzoyl
peroxide gel 5-3%
44
escitalopram oral soln.
1mg/ ml
17
escitalopram tab 5mg,
10mg, 20mg
17
ESTRACE VAGINAL
CREAM 0.1MG/ GM
69
estradiol tab 0.5mg, 1mg,
2mg
52
estradiol/ norethindrone
tab 1/ 0.5mg
51
ESTRING 2MG 69
estropipate tab 0.75mg,
1.5mg, 3mg
52
ethambutol tab 100mg,
400mg
27
ethosuximide cap 250mg 16
ethosuximide soln. 250mg/
5ml
16
etidronate disodium tab
200mg, 400mg
50
etodolac cap 200mg,
300mg
8
etodolac ER tab 400mg,
500mg, 600mg
8
etodolac tab 400mg,
500mg
8
etoposide inj. 20mg/ ml 31
EURAX CREAM 10% 48
EURAX LOTION 10% 48
EVISTA TAB 60MG 50
EXELON PATCH 4.6MG/
24HR, 9.5MG/ 24HR,
13.3MG/ 24HR
64
EXELON SOLN. 2MG/
ML
64
exemestane tab 25mg 29
EXJADE TAB 125MG 21
EXJADE TAB 250MG,
500MG
21
EXTAVIA INJ. 0.3MG 64
F
FABRAZYME INJ. 35MG 51
famciclovir tab 125mg,
250mg, 500mg
37
famotidine inj. 10mg/ ml 66
famotidine susp. 40mg/ 5ml 66
famotidine tab 20mg 66
famotidine tab 40mg 67
famotidine/ nacl inj. 20mg/
50ml
67
FANAPT TAB 1MG,
2MG, 4MG, 6MG, 8MG,
10MG, 12MG
33
FANAPT TITRATION
PACK
33
FARESTON TAB 60MG 29
FASLODEX INJ. 50MG/
ML
29
FAZACLO TAB 12.5MG,
100MG
33
FAZACLO TAB 150MG 33
FAZACLO TAB 200MG 33
FAZACLO TAB 25MG 33
felbamate susp. 600mg/
5ml
16
felbamate tab 400mg,
600mg
16
felodipine tab 2.5mg, 5mg,
10mg
39
fenofibrate cap 67mg,
134mg, 200mg
23
fenofibrate tab 45mg,
54mg, 145mg, 160mg
23
fenoprofen tab 600mg 8
fentanyl lollipop 200mcg,
400mcg, 600mcg, 800mcg,
1200mcg, 1600mcg
9
fentanyl patch 12mcg/ hr,
25mcg/ hr, 50mcg/ hr,
75mcg/ hr, 100mcg/ hr
9
FINACEA GEL 15% 48
finasteride tab 5mg 53
flavoxate tab 100mg 68
flecainide tab 50mg,
100mg, 150mg
12
FLOVENT DISKUS
50MCG, 100MCG,
250MCG
13
FLOVENT HFA
INHALER 44MCG,
110MCG, 220MCG
13
fluconazole susp. 10mg/ ml,
40mg/ ml
22
fluconazole tab 50mg,
100mg, 150mg, 200mg
22
fluconazole/ dextrose inj.
400mg/ 200ml
22
flucytosine cap 250mg,
500mg
22
fludarabine inj. 50mg 28
fludrocortisone tab 0.1mg 44
FLUNISOLIDE NASAL
SPRAY
59
flunisolide nasal spray
0.025%
59
fluocinolone acetonide
cream 0.01%, 0.025%
47
fluocinolone acetonide oil 47
77
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
fluocinolone acetonide
oint. 0.025%
47
fluocinolone acetonide otic
oil 0.01%
62
fluocinolone acetonide
soln. 0.01%
47
fluocinonide cream 0.05% 47
fluocinonide gel 0.05% 47
fluocinonide oint 0.05% 47
fluocinonide soln. 0.05% 47
fluorouracil cream 5% 45
fluorouracil inj. 50mg/ ml 28
fluorouracil soln. 2%, 5% 45
fluoxetine cap 10mg, 20mg,
40mg
17
fluoxetine soln. 20mg/ 5ml 17
fluoxetine tab 10mg 17
fluoxetine tab 20mg 17
FLUOXETINE TAB
60MG
17
fluoxetine/ olanzapine cap
3/ 25mg, 6/ 25mg, 12/
25mg, 6/ 50mg, 12/ 50mg
64
fluphenazine decanoate inj.
25mg/ ml
34
fluphenazine elixir 2.5mg/
5ml
34
fluphenazine inj. 2.5mg/ ml 34
fluphenazine oral conc.
5mg/ ml
34
fluphenazine tab 1mg 34
fluphenazine tab 2.5mg,
5mg, 10mg
34
flurbiprofen ophth soln.
0.03%
62
flurbiprofen tab 50mg,
100mg
8
flutamide cap 125 29
fluticasone cream 0.05% 47
fluticasone nasal spray
50mcg
59
fluticasone oint. 0.005% 47
fluticasone propionate
lotion 0.05%
47
fluvoxamine tab 25mg 17
fluvoxamine tab 50mg,
100mg
17
FML FORTE OPHTH
SUSP 0.25%
61
FML OPHTH OINT. 0.1% 61
FOLOTYN INJ. 20MG/
ML
28
fomepizole inj. 1gm/ ml 21
fondaparinux inj. 2.5mg/
0.5ml
14
fondaparinux inj. 5mg/
0.4ml, 7.5mg/ 0.6ml, 10mg/
0.8ml
14
FORADIL CAP 13
FORFIVO XL TAB
450MG
17
FORTEO SOLN.
600MCG/ 2.4ML
50
FORTICAL NASAL
SPRAY 200UNIT/ ACT
50
FOSAMAX-D TAB
70-2800MG, 70-5600MG
50
FOSCARNET INJ. 24MG/
ML
36
fosinopril tab 10mg, 20mg,
40mg
24
fosinopril/ hctz tab 10/
12.5mg, 20-12.5mg
25
fosphenytoin inj. 75mg/ ml 16
FRAGMIN INJ. 2500U/
0.2ML
14
FRAGMIN INJ. 7500U/
0.3ML, 10000U/ ML,
12500U/ 0.5ML, 15000U/
0.6ML, 18000U/ 0.72ML
14
FREESTYLE INSULIN
SYRINGE
56
furosemide soln. 8mg/ ml,
10mg/ ml
49
furosemide tab 20mg,
40mg, 80mg
49
FUSILEV INJ. 50MG 31
FUZEON INJ. 90MG 35
G
gabapentin cap 100mg 15
gabapentin cap 300mg 15
gabapentin cap 400mg 15
gabapentin soln. 50mg/ ml 15
gabapentin tab 600mg 15
gabapentin tab 800mg 15
GABITRIL TAB 2MG,
4MG, 12MG, 16MG
16
galantamine ER cap 8mg,
16mg, 24mg
64
galantamine soln. 4mg/ ml 64
galantamine tab 4mg, 8mg,
12mg
64
GAMASTAN S/ D INJ. 62
GAMMAGARD INJ.
2.5GM/ 25ML
62
GAMMAPLEX INJ.
50MG/ ML
62
GAMUNEX INJ. 10% 62
ganciclovir inj. 50mg/ ml 36
GARDASIL INJ. 68
GAUZE PAD 56
gavilyte-c powder 240gm 55
gavilyte-n powder 420gm 55
gemcitabine inj. 38mg/ ml 28
gemfibrozil tab 600mg 23
GENERESS FE 28 42
generlac soln. 10gm/ 15ml 53
gengraf cap 25mg, 100mg 37
gengraf soln. 100mg/ ml 37
gentamicin inj. 10mg/ ml,
40mg/ ml
7
gentamicin ophth soln.
0.3%
60
gentamicin sulfate cream
0.1%
44
gentamicin sulfate oint.
0.1%
44
gentamicin/ nacl inj.
