Additions-Effective March 1, 2014 Drug Name Tier Limitations
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1 Additions-Effective March 1, 2014 Drug Name Tier Limitations ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 2 QL (60 per 30 days) ACAMPROSATE CALCIUM DR 2 QL (180 per 30 days) ACCUPRIL 4 ACCUPRIL 4 ACCUPRIL 4 ACCUPRIL 4 ACCURETIC 4 ACCURETIC 4 ACCURETIC 4 ACITRETIN 2 ACITRETIN 2 ACITRETIN 2 ACTEMRA 5 PA ACTOPLUS MET 4 QL (90 per 30 days) ACTOPLUS MET 4 QL (90 per 30 days) ACTOS 4 QL (30 per 30 days) ACTOS 4 QL (30 per 30 days) ACTOS 4 QL (30 per 30 days) ADEFOVIR DIPIVOXIL 5 QL (30 per 30 days) ADRENALIN 2 AEROSPAN 4 AFINITOR DISPERZ 5 QL (120 per 30 days); PA AFINITOR DISPERZ 5 QL (120 per 30 days); PA AFINITOR DISPERZ 5 QL (120 per 30 days); PA ALTACE 4 ALTACE 4 ALTACE 4 ALTACE 4 AMARYL 4 QL (120 per 30 days) AMARYL 4 QL (240 per 30 days) AMARYL 4 QL (60 per 30 days) ANGELIQ 3 PA ASTAGRAF XL 4 B/D PA ASTAGRAF XL 4 B/D PA ASTAGRAF XL 4 B/D PA ATACAND HCT 4 QL (30 per 30 days) ATACAND HCT 4 QL (30 per 30 days) ATACAND HCT 4 QL (30 per 30 days)
2 AVALIDE 4 QL (30 per 30 days) AVALIDE 4 QL (30 per 30 days) AVAPRO 4 QL (30 per 30 days) AVAPRO 4 QL (30 per 30 days) AVAPRO 4 QL (30 per 30 days) AZACITIDINE 5 BCG VACCINE 4 BONIVA 4 QL 1 per 28 days) BREO ELLIPTA 3 BRINTELLIX 4 BRINTELLIX 4 BRINTELLIX 4 CANDESARTAN CILEXETIL 1 QL (30 per 30 days) CANDESARTAN CILEXETIL 1 QL (30 per 30 days) CANDESARTAN CILEXETIL 1 QL (30 per 30 days) CANDESARTAN CILEXETIL 1 QL (30 per 30 days) CEFOTAXIME SODIUM 2 CEFOTAXIME SODIUM 2 CEFOTAXIME SODIUM 2 CELEXA 4 QL (90 per 30 days) CELEXA 4 QL (30 per 30 days) CELEXA 4 QL (60 per 30 days) CLINDAMYCIN PALMITATE HCL 2 CLONIDINE HCL ER 2 COZAAR 4 QL (30 per 30 days) COZAAR 4 QL (30 per 30 days) COZAAR 4 QL (30 per 30 days) DECITABINE 5 DEXMETHYLPHENIDATE HCL ER 2 QL (30 per 30 days) DEXMETHYLPHENIDATE HCL ER 2 QL (30 per 30 days) DEXMETHYLPHENIDATE HCL ER 2 QL (30 per 30 days) DICLOFENAC SODIUM 2 QL (100 per 30 days); PA DIOVAN HCT 4 QL (30 per 30 days) DIOVAN HCT 4 QL (30 per 30 days) DIOVAN HCT 4 QL (30 per 30 days) DIOVAN HCT 4 QL (30 per 30 days)
3 DIOVAN HCT 4 QL (30 per 30 days) DONEPEZIL HCL 2 QL (30 per 30 days) DUETACT 4 QL (30 per 30 days) DUETACT 4 QL (30 per 30 days) DULOXETINE HCL 2 QL (180 per 30 days) DULOXETINE HCL 2 QL (120 per 30 days) DULOXETINE HCL 2 QL (60 per 30 days) EFFEXOR XR 4 QL (90 per 30 days) EFFEXOR XR 4 QL (30 per 30 days) EFFEXOR XR 4 QL (30 per 30 days) EPANED 4 ESTRADIOL 2 QL (4 per 30 days); PA ESTRADIOL 2 QL (4 per 30 days); PA ESTRADIOL 2 QL (8 per 30 days); PA ESTRADIOL 2 QL (8 per 30 days); PA ESTRADIOL 2 QL (4 per 30 