text size


Print this page

Pending changes to the approved drug list

From time to time, we add drugs to or remove them from the approved drug list (formulary). We also may change their tier, which determines how much you pay for them. We make these changes based on the scientific evidence we have of their value in helping people get well and stay healthy.

If you are taking a drug that is being removed

If we remove drugs from the formulary during the year, we'll notify you of the change at least 60 days before the date that the change becomes effective. The exceptions to this 60-day notice are when the FDA decides a drug is not safe, or if a drug manufacturer removes the drug from the market.

You may ask Priority Health to make an exception for you. We must make a decision within 72 hours of your request. Contact Customer Service to make these requests.
Learn more about asking for an exception.

Current and pending changes to the approved drug list

KEY:

  • ALL CAPS = Brand names
  • lower case = generic names
  • B/D = Coverage varies under Medicare Part B (hospitalization) vs. Part D (prescription) benefits
  • FF = "Free first fill" drug will be provided at zero cost-sharing the first time you fill it
  • HI = Home infusion drug
  • LA = Limited availability (available only at certain pharmacies)
  • PA = Prior authorization from Priority Health is needed
  • QL = Quantity limits apply
  • ST = Step therapy (trying other drugs first) is required

Additions to the approved drug list:

Additions effective May 1, 2012
Drug name Tier Category
BYDUERON 2, ST, QL (4/28 days) Blood glucose regulators/Antidiabetic agents
calictriol oint 1 Dermatological agents
EDARBYCLOR 3, ST, QL (31/31 days) Cardiovascular agents/Renin-angiotensin-aldosterone system inhibitors
ERIVEDGE 4, PA, QL (31/31 days) Antineoplastics/Antinioplastics, other
escitalopram oxalate 1 Antidepressants/Serotonin/Norepinehrine reuptake inhibitors
ibandronate sodium 150mg tab 1 Metabolic bone disease agents
INLYTA TABS 4, ST Antineoplastics/Molecular target inhibitors
JANUMET XR 1000mg/100mg, 500mg/50mg 2, QL (31/31 days) Blood glucose regulators/Antidiabetic agents
JANUMET XR 1000mg/50mg 2, QL (62 per 31 days) Blood glucose regulators/Antidiabetic agents
JENADUETO 3, QL (62 per 31 days) Blood glucose regulators/Antidiabetic agents
LIPODOX 4 Antineoplastics/Antinioplastics, other
olanzapine hcl solr 1 Antipsychotics/Atypicals
PICATO GEL 3, ST Antineoplastics/Antinioplastics, other
progesterone caps 1 Hormonal agents, stimulant/ Replacement/ Modifying (sex hormones/ Modifiers) /Progestins
RECTIV OINT 3, QL (30gm/30 days) Cardiovascular agents/Vasodilators
ziprasidone hcl 1 Antipsychotics/Atypicals
Additions effective April 1, 2012
Drug name Tier Category
adriamycin 1 Antineoplastics
CAPRELSA 100mg tabs 4, PA, QL (62/31 days) Antineoplastics/Antiangiogenic agents
CAPRELSA 300mg tabs 4, PA, QL (62/31 days) Antineoplastics/Antiangiogenic agents
dexrazoxane 1 Antineoplastics
epirubicin 1 Antineoplastics
ERBITUX 4, PA Antineoplastics/Monoclonal antibodies
etoposide 1 Antineoplastics
idrarubicin hcl 1 Antineoplastics
irinotecan 1 Antineoplastics
mesna 1 Antineoplastics
mitomycin 1 Antineoplastics
oxaliplatin 1 Antineoplastics
SANDIMMUNE oral solution 2, B/D Immunological agents/Immune suppressants
toposar 1 Antineoplastics
trimipramine maleate 1 Antidepressants/Tricyclics
VECTIBIX 4, PA Antineoplastics/Monoclonal antibodies
vinblastine sulfate 1 Antineoplastics
vincasar pfs 1 Antineoplastics
vincristine sulfate 1 Antineoplastics
vinorelbine tartrate 1 Antineoplastics
ZYCLARA pump 3 Dermatological agents
Additions effective March 1, 2012
Drug name Tier Category
alfuzosin hcl er 1 Genitourinary agents/Benign prostatic hypertrophy agents
amethia 1 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens
amethyst 1 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens
ANDROGEL pump 1.62% 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Androgens
ARCAPTA neohaler 3, QL (31/31 days), ST Respiratory tract agents/Bronchodilators, sympathomimetic
ASMANEX 30 metered doses 110mcg/inh 3 Respiratory tract agents/Anti-inflammatories, inhaled corticosteroids
atorvastatin calcium 1 Cardiovascular agents/Dyslipidemics
atovaquone/proguanil hcl 1 Antiparasitics/Antiprotozoals
BENLYSTA 4 Immunological agents/Immune suppressants
BRILINTA 2, QL (62/31 days) Blood products/Modifiers/Volume expanders/Coagulants
CARAFATE oral suspension 2 Gastrointestinal agents/Protectants
CARBAGLU 4, PA Enzyme replacements/Modifiers
CIALIS tablet 2.5mg; 5mg 2, QL (31/31 days), ST Genitourinary agents
COMPLERA 4, QL (31/31 days) Antivirals anti-HIV agents, non-nucleoside/Reverse transcriptase inhibitors
CUVPOSA 3 Gastrointestinal agents/Antispasmodics, gastrointestinal
DALIRESP 3, PA, QL (31/31 days) Respiratory tract agents
DERMA-SMOOTHE/FS body oil 2 Hormonal agents, stimulant/replacement/modifying/Glucocorticoids/Mineralocorticoids
Drug name Tier Category
DIFICID 4, QL (20/30 days), ST Antibacterials/Macrolides
disulfiram 1 Antidotes, deterrents, toxicologic agents
ELESTRIN 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens
EPIPEN 2-pak 2 Respiratory tract agents/Bronchodilators, sympathomimetic
eprosartan mesylate 1 Cardiovascular agents/Renin-angiotensin-aldosterone system inhibitors
ESTRADERM 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens
felbamate 1 Anticonvulsants/Glutamate reducing agents
FERRIPROX 4 Antidotes, deterrents, and toxicologic agents
FIRAZYR 4 Miscellaneous therapeutic agents
FOLOTYN 4 Antineoplastics/Antimetabolites
fondaparinux sodium 2.5mg/0.5ml 1, QL (31/31 days) Blood Products/Modifiers/Volume expanders/Anticoagulants
fondaparinux sodium injection 10mg/0.8ml; 5mg/0.4ml; 7.5mg/0.6ml 4 Blood Products/Modifiers/Volume expanders/Anticoagulants
gemcitabine hcl 4 Antineoplastics/Antimetabolites
gentamicin sulfate 1 Antibacterials/Aminoglycosides
GRALISE 3, QL (31/31 days), ST Analgesics
GRALISE starter 3, QL (31/31 days), ST Analgesics
hydrocodone bitartrate/acetaminophen 1 Analgesics/Opioid analgesics
imipenem/cilastatin 1 Antibacterials/Beta-lactam, other
INCIVEK 4, QL (186/31 days) Antivirals/Antihepatitis agents
JAKAFI 4, PA Antineoplastics
JUVISYNC 2, QL (31/31 days) Blood glucose regulators/Antidiabetic agents
lamivudine 1 Antivirals/Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors
lamivudine/zidovudine 1 Antivirals/Anti-HIV agents, nucleoside and nucleotide reverse transcriptase inhibitors
levetiracetam er 1 Anticonvulsants
levocetirizine dihydrochloride 1 Respiratory tract agents/antihistamines
Drug name Tier Category
morphine sulfate er capsule 100mg; 20mg; 60mg; 80mg 1, QL (62/31 days) Analgesics/Opioid analgesics
morphine sulfate er capsule 30mg; 50mg 1, QL (31/31 days) Analgesics/Opioid analgesics
olanzapine 1, QL (31/31 days) Antipsychotics/Atypicals
olanzapine odt 1, QL (31/31 days) Antipsychotics/Atypicals
ORENCIA 125mg/1ml 4, PA Immunological agents/Immune suppressants
PEGASYS PROCLICK 4 Immunological agents/Immunomodulators
PHOSLYRA 3 Genitourinary agents/Phosphate binders
SPRIX 3, QL (5/30 days) Analgesics/Nonsteroidal anti-inflammatory drugs
SYLATRON 4, PA Antineoplastics
TRADJENTA 3, QL (31/31 days), ST Blood glucose regulators/Antidiabetic agents
TRIGLIDE 160mg 3 Cardiovascular agents/Dyslipidemics
tropicamide 0.5% 1 Ophthalmic agents
VIVELLE-DOT 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens
XALKORI 4, PA, QL (62/31 days) Antineoplastics/Molecular target inhibitors
XARELTO 2, QL (31/31 days) Blood Products/Modifiers/Volume expanders/Anticoagulants
YERVOY 4, PA Antineoplastics/Monoclonal antibodies
ZELBORAF 4, PA, QL (248/31 days) Antineoplastics/Molecular target inhibitors
ZIRGAN 3 Antivirals/Antiherpetic agents

