SSI_2023_GROUP_FORMULARY_COMP_PLUS

●

P.O. Box 30006, Pittsburgh, PA 15222-0330

Aetna Medicare Rx offered by SilverScript

2023 Formulary

(List of Covered Drugs)

5T Comprehensive+ Formulary

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 03/20/2023. For more recent information or other questions, please

contact Aetna Medicare Rx offered by SilverScript at the number on your ID card

.

Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no

cost to you, even if your plan has a deductible that you haven’t paid. Call Customer Care for more

information.

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a

one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on,

even if your plan has a deductible that you haven’t paid.

Formulary ID Number: 23021

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 SilverScript

®

Insurance

Company. When it refers to “plan” or “our plan,” it means Aetna Medicare Rx offered by SilverScript.

This document includes a list of the drugs (formulary) for our plan, which is current as of March 20,

2023. For an updated formulary, please contact us. Our contact information, along with the date we last

updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,

pharmacy network, and/or copayments/coinsurance may change on January 1, 2024, and from time to time

during the year.

Y0001_GRP_4676_2023_C

03/20/2023

What is the Aetna Medicare Rx offered by SilverScript Formulary?

A formulary is a list of covered drugs selected by Aetna Medicare Rx offered by SilverScript 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. Aetna Medicare Rx offered by SilverScript will

generally cover the drugs listed in our formulary as long as the drug is medically necessary, the

prescription is filled at an Aetna Medicare Rx offered by SilverScript network pharmacy, and other plan

rules are followed. For more information on how to fill your prescriptions, please review your Evidence

of Coverage.

Please note: Aetna Medicare Rx offered by SilverScript may provide additional coverage for

prescription drugs not included in your Medicare Part D benefit. For more information about your share

of the cost or which prescription drugs may or may not be covered, please call Customer Care, or refer

to your Evidence of Coverage.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List

during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow

Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes

during the year:

● New generic drugs.

When adding a new generic drug, we may move the brand drug to a

different cost-sharing tier or add new restrictions. If you are currently taking that brand-name

drug, we may not tell you in advance before we make that change, but we will later provide

you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and

continue to cover the brand-name drug for you. The notice we provide you will also

include information on how to request an exception, and you can find information in the

section below titled “How do I request an exception to the Aetna Medicare Rx offered by

SilverScript Formulary?”

● Drugs removed from the market. 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 may

immediately remove the drug from our formulary and provide notice to members who take

the drug.

● Other changes.

We may make changes based on new clinical guidelines. If we remove drugs

from our formulary, add quantity limits, prior authorization, 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 30 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 30-day supply of the

drug.

o If we make these other changes, you or your prescriber can ask us to make an exception

and continue to cover the brand-name drug for you. The notice we provide you will also

include information on how to request an exception, and you can find information in the

section below titled “How do I request an exception to the Aetna Medicare Rx offered by

SilverScript Formulary?”

03/20/2023 II

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a

drug on our 2023 formulary that was covered at the beginning of the year, we will not discontinue or

reduce coverage of the drug during the 2023 coverage year except as described above. This means these

drugs will remain available at the same cost-sharing and with no new restrictions for those members

taking them for the remainder of the coverage year. You will not get direct notice this year about

changes that do not affect you. However, on January 1 of the next year, such changes would affect you,

and it is important to check the Drug List for the new benefit year for any changes to drugs.

This formulary is current as of March 20, 2023. To get updated information about the drugs covered by

our plan, please contact us at the number on your member ID card. Our contact information also 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:

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index at the

back of this document. 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. Next to your drug,

you will see the page number where you can find coverage information. Turn to the page listed

in the Index and find the name of your drug in the first column of the list.

Medical Condition

The formulary begins on page 1. 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 1. Then look under the

category name for your drug.

What are generic drugs?

Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as

having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than

brand-name drugs.

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 (PA): Some drugs require you or your physician to get prior

authorization. You must get an approval from us before you can get your prescription filled.

If you don’t get approval, we may not cover the drug.

● Quantity Limits (QL): For certain drugs, there is a quantity limit in the amount of the drug

that we will cover. For example, our plan provides up to 30 tablets per 30-day prescription

for atorvastatin. This may be in addition to a standard one-month or three-month supply.

● Step Therapy (ST): In some cases, our plan requires you to first try certain drugs to treat

your medical condition before we will cover another drug for that condition. For example, if

03/20/2023 III

Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you

try Drug A first. If Drug A does not work for you, Aetna Medicare Rx offered by SilverScript

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 1. You may ask us to send you a copy. Our contact information, along with the date we

last updated the formulary, appears on the front and back cover pages.

You can ask Aetna Medicare Rx offered by SilverScript 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 Aetna Medicare Rx offered by SilverScript Formulary?” 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

Care and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

◼ You can ask Customer Care for a list of similar drugs that are covered by our plan. When you

receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is

covered by our plan.

◼ You can ask us 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 Aetna Medicare Rx offered by SilverScript Formulary?

You can ask us 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 unless the drug is 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 our plan limits the amount of the drug that we will cover. If your drug has a quantity limit,

you can ask us to waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drug is included on the

plan’s formulary or if 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.

03/20/2023 IV

You should contact us to ask 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 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. If your prescription is written for fewer than 30 days, we’ll allow

refills to provide up to a maximum 30-day supply of medication. 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 and 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 while you pursue a formulary exception.

If you experience a change in your level of care, such as a move from a home to a long-term care

setting, and need a drug that is not on our formulary (or if your ability to get your drugs is limited), we

may cover a one-time temporary supply from a network pharmacy for up to 31 days, unless you have a

prescription for fewer days. You should use the plan’s exception process if you wish to have continued

coverage of the drug after the temporary supply is finished.

Drug Tier Copay Levels

This comprehensive formulary is a listing of brand-name and generic drugs. This formulary covers most

drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at

which the drug resides.

The copay tiers for covered prescription medications are listed below. Please refer to your 2023

Evidence of Coverage for copay information specific to your plan.

Formulary Name 5T Comprehensive+ Formulary

Tier 1 Preferred Generic

Tier 2 Generic

Tier 3 Preferred Brand

Tier 4 Non-Preferred Brand

Tier 5 Specialty

03/20/2023 V

You can find complete cost-sharing and days’ supply information, including costs for long-term

supplies, long-term care, and out-of-network pharmacy pricing, in your Evidence of Coverage.

For more information

For more detailed information about your Aetna Medicare Rx offered by SilverScript prescription drug

coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us at the number on the back of your member ID

card. 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 Part D 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.

Aetna Medicare Rx offered by SilverScript’s Formulary

The formulary that begins on page 1 provides coverage information about the drugs covered by our plan.

If you have trouble finding your drug in the list, turn to the Index at the back of this book.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SYNTHROID)

and generic drugs are listed in lower-case italics (e.g., levothyroxine).

The information in the Requirements/Limits column tells you if Aetna Medicare Rx offered by

SilverScript has any special requirements for coverage of your drug.

PA Prior Authorization

QL Drug has Quantity Limits

ST Step Therapy required

MO Available at our mail-order pharmacies

LA

Limited Access. This prescription may be available only at certain

pharmacies.

B/D

This drug may be covered under Medicare Part B or D depending

upon the circumstances. Information may need to be submitted

describing the use and setting of the drug to make the determination.

03/20/2023 VI

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

ANALGESICS

GOUT

allopurinol sodium inj

2

ALLOPURINOL TABS 200MG

4

MO

allopurinol tabs 100mg, 300mg

1

MO

ALOPRIM

4

COLCHICINE CAPS

3

QL (60 EA per 30 days) MO

colchicine tabs

2

QL (120 EA per 30 days) MO

COLCRYS

4

QL (120 EA per 30 days) MO

febuxostat

2

ST MO

GLOPERBA

4

QL (300 ML per 30 days) PA MO

KRYSTEXXA

5

QL (2 ML per 28 days) PA LA

MITIGARE

3

QL (60 EA per 30 days) MO

probenecid

2

MO

probenecid/colchicine

2

MO

ULORIC

4

ST MO

ZYLOPRIM

4

MO

MISCELLANEOUS

acetaminophen inj

2

ALLZITAL

4

QL (180 EA per 30 days) PA MO

bupap

2

QL (180 EA per 30 days) PA

butalbital/acetaminophen/caffeine

2

QL (180 EA per 30 days) PA MO

butalbital/acetaminophen caps

2

QL (180 EA per 30 days) PA MO

butalbital/acetaminophen tabs 325mg; 25mg

2

QL (180 EA per 30 days) PA

butalbital/acetaminophen tabs 325mg; 50mg

2

QL (180 EA per 30 days) PA MO

butalbital/acetaminophen tabs 300mg; 50mg

5

QL (180 EA per 30 days) PA MO

butalbital/aspirin/caffeine

2

QL (180 EA per 30 days) PA MO

clonidine hcl inj 100mcg/ml, 500mcg/ml

2

DURACLON

4

ESGIC TABS

4

QL (180 EA per 30 days) PA MO

esgic caps

2

QL (180 EA per 30 days) PA

FIORICET

4

QL (180 EA per 30 days) PA MO

PRIALT INJ 500MCG/20ML, 500MCG/5ML

4

B/D

PRIALT INJ 100MCG/ML

5

B/D

tencon

2

QL (180 EA per 30 days) PA

vtol lq

5

QL (2700 ML per 30 days) PA

zebutal

2

QL (180 EA per 30 days) PA

NSAIDS

ARTHROTEC 50

4

QL (120 EA per 30 days) MO

ARTHROTEC 75

4

QL (90 EA per 30 days) MO

CALDOLOR

4

cataflam

2

QL (120 EA per 30 days)

CELEBREX CAPS 400MG

4

QL (30 EA per 30 days) ST MO

CELEBREX CAPS 100MG, 200MG, 50MG

4

QL (60 EA per 30 days) ST MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 1

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

celecoxib caps 400mg

2

QL (30 EA per 30 days) MO

celecoxib caps 100mg, 200mg, 50mg

2

QL (60 EA per 30 days) MO

DAYPRO

4

QL (90 EA per 30 days) MO

diclofenac potassium caps 25mg

2

QL (120 EA per 30 days) PA MO

diclofenac potassium tabs 50mg

2

QL (120 EA per 30 days) MO

diclofenac potassium tabs 25mg

5

QL (120 EA per 30 days) PA MO

diclofenac sodium dr

2

MO

diclofenac sodium er

2

QL (60 EA per 30 days) MO

diclofenac sodium/misoprostol tbec 50mg; 200mcg

2

QL (120 EA per 30 days) MO

diclofenac sodium/misoprostol tbec 75mg; 200mcg

2

QL (90 EA per 30 days) MO

diflunisal

2

QL (90 EA per 30 days) MO

DUEXIS

5

QL (90 EA per 30 days) PA MO

ec-naproxen tbec 375mg

2

QL (120 EA per 30 days)

ec-naproxen tbec 500mg

2

QL (90 EA per 30 days) MO

etodolac er tb24 600mg

2

QL (30 EA per 30 days) MO

etodolac er tb24 400mg, 500mg

2

QL (60 EA per 30 days) MO

etodolac caps 300mg

2

QL (120 EA per 30 days) MO

etodolac caps 200mg

2

QL (90 EA per 30 days) MO

etodolac tabs 500mg

2

QL (60 EA per 30 days) MO

etodolac tabs 400mg

2

QL (90 EA per 30 days) MO

FELDENE CAPS 20MG

4

QL (30 EA per 30 days) MO

FELDENE CAPS 10MG

4

QL (60 EA per 30 days) MO

FENOPROFEN CALCIUM CAPS

4

QL (240 EA per 30 days) MO

fenoprofen calcium tabs

2

QL (150 EA per 30 days) MO

flurbiprofen tabs 100mg

2

QL (90 EA per 30 days) MO

ibu tabs 600mg, 800mg

2

ibuprofen tabs 400mg, 600mg, 800mg, susp 100mg/5ml

2

MO

ibuprofen/famotidine

2

QL (90 EA per 30 days) PA MO

INDOCIN

5

PA MO

indomethacin

2

PA MO

indomethacin er

2

PA MO

ketoprofen er

2

QL (30 EA per 30 days) MO

ketoprofen caps 25mg

5

QL (120 EA per 30 days) MO

ketoprofen caps 50mg

5

QL (180 EA per 30 days)

ketorolac tromethamine inj 15mg/ml, 30mg/ml, 60mg/2ml

2

QL (20 ML per 30 days) PA MO

ketorolac tromethamine nasal soln 15.75mg/spray

5

QL (5 EA per 30 days) PA

ketorolac tromethamine tabs 10mg

2

QL (20 EA per 30 days) PA MO

LODINE

4

QL (90 EA per 30 days) ST MO

lofena

5

QL (120 EA per 30 days) PA MO

meclofenamate sodium

2

QL (120 EA per 30 days) MO

mefenamic acid

2

MO

meloxicam caps 10mg

2

MO

meloxicam caps 5mg

5

MO

meloxicam tabs

1

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 2

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

MOBIC

4

MO

nabumetone

2

MO

NALFON TABS

4

QL (150 EA per 30 days) ST MO

NALFON CAPS

4

QL (240 EA per 30 days) ST MO

NAPRELAN TB24 375MG

4

QL (120 EA per 30 days) ST MO

NAPRELAN TB24 500MG

4

QL (90 EA per 30 days) ST MO

NAPRELAN TB24 750MG

5

QL (60 EA per 30 days) ST MO

NAPROXEN SODIUM CR

4

QL (120 EA per 30 days) MO

NAPROXEN SODIUM ER TB24 375MG

4

QL (120 EA per 30 days) MO

naproxen sodium er tb24 500mg

5

QL (90 EA per 30 days) MO

NAPROXEN SODIUM TB24

4

QL (60 EA per 30 days) MO

naproxen sodium tabs 275mg, 550mg

2

MO

naproxen/esomeprazole magnesium

5

QL (60 EA per 30 days) PA MO

naproxen tabs 250mg, 375mg, 500mg

1

MO

naproxen susp

2

MO

naproxen tbec 375mg

2

QL (120 EA per 30 days) MO

naproxen tbec 500mg

2

QL (90 EA per 30 days) MO

oxaprozin

2

QL (90 EA per 30 days) MO

piroxicam caps 20mg

2

QL (30 EA per 30 days) MO

piroxicam caps 10mg

2

QL (60 EA per 30 days) MO

relafen

2

RELAFEN DS

5

QL (60 EA per 30 days) ST MO

salsalate tabs 750mg

2

QL (120 EA per 30 days) MO

salsalate tabs 500mg

2

QL (180 EA per 30 days) MO

SPRIX

5

QL (5 EA per 30 days) PA

sulindac

2

QL (60 EA per 30 days) MO

VIMOVO

5

QL (60 EA per 30 days) PA MO

VIVLODEX CAPS 5MG

4

ST MO

VIVLODEX CAPS 10MG

5

ST MO

ZIPSOR

5

QL (120 EA per 30 days) PA MO

ZORVOLEX

4

QL (90 EA per 30 days) MO

OPIOID ANALGESICS, LONG-ACTING

BELBUCA

4

QL (60 EA per 30 days) PA MO

buprenorphine transdermal patch

2

QL (4 EA per 28 days) PA MO

BUTRANS

4

QL (4 EA per 28 days) PA MO

CONZIP CP24 100MG, 300MG

4

QL (30 EA per 30 days) PA MO

CONZIP CP24 200MG

5

QL (30 EA per 30 days) PA MO

fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 37.5mcg/hr,

50mcg/hr, 62.5mcg/hr, 75mcg/hr

2

QL (10 EA per 30 days) PA MO

fentanyl pt72 87.5mcg/hr

5

QL (10 EA per 30 days) PA MO

hydrocodone bitartrate er tabs

2

QL (30 EA per 30 days) PA MO

hydrocodone bitartrate er caps

2

QL (60 EA per 30 days) PA MO

hydromorphone hcl er tabs 32mg

5

QL (30 EA per 30 days) PA MO

hydromorphone hcl er tabs 8mg, 12mg, 16mg

2

QL (30 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 3

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

HYSINGLA ER

3

QL (30 EA per 30 days) PA MO

methadone hcl oral conc

2

QL (90 ML per 30 days) PA MO

METHADONE HCL INJ

5

PA

methadone hcl oral soln

2

QL (450 ML per 30 days) PA MO

methadone hcl tabs

2

QL (90 EA per 30 days) PA MO

METHADOSE

4

QL (90 ML per 30 days) PA MO

METHADOSE SUGAR-FREE

4

QL (90 ML per 30 days) PA MO

morphine sulfate er cp24 (generic Avinza) 120mg, 30mg,

45mg, 60mg, 75mg, 90mg

2

QL (30 EA per 30 days) PA MO

morphine sulfate er (generic Kadian) cp24 100mg, 10mg,

20mg, 30mg, 50mg, 60mg, 80mg

2

QL (60 EA per 30 days) PA MO

morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg

2

QL (60 EA per 30 days) PA MO

morphine sulfate er tbcr 15mg

2

QL (90 EA per 30 days) PA MO

MORPHINE SULFATE/SODIUM CHLORIDE

4

B/D

MS CONTIN TBCR 30MG

4

QL (60 EA per 30 days) PA MO

MS CONTIN TBCR 15MG

4

QL (90 EA per 30 days) PA MO

MS CONTIN TBCR 100MG, 200MG, 60MG

5

QL (60 EA per 30 days) PA MO

NUCYNTA ER TB12 50MG

4

QL (60 EA per 30 days) PA MO

NUCYNTA ER TB12 100MG, 150MG, 200MG, 250MG

5

QL (60 EA per 30 days) PA MO

OXYCODONE HCL ER T12A 15MG, 30MG, 60MG

4

QL (60 EA per 30 days) PA

OXYCODONE HCL ER T12A 10MG, 20MG, 40MG, 80MG

4

QL (60 EA per 30 days) PA MO

OXYCONTIN

4

QL (60 EA per 30 days) PA MO

oxymorphone hydrochloride er

2

QL (60 EA per 30 days) PA MO

oxymorphone hydrochloride er tb12 40mg

5

QL (60 EA per 30 days) PA MO

TRAMADOL HCL ER CP24

4

QL (30 EA per 30 days) PA MO

tramadol hcl er tb24

2

QL (30 EA per 30 days) PA MO

tramadol hydrochloride er

2

QL (30 EA per 30 days) PA MO

XTAMPZA ER C12A 36MG

4

QL (240 EA per 30 days) PA MO

XTAMPZA ER C12A 13.5MG, 18MG, 27MG, 9MG

4

QL (60 EA per 30 days) PA MO

OPIOID ANALGESICS, SHORT-ACTING

acetaminophen/caffeine/dihydrocodeine tabs

2

QL (300 EA per 30 days)

acetaminophen/caffeine/dihydrocodeine caps

2

QL (300 EA per 30 days) MO

acetaminophen/codeine tabs

2

QL (180 EA per 30 days) MO

acetaminophen/codeine soln

2

QL (2700 ML per 30 days) MO

ACTIQ

5

QL (120 EA per 30 days) PA MO

APADAZ

4

QL (168 EA per 30 days)

ascomp/codeine

2

QL (180 EA per 30 days) PA MO

BENZHYDROCODONE/ACETAMINOPHEN

4

QL (168 EA per 30 days)

BUPRENEX

5

MO

buprenorphine hcl inj 0.3mg/ml

2

MO

butalbital/acetaminophen/caffeine/codeine

2

QL (180 EA per 30 days) PA MO

butalbital/aspirin/caffeine/codeine

2

QL (180 EA per 30 days) PA MO

butorphanol tartrate nasal soln

2

QL (5 ML per 30 days) MO

butorphanol tartrate inj 1mg/ml

2

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 4

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

butorphanol tartrate inj 2mg/ml

2

MO

CODEINE SULFATE

4

QL (180 EA per 30 days) MO

DEMEROL INJ 100MG/2ML, 25MG/ML, 75MG/ML

4

PA

DEMEROL INJ 100MG/ML, 50MG/ML

4

PA MO

DILAUDID INJ

4

B/D

DILAUDID LIQD

4

QL (600 ML per 30 days) MO

DILAUDID TABS 2MG, 4MG

4

QL (180 EA per 30 days) MO

DILAUDID TABS 8MG

5

QL (180 EA per 30 days) MO

DURAMORPH

4

B/D

endocet

2

QL (180 EA per 30 days)

fentanyl citrate oral transmucosal lpop 200mcg

2

QL (120 EA per 30 days) PA MO

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg,

400mcg, 600mcg, 800mcg

5

QL (120 EA per 30 days) PA MO

FENTANYL CITRATE TABS

5

QL (120 EA per 30 days) PA MO

FENTANYL CITRATE PREFILLED SYRINGE

100MCG/2ML, 50MCG/ML

4

FENTANYL CITRATE INJ 1000MCG/20ML,

100MCG/2ML, 2500MCG/50ML, 250MCG/5ML,

500MCG/10ML, 50MCG/ML

4

B/D

fentanyl citrate inj cartridge 100mcg/2ml

2

B/D

FENTORA

5

QL (120 EA per 30 days) PA MO

FIORICET/CODEINE

5

QL (180 EA per 30 days) PA MO

hydrocodone bitartrate/acetaminophen tabs

2

QL (180 EA per 30 days) MO

hydrocodone bitartrate/acetaminophen soln

2

QL (2700 ML per 30 days) MO

hydrocodone/ibuprofen

2

QL (150 EA per 30 days) MO

hydromorphone hcl tabs

2

QL (180 EA per 30 days) MO

hydromorphone hcl liqd

2

QL (600 ML per 30 days) MO

HYDROMORPHONE HCL INJ 1MG/ML, 4MG/ML

4

B/D MO

hydromorphone hcl inj 10mg/ml

2

B/D

HYDROMORPHONE HYDROCHLORIDE PF INJ

1MG/ML, 2MG/ML

4

B/D

HYDROMORPHONE HYDROCHLORIDE PF INJ

4MG/ML

4

B/D MO

hydromorphone hydrochloride inj 50mg/5ml

2

B/D

hydromorphone hydrochloride inj 2mg/ml

2

B/D MO

INFUMORPH 200

4

B/D

INFUMORPH 500

4

B/D

LAZANDA

5

QL (30 EA per 30 days) PA MO

levorphanol tartrate

5

QL (180 EA per 30 days) MO

LORTAB

4

QL (2040 ML per 30 days) MO

meperidine hcl inj

2

PA MO

meperidine hcl oral soln

2

QL (3600 ML per 30 days) PA MO

meperidine hcl tabs

5

QL (120 EA per 30 days) PA MO

mitigo

2

B/D

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 5

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

morphine sulfate tabs

2

QL (180 EA per 30 days) MO

MORPHINE SULFATE INJ 10MG/ML PF VIAL IV OR IM,

2MG/ML, 4MG/ML IV OR IM VIAL AND PREFILLED

SYRINGE, 5MG/ML, 8MG/ML PF VIAL IV OR IM

4

B/D

morphine sulfate inj 0.5mg/ml pf vial, 10mg/ml iv only vial

and carpuject, 1mg/ml vial, 4mg/ml iv vial and prefilled

syringe, 50mg/ml, 8mg/ml vial and pf carpuject

2

B/D

morphine sulfate inj 1mg/ml pf vial

2

B/D MO

morphine sulfate oral soln 20mg/ml

2

QL (180 ML per 30 days) MO

morphine sulfate oral soln 10mg/5ml, 20mg/5ml

2

QL (900 ML per 30 days) MO

morphine sulfate supp 5mg

2

QL (60 EA per 30 days)

morphine sulfate supp 10mg, 20mg

2

QL (60 EA per 30 days) MO

morphine sulfate supp 30mg

5

QL (60 EA per 30 days)

nalbuphine hcl

2

MO

nalocet

5

QL (180 EA per 30 days)

NUCYNTA TABS 50MG, 75MG

4

QL (180 EA per 30 days) MO

NUCYNTA TABS 100MG

5

QL (180 EA per 30 days) MO

OXAYDO TABS 5MG

4

QL (180 EA per 30 days) MO

OXAYDO TABS 7.5MG

5

QL (180 EA per 30 days) MO

OXYCODONE AND ACETAMINOPHEN TABS 7.5MG;

300MG

5

QL (180 EA per 30 days) PA MO

OXYCODONE HYDROCHLORIDE/ACETAMINOPHEN

SOLN 325MG/5ML; 5MG/5ML

4

QL (1800 ML per 30 days) MO

oxycodone hydrochloride/acetaminophen soln 300mg/5ml;

10mg/5ml

5

QL (900 ML per 30 days) PA

oxycodone hydrochloride caps

2

QL (180 EA per 30 days) MO

oxycodone hydrochloride conc

2

QL (180 ML per 30 days) MO

oxycodone hydrochloride soln

2

QL (900 ML per 30 days) MO

oxycodone hydrochloride tabs 30mg

2

QL (120 EA per 30 days) MO

oxycodone hydrochloride tabs 10mg, 15mg, 20mg, 5mg

2

QL (180 EA per 30 days) MO

oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg,

325mg; 5mg, 325mg; 7.5mg

2

QL (180 EA per 30 days) MO

oxycodone/acetaminophen tabs 300mg; 2.5mg

5

QL (180 EA per 30 days)

oxycodone/acetaminophen tabs 300mg; 10mg

5

QL (180 EA per 30 days) PA

oxycodone/acetaminophen tabs 300mg; 5mg

5

QL (180 EA per 30 days) PA MO

oxymorphone hydrochloride

2

QL (180 EA per 30 days) MO

pentazocine/naloxone hcl

2

QL (360 EA per 30 days) PA MO

PERCOCET TABS 325MG; 2.5MG

4

QL (180 EA per 30 days) MO

PERCOCET TABS 325MG; 10MG, 325MG; 5MG, 325MG;

7.5MG

5

QL (180 EA per 30 days) MO

PROLATE SOLN

5

QL (900 ML per 30 days) PA

PROLATE TABS 300MG; 10MG

5

QL (180 EA per 30 days) PA

PROLATE TABS 300MG; 5MG, 300MG; 7.5MG

5

QL (180 EA per 30 days) PA MO

ROXICODONE TABS 15MG, 5MG

4

QL (180 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 6

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ROXICODONE TABS 30MG

5

QL (120 EA per 30 days) MO

ROXYBOND

5

QL (180 EA per 30 days)

SEGLENTIS

4

QL (120 EA per 30 days) PA MO

SUBSYS LIQD 100MCG, 200MCG, 400MCG, 600MCG,

800MCG

5

QL (120 EA per 30 days) PA MO

SUBSYS LIQD 1200MCG

5

QL (240 EA per 30 days) PA

SUBSYS LIQD 1600MCG

5

QL (240 EA per 30 days) PA MO

tramadol hcl tabs 100mg

2

QL (120 EA per 30 days) MO

tramadol hcl tabs 50mg

2

QL (240 EA per 30 days) MO

tramadol hydrochloride/acetaminophen

2

QL (240 EA per 30 days) MO

trezix

2

QL (300 EA per 30 days)

ULTRACET

4

QL (240 EA per 30 days) MO

ULTRAM

4

QL (240 EA per 30 days) MO

ANESTHETICS

LOCAL ANESTHETICS

bupivacaine hcl inj 0.25%

2

bupivacaine hcl inj 0.5%

2

MO

bupivacaine hydrochloride pf inj 0.25%, 0.75%

2

bupivacaine hydrochloride pf inj 0.5%

2

MO

bupivacaine/epinephrine inj 0.25%; 1:200000, 0.5%;

1:200000 pf

2

bupivacaine/epinephrine inj 0.5%; 1:200000

2

MO

EXPAREL

4

lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

2

lidocaine hydrochloride pf inj 1%, 2%

2

lidocaine/epinephrine

2

MARCAINE/EPINEPHRINE INJ 0.25%; 1:200000

4

MARCAINE/EPINEPHRINE INJ 0.5%; 1:200000

4

MO

MARCAINE INJ 0.25%, 0.75%

4

MARCAINE INJ 0.5%

4

MO

NAROPIN

4

ropivacaine hydrochloride

2

sensorcaine-mpf

2

SENSORCAINE-MPF/EPINEPHRINE INJ 0.5%; 1:200000,

0.75%; 1:200000

4

sensorcaine-mpf/epinephrine inj 0.25%; 1:200000

2

sensorcaine/epinephrine

2

SENSORCAINE INJ 0.25%

4

SENSORCAINE INJ 0.5%

4

MO

XYLOCAINE

4

XYLOCAINE-MPF

4

XYLOCAINE-MPF/EPINEPHRINE

4

XYLOCAINE/EPINEPHRINE

4

ANTI-INFECTIVES

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 7

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ANTI-INFECTIVES - MISCELLANEOUS

AEMCOLO

4

MO

albendazole

5

MO

ALBENZA

4

MO

amikacin sulfate

2

MO

ARIKAYCE

5

PA LA

atovaquone

5

PA MO

AZACTAM

4

aztreonam inj 1gm

2

MO

aztreonam inj 2gm

5

MO

bacitracin inj 50000unit

2

BACTRIM

4

MO

BACTRIM DS

4

MO

BENZNIDAZOLE

4

PA

BETHKIS

5

QL (224 ML per 56 days) PA LA

BILTRICIDE

5

MO

CAYSTON

5

PA LA

chloramphenicol sodium succinate

2

CLEOCIN PEDIATRIC GRANULES

4

MO

CLEOCIN PHOSPHATE INJ 300MG/2ML, 9GM/60ML

4

CLEOCIN PHOSPHATE INJ 600MG/4ML, 900MG/6ML

4

MO

CLEOCIN CAPS 150MG, 300MG, 75MG

4

MO

clindamycin hcl caps 150mg, 75mg

2

MO

clindamycin hcl caps 300mg

2

MO

clindamycin palmitate hcl

2

MO

clindamycin phosphate/dextrose

2

clindamycin phosphate inj 300mg/2ml, 9000mg/60ml

2

clindamycin phosphate inj 600mg/4ml, 900mg/6ml

2

MO

CLINDAMYCIN/SODIUM CHLORIDE

4

colistimethate sodium

5

PA MO

COLY-MYCIN M

4

PA MO

CUBICIN

5

CUBICIN RF

5

DALVANCE

5

dapsone tabs 100mg, 25mg

2

MO

DAPTOMYCIN INJ 350MG

5

daptomycin inj 500mg

5

DARAPRIM

5

QL (90 EA per 30 days) PA MO

EMVERM

5

QL (12 EA per 365 days) MO

ertapenem

2

MO

FIRVANQ ORAL SOLN 25MG/ML

4

QL (1800 ML per 180 days)

FIRVANQ ORAL SOLN 50MG/ML

4

QL (1800 ML per 180 days) MO

FLAGYL

4

MO

fosfomycin tromethamine

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 8

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

gentamicin sulfate pediatric

2

MO

gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9%,

1mg/ml; 0.9%, 2mg/ml; 0.9%

2

gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9%

2

MO

gentamicin sulfate inj 40mg/ml

2

MO

HIPREX

4

MO

HUMATIN

5

MO

imipenem/cilastatin

2

MO

IMPAVIDO

5

QL (90 EA per 30 days) PA MO

INVANZ

4

MO

isotonic gentamicin

2

MO

ivermectin tabs 3mg

2

QL (12 EA per 90 days) PA MO

KIMYRSA

5

KITABIS PAK

5

QL (280 ML per 56 days) PA LA

LAMPIT

4

PA

LINCOCIN

4

MO

lincomycin hcl

2

linezolid tabs

2

QL (56 EA per 28 days) PA MO

linezolid oral susp

5

QL (1800 ML per 30 days) PA MO

LINEZOLID INJ 600MG/300ML; 0.9%

4

PA

linezolid inj 600mg/300ml

2

PA

MACROBID

4

MO

MACRODANTIN

4

MO

me/naphos/mb/hyo 1

2

MO

MEPRON

5

PA MO

meropenem

2

MO

MEROPENEM/SODIUM CHLORIDE

4

methenamine hippurate

2

MO

methenamine mandelate

2

MO

metronidazole caps 375mg

2

MO

metronidazole inj 500mg/100ml

2

metronidazole tabs 250mg, 500mg

2

MO

MONUROL

4

MO

NEBUPENT

4

B/D MO

neomycin sulfate

2

MO

nitazoxanide

5

QL (6 EA per 30 days) MO

nitrofurantoin macrocrystals

2

MO

nitrofurantoin monohydrate/macrocrystals

2

MO

nitrofurantoin oral susp

5

MO

ORBACTIV

5

MO

paromomycin sulfate

2

MO

PENTAM 300

4

MO

pentamidine isethionate inhalation soln

2

B/D MO

pentamidine isethionate inj

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 9

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

polymyxin b sulfate inj

2

praziquantel

2

MO

PRIMAXIN IV

4

MO

pyrimethamine

5

QL (90 EA per 30 days) PA MO

RECARBRIO

5

PA

SIVEXTRO INJ

5

SIVEXTRO TABS

5

MO

SOLOSEC

4

MO

streptomycin sulfate

5

MO

STROMECTOL

4

QL (12 EA per 90 days) PA MO

sulfadiazine

2

MO

sulfamethoxazole/trimethoprim ds

1

MO

sulfamethoxazole/trimethoprim tabs

1

MO

sulfamethoxazole/trimethoprim inj, susp

2

MO

SYNERCID

5

tinidazole

2

MO

TOBI

5

QL (280 ML per 56 days) PA LA

TOBI PODHALER

5

QL (224 EA per 56 days) PA LA

tobramycin sulfate inj 10mg/ml, 2gm/50ml

2

tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml

2

MO

tobramycin sulfate inj 1.2gm

5

tobramycin nebu 300mg/4ml

5

QL (224 ML per 56 days) PA

tobramycin nebu 300mg/5ml

5

QL (280 ML per 56 days) PA

trimethoprim

1

uro-458

2

MO

UROGESIC-BLUE

4

MO

VABOMERE

5

PA

VANCOCIN CAPS 125MG

5

QL (120 EA per 30 days) MO

VANCOCIN CAPS 250MG

5

QL (240 EA per 30 days) MO

VANCOMYCIN INJ 0.9%; 500MG/100ML, 0.9%;

750MG/150ML, 2000MG/400ML

4

VANCOMYCIN HCL INJ 0.9%; 1GM/200ML

4

vancomycin hcl inj 100gm, 10gm

2

VANCOMYCIN HYDROCHLORIDE/DEXTROSE

4

VANCOMYCIN HYDROCHLORIDE ORAL SOLN

4

QL (1800 ML per 180 days) MO

vancomycin hydrochloride caps 125mg

2

QL (120 EA per 30 days) MO

vancomycin hydrochloride caps 250mg

2

QL (240 EA per 30 days) MO

VANCOMYCIN HYDROCHLORIDE INJ 1.25GM, 1.5GM,

1000MG/200ML, 1250MG/250ML, 1500MG/300ML,

1750MG/350ML, 500MG/100ML, 750MG/150ML

4

vancomycin hydrochloride inj 1gm, 5gm, 750mg

2

vancomycin hydrochloride inj 500mg

2

MO

VIBATIV

5

PA

XENLETA INJ

4

PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 10

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

XENLETA TABS

5

PA

XIFAXAN TABS 200MG

5

QL (9 EA per 30 days) PA MO

ZEMDRI

5

PA

ZYVOX INJ

4

PA

ZYVOX ORAL SUSP

4

QL (1800 ML per 30 days) PA MO

ZYVOX TABS

5

QL (56 EA per 28 days) PA MO

ANTIFUNGALS

ABELCET

4

B/D

AMBISOME

5

B/D MO

amphotericin b

2

B/D MO

amphotericin b liposome

5

B/D

ANCOBON CAPS 250MG

5

ANCOBON CAPS 500MG

5

MO

CANCIDAS INJ 50MG

5

CANCIDAS INJ 70MG

5

MO

caspofungin acetate inj 70mg

2

caspofungin acetate inj 50mg

5

CRESEMBA INJ

5

QL (34 EA per 30 days)

CRESEMBA CAPS

5

QL (70 EA per 30 days) MO

DIFLUCAN ORAL SUSP

4

MO

DIFLUCAN TABS 100MG, 150MG, 50MG

4

MO

DIFLUCAN TABS 200MG

5

MO

ERAXIS

5

PA

fluconazole

2

MO

fluconazole in sodium chloride inj 200mg; 100ml, 400mg;

100ml

2

fluconazole/sodium chloride inj 100mg/50ml

2

flucytosine

5

MO

griseofulvin microsize

2

MO

griseofulvin ultramicrosize

2

MO

itraconazole caps

2

PA MO

itraconazole soln

5

PA MO

ketoconazole tabs 200mg

2

PA MO

micafungin

5

NOXAFIL INJ

5

NOXAFIL PACK

5

QL (32 EA per 30 days)

NOXAFIL ORAL SUSP

5

QL (630 ML per 30 days) MO

NOXAFIL TBEC

5

QL (93 EA per 30 days) MO

nystatin tabs 500000unit

2

MO

posaconazole dr

5

QL (93 EA per 30 days) MO

SPORANOX

5

PA MO

SPORANOX PULSEPAK

5

PA MO

terbinafine hcl

2

QL (90 EA per 365 days) MO

TOLSURA

5

PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 11

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

VFEND IV

5

PA

VFEND ORAL SUSP

5

PA MO

VFEND TABS 200MG

4

QL (120 EA per 30 days) MO

VFEND TABS 50MG

5

QL (480 EA per 30 days) MO

VIVJOA

4

QL (18 EA per 84 days) PA

voriconazole inj

5

PA

voriconazole oral susp

5

PA MO

voriconazole tabs 200mg

2

QL (120 EA per 30 days) MO

voriconazole tabs 50mg

2

QL (480 EA per 30 days) MO

ANTIMALARIALS

atovaquone/proguanil hcl

2

MO

chloroquine phosphate

2

MO

COARTEM

4

MO

KRINTAFEL

4

PA

MALARONE

4

MO

mefloquine hcl

2

MO

primaquine phosphate

2

QUALAQUIN

4

PA MO

quinine sulfate

2

PA MO

ANTIRETROVIRAL AGENTS

abacavir

2

MO

APRETUDE

5

QL (21 ML per 365 days) LA MO

APTIVUS

5

MO

atazanavir sulfate

2

MO

EDURANT

5

MO

efavirenz

2

MO

emtricitabine

2

MO

EMTRIVA

4

MO

EPIVIR

4

MO

etravirine

5

MO

fosamprenavir calcium

5

MO

FUZEON

5

INTELENCE TABS 25MG

4

INTELENCE TABS 100MG, 200MG

5

MO

INVIRASE

5

MO

ISENTRESS HD

5

MO

ISENTRESS PACK, TABS

5

MO

ISENTRESS CHEW 25MG

4

MO

ISENTRESS CHEW 100MG

5

MO

lamivudine soln 10mg/ml

2

MO

lamivudine tabs 150mg, 300mg

2

MO

LEXIVA SUSP

4

MO

LEXIVA TABS

5

MO

maraviroc

5

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 12

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

nevirapine immediate release tabs, oral susp

2

MO

nevirapine er tb24 100mg

2

nevirapine er tb24 400mg

2

MO

NORVIR

4

MO

PIFELTRO

5

MO

PREZISTA SUSP

5

QL (400 ML per 30 days) MO

PREZISTA TABS 75MG

4

QL (480 EA per 30 days) MO

PREZISTA TABS 150MG

5

QL (240 EA per 30 days) MO

PREZISTA TABS 800MG

5

QL (30 EA per 30 days) MO

PREZISTA TABS 600MG

5

QL (60 EA per 30 days) MO

RETROVIR CAPS, ORAL SYRUP

4

MO

RETROVIR IV INFUSION

4

REYATAZ PACK

4

MO

REYATAZ CAPS

5

MO

ritonavir

2

MO

RUKOBIA

5

MO

SELZENTRY SOLN

5

MO

SELZENTRY TABS 25MG

3

SELZENTRY TABS 75MG

5

SELZENTRY TABS 150MG, 300MG

5

MO

stavudine

2

MO

SUNLENCA INJ

5

QL (3 ML per 180 days) LA MO

SUNLENCA TBPK (5 TAB PACK) 300MG

5

QL (10 EA per 365 days) LA MO

SUNLENCA TBPK (4 TAB PACK) 300MG

5

QL (8 EA per 365 days) LA MO

SUSTIVA TABS

5

MO

SUSTIVA CAPS 50MG

4

MO

SUSTIVA CAPS 200MG

5

MO

tenofovir disoproxil fumarate

2

MO

TIVICAY PD

5

MO

TIVICAY TABS 10MG

3

MO

TIVICAY TABS 25MG, 50MG

5

MO

TROGARZO

5

LA

TYBOST

4

MO

VIRACEPT

5

MO

VIRAMUNE XR

5

MO

VIREAD

5

MO

ZIAGEN

4

MO

zidovudine

2

MO

ANTIRETROVIRAL COMBINATION AGENTS

abacavir sulfate/lamivudine

2

MO

BIKTARVY

5

MO

CABENUVA INJ 400MG/2ML; 600MG/2ML

5

QL (4 ML per 30 days) MO

CABENUVA INJ 600MG/3ML; 900MG/3ML

5

QL (6 ML per 30 days) MO

CIMDUO

5

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 13

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

COMBIVIR

5

MO

COMPLERA

5

MO

DELSTRIGO

5

MO

DESCOVY

5

MO

DOVATO

5

MO

efavirenz/emtricitabine/tenofovir disoproxil fumarate

5

MO

efavirenz/lamivudine/tenofovir disoproxil fumarate

5

MO

emtricitabine/tenofovir disoproxil fumarate tabs 100mg;

150mg, 133mg; 200mg, 200mg; 300mg

5

QL (30 EA per 30 days) MO

emtricitabine/tenofovir disoproxil tabs 167mg; 250mg

5

QL (30 EA per 30 days) MO

EPZICOM

5

MO

EVOTAZ

5

MO

GENVOYA

5

MO

JULUCA

5

MO

KALETRA SOLN

5

MO

KALETRA TABS 100MG; 25MG

4

MO

KALETRA TABS 200MG; 50MG

5

MO

lamivudine/zidovudine

2

MO

lopinavir/ritonavir soln

2

MO

lopinavir/ritonavir tabs 100mg; 25mg

2

MO

lopinavir/ritonavir tabs 200mg; 50mg

5

MO

ODEFSEY

5

MO

PREZCOBIX

5

MO

STRIBILD

5

MO

SYMFI

5

MO

SYMFI LO

5

MO

SYMTUZA

5

MO

TEMIXYS

5

MO

TRIUMEQ

5

MO

TRIUMEQ PD

5

MO

TRIZIVIR

5

MO

TRUVADA

5

QL (30 EA per 30 days) MO

ANTITUBERCULAR AGENTS

CAPASTAT SULFATE

4

cycloserine

5

MO

ethambutol hydrochloride

2

MO

isoniazid tabs

1

MO

isoniazid inj

2

isoniazid syrp

2

MO

MYAMBUTOL

4

MO

MYCOBUTIN

5

MO

PASER

4

MO

PRETOMANID

4

QL (30 EA per 30 days) PA

PRIFTIN

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 14

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

pyrazinamide

2

MO

rifabutin

2

MO

RIFADIN

4

rifampin inj

2

rifampin caps

2

MO

SIRTURO

5

PA LA

TRECATOR

4

MO

ANTIVIRALS

acyclovir sodium inj

2

B/D

acyclovir caps 200mg

2

MO

acyclovir susp 200mg/5ml

2

MO

acyclovir tabs 400mg, 800mg

2

MO

adefovir dipivoxil

2

QL (30 EA per 30 days) MO

BARACLUDE TABS

5

QL (30 EA per 30 days) MO

BARACLUDE SOLN

5

QL (630 ML per 30 days) MO

cidofovir

2

entecavir

2

QL (30 EA per 30 days) MO

EPCLUSA

5

PA

EPIVIR HBV

4

MO

famciclovir tabs 500mg

2

QL (21 EA per 30 days) MO

famciclovir tabs 125mg, 250mg

2

QL (60 EA per 30 days) MO

foscarnet sodium

5

PA

ganciclovir

2

B/D

HARVONI

5

PA

HEPSERA

5

QL (30 EA per 30 days) ST MO

lamivudine tabs 100mg

2

MO

LEDIPASVIR/SOFOSBUVIR

5

PA

LIVTENCITY

5

QL (120 EA per 30 days) PA LA

MO

MAVYRET

5

PA

oseltamivir phosphate caps 30mg

2

QL (168 EA per 365 days) MO

oseltamivir phosphate caps 45mg, 75mg

2

QL (84 EA per 365 days) MO

oseltamivir phosphate oral susp

2

QL (1080 ML per 365 days) MO

PEGASYS

5

PA

PREVYMIS INJ

5

PREVYMIS TABS

5

QL (28 EA per 28 days) PA MO

RAPIVAB

5

RELENZA DISKHALER

3

QL (120 EA per 365 days) MO

ribavirin

2

rimantadine hydrochloride

2

MO

SITAVIG

5

QL (2 EA per 30 days) MO

SOFOSBUVIR/VELPATASVIR

5

PA

SOVALDI TABS

5

QL (28 EA per 28 days) PA

SOVALDI PACK 150MG

5

QL (28 EA per 28 days) PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 15

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

SOVALDI PACK 200MG

5

QL (56 EA per 28 days) PA

TAMIFLU ORAL SUSP

4

QL (1080 ML per 365 days) MO

TAMIFLU CAPS 30MG

4

QL (168 EA per 365 days) MO

TAMIFLU CAPS 45MG, 75MG

4

QL (84 EA per 365 days) MO

valacyclovir hcl tabs 1gm

2

MO

valacyclovir hcl tabs 500mg

2

MO

VALCYTE

5

MO

valganciclovir hydrochloride oral soln

5

MO

valganciclovir tabs

2

MO

VALTREX TABS 500MG

4

MO

VALTREX TABS 1GM

5

MO

VEKLURY

5

QL (4 EA per 30 days) PA

VEMLIDY

5

MO

VIEKIRA PAK

5

QL (112 EA per 28 days) PA

VOSEVI

5

PA

XOFLUZA

4

QL (1 EA per 180 days) MO

ZEPATIER

5

PA

ZOVIRAX SUSP 200MG/5ML

4

MO

CEPHALOSPORINS

AVYCAZ

5

PA

cefaclor

2

MO

CEFACLOR ER

4

MO

cefadroxil

2

MO

CEFAZOLIN SODIUM INJ 1GM/50ML; 4%

3

CEFAZOLIN SODIUM INJ 100GM, 300GM

4

cefazolin sodium inj 1gm iv

2

cefazolin sodium inj 10gm, 1gm, 500mg

2

MO

CEFAZOLIN/DEXTROSE INJ 1GM/50ML;4%,

2GM/50ML;3%

4

CEFAZOLIN INJ 2GM/100ML; 4%

3

cefazolin inj 2gm

2

cefdinir

2

MO

CEFEPIME HYDROCHLORIDE INJ 100GM

4

CEFEPIME/DEXTROSE

4

CEFEPIME INJ 1GM/50ML, 2GM/100ML

4

cefepime inj 1gm, 2gm

2

MO

cefixime

2

MO

CEFOTAN

4

cefotetan inj 1gm/10ml, 2gm/20ml

2

CEFOTETAN/DEXTROSE

4

CEFOXITIN SODIUM INJ 1GM; 4%, 2GM; 2.2%

4

cefoxitin sodium inj 10gm, 1gm, 2gm

2

cefpodoxime proxetil

2

MO

cefprozil

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 16

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

CEFTAZIDIME/DEXTROSE

4

ceftazidime inj 6gm

2

ceftazidime inj 1gm, 2gm

2

MO

ceftriaxone in iso-osmotic dextrose

2

CEFTRIAXONE SODIUM INJ 100GM

4

ceftriaxone sodium inj 1gm iv

2

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

2

MO

CEFTRIAXONE/DEXTROSE

4

cefuroxime axetil tabs

2

MO

cefuroxime sodium inj 1.5gm

2

cefuroxime sodium inj 750mg

2

MO

cephalexin

2

MO

FETROJA

5

FORTAZ INJ 2GM, 500MG

4

FORTAZ INJ 1GM

4

MO

SUPRAX CAPS

4

MO

SUPRAX CHEW 100MG

4

SUPRAX CHEW 200MG

4

MO

SUPRAX ORAL SUSP 500MG/5ML

3

SUPRAX ORAL SUSP 100MG/5ML, 200MG/5ML

4

MO

tazicef

2

TEFLARO

5

ZERBAXA

5

ERYTHROMYCINS/MACROLIDES

AZITHROMYCIN PACK

3

MO

azithromycin inj, oral susp, tabs

2

MO

clarithromycin er tabs

2

MO

clarithromycin immediate release tabs, oral susp

2

MO

DIFICID ORAL SUSP

5

DIFICID TABS

5

MO

e.e.s. 400

2

MO

E.E.S. GRANULES

4

MO

ery-tab

2

ERYPED 200

5

MO

ERYPED 400

5

MO

ERYTHROCIN LACTOBIONATE INJ

5

erythrocin stearate

2

MO

erythromycin base tabs 250mg, 500mg

2

MO

erythromycin dr tabs

2

MO

erythromycin ethylsuccinate tabs

2

MO

erythromycin ethylsuccinate oral susp 200mg/5ml

2

MO

erythromycin ethylsuccinate oral susp 400mg/5ml

5

MO

erythromycin lactobionate inj

5

erythromycin stearate

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 17

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

erythromycin dr caps 250mg

2

MO

ZITHROMAX INJ, POWDER PACK, ORAL SUSP, TABS

4

MO

ZITHROMAX TRI-PAK

4

MO

ZITHROMAX Z-PAK

4

MO

FLUOROQUINOLONES

BAXDELA INJ

5

PA

BAXDELA TABS

5

PA MO

CIPRO

4

MO

ciprofloxacin hcl tabs 100mg, 750mg

1

MO

ciprofloxacin hydrochloride tabs 250mg, 500mg

1

MO

ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%

2

ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%

2

MO

levofloxacin in d5w

2

levofloxacin inj 25mg/ml

2

levofloxacin oral soln 25mg/ml

2

MO

levofloxacin tabs 250mg, 500mg, 750mg

2

MO

moxifloxacin hydrochloride/sodium hydrochloride

2

moxifloxacin hydrochloride inj 400mg/250ml

2

moxifloxacin hydrochloride tabs 400mg

2

MO

ofloxacin tabs 300mg, 400mg

2

MO

PENICILLINS

amoxicillin

1

MO

amoxicillin/clavulanate potassium

2

MO

amoxicillin/clavulanate potassium er

2

MO

ampicillin caps

1

MO

ampicillin sodium inj 10gm, 125mg, 1gm iv, 250mg, 2gm iv

2

ampicillin sodium inj 1gm, 2gm, 500mg

2

MO

ampicillin-sulbactam

2

AUGMENTIN

4

MO

AUGMENTIN ES-600

4

MO

BICILLIN C-R INJ 900000UNIT/2ML; 300000UNIT/2ML

4

BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML

4

MO

BICILLIN L-A

4

MO

dicloxacillin sodium

2

MO

nafcillin sodium inj 1gm

2

nafcillin sodium inj 2gm

2

MO

nafcillin sodium inj 10gm, 2gm iv

5

NAFCILLIN INJ 5%; 1GM/50ML

4

NAFCILLIN INJ 5%; 2GM/100ML

5

OXACILLIN SODIUM INJ 1GM/50ML, 2GM/50ML

4

oxacillin sodium inj 10gm, 1gm

2

oxacillin sodium inj 2gm

2

MO

PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEXTROSE

4

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 18

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

penicillin g potassium inj 20000000unit

2

MO

penicillin g potassium inj 5000000unit

5

MO

PENICILLIN G PROCAINE

4

MO

penicillin g sodium

5

penicillin v potassium

1

MO

pfizerpen inj 20000000unit

2

pfizerpen inj 5000000unit

2

MO

piperacillin sodium/tazobactam sodium

2

UNASYN INJ BULK PACK 10GM;5GM

4

UNASYN INJ 1GM; 0.5GM

4

UNASYN INJ 2GM; 1GM

4

MO

ZOSYN

4

TETRACYCLINES

ACTICLATE

4

ST MO

demeclocycline hcl

2

MO

DORYX MPC TBEC 120MG

4

ST MO

DORYX MPC TBEC 60MG

5

ST

DORYX TBEC 50MG

4

ST MO

DORYX TBEC 80MG

5

ST

DORYX TBEC 200MG

5

ST MO

doxy 100 inj

2

MO

doxycycline hyclate tabs, caps, inj

2

MO

doxycycline hyclate dr tbec 100mg, 150mg, 200mg, 50mg,

75mg

2

MO

doxycycline hyclate dr tbec 80mg

5

MO

doxycycline monohydrate

2

MO

doxycycline oral susp 25mg/5ml

2

MO

MINOCIN

5

minocycline hcl caps 75mg

2

MO

minocycline hcl tabs 100mg, 50mg, 75mg

2

ST MO

minocycline hcl caps 100mg, 50mg

2

MO

minocycline hydrochloride er

2

ST MO

MINOLIRA

4

ST MO

mondoxyne nl

2

NUZYRA

5

LA

SEYSARA

5

QL (30 EA per 30 days) PA MO

SOLODYN TB24 80MG

4

ST MO

SOLODYN TB24 105MG, 115MG, 55MG, 65MG

5

ST MO

targadox

2

tetracycline hydrochloride

2

MO

tigecycline

5

TYGACIL

5

VIBRAMYCIN

4

ST MO

XERAVA INJ 50MG

4

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 19

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

XERAVA INJ 100MG 5

XIMINO 4 ST MO

ANTINEOPLASTIC AGENTS

ALKYLATING AGENTS

ALKERAN TABS

4

B/D MO

ALKERAN INJ

5

BENDAMUSTINE HYDROCHLORIDE INJ 100MG/4ML

5

bendamustine hydrochloride inj 100mg, 25mg

5

BENDEKA

5

LA

BICNU

5

busulfan

5

BUSULFEX

5

carboplatin

2

carmustine

5

cisplatin

2

CYCLOPHOSPHAMIDE INJ 2GM/10ML

4

CYCLOPHOSPHAMIDE TABS

3

B/D

cyclophosphamide caps

2

B/D MO

CYCLOPHOSPHAMIDE INJ 1GM/5ML, 500MG/2.5ML

5

cyclophosphamide inj 1gm

2

cyclophosphamide inj 2gm, 500mg

5

EVOMELA

5

GLEOSTINE CAPS 10MG, 40MG

4

GLEOSTINE CAPS 100MG

5

IFEX

4

IFOSFAMIDE INJ 3GM

4

ifosfamide inj 1gm/20ml, 1gm, 3gm/60ml

2

LEUKERAN

4

MO

melphalan hydrochloride inj

5

melphalan tabs

2

B/D MO

oxaliplatin inj 100mg/20ml, 200mg/40ml, 50mg/10ml

2

oxaliplatin inj 100mg, 50mg

5

paraplatin

2

TEMODAR

5

TEPADINA

5

thiotepa

5

TREANDA

5

LA

YONDELIS

5

PA

ZANOSAR

4

ZEPZELCA

5

PA LA

ANTIBIOTICS

adriamycin

2

B/D

bleomycin sulfate

2

B/D

COSMEGEN

5

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 20

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

dactinomycin

5

DAUNORUBICIN HYDROCHLORIDE INJ 50MG/10ML

4

daunorubicin hydrochloride inj 20mg/4ml

2

DOXIL

5

doxorubicin hcl

2

B/D

doxorubicin hydrochloride

2

B/D

doxorubicin hydrochloride liposomal

5

ELLENCE

5

IDAMYCIN PFS

5

idarubicin hcl

2

mitomycin inj 5mg

2

mitomycin inj 20mg, 40mg

5

mutamycin inj 20mg, 5mg

2

mutamycin inj 40mg

5

valrubicin

5

VALSTAR

5

ANTIMETABOLITES

ALIMTA

5

ARRANON

5

azacitidine

5

cladribine

5

B/D

clofarabine

5

CLOLAR

5

cytarabine

2

B/D

cytarabine aqueous

2

B/D

DACOGEN

5

decitabine

5

fludarabine phosphate

2

fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml,

5gm/100ml

2

B/D

FOLOTYN

5

gemcitabine hcl inj 1gm, 200mg, 2gm

2

GEMCITABINE HYDROCHLORIDE INJ 1GM/10ML,

2GM/20ML

4

gemcitabine hydrochloride inj 1gm/26.3ml, 200mg/2ml,

200mg/5.26ml, 2gm/52.6ml

2

INFUGEM

5

INQOVI

5

QL (5 EA per 28 days) PA LA

LONSURF

5

PA LA

mercaptopurine

2

MO

methotrexate sodium inj pf 50mg/2ml

2

MO

methotrexate sodium inj 1gm/40ml, 1gm

2

methotrexate sodium inj 250mg/10ml, 50mg/2ml

2

MO

nelarabine

5

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 21

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

ONUREG

5

QL (14 EA per 28 days) PA LA

PEMETREXED INJ 100MG/4ML, 100MG, 1GM/40ML,

500MG/20ML, 500MG

5

pemetrexed inj 1000mg, 100mg, 500mg, 750mg

5

PURIXAN

5

TABLOID

4

MO

VIDAZA

5

LA

HORMONAL ANTINEOPLASTIC AGENTS

abiraterone acetate

5

PA

anastrozole

2

MO

ARIMIDEX

5

MO

AROMASIN

5

MO

bicalutamide

2

MO

CASODEX

5

MO

ELIGARD

4

PA

EMCYT

5

MO

ERLEADA

5

PA LA

EULEXIN

5

MO

exemestane

2

MO

FARESTON

5

PA MO

FASLODEX

5

FEMARA

4

MO

FIRMAGON INJ 80MG

4

PA

FIRMAGON INJ 120MG/VIAL

5

PA

flutamide

2

MO

fulvestrant

5

hydroxyprogesterone caproate inj 1.25gm/5ml

5

letrozole

2

MO

LEUPROLIDE ACETATE INJ 22.5MG

5

PA

leuprolide acetate inj 1mg/0.2ml

2

PA

LUPRON DEPOT (1-MONTH)

