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- APAP/CODEINE SOL 120-12/5
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 4500 per 30-days (* depending on package size)
- APAP/CODEINE SOL 300-30MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 4500 per 30-days (* depending on package size)
- APAP/CODEINE TAB 300-15MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 390 per 30-days (* depending on package size)
- APAP/CODEINE TAB 300-30MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 390 per 30-days (* depending on package size)
- APAP/CODEINE TAB 300-60MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 390 per 30-days (* depending on package size)
- APAP-CAFFEIN CAP DIHYDROC
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 300 per 30-days (* depending on package size)
- BAC TAB
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 180 per 30-days (* depending on package size)
- BUPRENORPHIN DIS 10MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 4 per 28-days (* depending on package size)
- BUPRENORPHIN DIS 15MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 4 per 28-days (* depending on package size)
- BUPRENORPHIN DIS 20MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 4 per 28-days (* depending on package size)
- BUPRENORPHIN DIS 5MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 4 per 28-days (* depending on package size)
- BUPRENORPHIN DIS 7.5/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 4 per 28-days (* depending on package size)
- BUT/APAP/CAF TAB
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 180 per 30-days (* depending on package size)
- BUT/ASA/CAFF CAP
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 180 per 30-days (* depending on package size)
- BUTORPHANOL INJ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - BUTORPHANOL INJ 2MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - BUTORPHANOL SOL 10MG/ML
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 5 per 30-days (* depending on package size)
- CELECOXIB CAP 100MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory DrugsQuantity Limit: 60 per 30-days (* depending on package size)
- CELECOXIB CAP 200MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory DrugsQuantity Limit: 60 per 30-days (* depending on package size)
- CELECOXIB CAP 400MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory DrugsQuantity Limit: 60 per 30-days (* depending on package size)
- CELECOXIB CAP 50MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory DrugsQuantity Limit: 60 per 30-days (* depending on package size)
- CODEINE SULF TAB 15MG
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 180 per 30-days (* depending on package size)
- CODEINE SULF TAB 30MG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 180 per 30-days (* depending on package size)
- CODEINE SULF TAB 60MG
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 180 per 30-days (* depending on package size)
- DICLOFEN POT TAB 50MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - DICLOFENAC DIS 1.3%
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory DrugsQuantity Limit: 60 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
- DICLOFENAC GEL 1%
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - DICLOFENAC TAB 100MG ER
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - DICLOFENAC TAB 25MG DR
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - DICLOFENAC TAB 50MG DR
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - DICLOFENAC TAB 75MG DR
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - DIFLUNISAL TAB 500MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - DURAMORPH INJ 0.5MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - DURAMORPH INJ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - EC-NAPROXEN TAB 375MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - EC-NAPROXEN TAB 500MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - ENDOCET TAB 10-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 360 per 30-days (* depending on package size)
- ENDOCET TAB 2.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 360 per 30-days (* depending on package size)
- ENDOCET TAB 5-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 360 per 30-days (* depending on package size)
- ENDOCET TAB 7.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 360 per 30-days (* depending on package size)
- ETODOLAC CAP 200MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - ETODOLAC CAP 300MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - ETODOLAC TAB 400MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - ETODOLAC TAB 500MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - ETODOLAC ER TAB 400MG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - ETODOLAC ER TAB 500MG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - ETODOLAC ER TAB 600MG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - FENTANYL DIS 100MCG/H
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 15 per 30-days (* depending on package size)
- FENTANYL DIS 12MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 15 per 30-days (* depending on package size)
- FENTANYL DIS 25MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 15 per 30-days (* depending on package size)
- FENTANYL DIS 50MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 15 per 30-days (* depending on package size)
- FENTANYL DIS 75MCG/HR
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 15 per 30-days (* depending on package size)
- FENTANYL CIT INJ 0.05MG/1
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 100/2ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 1000/20
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 1000MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 100MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 250/5ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 2500/50
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 2500MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 250MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 500MCG
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL CIT INJ 50MCG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingPrior Authorization: Part B vs. Part D Prior Authorization
- FENTANYL OT LOZ 1200MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
- FENTANYL OT LOZ 1600MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
- FENTANYL OT LOZ 200MCG
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
- FENTANYL OT LOZ 400MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
- FENTANYL OT LOZ 600MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
- FENTANYL OT LOZ 800MCG
Classification: Tier 5 (specialty tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 120 per 30-days (* depending on package size)
Prior Authorization: Prior Authorization
- FLURBIPROFEN TAB 100MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - HYDROCO/APAP SOL 5-217MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 5400 per 30-days (* depending on package size)
- HYDROCO/APAP SOL 7.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 5400 per 30-days (* depending on package size)
- HYDROCO/APAP TAB 10-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 360 per 30-days (* depending on package size)
- HYDROCO/APAP TAB 5-325MG
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 360 per 30-days (* depending on package size)
- HYDROCO/APAP TAB 7.5-325
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 360 per 30-days (* depending on package size)
- HYDROCOD/IBU TAB 7.5-200
Classification: Tier 3 (preferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 150 per 30-days (* depending on package size)
- HYDROMORPHON INJ 0.5/0.5
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - HYDROMORPHON INJ 10MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - HYDROMORPHON INJ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - HYDROMORPHON INJ 2MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - HYDROMORPHON INJ 4MG/ML
Classification: Tier 4 (nonpreferred brand tier) brand drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - HYDROMORPHON INJ 500/50ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - HYDROMORPHON INJ 50MG/5ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-acting - HYDROMORPHON LIQ 1MG/ML
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 1500 per 30-days (* depending on package size)
- HYDROMORPHON TAB 12MG ER
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 60 per 30-days (* depending on package size)
- HYDROMORPHON TAB 16MG ER
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 60 per 30-days (* depending on package size)
- HYDROMORPHON TAB 2MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 240 per 30-days (* depending on package size)
- HYDROMORPHON TAB 32MG ER
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 60 per 30-days (* depending on package size)
- HYDROMORPHON TAB 4MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 240 per 30-days (* depending on package size)
- HYDROMORPHON TAB 8MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Short-actingQuantity Limit: 180 per 30-days (* depending on package size)
- HYDROMORPHON TAB 8MG ER
Classification: Tier 4 (nonpreferred brand tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Opioid Analgesics, Long-actingQuantity Limit: 60 per 30-days (* depending on package size)
- IBU TAB 400MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - IBU TAB 600MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - IBU TAB 800MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - IBUPROFEN SUS 100/5ML
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - IBUPROFEN TAB 400MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - IBUPROFEN TAB 600MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - IBUPROFEN TAB 800MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - INDOMETHACIN CAP 25MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs - INDOMETHACIN CAP 50MG
Classification: Tier 2 (generic tier) generic drug
Therapeutic Category: Analgesics
Therapeutic Class: Nonsteroidal Anti-inflammatory Drugs
Last updated 10/02/2023