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Empire BlueCross BlueShield HealthPlus – New York Essential Plan - Lista de medicamentos
Índice
NOTA: No todos los medicamentos y no todos los planes están sujetos a autorización previa y límites de
cantidad. Para obtener más información con respecto a autorización previa o límites de cantidad, póngase
en contacto con Servicios al Miembro al número telefónico que aparece en su tarjeta de identificación.
Lista de abreviaturas
Nivel 1: Los medicamentos del nivel 1 tienen el costo compartido más bajo. Estos medicamentos ofrecen el
mayor valor comparados con otros que tratan las mismas condiciones.
Nivel 2: El nivel 2 tiene un costo compartido medio. Pueden ser medicamentos preferidos, con base en su
efectividad y valor. Algunos son medicamentos genéricos más nuevos y más caros.
Nivel 3: Los medicamentos del nivel 3 tienen un costo compartido más alto. Pueden costar más que otros
usados para tratar la misma condición. El nivel 3 también puede incluir medicamentos que fueron
recientemente aprobados por la FDA.
Nivel 4: Los medicamentos especializados del nivel 4 tienen el costo compartido más alto. Pueden costar más
que otros usados para tratar la misma condición. Los medicamentos especializados son usados para tratar
condiciones complejas y crónicas y pueden necesitar manejo especial.
DO: SE REQUIERE OPTIMIZACIÓN DE DOSIS. Normalmente involucra la conversión de dosificación de
dos veces al día a un programa de dosificación de una vez al día.
PA: SE REQUIERE AUTORIZACIÓN PREVIA. La autorización previa es el proceso de obtener aprobación
de beneficios antes de que se puedan abastecer ciertas recetas.
QL: LÍMITES DE CANTIDAD. Ciertos medicamentos recetados tienen límites de calidad específicos por
receta o por mes.
ST: SE REQUIERE TERAPIA ESCALONADA. Tal vez deba usar un medicamento antes de que los
beneficios para el uso de otro medicamento se puedan autorizar. Tenga en cuenta: Foradil y Serevent son
ediciones de seguridad que evitan la duplicación de terapia.
www.empireblue.com/nyessentialplan
Empire BlueCross BlueShield HealthPlus es el nombre comercial de HealthPlus HP, LLC, licenciatario
independiente de Blue Cross and Blue Shield Association.
1
WEBMENY-0030-15
Revised 1/1/2016
2
Lista de medicamentos del New York
Essential Plan
Nombre del medicamento Nivel Notas
ANALGESICS
acetaminophen-codeine
oral solution 120 mg-12
mg /5 ml (5 ml), 120-12
mg/5 ml
Tier 1 QL
acetaminophen-codeine
oral solution 240 mg-24
mg /10 ml (10 ml), 300
mg-30 mg /12.5 ml
Tier 1
acetaminophen-codeine
oral tablet 300-15 mg,
300-30 mg, 300-60 mg
Tier 1 QL
almotriptan malate oral
tablet
Tier 1 QL
ascomp with codeine
oral capsule
Tier 1
buprenorphine hcl
injection solution
Tier 2
buprenorphine hcl
injection syringe
Tier 2
butalbital compound
w/codeine oral capsule
Tier 1
butalbital-acetaminop-
caf-cod oral capsule
Tier 1 QL
butalbital-
acetaminophen-caff oral
capsule
Tier 1
butalbital-
acetaminophen-caff oral
tablet
Tier 1
butalbital-aspirin-
caffeine oral capsule
Tier 1
butorphanol tartrate
nasal spray,non-aerosol
Tier 1 PA; QL
CAMBIA ORAL
POWDER IN
PACKET
Tier 3 QL
capacet oral capsule Tier 1
codeine sulfate oral
tablet 15 mg, 30 mg, 60
mg
Tier 1 QL
diclofenac potassium
oral tablet
Tier 1
diflunisal oral tablet
dihydroergotamine nasal
spray,non-aerosol
diskets oral tablet,
soluble
Tier 1
ELMIRON ORAL
CAPSULE
Tier 3
EMBEDA ORAL
CAPSULE,ORAL
ONLY,EXT.REL
PELL
Tier 3
endocet oral tablet Tier 1 QL
endodan oral tablet Tier 1
fentanyl transdermal
patch 72 hour
Tier 2 ST; QL
FROVA ORAL
TABLET
Tier 3 ST; QL
hydrocodone-
acetaminophen oral
solution 10-325 mg/15
ml(15 ml), 2.5-167 mg/5
ml, 5-163
mg/7.5ml(7.5ml)
Tier 1 QL
hydrocodone-
acetaminophen oral
tablet 10-300 mg, 10-325
mg, 2.5-325 mg, 5-300
mg, 5-325 mg, 7.5-300
mg, 7.5-325 mg
Tier 1 QL
hydromorphone oral
liquid
Tier 1 QL
hydromorphone oral
tablet 2 mg, 4 mg, 8 mg
Tier 1 QL
hydromorphone oral
tablet extended release
24 hr 12 mg, 16 mg, 32
mg, 8 mg
Tier 2 ST; QL
hydromorphone rectal
suppository
Tier 1
ibuprofen-oxycodone
oral tablet
Tier 1 QL
isometh-dichloral-
acetaminophn oral
capsule
Tier 1
ketorolac injection
cartridge 15 mg/ml, 30
mg/ml
Tier 2 QL
Nombre del medicamento
diflunisal oral tablet
dihydroergotamine nasal
spray,non-aerosol
Nivel
Tier 1
Tier 2
Notas
WEBMENY-0030-15
Revised 1/1/2016
3
ketorolac injection
solution 15 mg/ml, 30
mg/ml, 30 mg/ml (1 ml)
Tier 2 QL
ketorolac intramuscular
solution
Tier 2 QL
ketorolac oral tablet Tier 1 QL
levorphanol tartrate oral
tablet
Tier 2
margesic oral capsule Tier 1
marten-tab oral tablet Tier 1
mefenamic acid oral
capsule
Tier 1
meperidine oral solution Tier 1 QL
meperidine oral tablet
100 mg, 50 mg
Tier 1 QL
meperitab oral tablet Tier 1 QL
methadone intensol oral
concentrate
Tier 1 QL
methadone oral
concentrate
Tier 1 QL
methadone oral solution
10 mg/5 ml, 5 mg/5 ml
Tier 1 QL
methadone oral tablet 10
mg, 5 mg
Tier 1 QL
methadone oral
tablet,soluble
Tier 1
methadose oral
concentrate
Tier 1 QL
methadose oral
tablet,soluble
Tier 1
morphine concentrate
oral solution
Tier 1 QL
morphine oral
capsule,extend.release
pellets
Tier 2 QL
morphine oral solution
10 mg/5 ml, 20 mg/5 ml
Tier 1 QL
morphine oral tablet 15
mg, 30 mg
Tier 1 QL
morphine oral tablet
extended release 100 mg,
15 mg, 200 mg, 30 mg,
60 mg
Tier 2 QL
Nombre del medicamento Nivel Notas
morphine rectal
suppository
Tier 1
nalbuphine injection
solution
Tier 2
naratriptan oral tablet Tier 1 QL
nodolor oral capsule Tier 1
NUCYNTA ER ORAL
TABLET EXTENDED
RELEASE 12 HR
Tier 3 ST; QL
NUCYNTA ORAL
TABLET 100 MG, 50
MG, 75 MG
Tier 3 QL
oxycodone oral capsule Tier 1 QL
oxycodone oral
concentrate
Tier 1 QL
oxycodone oral solution Tier 1 QL
oxycodone oral tablet 10
mg, 15 mg, 20 mg, 30
mg, 5 mg
Tier 1 QL
oxycodone-
acetaminophen oral
tablet
Tier 1 QL
oxycodone-aspirin oral
tablet
Tier 1 QL
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR 10 MG, 15 MG, 20
MG, 30 MG, 40 MG, 60
MG, 80 MG
Tier 3 ST; QL
oxymorphone oral tablet
10 mg, 5 mg
Tier 1 QL
oxymorphone oral tablet
extended release 12 hr
10 mg, 15 mg, 20 mg, 30
mg, 40 mg, 5 mg, 7.5 mg
Tier 1 QL
RELPAX ORAL
TABLET
Tier 3 ST; QL
rizatriptan oral tablet Tier 1 QL
rizatriptan oral
tablet,disintegrating
Tier 1 QL
sumatriptan succinate
oral tablet
Tier 1 QL
sumatriptan succinate
subcutaneous cartridge
Tier 2 QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
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sumatriptan succinate
subcutaneous pen
injector
Tier 2 QL
sumatriptan succinate
subcutaneous solution
Tier 2 QL
sumatriptan succinate
subcutaneous syringe
Tier 2 QL
tramadol oral tablet Tier 1 QL
tramadol oral tablet
extended release 24 hr
Tier 1 QL
tramadol oral tablet, er
multiphase 24 hr
Tier 1 QL
vicodin es oral tablet Tier 1 QL
vicodin hp oral tablet Tier 1 QL
vicodin oral tablet Tier 1 QL
zamicet oral solution Tier 1 QL
zebutal oral capsule Tier 2
ZIPSOR ORAL
CAPSULE
Tier 3
zolmitriptan oral tablet Tier 1 QL
zolmitriptan oral
tablet,disintegrating
Tier 1 QL
Nombre del medicamento Nivel Notas
ANESTHETICS
lidocaine hcl mucous
membrane solution
Tier 1
lidocaine viscous
mucous membrane
solution
Tier 1
lidocaine-prilocaine
topical cream
Tier 1
lidocaine-prilocaine
topical kit
Tier 1
lta pre-attached
laryngotracheal solution
Tier 1
phenazopyridine oral
tablet
Tier 1
SYNERA TOPICAL
PATCH,
MEDICATED SELF-
HEATING
Tier 3
ANTIARTHRITICS
allopurinol oral tablet Tier 1
CALDOLOR
INTRAVENOUS
RECON SOLN
Tier 3
celecoxib oral capsule
100 mg, 200 mg, 400
mg, 50 mg
Tier 2 ST; QL
colchicine-probenecid
oral tablet
Tier 1
COLCRYS ORAL
TABLET
Tier 3 PA; QL
CUPRIMINE ORAL
CAPSULE
Tier 3
DAYPRO ORAL
TABLET
Tier 3
diclofenac sodium oral
tablet extended release
24 hr
Tier 1
diclofenac sodium oral
tablet,delayed release
(dr/ec)
Tier 1
ENBREL
SUBCUTANEOUS
RECON SOLN
Tier 3 PA; QL
ENBREL
SUBCUTANEOUS
SYRINGE 25
MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
Tier 3 PA; QL
ENBREL
SURECLICK
SUBCUTANEOUS
PEN INJECTOR
Tier 3 PA; QL
etodolac oral capsule Tier 1
etodolac oral tablet Tier 1
etodolac oral tablet
extended release 24 hr
Tier 1
fenoprofen oral tablet Tier 1
flurbiprofen oral tablet Tier 1
HUMIRA PEDIATRIC
CROHN'S START
SUBCUTANEOUS
SYRINGE KIT
Tier 3 PA; QL
HUMIRA PEN
CROHN'S-UC-HS
START
SUBCUTANEOUS
PEN INJECTOR KIT
Tier 3 PA; QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
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HUMIRA PEN
PSORIASIS
STARTER
SUBCUTANEOUS
PEN INJECTOR KIT
Tier 3 PA; QL
HUMIRA PEN
SUBCUTANEOUS
PEN INJECTOR KIT
Tier 3 PA; QL
HUMIRA
SUBCUTANEOUS
SYRINGE KIT
Tier 3 PA; QL
ibuprofen oral
suspension
Tier 1
ibuprofen oral tablet Tier 1
indomethacin oral
capsule
Tier 1
indomethacin oral
capsule, extended release
Tier 1
ketoprofen oral capsule Tier 1
ketoprofen oral
capsule,ext rel. pellets 24
hr
Tier 1
KINERET
SUBCUTANEOUS
SYRINGE
Tier 3 PA
leflunomide oral tablet Tier 2
meclofenamate oral
capsule
Tier 1
meloxicam oral
suspension
Tier 1
meloxicam oral tablet Tier 1 QL
nabumetone oral tablet Tier 1
naproxen oral suspension Tier 1
naproxen oral tablet Tier 1
naproxen oral
tablet,delayed release
(dr/ec)
Tier 1
naproxen sodium oral
tablet
Tier 1
ORENCIA (WITH
MALTOSE)
INTRAVENOUS
RECON SOLN
Tier 3 PA; QL
Nombre del medicamento Nivel Notas
ORENCIA
SUBCUTANEOUS
SYRINGE
Tier 3 PA; QL
oxaprozin oral tablet Tier 1
piroxicam oral capsule Tier 1
probenecid oral tablet Tier 1
SIMPONI ARIA
INTRAVENOUS
SOLUTION
Tier 3 PA
SIMPONI
SUBCUTANEOUS
PEN INJECTOR
Tier 3 PA; QL
SIMPONI
SUBCUTANEOUS
SYRINGE
Tier 3 PA; QL
sulindac oral tablet Tier 1
tolmetin oral capsule Tier 1
tolmetin oral tablet Tier 1
ULORIC ORAL
TABLET
Tier 3 ST
Nombre del medicamento Nivel Notas
ANTIASTHMATICS
acetylcysteine solution Tier 2
ADVAIR DISKUS
INHALATION
BLISTER WITH
DEVICE
Tier 2 QL
ADVAIR HFA
INHALATION HFA
AEROSOL INHALER
Tier 2 QL
albuterol sulfate
inhalation solution for
nebulization
Tier 1
albuterol sulfate oral
syrup
Tier 1
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
Tier 2 QL
BROVANA
INHALATION
SOLUTION FOR
NEBULIZATION
Tier 3 QL
WEBMENY-0030-15
Revised 1/1/2016
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budesonide inhalation
suspension for
nebulization 0.25 mg/2
ml, 0.5 mg/2 ml
Tier 1 QL
budesonide inhalation
suspension for
nebulization 1 mg/2 ml
Tier 1
cromolyn inhalation
solution for nebulization
Tier 1
DALIRESP ORAL
TABLET
Tier 3 QL
DULERA
INHALATION HFA
AEROSOL INHALER
Tier 2 QL
FLOVENT DISKUS
INHALATION
BLISTER WITH
DEVICE 100
MCG/ACTUATION,
250
MCG/ACTUATION,
50 MCG/ACTUATION
Tier 2 QL
FLOVENT HFA
INHALATION HFA
AEROSOL INHALER
110
MCG/ACTUATION,
220
MCG/ACTUATION,
44 MCG/ACTUATION
Tier 2 QL
ipratropium bromide
inhalation solution
Tier 1 QL
levalbuterol hcl
inhalation solution for
nebulization
Tier 2
metaproterenol oral
syrup
Tier 1
metaproterenol oral
tablet
Tier 1
montelukast oral
granules in packet
Tier 1 QL
montelukast oral tablet Tier 1 QL
montelukast oral
tablet,chewable
Tier 1 QL
PERFOROMIST
INHALATION
SOLUTION FOR
NEBULIZATION
Tier 3 QL
Nombre del medicamento Nivel Notas
PROAIR HFA
INHALATION HFA
AEROSOL INHALER
Tier 2 QL
PROVENTIL HFA
INHALATION HFA
AEROSOL INHALER
Tier 3 QL
PULMICORT
FLEXHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
Tier 2 QL
QVAR INHALATION
AEROSOL 40
MCG/ACTUATION,
80 MCG/ACTUATION
Tier 2 QL
SEREVENT DISKUS
INHALATION
BLISTER WITH
DEVICE
Tier 2 QL
SPIRIVA RESPIMAT
INHALATION MIST
1.25
MCG/ACTUATION
Tier 3
SPIRIVA RESPIMAT
INHALATION MIST
2.5
MCG/ACTUATION
Tier 3 QL
SPIRIVA WITH
HANDIHALER
INHALATION
CAPSULE,
W/INHALATION