5

PA

LUPRON DEPOT (3-MONTH)

5

PA

LUPRON DEPOT (4-MONTH)

5

PA

LUPRON DEPOT (6-MONTH)

5

PA

LYSODREN

5

MO

megestrol acetate tabs 20mg, 40mg

2

MO

NILANDRON

5

MO

nilutamide

5

MO

NUBEQA

5

PA LA

ORGOVYX

5

PA LA MO

SOLTAMOX

5

MO

tamoxifen citrate

2

MO

toremifene citrate

5

PA MO

TRELSTAR MIXJECT

5

PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 22

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

XTANDI

5

PA LA

YONSA

5

PA LA

ZOLADEX

4

ZYTIGA

5

PA LA

IMMUNOMODULATORS

lenalidomide caps 20mg, 25mg

5

QL (21 EA per 28 days) PA LA

lenalidomide caps 10mg, 15mg, 2.5mg, 5mg

5

QL (28 EA per 28 days) PA LA

POMALYST

5

QL (21 EA per 28 days) PA LA

REVLIMID CAPS 20MG, 25MG

5

QL (21 EA per 28 days) PA LA

REVLIMID CAPS 10MG, 15MG, 2.5MG, 5MG

5

QL (28 EA per 28 days) PA LA

THALOMID CAPS 100MG, 50MG

5

QL (28 EA per 28 days) PA LA

THALOMID CAPS 150MG, 200MG

5

QL (56 EA per 28 days) PA LA

MISCELLANEOUS

arsenic trioxide

5

ASPARLAS

5

PA LA

BESREMI

5

QL (2 ML per 28 days) PA LA

bexarotene caps 75mg

5

PA

CAMPTOSAR

4

dacarbazine

2

HYCAMTIN

5

HYDREA

4

MO

hydroxyurea

2

MO

IMLYGIC

5

PA

irinotecan hcl inj 500mg/25ml

2

irinotecan hydrochloride inj 300mg/15ml, 40mg/2ml

2

irinotecan hydrochloride inj 100mg/5ml

5

KISQALI FEMARA 200 DOSE

5

PA

KISQALI FEMARA 400 DOSE

5

PA

KISQALI FEMARA 600 DOSE

5

PA

MATULANE

5

LA MO

mitoxantrone hcl

2

NIPENT

5

ONCASPAR

5

PA

ONIVYDE

5

PA LA

RYLAZE

5

PA LA

SYNRIBO

5

PA

TARGRETIN CAPS 75MG

5

PA

TICE BCG

4

TOPOTECAN HCL INJ 4MG/4ML

5

topotecan hcl inj 4mg

5

tretinoin caps 10mg

5

MO

TRISENOX

5

VYXEOS

5

PA

WELIREG

5

QL (90 EA per 30 days) PA LA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 23

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

MITOTIC INHIBITORS

ABRAXANE

5

LA

DOCETAXEL INJ 160MG/16ML, 160MG/8ML,

20MG/2ML, 80MG/8ML

5

docetaxel inj 20mg/ml, 80mg/4ml

2

ETOPOPHOS

5

etoposide

2

HALAVEN

5

PA

IXEMPRA KIT

5

PA

JEVTANA

5

PA LA

MARQIBO

5

PA

paclitaxel

2

paclitaxel protein-bound particles

5

toposar

2

vinblastine sulfate

2

B/D

vincristine sulfate

2

B/D

vinorelbine tartrate

2

MOLECULAR TARGET AGENTS

AFINITOR DISPERZ TBSO 2MG

5

QL (150 EA per 30 days) PA

AFINITOR DISPERZ TBSO 5MG

5

QL (60 EA per 30 days) PA

AFINITOR DISPERZ TBSO 3MG

5

QL (90 EA per 30 days) PA

AFINITOR TABS

5

QL (30 EA per 30 days) PA

ALECENSA

5

QL (240 EA per 30 days) PA LA

ALIQOPA

5

QL (3 EA per 28 days) PA LA

ALUNBRIG TBPK

5

PA LA MO

ALUNBRIG TABS 30MG

5

QL (120 EA per 30 days) PA LA

MO

ALUNBRIG TABS 180MG, 90MG

5

QL (30 EA per 30 days) PA LA MO

ALYMSYS

5

PA

ARZERRA

5

PA LA

AVASTIN

5

PA LA

AYVAKIT

5

QL (30 EA per 30 days) PA LA MO

BALVERSA TABS 5MG

5

QL (28 EA per 28 days) PA LA

BALVERSA TABS 4MG

5

QL (56 EA per 28 days) PA LA

BALVERSA TABS 3MG

5

QL (84 EA per 28 days) PA LA

BAVENCIO

5

PA LA

BELEODAQ

5

PA LA

BESPONSA

5

PA LA

BLENREP

5

PA LA

BLINCYTO

5

PA

BORTEZOMIB INJ 1MG, 2.5MG, 3.5MG

5

PA

bortezomib inj 3.5mg

5

PA

BOSULIF TABS 100MG

5

QL (180 EA per 30 days) PA

BOSULIF TABS 400MG, 500MG

5

QL (30 EA per 30 days) PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 24

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

BRAFTOVI

5

QL (180 EA per 30 days) PA LA

BRUKINSA

5

QL (120 EA per 30 days) PA LA

MO

CABOMETYX

5

QL (30 EA per 30 days) PA LA

CALQUENCE

5

QL (60 EA per 30 days) PA LA MO

CAPRELSA TABS 300MG

5

QL (30 EA per 30 days) PA LA MO

CAPRELSA TABS 100MG

5

QL (60 EA per 30 days) PA LA MO

COMETRIQ KIT 140MG/DAY

5

QL (112 EA per 28 days) PA LA

COMETRIQ KIT 100MG/DAY

5

QL (56 EA per 28 days) PA LA

COMETRIQ KIT 60MG/DAY

5

QL (84 EA per 28 days) PA LA

COPIKTRA

5

QL (56 EA per 28 days) PA LA

COTELLIC

5

QL (63 EA per 28 days) PA LA

CYRAMZA

5

PA LA

DARZALEX

5

PA LA

DARZALEX FASPRO

5

PA LA

DAURISMO TABS 100MG

5

QL (30 EA per 30 days) PA LA

DAURISMO TABS 25MG

5

QL (60 EA per 30 days) PA LA

EMPLICITI

5

PA LA

ENHERTU

5

PA LA

ERBITUX

5

PA

ERIVEDGE

5

PA LA

erlotinib hydrochloride tabs 100mg, 150mg

5

QL (30 EA per 30 days) PA

erlotinib hydrochloride tabs 25mg

5

QL (90 EA per 30 days) PA

everolimus tabs 10mg, 2.5mg, 5mg, 7.5mg

5

QL (30 EA per 30 days) PA

everolimus tbso 2mg

5

QL (150 EA per 30 days) PA

everolimus tbso 5mg

5

QL (60 EA per 30 days) PA

everolimus tbso 3mg

5

QL (90 EA per 30 days) PA

EXKIVITY

5

QL (120 EA per 30 days) PA LA

MO

FARYDAK

5

PA LA

FOTIVDA

5

QL (21 EA per 28 days) PA LA MO

FYARRO

5

PA LA

GAVRETO

5

QL (120 EA per 30 days) PA LA

GAZYVA

5

PA LA

GILOTRIF

5

QL (30 EA per 30 days) PA LA MO

GLEEVEC TABS 400MG

5

QL (60 EA per 30 days) PA

GLEEVEC TABS 100MG

5

QL (90 EA per 30 days) PA

HERCEPTIN

5

PA LA

HERCEPTIN HYLECTA

5

PA LA

HERZUMA

5

PA LA

IBRANCE

5

QL (21 EA per 28 days) PA LA

ICLUSIG TABS 10MG, 30MG

5

PA LA MO

ICLUSIG TABS 15MG, 45MG

5

QL (30 EA per 30 days) PA LA MO

IDHIFA

5

QL (30 EA per 30 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 25

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

imatinib mesylate tabs 400mg

5

QL (60 EA per 30 days) PA

imatinib mesylate tabs 100mg

5

QL (90 EA per 30 days) PA

IMBRUVICA ORAL SUSP

5

QL (216 ML per 27 days) PA LA

MO

IMBRUVICA TABS

5

QL (30 EA per 30 days) PA LA MO

IMBRUVICA CAPS 70MG

5

QL (30 EA per 30 days) PA LA MO

IMBRUVICA CAPS 140MG

5

QL (90 EA per 30 days) PA LA MO

IMFINZI

5

PA LA

IMJUDO

5

PA LA

INLYTA TABS 5MG

5

QL (120 EA per 30 days) PA LA

INLYTA TABS 1MG

5

QL (180 EA per 30 days) PA LA

INREBIC

5

QL (120 EA per 30 days) PA LA

IRESSA

5

QL (30 EA per 30 days) PA LA

ISTODAX (OVERFILL)

5

JAKAFI

5

QL (60 EA per 30 days) PA LA

JAYPIRCA TABS 50MG

5

QL (30 EA per 30 days) PA LA

JAYPIRCA TABS 100MG

5

QL (60 EA per 30 days) PA LA

JEMPERLI

5

PA LA

KADCYLA

5

LA

KANJINTI

5

PA LA

KEYTRUDA

5

PA LA

KIMMTRAK

5

PA LA

KISQALI

5

PA

KOSELUGO

5

PA LA

KRAZATI

5

QL (180 EA per 30 days) PA LA

MO

KYPROLIS

5

PA LA

lapatinib ditosylate

5

QL (180 EA per 30 days) PA LA

LENVIMA 10 MG DAILY DOSE

5

PA LA

LENVIMA 12MG DAILY DOSE

5

PA LA

LENVIMA 14 MG DAILY DOSE

5

PA LA

LENVIMA 18 MG DAILY DOSE

5

PA LA

LENVIMA 20 MG DAILY DOSE

5

PA LA

LENVIMA 24 MG DAILY DOSE

5

PA LA

LENVIMA 4 MG DAILY DOSE

5

PA LA

LENVIMA 8 MG DAILY DOSE

5

PA LA

LIBTAYO

5

PA LA

LORBRENA TABS 100MG

5

QL (30 EA per 30 days) PA LA

LORBRENA TABS 25MG

5

QL (90 EA per 30 days) PA LA

LUMAKRAS

5

QL (240 EA per 30 days) PA LA

LUMOXITI

5

PA LA

LUNSUMIO

5

PA LA

LYNPARZA

5

QL (120 EA per 30 days) PA LA

LYTGOBI TBPK 16MG

5

QL (112 EA per 28 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 26

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

LYTGOBI TBPK 20MG

5

QL (140 EA per 28 days) PA LA

LYTGOBI TBPK 12MG

5

QL (84 EA per 28 days) PA LA

MARGENZA

5

PA LA

MEKINIST TABS 2MG

5

QL (30 EA per 30 days) PA LA

MEKINIST TABS 0.5MG

5

QL (90 EA per 30 days) PA LA

MEKTOVI

5

QL (180 EA per 30 days) PA LA

MONJUVI

5

PA LA

MVASI

5

PA LA

MYLOTARG

5

PA LA

NERLYNX

5

QL (180 EA per 30 days) PA LA

NEXAVAR

5

QL (120 EA per 30 days) PA LA

NINLARO

5

PA

ODOMZO

5

PA LA

OGIVRI

5

PA LA

ONTRUZANT

5

PA LA

OPDIVO

5

PA LA

OPDUALAG

5

PA

PADCEV

5

PA LA

PEMAZYRE

5

QL (14 EA per 21 days) PA LA

PERJETA

5

PA LA

PHESGO

5

PA LA

PIQRAY 200MG DAILY DOSE

5

QL (28 EA per 28 days) PA

PIQRAY 250MG DAILY DOSE

5

QL (56 EA per 28 days) PA

PIQRAY 300MG DAILY DOSE

5

QL (56 EA per 28 days) PA

POLIVY

5

PA LA

PORTRAZZA

5

PA LA

POTELIGEO

5

PA LA

QINLOCK

5

QL (90 EA per 30 days) PA LA MO

RETEVMO CAPS 80MG

5

QL (120 EA per 30 days) PA LA

RETEVMO CAPS 40MG

5

QL (180 EA per 30 days) PA LA

REZLIDHIA

5

QL (60 EA per 30 days) PA LA MO

RIABNI

5

PA LA

RITUXAN

5

PA LA

RITUXAN HYCELA

5

PA LA

romidepsin

5

ROZLYTREK CAPS 100MG

5

QL (150 EA per 30 days) PA LA

ROZLYTREK CAPS 200MG

5

QL (90 EA per 30 days) PA LA

RUBRACA

5

PA LA

RUXIENCE

5

PA

RYBREVANT

5

PA LA

RYDAPT

5

QL (224 EA per 28 days) PA

SARCLISA

5

PA LA

SCEMBLIX TABS 40MG

5

QL (300 EA per 30 days) PA

SCEMBLIX TABS 20MG

5

QL (60 EA per 30 days) PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 27

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

sorafenib tosylate

5

QL (120 EA per 30 days) PA

SPRYCEL TABS 100MG, 140MG, 50MG, 70MG, 80MG

5

QL (30 EA per 30 days) PA

SPRYCEL TABS 20MG

5

QL (90 EA per 30 days) PA

STIVARGA

5

QL (84 EA per 28 days) PA LA

sunitinib malate

5

QL (30 EA per 30 days) PA

SUTENT

5

QL (30 EA per 30 days) PA LA

TABRECTA

5

QL (112 EA per 28 days) PA

TAFINLAR

5

QL (120 EA per 30 days) PA LA

TAGRISSO

5

QL (30 EA per 30 days) PA LA

TALZENNA CAPS 0.5MG, 0.75MG, 1MG

5

QL (30 EA per 30 days) PA LA

TALZENNA CAPS 0.25MG

5

QL (90 EA per 30 days) PA LA

TARCEVA TABS 100MG, 150MG

5

QL (30 EA per 30 days) PA LA

TARCEVA TABS 25MG

5

QL (90 EA per 30 days) PA LA

TASIGNA

5

QL (120 EA per 30 days) PA

TAZVERIK

5

QL (240 EA per 30 days) PA LA

TECENTRIQ

5

PA LA

TECVAYLI

5

PA LA

temsirolimus

5

TEPMETKO

5

QL (60 EA per 30 days) PA LA MO

TIBSOVO

5

PA LA

TIVDAK

5

PA LA

TORISEL

5

TRAZIMERA

5

PA

TRODELVY

5

PA LA

TRUSELTIQ CAPSULE THERAPY PACK 100MG DAILY

DOSE

5

QL (21 EA per 28 days) PA LA

TRUSELTIQ CAPSULE THERAPY PACK 125MG DAILY

DOSE, 50MG DAILY DOSE

5

QL (42 EA per 28 days) PA LA

TRUSELTIQ CAPSULE THERAPY PACK 75MG DAILY

DOSE

5

QL (63 EA per 28 days) PA LA

TRUXIMA

5

PA

TUKYSA TABS 150MG

5

QL (120 EA per 30 days) PA LA

MO

TUKYSA TABS 50MG

5

QL (240 EA per 30 days) PA LA

MO

TURALIO

5

QL (120 EA per 30 days) PA LA

MO

TYKERB

5

QL (180 EA per 30 days) PA LA

UKONIQ

5

QL (120 EA per 30 days) PA LA

MO

VECTIBIX

5

PA

VELCADE

5

PA

VENCLEXTA STARTING PACK

5

QL (42 EA per 28 days) PA LA

VENCLEXTA TABS 10MG

4

QL (120 EA per 30 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 28

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

VENCLEXTA TABS 50MG

5

QL (120 EA per 30 days) PA LA

VENCLEXTA TABS 100MG

5

QL (180 EA per 30 days) PA LA

VERZENIO

5

PA LA

VITRAKVI SOLN

5

QL (300 ML per 30 days) PA LA

VITRAKVI CAPS 25MG

5

QL (180 EA per 30 days) PA LA

VITRAKVI CAPS 100MG

5

QL (60 EA per 30 days) PA LA

VIZIMPRO

5

QL (30 EA per 30 days) PA LA

VONJO

5

QL (120 EA per 30 days) PA LA

MO

VOTRIENT

5

QL (120 EA per 30 days) PA LA

XALKORI

5

QL (120 EA per 30 days) PA LA

XOSPATA

5

PA LA MO

XPOVIO 60 MG TWICE WEEKLY (20MG TABS)

5

QL (24 EA per 28 days) PA LA

XPOVIO 80 MG TWICE WEEKLY (20MG TABS)

5

QL (32 EA per 28 days) PA LA

XPOVIO TBPK 40MG ONCE WEEKLY (40MG TABS),

60MG ONCE WEEKLY (60MG TABS)

5

QL (4 EA per 28 days) PA LA MO

XPOVIO TBPK 40MG TWICE WEEKLY (40MG TABS),

80MG ONCE WEEKLY (40MG TABS), 100MG ONCE

WEEKLY (50MG TABS)

5

QL (8 EA per 28 days) PA LA MO

YERVOY

5

PA LA

ZALTRAP

5

PA LA

ZEJULA

5

PA LA

ZELBORAF

5

QL (240 EA per 30 days) PA LA

ZIRABEV

5

PA LA

ZOLINZA

5

PA

ZYDELIG

5

QL (60 EA per 30 days) PA LA

ZYKADIA

5

QL (84 EA per 28 days) PA LA

ZYNLONTA

5

PA LA

PROTECTIVE AGENTS

dexrazoxane inj 500mg

2

dexrazoxane inj 250mg

5

ELITEK

5

KEPIVANCE

5

KHAPZORY

5

B/D LA

leucovorin calcium inj

2

leucovorin calcium tabs

2

MO

levoleucovorin calcium inj 50mg

5

levoleucovorin calcium inj 250mg/25ml

2

levoleucovorin calcium inj 175mg/17.5ml

5

mesna

2

MESNEX INJ

4

MESNEX TABS

5

MO

CARDIOVASCULAR

ACE INHIBITOR COMBINATIONS

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 29

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ACCURETIC

4

MO

amlodipine besylate/benazepril hydrochloride

1

QL (30 EA per 30 days) MO

benazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg

1

MO

benazepril hydrochloride/hydrochlorothiazide tabs 10mg;

12.5mg, 20mg; 12.5mg, 20mg; 25mg

1

MO

enalapril maleate/hydrochlorothiazide

1

MO

fosinopril sodium/hydrochlorothiazide

1

MO

lisinopril/hydrochlorothiazide

1

MO

LOTENSIN HCT

4

MO

LOTREL

4

QL (30 EA per 30 days) MO

quinapril/hydrochlorothiazide

1

MO

trandolapril/verapamil hcl er

1

MO

VASERETIC

4

MO

ZESTORETIC

4

MO

ACE INHIBITORS

ACCUPRIL

4

MO

ALTACE

4

MO

benazepril hcl tabs 10mg, 40mg, 5mg

1

MO

benazepril hydrochloride tabs 20mg

1

MO

captopril

1

MO

enalapril maleate tabs

1

MO

enalapril maleate soln

5

MO

enalaprilat inj

2

EPANED

5

MO

fosinopril sodium

1

MO

lisinopril

1

MO

LOTENSIN

4

MO

moexipril hcl

1

MO

perindopril erbumine

1

MO

QBRELIS

5

MO

quinapril hcl tabs 20mg, 40mg

1

MO

quinapril hydrochloride tabs 10mg, 5mg

1

MO

ramipril

1

MO

trandolapril

1

MO

VASOTEC TABS 10MG, 2.5MG, 5MG

4

MO

VASOTEC TABS 20MG

5

MO

ZESTRIL

4

MO

ALDOSTERONE RECEPTOR ANTAGONISTS

ALDACTONE

4

MO

CAROSPIR

4

MO

eplerenone

2

MO

INSPRA

4

MO

KERENDIA

3

QL (30 EA per 30 days) MO

spironolactone

1

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 30

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ALPHA BLOCKERS

CARDURA TABS 2MG, 4MG, 8MG

4

MO

CARDURA TABS 1MG

5

MO

doxazosin mesylate

2

MO

MINIPRESS

4

MO

prazosin hydrochloride

2

MO

terazosin hcl caps 10mg, 1mg, 5mg

1

MO

terazosin hydrochloride caps 2mg

1

MO

ANGIOTENSIN II RECEPTOR ANTAGONIST

COMBINATIONS

amlodipine besylate/valsartan

1

QL (30 EA per 30 days) MO

amlodipine/olmesartan medoxomil

1

QL (30 EA per 30 days) MO

amlodipine/valsartan/hydrochlorothiazide

1

QL (30 EA per 30 days) MO

ATACAND HCT TABS 32MG; 12.5MG, 32MG; 25MG

4

QL (30 EA per 30 days) ST MO

ATACAND HCT TABS 16MG; 12.5MG

4

QL (60 EA per 30 days) ST MO

AVALIDE TABS 12.5MG; 300MG

4

QL (30 EA per 30 days) ST MO

AVALIDE TABS 12.5MG; 150MG

4

QL (60 EA per 30 days) ST MO

AZOR

4

QL (30 EA per 30 days) ST MO

BENICAR HCT

4

QL (30 EA per 30 days) ST MO

candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg,

32mg; 25mg

1

QL (30 EA per 30 days) MO

candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg

1

QL (60 EA per 30 days) MO

DIOVAN HCT

4

QL (30 EA per 30 days) ST MO

EDARBYCLOR

4

QL (30 EA per 30 days) MO

ENTRESTO

3

MO

EXFORGE

4

QL (30 EA per 30 days) ST MO

EXFORGE HCT

4

QL (30 EA per 30 days) ST MO

HYZAAR

4

QL (30 EA per 30 days) ST MO

irbesartan/hydrochlorothiazide tabs 12.5mg; 300mg

1

QL (30 EA per 30 days) MO

irbesartan/hydrochlorothiazide tabs 12.5mg; 150mg

1

QL (60 EA per 30 days) MO

losartan potassium/hydrochlorothiazide

1

QL (30 EA per 30 days) MO

MICARDIS HCT TABS 12.5MG; 40MG, 25MG; 80MG

4

QL (30 EA per 30 days) ST MO

MICARDIS HCT TABS 12.5MG; 80MG

4

QL (60 EA per 30 days) ST MO

olmesartan medoxomil/amlodipine/hydrochlorothiazide

1

QL (30 EA per 30 days) MO

olmesartan medoxomil/hydrochlorothiazide

1

QL (30 EA per 30 days) MO

telmisartan/amlodipine

1

QL (30 EA per 30 days) MO

telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg;

80mg

1

QL (30 EA per 30 days) MO

telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg

1

QL (60 EA per 30 days) MO

TRIBENZOR

4

QL (30 EA per 30 days) ST MO

valsartan/hydrochlorothiazide

1

QL (30 EA per 30 days) MO

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND TABS 32MG

4

QL (30 EA per 30 days) ST MO

ATACAND TABS 16MG, 4MG, 8MG

4

QL (60 EA per 30 days) ST MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 31

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

AVAPRO

4

QL (30 EA per 30 days) ST MO

BENICAR TABS 20MG, 40MG

4

QL (30 EA per 30 days) ST MO

BENICAR TABS 5MG

4

QL (60 EA per 30 days) ST MO

candesartan cilexetil tabs 32mg

1

QL (30 EA per 30 days) MO

candesartan cilexetil tabs 16mg, 4mg, 8mg

1

QL (60 EA per 30 days) MO

COZAAR TABS 100MG

4

QL (30 EA per 30 days) ST MO

COZAAR TABS 25MG, 50MG

4

QL (60 EA per 30 days) ST MO

DIOVAN TABS 320MG

4

QL (30 EA per 30 days) ST MO

DIOVAN TABS 160MG, 40MG, 80MG

4

QL (60 EA per 30 days) ST MO

EDARBI

4

QL (30 EA per 30 days) MO

irbesartan

1

QL (30 EA per 30 days) MO

losartan potassium tabs 100mg

1

QL (30 EA per 30 days) MO

losartan potassium tabs 25mg, 50mg

1

QL (60 EA per 30 days) MO

MICARDIS

4

QL (30 EA per 30 days) ST MO

olmesartan medoxomil tabs 20mg, 40mg

1

QL (30 EA per 30 days) MO

olmesartan medoxomil tabs 5mg

1

QL (60 EA per 30 days) MO

telmisartan

1

QL (30 EA per 30 days) MO

VALSARTAN SOLN

5

QL (2400 ML per 30 days) PA

valsartan tabs 320mg

1

QL (30 EA per 30 days) MO

valsartan tabs 160mg, 40mg, 80mg

1

QL (60 EA per 30 days) MO

ANTIARRHYTHMICS

amiodarone hcl inj 50mg/ml, 900mg/18ml

2

amiodarone hydrochloride inj 150mg/3ml, 450mg/9ml

2

amiodarone hydrochloride tabs

2

MO

BETAPACE

5

MO

BETAPACE AF

4

MO

disopyramide phosphate

2

PA MO

dofetilide

2

flecainide acetate

2

MO

LIDOCAINE HCL IN D5W

4

LIDOCAINE HCL INJ 100MG/5ML VIALS

4

lidocaine hcl inj 100mg/5ml prefilled syringe, 50mg/5ml

prefilled syringe with needle

2

mexiletine hcl

2

MO

MULTAQ

4

MO

NEXTERONE

4

NORPACE CR

4

MO

NORPACE CAPS 100MG

4

PA MO

NORPACE CAPS 150MG

5

PA MO

pacerone

2

procainamide hcl

2

propafenone hcl tabs

2

MO

propafenone hydrochloride er caps

2

MO

quinidine gluconate cr

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 32

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

quinidine gluconate er

2

MO

quinidine sulfate

2

MO

RYTHMOL SR CP12 225MG

4

MO

RYTHMOL SR CP12 325MG, 425MG

5

MO

sorine

2

sotalol hcl

2

MO

sotalol hydrochloride (af)

2

MO

SOTYLIZE

5

MO

TIKOSYN

4

ST

ANTILIPEMICS, FIBRATES

ANTARA

4

MO

fenofibrate tabs

2

MO

FENOFIBRATE MICRONIZED CAPS 30MG, 90MG

4

MO

fenofibrate micronized caps 150mg, 134mg, 130mg, 200mg,

67mg, 50mg, 43mg

2

MO

fenofibric acid dr

2

MO

FENOGLIDE

4

MO

gemfibrozil

2

MO

LIPOFEN

4

MO

LOPID

4

MO

TRICOR

4

MO

TRILIPIX

4

MO

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS

ALTOPREV

5

QL (30 EA per 30 days) ST MO

atorvastatin calcium

1

QL (30 EA per 30 days) MO

CRESTOR

4

QL (30 EA per 30 days) ST MO

EZALLOR SPRINKLE

4

QL (30 EA per 30 days) ST MO

FLOLIPID

4

QL (300 ML per 30 days) ST MO

fluvastatin caps

1

QL (60 EA per 30 days) MO

fluvastatin sodium er tabs

1

QL (30 EA per 30 days) MO

LESCOL XL

4

QL (30 EA per 30 days) ST MO

LIPITOR

4

QL (30 EA per 30 days) ST MO

LIVALO

4

QL (30 EA per 30 days) ST MO

lovastatin

1

MO

pravastatin sodium

1

QL (30 EA per 30 days) MO

rosuvastatin calcium

1

QL (30 EA per 30 days) MO

simvastatin

1

QL (30 EA per 30 days) MO

ZOCOR

4

QL (30 EA per 30 days) ST MO

ZYPITAMAG

4

QL (30 EA per 30 days) ST MO

ANTILIPEMICS, MISCELLANEOUS

cholestyramine

2

MO

cholestyramine light

2

MO

colesevelam hydrochloride

2

MO

COLESTID

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 33

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

COLESTID FLAVORED

4

MO

colestipol hcl

2

MO

EVKEEZA

5

PA LA MO

ezetimibe

2

MO

EZETIMIBE/ROSUVASTATIN

4

QL (30 EA per 30 days) ST MO

ezetimibe/simvastatin

2

QL (30 EA per 30 days) MO

icosapent ethyl

2

MO

JUXTAPID

5

PA LA

LEQVIO

4

PA MO

LOVAZA

4

QL (120 EA per 30 days) MO

NEXLETOL

4

QL (30 EA per 30 days) PA MO

NEXLIZET

4

QL (30 EA per 30 days) PA MO

niacin er tbcr 1000mg, 750mg

2

MO

niacin er tbcr 500mg

2

QL (60 EA per 30 days) MO

niacin immediate release tabs 500mg

2

MO

niacor

2

MO

omega-3-acid ethyl esters

2

QL (120 EA per 30 days) MO

PRALUENT

3

PA

prevalite

2

MO

QUESTRAN

4

MO

QUESTRAN LIGHT

4

MO

REPATHA

3

PA

REPATHA PUSHTRONEX SYSTEM

3

PA

REPATHA SURECLICK

3

PA

ROSZET

4

QL (30 EA per 30 days) ST MO

VASCEPA

4

MO

VYTORIN

4

QL (30 EA per 30 days) ST MO

WELCHOL

4

MO

ZETIA

4

MO

BETA-BLOCKER/DIURETIC COMBINATIONS

atenolol/chlorthalidone

2

MO

bisoprolol fumarate/hydrochlorothiazide

2

MO

metoprolol/hydrochlorothiazide

2

MO

TENORETIC 100

4

MO

TENORETIC 50

4

MO

ZIAC TABS 10MG; 6.25MG, 5MG; 6.25MG

4

MO

ZIAC TABS 2.5MG; 6.25MG

5

MO

BETA-BLOCKERS

acebutolol hydrochloride

2

MO

atenolol

1

MO

betaxolol hcl tabs 10mg, 20mg

2

MO

bisoprolol fumarate

2

MO

BYSTOLIC TABS 10MG, 2.5MG, 5MG

4

QL (30 EA per 30 days) MO

BYSTOLIC TABS 20MG

4

QL (60 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 34

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

carvedilol phosphate er caps

2

QL (30 EA per 30 days) MO

carvedilol tabs

1

MO

COREG CR CAPS

4

QL (30 EA per 30 days) MO

COREG TABS

4

MO

CORGARD

4

MO

HEMANGEOL

4

MO

INDERAL LA

5

MO

INDERAL XL

5

MO

INNOPRAN XL

5

MO

KAPSPARGO SPRINKLE

4

ST MO

labetalol hydrochloride tabs, inj 5mg/ml

2

MO

LABETALOL HYDROCHLORIDE/DEXTROSE

4

LABETALOL HYDROCHLORIDE/SODIUM CHLORIDE

4

LOPRESSOR

4

MO

metoprolol succinate er

2

MO

metoprolol tartrate tabs

1

MO

metoprolol tartrate inj

2

nadolol

2

MO

nebivolol hydrochloride tabs 10mg, 2.5mg, 5mg

2

QL (30 EA per 30 days) MO

nebivolol hydrochloride tabs 20mg

2

QL (60 EA per 30 days) MO

pindolol

2

MO

propranolol hcl er caps 120mg, 160mg

2

MO

propranolol hcl er caps 60mg, 80mg

2

MO

propranolol hcl tabs

2

MO

propranolol hcl inj

2

propranolol hcl oral soln

2

MO

TENORMIN

4

MO

timolol maleate tabs 10mg, 20mg, 5mg

1

MO

TOPROL XL

4

MO

CALCIUM CHANNEL BLOCKERS

afeditab cr

2

amlodipine besylate

1

MO

CALAN SR

4

MO

CARDENE IV

4

CARDIZEM CD CP24 180MG, 300MG

4

MO

CARDIZEM CD CP24 120MG, 240MG, 360MG

5

MO

CARDIZEM LA

4

MO

CARDIZEM TABS 120MG, 30MG

4

MO

CARDIZEM TABS 60MG

5

MO

cartia xt

2

CONJUPRI

4

dilt-xr

2

MO

diltiazem hcl cd caps

2

MO

diltiazem hcl er caps 12hr, er caps 24hr, er tabs

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 35

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

diltiazem hcl inj 25mg/5ml

2

diltiazem hcl immediate release tabs

2

MO

DILTIAZEM HCL INJ 100MG

4

diltiazem hcl inj 125mg/25ml, 50mg/10ml

2

felodipine er

2

MO

isradipine

2

MO

KATERZIA

4

MO

LEVAMLODIPINE

4

matzim la

2

MO

nicardipine hcl caps

2

MO

NICARDIPINE HYDROCHLORIDE/SODIUM CHLORIDE

40MG/200ML; 0.9%

4

NICARDIPINE HYDROCHLORIDE INJ 20MG/200ML;

0.9%

4

nicardipine hydrochloride inj 2.5mg/ml

2

nifedipine caps

2

PA MO

nifedipine er tabs

2

MO

nimodipine

5

MO

nisoldipine er

2

MO

NORLIQVA

5

MO

NORVASC

4

MO

NYMALIZE

5

PROCARDIA XL

4

MO

SULAR

5

MO

taztia xt

2

tiadylt er cp24 120mg, 180mg, 240mg, 300mg, 360mg

2

tiadylt er cp24 420mg

2

MO

TIAZAC

4

MO

verapamil hcl er tbcr 120mg, 180mg, 240mg

2

MO

verapamil hcl immediate release tabs 40mg, 80mg

1

MO

VERAPAMIL HCL SR CP24 360MG

3

MO

verapamil hcl sr cp24 120mg, 180mg, 240mg

2

MO

verapamil hcl sr tbcr 240mg

2

MO

verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2

MO

verapamil hcl immediate release tabs 120mg

1

MO

verapamil hydrochloride inj

2

MO

VERELAN

4

MO

VERELAN PM

4

MO

DIURETICS

acetazolamide er caps

2

MO

acetazolamide sodium inj

2

acetazolamide tabs

2

MO

ALDACTAZIDE TABS 50MG; 50MG

4

ALDACTAZIDE TABS 25MG; 25MG

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 36

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

amiloride hcl

2

MO

amiloride/hydrochlorothiazide

2

MO

bumetanide

2

MO

BUMEX

4

MO

chlorothiazide sodium

2

chlorthalidone

2

MO

dichlorphenamide

5

QL (120 EA per 30 days) PA LA

DIURIL ORAL SUSP

4

MO

DYRENIUM

4

MO

EDECRIN TABS

5

MO

ethacrynate sodium inj

5

ethacrynic acid tabs

5

MO

FUROSCIX

5

furosemide oral soln, tabs

1

MO

furosemide inj

2

MO

hydrochlorothiazide

1

MO

indapamide

2

MO

KEVEYIS

5

QL (120 EA per 30 days) PA LA

LASIX

4

MO

MANNITOL INJ 20%

4

mannitol inj 25%

2

MO

MAXZIDE

4

MO

MAXZIDE-25

4

MO

methazolamide

2

MO

metolazone

2

MO

OSMITROL VIAFLEX

4

SOAANZ

4

MO

SODIUM DIURIL INJ

4

SODIUM EDECRIN INJ

4

spironolactone/hydrochlorothiazide

2

MO

THALITONE

4

QL (390 EA per 30 days) MO

torsemide

2

MO

triamterene

2

MO

triamterene/hydrochlorothiazide

1

MO

MISCELLANEOUS

ADRENALIN INJ 30MG/30ML

4

ADRENALIN INJ 1MG/ML

4

MO

aliskiren

1

MO

amlodipine besylate/atorvastatin calcium

1

MO

ASPRUZYO SPRINKLE

4

QL (60 EA per 30 days) PA MO

BIDIL

4

MO

CADUET

4

MO

CAMZYOS

5

QL (30 EA per 30 days) PA LA

CATAPRES-TTS-1

4

QL (8 EA per 28 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 37

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

CATAPRES-TTS-2

4

QL (8 EA per 28 days) MO

CATAPRES-TTS-3

5

QL (8 EA per 28 days) MO

clonidine hcl patch weekly 0.1mg/24hr, 0.2mg/24hr,

0.3mg/24hr

2

QL (8 EA per 28 days) MO

clonidine hydrochloride tabs

2

MO

CORLANOR SOLN

4

CORLANOR TABS

4

MO

DEMSER

5

PA MO

DIBENZYLINE

5

MO

digitek

2

QL (30 EA per 30 days)

digox tabs 0.25mg

2

QL (30 EA per 30 days)

digoxin inj, oral soln

2

MO

digoxin tabs 125mcg, 250mcg

2

QL (30 EA per 30 days) MO

digoxin tabs 62.5mcg

2

QL (90 EA per 30 days) MO

dobutamine hcl inj 250mg/20ml

2

B/D

DOBUTAMINE HYDROCHLORIDE/DEXTROSE 5%

4

B/D

DOPAMINE HYDROCHLORIDE INJ 40MG/ML

4

B/D

DOPAMINE HYDROCHLORIDE/DEXTROSE

4

B/D

droxidopa caps 200mg, 300mg

5

QL (180 EA per 30 days) PA

droxidopa caps 100mg

5

QL (90 EA per 30 days) PA

epinephrine inj 1mg/ml, 30mg/30ml

2

guanfacine hcl

2

PA MO

guanfacine hydrochloride tabs 2mg

2

PA MO

hydralazine hcl

2

MO

isosorbide dinitrate/hydralazine hydrochloride

2

MO

LANOXIN PEDIATRIC

4

LANOXIN INJ

4

MO

LANOXIN TABS 125MCG, 250MCG

4

QL (30 EA per 30 days) MO

LANOXIN TABS 62.5MCG

4

QL (90 EA per 30 days) MO

metyrosine

5

PA MO

midodrine hcl

2

MO

milrinone lactate in dextrose

2

B/D

milrinone lactate inj 10mg/10ml, 50mg/50ml

2

B/D

milrinone lactate inj 20mg/20ml

5

B/D

minoxidil

2

MO

NORTHERA CAPS 200MG, 300MG

5

QL (180 EA per 30 days) PA LA

NORTHERA CAPS 100MG

5

QL (90 EA per 30 days) PA LA

phenoxybenzamine hydrochloride

5

MO

RANEXA

4

MO

ranolazine er

2

MO

TEKTURNA

4

MO

TEKTURNA HCT

4

MO

VECAMYL

5

QL (300 EA per 30 days) PA

VERQUVO

3

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 38

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

VYNDAMAX

5

QL (30 EA per 30 days) PA LA

VYNDAQEL

5

QL (120 EA per 30 days) PA LA

NITRATES

GONITRO

4

MO

ISORDIL TITRADOSE TABS 5MG

4

MO

ISORDIL TITRADOSE TABS 40MG

5

MO

isosorbide dinitrate tabs 10mg, 20mg, 30mg, 5mg

2

MO

isosorbide dinitrate tabs 40mg

5

MO

isosorbide mononitrate er tabs 30mg, 60mg, 120mg

2

MO

isosorbide mononitrate immediate release tabs 10mg, 20mg

1

MO

NITRO-BID

3

MO

NITRO-DUR PT24 0.1MG/HR, 0.2MG/HR, 0.4MG/HR,

0.6MG/HR

4

MO

NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR

5

MO

NITROGLYCERIN IN DEXTROSE 5%

4

nitroglycerin lingual spray

2

MO

nitroglycerin transdermal

2

MO

NITROGLYCERIN INJ

4

nitroglycerin sublingual tabs

2

MO

NITROLINGUAL PUMPSPRAY

4

MO

NITROSTAT

4

MO

PULMONARY ARTERIAL HYPERTENSION

ADCIRCA

5

PA

ADEMPAS

5

QL (90 EA per 30 days) PA LA

alyq

5

PA

ambrisentan

5

QL (30 EA per 30 days) PA LA

bosentan tabs 62.5mg

5

QL (120 EA per 30 days) PA LA

bosentan tabs 125mg

5

QL (60 EA per 30 days) PA LA

epoprostenol sodium

2

B/D LA

FLOLAN INJ 0.5MG

4

B/D LA

FLOLAN INJ 1.5MG

5

B/D LA

LETAIRIS

5

QL (30 EA per 30 days) PA LA

OPSUMIT

5

QL (30 EA per 30 days) PA LA

ORENITRAM TBCR 0.125MG

4

PA LA

ORENITRAM TBCR 0.25MG, 1MG, 2.5MG, 5MG

5

PA LA

REMODULIN

5

PA LA

REVATIO INJ

5

QL (1125 ML per 30 days) PA

REVATIO ORAL SUSP

5

QL (224 ML per 30 days) PA

REVATIO TABS

5

QL (90 EA per 30 days) PA

sildenafil inj

5

QL (1125 ML per 30 days) PA

sildenafil citrate tabs 20mg

2

QL (90 EA per 30 days) PA

sildenafil oral susp

5

QL (224 ML per 30 days) PA

tadalafil (generic adcirca) tabs 20mg

5

PA

TADLIQ

5

QL (300 ML per 30 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 39

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

TRACLEER ORAL TABLET SOLUBLE

5

QL (120 EA per 30 days) PA LA

TRACLEER TABS 62.5MG

5

QL (120 EA per 30 days) PA LA

TRACLEER TABS 125MG

5

QL (60 EA per 30 days) PA LA

treprostinil

5

PA LA

TYVASO

5

PA LA

TYVASO DPI MAINTENANCE KIT POWD 16MCG,

32MCG, 48MCG, 64MCG

5

QL (112 EA per 28 days) PA LA

TYVASO DPI MAINTENANCE KIT POWD 32MCG;

48MCG

5

QL (224 EA per 28 days) PA LA

TYVASO DPI TITRATION KIT POWD 16MCG; 32MCG

5

QL (196 EA per 28 days) PA LA

TYVASO DPI TITRATION KIT POWD 16MCG; 32MCG;

48MCG

5

QL (252 EA per 28 days) PA LA

TYVASO REFILL

5

PA

TYVASO STARTER

5

PA

UPTRAVI TITRATION PACK

5

PA LA

UPTRAVI INJ

5

QL (60 EA per 30 days) PA LA MO

UPTRAVI TABS 800MCG

5

QL (120 EA per 30 days) PA LA

UPTRAVI TABS 600MCG

5

QL (150 EA per 30 days) PA LA

UPTRAVI TABS 400MCG

5

QL (240 EA per 30 days) PA LA

UPTRAVI TABS 200MCG

5

QL (480 EA per 30 days) PA LA

UPTRAVI TABS 1200MCG, 1400MCG, 1600MCG

5

QL (60 EA per 30 days) PA LA

UPTRAVI TABS 1000MCG

5

QL (90 EA per 30 days) PA LA

VELETRI

5

B/D LA

VENTAVIS

5

PA LA

CENTRAL NERVOUS SYSTEM

ANTIANXIETY

alprazolam er tb24 0.5mg

2

MO

alprazolam er tb24 1mg

2

QL (30 EA per 30 days) MO

alprazolam er tb24 3mg

2

QL (60 EA per 30 days) MO

alprazolam er tb24 2mg

2

QL (90 EA per 30 days) MO

ALPRAZOLAM INTENSOL

4

QL (300 ML per 30 days) MO

alprazolam odt tbdp 0.25mg

2

QL (120 EA per 30 days) MO

alprazolam odt tbdp 0.5mg, 1mg, 2mg

2

QL (150 EA per 30 days) MO

ALPRAZOLAM XR TB24 1MG

4

QL (30 EA per 30 days) MO

ALPRAZOLAM XR TB24 3MG

4

QL (60 EA per 30 days) MO

ALPRAZOLAM XR TB24 2MG

4

QL (90 EA per 30 days) MO

alprazolam tabs 0.25mg, 0.5mg

2

QL (120 EA per 30 days) MO

alprazolam tabs 1mg, 2mg

2

QL (150 EA per 30 days) MO

ATIVAN INJ 4MG/ML

4

QL (150 ML per 30 days)

