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Medica Drug ListPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN YOUR PLAN.PLEASE NOTE, HOWEVER, THAT CERTAIN DRUGS ON THIS LIST MAY BE EXCLUDED UNDER YOUR SPECIFICPLAN DESIGN. PLEASE REFER TO YOUR COVERAGE DOCUMENTS TO DETERMINE SPECIFIC BENEFIT LEVELS.PLEASE NOTE: This list is subject to change and is not all-inclusive. Please review this document and contact MedicaCustomer Service with questions.The coverage level for prescription drugs is generally higher when a member receives them at an in-networkpharmacy, and, for some plans, members must use network pharmacies to receive prescription drug benefits. Planterms vary and members should consult their benefit plan documents for specific coverage information.Prior authorization may be required to obtain coverage for certain drugs on this list. Brand name drugs are listed inCAPITAL letters. Generic drugs are listed in italicized lower case letters. The coverage level of brand name drugs maychange when a generic equivalent or interchangeable biosimilar becomes available.If you have questions, please call the Medica Customer Service number listed on the back of your ID card.1
What is a Drug List?The Medica Drug List is comprised of drugs that meet the medical needs of our members and have proven safety andeffectiveness. It includes both brand name and generic drugs. The drugs on this list have been approved by the Foodand Drug Administration (FDA). A team of physicians and pharmacists meets regularly to review and update the list.Your doctor can use this list to select medications for your health care needs, while helping you maximize yourprescription drug benefit.Are both brand name and generic drugs on the list?Yes. The Drug List includes brand name and generic drugs from most therapeutic classifications.The terms “generic” and “brand name” are used in the health care industry in different ways. To better understandyour coverage, please review the following:Generic: A drug: (1) that contains the same active ingredient as a brand name drug and is chemically equivalent to abrand name drug in strength, concentration, dosage form and route of administration; or (2) that Medica identifies asa generic product. Medica uses industry standard resources to determine a drug’s classification as either brand nameor generic. Not all products identified as “generic” by the manufacturer, pharmacy or your provider may be classifiedby Medica as generic.Brand: A drug: (1) that is manufactured and marketed under a trademark or name by a specific drug manufacturer; or(2) that Medica identifies as a brand name product. Medica uses industry standard resources to determine a drug’sclassification as either brand name or generic. Not all products identified as “brand name” by the manufacturer,pharmacy or your provider may be classified by Medica as brand name.Preferred brand drugs on the Drug List have a higher copayment or coinsurance. You may consider a preferred brandcovered drug to treat your condition if you and your provider decide it is appropriate.Non-preferred brand drugs have the highest copayment or coinsurance. The covered non-preferred brand drugs areusually more costly.If you have questions about Medica’s Drug List or whether a specific drug is covered (and/or whether the drug is ageneric, preferred brand, or non-preferred brand), or if you would like to request a copy of the Medica Drug List at nocharge, call Customer Service at one of the telephone numbers listed inside the front cover of your benefit plandocument.Does the Drug List ever change?The Medica Drug List can change during the course of a calendar year. Medica strives to limit these changes.Examples of when changes may occur include when a new, less expensive generic drug becomes available or whennew adverse information about the safety or effectiveness of a drug is released.Certain drugs on the Drug List may be excluded under your specific plan design. Please refer to your benefit plandocument to determine specific benefit levels.2