DEVICE
Tier 3 QL
SYMBICORT
INHALATION HFA
AEROSOL INHALER
Tier 2 QL
terbutaline oral tablet Tier 1
theochron oral tablet
extended release 12 hr
Tier 1
theophylline oral tablet
extended release
Tier 1
theophylline oral tablet
extended release 12 hr
Tier 1
VENTOLIN HFA
INHALATION HFA
AEROSOL INHALER
Tier 3 QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
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XOPENEX HFA
INHALATION HFA
AEROSOL INHALER
Tier 3 QL
zafirlukast oral tablet Tier 1
ZYFLO CR ORAL
TABLET, ER
MULTIPHASE 12 HR
Tier 3 PA
ZYFLO ORAL
TABLET
Tier 3 PA
Nombre del medicamento Nivel Notas
ANTIBIOTICS
ak-poly-bac ophthalmic
ointment
Tier 1
amoxicillin oral capsule Tier 1
amoxicillin oral
suspension for
reconstitution
Tier 1
amoxicillin oral tablet Tier 1
amoxicillin oral
tablet,chewable
Tier 1
amoxicillin-pot
clavulanate oral
suspension for
reconstitution
Tier 1
amoxicillin-pot
clavulanate oral tablet
Tier 1
amoxicillin-pot
clavulanate oral tablet
extended release 12 hr
Tier 1
amoxicillin-pot
clavulanate oral
tablet,chewable
Tier 1
ampicillin oral capsule Tier 1
ampicillin oral
suspension for
reconstitution
Tier 1
avar topical cleanser Tier 1
avidoxy oral tablet Tier 1
azithromycin oral packet Tier 1 QL
azithromycin oral
suspension for
reconstitution 100 mg/5
ml, 200 mg/5 ml
Tier 1 QL
azithromycin oral tablet
250 mg, 500 mg, 600 mg
Tier 1 QL
bacitracin ophthalmic
ointment
Tier 1
bacitracin-polymyxin b
ophthalmic ointment
Tier 1
BESIVANCE
OPHTHALMIC
DROPS,SUSPENSION
Tier 3
bp 10-1 topical cleanser Tier 1
cefaclor oral capsule Tier 1
cefaclor oral suspension
for reconstitution
Tier 1
cefaclor oral tablet
extended release 12 hr
Tier 1
cefadroxil oral capsule Tier 1
cefadroxil oral
suspension for
reconstitution
Tier 1
cefadroxil oral tablet Tier 1
cefazolin in dextrose
(iso-os) intravenous
piggyback
Tier 2
cefazolin injection recon
soln
Tier 2
cefazolin intravenous
recon soln
Tier 2
cefdinir oral capsule Tier 1
cefdinir oral suspension
for reconstitution
Tier 1
cefditoren pivoxil oral
tablet
Tier 1
cefotaxime injection
recon soln
Tier 2
cefpodoxime oral
suspension for
reconstitution
Tier 2
cefpodoxime oral tablet Tier 2
cefprozil oral suspension
for reconstitution
Tier 1
cefprozil oral tablet Tier 1
ceftibuten oral capsule Tier 2
ceftibuten oral
suspension for
reconstitution
Tier 2
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
8
ceftriaxone in
dextrose,iso-os
intravenous piggyback
Tier 2
ceftriaxone injection
recon soln
Tier 2
ceftriaxone intravenous
recon soln
Tier 2
cefuroxime axetil oral
tablet
Tier 1
cephalexin oral capsule Tier 1
cephalexin oral
suspension for
reconstitution
Tier 1
cephalexin oral tablet Tier 1
chloramphenicol sod
succinate intravenous
recon soln
Tier 2
CIPRO HC OTIC
DROPS,SUSPENSION
Tier 3
CIPRODEX OTIC
DROPS,SUSPENSION
Tier 3 PA
ciprofloxacin (mixture)
oral tablet, er multiphase
24 hr 1,000 mg, 500 mg
Tier 1 QL
ciprofloxacin hcl
ophthalmic drops
Tier 1
ciprofloxacin hcl oral
tablet
Tier 1 QL
ciprofloxacin hcl otic
dropperette
Tier 1
ciprofloxacin in 5 %
dextrose intravenous
piggyback
Tier 2
ciprofloxacin lactate
intravenous solution
Tier 2
clarithromycin oral
suspension for
reconstitution
Tier 1
clarithromycin oral tablet Tier 1
clarithromycin oral tablet
extended release 24 hr
Tier 1
cleansing wash topical
cleanser
Tier 1
CLINDACIN ETZ
TOPICAL KIT
Tier 3
Nombre del medicamento Nivel Notas
clindacin etz topical
swab
Tier 1
clindacin p topical swab Tier 1
CLINDACIN PAC
TOPICAL KIT
Tier 3
clindamycin hcl oral
capsule
Tier 1
clindamycin palmitate
hcl oral recon soln
Tier 1
clindamycin pediatric
oral recon soln
Tier 1
clindamycin phosphate
topical foam
Tier 1
clindamycin phosphate
topical gel
Tier 1
clindamycin phosphate
topical lotion
Tier 1
clindamycin phosphate
topical solution
Tier 1
clindamycin phosphate
topical swab
Tier 1
clindamycin phosphate
vaginal cream
Tier 1
COLY-MYCIN S
OTIC
DROPS,SUSPENSION
Tier 3
CORTISPORIN
TOPICAL CREAM
Tier 3
CORTISPORIN
TOPICAL
OINTMENT
Tier 3
DAPSONE ORAL
TABLET
Tier 3
demeclocycline oral
tablet
Tier 2
dicloxacillin oral capsule Tier 1
DIFICID ORAL
TABLET
Tier 3 PA
doxycycline hyclate oral
capsule
Tier 1
doxycycline hyclate oral
tablet
Tier 1
doxycycline hyclate oral
tablet,delayed release
(dr/ec)
Tier 1 PA
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
9
doxycycline
monohydrate oral
capsule
Tier 1
doxycycline
monohydrate oral
suspension for
reconstitution
Tier 1
doxycycline
monohydrate oral tablet
Tier 1
e.e.s. 400 oral tablet Tier 1
ery pads topical swab Tier 1
erygel topical gel Tier 1
ery-tab oral
tablet,delayed release
(dr/ec)
Tier 1
erythrocin (as stearate)
oral tablet
Tier 1
erythromycin
ethylsuccinate oral tablet
Tier 1
erythromycin ophthalmic
ointment
Tier 1
erythromycin oral
capsule,delayed
release(dr/ec)
Tier 1
erythromycin oral tablet Tier 1
erythromycin with
ethanol topical gel
Tier 1
erythromycin with
ethanol topical solution
Tier 1
erythromycin with
ethanol topical swab
Tier 1
erythromycin-benzoyl
peroxide topical gel
Tier 1
ethambutol oral tablet Tier 1
FACTIVE ORAL
TABLET
Tier 3 QL
garamycin ophthalmic
drops
Tier 1
gatifloxacin ophthalmic
drops
Tier 1
gentak ophthalmic
ointment
Tier 1
gentamicin ophthalmic
drops
Tier 1
Nombre del medicamento Nivel Notas
gentamicin ophthalmic
ointment
Tier 1
isoniazid oral solution Tier 1
isoniazid oral tablet Tier 1
KETEK ORAL
TABLET
Tier 3
levofloxacin oral tablet Tier 1 QL
LINCOCIN
INJECTION
SOLUTION
Tier 3
linezolid oral tablet Tier 2 PA; QL
meropenem intravenous
recon soln
Tier 2
methenamine hippurate
oral tablet
Tier 2
methenamine mandelate
oral tablet
Tier 1
metronidazole oral
capsule
Tier 1
metronidazole oral tablet Tier 1
metronidazole vaginal
gel
Tier 1
minocycline oral capsule Tier 1
minocycline oral tablet Tier 1
minocycline oral tablet
extended release 24 hr
Tier 1 PA
MORGIDOX 1X100
KIT
Tier 3
MORGIDOX 2X100
KIT
Tier 3
morgidox oral capsule Tier 1
mupirocin topical
ointment
Tier 1
neomycin oral tablet Tier 1
neomycin-bacitracin-
poly-hc ophthalmic
ointment
Tier 1
neomycin-bacitracin-
polymyxin ophthalmic
ointment
Tier 1
neomycin-polymyxin b-
dexameth ophthalmic
drops,suspension
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
10
neomycin-polymyxin b-
dexameth ophthalmic
ointment
Tier 1
neomycin-polymyxin-
gramicidin ophthalmic
drops
Tier 1
neomycin-polymyxin-hc
ophthalmic
drops,suspension
Tier 1
neomycin-polymyxin-hc
otic drops,suspension
Tier 1
neomycin-polymyxin-hc
otic solution
Tier 1
neo-polycin hc
ophthalmic ointment
Tier 1
neo-polycin ophthalmic
ointment
Tier 1
nitrofurantoin
macrocrystal oral
capsule
Tier 1
nitrofurantoin
monohyd/m-cryst oral
capsule
Tier 1
nitrofurantoin oral
suspension
Tier 1
ofloxacin ophthalmic
drops
Tier 1
ofloxacin oral tablet Tier 1 QL
ofloxacin otic drops Tier 1
ORACEA ORAL
CAPSULE,IR &
DELAY
REL,BIPHASE
Tier 3
penicillin v potassium
oral recon soln
Tier 1
penicillin v potassium
oral tablet
Tier 1
piperacillin-tazobactam
intravenous recon soln
Tier 1
polycin ophthalmic
ointment
Tier 1
polymyxin b sulf-
trimethoprim ophthalmic
drops
Tier 1
Nombre del medicamento Nivel Notas
PRED-G
OPHTHALMIC
DROPS,SUSPENSION
Tier 3
PRED-G S.O.P.
OPHTHALMIC
OINTMENT
Tier 3
PRIMSOL ORAL
SOLUTION
Tier 3
pyrazinamide oral tablet Tier 1
rifabutin oral capsule Tier 2
rifampin oral capsule Tier 1
RIFATER ORAL
TABLET
Tier 3
silver sulfadiazine
topical cream
Tier 1
ssd topical cream Tier 1
sss 10-5 topical cream Tier 1
sss 10-5 topical foam Tier 1
sulfacetamide sodium
ophthalmic drops
Tier 1
sulfacetamide sodium
ophthalmic ointment
Tier 1
sulfacetamide sodium-
sulfur topical cleanser
Tier 1
sulfacetamide sodium-
sulfur topical cream
Tier 1
sulfacetamide sodium-
sulfur topical foam
Tier 1
sulfacetamide sodium-
sulfur topical lotion
Tier 1
sulfacetamide sodium-
sulfur topical pads,
medicated
Tier 1
sulfacetamide sodium-
sulfur topical suspension
Tier 1
sulfacetamide sod-sulfur-
urea topical cleanser
Tier 1
sulfacetamide-
prednisolone ophthalmic
drops
Tier 1
sulfacetamide-sulfur-
cleansr23 topical kit
Tier 1
sulfacleanse 8-4 topical
suspension
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
11
sulfadiazine oral tablet Tier 2
sulfamethoxazole-
trimethoprim oral
suspension
Tier 1
sulfamethoxazole-
trimethoprim oral tablet
Tier 1
SULFAMYLON
TOPICAL CREAM
Tier 3
sulfatrim oral suspension Tier 1
SUPRAX ORAL
CAPSULE
Tier 3
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTION
Tier 3
tetracycline oral capsule Tier 1
THALOMID ORAL
CAPSULE
Tier 3 PA
thermazene topical
cream
Tier 1
tobramycin in 0.225 %
nacl inhalation solution
for nebulization
Tier 3
tobramycin ophthalmic
drops
Tier 1
tobramycin-
dexamethasone
ophthalmic
drops,suspension
Tier 1
trimethoprim oral tablet Tier 1
vancomycin oral capsule Tier 2 PA
vandazole vaginal gel Tier 1
VIBATIV
INTRAVENOUS
RECON SOLN
Tier 3
VIGAMOX
OPHTHALMIC
DROPS
Tier 3
zencia topical cleanser Tier 1
ZYVOX ORAL
SUSPENSION FOR
RECONSTITUTION
Tier 3 PA; QL
Nombre del medicamento Nivel Notas
ANTICOAGULANTS
enoxaparin subcutaneous
solution
Tier 3 PA
enoxaparin subcutaneous
syringe
Tier 3 PA
fondaparinux
subcutaneous syringe
Tier 3 PA
FRAGMIN
SUBCUTANEOUS
SOLUTION
Tier 3 PA
FRAGMIN
SUBCUTANEOUS
SYRINGE
Tier 3 PA
hep flush-10 (pf)
intravenous solution
Tier 2
heparin (porcine) in 5 %
dex intravenous
parenteral solution
Tier 2
heparin (porcine) in nacl
(pf) intravenous
parenteral solution
Tier 2
heparin (porcine)
injection cartridge
Tier 2
heparin (porcine)
injection solution
Tier 2
heparin flush intravenous
kit
Tier 2
heparin flush(porcine)-
0.9nacl intravenous kit
Tier 2
heparin lock flush
(porcine) intravenous
solution
Tier 2
heparin lock flush
(porcine) intravenous
syringe
Tier 2
heparin lock flush
intravenous solution
Tier 2
heparin lock flush
intravenous syringe
Tier 2
heparin lock intravenous
solution
Tier 2
heparin
lockflush(porcine)(pf)
intravenous syringe
Tier 2
heparin(porcine) in
0.45% nacl intravenous
parenteral solution
Tier 2
heparin, porcine (pf)
injection solution
Tier 2
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
12
heparin, porcine (pf)
injection syringe
Tier 2
heparin, porcine (pf)
intravenous solution
Tier 2
heparin, porcine (pf)
intravenous syringe
Tier 2
jantoven oral tablet Tier 1
monoject prefill (pf)
intravenous syringe
Tier 2
monoject prefill
advanced (pf)
intravenous syringe
Tier 2
PRADAXA ORAL
CAPSULE
Tier 3 QL
warfarin oral tablet Tier 1
XARELTO ORAL
TABLET 10 MG, 15
MG, 20 MG
Tier 3 PA; QL
XARELTO ORAL
TABLETS,DOSE
PACK
Tier 3 PA
Nombre del medicamento Nivel Notas
ANTIDOTES
depade oral tablet Tier 1
naltrexone oral tablet Tier 1
RELISTOR
SUBCUTANEOUS
SOLUTION
Tier 3 PA
RELISTOR
SUBCUTANEOUS
SYRINGE
Tier 3 PA
ANTIFUNGALS
CANCIDAS
INTRAVENOUS
RECON SOLN
Tier 3
CICLODAN KIT
TOPICAL COMBO
PACK
Tier 3
CICLODAN KIT
TOPICAL SOLUTION
Tier 3
ciclodan topical cream Tier 1
ciclodan topical solution Tier 1
ciclopirox topical cream Tier 1
ciclopirox topical gel Tier 1
ciclopirox topical
shampoo
Tier 1
ciclopirox topical
solution
Tier 1
ciclopirox topical
suspension
Tier 1
clotrimazole mucous
membrane troche
Tier 1
clotrimazole topical
cream
Tier 1
clotrimazole topical
solution
Tier 1
clotrimazole-
betamethasone topical
cream
Tier 1
clotrimazole-
betamethasone topical
lotion
Tier 1
econazole topical cream Tier 1
ERAXIS(WATER
DILUENT)
INTRAVENOUS
RECON SOLN
Tier 3
ERTACZO TOPICAL
CREAM
Tier 3
EXELDERM
TOPICAL CREAM
Tier 3
EXELDERM
TOPICAL SOLUTION
Tier 3
fluconazole oral
suspension for
reconstitution
Tier 1
fluconazole oral tablet Tier 1
flucytosine oral capsule Tier 1