ATIVAN INJ 2MG/ML

4

QL (150 ML per 30 days) MO

ATIVAN TABS 0.5MG

5

QL (120 EA per 30 days) MO

ATIVAN TABS 1MG, 2MG

5

QL (150 EA per 30 days) MO

buspirone hcl

2

MO

chlordiazepoxide hcl

2

QL (120 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 40

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

droperidol

2

MO

fluvoxamine maleate er caps

2

QL (60 EA per 30 days) MO

fluvoxamine maleate tabs

2

MO

lorazepam intensol

2

QL (150 ML per 30 days) MO

lorazepam inj

2

QL (150 ML per 30 days) MO

lorazepam tabs 0.5mg

2

QL (120 EA per 30 days) MO

lorazepam tabs 1mg, 2mg

2

QL (150 EA per 30 days) MO

LOREEV XR CS24 1.5MG

5

QL (150 EA per 30 days) PA

LOREEV XR CS24 1MG, 2MG

5

QL (150 EA per 30 days) PA MO

LOREEV XR CS24 3MG

5

QL (90 EA per 30 days) PA MO

meprobamate

2

PA MO

oxazepam

2

QL (120 EA per 30 days) PA MO

XANAX XR TB24 1MG

4

QL (30 EA per 30 days) ST MO

XANAX XR TB24 3MG

4

QL (60 EA per 30 days) ST MO

XANAX XR TB24 2MG

4

QL (90 EA per 30 days) ST MO

XANAX XR TB24 0.5MG

4

ST MO

XANAX TABS 0.25MG, 0.5MG

4

QL (120 EA per 30 days) ST MO

XANAX TABS 1MG

4

QL (150 EA per 30 days) ST MO

XANAX TABS 2MG

5

QL (150 EA per 30 days) ST MO

ANTICONVULSANTS

APTIOM TABS 200MG, 400MG

5

QL (30 EA per 30 days) MO

APTIOM TABS 600MG, 800MG

5

QL (60 EA per 30 days) MO

BANZEL SUSP

5

QL (2760 ML per 30 days) PA MO

BANZEL TABS 400MG

5

QL (240 EA per 30 days) PA MO

BANZEL TABS 200MG

5

QL (480 EA per 30 days) PA MO

BRIVIACT TABS

5

QL (60 EA per 30 days) PA MO

BRIVIACT INJ

5

QL (600 ML per 30 days) PA

BRIVIACT ORAL SOLN

5

QL (600 ML per 30 days) PA MO

carbamazepine

2

MO

carbamazepine er

2

MO

CARBATROL

4

MO

CELONTIN

4

MO

CEREBYX INJ 500MG PE/10ML

4

MO

CEREBYX INJ 100MG PE/2ML

5

clobazam susp

2

QL (480 ML per 30 days) PA MO

clobazam tabs

2

QL (60 EA per 30 days) PA MO

clonazepam odt tbdp 2mg

2

QL (300 EA per 30 days) MO

clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg

2

QL (90 EA per 30 days) MO

clonazepam tabs 2mg

2

QL (300 EA per 30 days) MO

clonazepam tabs 0.5mg, 1mg

2

QL (90 EA per 30 days) MO

clorazepate dipotassium tabs 15mg

2

QL (180 EA per 30 days) PA MO

clorazepate dipotassium tabs 3.75mg, 7.5mg

2

QL (90 EA per 30 days) PA MO

DEPAKOTE

4

MO

DEPAKOTE ER

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 41

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

DEPAKOTE SPRINKLES

4

MO

DIACOMIT CAPS 500MG

5

QL (180 EA per 30 days) PA LA

DIACOMIT CAPS 250MG

5

QL (360 EA per 30 days) PA LA

DIACOMIT PACK 500MG

5

QL (180 EA per 30 days) PA LA

DIACOMIT PACK 250MG

5

QL (360 EA per 30 days) PA LA

DIASTAT ACUDIAL

4

MO

DIASTAT PEDIATRIC

4

MO

diazepam intensol

2

QL (240 ML per 30 days) PA MO

DIAZEPAM RECTAL GEL

4

MO

diazepam tabs

2

QL (120 EA per 30 days) PA MO

diazepam oral soln

2

QL (1200 ML per 30 days) PA MO

diazepam oral conc, inj

2

QL (240 ML per 30 days) PA MO

DILANTIN

4

MO

DILANTIN INFATABS

4

MO

DILANTIN-125

4

MO

divalproex sodium dr

2

MO

divalproex sodium er

2

MO

divalproex sodium sprinkle caps

2

MO

EPIDIOLEX

5

QL (600 ML per 30 days) PA LA

epitol

2

EPRONTIA

4

QL (480 ML per 30 days) PA MO

ethosuximide

2

MO

felbamate

2

MO

FELBATOL

5

MO

FINTEPLA

5

QL (360 ML per 30 days) PA LA

fosphenytoin sodium inj 100mg pe/2ml

2

fosphenytoin sodium inj 500mg pe/10ml

2

MO

FYCOMPA SUSP

5

QL (720 ML per 30 days) PA MO

FYCOMPA TABS 2MG

4

QL (60 EA per 30 days) PA MO

FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG

5

QL (30 EA per 30 days) PA MO

gabapentin caps 100mg

2

QL (180 EA per 30 days) MO

gabapentin caps 400mg

2

QL (270 EA per 30 days) MO

gabapentin caps 300mg

2

QL (360 EA per 30 days) MO

gabapentin soln

2

QL (2160 ML per 30 days) MO

gabapentin tabs 600mg

2

QL (180 EA per 30 days) MO

gabapentin tabs 800mg

2

QL (90 EA per 30 days) MO

GABITRIL

5

MO

KEPPRA XR

5

MO

KEPPRA INJ

4

KEPPRA ORAL SOLN

5

MO

KEPPRA TABS 250MG

4

MO

KEPPRA TABS 1000MG, 500MG, 750MG

5

MO

KLONOPIN TABS 2MG

4

QL (300 EA per 30 days) MO

KLONOPIN TABS 0.5MG, 1MG

4

QL (90 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 42

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

lacosamide inj

2

lacosamide oral soln

2

QL (1200 ML per 30 days) MO

lacosamide tabs 50mg

2

QL (120 EA per 30 days) MO

lacosamide tabs 100mg, 150mg, 200mg

2

QL (60 EA per 30 days) MO

LAMICTAL CHEWABLE DISPERSIBLE

5

MO

LAMICTAL ODT KIT

4

MO

LAMICTAL ODT TBDP

5

MO

LAMICTAL STARTER KIT (ORANGE)

4

MO

LAMICTAL STARTER KIT (GREEN)

5

MO

LAMICTAL STARTER KIT (BLUE)

4

MO

LAMICTAL TABS

5

MO

LAMICTAL XR TB24

5

MO

LAMICTAL XR TITRATION KIT BLUE, ORANGE

4

MO

LAMCITAL XR TITRATION KIT GREEN

5

MO

lamotrigine er

2

MO

lamotrigine immediate release tabs, chew tabs

2

MO

lamotrigine odt

2

MO

lamotrigine odt titration kit (orange)

2

MO

lamotrigine starter kit/blue

2

MO

lamotrigine starter kit/green

5

MO

lamotrigine starter kit/orange

2

MO

levetiracetam er

2

MO

levetiracetam/sodium chloride inj

2

levetiracetam inj

2

levetiracetam oral soln, tabs

2

MO

LYRICA SOLN

5

QL (900 ML per 30 days) PA MO

LYRICA CAPS 100MG, 150MG, 25MG, 50MG, 75MG

4

QL (120 EA per 30 days) PA MO

LYRICA CAPS 225MG, 300MG

4

QL (60 EA per 30 days) PA MO

LYRICA CAPS 200MG

4

QL (90 EA per 30 days) PA MO

MYSOLINE

5

MO

NAYZILAM

4

QL (10 EA per 30 days) PA MO

NEURONTIN SOLN

5

QL (2160 ML per 30 days) MO

NEURONTIN CAPS 100MG

4

QL (180 EA per 30 days) MO

NEURONTIN CAPS 400MG

5

QL (270 EA per 30 days) MO

NEURONTIN CAPS 300MG

5

QL (360 EA per 30 days) MO

NEURONTIN TABS 600MG

5

QL (180 EA per 30 days) MO

NEURONTIN TABS 800MG

5

QL (90 EA per 30 days) MO

ONFI SUSP

5

QL (480 ML per 30 days) PA MO

ONFI TABS

5

QL (60 EA per 30 days) PA MO

oxcarbazepine

2

MO

OXTELLAR XR TB24 150MG

4

MO

OXTELLAR XR TB24 300MG, 600MG

5

MO

phenobarbital sodium inj

2

PA

phenobarbital tabs

2

QL (120 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 43

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

phenobarbital elix

2

QL (1500 ML per 30 days) PA MO

PHENYTEK

4

MO

phenytoin chew tabs, oral susp

2

MO

phenytoin sodium extended release caps

2

MO

phenytoin sodium inj

2

pregabalin caps 100mg, 150mg, 25mg, 50mg, 75mg

2

QL (120 EA per 30 days) PA MO

pregabalin caps 225mg, 300mg

2

QL (60 EA per 30 days) PA MO

pregabalin caps 200mg

2

QL (90 EA per 30 days) PA MO

pregabalin soln

2

QL (900 ML per 30 days) PA MO

primidone

2

MO

QUDEXY XR CS24 25MG, 50MG

4

MO

QUDEXY XR CS24 100MG, 150MG, 200MG

5

MO

roweepra

2

rufinamide susp

5

QL (2760 ML per 30 days) PA MO

rufinamide tabs 200mg

2

QL (480 EA per 30 days) PA MO

rufinamide tabs 400mg

5

QL (240 EA per 30 days) PA MO

SABRIL

5

QL (180 EA per 30 days) PA LA

SPRITAM

4

PA MO

subvenite starter kit/blue

2

subvenite starter kit/green

5

subvenite starter kit/orange

2

subvenite tabs

2

SYMPAZAN

5

QL (60 EA per 30 days) PA MO

TEGRETOL

4

MO

TEGRETOL-XR

4

MO

tiagabine hydrochloride

2

MO

TOPAMAX SPRINKLE CPSP 15MG

4

MO

TOPAMAX SPRINKLE CPSP 25MG

5

MO

TOPAMAX TABS 25MG

4

QL (90 EA per 30 days) MO

TOPAMAX TABS 100MG

5

QL (120 EA per 30 days) MO

TOPAMAX TABS 200MG

5

QL (60 EA per 30 days) MO

TOPAMAX TABS 50MG

5

QL (90 EA per 30 days) MO

topiramate er caps (generic Trokendi XR)

2

topiramate er sprinkle caps (generic Qudexy XR)

2

MO

topiramate sprinkle caps

2

MO

topiramate tabs 100mg

2

QL (120 EA per 30 days) MO

topiramate tabs 200mg

2

QL (60 EA per 30 days) MO

topiramate tabs 25mg, 50mg

2

QL (90 EA per 30 days) MO

TRANXENE T

4

QL (90 EA per 30 days) PA MO

TRILEPTAL SUSP

5

MO

TRILEPTAL TABS 150MG

4

MO

TRILEPTAL TABS 300MG, 600MG

5

MO

TROKENDI XR CP24 25MG, 50MG

4

MO

TROKENDI XR CP24 100MG, 200MG

5

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 44

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

VALIUM

4

QL (120 EA per 30 days) PA MO

valproate sodium inj

5

valproic acid caps, oral soln

2

MO

VALTOCO LIQUID NASAL SPRAY

4

QL (10 EA per 30 days) PA MO

VALTOCO LIQUID THERAPY PACK

5

QL (10 EA per 30 days) PA MO

vigabatrin

5

QL (180 EA per 30 days) PA LA

vigadrone

2

QL (180 EA per 30 days) PA LA

VIMPAT INJ

5

VIMPAT ORAL SOLN

5

QL (1200 ML per 30 days) MO

VIMPAT TABS 50MG

5

QL (120 EA per 30 days) MO

VIMPAT TABS 100MG, 150MG, 200MG

5

QL (60 EA per 30 days) MO

XCOPRI TABS 100MG, 50MG

5

QL (30 EA per 30 days) MO

XCOPRI TABS 150MG, 200MG

5

QL (60 EA per 30 days) MO

XCOPRI TITRATION PACK 12.5MG; 25MG

4

QL (28 EA per 28 days) MO

XCOPRI TITRATION PACK 50MG; 100MG, 150MG;

200MG

5

QL (28 EA per 28 days) MO

XCOPRI MAINTENANCE PACK 100MG; 150MG, 150MG;

200MG

5

QL (56 EA per 28 days) MO

ZARONTIN

4

MO

ZONEGRAN

5

MO

ZONISADE

5

QL (900 ML per 30 days) PA MO

zonisamide

2

MO

ZTALMY

5

QL (1100 ML per 30 days) PA LA

MO

ANTIDEMENTIA

ADLARITY

4

QL (4 EA per 28 days) PA MO

ARICEPT

4

QL (30 EA per 30 days) MO

donepezil hcl odt tabs

2

QL (30 EA per 30 days) MO

donepezil hcl tabs

2

QL (30 EA per 30 days) MO

ergoloid mesylates

5

PA MO

EXELON

4

QL (30 EA per 30 days) MO

galantamine hydrobromide er caps

2

QL (30 EA per 30 days) MO

galantamine hydrobromide soln

2

QL (200 ML per 30 days) MO

galantamine hydrobromide tabs

2

QL (60 EA per 30 days) MO

memantine hcl titration pak

2

QL (98 EA per 365 days) PA MO

memantine hydrochloride er caps

2

PA MO

memantine hydrochloride soln

2

QL (360 ML per 30 days) PA MO

memantine hydrochloride tabs

2

QL (60 EA per 30 days) PA MO

NAMENDA

4

QL (60 EA per 30 days) PA MO

NAMENDA TITRATION PAK

4

QL (98 EA per 365 days) PA MO

NAMENDA XR

4

PA MO

NAMZARIC

4

MO

RAZADYNE ER

4

QL (30 EA per 30 days) MO

rivastigmine tartrate caps

2

QL (60 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 45

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

rivastigmine transdermal system

2

QL (30 EA per 30 days) MO

ANTIDEPRESSANTS

amitriptyline hcl tabs 100mg, 150mg, 75mg

2

MO

amitriptyline hydrochloride tabs 10mg, 25mg, 50mg

2

MO

amoxapine

2

MO

ANAFRANIL

5

PA MO

APLENZIN TB24 348MG, 522MG

5

QL (30 EA per 30 days) ST MO

APLENZIN TB24 174MG

5

QL (60 EA per 30 days) ST MO

AUVELITY

5

QL (60 EA per 30 days) PA MO

bupropion hcl immediate release tabs 100mg

2

QL (120 EA per 30 days) MO

bupropion hcl immediate release tabs 75mg

2

QL (180 EA per 30 days) MO

bupropion hydrochloride er (sr) tb12 100mg, 150mg, 200mg

2

QL (60 EA per 30 days) MO

BUPROPION HYDROCHLORIDE ER (XL) TB24 450MG

4

QL (30 EA per 30 days) MO

bupropion hydrochloride er (xl) tb24 150mg, 300mg

2

QL (30 EA per 30 days) MO

CELEXA TABS 10MG

4

QL (120 EA per 30 days) ST MO

CELEXA TABS 40MG

4

QL (30 EA per 30 days) ST MO

CELEXA TABS 20MG

4

QL (60 EA per 30 days) ST MO

chlordiazepoxide/amitriptyline

2

PA MO

CITALOPRAM HYDROBROMIDE CAPS

4

QL (30 EA per 30 days) PA MO

citalopram hydrobromide soln

2

QL (600 ML per 30 days) MO

citalopram hydrobromide tabs 10mg

1

QL (120 EA per 30 days) MO

citalopram hydrobromide tabs 40mg

1

QL (30 EA per 30 days) MO

citalopram hydrobromide tabs 20mg

1

QL (60 EA per 30 days) MO

clomipramine hydrochloride

2

PA MO

CYMBALTA

4

QL (60 EA per 30 days) MO

desipramine hydrochloride tabs

2

MO

DESVENLAFAXINE ER (GENERIC KHEDEZLA) TB24

100MG, 50MG

3

QL (30 EA per 30 days)

desvenlafaxine er (generic Pristiq) tb24 100mg, 25mg, 50mg

2

QL (30 EA per 30 days) PA MO

doxepin hcl oral conc, caps 75mg

2

MO

doxepin hydrochloride caps 100mg, 10mg, 150mg, 25mg,

50mg

2

MO

DRIZALMA SPRINKLE CSDR 20MG, 30MG, 60MG

4

QL (60 EA per 30 days) PA MO

DRIZALMA SPRINKLE CSDR 40MG

4

QL (90 EA per 30 days) PA MO

duloxetine hcl

2

QL (60 EA per 30 days) MO

EFFEXOR XR CP24 37.5MG, 75MG

4

QL (30 EA per 30 days) ST MO

EFFEXOR XR CP24 150MG

4

QL (60 EA per 30 days) ST MO

EMSAM

5

QL (30 EA per 30 days) PA MO

escitalopram oxalate soln

2

QL (600 ML per 30 days) MO

escitalopram oxalate tabs 20mg

2

QL (30 EA per 30 days) MO

escitalopram oxalate tabs 10mg, 5mg

2

QL (45 EA per 30 days) MO

FETZIMA TITRATION PACK

4

PA MO

FETZIMA CP24 120MG, 80MG

4

QL (30 EA per 30 days) PA MO

FETZIMA CP24 20MG, 40MG

4

QL (60 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 46

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

fluoxetine dr caps 90mg

2

QL (4 EA per 28 days) MO

fluoxetine hydrochloride caps 20mg

1

QL (120 EA per 30 days) MO

fluoxetine hcl soln

2

MO

fluoxetine hydrochloride caps 10mg

1

QL (30 EA per 30 days) MO

fluoxetine hydrochloride caps 40mg

1

QL (60 EA per 30 days) MO

fluoxetine hydrochloride (generic Prozac) tabs 10mg, 20mg,

60mg

2

MO

fluoxetine hydrochloride tabs (generic Sarafem) 20mg

2

QL (120 EA per 30 days) MO

fluoxetine hydrochloride tabs (generic Sarafem) 10mg

2

QL (30 EA per 30 days) MO

FORFIVO XL

4

QL (30 EA per 30 days) ST MO

imipramine hcl tabs 25mg, 50mg

2

MO

imipramine hydrochloride tabs 10mg

2

MO

imipramine pamoate

2

MO

LEXAPRO TABS 20MG

4

QL (30 EA per 30 days) MO

LEXAPRO TABS 10MG, 5MG

4

QL (45 EA per 30 days) MO

MARPLAN

4

QL (180 EA per 30 days) MO

mirtazapine odt

2

QL (30 EA per 30 days) MO

mirtazapine tabs

2

QL (30 EA per 30 days) MO

NARDIL

4

MO

nefazodone hydrochloride

2

MO

NORPRAMIN

4

PA MO

nortriptyline hcl caps 25mg, 75mg, soln 10mg/5ml

2

MO

nortriptyline hydrochloride caps 10mg, 50mg

2

MO

olanzapine/fluoxetine

2

QL (30 EA per 30 days) MO

PAMELOR

5

MO

PARNATE

5

MO

paroxetine hcl er tb24 37.5mg

2

QL (60 EA per 30 days) MO

paroxetine hcl er tb24 12.5mg, 25mg

2

QL (90 EA per 30 days) MO

paroxetine hcl tabs 40mg

2

QL (30 EA per 30 days) MO

paroxetine hcl tabs 30mg

2

QL (60 EA per 30 days) MO

paroxetine hcl tabs 10mg, 20mg

2

QL (30 EA per 30 days) MO

paroxetine hydrochloride susp

2

QL (900 ML per 30 days) MO

PAXIL CR TB24 37.5MG

4

QL (60 EA per 30 days) ST MO

PAXIL CR TB24 12.5MG, 25MG

4

QL (90 EA per 30 days) ST MO

PAXIL SUSP

4

QL (900 ML per 30 days) MO

PAXIL TABS 10MG, 20MG, 40MG

4

QL (30 EA per 30 days) ST MO

PAXIL TABS 30MG

4

QL (60 EA per 30 days) ST MO

perphenazine/amitriptyline

2

PA MO

PEXEVA TABS 10MG, 20MG, 40MG

4

QL (30 EA per 30 days) ST MO

PEXEVA TABS 30MG

4

QL (60 EA per 30 days) ST MO

phenelzine sulfate

2

MO

PRISTIQ

4

QL (30 EA per 30 days) ST MO

protriptyline hcl

2

PA MO

PROZAC CAPS 10MG

4

QL (30 EA per 30 days) ST MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 47

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

PROZAC CAPS 20MG

5

QL (120 EA per 30 days) ST MO

PROZAC CAPS 40MG

5

QL (60 EA per 30 days) ST MO

REMERON

4

QL (30 EA per 30 days) MO

REMERON SOLTAB

4

QL (30 EA per 30 days) MO

sertraline oral conc

2

QL (300 ML per 30 days) MO

sertraline hcl tabs 25mg

1

QL (30 EA per 30 days) MO

sertraline hcl tabs 50mg

1

QL (60 EA per 30 days) MO

SERTRALINE HYDROCHLORIDE CAPS

4

QL (30 EA per 30 days) ST MO

sertraline hcl tabs 100mg

1

QL (60 EA per 30 days) MO

SYMBYAX

4

QL (30 EA per 30 days) MO

tranylcypromine sulfate

2

MO

trazodone hydrochloride tabs

1

MO

trimipramine maleate caps 50mg

2

QL (120 EA per 30 days) PA MO

trimipramine maleate caps 25mg

2

QL (240 EA per 30 days) PA MO

trimipramine maleate caps 100mg

2

QL (60 EA per 30 days) PA MO

TRINTELLIX

4

QL (30 EA per 30 days) MO

VENLAFAXINE BESYLATE ER

4

QL (60 EA per 30 days) MO

venlafaxine hcl er cp24 37.5mg

2

QL (30 EA per 30 days) MO

venlafaxine hcl er cp24 150mg

2

QL (60 EA per 30 days) MO

venlafaxine hcl er tb24 37.5mg

2

QL (30 EA per 30 days) MO

venlafaxine hydrochloride immediate release tabs 100mg,

25mg, 37.5mg, 50mg, 75mg

2

MO

venlafaxine hcl er cp24 75mg

2

QL (30 EA per 30 days) MO

venlafaxine hydrochloride er tb24 225mg, 37.5mg, 75mg

2

QL (30 EA per 30 days) MO

venlafaxine hydrochloride er tb24 150mg

2

QL (60 EA per 30 days) MO

VIIBRYD

4

QL (30 EA per 30 days) MO

VIIBRYD STARTER PACK

4

MO

vilazodone hydrochloride

2

QL (30 EA per 30 days) MO

WELLBUTRIN SR

4

QL (60 EA per 30 days) ST MO

WELLBUTRIN XL

5

QL (30 EA per 30 days) ST MO

ZOLOFT ORAL CONC

4

QL (300 ML per 30 days) MO

ZOLOFT TABS 25MG

4

QL (30 EA per 30 days) ST MO

ZOLOFT TABS 100MG, 50MG

4

QL (60 EA per 30 days) ST MO

ZULRESSO

5

B/D LA

ANTIPARKINSONIAN AGENTS

amantadine hcl soln, tabs

2

MO

amantadine hcl caps

2

QL (120 EA per 30 days) MO

APOKYN

5

QL (60 ML per 30 days) PA LA

apomorphine hydrochloride

5

QL (60 ML per 30 days) PA

AZILECT

5

MO

benztropine mesylate inj

2

MO

benztropine mesylate tabs

2

PA MO

bromocriptine mesylate tabs, caps

2

MO

carbidopa tabs

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 48

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

carbidopa/levodopa

2

MO

carbidopa/levodopa er

2

MO

carbidopa/levodopa odt

2

MO

CARBIDOPA/LEVODOPA/ENTACAPONE

4

MO

COGENTIN

4

COMTAN

5

MO

DHIVY

4

MO

DUOPA

5

B/D LA

entacapone

2

MO

GOCOVRI CP24 68.5MG

5

QL (30 EA per 30 days) LA

GOCOVRI CP24 137MG

5

QL (60 EA per 30 days) LA

INBRIJA

5

QL (300 EA per 30 days) PA LA

KYNMOBI SUBLINGUAL FILM 10MG, 15MG, 20MG,

25MG, 30MG

5

QL (150 EA per 30 days) PA

LODOSYN

5

MO

MIRAPEX ER TB24 0.75MG, 2.25MG, 3.75MG, 3MG,

4.5MG

4

QL (30 EA per 30 days) ST MO

MIRAPEX ER TB24 0.375MG, 1.5MG

5

QL (30 EA per 30 days) ST MO

NEUPRO

4

MO

NOURIANZ

5

QL (30 EA per 30 days) PA LA

ONGENTYS CAPS 50MG

4

QL (30 EA per 30 days) PA MO

ONGENTYS CAPS 25MG

5

QL (30 EA per 30 days) PA MO

OSMOLEX ER

4

QL (30 EA per 30 days) ST LA

PARLODEL

4

MO

pramipexole dihydrochloride er

2

QL (30 EA per 30 days) MO

pramipexole dihydrochloride immediate release tabs

2

MO

rasagiline mesylate

2

MO

ropinirole er tb24 6mg

2

QL (120 EA per 30 days) MO

ropinirole er tb24 4mg

2

QL (150 EA per 30 days) MO

ropinirole er tb24 2mg

2

QL (30 EA per 30 days) MO

ropinirole er tb24 12mg

2

QL (60 EA per 30 days) MO

ropinirole er tb24 8mg

2

QL (90 EA per 30 days) MO

ropinirole hcl immediate release tabs 0.25mg, 3mg

2

MO

ropinirole hcl immediate release tabs 0.5mg, 1mg, 2mg, 4mg,

5mg

2

MO

RYTARY

4

ST MO

selegiline hcl tabs, caps

2

MO

SINEMET

4

MO

STALEVO 100

5

ST MO

STALEVO 125

5

ST MO

STALEVO 150

5

ST MO

STALEVO 200

5

ST MO

STALEVO 50

5

ST MO

STALEVO 75

5

ST MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 49

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

TASMAR

5

MO

tolcapone

5

MO

trihexyphenidyl hcl oral soln

2

PA MO

trihexyphenidyl hydrochloride tabs

2

PA MO

XADAGO

5

QL (30 EA per 30 days) ST MO

ZELAPAR

5

QL (60 EA per 30 days) MO

ANTIPSYCHOTICS

ABILIFY

5

QL (30 EA per 30 days) MO

ABILIFY MAINTENA

5

QL (1 EA per 28 days) MO

ABILIFY MYCITE

5

QL (30 EA per 30 days) PA

ABILIFY MYCITE MAINTENANCE KIT

5

QL (30 EA per 30 days) PA

ABILIFY MYCITE STARTER KIT

5

QL (30 EA per 30 days) PA

aripiprazole odt

2

QL (60 EA per 30 days) MO

aripiprazole tabs

2

QL (30 EA per 30 days) MO

aripiprazole soln

2

QL (900 ML per 30 days) MO

ARISTADA INITIO

5

ARISTADA INJ 441MG/1.6ML

5

QL (1.6 ML per 28 days)

ARISTADA INJ 662MG/2.4ML

5

QL (2.4 ML per 28 days)

ARISTADA INJ 882MG/3.2ML

5

QL (3.2 ML per 28 days)

ARISTADA INJ 1064MG/3.9ML

5

QL (3.9 ML per 56 days)

asenapine maleate sl

2

QL (60 EA per 30 days) MO

CAPLYTA

5

QL (30 EA per 30 days) PA MO

chlorpromazine hcl tabs

2

MO

chlorpromazine hcl inj 50mg/2ml

2

chlorpromazine hcl inj 25mg/ml

2

MO

chlorpromazine hydrochloride oral conc 100mg/ml, 30mg/ml

2

CLOZAPINE ODT TBDP 150MG

4

QL (180 EA per 30 days) PA

CLOZAPINE ODT TBDP 200MG

5

QL (120 EA per 30 days) PA

clozapine odt tbdp 12.5mg, 25mg

2

PA

clozapine odt tbdp 100mg

2

QL (270 EA per 30 days) PA

clozapine tabs 25mg, 50mg

2

clozapine tabs 200mg

2

QL (120 EA per 30 days)

clozapine tabs 100mg

2

QL (270 EA per 30 days)

CLOZARIL TABS 25MG, 50MG

4

CLOZARIL TABS 200MG

5

QL (120 EA per 30 days)

CLOZARIL TABS 100MG

5

QL (270 EA per 30 days)

FANAPT

5

QL (60 EA per 30 days) PA MO

FANAPT TITRATION PACK

4

PA MO

fluphenazine decanoate inj

2

MO

fluphenazine hcl oral conc, tabs, inj

2

MO

fluphenazine hydrochloride oral elixir

2

MO

GEODON INJ

4

QL (6 EA per 3 days) MO

GEODON CAPS

5

QL (60 EA per 30 days) MO

HALDOL DECANOATE 100

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 50

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

HALDOL DECANOATE 50

4

MO

haloperidol tabs, oral conc

2

MO

haloperidol decanoate inj

2

MO

haloperidol lactate inj

2

MO

INVEGA HAFYERA INJ 1092MG/3.5ML

5

QL (3.5 ML per 180 days)

INVEGA HAFYERA INJ 1560MG/5ML

5

QL (5 ML per 180 days)

INVEGA SUSTENNA INJ 39MG/0.25ML

4

QL (0.25 ML per 28 days) MO

INVEGA SUSTENNA INJ 78MG/0.5ML

5

QL (0.5 ML per 28 days) MO

INVEGA SUSTENNA INJ 117MG/0.75ML

5

QL (0.75 ML per 28 days) MO

INVEGA SUSTENNA INJ 156MG/ML

5

QL (1 ML per 28 days) MO

INVEGA SUSTENNA INJ 234MG/1.5ML

5

QL (1.5 ML per 28 days) MO

INVEGA TRINZA INJ 273MG/0.88ML

5

QL (0.88 ML per 90 days)

INVEGA TRINZA INJ 410MG/1.32ML

5

QL (1.32 ML per 90 days)

INVEGA TRINZA INJ 546MG/1.75ML

5

QL (1.75 ML per 90 days)

INVEGA TRINZA INJ 819MG/2.63ML

5

QL (2.63 ML per 90 days)

INVEGA TB24 1.5MG, 3MG, 9MG

5

QL (30 EA per 30 days) MO

INVEGA TB24 6MG

5

QL (60 EA per 30 days) MO

LATUDA TABS 120MG, 20MG, 40MG, 60MG

5

QL (30 EA per 30 days) MO

LATUDA TABS 80MG

5

QL (60 EA per 30 days) MO

loxapine

2

MO

lurasidone hydrochloride tabs 120mg, 20mg, 40mg, 60mg

5

QL (30 EA per 30 days)

lurasidone hydrochloride tabs 80mg

5

QL (60 EA per 30 days)

LYBALVI

5

QL (30 EA per 30 days) PA MO

molindone hydrochloride

2

NUPLAZID

5

QL (30 EA per 30 days) PA LA

olanzapine odt

2

QL (30 EA per 30 days) MO

olanzapine inj

2

QL (3 EA per 1 days) MO

olanzapine tabs 10mg, 15mg, 20mg, 7.5mg

2

QL (30 EA per 30 days) MO

olanzapine tabs 2.5mg, 5mg

2

QL (60 EA per 30 days) MO

paliperidone er tb24 1.5mg, 3mg, 9mg

2

QL (30 EA per 30 days) MO

paliperidone er tb24 6mg

2

QL (60 EA per 30 days) MO

perphenazine

2

MO

PERSERIS

5

QL (1 EA per 30 days)

pimozide

2

MO

quetiapine fumarate er tb24 150mg, 200mg

2

QL (30 EA per 30 days) PA MO

quetiapine fumarate er tb24 300mg, 400mg, 50mg

2

QL (60 EA per 30 days) PA MO

quetiapine fumarate tabs 200mg

2

QL (120 EA per 30 days) MO

quetiapine fumarate tabs 25mg

2

QL (180 EA per 30 days) MO

quetiapine fumarate tabs 300mg, 400mg

2

QL (60 EA per 30 days) MO

quetiapine fumarate tabs 100mg, 150mg, 50mg

2

QL (90 EA per 30 days) MO

REXULTI TABS 3MG, 4MG

5

QL (30 EA per 30 days) MO

REXULTI TABS 0.25MG, 0.5MG, 1MG, 2MG

5

QL (60 EA per 30 days) MO

RISPERDAL CONSTA INJ 12.5MG, 25MG

4

QL (2 EA per 28 days) MO

RISPERDAL CONSTA INJ 37.5MG, 50MG

5

QL (2 EA per 28 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 51

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

RISPERDAL SOLN

4

QL (480 ML per 30 days) MO

RISPERDAL TABS 1MG

4

QL (60 EA per 30 days) MO

RISPERDAL TABS 0.5MG

4

QL (90 EA per 30 days) MO

RISPERDAL TABS 4MG

5

QL (120 EA per 30 days) MO

RISPERDAL TABS 2MG

5

QL (60 EA per 30 days) MO

RISPERDAL TABS 3MG

5

QL (90 EA per 30 days) MO

risperidone odt tbdp 4mg

2

QL (120 EA per 30 days) MO

risperidone odt tbdp 1mg, 2mg, 3mg

2

QL (60 EA per 30 days) MO

risperidone odt tbdp 0.25mg, 0.5mg

2

QL (90 EA per 30 days) MO

risperidone soln

2

QL (480 ML per 30 days) MO

risperidone tabs 4mg

2

QL (120 EA per 30 days) MO

risperidone tabs 1mg, 2mg

2

QL (60 EA per 30 days) MO

risperidone tabs 0.25mg, 0.5mg, 3mg

2

QL (90 EA per 30 days) MO

SAPHRIS

5

QL (60 EA per 30 days) MO

SECUADO

5

QL (30 EA per 30 days) MO

SEROQUEL XR TB24 150MG, 200MG

4

QL (30 EA per 30 days) PA MO

SEROQUEL XR TB24 50MG

4

QL (60 EA per 30 days) PA MO

SEROQUEL XR TB24 300MG, 400MG

5

QL (60 EA per 30 days) PA MO

SEROQUEL TABS 200MG

4

QL (120 EA per 30 days) MO

SEROQUEL TABS 25MG

4

QL (180 EA per 30 days) MO

SEROQUEL TABS 300MG

4

QL (60 EA per 30 days) MO

SEROQUEL TABS 100MG, 50MG

4

QL (90 EA per 30 days) MO

SEROQUEL TABS 400MG

5

QL (60 EA per 30 days) MO

thioridazine hcl tabs

2

PA MO

thiothixene

2

MO

trifluoperazine hcl tabs 10mg, 2mg, 5mg

2

MO

trifluoperazine hydrochloride tabs 1mg

2

MO

VERSACLOZ

5

QL (600 ML per 30 days) PA

VRAYLAR CAPSULE THERAPY PACK

4

MO

VRAYLAR CAPS 3MG, 4.5MG, 6MG

5

QL (30 EA per 30 days) MO

VRAYLAR CAPS 1.5MG

5

QL (60 EA per 30 days) MO

ziprasidone hcl caps

2

QL (60 EA per 30 days) MO

ziprasidone mesylate inj

2

QL (6 EA per 3 days) MO

ZYPREXA RELPREVV INJ 210MG

4

QL (2 EA per 28 days) PA MO

ZYPREXA RELPREVV INJ 405MG

5

QL (1 EA per 28 days) PA MO

ZYPREXA RELPREVV INJ 300MG

5

QL (2 EA per 28 days) PA MO

ZYPREXA ZYDIS

5

QL (30 EA per 30 days) MO

ZYPREXA INJ

4

QL (3 EA per 1 days) MO

ZYPREXA TABS 7.5MG

4

QL (30 EA per 30 days) MO

ZYPREXA TABS 2.5MG, 5MG

4

QL (60 EA per 30 days) MO

ZYPREXA TABS 10MG, 15MG, 20MG

5

QL (30 EA per 30 days) MO

ATTENTION DEFICIT HYPERACTIVITY DISORDER

ADDERALL XR

4

QL (30 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 52

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ADDERALL TABS 5MG, 7.5MG, 10MG, 12.5MG, 15MG,

30MG

4

QL (60 EA per 30 days) MO

ADDERALL TABS 20MG

4

QL (90 EA per 30 days) MO

ADZENYS XR-ODT

4

QL (30 EA per 30 days) MO

amphetamine sulfate

2

QL (180 EA per 30 days) MO

amphetamine/dextroamphetamine cp24

2

QL (30 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 5mg, 7.5mg, 10mg,

12.5mg, 15mg, 30mg

2

QL (60 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 20 mg

2

QL (90 EA per 30 days) MO

APTENSIO XR

4

QL (30 EA per 30 days) MO

atomoxetine hydrochloride caps 10mg, 25mg

2

QL (120 EA per 30 days) MO

atomoxetine caps 18mg

2

QL (120 EA per 30 days) MO

atomoxetine caps 100mg, 60mg, 80mg

2

QL (30 EA per 30 days) MO

atomoxetine caps 40mg

2

QL (60 EA per 30 days) MO

AZSTARYS

4

QL (30 EA per 30 days) MO

clonidine hcl er tabs

2

MO

CONCERTA

4

QL (30 EA per 30 days) MO

COTEMPLA XR-ODT

4

QL (30 EA per 30 days) MO

DAYTRANA

4

QL (30 EA per 30 days) MO

DESOXYN

5

QL (150 EA per 30 days) MO

DEXEDRINE CP24 5MG

4

QL (120 EA per 30 days) MO

DEXEDRINE CP24 10MG, 15MG

5

QL (120 EA per 30 days) MO

dexmethylphenidate hcl er caps 20mg, 35mg

2

QL (30 EA per 30 days) MO

dexmethylphenidate hcl tabs

2

QL (60 EA per 30 days) MO

dexmethylphenidate hydrochloride er caps 10mg, 15mg,

30mg, 40mg, 5mg

2

QL (30 EA per 30 days) MO

dexmethylphenidate hydrochloride er cp24 25mg

2

QL (30 EA per 30 days) MO

dexmethylphenidate hydrochloride tabs 2.5mg

2

QL (60 EA per 30 days) MO

dextroamphetamine sulfate er caps

2

QL (120 EA per 30 days) MO

dextroamphetamine sulfate soln

2

QL (1800 ML per 30 days) MO

dextroamphetamine sulfate tabs 15mg

2

QL (120 EA per 30 days) MO

dextroamphetamine sulfate tabs 10mg, 5mg

2

QL (180 EA per 30 days) MO

dextroamphetamine sulfate tabs 30mg

2

QL (60 EA per 30 days) MO

dextroamphetamine sulfate tabs 20mg

2

QL (90 EA per 30 days) MO

DYANAVEL XR SUER

4

QL (240 ML per 30 days) MO

DYANAVEL XR CHER 10MG, 15MG, 20MG

4

QL (30 EA per 30 days) MO

DYANAVEL XR CHER 5MG

4

QL (60 EA per 30 days) MO

EVEKEO

4

QL (180 EA per 30 days) MO

EVEKEO ODT

4

QL (60 EA per 30 days) MO

FOCALIN

4

QL (60 EA per 30 days) MO

FOCALIN XR

4

QL (30 EA per 30 days) MO

guanfacine er tabs 2mg

2

QL (30 EA per 30 days) PA MO

guanfacine hydrochloride er tb24 1mg, 4mg

2

QL (30 EA per 30 days) PA MO

guanfacine hydrochloride er tb24 3mg

2

QL (60 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 53

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

INTUNIV TB24 1MG, 2MG, 4MG

4

QL (30 EA per 30 days) PA MO

INTUNIV TB24 3MG

4

QL (60 EA per 30 days) PA MO

JORNAY PM

4

QL (30 EA per 30 days) MO

KAPVAY

4

MO

methamphetamine hcl

5

QL (150 EA per 30 days) MO

METHYLIN SOLN 5MG/5ML

4

QL (1800 ML per 30 days) MO

METHYLIN SOLN 10MG/5ML

4

QL (900 ML per 30 days) MO

methylphenidate

2

QL (30 EA per 30 days) MO

methylphenidate hydrochloride cd er caps 10mg, 20mg, 30mg,

40mg, 50mg, 60mg

2

QL (30 EA per 30 days) MO

methylphenidate hydrochloride er cp24 (generic Ritalin LA)

10mg, 20mg, 40mg, 60mg

2

QL (30 EA per 30 days) MO

methylphenidate hydrochloride er cp24 (generic Aptensio XR)

10mg, 15mg, 20mg, 30mg, 40mg, 50mg, 60mg

2

QL (30 EA per 30 days) MO

methylphenidate hydrochloride er cp24 (generic Ritalin LA)

30mg

2

QL (60 EA per 30 days) MO

methylphenidate hydrochloride er tb24 18mg, 27mg, 36mg,

54mg

2

QL (30 EA per 30 days)

METHYLPHENIDATE HYDROCHLORIDE ER TBCR

45MG, 63MG, 72MG

4

QL (30 EA per 30 days) MO

methylphenidate hydrochloride er tbcr (generic Concerta)

18mg, 27mg, 36mg, 54mg

2

QL (30 EA per 30 days) MO

methylphenidate hydrochloride er tbcr 10mg, 20mg

2

QL (90 EA per 30 days) MO

methylphenidate hydrochloride chew tabs

2

QL (180 EA per 30 days) MO

methylphenidate hydrochloride immediate release tabs

2

QL (90 EA per 30 days) MO

methylphenidate hydrochloride soln 5mg/5ml

2

QL (1800 ML per 30 days) MO

methylphenidate hydrochloride soln 10mg/5ml

2

QL (900 ML per 30 days) MO

MYDAYIS

4

QL (30 EA per 30 days) MO

procentra

5

QL (1800 ML per 30 days)

QELBREE CP24 100MG

4

QL (30 EA per 30 days) PA MO

QELBREE CP24 150MG

4

QL (60 EA per 30 days) PA MO

QELBREE CP24 200MG

4

QL (90 EA per 30 days) PA MO

QUILLICHEW ER CHER 40MG

4

QL (30 EA per 30 days) MO

QUILLICHEW ER CHER 30MG

4

QL (60 EA per 30 days) MO

QUILLICHEW ER CHER 20MG

4

QL (90 EA per 30 days) MO

QUILLIVANT XR

4

QL (360 ML per 30 days) MO

RELEXXII

4

QL (30 EA per 30 days) MO

RITALIN LA CP24 10MG, 20MG, 40MG

4

QL (30 EA per 30 days) MO

RITALIN LA CP24 30MG

4

QL (60 EA per 30 days) MO

RITALIN TABS

4

QL (90 EA per 30 days) MO

STRATTERA CAPS 10MG, 18MG, 25MG

4

QL (120 EA per 30 days) MO

STRATTERA CAPS 100MG, 60MG, 80MG

4

QL (30 EA per 30 days) MO

STRATTERA CAPS 40MG

4

QL (60 EA per 30 days) MO

VYVANSE

4

QL (30 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 54

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

XELSTRYM

4

QL (30 EA per 30 days)

zenzedi tabs 15mg

2

QL (120 EA per 30 days)

zenzedi tabs 10mg, 5mg

2

QL (180 EA per 30 days)

zenzedi tabs 2.5mg

2

QL (180 EA per 30 days) MO

zenzedi tabs 7.5mg

2

QL (240 EA per 30 days) MO

zenzedi tabs 30mg

2

QL (60 EA per 30 days)

zenzedi tabs 20mg

2

QL (90 EA per 30 days)

HYPNOTICS

AMBIEN

4

QL (30 EA per 30 days) PA MO

AMBIEN CR

4

QL (30 EA per 30 days) PA MO

BELSOMRA

4

QL (30 EA per 30 days) MO

DAYVIGO

4

QL (30 EA per 30 days) PA MO

doxepin hydrochloride tabs 3mg, 6mg

2

QL (30 EA per 30 days) MO

EDLUAR SUBL 10MG

4

QL (30 EA per 30 days) PA MO

EDLUAR SUBL 5MG

4

QL (60 EA per 30 days) PA MO

estazolam

2

QL (30 EA per 30 days) PA MO

eszopiclone

2

QL (30 EA per 30 days) PA MO

flurazepam hcl

2

QL (30 EA per 30 days) MO

HALCION

4

QL (60 EA per 30 days) PA MO

HETLIOZ CAPS

5

QL (30 EA per 30 days) PA LA

HETLIOZ LQ ORAL SUSP

5

QL (158 ML per 30 days) PA LA

MO

LUNESTA

4

QL (30 EA per 30 days) PA MO

midazolam hcl inj

2

midazolam hcl syrp

2

QL (300 ML per 30 days)

midazolam hydrochloride

2

NEMBUTAL SODIUM

4

pentobarbital sodium

2

QUVIVIQ

4

QL (30 EA per 30 days) PA MO

ramelteon

2

QL (30 EA per 30 days) MO

RESTORIL CAPS 22.5MG

4

QL (30 EA per 30 days) PA MO

RESTORIL CAPS 15MG, 30MG, 7.5MG

5

QL (30 EA per 30 days) PA MO

ROZEREM

4

QL (30 EA per 30 days) MO

SILENOR

4

QL (30 EA per 30 days) MO

tasimelteon

5

QL (30 EA per 30 days) PA

temazepam

2

QL (30 EA per 30 days) PA MO

triazolam

2

QL (60 EA per 30 days) PA MO

zaleplon caps 5mg

2

QL (30 EA per 30 days) PA MO

zaleplon caps 10mg

2

QL (60 EA per 30 days) PA MO

zolpidem tartrate tabs, subl

2

QL (30 EA per 30 days) PA MO

zolpidem tartrate er

2

QL (30 EA per 30 days) PA MO

ZOLPIMIST

4

QL (9 ML per 30 days) PA MO

MIGRAINE

AIMOVIG

3

QL (1 ML per 30 days) PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 55

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

AJOVY AUTO-INJECTOR 225MG/1.5ML

4

QL (1.5 ML per 28 days) PA

AJOVY PREFILLED SYRINGE 225MG/1.5ML

4

QL (4.5 ML per 90 days) PA

almotriptan malate

2

QL (8 EA per 30 days) MO

AMERGE TABS 1MG

4

QL (9 EA per 30 days) ST MO

AMERGE TABS 2.5MG

5

QL (9 EA per 30 days) ST MO

CAMBIA

5

PA MO

D.H.E. 45

4

PA MO

diclofenac potassium pack 50mg

5

PA

dihydroergotamine mesylate inj

5

PA MO

dihydroergotamine mesylate nasal soln

5

QL (8 ML per 30 days) PA MO

eletriptan hydrobromide

2

QL (12 EA per 30 days) MO

ELYXYB

5

QL (28.8 ML per 21 days) PA MO

EMGALITY INJ 120MG/ML

3

QL (2 ML per 30 days) PA

EMGALITY INJ 100MG/ML

3

QL (3 ML per 30 days) PA

ERGOMAR

5

ergotamine tartrate/caffeine

2

QL (40 EA per 28 days) PA MO

FROVA

5

QL (12 EA per 30 days) ST MO

frovatriptan succinate

2

QL (12 EA per 30 days) MO

IMITREX STATDOSE REFILL INJ 4MG/0.5ML

4

QL (4 ML per 30 days) ST MO

IMITREX STATDOSE REFILL INJ 6MG/0.5ML

5

QL (4 ML per 30 days) ST MO

IMITREX STATDOSE SYSTEM INJ 4MG/0.5ML

4

QL (4 ML per 30 days) ST MO

IMITREX STATDOSE SYSTEM INJ 6MG/0.5ML

5

QL (4 ML per 30 days) ST MO

IMITREX NASAL SPRAY

4

QL (12 EA per 30 days) ST MO

IMITREX TABS 25MG

4

QL (9 EA per 30 days) ST MO

IMITREX TABS 100MG

5

QL (12 EA per 30 days) ST MO

IMITREX TABS 50MG

5

QL (9 EA per 30 days) ST MO

MAXALT

4

QL (12 EA per 30 days) ST MO

MAXALT-MLT

4

QL (12 EA per 30 days) ST MO

migergot

5

QL (20 EA per 28 days) PA MO

MIGRANAL

5

QL (8 ML per 30 days) PA MO

naratriptan hcl

2

QL (9 EA per 30 days) MO

NURTEC

3

QL (16 EA per 30 days) PA MO

ONZETRA XSAIL

5

QL (16 EA per 30 days) ST MO

QULIPTA

5

QL (30 EA per 30 days) PA MO

RELPAX TABS 20MG

4

QL (12 EA per 30 days) MO

RELPAX TABS 40MG

5

QL (12 EA per 30 days) MO

REYVOW

5

QL (8 EA per 30 days) PA MO

rizatriptan benzoate odt

2

QL (12 EA per 30 days) MO

rizatriptan benzoate tabs

2

QL (12 EA per 30 days) MO

sumatriptan nasal spray

2

QL (12 EA per 30 days) MO

sumatriptan succinate refill

2

QL (4 ML per 30 days) MO

sumatriptan succinate inj

2

QL (4 ML per 30 days) MO

sumatriptan succinate tabs 100mg

2

QL (12 EA per 30 days) MO

sumatriptan succinate tabs 25mg, 50mg

2

QL (9 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 56

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

sumatriptan/naproxen sodium

2

QL (9 EA per 30 days) MO

TOSYMRA

5

QL (12 EA per 30 days) ST MO

TREXIMET

5

QL (9 EA per 30 days) ST MO

TRUDHESA

5

QL (12 ML per 28 days) PA

UBRELVY

5

QL (16 EA per 30 days) PA MO

VYEPTI

5

QL (1 ML per 90 days) PA LA

ZEMBRACE SYMTOUCH

5

QL (8 ML per 30 days) ST MO

zolmitriptan odt

2

QL (6 EA per 30 days) MO

ZOLMITRIPTAN NASAL SPRAY

4

QL (12 EA per 30 days) ST MO

zolmitriptan tabs

2

QL (6 EA per 30 days) MO

ZOMIG TABS

5

QL (6 EA per 30 days) ST MO

ZOMIG NASAL SPRAY 2.5MG

4

QL (12 EA per 30 days) ST MO

ZOMIG NASAL SPRAY 5MG

5

QL (12 EA per 30 days) ST MO

MISCELLANEOUS

AMONDYS 45

5

PA MO

AMVUTTRA

5

QL (0.5 ML per 90 days) PA LA

AUSTEDO TABS 12MG, 9MG

5

QL (120 EA per 30 days) PA LA

AUSTEDO TABS 6MG

5

QL (60 EA per 30 days) PA LA

ENSPRYNG

5

PA LA

EQUETRO

4

MO

EVRYSDI

5

QL (80 ML per 12 days) PA LA

EXONDYS 51

5

PA

EXSERVAN

5

QL (60 EA per 30 days) LA MO

FIRDAPSE

5

PA LA

flumazenil

2

GRALISE TABS 300MG

4

QL (180 EA per 30 days) MO

GRALISE TABS 600MG

4

QL (90 EA per 30 days) MO

HORIZANT

4

QL (60 EA per 30 days) MO

INGREZZA THERAPY PACK

5

QL (28 EA per 28 days) PA LA

INGREZZA CAPS

5

QL (30 EA per 30 days) PA LA

lithium carbonate caps, tabs

1

MO

lithium carbonate er tabs

2

MO

LITHIUM ORAL SOLN

4

MO

LITHOBID

5

MO

LYRICA CR TB24 330MG

4

QL (60 EA per 30 days) PA MO

LYRICA CR TB24 165MG, 82.5MG

4

QL (90 EA per 30 days) PA MO

MESTINON IMMEDIATE RELEASE TABS, ORAL SOLN

5

MO

MESTINON TIMESPAN

5

MO

NUEDEXTA

5

QL (60 EA per 30 days) PA MO

paroxetine

2

PA MO

pregabalin er tb24 330mg

2

QL (60 EA per 30 days) PA MO

pregabalin er tb24 165mg, 82.5mg

2

QL (90 EA per 30 days) PA MO

pyridostigmine bromide immediate release tabs, oral soln

2

MO

pyridostigmine bromide er

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 57

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

RADICAVA

5

QL (2800 ML per 28 days) PA LA

RADICAVA ORS

5

QL (50 ML per 28 days) PA LA

RADICAVA ORS STARTER KIT

5

QL (140 ML per 365 days) PA LA

REGONOL

5

RELYVRIO

5

QL (56 EA per 28 days) PA

RILUTEK

5

MO

riluzole

2

MO

RUZURGI

5

PA LA

SAVELLA

4

QL (60 EA per 30 days) PA MO

SAVELLA TITRATION PACK

4

QL (110 EA per 365 days) PA MO

TEGSEDI

5

QL (6 ML per 28 days) PA LA

tetrabenazine tabs 25mg

5

QL (120 EA per 30 days) PA LA

tetrabenazine tabs 12.5mg

5

QL (90 EA per 30 days) PA LA

TIGLUTIK

5

QL (600 ML per 30 days) LA

UPLIZNA

5

PA LA

VILTEPSO

5

PA

VYONDYS 53

5

PA

XENAZINE TABS 25MG

5

QL (120 EA per 30 days) PA LA

XENAZINE TABS 12.5MG

5

QL (90 EA per 30 days) PA LA

MULTIPLE SCLEROSIS AGENTS

AMPYRA

5

PA LA

AUBAGIO

5

QL (30 EA per 30 days) PA LA

AVONEX

5

QL (1 EA per 28 days) PA

AVONEX PEN

5

QL (1 EA per 28 days) PA

BAFIERTAM

5

QL (120 EA per 30 days) PA LA

BETASERON

5

QL (14 EA per 28 days) PA

BRIUMVI

5

QL (42 ML per 365 days) PA LA

COPAXONE INJ 40MG/ML

5

QL (12 ML per 28 days) PA

COPAXONE INJ 20MG/ML

5

QL (30 ML per 30 days) PA

dalfampridine er

2

PA

dimethyl fumarate starterpack

5

QL (120 EA per 365 days) PA LA

dimethyl fumarate cpdr 120mg

5

QL (14 EA per 7 days) PA LA

dimethyl fumarate cpdr 240mg

5

QL (60 EA per 30 days) PA LA

EXTAVIA

5

QL (15 EA per 30 days) PA

fingolimod

5

QL (28 EA per 28 days) PA

GILENYA CAPS 0.5MG

5

QL (28 EA per 28 days) PA

glatiramer acetate inj 40mg/ml

5

QL (12 ML per 28 days) PA

glatiramer acetate inj 20mg/ml

5

QL (30 ML per 30 days) PA

glatopa inj 40mg/ml

5

QL (12 ML per 28 days) PA

glatopa inj 20mg/ml

5

QL (30 ML per 30 days) PA

KESIMPTA

5

QL (6.4 ML per 365 days) PA LA

LEMTRADA

5

QL (6 ML per 365 days) PA LA

MAVENCLAD TBPK (4 TAB PACK) 10MG

5

QL (16 EA per 999 days) PA LA

MAVENCLAD TBPK (5 TAB PACK) 10MG

5

QL (20 EA per 999 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 58

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

MAVENCLAD TBPK (6 TAB PACK) 10MG

5

QL (24 EA per 999 days) PA LA

MAVENCLAD TBPK (7 TAB PACK) 10MG

5

QL (28 EA per 999 days) PA LA

MAVENCLAD TBPK (8 TAB PACK) 10MG

5

QL (32 EA per 999 days) PA LA

MAVENCLAD TBPK (9 TAB PACK) 10MG

5

QL (36 EA per 999 days) PA LA

MAVENCLAD TBPK (10 TAB PACK) 10MG

5

QL (40 EA per 999 days) PA LA

MAYZENT STARTER PACK TBPK 0.25MG (FOR 1MG

MAINTENANCE DOSAGE)