How do I use the Drug List?There are two ways to find your drug within the Drug List:Drug CategoryThe Drug List begins on Page 7. The drugs in this Drug List are grouped into categories depending on theirclinical classification. For example, drugs that are considered “anti-infectives” will be listed under the “antiinfectives” category. If you know how your drug is classified, look for the category name in the list. Then lookunder the category name for your drug.Alphabetical ListingThe Drug List Index provides an alphabetical list of all of the drugs included in this document. Both brandname drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug,you will see the page number where you can find coverage information. Turn to the page listed in the Indexand find the name of your drug in the first column of the list.Preventive Drug and Supply Medications (ACA)Medications displayed as “Tier 6” in the Drug Tier column are defined as preventive health services under theAffordable Care Act (ACA) and are provided without member cost sharing. If your benefit includes mail order, pleasenote that some preventive drugs and supplies may not be available through this service.Please Note: Your benefit plan defines the level of coverage.Remember, just because a drug that you take is listed on the Drug List does not mean that your benefit plan coversthat medication. If you have questions, please refer to your benefit plan document or call the Medica CustomerService phone number listed on the back of your ID card to determine what level of coverage you have.Note: To Search the Drug List, use ctrl F on your keyboard and type in the search term.3
Are there any restrictions on my coverage?For some prescriptions there are special requirements that must be met in order to receive coverage. These include:Prior authorization (PA)Certain drugs require prior authorization (approval in advance) from Medica in order to be covered. Thesemedications are shown on the Drug List with the abbreviation “PA.” The Drug List is available to providers, includingpharmacies. Your network provider who prescribes the drug should initiate the prior authorization process. You willpay the entire cost of the drug received if you do not meet Medica’s authorization criteria.Step therapy (ST)Step therapy is a process that involves trying an alternative covered drug first (typically a generic drug) before movingto a preferred brand or non-preferred brand covered drug for treatment of the same medical condition. Themedications subject to step therapy are shown on the Medica Drug List with the abbreviation “ST.” You must meetapplicable step therapy requirements before Medica will cover these preferred brand or non-preferred brand drugs.Quantity limits (QL)Certain covered drugs have limits on the maximum quantity allowed per prescription over a specific time period. Themedications subject to quantity limits are shown on the Medica Drug List with the abbreviation “QL.” Some quantitylimits are based on the manufacturer’s packaging, FDA labeling or clinical guidelines.Medical Benefit (MB)Certain drugs fall under the medical benefits rather than pharmacy benefits. These drugs require administration byhealthcare professionals in a physician’s office, outpatient hospital or home infusion setting. The medications subjectto medical benefit coverage may be shown on the Medica