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Pharmacy PDL Connecticut2022 4-Tier Prescription Drug ListThis Prescription Drug List (PDL) outlines the most commonly prescribed medications for certainconditions and organizes them into cost levels, also known as tiers. This PDL is accurate as ofJanuary 1, 2022, and is subject to change after this date. The next anticipated update will be inMay 2022. Your estimated coverage and copayment/coinsurance may vary based on the benefitplan1 you choose and the effective date of the plan.For more information:Visit the member website listed on your health plan ID card for information to help you betterunderstand and manage your medications. View your current benefits Search for drug prices and lower-cost alternatives You could save time and money using home delivery through OptumRx Call the toll-free phone number on your health plan ID card.Effective January 1, 20221OptumRx is the administrator of your Oxford pharmacy benefit plan.Note: Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Specialized non-standard infant formulas and nutritional supplements may be subject to prior authorization.Please see your Summary of Benefits and Coverage (SBC) for specifics.In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.All brand-name medications are trademarks or registered trademarks of their respective owners.Oxford insurance products are underwritten by Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. Administrative services provided by Oxford Health Plans LLC.Created January 1, 2022 Prescription Drug List – Oxford Connecticut 4-Tier. 2022 Oxford Health Plans LLC. All Rights Reserved. WF4917715-A 072021
Your Prescription Drug ListThis PDL outlines covered medications and organizes them into cost levels, also known as tiers. An important part of the PDLis giving you choices so you and your doctor can choose the best course of treatment for you.Go to your member website for drug information.Since the PDL may change, we encourage you to visit the member website listed on your health plan ID card. It’s the bestsource for accessing up-to-date information about the medications your pharmacy benefit covers, possible lower-cost optionsand cost comparisons.We want to help you better understand your medication options.Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out ofyour pharmacy benefit, we’ve included some of the most commonly asked questions about the PDL below.What is a PDL?This document is a list of covered medications. They are placed into cost levels known as tiers. The PDL includes bothbrand-name and generic prescription medications approved by the Food and Drug Administration (FDA).Please note: Where differences are noted between this PDL and your health plan documents, the health plan documents willrule. Please look at your health plan documents to see which medications are covered under your health plan. You may also login to the member website listed on your health plan ID card or call us at the toll-free phone number on your ID card formore information.How do I use my PDL?Bring your PDL with you when you see your doctor. When choosing a medication, you and your doctor should consult thisguide. It will help