Changes to/removals from approved drug list:

Changes/deletions effective July 1, 2012
Drug name Tier Category Notes
ACTIVELLA tablet 0.1mg, 0.5mg 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Progestins Generic available: estradiol/norethindrone acetate
ANTABUSE 2 Antidotes, Deterrents, and Toxicologic agents Generic available: disulfiram, tier 1
ARIXTRA injection 2.5mg/0.5ml 3 Blood products/Modifiers/Volume expanders/Anticoagulants Generic available: fondaparinux sodium injection 2.5mg/0.5ml, tier 1
ARIXTRA injection 10mg/0.8ml 4 Blood products/Modifiers/Volume expanders/Anticoagulants Generic available: fondaparinux sodium injection 10mg/0.8ml, 5mg/0.4ml, 7.5mg/0.6ml, tier 4
COMBIVIR 4 Antivirals/Anti-HIV agents/Nucleoside and nucleotide reverse transcriptase inhibitors Generic available: lamivudine/zidovudine, tier 1
EPIVIR tablet 2 Antivirals/Anti-HIV Agents/Nucleoside and nucleotide reverse transcriptase inhibitors Generic available: lamivudine, tier 1
FELBATOL 3 Anticonvulsants/Glutamate reducing agents Generic available: felbamate, tier 1
FORTAMET 1000mg 2 Blood glucose regulators/Antidiabetic agents Generic available: metformin hcl er, tier 1
KEPPRA XR 3 Anticonvulsants Generic available: levetiracetam er, tier 1
LEVAQUIN injection 25mg/ml 2, HI Antibacterials/Quinolones Generic available: levofloxacin, tier 1
LEVAQUIN oral solution, tablet 2 Antibacterials/Quinolones Generic available: levofloxacin, tier 1
LIPITOR 3, ST Cardiovascular agents/Dyslipidemics Generic available: atorvastatin calcium, tier 1
LOSEASONIQUE 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Generic available: amethia lo, camrese lo, tier 1
LYBREL 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Generic available: amethyst, tier 1
MALARONE 2 Antiparasitics/Antiprotozoals Generic available: atovaquone/proguanil hcl, tier 1
NASACORT AQ 3 Respiratory tract agents/Anti-inflammatories, inhaled corticosteroids Generic available: triamcinolone acetonide, tier 1
RITALIN LA 20mg, 30mg, 40mg 3 Central nervous system agents/Non-amphetamines, ADHD Generic available: methylphenidate hcl er, tier 1
SEASONIQUE 2 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Generic available: amethia, camrese, tier 1
SURMONTIL 2 Antidepressants/Tricyclics Generic available: trimipramine maleate, tier 1
TAXOTERE 80mg/4 4 Antineoplastics Generic available: docetaxel, tier 4
TAXOTERE FNL 80mg/8 4 Antineoplastics Generic available: docetaxel, tier 4
TEVETEN 600mg 3, ST Cardiovascular agents/Renin-angiotensin-aldosterone system inhibitors Generic available: eprosartan mesylate, tier 1
UROXATRAL 3, ST Genitourinary agents/Benign prostatic hypertrophy agents Generic available: alfuzosin hcl er tablet, tier 1
XYZAL solution 3 Respiratory tract agents/Antihistamines Generic available: levocetirizine dihydrochloride, tier 1
ZYPREXA injection 2, QL (31/31 days) Antipsychotics/Atypicals Generic available: olanzapine, tier 1