Drug List with the abbreviation “MB”.Pharmacy requirementCertain self-administered and cancer treatment medications must be obtained from a Medica-designated specialtypharmacy in order to be covered.Can I request an exception to the coverage restrictions?Yes. Your doctor can find the information they need to make a request on your behalf on Medica’s website. Tofacilitate a thorough review, Medica asks that all information requested in the form be provided, includingdocumentation of which medications have been tried and failed, including the dosages used, and the identified reasonfor failure (e.g. side effects, lack of efficacy).4
Specialty Program (SP)Certain drugs are available only through your Specialty Pharmacy benefit. Specialty medications are high-technology,high cost, oral or injectable drugs used for the treatment of certain diseases that require complex therapies. Manyspecialty medications require special handling and in most cases are prescribed by a specialist.In order to receive a specialty medication, you must utilize Accredo Specialty Pharmacy (Medica’s designated specialtypharmacy).Limited Availability Drugs (LA)In certain circumstances, select medications may only be available at certain pharmacies. Limited availability (LA) orlimited distribution drugs (LDD) are medications that may have special dosing or lab monitoring requirements thatneed to be followed very closely. Because of this, the manufacturer sometimes chooses to limit the distribution of itsdrug to only a few pharmacies, or as part of the drug approval process the FDA may recommend this type ofdistribution in order for the drug to be approved. This type of restricted distribution helps the manufacturer keeptrack of drug inventory, properly educate dispensing pharmacists about any necessary monitoring, and ensure thatany risks that are associated with the LA drugs are minimized.Your provider typically knows where to send prescriptions for limited availability drugs, but if you have any questions,reach out to Accredo Specialty Pharmacy and they will assist you in which specialty pharmacies can dispense the drugyou need.Oral Oncology MedicationsOral drugs for the treatment of cancer are restricted to the Specialty Pharmacy Network (or LDD designatedpharmacy), but are not subject to the specialty prescription drug copay. Oral oncology specialty medications aresubject to the applicable outpatient prescription drug copay as outlined in your benefit plan document.PLEASE NOTE: Reference the Specialty Drug List on Medica’s website for further information.Coverage LimitationsProton Pump Inhibitors (PPI): Coverage limitations may apply to these medications. Inclusion in the MedicaDrug List does not imply coverage. You should refer to your benefit plan document for further information.Human Growth Hormones (GH): Coverage limitations may apply to these medications. Inclusion in theMedica Drug List does not imply coverage. You should refer to your benefit plan document for furtherinformation.Non-Sedating Antihistamines (NSA): Coverage limitations may apply to these medications. Inclusion in theMedica Drug List does not imply coverage. You should refer to your benefit plan document for furtherinformation.Erectile Dysfunction Drugs (ED): Coverage limitations may apply to these medications. Inclusion in theMedica Drug List does not imply coverage. You should refer to your benefit plan document for furtherinformation.Infertility Drugs (INF): Coverage limitations may apply to these medications. Inclusion in the Medica DrugList does not imply coverage. You should refer to your benefit plan document for further information.5