you and your doctor choose the most cost-effective prescription drugs. This guide will also help you know if amedication has special programs that apply to it.When a prescription drug product is excluded from coverage, you or your representative may request an exception to gainaccess to the excluded prescription drug product. To make a request, contact us in writing or call the toll-free phone number onyour ID card. We will notify you of our determination within 72 hours.What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employeror health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options.If your medication is placed in Tier 2, 3 or 4, look to see if there is a Tier 1 option available. You should discuss these optionswith your doctor.Check your health plan documents to find your specific pharmacy plan costs. Drug TierIncludesHelpful TipsTier 1Your lowest costSome brands and generics.Use Tier 1 drugs for the lowestout-of-pocket costs. Tier 2Your mid-range costPreferred brands.Use Tier 2 drugs instead of Tier 3 orTier 4 drugs to help reduce your out-ofpocket costs. Tier 3Your mid-range costPreferred specialty andnon-preferred brands.Use Tier 3 drugs instead of Tier 4 drugsto help reduce your out-of-pocket costs.Tier 4Your highest costHigher cost brands and generics.Non-preferred specialty andnon-preferred brands.Many Tier 4 drugs have lower-costoptions in Tiers 1, 2 or 3. Ask yourdoctor if they could work for you. 2
Please note: Some plans may have 2 or 3 tiers, while others may not have any. If you have a high-deductible health plan, the tiercost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on the member website listedon your health plan ID card, or call us at the toll-free phone number on your ID card for more information about your health plan.Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summaryof Benefits and Coverage (SBC) for specifics.When does the PDL change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a generic becomes available. Medications may move to a higher tier or be excluded from coverage, most often on Jan. 1, May 1, or Sept. 1.When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, callus at the toll-free phone number on your health plan ID card.Programs and limitsSome medications are in one or more of our pharmacy benefit programs. Your health plan determines how these medicationsare covered and may differ from what is noted in the PDL.Health care reform (HCR) preventive — This medication is part of a health care reform preventive benefit and may beavailable at no additional cost to you.Notification or precertification (sometimes referred to as prior authorization) required2 — Your doctor is required toprovide additional information to us to determine coverage.Supply limit — Amount of medication covered per copayment or in a specific time period.Step therapy — Trial of a different medication is required before another medication may be covered.To learn more about a pharmacy program or to find out if it applies to you, please visit the member website listed on yourhealth plan ID card or call us at the toll-free phone number on your ID card. TTY users can dial 711.Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to anover-the-counter (OTC) medication.3 Other medication options may be available.Should I talk to my doctor about over-the-counter (OTC) medications?An OTC medication may be the right treatment for some conditions. Talk to your doctor about available options.What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, butthey often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the sameactive ingredients. These types of medications are known as generic medications. Sometimes, the same company that makesa brand-name medication also makes the generic version.What if my doctor writes a prescription for a brand-name medication?The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost optionis available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For somehealth plans, if a brand-name medication is prescribed and a generic equivalent is available, your share of the cost may be thecopayment PLUS the cost difference between the brand-name medication and its generic equivalent. Visit the member websitelisted on your health plan ID card to make sure.Are you taking a specialty medication?Take advantage of personalized support designed to help you get the most out of your benefit plan. Visit the member websitelisted on your health plan ID card or call the toll-free phone number on your ID card to learn more. If you’re taking a specialtymedication that is on Tier 4, call us at the toll-free phone number on your ID card to talk with a pharmacist about finding lowercost options or a financial assistance program.2Depending on your benefit, you may have notification or precertification requirements for select medications.3
How do I get updated information about my pharmacy benefit?Since the PDL may change during your plan year, we encourage you to visit the member website listed on your health plan IDcard or call us at the toll-free phone number on your ID card for more current information.How do I locate and fill a prescription through the mail order pharmacy?UnitedHealthcare offers a Mail Order Pharmacy Program through OptumRx . Here’s how to fill prescriptions through the MailOrder Pharmacy Program.1. Call your prescribing provider to obtain a new prescription for each medication. When you call, ask the Physician to writethe prescription for a 90-day supply which represents 3 prescription units with up to 3 additional refills. The doctor will tellyou when to pick up the written prescription. (Note: OptumRx must have a new prescription to process any new Mail Orderrequest.)2. After picking up the prescription, complete the Mail Order Form included in your enrollment materials. (To obtain additionalforms or for assistance in completing the form, contact UnitedHealthcare’s Customer Service Department by calling thetelephone number on the back of your ID card. You can also find the form at optumrx.com.)3. Enclose the prescription and appropriate copayment via check, money order, or credit card. Your Pharmacy Schedule ofBenefits will have the applicable copayment for the Mail Order Pharmacy Program. Make the check or money order payableto OptumRx. No cash please.Important Tip: If you are starting a new Prescription Drug Product, please request 2 prescriptions