ZYPREXA tablet 2, QL (31/31 days) Antipsychotics/Atypicals Generic available: olanzapine, tier 1
ZYPREXA zydis 2, QL (31/31 days) Antipsychotics/Atypicals Generic available: olanzapine odt, tier 1
Changes/deletions effective May 1, 2012
Drug name Tier Category Notes
CAPRELSA 100MG 4, PA Antineoplastics/Antiangiogenic agents Removed QL, tier 4
CAPRELSA 300MG 4, PA Antineoplastics/Antiangiogenic agents Removed QL, tier 4
GRALISE 3, QL (93/31 days) Analgesics Increased quantity limit, tier 3
Changes/deletions effective April 1, 2012
Drug name Tier Category Notes
calcitonin-salmon 1 Metabolic bone disease agent Added to ESRD - always list per CMS, B/D, tier 1
cyclosporine 100mg/ml oral solution 1, B/D Immunological agents/Immune suppressants Removed by CMS.
Alternate available: SANDIMMUNE oral solution, tier 2, B/D
fexofenadine hcl 1 Respiratory tract agents/Antihistamines Removed by CMS - drug is no longer made as prescription, OTC only.
Alternate available: levocetirizine dihydrochloride, tier 1
fortical 1 Metabolic bone disease agent Added to ESRD - always list per CMS, B/D, tier 1
MIACALCIN nasal solution 2 Metabolic bone disease agent Added to ESRD - always list per CMS, B/D, tier 2
minitran 1 Cardiovascular agents/Vasodilators Removed by CMS.
Alternate available: nitroglycerin transdermal, tier 1
Changes/deletions effective March 1, 2012
Drug name Tier Category Notes
ABILIFY injection 2, B/D Antipsychotics/Atypicals Remove B/D, tier 2
ADAGEN 4, B/D Enzyme replacements/Modifiers Remove B/D, tier 4
ALDURAZYME 4, B/D Enzyme replacements/Modifiers Remove B/D, tier 4
ALIMTA 4, B/D Antineoplastics Remove B/D, tier 4
allopurinol sodium 1, B/D Antigout agents Remove B/D, tier 1
ALORA 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Lowered from tier 3 to tier 2
amifostine 4, B/D Antineoplastics Remove B/D, tier 4
amikacin sulfate 1, B/D, HI Antibacterials/Aminoglycosides Remove B/D, tier 1, HI
aminophylline injection 1, B/D Respiratory tract agents/Bronchodilators, phosphodiesterase inhibitors (xanthines) Remove B/D, tier 1
amiodarone hcl injection 1, B/D Cardiovascular agents/Antiarrhythmics Remove B/D, tier 1
amphotericin b 1, B/D Antifungals Remove B/D, tier 1
ampicillin sodium injection 1, B/D, HI Antibacterials/Beta-lactam, penicillins Remove B/D, tier 1, HI
ampicillin-sulbactam 1, B/D, HI Antibacterials/Beta-lactam, penicillins Remove B/D, tier 1, HI
ARALAST NP 4, B/D Respiratory tract agents Remove B/D, tier 4
AVASTIN 4, B/D Antineoplastics Remove B/D, tier 4
AZACTAM in iso-osmotic dextrose 2, B/D, HI Antibacterials/Beta-lactam, other Remove B/D, tier 2, HI
bactocill in dextrose injection 1, B/D, HI Antibacterials/Beta-lactam, penicillins Remove B/D, tier 1, HI
BICNU 3, B/D Antineoplastics/Alkylating agents Remove B/D, tier 3
bleomycin sulfate 1, B/D Antineoplastics Remove B/D, tier 1
buprenorphine hcl injection 1, B/D, HI Analgesics/Opioid analgesics Remove B/D, tier 1, HI
BUSULFEX