4

QL (14 EA per 365 days) PA LA

MAYZENT STARTER PACK TBPK 0.25MG (FOR 2MG

MAINTENANCE DOSAGE)

5

QL (24 EA per 365 days) PA LA

MAYZENT TABS 0.25MG

5

QL (112 EA per 28 days) PA LA

MAYZENT TABS 1MG, 2MG

5

QL (30 EA per 30 days) PA LA

OCREVUS

5

QL (20 ML per 180 days) PA LA

PLEGRIDY STARTER PACK

5

QL (2 ML per 365 days) PA LA

PLEGRIDY INTRAMUSCULAR INJ 125MCG/0.5ML

5

QL (0.5 ML per 14 days) PA LA

PLEGRIDY SUBUCUTANEOUS INJ 125MCG/0.5ML

5

QL (1 ML per 28 days) PA LA

PONVORY

5

QL (30 EA per 30 days) PA LA

PONVORY 14-DAY STARTER PACK

5

QL (28 EA per 365 days) PA LA

REBIF

5

QL (6 ML per 28 days) PA

REBIF REBIDOSE

5

QL (6 ML per 28 days) PA

REBIF REBIDOSE TITRATION PACK

5

QL (8.4 ML per 365 days) PA

REBIF TITRATION PACK

5

QL (8.4 ML per 365 days) PA

TASCENSO ODT TBDP 0.5MG

5

QL (30 EA per 30 days) PA LA

TASCENSO ODT TBDP 0.25MG

5

QL (30 EA per 30 days) PA LA MO

TECFIDERA STARTER PACK

5

QL (120 EA per 365 days) PA LA

TECFIDERA CPDR 120MG

5

QL (14 EA per 7 days) PA LA

TECFIDERA CPDR 240MG

5

QL (60 EA per 30 days) PA LA

TYSABRI

5

PA LA

VUMERITY

5

QL (120 EA per 30 days) PA LA

ZEPOSIA

5

QL (30 EA per 30 days) PA LA

ZEPOSIA 7-DAY STARTER PACK

5

QL (14 EA per 365 days) PA LA

ZEPOSIA STARTER KIT

5

QL (74 EA per 365 days) PA LA

MUSCULOSKELETAL THERAPY AGENTS

AMRIX

5

QL (30 EA per 30 days) PA MO

baclofen tabs

2

MO

BACLOFEN INJ 50MCG/ML

4

B/D

baclofen inj 20000mcg/20ml, 40mg/20ml, 500mcg/ml

2

B/D

BOTOX INJ 200UNIT

4

QL (2 EA per 84 days) PA

BOTOX INJ 100UNIT

4

QL (4 EA per 84 days) PA

carisoprodol

2

QL (84 EA per 30 days) PA MO

CHLORZOXAZONE TABS 250MG

5

QL (120 EA per 30 days) PA

chlorzoxazone tabs 375mg, 750mg

2

QL (120 EA per 30 days) PA MO

chlorzoxazone tabs 500mg

2

QL (180 EA per 30 days) PA MO

cyclobenzaprine hydrochloride tabs

2

QL (90 EA per 30 days) PA MO

cyclobenzaprine hydrochloride er caps

5

QL (30 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 59

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

DANTRIUM

4

MO

dantrolene sodium caps 25mg, 50mg, 100mg

2

MO

DYSPORT

4

PA

fexmid

2

QL (90 EA per 30 days) PA

FLEQSUVY

5

QL (480 ML per 30 days) PA MO

GABLOFEN INJ 10000MCG/20ML, 20000MCG/20ML,

50MCG/ML

4

B/D

GABLOFEN INJ 40000MCG/20ML

5

B/D

LIORESAL INTRATHECAL INJ 0.05MG/ML,

10MG/20ML, 10MG/5ML

4

B/D

LIORESAL INTRATHECAL INJ 40MG/20ML

5

B/D

LORZONE TABS 375MG

4

QL (120 EA per 30 days) PA

lorzone tabs 750mg

2

QL (120 EA per 30 days) PA

LYVISPAH PACK 10MG

4

QL (120 EA per 30 days) PA MO

LYVISPAH PACK 5MG

4

QL (360 EA per 30 days) PA

LYVISPAH PACK 20MG

5

QL (120 EA per 30 days) PA

metaxalone

2

QL (120 EA per 30 days) PA MO

methocarbamol inj

2

PA

methocarbamol tabs 750mg

2

QL (240 EA per 30 days) PA MO

methocarbamol tabs 500mg

2

QL (360 EA per 30 days) PA MO

methocarbamol tabs 1000mg

5

QL (120 EA per 30 days) PA

MYOBLOC

4

PA

norgesic

5

QL (120 EA per 30 days) PA

NORGESIC FORTE

5

QL (120 EA per 30 days) PA

orphenadrine citrate er tabs

2

QL (60 EA per 30 days) PA MO

orphenadrine citrate inj

2

PA

orphenadrine/aspirin/caffeine

5

QL (120 EA per 30 days) PA

orphengesic forte

2

QL (120 EA per 30 days) PA

ROBAXIN

4

PA MO

SKELAXIN

5

QL (120 EA per 30 days) PA MO

SOMA TABS 250MG

4

QL (84 EA per 30 days) PA MO

SOMA TABS 350MG

5

QL (84 EA per 30 days) PA MO

tizanidine hcl caps 4mg, tabs 2mg

2

MO

tizanidine hydrochloride caps 2mg, 6mg, tabs 4mg

2

MO

XEOMIN

4

PA LA

ZANAFLEX TABS

4

MO

ZANAFLEX CAPS 2MG, 4MG

4

MO

ZANAFLEX CAPS 6MG

5

MO

NARCOLEPSY/CATAPLEXY

armodafinil tabs 150mg, 200mg, 250mg

2

QL (30 EA per 30 days) PA MO

armodafinil tabs 50mg

2

QL (60 EA per 30 days) PA MO

modafinil tabs 100mg

2

QL (30 EA per 30 days) PA MO

modafinil tabs 200mg

2

QL (60 EA per 30 days) PA MO

NUVIGIL TABS 50MG

4

QL (60 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 60

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Drug Name

Drug

Tier

Requirements/Limits

NUVIGIL TABS 150MG, 200MG, 250MG

5

QL (30 EA per 30 days) PA MO

PROVIGIL TABS 100MG

5

QL (30 EA per 30 days) PA MO

PROVIGIL TABS 200MG

5

QL (60 EA per 30 days) PA MO

SODIUM OXYBATE

5

QL (540 ML per 30 days) PA LA

SUNOSI TABS 150MG

4

QL (30 EA per 30 days) PA MO

SUNOSI TABS 75MG

5

QL (30 EA per 30 days) PA MO

WAKIX

5

QL (60 EA per 30 days) PA LA

XYREM

5

QL (540 ML per 30 days) PA LA

XYWAV

5

QL (540 ML per 30 days) PA LA

PSYCHOTHERAPEUTIC-MISC

acamprosate calcium dr

2

MO

buprenorphine hcl/naloxone hcl subl tabs

2

QL (90 EA per 30 days) MO

buprenorphine hcl subl 2mg, 8mg

2

QL (90 EA per 30 days) PA MO

buprenorphine hydrochloride/naloxone hydrochloride film

12mg; 3mg

2

QL (60 EA per 30 days) MO

buprenorphine hydrochloride/naloxone hydrochloride film

2mg; 0.5mg, 4mg; 1mg, 8mg; 2mg

2

QL (90 EA per 30 days) MO

bupropion hydrochloride er (sr) tb12 150mg

2

QL (60 EA per 30 days) MO

disulfiram tabs

2

MO

KLOXXADO

4

MO

LUCEMYRA

5

QL (224 EA per 14 days) PA MO

naloxone hcl inj 2mg/2ml

2

naloxone hcl inj 4mg/10ml

2

MO

naloxone hydrochloride liqd nasal spray

2

MO

naloxone hydrochloride cartridge inj 0.4mg/ml

2

naloxone hydrochloride vial inj 0.4mg/ml

2

MO

naltrexone hcl tabs

2

MO

NARCAN

4

MO

NICOTROL INHALER

4

MO

NICOTROL NASAL SPRAY

4

QL (360 ML per 365 days) MO

SUBLOCADE

5

QL (1.5 ML per 30 days) PA

SUBOXONE FILM 12MG; 3MG

4

QL (60 EA per 30 days) MO

SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG

4

QL (90 EA per 30 days) MO

VARENICLINE STARTING MONTH BOX

4

PA MO

VARENICLINE TARTRATE

4

PA MO

VIVITROL

5

ZIMHI

4

ZUBSOLV SUBL 11.4MG; 2.9MG

4

QL (30 EA per 30 days) MO

ZUBSOLV SUBL 1.4MG; 0.36MG, 2.9MG; 0.71MG,

5.7MG; 1.4MG, 8.6MG; 2.1MG

4

QL (60 EA per 30 days) MO

ZUBSOLV SUBL 0.7MG; 0.18MG

4

QL (90 EA per 30 days) MO

Dermatological Agents

Topical Anti-infectives

EPSOLAY

4

QL (30 GM per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 61

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Drug Name

Drug

Tier Requirements/Limits

ENDOCRINE AND METABOLIC

ANDROGENS

ANDRODERM 4 QL (30 EA per 30 days) PA MO

ANDROGEL PUMP (1.62%) 5 QL (150 GM per 30 days) PA MO

ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM

(1.62%)

5 QL (150 GM per 30 days) PA MO

ANDROGEL GEL 25MG/2.5GM, 50MG/5GM (1%) 5 QL (300 GM per 30 days) PA MO

AVEED 4 LA

DEPO-TESTOSTERONE 4 PA MO

FORTESTA 4 QL (120 GM per 30 days) PA MO

JATENZO CAPS 158MG, 198MG 4 QL (120 EA per 30 days) PA MO

JATENZO CAPS 237MG 5 QL (60 EA per 30 days) PA MO

METHITEST 4 PA

methyltestosterone 5 PA MO

NATESTO 4 QL (21.96 GM per 30 days) PA MO

oxandrolone tabs 2.5mg 2 QL (120 EA per 30 days) PA MO

oxandrolone tabs 10mg 2 QL (60 EA per 30 days) PA MO

TESTIM 4 QL (300 GM per 30 days) PA MO

TESTOPEL 4 PA

testosterone cypionate inj 2 MO

testosterone enanthate inj 2 PA MO

testosterone pump gel 1.62% 2 QL (150 GM per 30 days) MO

testosterone pump gel 1% 2 QL (300 GM per 30 days) MO

testosterone gel 2% (10mg/act) pump 2 QL (120 GM per 30 days) MO

testosterone gel 20.25mg/1.25gm, 40.5mg/2.5gm (1.62%) 2 QL (150 GM per 30 days) MO

testosterone gel 25mg/2.5gm, 50mg/5gm (1%) 2 QL (300 GM per 30 days) MO

testosterone soln 2 QL (180 ML per 30 days) MO

TLANDO 4 QL (120 EA per 30 days) PA MO

VOGELXO 4 QL (300 GM per 30 days) PA MO

VOGELXO PUMP 4 QL (300 GM per 30 days) PA MO

XYOSTED 4 PA MO

ANTIDIABETICS, INSULINS

ADMELOG 4 ST MO

ADMELOG SOLOSTAR 4 ST MO

AFREZZA 4 MO

BD ALCOHOL SWABS 3 MO

APIDRA 4 ST MO

APIDRA SOLOSTAR 4 ST MO

BD INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X

5/16"

3 MO

BASAGLAR KWIKPEN 3 MO

BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 3 MO

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 1/2" 3 MO

BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 5/16" 3 MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 62

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

BD/NOVO PEN NEEDLE ULTRA-FINE

3

MO

BD INSULIN SYRINGE ULTRA-FINE/0.3ML/31G X

15/64"

3

MO

CURITY GAUZE PADS 2"X2"

3

MO

FIASP

3

MO

FIASP FLEXTOUCH

3

MO

FIASP PENFILL

3

MO

HUMALOG

4

ST MO

HUMALOG JUNIOR KWIKPEN

4

ST MO

HUMALOG KWIKPEN INJ 100UNIT/ML

4

ST MO

HUMALOG KWIKPEN INJ 200UNIT/ML

5

ST MO

HUMALOG MIX 50/50

5

ST MO

HUMALOG MIX 50/50 KWIKPEN

4

ST MO

HUMALOG MIX 75/25

4

ST MO

HUMALOG MIX 75/25 KWIKPEN

4

ST MO

HUMULIN 70/30

4

ST MO

HUMULIN 70/30 KWIKPEN

4

ST MO

HUMULIN N

4

ST MO

HUMULIN N KWIKPEN

4

ST MO

HUMULIN R

4

ST MO

HUMULIN R U-500 (CONCENTRATED)

5

B/D MO

HUMULIN R U-500 KWIKPEN

5

MO

INSULIN ASPART FLEXPEN

4

ST MO

INSULIN ASPART INJ 100UNIT/ML

4

ST MO

INSULIN ASPART PENFILL

4

ST MO

INSULIN ASPART PROTAMINE/INSULIN ASPART 70/30

FLEXPEN

4

ST MO

INSULIN ASPART PROTAMINE/INSULIN ASPART INJ

70/30

4

ST MO

INSULIN DEGLUDEC

4

ST MO

INSULIN DEGLUDEC FLEXTOUCH

4

ST MO

INSULIN GLARGINE SOLOSTAR

4

ST

INSULIN GLARGINE INJ 100UNIT/ML VIALS

4

ST

INSULIN GLARGINE INJ 100UNIT/ML PREFILL PEN

4

ST MO

INSULIN LISPRO

4

ST MO

INSULIN LISPRO JUNIOR KWIKPEN

4

ST MO

INSULIN LISPRO KWIKPEN

4

ST MO

INSULIN LISPRO PROTAMINE/INSULIN LISPRO INJ

75/25 KWIKPEN

4

ST MO

LANTUS

3

MO

LANTUS SOLOSTAR

3

MO

LEVEMIR

3

MO

LEVEMIR FLEXPEN

3

MO

LEVEMIR FLEXTOUCH

3

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 63

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

LYUMJEV

4

ST MO

LYUMJEV KWIKPEN

4

ST MO

MYXREDLIN

4

ST

NOVOLIN 70/30

3

MO

NOVOLIN 70/30 FLEXPEN

3

MO

NOVOLIN 70/30 FLEXPEN RELION

4

ST MO

NOVOLIN 70/30 RELION

4

ST MO

NOVOLIN N

3

MO

NOVOLIN N FLEXPEN

3

MO

NOVOLIN N FLEXPEN RELION

4

ST MO

NOVOLIN N RELION

4

ST MO

NOVOLIN R

3

MO

NOVOLIN R FLEXPEN

3

MO

NOVOLIN R FLEXPEN RELION

4

ST MO

NOVOLIN R RELION

4

ST MO

NOVOLOG

3

MO

NOVOLOG FLEXPEN

3

MO

NOVOLOG FLEXPEN RELION

4

ST MO

NOVOLOG MIX 70/30

3

MO

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

3

MO

NOVOLOG MIX 70/30 PREFILLED FLEXPEN RELION

4

ST MO

NOVOLOG MIX 70/30 RELION

4

ST MO

NOVOLOG PENFILL

3

MO

NOVOLOG RELION

4

ST MO

OMNIPOD 5 G6 INTRO KIT (GEN 5)

4

MO

OMNIPOD 5 G6 PODS (GEN 5)

4

MO

OMNIPOD CLASSIC PDM STARTER KIT (GEN 3)

4

MO

OMNIPOD CLASSIC PODS (GEN 3)

4

MO

OMNIPOD DASH INTRO KIT (GEN 4)

4

MO

OMNIPOD DASH PODS (GEN 4)

4

MO

SEMGLEE

4

ST MO

SOLIQUA 100/33

3

QL (15 ML per 25 days) MO

TOUJEO MAX SOLOSTAR

3

MO

TOUJEO SOLOSTAR

3

MO

TRESIBA

3

MO

TRESIBA FLEXTOUCH

3

MO

V-GO 20

4

QL (30 EA per 30 days) MO

V-GO 30

4

QL (30 EA per 30 days) MO

V-GO 40

4

QL (30 EA per 30 days) MO

XULTOPHY 100/3.6

3

QL (15 ML per 30 days) MO

ANTIDIABETICS

acarbose tabs

1

QL (90 EA per 30 days) MO

ACTOPLUS MET

4

QL (90 EA per 30 days) MO

ACTOS

4

QL (30 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 64

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

ADLYXIN

4

QL (6 ML per 28 days) ST MO

ADLYXIN STARTER PACK

4

QL (6 ML per 28 days) ST MO

ALOGLIPTIN

4

QL (30 EA per 30 days) ST MO

ALOGLIPTIN/METFORMIN HCL

4

QL (60 EA per 30 days) ST MO

ALOGLIPTIN/METFORMIN HYDROCHLORIDE

4

QL (60 EA per 30 days) ST MO

ALOGLIPTIN/PIOGLITAZONE

4

QL (30 EA per 30 days) ST MO

AMARYL TABS 4MG

4

QL (60 EA per 30 days) MO

AMARYL TABS 1MG, 2MG

4

QL (90 EA per 30 days) MO

BYDUREON BCISE

3

QL (3.4 ML per 28 days) MO

BYETTA INJ 5MCG/0.02ML

4

QL (1.2 ML per 30 days) MO

BYETTA INJ 10MCG/0.04ML

4

QL (2.4 ML per 30 days) MO

CYCLOSET

4

QL (180 EA per 30 days) PA MO

DUETACT

4

QL (30 EA per 30 days) MO

FARXIGA

3

QL (30 EA per 30 days) MO

glimepiride tabs 4mg

1

QL (60 EA per 30 days) MO

glimepiride tabs 1mg, 2mg

1

QL (90 EA per 30 days) MO

glipizide er tb24 10mg

1

QL (60 EA per 30 days) MO

glipizide er tb24 2.5mg, 5mg

1

QL (90 EA per 30 days) MO

glipizide xl tb24 10mg

1

QL (60 EA per 30 days) MO

glipizide xl tb24 2.5mg, 5mg

1

QL (90 EA per 30 days) MO

glipizide/metformin hydrochloride tabs 2.5mg; 500mg, 5mg;

500mg

1

QL (120 EA per 30 days) MO

glipizide/metformin hydrochloride tabs 2.5mg; 250mg

1

QL (240 EA per 30 days) MO

glipizide tabs 10mg

1

QL (120 EA per 30 days) MO

glipizide tabs 5mg

1

QL (240 EA per 30 days) MO

GLUCOTROL XL TB24 10MG

4

QL (60 EA per 30 days) MO

GLUCOTROL XL TB24 2.5MG, 5MG

4

QL (90 EA per 30 days) MO

GLUMETZA TB24 500MG

5

QL (120 EA per 30 days) PA MO

GLUMETZA TB24 1000MG

5

QL (60 EA per 30 days) PA MO

glyburide

2

PA MO

glyburide micronized

2

PA MO

glyburide/metformin hydrochloride

2

PA MO

GLYNASE

4

PA MO

GLYXAMBI

3

QL (30 EA per 30 days) MO

INVOKAMET XR TB24 50MG; 500MG

4

QL (120 EA per 30 days) ST MO

INVOKAMET XR TB24 150MG; 1000MG, 150MG;

500MG, 50MG; 1000MG

4

QL (60 EA per 30 days) ST MO

INVOKAMET TABS 50MG; 500MG

4

QL (120 EA per 30 days) ST MO

INVOKAMET TABS 150MG; 1000MG, 150MG; 500MG,

50MG; 1000MG

4

QL (60 EA per 30 days) ST MO

INVOKANA TABS 300MG

4

QL (30 EA per 30 days) ST MO

INVOKANA TABS 100MG

4

QL (60 EA per 30 days) ST MO

JANUMET

3

QL (60 EA per 30 days) MO

JANUMET XR TB24 1000MG; 100MG

3

QL (30 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 65

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Drug Name

Drug

Tier

Requirements/Limits

JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG

3

QL (60 EA per 30 days) MO

JANUVIA

3

QL (30 EA per 30 days) MO

JARDIANCE TABS 25MG

3

QL (30 EA per 30 days) MO

JARDIANCE TABS 10MG

3

QL (60 EA per 30 days) MO

JENTADUETO

3

QL (60 EA per 30 days) MO

JENTADUETO XR TB24 5MG; 1000MG

3

QL (30 EA per 30 days) MO

JENTADUETO XR TB24 2.5MG; 1000MG

3

QL (60 EA per 30 days) MO

KAZANO

4

QL (60 EA per 30 days) ST MO

KOMBIGLYZE XR TB24 1000MG; 5MG, 500MG; 5MG

4

QL (30 EA per 30 days) ST MO

KOMBIGLYZE XR TB24 1000MG; 2.5MG

4

QL (60 EA per 30 days) ST MO

metformin hydrochloride er (generic glucophage xr) tb24

500mg

1

QL (120 EA per 30 days) MO

metformin hydrochloride er (generic Glucophage XR) tb24

750mg

1

QL (60 EA per 30 days) MO

metformin hydrochloride er (generic Fortamet and Glumetza)

tb24 500mg

2

QL (120 EA per 30 days) PA MO

metformin hydrochloride er (generic Fortamet and Glumetza)

tb24 1000mg

5

QL (60 EA per 30 days) PA MO

metformin hydrochloride soln

2

MO

METFORMIN HYDROCHLORIDE TABS 625MG

5

QL (120 EA per 30 days) PA

metformin hydrochloride tabs 500mg

1

QL (150 EA per 30 days) MO

metformin hydrochloride tabs 1000mg

1

QL (75 EA per 30 days) MO

metformin hydrochloride tabs 850mg

1

QL (90 EA per 30 days) MO

miglitol

2

QL (90 EA per 30 days) MO

MOUNJARO INJ 10MG/0.5ML, 12.5MG/0.5ML,

15MG/0.5ML, 5MG/0.5ML, 7.5MG/0.5ML

4

QL (2 ML per 28 days) PA MO

MOUNJARO INJ 2.5MG/0.5ML

4

QL (4 ML per 365 days) PA MO

nateglinide

1

QL (90 EA per 30 days) MO

NESINA

4

QL (30 EA per 30 days) ST MO

ONGLYZA

4

QL (30 EA per 30 days) ST MO

OSENI

4

QL (30 EA per 30 days) ST MO

OZEMPIC INJ 2MG/1.5ML (0.25MG OR 0.5MG/DOSE)

3

QL (1.5 ML per 28 days) MO

OZEMPIC INJ 2MG/1.5ML (1MG/DOSE), 2MG/3ML

3

QL (3 ML per 28 days)

OZEMPIC INJ 4MG/3ML, 8MG/3ML

3

QL (3 ML per 28 days) MO

pioglitazone hcl tabs 45mg

1

QL (30 EA per 30 days) MO

pioglitazone hcl-glimepiride

1

QL (30 EA per 30 days) MO

pioglitazone hcl/metformin hcl

1

QL (90 EA per 30 days) MO

pioglitazone hydrochloride tabs 15mg, 30mg

1

QL (30 EA per 30 days) MO

PRECOSE

4

QL (90 EA per 30 days) MO

QTERN

4

QL (30 EA per 30 days) MO

repaglinide tabs 0.5mg, 1mg

1

QL (120 EA per 30 days) MO

repaglinide tabs 2mg

1

QL (240 EA per 30 days) MO

RIOMET

4

MO

RYBELSUS

3

QL (30 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 66

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

SEGLUROMET TABS 2.5MG; 500MG

4

QL (120 EA per 30 days) ST MO

SEGLUROMET TABS 2.5MG; 1000MG, 7.5MG; 1000MG,

7.5MG; 500MG

4

QL (60 EA per 30 days) ST MO

STEGLATRO TABS 15MG

4

QL (30 EA per 30 days) ST MO

STEGLATRO TABS 5MG

4

QL (60 EA per 30 days) ST MO

STEGLUJAN

4

QL (30 EA per 30 days) MO

SYMLINPEN 120

5

QL (10.8 ML per 30 days) PA MO

SYMLINPEN 60

5

QL (6 ML per 30 days) PA MO

SYNJARDY XR TB24 25MG; 1000MG

3

QL (30 EA per 30 days) MO

SYNJARDY XR TB24 10MG; 1000MG, 12.5MG; 1000MG,

5MG; 1000MG

3

QL (60 EA per 30 days) MO

SYNJARDY TABS 5MG; 500MG

3

QL (120 EA per 30 days) MO

SYNJARDY TABS 12.5MG; 1000MG, 12.5MG; 500MG,

5MG; 1000MG

3

QL (60 EA per 30 days) MO

TRADJENTA

3

QL (30 EA per 30 days) MO

TRIJARDY XR TB24 10MG; 5MG; 1000MG, 25MG; 5MG;

1000MG

3

QL (30 EA per 30 days) MO

TRIJARDY XR TB24 12.5MG; 2.5MG; 1000MG, 5MG;

2.5MG; 1000MG

3

QL (60 EA per 30 days) MO

TRULICITY

3

QL (2 ML per 28 days) MO

VICTOZA

3

QL (9 ML per 30 days) MO

XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG

3

QL (30 EA per 30 days) MO

XIGDUO XR TB24 2.5MG; 1000MG, 5MG; 1000MG, 5MG;

500MG

3

QL (60 EA per 30 days) MO

CALCIUM REGULATORS

ACTONEL TABS 150MG

4

QL (1 EA per 28 days) ST MO

ACTONEL TABS 35MG

4

QL (12 EA per 84 days) ST MO

alendronate sodium oral soln

1

MO

alendronate sodium tabs 10mg

1

QL (120 EA per 30 days) MO

alendronate sodium tabs 35mg, 70mg

1

QL (4 EA per 28 days) MO

ATELVIA

4

QL (4 EA per 28 days) ST MO

BINOSTO

4

QL (4 EA per 28 days) ST MO

calcitonin salmon inj

5

PA MO

calcitonin-salmon nasal spray

2

MO

EVENITY

5

QL (2.34 ML per 28 days) PA

FORTEO

5

PA

FOSAMAX

4

QL (4 EA per 28 days) ST MO

FOSAMAX PLUS D

4

QL (4 EA per 28 days) ST MO

ibandronate sodium tabs

2

QL (1 EA per 30 days) MO

ibandronate sodium inj

2

QL (3 ML per 90 days) MO

MIACALCIN

5

PA MO

NATPARA

5

PA LA

PAMIDRONATE DISODIUM INJ 6MG/ML

4

pamidronate disodium inj 30mg/10ml, 90mg/10ml

2

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 67

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

PROLIA

4

QL (1 ML per 180 days)

RECLAST

4

risedronate sodium dr tab 35mg

2

QL (4 EA per 28 days) MO

risedronate sodium tabs 150mg

2

QL (1 EA per 28 days) MO

risedronate sodium tabs 35mg

2

QL (12 EA per 84 days) MO

risedronate sodium tabs 30mg, 5mg

2

QL (30 EA per 30 days) MO

TERIPARATIDE

5

PA

TYMLOS

5

PA

XGEVA

5

PA

ZOLEDRONIC ACID INJ 4MG/100ML

4

zoledronic acid inj 4mg/5ml, 5mg/100ml

2

CHELATING AGENTS

CHEMET

4

MO

CUPRIMINE

5

deferasirox granules pack

5

PA

deferasirox tabs 90mg

2

PA

deferasirox tabs 180mg, 360mg

5

PA

deferasirox tablet soluble 125mg

2

PA

deferasirox tablet soluble 250mg, 500mg

5

PA

deferiprone

5

PA LA

deferoxamine mesylate

2

B/D

DEPEN TITRATABS

5

DESFERAL

5

B/D

EXJADE

5

PA LA

FERRIPROX

5

PA LA

FERRIPROX TWICE-A-DAY

5

PA LA

JADENU

5

PA LA

JADENU SPRINKLE PACK 90MG

4

PA LA

JADENU SPRINKLE PACK 180MG, 360MG

5

PA LA

LOKELMA PACK 10GM

3

QL (34 EA per 30 days) MO

LOKELMA PACK 5GM

3

QL (96 EA per 30 days) MO

penicillamine

5

sodium polystyrene sulfonate oral powder

2

MO

sps oral susp 15gm/60ml

2

MO

SYPRINE

5

PA

trientine hydrochloride

5

PA

VELTASSA PACK 16.8GM, 25.2GM

3

QL (30 EA per 30 days) MO

VELTASSA PACK 8.4GM

3

QL (90 EA per 30 days) MO

CONTRACEPTIVES

afirmelle

2

altavera

2

alyacen 1/35

2

MO

alyacen 7/7/7

2

amethia

2

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 68

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

amethyst 2

ANNOVERA 4 QL (1 EA per 365 days) MO

apri 2

aranelle 2 MO

ashlyna 2

aubra 2

aubra eq 2

aurovela 1.5/30 2

aurovela 24 fe 2

aurovela fe 1.5/30 2

aurovela fe 1/20 2

aviane 2

ayuna 2

BALCOLTRA 4 MO

balziva 2

BEYAZ 4 MO

blisovi 24 fe 2 MO

blisovi fe 1.5/30 2 MO

blisovi fe 1/20 2

briellyn 2

camila 2 MO

CAMRESE 3

CAMRESE LO 3

caziant 2

charlotte 24 fe 2

chateal 2

chateal eq 2

cryselle-28 2 MO

cyred 2

cyred eq 2

dasetta 1/35 2

dasetta 7/7/7 2

daysee 2

deblitane 2

delyla 2

DEPO-PROVERA CONTRACEPTIVE 4 MO

DEPO-SUBQ PROVERA 104 4 MO

desogestrel/ethinyl estradiol 2 MO

dolishale 2

drospirenone/ethinyl estradiol 2 MO

drospirenone/ethinyl estradiol/levomefolate calcium 2 MO

elinest 2

ELLA 3

eluryng 2

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 69

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

emoquette 2

enpresse-28 2

enskyce 2 MO

errin 2 MO

estarylla 2 MO

ethynodiol diacetate/ethinyl estradiol 2 MO

ETONOGESTREL/ETHINYL ESTRADIOL 4 MO

falmina 2

fayosim 2

femynor 2

finzala 2

gemmily 2

GENERESS FE 4 MO

GIANVI 3

hailey 1.5/30 2 MO

hailey 24 fe 2

hailey fe 1.5/30 2

hailey fe 1/20 2

haloette 2

heather 2

iclevia 2

incassia 2

introvale 2

isibloom 2

jaimiess 2 MO

jasmiel 2

jencycla 2

JOLESSA 3

juleber 2

junel 1.5/30 2 MO

junel 1/20 2

junel fe 1.5/30 2 MO

junel fe 1/20 2 MO

junel fe 24 2

kaitlib fe 2 MO

kalliga 2

kariva 2

kelnor 1/35 2 MO

kelnor 1/50 2 MO

kurvelo 2

KYLEENA 4

larin 1.5/30 2

larin 1/20 2

larin 24 fe 2

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 70

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

larin fe 1.5/30 2

larin fe 1/20 2

larissia 2

LAYOLIS FE 4

LEENA 3 MO

lessina 2

levonest 2

levonorgestrel/ethinyl estradiol 2 MO

levora 0.15/30-28 2

LILETTA 4

lillow 2

LO LOESTRIN FE 4 MO

lo-zumandimine 2 MO

loestrin 1.5/30-21 2

loestrin 1/20-21 2

loestrin fe 1.5/30 2

loestrin fe 1/20 2

lojaimiess 2 MO

loryna 2

LOSEASONIQUE 4 MO

low-ogestrel 2

lutera 2 MO

lyleq 2

lyza 2

marlissa 2 MO

medroxyprogesterone acetate inj 150mg/ml 2 MO

merzee 2 MO

mibelas 24 fe 2

MICROGESTIN 1.5/30 3

MICROGESTIN 1/20 3

microgestin 24 fe 2

MICROGESTIN FE 1.5/30 3

MICROGESTIN FE 1/20 3

mili 2

MINASTRIN 24 FE 4 MO

MIRCETTE 4 MO

MIRENA 4

mono-linyah 2

NATAZIA 4 MO

necon 0.5/35-28 2

NEXPLANON 4

NEXTSTELLIS 4 MO

nikki 2

NORA-BE 3

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 71

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

norethindrone tabs 0.35mg 2 MO

norethindrone & ethinyl estradiol ferrous fumarate 2 MO

norethindrone acetate/ethinyl estradiol/ferrous fumarate caps,

chew tabs, tabs

2 MO

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg,

30mcg; 1.5mg

2 MO

norgestimate/ethinyl estradiol 2 MO

norlyda 2

norlyroc 2

nortrel 0.5/35 (28) 2 MO

nortrel 1/35 28-day regimen 2

nortrel 1/35 21-day regimen 2 MO

nortrel 7/7/7 2

NUVARING 4 MO

nylia 1/35 2

nylia 7/7/7 2 MO

nymyo 2

OCELLA 3

orsythia 2

PARAGARD INTRAUTERINE COPPER

CONTRACEPTIVE T380A

4

PHEXXI 4 MO

philith 2

pimtrea 2

pirmella 1/35 2 MO

pirmella 7/7/7 2 MO

portia-28 2

previfem 2

QUARTETTE 4 MO

reclipsen 2

RIVELSA 3

SAFYRAL 4 MO

SEASONIQUE 4 MO

setlakin 2

sharobel 2

simliya 2

simpesse 2

SKYLA 4

SLYND 3 MO

sprintec 28 2

sronyx 2 MO

syeda 2

tarina 24 fe 2

tarina fe 1/20 2

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 72

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

tarina fe 1/20 eq 2

taysofy 2 MO

TAYTULLA 4 MO

TILIA FE 3

tri femynor 2

tri-estarylla 2 MO

tri-legest fe 2 MO

tri-linyah 2

tri-lo-estarylla 2

tri-lo-marzia 2

tri-lo-mili 2

tri-lo-sprintec 2 MO

tri-mili 2

tri-nymyo 2

tri-sprintec 2

tri-vylibra 2

tri-vylibra lo 2

trivora-28 2 MO

TYBLUME 4 MO

tydemy 2

velivet 2 MO

vestura 2 MO

vienva 2

viorele 2 MO

volnea 2

vyfemla 2 MO

vylibra 2

wera 2

wymzya fe 2

xulane 2 MO

YASMIN 28 4 MO

YAZ 4 MO

zafemy 2

zovia 1/35 2

zumandimine 2

ENDOMETRIOSIS

danazol caps 2 MO

ORILISSA TABS 150MG 5 QL (28 EA per 28 days) PA MO

ORILISSA TABS 200MG 5 QL (56 EA per 28 days) PA MO

SYNAREL 5 MO

ESTROGENS

ACTIVELLA 4 MO

amabelz 2 MO

ANGELIQ 4 MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 73

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

BIJUVA

4

QL (30 EA per 30 days) MO

CLIMARA

4

QL (4 EA per 28 days) MO

CLIMARA PRO

4

QL (4 EA per 28 days) MO

COMBIPATCH

4

QL (8 EA per 28 days) MO

DELESTROGEN

4

MO

DEPO-ESTRADIOL

4

MO

DIVIGEL

4

MO

dotti

2

QL (8 EA per 28 days)

DUAVEE

4

MO

ELESTRIN

4

MO

ESTRACE

4

MO

estradiol valerate inj inj 10mg/ml

2

estradiol valerate inj inj 20mg/ml, 40mg/ml

2

MO

estradiol/norethindrone acetate tabs 1mg/0.5mg, 0.5mg/0.1mg

2

MO

estradiol vaginal crea, topical gel, oral tabs, vaginal tabs

2

MO

estradiol patch weekly

2

QL (4 EA per 28 days) MO

estradiol patch twice weekly

2

QL (8 EA per 28 days) MO

ESTRING

4

QL (1 EA per 90 days) MO

ESTROGEL

4

MO

EVAMIST

4

QL (16.2 ML per 30 days) MO

FEMRING

4

QL (1 EA per 90 days) MO

fyavolv

2

MO

IMVEXXY MAINTENANCE PACK

4

PA MO

IMVEXXY STARTER PACK

4

PA MO

jinteli

2

lyllana

2

QL (8 EA per 28 days)

MENEST TABS 2.5MG

4

MENEST TABS 0.3MG, 0.625MG, 1.25MG

4

MO

MENOSTAR

4

QL (4 EA per 28 days) MO

mimvey

2

MINIVELLE

4

QL (8 EA per 28 days) MO

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg,

5mcg; 1mg

2

MO

PREFEST

4

MO

PREMARIN

4

MO

PREMPHASE

4

MO

PREMPRO

4

MO

VAGIFEM

4

MO

VIVELLE-DOT

4

QL (8 EA per 28 days) MO

yuvafem

2

GLUCOCORTICOIDS

ALKINDI SPRINKLE

5

PA LA

betamethasone sodium phosphate/betamethasone acetate inj

2

MO

CELESTONE-SOLUSPAN

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 74

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

CORTEF

4

MO

CORTISONE ACETATE

4

DEPO-MEDROL

4

B/D MO

DEXABLISS

4

dexamethasone 10-day dose pack

2

MO

dexamethasone 13-day dose pack

2

MO

dexamethasone 6-day dose pack

2

MO

DEXAMETHASONE INTENSOL

4

MO

dexamethasone sodium phosphate inj 10mg/ml vial, 10mg/ml

pf prefilled syringe

2

dexamethasone sodium phosphate vial 100mg/10ml, 10mg/ml

pf, 120mg/30ml, 20mg/5ml, 4mg/ml

2

MO

dexamethasone tabs, oral soln, oral elixir

2

MO

DXEVO 11-DAY

4

EMFLAZA

5

PA

fludrocortisone acetate tabs

2

MO

HEMADY

4

HEXATRIONE

4

hidex 6-day

2

hydrocortisone tabs 10mg, 20mg, 5mg

2

MO

KENALOG-10

4

MO

KENALOG-40

4

MO

KENALOG-80

4

MO

MEDROL

4

B/D MO

MEDROL DOSEPAK

4

MO

methylprednisolone acetate inj

2

B/D MO

methylprednisolone dose pack

2

MO

methylprednisolone sodium succinate inj 40mg, 125mg

2

B/D MO

methylprednisolone sodium succinate inj 500mg

2

B/D

methylprednisolone sodium succinate inj 1000mg

2

B/D MO

methylprednisolone tabs

2

B/D MO

MILLIPRED

5

B/D MO

ORAPRED ODT

4

B/D MO

PEDIAPRED

4

B/D MO

prednisolone sodium phosphate odt

2

B/D MO

prednisolone sodium phosphate oral soln 10mg/5ml,

15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml

2

B/D MO

PREDNISONE INTENSOL

4

B/D MO

prednisone soln, tabs

1

B/D MO

prednisone therapy pack

1

MO

RAYOS

5

B/D MO

SOLU-CORTEF

4

MO

SOLU-MEDROL INJ 2GM

4

B/D

SOLU-MEDROL INJ 1000MG, 125MG, 40MG, 500MG

4

B/D MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 75

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

taperdex 12-day

2

taperdex 6-day

2

MO

taperdex 7-day

2

triamcinolone acetonide inj 40mg/ml

2

MO

ZCORT 7-DAY

4

ZILRETTA

4

GLUCOSE ELEVATING AGENTS

BAQSIMI ONE PACK

4

MO

BAQSIMI TWO PACK

4

MO

diazoxide oral susp

5

MO

GLUCAGEN HYPOKIT

4

MO

GLUCAGON EMERGENCY KIT FOR LOW BLOOD

SUGAR

4

GVOKE HYPOPEN 1-PACK

3

MO

GVOKE HYPOPEN 2-PACK

3

MO

GVOKE KIT

3

MO

GVOKE PFS

3

MO

PROGLYCEM

5

MO

ZEGALOGUE

4

MO

MISCELLANEOUS

ACETADOTE

4

acetylcysteine inj 200mg/ml

2

ACTHAR

5

QL (1.5 ML per 1 days) PA LA

ALDURAZYME

5

PA LA

betaine anhydrous

5

LA MO

BUPHENYL

5

PA LA

cabergoline

2

MO

CARBAGLU

5

PA LA MO

carglumic acid

5

PA LA MO

CARNITOR

4

MO

CARNITOR SF

4

MO

CERDELGA

5

PA LA

CEREZYME

5

PA LA

CHORIONIC GONADOTROPIN

4

PA

cinacalcet hydrochloride tabs 30mg

2

QL (60 EA per 30 days)

cinacalcet hydrochloride tabs 90mg

5

QL (120 EA per 30 days)

cinacalcet hydrochloride tabs 60mg

5

QL (60 EA per 30 days)

CORTROPHIN

5

QL (1.5 ML per 1 days) PA LA

CRYSVITA

5

PA LA

CYSTADANE

5

LA

CYSTAGON

4

PA LA

DDAVP

5

MO

desmopressin acetate nasal soln, tabs

2

MO

desmopressin acetate pf inj 4mcg/ml

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 76

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

desmopressin acetate inj 4mcg/ml

5

MO

DOJOLVI

5

PA LA

EGRIFTA SV

5

QL (30 EA per 30 days) PA LA

ELAPRASE

5

PA LA

ELELYSO

5

PA LA

EVISTA

4

MO

FABRAZYME

5

PA LA

FENSOLVI

5

PA LA

fomepizole

5

GALAFOLD

5

QL (14 EA per 28 days) PA LA

GENOTROPIN CARTRIDGE 12MG, 5MG

5

PA

GENOTROPIN MINIQUICK INJ 0.2MG

3

PA

GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG,

1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5

PA

HUMATROPE

5

PA

INCRELEX

5

PA LA

ISTURISA TABS 10MG

5

QL (180 EA per 30 days) PA LA

ISTURISA TABS 1MG

5

QL (240 EA per 30 days) PA LA

ISTURISA TABS 5MG

5

QL (60 EA per 30 days) PA LA

javygtor

5

PA LA

JYNARQUE TABS

5

PA LA

JYNARQUE THERAPY PACK 30MG; 15MG, 45MG;

15MG, 60MG; 30MG, 90MG; 30MG

5

PA LA

JYNARQUE THERAPY PACK 15MG

5

PA LA MO

KANUMA

5

PA LA

KORLYM

5

PA LA

KUVAN

5

PA LA

LANREOTIDE ACETATE

5

PA

LEVOCARNITINE TABS

4

MO

levocarnitine soln

2

MO

LUMIZYME

5

PA LA

LUPRON DEPOT-PED (1-MONTH) INJ 11.25MG, 15MG,

7.5MG

5

PA

LUPRON DEPOT-PED (3-MONTH) INJ 11.25MG, 30MG

5

PA

MEPSEVII

5

PA

methergine

2

methylergonovine maleate tabs

5

MO

mifepristone

2

miglustat

5

QL (90 EA per 30 days) PA LA

MYALEPT

5

QL (30 EA per 30 days) PA LA

MYCAPSSA

5

QL (112 EA per 28 days) PA LA

MYFEMBREE

5

QL (28 EA per 28 days) PA MO

NAGLAZYME

5

PA LA

NEXVIAZYME

5

PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 77

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

nitisinone

5

PA

NITYR

5

PA LA

NOCDURNA

4

QL (30 EA per 30 days) PA MO

NORDITROPIN FLEXPRO

5

PA

NOVAREL

4

PA

NULIBRY

5

PA MO

NUTROPIN AQ NUSPIN 10

5

PA LA

NUTROPIN AQ NUSPIN 20

5

PA LA

NUTROPIN AQ NUSPIN 5

5

PA LA

octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml

2

PA

octreotide acetate inj 1000mcg/ml, 500mcg/ml

5

PA

OMNITROPE

5

PA LA

ORFADIN

5

PA LA

ORIAHNN

5

QL (56 EA per 28 days) PA MO

OSPHENA

4

QL (30 EA per 30 days) PA MO

PALYNZIQ

5

PA LA

PHEBURANE

5

PA LA MO

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL

4

PA

PROCYSBI PACK

5

PA LA

PROCYSBI CPDR 25MG

5

QL (120 EA per 30 days) PA LA

PROCYSBI CPDR 75MG

5

QL (810 EA per 30 days) PA LA

raloxifene hydrochloride

2

MO

RAVICTI

5

PA LA

RECORLEV

5

QL (240 EA per 30 days) PA LA

MO

REVCOVI

5

PA LA

SAIZEN

5

PA LA

SAIZENPREP RECONSTITUTIONKIT

5

PA LA

SAMSCA TABS 15MG

5

QL (30 EA per 30 days) PA LA

SAMSCA TABS 30MG

5

QL (60 EA per 30 days) PA LA

SANDOSTATIN

5

PA

SANDOSTATIN LAR DEPOT

5

PA

sapropterin dihydrochloride

5

PA

SENSIPAR TABS 30MG

4

QL (60 EA per 30 days)

SENSIPAR TABS 90MG

5

QL (120 EA per 30 days)

SENSIPAR TABS 60MG

5

QL (60 EA per 30 days)

SEROSTIM

5

PA LA

SIGNIFOR

5

PA LA

SIGNIFOR LAR

5

QL (1 EA per 28 days) PA LA

SKYTROFA

5

PA LA

sodium phenylbutyrate tabs, oral powder

5

PA

SOMATULINE DEPOT

5

PA LA

SOMAVERT

5

PA LA

STRENSIQ

5

PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 78

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

TEPEZZA

5

PA LA

tolvaptan tabs 15mg

5

QL (30 EA per 30 days) PA LA

tolvaptan tabs 30mg

5

QL (60 EA per 30 days) PA LA

TRIPTODUR

5

PA

vasopressin

2

VASOSTRICT

4

VIJOICE TBPK 125MG, 50MG

5

QL (28 EA per 28 days) PA LA

VIJOICE TBPK 250MG

5

QL (56 EA per 28 days) PA LA

VIMIZIM

5

PA LA

VISTOGARD

5

QL (20 EA per 166 days)