AbbreviationsAbbreviation/NotePACoverage Notes AbbreviationsDescriptionExplanationUtilization Management RestrictionsPrior Authorization RestrictionYour healthcare provider isrequired to get priorauthorization from Medicabefore you fill your prescriptionfor this drug. Without priorapproval, Medica may not coverthis drug.QLQuantity Limit RestrictionMedica limits the amount of thisdrug that is covered perprescription, or within a specifictime frame.STStep Therapy RestrictionBefore Medica will providecoverage for this drug, you mustfirst try another drug(s) to treatyour medical condition. This drugmay only be covered if the otherdrug(s) does not work for you.MBMedical BenefitTier 1 GenericsThese drugs requireadministration by healthcareprofessionals in a physician’soffice, outpatient hospital orhome infusion setting and willfall under your medical benefitcoverage rather than pharmacybenefits.Other Special Requirements for CoverageThis prescription is available at your Generic benefit.Tier 2 Preferred BrandsTier 3 Non-Preferred BrandsTier 4 Specialty Prescription DrugsTier 6 ACA Preventive DrugsThis prescription is available at your Preferred Brandbenefit.This prescription is available at your Non-PreferredBrand benefit.This prescription is available at your Specialty benefit.This prescription is available at your Preventive HealthService benefit.6
Table of ContentsANTI - INFECTIVES .8ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .13AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH.16CARDIOVASCULAR, HYPERTENSION & LIPIDS.28DERMATOLOGICALS/TOPICAL THERAPY .34DIAGNOSTICS & MISCELLANEOUS AGENTS .42EAR, NOSE & THROAT MEDICATIONS.44ENDOCRINE/DIABETES .45GASTROENTEROLOGY .51IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .56MUSCULOSKELETAL & RHEUMATOLOGY.59OBSTETRICS & GYNECOLOGY.60OPHTHALMOLOGY .65RESPIRATORY, ALLERGY, COUGH & COLD .70UROLOGICALS.74VITAMINS, HEMATINICS & ELECTROLYTES .75Index .797
Drug NameDrugTierRequirements/ LimitsDrug NameDrugTierANTI - INFECTIVESabacavir-lamivudine4ANTIFUNGAL AGENTSabacavirlamivudinezidovudine4acyclovir oralcapsule1clotrimazole mucousmembrane1CRESEMBA ORAL2fluconazole oralsuspension forreconstitution1acyclovir oralsuspension 200 mg/5ml1fluconazole oraltablet 100 mg, 200mg, 50 mg1acyclovir oral tablet1adefovir1fluconazole oraltablet 150 mg1amantadine rosize1BARACLUDEORAL O4itraconazole oralcapsule1DESCOVY4itraconazole oralsolution14ketoconazole oral1didanosine oralcapsule,delayedrelease(dr/ec) 250mg, 400 mgNOXAFIL ORALSUSPENSION2DOVATO4EDURANT4nystatin ov4posaconazole oraltablet,delayedrelease (dr/ec)efavirenz-lamivutenofov disop4terbinafine hcl oral1emtricitabine4voriconazole oral1PAQLQLPAPARequirements/ LimitsPAANTIVIRALSabacavir4January 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.8
Drug NameDrugTieremtricitabinetenofovir (tdf) oraltablet 100-150 mg,133-200 mg, 167250 mg4emtricitabinetenofovir (tdf) oraltablet 200-300 mg6EMTRIVA ORALSOLUTION4entecavir1EPCLUSA ORALTABLET4EPIVIR HBVORAL ONSUBCUTANEOUSRECON SOLNRequirements/ LimitsDrug NameDrugTierRequirements/ Limitslamivudine oraltablet 150 mg, 300mg4lamivudinezidovudine4LEXIVA IR ORALPOWDER INPACKET4NORVIR ORALSOLUTION4ODEFSEY4oseltamivir1QLPREVYMIS ORAL2QL4PREZISTA ORALSUSPENSION44GENVOYA4HARVONI4PREZISTA ORALTABLET 150 MG,600 MG, 75 MG,800 MGINTELENCE ORALTABLET 25 MG4RELENZADISKHALER3INVIRASE ORALTABLET44ISENTRESS4REYATAZ ORALPOWDER INPACKETISENTRESS HD4ribavirin inhalation1JULUCA4rimantadine1lamivudine oralsolution4ritonavir4SELZENTRY4lamivudine oraltablet 100 mg1stavudine oralcapsule 15 mg, 20mg, 40 mg4SYMTUZA4ACAPA; SP; QLQLPA; SP; QLQLJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.9