0.6mg/ ml, 0.8mg/ ml,
0.9mg/ ml, 1mg/ ml, 1.2mg/
ml, 1.4mg/ ml, 1.6mg/ ml
7
GEODON INJ. 20MG 32
gildagia tab 42
GILENYA CAP 0.5MG 64
GLEEVEC TAB 100MG,
400MG
30
78
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
glimepiride tab 1mg, 2mg,
4mg
20
glimepiride/ pioglitazone
tab 2mg/ 30mg, 4mg/ 30mg
19
glipizide ER tab 2.5mg,
5mg, 10mg
20
glipizide tab 5mg, 10mg 20
glipizide/ metformin tab
2.5/ 250mg, 2.5/ 500mg, 5/
500mg
19
GLUCAGEN HYPOKIT 19
GLUCAGON KIT 19
glyburide micronized tab
1.5mg, 3mg, 6mg
20
glyburide tab 1.25mg,
2.5mg, 5mg
20
glyburide/ metformin tab
1.25/ 250mg, 2.5/ 500mg,
5/ 500mg
19
glycopyrrolate inj. 0.2mg/
ml
66
glycopyrrolate tab 1mg,
2mg
66
GLYSET TAB 25MG,
50MG, 100MG
18
GOLYTELY POWDER
PACKET
55
granisetron inj. 0.1mg/ ml,
1mg/ ml
21
granisetron tab 1mg 21
GRANISOL SOLN. 2MG/
10ML
21
griseofulvin microsize susp.
125mg/ ml
22
griseofulvin microsize tab
500mg
22
griseofulvin ultramicrosize
tab 125mg, 250mg
22
guanfacine tab 1mg 24
guanfacine tab 2mg 24
GUANIDINE TAB 27
H
HALAVEN INJ. 0.5MG/
ML
31
halobetasol cream 0.05% 47
halobetasol oint 0.05% 47
haloperidol decanoate inj.
5mg/ ml, 100mg/ ml
33
haloperidol inj. 5mg/ ml 33
haloperidol oral conc.
2mg/ ml
33
haloperidol tab 0.5mg,
1mg, 2mg, 5mg
33
haloperidol tab 10mg,
20mg
33
HAVRIX INJ. 720UNIT,
1440UNIT
68
hc butyrate cream 0.1% 47
hc butyrate oint. 0.1% 47
hc butyrate soln. 0.1% 47
HECTOROL CAP
0.5MCG, 1MCG, 2.5MCG
51
HECTOROL INJ. 4MCG/
2ML
51
heparin inj. 1000u/ ml,
2000u/ ml, 5000u/ ml,
10000u/ ml, 20000u/ ml
14
heparin/ d5w 40unit/ ml 14
heparin/ nacl inj. 2u/ ml,
50u/ ml, 100u/ ml
14
HEPSERA TAB 10MG 36
HERCEPTIN INJ. 440MG 28
HEXALEN CAP 50MG 28
HUMALOG INJ.
100UNIT/ ML
19
HUMALOG MIX INJ. 75/
25, 50/ 50
19
HUMALOG MIX
KWIKPEN 75/ 25, 50/ 50
19
HUMIRA KIT 20MG/
0.4ML, 40MG/ 0.8ML
8
HUMULIN 70/ 30 19
HUMULIN 70/ 30 PEN 19
HUMULIN N PEN 20
HUMULIN N U-100 20
HUMULIN R U-100 20
HUMULIN R U-500 20
hydralazine tab 10mg,
25mg
25
hydralazine tab 50mg,
100mg
25
hydrochlorothiazide cap
12.5mg
49
hydrochlorothiazide tab
25mg, 50mg
49
hydrocodone/
acetaminophen soln.
7.5-325mg/ ml, 7.5-500mg/
15ml
10
hydrocodone/
acetaminophen tab (all
strengths)
10
hydrocodone/ ibuprofen
tab 7.5-200mg
10
hydrocortisone cream 1%,
2.5%
47
hydrocortisone enema
100mg/ 60ml
11
hydrocortisone lotion 2.5% 47
hydrocortisone oint. 1%,
2.5%
47
hydrocortisone tab 5mg,
10mg, 20mg
43
hydrocortisone valerate
cream 0.2%
47
hydrocortisone valerate
oint 0.2%
47
hydrocortisone/ acetic acid
otic soln. 1-2%
62
hydromorphone inj. 10mg/
ml
9
hydromorphone tab 2mg,
4mg, 8mg
9
hydroxychloroquine tab
200mg
27
hydroxyurea cap 500mg 30
hydroxyzine inj. 25mg/ ml,
50mg/ ml
12
hydroxyzine pamoate cap
25mg, 50mg, 100mg
12
hydroxyzine syrup 10mg/
5ml
12
hydroxyzine tab 10mg,
25mg, 50mg
12
I
ibandronic acid tab 150mg 50
79
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
ibuprofen susp. 100mg/
5ml
8
ibuprofen tab 400mg,
600mg, 800mg
8
ICLUSIG TAB 15MG,
45MG
30
idarubicin inj. 1mg/ ml 29
IFEX INJ. 3GM 28
ifosfamide inj. 1gm 28
imipenem/ cilastatin inj. 26
imipramine pamoate 75mg,
100mg, 125mg, 150mg
18
imipramine tab 10mg,
25mg, 50mg
18
imiquimod cream 5% 48
IMOVAX RABIES INJ. 68
INCIVEK TAB 375MG 36
INCRELEX INJ. 40MG/
4ML
50
indapamide tab 1.25mg,
2.5mg
49
INDOCIN SUSP. 25MG/
5ML
8
indomethacin cap 25mg 8
indomethacin cap 50mg 8
indomethacin ER cap 75mg 8
INFANRIX INJ. 66
INFERGEN INJ. 9MCG 36
INLYTA TAB 1MG, 4MG 30
INSULIN SYRINGE 56
INTELENCE TAB
100MG, 200MG
35
intralipid inj. 20%, 30% 59
INTRON-A INJ. 10MU,
18MU
30
introvale tab 42
INTUNIV TAB 1MG 7
INVANZ INJ. 1GM 26
INVEGA SUSTENNA
INJ. 39MG/ 0.25ML,
78MG/ 0.5ML, 117MG/
0.75ML, 156MG/ ML,
234MG/ 1.5ML
33
INVEGA TAB 1.5MG,
3MG, 9MG
33
INVEGA TAB 6MG 33
INVIRASE CAP 200MG 35
INVIRASE TAB 500MG 35
IPOL INACTIVATED
IPV INJ.
68
ipratropium nasal spray
0.03%, 0.06%
59
ipratropium neb 0.02% 13
ipratropium/ albuterol
soln.
13
irbesartan tab 75mg,
150mg, 300mg
24
irbesartan/ hctz tab
12.5-150mg, 12.5-300mg
25
irinotecan inj. 20mg/ ml 31
ISENTRESS TAB 25MG,
100MG
35
ISENTRESS TAB 400MG 35
ISOLYTE/ DEXTROSE
INJ.
57
ISOLYTE-S INJ. 57
isoniazid inj. 100mg/ ml 27
isoniazid syrup 50mg/ 5ml 27
isoniazid tab 100mg 27
isoniazid tab 300mg 27
ISORDIL TITRADOSE
TAB 40MG
11
isosorbide dinitrate ER tab
40mg
11
isosorbide dinitrate sl tab
2.5mg
11
isosorbide dinitrate tab
5mg, 10mg, 20mg, 30mg
11
isosorbide mononitrate er
tab 120mg
11
isosorbide mononitrate er
tab 30mg, 60mg
11
isosorbide mononitrate tab
10mg, 20mg
11
isradipine cap 2.5mg, 5mg 39
itraconazole cap 100mg 22
IXIARO INJ. 0.012MG/
ML
68
J
JAKAFI TAB 5MG,
10MG, 15MG, 20MG,
25MG
30
JALYN CAP 0.5-0.4MG 53
jantoven tab 1mg, 2mg,
2.5mg, 3mg, 4mg, 5mg,
6mg, 7.5mg, 10mg
14
JANUMET TAB 50/
500MG, 50/ 1000MG
19
JANUMET XR TAB
500-50MG, 1000-50MG,
1000-100MG
19
JANUVIA TAB 25MG,
50MG, 100MG
19
JEVTANA INJ. 60/ 1.5ML 31
jinteli tab 51
jolivette tab 43
junel fe tab 1-20, 1.5-30 42
junel tab 1-20, 1.5-30 42
JUVISYNC TAB
10-50MG, 20-50MG,
40-50MG, 10-100MG,
20-100MG, 40-100MG
19
K
KADCYLA INJ. 20MG/
ML
28
KALETRA SOLN.
