New Added Products: Effective 3/1/2017 Drug Reason Tier Restrictions abacavir 600 mg-lamivudine 300 QL ADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO- INJECTOR ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR Tier 2 QL Tier 2 QL ADRIAMYCIN 20 MG/10 ML INTRAVENOUS SOLUTION PA ALA-CORT 2.5 % TOPICAL CREAM ST allopurinol 500 mg intravenous solution PA ALYACEN 1/35 (28) 1 MG-35 MCG TABLET AMABELZ 0.5 MG-0.1 MG TABLET AMABELZ 1 MG-0.5 MG TABLET amlodipine 10 mg-olmesartan 20 amlodipine 10 mg-olmesartan 40 amlodipine 5 mg-olmesartan 20 amlodipine 5 mg-olmesartan 40 aprepitant 125 mg (1)-80 mg (2) capsules in a dose pack PA aprepitant 125 mg capsule PA aprepitant 40 mg capsule PA aprepitant 80 mg capsule PA azithromycin 500 (3 pack) bupropion hcl 150,sustained release (as a smoking deterrent) carbamazepine er 100,extended release,12 hr ST carbamazepine er 200,extended release,12 hr ST carbamazepine er 400,extended release,12 hr ST carboplatin 10 mg/ml intravenous solution PA CAZIANT (28) 0.1 MG/0.125 MG/0.15 MG-25 MCG TABLET CHOLESTYRAMINE LIGHT 4 GRAM ORAL POWDER cisplatin 1 mg/ml intravenous solution PA clindamycin 1.2 % (1 % base)-benzoyl peroxide 5 % topical gel daptomycin 500 mg intravenous solution PA docetaxel 80 mg/4 ml (20 mg/ml) intravenous solution PA DOCETAXEL 80 MG/8 ML (10 MG/ML) INTRAVENOUS SOLUTION PA ELITEK 1.5 MG INTRAVENOUS SOLUTION EMEND 125 MG (25 MG/ML FINAL CONC.) ORAL SUSPENSION EPCLUSA 400 MG-100 MG TABLET 1
2 Drug Reason Tier Restrictions epinephrine 0.15 mg/0.15 ml injection,auto-injector QL epinephrine 0.15 mg/0.3 ml injection,auto-injector QL epinephrine 0.3 mg/0.3 ml injection, auto-injector QL epirubicin 200 mg/100 ml intravenous solution PA ERAXIS(WATER DILUENT) 50 MG INTRAVENOUS SOLUTION erythromycin ethylsuccinate 200 mg/5 ml oral powder for suspension ethynodiol diac-eth estradiol 1 mg-50 mcg tablet EXONDYS 51 50 MG/ML INTRAVENOUS SOLUTION EXONDYS 51 50 MG/ML INTRAVENOUS SOLUTION (3 PACK) ezetimibe 10 FEMYNOR 0.25 MG-35 MCG TABLET fenofibrate nanocrystallized 145 fenofibrate nanocrystallized 48 FLUOCINONIDE-E 0.05% TOPICAL CREAM ST GAMASTAN S/D 15 %-18 % RANGE INTRAMUSCULAR SOLUTION (10 ML) GAMASTAN S/D 15 %-18 % RANGE INTRAMUSCULAR SOLUTION (2 ML) GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM INTRAVENOUS SOLUTION GAMMAGARD S-D (IGA < 1 MCG/ML) 5 GRAM INTRAVENOUS SOLUTION GENGRAF 50 MG CAPSULE PA GLEOSTINE 10 MG CAPSULE GLEOSTINE 100 MG CAPSULE GLEOSTINE 5 MG CAPSULE glipizide 2.5 mg-metformin 250 ST QL glipizide 2.5 mg-metformin 500 ST QL glipizide 5 mg-metformin 500 ST QL glyburide 1.25 mg-metformin 250 PA ST QL glyburide 2.5 mg-metformin 500 PA ST QL glyburide 5 mg-metformin 500 PA ST QL HERCEPTIN 440 MG INTRAVENOUS SOLUTION HUMIRA PEN PSORIASIS-UVEITIS STARTER 40 MG/0.8 ML SUBCUTANEOUS KIT INFLECTRA 100 MG INTRAVENOUS SOLUTION INVOKAMET XR 150 MG-1,000 MG TABLET, EXTENDED INVOKAMET XR 150 MG-500 MG TABLET, EXTENDED INVOKAMET XR 50 MG-1,000 MG TABLET, EXTENDED INVOKAMET XR 50 MG-500 MG TABLET, EXTENDED irinotecan 100 mg/5 ml intravenous solution PA