3, B/D

 Antineoplastics/Alkylating agents Remove B/D, tier 3
Drug name Tier Category Notes
CAMPATH 4, B/D Antineoplastics monoclonal antibodies Remove B/D, tier 4
CANCIDAS 4, B/D Antifungals Remove B/D, tier 4
CAPASTAT SULFATE 2, B/D Antimycobacterials/Antituberculars Remove B/D, tier 2
carboplatin 1, B/D Antineoplastics Remove B/D, tier 1
cefazolin sodium injection 1, B/D, HI Antibacterials/Beta-lactam, cephalosporins Remove B/D, tier 1, HI
cefepime 1, B/D, HI Antibacterials/Beta-lactam, cephalosporins Remove B/D, tier 1, HI
cefotaxime sodium injection 1, B/D, HI Antibacterials/Beta-lactam, cephalosporins Remove B/D, tier 1, HI
cefoxitin sodium injection 1, B/D, HI Antibacterials/Beta-lactam, cephalosporins Remove B/D, tier 1, HI
ceftazidime 1, B/D, HI Antibacterials/Beta-lactam, cephalosporins Remove B/D, tier 1, HI
ceftriaxone sodium 1, B/D, HI Antibacterials/Beta-lactam, cephalosporins Remove B/D, tier 1, HI
cefuroxime sodium 1, B/D, HI Antibacterials/Beta-lactam, cephalosporins Remove B/D, tier 1, HI
CEREDASE 4, B/D Enzyme replacements/modifiers Remove B/D, tier 4
CEREZYME 2, B/D Enzyme replacements/modifiers Remove B/D, tier 2
chlorpromazine hcl injection 1, B/D Antipsychotics/Conventional Remove B/D, tier 1
chorionic gonadotropin 1, PA Hormonal agents, stimulant/replacement/modifying (pituitary) Remove PA, tier 1
cimetidine hcl injection 1, B/D Gastrointestinal agents/Histamine2 (H2) blocking agents Remove B/D, tier 1
cisplatin 1, B/D Antineoplastics Remove B/D, tier 1
cladribine 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
CLOLAR 3, B/D Antineoplastics/Antimetabolites Remove B/D, tier 3
colistimethate sodium 1, B/D, HI Antibacterials Remove B/D, tier 1, HI
COUMADIN injection 2, B/D Blood products/Modifiers/Volume expanders/Anticoagulants Remove B/D, tier 2
CYKLOKAPRON 2, B/D Blood products/Modifiers/Volume expanders/Coagulants Remove B/D, tier 2
cytarabine 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
cytarabine aqueous 1, B/D Antineoplastics/Alkylating agents Remove B/D, tier 1
dacarbazine 1, B/D Antineoplastics/Alkylating agents Remove B/D, tier 1
DACOGEN 4, B/D Antineoplastics Remove B/D, tier 4
daunorubicin hcl 1, B/D Antineoplastics Remove B/D, tier 1
DAUNOXOME 3, B/D Antineoplastics Remove B/D, tier 3
desmopressin acetate injection 1, B/D Hormonal agents, Stimulant/Replacement/Modifying (pituitary) Remove B/D, tier 1
dexamethasone sodium phosphate 1, B/D Hormonal agents, Stimulant/Replacement/Modifying (adrenal)/Glucocorticoids/Mineralocorticoids Remove B/D, tier 1
digoxin injection 1, B/D Cardiovascular agents Remove B/D, tier 1
diltiazem hcl injection 25mg/5ml 1, B/D Cardiovascular agents/Calcium channel blocking agents Remove B/D, tier 1
DIVIGEL 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Lowered from tier 3 to tier 2
docetaxel 4, B/D Antineoplastics Remove B/D, tier 4
DOXIL 4, B/D Antineoplastics Remove B/D, tier 4
doxorubicin hcl 1, B/D Antineoplastics Remove B/D, tier 1
doxycycline hyclate injection 1, B/D Antibacterials/Tetracyclines Remove B/D, tier 1
Drug name Tier Category Notes
ELITEK 3, B/D Antineoplastics/Antimetabolites Remove B/D, tier 3
epinephrine hcl 1, B/D Respiratory tract agents/Bronchodilators, Sympathomimetic Remove B/D, tier 1
ERAXIS 3, B/D Antifungals Remove B/D, tier 3
ERYTHROCIN LACTOBIONATE 2, B/D Antibacterials/Macrolides Remove B/D, tier 2
estradiol valerate 1, B/D Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Remove B/D, tier 1
EVAMIST 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Lowered from tier 3 to tier 2
FABRAZYME 4, B/D Enzyme replacements/Modifiers Remove B/D, tier 4
famotidine injection 1, B/D Gastrointestinal agents/Histamine2 (H2) blocking agents Remove B/D, tier 1