400-100MG/ 5ML
35
KALETRA TAB
100-25MG
35
KALETRA TAB
200-50MG
35
KALYDECO TAB 150MG 65
kariva tab 42
kcl/ d5w/ lactated ringers
inj.
57
kcl/ d5w/ nacl inj. (all
strengths)
57
kelnor tab 1-35 42
KENALOG AEROSOL
SPRAY
47
KEPIVANCE INJ 6.25MG 31
ketoconazole cream 2% 45
ketoconazole shampoo 2% 45
ketoconazole tab 200mg 22
ketoprofen cap 50mg,
75mg
8
ketorolac ophth soln. 0.4%,
0.5%
62
80
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
ketorolac tab 10mg 8
KINERET INJ. 8
kionex powder 38
KLOR-CON 8MEQ,
10MEQ
58
KLOR-CON M15, M20 58
KOMBIGLYZE ER TAB
5-500MG, 2.5-1000MG,
5-1000MG
19
KRISTALOSE PACKET 55
KRISTALOSE PACKET
10GM
55
KUVAN TAB 100MG 51
L
labetalol inj. 5mg/ ml 38
labetalol tab 100mg,
200mg, 300mg
38
lactated ringers irrigation 38
lactulose soln. 10gm/ 15ml 55
LAMICTAL STARTER
KIT 35, 49, 98
15
LAMICTAL XR KIT 15
lamivudine tab 150mg,
300mg
35
lamivudine/ zidovudine tab
150/ 300mg
35
lamotrigine chew tab 5mg,
25mg
15
lamotrigine er tab 25mg,
50mg, 100mg, 200mg,
250mg, 300mg
15
lamotrigine tab 25mg,
100mg, 150mg, 200mg
15
lansoprazole cap 15mg,
30mg
67
LANTUS INJ. 20
LANTUS SOLOSTAR 20
latanoprost ophth soln.
0.005%
62
LATUDA TAB 20MG,
40MG, 80MG, 120MG
32
LAZANDA SPRAY
100MCG, 400MCG
9
LAZANDA SPRAY
100MCG, 400MCG
9
leena tab 42
leflunomide tab 10mg,
20mg
9
lessina-28 tab 42
LETAIRIS TAB 5MG,
10MG
40
letrozole tab 2.5mg 29
leucovorin inj. 100mg,
350mg
31
leucovorin tab 5mg, 10mg,
15mg, 25mg
31
LEUKERAN TAB 2MG 28
LEUKINE INJ. 250MCG/
ML, 500MCG/ ML
54
leuprolide inj. 5mg/ ml 29
levalbuterol neb 0.31mg/
3ml, 0.63mg/ ml
13
levalbuterol neb 1.25mg/
0.5ml
13
LEVAQUIN/ D5W INJ.
5MG/ ML
52
LEVEMIR FLEXPEN 20
LEVEMIR INJ. 20
levetiracetam ER tab
500mg, 750mg
15
levetiracetam inj 500mg/
5ml
15
levetiracetam soln. 100mg/
ml
15
levetiracetam tab 250mg,
500mg, 750mg, 1000mg
15
levobunolol ophth soln.
0.5%
60
levocarnitine inj. 200mg/
ml
51
levocarnitine soln. 1gm/
10ml
51
levocarnitine tab 330mg 51
levocetirizine oral soln.
0.5mg/ ml
22
levocetirizine tab 5mg 22
levofloxacin inj. 25mg/ ml 52
levofloxacin ophth soln.
5mg/ ml
60
levofloxacin soln. 25mg/ ml 52
levofloxacin tab 250mg,
500mg, 750mg
52
levofloxacin/ D5W inj. 52
levonest tab 42
levonorgestrel/ ethinyl
estradiol tab
42
levora-28 tab 42
levothroid tab 25, 50, 75,
88, 100, 112, 125, 137,
150, 175, 200, 300 mcg
65
levothyroxine tab 25, 50,
75, 88, 100, 112, 125, 137,
150, 175, 200mcg
66
levothyroxine tab 300 mcg 66
levoxyl tab 25, 50, 75, 88,
100, 112, 125, 137, 150,
175, 200, 300 mcg
66
LEXIVA SUSP. 50MG/
ML
35
LEXIVA TAB 700MG 35
lidocaine gel 2% 48
lidocaine inj. 0.5%, 1% 56
lidocaine oint. 5% 48
lidocaine soln. 4% 48
lidocaine viscous 2% 58
lidocaine/ prilocaine cream
2.5-2.5%
48
LIDODERM PATCH 5% 48
LINCOCIN INJ. 300MG/
ML
26
lindane lotion 1% 48
lindane shampoo 1% 48
LINZESS CAP 145MCG,
290MCG
53
liothyronine inj. 10mcg/ ml 66
liothyronine tab 5mcg,
25mcg, 50mcg
66
LIPOSYN III INJ. 10%,
20%, 30%
59
lisinopril tab 2.5mg, 5mg,
10mg, 20mg
24
lisinopril tab 30mg, 40mg 24
lisinopril/ hctz tab 10/
12.5mg, 20/ 12.5mg, 20/
25mg
25
lithium carbonate cap
150mg, 600mg
32
81
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
lithium carbonate cap
300mg
32
lithium carbonate ER tab
300mg, 450mg
32
lithium carbonate tab
300mg
32
lithium citrate soln. 8meq/
5ml
32
loperamide cap 2mg 20
lorazepam oral soln. 2mg/
ml
12
lorazepam tab 0.5mg, 1mg,
2mg
12
losartan tab 25mg, 50mg,
100mg
24
losartan/ hctz tab 50/
12.5mg, 100/ 12.5mg, 100/
25mg
25
LOTEMAX OPHTH GEL 61
LOTEMAX OPHTH
OINT.
61
LOTRONEX TAB 0.5MG,
1MG
53
lovastatin tab 10mg, 20mg 23
lovastatin tab 40mg 23
LOVAZA CAP 1GM 23
low-ogestrel tab 42
loxapine cap 5mg, 10mg,
25mg, 50mg
33
LUMIGAN SOLN. 0.01% 62
LUMIZYME INJ. 50MG 51
LUNESTA TAB 1MG,
2MG, 3MG
55
LUPRON DEPOT INJ.
3.75MG, 11.25MG
29
LUPRON DEPOT INJ.
3.75MG, 11.25MG
29
LUPRON DEPOT INJ.
7.5MG, 22.5MG, 30MG
29
LUPRON DEPOT KIT
45MG
29
LUPRON DEPOT
PEDIATRIC INJ. 11.25,
15MG
50
lutera tab 42
LYRICA CAP 25MG,
50MG, 75MG, 100MG,
150MG, 200MG, 225MG,
300MG
15
LYRICA SOLN. 20MG/
ML
15
LYSODREN TAB 500MG 29
M
MACRODANTIN CAP
25MG
67
mafenide acetate topical
soln 5% (50 GM)
46
magnesium sulfate inj. 4%,
8%, 50%
57
MALARONE TAB
62.5-25MG, 250-100MG
26
malathion lotion 0.5% 48
maprotiline tab 25mg,
50mg, 75mg
17
marlissa 28 day tab 42
MARPLAN TAB 10MG 17
MATULANE CAP 50MG 30
matzim la tab 180mg,
240mg, 300mg, 360mg,
420mg
39
meclizine tab 12.5mg,
25mg
21
MECLOFENAMATE
SODIUM CAP 50MG,
100MG
8
medroxyprogesterone
acetate inj. 150mg/ ml
43
medroxyprogesterone tab
2.5mg, 5mg, 10mg
63
mefloquine tab 250mg 27
MEGACE ES SUSP.
625MG/ 5ML
63
megestrol acetate susp
40mg/ ml
29
megestrol acetate tab
20mg, 40mg
29
MEKINIST TAB 30
meloxicam susp. 7.5mg/
5ml
8
meloxicam tab 7.5mg,
15mg
8
melphalan inj. 50mg 28
MENACTRA INJ. 68
MENEST TAB 52
MENOMUNE A-C-Y-W
INJ.