from your physician. Have1 filled immediately at a network pharmacy while mailing the second prescription to UnitedHealthcare’s Mail Order Pharmacy.Once you receive your medication through the Mail Order Pharmacy Program, you should stop filling the prescription at thenetwork pharmacy.Learn more3Call the toll-free member phone number listed on your health plan ID card,or visit your member website for more information.This is not applicable for Connecticut Public Sector plans. For Connecticut commercial business, a prescription drug product that is therapeutically equivalent to an over-the-counter drug may be covered if it isdetermined to be medically necessary.4
Nondiscrimination notice andaccess to communication servicesOxford Health Plans (CT), Inc. and Oxford Health Insurance, Inc. do not treat members differently because of sex, age, race,color, disability or national origin.If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send acomplaint to the Civil Rights Coordinator.Online:UHC Civil [email protected]:Civil Rights CoordinatorUnitedHealthcare Civil Rights GrievanceP.O. Box 30608Salt Lake City, UT 84130You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. Ifyou disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please callthe toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 6 p.m.You can also file a complaint with the U.S. Dept. of Health and Human al/lobby.jsfComplaint forms are available at :Toll free 1-800-368-1019, 1-800-537-7697 (TDD)Mail:U.S. Dept. of Health and Human Services200 Independence Avenue SWRoom 509F, HHH BuildingWashington, D.C. 20201We provide free services to help you communicate with us, such as letters in other languages or large print. Or, you can askfor an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday throughFriday, 8 a.m. to 6 p.m.5
Multi-language interpreter servicesATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please callthe toll-free phone number listed on your identification card.ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición.Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.請注意：如果您說中文 話號碼。XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễnphí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에기재된 무료 회원 전화번호로 문의하십시오.PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sawika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card.ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык являетсярусском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашейидентификационной карте. هيبنت : ( ةيبرعلا ثدحتت تنك اذإ Arabic)، كل ةحاتم ةيناجملا ةيوغللا ةدعاسملا تامدخ نإف . فتاهلا مقر ىلع لاصتالا ءاجرلا ةيوضعلا فّرعم ىلع دوجوملا يناجملا .ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan langpa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w.ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposésgratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification.UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić podbezpłatny numer telefonu podany na karcie identyfikacyjnej.ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Liguegratuitamente para o número encontrado no seu cartão de identificação.ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguisticagratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa.ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zurVerfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises ださい。 هجوت : ( یسراف امش نابز رگا Farsi) تسا ، دشاب یم امش رایتخا رد ناگیار روط هب ینابز دادما تامدخ . نفلت هرامش اب افطل ديريگب سامت هدش دیق امش یياسانش تراک یور هک یناگیار .ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र परसूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें।CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xovtooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus គិតថ្លៃ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ketsidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identificationcard mo.DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, beená’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dęę́́ › t’áá jíík’ehgo béésh bee hane’í biká’ígíí beehodíilnih.OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad helikartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.6
Therapeutic ClassLabel NameAnalgesicsABSTRAL SUB400MCGABSTRAL SUB600MCGABSTRAL SUB800MCGACTIQLOZ1200MCGACTIQLOZ1600MCGACTIQLOZ gesicsAnalgesicsAnalgesicsAnalgesicsGeneric NameFENTANYL CITRATE SL TAB 400 MCG(BASE EQUIV)FENTANYL CITRATE SL TAB 600 MCG(BASE EQUIV)FENTANYL CITRATE SL TAB 800 MCG(BASE EQUIV)FENTANYL CITRATE LOZENGE ON AHANDLE 1200 MCGFENTANYL CITRATE LOZENGE ON AHANDLE 1600 MCGFENTANYL CITRATE LOZENGE ON AHANDLE 200 MCGACTIQLOZ 400MCG FENTANYL CITRATE LOZENGE ON AHANDLE 400 MCGACTIQLOZ 600MCG FENTANYL CITRATE LOZENGE ON AHANDLE 600 MCGACTIQLOZ 800MCG FENTANYL CITRATE LOZENGE ON AHANDLE 800 MCGALLZITAL TAB 25BUTALBITAL-ACETAMINOPHEN TAB 25-325325MGMGAPAP/CAFFEIN TABACETAMINOPHEN-CAFFEINEDIHYDROCDIHYDROCODEINE TAB 325-30-16 MGAPAP/CODEINE SOLACETAMINOPHEN W/ CODEINE SOLN120-12/5120-12 MG/5MLAPAP/CODEINE TABACETAMINOPHEN W/ CODEINE TAB 300300-15MG15 MGAPAP/CODEINE TABACETAMINOPHEN W/ CODEINE TAB 300300-30MG30 MGAPAP/CODEINE TABACETAMINOPHEN W/ CODEINE TAB 300300-60MG60 MGAPAP-CAFFEIN CAPACETAMINOPHEN-CAFFEINEDIHYDROCDIHYDROCODEINE CAP 320.5-30-16 MGARTHROTEC 50 TABDICLOFENAC W/ MISOPROSTOL TABDELAYED RELEASE 50-0.2 MGARTHROTEC 75 TABDICLOFENAC W/ MISOPROSTOL TABDELAYED RELEASE 75-0.2 MGARYMO ER TAB 15MG MORPHINE SULFATE TAB ER ABUSEDETERRENT 15 MGARYMO ER TAB 30MG MORPHINE SULFATE TAB ER ABUSEDETERRENT 30 MGARYMO ER TAB 60MG MORPHINE SULFATE TAB ER ABUSEDETERRENT 60 MGASCOMP/COD CAPBUTALBITAL-ASPIRIN-CAFF W/ CODEINE30MGCAP 50-325-40-30 MGBACTABBUTALBITAL-ACETAMINOPHEN-CAFFEINETAB 50-325-40 MGBELBUCA MISBUPRENORPHINE HCL BUCCAL FILM 150150MCGMCG (BASE EQUIVALENT)BELBUCA MISBUPRENORPHINE HCL BUCCAL FILM 300300MCGMCG (BASE EQUIVALENT)BELBUCA MISBUPRENORPHINE HCL BUCCAL FILM 450450MCGMCG (BASE EQUIVALENT)BELBUCA MISBUPRENORPHINE HCL BUCCAL FILM 600600MCGMCG (BASE EQUIVALENT)BELBUCA MISBUPRENORPHINE HCL BUCCAL FILM 750750MCGMCG (BASE EQUIVALENT)BELBUCA MIS 75MCG BUPRENORPHINE HCL BUCCAL FILM 75MCG (BASE EQUIVALENT)BELBUCA MISBUPRENORPHINE HCL BUCCAL FILM 900900MCGMCG (BASE EQUIVALENT)BUPAPTAB 50BUTALBITAL-ACETAMINOPHEN TAB 50-300300MGMGBUPREN BUCC MISBUPRENORPHINE HCL BUCCAL FILM 150150MCGMCG (BASE EQUIVALENT)BUPREN BUCC MISBUPRENORPHINE HCL BUCCAL FILM 300300MCGMCG (BASE EQUIVALENT)BUPREN BUCC MISBUPRENORPHINE HCL BUCCAL FILM 450450MCGMCG (BASE EQUIVALENT)Tier ValuePriorSupplyAuthorization LimitStep SpecialtyTherapyTier 4XXXTier 4XXXTier 4XXXTier 4XXXTier 4XXXTier 4XXXTier 4XXXTier 4XXXTier 4XXXTier 4XTier 1XTier 1Tier 1Tier 1Tier 1Tier 1XTier 4XTier 4XTier 4XTier 4XTier 4XTier 1Tier 1XTier 3XXTier 3XXTier 3XXTier 3XXTier 3XXTier 3XXTier 3XXTier 1XXTier 1XXTier 1XXTier 47