VOXZOGO

5

QL (30 EA per 30 days) PA LA

VPRIV

5

PA LA

XENPOZYME

5

PA LA

XIAFLEX

5

PA

XURIDEN

5

QL (120 EA per 30 days) PA

ZAVESCA

5

QL (90 EA per 30 days) PA LA

ZOKINVY

5

QL (120 EA per 30 days) PA MO

ZOMACTON

4

PA

ZORBTIVE

5

PA

PHOSPHATE BINDER AGENTS

AURYXIA

5

QL (360 EA per 30 days) PA MO

calcium acetate caps, tabs 667mg

2

QL (360 EA per 30 days) MO

FOSRENOL

5

MO

lanthanum carbonate

5

MO

PHOSLYRA

4

MO

RENAGEL

5

ST MO

RENVELA TABS

5

QL (540 EA per 30 days) ST MO

RENVELA PACK 2.4GM

5

QL (180 EA per 30 days) ST MO

RENVELA PACK 0.8GM

5

QL (540 EA per 30 days) ST MO

sevelamer carbonate (generic Renvela) tabs 800mg

2

QL (540 EA per 30 days) MO

sevelamer carbonate pack 2.4gm

5

QL (180 EA per 30 days) MO

sevelamer carbonate pack 0.8gm

5

QL (540 EA per 30 days) MO

sevelamer hydrochloride

2

MO

VELPHORO

5

QL (180 EA per 30 days) MO

PROGESTINS

AYGESTIN

4

MO

CRINONE

4

PA MO

hydroxyprogesterone caproate inj 250mg/ml

5

MAKENA

5

medroxyprogesterone acetate tabs 10mg, 2.5mg, 5mg

2

MO

megestrol acetate susp 40mg/ml, 625mg/5ml

2

MO

norethindrone acetate tabs 5mg

2

MO

progesterone

2

MO

PROMETRIUM

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 79

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

PROVERA

4

MO

THYROID AGENTS

ARMOUR THYROID

4

MO

CYTOMEL

4

MO

ERMEZA

4

euthyrox

1

MO

LEVO-T

4

LEVOTHYROXINE SODIUM CAPS

4

MO

levothyroxine sodium tabs

1

MO

LEVOTHYROXINE SODIUM INJ 100MCG/ML,

200MCG/5ML, 500MCG/5ML

4

LEVOTHYROXINE SODIUM INJ 100MCG/5ML

5

levothyroxine sodium inj 100mcg, 200mcg, 500mcg

5

MO

LEVOXYL

3

MO

liothyronine sodium tabs

2

MO

liothyronine sodium inj

5

methimazole tabs

1

MO

np thyroid 120

2

MO

np thyroid 15

2

MO

np thyroid 30

2

MO

np thyroid 60

2

MO

np thyroid 90

2

MO

propylthiouracil tabs

2

MO

SYNTHROID

4

MO

THYQUIDITY

4

MO

TIROSINT

4

MO

TIROSINT-SOL SOLN 37.5MCG/ML, 44MCG/ML

4

TIROSINT-SOL SOLN 100MCG/ML, 112MCG/ML,

125MCG/ML, 137MCG/ML, 13MCG/ML, 150MCG/ML,

175MCG/ML, 200MCG/ML, 25MCG/ML, 50MCG/ML,

62.5MCG/ML, 75MCG/ML, 88MCG/ML

4

MO

TRIOSTAT

5

UNITHROID

3

VITAMIN D ANALOGS

calcitriol caps 0.25mcg, 0.5mcg

2

MO

calcitriol inj 1mcg/ml

2

calcitriol oral soln 1mcg/ml

2

MO

doxercalciferol inj

2

doxercalciferol caps

2

MO

HECTOROL

4

paricalcitol

2

MO

RAYALDEE

5

MO

ROCALTROL

4

MO

ZEMPLAR CAPS

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 80

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ZEMPLAR INJ 2MCG/ML

4

MO

ZEMPLAR INJ 5MCG/ML

5

MO

GASTROINTESTINAL

ANTIEMETICS

AKYNZEO CAPS

5

QL (4 EA per 30 days) B/D

AKYNZEO INJ 235MG; 0.25MG

4

MO

AKYNZEO INJ 235MG/20ML; 0.25MG/20ML

5

MO

ALOXI

4

ANTIVERT

4

PA

ANZEMET

4

B/D

aprepitant caps therapy pack, caps 40mg, caps 80mg

2

B/D MO

aprepitant caps 125mg

5

B/D MO

BONJESTA

4

QL (60 EA per 30 days) MO

CINVANTI

4

PA

compro

2

MO

DICLEGIS

4

QL (120 EA per 30 days) MO

DIMENHYDRINATE INJ

4

doxylamine succinate/pyridoxine hydrochloride

2

QL (120 EA per 30 days) MO

dronabinol

2

QL (60 EA per 30 days) PA MO

EMEND TRIPACK

4

B/D MO

EMEND CAPS

4

B/D MO

EMEND INJ

4

MO

EMEND ORAL SUSP

5

B/D MO

fosaprepitant dimeglumine

2

MO

GIMOTI

5

QL (9.8 ML per 28 days) PA

granisetron hcl inj

2

MO

granisetron hcl tabs

2

QL (60 EA per 30 days) B/D MO

MARINOL CAPS 2.5MG

4

QL (60 EA per 30 days) PA MO

MARINOL CAPS 10MG, 5MG

5

QL (60 EA per 30 days) PA MO

meclizine hcl tabs 12.5mg, 25mg

2

MO

metoclopramide hcl tabs 5mg

1

MO

metoclopramide hcl inj, oral soln

2

MO

metoclopramide hydrochloride tabs 10mg

1

MO

METOCLOPRAMIDE ODT TBDP 10MG

3

MO

metoclopramide odt tbdp 5mg

2

MO

ondansetron hcl tabs 24mg

2

B/D

ondansetron hcl oral soln

2

QL (900 ML per 30 days) B/D MO

ondansetron hcl tabs 4mg, 8mg

2

B/D MO

ondansetron hydrochloride inj

2

MO

ondansetron odt

2

B/D MO

PALONOSETRON HYDROCHLORIDE INJ 0.25MG/2ML

4

palonosetron hydrochloride inj 0.25mg/5ml

2

PHENERGAN

4

PA MO

prochlorperazine edisylate inj

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 81

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

prochlorperazine maleate tabs

2

MO

prochlorperazine rectal supp

2

MO

promethazine hcl tabs 12.5mg, inj, supp

2

PA MO

promethazine hcl plain syrp 6.25mg/5ml

2

PA MO

promethazine hydrochloride tabs 25mg, 50mg

2

PA MO

PROMETHEGAN SUPP 50MG

2

PA MO

promethegan supp 12.5mg

2

PA

promethegan supp 25mg

2

PA MO

REGLAN

4

MO

SANCUSO

5

QL (4 EA per 28 days) MO

scopolamine patch

2

QL (10 EA per 30 days) PA MO

SUSTOL

4

SYNDROS

5

PA MO

TIGAN

5

PA MO

TRANSDERM-SCOP

4

QL (10 EA per 30 days) PA MO

trimethobenzamide hydrochloride caps

2

PA MO

VARUBI

5

QL (4 EA per 30 days) B/D MO

ANTISPASMODICS

ANASPAZ

4

PA MO

ATROPINE SULFATE INJ 0.25MG/5ML, 8MG/20ML

4

PA

ATROPINE SULFATE INJ 1MG/10ML

4

PA MO

atropine sulfate inj 0.4mg/ml, 0.5mg/5ml, 1mg/ml, 8mg/20ml

2

PA

atropine sulfate inj 0.4mg/ml

2

PA MO

BELLADONNA/OPIUM

4

PA MO

BENTYL

4

PA MO

CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE

5

QL (240 EA per 30 days) PA MO

CHLORDIAZEPOXIDE HYDROCHLORIDE/CLIDINIUM

BROMIDE

5

QL (240 EA per 30 days) PA MO

CUVPOSA

4

QL (1350 ML per 30 days) MO

DARTISLA ODT

4

QL (120 EA per 30 days) MO

dicyclomine hcl oral soln

2

MO

dicyclomine hydrochloride caps, tabs

2

MO

dicyclomine hydrochloride inj

2

PA MO

ed-spaz

2

PA

GLYCATE

4

MO

glycopyrrolate oral soln

2

MO

glycopyrrolate inj 0.2mg/ml pf, 0.4mg/2ml, 0.6mg/3ml

2

glycopyrrolate inj 0.2mg/ml, 1mg/5ml, 4mg/20ml

2

MO

GLYCOPYRROLATE TABS 1.5MG

4

MO

glycopyrrolate tabs 1mg, 2mg

2

MO

hyoscyamine sulfate odt

2

PA MO

hyoscyamine sulfate elix, subl, tabs

2

PA MO

hyoscyamine sulfate soln

5

PA MO

LEVSIN/SL

4

PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 82

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

LEVSIN INJ

4

PA

LEVSIN TABS

4

PA MO

LIBRAX

5

QL (240 EA per 30 days) PA MO

methscopolamine bromide tabs

2

PA MO

nulev

2

PA MO

oscimin tabs

2

PA

oscimin subl

2

PA MO

ROBINUL

4

MO

ROBINUL FORTE

4

MO

GLUCOCORTICOIDS

TARPEYO

5

QL (120 EA per 30 days) PA LA

MO

H2-RECEPTOR ANTAGONISTS

cimetidine hcl

2

MO

cimetidine hydrochloride oral soln

2

MO

cimetidine tabs

2

MO

famotidine premixed inj

2

famotidine inj

2

famotidine oral susp, tabs

2

MO

nizatidine

2

MO

PEPCID TABS 20MG

4

MO

PEPCID TABS 40MG

5

MO

INFLAMMATORY BOWEL DISEASE

APRISO

4

QL (120 EA per 30 days) MO

ASACOL HD

5

MO

AZULFIDINE

4

MO

AZULFIDINE EN-TABS

4

MO

balsalazide disodium

2

MO

budesonide er tabs 9mg

5

MO

budesonide dr caps 3mg

2

MO

CANASA

5

MO

COLAZAL

5

MO

CORTENEMA

4

MO

DELZICOL

4

MO

DIPENTUM

5

MO

ENTOCORT EC

5

MO

hydrocortisone enem 100mg/60ml

2

MO

LIALDA

5

MO

mesalamine

2

MO

mesalamine dr caps 400mg, tabs 1.2gm, 800mg

2

MO

mesalamine er caps 0.375gm

2

QL (120 EA per 30 days) MO

mesalamine er caps 500mg

5

QL (240 EA per 30 days) MO

ORTIKOS

5

MO

PENTASA CPCR 500MG

5

QL (240 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 83

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

PENTASA CPCR 250MG

5

QL (480 EA per 30 days) MO

ROWASA

5

MO

SFROWASA

5

QL (1680 ML per 28 days) MO

sulfasalazine

2

MO

UCERIS FOAM

4

QL (66.8 GM per 28 days) MO

UCERIS TB24

5

MO

LAXATIVES

CLENPIQ

4

MO

constulose

2

enulose

2

MO

gavilyte-c

1

MO

gavilyte-g

1

MO

gavilyte-n/flavor pack

1

generlac

2

GOLYTELY

3

MO

KRISTALOSE

4

PA MO

LACTULOSE PACK

5

PA MO

lactulose soln

2

MO

MOVIPREP

4

MO

NULYTELY

3

MO

OSMOPREP

4

MO

peg-3350/electrolytes

2

MO

peg-3350/electrolytes/ascorbate

2

peg-3350/nacl/na bicarbonate/kcl

1

MO

PLENVU

4

MO

SODIUM SULFATE/POTASSIUM

SULFATE/MAGNESIUM SULFATE

4

MO

SUPREP BOWEL PREP KIT

4

MO

SUTAB

4

MO

MISCELLANEOUS

alosetron hydrochloride tabs 0.5mg

2

QL (60 EA per 30 days) PA MO

alosetron hydrochloride tabs 1mg

5

QL (60 EA per 30 days) PA MO

AMITIZA

4

QL (60 EA per 30 days) PA MO

BYLVAY (PELLETS) CPSP 600MCG

5

QL (300 EA per 30 days) PA LA

MO

BYLVAY (PELLETS) CPSP 200MCG

5

QL (900 EA per 30 days) PA LA

MO

BYLVAY CAPS 1200MCG

5

QL (150 EA per 30 days) PA LA

MO

BYLVAY CAPS 400MCG

5

QL (450 EA per 30 days) PA LA

MO

CARAFATE

4

MO

CHENODAL

5

PA MO

CHOLBAM

5

PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 84

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

cromolyn sodium oral conc 100mg/5ml

2

MO

CYTOTEC

4

MO

diphenoxylate hydrochloride/atropine sulfate tabs

2

MO

diphenoxylate/atropine oral soln

2

MO

GASTROCROM

5

MO

GATTEX

5

PA LA

HELIDAC THERAPY

5

QL (448 EA per 365 days)

IBSRELA

5

QL (60 EA per 30 days) PA MO

lansoprazole/amoxicillin/clarithromycin

2

QL (224 EA per 365 days) MO

LINZESS

4

QL (30 EA per 30 days) MO

LIVMARLI

5

QL (90 ML per 30 days) PA LA MO

LOMOTIL

4

MO

loperamide hcl caps

2

MO

LOTRONEX

5

QL (60 EA per 30 days) PA MO

LUBIPROSTONE

4

QL (60 EA per 30 days) PA MO

misoprostol tabs

2

MO

MOTEGRITY

4

QL (30 EA per 30 days) PA MO

MOTOFEN

4

QL (240 EA per 30 days) ST MO

MOVANTIK TABS 25MG

3

QL (30 EA per 30 days) MO

MOVANTIK TABS 12.5MG

3

QL (60 EA per 30 days) MO

MYTESI

5

PA

OCALIVA

5

QL (30 EA per 30 days) PA LA

OMECLAMOX-PAK

4

QL (160 EA per 365 days) MO

opium tincture

2

MO

PYLERA

5

MO

REBYOTA

5

PA LA

RELISTOR INJ

5

PA MO

RELISTOR TABS

5

QL (90 EA per 30 days) PA MO

RELTONE

5

PA

SUCRAID

5

LA

SUCRALFATE SUSP

4

MO

sucralfate tabs

2

MO

SYMPROIC

4

MO

TALICIA

4

QL (336 EA per 365 days) MO

TRULANCE

4

QL (30 EA per 30 days) MO

URSO 250

4

MO

URSO FORTE

4

MO

URSODIOL CAPS 200MG, 400MG

4

PA

ursodiol caps 300mg

2

MO

ursodiol tabs

2

MO

VIBERZI

5

QL (60 EA per 30 days) PA MO

VOQUEZNA DUAL PAK

4

QL (224 EA per 365 days)

VOQUEZNA TRIPLE PAK

4

QL (224 EA per 365 days)

XERMELO

5

QL (84 EA per 28 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 85

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

XIFAXAN TABS 550MG

5

PA MO

PANCREATIC ENZYMES

CREON

3

MO

PANCREAZE CPEP 2600UNIT, 4200UNIT, 10500UNIT

4

MO

PANCREAZE CPEP 16800UNIT, 21000UNIT, 37000UNIT

5

MO

PERTZYE CPEP 4000UNIT, 8000UNIT

4

MO

PERTZYE CPEP 16000UNIT, 24000UNIT

5

MO

VIOKACE TABS 10440UNIT

4

MO

VIOKACE TABS 20880UNIT

5

MO

ZENPEP

4

MO

PROTON PUMP INHIBITORS

ACIPHEX

4

QL (30 EA per 30 days) MO

DEXILANT

4

QL (30 EA per 30 days) MO

dexlansoprazole

2

QL (30 EA per 30 days) MO

esomeprazole magnesium caps, oral packet

2

QL (30 EA per 30 days) MO

esomeprazole sodium inj

2

lansoprazole cpdr 15mg

2

QL (30 EA per 30 days) MO

lansoprazole cpdr 30mg

2

QL (42 EA per 30 days) MO

lansoprazole tbdd 15mg

2

QL (30 EA per 30 days) MO

lansoprazole tbdd 30mg

2

QL (42 EA per 30 days) MO

NEXIUM

4

QL (30 EA per 30 days) MO

NEXIUM I.V.

4

PA

omeprazole

2

QL (60 EA per 30 days) MO

omeprazole dr caps 10mg

2

QL (30 EA per 30 days) MO

omeprazole/sodium bicarbonate

5

QL (30 EA per 30 days) MO

pantoprazole sodium inj

2

pantoprazole sodium pack

2

QL (30 EA per 30 days) MO

pantoprazole sodium tbec 20mg

1

QL (30 EA per 30 days) MO

pantoprazole sodium tbec 40mg

1

QL (60 EA per 30 days) MO

PREVACID

4

QL (42 EA per 30 days) MO

PREVACID SOLUTAB TBDD 15MG

4

QL (30 EA per 30 days) MO

PREVACID SOLUTAB TBDD 30MG

4

QL (42 EA per 30 days) MO

PRILOSEC PACK 10MG

4

QL (120 EA per 30 days) MO

PRILOSEC PACK 2.5MG

4

QL (90 EA per 30 days) MO

PROTONIX INJ

4

PROTONIX PACK

4

QL (30 EA per 30 days) MO

PROTONIX TBEC 20MG

4

QL (30 EA per 30 days) MO

PROTONIX TBEC 40MG

4

QL (60 EA per 30 days) MO

rabeprazole sodium dr tabs 20mg

2

QL (30 EA per 30 days) MO

ZEGERID

5

QL (30 EA per 30 days) PA MO

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA

alfuzosin hcl er

2

QL (30 EA per 30 days) MO

AVODART

4

QL (30 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 86

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

CARDURA XL TB24 8MG

4

QL (30 EA per 30 days) MO

CARDURA XL TB24 4MG

4

QL (60 EA per 30 days) MO

dutasteride

2

QL (30 EA per 30 days) MO

dutasteride/tamsulosin hydrochloride

2

QL (30 EA per 30 days) MO

ENTADFI

4

QL (30 EA per 30 days) PA

finasteride tabs

1

QL (30 EA per 30 days) MO

FLOMAX

4

QL (60 EA per 30 days) MO

JALYN

4

QL (30 EA per 30 days) MO

PROSCAR

4

QL (30 EA per 30 days) MO

RAPAFLO

4

QL (30 EA per 30 days) MO

silodosin

2

QL (30 EA per 30 days) MO

tamsulosin hydrochloride

2

QL (60 EA per 30 days) MO

UROXATRAL

4

QL (30 EA per 30 days) MO

MISCELLANEOUS

acetic acid 0.25% irrigation soln

2

MO

bethanechol chloride

2

MO

ELMIRON

5

QL (90 EA per 30 days) MO

flavoxate hcl

2

MO

INTRAROSA

4

QL (28 EA per 28 days) PA MO

LITHOSTAT

5

MO

neomycin/polymyxin b sulfates irrigation soln

2

MO

ORACIT

4

MO

OXLUMO

5

PA LA MO

potassium citrate er tabs

2

MO

potassium citrate/citric acid oral soln

2

MO

potassium citrate/sodium citrate/citric acid oral soln

2

MO

RENACIDIN

4

MO

RIMSO-50

5

MO

sodium citrate/citric acid

2

MO

SORBITOL IRRIGATION SOLN

4

THIOLA

5

LA MO

THIOLA EC

5

MO

tiopronin

5

tricitrates

2

MO

UROCIT-K 10

4

MO

UROCIT-K 15

4

MO

UROCIT-K 5

4

MO

URINARY ANTISPASMODICS

darifenacin hydrobromide er

2

QL (30 EA per 30 days) MO

DETROL

4

QL (60 EA per 30 days) ST MO

DETROL LA

4

QL (30 EA per 30 days) ST MO

DITROPAN XL TB24 5MG

4

QL (30 EA per 30 days) MO

DITROPAN XL TB24 10MG

4

QL (60 EA per 30 days) MO

fesoterodine fumarate er

2

QL (30 EA per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 87

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

GELNIQUE

4

QL (30 GM per 30 days) MO

GEMTESA

4

QL (30 EA per 30 days) MO

MYRBETRIQ TB24

4

QL (30 EA per 30 days) MO

MYRBETRIX ORAL SUSP

4

QL (300 ML per 28 days) MO

oxybutynin chloride er tb24 5mg

2

QL (30 EA per 30 days) MO

oxybutynin chloride er tb24 10mg, 15mg

2

QL (60 EA per 30 days) MO

oxybutynin chloride immediate release tabs 5mg

2

QL (120 EA per 30 days) MO

oxybutynin chloride syrp

2

QL (600 ML per 30 days) MO

OXYTROL

4

QL (8 EA per 28 days) MO

solifenacin succinate

2

QL (30 EA per 30 days) ST MO

tolterodine tartrate er caps

2

QL (30 EA per 30 days) ST MO

tolterodine tartrate tabs

2

QL (60 EA per 30 days) ST MO

TOVIAZ

4

QL (30 EA per 30 days) ST MO

trospium chloride er caps

2

QL (30 EA per 30 days) MO

trospium chloride tab

2

QL (60 EA per 30 days) MO

VESICARE

4

QL (30 EA per 30 days) ST MO

VESICARE LS

4

QL (300 ML per 30 days) ST

VAGINAL ANTI-INFECTIVES

CLEOCIN CREA 2%

4

MO

CLEOCIN SUPP 100MG

4

MO

clindamycin phosphate vaginal cre 2%

2

MO

CLINDESSE

4

QL (5 GM per 30 days) MO

GYNAZOLE-1

4

MO

metronidazole vaginal

2

MO

miconazole 3

2

MO

NUVESSA

4

MO

terconazole

2

MO

VANDAZOLE

4

MO

HEMATOLOGIC

ANTICOAGULANTS

ARGATROBAN

4

ARIXTRA INJ 2.5MG/0.5ML

4

MO

ARIXTRA INJ 10MG/0.8ML, 5MG/0.4ML, 7.5MG/0.6ML

5

MO

dabigatran etexilate

2

QL (60 EA per 30 days) MO

ELIQUIS STARTER PACK

3

QL (74 EA per 30 days) MO

ELIQUIS TABS 2.5MG

3

QL (60 EA per 30 days) MO

ELIQUIS TABS 5MG

3

QL (74 EA per 30 days) MO

enoxaparin sodium

2

MO

fondaparinux sodium inj 2.5mg/0.5ml

2

MO

fondaparinux sodium inj 10mg/0.8ml, 5mg/0.4ml, 7.5mg/0.6ml

5

MO

FRAGMIN INJ 2500UNIT/ML

4

FRAGMIN INJ 2500UNIT/0.2ML, 95000UNIT/3.8ML

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 88

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML,

15000UNIT/0.6ML, 18000UNT/0.72ML, 5000UNIT/0.2ML,

7500UNIT/0.3ML

5

MO

HEPARIN SODIUM/DEXTROSE

4

HEPARIN SODIUM/NACL 0.45%

3

HEPARIN SODIUM INJ 5000UNIT/0.5ML, 5000UNIT/ML

3

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml,

5000unit/0.5ml, 5000unit/ml

2

MO

jantoven

1

MO

LOVENOX INJ 300MG/3ML, 30MG/0.3ML

4

MO

LOVENOX INJ 100MG/ML, 120MG/0.8ML, 150MG/ML,

40MG/0.4ML, 60MG/0.6ML, 80MG/0.8ML

5

MO

PRADAXA CAPS 110MG

4

QL (120 EA per 30 days) MO

PRADAXA CAPS 150MG, 75MG

4

QL (60 EA per 30 days) MO

SAVAYSA

4

QL (30 EA per 30 days) ST MO

warfarin sodium

1

MO

XARELTO STARTER PACK

3

QL (51 EA per 30 days) MO

XARELTO ORAL SUSP

3

QL (620 ML per 30 days) MO

XARELTO TABS 10MG, 15MG, 20MG

3

QL (30 EA per 30 days) MO

XARELTO TABS 2.5MG

3

QL (60 EA per 30 days) MO

HEMATOPOIETIC GROWTH FACTORS

ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4

QL (1.2 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML,

40MCG/0.4ML

4

QL (1.6 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML

4

QL (1.68 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML,

60MCG/ML

4

QL (4 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 500MCG/ML

5

QL (1 ML per 21 days) PA

ARANESP ALBUMIN FREE INJ 150MCG/0.3ML

5

QL (1.2 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 200MCG/0.4ML

5

QL (1.6 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML

5

QL (2 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 300MCG/0.6ML

5

QL (2.4 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 100MCG/ML,

200MCG/ML

5

QL (4 ML per 28 days) PA

EPOGEN INJ 10000UNIT/ML, 2000UNIT/ML,

3000UNIT/ML, 4000UNIT/ML

4

QL (12 ML per 28 days) PA

EPOGEN INJ 20000UNIT/ML

5

QL (12 ML per 28 days) PA

FULPHILA

5

PA

FYLNETRA

5

PA LA

GRANIX

5

PA

LEUKINE

5

PA

MOZOBIL

5

PA LA

NEULASTA

5

PA

NEULASTA ONPRO KIT

5

PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 89

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

NEUPOGEN

5

PA

NIVESTYM

5

PA

NPLATE

5

PA

NYVEPRIA

5

PA

PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML,

3000UNIT/ML, 4000UNIT/ML

3

PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

5

PA

RELEUKO

5

PA LA

RETACRIT INJ 10000UNIT/ML, 20000UNIT/2ML,

2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4

PA

RETACRIT INJ 20000UNIT/ML, 40000UNIT/ML

5

PA

ROLVEDON

5

PA LA

UDENYCA

5

PA

ZARXIO

5

PA

ZIEXTENZO

5

PA

MISCELLANEOUS

ADAKVEO

5

PA

AGRYLIN

4

MO

AMICAR

5

MO

aminocaproic acid inj

2

aminocaproic acid oral soln, tabs

5

MO

anagrelide hydrochloride

2

MO

BERINERT

5

QL (24 EA per 30 days) PA LA

CABLIVI

5

PA LA

cilostazol

1

MO

CINRYZE

5

QL (20 EA per 30 days) PA LA

CYKLOKAPRON

4

DOPTELET

5

QL (60 EA per 30 days) PA LA

DROXIA

3

MO

EMPAVELI

5

QL (200 ML per 30 days) PA LA

MO

ENDARI

5

PA LA

ENJAYMO

5

PA LA

FIRAZYR

5

QL (27 ML per 30 days) PA

GIVLAARI

5

PA LA

HAEGARDA INJ 3000UNIT

5

QL (20 EA per 30 days) PA LA

HAEGARDA INJ 2000UNIT

5

QL (30 EA per 30 days) PA LA

icatibant acetate

5

QL (27 ML per 30 days) PA

KALBITOR

5

QL (12 ML per 30 days) PA LA

MULPLETA

5

QL (14 EA per 365 days) PA

ORLADEYO

5

QL (28 EA per 28 days) PA LA MO

OXBRYTA SOLUBLE TABS

5

QL (150 EA per 30 days) PA LA

OXBRYTA TABS 300MG

5

QL (90 EA per 30 days) PA

OXBRYTA TABS 500MG

5

QL (90 EA per 30 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 90

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

pentoxifylline er

2

MO

PROMACTA PACK 25MG

5

QL (180 EA per 30 days) PA LA

PROMACTA PACK 12.5MG

5

QL (360 EA per 30 days) PA LA

PROMACTA TABS 12.5MG, 25MG

5

QL (30 EA per 30 days) PA LA

PROMACTA TABS 50MG, 75MG

5

QL (60 EA per 30 days) PA LA

PYRUKYND TABS

5

QL (56 EA per 28 days) PA LA MO

PYRUKYND TAPER PACK TBPK 20MG; 5MG, 50MG;

20MG

5

QL (14 EA per 14 days) PA LA MO

PYRUKYND TAPER PACK TBPK 5MG

5

QL (7 EA per 7 days) PA LA MO

REBLOZYL

5

PA LA

RUCONEST

5

QL (12 EA per 30 days) PA LA

sajazir

5

QL (27 ML per 30 days) PA LA MO

SIKLOS TABS 100MG

4

PA MO

SIKLOS TABS 1000MG

5

PA MO

SOLIRIS

5

PA LA

TAKHZYRO

5

QL (4 ML per 28 days) PA LA

TAVALISSE

5

QL (60 EA per 30 days) PA LA

TAVNEOS

5

QL (180 EA per 30 days) PA LA

MO

tranexamic acid inj

2

tranexamic acid tabs

2

MO

ULTOMIRIS

5

PA LA

PLATELET AGGREGATION INHIBITORS

aspirin/dipyridamole er

2

QL (60 EA per 30 days) MO

BRILINTA

3

MO

clopidogrel tabs 300mg

1

QL (2 EA per 365 days) MO

clopidogrel tabs 75mg

1

QL (30 EA per 30 days) MO

dipyridamole tabs

2

PA MO

EFFIENT

4

MO

PLAVIX

4

QL (30 EA per 30 days) ST MO

prasugrel

2

MO

ZONTIVITY

4

MO

IMMUNOLOGIC AGENTS

AUTOIMMUNE AGENTS

ACTEMRA ACTPEN

5

QL (3.6 ML per 28 days) PA LA

ACTEMRA INJ 162MG/0.9ML

5

QL (3.6 ML per 28 days) PA

ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5

QL (40 ML per 28 days) PA LA

ADBRY

5

QL (56 ML per 365 days) PA LA

AVSOLA

5

PA LA

CIBINQO

5

QL (30 EA per 30 days) PA

CIMZIA

5

QL (2 EA per 28 days) PA

CIMZIA STARTER KIT

5

QL (6 EA per 365 days) PA

COSENTYX SENSOREADY PEN

5

QL (32 ML per 365 days) PA LA

COSENTYX INJ 150MG/ML

5

QL (32 ML per 365 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 91

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

COSENTYX INJ 75MG/0.5ML

5

QL (8 ML per 365 days) PA LA

DUPIXENT INJ 100MG/0.67ML

5

QL (1.34 ML per 28 days) PA

DUPIXENT INJ 200MG/1.14ML

5

QL (4.56 ML per 28 days) PA

DUPIXENT INJ 300MG/2ML

5

QL (8 ML per 28 days) PA

ENBREL MINI

5

QL (8 ML per 28 days) PA

ENBREL SURECLICK

5

QL (8 ML per 28 days) PA

ENBREL INJ 25MG/VIAL

5

QL (8 EA per 28 days) PA

ENBREL INJ 25MG/0.5ML, 50MG/ML

5

QL (8 ML per 28 days) PA

ENTYVIO

5

QL (8 EA per 365 days) PA LA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER

PACK

5

PA

HUMIRA PEN-CD/UC/HS STARTER

5

PA

HUMIRA PEN-PEDIATRIC UC STARTER PACK

5

PA

HUMIRA PEN-PS/UV STARTER

5

PA

HUMIRA PEN INJ 80MG/0.8ML

5

PA

HUMIRA PEN INJ 40MG/0.4ML, 40MG/0.8ML

5

QL (6 EA per 28 days) PA

HUMIRA INJ 10MG/0.1ML, 20MG/0.2ML

5

QL (2 EA per 28 days) PA

HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML

5

QL (6 EA per 28 days) PA

ILUMYA

5

PA LA

INFLECTRA

5

PA LA

INFLIXIMAB

5

PA LA

KEVZARA

5

QL (2.28 ML per 28 days) PA

KINERET

5

QL (18.76 ML per 28 days) PA

OLUMIANT

5

QL (30 EA per 30 days) PA LA

ORENCIA CLICKJECT

5

QL (4 ML per 28 days) PA

ORENCIA INJ 250MG

5

PA

ORENCIA INJ 50MG/0.4ML

5

QL (1.6 ML per 28 days) PA

ORENCIA INJ 87.5MG/0.7ML

5

QL (2.8 ML per 28 days) PA

ORENCIA INJ 125MG/ML

5

QL (4 ML per 28 days) PA

OTEZLA TABLET THERAPY PACK

5

QL (110 EA per 365 days) PA

OTEZLA TABS

5

QL (60 EA per 30 days) PA

REMICADE

5

PA LA

RENFLEXIS

5

PA LA

RINVOQ

5

QL (30 EA per 30 days) PA

SILIQ

5

QL (4.5 ML per 28 days) PA

SIMPONI ARIA

5

PA

SIMPONI INJ 50MG/0.5ML

5

QL (0.5 ML per 28 days) PA

SIMPONI INJ 100MG/ML

5

QL (3 ML per 28 days) PA

SKYRIZI PEN

5

QL (6 ML per 365 days) PA

SKYRIZI INJ 180MG/1.2ML

5

QL (1.2 ML per 56 days) PA

SKYRIZI INJ 360MG/2.4ML

5

QL (2.4 ML per 56 days) PA

SKYRIZI INJ 150MG/ML

5

QL (6 ML per 365 days) PA

SKYRIZI INJ 600MG/10ML

5

QL (60 ML per 365 days) PA

SOTYKTU

5

QL (30 EA per 30 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 92

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

SPEVIGO

5

PA LA MO

STELARA INJ 45MG/0.5ML PREFILLED SYRINGE

5

QL (0.5 ML per 28 days) PA

STELARA INJ 45MG/0.5ML VIAL

5

QL (0.5 ML per 28 days) PA LA

STELARA INJ 90MG/ML

5

QL (1 ML per 28 days) PA

STELARA INJ 130MG/26ML

5

QL (104 ML per 365 days) PA LA

TALTZ

5

QL (3 ML per 28 days) PA LA

TREMFYA

5

QL (1 ML per 28 days) PA

XELJANZ XR

5

QL (30 EA per 30 days) PA

XELJANZ ORAL SOLN

5

QL (480 ML per 24 days) PA

XELJANZ TABS

5

QL (60 EA per 30 days) PA

DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS

(DMARDS)

ARAVA

5

QL (30 EA per 30 days) MO

HYDROXYCHLOROQUINE SULFATE TABS 100MG,

300MG, 400MG

4

MO

hydroxychloroquine sulfate tabs 200mg

2

MO

leflunomide

1

QL (30 EA per 30 days) MO

methotrexate sodium tabs 2.5mg

1

MO

OTREXUP

4

QL (1.6 ML per 28 days)

PLAQUENIL

4

MO

RASUVO INJ 7.5MG/0.15ML

4

QL (0.6 ML per 28 days)

RASUVO INJ 10MG/0.2ML

4

QL (0.8 ML per 28 days)

RASUVO INJ 12.5MG/0.25ML

4

QL (1 ML per 28 days)

RASUVO INJ 15MG/0.3ML

4

QL (1.2 ML per 28 days)

RASUVO INJ 17.5MG/0.35ML

4

QL (1.4 ML per 28 days)

RASUVO INJ 20MG/0.4ML

4

QL (1.6 ML per 28 days)

RASUVO INJ 22.5MG/0.45ML

4

QL (1.8 ML per 28 days)

RASUVO INJ 25MG/0.5ML

4

QL (2 ML per 28 days)

RASUVO INJ 30MG/0.6ML

4

QL (2.4 ML per 28 days)

REDITREX INJ 7.5MG/0.3ML

4

QL (1.2 ML per 28 days)

REDITREX INJ 10MG/0.4ML

4

QL (1.6 ML per 28 days)

REDITREX INJ 12.5MG/0.5ML

4

QL (2 ML per 28 days)

REDITREX INJ 15MG/0.6ML

4

QL (2.4 ML per 28 days)

REDITREX INJ 17.5MG/0.7ML

4

QL (2.8 ML per 28 days)

REDITREX INJ 20MG/0.8ML

4

QL (3.2 ML per 28 days)

REDITREX INJ 22.5MG/0.9ML

4

QL (3.6 ML per 28 days)

REDITREX INJ 25MG/ML

4

QL (4 ML per 28 days)

RIDAURA

5

MO

TREXALL

4

MO

XATMEP

4

MO

IMMUNOGLOBULINS

ASCENIV

5

PA

BIVIGAM

5

PA LA

CUTAQUIG

5

PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 93

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

CUVITRU

5

PA LA

CYTOGAM

5

FLEBOGAMMA DIF

5

PA

GAMASTAN

3

B/D LA

GAMMAGARD LIQUID

5

PA

GAMMAGARD S/D 5GM, 10GM

5

PA

GAMMAKED

5

PA

GAMMAPLEX

5

PA LA

GAMUNEX-C

5

PA

HEPAGAM B

4

HIZENTRA

5

PA LA

HYPERHEP B

4

HYPERRAB INJ 300UNIT/ML

4

HYPERRAB INJ 1500UNIT/5ML, 900UNIT/3ML

5

HYPERRHO S/D

4

HYPERRHO S/D MINI-DOSE

4

HYPERTET

4

HYQVIA

5

PA LA

IMOGAM RABIES-HT

4

KEDRAB INJ 300UNIT/2ML

4

KEDRAB INJ 1500UNIT/10ML

5

MICRHOGAM ULTRA-FILTERED PLUS

4

NABI-HB

4

OCTAGAM

5

PA

PANZYGA

5

PA

PRIVIGEN

5

PA

RHOGAM ULTRA-FILTERED PLUS

4

RHOPHYLAC

4

VARIZIG

5

WINRHO SDF

4

XEMBIFY

5

PA LA

IMMUNOMODULATORS

ACTIMMUNE

5

PA LA

ARCALYST

5

PA LA

GRASTEK

4

QL (30 EA per 30 days) PA MO

ILARIS

5

QL (2 ML per 28 days) PA LA

INTRON A

5

LA

ODACTRA

4

QL (30 EA per 30 days) PA MO

ORALAIR

4

QL (30 EA per 30 days) PA LA

RAGWITEK

4

QL (30 EA per 30 days) PA MO

SYNAGIS

5

VYVGART

5

QL (240 ML per 28 days) PA LA

ZINPLAVA

5

PA

IMMUNOSUPPRESSANTS

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 94

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ASTAGRAF XL CP24 0.5MG, 1MG

4

B/D MO

ASTAGRAF XL CP24 5MG

5

B/D MO

ATGAM

5

B/D

azasan

2

B/D

AZATHIOPRINE INJ

4

B/D

azathioprine tabs

2

B/D MO

BENLYSTA

5

PA LA

CELLCEPT INTRAVENOUS

4

B/D

CELLCEPT ORAL SUSP, CAPS, TABS

5

B/D MO

cyclosporine modified

2

B/D MO

cyclosporine caps 100mg, 25mg

2

B/D MO

cyclosporine inj 50mg/ml

2

B/D MO

ENVARSUS XR TB24 0.75MG, 1MG

4

B/D MO

ENVARSUS XR TB24 4MG

5

B/D MO

everolimus tabs 0.25mg

2

B/D MO

everolimus tabs 0.5mg, 0.75mg, 1mg

5

B/D MO

gengraf caps

2

B/D

gengraf soln

2

B/D MO

IMURAN

4

B/D MO

LUPKYNIS

5

QL (180 EA per 30 days) PA LA

MO

mycohpenolic acid tabs dr

2

B/D MO

mycophenolate mofetil caps, inj, tabs

2

B/D MO

mycohpenolate mofetil oral susp

5

B/D MO

MYFORTIC TBEC 180MG

4

B/D MO

MYFORTIC TBEC 360MG

5

B/D MO

NEORAL

4

B/D MO

NULOJIX

5

B/D

PROGRAF INJ

4

B/D

PROGRAF GRANULES

4

B/D MO

PROGRAF CAPS 0.5MG, 1MG

4

B/D MO

PROGRAF CAPS 5MG

5

B/D MO

RAPAMUNE SOLN

5

B/D MO

RAPAMUNE TABS 0.5MG

4

B/D MO

RAPAMUNE TABS 1MG, 2MG

5

B/D MO

REZUROCK

5

QL (30 EA per 30 days) PA LA MO

SANDIMMUNE INJ

4

B/D

SANDIMMUNE ORAL SOLN

4

B/D MO

SANDIMMUNE CAPS 25MG

4

B/D MO

SANDIMMUNE CAPS 100MG

5

B/D MO

SAPHNELO

5

QL (2 ML per 28 days) PA LA MO

SIMULECT

5

B/D

sirolimus soln

5

B/D MO

sirolimus tabs 0.5mg, 1mg

2

B/D MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 95

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

sirolimus tabs 2mg

5

B/D MO

tacrolimus caps 0.5mg, 1mg, 5mg

2

B/D MO

THYMOGLOBULIN

5

B/D

ZORTRESS

5

B/D MO

VACCINES

ACTHIB

3

ADACEL

3

BCG VACCINE

3

BEXSERO

3

BOOSTRIX

3

DAPTACEL

3

DENGVAXIA

3

DIPHTHERIA/TETANUS TOXOIDS ADSORBED

PEDIATRIC

3

B/D

ENGERIX-B

3

B/D

GARDASIL 9

3

HAVRIX

3

HIBERIX

3

IMOVAX RABIES (H.D.C.V.)

3

B/D

INFANRIX

3

IPOL INACTIVATED IPV

3

IXIARO

3

JYNNEOS

3

B/D

KINRIX

3

M-M-R II

3

MENACTRA

3

MENQUADFI

3

MENVEO

3

PEDIARIX

3

PEDVAX HIB

3

PENTACEL

3

PREHEVBRIO

3

B/D

PRIORIX

3

PROQUAD

3

QUADRACEL

3

RABAVERT

3

B/D

RECOMBIVAX HB

3

B/D

ROTARIX

3

ROTATEQ

3

SHINGRIX

3

QL (2 EA per 999 days)

TDVAX

3

B/D

TENIVAC

3

B/D

TICOVAC

3

TRUMENBA

3

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 96

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

TWINRIX

3

TYPHIM VI

3

VAQTA

3

VARIVAX

3

YF-VAX

3

NUTRITIONAL/SUPPLEMENTS

ELECTROLYTES/MINERALS, INJECTABLE

CALCIUM GLUCONATE

4

MO

DEXTROSE 10%/NACL 0.45%

4

DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX

3

DEXTROSE 10%/NACL 0.2%

4

DEXTROSE 2.5%/NACL 0.45%

4

DEXTROSE 5%/LACTATED RINGERS

4

DEXTROSE 5%/NACL 0.2%

4

dextrose 5%/nacl 0.3%

2

DEXTROSE 5%/NACL 0.33%

4

DEXTROSE 5%/NACL 0.45%

4

DEXTROSE 5%/NACL 0.9%

4

MO

DEXTROSE 5%/NACL 0.225%

4

hyperlyte-cr

2

B/D

ISOLYTE-P/DEXTROSE 5%

4

ISOLYTE-S

4

B/D

ISOLYTE-S PH 7.4

4

B/D

KCL 0.075%/D5W/NACL 0.45%

4

KCL 0.15%/D5W/NACL 0.2%

4

KCL 0.15%/D5W/NACL 0.45%

4

KCL 0.15%/D5W/NACL 0.9%

4

KCL 0.3%/D5W/NACL 0.45%

4

KCL 0.3%/D5W/NACL 0.9%

4

lactated ringers

2

magnesium sulfate in d5w 1gm/100ml

2

MAGNESIUM SULFATE INJ 20GM/500ML,

40GM/1000ML, 4GM/50ML

4

magnesium sulfate inj 2gm/50ml, 4gm/100ml, 50%

2

PLASMA-LYTE A

4

PLASMA-LYTE-148

4

POTASSIUM ACETATE

4

POTASSIUM CHLORIDE/DEXTROSE

4

POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS

4

POTASSIUM CHLORIDE/DEXTROSE/SODIUM

CHLORIDE

4

POTASSIUM CHLORIDE/SODIUM CHLORIDE INJ

40MEQ/L; 0.9%

4

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 97

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

potassium chloride/sodium chloride inj 20meq/l; 0.45%,

20meq/l; 0.9%

2

POTASSIUM CHLORIDE INJ 0.4MEQ/ML,

10MEQ/100ML, 10MEQ/50ML, 20MEQ/100ML,

40MEQ/100ML

4

potassium chloride inj 2meq/ml

2

MO

potassium phosphate

2

RINGERS INJECTION

3

SODIUM ACETATE INJ 2MEQ/ML

4

sodium acetate inj 4meq/ml

2

SODIUM BICARBONATE INJ 7.5%

4

MO

sodium bicarbonate inj 4.2%

2

sodium bicarbonate inj 8.4%

2

MO

sodium chloride 0.45%

2

SODIUM CHLORIDE INJ 2.5MEQ/ML, 5%

4

MO

sodium chloride inj 0.9%, 3%, 4meq/ml

2

MO

sodium phosphate

2

sodium phosphates

2

TPN ELECTROLYTES

4

B/D

ELECTROLYTES/MINERALS/VITAMINS, ORAL

adc/fluoride drops

2

MO

C-NATE DHA

3

MO

CITRANATAL 90 DHA

3

MO

CITRANATAL B-CALM

3

MO

CITRANATAL BLOOM

3

MO

CITRANATAL HARMONY

3

MO

CITRANATAL MEDLEY

3

CITRANATAL RX

3

COMPLETENATE

3

MO

CONCEPT DHA

3

MO

CONCEPT OB

3

MO

DUET DHA 400

3

MO

DUET DHA BALANCED

3

MO

EFFER-K TBEF 0.84GM; 1GM, 1.68GM; 2GM

4

MO

effer-k tbef 25meq

2

MO

ELITE-OB

3

MO

ENBRACE HR

3

MO

FLORIVA

4

MO

fluoride chew

2

MO

fluoritab

2

FOLIVANE-OB

3

MO

K-TAB

4

MO

klor-con 10

2

klor-con 8

2

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 98

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

klor-con m10

2

MO

klor-con m15

2

MO

klor-con m20

2

MO

klor-con powder packet 20meq

2

klor-con/ef 25meq

2

MO

M-NATAL PLUS

3

MO

multi-vitamin/fluoride chew

2

MO

multi-vitamin/fluoride drops

2

MO

multi-vitamin/fluoride/iron drops

2

MO

NATACHEW

3

MO

NEONATAL 19

3

NEONATAL COMPLETE

3

MO

NEONATAL FE

3

NEONATAL PLUS

3

MO

NESTABS

3

MO

NESTABS ONE

3

MO

NIVA-PLUS

3

MO

OB COMPLETE

3

MO

OB COMPLETE ONE

3

MO

OB COMPLETE PETITE

3

MO

OB COMPLETE PREMIER

3

MO

OB COMPLETE/DHA

3

MO

PNV PRENATAL PLUS MULTIVITAMIN

3

MO

PNV TABS 29-1

3

MO

pnv-dha

2

MO

PNV-DHA+DOCUSATE

3

MO

PNV-OMEGA

3

MO

pnv-select

2

MO

POLY-VI-FLOR

4

MO

POLY-VI-FLOR/IRON

4

MO

poly-vitamin/fluoride drops

2

potassium chloride er caps

2

MO

potassium chloride er tabs 15meq

2

potassium chloride er tabs 10meq, 20meq, 8meq

2

MO

potassium chloride pack 20meq

2

MO

potassium chloride oral soln 10%, 20%

2

MO

PRENAISSANCE

3

MO

PRENAISSANCE PLUS

3

MO

PRENATAL

3

MO

PRENATAL PLUS

3

MO

PRENATAL VITAMINS PLUS LOW IRON

3

MO

PRENATE

3

MO

PRENATE AM

3

MO

PRENATE DHA

3

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 99

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

PRENATE ELITE

3

MO

PRENATE ENHANCE

3

MO

PRENATE ESSENTIAL

3

MO

PRENATE MINI

3

MO

PRENATE PIXIE

3

MO

PRENATE RESTORE

3

MO

PRENATVITE COMPLETE

3

PRENATVITE PLUS

3

PREPLUS

3

MO

PRETAB

3

MO

PRIMACARE

3

MO

PROVIDA OB

3

MO

QUFLORA FE CHEW

4

QUFLORA FE PEDIATRIC DROPS

4

QUFLORA GUMMIES

4

MO

QUFLORA PEDIATRIC CHEW

4

MO

QUFLORA PEDIATRIC SOLN W/FLUORIDE 0.5MG/ML

4

QUFLORA PEDIATRIC SOLN W/FLUORIDE 0.25MG/ML

4

MO

SE-NATAL 19

3

MO

SELECT-OB CHEW 29MG-1MG

3

SELECT-OB CHEW 26MG-0.6MG-0.4MG

3

MO

sodium fluoride chew 0.25mg, 0.5mg, 1mg

2

MO

sodium fluoride oral soln 0.5mg/ml

2

MO

TARON-C DHA

3

MO

THRIVITE RX

3

MO

TRI-VI-FLOR

4

MO

tri-vite/fluoride drops

2

MO

TRICARE PRENATAL TABS

3

MO

TRINATAL RX 1

3

MO

TRISTART DHA

3

MO

TRISTART FREE

3

TRISTART ONE

3

VIRT-C DHA

3

MO

VIRT-NATE DHA

3

MO

VIRT-PN DHA

3

MO

VIRT-PN PLUS

3

MO

VITAFOL GUMMIES

3

MO

VITAFOL STRIPS

3

VITAFOL ULTRA

3

MO

VITAFOL-NANO

3

MO

VITAFOL-OB

3

MO

VITAFOL-ONE

3

MO

VITAMEDMD ONE RX/QUATREFOLIC

3

MO

VP-PNV-DHA

3

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 100

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

WESCAP-C DHA

3

MO

WESCAP-PN DHA

3

MO

WESNATE DHA

3

MO

WESTAB PLUS

3

MO

WESTGEL DHA

3

MO

IV NUTRITION

CLINIMIX 4.25%/DEXTROSE 10%

4

B/D

CLINIMIX 4.25%/DEXTROSE 5%

4

B/D

CLINIMIX 5%/DEXTROSE 15%

4

B/D

CLINIMIX 5%/DEXTROSE 20%

4

B/D

CLINIMIX 6/5

4

B/D

CLINIMIX 8/10

4

B/D

CLINIMIX 8/14

4

B/D

CLINIMIX E 2.75%/DEXTROSE 5%

4

B/D

CLINIMIX E 4.25%/DEXTROSE 10%

4

B/D

CLINIMIX E 4.25%/DEXTROSE 5%

4

B/D

CLINIMIX E 5%/DEXTROSE 15%

4

B/D

CLINIMIX E 5%/DEXTROSE 20%

4

B/D

CLINIMIX E 8/10

4

B/D

CLINIMIX E 8/14

4

B/D

clinisol sf 15%

2

B/D MO

CLINOLIPID

3

B/D

dextrose 10%

2

DEXTROSE 25%

4

B/D

dextrose 5%

2

MO

DEXTROSE 50%

3

B/D

DEXTROSE 70%

3

B/D

FREAMINE III

4

B/D

HEPATAMINE

4

B/D

INTRALIPID INJ 20GM/100ML

3

B/D

INTRALIPID INJ 30GM/100ML

4

B/D

KABIVEN

4

B/D

NUTRILIPID

3

B/D

OMEGAVEN

5

B/D

PERIKABIVEN

4

B/D

plenamine

2

B/D

POTASSIUM PHOSPHATES

4

PREMASOL

5

B/D

PROCALAMINE

4

B/D

PROSOL

4

B/D

SMOFLIPID

4

B/D

TRAVASOL

4

B/D

TROPHAMINE

4

B/D

OPHTHALMIC

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 101

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ANTI-INFECTIVE/ANTI-INFLAMMATORY

BLEPHAMIDE S.O.P. OINT

4

MO

BLEPHAMIDE SUSP

4

MO

MAXITROL

4

MO

neo-polycin hc oint

2

neomycin/polymyxin/bacitracin/hydrocortisone oint

2

MO

neomycin/polymyxin/dexamethasone

2

MO

neomycin/polymyxin/hydrocortisone ophthalmic susp 1%;

3.5mg/ml; 10000unit/ml

2

MO

PRED-G S.O.P. OINT

4

MO

PRED-G SUSP

4

MO

sulfacetamide sodium/prednisolone sodium phosphate

2

MO

TOBRADEX ST SUSP

3

MO

TOBRADEX OINT

3

MO

TOBRADEX SUSP

4

MO

tobramycin dexamethasone susp

2

MO

ZYLET

3

MO

ANTI-INFECTIVES

ak-poly-bac oint

2

AZASITE

4

MO

bacitracin/polymyxin b oint

2

MO

bacitracin oint 500unit/gm

2

MO

BESIVANCE

3

MO

BETADINE OPHTHALMIC PREP

4

MO

BLEPH-1O SOLN

4

QL (90 ML per 30 days) MO

CILOXAN OINT

3

QL (42 GM per 30 days) MO

CILOXAN SOLN

4

QL (30 ML per 30 days) MO

ciprofloxacin hydrochloride ophthalmic soln 0.3%

2

QL (30 ML per 30 days) MO

erythromycin oint 5mg/gm

2

QL (42 GM per 30 days) MO

gatifloxacin soln

2

QL (20 ML per 30 days) MO

gentak oint

2

QL (42 GM per 30 days) MO

gentamicin sulfate ophthalmic soln 0.3%

2

QL (30 ML per 30 days) MO

levofloxacin ophthalmic soln 1.5%

2

QL (20 ML per 30 days)

levofloxacin ophthalmic soln 0.5%

2

QL (30 ML per 30 days) MO

MOXEZA

4

QL (12 ML per 30 days) MO

moxifloxacin hydrochloride ophthalmic soln 0.5%

2

QL (12 ML per 30 days) MO

NATACYN

4

MO

neo-polycin oint

2

neomycin/bacitracin/polymyxin oint

2

MO

neomycin/polymyxin/gramicidin soln

2

MO

OCUFLOX

4

QL (60 ML per 30 days) MO

ofloxacin ophthalmic soln 0.3%

2

QL (60 ML per 30 days) MO

polycin oint

2

polymyxin b sulfate/trimethoprim sulfate soln

1

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 102

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

POLYTRIM

4

MO

sulfacetamide sodium oint 10%

2

QL (42 GM per 30 days) MO

sulfacetamide sodium soln 10%

2

QL (90 ML per 30 days) MO

tobramycin soln 0.3%

2

QL (30 ML per 30 days) MO

TOBREX OINT

4

MO

TOBREX SOLN

4

QL (30 ML per 30 days) MO

trifluridine

2

MO

trimethoprim sulfate/polymyxin b sulfate soln

1

MO

VIGAMOX

4

QL (12 ML per 30 days) MO

ZIRGAN

4

MO

ZYMAXID

4

QL (20 ML per 30 days) MO

ANTI-INFLAMMATORIES

ACULAR

4

MO

ACULAR LS

4

MO

ACUVAIL

4

MO

ALREX

3

MO

bromfenac

2

MO

BROMSITE

4

MO

dexamethasone sodium phosphate ophthalmic soln 0.1%

2

MO

DEXYCU

5

LA

diclofenac sodium ophthalmic soln 0.1%

2

QL (10 ML per 30 days) MO

difluprednate

2

MO

DUREZOL

3

MO

EYSUVIS

4

PA MO

FLAREX

4

MO

FLUOROMETHOLONE

3

MO

flurbiprofen sodium ophthalmic soln 0.03%

2

MO

FML FORTE SUSP

4

MO

FML LIQUIFILM

4

MO

FML OINT

4

MO

ILEVRO

3

MO

INVELTYS

4

MO

ketorolac tromethamine ophthalmic soln 0.4%, 0.5%

2

MO

LOTEMAX SM GEL 0.38%

3

MO

LOTEMAX OINT

3

MO

LOTEMAX GEL 0.5%, SUSP

4

MO

loteprednol etabonate

2

MO

MAXIDEX

4

MO

NEVANAC

4

MO

OZURDEX

5

PRED FORTE

4

MO

PRED MILD

4

MO

prednisolone acetate ophthalmic susp

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 103

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC

SOLN 1%

3

MO

PROLENSA

3

MO

TRIESENCE

4

MO

XIPERE

5

PA LA MO

YUTIQ

5

LA

ANTIALLERGICS

ALOCRIL

4

MO

ALOMIDE

4

MO

azelastine hcl ophthalmic soln 0.05%

2

MO

bepotastine besilate

2

MO

BEPREVE

4

MO

cromolyn sodium soln 4%

2

MO

epinastine hcl

2

MO

LASTACAFT

4

olopatadine hcl ophthalmic soln 0.1%

2

MO

olopatadine hydrochloride ophthalmic soln 0.2%

2

MO

ZERVIATE

4

MO

ANTIGLAUCOMA

ALPHAGAN P SOLN 0.1%

3

MO

ALPHAGAN P SOLN 0.15%

4

MO

apraclonidine

2

MO

AZOPT

4

MO

betaxolol hcl soln 0.5%

2

MO

BETIMOL

4

MO

BETOPTIC-S

3

MO

bimatoprost

2

MO

brimonidine tartrate/timolol maleate

2

MO

BRIMONIDINE TARTRATE SOLN 0.15%

3

MO

brimonidine tartrate soln 0.2%

2

MO

brinzolamide

2

MO

carteolol hcl

2

MO

COMBIGAN

3

MO

COSOPT

4

MO

COSOPT PF

4

MO

dorzolamide hcl/timolol maleate soln 22.3-6.8mg/ml

2

MO

dorzolamide hydrochloride

1

MO

dorzolamide hydrochloride/timolol maleate pf

2

MO

DURYSTA

5

PA

IOPIDINE

5

MO

ISTALOL

4

MO

latanoprost

2

MO

levobunolol hcl

2

MO

LUMIGAN

3

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 104

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

PHOSPHOLINE IODIDE

4

pilocarpine hcl ophthalmic soln

2

MO

RHOPRESSA

3

MO

ROCKLATAN

4

MO

SIMBRINZA

3

MO

tafluprost

2

ST MO

TIMOLOL MALEATE OPHTHALMIC GEL FORMING

4

MO

timolol maleate (generic Timoptic) soln 0.25%, 0.5%

1

MO

timolol maleate (generic Istalol and Timoptic Ocudose) soln

0.25%, 0.5%

2

MO

TIMOPTIC

4

MO

TIMOPTIC OCUDOSE

4

MO

TIMOPTIC-XE

4

MO

TRAVATAN Z

4

MO

travoprost

2

MO

TRUSOPT

4

MO

VUITY

4

PA MO

VYZULTA

4

MO

XALATAN

4

MO

XELPROS

4

ST

ZIOPTAN

4

ST MO

MISCELLANEOUS

ALCAINE

4

MO

atropine sulfate oint 1%

2

MO

ATROPINE SULFATE OPHTHALMIC SOLN 1%

3

MO

BEOVU

5

PA LA

BYOOVIZ

5

PA LA

CEQUA

4

QL (60 EA per 30 days) PA MO

CIMERLI SOLN 0.5MG/0.05ML

5

PA

CIMERLI SOLN 0.3MG/0.05ML

5

PA LA

CYCLOGYL

4

MO

cyclopentolate hcl soln 0.5%, 1%, 2%

2

MO

cyclosporine emul 0.05%

2

QL (60 EA per 30 days) MO

CYSTADROPS

5

PA LA

CYSTARAN

5

PA LA

EYLEA

5

PA LA

ISOPTO ATROPINE

3

MO

LACRISERT

4

MO

LUCENTIS INJ

5

PA LA

LUCENTIS SOSY PREFILLED SYRINGE 0.5MG/0.05ML

5

PA

LUCENTIS SOSY PREFILLED SYRINGE 0.3MG/0.05ML

5

PA LA

OXERVATE

5

QL (28 ML per 28 days) PA LA

PHENYLEPHRINE HCL SOLN 10%

4

PHENYLEPHRINE HCL SOLN 2.5%

4

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 105

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

proparacaine hcl

2

MO

RESTASIS

3

QL (60 EA per 30 days) MO

RESTASIS MULTIDOSE

3

QL (5.5 ML per 30 days) MO

SUSVIMO

5

PA LA

TETRACAINE HYDROCHLORIDE

4

MO

TYRVAYA

4

QL (8.4 ML per 30 days) MO

VABYSMO

5

PA LA

VERKAZIA

5

QL (120 EA per 30 days) PA MO

XIIDRA

3

QL (60 EA per 30 days) MO

OTIC

OTIC AGENTS

acetic acid otic soln 2%

2

MO

CETRAXAL

4

MO

CIPRO HC

4

MO

CIPRODEX

4

MO

CIPROFLOXACIN OTIC SOLN 0.2%

3

MO

ciprofloxacin/dexamethasone

2

MO

CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF

4

MO

CORTISPORIN-TC

4

MO

DERMOTIC

4

QL (20 ML per 30 days) MO

flac otic oil

2

QL (20 ML per 30 days)

fluocinolone acetonide oil 0.01%

2

QL (20 ML per 30 days) MO

hydrocortisone/acetic acid otic soln

2

MO

neomycin/polymyxin/hc otic soln

2

MO

neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml;