68
MENVEO INJ. 68
MEPRON SUSP. 750MG/
5ML
26
mercaptopurine tab 50mg 28
meropenem inj. 500mg 26
mesalamine enema 4gm 53
mesna inj. 100mg/ ml 31
MESNEX TAB 400MG 31
MESTINON SYRUP
60MG/ 5ML
27
MESTINON TIMESPAN
TAB 180MG
27
metformin er tab 500mg,
750mg, 1000mg
19
metformin tab 500mg,
1000mg
19
metformin tab 850mg 19
metformin/ pioglitazone tab
500/ 15mg, 850/ 15mg
19
methadone conc. 10mg/ ml 9
methadone soln. 5mg/ 5ml,
10mg/ 5ml
9
methadone tab 5mg, 10mg 9
methazolamide tab 25mg,
50mg
49
methenamine hippurate tab
1gm
67
methimazole tab 5mg,
10mg
65
METHITEST TAB 10MG 11
methocarbamol tab 500mg,
750mg
58
methotrexate inj. 1gm 28
methotrexate inj. 25mg/ ml 28
methotrexate tab 2.5mg 28
methyldopa tab 250mg 24
methyldopa tab 500mg 24
methyldopa/ hctz tab 250/
15mg, 250/ 25mg, 250/
50mg
25
82
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
METHYLIN CHEW TAB
2.5MG, 5MG, 10MG
7
methylphenidate soln. 5mg/
5ml, 10mg/ 5ml
7
methylphenidate SR tab
20mg
7
methylphenidate tab 5mg,
10mg, 20mg
7
methylprednisolone acetate
inj. 40mg/ ml, 80mg/ ml
43
methylprednisolone dose
pak 4mg
43
methylprednisolone inj.
125mg
43
methylprednisolone inj.
40mg/ ml
43
methylprednisolone tab
4mg, 8mg, 16mg, 32mg
43
metipranolol ophth soln.
0.3%
60
metoclopramide inj. 5mg/
ml
52
metoclopramide soln. 5mg/
5ml
52
metoclopramide tab 10mg 52
metoclopramide tab 5mg 52
metolazone tab 2.5mg,
5mg, 10mg
49
metoprolol ER tab 25mg,
50mg, 100mg, 200mg
38
metoprolol inj. 1mg/ ml 38
metoprolol tab 25mg,
50mg, 100mg
38
metoprolol/ hctz tab 50/
25mg, 100/ 25mg, 100/
50mg
25
METROGEL 1% 48
metronidazole cream
0.75%
48
metronidazole gel 0.75% 48
metronidazole lotion 0.75% 48
metronidazole tab 250mg,
500mg
25
metronidazole vaginal gel
0.75%
69
metronidazole/ nacl inj.
500mg/ 100ml
25
mexiletine cap 150mg,
200mg, 250mg
12
MIACALCIN INJ.
200UNIT/ ML
50
microgestin tab 1-20,
1.5-30
42
midodrine tab 2.5mg, 5mg,
10mg
69
MIGERGOT
SUPPOSITORY
57
MIGRANAL NASAL
SPRAY 4MG/ ML
57
MINIVELLE PATCH
0.0375MG, 0.05MG,
0.075MG, 0.1MG
52
minocycline cap 50mg,
75mg, 100mg
65
minocycline tab 50mg,
75mg, 100mg
65
minoxidil tab 2.5mg, 10mg 25
mirtazapine odt tab 15mg,
30mg, 45mg
17
mirtazapine tab 7.5mg,
15mg, 30mg, 45mg
17
misoprostol tab 100mcg,
200mcg
67
mitomycin inj. 20mg 29
mitoxantrone inj. 2mg/ ml 29
M-M-R II WITH
DILUENT
68
moexipril tab 7.5mg, 15mg 24
moexipril/ hctz tab 7.5/
12.5mg, 15/ 12.5mg, 15/
25mg
25
mometasone cream 0.1% 47
mometasone oint 0.1% 47
mometasone topical soln. 47
mononessa tab 42
montelukast chew tab 4mg,
5mg
13
montelukast granules 13
montelukast tab 10mg 13
morphine inj. 0.5mg/ ml,
1mg/ ml
9
morphine sulfate er tab
15mg, 30mg, 60mg,
100mg, 200mg
9
morphine sulfate soln.
10mg/ 5ml, 20mg/ ml,
20mg/ 5ml
9
morphine sulfate tab 15mg,
30mg
9
MOZOBIL INJ. 20MG/
ML
55
MULTAQ TAB 400MG 12
mupirocin cream 44
mupirocin oint. 2% 44
MUSTARGEN INJ. 10MG 28
MYCAMINE INJ. 50MG,
100MG
21
MYCOBUTIN CAP
150MG
27
mycophenolate cap 250mg 37
mycophenolate tab 500mg 37
MYFORTIC TAB 180MG,
360MG
37
MYOZYME INJ. 50MG 51
MYRBETRIQ TAB
25MG, 50MG
67
N
nabumetone tab 500mg,
750mg
8
nadolol tab 20mg, 40mg 38
nadolol tab 80mg 38
nafcillin inj. 1gm, 10gm 63
nafcillin/ dextrose inj. 1gm/
50ml
63
NAGLAZYME INJ. 1MG/
ML
51
nalbuphine inj. 10mg/ ml,
20mg/ ml
10
naloxone inj. 0.4mg/ ml,
1mg/ ml
21
naltrexone tab 50mg 21
NAMENDA SOLN. 2MG/
ML
64
NAMENDA TAB 5MG,
10MG
64
NAMENDA TITRATION
PACK
64
83
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
naproxen dr tab 375mg,
500mg
8
naproxen sodium tab
275mg, 550mg
8
naproxen susp. 125mg/ 5ml 8
naproxen tab 250mg,
375mg, 500mg
8
naratriptan tab 1mg, 2.5mg 57
NASONEX NASAL
SPRAY 50MCG/ ACT
59
NATACYN OPHTH
SUSP. 5%
60
nateglinide tab 60mg,
120mg
20
NEBUPENT NEB 25
necon tab 0.5-35, 1-35,
7-7-7
42
necon tab 10-11 42
NEFAZODONE TAB
50MG, 100MG, 150MG,
200MG, 250MG
17
neomycin tab 500mg 7
neomycin/ bacitracin/
polymyxin ophth oint.
60
neomycin/ polymyxin B GU
irrigation soln.
53
neomycin/ polymyxin/
bacitracin/ hc ophth oint.
1%
61
neomycin/ polymyxin/
dexamethasone ophth oint.
0.1%
61
neomycin/ polymyxin/
dexamethasone ophth soln.
0.1%
61
neomycin/ polymyxin/
gramicidin ophth soln.
61
neomycin/ polymyxin/ hc
ophth susp.
61
neomycin/ polymyxin/ hc
otic soln. 1%
62
neomycin/ polymyxin/ hc
otic susp. 1%
62
NEORAL CAP 25MG,
100MG
37
NEORAL SOLN. 100MG/
ML
37
NEPHRAMINE INJ. 5.4% 60
NEULASTA INJ. 6MG/
0.6ML
55
NEUMEGA INJ. 5MG 55
NEUPOGEN INJ.
300MCG/ ML, 600MCG/
ML
55
nevirapine tab 200mg 35
NEXAVAR TAB 200MG 30
NEXIUM IV 20MG,
40MG
67
NEXTERONE INJ. 12
NIASPAN ER TAB
500MG, 750MG, 1000MG
23
nicardipine cap 20mg,
30mg
39
NICOTROL INHALER
10MG
65
nifediac cc tab 90mg 39
nifedical XL tab 30mg,
60mg
39
nifedipine cap 10mg, 20mg 39
nifedipine ER tab 30mg,
60mg, 90mg
39
NILANDRON TAB
150MG
29
nimodipine cap 30mg 39
nisoldipine er tab 8.5mg,
17mg, 20mg, 25.5mg,
30mg, 34mg, 40mg
39
nitrofurantoin macro cap
50mg
67
nitrofurantoin mono cap
100mg
67
nitrofurantoin susp. 25mg/
5ml
67
nitroglycerin inj. 5mg/ ml 11
nitroglycerin patch 0.1mg/
hr, 0.2mg/ hr, 0.4mg/ hr,
0.6mg/ hr
11
NITROLINGUAL
PUMPSPRAY
11
NITROSTAT SL TAB
0.3MG, 0.4MG, 0.6MG
11
nizatidine cap 150mg,
300mg
67
nizatidine soln. 15mg/ ml 67
nora-be tab 43
NORDITROPIN INJ.