Drug NameDrugTierTEMIXYS4tenofovir disoproxilfumarate4TIVICAYRequirements/ LimitsDrug NameDrugTier14cefadroxil oralsuspension forreconstitution 250mg/5 ml, 500 mg/5mlTIVICAY PD4cefadroxil oral lin injectionrecon soln 1 gram,10 gram, 20 gram,500 mgVEMLIDY2cefdinir1VIRACEPT ORALTABLET4cefditoren pivoxil1VIRAZOLE3cefixime1VIREAD ORALPOWDER4cefpodoxime1cefprozil1VIREAD ORALTABLET 150 MG,200 MG, 250 MG4cefuroxime axetiloral tablet1cephalexin1VOSEVI4PA; SP; QL3XOFLUZA3QLZEPATIER4PA; SP; QLSUPRAX ORALSUSPENSION FORRECONSTITUTION 500 MG/5 MLzidovudine4SUPRAX ORALTABLET,CHEWABLE3CEPHALOSPORINScefaclor oral capsule1cefaclor oralsuspension forreconstitution 125mg/5 ml, 250 mg/5ml, 375 mg/5 ml1cefaclor oral tabletextended release 12hr1cefadroxil oralcapsule1QLRequirements/ LimitsERYTHROMYCINS & OTHERMACROLIDESazithromycin oral1clarithromycin1DIFICID3e.e.s. 400 oral tablet1ery-tab oraltablet,delayedrelease (dr/ec) 250mg, 333 mg1QLJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.10
Drug NameDrugTiererythrocin (asstearate) oral tablet250 mg1erythromycinethylsuccinate oralsuspension forreconstitution1erythromycinethylsuccinate oraltablet1erythromycin oral1Requirements/ LimitsMISCELLANEOUSANTIINFECTIVESDrug NameDrugTierRequirements/ LimitsHYDROXYCHLOROQUINE ORALTABLET 100 MG,300 MG, 400 MG3hydroxychloroquineoral tablet 200 mg1IMPAVIDO2isoniazid oral1ivermectin oral1PA; QLKITABIS PAK4PA; SP; QLKRINTAFEL3QLlinezolid1PAQLPA; QLAEMCOLO3QLmefloquine1albendazole1QLmetronidazole oral1ARAKODA3QLneomycin1ARIKAYCE4PA; SP; OLECAYSTON4PA; SP; razinamide1pyrimethamine4PA; SPquinine sulfate1QLQLQLPAchloroquinephosphate1clindamycin utin1dapsone oral1rifampin oral1EMVERM2SIRTURO2PA; LAethambutol1SIVEXTRO ORAL3PASOLOSEC2QLtinidazole1QLQLQLQLJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.11
Drug NameDrugTierTOBI mycin in 0.225% nacl4tobramycininhalation4TRECATOR3XENLETA ORAL3XIFAXAN2PENICILLINSRequirements/ LimitsDrug NamePA; SP; QLQUINOLONESPA; SP; QLPA; SP; QLPA; QLDrugTierBAXDELA ORAL2ciprofloxacin1ciprofloxacin hcloral1FACTIVE3levofloxacin oral1moxifloxacin oral1ofloxacin oral tablet300 mg, 400 mg1Requirements/ LimitsQLSULFA'S & RELATED AGENTSsulfadiazine1amoxicillin oralcapsule1sulfamethoxazoletrimethoprim oral1amoxicillin oralsuspension forreconstitution1sulfatrim1amoxicillin oraltablet1amoxicillin oraltablet,chewable 125mg, 250 AVIDOXY DK3STcoremino1STdemeclocycline11doxycycline hyclateoral capsule1ampicillin oralcapsule 500 mg11AUGMENTINORALSUSPENSION FORRECONSTITUTION 125-31.25 MG/5ML2doxycycline hyclateoral tablet 100 mg,20 mgdoxycycline hyclateoral tablet 150 mg,50 mg, 75 mg1ST1STdicloxacillin1MOXATAG3doxycycline hyclateoral tablet,delayedrelease (dr/ec) 100mg, 150 mg, 200 mg,50 mg, 75 mgpenicillin vpotassium1January 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.12
Drug NameDrugTierRequirements/ Limitsdoxycyclinemonohydrate oralcapsule 100 mg, 50mg, 75 mg1doxycyclinemonohydrate oralcapsule 150 mg1doxycyclinemonohydrate oralsuspension forreconstitution1doxycyclinemonohydrate oraltablet1minocycline oralcapsule1minocycline oraltablet1minocycline oraltablet extendedrelease 24 hr1MINOLIRA ER3mondoxyne nl oralcapsule 100 mg, 75mg1MORGIDOX 1X 503STMORGIDOX 2X1003STmorgidox oralcapsule 100 mg1NUZYRA ORAL3ORACEASTDrug RIMSOL3trimethoprim1Requirements/ LimitsVANCOMYCINvancomycin oralcapsule1QLSTvancomycin oralrecon soln1QLSTANTINEOPLASTIC &IMMUNOSUPPRESSANTDRUGSADJUNCTIVE AGENTSleucovorin calciumoral1MESNEX ORAL2VISTOGARD4PA; SPQLXGEVA4PA; SP3STSEYSARA3STANTINEOPLASTIC &IMMUNOSUPPRESSANT DRUGSTARGADOX3STtetracycline1VIBRAMYCINORAL SYRUP3STabiraterone4PA; SP; QLAFINITORDISPERZ4PA; SP; QLAFINITOR ORALTABLET 10 MG4PA; SP; QLURINARY TRACT AGENTSJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.13