griseofulvin microsize
oral suspension
Tier 1
griseofulvin microsize
oral tablet
Tier 1
griseofulvin
ultramicrosize oral tablet
Tier 1
itraconazole oral capsule Tier 2 PA
ketoconazole oral tablet Tier 1
ketoconazole topical
cream
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
13
ketoconazole topical
foam
Tier 1
ketoconazole topical
shampoo
Tier 1
MENTAX TOPICAL
CREAM
Tier 3
miconazole-3 vaginal
suppository
Tier 1
NAFTIN TOPICAL
CREAM
Tier 3
NAFTIN TOPICAL
GEL
Tier 3
NATACYN
OPHTHALMIC
DROPS,SUSPENSION
Tier 3
nyamyc topical powder Tier 1
nystatin oral powder Tier 1
nystatin oral suspension Tier 1
nystatin oral tablet Tier 1
nystatin topical cream Tier 1
nystatin topical ointment Tier 1
nystatin topical powder Tier 1
nystatin-triamcinolone
topical cream
Tier 1
nystatin-triamcinolone
topical ointment
Tier 1
nystop topical powder Tier 1
OXISTAT TOPICAL
CREAM
Tier 3
OXISTAT TOPICAL
LOTION
Tier 3
terbinafine hcl oral tablet Tier 1 PA
terconazole vaginal
cream
Tier 1
terconazole vaginal
suppository
Tier 1
Nombre del medicamento Nivel Notas
ANTIHISTAMINE AND DECONGESTANT
COMBINATION
promethazine vc oral
syrup
Tier 1
ANTIHISTAMINES
arbinoxa oral liquid Tier 1
arbinoxa oral tablet Tier 1
azelastine ophthalmic
drops
Tier 1 QL
BEPREVE
OPHTHALMIC
DROPS
Tier 3 PA; QL
carbinoxamine maleate
oral liquid
Tier 1
carbinoxamine maleate
oral tablet
Tier 1
cetirizine oral solution Tier 1 QL
clemastine oral tablet Tier 1
cyproheptadine oral
tablet
Tier 1
desloratadine oral tablet Tier 1 QL
desloratadine oral
tablet,disintegrating
Tier 1 QL
diphenhydramine hcl
injection solution
Tier 2
diphenhydramine hcl
injection syringe
Tier 2
diphenhydramine hcl
oral capsule
Tier 1
EMADINE
OPHTHALMIC
DROPS
Tier 3 PA; QL
epinastine ophthalmic
drops
Tier 1 QL
fexofenadine oral tablet Tier 1 QL
hydroxyzine hcl oral
tablet
Tier 1
hydroxyzine pamoate
oral capsule
Tier 1
LASTACAFT
OPHTHALMIC
DROPS
Tier 3 QL
PATADAY
OPHTHALMIC
DROPS
Tier 3 PA; QL
PATANOL
OPHTHALMIC
DROPS
Tier 3 PA; QL
promethazine oral syrup Tier 1
promethazine oral tablet Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
14
Nombre del medicamento Nivel Notas
ANTIHYPERGLYCEMICS
acarbose oral tablet Tier 1
APIDRA SOLOSTAR
SUBCUTANEOUS
INSULIN PEN
Tier 3 ST
APIDRA
SUBCUTANEOUS
SOLUTION
Tier 3 ST
BYDUREON
SUBCUTANEOUS
PEN INJECTOR
Tier 3 ST; QL
BYDUREON
SUBCUTANEOUS
SUSPENSION,EXTEN
DED REL RECON
Tier 3 ST; QL
chlorpropamide oral
tablet
Tier 1
glimepiride oral tablet Tier 1
glipizide oral tablet Tier 1
glipizide oral tablet
extended release 24hr
Tier 1
glipizide-metformin oral
tablet
Tier 1
glyburide oral tablet Tier 1
glyburide-metformin oral
tablet
Tier 1
GLYSET ORAL
TABLET
Tier 3
HUMALOG
KWIKPEN
SUBCUTANEOUS
INSULIN PEN
Tier 2
HUMALOG MIX 50-
50 KWIKPEN
SUBCUTANEOUS
INSULIN PEN
Tier 2
HUMALOG MIX 50-
50 SUBCUTANEOUS
SUSPENSION
Tier 2
HUMALOG MIX 75-
25 KWIKPEN
SUBCUTANEOUS
INSULIN PEN
Tier 2
HUMALOG MIX 75-
25 SUBCUTANEOUS
SUSPENSION
Tier 2
HUMALOG
SUBCUTANEOUS
CARTRIDGE
Tier 2
HUMALOG
SUBCUTANEOUS
SOLUTION
Tier 2
HUMULIN 70/30
KWIKPEN
SUBCUTANEOUS
INSULIN PEN
Tier 2
HUMULIN 70/30
SUBCUTANEOUS
SUSPENSION
Tier 2
HUMULIN N
KWIKPEN
SUBCUTANEOUS
INSULIN PEN
Tier 2
HUMULIN N
SUBCUTANEOUS
SUSPENSION
Tier 2
HUMULIN R
INJECTION
SOLUTION
Tier 2
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS
SOLUTION
Tier 2
JANUMET ORAL
TABLET
Tier 3 ST; QL
JANUMET XR ORAL
TABLET, ER
MULTIPHASE 24 HR
100-1,000 MG, 50-1,000
MG, 50-500 MG
Tier 3 ST; QL
JANUVIA ORAL
TABLET
Tier 3 ST; QL
JARDIANCE ORAL
TABLET
Tier 3 ST
LANTUS SOLOSTAR
SUBCUTANEOUS
INSULIN PEN
Tier 2
LANTUS
SUBCUTANEOUS
SOLUTION
Tier 2
LEVEMIR
FLEXTOUCH
SUBCUTANEOUS
INSULIN PEN
Tier 2
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
15
LEVEMIR
SUBCUTANEOUS
SOLUTION
Tier 2
metformin oral tablet Tier 1
metformin oral tablet
extended release 24 hr
Tier 1
metformin oral tablet
extended release 24hr
Tier 1
nateglinide oral tablet Tier 2 PA
NOVOLIN 70/30
SUBCUTANEOUS
SUSPENSION
Tier 2
NOVOLIN N
SUBCUTANEOUS
SUSPENSION
Tier 2
NOVOLIN R
INJECTION
SOLUTION
Tier 2
NOVOLOG FLEXPEN
SUBCUTANEOUS
INSULIN PEN
Tier 2
NOVOLOG MIX 70-30
FLEXPEN
SUBCUTANEOUS
INSULIN PEN
Tier 2
NOVOLOG MIX 70-30
SUBCUTANEOUS
SOLUTION
Tier 2
NOVOLOG PENFILL
SUBCUTANEOUS
CARTRIDGE
Tier 2
NOVOLOG
SUBCUTANEOUS
SOLUTION
Tier 2
ONGLYZA ORAL
TABLET 2.5 MG
Tier 3 ST; DO
ONGLYZA ORAL
TABLET 5 MG
Tier 3 ST; QL
pioglitazone oral tablet Tier 1 QL
repaglinide oral tablet Tier 2
SYMLINPEN 120
SUBCUTANEOUS
PEN INJECTOR
Tier 3 PA
SYMLINPEN 60
SUBCUTANEOUS
PEN INJECTOR
Tier 3 PA
Nombre del medicamento Nivel Notas
tolazamide oral tablet Tier 1
tolbutamide oral tablet Tier 1
TRADJENTA ORAL
TABLET
Tier 3 ST; DO
VICTOZA 2-PAK
SUBCUTANEOUS
PEN INJECTOR
Tier 3 ST; QL
VICTOZA 3-PAK
SUBCUTANEOUS
PEN INJECTOR
Tier 3 ST; QL
Nombre del medicamento Nivel Notas
ANTIINFECTIVES/MISCELLANEOUS
ALBENZA ORAL
TABLET
Tier 3
ALINIA ORAL
SUSPENSION FOR
RECONSTITUTION
Tier 3
ALINIA ORAL
TABLET
Tier 3
atovaquone oral
suspension
Tier 2
atovaquone-proguanil
oral tablet
Tier 1
BILTRICIDE ORAL
TABLET
Tier 3
chloroquine phosphate
oral tablet
Tier 1
COARTEM ORAL
TABLET
Tier 3
DARAPRIM ORAL
TABLET
Tier 3
hydroxychloroquine oral
tablet
Tier 1
ivermectin oral tablet Tier 1
mefloquine oral tablet Tier 1
paromomycin oral
capsule
Tier 1
PRIMAQUINE ORAL
TABLET
Tier 3
quinine sulfate oral
capsule
Tier 1 PA; QL
ANTIINFECTIVES
ARESTIN DENTAL
CARTRIDGE
Tier 3
WEBMENY-0030-15
Revised 1/1/2016
16
Nombre del medicamento Nivel Notas
ANTINEOPLASTICS
AFINITOR DISPERZ
ORAL TABLET FOR
SUSPENSION
Tier 3 PA
AFINITOR ORAL
TABLET
Tier 3 PA
ALFERON N
INJECTION
SOLUTION
Tier 3
ALKERAN ORAL
TABLET
Tier 3
anastrozole oral tablet Tier 3 PA
bexarotene oral capsule Tier 3 PA; QL
bicalutamide oral tablet Tier 3
BOSULIF ORAL
TABLET
Tier 3 PA
capecitabine oral tablet Tier 3 PA
CAPRELSA ORAL
TABLET
Tier 3 PA
COMETRIQ ORAL
CAPSULE 100
MG/DAY(80 MG[1]-20
MG[1]), 140
MG/DAY(80 MG[1]-20
MG[3]), 60 MG/DAY
(20 MG [3]/DAY)
Tier 3 PA; QL
CYCLOPHOSPHAMI
DE ORAL CAPSULE
Tier 3
diclofenac sodium
topical gel
Tier 2 PA
EMCYT ORAL
CAPSULE
Tier 3 PA
ERIVEDGE ORAL
CAPSULE
Tier 3 PA
etoposide oral capsule Tier 3
exemestane oral tablet Tier 3 PA
FARESTON ORAL
TABLET
Tier 3
FIRMAGON KIT W
DILUENT SYRINGE
SUBCUTANEOUS
RECON SOLN
Tier 3 PA
FIRMAGON
SUBCUTANEOUS
RECON SOLN
Tier 3 PA
FLUOROPLEX
TOPICAL CREAM
Tier 3
fluorouracil topical
cream
Tier 1
fluorouracil topical
solution
Tier 1
flutamide oral capsule Tier 3
GILOTRIF ORAL
TABLET
Tier 3 QL
GLEEVEC ORAL
TABLET
Tier 3 PA
HEXALEN ORAL
CAPSULE
Tier 3
HYCAMTIN ORAL
CAPSULE
Tier 3
hydroxyurea oral capsule Tier 3
ICLUSIG ORAL
TABLET 15 MG, 45
MG
Tier 3 PA; QL
INLYTA ORAL
TABLET
Tier 3 PA
INTRON A
INJECTION RECON
SOLN
Tier 3 PA
INTRON A
INJECTION
SOLUTION
Tier 3 PA
IRESSA ORAL
TABLET
Tier 3
JAKAFI ORAL
TABLET
Tier 3 PA
letrozole oral tablet Tier 3
LEUKERAN ORAL
TABLET
Tier 3
leuprolide subcutaneous
kit
Tier 3 PA
LOMUSTINE ORAL
CAPSULE
Tier 3
LYSODREN ORAL
TABLET
Tier 3
MATULANE ORAL
CAPSULE
Tier 3
MEKINIST ORAL
TABLET 0.5 MG, 2
MG
Tier 3 PA; QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
17
mercaptopurine oral
tablet
Tier 3
methotrexate sodium
oral tablet
Tier 3
mitoxantrone
intravenous concentrate
Tier 3
MYLERAN ORAL
TABLET
Tier 3
NEXAVAR ORAL
TABLET
Tier 3 PA
NILANDRON ORAL
TABLET
Tier 3
PANRETIN TOPICAL
GEL
Tier 3
POMALYST ORAL
CAPSULE 1 MG, 2
MG, 3 MG, 4 MG
Tier 3 QL
REVLIMID ORAL
CAPSULE
Tier 3 PA; QL
RITUXAN
INTRAVENOUS
CONCENTRATE
Tier 3 PA
SPRYCEL ORAL
TABLET
Tier 3 PA
STIVARGA ORAL
TABLET
Tier 3 PA
SUTENT ORAL
CAPSULE
Tier 3 PA
TABLOID ORAL
TABLET
Tier 3
TAFINLAR ORAL
CAPSULE
Tier 3
tamoxifen oral tablet Tier 3
TARCEVA ORAL
TABLET
Tier 3 PA
TARGRETIN
TOPICAL GEL
Tier 3 PA
TASIGNA ORAL
CAPSULE
Tier 3 PA
temozolomide oral
capsule
Tier 3 PA
TORISEL
INTRAVENOUS
RECON SOLN
Tier 3
Nombre del medicamento Nivel Notas
TRELSTAR DEPOT
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
Tier 3 PA
TRELSTAR
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
Tier 3 PA
TRELSTAR
INTRAMUSCULAR
SYRINGE
Tier 3 PA
TRELSTAR LA
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
Tier 3 PA
tretinoin (chemotherapy)
oral capsule
Tier 3
TYKERB ORAL
TABLET
Tier 3 PA
VOTRIENT ORAL
TABLET
Tier 3 PA
XALKORI ORAL
CAPSULE
Tier 3 PA
XTANDI ORAL
CAPSULE
Tier 3 PA
ZANOSAR
INTRAVENOUS
RECON SOLN
Tier 3
ZELBORAF ORAL
TABLET
Tier 3 PA
ZOLINZA ORAL
CAPSULE
Tier 3 PA
ZYTIGA ORAL
TABLET
Tier 3 PA
Nombre del medicamento Nivel Notas
ANTIPARKINSON DRUGS
amantadine hcl oral
capsule
Tier 1
amantadine hcl oral
solution
Tier 1
amantadine hcl oral
tablet
Tier 1
AZILECT ORAL
TABLET
Tier 3
benztropine oral tablet Tier 1
bromocriptine oral
capsule
Tier 1
WEBMENY-0030-15
Revised 1/1/2016
18
bromocriptine oral tablet Tier 1
carbidopa oral tablet Tier 2
carbidopa-levodopa oral
tablet
Tier 1
carbidopa-levodopa oral
tablet extended release
Tier 1
carbidopa-levodopa oral
tablet,disintegrating
Tier 1
entacapone oral tablet Tier 2
pramipexole oral tablet Tier 1
ropinirole oral tablet Tier 1
ropinirole oral tablet
extended release 24 hr
Tier 1
selegiline hcl oral
capsule
Tier 1
selegiline hcl oral tablet Tier 1
tolcapone oral tablet Tier 2
trihexyphenidyl oral
elixir
Tier 1
trihexyphenidyl oral
tablet
Tier 1
Nombre del medicamento Nivel Notas
ANTIPLATELET DRUGS
anagrelide oral capsule Tier 3
aspirin-dipyridamole oral
capsule, er multiphase 12
hr
Tier 2
BRILINTA ORAL
TABLET 60 MG, 90
MG
Tier 3 QL
cilostazol oral tablet Tier 2
clopidogrel oral tablet
300 mg
Tier 1
clopidogrel oral tablet 75
mg
Tier 1 QL
dipyridamole oral tablet Tier 1
EFFIENT ORAL
TABLET 10 MG
Tier 3 QL
EFFIENT ORAL
TABLET 5 MG
Tier 3 DO
ticlopidine oral tablet Tier 1
ANTIVIRALS
abacavir oral tablet Tier 3
abacavir-lamivudine-
zidovudine oral tablet
Tier 3
acyclovir oral capsule Tier 1
acyclovir oral suspension Tier 1
acyclovir oral tablet Tier 1
adefovir oral tablet Tier 3
APTIVUS ORAL
CAPSULE
Tier 3
APTIVUS ORAL
SOLUTION
Tier 3
ATRIPLA ORAL
TABLET
Tier 3
BARACLUDE ORAL
SOLUTION
Tier 3 PA
CRIXIVAN ORAL
CAPSULE
Tier 3
DAKLINZA ORAL
TABLET
Tier 1 QL
didanosine oral
capsule,delayed
release(dr/ec)
Tier 3
EDURANT ORAL
TABLET
Tier 3
EMTRIVA ORAL
CAPSULE
Tier 3
EMTRIVA ORAL
SOLUTION
Tier 3
entecavir oral tablet Tier 3 PA
EPIVIR HBV ORAL
SOLUTION
Tier 3 PA
EPZICOM ORAL
TABLET
Tier 3
famciclovir oral tablet Tier 1
foscarnet intravenous
solution
Tier 2
FUZEON
SUBCUTANEOUS
RECON SOLN
Tier 3
ganciclovir sodium
intravenous recon soln
Tier 3
HARVONI ORAL
TABLET
Tier 3 PA; QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
19
INTELENCE ORAL
TABLET
Tier 3
INVIRASE ORAL
CAPSULE
Tier 3
INVIRASE ORAL
TABLET
Tier 3
ISENTRESS ORAL
TABLET
Tier 3
ISENTRESS ORAL
TABLET,CHEWABLE
Tier 3
KALETRA ORAL
SOLUTION
Tier 3
KALETRA ORAL
TABLET
Tier 3
lamivudine oral tablet Tier 3
lamivudine-zidovudine
oral tablet
Tier 3
LEXIVA ORAL
SUSPENSION
Tier 3
LEXIVA ORAL
TABLET
Tier 3
moderiba dose pack oral
tablets,dose pack
Tier 2
moderiba oral tablet Tier 2
nevirapine oral
suspension
Tier 3
nevirapine oral tablet Tier 3
NORVIR ORAL
CAPSULE
Tier 3
NORVIR ORAL
SOLUTION
Tier 3
NORVIR ORAL
TABLET
Tier 3
PEGASYS
PROCLICK
SUBCUTANEOUS
PEN INJECTOR
Tier 3 PA; QL
PEGASYS
SUBCUTANEOUS
SOLUTION
Tier 3 PA; QL
PEGASYS
SUBCUTANEOUS
SYRINGE
Tier 3 PA; QL
Nombre del medicamento Nivel Notas
PEGINTRON
REDIPEN
SUBCUTANEOUS
PEN INJECTOR KIT
Tier 3 PA
PEGINTRON
SUBCUTANEOUS
KIT
Tier 3 PA
PREZISTA ORAL
SUSPENSION
Tier 3
PREZISTA ORAL
TABLET
Tier 3
RELENZA
DISKHALER
INHALATION
BLISTER WITH
DEVICE
Tier 2 QL
RESCRIPTOR ORAL
TABLET
Tier 3
RESCRIPTOR ORAL
TABLET,
DISPERSIBLE
Tier 3
REYATAZ ORAL
CAPSULE
Tier 3
ribasphere oral capsule Tier 3 PA