10000unit/ml

2

MO

ofloxacin otic soln 0.3%

2

MO

OTOVEL

4

MO

RESPIRATORY

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ANORO ELLIPTA

3

QL (60 EA per 30 days) MO

BEVESPI AEROSPHERE

3

QL (10.7 GM per 30 days) MO

BREZTRI AEROSPHERE

3

QL (10.7 GM per 30 days) MO

COMBIVENT RESPIMAT

4

QL (8 GM per 30 days) MO

DUAKLIR PRESSAIR

4

QL (1 EA per 30 days) ST MO

ipratropium bromide/albuterol sulfate neb soln

2

B/D MO

STIOLTO RESPIMAT

4

QL (4 GM per 30 days) MO

TRELEGY ELLIPTA

3

QL (60 EA per 30 days) MO

ANTICHOLINERGICS

ATROVENT HFA

4

QL (25.8 GM per 30 days) MO

INCRUSE ELLIPTA

3

QL (30 EA per 30 days) MO

ipratropium bromide inhalation soln

2

B/D MO

ipratropium bromide nasal soln 0.03%

2

QL (30 ML per 28 days) MO

ipratropium bromide nasal soln 0.06%

2

QL (45 ML per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 106

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

LONHALA MAGNAIR REFILL KIT

4

QL (60 ML per 30 days) MO

SPIRIVA HANDIHALER

4

QL (30 EA per 30 days) MO

SPIRIVA RESPIMAT

4

QL (4 GM per 30 days) MO

TUDORZA PRESSAIR

4

QL (1 EA per 30 days) ST MO

YUPELRI

5

QL (90 ML per 30 days) PA MO

ANTIHISTAMINE COMBINATIONS

azelastine hydrochloride/fluticasone propionate

2

QL (23 GM per 30 days) MO

CLARINEX-D 12 HOUR

4

MO

DYMISTA

4

QL (23 GM per 30 days) MO

promethazine vc

2

PA MO

RYALTRIS

4

QL (29 GM per 30 days) MO

ANTIHISTAMINES

azelastine hcl nasal soln 0.15%

2

QL (30 ML per 25 days) MO

azelastine hydrochloride nasal spray 0.1%

2

QL (30 ML per 25 days) MO

carbinoxamine maleate soln

2

PA MO

CARBINOXAMINE MALEATE TABS 6MG

5

PA MO

carbinoxamine maleate tabs 4mg

2

PA MO

cetirizine hydrochloride oral soln 1mg/ml

2

QL (300 ML per 30 days) MO

CLARINEX

4

QL (30 EA per 30 days) MO

CLEMASTINE FUMARATE SYRP

5

QL (1800 ML per 30 days) PA

clemastine fumarate tabs

2

PA MO

cyproheptadine hcl oral syrup 2mg/5ml

2

PA MO

cyproheptadine hcl tabs 4mg

2

PA MO

desloratadine odt tabs 2.5mg, 5mg

2

QL (30 EA per 30 days) MO

desloratadine tabs 5mg

2

QL (30 EA per 30 days) MO

diphenhydramine hcl inj

2

MO

diphenhydramine hcl elix

2

PA

hydroxyzine hcl tabs

2

PA MO

hydroxyzine hydrochloride inj, syrp 10mg/5ml

2

PA MO

hydroxyzine pamoate caps

2

PA MO

levocetirizine dihydrochloride tabs

1

QL (30 EA per 30 days) MO

levocetirizine dihydrochloride soln

2

MO

olopatadine hcl nasal soln 0.6%

2

QL (30.5 GM per 30 days) MO

PATANASE

4

QL (30.5 GM per 30 days) MO

QUZYTTIR

5

PA MO

ryclora

2

PA MO

RYVENT

4

PA MO

VISTARIL

4

PA MO

BETA AGONISTS

albuterol sulfate hfa (generic Proventil HFA) aers 108mcg/act

2

QL (13.4 GM per 30 days) MO

albuterol sulfate hfa (generic ProAir HFA) aers 108mcg/act

2

QL (17 GM per 30 days) MO

albuterol sulfate hfa (generic Ventolin HFA) aers 108mcg/act

2

QL (36 GM per 30 days) MO

albuterol sulfate nebu

2

B/D MO

albuterol sulfate syrp, tabs

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 107

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

ARFORMOTEROL TARTRATE

4

QL (120 ML per 30 days) PA MO

BROVANA

5

QL (120 ML per 30 days) PA MO

formoterol fumarate

5

QL (120 ML per 30 days) PA MO

levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml

2

B/D MO

levalbuterol hydrochloride

2

B/D MO

levalbuterol nebu 1.25mg/0.5ml

2

B/D MO

LEVALBUTEROL TARTRATE HFA

3

QL (30 GM per 30 days) MO

PERFOROMIST

5

QL (120 ML per 30 days) PA MO

PROAIR DIGIHALER

4

QL (2 EA per 30 days) PA MO

PROAIR HFA

4

QL (17 GM per 30 days) MO

PROAIR RESPICLICK

4

QL (2 EA per 30 days) MO

PROVENTIL HFA

4

QL (13.4 GM per 30 days) MO

SEREVENT DISKUS

3

QL (60 EA per 30 days) MO

STRIVERDI RESPIMAT

4

QL (4 GM per 30 days) MO

terbutaline sulfate inj, tabs

2

MO

VENTOLIN HFA

3

QL (36 GM per 30 days) MO

XOPENEX CONCENTRATE

4

B/D MO

XOPENEX HFA

4

QL (30 GM per 30 days) MO

XOPENEX NEBU 0.31MG/3ML, 0.63MG/3ML

4

B/D MO

XOPENEX NEBU 1.25MG/3ML

5

B/D MO

LEUKOTRIENE MODULATORS

ACCOLATE

4

QL (60 EA per 30 days) MO

montelukast sodium

2

QL (30 EA per 30 days) MO

SINGULAIR

4

QL (30 EA per 30 days) ST MO

zafirlukast

2

QL (60 EA per 30 days) MO

zileuton er

5

QL (120 EA per 30 days) MO

ZYFLO

5

QL (120 EA per 30 days) MO

MISCELLANEOUS

acetylcysteine inhalation soln 10%, 20%

2

B/D MO

aminophylline

2

ARALAST NP

5

PA LA

AUVI-Q INJ 0.1MG/0.1ML

5

QL (2 EA per 30 days)

AUVI-Q INJ 0.15MG/0.15ML, 0.3MG/0.3ML

5

QL (2 EA per 30 days) ST MO

BRONCHITOL

5

QL (560 EA per 28 days) PA LA

BRONCHITOL TOLERANCE TEST

5

QL (560 EA per 28 days) PA LA

CINQAIR

5

PA LA

COCAINE HYDROCHLORIDE

4

PA

cromolyn sodium nebu 20mg/2ml

2

B/D MO

DALIRESP

4

MO

elixophyllin

2

MO

epinephrine inj 0.15mg/0.15ml, 0.15mg/0.3ml, 0.3mg/0.3ml

2

QL (2 EA per 30 days) MO

EPIPEN 2-PAK

4

QL (2 EA per 30 days) MO

EPIPEN-JR 2-PAK

4

QL (2 EA per 30 days) MO

ESBRIET CAPS

5

QL (270 EA per 30 days) PA LA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 108

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

ESBRIET TABS 267MG

5

QL (270 EA per 30 days) PA LA

ESBRIET TABS 801MG

5

QL (90 EA per 30 days) PA LA

FASENRA

5

QL (1 ML per 28 days) PA LA

FASENRA PEN

5

QL (1 ML per 28 days) PA LA

GLASSIA

5

PA LA

GOPRELTO

4

PA

KALYDECO PACK

5

QL (56 EA per 28 days) PA LA

KALYDECO TABS

5

QL (60 EA per 30 days) PA LA

NUCALA INJ 40MG/0.4ML

5

QL (0.4 ML per 28 days) PA LA

NUCALA VIAL INJ 100MG

5

QL (3 EA per 28 days) PA LA

NUCALA INJ 100MG/ML PREFILLED SYRINGE, AUTO

INJECTOR

5

QL (3 ML per 28 days) PA LA

NUMBRINO

4

PA

OFEV

5

QL (60 EA per 30 days) PA LA

ORKAMBI TABS

5

QL (112 EA per 28 days) PA LA

ORKAMBI PACK 125MG; 100MG, 188MG; 150MG

5

QL (56 EA per 28 days) PA LA

ORKAMBI PACK 94MG; 75MG

5

QL (56 EA per 28 days) PA LA MO

pirfenidone caps

5

QL (270 EA per 30 days) PA

pirfenidone tabs 267mg

5

QL (270 EA per 30 days) PA

pirfenidone tabs 534mg, 801mg

5

QL (90 EA per 30 days) PA

PROLASTIN-C

5

PA LA

PULMOZYME

5

PA

roflumilast

2

MO

SYMDEKO

5

QL (56 EA per 28 days) PA LA

SYMJEPI

4

QL (2 EA per 30 days) MO

TEZSPIRE

5

QL (1.91 ML per 28 days) PA LA

THEO-24

4

MO

theophylline er tabs

2

MO

theophylline oral soln

2

MO

TRIKAFTA TBPK 100MG; 75MG; 50MG

5

QL (84 EA per 28 days) PA LA

TRIKAFTA TBPK 50MG; 37.5MG; 25MG

5

QL (84 EA per 28 days) PA LA MO

XOLAIR

5

PA LA

ZEMAIRA

5

PA LA

NASAL STEROIDS

BECONASE AQ

4

QL (50 GM per 30 days) MO

flunisolide nasal spray 0.025%

2

QL (75 ML per 30 days) MO

fluticasone propionate susp 50mcg/act

2

QL (16 GM per 30 days) MO

mometasone furoate susp 50mcg/act

2

QL (34 GM per 30 days) MO

OMNARIS

4

QL (12.5 GM per 30 days) MO

QNASL

4

QL (10.6 GM per 30 days) MO

QNASL CHILDRENS

4

QL (6.8 GM per 30 days) MO

XHANCE

4

QL (32 ML per 30 days) PA MO

ZETONNA

4

QL (6.1 GM per 30 days) MO

STEROID INHALANTS

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 109

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ALVESCO

4

QL (12.2 GM per 30 days) ST MO

ARMONAIR DIGIHALER

4

QL (1 EA per 30 days) ST MO

ARNUITY ELLIPTA

3

QL (30 EA per 30 days) MO

ASMANEX HFA

4

QL (13 GM per 30 days) ST MO

ASMANEX TWISTHALER 120 METERED DOSES

4

QL (1 EA per 30 days) ST MO

ASMANEX TWISTHALER 14 METERED DOSES

4

QL (2 EA per 28 days) ST MO

ASMANEX TWISTHALER 30 METERED DOSES

4

QL (1 EA per 30 days) ST MO

ASMANEX TWISTHALER 60 METERED DOSES

4

QL (1 EA per 30 days) ST MO

budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

2

B/D MO

FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3

QL (120 EA per 30 days) MO

FLOVENT DISKUS AEPB 250MCG/BLIST

3

QL (240 EA per 30 days) MO

FLOVENT HFA AERO 44MCG/ACT

3

QL (21.2 GM per 30 days) MO

FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT

3

QL (24 GM per 30 days) MO

FLUTICASONE PROPIONATE HFA AERO 44MCG/ACT

4

QL (21.2 GM per 30 days) PA MO

FLUTICASONE PROPIONATE HFA AERO 110MCG/ACT,

220MCG/ACT

4

QL (24 GM per 30 days) PA MO

PULMICORT FLEXHALER

4

QL (2 EA per 30 days) MO

PULMICORT SUSP 0.25MG/2ML, 0.5MG/2ML

4

B/D MO

PULMICORT SUSP 1MG/2ML

5

B/D MO

QVAR REDIHALER

4

QL (21.2 GM per 30 days) ST MO

STEROID/BETA-AGONIST COMBINATIONS

ADVAIR DISKUS

3

QL (60 EA per 30 days) MO

ADVAIR HFA

3

QL (12 GM per 30 days) MO

AIRDUO DIGIHALER 113/14

4

QL (1 EA per 30 days) ST MO

AIRDUO DIGIHALER 232/14

4

QL (1 EA per 30 days) ST MO

AIRDUO DIGIHALER 55/14

4

QL (1 EA per 30 days) ST MO

AIRDUO RESPICLICK 113/14

4

QL (1 EA per 30 days) ST MO

AIRDUO RESPICLICK 232/14

4

QL (1 EA per 30 days) ST MO

AIRDUO RESPICLICK 55/14

4

QL (1 EA per 30 days) ST MO

BREO ELLIPTA

3

QL (60 EA per 30 days) MO

BUDESONIDE/FORMOTEROL FUMARATE

DIHYDRATE

3

QL (10.2 GM per 30 days) MO

DULERA

4

QL (13 GM per 30 days) ST MO

FLUTICASONE FUROATE/VILANTEROL ELLIPTA

4

QL (60 EA per 30 days) PA MO

FLUTICASONE PROPIONATE/SALMETEROL

4

QL (1 EA per 30 days) ST MO

FLUTICASONE PROPIONATE/SALMETEROL DISKUS

3

QL (60 EA per 30 days) MO

SYMBICORT

3

QL (10.2 GM per 30 days) MO

wixela inhub

2

QL (60 EA per 30 days) MO

TOPICAL

DERMATOLOGY, ACNE

ABSORICA

5

PA

ABSORICA LD

5

ACANYA

4

MO

accutane

2

PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 110

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

ACZONE

4

QL (90 GM per 30 days) MO

adapalene/benzoyl peroxide gel 0.1%; 2.5%

2

QL (45 GM per 30 days) PA MO

adapalene/benzoyl peroxide gel 0.3%; 2.5%

2

QL (70 GM per 30 days) PA MO

ADAPALENE SOLN

4

QL (60 ML per 30 days) PA

adapalene crea, gel

2

QL (45 GM per 30 days) PA MO

adapalene pads

5

QL (28 EA per 28 days) PA

AKLIEF

4

QL (45 GM per 30 days) PA MO

ALTRENO

4

QL (45 GM per 30 days) PA MO

amnesteem

2

PA

AMZEEQ

4

QL (30 GM per 30 days) MO

ARAZLO

4

MO

ATRALIN

4

QL (45 GM per 30 days) PA MO

AVITA CREA

4

QL (45 GM per 30 days) PA

AVITA GEL

4

QL (45 GM per 30 days) PA MO

AZELEX

4

QL (50 GM per 30 days) MO

BENZACLIN

4

MO

BENZACLIN WITH PUMP

4

MO

BENZAMYCIN

4

MO

claravis

2

PA

CLEOCIN-T

4

QL (60 ML per 30 days) MO

clindacin etz pledgets

2

MO

clindacin-p

2

MO

CLINDAGEL

5

QL (75 ML per 30 days) MO

clindamycin phosphate/benzoyl peroxide gel 1.2-2.5%, 1.2-5%

2

MO

clindamycin phosphate/tretinoin

2

QL (60 GM per 30 days) PA MO

clindamycin phosphate foam 1%

2

QL (100 GM per 30 days) MO

clindamycin phosphate gel 1%

2

QL (75 GM per 30 days) MO

clindamycin phosphate lotn 1%

2

QL (60 ML per 30 days) MO

clindamycin phosphate external soln 1%

2

QL (60 ML per 30 days) MO

clindamycin phosphate swab 1%

2

MO

clindamycin/benzoyl peroxide gel 1-5%

2

MO

dapsone gel 5%, 7.5%

2

QL (90 GM per 30 days) MO

DIFFERIN CREA, GEL

4

QL (45 GM per 30 days) PA MO

DIFFERIN LOTN

4

QL (59 ML per 30 days) PA MO

EPIDUO

4

QL (45 GM per 30 days) PA MO

EPIDUO FORTE

4

QL (70 GM per 30 days) PA MO

ery pad 2%

2

MO

ERYGEL

4

QL (60 GM per 30 days) MO

erythromycin/benzoyl peroxide

2

MO

erythromycin gel 2%

2

QL (60 GM per 30 days) MO

erythromycin soln 2%

2

QL (60 ML per 30 days) MO

EVOCLIN

4

QL (100 GM per 30 days) MO

FABIOR

4

QL (100 GM per 30 days) MO

isotretinoin

2

PA

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 111

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Drug Name

Drug

Tier

Requirements/Limits

KLARON

4

MO

myorisan

2

PA

neuac

2

ONEXTON

4

MO

RETIN-A

4

QL (45 GM per 30 days) PA MO

RETIN-A MICRO GEL 0.04%, 0.06%, 0.1%

5

QL (50 GM per 30 days) PA MO

RETIN-A MICRO PUMP GEL 0.04%

4

QL (50 GM per 30 days) PA MO

RETIN-A MICRO PUMP GEL 0.08%, 0.1%

5

QL (50 GM per 30 days) PA MO

SODIUM SULFACETAMIDE/SULFUR CLEANSER IN

UREA EMULSION

4

QL (355 ML per 30 days) MO

sodium sulfacetamide/sulfur susp

2

QL (473 ML per 30 days) MO

sulfacetamide sodium lotn 10%

2

MO

sulfacleanse 8/4

2

QL (473 ML per 30 days) MO

TAZAROTENE FOAM 0.1%

4

QL (100 GM per 30 days) MO

TRETINOIN MICROSPHERE GEL 0.04%, 0.1%

4

QL (50 GM per 30 days) PA MO

TRETINOIN MICROSPHERE GEL PUMP 0.04%, 0.1%

4

QL (50 GM per 30 days) PA MO

tretinoin crea 0.025%, 0.05%, 0.1%

2

QL (45 GM per 30 days) PA MO

tretinoin gel 0.01%, 0.025%, 0.05%

2

QL (45 GM per 30 days) PA MO

TWYNEO

4

QL (30 GM per 30 days) PA MO

VELTIN

4

QL (60 GM per 30 days) PA MO

WINLEVI

4

QL (60 GM per 30 days) PA MO

zenatane

2

PA

ZIANA

4

QL (60 GM per 30 days) PA MO

DERMATOLOGY, ANTIBIOTICS

ALTABAX

4

QL (30 GM per 30 days) MO

CENTANY

4

QL (30 GM per 30 days) MO

gentamicin sulfate crea 0.1%

2

QL (30 GM per 30 days) MO

gentamicin sulfate oint 0.1%

2

QL (30 GM per 30 days) MO

mafenide acetate packets

2

MO

mupirocin

2

QL (30 GM per 30 days) MO

NEO-SYNALAR

5

QL (60 GM per 30 days) MO

SILVADENE

4

MO

silver sulfadiazine cream

2

MO

SSD

3

SULFAMYLON

4

MO

DERMATOLOGY, ANTIFUNGALS

ciclodan

2

QL (6.6 ML per 30 days)

ciclopirox nail lacquer

2

QL (6.6 ML per 30 days) MO

ciclopirox olamine crea 0.77%

2

QL (90 GM per 30 days) MO

ciclopirox gel

2

QL (100 GM per 30 days) MO

ciclopirox sham

2

QL (120 ML per 30 days) MO

ciclopirox susp

2

QL (60 ML per 30 days) MO

clotrimazole/betamethasone dipropionate lotn

2

QL (30 ML per 30 days) MO

clotrimazole/betamethasone dipropionate crea

2

QL (45 GM per 30 days) MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 112

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Drug Name

Drug

Tier Requirements/Limits

clotrimazole crea 1%

2

QL (45 GM per 30 days) MO

clotrimazole soln 1%

2

QL (30 ML per 30 days) MO

econazole nitrate cream

2

QL (85 GM per 30 days) MO

ERTACZO

5

QL (60 GM per 30 days) MO

EXELDERM SOLN

4

QL (30 ML per 30 days) MO

EXELDERM CREA

4

QL (60 GM per 30 days) MO

EXTINA

5

QL (100 GM per 30 days) MO

JUBLIA

5

QL (8 ML per 30 days) PA MO

KERYDIN

5

QL (10 ML per 30 days) PA MO

ketoconazole crea 2%

2

QL (60 GM per 30 days) MO

ketoconazole foam 2%

2

QL (100 GM per 30 days) MO

ketodan

2

QL (100 GM per 30 days)

LOPROX SHAMPOO

4

QL (120 ML per 30 days) MO

LOPROX SUSP

4

QL (60 ML per 30 days) MO

LOPROX CREA

4

QL (90 GM per 30 days) MO

LULICONAZOLE

4

QL (60 GM per 30 days) ST MO

LUZU

4

QL (60 GM per 30 days) ST MO

MENTAX

5

QL (30 GM per 30 days) MO

MICONAZOLE NITRATE/ZINC OXIDE/WHITE

PETROLATUM

4

QL (50 GM per 30 days) PA MO

naftifine hcl cream 1%

2

QL (90 GM per 30 days) MO

naftifine hydrochloride crea 2%

2

QL (60 GM per 30 days) MO

naftifine hydrochloride gel

2

QL (90 GM per 30 days) MO

NAFTIN GEL 2%

4

QL (60 GM per 30 days) MO

NAFTIN GEL 1%

4

QL (90 GM per 30 days) MO

nyamyc

2

QL (60 GM per 30 days)

nystatin/triamcinolone crea, oint

2

QL (60 GM per 30 days) MO

nystatin crea 100000unit/gm

2

QL (30 GM per 30 days) MO

nystatin oint 100000unit/gm

2

QL (30 GM per 30 days) MO

nystatin powd 100000unit/gm

2

QL (60 GM per 30 days) MO

nystop

2

QL (60 GM per 30 days)

oxiconazole nitrate

5

QL (90 GM per 30 days) MO

OXISTAT LOTN

4

QL (60 ML per 30 days) MO

OXISTAT CREA

4

QL (90 GM per 30 days) MO

tavaborole

5

QL (10 ML per 30 days) PA MO

VUSION

4

QL (50 GM per 30 days) PA MO

DERMATOLOGY, ANTIPSORIATICS

acitretin

2

PA MO

CALCIPOTRIENE FOAM

4

QL (120 GM per 30 days) PA

calcipotriene crea, oint

2

QL (120 GM per 30 days) PA MO

calcipotriene soln

2

QL (60 ML per 30 days) PA MO

calcitrene

2

QL (120 GM per 30 days) PA MO

CALCITRIOL OINT 3MCG/GM

4

QL (800 GM per 28 days) PA MO

DOVONEX

5

QL (120 GM per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 113

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Drug Name

Drug

Tier

Requirements/Limits

methoxsalen caps

5

MO

SORILUX

5

QL (120 GM per 30 days) PA MO

tazarotene crea 0.1%

2

QL (60 GM per 30 days) PA MO

tazarotene gel 0.05%, 0.1%

2

QL (100 GM per 30 days) PA MO

TAZORAC GEL

4

QL (100 GM per 30 days) PA MO

TAZORAC CREA

4

QL (60 GM per 30 days) PA MO

VECTICAL

5

QL (800 GM per 28 days) PA MO

VTAMA

5

QL (60 GM per 30 days) PA MO

ZORYVE

4

QL (60 GM per 30 days) PA MO

DERMATOLOGY, ANTISEBORRHEICS

ketoconazole sham 2%

2

MO

selenium sulfide lotn

2

MO

selenium sulfide sham

2

QL (180 ML per 30 days) MO

XOLEGEL

5

QL (45 GM per 30 days) MO

DERMATOLOGY, CORTICOSTEROIDS

ala-cort crea 1%

1

ala-cort crea 2.5%

1

QL (30 GM per 30 days)

ALA-SCALP

4

MO

alclometasone dipropionate

2

MO

AMCINONIDE OINT

4

QL (60 GM per 30 days) MO

amcinonide crea

2

QL (60 GM per 30 days) MO

amcinonide lotn

2

QL (60 ML per 30 days) MO

APEXICON E

5

QL (60 GM per 30 days) MO

betamethasone dipropionate

2

MO

betamethasone dipropionate augmented crea, gel, oint

2

MO

betamethasone dipropionate augmented lotn

2

QL (60 ML per 30 days) MO

betamethasone valerate crea, lotn, oint

2

MO

betamethasone valerate foam

2

QL (100 GM per 30 days) MO

BRYHALI

4

QL (100 GM per 30 days) MO

CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE

SUSP

5

QL (120 GM per 30 days) PA MO

calcipotriene/betamethasone dipropionate oint

2

QL (400 GM per 28 days) PA MO

CAPEX

4

QL (120 ML per 30 days) MO

clobetasol propionate e cream 0.05%

2

QL (60 GM per 30 days) MO

clobetasol propionate emulsion foam

2

QL (100 GM per 30 days) MO

clobetasol propionate foam

2

QL (100 GM per 30 days) MO

clobetasol propionate lotn, sham

2

QL (118 ML per 30 days) MO

clobetasol propionate spray liquid

2

QL (125 ML per 30 days) MO

clobetasol propionate soln

2

QL (50 ML per 30 days) MO

clobetasol propionate crea, gel, oint

2

QL (60 GM per 30 days) MO

CLOBEX LOTN, SHAM

4

QL (118 ML per 30 days) MO

CLOBEX LIQD

5

QL (125 ML per 30 days) MO

CLOCORTOLONE PIVALATE

4

QL (90 GM per 30 days) MO

clodan

2

QL (118 ML per 30 days)

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 114

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

CLODERM

4

QL (90 GM per 30 days) MO

CORDRAN CREA

4

QL (120 GM per 30 days) MO

CORDRAN TAPE

5

MO

CORDRAN LOTN

5

QL (120 ML per 30 days) MO

CORDRAN OINT

5

QL (60 GM per 30 days) MO

CUTIVATE

4

QL (120 ML per 30 days) MO

DERMA-SMOOTHE/FS BODY

4

QL (118.28 ML per 30 days) MO

DERMA-SMOOTHE/FS SCALP

4

QL (118.28 ML per 30 days) MO

desonide lotn

2

QL (118 ML per 30 days) MO

desonide crea, gel, oint

2

QL (60 GM per 30 days) MO

DESOWEN

4

QL (60 GM per 30 days) MO

desoximetasone crea, oint

2

QL (100 GM per 30 days) MO

desoximetasone spray liquid

2

QL (100 ML per 30 days) MO

desoximetasone gel

2

QL (60 GM per 30 days) MO

desrx

2

QL (60 GM per 30 days)

diflorasone diacetate crea

2

QL (60 GM per 30 days) MO

diflorasone diacetate oint

5

QL (60 GM per 30 days) MO

DIPROLENE

4

MO

DIPROLENE AF

4

MO

DUOBRII

4

QL (200 GM per 28 days) PA MO

ENSTILAR

5

QL (120 GM per 30 days) PA MO

EPIFOAM

4

QL (10 GM per 30 days) MO

fluocinolone acetonide body

2

QL (118.28 ML per 30 days) MO

fluocinolone acetonide scalp

2

QL (118.28 ML per 30 days) MO

fluocinolone acetonide crea 0.025%

2

QL (120 GM per 30 days) MO

fluocinolone acetonide crea 0.01%

2

QL (60 GM per 30 days) MO

fluocinolone acetonide oint 0.025%

2

QL (120 GM per 30 days) MO

fluocinolone acetonide soln 0.01%

2

QL (90 ML per 30 days) MO

fluocinonide emulsified base cream 0.05%

2

QL (120 GM per 30 days) MO

fluocinonide crea 0.05%

2

QL (120 GM per 30 days) MO

fluocinonide crea 0.1%

5

QL (120 GM per 30 days) MO

fluocinonide gel, oint

2

QL (60 GM per 30 days) MO

fluocinonide soln

2

QL (60 ML per 30 days) MO

flurandrenolide crea

2

QL (120 GM per 30 days) MO

flurandrenolide lotn

2

QL (120 ML per 30 days) MO

flurandrenolide oint

5

QL (60 GM per 30 days) MO

fluticasone propionate crea 0.05%

2

MO

fluticasone propionate lotn 0.05%

2

QL (120 ML per 30 days) MO

fluticasone propionate oint 0.005%

2

MO

halcinonide

5

QL (60 GM per 30 days) MO

HALOBETASOL PROPIONATE FOAM

5

QL (100 GM per 30 days) MO

halobetasol propionate crea, oint

2

QL (50 GM per 30 days) MO

HALOG CREA, OINT

4

QL (60 GM per 30 days) MO

HALOG SOLN

5

QL (120 ML per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 115

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Drug Name

Drug

Tier Requirements/Limits

hydrocortisone butyrate (lipophilic)

2

QL (60 GM per 30 days) MO

hydrocortisone butyrate lotn

2

QL (118 ML per 30 days) MO

hydrocortisone butyrate crea, oint

2

QL (45 GM per 30 days) MO

hydrocortisone butyrate soln

2

QL (60 ML per 30 days) MO

hydrocortisone valerate

2

QL (60 GM per 30 days) MO

hydrocortisone crea 1%

1

MO

hydrocortisone crea 2.5%

1

QL (30 GM per 30 days) MO

hydrocortisone lotn 2.5%

2

MO

hydrocortisone oint 2.5%

1

QL (30 GM per 30 days) MO

hydrocortisone oint 1%

2

QL (30 GM per 30 days) MO

IMPEKLO

4

QL (68 GM per 30 days) MO

KENALOG AEROSOL SOLN

4

MO

LEXETTE

5

QL (100 GM per 30 days) MO

LOCOID

4

QL (118 ML per 30 days) MO

LOCOID LIPOCREAM

4

QL (60 GM per 30 days) MO

LUXIQ

4

QL (100 GM per 30 days) MO

mometasone furoate crea 0.1%

2

MO

mometasone furoate oint 0.1%

2

MO

mometasone furoate soln 0.1%

2

MO

nolix crea

2

QL (120 GM per 30 days) MO

nolix lotn

2

QL (120 ML per 30 days)

OLUX

4

QL (100 GM per 30 days) MO

OLUX-E

5

QL (100 GM per 30 days) MO

PANDEL

5

QL (80 GM per 30 days) MO

prednicarbate

2

QL (60 GM per 30 days) MO

proctosol hc

2

PSORCON

4

QL (60 GM per 30 days)

SERNIVO

5

QL (120 ML per 30 days) MO

SYNALAR CREA, OINT

4

QL (120 GM per 30 days) MO

SYNALAR SOLN

4

QL (90 ML per 30 days) MO

TACLONEX SUSP

5

QL (120 GM per 30 days) PA MO

TACLONEX OINT

5

QL (400 GM per 28 days) PA MO

TEMOVATE OINT

4

QL (60 GM per 30 days) MO

TEMOVATE CREA

5

QL (60 GM per 30 days) MO

TEXACORT

4

MO

TOPICORT CREA, OINT

4

QL (100 GM per 30 days) MO

TOPICORT SPRAY LIQUID

4

QL (100 ML per 30 days) MO

TOPICORT GEL

5

QL (60 GM per 30 days) MO

tovet

2

QL (100 GM per 30 days)

triamcinolone acetonide aers 0.147mg/gm

2

MO

triamcinolone acetonide crea 0.025%, 0.5%

2

MO

triamcinolone acetonide crea 0.1%

2

QL (454 GM per 30 days) MO

triamcinolone acetonide lotn 0.025%, 0.1%

2

MO

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 116

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

triamcinolone acetonide oint 0.05%

2

QL (430 GM per 30 days) MO

trianex

2

QL (430 GM per 30 days)

triderm crea 0.5%

2

triderm crea 0.1%

2

QL (454 GM per 30 days)

tritocin

2

QL (430 GM per 30 days)

ULTRAVATE

5

QL (60 ML per 30 days) MO

VANOS

5

QL (120 GM per 30 days) MO

VERDESO

5

QL (100 GM per 30 days) MO

DERMATOLOGY, LOCAL ANESTHETICS

glydo

2

QL (60 ML per 30 days) PA MO

lidocaine hcl jelly

2

QL (30 ML per 30 days) PA MO

lidocaine hcl gel prefilled syringe 2%

2

QL (60 ML per 30 days) PA MO

lidocaine hcl external soln 4%

2

QL (50 ML per 30 days) PA MO

lidocaine/prilocaine

2

QL (30 GM per 30 days) MO

lidocaine patch 5%

2

QL (3 EA per 1 days) PA MO

lidocaine oint

2

QL (35.44 GM per 30 days) PA MO

LIDODERM PATCH 5%

5

QL (3 EA per 1 days) PA MO

PLIAGLIS

4

QL (30 GM per 30 days) PA

QUTENZA KIT 8% (1-PATCH)

5

QL (1 EA per 90 days) PA LA MO

QUTENZA KIT 8% (2-PATCH)

5

QL (2 EA per 90 days) PA LA

QUTENZA KIT 8% (4-PATCH)

5

QL (4 EA per 90 days) PA LA

SYNERA

4

QL (10 EA per 30 days) PA MO

ZTLIDO

4

QL (3 EA per 1 days) PA MO

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS

MEMBRANE

ACYCLOVIR CREA 5%

5

QL (5 GM per 30 days) MO

acyclovir oint 5%

2

QL (30 GM per 30 days) MO

ALDARA

4

QL (24 EA per 30 days) MO

ammonium lactate

2

MO

ANUSOL-HC

4

MO

azelaic acid gel

2

QL (50 GM per 30 days) MO

BENSAL HP

5

QL (30 GM per 30 days) MO

bexarotene gel 1%

5

QL (60 GM per 30 days) PA

brimonidine tartrate gel 0.33%

2

MO

CARAC

5

QL (30 GM per 30 days) PA MO

CONDYLOX

4

QL (7 GM per 28 days) MO

CORTIFOAM

4

QL (15 GM per 30 days) MO

DENAVIR

5

QL (5 GM per 30 days) MO

DICLOFENAC EPOLAMINE PATCH

4

QL (60 EA per 30 days) PA MO

diclofenac sodium gel 3%

2

QL (100 GM per 30 days) PA MO

diclofenac sodium gel 1%

2

QL (1000 GM per 30 days) MO

diclofenac sodium external soln 1.5%

2

QL (300 ML per 28 days) PA MO

diclofenac sodium external soln 2%

5

QL (224 GM per 28 days) PA MO

DOXEPIN HYDROCHLORIDE CREA 5%

5

QL (45 GM per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 117

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier Requirements/Limits

DOXYCYCLINE CPDR 40MG

4

QL (30 EA per 30 days) PA MO

EFUDEX

4

QL (40 GM per 30 days) PA MO

ELIDEL

4

QL (100 GM per 30 days) ST MO

EUCRISA

4

QL (60 GM per 30 days) ST MO

FINACEA

4

QL (50 GM per 30 days) MO

FLECTOR

4

QL (60 EA per 30 days) PA MO

FLUOROPLEX

5

QL (30 GM per 30 days) PA MO

FLUOROURACIL CREA 0.5%

5

QL (30 GM per 30 days) PA MO

fluorouracil crea 5%

2

QL (40 GM per 30 days) PA MO

fluorouracil external soln 2%, 5%

2

QL (10 ML per 30 days) MO

hydrocortisone acetate/pramoxine

2

QL (30 GM per 30 days) MO

hydrocortisone perianal cream 1%

2

MO

HYFTOR

5

QL (20 GM per 25 days) PA LA MO

IMIQUIMOD PUMP

5

QL (15 GM per 28 days) MO

imiquimod crea 5%

2

QL (24 EA per 30 days) MO

imiquimod crea 3.75%

5

QL (28 EA per 28 days) MO

ivermectin crea 1%

2

QL (45 GM per 30 days) MO

KLISYRI

5

QL (5 EA per 30 days) PA MO

LEVULAN KERASTICK

4

QL (6 EA per 30 days)

LICART

5

PA MO

METROCREAM

4

MO

METROGEL

4

MO

METROLOTION

4

MO

metronidazole crea 0.75%

2

MO

metronidazole gel 0.75%, 1%

2

MO

metronidazole lotn 0.75%

2

MO

MIRVASO

4

MO

NORITATE

5

QL (60 GM per 30 days) MO

OPZELURA

5

QL (60 GM per 28 days) PA MO

ORACEA

4

QL (30 EA per 30 days) PA MO

PANRETIN

5

QL (60 GM per 30 days)

penciclovir

5

QL (5 GM per 30 days) MO

PENNSAID

5

QL (224 GM per 28 days) PA MO

pimecrolimus

2

QL (100 GM per 30 days) ST MO

PODOCON-25

4

QL (15 ML per 30 days)

podofilox

2

MO

procto-med hc

2

procto-pak

2

MO

PROCTOCORT

4

MO

PROCTOFOAM HC

4

QL (10 GM per 30 days) MO

proctozone-hc

2

PROTOPIC

4

QL (60 GM per 30 days) ST MO

PRUDOXIN

4

QL (45 GM per 30 days) PA MO

QBREXZA

4

QL (30 EA per 30 days) PA MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 118

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

RECTIV

4

QL (30 GM per 30 days) MO

RHOFADE

4

QL (60 GM per 30 days) PA MO

rosadan

2

salicylic acid wart remover film forming liquid 27.5%

2

QL (10 ML per 30 days) MO

SALICYLIC ACID OINT

4

QL (30 GM per 30 days) MO

salicylic acid soln

2

QL (10 ML per 30 days) MO

salicylic acid sham

2

QL (177 ML per 30 days) MO

SILVER NITRATE

4

QL (960 ML per 30 days) MO

SOOLANTRA

4

QL (45 GM per 30 days) MO

tacrolimus oint 0.03%, 0.1%

2

QL (60 GM per 30 days) MO

TARGRETIN GEL 1%

5

QL (60 GM per 30 days) PA

VALCHLOR

5

QL (60 GM per 30 days) PA LA

VEREGEN

5

QL (30 GM per 28 days) MO

VIRASAL

4

QL (10 ML per 30 days) MO

XERESE

5

QL (5 GM per 30 days) MO

ZILXI

4

QL (30 GM per 30 days) PA MO

ZONALON

4

QL (45 GM per 30 days) PA MO

ZOVIRAX CREA 5%

5

QL (5 GM per 30 days) MO

ZOVIRAX OINT 5%

4

QL (30 GM per 30 days) MO

ZYCLARA

5

QL (28 EA per 28 days) MO

ZYCLARA PUMP CREA 3.75%

5

QL (15 GM per 28 days) MO

ZYCLARA PUMP CREA 2.5%

5

QL (7.5 GM per 28 days) MO

DERMATOLOGY, SCABICIDES AND PEDICULIDES

crotan

5

QL (237 GM per 30 days)

ivermectin lotn 0.5%

2

QL (117 GM per 30 days) MO

lindane

2

MO

malathion

2

MO

NATROBA

4

QL (120 ML per 30 days) MO

OVIDE

4

MO

permethrin cream 5%

2

MO

SPINOSAD

4

QL (120 ML per 30 days) MO

DERMATOLOGY, WOUND CARE AGENTS

LACTATED RINGERS IRRIGATION

4

PHYSIOLYTE

4

REGRANEX

5

QL (30 GM per 30 days) PA MO

RINGERS IRRIGATION

4

SANTYL

4

MO

sodium chloride 0.9% irrigation soln

2

MO

sterile water for irrigation

2

MO

TIS-U-SOL

4

MOUTH/THROAT/DENTAL AGENTS

ARESTIN

5

PA

cevimeline hydrochloride

2

MO

chlorhexidine gluconate oral rinse 0.12%

1

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 119

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

Drug Name

Drug

Tier

Requirements/Limits

clinpro 5000

2

MO

clotrimazole troc 10mg

2

MO

denta 5000 plus crea 1.1% (2-pack)

2

QL (51 GM per 30 days)

denta 5000 plus crea 1.1%

2

QL (51 GM per 30 days) MO

dentagel

2

MO

EVOXAC

4

MO

fluoridex daily defense

2

fluoridex sensitivity relief/sls free

2

fluorimax 5000

2

fluorimax 5000 sensitive

2

just right 5000

2

lidocaine hcl mouth/throat soln 4%

2

lidocaine viscous soln 2%

2

MO

nystatin susp 100000unit/ml

2

MO

oralone dental paste

2

paroex

1

periogard

1

pilocarpine hydrochloride tabs

2

MO

PREVIDENT 5000 BOOSTER PLUS

4

MO

PREVIDENT 5000 DRY MOUTH

4

MO

PREVIDENT 5000 ENAMEL PROTECT

4

MO

PREVIDENT 5000 PLUS

4

QL (51 GM per 30 days) MO

PREVIDENT FLUORIDE GEL

4

MO

PREVIDENT RINSE

4

MO

SALAGEN

4

MO

sf 5000 plus

2

QL (51 GM per 30 days) MO

sf gel

2

MO

sodium fluoride 5000 plus

2

QL (51 GM per 30 days)

sodium fluoride 5000 ppm sensitive gel

2

MO

sodium fluoride 5000 ppm pste

2

MO

sodium fluoride 5000 ppm crea

2

QL (51 GM per 30 days)

sodium fluoride gel 1.1%

2

MO

sodium fluoride mouth/throat soln 0.2%

2

MO

triamcinolone acetonide dental paste

2

MO

Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start

of the drug list.

04/01/2023 Page 120

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
Index 
abacavir  12, 13  
abacavir sulfate/lamivudine  13  
ABELCET  11  
ABILIFY  50  
ABILIFY MAINTENA  50  
ABILIFY MYCITE  50  
ABILIFY MYCITE MAINTENANCE KIT  50  
ABILIFY MYCITE STARTER KIT  50  
abiraterone acetate  22  
ABRAXANE  24  
ABSORICA  110  
ABSORICA LD  110  
acamprosate calcium dr  61  
ACANYA  110  
acarbose  64  
ACCOLATE  108  
ACCUPRIL  30  
ACCURETIC  30  
accutane  110  
acebutolol hydrochloride  34  
ACETADOTE  76  
acetaminophen  1  
acetaminophen/caffeine/dihydrocodeine  4  
acetaminophen/codeine  4  
acetazolamide  36  
acetazolamide er  36  
acetazolamide sodium  36  
acetic acid  87, 106  
acetylcysteine  76, 108  
ACIPHEX  86  
acitretin  113  
ACTEMRA  91  
ACTEMRA ACTPEN  91  
ACTHAR  76  
ACTHIB  96  
ACTICLATE  19  
ACTIMMUNE  94  
ACTIQ  4  
ACTIVELLA  73  
ACTONEL  67  
ACTOPLUS MET  64  
ACTOS  64  
ACULAR  103  
ACULAR LS  103  
ACUVAIL  103  
acyclovir  15, 117  
04/01/2023  
ACYCLOVIR  117  
acyclovir sodium  15  
ACZONE  111  
ADACEL   96  
ADAKVEO   90  
adapalene  111  
ADAPALENE  111  
adapalene/benzoyl peroxide  111  
ADBRY  91  
adc/fluoride  98  
ADCIRCA  39  
ADDERALL  53  
ADDERALL XR  52  
adefovir dipivoxil  15  
ADEMPAS  39  
ADLARITY  45  
ADLYXIN  65  
ADLYXIN STARTER PACK  65  
ADMELOG  62  
ADMELOG SOLOSTAR  62  
ADRENALIN  37  
adriamycin  20  
ADVAIR DISKUS  110  
ADVAIR HFA  110  
ADZENYS XR-ODT  53  
AEMCOLO  8  
afeditab cr  35  
AFINITOR  24  
AFINITOR DISPERZ  24  
afirmelle  68  
AFREZZA  62  
AGRYLIN  90  
AIMOVIG  55  
AIRDUO DIGIHALER  110  
AIRDUO RESPICLICK  110  
AJOVY  56  
AKLIEF  111  
ak-poly-bac  102  
AKYNZEO   81  
ala-cort  114  
ALA-SCALP  114  
albendazole   8  
ALBENZA   8  
albuterol sulfate  107  
albuterol sulfate hfa  107  
ALCAINE  105  
Page 121  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
alclometasone dipropionate  114 
ALDACTAZIDE  36 
ALDACTONE  30 
ALDARA  117 
ALDURAZYME  76 
ALECENSA  24 
alendronate sodium  67 
alfuzosin hcl  86 
ALIMTA  21 
ALIQOPA  24 
aliskiren  37 
ALKERAN  20 
ALKINDI SPRINKLE  74 
allopurinol  1 
allopurinol sodium  1 
ALLZITAL  1 
almotriptan malate  56 
ALOCRIL  104 
ALOGLIPTIN  65 
ALOGLIPTIN/METFORMIN HCL 
65 
ALOGLIPTIN/METFORMIN 
HYDROCHLORIDE  65 
ALOGLIPTIN/PIOGLITAZONE  65 
ALOMIDE  104 
ALOPRIM  1 
alosetron hydrochloride  84 
ALOXI  81 
ALPHAGAN P  104 
alprazolam  40 
alprazolam er  40 
ALPRAZOLAM INTENSOL  40 
alprazolam odt  40 
ALPRAZOLAM XR  40 
ALREX  103 
ALTABAX  112 
ALTACE  30 
altavera  68 
ALTOPREV  33 
ALTRENO  111 
ALUNBRIG  24 
ALVESCO  110 
alyacen 1/35  68 
alyacen 7/7/7  68 
ALYMSYS  24 
alyq  39 
amabelz  73 
amantadine hcl  48 
AMARYL  65 
AMBIEN  55 
AMBIEN CR  55 
AMBISOME  11 
ambrisentan  39 
amcinonide  114 
AMCINONIDE  114 
AMERGE  56 
amethia  68 
amethyst  69 
AMICAR  90 
amikacin sulfate  8 
amiloride hcl  37 
amiloride/hydrochlorothiazide  37 
aminocaproic acid  90 
aminophylline  108 
amiodarone hcl  32 
amiodarone hydrochloride  32 
AMITIZA  84 
amitriptyline hcl  46 
amitriptyline hydrochloride  46 
amlodipine besylate  30, 31, 35, 37 
amlodipine besylate/atorvastatin calcium  37 
amlodipine besylate/benazepril hydrochloride  30 
amlodipine besylate/valsartan  31 
amlodipine/olmesartan medoxomil  31 
amlodipine/valsartan/hydrochlorothiazide  31 
ammonium lactate  117 
amnesteem  111 
AMONDYS 45  57 
amoxapine  46 
amoxicillin  18 
amoxicillin/clavulanate potassium  18 
amoxicillin/clavulanate potassium er  18 
amphetamine sulfate  53 
amphetamine/dextroamphetamine  53 
amphotericin b  11 
amphotericin b liposome  11 
ampicillin  18 
ampicillin sodium  18 
ampicillin-sulbactam  18 
AMPYRA  58 
AMRIX  59 
AMVUTTRA  57 
AMZEEQ  111 
ANAFRANIL  46 
anagrelide hydrochloride  90 
ANASPAZ  82 
anastrozole  22 
ANCOBON  11 
ANDRODERM  62 
04/01/2023  Page 122 