5MG/ 1.5ML, 10MG/
1.5ML, 15MG/ 1.5ML
50
NORDITROPIN
NORDIFLEX PEN 10MG/
ML
50
norethindrone tab 5mg 63
NORMOSOL/
DEXTROSE INJ.
57
NORMOSOL-R INJ. 57
NORPACE CR CAP
100MG
12
nortrel tab 0.5-35, 1-35,
7-7-7
42
nortriptyline cap 10mg,
25mg
18
nortriptyline cap 50mg,
75mg
18
NORVIR CAP 100MG 35
NORVIR SOLN. 80MG/
ML
35
NORVIR TAB 100MG 35
NOVAREL INJ.
10000UNIT/ ML
50
NOVOLIN 70/ 30 20
NOVOLIN N U-100 20
NOVOLIN R U-100 20
NOVOLOG FLEXPEN 20
NOVOLOG INJ. 20
NOVOLOG MIX 70/ 30 20
NOVOLOG MIX 70/ 30
PEN
20
NOXAFIL SUSP 40MG/
ML
22
NUEDEXTA CAP
20-10MG
65
NUVARING 43
NUVIGIL TAB 50MG,
250MG
7
nystatin cream 100000unit/
gm
45
84
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
nystatin oint. 100000unit/
gm
45
nystatin susp. 100000unit/
ml
58
nystatin tab 500000unit 22
nystatin topical powder 45
nystatin/ triamcinolone
cream
45
nystatin/ triamcinolone
oint.
45
nystop topical powder 45
O
octreotide inj. 500mcg/ ml,
1000mcg/ ml
51
octreotide inj. 50mcg/ ml,
100mcg/ ml, 200mcg/ ml
51
ofloxacin ophth soln. 0.3% 61
ofloxacin otic soln. 0.3% 62
ofloxacin tab 200mg,
300mg, 400mg
52
olanzapine inj. 5mg/ ml 33
olanzapine ODT tab 5mg,
10mg, 15mg, 20mg
33
olanzapine tab 2.5mg, 5mg,
7.5mg, 10mg, 15mg, 20mg
33
OLEPTRO ER TAB
150MG, 300MG
17
omeprazole cap 10mg,
20mg, 40mg
67
ondansetron inj. 4mg/ 2ml 21
ondansetron odt tab 4mg,
8mg
21
ondansetron soln. 4mg/
5ml
21
ondansetron tab 24mg 21
ondansetron tab 4mg, 8mg 21
ONFI TAB 5MG, 10MG,
20MG
15
ONGLYZA TAB 2.5MG,
5MG
19
ONTAK INJ. 150MCG/
ML
30
ORAP TAB 1MG, 2MG 65
ORFADIN CAP 2MG,
5MG, 10MG
51
orphenadrine/ aspirin/
caffeine 25/ 385/ 30mg
59
orsythia tab 42
ORTHO EVRA PATCH 42
OXACILLIN INJ. 1GM,
10GM
63
OXACILLIN/
DEXTROSE INJ. 1GM/
50ML, 2GM/ 50ML
63
oxaliplatin inj. 100mg 28
oxandrolone tab 2.5mg,
10mg
10
oxaprozin tab 600mg 8
oxcarbazepine oral susp. 15
oxcarbazepine tab 150mg,
300mg, 600mg
15
OXISTAT CREAM 1% 45
OXISTAT LOTION 1% 45
OXSORALEN ULTRA
CAP 10MG
45
oxybutynin ER tab 5mg,
10mg, 15mg
68
oxybutynin syrup 5mg/ 5ml 68
oxybutynin tab 5mg 68
oxycodone cap 5mg 9
oxycodone soln. 20mg/ ml 9
oxycodone tab 5mg, 10mg,
15mg, 20mg, 30mg
9
oxycodone/ acetaminophen
cap 5-500mg
10
oxycodone/ acetaminophen
tab 2.5-325mg, 5-325mg,
7.5-325mg, 7.5-500mg,
10-325mg, 10-650mg
10
oxycodone/ aspirin tab 10
OXYCONTIN TAB
10MG, 15MG, 20MG,
30MG, 40MG, 60MG,
80MG
9
P
PACERONE TAB 100MG 12
paclitaxel inj. 6mg/ ml 31
PANCREAZE CAP
4200UNIT, 10500UNIT,
16800UNIT, 21000UNIT
48
PANRETIN GEL 0.1% 45
pantoprazole inj. 67
pantoprazole tab 20mg,
40mg
67
paromomycin cap 250mg 7
paroxetine er tab 12.5mg,
25mg, 37.5mg
18
paroxetine tab 10mg, 20mg 18
paroxetine tab 30mg, 40mg 18
PASER GRANULE 4GM 27
PATADAY OPHTH
SOLN. 0.2%
62
PATANASE NASAL
SPRAY 0.6%
59
PAXIL SUSP. 10MG/
5ML
18
pedi-dri topical powder 45
PEDVAX HIB INJ. 68
PEGANONE TAB 250MG 16
PEGASYS INJ. 135MCG/
0.5ML, 180MCG/ ML,
PEGASYS KIT
36
PEG-INTRON KIT
50MCG, 50MCG RP,
80MCG RP, 120 RP, 150
RP
36
PEN NEEDLE 56
penicillin g potassium inj.
5mu
63
PENICILLIN G
PROCAINE INJ.
600000UNIT/ ML
63
penicillin g sodium inj.
5mu
63
penicillin g/ dextrose
40000unit/ ml, 60000unit/
ml
63
penicillin v potassium soln.
125mg/ 5ml, 250mg/ 5ml
63
penicillin v potassium tab
250mg, 500mg
63
PENTAM 300 25
PENTASA CAP 250MG,
500MG
53
pentostatin inj. 10mg 30
pentoxifylline ER tab
400mg
54
85
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
perindopril tab 2mg, 4mg,
8mg
24
PERJETA INJ. 28
permethrin cream 5% 48
perphenazine tab 2mg,
4mg, 8mg, 16mg
34
perphenazine/ amitriptyline
tab 2/ 10mg, 2/ 25mg, 4/
10mg, 4/ 25mg, 4/ 50mg
64
phenadoz supp. 12.5mg 22
phenelzine tab 15mg 17
phenobarbital oral soln.
4mg/ ml
55
phenobarbital tab 15mg,
16.2mg, 30mg, 32.4mg,
60mg, 64.8mg, 97.2mg,
100mg
55
phenytoin cap 100mg,
200mg, 300mg
16
phenytoin chew tab 50mg 16
phenytoin inj. 50mg/ ml 16
phenytoin susp. 125mg/
5ml
16
PHOSLYRA SOLN.
667MG/ 5ML
53
PHOSPHOLINE IODIDE
OPHTH SOLN. 0.125%
60
physiolyte irrigation soln. 38
physiosol irrigation soln. 38
pilocarpine tab 5mg, 7.5mg 58
PILOPINE HS OPHTH
GEL 4%
60
pindolol tab 5mg, 10mg 38
pioglitazone tab 15mg,
30mg, 45mg
20
piperacillin/ tazobactam
inj. 3-0.375gm, 4-0.5gm
63
piroxicam cap 10mg, 20mg 9
PLASMA-LYTE INJ. 57
PLASMA-LYTE/ D5W
INJ.
57
podofilox soln. 0.5% 48
polyethylene glycol powder
3350
56
polymyxin B inj.
500000unit
26
polymyxin B/ trimethoprim
ophth soln.
61
POMALYST CAP 1MG,
2MG, 3MG, 4MG
30
portia-28 tab 42
potassium chloride ER cap
8meq, 10meq
58
potassium chloride er tab
10meq, 20meq
58
potassium chloride inj. 58
potassium chloride inj.
2meq/ ml, 10meq/ 50ml,
10meq/ 100ml
58
potassium chloride/
dextrose inj.
57
potassium chloride/ nacl
inj.