Drug NameDrugTierRequirements/ LimitsDrug NameDrugTierALECENSA4PA; SP; QLELIGARD4PA; SPALUNBRIG4PA; SP; QL4PA; SPanastrozole6ACAELIGARD (3MONTH)azathioprine4ELIGARD (4MONTH)4PA; SPBALVERSA4PA; SP3ELIGARD (6MONTH)4BEVACIZUMABINTRAVITREALSYRINGE 1.25MG/0.05 MLEMCYT2ENSPRYNG4PA; SPbexarotene4ERIVEDGE4PA; SP; QLbicalutamide1ERLEADA4PA; SP; QLBOSULIF4PA; SP; QLerlotinib4PA; SP; QLCABOMETYXORAL TABLET 20MG4PA; SP; LA;QLetoposide oral1everolimus(antineoplastic)4CABOMETYXORAL TABLET 40MG, 60 MG4PA; SP; LAeverolimus(immunosuppressive)4CALQUENCE4PA; SP; LA;QLexemestane6ACAcapecitabine4PA; SP4PA; SPCAPRELSA4PA; SP; LA;QLFIRMAGON KIT WDILUENTSYRINGEflutamide1COMETRIQ4PA; SPGAVRETO4COTELLIC4PA; SP; LA;QLgengraf4GILOTRIF4GLEOSTINE2HYCAMTIN ORAL4hydroxyurea1IBRANCE4PA; SP; QLICLUSIG4PA; SP; QLIDHIFA4PA; SP; LA;QLcyclophosphamideoral capsule1CYCLOPHOSPHAMIDE ORALTABLET3cyclosporinemodified4cyclosporine oralcapsule4DROXIA2PA; SP; LAPA; SPRequirements/ LimitsPA; SP; QLPA; SP; LA;QLPA; SP; QLPA; SPJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.14
Drug NameDrugTierRequirements/ LimitsDrug NameDrugTierRequirements/ Limitsimatinib4PA; SP; QLmelphalan1IMBRUVICA4PA; SP; QLmercaptopurine1INLYTA4PA; SP; QLmethotrexate sodium1IRESSA4PA; SP; QL1JAKAFI4PA; SP; QLmethotrexate sodium(pf)lapatinib4PA; SP; QLmycophenolatemofetil4LENVIMA4PA; euprolidesubcutaneous kit4PA; SPNERLYNX4PA; SP; LANEXAVAR4LONSURF4PA; SPPA; SP; LA;QLLORBRENA4PA; SP; QLnilutamide1PALUPRON DEPOT(3 MONTH)INTRAMUSCULAR SYRINGE KIT11.25 MG4PA; SPNINLARO4PA; SP; QLNUBEQA4PA; SP; LA;QLoctreotide acetate4PA; SPLUPRON DEPOTINTRAMUSCULAR SYRINGE KIT3.75 MG4PA; SPODOMZO4PA; SP; LA;QL4LUPRON DEPOTPED4PA; SPPROGRAF ORALGRANULES INPACKETPURIXAN4SPLUPRON DEPOTPED (3 MONTH)4PA; SPROZLYTREK4PA; SP; LA;QLLYNPARZA4PA; SP; QLRUBRACA4LYSODREN4SPPA; SP; LA;QLMATULANE4SPRYDAPT4PA; SPmegestrol oralsuspension 400mg/10 ml (40mg/ml), 625 mg/5 ml(125 mg/ml)1SANDIMMUNEORAL SOLUTION4SIGNIFOR4sirolimus4megestrol oral tablet1SOLTAMOX6MEKINIST4PA; SPACAPA; SP; QLJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.15
Drug NameDrugTierRequirements/ LimitsDrug NameDrugTierRequirements/ LimitsVOTRIENT4PA; SP; QLXALKORI4PA; SP; QLXERMELO4PA; SP; LA;QLSOMATULINEDEPOT4PA; SPSPRYCEL4PA; SP; QLSTIVARGA4PA; SP; QLsunitinib4PA; SP; QLXOSPATA4PA; SP; LASYNRIBO4PA; SP4PA; SP; QLTABLOID3XTANDI ORALCAPSULETABRECTA4PA; SPXTANDI ORALTABLET 40 MG4PA; SPtacrolimus oral4PA; SP; QL4PA; SP; QLXTANDI ORALTABLET 80 MG4TAFINLARTAGRISSO4PA; SP; LA;QLYONSA4PA; SP; QLZEJULA4TALZENNA4PA; SP; QLPA; SP; LA;QLtamoxifen6ACAZELBORAF4PA; SP; QLTARGRETINTOPICAL4PA; SPZOLINZA4PA; SP4PA; SP; QLZORTRESS ORALTABLET 1 MG4TASIGNAtemozolomide4PA; SPZYDELIG4PA; SP; QLTHALOMID4PA; SP; QL4PA; SP; QLTIBSOVO4PA; SPZYKADIA XALL3TRIPTODUR4PA; SPVENCLEXTA4PA; SP; LAVENCLEXTASTARTING PACK4PA; SP; QLVERZENIO4PA; SP; LA;QLVITRAKVI4PA; SP; LA;QLVIZIMPRO4PA; SP; QLAUTONOMIC & CNS DRUGS,NEUROLOGY & PSYCHANTICONVULSANTSBRIVIACT ORAL3carbamazepine oralcapsule, ermultiphase 12 hr1carbamazepine oralsuspension 100 mg/5ml, 200 mg/10 ml1carbamazepine oraltablet1STJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.16
Drug NameDrugTierRequirements/ LimitsDrug NameDrugTierRequirements/ Limitscarbamazepine oraltablet extendedrelease 12 hr1LAMICTAL XRSTARTER(GREEN)3STcarbamazepine oraltablet,chewable13STCELONTIN ORALCAPSULE 300 MG2LAMICTAL m azepam rectal1OXTELLAR XR3DILANTIN2phenobarbital1divalproex11ELEPSIA XR3STphenytoin oralsuspensionEPIDIOLEX4PA; SP; LAphenytoin oraltablet,chewable1epitol13phenytoin abalin oralcapsuleFYCOMPA21gabapentin oralcapsule1pregabalin oralsolution1gabapentin oralsolution 250 mg/5ml, 300 mg/6 ml (6ml)1pregabalin oraltablet extendedrelease 24 hrprimidone1roweepra1gabapentin oraltablet 600 mg, 800mg1rufinamide1PASPRITAM3STGRALISE ORALTABLETEXTENDEDRELEASE 24 HR3subvenite1subvenite starter(blue) kit11LAMICTAL XRSTARTER (BLUE)3subvenite starter(green) kitsubvenite starter(orange) kit1PAPA; SPSTSTPA; QLPAPAJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.17