ribasphere oral tablet Tier 3 PA
ribasphere ribapak oral
tablets,dose pack
Tier 3 PA
ribavirin oral capsule Tier 3 PA
ribavirin oral tablet Tier 3 PA
rimantadine oral tablet Tier 1
SELZENTRY ORAL
TABLET
Tier 3
stavudine oral capsule Tier 3
stavudine oral recon soln Tier 3
SUSTIVA ORAL
CAPSULE
Tier 3
SUSTIVA ORAL
TABLET
Tier 3
TAMIFLU ORAL
CAPSULE 30 MG, 45
MG, 75 MG
Tier 2 QL
TAMIFLU ORAL
SUSPENSION FOR
RECONSTITUTION
Tier 2 QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
20
trifluridine ophthalmic
drops
Tier 1
TRUVADA ORAL
TABLET
Tier 3
TYZEKA ORAL
TABLET
Tier 3 PA
valacyclovir oral tablet Tier 1
VEREGEN TOPICAL
OINTMENT
Tier 3
VIRACEPT ORAL
TABLET
Tier 3
VIREAD ORAL
TABLET
Tier 3 PA
zidovudine oral capsule Tier 3
zidovudine oral syrup Tier 3
zidovudine oral tablet Tier 3
ZIRGAN
OPHTHALMIC GEL
Tier 3
Nombre del medicamento Nivel Notas
AUTONOMIC DRUGS
amphetamine salt combo
oral tablet
Tier 1 PA
bethanechol chloride oral
tablet
Tier 2
cevimeline oral capsule Tier 2
dextroamphetamine oral
capsule, extended release
Tier 1 PA
dextroamphetamine oral
solution
Tier 1 PA
dextroamphetamine oral
tablet
Tier 1 PA
dextroamphetamine-
amphetamine oral
capsule,extended release
24hr
Tier 1 PA
donepezil oral tablet Tier 1 QL
donepezil oral
tablet,disintegrating
Tier 1 QL
epinephrine injection
auto-injector
Tier 2
EPIPEN 2-PAK
INJECTION AUTO-
INJECTOR
Tier 2
EPIPEN JR 2-PAK
INJECTION AUTO-
INJECTOR
Tier 2
galantamine oral
capsule,ext rel. pellets 24
hr 16 mg, 24 mg
Tier 2 QL
galantamine oral
capsule,ext rel. pellets 24
hr 8 mg
Tier 2 DO
galantamine oral solution Tier 2 QL
galantamine oral tablet
12 mg, 4 mg
Tier 2 DO
galantamine oral tablet 8
mg
Tier 2 QL
guanidine oral tablet Tier 1
methamphetamine oral
tablet
Tier 1 PA
midodrine oral tablet Tier 1
phenoxybenzamine oral
capsule
Tier 2
pilocarpine hcl oral
tablet
Tier 2
procentra oral solution Tier 1 PA
rivastigmine tartrate oral
capsule 1.5 mg, 3 mg
Tier 2 DO
rivastigmine tartrate oral
capsule 4.5 mg, 6 mg
Tier 2 QL
zenzedi oral tablet Tier 1 PA
Nombre del medicamento Nivel Notas
BIOLOGICALS
ACTHIB (PF)
INTRAMUSCULAR
RECON SOLN
Tier 3
ADACEL(TDAP
ADOLESN/ADULT)(P
F) INTRAMUSCULAR
SUSPENSION
Tier 3
ADACEL(TDAP
ADOLESN/ADULT)(P
F) INTRAMUSCULAR
SYRINGE
Tier 3
BOOSTRIX TDAP
INTRAMUSCULAR
SUSPENSION
Tier 3
WEBMENY-0030-15
Revised 1/1/2016
21
BOOSTRIX TDAP
INTRAMUSCULAR
SYRINGE
Tier 3
CERVARIX
VACCINE (PF)
INTRAMUSCULAR
SYRINGE
Tier 2
COMVAX (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
DAPTACEL (DTAP
PEDIATRIC) (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
ENGERIX-B (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
ENGERIX-B (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
FLUARIX QUAD
2015-2016 (PF)
INTRAMUSCULAR
SYRINGE
Tier 1 QL
FLUMIST QUAD
2015-2016 NASAL
NASAL SPRAY
SYRINGE
Tier 1
FLUZONE 2015-2016
INTRAMUSCULAR
SUSPENSION
Tier 1 QL
FLUZONE HIGH-
DOSE 2015-16 (PF)
INTRAMUSCULAR
SYRINGE
Tier 1 QL
FLUZONE
INTRADERM QUAD
2015-16
INTRADERMAL
SYRINGE
Tier 1 QL
Nombre del medicamento Nivel Notas
FLUZONE QUAD
2015-2016 (PF)
INTRAMUSCULAR
SUSPENSION
Tier 1 QL
FLUZONE QUAD
2015-2016 (PF)
INTRAMUSCULAR
SYRINGE
Tier 1 QL
FLUZONE QUAD
2015-2016
INTRAMUSCULAR
SUSPENSION
Tier 1 QL
FLUZONE QUAD
PEDI 2015-16 (PF)
INTRAMUSCULAR
SYRINGE
Tier 1 QL
GAMASTAN S/D
INTRAMUSCULAR
SOLUTION
Tier 3
GARDASIL (PF)
INTRAMUSCULAR
SUSPENSION
Tier 2
GARDASIL (PF)
INTRAMUSCULAR
SYRINGE
Tier 2
GARDASIL 9 (PF)
INTRAMUSCULAR
SUSPENSION
Tier 2
GARDASIL 9 (PF)
INTRAMUSCULAR
SYRINGE
Tier 2
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
IMOVAX RABIES
VACCINE (PF)
INTRAMUSCULAR
RECON SOLN
Tier 3
INFANRIX (DTAP)
(PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
INFANRIX (DTAP)
(PF)
INTRAMUSCULAR
SYRINGE
Tier 3
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
22
IPOL INJECTION
SUSPENSION
Tier 3
IXIARO (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
KINRIX (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
KINRIX (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
MENACTRA (PF)
INTRAMUSCULAR
SOLUTION
Tier 3
MENHIBRIX (PF)
INTRAMUSCULAR
RECON SOLN
Tier 3
MENOMUNE -
A/C/Y/W-135 (PF)
SUBCUTANEOUS
RECON SOLN
Tier 3
MENOMUNE -
A/C/Y/W-135
SUBCUTANEOUS
RECON SOLN
Tier 3
MENVEO A-C-Y-W-
135-DIP (PF)
INTRAMUSCULAR
KIT
Tier 3
M-M-R II (PF)
SUBCUTANEOUS
RECON SOLN
Tier 3
PEDIARIX (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
PEDVAX HIB (PF)
INTRAMUSCULAR
SOLUTION
Tier 3
PENTACEL (PF)
INTRAMUSCULAR
KIT
Tier 3
PNEUMOVAX 23
INJECTION
SOLUTION
Tier 2
PNEUMOVAX 23
INJECTION
SYRINGE
Tier 2
Nombre del medicamento Nivel Notas
PREVNAR 13 (PF)
INTRAMUSCULAR
SYRINGE
Tier 2
PROQUAD (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION
Tier 3
RABAVERT (PF)
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
Tier 3
RECOMBIVAX HB
(PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
RECOMBIVAX HB
(PF)
INTRAMUSCULAR
SYRINGE
Tier 3
ROTARIX ORAL
SUSPENSION FOR
RECONSTITUTION
Tier 3
ROTATEQ VACCINE
ORAL SUSPENSION
Tier 3
TENIVAC (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
TENIVAC (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
TETANUS,DIPHTHE
RIA TOX PED(PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
TETANUS-
DIPHTHERIA
TOXOIDS-TD
INTRAMUSCULAR
SUSPENSION
Tier 3
TRUMENBA
INTRAMUSCULAR
SYRINGE
Tier 2
TWINRIX (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
TWINRIX (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
23
TYPHIM VI
INTRAMUSCULAR
SOLUTION
Tier 3
TYPHIM VI
INTRAMUSCULAR
SYRINGE
Tier 3
VAQTA (PF)
INTRAMUSCULAR
SUSPENSION
Tier 3
VAQTA (PF)
INTRAMUSCULAR
SYRINGE
Tier 3
VARIVAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION
Tier 3
VIVOTIF BERNA
VACCINE ORAL
CAPSULE,DELAYED
RELEASE(DR/EC)
Tier 2
YF-VAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION
Tier 3
ZOSTAVAX (PF)
SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION
Tier 2
Nombre del medicamento Nivel Notas
BLOOD
DROXIA ORAL
CAPSULE
Tier 3
pentoxifylline oral tablet
extended release
Tier 1
tranexamic acid
intravenous solution
Tier 2
tranexamic acid oral
tablet
Tier 1
CARDIAC DRUGS
afeditab cr oral tablet
extended release 30 mg
Tier 1 DO
afeditab cr oral tablet
extended release 60 mg
Tier 1 QL
amlodipine oral tablet 10
mg
Tier 1 QL
amlodipine oral tablet
2.5 mg, 5 mg
Tier 1 DO
cartia xt oral
capsule,extended release
24hr 120 mg, 180 mg
Tier 1 DO
cartia xt oral
capsule,extended release
24hr 240 mg, 300 mg
Tier 1 QL
digox oral tablet Tier 1
digoxin oral solution Tier 1
digoxin oral tablet Tier 1
diltiazem hcl oral
capsule, extended release
120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral
capsule, extended release
240 mg, 300 mg, 360
mg, 420 mg
Tier 1 QL
diltiazem hcl oral
capsule,ext release
degradable 120 mg, 180
mg
Tier 1 DO
diltiazem hcl oral
capsule,ext release
degradable 240 mg
Tier 1 QL
diltiazem hcl oral
capsule,extended release
12 hr 120 mg, 90 mg
Tier 1 QL
diltiazem hcl oral
capsule,extended release
12 hr 60 mg
Tier 1 DO
diltiazem hcl oral
capsule,extended release
24hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral
capsule,extended release
24hr 240 mg, 300 mg,
360 mg
Tier 1 QL
diltiazem hcl oral tablet Tier 1
diltiazem hcl oral tablet
extended release 24 hr
180 mg
Tier 1 DO
diltiazem hcl oral tablet
extended release 24 hr
240 mg, 300 mg, 360
mg, 420 mg
Tier 1
dilt-xr oral capsule,ext
release degradable 120
mg, 180 mg
Tier 1 DO
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
24
dilt-xr oral capsule,ext
release degradable 240
mg
Tier 1 QL
disopyramide phosphate
oral capsule
Tier 1
felodipine oral tablet
extended release 24 hr
10 mg
Tier 1 QL
felodipine oral tablet
extended release 24 hr
2.5 mg, 5 mg
Tier 1 DO
flecainide oral tablet Tier 2
isosorbide dinitrate oral
tablet
Tier 1
isosorbide dinitrate oral
tablet extended release
Tier 1
isosorbide mononitrate
oral tablet
Tier 1
isosorbide mononitrate
oral tablet extended
release 24 hr
Tier 1
isradipine oral capsule Tier 1
LANOXIN ORAL
TABLET
Tier 3
matzim la oral tablet
extended release 24 hr
180 mg
Tier 1 DO
matzim la oral tablet
extended release 24 hr
240 mg, 300 mg, 360
mg, 420 mg
Tier 1 QL
mexiletine oral capsule Tier 2
MULTAQ ORAL
TABLET
Tier 3
nicardipine oral capsule Tier 1
nifedical xl oral tablet
extended release 24hr 30
mg
Tier 1 DO
nifedical xl oral tablet
extended release 24hr 60
mg
Tier 1 QL
nifedipine oral capsule Tier 1
nifedipine oral tablet
extended release 24hr 30
mg
Tier 1 DO
Nombre del medicamento Nivel Notas
nifedipine oral tablet
extended release 24hr 60
mg, 90 mg
Tier 1 QL
nifedipine oral tablet
extended release 30 mg
Tier 1 DO
nifedipine oral tablet
extended release 60 mg,
90 mg
Tier 1 QL
nimodipine oral capsule Tier 2
nisoldipine oral tablet
extended release 24 hr
17 mg, 20 mg, 8.5 mg
Tier 1 DO
nisoldipine oral tablet
extended release 24 hr
25.5 mg, 30 mg, 34 mg,
40 mg
Tier 1 QL
nitro-bid transdermal
ointment
Tier 1
nitroglycerin oral
capsule, extended release
Tier 1
nitroglycerin translingual
aerosol,spray
Tier 2
nitroglycerin translingual
spray,non-aerosol
Tier 2
NITROSTAT
SUBLINGUAL
TABLET
Tier 2
nitro-time oral capsule,
extended release
Tier 1
procainamide injection
solution
Tier 2
propafenone oral
capsule,extended release
12 hr
Tier 2
propafenone oral tablet Tier 2
quinidine sulfate oral
tablet
Tier 1
quinidine sulfate oral
tablet extended release
Tier 1
RANEXA ORAL
TABLET EXTENDED
RELEASE 12 HR
Tier 3
taztia xt oral capsule,
extended release 120 mg,
180 mg
Tier 1 DO
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
25
taztia xt oral capsule,
extended release 240 mg,
300 mg, 360 mg
Tier 1 QL
TIKOSYN ORAL
CAPSULE
Tier 3
verapamil oral capsule,
24 hr er pellet ct 100 mg
Tier 1 DO
verapamil oral capsule,
24 hr er pellet ct 200 mg,
300 mg
Tier 1 QL
verapamil oral
capsule,ext rel. pellets 24
hr
Tier 1
verapamil oral tablet 120
mg, 80 mg
Tier 1 QL
verapamil oral tablet 40
mg
Tier 1
verapamil oral tablet
extended release
Tier 1
Nombre del medicamento Nivel Notas
CARDIOVASCULAR
acebutolol oral capsule Tier 1
ADCIRCA ORAL
TABLET
Tier 3 PA
amlodipine-atorvastatin
oral tablet 10-10 mg, 10-
20 mg, 10-40 mg, 10-80
mg, 5-80 mg
Tier 1 QL
amlodipine-atorvastatin
oral tablet 2.5-10 mg,
2.5-20 mg, 2.5-40 mg, 5-
10 mg, 5-20 mg, 5-40
mg
Tier 1 DO
amlodipine-benazepril
oral capsule
Tier 1
atenolol oral tablet Tier 1
atenolol-chlorthalidone
oral tablet
Tier 1
atorvastatin oral tablet 10
mg, 20 mg, 40 mg
Tier 1 DO
atorvastatin oral tablet 80
mg
Tier 1 QL
benazepril oral tablet Tier 1
benazepril-
hydrochlorothiazide oral
tablet
Tier 1
BENICAR HCT ORAL
TABLET 20-12.5 MG
Tier 3 DO
BENICAR HCT ORAL
TABLET 40-12.5 MG,
40-25 MG
Tier 3 QL
BENICAR ORAL
TABLET 20 MG
Tier 3 DO
BENICAR ORAL
TABLET 40 MG
Tier 3 QL
BENICAR ORAL
TABLET 5 MG
Tier 3 DO; QL
betaxolol oral tablet Tier 1
bisoprolol fumarate oral
tablet
Tier 1
bisoprolol-
hydrochlorothiazide oral
tablet
Tier 1
BYSTOLIC ORAL
TABLET
Tier 3
candesartan oral tablet
16 mg, 32 mg
Tier 1 QL
candesartan oral tablet 4
mg, 8 mg
Tier 1 DO; QL
candesartan-
hydrochlorothiazid oral
tablet 16-12.5 mg
Tier 1 DO
candesartan-
hydrochlorothiazid oral
tablet 32-12.5 mg
Tier 1 QL
candesartan-
hydrochlorothiazid oral
tablet 32-25 mg
Tier 1
captopril oral tablet Tier 1
carvedilol oral tablet Tier 1
cholestyramine (with
sugar) oral powder
Tier 1
cholestyramine (with
sugar) oral powder in
packet
Tier 1
cholestyramine light oral
powder
Tier 1
cholestyramine light oral
powder in packet
Tier 1
clonidine hcl oral tablet Tier 1
colestipol oral granules Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
26