57
potassium citrate ER tab
5meq, 10meq
53
POTIGA TAB 50MG,
200MG, 300MG, 400MG
15
PRADAXA CAP 75MG,
150MG
14
pramipexole tab 0.125mg,
0.25mg, 0.5mg, 0.75mg,
1mg, 1.5mg
32
PRANDIMET TAB 1/
500MG, 2/ 500MG
19
PRANDIN TAB 0.5MG,
1MG, 2MG
20
pravastatin tab 10mg,
20mg, 40mg
23
pravastatin tab 80mg 23
prazosin cap 1mg 24
prazosin cap 2mg, 5mg 24
PRECISION INSULIN
SYRINGE
56
PRED MILD OPHTH
SUSP. 0.12%
61
prednicarbate cream 0.1% 47
prednicarbate oint. 0.1% 47
prednisolone ophth susp.
1%
61
prednisolone sodium
phosphate ophth soln. 1%
61
prednisolone sodium
phosphate soln. 5mg/ 5ml,
15mg/ 5ml, 25mg/ 5ml
43
PREDNISONE
INTENSOL 5MG/ ML
43
prednisone soln. 5mg/ 5ml 43
prednisone tab 1mg, 50mg 43
prednisone tab 2.5mg,
5mg, 10mg, 20mg
43
PREMARIN INJ. 25MG 52
PREMARIN TAB 0.3MG,
0.45MG, 0.9MG, 1.25MG
52
PREMARIN VAGINAL
CREAM
69
premasol soln. 6% 60
PREMPHASE TAB 0.625/
5MG
51
PREMPRO TAB
0.625-2.5MG, 0.625-5MG,
0.3-1.5MG, 0.45-1.5MG
51
PRENATAL VITAMIN 58
PREPOPIK PACK 55
previfem tab 42
PREVPAC 67
PREZISTA SUSP.
100MG/ ML
35
PREZISTA TAB 75MG,
150MG, 400MG, 600MG,
800MG
35
PRIFTIN TAB 150MG 27
PRIMAQUINE TAB
26.3MG
27
primidone tab 50mg,
250mg
15
PRISTIQ TAB 50MG,
100MG
18
PRIVIGEN INJ.
20GRAMS
62
probenecid tab 500mg 54
procainamide inj. 100mg/
ml, 500mg/ ml
12
PROCALAMINE INJ. 3% 60
prochlorperazine edisylate
inj. 5mg/ ml
34
prochlorperazine
suppository 25mg
34
86
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
prochlorperazine tab 5mg,
10mg
34
PROCRIT INJ. 2000/ ML,
3000/ ML, 4000/ ML,
10000/ ML
55
PROCRIT INJ. 20000/
ML, 40000/ ML
55
procto-pak rectal cream
1%
11
proctozone hc rectal cream 11
PROGLYCEM SUSP.
50MG/ ML
19
PROGRAF CAP 0.5MG,
1MG, 5MG
37
PROLASTIN INJ. 500MG,
1000MG
65
PROLEUKINE IV SOLN. 30
PROLIA SOLN 60MG/
ML
50
PROMACTA TAB
12.5MG, 25MG, 50MG,
75MG
55
promethazine inj. 25mg/
ml, 50mg/ ml
22
promethazine supp.
12.5mg, 25mg
22
promethazine syrup
6.25mg/ 5ml
22
promethazine tab 12.5mg,
50mg
22
promethazine tab 25mg 22
promethazine VC syrup
6.25-5mg/ 5ml
23
promethegan supp. 25mg,
50mg
23
propafenone tab 150mg,
225mg, 300mg
12
propranolol er cap 60mg,
80mg, 120mg, 160mg
38
propranolol inj. 1mg/ ml 38
propranolol oral soln.
20mg/ 5ml, 40mg/ 5ml
38
propranolol tab 10mg,
20mg, 40mg, 80mg
38
propranolol tab 60mg 38
propranolol/ hctz tab 40/
25mg, 80/ 25mg
25
propylthiouracil tab 50mg 65
PROQUAD INJ. 68
PROSOL INJ. 20% 60
PROTOPIC OINT 0.03%,
0.1%
48
protriptyline tab 5mg,
10mg
18
PULMICORT
FLEXHALER
13
PULMOZYME SOLN.
1MG/ ML
65
PYLERA CAP 67
pyrazinamide tab 27
pyridostigmine tab 60mg 27
Q
quasense tab 42
quetiapine tab 25mg,
50mg, 100mg, 200mg,
300mg, 400mg
33
quinapril tab 5mg, 10mg,
20mg, 40mg
24
quinapril/ hctz tab
10-12.5mg, 20-12.5mg,
20-25mg
25
quinidine gluconate er tab 12
quinidine gluconate inj.
80mg/ ml
12
quinidine sulfate er tab
300mg
12
quinidine sulfate tab
200mg, 300mg
12
QVAR INHALER
40MCG/ ACT, 80MCG/
ACT
13
R
RABAVERT INJ. 68
ramipril cap 1.25mg,
2.5mg, 5mg, 10mg
24
RANEXA TAB 500MG,
1000MG
11
ranitidine cap 150mg,
300mg
67
ranitidine inj. 25mg/ ml 67
ranitidine syrup 15mg/ ml 67
ranitidine tab 150mg,
300mg
67
RAPAFLO CAP 4MG,
8MG
54
RAPAMUNE SOLN.
1MG/ ML
37
RAPAMUNE TAB
0.5MG, 1MG, 2MG
38
REBETOL SOLN. 40MG/
ML
36
REBIF INJ. 22/ 0.5, 44/
0.5, TITRATION PAK
64
RECOMBIVAX-HB INJ.
10MCG/ ML, 40MCG/
ML
68
RELISTOR INJ. 12MG/
0.6ML
53
REMICADE INJ. 100MG 53
REMODULIN INJ. 1MG/
ML, 2.5MG/ ML, 5MG/
ML, 10MG/ ML
40
RENAGEL TAB 400MG,
800MG
53
RENVELA PACKET
0.8GM, 2.4GM
53
RENVELA TAB 800MG 53
RESCRIPTOR TAB
100MG, 200MG
35
reserpine tab 0.1mg,
0.25mg
24
RESTASIS EMULSION
0.05%
61
RETIN-A MICRO GEL
0.04%, 0.1%
44
RETROVIR INJ. 10MG/
ML
35
REVATIO INJ. 0.8MG/
ML
40
REVLIMID CAP 5MG,
10MG, 15MG, 25MG
37
REYATAZ CAP 100MG 35
REYATAZ CAP 150MG,
200MG, 300MG
35
RHEUMATREX TAB
2.5MG
7
87
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
ribasphere cap 200mg 36
ribasphere tab 200mg 36
ribavirin cap 200mg 36
ribavirin tab 200mg 36
RIDAURA CAP 3MG 8
RIFAMATE CAP 27
rifampin cap 150mg,
300mg
27
rifampin inj. 600mg 27
RIFATER TAB 27
RILUTEK TAB 50MG 59
riluzole tab 59
rimantadine tab 100mg 37
ringers inj. 57
ringers irrigation soln. 38
RISPERDAL INJ.
12.5MG, 25MG, 37.5MG,
50MG
33
risperidone odt 0.25mg,
0.5mg, 1mg, 2mg, 3mg
33
risperidone odt 4mg 33
risperidone soln. 1mg/ ml 33
risperidone tab 0.25mg,
0.5mg, 1mg, 2mg, 3mg
33
risperidone tab 4mg 33
RITUXAN INJ. 10MG/
ML
28
rivastigmine tab 1.5mg,
3mg, 4.5mg, 6mg
64
rizatriptan ODT tab 5mg,
10mg
57
rizatriptan tab 5mg, 10mg 57
ropinirole ER tab 2mg,
4mg, 6mg, 8mg, 12mg
32
ropinirole tab 0.25mg,
0.5mg, 1mg, 2mg, 3mg,
4mg, 5mg
32
ROTATEQ ORAL SUSP. 68
ROXICET SOLN.
5-325MG/ 5ML
10
S
SABRIL POWDER
500MG
16
SABRIL TAB 500MG 16
SANDIMMUNE CAP
25MG, 100MG
38
SANDIMMUNE INJ.
50MG/ ML
38
SANDIMMUNE ORAL
SOLN. 100MG/ ML
38
SANDOSTATIN KIT
LAR 10MG, 20MG, 30MG
51
SANTYL OINT.