Therapeutic ClassLabel NameGeneric NameAnalgesicsAnalgesicsBUPREN BUCC MIS600MCGBUPREN BUCC MIS750MCGBUPREN BUCC MIS75MCGBUPREN BUCC MIS900MCGBUPRENORPHIN SUB2MGBUPRENORPHIN SUB8MGBUT/APAP/CAF CAPAnalgesicsBUT/APAP/CAF CAPAnalgesicsAnalgesicsBUT/APAP/CAF CAPCODEINEBUT/APAP/CAF CAPCODEINEBUT/APAP/CAF TABAnalgesicsBUT/ASA/CAF TABAnalgesicsBUT/ASA/CAF/ CAPCOD 30MGBUT/ASA/CAF/ CAPCODEINEBUT/ASA/CAFF CAPBUPRENORPHINE HCL BUCCAL FILM 600MCG (BASE EQUIVALENT)BUPRENORPHINE HCL BUCCAL FILM 750MCG (BASE EQUIVALENT)BUPRENORPHINE HCL BUCCAL FILM 75MCG (BASE EQUIVALENT)BUPRENORPHINE HCL BUCCAL FILM 900MCG (BASE EQUIVALENT)BUPRENORPHINE HCL SL TAB 2 MG(BASE EQUIV)BUPRENORPHINE HCL SL TAB 8 MG(BASE EQUIV)BUTALBITAL-ACETAMINOPHEN-CAFFEINECAP 50-325-40 MGBUTALBITAL-ACETAMINOPHEN-CAFFEINECAP 50-300-40 MGBUTALBITAL-ACETAMINOPHEN-CAFF W/COD CAP 50-300-40-30 MGBUTALBITAL-ACETAMINOPHEN-CAFF W/COD CAP 50-325-40-30 MGBUTALBITAL-ACETAMINOPHEN-CAFFEINETAB 50-325-40 MGBUTALBITAL-ASPIRIN-CAFFEINE TAB 50325-40 MGBUTALBITAL-ASPIRIN-CAFF W/ CODEINECAP 50-325-40-30 MGBUTALBITAL-ASPIRIN-CAFF W/ CODEINECAP 50-325-40-30 MGBUTALBITAL-ASPIRIN-CAFFEINE CAP 50325-40 MGBUTALBITAL-ACETAMINOPHEN TAB 25-325MGBUTALBITAL-ACETAMINOPHEN CAP 50-300MGBUTALBITAL-ACETAMINOPHEN CAP 50-300MGBUTALBITAL-ACETAMINOPHEN TAB 50-325MGBUTALBITAL-ACETAMINOPHEN TAB 50-300MGBUTORPHANOL TARTRATE NASAL SOLN10 MG/MLDICLOFENAC POTASSIUM PACKET 50 MGDICLOFENAC POTASSIUM TAB 50 MGCELECOXIB CAP 100 csBUTAL/ACETAM TAB25-325MGBUTAL/APAP CAP 50300MGBUTAL/APAP CAP 50300MGBUTAL/APAP TAB 50325MGBUTALB/ACETA TAB50-300MGBUTORPHANOL SOL10MG/MLCAMBIA POW 50MGCATAFLAM TAB 50MGCELEBREX CAP100MGCELEBREX CAP200MGCELEBREX CAP400MGCELEBREX CAP 50MGCELECOXIB CAP100MGCELECOXIB CAP200MGCELECOXIB CAP400MGCELECOXIB CAP 50MGCODEINE SULF TAB15MGCODEINE SULF TAB30MGCODEINE SULF TAB60MGCONZIP CAP sCAP 200MGCELECOXIB CAP 200 MGCELECOXIB CAP 400 MGCELECOXIB CAP 50 MGCELECOXIB CAP 100 MGCELECOXIB CAP 200 MGCELECOXIB CAP 400 MGCELECOXIB CAP 50 MGCODEINE SULFATE TAB 15 MGCODEINE SULFATE TAB 30 MGCODEINE SULFATE TAB 60 MGTRAMADOL HCL CAP ER 24HR BIPHASICRELEASE 100 MGTRAMADOL HCL CAP ER 24HR BIPHASICRELEASE 200 MGTier ValuePriorSupplyAuthorization LimitTier 1XXTier 1XXTier 1XXTier 1XXTier 1XTier 1XTier 1XTier 1XTier 1XTier 1XTier 1XStep SpecialtyTherapyXTier 1Tier 1Tier 1Tier 1Tier 1XTier 4XXTier 1XXTier 1Tier 1Tier 1XTier 4Tier 4XXXTier 4XXTier 4XXTier 4XXTier 4XXTier 1XTier 1XTier 1XTier 1XTier 1Tier 1Tier 1Tier 4XXTier 4XX8