days); PA ESTRADIOL 2 QL (4 per 30 days); PA FENOFIBRATE 2 QL (30 per 30 days) FENOFIBRATE 2 QL (30 per 30 days) FENOFIBRIC ACID DR 2 QL (30 per 30 days) FENOFIBRIC ACID DR 2 QL (30 per 30 days) FETZIMA 4 FETZIMA 4 FETZIMA 4 FETZIMA 4 FETZIMA TITRATION PACK 4 FOSAMAX 4 FYCOMPA 4 FYCOMPA 4 FYCOMPA 4 FYCOMPA 4 GATIFLOXACIN 2 GENTAMICIN SULFATE 2 GILOTRIF 5 PA GILOTRIF 5 PA GILOTRIF 5 PA GLUCOPHAGE 4 QL (60 per 30 days) GLUCOPHAGE 4 QL (150 per 30 days) GLUCOPHAGE 4 QL (90 per 30 days) GLUCOPHAGE XR 4 QL (120 per 30 days) GLUCOPHAGE XR 4 QL (60 per 30 days) GLUCOTROL 4 QL (240 per 30 days) GLUCOTROL 4 QL (120 per 30 days) GLUCOTROL XL 4 QL (60 per 30 days) GLUCOTROL XL 4 QL (240 per 30 days) GLUCOTROL XL 4 QL (120 per 30 days) HYDROCORTISONE BUTYRATE (LIPOPHILIC) 2
4 HYZAAR 4 QL (30 per 30 days) HYZAAR 4 QL (30 per 30 days) HYZAAR 4 QL (30 per 30 days) IMBRUVICA 5 PA INTELENCE 4 JUXTAPID 5 PA JUXTAPID 5 PA JUXTAPID 5 PA KHEDEZLA 4 QL (30 per 30 days) KHEDEZLA 4 QL (30 per 30 days) LANOXIN 4 LANOXIN 4 LANOXIN 4 LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN 2 LATUDA 4 QL (30 per 30 days) LESCOL 4 QL (30 per 30 days) LESCOL 4 QL (60 per 30 days) LEXAPRO 4 QL (45 per 30 days) LEXAPRO 4 QL (30 per 30 days) LEXAPRO 4 QL (30 per 30 days) LEXAPRO 4 QL (600 per 30 days) LIDOCAINE 2 QL (90 per 30 days) LIPITOR 4 QL (30 per 30 days) LIPITOR 4 QL (30 per 30 days) LIPITOR 4 QL (45 per 30 days) LIPITOR 4 QL (30 per 30 days) LIPTRUZET 4 LIPTRUZET 4 LIPTRUZET 4 LIPTRUZET 4 LO MINASTRIN FE 4 LOMUSTINE 4 LOMUSTINE 4 LOMUSTINE 4 LOTENSIN 4 LOTENSIN 4 LOTENSIN HCT 4 LOTENSIN HCT 4 LOTENSIN HCT 4 LYZA 2 METAXALONE 2 PA
5 METHYLPHENIDATE HCL ER 2 QL (30 per 30 days) METRONIDAZOLE 2 MORPHINE SULFATE ER 2 NAFTIN 3 NORETHINDRONE 2 NORTRIPTYLINE HCL 2 NOXAFIL 3 PA NUVIGIL 4 QL (30 per 30 days) NUVIGIL 4 QL (30 per 30 days) NUVIGIL 4 QL (30 per 30 days) ONFI 3 OXYCODONE HCL 2 PARICALCITOL 2 PARICALCITOL 2 PARICALCITOL 2 PHENADOZ 2 PA PIMTREA 2 PIRMELLA 1/35 2 PRAVACHOL 4 QL (30 per 30 days) PRAVACHOL 4 QL (60 per 30 days) PRAVACHOL 4 QL (30 per 30 days) PROLENSA 4 PROZAC 4 QL (120 per 30 days) PROZAC 4 QL (240 per 30 days) PROZAC 4 QL (60 per 30 days) QUARTETTE 4 QL (91 per 91 days) RABEPRAZOLE SODIUM 2 QL (30 per 30 days) REGRANEX 4 REPAGLINIDE 1 QL (120 per 30 days) REPAGLINIDE 1 QL (120 per 30 days) REPAGLINIDE 1 QL (240 per 30 days) REVLIMID 5 QL (28 per 28 days); PA REVLIMID 5 QL (28 per 28 days); PA SIMBRINZA 3 SIMPONI ARIA 5 QL (1 per 30 days); PA STARLIX 4 QL (90 per 30 days) STARLIX 4 QL (90 per 30 days) STRIANT 4 PA TEVETEN 4 TIVICAY 5 TOBRAMYCIN 5 B/D PA TOPROL XL 4 TOPROL XL 4 TOPROL XL 4 TOPROL XL 4 TRIAMTERENE/HYDROCHLOROTHIAZIDE 2 VASERETIC 4