Drug NameDrugTierRequirements/ LimitsDrug NameSYMPAZAN3tiagabinePAbenztropine oral11bromocriptine1topiramate oralcapsule, sprinkle1carbidopa1carbidopa-levodopa1topiramate capone1topiramate oraltablet1entacapone14PA; SP; QLTROKENDI XR3valproic acid1valproic acid (assodium salt) oralsolution 250 mg/5ml, 500 mg/10 ml(10 ; QLVALTOCO3PA; QLKYNMOBISUBLINGUALFILM 10 MG, 15MG, 20 MG, 25MG, 30 MGvigabatrin4PA; SP; LANEUPRO3vigadrone4PA; SPpramipexole1VIMPAT ORALSOLUTION2rasagiline1ropinirole1VIMPAT ORALTABLET2RYTARY3selegiline hcl1XCOPRI3QLtolcapone1XCOPRIMAINTENANCEPACK ORALTABLET250MG/DAY(150MG X1-100MGX1), 350 MG/DAY(200 MG X1150MG X1)3QLtrihexyphenidyl1XCOPRITITRATION PACK3zonisamide1STSTDrugTierRequirements/ LimitsPAPAMIGRAINE & CLUSTERHEADACHE THERAPYQLANTIPARKINSONISM AGENTSAIMOVIGAUTOINJECTOR2PA; QLAJOVYAUTOINJECTOR2PA; QLAJOVY SYRINGE2PA; QLalmotriptan malate1QLdihydroergotamineinjection1January 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.18
Drug NameDrugTierRequirements/ LimitsDrug NameDrugTierdihydroergotaminenasal1ST; QLZOMIG NASALeletriptan1QLMISCELLANEOUSNEUROLOGICAL THERAPYEMGALITY PEN2PA; QLAUSTEDO4EMGALITYSYRINGE2PA; QLPA; SP; LA;QLdalfampridine4PA; SP; QLERGOMAR31ergotamine-caffeine1donepezil oral tablet10 mg, 5 mgfrovatriptan1QL1migergot1donepezil oral tablet23 mgnaratriptan1QLdonepezil oraltablet,disintegrating1NURTEC ODT3PA; QLgalantamine1REYVOW3PA; QLHORIZANT3rizatriptan1QL1QLsumatriptansuccinate oral1QLmemantine nsuccinatesubcutaneouscartridge1memantine oralsolutionmemantine oraltablet13sumatriptansuccinatesubcutaneous NDATITRATION riptannaproxen1ST; QLNAMENDA XRORALCAP,SPRINKLE,ER24HR DOSE PACKNAMZARIC2STTOSYMRA3ST; QLNUEDEXTA2PAUBRELVY3PA; QLrivastigmine1ZEMBRACESYMTOUCH3ST; QLrivastigmine tartrate1zolmitriptan oral1QLRUZURGI4QL2Requirements/ LimitsST; QLSTSTPA; SPJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.19
Drug NameDrugTierRequirements/ LimitsDrug deine oral solution120-12 mg/5 ml, 300mg-30 mg /12.5 ml1QLacetaminophencodeine oral tablet1QLALLZITAL3STascomp with codeine1QLTEGSEDI4PA; SP; LAtetrabenazine4PA; SP; QLMUSCLE RELAXANTS &ANTISPASMODIC THERAPYDrugTierRequirements/ Limitsbaclofen laspirin-codeine1chlorzoxazone1BELBUCA2ST; QLcyclobenzaprine1buprenorphine1ST; QLdantrolene oral16ACAmeprobamate1buprenorphine hclsublingualmetaxalone1butalbital compoundw/codeine1QLmethocarbamol oral1QL1butalbitalacetaminop-caf-cod1orphenadrine c fortepyridostigminebromide oral MIDE ORALTABLET 30 MG3codeine inebromide oral tablet60 mg1diskets1PADSUVIA3pyridostigminebromide oral tabletextended release1dvorah1QLendocet1QLtizanidine1fentanyl1PA; QLvanadom1fentanyl citratebuccal lozenge on ahandle1PA; QLNARCOTIC ANALGESICSQLJanuary 2022You can find information on what the symbols and abbreviations on this table mean by going to the beginningof this table.20
Drug NameDrugTierRequirements/ LimitsDrug NameDrugTierRequirements/ LimitsPA; QLmethadone oralsolution1PAmethadone oraltablet1PAmethadone oraltablet,soluble1PAmethadose oralconcentrate1PAmethadose oraltablet,soluble1PAmorphineconcentrate oralsolution1QLmorphine oralcapsule, ermultiphase 24 hr1PA; QLmorphine oralcapsule,extend.rele
How do I use the Drug List? There are two ways to find your drug within the Drug List: Drug Category The Drug List begins on Page 7. The drugs in this Drug List are grouped into categories depending on their clinical classification. For example, drugs that are considered "anti-infectives" will be listed under the "anti-infectives" category.