Therapeutic ClassLabel NameGeneric NameAnalgesicsCONZIPAnalgesicsAnalgesicsDAYPRO TAB 600MGDICLO/MISOPR TAB50-0.2MGDICLO/MISOPR TAB75-0.2MGDICLOFEN POT TAB50MGDICLOFENAC CAP35MGDICLOFENAC TAB100MG ERDICLOFENAC TAB25MG DRDICLOFENAC TAB50MG DRDICLOFENAC TAB75MG DRDIFLUNISAL TAB500MGDILAUDID LIQ 1MG/MLDILAUDID TAB 2MGDILAUDID TAB 4MGDILAUDID TAB 8MGDOLOPHINE TAB 10MGDOLOPHINE TAB 5MGDURAGESIC DIS100MCG/HDURAGESIC DIS12MCG/HRDURAGESIC DIS25MCG/HRDURAGESIC DIS50MCG/HRDURAGESIC DIS75MCG/HRDVORAH TABTRAMADOL HCL CAP ER 24HR BIPHASICRELEASE 300 MGOXAPROZIN TAB 600 MGDICLOFENAC W/ MISOPROSTOL TABDELAYED RELEASE 50-0.2 MGDICLOFENAC W/ MISOPROSTOL TABDELAYED RELEASE 75-0.2 MGDICLOFENAC POTASSIUM TAB 50 csAnalgesicsCAP 300MGAnalgesicsEC-NAPROSYN TAB375MGEC-NAPROSYN TAB500MGEC-NAPROXEN TAB375MGEC-NAPROXEN TAB500MGENDOCET TAB 10325MGENDOCET TAB2.5-325ENDOCET TAB5-325MGENDOCET TAB7.5-325ENOVARX CRE ETODOLAC CAP200MGETODOLAC CAP300MGETODOLAC CLOFENAC CAP 35 MGDICLOFENAC SODIUM TAB ER 24HR 100MGDICLOFENAC SODIUM TAB DELAYEDRELEASE 25 MGDICLOFENAC SODIUM TAB DELAYEDRELEASE 50 MGDICLOFENAC SODIUM TAB DELAYEDRELEASE 75 MGDIFLUNISAL TAB 500 MGHYDROMORPHONE HCL LIQD 1 MG/MLHYDROMORPHONE HCL TAB 2 MGHYDROMORPHONE HCL TAB 4 MGHYDROMORPHONE HCL TAB 8 MGMETHADONE HCL TAB 10 MGMETHADONE HCL TAB 5 MGFENTANYL TD PATCH 72HR 100 MCG/HRFENTANYL TD PATCH 72HR 12 MCG/HRFENTANYL TD PATCH 72HR 25 MCG/HRFENTANYL TD PATCH 72HR 50 MCG/HRFENTANYL TD PATCH 72HR 75 MCG/HRACETAMINOPHEN-CAFFEINEDIHYDROCODEINE TAB 325-30-16 MGNAPROXEN TAB EC 375 MGNAPROXEN TAB EC 500 MGNAPROXEN TAB EC 375 MGNAPROXEN TAB EC 500 MGOXYCODONE W/ ACETAMINOPHEN TAB10-325 MGOXYCODONE W/ ACETAMINOPHEN TAB2.5-325 MGOXYCODONE W/ ACETAMINOPHEN TAB5-325 MGOXYCODONE W/ ACETAMINOPHEN TAB7.5-325 MG*DICLOFENAC SODIUM CREAM 2.5%(COMPOUNDING KIT)**BUTALBITAL-ACETAMINOPHEN-CAFFEINECAP 50-325-40 MGBUTALBITAL-ACETAMINOPHEN-CAFFEINETAB 50-325-40 MGETODOLAC CAP 200 MGETODOLAC CAP 300 MGETODOLAC TAB 400 MGTier ValuePriorSupplyAuthorization LimitTier 4XStep SpecialtyTherapyXTier 4Tier 1Tier 1Tier 1Tier 4XTier 1Tier 1Tier 1Tier 1Tier 1Tier 4Tier 4Tier 4Tier 4Tier 3Tier 3XXXXTier 4XXXTier 4XXXTier 4XXXTier 4XXXTier 4XXXXXTier 4Tier 3Tier 4Tier 1Tier 1Tier 1Tier 1Tier 1Tier 1Tier 3XXTier 4XTier 4XTier 1Tier 1Tier 19
Therapeutic ClassLabel NameGeneric NameAnalgesicsETODOLAC TAB500MGETODOLAC ER TAB400MGETODOLAC ER TAB500MGETODOLAC ER TAB600MGFELDENE CAP 10MGFELDENE CAP 20MGFENTANYL DIS100MCG/HFENTANYL DIS12MCG/HRFENTANYL DIS25MCG/HRFENTANYL DIS37.5MCGFENTANYL DIS50MCG/HRFENTANYL DIS62.5MCGFENTANYL DIS75MCG/HRFENTANYL DIS87.5MCGFENTANYL POWCITRATEFENTANYL CIT TAB100MCGFENTANYL CIT TAB200MCGFENTANYL CIT TAB400MCGFENTANYL CIT TAB600MCGFENTANYL CIT TAB800MCGFENTANYL OT LOZ1200MCGFENTANYL OT LOZ1600MCGFENTANYL OT LOZ200MCGFENTANYL OT LOZ400MCGFENTANYL OT LOZ600MCGFENTANYL OT LOZ800MCGFENTORA TAB100MCGFENTORA TAB200MCGFENTORA TAB400MCGFENTORA TAB600MCGFENTORA TAB800MCGFIORICET CAPETODOLAC TAB 500 csFIORICET CAPCODEINEFIORINAL CAPFIORINAL/COD CAP30MGFLURBIPROFEN POWETODOLAC TAB ER 24HR 400 MGETODOLAC TAB ER 24HR 500 MGETODOLAC TAB ER 24HR 600 MGPIROXICAM CAP 10 MGPIROXICAM CAP 20 MGFENTANYL TD PATCH 72HR 100 MCG/HRFENTANYL TD PATCH 72HR 12 MCG/HRFENTANYL TD PATCH 72HR 25 MCG/HRFENTANYL TD PATCH 72HR 37.5 MCG/HRFENTANYL TD PATCH 72HR 50 MCG/HRFENTANYL TD PATCH 72HR 62.5 MCG/HRFENTANYL TD PATCH 72HR 75 MCG/HRFENTANYL TD PATCH 72HR 87.5 MCG/HRFENTANYL CITRATE POWDERFENTANYL CITRATE BUCCAL TAB 100MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 200MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 400MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 600MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 800MCG (BASE EQUIV)FENTANYL CITRATE LOZENGE ON AHANDLE 1200 MCGFENTANYL CITRATE LOZENGE ON AHANDLE 1600 MCGFENTANYL CITRATE LOZENGE ON AHANDLE 200 MCGFENTANYL CITRATE LOZENGE ON AHANDLE 400 MCGFENTANYL CITRATE LOZENGE ON AHANDLE 600 MCGFENTANYL CITRATE LOZENGE ON AHANDLE 800 MCGFENTANYL CITRATE BUCCAL TAB 100MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 200MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 400MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 600MCG (BASE EQUIV)FENTANYL CITRATE BUCCAL TAB 800MCG (BASE EQUIV)BUTALBITAL-ACETAMINOPHEN-CAFFEINECAP 50-300-40 MGBUTALBITAL-ACETAMINOPHEN-CAFF W/COD CAP 50-300-40-30 MGBUTALBITAL-ASPIRIN-CAFFEINE CAP 50325-40 MGBUTALBITAL-ASPIRIN-CAFF W/ CODEINECAP 50-325-40-30 MGFLURBIPROFEN POWDERTier ValuePriorSupplyAuthorization LimitStep SpecialtyTherapyTier 1Tier 1Tier 1Tier 1Tier 4Tier 4Tier 1XXTier 1XXTier 1XXTier 1XXTier 1XXTier 1XXTier 1XXTier 1XXXTier 3XTier 3XXXTier 3XXXTier 3XXXTier 3XXXTier 3XXXTier 1XXTier 1XXTier 1XXTier 1XXTier 1XXTier 1XXTier 3XXXTier 3XXXTier 3XXXTier 3XXXTier 3XXXTier 4XTier 4XXXXTier 4Tier 4Tier 3X10
Therapeutic ClassLabel NameGeneric NameAnalgesicsFLURBIPROFEN TAB100MGFLURBIPROFEN TAB50MGHYDRO/ACETA SOL10-325MGHYDROCO/APAP SOL7.5-325HYDROCO/APAP TAB10-300MGHYDROCO/APAP TAB10-325MGHYDROCO/APAP TAB5-300MGHYDROCO/APAP TAB5-325MGHYDROCO/APAP TAB7.5-300HYDROCO/APAP TAB7.5-325HYDROCOD/IBU TAB10-200MGHYDROCOD/IBU TAB5-200MGHYDROCOD/IBU TAB7.5-200HYDROCODONE CAP10MG ERHYDROCODONE CAP15MG ERHYDROCODONE CAP20MG ERHYDROCODONE CAP30MG ERHYDROCODONE CAP40MG ERHYDROCODONE CAP50MG ERHYDROCODONE TAB100MG ERHYDROCODONE TAB120MG ERHYDROCODONE TAB20MG ERHYDROCODONE TAB30MG ERHYDROCODONE TAB40MG ERHYDROCODONE TAB60MG ERHYDROCODONE TAB80MG ERHYDROMORPHON LIQ1MG/MLHYDROMORPHON POWHCLHYDROMORPHON SUP3MGHYDROMORPHON TAB12MG ERHYDROMORPHON TAB16MG ERHYDROMORPHON TAB2MGHYDROMORPHON TAB32MG ERHYDROMORPHON TAB4MGFLURBIPROFEN TAB 100 csAnalgesicsAnalgesicsAnalgesicsFLURBIPROFEN TAB 50 MGHYDROCODONE-ACETAMINOPHEN SOLN10-325 MG/15MLHYDROCODONE-ACETAMINOPHEN SOLN7.5-325 MG/15MLHYDROCODONE-ACETAMINOPHEN TAB10-300 MGHYDROCODONE-ACETAMINOPHEN TAB10-325 MGHYDROCODONE-ACETAMINOPHEN TAB5-300 MGHYDROCODONE-ACETAMINOPHEN TAB5-325 MGHYDROCODONE-ACETAMINOPHEN TAB7.5-300 MGHYDROCODONE-ACETAMINOPHEN TAB7.5-325 MGHYDROCODONE-IBUPROFEN TAB 10-200MGHYDROCODONE-IBUPROFEN TAB 5-200MGHYDROCODONE-IBUPROFEN TAB 7.5-200MGHYDROCODONE BITARTRATE CAP ER12HR 10 MGHYDROCODONE BITARTRATE CAP ER12HR 15 MGHYDROCODONE BITARTRATE CAP ER12HR 20 MGHYDROCODONE BITARTRATE CAP ER12HR 30 MGHYDROCODONE BITARTRATE CAP ER12HR 40 MGHYDROCODONE BITARTRATE CAP ER12HR 50 MGHYDROCODONE BITARTRATE TAB ER24HR DETER 100 MGHYDROCODONE BITARTRATE TAB ER24HR DETER 120 MGHYDROCODONE BITARTRATE TAB ER24HR DETER 20 MGHYDROCODONE BITARTRATE TAB ER24HR DETER 30 MGHYDROCODONE BITARTRATE TAB ER24HR DETER 40 MGHYDROCODONE BITARTRATE TAB ER24HR DETER 60 MGHYDROCODONE BITARTRATE TAB ER24HR DETER 80 MGHYDROMORPHONE HCL LIQD 1 MG/MLHYDROMORPHONE HCL POWDERHYDROMORPHONE HCL SUPPOS
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