colestipol oral packet Tier 1
colestipol oral tablet Tier 1
CRESTOR ORAL
TABLET 10 MG, 20
MG, 5 MG
Tier 3 ST; DO
CRESTOR ORAL
TABLET 40 MG
Tier 3 ST; QL
doxazosin oral tablet Tier 1
EDARBI ORAL
TABLET 40 MG
Tier 3 DO
EDARBI ORAL
TABLET 80 MG
Tier 3 QL
enalapril maleate oral
tablet
Tier 1
enalapril-
hydrochlorothiazide oral
tablet
Tier 1
eprosartan oral tablet Tier 1 QL
ergoloid oral tablet Tier 2
fenofibrate micronized
oral capsule
Tier 1
fenofibrate
nanocrystallized oral
tablet
Tier 1
fenofibrate oral tablet Tier 1
fenofibric acid (choline)
oral capsule,delayed
release(dr/ec)
Tier 1
fenofibric acid oral tablet Tier 1
fluvastatin oral capsule Tier 1 DO
fosinopril oral tablet Tier 1
fosinopril-
hydrochlorothiazide oral
tablet
Tier 1
gemfibrozil oral tablet Tier 1
guanfacine oral tablet Tier 1
hydralazine injection
solution
Tier 2
hydralazine oral tablet Tier 1
indomethacin sodium
intravenous recon soln
Tier 2
irbesartan oral tablet 150
mg, 75 mg
Tier 1 DO
Nombre del medicamento Nivel Notas
irbesartan oral tablet 300
mg
Tier 1 QL
irbesartan-
hydrochlorothiazide oral
tablet 150-12.5 mg
Tier 1 QL
irbesartan-
hydrochlorothiazide oral
tablet 300-12.5 mg
Tier 1
labetalol oral tablet Tier 1
LETAIRIS ORAL
TABLET
Tier 3 PA
LEVATOL ORAL
TABLET
Tier 3
lisinopril oral tablet Tier 1
lisinopril-
hydrochlorothiazide oral
tablet
Tier 1
LIVALO ORAL
TABLET 1 MG, 2 MG
Tier 3 ST; DO
LIVALO ORAL
TABLET 4 MG
Tier 3 ST; QL
losartan oral tablet 100
mg
Tier 1 QL
losartan oral tablet 25
mg, 50 mg
Tier 1 DO
losartan-
hydrochlorothiazide oral
tablet 100-12.5 mg, 100-
25 mg
Tier 1 QL
losartan-
hydrochlorothiazide oral
tablet 50-12.5 mg
Tier 1 DO
lovastatin oral tablet 10
mg, 20 mg
Tier 1 DO
lovastatin oral tablet 40
mg
Tier 1 QL
methyldopa oral tablet Tier 1
methyldopa-
hydrochlorothiazide oral
tablet
Tier 1
metoprolol succinate oral
tablet extended release
24 hr
Tier 1
metoprolol ta-
hydrochlorothiaz oral
tablet
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
27
metoprolol tartrate oral
tablet
Tier 1
minoxidil oral tablet Tier 1
moexipril oral tablet Tier 1
moexipril-
hydrochlorothiazide oral
tablet
Tier 1
nadolol oral tablet Tier 1
nadolol-
bendroflumethiazide oral
tablet
Tier 1
niacin oral tablet
extended release 24 hr
1,000 mg, 500 mg, 750
mg
Tier 1 QL
perindopril erbumine
oral tablet
Tier 1
pindolol oral tablet Tier 1
pravastatin oral tablet 10
mg, 20 mg, 40 mg
Tier 1 DO
pravastatin oral tablet 80
mg
Tier 1 QL
prazosin oral capsule Tier 1
prevalite oral powder Tier 1
prevalite oral powder in
packet
Tier 1
propranolol oral
capsule,extended release
24 hr
Tier 1
propranolol oral solution Tier 1
propranolol oral tablet Tier 1
propranolol-
hydrochlorothiazid oral
tablet
Tier 1
quinapril oral tablet Tier 1
quinapril-
hydrochlorothiazide oral
tablet
Tier 1
ramipril oral capsule Tier 1
REMODULIN
INJECTION
SOLUTION
Tier 3 PA
sildenafil oral tablet Tier 3 PA
Nombre del medicamento Nivel Notas
simvastatin oral tablet 10
mg, 20 mg, 40 mg, 5 mg
Tier 1 DO
simvastatin oral tablet 80
mg
Tier 1 PA; QL
sorine oral tablet Tier 2
sotalol af oral tablet Tier 2
sotalol oral tablet Tier 2
TEKTURNA ORAL
TABLET 150 MG
Tier 3 DO
TEKTURNA ORAL
TABLET 300 MG
Tier 3 QL
telmisartan oral tablet 20
mg, 40 mg
Tier 1 DO
telmisartan oral tablet 80
mg
Tier 1 QL
terazosin oral capsule Tier 1
timolol maleate oral
tablet
Tier 1
trandolapril oral tablet Tier 1
trandolapril-verapamil
oral tablet, ir & er,
biphasic 24hr
Tier 1
valsartan oral tablet 160
mg, 320 mg
Tier 1 QL
valsartan oral tablet 40
mg, 80 mg
Tier 1 DO; QL
valsartan-
hydrochlorothiazide oral
tablet 160-12.5 mg, 80-
12.5 mg
Tier 1 DO
valsartan-
hydrochlorothiazide oral
tablet 160-25 mg, 320-
12.5 mg, 320-25 mg
Tier 1 QL
VENTAVIS
INHALATION
SOLUTION FOR
NEBULIZATION
Tier 3 PA
WELCHOL ORAL
POWDER IN
PACKET
Tier 3
WELCHOL ORAL
TABLET
Tier 3
ZETIA ORAL
TABLET
Tier 3 PA; QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
28
Nombre del medicamento Nivel Notas
CNS DRUGS
AUBAGIO ORAL
TABLET
Tier 3 PA; QL
carbamazepine oral
capsule, er multiphase 12
hr
Tier 1
carbamazepine oral
suspension
Tier 1
carbamazepine oral
tablet
Tier 1
carbamazepine oral
tablet extended release
12 hr
Tier 1
carbamazepine oral
tablet,chewable
Tier 1
CELONTIN ORAL
CAPSULE
Tier 3
clonazepam oral tablet Tier 1
clonazepam oral
tablet,disintegrating
Tier 1
divalproex oral capsule,
sprinkle
Tier 1
divalproex oral tablet
extended release 24 hr
Tier 1
divalproex oral
tablet,delayed release
(dr/ec)
Tier 1
epitol oral tablet Tier 1
ethosuximide oral
capsule
Tier 1
ethosuximide oral
solution
Tier 1
EXTAVIA
SUBCUTANEOUS
KIT
Tier 3 PA
EXTAVIA
SUBCUTANEOUS
RECON SOLN
Tier 3 PA
felbamate oral
suspension
Tier 1
felbamate oral tablet Tier 1
fosphenytoin injection
solution
Tier 2
gabapentin oral capsule Tier 2
gabapentin oral solution Tier 2
gabapentin oral tablet Tier 2
HORIZANT ORAL
TABLET EXTENDED
RELEASE
Tier 3 PA
lamotrigine oral tablet Tier 1
lamotrigine oral tablet,
chewable dispersible
Tier 1
levetiracetam oral
solution
Tier 2
levetiracetam oral tablet Tier 2
levetiracetam oral tablet
extended release 24 hr
500 mg, 750 mg
Tier 2 PA; QL
LYRICA ORAL
CAPSULE 100 MG,
150 MG, 200 MG, 225
MG, 25 MG, 300 MG,
50 MG, 75 MG
Tier 3 PA; QL
LYRICA ORAL
SOLUTION
Tier 3 PA; QL
memantine oral tablet Tier 2
memantine oral
tablets,dose pack
Tier 2
NAMENDA ORAL
SOLUTION
Tier 3 QL
NUEDEXTA ORAL
CAPSULE
Tier 3
oxcarbazepine oral
suspension
Tier 1
oxcarbazepine oral tablet Tier 1
PEGANONE ORAL
TABLET
Tier 3
phenytoin sodium
extended oral capsule
Tier 1
primidone oral tablet Tier 1
REBIF (WITH
ALBUMIN)
SUBCUTANEOUS
SYRINGE
Tier 3 PA
REBIF REBIDOSE
SUBCUTANEOUS
PEN INJECTOR
Tier 3 PA
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
29
REBIF TITRATION
PACK
SUBCUTANEOUS
SYRINGE
Tier 3 PA
riluzole oral tablet Tier 3
SABRIL ORAL
POWDER IN
PACKET
Tier 3
SABRIL ORAL
TABLET
Tier 3
tiagabine oral tablet Tier 2
topiramate oral capsule,
sprinkle
Tier 1 PA
topiramate oral tablet Tier 1 PA
valproic acid (as sodium
salt) oral solution
Tier 1
valproic acid oral
capsule
Tier 1
XENAZINE ORAL
TABLET
Tier 3 PA
zonisamide oral capsule Tier 2
Nombre del medicamento Nivel Notas
COLONY STIMULATING FACTORS
ARANESP (IN
POLYSORBATE)
INJECTION
SOLUTION
Tier 3 PA
ARANESP (IN
POLYSORBATE)
INJECTION
SYRINGE
Tier 3 PA
LEUKINE
INJECTION RECON
SOLN
Tier 3 PA
MOZOBIL
SUBCUTANEOUS
SOLUTION
Tier 3 PA
NEULASTA
SUBCUTANEOUS
SYRINGE
Tier 3 PA; QL
NEUPOGEN
INJECTION
SOLUTION
Tier 3 PA
NEUPOGEN
INJECTION
SYRINGE
Tier 3 PA
PROCRIT
INJECTION
SOLUTION
Tier 3 PA
PROMACTA ORAL
TABLET
Tier 3 PA
ZARXIO INJECTION
SYRINGE
Tier 1
Nombre del medicamento Nivel Notas
CONTRACEPTIVES
altavera (28) oral tablet Tier 1
alyacen 1/35 (28) oral
tablet
Tier 1
alyacen 7/7/7 (28) oral
tablet
Tier 1
amethia lo oral
tablets,dose pack,3
month
Tier 1
amethia oral tablets,dose
pack,3 month
Tier 1
amethyst oral tablet Tier 1
apri oral tablet Tier 1
aranelle (28) oral tablet Tier 1
ashlyna oral tablets,dose
pack,3 month
Tier 1
aubra oral tablet Tier 1
aviane oral tablet Tier 1
azurette (28) oral tablet Tier 1
balziva (28) oral tablet Tier 1
BEYAZ ORAL
TABLET
Tier 3
briellyn oral tablet Tier 1
camila oral tablet Tier 1
camrese lo oral
tablets,dose pack,3
month
Tier 1
camrese oral tablets,dose
pack,3 month
Tier 1
caziant (28) oral tablet Tier 1
chateal oral tablet Tier 1
cryselle (28) oral tablet Tier 1
cyclafem 1/35 (28) oral
tablet
Tier 1
WEBMENY-0030-15
Revised 1/1/2016
30
cyclafem 7/7/7 (28) oral
tablet
Tier 1
cyred oral tablet Tier 1
dasetta 1/35 (28) oral
tablet
Tier 1
dasetta 7/7/7 (28) oral
tablet
Tier 1
daysee oral tablets,dose
pack,3 month
Tier 1
deblitane oral tablet Tier 1
delyla (28) oral tablet Tier 1
desog-
e.estradiol/e.estradiol
oral tablet
Tier 1
desogestrel-ethinyl
estradiol oral tablet
Tier 1
drospirenone-ethinyl
estradiol oral tablet
Tier 1
elinest oral tablet Tier 1
ELLA ORAL TABLET Tier 3
emoquette oral tablet Tier 1
enpresse oral tablet Tier 1
enskyce oral tablet Tier 1
errin oral tablet Tier 1
estarylla oral tablet Tier 1
falmina (28) oral tablet Tier 1
gianvi (28) oral tablet Tier 1
gildagia oral tablet Tier 1
gildess 24 fe oral tablet Tier 1
gildess fe oral tablet Tier 1
gildess oral tablet Tier 1
heather oral tablet Tier 1
introvale oral
tablets,dose pack,3
month
Tier 1
jencycla oral tablet Tier 1
jolessa oral tablets,dose
pack,3 month
Tier 1
jolivette oral tablet Tier 1
junel 1.5/30 (21) oral
tablet
Tier 1
Nombre del medicamento Nivel Notas
junel 1/20 (21) oral
tablet
Tier 1
junel fe 1.5/30 (28) oral
tablet
Tier 1
junel fe 1/20 (28) oral
tablet
Tier 1
junel fe 24 oral tablet Tier 1
kariva (28) oral tablet Tier 1
kelnor 1/35 (28) oral
tablet
Tier 1
kimidess (28) oral tablet Tier 1
kurvelo oral tablet Tier 1
l norgest/e.estradiol-
e.estrad oral tablets,dose
pack,3 month
Tier 1
larin 1.5/30 (21) oral
tablet
Tier 1
larin 1/20 (21) oral tablet Tier 1
larin 24 fe oral tablet Tier 1
larin fe oral tablet Tier 1
layolis fe oral
tablet,chewable
Tier 1
leena 28 oral tablet Tier 1
lessina oral tablet Tier 1
levonest (28) oral tablet Tier 1
levonorgestrel oral tablet Tier 1
levonorgestrel-ethinyl
estrad oral tablet
Tier 1
levonorgestrel-ethinyl
estrad oral tablets,dose
pack,3 month
Tier 1
LEVORA 0.15/30 (28)
ORAL TABLET
Tier 1
levora-28 oral tablet Tier 1
LO LOESTRIN FE
ORAL TABLET
Tier 3
lomedia 24 fe oral tablet Tier 1
loryna (28) oral tablet Tier 1
low-ogestrel (28) oral
tablet
Tier 1
lutera (28) oral tablet Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
31
lyza oral tablet Tier 1
marlissa oral tablet Tier 1
medroxyprogesterone
intramuscular suspension
Tier 1
medroxyprogesterone
intramuscular syringe
Tier 1
microgestin 1.5/30 (21)
oral tablet
Tier 1
microgestin 1/20 (21)
oral tablet
Tier 1
microgestin fe 1.5/30
(28) oral tablet
Tier 1
microgestin fe 1/20 (28)
oral tablet
Tier 1
MINASTRIN 24 FE
ORAL
TABLET,CHEWABLE
Tier 3
MIRENA
INTRAUTERINE
INTRAUTERINE
DEVICE
Tier 2
mono-linyah oral tablet Tier 1
mononessa (28) oral
tablet
Tier 1
my way oral tablet Tier 1
myzilra oral tablet Tier 1
NATAZIA ORAL
TABLET
Tier 3
necon 0.5/35 (28) oral
tablet
Tier 1
necon 1/35 (28) oral
tablet
Tier 1
necon 1/50 (28) oral
tablet
Tier 1
necon 10/11 (28) oral
tablet
Tier 1
necon 7/7/7 (28) oral
tablet
Tier 1
next choice one dose oral
tablet
Tier 1 QL
nikki (28) oral tablet Tier 1
nora-be oral tablet Tier 1
Nombre del medicamento Nivel Notas
noreth-ethinyl estradiol-
iron oral tablet,chewable
Tier 1
norethindrone
(contraceptive) oral
tablet
Tier 1
norethindrone ac-eth
estradiol oral tablet
Tier 1
norethindrone-
e.estradiol-iron oral
tablet
Tier 1
norgestimate-ethinyl
estradiol oral tablet
Tier 1
norgestrel-ethinyl
estradiol oral tablet
Tier 1
norlyroc oral tablet Tier 1
nortrel 0.5/35 (28) oral
tablet
Tier 1
nortrel 1/35 (21) oral
tablet
Tier 1
nortrel 1/35 (28) oral
tablet
Tier 1
nortrel 7/7/7 (28) oral
tablet
Tier 1
NUVARING
VAGINAL RING
Tier 3
ocella oral tablet Tier 1
ogestrel (28) oral tablet Tier 1
orsythia oral tablet Tier 1
ORTHO TRI-
CYCLEN LO (28)
ORAL TABLET
Tier 3
PARAGARD T 380A
INTRAUTERINE
INTRAUTERINE
DEVICE
Tier 2
philith oral tablet Tier 1
pimtrea (28) oral tablet Tier 1
pirmella oral tablet Tier 1
portia oral tablet Tier 1
previfem oral tablet Tier 1
QUARTETTE ORAL
TABLETS,DOSE
PACK,3 MONTH
Tier 3
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
32
quasense oral
tablets,dose pack,3
month
Tier 1
reclipsen (28) oral tablet Tier 1
SAFYRAL ORAL
TABLET
Tier 3
setlakin oral tablets,dose
pack,3 month
Tier 1
sharobel oral tablet Tier 1
sprintec (28) oral tablet Tier 1
sronyx oral tablet Tier 1
syeda oral tablet Tier 1