FASLODEX 4, B/D Antineoplastics/Antiestrogens/Modifiers Remove B/D, tier 4
fentanyl citrate 1, B/D, HI Analgesics/Opioid analgesics Remove B/D, tier 1, HI
fludarabine phosphate 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
fluorouracil 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
fluphenazine decanoate 1, B/D Antipsychotics/Conventional Remove B/D, tier 1
fluphenazine hcl injection 1, B/D Antipsychotics/Conventional Remove B/D, tier 1
foscarnet sodium 1, B/D Antivirals/Anti-cytomegalovirus (CMV) agents Remove B/D, tier 1
fosphenytoin sodium 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
furosemide injection 1, B/D Cardiovascular agents/Diuretics Remove B/D, tier 1
gentamicin sulfate/0.9% sodium chloride 1, B/D, HI Antibacterials/Aminoglycosides Remove B/D, tier 1, HI
GEODON injection 2, B/D Antipsychotics/Atypicals Remove B/D, tier 2
granisetron hcl injection 1, B/D, HI Antiemetics Remove B/D, tier 1, HI
HALAVEN 4, B/D Antineoplastics Remove B/D, tier 4
haloperidol decanoate 1, B/D Antipsychotics/Conventional Remove B/D, tier 1
haloperidol lactate 1, B/D Antipsychotics/Conventional Remove B/D, tier 1
heparin sodium/d5w 1, B/D Blood products/Modifiers/Volume expanders/Anticoagulants Remove B/D, tier 1
heparin sodium/nacl 0.45% 1, B/D Blood products/Modifiers/Volume expanders/Anticoagulants Remove B/D, tier 1
heparin sodium/sodium chloride 0.9% premix 1, B/D Blood products/Modifiers/Volume expanders/Anticoagulants Remove B/D, tier 1
HERCEPTIN 4, B/D Antineoplastics/Monoclonal antibodies Remove B/D, tier 4
hydralazine hcl injection 1, B/D Cardiovascular agents/Vasodilators Remove B/D, tier 1
hydromorphone hcl injection 1, B/D Analgesics/Opioid analgesics Remove B/D, tier 1
Drug name Tier Category Notes
ifosfamide 1, B/D Antineoplastics/Alkylating agents Remove B/D, tier 1
ifosfamide/mesna 1, B/D Antineoplastics/Alkylating agents Remove B/D, tier 1
INFUMORPH 500 2, B/D Analgesics/Opioid analgesics Remove B/D, tier 2
INVEGA SUSTENNA injection 117mg/0.75ml, 156mg/ml, 234mg/1.5ml 4, B/D Antipsychotics/Atypicals Remove B/D, tier 4
INVEGA SUSTENNA injection 39mg/0.25ml, 78mg/0.5ml 3, B/D Antipsychotics/Atypicals Remove B/D, tier 3
ISTODAX 4, B/D Antineoplastics Remove B/D, tier 4
labetalol hcl injection 1, B/D Cardiovascular agents/Beta-adrenergic blocking agents Remove B/D, tier 1
LEUKINE 4, B/D Blood products/Modifiers/Volume expanders/Blood formation products Remove B/D, tier 4
LEVAQUIN injection 25mg/ml 2, B/D, HI Antibacterials/Quinolones Remove B/D, tier 2, HI
levetiracetam injection 1, B/D Anticonvulsants Remove B/D, tier 1
LINCOCIN 3, B/D, HI Antibacterials Remove B/D, tier 3, HI
melphalan hydrochloride 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
MENOSTAR 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Estrogens Lowered from tier 3 to tier 2
MERREM 3, B/D Antibacterials/Beta-lactam Remove B/D, tier 3
methotrexate sodium 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
metoprolol tartrate injection 1, B/D Cardiovascular agents/Beta-adrenergic blocking agents Remove B/D, tier 1
metronidazole in nacl 0.79% 1, B/D, HI Antibacterials Remove B/D, tier 1, HI
morphine sulfate injection 1, B/D Analgesics/Opioid analgesics Remove B/D, tier 1
MUSTARGEN 3, B/D Antineoplastics/Alkylating agents Remove B/D, tier 3
MYCAMINE 4, B/D Antifungals Remove B/D, tier 4
Drug name Tier Category Notes
nafcillin sodium 1, B/D Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 1
NAGLAZYME 4, B/D Enzyme replacements/Modifiers enzyme replacements/Modifiers Remove B/D, tier 4
nalbuphine hcl 1, B/D, HI Analgesics/Opioid analgesics Remove B/D, tier 1, HI
naloxone hcl 1, B/D Antidotes, Deterrents, Toxicologic agents Remove B/D, tier 1
NEULASTA 4, B/D Blood products/Modifiers/Volume expanders/Blood formation products Remove B/D, tier 4