Drug Reason Tier Restrictions JANUMET 50 MG-1,000 MG TABLET JANUMET 50 MG-500 MG TABLET JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED JANUMET XR 50 MG-500 MG TABLET,EXTENDED KINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE Tier 2 KYPROLIS 30 MG INTRAVENOUS SOLUTION KYPROLIS 60 MG INTRAVENOUS SOLUTION LARISSIA 0.1 MG-20 MCG TABLET LARTRUVO 10 MG/ML INTRAVENOUS SOLUTION LOW-OGESTREL (28) 0.3 MG-30 MCG TABLET methotrexate sodium 25 mg/ml injection solution MORGIDOX 50 MG CAPSULE mycophenolate 500 mg intravenous solution PA nifedipine er 30,extended release 24 hr ST nifedipine er 60,extended release 24 hr ST nifedipine er 90,extended release 24 hr ST nilutamide 150 NINLARO 2.3 MG CAPSULE NINLARO 4 MG CAPSULE nitroglycerin 0.3 mg sublingual tablet nitroglycerin 0.4 mg sublingual tablet nitroglycerin 0.6 mg sublingual tablet norethindrone acetate 1 mg-ethinyl estradiol 20 mcg tablet norgestimate-ethinyl estradiol 0.18 mg/0.215mg/0.25mg-35 mcg(28)tablet NYATA 100,000 UNIT/GRAM TOPICAL POWDER OCALIVA 10 MG TABLET OCALIVA 5 MG TABLET ofloxacin 300 olmesartan 20 ST olmesartan 20 mg-amlodipine 5 mg-hydrochlorothiazide 12.5 3 olmesartan 20 mg-hydrochlorothiazide 12.5 ST olmesartan 40 ST olmesartan 40 mg-amlodipine 10 mg-hydrochlorothiazide 12.5 olmesartan 40 mg-amlodipine 10 mg-hydrochlorothiazide 25 olmesartan 40 mg-amlodipine 5 mg-hydrochlorothiazide 12.5
Drug Reason Tier Restrictions olmesartan 40 mg-amlodipine 5 mg-hydrochlorothiazide 25 olmesartan 40 mg-hydrochlorothiazide 12.5 ST olmesartan 40 mg-hydrochlorothiazide 25 ST olmesartan 5 ST ORENCIA CLICKJECT 125 MG/ML SUBCUTANEOUS AUTO-INJECTOR ORKAMBI 100 MG-125 MG TABLET oseltamivir 30 mg capsule QL oseltamivir 45 mg capsule QL oseltamivir 75 mg capsule QL oxaliplatin 100 mg/20 ml intravenous solution PA paclitaxel 6 mg/ml concentrate,intravenous PA PEDIARIX (PF) 10 MCG-25 LF-25 MCG-10 LF/0.5 ML INTRAMUSCULAR SYRINGE Tier 2 perphenazine-amitriptyline 2 mg-25 PA perphenazine-amitriptyline 4 mg-10 PA perphenazine-amitriptyline 4 mg-25 PA perphenazine-amitriptyline 4 mg-50 PA phenytoin sodium extended 200 mg capsule ST phenytoin sodium extended 300 mg capsule ST pioglitazone 15 mg-metformin 500 QL pioglitazone 15 mg-metformin 850 QL prednisone 10 s in a dose pack prednisone 10 s in a dose pack (48 pack) prednisone 5 s in a dose pack prednisone 5 s in a dose pack (48 pack) quetiapine er 150,extended release 24 hr QL quetiapine er 200,extended release 24 hr QL quetiapine er 300,extended release 24 hr QL quetiapine er 400,extended release 24 hr QL quetiapine er 50,extended release 24 hr QL rasagiline 0.5 rasagiline 1 RELISTOR 150 MG TABLET REPATHA PUSHTRONEX 420 MG/3.5 ML SUBCUTANEOUS WEARABLE INJECTOR RUBRACA 200 MG TABLET RUBRACA 300 MG TABLET SEROQUEL XR 50 MG TABLET,EXTENDED Tier 2 QL SPS (WITH SORBITOL) 15 GRAM-20 GRAM/60 ML ORAL SUSPENSION STELARA 130 MG/26 ML INTRAVENOUS SOLUTION sumatriptan 4 mg/0.5 ml subcutaneous pen injector QL SYLATRON 200 MCG SUBCUTANEOUS KIT 4
Drug Reason Tier Restrictions SYLATRON 300 MCG SUBCUTANEOUS KIT TREXIMET 10 MG-60 MG TABLET Tier 2 valganciclovir 50 mg/ml oral solution VELCADE 3.5 MG SOLUTION FOR INJECTION VEMLIDY 25 MG TABLET Tier 2 YERVOY 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION YONDELIS 1 MG INTRAVENOUS SOLUTION YUVAFEM 10 MCG VAGINAL TABLET ZARAH 3 MG-0.03 MG TABLET ZEPATIER 50 MG-100 MG TABLET ZERIT 1 MG/ML ORAL SOLUTION Tier 2 5
Removed Products: Effective 3/1/2017 Drug Reason Alternative HUMAN PAPILLOMAVIRUS TYPE 16, L1 CAPSID Deletion PROTEIN (RESIDUES 2-471) VACCINE 0.04 MG/ML / HUMAN PAPILLOMAVIRUS TYPE 18, L1 CAPSID PROTEIN (RESIDUES 2-472) VACCINE 0.04 MG/ML PREFILLED SYRINGE Gardasil STAVUDINE 1 MG/ML ORAL SOLUTION Deletion ZERIT 1 MG/ML SOLN RECON 6
Updated Products: Effective 3/1/2017 Drug Reason Tier Restrictions atorvastatin 10 ST Removed 1 atorvastatin 20 ST Removed 1 atorvastatin 40 ST Removed 1 atorvastatin 80 ST Removed 1 rosuvastatin 10 ST Removed 1 rosuvastatin 20 ST Removed 1 rosuvastatin 5 ST Removed 1 simvastatin 20 ST Removed 1 simvastatin 40 ST Removed 1 simvastatin 80 ST Removed 1 7