6 VASOTEC 4 VASOTEC 4 VASOTEC 4 VASOTEC 4 VERSACLOZ 3 VESTURA 2 VORICONAZOLE 2 QL (300 per 30 days) WELLBUTRIN 4 WELLBUTRIN 4 WELLBUTRIN SR 4 QL (60 per 30 days) WELLBUTRIN SR 4 QL (60 per 30 days) WELLBUTRIN SR 4 QL (60 per 30 days) WELLBUTRIN XL 4 QL (90 per 30 days) WELLBUTRIN XL 4 QL (30 per 30 days) ZOCOR 4 QL (30 per 30 days) ZOCOR 4 QL (30 per 30 days) ZOCOR 4 QL (30 per 30 days) ZOCOR 4 ZOCOR 4 QL (30 per 30 days) ZOLOFT 4 QL (60 per 30 days) ZOLOFT 4 QL (90 per 30 days) ZOLOFT 4 QL (60 per 30 days) ZOLOFT 4 QL (300 per 30 days) ZOMIG 4 QL (8 per 30 days) Modifications-Effective March 1, 2014 Tradename Tier Limitations Comments ACTONEL 4 QL (1 per 30 days) Step Therapy Removed ACTONEL 4 QL (30 per 30 days) Step Therapy Removed ACTONEL 4 QL (30 per 30 days) Step Therapy Removed ACTONEL 4 QL (4 per 28 days) Step Therapy Removed ALENDRONATE SODIUM 2 QL (4 per 28 days) Step Therapy Removed ALENDRONATE SODIUM 2 QL (30 per 30 days) Step Therapy Removed ALENDRONATE SODIUM 2 QL (30 per 30 days) Step Therapy Removed ALENDRONATE SODIUM 2 QL (30 per 30 days) Step Therapy Removed ALENDRONATE SODIUM 2 QL (4 per 28 days) Step Therapy Removed ALENDRONATE SODIUM 2 Step Therapy Removed ALPRAZOLAM 2 QL (90 per 30 days) PA removed ALPRAZOLAM 2 QL (150 per 30 days) PA removed ALPRAZOLAM 2 QL (90 per 30 days) PA removed ALPRAZOLAM 2 QL (90 per 30 days) PA removed ATELVIA 4 QL (4 per 28 days) Step Therapy Removed BENTYL 4 PA removed CHLORDIAZEPOXIDE HCL 2 QL (120 per 30 days) PA removed CHLORDIAZEPOXIDE HCL 2 QL (120 per 30 days) PA removed CHLORDIAZEPOXIDE HCL 2 QL (120 per 30 days) PA removed DEXMETHYLPHENIDATE HCL 2 QL (60 per 30 days) PA removed
7 DEXMETHYLPHENIDATE HCL 2 QL (60 per 30 days) PA removed DEXMETHYLPHENIDATE HCL 2 QL (60 per 30 days) PA removed DICYCLOMINE HCL 2 PA removed DICYCLOMINE HCL 2 PA removed DICYCLOMINE HCL 2 PA removed DIOVAN 3 QL (30 per 30 days) Move to Tier 3 DIOVAN 3 QL (30 per 30 days) Move to Tier 3 DIOVAN 3 QL (30 per 30 days) Move to Tier 3 DIOVAN 3 QL (30 per 30 days) Move to Tier 3 DIPHENOXYLATE/ATROPINE 2 PA removed DIPHENOXYLATE/ATROPINE 2 PA removed EPROSARTAN MESYLATE 2 QLL removed ESTAZOLAM 2 QL (30 per 30 days) PA removed ESTAZOLAM 2 QL (30 per 30 days) PA removed FLURAZEPAM HCL 2 QL (30 per 30 days) PA removed FLURAZEPAM HCL 2 QL (30 per 30 days) PA removed HUMALOG MIX 50/50 4 QL (60 per 30 days) Step Therapy Removed IBANDRONATE SODIUM 2 Step Therapy Removed INVOKANA 3 Move to Tier 3 INVOKANA 3 Move to Tier 3 LIDODERM 4 QL (90 per 30 days) PA removed METADATE ER 2 QL (90 per 30 days) PA removed METHYLPHENIDATE HCL 2 QL (90 per 