NEUMEGA 4, B/D Blood products/Modifiers/Volume expanders/Blood formation products Remove B/D, tier 4
NEXIUM IV 3, B/D Gastrointestinal agents/Proton pump inhibitors Remove B/D, tier 3
ondansetron hcl injection 1, B/D, HI Antiemetics Remove B/D, tier 1, HI
ORENCIA 250mg 4, B/D Immunological agents/Immune suppressants Remove B/D, tier 4
orphenadrine citrate injection 1, B/D Skeletal muscle relaxants Remove B/D, tier 1
ORTHOCLONE OKT3 3, B/D Antineoplastics/Antimetabolites Remove B/D, tier 3
oxacillin sodium 1, B/D, HI Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 1, HI
penicillin g potassium 1, B/D, HI Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 1, HI
penicillin g potassium in iso-osmotic dextrose 1, B/D, HI Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 1, HI
penicillin g procaine 1, B/D Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 1
penicillin g sodium 1, B/D Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 1
pentostatin 1, B/D Antineoplastics/Antimetabolites Remove B/D, tier 1
phenytoin sodium 1, B/D Anticonvulsants/Sodium channel inhibitors Remove B/D, tier 1
piperacillin sodium 1, B/D, HI Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 1, HI
PRIMAXIN IM 3, B/D Antibacterials/Beta-lactam, other Remove B/D, tier 3
PRIMAXIN IV 2, B/D, HI Antibacterials/Beta-lactam, other Remove B/D, tier 2, HI
prochlorperazine edisylate 1, B/D Antiemetics Remove B/D, tier 1
promethazine hcl injection 25mg/ml 1, B/D Antiemetics Remove B/D, tier 1
propranolol hcl injection 1, B/D Cardiovascular agents/Beta-adrenergic blocking agents Remove B/D, tier 1
rifampin injection 1, B/D Antimycobacterials/Antituberculars Remove B/D, tier 1
RISPERDAL CONSTA 3, B/D Antipsychotics/Atypicals Remove B/D, tier 3
SANDOSTATIN LAR DEPOT 4, B/D Hormonal Agents, Suppressant (pituitary) Remove B/D, tier 4
SIMULECT 3, B/D Antineoplastics/Antimetabolites Remove B/D, tier 3
sulfamethoxazole/trimethoprim injection 1, B/D Antibacterials/Sulfonamides Remove B/D, tier 1
Drug name Tier Category Notes
TAXOTERE 4, B/D Antineoplastics Remove B/D, tier 4
tazicef 1, B/D, HI Antibacterials/Beta-lactam, Cephalosporins Remove B/D, tier 1, HI
terbutaline sulfate injection 1, B/D Respiratory tract agents/Bronchodilators, Sympathomimetic Remove B/D, tier 1
testosterone cypionate 1, B/D Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Androgens Remove B/D, tier 1
testosterone enanthate 1, B/D Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers)/Androgens Remove B/D, tier 1
thiotepa 1, B/D Antineoplastics/Alkylating agents Remove B/D, tier 1
tobramycin sulfate injection 1, B/D, HI Antibacterials/Aminoglycosides Remove B/D, tier 1, HI
tobramycin sulfate/sodium chloride 1, B/D, HI Antibacterials/Aminoglycosides Remove B/D, tier 1, HI
topotecan hcl 4, B/D Antineoplastics Remove B/D, tier 4
TREANDA 4, B/D Antineoplastics/Alkylating agents Remove B/D, tier 4
TRELSTAR MIXJECT 4, B/D Hormonal Agents, Suppressant (pituitary) Remove B/D, tier 4
TYGACIL 2, B/D, HI Antibacterials Remove B/D, tier 2, HI
valproate sodium 1, B/D Anticonvulsants/Gamma-aminobutyric acid (GABA) augmenting agents Remove B/D, tier 3
VFEND IV 3, B/D Antifungals Remove B/D, tier 3
VIMPAT INJECTION 3, B/D Anticonvulsants Remove B/D, tier 3
VIVELLE-DOT patch bi-weekly 0.0375mg/24hr 3 Hormonal agents, stimulant/replacement/modifying (sex hormones/modifiers) Lowered from tier 3 to tier 2
ZANOSAR 3, B/D Antineoplastics/Alkylating Agents Remove B/D, tier 3
ZOSYN 3, B/D, HI Antibacterials/Beta-lactam, Penicillins Remove B/D, tier 3, HI
ZYPREXA injection 2, QL (31/31 days), B/D Antipsychotics/Atypicals Remove B/D, tier 2, QL (31/31 days)

Return to top

« return to home page




You need to install a Flash plugin to see this video.