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

ANDROGEL 62

ANDROGEL PUMP 62

ANGELIQ 73

ANNOVERA 69

ANORO ELLIPTA 106

ANTARA 33

ANTIVERT 81

ANUSOL-HC 117

ANZEMET 81

APADAZ 4

APEXICON E 114

APIDRA 62

APIDRA SOLOSTAR 62

APLENZIN 46

APOKYN 48

apomorphine hydrochloride 48

apraclonidine 104

aprepitant 81

APRETUDE 12

apri 69

APRISO 83

APTENSIO XR 53

APTIOM 41

APTIVUS 12

ARALAST NP 108

aranelle 69

ARANESP ALBUMIN FREE 89

ARAVA 93

ARAZLO 111

ARCALYST 94

ARESTIN 119

ARFORMOTEROL TARTRATE 108

ARGATROBAN 88

ARICEPT 45

ARIKAYCE 8

ARIMIDEX 22

aripiprazole 50

aripiprazole odt 50

ARISTADA 50

ARISTADA INITIO 50

ARIXTRA 88

armodafinil 60

ARMONAIR DIGIHALER 110

ARMOUR THYROID 80

ARNUITY ELLIPTA 110

AROMASIN 22

ARRANON 21

arsenic trioxide 23

ARTHROTEC 50 1

ARTHROTEC 75 1

ARZERRA 24

ASACOL HD 83

ASCENIV 93

ascomp/codeine 4

asenapine maleate sl 50

ashlyna 69

ASMANEX HFA 110

ASMANEX TWISTHALER 110

ASPARLAS 23

aspirin/dipyridamole er 91

ASPRUZYO 37

ASTAGRAF XL 95

ATACAND 31

ATACAND HCT 31

atazanavir sulfate 12

ATELVIA 67

atenolol 34

atenolol/chlorthalidone 34

ATGAM 95

ATIVAN 40

atomoxetine 53

atomoxetine hydrochloride 53

atorvastatin calcium 33

atovaquone 8, 12

atovaquone/proguanil hcl 12

ATRALIN 111

atropine sulfate 82, 105

ATROPINE SULFATE 82, 105

ATROVENT HFA 106

AUBAGIO 58

aubra 69

aubra eq 69

AUGMENTIN 18

AUGMENTIN ES-600 18

aurovela 1.5/30 69

aurovela 24 fe 69

aurovela fe 1.5/30 69

aurovela fe 1/20 69

AURYXIA 79

AUSTEDO 57

AUVELITY 46

AUVI-Q 108

AVALIDE 31

AVAPRO 32

AVASTIN 24

AVEED 62

aviane 69

AVITA 111

04/01/2023 Page 123

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
AVODART  86  
AVONEX  58  
AVSOLA  91  
AVYCAZ  16  
AYGESTIN  79  
ayuna  69  
AYVAKIT  24  
azacitidine  21  
AZACTAM  8  
azasan  95  
AZASITE  102  
azathioprine  95  
azelaic acid  117  
azelastine hcl  104, 107  
azelastine hydrochloride  107  
azelastine hydrochloride/fluticasone propionate  
107  
AZELEX  111  
AZILECT  48  
azithromycin  17  
AZITHROMYCIN  17  
AZOPT  104  
AZOR  31  
AZSTARYS  53  
aztreonam  8  
AZULFIDINE  83  
AZULFIDINE EN-TABS  83  
bacitracin  8, 102  
bacitracin/polymyxin b  102  
baclofen  59  
BACLOFEN  59  
BACTRIM  8  
BACTRIM DS  8  
BAFIERTAM  58  
BALCOLTRA  69  
balsalazide disodium  83  
BALVERSA  24  
balziva  69  
BANZEL  41  
BAQSIMI ONE PACK  76  
BAQSIMI TWO PACK  76  
BARACLUDE  15  
BASAGLAR KWIKPEN  62  
BAVENCIO  24  
BAXDELA  18  
BCG VACCINE  96  
BD ALCOHOL SWABS  62  
BD INSULIN SYRINGE  62, 63  
BD/NOVO PEN NEEDLE  63  
BECONASE AQ  109  
BELBUCA  
3  
BELEODAQ   24  
BELLADONNA/OPIUM   82  
BELSOMRA   55  
benazepril hcl  30  
benazepril hcl/hydrochlorothiazide  30  
benazepril hydrochloride  30  
benazepril hydrochloride/hydrochlorothiazide  30  
bendamustine hydrochloride   20  
BENDAMUSTINE HYDROCHLORIDE  20  
BENDEKA  20  
BENICAR  32  
BENICAR HCT  31  
BENLYSTA  95  
BENSAL HP  117  
BENTYL  82  
BENZACLIN  111  
BENZACLIN WITH PUMP  111  
BENZAMYCIN  111  
BENZHYDROCODONE/ACETAMINOPHEN 
4  
BENZNIDAZOLE  8  
benztropine mesylate  48  
BEOVU  105  
bepotastine besilate  104  
BEPREVE  104  
BERINERT  90  
BESIVANCE  102  
BESPONSA  24  
BESREMI  23  
BETADINE OPHTHALMIC PREP  102  
betaine anhydrous  76  
betamethasone dipropionate  114  
betamethasone dipropionate augmented 
114  
betamethasone sodium phosphate/betamethasone
acetate 
74  
betamethasone valerate  114  
BETAPACE  32  
BETAPACE AF  32  
BETASERON   58  
betaxolol hcl  34, 104  
bethanechol chloride  87  
BETHKIS   8  
BETIMOL  104  
BETOPTIC-S  104  
BEVESPI AEROSPHERE   106  
bexarotene  23, 117  
BEXSERO  96  
BEYAZ  69  
04/01/2023  Page 124  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
bicalutamide  22  
BICILLIN C-R  18  
BICILLIN L-A  18  
BICNU  20  
BIDIL  37  
BIJUVA  74  
BIKTARVY  13  
BILTRICIDE  8  
bimatoprost  104  
BINOSTO  67  
bisoprolol fumarate  34  
bisoprolol fumarate/hydrochlorothiazide  34  
BIVIGAM  93  
BLENREP  24  
bleomycin sulfate  20  
BLEPH-1O  102  
BLEPHAMIDE  102  
BLEPHAMIDE S.O.P. OINT  102  
BLINCYTO  24  
blisovi 24 fe  69  
blisovi fe 1.5/30  69  
blisovi fe 1/20  69  
BONJESTA  81  
BOOSTRIX  96  
bortezomib  24  
BORTEZOMIB  24  
bosentan  39  
BOSULIF  24  
BOTOX  59  
BRAFTOVI  25  
BREO ELLIPTA  110  
BREZTRI AEROSPHERE  106  
briellyn  69  
BRILINTA  91  
brimonidine tartrate  104, 117  
BRIMONIDINE TARTRATE  104  
brimonidine tartrate/timolol maleate  104  
brinzolamide  104  
BRIUMVI  58  
BRIVIACT  41  
bromfenac  103  
bromocriptine mesylate  48  
BROMSITE  103  
BRONCHITOL  108  
BROVANA  108  
BRUKINSA  25  
BRYHALI  114  
budesonide  110  
budesonide dr  83  
budesonide er  83  
BUDESONIDE/FORMOTEROL FUMARATE
DIHYDRATE 
  
110  
bumetanide  37  
BUMEX  37  
bupap   1  
BUPHENYL   76  
bupivacaine hcl  7  
bupivacaine hydrochloride  7  
bupivacaine/epinephrine  7  
BUPRENEX  4  
buprenorphine  3  
buprenorphine hcl  4, 61  
buprenorphine hcl/naloxone hcl 
61  
buprenorphine hydrochloride/naloxone  
hy
drochloride  61  
bupropion hcl  46  
bupropion hydrochloride er  61  
bupropion hydrochloride er (sr)  46  
bupropion hydrochloride er (xl)  46  
BUPROPION HYDROCHLORIDE ER (XL)  46  
buspirone hcl  40  
busulfan  20  
BUSULFEX  20  
butalbital/acetaminophen  1  
butalbital/acetaminophen/caffeine  1, 4  
butalbital/acetaminophen/caffeine/codeine  4  
butalbital/aspirin/caffeine  1, 4  
butalbital/aspirin/caffeine/codeine  4  
butorphanol tartrate  4, 5  
BUTRANS  3  
BYDUREON BCISE  65  
BYETTA  65  
BYLVAY  84  
BYOOVIZ  105  
BYSTOLIC  34  
CABENUVA  13  
cabergoline  76  
CABLIVI  90  
CABOMETYX   25  
CADUET   37  
CALAN SR   35  
calcipotriene  113  
CALCIPOTRIENE   113  
calcipotriene/betamethasone dipropionate  114  
CALCIPOTRIENE/BETAMETHASONE  
DIPROPIONATE 
114  
calcitonin salmon  67  
calcitonin-salmon  67  
04/01/2023  Page 125  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
calcitrene  113  
calcitriol  80  
CALCITRIOL  113  
calcium acetate  79  
CALCIUM GLUCONATE  97  
CALDOLOR  1  
CALQUENCE  25  
CAMBIA  56  
camila  69  
CAMPTOSAR  23  
CAMRESE  69  
CAMRESE LO  69  
CAMZYOS  37  
CANASA  83  
CANCIDAS  11  
candesartan cilexetil  32  
candesartan cilexetil/hydrochlorothiazide  31  
CAPASTAT SULFATE  14  
CAPEX  114  
CAPLYTA  50  
CAPRELSA  25  
captopril  30  
CARAC  117  
CARAFATE  84  
CARBAGLU  76  
carbamazepine  41  
carbamazepine er  41  
CARBATROL  41  
carbidopa  48  
carbidopa/levodopa  49  
carbidopa/levodopa er  49  
carbidopa/levodopa odt  49  
CARBIDOPA/LEVODOPA/ENTACAPONE  49  
carbinoxamine maleate  107  
CARBINOXAMINE MALEATE  107  
carboplatin  20  
CARDENE IV  35  
CARDIZEM  35  
CARDIZEM CD  35  
CARDIZEM LA  35  
CARDURA  31, 87  
CARDURA XL  87  
carglumic acid  76  
carisoprodol  59  
carmustine  20  
CARNITOR  76  
CARNITOR SF  76  
CAROSPIR  30  
carteolol hcl  104  
04/01/2023  Page 126  
cartia xt  35  
carvedilol   35  
carvedilol phosphate er  35  
CASODEX   22  
caspofungin acetate  11  
cataflam  1  
CATAPRES-TTS-1   37  
CATAPRES-TTS-2   38  
CATAPRES-TTS-3   38  
CAYSTON   8  
caziant  69  
cefaclor  16  
CEFACLOR ER  16  
cefadroxil  16  
cefazolin  16  
CEFAZOLIN  16  
cefazolin sodium  16  
CEFAZOLIN SODIUM  16  
CEFAZOLIN/DEXTROSE  16  
cefdinir  16  
cefepime  16  
CEFEPIME  16  
CEFEPIME HYDROCHLORIDE  16  
CEFEPIME/DEXTROSE  16  
cefixime  16  
CEFOTAN  16  
cefotetan  16  
CEFOTETAN/DEXTROSE  16  
cefoxitin sodium  16  
CEFOXITIN SODIUM  16  
cefpodoxime proxetil  16  
cefprozil  16  
ceftazidime  17  
CEFTAZIDIME/DEXTROSE  17  
ceftriaxone in iso-osmotic dextrose  17  
ceftriaxone sodium  17  
CEFTRIAXONE SODIUM  17  
CEFTRIAXONE/DEXTROSE  17  
cefuroxime axetil  17  
cefuroxime sodium   17  
CELEBREX   1  
celecoxib  2  
CELESTONE-SOLUSPAN   74  
CELEXA  46  
CELLCEPT   95  
CELONTIN   41  
CENTANY  112  
cephalexin   17  
CEQUA  105  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
CERDELGA  76  
CEREBYX 
41  
CEREZYME  76  
cetirizine hydrochloride  107  
CETRAXAL  106  
cevimeline hydrochloride  119  
charlotte 24 fe  69  
chateal  69  
chateal eq  69  
CHEMET  68  
CHENODAL  84  
chloramphenicol sodium succinate  8  
chlordiazepoxide hcl  40, 82  
CHLORDIAZEPOXIDE HCL/CLIDINIUM  
BROMIDE 
82  
chlordiazepoxide hydrochloride  82  
CHLORDIAZEPOXIDE  
HYDROCHLORIDE/CLIDINIUM BROMIDE  
82  
chlordiazepoxide/amitriptyline  46  
chlorhexidine gluconate  119  
chloroquine phosphate  12  
chlorothiazide sodium  37  
chlorpromazine hcl  50  
chlorpromazine hydrochloride  50  
chlorthalidone  37  
chlorzoxazone  59  
CHLORZOXAZONE  59  
CHOLBAM  84  
cholestyramine  33  
cholestyramine light  33  
CHORIONIC GONADOTROPIN  76  
CIBINQO  91  
ciclodan  112  
ciclopirox  112  
ciclopirox nail lacquer  112  
ciclopirox olamine  112  
cidofovir  15  
cilostazol  90  
CILOXAN  102  
CIMDUO  13  
CIMERLI  105  
cimetidine  83  
cimetidine hcl  83  
cimetidine hydrochloride  83  
CIMZIA  91  
CIMZIA STARTER KIT  91  
cinacalcet hydrochloride  76  
CINQAIR  108  
04/01/2023  Page 127  
CINRYZE  90  
CINVANTI   81  
CIPRO  18, 106  
CIPRO HC  106  
CIPRODEX  106  
CIPROFLOXACIN   106  
ciprofloxacin hcl  18  
ciprofloxacin hydrochloride  18, 102  
ciprofloxacin i.v.-in d5w  18  
ciprofloxacin/dexamethasone   106  
CIPROFLOXACIN/FLUOCINOLONE  
ACETONIDE PF 
106  
cisplatin  20  
citalopram hydrobromide  46  
CITALOPRAM HYDROBROMIDE  46  
CITRANATAL 90 DHA  98  
CITRANATAL B-CALM  98  
CITRANATAL BLOOM  98  
CITRANATAL HARMONY  98  
CITRANATAL MEDLEY  98  
CITRANATAL RX  98  
cladribine  21  
claravis  111  
CLARINEX  107  
CLARINEX-D  107  
clarithromycin  17  
clarithromycin er  17  
clemastine fumarate  107  
CLEMASTINE FUMARATE  107  
CLENPIQ  84  
CLEOCIN  8, 88  
CLEOCIN PEDIATRIC  8  
CLEOCIN PHOSPHATE  8  
CLEOCIN-T  111  
CLIMARA  74  
CLIMARA PRO  74  
clindacin etz pledgets  111  
clindacin-p  111  
CLINDAGEL  111  
clindamycin hcl  8  
clindamycin palmitate hcl  8  
clindamycin phosphate  8, 88, 111  
clindamycin phosphate/benzoyl peroxide  111  
clindamycin phosphate/dextrose   8  
clindamycin phosphate/tretinoin  111  
clindamycin/benzoyl peroxide  111  
CLINDAMYCIN/SODIUM CHLORIDE   8  
CLINDESSE   88  
CLINIMIX 4.25%/DEXTROSE 10%   101  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
CLINIMIX 4.25%/DEXTROSE 5%  101  
CLINIMIX 5%/DEXTROSE 15%  101  
CLINIMIX 5%/DEXTROSE 20%  101  
CLINIMIX 6/5  101  
CLINIMIX 8/10  101  
CLINIMIX 8/14  101  
CLINIMIX E 2.75%/DEXTROSE 5%  101  
CLINIMIX E 4.25%/DEXTROSE 10%  101  
CLINIMIX E 4.25%/DEXTROSE 5%  101  
CLINIMIX E 5%/DEXTROSE 15%  101  
CLINIMIX E 5%/DEXTROSE 20%  101  
CLINIMIX E 8/10  101  
CLINIMIX E 8/14  101  
clinisol sf 15%  101  
CLINOLIPID  101  
clinpro 5000  120  
clobazam  41  
clobetasol propionate  114  
clobetasol propionate e  114  
CLOBEX  114  
CLOCORTOLONE PIVALATE  114  
clodan  114  
CLODERM  115  
clofarabine  21  
CLOLAR  21  
clomipramine hydrochloride  46  
clonazepam  41  
clonazepam odt  41  
clonidine hcl  1, 38  
clonidine hcl er  53  
clonidine hydrochloride  38  
clopidogrel  91  
clorazepate dipotassium  41  
clotrimazole  113  
clotrimazole troc  120  
clotrimazole/betamethasone dipropionate  112  
clozapine  50  
clozapine odt  50  
CLOZAPINE ODT  50  
CLOZARIL  50  
C-NATE DHA  98  
COARTEM  12  
COCAINE HYDROCHLORIDE  108  
CODEINE SULFATE  5  
COGENTIN  49  
COLAZAL  83  
colchicine  1  
COLCHICINE  1  
COLCRYS  1  
colesevelam hydrochloride  33  
COLESTID  33, 34  
COLESTID FLAVORED  34  
colestipol hcl   34  
colistimethate sodium  8  
COLY-MYCIN M   8  
COMBIGAN  104  
COMBIPATCH   74  
COMBIVENT RESPIMAT   106  
COMBIVIR   14  
COMETRIQ  25  
COMPLERA  14  
COMPLETENATE  98  
compro  81  
COMTAN  49  
CONCEPT DHA  98  
CONCEPT OB  98  
CONCERTA  53  
CONDYLOX  117  
CONJUPRI  35  
constulose  84  
CONZIP  3  
COPAXONE  58  
COPIKTRA  25  
CORDRAN  115  
COREG  35  
COREG CR  35  
CORGARD  35  
CORLANOR  38  
CORTEF  75  
CORTENEMA  83  
CORTIFOAM  117  
CORTISONE ACETATE  75  
CORTISPORIN-TC  106  
CORTROPHIN  76  
COSENTYX  91, 92  
COSENTYX SENSOREADY PEN  91  
COSMEGEN  20  
COSOPT  104  
COSOPT PF  104  
COTELLIC   25  
COTEMPLA XR-ODT   53  
COZAAR   32  
CREON  86  
CRESEMBA   11  
CRESTOR   33  
CRINONE   79  
cromolyn sodium  85, 104, 108  
crotan  119  
04/01/2023  Page 128  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
cryselle-28  69  
CRYSVITA   76  
CUBICIN   8  
CUBICIN RF   8  
CUPRIMINE   68  
CURITY GAUZE PADS 2   63  
CUTAQUIG   93  
CUTIVATE   115  
CUVITRU   94  
CUVPOSA   82  
cyclobenzaprine hydrochloride  59  
cyclobenzaprine hydrochloride er  59  
CYCLOGYL  105  
cyclopentolate hcl  105  
cyclophosphamide  20  
CYCLOPHOSPHAMIDE  20  
cycloserine  14  
CYCLOSET  65  
cyclosporine  95, 105  
cyclosporine modified  95  
CYKLOKAPRON  90  
CYMBALTA  46  
cyproheptadine hcl  107  
CYRAMZA  25  
cyred  69  
cyred eq  69  
CYSTADANE  76  
CYSTADROPS  105  
CYSTAGON  76  
CYSTARAN  105  
cytarabine  21  
cytarabine aqueous  21  
CYTOGAM  94  
CYTOMEL  80  
CYTOTEC  85  
D.H.E. 45   56  
dabigatran etexilate  88  
dacarbazine  23  
DACOGEN  21  
dactinomycin  21  
dalfampridine er  58  
DALIRESP  108  
DALVANCE  8  
danazol  73  
DANTRIUM  60  
dantrolene sodium  60  
dapsone  8, 111  
DAPTACEL  96  
daptomycin  8  
04/01/2023  Page 129  
DAPTOMYCIN  8  
DARAPRIM   8  
darifenacin hydrobromide er  87  
DARTISLA ODT   82  
DARZALEX   25  
DARZALEX FASPRO   25  
dasetta 1/35  69  
dasetta 7/7/7  69  
daunorubicin hydrochloride  21  
DAUNORUBICIN HYDROCHLORIDE   21  
DAURISMO  25  
DAYPRO  2  
daysee  69  
DAYTRANA  53  
DAYVIGO  55  
DDAVP  76  
deblitane  69  
decitabine  21  
deferasirox  68  
deferiprone  68  
deferoxamine mesylate  68  
DELESTROGEN  74  
DELSTRIGO  14  
delyla  69  
DELZICOL  83  
demeclocycline hcl  19  
DEMEROL  5  
DEMSER  38  
DENAVIR  117  
DENGVAXIA  96  
denta 5000 plus  120  
dentagel  120  
DEPAKOTE  41, 42  
DEPAKOTE ER  41  
DEPAKOTE SPRINKLES  42  
DEPEN TITRATABS  68  
DEPO-ESTRADIOL  74  
DEPO-MEDROL  75  
DEPO-PROVERA CONTRACEPTIVE  69  
DEPO-SUBQ PROVERA   69  
DEPO-TESTOSTERONE   62  
DERMA-SMOOTHE/FS BODY   115  
DERMA-SMOOTHE/FS SCALP   115  
DERMOTIC  106  
DESCOVY   14  
DESFERAL   68  
desipramine hydrochloride  46  
desloratadine  107  
desmopressin acetate  76, 77  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
desogestrel/ethinyl estradiol  69  
desonide  115  
DESOWEN  115  
desoximetasone  115  
DESOXYN  53  
desrx  115  
desvenlafaxine er  46  
DETROL  87  
DETROL LA  87  
DEXABLISS  75  
dexamethasone  75  
dexamethasone 10-day dose pack  75  
dexamethasone 13-day dose pack  75  
dexamethasone 6-day dose pack  75  
DEXAMETHASONE INTENSOL  75  
dexamethasone sodium phosphate  75, 103  
DEXEDRINE  53  
DEXILANT  86  
dexlansoprazole  86  
dexmethylphenidate hcl  53  
dexmethylphenidate hcl er  53  
dexmethylphenidate hydrochloride  53  
dexmethylphenidate hydrochloride er  53  
dexrazoxane  29  
dextroamphetamine sulfate  53  
dextroamphetamine sulfate er  53  
DEXTROSE  10%/NACL 0.45%  97  
DEXTROSE  5% /ELECTROLYTE #48 
VIAFLEX 
97  
dextrose 10%  97, 101  
DEXTROSE 10%/NACL 0.2%  97  
DEXTROSE 2.5%/NACL 0.45%  97  
DEXTROSE 25%  101  
dextrose 5%  97, 101  
DEXTROSE 5%/LACTATED RINGERS  97  
DEXTROSE 5%/NACL 0.2%  97  
DEXTROSE 5%/NACL 0.225%  97  
dextrose 5%/nacl 0.3%  97  
DEXTROSE 5%/NACL 0.33%   97  
DEXTROSE 5%/NACL 0.45%   97  
DEXTROSE 5%/NACL 0.9%   97  
DEXTROSE 50%   101  
DEXTROSE 70%   101  
DEXYCU   103  
DHIVY   49  
DIACOMIT   42  
DIASTAT ACUDIAL   42  
DIASTAT PEDIATRIC   42  
diazepam  42  
04/01/2023  Page 130  
DIAZEPAM RECTAL GEL  42  
diazoxide  76  
DIBENZYLINE   38  
dichlorphenamide  37  
DICLEGIS   81  
DICLOFENAC EPOLAMINE   117  
diclofenac potassium  2, 56  
diclofenac sodium  103, 117  
diclofenac sodium dr  2  
diclofenac sodium er   2  
diclofenac sodium external  117  
diclofenac sodium/misoprostol  2  
dicloxacillin sodium  18  
dicyclomine hcl  82  
dicyclomine hydrochloride  82  
DIFFERIN  111  
DIFICID  17  
diflorasone diacetate  115  
DIFLUCAN  11  
diflunisal  2  
difluprednate  103  
digitek  38  
digox  38  
digoxin  38  
dihydroergotamine mesylate  56  
DILANTIN  42  
DILANTIN INFATABS  42  
DILANTIN-125  42  
DILAUDID  5  
diltiazem hcl  36  
DILTIAZEM HCL  36  
diltiazem hcl cd  35  
diltiazem hcl er  35  
diltiazem hcl inj  36  
dilt-xr  35  
DIMENHYDRINATE  81  
dimethyl fumarate  58  
dimethyl fumarate starterpack  58  
DIOVAN  32  
DIOVAN HCT   31  
DIPENTUM   83  
diphenhydramine hcl  107  
diphenoxylate hydrochloride/atropine sulfate  85  
diphenoxylate/atropine   85  
DIPHTHERIA/TETANUS TOXOIDS  
ADSORBED PEDIATRIC  
96  
DIPROLENE  115  
DIPROLENE AF   115  
dipyridamole  91  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
disopyramide phosphate  32  
disulfiram  61  
DITROPAN XL  87  
DIURIL  37  
divalproex sodium  42  
divalproex sodium dr  42  
divalproex sodium er  42  
DIVIGEL  74  
dobutamine hcl  38  
DOBUTAMINE  
HYDROCHLORIDE/DEXTROSE 5% 
38  
docetaxel  24  
DOCETAXEL  24  
dofetilide  32  
DOJOLVI  77  
dolishale  69  
donepezil hcl  45  
donepezil hcl odt  45  
DOPAMINE HYDROCHLORIDE  38  
DOPAMINE HYDROCHLORIDE/DEXTROSE  
38  
DOPTELET  90  
DORYX  19  
dorzolamide hcl/timolol maleate  104  
dorzolamide hydrochloride  104  
dorzolamide hydrochloride/timolol maleate pf 
104  
dotti  74  
DOVATO  14  
DOVONEX  113  
doxazosin mesylate  31  
doxepin hcl  46  
doxepin hydrochloride  46, 55  
DOXEPIN HYDROCHLORIDE  117  
doxercalciferol  80  
DOXIL  21  
doxorubicin hcl  21  
doxorubicin hydrochloride  21  
doxorubicin hydrochloride liposomal  21  
doxy 100  19  
doxycycline  19  
DOXYCYCLINE  118  
doxycycline hyclate  19  
doxycycline hyclate dr  19  
doxycycline monohydrate  19  
doxylamine succinate/pyridoxine hydrochloride
81  
DRIZALMA  46  
dronabinol  81  
droperidol  41  
drospirenone/ethinyl estradiol  69  
drospirenone/ethinyl estradiol/levomefolate 
calcium  69  
DROXIA  90  
droxidopa   38  
DUAKLIR PRESSAIR   106  
DUAVEE   74  
DUET DHA 400   98  
DUET DHA BALANCED   98  
DUETACT   65  
DUEXIS   2  
DULERA  110  
duloxetine hcl  46  
DUOBRII  115  
DUOPA  49  
DUPIXENT  92  
DURACLON  1  
DURAMORPH  5  
DUREZOL  103  
DURYSTA  104  
dutasteride  87  
dutasteride/tamsulosin hydrochloride  87  
DXEVO 11-DAY  75  
DYANAVEL XR  53  
DYMISTA  107  
DYRENIUM  37  
DYSPORT  60  
e.e.s. 400  17  
E.E.S. GRANULES  17  
ec-naproxen  2  
econazole nitrate  113  
EDARBI  32  
EDARBYCLOR  31  
EDECRIN  37  
EDLUAR  55  
ed-spaz  82  
EDURANT  12  
efavirenz 
12, 14  
efavirenz/emtricitabine/tenofovir disoproxil  
fumarate 
14  
efavirenz/lamivudine/tenofovir disoproxil  
fumarate 
14  
effer-k  98  
EFFER-K   98  
EFFEXOR XR   46  
EFFIENT   91  
EFUDEX  118  
EGRIFTA SV   77  
ELAPRASE   77  
ELELYSO   77  
04/01/2023  Page 131  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
ELESTRIN  74  
eletriptan hydrobromide  56  
ELIDEL  118  
ELIGARD  22  
elinest  69  
ELIQUIS  88  
ELIQUIS STARTER PACK  88  
ELITEK  29  
ELITE-OB  98  
elixophyllin  108  
ELLA  69  
ELLENCE  21  
ELMIRON  87  
eluryng  69  
ELYXYB  56  
EMCYT  22  
EMEND  81  
EMEND TRIPACK  81  
EMFLAZA  75  
EMGALITY  56  
emoquette  70  
EMPAVELI  90  
EMPLICITI  25  
EMSAM  46  
emtricitabine  12, 14  
emtricitabine/tenofovir disoproxil  14  
emtricitabine/tenofovir disoproxil fumarate  14  
EMTRIVA  12  
EMVERM  8  
enalapril maleate  30  
enalapril maleate/hydrochlorothiazide  30  
enalaprilat  30  
ENBRACE HR  98  
ENBREL  92  
ENBREL MINI  92  
ENBREL SURECLICK  92  
ENDARI  90  
endocet  5  
ENGERIX-B  96  
ENHERTU  25  
ENJAYMO  90  
enoxaparin sodium  88  
enpresse-28  70  
enskyce  70  
ENSPRYNG  57  
ENSTILAR  115  
entacapone  49  
ENTADFI  87  
entecavir  15  
ENTOCORT EC  83  
ENTRESTO   31  
ENTYVIO   92  
enulose  84  
ENVARSUS XR   95  
EPANED  30  
EPCLUSA   15  
EPIDIOLEX   42  
EPIDUO  111  
EPIDUO FORTE   111  
EPIFOAM  115  
epinastine hcl  104  
epinephrine  38, 108  
EPIPEN  108  
EPIPEN-JR  108  
epitol  42  
EPIVIR  12, 15  
EPIVIR HBV  15  
eplerenone  30  
EPOGEN  89  
epoprostenol sodium  39  
EPRONTIA  42  
EPSOLAY  61  
EPZICOM  14  
EQUETRO  57  
ERAXIS  11  
ERBITUX  25  
ergoloid mesylates  45  
ERGOMAR  56  
ergotamine tartrate/caffeine  56  
ERIVEDGE  25  
ERLEADA  22  
erlotinib hydrochloride  25  
ERMEZA  80  
errin  70  
ERTACZO  113  
ertapenem  8  
ery  111  
ERYGEL  111  
ERYPED 200   17  
ERYPED 400   17  
ery-tab  17  
ERYTHROCIN LACTOBIONATE   17  
erythrocin stearate  17  
erythromycin  102, 111  
erythromycin base  17  
erythromycin dr  17, 18  
erythromycin ethylsuccinate  17  
erythromycin lactobionate   17  
04/01/2023  Page 132  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
erythromycin stearate  17  
erythromycin/benzoyl peroxide  111  
ESBRIET  109  
escitalopram oxalate  46  
esgic  1  
ESGIC  1  
esomeprazole magnesium  86  
esomeprazole sodium  86  
estarylla  70  
estazolam  55  
ESTRACE  74  
estradiol  74  
estradiol valerate  74  
estradiol/norethindrone acetate  74  
ESTRING  74  
ESTROGEL  74  
eszopiclone  55  
ethacrynate sodium  37  
ethacrynic acid  37  
ethambutol hydrochloride  14  
ethosuximide  42  
ethynodiol diacetate/ethinyl estradiol  70  
etodolac  2  
etodolac er  2  
ETONOGESTREL/ETHINYL ESTRADIOL  70  
ETOPOPHOS  24  
etoposide  24  
etravirine  12  
EUCRISA  118  
EULEXIN  22  
euthyrox  80  
EVAMIST  74  
EVEKEO  53  
EVEKEO ODT  53  
EVENITY  67  
everolimus  25, 95  
EVISTA  77  
EVKEEZA  34  
EVOCLIN  111  
EVOMELA  20  
EVOTAZ  14  
EVOXAC  120  
EVRYSDI  57  
EXELDERM  113  
EXELON  45  
exemestane  22  
EXFORGE  31  
EXFORGE HCT  31  
EXJADE  68  
EXKIVITY  25  
EXONDYS 51   57  
EXPAREL   7  
EXSERVAN   57  
EXTAVIA   58  
EXTINA  113  
EYLEA  105  
EYSUVIS  103  
EZALLOR SPRINKLE   33  
ezetimibe  34  
EZETIMIBE/ROSUVASTATIN  34  
ezetimibe/simvastatin  34  
FABIOR  111  
FABRAZYME  77  
falmina  70  
famciclovir  15  
famotidine  83  
famotidine premixed  83  
FANAPT  50  
FANAPT TITRATION PACK  50  
FARESTON  22  
FARXIGA  65  
FARYDAK  25  
FASENRA  109  
FASENRA PEN  109  
FASLODEX  22  
fayosim  70  
febuxostat  1  
felbamate  42  
FELBATOL  42  
FELDENE  2  
felodipine er  36  
FEMARA  22  
FEMRING  74  
femynor  70  
fenofibrate  33  
FENOFIBRATE MICRONIZED  33  
fenofibric acid dr  33  
FENOGLIDE  33  
fenoprofen calcium   2  
FENOPROFEN CALCIUM   2  
FENSOLVI   77  
fentanyl  3, 5  
fentanyl citrate  5  
FENTANYL CITRATE   5  
FENTORA   5  
FERRIPROX   68  
FERRIPROX TWICE-A-DAY   68  
fesoterodine fumarate er  87  
04/01/2023  Page 133  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
FETROJA  17  
FETZIMA  46  
FETZIMA TITRATION PACK  46  
fexmid  60  
FIASP  63  
FIASP FLEXTOUCH  63  
FIASP PENFILL  63  
FINACEA  118  
finasteride  87  
fingolimod  58  
FINTEPLA  42  
finzala  70  
FIORICET  1, 5  
FIORICET/CODEINE  5  
FIRAZYR  90  
FIRDAPSE  57  
FIRMAGON  22  
FIRVANQ  8  
flac otic oil  106  
FLAGYL  8  
FLAREX  103  
flavoxate hcl  87  
FLEBOGAMMA DIF  94  
flecainide acetate  32  
FLECTOR  118  
FLEQSUVY  60  
FLOLAN  39  
FLOLIPID  33  
FLOMAX  87  
FLORIVA  98  
FLOVENT DISKUS  110  
FLOVENT HFA  110  
fluconazole  11  
fluconazole in sodium chloride  11  
fluconazole/sodium chloride  11  
flucytosine  11  
fludarabine phosphate  21  
fludrocortisone acetate  75  
flumazenil  57  
flunisolide  109  
fluocinolone acetonide  106, 115  
fluocinolone acetonide body  115  
fluocinolone acetonide scalp  115  
fluocinonide  115  
fluocinonide emulsified base  115  
fluoride  98  
fluoridex  120  
fluoridex sensitivity relief/sls free  120  
fluorimax 5000  120  
fluorimax 5000 sensitive  120  
fluoritab 
98  
FLUOROMETHOLONE   103  
FLUOROPLEX   118  
fluorouracil  21, 118  
FLUOROURACIL CREA 0.5%  118  
fluorouracil external   118  
fluoxetine dr  47  
fluoxetine hcl  47  
fluoxetine hydrochloride  47  
fluphenazine decanoate  50  
fluphenazine hcl  50  
fluphenazine hydrochloride  50  
flurandrenolide  115  
flurazepam hcl  55  
flurbiprofen  2  
flurbiprofen sodium  103  
flutamide  22  
FLUTICASONE FUROATE/VILANTEROL 
ELLIPTA 
 
110  
fluticasone propionate  109, 115  
FLUTICASONE PROPIONATE HFA
110  
FLUTICASONE  
PROPIONATE/SALMETEROL 
110  
FLUTICASONE  
PROPIONATE/SALMETEROL DISKUS 
110  
fluvastatin  33  
fluvastatin sodium er  33  
fluvoxamine maleate  41  
fluvoxamine maleate er  41  
FML  103  
FML FORTE  103  
FML LIQUIFILM  103  
FOCALIN  53  
FOCALIN XR  53  
FOLIVANE-OB  98  
FOLOTYN  21  
fomepizole  77  
fondaparinux sodium  88  
FORFIVO XL   47  
formoterol fumarate  108  
FORTAZ  17  
FORTEO  67  
FORTESTA   62  
FOSAMAX   67  
FOSAMAX PLUS D   67  
fosamprenavir calcium  12  
fosaprepitant dimeglumine  81  
foscarnet sodium  15  
04/01/2023  Page 134  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
fosfomycin tromethamine  8  
fosinopril sodium  30  
fosinopril sodium/hydrochlorothiazide  30  
fosphenytoin sodium  42  
FOSRENOL  79  
FOTIVDA  25  
FRAGMIN  88, 89  
FREAMINE III  101  
FROVA  56  
frovatriptan succinate  56  
FULPHILA  89  
fulvestrant  22  
FUROSCIX  37  
furosemide  37  
FUZEON  12  
FYARRO  25  
fyavolv  74  
FYCOMPA  42  
FYLNETRA  89  
gabapentin  42  
GABITRIL  42  
GABLOFEN  60  
GALAFOLD  77  
galantamine hydrobromide  45  
galantamine hydrobromide er  45  
GAMASTAN  94  
GAMMAGARD LIQUID  94  
GAMMAGARD S/D  94  
GAMMAKED  94  
GAMMAPLEX  94  
GAMUNEX-C  94  
ganciclovir  15  
GARDASIL 9  96  
GASTROCROM  85  
gatifloxacin  102  
GATTEX  85  
gavilyte-c  84  
gavilyte-g  84  
gavilyte-n/flavor pack  84  
GAVRETO  25  
GAZYVA  25  
GELNIQUE  88  
gemcitabine hcl  21  
gemcitabine hydrochloride  21  
GEMCITABINE HYDROCHLORIDE  21  
gemfibrozil  33  
gemmily  70  
GEMTESA  88  
GENERESS FE  70  
04/01/2023  Page 135  
generlac  84  
gengraf 
95  
GENOTROPIN   77  
GENOTROPIN MINIQUICK   77  
gentak  102  
gentamicin sulfate  9, 102, 112  
gentamicin sulfate pediatric  9  
gentamicin sulfate/0.9% sodium chloride   9  
GENVOYA   14  
GEODON   50  
GIANVI  70  
GILENYA  58  
GILOTRIF  25  
GIMOTI  81  
GIVLAARI  90  
GLASSIA  109  
glatiramer acetate  58  
glatopa  58  
GLEEVEC  25  
GLEOSTINE  20  
glimepiride  65  
glipizide  65  
glipizide er  65  
glipizide xl  65  
glipizide/metformin hydrochloride  65  
GLOPERBA  1  
GLUCAGEN HYPOKIT  76  
GLUCAGON EMERGENCY KIT FOR LOW 
BLOOD SUGAR 
 
76  
GLUCOTROL XL  65  
GLUMETZA  65  
glyburide  65  
glyburide micronized  65  
glyburide/metformin hydrochloride  65  
GLYCATE  82  
glycopyrrolate  82  
GLYCOPYRROLATE 
82  
glydo  117  
GLYNASE  65  
GLYXAMBI   65  
GOCOVRI   49  
GOLYTELY   84  
GONITRO   39  
GOPRELTO  109  
GRALISE   57  
granisetron hcl  81  
GRANIX  89  
GRASTEK   94  
griseofulvin microsize  11  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
griseofulvin ultramicrosize  11 
guanfacine er  53 
guanfacine hcl  38 
guanfacine hydrochloride  38 
guanfacine hydrochloride er  53 
GVOKE HYPOPEN  76 
GVOKE KIT  76 
GVOKE PFS  76 
GYNAZOLE-1  88 
HAEGARDA  90 
hailey 1.5/30  70 
hailey 24 fe  70 
hailey fe 1.5/30  70 
hailey fe 1/20  70 
HALAVEN  24 
halcinonide  115 
HALCION  55 
HALDOL DECANOATE 100  50 
HALDOL DECANOATE 50  51 
halobetasol propionate  115 
HALOBETASOL PROPIONATE  115 
haloette  70 
HALOG  115 
haloperidol  51 
haloperidol decanoate  51 
haloperidol lactate  51 
HARVONI  15 
HAVRIX  96 
heather  70 
HECTOROL  80 
HELIDAC THERAPY  85 
HEMADY  75 
HEMANGEOL  35 
HEPAGAM B  94 
heparin sodium  89 
HEPARIN SODIUM  89 
HEPARIN SODIUM/DEXTROSE  89 
HEPARIN SODIUM/NACL 0.45%  89 
HEPATAMINE  101 
HEPSERA  15 
HERCEPTIN  25 
HERCEPTIN HYLECTA  25 
HERZUMA  25 
HETLIOZ  55 
HETLIOZ LQ ORAL SUSP  55 
HEXATRIONE  75 
HIBERIX  96 
hidex 6-day  75 
HIPREX  9 
HIZENTRA  94 
HORIZANT  57 
HUMALOG  63 
HUMALOG JUNIOR KWIKPEN  63 
HUMALOG KWIKPEN  63 
HUMALOG MIX 50/50  63 
HUMALOG MIX 50/50 KWIKPEN  63 
HUMALOG MIX 75/25  63 
HUMALOG MIX 75/25 KWIKPEN  63 
HUMATIN  9 
HUMATROPE  77 
HUMIRA  92 
HUMIRA PEDIATRIC CROHNS DISEASE 
STARTER PACK  92 
HUMIRA PEN  92 
HUMIRA PEN-PEDIATRIC UC STARTER 
PACK  92 
HUMULIN 70/30  63 
HUMULIN 70/30 KWIKPEN  63 
HUMULIN N  63 
HUMULIN N KWIKPEN  63 
HUMULIN R  63 
HUMULIN R U-500 (CONCENTRATED)  63 
HUMULIN R U-500 KWIKPEN  63 
HYCAMTIN  23 
hydralazine hcl  38 
HYDREA  23 
hydrochlorothiazide  37 
hydrocodone bitartrate er  3 
hydrocodone bitartrate/acetaminophen  5 
hydrocodone/ibuprofen  5 
hydrocortisone  75, 83, 116 
hydrocortisone acetate/pramoxine  118 
hydrocortisone butyrate  116 
hydrocortisone butyrate (lipophilic)  116 
hydrocortisone perianal  118 
hydrocortisone valerate  116 
hydrocortisone/acetic acid  106 
hydromorphone hcl  5 
HYDROMORPHONE HCL  5 
hydromorphone hcl er  3 
hydromorphone hydrochloride  5 
HYDROMORPHONE HYDROCHLORIDE  5 
hydroxychloroquine sulfate  93 
HYDROXYCHLOROQUINE SULFATE  93 
hydroxyprogesterone caproate  22, 79 
hydroxyurea  23 
hydroxyzine hcl  107 
hydroxyzine hydrochloride  107 
04/01/2023  Page 136 

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
hydroxyzine pamoate  107  
HYFTOR  118  
hyoscyamine sulfate  82  
HYPERHEP B  94  
hyperlyte-cr  97  
HYPERRAB  94  
HYPERRHO S/D  94  
HYPERRHO S/D MINI-DOSE  94  
HYPERTET  94  
HYQVIA  94  
HYSINGLA ER  4  
HYZAAR  31  
ibandronate sodium  67  
IBRANCE  25  
IBSRELA  85  
ibu  2  
ibuprofen  2  
ibuprofen/famotidine  2  
icatibant acetate  90  
iclevia  70  
ICLUSIG  25  
icosapent ethyl  34  
IDAMYCIN PFS  21  
idarubicin hcl  21  
IDHIFA  25  
IFEX  20  
ifosfamide  20  
IFOSFAMIDE  20  
ILARIS  94  
ILEVRO  103  
ILUMYA  92  
imatinib mesylate  26  
IMBRUVICA  26  
IMFINZI  26  
imipenem/cilastatin  9  
imipramine hcl  47  
imipramine hydrochloride  47  
imipramine pamoate  47  
imiquimod  118  
IMIQUIMOD PUMP  118  
IMITREX  56  
IMITREX STATDOSE REFILL  56  
IMITREX STATDOSE SYSTEM  56  
IMJUDO  26  
IMLYGIC  23  
IMOGAM RABIES-HT  94  
IMOVAX RABIES (H.D.C.V.)  96  
IMPAVIDO  9  
IMPEKLO  116  
IMURAN  95  
IMVEXXY MAINTENANCE PACK   74  
IMVEXXY STARTER PACK   74  
INBRIJA  49  
incassia  70  
INCRELEX   77  
INCRUSE ELLIPTA   106  
indapamide  37  
INDERAL LA   35  
INDERAL XL   35  
INDOCIN  2  
indomethacin  2  
indomethacin er  2  
INFANRIX  96  
INFLECTRA  92  
INFLIXIMAB  92  
INFUGEM  21  
INFUMORPH 200  5  
INFUMORPH 500  5  
INGREZZA  57  
INLYTA  26  
INNOPRAN XL  35  
INQOVI  21  
INREBIC  26  
INSPRA  30  
INSULIN ASPART  63  
INSULIN ASPART FLEXPEN  63  
INSULIN ASPART PENFILL  63  
INSULIN ASPART PROTAMINE/INSULIN 
ASPART 70/30 
 
63  
INSULIN DEGLUDEC  63  
INSULIN DEGLUDEC FLEXTOUCH  63  
INSULIN GLARGINE  63  
INSULIN GLARGINE SOLOSTAR  63  
INSULIN LISPRO  63  
INSULIN LISPRO JUNIOR KWIKPEN  63  
INSULIN LISPRO KWIKPEN  63  
INSULIN LISPRO PROTAMINE/INSULIN  
LISPRO 75/25 
63  
INTELENCE   12  
INTRALIPID  101  
INTRAROSA   87  
INTRON A   94  
introvale  70  
INTUNIV   54  
INVANZ   9  
INVEGA  51  
INVEGA HAFYERA   51  
INVEGA SUSTENNA   51  
04/01/2023  Page 137  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
INVEGA TRINZA  51  
INVELTYS  103  
INVIRASE  12  
INVOKAMET  65  
INVOKAMET XR  65  
INVOKANA  65  
IOPIDINE  104  
IPOL INACTIVATED IPV  96  
ipratropium bromide  106  
ipratropium bromide nasal  106  
ipratropium bromide/albuterol sulfate  106  
irbesartan  31, 32  
irbesartan/hydrochlorothiazide  31  
IRESSA  26  
irinotecan hcl  23  
irinotecan hydrochloride  23  
ISENTRESS  12  
ISENTRESS HD  12  
isibloom  70  
ISOLYTE-P/DEXTROSE 5%  97  
ISOLYTE-S  97  
ISOLYTE-S PH 7.4  97  
isoniazid  14  
ISOPTO ATROPINE  105  
ISORDIL  39  
ISORDIL TITRADOSE  39  
isosorbide dinitrate  38, 39  
isosorbide dinitrate/hydralazine hydrochloride 
38  
isosorbide mononitrate  39  
isosorbide mononitrate er  39  
isotonic gentamicin  9  
isotretinoin  111  
isradipine  36  
ISTALOL  104  
ISTODAX (OVERFILL)  26  
ISTURISA  77  
itraconazole  11  
ivermectin  9, 118, 119  
IXEMPRA KIT  24  
IXIARO  96  
JADENU  68  
JADENU SPRINKLE  68  
jaimiess  70  
JAKAFI  26  
JALYN  87  
jantoven  89  
JANUMET  65, 66  
JANUMET XR  65, 66  
JANUVIA  66  
JARDIANCE  66  
jasmiel  70  
JATENZO   62  
javygtor  77  
JAYPIRCA   26  
JEMPERLI   26  
jencycla  70  
JENTADUETO   66  
JENTADUETO XR   66  
JEVTANA   24  
jinteli  74  
JOLESSA  70  
JORNAY PM  54  
JUBLIA  113  
juleber  70  
JULUCA  14  
junel 1.5/30  70  
junel 1/20  70  
junel fe 1.5/30  70  
junel fe 1/20  70  
junel fe 24  70  
just right 5000  120  
JUXTAPID  34  
JYNARQUE  77  
JYNNEOS  96  
KABIVEN  101  
KADCYLA  26  
kaitlib fe  70  
KALBITOR  90  
KALETRA  14  
kalliga  70  
KALYDECO  109  
KANJINTI  26  
KANUMA  77  
KAPSPARGO SPRINKLE  35  
KAPVAY  54  
kariva  70  
KATERZIA  36  
KAZANO  66  
KCL 0.075%/D5W/NACL 0.45%   97  
KCL 0.15%/D5W/NACL 0.2%   97  
KCL 0.15%/D5W/NACL 0.45%   97  
KCL 0.15%/D5W/NACL 0.9%   97  
KCL 0.3%/D5W/NACL 0.45%   97  
KCL 0.3%/D5W/NACL 0.9%   97  
KEDRAB   94  
kelnor 1/35  70  
kelnor 1/50  70  
KENALOG  116  
04/01/2023  Page 138  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
KENALOG-10   75  
KENALOG-40   75  
KENALOG-80   75  
KEPIVANCE   29  
KEPPRA   42  
KEPPRA XR   42  
KERENDIA   30  
KERYDIN   113  
KESIMPTA   58  
ketoconazole  11, 113, 114  
ketodan  113  
ketoprofen  2  
ketoprofen er  2  
ketorolac tromethamine  2, 103  
KEVEYIS  37  
KEVZARA  92  
KEYTRUDA  26  
KHAPZORY  29  
KIMMTRAK  26  
KIMYRSA  9  
KINERET  92  
KINRIX  96  
KISQALI  23, 26  
KISQALI FEMARA 200 DOSE  23  
KISQALI FEMARA 400 DOSE  23  
KISQALI FEMARA 600 DOSE  23  
KITABIS PAK  9  
KLARON  112  
KLISYRI  118  
KLONOPIN  42  
klor-con   99  
klor-con 10   98  
klor-con 8   98  
klor-con m10   99  
klor-con m15   99  
klor-con m20   99  
klor-con/ef   99  
KLOXXADO  61  
KOMBIGLYZE XR  66  
KORLYM  77  
KOSELUGO  26  
KRAZATI  26  
KRINTAFEL  12  
KRISTALOSE  84  
KRYSTEXXA  1  
K-TAB  98  
kurvelo  70  
KUVAN  77  
KYLEENA  70  
KYNMOBI  49  
KYPROLIS   26  
labetalol hydrochloride  35  
LABETALOL  
HYDROCHLORIDE/DEXTROSE  
35  
LABETALOL HYDROCHLORIDE/SODIUM
CHLORIDE 
  
35  
lacosamide  43  
LACRISERT  105  
lactated ringers  97, 119  
LACTATED RINGERS IRRIGATION  119  
lactulose  84  
LACTULOSE  84  
LAMCITAL XR  43  
LAMICTAL  43  
LAMICTAL ODT  43  
LAMICTAL STARTER KIT  43  
LAMICTAL XR  43  
LAMICTAL XR TITRATION KIT  43  
lamivudine  12, 15  
lamivudine/zidovudine  14  
lamotrigine  43  
lamotrigine er  43  
lamotrigine odt  43  
lamotrigine odt titration kit  43  
lamotrigine starter kit/blue  43  
lamotrigine starter kit/green  43  
lamotrigine starter kit/orange  43  
LAMPIT  9  
LANOXIN  38  
LANOXIN PEDIATRIC  38  
LANREOTIDE ACETATE  77  
lansoprazole  86  
lansoprazole/amoxicillin/clarithromycin  85  
lanthanum carbonate  79  
LANTUS  63  
LANTUS SOLOSTAR  63  
lapatinib ditosylate  26  
larin 1.5/30  70  
larin 1/20  70  
larin 24 fe   70  
larin fe 1.5/30  71  
larin fe 1/20  71  
larissia  71  
LASIX  37  
LASTACAFT  104  
latanoprost  104  
LATUDA   51  
LAYOLIS FE   71  
04/01/2023  Page 139  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
LAZANDA  5  
LEDIPASVIR/SOFOSBUVIR  15  
LEENA  71  
leflunomide  93  
LEMTRADA  58  
lenalidomide  23  
LENVIMA  26  
LENVIMA 10 MG DAILY DOSE  26  
LENVIMA 14 MG DAILY DOSE  26  
LENVIMA 18 MG DAILY DOSE  26  
LENVIMA 20 MG DAILY DOSE  26  
LENVIMA 24 MG DAILY DOSE  26  
LENVIMA 8 MG DAILY DOSE  26  
LEQVIO  34  
LESCOL XL  33  
lessina  71  
LETAIRIS  39  
letrozole  22  
leucovorin calcium  29  
LEUKERAN  20  
LEUKINE  89  
leuprolide acetate  22  
LEUPROLIDE ACETATE  22  
levalbuterol  108  
levalbuterol hcl  108  
levalbuterol hydrochloride  108  
LEVALBUTEROL TARTRATE HFA  108  
LEVAMLODIPINE  36  
LEVEMIR  63  
LEVEMIR FLEXPEN  63  
LEVEMIR FLEXTOUCH  63  
levetiracetam  43  
levetiracetam er  43  
levetiracetam/sodium chloride  43  
levobunolol hcl  104  
levocarnitine  77  
LEVOCARNITINE  77  
levocetirizine dihydrochloride  107  
levofloxacin  18, 102  
levofloxacin in d5w  18  
levoleucovorin calcium  29  
levonest  71  
levonorgestrel/ethinyl estradiol  71  
levora  71  
levorphanol tartrate  5  
LEVO-T  80  
levothyroxine sodium  80  
LEVOTHYROXINE SODIUM  80  
LEVOXYL  80  
LEVSIN  83  
LEVSIN/SL   82  
LEVULAN KERASTICK   118  
LEXAPRO   47  
LEXETTE  116  
LEXIVA  12  
LIALDA  83  
LIBRAX  83  
LIBTAYO   26  
LICART  118  
lidocaine  117  
lidocaine hcl  7, 32, 117  
LIDOCAINE HCL  32  
lidocaine hcl external  117  
LIDOCAINE HCL IN D5W  32  
lidocaine hcl jelly  117  
lidocaine hcl mouth/throat  120  
lidocaine hydrochloride  7  
lidocaine patch  117  
lidocaine viscous  120  
lidocaine/epinephrine  7  
lidocaine/prilocaine  117  
LIDODERM  117  
LILETTA  71  
lillow  71  
LINCOCIN  9  
lincomycin hcl  9  
lindane  119  
linezolid  9  
LINEZOLID  9  
LINZESS  85  
LIORESAL INTRATHECAL  60  
liothyronine sodium  80  
LIPITOR  33  
LIPOFEN  33  
lisinopril  30  
lisinopril/hydrochlorothiazide  30  
LITHIUM  57  
lithium carbonate  57  
lithium carbonate er   57  
LITHOBID   57  
LITHOSTAT   87  
LIVALO  33  
LIVMARLI   85  
LIVTENCITY   15  
LO LOESTRIN FE   71  
LOCOID  116  
LOCOID LIPOCREAM   116  
LODINE   2  
04/01/2023  Page 140  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023 
LODOSYN  49  
loestrin 1.5/30-21  71  
loestrin 1/20-21  71  
loestrin fe 1.5/30  71  
loestrin fe 1/20  71  
lofena  2  
lojaimiess  71  
LOKELMA  68  
LOMOTIL  85  
LONHALA MAGNAIR  107  
LONSURF  21  
loperamide hcl  85  
LOPID  33  
lopinavir/ritonavir  14  
LOPRESSOR  35  
LOPROX  113  
lorazepam  41  
lorazepam intensol  41  
LORBRENA  26  
LOREEV XR  41  
LORTAB  5  
loryna  71  
lorzone  60  
LORZONE  60  
losartan potassium  32  
losartan potassium/hydrochlorothiazide  31  
LOSEASONIQUE  71  
LOTEMAX  103  
LOTEMAX SM  103  
LOTENSIN  30  
LOTENSIN HCT  30  
loteprednol etabonate  103  
LOTREL  30  
LOTRONEX  85  
lovastatin  33  
LOVAZA  34  
LOVENOX  89  
low-ogestrel  71  
loxapine  51  
lo-zumandimine  71  
LUBIPROSTONE  85  
LUCEMYRA  61  
LUCENTIS  105  
LULICONAZOLE  113  
LUMAKRAS  26  
LUMIGAN  104  
LUMIZYME  77  
LUMOXITI  26  
LUNESTA  55  
LUNSUMIO  26  
LUPKYNIS   95  
LUPRON DEPOT (1-MONTH)   22  
LUPRON DEPOT (3-MONTH)   22  
LUPRON DEPOT (4-MONTH)   22  
LUPRON DEPOT (6-MONTH)   22  
LUPRON DEPOT-PED (1-MONTH)   77  
LUPRON DEPOT-PED (3-MONTH)   77  
lurasidone hydrochloride  51  
lutera  71  
LUXIQ  116  
LUZU  113  
LYBALVI  51  
lyleq  71  
lyllana  74  
LYNPARZA  26  
LYRICA  43  
LYRICA CR  57  
LYSODREN  22  
LYTGOBI  26, 27  
LYUMJEV  64  
LYUMJEV KWIKPEN  64  
LYVISPAH  60  
lyza  71  
MACROBID  9  
MACRODANTIN  9  
mafenide acetate  112  
magnesium sulfate  97
MAGNESIUM SULFATE  97  
magnesium sulfate in d5w  97  
MAKENA  79  
  