30 days) PA removed METHYLPHENIDATE HCL 2 QL (90 per 30 days) PA removed METHYLPHENIDATE HCL 2 QL (90 per 30 days) PA removed METHYLPHENIDATE HCL ER 2 QL (60 per 30 days) PA removed METHYLPHENIDATE HCL ER 2 QL (30 per 30 days) PA removed METHYLPHENIDATE HCL ER 2 QL (60 per 30 days) PA removed METHYLPHENIDATE HCL ER 2 QL (60 per 30 days) PA removed METHYLPHENIDATE HCL ER 2 QL (60 per 30 days) PA removed METHYLPHENIDATE HCL ER 2 QL (30 per 30 days) PA removed METHYLPHENIDATE HCL ER 2 QL (90 per 30 days) PA removed METHYLPHENIDATE HYDROCHLORIDE 2 QL (1080 per 30 days) PA removed METHYLPHENIDATE HYDROCHLORIDE 2 QL (2160 per 30 days) PA removed MODAFINIL 2 QL (60 per 30 days) PA removed MODAFINIL 2 QL (150 per 30 days) PA removed OXAZEPAM 2 QL (120 per 30 days) PA removed OXAZEPAM 2 QL (120 per 30 days) PA removed OXAZEPAM 2 QL (120 per 30 days) PA removed
8 PROLIA 4 QL ( per days) PA removed RITALIN LA 4 QL (90 per 30 days) PA removed ROZEREM 2 QL (30 per 30 days) Move to Tier 2 TRANSDERM-SCOP 4 PA removed TRIAZOLAM 2 QL (30 per 30 days) PA removed TRIAZOLAM 2 QL (30 per 30 days) PA removed Deletions-Effective March 1, 2014 Tradename Dosage Reason for Change ASACOL 400MG The medication will no ENDOCET 500MG; 7.5MG The medication will no ENDOCET 650MG; 10MG The medication will no TYZINE 0.1% The medication will no ICLUSIG 15MG The medication will no ICLUSIG 45MG The medication will no LEUKINE 500MCG/ML The medication will no TOBRAMYCIN SULFATE/SODIUM CHLORIDE 0.9%; 1.2MG/ML The medication will no CELESTONE 0.6MG/5ML The medication will no FREAMINE III The medication will no PREZISTA 400MG The medication will no COMBIVENT 103MCG/ACT; 18MCG/ACT The medication will no
9 HYDROCODONE/ACETAMINOPHEN 500MG; 2.5MG The medication will no ONSOLIS 1200MCG The medication will no ONSOLIS 200MCG The medication will no ONSOLIS 400MCG The medication will no ONSOLIS 600MCG The medication will no ONSOLIS 800MCG The medication will no ELSPAR 10000UNIT The medication will no LEVOTHROID 25MCG The medication will no LEVOTHROID 50MCG The medication will no LEVOTHROID 75MCG The medication will no LEVOTHROID 88MCG The medication will no LEVOTHROID 100MCG The medication will no LEVOTHROID 112MCG The medication will no LEVOTHROID 137MCG The medication will no LEVOTHROID 150MCG The medication will no LEVOTHROID 175MCG The medication will no
10 LEVOTHROID 200MCG The medication will no LEVOTHROID 300MCG The medication will no LEVOTHROID 125MCG The medication will no MAXAIR AUTOHALER 200MCG/INH The medication will no ORPHENADRINE/ASA/CAFFEINE 385MG; 30MG; 25MG The medication will no
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