250UNIT/ GM
48
SAPHRIS SL TAB 5MG,
10MG
33
SAVELLA TAB 12.5MG,
25MG, 50MG, 100MG
64
SAVELLA TITRATION
PACK
64
selegiline cap 5mg 32
selegiline tab 5mg 32
selenium sulfide lotion
2.5%
45
SELZENTRY TAB
150MG, 300MG
35
SENSIPAR TAB 30MG,
60MG, 90MG
51
SEREVENT INHALER
50MCG
13
SEROMYCIN CAP
250MG
27
SEROQUEL XR TAB
300MG, 400MG
33
SEROQUEL XR TAB
50MG, 150MG, 200MG
34
sertraline conc. 20mg/ ml 18
sertraline tab 25mg, 50mg,
100mg
18
sildenafil tab 20mg 40
silver sulfadiazine cream
1%
46
SIMCOR TAB 500-40MG,
1000-20MG, 1000-40MG
23
SIMPONI INJ. 50MG 8
simvastatin tab 5mg, 10mg,
20mg, 40mg, 80mg
23
sodium chloride inj. 0.45%,
0.9%, 3%, 5%
58
sodium chloride inj.
2.5meq/ ml
58
sodium chloride irrigation
soln. 0.9%
53
sodium fluoride tab 1mg 57
sodium lactate inj. 5meq/
ml
57
sodium lactate IV soln. 57
sodium polystyrene
sulfonate powder
38
sodium sulfacetamide
ophth soln. 10%
61
SOLARAZE GEL 3% 45
SOLTAMOX SUSP.
10MG/ 5ML
29
SOLU-CORTEF INJ
250MG
43
SOMATULINE INJ. 60/
0.2ML, 90/ 0.3ML, 120/
.5ML
51
SOMAVERT INJ. 10MG,
15MG, 20MG
50
SORIATANE CAP 10MG,
17.5MG, 25MG
45
sorine tab 80mg, 120mg,
160mg, 240mg
39
sotalol tab 120mg, 160mg,
240mg
39
sotalol tab 80mg 39
SPIRIVA CAP
HANDIHALER
13
spironolactone tab 25mg 49
spironolactone tab 50mg,
100mg
49
spironolactone/ hctz tab
25/ 25mg
49
SPORANOX SOLN.
10MG/ ML
22
sprintec-28 tab 42
SPRYCEL TAB 20MG,
50MG, 70MG, 80MG,
100MG, 140MG
30
sronyx tab 42
STALEVO TAB 50MG,
75MG, 100MG, 125MG,
150MG, 200MG
32
stavudine cap 15mg, 20mg,
30mg, 40mg
35
88
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
stavudine oral solution 35
STIVARGA TAB 40MG 30
STRATTERA CAP 10MG,
60MG, 80MG, 100MG
7
STRATTERA CAP 18MG,
25MG, 40MG
7
STREPTOMYCIN INJ.
1GM
7
STRIBILD TAB 35
STROMECTOL TAB
3MG
11
SUBOXONE SL FILM
2-0.5MG, 4-1MG, 8-2MG,
12-3MG
10
SUCRAID SUSP. 48
sucralfate tab 1gm 67
sulfacetamide sodium
ophth oint. 10%
61
sulfacetamide sodium
topical lotion
44
sulfacetamide sodium/
prednisolone ophth soln.
61
SULFADIAZINE TAB
500MG
65
sulfamethoxazole/
trimethoprim inj 400-80mg
26
sulfamethoxazole/
trimethoprim susp.
200-40mg/ 5ml
26
sulfamethoxazole/
trimethoprim tab
400-80mg, 800-160mg
26
SULFAMYLON CREAM
85MG/ GM
46
sulfasalazine tab 500mg 53
sulfazine EC tab 500mg 53
sulindac tab 150mg, 200mg 9
sumatriptan inj. 6mg/
0.5ml
57
sumatriptan tab 25mg,
50mg, 100mg
57
SUPRAX CAP 41
SUPRAX CHEW TAB
100MG, 200MG
41
SUPRAX SUSP. 100MG/
5ML, 200MG/ 5ML,
500MG/ 5ML
41
SUPRAX TAB 400MG 41
SUPREP BOWEL SOLN. 55
SUSTIVA CAP 50MG,
200MG
35
SUSTIVA TAB 600MG 35
SUTENT CAP 12.5MG,
25MG, 50MG
30
SYLATRON INJ.
296MCG, 444MCG,
888MCG
30
SYMBICORT INHALER
80, 160
14
SYMLINPEN 60, 120 18
SYNAREL SOLN. 2MG/
ML
50
SYNRIBO INJ. 30
SYNTHROID TAB 25, 50,
75, 88, 100, 112, 125, 137,
150, 175, 200, 300 MCG
66
SYPRINE CAP 250MG 37
T
TABLOID TAB 40MG 28
tacrolimus cap 0.5mg,
1mg, 5mg
38
TAFINLAR CAP 50MG,
75MG
30
TAMIFLU CAP 30MG 37
TAMIFLU CAP 45MG,
75MG
37
TAMIFLU SUSP. 6MG/
ML
37
tamoxifen citrate tab 10mg,
20mg
29
tamsulosin cap 0.4mg 54
TARCEVA TAB 25MG,
100MG, 150MG
30
TARGRETIN CAP 75MG 30
TARGRETIN GEL 1% 45
TASIGNA CAP 150MG,
200MG
30
TASMAR TAB 100MG 32
TAXOTERE INJ. 20MG/
0.5ML, 20MG/ ML
31
TAZORAC CREAM
0.05%, 0.1%
45
TAZORAC GEL 0.05%,
0.1%
45
taztia-xt cap 120mg,
180mg, 240mg, 300mg,
360mg
39
TEFLARO INJ. 400MG,
600MG
41
TEGRETOL-XR TAB
100MG
16
terazosin cap 1mg, 2mg,
5mg, 10mg
24
terbinafine tab 250mg 22
terbutaline inj. 1mg/ ml 14
terbutaline tab 2.5mg, 5mg 14
terconazole vaginal cream
0.4%, 0.8%
69
terconazole vaginal
suppository 80mg
69
testosterone cypionate inj.
100mg/ ml
11
testosterone cypionate inj.
200mg/ ml
11
testosterone enanthate inj.
200mg/ ml
11
TETANUS TOXOID INJ. 66
TETANUS/
DIPHTHERIA TOXOID
INJ. 2-2
66
THALOMID CAP 50MG,
100MG, 150MG, 200MG
37
theophylline ER tab
100mg, 200mg, 300mg,
400mg, 450mg, 600mg
14
thermazene cream 1% 46
thioridazine tab 10mg,
100mg
34
thioridazine tab 25mg,
50mg
34
THIOTEPA INJ. 15MG 28
thiothixene cap 1mg, 2mg,
5mg, 10mg
34
ticlopidine tab 250mg 54
tigabine tab 16
89
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
TIKOSYN CAP 125MCG,
250MCG, 500MCG
12
timolol maleate ophth gel
0.25%, 0.5%
60
timolol maleate ophth soln.
0.25%, 0.5%
60
timolol maleate tab 5mg,
10mg, 20mg
39
tinidazole tab 250mg,
500mg
25
tizanidine cap 2mg, 4mg,
6mg
58
tizanidine tab 2mg, 4mg 58
TOBI NEB 300MG/ 5ML 7
TOBI PODHALER 28MG 7
TOBRADEX OPHTH
OINT. 0.3-0.1%
61
tobramycin inj. 10mg/ ml,
40mg/ ml
7
tobramycin ophth soln.
0.3%
61
tobramycin/
dexamethasone ophth soln.
0.3-0.1%
61
tobramycin/ nacl 0.8mg/
ml, 1.2mg/ ml
7
TOBREX OPHTH OINT.