MALARONE  12  
malathion  119  
mannitol  37  
MANNITOL  37  
maraviroc  12  
MARCAINE  7  
MARCAINE/EPINEPHRINE  7  
MARGENZA  27  
MARINOL   81  
marlissa  71  
MARPLAN   47  
MARQIBO   24  
MATULANE   23  
matzim la  36  
MAVENCLAD  58, 59  
MAVYRET  15  
MAXALT   56  
MAXALT-MLT   56  
04/01/2023  Page 141  

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

MAXIDEX 103

MAXITROL 102

MAXZIDE 37

MAXZIDE-25 37

MAYZENT 59

MAYZENT STARTER PACK 59

me/naphos/mb/hyo 1 9

meclizine hcl 81

meclofenamate sodium 2

MEDROL 75

MEDROL DOSEPAK 75

medroxyprogesterone acetate 71, 79

mefenamic acid 2

mefloquine hcl 12

megestrol acetate 22, 79

MEKINIST 27

MEKTOVI 27

meloxicam 2

melphalan 20

melphalan hydrochloride 20

memantine hcl 45

memantine hydrochloride 45

memantine hydrochloride er 45

MENACTRA 96

MENEST 74

MENOSTAR 74

MENQUADFI 96

MENTAX 113

MENVEO 96

meperidine hcl 5

meprobamate 41

MEPRON 9

MEPSEVII 77

mercaptopurine 21

meropenem 9

MEROPENEM/SODIUM CHLORIDE 9

merzee 71

mesalamine 83

mesalamine dr 83

mesalamine er 83

mesna 29

MESNEX 29

MESTINON 57

MESTINON TIMESPAN 57

metaxalone 60

metformin hydrochloride 66

METFORMIN HYDROCHLORIDE 66

metformin hydrochloride er 66

methadone hcl 4

04/01/2023 Page 142

METHADONE HCL INJ 4

MET

HADOSE 4

METHADOSE SUGAR-FREE 4

methamphetamine hcl 54

methazolamide 37

methenamine hippurate 9

methenamine mandelate 9

methergine 77

methimazole 80

METHITEST 62

methocarbamol 60

methotrexate sodium 21, 93

methoxsalen 114

methscopolamine bromide 83

methylergonovine maleate 77

METHYLIN 54

methylphenidate 54

methylphenidate hydrochloride 54

methylphenidate hydrochloride cd 54

methylphenidate hydrochloride er 54

METHYLPHENIDATE HYDROCHLORIDE ER

54

methylprednisolone 75

methylprednisolone acetate 75

methylprednisolone sodium succinate 75

methyltestosterone 62

metoclopramide hcl 81

metoclopramide hydrochloride 81

metoclopramide odt 81

METOCLOPRAMIDE ODT 81

metolazone 37

metoprolol succinate er 35

metoprolol tartrate 35

metoprolol/hydrochlorothiazide 34

METROCREAM 118

METROGEL 118

METROLOTION 118

metronidazole 9, 118

metronidazole vaginal 88

metyrosine 38

mexiletine hcl 32

MIACALCIN 67

mibelas 24 fe 71

micafungin 11

MICARDIS 31, 32

MICARDIS HCT 31

miconazole 3 88

MICONAZOLE NITRATE/ZINC

OXIDE/WHITE PETROLATUM 113

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

MICRHOGAM ULTRA-FILTERED PLUS 94

MICROGESTIN 1.5/30 71

MICROGESTIN 1/20 71

microgestin 24 fe 71

MICROGESTIN FE 1.5/30 71

MICROGESTIN FE 1/20 71

midazolam hcl 55

midazolam hydrochloride 55

midodrine hcl 38

mifepristone 77

migergot 56

miglitol 66

miglustat 77

MIGRANAL 56

mili 71

MILLIPRED 75

milrinone lactate 38

milrinone lactate in dextrose 38

mimvey 74

MINASTRIN 24 FE 71

MINIPRESS 31

MINIVELLE 74

MINOCIN 19

minocycline hcl 19

minocycline hydrochloride er 19

MINOLIRA 19

minoxidil 38

MIRAPEX ER 49

MIRCETTE 71

MIRENA 71

mirtazapine 47

mirtazapine odt 47

MIRVASO 118

misoprostol 85

MITIGARE 1

mitigo 5

mitomycin 21

mitoxantrone hcl 23

M-M-R II 96

M-NATAL PLUS 99

MOBIC 3

modafinil 60

moexipril hcl 30

molindone hydrochloride 51

mometasone furoate 109, 116

mondoxyne nl 19

MONJUVI 27

mono-linyah 71

montelukast sodium 108

MONUROL 9

morphine sulfate 6

MORPHINE SULFATE 6

morphine sulfate er 4

MORPHINE SULFATE/SODIUM CHLORIDE 4

MOTEGRITY 85

MOTOFEN 85

MOUNJARO 66

MOVANTIK 85

MOVIPREP 84

MOXEZA 102

moxifloxacin hydrochloride/sodium

hydrochloride 18

moxifloxacin hydrochloride 18, 102

MOZOBIL 89

MS CONTIN 4

MULPLETA 90

MULTAQ 32

multi-vitamin/fluoride 99

multi-vitamin/fluoride/iron 99

mupirocin 112

mutamycin 21

MVASI 27

MYALEPT 77

MYAMBUTOL 14

MYCAPSSA 77

MYCOBUTIN 14

mycohpenolic acid 95

mycophenolate mofetil 95

MYDAYIS 54

MYFEMBREE 77

MYFORTIC 95

MYLOTARG 27

MYOBLOC 60

myorisan 112

MYRBETRIQ 88

MYRBETRIX 88

MYSOLINE 43

MYTESI 85

MYXREDLIN 64

NABI-HB 94

nabumetone 3

nadolol 35

NAFCILLIN 18

nafcillin sodium 18

naftifine hcl 113

naftifine hydrochloride 113

NAFTIN 113

NAGLAZYME 77

04/01/2023 Page 143

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

nalbuphine hcl 6

NALFON 3

nalocet 6

naloxone hcl 61

naloxone hydrochloride 61

naltrexone hcl 61

NAMENDA 45

NAMENDA TITRATION PAK 45

NAMENDA XR 45

NAMZARIC 45

NAPRELAN 3

naproxen 3

naproxen sodium 3

NAPROXEN SODIUM 3

NAPROXEN SODIUM CR 3

naproxen sodium er 3

NAPROXEN SODIUM ER 3

naproxen/esomeprazole magnesium 3

naratriptan hcl 56

NARCAN 61

NARDIL 47

NAROPIN 7

NATACHEW 99

NATACYN 102

NATAZIA 71

nateglinide 66

NATESTO 62

NATPARA 67

NATROBA 119

NAYZILAM 43

nebivolol hydrochloride 35

NEBUPENT 9

necon 0.5/35-28 71

nefazodone hydrochloride 47

nelarabine 21

NEMBUTAL SODIUM 55

neomycin sulfate 9

neomycin/bacitracin/polymyxin 102

neomycin/polymyxin b sulfates irrigation 87

neomycin/polymyxin/bacitracin/hydrocortisone

102

neomycin/polymyxin/dexamethasone 102

neomycin/polymyxin/gramicidin 102

neomycin/polymyxin/hc 106

neomycin/polymyxin/hydrocortisone 102, 106

NEONATAL 19 99

NEONATAL COMPLETE 99

NEONATAL FE 99

NEONATAL PLUS 99

neo-polycin 102

neo-polycin hc 102

NEORAL 95

NEO-SYNALAR 112

NERLYNX 27

NESINA 66

NESTABS 99

NESTABS ONE 99

neuac 112

NEULASTA 89

NEULASTA ONPRO KIT 89

NEUPOGEN 90

NEUPRO 49

NEURONTIN 43

NEVANAC 103

nevirapine 13

nevirapine er 13

NEXAVAR 27

NEXIUM 86

NEXIUM I.V. 86

NEXLETOL 34

NEXLIZET 34

NEXPLANON 71

NEXTERONE 32

NEXTSTELLIS 71

NEXVIAZYME 77

niacin 34

niacin er 34

niacor 34

nicardipine hcl 36

nicardipine hydrochloride 36

NICARDIPINE HYDROCHLORIDE 36

NICARDIPINE HYDROCHLORIDE/SODIUM

CHLORIDE 36

NICOTROL 61

NICOTROL INHALER 61

nifedipine 36

nifedipine er 36

nikki 71

NILANDRON 22

nilutamide 22

nimodipine 36

NINLARO 27

NIPENT 23

nisoldipine er 36

nitazoxanide 9

nitisinone 78

NITRO-BID 39

NITRO-DUR 39

04/01/2023 Page 144

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

nitrofurantoin 9

nitrofurantoin macrocrystals 9

nitrofurantoin monohydrate/macrocrystals 9

NITROGLYCERIN IN DEXTROSE 5% 39

NITROGLYCERIN INJ 39

nitroglycerin lingual spray 39

nitroglycerin subl 39

nitroglycerin sublingual 39

nitroglycerin transdermal 39

NITROLINGUAL PUMPSPRAY 39

NITROSTAT 39

NITYR 78

NIVA-PLUS 99

NIVESTYM 90

nizatidine 83

NOCDURNA 78

nolix 116

NORA-BE 71

NORDITROPIN FLEXPRO 78

norethindrone 72

norethindrone & ethinyl estradiol ferrous

fumarate 72

norethindrone acetate 79

norethindrone acetate/ethinyl estradiol 72, 74

norethindrone acetate/ethinyl estradiol/ferrous

fumarate 72

norgesic 60

NORGESIC FORTE 60

norgestimate/ethinyl estradiol 72

NORITATE 118

NORLIQVA 36

norlyda 72

norlyroc 72

NORPACE 32

NORPACE CR 32

NORPRAMIN 47

NORTHERA 38

nortrel 0.5/35 (28) 72

nortrel 1/35 72

nortrel 7/7/7 72

nortriptyline hcl 47

nortriptyline hydrochloride 47

NORVASC 36

NORVIR 13

NOURIANZ 49

NOVAREL 78

NOVOLIN 70/30 64

NOVOLIN 70/30 FLEXPEN 64

NOVOLIN 70/30 FLEXPEN RELION 64

NOVOLIN 70/30 RELION 64

NOVOLIN N 64

NOVOLIN N FLEXPEN 64

NOVOLIN N FLEXPEN RELION 64

NOVOLIN N RELION 64

NOVOLIN R 64

NOVOLIN R FLEXPEN 64

NOVOLIN R FLEXPEN RELION 64

NOVOLIN R RELION 64

NOVOLOG 64

NOVOLOG FLEXPEN 64

NOVOLOG FLEXPEN RELION 64

NOVOLOG MIX 70/30 64

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

64

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

RELION 64

NOVOLOG MIX 70/30 RELION 64

NOVOLOG PENFILL 64

NOVOLOG RELION 64

NOXAFIL

11

np thyroid 80

NPLATE 90

NUBEQA 22

NUCALA 109

NUCYNTA 4, 6

NUCYNTA ER 4

NUEDEXTA 57

nulev 83

NULIBRY 78

NULOJIX 95

NULYTELY 84

NUMBRINO 109

NUPLAZID 51

NURTEC 56

NUTRILIPID 101

NUTROPIN AQ NUSPIN 78

NUVARING 72

NUVESSA 88

NUVIGIL 60, 61

NUZYRA 19

nyamyc 113

nylia 1/35 72

nylia 7/7/7 72

NYMALIZE 36

nymyo 72

nystatin 11, 113, 120

nystatin/triamcinolone 113

nystop 113

04/01/2023 Page 145

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

NYVEPRIA 90

OB COMPLETE 99

OB COMPLETE ONE 99

OB COMPLETE PETITE 99

OB COMPLETE PREMIER 99

OB COMPLETE/DHA 99

OCALIVA 85

OCELLA 72

OCREVUS 59

OCTAGAM 94

octreotide acetate 78

OCUFLOX 102

ODACTRA 94

ODEFSEY 14

ODOMZO 27

OFEV 109

ofloxacin 18, 102, 106

OGIVRI 27

olanzapine 51

olanzapine odt 51

olanzapine/fluoxetine 47

olmesartan medoxomil 32

olmesartan

medoxomil/amlodipine/hydrochlorothiazide 31

olmesartan medoxomil/hydrochlorothiazide 31

olopatadine hcl 104, 107

olopatadine hydrochloride 104

OLUMIANT 92

OLUX 116

OLUX-E 116

OMECLAMOX-PAK 85

omega-3-acid ethyl esters 34

OMEGAVEN 101

omeprazole 86

omeprazole/sodium bicarbonate 86

OMNARIS 109

OMNIPOD 5 64

OMNIPOD CLASSIC 64

OMNIPOD DASH 64

OMNITROPE 78

ONCASPAR 23

ondansetron hcl 81

ondansetron hydrochloride 81

ondansetron odt 81

ONEXTON 112

ONFI 43

ONGENTYS 49

ONGLYZA 66

ONIVYDE 23

04/01/2023 Page 146

ONTRUZANT 27

ONURE

G 22

ONZETRA XSAIL 56

OPDIVO 27

OPDUALAG 27

opium tincture 85

OPSUMIT 39

OPZELURA 118

ORACEA 118

ORACIT 87

ORALAIR 94

oralone dental paste 120

ORAPRED ODT 75

ORBACTIV 9

ORENCIA 92

ORENCIA CLICKJECT 92

ORENITRAM 39

ORFADIN 78

ORGOVYX 22

ORIAHNN 78

ORILISSA 73

ORKAMBI 109

ORLADEYO 90

orphenadrine citrate 60

orphenadrine citrate er 60

orphenadrine/aspirin/caffeine 60

orphengesic forte 60

orsythia 72

ORTIKOS 83

oscimin 83

oseltamivir phosphate 15

OSENI 66

OSMITROL VIAFLEX 37

OSMOLEX ER 49

OSMOPREP 84

OSPHENA 78

OTEZLA 92

OTOVEL 106

OTREXUP 93

OVIDE 119

oxacillin sodium 18

OXACILLIN SODIUM 18

oxaliplatin 20

oxandrolone 62

oxaprozin 3

OXAYDO 6

oxazepam 41

OXBRYTA 90

oxcarbazepine 43

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

OXERVATE 105

oxiconazole nitrate 113

OXISTAT 113

OXLUMO 87

OXTELLAR XR 43

oxybutynin chloride 88

oxybutynin chloride er 88

OXYCODONE AND ACETAMINOPHEN 6

oxycodone hcl 4

OXYCODONE HCL ER 4

oxycodone hydrochloride 6

oxycodone hydrochloride/acetaminophen 6

OXYCODONE

HYDROCHLORIDE/ACETAMINOPHEN 6

oxycodone/acetaminophen 6

OXYCONTIN 4

oxymorphone hydrochloride 4, 6

oxymorphone hydrochloride er 4

OXYTROL 88

OZEMPIC 66

OZURDEX 103

pacerone 32

paclitaxel 24

paclitaxel protein-bound particles 24

PADCEV 27

paliperidone er 51

palonosetron hydrochloride 81

PALONOSETRON HYDROCHLORIDE 81

PALYNZIQ 78

PAMELOR 47

pamidronate disodium 67

PAMIDRONATE DISODIUM 67

PANCREAZE 86

PANDEL 116

PANRETIN 118

pantoprazole sodium 86

PANZYGA 94

PARAGARD INTRAUTERINE COPPER

CONTRACEPTIVE 72

paraplatin 20

paricalcitol 80

PARLODEL 49

PARNATE 47

paroex 120

paromomycin sulfate 9

paroxetine 47, 57

paroxetine hcl 47

paroxetine hcl er 47

paroxetine hydrochloride 47

04/01/2023

PASER 14

PATANASE 107

PAXIL 47

PAXIL CR 47

PEDIAPRED 75

PEDIARIX 96

PEDVAX HIB 96

peg-3350/electrolytes 84

peg-3350/electrolytes/ascorbate 84

peg-3350/nacl/na bicarbonate/kcl 84

PEGASYS 15

PEMAZYRE 27

pemetrexed 22

PEMETREXED 22

penciclovir 118

penicillamine 68

penicillin g potassium 18, 19

PENICILLIN G POTASSIUM IN ISO-

OSMOTIC DEXTROSE 18

PENICILLIN G PROCAINE 19

penicillin g sodium 19

penicillin v potassium 19

PENNSAID 118

PENTACEL 96

PENTAM 300 9

pentamidine isethionate 9

PENTASA 83, 84

pentazocine/naloxone hcl 6

pentobarbital sodium 55

pentoxifylline er 91

PEPCID 83

PERCOCET 6

PERFOROMIST 108

PERIKABIVEN 101

perindopril erbumine 30

periogard 120

PERJETA 27

permethrin 119

perphenazine 47, 51

perphenazine/amitriptyline 47

PERSERIS 51

PERTZYE 86

PEXEVA 47

pfizerpen 19

PHEBURANE 78

phenelzine sulfate 47

PHENERGAN 81

phenobarbital 43, 44

phenobarbital sodium 43

Page 147

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

phenoxybenzamine hydrochloride 38

PHENYLEPHRINE HCL 105

PHENYTEK 44

phenytoin 44

phenytoin sodium 44

phenytoin sodium extended release 44

PHESGO 27

PHEXXI 72

philith 72

PHOSLYRA 79

PHOSPHOLINE IODIDE 105

PHYSIOLYTE 119

PIFELTRO 13

pilocarpine hcl 105

pilocarpine hydrochloride 120

pimecrolimus 118

pimozide 51

pimtrea 72

pindolol 35

pioglitazone hcl 66

pioglitazone hcl/metformin hcl 66

pioglitazone hcl-glimepiride 66

pioglitazone hydrochloride 66

piperacillin sodium/tazobactam sodium 19

PIQRAY 27

pirfenidone 109

pirmella 1/35 72

pirmella 7/7/7 72

piroxicam 3

PLAQUENIL 93

PLASMA-LYTE A 97

PLASMA-LYTE-148 97

PLAVIX 91

PLEGRIDY 59

PLEGRIDY STARTER PACK 59

plenamine 101

PLENVU 84

PLIAGLIS 117

PNV 99

PNV PRENATAL PLUS MULTIVITAMIN 99

pnv-dha 99

PNV-DHA+DOCUSATE 99

PNV-OMEGA 99

pnv-select 99

PODOCON-25 118

podofilox 118

POLIVY 27

polycin 102

polymyxin b sulfate 10

04/01/2023 Page 148

polymyxin b sulfate/trimethoprim sulfate 102

POLYT

RIM 103

POLY-VI-FLOR 99

POLY-VI-FLOR/IRON 99

poly-vitamin/fluoride 99

POMALYST 23

PONVORY 59

PONVORY 14-DAY STARTER PACK 59

portia-28 72

PORTRAZZA 27

posaconazole dr 11

POTASSIUM ACETATE 97

potassium chloride 98, 99

POTASSIUM CHLORIDE 98

potassium chloride er 99

POTASSIUM CHLORIDE/DEXTROSE 97

POTASSIUM

CHLORIDE/DEXTROSE/LACTATED

RINGERS 97

POTASSIUM

CHLORIDE/DEXTROSE/SODIUM

CHLORIDE 97

potassium chloride/sodium chloride 98

POTASSIUM CHLORIDE/SODIUM

CHLORIDE 97

potassium citrate er 87

potassium citrate/citric acid 87

potassium citrate/sodium citrate/citric acid 87

potassium phosphate 98, 101

POTASSIUM PHOSPHATES 101

POTELIGEO 27

PRADAXA 89

PRALUENT 34

pramipexole dihydrochloride 49

pramipexole dihydrochloride er 49

prasugrel 91

pravastatin sodium 33

praziquantel 10

prazosin hydrochloride 31

PRECOSE 66

PRED FORTE 103

PRED MILD 103

PRED-G 102

PRED-G S.O.P. 102

prednicarbate 116

prednisolone 75, 103, 104

prednisolone acetate 103

prednisolone sodium phosphate 75

prednisolone sodium phosphate odt 75

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMIC SOLN 1% 104

prednisone 75

PREDNISONE INTENSOL 75

PREFEST 74

pregabalin 44

pregabalin er 57

PREGNYL W/DILUENT BENZYL

ALCOHOL/NACL 78

PREHEVBRIO 96

PREMARIN 74

PREMASOL 101

PREMPHASE 74

PREMPRO 74

PRENAISSANCE 99

PRENAISSANCE PLUS 99

PRENATAL 99

PRENATAL PLUS 99

PRENATAL PLUS LOW IRON 99

PRENATE 99, 100

PRENATE AM 99

PRENATE DHA 99

PRENATE ELITE 100

PRENATE ENHANCE 100

PRENATE ESSENTIAL 100

PRENATE MINI 100

PRENATE PIXIE 100

PRENATE RESTORE 100

PRENATVITE COMPLETE 100

PRENATVITE PLUS 100

PREPLUS 100

PRETAB 100

PRETOMANID 14

PREVACID 86

PREVACID SOLUTAB 86

prevalite 34

PREVIDENT 5000 BOOSTER PLUS 120

PREVIDENT 5000 DRY MOUTH 120

PREVIDENT 5000 ENAMEL PROTECT 120

PREVIDENT 5000 PLUS 120

PREVIDENT FLUORIDE 120

PREVIDENT RINSE 120

previfem 72

PREVYMIS 15

PREZCOBIX 14

PREZISTA 13

PRIALT 1

PRIFTIN 14

PRILOSEC 86

PRIMACARE 100

primaquine phosphate 12

PRIMAXIN IV 10

primidone 44

PRIORIX 96

PRISTIQ 47

PRIVIGEN 94

PROAIR DIGIHALER 108

PROAIR HFA 108

PROAIR RESPICLICK 108

probenecid 1

probenecid/colchicine 1

procainamide hcl 32

PROCALAMINE 101

PROCARDIA XL 36

procentra 54

prochlorperazine 82

prochlorperazine edisylate 81

prochlorperazine maleate 82

PROCRIT

90

PROCTOCORT 118

PROCTOFOAM HC 118

procto-med hc 118

procto-pak 118

proctosol hc 116

proctozone-hc 118

PROCYSBI 78

progesterone 79

PROGLYCEM 76

PROGRAF 95

PROLASTIN-C 109

PROLATE 6

PROLENSA 104

PROLIA 68

PROMACTA 91

promethazine hcl 82

promethazine hydrochloride 82

promethazine vc 107

promethegan 82

PROMETHEGAN 82

PROMETRIUM 79

propafenone hcl 32

propafenone hydrochloride er 32

proparacaine hcl 106

propranolol hcl 35

propranolol hcl er 35

propylthiouracil 80

PROQUAD 96

PROSCAR 87

04/01/2023 Page 149

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

PROSOL 101

PROTONIX 86

PROTONIX PACK 86

PROTOPIC 118

protriptyline hcl 47

PROVENTIL HFA 108

PROVERA 80

PROVIDA OB 100

PROVIGIL 61

PROZAC 47, 48

PRUDOXIN 118

PSORCON 116

PULMICORT 110

PULMICORT FLEXHALER 110

PULMOZYME 109

PURIXAN 22

PYLERA 85

pyrazinamide 15

pyridostigmine bromide 57

pyridostigmine bromide er 57

pyrimethamine 10

PYRUKYND 91

PYRUKYND TAPER PACK 91

QBRELIS 30

QBREXZA 118

QELBREE 54

QINLOCK 27

QNASL 109

QNASL CHILDRENS 109

QTERN 66

QUADRACEL 96

QUALAQUIN 12

QUARTETTE 72

QUDEXY XR 44

QUESTRAN 34

QUESTRAN LIGHT 34

quetiapine fumarate 51

quetiapine fumarate er 51

QUFLORA 100

QUFLORA FE 100

QUFLORA PEDIATRIC 100

QUILLICHEW ER 54

QUILLIVANT XR 54

quinapril hcl 30

quinapril hydrochloride 30

quinapril/hydrochlorothiazide 30

quinidine gluconate cr 32

quinidine gluconate er 33

quinidine sulfate 33

quinine sulfate 12

QULIPTA 56

QUTENZA KIT 117

QUVIVIQ 55

QUZYTTIR 107

QVAR REDIHALER 110

RABAVERT 96

rabeprazole sodium dr 86

RADICAVA 58

RADICAVA ORS 58

RADICAVA ORS STARTER KIT 58

RAGWITEK 94

raloxifene hydrochloride 78

ramelteon 55

ramipril 30

RANEXA 38

ranolazine er 38

RAPAFLO 87

RAPAMUNE 95

RAPIVAB 15

rasagiline mesylate 49

RASUVO 93

RAVICTI 78

RAYALDEE 80

RAYOS 75

RAZADYNE ER 45

REBIF 59

REBIF REBIDOSE 59

REBIF REBIDOSE TITRATION PACK 59

REBIF TITRATION PACK 59

REBLOZYL 91

REBYOTA 85

RECARBRIO 10

RECLAST 68

reclipsen 72

RECOMBIVAX HB 96

RECORLEV 78

RECTIV 119

REDITREX 93

REGLAN 82

REGONOL 58

REGRANEX 119

relafen 3

RELAFEN DS 3

RELENZA DISKHALER 15

RELEUKO 90

RELEXXII 54

RELISTOR 85

RELPAX 56

04/01/2023 Page 150

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

RELTONE 85

RELYVRIO 58

REMERON 48

REMERON SOLTAB 48

REMICADE 92

REMODULIN 39

RENACIDIN 87

RENAGEL 79

RENFLEXIS 92

RENVELA 79

RENVELA PACK 79

repaglinide 66

REPATHA 34

REPATHA PUSHTRONEX SYSTEM 34

REPATHA SURECLICK 34

RESTASIS 106

RESTASIS MULTIDOSE 106

RESTORIL 55

RETACRIT 90

RETEVMO 27

RETIN-A 112

RETIN-A MICRO PUMP 112

RETROVIR 13

RETROVIR IV 13

REVATIO 39

REVCOVI 78

REVLIMID 23

REXULTI 51

REYATAZ 13

REYVOW 56

REZLIDHIA 27

REZUROCK 95

RHOFADE 119

RHOGAM ULTRA-FILTERED PLUS 94

RHOPHYLAC 94

RHOPRESSA 105

RIABNI 27

ribavirin 15

RIDAURA 93

rifabutin 15

RIFADIN 15

rifampin 15

RILUTEK 58

riluzole 58

rimantadine hydrochloride 15

RIMSO-50 87

RINGERS INJECTION 98

RINGERS IRRIGATION 119

RINVOQ 92

04/01/2023 Page 151

RIOMET 66

rise

dronate sodium 68

risedronate sodium dr 68

RISPERDAL 52

RISPERDAL CONSTA 51

risperidone 52

risperidone odt 52

RITALIN 54

RITALIN LA 54

ritonavir 13

RITUXAN 27

RITUXAN HYCELA 27

rivastigmine tartrate 45

rivastigmine transdermal system 46

RIVELSA 72

rizatriptan benzoate 56

rizatriptan benzoate odt 56

ROBAXIN 60

ROBINUL 83

ROBINUL FORTE 83

ROCALTROL 80

ROCKLATAN 105

roflumilast 109

ROLVEDON 90

romidepsin 27

ropinirole er 49

ropinirole hcl 49

ropivacaine hydrochloride 7

rosadan 119

rosuvastatin calcium 33

ROSZET 34

ROTARIX 96

ROTATEQ 96

ROWASA 84

roweepra 44

ROXICODONE 6, 7

ROXYBOND 7

ROZEREM 55

ROZLYTREK 27

RUBRACA 27

RUCONEST 91

rufinamide 44

RUKOBIA 13

RUXIENCE 27

RUZURGI 58

RYALTRIS 107

RYBELSUS 66

RYBREVANT 27

ryclora 107

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

RYDAPT 27

RYLAZE 23

RYTARY 49

RYTHMOL SR 33

RYVENT 107

SABRIL 44

SAFYRAL 72

SAIZEN 78

SAIZENPREP RECONSTITUTIONKIT 78

sajazir 91

SALAGEN 120

salicylic acid 119

SALICYLIC ACID 119

salicylic acid wart remover 119

salsalate 3

SAMSCA 78

SANCUSO 82

SANDIMMUNE 95

SANDOSTATIN 78

SANDOSTATIN LAR 78

SANTYL 119

SAPHNELO 95

SAPHRIS 52

sapropterin dihydrochloride 78

SARCLISA 27

SAVAYSA 89

SAVELLA 58

SAVELLA TITRATION PACK 58

SCEMBLIX 27

scopolamine 82

SEASONIQUE 72

SECUADO 52

SEGLENTIS 7

SEGLUROMET 67

SELECT-OB 100

selegiline hcl 49

selenium sulfide 114

SELZENTRY 13

SEMGLEE 64

SE-NATAL 19 100

SENSIPAR 78

SENSORCAINE 7

sensorcaine/epinephrine 7

sensorcaine-mpf 7

sensorcaine-mpf/epinephrine 7

SENSORCAINE-MPF/EPINEPHRINE 7

SEREVENT DISKUS 108

SERNIVO 116

SEROQUEL 52

04/01/2023 Page 152

SEROQUEL XR 52

SER

OSTIM 78

sertraline hcl 48

SERTRALINE HYDROCHLORIDE 48

setlakin 72

sevelamer carbonate 79

sevelamer hydrochloride 79

SEYSARA 19

sf 5000 plus 120

sf gel 120

SFROWASA 84

sharobel 72

SHINGRIX 96

SIGNIFOR 78

SIGNIFOR LAR 78

SIKLOS 91

sildenafil 39

SILENOR 55

SILIQ 92

silodosin 87

SILVADENE 112

SILVER NITRATE 119

silver sulfadiazine 112

SIMBRINZA 105

simliya 72

simpesse 72

SIMPONI 92

SIMPONI ARIA 92

SIMULECT 95

simvastatin 33

SINEMET 49

SINGULAIR 108

sirolimus 95, 96

SIRTURO 15

SITAVIG 15

SIVEXTRO 10

SKELAXIN 60

SKYLA 72

SKYRIZI 92

SKYRIZI PEN 92

SKYTROFA 78

SLYND 72

SMOFLIPID 101

SOAANZ 37

sodium acetate 98

SODIUM ACETATE 98

sodium bicarbonate 98

SODIUM BICARBONATE 98

sodium chloride 98

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

SODIUM CHLORIDE 98

sodium chloride 0.45% 98

sodium chloride 0.9% irrigation soln 119

sodium citrate/citric acid 87

SODIUM DIURIL 37

SODIUM EDECRIN 37

sodium fluoride 100, 120

sodium fluoride 5000 plus 120

sodium fluoride 5000 ppm 120

sodium fluoride 5000 ppm pste 120

sodium fluoride 5000 ppm sensitive 120

sodium fluoride mouth/throat soln 0.2% 120

SODIUM OXYBATE 61

sodium phenylbutyrate 78

sodium phosphate 98

sodium phosphates 98

sodium polystyrene sulfonate 68

sodium sulfacetamide/sulfur 112

SODIUM SULFACETAMIDE/SULFUR

CLEANSER IN UREA EMULSION 112

SODIUM SULFATE/POTASSIUM

SULFATE/MAGNESIUM SULFATE 84

SOFOSBUVIR/VELPATASVIR 15

solifenacin succinate 88

SOLIQUA 100/33 64

SOLIRIS 91

SOLODYN 19

SOLOSEC 10

SOLTAMOX 22

SOLU-CORTEF 75

SOLU-MEDROL 75

SOMA 60

SOMATULINE DEPOT 78

SOMAVERT 78

SOOLANTRA 119

sorafenib tosylate 28

SORBITOL IRRIGATION 87

SORILUX 114

sorine 33

sotalol hcl 33

sotalol hydrochloride (af) 33

SOTYKTU 92

SOTYLIZE 33

SOVALDI 15, 16

SPEVIGO 93

SPINOSAD 119

SPIRIVA HANDIHALER 107

SPIRIVA RESPIMAT 107

spironolactone 30, 37

spironolactone/hydrochlorothiazide 37

SPORANOX 11

sprintec 28 72

SPRITAM 44

SPRIX 3

SPRYCEL 28

sps 68

sronyx 72

SSD 112

STALEVO 100 49

STALEVO 125 49

STALEVO 150 49

STALEVO 200 49

STALEVO 50 49

STALEVO 75 49

stavudine 13

STEGLATRO 67

STEGLUJAN 67

STELARA 93

sterile water for irrigation 119

STIOLTO RESPIMAT 106

STIVARGA 28

STRATTERA 54

STRENSIQ 78

streptomycin sulfate 10

STRIBILD 14

STRIVERDI RESPIMAT 108

STROMECTOL 10

SUBLOCADE 61

SUBOXONE 61

SUBSYS 7

subvenite 44

subvenite starter kit 44

SUCRAID 85

sucralfate 85

SUCRALFATE SUSP 85

SULAR 36

sulfacetamide sodium 103, 112

sulfacetamide sodium/prednisolone sodium

phosphate 102

sulfacleanse 112

sulfadiazine 10

sulfamethoxazole/trimethoprim 10

sulfamethoxazole/trimethoprim ds 10

SULFAMYLON 112

sulfasalazine 84

sulindac 3

sumatriptan 56

sumatriptan succinate 56

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2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

sumatriptan succinate refill 56

sumatriptan/naproxen sodium 57

sunitinib malate 28

SUNLENCA 13

SUNOSI 61

SUPRAX 17

SUPREP BOWEL PREP 84

SUSTIVA 13

SUSTOL 82

SUSVIMO 106

SUTAB 84

SUTENT 28

syeda 72

SYMBICORT 110

SYMBYAX 48

SYMDEKO 109

SYMFI 14

SYMFI LO 14

SYMJEPI 109

SYMLINPEN 120 67

SYMLINPEN 60 67

SYMPAZAN 44

SYMPROIC 85

SYMTUZA 14

SYNAGIS 94

SYNALAR 116

SYNAREL 73

SYNDROS 82

SYNERA 117

SYNERCID 10

SYNJARDY 67

SYNJARDY XR 67

SYNRIBO 23

SYNTHROID 80

SYPRINE 68

TABLOID 22

TABRECTA 28

TACLONEX 116

tacrolimus 96, 119

tadalafil 39

TADLIQ 39

TAFINLAR 28

tafluprost 105

TAGRISSO 28

TAKHZYRO 91

TALICIA 85

TALTZ 93

TALZENNA 28

TAMIFLU 16

tamoxifen citrate 22

tamsulosin hydrochloride 87

taperdex 12-day 76

taperdex 6-day 76

taperdex 7-day 76

TARCEVA 28

targadox 19

TARGRETIN 23, 119

tarina 24 fe 72

tarina fe 1/20 72, 73

tarina fe 1/20 eq 73

TARON-C DHA 100

TARPEYO 83

TASCENSO ODT 59

TASIGNA 28

tasimelteon 55

TASMAR 50

tavaborole 113

TAVALISSE 91

TAVNEOS 91

taysofy 73

TAYTULLA 73

tazarotene 114

TAZAROTENE 112

tazicef 17

TAZORAC 114

taztia xt 36

TAZVERIK 28

TDVAX 96

TECENTRIQ 28

TECFIDERA 59

TECFIDERA STARTER PACK 59

TECVAYLI 28

TEFLARO 17

TEGRETOL 44

TEGRETOL-XR 44

TEGSEDI 58

TEKTURNA 38

TEKTURNA HCT 38

telmisartan 31, 32

telmisartan/amlodipine 31

telmisartan/hydrochlorothiazide 31

temazepam 55

TEMIXYS 14

TEMODAR 20

TEMOVATE 116

temsirolimus 28

tencon 1

TENIVAC 96

04/01/2023 Page 154

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

tenofovir disoproxil fumarate 13

TENORETIC 100 34

TENORETIC 50 34

TENORMIN 35

TEPADINA 20

TEPEZZA 79

TEPMETKO 28

terazosin hcl 31

terazosin hydrochloride 31

terbinafine hcl 11

terbutaline sulfate 108

terconazole 88

TERIPARATIDE 68

TESTIM 62

TESTOPEL 62

testosterone 62

testosterone cypionate 62

testosterone enanthate 62

testosterone pump 62

tetrabenazine 58

TETRACAINE HYDROCHLORIDE 106

tetracycline hydrochloride 19

TEXACORT 116

TEZSPIRE 109

THALITONE 37

THALOMID 23

THEO-24 109

theophylline 109

theophylline er 109

THIOLA 87

THIOLA EC 87

thioridazine hcl 52

thiotepa 20

thiothixene 52

THRIVITE RX 100

THYMOGLOBULIN 96

THYQUIDITY 80

tiadylt er 36

tiagabine hydrochloride 44

TIAZAC 36

TIBSOVO 28

TICE BCG 23

TICOVAC 96

TIGAN 82

tigecycline 19

TIGLUTIK 58

TIKOSYN 33

TILIA FE 73

timolol maleate 35, 105

04/01/2023 Page 155

TIMOLOL MALEATE 105

TIM

OPTIC 105

TIMOPTIC OCUDOSE 105

TIMOPTIC-XE 105

tinidazole 10

tiopronin 87

TIROSINT 80

TIROSINT-SOL 80

TIS-U-SOL 119

TIVDAK 28

TIVICAY 13

TIVICAY PD 13

tizanidine hcl 60

tizanidine hydrochloride 60

TLANDO 62

TOBI 10

TOBI PODHALER 10

TOBRADEX 102

TOBRADEX ST 102

tobramycin 10, 103

tobramycin dexamethasone 102

tobramycin nebu 10

tobramycin sulfate 10

TOBREX 103

tolcapone 50

TOLSURA 11

tolterodine tartrate 88

tolterodine tartrate er 88

tolvaptan 79

TOPAMAX 44

TOPAMAX SPRINKLE 44

TOPICORT 116

topiramate 44

topiramate er 44

toposar 24

topotecan hcl 23

TOPOTECAN HCL 23

TOPROL XL 35

toremifene citrate 22

TORISEL 28

torsemide 37

TOSYMRA 57

TOUJEO MAX SOLOSTAR 64

TOUJEO SOLOSTAR 64

tovet 116

TOVIAZ 88

TPN ELECTROLYTES 98

TRACLEER 40

TRADJENTA 67

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

tramadol hcl 7

tramadol hcl er 4

TRAMADOL HCL ER 4

tramadol hydrochloride er 4

tramadol hydrochloride/acetaminophen 7

trandolapril 30

trandolapril/verapamil hcl er 30

tranexamic acid 91

TRANSDERM-SCOP 82

TRANXENE T 44

tranylcypromine sulfate 48

TRAVASOL 101

TRAVATAN Z 105

travoprost 105

TRAZIMERA 28

trazodone hydrochloride 48

TREANDA 20

TRECATOR 15

TRELEGY ELLIPTA 106

TRELSTAR MIXJECT 22

TREMFYA 93

treprostinil 40

TRESIBA 64

TRESIBA FLEXTOUCH 64

tretinoin 23, 112

TRETINOIN MICROSPHERE 112

TRETINOIN MICROSPHERE PUMP 112

TREXALL 93

TREXIMET 57

trezix 7

tri femynor 73

triamcinolone acetonide 76, 116, 117

triamcinolone acetonide dental paste 120

triamterene 37

triamterene/hydrochlorothiazide 37

trianex 117

triazolam 55

TRIBENZOR 31

TRICARE PRENATAL 100

tricitrates 87

TRICOR 33

triderm 117

trientine hydrochloride 68

TRIESENCE 104

tri-estarylla 73

trifluoperazine hcl 52

trifluoperazine hydrochloride 52

trifluridine 103

trihexyphenidyl hcl 50

04/01/2023 Page 156

trihexyphenidyl hydrochloride 50

TRI

JARDY XR 67

TRIKAFTA 109

tri-legest fe 73

TRILEPTAL 44

tri-linyah 73

TRILIPIX 33

tri-lo-estarylla 73

tri-lo-marzia 73

tri-lo-mili 73

tri-lo-sprintec 73

trimethobenzamide hydrochloride 82

trimethoprim 10, 103

trimethoprim sulfate/polymyxin b sulfate 103

tri-mili 73

trimipramine maleate 48

TRINATAL RX 1 100

TRINTELLIX 48

tri-nymyo 73

TRIOSTAT 80

TRIPTODUR 79

TRISENOX 23

tri-sprintec 73

TRISTART DHA 100

TRISTART FREE 100

TRISTART ONE 100

tritocin 117

TRIUMEQ 14

TRIUMEQ PD 14

TRI-VI-FLOR 100

tri-vite/fluoride 100

trivora-28 73

tri-vylibra 73

tri-vylibra lo 73

TRIZIVIR 14

TRODELVY 28

TROGARZO 13

TROKENDI XR 44

TROPHAMINE 101

trospium chloride 88

trospium chloride er 88

TRUDHESA 57

TRULANCE 85

TRULICITY 67

TRUMENBA 96

TRUSELTIQ 28

TRUSOPT 105

TRUVADA 14

TRUXIMA 28

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

TUDORZA PRESSAIR 107

TUKYSA 28

TURALIO 28

TWINRIX 97

TWYNEO 112

TYBLUME 73

TYBOST 13

tydemy 73

TYGACIL 19

TYKERB 28

TYMLOS 68

TYPHIM VI 97

TYRVAYA 106

TYSABRI 59

TYVASO 40

TYVASO DPI MAINTENANCE KIT 40

TYVASO DPI TITRATION KIT 40

TYVASO REFILL 40

TYVASO STARTER 40

UBRELVY 57

UCERIS 84

UCERIS FOAM 84

UDENYCA 90

UKONIQ 28

ULORIC 1

ULTOMIRIS 91

ULTRACET 7

ULTRAM 7

ULTRAVATE 117

UNASYN 19

UNITHROID 80

UPLIZNA 58

UPTRAVI 40

UPTRAVI TITRATION PACK 40

uro-458 10

UROCIT-K 87

UROGESIC-BLUE 10

UROXATRAL 87

URSO 250 85

URSO FORTE 85

ursodiol 85

URSODIOL 85

VABOMERE 10

VABYSMO 106

VAGIFEM 74

valacyclovir hcl 16

VALCHLOR 119

VALCYTE 16

valganciclovir 16

04/01/2023

valganciclovir hydrochloride 16

VALIUM 45

valproate sodium 45

valproic acid 45

valrubicin 21

valsartan 32

VALSARTAN 32

valsartan/hydrochlorothiazide 31

VALSTAR 21

VALTOCO 45

VALTREX 16

VANCOCIN 10

VANCOMYCIN 10

vancomycin hcl 10

VANCOMYCIN HCL 10

vancomycin hydrochloride 10

VANCOMYCIN HYDROCHLORIDE 10

VANCOMYCIN

HYDROCHLORIDE/DEXTROSE 10

VANDAZOLE 88

VANOS 117

VAQTA 97

VARENICLINE STARTING MONTH BOX 61

VARENICLINE TARTRATE 61

VARIVAX 97

VARIZIG 94

VARUBI 82

VASCEPA 34

VASERETIC 30

vasopressin 79

VASOSTRICT 79

VASOTEC 30

VECAMYL 38

VECTIBIX 28

VECTICAL 114

VEKLURY 16

VELCADE 28

VELETRI 40

velivet 73

VELPHORO 79

VELTASSA 68

VELTIN 112

VEMLIDY 16

VENCLEXTA 28, 29

VENCLEXTA STARTING PACK 28

VENLAFAXINE BESYLATE ER 48

venlafaxine hcl er 48

venlafaxine hydrochloride 48

venlafaxine hydrochloride er 48

Page 157

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

VENTAVIS 40

VENTOLIN HFA 108

verapamil hcl 36

verapamil hcl er 36

verapamil hcl sr 36

VERAPAMIL HCL SR 36

verapamil hydrochloride 36

VERDESO 117

VEREGEN 119

VERELAN 36

VERELAN PM 36

VERKAZIA 106

VERQUVO 38

VERSACLOZ 52

VERZENIO 29

VESICARE 88

VESICARE LS 88

vestura 73

VFEND 12

VFEND IV 12

V-GO 20 64

V-GO 30 64

V-GO 40 64

VIBATIV 10

VIBERZI 85

VIBRAMYCIN 19

VICTOZA 67

VIDAZA 22

VIEKIRA PAK 16

vienva 73

vigabatrin 45

vigadrone 45

VIGAMOX 103

VIIBRYD 48

VIIBRYD STARTER PACK 48

VIJOICE 79

vilazodone hydrochloride 48

VILTEPSO 58

VIMIZIM 79

VIMOVO 3

VIMPAT 45

vinblastine sulfate 24

vincristine sulfate 24

vinorelbine tartrate 24

VIOKACE 86

viorele 73

VIRACEPT 13

VIRAMUNE XR 13

VIRASAL 119

VIREAD 13

VIRT-C DHA 100

VIRT-NATE DHA 100

VIRT-PN DHA 100

VIRT-PN PLUS 100

VISTARIL 107

VISTOGARD 79

VITAFOL GUMMIES 100

VITAFOL STRIPS 100

VITAFOL ULTRA 100

VITAFOL-NANO 100

VITAFOL-OB 100

VITAFOL-ONE 100

VITAMEDMD ONE RX/QUATREFOLIC 100

VITRAKVI 29

VIVELLE-DOT 74

VIVITROL 61

VIVJOA 12

VIVLODEX 3

VIZIMPRO 29

VOGELXO 62

VOGE

LXO PUMP 62

volnea 73

VONJO 29

VOQUEZNA DUAL PAK 85

VOQUEZNA TRIPLE PAK 85

voriconazole 12

VOSEVI 16

VOTRIENT 29

VOXZOGO 79

VP-PNV-DHA 100

VPRIV 79

VRAYLAR 52

VTAMA 114

vtol lq 1

VUITY 105

VUMERITY 59

VUSION 113

VYEPTI 57

vyfemla 73

vylibra 73

VYNDAMAX 39

VYNDAQEL 39

VYONDYS 53 58

VYTORIN 34

VYVANSE 54

VYVGART 94

VYXEOS 23

VYZULTA 105

04/01/2023 Page 158

2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

WAKIX 61

warfarin sodium 89

WELCHOL 34

WELIREG 23

WELLBUTRIN SR 48

WELLBUTRIN XL 48

wera 73

WESCAP-C DHA 101

WESCAP-PN DHA 101

WESNATE DHA 101

WESTAB PLUS 101

WESTGEL DHA 101

WINLEVI 112

WINRHO SDF 94

wixela inhub 110

wymzya fe 73

XADAGO 50

XALATAN 105

XALKORI 29

XANAX 41

XANAX XR 41

XARELTO 89

XARELTO STARTER PACK 89

XATMEP 93

XCOPRI 45

XELJANZ 93

XELJANZ XR 93

XELPROS 105

XELSTRYM 55

XEMBIFY 94

XENAZINE 58

XENLETA 10, 11

XENPOZYME 79

XEOMIN 60

XERAVA 19, 20

XERESE 119

XERMELO 85

XGEVA 68

XHANCE 109

XIAFLEX 79

XIFAXAN 11

XIGDUO XR 67

XIIDRA 106

XIMINO 20

XIPERE 104

XOFLUZA 16

XOLAIR 109

XOLEGEL 114

XOPENEX 108

XOPENEX CONCENTRATE 108

XOPENEX HFA 108

XOSPATA 29

XPOVIO 29

XTAMPZA ER 4

XTANDI 23

xulane 73

XULTOPHY 64

XURIDEN 79

XYLOCAINE 7

XYLOCAINE/EPINEPHRINE 7

XYLOCAINE-MPF 7

XYLOCAINE-MPF/EPINEPHRINE 7

XYOSTED 62

XYREM 61

XYWAV 61

YASMIN 28 73

YAZ 73

YERVOY 29

YF-VAX 97

YONDELIS 20

YONSA 23

YUPELRI 107

YUTIQ 104

yuvafem 74

zafemy 73

zafirlukast 108

zaleplon 55

ZALTRAP 29

ZANAFLEX 60

ZANOSAR 20

ZARONTIN 45

ZARXIO 90

ZAVESCA 79

ZCORT 7-DAY 76

zebutal 1

ZEGALOGUE 76

ZEGERID 86

ZEJULA 29

ZELAPAR 50

ZELBORAF 29

ZEMAIRA 109

ZEMBRACE SYMTOUCH 57

ZEMDRI 11

ZEMPLAR 80, 81

zenatane 112

ZENPEP 86

zenzedi 55

ZEPATIER 16

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2023 Comprehensive Plus 5 Tier v12 effective 04/01/2023

ZEPOSIA 59

ZEPOSIA 7-DAY STARTER PACK 59

ZEPOSIA STARTER KIT 59

ZEPZELCA 20

ZERBAXA 17

ZERVIATE 104

ZESTORETIC 30

ZESTRIL 30

ZETIA 34

ZETONNA 109

ZIAC 34

ZIAGEN 13

ZIANA 112

zidovudine 13

ZIEXTENZO 90

zileuton er 108

ZILRETTA 76

ZILXI 119

ZIMHI 61

ZINPLAVA 94

ZIOPTAN 105

ziprasidone hcl 52

ziprasidone mesylate 52

ZIPSOR 3

ZIRABEV 29

ZIRGAN 103

ZITHROMAX 18

ZITHROMAX TRI-PAK 18

ZITHROMAX Z-PAK 18

ZOCOR 33

ZOKINVY 79

ZOLADEX 23

zoledronic acid 68

ZOLEDRONIC ACID 68

ZOLINZA 29

zolmitriptan 57

ZOLMITRIPTAN 57

zolmitriptan odt 57

ZOLOFT 48

zolpidem tartrate 55

zolpidem tartrate er 55

ZOLPIMIST 55

ZOMACTON 79

ZOMIG 57

ZONALON 119

ZONEGRAN 45

ZONISADE 45

zonisamide 45

ZONTIVITY 91

ZORBTIVE 79

ZORTRESS 96

ZORVOLEX 3

ZORYVE 114

ZOSYN 19

zovia 1/35 73

ZOVIRAX 16, 119

ZTALMY 45

ZTLIDO 117

ZUBSOLV 61

ZULRESSO 48

zumandimine 73

ZYCLARA 119

ZYCLARA PUMP 119

ZYDELIG 29

ZYFLO 108

ZYKADIA 29

ZYLET 102

ZYLOPRIM 1

ZYMAXID 103

ZYNLONTA 29

ZYPITAMAG 33

ZYPREXA 52

ZYPREXA RELPREVV 52

ZYPREXA ZYDIS 52

ZYTIGA 23

ZYVOX 11

04/01/2023

Page 160

P.O. Box 30006, Pittsburgh, PA 15222-0330

This formulary was updated on 03/20/2023. For more recent information or other questions, please contact

Customer Care at the number on your ID card, 24 hours a day, 7 days a week. TTY users should call 711.

The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.

Aetna Medicare Rx offered by SilverScript is a group standalone Medicare Prescription Drug Plan (PDP).

This Plan is offered by SilverScript Insurance Company, which has a Medicare contract. SilverScript

Insurance Company and Aetna are affiliated companies. Enrollment in the Plan depends on Medicare

contract renewal.

03/20/2023