tarina fe oral tablet Tier 1
tilia fe oral tablet Tier 1
tri-estarylla oral tablet Tier 1
tri-legest fe oral tablet Tier 1
tri-linyah oral tablet Tier 1
trinessa (28) oral tablet Tier 1
tri-previfem (28) oral
tablet
Tier 1
tri-sprintec (28) oral
tablet
Tier 1
trivora (28) oral tablet Tier 1
velivet triphasic regimen
(28) oral tablet
Tier 1
vestura (28) oral tablet Tier 1
viorele (28) oral tablet Tier 1
vyfemla (28) oral tablet Tier 1
wera (28) oral tablet Tier 1
wymzya fe oral
tablet,chewable
Tier 1
xulane transdermal patch
weekly
Tier 1
zarah oral tablet Tier 1
zenchent (28) oral tablet Tier 1
zenchent fe oral
tablet,chewable
Tier 1
zeosa oral
tablet,chewable
Tier 1
zovia 1/35e (28) oral
tablet
Tier 1
Nombre del medicamento Nivel Notas
zovia 1/50e (28) oral
tablet
Tier 1
Nombre del medicamento Nivel Notas
COUGH/COLD PREPARATIONS
benzonatate oral capsule Tier 1
cheratussin ac oral liquid Tier 1
guaifenesin ac oral liquid Tier 1
iophen c-nr oral liquid Tier 1
promethazine vc-codeine
oral syrup
Tier 1
promethazine-codeine
oral syrup
Tier 1
promethazine-dm oral
syrup
Tier 1
promethazine-
phenyleph-codeine oral
syrup
Tier 1
DIAGNOSTIC
ACCU-CHEK
ACTIVE TEST STRIP
Tier 2 QL
ACCU-CHEK AVIVA
PLUS TEST STRP
STRIP
Tier 2 QL
ACCU-CHEK
COMPACT PLUS
TEST STRIP
Tier 2 QL
ACCU-CHEK
COMPACT TEST
STRIP
Tier 2 QL
ACCU-CHEK
SMARTVIEW TEST
STRIP STRIP
Tier 2 QL
ACCUTREND
GLUCOSE STRIP
Tier 2 QL
dipyridamole
intravenous solution
Tier 2
GLUCAGEN
DIAGNOSTIC KIT
INJECTION RECON
SOLN
Tier 2
ONETOUCH ULTRA
TEST STRIP
Tier 2 QL
ONETOUCH VERIO
STRIP
Tier 2 QL
DIURETICS
WEBMENY-0030-15
Revised 1/1/2016
33
acetazolamide oral
capsule, extended release
Tier 1
acetazolamide oral tablet Tier 1
amiloride oral tablet Tier 1
AMMONIUM
CHLORIDE
INTRAVENOUS
SOLUTION
Tier 3
bumetanide oral tablet Tier 1
chlorothiazide oral tablet Tier 1
chlorthalidone oral tablet Tier 1
DYRENIUM ORAL
CAPSULE
Tier 3
EDECRIN ORAL
TABLET
Tier 3
eplerenone oral tablet Tier 2
furosemide oral solution Tier 1
furosemide oral tablet Tier 1
hydrochlorothiazide oral
capsule
Tier 1
hydrochlorothiazide oral
tablet
Tier 1
indapamide oral tablet Tier 1
methazolamide oral
tablet
Tier 1
methyclothiazide oral
tablet
Tier 1
SAMSCA ORAL
TABLET
Tier 3
spironolactone oral tablet Tier 1
torsemide oral tablet Tier 1
triamterene-
hydrochlorothiazid oral
capsule
Tier 1
triamterene-
hydrochlorothiazid oral
tablet
Tier 1
Nombre del medicamento Nivel Notas
EENT PREPS
acetasol hc otic drops Tier 1
acetic acid otic solution Tier 1
acetic acid-aluminum
acetate otic drops
Tier 1
ALOCRIL
OPHTHALMIC
DROPS
Tier 3 PA; QL
ALOMIDE
OPHTHALMIC
DROPS
Tier 3 PA; QL
apraclonidine ophthalmic
drops
Tier 1
azelastine nasal
aerosol,spray
Tier 1 QL
AZOPT
OPHTHALMIC
DROPS,SUSPENSION
Tier 3
betaxolol ophthalmic
drops
Tier 1
bimatoprost ophthalmic
drops
Tier 2
brimonidine ophthalmic
drops
Tier 1
bromfenac ophthalmic
drops
Tier 2
carteolol ophthalmic
drops
Tier 1
COMBIGAN
OPHTHALMIC
DROPS
Tier 3
cromolyn ophthalmic
drops
Tier 1 QL
dexamethasone sodium
phosphate ophthalmic
drops
Tier 1
diclofenac sodium
ophthalmic drops
Tier 1
dorzolamide ophthalmic
drops
Tier 1
dorzolamide-timolol
ophthalmic drops
Tier 1
DUREZOL
OPHTHALMIC
DROPS
Tier 3 QL
flunisolide nasal
spray,non-aerosol
Tier 1 ST; QL
fluocinolone acetonide
oil otic drops
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
34
fluorometholone
ophthalmic
drops,suspension
Tier 1
flurbiprofen sodium
ophthalmic drops
Tier 1
fluticasone nasal
spray,suspension
Tier 1 QL
FML S.O.P.
OPHTHALMIC
OINTMENT
Tier 3
hydrocortisone-acetic
acid otic drops
Tier 1
ketorolac ophthalmic
drops
Tier 1
LACRISERT
OPHTHALMIC
INSERT
Tier 3
latanoprost ophthalmic
drops
Tier 1
levobunolol ophthalmic
drops
Tier 1
LOTEMAX
OPHTHALMIC
DROPS,GEL
Tier 3
LOTEMAX
OPHTHALMIC
DROPS,SUSPENSION
Tier 3
LOTEMAX
OPHTHALMIC
OINTMENT
Tier 3
LUMIGAN
OPHTHALMIC
DROPS
Tier 3
metipranolol ophthalmic
drops
Tier 1
naphazoline ophthalmic
drops
Tier 1
NEVANAC
OPHTHALMIC
DROPS,SUSPENSION
Tier 3
olopatadine nasal
spray,non-aerosol
Tier 1 QL
OMNARIS NASAL
SPRAY,NON-
AEROSOL
Tier 3 ST; QL
Nombre del medicamento Nivel Notas
PHOSPHOLINE
IODIDE
OPHTHALMIC
DROPS
Tier 3
pilocarpine hcl
ophthalmic drops
Tier 1
prednisolone acetate
ophthalmic
drops,suspension
Tier 1
prednisolone sodium
phosphate ophthalmic
drops
Tier 1
RESTASIS
OPHTHALMIC
DROPPERETTE
Tier 3
timolol maleate
ophthalmic drops
Tier 1
timolol maleate
ophthalmic gel forming
solution
Tier 1
TRAVATAN Z
OPHTHALMIC
DROPS
Tier 3
triamcinolone acetonide
nasal aerosol,spray
Tier 1 QL
tropicamide ophthalmic
drops
Tier 1
TYZINE NASAL
DROPS
Tier 3
TYZINE NASAL
SPRAY,NON-
AEROSOL
Tier 3
VEXOL
OPHTHALMIC
DROPS,SUSPENSION
Tier 3
ZIOPTAN (PF)
OPHTHALMIC
DROPPERETTE
Tier 3
Nombre del medicamento Nivel Notas
ELECT/CALORIC/H2O
calcium acetate oral
tablet
Tier 2
denta 5000 plus dental
cream
Tier 1
dentagel dental gel Tier 1
WEBMENY-0030-15
Revised 1/1/2016
35
EFFER-K ORAL
TABLET,
EFFERVESCENT
Tier 3
eliphos oral tablet Tier 2 PA
fe c plus oral tablet Tier 1
fluoridex daily defense
dental gel
Tier 1
FLUORIDEX
SENSITIVITY
RELIEF DENTAL
GEL
Tier 3
fluoritab oral
tablet,chewable
Tier 1
FOSRENOL ORAL
POWDER IN
PACKET
Tier 3 PA
FOSRENOL ORAL
TABLET,CHEWABLE
Tier 3 PA
GLUCAGEN
HYPOKIT
INJECTION RECON
SOLN
Tier 2
ISOLYTE S PH 7.4
INTRAVENOUS
PARENTERAL
SOLUTION
Tier 3
ISOLYTE-S
INTRAVENOUS
PARENTERAL
SOLUTION
Tier 3
kionex oral powder Tier 1
kionex oral suspension Tier 1
klor-con 10 oral tablet
extended release
Tier 1
klor-con 8 oral tablet
extended release
Tier 1
klor-con m10 oral
tablet,er
particles/crystals
Tier 1
klor-con m15 oral
tablet,er
particles/crystals
Tier 1
klor-con m20 oral
tablet,er
particles/crystals
Tier 1
Nombre del medicamento Nivel Notas
ludent fluoride oral
tablet,chewable
Tier 1
magnesium sulfate
injection syringe
Tier 2
NORMOSOL-R
INTRAVENOUS
PARENTERAL
SOLUTION
Tier 3
NORMOSOL-R PH 7.4
INTRAVENOUS
PARENTERAL
SOLUTION
Tier 3
NUTRAMINE ORAL
POWDER
Tier 3
PLASMA-LYTE 148
INTRAVENOUS
PARENTERAL
SOLUTION
Tier 3
PLASMA-LYTE A
INTRAVENOUS
PARENTERAL
SOLUTION
Tier 3
potassium chloride in
0.9%nacl intravenous
parenteral solution
Tier 2
potassium chloride oral
capsule, extended release
Tier 1
potassium chloride oral
tablet extended release
Tier 1
potassium chloride oral
tablet,er
particles/crystals
Tier 1
potassium chloride-0.45
% nacl intravenous
parenteral solution
Tier 2
potassium citrate oral
tablet extended release
Tier 1
PREVIDENT 5000
BOOSTER PLUS
DENTAL PASTE
Tier 3
PROGLYCEM ORAL
SUSPENSION
Tier 3
RENVELA ORAL
POWDER IN
PACKET
Tier 3 PA
RENVELA ORAL
TABLET
Tier 3 PA
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
36
sf 5000 plus dental
cream
Tier 1
sf dental gel Tier 1
sodium chloride 0.45 %
intravenous parenteral
solution
Tier 2
sodium chloride 0.45 %
intravenous piggyback
Tier 2
sodium chloride 0.9 %
intravenous parenteral
solution
Tier 2
sodium chloride 0.9 %
intravenous piggyback
Tier 2
sodium chloride 3 %
intravenous parenteral
solution
Tier 2
sodium chloride 5 %
intravenous parenteral
solution
Tier 2
sodium chloride
intravenous parenteral
solution
Tier 2
sodium fluoride dental
solution
Tier 1
sodium fluoride oral
drops
Tier 1
sodium fluoride oral
tablet,chewable
Tier 1
sodium polystyrene (sorb
free) oral suspension
Tier 1
sodium polystyrene
sulfonate oral powder
Tier 1
sodium polystyrene
sulfonate oral suspension
Tier 1
sodium polystyrene
sulfonate rectal enema
Tier 1
sps oral suspension Tier 1
sps rectal enema Tier 1
Nombre del medicamento Nivel Notas
GASTROINTESTINAL
alosetron oral tablet Tier 2
ALOXI
INTRAVENOUS
SOLUTION
Tier 3
AMITIZA ORAL
CAPSULE
Tier 3
anaspaz oral
tablet,disintegrating
Tier 2
anucort-hc rectal
suppository
Tier 1
ANZEMET ORAL
TABLET 100 MG, 50
MG
Tier 3 QL
APRISO ORAL
CAPSULE,EXTENDE
D RELEASE 24HR
Tier 3
balsalazide oral capsule Tier 1
BUPHENYL ORAL
TABLET
Tier 3 PA
CANTIL ORAL
TABLET
Tier 3
carafate oral suspension Tier 1
CESAMET ORAL
CAPSULE
Tier 3
cimetidine hcl oral
solution
Tier 1
cimetidine oral tablet Tier 1
CIMZIA POWDER
FOR RECONST
SUBCUTANEOUS
KIT
Tier 3 PA; QL
CIMZIA STARTER
KIT
SUBCUTANEOUS
SYRINGE KIT
Tier 3 PA; QL
CIMZIA
SUBCUTANEOUS
SYRINGE KIT
Tier 3 PA; QL
COMPAZINE ORAL
TABLET
Tier 1
constulose oral solution Tier 1
DEXILANT ORAL
CAPSULE,BIPHASE
DELAYED RELEAS
Tier 3 PA; QL
dicyclomine oral capsule Tier 1
dicyclomine oral
solution
Tier 1
dicyclomine oral tablet Tier 1
DIPENTUM ORAL
CAPSULE
Tier 3
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
37
diphenoxylate-atropine
oral liquid
Tier 1
diphenoxylate-atropine
oral tablet
Tier 1
enulose oral solution Tier 1
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec)
Tier 2 PA; QL
famotidine oral
suspension
Tier 1
famotidine oral tablet Tier 1
gavilyte-c oral recon soln Tier 1
gavilyte-g oral recon
soln
Tier 1
gavilyte-n oral recon
soln
Tier 1
generlac oral solution Tier 1
granisetron hcl oral
tablet
Tier 2 QL
grx hicort 25 rectal
suppository
Tier 1
hydrocortisone acetate
rectal suppository
Tier 1
hydrocortisone-pramox-
e-pram#1 rectal
kit,cream and towelette
Tier 1
hydrocortisone-
pramoxine rectal cream
Tier 1
lactulose oral solution Tier 1
lansoprazole oral
capsule,delayed
release(dr/ec)
Tier 1 QL
lidocaine hcl-
hydrocortison ac rectal
cream
Tier 1
lidocaine hcl-
hydrocortison ac rectal
kit
Tier 1
lidocaine-
hydrocortisone-aloe
rectal gel
Tier 1
lidocaine-
hydrocortisone-aloe
rectal kit
Tier 1
Nombre del medicamento Nivel Notas
LOVAZA ORAL
CAPSULE
Tier 3 QL
meclizine oral tablet Tier 1
methscopolamine oral
tablet
Tier 1
metoclopramide hcl oral
solution
Tier 1
metoclopramide hcl oral
tablet
Tier 1
misoprostol oral tablet Tier 1
MOTOFEN ORAL
TABLET
Tier 3
MOVIPREP ORAL
POWDER IN
PACKET
Tier 3
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET
Tier 3 PA; QL
nizatidine oral capsule Tier 1
nizatidine oral solution Tier 1
omega-3 acid ethyl esters
oral capsule
Tier 1 QL
omeprazole oral
capsule,delayed
release(dr/ec)
Tier 1 QL
ondansetron hcl oral
solution
Tier 2 QL
ondansetron hcl oral
tablet 24 mg, 4 mg, 8 mg
Tier 2 QL
ondansetron oral
tablet,disintegrating 4
mg, 8 mg
Tier 2 QL
pancrelipase 5000 oral
capsule,delayed
release(dr/ec)
Tier 1
pantoprazole oral
tablet,delayed release
(dr/ec)
Tier 2 QL
peg 3350-electrolytes
oral recon soln
Tier 1
peg-3350 with flavor
packs oral recon soln
Tier 1
phenadoz rectal
suppository
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
38
pramcort rectal cream Tier 1
prochlorperazine maleate
oral tablet
Tier 1
proctosol hc rectal cream Tier 1
proctozone-hc rectal
cream
Tier 1
promethazine rectal
suppository
Tier 1
promethegan rectal
suppository
Tier 1
rabeprazole oral
tablet,delayed release
(dr/ec)
Tier 2 QL
ranitidine hcl oral
capsule
Tier 1
ranitidine hcl oral syrup Tier 1
ranitidine hcl oral tablet Tier 1
RECTIV RECTAL
OINTMENT
Tier 3
REMICADE
INTRAVENOUS
RECON SOLN
Tier 3 PA
sucralfate oral tablet Tier 1
sulfasalazine oral tablet Tier 1
sulfasalazine oral
tablet,delayed release
(dr/ec)
Tier 1
sulfazine ec oral
tablet,delayed release
(dr/ec)
Tier 1
sulfazine oral tablet Tier 1
SUPREP BOWEL
PREP KIT ORAL
RECON SOLN
Tier 3
TRANSDERM-SCOP
TRANSDERMAL
PATCH 3 DAY
Tier 3
trilyte with flavor
packets oral recon soln
Tier 1
trimethobenzamide oral
capsule
Tier 1
ursodiol oral capsule Tier 2
ursodiol oral tablet Tier 2
Nombre del medicamento Nivel Notas
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC)
Tier 2
Nombre del medicamento Nivel Notas
HORMONES
ANADROL-50 ORAL
TABLET
Tier 3
ANDROGEL
TRANSDERMAL GEL
IN METERED-DOSE
PUMP
Tier 3 PA; QL
ANDROGEL
TRANSDERMAL GEL
IN PACKET 1.62 %
(20.25 MG/1.25