0.3%
61
tolazamide tab 250mg,
500mg
20
tolbutamide tab 500mg 20
tolmetin cap 400mg 9
tolmetin tab 200mg, 600mg 9
tolterodine tab 1mg, 2mg 68
topiramate sprinkle cap
15mg, 25mg
16
topiramate tab 25mg,
50mg, 100mg, 200mg
16
toposar inj. 20mg/ ml 31
topotecan inj. 1mg/ ml 31
TORSEMIDE INJ. 10MG/
ML
49
torsemide tab 5mg, 10mg,
20mg, 100mg
49
TOVIAZ TAB 4MG, 8MG 68
tpn electrolytes inj. 57
TRACLEER TAB
62.5MG, 125MG
40
tramadol hcl tab 50mg 9
tramadol/ apap tab
37.5-325
10
trandolapril tab 1mg, 2mg,
4mg
24
tranexamic acid inj.
100mg/ ml
55
tranexamic acid tab 55
TRANSDERM-SCOP
PATCH 1.5MG
21
tranylcypromine tab 10mg 17
TRAVASOL INJ. 10% 60
trazodone tab 300mg 17
trazodone tab 50mg,
100mg, 150mg
17
TRECATOR TAB 250MG 27
TRELSTAR DEPOT
MIXJECT INJ.
29
TRELSTAR LA MIXJECT
INJ.
29
TRELSTAR MIXJECT
INJ.
29
tretinoin cap 10mg 30
tretinoin cream 0.025%,
0.05%, 0.1%
44
tretinoin gel 0.01%,
0.025%
44
triamcinolone cream
0.025%, 0.1%, 0.5%
47
triamcinolone in orabase
paste 0.1%
58
triamcinolone lotion
0.025%, 0.1%
47
triamcinolone nasal spray
55mcg/ act
59
triamcinolone oint 0.025%,
0.5%
47
triamcinolone oint 0.1% 47
triamterene/ hctz cap 37.5/
25mg
49
triamterene/ hctz tab 37.5/
25mg
49
triamterene/ hctz tab 75/
50mg
49
triderm cream 0.1% 47
trifluoperazine tab 1mg,
2mg, 5mg, 10mg
34
trifluridine ophth soln. 1% 61
trihexypenidyl elixir 0.4mg/
ml
31
trihexyphenidyl tab 2mg 31
trihexyphenidyl tab 5mg 31
TRILIPIX CAP 45MG,
135MG
23
trilyte powder 420gm 55
trimethoprim tab 100mg 25
trimipramine cap 25mg,
50mg, 100mg
18
trinessa tab 42
tri-previfem tab 42
TRISENOX INJ. 10MG/
10ML
31
tri-sprintec tab 42
trivora-28 tab 42
TRIZIVIR TAB 36
TRUVADA TAB 36
TWINRIX INJ. 68
TYGACIL INJ. 50MG 26
TYKERB TAB 250MG 30
TYPHIM VI INJ. 68
TYSABRI INJ. 64
TYZEKA TAB 600MG 36
TYZINE NASAL SOLN.
0.1%
59
U
ULORIC TAB 40MG,
80MG
54
unithroid tab 25, 50, 75,
88, 100, 112, 125, 137,
150, 175, 200, 300 mcg
66
ursodiol cap 300mg 52
ursodiol tab 250mg, 500mg 52
V
valacyclovir tab 500mg,
1000mg
37
VALCYTE SOLN. 50MG/
ML
36
VALCYTE TAB 450MG 36
90
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
valproate sodium inj.
100mg/ ml
16
valproic acid cap 250mg 16
valproic acid syrup 250mg/
5ml
16
valsartan/
hydrochlorothiazide tab
25
vancomycin cap 125mg,
250mg
25
vancomycin inj. 1000mg 25
vancomycin inj. 500mg 25
vandazole vaginal gel
0.75%
69
VAQTA INJ. 68
VARIVAX INJ. 68
VASCEPA CAP 1GM 23
VECTICAL OINT.
3MCG/ GM
45
VELCADE INJ. 3.5MG 30
velivet tab 42
venlafaxine ER cap
37.5mg, 75mg, 150mg
18
venlafaxine tab 25mg,
37.5mg, 50mg, 75mg,
100mg
18
VENTAVIS INH. 10MCG/
ML, 20MCG/ ML
40
VENTOLIN HFA
INHALER
14
verapamil ER cap 100mg,
200mg, 300mg
39
verapamil ER cap 120mg,
180mg, 240mg, 360mg
39
verapamil ER tab 120mg,
180mg, 240mg
39
verapamil inj. 2.5mg/ ml 39
verapamil tab 40mg 40
verapamil tab 80mg,
120mg
40
VESICARE TAB 5MG,
10MG
68
VFEND SUSP. 40MG/ ML 22
VIBRAMYCIN SYRUP
50MG/ 5ML
65
VICTOZA INJ. 18MG/
3ML
19
VICTRELIS CAP 200MG 36
VIDAZA INJ. 100MG 28
VIDEX SOLN. 2GM 36
VIGAMOX OPHTH
SOLN. 0.5%
61
VIIBRYD PACK 17
VIIBRYD TAB 10MG,
20MG, 40MG
17
VIMPAT INJ. 200MG/
20ML
16
VIMPAT SOLN. 10MG/
ML
16
VIMPAT TAB 50MG,
100MG, 150MG, 200MG
16
VINBLASTINE
SULFATE INJ. 10MG
31
vincasar pfs inj. 1mg/ ml 31
vincristine inj. 1mg/ ml 31
vinorelbine inj. 10mg/ ml 31
VIRACEPT TAB 250MG,
625MG
36
VIRAMUNE SUSP.
50MG/ 5ML
36
VIRAMUNE XR TAB
100MG, 400MG
36
VIREAD POWDER
40MG/ GM
36
VIREAD TAB 150MG,
200MG, 250MG, 300MG
36
VIVELLE-DOT PATCH
0.025MG, 0.0375MG,
0.05MG, 0.075MG, 0.1MG
52
VOLTAREN GEL 1% 45
voriconazole inj. 10mg/ ml 22
voriconazole tab 50mg,
200mg
22
VOTRIENT TAB 200MG 30
W
warfarin tab 1mg, 2mg,
2.5mg, 3mg, 4mg, 5mg,
6mg, 7.5mg, 10mg
14
WELCHOL TAB 625MG 23
X
XALKORI CAP 200MG,
250MG
30
XARELTO TAB 10MG,
15MG, 20MG
14
XENAZINE TAB
12.5MG, 25MG
64
XGEVA INJ. 50
XOLAIR INJ. 150MG 13
XTANDI CAP 29
XYREM SOLN. 500MG/
ML
64
Y
YASMIN TAB 42
YAZ TAB 42
YF-VAX INJ. 68
Z
zafirlukast tab 10mg, 20mg 13
zaleplon cap 5mg, 10mg 55
ZALTRAP INJ. 28
ZAVESCA CAP 100MG 54
zazole vaginal cream 0.4% 69
ZELBORAF TAB 240MG 30
ZEMPLAR CAP 1MCG,
2MCG, 4MCG
51
ZEMPLAR INJ. 2MCG/
ML, 5MCG/ ML
51
zenchent fe 42
ZETIA TAB 10MG 23
ZIAGEN SOLN. 20MG/
ML
36
zidovudine cap 100mg 36
zidovudine syrup 10mg/ ml 36
zidovudine tab 300mg 36
ziprasidone cap 20mg,
40mg, 60mg, 80mg
33
ZIRGAN OPHTH GEL
0.15%
61
zoledronic acid inj. 4mg/
5ml, 5mg/ 100ml
50
ZOLINZA CAP 100MG 30
zolpidem tab 5mg, 10mg 55
ZOMETA INJ. 4MG/ 5ML 50
ZONALON CREAM 5% 45
zonisamide cap 25mg,
50mg, 100mg
16
ZORTRESS TAB 0.25MG 38
ZOSTAVAX INJ. 68
91
DRUG NAME DRUG TIER
ALPHABETICAL LISTING OF DRUGS
REQUIREMENTS/LIMITS
ZOSYN INJ. 2-0.25GM/
50ML, 3-0.375GM/ 50ML
63
zovia tab 1-35e, 1-50e 42
ZOVIRAX CREAM 45
ZOVIRAX OINT. 45
ZYMAXID OPHTH
SOLN. 0.5%
61
ZYTIGA TAB 250MG 29
ZYVOX INJ. 2MG/ ML 26
ZYVOX SUSP. 100MG/
5ML
26
ZYVOX TAB 600MG 26
92
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