GRAM), 1.62 % (40.5
MG/2.5 GRAM)
Tier 3 PA; QL
androxy oral tablet Tier 1
budesonide oral
capsule,delayed,extend.r
elease
Tier 2
cabergoline oral tablet Tier 1
calcitonin (salmon) nasal
spray,non-aerosol
Tier 2 QL
chorionic gonadotropin,
human intramuscular
recon soln
Tier 3
cortisone oral tablet Tier 1
covaryx h.s. oral tablet Tier 1
covaryx oral tablet Tier 1
danazol oral capsule Tier 2
desmopressin injection
solution
Tier 1
desmopressin nasal
aerosol,spray
Tier 1
desmopressin nasal
solution
Tier 1
desmopressin nasal
spray,non-aerosol
Tier 1
desmopressin oral tablet Tier 1
dexamethasone intensol
oral drops
Tier 1
dexamethasone oral
elixir
Tier 1
dexamethasone oral
solution
Tier 1
WEBMENY-0030-15
Revised 1/1/2016
39
dexamethasone oral
tablet
Tier 1
eemt hs oral tablet Tier 1
eemt oral tablet Tier 1
ENJUVIA ORAL
TABLET
Tier 3
estradiol oral tablet Tier 1
estradiol transdermal
patch semiweekly
Tier 1 QL
estradiol transdermal
patch weekly
Tier 1 QL
estradiol-norethindrone
acet oral tablet
Tier 1
ESTRING VAGINAL
RING
Tier 3
estrogens-
methyltestosterone oral
tablet
Tier 1
estropipate oral tablet Tier 1
fludrocortisone oral
tablet
Tier 1
fortical nasal spray,non-
aerosol
Tier 2 QL
hydrocortisone oral
tablet
Tier 1
hydrocortisone rectal
enema
Tier 1
INCRELEX
SUBCUTANEOUS
SOLUTION
Tier 3 PA
jinteli oral tablet Tier 1
medroxyprogesterone
oral tablet
Tier 1
MENEST ORAL
TABLET
Tier 3
METHITEST ORAL
TABLET
Tier 3
methylergonovine oral
tablet
Tier 1
methylprednisolone oral
tablet
Tier 1
methylprednisolone oral
tablets,dose pack
Tier 1
Nombre del medicamento Nivel Notas
millipred dp oral
tablets,dose pack
Tier 1
millipred oral tablet Tier 1
mimvey oral tablet Tier 1
norethindrone acetate
oral tablet
Tier 1
OMNITROPE
SUBCUTANEOUS
CARTRIDGE
Tier 3 PA
OMNITROPE
SUBCUTANEOUS
RECON SOLN
Tier 3 PA
oxandrolone oral tablet Tier 2 PA
prednisolone oral
solution
Tier 1
prednisolone sodium
phosphate oral solution
Tier 1
prednisone intensol oral
concentrate
Tier 1
prednisone oral solution Tier 1
prednisone oral tablet Tier 1
prednisone oral
tablets,dose pack
Tier 1
PREMARIN ORAL
TABLET
Tier 3
PREMARIN
VAGINAL CREAM
Tier 3
PREMPHASE ORAL
TABLET
Tier 3
PREMPRO ORAL
TABLET
Tier 3
progesterone micronized
oral capsule
Tier 1
SOMATULINE
DEPOT
SUBCUTANEOUS
SYRINGE
Tier 3
SYNAREL NASAL
SPRAY,NON-
AEROSOL
Tier 3 PA
testosterone cypionate
intramuscular oil
Tier 1
testosterone transdermal
gel in metered-dose
pump
Tier 2 PA; QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
40
testosterone transdermal
gel in packet 1 % (25
mg/2.5gram), 1 % (50
mg/5 gram)
Tier 2 PA; QL
VAGIFEM VAGINAL
TABLET
Tier 3
veripred 20 oral solution Tier 1
Nombre del medicamento Nivel Notas
IMMUNOSUPPRESANT
azathioprine oral tablet Tier 3
cyclosporine modified
oral capsule
Tier 3
cyclosporine modified
oral solution
Tier 3
cyclosporine oral capsule Tier 3
ELIDEL TOPICAL
CREAM
Tier 3 PA
gengraf oral capsule Tier 3
gengraf oral solution Tier 3
mycophenolate mofetil
oral capsule
Tier 3
mycophenolate mofetil
oral tablet
Tier 3
mycophenolate sodium
oral tablet,delayed
release (dr/ec)
Tier 3
RAPAMUNE ORAL
SOLUTION
Tier 3
sirolimus oral tablet Tier 3
tacrolimus oral capsule Tier 3
tacrolimus topical
ointment
Tier 1 PA
ZORTRESS ORAL
TABLET
Tier 3 PA
MUSCLE RELAXANTS
baclofen oral tablet Tier 1
carisoprodol oral tablet Tier 1
chlorzoxazone oral tablet Tier 1
cyclobenzaprine oral
tablet
Tier 1
dantrolene oral capsule Tier 2
metaxalone oral tablet Tier 1
methocarbamol oral
tablet
Tier 1
orphenadrine citrate oral
tablet extended release
Tier 1
tizanidine oral capsule Tier 1
tizanidine oral tablet Tier 1
Nombre del medicamento Nivel Notas
PRE-NATAL VITAMINS
bal-care dha oral combo
pack,tablet & cap,dr
Tier 1
c-nate dha oral capsule Tier 1
complete natal dha oral
combo pack
Tier 1
completenate oral
tablet,chewable
Tier 1
elite-ob 400 oral capsule Tier 1
elite-ob oral capsule Tier 1
elite-ob oral tablet Tier 1
folbecal oral tablet, er
multiphase 24 hr
Tier 1
folivane-ob oral capsule Tier 1
hemenatal ob + dha oral
combo pack
Tier 1
hemenatal ob oral tablet Tier 1
inatal advance oral tablet Tier 1
inatal ultra oral tablet Tier 1
levomefolate dha oral
capsule
Tier 1
macnatal cn dha oral
capsule
Tier 1
mynatal advance oral
tablet
Tier 1
mynatal oral capsule Tier 1
mynatal oral tablet Tier 1
mynatal plus oral tablet Tier 1
mynatal-z oral tablet Tier 1
mynate 90 plus oral
tablet extended release
Tier 1
obstetrix dha oral combo
pack,tablet & cap,dr
Tier 1
pnv ob+dha oral combo
pack
Tier 1
WEBMENY-0030-15
Revised 1/1/2016
41
pnv-dha + docusate oral
capsule
Tier 1
pnv-dha oral capsule Tier 1
pnv-ferrous fumarate-
docu-fa oral tablet
Tier 1
pnv-omega oral capsule Tier 1
pnv-select oral tablet Tier 1
pr natal 400 ec oral
combo pack,tablet &
cap,dr
Tier 1
pr natal 400 oral combo
pack
Tier 1
pr natal 430 ec oral
combo pack,tablet &
cap,dr
Tier 1
pr natal 430 oral combo
pack
Tier 1
prenaissance next oral
tablet
Tier 1
prenaissance oral capsule Tier 1
prenaissance plus oral
capsule
Tier 1
prenatabs fa oral tablet Tier 1
prenatabs rx oral tablet Tier 1
PRENATAL 19 (WITH
DOCUSATE) ORAL
TABLET
Tier 1
PRENATAL 19 ORAL
TABLET,CHEWABLE
Tier 1
prenatal low iron oral
tablet
Tier 1
prenatal plus (calcium
carb) oral tablet
Tier 1
prenatal plus oral tablet Tier 1
prenatal-u oral capsule Tier 1
preplus oral tablet Tier 1
relnate dha oral capsule Tier 1
se-natal 19 (with
docusate) oral tablet
Tier 1
se-natal 19 oral
tablet,chewable
Tier 1
se-tan dha oral capsule Tier 1
Nombre del medicamento Nivel Notas
taron-bc oral tablets,
sequential
Tier 1
taron-c dha oral capsule Tier 1
taron-prex prenatal-dha
oral capsule
Tier 1
tl-select oral capsule Tier 1
triadvance oral tablet Tier 1
trinatal gt oral tablet Tier 1
trinatal rx 1 oral tablet Tier 1
trinate oral tablet Tier 1
tri-tabs dha oral combo
pack
Tier 1
triveen-duo dha oral
combo pack
Tier 1
triveen-one oral capsule Tier 1
triveen-prx rnf oral
capsule
Tier 1
triveen-u oral capsule Tier 1
trust natal dha oral
combo pack
Tier 1
ultimatecare one nf oral
capsule
Tier 1
ultimatecare one oral
capsule
Tier 1
vemavite-prx-2 oral
capsule
Tier 1
vena-bal dha oral combo
pack,tablet & cap,dr
Tier 1
venatal complete dha
oral combo pack,tablet &
cap,dr
Tier 1
vinacal oral tablet Tier 1
vinate care oral
tablet,chewable
Tier 1
vinate dha oral capsule Tier 1
vinate gt oral tablet Tier 1
vinate ii oral tablet Tier 1
vinate m oral tablet Tier 1
vinate one oral tablet Tier 1
vinate pn care oral tablet Tier 1
vinate ultra oral tablet Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
42
virt-pn dha oral capsule Tier 1
virt-pn oral tablet Tier 1
virt-pn plus oral capsule Tier 1
virt-select oral capsule Tier 1
vitafol-ob oral tablet Tier 1
vitaspire oral tablet Tier 1
vol-nate oral tablet Tier 1
vol-tab rx oral tablet Tier 1
vp-ch plus oral capsule Tier 1
vp-ch-pnv oral capsule Tier 1
vp-ggr-b6 oral tablet Tier 1
vp-heme ob + dha oral
combo pack
Tier 1
vp-heme ob oral tablet Tier 1
vp-heme one oral
capsule
Tier 1
zatean-ch oral capsule Tier 1
zatean-pn dha oral
capsule
Tier 1
zatean-pn plus oral
capsule
Tier 1
zingiber oral tablet Tier 1
Nombre del medicamento Nivel Notas
PSYCHOTHERAPEUTIC DRUGS
alprazolam oral tablet Tier 1
amitriptyline oral tablet Tier 1
amoxapine oral tablet Tier 1
aripiprazole oral solution Tier 2 PA
aripiprazole oral tablet Tier 2 PA
bupropion hcl oral tablet
100 mg
Tier 1 QL
bupropion hcl oral tablet
75 mg
Tier 1
bupropion hcl oral tablet
extended release 100 mg
Tier 1 DO
bupropion hcl oral tablet
extended release 150 mg,
200 mg
Tier 1 QL
bupropion hcl oral tablet
extended release 24 hr
150 mg
Tier 1 DO
bupropion hcl oral tablet
extended release 24 hr
300 mg
Tier 1 QL
buspirone oral tablet Tier 1
chlorpromazine oral
tablet
Tier 1 PA
citalopram oral solution Tier 1 QL
citalopram oral tablet 10
mg, 20 mg
Tier 1 DO
citalopram oral tablet 40
mg
Tier 1 QL
clomipramine oral
capsule
Tier 1
clonidine hcl oral tablet
extended release 12 hr
Tier 1 PA
clozapine oral tablet Tier 2 PA
clozapine oral
tablet,disintegrating
Tier 2 PA
desipramine oral tablet Tier 2
dexmethylphenidate oral
capsule,er biphasic 50-50
Tier 1 PA
dexmethylphenidate oral
tablet
Tier 1 PA
diazepam intensol oral
concentrate
Tier 1
diazepam oral
concentrate
Tier 1
diazepam oral solution Tier 1
diazepam oral tablet Tier 1
doxepin oral capsule Tier 1
doxepin oral concentrate Tier 1
duloxetine oral
capsule,delayed
release(dr/ec) 20 mg, 60
mg
Tier 2 PA; QL
duloxetine oral
capsule,delayed
release(dr/ec) 30 mg
Tier 2 PA; DO
duloxetine oral
capsule,delayed
release(dr/ec) 40 mg
Tier 2 PA
EMSAM
TRANSDERMAL
PATCH 24 HOUR
Tier 3 QL
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
43
escitalopram oxalate oral
solution
Tier 1 QL
escitalopram oxalate oral
tablet 10 mg, 5 mg
Tier 1 DO
escitalopram oxalate oral
tablet 20 mg
Tier 1 QL
FANAPT ORAL
TABLET
Tier 3 PA
FANAPT ORAL
TABLETS,DOSE
PACK
Tier 3 PA
fluoxetine oral capsule
10 mg, 20 mg
Tier 1 DO
fluoxetine oral capsule
40 mg
Tier 1 QL
fluoxetine oral
capsule,delayed
release(dr/ec)
Tier 1 QL
fluoxetine oral solution Tier 1 QL
fluoxetine oral tablet Tier 1 DO
fluphenazine hcl oral
concentrate
Tier 1 PA
fluphenazine hcl oral
elixir
Tier 1 PA
fluphenazine hcl oral
tablet
Tier 1 PA
fluvoxamine oral tablet
100 mg
Tier 1 QL
fluvoxamine oral tablet
25 mg, 50 mg
Tier 1 DO
FOCALIN XR ORAL
CAPSULE,ER
BIPHASIC 50-50
Tier 3 PA
guanfacine oral tablet
extended release 24 hr
Tier 1 PA
haloperidol oral tablet Tier 1 PA
imipramine hcl oral
tablet
Tier 1
INVEGA ORAL
TABLET EXTENDED
RELEASE 24HR
Tier 3 PA
LATUDA ORAL
TABLET
Tier 3 PA
lithium carbonate oral
capsule
Tier 1
Nombre del medicamento Nivel Notas
lithium carbonate oral
tablet
Tier 1
lithium carbonate oral
tablet extended release
Tier 1
lithium citrate oral
solution
Tier 1
loxapine succinate oral
capsule
Tier 1 PA
maprotiline oral tablet Tier 1
MARPLAN ORAL
TABLET
Tier 3
meprobamate oral tablet Tier 1
metadate er oral tablet
extended release
Tier 1 PA
methylphenidate oral
capsule, er biphasic 30-
70
Tier 1 PA
methylphenidate oral
capsule,er biphasic 50-50
Tier 1 PA
methylphenidate oral
solution
Tier 1 PA
methylphenidate oral
tablet
Tier 1 PA
methylphenidate oral
tablet extended release
Tier 1 PA
methylphenidate oral
tablet extended release
24hr
Tier 1 PA
mirtazapine oral tablet Tier 1
mirtazapine oral
tablet,disintegrating
Tier 1
modafinil oral tablet 100
mg
Tier 1 PA; DO
modafinil oral tablet 200
mg
Tier 1 PA; QL
nefazodone oral tablet Tier 1
nortriptyline oral capsule Tier 1
nortriptyline oral
solution
Tier 1
NUVIGIL ORAL
TABLET 150 MG, 250
MG, 50 MG
Tier 3 PA; QL
olanzapine oral tablet Tier 2 PA
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
44
olanzapine oral
tablet,disintegrating
Tier 2 PA
ORAP ORAL
TABLET
Tier 3 PA
paliperidone oral tablet
extended release 24hr
Tier 2 PA
paroxetine hcl oral tablet
10 mg, 20 mg
Tier 1 DO
paroxetine hcl oral tablet
30 mg, 40 mg
Tier 1 QL
paroxetine hcl oral tablet
extended release 24 hr
12.5 mg
Tier 1 DO
paroxetine hcl oral tablet
extended release 24 hr
25 mg, 37.5 mg
Tier 1 QL
perphenazine oral tablet Tier 1 PA
phenelzine oral tablet Tier 1
pimozide oral tablet Tier 2 PA
PRISTIQ ORAL
TABLET EXTENDED
RELEASE 24 HR 100
MG
Tier 3 QL
PRISTIQ ORAL
TABLET EXTENDED
RELEASE 24 HR 25
MG
Tier 3
PRISTIQ ORAL
TABLET EXTENDED
RELEASE 24 HR 50
MG
Tier 3 DO
protriptyline oral tablet Tier 1
quetiapine oral tablet Tier 1 PA
risperidone oral solution Tier 1 PA
risperidone oral tablet Tier 1 PA
risperidone oral
tablet,disintegrating
Tier 1 PA
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET
Tier 3 PA
SEROQUEL XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
Tier 3 PA
Nombre del medicamento Nivel Notas
sertraline oral
concentrate
Tier 1 QL
sertraline oral tablet 100
mg
Tier 1 QL
sertraline oral tablet 25
mg, 50 mg
Tier 1 DO
STRATTERA ORAL
CAPSULE
Tier 3 PA
thioridazine oral tablet Tier 1 PA
thiothixene oral capsule Tier 1 PA
tranylcypromine oral
tablet
Tier 1
trazodone oral tablet Tier 1
trifluoperazine oral tablet Tier 1 PA
trimipramine oral
capsule
Tier 1
venlafaxine oral
capsule,extended release
24hr 150 mg
Tier 1 QL
venlafaxine oral
capsule,extended release
24hr 37.5 mg, 75 mg
Tier 1 DO
venlafaxine oral tablet Tier 1
VENLAFAXINE
ORAL TABLET
EXTENDED
RELEASE 24HR 150
MG, 225 MG
Tier 1 QL
venlafaxine oral tablet
extended release 24hr
37.5 mg, 75 mg
Tier 1 DO
VIIBRYD ORAL
TABLET
Tier 3 ST
VIIBRYD ORAL
TABLETS,DOSE
PACK
Tier 3
VYVANSE ORAL
CAPSULE
Tier 3 PA
ziprasidone hcl oral
capsule
Tier 1 PA
Nombre del medicamento Nivel Notas
SEDATIVE/HYPNOTICS
eszopiclone oral tablet 1
mg, 2 mg
Tier 1 QL
eszopiclone oral tablet 3
mg
Tier 1 PA; QL
WEBMENY-0030-15
Revised 1/1/2016
45
phenobarbital oral elixir Tier 1
phenobarbital oral tablet Tier 1
ROZEREM ORAL
TABLET
Tier 3 ST; QL
SILENOR ORAL
TABLET
Tier 3
XYREM ORAL
SOLUTION
Tier 3 PA; QL
zaleplon oral capsule Tier 1 QL
zolpidem oral tablet Tier 1 QL
Nombre del medicamento Nivel Notas
SKIN PREPS
acitretin oral capsule Tier 2
ACZONE TOPICAL
GEL
Tier 3
adapalene topical cream Tier 1
adapalene topical gel Tier 1
adapalene topical gel
with pump
Tier 1
alclometasone topical
cream
Tier 1
alclometasone topical
ointment
Tier 1
ALTABAX TOPICAL
OINTMENT
Tier 3
amcinonide topical
cream
Tier 1
amcinonide topical
lotion
Tier 1
amcinonide topical
ointment
Tier 1
ammonium lactate
topical cream
Tier 1
ammonium lactate
topical lotion
Tier 1
amnesteem oral capsule Tier 1 PA
avita topical cream Tier 1 PA
AZELEX TOPICAL
CREAM
Tier 3 PA
benzoyl peroxide topical
cleanser
Tier 1
benzoyl peroxide topical
foam
Tier 1
betamethasone
dipropionate topical
cream
Tier 1
betamethasone
dipropionate topical
lotion
Tier 1
betamethasone
dipropionate topical
ointment
Tier 1
betamethasone valerate
topical cream
Tier 1
betamethasone valerate
topical foam
Tier 1
betamethasone valerate
topical lotion
Tier 1
betamethasone valerate
topical ointment
Tier 1
betamethasone,
augmented topical cream
Tier 1
betamethasone,
augmented topical gel
Tier 1
betamethasone,
augmented topical lotion
Tier 1
betamethasone,
augmented topical
ointment
Tier 1
bpo topical gel Tier 1
bpo topical towelette Tier 1
calcipotriene topical
cream
Tier 1
calcipotriene topical
ointment
Tier 1
calcipotriene topical
solution
Tier 1
calcitrene topical
ointment
Tier 1
calcitriol topical
ointment
Tier 1
claravis oral capsule Tier 1 PA
clindamycin-benzoyl
peroxide topical gel
Tier 1
clobetasol topical cream Tier 1
clobetasol topical foam Tier 1
clobetasol topical gel Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
46
clobetasol topical lotion Tier 1
clobetasol topical
ointment
Tier 1
clobetasol topical
shampoo
Tier 1
clobetasol topical
solution
Tier 1
clobetasol-emollient
topical cream
Tier 1
CLODERM TOPICAL
CREAM
Tier 3
CORDRAN TAPE
LARGE ROLL
TOPICAL TAPE
Tier 3
CORDRAN TAPE
SMALL ROLL
TOPICAL TAPE
Tier 3
CORDRAN TOPICAL
CREAM
Tier 3
CORDRAN TOPICAL
LOTION
Tier 3
cormax topical solution Tier 1
dermazene topical cream Tier 1
desonide topical cream Tier 1
desonide topical lotion Tier 1
desonide topical
ointment
Tier 1
desoximetasone topical
cream
Tier 1
desoximetasone topical
gel
Tier 1
desoximetasone topical
ointment
Tier 1
DIFFERIN TOPICAL
LOTION
Tier 3
diflorasone topical cream Tier 1
diflorasone topical
ointment
Tier 1
EPIDUO TOPICAL
GEL
Tier 3
EPIDUO TOPICAL
GEL WITH PUMP
Tier 3
Nombre del medicamento Nivel Notas
EURAX TOPICAL
CREAM
Tier 3
EURAX TOPICAL
LOTION
Tier 3
FINACEA TOPICAL
GEL
Tier 3
FLECTOR
TRANSDERMAL
PATCH 12 HOUR
Tier 3 ST
fluocinolone topical
cream
Tier 1
fluocinolone topical oil Tier 1
fluocinolone topical
ointment
Tier 1
fluocinolone topical
solution
Tier 1
fluocinolone-shower cap
topical oil
Tier 1
fluocinonide topical
cream
Tier 1
fluocinonide topical gel Tier 1
fluocinonide topical
ointment
Tier 1
fluocinonide topical
solution
Tier 1
fluocinonide-e topical
cream
Tier 1
fluticasone topical cream Tier 1
fluticasone topical lotion Tier 1
fluticasone topical
ointment
Tier 1
halobetasol propionate
topical cream
Tier 1
halobetasol propionate
topical ointment
Tier 1
HALOG TOPICAL
CREAM
Tier 3
HALOG TOPICAL
OINTMENT
Tier 3
hydrocortisone butyrate
topical cream
Tier 1
hydrocortisone butyrate
topical ointment
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
47
hydrocortisone butyrate
topical solution
Tier 1
hydrocortisone topical
cream
Tier 1
hydrocortisone topical
lotion
Tier 1
hydrocortisone topical
ointment
Tier 1
hydrocortisone valerate
topical cream
Tier 1
hydrocortisone valerate
topical ointment
Tier 1
hydrocortisone-
pramoxine topical cream
Tier 1
imiquimod topical cream
in packet
Tier 1 PA; QL
IODOFLEX TOPICAL
PADS, MEDICATED
Tier 3
iodoquinol-hc topical
cream
Tier 1
lidocaine hcl-
hydrocortison ac topical
cream
Tier 1
lindane topical lotion Tier 1
lindane topical shampoo Tier 1
malathion topical lotion Tier 1
methoxsalen rapid oral
capsule
Tier 2 PA
metronidazole topical
cream
Tier 1
metronidazole topical gel Tier 1
metronidazole topical gel
with pump
Tier 1
metronidazole topical
lotion
Tier 1
mometasone topical
cream
Tier 1
mometasone topical
ointment
Tier 1
mometasone topical
solution
Tier 1
NUOX TOPICAL GEL Tier 3
Nombre del medicamento Nivel Notas
OVACE PLUS
TOPICAL
CLEANSER,EXTEND
ED RELEASE
Tier 3
OVACE PLUS
TOPICAL CREAM
Tier 3
OVACE PLUS WASH
TOPICAL
CLEANSER,GEL
EXTENDED
RELEASE
Tier 3
OXSORALEN
TOPICAL LOTION
Tier 3
permethrin topical cream Tier 1
podofilox topical
solution
Tier 1
prednicarbate topical
cream
Tier 1
prednicarbate topical
ointment
Tier 1
prudoxin topical cream Tier 2
REGRANEX
TOPICAL GEL
Tier 3
rosadan topical cream Tier 1
rosadan topical gel Tier 1
ROSADAN TOPICAL
KIT, CLEANSER &
GEL
Tier 3
ROSADAN TOPICAL
KIT,CLEANSER AND
CREAM
Tier 3
salacyn topical cream Tier 1
salacyn topical lotion Tier 1
salicylic acid sr-
ceramides topical combo
pack
Tier 1
salicylic acid sr-
ceramides topical
kit,cleanser & cream er
Tier 1
salicylic acid topical
cream
Tier 1
salicylic acid topical
cream,extended release
Tier 1
salicylic acid topical film
forming liquid w/appl
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
48
salicylic acid topical
foam
Tier 1
salicylic acid topical gel Tier 1
salicylic acid topical
liquid
Tier 1
salicylic acid topical
lotion
Tier 1
salicylic acid topical
lotion,extended release
Tier 1
salicylic acid topical
shampoo
Tier 1
salvax topical foam Tier 1
SANTYL TOPICAL
OINTMENT
Tier 3
seb-prev topical cleanser Tier 1
selenium sulfide topical
shampoo
Tier 1
selenium sulfide topical
suspension
Tier 1
sodium chloride
irrigation solution
Tier 2
spinosad topical
suspension
Tier 1
sulfacetamide sodium
(acne) topical suspension
Tier 1
sulfacetamide sodium
topical cleanser
Tier 1
sulfacetamide sodium
topical shampoo
Tier 1
TAZORAC TOPICAL
CREAM
Tier 3 PA
TAZORAC TOPICAL
GEL
Tier 3 PA
tretinoin (emollient)
topical cream
Tier 1
tretinoin topical cream Tier 1 PA
tretinoin topical gel Tier 1 PA
triamcinolone acetonide
topical cream
Tier 1
triamcinolone acetonide
topical lotion
Tier 1
triamcinolone acetonide
topical ointment
Tier 1
Nombre del medicamento Nivel Notas
trianex topical ointment Tier 1
triderm topical cream Tier 1
ULESFIA TOPICAL
LOTION
Tier 3
VOLTAREN
TOPICAL GEL
Tier 3
zenatane oral capsule Tier 1 PA
ZIANA TOPICAL
GEL
Tier 3 PA
Nombre del medicamento Nivel Notas
SMOKING DETERRENTS
buproban oral tablet
extended release
Tier 1 QL
CHANTIX
CONTINUING
MONTH BOX ORAL
TABLET
Tier 3 QL
CHANTIX
CONTINUING
MONTH PAK ORAL
TABLET
Tier 3 QL
CHANTIX ORAL
TABLET
Tier 3 QL
CHANTIX STARTING
MONTH BOX ORAL
TABLETS,DOSE
PACK
Tier 3 QL
CHANTIX STARTING
MONTH PAK ORAL
TABLETS,DOSE
PACK
Tier 3 QL
THYROID PREPS
levothyroxine oral tablet Tier 1
levoxyl oral tablet Tier 1
liothyronine oral tablet Tier 1
methimazole oral tablet Tier 1
nature-throid oral tablet Tier 1
np thyroid oral tablet Tier 1
propylthiouracil oral
tablet
Tier 1
THYROLAR-1 ORAL
TABLET
Tier 3
THYROLAR-1/2
ORAL TABLET
Tier 3
WEBMENY-0030-15
Revised 1/1/2016
49
THYROLAR-1/4
ORAL TABLET
Tier 3
THYROLAR-2 ORAL
TABLET
Tier 3
THYROLAR-3 ORAL
TABLET
Tier 3
unithroid oral tablet Tier 1
westhroid oral tablet Tier 1
Nombre del medicamento Nivel Notas
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral
tablet,delayed release
(dr/ec)
Tier 2
alendronate oral solution Tier 1 QL
alendronate oral tablet 10
mg, 35 mg, 40 mg, 5 mg,
70 mg
Tier 1 QL
alfuzosin oral tablet
extended release 24 hr
Tier 1
AVODART ORAL
CAPSULE
Tier 3 PA
buprenorphine hcl
sublingual tablet 2 mg, 8
mg
Tier 1 PA; QL
buprenorphine-naloxone
sublingual tablet 2-0.5
mg, 8-2 mg
Tier 1 PA; QL
calcipotriene-
betamethasone topical
ointment
Tier 1
CARBAGLU ORAL
TABLET,
DISPERSIBLE
Tier 3
CHEMET ORAL
CAPSULE
Tier 3
chlorhexidine gluconate
mucous membrane
mouthwash
Tier 1
CIALIS ORAL
TABLET
Tier 3 PA; QL
CYSTADANE ORAL
POWDER
Tier 3
disulfiram oral tablet Tier 1
doxycycline hyclate oral
tablet
Tier 1
dutasteride oral capsule Tier 2 PA
ENABLEX ORAL
TABLET EXTENDED
RELEASE 24 HR
Tier 3 ST
EXJADE ORAL
TABLET,
DISPERSIBLE
Tier 3 PA
FABRAZYME
INTRAVENOUS
RECON SOLN
Tier 3 PA
FERRIPROX ORAL
TABLET
Tier 3 PA
finasteride oral tablet Tier 1 PA
flavoxate oral tablet Tier 1
FORTEO
SUBCUTANEOUS
PEN INJECTOR
Tier 3 PA; QL
FOSAMAX PLUS D
ORAL TABLET
Tier 3 ST; QL
ibandronate oral tablet Tier 1 QL
JALYN ORAL
CAPSULE, ER
MULTIPHASE 24 HR
Tier 3
leucovorin calcium oral
tablet
Tier 3
levocarnitine (with
sugar) oral solution
Tier 2
levocarnitine oral tablet Tier 2
NYSTATIN (BULK)
POWDER
Tier 1
oralone dental paste Tier 1
ORFADIN ORAL
CAPSULE
Tier 3
oxybutynin chloride oral
syrup
Tier 1
oxybutynin chloride oral
tablet
Tier 1
oxybutynin chloride oral
tablet extended release
24hr
Tier 1
paroex oral rinse mucous
membrane mouthwash
Tier 1
periogard mucous
membrane mouthwash
Tier 1
Nombre del medicamento Nivel Notas
WEBMENY-0030-15
Revised 1/1/2016
50
PROLIA
SUBCUTANEOUS
SYRINGE
Tier 3 PA; QL
raloxifene oral tablet Tier 1
RAPAFLO ORAL
CAPSULE
Tier 3
risedronate oral tablet
150 mg, 30 mg, 5 mg
Tier 1 QL
risedronate oral tablet 35
mg
Tier 1
risedronate oral
tablet,delayed release
(dr/ec)
Tier 1
SAVELLA ORAL
TABLET
Tier 3 QL
SAVELLA ORAL
TABLETS,DOSE
PACK
Tier 3 QL
SENSIPAR ORAL
TABLET
Tier 3
sodium chlor 0.9%
bacteriostat injection
solution
Tier 2
SUBOXONE
SUBLINGUAL FILM
12-3 MG, 2-0.5 MG, 4-1
MG, 8-2 MG
Tier 3 PA; QL
SYPRINE ORAL
CAPSULE
Tier 3
TACLONEX
TOPICAL
SUSPENSION
Tier 3
tamsulosin oral
capsule,extended release
24hr
Tier 1
tolterodine oral tablet Tier 1
TOVIAZ ORAL
TABLET EXTENDED
RELEASE 24 HR
Tier 3
triamcinolone acetonide
dental paste
Tier 1
trospium oral
capsule,extended release
24hr
Tier 2
Nombre del medicamento Nivel Notas
TYSABRI
INTRAVENOUS
SOLUTION
Tier 3 PA
VESICARE ORAL
TABLET
Tier 3
XIAFLEX
INJECTION RECON
SOLN
Tier 3 PA
ZEMAIRA
INTRAVENOUS
RECON SOLN
Tier 3
zoledronic acid
intravenous recon soln
Tier 3
zoledronic acid-
mannitol-water
intravenous solution
Tier 3 PA
Nombre del medicamento Nivel Notas
VITAMINS
calcitriol oral capsule Tier 1
calcitriol oral solution Tier 1
cyanocobalamin (vitamin
b-12) injection solution
Tier 1
ergocalciferol (vitamin
d2) oral capsule
Tier 1
folic acid oral tablet Tier 1
vitamin d2 oral capsule Tier 1